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The coronavirus disease 2019 (COVID-19) pandemic has had major implications for general surgery practice. We sought to characterize general surgeons' perceptions of their surgical practice in Ontario, Canada, regarding operating room precautions to maximize safety during the pandemic.A web-administered cross-sectional survey was sent to general surgeons registered with the College of Physicians and Surgeons of Ontario on May 19, 2020. Surgeons were surveyed regarding their practices in pre-operative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing, use of intra-operative personal protective equipment (PPE) given a patient's COVID-19 status, and management of common general surgical emergencies with COVID-19 patients. Responses were compared between surgeons from high- and low-prevalence public health units (PHUs) in Ontario using chi-square tests.There were 81 respondents (rate: 81/271, 30%), 48 (59%) of whom were from a PHU in the top quartile of COVID-19 prevalence. Surgeons from low-prevalence PHUs reported pre-procedural COVID-19 testing rates similar to those reported in high-prevalence PHUs for elective (36% versus 55%), urgent (36% versus 54%), and emergent (20% versus 33%) surgeries. Seventy-eight percent of surgeons with COVID-19-negative patients limited trainees in the operating room compared with 96% of surgeons with COVID-19-positive patients. Use of N95 respirators was 17% for surgeons with COVID-19-negative patients, which dramatically increased to 62% for surgeons with patients whose COVID-19 status was unknown.These findings support a need for improved understanding of local disease prevalence and risk of COVID-19 transmission to conserve PPE and return surgical trainees to pre-pandemic standards.La pandémie de maladie à coronavirus 2019 (COVID-19) a eu des conséquences majeures en chirurgie générale. Les chercheurs ont cherché à caractériser le point de vue des chirurgiens généralistes à l’égard des précautions à prendre en salle d’opération pour optimiser la sécurité pendant la pandémie, dans le cadre de leur pratique chirurgicale en Ontario, au Canada.Le 19 mai 2020, les chercheurs ont expédié un sondage transversal en ligne aux chirurgiens généralistes inscrits au Collège des médecins et chirurgiens de l’Ontario. Ceux-ci ont répondu à des questions sur leurs pratiques à l’égard du dépistage du coronavirus 2 du syndrome respiratoire aigu sévère (SARS-CoV-2) avant l’opération, du port de l’équipement de protection individuelle (ÉPI) pendant l’opération en fonction de l’infection du patient par la COVID-19 et de la gestion des urgences courantes en chirurgie générale lorsque les patients sont atteints de la COVID-19. Les chercheurs ont utilisé le test du chi carré pour comparer les réponses entre des unités de santé publique (USP) à forte et faible prévalence de l’Ontario.Sur un total de 81 réponses (81 sur 271, 30 %), 48 (59 %) provenaient d’une USP du quartile supérieur de prévalence de la COVID-19. Les chirurgiens travaillant dans des USP à faible prévalence ont déclaré des taux de dépistage de COVID-19 avant l’opération semblables à ceux signalés dans les USP à forte prévalence dans le cadre des opérations non urgentes (36 % par rapport à 55 %), urgentes (36 % par rapport à 54 %) et très urgentes (20 % par rapport à 33 %). Ainsi, 78 % des chirurgiens dont les patients avaient obtenu un résultat négatif à la COVID-19 limitaient le nombre de stagiaires dans la salle d’opération par rapport à 96 % de ceux dont les patients avaient reçu un résultat positif. Par ailleurs, 17 % des chirurgiens dont les patients avaient obtenu un résultat négatif à la COVID-19 portaient le masque N95, par rapport à une proportion remarquable de 62 % chez ceux qui ne savaient pas si leur patient était atteint de la COVID-19.Ces résultats démontrent la nécessité de mieux comprendre la prévalence locale et le risque de transmission de la COVID-19 pour maintenir l’ÉPI et le retour des stagiaires en chirurgie aux normes prépandémiques.

The impact of Coronavirus disease 2019 pandemic on Italian Gynaecological Units practice and the compliance and satisfaction with available guidelines/recommendations is unknown. Therefore, a survey was conducted among all Italian Gynaecological Units Directors in April 2020. The response rate was 90% (135/150). 77.8% of centres performed surgery only for oncologic or not deferrable pathologies, and 9.6% was closed. 68.7% of directors were at least moderately satisfied by published guidelines/recommendations, but 94.8% of respondents identified limitations, mainly (83%) the absent definition of benign non-deferrable pathology. Responders considered as non-deferrable severe endometriosis (69.6%), endometriosis with organ failure/dysfunction (74.1%), and unresponsive symptomatic fibroids (89.6%). Despite guidelines/recommendations, respondents treated ovarian (77%) and endometrial (71.6%) cancer as usual. Only a minority of respondents reduced the laparoscopic approach (11.2%) and adopted all recommended surgical precautions (9.6%). Compliance with available guidelines/recommendations appears incomplete. Reconsidering guidelines/recommendations regarding oncological cases and specify non-deferrable benign pathologies would improve guidelines/recommendations compliance.Impact statementWhat is already known on this subject? The SARS-CoV-2 pandemic has profoundly influenced medical routine practice worldwide. Surgery units have been forced to reduce or even completely restrict their activity to re-allocate human resources. Many major international gynaecological societies have released statements and guidelines, providing various recommendations to guide practice changes. However, the impact of the SARS-CoV-2 pandemic on Italian Gynaecological Units practice and the compliance and satisfaction with available guidelines/recommendations is unknown.What do the results of this study add? Study results provide evidence showing how the SARS-CoV-2 pandemic has changed surgical activity in the Italian Gynaecological Units. Most centres reduced surgical activity, limiting surgery only for oncologic or not deferrable pathologies. Moreover, our research shows the level of compliance and satisfaction with available guidelines/recommendations and where they need to be improved. Most directors were at least moderately satisfied but identified different limitations. Guidelines/recommendations do not provide enough details, such as the absent definition of benign non-deferrable pathologies.What are the implications of these findings for clinical practice and/or further research? The limited compliance with available guidelines/recommendations and identified limitations suggest reconsidering guidelines/recommendations focussing on identified gaps. Provide more details, such as specifying non-deferrable benign pathologies, would improve guidelines/recommendations compliance.

Background: The COVID-19 pandemic presented unique challenges for endoscopic skull base surgery (ESBS) given the elevated viral load in the nasopharynx and aerosolization of particles inherent to the endoscopic endonasal approach (EEA). Furthermore, reports and anecdotes shared within the skull base surgeon community suggesting potential elevated risk of COVID-19 transmission during ESBS led to an abundance of precaution and scrutiny regarding endonasal procedures during the pandemic. The Mount Sinai Hospital is a busy ESBS center located in New York City, the United States COVID-19 pandemic epicenter. We report a case series describing the early experience of resuming ESBS during the COVID-19 pandemic, including systems for case selection, surgical precautions and modifications, and patient outcomes. Methods: All consecutive ESBS cases and deferred surgical cases were identified prospectively within the first three-week period after resumption of urgent scheduled surgery. Data regarding indications, pre-surgical screening, operative results, and postoperative course were collected retrospectively. All data are presented using descriptive statistics. Results: With the study time frame, 14 patients underwent ESBS. Four patients had surgery deferred. The mean age was 57. The most common pathology was pituitary tumor, in 57% of patients. Visual symptoms precipitated the urgency in 36% of cases. All patients underwent COVID-19 screening with a minimum of one SARSCoV-2 reverse transcriptase polymerase chain reaction (RT-PCR) nasal swab within 48 hours preceding surgery. All patients tested negative. There were no intraoperative complications. Median length of stay was two days. A total of 14% of patients experienced postoperative complications. Mean follow-up was 100.9 days. Conclusions: Due to its relatively low morbidity and potential short length of stay, ESBS is adaptable to unique pandemic challenges such as bed scarcity and exposure minimization. As endoscopic centers return to normal operations during the COVID-19 era, standard testing, case selection algorithms, and systematic surgical precautions and modifications can enable a safe resumption of ESBS.

Introduction: The differential diagnosis of a firm, immobile lesion of the forehead includes more than just osteoma. Preoperative computed tomography (CT) imaging may alter surgical precautions and reduce the complications to allow for a minimally invasive approach. Materials and Methods: This is a retrospective case series of a single, private facial plastic surgeon in New York, New York, of patients evaluated for a firm, immobile forehead mass. The impact of CT scan on diagnosis and treatment was analyzed. Intraoperative and postoperative complications, recurrences, and patient satisfaction were recorded. Results: Nineteen patients (age range = 19–66 years; mean age = 36 years) presented with one or more firm, immobile forehead masses measuring Conclusions: The differential diagnosis of a firm, immobile forehead mass includes various pathologies of the scalp and calvarium. Though these masses are most commonly osteomas, other pathologies may present similarly. Preoperative CT scans without contrast can distinguish these unexpected etiologies. With proper evaluation and diagnosis, minimally invasive excision may be performed with excellent results.

We present two cases of high tibial osteotomies performed at our institution. Both cases were complicated with the immediate postoperative occurrence of an ischaemic syndrome of the lower leg. Urgent diagnostics revealed a complete rupture of the popliteal artery that required re-operation and a vascular repair. Although neurovascular complications during high tibial osteotomies are rare the awareness of this potentially catastrophic complication should be present when performing this common procedure. All precautions to minimize the harm to the neurovascular bundle should be put into practice. A summary of the surgical precautions is presented and discussed in this paper.

Direct insertion of the anterior papillary muscle (DPM) into the mitral valve is uncommon. During the routine dissection of an adult female, a DPM into the mitral valve with abnormal chordae tendinae was observed. This abnormal papillary muscle was measured as 28.0 mm in length from myocardial to insertion, 14.8 mm in width, and 7.0 mm in depth. The embryology, symptoms, associated cardiac diseases, and surgical precautions of this congenital malformation in the heart are reviewed.

Orbital neurofibromas are uncommon in adults, accounting for approximately 1%-3% of all space occupying lesions of the orbit. The complex anatomy of the orbital region, with the pronounced vulnerability of its neurovascular structures, requires particular surgical precautions. Neuronavigation, as a high-tech device for intraoperative safety, represents a valuable option for the confined orbital space. However, the application of neuronavigation in orbital surgery has been rarely reported. The authors present a case report of a 32-year-old female with an isolated localized neurofibroma surgically approached by intraoperative navigation and a review of the literature.

The hydatid disease is common and remains endemic in Morocco. The treatment relies mainly on surgery. This may be accompanied by rare but serious complications that can certainly be life-threatening. Allergic reactions can manifest as anaphylactic shock which is characterized by its brutal onset and its severity. We stress through the pediatric case reported the exceptional occurrence of anaphylactic shock during surgery and the need for its early recognition in order to establish effective treatment. Prevention relies mainly on surgical precautions taken to avoid seeding of the abdominal cavity.

Summary Hydatid cysts of the cervical region are extremely rare especially in children and the diagnosis is quite challenging. We report herein a child with a hydatid cyst that was primarily located in the submental region without any pulmonary or hepatic involvement. A hydatid cyst of the neck should be considered as a possible diagnosis while evaluating any slow growing cyst in the cervical region especially in a patient living in endemic areas so as to keep surgical precautions in mind while operating to avoid any dangerous complications such as contamination and a fatal anaphylactic reaction.

The AIDS epidemic has become one of the most important public health problems of this century. As the prevalence of HIV infection continues to rise, health care practitioners in all geographic regions can expect greater clinical exposure to patients infected with HIV. We conducted an anonymous survey of all practicing otolaryngologists in Ohio and California to investigate regional differences in attitudes, knowledge, and practices regarding the care of patients infected with HIV. We also examined the data with respect to year of completion of residency training to identify differences in attitudes or practices among otolaryngologists who trained in the era of AIDS (post-1982 graduates) in comparison with their predecessors (pre-1982 graduates). In comparison with Ohio otolaryngologists, California otolaryngologists reported more frequent clinical encounters with HIV-infected patients and displayed significantly better knowledge regarding the otolaryngologic aspects of HIV infection. Californians were more likely to support the right of an HIV-infected physician to maintain an unrestricted practice and would be less likely to disclose their HIV status to their patients and hospital if they were to become infected with HIV. Post-1982 graduates had more frequent encounters with HIV-infected patients than did pre-1982 graduates and demonstrated a better fund of knowledge. Although Californians were more likely than Ohioans to routinely double glove in surgery, the overall double gloving rate was low at 21%. Californians were no more likely than Ohioans to routinely use protective eyewear, water-impervious gowns, or indirect instrument-passing techniques in surgery. No differences were observed in prevalence of protective surgical precautions between pre-1982 and post-1982 graduates. The results of the survey indicate a need for broader acceptance and use of "universal" surgical precautions among otolaryngologists. (OTOLARYNGOL HEAD NECK SURG 1995;113:733-9.)

This paper describes the rehabilitation of a patient following a medial meniscus transplant. Both preoperative and postoperative history and relevant physical findings are presented. Rehabilitation goals and the corresponding treatment plan are discussed, with an emphasis on functional outcomes. A general framework for treatment addressing impairment and functional goals is outlined. Progression of the rehabilitation program was based on surgical precautions and the patient's tolerance to the exercise progression. This case study demonstrates that appropriate surgical intervention combined with a properly designed rehabilitation program contributed to the improved functional abilities of this patient.

As the average life expectancy is gradually increasing, more elderly patients are seen in neurosurgical clinics but those aged 80 years or more pose significant medical and ethical dilemmas for neurosurgeons. A retrospective study of eleven patients assessed the post-operative short term outcome in very old patients with benign brain tumors. Six had total surgical excision and five had partial resection. The outcome was good for six, unchanged in one and four died. Post-operative intracranial complications were not tolerated and resulted in a poor outcome in this age group. However; it is suggested that carefully selected patients over the age of 80 years with symptomatic benign brain tumors can be considered for surgical intervention.

Twiddler's syndrome is a highly recognized yet rare complication of pacemaker and cardioverter defibrillator (i.c.d.) implantation. We present a case in which persistent generator rotation resulted in lead dislodgment and inappropriate shocks in an initial ICD and recurrent lead fracture in a second ICD system. This case is unusual in that even with extensive surgical precautions including use of a Dacron pouch, generator rotation could not be prevented. Submuscular implantation and use of a smaller generator may prevent Twiddler's syndrome.

Pacemaker twiddler's syndrome is the phenomenon whereby a pacemaker patient may actively dislodge a pacing electrode by manipulating, often unconsciously, the permanent implanted pacemaker. This unusual case is remarkable in several respects: surgical precautions, originally taken to secure the pulse generator against migration, proved ineffective; the displaced lead featured an active fixation "screw-in" electrode; and the reported dislodgement occurred not in the early postimplant stage, but fully three months later. It can be concluded that even with advanced lead technology and operative precaution, electrode dislodgement cannot be absolutely prevented. Awareness of this phenomenon, especially by pacemaker follow-up care personnel, could lessen its occurrence.

Perforating diathermy coagulation can be used efficiently to destroy large angiomas of the retina. Five patients who had developed large angiomas (greater than 5 disc diameters) in association with various retinal diseases were treated with this technique. The follow-up period ranged from 1 1/2 to 7 years, except for one case in which the patient died five days after the surgical procedure. Several techniques of perforating diathermy are described, and the indications, surgical precautions, and complications of each method are discussed.

Perhaps the aneurysmal bone cyst is not a distinct clinicopathologic entity in itself, but its existence does necessitate additional diagnostic evaluation and surgical precautions. Because of this, lesions with aneurysmal bone cyst involvement should be classified distinctly from lesions that do not present this complication.