Intraoperative Near-infrared Imaging for Parathyroid Gland Identification by Auto-fluorescence: A Feasibility Study.

PubMed

De Leeuw, Frederic; Breuskin, Ingrid; Abbaci, Muriel; Casiraghi, Odile; Mirghani, Haïtham; Ben Lakhdar, Aïcha; Laplace-Builhé, Corinne; Hartl, Dana

2016-09-01

Parathyroid glands (PGs) can be particularly hard to distinguish from surrounding tissue and thus can be damaged or removed during thyroidectomy. Postoperative hypoparathyroidism is the most common complication after thyroidectomy. Very recently, it has been found that the parathyroid tissue shows near-infrared (NIR) auto-fluorescence which could be used for intraoperative detection, without any use of contrast agents. The work described here presents a histological validation ex vivo of the NIR imaging procedure and evaluates intraoperative PG detection by NIR auto-fluorescence using for the first time to our knowledge a commercially available clinical NIR imaging device. Ex vivo study on resected operative specimens combined with a prospective in vivo study of consecutive patients who underwent total or partial thyroid, or parathyroid surgery at a comprehensive cancer center. During surgery, any tissue suspected to be a potential PG by the surgeon was imaged with the Fluobeam 800 (®) system. NIR imaging was compared to conventional histology (ex vivo) and/or visual identification by the surgeon (in vivo). We have validated NIR auto-fluorescence with an ex vivo study including 28 specimens. Sensitivity and specificity were 94.1 and 80 %, respectively. Intraoperative NIR imaging was performed in 35 patients and 81 parathyroids were identified. In 80/81 cases, the fluorescence signal was subjectively obvious on real-time visualization. We determined that PG fluorescence is 2.93 ± 1.59 times greater than thyroid fluorescence in vivo. Real-time NIR imaging based on parathyroid auto-fluorescence is fast, safe, and non-invasive and shows very encouraging results, for intraoperative parathyroid identification.

Intraoperative Injection of Technetium-99m Sulfur Colloid for Sentinel Lymph Node Biopsy in Breast Cancer Patients: A Single Institution Experience

PubMed Central

Berrocal, Julian; Saperstein, Lawrence; Grube, Baiba; Horowitz, Nina R.; Chagpar, Anees B.

2017-01-01

Background. Most institutions require a patient undergoing sentinel lymph node biopsy to go through nuclear medicine prior to surgery to be injected with radioisotope. This study describes the long-term results using intraoperative injection of radioisotope. Methods. Since late 2002, all patients undergoing a sentinel lymph node biopsy at the Yale-New Haven Breast Center underwent intraoperative injection of technetium-99m sulfur colloid. Endpoints included number of sentinel and nonsentinel lymph nodes obtained and number of positive sentinel and nonsentinel lymph nodes. Results. At least one sentinel lymph node was obtained in 2,333 out of 2,338 cases of sentinel node biopsy for an identification rate of 99.8%. The median number of sentinel nodes found was 2 and the mean was 2.33 (range: 1–15). There were 512 cases (21.9%) in which a sentinel node was positive for metastatic carcinoma. Of the patients with a positive sentinel lymph node who underwent axillary dissection, there were 242 cases (54.2%) with no additional positive nonsentinel lymph nodes. Advantages of intraoperative injection included increased comfort for the patient and simplification of scheduling. There were no radiation related complications. Conclusion. Intraoperative injection of technetium-99m sulfur colloid is convenient, effective, safe, and comfortable for the patient. PMID:28492062

Identification of the subthalamic nucleus in deep brain stimulation surgery with a novel wavelet-derived measure of neural background activity.

PubMed

Snellings, André; Sagher, Oren; Anderson, David J; Aldridge, J Wayne

2009-10-01

The authors developed a wavelet-based measure for quantitative assessment of neural background activity during intraoperative neurophysiological recordings so that the boundaries of the subthalamic nucleus (STN) can be more easily localized for electrode implantation. Neural electrophysiological data were recorded in 14 patients (20 tracks and 275 individual recording sites) with dopamine-sensitive idiopathic Parkinson disease during the target localization portion of deep brain stimulator implantation surgery. During intraoperative recording, the STN was identified based on audio and visual monitoring of neural firing patterns, kinesthetic tests, and comparisons between neural behavior and the known characteristics of the target nucleus. The quantitative wavelet-based measure was applied offline using commercially available software to measure the magnitude of the neural background activity, and the results of this analysis were compared with the intraoperative conclusions. Wavelet-derived estimates were also compared with power spectral density measurements. The wavelet-derived background levels were significantly higher in regions encompassed by the clinically estimated boundaries of the STN than in the surrounding regions (STN, 225 +/- 61 microV; ventral to the STN, 112 +/- 32 microV; and dorsal to the STN, 136 +/- 66 microV). In every track, the absolute maximum magnitude was found within the clinically identified STN. The wavelet-derived background levels provided a more consistent index with less variability than measurements with power spectral density. Wavelet-derived background activity can be calculated quickly, does not require spike sorting, and can be used to identify the STN reliably with very little subjective interpretation required. This method may facilitate the rapid intraoperative identification of STN borders.

Use of 99mTc-Tilmanocept as a Single Agent for Sentinel Lymph Node Identification in Breast Cancer: A Retrospective Pilot Study.

PubMed

Unkart, Jonathan T; Wallace, Anne M

2017-09-01

99m Tc-tilmanocept received recent Food and Drug Administration approval for lymphatic mapping in 2013. However, to our knowledge, no prior studies have evaluated the use of 99m Tc-tilmanocept as a single agent in sentinel lymph node (SLN) biopsy in breast cancer. Methods: We executed this retrospective pilot study to assess the ability of 99m Tc-tilmanocept to identify sentinel nodes as a single agent in clinically node-negative breast cancer patients. Patients received a single intradermal injection overlying the tumor of either 18.5 MBq (0.5 mCi) of 99m Tc-tilmanocept on the day of surgery or 74.0 MBq (2.0 mCi) on the day before surgery by a radiologist. Immediate 3-view lymphoscintigraphy was performed. Intraoperatively, SLNs were identified with a portable γ-probe. A node was classified as hot if the count (per second) of the node was more than 3 times the background count. Descriptive statistics are reported. Results: Nineteen patients underwent SLN biopsy with single-agent 99m Tc-tilmanocept. Immediate lymphoscintigraphy identified at least 1 sentinel node in 13 of 17 patients (76.5%). Intraoperatively, at least 1 (mean, 1.7 ± 0.8; range, 1-3) hot node was identified in all patients. Three patients (15.8%) had 1 disease-positive SLN. Conclusion: In this small, retrospective pilot study, 99m Tc-tilmanocept performed well as a single agent for intraoperative sentinel node identification in breast cancer. A larger, randomized clinical trial is warranted to compare 99m Tc-tilmanocept as a single agent with other radiopharmaceuticals for sentinel node identification in breast cancer. © 2017 by the Society of Nuclear Medicine and Molecular Imaging.

Identification of the subthalamic nucleus in deep brain stimulation surgery with a novel wavelet-derived measure of neural background activity

PubMed Central

Snellings, André; Sagher, Oren; Anderson, David J.; Aldridge, J. Wayne

2016-01-01

Object A wavelet-based measure was developed to quantitatively assess neural background activity taken during surgical neurophysiological recordings to localize the boundaries of the subthalamic nucleus during target localization for deep brain stimulator implant surgery. Methods Neural electrophysiological data was recorded from 14 patients (20 tracks, n = 275 individual recording sites) with dopamine-sensitive idiopathic Parkinson’s disease during the target localization portion of deep brain stimulator implant surgery. During intraoperative recording the STN was identified based upon audio and visual monitoring of neural firing patterns, kinesthetic tests, and comparisons between neural behavior and known characteristics of the target nucleus. The quantitative wavelet-based measure was applied off-line using MATLAB software to measure the magnitude of the neural background activity, and the results of this analysis were compared to the intraoperative conclusions. Wavelet-derived estimates were compared to power spectral density measures. Results The wavelet-derived background levels were significantly higher in regions encompassed by the clinically estimated boundaries of the STN than in surrounding regions (STN: 225 ± 61 μV vs. ventral to STN: 112 ± 32 μV, and dorsal to STN: 136 ± 66 μV). In every track, the absolute maximum magnitude was found within the clinically identified STN. The wavelet-derived background levels provided a more consistent index with less variability than power spectral density. Conclusions The wavelet-derived background activity assessor can be calculated quickly, requires no spike sorting, and can be reliably used to identify the STN with very little subjective interpretation required. This method may facilitate rapid intraoperative identification of subthalamic nucleus borders. PMID:19344225

Can the rapid identification of mature spermatozoa during microdissection testicular sperm extraction guide operative planning?

PubMed

Alrabeeah, K; Doucet, R; Boulet, E; Phillips, S; Al-Hathal, N; Bissonnette, F; Kadoch, I J; Zini, A

2015-05-01

The minimum sperm count and quality that must be identified during microdissection testicular sperm extraction (micro-TESE) to deem the procedure successful remains to be established. We conducted a retrospective study of 81 consecutive men with non-obstructive azoospermia who underwent a primary (first) micro-TESE between March 2007 and October 2013. Final assessment of sperm recovery [reported on the day of (intracytoplasmic sperm injection) ICSI] was recorded as (i) successful (available spermatozoa for ICSI) or (ii) unsuccessful (no spermatozoa for ICSI). The decision to perform a unilateral (with limited or complete microdissection) or bilateral micro-TESE was guided by the intra-operative identification of sperm recovery (≥5 motile or non-motile sperm) from the first testicle. Overall, sperm recovery was successful in 56% (45/81) of the men. A unilateral micro-TESE was performed in 47% (38/81) of the men (based on intra-operative identification of sperm) and in 100% (38/38) of these men, spermatozoa was found on final assessment. In 42% (16/38) of the unilateral cases, a limited microdissection was performed (owing to the rapid intra-operative identification of sperm). The remaining 43 men underwent a bilateral micro-TESE and 16% (7/43) of these men had sperm identified on final assessment. The cumulative ICSI pregnancy rates (per cycle started and per embryo transfer) were 47% (21/45) and 60% (21/35), respectively, with a mean (±SD) of 1.9 ± 1.0 embryos transferred. The data demonstrate that intra-operative assessment of sperm recovery can correctly identify those men that require a unilateral micro-TESE. Moreover, the rapid identification of sperm recovery can allow some men to undergo a limited unilateral micro-TESE and avoid the need for complete testicular microdissection. © 2015 American Society of Andrology and European Academy of Andrology.

Intraoperative identification of the facial nerve by needle electromyography stimulation with a burr

PubMed Central

KHAMGUSHKEEVA, N.N.; ANIKIN, I.A.; KORNEYENKOV, A.A.

2016-01-01

The purpose of this research is to improve the safety of surgery for patients with a pathology of the middle and inner ear by preventing damage to the facial nerve by conducting intraoperative monitoring of the facial nerve by needle electromyography with continuous stimulation with a burr. Patients and Methods The clinical part of the prospective study was carried out on 48 patients that were diagnosed with suppurative otitis media. After the surgery with intraoperative monitoring, the facial nerve with an intact bone wall was stimulated electrically in the potentially dangerous places of damage. Minimum (threshold) stimulation (mA) of the facial nerve with a threshold event of 100 μV was used to register EMG events. The anatomical part of the study was carried out on 30 unformalinized cadaver temporal bones from adult bodies. The statistical analysis of obtained data was carried out with parametric methods (Student’s t-test), non-parametric correlation (Spearman’s method) and regression analysis. Results It was found that 1 mA of threshold amperage corresponded to 0.8 mm thickness of the bone wall of the facial canal. Values of transosseous threshold stimulation in potentially dangerous sections of the injury to the facial nerve were obtained. Conclusion These data lower the risk of paresis (paralysis) of the facial muscles during otologic surgery. PMID:27142821

Endoscopic Evacuation of Subdural Collections.

PubMed

Boyaci, Suat; Gumustas, Oguzhan Guven; Korkmaz, Serdar; Aksoy, Kaya

2016-01-01

Intraoperative use of the endoscope is a hot topic in neurosurgery and it gives broader visualization of critical and hardlyreached areas. Endoscope-assisted surgical approach to chronic subdural haematoma (SDH) is a minimally invasive technique and may give an expansion to the regular method of burr-hole haematoma drainage. Endoscope-assisted haematoma drainage with mini-craniotomy was performed over a 24-month period, and prospectively collected data is reviewed. A total of 10 procedures (8 patients) were performed using the endoscopeassisted technique. Four of them were chronic SDH and six were subacute SDH. Procedures were extended 20 minutes in average because of endoscopic intervention. There was no extra-morbidity through the study as a consequence of endoscopic assessment. Endoscope-assisted techniques can make the operation safe in selected circumstances with improved intraoperative visualization. It may likewise take into consideration the identification and destruction of neo-membranes, septums and solid clots. In addition, the source of bleeding can be easily coagulated. The endoscope-assisted techniques, with all of these features, can alter the pre- and intra-operative decision-making for selected patients.

Utility of Indocyanine Green Fluorescence Imaging for Intraoperative Localization in Reoperative Parathyroid Surgery.

PubMed

Sound, Sara; Okoh, Alexis; Yigitbas, Hakan; Yazici, Pinar; Berber, Eren

2015-10-27

Due to the variations in anatomic location, the identification of parathyroid glands may be challenging. Although there have been advances in preoperative imaging modalities, there is still a need for an accurate intraoperative guidance. Indocyanine green (ICG) is a new agent that has been used for intraoperative fluorescence imaging in a number of general surgical procedures. Its utility for parathyroid localization in humans has not been reported in the literature. We report 3 patients who underwent reoperative neck surgery for primary hyperparathyroidism. Using a video-assisted technique with intraoperative ICG fluorescence imaging, the parathyroid glands were recognized and removed successfully in all cases. Surrounding soft tissue structures remained nonfluorescent, and could be distinguished from the parathyroid glands. This report suggests a potential utility of ICG imaging in intraoperative localization of parathyroid glands in reoperative neck surgery. Future work is necessary to assess its benefit for first-time parathyroid surgery. © The Author(s) 2015.

Intraoperative magnetic resonance imaging to update interactive navigation in neurosurgery: method and preliminary experience.

PubMed

Wirtz, C R; Bonsanto, M M; Knauth, M; Tronnier, V M; Albert, F K; Staubert, A; Kunze, S

1997-01-01

We report on the first successful intraoperative update of interactive image guidance based on an intraoperatively acquired magnetic resonance imaging (MRI) date set. To date, intraoperative imaging methods such as ultrasound, computerized tomography (CT), or MRI have not been successfully used to update interactive navigation. We developed a method of imaging patients intraoperatively with the surgical field exposed in an MRI scanner (Magnetom Open; Siemens Corp., Erlangen, Germany). In 12 patients, intraoperatively acquired 3D data sets were used for successful recalibration of neuronavigation, accounting for any anatomical changes caused by surgical manipulations. The MKM Microscope (Zeiss Corp., Oberkochen, Germany) was used as navigational system. With implantable fiducial markers, an accuracy of 0.84 +/- 0.4 mm for intraoperative reregistration was achieved. Residual tumor detected on MRI was consequently resected using navigation with the intraoperative data. No adverse effects were observed from intraoperative imaging or the use of navigation with intraoperative images, demonstrating the feasibility of recalibrating navigation with intraoperative MRI.

Neurosurgical sapphire handheld probe for intraoperative optical diagnostics, laser coagulation and aspiration of malignant brain tissue

NASA Astrophysics Data System (ADS)

Shikunova, Irina A.; Zaytsev, Kirill I.; Stryukov, Dmitrii O.; Dubyanskaya, Evgenia N.; Kurlov, Vladimir N.

2017-07-01

In this paper, a handheld contact probe based on sapphire shaped crystal was developed for the intraoperative optical diagnosis and aspiration of malignant brain tissue combined with the laser hemostasis. Such a favorable combination of several functions in a single instrument significantly increases its clinical relevance. It makes possible highly-accurate real-time detection and removal of either large-scale malignancies or even separate invasive cancer cells. The proposed neuroprobe was integrated into the clinical neurosurgical workflow for the intraoperative fluorescence identification and removal of malignant tissues of the brain.

Navigation system for minimally invasive esophagectomy: experimental study in a porcine model.

PubMed

Nickel, Felix; Kenngott, Hannes G; Neuhaus, Jochen; Sommer, Christof M; Gehrig, Tobias; Kolb, Armin; Gondan, Matthias; Radeleff, Boris A; Schaible, Anja; Meinzer, Hans-Peter; Gutt, Carsten N; Müller-Stich, Beat-Peter

2013-10-01

Navigation systems potentially facilitate minimally invasive esophagectomy and improve patient outcome by improving intraoperative orientation, position estimation of instruments, and identification of lymph nodes and resection margins. The authors' self-developed navigation system is highly accurate in static environments. This study aimed to test the overall accuracy of the navigation system in a realistic operating room scenario and to identify the different sources of error altering accuracy. To simulate a realistic environment, a porcine model (n = 5) was used with endoscopic clips in the esophagus as navigation targets. Computed tomography imaging was followed by image segmentation and target definition with the medical imaging interaction toolkit software. Optical tracking was used for registration and localization of animals and navigation instruments. Intraoperatively, the instrument was displayed relative to segmented organs in real time. The target registration error (TRE) of the navigation system was defined as the distance between the target and the navigation instrument tip. The TRE was measured on skin targets with the animal in the 0° supine and 25° anti-Trendelenburg position and on the esophagus during laparoscopic transhiatal preparation. On skin targets, the TRE was significantly higher in the 25° position, at 14.6 ± 2.7 mm, compared with the 0° position, at 3.2 ± 1.3 mm. The TRE on the esophagus was 11.2 ± 2.4 mm. The main source of error was soft tissue deformation caused by intraoperative positioning, pneumoperitoneum, surgical manipulation, and tissue dissection. The navigation system obtained acceptable accuracy with a minimally invasive transhiatal approach to the esophagus in a realistic experimental model. Thus the system has the potential to improve intraoperative orientation, identification of lymph nodes and adequate resection margins, and visualization of risk structures. Compensation methods for soft tissue deformation may lead to an even more accurate navigation system in the future.

Ambient Mass Spectrometry in Cancer Research.

PubMed

Takats, Z; Strittmatter, N; McKenzie, J S

2017-01-01

Ambient ionization mass spectrometry was developed as a sample preparation-free alternative to traditional MS-based workflows. Desorption electrospray ionization (DESI)-MS methods were demonstrated to allow the direct analysis of a broad range of samples including unaltered biological tissue specimens. In contrast to this advantageous feature, nowadays DESI-MS is almost exclusively used for sample preparation intensive mass spectrometric imaging (MSI) in the area of cancer research. As an alternative to MALDI, DESI-MSI offers matrix deposition-free experiment with improved signal in the lower (<500m/z) range. DESI-MSI enables the spatial mapping of tumor metabolism and has been broadly demonstrated to offer an alternative to frozen section histology for intraoperative tissue identification and surgical margin assessment. Rapid evaporative ionization mass spectrometry (REIMS) was developed exclusively for the latter purpose by the direct combination of electrosurgical devices and mass spectrometry. In case of the REIMS technology, aerosol particles produced by electrosurgical dissection are subjected to MS analysis, providing spectral information on the structural lipid composition of tissues. REIMS technology was demonstrated to give real-time information on the histological nature of tissues being dissected, deeming it an ideal tool for intraoperative tissue identification including surgical margin control. More recently, the method has also been used for the rapid lipidomic phenotyping of cancer cell lines as it was demonstrated in case of the NCI-60 cell line collection. © 2017 Elsevier Inc. All rights reserved.

Improved facial nerve identification during parotidectomy with fluorescently labeled peptide.

PubMed

Hussain, Timon; Nguyen, Linda T; Whitney, Michael; Hasselmann, Jonathan; Nguyen, Quyen T

2016-12-01

Additional intraoperative guidance could reduce the risk of iatrogenic injury during parotid gland cancer surgery. We evaluated the intraoperative use of fluorescently labeled nerve binding peptide NP41 to aid facial nerve identification and preservation during parotidectomy in an orthotopic model of murine parotid gland cancer. We also quantified the accuracy of intraoperative nerve detection for surface and buried nerves in the head and neck with NP41 versus white light (WL) alone. Twenty-eight mice underwent parotid gland cancer surgeries with additional fluorescence (FL) guidance versus WL reflectance (WLR) alone. Eight mice were used for additional nerve-imaging experiments. Twenty-eight parotid tumor-bearing mice underwent parotidectomy. Eight mice underwent imaging of both sides of the face after skin removal. Postoperative assessment of facial nerve function measured by automated whisker tracking were compared between FL guidance (n = 13) versus WL alone (n=15). In eight mice, nerve to surrounding tissue contrast was measured under FL versus WLR for all nerve branches detectable in the field of view. Postoperative facial nerve function after parotid gland cancer surgery tended to be better with additional FL guidance. Fluorescent labeling significantly improved nerve to surrounding tissue contrast for both large and smaller buried nerve branches compared to WLR visualization and improved detection sensitivity and specificity. NP41 FL imaging significantly aids the intraoperative identification of nerve braches otherwise nearly invisible to the naked eye. Its application in a murine model of parotid gland cancer surgery tended to improve functional preservation of the facial nerve. NA Laryngoscope, 126:2711-2717, 2016. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Neurosurgical confocal endomicroscopy: A review of contrast agents, confocal systems, and future imaging modalities

PubMed Central

Zehri, Aqib H.; Ramey, Wyatt; Georges, Joseph F.; Mooney, Michael A.; Martirosyan, Nikolay L.; Preul, Mark C.; Nakaji, Peter

2014-01-01

Background: The clinical application of fluorescent contrast agents (fluorescein, indocyanine green, and aminolevulinic acid) with intraoperative microscopy has led to advances in intraoperative brain tumor imaging. Their properties, mechanism of action, history of use, and safety are analyzed in this report along with a review of current laser scanning confocal endomicroscopy systems. Additional imaging modalities with potential neurosurgical utility are also analyzed. Methods: A comprehensive literature search was performed utilizing PubMed and key words: In vivo confocal microscopy, confocal endomicroscopy, fluorescence imaging, in vivo diagnostics/neoplasm, in vivo molecular imaging, and optical imaging. Articles were reviewed that discussed clinically available fluorophores in neurosurgery, confocal endomicroscopy instrumentation, confocal microscopy systems, and intraoperative cancer diagnostics. Results: Current clinically available fluorescent contrast agents have specific properties that provide microscopic delineation of tumors when imaged with laser scanning confocal endomicroscopes. Other imaging modalities such as coherent anti-Stokes Raman scattering (CARS) microscopy, confocal reflectance microscopy, fluorescent lifetime imaging (FLIM), two-photon microscopy, and second harmonic generation may also have potential in neurosurgical applications. Conclusion: In addition to guiding tumor resection, intraoperative fluorescence and microscopy have the potential to facilitate tumor identification and complement frozen section analysis during surgery by providing real-time histological assessment. Further research, including clinical trials, is necessary to test the efficacy of fluorescent contrast agents and optical imaging instrumentation in order to establish their role in neurosurgery. PMID:24872922

Navigation surgery for intraoperative sentinel lymph node detection using Indocyanine green (ICG) fluorescence real-time imaging in breast cancer.

PubMed

Toh, U; Iwakuma, N; Mishima, M; Okabe, M; Nakagawa, S; Akagi, Y

2015-09-01

A new sensitive fluorescence imaging system was developed for the real-time identification of sentinel lymph nodes (SLNs) in patients with early breast cancer. The purpose of this study was to evaluate the utility of a color charge-coupled device camera system for the intraoperative detection of SLNs and to determine its clinical efficacy and sensitivity in patients with operable breast cancer. We assessed a total of 168 patients diagnosed with or suspected of having early-stage breast cancer without metastasis in SLNs. The intraoperative detection of SLNs was performed using the conventional Indigo Carmine dye (indigotindisulfonate sodium) technique combined with a new Indocyanine green (ICG) imaging system (HyperEye Medical System: HEMS, MIZUHO IKAKOGYO, Japan) to map SLNs, in which the lymphatic vessels and SLNs were visualized transcutaneously with illuminating ICG fluorescence. Between January 2012 and May 2013, SLNs were successfully identified in all 168 patients (detection rate: 100%). By histopathology, the sensitivity was 93.8% for the detection of the metastatic involvement of SLNs (15 of 16 nodal-positive patients). After a median follow-up of 30.5 months, none of the patients presented with axillary recurrence. These results suggest that the HEMS imaging system is a feasible and effective method for the detection of SLNs in breast cancer. Furthermore, the HEMS device permitted the transcutaneous visualization of lymphatic vessels under light conditions, thus facilitating the identification and detection of SLNs without affecting the surgical procedure, together with a high sensitivity and specificity.

Optimisation of fluorescence guidance during robot-assisted laparoscopic sentinel node biopsy for prostate cancer.

PubMed

KleinJan, Gijs H; van den Berg, Nynke S; Brouwer, Oscar R; de Jong, Jeroen; Acar, Cenk; Wit, Esther M; Vegt, Erik; van der Noort, Vincent; Valdés Olmos, Renato A; van Leeuwen, Fijs W B; van der Poel, Henk G

2014-12-01

The hybrid tracer was introduced to complement intraoperative radiotracing towards the sentinel nodes (SNs) with fluorescence guidance. Improve in vivo fluorescence-based SN identification for prostate cancer by optimising hybrid tracer preparation, injection technique, and fluorescence imaging hardware. Forty patients with a Briganti nomogram-based risk >10% of lymph node (LN) metastases were included. After intraprostatic tracer injection, SN mapping was performed (lymphoscintigraphy and single-photon emission computed tomography with computed tomography (SPECT-CT)). In groups 1 and 2, SNs were pursued intraoperatively using a laparoscopic gamma probe followed by fluorescence imaging (FI). In group 3, SNs were initially located via FI. Compared with group 1, in groups 2 and 3, a new tracer formulation was introduced that had a reduced total injected volume (2.0 ml vs. 3.2 ml) but increased particle concentration. For groups 1 and 2, the Tricam SLII with D-Light C laparoscopic FI (LFI) system was used. In group 3, the LFI system was upgraded to an Image 1 HUB HD with D-Light P system. Hybrid tracer-based SN biopsy, extended pelvic lymph node dissection, and robot-assisted radical prostatectomy. Number and location of the preoperatively identified SNs, in vivo fluorescence-based SN identification rate, tumour status of SNs and LNs, postoperative complications, and biochemical recurrence (BCR). Mean fluorescence-based SN identification improved from 63.7% (group 1) to 85.2% and 93.5% for groups 2 and 3, respectively (p=0.012). No differences in postoperative complications were found. BCR occurred in three pN0 patients. Stepwise optimisation of the hybrid tracer formulation and the LFI system led to a significant improvement in fluorescence-assisted SN identification. Preoperative SPECT-CT remained essential for guiding intraoperative SN localisation. Intraoperative fluorescence-based SN visualisation can be improved by enhancing the hybrid tracer formulation and laparoscopic fluorescence imaging system. Copyright © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Imaging the urinary pathways in mice by liposomal indocyanine green.

PubMed

Portnoy, Emma; Nizri, Eran; Golenser, Jacob; Shmuel, Miriam; Magdassi, Shlomo; Eyal, Sara

2015-07-01

Intraoperative ureter identification can assist in the prevention of ureteral injury and consequently improve surgery outcomes. Our aim was to take advantage of the altered pharmacokinetics of liposomal indocyanine green (ICG), the only FDA-approved near-infrared (NIR) dye, for imaging of ureters during surgeries. ICG was passively adsorbed to liposomes. NIR whole mice body and isolated tissue imaging were used to study liposomal ICG properties vs. free ICG. In vivo, the urinary bladder could be clearly observed in most of the liposome-treated mice. Liposomal encapsulation of ICG enhanced ureteral emission up to 1.9 fold compared to free ICG (P<0.01). Increase in liposomal micropolarity and microviscosity and differential scanning calorimetry supported ICG localization within the liposomal bilayer. Our findings suggest that liposomal ICG could be utilized for ureteral imaging intra-operatively, thus potentially improving surgical outcomes. Iatrogenic ureteral injury is a serious complication of abdominal surgery and intra-operative recognition of the ureters is usually the best method of injury prevention. In this article, the authors developed liposomal indocyanine green, which could be excreted via the urinary system and investigated its in-vivo use in mice. Copyright © 2015 Elsevier Inc. All rights reserved.

[Does intraoperative nerve monitoring reduce the rate of recurrent nerve palsies during thyroid surgery?].

PubMed

Timmermann, W; Dralle, H; Hamelmann, W; Thomusch, O; Sekulla, C; Meyer, Th; Timm, S; Thiede, A

2002-05-01

Two different aspects of the influence of neuromonitoring on the possible reduction of post-operative recurrent laryngeal nerve palsies require critical examination: the nerve identification and the monitoring of it's functions. Due to the additional information from the EMG signals, neuromonitoring is the best method for identifying the nerves as compared to visual identification alone. There are still no randomized studies available that compare the visual and electrophysiological recurrent laryngeal nerve detection in thyroid operations with respect to the postoperative nerve palsies. Nevertheless, comparisons with historical collectives show that a constant low nerve-palsy-rate was achieved with electrophysiological detection in comparison to visual detection. The rate of nerve identification is normally very high and amounts to 99 % in our own patients. The data obtained during the "Quality assurance of benign and malignant Goiter" study show that in hemithyreoidectomy and subtotal resection, lower nerve-palsy-rates are achieved with neuromonitoring as compared to solely visual detection. Following subtotal resection, this discrepancy becomes even statistically significant. While monitoring the nerve functions with the presently used neuromonitoring technique, it is possible to observe the EMG-signal remaining constant or decreasing in volume. Assuming that a constant neuromonitoring signal represents a normal vocal cord, our evaluation shows that there is a small percentage of false negative and positive results. Looking at the permanent recurrent nerve palsy rates, this method has a specificity of 98 %, a sensitivity of 100 %, a positive prognostic value of 10 %, and a negative prognostic value of 100 %. Although an altered neuromonitoring signal can be taken as a clear indication of eventual nerve damage, an absolutely reliable statement about the postoperative vocal cord function is presently not possible with intraoperative neuromonitoring.

Endodontic and Clinical Considerations in the Management of Variable Anatomy in Mandibular Premolars: A Literature Review

PubMed Central

Hammo, Mohammad

2014-01-01

Mandibular premolars are known to have numerous anatomic variations of their roots and root canals, which are a challenge to treat endodontically. The paper reviews literature to detail the various clinically relevant anatomic considerations with detailed techniques and methods to successfully manage these anomalies. An emphasis and detailed description of every step of treatment including preoperative diagnosis, intraoperative identification and management, and surgical endodontic considerations for the successful management of these complex cases have been included. PMID:24895584

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sinilkin, I. G.; Chernov, V. I.; Medvedeva, A. A.

The purpose of the study was to evaluate the feasibility of using {sup 99m}Tc-Al{sub 2}O{sub 3}-based radiopharmaceutical, a novel molecular imaging agent for sentinel lymph node detection in patients with invasive cervical cancer. The study included 23 cervical cancer patients (T1aNxMx-T2bNxMx) treated at the Tomsk Cancer Research Institute. In the 18 hours before surgery, 80 MBq of the {sup 99m}Tc-Al{sub 2}O{sub 3} in peritumoral injected, followed by single-photon emission computed tomography (SPECT) of the pelvis and intraoperative SLN identification. Twenty-seven SLNs were detected by SPECT, and 34 SLNs were identified by intraoperative gamma probe. The total number of identified SLNsmore » per patient ranged from 1 to 3 (the mean number of SLNs was 1.4 per patient). The most common site for SLN detection was the external iliac region (57.2%), followed by the internal iliac (14%), obturator (14%), presacral and retrosacral regions (14%), and the parametrial region (1%). Sensitivity in detecting SLNs was 100% for intraoperative SLN identification and 79% for SPECT image.« less

Robust and fast characterization of OCT-based optical attenuation using a novel frequency-domain algorithm for brain cancer detection

NASA Astrophysics Data System (ADS)

Yuan, Wu; Kut, Carmen; Liang, Wenxuan; Li, Xingde

2017-03-01

Cancer is known to alter the local optical properties of tissues. The detection of OCT-based optical attenuation provides a quantitative method to efficiently differentiate cancer from non-cancer tissues. In particular, the intraoperative use of quantitative OCT is able to provide a direct visual guidance in real time for accurate identification of cancer tissues, especially these without any obvious structural layers, such as brain cancer. However, current methods are suboptimal in providing high-speed and accurate OCT attenuation mapping for intraoperative brain cancer detection. In this paper, we report a novel frequency-domain (FD) algorithm to enable robust and fast characterization of optical attenuation as derived from OCT intensity images. The performance of this FD algorithm was compared with traditional fitting methods by analyzing datasets containing images from freshly resected human brain cancer and from a silica phantom acquired by a 1310 nm swept-source OCT (SS-OCT) system. With graphics processing unit (GPU)-based CUDA C/C++ implementation, this new attenuation mapping algorithm can offer robust and accurate quantitative interpretation of OCT images in real time during brain surgery.

Temperature-controlled optical stimulation of the rat prostate cavernous nerves

NASA Astrophysics Data System (ADS)

Tozburun, Serhat; Hutchens, Thomas C.; McClain, Michael A.; Lagoda, Gwen A.; Burnett, Arthur L.; Fried, Nathaniel M.

2013-06-01

Optical nerve stimulation (ONS) may be useful as a diagnostic tool for intraoperative identification and preservation of the prostate cavernous nerves (CN), responsible for erectile function, during prostate cancer surgery. Successful ONS requires elevating the nerve temperature to within a narrow range (˜42 to 47°C) for nerve activation without thermal damage to the nerve. This preliminary study explores a prototype temperature-controlled optical nerve stimulation (TC-ONS) system for maintaining a constant (±1°C) nerve temperature during short-term ONS of the rat prostate CNs. A 150-mW, 1455-nm diode laser was operated in continuous-wave mode, with and without temperature control, during stimulation of the rat CNs for 15 to 30 s through a fiber optic probe with a 1-mm-diameter spot. A microcontroller opened and closed an in-line mechanical shutter in response to an infrared sensor, with a predetermined temperature set point. With TC-ONS, higher laser power settings were used to rapidly and safely elevate the CNs to a temperature necessary for a fast intracavernous pressure response, while also preventing excessive temperatures that would otherwise cause thermal damage to the nerve. With further development, TC-ONS may provide a rapid, stable, and safe method for intraoperative identification and preservation of the prostate CNs.

Multispectral Fluorescence Imaging During Robot-assisted Laparoscopic Sentinel Node Biopsy: A First Step Towards a Fluorescence-based Anatomic Roadmap.

PubMed

van den Berg, Nynke S; Buckle, Tessa; KleinJan, Gijs H; van der Poel, Henk G; van Leeuwen, Fijs W B

2017-07-01

During (robot-assisted) sentinel node (SN) biopsy procedures, intraoperative fluorescence imaging can be used to enhance radioguided SN excision. For this combined pre- and intraoperative SN identification was realized using the hybrid SN tracer, indocyanine green- 99m Tc-nanocolloid. Combining this dedicated SN tracer with a lymphangiographic tracer such as fluorescein may further enhance the accuracy of SN biopsy. Clinical evaluation of a multispectral fluorescence guided surgery approach using the dedicated SN tracer ICG- 99m Tc-nanocolloid, the lymphangiographic tracer fluorescein, and a commercially available fluorescence laparoscope. Pilot study in ten patients with prostate cancer. Following ICG- 99m Tc-nanocolloid administration and preoperative lymphoscintigraphy and single-photon emission computed tomograpy imaging, the number and location of SNs were determined. Fluorescein was injected intraprostatically immediately after the patient was anesthetized. A multispectral fluorescence laparoscope was used intraoperatively to identify both fluorescent signatures. Multispectral fluorescence imaging during robot-assisted radical prostatectomy with extended pelvic lymph node dissection and SN biopsy. (1) Number and location of preoperatively identified SNs. (2) Number and location of SNs intraoperatively identified via ICG- 99m Tc-nanocolloid imaging. (3) Rate of intraoperative lymphatic duct identification via fluorescein imaging. (4) Tumor status of excised (sentinel) lymph node(s). (5) Postoperative complications and follow-up. Near-infrared fluorescence imaging of ICG- 99m Tc-nanocolloid visualized 85.3% of the SNs. In 8/10 patients, fluorescein imaging allowed bright and accurate identification of lymphatic ducts, although higher background staining and tracer washout were observed. The main limitation is the small patient population. Our findings indicate that a lymphangiographic tracer can provide additional information during SN biopsy based on ICG- 99m Tc-nanocolloid. The study suggests that multispectral fluorescence image-guided surgery is clinically feasible. We evaluated the concept of surgical fluorescence guidance using differently colored dyes that visualize complementary features. In the future this concept may provide better guidance towards diseased tissue while sparing healthy tissue, and could thus improve functional and oncologic outcomes. Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

5-Aminolevulinic acid induced fluorescence is a powerful intraoperative marker for precise histopathological grading of gliomas with non-significant contrast-enhancement.

PubMed

Widhalm, Georg; Kiesel, Barbara; Woehrer, Adelheid; Traub-Weidinger, Tatjana; Preusser, Matthias; Marosi, Christine; Prayer, Daniela; Hainfellner, Johannes A; Knosp, Engelbert; Wolfsberger, Stefan

2013-01-01

Intraoperative identification of anaplastic foci in diffusely infiltrating gliomas (DIG) with non-significant contrast-enhancement on MRI is indispensible to avoid histopathological undergrading and subsequent treatment failure. Recently, we found that 5-aminolevulinic acid (5-ALA) induced protoporphyrin IX (PpIX) fluorescence can visualize areas with increased proliferative and metabolic activity in such gliomas intraoperatively. As treatment of DIG is predominantely based on histopathological World Health Organisation (WHO) parameters, we analyzed whether PpIX fluorescence can detect anaplastic foci according to these criteria. We prospectively included DIG patients with non-significant contrast-enhancement that received 5-ALA prior to resection. Intraoperatively, multiple samples from PpIX positive and negative intratumoral areas were collected using a modified neurosurgical microscope. In all samples, histopathological WHO criteria and proliferation rate were assessed and correlated to the PpIX fluorescence status. A total of 215 tumor specimens were collected in 59 patients. Of 26 WHO grade III gliomas, 23 cases (85%) showed focal PpIX fluorescence, whereas 29 (91%) of 33 WHO grade II gliomas were PpIX negative. In intratumoral areas with focal PpIX fluorescence, mitotic rate, cell density, nuclear pleomorphism, and proliferation rate were significantly higher than in non-fluorescing areas. The positive predictive value of focal PpIX fluorescence for WHO grade III histology was 85%. Our study indicates that 5-ALA induced PpIX fluorescence is a powerful marker for intraoperative identification of anaplastic foci according to the histopathological WHO criteria in DIG with non-significant contrast-enhancement. Therefore, application of 5-ALA optimizes tissue sampling for precise histopathological diagnosis independent of brain-shift.

Ventilator waveforms on anesthesia machine: a simple tool for intraoperative mapping of phrenic nerve and mid-cervical roots.

PubMed

Georgoulis, George; Papagrigoriou, Eirini; Sindou, Marc

2015-12-01

A crucial aspect of surgery on the supraclavicular region, lateral neck, and mid-cervical vertebral region is the identification and sparing of the phrenic nerve and cervical (C4) root that are responsible for diaphragmatic innervation. Therefore intraoperative mapping of these nerve structures can be useful for difficult cases. Electrical stimulation with simultaneous observation of the ventilator waveforms of the anesthesia machine provides an effective method for the precise intraoperative mapping of these structures. In the literature, there is only one publication reporting the use of one of the waveforms (capnography) for this purpose. Capnography and pressure-time waveforms, two mandatory curves in anesthesiological monitoring, were studied under electrical stimulation of the phrenic nerve (one patient) and the C4 root (eight patients). The aim was to detect changes that would verify diaphragmatic contraction. No modifications in anesthesia or surgery and no additional maneuvers were required. In all patients, stimulation was followed by identifiable changes in the two waveforms, compatible with diaphragmatic contraction: acute reduction in amplitude on capnography and repetitive saw-like elevations on pressure-time curve. Frequency of patterns on pressure-time curve coincided with the frequency of stimulation; therefore the two recordings were complementary. This simple method proved effective in identifying the neural structures responsible for diaphragmatic function. We therefore suggest that it should be employed in the various types of surgery where these structures are at risk.

Dynamic optical projection of acquired luminescence for aiding oncologic surgery

NASA Astrophysics Data System (ADS)

Sarder, Pinaki; Gullicksrud, Kyle; Mondal, Suman; Sudlow, Gail P.; Achilefu, Samuel; Akers, Walter J.

2013-12-01

Optical imaging enables real-time visualization of intrinsic and exogenous contrast within biological tissues. Applications in human medicine have demonstrated the power of fluorescence imaging to enhance visualization in dermatology, endoscopic procedures, and open surgery. Although few optical contrast agents are available for human medicine at this time, fluorescence imaging is proving to be a powerful tool in guiding medical procedures. Recently, intraoperative detection of fluorescent molecular probes that target cell-surface receptors has been reported for improvement in oncologic surgery in humans. We have developed a novel system, optical projection of acquired luminescence (OPAL), to further enhance real-time guidance of open oncologic surgery. In this method, collected fluorescence intensity maps are projected onto the imaged surface rather than via wall-mounted display monitor. To demonstrate proof-of-principle for OPAL applications in oncologic surgery, lymphatic transport of indocyanine green was visualized in live mice for intraoperative identification of sentinel lymph nodes. Subsequently, peritoneal tumors in a murine model of breast cancer metastasis were identified using OPAL after systemic administration of a tumor-selective fluorescent molecular probe. These initial results clearly show that OPAL can enhance adoption and ease-of-use of fluorescence imaging in oncologic procedures relative to existing state-of-the-art intraoperative imaging systems.

In vivo multiphoton tomography and fluorescence lifetime imaging of human brain tumor tissue.

PubMed

Kantelhardt, Sven R; Kalasauskas, Darius; König, Karsten; Kim, Ella; Weinigel, Martin; Uchugonova, Aisada; Giese, Alf

2016-05-01

High resolution multiphoton tomography and fluorescence lifetime imaging differentiates glioma from adjacent brain in native tissue samples ex vivo. Presently, multiphoton tomography is applied in clinical dermatology and experimentally. We here present the first application of multiphoton and fluorescence lifetime imaging for in vivo imaging on humans during a neurosurgical procedure. We used a MPTflex™ Multiphoton Laser Tomograph (JenLab, Germany). We examined cultured glioma cells in an orthotopic mouse tumor model and native human tissue samples. Finally the multiphoton tomograph was applied to provide optical biopsies during resection of a clinical case of glioblastoma. All tissues imaged by multiphoton tomography were sampled and processed for conventional histopathology. The multiphoton tomograph allowed fluorescence intensity- and fluorescence lifetime imaging with submicron spatial resolution and 200 picosecond temporal resolution. Morphological fluorescence intensity imaging and fluorescence lifetime imaging of tumor-bearing mouse brains and native human tissue samples clearly differentiated tumor and adjacent brain tissue. Intraoperative imaging was found to be technically feasible. Intraoperative image quality was comparable to ex vivo examinations. To our knowledge we here present the first intraoperative application of high resolution multiphoton tomography and fluorescence lifetime imaging of human brain tumors in situ. It allowed in vivo identification and determination of cell density of tumor tissue on a cellular and subcellular level within seconds. The technology shows the potential of rapid intraoperative identification of native glioma tissue without need for tissue processing or staining.

The use of 99mTc-Al2O3 for detection of sentinel lymph nodes in cervical cancer patients

NASA Astrophysics Data System (ADS)

Sinilkin, I. G.; Chernov, V. I.; Lyapunov, A. Yu; Medvedeva, A. A.; Zelchan, R. V.; Chernyshova, A. L.; Kolomiets, L. A.

2016-06-01

The purpose of the study was to evaluate the feasibility of using 99mTc-Al2O3- based radiopharmaceutical, a novel molecular imaging agent for sentinel lymph node detection in patients with invasive cervical cancer. The study included 23 cervical cancer patients (TlaNxMx- T2bNxMx) treated at the Tomsk Cancer Research Institute. At 18 hours before surgery, 80 MBq of the 99mTc-Al2O3 were injected peritumorally, followed by single-photon emission computed tomography (SPECT) of the pelvis and intraoperative SLN identification. Twenty-seven SLNs were detected by SPECT, and 34 SLNs were identified by intraoperative gamma probe. The total number of identified SLNs per patient ranged from 1 to 3(the mean number of SLNs was 1.4 per patient). The most common site for SLN detection was the external iliac region (57.2%), followed by the internal iliac, obturator, presacral and retrosacral regions (they amounted to 14%, respectively),and the parametrial region (1%). Sensitivity in detecting SLNs was 100% for intraoperative SLN identification and 79% for SPECT image.

The first experience of using 99mTc-Al2O3-based radiopharmaceutical for the detection of sentinel lymph nodes in cervical cancer patients

NASA Astrophysics Data System (ADS)

Sinilkin, I. G.; Chernov, V. I.; Lyapunov, A. Yu.; Medvedeva, A. A.; Zelchan, R. V.; Chernyshova, A. L.; Kolomiets, L. A.

2016-08-01

The purpose of the study was to evaluate the feasibility of using 99mTc-Al2O3-based radiopharmaceutical, a novel molecular imaging agent for sentinel lymph node detection in patients with invasive cervical cancer. The study included 23 cervical cancer patients (T1aNxMx-T2bNxMx) treated at the Tomsk Cancer Research Institute. In the 18 hours before surgery, 80 MBq of the 99mTc-Al2O3 in peritumoral injected, followed by single-photon emission computed tomography (SPECT) of the pelvis and intraoperative SLN identification. Twenty-seven SLNs were detected by SPECT, and 34 SLNs were identified by intraoperative gamma probe. The total number of identified SLNs per patient ranged from 1 to 3 (the mean number of SLNs was 1.4 per patient). The most common site for SLN detection was the external iliac region (57.2%), followed by the internal iliac (14%), obturator (14%), presacral and retrosacral regions (14%), and the parametrial region (1%). Sensitivity in detecting SLNs was 100% for intraoperative SLN identification and 79% for SPECT image.

Intraoperative imaging-guided cancer surgery: from current fluorescence molecular imaging methods to future multi-modality imaging technology.

PubMed

Chi, Chongwei; Du, Yang; Ye, Jinzuo; Kou, Deqiang; Qiu, Jingdan; Wang, Jiandong; Tian, Jie; Chen, Xiaoyuan

2014-01-01

Cancer is a major threat to human health. Diagnosis and treatment using precision medicine is expected to be an effective method for preventing the initiation and progression of cancer. Although anatomical and functional imaging techniques such as radiography, computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) have played an important role for accurate preoperative diagnostics, for the most part these techniques cannot be applied intraoperatively. Optical molecular imaging is a promising technique that provides a high degree of sensitivity and specificity in tumor margin detection. Furthermore, existing clinical applications have proven that optical molecular imaging is a powerful intraoperative tool for guiding surgeons performing precision procedures, thus enabling radical resection and improved survival rates. However, detection depth limitation exists in optical molecular imaging methods and further breakthroughs from optical to multi-modality intraoperative imaging methods are needed to develop more extensive and comprehensive intraoperative applications. Here, we review the current intraoperative optical molecular imaging technologies, focusing on contrast agents and surgical navigation systems, and then discuss the future prospects of multi-modality imaging technology for intraoperative imaging-guided cancer surgery.

Intraoperative Imaging-Guided Cancer Surgery: From Current Fluorescence Molecular Imaging Methods to Future Multi-Modality Imaging Technology

PubMed Central

Chi, Chongwei; Du, Yang; Ye, Jinzuo; Kou, Deqiang; Qiu, Jingdan; Wang, Jiandong; Tian, Jie; Chen, Xiaoyuan

2014-01-01

Cancer is a major threat to human health. Diagnosis and treatment using precision medicine is expected to be an effective method for preventing the initiation and progression of cancer. Although anatomical and functional imaging techniques such as radiography, computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) have played an important role for accurate preoperative diagnostics, for the most part these techniques cannot be applied intraoperatively. Optical molecular imaging is a promising technique that provides a high degree of sensitivity and specificity in tumor margin detection. Furthermore, existing clinical applications have proven that optical molecular imaging is a powerful intraoperative tool for guiding surgeons performing precision procedures, thus enabling radical resection and improved survival rates. However, detection depth limitation exists in optical molecular imaging methods and further breakthroughs from optical to multi-modality intraoperative imaging methods are needed to develop more extensive and comprehensive intraoperative applications. Here, we review the current intraoperative optical molecular imaging technologies, focusing on contrast agents and surgical navigation systems, and then discuss the future prospects of multi-modality imaging technology for intraoperative imaging-guided cancer surgery. PMID:25250092

Identification of inferior pancreaticoduodenal artery during pancreaticoduodenectomy using augmented reality-based navigation system.

PubMed

Onda, Shinji; Okamoto, Tomoyoshi; Kanehira, Masaru; Suzuki, Fumitake; Ito, Ryusuke; Fujioka, Shuichi; Suzuki, Naoki; Hattori, Asaki; Yanaga, Katsuhiko

2014-04-01

In pancreaticoduodenectomy (PD), early ligation of the inferior pancreaticoduodenal artery (IPDA) before efferent veins has been advocated to decrease blood loss by congestion of the pancreatic head to be resected. In this study, we herein report the utility of early identification of the IPDA using an augmented reality (AR)-based navigation system (NS). Seven nonconsecutive patients underwent PD using AR-based NS. After paired-point matching registration, the reconstructed image obtained by preoperative computed tomography (CT) was fused with a real-time operative field image and displayed on 3D monitors. The vascular reconstructed images, including the superior mesenteric artery, jejunal artery, and IPDA were visualized to facilitate image-guided surgical procedures. We compared operating time and intraoperative blood loss of six patients who successfully underwent identification of IPDA using AR-based NS (group A) with nine patients who underwent early ligation of IPDA without using AR (group B) and 18 patients who underwent a conventional PD (group C). The IPDA or the jejunal artery was rapidly identified and ligated in six patients. The mean operating time and intraoperative blood loss in group A was 415 min and 901 ml, respectively. There was no significant difference in operating time and intraoperative blood loss among the groups. The AR-based NS provided precise anatomical information, which allowed the surgeons to rapidly identify and perform early ligation of IPDA in PD. © 2013 Japanese Society of Hepato-Biliary-Pancreatic Surgery.

Surgical instrument similarity metrics and tray analysis for multi-sensor instrument identification

NASA Astrophysics Data System (ADS)

Glaser, Bernhard; Schellenberg, Tobias; Franke, Stefan; Dänzer, Stefan; Neumuth, Thomas

2015-03-01

A robust identification of the instrument currently used by the surgeon is crucial for the automatic modeling and analysis of surgical procedures. Various approaches for intra-operative surgical instrument identification have been presented, mostly based on radio-frequency identification (RFID) or endoscopic video analysis. A novel approach is to identify the instruments on the instrument table of the scrub nurse with a combination of video and weight information. In a previous article, we successfully followed this approach and applied it to multiple instances of an ear, nose and throat (ENT) procedure and the surgical tray used therein. In this article, we present a metric for the suitability of the instruments of a surgical tray for identification by video and weight analysis and apply it to twelve trays of four different surgical domains (abdominal surgery, neurosurgery, orthopedics and urology). The used trays were digitized at the central sterile services department of the hospital. The results illustrate that surgical trays differ in their suitability for the approach. In general, additional weight information can significantly contribute to the successful identification of surgical instruments. Additionally, for ten different surgical instruments, ten exemplars of each instrument were tested for their weight differences. The samples indicate high weight variability in instruments with identical brand and model number. The results present a new metric for approaches aiming towards intra-operative surgical instrument detection and imply consequences for algorithms exploiting video and weight information for identification purposes.

Accurate, safe, and rapid method of intraoperative tumor identification for totally laparoscopic distal gastrectomy: injection of mixed fluid of sodium hyaluronate and patent blue.

PubMed

Nakagawa, Masatoshi; Ehara, Kazuhisa; Ueno, Masaki; Tanaka, Tsuyoshi; Kaida, Sachiko; Udagawa, Harushi

2014-04-01

In totally laparoscopic distal gastrectomy, determining the resection line with safe proximal margins is often difficult, particularly for tumors located in a relatively upper area. This is because, in contrast to open surgery, identifying lesions by palpating or opening the stomach is essentially impossible. This study introduces a useful method of tumor identification that is accurate, safe, and rapid. On the operation day, after inducing general anesthesia, a mixture of sodium hyaluronate and patent blue is injected into the submucosal layer of the proximal margin. When resecting stomach, all marker spots should be on the resected side. In all cases, the proximal margin is examined histologically by using frozen sections during the operation. From October 2009 to September 2011, a prospective study that evaluated this method was performed. A total of 34 patients who underwent totally laparoscopic distal gastrectomy were enrolled in this study. Approximately 5 min was required to complete the procedure. Proximal margins were negative in all cases, and the mean ± standard deviation length of the proximal margin was 23.5 ± 12.8 mm. No side effects, such as allergy, were encountered. As a method of tumor identification for totally laparoscopic distal gastrectomy, this procedure appears accurate, safe, and rapid.

Electrophysiological neural monitoring of the laryngeal nerves in thyroid surgery: review of the current literature

PubMed Central

Deniwar, Ahmed; Randolph, Gregory

2015-01-01

Recurrent laryngeal nerve (RLN) injury is one of the most common complications of thyroid surgery. RLN injury can cause vocal cord paralysis, affecting the patient’s voice and the quality of life. Injury of the external branch of the superior laryngeal nerve (EBSLN) can cause cricothyroid muscle denervation affecting high vocal tones. Thus, securing the laryngeal nerves in these surgeries is of utmost importance. Visual identification of the nerves has long been the standard method for this precaution. Intraoperative neuromonitoring (IONM) has been introduced as a novel technology to improve the protection of the laryngeal nerves and reduce the rate of RLN injury. The aim of this article is to provide a brief description of the technique and review the literature to illustrate the value of IONM. IONM can provide early identification of anatomical variations and unusual nerve routes, which carry a higher risk of injury if not detected. IONM helps in prognosticating postoperative nerve function. Moreover, by detecting nerve injury intraoperatively, it aids in staging bilateral surgeries to avoid bilateral vocal cord paralysis and tracheostomy. The article will discuss the value of continuous IONM (C-IOMN) that may prevent nerve injury by detecting EMG waveform changes indicating impending nerve injury. Herein, we are also discussing anatomy of laryngeal nerves and aspects of its injury. PMID:26425449

Application of Failure Mode and Effects Analysis to Intraoperative Radiation Therapy Using Mobile Electron Linear Accelerators

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ciocca, Mario, E-mail: mario.ciocca@cnao.it; Cantone, Marie-Claire; Veronese, Ivan

2012-02-01

Purpose: Failure mode and effects analysis (FMEA) represents a prospective approach for risk assessment. A multidisciplinary working group of the Italian Association for Medical Physics applied FMEA to electron beam intraoperative radiation therapy (IORT) delivered using mobile linear accelerators, aiming at preventing accidental exposures to the patient. Methods and Materials: FMEA was applied to the IORT process, for the stages of the treatment delivery and verification, and consisted of three steps: 1) identification of the involved subprocesses; 2) identification and ranking of the potential failure modes, together with their causes and effects, using the risk probability number (RPN) scoring system,more » based on the product of three parameters (severity, frequency of occurrence and detectability, each ranging from 1 to 10); 3) identification of additional safety measures to be proposed for process quality and safety improvement. RPN upper threshold for little concern of risk was set at 125. Results: Twenty-four subprocesses were identified. Ten potential failure modes were found and scored, in terms of RPN, in the range of 42-216. The most critical failure modes consisted of internal shield misalignment, wrong Monitor Unit calculation and incorrect data entry at treatment console. Potential causes of failure included shield displacement, human errors, such as underestimation of CTV extension, mainly because of lack of adequate training and time pressures, failure in the communication between operators, and machine malfunctioning. The main effects of failure were represented by CTV underdose, wrong dose distribution and/or delivery, unintended normal tissue irradiation. As additional safety measures, the utilization of a dedicated staff for IORT, double-checking of MU calculation and data entry and finally implementation of in vivo dosimetry were suggested. Conclusions: FMEA appeared as a useful tool for prospective evaluation of patient safety in radiotherapy. The application of this method to IORT lead to identify three safety measures for risk mitigation.« less

Fluorescence guided surgery and tracer-dose, fact or fiction?

PubMed

KleinJan, Gijs H; Bunschoten, Anton; van den Berg, Nynke S; Olmos, Renato A Valdès; Klop, W Martin C; Horenblas, Simon; van der Poel, Henk G; Wester, Hans-Jürgen; van Leeuwen, Fijs W B

2016-09-01

Fluorescence guidance is an upcoming methodology to improve surgical accuracy. Challenging herein is the identification of the minimum dose at which the tracer can be detected with a clinical-grade fluorescence camera. Using a hybrid tracer such as indocyanine green (ICG)-(99m)Tc-nanocolloid, it has become possible to determine the accumulation of tracer and correlate this to intraoperative fluorescence-based identification rates. In the current study, we determined the lower detection limit of tracer at which intraoperative fluorescence guidance was still feasible. Size exclusion chromatography (SEC) provided a laboratory set-up to analyze the chemical content and to simulate the migratory behavior of ICG-nanocolloid in tissue. Tracer accumulation and intraoperative fluorescence detection findings were derived from a retrospective analysis of 20 head-and-neck melanoma patients, 40 penile and 20 prostate cancer patients scheduled for sentinel node (SN) biopsy using ICG-(99m)Tc-nanocolloid. In these patients, following tracer injection, single photon emission computed tomography fused with computed tomography (SPECT/CT) was used to identify the SN(s). The percentage injected dose (% ID), the amount of ICG (in nmol), and the concentration of ICG in the SNs (in μM) was assessed for SNs detected on SPECT/CT and correlated with the intraoperative fluorescence imaging findings. SEC determined that in the hybrid tracer formulation, 41 % (standard deviation: 12 %) of ICG was present in nanocolloid-bound form. In the SNs detected using fluorescence guidance a median of 0.88 % ID was present, compared to a median of 0.25 % ID in the non-fluorescent SNs (p-value < 0.001). The % ID values could be correlated to the amount ICG in a SN (range: 0.003-10.8 nmol) and the concentration of ICG in a SN (range: 0.006-64.6 μM). The ability to provide intraoperative fluorescence guidance is dependent on the amount and concentration of the fluorescent dye accumulated in the lesion(s) of interest. Our findings indicate that intraoperative fluorescence detection with ICG is possible above a μM concentration.

An endoscopic mucosal grading system is predictive of leak in stapled rectal anastomoses.

PubMed

Sujatha-Bhaskar, Sarath; Jafari, Mehraneh D; Hanna, Mark; Koh, Christina Y; Inaba, Colette S; Mills, Steven D; Carmichael, Joseph C; Nguyen, Ninh T; Stamos, Michael J; Pigazzi, Alessio

2018-04-01

Anastomotic leak is a devastating postoperative complication following rectal anastomoses associated with significant clinical and oncological implications. As a result, there is a need for novel intraoperative methods that will help predict anastomotic leak. From 2011 to 2014, patient undergoing rectal anastomoses by colorectal surgeons at our institution underwent prospective application of intraoperative flexible endoscopy with mucosal grading. Retrospective review of patient medical records was performed. After creation of the colorectal anastomosis, application of a three-tier endoscopic mucosal grading system occurred. Grade 1 was defined as circumferentially normal appearing peri-anastomotic mucosa. Grade 2 was defined as ischemia or congestion involving <30% of either the colon or rectal mucosa. Grade 3 was defined as ischemia or congestion involving >30% of the colon or rectal mucosa or ischemia/congestion involving both sides of the staple line. From 2011 to 2014, a total of 106 patients were reviewed. Grade 1 anastomoses were created in 92 (86.7%) patients and Grade 2 anastomoses were created in 10 (9.4%) patients. All 4 (3.8%) Grade 3 patients underwent immediate intraoperative anastomosis takedown and re-creation, with subsequent re-classification as Grade 1. Demographic and comorbidity data were similar between Grade 1 and Grade 2 patients. Anastomotic leak rate for the entire cohort was 12.2%. Grade 1 patients demonstrated a leak rate of 9.4% (9/96) and Grade 2 patients demonstrated a leak rate of 40% (4/10). Multivariate logistic regression associated Grade 2 classification with an increased risk of anastomotic leak (OR 4.09, 95% CI 1.21-13.63, P = 0.023). Endoscopic mucosal grading is a feasible intraoperative technique that has a role following creation of a rectal anastomosis. Identification of a Grade 2 or Grade 3 anastomosis should provoke strong consideration for immediate intraoperative revision.

Intraoperative application of geometric three-dimensional mitral valve assessment package: a feasibility study.

PubMed

Mahmood, Feroze; Karthik, Swaminathan; Subramaniam, Balachundhar; Panzica, Peter J; Mitchell, John; Lerner, Adam B; Jervis, Karinne; Maslow, Andrew D

2008-04-01

To study the feasibility of using 3-dimensional (3D) echocardiography in the operating room for mitral valve repair or replacement surgery. To perform geometric analysis of the mitral valve before and after repair. Prospective observational study. Academic, tertiary care hospital. Consecutive patients scheduled for mitral valve surgery. Intraoperative reconstruction of 3D images of the mitral valve. One hundred and two patients had 3D analysis of their mitral valve. Successful image reconstruction was performed in 93 patients-8 patients had arrhythmias or a dilated mitral valve annulus resulting in significant artifacts. Time from acquisition to reconstruction and analysis was less than 5 minutes. Surgeon identification of mitral valve anatomy was 100% accurate. The study confirms the feasibility of performing intraoperative 3D reconstruction of the mitral valve. This data can be used for confirmation and communication of 2-dimensional data to the surgeons by obtaining a surgical view of the mitral valve. The incorporation of color-flow Doppler into these 3D images helps in identification of the commissural or perivalvular location of regurgitant orifice. With improvements in the processing power of the current generation of echocardiography equipment, it is possible to quickly acquire, reconstruct, and manipulate images to help with timely diagnosis and surgical planning.

Intraoperative sentinel node identification in early stage cervical cancer using a combination of radiolabeled albumin injection and isosulfan blue dye injection.

PubMed

Martínez-Palones, José M; Gil-Moreno, Antonio; Pérez-Benavente, María A; Roca, Isabel; Xercavins, Jordi

2004-03-01

We investigated the feasibility of sentinel lymph node identification using radioisotopic lymphatic mapping with technetium-99m-labeled human serum albumin and isosulfan blue dye injection in patients undergoing radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer. Between September 2000 and October 2002, 25 patients with cervical cancer FIGO stage I (n=24) or stage II (n=1) underwent sentinel lymph node detection with preoperative lymphoscintigraphy (technetium-99m colloid albumin injection around the tumor) and intraoperative lymphatic mapping with blue dye and a handheld or laparoscopic gamma probe. Complete pelvic or paraaortic lymphadenectomy was performed in all cases by open surgery or laparoscopic surgery. In 23 evaluable patients, a total of 51 sentinel lymph nodes were detected by lymphoscintigraphy (mean 2.21 nodes per patient). Intraoperatively, 61 sentinel lymph nodes were identified, with a mean of 2.52 nodes per patient by gamma probe and a mean of 1.94 nodes per patient after isosulfan blue injection. Forty percent of sentinel nodes were found in the interiliac region and 25% in the external iliac area. Microscopic nodal metastases (four nodes) were confirmed in 12% of cases. All these lymph nodes were previously detected as sentinel lymph nodes. The remaining 419 nodes after pelvic lymphadenectomy were histologically negative. Sentinel lymph node identification with technetium-99m-labeled nanocolloid combined with blue dye injection is feasible and showed a 100% negative predictive value, and potentially identified women in whom lymph node dissection can be avoided.

Real-Time Intraoperative Detection of Breast Cancer using Near-infrared Fluorescence Imaging and Methylene Blue

PubMed Central

Tummers, Quirijn R.J.G.; Verbeek, Floris P.R.; Schaafsma, Boudewijn E.; Boonstra, Martin C.; van der Vorst, Joost R.; Liefers, Gerrit-Jan; van de Velde, Cornelis J.H.; Frangioni, John V.; Vahrmeijer, Alexander L.

2014-01-01

Background Despite recent developments in preoperative breast cancer imaging, intraoperative localization of tumor tissue can be challenging, resulting in tumor-positive resection margins during breast-conserving surgery. Based on certain physicochemical similarities between Technetium(99mTc)-sestamibi (MIBI), a SPECT radiodiagnostic with a sensitivity of 83–90% to detect breast cancer preoperatively, and the near-infrared (NIR) fluorophore Methylene Blue (MB), we hypothesized that MB might detect breast cancer intraoperatively using NIR fluorescence imaging. Methods Twenty-four patients with breast cancer, planned for surgical resection, were included. Patients were divided in 2 administration groups, which differed with respect to the timing of MB administration. N = 12 patients per group were administered 1.0 mg/kg MB intravenously either immediately or 3 h before surgery. The mini-FLARE imaging system was used to identify the NIR fluorescent signal during surgery and on post-resected specimens transferred to the pathology department. Results were confirmed by NIR fluorescence microscopy. Results 20/24 (83%) of breast tumors (carcinoma in N=21 and ductal carcinoma in situ in N=3) were identified in the resected specimen using NIR fluorescence imaging. Patients with non-detectable tumors were significantly older. No significant relation to receptor status or tumor grade was seen. Overall tumor-to-background ratio (TBR) was 2.4 ± 0.8. There was no significant difference between TBR and background signal between administration groups. In 2/4 patients with positive resection margins, breast cancer tissue identified in the wound bed during surgery would have changed surgical management. Histology confirmed the concordance of fluorescence signal and tumor tissue. Conclusions This feasibility study demonstrated an overall breast cancer identification rate using MB of 83%, with real-time intraoperative guidance having the potential to alter patient management. PMID:24862545

Monitoring of recurrent and superior laryngeal nerve function using an Airwayscope™ during thyroid surgery.

PubMed

Ijichi, Kei; Sasano, Hiroshi; Harima, Megumi; Murakami, Shingo

2017-10-01

In thyroid surgery, intraoperative identification and preservation of the recurrent laryngeal nerve (RLN) and superior laryngeal nerve external branch (SLNEB) are crucial. Several reports have proposed that electromyography (EMG) monitoring is an acceptable adjunct for identification and preservation of the RLN. However, a limited number of hospitals have access to an EMG monitoring system. Therefore, the development of another viable monitoring method is required. The aim of the present study was to design a new RLN and SLNEB monitoring method combining an Airwayscope™ (AWS) and a facial nerve stimulator. The facial nerve-stimulating electrode stimulates the RLN or SLNEB, so that the movement of the vocal cord may be observed with an AWS. This monitoring method was performed on 10 patients with a thyroid tumor. In all the cases, RLN and SLNEB were identified and vocal cord function was preserved. All the patients exhibited normal vocal cord function following surgery. Thus, the new RLN and SLNEB monitoring method using an AWS and a facial nerve stimulator is useful in thyroid surgery, and this method may be used as a reliable and available alternative to EMG monitoring to ensure the normal function of the vocal cord.

Improved Visualization of Intracranial Vessels with Intraoperative Coregistration of Rotational Digital Subtraction Angiography and Intraoperative 3D Ultrasound

PubMed Central

Podlesek, Dino; Meyer, Tobias; Morgenstern, Ute; Schackert, Gabriele; Kirsch, Matthias

2015-01-01

Introduction Ultrasound can visualize and update the vessel status in real time during cerebral vascular surgery. We studied the depiction of parent vessels and aneurysms with a high-resolution 3D intraoperative ultrasound imaging system during aneurysm clipping using rotational digital subtraction angiography as a reference. Methods We analyzed 3D intraoperative ultrasound in 39 patients with cerebral aneurysms to visualize the aneurysm intraoperatively and the nearby vascular tree before and after clipping. Simultaneous coregistration of preoperative subtraction angiography data with 3D intraoperative ultrasound was performed to verify the anatomical assignment. Results Intraoperative ultrasound detected 35 of 43 aneurysms (81%) in 39 patients. Thirty-nine intraoperative ultrasound measurements were matched with rotational digital subtraction angiography and were successfully reconstructed during the procedure. In 7 patients, the aneurysm was partially visualized by 3D-ioUS or was not in field of view. Post-clipping intraoperative ultrasound was obtained in 26 and successfully reconstructed in 18 patients (69%) despite clip related artefacts. The overlap between 3D-ioUS aneurysm volume and preoperative rDSA aneurysm volume resulted in a mean accuracy of 0.71 (Dice coefficient). Conclusions Intraoperative coregistration of 3D intraoperative ultrasound data with preoperative rotational digital subtraction angiography is possible with high accuracy. It allows the immediate visualization of vessels beyond the microscopic field, as well as parallel assessment of blood velocity, aneurysm and vascular tree configuration. Although spatial resolution is lower than for standard angiography, the method provides an excellent vascular overview, advantageous interpretation of 3D-ioUS and immediate intraoperative feedback of the vascular status. A prerequisite for understanding vascular intraoperative ultrasound is image quality and a successful match with preoperative rotational digital subtraction angiography. PMID:25803318

A Novel Color Fluorescence Navigation System for Intraoperative Transcutaneous Lymphatic Mapping and Resection of Sentinel Lymph Nodes in Breast Cancer: Comparison with the Combination of Gamma Probe Scanning and Visible Dye Methods.

PubMed

Hokimoto, Norihiro; Sugimoto, Takeki; Namikawa, Tsutomu; Funakoshi, Taku; Oki, Toyokazu; Ogawa, Maho; Fukuhara, Hideo; Inoue, Keiji; Sato, Takayuki; Hanazaki, Kazuhiro

2018-01-01

This study evaluated the clinical efficacy of a novel imaging system (HyperEye Medical System [HEMS]; Mizuho Corp., Tokyo, Japan) that uses the near-infrared (NIR) fluorescence of indocyanine green to analyze sentinel lymph node (SLN) biopsies for the staging of breast cancer. This study enrolled 91 patients with histologically confirmed breast cancer that was clinically node negative with a tumor size <3 cm. We compared SLN identification rates between HEMS and conventional methods (gamma probe scanning using a colloidal radioisotope [RI] and a blue dye method) by analyzing the relationships of lymphatic to axillary lesions and SLNs. The identification rate of SLNs was 100% using HEMS, 97.8% using the RI method, and 95.6% using the blue dye method. Two types of lymphatic pathway (LP) were detected in 39 patients (42.9%) and also clearly identified using HEMS-captured color and NIR fluorescence. The incidence of two or more SLNs was significantly higher in patients with a two-route LP to the axilla group than in those with only one route (p < 0.001; 43.6 vs. 9.6%). The HEMS NIR fluorescence color imaging method is a promising potential modality for higher-level identification of SLNs than a standard combination of the RI and blue dye methods. © 2017 S. Karger AG, Basel.

Intraoperative optical biopsy for brain tumors using spectro-lifetime properties of intrinsic fluorophores

NASA Astrophysics Data System (ADS)

Vasefi, Fartash; Kittle, David S.; Nie, Zhaojun; Falcone, Christina; Patil, Chirag G.; Chu, Ray M.; Mamelak, Adam N.; Black, Keith L.; Butte, Pramod V.

2016-04-01

We have developed and tested a system for real-time intra-operative optical identification and classification of brain tissues using time-resolved fluorescence spectroscopy (TRFS). A supervised learning algorithm using linear discriminant analysis (LDA) employing selected intrinsic fluorescence decay temporal points in 6 spectral bands was employed to maximize statistical significance difference between training groups. The linear discriminant analysis on in vivo human tissues obtained by TRFS measurements (N = 35) were validated by histopathologic analysis and neuronavigation correlation to pre-operative MRI images. These results demonstrate that TRFS can differentiate between normal cortex, white matter and glioma.

Identification of disappearing brain lesions with intraoperative magnetic resonance imaging prevents surgery.

PubMed

Sutherland, Christina S; Kelly, John Jp; Morrish, William; Sutherland, Garnette R

2010-10-01

Typically, neurosurgery is performed several weeks after diagnostic imaging. In the majority of cases, histopathology confirms the diagnosis of neoplasia. In a small number of cases, a different diagnosis is established or histopathology is nondiagnostic. The frequency with which these outcomes occur has not been established. To determine the frequency and outcome of disappearing brain lesions within a group of patients undergoing surgery for suspected brain tumor. Over the past decade, 982 patients were managed in the intraoperative magnetic resonance imaging unit at the University of Calgary, Calgary, Alberta, Canada. These patients have been prospectively evaluated. In 652 patients, a brain tumor was suspected. In 6 of the 652 patients, histopathology indicated a nontumor diagnosis. In 5 patients, intraoperative images, acquired after induction of anesthesia, showed complete or nearly complete resolution of the suspected tumor identified on diagnostic magnetic resonance imaging acquired 6 ± 4 (mean ± SD) weeks previously. Anesthesia was reversed, and the surgical procedure aborted. The lesions have not progressed with 6 ± 2 years of follow-up. Intraoperative magnetic resonance imaging prevented surgery on 5 patients with disappearing lesions.

Intraoperative Subcortical Electrical Mapping of the Optic Tract in Awake Surgery Using a Virtual Reality Headset.

PubMed

Mazerand, Edouard; Le Renard, Marc; Hue, Sophie; Lemée, Jean-Michel; Klinger, Evelyne; Menei, Philippe

2017-01-01

Brain mapping during awake craniotomy is a well-known technique to preserve neurological functions, especially the language. It is still challenging to map the optic radiations due to the difficulty to test the visual field intraoperatively. To assess the visual field during awake craniotomy, we developed the Functions' Explorer based on a virtual reality headset (FEX-VRH). The impaired visual field of 10 patients was tested with automated perimetry (the gold standard examination) and the FEX-VRH. The proof-of-concept test was done during the surgery performed on a patient who was blind in his right eye and presenting with a left parietotemporal glioblastoma. The FEX-VRH was used intraoperatively, simultaneously with direct subcortical electrostimulation, allowing identification and preservation of the optic radiations. The FEX-VRH detected 9 of the 10 visual field defects found by automated perimetry. The patient who underwent an awake craniotomy with intraoperative mapping of the optic tract using the FEX-VRH had no permanent postoperative visual field defect. Intraoperative visual field assessment with the FEX-VRH during direct subcortical electrostimulation is a promising approach to mapping the optical radiations and preventing a permanent visual field defect during awake surgery for epilepsy or tumor. Copyright © 2016 Elsevier Inc. All rights reserved.

Intraoperative endoscopic ultrasound guidance for laparoscopic excision of invisible symptomatic deep intramural myomas.

PubMed

Urman, Bulent; Boza, Aysen; Ata, Baris; Aksu, Sertan; Arslan, Tonguc; Taskiran, Cagatay

2018-01-01

The aim of this study was to evaluate the feasibility of intraoperative endoscopic ultrasound guidance for excision of symptomatic deep intramural myomas that are not otherwise visible at laparoscopy. Seventeen patients with symptomatic deep intramural myomas who underwent laparoscopic myomectomy with intraoperative endoscopic ultrasound guidance were followed up and reported. All myomas were removed successfully. The endometrium was breached in one patient. All patients were relieved of their symptoms and three patients presenting with infertility conceived. There were no short- or long-term complications associated with the procedure. One patient who had multiple myomas necessitated intravenous iron treatment prior to discharge. Laparoscopic removal of small symptomatic deep intramural myomas is facilitated by the use of intraoperative endoscopic ultrasound that enables exact localisation and correct placement of the serosal incision. Impact statement What is already known on this subject: When the myoma is symptomatic, compressing the endometrium, does not show serosal protrusion and is not amenable to hysteroscopic resection, laparoscopic surgery may become challenging. What do the results of this study add: The use of intraoperative endoscopic ultrasound under these circumstances may facilitate the procedure by accurate identification of the myoma and correct placement of the serosal incision. What are the implications of these findings for clinical practice and/or further research: Intraoperative ultrasound should be more oftenly used to accurately locate deep intramural myomas to the end of making laparoscopy feasible and possibly decreasing recurrence by facilitating removal of otherwise unidentifiable disease.

VISUALIZATION FROM INTRAOPERATIVE SWEPT-SOURCE MICROSCOPE-INTEGRATED OPTICAL COHERENCE TOMOGRAPHY IN VITRECTOMY FOR COMPLICATIONS OF PROLIFERATIVE DIABETIC RETINOPATHY.

PubMed

Gabr, Hesham; Chen, Xi; Zevallos-Carrasco, Oscar M; Viehland, Christian; Dandrige, Alexandria; Sarin, Neeru; Mahmoud, Tamer H; Vajzovic, Lejla; Izatt, Joseph A; Toth, Cynthia A

2018-01-10

To evaluate the use of live volumetric (4D) intraoperative swept-source microscope-integrated optical coherence tomography in vitrectomy for proliferative diabetic retinopathy complications. In this prospective study, we analyzed a subgroup of patients with proliferative diabetic retinopathy complications who required vitrectomy and who were imaged by the research swept-source microscope-integrated optical coherence tomography system. In near real time, images were displayed in stereo heads-up display facilitating intraoperative surgeon feedback. Postoperative review included scoring image quality, identifying different diabetic retinopathy-associated pathologies and reviewing the intraoperatively documented surgeon feedback. Twenty eyes were included. Indications for vitrectomy were tractional retinal detachment (16 eyes), combined tractional-rhegmatogenous retinal detachment (2 eyes), and vitreous hemorrhage (2 eyes). Useful, good-quality 2D (B-scans) and 4D images were obtained in 16/20 eyes (80%). In these eyes, multiple diabetic retinopathy complications could be imaged. Swept-source microscope-integrated optical coherence tomography provided surgical guidance, e.g., in identifying dissection planes under fibrovascular membranes, and in determining residual membranes and traction that would benefit from additional peeling. In 4/20 eyes (20%), acceptable images were captured, but they were not useful due to high tractional retinal detachment elevation which was challenging for imaging. Swept-source microscope-integrated optical coherence tomography can provide important guidance during surgery for proliferative diabetic retinopathy complications through intraoperative identification of different complications and facilitation of intraoperative decision making.

Dense soft tissue 3D reconstruction refined with super-pixel segmentation for robotic abdominal surgery.

PubMed

Penza, Veronica; Ortiz, Jesús; Mattos, Leonardo S; Forgione, Antonello; De Momi, Elena

2016-02-01

Single-incision laparoscopic surgery decreases postoperative infections, but introduces limitations in the surgeon's maneuverability and in the surgical field of view. This work aims at enhancing intra-operative surgical visualization by exploiting the 3D information about the surgical site. An interactive guidance system is proposed wherein the pose of preoperative tissue models is updated online. A critical process involves the intra-operative acquisition of tissue surfaces. It can be achieved using stereoscopic imaging and 3D reconstruction techniques. This work contributes to this process by proposing new methods for improved dense 3D reconstruction of soft tissues, which allows a more accurate deformation identification and facilitates the registration process. Two methods for soft tissue 3D reconstruction are proposed: Method 1 follows the traditional approach of the block matching algorithm. Method 2 performs a nonparametric modified census transform to be more robust to illumination variation. The simple linear iterative clustering (SLIC) super-pixel algorithm is exploited for disparity refinement by filling holes in the disparity images. The methods were validated using two video datasets from the Hamlyn Centre, achieving an accuracy of 2.95 and 1.66 mm, respectively. A comparison with ground-truth data demonstrated the disparity refinement procedure: (1) increases the number of reconstructed points by up to 43 % and (2) does not affect the accuracy of the 3D reconstructions significantly. Both methods give results that compare favorably with the state-of-the-art methods. The computational time constraints their applicability in real time, but can be greatly improved by using a GPU implementation.

Real-time Fluorescence Image-Guided Oncologic Surgery

PubMed Central

Mondal, Suman B.; Gao, Shengkui; Zhu, Nan; Liang, Rongguang; Gruev, Viktor; Achilefu, Samuel

2014-01-01

Medical imaging plays a critical role in cancer diagnosis and planning. Many of these patients rely on surgical intervention for curative outcomes. This requires a careful identification of the primary and microscopic tumors, and the complete removal of cancer. Although there have been efforts to adapt traditional imaging modalities for intraoperative image guidance, they suffer from several constraints such as large hardware footprint, high operation cost, and disruption of the surgical workflow. Because of the ease of image acquisition, relatively low cost devices and intuitive operation, optical imaging methods have received tremendous interests for use in real-time image-guided surgery. To improve imaging depth under low interference by tissue autofluorescence, many of these applications utilize light in the near-infra red (NIR) wavelengths, which is invisible to human eyes. With the availability of a wide selection of tumor-avid contrast agents, advancements in imaging sensors, electronic and optical designs, surgeons are able to combine different attributes of NIR optical imaging techniques to improve treatment outcomes. The emergence of diverse commercial and experimental image guidance systems, which are in various stages of clinical translation, attests to the potential high impact of intraoperative optical imaging methods to improve speed of oncologic surgery with high accuracy and minimal margin positivity. PMID:25287689

[BILIARY HYPERTENSION IN CHRONIC PANCREATITIS AND PECULIARITIES OF ITS DIAGNOSIS].

PubMed

Kopchak, V M; Pylypchuk, V I; Khomyak, I V; Pererva, L O; Shevkolenko, G G; Davydenko, N G

2016-02-01

Possibilities of various diagnostic methods for biliary hypertension detection in chronic pancreatitis were analyzed. Biliary hypertension was revealed in 163 (31%) patients, suffering chronic pancreatitis. The laboratory investigations data, ultrasonographic investigation, computer tomography, endoscopic retrograde cholangiopancreatography, magnet-resonance cholangiopancreatography, intraoperative measurement of the biliary ducts width, intraoperative measurement of biliary pressure were applied for diagnosis. Endoscopic retrograde cholangiopancreatography, magnet-resonance cholangiopancreatography and intraoperative measurement of biliary pressure are considered the most sensitive methods for chronic pancreatitis diagnosis.

Intraoperative Near-Infrared Fluorescence Imaging using indocyanine green in colorectal carcinomatosis surgery: Proof of concept.

PubMed

Barabino, G; Klein, J P; Porcheron, J; Grichine, A; Coll, J-L; Cottier, M

2016-12-01

This study assesses the value of using Intraoperative Near Infrared Fluorescence Imaging and Indocyanine green to detect colorectal carcinomatosis during oncological surgery. In colorectal carcinomatosis cancer, two of the most important prognostic factors are completeness of staging and completeness of cytoreductive surgery. Presently, intraoperative assessment of tumoral margins relies on palpation and visual inspection. The recent introduction of Near Infrared fluorescence image guidance provides new opportunities for surgical roles, particularly in cancer surgery. The study was a non-randomized, monocentric, pilot "ex vivo" blinded clinical trial validated by the ethical committee of University Hospital of Saint Etienne. Ten patients with colorectal carcinomatosis cancer scheduled for cytoreductive surgery were included. Patients received 0.25 mg/kg of Indocyanine green intravenously 24 h before surgery. A Near Infrared camera was used to detect "ex-vivo" fluorescent lesions. There was no surgical mortality. Each analysis was done blindly. In a total of 88 lesions analyzed, 58 were classified by a pathologist as cancerous and 30 as non-cancerous. Among the 58 cancerous lesions, 42 were correctly classified by the Intraoperative Near-Infrared camera (sensitivity of 72.4%). Among the 30 non-cancerous lesions, 18 were correctly classified by the Intraoperative Near-Infrared camera (specificity of 60.0%). Near Infrared fluorescence imaging is a promising technique for intraoperative tumor identification. It could help the surgeon to determine resection margins and reduce the risk of locoregional recurrence. Copyright © 2016 Elsevier Ltd, BASO ~ the Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Assistance of intraoperative microvascular Doppler in the surgical obliteration of spinal dural arteriovenous fistula: cases description and technical considerations.

PubMed

Iacopino, D G; Conti, A; Giusa, M; Cardali, S; Tomasello, F

2003-02-01

Intraoperative microvascular Doppler may be valuable in assisting in the surgical obliteration of dural arteriovenous fistula of the spinal cord. It enables identification, through flow spectrum analysis, of the anatomic components and haemodynamic features of this type of vascular malformation. In two cases, intraoperative microvascular Doppler was used to assist in the surgical obliteration of dural arteriovenous fistula of the spinal cord. The fistulas were identified prior to the dura opening, and for this only minimally invasive surgery was required. Direct recordings of the arterialised draining vein and the nidus of the fistula demonstrated a pathological spectrum caused by the arterial supply and the disturbed venous outflow in which a high-resistance flow pattern and low diastolic flow resembling an arterial-like flow velocity were observed. The fistulas were obliterated by interruption of the draining vein, and Doppler measurements provided information on flow velocity changes in the medullary veins from an arterial to a venous pattern. The absence of any residual flow in the draining vein confirmed successful haemodynamic treatment. Intraoperative microvascular Doppler recording is valuable assistance in surgical closure of spinal arteriovenous fistula.

[Vocal cord paralysis after thyroid surgery : Current medicolegal aspects of intraoperative neuromonitoring].

PubMed

Dralle, H; Schneider, R; Lorenz, K; Phuong, N Thanh; Sekulla, C; Machens, A

2015-07-01

Intraoperative neuromonitoring (IONM) has been commercially available for approximately 15 years and is highly predictive in thyroid gland surgery concerning either postoperative vocal fold mobility in the case of an intact signal for muscle action electromyogram (EMG, > 99 % right negative) or vocal fold dysfunction in the case of loss of signal (> 70 % right positive). The use of IONM improves the intraoperative identification of recurrent laryngeal nerve function and due to the high predictive value with respect to the expected vocal cord function the result of IONM has to be integrated into the surgical concept of thyroidectomy. Unilateral loss of function of the recurrent laryngeal nerve cannot be completely avoided despite correct application of IONM; however, bilateral vocal fold palsy can be safely avoided when contralateral surgery is cancelled after a loss of signal occurs during resection of the first side in planned bilateral surgery (alternative strategy). Patients have to be informed preoperatively about the limitations of IONM and potential strategy changes during planned bilateral surgery. Surgeons should apply IONM according to the published current recommendations and by selecting a risk-oriented intraoperative strategy in the case of loss of signal from the recurrent laryngeal nerve.

Comparison of Intraoperatively Built Custom Linked Seeds Versus Loose Seed Gun Applicator Technique Using Real-Time Intraoperative Planning for Permanent Prostate Brachytherapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zauls, A. Jason; Ashenafi, Michael S.; Onicescu, Georgiana

2011-11-15

Purpose: To report our dosimetric results using a novel push-button seed delivery system that constructs custom links of seeds intraoperatively. Methods and Materials: From 2005 to 2007, 43 patients underwent implantation using a gun applicator (GA), and from 2007 to 2008, 48 patientsunderwent implantation with a novel technique allowing creation of intraoperatively built custom links of seeds (IBCL). Specific endpoint analyses were prostate D90% (pD90%), rV100% > 1.3 cc, and overall time under anesthesia. Results: Final analyses included 91 patients, 43 GA and 48 IBCL. Absolute change in pD90% ({Delta}pD90%) between intraoperative and postoperative plans was evaluated. Using GA method,more » the {Delta}pD90% was -8.1Gy and -12.8Gy for I-125 and Pd-103 implants, respectively. Similarly, the IBCL technique resulted in a {Delta}pD90% of -8.7Gy and -9.8Gy for I-125 and Pd-103 implants, respectively. No statistically significant difference in {Delta}pD90% was found comparing methods. The GA method had two intraoperative and 10 postoperative rV100% >1.3 cc. For IBCL, five intraoperative and eight postoperative plans had rV100% >1.3 cc. For GA, the mean time under anesthesia was 75 min and 87 min for Pd-103 and I-125 implants, respectively. For IBCL, the mean time was 86 and 98 min for Pd-103 and I-125. There was a statistical difference between the methods when comparing mean time under anesthesia. Conclusions: Dosimetrically relevant endpoints were equivalent between the two methods. Currently, time under anesthesia is longer using the IBCL technique but has decreased over time. IBCL is a straightforward brachytherapy technique that can be implemented into clinical practice as an alternative to gun applicators.« less

Intraoperative laparoscopic complications for urological cancer procedures

PubMed Central

Montes, Sergio Fernández-Pello; Rodríguez, Ivan Gonzalez; Ugarteburu, Rodrigo Gil; Villamil, Luis Rodríguez; Mendez, Begoña Diaz; Gil, Patricio Suarez; Madera, Javier Mosquera

2015-01-01

AIM: To structure the rate of intraoperative complications that requires an intraoperative or perioperative resolution. METHODS: We perform a literature review of Medline database. The research was focused on intraoperative laparoscopic procedures inside the field of urological oncology. General rate of perioperative complications in laparoscopic urologic surgery is described to be around 12.4%. Most of the manuscripts published do not make differences between pure intraoperative, intraoperative with postoperative consequences and postoperative complications. RESULTS: We expose a narrative statement of complications, possible solutions and possible preventions for most frequent retroperitoneal and pelvic laparoscopic surgery. We expose the results with the following order: retroperitoneal laparoscopic surgery (radical nephrectomy, partial nephrectomy, nephroureterectomy and adrenalectomy) and pelvic laparoscopic surgery (radical prostatectomy and radical cystectomy). CONCLUSION: Intraoperative complications vary from different series. More scheduled reports should be done in order to better understand the real rates of complications. PMID:25984519

Analysis of the Istanbul Forensic Medicine Institute expert decisions on recurrent laryngeal nerve injuries due to thyroidectomy between 2008–2012

PubMed Central

Karakaya, M. Arif; Koç, Okay; Ekiz, Feza; Ağaçhan, A. Feran; Göret, Nuri Emrah

2016-01-01

Objective: The aim of this study was to evaluate the approach of Forensic Medicine Institution for recurrent laryngeal nerve injuries. In addition, parameters that were taken into consideration by Forensic Medicine Institution in the differentiation of complication and malpractice were evaluated. Material and Methods: The files of 38 patients, with recurrent laryngeal nerve injury following thyroidectomy, that were referred to Istanbul Forensic Medicine Institute with request of expert opinion between 2008–2012 were retrospectively investigated. Data regarding expert decisions, age, gender, diagnosis, hospital type, preoperative vocal cord examination, intraoperative nerve monitoring (IONM), identification of nerve injury during operation, repair of nerve during operation, and type of injury were assessed. Results: Surgeons were found to be faulty in all files with bilateral nerve injury, however, one-sided injury files were considered as a medical complication. Twenty-one (55.2%) patients were female, and 17 (44.8%) were male, with a mean age of 35,8 in women, and 34,1 in men. None of these patients had undergone preoperative vocal cord assessment. The recurrent laryngeal nerve was intraoperatively identified in 21 (55.2%) patients, while it was not seen in 17 (44.8%) patients. IONM was not applied in any patients. There was no attempt for nerve repair during any operation. Nineteen patients had unilateral, and 19 patients had bilateral nerve damage. Conclusion: Bilateral recurrent laryngeal nerve injuries are considered as malpractice, when imaging or pathology reports fail to state a cause for difficulty in nerve identification. PMID:26985157

Near-infrared intraoperative imaging during resection of an anterior mediastinal soft tissue sarcoma.

PubMed

Predina, Jarrod D; Newton, Andrew D; Desphande, Charuhas; Singhal, Sunil

2018-01-01

Sarcomas are rare malignancies that are generally treated with multimodal therapy protocols incorporating complete local resection, chemotherapy and radiation. Unfortunately, even with this aggressive approach, local recurrences are common. Near-infrared intraoperative imaging is a novel technology that provides real-time visual feedback that can improve identification of disease during resection. The presented study describes utilization of a near-infrared agent (indocyanine green) during resection of an anterior mediastinal sarcoma. Real-time fluorescent feedback provided visual information that helped the surgeon during tumor localization, margin assessment and dissection from mediastinal structures. This rapidly evolving technology may prove useful in patients with primary sarcomas arising from other locations or with other mediastinal neoplasms.

Effect of intraoperative neuromonitoring on recurrent laryngeal nerve palsy rates after thyroid surgery--a meta-analysis.

PubMed

Zheng, Shixing; Xu, Zhiwen; Wei, Yuanyuan; Zeng, Manli; He, Jinnian

2013-08-01

Though intraoperative nerve monitoring (IONM) during thyroid surgery has gained universal acceptance for localizing and identifying the recurrent laryngeal nerve (RLN), its role in reducing the rate of RLN injury remains controversial. In order to assess the effect of IONM during thyroid surgery, its value in reducing the incidence of RLN palsy was systematically evaluated. Studies were evaluated for inclusion in this analysis by researching PubMed, Embase, the Cochrane Central Register of Controlled Trials, and the references of included studies. The initial screening of article titles and abstracts was independently performed by five reviewers based on the research protocol criteria. Each article was then read in detail and discussed before inclusion in the meta-analysis. Data were independently extracted, including the level of evidence, number of at-risk nerves, allocation method, baseline equivalence between groups, definitions of transient and permanent vocal fold palsy, systematic application of electrodes, etc. The meta-analysis was then performed. Odds ratios were pooled using a random effects model. Five randomized clinical trials and 12 comparative trials evaluating 36,487 at-risk nerves were included. Statistically significant differences in terms of total recurrent laryngeal nerve palsy (3.37% with intraoperative nerve monitoring [IONM] vs. 3.76% without IONM [OR: 0.74; 95% confidence interval [CI]: 0.59-0.92]) and transient recurrent laryngeal nerve palsy (2.56% with IONM vs. 2.71% without IONM [OR: 0.80; 95% CI: 0.65-0.99]) were identified. The persistent incidence of recurrent laryngeal nerve palsy was 0.78% for IONM versus 0.96% for nerve identification alone (OR: 0.80; 95% CI: 0.62-1.03). Based on this meta-analysis, statistically significant differences were determined in terms of the incidences of total and transient recurrent laryngeal nerve palsy after using IONM versus recurrent laryngeal nerve identification alone during thyroidectomy. However, no statistically significant differences were identified regarding the incidence of persistent recurrent laryngeal nerve palsy between groups. Copyright © 2012. Published by Elsevier B.V.

Detection and identification of oral anaerobes in intraoperative bronchial fluids of patients with pulmonary carcinoma.

PubMed

Hasegawa, Ayako; Sato, Takuichi; Hoshikawa, Yasushi; Ishida, Naoko; Tanda, Naoko; Kawamura, Yoshiaki; Kondo, Takashi; Takahashi, Nobuhiro

2014-07-01

Postoperative pneumonia may occur when upper respiratory tract protective reflexes such as cough and/or swallowing reflexes are impaired; thus, silent aspiration of oral bacteria may be a causative factor in postoperative pneumonia. This study aimed to quantify and identify bacteria in intraoperative bronchial fluids and to evaluate the relationship between impairment of cough/swallowing reflexes and silent aspiration of oral bacteria in elderly patients. After obtaining informed consent, cough and swallowing reflexes were assessed using an ultrasonic nebulizer and a nasal catheter, respectively. Using a micro-sampling probe, intraoperative bronchial fluids were collected from nine subjects with pulmonary carcinoma and cultured anaerobically on blood agar plates. After 7 days, CFUs were counted and isolated bacteria were identified by 16S rRNA gene sequencing. Four subjects (aged 71.0 ± 8.4 years) had impaired swallowing reflexes with normal cough reflexes, whereas five subjects (73.6 ± 6.5 years) had normal cough and swallowing reflexes. The bacterial counts (mean CFU ± SD) tended to be higher in intraoperative bronchial fluids of subjects with impaired swallowing reflexes ([5.1 ± 7.7] × 10(5)) than in those of subjects with normal reflexes ([1.2 ± 1.9] × 10(5)); however, this difference was not statistically significant. Predominant isolates from intraoperative bronchial fluids were Streptococcus (41.8%), Veillonella (11.4%), Gemella (8.9%), Porphyromonas (7.6%), Olsenella (6.3%) and Eikenella (6.3%). These findings indicate that intraoperative bronchial fluids contain bacteria, probably derived from the oral microbiota, and suggest that silent aspiration of oral bacteria occurs in elderly patients irrespective of impairment of swallowing reflex. © 2014 The Societies and Wiley Publishing Asia Pty Ltd.

Multimodal Approach for Radical Excision of Focal Cortical Dysplasia by Combining Advanced Magnetic Resonance Imaging Data to Intraoperative Ultrasound, Electrocorticography, and Cortical Stimulation: A Preliminary Experience.

PubMed

Tringali, Giovanni; Bono, Beatrice; Dones, Ivano; Cordella, Roberto; Didato, Giuseppe; Villani, Flavio; Prada, Francesco

2018-05-01

Type II focal cortical dysplasia is the most common malformation of cortical development associated with drug resistant epilepsy and susceptible to surgical resection. Although, at present, advanced imaging modalities are capable of detecting most cortical disorders, it is still a challenge for the surgeon to visualize them intraoperatively. The lack of direct identification between normal brain and subtle dysplastic tissue may explain the poor results in terms of being seizure-free versus other forms of epilepsy. The aim of this study is to compare magnetic resonance imaging (MRI) and intraoperative ultrasound-guided neuronavigation, along with cortical stimulation and acute electrocorticography, as a multimodal surgical approach to cortical dysplasia's tailored resection. Six consecutive patients with type II cortical dysplasia underwent epilepsy surgery by means of MRI/intraoperative ultrasound-guided neuronavigation. Intraoperative cortical stimulation of sensory/motor cortex was performed to localize cortical eloquent areas. Acute electrocorticography was used to identify epileptogenic tissue. These findings were correlated to real-time ultrasound imaging to establish the extent of the resection. Intraoperative ultrasound depicted cortical dysplasias at a higher resolution and accuracy than MRI. Therefore it maximized the extent of the resection. Both postoperative MRIs and pathology documented the extent of the resection in all patients. Seizure-freedom was achieved in 5 cases (Engel class IA), and in 1 patient it was classified as Engel class IB. No postoperative neurological deficits were observed. These results strongly suggest feasibility of ultrasound-guided resection of focal cortical dysplasia. Providing high resolution and accuracy, it allows an easy, real-time discrimination between normal and dysplastic brain. Copyright © 2018 Elsevier Inc. All rights reserved.

Classifying multiple types of hand motions using electrocorticography during intraoperative awake craniotomy and seizure monitoring processes—case studies

PubMed Central

Xie, Tao; Zhang, Dingguo; Wu, Zehan; Chen, Liang; Zhu, Xiangyang

2015-01-01

In this work, some case studies were conducted to classify several kinds of hand motions from electrocorticography (ECoG) signals during intraoperative awake craniotomy & extraoperative seizure monitoring processes. Four subjects (P1, P2 with intractable epilepsy during seizure monitoring and P3, P4 with brain tumor during awake craniotomy) participated in the experiments. Subjects performed three types of hand motions (Grasp, Thumb-finger motion and Index-finger motion) contralateral to the motor cortex covered with ECoG electrodes. Two methods were used for signal processing. Method I: autoregressive (AR) model with burg method was applied to extract features, and additional waveform length (WL) feature has been considered, finally the linear discriminative analysis (LDA) was used as the classifier. Method II: stationary subspace analysis (SSA) was applied for data preprocessing, and the common spatial pattern (CSP) was used for feature extraction before LDA decoding process. Applying method I, the three-class accuracy of P1~P4 were 90.17, 96.00, 91.77, and 92.95% respectively. For method II, the three-class accuracy of P1~P4 were 72.00, 93.17, 95.22, and 90.36% respectively. This study verified the possibility of decoding multiple hand motion types during an awake craniotomy, which is the first step toward dexterous neuroprosthetic control during surgical implantation, in order to verify the optimal placement of electrodes. The accuracy during awake craniotomy was comparable to results during seizure monitoring. This study also indicated that ECoG was a promising approach for precise identification of eloquent cortex during awake craniotomy, and might form a promising BCI system that could benefit both patients and neurosurgeons. PMID:26483627

Intra-operative visualization of brain tumors with 5-aminolevulinic acid-induced fluorescence.

PubMed

Widhalm, Georg

2014-01-01

Precise histopathological diagnosis of brain tumors is essential for the correct patient management. Furthermore, complete resection of brain tumors is associated with an improved patient prognosis. However, histopathological undergrading and incomplete tumor removal are not uncommon, especially due to insufficient intra-operative visualization of brain tumor tissue. The fluorescent dye 5-aminolevulinic acid (5-ALA) is currently applied for fluorescence-guided resections of high-grade gliomas. The value of 5-ALA-induced protoporphyrin (PpIX) fluorescence for intra-operative visualization of other tumors than high-grade gliomas remains unclear. Within the frame of this thesis, we found a significantly higher rate of complete resections of our high-grade gliomas as compared to control cases by using the newly established 5-ALA fluorescence technology at our department. Additionally, we showed that MRI spectroscopy-based chemical shift imaging (CSI) is capable to identify intratumoral high-grade glioma areas (= anaplastic foci) during navigation guided resections to avoid histopathological undergrading. However, the accuracy of navigation systems with integrated pre-operative imaging data such as CSI declines during resections due to intra-operative brainshift. In two further studies, we found that 5-ALA induced PpIX fluorescence is capable as a novel intra-operative marker to detect anaplastic foci within initially suspected low-grade gliomas independent of brainshift. Finally, we showed that the application of 5-ALA is also of relevance in needle biopsies for intra-operative identification of representative brain tumor tissue. These data indicate that 5-ALA is not only of major importance for resection of high-grade gliomas, but also for intra-operative visualization of anaplastic foci as well as representative brain tumor tissue in needle biopsies unaffected by brainshift. Consequently, this new technique might become a novel standard in brain tumor surgery that optimizes the patient management and improves the patient prognosis by maximizing the extent of tumor resection and enabling a precise histopathological tumor diagnosis.

A new technique of laparoscopic cholangiography.

PubMed

Hagan, K D; Rosemurgy, A S; Albrink, M H; Carey, L C

1992-04-01

With the advent and rapid proliferation of laparoscopic cholecystectomy, numerous techniques and "tips" have been described. Intraoperative cholangiography during laparoscopic cholecystectomy can be tedious, frustrating, and time consuming. Described herein is a technique of intraoperative cholangiography during laparoscopic cholecystectomy which has proven to be easy, fast, and succinct. This method utilizes a rigid cholangiogram catheter which is placed into the peritoneal cavity through a small additional puncture site. This catheter is easily inserted into the cystic duct by extracorporeal manipulation. We suggest this method to surgeons who have shared our prior frustration with intraoperative cholangiography.

Intraoperative tremor in surgeons and trainees.

PubMed

Verrelli, David I; Qian, Yi; Wilson, Michael K; Wood, James; Savage, Craig

2016-09-01

Tremor may be expected to interfere with the performance of fine motor tasks such as surgery. While tremor is readily quantified in inactive subjects, it is more challenging to measure tremor as the subjects perform complex tasks. The objective of this work was to quantify tremor during the performance of a realistic simulated surgery. Our novel surgical simulator incorporates a force sensor that allows identification and quantification of the intraoperative effects of tremor on the manipulandum. We have collected preliminary data from trainees and experienced surgeons carrying out multiple simulated anastomoses on silicone vessels, mimicking a procedure such as distal coronary anastomosis. We calculated transient and overall tremor intensity, and tested for a hypothesized 'learning effect'. Several of the recordings of intraoperative force data manifested distinctive features corresponding to substantial oscillation in the range of 8-12 Hz. We attribute this to enhanced physiological tremor. These early results indicate a significant reduction in the transmission of surgeon's tremor to the operative field from the first attempt to later attempts (P = 0.039, standardized effect size = 0.91), which may be associated with increasing confidence. This new method does not just quantify tremor, but quantifies the transmission of tremor to a manipulandum in the operative field during high-fidelity simulated coronary surgery. This may be used to assess and provide feedback on the performance of trainees and experienced surgeons, along with other fields in which fine motor skills are of vital importance. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Fluorescein-guided intraoperative endoscopy in patients with hereditary hemorrhagic telangiectasia: first impressions.

PubMed

Pagella, Fabio; Pusateri, Alessandro; Zaccari, Dario; Bongetta, Daniele; Zoia, Cesare; Spinozzi, Giuseppe; Olivieri, Carla; Matti, Elina

2017-03-01

Hereditary hemorrhagic telangiectasia (HHT) is a rare genetic disease that results in mucocutaneous telangiectasias and arteriovenous visceral malformations. Nasal telangiectasias lead to recurrent epistaxis, which affects up to 96% of patients. Different morphologic classifications and methods of visualization of nasal lesions have been described in the literature. We developed a new method of intraoperative endoscopy based on the intravenous administration of fluorescein. Preliminary data of this technique are reported. After the intravenous administration of sodium fluorescein, an intraoperative fluorescein-guided endoscopy was carried out using photographic customized yellow filters on top of a 0-degree, 4-mm endoscope. In 2015, 65 HHT patients underwent surgery for their epistaxis in our institution, and in 7 patients (3 males, 4 females; mean age, 54 years) an intraoperative fluorescein-guided intraoperative nasal endoscopy was performed. No adverse events or complications were observed. First impressions regarding the usage of this technique in HHT patients seem to be promising and positive in terms of efficacy and safety. However, further studies with larger cohorts of patients should be performed in order to better investigate the use of this method for diagnostic and surgical purposes in HHT. © 2016 ARS-AAOA, LLC.

Influence of the quality of intraoperative fluoroscopic images on the spatial positioning accuracy of a CAOS system.

PubMed

Wang, Junqiang; Wang, Yu; Zhu, Gang; Chen, Xiangqian; Zhao, Xiangrui; Qiao, Huiting; Fan, Yubo

2018-06-01

Spatial positioning accuracy is a key issue in a computer-assisted orthopaedic surgery (CAOS) system. Since intraoperative fluoroscopic images are one of the most important input data to the CAOS system, the quality of these images should have a significant influence on the accuracy of the CAOS system. But the regularities and mechanism of the influence of the quality of intraoperative images on the accuracy of a CAOS system have yet to be studied. Two typical spatial positioning methods - a C-arm calibration-based method and a bi-planar positioning method - are used to study the influence of different image quality parameters, such as resolution, distortion, contrast and signal-to-noise ratio, on positioning accuracy. The error propagation rules of image error in different spatial positioning methods are analyzed by the Monte Carlo method. Correlation analysis showed that resolution and distortion had a significant influence on spatial positioning accuracy. In addition the C-arm calibration-based method was more sensitive to image distortion, while the bi-planar positioning method was more susceptible to image resolution. The image contrast and signal-to-noise ratio have no significant influence on the spatial positioning accuracy. The result of Monte Carlo analysis proved that generally the bi-planar positioning method was more sensitive to image quality than the C-arm calibration-based method. The quality of intraoperative fluoroscopic images is a key issue in the spatial positioning accuracy of a CAOS system. Although the 2 typical positioning methods have very similar mathematical principles, they showed different sensitivities to different image quality parameters. The result of this research may help to create a realistic standard for intraoperative fluoroscopic images for CAOS systems. Copyright © 2018 John Wiley & Sons, Ltd.

Agreement between preoperative transvaginal ultrasound and intraoperative macroscopic examination for assessing myometrial infiltration in low-risk endometrioid carcinoma.

PubMed

Pineda, L; Alcázar, J L; Caparrós, M; Mínguez, J A; Idoate, M A; Quiceno, H; Solórzano, J L; Jurado, M

2016-03-01

To compare diagnostic performance of preoperative transvaginal ultrasound (TVS) and intraoperative macroscopic examination for determining myometrial infiltration in women with low-risk endometrial cancer, and to estimate the agreement between the two methods. This was a single-center observational study comprising women with preoperative diagnosis of well- or moderately differentiated endometrioid carcinoma of the endometrium. All women underwent preoperative TVS by a single examiner. According to the examiner's subjective impression, myometrial infiltration was stated as ≥ 50% or < 50%. Surgical staging was performed in all cases. Intraoperative macroscopic examination of the removed uterus was performed by pathologists who were unaware of the ultrasound findings, and myometrial infiltration was stated as ≥ 50% or < 50%. Definitive histological diagnosis of myometrial infiltration was made by frozen section analysis and was used as the gold standard. Sensitivity and specificity with 95% CIs were calculated for TVS and intraoperative macroscopic inspection and compared using McNemar's test. Agreement between TVS and intraoperative macroscopic inspection was estimated using Cohen's kappa index (κ) and percentage of agreement. Of 209 eligible women, 152 were ultimately included. Mean (± SD) age was 60.9 ± 10.2 years, with a range of 32-91 years. Definitive histological diagnosis revealed that myometrial infiltration was < 50% in 114 women and ≥ 50% in 38 women. Sensitivity and specificity of TVS for detecting deep myometrial infiltration were 81.6% and 89.5%, respectively, whereas the respective values for intraoperative macroscopic examination were 78.9% and 90.4% (McNemar's test, P > 0.05 when comparing TVS and intraoperative macroscopic examination). Agreement between methods was moderate with κ = 0.54 (95% CI, 0.39-0.69) and percentage of agreement of 82%. Although the agreement between preoperative TVS and intraoperative macroscopic examination for detecting deep myometrial infiltration was only moderate, both methods had similar accuracy when compared with frozen section histology. Preoperative TVS might reasonably be proposed as a method for assessing myometrial infiltration as an alternative to intraoperative macroscopic examination, especially when performed by an experienced examiner and image quality is not poor. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Predictive factor analysis for successful performance of iris recognition-assisted dynamic rotational eye tracking during laser in situ keratomileusis.

PubMed

Prakash, Gaurav; Ashok Kumar, Dhivya; Agarwal, Amar; Jacob, Soosan; Sarvanan, Yoga; Agarwal, Athiya

2010-02-01

To analyze the predictive factors associated with success of iris recognition and dynamic rotational eye tracking on a laser in situ keratomileusis (LASIK) platform with active assessment and correction of intraoperative cyclotorsion. Interventional case series. Two hundred seventy-five eyes of 142 consecutive candidates underwent LASIK with attempted iris recognition and dynamic rotational tracking on the Technolas 217z100 platform (Techolas Perfect Vision, St Louis, Missouri, USA) at a tertiary care ophthalmic hospital. The main outcome measures were age, gender, flap creation method (femtosecond, microkeratome, epi-LASIK), success of static rotational tracking, ablation algorithm, pulses, and depth; preablation and intraablation rotational activity were analyzed and evaluated using regression models. Preablation static iris recognition was successful in 247 eyes, without difference in flap creation methods (P = .6). Age (partial correlation, -0.16; P = .014), amount of pulses (partial correlation, 0.39; P = 1.6 x 10(-8)), and gender (P = .02) were significant predictive factors for the amount of intraoperative cyclodeviation. Tracking difficulties leading to linking the ablation with a new intraoperatively acquired iris image were more with femtosecond-assisted flaps (P = 2.8 x 10(-7)) and the amount of intraoperative cyclotorsion (P = .02). However, the number of cases having nonresolvable failure of intraoperative rotational tracking was similar in the 3 flap creation methods (P = .22). Intraoperative cyclotorsional activity depends on the age, gender, and duration of ablation (pulses delivered). Femtosecond flaps do not seem to have a disadvantage over microkeratome flaps as far as iris recognition and success of intraoperative dynamic rotational tracking is concerned. Copyright (c) 2010 Elsevier Inc. All rights reserved.

Persistent and automatic intraoperative 3D digitization of surfaces under dynamic magnifications of an operating microscope

PubMed Central

Kumar, Ankur N.; Miga, Michael I.; Pheiffer, Thomas S.; Chambless, Lola B.; Thompson, Reid C.; Dawant, Benoit M.

2014-01-01

One of the major challenges impeding advancement in image-guided surgical (IGS) systems is the soft-tissue deformation during surgical procedures. These deformations reduce the utility of the patient’s preoperative images and may produce inaccuracies in the application of preoperative surgical plans. Solutions to compensate for the tissue deformations include the acquisition of intraoperative tomographic images of the whole organ for direct displacement measurement and techniques that combines intraoperative organ surface measurements with computational biomechanical models to predict subsurface displacements. The later solution has the advantage of being less expensive and amenable to surgical workflow. Several modalities such as textured laser scanners, conoscopic holography, and stereo-pair cameras have been proposed for the intraoperative 3D estimation of organ surfaces to drive patient-specific biomechanical models for the intraoperative update of preoperative images. Though each modality has its respective advantages and disadvantages, stereo-pair camera approaches used within a standard operating microscope is the focus of this article. A new method that permits the automatic and near real-time estimation of 3D surfaces (at 1Hz) under varying magnifications of the operating microscope is proposed. This method has been evaluated on a CAD phantom object and on full-length neurosurgery video sequences (~1 hour) acquired intraoperatively by the proposed stereovision system. To the best of our knowledge, this type of validation study on full-length brain tumor surgery videos has not been done before. The method for estimating the unknown magnification factor of the operating microscope achieves accuracy within 0.02 of the theoretical value on a CAD phantom and within 0.06 on 4 clinical videos of the entire brain tumor surgery. When compared to a laser range scanner, the proposed method for reconstructing 3D surfaces intraoperatively achieves root mean square errors (surface-to-surface distance) in the 0.28-0.81mm range on the phantom object and in the 0.54-1.35mm range on 4 clinical cases. The digitization accuracy of the presented stereovision methods indicate that the operating microscope can be used to deliver the persistent intraoperative input required by computational biomechanical models to update the patient’s preoperative images and facilitate active surgical guidance. PMID:25189364

Persistent and automatic intraoperative 3D digitization of surfaces under dynamic magnifications of an operating microscope.

PubMed

Kumar, Ankur N; Miga, Michael I; Pheiffer, Thomas S; Chambless, Lola B; Thompson, Reid C; Dawant, Benoit M

2015-01-01

One of the major challenges impeding advancement in image-guided surgical (IGS) systems is the soft-tissue deformation during surgical procedures. These deformations reduce the utility of the patient's preoperative images and may produce inaccuracies in the application of preoperative surgical plans. Solutions to compensate for the tissue deformations include the acquisition of intraoperative tomographic images of the whole organ for direct displacement measurement and techniques that combines intraoperative organ surface measurements with computational biomechanical models to predict subsurface displacements. The later solution has the advantage of being less expensive and amenable to surgical workflow. Several modalities such as textured laser scanners, conoscopic holography, and stereo-pair cameras have been proposed for the intraoperative 3D estimation of organ surfaces to drive patient-specific biomechanical models for the intraoperative update of preoperative images. Though each modality has its respective advantages and disadvantages, stereo-pair camera approaches used within a standard operating microscope is the focus of this article. A new method that permits the automatic and near real-time estimation of 3D surfaces (at 1 Hz) under varying magnifications of the operating microscope is proposed. This method has been evaluated on a CAD phantom object and on full-length neurosurgery video sequences (∼1 h) acquired intraoperatively by the proposed stereovision system. To the best of our knowledge, this type of validation study on full-length brain tumor surgery videos has not been done before. The method for estimating the unknown magnification factor of the operating microscope achieves accuracy within 0.02 of the theoretical value on a CAD phantom and within 0.06 on 4 clinical videos of the entire brain tumor surgery. When compared to a laser range scanner, the proposed method for reconstructing 3D surfaces intraoperatively achieves root mean square errors (surface-to-surface distance) in the 0.28-0.81 mm range on the phantom object and in the 0.54-1.35 mm range on 4 clinical cases. The digitization accuracy of the presented stereovision methods indicate that the operating microscope can be used to deliver the persistent intraoperative input required by computational biomechanical models to update the patient's preoperative images and facilitate active surgical guidance. Copyright © 2014 Elsevier B.V. All rights reserved.

Improved visualization of intracranial vessels with intraoperative coregistration of rotational digital subtraction angiography and intraoperative 3D ultrasound.

PubMed

Podlesek, Dino; Meyer, Tobias; Morgenstern, Ute; Schackert, Gabriele; Kirsch, Matthias

2015-01-01

Ultrasound can visualize and update the vessel status in real time during cerebral vascular surgery. We studied the depiction of parent vessels and aneurysms with a high-resolution 3D intraoperative ultrasound imaging system during aneurysm clipping using rotational digital subtraction angiography as a reference. We analyzed 3D intraoperative ultrasound in 39 patients with cerebral aneurysms to visualize the aneurysm intraoperatively and the nearby vascular tree before and after clipping. Simultaneous coregistration of preoperative subtraction angiography data with 3D intraoperative ultrasound was performed to verify the anatomical assignment. Intraoperative ultrasound detected 35 of 43 aneurysms (81%) in 39 patients. Thirty-nine intraoperative ultrasound measurements were matched with rotational digital subtraction angiography and were successfully reconstructed during the procedure. In 7 patients, the aneurysm was partially visualized by 3D-ioUS or was not in field of view. Post-clipping intraoperative ultrasound was obtained in 26 and successfully reconstructed in 18 patients (69%) despite clip related artefacts. The overlap between 3D-ioUS aneurysm volume and preoperative rDSA aneurysm volume resulted in a mean accuracy of 0.71 (Dice coefficient). Intraoperative coregistration of 3D intraoperative ultrasound data with preoperative rotational digital subtraction angiography is possible with high accuracy. It allows the immediate visualization of vessels beyond the microscopic field, as well as parallel assessment of blood velocity, aneurysm and vascular tree configuration. Although spatial resolution is lower than for standard angiography, the method provides an excellent vascular overview, advantageous interpretation of 3D-ioUS and immediate intraoperative feedback of the vascular status. A prerequisite for understanding vascular intraoperative ultrasound is image quality and a successful match with preoperative rotational digital subtraction angiography.

Intraoperative indocyanine green videoangiography for identification of pituitary adenomas using a microscopic transsphenoidal approach.

PubMed

Sandow, N; Klene, W; Elbelt, U; Strasburger, C J; Vajkoczy, P

2015-10-01

Initial successful surgical treatment of pituitary adenomas is crucial to reach long-term remission. Indocyanine green (ICG) videoangiography (VA) is well established in vascular neurosurgery nowadays and several reports described ICG application in brain tumor surgery. We designed this study to evaluate the feasibility of intravenous application of ICG and visualisation of a pituitary lesion via the fluorescence mode of the operation microscope. 22 patients with pituitary adenomas were treated with transsphenoidal microsurgery and were included in this study. Intraoperatively 25 mg ICG was administered intravenously and visualized via the fluorescence mode of the operation microscope (Pentero/Zeiss). 22 patients qualified for transsphenoidal surgery presenting with different clinical symptoms (13 patients with acromegaly, 6 with M. Cushing and 3 with other symptoms like vision disorder or dizziness) and identification of a pituitary lesion (21 of 22 patients) in preoperative MR-imaging (mean diameter: 9 mm; SD 3.6; 6 macroadenomas, 15 microadenomas, 1 MR-negative). In all 22 patients ICG VA was performed during surgery. No technical failures or adverse events after drug administration occurred. Visualization was optimal approximately 2.4 min after intravenous application. In all patients the adenoma could be detected via two different types of visualization: direct visualization by fluorophore emission versus indirect detection of the adenoma by a lower ICG fluorescence compared to the surrounding tissue. Our data show that intraoperative ICG VA can be a useful and easily applicable additional diagnostic tool for visualization of pituitary lesions using the microscopic approach.

Intraoperative ultrasound in colorectal surgery.

PubMed

Greif, Franklin; Aranovich, David; Hananel, Nissim; Knizhnik, Mikhail; Belenky, Alexander

2009-09-01

To assess the accuracy of intraoperative ultrasound (IOUS) as a localizing technique for colorectal resections, and its impact on surgical management. Twenty-five patients (15 men and 10 women; mean age, 74.4 years) with early cancers (p T1), or polyps, not amenable to endoscopic removal were selected. IOUS was used as a sole method of intraoperative localization. Its performance was evaluated through review of preoperative colonoscopy reports, intraoperative findings, histopathology reports, and clinical follow-up. The lesions were situated in the cecum (n = 5), ascending colon (n = 3), transverse colon (n = 4), descending colon (n = 7), and rectum (n = 6). IOUS technique allowed correct localization in 24 of 25 patients, visualization of the bowel wall, and its penetration by malignant tumors. In rectal lesions, IOUS showed clearly the tumor and its margin, which facilitated performance sphincter-sparing procedure. In patients with small polyps and early cancers of colon and rectum, IOUS may be effectively used as a sole method of intraoperative localization and provide additional information that may alter decision making with regard to surgical technique. (c) 2009 Wiley Periodicals, Inc.

Toward real-time tumor margin identification in image-guided robotic brain tumor resection

NASA Astrophysics Data System (ADS)

Hu, Danying; Jiang, Yang; Belykh, Evgenii; Gong, Yuanzheng; Preul, Mark C.; Hannaford, Blake; Seibel, Eric J.

2017-03-01

For patients with malignant brain tumors (glioblastomas), a safe maximal resection of tumor is critical for an increased survival rate. However, complete resection of the cancer is hard to achieve due to the invasive nature of these tumors, where the margins of the tumors become blurred from frank tumor to more normal brain tissue, but in which single cells or clusters of malignant cells may have invaded. Recent developments in fluorescence imaging techniques have shown great potential for improved surgical outcomes by providing surgeons intraoperative contrast-enhanced visual information of tumor in neurosurgery. The current near-infrared (NIR) fluorophores, such as indocyanine green (ICG), cyanine5.5 (Cy5.5), 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX), are showing clinical potential to be useful in targeting and guiding resections of such tumors. Real-time tumor margin identification in NIR imaging could be helpful to both surgeons and patients by reducing the operation time and space required by other imaging modalities such as intraoperative MRI, and has the potential to integrate with robotically assisted surgery. In this paper, a segmentation method based on the Chan-Vese model was developed for identifying the tumor boundaries in an ex-vivo mouse brain from relatively noisy fluorescence images acquired by a multimodal scanning fiber endoscope (mmSFE). Tumor contours were achieved iteratively by minimizing an energy function formed by a level set function and the segmentation model. Quantitative segmentation metrics based on tumor-to-background (T/B) ratio were evaluated. Results demonstrated feasibility in detecting the brain tumor margins at quasi-real-time and has the potential to yield improved precision brain tumor resection techniques or even robotic interventions in the future.

Clinical significance of sentinel lymph node detection in patients with invasive cervical cancer

NASA Astrophysics Data System (ADS)

Sinilkin, I. G.; Chernov, V. I.; Lyapunov, A. Yu.; Medvedeva, A. A.; Zelchan, R. V.; Chernyshova, A. L.; Kolomiets, L. A.; Bragina, O. D.

2017-09-01

The clinical significance of determining sentinel lymph nodes (SLN) in patients with invasive cervical cancer was studied. From 2013 to 2014, 30 cervical cancer patients (T1a1NxM0-T1b1NxM0) were treated at the Gynecological Oncology Department of the Cancer Research Institute. The day before surgery, four submucosal injections of 99mTc Al2O3 at a total dose of 80 MBq were made in each quadrant around the cervical tumor. Patients were submitted to preoperative lymphoscintigraphy and intraoperative SLN detection. The feasibility of preserving the reproductive potential in patients after radical abdominal trachelectomy was assessed. The 3-year, overall, disease-free and metastasis-free survival rates were analyzed. Thirty-four SLNs were detected by single-photon emission computed tomography (SPECT) and 42 SLNs were identified by intraoperative gamma probe. The sensitivity in detecting SLNs was 100% for intraoperative SLN identification and 80% for SPECT image. The reproductive potential was preserved in 86% of patients. The 3-year overall and metastases-free survival rates were 100%. Recurrence occurred in 8.6% of cases.

Recent advances in near-infrared fluorescence-guided imaging surgery using indocyanine green.

PubMed

Namikawa, Tsutomu; Sato, Takayuki; Hanazaki, Kazuhiro

2015-12-01

Near-infrared (NIR) fluorescence imaging has better tissue penetration, allowing for the effective rejection of excitation light and detection deep inside organs. Indocyanine green (ICG) generates NIR fluorescence after illumination by an NIR ray, enabling real-time intraoperative visualization of superficial lymphatic channels and vessels transcutaneously. The HyperEye Medical System (HEMS) can simultaneously detect NIR rays under room light to provide color imaging, which enables visualization under bright light. Thus, NIR fluorescence imaging using ICG can provide for excellent diagnostic accuracy in detecting sentinel lymph nodes in cancer and microvascular circulation in various ischemic diseases, to assist us with intraoperative decision making. Including HEMS in this system could further improve the sentinel lymph node mapping and intraoperative identification of blood supply in reconstructive organs and ischemic diseases, making it more attractive than conventional imaging. Moreover, the development of new laparoscopic imaging systems equipped with NIR will allow fluorescence-guided surgery in a minimally invasive setting. Future directions, including the conjugation of NIR fluorophores to target specific cancer markers might be realistic technology with diagnostic and therapeutic benefits.

Beyond the margins: real-time detection of cancer using targeted fluorophores

PubMed Central

Zhang, Ray R.; Schroeder, Alexandra B.; Grudzinski, Joseph J.; Rosenthal, Eben L.; Warram, Jason M.; Pinchuk, Anatoly N.; Eliceiri, Kevin W.; Kuo, John S.; Weichert, Jamey P.

2017-01-01

Over the past two decades, synergistic innovations in imaging technology have resulted in a revolution in which a range of biomedical applications are now benefiting from fluorescence imaging. Specifically, advances in fluorophore chemistry and imaging hardware, and the identification of targetable biomarkers have now positioned intraoperative fluorescence as a highly specific real-time detection modality for surgeons in oncology. In particular, the deeper tissue penetration and limited autofluorescence of near-infrared (NIR) fluorescence imaging improves the translational potential of this modality over visible-light fluorescence imaging. Rapid developments in fluorophores with improved characteristics, detection instrumentation, and targeting strategies led to the clinical testing in the early 2010s of the first targeted NIR fluorophores for intraoperative cancer detection. The foundations for the advances that underline this technology continue to be nurtured by the multidisciplinary collaboration of chemists, biologists, engineers, and clinicians. In this Review, we highlight the latest developments in NIR fluorophores, cancer-targeting strategies, and detection instrumentation for intraoperative cancer detection, and consider the unique challenges associated with their effective application in clinical settings. PMID:28094261

Sensitivity and Specificity of Cardiac Tissue Discrimination Using Fiber-Optics Confocal Microscopy.

PubMed

Huang, Chao; Sachse, Frank B; Hitchcock, Robert W; Kaza, Aditya K

2016-01-01

Disturbances of the cardiac conduction system constitute a major risk after surgical repair of complex cases of congenital heart disease. Intraoperative identification of the conduction system may reduce the incidence of these disturbances. We previously developed an approach to identify cardiac tissue types using fiber-optics confocal microscopy and extracellular fluorophores. Here, we applied this approach to investigate sensitivity and specificity of human and automated classification in discriminating images of atrial working myocardium and specialized tissue of the conduction system. Two-dimensional image sequences from atrial working myocardium and nodal tissue of isolated perfused rodent hearts were acquired using a fiber-optics confocal microscope (Leica FCM1000). We compared two methods for local application of extracellular fluorophores: topical via pipette and with a dye carrier. Eight blinded examiners evaluated 162 randomly selected images of atrial working myocardium (n = 81) and nodal tissue (n = 81). In addition, we evaluated the images using automated classification. Blinded examiners achieved a sensitivity and specificity of 99.2 ± 0.3% and 98.0 ± 0.7%, respectively, with the dye carrier method of dye application. Sensitivity and specificity was similar for dye application via a pipette (99.2 ± 0.3% and 94.0 ± 2.4%, respectively). Sensitivity and specificity for automated methods of tissue discrimination were similarly high. Human and automated classification achieved high sensitivity and specificity in discriminating atrial working myocardium and nodal tissue. We suggest that our findings facilitate clinical translation of fiber-optics confocal microscopy as an intraoperative imaging modality to reduce the incidence of conduction disturbances during surgical correction of congenital heart disease.

Fast algorithm for probabilistic bone edge detection (FAPBED)

NASA Astrophysics Data System (ADS)

Scepanovic, Danilo; Kirshtein, Joshua; Jain, Ameet K.; Taylor, Russell H.

2005-04-01

The registration of preoperative CT to intra-operative reality systems is a crucial step in Computer Assisted Orthopedic Surgery (CAOS). The intra-operative sensors include 3D digitizers, fiducials, X-rays and Ultrasound (US). FAPBED is designed to process CT volumes for registration to tracked US data. Tracked US is advantageous because it is real time, noninvasive, and non-ionizing, but it is also known to have inherent inaccuracies which create the need to develop a framework that is robust to various uncertainties, and can be useful in US-CT registration. Furthermore, conventional registration methods depend on accurate and absolute segmentation. Our proposed probabilistic framework addresses the segmentation-registration duality, wherein exact segmentation is not a prerequisite to achieve accurate registration. In this paper, we develop a method for fast and automatic probabilistic bone surface (edge) detection in CT images. Various features that influence the likelihood of the surface at each spatial coordinate are combined using a simple probabilistic framework, which strikes a fair balance between a high-level understanding of features in an image and the low-level number crunching of standard image processing techniques. The algorithm evaluates different features for detecting the probability of a bone surface at each voxel, and compounds the results of these methods to yield a final, low-noise, probability map of bone surfaces in the volume. Such a probability map can then be used in conjunction with a similar map from tracked intra-operative US to achieve accurate registration. Eight sample pelvic CT scans were used to extract feature parameters and validate the final probability maps. An un-optimized fully automatic Matlab code runs in five minutes per CT volume on average, and was validated by comparison against hand-segmented gold standards. The mean probability assigned to nonzero surface points was 0.8, while nonzero non-surface points had a mean value of 0.38 indicating clear identification of surface points on average. The segmentation was also sufficiently crisp, with a full width at half maximum (FWHM) value of 1.51 voxels.

Quantification of bone strength by intraoperative torque measurement: a technical note.

PubMed

Suhm, Norbert; Haenni, Markus; Schwyn, Ronald; Hirschmann, Michael; Müller, Andreas Marc

2008-06-01

Bone strength describes the resistance of bone against mechanical failure. Bone strength depends on both the amount of bone and the bone's quality, and the bone strength may be looked upon as a relevant parameter to judge an osteosynthesis' stability. Information about bone strength was barely available intraoperatively in the past. The previous work of our group reported on development and laboratory evaluation of mechanical torque measurement as a method for the intraoperative quantification of bone strength. With the clinical series presented here we intend to verify that the im gesamten Text DensiProbe instrumentation for intraoperative torque measurement and the related measurement method are eligible for intraoperative use based on the following criteria: application of the method may not create complications, the measurement can be performed by the surgeon himself and may only cause a limited increase in the procedure time. From December 2006 until May 2007 ten patients with a pertrochanteric femoral fracture or a lateral femoral neck fracture eligible for stabilization with DHS were included in the study after having received informed consent. Any medication and comorbidity that might have influenced bone quality or bone mineral density (BMD) in these patients was documented. Bone strength was intraoperatively measured with DensiProbe. Complications that were obviously related with torque measurement were documented as well as any deviation from the suggested procedure; 6 and 12 weeks postoperative follow-up included clinical and radiological examination. The time required for torque measurement, the overall operating time and the number of persons present in the operating room were protocolled. BMD values of the contralateral femoral neck were postoperatively assessed by dual energy X-ray absorptiometry (DEXA) and compared to intraoperative peak torque values measured by DensiProbe. No major complication was observed during intraoperative application of DensiProbe by trained surgeons. The unintended extraction of the guide wire together with the torque measurement probe was reported only once and is looked upon as a minor complication. Fracture healing was uneventful in all patients. The mean time for torque measurement was 2.35 +/- 0.9 min accounting for 2.2 +/- 1.1% of total surgery time. The presence of an additional person was not required to perform torque measurement but to protocol the data. There was a tendency towards correlation between BMD values of the femoral neck and intraoperative peak torque values. The data presented clearly indicate that the DensiProbe instrumentation and measurement principle are eligible for routine intraoperative use by trained surgeons. Interpretation of possible correlations between BMD values measured by means of DEXA and the Peak Torque values assessed by DensiProbe has to be considered very carefully, because BMD and Peak Torque analyse bone at a different scale. Only within the framework of a multicenter study it will be possible to include a sufficient number of patients for calculation of the methods' predictive value towards implant failure and to verify acceptance of the method by the surgeons.

Usefulness of intraoperative radiographs in reducing errors of cup placement and leg length during total hip arthroplasty.

PubMed

Wind, Michael A; Morrison, J Craig; Christie, Michael J

2013-11-01

Traditional methods of component placement during total hip arthroplasty (THA) can lead to errors in cup abduction angle and leg length. Intraoperative radiographs were used to assess and correct errors during surgery in a consecutive series of 278 THAs performed by a single surgeon. After exclusions, 262 cases were available for cup abduction angle assessment and 224 for leg length discrepancy (LLD) assessment. Components were initially placed in a position determined as appropriate by the surgeon. Intraoperative radiographs were taken and appropriate corrections made. Postoperative radiographs were assessed at 6 weeks. Mean abduction angle on intraoperative radiographs was 39.6°±5.9° versus 38.6°±4.1° on postoperative radiographs. Thirty-eight cups were outside the target abduction range on intraoperative radiographs versus 4 on postoperative radiographs. Mean LLD was 3.7 mm ± 3.6 mm on intraoperative radiographs and 2.5 mm ± 2.7 mm on postoperative radiographs. Use of intraoperative radiographs is a valid, useful technique for minimizing errors in THA.

Image-guided removal of supratentorial cavernomas in critical brain areas: application of neuronavigation and intraoperative magnetic resonance imaging.

PubMed

Gralla, J; Ganslandt, O; Kober, H; Buchfelder, M; Fahlbusch, R; Nimsky, C

2003-04-01

In a retrospective study the postoperative results of 26 patients operated on for supratentorial cavernous hemangiomas either deep-seated or near eloquent brain areas are summarized. An exact surgical approach to these lesions is essential to prevent neurological deterioration. Three different navigation systems were used and compared according to their clinical applicability. Complete removal of the lesion was obtained in all patients of this series. In six cases (23 %) functional data from magnetoencephalography or functional magnetic resonance imaging were integrated into the navigational setup. In 14 cases (54 %) intraoperative magnetic resonance imaging was performed. The follow-up time was 3 - 26 months (mean: 10 months). In the postoperative course one patient (3.8 %) developed a hemiparesis, another one developed quadrantopia. Nineteen patients presented with preoperative seizure history, 16 of these (84 %) had no further or rare seizures after surgery. The better results in seizure control were achieved in those patients with shorter duration of seizure history before surgery. The study indicates that the application of neuronavigation allows surgery on supratentorial cavernous hemangiomas in critical brain areas with low morbidity. The intraoperative visualization of eloquent cortex areas by integration of functional data allows a fast identification and exemption of eloquent brain areas, preventing neurological deterioration. Furthermore, the intraoperative MR resection control ensures a complete resection and illustrates the minimal invasive approach.

Axillary nerve monitoring during arthroscopic shoulder stabilization.

PubMed

Esmail, Adil N; Getz, Charles L; Schwartz, Daniel M; Wierzbowski, Lawrence; Ramsey, Matthew L; Williams, Gerald R

2005-06-01

This study evaluated the ability of a novel intraoperative neurophysiologic monitoring method used to locate the axillary nerve, predict relative capsule thickness, and identify impending injury to the axillary nerve during arthroscopic thermal capsulorrhaphy of the shoulder. Prospective cohort study. Twenty consecutive patients with glenohumeral instability were monitored prospectively during arthroscopic shoulder surgery. Axillary nerve mapping and relative capsule thickness estimates were recorded before the stabilization portion of the procedure. During labral repair and/or thermal capsulorrhaphy, continuous and spontaneous electromyography recorded nerve activity. In addition, trans-spinal motor-evoked potentials of the fourth and fifth cervical roots and brachial plexus electrical stimulation, provided real-time information about nerve integrity. Axillary nerve mapping and relative capsule thickness were recorded in all patients. Continuous axillary nerve monitoring was successfully performed in all patients. Eleven of the 20 patients underwent thermal capsulorrhaphy alone or in combination with arthroscopic labral repair. Nine patients underwent arthroscopic labral repair alone. In 4 of the 11 patients who underwent thermal capsulorrhaphy, excessive spontaneous neurotonic electromyographic activity was noted, thereby altering the pattern of heat application by the surgeon. In 1 of these 4 patients, a small increase in the motor latency was noted after the procedure but no clinical deficit was observed. There were no neuromonitoring or clinical neurologic changes observed in the labral repair group without thermal application. At last follow-up, no patient in either group had any clinical evidence of nerve injury or complications from neurophysiologic monitoring. We successfully evaluated the use of intraoperative nerve monitoring to identify axillary nerve position, capsule thickness, and provide real-time identification of impending nerve injury and function during shoulder thermal capsulorrhaphy. The use of intraoperative nerve monitoring altered the heat application technique in 4 of 11 patients and may have prevented nerve injury. Level II, prospective cohort study.

Preoperative planning and intraoperative technique for accurate realignment of the Dwyer calcaneal osteotomy.

PubMed

Lamm, Bradley M; Gesheff, Martin G; Salton, Heather L; Dupuis, Travis W; Zeni, Ferras

2012-01-01

The Dwyer calcaneal osteotomy is an effective procedure for the correction of calcaneal varus deformity. However, no intraoperative method has been described to determine the amount of bone resection. We describe a simple intraoperative method for assuring accurate bone resection and measure the realignment effects of the Dwyer calcaneal osteotomy. We also review radiographic outcomes associated with 20 Dwyer calcaneal osteotomies (in 17 patients) using the intraoperative realignment technique described in this report. Preoperative and postoperative radiographs at a mean of 2.5 (range 1.5 to 5) years taken after Dwyer osteotomy were measured and compared, which revealed a mean reduction in calcaneal varus of 18° (range 2° to 36°) (p < .001), a mean decrease in the calcaneal inclination angle of 5° (range -40° to 7°) (p < .05), a mean decrease in medial calcaneal translation of 10 (range 0 to 18) mm (p < .001) relative to the tibia, and a mean dorsal translation of 2 (range 0 to 7) mm (p = .002). In an effort to attempt to structurally realign the calcaneus to a more rectus alignment, by means of Dwyer osteotomy, we recommend the use of the intraoperative bone wedge resection technique described in this report. Our experience with the patients described in this report demonstrates the usefulness of the intraoperative method that we describe in order to accurately restore the axial tibial and calcaneal relationship. Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

Intra-operative localisation of thoracic spine level: a simple "'K'-wire in pedicle" technique.

PubMed

Thambiraj, Sathya; Quraishi, Nasir A

2012-05-01

To describe a simple and reliable method of intra-operative localisation of thoracic spine in a single surgical setting. Intra-operative localisation of thoracic spine levels can be difficult due to anatomical constraints, such as scapular shadow, patient's size and poor bone quality. This is particularly true in cases of thoracic discectomies in which the vertebral bodies appear normal. There are several methods described in recent literature to address this. Many of them require a separate procedure which was performed often the previous day. We report a technique which addresses the issue of localising thoracic level intra-operatively. After induction of general anaesthesia, the patient was placed prone and the pedicle of interest was identified using fluoroscopy. A K-wire was then inserted percutaneously into this pedicle under image guidance [confirmed in the antero-posterior (AP) and lateral views]. The wire was then cut close to the skin after bending it. The patient was now positioned laterally and the intended procedure performed through an anterior trans-thoracic approach. The 'K' wire was removed at the end of the procedure. We routinely used this technique in all our thoracic discectomies (four cases in 2 years). There were no intra-operative complications. This method is simple, avoids the patient undergoing two procedures and requires no more ability than placing an implant in the pedicle under fluoroscopy. Placing the 'K' wire into a fixed point like the pedicle facilitates rapid intra-operative viewing of the level of interest and is removed easily at the conclusion of surgery.

A survey of the accuracy of interpretation of intraoperative cholangiograms

PubMed Central

Sanjay, Pandanaboyana; Tagolao, Sherry; Dirkzwager, Ilse; Bartlett, Adam

2012-01-01

Objectives There are few data in the literature regarding the ability of surgical trainees and surgeons to correctly interpret intraoperative cholangiograms (IOCs) during laparoscopic cholecystectomy (LC). The aim of this study was to determine the accuracy of surgeons' interpretations of IOCs. Methods Fifteen IOCs, depicting normal, variants of normal and abnormal anatomy, were sent electronically in random sequence to 20 surgical trainees and 20 consultant general surgeons. Information was also sought on the routine or selective use of IOC by respondents. Results The accuracy of IOC interpretation was poor. Only nine surgeons and nine trainees correctly interpreted the cholangiograms showing normal anatomy. Six consultant surgeons and five trainees correctly identified variants of normal anatomy on cholangiograms. Abnormal anatomy on cholangiograms was identified correctly by 18 consultant surgeons and 19 trainees. Routine IOC was practised by seven consultants and six trainees. There was no significant difference between those who performed routine and selective IOC with respect to correct identification of normal, variant and abnormal anatomy. Conclusions The present study shows that the accuracy of detection of both normal and variants of normal anatomy was poor in all grades of surgeon irrespective of a policy of routine or selective IOC. Improving operators' understanding of biliary anatomy may help to increase the diagnostic accuracy of IOC interpretation. PMID:22954003

Resection-Reconstruction of Aberrant Right Hepatic Artery During Whipple Procedure (Pancreaticoduodenectomy).

PubMed

Sayyed, Raza; Rehman, Iffat; Niazi, Imran Khalid; Yusuf, Muhammed Aasim; Syed, Aamir Ali; V, Faisal

2016-06-01

Aberrant hepatic arterial anatomy poses a challenge for the surgeon during Whipple procedure. Intraoperative injury to the aberrant vasculature results in hemorrhagic or ischemic complications involving the liver and biliary tree. We report a case of replaced right hepatic artery arising from the superior mesenteric artery in a patient with periampullary carcinoma of the pancreas, undergoing pancreaticoduodenectomy. The aberrant artery was found to be coursing through the pancreatic parenchyma. This is a rare vascular anomaly. Resection of the arterial segment and end-to-end anastomosis was fashioned. Intrapancreatic course of the replaced right hepatic artery is a rare anomaly and is best managed by preoperative identification on radiology and meticulous intra-operative dissection and preservation. However, for an intrapancreatic course, resection and reconstruction may occasionally be required.

Use of Intraoperative Computed Tomography for Revisional Procedures in Patients with Complex Maxillofacial Trauma

PubMed Central

Singh, Mansher; Ricci, Joseph A.

2015-01-01

Background: In patients with panfacial fractures and distorted anatomic landmarks of zygomatic and orbital complex, there is a risk of zygomaticomaxillary complex (ZMC) malpositioning even with the best efforts for surgical repair. This results in increased number of additional procedures to achieve accurate positioning. Methods: We describe the usage of intraoperative C-arm cone-beam computed tomographic (CT) scan for ZMC malpositioning in a representative patient with panfacial fractures. Results: We have successfully used intraoperative CT scan for ZMC malpositioning in 3 patients. The representative patient had ZMC malposition after the initial attempt of surgical repair without any intraoperative imaging. On using intraoperative CT scan during the next attempt, we were able to reposition the ZMC accurately. Conclusions: Intraoperative CT scan might improve the accuracy of ZMC positioning and decrease the chances of potential additional surgeries. In patients with distorted anatomical landmarks and panfacial fractures, it can be especially helpful toward correcting ZMC malposition. PMID:26301152

Intraoperative near-infrared autofluorescence imaging of parathyroid glands.

PubMed

Ladurner, Roland; Sommerey, Sandra; Arabi, Nora Al; Hallfeldt, Klaus K J; Stepp, Herbert; Gallwas, Julia K S

2017-08-01

To identify parathyroid glands intraoperatively by exposing their autofluorescence using near-infrared light. Fluorescence imaging was carried out during minimally invasive and open parathyroid and thyroid surgery. After identification, the parathyroid glands as well as the surrounding tissue were exposed to near-infrared (NIR) light with a wavelength of 690-770 nm using a modified Karl Storz near-infrared/indocyanine green (NIR/ICG) endoscopic system. Parathyroid tissue was expected to show near-infrared autofluorescence, captured in the blue channel of the camera. Whenever possible the visual identification of parathyroid tissue was confirmed histologically. In preliminary investigations, using the original NIR/ICG endoscopic system we noticed considerable interference of light in the blue channel overlying the autofluorescence. Therefore, we modified the light source by interposing additional filters. In a second series, we investigated 35 parathyroid glands from 25 patients. Twenty-seven glands were identified correctly based on NIR autofluorescence. Regarding the extent of autofluorescence, there were no noticeable differences between parathyroid adenomas, hyperplasia and normal parathyroid glands. In contrast, thyroid tissue, lymph nodes and adipose tissue revealed no substantial autofluorescence. Parathyroid tissue is characterized by showing autofluorescence in the near-infrared spectrum. This effect can be used to distinguish parathyroid glands from other cervical tissue entities.

Suprapubic cystostomy using optical urethrotome in female patients.

PubMed

Sawant, Ajit Somaji; Patwardhan, Sujata K; Attar, Mohammad Ismail; Varma, Radheshyam; Bansal, Ujjwal

2009-08-01

In many female patients for lower urinary tract reconstructive procedures, a suprapubic cystostomy along with perurethral catheter is required for urinary diversion. We describe a new and simple method of intraoperative suprapubic catheter placement using optical urethrotome wherein distension of bladder is not required. A total of 26 patients underwent suprapubic catheter placement intraoperatively with the aid of Sachse' optical urethrotome and its outer sheath from January 2005 to May 2008. A 16F Foley catheter could be successfully placed suprapubically in all patients with this method. There were no complications like injury to intraabdominal viscera, retropubic hematoma, hematuria, or catheter dislodgement. We describe a new method of intraoperative suprapubic catheter placement in female patients that is minimally invasive, technically safe, simple, and effective, and does not require bladder distension.

Visual Enhancement of Laparoscopic Partial Nephrectomy With 3-Charge Coupled Device Camera: Assessing Intraoperative Tissue Perfusion and Vascular Anatomy by Visible Hemoglobin Spectral Response

DTIC Science & Technology

2010-10-01

open nephron spanng surgery a single institution expenence. J Ural 2005; 174: 855 21 Bhayan• SB, Aha KH Pmto PA et al Laparoscopic partial...noninvasively assess laparoscopic intraoperative changes in renal tissue perfusion during and after warm ischemia. Materials and Methods: We analyzed select...TITLE AND SUBTITLE Visual Enhancement of Laparoscopic Partial Nephrectomy With 3-Charge Coupled Device Camera: Assessing Intraoperative Tissue

Edema and Seed Displacements Affect Intraoperative Permanent Prostate Brachytherapy Dosimetry

DOE Office of Scientific and Technical Information (OSTI.GOV)

Westendorp, Hendrik, E-mail: r.westendorp@radiotherapiegroep.nl; Nuver, Tonnis T.; Department of Radiation Oncology, Radiotherapiegroep Behandellocatie Deventer, Deventer

Purpose: We sought to identify the intraoperative displacement patterns of seeds and to evaluate the correlation of intraoperative dosimetry with day 30 for permanent prostate brachytherapy. Methods and Materials: We analyzed the data from 699 patients. Intraoperative dosimetry was acquired using transrectal ultrasonography (TRUS) and C-arm cone beam computed tomography (CBCT). Intraoperative dosimetry (minimal dose to 40%-95% of the volume [D{sub 40}-D{sub 95}]) was compared with the day 30 dosimetry for both modalities. An additional edema-compensating comparison was performed for D{sub 90}. Stranded seeds were linked between TRUS and CBCT using an automatic and fast linking procedure. Displacement patterns weremore » analyzed for each seed implantation location. Results: On average, an intraoperative (TRUS to CBCT) D{sub 90} decline of 10.6% ± 7.4% was observed. Intraoperative CBCT D{sub 90} showed a greater correlation (R{sup 2} = 0.33) with respect to Day 30 than did TRUS (R{sup 2} = 0.17). Compensating for edema, the correlation increased to 0.41 for CBCT and 0.38 for TRUS. The mean absolute intraoperative seed displacement was 3.9 ± 2.0 mm. The largest seed displacements were observed near the rectal wall. The central and posterior seeds showed less caudal displacement than lateral and anterior seeds. Seeds that were implanted closer to the base showed more divergence than seeds close to the apex. Conclusions: Intraoperative CBCT D{sub 90} showed a greater correlation with the day 30 dosimetry than intraoperative TRUS. Edema seemed to cause most of the systematic difference between the intraoperative and day 30 dosimetry. Seeds near the rectal wall showed the most displacement, comparing TRUS and CBCT, probably because of TRUS probe–induced prostate deformation.« less

Living donor right liver lobes: preoperative CT volumetric measurement for calculation of intraoperative weight and volume.

PubMed

Lemke, Arne-Jörn; Brinkmann, Martin Julius; Schott, Thomas; Niehues, Stefan Markus; Settmacher, Utz; Neuhaus, Peter; Felix, Roland

2006-09-01

To prospectively develop equations for the calculation of expected intraoperative weight and volume of a living donor's right liver lobe by using preoperative computed tomography (CT) for volumetric measurement. After medical ethics committee and state medical board approval, informed consent was obtained from eight female and eight male living donors (age range, 18-63 years) for participation in preoperative CT volumetric measurement of the right liver lobes by using the summation-of-area method. Intraoperatively, the graft was weighed, and the volume of the graft was determined by means of water displacement. Distributions of pre- and intraoperative data were depicted as Tukey box-and-whisker diagrams. Then, linear regressions were calculated, and the results were depicted as scatterplots. On the basis of intraoperative data, physical density of the parenchyma was calculated by dividing weight by volume of the graft. Preoperative measurement of grafts resulted in a mean volume of 929 mL +/- 176 (standard deviation); intraoperative mean weight and volume of the grafts were 774 g +/- 138 and 697 mL +/- 139, respectively. All corresponding pre- and intraoperative data correlated significantly (P < .001) with each other. Intraoperatively expected volume (V(intraop)) in millilliters and weight (W(intraop)) in grams can be calculated with the equations V(intra)(op) = (0.656 . V(preop)) + 87.629 mL and W(intra)(op) = (0.678 g/mL . V(preop)) + 143.704 g, respectively, where preoperative volume is V(preop) in milliliters. Physical density of transplanted liver lobes was 1.1172 g/mL +/- 0.1015. By using two equations developed from the data obtained in this study, expected intraoperative weight and volume can properly be determined from CT volumetric measurements. (c) RSNA, 2006.

Radio-guided surgery with the use of [99mTc-EDDA/HYNIC]octreotate in intra-operative detection of neuroendocrine tumours of the gastrointestinal tract.

PubMed

Hubalewska-Dydejczyk, A; Kulig, J; Szybinski, P; Mikolajczak, R; Pach, D; Sowa-Staszczak, A; Fröss-Baron, K; Huszno, B

2007-10-01

Radio-guided surgery (RGS) is an intra-operative localising technique which enables identification of tissue "marked" by a specific radiotracer injected before surgery. It is mainly used for sentinel node mapping and for detection of parathyroid adenomas and other tumours, including neuroendocrine tumours of the gastrointestinal tract (GEP-NET). The aim of this study was to determine whether intra-operative radio-detection with the use of [(99m)Tc-EDDA/HYNIC]octreotate, a new somatostatin analogue, is able to reveal an unknown primary and secondary sites, thereby improving surgical treatment and the final outcome of GEP-NET. The study group included nine patients with suspected GEP-NET (four carcinoids, five pancreatic NET) localised with somatostatin receptor scintigraphy (with [(99m)Tc-EDDA/HYNIC]octreotate), who had negative results on other pre-operative imaging tests. At surgery, suspected tumours were measured in situ and ex vivo and precise exploration of the abdominal cavity was performed with the intra-operative scintillation detector (Navigator). Intra-operative gamma counting localised three carcinoids. In one patient SRS was false positive (owing to inflammatory infiltration). Compared with SRS, RGS revealed additional lymph node metastases in one case. RGS resulted in successful localisation of all pancreatic NET (the smallest lesion was 8 mm in diameter). [(99m)Tc-EDDA/HYNIC]octreotate SRS followed by RGS is a promising technique to improve the rate of detection and efficacy of treatment of GEP-NET, especially in the presence of occult endocrine tumours. The imaging properties of [(99m)Tc-EDDA/HYNIC]octreotate and the 1-day imaging protocol offer opportunities for more widespread application of this tracer followed by RGS in oncology.

Management of the Facial Nerve in Lateral Skull Base Surgery Analytic Retrospective Study

PubMed Central

El Shazly, Mohamed A.; Mokbel, Mahmoud A.M.; Elbadry, Amr A.; Badran, Hatem S.

2011-01-01

Background: Surgical approaches to the jugular foramen are often complex and lengthy procedures associated with significant morbidity based on the anatomic and tumor characteristics. In addition to the risk of intra-operative hemorrhage from vascular tumors, lower cranial nerves deficits are frequently increased after intra-operative manipulation. Accordingly, modifications in the surgical techniques have been developed to minimize these risks. Preoperative embolization and intra-operative ligation of the external carotid artery have decreased the intraoperative blood loss. Accurate identification and exposure of the cranial nerves extracranially allows for their preservation during tumor resection. The modification of facial nerve mobilization provides widened infratemporal exposure with less postoperative facial weakness. The ideal approach should enable complete, one stage tumor resection with excellent infratemporal and posterior fossa exposure and would not aggravate or cause neurologic deficit. The aim of this study is to present our experience in handling jugular foramen lesions (mainly glomus jugulare) without the need for anterior facial nerve transposition. Methods: In this series we present our experience in Kasr ElEini University hospital (Cairo—Egypt) in handling 36 patients with jugular foramen lesions over a period of 20 years where the previously mentioned preoperative and operative rules were followed. The clinical status, operative technique and postoperative care and outcome are detailed and analyzed in relation to the outcome. Results: Complete cure without complications was achieved in four cases of congenital cholesteatoma and four cases with class B glomus. In advanced cases of glomus jugulare (28 patients) (C and D stages) complete cure was achieved in 21 of them (75%). The operative complications were also related to this group of 28 patients, in the form of facial paralysis in 20 of them (55.6%) and symptomatic vagal paralysis in 18 of them (50%). Conclusions: Total anterior rerouting of the facial nerve carries a high risk of facial paralysis. So it should be reserved for cases where the lesion extends beyond the vertical ICA. Otherwise, for less extensive lesions and less aggressive pathologies, less aggressive approaches could be adopted with less hazards. PMID:24179402

Utility of Intraoperative Neuromonitoring during Minimally Invasive Fusion of the Sacroiliac Joint.

PubMed

Woods, Michael; Birkholz, Denise; MacBarb, Regina; Capobianco, Robyn; Woods, Adam

2014-01-01

Study Design. Retrospective case series. Objective. To document the clinical utility of intraoperative neuromonitoring during minimally invasive surgical sacroiliac joint fusion for patients diagnosed with sacroiliac joint dysfunction (as a direct result of sacroiliac joint disruptions or degenerative sacroiliitis) and determine stimulated electromyography thresholds reflective of favorable implant position. Summary of Background Data. Intraoperative neuromonitoring is a well-accepted adjunct to minimally invasive pedicle screw placement. The utility of intraoperative neuromonitoring during minimally invasive surgical sacroiliac joint fusion using a series of triangular, titanium porous plasma coated implants has not been evaluated. Methods. A medical chart review of consecutive patients treated with minimally invasive surgical sacroiliac joint fusion was undertaken at a single center. Baseline patient demographics and medical history, intraoperative electromyography thresholds, and perioperative adverse events were collected after obtaining IRB approval. Results. 111 implants were placed in 37 patients. Sensitivity of EMG was 80% and specificity was 97%. Intraoperative neuromonitoring potentially avoided neurologic sequelae as a result of improper positioning in 7% of implants. Conclusions. The results of this study suggest that intraoperative neuromonitoring may be a useful adjunct to minimally invasive surgical sacroiliac joint fusion in avoiding nerve injury during implant placement.

Intraoperative Clinical Decision Support for Anesthesia: A Narrative Review of Available Systems.

PubMed

Nair, Bala G; Gabel, Eilon; Hofer, Ira; Schwid, Howard A; Cannesson, Maxime

2017-02-01

With increasing adoption of anesthesia information management systems (AIMS), there is growing interest in utilizing AIMS data for intraoperative clinical decision support (CDS). CDS for anesthesia has the potential for improving quality of care, patient safety, billing, and compliance. Intraoperative CDS can range from passive and post hoc systems to active real-time systems that can detect ongoing clinical issues and deviations from best practice care. Real-time CDS holds the most promise because real-time alerts and guidance can drive provider behavior toward evidence-based standardized care during the ongoing case. In this review, we describe the different types of intraoperative CDS systems with specific emphasis on real-time systems. The technical considerations in developing and implementing real-time CDS are systematically covered. This includes the functional modules of a CDS system, development and execution of decision rules, and modalities to alert anesthesia providers concerning clinical issues. We also describe the regulatory aspects that affect development, implementation, and use of intraoperative CDS. Methods and measures to assess the effectiveness of intraoperative CDS are discussed. Last, we outline areas of future development of intraoperative CDS, particularly the possibility of providing predictive and prescriptive decision support.

Intraoperative complications in pediatric neurosurgery: review of 1807 cases.

PubMed

van Lindert, Erik J; Arts, Sebastian; Blok, Laura M; Hendriks, Mark P; Tielens, Luc; van Bilsen, Martine; Delye, Hans

2016-09-01

OBJECTIVE Minimal literature exists on the intraoperative complication rate of pediatric neurosurgical procedures with respect to both surgical and anesthesiological complications. The aim of this study, therefore, was to establish intraoperative complication rates to provide patients and parents with information on which to base their informed consent and to establish a baseline for further targeted improvement of pediatric neurosurgical care. METHODS A clinical complication registration database comprising a consecutive cohort of all pediatric neurosurgical procedures carried out in a general neurosurgical department from January 1, 2004, until July 1, 2012, was analyzed. During the study period, 1807 procedures were performed on patients below the age of 17 years. RESULTS Sixty-four intraoperative complications occurred in 62 patients (3.5% of procedures). Intraoperative mortality was 0.17% (n = 3). Seventy-eight percent of the complications (n = 50) were related to the neurosurgical procedures, whereas 22% (n = 14) were due to anesthesiology. The highest intraoperative complication rates were for cerebrovascular surgery (7.7%) and tumor surgery (7.4%). The most frequently occurring complications were cerebrovascular complications (33%). CONCLUSIONS Intraoperative complications are not exceptional during pediatric neurosurgical procedures. Awareness of these complications is the first step in preventing them.

Mechanistic background and clinical applications of indocyanine green fluorescence imaging of hepatocellular carcinoma.

PubMed

Ishizawa, Takeaki; Masuda, Koichi; Urano, Yasuteru; Kawaguchi, Yoshikuni; Satou, Shouichi; Kaneko, Junichi; Hasegawa, Kiyoshi; Shibahara, Junji; Fukayama, Masashi; Tsuji, Shingo; Midorikawa, Yutaka; Aburatani, Hiroyuki; Kokudo, Norihiro

2014-02-01

Although clinical applications of intraoperative fluorescence imaging of liver cancer using indocyanine green (ICG) have begun, the mechanistic background of ICG accumulation in the cancerous tissues remains unclear. In 170 patients with hepatocellular carcinoma cells (HCC), the liver surfaces and resected specimens were intraoperatively examined by using a near-infrared fluorescence imaging system after preoperative administration of ICG (0.5 mg/kg i.v.). Microscopic examinations, gene expression profile analysis, and immunohistochemical staining were performed for HCCs, which showed ICG fluorescence in the cancerous tissues (cancerous-type fluorescence), and HCCs showed fluorescence only in the surrounding non-cancerous liver parenchyma (rim-type fluorescence). ICG fluorescence imaging enabled identification of 273 of 276 (99%) HCCs in the resected specimens. HCCs showed that cancerous-type fluorescence was associated with higher cancer cell differentiation as compared with rim-type HCCs (P < 0.001). Fluorescence microscopy identified the presence of ICG in the canalicular side of the cancer cell cytoplasm, and pseudoglands of the HCCs showed a cancerous-type fluorescence pattern. The ratio of the gene and protein expression levels in the cancerous to non-cancerous tissues for Na(+)/taurocholate cotransporting polypeptide (NTCP) and organic anion-transporting polypeptide 8 (OATP8), which are associated with portal uptake of ICG by hepatocytes that tended to be higher in the HCCs that showed cancerous-type fluorescence than in those that showed rim-type fluorescence. Preserved portal uptake of ICG in differentiated HCC cells by NTCP and OATP8 with concomitant biliary excretion disorders causes accumulation of ICG in the cancerous tissues after preoperative intravenous administration. This enables highly sensitive identification of HCC by intraoperative ICG fluorescence imaging.

Intraoperative Assessment of Tricuspid Valve Function After Conservative Repair

PubMed Central

Revuelta, J.M.; Gomez-Duran, C.; Garcia-Rinaldi, R.; Gallagher, M.W.

1982-01-01

It is desirable to repair coexistent tricuspid valve pathology at the time of mitral valve corrections. Conservative tricuspid repair may consist of commissurotomy, annuloplasty, or both. It is important that the repair be appropriate or tricuspid valve replacement may be necessary. A simple reproducible method of intraoperative testing for tricuspid valve insufficiency has been developed and used in 25 patients. Fifteen patients have been recatheterized, and the correlation between the intraoperative and postoperative findings has been consistent. PMID:15226931

Localizing ECoG electrodes on the cortical anatomy without post-implantation imaging

PubMed Central

Gupta, Disha; Hill, N. Jeremy; Adamo, Matthew A.; Ritaccio, Anthony; Schalk, Gerwin

2014-01-01

Introduction Electrocorticographic (ECoG) grids are placed subdurally on the cortex in people undergoing cortical resection to delineate eloquent cortex. ECoG signals have high spatial and temporal resolution and thus can be valuable for neuroscientific research. The value of these data is highest when they can be related to the cortical anatomy. Existing methods that establish this relationship rely either on post-implantation imaging using computed tomography (CT), magnetic resonance imaging (MRI) or X-Rays, or on intra-operative photographs. For research purposes, it is desirable to localize ECoG electrodes on the brain anatomy even when post-operative imaging is not available or when intra-operative photographs do not readily identify anatomical landmarks. Methods We developed a method to co-register ECoG electrodes to the underlying cortical anatomy using only a pre-operative MRI, a clinical neuronavigation device (such as BrainLab VectorVision), and fiducial markers. To validate our technique, we compared our results to data collected from six subjects who also had post-grid implantation imaging available. We compared the electrode coordinates obtained by our fiducial-based method to those obtained using existing methods, which are based on co-registering pre- and post-grid implantation images. Results Our fiducial-based method agreed with the MRI–CT method to within an average of 8.24 mm (mean, median = 7.10 mm) across 6 subjects in 3 dimensions. It showed an average discrepancy of 2.7 mm when compared to the results of the intra-operative photograph method in a 2D coordinate system. As this method does not require post-operative imaging such as CTs, our technique should prove useful for research in intra-operative single-stage surgery scenarios. To demonstrate the use of our method, we applied our method during real-time mapping of eloquent cortex during a single-stage surgery. The results demonstrated that our method can be applied intra-operatively in the absence of post-operative imaging to acquire ECoG signals that can be valuable for neuroscientific investigations. PMID:25379417

Updating a preoperative surface model with information from real-time tracked 2D ultrasound using a Poisson surface reconstruction algorithm

NASA Astrophysics Data System (ADS)

Sun, Deyu; Rettmann, Maryam E.; Holmes, David R.; Linte, Cristian A.; Packer, Douglas; Robb, Richard A.

2014-03-01

In this work, we propose a method for intraoperative reconstruction of a left atrial surface model for the application of cardiac ablation therapy. In this approach, the intraoperative point cloud is acquired by a tracked, 2D freehand intra-cardiac echocardiography device, which is registered and merged with a preoperative, high resolution left atrial surface model built from computed tomography data. For the surface reconstruction, we introduce a novel method to estimate the normal vector of the point cloud from the preoperative left atrial model, which is required for the Poisson Equation Reconstruction algorithm. In the current work, the algorithm is evaluated using a preoperative surface model from patient computed tomography data and simulated intraoperative ultrasound data. Factors such as intraoperative deformation of the left atrium, proportion of the left atrial surface sampled by the ultrasound, sampling resolution, sampling noise, and registration error were considered through a series of simulation experiments.

Operative record using intraoperative digital data in neurosurgery.

PubMed

Houkin, K; Kuroda, S; Abe, H

2000-01-01

The purpose of this study was to develop a new method for more efficient and accurate operative records using intra-operative digital data in neurosurgery, including macroscopic procedures and microscopic procedures under an operating microscope. Macroscopic procedures were recorded using a digital camera and microscopic procedures were also recorded using a microdigital camera attached to an operating microscope. Operative records were then recorded digitally and filed in a computer using image retouch software and database base software. The time necessary for editing of the digital data and completing the record was less than 30 minutes. Once these operative records are digitally filed, they are easily transferred and used as database. Using digital operative records along with digital photography, neurosurgeons can document their procedures more accurately and efficiently than by the conventional method (handwriting). A complete digital operative record is not only accurate but also time saving. Construction of a database, data transfer and desktop publishing can be achieved using the intra-operative data, including intra-operative photographs.

Rapid and accurate intraoperative pathological diagnosis by artificial intelligence with deep learning technology.

PubMed

Zhang, Jing; Song, Yanlin; Xia, Fan; Zhu, Chenjing; Zhang, Yingying; Song, Wenpeng; Xu, Jianguo; Ma, Xuelei

2017-09-01

Frozen section is widely used for intraoperative pathological diagnosis (IOPD), which is essential for intraoperative decision making. However, frozen section suffers from some drawbacks, such as time consuming and high misdiagnosis rate. Recently, artificial intelligence (AI) with deep learning technology has shown bright future in medicine. We hypothesize that AI with deep learning technology could help IOPD, with a computer trained by a dataset of intraoperative lesion images. Evidences supporting our hypothesis included the successful use of AI with deep learning technology in diagnosing skin cancer, and the developed method of deep-learning algorithm. Large size of the training dataset is critical to increase the diagnostic accuracy. The performance of the trained machine could be tested by new images before clinical use. Real-time diagnosis, easy to use and potential high accuracy were the advantages of AI for IOPD. In sum, AI with deep learning technology is a promising method to help rapid and accurate IOPD. Copyright © 2017 Elsevier Ltd. All rights reserved.

Aortic balloon occlusion for controlling intraoperative hemorrhage in patients with placenta previa increta/percreta.

PubMed

Wang, Ying-Lan; Su, Fang-Ming; Zhang, Hai-Ying; Wang, Fang; Zhe, Rui-Lian; Shen, Xin-Ying

2017-11-01

To investigate whether abdominal aortic balloon occlusion (ABO) effectively reduces intraoperative hemorrhage in patents with placenta previa increta/increta. Forty-three women were diagnosed as placenta previa increta/percreta by ultrasound and MRI. These patients' assessments were taken by their chief physician, and they were under necessity of previous cesarean section as confirmed by the committee of experts during consultation. There was no significant difference in disease risk rating between them in whole process. Although our department provided a more appropriate method, 10 of 43 patients chose intraoperative aortic balloon occlusion (IABO). Other 33 patients who refused that suggestion were considered as control group. Fully informed consents were obtained from all patients in this study group. The intraoperative blood loss, blood transfusion, rate of hysterectomy and complications of mothers and fetus of IABO group and control group were analyzed. The median intraoperative blood loss was 1000 ml in the IABO group compared with 2000 ml in the control group (p < 0.05). The median volume of transfused red blood cells was 1100 ml in the IABO group compared with 2000 ml in the control group (p < 0.05). 33.3% (11/33) patients in the control group had hemorrhagic shock, and one of them suffered from cardiac arrest intraoperatively because of severe bleeding. However, none of these serious events occurred in the IABO group (p < 0.05). The hysterectomy rate was 70% (7/10) in the IABO group and 63.3% (21/33) in the control group (p > 0.05). No IABO-related complications were observed in the mother and fetus. IABO is an effective and safe method to control intraoperative blood loss and blood transfusion in patients with placenta previa increta/percreta.

Hybrid surgical guidance based on the integration of radionuclear and optical technologies

PubMed Central

Valdés-Olmos, Renato; Buckle, Tessa; Vidal-Sicart, Sergi

2016-01-01

With the evolution of imaging technologies and tracers, the applications for nuclear molecular imaging are growing rapidly. For example, nuclear medicine is increasingly being used to guide surgical resections in complex anatomical locations. Here, a future workflow is envisioned that uses a combination of pre-operative diagnostics, navigation and intraoperative guidance. Radioguidance can provide means for pre-operative and intraoperative identification of “hot” lesions, forming the basis of a virtual data set that can be used for navigation. Luminescence guidance has shown great potential in the intraoperative setting by providing optical feedback, in some cases even in real time. Both of these techniques have distinct drawbacks, which include inaccuracy in areas that contain a background signal (radioactivity) or a limited degree of signal penetration (luminescence). We, and others, have reasoned that hybrid/multimodal approaches that integrate the use of these complementary modalities may help overcome their individual weaknesses. Ultimately, this will lead to advancement of the field of interventional molecular imaging/image-guided surgery. In this review, an overview of clinically applied hybrid surgical guidance technologies is given, whereby the focus is placed on tracers and hardware. PMID:26943463

Localizing ECoG electrodes on the cortical anatomy without post-implantation imaging.

PubMed

Gupta, Disha; Hill, N Jeremy; Adamo, Matthew A; Ritaccio, Anthony; Schalk, Gerwin

2014-01-01

Electrocorticographic (ECoG) grids are placed subdurally on the cortex in people undergoing cortical resection to delineate eloquent cortex. ECoG signals have high spatial and temporal resolution and thus can be valuable for neuroscientific research. The value of these data is highest when they can be related to the cortical anatomy. Existing methods that establish this relationship rely either on post-implantation imaging using computed tomography (CT), magnetic resonance imaging (MRI) or X-Rays, or on intra-operative photographs. For research purposes, it is desirable to localize ECoG electrodes on the brain anatomy even when post-operative imaging is not available or when intra-operative photographs do not readily identify anatomical landmarks. We developed a method to co-register ECoG electrodes to the underlying cortical anatomy using only a pre-operative MRI, a clinical neuronavigation device (such as BrainLab VectorVision), and fiducial markers. To validate our technique, we compared our results to data collected from six subjects who also had post-grid implantation imaging available. We compared the electrode coordinates obtained by our fiducial-based method to those obtained using existing methods, which are based on co-registering pre- and post-grid implantation images. Our fiducial-based method agreed with the MRI-CT method to within an average of 8.24 mm (mean, median = 7.10 mm) across 6 subjects in 3 dimensions. It showed an average discrepancy of 2.7 mm when compared to the results of the intra-operative photograph method in a 2D coordinate system. As this method does not require post-operative imaging such as CTs, our technique should prove useful for research in intra-operative single-stage surgery scenarios. To demonstrate the use of our method, we applied our method during real-time mapping of eloquent cortex during a single-stage surgery. The results demonstrated that our method can be applied intra-operatively in the absence of post-operative imaging to acquire ECoG signals that can be valuable for neuroscientific investigations.

Management of Spinal Arteriovenous Fistulae with Intraarterial Indocyanine Green Angiography: A Case Report.

PubMed

Caglar, Y Sukru; Ozdemir, Mevci; Kahilogullari, Gokmen; Bozkurt, Melih; Attar, Ayhan

2018-01-01

We describe herein intraoperative effectiveness of indocyanine green (ICG) video angiography to confirm dural arteriovenous fistulae. A 62-year-old man with a residual symptomatic dural arteriovenous fistula that was previously embolized at another institution is presented. On neurological examination, the motor strength in his both lower extremities was documented as grade 4 and the patella reflex was slightly increased. After verifying the presence of abnormal early venous drainage and retrograde flow with indocyanine green video angiography, the fistula was repaired. Postoperatively there was no additional neurologic deficit. Five days after the operation, the patient was discharged. Intraoperative ICG video angiography provides non-invasive and realtime information, reduction of spinal cord ischemic damage, rapid identification of feeding artery and confirmation of its complete disconnection during surgery, reduction of operative time, and improved outcome with no radiation hazard.

Non-recurrent laryngeal nerve with a coexisting contralateral nerve demonstrating extralaryngeal branching.

PubMed

Constable, James D; Bathala, Srinivasalu; Ahmed, Jacob J; McGlashan, Julian A

2017-03-17

Non-recurrence and extralaryngeal branching are 2 of the more frequently encountered anomalies of the recurrent laryngeal nerve. If not anticipated intraoperatively, these abnormalities can put the nerve at risk, with subsequent vocal cord palsy. It is therefore important to report on and understand these abnormalities. We present a unique case of a non-recurrent laryngeal nerve with a coexisting contralateral nerve demonstrating extralaryngeal branching. This case allows us to demonstrate the importance of arteria lusoria in head and neck surgery, and to conclude that non-recurrence and extralaryngeal branching can occur separately within individual nerves in the same patient. The case also highlights the importance of a systematic intraoperative approach to the identification of every recurrent laryngeal nerve, especially in bilateral procedures having already exposed an anomalous nerve on one side. 2017 BMJ Publishing Group Ltd.

Intraoperative fracture of phacoemulsification sleeve

PubMed Central

2010-01-01

Background We describe a case of intraoperative fracture of phacoemulsification sleeve during phacoemulsification surgery. Case presentation Phacoemulsification surgery was performed in the left eye of a 58-year-old lady with grade II nuclear sclerosis & grade I cortical cataract. Towards the end of quadrant removal, there was anterior chamber instability with impaired followability of nuclear fragments. The distal part of the fractured sleeve remained inside the anterior chamber upon removal of the phacoemulsification probe. The retained sleeve was retrieved with a pair of forceps through the corneal incision site, which did not require widening. There was no missing fragments retained intraocularly and the patient had an uneventful recovery with vision of 20/25 at three months post-operatively. Conclusion Phacoemulsification sleeve fracture is an uncommon complication. With early identification of this condition and proper management, major complications can be avoided. PMID:21118542

Preoperative Recipient Parameters Allow Early Estimation of Postoperative Outcome and Intraoperative Transfusion Requirements in Liver Transplantation.

PubMed

Schumacher, Carsten; Eismann, Hendrik; Sieg, Lion; Friedrich, Lars; Scheinichen, Dirk; Vondran, Florian W R; Johanning, Kai

2018-01-01

Liver transplantation is a complex intervention, and early anticipation of personnel and logistic requirements is of great importance. Early identification of high-risk patients could prove useful. We therefore evaluated prognostic values of recipient parameters commonly available in the early preoperative stage regarding postoperative 30- and 90-day outcomes and intraoperative transfusion requirements in liver transplantation. All adult patients undergoing first liver transplantation at Hannover Medical School between January 2005 and December 2010 were included in this retrospective study. Demographic, clinical, and laboratory data as well as clinical courses were recorded. Prognostic values regarding 30- and 90-day outcomes were evaluated by uni- and multivariate statistical tests. Identified risk parameters were used to calculate risk scores. There were 426 patients (40.4% female) included with a mean age of 48.6 (11.9) years. Absolute 30-day mortality rate was 9.9%, and absolute 90-day mortality rate was 13.4%. Preoperative leukocyte count >5200/μL, platelet count <91 000/μL, and creatinine values ≥77 μmol/L were relevant risk factors for both observation periods ( P < .05, respectively). A score based on these factors significantly differentiated between groups of varying postoperative outcomes and intraoperative transfusion requirements ( P < .05, respectively). A score based on preoperative creatinine, leukocyte, and platelet values allowed early estimation of postoperative 30- and 90-day outcomes and intraoperative transfusion requirements in liver transplantation. Results might help to improve timely logistic and personal strategies.

Clinical application of indocyanine green-fluorescence imaging during hepatectomy

PubMed Central

Ishizawa, Takeaki; Saiura, Akio

2016-01-01

In hepatobiliary surgery, the fluorescence and bile excretion of indocyanine green (ICG) can be used for real-time visualization of biological structure. Fluorescence cholangiography is used to obtain fluorescence images of the bile ducts following intrabiliary injection of 0.025−0.5 mg/mL ICG or intravenous injection of 2.5 mg ICG. Recently, the latter technique has been used in laparoscopic/robotic cholecystectomy. Intraoperative fluorescence imaging can be used to identify subcapsular hepatic tumors. Primary and secondary hepatic malignancy can be identified by intraoperative fluorescence imaging using preoperative intravenous injection of ICG through biliary excretion disorders that exist in cancerous tissues of hepatocellular carcinoma (HCC) and in non-cancerous hepatic parenchyma around adenocarcinoma foci. Intraoperative fluorescence imaging may help detect tumors to be removed, especially during laparoscopic hepatectomy, in which visual inspection and palpation are limited, compared with open surgery. Fluorescence imaging can also be used to identify hepatic segments. Boundaries of hepatic segments can be visualized following injection of 0.25−2.5 mg/mL ICG into the portal veins or by intravenous injection of 2.5 mg ICG following closure of the proximal portal pedicle toward hepatic regions to be removed. These techniques enable identification of hepatic segments before hepatectomy and during parenchymal transection for anatomic resection. Advances in imaging systems will increase the use of fluorescence imaging as an intraoperative navigation tool that can enhance the safety and accuracy of open and laparoscopic/robotic hepatobiliary surgery. PMID:27500144

Rationale and study design for an individualized perioperative open lung ventilatory strategy (iPROVE): study protocol for a randomized controlled trial.

PubMed

Ferrando, Carlos; Soro, Marina; Canet, Jaume; Unzueta, Ma Carmen; Suárez, Fernando; Librero, Julián; Peiró, Salvador; Llombart, Alicia; Delgado, Carlos; León, Irene; Rovira, Lucas; Ramasco, Fernando; Granell, Manuel; Aldecoa, César; Diaz, Oscar; Balust, Jaume; Garutti, Ignacio; de la Matta, Manuel; Pensado, Alberto; Gonzalez, Rafael; Durán, M Eugenia; Gallego, Lucia; Del Valle, Santiago García; Redondo, Francisco J; Diaz, Pedro; Pestaña, David; Rodríguez, Aurelio; Aguirre, Javier; García, Jose M; García, Javier; Espinosa, Elena; Charco, Pedro; Navarro, Jose; Rodríguez, Clara; Tusman, Gerardo; Belda, Francisco Javier

2015-04-27

Postoperative pulmonary and non-pulmonary complications are common problems that increase morbidity and mortality in surgical patients, even though the incidence has decreased with the increased use of protective lung ventilation strategies. Previous trials have focused on standard strategies in the intraoperative or postoperative period, but without personalizing these strategies to suit the needs of each individual patient and without considering both these periods as a global perioperative lung-protective approach. The trial presented here aims at comparing postoperative complications when using an individualized ventilatory management strategy in the intraoperative and immediate postoperative periods with those when using a standard protective ventilation strategy in patients scheduled for major abdominal surgery. This is a comparative, prospective, multicenter, randomized, and controlled, four-arm trial that will include 1012 patients with an intermediate or high risk for postoperative pulmonary complications. The patients will be divided into four groups: (1) individualized perioperative group: intra- and postoperative individualized strategy; (2) intraoperative individualized strategy + postoperative continuous positive airway pressure (CPAP); (3) intraoperative standard ventilation + postoperative CPAP; (4) intra- and postoperative standard strategy (conventional strategy). The primary outcome is a composite analysis of postoperative complications. The Individualized Perioperative Open-lung Ventilatory Strategy (iPROVE) is the first multicenter, randomized, and controlled trial to investigate whether an individualized perioperative approach prevents postoperative pulmonary complications. Registered on 5 June 2014 with identification no. NCT02158923 .

Squash preparation: A reliable diagnostic tool in the intraoperative diagnosis of central nervous system tumors

PubMed Central

Mitra, Sumit; Kumar, Mohan; Sharma, Vivek; Mukhopadhyay, Debasis

2010-01-01

Background: Intraoperative cytology is an important diagnostic modality improving on the accuracy of the frozen sections. It has shown to play an important role especially in the intraoperative diagnosis of central nervous system tumors. Aim: To study the diagnostic accuracy of squash preparation and frozen section (FS) in the intraoperative diagnosis of central nervous system (CNS) tumors. Materials and Methods: This prospective study of 114 patients with CNS tumors was conducted over a period of 18 months (September 2004 to February 2006). The cytological preparations were stained by the quick Papanicolaou method. The squash interpretation and FS diagnosis were later compared with the paraffin section diagnosis. Results: Of the 114 patients, cytological diagnosis was offered in 96 cases. Eighteen nonneoplastic or noncontributory cases were excluded. Using hematoxylin and eosin-stained histopathology sections as the gold standard, the diagnostic accuracy of cytology was 88.5% (85/96) and the accuracy on FS diagnosis was 90.6% (87/96). Among these cases, gliomas formed the largest category of tumors (55.2%). The cytological accuracy in this group was 84.9% (45/53) and the comparative FS figure was 86.8% (46/53). In cases where the smear and the FS diagnosis did not match, the latter opinion was offered. Conclusions: Squash preparation is a reliable, rapid and easy method and can be used as a complement to FS in the intraoperative diagnosis of CNS tumors. PMID:21187881

Inside the beating heart: an in vivo feasibility study on fusing pre- and intra-operative imaging for minimally invasive therapy.

PubMed

Linte, Cristian A; Moore, John; Wedlake, Chris; Bainbridge, Daniel; Guiraudon, Gérard M; Jones, Douglas L; Peters, Terry M

2009-03-01

An interventional system for minimally invasive cardiac surgery was developed for therapy delivery inside the beating heart, in absence of direct vision. A system was developed to provide a virtual reality (VR) environment that integrates pre-operative imaging, real-time intra-operative guidance using 2D trans-esophageal ultrasound, and models of the surgical tools tracked using a magnetic tracking system. Detailed 3D dynamic cardiac models were synthesized from high-resolution pre-operative MR data and registered within the intra-operative imaging environment. The feature-based registration technique was employed to fuse pre- and intra-operative data during in vivo intracardiac procedures on porcine subjects. This method was found to be suitable for in vivo applications as it relies on easily identifiable landmarks, and hence, it ensures satisfactory alignment of pre- and intra-operative anatomy in the region of interest (4.8 mm RMS alignment accuracy) within the VR environment. Our initial experience in translating this work to guide intracardiac interventions, such as mitral valve implantation and atrial septal defect repair demonstrated feasibility of the methods. Surgical guidance in the absence of direct vision and with no exposure to ionizing radiation was achieved, so our virtual environment constitutes a feasible candidate for performing various off-pump intracardiac interventions.

Intraoperative analysis of sentinel lymph nodes by imprint cytology for cancer of the breast.

PubMed

Shiver, Stephen A; Creager, Andrew J; Geisinger, Kim; Perrier, Nancy D; Shen, Perry; Levine, Edward A

2002-11-01

The utilization of lymphatic mapping techniques for breast carcinoma has made intraoperative evaluation of sentinel lymph nodes (SLN) attractive, because axillary lymph node dissection can be performed during the initial surgery if the SLN is positive. The optimal technique for rapid SLN assessment has not been determined. Both frozen sectioning and imprint cytology are used for rapid intraoperative SLN evaluation. A retrospective review of the intraoperative imprint cytology results of 133 SLN mapping procedures from 132 breast carcinoma patients was performed. SLN were evaluated intraoperatively by bisecting the lymph node and making imprints of each cut surface. Imprints were stained with hematoxylin and eosin (H&E) and Diff-Quik. Permanent sections were evaluated with up to four H&E stained levels and cytokeratin immunohistochemistry. Imprint cytology results were compared with final histologic results. Sensitivity and specificity of imprint cytology were 56% and 100%, respectively, producing a 100% positive predictive value and 88% negative predictive value. Imprint cytology was significantly more sensitive for macrometastasis than micrometastasis 87% versus 22% (P = 0.00007). Of 13 total false negatives, 11 were found to be due to sampling error and 2 due to errors in intraoperative interpretation. Both intraoperative interpretation errors involved a diagnosis of lobular breast carcinoma. The sensitivity and specificity of imprint cytology are similar to that of frozen section evaluation. Imprint cytology is therefore a viable alternative to frozen sectioning when intraoperative evaluation is required. If SLN micrometastasis is used to determine the need for further lymphadenectomy, more sensitive intraoperative methods will be needed to avoid a second operation.

Early Experience with Combining Awake Craniotomy and Intraoperative Navigable Ultrasound for Resection of Eloquent Region Gliomas.

PubMed

Moiyadi, Aliasgar; Shetty, Prakash

2017-03-01

Introduction  Optimal resection of tumors in eloquent locations requires a combination of intraoperative imaging and functional monitoring during surgery. Combining awake surgery with intraoperative magnetic resonanceis logistically challenging. Navigable ultrasound (US) is a useful alternative in such cases. Methods  A total of 22 subjects with eloquent tumors were operated on (1 intended biopsy and 21 intended radical resections) using combined modality three-dimensional (3D) US and awake craniotomy with intraoperative clinical monitoring. We describe the technical details for these cases specifically addressing the feasibility of combining the two modalities. Results  US was used for resection control in 18 cases. There were technical limitations in three cases. Transient intraoperative worsening was encountered in eight, necessitating premature termination of the procedure. All patients tolerated the awake procedure well. Mean duration of the surgery was 3.2 hours. Radical resections were obtained in 14 of 18 where this was intended and in 12 of the 13 where there was no adverse intraoperative monitoring event prompting premature termination of the resection. Conclusions  Combining awake surgery with 3DUS is feasible and beneficial. It does not entail any additional surgical workflow modification or patient discomfort. This combined modality intraoperative monitoring can be beneficial for eloquent region tumors. Georg Thieme Verlag KG Stuttgart · New York.

Intraoperative CT in the assessment of posterior wall acetabular fracture stability.

PubMed

Cunningham, Brian; Jackson, Kelly; Ortega, Gil

2014-04-01

Posterior wall acetabular fractures that involve 10% to 40% of the posterior wall may or may not require an open reduction and internal fixation. Dynamic stress examination of the acetabular fracture under fluoroscopy has been used as an intraoperative method to assess joint stability. The aim of this study was to demonstrate the value of intraoperative ISO computed tomography (CT) examination using the Siemens ISO-C imaging system (Siemens Corp, Malvern, Pennsylvania) in the assessment of posterior wall acetabular fracture stability during stress examination under anesthesia. In 5 posterior wall acetabular fractures, standard fluoroscopic images (including anteroposterior pelvis and Judet radiographs) with dynamic stress examinations were compared with the ISO-C CT imaging system to assess posterior wall fracture stability during stress examination. After review of standard intraoperative fluoroscopic images under dynamic stress examination, all 5 cases appeared to demonstrate posterior wall stability; however, when the intraoperative images from the ISO-C CT imaging system demonstrated that 1 case showed fracture instability of the posterior wall segment during stress examination, open reduction and internal fixation was performed. The use of intraoperative ISO CT imaging has shown an initial improvement in the surgeon's ability to assess the intraoperative stability of posterior wall acetabular fractures during stress examination when compared with standard fluoroscopic images. Copyright 2014, SLACK Incorporated.

Microelectrode Recordings Validate the Clinical Visualization of Subthalamic-Nucleus Based on 7T Magnetic Resonance Imaging and Machine Learning for Deep Brain Stimulation Surgery.

PubMed

Shamir, Reuben R; Duchin, Yuval; Kim, Jinyoung; Patriat, Remi; Marmor, Odeya; Bergman, Hagai; Vitek, Jerrold L; Sapiro, Guillermo; Bick, Atira; Eliahou, Ruth; Eitan, Renana; Israel, Zvi; Harel, Noam

2018-05-24

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a proven and effective therapy for the management of the motor symptoms of Parkinson's disease (PD). While accurate positioning of the stimulating electrode is critical for success of this therapy, precise identification of the STN based on imaging can be challenging. We developed a method to accurately visualize the STN on a standard clinical magnetic resonance imaging (MRI). The method incorporates a database of 7-Tesla (T) MRIs of PD patients together with machine-learning methods (hereafter 7 T-ML). To validate the clinical application accuracy of the 7 T-ML method by comparing it with identification of the STN based on intraoperative microelectrode recordings. Sixteen PD patients who underwent microelectrode-recordings guided STN DBS were included in this study (30 implanted leads and electrode trajectories). The length of the STN along the electrode trajectory and the position of its contacts to dorsal, inside, or ventral to the STN were compared using microelectrode-recordings and the 7 T-ML method computed based on the patient's clinical 3T MRI. All 30 electrode trajectories that intersected the STN based on microelectrode-recordings, also intersected it when visualized with the 7 T-ML method. STN trajectory average length was 6.2 ± 0.7 mm based on microelectrode recordings and 5.8 ± 0.9 mm for the 7 T-ML method. We observed a 93% agreement regarding contact location between the microelectrode-recordings and the 7 T-ML method. The 7 T-ML method is highly consistent with microelectrode-recordings data. This method provides a reliable and accurate patient-specific prediction for targeting the STN.

Near-Infrared Imaging for the Assessment of Anastomotic Patency, Thrombosis, and Reperfusion in Microsurgery: A Pilot Study in a Porcine Model

PubMed Central

Vargas, Christina R.; Nguyen, John T.; Ashitate, Yoshitomo; Silvestre, Jason; Venugopal, Vivek; Neacsu, Florin; Kettenring, Frank; Frangioni, John V.; Gioux, Sylvain; Lee, Bernard T.

2015-01-01

Background Advances in microsurgical techniques have increased the use of free tissue transfer. Methods of intraoperative flap perfusion assessment, however, still rely primarily on subjective evaluation of traditional clinical parameters. Anastomotic thrombosis, if not expeditiously identified and revised, can result in flap loss with significant associated morbidity. This study aims to evaluate the use of near-infrared (NIR) fluorescence imaging in the assessment of microsurgical anastomotic patency, thrombosis, and vascular revision. Materials and Methods A model of pedicle thrombosis was created using bilateral abdominal flaps isolated on deep superior epigastric vascular pedicles in four Yorkshire pigs. Following flap elevation, microvascular arterial and venous anastomoses were performed unilaterally, preserving an intact contralateral control flap. Thrombosis was induced at the arterial anastomosis site using ferric chloride, and both flaps imaged using NIR fluorescence angiography. The thrombosed vascular segments were subsequently excised and new anastomoses performed to restore flow. Follow-up imaging of both flaps was then obtained to confirm patency using fluorescence imaging technology. Results Pedicled abdominal flaps were created and successful anastomotic thrombosis was induced unilaterally in each pig. Fluorescence imaging technology identified large decreases in tissue perfusion of the thrombosed flap within 2 minutes. After successful revision anastomosis, NIR imaging demonstrated dramatic increase in flow to the reconstructed flap, but intensity did not return to pre-thrombosis levels. Conclusions Early identification of anastomotic thrombosis is important in successful free tissue transfer. Real-time, intraoperative evaluation of flap perfusion, anastomotic thrombosis, and successful revision can be performed using NIR fluorescence imaging. PMID:25571855

Intraoperative computed tomography guided neuronavigation: concepts, efficiency, and work flow.

PubMed

Matula, C; Rössler, K; Reddy, M; Schindler, E; Koos, W T

1998-01-01

Image-guided surgery is currently considered to be of undisputed value in microsurgical and endoscopical neurosurgery, but one of its major drawbacks is the degradation of accuracy during frameless stereotactic neuronavigation due to brain and/or lesion shift. A computed tomography (CT) scanner system (Philips Tomoscan M) developed for the operating room was connected to a pointer device navigation system for image-guided surgery (Philips EasyGuide system) in order to provide an integrated solution to this problem, and the advantages of this combination were evaluated in 20 cases (15 microsurgical and 5 endoscopic). The integration of the scanner into the operating room setup was successful in all procedures. The patients were positioned on a specially developed scanner table, which permitted movement to a scanning position then back to the operating position at any time during surgery. Contrast-enhanced preoperative CCTs performed following positioning and draping were of high quality in all cases, because a radiolucent head fixation technique was used. The accuracy achieved with this combination was significantly better (1.6:1.22.2). The overall concept is one of working in a closed system where everything is done in the same room, and the efficiency of this is clearly proven in different ways. The most important fact is the time saved in the overall treatment process (about 55 h for one operating room over a 6-month period). The combination of an intraoperative CCT scanner with the pointer device neuronavigation system permits not only the intraoperative control of resection of brain tumors, but also (in about 20% of cases) the identification of otherwise invisible residual tumor tissue by intraoperative update of the neuronavigation data set. Additionally, an image update solves the problem of intraoperative brain and/or tumor shifts during image-guided resection. Having the option of making an intraoperative quality check at any time leads to significantly increased efficiency, improves the operating work flow because of the closed-system concept, and offers an integrated solution for improved patient work flow and clinical outcome.

Intra-Operative Predictors of difficult cholecystectomy and Conversion to Open Cholecystectomy - A New Scoring System.

PubMed

Ahmed, Nauman; Hassan, Maaz Ul; Tahira, Maham; Samad, Abdul; Rana, Hamad Naeem

2018-01-01

To evaluate the intra-operative scoring system to predict difficult cholecystectomy and conversion to open surgery. This descriptive study was conducted from March 2016 to August, 2016 in the Department of Surgery, Shalimar Hospital. The study recruited 120 patients of either gender, age greater than 18 years and indicated for laparoscopic cholecystectomy (LC). Intra-operatively all patients were evaluated using the new scoring system. The scoring system included five aspects; appearance and adhesion of Gall Bladder (GB), distension or contracture degree of GB, ease in access, local or septic complications, and time required for cystic artery and duct identification. The scoring system ranges from 0 to 10, classified as score of <2 being considered easy, 2 to 4 moderate, 5-7 very difficult, and 8 to 10, extreme. Patient demographic data (i.e. age, gender), co-morbidities, intra-operative scores using the scoring system and conversion to open were recorded. The data was analysed using statistical analysis software SPSS (IBM). Among one hundred and twenty participants, sixty seven percent were females and the mean age (years) was 43.05 ± 14.16. Co-morbidities were present in twenty percent patients with eleven diagnosed with diabetes, six with hypertension and five with both hypertension and diabetes. The conversion rate to open surgery was 6.7%. The overall mean intra-operative scores were 3.52 ± 2.23; however significant difference was seen in mean operative score of converted to open and those not converted to open (8.00 ± 0.92 Vs. 3.20 V 1.92; p-value = 0.001). Among eight cases converted to open, three (37.5%) were in very difficult category while five (62.5%) were in extreme category. Moreover, age greater than 40 years and being diabetic were also the risk factors for conversion to open surgery. The new intra-operative scoring system is a valuable assessment tool to predict difficult laparoscopic cholecystectomy and conversion parameters to open surgery and its utility could improve patient's clinical outcome indicated for laparoscopic cholecystectomy.

The Dutch Linguistic Intraoperative Protocol: a valid linguistic approach to awake brain surgery.

PubMed

De Witte, E; Satoer, D; Robert, E; Colle, H; Verheyen, S; Visch-Brink, E; Mariën, P

2015-01-01

Intraoperative direct electrical stimulation (DES) is increasingly used in patients operated on for tumours in eloquent areas. Although a positive impact of DES on postoperative linguistic outcome is generally advocated, information about the neurolinguistic methods applied in awake surgery is scarce. We developed for the first time a standardised Dutch linguistic test battery (measuring phonology, semantics, syntax) to reliably identify the critical language zones in detail. A normative study was carried out in a control group of 250 native Dutch-speaking healthy adults. In addition, the clinical application of the Dutch Linguistic Intraoperative Protocol (DuLIP) was demonstrated by means of anatomo-functional models and five case studies. A set of DuLIP tests was selected for each patient depending on the tumour location and degree of linguistic impairment. DuLIP is a valid test battery for pre-, intraoperative and postoperative language testing and facilitates intraoperative mapping of eloquent language regions that are variably located. Copyright © 2014 Elsevier Inc. All rights reserved.

Rapid Intraoperative Molecular Characterization of Glioma

PubMed Central

Shankar, Ganesh M.; Francis, Joshua M.; Rinne, Mikael L.; Ramkissoon, Shakti H.; Huang, Franklin W.; Venteicher, Andrew S.; Akama-Garren, Elliot H.; Kang, Yun Jee; Lelic, Nina; Kim, James C.; Brown, Loreal E.; Charbonneau, Sarah K.; Golby, Alexandra J.; Pedamallu, Chandra Sekhar; Hoang, Mai P.; Sullivan, Ryan J.; Cherniack, Andrew D.; Garraway, Levi A.; Stemmer-Rachamimov, Anat; Reardon, David A.; Wen, Patrick Y.; Brastianos, Priscilla K.; Curry, William T.; Barker, Fred G.; Hahn, William C.; Nahed, Brian V.; Ligon, Keith L.; Louis, David N.; Cahill, Daniel P.; Meyerson, Matthew

2016-01-01

IMPORTANCE Conclusive intraoperative pathologic confirmation of diffuse infiltrative glioma guides the decision to pursue definitive neurosurgical resection. Establishing the intraoperative diagnosis by histologic analysis can be difficult in low-cellularity infiltrative gliomas. Therefore, we developed a rapid and sensitive genotyping assay to detect somatic single-nucleotide variants in the telomerase reverse transcriptase (TERT) promoter and isocitrate dehydrogenase 1 (IDH1). OBSERVATIONS This assay was applied to tissue samples from 190 patients with diffuse gliomas, including archived fixed and frozen specimens and tissue obtained intraoperatively. Results demonstrated 96% sensitivity (95% CI, 90%–99%) and 100% specificity (95% CI, 95%–100%) for World Health Organization grades II and III gliomas. In a series of live cases, glioma-defining mutations could be identified within 60 minutes, which could facilitate the diagnosis in an intraoperative timeframe. CONCLUSIONS AND RELEVANCE The genotyping method described herein can establish the diagnosis of low-cellularity tumors like glioma and could be adapted to the point-of-care diagnosis of other lesions that are similarly defined by highly recurrent somatic mutations. PMID:26181761

Role of 5-ALA in improving extent of tumour resection in patients with Glioblastoma Multiforme.

PubMed

Waqas, Muhammad; Khan, Inamullah; Shamim, Muhammad Shahzad

2017-10-01

Goal of surgery for patients with Glioblastoma Multiforme (GBM) is gross total resection with no new neurological deficits. Surgical resection is often restricted due the difficulty in differentiating the tumour from surrounding normal brain using either naked eye, or standard intra-operative white light microscopy. GBM uptakes orally administered 5-ALA becomes fluorescent when viewed by a special light, and this property has been used to improve intra-operative tumour identification. This technique should therefore allow better extent of tumour resection. The hypothesis has been tested through several studies and even though most studies are of low quality, they strongly favour the use of 5- ALA in improving the extent of resection when compared to white light microscopy. A systematic review on the topic had a similar conclusion. Few studies have also hinted on a high false negative rate with the use of this technique..

Novel technique for preoperative pedicle localization in spinal surgery with challenging anatomy.

PubMed

Young, Richard M; Prasad, Vikram; Wind, Joshua J; Olan, Wayne; Caputy, Anthony J

2014-04-01

Accurately localizing a spine level in the thoracic spine is often not easily achieved with the existing imaging modalities available in the operating room. The coordination of the preoperative imaging pathology with intraoperative imaging is even more difficult in patients with challenging anatomy. Using standard percutaneous techniques, the authors placed a radiopaque embolization coil into the pedicle of interest under biplanar fluoroscopy in 1 patient. Thoracic spine MRI along with scout MRI was then performed to confirm coil marker placement in relation to the actual spine pathology prior to surgical intervention. No complications were observed during placement of the radiopaque marker. Intraoperatively, the marker was immediately and easily visualized, leading to a confident identification of the correct thoracic spinal level. The preoperative placement of a radiopaque marker into the vertebral pedicle of the identified pathological level combined with postplacement MRI verification provides an advantage over previously proposed techniques in the literature.

Actual Time Required for Dynamic Fluoroscopic Intraoperative Cholangiography

PubMed Central

Whitwam, Paul; Turner, David; Kennedy, Kathy; Hashmi, Syed

2005-01-01

Objectives: This study was undertaken to determine the actual amount of time a dynamic fluoroscopic intraoperative cholangiogram adds to a laparoscopic cholecystectomy. A secondary objective was to define the information gained from this procedure. Methods: A consecutive case study of 52 patients undergoing laparoscopic cholecystectomy was used. Time was recorded from placement of a laparoscopic hemoclip across the cystic duct at its junction with the gallbladder until successful completion of the intraoperative cholangiogram. The mean, median, and range of times for these cases, as well as the results and false-negative rates, were determined. Results: Cholangiography was successfully completed in 96% of patients. The mean time added to laparoscopic cholecystectomy by the addition of dynamic fluoroscopic intraoperative cholangiography was 4.3 minutes. The median time was 3.0 minutes. The times ranged from 2.0 minutes to 16.0 minutes. Choledocholithiasis was present in 15.4% of these patients. The false-positive rate was zero in this study. Conclusions: Dynamic fluoroscopic intraoperative cholangiogram was fast and efficient. The information gained was significant in that 15% of patients proceeded on to laparoscopic common bile duct exploration. We conclude that intraoperative cholangiography should be a routine addition to laparoscopic cholecystectomy. PMID:15984705

Warmed, humidified CO2 insufflation benefits intraoperative core temperature during laparoscopic surgery: A meta‐analysis

PubMed Central

Dean, Meara; Ramsay, Robert; Heriot, Alexander; Mackay, John; Hiscock, Richard

2016-01-01

Abstract Background Intraoperative hypothermia is linked to postoperative adverse events. The use of warmed, humidified CO2 to establish pneumoperitoneum during laparoscopy has been associated with reduced incidence of intraoperative hypothermia. However, the small number and variable quality of published studies have caused uncertainty about the potential benefit of this therapy. This meta‐analysis was conducted to specifically evaluate the effects of warmed, humidified CO2 during laparoscopy. Methods An electronic database search identified randomized controlled trials performed on adults who underwent laparoscopic abdominal surgery under general anesthesia with either warmed, humidified CO2 or cold, dry CO2. The main outcome measure of interest was change in intraoperative core body temperature. Results The database search identified 320 studies as potentially relevant, and of these, 13 met the inclusion criteria and were included in the analysis. During laparoscopic surgery, use of warmed, humidified CO2 is associated with a significant increase in intraoperative core temperature (mean temperature change, 0.3°C), when compared with cold, dry CO2 insufflation. Conclusion Warmed, humidified CO2 insufflation during laparoscopic abdominal surgery has been demonstrated to improve intraoperative maintenance of normothermia when compared with cold, dry CO2. PMID:27976517

Preparing Platelet-Rich Plasma with Whole Blood Harvested Intraoperatively During Spinal Fusion.

PubMed

Shen, Bin; Zhang, Zheng; Zhou, Ning-Feng; Huang, Yu-Feng; Bao, Yu-Jie; Wu, De-Sheng; Zhang, Ya-Dong

2017-07-22

BACKGROUND Platelet-rich plasma (PRP) has gained growing popularity in use in spinal fusion procedures in the last decade. Substantial intraoperative blood loss is frequently accompanied with spinal fusion, and it is unknown whether blood harvested intraoperatively qualifies for PRP preparation. MATERIAL AND METHODS Whole blood was harvested intraoperatively and venous blood was collected by venipuncture. Then, we investigated the platelet concentrations in whole blood and PRP, the concentration of growth factors in PRP, and the effects of PRP on the proliferation and viability of human bone marrow-derived mesenchymal stem cells (HBMSCs). RESULTS Our results revealed that intraoperatively harvested whole blood and whole blood collected by venipuncture were similar in platelet concentration. In addition, PRP formulations prepared from both kinds of whole blood were similar in concentration of platelet and growth factors. Additional analysis showed that the similar concentrations of growth factors resulted from the similar platelet concentrations of whole blood and PRP between the two groups. Moreover, these two kinds of PRP formulations had similar effects on promoting cell proliferation and enhancing cell viability. CONCLUSIONS Therefore, intraoperatively harvested whole blood may be a potential option for preparing PRP spinal fusion.

Intraoperative colonic pulse oximetry in left-sided colorectal surgery: can it predict anastomotic leak?

PubMed

Salusjärvi, Johannes M; Carpelan-Holmström, Monika A; Louhimo, Johanna M; Kruuna, Olli; Scheinin, Tom M

2018-03-01

An anastomotic leak is a fairly common and a potentially lethal complication in colorectal surgery. Objective methods to assess the viability and blood circulation of the anastomosis could help in preventing leaks. Intraoperative pulse oximetry is a cheap, easy to use, fast, and readily available method to assess tissue viability. Our aim was to study whether intraoperative pulse oximetry can predict the development of an anastomotic leak. The study was a prospective single-arm study conducted between the years 2005 and 2011 in Helsinki University Hospital. Patient material consisted of 422 patients undergoing elective left-sided colorectal surgery. The patients were operated by one of the three surgeons. All of the operations were partial or total resections of the left side of the colon with a colorectal anastomosis. The intraoperative colonic oxygen saturation was measured with pulse oximetry from the colonic wall, and the values were analyzed with respect to post-operative complications. 2.3 times more operated anastomotic leaks occurred when the colonic StO 2 was ≤ 90% (11/129 vs 11/293). The mean colonic StO 2 was 91.1 in patients who developed an operated anastomotic leak and 93.0 in patients who did not. With logistic regression analysis, the risk of operated anastomotic leak was 4.2 times higher with StO 2 values ≤ 90%. Low intraoperative colonic StO 2 values are associated with the occurrence of anastomotic leak. Despite its handicaps, the method seems to be useful in assessing anastomotic viability.

An Analysis of the Utility of Handheld PET Probes for the Intraoperative Localization of Malignant Tissue

PubMed Central

González, Segundo Jaime; González, Lorena; Wong, Joyce; Brader, Peter; Zakowski, Maureen; Gönen, Mithat; Daghighian, Farhad; Fong, Yuman

2012-01-01

Introduction The intraoperative localization of suspicious lesions detected by positron emission tomography (PET) scan remains a challenge. To solve this, two novel probes have been created to accurately detect the 18F-FDG radiotracer intraoperatively. Methods Nude rats were inoculated with mesothelioma. When PET scans detected 10-mm tumors, animals were dissected and the PET probes analyzed the intraoperative radiotracer uptake of these lesions as tumor to background ratio (TBR). Results The 17 suspicious lesions seen on PET scan were localized intraoperatively (by their high TBR) using the PET probes and found malignant on pathology. Interestingly, smaller tumors not visualized on PET scan were detected intraoperatively by their high TBR and found malignant on pathology. Furthermore, using a TBR threshold as low as 2.0, both gamma (sensitivity, 100%; specificity, 80%; positive predictive value (PPV), 96%; and negative predictive value (NPV), 100%) and beta (sensitivity, 100%; specificity, 60%; PPV, 93%; and NPV, 100%) probes reliably detected suspicious lesions on PET scan imaging. They also showed an excellent area under the curve of 0.9 and 0.97 (95% CI of 0.81–0.99 and 0.93–1.0) for gamma and beta probes, respectively, in the receiver operating characteristic analysis for detecting malignancy. Conclusion This novel tool could be used synergistically with a PET scan imaging to maximize tissue selection intraoperatively. PMID:21108016

[Electrical stimulation of the facial nerve with a prognostic function in parotid surgery].

PubMed

García-Losarcos, N; González-Hidalgo, M; Franco-Carcedo, C; Poch-Broto, J

Continuous electromyography during parotidectomies and direct stimulation of the facial nerve as an intraoperative identification technique significantly lower the rate of post-operative morbidity. To determine the usefulness of intra-operative neurophysiological parameters registered by means of electrical stimulation of the facial nerve as values capable of predicting the type of lesion and the functional prognosis. Our sample consisted of a correlative series of 20 cases of monitored parotidectomies. Post-operative facial functioning, type of lesion and its prognosis were compared with the variations in latency/amplitude of the muscle response between two stimulations of the facial nerve before and after resection, as well as in the absence or presence of muscle response to stimulation after resection. All the patients except one presented motor evoked potentials (MEP) to stimulation after resection. There was no facial damage following the operation in 55% of patients and 45% presented some kind of paresis. The 21% drop in the amplitude of the intra-operative MEP and the mean increase in latency of 13.5% correspond to axonal and demyelinating insult, respectively, with a mean recovery time of three and six months. The only case of absence of response to the post-resection stimulation presented permanent paresis. The presence of MEP following resection does not ensure that functioning of the nerve remains undamaged. Nevertheless, it can be considered a piece of data that suggests a lower degree of compromise, if it is present, and a better prognosis. The variations in latency and amplitude of the MEP tend to be intra-operative parameters that indicate the degree of compromise and functional prognosis.

Minimally Invasive Spinal Surgery with Intraoperative Image-Guided Navigation

PubMed Central

Kim, Terrence T.; Johnson, J. Patrick; Pashman, Robert; Drazin, Doniel

2016-01-01

We present our perioperative minimally invasive spine surgery technique using intraoperative computed tomography image-guided navigation for the treatment of various lumbar spine pathologies. We present an illustrative case of a patient undergoing minimally invasive percutaneous posterior spinal fusion assisted by the O-arm system with navigation. We discuss the literature and the advantages of the technique over fluoroscopic imaging methods: lower occupational radiation exposure for operative room personnel, reduced need for postoperative imaging, and decreased revision rates. Most importantly, we demonstrate that use of intraoperative cone beam CT image-guided navigation has been reported to increase accuracy. PMID:27213152

The Role of Simulation in Planning Intraoperative Magnetic Resonance Imaging-Guided Neurosurgical Procedures: A Case Report.

PubMed

Chowdhury, Tumul; Bergese, Sergio D; Soghomonyan, Suren; Cappellani, Ronald B

2017-04-01

Simulation of the actual procedure is a simple and yet effective method of increasing patient safety and reducing the rate of unexpected adverse effects. We present our experience with 2 cases of preprocedural simulation on healthy volunteers that were performed in the intraoperative magnetic resonance imaging suite. During one of the cases, we also simulated a scenario of sudden cardiac arrest. Such an approach helped us to refine the procedures and coordinate the work of different teams within the intraoperative magnetic resonance imaging suite as well as improve the quality of patient management.

Targeted delivery of cancer-specific multimodal contrast agents for intraoperative detection of tumor boundaries and therapeutic margins

NASA Astrophysics Data System (ADS)

Xu, Ronald X.; Xu, Jeff S.; Huang, Jiwei; Tweedle, Michael F.; Schmidt, Carl; Povoski, Stephen P.; Martin, Edward W.

2010-02-01

Background: Accurate assessment of tumor boundaries and intraoperative detection of therapeutic margins are important oncologic principles for minimal recurrence rates and improved long-term outcomes. However, many existing cancer imaging tools are based on preoperative image acquisition and do not provide real-time intraoperative information that supports critical decision-making in the operating room. Method: Poly lactic-co-glycolic acid (PLGA) microbubbles (MBs) and nanobubbles (NBs) were synthesized by a modified double emulsion method. The MB and NB surfaces were conjugated with CC49 antibody to target TAG-72 antigen, a human glycoprotein complex expressed in many epithelial-derived cancers. Multiple imaging agents were encapsulated in MBs and NBs for multimodal imaging. Both one-step and multi-step cancer targeting strategies were explored. Active MBs/NBs were also fabricated for therapeutic margin assessment in cancer ablation therapies. Results: The multimodal contrast agents and the cancer-targeting strategies were tested on tissue simulating phantoms, LS174 colon cancer cell cultures, and cancer xenograft nude mice. Concurrent multimodal imaging was demonstrated using fluorescence and ultrasound imaging modalities. Technical feasibility of using active MBs and portable imaging tools such as ultrasound for intraoperative therapeutic margin assessment was demonstrated in a biological tissue model. Conclusion: The cancer-specific multimodal contrast agents described in this paper have the potential for intraoperative detection of tumor boundaries and therapeutic margins.

Intraoperative Imaging Guidance for Sentinel Node Biopsy in Melanoma Using a Mobile Gamma Camera

DOE Office of Scientific and Technical Information (OSTI.GOV)

Dengel, Lynn T; Judy, Patricia G; Petroni, Gina R

2011-04-01

The objective is to evaluate the sensitivity and clinical utility of intraoperative mobile gamma camera (MGC) imaging in sentinel lymph node biopsy (SLNB) in melanoma. The false-negative rate for SLNB for melanoma is approximately 17%, for which failure to identify the sentinel lymph node (SLN) is a major cause. Intraoperative imaging may aid in detection of SLN near the primary site, in ambiguous locations, and after excision of each SLN. The present pilot study reports outcomes with a prototype MGC designed for rapid intraoperative image acquisition. We hypothesized that intraoperative use of the MGC would be feasible and that sensitivitymore » would be at least 90%. From April to September 2008, 20 patients underwent Tc99 sulfur colloid lymphoscintigraphy, and SLNB was performed with use of a conventional fixed gamma camera (FGC), and gamma probe followed by intraoperative MGC imaging. Sensitivity was calculated for each detection method. Intraoperative logistical challenges were scored. Cases in which MGC provided clinical benefit were recorded. Sensitivity for detecting SLN basins was 97% for the FGC and 90% for the MGC. A total of 46 SLN were identified: 32 (70%) were identified as distinct hot spots by preoperative FGC imaging, 31 (67%) by preoperative MGC imaging, and 43 (93%) by MGC imaging pre- or intraoperatively. The gamma probe identified 44 (96%) independent of MGC imaging. The MGC provided defined clinical benefit as an addition to standard practice in 5 (25%) of 20 patients. Mean score for MGC logistic feasibility was 2 on a scale of 1-9 (1 = best). Intraoperative MGC imaging provides additional information when standard techniques fail or are ambiguous. Sensitivity is 90% and can be increased. This pilot study has identified ways to improve the usefulness of an MGC for intraoperative imaging, which holds promise for reducing false negatives of SLNB for melanoma.« less

Relation between Birth Weight and Intraoperative Hemorrhage during Cesarean Section in Pregnancy with Placenta Previa

PubMed Central

Ishibashi, Hiroki; Takano, Masashi; Sasa, Hidenori; Furuya, Kenichi

2016-01-01

Background Placenta previa, one of the most severe obstetric complications, carries an increased risk of intraoperative massive hemorrhage. Several risk factors for intraoperative hemorrhage have been identified to date. However, the correlation between birth weight and intraoperative hemorrhage has not been investigated. Here we estimate the correlation between birth weight and the occurrence of intraoperative massive hemorrhage in placenta previa. Materials and Methods We included all 256 singleton pregnancies delivered via cesarean section at our hospital because of placenta previa between 2003 and 2015. We calculated not only measured birth weights but also standard deviation values according to the Japanese standard growth curve to adjust for differences in gestational age. We assessed the correlation between birth weight and the occurrence of intraoperative massive hemorrhage (>1500 mL blood loss). Receiver operating characteristic curves were constructed to determine the cutoff value of intraoperative massive hemorrhage. Results Of 256 pregnant women with placenta previa, 96 (38%) developed intraoperative massive hemorrhage. Receiver-operating characteristic curves revealed that the area under the curve of the combination variables between the standard deviation of birth weight and intraoperative massive hemorrhage was 0.71. The cutoff value with a sensitivity of 81.3% and specificity of 55.6% was −0.33 standard deviation. The multivariate analysis revealed that a standard deviation of >−0.33 (odds ratio, 5.88; 95% confidence interval, 3.04–12.00), need for hemostatic procedures (odds ratio, 3.31; 95% confidence interval, 1.79–6.25), and placental adhesion (odds ratio, 12.68; 95% confidence interval, 2.85–92.13) were independent risk of intraoperative massive hemorrhage. Conclusion In patients with placenta previa, a birth weight >−0.33 standard deviation was a significant risk indicator of massive hemorrhage during cesarean section. Based on this result, further studies are required to investigate whether fetal weight estimated by ultrasonography can predict hemorrhage during cesarean section in patients with placental previa. PMID:27902772

Predictors of contemporary coronary artery bypass grafting outcomes.

PubMed

Weisel, Richard D; Nussmeier, Nancy; Newman, Mark F; Pearl, Ronald G; Wechsler, Andrew S; Ambrosio, Giuseppe; Pitt, Bertram; Clare, Robert M; Pieper, Karen S; Mongero, Linda; Reece, Tammy L; Yau, Terrence M; Fremes, Stephen; Menasché, Philippe; Lira, Armando; Harrington, Robert A; Ferguson, T Bruce

2014-12-01

The study objective was to identify the predictors of outcomes in a contemporary cohort of patients from the Reduction in cardiovascular Events by acaDesine in patients undergoing CABG (RED-CABG) trial. Despite the increasing risk profile of patients who undergo coronary artery bypass grafting, morbidity and mortality have remained low, and identification of the current predictors of adverse outcomes may permit new treatments to further improve outcomes. The RED-CABG trial was a multicenter, randomized, double-blind, placebo-controlled study that determined that acadesine did not reduce adverse events in moderately high-risk patients undergoing nonemergency coronary artery bypass grafting. The primary efficacy end point was a composite of all-cause death, nonfatal stroke, or the need for mechanical support for severe left ventricular dysfunction through postoperative day 28. Logistic regression modeling with stepwise variable selection identified which prespecified baseline characteristics were associated with the primary outcome. A second logistic model included intraoperative variables as potential covariates. The 4 independent preoperative risk factors predictive of the composite end point were (1) a history of heart failure (odds ratio, 2.9); (2) increasing age (odds ratio, 1.033 per decade); (3) a history of peripheral vascular disease (odds ratio, 1.6); and (4) receiving aspirin before coronary artery bypass grafting (odds ratio, 0.5), which was protective. The duration of the cardiopulmonary bypass (odds ratio, 1.8) was the only intraoperative variable that contributed to adverse outcomes. Patients who had heart failure and preserved systolic function had a similar high risk of adverse outcomes as those with low ejection fractions, and new approaches may mitigate this risk. Recognition of patients with excessive atherosclerotic burden may permit perioperative interventions to improve their outcomes. The contemporary risks of coronary artery bypass grafting have changed, and their identification may permit new methods to improve outcomes. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Monitored transoral endoscopic thyroidectomy via long monopolar stimulation probe.

PubMed

Dionigi, Gianlorenzo; Wu, Che-Wei; Tufano, Ralph P; Rizzo, Antonio Giacomo; Anuwong, Angkoon; Sun, Hui; Carcoforo, Paolo; Antonino, Cancellieri; Portinari, Mattia; Kim, Hoon Yub

2018-01-01

This video aimed to describe the role of intraoperative neuromonitoring (IONM) during transoral endoscopic thyroidectomy vestibular approach (TOETVA) with emphasis given to IONM technical and technological notes, the identification of recurrent laryngeal nerve (RLN). Standardized technique of IONM consist in identifying and monitoring both the vagus nerve and the RLNs before and after resection (V1, V2, R1, R2). According to this report, IONM during TOETVA is feasible and safe in providing identification and function of laryngeal nerves. IONM enable surgeons to feel more comfortable with their initial approach to TOETVA or extended indications. Larger series are needed for appropriated evaluation of IONM in reduction of the rates for RLN complications.

Monitored transoral endoscopic thyroidectomy via long monopolar stimulation probe

PubMed Central

Wu, Che-Wei; Tufano, Ralph P.; Rizzo, Antonio Giacomo; Anuwong, Angkoon; Sun, Hui; Carcoforo, Paolo; Antonino, Cancellieri; Portinari, Mattia; Kim, Hoon Yub

2018-01-01

This video aimed to describe the role of intraoperative neuromonitoring (IONM) during transoral endoscopic thyroidectomy vestibular approach (TOETVA) with emphasis given to IONM technical and technological notes, the identification of recurrent laryngeal nerve (RLN). Standardized technique of IONM consist in identifying and monitoring both the vagus nerve and the RLNs before and after resection (V1, V2, R1, R2). According to this report, IONM during TOETVA is feasible and safe in providing identification and function of laryngeal nerves. IONM enable surgeons to feel more comfortable with their initial approach to TOETVA or extended indications. Larger series are needed for appropriated evaluation of IONM in reduction of the rates for RLN complications. PMID:29445610

Real-time endoscopic guidance using near-infrared fluorescent light for thoracic surgery

NASA Astrophysics Data System (ADS)

Venugopal, Vivek; Stockdale, Alan; Neacsu, Florin; Kettenring, Frank; Frangioni, John V.; Gangadharan, Sidharta P.; Gioux, Sylvain

2013-03-01

Lung cancer is the leading cause of cancer death in the United States, accounting for 28% of all cancer deaths. Standard of care for potentially curable lung cancer involves preoperative radiographic or invasive staging, followed by surgical resection. With recent adjuvant chemotherapy and radiation studies showing a survival advantage in nodepositive patients, it is crucial to accurately stage these patients surgically in order to identify those who may benefit. However, lymphadenectomy in lung cancer is currently performed without guidance, mainly due to the lack of tools permitting real-time, intraoperative identification of lymph nodes. In this study we report the design and validation of a novel, clinically compatible near-infrared (NIR) fluorescence thoracoscope for real-time intraoperative guidance during lymphadenectomy. A novel, NIR-compatible, clinical rigid endoscope has been designed and fabricated, and coupled to a custom source and a dual channel camera to provide simultaneous color and NIR fluorescence information to the surgeon. The device has been successfully used in conjunction with a safe, FDA-approved fluorescent tracer to detect and resect mediastinal lymph nodes during thoracic surgery on Yorkshire pigs. Taken together, this study lays the foundation for the clinical translation of endoscopic NIR fluorescence intraoperative guidance and has the potential to profoundly impact the management of lung cancer patients.

Intraoperative Neurophysiological Monitoring in Spine Surgery: A Significant Tool for Neuronal Protection and Functional Restoration.

PubMed

Scibilia, Antonino; Raffa, Giovanni; Rizzo, Vincenzo; Quartarone, Angelo; Visocchi, Massimiliano; Germanò, Antonino; Tomasello, Francesco

2017-01-01

Although there is recent evidence for the role of intraoperative neurophysiological monitoring (IONM) in spine surgery, there are no uniform opinions on the optimal combination of the different tools. At our institution, multimodal IONM (mIONM) approach in spine surgery involves the evaluation of somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) with electrical transcranial stimulation, including the use of a multipulse technique with multiple myomeric registration of responses from limbs, and a single-pulse technique with D-wave registration through epi- and intradural recording, and free running and evoked electromyography (frEMG and eEMG) with bilateral recording from segmental target muscles. We analyzed the impact of the mIONM on the preservation of neuronal structures and on functional restoration in a prospective series of patients who underwent spine surgery. We observed an improvement of neurological status in 50 % of the patients. The D-wave registration was the most useful intraoperative tool, especially when MEP and SEP responses were absent or poorly recordable. Our preliminary data confirm that mIONM plays a fundamental role in the identification and functional preservation of the spinal cord and nerve roots. It is highly sensitive and specific for detecting and avoiding neurological injury during spine surgery and represents a helpful tool for achieving optimal postoperative functional outcome.

Unique migration of a dental needle into the parapharyngeal space: successful removal by an intraoral approach and simulation for tracking visibility in X-ray fluoroscopy.

PubMed

Okumura, Yuri; Hidaka, Hiroshi; Seiji, Kazumasa; Nomura, Kazuhiro; Takata, Yusuke; Suzuki, Takahiro; Katori, Yukio

2015-02-01

The first objective was to describe a novel case of migration of a broken dental needle into the parapharyngeal space. The second was to address the importance of simulation elucidating visualization of such a thin needle under X-ray fluoroscopy. Clinical case records (including computed tomography [CT] and surgical approaches) were reviewed, and a simulation experiment using a head phantom was conducted using the same settings applied intraoperatively. A 36-year-old man was referred after failure to locate a broken 31-G dental needle. Computed tomography revealed migration of the needle into the parapharyngeal space. Intraoperative X-ray fluoroscopy failed to identify the needle, so a steel wire was applied as a reference during X-ray to locate the foreign body. The needle was successfully removed using an intraoral approach with tonsillectomy under surgical microscopy. The simulation showed that the dental needle was able to be identified only after applying an appropriate compensating filter, contrasting with the steel wire. Meticulous preoperative simulation regarding visual identification of dental needle foreign bodies is mandatory. Intraoperative radiography and an intraoral approach with tonsillectomy under surgical microscopy offer benefits for accessing the parapharyngeal space, specifically for cases medial to the great vessels. © The Author(s) 2014.

Direct Tumor Embolization of Sinonasal Unclassified Spindle Cell Sarcoma with Onyx.

PubMed

Kansal, Ankit; Srinet, Prateek; Manes, Richard Peter

2016-07-01

To evaluate the use of a new tumor embolization agent, Onyx (Covidien, Dublin, Ireland), for the use of intraoperative embolization of a sinonasal unclassified spindle cell sarcoma. A 45-year-old female patient presented to the rhinology clinic with a nasal mass. A biopsy revealed a highly vascular mass consistent with a sinonasal unclassified spindle cell sarcoma. Secondary to its extensive vascularity, the patient underwent preoperative transarterial embolization (TAE) before definitive resection. Due to complex vascular anatomy including feeding vessels emanating from intracranial circulation, incomplete embolization was achieved. Subsequently, intraoperative embolization with Onyx at the time of resection was performed. Intraoperative Onyx use resulted in almost complete devascularization of the tumor with decreased risk of intracranial embolization. Intraoperative embolization with Onyx after an incomplete TAE can be a safe and effective method of achieving near-total embolization of sinonasal tumors.

A comparative analysis of toluidine blue with frozen section in oral squamous cell carcinoma

PubMed Central

2012-01-01

Background Surgical excision of the primary tumor with safe margins remains the mainstay of treatment for oral cavity squamous cell carcinoma (OSCC). The standard of care for assessment of intraoperative margins is frozen section histopathology. Unfortunately the facility is not available at most centers in limited resource countries. Toluidine blue, a metachromatic dye, has been well described in clinical identification of malignant and premalignant lesion in the oral cavity. Considering this we decided to explore intraoperative use of toluidine blue staining, in comparison with frozen sections, for the assessment of tumor-free margins. Methods After obtaining clearance from the in-house ethical review committee, a prospective study was conducted at Aga Khan University Hospital, Karachi, from August 15, 2009 to March 14, 2010. A sample of 56 consenting patients with biopsy-proven OSCC were included in the study, giving us 280 tumor margins. Margins were analyzed using toluidine blue staining and frozen section histopathology. A receiver operator curve (ROC) was then applied to compare assessment of margin status by toluidine blue and frozen section. Results Of the 280 examined margins 11 stained positive with toluidine blue, three were positive on frozen section biopsy, and three were positive on final histopathology. Toluidine blue staining had sensitivity and specificity of 100% and 97%, respectively. The diagnostic accuracy of toluidine blue was found to be 97.1% with a positive predictive value (PPV) of 27.2% and a negative predictive value (NPV) of 100%. Conclusions Toluidine blue can be used as an effective screening modality for the assessment of intraoperative margins in resource limited environments and reducing the number of frozen section biopsies performed. Further by providing real-time clinical information within minutes it can reduce indirect costs such as operating room time. It may also be used as an ad hoc for frozen section biopsies where frozen section facilities are available. PMID:22500814

Combining fibre optic Raman spectroscopy and tactile resonance measurement for tissue characterization

NASA Astrophysics Data System (ADS)

Candefjord, Stefan; Nyberg, Morgan; Jalkanen, Ville; Ramser, Kerstin; Lindahl, Olof A.

2010-12-01

Tissue characterization is fundamental for identification of pathological conditions. Raman spectroscopy (RS) and tactile resonance measurement (TRM) are two promising techniques that measure biochemical content and stiffness, respectively. They have potential to complement the golden standard--histological analysis. By combining RS and TRM, complementary information about tissue content can be obtained and specific drawbacks can be avoided. The aim of this study was to develop a multivariate approach to compare RS and TRM information. The approach was evaluated on measurements at the same points on porcine abdominal tissue. The measurement points were divided into five groups by multivariate analysis of the RS data. A regression analysis was performed and receiver operating characteristic (ROC) curves were used to compare the RS and TRM data. TRM identified one group efficiently (area under ROC curve 0.99). The RS data showed that the proportion of saturated fat was high in this group. The regression analysis showed that stiffness was mainly determined by the amount of fat and its composition. We concluded that RS provided additional, important information for tissue identification that was not provided by TRM alone. The results are promising for development of a method combining RS and TRM for intraoperative tissue characterization.

Automatic Intra-Operative Stitching of Non-Overlapping Cone-Beam CT Acquisitions

PubMed Central

Fotouhi, Javad; Fuerst, Bernhard; Unberath, Mathias; Reichenstein, Stefan; Lee, Sing Chun; Johnson, Alex A.; Osgood, Greg M.; Armand, Mehran; Navab, Nassir

2018-01-01

Purpose Cone-Beam Computed Tomography (CBCT) is one of the primary imaging modalities in radiation therapy, dentistry, and orthopedic interventions. While CBCT provides crucial intraoperative information, it is bounded by a limited imaging volume, resulting in reduced effectiveness. This paper introduces an approach allowing real-time intraoperative stitching of overlapping and non-overlapping CBCT volumes to enable 3D measurements on large anatomical structures. Methods A CBCT-capable mobile C-arm is augmented with a Red-Green-Blue-Depth (RGBD) camera. An off-line co-calibration of the two imaging modalities results in co-registered video, infrared, and X-ray views of the surgical scene. Then, automatic stitching of multiple small, non-overlapping CBCT volumes is possible by recovering the relative motion of the C-arm with respect to the patient based on the camera observations. We propose three methods to recover the relative pose: RGB-based tracking of visual markers that are placed near the surgical site, RGBD-based simultaneous localization and mapping (SLAM) of the surgical scene which incorporates both color and depth information for pose estimation, and surface tracking of the patient using only depth data provided by the RGBD sensor. Results On an animal cadaver, we show stitching errors as low as 0.33 mm, 0.91 mm, and 1.72mm when the visual marker, RGBD SLAM, and surface data are used for tracking, respectively. Conclusions The proposed method overcomes one of the major limitations of CBCT C-arm systems by integrating vision-based tracking and expanding the imaging volume without any intraoperative use of calibration grids or external tracking systems. We believe this solution to be most appropriate for 3D intraoperative verification of several orthopedic procedures. PMID:29569728

Temporary Intraoperative Porto-Caval Shunts in Piggy-Back Liver Transplantation Reduce Intraoperative Blood Loss and Improve Postoperative Transaminases and Renal Function: A Meta-Analysis.

PubMed

Pratschke, Sebastian; Rauch, Alexandra; Albertsmeier, Markus; Rentsch, Markus; Kirschneck, Michaela; Andrassy, Joachim; Thomas, Michael; Hartwig, Werner; Figueras, Joan; Del Rio Martin, Juan; De Ruvo, Nicola; Werner, Jens; Guba, Markus; Weniger, Maximilian; Angele, Martin K

2016-12-01

The value of temporary intraoperative porto-caval shunts (TPCS) in cava-sparing liver transplantation is discussed controversially. Aim of this meta-analysis was to analyze the impact of temporary intraoperative porto-caval shunts on liver injury, primary non-function, time of surgery, transfusion of blood products and length of hospital stay in cava-sparing liver transplantation. A systematic search of MEDLINE/PubMed, EMBASE and PsycINFO retrieved a total of 909 articles, of which six articles were included. The combined effect size and 95 % confidence interval were calculated for each outcome by applying the inverse variance weighting method. Tests for heterogeneity (I 2 ) were also utilized. Usage of a TPCS was associated with significantly decreased AST values, significantly fewer transfusions of packed red blood cells and improved postoperative renal function. There were no statistically significant differences in primary graft non-function, length of hospital stay or duration of surgery. This meta-analysis found that temporary intraoperative porto-caval shunts in cava-sparing liver transplantation reduce blood loss as well as hepatic injury and enhance postoperative renal function without prolonging operative time. Randomized controlled trials investigating the use of temporary intraoperative porto-caval shunts are needed to confirm these findings.

An evaluation of intraoperative and postoperative outcomes of torsional mode versus longitudinal ultrasound mode phacoemulsification: a Meta-analysis

PubMed Central

Leon, Pia; Umari, Ingrid; Mangogna, Alessandro; Zanei, Andrea; Tognetto, Daniele

2016-01-01

AIM To evaluate and compare the intraoperative parameters and postoperative outcomes of torsional mode and longitudinal mode of phacoemulsification. METHODS Pertinent studies were identified by a computerized MEDLINE search from January 2002 to September 2013. The Meta-analysis is composed of two parts. In the first part the intraoperative parameters were considered: ultrasound time (UST) and cumulative dissipated energy (CDE). The intraoperative values were also distinctly considered for two categories (moderate and hard cataract group) depending on the nuclear opacity grade. In the second part of the study the postoperative outcomes as the best corrected visual acuity (BCVA) and the endothelial cell loss (ECL) were taken in consideration. RESULTS The UST and CDE values proved statistically significant in support of torsional mode for both moderate and hard cataract group. The analysis of BCVA did not present statistically significant difference between the two surgical modalities. The ECL count was statistically significant in support of torsional mode (P<0.001). CONCLUSION The Meta-analysis shows the superiority of the torsional mode for intraoperative parameters (UST, CDE) and postoperative ECL outcomes. PMID:27366694

3-Tesla MRI-assisted detection of compression points in ulnar neuropathy at the elbow in correlation with intraoperative findings.

PubMed

Hold, Alina; Mayr-Riedler, Michael S; Rath, Thomas; Pona, Igor; Nierlich, Patrick; Breitenseher, Julia; Kasprian, Gregor

2018-03-06

Releasing the ulnar nerve from all entrapments is the primary objective of every surgical method in ulnar neuropathy at the elbow (UNE). The aim of this retrospective diagnostic study was to validate preoperative 3-Tesla MRI results by comparing the MRI findings with the intraoperative aspects during endoscopic-assisted or open surgery. Preoperative MRI studies were assessed by a radiologist not informed about intraoperative findings in request for the exact site of nerve compression. The localizations of compression were then correlated with the intraoperative findings obtained from the operative records. Percent agreement and Cohen's kappa (κ) values were calculated. From a total of 41 elbows, there was a complete agreement in 27 (65.8%) cases and a partial agreement in another 12 (29.3%) cases. Cohen's kappa showed fair-to-moderate agreement. High-resolution MRI cannot replace thorough intraoperative visualization of the ulnar nerve and its surrounding structures but may provide valuable information in ambiguous cases or relapses. Copyright © 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

A Novel Imaging System Distinguishes Neoplastic from Normal Tissue During Resection of Soft Tissue Sarcomas and Mast Cell Tumors in Dogs.

PubMed

Bartholf DeWitt, Suzanne; Eward, William C; Eward, Cindy A; Lazarides, Alexander L; Whitley, Melodi Javid; Ferrer, Jorge M; Brigman, Brian E; Kirsch, David G; Berg, John

2016-08-01

To assess the ability of a novel imaging system designed for intraoperative detection of residual cancer in tumor beds to distinguish neoplastic from normal tissue in dogs undergoing resection of soft tissue sarcoma (STS) and mast cell tumor (MCT). Non-randomized prospective clinical trial. 12 dogs with STS and 7 dogs with MCT. A fluorescent imaging agent that is activated by proteases in vivo was administered to the dogs 4-6 or 24-26 hours before tumor resection. During surgery, a handheld imaging device was used to measure fluorescence intensity within the cancerous portion of the resected specimen and determine an intensity threshold for subsequent identification of cancer. Selected areas within the resected specimen and tumor bed were then imaged, and biopsies (n=101) were obtained from areas that did or did not have a fluorescence intensity exceeding the threshold. Results of intraoperative fluorescence and histology were compared. The imaging system correctly distinguished cancer from normal tissue in 93/101 biopsies (92%). Using histology as the reference, the sensitivity and specificity of the imaging system for identification of cancer in biopsies were 92% and 92%, respectively. There were 10/19 (53%) dogs which exhibited transient facial erythema soon after injection of the imaging agent which responded to but was not consistently prevented by intravenous diphenhydramine. A fluorescence-based imaging system designed for intraoperative use can distinguish canine soft tissue sarcoma (STS) and mast cell tumor (MCT) tissue from normal tissue with a high degree of accuracy. The system has potential to assist surgeons in assessing the adequacy of tumor resections during surgery, potentially reducing the risk of local tumor recurrence. Although responsive to antihistamines, the risk of hypersensitivity needs to be considered in light of the potential benefits of this imaging system in dogs. © Copyright 2016 by The American College of Veterinary Surgeons.

Intraoperatively Testing the Anastomotic Integrity of Esophagojejunostomy Using Methylene Blue.

PubMed

Celik, S; Almalı, N; Aras, A; Yılmaz, Ö; Kızıltan, R

2017-03-01

Intraoperative testing of gastrointestinal anastomosis effectively ensures anastomotic integrity. This study investigated whether the routine use of methylene blue intraoperatively identified leaks to reduce the postoperative proportion of clinical leaks. This study retrospectively analyzed consecutive total gastrectomies performed from January 2007 to December 2014 in a university hospital setting by a general surgical group that exclusively used the methylene blue test. All surgeries were performed for gastric or junctional cancers (n = 198). All reconstructions (Roux-en Y esophagojejunostomy) were performed using a stapler. The methylene blue test was used in 108 cases (group 1) via a nasojejunal tube. No test was performed for the other 90 cases (group 2). Intraoperative leakage rate, postoperative clinical leakage rate, length of hospitalization, and mortality rate were the outcome measures. The intraoperative leakage rate was 7.4% in group 1. The postoperative clinical leakage rate was 8.6%. The postoperative clinical leakage rate was 3.7% in group 1 and 14.4% in group 2 (p = 0.007). There were no postoperative clinical leaks when an intraoperative leak led to concomitant intraoperative repair. The median length of hospital stay was 6 days in group 1 and 8 days in group 2 (p < 0.001). One death occurred in each group. No test-related complications were observed. The methylene blue test for esophagojejunostomy is a safe and reliable method for the assessment of anastomosis integrity, especially in cases with difficult esophagojejunostomic construction.

Lag screw fixation of anterior mandibular fractures: a retrospective analysis of intraoperative and postoperative complications.

PubMed

Tiwana, Paul S; Kushner, George M; Alpert, Brian

2007-06-01

To review, retrospectively, the outcomes of 102 patients who underwent lag screw technique fixation of fractures of the anterior mandible. A total of 102 consecutive, skeletally mature patients who have undergone open reduction internal fixation for fractures of the anterior mandible utilizing the lag screw technique were reviewed. All patients had a clinically mobile fracture between the mental foramina of the mandible. The patients were followed at usual postoperative intervals with shortest long-term follow-up of 2 months. Intraoperative and long-term postoperative outcomes including status of union, infection, and intraoperative surgical misadventure were recorded. Data from the 102 patients showed that there was 1 fixation failure due to inappropriate patient selection, 1 nonunion requiring bone grafting, 1 with infected screws but with union, 1 with an infected screw and delayed union treated conservatively, and 6 with broken drills from intraoperative surgical misadventures. Lag screw osteosynthesis of anterior mandibular fractures is a sensitive, facile, predictable, and relatively inexpensive method for internal fixation of indicated fractures. As with all methods of rigid internal fixation, most failures or complications are the result of operator judgment or technique.

Intraoperative Raman Spectroscopy of Soft Tissue Sarcomas

PubMed Central

Nguyen, John Q.; Gowani, Zain S.; O’Connor, Maggie; Pence, Isaac J.; Nguyen, The-Quyen; Holt, Ginger E.; Schwartz, Herbert S.; Halpern, Jennifer L.; Mahadevan-Jansen, Anita

2017-01-01

Background and Objective Soft tissue sarcomas (STS) are a rare and heterogeneous group of malignant tumors that are often treated through surgical resection. Current intraoperative margin assessment methods are limited and highlight the need for an improved approach with respect to time and specificity. Here we investigate the potential of near-infrared Raman spectroscopy for the intraoperative differentiation of STS from surrounding normal tissue. Materials and Methods In vivo Raman measurements at 785 nm excitation were intraoperatively acquired from subjects undergoing STS resection using a probe based spectroscopy system. A multivariate classification algorithm was developed in order to automatically identify spectral features that can be used to differentiate STS from the surrounding normal muscle and fat. The classification algorithm was subsequently tested using leave-one-subject-out cross-validation. Results With the exclusion of well-differentiated liposarcomas, the algorithm was able to classify STS from the surrounding normal muscle and fat with a sensitivity and specificity of 89.5% and 96.4%, respectively. Conclusion These results suggest that single point near-infrared Raman spectroscopy could be utilized as a rapid and non-destructive surgical guidance tool for identifying abnormal tissue margins in need of further excision. PMID:27454580

Behavioral Modification of Intraoperative Hyperglycemia Management with a Novel Real-time Audiovisual Monitor.

PubMed

Sathishkumar, Subramanian; Lai, Manda; Picton, Paul; Kheterpal, Sachin; Morris, Michelle; Shanks, Amy; Ramachandran, Satya Krishna

2015-07-01

Hyperglycemia, defined as blood glucose (BG) levels above 200 mg/dl (11.1 mM), is associated with increased postoperative morbidity. Yet, the treatment standard for intraoperative glycemic control is poorly defined for noncardiac surgery. Little is known of the interindividual treatment variability or methods to modify intraoperative glycemic management behaviors. AlertWatch (AlertWatch, USA) is a novel audiovisual alert system that serves as a secondary patient monitor for use in operating rooms. The authors evaluated the influence of use of AlertWatch on intraoperative glycemic management behavior. AlertWatch displays historical patient data (risk factors and laboratory results) from multiple networked information systems, combined with the patient's live physiologic data. The authors extracted intraoperative data for 19 months to evaluate the relationship between AlertWatch usage and initiation of insulin treatment for hyperglycemia. Outcome associations were adjusted for physical status, case duration, procedural complexity, emergent procedure, fasting BG value, home insulin therapy, patient age, and primary anesthetist. Overall, 2,341 patients had documented intraoperative hyperglycemia. Use of AlertWatch (791 of 2,341; 33.5%) was associated with 55% increase in insulin treatment (496 of 791 [62.7%] with and 817 of 1,550 [52.7%] without AlertWatch; adjusted odds ratio [95% CI], 1.55 [1.23 to 1.95]; P < 0.001) and 44% increase in BG recheck after insulin administration (407 of 791 [51.5%] with AlertWatch and 655 of 1,550 [42.3%] in controls; adjusted odds ratio [95% CI], 1.44 [1.14 to 1.81]; P = 0.002). AlertWatch is associated with a significant increase in desirable intraoperative glycemic management behavior and may help achieve tighter intraoperative glycemic control.

What is the optimal management of an intra-operative air leak in a colorectal anastomosis?

PubMed

Mitchem, J B; Stafford, C; Francone, T D; Roberts, P L; Schoetz, D J; Marcello, P W; Ricciardi, R

2018-02-01

An airtight anastomosis on intra-operative leak testing has been previously demonstrated to be associated with a lower risk of clinically significant postoperative anastomotic leak following left-sided colorectal anastomosis. However, to date, there is no consistently agreed upon method for management of an intra-operative anastomotic leak. Therefore, we powered a noninferiority study to determine whether suture repair alone was an appropriate strategy for the management of an intra-operative air leak. This is a retrospective cohort analysis of prospectively collected data from a tertiary care referral centre. We included all consecutive patients with left-sided colorectal or ileorectal anastomoses and evidence of air leak during intra-operative leak testing. Patients were excluded if proximal diversion was planned preoperatively, a pre-existing proximal diversion was present at the time of surgery or an anastomosis was ultimately unable to be completed. The primary outcome measure was clinically significant anastomotic leak, as defined by the Surgical Infection Study Group at 30 days. From a sample of 2360 patients, 119 had an intra-operative air leak during leak testing. Sixty-eight patients underwent suture repair alone and 51 underwent proximal diversion or anastomotic reconstruction. The clinically significant leak rate was 9% (6/68; 95% CI: 2-15%) in the suture repair alone arm and 0% (0/51) in the diversion or reconstruction arm. Suture repair alone does not meet the criteria for noninferiority for the management of intra-operative air leak during left-sided colorectal anastomosis. Further repair of intra-operative air leak by suture repair alone should be reconsidered given these findings. Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.

Towards a model of surgeons' leadership in the operating room.

PubMed

Henrickson Parker, Sarah; Yule, Steven; Flin, Rhona; McKinley, Aileen

2011-07-01

There is widespread recognition that leadership skills are essential for effective performance in the workplace, but the evidence detailing effective leadership behaviours for surgeons during operations is unclear. Boolean searches of four on-line databases and detailed hand search of relevant references were conducted. A four stage screening process was adopted stipulating that articles presented empirical data on surgeons' intraoperative leadership behaviours. Ten relevant articles were identified and organised by method of investigation into (i) observation, (ii) questionnaire and (iii) interview studies. This review summarises the limited literature on surgeons' intraoperative leadership, and proposes a preliminary theoretically based structure for intraoperative leadership behaviours. This structure comprises seven categories with corresponding leadership components and covers two overarching themes related to task- and team-focus. Selected leadership theories which may be applicable to the operating room environment are also discussed. Further research is required to determine effective intraoperative leadership behaviours for safe surgical practice.

In Vivo Investigation of the Effectiveness of a Hyper-viscoelastic Model in Simulating Brain Retraction

NASA Astrophysics Data System (ADS)

Li, Ping; Wang, Weiwei; Zhang, Chenxi; An, Yong; Song, Zhijian

2016-07-01

Intraoperative brain retraction leads to a misalignment between the intraoperative positions of the brain structures and their previous positions, as determined from preoperative images. In vitro swine brain sample uniaxial tests showed that the mechanical response of brain tissue to compression and extension could be described by the hyper-viscoelasticity theory. The brain retraction caused by the mechanical process is a combination of brain tissue compression and extension. In this paper, we first constructed a hyper-viscoelastic framework based on the extended finite element method (XFEM) to simulate intraoperative brain retraction. To explore its effectiveness, we then applied this framework to an in vivo brain retraction simulation. The simulation strictly followed the clinical scenario, in which seven swine were subjected to brain retraction. Our experimental results showed that the hyper-viscoelastic XFEM framework is capable of simulating intraoperative brain retraction and improving the navigation accuracy of an image-guided neurosurgery system (IGNS).

Accuracy of pedicle screw placement based on preoperative computed tomography versus intraoperative data set acquisition for spinal navigation system.

PubMed

Liu, Hao; Chen, Weikai; Liu, Tao; Meng, Bin; Yang, Huilin

2017-01-01

To investigate the accuracy of pedicle screw placement based on preoperative computed tomography in comparison with intraoperative data set acquisition for spinal navigation system. The PubMed (MEDLINE), EMBASE, and Web of Science were systematically searched for the literature published up to September 2015. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Statistical analysis was performed using the Review Manager 5.3. The dichotomous data for the pedicle violation rate was summarized using relative risk (RR) and 95% confidence intervals (CIs) with the fixed-effects model. The level of significance was set at p < 0.05. For this meta-analysis, seven studies used a total of 579 patients and 2981 screws. The results revealed that the accuracy of intraoperative data set acquisition method is significantly higher than preoperative one using 2 mm grading criteria (RR: 1.82, 95% CI: 1.09, 3.04, I 2 = 0%, p = 0.02). However, there was no significant difference between two kinds of methods at the 0 mm grading criteria (RR: 1.13, 95% CI: 0.88, 1.46, I 2 = 17%, p = 0.34). Using the 2-mm grading criteria, there was a higher accuracy of pedicle screw insertion in O-arm-assisted navigation than CT-based navigation method (RR: 1.96, 95% CI: 1.05, 3.64, I 2 = 0%, p = 0.03). The accuracy between CT-based navigation and two-dimensional-based navigation showed no significant difference (RR: 1.02, 95% CI: 0.35-3.03, I 2 = 0%, p = 0.97). The intraoperative data set acquisition method may decrease the incidence of perforated screws over 2 mm but not increase the number of screws fully contained within the pedicle compared to preoperative CT-based navigation system. A significantly higher accuracy of intraoperative (O-arm) than preoperative CT-based navigation was revealed using 2 mm grading criteria.

Effect and Outcome of Intraoperative Fluid Restriction in Living Liver Donor Hepatectomy.

PubMed

Wang, Chih-Hsien; Cheng, Kwok-Wai; Chen, Chao-Long; Wu, Shao-Chun; Shih, Tsung-Hsiao; Yang, Sheng-Chun; Lee, Ying-En; Jawan, Bruno; Huang, Chiu-En; Juang, Sin-Ei; Huang, Chia-Jung

2017-11-10

BACKGROUND The purpose of this study was to evaluate the effect and outcome of intraoperative fluid restriction in living liver donor hepatectomy, regarding changes in intraoperative CVP levels, blood loss, and postoperative renal function. MATERIAL AND METHODS The charts of 167 patients were reviewed and analyzed retrospectively. Intraoperative central venous pressure levels, blood loss, fluids infused, and urine output per hour, before and after the liver allograft procurement, were calculated. Perioperative renal functions were also analyzed. RESULTS Fluid infused before and after liver allograft procurement was 3.21±1.5 and 9.0±3.9 mL/Kg/h and urine output was 1.5±0.7 and 1.8±1.4 mL/Kg/h, respectively. Intraoperative estimated blood loss was 91.3±78.9 mL. No patients required blood transfusion. Their preoperative and postoperative hemoglobin were 12.3±2.7 and 11.7±1.7 g/dL. CVP levels decreased gradually from 10.4±3.0 to a low of 8.1±1.9 mmHg at the time of transection of the liver parenchyma. Renal functions were not significantly affected based on the determination of BUN and creatinine levels. CONCLUSIONS The methods used to lower CVP are moderate and slow, with 2 main goals achieved: minimal blood loss (91.3±78.9 ml) and no blood transfusion. Furthermore, it did not have any negative effect on renal function.

A Modified Personalized Image-Based Drill Guide Template for Atlantoaxial Pedicle Screw Placement: A Clinical Study

PubMed Central

Jiang, Lianghai; Dong, Liang; Tan, Mingsheng; Qi, Yingna; Yang, Feng; Yi, Ping; Tang, Xiangsheng

2017-01-01

Background Atlantoaxial posterior pedicle screw fixation has been widely used for treatment of atlantoaxial instability (AAI). However, precise and safe insertion of atlantoaxial pedicle screws remains challenging. This study presents a modified drill guide template based on a previous template for atlantoaxial pedicle screw placement. Material/Methods Our study included 54 patients (34 males and 20 females) with AAI. All the patients underwent posterior atlantoaxial pedicle screw fixation: 25 patients underwent surgery with the use of a modified drill guide template (template group) and 29 patients underwent surgery via the conventional method (conventional group). In the template group, a modified drill guide template was designed for each patient. The modified drill guide template and intraoperative fluoroscopy were used for surgery in the template group, while only intraoperative fluoroscopy was used in the conventional group. Results Of the 54 patients, 52 (96.3%) completed the follow-up for more than 12 months. The template group had significantly lower intraoperative fluoroscopy frequency (p<0.001) and higher accuracy of screw insertion (p=0.045) than the conventional group. There were no significant differences in surgical duration, intraoperative blood loss, or improvement of neurological function between the 2 groups (p>0.05). Conclusions Based on the results of this study, it is feasible to use the modified drill guide template for atlantoaxial pedicle screw placement. Using the template can significantly lower the screw malposition rate and the frequency of intraoperative fluoroscopy. PMID:28301445

The Association of Targeted Cell Salvage Blood Transfusion During Cesarean Delivery With Allogeneic Packed Red Blood Cell Transfusions in a Maternity Hospital in China.

PubMed

Yan, Haiya; Hu, Ling-Qun; Wu, Yun; Fan, Qihui; Wong, Cynthia A; McCarthy, Robert J

2018-03-01

Autologous transfusion of intraoperative cell salvage blood may be a potential method to decrease the need for allogeneic packed red blood cell transfusions after cesarean delivery, although there are limited data on the benefits of this method. This study evaluated the implementation of targeted intraoperative cell salvage during cesarean delivery in women at increased risk for hemorrhage at the Women's and Children's Hospital in Ningbo, China. All women who underwent cesarean delivery >28 weeks of gestation were included in the study. The period before intraoperative cell collection (October 1, 2010, to August 31, 2012, n = 11,322) was compared with the postimplementation period (September 1, 2012, to June 30, 2015, n = 17,456) using an interrupted time series analysis. In the postimplementation period, women suspected to be at increased risk of the need for a blood transfusion (1604, 9.2%) underwent intraoperative cell salvage collection. The primary outcomes were the monthly rate of allogeneic packed red blood cell use and the incidence of clinical manifestation of acute blood transfusion reactions. The mean (standard deviation) estimated monthly allogeneic packed blood cell transfusion rate at the end of the 57-month study was 2.2% ± 0.7% with the implementation compared with 2.7% ± 0.9% without, difference -0.5%, 95% CI, -1.4% to 0.3%; P = .22. The mean number of allogeneic units transfused per patient was 4.1 ± 0.4 units with implementation and 3.9 ± 0.9 units without, difference 0.2, 95% CI, -1.7 to 1.1 units; P = .69. Intraoperative cell salvage blood was reinfused in 757 (47%) and wasted in 847 (53%) cases. The monthly intraoperative allogeneic packed red blood cells use rate was lower after implementation (difference -0.7%, 95% CI, -0.1% to -1.4%; P = .03); however, the monthly postpartum allogeneic packed red blood cell use rate was unchanged (difference -0.2%, 95% CI, -0.4% to 0.7%; P = .56). The clinical manifestation of acute blood transfusion reactions rate was unchanged (difference -2%, 99% CI, -9% to 5%; P = .55) between the periods. Our findings suggest that targeted intraoperative cell salvage in women undergoing cesarean delivery was associated with less allogeneic blood exposure in the operating room, but not in the postoperative period. Intraoperative cell salvage in targeted cesarean deliveries was not associated with a lesser allogeneic red blood cell exposure over the hospital admission period. The lack of adverse events associated with intraoperative cell salvage supports the safety of intraoperative cell salvage in cesarean delivery.

Intraoperative Use of Low-Dose Recombinant Activated Factor VII During Thoracic Aortic Operations

PubMed Central

Andersen, Nicholas D.; Bhattacharya, Syamal D.; Williams, Judson B.; Fosbol, Emil L.; Lockhart, Evelyn L.; Patel, Mayur B.; Gaca, Jeffrey G.; Welsby, Ian J.; Hughes, G. Chad

2013-01-01

Background Numerous studies have supported the effectiveness of recombinant activated factor VII (rFVIIa) for the control of bleeding after cardiac procedures; however safety concerns persist. Here we report the novel use of intraoperative low-dose rFVIIa in thoracic aortic operations, a strategy intended to improve safety by minimizing rFVIIa exposure. Methods Between July 2005 and December 2010, 425 consecutive patients at a single referral center underwent thoracic aortic operations with cardiopulmonary bypass (CPB); 77 of these patients received intraoperative low-dose rFVIIa (≤60 μg/kg) for severe coagulopathy after CPB. Propensity matching produced a cohort of 88 patients (44 received intraoperative low-dose rFVIIa and 44 controls) for comparison. Results Matched patients receiving intraoperative low-dose rFVIIa got an initial median dose of 32 μg/kg (interquartile range [IQR], 16–43 μg/kg) rFVIIa given 51 minutes (42–67 minutes) after separation from CPB. Patients receiving intraoperative low-dose rFVIIa demonstrated improved postoperative coagulation measurements (partial thromboplastin time 28.6 versus 31.5 seconds; p = 0.05; international normalized ratio, 0.8 versus 1.2; p < 0.0001) and received 50% fewer postoperative blood product transfusions (2.5 versus 5.0 units; p = 0.05) compared with control patients. No patient receiving intraoperative low-dose rFVIIa required postoperative rFVIIa administration or reexploration for bleeding. Rates of stroke, thromboembolism, myocardial infarction, and other adverse events were equivalent between groups. Conclusions Intraoperative low-dose rFVIIa led to improved postoperative hemostasis with no apparent increase in adverse events. Intraoperative rFVIIa administration in appropriately selected patients may correct coagulopathy early in the course of refractory blood loss and lead to improved safety through the use of smaller rFVIIa doses. Appropriately powered randomized studies are necessary to confirm the safety and efficacy of this approach. PMID:22551846

Intraoperative detection of 18F-FDG-avid tissue sites using the increased probe counting efficiency of the K-alpha probe design and variance-based statistical analysis with the three-sigma criteria

PubMed Central

2013-01-01

Background Intraoperative detection of 18F-FDG-avid tissue sites during 18F-FDG-directed surgery can be very challenging when utilizing gamma detection probes that rely on a fixed target-to-background (T/B) ratio (ratiometric threshold) for determination of probe positivity. The purpose of our study was to evaluate the counting efficiency and the success rate of in situ intraoperative detection of 18F-FDG-avid tissue sites (using the three-sigma statistical threshold criteria method and the ratiometric threshold criteria method) for three different gamma detection probe systems. Methods Of 58 patients undergoing 18F-FDG-directed surgery for known or suspected malignancy using gamma detection probes, we identified nine 18F-FDG-avid tissue sites (from amongst seven patients) that were seen on same-day preoperative diagnostic PET/CT imaging, and for which each 18F-FDG-avid tissue site underwent attempted in situ intraoperative detection concurrently using three gamma detection probe systems (K-alpha probe, and two commercially-available PET-probe systems), and then were subsequently surgical excised. Results The mean relative probe counting efficiency ratio was 6.9 (± 4.4, range 2.2–15.4) for the K-alpha probe, as compared to 1.5 (± 0.3, range 1.0–2.1) and 1.0 (± 0, range 1.0–1.0), respectively, for two commercially-available PET-probe systems (P < 0.001). Successful in situ intraoperative detection of 18F-FDG-avid tissue sites was more frequently accomplished with each of the three gamma detection probes tested by using the three-sigma statistical threshold criteria method than by using the ratiometric threshold criteria method, specifically with the three-sigma statistical threshold criteria method being significantly better than the ratiometric threshold criteria method for determining probe positivity for the K-alpha probe (P = 0.05). Conclusions Our results suggest that the improved probe counting efficiency of the K-alpha probe design used in conjunction with the three-sigma statistical threshold criteria method can allow for improved detection of 18F-FDG-avid tissue sites when a low in situ T/B ratio is encountered. PMID:23496877

Real-time intraoperative detection of breast cancer using near-infrared fluorescence imaging and Methylene Blue.

PubMed

Tummers, Q R J G; Verbeek, F P R; Schaafsma, B E; Boonstra, M C; van der Vorst, J R; Liefers, G-J; van de Velde, C J H; Frangioni, J V; Vahrmeijer, A L

2014-07-01

Despite recent developments in preoperative breast cancer imaging, intraoperative localization of tumor tissue can be challenging, resulting in tumor-positive resection margins during breast conserving surgery. Based on certain physicochemical similarities between Technetium((99m)Tc)-sestamibi (MIBI), an SPECT radiodiagnostic with a sensitivity of 83-90% to detect breast cancer preoperatively, and the near-infrared (NIR) fluorophore Methylene Blue (MB), we hypothesized that MB might detect breast cancer intraoperatively using NIR fluorescence imaging. Twenty-four patients with breast cancer, planned for surgical resection, were included. Patients were divided in 2 administration groups, which differed with respect to the timing of MB administration. N = 12 patients per group were administered 1.0 mg/kg MB intravenously either immediately or 3 h before surgery. The mini-FLARE imaging system was used to identify the NIR fluorescent signal during surgery and on post-resected specimens transferred to the pathology department. Results were confirmed by NIR fluorescence microscopy. 20/24 (83%) of breast tumors (carcinoma in N = 21 and ductal carcinoma in situ in N = 3) were identified in the resected specimen using NIR fluorescence imaging. Patients with non-detectable tumors were significantly older. No significant relation to receptor status or tumor grade was seen. Overall tumor-to-background ratio (TBR) was 2.4 ± 0.8. There was no significant difference between TBR and background signal between administration groups. In 2/4 patients with positive resection margins, breast cancer tissue identified in the wound bed during surgery would have changed surgical management. Histology confirmed the concordance of fluorescence signal and tumor tissue. This feasibility study demonstrated an overall breast cancer identification rate using MB of 83%, with real-time intraoperative guidance having the potential to alter patient management. Copyright © 2014 Elsevier Ltd. All rights reserved.

Fast elastic registration of soft tissues under large deformations.

PubMed

Peterlík, Igor; Courtecuisse, Hadrien; Rohling, Robert; Abolmaesumi, Purang; Nguan, Christopher; Cotin, Stéphane; Salcudean, Septimiu

2018-04-01

A fast and accurate fusion of intra-operative images with a pre-operative data is a key component of computer-aided interventions which aim at improving the outcomes of the intervention while reducing the patient's discomfort. In this paper, we focus on the problematic of the intra-operative navigation during abdominal surgery, which requires an accurate registration of tissues undergoing large deformations. Such a scenario occurs in the case of partial hepatectomy: to facilitate the access to the pathology, e.g. a tumor located in the posterior part of the right lobe, the surgery is performed on a patient in lateral position. Due to the change in patient's position, the resection plan based on the pre-operative CT scan acquired in the supine position must be updated to account for the deformations. We suppose that an imaging modality, such as the cone-beam CT, provides the information about the intra-operative shape of an organ, however, due to the reduced radiation dose and contrast, the actual locations of the internal structures necessary to update the planning are not available. To this end, we propose a method allowing for fast registration of the pre-operative data represented by a detailed 3D model of the liver and its internal structure and the actual configuration given by the organ surface extracted from the intra-operative image. The algorithm behind the method combines the iterative closest point technique with a biomechanical model based on a co-rotational formulation of linear elasticity which accounts for large deformations of the tissue. The performance, robustness and accuracy of the method is quantitatively assessed on a control semi-synthetic dataset with known ground truth and a real dataset composed of nine pairs of abdominal CT scans acquired in supine and flank positions. It is shown that the proposed surface-matching method is capable of reducing the target registration error evaluated of the internal structures of the organ from more than 40 mm to less then 10 mm. Moreover, the control data is used to demonstrate the compatibility of the method with intra-operative clinical scenario, while the real datasets are utilized to study the impact of parametrization on the accuracy of the method. The method is also compared to a state-of-the art intensity-based registration technique in terms of accuracy and performance. Copyright © 2017 Elsevier B.V. All rights reserved.

Intraoperative protective mechanical ventilation for prevention of postoperative pulmonary complications: a comprehensive review of the role of tidal volume, positive end-expiratory pressure, and lung recruitment maneuvers.

PubMed

Güldner, Andreas; Kiss, Thomas; Serpa Neto, Ary; Hemmes, Sabrine N T; Canet, Jaume; Spieth, Peter M; Rocco, Patricia R M; Schultz, Marcus J; Pelosi, Paolo; Gama de Abreu, Marcelo

2015-09-01

Postoperative pulmonary complications are associated with increased morbidity, length of hospital stay, and mortality after major surgery. Intraoperative lung-protective mechanical ventilation has the potential to reduce the incidence of postoperative pulmonary complications. This review discusses the relevant literature on definition and methods to predict the occurrence of postoperative pulmonary complication, the pathophysiology of ventilator-induced lung injury with emphasis on the noninjured lung, and protective ventilation strategies, including the respective roles of tidal volumes, positive end-expiratory pressure, and recruitment maneuvers. The authors propose an algorithm for protective intraoperative mechanical ventilation based on evidence from recent randomized controlled trials.

Label-free optical imaging technologies for rapid translation and use during intraoperative surgical and tumor margin assessment

NASA Astrophysics Data System (ADS)

Boppart, Stephen A.; Brown, J. Quincy; Farah, Camile S.; Kho, Esther; Marcu, Laura; Saunders, Christobel M.; Sterenborg, Henricus J. C. M.

2018-02-01

The biannual International Conference on Biophotonics was recently held on April 30 to May 1, 2017, in Fremantle, Western Australia. This continuing conference series brought together key opinion leaders in biophotonics to present their latest results and, importantly, to participate in discussions on the future of the field and what opportunities exist when we collectively work together for using biophotonics for biological discovery and medical applications. One session in this conference, entitled "Tumor Margin Identification: Critiquing Technologies," challenged invited speakers and attendees to review and critique representative label-free optical imaging technologies and their application for intraoperative assessment and guidance in surgical oncology. We are pleased to share a summary in this outlook paper, with the intent to motivate more research inquiry and investigations, to challenge these and other optical imaging modalities to evaluate and improve performance, to spur translation and adoption, and ultimately, to improve the care and outcomes of patients.

Identification of cranial nerves around trigeminal schwannomas using diffusion tensor tractography: a technical note and report of 3 cases.

PubMed

Wei, Peng-Hu; Qi, Zhi-Gang; Chen, Ge; Li, Ming-Chu; Liang, Jian-Tao; Guo, Hong-Chuan; Bao, Yu-Hai; Hao, Qiang

2016-03-01

There are no large series studies identifying the locations of cranial nerves (CNs) around trigeminal schwannomas (TSs); however, surgically induced cranial neuropathies are commonly observed after surgeries to remove TSs. In this study, we preoperatively identified the location of CNs near TSs using diffusion tensor tractography (DTT). An observational study of the DTT results and intraoperative findings was performed. We preoperatively completed tractography from images of patients with TSs who received surgical therapy. The result was later validated during tumorectomy. A total of three consecutive patients were involved in this study. The locations of CNs V-VIII in relation to the tumor was clearly revealed in all cases, except for CN VI in case 3.The predicted fiber tracts were in agreement with intraoperative observations. In this study, preoperative DTT accurately predicted the location of the majority of the nerves of interest. This technique can be applied by surgeons to preoperatively visualize nerve arrangements.

Intraoperative metastases detection by laser-induced fluorescence spectroscopy

NASA Astrophysics Data System (ADS)

Vari, Sandor G.; Papazoglou, Theodore G.; van der Veen, Maurits J.; Fishbein, Michael C.; Young, J. D.; Chandra, Mudjianto; Papaioannou, Thanassis; Beeder, Clain; Shi, Wei-Qiang; Grundfest, Warren S.

1991-06-01

The authors studied the ability of Laser Induced Fluorescence Spectroscopy (LIFS) for the intraoperative identification of metastases using a photosensitizing agent Photofrin IIr to enhance spectroscopic detection. A He-Cd laser source (442 nm) was used to produce low-power illumination of tissue via a hand-held 400 micrometers fiberoptic probe. Through the same fiber, reflected and emitted light was returned to an optical multi-channel analyzer (OMA III) for analysis. Spectroscopic signals were displayed on a screen for immediate examination. Lobund Wistar rats, inoculated with Pollard rat adenocarcinoma cells, were used as an animal model. Photofrin IIr was administered intraperitoneal 24 or 48 hours prior to surgical exploration in doses varying from 0.75-7.5 mg/kg. Metastases detection was performed during abdominal exploration directed to ipsilateral and contralateral inguinal, iliac, para-aortic and renal lymph nodes. Nineteen tissue samples, identified as abnormal by LIFS, were removed for histologic analysis; 11 of these samples were larger than 5mm and histologic examination revealed malignancy in all cases. While LIFS signals showed malignancy in 8 tissue samples with dimensions less than 5mm, histology confirmed this in only 3. However, serial histologic sections were not performed. From the initial results, it was concluded that LIFS detection of malignant tissue is feasible and enhanced by the addition of Photofrin IIr. LIFS may be a promising technique for the intraoperative detection of primary malignant and metastatic tissue.

Technical principles of direct bipolar electrostimulation for cortical and subcortical mapping in awake craniotomy.

PubMed

Pallud, J; Mandonnet, E; Corns, R; Dezamis, E; Parraga, E; Zanello, M; Spena, G

2017-06-01

Intraoperative application of electrical current to the brain is a standard technique during brain surgery for inferring the function of the underlying brain. The purpose of intraoperative functional mapping is to reliably identify cortical areas and subcortical pathways involved in eloquent functions, especially motor, sensory, language and cognitive functions. The aim of this article is to review the rationale and the electrophysiological principles of the use of direct bipolar electrostimulation for cortical and subcortical mapping under awake conditions. Direct electrical stimulation is a window into the whole functional network that sustains a particular function. It is an accurate (spatial resolution of about 5mm) and a reproducible technique particularly adapted to clinical practice for brain resection in eloquent areas. If the procedure is rigorously applied, the sensitivity of direct electrical stimulation for the detection of cortical and subcortical eloquent areas is nearly 100%. The main disadvantage of this technique is its suboptimal specificity. Another limitation is the identification of eloquent areas during surgery, which, however, could have been functionally compensated postoperatively if removed surgically. Direct electrical stimulation is an easy, accurate, reliable and safe invasive technique for the intraoperative detection of both cortical and subcortical functional brain connectivity for clinical purpose. In our opinion, it is the optimal technique for minimizing the risk of neurological sequelae when resecting in eloquent brain areas. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Risk factors for indications of intraoperative blood transfusion among patients undergoing surgical treatment for colorectal adenocarcinoma.

PubMed

Gonçalves, Iara; Linhares, Marcelo; Bordin, Jose; Matos, Delcio

2009-01-01

Identification of risk factors for requiring transfusions during surgery for colorectal cancer may lead to preventive actions or alternative measures, towards decreasing the use of blood components in these procedures, and also rationalization of resources use in hemotherapy services. This was a retrospective case-control study using data from 383 patients who were treated surgically for colorectal adenocarcinoma at 'Fundação Pio XII', in Barretos-SP, Brazil, between 1999 and 2003. To recognize significant risk factors for requiring intraoperative blood transfusion in colorectal cancer surgical procedures. Univariate analyses were performed using Fisher's exact test or the chi-squared test for dichotomous variables and Student's t test for continuous variables, followed by multivariate analysis using multiple logistic regression. In the univariate analyses, height (P = 0.06), glycemia (P = 0.05), previous abdominal or pelvic surgery (P = 0.031), abdominoperineal surgery (P<0.001), extended surgery (P<0.001) and intervention with radical intent (P<0.001) were considered significant. In the multivariate analysis using logistic regression, intervention with radical intent (OR = 10.249, P<0.001, 95% CI = 3.071-34.212) and abdominoperineal amputation (OR = 3.096, P = 0.04, 95% CI = 1.445-6.623) were considered to be independently significant. This investigation allows the conclusion that radical intervention and the abdominoperineal procedure in the surgical treatment of colorectal adenocarcinoma are risk factors for requiring intraoperative blood transfusion.

Evaluation of the White Test for the Intraoperative Detection of Bile Leakage

PubMed Central

Leelawat, Kawin; Chaiyabutr, Kittipong; Subwongcharoen, Somboon; Treepongkaruna, Sa-ad

2012-01-01

We assess whether the White test is better than the conventional bile leakage test for the intraoperative detection of bile leakage in hepatectomized patients. This study included 30 patients who received elective liver resection. Both the conventional bile leakage test (injecting an isotonic sodium chloride solution through the cystic duct) and the White test (injecting a fat emulsion solution through the cystic duct) were carried out in the same patients. The detection of bile leakage was compared between the conventional method and the White test. A bile leak was demonstrated in 8 patients (26.7%) by the conventional method and in 19 patients (63.3%) by the White test. In addition, the White test detected a significantly higher number of bile leakage sites compared with the conventional method (Wilcoxon signed-rank test; P < 0.001). The White test is better than the conventional test for the intraoperative detection of bile leakage. Based on our study, we recommend that surgeons investigating bile leakage sites during liver resections should use the White test instead of the conventional bile leakage test. PMID:22547901

Evaluation of the white test for the intraoperative detection of bile leakage.

PubMed

Leelawat, Kawin; Chaiyabutr, Kittipong; Subwongcharoen, Somboon; Treepongkaruna, Sa-Ad

2012-01-01

We assess whether the White test is better than the conventional bile leakage test for the intraoperative detection of bile leakage in hepatectomized patients. This study included 30 patients who received elective liver resection. Both the conventional bile leakage test (injecting an isotonic sodium chloride solution through the cystic duct) and the White test (injecting a fat emulsion solution through the cystic duct) were carried out in the same patients. The detection of bile leakage was compared between the conventional method and the White test. A bile leak was demonstrated in 8 patients (26.7%) by the conventional method and in 19 patients (63.3%) by the White test. In addition, the White test detected a significantly higher number of bile leakage sites compared with the conventional method (Wilcoxon signed-rank test; P < 0.001). The White test is better than the conventional test for the intraoperative detection of bile leakage. Based on our study, we recommend that surgeons investigating bile leakage sites during liver resections should use the White test instead of the conventional bile leakage test.

Feasibility of rapid and automated importation of 3D echocardiographic left ventricular (LV) geometry into a finite element (FEM) analysis model

PubMed Central

Verhey, Janko F; Nathan, Nadia S

2004-01-01

Background Finite element method (FEM) analysis for intraoperative modeling of the left ventricle (LV) is presently not possible. Since 3D structural data of the LV is now obtainable using standard transesophageal echocardiography (TEE) devices intraoperatively, the present study describes a method to transfer this data into a commercially available FEM analysis system: ABAQUS©. Methods In this prospective study TomTec LV Analysis TEE© Software was used for semi-automatic endocardial border detection, reconstruction, and volume-rendering of the clinical 3D echocardiographic data. A newly developed software program MVCP FemCoGen©, written in Delphi, reformats the TomTec file structures in five patients for use in ABAQUS and allows visualization of regional deformation of the LV. Results This study demonstrates that a fully automated importation of 3D TEE data into FEM modeling is feasible and can be efficiently accomplished in the operating room. Conclusion For complete intraoperative 3D LV finite element analysis, three input elements are necessary: 1. time-gaited, reality-based structural information, 2. continuous LV pressure and 3. instantaneous tissue elastance. The first of these elements is now available using the methods presented herein. PMID:15473901

Medical Error Avoidance in Intraoperative Neurophysiological Monitoring: The Communication Imperative.

PubMed

Skinner, Stan; Holdefer, Robert; McAuliffe, John J; Sala, Francesco

2017-11-01

Error avoidance in medicine follows similar rules that apply within the design and operation of other complex systems. The error-reduction concepts that best fit the conduct of testing during intraoperative neuromonitoring are forgiving design (reversibility of signal loss to avoid/prevent injury) and system redundancy (reduction of false reports by the multiplication of the error rate of tests independently assessing the same structure). However, error reduction in intraoperative neuromonitoring is complicated by the dichotomous roles (and biases) of the neurophysiologist (test recording and interpretation) and surgeon (intervention). This "interventional cascade" can be given as follows: test → interpretation → communication → intervention → outcome. Observational and controlled trials within operating rooms demonstrate that optimized communication, collaboration, and situational awareness result in fewer errors. Well-functioning operating room collaboration depends on familiarity and trust among colleagues. Checklists represent one method to initially enhance communication and avoid obvious errors. All intraoperative neuromonitoring supervisors should strive to use sufficient means to secure situational awareness and trusted communication/collaboration. Face-to-face audiovisual teleconnections may help repair deficiencies when a particular practice model disallows personal operating room availability. All supervising intraoperative neurophysiologists need to reject an insular or deferential or distant mindset.

Intraoperative Transpedicular Onyx Injection to Reduce Vascularity of a Thoracic Hemangiopericytoma After Unsuccessful Preoperative Endovascular Embolization: a Technical Report.

PubMed

Mashaly, Hazem; Zhang, Zoe; Shaw, Andrew; Youssef, Patrick; Mendel, Ehud

2018-02-01

Hemangiopericytoma is a rare vascular tumor with central nervous system involvement representing only 1% of central nervous system tumors. They rarely affect the vertebral column. Complete surgical resection is the treatment of choice for hemangiopericytoma given their high rates of local recurrence. However, the high vascularity of such tumors with the risk of massive bleeding during surgery represents a significant challenge to surgeons. Therefore, preoperative endovascular embolization via the transarterial route has been advocated. In the current study, we present a case of a T12 hemangiopericytoma that was managed by a 2-stage surgical resection, with the use of intraoperative transpedicular onyx injection to reduce intraoperative blood loss following an unsuccessful trial of preoperative endovascular embolization. Preoperative endovascular embolization is not feasible in some cases due to the location of the segmental or radiculomedullary arteries in relation to tumor feeders and, rarely, small size of these arterial feeders. Percutaneous injection of onyx is an option. In this case report, we discuss direct intraoperative injection via a transpedicular route as a safe and effective method for decreasing the vascularity of some lesions and improving intraoperative blood loss. Copyright © 2017 by the Congress of Neurological Surgeons

The clinical use of indocyanine green as a near-infrared fluorescent contrast agent for image-guided oncologic surgery

PubMed Central

Schaafsma, Boudewijn E.; Mieog, J.Sven D.; Hutteman, Merlijn; van der Vorst, Joost R.; Kuppen, Peter J.K.; Löwik, Clemens W.G.M.; Frangioni, John V.; van de Velde, Cornelis J.H.; Vahrmeijer, Alexander L.

2011-01-01

Optical imaging using near-infrared (NIR) fluorescence provides new prospects for general and oncologic surgery. ICG is currently utilised in NIR fluorescence cancer-related surgery for three indications: sentinel lymph node (SLN) mapping, intraoperative identification of solid tumours, and angiography during reconstructive surgery. Therefore, understanding its advantages and limitations is of significant importance. Although non-targeted and non-conjugatable, ICG appears to be laying the foundation for more widespread use of NIR fluorescence-guided surgery. PMID:21495033

Clinical implementation of intraoperative cone-beam CT in head and neck surgery

NASA Astrophysics Data System (ADS)

Daly, M. J.; Chan, H.; Nithiananthan, S.; Qiu, J.; Barker, E.; Bachar, G.; Dixon, B. J.; Irish, J. C.; Siewerdsen, J. H.

2011-03-01

A prototype mobile C-arm for cone-beam CT (CBCT) has been translated to a prospective clinical trial in head and neck surgery. The flat-panel CBCT C-arm was developed in collaboration with Siemens Healthcare, and demonstrates both sub-mm spatial resolution and soft-tissue visibility at low radiation dose (e.g., <1/5th of a typical diagnostic head CT). CBCT images are available ~15 seconds after scan completion (~1 min acquisition) and reviewed at bedside using custom 3D visualization software based on the open-source Image-Guided Surgery Toolkit (IGSTK). The CBCT C-arm has been successfully deployed in 15 head and neck cases and streamlined into the surgical environment using human factors engineering methods and expert feedback from surgeons, nurses, and anesthetists. Intraoperative imaging is implemented in a manner that maintains operating field sterility, reduces image artifacts (e.g., carbon fiber OR table) and minimizes radiation exposure. Image reviews conducted with surgical staff indicate bony detail and soft-tissue visualization sufficient for intraoperative guidance, with additional artifact management (e.g., metal, scatter) promising further improvements. Clinical trial deployment suggests a role for intraoperative CBCT in guiding complex head and neck surgical tasks, including planning mandible and maxilla resection margins, guiding subcranial and endonasal approaches to skull base tumours, and verifying maxillofacial reconstruction alignment. Ongoing translational research into complimentary image-guidance subsystems include novel methods for real-time tool tracking, fusion of endoscopic video and CBCT, and deformable registration of preoperative volumes and planning contours with intraoperative CBCT.

Patient-Specific Biomechanical Modeling for Guidance During Minimally-Invasive Hepatic Surgery.

PubMed

Plantefève, Rosalie; Peterlik, Igor; Haouchine, Nazim; Cotin, Stéphane

2016-01-01

During the minimally-invasive liver surgery, only the partial surface view of the liver is usually provided to the surgeon via the laparoscopic camera. Therefore, it is necessary to estimate the actual position of the internal structures such as tumors and vessels from the pre-operative images. Nevertheless, such task can be highly challenging since during the intervention, the abdominal organs undergo important deformations due to the pneumoperitoneum, respiratory and cardiac motion and the interaction with the surgical tools. Therefore, a reliable automatic system for intra-operative guidance requires fast and reliable registration of the pre- and intra-operative data. In this paper we present a complete pipeline for the registration of pre-operative patient-specific image data to the sparse and incomplete intra-operative data. While the intra-operative data is represented by a point cloud extracted from the stereo-endoscopic images, the pre-operative data is used to reconstruct a biomechanical model which is necessary for accurate estimation of the position of the internal structures, considering the actual deformations. This model takes into account the patient-specific liver anatomy composed of parenchyma, vascularization and capsule, and is enriched with anatomical boundary conditions transferred from an atlas. The registration process employs the iterative closest point technique together with a penalty-based method. We perform a quantitative assessment based on the evaluation of the target registration error on synthetic data as well as a qualitative assessment on real patient data. We demonstrate that the proposed registration method provides good results in terms of both accuracy and robustness w.r.t. the quality of the intra-operative data.

Peripheral Nerve Block as a Supplement to Light or Deep General Anesthesia in Elderly Patients Receiving Total Hip Arthroplasty: A Prospective Randomized Study.

PubMed

Mei, Bin; Zha, Hanning; Lu, Xiaolong; Cheng, Xinqi; Chen, Shishou; Liu, Xuesheng; Li, Yuanhai; Gu, Erwei

2017-12-01

Peripheral nerve block combined with general anesthesia is a preferable anesthesia method for elderly patients receiving hip arthroplasty. The depth of sedation may influence patient recovery. Therefore, we investigated the influence of peripheral nerve blockade and different intraoperative sedation levels on the short-term recovery of elderly patients receiving total hip arthroplasty. Patients aged 65 years and older undergoing total hip arthroplasty were randomized into 3 groups: a general anesthesia without lumbosacral plexus block group, and 2 general anesthesia plus lumbosacral plexus block groups, each with a different level of sedation (light or deep). The extubation time and intraoperative consumption of propofol, sufentanil, and vasoactive agent were recorded. Postoperative delirium and early postoperative cognitive dysfunction were assessed using the Confusion Assessment Method and Mini-Mental State Examination, respectively. Postoperative analgesia was assessed by the consumption of patient-controlled analgesics and visual analog scale scores. Discharge time and complications over a 30-day period were also recorded. Lumbosacral plexus block reduced opioid intake. With lumbosacral plexus block, intraoperative deep sedation was associated with greater intake of propofol and vasoactive agent. In contrast, patients with lumbosacral plexus block and intraoperative light sedation had lower incidences of postoperative delirium and postoperative cognitive decline, and earlier discharge readiness times. The 3 groups showed no difference in complications within 30 days of surgery. Lumbosacral plexus block reduced the need for opioids and offered satisfactory postoperative analgesia. It led to better postoperative outcomes in combination with intraoperative light sedation (high bispectral index).

Real Time Intraoperative Monitoring of Blood Loss with a Novel Tablet Application

PubMed Central

Sharareh, Behnam; Woolwine, Spencer; Satish, Siddarth; Abraham, Peter; Schwarzkopf, Ran

2015-01-01

Introduction : Real-time monitoring of blood loss is critical in fluid management. Visual estimation remains the standard of care in estimating blood loss, yet is demonstrably inaccurate. Photometric analysis, which is the referenced “gold-standard” for measuring blood loss, is both time-consuming and costly. The purpose of this study was to evaluate the efficacy of a novel tablet-monitoring device for measurement of Hb loss during orthopaedic procedures. Methods : This is a prospective study of 50 patients in a consecutive series of joint arthroplasty cases. The novel System with Feature Extraction Technology was used to measure the amount of Hb contained within surgical sponges intra-operatively. The system’s measures were then compared with those obtained via gravimetric method and photometric analysis. Accuracy was evaluated using linear regression and Bland-Altman analysis. Results : Our results showed a significant positive correlation between Triton tablet system and photometric analysis with respect to intra-operative hemoglobin and blood loss at 0.92 and 0.91, respectively. Discussion : This novel system can accurately determine Hb loss contained within surgical sponges. We believe that this user-friendly software can be used for measurement of total intraoperative blood loss and thus aid in a more accurate fluid management protocols during orthopaedic surgical procedures. PMID:26401167

A multimodal imaging framework for enhanced robot-assisted partial nephrectomy guidance

NASA Astrophysics Data System (ADS)

Halter, Ryan J.; Wu, Xiaotian; Hartov, Alex; Seigne, John; Khan, Shadab

2015-03-01

Robot-assisted laparoscopic partial nephrectomies (RALPN) are performed to treat patients with locally confined renal carcinoma. There are well-documented benefits to performing partial (opposed to radical) kidney resections and to using robot-assisted laparoscopic (opposed to open) approaches. However, there are challenges in identifying tumor margins and critical benign structures including blood vessels and collecting systems during current RALPN procedures. The primary objective of this effort is to couple multiple image and data streams together to augment visual information currently provided to surgeons performing RALPN and ultimately ensure complete tumor resection and minimal damage to functional structures (i.e. renal vasculature and collecting systems). To meet this challenge we have developed a framework and performed initial feasibility experiments to couple pre-operative high-resolution anatomic images with intraoperative MRI, ultrasound (US) and optical-based surface mapping and kidney tracking. With these registered images and data streams, we aim to overlay the high-resolution contrast-enhanced anatomic (CT or MR) images onto the surgeon's view screen for enhanced guidance. To date we have integrated the following components of our framework: 1) a method for tracking an intraoperative US probe to extract the kidney surface and a set of embedded kidney markers, 2) a method for co-registering intraoperative US scans with pre-operative MR scans, and 3) a method for deforming pre-op scans to match intraoperative scans. These components have been evaluated through phantom studies to demonstrate protocol feasibility.

Intraoperative aberrometry versus standard preoperative biometry and a toric IOL calculator for bilateral toric IOL implantation with a femtosecond laser: One-month results.

PubMed

Woodcock, Michael G; Lehmann, Robert; Cionni, Robert J; Breen, Michael; Scott, Maria C

2016-06-01

To compare astigmatic outcomes in patients with bilateral cataracts having toric intraocular lens (IOL) implantation with intraoperative aberrometry measurements in 1 eye and standard power calculation and a toric IOL calculator with inked axis marking in the contralateral eye. Twelve sites in the United States. Prospective cohort study. The eye with the more visually significant cataract was randomized to intraoperative aberrometry measurements (Ocular Response Analyzer with Verifeye) or standard preoperative biometry and use of a toric calculator with the contralateral eye automatically assigned to the other group. The primary effectiveness outcome was the proportion of eyes with a postoperative refractive astigmatism of 0.50 diopter (D) or less at 1 month. Of the 130 patients (260 eyes) enrolled, 124 (248 eyes) were randomized; 121 (242 eyes) completed the trial. The percentage of eyes with astigmatism of 0.50 D or less at 1 month was higher in the intraoperative aberrometry group than in the standard group (89.2% versus 76.6%) (P = .006). The mean postoperative refractive astigmatism was lower in the intraoperative aberrometry group (0.29 D ± 0.28 [SD] versus 0.36 ± 0.35 D) (P = .041). Secondary effectiveness endpoints, including manifest refraction spherical equivalent prediction error, uncorrected distance visual acuity, and corrected distance visual acuity, were similar. Compared with standard methods, the use of the intraoperative aberrometry system increased the proportion of eyes with postoperative refractive astigmatism of 0.50 D or less and reduced the mean postoperative refractive astigmatism at 1 month. Other efficacy outcomes were similar. Drs. Woodcock, Lehmann, and Cionni are consultants to Alcon Laboratories, Inc. Dr. Breen is an employee of Alcon Laboratories, Inc. Dr. Scott has no financial or proprietary interest in any material or method mentioned. Copyright © 2016 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.

Which imaging modality is most effective for identifying pseudotumours in metal-on-metal hip resurfacings requiring revision: ultrasound or MARS-MRI or both?

PubMed

Matharu, G S; Mansour, R; Dada, O; Ostlere, S; Pandit, H G; Murray, D W

2016-01-01

The aims of this study were to compare the diagnostic test characteristics of ultrasound alone, metal artefact reduction sequence MRI (MARS-MRI) alone, and ultrasound combined with MARS-MRI for identifying intra-operative pseudotumours in metal-on-metal hip resurfacing (MoMHR) patients undergoing revision surgery. This retrospective diagnostic accuracy study involved 39 patients (40 MoMHRs). The time between imaging modalities was a mean of 14.6 days (0 to 90), with imaging performed at a mean of 5.3 months (0.06 to 12) before revision. The prevalence of intra-operative pseudotumours was 82.5% (n = 33). Agreement with the intra-operative findings was 82.5% (n = 33) for ultrasound alone, 87.5% (n = 35) for MARS-MRI alone, and 92.5% (n = 37) for ultrasound and MARS-MRI combined. The diagnostic characteristics for ultrasound alone and MARS-MRI alone reached similar sensitivities (90.9% vs 93.9%) and positive predictive values (PPVs; 88.2% vs 91.2%), but higher specificities (57.1% vs 42.9%) and negative predictive values (NPVs; 66.7% vs 50.0%) were achieved with MARS-MRI. Ultrasound and MARS-MRI combined produced 100% sensitivity and 100% NPV, whilst maintaining both specificity (57.1%) and PPV (91.7%). For the identification of a pseudotumour, which was confirmed at revision surgery, agreement was substantial for ultrasound and MARS-MRI combined (κ = 0.69), moderate for MARS-MRI alone (κ = 0.54), and fair for ultrasound alone (κ = 0.36). These findings suggest that ultrasound and/or MARS-MRI have a role when assessing patients with a MoMHR, with the choice dependent on local financial constraints and the availability of ultrasound expertise. However in patients with a MoMHR who require revision, combined imaging was most effective. Combined imaging with ultrasound and MARS-MRI always identified intra-operative pseudotumours if present. Furthermore, if neither imaging modality showed a pseudotumour, one was not found intra-operatively. ©2016 The British Editorial Society of Bone & Joint Surgery.

Implementation of molecular intra-operative assessment of sentinel lymph node in breast cancer.

PubMed

Khaddage, Abir; Berremila, Sid-Ali; Forest, Fabien; Clemenson, Alix; Bouteille, Catherine; Seffert, Pierre; Peoc'h, Michel

2011-02-01

Sentinel lymph node (SLN) biopsy is used as a staging procedure in early breast cancer, however, histology based intra-operative assessment of the SLN status has a low sensitivity. The one-step nucleic acid amplification (OSNA) method was developed to detect metastases by amplification of cytokeratin (CK) 19 mRNA. Experience with OSNA during a French multi-centric prospective study, as well as intra-operative clinical routine use, is reported. For the clinical study 80 SLNs from 46 patients were assessed. During routine use, the central slice of the SLN from 197 patients was investigated by permanent histology and the remainder was assessed by OSNA. During the clinical study, OSNA detected 15/17 metastases, including all the macrometastases, reaching a 96.3% concordance rate, 88.2% sensitivity and 98.4% specificity. During routine use, both OSNA and histology detected 25 patients with metastasis. OSNA is an accurate tool for intra-operative assessment of SLN status and could reduce the need for second surgery.

Intraoperative diagnostics and elimination of residual microtumours with plasmonic nanobubbles

NASA Astrophysics Data System (ADS)

Lukianova-Hleb, Ekaterina Y.; Kim, Yoo-Shin; Belatsarkouski, Ihor; Gillenwater, Ann M.; O'Neill, Brian E.; Lapotko, Dmitri O.

2016-06-01

Failure of cancer surgery to intraoperatively detect and eliminate microscopic residual disease (MRD) causes lethal recurrence and metastases, and the removal of important normal tissues causes excessive morbidity. Here, we show that a plasmonic nanobubble (PNB), a non-stationary laser pulse-activated nanoevent, intraoperatively detects and eliminates MRD in the surgical bed. PNBs were generated in vivo in head and neck cancer cells by systemically targeting tumours with gold colloids and locally applying near-infrared, low-energy short laser pulses, and were simultaneously detected with an acoustic probe. In mouse models, between 3 and 30 residual cancer cells and MRD (undetectable with current methods) were non-invasively detected up to 4 mm deep in the surgical bed within 1 ms. In resectable MRD, PNB-guided surgery prevented local recurrence and delivered 100% tumour-free survival. In unresectable MRD, PNB nanosurgery improved survival twofold compared with standard surgery. Our results show that PNB-guided surgery and nanosurgery can rapidly and precisely detect and remove MRD in simple intraoperative procedures.

Intraoperative detection and elimination of microscopic tumors in head and neck (Conference Presentation)

NASA Astrophysics Data System (ADS)

Lukianova-Hleb, Ekaterina Y.; Kim, Yoo-Shin; Belatsarkouski, Ihar; Hanna, Ehab Y.; Gillenwater, Ann M.; O'Neill, Brian; Lapotko, Dmitri

2016-02-01

Failure of cancer surgery to intraoperatively detect and eliminate microscopic residual disease (MRD) causes lethal recurrence and metastases, whereas removal of important normal tissues causes excessive morbidity. We report plasmonic nanobubble (PNB) surgical technology to intraoperatively detect and eliminate MRD in surgical bed. PNBs were generated in vivo in head and neck cancer cells by systemically targeting tumor with gold colloids and locally-applied near-infrared low energy short laser pulse, and were simultaneously detected with acoustic probe. In mouse models of head and neck squamous cell carcinoma, single cancer cells and MRD (undetectable with standard histological methods) were instantaneously non-invasively detected in solid tissue in surgical bed. In resectable MRD, PNB-guided surgery prevented local recurrence and delivered 100% tumor-free survival. In unresectable MRD, PNB nano-surgery improved survival by two-fold compared to standard surgery. PNB metrics correlated with the tumor recurrence rate. PNB surgical technology precisely detects and immediately eliminates MRD at macro- and micro-scale in a simple and safe intraoperative procedure.

In Vivo Investigation of the Effectiveness of a Hyper-viscoelastic Model in Simulating Brain Retraction

PubMed Central

Li, Ping; Wang, Weiwei; Zhang, Chenxi; An, Yong; Song, Zhijian

2016-01-01

Intraoperative brain retraction leads to a misalignment between the intraoperative positions of the brain structures and their previous positions, as determined from preoperative images. In vitro swine brain sample uniaxial tests showed that the mechanical response of brain tissue to compression and extension could be described by the hyper-viscoelasticity theory. The brain retraction caused by the mechanical process is a combination of brain tissue compression and extension. In this paper, we first constructed a hyper-viscoelastic framework based on the extended finite element method (XFEM) to simulate intraoperative brain retraction. To explore its effectiveness, we then applied this framework to an in vivo brain retraction simulation. The simulation strictly followed the clinical scenario, in which seven swine were subjected to brain retraction. Our experimental results showed that the hyper-viscoelastic XFEM framework is capable of simulating intraoperative brain retraction and improving the navigation accuracy of an image-guided neurosurgery system (IGNS). PMID:27387301

Quantitative Analysis of Transnasal Anterior Skull Base Approach: Report of Technology for Intraoperative Assessment of Instrument Motion.

PubMed

Berens, Angelique M; Harbison, Richard Alex; Li, Yangming; Bly, Randall A; Aghdasi, Nava; Ferreira, Manuel; Hannaford, Blake; Moe, Kris S

2017-08-01

To develop a method to measure intraoperative surgical instrument motion. This model will be applicable to the study of surgical instrument kinematics including surgical training, skill verification, and the development of surgical warning systems that detect aberrant instrument motion that may result in patient injury. We developed an algorithm to automate derivation of surgical instrument kinematics in an endoscopic endonasal skull base surgery model. Surgical instrument motion was recorded during a cadaveric endoscopic transnasal approach to the pituitary using a navigation system modified to record intraoperative time-stamped Euclidian coordinates and Euler angles. Microdebrider tip coordinates and angles were referenced to the cadaver's preoperative computed tomography scan allowing us to assess surgical instrument kinematics over time. A representative cadaveric endoscopic endonasal approach to the pituitary was performed to demonstrate feasibility of our algorithm for deriving surgical instrument kinematics. Technical feasibility of automatically measuring intraoperative surgical instrument motion and deriving kinematics measurements was demonstrated using standard navigation equipment.

Performance of residents and anesthesiologists in a simulation-based skill assessment.

PubMed

Murray, David J; Boulet, John R; Avidan, Michael; Kras, Joseph F; Henrichs, Bernadette; Woodhouse, Julie; Evers, Alex S

2007-11-01

Anesthesiologists and anesthesia residents are expected to acquire and maintain skills to manage a wide range of acute intraoperative anesthetic events. The purpose of this study was to determine whether an inventory of simulated intraoperative scenarios provided a reliable and valid measure of anesthesia residents' and anesthesiologists' skill. Twelve simulated acute intraoperative scenarios were designed to assess the performance of 64 residents and 35 anesthesiologists. The participants were divided into four groups based on their training and experience. There were 31 new CA-1, 12 advanced CA-1, and 22 CA-2/CA-3 residents as well as a group of 35 experienced anesthesiologists who participated in the assessment. Each participant managed a set of simulated events. The advanced CA-1 residents, CA-2/CA-3 residents, and 35 anesthesiologists managed 8 of 12 intraoperative simulation exercises. The 31 CA-1 residents each managed 3 intraoperative scenarios. The new CA-1 residents received lower scores on the simulated intraoperative events than the other groups of participants. The advanced CA-1 residents, CA-2/CA-3 residents, and anesthesiologists performed similarly on the overall assessment. There was a wide range of scores obtained by individuals in each group. A number of the exercises were difficult for the majority of participants to recognize and treat, but most events effectively discriminated among participants who achieved higher and lower overall scores. This simulation-based assessment provided a valid method to distinguish the skills of more experienced anesthesia residents and anesthesiologists from residents in early training. The overall score provided a reliable measure of a participant's ability to recognize and manage simulated acute intraoperative events. Additional studies are needed to determine whether these simulation-based assessments are valid measures of clinical performance.

Intraoperative adverse events can be compensated by technical performance in neonates and infants after cardiac surgery: a prospective study.

PubMed

Nathan, Meena; Karamichalis, John M; Liu, Hua; del Nido, Pedro; Pigula, Frank; Thiagarajan, Ravi; Bacha, Emile A

2011-11-01

Our objective was to define the relationship between surgical technical performance score, intraoperative adverse events, and major postoperative adverse events in complex pediatric cardiac repairs. Infants younger than 6 months were prospectively followed up until discharge from the hospital. Technical performance scores were graded as optimal, adequate, or inadequate based on discharge echocardiograms and need for reintervention after initial surgery. Case complexity was determined by Risk Adjustment in Congenital Heart Surgery (RACHS-1) category, and preoperative illness severity was assessed by Pediatric Risk of Mortality (PRISM) III score. Intraoperative adverse events were prospectively monitored. Outcomes were analyzed using nonparametric methods and a logistic regression model. A total of 166 patients (RACHS 4-6 [49%]), neonates [50%]) were observed. Sixty-one (37%) had at least 1 intraoperative adverse event, and 47 (28.3%) had at least 1 major postoperative adverse event. There was no correlation between intraoperative adverse events and RACHS, preoperative PRISM III, technical performance score, or postoperative adverse events on multivariate analysis. For the entire cohort, better technical performance score resulted in lower postoperative adverse events, lower postoperative PRISM, and lower length of stay and ventilation time (P < .001). Patients requiring intraoperative revisions fared as well as patients without, provided the technical score was at least adequate. In neonatal and infant open heart repairs, technical performance score is one of the main predictors of postoperative morbidity. Outcomes are not affected by intraoperative adverse events, including surgical revisions, provided technical performance score is at least adequate. Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Deformable Image Registration for Cone-Beam CT Guided Transoral Robotic Base of Tongue Surgery

PubMed Central

Reaungamornrat, S.; Liu, W. P.; Wang, A. S.; Otake, Y.; Nithiananthan, S.; Uneri, A.; Schafer, S.; Tryggestad, E.; Richmon, J.; Sorger, J. M.; Siewerdsen, J. H.; Taylor, R. H.

2013-01-01

Transoral robotic surgery (TORS) offers a minimally invasive approach to resection of base of tongue tumors. However, precise localization of the surgical target and adjacent critical structures can be challenged by the highly deformed intraoperative setup. We propose a deformable registration method using intraoperative cone-beam CT (CBCT) to accurately align preoperative CT or MR images with the intraoperative scene. The registration method combines a Gaussian mixture (GM) model followed by a variation of the Demons algorithm. First, following segmentation of the volume of interest (i.e., volume of the tongue extending to the hyoid), a GM model is applied to surface point clouds for rigid initialization (GM rigid) followed by nonrigid deformation (GM nonrigid). Second, the registration is refined using the Demons algorithm applied to distance map transforms of the (GM-registered) preoperative image and intraoperative CBCT. Performance was evaluated in repeat cadaver studies (25 image pairs) in terms of target registration error (TRE), entropy correlation coefficient (ECC), and normalized pointwise mutual information (NPMI). Retraction of the tongue in the TORS operative setup induced gross deformation >30 mm. The mean TRE following the GM rigid, GM nonrigid, and Demons steps was 4.6, 2.1, and 1.7 mm, respectively. The respective ECC was 0.57, 0.70, and 0.73 and NPMI was 0.46, 0.57, and 0.60. Registration accuracy was best across the superior aspect of the tongue and in proximity to the hyoid (by virtue of GM registration of surface points on these structures). The Demons step refined registration primarily in deeper portions of the tongue further from the surface and hyoid bone. Since the method does not use image intensities directly, it is suitable to multi-modality registration of preoperative CT or MR with intraoperative CBCT. Extending the 3D image registration to the fusion of image and planning data in stereo-endoscopic video is anticipated to support safer, high-precision base of tongue robotic surgery. PMID:23807549

Deformable image registration for cone-beam CT guided transoral robotic base-of-tongue surgery

NASA Astrophysics Data System (ADS)

Reaungamornrat, S.; Liu, W. P.; Wang, A. S.; Otake, Y.; Nithiananthan, S.; Uneri, A.; Schafer, S.; Tryggestad, E.; Richmon, J.; Sorger, J. M.; Siewerdsen, J. H.; Taylor, R. H.

2013-07-01

Transoral robotic surgery (TORS) offers a minimally invasive approach to resection of base-of-tongue tumors. However, precise localization of the surgical target and adjacent critical structures can be challenged by the highly deformed intraoperative setup. We propose a deformable registration method using intraoperative cone-beam computed tomography (CBCT) to accurately align preoperative CT or MR images with the intraoperative scene. The registration method combines a Gaussian mixture (GM) model followed by a variation of the Demons algorithm. First, following segmentation of the volume of interest (i.e. volume of the tongue extending to the hyoid), a GM model is applied to surface point clouds for rigid initialization (GM rigid) followed by nonrigid deformation (GM nonrigid). Second, the registration is refined using the Demons algorithm applied to distance map transforms of the (GM-registered) preoperative image and intraoperative CBCT. Performance was evaluated in repeat cadaver studies (25 image pairs) in terms of target registration error (TRE), entropy correlation coefficient (ECC) and normalized pointwise mutual information (NPMI). Retraction of the tongue in the TORS operative setup induced gross deformation >30 mm. The mean TRE following the GM rigid, GM nonrigid and Demons steps was 4.6, 2.1 and 1.7 mm, respectively. The respective ECC was 0.57, 0.70 and 0.73, and NPMI was 0.46, 0.57 and 0.60. Registration accuracy was best across the superior aspect of the tongue and in proximity to the hyoid (by virtue of GM registration of surface points on these structures). The Demons step refined registration primarily in deeper portions of the tongue further from the surface and hyoid bone. Since the method does not use image intensities directly, it is suitable to multi-modality registration of preoperative CT or MR with intraoperative CBCT. Extending the 3D image registration to the fusion of image and planning data in stereo-endoscopic video is anticipated to support safer, high-precision base-of-tongue robotic surgery.

Achieving hemostasis in dermatology – Part 1: Preoperative, intraoperative, and postoperative management

PubMed Central

Kaur, Ravneet Ruby; Glick, Jaimie B.; Siegel, Daniel

2013-01-01

As dermatological procedures continue to become increasingly complex, improved methods and tools to achieve appropriate hemostasis become necessary. The methods for achieving adequate hemostasis are variable and depend greatly on the type of procedure performed and the unique characteristics of the individual patient. In Part 1 of this review, we discuss the preoperative, intraoperative, and postoperative management of patients undergoing dermatologic surgery. We address oral medications and supplements that affect hemostasis, hemostatic anesthesia, and intraoperative interventions such as suture ligation and heat-generating cautery devices. In Part 2 of this review, we will discuss topical hemostats. The authors conducted an extensive literature review using the following keywords: “hemostasis,” “dermatology,” “dermatological surgery,” “dermatologic sutures,” “electrosurgery,” “hemostatic anesthesia,” and “laser surgery.” Sources for this article were identified by searching the English literature in the Pubmed database for the time period from 1940 to March 2012. A thorough bibliography search was also conducted and key references were examined. PMID:23741660

Silk-elastin-like protein polymer matrix for intraoperative delivery of an oncolytic vaccinia virus

PubMed Central

Price, Daniel L.; Li, Pingdong; Chen, Chun-Hao; Wong, Danni; Yu, Zhenkun; Chen, Nanhai G.; Yu, Yong A.; Szalay, Aladar A.; Cappello, Joseph; Fong, Yuman; Wong, Richard J.

2016-01-01

Background Oncolytic viral efficacy may be limited by the penetration of the virus into tumors. This may be enhanced by intraoperative application of virus immediately after surgical resection. Methods Oncolytic vaccinia virus GLV-1h68 was delivered in silk-elastin-like protein polymer (SELP) in vitro and in vivo in anaplastic thyroid carcinoma cell line 8505c in nude mice. Results GLV-1h68 in SELP infected and lysed anaplastic thyroid cancer cells in vitro equally as effectively as in phosphate-buffered saline (PBS), and at 1 week retains a thousand fold greater infectious plaque-forming units. In surgical resection models of residual tumor, GLV-1h68 in SELP improves tumor control and shows increased viral β-galactosidase expression as compared to PBS. Conclusion The use of SELP matrix for intraoperative oncolytic viral delivery protects infectious viral particles from degradation, facilitates sustained viral delivery and transgene expression, and improves tumor control. Such optimization of methods of oncolytic viral delivery may enhance therapeutic outcomes. PMID:25244076

Awake craniotomy for brain lesions within and near the primary motor area: A retrospective analysis of factors associated with worsened paresis in 102 consecutive patients

PubMed Central

Shinoura, Nobusada; Midorikawa, Akira; Yamada, Ryoji; Hana, Taijun; Saito, Akira; Hiromitsu, Kentaro; Itoi, Chisato; Saito, Syoko; Yagi, Kazuo

2013-01-01

Background: We analyzed factors associated with worsened paresis in a large series of patients with brain lesions located within or near the primary motor area (M1) to establish protocols for safe, awake craniotomy of eloquent lesions. Methods: We studied patients with brain lesions involving M1, the premotor area (PMA) and the primary sensory area (S1), who underwent awake craniotomy (n = 102). In addition to evaluating paresis before, during, and one month after surgery, the following parameters were analyzed: Intraoperative complications; success or failure of awake surgery; tumor type (A or B), tumor location, tumor histology, tumor size, and completeness of resection. Results: Worsened paresis at one month of follow-up was significantly associated with failure of awake surgery, intraoperative complications and worsened paresis immediately after surgery, which in turn was significantly associated with intraoperative worsening of paresis. Intraoperative worsening of paresis was significantly related to preoperative paresis, type A tumor (motor tract running in close proximity to and compressed by the tumor), tumor location within or including M1 and partial removal (PR) of the tumor. Conclusions: Successful awake surgery and prevention of deterioration of paresis immediately after surgery without intraoperative complications may help prevent worsening of paresis at one month. Factors associated with intraoperative worsening of paresis were preoperative motor deficit, type A and tumor location in M1, possibly leading to PR of the tumor. PMID:24381792

Confocal laser endomicroscopy for brain tumor surgery: a milestone journey from microscopy to cellular surgery (Conference Presentation)

NASA Astrophysics Data System (ADS)

Charalampaki, Cleopatra

2017-02-01

The aim in brain tumor surgery is maximal tumor resection with minimal damage of normal neuronal tissue. Today diagnosis of tumor and definition of tumor borders intraoperatively is based on various visualization methods as well as on the histopathologic examination of a limited number of biopsy specimens via frozen sections. Unfortunately, intraoperative histopathology bears several shortcomings, and many biopsies are inconclusive. Therefore, the desirable treatment could be to have the ability to identify intraoperative cellular structures, and differentiate tumor from normal functional brain tissue on a cellular level. To achieve this goal new technological equipment integrated with new surgical concepts is needed.Confocal Laser Endomicroscopy (CLE) is an imaging technique which provides microscopic information of tissue in real-time. We are able to use these technique to perform intraoperative "optical biopsies" in bringing the microscope inside to the patients brain through miniaturized fiber-optic probes, and allow real-time histopathology. In our knowledge we are worldwide the only one neurosurgical group using CLE intraoperative for brain tumor surgery. We can detect and characterize intraoperative tumor cells, providing immediate online diagnosis without the need for frozen sections. It also provides delineation of borders between tumor and normal tissue on a cellular level, making surgical margins more accurate than ever before. The applications of CLE-assisted neurosurgery help to accurate the therapy by extending the resection borders and protecting the functionality of normal brain tissue in critical eloquent areas.

The method of intraoperative analysis of structural and metabolic changes in the area of tumor resection

NASA Astrophysics Data System (ADS)

Savelieva, Tatiana A.; Loshchenov, Victor B.; Volkov, Vladimir V.; Linkov, Kirill G.; Goryainov, Sergey A.; Potapov, Alexander A.

2014-05-01

The method of intraoperative analysis of tumor markers such as structural changes, concentrations of 5- ALA induced protoporphyrin IX and hemoglobin in the area of tissue resection was developed. A device for performing this method is a neurosurgical aspiration cannulae coupled with the fiber optic probe. The configuration of fibers at the end of cannulae was developed according to the results of numerical modeling of light distribution in biological tissues. The optimal distance between the illuminating and receiving fiber was found for biologically relevant interval of optical properties. On this particular distance the detected diffuse reflectance depends on scattering coefficient almost linearly. Array of optical phantoms containing hemoglobin, protoporphyrin IX and fat emulsion (as scattering media) in various concentrations was prepared to verify the method. The recovery of hemoglobin and protoporphyrin IX concentrations in the scattering media with an error less than 10% has been demonstrated. The fat emulsion concentration estimation accuracy was less than 12%. The first clinical test was carried out during glioblastoma multiforme resection in Burdenko Neurosurgery Institute and confirmed that sensitivity of this method is enough to detect investigated tumor markers in vivo. This method will allow intraoperative analysis of the structural and metabolical tumor markers directly in the zone of destruction of tumor tissue, thereby increasing the degree of radical removal and preservation of healthy tissue.

Intraoperative high-field magnetic resonance imaging, multimodal neuronavigation, and intraoperative electrophysiological monitoring-guided surgery for treating supratentorial cavernomas.

PubMed

Li, Fang-Ye; Chen, Xiao-Lei; Xu, Bai-Nan

2016-09-01

To determine the beneficial effects of intraoperative high-field magnetic resonance imaging (MRI), multimodal neuronavigation, and intraoperative electrophysiological monitoring-guided surgery for treating supratentorial cavernomas. Twelve patients with 13 supratentorial cavernomas were prospectively enrolled and operated while using a 1.5 T intraoperative MRI, multimodal neuronavigation, and intraoperative electrophysiological monitoring. All cavernomas were deeply located in subcortical areas or involved critical areas. Intraoperative high-field MRIs were obtained for the intraoperative "visualization" of surrounding eloquent structures, "brain shift" corrections, and navigational plan updates. All cavernomas were successfully resected with guidance from intraoperative MRI, multimodal neuronavigation, and intraoperative electrophysiological monitoring. In 5 cases with supratentorial cavernomas, intraoperative "brain shift" severely deterred locating of the lesions; however, intraoperative MRI facilitated precise locating of these lesions. During long-term (>3 months) follow-up, some or all presenting signs and symptoms improved or resolved in 4 cases, but were unchanged in 7 patients. Intraoperative high-field MRI, multimodal neuronavigation, and intraoperative electrophysiological monitoring are helpful in surgeries for the treatment of small deeply seated subcortical cavernomas.

Analysis of the Istanbul Forensic Medicine Institute expert decisions on recurrent laryngeal nerve injuries due to thyroidectomy between 2008-2012.

PubMed

Karakaya, M Arif; Koç, Okay; Ekiz, Feza; Ağaçhan, A Feran; Göret, Nuri Emrah

2016-01-01

The aim of this study was to evaluate the approach of Forensic Medicine Institution for recurrent laryngeal nerve injuries. In addition, parameters that were taken into consideration by Forensic Medicine Institution in the differentiation of complication and malpractice were evaluated. The files of 38 patients, with recurrent laryngeal nerve injury following thyroidectomy, that were referred to Istanbul Forensic Medicine Institute with request of expert opinion between 2008-2012 were retrospectively investigated. Data regarding expert decisions, age, gender, diagnosis, hospital type, preoperative vocal cord examination, intraoperative nerve monitoring (IONM), identification of nerve injury during operation, repair of nerve during operation, and type of injury were assessed. Surgeons were found to be faulty in all files with bilateral nerve injury, however, one-sided injury files were considered as a medical complication. Twenty-one (55.2%) patients were female, and 17 (44.8%) were male, with a mean age of 35,8 in women, and 34,1 in men. None of these patients had undergone preoperative vocal cord assessment. The recurrent laryngeal nerve was intraoperatively identified in 21 (55.2%) patients, while it was not seen in 17 (44.8%) patients. IONM was not applied in any patients. There was no attempt for nerve repair during any operation. Nineteen patients had unilateral, and 19 patients had bilateral nerve damage. Bilateral recurrent laryngeal nerve injuries are considered as malpractice, when imaging or pathology reports fail to state a cause for difficulty in nerve identification.

Visualization of subcapsular hepatic malignancy by indocyanine-green fluorescence imaging during laparoscopic hepatectomy.

PubMed

Kudo, Hiroki; Ishizawa, Takeaki; Tani, Keigo; Harada, Nobuhiro; Ichida, Akihiko; Shimizu, Atsushi; Kaneko, Junichi; Aoki, Taku; Sakamoto, Yoshihiro; Sugawara, Yasuhiko; Hasegawa, Kiyoshi; Kokudo, Norihiro

2014-08-01

Although laparoscopic hepatectomy has increasingly been used to treat cancers in the liver, the accuracy of intraoperative diagnosis may be inferior to that of open surgery because the ability to visualize and palpate the liver surface during laparoscopy is relatively limited. Fluorescence imaging has the potential to provide a simple compensatory diagnostic tool for identification of cancers in the liver during laparoscopic hepatectomy. In 17 patients who were to undergo laparoscopic hepatectomy, 0.5 mg/kg body weight of indocyanine green (ICG) was administered intravenously within the 2 weeks prior to surgery. Intraoperatively, a laparoscopic fluorescence imaging system obtained fluorescence images of its surfaces during mobilization of the liver. In all, 16 hepatocellular carcinomas (HCCs) and 16 liver metastases (LMs) were resected. Of these, laparoscopic ICG fluorescence imaging identified 12 HCCs (75%) and 11 LMs (69%) on the liver surfaces distributed over Couinaud's segments 1-8, including the 17 tumors that had not been identified by visual inspections of normal color images. The 23 tumors that were identified by fluorescence imaging were located closer to the liver surfaces than another nine tumors that were not identified by fluorescence imaging (median [range] depth 1 [0-5] vs. 11 [8-30] mm; p < 0.001). Like palpation during open hepatectomy, laparoscopic ICG fluorescence imaging enables real-time identification of subcapsular liver cancers, thus facilitating estimation of the required extent of hepatic mobilization and determination of the location of an appropriate hepatic transection line.

Brain-shift compensation using intraoperative ultrasound and constraint-based biomechanical simulation.

PubMed

Morin, Fanny; Courtecuisse, Hadrien; Reinertsen, Ingerid; Le Lann, Florian; Palombi, Olivier; Payan, Yohan; Chabanas, Matthieu

2017-08-01

During brain tumor surgery, planning and guidance are based on preoperative images which do not account for brain-shift. However, this deformation is a major source of error in image-guided neurosurgery and affects the accuracy of the procedure. In this paper, we present a constraint-based biomechanical simulation method to compensate for craniotomy-induced brain-shift that integrates the deformations of the blood vessels and cortical surface, using a single intraoperative ultrasound acquisition. Prior to surgery, a patient-specific biomechanical model is built from preoperative images, accounting for the vascular tree in the tumor region and brain soft tissues. Intraoperatively, a navigated ultrasound acquisition is performed directly in contact with the organ. Doppler and B-mode images are recorded simultaneously, enabling the extraction of the blood vessels and probe footprint, respectively. A constraint-based simulation is then executed to register the pre- and intraoperative vascular trees as well as the cortical surface with the probe footprint. Finally, preoperative images are updated to provide the surgeon with images corresponding to the current brain shape for navigation. The robustness of our method is first assessed using sparse and noisy synthetic data. In addition, quantitative results for five clinical cases are provided, first using landmarks set on blood vessels, then based on anatomical structures delineated in medical images. The average distances between paired vessels landmarks ranged from 3.51 to 7.32 (in mm) before compensation. With our method, on average 67% of the brain-shift is corrected (range [1.26; 2.33]) against 57% using one of the closest existing works (range [1.71; 2.84]). Finally, our method is proven to be fully compatible with a surgical workflow in terms of execution times and user interactions. In this paper, a new constraint-based biomechanical simulation method is proposed to compensate for craniotomy-induced brain-shift. While being efficient to correct this deformation, the method is fully integrable in a clinical process. Copyright © 2017 Elsevier B.V. All rights reserved.

Diagnosis and Management of Intraoperative Colorectal Anastomotic Leaks: A Global Retrospective Patient Chart Review Study.

PubMed

Schiff, A; Roy, S; Pignot, M; Ghosh, S K; Fegelman, E J

2017-01-01

This targeted chart review study reports the first ever detailed global account of clinical approaches adopted to detect and manage anastomotic leaks identified during surgery in routine clinical practice. 156 surgeons from eight countries retrospectively extracted data from surgical records of 458 patients who underwent colorectal surgery with an identified intraoperative leak at the circular anastomosis. Demographic details, procedures, and outcomes were analyzed descriptively, by country. Most surgeries were performed laparoscopically (57.6%), followed by open surgeries (35.8%). The burden of intraoperative leaks on the healthcare system is driven in large part by the additional interventions such as using a sealant, recreating the anastomosis, and diverting the anastomosis to a colostomy bag, undertaken to manage the leak. The mean duration of hospitalization was 19.9 days. Postoperative anastomotic leaks occurred in 62 patients (13.5%), most frequently 4 to 7 days after surgery. Overall, country-specific differences were observed in patient characteristics, surgical procedures, method of diagnosis of intraoperative leak, interventions, and length of hospital stay. The potential cost of time and material needed to repair intraoperative leaks during surgery is substantial and often hidden to the healthcare system, potentially leading to an underestimation of the impact of this complication.

Radiation dose reduction in thoracic and lumbar spine instrumentation using navigation based on an intraoperative cone beam CT imaging system: a prospective randomized clinical trial.

PubMed

Pireau, Nathalie; Cordemans, Virginie; Banse, Xavier; Irda, Nadia; Lichtherte, Sébastien; Kaminski, Ludovic

2017-11-01

Spine surgery still remains a challenge for every spine surgeon, aware of the potential serious outcomes of misplaced instrumentation. Though many studies have highlighted that using intraoperative cone beam CT imaging and navigation systems provides higher accuracy than conventional freehand methods for placement of pedicle screws in spine surgery, few studies are concerned about how to reduce radiation exposure for patients with the use of such technology. One of the main focuses of this study is based on the ALARA principle (as low as reasonably achievable). A prospective randomized trial was conducted in the hybrid operating room between December 2015 and December 2016, including 50 patients operated on for posterior instrumented thoracic and/or lumbar spinal fusion. Patients were randomized to intraoperative 3D acquisition high-dose (standard dose) or low-dose protocol, and a total of 216 pedicle screws were analyzed in terms of screw position. Two different methods were used to measure ionizing radiation: the total skin dose (derived from the dose-area product) and the radiation dose evaluated by thermoluminescent dosimeters on the surgical field. According to Gertzbein and Heary classifications, low-dose protocol provided a significant higher accuracy of pedicle screw placement than the high-dose protocol (96.1 versus 92%, respectively). Seven screws (3.2%), all implanted with the high-dose protocol, needed to be revised intraoperatively. The use of low-dose acquisition protocols reduced patient exposure by a factor of five. This study emphasizes the paramount importance of using low-dose protocols for intraoperative cone beam CT imaging coupled with the navigation system, as it at least does not affect the accuracy of pedicle screw placement and irradiates drastically less.

Orbit-associated tumors: navigation and control of resection using intraoperative computed tomography.

PubMed

Terpolilli, Nicole A; Rachinger, Walter; Kunz, Mathias; Thon, Niklas; Flatz, Wilhelm H; Tonn, Jörg-Christian; Schichor, Christian

2016-05-01

OBJECT Treatment of skull base lesions is complex and usually requires a multidisciplinary approach. In meningioma, which is the most common tumor entity in this region, resection is considered to be the most important therapeutic step to avoid tumor recurrence. However, resection of skull base lesions with orbital or optic nerve involvement poses a challenge due to their anatomical structure and their proximity to eloquent areas. Therefore the main goal of surgery should be to achieve the maximum extent of resection while preserving neurological function. In the postoperative course, medical and radiotherapeutic strategies may then be successfully used to treat possible tumor residues. Methods to safely improve the extent of resection in skull base lesions therefore are desirable. The current study reports the authors' experience with the use of intraoperative CT (iCT) combined with neuronavigation with regard to feasibility and possible benefits of the method. METHODS Those patients with tumorous lesions in relationship to the orbit, sphenoid wing, or cavernous sinus who were surgically treated between October 2008 and December 2013 using iCT-based neuronavigation and in whom an intraoperative scan was obtained for control of resection were included. In all cases a second iCT scan was performed under sterile conditions after completion of navigation-guided microsurgical tumor resection. The surgical strategy was adapted accordingly; if necessary, resection was continued. RESULTS Twenty-three patients (19 with WHO Grade I meningioma and 4 with other lesions) were included. The most common clinical symptoms were loss of visual acuity and exophthalmus. Intraoperative control of resection by iCT was successfully obtained in all cases. Intraoperative imaging changed the surgical approach in more than half (52.2%) of these patients, either because iCT demonstrated unexpected residual tumor masses or because the second scan revealed additional tumor tissue that was not detected in the first scan due to overlay by osseous tumor parts; in these cases resection was continued. In the remaining cases resection was concluded as planned because iCT verified the surgeon's microscopic estimation of tumor resection status. Postoperative visual outcome was favorable in more than 80% of patients. CONCLUSIONS Intraoperative CT allows control of resection in case of uncertainty and can help to improve the extent of maximal safe resection, especially in case of osseous tumor parts and masses within the orbit.

Intraoperative acceleration measurements to quantify improvement in tremor during deep brain stimulation surgery.

PubMed

Shah, Ashesh; Coste, Jérôme; Lemaire, Jean-Jacques; Taub, Ethan; Schüpbach, W M Michael; Pollo, Claudio; Schkommodau, Erik; Guzman, Raphael; Hemm-Ode, Simone

2017-05-01

Deep brain stimulation (DBS) surgery is extensively used in the treatment of movement disorders. Nevertheless, methods to evaluate the clinical response during intraoperative stimulation tests to identify the optimal position for the implantation of the chronic DBS lead remain subjective. In this paper, we describe a new, versatile method for quantitative intraoperative evaluation of improvement in tremor with an acceleration sensor that is mounted on the patient's wrist during surgery. At each anatomical test position, the improvement in tremor compared to the initial tremor is estimated on the basis of extracted outcome measures. This method was tested on 15 tremor patients undergoing DBS surgery in two centers. Data from 359 stimulation tests were acquired. Our results suggest that accelerometric evaluation detects tremor changes more sensitively than subjective visual ratings. The effective stimulation current amplitudes identified from the quantitative data (1.1 ± 0.8 mA) are lower than those identified by visual evaluation (1.7 ± 0.8 mA) for similar improvement in tremor. Additionally, if these data had been used to choose the chronic implant position of the DBS lead, 15 of the 26 choices would have been different. These results show that our method of accelerometric evaluation can potentially improve DBS targeting.

Label-free imaging of brain and brain tumor specimens with combined two-photon excited fluorescence and second harmonic generation microscopy

NASA Astrophysics Data System (ADS)

Jiang, Liwei; Wang, Xingfu; Wu, Zanyi; Du, Huiping; Wang, Shu; Li, Lianhuang; Fang, Na; Lin, Peihua; Chen, Jianxin; Kang, Dezhi; Zhuo, Shuangmu

2017-10-01

Label-free imaging techniques are gaining acceptance within the medical imaging field, including brain imaging, because they have the potential to be applied to intraoperative in situ identifications of pathological conditions. In this paper, we describe the use of two-photon excited fluorescence (TPEF) and second harmonic generation (SHG) microscopy in combination for the label-free detection of brain and brain tumor specimens; gliomas. Two independently detecting channels were chosen to subsequently collect TPEF/SHG signals from the specimen to increase TPEF/SHG image contrasts. Our results indicate that the combined TPEF/SHG microscopic techniques can provide similar rat brain structural information and produce a similar resolution like conventional H&E staining in neuropathology; including meninges, cerebral cortex, white-matter structure corpus callosum, choroid plexus, hippocampus, striatum, and cerebellar cortex. It can simultaneously detect infiltrating human brain tumor cells, the extracellular matrix collagen fiber of connective stroma within brain vessels and collagen depostion in tumor microenvironments. The nuclear-to-cytoplasmic ratio and collagen content can be extracted as quantitative indicators for differentiating brain gliomas from healthy brain tissues. With the development of two-photon fiberscopes and microendoscope probes and their clinical applications, the combined TPEF and SHG microcopy may become an important multimodal, nonlinear optical imaging approach for real-time intraoperative histological diagnostics of residual brain tumors. These occur in various brain regions during ongoing surgeries through the method of simultaneously identifying tumor cells, and the change of tumor microenvironments, without the need for the removal biopsies and without the need for tissue labelling or fluorescent markers.

Taking label-free optical spectroscopy techniques into the operating theatre: biopsy needles and surgical guidance probes (Conference Presentation)

NASA Astrophysics Data System (ADS)

Leblond, Frédéric

2017-02-01

Recent advances will be described relating to the development and clinical translation of optical spectroscopy techniques designed to guide surgical interventions in brain and prostate oncology applications. The use of molecular imaging guidance systems can enable true intra-operative tissue identification, increasing the effectiveness of cancer surgery and potentially positively impacting patient survival. Surgical resection is a fundamental cancer treatment, but its effectiveness is reduced by the inability to rapidly and accurately identify cancer margins. We will introduce a portable intraoperative label-free multimodal optical spectroscopy system combining intrinsic fluorescence, diffuse reflectance, and Raman spectroscopy that can identify cancer in situ during surgery. We will show that this on-line guidance system can detect primary cancer such as glioma as well as metastatic melanoma and cancer of the lung and colon with an accuracy, sensitivity, and specificity of 97%, 100%, and 93% respectively. Moreover, a method will be presented, along with preliminary tissue classification results, based on the interrogation of whole human prostates from prostatectomies. The development and in vivo validation of an optical brain needle biopsy instrument will be presented demonstrating its ability to detect bulk tumor using Raman spectroscopy with the goal of reducing the number of non-diagnostic samples during a procedure. The extraction of tissue can cause life-threatening hemorrhage because of significant blood vessel injury during the procedure. We will demonstrate that a sub-diffuse optical tomography technique integrated with a commercial biopsy needle can detect the presence of blood vessels to limit the hemorrhage risk.

Can surface electromyography improve surgery planning? Electromyographic assessment and intraoperative verification of the nerve bundle entry point location of the gracilis muscle.

PubMed

Romaniszyn, Michal; Walega, Piotr; Nowakowski, Michal; Nowak, Wojciech

2016-06-01

To verify the precision of surface electromyography (sEMG) in locating the innervation zone of the gracilis muscle, by comparing the location of the IZ estimated by means of sEMG with in vivo location of the nerve bundle entry point in patients before graciloplasty procedure due to fecal incontinence. Nine patients who qualified for the graciloplasty procedure underwent sEMG on both gracilis muscle before their operations. During surgery the nerve bundle was identified by means of electrical stimulation. The distance between the proximal attachment and the nerve entry point into the muscle's body was measured. Both measurements (sEMG and in vivo identification) were compared for each subject. On average, the IZ was located 65.5mm from the proximal attachment. The mean difference in location of the innervation zones in each individual was 10±9.7mm, maximal - 30mm, the difference being statistically significant (p=0.017). It was intraoperatively confirmed, that the nerve entered the muscle an average of 62mm from the proximal attachment. The largest difference between the EMG IZ estimation and nerve bundle entry point was 5mm (mean difference 2.8mm, p=0.767). Preoperative surface electromyography of both gracilis muscles is a safe, precise and reliable method of assessing the location of the innervation zones of the gracilis muscles. The asymmetry of the IZ location in left and right muscles may be important in context of technical aspects of the graciloplasty procedure. Copyright © 2016 Elsevier Ltd. All rights reserved.

Contribution of sonicate-fluid cultures and broad-range PCR to microbiological diagnosis in vascular graft infections.

PubMed

Kokosar Ulcar, Barbara; Lakic, Nikola; Jeverica, Samo; Pecavar, Blaz; Logar, Mateja; Cerar, Tjasa Kisek; Lejko-Zupanc, Tatjana

2018-06-01

Vascular graft infections (VGI) are associated with considerable morbidity and mortality, and antimicrobial treatment is an important adjunct to surgical treatment. While microbial aetiology of VGI is often difficult to determine, other techniques such as sonication of implanted material may be used to enhance the recovery of biofilm-associated organisms. We performed a retrospective analysis of 22 consecutive patients treated for VGI at University Medical Centre Ljubljana from May 2011 through January 2015. Explanted vascular grafts were flooded with sterile Ringer solution, sonicated for 1 min at a frequency of 40 kHz and inoculated on solid and liquid culture media. Aerobic and anaerobic cultures were performed, incubated for 14 days and any significant bacterial growth was quantitatively evaluated. Additionally, broad-range PCR from sonicate fluid was performed. Microbiological results were compared with the results of preoperatively taken blood cultures and the results of intraoperative tissue cultures (material from peri-graft collection). Identification of the causative organism (irrespective of the method) was achieved in 95.8%. Preoperative blood cultures were positive in 35.3%, intraoperative tissue cultures in 31.8%, sonicate fluid culture in 79.2%, while broad-range PCR from sonicate fluid was positive in 66.7%. In 37.5% the pathogen detected in sonicate fluid culture or broad-range PCR was the only positive microbiological result. Sonicate fluid culture and broad-range PCR from explanted vascular grafts may contribute to optimization of antimicrobial treatment. Optimal timing of antibiotic therapy before explantation should be further assessed to improve diagnostic yield.

Intraoperative magnetic resonance imaging in pediatric neurosurgery: safety and utility.

PubMed

Giordano, Mario; Samii, Amir; Lawson McLean, Anna C; Bertalanffy, Helmut; Fahlbusch, Rudolf; Samii, Madjid; Di Rocco, Concezio

2017-01-01

OBJECTIVE The use of high-field intraoperative MRI has been largely studied for the treatment of intracranial tumors in adult patients. In this study, the authors investigated the safety, advantages, and limitations of high-field iMRI for cranial neurosurgical procedures in pediatric patients, with particular attention to craniopharyngiomas and gliomas. METHODS The authors performed 82 surgical procedures in patients under 16 years of age (range 0.8-15 years) over an 8-year period (2007-2014) using iMRI. The population was divided into 3 groups based on the condition treated: sellar region tumors (Group 1), gliomas (Group 2), and other pathological entities (Group 3). The patients' pre- and postoperative neurological status, the presence of residual tumor, the number of intraoperative scans, and complications were evaluated. RESULTS In Group 1, gross-total resection (GTR) was performed in 22 (88%) of the procedures and subtotal resection (STR) in 3 (12%). In Group 2, GTR, STR, and partial resection (PR) were performed, respectively, in 15 (56%), 7 (26%), and 5 (18%) of the procedures. In Group 3, GTR was performed in 28 (93%) and STR in 2 (7%) of the procedures. In cases of craniopharyngioma (Group 1) and glioma (Group 2) in which a complete removal was planned, iMRI allowed localization of residual lesions and attainment of the surgical goal through further resection, respectively, in 18% and 27% of the procedures. Moreover, in gliomas the resection could be extended from partial to subtotal in 50% of the cases. In 17% of the patients in Group 3, iMRI enabled the identification and further removal of tumor remnants. There was no intra- or postoperative complication related to the use of iMRI despite special technical difficulties in smaller children. CONCLUSIONS In this study, the use of iMRI in children proved to be safe. It was most effective in increasing the extent of tumor resection, especially in patients with low-grade gliomas and craniopharyngiomas. The most prominent disadvantage of high-field iMRI was the limitation with respect to operative positioning due to the configuration of the surgical table.

Intraoperative measurements on the mitral apparatus using optical tracking: a feasibility study

NASA Astrophysics Data System (ADS)

Engelhardt, Sandy; De Simone, Raffaele; Wald, Diana; Zimmermann, Norbert; Al Maisary, Sameer; Beller, Carsten J.; Karck, Matthias; Meinzer, Hans-Peter; Wolf, Ivo

2014-03-01

Mitral valve reconstruction is a widespread surgical method to repair incompetent mitral valves. During reconstructive surgery the judgement of mitral valve geometry and subvalvular apparatus is mandatory in order to choose for the appropriate repair strategy. To date, intraoperative analysis of mitral valve is merely based on visual assessment and inaccurate sizer devices, which do not allow for any accurate and standardized measurement of the complex three-dimensional anatomy. We propose a new intraoperative computer-assisted method for mitral valve measurements using a pointing instrument together with an optical tracking system. Sixteen anatomical points were defined on the mitral apparatus. The feasibility and the reproducibility of the measurements have been tested on a rapid prototyping (RP) heart model and a freshly exercised porcine heart. Four heart surgeons repeated the measurements three times on each heart. Morphologically important distances between the measured points are calculated. We achieved an interexpert variability mean of 2.28 +/- 1:13 mm for the 3D-printed heart and 2.45 +/- 0:75 mm for the porcine heart. The overall time to perform a complete measurement is 1-2 minutes, which makes the method viable for virtual annuloplasty during an intervention.

Active illumination based 3D surface reconstruction and registration for image guided medialization laryngoplasty

NASA Astrophysics Data System (ADS)

Jin, Ge; Lee, Sang-Joon; Hahn, James K.; Bielamowicz, Steven; Mittal, Rajat; Walsh, Raymond

2007-03-01

The medialization laryngoplasty is a surgical procedure to improve the voice function of the patient with vocal fold paresis and paralysis. An image guided system for the medialization laryngoplasty will help the surgeons to accurately place the implant and thus reduce the failure rates of the surgery. One of the fundamental challenges in image guided system is to accurately register the preoperative radiological data to the intraoperative anatomical structure of the patient. In this paper, we present a combined surface and fiducial based registration method to register the preoperative 3D CT data to the intraoperative surface of larynx. To accurately model the exposed surface area, a structured light based stereo vision technique is used for the surface reconstruction. We combined the gray code pattern and multi-line shifting to generate the intraoperative surface of the larynx. To register the point clouds from the intraoperative stage to the preoperative 3D CT data, a shape priori based ICP method is proposed to quickly register the two surfaces. The proposed approach is capable of tracking the fiducial markers and reconstructing the surface of larynx with no damage to the anatomical structure. We used off-the-shelf digital cameras, LCD projector and rapid 3D prototyper to develop our experimental system. The final RMS error in the registration is less than 1mm.

Intraoperative use of fibrin glue dyed with methylene blue in surgery for branchial cleft anomalies.

PubMed

Piccioni, Michela; Bottazzoli, Marco; Nassif, Nader; Stefini, Stefania; Nicolai, Piero

2016-09-01

We present a new method of optimizing the results of surgery for branchial cleft anomalies based on the intraoperative injection of fibrin glue combined with methylene blue dye. Retrospective single-center cohort study. The method was applied in 17 patients suffering from branchial anomalies. Six (35.29%) had a preauricular lesion; three (17.65%) had lesions derived from the first arch/pouch/groove (type I), four (23.53%) had lesions derived from the first (type II), one (5.88%) had lesions derived from the second, one (5.88%) had lesions derived from the third, and two (11.76%) had lesions derived from the fourth. The median and mean age at surgery were 10 and 10.6 years, respectively. All patients were followed by periodic clinical and ultrasonographic examination. The combination of fibrin glue with methylene blue facilitated the correct assessment of the extension of the lesions and their intraoperative manipulation. After a mean follow-up of 47.8 months, all patients were free of disease. Intraoperative injection of branchial fistulae and cysts by a mixture of fibrin glue and methylene blue is an effective, easy, and safe tool to track lesions and achieve radical resection. The technique requires a definitive validation on a large cohort with adequate stratification of patients. 4 Laryngoscope, 126:2147-2150, 2016. © 2015 The American Laryngological, Rhinological and Otological Society, Inc.

Intraoperative panoramic image using alignment grid, is it accurate?

PubMed

Apivatthakakul, T; Duanghakrung, M; Luevitoonvechkit, S; Patumasutra, S

2013-07-01

Minimally invasive orthopedic trauma surgery relies heavily on intraoperative fluoroscopic images to evaluate the quality of fracture reduction and fixation. However, fluoroscopic images have a narrow field of view and often cannot visualize the entire long bone axis. To compare the coronal femoral alignment between conventional X-rays to that achieved with a new method of acquiring a panoramic intraoperative image. Twenty-four cadaveric femurs with simple diaphyseal fractures were fixed with an angulated broad DCP to create coronal plane malalignment. An intraoperative alignment grid was used to help stitch different fluoroscopic images together to produce a panoramic image. A conventional X-ray of the entire femur was then performed. The coronal plane angulation in the panoramic images was then compared to the conventional X-rays using a Wilcoxon signed rank test. The mean angle measured from the panoramic view was 173.9° (range 169.3°-178.0°) with median of 173.2°. The mean angle measured from the conventional X-ray was 173.4° (range 167.7°-178.7°) with a median angle of 173.5°. There was no significant difference between both methods of measurement (P = 0.48). Panoramic images produced by stitching fluoroscopic images together with help of an alignment grid demonstrated the same accuracy at evaluating the coronal plane alignment of femur fractures as conventional X-rays.

Intraoperative Macula Protection by Perfluorocarbon Liquid for the Metallic Intraocular Foreign Body Removal during 23-Gauge Vitrectomy.

PubMed

Rejdak, Robert; Choragiewicz, Tomasz; Moneta-Wielgos, Joanna; Wrzesinska, Dominika; Borowicz, Dorota; Forlini, Matteo; Jünemann, Anselm G; Nowomiejska, Katarzyna

2017-01-01

Purpose. To evaluate visual and safety outcomes of 23-gauge (G) pars plana vitrectomy (PPV) with application of perfluorocarbon liquid (PFCL) for intraoperative protection of the macula during intraocular foreign body (IOFB) removal. Methods. Retrospective study of 42 patients who underwent 23 G PPV for IOFB removal from posterior segment with intraoperative PFCL application for the macula shielding. Collected data included corrected distance visual acuity (CDVA), size of IOFB, and complication rate. The mean follow-up period was 12 months. Results . The mean preoperative CDVA was 0.54 logMAR (SD 0.46), and the final mean CDVA was 0.68 logMAR (SD 0.66). All IOFBs were metallic with mean dimensions of 4.6 mm × 2.1 mm. Twenty-two IOFBs were removed through the corneal tunnel and 20 IOFBs through the sclerotomy. No intraoperative iatrogenic lesion of the macula was observed. As a tamponade, silicon oil was applied in 31 eyes, SF 6 gas in 5 eyes, air in 4 eyes, and 2 eyes required no tamponade. Secondary retinal detachment was observed in 17% of cases, but at the end of the follow-up, all the retinas were attached. Conclusion . PFCL application during PPV is a safe method of protecting the macula from unexpected falling of the metallic IOFB during its removal.

Nonrigid liver registration for image-guided surgery using partial surface data: a novel iterative approach

NASA Astrophysics Data System (ADS)

Rucker, D. Caleb; Wu, Yifei; Ondrake, Janet E.; Pheiffer, Thomas S.; Simpson, Amber L.; Miga, Michael I.

2013-03-01

In the context of open abdominal image-guided liver surgery, the efficacy of an image-guidance system relies on its ability to (1) accurately depict tool locations with respect to the anatomy, and (2) maintain the work flow of the surgical team. Laser-range scanned (LRS) partial surface measurements can be taken intraoperatively with relatively little impact on the surgical work flow, as opposed to other intraoperative imaging modalities. Previous research has demonstrated that this kind of partial surface data may be (1) used to drive a rigid registration of the preoperative CT image volume to intraoperative patient space, and (2) extrapolated and combined with a tissue-mechanics-based organ model to drive a non-rigid registration, thus compensating for organ deformations. In this paper we present a novel approach for intraoperative nonrigid liver registration which iteratively reconstructs a displacement field on the posterior side of the organ in order to minimize the error between the deformed model and the intraopreative surface data. Experimental results with a phantom liver undergoing large deformations demonstrate that this method achieves target registration errors (TRE) with a mean of 4.0 mm in the prediction of a set of 58 locations inside the phantom, which represents a 50% improvement over rigid registration alone, and a 44% improvement over the prior non-iterative single-solve method of extrapolating boundary conditions via a surface Laplacian.

Surgical tips and tricks during urethroplasty for bulbar urethral strictures focusing on accurate localisation of the stricture: results from a tertiary centre.

PubMed

Kuo, Tricia L C; Venugopal, Suresh; Inman, Richard D; Chapple, Christopher R

2015-04-01

There are several techniques for characterising and localising an anterior urethral stricture, such as preoperative retrograde urethrography, ultrasonography, and endoscopy. However, these techniques have some limitations. The final determinant is intraoperative assessment, as this yields the most information and defines what surgical procedure is undertaken. We present our intraoperative approach for localising and operating on a urethral stricture, with assessment of outcomes. A retrospective review of urethral strictures operated was carried out. All patients had a bulbar or bulbomembranous urethroplasty. All patients were referred to a tertiary centre and operated on by two urethral reconstructive surgeons. Intraoperative identification of the stricture was performed by cystoscopy. The location of the stricture is demonstrated externally on the urethra by external transillumination of the urethra and comparison with the endoscopic picture. This is combined with accurate placement of a suture through the urethra, at the distal extremity of the stricture, verified precisely by endoscopy. Clinical data were collected in a dedicated database. Intraoperative details and postoperative follow-up data for each patient were recorded and analysed. A descriptive data analysis was performed. A representative group of 35 male patients who had surgery for bulbar stricture was randomly selected from January 2010 to December 2013. Mean follow-up was 13.8 mo (range 2-43 mo). Mean age was 46.5 yr (range 17-70 yr). Three patients had undergone previous urethroplasty and 26 patients had previous urethrotomy or dilatation. All patients had preoperative retrograde urethrography and most (85.7%) had endoscopic assessment. The majority of patients (48.6%) had a stricture length of >2-7 cm and 45.7% of patients required a buccal mucosa graft. There were no intraoperative complications. Postoperatively, two patients had a urinary tract infection. All patients were assessed postoperatively via flexible cystoscopy. Only one patient required subsequent optical urethrotomy for recurrence. Our intraoperative strategy for anterior urethral stricture assessment provides a clear stepwise approach, regardless of the type of urethroplasty eventually chosen (anastomotic disconnected or Heineke-Mikulicz) or augmentation (dorsal, ventral, or augmented roof strip). It is useful in all cases by allowing precise localisation of the incision in the urethra, whether the stricture is simple or complex. We studied the treatment of bulbar urethral strictures with different types of urethroplasty, using a specific technique to identify and characterise the length of the stricture. This technique is effective, precise, and applicable to all patients undergoing urethroplasty for bulbar urethral stricture. Copyright © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Direct cellular vs. indirect pager communication during orthopaedic surgical procedures: a prospective study.

PubMed

Ortega, Gil R; Taksali, Sudeep; Smart, Ryan; Baumgaertner, Michael R

2009-01-01

Cellular phone use within the hospital setting has increased as physicians, nurses, and ancillary staff incorporate wireless technologies in improving efficiencies, cost, and maintaining patient safety and high quality healthcare [11]. Through the use of wireless, cellular communication, an overall improvement in communication accuracy and efficiency between intraoperative orthopaedic surgeons and floor nurses may be achieved. Both communication types occurred while the surgeon was scrubbed in the operating room (OR). Indirect communication occurred when the pager call was answered by the OR circulating nurse with communication between the surgeon, circulating nurse, and floor nurse. Direct communication consisted of cell phone and Jabra Bluetooth BT200 wireless ear piece used by the surgeon. The surgeon answered the floor nurse's cellular call by phone ring-activated automatic answering. The study was conducted during scheduled orthopaedic procedures. An independent observer measured time variables with a stop-watch while orthopaedic nurses randomly called via pager or cell phone. The nurses asked for patient caregiver confirmation and answers to 30 different patient-care questions. Sixty trials were performed with 30 cell and 30 page communications. Direct cellular communication showed a better response rate than indirect page (Cell 100%, Page 73%). Indirect page communication allowed a 27% and 33% error rate with patient problem and surgeon solution communications, respectively. There were no reported communication errors while using direct wireless, cellular communication. When compared to page communications, cellular communications showed statistically significant improvements in mean time intervals in response time (Cell = 11s, Page = 211s), correct patient identification (Cell = 5s, Page = 172s), patient problem and solution time (Cell = 13s, Page = 189s), and total communication time (Cell = 32s, Page = 250s) (s = seconds, all P < 0.001). Floor nurse satisfaction ratings (dependent on communication times and/or difficulties) were improved with direct cellular communication (Cell = 29 excellent, Page = 11 excellent). Intraoperative case interruptions (defined as delaying surgical progress) were more frequent with indirect page communication (10 page v. 0 cell). Our study demonstrates that direct wireless communication may be used to improve intraoperative communication and enhance patient safety. Direct wireless, cellular intraoperative communication improves communication times, communication accuracy, communication satisfaction, and minimizes intraoperative case interruption. As a result of this study, we hope to maintain our transition to direct wireless, cellular intraoperative orthopaedic communication to reduce medical errors, improve patient care, and enhance both orthopaedic surgeon and nursing efficiencies.

Utility of percutaneous joint aspiration and synovial biopsy in identifying culture-positive infected hip arthroplasty.

PubMed

Cross, M Connor; Kransdorf, Mark J; Chivers, F Spencer; Lorans, Roxanne; Roberts, Catherine C; Schwartz, Adam J; Beauchamp, Christopher P

2014-02-01

Percutaneous synovial biopsy has recently been reported to have a high diagnostic value in the preoperative identification of periprosthetic infection of the hip. We report our experience with this technique in the evaluation of patients undergoing revision hip arthroplasty, comparing results of preoperative synovial biopsy with joint aspiration in identifying an infected hip arthroplasty by bacteriological analysis. We retrospectively reviewed the results of the 110 most recent revision hip arthroplasties in which preoperative synovial biopsy and joint aspiration were both performed. Revision surgery for these patients occurred during the period from September 2005 to March 2012. Using this study group, results from preoperative cultures were compared with preoperative laboratory studies and the results of intraoperative cultures. Synovial aspiration was done using an 18- or 20-gauge spinal needle. Synovial biopsy was done coaxially following aspiration using a 22-gauge Chiba needle or 21-gauge Sure-Cut needle. Standard microbiological analysis was performed on preoperative synovial fluid aspirate and synovial biopsy. Intraoperative tissue biopsy bacteriological analysis results at surgical revision were accepted as the "gold standard" for the presence or absence of infection. Seventeen of 110 (15 %) of patients had intraoperative culture-positive periprosthetic infection. Of these 17 cases, there were ten cases where either the synovial fluid aspiration and/or the synovial biopsy were true positive (sensitivity of 59 %, specificity of 100 %, positive predictive value of 100 % and accuracy of 94 %). There were seven cases where aspiration and biopsy results were both falsely negative, but no false-positive results. Similar results were found for synovial fluid aspiration alone. The results of synovial biopsy alone resulted in the identification of seven infected joints with no false-positive result (sensitivity of 41 %, specificity of 100 %, positive predictive value of 100 %, and accuracy of 91 %). Standard microbiological analyses performed on percutaneous synovial biopsy specimen during the preoperative evaluation of patients undergoing revision hip arthroplasty did not improve detection of culture-positive periprosthetic infection as compared to synovial fluid aspiration alone.

WE-AB-BRA-09: Registration of Preoperative MRI to Intraoperative Radiographs for Automatic Vertebral Target Localization

DOE Office of Scientific and Technical Information (OSTI.GOV)

De Silva, T; Uneri, A; Ketcha, M

Purpose: Accurate localization of target vertebrae is essential to safe, effective spine surgery, but wrong-level surgery occurs with surprisingly high frequency. Recent research yielded the “LevelCheck” method for 3D-2D registration of preoperative CT to intraoperative radiographs, providing decision support for level localization. We report a new method (MR-LevelCheck) to perform 3D-2D registration based on preoperative MRI, presenting a solution for the increasingly common scenario in which MRI (not CT) is used for preoperative planning. Methods: Direct extension of LevelCheck is confounded by large mismatch in image intensity between MRI and radiographs. The proposed method overcomes such challenges with a simplemore » vertebrae segmentation. Using seed points at centroids, vertebrae are segmented using continuous max-flow method and dilated by 1.8 mm to include surrounding cortical bone (inconspicuous in T2w-MRI). MRI projections are computed (analogous to DRR) using segmentation and registered to intraoperative radiographs. The method was tested in a retrospective IRB-approved study involving 11 patients undergoing cervical, thoracic, or lumbar spine surgery following preoperative MRI. Registration accuracy was evaluated in terms of projection-distance-error (PDE) between the true and estimated location of vertebrae in each radiograph. Results: The method successfully registered each preoperative MRI to intraoperative radiographs and maintained desirable properties of robustness against image content mismatch, and large capture range. Segmentation achieved Dice coefficient = 89.2 ± 2.3 and mean-absolute-distance (MAD) = 1.5 ± 0.3 mm. Registration demonstrated robust performance under realistic patient variations, with PDE = 4.0 ± 1.9 mm (median ± iqr) and converged with run-time = 23.3 ± 1.7 s. Conclusion: The MR-LevelCheck algorithm provides an important extension to a previously validated decision support tool in spine surgery by extending its utility to preoperative MRI. With initial studies demonstrating PDE <5 mm and 0% failure rate, the method is now in translation to larger scale prospective clinical studies. S. Vogt and G. Kleinszig are employees of Siemens Healthcare.« less

Identification of the optimal therapeutic antibody for fluorescent imaging of cutaneous squamous cell carcinoma

PubMed Central

Day, Kristine E.; Beck, Lauren N.; Heath, C. Hope; Huang, Conway C.; Zinn, Kurt R.; Rosenthal, Eben L.

2013-01-01

Intraoperative, real-time fluorescence imaging may significantly improve tumor visualization and resection and postoperatively, in pathological assessment. To this end, we sought to determine the optimal FDA approved therapeutic monoclonal antibody for optical imaging of human cutaneous squamous cell carcinoma (cSCC). A near-infrared (NIR) fluorescent probe (IRDye800) was covalently linked to bevacizumab, panitumumab or tocilizumab and injected systemically into immunodeficient mice bearing either cutaneous tumor cell lines (SCC13) or cutaneous human tumor explants. Tumors were then imaged and resected under fluorescent guidance with the SPY, an FDA-approved intraoperative imaging system, and the Pearl Impulse small animal imaging system. All fluorescently labeled antibodies delineated normal tissue from tumor in SCC13 xenografts based on tumor-to-background (TBR) ratios. The conjugated antibodies produced TBRs of 1.2–2 using SPY and 1.6–3.6 using Pearl; in comparison, isotype control antibody IgG-IRDye produced TBRs of 1.0 (SPY) and 0.98 (Pearl). Comparison between antibodies revealed them to be roughly equivalent for imaging purposes with both the SPY and Pearl (p = 0.89 SPY, p = 0.99 Pearl; one way ANOVA). Human tumor explants were also imaged and tumor detection was highest with panitumumab-IRDye800 when using the SPY (TBR 3.0) and Pearl (TBR 4.0). These data suggest that FDA approved antibodies may be clinically used for intraoperative detection of cSCC. PMID:23298904

Novel technology of molecular radio-guidance for lymph node dissection in recurrent prostate cancer by PSMA-ligands.

PubMed

Rauscher, Isabel; Horn, Thomas; Eiber, Matthias; Gschwend, Jürgen E; Maurer, Tobias

2018-04-01

Recently, prostate-specific membrane antigen-radioguided surgery (PSMA-RGS) has been introduced as a promising new and individual treatment concept in patients with localised recurrent prostate cancer (PC). In the following, we want to review our experience with PSMA-RGS in patients with localised biochemical recurrent PC. A non-systematic review of the literature was carried out with focus on technical and logistical aspects of PSMA-RGS. Furthermore, published data on intraoperative detection of metastatic lesions compared to preoperative PSMA-PET and postoperative histopathology, postoperative complications as well as oncological follow-up data are summarized. Finally, relevant aspects on prerequisites for PSMA-RGS, patient selection, and the potential benefit of additional salvage radiotherapy or potential future applications of robotic PSMA-RGS with drop-in γ-probes are discussed. First results show that PSMA-RGS is very sensitive and specific in tracking suspicious lesions intraoperatively. Prerequisite for patient selection and localisation of tumour recurrence is a positive Ga-HBED-CC PSMA positron-emission tomography (PET) scan with preferably only singular soft tissue or lymph node recurrence after primary treatment. Furthermore, PSMA-RGS has the potential to positively influence oncological outcome. PSMA-RGS seems to be of high value in patients with localised PC recurrence for exact localisation and resection of oftentimes small metastatic lesions using intraoperative and ex vivo γ-probe measurements. However, patient identification on the basis of Ga-HBED-CC-PSMA PET imaging as well as clinical parameters is crucial to obtain satisfactory results.

[Surgical treatment of intraoperative injuries and cicatricial strictures of extrahepatic bile ducts].

PubMed

Tret'iakov, A A; Slepykh, N I; Kornilov, A K; Karimov, Z Kh

1998-01-01

The analysis of 70 cases of surgical treatment for intraoperative injuries and cicatricial strictures of extrahepatic bile ducts was carried out. In 25 patients surgical procedure was restorative and in 45--reconstructiver. Most common causes of corrective operations were: iatrogenic injuries of extrahepatic bile ducts (14) and cicatricial strictures of hepaticocholedochal duct due to intraoperative trauma (31). The problems of operative technique in performing biliobilio-, hepato-hepatico and hepatico-jejuno-anastomoses are considered. There were three deaths in the early postoperative period: 2 patients died of hepatic failure, pyogenic cholangiogenic intoxication caused by cholangioectasies and intrahepatic abscesses, and 1-due to generalyzed peritonitis caused by acute gastric ulcer perforation. Special attention is paid to the choice of the method of prolonged drainage used in reconstructive as well as in restorative operations.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chernyshova, A. L.; Lyapunov, A. Yu., E-mail: Lyapunov1720.90@mail.ru; Kolomiets, L. A.

The study included 26 patients with FIGO stage Ia1–Ib1 cervical cancer who underwent fertility-sparing surgery (transabdominaltrachelectomy). To visualize sentinel lymph nodes, lymphoscintigraphy with injection of 99mTc-labelled nanocolloid was performed the day before surgery. Intraoperative identification of sentinel lymph nodes using hand-held gamma probe was carried out to determine the radioactive counts over the draining lymph node basin. The sentinel lymph node detection in cervical cancer patients contributes to the accurate clinical assessment of the pelvic lymph node status, precise staging of the disease and tailoring of surgical treatment to individual patient.

Facial Nerve Schwannoma: A Case Report, Radiological Features and Literature Review.

PubMed

Pilloni, Giulia; Mico, Barbara Massa; Altieri, Roberto; Zenga, Francesco; Ducati, Alessandro; Garbossa, Diego; Tartara, Fulvio

2017-12-22

Facial nerve schwannoma localized in the middle fossa is a rare lesion. We report a case of a facial nerve schwannoma in a 30-year-old male presenting with facial nerve palsy. Magnetic resonance imaging (MRI) showed a 3 cm diameter tumor of the right middle fossa. The tumor was removed using a sub-temporal approach. Intraoperative monitoring allowed for identification of the facial nerve, so it was not damaged during the surgical excision. Neurological clinical examination at discharge demonstrated moderate facial nerve improvement (Grade III House-Brackmann).

Endocardial left ventricle feature tracking and reconstruction from tri-plane trans-esophageal echocardiography data

NASA Astrophysics Data System (ADS)

Dangi, Shusil; Ben-Zikri, Yehuda K.; Cahill, Nathan; Schwarz, Karl Q.; Linte, Cristian A.

2015-03-01

Two-dimensional (2D) ultrasound (US) has been the clinical standard for over two decades for monitoring and assessing cardiac function and providing support via intra-operative visualization and guidance for minimally invasive cardiac interventions. Developments in three-dimensional (3D) image acquisition and transducer design and technology have revolutionized echocardiography imaging enabling both real-time 3D trans-esophageal and intra-cardiac image acquisition. However, in most cases the clinicians do not access the entire 3D image volume when analyzing the data, rather they focus on several key views that render the cardiac anatomy of interest during the US imaging exam. This approach enables image acquisition at a much higher spatial and temporal resolution. Two such common approaches are the bi-plane and tri-plane data acquisition protocols; as their name states, the former comprises two orthogonal image views, while the latter depicts the cardiac anatomy based on three co-axially intersecting views spaced at 600 to one another. Since cardiac anatomy is continuously changing, the intra-operative anatomy depicted using real-time US imaging also needs to be updated by tracking the key features of interest and endocardial left ventricle (LV) boundaries. Therefore, rapid automatic feature tracking in US images is critical for three reasons: 1) to perform cardiac function assessment; 2) to identify location of surgical targets for accurate tool to target navigation and on-target instrument positioning; and 3) to enable pre- to intra-op image registration as a means to fuse pre-op CT or MR images used during planning with intra-operative images for enhanced guidance. In this paper we utilize monogenic filtering, graph-cut based segmentation and robust spline smoothing in a combined work flow to process the acquired tri-plane TEE time series US images and demonstrate robust and accurate tracking of the LV endocardial features. We reconstruct the endocardial LV geometry using the tri-plane contours and spline interpolation, and assess the accuracy of the proposed work flow against gold-standard results from the GE Echopac PC clinical software according to quantitative clinical LV characterization parameters, such as the length, circumference, area and volume. Our proposed combined work flow leads to consistent, rapid and automated identification of the LV endocardium, suitable for intra-operative applications and "on-the-fly" computer-assisted assessment of ejection fraction for cardiac function monitoring.Two-dimensional (2D) ultrasound (US) has been the clinical standard for over two decades for monitoring and assessing cardiac function and providing support via intra-operative visualization and guidance for minimally invasive cardiac interventions. Developments in three-dimensional (3D) image acquisition and transducer design and technology have revolutionized echocardiography imaging enabling both real-time 3D trans-esophageal and intra-cardiac image acquisition. However, in most cases the clinicians do not access the entire 3D image volume when analyzing the data, rather they focus on several key views that render the cardiac anatomy of interest during the US imaging exam. This approach enables image acquisition at a much higher spatial and temporal resolution. Two such common approaches are the bi-plane and tri-plane data acquisition protocols; as their name states, the former comprises two orthogonal image views, while the latter depicts the cardiac anatomy based on three co-axially intersecting views spaced at 600 to one another. Since cardiac anatomy is continuously changing, the intra-operative anatomy depicted using real-time US imaging also needs to be updated by tracking the key features of interest and endocardial left ventricle (LV) boundaries. Therefore, rapid automatic feature tracking in US images is critical for three reasons: 1) to perform cardiac function assessment; 2) to identify location of surgical targets for accurate tool to target navigation and on-target instrument positioning; and 3) to enable pre- to intra-op image registration as a means to fuse pre-op CT or MR images used during planning with intra-operative images for enhanced guidance. In this paper we utilize monogenic filtering, graph-cut based segmentation and robust spline smoothing in a combined work flow to process the acquired tri-plane TEE time series US images and demonstrate robust and accurate tracking of the LV endocardial features. We reconstruct the endocardial LV geometry using the tri-plane contours and spline interpolation, and assess the accuracy of the proposed work flow against gold-standard results from the GE Echopac PC clinical software according to quantitative clinical LV characterization parameters, such as the length, circumference, area and volume. Our proposed combined work flow leads to consistent, rapid and automated identification of the LV endocardium, suitable for intra-operative applications and on-the- y" computer-assisted assessment of ejection fraction for cardiac function monitoring.

Intraoperative culture positive allograft bone and subsequent postoperative infections: a retrospective review

PubMed Central

Sims, Laura; Kulyk, Paul; Woo, Allan

2017-01-01

Background Obtaining intraoperative cultures of allograft bone just before use in orthopedic procedures is standard practice in many centres; however, the association between positive cultures and subsequent surgical infections is unknown. Our study had 3 goals: to determine the prevalence of positive intraoperative allograft culture and subsequent infection; to determine if, in cases of subsequent infection, organisms isolated at reoperation were the same as those cultured from the allograft at the time of the index procedure; and to assess the costs associated with performing intraoperative allograft cultures. Methods In this retrospective case series, we obtained data on patients receiving allograft bone between 2009 and 2012. Patients receiving allograft with positive cultures were reviewed to identify cases of significant infection. Organisms isolated at reoperation were compared with the allograft culture taken at the time of implantation, and we performed a cost assessment. Results Of the 996 allograft bone grafts used, 43 (4.3%) had positive intraoperative cultures and significant postoperative infections developed in 2, requiring reoperation. Antibiotics based on culture results were prescribed in 24% of cases. Organisms cultured at the time of reoperation differed from those isolated initially. The cost of performing 996 allograft cultures was $169 320. Conclusion This series suggests that rates of positive intraoperative bone allograft culture are low, and subsequent infection is rare. In cases of postoperative infection, primary allograft culture and secondary tissue cultures isolated different organisms. Costs associated with performing cultures are high. Eliminating initial culture testing could save $42 500 per year in our health region. PMID:28234217

Validation of model-based brain shift correction in neurosurgery via intraoperative magnetic resonance imaging: preliminary results

NASA Astrophysics Data System (ADS)

Luo, Ma; Frisken, Sarah F.; Weis, Jared A.; Clements, Logan W.; Unadkat, Prashin; Thompson, Reid C.; Golby, Alexandra J.; Miga, Michael I.

2017-03-01

The quality of brain tumor resection surgery is dependent on the spatial agreement between preoperative image and intraoperative anatomy. However, brain shift compromises the aforementioned alignment. Currently, the clinical standard to monitor brain shift is intraoperative magnetic resonance (iMR). While iMR provides better understanding of brain shift, its cost and encumbrance is a consideration for medical centers. Hence, we are developing a model-based method that can be a complementary technology to address brain shift in standard resections, with resource-intensive cases as referrals for iMR facilities. Our strategy constructs a deformation `atlas' containing potential deformation solutions derived from a biomechanical model that account for variables such as cerebrospinal fluid drainage and mannitol effects. Volumetric deformation is estimated with an inverse approach that determines the optimal combinatory `atlas' solution fit to best match measured surface deformation. Accordingly, preoperative image is updated based on the computed deformation field. This study is the latest development to validate our methodology with iMR. Briefly, preoperative and intraoperative MR images of 2 patients were acquired. Homologous surface points were selected on preoperative and intraoperative scans as measurement of surface deformation and used to drive the inverse problem. To assess the model accuracy, subsurface shift of targets between preoperative and intraoperative states was measured and compared to model prediction. Considering subsurface shift above 3 mm, the proposed strategy provides an average shift correction of 59% across 2 cases. While further improvements in both the model and ability to validate with iMR are desired, the results reported are encouraging.

Intra-operatively customized implant coating strategies for local and controlled drug delivery to bone.

PubMed

Trajkovski, Branko; Petersen, Ansgar; Strube, Patrick; Mehta, Manav; Duda, Georg N

2012-09-01

Bone is one of the few tissues in the human body with high endogenous healing capacity. However, failure of the healing process presents a significant clinical challenge; it is a tremendous burden for the individual and has related health and economic consequences. To overcome such healing deficits, various concepts for a local drug delivery to bone have been developed during the last decades. However, in many cases these concepts do not meet the specific requirements of either surgeons who must use these strategies or individual patients who might benefit from them. We describe currently available methods for local drug delivery and their limitations in therapy. Various solutions for drug delivery to bone focusing on clinical applications and intra-operative constraints are discussed and drug delivery by implant coating is highlighted. Finally, a new set of design and performance requirements for intra-operatively customized implant coatings for controlled drug delivery is proposed. In the future, these requirements may improve approaches for local and intra-operative treatment of patients. Copyright © 2012 Elsevier B.V. All rights reserved.

An intraoperative diagnosis of parotid gland tumors using Raman spectroscopy and support vector machine

NASA Astrophysics Data System (ADS)

Yan, Bing; Wen, Zhining; Li, Yi; Li, Longjiang; Xue, Lili

2014-11-01

The preoperative and intraoperative diagnosis of parotid gland tumors is difficult, but is important for their surgical management. In order to explore an intraoperative diagnostic method, Raman spectroscopy is applied to detect the normal parotid gland and tumors, including pleomorphic adenoma, Warthin’s tumor and mucoepidermoid carcinoma. In the 600-1800 cm-1 region of the Raman shift, there are numerous spectral differences between the parotid gland and tumors. Compared with Raman spectra of the normal parotid gland, the Raman spectra of parotid tumors show an increase of the peaks assigned to nucleic acids and proteins, but a decrease of the peaks related to lipids. Spectral differences also exist between the spectra of parotid tumors. Based on these differences, a remarkable classification and diagnosis of the parotid gland and tumors are carried out by support vector machine (SVM), with high accuracy (96.7~100%), sensitivity (93.3~100%) and specificity (96.7~100%). Raman spectroscopy combined with SVM has a great potential to aid the intraoperative diagnosis of parotid tumors and could provide an accurate and rapid diagnostic approach.

Frequency of whole breast radiation therapy after intraoperative radiation therapy due to criteria identified by lumpectomy.

PubMed

Mellon, Eric A; Orman, Amber; Joya, Luis E; Montejo, Michael E; Laronga, Christine; Hoover, Susan J; Lee, M Catherine; Khakpour, Nazanin; Kubal, Pamela F; Diaz, Roberto

For selected early breast cancers, intraoperative radiation therapy (IORT) at the time of lumpectomy can be an efficient alternative to fractionated whole breast radiation therapy (WBRT). However, some patients are later recommended WBRT after IORT due to surgical pathologic findings. To understand risk factor identification rates triggering WBRT recommendation, we analyzed adverse prognostic features based on multiple international criteria for suitability for accelerated partial breast irradiation. We performed a single-institution retrospective review of all 200 nonrecurrent invasive breast carcinomas that received IORT in 20 Gy to the tumor cavity using a 50 kV photon applicator between January 2011 and December 2015. IORT eligibility was based on the 2009 accelerated partial breast irradiation Consensus Statement from the American Society for Radiation Oncology (ASTRO). IORT was offered as the sole radiation modality to patients meeting 0-1 "cautionary" and no "unsuitable" criteria before lumpectomy. WBRT was recommended after IORT when 2+ cautionary and/or 1+ unsuitable criteria were met after accounting for resection pathology. We recalculated WBRT recommendation rates using initial and reresection margins for ASTRO consensus, Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology recommendations, and TARGeted Intraoperative radioTherapy vs. Postoperative Radiotherapy trial "prepathology" stratum protocol. Depending on the selection criteria chosen, rates of WBRT recommendation can vary from 4.5% to 33%. WBRT recommendation rates of 30-33% after lumpectomy and IORT are observed when the WBRT indication is a single ASTRO cautionary/unsuitable, Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology intermediate/high-risk criterion, or TARGeted Intraoperative radioTherapy vs. postoperative radiotherapy trial protocol recommendation. Alternatively, allowing for re-excision to clear margins and accepting one ASTRO cautionary factor lowered the rate of WBRT recommendation to 9.5%. Copyright © 2016 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.

Use of computer-assisted design and manufacturing to localize dural venous sinuses during reconstructive surgery for craniosynostosis.

PubMed

Iyer, Rajiv R; Wu, Adela; Macmillan, Alexandra; Musavi, Leila; Cho, Regina; Lopez, Joseph; Jallo, George I; Dorafshar, Amir H; Ahn, Edward S

2018-01-01

Cranial vault remodeling surgery for craniosynostosis carries the potential risk of dural venous sinus injury given the extensive bony exposure. Identification of the dural venous sinuses can be challenging in patients with craniosynostosis given the lack of accurate surface-localizing landmarks. Computer-aided design and manufacturing (CAD/CAM) has allowed surgeons to pre-operatively plan these complex procedures in an effort to increase reconstructive efficiency. An added benefit of this technology is the ability to intraoperatively map the dural venous sinuses based on pre-operative imaging. We utilized CAD/CAM technology to intraoperatively map the dural venous sinuses for patients undergoing reconstructive surgery for craniosynostosis in an effort to prevent sinus injury, increase operative efficiency, and enhance patient safety. Here, we describe our experience utilizing this intraoperative technology in pediatric patients with craniosynostosis. We retrospectively reviewed the charts of children undergoing reconstructive surgery for craniosynostosis using CAD/CAM surgical planning guides at our institution between 2012 and 2016. Data collected included the following: age, gender, type of craniosynostosis, estimated blood loss, sagittal sinus deviation from the sagittal suture, peri-operative outcomes, and hospital length of stay. Thirty-two patients underwent reconstructive cranial surgery for craniosynostosis, with a median age of 11 months (range, 7-160). Types of synostosis included metopic (6), unicoronal (6), sagittal (15), lambdoid (1), and multiple suture (4). Sagittal sinus deviation from the sagittal suture was maximal in unicoronal synostosis patients (10.2 ± 0.9 mm). All patients tolerated surgery well, and there were no occurrences of sagittal sinus, transverse sinus, or torcular injury. The use of CAD/CAM technology allows for accurate intraoperative dural venous sinus localization during reconstructive surgery for craniosynostosis and enhances operative efficiency and surgeon confidence while minimizing the risk of patient morbidity.

Guidelines for intraoperative neuromonitoring using raw (analog or digital waveforms) and quantitative electroencephalography: a position statement by the American Society of Neurophysiological Monitoring.

PubMed

Isley, Michael R; Edmonds, Harvey L; Stecker, Mark

2009-12-01

Electroencephalography (EEG) is one of the oldest and most commonly utilized modalities for intraoperative neuromonitoring. Historically, interest in the EEG patterns associated with anesthesia is as old as the discovery of the EEG itself. The evolution of its intraoperative use was also expanded to include monitoring for assessing cortical perfusion and oxygenation during a variety of vascular, cardiac, and neurosurgical procedures. Furthermore, a number of quantitative or computer-processed algorithms have also been developed to aid in its visual representation and interpretation. The primary clinical outcomes for which modern EEG technology has made significant intraoperative contributions include: (1) recognizing and/or preventing perioperative ischemic insults, and (2) monitoring of brain function for anesthetic drug administration in order to determine depth of anesthesia (and level of consciousness), including the tailoring of drug levels to achieve a predefined neural effect (e.g., burst suppression). While the accelerated development of microprocessor technologies has fostered an extraordinarily rapid growth in the use of intraoperative EEG, there is still no universal adoption of a monitoring technique(s) or of criteria for its neural end-point(s) by anesthesiologists, surgeons, neurologists, and neurophysiologists. One of the most important limitations to routine intraoperative use of EEG may be the lack of standardization of methods, alarm criteria, and recommendations related to its application. Lastly, refinements in technology and signal processing can be expected to advance the usefulness of the intraoperative EEG for both anesthetic and surgical management of patients. This paper is the position statement of the American Society of Neurophysiological Monitoring. It is the practice guidelines for the intraoperative use of raw (analog and digital) and quantitative EEG. The following recommendations are based on trends in the current scientific and clinical literature and meetings, guidelines published by other organizations, expert opinion, and public review by the members of the American Society of Neurophysiological Monitoring. This document may not include all possible methodologies and interpretative criteria, nor do the authors and their sponsor intentionally exclude any new alternatives. The use of the techniques reviewed in these guidelines may reduce perioperative neurological morbidity and mortality. This position paper summarizes commonly used protocols for recording and interpreting the intraoperative use of EEG. Furthermore, the American Society of Neurophysiological Monitoring recognizes this as primarily an educational service.

Lumbar Lordosis of Spinal Stenosis Patients during Intraoperative Prone Positioning

PubMed Central

Lee, Su-Keon; Song, Kyung-Sub; Park, Byung-Moon; Lim, Sang-Youn; Jang, Geun; Lee, Beom-Seok; Moon, Seong-Hwan; Lee, Hwan-Mo

2016-01-01

Background To evaluate the effect of spondylolisthesis on lumbar lordosis on the OSI (Jackson; Orthopaedic Systems Inc.) frame. Restoration of lumbar lordosis is important for maintaining sagittal balance. Physiologic lumbar lordosis has to be gained by intraoperative prone positioning with a hip extension and posterior instrumentation technique. There are some debates about changing lumbar lordosis on the OSI frame after an intraoperative prone position. We evaluated the effect of spondylolisthesis on lumbar lordosis after an intraoperative prone position. Methods Sixty-seven patients, who underwent spinal fusion at the Department of Orthopaedic Surgery of Gwangmyeong Sungae Hospital between May 2007 and February 2012, were included in this study. The study compared lumbar lordosis on preoperative upright, intraoperative prone and postoperative upright lateral X-rays between the simple stenosis (SS) group and spondylolisthesis group. The average age of patients was 67.86 years old. The average preoperative lordosis was 43.5° (± 14.9°), average intraoperative lordosis was 48.8° (± 13.2°), average postoperative lordosis was 46.5° (± 16.1°) and the average change on the frame was 5.3° (± 10.6°). Results Among all patients, 24 patients were diagnosed with simple spinal stenosis, 43 patients with spondylolisthesis (29 degenerative spondylolisthesis and 14 isthmic spondylolisthesis). Between the SS group and spondylolisthesis group, preoperative lordosis, intraoperative lordosis and postoperative lordosis were significantly larger in the spondylolisthesis group. The ratio of patients with increased lordosis on the OSI frame compared to preoperative lordosis was significantly higher in the spondylolisthesis group. The risk of increased lordosis on frame was significantly higher in the spondylolisthesis group (odds ratio, 3.325; 95% confidence interval, 1.101 to 10.039; p = 0.033). Conclusions Intraoperative lumbar lordosis on the OSI frame with a prone position was larger in the SS patients than the spondylolisthesis patients, which also produced a larger postoperative lordosis angle after posterior spinal fusion surgery. An increase in lumbar lordosis on the OSI frame should be considered during posterior spinal fusion surgery, especially in spondylolisthesis patients. PMID:26929801

Useful Method for Intraoperative Monitoring of Facial Nerve in a Scarred Bed.

PubMed

Aysal, Bilge Kagan; Yapici, Abdulkerim; Bayram, Yalcin; Zor, Fatih

2016-10-01

Facial nerve is the main cranial nerve for the innervation of facial expression muscles. Main trunk of facial nerve passes approximately 1 to 2 cm deep to tragal pointer. In some patients, where a patient has multiple operations, fibrosis due to previous operations may change the natural anatomy and direction of the branches of facial nerve. A 22-year-old male patient had 2 operations for mandibular reconstruction after gunshot wound. During the second operation, there was a possible injury to the marginal mandibular nerve and a nerve stimulator was used intraoperatively to monitor the nerve at the tragal pointer because the excitability of the distal segments remains intact for 24 to 48 hours after nerve injuries. Thus, using a nerve stimulator at the operational site may lead to false-positive muscle movements in case of injuries. Using the nerve stimulator to stimulate the main trunk at the tragal point may help to distinguish the presence of possible injuries. A reliable method for intraoperative facial nerve monitoring in a scarred operational site was introduced in this letter.

Optimizing brain tumor resection. Midfield interventional MR imaging.

PubMed

Alexander, E

2001-11-01

The development of the intraoperative MR imager represents an important example of creative vision and interdisciplinary teamwork. The result is a remarkable tool for neurosurgical applications. MRT allows surgical manipulation under direct visualization of the intracranial contents through the eye of the surgeon and through the volumetric images of the MR imaging system. This technology can be applied to cranial and spinal cases, and forseeably can encompass application to the entire gamut of neurosurgical efforts. The author's experience has been that this device is easy and comfortable for the surgeon to use. Image acquisition, giving views in the plane of choice, lasts no more than 2 to 60 seconds (depending on the imaging method), and does not increase the duration of a given procedure substantially. The author believes that the information received through intraoperative MR imaging scanning ultimately will contribute to decreasing the duration of surgery. Future possibilities include combining the intraoperative MR imager with other technologies, such as the endoscope, focused ultrasound, robotics, and the evaluation of brain function intraoperatively. The development of the intraoperative MR imager marks a significant advance in neurosurgery, an advance that will revolutionize intraoperative visualization as fully as the operating microscope. The combination of intraoperative visualization and precise surgical navigation is unparalleled, and its enhancement of surgical applications will be widespread. Considering the remarkable potential of the intraoperative MR imager for neurosurgical applications, optimal magnet design, image quality, and navigational methods are necessary to capitalize on the advantages of this revolutionary tool. The intraoperative MR imaging system that the author's team has developed and used has combined these features, and allows the performance of open surgical procedures without the need of patient or magnet repositioning. By using advanced navigational tools and computer technology, it represents an integration of frameless stereotactic methods with real-time interactive imaging. The midfield imager provides sufficient spatial and temporal resolution and image quality to assess anatomy and pathology adequately, to monitor a surgical procedure, and make image-based decisions. The intraoperative use of this unique system is not limited to biopsies or limited-access procedures. The entire range of neurosurgical procedures can be performed, if the requisite instrumentation is available. Much work remains to be done, however. The team did not develop this system only to enable the performance of current neurosurgical procedures. Forty years ago, the operating microscope enabled not only the performance of undreamt-of procedures but opened the door to entire new subspecialties. The entire landscape of neurosurgery will change at a fundamental level as the full ramifications of this exciting idea come to fruition. The holy grail of image-guided surgery is a seamless interface between the eye and hand in the purest sense (i.e., the mind's eye and hand). Ideally, this seamless interface represents effortless flow between the procedural goal compared with the present situation and the manipulation of the tools available to accomplish the task, whether they be the scalpel, drill, laser, ultrasonic aspirator, phased array focused ultrasound, microrobot, or high-dose irradiator. As in the realm of high-performance military jet fighters, the physical limits of the human being demarcate the confining boundary of the system. Those limits are much tighter around the domain of tool manipulation, where the surgeon will yield, early on, to the enhanced performance of robotics and other technical adjuncts. The era of large open magnet imaging systems for surgical procedures then will come to a close; however, the grander era of the surgeon's integration of precision-guided, multimodality therapeutics will just be beginning. The future will be very bright, indeed.

Intraoperative Molecular Imaging of Lung Adenocarcinoma Can Identify Residual Tumor Cells at the Surgical Margins

PubMed Central

Keating, Jane J.; Okusanya, Olugbenga T.; De Jesus, Elizabeth; Judy, Ryan; Jiang, Jack; Deshpande, Charuhas; Nie, Shuming; Low, Philip; Singhal, Sunil

2017-01-01

Purpose During lung surgery, identification of surgical margins is challenging. We hypothesized that molecular imaging with a fluorescent probe to pulmonary adenocarcinomas could enhance residual tumor during resection. Procedures Mice with flank tumors received a contrast agent targeting folate receptor alpha. Optimal dose and time of injection was established. Margin detection was compared using traditional methods versus molecular imaging. A pilot study was then performed in 3 humans with lung adenocarcinoma. Results The peak tumor-to background ratio (TBR) of murine tumors was 3.9. Fluorescence peaked at 2 hours and was not improved beyond 0.1 mg/kg. Traditional inspection identified 30% of mice with positive margins. Molecular imaging identified an additional 50% of residual tumor deposits (P<0.05). The fluorescent probe visually enhanced all human tumors with a mean TBR of 3.5. Conclusions Molecular imaging is an important adjunct to traditional inspection to identify surgical margins after tumor resection. PMID:26228697

War stories: a qualitative analysis of narrative teaching strategies in the operating room

PubMed Central

Hu, Yue-Yung; Peyre, Sarah E.; Arriaga, Alexander F.; Roth, Emilie M.; Corso, Katherine A.; Greenberg, Caprice C.

2015-01-01

BACKGROUND “War stories” are commonplace in surgical education, yet little is known about their purpose, construct, or use in the education of trainees. METHODS Ten complex operations were videotaped and audiotaped. Narrative stories were analyzed using grounded theory to identify emergent themes in both the types of stories being told and the teaching objectives they illustrated. RESULTS Twenty-four stories were identified in 9 of the 10 cases (mean, 2.4/case). They were brief (mean, 58 seconds), illustrative of multiple teaching points (mean, 1.5/story), and appeared throughout the operations. Anchored in personal experience, these stories taught both clinical (eg, operative technique, decision making, error identification) and programmatic (eg, resource management, professionalism) topics. CONCLUSIONS Narrative stories are used frequently and intuitively by physicians to emphasize a variety of intraoperative teaching points. They socialize trainees in the culture of surgery and may represent an underrecognized approach to teaching the core competencies. More understanding is needed to maximize their potential. PMID:22088266

Intraoperative transfusion practices in Europe

PubMed Central

Meier, J.; Filipescu, D.; Kozek-Langenecker, S.; Llau Pitarch, J.; Mallett, S.; Martus, P.; Matot, I.

2016-01-01

Background. Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe. Methods. We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013. Results. The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl−1 and increased to 9.8 (1.8) g dl−1 after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2). Conclusion. Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7–9 g dl−1), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold. Clinical trial registration. NCT 01604083. PMID:26787795

Intra-operative periarticular multimodal injection in total knee arthroplasty: a local hospital experience in Hong Kong.

PubMed

Fan, J Ch

2018-04-01

Data from a local report revealed the superior outcome of regional anaesthesia and analgesia compared with general anaesthesia and intravenous patient-controlled analgesia in total knee arthroplasty. This retrospective study aimed to assess the efficacy of intra-operative periarticular multimodal injection in improving postoperative pain and reducing morphine consumption with patient-controlled analgesia after total knee arthroplasty in patients with knee osteoarthritis. From July 2005 to May 2009, 213 total knee arthroplasties without intra-operative periarticular multimodal injection (control group) were performed at a local hospital. From June 2009 to December 2012, 185 total knee arthroplasties were performed with intra-operative periarticular multimodal injection (cocktail group). The inclusion criteria were osteoarthritis of the knee, single method of anaesthesia (general or neuraxial), simple total knee arthroplasty without any metal augmentation or constraint, and postoperative patient-controlled analgesia. Postoperative patient-controlled morphine doses were compared. A total of 152 total knee arthroplasties were recruited to the cocktail group, and 89 to the control group. Duration of tourniquet application and preoperative knee score did not significantly correlate with morphine consumption by patient-controlled analgesia. Multimodal injection significantly decreased such consumption for 36 h. When injection was separately analysed for general and neuraxial anaesthesia, the effect lasted for 42 h and 24 h, respectively. Intra-operative periarticular multimodal injection decreased morphine consumption for up to 42 h postoperatively.

Primary Closure Following Laparoscopic Common Bile Duct Exploration Combined with Intraoperative Choledochoscopy and D-J Tube Drainage for Treating Choledocholithiasis.

PubMed

Yu, Miao; Xue, Huanzhou; Shen, Quan; Zhang, Xiao; Li, Ke; Jia, Meng; Jia, Jiangkun; Xu, Jian

2017-09-19

BACKGROUND This study aimed to assess the clinical short-term results of a primary closure following laparoscopic common bile duct exploration (LCBDE) combined with intraoperative choledochoscopy and D-J tube drainage for choledocholithiasis treatment. MATERIAL AND METHODS Twenty-five patients (14 women and 11 men) who underwent LCBDE with primary duct closure and D-J tube drainage for choledocholithiasis were retrospectively enrolled. The D-J tube (4.7F×14 cm) was removed using a duodenoscope if there was no bile leakage. Before discharge, patients were examined for blood amylase. After discharge or D-J tube removal, all patients were routinely assessed for complications. RESULTS Mean operating time was 135±46 min (range, 78-195 min). Mean intraoperative blood loss was 71±24 mL (range, 25-110 mL). Total hospital stay was 6-9 days (mean, 8.04±1.37 days). Two patients experienced intraoperative bile leakage, which was stopped with re-suturing. None of these patients experienced postoperative bile leaks. Three patients had slight elevation of serum amylase before discharge but without pancreatitis signs. The successful clearance rate of stones was 100%. During 1-year follow-up, no recurrence or severe complications occurred. CONCLUSIONS A primary closure following LCBDE combined with intraoperative choledochoscopy and D-J tube drainage is safe and feasible for choledocholithiasis treatment.

Intra-operative monitoring of the common peroneal nerve during total knee replacement.

PubMed Central

Unwin, A J; Thomas, M

1994-01-01

We present a method allowing intra-operative monitoring of the common peroneal nerve during total knee arthroplasty using a magnetic stimulator. Previous reports have shown no pre-operative method successful in selecting those patients prone to develop a post-operative palsy. The device, placed beneath the lumbar spine, stimulates the cauda equina; common peroneal nerve function is assessed via the response in extensor digitorum brevis. There is a loss of signal from the nerve with the use of a tourniquet 25 min following its application. The protocol therefore requires that a tourniquet is used at least only for fixation of the prosthetic components. The method is quick, safe, non-invasive and reproducible, and is of use both in at-risk patients and in research work. Images Figure 6. PMID:7837197

Morbidity Assessment in Surgery: Refinement Proposal Based on a Concept of Perioperative Adverse Events

PubMed Central

Kazaryan, Airazat M.; Røsok, Bård I.; Edwin, Bjørn

2013-01-01

Background. Morbidity is a cornerstone assessing surgical treatment; nevertheless surgeons have not reached extensive consensus on this problem. Methods and Findings. Clavien, Dindo, and Strasberg with coauthors (1992, 2004, 2009, and 2010) made significant efforts to the standardization of surgical morbidity (Clavien-Dindo-Strasberg classification, last revision, the Accordion classification). However, this classification includes only postoperative complications and has two principal shortcomings: disregard of intraoperative events and confusing terminology. Postoperative events have a major impact on patient well-being. However, intraoperative events should also be recorded and reported even if they do not evidently affect the patient's postoperative well-being. The term surgical complication applied in the Clavien-Dindo-Strasberg classification may be regarded as an incident resulting in a complication caused by technical failure of surgery, in contrast to the so-called medical complications. Therefore, the term surgical complication contributes to misinterpretation of perioperative morbidity. The term perioperative adverse events comprising both intraoperative unfavourable incidents and postoperative complications could be regarded as better alternative. In 2005, Satava suggested a simple grading to evaluate intraoperative surgical errors. Based on that approach, we have elaborated a 3-grade classification of intraoperative incidents so that it can be used to grade intraoperative events of any type of surgery. Refinements have been made to the Accordion classification of postoperative complications. Interpretation. The proposed systematization of perioperative adverse events utilizing the combined application of two appraisal tools, that is, the elaborated classification of intraoperative incidents on the basis of the Satava approach to surgical error evaluation together with the modified Accordion classification of postoperative complication, appears to be an effective tool for comprehensive assessment of surgical outcomes. This concept was validated in regard to various surgical procedures. Broad implementation of this approach will promote the development of surgical science and practice. PMID:23762627

Chromogranin A and cortisol at intraoperative repeated noxious stimuli: Surgical stress in a dog model

PubMed Central

Hagman, Ragnvi; Stridsberg, Mats

2015-01-01

Objectives: Biomarkers representing sympathetic tone and the surgical stress response are measured to objectively evaluate surgical techniques and anaesthetic protocols. If a part of the intraoperative procedure is repeated on the contralateral organ, one animal may potentially serve as its own control and, if so, may minimize the problem of individual differences of the stress response to anaesthesia and surgery. This study aimed to investigate the use of chromogranin A for measurement of the intraoperative sympathetic tone. Additional aims were to investigate chromogranin A and cortisol as indicators of the intraoperative surgical stress response caused by repeated noxious stimuli in dogs subjected to ovariohysterectomy and thereby to investigate the possibility of one dog serving as its own control. Methods: Experiments were carried out on 10 dogs subjected to ovariohysterectomy. Perioperative blood samples (0–6) were collected after premedication, immediately before induction of anaesthesia (0), after induction of anaesthesia and before incision (1), before (2) and after (3) removal of the first ovary, after a 15-min pause before removal of the second ovary (4), after removal of the second ovary (5) and after closing the abdomen (6). Plasma chromogranin A and cortisol were analysed. Results: Plasma chromogranin A did not change. Plasma cortisol concentration did not change between before anaesthesia and opening of the abdomen. Plasma cortisol increased at removal of the first ovary. Cortisol did not change at removal of the second ovary but remained increased compared to initial sample. Conclusion: The results suggest chromogranin A is a poor indicator of intraoperative sympathetic tone during elective surgery in dogs. Cortisol measurement was useful for assessment of intraoperative noxious stimuli. However, at these test conditions, neither plasma chromogranin A nor plasma cortisol was useful for assessment of repeated intraoperative noxious stimuli where one dog served as its own control. PMID:26770773

The impact of use of an intraoperative margin assessment device on re-excision rates.

PubMed

Sebastian, Molly; Akbari, Stephanie; Anglin, Beth; Lin, Erin H; Police, Alice M

2015-01-01

Historically there has been a high rate of surgical interventions to obtain clear margins for breast cancer patients undergoing breast conserving local therapy. An intraoperative margin assessment tool (MarginProbe) has been approved for use in the US since 2013. This study is the first compilation of data from routine use of the device, to assess the impact of device utilization on re-excision rates. We present a retrospective, observational, review from groups of consecutive patients, before and after the implementation of intraoperative use of the device during lumpectomy procedures. Lesions were localized by standard methods. The intraoperative margin assessment device was used on all circumferential margins of the main specimen, but not on any additional shavings. A positive reading by the device led to an additional shaving of the corresponding cavity location. Specimens were also, when feasible, imaged intra-operatively by X-ray, and additional shavings were taken if needed based on clinical assessment. For each surgeon, historical re-excision rates were established based on a consecutive set of patients from a time period proximal to initiation of use of the device. From March 2013 to April 2014 the device was routinely used by 4 surgeons in 3 centers. In total, 165 cases lumpectomy cases were performed. Positive margins resulted in additional re-excision procedures in 9.7% (16/165) of the cases. The corresponding historical set from 2012 and 2013 consisted of 186 Lumpectomy cases, in which additional re-excision procedures were performed in 25.8% (48/186) of the cases. The reduction in the rate of re-excision procedures was significant 62% (P < 0.0001). Use of an intraoperative margin assessment device contributes to achieving clear margins and reducing re-excision procedures. As in some cases positive margins were found on shavings, future studies of interest may include an analysis of the effect of using the device on the shavings intra-operatively.

Intraoperative β{sup -} detecting probe for radio-guided surgery in tumour resection

DOE Office of Scientific and Technical Information (OSTI.GOV)

Solfaroli Camillocci, Elena; Bellini, Fabio; Bocciy, Valerio

The development of the β{sup -} based radio-guided surgery aims to extend the technique to those tumours where surgery is the only possible treatment and the assessment of the resection would most profit from the low background around the lesion, as for brain tumours. Feasibility studies on meningioma and gliomas already estimated the potentiality of this new treatment. To validate the technique, a prototype of the intraoperative probe detecting β{sup -} decays and specific phantoms simulating tumour remnant patterns embedded in healthy tissue have been realized. The response of the probe in this simulated environment is tested with dedicated procedures.more » This document discusses the innovative aspects of the method, the status of the developed intraoperative β{sup -} detecting probe and the results of the preclinical tests. (authors)« less

MRI Signal Intensity Based B-Spline Nonrigid Registration for Pre- and Intraoperative Imaging During Prostate Brachytherapy

PubMed Central

Oguro, Sota; Tokuda, Junichi; Elhawary, Haytham; Haker, Steven; Kikinis, Ron; Tempany, Clare M.C.; Hata, Nobuhiko

2009-01-01

Purpose To apply an intensity-based nonrigid registration algorithm to MRI-guided prostate brachytherapy clinical data and to assess its accuracy. Materials and Methods A nonrigid registration of preoperative MRI to intraoperative MRI images was carried out in 16 cases using a Basis-Spline algorithm in a retrospective manner. The registration was assessed qualitatively by experts’ visual inspection and quantitatively by measuring the Dice similarity coefficient (DSC) for total gland (TG), central gland (CG), and peripheral zone (PZ), the mutual information (MI) metric, and the fiducial registration error (FRE) between corresponding anatomical landmarks for both the nonrigid and a rigid registration method. Results All 16 cases were successfully registered in less than 5 min. After the nonrigid registration, DSC values for TG, CG, PZ were 0.91, 0.89, 0.79, respectively, the MI metric was −0.19 ± 0.07 and FRE presented a value of 2.3 ± 1.8 mm. All the metrics were significantly better than in the case of rigid registration, as determined by one-sided t-tests. Conclusion The intensity-based nonrigid registration method using clinical data was demonstrated to be feasible and showed statistically improved metrics when compare to only rigid registration. The method is a valuable tool to integrate pre- and intraoperative images for brachytherapy. PMID:19856437

Intraoperative Computed Tomography (CT) for Treating Giant Carotid Intracavernous Aneurysms

PubMed Central

Xue, Zhe; Wang, Fuyu; Sun, Zhenghui; Zhang, Hui; Wu, Chen; Kong, Dongsheng; Xu, Bainan

2017-01-01

Background Giant carotid intracavernous aneurysm refers to those lesions larger than 2.5 cm and derived from a cavernous segment, accounting for about 30% of all intracranial tumors. Dynamic CT perfusion imaging (PCT) is a common method recently employed to evaluate cerebral perfusion. This study investigated the efficacy and clinical application of intraoperative CT in the surgery for giant symptomatic carotid intracavernous aneurysm. Material/Methods A retrospective analysis was performed on 23 cases with giant symptomatic carotid intracavernous aneurysm. BTO testing was performed before surgery. Differential treatments were performed based on the condition of aneurysm, and some patients received intraoperative PCT. Postoperative anti-coagulation was given with DSA or CTA follow-up examinations at 3–6 months, 1 year, and 2 years after surgery. Results A total of 17 patients received aneurysm isolation coupled with high-flow bypass surgery. Among those, 9 developed early-onset neurological function after surgery, with gradual recover within 6 months. One coma patient died 25 months after discharge. One patient had aneurysm isolation with clapping of anterior communicating artery, and the other 5 cases received artery clapping only. In those patients, 4 had improvement at early phase, while 1 patient had numbness of the oculomotor nerve. Six patients received surgery in the CT room, including 5 cases with single proximal ligation of the internal carotid artery plus 1 aneurysm isolation combined with high-flow bypass surgery. Conclusions Intraoperative PCT can provide objective evidence and effective evaluation of cerebral perfusion. PMID:28640793

Semi-closed reduction of tripod fractures of zygoma under intraoperative assessment using ultrasonography.

PubMed

Soejima, Kazutaka; Sakurai, Hiroyuki; Nozaki, Motohiro; Kitazawa, Yoshihiko; Takeuchi, Masaki; Yamaki, Takashi; Kono, Taro

2009-04-01

We conducted semi-closed reduction of isolated tripod fractures of the zygoma through only a brow incision under intraoperative assessment with ultrasonography. Twenty-three patients with unilateral, non-comminuted tripod fractures of zygoma were selected for application of this method at Tokyo Women's Medical University and Tokyo Metropolitan Hiroo General Hospital between April 2002 and April 2006. Patients with orbital floor blowout fractures were excluded. A skin incision was made only at the lateral brow region and the reduction was performed by inserting an elevator beneath the zygomatic arch. The bone alignment was intraoperatively assessed by ultrasonography. When the reduction was accurate, the frontozygomatic suture was immobilised with a mini-plate under direct visualisation and transmaler Kirshner wire fixation was performed. The accuracy of the reduction and postoperative movement were evaluated by computed tomography (CT) scans taken at 1 and 6 months. In five cases, the DICOM (Digital Imaging and Communication in Medicine) data from the CT were analysed with 3D imaging software (V-works, CyberMed Co., Korea). In all cases, accurate reduction was obtained. The analysis of the 3D imaging data revealed that postoperative movement of bone fragment was minimal. When the accurate reduction was obtained under intraoperative assessment, the semi-closed reduction and one-plate fixation with transmaler Kirshner wire is enough to treat the simple tripod fractures of zygoma. This method is minimally invasive and takes less operative time.

The neurolinguistic approach to awake surgery reviewed.

PubMed

De Witte, Elke; Mariën, Peter

2013-02-01

Intraoperative direct electrical stimulation (DES) is increasingly used in patients operated on for tumours in critical language areas. Although a positive impact of DES on postoperative linguistic outcome is generally advocated, the literature is only scantily documented with information about the linguistic methods applied in awake surgery. This article critically reviews the neurolinguistic procedures currently used in awake studies. Based on an extensive review of the literature, an overview is given of the language mapping techniques applied in brain tumour surgery. Studies investigating linguistic testing and outcome in awake surgery were analysed. Information about the timing of the assessment(s), the linguistic tasks, the linguistic stimuli and the indication for awake surgery was also discussed. Intraoperative DES remains the 'gold standard' for language mapping, but pre- and postoperative non-invasive mapping methods are important adjuncts. In the pre- and postoperative phase, standardised linguistic test batteries are generally used to assess language function. In the intraoperative phase, only naming and number counting are commonly applied. Most often no detailed information about the linguistic stimuli is provided and no standardised protocols measuring different linguistic levels have been described. Awake surgery with DES is a useful tool for preserving linguistic functions in patients undergoing surgery in critical brain regions. However, no studies exist that apply a well-balanced and standardised linguistic protocol to reliably identify the critical language zones. The availability of a standardised linguistic protocol might substantially increase intraoperative comfort and might improve outcome and quality of life. Copyright © 2012 Elsevier B.V. All rights reserved.

Intraoperative Right Ventricular Fractional Area Change Is a Good Indicator of Right Ventricular Contractility: A Retrospective Comparison Using Two- and Three-Dimensional Echocardiography.

PubMed

Imada, Tatsuyuki; Kamibayashi, Takahiko; Ota, Chiho; Carl Shibata, Sho; Iritakenishi, Takeshi; Sawa, Yoshiki; Fujino, Yuji

2015-08-01

Intraoperative two-dimensional echocardiography is technically challenging, given the unique geometry of the right ventricle (RV). It was hypothesized that the RV fractional area change (RVFAC) could be used as a simple method to evaluate RV function during surgery. Therefore, the correlation between the intraoperative RVFAC and the true right ventricular ejection fraction (RVEF), as measured using newly developed three-dimensional (3D) analysis software, was evaluated. Retrospective study. University hospital. Patients who underwent cardiac surgery with transesophageal echocardiography monitoring between March 2014 and June 2014. None. Sixty-two patients were included in this study. After the exclusion of poor imaging data and patients with arrhythmias, 54 data sets were analyzed. RVFAC was measured by one anesthesiologist during surgery, and full-volume 3D echocardiographic data were recorded simultaneously. The 3D data were analyzed postoperatively using off-line 3D analysis software by a second anesthesiologist, who was blinded to the RVFAC results. The mean RVFAC was 38.8% ± 8.7%, the mean RVEF was 41.4% ± 8.3%, and there was a good correlation between the RVFAC and the RVEF (r(2) = 0.638; p<0.0001). The RVFAC was well-correlated with the RVEF calculated using 3D echocardiography; therefore, RVFAC provides a simple and useful method for anesthesiologists to evaluate intraoperative RV function. Copyright © 2015 Elsevier Inc. All rights reserved.

Intraoperative tight glucose control using hyperinsulinemic normoglycemia increases delirium after cardiac surgery.

PubMed

Saager, Leif; Duncan, Andra E; Yared, Jean-Pierre; Hesler, Brian D; You, Jing; Deogaonkar, Anupa; Sessler, Daniel I; Kurz, Andrea

2015-06-01

Postoperative delirium is common in patients recovering from cardiac surgery. Tight glucose control has been shown to reduce mortality and morbidity. Therefore, the authors sought to determine the effect of tight intraoperative glucose control using a hyperinsulinemic-normoglycemic clamp approach on postoperative delirium in patients undergoing cardiac surgery. The authors enrolled 198 adult patients having cardiac surgery in this randomized, double-blind, single-center trial. Patients were randomly assigned to either tight intraoperative glucose control with a hyperinsulinemic-normoglycemic clamp (target blood glucose, 80 to 110 mg/dl) or standard therapy (conventional insulin administration with blood glucose target, <150 mg/dl). Delirium was assessed using a comprehensive delirium battery. The authors considered patients to have experienced postoperative delirium when Confusion Assessment Method testing was positive at any assessment. A positive Confusion Assessment Method was defined by the presence of features 1 (acute onset and fluctuating course) and 2 (inattention) and either 3 (disorganized thinking) or 4 (altered consciousness). Patients randomized to tight glucose control were more likely to be diagnosed as being delirious than those assigned to routine glucose control (26 of 93 vs. 15 of 105; relative risk, 1.89; 95% CI, 1.06 to 3.37; P = 0.03), after adjusting for preoperative usage of calcium channel blocker and American Society of Anesthesiologist physical status. Delirium severity, among patients with delirium, was comparable with each glucose management strategy. Intraoperative hyperinsulinemic-normoglycemia augments the risk of delirium after cardiac surgery, but not its severity.

A Systematic Review of Topical Vasodilators for the Treatment of Intraoperative Vasospasm in Reconstructive Microsurgery.

PubMed

Vargas, Christina R; Iorio, Matthew L; Lee, Bernard T

2015-08-01

Intraoperative vasospasm during reconstructive microsurgery is common, often unpredictable, and potentially devastating with regard to flap survival. Current methods of pharmacologic management vary, and may be shifting as a result of changes in the availability of individual medications. This review aims to provide a concise examination of the published literature regarding use, efficacy, and adverse effects of the agents described for local management of vascular spasm during microsurgery. A systematic review of the literature was performed to identify articles relevant to pharmacologic treatment of intraoperative vasospasm in vivo. An additional review of the literature was performed with regard to each agent identified in order to provide clinical background information. Systematic review identified 20 articles, in which 14 vasodilator agents were evaluated. Drugs were classified into five pharmacologic categories: phosphodiesterase inhibitors (papaverine, pentoxifylline, and amrinone), local anesthetics (lidocaine), calcium channel blockers (nicardipine, verapamil, nifedipine, and magnesium sulfate), direct vasodilators (sodium nitroprusside, prostaglandin E1, nitroglycerin, and hydralazine), and alpha antagonists (phentolamine and chlorpromazine). Despite a variety of methods, these studies indicate some degree of experimental evidence of efficacy for each of these agents. Available literature regarding use of topical vasodilating agents for intraoperative management of vasospasm during microsurgery is limited and largely based on animal models, which may not reliably generalize to the reconstructive patient population. Well-controlled translational study in clinically applicable and reproducible models is needed to guide evidence-based clinical management of this important phenomenon.

MRI signal intensity based B-spline nonrigid registration for pre- and intraoperative imaging during prostate brachytherapy.

PubMed

Oguro, Sota; Tokuda, Junichi; Elhawary, Haytham; Haker, Steven; Kikinis, Ron; Tempany, Clare M C; Hata, Nobuhiko

2009-11-01

To apply an intensity-based nonrigid registration algorithm to MRI-guided prostate brachytherapy clinical data and to assess its accuracy. A nonrigid registration of preoperative MRI to intraoperative MRI images was carried out in 16 cases using a Basis-Spline algorithm in a retrospective manner. The registration was assessed qualitatively by experts' visual inspection and quantitatively by measuring the Dice similarity coefficient (DSC) for total gland (TG), central gland (CG), and peripheral zone (PZ), the mutual information (MI) metric, and the fiducial registration error (FRE) between corresponding anatomical landmarks for both the nonrigid and a rigid registration method. All 16 cases were successfully registered in less than 5 min. After the nonrigid registration, DSC values for TG, CG, PZ were 0.91, 0.89, 0.79, respectively, the MI metric was -0.19 +/- 0.07 and FRE presented a value of 2.3 +/- 1.8 mm. All the metrics were significantly better than in the case of rigid registration, as determined by one-sided t-tests. The intensity-based nonrigid registration method using clinical data was demonstrated to be feasible and showed statistically improved metrics when compare to only rigid registration. The method is a valuable tool to integrate pre- and intraoperative images for brachytherapy.

Quantitative fluorescence angiography for neurosurgical interventions.

PubMed

Weichelt, Claudia; Duscha, Philipp; Steinmeier, Ralf; Meyer, Tobias; Kuß, Julia; Cimalla, Peter; Kirsch, Matthias; Sobottka, Stephan B; Koch, Edmund; Schackert, Gabriele; Morgenstern, Ute

2013-06-01

Present methods for quantitative measurement of cerebral perfusion during neurosurgical operations require additional technology for measurement, data acquisition, and processing. This study used conventional fluorescence video angiography--as an established method to visualize blood flow in brain vessels--enhanced by a quantifying perfusion software tool. For these purposes, the fluorescence dye indocyanine green is given intravenously, and after activation by a near-infrared light source the fluorescence signal is recorded. Video data are analyzed by software algorithms to allow quantification of the blood flow. Additionally, perfusion is measured intraoperatively by a reference system. Furthermore, comparing reference measurements using a flow phantom were performed to verify the quantitative blood flow results of the software and to validate the software algorithm. Analysis of intraoperative video data provides characteristic biological parameters. These parameters were implemented in the special flow phantom for experimental validation of the developed software algorithms. Furthermore, various factors that influence the determination of perfusion parameters were analyzed by means of mathematical simulation. Comparing patient measurement, phantom experiment, and computer simulation under certain conditions (variable frame rate, vessel diameter, etc.), the results of the software algorithms are within the range of parameter accuracy of the reference methods. Therefore, the software algorithm for calculating cortical perfusion parameters from video data presents a helpful intraoperative tool without complex additional measurement technology.

Bleeding control in endoscopic sinus surgery: a systematic review of the literature.

PubMed

Rodriguez Valiente, A; Roldan Fidalgo, A; Laguna Ortega, D

2013-12-01

In the literature various methods are described to reduce bleeding in endoscopic sinus surgery. Scientific evidence and results were gathered and analysed to determine the effectiveness of the various methods used. A total of 20 articles fulfilled the inclusion criteria. Two retrospective articles studied the differences between local and general anaesthesia. Three articles analysed the use of local methods to control bleeding. The majority of the articles analysed the use of different systemic drugs to control intraoperative bleeding. Certain procedures, such as the reverse Trendelenburg position, the use of high doses of epinephrine, the infiltration of phenylephrine and lidocaine into the pterygopalatine fossa, the preoperative use of prednisone, and the control of the heart rate (with dexmedetomidine or remifentanil), appear to reduce the intraoperative blood loss and/or improve the visualisation of the surgical field. However, the evidence supporting these conclusions is poor. The benefits of other procedures, such as the preoperative use of β-blockers, antihypertensive agents, and surgical pledgets with oxymetazoline, phenylephrine, or cocaine, for bleeding control are not evidenced in the literature. In addition, the literature does not present any evidence on the benefits of local anaesthesia compared with general anaesthesia or the use of propofol compared to inhaled analgesics in terms of intraoperative bleeding or complication rates.

Intraocular lens power selection and positioning with and without intraoperative aberrometry.

PubMed

Hatch, Kathryn M; Woodcock, Emily C; Talamo, Jonathan H

2015-04-01

To determine the value of intraoperative aberrometry in cases of toric intraocular lens (IOL) implantation and positioning. In this non-randomized retrospective comparative trial, two groups of eyes underwent cataract extraction with toric IOL implantation: the aberrometry group (n = 37 eyes), where toric IOL power and alignment were determined before surgery with automated keratometry, standard optical biometry, and an online calculator and then refined using intraoperative aberrometry, and the toric calculator group (n = 27 eyes), where IOL selection was performed in a similar manner but without intraoperative aberrometry. The primary outcome measure was mean postoperative residual refractive astigmatism (RRA). Mean RRA measured at follow-up after surgery was 0.46 ± 0.42 and 0.68 ± 0.34 diopters (D) in the aberrometry and toric calculator groups, respectively (P = .0153). A 75% and 57% reduction in cylinder was noted between preoperative keratometric astigmatism and postoperative RRA in the aberrometry and toric calculator groups, respectively (P = .0027). RRA of 0.25 D or less, 0.50 D or less, 0.75 D or less, and 1.00 D or less was seen 38%, 78%, 86%, and 95% of the time, respectively, in the aberrometry group and 22%, 33%, 74%, and 89% of the time, respectively, in the toric calculator group. These data show that the chance of a patient being in a lower postoperative RRA range increased when intraoperative aberrometry was used (P = .0130). Patients undergoing cataract extraction with toric IOL placement aided by intraoperative aberrometry were 2.4 times more likely to have less than 0.50 D of RRA compared to standard methods. Copyright 2015, SLACK Incorporated.

Automatic localization of endoscope in intraoperative CT image: A simple approach to augmented reality guidance in laparoscopic surgery.

PubMed

Bernhardt, Sylvain; Nicolau, Stéphane A; Agnus, Vincent; Soler, Luc; Doignon, Christophe; Marescaux, Jacques

2016-05-01

The use of augmented reality in minimally invasive surgery has been the subject of much research for more than a decade. The endoscopic view of the surgical scene is typically augmented with a 3D model extracted from a preoperative acquisition. However, the organs of interest often present major changes in shape and location because of the pneumoperitoneum and patient displacement. There have been numerous attempts to compensate for this distortion between the pre- and intraoperative states. Some have attempted to recover the visible surface of the organ through image analysis and register it to the preoperative data, but this has proven insufficiently robust and may be problematic with large organs. A second approach is to introduce an intraoperative 3D imaging system as a transition. Hybrid operating rooms are becoming more and more popular, so this seems to be a viable solution, but current techniques require yet another external and constraining piece of apparatus such as an optical tracking system to determine the relationship between the intraoperative images and the endoscopic view. In this article, we propose a new approach to automatically register the reconstruction from an intraoperative CT acquisition with the static endoscopic view, by locating the endoscope tip in the volume data. We first describe our method to localize the endoscope orientation in the intraoperative image using standard image processing algorithms. Secondly, we highlight that the axis of the endoscope needs a specific calibration process to ensure proper registration accuracy. In the last section, we present quantitative and qualitative results proving the feasibility and the clinical potential of our approach. Copyright © 2016 Elsevier B.V. All rights reserved.

Intraoperative low tidal volume ventilation strategy has no benefits during laparoscopic cholecystectomy

PubMed Central

Arora, Vandna; Tyagi, Asha; Kumar, Surendra; Kakkar, Aanchal; Das, Shukla

2017-01-01

Background and Aims: Benefits of intraoperative low tidal volume ventilation during laparoscopic surgery are not conclusively proven, even though its advantages were seen in other situations with intraoperative respiratory compromise such as one-lung ventilation. The present study compared the efficacy of intraoperative low tidal volume ventilatory strategy (6 ml/kg along with positive end-expiratory pressure [PEEP] of 10 cmH2O) versus one with higher tidal volume (10 ml/kg with no PEEP) on various clinical parameters and plasma levels of interleukin (IL)-6 in patients undergoing laparoscopic cholecystectomy. Material and Methods: A total of 58 adult patients with American Society of Anesthesiologists physical status I or II, undergoing laparoscopic cholecystectomy were randomized to receive the low or higher tidal volume strategy as above (n = 29 each). The primary outcome measure was postoperative PaO2. Systemic levels of IL-6 along with clinical indices of intraoperative gas exchange, pulmonary mechanics, and hemodynamic consequences were measured as secondary outcome measures. Results: There was no statistically significant difference in oxygenation; intraoperative dynamic compliance, peak airway pressures, or hemodynamic parameters, or the IL-6 levels between the two groups (P > 0.05). Low tidal volume strategy was associated with significantly higher mean airway pressure, lower airway resistance, greater respiratory rates, and albeit clinically similar, higher PaCO2and lower pH (P < 0.05). Conclusion: Strategy using 6 ml/kg tidal volume along with 10 cmH2O of PEEP was not associated with any significant improvement in gas exchange, hemodynamic parameters, or systemic inflammatory response over ventilation with 10 ml/kg volume without PEEP during laparoscopic cholecystectomy. PMID:28413273

Automated construction of an intraoperative high-dose-rate treatment plan library for the Varian brachytherapy treatment planning system.

PubMed

Deufel, Christopher L; Furutani, Keith M; Dahl, Robert A; Haddock, Michael G

2016-01-01

The ability to create treatment plans for intraoperative high-dose-rate (IOHDR) brachytherapy is limited by lack of imaging and time constraints. An automated method for creation of a library of high-dose-rate brachytherapy plans that can be used with standard planar applicators in the intraoperative setting is highly desirable. Nonnegative least squares algebraic methods were used to identify dwell time values for flat, rectangular planar applicators. The planar applicators ranged in length and width from 2 cm to 25 cm. Plans were optimized to deliver an absorbed dose of 10 Gy to three different depths from the patient surface: 0 cm, 0.5 cm, and 1.0 cm. Software was written to calculate the optimized dwell times and insert dwell times and positions into a .XML plan template that can be imported into the Varian brachytherapy treatment planning system. The user may import the .XML template into the treatment planning system in the intraoperative setting to match the patient applicator size and prescribed treatment depth. A total of 1587 library plans were created for IOHDR brachytherapy. Median plan generation time was approximately 1 minute per plan. Plan dose was typically 100% ± 1% (mean, standard deviation) of the prescribed dose over the entire length and width of the applicator. Plan uniformity was best for prescription depths of 0 cm and 0.5 cm from the patient surface. An IOHDR plan library may be created using automated methods. Thousands of plan templates may be optimized and prepared in a few hours to accommodate different applicator sizes and treatment depths and reduce treatment planning time. The automated method also enforces dwell time symmetry for symmetrical applicator geometries, which simplifies quality assurance. Copyright © 2016 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.

Intraoperative cone-beam computed tomography and multi-slice computed tomography in temporal bone imaging for surgical treatment.

PubMed

Erovic, Boban M; Chan, Harley H L; Daly, Michael J; Pothier, David D; Yu, Eugene; Coulson, Chris; Lai, Philip; Irish, Jonathan C

2014-01-01

Conventional computed tomography (CT) imaging is the standard imaging technique for temporal bone diseases, whereas cone-beam CT (CBCT) imaging is a very fast imaging tool with a significant less radiation dose compared with conventional CT. We hypothesize that a system for intraoperative cone-beam CT provides comparable image quality to diagnostic CT for identifying temporal bone anatomical landmarks in cadaveric specimens. Cross-sectional study. University tertiary care facility. Twenty cadaveric temporal bones were affixed into a head phantom and scanned with both a prototype cone-beam CT C-arm and multislice helical CT. Imaging performance was evaluated by 3 otologic surgeons and 1 head and neck radiologist. Participants were presented images in a randomized order and completed landmark identification questionnaires covering 21 structures. CBCT and multislice CT have comparable performance in identifying temporal structures. Three otologic surgeons indicated that CBCT provided statistically equivalent performance for 19 of 21 landmarks, with CBCT superior to CT for the chorda tympani and inferior for the crura of the stapes. Subgroup analysis showed that CBCT performed superiorly for temporal bone structures compared with CT. The radiologist rated CBCT and CT as statistically equivalent for 18 of 21 landmarks, with CT superior to CBCT for the crura of stapes, chorda tympani, and sigmoid sinus. CBCT provides comparable image quality to conventional CT for temporal bone anatomical sites in cadaveric specimens. Clinical applications of low-dose CBCT imaging in surgical planning, intraoperative guidance, and postoperative assessment are promising but require further investigation.

Cadaveric in-situ testing of optical coherence tomography system-based skull base surgery guidance

NASA Astrophysics Data System (ADS)

Sun, Cuiru; Khan, Osaama H.; Siegler, Peter; Jivraj, Jamil; Wong, Ronnie; Yang, Victor X. D.

2015-03-01

Optical Coherence Tomography (OCT) has extensive potential for producing clinical impact in the field of neurological diseases. A neurosurgical OCT hand-held forward viewing probe in Bayonet shape has been developed. In this study, we test the feasibility of integrating this imaging probe with modern navigation technology for guidance and monitoring of skull base surgery. Cadaver heads were used to simulate relevant surgical approaches for treatment of sellar, parasellar and skull base pathology. A high-resolution 3D CT scan was performed on the cadaver head to provide baseline data for navigation. The cadaver head was mounted on existing 3- or 4-point fixation systems. Tracking markers were attached to the OCT probe and the surgeon-probe-OCT interface was calibrated. 2D OCT images were shown in real time together with the optical tracking images to the surgeon during surgery. The intraoperative video and multimodality imaging data set, consisting of real time OCT images, OCT probe location registered to neurosurgical navigation were assessed. The integration of intraoperative OCT imaging with navigation technology provides the surgeon with updated image information, which is important to deal with tissue shifts and deformations during surgery. Preliminary results demonstrate that the clinical neurosurgical navigation system can provide the hand held OCT probe gross anatomical localization. The near-histological imaging resolution of intraoperative OCT can improve the identification of microstructural/morphology differences. The OCT imaging data, combined with the neurosurgical navigation tracking has the potential to improve image interpretation, precision and accuracy of the therapeutic procedure.

A gaussian mixture + demons deformable registration method for cone-beam CT-guided robotic transoral base-of-tongue surgery

NASA Astrophysics Data System (ADS)

Reaungamornrat, S.; Liu, W. P.; Schafer, S.; Otake, Y.; Nithiananthan, S.; Uneri, A.; Richmon, J.; Sorger, J.; Siewerdsen, J. H.; Taylor, R. H.

2013-03-01

Purpose: An increasingly popular minimally invasive approach to resection of oropharyngeal / base-of-tongue cancer is made possible by a transoral technique conducted with the assistance of a surgical robot. However, the highly deformed surgical setup (neck flexed, mouth open, and tongue retracted) compared to the typical patient orientation in preoperative images poses a challenge to guidance and localization of the tumor target and adjacent critical anatomy. Intraoperative cone-beam CT (CBCT) can account for such deformation, but due to the low contrast of soft-tissue in CBCT images, direct localization of the target and critical tissues in CBCT images can be difficult. Such structures may be more readily delineated in preoperative CT or MR images, so a method to deformably register such information to intraoperative CBCT could offer significant value. This paper details the initial implementation of a deformable registration framework to align preoperative images with the deformed intraoperative scene and gives preliminary evaluation of the geometric accuracy of registration in CBCT-guided TORS. Method: The deformable registration aligns preoperative CT or MR to intraoperative CBCT by integrating two established approaches. The volume of interest is first segmented (specifically, the region of the tongue from the tip to the hyoid), and a Gaussian mixture (GM) mode1 of surface point clouds is used for rigid initialization (GMRigid) as well as an initial deformation (GMNonRigid). Next, refinement of the registration is performed using the Demons algorithm applied to distance transformations of the GM-registered and CBCT volumes. The registration accuracy of the framework was quantified in preliminary studies using a cadaver emulating preoperative and intraoperative setups. Geometric accuracy of registration was quantified in terms of target registration error (TRE) and surface distance error. Result: With each step of the registration process, the framework demonstrated improved registration, achieving mean TRE of 3.0 mm following the GM rigid, 1.9 mm following GM nonrigid, and 1.5 mm at the output of the registration process. Analysis of surface distance demonstrated a corresponding improvement of 2.2, 0.4, and 0.3 mm, respectively. The evaluation of registration error revealed the accurate alignment in the region of interest for base-of-tongue robotic surgery owing to point-set selection in the GM steps and refinement in the deep aspect of the tongue in the Demons step. Conclusions: A promising framework has been developed for CBCT-guided TORS in which intraoperative CBCT provides a basis for registration of preoperative images to the highly deformed intraoperative setup. The registration framework is invariant to imaging modality (accommodating preoperative CT or MR) and is robust against CBCT intensity variations and artifact, provided corresponding segmentation of the volume of interest. The approach could facilitate overlay of preoperative planning data directly in stereo-endoscopic video in support of CBCT-guided TORS.

Comparison of indocyanine green fluorescence and parathyroid autofluorescence imaging in the identification of parathyroid glands during thyroidectomy

PubMed Central

Kahramangil, Bora

2017-01-01

Background Indocyanine green fluorescence (ICGF) and parathyroid autofluorescence (AF) are two new techniques that aid in the identification of parathyroid glands (PG) intraoperatively during thyroidectomy. There is no study comparing the efficacy of these techniques. Methods This was an IRB-approved clinical study comparing the utility of ICGF and AF for identification of PGs during thyroidectomy. Data were collected prospectively. Both techniques were compared to naked eye (NE) for PG detection. Standard statistical methods were used for data analysis. Results Twenty-two patients in each group underwent a total of 39 total thyroidectomies and 5 thyroid lobectomies. AF and ICGF had similar detection rates for PGs [98% (61 of 62) and 95% (60 of 63) of PGs, respectively; P=0.31]. The location of PGs was suggested before detection with NE more frequently by AF than ICGF [52% (32 of 62) vs. 6% (4 of 63) of PGs; P<0.001]. In 82% (18 of 22) of patients at least one PG was detected by AF before NE, as opposed to 14% (3 of 22) by ICGF (P<0.001). The median (range) number of PGs detected before NE per patient was greater with AF than ICGF [2 (0–3) vs. 0 (0–2)];. Upper PGs were more likely to be detected by AF before recognition with NE than the lower ones (P=0.03). There was no predictive factor for ICGF detection. Postoperative hypocalcemia rates were similar [9% (2 of 22) and 5% (1 of 22) for AF and ICGF, respectively; P>0.99]. Conclusions To the best of our knowledge, this is the first comparative study between parathyroid AF and ICGF in detection of PGs during thyroidectomy. Our data suggest both techniques have similarly high detection rates and that the main difference lies in the timing of detection. AF more frequently detects PGs before recognition with NE compared to ICGF. PMID:29302480

Fluorescent Imaging With Indocyanine Green During Laparoscopic Cholecystectomy in Patients at Increased Risk of Bile Duct Injury

PubMed Central

Ankersmit, Marjolein; van Dam, Dieuwertje A.; van Rijswijk, Anne-Sophie; van den Heuvel, Baukje; Tuynman, Jurriaan B.; Meijerink, Wilhelmus J. H. J.

2017-01-01

Background. Although rare, injury to the common bile duct (CBD) during laparoscopic cholecystectomy (LC) can be reduced by better intraoperative visualization of the cystic duct (CD) and CBD. The aim of this study was to establish the efficacy of early visualization of the CD and the added value of CBD identification, using near-infrared (NIR) light and the fluorescent agent indocyanine green (ICG), in patients at increased risk of bile duct injury. Materials and Methods. Patients diagnosed with complicated cholecystitis and scheduled for LC were included. The CBD and CD were visualized with NIR light before and during dissection of the liver hilus and at critical view of safety (CVS). Results. Of the 20 patients originally included, 2 were later excluded due to conversion. In 6 of 18 patients, the CD was visualized early during dissection and prior to imaging with conventional white light. The CBD was additionally visualized with ICG-NIR in 7 of 18 patients. In 1 patient, conversion was prevented due to detection of the CD and CBD with ICG-NIR. Conclusions. Early visualization of the CD or additional identification of the CBD using ICG-NIR in patients with complicated cholecystolithiasis can be helpful in preventing CBD injury. Future studies should attempt to establish the optimal dosage and time frame for ICG administration and bile duct visualization with respect to different gallbladder pathologies. PMID:28178882

Real Time Intraoperative Monitoring of Blood Loss with a Novel Tablet Application.

PubMed

Sharareh, Behnam; Woolwine, Spencer; Satish, Siddarth; Abraham, Peter; Schwarzkopf, Ran

2015-01-01

Real-time monitoring of blood loss is critical in fluid management. Visual estimation remains the standard of care in estimating blood loss, yet is demonstrably inaccurate. Photometric analysis, which is the referenced "gold-standard" for measuring blood loss, is both time-consuming and costly. The purpose of this study was to evaluate the efficacy of a novel tablet-monitoring device for measurement of Hb loss during orthopaedic procedures. This is a prospective study of 50 patients in a consecutive series of joint arthroplasty cases. The novel System with Feature Extraction Technology was used to measure the amount of Hb contained within surgical sponges intra-operatively. The system's measures were then compared with those obtained via gravimetric method and photometric analysis. Accuracy was evaluated using linear regression and Bland-Altman analysis. Our results showed a significant positive correlation between Triton tablet system and photometric analysis with respect to intra-operative hemoglobin and blood loss at 0.92 and 0.91, respectively. This novel system can accurately determine Hb loss contained within surgical sponges. We believe that this user-friendly software can be used for measurement of total intraoperative blood loss and thus aid in a more accurate fluid management protocols during orthopaedic surgical procedures.

Intraoperative brain tumor resection cavity characterization with conoscopic holography

NASA Astrophysics Data System (ADS)

Simpson, Amber L.; Burgner, Jessica; Chen, Ishita; Pheiffer, Thomas S.; Sun, Kay; Thompson, Reid C.; Webster, Robert J., III; Miga, Michael I.

2012-02-01

Brain shift compromises the accuracy of neurosurgical image-guided interventions if not corrected by either intraoperative imaging or computational modeling. The latter requires intraoperative sparse measurements for constraining and driving model-based compensation strategies. Conoscopic holography, an interferometric technique that measures the distance of a laser light illuminated surface point from a fixed laser source, was recently proposed for non-contact surface data acquisition in image-guided surgery and is used here for validation of our modeling strategies. In this contribution, we use this inexpensive, hand-held conoscopic holography device for intraoperative validation of our computational modeling approach to correcting for brain shift. Laser range scan, instrument swabbing, and conoscopic holography data sets were collected from two patients undergoing brain tumor resection therapy at Vanderbilt University Medical Center. The results of our study indicate that conoscopic holography is a promising method for surface acquisition since it requires no contact with delicate tissues and can characterize the extents of structures within confined spaces. We demonstrate that for two clinical cases, the acquired conoprobe points align with our model-updated images better than the uncorrected images lending further evidence that computational modeling approaches improve the accuracy of image-guided surgical interventions in the presence of soft tissue deformations.

Intraoperative echocardiographic detection of regurgitant jets after valve replacement

NASA Technical Reports Server (NTRS)

Morehead, A. J.; Firstenberg, M. S.; Shiota, T.; Qin, J.; Armstrong, G.; Cosgrove, D. M. 3rd; Thomas, J. D.

2000-01-01

BACKGROUND: Paravalvular jets, documented by intraoperative transesophageal echocardiography, have prompted immediate valve explantation by others, yet the significance of these jets is unknown. METHODS: Twenty-seven patients had intraoperative transesophageal two-dimensional color Doppler echocardiography, performed to assess the number and area of regurgitant jets after valve replacement, before and after protamine. Patients were grouped by first time versus redo operation, valve position and type. RESULTS: Before protamine, 55 jets were identified (2.04+/-1.4 per patient) versus 29 jets after (1.07+/-1.2 per patient, p = 0.0002). Total jet area improved from 2.0+/-2.2 cm2 to 0.86+/-1.7 cm2 with protamine (p<0.0001). In all patients jet area decreased (average decrease, 70.7%+/-27.0%). First time and redo operations had similar improvements in jet number and area (both p>0.6). Furthermore, mitral and mechanical valves each had more jets and overall greater jet area when compared to aortic and tissue valves, respectively. CONCLUSIONS: Following valve replacement, multiple jets are detected by intraoperative transesophageal echocardiography. They are more common and larger in the mitral position and with mechanical valves. Improvement occurs with reversal of anticoagulation.

The effect of ephedrine on intraoperative hypothermia

PubMed Central

Jo, Youn Yi; Kim, Ji Young; Kim, Joon-Sik; Kwon, Youngjun

2011-01-01

Background Prevention of intraoperative hypothermia has become a standard of operative care. Since ephedrine has a thermogenic effect and it is frequently used to treat hypotension during anesthesia, this study was designed to determine the effect of ephedrine on intraoperative hypothermia of patients who are undergoing spine surgery. Methods Twenty-four patients were randomly divided to receive an ephedrine (the ephedrine group, n = 12) or normal saline (the control group, n = 12) infusion for 2 h. The esophageal temperature (the core temperature), the index finger temperature (the peripheral temperature) and the hemodynamic variables such as the mean blood pressure and heart rate were measured every 15 minutes after the intubation. Results At the end of the study period, the esophageal temperature and hemodynamic variables were significantly decreased in the control group, whereas those in the ephedrine group were stably maintained. The index finger temperature was significantly lower in the ephedrine group compared to that in the control group, suggesting the prevention of core-to-peripheral redistribution of the heat as the cause of temperature maintenance. Conclusions An intraoperative infusion of ephedrine minimized the decrease of the core temperature and it stably maintained the hemodynamic variables during spine surgery with the patient under general anesthesia. PMID:21602974

[Fusion of MRI, fMRI and intraoperative MRI data. Methods and clinical significance exemplified by neurosurgical interventions].

PubMed

Moche, M; Busse, H; Dannenberg, C; Schulz, T; Schmitgen, A; Trantakis, C; Winkler, D; Schmidt, F; Kahn, T

2001-11-01

The aim of this work was to realize and clinically evaluate an image fusion platform for the integration of preoperative MRI and fMRI data into the intraoperative images of an interventional MRI system with a focus on neurosurgical procedures. A vertically open 0.5 T MRI scanner was equipped with a dedicated navigation system enabling the registration of additional imaging modalities (MRI, fMRI, CT) with the intraoperatively acquired data sets. These merged image data served as the basis for interventional planning and multimodal navigation. So far, the system has been used in 70 neurosurgical interventions (13 of which involved image data fusion--requiring 15 minutes extra time). The augmented navigation system is characterized by a higher frame rate and a higher image quality as compared to the system-integrated navigation based on continuously acquired (near) real time images. Patient movement and tissue shifts can be immediately detected by monitoring the morphological differences between both navigation scenes. The multimodal image fusion allowed a refined navigation planning especially for the resection of deeply seated brain lesions or pathologies close to eloquent areas. Augmented intraoperative orientation and instrument guidance improve the safety and accuracy of neurosurgical interventions.

Intraoperative Raman spectroscopy of soft tissue sarcomas.

PubMed

Nguyen, John Q; Gowani, Zain S; O'Connor, Maggie; Pence, Isaac J; Nguyen, The-Quyen; Holt, Ginger E; Schwartz, Herbert S; Halpern, Jennifer L; Mahadevan-Jansen, Anita

2016-10-01

Soft tissue sarcomas (STS) are a rare and heterogeneous group of malignant tumors that are often treated through surgical resection. Current intraoperative margin assessment methods are limited and highlight the need for an improved approach with respect to time and specificity. Here we investigate the potential of near-infrared Raman spectroscopy for the intraoperative differentiation of STS from surrounding normal tissue. In vivo Raman measurements at 785 nm excitation were intraoperatively acquired from subjects undergoing STS resection using a probe based spectroscopy system. A multivariate classification algorithm was developed in order to automatically identify spectral features that can be used to differentiate STS from the surrounding normal muscle and fat. The classification algorithm was subsequently tested using leave-one-subject-out cross-validation. With the exclusion of well-differentiated liposarcomas, the algorithm was able to classify STS from the surrounding normal muscle and fat with a sensitivity and specificity of 89.5% and 96.4%, respectively. These results suggest that single point near-infrared Raman spectroscopy could be utilized as a rapid and non-destructive surgical guidance tool for identifying abnormal tissue margins in need of further excision. Lasers Surg. Med. 48:774-781, 2016. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Characterizing the Epidemiology of Perioperative Transfusion-associated Circulatory Overload

PubMed Central

Clifford, Leanne; Jia, Qing; Yadav, Hemang; Subramanian, Arun; Wilson, Gregory A.; Murphy, Sean P.; Pathak, Jyotishman; Schroeder, Darrell R.; Ereth, Mark H.; Kor, Daryl J.

2016-01-01

Background Transfusion-associated circulatory overload (TACO) is a leading cause of transfusion-related fatalities, but its incidence and associated patient and transfusion characteristics are poorly understood. To inform surgical transfusion practice and to begin mitigating perioperative TACO, the authors aimed to define its epidemiology. Methods In this retrospective cohort study, the medical records of adult patients undergoing noncardiac surgery with general anesthesia during 2004 or 2011 and receiving intraoperative transfusions were screened using an electronic algorithm for identification of TACO. Those patients who were screened as high probability for TACO underwent rigorous manual review. Univariate and multivariate analyses evaluated associations between patient and transfusion characteristics with TACO rates in a before-and-after study design. Results A total of 2,162 and 1,908 patients met study criteria for 2004 and 2011, respectively. The incidence of TACO was 5.5% (119 of 2,162) in 2004 versus 3.0% (57 of 1,908) in 2011 (P < 0.001), with comparable rates for men (4.8% [98 of 2,023]) and women (3.8% [78 of 2,047]) (P = 0.09). Overall, vascular (12.1% [60 of 497]), transplant (8.8% [17 of 193]), and thoracic surgeries (7.2% [10 of 138]) carried the highest TACO rates. Obstetric and gynecologic patients had the lowest rate (1.4% [4 of 295]). The incidence of TACO increased with volume transfused, advancing age, and total intraoperative fluid balance (all P < 0.001). Conclusions The incidence of perioperative TACO is similar to previous estimates in nonsurgical populations. There was a reduction in TACO rate between 2004 and 2011, with incidence patterns remaining comparable in subgroup analyses. Future efforts exploring risk factors for TACO may guide preventive or therapeutic interventions, helping to further mitigate this transfusion complication. PMID:25611653

Predicting pituitary stalk position by in vivo visualization of the hypothalamo-hypophyseal tract in craniopharyngioma using diffusion tensor imaging tractography.

PubMed

Wang, Fuyu; Jiang, Jinli; Zhang, Jiashu; Wang, Qun

2018-07-01

The pituitary stalk (PS) is crucial to endocrine function and water-electrolyte equilibrium. Preservation of the PS during craniopharyngioma (CP) surgery is critical; however, in a pathological state, it is difficult to identify. The hypothalamo-hypophyseal tract (HHT) connects the hypothalamus and the posterior pituitary gland and projects through the PS. Thus, visualization of the HHT can help locate the PS. Preoperative visualization of the neural fasciculus has been widely achieved using diffusion tensor imaging (DTI) tractography. Therefore, this study evaluated the use of DTI tractography to identify and characterize the human HHT. We used DTI tractography to track the HHT in 10 patients with CP and compared the location of the tract with the intraoperative view of the PS in these patients. We successfully tracked the HHT in nine patients, indicating that delineating and quantifying the tracked HHT using this method is feasible. In addition, we found that the tract was consistent with the intraoperative view of the PS in seven out of eight patients (87.50%). Finally, we found that the mean number of tracts was 7.11 ± 12.28, the mean fractional anisotropy (FA) was 0.11 ± 0.04, and the mean tract length was 24.22 ± 9.39 mm. Taken together, our results demonstrate that the HHT can be visualized and characterized with DTI even in a clinical application, which may aid in preoperative identification of the PS. Characterization of the tracked HHT with this technique could also be used to advance our understanding of the HHT.

[Dynamics of lagophthalmos depending on facial nerve repair and its intraoperative monitoring in neurosurgical patients].

PubMed

Tabachnikova, T V; Serova, N K; Shimansky, V N

2014-01-01

Over 200 patients with acoustic neuromas and over 100 patients with posterior cranial fossa meningiomas are annually operated on at the N.N. Burdenko Neurosurgical Institute. Intraoperative monitoring of the facial nerve function is used in most patients with tumors of the posterior cranial fossa to identify the facial nerve in the surgical wound. If the anatomical integrity of the facial nerve in the cranial cavity cannot be retained, facial nerve repair is performed to restore the facial muscle function. Intraoperative electrical stimulation of the facial nerve has a great prognostic significance to evaluate the dynamics of lagophthalmos in the late postoperative period and to select the proper method for lagophthalmos correction. When the facial nerve was reinnervated by the descending branch or trunk of the hypoglossal nerve, sufficient eyelid closure was observed only in 3 patients out of 17.

Dorsal rhizotomy for children with spastic diplegia of cerebral palsy origin: usefulness of intraoperative monitoring.

PubMed

Georgoulis, George; Brînzeu, Andrei; Sindou, Marc

2018-04-13

OBJECTIVE The utility of intraoperative neuromonitoring (ION), namely the study of muscle responses to radicular stimulation, remains controversial. The authors performed a prospective study combining ventral root (VR) stimulation for mapping anatomical levels and dorsal root (DR) stimulation as physiological testing of metameric excitability. The purpose was to evaluate to what extent the intraoperative data led to modifications in the initial decisions for surgical sectioning established by the pediatric multidisciplinary team (i.e., preoperative chart), and thus estimate its practical usefulness. METHODS Thirteen children with spastic diplegia underwent the following surgical protocol. First, a bilateral intradural approach was made to the L2-S2 VRs and DRs at the exit from or entry to their respective dural sheaths, through multilevel interlaminar enlarged openings. Second, stimulation-just above the threshold-of the VR at 2 Hz to establish topography of radicular myotome distribution, and then of the DR at 50 Hz as an excitability test of root circuitry, with independent identification of muscle responses by the physiotherapist and by electromyographic recordings. The study aimed to compare the final amounts of root sectioning-per radicular level, established after intraoperative neuromonitoring guidance-with those determined by the multidisciplinary team in the presurgical chart. RESULTS The use of ION resulted in differences in the final percentage of root sectioning for all root levels. The root levels corresponding to the upper lumbar segments were modestly excitable under DR stimulation, whereas progressively lower root levels displayed higher excitability. The difference between root levels was highly significant, as evaluated by electromyography (p = 0.00004) as well as by the physiotherapist (p = 0.00001). Modifications were decided in 11 of the 13 patients (84%), and the mean absolute difference in the percentage of sectioning quantity per radicular level was 8.4% for L-2 (p = 0.004), 6.4% for L-3 (p = 0.0004), 19.6% for L-4 (p = 0.00003), 16.5% for L-5 (p = 0.00006), and 3.2% for S-1 roots (p = 0.016). Decreases were most frequently decided for roots L-2 and L-3, whereas increases most frequently involved roots L-4 and L-5, with the largest changes in terms of percentage of sectioning. CONCLUSIONS The use of ION during dorsal rhizotomy led to modifications regarding which DRs to section and to what extent. This was especially true for L-4 and L-5 roots, which are known to be involved in antigravity and pelvic stability functions. In this series, ION contributed significantly to further adjust the patient-tailored dorsal rhizotomy procedure to the clinical presentation and the therapeutic goals of each patient.

Novel Handheld Magnetometer Probe Based on Magnetic Tunnelling Junction Sensors for Intraoperative Sentinel Lymph Node Identification

PubMed Central

Cousins, A.; Balalis, G. L.; Thompson, S. K.; Forero Morales, D.; Mohtar, A.; Wedding, A. B.; Thierry, B.

2015-01-01

Using magnetic tunnelling junction sensors, a novel magnetometer probe for the identification of the sentinel lymph node using magnetic tracers was developed. Probe performance was characterised in vitro and validated in a preclinical swine model. Compared to conventional gamma probes, the magnetometer probe showed excellent spatial resolution of 4.0 mm, and the potential to detect as few as 5 μg of magnetic tracer. Due to the high sensitivity of the magnetometer, all first-tier nodes were identified in the preclinical experiments, and there were no instances of false positive or false negative detection. Furthermore, these preliminary data encourage the application of the magnetometer probe for use in more complex lymphatic environments, such as in gastrointestinal cancers, where the sentinel node is often in close proximity to other non-sentinel nodes, and high spatial resolution detection is required. PMID:26038833

Intraoperative neurophysiological monitoring of the cortico-spinal tract in image-guided mini-invasive neurosurgery.

PubMed

Cordella, Roberto; Acerbi, Francesco; Broggi, Morgan; Vailati, Davide; Nazzi, Vittoria; Schiariti, Marco; Tringali, Giovanni; Ferroli, Paolo; Franzini, Angelo; Broggi, Giovanni

2013-06-01

To evaluate the role of intraoperative neurophysiological monitoring in image-guided mini-invasive neurosurgery. Twenty-one patients were operated under general anaesthesia with the aid of multimodal intraoperative neurophysiological monitoring to remove supratentorials tumors closely related to the cortico-spinal tract. Pre-operative assessment included fMRI scans and tractography that were uploaded into the intraoperative neuro-navigation system. Monitoring consisted in simultaneously recording EEG, electrocorticography, transcranial and direct motor evoked potentials (tMEP and dMEP), somatosensory evoked potentials and subcortical stimulation during the whole procedures. The recording of all the electrophysiological signals was possible in all procedures. SSEP guided the positioning of the strip electrode over the motor cortex (N20 phase inversion) that was used to evoke dMEP and monitor the lower limb motor responses; subcortical stimulation to unveil the spatial relationship between the tumors and motor fibers. Four patients had transient worsening of the symptoms, but only two had a long-term worsening, although not severe, of the pre-op clinical status. Intraoperative neurophysiology has a great value in mini-invasive neurosurgery, especially because the motor cortex is not exposed, consequently it cannot be directly mapped. This report describes a valuable scheme making use of as many electrophysiological signals as possible to constantly monitor the motor functions. A useful method to monitor motor functions in mini-invasive neurosurgery was described. Copyright © 2012 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.

Fusion of intraoperative force sensoring, surface reconstruction and biomechanical modeling

NASA Astrophysics Data System (ADS)

Röhl, S.; Bodenstedt, S.; Küderle, C.; Suwelack, S.; Kenngott, H.; Müller-Stich, B. P.; Dillmann, R.; Speidel, S.

2012-02-01

Minimally invasive surgery is medically complex and can heavily benefit from computer assistance. One way to help the surgeon is to integrate preoperative planning data into the surgical workflow. This information can be represented as a customized preoperative model of the surgical site. To use it intraoperatively, it has to be updated during the intervention due to the constantly changing environment. Hence, intraoperative sensor data has to be acquired and registered with the preoperative model. Haptic information which could complement the visual sensor data is still not established. In addition, biomechanical modeling of the surgical site can help in reflecting the changes which cannot be captured by intraoperative sensors. We present a setting where a force sensor is integrated into a laparoscopic instrument. In a test scenario using a silicone liver phantom, we register the measured forces with a reconstructed surface model from stereo endoscopic images and a finite element model. The endoscope, the instrument and the liver phantom are tracked with a Polaris optical tracking system. By fusing this information, we can transfer the deformation onto the finite element model. The purpose of this setting is to demonstrate the principles needed and the methods developed for intraoperative sensor data fusion. One emphasis lies on the calibration of the force sensor with the instrument and first experiments with soft tissue. We also present our solution and first results concerning the integration of the force sensor as well as accuracy to the fusion of force measurements, surface reconstruction and biomechanical modeling.

The intraoperative use of ultrasound facilitates significantly the arthroscopic debridement of calcific rotator cuff tendinitis.

PubMed

Sabeti, M; Schmidt, M; Ziai, P; Graf, A; Nemecek, E; Schueller-Weidekamm, C

2014-05-01

During arthroscopy, the localization of calcific deposit in patients suffering from calcifying tendinitis can be demanding and time consuming, frequently using ionizing radiation. Intraoperative ultrasound has been recently promoted, facilitating deposit localization and reducing radiation dose. In this prospective, randomized, controlled and clinical observer-blinded pilot trial, 20 patients with calcific tendinitis were operated. In group I, the deposit was localized conventionally. In group II, the deposit was localized using intraoperative ultrasound. The needle punctures to detect the deposit and operation times were noted. Patients were postoperatively evaluated after 2 and 6 weeks and 9 months. In group II, the needle punctures to detect the deposit were significantly lower than in group I (p < 0.0001). Operation time to localize the deposit was also significantly less in group II (p < 0.033). In both groups, patients improved significantly with increased shoulder function (p < 0.0001) and decreased pain (p < 0.0001) 2 weeks and 9 months (p < 0.001) after surgery. The difference between the groups was not significant. Excellent radiological findings were obtained in both groups after 9 months. Intraoperative US significantly facilitates the detection of calcific deposits during arthroscopic debridement by speeding up surgery and reducing the number of needle punctures. Hence, we have changed our method of detecting calcific deposits intraoperatively from fluoroscopy to ultrasound.

A simple method for in vivo measurement of implant rod three-dimensional geometry during scoliosis surgery.

PubMed

Salmingo, Remel A; Tadano, Shigeru; Fujisaki, Kazuhiro; Abe, Yuichiro; Ito, Manabu

2012-05-01

Scoliosis is defined as a spinal pathology characterized as a three-dimensional deformity of the spine combined with vertebral rotation. Treatment for severe scoliosis is achieved when the scoliotic spine is surgically corrected and fixed using implanted rods and screws. Several studies performed biomechanical modeling and corrective forces measurements of scoliosis correction. These studies were able to predict the clinical outcome and measured the corrective forces acting on screws, however, they were not able to measure the intraoperative three-dimensional geometry of the spinal rod. In effect, the results of biomechanical modeling might not be so realistic and the corrective forces during the surgical correction procedure were intra-operatively difficult to measure. Projective geometry has been shown to be successful in the reconstruction of a three-dimensional structure using a series of images obtained from different views. In this study, we propose a new method to measure the three-dimensional geometry of an implant rod using two cameras. The reconstruction method requires only a few parameters, the included angle θ between the two cameras, the actual length of the rod in mm, and the location of points for curve fitting. The implant rod utilized in spine surgery was used to evaluate the accuracy of the current method. The three-dimensional geometry of the rod was measured from the image obtained by a scanner and compared to the proposed method using two cameras. The mean error in the reconstruction measurements ranged from 0.32 to 0.45 mm. The method presented here demonstrated the possibility of intra-operatively measuring the three-dimensional geometry of spinal rod. The proposed method could be used in surgical procedures to better understand the biomechanics of scoliosis correction through real-time measurement of three-dimensional implant rod geometry in vivo.

Assessment of the use of latissimus dorsi restoration during modified radical mastectomy in breast cancer patients.

PubMed

Yang, Chao; Wang, Xinle; Zhang, Geng; Yang, Liu; Guo, Xuan; Wang, Xue; Song, Zhenchuan

2017-12-01

The incision area of modified radical mastectomy in breast cancer patients is associated with subcutaneous effusion and skin flap necrosis as the most common complications. The aim of the present study was to assess the effect of latissimus dorsi restoration during modified radical mastectomy in breast cancer patients by evaluating 365 cases. Among these cases, 185 received modified radical mastectomy combined with intraoperative latissimus dorsi restoration, while 180 received modified radical mastectomy alone. The flap tension, drainage fluid amount and extubation time were compared between the two methods. The flap tension in patients who received modified radical mastectomy combined with intraoperative latissimus dorsi restoration was significantly lower and the blood supply was better. After surgery, the drainage fluid amount was also significantly lower in these patients compared with the control group. Furthermore, the mean time to drainage tube removal was significantly shorter in these patients and the postoperative cosmetic outcome was superior. Thus, it was concluded that modified radical mastectomy combined with intraoperative latissimus dorsi restoration in breast cancer patients was associated with reduced drainage fluid effusion, shorter hospitalization time and decreased flap tension. Overall, this method appears to be potentially suitable for extensive application in the clinical setting.

Assessment of recurrent laryngeal nerve function during thyroid surgery

PubMed Central

Douglas, J; Smith, B; Dougherty, T; Ayshford, C

2014-01-01

Introduction There is disparity in the reported incidence of temporary and permanent recurrent laryngeal nerve (RLN) palsy following thyroidectomy. Much of the disparity is due to the method of assessing vocal cord function. We sought to identify the incidence and natural history of temporary and permanent vocal cord palsy following thyroid surgery. The authors wanted to establish whether intraoperative nerve monitoring and stimulation aids in prognosis when managing vocal cord palsy. Methods Prospective data on consecutive thyroid operations were collected. Intraoperative nerve monitoring and stimulation, using an endotracheal tube mounted device, was performed in all cases. Endoscopic examination of the larynx was performed on the first postoperative day and at three weeks. Results Data on 102 patients and 123 nerves were collated. Temporary and permanent RLN palsy rates were 6.1% and 1.7%. Most RLN palsies were identified on the first postoperative day with all recognised at the three-week review. No preoperative clinical risk factors were identified. Although dysphonia at the three-week follow-up visit was the only significant predictor of vocal cord palsy, only two-thirds of patients with cord palsies were dysphonic. Intraoperative nerve monitoring and stimulation did not predict outcome in terms of vocal cord function. Conclusions Temporary nerve palsy rates were consistent with other series where direct laryngoscopy is used to assess laryngeal function. Direct laryngoscopy is the only reliable measure of cord function, with intraoperative monitoring being neither a reliable predictor of cord function nor a predictor of eventual laryngeal function. The fact that all temporary palsies recovered within four months has implications for staged procedures. PMID:24780671

Words are not enough: nonword repetition as an indicator of arcuate fasciculus integrity during brain tumor resection.

PubMed

Sierpowska, Joanna; Gabarrós, Andreu; Fernandez-Coello, Alejandro; Camins, Àngels; Castañer, Sara; Juncadella, Montserrat; Morís, Joaquín; Rodríguez-Fornells, Antoni

2017-02-01

OBJECTIVE Subcortical electrical stimulation during brain surgery may allow localization of functionally crucial white matter fibers and thus tailoring of the tumor resection according to its functional limits. The arcuate fasciculus (AF) is a white matter bundle connecting frontal, temporal, and parietal cortical areas that is often disrupted by left brain lesions. It plays a critical role in several cognitive functions related to phonological processing, but current intraoperative monitoring methods do not yet allow mapping of this tract with sufficient precision. In the present study the authors aimed to test a new paradigm for the intraoperative monitoring of the AF. METHODS In this report, the authors studied 12 patients undergoing awake brain surgery for tumor resection with a related risk of AF damage. To preserve AF integrity and the cognitive processes sustained by this tract in the intraoperative context, the authors used real word repetition (WR) and nonword repetition (NWR) tasks as complements to standard picture naming. RESULTS Compared with the errors identified by WR or picture naming, the NWR task allowed the detection of subtle errors possibly related to AF alterations. Moreover, only 3 patients demonstrated phonological paraphasias in standard picture naming, and in 2 of these patients the paraphasias co-occurred with the total loss of WR and NWR ability. Before surgery, lesion volume predicted a patient's NWR performance. CONCLUSIONS The authors suggest that monitoring NWR intraoperatively may complement the standard naming tasks and could permit better preservation of the important language production functions subserved by the AF.

Intraoperative Localization of Tantalum Markers for Proton Beam Radiation of Choroidal Melanoma by an Opto-Electronic Navigation System: A Novel Technique

DOE Office of Scientific and Technical Information (OSTI.GOV)

Amstutz, Christoph A., E-mail: christoph.amstutz@usz.ch; Bechrakis, Nikolaos E.; Foerster, Michael H.

2012-03-15

Purpose: External beam proton radiation therapy has been used since 1975 to treat choroidal melanoma. For tumor location determination during proton radiation treatment, surgical tantalum clips are registered with image data. This report introduces the intraoperative application of an opto-electronic navigation system to determine with high precision the position of the tantalum markers and their spatial relationship to the tumor and anatomical landmarks. The application of the technique in the first 4 patients is described. Methods and Materials: A navigated reference base was attached noninvasively to the eye, and a navigated pointer device was used to record the spatial positionmore » of the tantalum markers, the tumor, and anatomical landmarks. Measurement accuracy was assessed on ex vivo porcine eye specimen by repetitive recording of the tantalum marker positions. The method was applied intraoperatively on 4 patients undergoing routine tantalum clip surgery. The spatial position information delivered by the navigation system was compared to the geometric data generated by the EYEPLAN software. Results: In the ex vivo experiments, the maximum repetition error was 0.34 mm. For the intraoperative application, the root mean square error of paired-points matching of the marker positions from the navigation system and from the EYEPLAN software was 0.701-1.25 mm. Conclusions: Navigation systems are a feasible tool for accurate localization of tantalum markers and anatomic landmarks. They can provide additional geometric information, and therefore have the potential to increase the reliability and accuracy of external beam proton radiation therapy for choroidal melanoma.« less

Phrenic nerve stimulation during neck dissection for advanced thyroid cancer involving level IV: is it worth doing it?

PubMed

Duque, Carlos S; Dueñas, Juan P; Marulanda, Marcela; Pérez, Diana; Londoňo, Andres; Roy, Soham; Khadem, Mai Al

2017-03-01

During thyroidectomy and neck dissection surgery for advanced or recurrent metastatic thyroid cancer under intraoperative monitoring, we used the available technology to assess the feasibility of such an intervention to monitor those patients with phrenic nerves at risk. A retrospective review of patients operated on from January 2009 to December 2015 by a single surgeon (CSD) was conducted. Patients who had neck and mediastinal dissection, with or without total thyroidectomy, due to advanced or recurrent metastatic disease to the neck were selected. The procedures were done under intraoperative nerve monitoring using nerve monitoring systems (NIM 2.0 or 3.0; Medtronic, Jacksonville, FL, USA). A total of 19 patients were included in the study, with a mean age of 57.6 years ± 16.3 and a male/female ratio of 10:9. Overall, all patients had an intact phrenic nerve at the conclusion of the surgery. One patient had an aggressive tumor that precluded sacrifice of the left recurrent laryngeal nerve and ipsilateral thoracic duct. The procedure was complicated by a temporary impairment of the diaphragm contraction with intraoperative nerve monitoring as well as a chyle fistula. This was due to the manipulation of the tissue surrounding the phrenic nerve. Intraoperative nerve monitoring of the phrenic nerve offers the surgeon a "potential" method of ensuring phrenic nerve integrity in cases of advanced thyroid cancers with gross level IV metastatic disease. Further prospective studies are needed to assess the risks of this intervention and evaluate the method of recording diaphragm contraction movement.

Phase I-II Study of Intraoperative Radiation Therapy (IORT) After Radical Prostatectomy for Prostate Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Saracino, Biancamaria; Gallucci, Michele; De Carli, Piero

2008-07-15

Purpose: Recent studies have suggested an {alpha}/{beta} ratio in prostate cancer of 1.5-3 Gy, which is lower than that assumed for late-responsive normal tissues. Therefore the administration of a single, intraoperative dose of irradiation should represent a convenient irradiation modality in prostate cancer. Materials and Methods: Between February 2002 and June 2004, 34 patients with localized prostate cancer with only one risk factor (Gleason score {>=}7, Clinical Stage [cT] {>=}2c, or prostate-specific antigen [PSA] of 11-20 ng/mL) and without clinical evidence of lymph node metastases were treated with radical prostatectomy (RP) and intraoperative radiotherapy on the tumor bed. A dose-findingmore » procedure based on the Fibonacci method was employed. Dose levels of 16, 18, and 20 Gy were selected, which are biologically equivalent to total doses of about 60-80 Gy administered with conventional fractionation, using an {alpha}/{beta} ratio value of 3. Results: At a median follow-up of 41 months, 24 (71%) patients were alive with an undetectable PSA value. No patients died from disease, whereas 2 patients died from other malignancies. Locoregional failures were detected in 3 (9%) patients, 2 in the prostate bed and 1 in the common iliac node chain outside the radiation field. A PSA rise without local or distant disease was observed in 7 (21%) cases. The overall 3-year biochemical progression-free survival rate was 77.3%. Conclusions: Our dose-finding study demonstrated the feasibility of intraoperative radiotherapy in prostate cancer also at the highest administered dose.« less

Intraoperative /sup 99m/Tc bone imaging in the treatment of benign osteoblastic tumors

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sty, J.; Simons, G.

1982-05-01

Benign bone tumors can be successfully treated by local resection with the use of intraoperative bone imaging. Intraoperative bone imaging provided accurate localization of an osteoid osteoma in a patella of a 16-year-old girl when standard radiographs failed to demonstrate the lesion. In a case of osteoblastoma of the sacrum in a 12-year old girl, intraoperative scanning was used repeatedly to guide completeness of resection. In these cases in which routine intraoperative radiographs would have failed, intraoperative scanning proved to be essential for success.

Vaccum drainage system application in the management of operation-related non-regional epidural hematoma

PubMed Central

2013-01-01

Background Epidural intracranial hematoma is one of the most common complications of surgeries for intracranial tumors. The non-regional epidural hematoma is related to severe fluctuation of the intracranial pressure during the operation. The traditional management of hematoma evacuation through craniotomy is time-consuming and may aggravate intracranial pressure imbalance, which causes further complications. We designed a method using vaccum epidural drainage system, and tried to evaluate advantage and the disadvantage of this new technique. Methods Seven patients of intracranial tumors were selected. All of the patients received tumor resection and intra-operative non-regional epidural hematoma was confirmed through intra-operative ultrasound or CT scan. The vaccum drainage system was applied. Another ten patients who received craniotomy for intra-operative non-regional epidural hematoma evacuation were selected as comparison. Regular tests, like serial CT scan, were performed afterward to evaluate the effectiveness and to help deciding when to remove the drainage system. Results The vaccum drainage method was effective in epidual hemotoma clearance and prevented recurrent epidural hemorrhage. The drainage systems were removed within 4 days. All of the patients recovered well. No complications related to the drainage system were observed. Conclusions Compared to the traditional craniotomy, the new method of epidural hemoatoma management using vaccum epidural drainage system proved to be as effective in hematoma clearance, and was less-invasive and easier to perform, with less complication, shorter hospitalization, less economic burden, and better prognosis. PMID:23842198

Impact of autofluorescence-based identification of parathyroids during total thyroidectomy on postoperative hypocalcemia: a before and after controlled study.

PubMed

Benmiloud, Fares; Rebaudet, Stanislas; Varoquaux, Arthur; Penaranda, Guillaume; Bannier, Marie; Denizot, Anne

2018-01-01

The clinical impact of intraoperative autofluorescence-based identification of parathyroids using a near-infrared camera remains unknown. In a before and after controlled study, we compared all patients who underwent total thyroidectomy by the same surgeon during Period 1 (January 2015 to January 2016) without near-infrared (near-infrared- group) and those operated on during Period 2 (February 2016 to September 2016) using a near-infrared camera (near-infrared+ group). In parallel, we also compared all patients who underwent surgery without near-infrared during those same periods by another surgeon in the same unit (control groups). Main outcomes included postoperative hypocalcemia, parathyroid identification, autotransplantation, and inadvertent resection. The near-infrared+ group displayed significantly lower postoperative hypocalcemia rates (5.2%) than the near-infrared- group (20.9%; P < .001). Compared with the near-infrared- patients, the near-infrared+ group exhibited an increased mean number of identified parathyroids and reduced parathyroid autotransplantation rates, although no difference was observed in inadvertent resection rates. Parathyroids were identified via near-infrared before they were visualized by the surgeon in 68% patients. In the control groups, parathyroid identification improved significantly from Period 1 to Period 2, although autotransplantation, inadvertent resection and postoperative hypocalcemia rates did not differ. Near-infrared use during total thyroidectomy significantly reduced postoperative hypocalcemia, improved parathyroid identification and reduced their autotransplantation rate. Copyright © 2017 Elsevier Inc. All rights reserved.

The accuracy of frozen section diagnosis of pulmonary nodules: evaluation of inflation method during intraoperative pathology consultation with cryosection.

PubMed

Xu, Xianhua; Chung, Jin-Haeng; Jheon, Sanghoon; Sung, Sook Whan; Lee, Choon-Taek; Lee, Jae Ho; Choe, Gheeyoung

2010-01-01

Intraoperative frozen section diagnosis (FSD) is a very important pathologic examination that can determine the extent of the subsequent surgical procedure. However, FSD is especially difficult in small pulmonary nodules due to severe architectural distortion during cryosection. This study was undertaken to determine the accuracy of FSD of pulmonary nodules and to evaluate the inflation method during cryosection. We retrospectively reviewed FSD of 229 consecutive pulmonary nodules and evaluated the diagnostic accuracy and efficacy of inflation method during cryosection. Since August 2006, all frozen sections (165, 72.1%) were made after inflation with optimally diluted embedding medium. The FSD were as follows: nonneoplastic lesions (29, 12.7%), benign neoplasms (28, 12.2%), and malignant neoplasms (172, 75.1%). The proportion of the lesions smaller than 2 cm was 60.3% (138 of 229). The frozen section quality of lung tissue was excellent after inflation with diluted embedding medium. Inflated lung specimens harboring minute lesion displayed distinct gross appearance, which could not be palpated. Histologically, open air spaces and normal parenchymal architectures were well preserved. Minute precancerous foci such as atypical adenomatous hyperplasia and bronchioloalveolar carcinoma could be readily identified. After using inflation method during cryosection, both the sensitivity and specificity reached 100%, and the incidence of intraoperative pathology consultation increased markedly, especially small impalpable lesions. The accuracy of FSD and histologic qualities were excellent by using inflation method, especially in cases of impalpable small precancerous lesions. The pathologist could guide with confidence the surgeon in planning the surgical management.

Intra-operative 3D guidance and edema detection in prostate brachytherapy using a non-isocentric C-arm

PubMed Central

Jain, A.; Deguet, A.; Iordachita, I.; Chintalapani, G.; Vikal, S.; Blevins, J.; Le, Y.; Armour, E.; Burdette, C.; Song, D.; Fichtinger, G.

2015-01-01

Purpose Brachytherapy (radioactive seed insertion) has emerged as one of the most effective treatment options for patients with prostate cancer, with the added benefit of a convenient outpatient procedure. The main limitation in contemporary brachytherapy is faulty seed placement, predominantly due to the presence of intra-operative edema (tissue expansion). Though currently not available, the capability to intra-operatively monitor the seed distribution, can make a significant improvement in cancer control. We present such a system here. Methods Intra-operative measurement of edema in prostate brachytherapy requires localization of inserted radioactive seeds relative to the prostate. Seeds were reconstructed using a typical non-isocentric C-arm, and exported to a commercial brachytherapy treatment planning system. Technical obstacles for 3D reconstruction on a non-isocentric C-arm include pose-dependent C-arm calibration; distortion correction; pose estimation of C-arm images; seed reconstruction; and C-arm to TRUS registration. Results In precision-machined hard phantoms with 40–100 seeds and soft tissue phantoms with 45–87 seeds, we correctly reconstructed the seed implant shape with an average 3D precision of 0.35 mm and 0.24 mm, respectively. In a DoD Phase-1 clinical trial on six patients with 48–82 planned seeds, we achieved intra-operative monitoring of seed distribution and dosimetry, correcting for dose inhomogeneities by inserting an average of over four additional seeds in the six enrolled patients (minimum 1; maximum 9). Additionally, in each patient, the system automatically detected intra-operative seed migration induced due to edema (mean 3.84 mm, STD 2.13 mm, Max 16.19 mm). Conclusions The proposed system is the first of a kind that makes intra-operative detection of edema (and subsequent re-optimization) possible on any typical non-isocentric C-arm, at negligible additional cost to the existing clinical installation. It achieves a significantly more homogeneous seed distribution, and has the potential to affect a paradigm shift in clinical practice. Large scale studies and commercialization are currently underway. PMID:21168357

SU-F-T-44: A Comparison of the Pre-Plan, Intra-Operative Plan, and Post-Implant Dosimetry for a Prostate Implant Case Using Prefabricated Linear Polymer-Encapsulated Pd-103

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sheu, R; Powers, A; McGee, H

Purpose: To investigate the reproducibility and limitations of Pd-103 prostate brachytherapy using fixed length linear sources (CivaString). Methods: An LDR prostate brachytherapy case which was preplanned on MR images with prefabricated linear polymer-encapsulated Pd-103 sources (CivaString) was studied and compared with ultrasound based intra-operative planning and CT based post-implant dosimetry. We evaluated the following parameters among the three studies: prostate geometry (volume and cross sectional area), needle position and alignment deviations, and dosimetry parameters (D90). Results: The prostate volumes and axial cross sectional areas at center of prostate were measured as 41.8, 39.3 and 36.8 cc, and 14.9, 14.3, andmore » 11.3 respectively on pre-plan MR, inter-op US, and post-implant CT studies. The deviation of prostate volumes and axial cross sectional areas measured on pre-planning MR and intra-operative US were within 5%. 17 out of 19 pre-planned needles were positioned within 5mm (the template grid size). One needle location was adjusted intra-operatively and another needle was removed due to proximity to urethra. The needle pathways were not always parallel to the trans-rectal probe due to the flexibility of CivaString. The angle of deviation was up to 10 degrees. Two pairs of needles were exchanged to better fit the length of prostate at the time of implant. This resulted in a prostate D90 of 153.8 Gy (124%) and 131.4 Gy (106.7%) for intra-op and PID respectively. Conclusion: Preplanning is a necessary part of implants performed with prefabricated linear polymer sources. However, as is often the case, there were real-time deviations from the pre-plan. Intra-op planning provides the ability conform to anatomy at the time of implant. Therefore, we propose to develop a systematic way to order extra strings of different length to provide the flexibility to perform intra-operative planning with fixed length strands.« less

Virtual skeletal complex model- and landmark-guided orthognathic surgery system.

PubMed

Lee, Sang-Jeong; Woo, Sang-Yoon; Huh, Kyung-Hoe; Lee, Sam-Sun; Heo, Min-Suk; Choi, Soon-Chul; Han, Jeong Joon; Yang, Hoon Joo; Hwang, Soon Jung; Yi, Won-Jin

2016-05-01

In this study, correction of the maxillofacial deformities was performed by repositioning bone segments to an appropriate location according to the preoperative planning in orthognathic surgery. The surgery was planned using the patient's virtual skeletal models fused with optically scanned three-dimensional dentition. The virtual maxillomandibular complex (MMC) model of the patient's final occlusal relationship was generated by fusion of the maxillary and mandibular models with scanned occlusion. The final position of the MMC was simulated preoperatively by planning and was used as a goal model for guidance. During surgery, the intraoperative registration was finished immediately using only software processing. For accurate repositioning, the intraoperative MMC model was visualized on the monitor with respect to the simulated MMC model, and the intraoperative positions of multiple landmarks were also visualized on the MMC surface model. The deviation errors between the intraoperative and the final positions of each landmark were visualized quantitatively. As a result, the surgeon could easily recognize the three-dimensional deviation of the intraoperative MMC state from the final goal model without manually applying a pointing tool, and could also quickly determine the amount and direction of further MMC movements needed to reach the goal position. The surgeon could also perform various osteotomies and remove bone interference conveniently, as the maxillary tracking tool could be separated from the MMC. The root mean square (RMS) difference between the preoperative planning and the intraoperative guidance was 1.16 ± 0.34 mm immediately after repositioning. After surgery, the RMS differences between the planning and the postoperative computed tomographic model were 1.31 ± 0.28 mm and 1.74 ± 0.73 mm for the maxillary and mandibular landmarks, respectively. Our method provides accurate and flexible guidance for bimaxillary orthognathic surgery based on intraoperative visualization and quantification of deviations for simulated postoperative MMC and landmarks. The guidance using simulated skeletal models and landmarks can complement and improve conventional navigational surgery for bone repositioning in the craniomaxillofacial area. Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Brain activity monitoring by compressed spectral array during deep hypothermic circulatory arrest in acute aortic dissection surgery.

PubMed

Urbanowicz, Tomasz K; Budniak, Wiktor; Buczkowski, Piotr; Perek, Bartłomiej; Walczak, Maciej; Tomczyk, Jadwiga; Katarzyński, Sławomir; Jemielity, Marek

2014-12-01

Monitoring the central nervous system during aortic dissection repair may improve the understanding of the intraoperative changes related to its bioactivity. The aim of the study was to evaluate the influence of deep hypothermia on intraoperative brain bioactivity measured by the compressed spectral array (CSA) method and to assess the influence of the operations on postoperative cognitive function. The study enrolled 40 patients (31 men and 9 women) at the mean age of 60.2 ± 8.6 years, diagnosed with acute aortic dissection. They underwent emergency operations in deep hypothermic circulatory arrest (DHCA). During the operations, brain bioactivity was monitored with the compressed spectral array method. There were no intraoperative deaths. Electrocerebral silence during DHCA was observed in 31 patients (74%). The lowest activity was observed during DHCA: it was 0.01 ± 0.05 nW in the left hemisphere and 0.01 ± 0.03 nW in the right hemisphere. The postoperative results of neurological tests deteriorated statistically significantly (26.9 ± 1.7 points vs. 22.0 ± 1.7 points; p < 0.001), especially among patients who exhibited brain activity during DHCA. The compressed spectral array method is clinically useful in monitoring brain bioactivity during emergency operations of acute aortic dissections. Electrocerebral silence occurs in 75% of patients during DHCA. The cognitive function of patients deteriorates significantly after operations with DHCA.

Language Mapping in Awake Surgery: Report of Two Cases with Review of Language Networks.

PubMed

Lim, Liang Hooi; Idris, Zamzuri; Reza, Faruque; Wan Hassan, Wan Mohd Nazaruddin; Mukmin, Laila Abd; Abdullah, Jafri Malin

2018-01-01

The role of language in communication plays a crucial role in human development and function. In patients who have a surgical lesion at the functional language areas, surgery should be intricately planned to avoid incurring further morbidity. This normally requires extensive functional and anatomical mappings of the brain to identify regions that are involved in language processing and production. In our case report, regions of the brain that are important for language functions were studied before surgery by employing (a) extraoperative methods such as functional magnetic resonance imaging, transmagnetic stimulation, and magnetoencephalography; (b) during the surgery by utilizing intraoperative awake surgical methods such as an intraoperative electrical stimulation; and (c) a two-stage surgery, in which electrical stimulation and first mapping are made thoroughly in the ward before second remapping during surgery. The extraoperative methods before surgery can guide the neurosurgeon to localize the functional language regions and tracts preoperatively. This will be confirmed using single-stage intraoperative electrical brain stimulation during surgery or a two-stage electrical brain stimulation before and during surgery. Here, we describe two cases in whom one has a superficial lesion and another a deep-seated lesion at language-related regions, in which language mapping was done to preserve its function. Additional review on the neuroanatomy of language regions, language network, and its impairment was also described.

Matching CT and ultrasound data of the liver by landmark constrained image registration

NASA Astrophysics Data System (ADS)

Olesch, Janine; Papenberg, Nils; Lange, Thomas; Conrad, Matthias; Fischer, Bernd

2009-02-01

In navigated liver surgery the key challenge is the registration of pre-operative planing and intra-operative navigation data. Due to the patients individual anatomy the planning is based on segmented, pre-operative CT scans whereas ultrasound captures the actual intra-operative situation. In this paper we derive a novel method based on variational image registration methods and additional given anatomic landmarks. For the first time we embed the landmark information as inequality hard constraints and thereby allowing for inaccurately placed landmarks. The yielding optimization problem allows to ensure the accuracy of the landmark fit by simultaneous intensity based image registration. Following the discretize-then-optimize approach the overall problem is solved by a generalized Gauss-Newton-method. The upcoming linear system is attacked by the MinRes solver. We demonstrate the applicability of the new approach for clinical data which lead to convincing results.

Effective 2D-3D medical image registration using Support Vector Machine.

PubMed

Qi, Wenyuan; Gu, Lixu; Zhao, Qiang

2008-01-01

Registration of pre-operative 3D volume dataset and intra-operative 2D images gradually becomes an important technique to assist radiologists in diagnosing complicated diseases easily and quickly. In this paper, we proposed a novel 2D/3D registration framework based on Support Vector Machine (SVM) to compensate the disadvantages of generating large number of DRR images in the stage of intra-operation. Estimated similarity metric distribution could be built up from the relationship between parameters of transform and prior sparse target metric values by means of SVR method. Based on which, global optimal parameters of transform are finally searched out by an optimizer in order to guide 3D volume dataset to match intra-operative 2D image. Experiments reveal that our proposed registration method improved performance compared to conventional registration method and also provided a precise registration result efficiently.

Simultaneous multi-scale microscopy as a potential dedicated tool for intra-operative parathyroid identification during thyroid surgery (Conference Presentation)

NASA Astrophysics Data System (ADS)

De Montigny, Étienne; Goulamhoussen, Nadir; Madore, Wendy-Julie; Strupler, Mathias; Maniakas, Anastasios; Ayad, Tareck; Boudoux, Caroline

2016-02-01

While thyroidectomy is considered a safe surgery, dedicated tools facilitating tissue identification during surgery could improve its outcome. The most common complication following surgery is hypocalcaemia, which results from iatrogenic removal or damage to parathyroid glands. This research project aims at developing and validating an instrument based on optical microscopy modalities to identify tissues in real time during surgery. Our approach is based on a combination of reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) to obtain multi-scale morphological contrast images. The orthogonal field of views provide information to navigate through the sample. To allow simultaneous, synchronized video-rate imaging in both modalities, we designed and built a dual-band wavelength-swept laser which scans a 30 nm band centered at 780 nm and a 90 nm band centered at 1310 nm. We built an imaging setup integrating a custom-made objective lens and a double-clad fibre coupler optimized for confocal microscopy. It features high resolutions in RCM (2µm lateral and 20 µm axial) in a 500 µm x 500 µm field-of-view and a larger field-of-view of 2 mm (lateral) x 5 mm (axial) with 20 µm lateral and axial resolutions in OCT. Imaging of ex vivo animal samples is demonstrated on a bench-top system. Tissues that are visually difficult to distinguish from each other intra-operatively such as parathyroid gland, lymph nodes and adipose tissue are imaged to show the potential of this approach in differentiating neck tissues. We will also provide an update on our ongoing clinical pilot study on patients undergoing thyroidectomy.

[Surgical anatomy of the peri-insular association tracts. Part I.The superior longitudinal fascicle system].

PubMed

Bykanov, A E; Pitskhelauri, D I; Batalov, A I; Pronin, I N; Shkarubo, M A; Dobrovol'sky, G F; Kobyakov, G L; Buklina, S B; Puchkov, V L; Zakharova, N E; Smirnov, A S; Sanikidze, A Z; Gol'bin, D A; Pogosbekyan, E L; Kudieva, E S; Shkatova, A M; Potapov, A A

To study the peri-insular association tract anatomy and define the permissible anatomical boundaries for resection of glial insular tumors with allowance for the surgical anatomy of the peri-insular association tracts. In an anatomic study of the superior longitudinal fascicle system (SLF I, SLF II, SLF III, arcuate fascicle), we used 12 anatomical specimens (6 left and 6 right hemispheres) prepared according to the Klingler's fiber dissection technique. To confirm the dissection data, we used MR tractography (HARDI-CSD-tractography) of the conduction tracts, which was performed in two healthy volunteers. Except the SLF I (identified in 7 hemispheres by fiber dissection), all fascicles of the SLF system were found in all investigated hemispheres by both fiber dissection and MR tractography. The transcortical approach to the insula through the frontal and (or) parietal operculum is associated with a significant risk of transverse transection of the SLF III fibers passing in the frontal and parietal opercula. The most optimal area for the transcortical approach to the insula is the anterior third of the superior temporal gyrus that lacks important association tracts and, consequently, a risk of their injury. The superior peri-insular sulcus is an intraoperative landmark for the transsylvian approach, which enables identification of the SLF II and arcuate fascicle in the surgical wound. Detailed knowledge of the peri-insular association tract anatomy is the prerequisite for neurosurgery in the insular region. Our findings facilitate correct identification of both the site for cerebral operculum dissection upon the transcortical approach and the intraoperative landmarks for locating the association tracts in the surgical wound upon the transsylvian approach to the insula.

Computed tomography-based virtual colonoscopy in the assessment of bowel endometriosis: The surgeon's point of view.

PubMed

Roman, H; Carilho, J; Da Costa, C; De Vecchi, C; Suaud, O; Monroc, M; Hochain, P; Vassilieff, M; Savoye-Collet, C; Saint-Ghislain, M

2016-01-01

To discuss the role of computed tomography-based virtual colonoscopy (CTC) in preoperative assessment of bowel endometriosis. Retrospective study using data prospectively recorded, including 127 patients with colorectal endometriosis, having undergone CTC for bowel endometriosis. The study was conducted in a tertiary referral center during 38 consecutive months. Preoperative assessment included CTC, magnetic resonance imaging (MRI), endorectal ultrasound (ERUS) and clinical examination. Information concerning identification of deep infiltrating endometriosis (DIE) of the bowel, the length and height of colorectal involvement, stenosis of digestive lumen and associated digestive localizations were compared with intraoperative findings. Sensitivity and specificity of CTC for DIE of the rectum, the sigmoid colon, associated digestive localizations, and stenosis of the digestive lumen were respectively 97% and 84%, 93% and 88%, 84% and 97%, 96% and 96%. Intraoperative estimation of the length of digestive tract involved by DIE was closer to that provided by CTC than those provided by MRI and ERUS. When CTC revealed stenosis of digestive lumen, higher rates of colorectal resection (63% vs. 9.6%, < 0.001) and disc excision (25.9% vs. 11%, 0.03) were recorded. For those surgeons using various procedures for management of bowel endometriosis, accurate information on the length and height of bowel involvement, as well as the existence of bowel stenosis enables informed decision regarding the feasibility of conservative techniques versus bowel resection. Preoperative identification of associated localizations above the sigmoid colon is another major advantage related to CTC. CTC provides accurate data on the length and height of colorectal involvement by DIE, stenosis of digestive lumen and associated lesions of digestive tract, which impact on the choice of surgical procedure. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

The role of intraoperative radiotherapy in solid tumors.

PubMed

Skandarajah, A R; Lynch, A C; Mackay, J R; Ngan, S; Heriot, A G

2009-03-01

Combined multimodality therapy is becoming standard treatment for many solid tumors, but the role of intraoperative radiotherapy in the management of solid tumors remains uncertain. The aim is to review the indication, application, and outcomes of intraoperative radiotherapy in the management of nongynecological solid tumors. A literature search was performed using Medline, Embase, Ovid, and Cochrane database for studies between 1965 and 2008 assessing intraoperative radiotherapy, using the keywords "intraoperative radiotherapy," "colorectal cancer," "breast cancer," "gastric cancer," "pancreatic cancer," "soft tissue tumor," and "surgery." Only publications in English with available abstracts and regarding adult humans were included, and the evidence was critically evaluated. Our search retrieved 864 publications. After exclusion of nonclinical papers, duplicated papers and exclusion of brachytherapy papers, 77 papers were suitable to assess the current role of intraoperative radiotherapy. The clinical application and evidence base of intraoperative radiotherapy for each cancer is presented. Current studies in all common cancers show an additional benefit in local recurrence rates when intraoperative radiotherapy is included in the multimodal treatment. However, intraoperative radiotherapy may not improve overall survival and has significant morbidity depending on the site of the tumor. Intraoperative radiotherapy does have a role in the multidisciplinary management of solid tumors, but further studies are required to more precisely determine the extent of benefit.

Intraoperative neuropathology of glioma recurrence: cell detection and classification

NASA Astrophysics Data System (ADS)

Abas, Fazly S.; Gokozan, Hamza N.; Goksel, Behiye; Otero, Jose J.; Gurcan, Metin N.

2016-03-01

Intraoperative neuropathology of glioma recurrence represents significant visual challenges to pathologists as they carry significant clinical implications. For example, rendering a diagnosis of recurrent glioma can help the surgeon decide to perform more aggressive resection if surgically appropriate. In addition, the success of recent clinical trials for intraoperative administration of therapies, such as inoculation with oncolytic viruses, may suggest that refinement of the intraoperative diagnosis during neurosurgery is an emerging need for pathologists. Typically, these diagnoses require rapid/STAT processing lasting only 20-30 minutes after receipt from neurosurgery. In this relatively short time frame, only dyes, such as hematoxylin and eosin (H and E), can be implemented. The visual challenge lies in the fact that these patients have undergone chemotherapy and radiation, both of which induce cytological atypia in astrocytes, and pathologists are unable to implement helpful biomarkers in their diagnoses. Therefore, there is a need to help pathologists differentiate between astrocytes that are cytologically atypical due to treatment versus infiltrating, recurrent, neoplastic astrocytes. This study focuses on classification of neoplastic versus non-neoplastic astrocytes with the long term goal of providing a better neuropathological computer-aided consultation via classification of cells into reactive gliosis versus recurrent glioma. We present a method to detect cells in H and E stained digitized slides of intraoperative cytologic preparations. The method uses a combination of the `value' component of the HSV color space and `b*' component of the CIE L*a*b* color space to create an enhanced image that suppresses the background while revealing cells on an image. A composite image is formed based on the morphological closing of the hue-luminance combined image. Geometrical and textural features extracted from Discrete Wavelet Frames and combined to classify cells into neoplastic and non-neoplastic categories. Experimental results show that there is a strong consensus between the proposed method's cell detection markings with those of the pathologist's. Experiments on 48 images from six patients resulted in F1-score as high as 87.48%, 88.08% and 86.12% for Reader 1, Reader 2 and the reader consensus, respectively. Classification results showed that for both readers, binary classification tree and support vector machine performed the best with F1-scores ranging 0.92 to 0.94.

Improved surgical procedure using intraoperative navigation for the implantation of the SPG microstimulator in patients with chronic cluster headache.

PubMed

Kohlmeier, Carsten; Behrens, Peter; Böger, Andreas; Ramachandran, Brinda; Caparso, Anthony; Schulze, Dirk; Stude, Philipp; Heiland, Max; Assaf, Alexandre T

2017-12-01

The ATI SPG microstimulator is designed to be fixed on the posterior maxilla, with the integrated lead extending into the pterygopalatine fossa to electrically stimulate the sphenopalatine ganglion (SPG) as a treatment for cluster headache. Preoperative surgical planning to ensure the placement of the microstimulator in close proximity (within 5 mm) to the SPG is critical for treatment efficacy. The aim of this study was to improve the surgical procedure by navigating the initial dissection prior to implantation using a passive optical navigation system and to match the post-operative CBCT images with the preoperative treatment plan to verify the accuracy of the intraoperative placement of the microstimulator. Custom methods and software were used that result in a 3D rotatable digitally reconstructed fluoroscopic image illustrating the patient-specific placement with the ATI SPG microstimulator. Those software tools were preoperatively integrated with the planning software of the navigation system to be used intraoperatively for navigated placement. Intraoperatively, the SPG microstimulator was implanted by completing the initial dissection with CT navigation, while the final position of the stimulator was verified by 3D CBCT. Those reconstructed images were then immediately matched with the preoperative CT scans with the digitally inserted SPG microstimulator. This method allowed for visual comparison of both CT scans and verified correct positioning of the SPG microstimulator. Twenty-four surgeries were performed using this new method of CT navigated assistance during SPG microstimulator implantation. Those results were compared to results of 21 patients previously implanted without the assistance of CT navigation. Using CT navigation during the initial dissection, an average distance reduction of 1.2 mm between the target point and electrode tip of the SPG microstimulator was achieved. Using the navigation software for navigated implantation and matching the preoperative planned scans with those performed post-operatively, the average distance was 2.17 mm with navigation, compared to 3.37 mm in the 28 surgeries without navigation. Results from this new procedure showed a significant reduction (p = 0.009) in the average distance from the SPG microstimulator to the desired target point. Therefore, a distinct improvement could be achieved in positioning of the SPG microstimulator through the use of intraoperative navigation during the initial dissection and by post-operative matching of pre- and post-operatively performed CBCT scans.

A virtual surgical environment for rehearsal of tympanomastoidectomy.

PubMed

Chan, Sonny; Li, Peter; Lee, Dong Hoon; Salisbury, J Kenneth; Blevins, Nikolas H

2011-01-01

This article presents a virtual surgical environment whose purpose is to assist the surgeon in preparation for individual cases. The system constructs interactive anatomical models from patient-specific, multi-modal preoperative image data, and incorporates new methods for visually and haptically rendering the volumetric data. Evaluation of the system's ability to replicate temporal bone dissections for tympanomastoidectomy, using intraoperative video of the same patients as guides, showed strong correlations between virtual and intraoperative anatomy. The result is a portable and cost-effective tool that may prove highly beneficial for the purposes of surgical planning and rehearsal.

[Perioperative nursing of internal sinus floor elevation surgery with piezosurgery].

PubMed

He, Jing; Lei, Yiling; Wang, Liqiong

2013-12-01

This study aims to summarize the nursing experience in the internal sinus floor elevation surgery with piezosurgery. The medical records of 48 patients who underwent sinus floor elevation surgery with piezosurgery in the Department of Implantation, West China Hospital of Stomatology, Sichuan University, were reviewed. The preoperative, intraoperative, and postoperative nursing methods were summarized. All 48 patients underwent smooth surgeries and did not encounter complications. Careful preoperative preparation, careful and meticulous intraoperative nursing cooperation, and provision of sufficient health education after surgery to the patients are the key factors that ensure the success of internal sinus floor elevation surgery with piezosurgery.

Methods for intraoperative, sterile pose-setting of patient-specific microstereotactic frames

NASA Astrophysics Data System (ADS)

Vollmann, Benjamin; Müller, Samuel; Kundrat, Dennis; Ortmaier, Tobias; Kahrs, Lüder A.

2015-03-01

This work proposes new methods for a microstereotactic frame based on bone cement fixation. Microstereotactic frames are under investigation for minimal invasive temporal bone surgery, e.g. cochlear implantation, or for deep brain stimulation, where products are already on the market. The correct pose of the microstereotactic frame is either adjusted outside or inside the operating room and the frame is used for e.g. drill or electrode guidance. We present a patientspecific, disposable frame that allows intraoperative, sterile pose-setting. Key idea of our approach is bone cement between two plates that cures while the plates are positioned with a mechatronics system in the desired pose. This paper includes new designs of microstereotactic frames, a system for alignment and first measurements to analyze accuracy and applicable load.

Management of the facial nerve in lateral skull base surgery analytic retrospective study.

PubMed

El Shazly, Mohamed A; Mokbel, Mahmoud A M; Elbadry, Amr A; Badran, Hatem S

2011-01-01

Surgical approaches to the jugular foramen are often complex and lengthy procedures associated with significant morbidity based on the anatomic and tumor characteristics. In addition to the risk of intra-operative hemorrhage from vascular tumors, lower cranial nerves deficits are frequently increased after intra-operative manipulation. Accordingly, modifications in the surgical techniques have been developed to minimize these risks. Preoperative embolization and intra-operative ligation of the external carotid artery have decreased the intraoperative blood loss. Accurate identification and exposure of the cranial nerves extracranially allows for their preservation during tumor resection. The modification of facial nerve mobilization provides widened infratemporal exposure with less postoperative facial weakness. The ideal approach should enable complete, one stage tumor resection with excellent infratemporal and posterior fossa exposure and would not aggravate or cause neurologic deficit. The aim of this study is to present our experience in handling jugular foramen lesions (mainly glomus jugulare) without the need for anterior facial nerve transposition. In this series we present our experience in Kasr ElEini University hospital (Cairo-Egypt) in handling 36 patients with jugular foramen lesions over a period of 20 years where the previously mentioned preoperative and operative rules were followed. The clinical status, operative technique and postoperative care and outcome are detailed and analyzed in relation to the outcome. Complete cure without complications was achieved in four cases of congenital cholesteatoma and four cases with class B glomus. In advanced cases of glomus jugulare (28 patients) (C and D stages) complete cure was achieved in 21 of them (75%). The operative complications were also related to this group of 28 patients, in the form of facial paralysis in 20 of them (55.6%) and symptomatic vagal paralysis in 18 of them (50%). Total anterior rerouting of the facial nerve carries a high risk of facial paralysis. So it should be reserved for cases where the lesion extends beyond the vertical ICA. Otherwise, for less extensive lesions and less aggressive pathologies, less aggressive approaches could be adopted with less hazards.

The pros and cons of intraoperative CT scan in evaluation of deep brain stimulation lead implantation: A retrospective study

PubMed Central

Servello, Domenico; Zekaj, Edvin; Saleh, Christian; Pacchetti, Claudio; Porta, Mauro

2016-01-01

Background: Deep brain stimulation (DBS) is an established therapy for movement disorders, such as Parkinson's disease (PD), dystonia, and tremor. The efficacy of DBS depends on the correct lead positioning. The commonly adopted postoperative radiological evaluation is performed with computed tomography (CT) scan and/or magnetic resonance imaging (MRI). Methods: We conducted a retrospective study on 202 patients who underwent DBS from January 2009 to October 2013. DBS indications were PD, progressive supranuclear palsy, tremor, dystonia, Tourette syndrome, obsessive compulsive disorder, depression, and Huntington's disease. Preoperatively, all patients underwent brain MRI and brain CT scan with the stereotactic frame positioned. The lead location was confirmed intraoperatively with CT. The CT images were subsequently transferred to the Stealth Station Medtronic and merged with the preoperative planning. On the first or second day after, implantation we performed a brain MRI to confirm the correct position of the lead. Results: In 14 patients, leads were in suboptimal position after intraoperative CT scan positioning. The cases with alteration in the Z-axis were corrected immediately under fluoroscopic guidance. In all the 14 patients, an immediate repositioning was done. Conclusions: Based on our data, intraoperative CT scan is fast, safe, and a useful tool in the evaluation of the position of the implanted lead. It also reduces the patient's discomfort derived from the transfer of the patient from the operating room to the radiological department. However, intraoperative CT should not be considered as a substitute for postoperative MRI. PMID:27583182

Rotational X-ray angiography: a method for intra-operative volume imaging of the left-atrium and pulmonary veins for atrial fibrillation ablation guidance

NASA Astrophysics Data System (ADS)

Manzke, R.; Zagorchev, L.; d'Avila, A.; Thiagalingam, A.; Reddy, V. Y.; Chan, R. C.

2007-03-01

Catheter-based ablation in the left atrium and pulmonary veins (LAPV) for treatment of atrial fibrillation in cardiac electrophysiology (EP) are complex and require knowledge of heart chamber anatomy. Electroanatomical mapping (EAM) is typically used to define cardiac structures by combining electromagnetic spatial catheter localization with surface models which interpolate the anatomy between EAM point locations in 3D. Recently, the incorporation of pre-operative volumetric CT or MR data sets has allowed for more detailed maps of LAPV anatomy to be used intra-operatively. Preoperative data sets are however a rough guide since they can be acquired several days to weeks prior to EP intervention. Due to positional and physiological changes, the intra-operative cardiac anatomy can be different from that depicted in the pre-operative data. We present an application of contrast-enhanced rotational X-ray imaging for CT-like reconstruction of 3D LAPV anatomy during the intervention itself. Depending on the heart size a single or two selective contrastenhanced rotational acquisitions are performed and CT-like volumes are reconstructed with 3D filtered back projection. In case of dual injection, the two volumes depicting the left and right portions of the LAPV are registered and fused. The data sets are visualized and segmented intra-procedurally to provide anatomical data and surface models for intervention guidance. Our results from animal and human experiments indicate that the anatomical information from intra-operative CT-like reconstructions compares favorably with preacquired imaging data and can be of sufficient quality for intra-operative guidance.

Intraoperative muscle electrical stimulation for accurate positioning of the temporalis muscle tendon during dynamic, one-stage lengthening temporalis myoplasty for facial and lip reanimation.

PubMed

Har-Shai, Yaron; Gil, Tamir; Metanes, Issa; Labbé, Daniel

2010-07-01

Facial paralysis is a significant functional and aesthetic handicap. Facial reanimation is performed either by two-stage microsurgical methods or by regional one-stage muscle pedicle flaps. Labbé has modified and improved the regional muscle pedicle transfer flaps for facial reanimation (i.e., the lengthening temporalis myoplasty procedure). This true myoplasty technique is capable of producing a coordinated, spontaneous, and symmetrical smile. An intraoperative electrical stimulation of the temporal muscle is proposed to simulate the smile of the paralyzed side on the surgical table. The intraoperative electrical stimulation of the temporalis muscle, employing direct percutaneous electrode needles or transcutaneous electrical stimulation electrodes, was utilized in 11 primary and four secondary cases with complete facial palsy. The duration of the facial paralysis was up to 12 years. Postoperative follow-up ranged from 3 to 12 months. The insertion points of the temporalis muscle tendon to the nasolabial fold, upper lip, and oral commissure had been changed according to the intraoperative muscle stimulation in six patients of the 11 primary cases (55 percent) and in all four secondary (revisional) cases. A coordinated, spontaneous, and symmetrical smile was achieved in all patients by 3 months after surgery by employing speech therapy and biofeedback. This adjunct intraoperative refinement provides crucial feedback for the surgeon in both primary and secondary facial palsy cases regarding the vector of action of the temporalis muscle and the accuracy of the anchoring points of its tendon, thus enhancing a more coordinated and symmetrical smile.

Intraoperative loss of core biopsy clips: clinical implications.

PubMed

Calhoun, Kristine; Giuliano, Armando; Brenner, R James

2008-03-01

The purpose of this study was to report the occurrence of intraoperative loss of metallic marking clips placed during image-guided biopsy and to hypothesize the likely mechanism of this clinical problem. From January 2003 through December 2004, patients presenting for preoperative mammographic localization and operative excision of biopsy site marking clips were identified. Age, method of image-guided biopsy, number of excised specimens, and tissue diagnosis were determined. Specimen radiographs were used to identify cases of suspected intraoperative clip loss. Clips absent on specimen radiographs and postoperative mammograms were defined as lost intraoperatively. Biopsy site marking clips, surgical clips, and suction device apertures were measured. In 78 surgical procedures performed during the study period, three (3.8%) of the patients experienced clip loss. Specimen radiographs confirmed the absence of clips in all submitted tissues. A median of four (range, three to five) separate biopsy specimens were excised among these three cases. A healing biopsy site from the stereotactic biopsy preceding the clip placement procedure was confirmed in all cases. Absence of the metallic clip was confirmed on postoperative mammograms. The apertures of two types of suction device were four and two times those of the biopsy clips. Intraoperative loss of metallic clips placed at the conclusion of image-guided breast biopsy is unusual but can occur during subsequent surgical excision. Repeated inability to locate the clip on specimen radiographs after accurate preoperative localization should raise the suspicion that the target clip has been lost, not missed, during surgery, likely because of inadvertent removal of the clip with the suction device.

Role of imprint cytology in intra operative diagnosis of thyroid lesions.

PubMed

Anila, K R; Krishna, G

2014-07-01

Intra-operative imprint cytology is an important diagnostic modality in the diagnosis of thyroid lesions. A correct intra-operative diagnosis helps eliminate the need for second surgery. To study diagnostic accuracy of imprint cytology and to compare the imprint cytology results with that of the corresponding paraffin section diagnosis in thyroidectomy cases. This is a prospective study of 84 patients who have undergone thyroidectomies over a period of one year at the Department of Surgery, Thiruvananthapuram, Kerala, India. The intraoperative imprint cytology smears were stained by Papanicolaou method. The imprint cytology interpretation was later compared with the paraffin section diagnosis. Of the 84 patients using haematoxylin and eosin stained histopathology sections as the gold standard, the diagnostic sensitivity of imprint cytology was 75% and specificity was 100%. Positive predictive value was 100%. Negative predictive value was 98.74%. Imprint cytology has high sensitivity and specificity in diagnosing lesions of the thyroid. The problems faced were in diagnosing follicular carcinomas and differentiating low grade lymphoma from lymphocytic thyroiditis. Imprint cytology is a simple, reliable diagnostic technique. It has high sensitivity and specificity in intra-operative diagnosis of lesions of thyroid. In spite of the advent of newer diagnostic modalities like frozen sections, imprint cytology still holds its unique position in the current perspective.

Accuracy of intraoperative frozen section in the diagnosis of ovarian neoplasms: Experience at a tertiary oncology center

PubMed Central

Maheshwari, Amita; Gupta, Sudeep; Kane, Shubhada; Kulkarni, Yogesh; Goyal, Lt Col Bhupesh Kumar; Tongaonkar, Hemant B

2006-01-01

Background Epithelial ovarian neoplasms are an important cause of morbidity and mortality in women. The surgical management of ovarian neoplasms depends on their correct categorization as benign, borderline or malignant. This study was undertaken to evaluate the accuracy of intra-operative frozen section in the diagnosis of various categories of ovarian neoplasms. Methods Intraoperative frozen section diagnosis was retrospectively evaluated in 217 patients with suspected ovarian neoplasms who underwent surgery as primary line of therapy at our institution. This was compared with the final histopathologic diagnosis on paraffin sections. Results In 7 patients (3.2%) no opinion on frozen section was possible. In the remaining 210 patients frozen section report had a sensitivity of 100%, 93.5% and 45.5% for benign, malignant and borderline tumors. The corresponding specificities were 93.2%, 98.3% and 98.5% respectively. The overall accuracy of frozen section diagnosis was 91.2%. The majority of cases of disagreement were in the mucinous and borderline tumors. Conclusion Intraoperative frozen section has high accuracy in the diagnosis of suspected ovarian neoplasms. It is a valuable tool to guide the surgical management of these patients and should be routinely used in all major oncology centers. PMID:16504109

Application of Rapid Prototyping Technique and Intraoperative Navigation System for the Repair and Reconstruction of Orbital Wall Fractures

PubMed Central

Cha, Jong Hyun; Lee, Yong Hae; Ruy, Wan Chul; Roe, Young; Moon, Myung Ho

2016-01-01

Background Restoring the orbital cavity in large blow out fractures is a challenge for surgeons due to the anatomical complexity. This study evaluated the clinical outcomes and orbital volume after orbital wall fracture repair using a rapid prototyping (RP) technique and intraoperative navigation system. Methods This prospective study was conducted on the medical records and radiology records of 12 patients who had undergone a unilateral blow out fracture reconstruction using a RP technique and an intraoperative navigation system from November 2014 to March 2015. The surgical results were assessed by an ophthalmic examination and a comparison of the preoperative and postoperative orbital volume ratio (OVR) values. Results All patients had a successful treatment outcome without complications. Volumetric analysis revealed a significant decrease in the mean OVR from 1.0952±0.0662 (ranging from 0.9917 to 1.2509) preoperatively to 0.9942±0.0427 (ranging from 0.9394 to 1.0680) postoperatively. Conclusion The application of a RP technique for the repair of orbital wall fractures is a useful tool that may help improve the clinical outcomes by understanding the individual anatomy, determining the operability, and restoring the orbital cavity volume through optimal implant positioning along with an intraoperative navigation system. PMID:28913272

Selective pelvic autonomic nerve stimulation with simultaneous intraoperative monitoring of internal anal sphincter and bladder innervation.

PubMed

Kneist, W; Kauff, D W; Koch, K P; Schmidtmann, I; Heimann, A; Hoffmann, K P; Lang, H

2011-01-01

Pelvic autonomic nerve preservation avoids postoperative functional disturbances. The aim of this feasibility study was to develop a neuromonitoring system with simultaneous intraoperative verification of internal anal sphincter (IAS) activity and intravesical pressure. 14 pigs underwent low anterior rectal resection. During intermittent bipolar electric stimulation of the inferior hypogastric plexus (IHP) and the pelvic splanchnic nerves (PSN), electromyographic signals of the IAS and manometry of the urinary bladder were observed simultaneously. Stimulation of IHP and PSN as well as simultaneous intraoperative monitoring could be realized with an adapted neuromonitoring device. Neurostimulation resulted in either bladder or IAS activation or concerted activation of both. Intravesical pressure increase as well as amplitude increase of the IAS neuromonitoring signal did not differ significantly between stimulation of IHP and PSN [6.0 cm H(2)O (interquartile range [IQR] 3.5-9.0) vs. 6.0 cm H(2)O (IQR 3.0-10.0) and 12.1 μV (IQR 3.0-36.7) vs. 40.1 μV (IQR 9.0-64.3)] (p > 0.05). Pelvic autonomic nerve stimulation with simultaneous intraoperative monitoring of IAS and bladder innervation is feasible. The method may enable neuromonitoring with increasing selectivity for pelvic autonomic nerve preservation. Copyright © 2011 S. Karger AG, Basel.

Quantitative Evaluation of Adult Subglottic Stenosis Using Intraoperative Long-range Optical Coherence Tomography

PubMed Central

Sharma, Giriraj K.; Loy, Anthony Chin; Su, Erica; Jing, Joe; Chen, Zhongping; Wong, Brian J-F.; Verma, Sunil

2016-01-01

Objectives To determine the feasibility of long-range optical coherence tomography (LR-OCT) as a tool to intraoperatively image and measure the subglottis and trachea during suspension microlaryngoscopy before and after endoscopic treatment of subglottic stenosis (SGS). Methods Long-range optical coherence tomography of the adult subglottis and trachea was performed during suspension microlaryngoscopy before and after endoscopic treatment for SGS. The anteroposterior and transverse diameters, cross-sectional area (CSA), distance from the vocal cords, and length of the SGS were measured using a MATLAB software. Pre-intervention and postintervention airway dimensions were compared. Three-dimensional volumetric airway reconstructions were generated using medical image processing software (MIMICS). Results Intraoperative LR-OCT imaging was performed in 3 patients undergoing endoscopic management of SGS. Statistically significant differences in mean anteroposterior diameter (P < .01), transverse diameter (P < .001), and CSA (P < .001) were noted between pre-intervention and postintervention data. Three-dimensional airway models were viewed in cross-sectional format and via virtual “fly through” bronchoscopy. Conclusions This is the first report of intraoperative LR-OCT of the subglottic and tracheal airway before and after surgical management of SGS in humans. Long-range optical coherence tomography offers a practical means to measure the dimensions of SGS and acquire objective data on the response to endoscopic treatment of SGS. PMID:27354215

Rapid immunohistochemistry based on alternating current electric field for intraoperative diagnosis of brain tumors.

PubMed

Tanino, Mishie; Sasajima, Toshio; Nanjo, Hiroshi; Akesaka, Shiori; Kagaya, Masami; Kimura, Taichi; Ishida, Yusuke; Oda, Masaya; Takahashi, Masataka; Sugawara, Taku; Yoshioka, Toshiaki; Nishihara, Hiroshi; Akagami, Yoichi; Goto, Akiteru; Minamiya, Yoshihiro; Tanaka, Shinya

2015-01-01

Rapid immunohistochemistry (R-IHC) can contribute to the intraoperative diagnosis of central nervous system (CNS) tumors. We have recently developed a new IHC method based on an alternating current electric field to facilitate the antigen-antibody reaction. To ensure the requirement of R-IHC for intraoperative diagnosis, 183 cases of CNS tumors were reviewed regarding the accuracy rate of diagnosis without R-IHC. The diagnostic accuracy was 90.7 % (166/183 cases) [corrected] in which definitive diagnoses were not provided in 17 cases because of the failure of glioma grading and differential diagnosis of lymphoma and glioma. To establish the clinicopathological application, R-IHC for frozen specimens was compared with standard IHC for permanent specimens. 33 gliomas were analyzed, and the Ki-67/MIB-1 indices of frozen specimens by R-IHC were consistent with the grade and statistically correlated with those of permanent specimens. Thus, R-IHC provided supportive information to determine the grade of glioma. For discrimination between glioma and lymphoma, R-IHC was able to provide clear results of CD20 and Ki-67/MIB-1 in four frozen specimens of CNS lymphoma as well as standard IHC. We conclude that the R-IHC for frozen specimens can provide important information for intraoperative diagnosis of CNS tumors.

Fast radioactive seed localization in intraoperative cone beam CT for low-dose-rate prostate brachytherapy

NASA Astrophysics Data System (ADS)

Hu, Yu-chi; Xiong, Jian-ping; Cohan, Gilad; Zaider, Marco; Mageras, Gig; Zelefsky, Michael

2013-03-01

A fast knowledge-based radioactive seed localization method for brachytherapy was developed to automatically localize radioactive seeds in an intraoperative volumetric cone beam CT (CBCT) so that corrections, if needed, can be made during prostate implant surgery. A transrectal ultrasound (TRUS) scan is acquired for intraoperative treatment planning. Planned seed positions are transferred to intraoperative CBCT following TRUS-to-CBCT registration using a reference CBCT scan of the TRUS probe as a template, in which the probe and its external fiducial markers are pre-segmented and their positions in TRUS are known. The transferred planned seeds and probe serve as an atlas to reduce the search space in CBCT. Candidate seed voxels are identified based on image intensity. Regions are grown from candidate voxels and overlay regions are merged. Region volume and intensity variance is checked against known seed volume and intensity profile. Regions meeting the above criteria are flagged as detected seeds; otherwise they are flagged as likely seeds and sorted by a score that is based on volume, intensity profile and distance to the closest planned seed. A graphical interface allows users to review and accept or reject likely seeds. Likely seeds with approximately twice the seed volume are automatically split. Five clinical cases are tested. Without any manual correction in seed detection, the method performed the localization in 5 seconds (excluding registration time) for a CBCT scan with 512×512×192 voxels. The average precision rate per case is 99% and the recall rate is 96% for a total of 416 seeds. All false negative seeds are found with 15 in likely seeds and 1 included in a detected seed. With the new method, updating of calculations of dose distribution during the procedure is possible and thus facilitating evaluation and improvement of treatment quality.

[Technique and advantages of multimodal intraoperative neuromonitoring for complex spinal interventions in older patients].

PubMed

Campos-Friz, M; Hubbe, U

2018-04-01

Complex spinal surgery in elderly patients mostly treats degenerative spine alterations. The use of multimodal intraoperative neuromonitoring (IONM) has proven to be a useful tool to recognize neural deterioration during such operations. Elderly patients often have preexisting neural impairment, which leads to difficulties in deriving some potentials or can even lead to not obtaining any potentials at all. For reliable benefits from IONM a combined use of monitoring and mapping methods as well as the right choice of methods according to the spine level to be treated and a definition of the neural structures in danger is needed. This article intends to explain IONM methods in procedures treating degenerative spine alterations in a comprehensive way and to show our point of view on pedicle stimulation. Readers should be motivated to deepen their knowledge in these methods and to gain confidence and experience to increase the safety of these operations for the benefit of our patients.

[Role of the intraoperative electrical brain stimulation in conserving the speech and language function in neurosurgical procedures on conscious patients].

PubMed

Eross, Loránd; Fekete, Gábor; Entz, László; Fabó, Dániel; Borbély, Csaba; Kozák, Lajos Rudolf; Andrejkovics, Mónika; Czirják, Sándor; Fedorcsák, Imre; Novák, László; Bognár, László

2012-09-30

To summarize the results gained with awake craniotomies, which were performed in either low grade glioma patients or epilepsy surgical patients whose tumor or epileptogenic zone, was in the vicinity of eloquent, mostly language, cortices. PATIENT SELECTION AND METHODS: In our retrospective study we selected 16 patients who were operated awake between 1999-2011 at the Neurosurgical Department of MAV Kórház Budapest, or at the National Institute of Neurosciences in Budapest, or at the Neurosurgical Department of the University of Debrecen in Debrecen. In the presurgical evaluation if it was possible we performed functional magnetic resonance imaging, tractography and detailed neuropsychological testing. At the National Institute of Neurosciences all patients were operated with the aid of MR guided neuronavigation. Anesthesia was carried out without complications in all of the 16 cases. Monitoring of sleep deepness has significantly contributed to the safety of anesthesia during the superficial anesthezied states of the operation. The intraoperative neuropsychological tasks used for testing language were sensitive enough to judge the little disturbances in speech during stimulation. Stimulation evoked seizures could be adequately managed during surgery and did not influence the outcome of the procedures. The use of neuronavigation helped significantly by planning the optimal place for the craniotomy and by intraoperative orientation. Awake craniotomies require well practiced surgical teams, which requires the cooperation of neuro-anesthesiologits, neurosurgeons, neuropsychologist and electrophysiologists. It has two goals, first to reduce the time of surgery to minimize surgical complications, secondly the detailed intraoperative mapping of cognitive and motor functions to avoid any neurological deficit. The intraoperative anatomical data provided by the neuronavigation and the functional data provided by awake intraoperative stimulation of the patient together serve the safety of the patient which is essential in the neurologically minimal invasive neurosurgical approach of the 21st century.

What Are the Principles That Guide Behaviors in the Operating Room?: Creating a Framework to Define and Measure Performance.

PubMed

Madani, Amin; Vassiliou, Melina C; Watanabe, Yusuke; Al-Halabi, Becher; Al-Rowais, Mohammed S; Deckelbaum, Dan L; Fried, Gerald M; Feldman, Liane S

2017-02-01

To identify the core principles that guide expert intraoperative behaviors and to use these principles to develop a universal framework that defines intraoperative performance. Surgical outcomes are associated with intraoperative cognitive skills. Yet, our understanding of factors that control intraoperative judgment and decision-making are limited. As a result, current methods for training and measuring performance are somewhat subjective-more task rather than procedure-oriented-and usually not standardized. They thus provide minimal insight into complex cognitive processes that are fundamental to patient safety. Cognitive task analyses for 6 diverse surgical procedures were performed using semistructured interviews and field observations to describe the thoughts, behaviors, and actions that characterize and guide expert performance. Verbal data were transcribed, supplemented with content from published literature, coded, thematically analyzed using grounded-theory by 4 independent reviewers, and synthesized into a list of items. A conceptual framework was developed based on 42 semistructured interviews lasting 45 to 120 minutes, 5 expert panels and 51 field observations involving 35 experts, and 135 sources from the literature. Five domains of intraoperative performance were identified: psychomotor skills, declarative knowledge, advanced cognitive skills, interpersonal skills, and personal resourcefulness. Within the advanced cognitive skills domain, 21 themes were perceived to guide the behaviors of surgeons: 18 for surgical planning and error prevention, and 3 for error/injury recognition, rescue, and recovery. The application of these thought patterns was highly case-specific and variable amongst subspecialties, environments, and individuals. This study provides a comprehensive definition of intraoperative expertise, with greater insight into the complex cognitive processes that seem to underlie optimal performance. This framework provides trainees and other nonexperts with the necessary information to use in deliberate practice and the creation of effective thought habits that characterize expert performance. It may help to identify gaps in performance, and to isolate root causes of surgical errors with the ultimate goal of improving patient safety.

Incidence of intraoperative seizures during motor evoked potential monitoring in a large cohort of patients undergoing different surgical procedures.

PubMed

Ulkatan, Sedat; Jaramillo, Ana Maria; Téllez, Maria J; Kim, Jinu; Deletis, Vedran; Seidel, Kathleen

2017-04-01

OBJECTIVE The purpose of this study was to investigate the incidence of seizures during the intraoperative monitoring of motor evoked potentials (MEPs) elicited by electrical brain stimulation in a wide spectrum of surgeries such as those of the orthopedic spine, spinal cord, and peripheral nerves, interventional radiology procedures, and craniotomies for supra- and infratentorial tumors and vascular lesions. METHODS The authors retrospectively analyzed data from 4179 consecutive patients who underwent surgery or an interventional radiology procedure with MEP monitoring. RESULTS Of 4179 patients, only 32 (0.8%) had 1 or more intraoperative seizures. The incidence of seizures in cranial procedures, including craniotomies and interventional neuroradiology, was 1.8%. In craniotomies in which transcranial electrical stimulation (TES) was applied to elicit MEPs, the incidence of seizures was 0.7% (6/850). When direct cortical stimulation was additionally applied, the incidence of seizures increased to 5.4% (23/422). Patients undergoing craniotomies for the excision of extraaxial brain tumors, particularly meningiomas (15 patients), exhibited the highest risk of developing an intraoperative seizure (16 patients). The incidence of seizures in orthopedic spine surgeries was 0.2% (3/1664). None of the patients who underwent surgery for conditions of the spinal cord, neck, or peripheral nerves or who underwent cranial or noncranial interventional radiology procedures had intraoperative seizures elicited by TES during MEP monitoring. CONCLUSIONS In this largest such study to date, the authors report the incidence of intraoperative seizures in patients who underwent MEP monitoring during a wide spectrum of surgeries such as those of the orthopedic spine, spinal cord, and peripheral nerves, interventional radiology procedures, and craniotomies for supra- and infratentorial tumors and vascular lesions. The low incidence of seizures induced by electrical brain stimulation, particularly short-train TES, demonstrates that MEP monitoring is a safe technique that should not be avoided due to the risk of inducing seizures.

Open-air multispectral fluorescence-guided surgery platform for intraoperative detection of malignant tissue under ambient lighting conditions

NASA Astrophysics Data System (ADS)

Behrooz, Ali; Vasquez, Kristine O.; Waterman, Peter; Meganck, Jeff; Peterson, Jeffrey D.; Miller, Peter; Kempner, Joshua

2017-02-01

Intraoperative resection of tumors currently relies upon the surgeon's ability to visually locate and palpate tumor nodules. Undetected residual malignant tissue often results in the need for additional treatment or surgical intervention. The Solaris platform is a multispectral open-air fluorescence imaging system designed for translational fluorescence-guided surgery. Solaris supports video-rate imaging in four fixed fluorescence channels ranging from visible to near infrared, and a multispectral channel equipped with a liquid crystal tunable filter (LCTF) for multispectral image acquisition (520-620 nm). Identification of tumor margins using reagents emitting in the visible spectrum (400-650 nm), such as fluorescein isothiocyanate (FITC), present challenges considering the presence of auto-fluorescence from tissue and food in the gastrointestinal (GI) tract. To overcome this, Solaris acquires LCTF-based multispectral images, and by applying an automated spectral unmixing algorithm to the data, separates reagent fluorescence from tissue and food auto-fluorescence. The unmixing algorithm uses vertex component analysis to automatically extract the primary pure spectra, and resolves the reagent fluorescent signal using non-negative least squares. For validation, intraoperative in vivo studies were carried out in tumor-bearing rodents injected with FITC-dextran reagent that is primarily residing in malignant tissue 24 hours post injection. In the absence of unmixing, fluorescence from tumors is not distinguishable from that of surrounding tissue. Upon spectral unmixing, the FITC-labeled malignant regions become well defined and detectable. The results of these studies substantiate the multispectral power of Solaris in resolving FITC-based agent signal in deep tumor masses, under ambient and surgical light, and enhancing the ability to surgically resect them.

Functional outcomes following immediate repair of penile fracture: a tertiary referral centre experience with 76 consecutive patients.

PubMed

De Luca, Francesco; Garaffa, Giulio; Falcone, Marco; Raheem, Amr; Zacharakis, Evangelos; Shabbir, Majed; Aljubran, Abdelkareem; Muneer, Asif; Holden, Fiona; Akers, Claire; Christopher, Nim; Ralph, David J

2017-04-01

The aim of this study was to report surgical and functional outcomes in patients who underwent immediate penile fracture repair following location of the tunical tear with ultrasonography. Patients' clinical notes from September 2005 to October 2015 were reviewed. The inclusion criteria were the documented presence of an albugineal laceration at the preoperative ultrasonography and during surgical exploration. In total, 76 patients were enrolled in the study. The aetiology, presentation, imaging results, intraoperative findings, functional outcomes and complications of surgical repair were retrospectively extrapolated from the clinical notes. Patients were questioned about their erectile and urinary function 12 months after the traumatic event. Validated questionnaires were administered to enquire about sexual and urinary function. Finally, the accuracy of the ultrasound in detecting the site of the tunical defect was evaluated. The mean age was 39.5 years (range 21-72 years) and the median follow-up was 13 weeks. The aetiology of the fracture was sexual intercourse in 70 patients, the taqaandan manoeuvre in three and trauma while sleeping in three. The intraoperative findings showed a ventral and transverse tear in 93.5% of cases. Urethral injuries were evident in one-quarter of the patients. Ultrasonographic findings were confirmed intraoperatively in all patients. Worsening of the quality of erections was reported by 5% of patients, and 5.2% reported a penile curvature postoperatively. Penile fracture is a rare urological emergency and requires early surgical exploration and repair. Ultrasonography is a cheap and readily available investigation that allows confirmation of the diagnosis, and identification of the location of the tear and the associated urethral injury.

Intraoperative Detection of Superficial Liver Tumors by Fluorescence Imaging Using Indocyanine Green and 5-aminolevulinic Acid.

PubMed

Kaibori, Masaki; Matsui, Kosuke; Ishizaki, Morihiko; Iida, Hiroya; Okumura, Tadayoshi; Sakaguchi, Tatsuma; Inoue, Kentaro; Ikeura, Tsukasa; Asano, Hiroaki; Kon, Masanori

2016-04-01

Indocyanine green (ICG) and the porphyrin precursor 5-aminolevulinic acid (5-ALA) have been approved as fluorescence imaging agents in the clinical setting. This study evaluated the usefulness of fluorescence imaging with both ICG and 5-ALA for intraoperative identification of latent small liver tumors. There were 48 patients who had main tumors within 5 mm of the liver surface. 5-ALA hydrochloride was orally administered to patients 3 h before surgery. ICG had been intravenously injected within 14 days prior to surgery. Intraoperatively, after visual inspection, manual palpation and ultrasonography fluorescence images of the liver surface were obtained with ICG and 5-ALA prior to resection. With ICG, the sensitivity, specificity and accuracy for detecting the preoperatively identified main tumors were 96%, 50% and 94%, respectively. Twelve latent small tumors were newly detected on the liver surface using ICG, five of which proved to be carcinomas. With 5-ALA, the sensitivity, specificity and accuracy for detecting the main tumors were 57%, 100% and 58%, respectively. Five latent small tumors were newly detected using 5-ALA; all were carcinomas. Overall, five new tumors were detected by both ICG and 5-ALA fluorescence imaging; two were hepatocellular carcinomas (HCCs) and three were metastases of colorectal cancer. The sensitivity and specificity of ICG fluorescence imaging for main tumor detection were relatively high and low, respectively, but the opposite was true of 5-ALA imaging. Fluorescence imaging using 5-ALA may provide greater specificity in the detection of surface-invisible malignant liver tumors than using ICG fluorescence imaging alone. Copyright© 2016 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.

Intraoperative laparoscopic complications for urological cancer procedures.

PubMed

Montes, Sergio Fernández-Pello; Rodríguez, Ivan Gonzalez; Ugarteburu, Rodrigo Gil; Villamil, Luis Rodríguez; Mendez, Begoña Diaz; Gil, Patricio Suarez; Madera, Javier Mosquera

2015-05-16

To structure the rate of intraoperative complications that requires an intraoperative or perioperative resolution. We perform a literature review of Medline database. The research was focused on intraoperative laparoscopic procedures inside the field of urological oncology. General rate of perioperative complications in laparoscopic urologic surgery is described to be around 12.4%. Most of the manuscripts published do not make differences between pure intraoperative, intraoperative with postoperative consequences and postoperative complications. We expose a narrative statement of complications, possible solutions and possible preventions for most frequent retroperitoneal and pelvic laparoscopic surgery. We expose the results with the following order: retroperitoneal laparoscopic surgery (radical nephrectomy, partial nephrectomy, nephroureterectomy and adrenalectomy) and pelvic laparoscopic surgery (radical prostatectomy and radical cystectomy). Intraoperative complications vary from different series. More scheduled reports should be done in order to better understand the real rates of complications.

Filter paper-assisted cell transfer (FaCT) technique: A novel cell-sampling technique for intraoperative diagnosis of central nervous system tumors.

PubMed

Kawamura, Jumpei; Kamoshida, Shingo; Shimakata, Takaaki; Hayashi, Yurie; Sakamaki, Kuniko; Denda, Tamami; Kawai, Kenji; Kuwao, Sadahito

2017-04-01

Intraoperative diagnosis of central nervous system (CNS) tumors provides critical guidance to surgeons in the determination of surgical resection margins and treatment. The techniques and preparations used for the intraoperative diagnosis of CNS tumors include frozen sectioning and cytologic methods (squash smear and touch imprint). Cytologic specimens, which do not have freezing artifacts, are important as an adjuvant tool to frozen sections. However, if the amount of submitted tissue samples is limited, then it is difficult to prepare both frozen sections and squash smears or touch imprint specimens from a single sample at the same time. Therefore, the objective of this study was to derive cells directly from filter paper on which tumor samples are placed. The authors established the filter paper-assisted cell transfer (FaCT) smear technique, in which tumor cells are transferred onto a glass slide directly from the filter paper sample spot after the biopsy is removed. Cell yields and diagnostic accuracy of the FaCT smears were assessed in 40 CNS tumors. FaCT smears had ample cell numbers and well preserved cell morphology sufficient for cytologic diagnosis, even if the submitted tissues were minimal. The overall diagnostic concordance rates between frozen sections and FaCT smears were 90% and 87.5%, respectively (no significant differences). When combining FaCT smears with frozen sections, the diagnostic concordance rate rose to 92.5%. The current results suggest that the FaCT smear technique is a simple and effective processing method that has significant value for intraoperative diagnosis of CNS tumors. Cancer Cytopathol 2017;125:277-282. © 2016 American Cancer Society. © 2017 American Cancer Society.

Prospective evaluation of biodegradable polymeric sealant for intraoperative air leaks.

PubMed

Park, Bernard J; Snider, John M; Bates, Nathan R; Cassivi, Stephen D; Jett, G Kimble; Sonett, Joshua R; Toloza, Eric M

2016-12-12

A biodegradable polymeric sealant has been previously shown to reduce postoperative air leaks after open pulmonary resection. The aim of this study was to evaluate safety and efficacy during minimally invasive pulmonary resection. In a multicenter prospective single-arm trial, 112 patients with a median age of 69 years (range 34-87 years) were treated with sealant for at least one intraoperative air leak after standard methods of repair (sutures, staples or cautery) following minimally invasive pulmonary resection (Video-Assisted Thoracic Surgery (VATS) or Robotic-Assisted). Patients were followed in hospital and 1 month after surgery for procedure-related and device-related complications and presence of air leak. Forty patients had VATS and 72 patients had Robotic-Assisted procedures with the majority (80/112, 71%) undergoing anatomic resection (61 lobectomy, 13 segmentectomy, 6 bilobectomy). There were no device-related adverse events. The overall morbidity rate was 41% (46/112), with major complications occurring in 16.1% (18/112). In-hospital mortality and 30-day mortality were 1.9% (2/103). The majority of intraoperative air leaks (107/133, 81%) were sealed after sealant application, and an additional 16% (21/133) were considered reduced. Forty-nine percent of patients (55/112) were free of air leak throughout the entire postoperative study period. Median chest tube duration was 2 days (range 1 - 46 days), and median length of hospitalization was 3 days (range 1 - 20 days). This study demonstrated that use of a biodegradable polymer for closure of intraoperative air leaks as an adjunct to standard methods is safe and effective following minimally invasive pulmonary resection. ClinicalTrials.gov: NCT01867658 . Registered 3 May 2013.

Diagnosing periprosthetic infection: false-positive intraoperative Gram stains.

PubMed

Oethinger, Margret; Warner, Debra K; Schindler, Susan A; Kobayashi, Hideo; Bauer, Thomas W

2011-04-01

Intraoperative Gram stains have a reported low sensitivity but high specificity when used to help diagnose periprosthetic infections. In early 2008, we recognized an unexpectedly high frequency of apparent false-positive Gram stains from revision arthroplasties. The purpose of this report is to describe the cause of these false-positive test results. We calculated the sensitivity and specificity of all intraoperative Gram stains submitted from revision arthroplasty cases during a 3-month interval using microbiologic cultures of the same samples as the gold standard. Methods of specimen harvesting, handling, transport, distribution, specimen processing including tissue grinding/macerating, Gram staining, and interpretation were studied. After a test modification, results of specimens were prospectively collected for a second 3-month interval, and the sensitivity and specificity of intraoperative Gram stains were calculated. The retrospective review of 269 Gram stains submitted from revision arthroplasties indicated historic sensitivity and specificity values of 23% and 92%, respectively. Systematic analysis of all steps of the procedure identified Gram-stained but nonviable bacteria in commercial broth reagents used as diluents for maceration of periprosthetic membranes before Gram staining and culture. Polymerase chain reaction and sequencing showed mixed bacterial DNA. Evaluation of 390 specimens after initiating standardized Millipore filtering of diluent fluid revealed a reduced number of positive Gram stains, yielding 9% sensitivity and 99% specificity. Clusters of false-positive Gram stains have been reported in other clinical conditions. They are apparently rare related to diagnosing periprosthetic infections but have severe consequences if used to guide treatment. Even occasional false-positive Gram stains should prompt review of laboratory methods. Our observations implicate dead bacteria in microbiologic reagents as potential sources of false-positive Gram stains.

A prospective observational study evaluating the efficacy of prophylactic internal iliac artery balloon catheterization in the management of placenta previa–accreta

PubMed Central

Fan, Yao; Gong, Xun; Wang, Nan; Mu, Ketao; Feng, Ling; Qiao, Fuyuan; Chen, Suhua; Zeng, Wanjiang; Liu, Haiyi; Wu, Yuanyuan; Zhou, Qiong; Tian, Yuan; Li, Qiang; Yang, Meitao; Li, Fanfan; He, Mengzhou; Beejadhursing, Rajluxmee; Deng, Dongrui

2017-01-01

Abstract We studied the efficacy of prophylactic internal iliac artery balloon catheterization for managing severe hemorrhage caused by pernicious placenta previa. This prospective observational study was conducted in Tongji Hospital, Wuhan, China. One hundred sixty-three women past 32-week's gestation with placenta previa–accreta were recruited and managed. Women in the balloon group accepted prophylactic internal iliac artery balloon catheterization before scheduled caesarean delivery and controls had a conventional caesarean delivery. Intraoperative hemorrhage, transfusion volume, radiation dose, exposure time, complications, and neonatal outcomes were discussed. Significant differences were detected in estimated blood loss (1236.0 mL vs 1694.0 mL, P = .01), calculated blood loss (CBL) (813.8 mL vs 1395.0 mL, P < .001), CBL of placenta located anteriorly (650.5 mL vs 1196.0 mL, P = .03), and anterioposteriorly (928.3 mL vs 1680.0 mL, P = .02). Prophylactic balloon catheterization could reduce intraoperative red blood cell transfusion (728.0 mL vs 1205.0 mL, P = .01) and lessen usage of perioperative hemostatic methods. The incidence of hysterectomy was lower in balloon group. Mean radiation dose was 29.2 mGy and mean exposure time was 92.2 seconds. Neonatal outcomes and follow-up data did not have significant difference. Prophylactic internal iliac artery balloon catheterization is an effective method for managing severe hemorrhage caused by placenta previa–accreta as it reduced intraoperative blood loss, lessened perioperative hemostatic measures and intraoperative red cell transfusions, and reduce hysterectomies. PMID:29137011

Intraoperative Fluorescence Imaging for Detection of Sentinel Lymph Nodes and Lymphatic Vessels during Open Prostatectomy using Indocyanine Green.

PubMed

Yuen, Keiji; Miura, Tetsuya; Sakai, Iori; Kiyosue, Akiko; Yamashita, Masuo

2015-08-01

We investigated the feasibility and validity of intraoperative fluorescence imaging using indocyanine green for the detection of sentinel lymph nodes and lymphatic vessels during open prostatectomy. Indocyanine green was injected into the prostate under transrectal ultrasound guidance just before surgery. Intraoperative fluorescence imaging was performed using a near-infrared camera system in 66 consecutive patients with clinically localized prostate cancer after a 10-patient pilot test to optimize indocyanine green dosing, observation timing and injection method. Lymphatic vessels were visualized and followed to identify the sentinel lymph nodes. Confirmatory pelvic lymph node dissection including all fluorescent nodes and open radical prostatectomy were performed in all patients. Lymphatic vessels were successfully visualized in 65 patients (98%) and sentinel lymph nodes in 64 patients (97%). Sentinel lymph nodes were located in the obturator fossa, internal and external iliac regions, and rarely in the common iliac and presacral regions. A median of 4 sentinel lymph nodes per patient was detected. Three lymphatic pathways, the paravesical, internal and lateral routes, were identified. Pathological examination revealed metastases to 9 sentinel lymph nodes in 6 patients (9%). All pathologically positive lymph nodes were detected as sentinel lymph nodes using this imaging. No adverse reactions due to the use of indocyanine green were observed. Intraoperative fluorescence imaging using indocyanine green during open prostatectomy enables the detection of lymphatic vessels and sentinel lymph nodes with high sensitivity. This novel method is technically feasible, safe and easy to apply with minimal additional operative time. Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Intraoperative laser speckle contrast imaging with retrospective motion correction for quantitative assessment of cerebral blood flow

PubMed Central

Richards, Lisa M.; Towle, Erica L.; Fox, Douglas J.; Dunn, Andrew K.

2014-01-01

Abstract. Although multiple intraoperative cerebral blood flow (CBF) monitoring techniques are currently available, a quantitative method that allows for continuous monitoring and that can be easily integrated into the surgical workflow is still needed. Laser speckle contrast imaging (LSCI) is an optical imaging technique with a high spatiotemporal resolution that has been recently demonstrated as feasible and effective for intraoperative monitoring of CBF during neurosurgical procedures. This study demonstrates the impact of retrospective motion correction on the quantitative analysis of intraoperatively acquired LSCI images. LSCI images were acquired through a surgical microscope during brain tumor resection procedures from 10 patients under baseline conditions and after a cortical stimulation in three of those patients. The patient’s electrocardiogram (ECG) was recorded during acquisition for postprocess correction of pulsatile artifacts. Automatic image registration was retrospectively performed to correct for tissue motion artifacts, and the performance of rigid and nonrigid transformations was compared. In baseline cases, the original images had 25%±27% noise across 16 regions of interest (ROIs). ECG filtering moderately reduced the noise to 20%±21%, while image registration resulted in a further noise reduction of 15%±4%. Combined ECG filtering and image registration significantly reduced the noise to 6.2%±2.6% (p<0.05). Using the combined motion correction, accuracy and sensitivity to small changes in CBF were improved in cortical stimulation cases. There was also excellent agreement between rigid and nonrigid registration methods (15/16 ROIs with <3% difference). Results from this study demonstrate the importance of motion correction for improved visualization of CBF changes in clinical LSCI images. PMID:26157974

The current status and future prospects of computer-assisted hip surgery.

PubMed

Inaba, Yutaka; Kobayashi, Naomi; Ike, Hiroyuki; Kubota, So; Saito, Tomoyuki

2016-03-01

The advances in computer assistance technology have allowed detailed three-dimensional preoperative planning and simulation of preoperative plans. The use of a navigation system as an intraoperative assistance tool allows more accurate execution of the preoperative plan, compared to manual operation without assistance of the navigation system. In total hip arthroplasty using CT-based navigation, three-dimensional preoperative planning with computer software allows the surgeon to determine the optimal angle of implant placement at which implant impingement is unlikely to occur in the range of hip joint motion necessary for daily activities of living, and to determine the amount of three-dimensional correction for leg length and offset. With the use of computer navigation for intraoperative assistance, the preoperative plan can be precisely executed. In hip osteotomy using CT-based navigation, the navigation allows three-dimensional preoperative planning, intraoperative confirmation of osteotomy sites, safe performance of osteotomy even under poor visual conditions, and a reduction in exposure doses from intraoperative fluoroscopy. Positions of the tips of chisels can be displayed on the computer monitor during surgery in real time, and staff other than the operator can also be aware of the progress of surgery. Thus, computer navigation also has an educational value. On the other hand, its limitations include the need for placement of trackers, increased radiation exposure from preoperative CT scans, and prolonged operative time. Moreover, because the position of a bone fragment cannot be traced after osteotomy, methods to find its precise position after its movement need to be developed. Despite the need to develop methods for the postoperative evaluation of accuracy for osteotomy, further application and development of these systems are expected in the future. Copyright © 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.

Navigation and Image Injection for Control of Bone Removal and Osteotomy Planes in Spine Surgery.

PubMed

Kosterhon, Michael; Gutenberg, Angelika; Kantelhardt, Sven Rainer; Archavlis, Elefterios; Giese, Alf

2017-04-01

In contrast to cranial interventions, neuronavigation in spinal surgery is used in few applications, not tapping into its full technological potential. We have developed a method to preoperatively create virtual resection planes and volumes for spinal osteotomies and export 3-D operation plans to a navigation system controlling intraoperative visualization using a surgical microscope's head-up display. The method was developed using a Sawbone ® model of the lumbar spine, demonstrating feasibility with high precision. Computer tomographic and magnetic resonance image data were imported into Amira ® , a 3-D visualization software. Resection planes were positioned, and resection volumes representing intraoperative bone removal were defined. Fused to the original Digital Imaging and Communications in Medicine data, the osteotomy planes were exported to the cranial version of a Brainlab ® navigation system. A navigated surgical microscope with video connection to the navigation system allowed intraoperative image injection to visualize the preplanned resection planes. The workflow was applied to a patient presenting with a congenital hemivertebra of the thoracolumbar spine. Dorsal instrumentation with pedicle screws and rods was followed by resection of the deformed vertebra guided by the in-view image injection of the preplanned resection planes into the optical path of a surgical microscope. Postoperatively, the patient showed no neurological deficits, and the spine was found to be restored in near physiological posture. The intraoperative visualization of resection planes in a microscope's head-up display was found to assist the surgeon during the resection of a complex-shaped bone wedge and may help to further increase accuracy and patient safety. Copyright © 2017 by the Congress of Neurological Surgeons

Optimization of the extent of surgical treatment in patients with stage I in cervical cancer

NASA Astrophysics Data System (ADS)

Chernyshova, A. L.; Kolomiets, L. A.; Sinilkin, I. G.; Chernov, V. I.; Lyapunov, A. Yu.

2016-08-01

The study included 26 patients with FIGO stage Ia1-Ib1 cervical cancer who underwent fertility-sparing surgery (transabdominaltrachelectomy). To visualize sentinel lymph nodes, lymphoscintigraphy with injection of 99mTc-labelled nanocolloid was performed the day before surgery. Intraoperative identification of sentinel lymph nodes using hand-held gamma probe was carried out to determine the radioactive counts over the draining lymph node basin. The sentinel lymph node detection in cervical cancer patients contributes to the accurate clinical assessment of the pelvic lymph node status, precise staging of the disease and tailoring of surgical treatment to individual patient.

Fluorescence Imaging/Agents in Tumor Resection.

PubMed

Stummer, Walter; Suero Molina, Eric

2017-10-01

Intraoperative fluorescence imaging allows real-time identification of diseased tissue during surgery without being influenced by brain shift and surgery interruption. 5-Aminolevulinic acid, useful for malignant gliomas and other tumors, is the most broadly explored compound approved for fluorescence-guided resection. Intravenous fluorescein sodium has recently received attention, highlighting tumor tissue based on extravasation at the blood-brain barrier (defective in many brain tumors). Fluorescein in perfused brain, unselective extravasation in brain perturbed by surgery, and propagation with edema are concerns. Fluorescein is not approved but targeted fluorochromes with affinity to brain tumor cells, in development, may offer future advantages. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Imaging-guided thoracoscopic resection of a ground-glass opacity lesion in a hybrid operating room equipped with a robotic C-arm CT system.

PubMed

Hsieh, Chen-Ping; Hsieh, Ming-Ju; Fang, Hsin-Yueh; Chao, Yin-Kai

2017-05-01

The intraoperative identification of small pulmonary nodules through video-assisted thoracoscopic surgery remains challenging. Although preoperative CT-guided nodule localization is commonly used to detect tumors during video-assisted thoracoscopic surgery (VATS), this approach carries inherent risks. We report the case of a patient with stage I lung cancer presenting as an area of ground-glass opacity (GGO) in the right upper pulmonary lobe. He successfully underwent a single-stage, CT-guided localization and removal of the pulmonary nodule within a hybrid operating room (OR) equipped with a robotic C-arm.

The challenge of Propionibacterium acnes and revision shoulder arthroplasty: a review of current diagnostic options.

PubMed

Shields, Margaret V; Abdullah, Leath; Namdari, Surena

2016-06-01

Propionibacterium acnes is the most common cause of infection after shoulder arthroplasty. Whereas there are several methods that can aid in the diagnosis of P. acnes infection, there is not a single "gold standard" because of the difficulties inherent in identifying this bacterium. We present an evidence-based discussion of the demographic, clinical, and radiographic predictors of P. acnes infection and review the current options for diagnosis. This review was written after a comprehensive analysis of the current literature related to shoulder periprosthetic joint infection and P. acnes identification. Of the techniques reviewed, α-defensin had the highest sensitivity in detecting P. acnes infection (63%). C-reactive protein level and erythrocyte sedimentation rate were often normal in cases of infection. Whereas P. acnes can be challenging to successfully diagnose, there are several options that are considered preferable because of their higher sensitivities and specificities. The current gold standard is intraoperative culture, but major advances in molecular techniques may provide future improvements in diagnostic accuracy. Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Silk-elastin-like protein polymer matrix for intraoperative delivery of an oncolytic vaccinia virus.

PubMed

Price, Daniel L; Li, Pingdong; Chen, Chun-Hao; Wong, Danni; Yu, Zhenkun; Chen, Nanhai G; Yu, Yong A; Szalay, Aladar A; Cappello, Joseph; Fong, Yuman; Wong, Richard J

2016-02-01

Oncolytic viral efficacy may be limited by the penetration of the virus into tumors. This may be enhanced by intraoperative application of virus immediately after surgical resection. Oncolytic vaccinia virus GLV-1h68 was delivered in silk-elastin-like protein polymer (SELP) in vitro and in vivo in anaplastic thyroid carcinoma cell line 8505c in nude mice. GLV-1h68 in SELP infected and lysed anaplastic thyroid cancer cells in vitro equally as effectively as in phosphate-buffered saline (PBS), and at 1 week retains a thousand fold greater infectious plaque-forming units. In surgical resection models of residual tumor, GLV-1h68 in SELP improves tumor control and shows increased viral β-galactosidase expression as compared to PBS. The use of SELP matrix for intraoperative oncolytic viral delivery protects infectious viral particles from degradation, facilitates sustained viral delivery and transgene expression, and improves tumor control. Such optimization of methods of oncolytic viral delivery may enhance therapeutic outcomes. © 2014 Wiley Periodicals, Inc.

Review of the potential of optical technologies for cancer diagnosis in neurosurgery: a step toward intraoperative neurophotonics

PubMed Central

Vasefi, Fartash; MacKinnon, Nicholas; Farkas, Daniel L.; Kateb, Babak

2016-01-01

Abstract. Advances in image-guided therapy enable physicians to obtain real-time information on neurological disorders such as brain tumors to improve resection accuracy. Image guidance data include the location, size, shape, type, and extent of tumors. Recent technological advances in neurophotonic engineering have enabled the development of techniques for minimally invasive neurosurgery. Incorporation of these methods in intraoperative imaging decreases surgical procedure time and allows neurosurgeons to find remaining or hidden tumor or epileptic lesions. This facilitates more complete resection and improved topology information for postsurgical therapy (i.e., radiation). We review the clinical application of recent advances in neurophotonic technologies including Raman spectroscopy, thermal imaging, optical coherence tomography, and fluorescence spectroscopy, highlighting the importance of these technologies in live intraoperative tissue mapping during neurosurgery. While these technologies need further validation in larger clinical trials, they show remarkable promise in their ability to help surgeons to better visualize the areas of abnormality and enable safe and successful removal of malignancies. PMID:28042588

[Non-invasive mechanical ventilation in the pre- and intraoperative period and difficult airway].

PubMed

Esquinas, A M; Jover, J L; Úbeda, A; Belda, F J

2015-11-01

Non-invasive mechanical ventilation is a method of ventilatory assistance aimed at increasing alveolar ventilation, thus achieving, in selected subjects, the avoidance of endotracheal intubation and invasive mechanical ventilation, with the consequent improvement in survival. There has been a systematic review and study of the technical, clinical experiences, and recommendations concerning the application of non-invasive mechanical ventilation in the pre- and intraoperative period. The use of prophylactic non-invasive mechanical ventilation before surgery that involves significant alterations in the ventilatory function may decrease the incidence of postoperative respiratory complications. Its intraoperative use will mainly depend on the type of surgery, type of anaesthetic technique, and the clinical status of the patient. Its use allows greater anaesthetic depth without deterioration of oxygenation and ventilation of patients. Copyright © 2015 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

A New Volumetric Radiologic Method to Assess Indirect Decompression After Extreme Lateral Interbody Fusion Using High-Resolution Intraoperative Computed Tomography.

PubMed

Navarro-Ramirez, Rodrigo; Berlin, Connor; Lang, Gernot; Hussain, Ibrahim; Janssen, Insa; Sloan, Stephen; Askin, Gulce; Avila, Mauricio J; Zubkov, Micaella; Härtl, Roger

2018-01-01

Two-dimensional radiographic methods have been proposed to evaluate the radiographic outcome after indirect decompression through extreme lateral interbody fusion (XLIF). However, the assessment of neural decompression in a single plane may underestimate the effect of indirect decompression on central canal and foraminal volumes. The present study aimed to assess the reliability and consistency of a novel 3-dimensional radiographic method that assesses neural decompression by volumetric analysis using a new generation of intraoperative fan-beam computed tomography scanner in patients undergoing XLIF. Prospectively collected data from 7 patients (9 levels) undergoing XLIF was retrospectively analyzed. Three independent, blind raters using imaging analysis software performed volumetric measurements pre- and postoperatively to determine central canal and foraminal volumes. Intrarater and Interrater reliability tests were performed to assess the reliability of this novel volumetric method. The interrater reliability between the three raters ranged from 0.800 to 0.952, P < 0.0001. The test-retest analysis on a randomly selected subset of three patients showed good to excellent internal reliability (range of 0.78-1.00) for all 3 raters. There was a significant increase in mean volume ≈20% for right foramen, left foramen, and central canal volumes postoperatively (P = 0.0472; P = 0.0066; P = 0.0003, respectively). Here we demonstrate a new volumetric analysis technique that is feasible, reliable, and reproducible amongst independent raters for central canal and foraminal volumes in the lumbar spine using an intraoperative computed tomography scanner. Copyright © 2017. Published by Elsevier Inc.

Validation of model-based deformation correction in image-guided liver surgery via tracked intraoperative ultrasound: preliminary method and results

NASA Astrophysics Data System (ADS)

Clements, Logan W.; Collins, Jarrod A.; Wu, Yifei; Simpson, Amber L.; Jarnagin, William R.; Miga, Michael I.

2015-03-01

Soft tissue deformation represents a significant error source in current surgical navigation systems used for open hepatic procedures. While numerous algorithms have been proposed to rectify the tissue deformation that is encountered during open liver surgery, clinical validation of the proposed methods has been limited to surface based metrics and sub-surface validation has largely been performed via phantom experiments. Tracked intraoperative ultrasound (iUS) provides a means to digitize sub-surface anatomical landmarks during clinical procedures. The proposed method involves the validation of a deformation correction algorithm for open hepatic image-guided surgery systems via sub-surface targets digitized with tracked iUS. Intraoperative surface digitizations were acquired via a laser range scanner and an optically tracked stylus for the purposes of computing the physical-to-image space registration within the guidance system and for use in retrospective deformation correction. Upon completion of surface digitization, the organ was interrogated with a tracked iUS transducer where the iUS images and corresponding tracked locations were recorded. After the procedure, the clinician reviewed the iUS images to delineate contours of anatomical target features for use in the validation procedure. Mean closest point distances between the feature contours delineated in the iUS images and corresponding 3-D anatomical model generated from the preoperative tomograms were computed to quantify the extent to which the deformation correction algorithm improved registration accuracy. The preliminary results for two patients indicate that the deformation correction method resulted in a reduction in target error of approximately 50%.

Assessment of incomplete clipping of aneurysms intraoperatively by a near-infrared indocyanine green-video angiography (Niicg-Va) integrated microscope.

PubMed

Imizu, S; Kato, Y; Sangli, A; Oguri, D; Sano, H

2008-08-01

The objective of this article was to assess the clinical use and the completeness of clipping with total occlusion of the aneurysmal lumen, real-time assessment of vascular patency in the parent, branching and perforating vessels, intraoperative assessment of blood flow, image quality, spatial resolution and clinical value in difficult aneurysms using near infrared indocyanine green video angiography integrated on to an operative Pentero neurosurgical microscope (Carl Zeiss, Oberkochen Germany). Thirteen patients with aneurysms were operated upon. An infrared camera with near infrared technology was adapted on to the OPMI Pentero microscope with a special filter and infrared excitation light to illuminate the operating field which was designed to allow passage of the near infrared light required for excitation of indocyanine green (ICG) which was used as the intravascular marker. The intravascular fluorescence was imaged with a video camera attached to the microscope. ICG fluorescence (700-850 nm) from a modified microscope light source on to the surgical field and passage of ICG fluorescence (780-950 nm) from the surgical field, back into the optical path of the microscope was used to detect the completeness of aneurysmal clipping Incomplete clipping in three patients (1 female and 2 males) with unruptured complicated aneurysms was detected using indocyanine green video angiography. There were no adverse effects after injection of indocyanine green. The completeness of clipping was inadequately detected by Doppler ultrasound miniprobe and rigid endoscopy and was thus complemented by indocyanine green video angiography. The operative microscope-integrated ICG video angiography as a new intraoperative method for detecting vascular flow, was found to be quick, reliable, cost-effective and possibly a substitute or adjunct for Doppler ultrasonography or intraoperative DSA, which is presently the gold standard. The simplicity of the method, the speed with which the investigation can be performed, the quality of the images, and the outcome of surgical procedures have all reduced the need for angiography. This technique may be useful during routine aneurysm surgery as an independent form of angiography and/or as an adjunct to intraoperative or postoperative DSA.

[Motor evoked potentials in thoracoabdominal aortic surgery].

PubMed

Magro, Cátia; Nora, David; Marques, Miguel; Alves, Angela Garcia

2012-01-01

Thoracoabdominal aortic disease (aneurysm or dissection) has increased in recent decades. Surgery is the curative treatment but is associated to high perioperative morbidity and mortality risks. Paraplegia is one of the most severe complications, whose incidence has decreased significantly with the implementation of spinal cord protection strategies. No single method or combination of methods has proven to be fully effective in preventing paraplegia. This review is intended to analyse the scientific evidence available on the role of intraoperative monitoring with motor evoked potentials in the neurological outcome of patients undergoing thoracoabdominal aortic surgery. An online search (PubMed) was conducted. Relevant references were selected and reviewed. Intraoperative monitoring with motor evoked potentials (MEP) allows early detection of ischemic events and a targeted intervention to prevent the development of spinal cord injury, significantly reducing the incidence of postoperative paraplegia. MEP monitoring may undergo several intraoperative interferences which may compromise their interpretation. Neuromuscular blockade is the main limiting factor of anesthetic origin. It is essential to strike a balance between monitoring conditions and surgical and anesthetic needs as well as to evaluate the risks and benefits of the technique for each patient. MEP monitoring improves neurological outcome when integrated in a multidisciplinary strategy which must include multiple protective mechanisms that should be tailored to each hospital reality.

Graft reduction using a powered stapler in pediatric living donor liver transplantation.

PubMed

Yoshimaru, Koichiro; Matsuura, Toshiharu; Kinoshita, Yoshiaki; Hayashida, Makoto; Takahashi, Yoshiaki; Yanagi, Yusuke; Harimoto, Norifumi; Ikegami, Toru; Uchiyama, Hideaki; Yoshizumi, Tomoharu; Maehara, Yoshihiko; Taguchi, Tomoaki

2017-09-01

Large-for-size syndrome is defined by inadequate tissue oxygenation, which results in vascular complications and graft compression after abdominal closure in living donor liver transplantation recipients. An accurate graft reduction that matches the optimal liver volume for the recipient is essential. We herein initially present the feasibility and safety of graft reduction using a powered stapler to obtain an optimal graft size. From October 1996 to October 2015, a total of eight graft reductions were performed using a powered stapler (group A; n=4) or by the conventional method using a cavitron ultrasonic surgical aspirator and portal triad suturing (group B; n=4). The background, intraoperative findings and the post-operative outcomes of these eight patients were retrospectively investigated. There were no statistically significant differences in the background of the patients in the two groups. Graft reduction was successfully achieved without any intraoperative complications in group A, whereas intraoperative complications, such as bleeding and bile leakage, occurred in two patients of group B. No post-operative surgical complications were detected on computed tomography; moreover, the serum aspartate aminotransferase level normalized significantly earlier in group A (P<.05). In summary, graft reduction using a powered stapler was feasible and safe in comparison with the conventional method. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Preliminary results in large bone segmentation from 3D freehand ultrasound

NASA Astrophysics Data System (ADS)

Fanti, Zian; Torres, Fabian; Arámbula Cosío, Fernando

2013-11-01

Computer Assisted Orthopedic Surgery (CAOS) requires a correct registration between the patient in the operating room and the virtual models representing the patient in the computer. In order to increase the precision and accuracy of the registration a set of new techniques that eliminated the need to use fiducial markers have been developed. The majority of these newly developed registration systems are based on costly intraoperative imaging systems like Computed Tomography (CT scan) or Magnetic resonance imaging (MRI). An alternative to these methods is the use of an Ultrasound (US) imaging system for the implementation of a more cost efficient intraoperative registration solution. In order to develop the registration solution with the US imaging system, the bone surface is segmented in both preoperative and intraoperative images, and the registration is done using the acquire surface. In this paper, we present the a preliminary results of a new approach to segment bone surface from ultrasound volumes acquired by means 3D freehand ultrasound. The method is based on the enhancement of the voxels that belongs to surface and its posterior segmentation. The enhancement process is based on the information provided by eigenanalisis of the multiscale 3D Hessian matrix. The preliminary results shows that from the enhance volume the final bone surfaces can be extracted using a singular value thresholding.

In Vivo Dosimetry for Single-Fraction Targeted Intraoperative Radiotherapy (TARGIT) for Breast Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Eaton, David J., E-mail: davideaton@nhs.net; Best, Bronagh; Brew-Graves, Chris

Purpose: In vivo dosimetry provides an independent check of delivered dose and gives confidence in the introduction or consistency of radiotherapy techniques. Single-fraction intraoperative radiotherapy of the breast can be performed with the Intrabeam compact, mobile 50 kV x-ray source (Carl Zeiss Surgical, Oberkochen, Germany). Thermoluminescent dosimeters (TLDs) can be used to estimate skin doses during these treatments. Methods and Materials: Measurements of skin doses were taken using TLDs for 72 patients over 3 years of clinical treatments. Phantom studies were also undertaken to assess the uncertainties resulting from changes in beam quality and backscatter conditions in vivo. Results: Themore » mean measured skin dose was 2.9 {+-} 1.6 Gy, with 11% of readings higher than the prescription dose of 6 Gy, but none of these patients showed increased complications. Uncertainties due to beam hardening and backscatter reduction were small compared with overall accuracy. Conclusions: TLDs are a useful and effective method to measure in vivo skin doses in intraoperative radiotherapy and are recommended for the initial validation or any modification to the delivery of this technique. They are also an effective tool to show consistent and safe delivery on a more frequent basis or to determine doses to other critical structures as required.« less

Intraoperative neuromonitoring alerts that reverse with intervention: treatment paradox and what to do about it.

PubMed

Skinner, Stanley A; Holdefer, Robert N

2014-04-01

Intervention-mediated recovery from adversely changed evoked potential recordings may provide evidence for improved outcomes during neurophysiological intraoperative monitoring. However, these reversible signal changes (RSCs) are ambiguous because the patient's neurologic status cannot be known either at signal decline or after intervention. This article describes methods to reduce this ambiguity. Randomized control trials are not always possible or ethical. Recent thought on grading evidence has acknowledged that guidelines first described by Sir Austin Bradford Hill may support evidence for causation. Causality guidelines identified RSCs most likely to be truly positive in three reported studies. Diagnostic statistics were revised accordingly. A range of revised positive predictive values and likelihood ratios was calculated in the three studies, using causality guidelines. The revised data were similar to those reported for other diagnostic tests used in medicine. The RSCs may be assessed using causality guidelines for more accurate reporting of diagnostic statistics while preserving information related to surgical intervention and recovery that is lost with end of surgery diagnostics or when RSCs are ignored. A method is described for including RSCs in diagnostic statistics. This approach will more readily permit assessment of the value of neurophysiological intraoperative monitoring in prediction and prevention of neurologic deficits.

Assessment of the use of latissimus dorsi restoration during modified radical mastectomy in breast cancer patients

PubMed Central

Yang, Chao; Wang, Xinle; Zhang, Geng; Yang, Liu; Guo, Xuan; Wang, Xue; Song, Zhenchuan

2017-01-01

The incision area of modified radical mastectomy in breast cancer patients is associated with subcutaneous effusion and skin flap necrosis as the most common complications. The aim of the present study was to assess the effect of latissimus dorsi restoration during modified radical mastectomy in breast cancer patients by evaluating 365 cases. Among these cases, 185 received modified radical mastectomy combined with intraoperative latissimus dorsi restoration, while 180 received modified radical mastectomy alone. The flap tension, drainage fluid amount and extubation time were compared between the two methods. The flap tension in patients who received modified radical mastectomy combined with intraoperative latissimus dorsi restoration was significantly lower and the blood supply was better. After surgery, the drainage fluid amount was also significantly lower in these patients compared with the control group. Furthermore, the mean time to drainage tube removal was significantly shorter in these patients and the postoperative cosmetic outcome was superior. Thus, it was concluded that modified radical mastectomy combined with intraoperative latissimus dorsi restoration in breast cancer patients was associated with reduced drainage fluid effusion, shorter hospitalization time and decreased flap tension. Overall, this method appears to be potentially suitable for extensive application in the clinical setting. PMID:29285380

Patient-specific model-based segmentation of brain tumors in 3D intraoperative ultrasound images.

PubMed

Ilunga-Mbuyamba, Elisee; Avina-Cervantes, Juan Gabriel; Lindner, Dirk; Arlt, Felix; Ituna-Yudonago, Jean Fulbert; Chalopin, Claire

2018-03-01

Intraoperative ultrasound (iUS) imaging is commonly used to support brain tumor operation. The tumor segmentation in the iUS images is a difficult task and still under improvement because of the low signal-to-noise ratio. The success of automatic methods is also limited due to the high noise sensibility. Therefore, an alternative brain tumor segmentation method in 3D-iUS data using a tumor model obtained from magnetic resonance (MR) data for local MR-iUS registration is presented in this paper. The aim is to enhance the visualization of the brain tumor contours in iUS. A multistep approach is proposed. First, a region of interest (ROI) based on the specific patient tumor model is defined. Second, hyperechogenic structures, mainly tumor tissues, are extracted from the ROI of both modalities by using automatic thresholding techniques. Third, the registration is performed over the extracted binary sub-volumes using a similarity measure based on gradient values, and rigid and affine transformations. Finally, the tumor model is aligned with the 3D-iUS data, and its contours are represented. Experiments were successfully conducted on a dataset of 33 patients. The method was evaluated by comparing the tumor segmentation with expert manual delineations using two binary metrics: contour mean distance and Dice index. The proposed segmentation method using local and binary registration was compared with two grayscale-based approaches. The outcomes showed that our approach reached better results in terms of computational time and accuracy than the comparative methods. The proposed approach requires limited interaction and reduced computation time, making it relevant for intraoperative use. Experimental results and evaluations were performed offline. The developed tool could be useful for brain tumor resection supporting neurosurgeons to improve tumor border visualization in the iUS volumes.

[Preoperative fluid management contributes to the prevention of intraoperative hypothermia].

PubMed

Yatabe, Tomoaki; Yokoyama, Masataka

2011-07-01

Intraoperative hypothermia causes several unfavorable events such as surgical site infection and cardiovascular events. Therefore, during anesthesia, temperature is routinely regulated, mainly by using external heating devices. Recently, oral amino acid intake and intravenous amino acid or fructose infusion have been reported to prevent intraoperative hypothermia during general and regional anesthesia. Diet (nutrient)-induced thermogenesis is considered to help prevent intraoperative hypothermia. Since the Enhanced Recovery After Surgery (ERAS) protocol has been introduced, it has been used in perioperative management in many hospitals. Prevention of intraoperative hypothermia is included in this protocol. According to the protocol, anesthesiologists play an important role in both intraoperative and perioperative management. Management of optimal body temperature by preoperative fluid management alone may be difficult. To this end, preoperative fluid management and nutrient management strategies such as preoperative oral fluid intake and carbohydrate loading have the potential to contribute to the prevention of intraoperative hypothermia.

Intraoperative radiotherapy. Literature updating with an overview of results presented at the 6th International Symposium of Intraoperative Radiation Therapy.

PubMed

Calvo, F A; Santos, M; Azinovic, I

1998-01-01

Intraoperative radiotherapy is a technique that can be integrated into multidisciplinary treatment strategies in oncology. A radiation boost delivered with high energy electron beams can intensify locoregional antitumor therapy in patients undergoing cancer surgery. Intraoperative radiotherapy can increase the therapeutic index of the conventional combination of surgery and radiotherapy by improving the precision of radiation dose location, while decreasing the normal tissue damage in mobile structures and enhancing the biological effect of radiation when combined with surgical debulking. Intraoperative radiotherapy has been extensively investigated in clinical oncology in the last 15 years. Commercially available linear accelerators require minimal changes to be suitable for intraoperative radiotherapy. Its successful implementation in clinical protocols depends on the support given by the single institutions and on a clinical research-oriented mentality. Tumors where intraoperative radiotherapy as a treatment component has shown promising rates of local control include locally advanced rectal, gastric and gynecologic cancer, bone and soft tissue sarcoma. Intraoperative radiotherapy can be applied to brain tumors, head and neck cancer, NSCLC and pancreatic carcinoma.

Registration of MRI to Intraoperative Radiographs for Target Localization in Spinal Interventions

PubMed Central

De Silva, T; Uneri, A; Ketcha, M D; Reaungamornrat, S; Goerres, J; Jacobson, M W; Vogt, S; Kleinszig, G; Khanna, A J; Wolinsky, J-P; Siewerdsen, J H

2017-01-01

Purpose Decision support to assist in target vertebra localization could provide a useful aid to safe and effective spine surgery. Previous solutions have shown 3D-2D registration of preoperative CT to intraoperative radiographs to reliably annotate vertebral labels for assistance during level localization. We present an algorithm (referred to as MR-LevelCheck) to perform 3D-2D registration based on a preoperative MRI to accommodate the increasingly common clinical scenario in which MRI is used instead of CT for preoperative planning. Methods Straightforward adaptation of gradient/intensity-based methods appropriate to CT-to-radiograph registration is confounded by large mismatch and noncorrespondence in image intensity between MRI and radiographs. The proposed method overcomes such challenges with a simple vertebrae segmentation step using vertebra centroids as seed points (automatically defined within existing workflow). Forwards projections are computed using segmented MRI and registered to radiographs via gradient orientation (GO) similarity and the CMA-ES (Covariance-Matrix-Adaptation Evolutionary-Strategy) optimizer. The method was tested in an IRB-approved study involving 10 patients undergoing cervical, thoracic, or lumbar spine surgery following preoperative MRI. Results The method successfully registered each preoperative MRI to intraoperative radiographs and maintained desirable properties of robustness against image content mismatch and large capture range. Robust registration performance was achieved with projection distance error (PDE) (median ± iqr) = 4.3 ± 2.6 mm (median ± iqr) and 0% failure rate. Segmentation accuracy for the continuous max-flow method yielded Dice coefficient = 88.1 ± 5.2, Accuracy = 90.6 ± 5.7, RMSE = 1.8 ± 0.6 mm, and contour affinity ratio (CAR) = 0.82 ± 0.08. Registration performance was found to be robust for segmentation methods exhibiting RMSE < 3 mm and CAR > 0.50. Conclusion The MR-LevelCheck method provides a potentially valuable extension to a previously developed decision support tool for spine surgery target localization by extending its utility to preoperative MRI while maintaining characteristics of accuracy and robustness. PMID:28050972

The learning curve in short-stem THA: influence of the surgeon's experience on intraoperative adjustments due to intraoperative radiography.

PubMed

Loweg, Lennard; Kutzner, Karl Philipp; Trost, Matthias; Hechtner, Marlene; Drees, Philipp; Pfeil, Joachim; Schneider, Michael

2018-02-01

Short-stem THA has become increasingly popular over the last decade. However, implantation technique differs from conventional THA and thus possibly involves a distinct learning curve. The purpose of this study was to evaluate the value of intraoperative radiography and the influence of the surgeon's experience on intraoperative adjustments in short-stem THA. A total of 287 consecutive short-stem THAs, operated by a total of 24 senior consultants, consultants and residents in training, were prospectively included. Intraoperative radiography was performed after trial reduction. Preoperative planning and intraoperative outcome with regard to positioning, sizing of components as well as resulting offset and leg length were compared. Frequency, reason and type of intraoperative adjustments were documented in relation to the surgeon's experience. Operation time was assessed. One hundred and fifty-six (54.4%) procedures were carried out by one of three senior consultants, and a total of nine consultants and 12 residents in training performed 105 (36.6%) and 26 (9.0%) operations, respectively. In 121 cases (42.2%), intraoperative adjustments were made following intraoperative radiography. Intraoperative adjustments of one or more components were made by senior consultants in 51 cases (32.7%), by consultants in 53 cases (50.5%) and by residents in 17 cases (65.4%), respectively. The most common cause was undersizing of the stem. Operation time varied markedly between groups of surgeons. Short-stem THA involves a learning curve. Intraoperative radiography is decisive for prevention of malpositioning and undersizing of components, as well as loss of offset and leg length discrepancies. Hence, it should be considered mandatory, especially for less experienced surgeons.

Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas.

PubMed

Mehta, Gautam U; Oldfield, Edward H

2012-06-01

Cerebrospinal fluid leakage is a major complication of transsphenoidal surgery. An intraoperative CSF leak, which occurs in up to 50% of pituitary tumor cases, is the only modifiable risk factor for postoperative leaks. Although several techniques have been described for surgical repair when an intraoperative leak is noted, none has been proposed to prevent an intraoperative CSF leak. The authors postulated that intraoperative CSF drainage would diminish tension on the arachnoid, decrease the rate of intraoperative CSF leakage during surgery for larger tumors, and reduce the need for surgical repair of CSF leaks. The results of 114 transsphenoidal operations for pituitary macroadenoma performed without intraoperative CSF drainage were compared with the findings from 44 cases in which a lumbar subarachnoid catheter was placed before surgery to drain CSF at the time of dural exposure and tumor removal. Cerebrospinal fluid drainage reduced the rate of intraoperative CSF leakage from 41% to 5% (p < 0.001). This reduction occurred in macroadenomas with (from 57% to 5%, p < 0.001) and those without suprasellar extension (from 29% to 0%, p = 0.31). The rate of postoperative CSF leakage was similar (5% vs 5%), despite the fact that intraoperative CSF drainage reduced the need for operative repair (from 32% to 5%, p < 0.001). There were no significant catheter-related complications. Cerebrospinal fluid drainage during transsphenoidal surgery for macroadenomas reduces the rate of intraoperative CSF leaks. This preventative measure obviated the need for surgical repair of intraoperative CSF leaks using autologous fat graft placement, other operative techniques, postoperative lumbar drainage, and/or reoperation in most patients and is associated with minimal risks.

Image updating for brain deformation compensation in tumor resection

NASA Astrophysics Data System (ADS)

Fan, Xiaoyao; Ji, Songbai; Olson, Jonathan D.; Roberts, David W.; Hartov, Alex; Paulsen, Keith D.

2016-03-01

Preoperative magnetic resonance images (pMR) are typically used for intraoperative guidance in image-guided neurosurgery, the accuracy of which can be significantly compromised by brain deformation. Biomechanical finite element models (FEM) have been developed to estimate whole-brain deformation and produce model-updated MR (uMR) that compensates for brain deformation at different surgical stages. Early stages of surgery, such as after craniotomy and after dural opening, have been well studied, whereas later stages after tumor resection begins remain challenging. In this paper, we present a method to simulate tumor resection by incorporating data from intraoperative stereovision (iSV). The amount of tissue resection was estimated from iSV using a "trial-and-error" approach, and the cortical shift was measured from iSV through a surface registration method using projected images and an optical flow (OF) motion tracking algorithm. The measured displacements were employed to drive the biomechanical brain deformation model, and the estimated whole-brain deformation was subsequently used to deform pMR and produce uMR. We illustrate the method using one patient example. The results show that the uMR aligned well with iSV and the overall misfit between model estimates and measured displacements was 1.46 mm. The overall computational time was ~5 min, including iSV image acquisition after resection, surface registration, modeling, and image warping, with minimal interruption to the surgical flow. Furthermore, we compare uMR against intraoperative MR (iMR) that was acquired following iSV acquisition.

Real-time quantitative fluorescence imaging using a single snapshot optical properties technique for neurosurgical guidance

NASA Astrophysics Data System (ADS)

Valdes, Pablo A.; Angelo, Joseph; Gioux, Sylvain

2015-03-01

Fluorescence imaging has shown promise as an adjunct to improve the extent of resection in neurosurgery and oncologic surgery. Nevertheless, current fluorescence imaging techniques do not account for the heterogeneous attenuation effects of tissue optical properties. In this work, we present a novel imaging system that performs real time quantitative fluorescence imaging using Single Snapshot Optical Properties (SSOP) imaging. We developed the technique and performed initial phantom studies to validate the quantitative capabilities of the system for intraoperative feasibility. Overall, this work introduces a novel real-time quantitative fluorescence imaging method capable of being used intraoperatively for neurosurgical guidance.

Diffusion tractography: methods, validation and applications in patients with neurosurgical lesions.

PubMed

Leclercq, Delphine; Delmaire, Christine; de Champfleur, Nicolas Menjot; Chiras, Jacques; Lehéricy, Stéphane

2011-04-01

Diffusion tensor imaging (DTI) tractography is increasingly used in presurgical mapping in tumors located in eloquent areas since it is the only non invasive technique that permits in vivo dissection of white matter tracts. Concordance between the DTI tracts and subcortical electrical intraoperative mapping is high, and DTI tractography has proven useful to guide surgery. However, it presents limitations due to the technique and the tumor, which must be known before using the images in the operative room. This review focuses on the possibilities and limits of DTI imaging in intraoperative tumoral mapping and presents an overview of current knowledge. Copyright © 2011 Elsevier Inc. All rights reserved.

Tibial rotation kinematics subsequent to knee arthroplasty

PubMed Central

Collins, Duane J.; Khatib, Yasser H.; Parker, David A.; Jenkin, Deanne E.; Molnar, Robert B.

2015-01-01

Background The use of computer assisted joint replacement has facilitated precise intraoperative measurement of knee kinematics. The changes in “screw home mechanism” (SHM) resulting from Total Knee Arthroplasty (TKA) with different prostheses and constraints has not yet been accurately described. Methods A pilot study was first completed. Intraoperative kinematic data was collected two groups of 15 patients receiving different prostheses. Results On average, patients lost 5.3° of ER (SD = 6.1°). There was no significant difference between the prostheses or different prosthetic constraints. Conclusions There significant loss of SHM after TKA. Further research is required to understand its impact on patient function. PMID:25829754

Gamma-ray blind beta particle probe

DOEpatents

Weisenberger, Andrew G.

2001-01-01

An intra-operative beta particle probe is provided by placing a suitable photomultiplier tube (PMT), micro channel plate (MCP) or other electron multiplier device within a vacuum housing equipped with: 1) an appropriate beta particle permeable window; and 2) electron detection circuitry. Beta particles emitted in the immediate vicinity of the probe window will be received by the electron multiplier device and amplified to produce a detectable signal. Such a device is useful as a gamma insensitive, intra-operative, beta particle probe in surgeries where the patient has been injected with a beta emitting radiopharmaceutical. The method of use of such a device is also described, as is a position sensitive such device.

Increasing the automation of a 2D-3D registration system.

PubMed

Varnavas, Andreas; Carrell, Tom; Penney, Graeme

2013-02-01

Routine clinical use of 2D-3D registration algorithms for Image Guided Surgery remains limited. A key aspect for routine clinical use of this technology is its degree of automation, i.e., the amount of necessary knowledgeable interaction between the clinicians and the registration system. Current image-based registration approaches usually require knowledgeable manual interaction during two stages: for initial pose estimation and for verification of produced results. We propose four novel techniques, particularly suited to vertebra-based registration systems, which can significantly automate both of the above stages. Two of these techniques are based upon the intraoperative "insertion" of a virtual fiducial marker into the preoperative data. The remaining two techniques use the final registration similarity value between multiple CT vertebrae and a single fluoroscopy vertebra. The proposed methods were evaluated with data from 31 operations (31 CT scans, 419 fluoroscopy images). Results show these methods can remove the need for manual vertebra identification during initial pose estimation, and were also very effective for result verification, producing a combined true positive rate of 100% and false positive rate equal to zero. This large decrease in required knowledgeable interaction is an important contribution aiming to enable more widespread use of 2D-3D registration technology.

No association between intraoperative hypothermia or supplemental protective drug and neurologic outcomes in patients undergoing temporary clipping during cerebral aneurysm surgery: findings from the Intraoperative Hypothermia for Aneurysm Surgery Trial.

PubMed

Hindman, Bradley J; Bayman, Emine O; Pfisterer, Wolfgang K; Torner, James C; Todd, Michael M

2010-01-01

Although hypothermia and barbiturates improve neurologic outcomes in animal temporary focal ischemia models, the clinical efficacy of these interventions during temporary occlusion of the cerebral vasculature during intracranial aneurysm surgery (temporary clipping) is not established. A post hoc analysis of patients from the Intraoperative Hypothermia for Aneurysm Surgery Trial who underwent temporary clipping was performed. Univariate and multivariate logistic regression methods were used to test for associations between hypothermia, supplemental protective drug, and short- (24-h) and long-term (3-month) neurologic outcomes. An odds ratio more than 1 denotes better outcome. Patients undergoing temporary clipping (n = 441) were assigned to intraoperative hypothermia (33.3 degrees +/- 0.8 degrees C, n = 208) or normothermia (36.7 degrees +/- 0.5 degrees C, n = 233), with 178 patients also receiving supplemental protective drug (thiopental or etomidate) during temporary clipping. Three months after surgery, 278 patients (63%) had good outcome (Glasgow Outcome Score = 1). Neither hypothermia (P = 0.847; odds ratio = 1.043, 95% CI = 0.678-1.606) nor supplemental protective drug (P = 0.835; odds ratio = 1.048, 95% CI = 0.674-1.631) were associated with 3-month Glasgow Outcome Score. The effect of supplemental protective drug did not significantly vary with temperature. The effects of hypothermia and protective drug did not significantly vary with temporary clip duration. Similar findings were made for 24-h neurologic status and 3-month Neuropsychological Composite Score. In the Intraoperative Hypothermia for Aneurysm Surgery Trial, neither systemic hypothermia nor supplemental protective drug affected short- or long-term neurologic outcomes of patients undergoing temporary clipping.

Effects of Hypotensive Anesthesia on Reducing Intraoperative Blood Loss, Duration of Operation, and Quality of Surgical Field During Orthognathic Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PubMed

Lin, Susie; McKenna, Samuel J; Yao, Chuan-Fong; Chen, Yu-Ray; Chen, Chit

2017-01-01

The objective of this study was to evaluate the efficacy of hypotensive anesthesia in reducing intraoperative blood loss, decreasing operation time, and improving the quality of the surgical field during orthognathic surgery. A systematic review and meta-analysis of randomized controlled trials addressing these issues were carried out. An electronic database search was performed. The risk of bias was evaluated with the Jadad Scale and Delphi List. The inverse variance statistical method and a random-effects model were used. Ten randomized controlled trials were included for analysis. Our meta-analysis indicated that hypotensive anesthesia reduced intraoperative blood loss by a mean of about 169 mL. Hypotensive anesthesia was not shown to reduce the operation time for orthognathic surgery, but it did improve the quality of the surgical field. Subgroup analysis indicated that for blood loss in double-jaw surgery, the weighted mean difference favored the hypotensive group, with a reduction in blood loss of 175 mL, but no statistically significant reduction in blood loss was found for anterior maxillary osteotomy. If local anesthesia with epinephrine was used in conjunction with hypotensive anesthesia, the reduction in intraoperative blood loss was increased to 254.93 mL. Hypotensive anesthesia was effective in reducing blood loss and improving the quality of the surgical field, but it did not reduce the operation time for orthognathic surgery. The use of local anesthesia in conjunction with hypotensive general anesthesia further reduced the amount of intraoperative blood loss for orthognathic surgery. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Cerebral hyperperfusion following carotid endarterectomy: diagnostic utility of intraoperative transcranial Doppler ultrasonography compared with single-photon emission computed tomography study.

PubMed

Ogasawara, Kuniaki; Inoue, Takashi; Kobayashi, Masakazu; Endo, Hidehoko; Yoshida, Kenji; Fukuda, Takeshi; Terasaki, Kazunori; Ogawa, Akira

2005-02-01

Cerebral hyperperfusion syndrome is a rare but serious complication of carotid endarterectomy (CEA). The aim of the present study was to determine whether intraoperative blood flow velocity (BFV) monitoring in the middle cerebral artery (MCA) by using transcranial Doppler ultrasonography (TCD) could be used as a reliable technique to detect cerebral hyperperfusion following CEA by comparing findings with those of brain single photon emission CT (SPECT). Intraoperative BFV monitoring was attempted in 67 patients undergoing CEA for treatment of ipsilateral internal carotid artery (ICA) stenosis (> or =70%). Cerebral blood flow (CBF) was also assessed using SPECT, which was performed before and immediately after CEA. Intraoperative BFV monitoring was achieved in 60 patients. Of the 60 patients, post-CEA hyperperfusion (CBF increase > or =100%, compared with preoperative values) was observed in six patients. The sensitivity, specificity, and positive predictive value of the BFV increases immediately after declamping of the ICA for detecting post-CEA hyperperfusion was 100%, 94% and 67%, respectively, with a cut-off point 2.0-fold that of preclamping BFV. The sensitivity and specificity of the BFV increases at the end of the procedure for detecting post-CEA hyperperfusion were 100% for both parameters, with cut-off points of 2.0- to 2.2-fold BFV of preclamping value. Hyperperfusion syndrome developed in two patients with post-CEA hyperperfusion, but intracerebral hemorrhage did not occur. In one of these two patients, BFV monitoring was not possible because of failure to obtain an adequate bone window. Intraoperative MCA BFV monitoring by using TCD is a less reliable method to detect cerebral hyperperfusion following CEA than postoperative MCA BFV monitoring, provided adequate monitoring can be achieved.

Inhalation of volatile anesthetics via a laryngeal mask is associated with lower incidence of intraoperative awareness in non-critically ill patients

PubMed Central

Wang, Jen-Huang; Hsieh, Shiu-Ying; Huang, Shian-Che

2017-01-01

Background Increased incidence of intraoperative awareness was reported in critically ill patients during major operations, particularly under total intravenous (TIVA) or endotracheal general anesthesia (ETGA). However, the incidence and effect of anesthesia techniques on awareness in generally healthy, non-critically ill patients during operations have yet to receive significant attention. Methods and results This retrospective matched case-control study was conducted between January 2009 to December 2014. Surgical patients (ASA physical status I-III) whom reported intraoperative awareness during this study period were interviewed and their medical records were reviewed. The potential risk factors for awareness were compared with the non-case matched controls, who were randomly selected from the database. A total of 61436 patients were included and 16 definite cases of intraoperative awareness were identified. Patients who received ETGA and TIVA had significantly higher incidence of developing awareness compared to those who were anesthetized using laryngeal masks (LMA) (P = 0.03). Compared with the matched controls (n = 80), longer anesthesia time was associated with increased incidence of awareness (odds ratio 2.04; 95% CI 1.30–3.20, per hour increase). Perioperative use of muscle relaxant was also associated with increased incidence of awareness, while significantly lower incidence of awareness was found in patients who were anesthetized with volatile anesthetics. Conclusions The overall incidence of awareness was 0.023% in the ASA≤ III surgical patients who received general anesthesia. Anesthesia with a laryngeal mask under spontaneous ventilation and supplemented with volatile anesthetics may be the preferred anesthesia technique in generally healthy patients in order to provide a lower risk of intraoperative awareness. PMID:29073151

Evaluation of Transmitral Pressure Gradients in the Intraoperative Echocardiographic Diagnosis of Mitral Stenosis after Mitral Valve Repair

PubMed Central

Segal, Scott; Fox, John A.; Eltzschig, Holger K.; Shernan, Stanton K.

2011-01-01

Objective Acute mitral stenosis (MS) following mitral valve (MV) repair is a rare but severe complication. We hypothesize that intraoperative echocardiography can be utilized to diagnose iatrogenic MS immediately after MV repair. Methods The medical records of 552 consecutive patients undergoing MV repair at a single institution were reviewed. Post-cardiopulmonary bypass peak and mean transmitral pressure gradients (TMPG), and pressure half time (PHT) were obtained from intraoperative transesophageal echocardiographic (TEE) examinations in each patient. Results Nine patients (9/552 = 1.6%) received a reoperation for primary MS, prior to hospital discharge. Interestingly, all of these patients already showed intraoperative post-CPB mean and peak TMPGs that were significantly higher compared to values for those who did not: 10.7±4.8 mmHg vs 2.9±1.6 mmHg; p<0.0001 and 22.9±7.9 mmHg vs 7.6±3.7 mmHg; p<0.0001, respectively. However, PHT varied considerably (87±37 ms; range: 20–439 ms) within the entire population, and only weakly predicted the requirement for reoperation (113±56 vs. 87±37 ms, p = 0.034). Receiver operating characteristic curves showed strong discriminating ability for mean gradients (AUC = 0.993) and peak gradients (area under the curve, AUC = 0.996), but poor performance for PHT (AUC = 0.640). A value of ≥7 mmHg for mean, and ≥17 mmHg for peak TMPG, best separated patients who required reoperation for MS from those who did not. Conclusions Intraoperative TEE diagnosis of a peak TMPG ≥17 mmHg or mean TMPG ≥7 mmHg immediately following CPB are suggestive of clinically relevant MS after MV repair. PMID:22087230

Validation of Open-Heart Intraoperative Risk score to predict a prolonged intensive care unit stay for adult patients undergoing cardiac surgery with cardiopulmonary bypass

PubMed Central

Tribuddharat, Sirirat; Sathitkarnmanee, Thepakorn; Ngamsaengsirisup, Kriangsak; Wongbuddha, Chawalit

2018-01-01

Background A prolonged stay in an intensive care unit (ICU) after cardiac surgery with cardiopulmonary bypass (CPB) increases the cost of care as well as morbidity and mortality. Several predictive models aim at identifying patients at risk of prolonged ICU stay after cardiac surgery with CPB, but almost all of them involve a preoperative assessment for proper resource management, while one – the Open-Heart Intraoperative Risk (OHIR) score – focuses on intra-operative manipulatable risk factors for improving anesthetic care and patient outcome. Objective We aimed to revalidate the OHIR score in a different context. Materials and methods The ability of the OHIR score to predict a prolonged ICU stay was assessed in 123 adults undergoing cardiac surgery (both coronary bypass graft and valvular surgery) with CPB at two tertiary university hospitals between January 2013 and December 2014. The criteria for a prolonged ICU stay matched a previous study (ie, a stay longer than the median). Results The area under the receiver operating characteristic curve of the OHIR score to predict a prolonged ICU stay was 0.95 (95% confidence interval 0.90–1.00). The respective sensitivity, specificity, positive predictive value, and accuracy of an OHIR score of ≥3 to discriminate a prolonged ICU stay was 93.10%, 98.46%, 98.18%, and 95.9%. Conclusion The OHIR score is highly predictive of a prolonged ICU stay among intraopera-tive patients undergoing cardiac surgery with CPB. The OHIR comprises of six risk factors, five of which are manipulatable intraoperatively. The OHIR can be used to identify patients at risk as well as to improve the outcome of those patients. PMID:29379295

Liberal perioperative fluid administration is an independent risk factor for morbidity and is associated with longer hospital stay after rectal cancer surgery.

PubMed

Boland, M R; Reynolds, I; McCawley, N; Galvin, E; El-Masry, S; Deasy, J; McNamara, D A

2017-02-01

INTRODUCTION Recent studies have advocated the use of perioperative fluid restriction in patients undergoing major abdominal surgery as part of an enhanced recovery protocol. Series reported to date include a heterogenous group of high- and low-risk procedures but few studies have focused on rectal cancer surgery alone. The aim of this study was to assess the effects of perioperative fluid volumes on outcomes in patients undergoing elective rectal cancer resection. METHODS A prospectively maintained database of patients with rectal cancer who underwent elective surgery over a 2-year period was reviewed. Total volume of fluid received intraoperatively was calculated, as well as blood products required in the perioperative period. The primary outcome was postoperative morbidity (Clavien-Dindo grade I-IV) and the secondary outcomes were length of stay and major morbidity (Clavien-Dindo grade III-IV). RESULTS Over a 2-year period (2012-2013), 120 patients underwent elective surgery with curative intent for rectal cancer. Median total intraoperative fluid volume received was 3680ml (range 1200-9670ml); 65/120 (54.1%) had any complications, with 20/120 (16.6%) classified as major (Clavien-Dindo grade III-IV). Intraoperative volume >3500ml was an independent risk factor for the development of postoperative all-cause morbidity (P=0.02) and was associated with major morbidity (P=0.09). Intraoperative fluid volumes also correlated with length of hospital stay (Pearson's correlation coefficient 0.33; P<0.01). CONCLUSIONS Intraoperative fluid infusion volumes in excess of 3500ml are associated with increased morbidity and length of stay in patients undergoing elective surgery for rectal cancer.

Effect of brain shift on the creation of functional atlases for deep brain stimulation surgery

PubMed Central

Pallavaram, Srivatsan; Remple, Michael S.; Neimat, Joseph S.; Kao, Chris; Konrad, Peter E.; D’Haese, Pierre-François

2011-01-01

Purpose In the recent past many groups have tried to build functional atlases of the deep brain using intra-operatively acquired information such as stimulation responses or micro-electrode recordings. An underlying assumption in building such atlases is that anatomical structures do not move between pre-operative imaging and intra-operative recording. In this study, we present evidences that this assumption is not valid. We quantify the effect of brain shift between pre-operative imaging and intra-operative recording on the creation of functional atlases using intra-operative somatotopy recordings and stimulation response data. Methods A total of 73 somatotopy points from 24 bilateral subthalamic nucleus (STN) implantations and 52 eye deviation stimulation response points from 17 bilateral STN implantations were used. These points were spatially normalized on a magnetic resonance imaging (MRI) atlas using a fully automatic non-rigid registration algorithm. Each implantation was categorized as having low, medium or large brain shift based on the amount of pneumocephalus visible on post-operative CT. The locations of somatotopy clusters and stimulation maps were analyzed for each category. Results The centroid of the large brain shift cluster of the somatotopy data (posterior, lateral, inferior: 3.06, 11.27, 5.36 mm) was found posterior, medial and inferior to that of the medium cluster (2.90, 13.57, 4.53 mm) which was posterior, medial and inferior to that of the low shift cluster (1.94, 13.92, 3.20 mm). The coordinates are referenced with respect to the mid-commissural point. Euclidean distances between the centroids were 1.68, 2.44 and 3.59 mm, respectively for low-medium, medium-large and low-large shift clusters. We found similar trends for the positions of the stimulation maps. The Euclidian distance between the highest probability locations on the low and medium-large shift maps was 4.06 mm. Conclusion The effect of brain shift in deep brain stimulation (DBS) surgery has been demonstrated using intra-operative somatotopy recordings as well as stimulation response data. The results not only indicate that considerable brain shift happens before micro-electrode recordings in DBS but also that brain shift affects the creation of accurate functional atlases. Therefore, care must be taken when building and using such atlases of intra-operative data and also when using intra-operative data to validate anatomical atlases. PMID:20033503

The surgical learning curve and accuracy of minimally invasive lumbar pedicle screw placement using CT based computer-assisted navigation plus continuous electromyography monitoring – a retrospective review of 627 screws in 150 patients

PubMed Central

McMillen, Jason

2014-01-01

Objective This study retrospectively assessed the accuracy of placement of lumbar pedicle screws placed by a single surgeon using a minimally-invasive, intra-operative CT-based computer navigated technique in combination with continuous electromyography (EMG) monitoring. The rates of incorrectly positioned screws were reviewed in the context of the surgeon's experience and learning curve. Methods Data was retrospectively reviewed from all consecutive minimally invasive lumbar fusions performed by the primary author over a period of over 4 years from April 2008 until October 2012. All cases that had utilized computer-assisted intra-operative CT-based image guidance and continuous EMG monitoring to guide percutaneous pedicle screw placement were analysed for the rates of malposition of the pedicle screws. Pedicle screw malposition was defined as having occurred if the screw trajectory was adjusted intraoperatively due to positive EMG responses, or due to breach of the pedicle cortex by more than 2mm on intraoperative CT imaging performed at the end of the instrumentation procedure. Further analysis of the data was undertaken to determine if the rates of malposition changed with the surgeon's experience with the technique. Results Six hundred and twenty-seven pedicle screws were placed in one hundred and fifty patients. The overall rate of intraoperative malposition and subsequent adjustment of pedicle screw placement was 3.8% (24 of 627 screws). Screw malposition was detected by intraoperative CT imaging. Warning of potential screw misplacement was provided by use of the EMG monitoring. With increased experience with the technique, rates of intraoperative pedicle screw malposition were found to decrease from 5.1% of screws in the first fifty patients, to 2.0% in the last 50 patients. Only one screw was suboptimally placed at the end of surgery, which did not result in a neurological deficit. Conclusion The use of CT-based computer-assisted navigation in combination with continuous EMG monitoring during percutaneous transpedicular screw placement results in very low rates of malposition and neural injury that compare favourably with previously reported rates. Pedicle screw placement accuracy continues to improve as the surgeon becomes more experienced with the technique. PMID:25694919

Usefulness of intraoperative ultrasonography in liver resections due to colon cancer metastasis.

PubMed

Lucchese, Angélica Maria; Kalil, Antônio Nocchi; Schwengber, Alex; Suwa, Eiji; Rolim de Moura, Gabriel Garcia

2015-08-01

Intraoperative ultrasonography (IOUS) of the liver has been used both as an aid for intraoperative anatomical definition and for the detection of new lesions. The present study aimed to evaluate the impact of IOUS and to identify factors that can predict the detection of new lesions intraoperatively. In this observational and prospective study, with a cross-sectional design, patients with colorectal cancer metastases who underwent hepatectomy were selected. Abdominal computed tomography, magnetic resonance imaging, and positron emission tomography were the preoperative evaluation tests. All patients underwent IOUS performed by the same surgeon. The intraoperative findings were compared with the preoperative tests results. In total, 56 hepatectomies were evaluated. Half of the patients were men, with a mean age of 57 (30-85) years. New lesions were found intraoperatively in 12 patients (21.4% of cases) and were detected on both palpation and ultrasonography in 11 of these patients. Ultrasonography helped to revise the surgical plans by providing additional information in 35.7% of cases. On multivariate analysis, the presence of more than 4 preoperative nodules was predictive of the intraoperative occurrence of new lesions. IOUS remains the only way to evaluate the relationships between tumors, liver vascular structures, and bile ducts intraoperatively. Alone, IOUS was not useful for identifying new lesions intraoperatively, as all new lesions were also detected on palpation. The number of lesions diagnosed on preoperative tests influenced the probability of identifying new lesions intraoperatively. There may be additional influential factors. Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

Fluorescence lifetime-based contrast enhancement of indocyanine green-labeled tumors

NASA Astrophysics Data System (ADS)

Kumar, Anand T. N.; Carp, Stefan A.; Yang, Jing; Ross, Alana; Medarova, Zdravka; Ran, Chongzhao

2017-04-01

Although the development of tumor-targeted fluorescent probes is a major area of investigation, it will be several years before these probes are realized for clinical use. Here, we report an approach that employs indocyanine-green (ICG), a clinically approved, nontargeted dye, in conjunction with fluorescence lifetime (FLT) detection to provide high accuracy for tumor-tissue identification in mouse models of subcutaneous human breast and brain tmors. The improved performance relies on the distinct FLTs of ICG within tumors versus tissue autofluorescence and is further aided by the well-known enhanced permeability and retention of ICG in tumors and the clearance of ICG from normal tissue several hours after intravenous injection. We demonstrate that FLT detection can provide more than 98% sensitivity and specificity, and a 10-fold reduction in error rates compared to intensity-based detection. Our studies suggest the significant potential of FLT-contrast for accurate tumor-tissue identification using ICG and other targeted probes under development, both for intraoperative imaging and for ex-vivo margin assessment of surgical specimens.

Use of cognitive task analysis to guide the development of performance-based assessments for intraoperative decision making.

PubMed

Pugh, Carla M; DaRosa, Debra A

2013-10-01

There is a paucity of performance-based assessments that focus on intraoperative decision making. The purpose of this article is to review the performance outcomes and usefulness of two performance-based assessments that were developed using cognitive task analysis (CTA) frameworks. Assessment-A used CTA to create a "think aloud" oral examination that was administered while junior residents (PGY 1-2's, N = 69) performed a porcine-based laparoscopic cholecystectomy. Assessment-B used CTA to create a simulation-based, formative assessment of senior residents' (PGY 4-5's, N = 29) decision making during a laparoscopic ventral hernia repair. In addition to survey-based assessments of usefulness, a multiconstruct evaluation was performed using eight variables. When comparing performance outcomes, both approaches revealed major deficiencies in residents' intraoperative decision-making skills. Multiconstruct evaluation of the two CTA approaches revealed assessment method advantages for five of the eight evaluation areas: (1) Cognitive Complexity, (2) Content Quality, (3) Content Coverage, (4) Meaningfulness, and (5) Transfer and Generalizability. The two CTA performance assessments were useful in identifying significant training needs. While there are pros and cons to each approach, the results serve as a useful blueprint for program directors seeking to develop performance-based assessments for intraoperative decision making. Reprint & Copyright © 2013 Association of Military Surgeons of the U.S.

The Usefulness of Virtual Fluoroscopic Preprocedural Planning During Percutaneous Transhepatic Biliary Drainage

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kinoshita, Mitsuhiro, E-mail: kinoshita.3216@tokushima-u.ac.jp; Shirono, Ryozo; Takechi, Katsuya

Purpose To retrospectively evaluate the usefulness of virtual fluoroscopic preprocedural planning (VFPP) in the percutaneous transhepatic biliary drainage (PTBD) procedure.Materials and MethodsTwenty-two patients who were treated by PTBD were included in this study. Twelve patients were treated using PTBD intraoperative referencing coronal computed tomography (CT) images (i.e., coronal CT group), and ten patients were treated using PTBD intraoperative referencing VFPP images (i.e., VFPP group). To analyze the effect of the intraoperative referencing VFPP image, the VFPP group was retrospectively compared with the coronal CT group.ResultsThe characteristics of both patient groups were not statistically significantly different. There were no significant differencesmore » in the targeted bile duct, diameter and depth of the target bile, breath-holding ability, number of targeted bile duct puncture attempts, change in the targeted bile duct, and exchange of the drainage catheter. However, the X-ray fluoroscopy time and the procedure time were significantly shorter in the VFPP group than in the coronal CT group (196 vs. 334 s, P < 0.05; and 16.0 vs. 27.2 min, P < 0.05).ConclusionIntraoperative referencing using the VFPP imaging in PTBD intuitively can be a useful tool for better localization of the guidewire in the bile duct and thereby shorten the X-ray fluoroscopy time and procedure time while minimizing radiation exposure and complications.« less

Intra-operative characterisation of subthalamic oscillations in Parkinson’s disease

PubMed Central

Geng, Xinyi; Xu, Xin; Horn, Andreas; Li, Ningfei; Ling, Zhipei; Brown, Peter; Wang, Shouyan

2018-01-01

Objective This study aims to use the activities recorded directly from the deep brain stimulation (DBS) electrode to address the focality and distinct nature of the local field potential (LFP) activities of different frequency. Methods Pre-operative and intra-operative magnetic resonance imaging (MRI) were acquired from patients with Parkinson’s disease (PD) who underwent DBS in the subthalamic nucleus and intra-operative LFP recording at rest and during cued movements. Images were reconstructed and 3-D visualized using Lead-DBS® toolbox to determine the coordinates of contact. The resting spectral power and movement-related power modulation of LFP oscillations were estimated. Results Both subthalamic LFP activity recorded at rest and its modulation by movement had focal maxima in the alpha, beta and gamma bands. The spatial distribution of alpha band activity and its modulation was significantly different to that in the beta band. Moreover, there were significant differences in the scale and timing of movement related modulation across the frequency bands. Conclusion Subthalamic LFP activities within specific frequency bands can be distinguished by spatial topography and pattern of movement related modulation. Significance Assessment of the frequency, focality and pattern of movement related modulation of subthalamic LFPs reveals a heterogeneity of neural population activity in this region. This could potentially be leveraged to finesse intra-operative targeting and post-operative contact selection. PMID:29567582

Can we trust intraoperative culture results in nonunions?

PubMed

Palmer, Michael P; Altman, Daniel T; Altman, Gregory T; Sewecke, Jeffrey J; Ehrlich, Garth D; Hu, Fen Z; Nistico, Laura; Melton-Kreft, Rachel; Gause, Trent M; Costerton, John W

2014-07-01

To identify the presence of bacterial biofilms in nonunions comparing molecular techniques (multiplex polymerase chain reaction and mass spectrometry, fluorescent in situ hybridization) with routine intraoperative cultures. Thirty-four patients with nonunions were scheduled for surgery and enrolled in this ongoing prospective study. Intraoperative specimens were collected from removed implants, surrounding tissue membrane, and local soft tissue followed by standard culture analysis, Ibis's second generation molecular diagnostics (Ibis Biosystems), and bacterial 16S rRNA-based fluorescence in situ hybridization (FISH). Confocal microscopy was used to visualize the tissue specimens reacted with the FISH probes, which were chosen based on the Ibis analysis. Thirty-four patient encounters were analyzed. Eight were diagnosed as infected nonunions by positive intraoperative culture results. Ibis confirmed the presence of bacteria in all 8 samples. Ibis identified bacteria in a total of 30 of 34 encounters, and these data were confirmed by FISH. Twenty-two of 30 Ibis-positive samples were culture-negative. Four samples were negative by all methods of analysis. No samples were positive by culture, but negative by molecular techniques. Our preliminary data indicate that molecular diagnostics are more sensitive for identifying bacteria than cultures in cases of bony nonunion. This is likely because of the inability of cultures to detect biofilms and bacteria previously exposed to antibiotic therapy. Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Intraoperative optical coherence tomography: past, present, and future

PubMed Central

Ehlers, J P

2016-01-01

To provide an overview of the current state of intraoperative optical coherence tomography (OCT). Literature review of studies pertaining to intraoperative OCT examining both the technology aspects of the imaging platform and the current evidence for patient care. Over the last several years, there have been significant advances in integrative technology for intraoperative OCT. This has resulted in the development of multiple microscope-integrated systems and a rapidly expanding field of image-guided surgical care. Multiple studies have demonstrated the potential role for intraoperative OCT in facilitating surgeon understanding of the surgical environment, tissue configuration, and overall changes to anatomy. In fact, the PIONEER and DISCOVER studies, both demonstrated a potential significant percentage of cases that intraoperative OCT alters surgical decision-making in both anterior and posterior segment surgery. Current areas of exploration and development include OCT-compatible instrumentation, automated tracking, intraoperative OCT software platforms, and surgeon feedback/visualization platforms. Intraoperative OCT is an emerging technology that holds promise for enhancing the surgical care of both anterior segment and posterior segment conditions. Hurdles remain for adoption and widespread utilization, including cost, optimized feedback platforms, and more definitive value for individualized surgical care with image guidance. PMID:26681147

Fluorescently labeled bevacizumab in human breast cancer: defining the classification threshold

NASA Astrophysics Data System (ADS)

Koch, Maximilian; de Jong, Johannes S.; Glatz, Jürgen; Symvoulidis, Panagiotis; Lamberts, Laetitia E.; Adams, Arthur L. L.; Kranendonk, Mariëtte E. G.; Terwisscha van Scheltinga, Anton G. T.; Aichler, Michaela; Jansen, Liesbeth; de Vries, Jakob; Lub-de Hooge, Marjolijn N.; Schröder, Carolien P.; Jorritsma-Smit, Annelies; Linssen, Matthijs D.; de Boer, Esther; van der Vegt, Bert; Nagengast, Wouter B.; Elias, Sjoerd G.; Oliveira, Sabrina; Witkamp, Arjen J.; Mali, Willem P. Th. M.; Van der Wall, Elsken; Garcia-Allende, P. Beatriz; van Diest, Paul J.; de Vries, Elisabeth G. E.; Walch, Axel; van Dam, Gooitzen M.; Ntziachristos, Vasilis

2017-07-01

In-vivo fluorescently labelled drug (bevacizumab) breast cancer specimen where obtained from patients. We propose a new structured method to determine the optimal classification threshold in targeted fluorescence intra-operative imaging.

Intraoperative computed tomography.

PubMed

Tonn, J C; Schichor, C; Schnell, O; Zausinger, S; Uhl, E; Morhard, D; Reiser, M

2011-01-01

Intraoperative computed tomography (iCT) has gained increasing impact among modern neurosurgical techniques. Multislice CT with a sliding gantry in the OR provides excellent diagnostic image quality in the visualization of vascular lesions as well as bony structures including skull base and spine. Due to short acquisition times and a high spatial and temporal resolution, various modalities such as iCT-angiography, iCT-cerebral perfusion and the integration of intraoperative navigation with automatic re-registration after scanning can be performed. This allows a variety of applications, e.g. intraoperative angiography, intraoperative cerebral perfusion studies, update of cerebral and spinal navigation, stereotactic procedures as well as resection control in tumour surgery. Its versatility promotes its use in a multidisciplinary setting. Radiation exposure is comparable to standard CT systems outside the OR. For neurosurgical purposes, however, new hardware components (e.g. a radiolucent headholder system) had to be developed. Having a different range of applications compared to intraoperative MRI, it is an attractive modality for intraoperative imaging being comparatively easy to install and cost efficient.

Safety, efficacy, and cost of intraoperative indocyanine green angiography compared to intraoperative catheter angiography in cerebral aneurysm surgery.

PubMed

Hardesty, Douglas A; Thind, Harjot; Zabramski, Joseph M; Spetzler, Robert F; Nakaji, Peter

2014-08-01

Intraoperative angiography in cerebrovascular neurosurgery can drive the repositioning or addition of aneurysm clips. Our institution has switched from a strategy of intraoperative digital subtraction angiography (DSA) universally, to a strategy of indocyanine green (ICG) videoangiography with DSA on an as-needed basis. We retrospectively evaluated whether the rates of perioperative stroke, unexpected postoperative aneurysm residual, or parent vessel stenosis differed in 100 patients from each era (2002, "DSA era"; 2007, "ICG era"). The clip repositioning rate for neck residual or parent vessel stenosis did not differ significantly between the two eras. There were no differences in the rate of perioperative stroke or rate of false-negative studies. The per-patient cost of intraoperative imaging within the DSA era was significantly higher than in the ICG era. The replacement of routine intraoperative DSA with ICG videoangiography and selective intraoperative DSA in cerebrovascular aneurysm surgery is safe and effective. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.

Multimodal correlation and intraoperative matching of virtual models in neurosurgery

NASA Technical Reports Server (NTRS)

Ceresole, Enrico; Dalsasso, Michele; Rossi, Aldo

1994-01-01

The multimodal correlation between different diagnostic exams, the intraoperative calibration of pointing tools and the correlation of the patient's virtual models with the patient himself, are some examples, taken from the biomedical field, of a unique problem: determine the relationship linking representation of the same object in different reference frames. Several methods have been developed in order to determine this relationship, among them, the surface matching method is one that gives the patient minimum discomfort and the errors occurring are compatible with the required precision. The surface matching method has been successfully applied to the multimodal correlation of diagnostic exams such as CT, MR, PET and SPECT. Algorithms for automatic segmentation of diagnostic images have been developed to extract the reference surfaces from the diagnostic exams, whereas the surface of the patient's skull has been monitored, in our approach, by means of a laser sensor mounted on the end effector of an industrial robot. An integrated system for virtual planning and real time execution of surgical procedures has been realized.

Recent advances in photodynamic diagnosis of gastric cancer using 5-aminolevulinic acid.

PubMed

Koizumi, Noriaki; Harada, Yoshinori; Minamikawa, Takeo; Tanaka, Hideo; Otsuji, Eigo; Takamatsu, Tetsuro

2016-01-21

Photodynamic diagnosis based on 5-aminolevulinic acid-induced protoporphyrin IX has been clinically applied in many fields based upon its evidenced efficacy and adequate safety. In order to establish a personalized medicine approach for treating gastric cancer patients, rapid intraoperative detection of malignant lesions has become important. Feasibility of photodynamic diagnosis using 5-aminolevulinic acid for gastric cancer patients has been investigated, especially for the detection of peritoneal dissemination and lymph node metastasis. This method enables intraoperative real-time fluorescence detection of peritoneal dissemination, exhibiting higher sensitivity than white light observation without histopathological examination. The method also enables detection of metastatic foci within excised lymph nodes, exhibiting a diagnostic accuracy comparable to that of a current molecular diagnostics technique. Although several complicating issues still need to be resolved, such as the effect of tissue autofluorescence and the insufficient depth penetration of excitation light, this simple and rapid method has the potential to become a useful diagnostic tool for gastric cancer, as well as urinary bladder cancer and glioma.

Intraoperative magnetic resonance imaging with the magnetom open scanner: concepts, neurosurgical indications, and procedures: a preliminary report.

PubMed

Steinmeier, R; Fahlbusch, R; Ganslandt, O; Nimsky, C; Buchfelder, M; Kaus, M; Heigl, T; Lenz, G; Kuth, R; Huk, W

1998-10-01

Intraoperative magnetic resonance imaging (MRI) is now available with the General Electric MRI system for dedicated intraoperative use. Alternatively, non-dedicated MRI systems require fewer specific adaptations of instrumentation and surgical techniques. In this report, clinical experiences with such a system are presented. All patients were surgically treated in a "twin operating theater," consisting of a conventional operating theater with complete neuronavigation equipment (StealthStation and MKM), which allowed surgery with magnetically incompatible instruments, conventional instrumentation and operating microscope, and a radiofrequency-shielded operating room designed for use with an intraoperative MRI scanner (Magnetom Open; Siemens AG, Erlangen, Germany). The Magnetom Open is a 0.2-T MRI scanner with a resistive magnet and specific adaptations that are necessary to integrate the scanner into the surgical environment. The operating theaters lie close together, and patients can be intraoperatively transported from one room to the other. This retrospective analysis includes 55 patients with cerebral lesions, all of whom were surgically treated between March 1996 and September 1997. Thirty-one patients with supratentorial tumors were surgically treated (with navigational guidance) in the conventional operating room, with intraoperative MRI for resection control. For 5 of these 31 patients, intraoperative resection control revealed significant tumor remnants, which led to further tumor resection guided by the information provided by intraoperative MRI. Intraoperative MRI resection control was performed in 18 transsphenoidal operations. In cases with suspected tumor remnants, the surgeon reexplored the sellar region; additional tumor tissue was removed in three of five cases. Follow-up scans were obtained for all patients 1 week and 2 to 3 months after surgery. For 14 of the 18 patients, the images obtained intraoperatively were comparable to those obtained after 2 to 3 months. Intraoperative MRI was also used for six patients undergoing temporal lobe resections for treatment of pharmacoresistant seizures. For these patients, the extent of neocortical and mesial resection was tailored to fit the preoperative findings of morphological and electrophysiological alterations, as well as intraoperative electrocorticographic findings. Intraoperative MRI with the Magnetom Open provides considerable additional information to optimize resection during surgical treatment of supratentorial tumors, pituitary adenomas, and epilepsy. The twin operating theater is a true alternative to a dedicated MRI system. Additional efforts are necessary to improve patient transportation time and instrument guidance within the scanner.

Implication of Gastric Cancer Molecular Genetic Markers in Surgical Practice.

PubMed

Nemtsova, Marina V; Strelnikov, Vladimir V; Tanas, Alexander S; Bykov, Igor I; Zaletaev, Dmitry V; Rudenko, Viktoria V; Glukhov, Alexander I; Kchorobrich, Tatiana V; Li, Yi; Tarasov, Vadim V; Barreto, George E; Aliev, Gjumrakch

2017-10-01

We have investigated aberrant methylation of genes CDH1, RASSF1A, MLH1, N33, DAPK, expression of genes hTERT, MMP7, MMP9, BIRC5 (survivin), PTGS2, and activity of telomerase of 106 gastric tumor samples obtained intra-operatively and 53 gastric tumor samples from the same group of patients obtained endoscopically before surgery. Biopsy specimens obtained from 50 patients with chronic calculous cholecystitis were used as a control group. Together with tissue samples obtained from different sites remote to tumors, a total of 727 samples have been studied. The selected parameters comprise a system of molecular markers that can be used in both diagnostics of gastric cancer and in dynamic monitoring of patients after surgery. Special attention was paid to the use of molecular markers for the diagnostics of malignant process in the material obtained endoscopically since the efficacy of morphological diagnostics in biopsies is compromised by intratumoral heterogeneity, which may prevent reliable identification of tumor cells in the sampling. Our data indicated that certain molecular genetic events provided more sensitive yet specific markers of the tumor. We demonstrated that molecular profiles detected in preoperative biopsies were confirmed by the material obtained intra-operatively. The use of endoscopic material facilitates gastric tumors pre-operative diagnostics, improving early detection of gastric cancer and potential effective treatment strategies.

A survey of the accuracy of interpretation of intraoperative cholangiograms.

PubMed

Sanjay, Pandanaboyana; Tagolao, Sherry; Dirkzwager, Ilse; Bartlett, Adam

2012-10-01

There are few data in the literature regarding the ability of surgical trainees and surgeons to correctly interpret intraoperative cholangiograms (IOCs) during laparoscopic cholecystectomy (LC). The aim of this study was to determine the accuracy of surgeons' interpretations of IOCs. Fifteen IOCs, depicting normal, variants of normal and abnormal anatomy, were sent electronically in random sequence to 20 surgical trainees and 20 consultant general surgeons. Information was also sought on the routine or selective use of IOC by respondents. The accuracy of IOC interpretation was poor. Only nine surgeons and nine trainees correctly interpreted the cholangiograms showing normal anatomy. Six consultant surgeons and five trainees correctly identified variants of normal anatomy on cholangiograms. Abnormal anatomy on cholangiograms was identified correctly by 18 consultant surgeons and 19 trainees. Routine IOC was practised by seven consultants and six trainees. There was no significant difference between those who performed routine and selective IOC with respect to correct identification of normal, variant and abnormal anatomy. The present study shows that the accuracy of detection of both normal and variants of normal anatomy was poor in all grades of surgeon irrespective of a policy of routine or selective IOC. Improving operators' understanding of biliary anatomy may help to increase the diagnostic accuracy of IOC interpretation. © 2012 International Hepato-Pancreato-Biliary Association.

[Comparative description and retrospective analisis of modern methods of surgical wounds closure for intraoperative prophylaxis of development of pathologic cutaneous cicatrices].

PubMed

Stavyts'kyĭ, S O; Avetikov, D S; Lokes, K P; Rozkolupa, O O; Boĭko, I V

2014-05-01

The experience of application of various methods of closure was presented for the head and neck cutaneous wound surfaces after elective operative interventions. The variant of the postoperative results estimation and optimization of the wounds healing by primary closure was proposed.

The Effect of Intraoperative Hypothermia on Shoulder Arthroplasty.

PubMed

Jildeh, Toufic R; Okoroha, Kelechi R; Marshall, Nathan E; Amato, Chad; Trafton, Hunter; Muh, Stephanie J; Kolowich, Patricia

2018-05-16

Limited evidence is available regarding the correlation between intraoperative hypothermia and perioperative complications in shoulder arthroplasty. The purpose of this study was to determine the incidence of intraoperative hypothermia in patients treated with shoulder arthroplasty and its effect on perioperative complications. A retrospective chart review was performed on 657 consecutive patients who underwent shoulder arthroplasty at a single institution between August 2013 and June 2016. Demographic data, surgery-specific data, postoperative complications, length of stay, and 30-day read-mission were recorded. Patients were classified as hypothermic if their mean intraoperative temperature was less than 36°C. Statistical analyses with univariate and multivariate logistic regression were performed to evaluate the association of intraoperative hypothermia with perioperative complications. The incidence of intraoperative hypothermia in shoulder arthroplasty was 52.7%. Increasing age (P=.002), lower body mass index (P=.006), interscalene anesthetic (P=.004), and lower white blood cell count (P<.001) demonstrated increased association with hypothermia. Longer operating room times and increased estimated blood loss were not found to be associated with intraoperative hypothermia. Hypothermia demonstrated no significant association with surgical site infections nor any other perioperative complications. Patients undergoing shoulder arthroplasty showed a high incidence of intraoperative hypothermia. Lower body mass index, increasing age, interscalene anesthetic, and lower white blood cell count were associated with an increased incidence of hypothermia. Contrary to previous studies, intraoperative hypothermia was not found to contribute to perioperative complications in shoulder arthroplasty. [Orthopedics. 201x; xx(x):xx-xx.]. Copyright 2018, SLACK Incorporated.

Intra-abdominal saline irrigation at cesarean section: a systematic review and meta-analysis.

PubMed

Eke, Ahizechukwu Chigoziem; Shukr, Ghadear Hussein; Chaalan, Tina Taissir; Nashif, Sereen Khaled; Eleje, George Uchenna

2016-01-01

The aim of this study was to examine the evidence guiding intraoperative saline irrigation at cesarean sections. We searched "cesarean sections", "pregnancy", "saline irrigation" and "randomized clinical trials" in ClinicalTrials.gov, the Cochrane Central Register of Controlled Trials, AJOL, MEDLINE, LILACS and CINAHL from inception of each database to April 2015. The primary outcomes were predefined as intraoperative nausea and emesis. The pooled results were reported as relative risk (RR) with 95% confidence interval (95% CI). Three randomized trials including 862 women were analyzed. Intraoperative saline irrigation was associated with a 68% increased risk of developing intraoperative nausea (RR = 1.68, 95% CI 1.36-2.06), 70% increased risk of developing intraoperative emesis (RR = 1.70, 95% CI 1.28-2.25), 92% increased risk of developing post-operative nausea and 84% increased risk of using anti-emetics post-operatively (RR = 1.84, 95% CI 0.21-2.78) when compared with controls. There were no significant differences between intraoperative saline irrigation and no treatment for post-operative emesis (RR = 1.65, 95% CI 0.74-3.67), estimated blood loss, time to return of gastrointestinal function, postpartum endometritis (RR = 0.95, 95% CI 0.64-1.40), urinary tract infection and wound infection. Intraoperative saline irrigation at cesarean delivery increases intraoperative and post-operative nausea, requiring increasing use of anti-emetics without significant reduction in infectious, intraoperative and postpartum complications. Routine abdominal irrigation at cesarean section is not supported by current data.

The evolution of image-guided lumbosacral spine surgery.

PubMed

Bourgeois, Austin C; Faulkner, Austin R; Pasciak, Alexander S; Bradley, Yong C

2015-04-01

Techniques and approaches of spinal fusion have considerably evolved since their first description in the early 1900s. The incorporation of pedicle screw constructs into lumbosacral spine surgery is among the most significant advances in the field, offering immediate stability and decreased rates of pseudarthrosis compared to previously described methods. However, early studies describing pedicle screw fixation and numerous studies thereafter have demonstrated clinically significant sequelae of inaccurate surgical fusion hardware placement. A number of image guidance systems have been developed to reduce morbidity from hardware malposition in increasingly complex spine surgeries. Advanced image guidance systems such as intraoperative stereotaxis improve the accuracy of pedicle screw placement using a variety of surgical approaches, however their clinical indications and clinical impact remain debated. Beginning with intraoperative fluoroscopy, this article describes the evolution of image guided lumbosacral spinal fusion, emphasizing two-dimensional (2D) and three-dimensional (3D) navigational methods.

Incidence of Inadvertent Intraoperative Hypothermia and Its Risk Factors in Patients Undergoing General Anesthesia in Beijing: A Prospective Regional Survey

PubMed Central

Deng, Xiaoming; Fan, Ting; Fu, Runqiao; Geng, Wanming; Guo, Ruihong; He, Nong; Li, Chenghui; Li, Lei; Li, Min; Li, Tianzuo; Tian, Ming; Wang, Geng; Wang, Lei; Wang, Tianlong; Wu, Anshi; Wu, Di; Xue, Xiaodong; Xu, Mingjun; Yang, Xiaoming; Yang, Zhanmin; Yuan, Jianhu; Zhao, Qiuhua; Zhou, Guoqing; Zuo, Mingzhang; Pan, Shuang; Zhan, Lujing; Yao, Min; Huang, Yuguang

2015-01-01

Background/Objective Inadvertent intraoperative hypothermia (core temperature <360 C) is a recognized risk in surgery and has adverse consequences. However, no data about this complication in China are available. Our study aimed to determine the incidence of inadvertent intraoperative hypothermia and its associated risk factors in a sample of Chinese patients. Methods We conducted a regional cross-sectional survey in Beijing from August through December, 2013. Eight hundred thirty patients who underwent various operations under general anesthesia were randomly selected from 24 hospitals through a multistage probability sampling. Multivariate logistic regression analyses were applied to explore the risk factors of developing hypothermia. Results The overall incidence of intraoperative hypothermia was high, 39.9%. All patients were warmed passively with surgical sheets or cotton blankets, whereas only 10.7% of patients received active warming with space heaters or electric blankets. Pre-warmed intravenous fluid were administered to 16.9% of patients, and 34.6% of patients had irrigation of wounds with pre-warmed fluid. Active warming (OR = 0.46, 95% CI 0.26–0.81), overweight or obesity (OR = 0.39, 95% CI 0.28–0.56), high baseline core temperature before anesthesia (OR = 0.08, 95% CI 0.04–0.13), and high ambient temperature (OR = 0.89, 95% CI 0.79–0.98) were significant protective factors for hypothermia. In contrast, major-plus operations (OR = 2.00, 95% CI 1.32–3.04), duration of anesthesia (1–2 h) (OR = 3.23, 95% CI 2.19–4.78) and >2 h (OR = 3.44, 95% CI 1.90–6.22,), and intravenous un-warmed fluid (OR = 2.45, 95% CI 1.45–4.12) significantly increased the risk of hypothermia. Conclusions The incidence of inadvertent intraoperative hypothermia in Beijing is high, and the rate of active warming of patients during operation is low. Concern for the development of intraoperative hypothermia should be especially high in patients undergoing major operations, requiring long periods of anesthesia, and receiving un-warmed intravenous fluids. PMID:26360773

Intra-operative cardiac monitoring by trans-oesophageal Doppler is not risk free in surgical patients.

PubMed

Siddiqui, Muhammad Rafay Sameen; Sajid, Muhammad Shafiq; Baig, Mirza Khurram

2009-04-01

The advancement of medical technology and future improvements in public health will lead to surgeons operating on high risk patients. One of these advances is to use intra-operative trans-oesophageal Doppler (TOD) to optimise fluid management. TOD is known to be the most effective technique for intraoperative cardiac monitoring. We report a case of a potentially life threatening complication from intraoperative TOD monitoring.

The application of intraoperative transit time flow measurement to accurately assess anastomotic quality in sequential vein grafting

PubMed Central

Yu, Yang; Zhang, Fan; Gao, Ming-Xin; Li, Hai-Tao; Li, Jing-Xing; Song, Wei; Huang, Xin-Sheng; Gu, Cheng-Xiong

2013-01-01

OBJECTIVES Intraoperative transit time flow measurement (TTFM) is widely used to assess anastomotic quality in coronary artery bypass grafting (CABG). However, in sequential vein grafting, the flow characteristics collected by the conventional TTFM method are usually associated with total graft flow and might not accurately indicate the quality of every distal anastomosis in a sequential graft. The purpose of our study was to examine a new TTFM method that could assess the quality of each distal anastomosis in a sequential graft more reliably than the conventional TTFM approach. METHODS Two TTFM methods were tested in 84 patients who underwent sequential saphenous off-pump CABG in Beijing An Zhen Hospital between April and August 2012. In the conventional TTFM method, normal blood flow in the sequential graft was maintained during the measurement, and the flow probe was placed a few centimetres above the anastomosis to be evaluated. In the new method, blood flow in the sequential graft was temporarily reduced during the measurement by placing an atraumatic bulldog clamp at the graft a few centimetres distal to the anastomosis to be evaluated, while the position of the flow probe remained the same as in the conventional method. This new TTFM method was named the flow reduction TTFM. Graft flow parameters measured by both methods were compared. RESULTS Compared with the conventional TTFM, the flow reduction TTFM resulted in significantly lower mean graft blood flow (P < 0.05); in contrast, yielded significantly higher pulsatility index (P < 0.05). Diastolic filling was not significantly different between the two methods and was >50% in both cases. Interestingly, the flow reduction TTFM identified two defective middle distal anastomoses that the conventional TTFM failed to detect. Graft flows near the defective distal anastomoses were improved substantially after revision. CONCLUSIONS In this study, we found that temporary reduction of graft flow during TTFM seemed to enhance the sensitivity of TTFM to less-than-critical anastomotic defects in a sequential graft and to improve the overall accuracy of the intraoperative assessment of anastomotic quality in sequential vein grafting. PMID:24000314

Intraoperative assessment of mitral valve area after mitral valve repair: comparison of different methods.

PubMed

Maslow, Andrew; Gemignani, Anthony; Singh, Arun; Mahmood, Feroze; Poppas, Athena

2011-04-01

In the present study, 3 different methods to measure the mitral valve area (MVA) after mitral valve repair (MVRep) were studied. Data obtained immediately after repair were compared with postoperative data. The objective was to determine the feasibility and correlation between intraoperative and postoperative MVA data. A prospective study. A tertiary care medical center. Twenty-five elective adult surgical patients scheduled for MVRep. Echocardiographic data included MVAs obtained using the pressure half-time (PHT), 2-dimensional planimetry (2D-PLAN), and the continuity equation (CE). These data were obtained immediately after cardiopulmonary bypass and were compared with data obtained before hospital discharge (transthoracic echocardiogram 1) and 6 to 12 months after surgery (transthoracic echocardiogram 2). Intraoperative care was guided by hemodynamic goals designed to optimize cardiac function. The data show good agreement and correlation between MVA obtained with PHT and 2D-PLAN within and between each time period. MVA data obtained with the CE in the postoperative period were lower than and did not correlate or agree as well with other MVA data. The MVA recorded immediately after valve repair, using PHT, correlated and agreed with MVA data obtained in the postoperative period. These results contrast with previously published data and could highlight the impact of hemodynamic function during the assessment of MVA. Copyright © 2011 Elsevier Inc. All rights reserved.

Real-Time Ultrasound-Guided Catheter Navigation for Approaching Deep-Seated Brain Lesions: Role of Intraoperative Neurosonography with and without Fusion with Magnetic Resonance Imaging.

PubMed

Manjila, Sunil; Karhade, Aditya; Phi, Ji Hoon; Scott, R Michael; Smith, Edward R

2017-01-01

Brain shift during the exposure of cranial lesions may reduce the accuracy of frameless stereotaxy. We describe a rapid, safe, and effective method to approach deep-seated brain lesions using real-time intraoperative ultrasound placement of a catheter to mark the dissection trajectory to the lesion. With Institutional Review Board approval, we retrospectively reviewed the radiographic, pathologic, and intraoperative data of 11 pediatric patients who underwent excision of 12 lesions by means of this technique. Full data sets were available for 12 lesions in 11 patients. Ten lesions were tumors and 2 were cavernous malformations. Lesion locations included the thalamus (n = 4), trigone (n = 3), mesial temporal lobe (n = 3), and deep white matter (n = 2). Catheter placement was successful in all patients, and the median time required for the procedure was 3 min (range 2-5 min). There were no complications related to catheter placement. The median diameter of surgical corridors on postresection magnetic resonance imaging was 6.6 mm (range 3.0-12.1 mm). Use of real-time ultrasound guidance to place a catheter to aid in the dissection to reach a deep-seated brain lesion provides advantages complementary to existing techniques, such as frameless stereotaxy. The catheter insertion technique described here provides a quick, accurate, and safe method for reaching deep-seated lesions. © 2017 S. Karger AG, Basel.

Heated wire humidification circuit attenuates the decrease of core temperature during general anesthesia in patients undergoing arthroscopic hip surgery

PubMed Central

Park, Sooyong; Song, Seung Hyun; Hwang, Ja Gyung

2017-01-01

Background Intraoperative hypothermia is common in patients undergoing general anesthesia during arthroscopic hip surgery. In the present study, we assessed the effect of heating and humidifying the airway with a heated wire humidification circuit (HHC) to attenuate the decrease of core temperature and prevent hypothermia in patients undergoing arthroscopic hip surgery under general anesthesia. Methods Fifty-six patients scheduled for arthroscopic hip surgery were randomly assigned to either a control group using a breathing circuit connected with a heat and moisture exchanger (HME) (n = 28) or an HHC group using a heated wire humidification circuit (n = 28). The decrease in core temperature was measured from anesthetic induction and every 15 minutes thereafter using an esophageal stethoscope. Results Decrease in core temperature from anesthetic induction to 120 minutes after induction was lower in the HHC group (–0.60 ± 0.27℃) compared to the control group (–0.86 ± 0.29℃) (P = 0.001). However, there was no statistically significant difference in the incidence of intraoperative hypothermia or the incidence of shivering in the postanesthetic care unit. Conclusions The use of HHC may be considered as a method to attenuate intraoperative decrease in core temperature during arthroscopic hip surgery performed under general anesthesia and exceeding 2 hours in duration. PMID:29225745

New chemical probe technologies: applications to imaging and drug discovery (Conference Presentation)

NASA Astrophysics Data System (ADS)

Bogyo, Matthew

2017-02-01

Proteases are enzymes that play pathogenic roles in many common human diseases such as cancer, asthma, arthritis, atherosclerosis and infection by pathogens. Tools to dynamically monitor their activity can be used as diagnostic agents, as imaging contrast agents for intra-operative image guidance and for the identification of novel classes of protease-targeted drugs. I will describe our efforts to design and synthesize small molecule probes that produce a fluorescent signal upon binding to a protease target. We have identified probes that show tumor-specific retention, fast activation kinetics, and rapid systemic distribution making them useful for real-time fluorescence guided tumor resection and other diagnostic imaging applications.

Microscope-Integrated OCT Feasibility and Utility With the EnFocus System in the DISCOVER Study.

PubMed

Runkle, Anne; Srivastava, Sunil K; Ehlers, Justis P

2017-03-01

To evaluate the feasibility and utility of a novel microscope-integrated intraoperative optical coherence tomography (OCT) system. The DISCOVER study is an investigational device study evaluating microscope-integrated intraoperative OCT systems for ophthalmic surgery. This report focuses on subjects imaged with the EnFocus prototype system (Leica Microsystems/Bioptigen, Morrisville, NC). OCT was performed at surgeon-directed milestones. Surgeons completed a questionnaire after each case to evaluate the impact of OCT on intraoperative management. Fifty eyes underwent imaging with the EnFocus system. Successful imaging was obtained in 46 of 50 eyes (92%). In eight cases (16%), surgical management was changed based on intraoperative OCT findings. In membrane peeling procedures, intraoperative OCT findings were discordant from the surgeon's initial impression in seven of 20 cases (35%). This study demonstrates the feasibility of microscope-integrated intraoperative OCT using the Bioptigen EnFocus system. Intraoperative OCT may provide surgeons with additional information that may influence surgical decision-making. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:216-222.]. Copyright 2017, SLACK Incorporated.

Intraoperative nerve monitoring in laryngotracheal surgery.

PubMed

Bolufer, Sergio; Coves, María Dolores; Gálvez, Carlos; Villalona, Gustavo Adolfo

Laryngotracheal surgery has an inherent risk of injury to the recurrent laryngeal nerves (RLN). These complications go from minor dysphonia to even bilateral vocal cord paralysis. The intraoperative neuromonitoring of the RLN was developed in the field of thyroid surgery, in order to preserve nerve and vocal cord function. However, tracheal surgery requires in-field intubation of the distal trachea, which limits the use of nerve monitoring using conventional endotracheal tube with surface electrodes. Given these challenges, we present an alternative method for nerve monitoring during laryngotracheal surgery through the insertion of electrodes within the endolaryngeal musculature by bilateral puncture. Copyright © 2016 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

Surgical Tip for Prevention of Lip Injury During Orthognathic and Facial Bone Contouring Surgery.

PubMed

Lee, Tae Sung; Park, Sanghoon

2017-10-01

Iatrogenic lip injury is a rather common complication after facial bone surgery, but is usually treated lightly by the surgeon compared with other more severe functional complications. However, these injuries can have permanent sequelae and can therefore be a reason for patient dissatisfaction, especially after cosmetic surgery. Intraoperative lip injuries during facial bone surgery are usually caused by heat-generating surgical instruments or forced traction on the operative fields. The authors have applied a special technical strategy using a hydrocolloid dressing material to avoid these intraoperative lip injuries. This method does not disturb the operative procedure itself, but efficiently prevents lip injuries and decreases surgical morbidities and postoperative swelling.

Manifold Embedding and Semantic Segmentation for Intraoperative Guidance With Hyperspectral Brain Imaging.

PubMed

Ravi, Daniele; Fabelo, Himar; Callic, Gustavo Marrero; Yang, Guang-Zhong

2017-09-01

Recent advances in hyperspectral imaging have made it a promising solution for intra-operative tissue characterization, with the advantages of being non-contact, non-ionizing, and non-invasive. Working with hyperspectral images in vivo, however, is not straightforward as the high dimensionality of the data makes real-time processing challenging. In this paper, a novel dimensionality reduction scheme and a new processing pipeline are introduced to obtain a detailed tumor classification map for intra-operative margin definition during brain surgery. However, existing approaches to dimensionality reduction based on manifold embedding can be time consuming and may not guarantee a consistent result, thus hindering final tissue classification. The proposed framework aims to overcome these problems through a process divided into two steps: dimensionality reduction based on an extension of the T-distributed stochastic neighbor approach is first performed and then a semantic segmentation technique is applied to the embedded results by using a Semantic Texton Forest for tissue classification. Detailed in vivo validation of the proposed method has been performed to demonstrate the potential clinical value of the system.

Preoperative Bladder Urine Culture as a Predictor of Intraoperative Stone Culture Results: Clinical Implications and Relationship to Stone Composition

PubMed Central

Paonessa, Jessica E.; Gnessin, Ehud; Bhojani, Naeem; Williams, James C.; Lingeman, James E.

2018-01-01

Purpose We examine the relationship between urine and stone cultures in a large cohort of patients undergoing percutaneous stone removal and compare the findings in infectious vs metabolic calculi. Materials and Methods A total of 776 patients treated with percutaneous nephrolithotomy who had preoperative urine cultures and intraoperative stone cultures were included in the study. Statistical analysis used chi-square or logistic fit analysis as appropriate. Results Preoperative urine culture was positive in 352 patients (45.4%) and stone cultures were positive in 300 patients (38.7%). There were 75 patients (9.7%) with negative preoperative cultures who had positive stone cultures, and in patients with both cultures positive the organisms differed in 103 (13.3%). Gram-positive organisms predominated in preoperative urine and stone cultures. Conclusions Preoperative urine cultures in patients undergoing percutaneous nephrolithotomy are unreliable as there is a discordance with intraoperative stone cultures in almost a quarter of cases. There has been a notable shift toward gram-positive organisms in this cohort of patients. PMID:27038771

Adjuvant Bidirectional Chemotherapy Using an Intraperitoneal Port

PubMed Central

Sugarbaker, Paul H.; Bijelic, Lana

2012-01-01

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been established as treatment options for patients with peritoneal metastases or peritoneal mesothelioma. However, this novel treatment strategy remains associated with a large percentage of local-regional treatment failures. These treatment failures are attributed to the inadequacy of HIPEC to maintain a surgical complete response. Management strategies to supplement CRS and HIPEC are indicated. A simplified approach to the intraoperative placement of an intraperitoneal port for adjuvant bidirectional chemotherapy (ABC) was devised. Four different chemotherapy treatment plans were utilized depending upon the primary site of the malignancy. Thirty-one consecutive patients with an intraoperative placement of the intraperitoneal port were available for study. The incidence of adverse events that caused an early discontinuation of the bidirectional chemotherapy occurred in 75% of the 8 patients who had an incomplete cytoreduction and in 0% of patients who had a complete cytoreduction. All of the patients who had complete cytoreduction completed at least 5 of the scheduled 6 bidirectional chemotherapy treatments. Adjuvant bidirectional chemotherapy is possible following a major cytoreductive surgical procedure using a simplified method of intraoperative intraperitoneal port placement. PMID:22888340

Combined excision, cryotherapy, and intraoperative mitomycin C (EXCRIM) for localized intraepithelial and squamous cell carcinoma of the conjunctiva.

PubMed

Sarici, Ahmet M; Arvas, Sema; Pazarli, Halit

2013-09-01

To report the results of patients undergoing combined excision, cryotherapy, and intraoperative mitomycin-C (EXCRIM) for primary ocular surface squamous neoplasia (OSSN) METHODS: A retrospective review of a non-comparative interventional case series. Histopathologically confirmed primary localized (less than four clock hours) OSSN treated with EXCRIM using adjuvant 0.02 % mitomycin-C (MMC) were included in the study. The main outcome measures were recurrence and complications related to MMC. The study enrolled 28 eyes of 28 patients with OSSN with a median age of 64.5 (range 43 to 84) years. The mean tumor size was 6.9 × 4.35 mm. There was corneal involvement in 23 of 28 (82 %). Seven patients (21 %) had delayed epithelial healing. Two of eight patients (25 %) with squamous cell carcinoma (SCC) had positive lateral margins. There were no recurrences over a mean follow-up of 49 months (range 24 to 96). The excision of OSSN combined with cryotherapy and intraoperative MMC is effective with a low recurrence rate. Long-term follow-up yielded favorable results.

Clinical Analysis of Ocular Parameters Contributing to Intraoperative Pain during Standard Phacoemulsification

PubMed Central

Kim, Myung Jun

2017-01-01

Purpose. To study the correlation between ocular parameters and subjective pain that patients perceived during phacoemulsification. Methods. Medical records of 142 patients who underwent standard phacoemulsification under topical anesthesia between March and August 2016 were retrospectively reviewed. The pain during phacoemulsification and 1 h after surgery was assessed and compared using a visual analog scale. In addition, demographic data, preoperative biometric parameters, and intraoperative surgical parameters were recorded. Results. Mean age of patients was 67.49 ± 12.50 years. The mean pain score was 2.26 ± 0.85 during phacoemulsification and 0.40 ± 0.69 postoperatively. Intraoperative pain was significantly associated with higher preoperative intraocular pressure (β = 0.220, P = 0.016), greater anterior chamber depth (β = 0.210, P = 0.028), and greater axial length (β = 0.181, P = 0.043). Conclusions. To reduce the subjective pain when patients have high preoperative intraocular pressure, large anterior chamber depth, or great axial length, supplementary procedures may be required. PMID:28491473

Use of intracranial and ocular thermography before and after arteriovenous malformation excision

NASA Astrophysics Data System (ADS)

Hwang, Peter Y. K.; Lewis, Philip M.; Maller, Jerome J.

2014-11-01

Excision of arteriovenous malformations (AVMs) is known to carry a risk of postoperative hemorrhage, postulated to be the result of normal perfusion pressure breakthrough. It is also possible that AVMs may cause a steal effect, reducing perfusion in nearby vessels. There is currently no simple method of visualizing the presence or absence of steal effect intraoperatively. We hypothesized that the infrared thermographic (heat sensitive) imaging of perilesional brain may be useful for detecting reduced perfusion due to steal. Moreover, we hypothesized that if steal effect was present, it could impact on ocular perfusion and thereby temperature. Our objective was, therefore, to investigate whether perilesional cortical and ocular temperature (OT) may be a marker of steal effect. We intraoperatively acquired conventional and thermal images of the surgical field and eyes bilaterally, pre- and post-excisions of a large left hemisphere AVM. We found OT asymmetry preoperatively, which was absent after the AVM was excised. Intraoperative thermal images showed an increase of perilesional temperature, although this could be confounded by generalized changes in cortical perfusion due to anesthetics or surgery.

Known-component 3D-2D registration for quality assurance of spine surgery pedicle screw placement

NASA Astrophysics Data System (ADS)

Uneri, A.; De Silva, T.; Stayman, J. W.; Kleinszig, G.; Vogt, S.; Khanna, A. J.; Gokaslan, Z. L.; Wolinsky, J.-P.; Siewerdsen, J. H.

2015-10-01

A 3D-2D image registration method is presented that exploits knowledge of interventional devices (e.g. K-wires or spine screws—referred to as ‘known components’) to extend the functionality of intraoperative radiography/fluoroscopy by providing quantitative measurement and quality assurance (QA) of the surgical product. The known-component registration (KC-Reg) algorithm uses robust 3D-2D registration combined with 3D component models of surgical devices known to be present in intraoperative 2D radiographs. Component models were investigated that vary in fidelity from simple parametric models (e.g. approximation of a screw as a simple cylinder, referred to as ‘parametrically-known’ component [pKC] registration) to precise models based on device-specific CAD drawings (referred to as ‘exactly-known’ component [eKC] registration). 3D-2D registration from three intraoperative radiographs was solved using the covariance matrix adaptation evolution strategy (CMA-ES) to maximize image-gradient similarity, relating device placement relative to 3D preoperative CT of the patient. Spine phantom and cadaver studies were conducted to evaluate registration accuracy and demonstrate QA of the surgical product by verification of the type of devices delivered and conformance within the ‘acceptance window’ of the spinal pedicle. Pedicle screws were successfully registered to radiographs acquired from a mobile C-arm, providing TRE 1-4 mm and  <5° using simple parametric (pKC) models, further improved to  <1 mm and  <1° using eKC registration. Using advanced pKC models, screws that did not match the device models specified in the surgical plan were detected with an accuracy of  >99%. Visualization of registered devices relative to surgical planning and the pedicle acceptance window provided potentially valuable QA of the surgical product and reliable detection of pedicle screw breach. 3D-2D registration combined with 3D models of known surgical devices offers a novel method for intraoperative QA. The method provides a near-real-time independent check against pedicle breach, facilitating revision within the same procedure if necessary and providing more rigorous verification of the surgical product.

Microfluidics for rapid detection of isocitrate dehydrogenase 1 mutation for intraoperative application.

PubMed

Aibaidula, Abudumijiti; Zhao, Wang; Wu, Jin-Song; Chen, Hong; Shi, Zhi-Feng; Zheng, Lu-Lu; Mao, Ying; Zhou, Liang-Fu; Sui, Guo-Dong

2016-06-01

OBJECT Conventional methods for isocitrate dehydrogenase 1 (IDH1) detection, such as DNA sequencing and immunohistochemistry, are time- and labor-consuming and cannot be applied for intraoperative analysis. To develop a new approach for rapid analysis of IDH1 mutation from tiny tumor samples, this study used microfluidics as a method for IDH1 mutation detection. METHODS Forty-seven glioma tumor samples were used; IDH1 mutation status was investigated by immunohistochemistry and DNA sequencing. The microfluidic device was fabricated from polydimethylsiloxane following standard soft lithography. The immunoanalysis was conducted in the microfluidic chip. Fluorescence images of the on-chip microcolumn taken by the charge-coupled device camera were collected as the analytical results readout. Fluorescence signals were analyzed by NIS-Elements software to gather detailed information about the IDH1 concentration in the tissue samples. RESULTS DNA sequencing identified IDH1 R132H mutation in 33 of 47 tumor samples. The fluorescence signal for IDH1-mutant samples was 5.49 ± 1.87 compared with 3.90 ± 1.33 for wild type (p = 0.005). Thus, microfluidics was capable of distinguishing IDH1-mutant tumor samples from wild-type samples. When the cutoff value was 4.11, the sensitivity of microfluidics was 87.9% and the specificity was 64.3%. CONCLUSIONS This new approach was capable of analyzing IDH1 mutation status of tiny tissue samples within 30 minutes using intraoperative microsampling. This approach might also be applied for rapid pathological diagnosis of diffuse gliomas, thus guiding personalized resection.

Review of intraoperative optical coherence tomography: technology and applications [Invited

PubMed Central

Carrasco-Zevallos, Oscar M.; Viehland, Christian; Keller, Brenton; Draelos, Mark; Kuo, Anthony N.; Toth, Cynthia A.; Izatt, Joseph A.

2017-01-01

During microsurgery, en face imaging of the surgical field through the operating microscope limits the surgeon’s depth perception and visualization of instruments and sub-surface anatomy. Surgical procedures outside microsurgery, such as breast tumor resections, may also benefit from visualization of the sub-surface tissue structures. The widespread clinical adoption of optical coherence tomography (OCT) in ophthalmology and its growing prominence in other fields, such as cancer imaging, has motivated the development of intraoperative OCT for real-time tomographic visualization of surgical interventions. This article reviews key technological developments in intraoperative OCT and their applications in human surgery. We focus on handheld OCT probes, microscope-integrated OCT systems, and OCT-guided laser treatment platforms designed for intraoperative use. Moreover, we discuss intraoperative OCT adjuncts and processing techniques currently under development to optimize the surgical feedback derivable from OCT data. Lastly, we survey salient clinical studies of intraoperative OCT for human surgery. PMID:28663853

Sentinel node detection in cervical cancer with (99m)Tc-phytate.

PubMed

Silva, Lucas B; Silva-Filho, Agnaldo L; Traiman, Paulo; Triginelli, Sérgio A; de Lima, Carla Flávia; Siqueira, Cristiano Ferrari; Barroso, Adelanir; Rossi, Telma Maria F F; Pedrosa, Moises Salgado; Miranda, Dairton; Melo, José Renan Cunha

2005-05-01

The aim of this study was to investigate the feasibility of sentinel lymph node (SLN) identification using radioisotopic lymphatic mapping with technetium-99 m-labeled phytate in patients undergoing radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer. Between July 2001 and February 2003, 56 patients with cervical cancer FIGO stage I (n = 53) or stage II (n = 3) underwent sentinel lymph node detection with preoperative lymphoscintigraphy ((99m)Tc-labeled phytate injected into the uterine cervix, at 3, 6, 9, and 12 o'clock, at a dose of 55-74 MBq in a volume of 0.8 ml) and intraoperative lymphatic mapping with a handheld gamma probe. Radical hysterectomy was aborted in three cases because parametrial invasion was found intraoperatively and we performed only sentinel node resection. The remaining 53 patients underwent radical hysterectomy with complete pelvic lymphadenectomy. Sentinel nodes were detected using a handheld gamma-probe and removed for pathological assessment during the abdominal radical hysterectomy and pelvic lymphadenectomy. One or more sentinel nodes were detected in 52 out of 56 eligible patients (92.8%). A total of 120 SLNs were detected by lymphoscintigraphy (mean 2.27 nodes per patient) and intraoperatively by gamma probe. Forty-four percent of SLNs were found in the external iliac area, 39% in the obturator region, 8.3% in interiliac region, and 6.7% in the common iliac area. Unilateral sentinel nodes were found in thirty-one patients (59%). The remaining 21 patients (41%) had bilateral sentinel nodes. Microscopic nodal metastases were confirmed in 17 (32%) cases. In 10 of these patients, only SLNs had metastases. The 98 sentinel nodes that were negative on hematoxylin and eosin were submitted to cytokeratin immunohistochemical analysis. Five (5.1%) micrometastases were identified with this technique. The sensitivity of the sentinel node was 82.3% (CI 95% = 56.6-96.2) and the negative predictive value was 92.1% (CI 95% = 78.6-98.3). The accuracy of sentinel node in predicting the lymph node status was 94.2%. Preoperative lymphoscintigraphy and intraoperative lymphatic mapping with (99m)Tc-labeled phytate are effective in identifying sentinel nodes in patients undergoing radical hysterectomy and to select women in whom lymph node dissection can be avoided.

Intraoperative near-infrared fluorescent imaging during robotic operations.

PubMed

Macedo, Antonio Luiz de Vasconcellos; Schraibman, Vladimir

2016-01-01

The intraoperative identification of certain anatomical structures because they are small or visually occult may be challenging. The development of minimally invasive surgery brought additional difficulties to identify these structures due to the lack of complete tactile sensitivity. A number of different forms of intraoperative mapping have been tried. Recently, the near-infrared fluorescence imaging technology with indocyanine green has been added to robotic platforms. In addition, this technology has been tested in several types of operations, and has advantages such as safety, low cost and good results. Disadvantages are linked to contrast distribution in certain clinical scenarios. The intraoperative near-infrared fluorescent imaging is new and promising addition to robotic surgery. Several reports show the utility of this technology in several different procedures. The ideal dose, time and site for dye injection are not well defined. No high quality evidence-based comparative studies and long-term follow-up outcomes have been published so far. Initial results, however, are good and safe. RESUMO A identificação intraoperatória de certas estruturas anatômicas, por seu tamanho ou por elas serem ocultas à visão, pode ser desafiadora. O desenvolvimento da cirurgia minimamente invasiva trouxe dificuldades adicionais, pela falta da sensibilidade tátil completa. Diversas formas de detecção intraoperatória destas estruturas têm sido tentadas. Recentemente, a tecnologia de fluorescência infravermelha com verde de indocianina foi associada às plataformas robóticas. Além disso, essa tecnologia tem sido testada em uma variedade de cirurgias, e suas vantagens parecem estar ligadas a baixo custo, segurança e bons resultados. As desvantagens estão associadas à má distribuição do contraste em determinados cenários. A imagem intraoperatória por fluorescência infravermelha é uma nova e promissora adição à cirurgia robótica. Diversas séries mostram a utilidade da tecnologia em diferentes procedimentos. Dose ideal, local e tempo da injeção do corante ainda não estão bem estabelecidos. Estudos comparativos de alta qualidade epidemiológica baseados em evidência ainda não estão disponíveis. No entanto, os resultados iniciais são bons e seguros.

Intraoperative Evaluation of Reverse Bypass Using a Naturally Formed "Bonnet" Superficial Temporal Artery: Technical Note.

PubMed

Nagm, Alhusain; Horiuchi, Tetsuyoshi; Hasegawa, Takatoshi; Hongo, Kazuhiro

2016-04-01

In reverse bypass that used a naturally formed "bonnet" superficial temporal artery, intraoperative volume flow measurement quantifies flow augmentation after revascularization, confirms flow preservation, and identifies inadvertent vessel compromise. A 75-year-old man presented with transient ischemic attacks attributed to right internal carotid artery stenosis. He underwent successful reverse bypass via a naturally formed "bonnet" superficial temporal artery middle cerebral artery bypass. As the result of proper intraoperative volume flow evaluation, a successful reverse bypass was achieved. Modification of the intraoperative stroke risk and prediction of the long-term patency after reverse bypass can be achieved by meticulous intraoperative blood flow evaluation. Copyright © 2016 Elsevier Inc. All rights reserved.

Development of a novel handheld intra-operative laparoscopic Compton camera for 18F-Fluoro-2-deoxy-2-D-glucose-guided surgery

NASA Astrophysics Data System (ADS)

Nakamura, Y.; Shimazoe, K.; Takahashi, H.; Yoshimura, S.; Seto, Y.; Kato, S.; Takahashi, M.; Momose, T.

2016-08-01

As well as pre-operative roadmapping by 18F-Fluoro-2-deoxy-2-D-glucose (FDG) positron emission tomography, intra-operative localization of the tracer is important to identify local margins for less-invasive surgery, especially FDG-guided surgery. The objective of this paper is to develop a laparoscopic Compton camera and system aimed at use for intra-operative FDG imaging for accurate and less-invasive dissections. The laparoscopic Compton camera consists of four layers of a 12-pixel cross-shaped array of GFAG crystals (2× 2× 3 mm3) and through silicon via multi-pixel photon counters and dedicated individual readout electronics based on a dynamic time-over-threshold method. Experimental results yielded a spatial resolution of 4 mm (FWHM) for a 10 mm working distance and an absolute detection efficiency of 0.11 cps kBq-1, corresponding to an intrinsic detection efficiency of  ˜0.18%. In an experiment using a NEMA-like well-shaped FDG phantom, a φ 5× 10 mm cylindrical hot spot was clearly obtained even in the presence of a background distribution surrounding the Compton camera and the hot spot. We successfully obtained reconstructed images of a resected lymph node and primary tumor ex vivo after FDG administration to a patient having esophageal cancer. These performance characteristics indicate a new possibility of FDG-directed surgery by using a Compton camera intra-operatively.

Facial nerve mapping and monitoring in lymphatic malformation surgery.

PubMed

Chiara, Jospeh; Kinney, Greg; Slimp, Jefferson; Lee, Gi Soo; Oliaei, Sepehr; Perkins, Jonathan A

2009-10-01

Establish the efficacy of preoperative facial nerve mapping and continuous intraoperative EMG monitoring in protecting the facial nerve during resection of cervicofacial lymphatic malformations. Retrospective study in which patients were clinically followed for at least 6 months postoperatively, and long-term outcome was evaluated. Patient demographics, lesion characteristics (i.e., size, stage, location) were recorded. Operative notes revealed surgical techniques, findings, and complications. Preoperative, short-/long-term postoperative facial nerve function was standardized using the House-Brackmann Classification. Mapping was done prior to incision by percutaneously stimulating the facial nerve and its branches and recording the motor responses. Intraoperative monitoring and mapping were accomplished using a four-channel, free-running EMG. Neurophysiologists continuously monitored EMG responses and blindly analyzed intraoperative findings and final EMG interpretations for abnormalities. Seven patients collectively underwent 8 lymphatic malformation surgeries. Median age was 30 months (2-105 months). Lymphatic malformation diagnosis was recorded in 6/8 surgeries. Facial nerve function was House-Brackmann grade I in 8/8 cases preoperatively. Facial nerve was abnormally elongated in 1/8 cases. EMG monitoring recorded abnormal activity in 4/8 cases--two suggesting facial nerve irritation, and two with possible facial nerve damage. Transient or long-term facial nerve paresis occurred in 1/8 cases (House-Brackmann grade II). Preoperative facial nerve mapping combined with continuous intraoperative EMG and mapping is a successful method of identifying the facial nerve course and protecting it from injury during resection of cervicofacial lymphatic malformations involving the facial nerve.

The Effect of Technical Performance on Patient Outcomes in Surgery: A Systematic Review.

PubMed

Fecso, Andras B; Szasz, Peter; Kerezov, Georgi; Grantcharov, Teodor P

2017-03-01

Systematic review of the effect of intraoperative technical performance on patient outcomes. The operating room is a high-stakes, high-risk environment. As a result, the quality of surgical interventions affecting patient outcomes has been the subject of discussion and research for years. MEDLINE, EMBASE, PsycINFO, and Cochrane databases were searched. All surgical specialties were eligible for inclusion. Data were reviewed in regards to the methods by which technical performance was measured, what patient outcomes were assessed, and how intraoperative technical performance affected patient outcomes. Quality of evidence was assessed using the Medical Education Research Study Quality Instrument (MERSQI). Of the 12,758 studies initially identified, 24 articles (7775 total participants) were ultimately included in this review. Seventeen studies assessed the performance of the faculty alone, 2 assessed both the faculty and trainees, 1 assessed trainees alone, and in 4 studies, the level of the operating surgeon was not specified. In 18 studies, a performance assessment tool was used. Patient outcomes were evaluated using intraoperative complications, short-term morbidity, long-term morbidity, short-term mortality, and long-term mortality. The average MERSQI score was 11.67 (range 9.5-14.5). Twenty-one studies demonstrated that superior technical performance was related to improved patient outcomes. The results of this systematic review demonstrated that superior technical performance positively affects patient outcomes. Despite this initial evidence, more robust research is needed to directly assess intraoperative technical performance and its effect on postoperative patient outcomes using meaningful assessment instruments and reliable processes.

Continuous intraoperative neuromonitoring (CIONM) of the recurrent laryngeal nerve is sufficient as the only neuromonitoring technique in thyroidectomy performed because of benign goitre.

PubMed

Adamczewski, Zbigniew; Chwałkiewicz, Michał; Lewiński, Andrzej; Brzeziński, Jan; Dedecjus, Marek

2015-01-01

Recently, intraoperative neurophysiological neuromonitoring (IONM) of recurrent laryngeal nerves (RLN) has been evolving quickly. This evolution touched many aspects of the technique, leading to continuous stimulation of the RLN with real time analysis of the electrical signal. The aim of the study was to estimate the value of continuous intraoperative neuromonitoring (CIONM) as the only technique for intraoperative neuromonitoring in thyroidectomy performed because of benign goitre. The study comprised 80 women qualified for thyroidectomy due to nodular goitre. The patients were divided into 4 groups depending on the technique used for RLN integrity verification: group 1 - thyroidectomy with CIONM; group 2 - thyroidectomy with direct, intermittent stimulation of RLN and vagus nerve (NX); group 3 - both CIONM and intermittent stimulation of RLN and NX; group 4 - thyroidectomy without any IONM. Mean operation time did not differ significantly among the groups with IONM, but was significantly longer in comparison to group 4, as well as the operation's cost. In the analysed groups there was no significant difference in complication ratio. CIONM with RLN visualization in thyroidectomy performed because of benign goitre is as safe as other methods of IONM and gives a continuous confirmation of the electrical integrity of the loop NX-RLN-vocal folds during almost the entire procedure. There is a clinical need for the development of external stimulation of NX (transdermal or trancranial), particularly for minimally invasive techniques in which access to NX is limited (i.e. transoral thyroidectomy).

Probabilistic sparse matching for robust 3D/3D fusion in minimally invasive surgery.

PubMed

Neumann, Dominik; Grbic, Sasa; John, Matthias; Navab, Nassir; Hornegger, Joachim; Ionasec, Razvan

2015-01-01

Classical surgery is being overtaken by minimally invasive and transcatheter procedures. As there is no direct view or access to the affected anatomy, advanced imaging techniques such as 3D C-arm computed tomography (CT) and C-arm fluoroscopy are routinely used in clinical practice for intraoperative guidance. However, due to constraints regarding acquisition time and device configuration, intraoperative modalities have limited soft tissue image quality and reliable assessment of the cardiac anatomy typically requires contrast agent, which is harmful to the patient and requires complex acquisition protocols. We propose a probabilistic sparse matching approach to fuse high-quality preoperative CT images and nongated, noncontrast intraoperative C-arm CT images by utilizing robust machine learning and numerical optimization techniques. Thus, high-quality patient-specific models can be extracted from the preoperative CT and mapped to the intraoperative imaging environment to guide minimally invasive procedures. Extensive quantitative experiments on 95 clinical datasets demonstrate that our model-based fusion approach has an average execution time of 1.56 s, while the accuracy of 5.48 mm between the anchor anatomy in both images lies within expert user confidence intervals. In direct comparison with image-to-image registration based on an open-source state-of-the-art medical imaging library and a recently proposed quasi-global, knowledge-driven multi-modal fusion approach for thoracic-abdominal images, our model-based method exhibits superior performance in terms of registration accuracy and robustness with respect to both target anatomy and anchor anatomy alignment errors.

[Diagnostic validity of the intraoperative analysis in frozen section of the sentinel lymph node in the surgical management of breast cancer].

PubMed

Bañuelos-Andrío, Luis; Rodríguez-Caravaca, Gil; Argüelles-Pintos, Miguel; Mitjavilla-Casanovas, Mercedes

2014-01-01

The method for intraoperative sentinel lymph node (SLN) evaluation has still not been established in breast cancer staging. This study has evaluated the diagnostic validity and impact of intraoperative analysis using the frozen section (FS) of SLN. We performed a descriptive study of the diagnostic validity of the FS of the SLN in patients with breast cancer and selective sentinel node biopsy (SSNB) from October-2006 to October-2012. The diagnostic validity indexes were evaluated using sensitivity, specificity, positive and negative predictive values and global value. Gold standard was considered as the final histopathological results of the biopsies. A total of 370 patients were studied. Sensitivity and specificity for detection of metastasis by FS in the SLN were 67% and 100%, respectively. Global diagnostic validity was 95%. There was a correlation between detection of metastasis and tumor size (p<0.05). Twelve of the 15 patients with SLN micro-metastases underwent axillary lymph node dissection (ALND). Metastatic lymph nodes were not found in any of them. Intraoperative FS examination of the SLN is a useful and reliable predictor of axillary lymph node staging in patients with initial stages of breast cancer. FS reduces the need for second interventions, at least for most patients who have breast cancer with identifiable positive SLN and unequivocal evidence of positive lymph node disease. Copyright © 2013 Elsevier España, S.L. and SEMNIM. All rights reserved.

Bimanual, intra-operative, fluoroscopy-guided removal of nasopharyngeal migratory fish bone from carotid space.

PubMed

Al-Abduwani, J A; Bhargava, D; Sawhney, S; Al-Abri, R

2010-07-01

We report a rare and unusual case of a patient with an ingested fishbone which migrated from the oropharynx to the anterior compartment of the retropharyngeal space and then to the deep neck space in the nasopharynx (i.e. the carotid space). This report aims to describe a successful, minimally invasive method of foreign body removal which avoided both major skull base surgery and any potential life-threatening complications. A secondary aim is to highlight the role of intra-operative fluoroscopy, an under-used tool. We present a 67-year-old man with a history of fish bone impaction but no fish bone visible on plain X-ray or flexible endoscopy. The diagnosis of fish bone lodged in the retropharyngeal space was confirmed by computed tomography. Surgical exploration of the anterior retropharyngeal space failed to locate the fish bone, as it had migrated to a new, unknown location. Intra-operative fluoroscopy was vital for the removal of the fish bone, as it was impossible to see with the naked eye and had migrated from its previously imaged position. The fish bone was finally retrieved bimanually using external pressure on the submandibular region, which displaced the fish bone, and fluoroscopic guidance, which assisted its removal from the nasopharyngeal lumen. To the best of our knowledge, this is the first reported case of bimanual, intra-operative, fluoroscopy-guided, intra-luminal removal of a migratory fish bone from the deep neck space in this region of the nasopharynx.

Incorporation of a laser range scanner into image-guided liver surgery: surface acquisition, registration, and tracking.

PubMed

Cash, David M; Sinha, Tuhin K; Chapman, William C; Terawaki, Hiromi; Dawant, Benoit M; Galloway, Robert L; Miga, Michael I

2003-07-01

As image guided surgical procedures become increasingly diverse, there will be more scenarios where point-based fiducials cannot be accurately localized for registration and rigid body assumptions no longer hold. As a result, procedures will rely more frequently on anatomical surfaces for the basis of image alignment and will require intraoperative geometric data to measure and compensate for tissue deformation in the organ. In this paper we outline methods for which a laser range scanner may be used to accomplish these tasks intraoperatively. A laser range scanner based on the optical principle of triangulation acquires a dense set of three-dimensional point data in a very rapid, noncontact fashion. Phantom studies were performed to test the ability to link range scan data with traditional modes of image-guided surgery data through localization, registration, and tracking in physical space. The experiments demonstrate that the scanner is capable of localizing point-based fiducials to within 0.2 mm and capable of achieving point and surface based registrations with target registration error of less than 2.0 mm. Tracking points in physical space with the range scanning system yields an error of 1.4 +/- 0.8 mm. Surface deformation studies were performed with the range scanner in order to determine if this device was capable of acquiring enough information for compensation algorithms. In the surface deformation studies, the range scanner was able to detect changes in surface shape due to deformation comparable to those detected by tomographic image studies. Use of the range scanner has been approved for clinical trials, and an initial intraoperative range scan experiment is presented. In all of these studies, the primary source of error in range scan data is deterministically related to the position and orientation of the surface within the scanner's field of view. However, this systematic error can be corrected, allowing the range scanner to provide a rapid, robust method of acquiring anatomical surfaces intraoperatively.

Feasibility assessment of the interactive use of a Monte Carlo algorithm in treatment planning for intraoperative electron radiation therapy

NASA Astrophysics Data System (ADS)

Guerra, Pedro; Udías, José M.; Herranz, Elena; Santos-Miranda, Juan Antonio; Herraiz, Joaquín L.; Valdivieso, Manlio F.; Rodríguez, Raúl; Calama, Juan A.; Pascau, Javier; Calvo, Felipe A.; Illana, Carlos; Ledesma-Carbayo, María J.; Santos, Andrés

2014-12-01

This work analysed the feasibility of using a fast, customized Monte Carlo (MC) method to perform accurate computation of dose distributions during pre- and intraplanning of intraoperative electron radiation therapy (IOERT) procedures. The MC method that was implemented, which has been integrated into a specific innovative simulation and planning tool, is able to simulate the fate of thousands of particles per second, and it was the aim of this work to determine the level of interactivity that could be achieved. The planning workflow enabled calibration of the imaging and treatment equipment, as well as manipulation of the surgical frame and insertion of the protection shields around the organs at risk and other beam modifiers. In this way, the multidisciplinary team involved in IOERT has all the tools necessary to perform complex MC dosage simulations adapted to their equipment in an efficient and transparent way. To assess the accuracy and reliability of this MC technique, dose distributions for a monoenergetic source were compared with those obtained using a general-purpose software package used widely in medical physics applications. Once accuracy of the underlying simulator was confirmed, a clinical accelerator was modelled and experimental measurements in water were conducted. A comparison was made with the output from the simulator to identify the conditions under which accurate dose estimations could be obtained in less than 3 min, which is the threshold imposed to allow for interactive use of the tool in treatment planning. Finally, a clinically relevant scenario, namely early-stage breast cancer treatment, was simulated with pre- and intraoperative volumes to verify that it was feasible to use the MC tool intraoperatively and to adjust dose delivery based on the simulation output, without compromising accuracy. The workflow provided a satisfactory model of the treatment head and the imaging system, enabling proper configuration of the treatment planning system and providing good accuracy in the dosage simulation.

In vivo lymph node mapping by Cadmium Tellurium quantum dots in rats.

PubMed

Si, Chengshuai; Zhang, Yunpeng; Lv, Xianbo; Yang, Wuli; Ran, Zhipeng; Sun, Peng

2014-12-01

Intraoperative lymph node mapping (LNM) is highly significant for many surgeries in patients with cancer. Many types of tracers are currently used, but the ideal method has not yet been identified. We aimed to identify a stable lymphatic drainage pathway in an animal model and compared the effects of quantum dots (QD), a new fluorescent tracer, with those of methylene blue in intraoperative LNM. Indian ink (0.2 mL) was subcutaneously injected into the plantar metatarsal regions of six Sprague-Dawley rats. After 2 wk of incubation and subsequent dissection, the potentially stained LNs were examined pathologically to identify the lymphatic drainage pathway. After applying anesthesia, 0.1 mL methylene blue (2%) and QD (1 mg/mL) were injected into the plantar metatarsal regions of six rats for intraoperative LNM. The QD group was observed with a near-infrared imaging system, and the methylene blue group was directly observed. Drainages were recorded at 5, 10, 30, 60, and 120 min and at 1 d. Two three-level drainage pathways, that is, a peripheral drainage (popliteal LNs, inguinal LNs, and axillary LNs) and a central drainage (popliteal lymph node [LN], iliac LN, and renal LN) pathways were identified. Both methylene blue and QD stained the sentinel lymph node (SLNs) quickly, but methylene blue was difficult to identify in the deep tissues and the LNs beyond the SLN. Furthermore, the blue-stained LNs remain dyed for only 2 h. In contrast, the QDs exhibited high target-to-background ratios in both the SLNs and the following LNs. Additionally, the fluorescence lasted from 5 min-1 d after injection. An ideal lymphatic drainage model was found. QDs are excellent tracers for intraoperative LNM compared with methylene blue. Near infrared fluorescent imaging is a promising LNM method for clinical practice. Copyright © 2014 Elsevier Inc. All rights reserved.

Intraoperative leak testing has no correlation with leak after laparoscopic sleeve gastrectomy.

PubMed

Sethi, Monica; Zagzag, Jonathan; Patel, Karan; Magrath, Melissa; Somoza, Eduardo; Parikh, Manish S; Saunders, John K; Ude-Welcome, Aku; Schwack, Bradley F; Kurian, Marina S; Fielding, George A; Ren-Fielding, Christine J

2016-03-01

Staple line leak is a serious complication of sleeve gastrectomy. Intraoperative methylene blue and air leak tests are routinely used to evaluate for leak; however, the utility of these tests is controversial. We hypothesize that the practice of routine intraoperative leak testing is unnecessary during sleeve gastrectomy. A retrospective cohort study was designed using a prospectively collected database of seven bariatric surgeons from two institutions. All patients who underwent sleeve gastrectomy from March 2012 to November 2014 were included. The performance of intraoperative leak testing and the type of test (air or methylene blue) were based on surgeon preference. Data obtained included BMI, demographics, comorbidity, presence of intraoperative leak test, result of test, and type of test. The primary outcome was leak rate between the leak test (LT) and no leak test (NLT) groups. SAS version 9.4 was used for univariate and multivariate analyses. A total of 1550 sleeve gastrectomies were included; most were laparoscopic (99.8%), except for one converted and two open cases. Routine intraoperative leak tests were performed in 1329 (85.7%) cases, while 221 (14.3%) did not have LTs. Of the 1329 cases with LTs, there were no positive intraoperative results. Fifteen (1%) patients developed leaks, with no difference in leak rate between the LT and NLT groups (1 vs. 1%, p = 0.999). After adjusting for baseline differences between the groups with a propensity analysis, the observed lack of association between leak and intraoperative leak test remained. In this cohort, leaks presented at a mean of 17.3 days postoperatively (range 1-67 days). Two patients with staple line leaks underwent repeat intraoperative leak testing at leak presentation, and the tests remained negative. Intraoperative leak testing has no correlation with leak due to laparoscopic sleeve gastrectomy and is not predictive of the later development of staple line leak.

Relation between Birth Weight and Intraoperative Hemorrhage during Cesarean Section in Pregnancy with Placenta Previa.

PubMed

Soyama, Hiroaki; Miyamoto, Morikazu; Ishibashi, Hiroki; Takano, Masashi; Sasa, Hidenori; Furuya, Kenichi

2016-01-01

Placenta previa, one of the most severe obstetric complications, carries an increased risk of intraoperative massive hemorrhage. Several risk factors for intraoperative hemorrhage have been identified to date. However, the correlation between birth weight and intraoperative hemorrhage has not been investigated. Here we estimate the correlation between birth weight and the occurrence of intraoperative massive hemorrhage in placenta previa. We included all 256 singleton pregnancies delivered via cesarean section at our hospital because of placenta previa between 2003 and 2015. We calculated not only measured birth weights but also standard deviation values according to the Japanese standard growth curve to adjust for differences in gestational age. We assessed the correlation between birth weight and the occurrence of intraoperative massive hemorrhage (>1500 mL blood loss). Receiver operating characteristic curves were constructed to determine the cutoff value of intraoperative massive hemorrhage. Of 256 pregnant women with placenta previa, 96 (38%) developed intraoperative massive hemorrhage. Receiver-operating characteristic curves revealed that the area under the curve of the combination variables between the standard deviation of birth weight and intraoperative massive hemorrhage was 0.71. The cutoff value with a sensitivity of 81.3% and specificity of 55.6% was -0.33 standard deviation. The multivariate analysis revealed that a standard deviation of >-0.33 (odds ratio, 5.88; 95% confidence interval, 3.04-12.00), need for hemostatic procedures (odds ratio, 3.31; 95% confidence interval, 1.79-6.25), and placental adhesion (odds ratio, 12.68; 95% confidence interval, 2.85-92.13) were independent risk of intraoperative massive hemorrhage. In patients with placenta previa, a birth weight >-0.33 standard deviation was a significant risk indicator of massive hemorrhage during cesarean section. Based on this result, further studies are required to investigate whether fetal weight estimated by ultrasonography can predict hemorrhage during cesarean section in patients with placental previa.

Benchmarking of surgical complications in gynaecological oncology: prospective multicentre study.

PubMed

Burnell, M; Iyer, R; Gentry-Maharaj, A; Nordin, A; Liston, R; Manchanda, R; Das, N; Gornall, R; Beardmore-Gray, A; Hillaby, K; Leeson, S; Linder, A; Lopes, A; Meechan, D; Mould, T; Nevin, J; Olaitan, A; Rufford, B; Shanbhag, S; Thackeray, A; Wood, N; Reynolds, K; Ryan, A; Menon, U

2016-12-01

To explore the impact of risk-adjustment on surgical complication rates (CRs) for benchmarking gynaecological oncology centres. Prospective cohort study. Ten UK accredited gynaecological oncology centres. Women undergoing major surgery on a gynaecological oncology operating list. Patient co-morbidity, surgical procedures and intra-operative (IntraOp) complications were recorded contemporaneously by surgeons for 2948 major surgical procedures. Postoperative (PostOp) complications were collected from hospitals and patients. Risk-prediction models for IntraOp and PostOp complications were created using penalised (lasso) logistic regression using over 30 potential patient/surgical risk factors. Observed and risk-adjusted IntraOp and PostOp CRs for individual hospitals were calculated. Benchmarking using colour-coded funnel plots and observed-to-expected ratios was undertaken. Overall, IntraOp CR was 4.7% (95% CI 4.0-5.6) and PostOp CR was 25.7% (95% CI 23.7-28.2). The observed CRs for all hospitals were under the upper 95% control limit for both IntraOp and PostOp funnel plots. Risk-adjustment and use of observed-to-expected ratio resulted in one hospital moving to the >95-98% CI (red) band for IntraOp CRs. Use of only hospital-reported data for PostOp CRs would have resulted in one hospital being unfairly allocated to the red band. There was little concordance between IntraOp and PostOp CRs. The funnel plots and overall IntraOp (≈5%) and PostOp (≈26%) CRs could be used for benchmarking gynaecological oncology centres. Hospital benchmarking using risk-adjusted CRs allows fairer institutional comparison. IntraOp and PostOp CRs are best assessed separately. As hospital under-reporting is common for postoperative complications, use of patient-reported outcomes is important. Risk-adjusted benchmarking of surgical complications for ten UK gynaecological oncology centres allows fairer comparison. © 2016 Royal College of Obstetricians and Gynaecologists.

Laparoscopic Filshie clip sterilization and selective use of the methylene blue dye test.

PubMed

Karoshi, Mahantesh; Yoong, Wai

2004-01-01

In laparoscopic Filshie clip sterilization, difficulties may arise in identifying the length of the fallopian tube, with the possibility of failure of sterilization. This article describes a novel intraoperative method of demonstrating adequate tubal closure.

Intraoperative Recurrent Laryngeal Nerve Monitoring in a Patient with Contralateral Vocal Fold Palsy.

PubMed

Na, Bub-Se; Choi, Jin-Ho; Park, In Kyu; Kim, Young Tae; Kang, Chang Hyun

2017-10-01

Recurrent laryngeal nerve injury can develop following cervical or thoracic surgery; however, few reports have described intraoperative recurrent laryngeal nerve monitoring. Consensus regarding the use of this technique during thoracic surgery is lacking. We used intraoperative recurrent laryngeal nerve monitoring in a patient with contralateral vocal cord paralysis who was scheduled for completion pneumonectomy. This case serves as an example of intraoperative recurrent laryngeal nerve monitoring during thoracic surgery and supports this indication for its use.

Performance Evaluation of MIND Demons Deformable Registration of MR and CT Images in Spinal Interventions

PubMed Central

Reaungamornrat, S.; De Silva, T.; Uneri, A.; Goerres, J.; Jacobson, M.; Ketcha, M.; Vogt, S.; Kleinszig, G.; Khanna, A. J.; Wolinsky, J.-P.; Prince, J. L.; Siewerdsen, J. H.

2016-01-01

Accurate intraoperative localization of target anatomy and adjacent nervous and vascular tissue is essential to safe, effective surgery, and multimodality deformable registration can be used to identify such anatomy by fusing preoperative CT or MR images with intraoperative images. A deformable image registration method has been developed to estimate viscoelastic diffeomorphisms between preoperative MR and intraoperative CT using modality-independent neighborhood descriptors (MIND) and a Huber metric for robust registration. The method, called MIND Demons, optimizes a constrained symmetric energy functional incorporating priors on smoothness, geodesics, and invertibility by alternating between Gauss-Newton optimization and Tikhonov regularization in a multiresolution scheme. Registration performance was evaluated for the MIND Demons method with a symmetric energy formulation in comparison to an asymmetric form, and sensitivity to anisotropic MR voxel-size was analyzed in phantom experiments emulating image-guided spine-surgery in comparison to a free-form deformation (FFD) method using local mutual information (LMI). Performance was validated in a clinical study involving 15 patients undergoing intervention of the cervical, thoracic, and lumbar spine. The target registration error (TRE) for the symmetric MIND Demons formulation [1.3 ± 0.8 mm (median ± interquartile)] outperformed the asymmetric form [3.6 ± 4.4 mm]. The method demonstrated fairly minor sensitivity to anisotropic MR voxel size, with median TRE ranging 1.3 – 2.9 mm for MR slice thickness ranging 0.9 – 9.9 mm, compared to TRE = 3.2 – 4.1 mm for LMI FFD over the same range. Evaluation in clinical data demonstrated sub-voxel TRE (< 2 mm) in all fifteen cases with realistic deformations that preserved topology with sub-voxel invertibility (0.001 mm) and positive-determinant spatial Jacobians. The approach therefore appears robust against realistic anisotropic resolution characteristics in MR and yields registration accuracy suitable to application in image-guided spine-surgery. PMID:27811396

Performance evaluation of MIND demons deformable registration of MR and CT images in spinal interventions.

PubMed

Reaungamornrat, S; De Silva, T; Uneri, A; Goerres, J; Jacobson, M; Ketcha, M; Vogt, S; Kleinszig, G; Khanna, A J; Wolinsky, J-P; Prince, J L; Siewerdsen, J H

2016-12-07

Accurate intraoperative localization of target anatomy and adjacent nervous and vascular tissue is essential to safe, effective surgery, and multimodality deformable registration can be used to identify such anatomy by fusing preoperative CT or MR images with intraoperative images. A deformable image registration method has been developed to estimate viscoelastic diffeomorphisms between preoperative MR and intraoperative CT using modality-independent neighborhood descriptors (MIND) and a Huber metric for robust registration. The method, called MIND Demons, optimizes a constrained symmetric energy functional incorporating priors on smoothness, geodesics, and invertibility by alternating between Gauss-Newton optimization and Tikhonov regularization in a multiresolution scheme. Registration performance was evaluated for the MIND Demons method with a symmetric energy formulation in comparison to an asymmetric form, and sensitivity to anisotropic MR voxel-size was analyzed in phantom experiments emulating image-guided spine-surgery in comparison to a free-form deformation (FFD) method using local mutual information (LMI). Performance was validated in a clinical study involving 15 patients undergoing intervention of the cervical, thoracic, and lumbar spine. The target registration error (TRE) for the symmetric MIND Demons formulation (1.3  ±  0.8 mm (median  ±  interquartile)) outperformed the asymmetric form (3.6  ±  4.4 mm). The method demonstrated fairly minor sensitivity to anisotropic MR voxel size, with median TRE ranging 1.3-2.9 mm for MR slice thickness ranging 0.9-9.9 mm, compared to TRE  =  3.2-4.1 mm for LMI FFD over the same range. Evaluation in clinical data demonstrated sub-voxel TRE (<2 mm) in all fifteen cases with realistic deformations that preserved topology with sub-voxel invertibility (0.001 mm) and positive-determinant spatial Jacobians. The approach therefore appears robust against realistic anisotropic resolution characteristics in MR and yields registration accuracy suitable to application in image-guided spine-surgery.

Performance evaluation of MIND demons deformable registration of MR and CT images in spinal interventions

NASA Astrophysics Data System (ADS)

Reaungamornrat, S.; De Silva, T.; Uneri, A.; Goerres, J.; Jacobson, M.; Ketcha, M.; Vogt, S.; Kleinszig, G.; Khanna, A. J.; Wolinsky, J.-P.; Prince, J. L.; Siewerdsen, J. H.

2016-12-01

Accurate intraoperative localization of target anatomy and adjacent nervous and vascular tissue is essential to safe, effective surgery, and multimodality deformable registration can be used to identify such anatomy by fusing preoperative CT or MR images with intraoperative images. A deformable image registration method has been developed to estimate viscoelastic diffeomorphisms between preoperative MR and intraoperative CT using modality-independent neighborhood descriptors (MIND) and a Huber metric for robust registration. The method, called MIND Demons, optimizes a constrained symmetric energy functional incorporating priors on smoothness, geodesics, and invertibility by alternating between Gauss-Newton optimization and Tikhonov regularization in a multiresolution scheme. Registration performance was evaluated for the MIND Demons method with a symmetric energy formulation in comparison to an asymmetric form, and sensitivity to anisotropic MR voxel-size was analyzed in phantom experiments emulating image-guided spine-surgery in comparison to a free-form deformation (FFD) method using local mutual information (LMI). Performance was validated in a clinical study involving 15 patients undergoing intervention of the cervical, thoracic, and lumbar spine. The target registration error (TRE) for the symmetric MIND Demons formulation (1.3  ±  0.8 mm (median  ±  interquartile)) outperformed the asymmetric form (3.6  ±  4.4 mm). The method demonstrated fairly minor sensitivity to anisotropic MR voxel size, with median TRE ranging 1.3-2.9 mm for MR slice thickness ranging 0.9-9.9 mm, compared to TRE  =  3.2-4.1 mm for LMI FFD over the same range. Evaluation in clinical data demonstrated sub-voxel TRE (<2 mm) in all fifteen cases with realistic deformations that preserved topology with sub-voxel invertibility (0.001 mm) and positive-determinant spatial Jacobians. The approach therefore appears robust against realistic anisotropic resolution characteristics in MR and yields registration accuracy suitable to application in image-guided spine-surgery.

MRI directed bilateral stimulation of the subthalamic nucleus in patients with Parkinson's disease

PubMed Central

Patel, N; Plaha, P; O'Sullivan, K; McCarter, R; Heywood, P; Gill, S

2003-01-01

Objective: Bilateral chronic high frequency deep brain stimulation (DBS) of the subthalamic nucleus (STN) has emerged as an appropriate therapy for patients with advanced Parkinson's disease refractory to medical therapy. Advances in neuroimaging and neurophysiology have led to the development of varied targeting methods for the delivery of this treatment. Intraoperative neurophysiological and clinical monitoring is regarded by many to be mandatory for accurate STN localisation. We have examined efficacy of bilateral STN stimulation using a predominantly magnetic resonance imaging (MRI)-directed technique. Methods: DBS leads were stereotactically implanted into the STN using an MRI directed method, with intraoperative macrostimulation used purely for adjustment. The effects of DBS were evaluated in 16 patients followed up to 12 months, and compared with baseline assessments. Assessments were performed in both off and on medication states, and were based on the Unified Parkinson's Disease Rating Scale (UPDRS) and timed motor tests. Functional status outcomes were examined using the PDQ-39 quality of life questionnaire. A battery of psychometric tests was used to assess cognition. Results: After 12 months, stimulation in the off medication state resulted in significant improvements in Activities of Daily Living and Motor scores (UPDRS parts II and III) by 62% and 61% respectively. Timed motor tests were significantly improved in the off medication state. Motor scores (UPDRS part III) were significantly improved by 40% in the on medication state. Dyskinesias and off duration were significantly reduced and the mean dose of L-dopa equivalents was reduced by half. Psychometric test scores were mostly unchanged or improved. Adverse events were few. Conclusions: An MRI directed targeting method for implantation of DBS leads into the STN can be used safely and effectively, and results are comparable with studies using intraoperative microelectrode neurophysiological targeting. In addition, our method was associated with an efficient use of operating time, and without the necessary costs of microelectrode recording. PMID:14638880

Intraoperative confocal microscopy in the visualization of 5-aminolevulinic acid fluorescence in low-grade gliomas.

PubMed

Sanai, Nader; Snyder, Laura A; Honea, Norissa J; Coons, Stephen W; Eschbacher, Jennifer M; Smith, Kris A; Spetzler, Robert F

2011-10-01

Greater extent of resection (EOR) for patients with low-grade glioma (LGG) corresponds with improved clinical outcome, yet remains a central challenge to the neurosurgical oncologist. Although 5-aminolevulinic acid (5-ALA)-induced tumor fluorescence is a strategy that can improve EOR in gliomas, only glioblastomas routinely fluoresce following 5-ALA administration. Intraoperative confocal microscopy adapts conventional confocal technology to a handheld probe that provides real-time fluorescent imaging at up to 1000× magnification. The authors report a combined approach in which intraoperative confocal microscopy is used to visualize 5-ALA tumor fluorescence in LGGs during the course of microsurgical resection. Following 5-ALA administration, patients with newly diagnosed LGG underwent microsurgical resection. Intraoperative confocal microscopy was conducted at the following points: 1) initial encounter with the tumor; 2) the midpoint of tumor resection; and 3) the presumed brain-tumor interface. Histopathological analysis of these sites correlated tumor infiltration with intraoperative cellular tumor fluorescence. Ten consecutive patients with WHO Grades I and II gliomas underwent microsurgical resection with 5-ALA and intraoperative confocal microscopy. Macroscopic tumor fluorescence was not evident in any patient. However, in each case, intraoperative confocal microscopy identified tumor fluorescence at a cellular level, a finding that corresponded to tumor infiltration on matched histological analyses. Intraoperative confocal microscopy can visualize cellular 5-ALA-induced tumor fluorescence within LGGs and at the brain-tumor interface. To assess the clinical value of 5-ALA for high-grade gliomas in conjunction with neuronavigation, and for LGGs in combination with intraoperative confocal microscopy and neuronavigation, a Phase IIIa randomized placebo-controlled trial (BALANCE) is underway at the authors' institution.

Can Fan-Beam Interactive Computed Tomography Accurately Predict Indirect Decompression in Minimally Invasive Spine Surgery Fusion Procedures?

PubMed

Janssen, Insa; Lang, Gernot; Navarro-Ramirez, Rodrigo; Jada, Ajit; Berlin, Connor; Hilis, Aaron; Zubkov, Micaella; Gandevia, Lena; Härtl, Roger

2017-11-01

Recently, novel mobile intraoperative fan-beam computed tomography (CT) was introduced, allowing for real-time navigation and immediate intraoperative evaluation of neural decompression in spine surgery. This study sought to investigate whether intraoperatively assessed neural decompression during minimally invasive spine surgery (MISS) has a predictive value for clinical and radiographic outcome. A retrospective study of patients undergoing intraoperative CT (iCT)-guided extreme lateral interbody fusion or transforaminal lumbar interbody fusion was conducted. 1) Preoperative, 2) intraoperative (after cage implantation, 3) postoperative, and 4) follow-up radiographic and clinical parameters obtained from radiography or CT were quantified. Thirty-four patients (41 spinal segments) were analyzed. iCT-based navigation was successfully accomplished in all patients. Radiographic parameters showed significant improvement from preoperatively to intraoperatively after cage implantation in both MISS procedures (extreme lateral interbody fusion/transforaminal lumbar interbody fusion) (P ≤ 0.05). Radiologic parameters for both MISS fusion procedures did not show significant differences to the assessed radiographic measures at follow-up (P > 0.05). Radiologic outcome values did not decrease when compared intraoperatively (after cage implantation) to latest follow-up. Intraoperative fan-beam CT is capable of assessing neural decompression intraoperatively with high accuracy, allowing for precise prediction of radiologic outcome and earliest possible feedback during MISS fusion procedures. These findings are highly valuable for routine practice and future investigations toward finding a threshold for neural decompression that translates into clinical improvement. If sufficient neural decompression has been confirmed with iCT imaging studies, additional postoperative and/or follow-up imaging studies might no longer be required if patients remain asymptomatic. Copyright © 2017 Elsevier Inc. All rights reserved.

Impact of Intraoperative Steroids on Postoperative Infection Rates and Length of Hospital Stay: A Study of 1200 Spine Surgery Patients.

PubMed

Elsamadicy, Aladine A; Wang, Timothy Y; Back, Adam G; Sergesketter, Amanda; Warwick, Hunter; Karikari, Isaac O; Gottfried, Oren N

2016-12-01

The use of intraoperative steroids and their effects are relatively unknown and remain controversial. The aim of this study was to determine the effects of intraoperative steroid use on postoperative complications and length of hospital stay after spine surgery. Medical records of 1200 adult patients undergoing spine surgery at Duke University Medical Center during the period 2008-2010 were retrospectively reviewed; 495 (41.25%) patients were administered intraoperative steroids, and 705 (58.75%) patients were not administered intraoperative steroids. Patient demographics, comorbidities, and postoperative complication rates were collected. The primary outcomes investigated were postoperative complications, specifically length of hospital stay and infection rates. Patient demographics were similar between both cohorts. Comorbidities were also similar, with the intraoperative steroid use cohort having a higher number of patients with long-term steroid use than the no intraoperative steroid use cohort (6.95% [no steroids] vs. 13.74% [steroid use], P < 0.001). Operative variables, including length of operation and median number of fusion levels operated, were also similar between the 2 groups. Lumbar spine was the most common surgical location. Patients who were administered intraoperative steroids had a shorter length of hospital stay by an average of 1 day (6.06 days ± 6.76 [no steroids] vs. 5.04 days ± 4.86 [steroid use], P = 0.0025), lower rates of urinary tract infections (10.37% [no steroids] vs. 6.88% [steroid use], P = 0.040), and lower rates of other infections that were not deep or superficial surgical site infections (9.22% [no steroids] vs. 6.06% [steroid use], P = 0.0460). Patients who receive intraoperative steroids have shorter hospital stays and lower infection rates after spine surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Factors impacting cerebrospinal fluid leak rates in endoscopic sellar surgery.

PubMed

Karnezis, Tom T; Baker, Andrew B; Soler, Zachary M; Wise, Sarah K; Rereddy, Shruthi K; Patel, Zara M; Oyesiku, Nelson M; DelGaudio, John M; Hadjipanayis, Constantinos G; Woodworth, Bradford A; Riley, Kristen O; Lee, John; Cusimano, Michael D; Govindaraj, Satish; Psaltis, Alkis; Wormald, Peter John; Santoreneos, Steve; Sindwani, Raj; Trosman, Samuel; Stokken, Janalee K; Woodard, Troy D; Recinos, Pablo F; Vandergrift, W Alexander; Schlosser, Rodney J

2016-11-01

In patients undergoing transnasal endoscopic sellar surgery, an analysis of risk factors and predictors of intraoperative and postoperative cerebrospinal fluid leak (CSF) would provide important prognostic information. A retrospective review of patients undergoing endoscopic sellar surgery for pituitary adenomas or craniopharyngiomas between 2002 and 2014 at 7 international centers was performed. Demographic, comorbidity, and tumor characteristics were evaluated to determine the associations between intraoperative and postoperative CSF leaks. Correlations between reconstructive and CSF diversion techniques were associated with postoperative CSF leak rates. Odds ratios (OR) were identified using a multivariate logistic regression model. Data were collected on 1108 pituitary adenomas and 53 craniopharyngiomas. Overall, 30.1% of patients had an intraoperative leak and 5.9% had a postoperative leak. Preoperative factors associated with increased intraoperative leaks were mild liver disease, craniopharyngioma, and extension into the anterior cranial fossa. In patients with intraoperative CSF leaks, postoperative leaks occurred in 10.3%, with a higher postoperative leak rate in craniopharyngiomas (20.8% vs 5.1% in pituitary adenomas). Once an intraoperative leak occurred, craniopharyngioma (OR = 4.255, p = 0.010) and higher body mass index (BMI) predicted postoperative leak (OR = 1.055, p = 0.010). In patients with an intraoperative leak, the use of septal flaps reduced the occurrence of postoperative leak (OR = 0.431, p = 0.027). Rigid reconstruction and CSF diversion techniques did not impact postoperative leak rates. Intraoperative CSF leaks can occur during endoscopic sellar surgery, especially in larger tumors or craniopharyngiomas. Once an intraoperative leak occurs, risk factors for postoperative leaks include craniopharyngiomas and higher BMI. Use of septal flaps decreases this risk. © 2016 ARS-AAOA, LLC.

Intraoperative magnetic resonance imaging during surgery for pituitary adenomas: pros and cons.

PubMed

Buchfelder, Michael; Schlaffer, Sven-Martin

2012-12-01

Surgery for pituitary adenomas still remains a mainstay in their treatment, despite all advances in sophisticated medical treatments and radiotherapy. Total tumor excision is often attempted, but there are limitations in the intraoperative assessment of the radicalism of tumor resection by the neurosurgeon. Standard postoperative imaging is usually performed with a few months delay from the surgical intervention. The purpose of this report is to review briefly the facilities and kinds of intraoperative magnetic resonance imaging for all physician and surgeons involved in the management of pituitary adenomas on the basis of current literature. To date, there are several low- and high-field magnetic resonance imaging systems available for intraoperative use and depiction of the extent of tumor removal during surgery. Recovery of vision and the morphological result of surgery can be largely predicted from the intraoperative images. A variety of studies document that depiction of residual tumor allows targeted attack of the remnant and extent the resection. Intraoperative magnetic resonance imaging offers an immediate feedback to the surgeon and is a perfect quality control for pituitary surgery. It is also used as a basis of datasets for intraoperative navigation which is particularly useful in any kind of anatomical variations and repeat operations in which primary surgery has distorted the normal anatomy. However, setting up the technology is expensive and some systems even require extensive remodeling of the operation theatre. Intraoperative imaging prolongs the operation, but may also depict evolving problems, such as hematomas in the tumor cavity. There are several artifacts in intraoperative MR images possible that must be considered. The procedures are not associated with an increased complication rate.

Threshold dose for peripheral neuropathy following intraoperative radiotherapy (IORT) in a large animal model

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kinsella, T.J.; DeLuca, A.M.; Barnes, M.

1991-04-01

Radiation injury to peripheral nerve is a dose-limiting toxicity in the clinical application of intraoperative radiotherapy, particularly for pelvic and retroperitoneal tumors. Intraoperative radiotherapy-related peripheral neuropathy in humans receiving doses of 20-25 Gy is manifested as a mixed motor-sensory deficit beginning 6-9 months following treatment. In a previous experimental study of intraoperative radiotherapy-related neuropathy of the lumbro-sacral plexus, an approximate inverse linear relationship was reported between the intraoperative dose (20-75 Gy range) and the time to onset of hind limb paresis (1-12 mos following intraoperative radiotherapy). The principal histological lesion in irradiated nerve was loss of large nerve fibers andmore » perineural fibrosis without significant vascular injury. Similar histological changes in irradiated nerves were found in humans. To assess peripheral nerve injury to lower doses of intraoperative radiotherapy in this same large animal model, groups of four adult American Foxhounds received doses of 10, 15, or 20 Gy to the right lumbro-sacral plexus and sciatic nerve using 9 MeV electrons. The left lumbro-sacral plexus and sciatic nerve were excluded from the intraoperative field to allow each animal to serve as its own control. Following treatment, a complete neurological exam, electromyogram, and nerve conduction studies were performed monthly for 1 year. Monthly neurological exams were performed in years 2 and 3 whereas electromyogram and nerve conduction studies were performed every 3 months during this follow-up period. With follow-up of greater than or equal to 42 months, no dog receiving 10 or 15 Gy IORT shows any clinical or laboratory evidence of peripheral nerve injury. However, all four dogs receiving 20 Gy developed right hind limb paresis at 8, 9, 9, and 12 mos following intraoperative radiotherapy.« less

Dual-modality optical biopsy of glioblastomas multiforme with diffuse reflectance and fluorescence: ex vivo retrieval of optical properties

NASA Astrophysics Data System (ADS)

Du Le, Vinh Nguyen; Provias, John; Murty, Naresh; Patterson, Michael S.; Nie, Zhaojun; Hayward, Joseph E.; Farrell, Thomas J.; McMillan, William; Zhang, Wenbin; Fang, Qiyin

2017-02-01

Glioma itself accounts for 80% of all malignant primary brain tumors, and glioblastoma multiforme (GBM) accounts for 55% of such tumors. Diffuse reflectance and fluorescence spectroscopy have the potential to discriminate healthy tissues from abnormal tissues and therefore are promising noninvasive methods for improving the accuracy of brain tissue resection. Optical properties were retrieved using an experimentally evaluated inverse solution. On average, the scattering coefficient is 2.4 times higher in GBM than in low grade glioma (LGG), and the absorption coefficient is 48% higher. In addition, the ratio of fluorescence to diffuse reflectance at the emission peak of 460 nm is 2.6 times higher for LGG while reflectance at 650 nm is 2.7 times higher for GBM. The results reported also show that the combination of diffuse reflectance and fluorescence spectroscopy could achieve sensitivity of 100% and specificity of 90% in discriminating GBM from LGG during ex vivo measurements of 22 sites from seven glioma specimens. Therefore, the current technique might be a promising tool for aiding neurosurgeons in determining the extent of surgical resection of glioma and, thus, improving intraoperative tumor identification for guiding surgical intervention.

Dual-modality optical biopsy of glioblastomas multiforme with diffuse reflectance and fluorescence: ex vivo retrieval of optical properties.

PubMed

Du Le, Vinh Nguyen; Provias, John; Murty, Naresh; Patterson, Michael S; Nie, Zhaojun; Hayward, Joseph E; Farrell, Thomas J; McMillan, William; Zhang, Wenbin; Fang, Qiyin

2017-02-01

Glioma itself accounts for 80% of all malignant primary brain tumors, and glioblastoma multiforme (GBM) accounts for 55% of such tumors. Diffuse reflectance and fluorescence spectroscopy have the potential to discriminate healthy tissues from abnormal tissues and therefore are promising noninvasive methods for improving the accuracy of brain tissue resection. Optical properties were retrieved using an experimentally evaluated inverse solution. On average, the scattering coefficient is 2.4 times higher in GBM than in low grade glioma (LGG), and the absorption coefficient is 48% higher. In addition, the ratio of fluorescence to diffuse reflectance at the emission peak of 460 nm is 2.6 times higher for LGG while reflectance at 650 nm is 2.7 times higher for GBM. The results reported also show that the combination of diffuse reflectance and fluorescence spectroscopy could achieve sensitivity of 100% and specificity of 90% in discriminating GBM from LGG during ex vivo measurements of 22 sites from seven glioma specimens. Therefore, the current technique might be a promising tool for aiding neurosurgeons in determining the extent of surgical resection of glioma and, thus, improving intraoperative tumor identification for guiding surgical intervention.

The role of intraoperative ultrasound in small renal mass robotic enucleation.

PubMed

Gunelli, Roberta; Fiori, Massimo; Salaris, Cristiano; Salomone, Umberto; Urbinati, Marco; Vici, Alexia; Zenico, Teo; Bertocco, Mauro

2016-12-30

As a result of the growing evidence on tumor radical resection in literature, simple enucleation has become one of the best techniques associated to robotic surgery in the treatment of renal neoplasia, as it guarantees minimal invasiveness and the maximum sparing of renal tissue, facilitating the use of reduced or zero ischemia techniques during resection. The use of a robotic ultrasound probe represents a useful tool to detect and define tumor location, especially in poorly exophytic small renal mass. A total of 22 robotic enucleations were performed on < 3 cm renal neoplasias (PADUA score 18 Pz 6/7 e 4 Pz 8) using a 12-5 MHz robotic ultrasound probe (BK Drop-In 8826). Once kidney had been isolated from the adipose capsule at the site of the neoplasia (2), the exact position of the lesion could be easily identified in all cases (22/22), even for mostly endophytic lesions, thanks to the insertion of the ultrasound probe through the assistant port. Images were produced and visualized by the surgeon using the TilePro feature of the DaVinci surgical system for producing a picture-in-picture image on the console screen. The margins of resection were then marked with cautery, thus allowing for speedy anatomical dissection. This reduced the time of ischemia to 8 min (6-13) and facilitated the enucleation technique when performed without clamping the renal peduncle (6/22). No complications due to the use of the ultrasound probe were observed. The use of an intraoperative robotic ultrasound probe has allowed for easier identification of small, mostly endophytic neoplasias, better anatomical approach, shorter ischemic time, reduced risk of pseudocapsule rupture during dissection, and easier enucleation in cases performed without clamping. It is noteworthy that the use of intraoperative ultrasound probe allows mental reconstruction of the tumor through an accurate 3D vision of the hidden field during surgical dissection.

Intraoperative Identification of a Normal Pituitary Gland and an Adenoma Using Near-Infrared Fluorescence Imaging and Low-Dose Indocyanine Green.

PubMed

Verstegen, Marco J T; Tummers, Quirijn R J G; Schutte, Pieter J; Pereira, Alberto M; van Furth, Wouter R; van de Velde, Cornelis J H; Malessy, Martijn J A; Vahrmeijer, Alexander L

2016-09-01

The intraoperative distinction between normal and abnormal pituitary tissue is crucial during pituitary adenoma surgery to obtain a complete tumor resection while preserving endocrine function. Near-infrared (NIR) fluorescence imaging is a technique to intraoperatively visualize tumors by using indocyanine green (ICG), a contrast agent allowing visualization of differences in tissue vascularization. Although NIR fluorescence imaging has been described in pituitary surgery, it has, in contrast to other surgical areas, never become widely used. To evaluate NIR fluorescence imaging in pituitary surgery, both qualitatively and quantitatively, and to assess the additional value of resecting adenoma tissue under NIR fluorescence guidance. We included 10 patients planned to undergo transnasal transsphenoidal selective adenomectomy. Patients received multiple intravenous administrations of 5 mg ICG, up to a maximum of 15 mg per patient. Endoscopic NIR fluorescence imaging was performed at multiple points in time. The NIR fluorescent signal in both the adenoma and pituitary gland was obtained, and the fluorescence contrast ratio was assessed. Four patients had Cushing disease, 1 had acromegaly, and 1 had a prolactinoma. Four patients had a nonfunctioning macroadenoma. In 9 of 10 patients with a histologically proven pituitary adenoma, the normal pituitary gland showed a stronger fluorescent signal than the adenoma. A fluorescence contrast ratio of normal pituitary gland to adenoma of 1.5 ± 0.2 was obtained. In 2 patients; adenoma resection was actually performed under NIR fluorescence guidance instead of under white light. NIR fluorescence imaging can easily and safely be implemented in pituitary surgery. The timing of ICG administration is important for optimal results and warrants further study. It appears that injection of ICG can best be postponed until some part of the normal pituitary gland is identified. Subsequent repeated low-dose ICG administrations improved the distinction between adenoma and gland.

Minimally invasive radioguided parathyroid surgery using low-dose Tc-99m-MIBI - comparison with standard high dose.

PubMed

Jangjoo, Ali; Sadeghi, Ramin; Mousavi, Zohreh; Mohebbi, Masoud; Khaje, Mahtab; Asadi, Mehdi

2017-01-01

Surgery remains the most effective treatment for primary hyperparathyroidism (PHPT). Minimally invasive radioguided parathyroidectomy (MIRP) is a common technique for detecting and excising abnormal parathyroid glands. The aim of this study was to compare injections of low-dose and high-dose (99m) Tc methoxy isobutyl isonitrile (MIBI) for intraoperative localisation of parathyroid adenomas by means of a gamma probe in patients with primary hyperparathyroidism (PHPT). Thirty patients with PHPT and a preoperative diagnosis of parathyroid adenoma were enrolled between 2010 and 2012. They were considered as Group B and underwent MIRP using 5 mCi Tc-99m MIBI, and their perioperative data were compared with twenty patients treated with conventional 20 mCi Tc-99m MIBI previously (Group A). Group A was made up of 20 patients (mean age, 41.55 years; 14 women and 6 men), and group B included 30 patients (mean age, 40.43 years; 19 women and 11 men). The mean serum parathyroid hormone (PTH) and calcium values were recorded pre- and postoperatively. The mean follow-up period for the patients in the two groups was 18.4 and 16.5 months, respectively. Pre-operative evaluation demonstrated that the groups were statistically similar. Intraoperative data and success rate of surgery showed no difference between the two groups. No significant complication was detected after surgeries and no recurrence happened in either of the two groups during the follow-up period. A new protocol of MIRP using low doses of Tc-99m-MIBI resulted in an excellent success rate. Comparing results of the study, we conclude that low-dose Tc-99m-MIBI may be preferred for identification of parathyroid adenomas intraoperatively by means of a gamma probe in PHPT patients because it appears to be as effective as high-dose Tc-99m-MIBI.

Anaesthesia for awake craniotomy: A retrospective study of 54 cases

PubMed Central

Sokhal, Navdeep; Rath, Girija Prasad; Chaturvedi, Arvind; Dash, Hari Hara; Bithal, Parmod Kumar; Chandra, P Sarat

2015-01-01

Background and Aims: The anaesthetic challenge of awake craniotomy is to maintain adequate sedation, analgesia, respiratory and haemodynamic stability in an awake patient who should be able to co-operate during intraoperative neurological assessment. The current literature, sharing the experience on awake craniotomy, in Indian context, is minimal. Hence, we carried out a retrospective study with the aim to review and analyse the anaesthetic management and perioperative complications in patients undergoing awake craniotomy, at our centre. Methods: Medical records of 54 patients who underwent awake craniotomy for intracranial lesions over a period of 10 years were reviewed, retrospectively. Data regarding anaesthetic management, intraoperative complications and post-operative course were recorded. Results: Propofol (81.5%) and dexmedetomidine (18.5%) were the main agents used for providing conscious sedation to facilitate awake craniotomy. Hypertension (16.7%) was the most commonly encountered complication during intraoperative period, followed by seizures (9.3%), desaturation (7.4%), tight brain (7.4%), and shivering (5.6%). The procedure had to be converted to general anaesthesia in one of patients owing to refractory brain bulge. The incidence of respiratory and haemodynamic complications were comparable in the both groups (P > 0.05). There was less incidence of intraoperative seizures in patients who received propofol (P = 0.03). In post-operative period, 20% of patients developed new motor deficit. Mean intensive care unit stay was 2.8 ± 1.9 day (1–14 days) and mean hospital stay was 7.0 ± 5.0 day (3–30 days). Conclusions: ‘Conscious sedation’ was the technique of choice for awake craniotomy, at our institute. Fentanyl, propofol, and dexmedetomidine were the main agents used for this purpose. Patients receiving propofol had less incidence of intraoperative seizure. Appropriate selection of patients, understanding the procedure of surgery, and judicious use of sedatives or anaesthetic agents are key to the success for awake craniotomy as a procedure. PMID:26019355

Segmental Mirroring: Does It Eliminate the Need for Intraoperative Readjustment of the Virtually Pre-Bent Reconstruction Plates and Is It Economically Valuable?

PubMed

Khalifa, Ghada Amin; Abd El Moniem, Nahed Adly; Elsayed, Shadia Abd-ElHameed; Qadry, Yara

2016-03-01

The aim of this study was to compare segmental mirroring with mirroring of the entire unaffected side to determine which method obviates intraoperative readjustment of virtually planned pre-bent plates and to evaluate the effect on costs. Patients eligible for inclusion in this prospective study had unilateral mandibular discontinuity defects. Patients were randomly divided into 2 groups. In group I, models were constructed by mirroring the entire unaffected side of the mandible at the midsagittal plane. In group II, only the resected segments were cut and replaced by the corresponding mirrored healthy segments. The lesions were resected, and their sites were reconstructed using pre-bent reconstruction plates. The need for intraoperative plate readjustment, plate placement time, operation time, and operation costs were reviewed. Fifty patients were enrolled in this study. All but 5 plates in group I required readjustment. In group II, plates were placed without intraoperative handling. Average operating times were 4.20 ± 0.56 hours in group I and 3.186 ± 0.28 hours in group II (P = .00002). Mean times for plate placement were 33.36 ± 8.20 and 21.88 ± 5.73 minutes in groups I and II, respectively. The difference resulted in an average time gain of 11.48 minutes. Average personal costs per minute were US$740.77 for group I and US$560.87 for group II. The difference resulted in an average saving of approximately US$179.90. Segmental mirroring is superior in reflecting the bone anatomy in 3-dimensional models, thus eliminating intraoperative plate readjustment and providing better plate adaptation with better contour. It decreases operating time and costs and thus can be recommended for lesions that do not cross the midline. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

The Impact of Operating Room Noise Upon Communication During Percutaneous Nephrostolithotomy.

PubMed

Cheriyan, Salim; Mowery, Hayley; Ruckle, David; Keheila, Mohamed; Myklak, Kristene; Alysouf, Muhannad; Atiga, Chase; Khuri, Jacob; Khater, Nazih; Faaborg, Daniel; Ruckle, Herbert C; Baldwin, D Daniel; Baldwin, D Duane

2016-10-01

Equipment and personnel contribute to the overall noise level in the operating room (OR). This study aims to determine intraoperative noise levels during percutaneous nephrostolithotomy (PCNL) and the effects of this noise upon intraoperative communication. A PCNL benchtop model was used to measure intraoperative noise and determine its effect upon communication in three progressively increasing sound environments (baseline ambient noise, ambient noise with PCNL equipment, and ambient noise with both PCNL equipment and music). Five trials with 20 different medical words/phrases were spoken by the surgeon and responses were recorded by the first assistant, anesthesiologist, and circulating nurse. In addition, noise levels during PCNL were compared to common environmental noise levels. In the bench top model, noise levels were 53.49 A-weighted decibels (dBA) with ambient noise, 78.79 dBA with equipment in use, and 81.78 dBA with equipment and music. At the ambient noise level, the first assistant, anesthesiologist, and circulator correctly recorded 100%, 100%, and 96% of the words, respectively. The correct response rate by the subjects decreased to 97% (p = 0.208), 81% (p = 0.012), and 56% (p < 0.001) upon addition of PCNL equipment, and 90% (p = 0.022), 48% (p = 0.002), and 13% (p < 0.001) upon addition of music and PCNL equipment in the first assistant, anesthesiologist, and circulator, respectively. In the simulated OR model, PCNL noise level (81.78 dBA) was comparable to a passing freight train at 30 feet (82.2 dBA, p = 0.44). Noise pollution decreases effective intraoperative communication during PCNL. It is important for surgeons to understand the effect noise can have on attempted communication to prevent errors due to miscommunication. In addition, methods to decrease intraoperative noise pollution and improve communication in the OR could improve patient safety and outcomes.

The Physiologic Effects of Pneumoperitoneum in the Morbidly Obese

PubMed Central

Nguyen, Ninh T.; Wolfe, Bruce M.

2005-01-01

Objective: To review the physiologic effects of carbon dioxide (CO2) pneumoperitoneum in the morbidly obese. Summary Background Data: The number of laparoscopic bariatric operations performed in the United States has increased dramatically over the past several years. Laparoscopic bariatric surgery requires abdominal insufflation with CO2 and an increase in the intraabdominal pressure up to 15 mm Hg. Many studies have demonstrated the adverse consequences of pneumoperitoneum; however, few studies have examined the physiologic effects of pneumoperitoneum in the morbidly obese. Methods: A MEDLINE search from 1994 to 2003 was performed using the key words morbid obesity, laparoscopy, bariatric surgery, pneumoperitoneum, and gastric bypass. The authors reviewed papers evaluating the physiologic effects of pneumoperitoneum in morbidly obese subjects undergoing laparoscopy. The topics examined included alteration in acid-base balance, hemodynamics, femoral venous flow, and hepatic, renal, and cardiorespiratory function. Results: Physiologically, morbidly obese patients have a higher intraabdominal pressure at 2 to 3 times that of nonobese patients. The adverse consequences of pneumoperitoneum in morbidly obese patients are similar to those observed in nonobese patients. Laparoscopy in the obese can lead to systemic absorption of CO2 and increased requirements for CO2 elimination. The increased intraabdominal pressure enhances venous stasis, reduces intraoperative portal venous blood flow, decreases intraoperative urinary output, lowers respiratory compliance, increases airway pressure, and impairs cardiac function. Intraoperative management to minimize the adverse changes include appropriate ventilatory adjustments to avoid hypercapnia and acidosis, the use of sequential compression devices to minimizes venous stasis, and optimize intravascular volume to minimize the effects of increased intraabdominal pressure on renal and cardiac function. Conclusions: Morbidly obese patients undergoing laparoscopic bariatric surgery are at risk for intraoperative complications relating to the use of CO2 pneumoperitoneum. Surgeons performing laparoscopic bariatric surgery should understand the physiologic effects of CO2 pneumoperitoneum in the morbidly obese and make appropriate intraoperative adjustments to minimize the adverse changes. PMID:15650630

Intra-Operative Surgical Irrigation of the Surgical Incision: What Does the Future Hold-Saline, Antibiotic Agents, or Antiseptic Agents?

PubMed

Edmiston, Charles E; Leaper, David J

2016-12-01

Intra-operative surgical site irrigation (lavage) is common practice in surgical procedures in general, with all disciplines advocating some form of irrigation before incision closure. This practice, however, has been neither standardized nor is there compelling evidence that it effectively reduces the risk of surgical site infection (SSI). This narrative review addresses the laboratory and clinical evidence that is available to support the practice of irrigation of the abdominal cavity and superficial/deep incisional tissues, using specific irrigation solutions at the end of an operative procedure to reduce the microbial burden at wound closure. Review of PubMed and OVID for pertinent, scientific, and clinical publications in the English language was performed. Incision irrigation was found to afford a three-fold benefit: First, to hydrate the bed; second, to assist in allowing better examination of the area immediately before closure; and finally, by removing superficial and deep incisional contamination and lowering the bioburden, expedite the healing process. The clinical practice of intra-operative peritoneal lavage is highly variable and is dependent solely on surgeon preference. By contrast, intra-operative irrigation after device-related procedures has become a standard of care for the prophylaxis of acute peri-prosthetic infection. The clinical evidence that supports the use of antibiotic irrigation is limited and based on retrospective analysis and few acceptable randomized controlled trials. The results of laboratory and animal studies using aqueous 0.05% chlorhexidine gluconate are favorable, suggesting that further studies are justified to determine its clinical efficacy. The adoption of appropriate and standardized intra-operative irrigation practices into peri-operative care bundles, which include other evidence-based strategies (weight-based antimicrobial prophylaxis, antimicrobial sutures, maintenance of normothermia, and glycemic control), offers an inexpensive and effective method to reduce the risk of post-operative SSI and deserves further evaluation.

Aggressive resection at the infiltrative margins of glioblastoma facilitated by intraoperative fluorescein guidance.

PubMed

Neira, Justin A; Ung, Timothy H; Sims, Jennifer S; Malone, Hani R; Chow, Daniel S; Samanamud, Jorge L; Zanazzi, George J; Guo, Xiaotao; Bowden, Stephen G; Zhao, Binsheng; Sheth, Sameer A; McKhann, Guy M; Sisti, Michael B; Canoll, Peter; D'Amico, Randy S; Bruce, Jeffrey N

2017-07-01

OBJECTIVE Extent of resection is an important prognostic factor in patients undergoing surgery for glioblastoma (GBM). Recent evidence suggests that intravenously administered fluorescein sodium associates with tumor tissue, facilitating safe maximal resection of GBM. In this study, the authors evaluate the safety and utility of intraoperative fluorescein guidance for the prediction of histopathological alteration both in the contrast-enhancing (CE) regions, where this relationship has been established, and into the non-CE (NCE), diffusely infiltrated margins. METHODS Thirty-two patients received fluorescein sodium (3 mg/kg) intravenously prior to resection. Fluorescence was intraoperatively visualized using a Zeiss Pentero surgical microscope equipped with a YELLOW 560 filter. Stereotactically localized biopsy specimens were acquired from CE and NCE regions based on preoperative MRI in conjunction with neuronavigation. The fluorescence intensity of these specimens was subjectively classified in real time with subsequent quantitative image analysis, histopathological evaluation of localized biopsy specimens, and radiological volumetric assessment of the extent of resection. RESULTS Bright fluorescence was observed in all GBMs and localized to the CE regions and portions of the NCE margins of the tumors, thus serving as a visual guide during resection. Gross-total resection (GTR) was achieved in 84% of the patients with an average resected volume of 95%, and this rate was higher among patients for whom GTR was the surgical goal (GTR achieved in 93.1% of patients, average resected volume of 99.7%). Intraoperative fluorescein staining correlated with histopathological alteration in both CE and NCE regions, with positive predictive values by subjective fluorescence evaluation greater than 96% in NCE regions. CONCLUSIONS Intraoperative administration of fluorescein provides an easily visualized marker for glioma pathology in both CE and NCE regions of GBM. These findings support the use of fluorescein as a microsurgical adjunct for guiding GBM resection to facilitate safe maximal removal.

SU-F-T-80: A Mobile Application for Intra-Operative Electron Radiotherapy Treatment Planning

DOE Office of Scientific and Technical Information (OSTI.GOV)

Williams, C; Harvard Medical School, Boston, MA; Crowley, E

Purpose: Intraoperative electron radiotherapy (IORT) poses a unique set of challenges for treatment planning. Planning must be performed in a busy operating room environment over a short timeframe often with little advance knowledge of the treatment depth or applicator size. Furthermore, IORT accelerators can have a large number of possible applicators, requiring extensive databooks that must be searched for the appropriate dosimetric parameters. The goal of this work is to develop a software tool to assist in the planning process that is suited to the challenges faced in the IORT environment. Methods: We developed a mobile application using HTML5 andmore » Javascript that can be deployed to tablet devices suitable for use in the operating room. The user selects the desired treatment parameters cone diameter, bevel angle, and energy (a total of 141 datasets) and desired bolus. The application generates an interactive display that allows the user to dynamically select points on the depth-dose curve and to visualize the shape of the corresponding isodose contours. The user can indicate a prescription isodose line or depth. The software performs a monitor unit calculation and generates a PDF report. Results: We present our application, which is now used routinely in our IORT practice. It has been employed successfully in over 23 cases. The interactivity of the isodose distributions was found to be of particular use to physicians who are less-frequent IORT users, as well as for the education of residents and trainees. Conclusion: This software has served as a useful tool in IORT planning, and demonstrates the need for treatment planning tools that are designed for the specialized challenges encountered in IORT. This software is the subject of a license agreement with the IntraOp Medical Corporation. This software is the subject of a license agreement between Massachusetts General Hospital / Partners Healthcare and the IntraOp Medical Corporation. CLW is consulting on software development with the IntraOp Medical Corporation.« less

[Risk factors of rupture of internal carotid artery during surgical resection of carotid body tumor].

PubMed

Li, Y H; Wang, J S; Yao, C; Chang, G Q; Yin, H H; Li, S Q; Lü, W M; Hu, Z J; Wang, S M

2017-06-13

Objective: To investigate risk factors of rupture of internal carotid artery resection during carotid body tumor resection and to summarize our treatment experience. Methods: During the period from 1991 to 2016, rupture of internal carotid artery occurred in 27 patients (28 tumors) during surgical resection of carotid body tumor in the First Affiliated Hospital of Sun Yat-sen University. Their clinical and follow-up data were retrospectively collected and analyzed. For all patients underwent surgical resection during this period, Logistic regression analysis was used to investigate the risk factors of intraoperative rupture of internal carotid artery. Results: Of these 28 tumors, there were 15 (53.6%) tumors with diameter≥5 cm and 20 (71.4%) Shamblin Ⅲ tumors. Intraoperatively, shunt was applied for 8 (28.6%) cases. Thirteen (46.4%) patients underwent ligation of external carotid artery, while 2 (7.1%) patients accepted resection of cranial nerves. Direct closure/patchplasty, autologous vessels or graft reconstruction was used in 16, 10 and 2 cases, respectively. Postoperatively, stroke occurred in 4(14.3%) cases and cranial nerve deficit in 15 (53.6%) cases. During a median length of 36 (14-125) months, cranial nerve deficit persisted in 5 cases. Follow-up radiologic examination indicated 3 (10.7%) cases of targeted vessel occlusion. However, no new-onset stroke was identified. Among all patients underwent surgical resection of carotid body tumor, female ( OR =3.650, P =0.012), age≤25 years old ( OR =3.710, P =0.013) and Shamblin Ⅲ tumor ( OR =4.631, P =0.008) increase the risks of intraoperative carotid artery rupture. Conclusions: Shamblin Ⅲ tumor is the predictor of rupture of internal carotid artery. Intraoperative, properly increased blood pressure, intraoperative heparinization and use of shunt for those cases without well-compensated cranial collateral arteries are likely to decreasing the incidence of stroke.

Does the Surgical Apgar Score Measure Intraoperative Performance?

PubMed Central

Regenbogen, Scott E.; Lancaster, R. Todd; Lipsitz, Stuart R.; Greenberg, Caprice C.; Hutter, Matthew M.; Gawande, Atul A.

2008-01-01

Objective To evaluate whether Surgical Apgar Scores measure the relationship between intraoperative care and surgical outcomes. Summary Background Data With preoperative risk-adjustment now well-developed, the role of intraoperative performance in surgical outcomes may be considered. We previously derived and validated a ten-point Surgical Apgar Score—based on intraoperative blood loss, heart rate, and blood pressure—that effectively predicts major postoperative complications within 30 days of general and vascular surgery. This study evaluates whether the predictive value of this score comes solely from patients’ preoperative risk, or also measures care in the operating room. Methods Among a systematic sample of 4,119 general and vascular surgery patients at a major academic hospital, we constructed a detailed risk-prediction model including 27 patient-comorbidity and procedure-complexity variables, and computed patients’ propensity to suffer a major postoperative complication. We evaluated the prognostic value of patients’ Surgical Apgar Scores before and after adjustment for this preoperative risk. Results After risk-adjustment, the Surgical Apgar Score remained strongly correlated with postoperative outcomes (p<0.0001). Odds of major complications among average-scoring patients (scores 7–8) were equivalent to preoperative predictions (likelihood ratio (LR) 1.05, 95%CI 0.78–1.41), significantly decreased for those who achieved the best scores of 9–10 (LR 0.52, 95%CI 0.35–0.78), and were significantly poorer for those with low scores—LRs 1.60 (1.12–2.28) for scores 5–6, and 2.80 (1.50–5.21) for scores 0–4. Conclusions Even after accounting for fixed preoperative risk—due to patients’ acute condition, comorbidities and/or operative complexity—the Surgical Apgar Score appears to detect differences in intraoperative management that reduce odds of major complications by half, or increase them by nearly three-fold. PMID:18650644

Comparison of indocyanine green fluorescence and parathyroid autofluorescence imaging in the identification of parathyroid glands during thyroidectomy.

PubMed

Kahramangil, Bora; Berber, Eren

2017-12-01

Indocyanine green fluorescence (ICGF) and parathyroid autofluorescence (AF) are two new techniques that aid in the identification of parathyroid glands (PG) intraoperatively during thyroidectomy. There is no study comparing the efficacy of these techniques. This was an IRB-approved clinical study comparing the utility of ICGF and AF for identification of PGs during thyroidectomy. Data were collected prospectively. Both techniques were compared to naked eye (NE) for PG detection. Standard statistical methods were used for data analysis. Twenty-two patients in each group underwent a total of 39 total thyroidectomies and 5 thyroid lobectomies. AF and ICGF had similar detection rates for PGs [98% (61 of 62) and 95% (60 of 63) of PGs, respectively; P=0.31]. The location of PGs was suggested before detection with NE more frequently by AF than ICGF [52% (32 of 62) vs. 6% (4 of 63) of PGs; P<0.001]. In 82% (18 of 22) of patients at least one PG was detected by AF before NE, as opposed to 14% (3 of 22) by ICGF (P<0.001). The median (range) number of PGs detected before NE per patient was greater with AF than ICGF [2 (0-3) vs. 0 (0-2)];. Upper PGs were more likely to be detected by AF before recognition with NE than the lower ones (P=0.03). There was no predictive factor for ICGF detection. Postoperative hypocalcemia rates were similar [9% (2 of 22) and 5% (1 of 22) for AF and ICGF, respectively; P>0.99]. To the best of our knowledge, this is the first comparative study between parathyroid AF and ICGF in detection of PGs during thyroidectomy. Our data suggest both techniques have similarly high detection rates and that the main difference lies in the timing of detection. AF more frequently detects PGs before recognition with NE compared to ICGF.

A combined registration and finite element analysis method for fast estimation of intraoperative brain shift; phantom and animal model study.

PubMed

Mohammadi, Amrollah; Ahmadian, Alireza; Rabbani, Shahram; Fattahi, Ehsan; Shirani, Shapour

2017-12-01

Finite element models for estimation of intraoperative brain shift suffer from huge computational cost. In these models, image registration and finite element analysis are two time-consuming processes. The proposed method is an improved version of our previously developed Finite Element Drift (FED) registration algorithm. In this work the registration process is combined with the finite element analysis. In the Combined FED (CFED), the deformation of whole brain mesh is iteratively calculated by geometrical extension of a local load vector which is computed by FED. While the processing time of the FED-based method including registration and finite element analysis was about 70 s, the computation time of the CFED was about 3.2 s. The computational cost of CFED is almost 50% less than similar state of the art brain shift estimators based on finite element models. The proposed combination of registration and structural analysis can make the calculation of brain deformation much faster. Copyright © 2016 John Wiley & Sons, Ltd.

Interventional endocardial motion estimation from electroanatomical mapping data: application to scar characterization.

PubMed

Porras, Antonio R; Piella, Gemma; Berruezo, Antonio; Hoogendoorn, Corne; Andreu, David; Fernandez-Armenta, Juan; Sitges, Marta; Frangi, Alejandro F

2013-05-01

Scar presence and its characteristics play a fundamental role in several cardiac pathologies. To accurately define the extent and location of the scar is essential for a successful ventricular tachycardia ablation procedure. Nowadays, a set of widely accepted electrical voltage thresholds applied to local electrograms recorded are used intraoperatively to locate the scar. Information about cardiac mechanics could be considered to characterize tissues with different viability properties. We propose a novel method to estimate endocardial motion from data obtained with an electroanatomical mapping system together with the endocardial geometry segmented from preoperative 3-D magnetic resonance images, using a statistical atlas constructed with bilinear models. The method was validated using synthetic data generated from ultrasound images of nine volunteers and was then applied to seven ventricular tachycardia patients. Maximum bipolar voltages, commonly used to intraoperatively locate scar tissue, were compared to endocardial wall displacement and strain for all the patients. The results show that the proposed method allows endocardial motion and strain estimation and that areas with low-voltage electrograms also present low strain values.

[Basic concept in computer assisted surgery].

PubMed

Merloz, Philippe; Wu, Hao

2006-03-01

To investigate application of medical digital imaging systems and computer technologies in orthopedics. The main computer-assisted surgery systems comprise the four following subcategories. (1) A collection and recording process for digital data on each patient, including preoperative images (CT scans, MRI, standard X-rays), intraoperative visualization (fluoroscopy, ultrasound), and intraoperative position and orientation of surgical instruments or bone sections (using 3D localises). Data merging based on the matching of preoperative imaging (CT scans, MRI, standard X-rays) and intraoperative visualization (anatomical landmarks, or bone surfaces digitized intraoperatively via 3D localiser; intraoperative ultrasound images processed for delineation of bone contours). (2) In cases where only intraoperative images are used for computer-assisted surgical navigation, the calibration of the intraoperative imaging system replaces the merged data system, which is then no longer necessary. (3) A system that provides aid in decision-making, so that the surgical approach is planned on basis of multimodal information: the interactive positioning of surgical instruments or bone sections transmitted via pre- or intraoperative images, display of elements to guide surgical navigation (direction, axis, orientation, length and diameter of a surgical instrument, impingement, etc. ). And (4) A system that monitors the surgical procedure, thereby ensuring that the optimal strategy defined at the preoperative stage is taken into account. It is possible that computer-assisted orthopedic surgery systems will enable surgeons to better assess the accuracy and reliability of the various operative techniques, an indispensable stage in the optimization of surgery.

Intraoperative floppy iris and prevalence of intraoperative complications: results from ophthalmic surgery outcomes database.

PubMed

Vollman, David E; Gonzalez-Gonzalez, Luis A; Chomsky, Amy; Daly, Mary K; Baze, Elizabeth; Lawrence, Mary

2014-06-01

To estimate the prevalence of untoward events during cataract surgery with the use of pupillary expansion devices and intraoperative floppy iris (IFIS). Retrospective analysis of 4923 cataract surgery cases from the Veterans Affairs Ophthalmic Surgical Outcomes Data Project. Outcomes from 5 Veterans Affairs medical centers were analyzed, including use of alpha-blockers (both selective and nonselective), IFIS, intraoperative iris trauma, intraoperative iris prolapse, posterior capsular tear, anterior capsule tear, intraoperative vitreous prolapse, and use of pupillary expansion devices. P values were calculated using the χ(2) test. A total of 1254 patients (25.5%) took alpha-blockers preoperatively (selective, 587; nonselective, 627; both, 40). Of these 1254 patients, 428 patients (34.1%) had documented IFIS. However, 75.2% of patients with IFIS (428/569) had taken alpha-blockers preoperatively (P < .00001). A total of 430 patients (8.7%) had a pupillary expansion device used during their cataract surgery, of which 186 patients (43.4%) had IFIS (P < .0001). Eighty-six patients with IFIS had at least 1 intraoperative complication and 39 patients with IFIS had more than 1 intraoperative complication (P < .001). The use of either selective or nonselective alpha-antagonists preoperatively demonstrated a significant risk of IFIS. Nonselective alpha-antagonists caused IFIS at a higher prevalence than previously reported. This study did demonstrate statistically significant increased odds of surgical complications in patients with IFIS vs those without IFIS in all groups (those taking selective and nonselective alpha-antagonists and also those not taking medications). Published by Elsevier Inc.

A Ratiometric Threshold for Determining Presence of Cancer During Fluorescence-guided Surgery

PubMed Central

Warram, Jason M; de Boer, Esther; Moore, Lindsay S.; Schmalbach, Cecelia E; Withrow, Kirk P; Carroll, William R; Richman, Joshua S; Morlandt, Anthony B; Brandwein-Gensler, Margaret; Rosenthal, Eben L

2015-01-01

Background&Objective Fluorescence-guided imaging to assist in identification of malignant margins has the potential to dramatically improve oncologic surgery. However a standardized method for quantitative assessment of disease-specific fluorescence has not been investigated. Introduced here is a ratiometric threshold derived from mean fluorescent tissue intensity that can be used to semi-quantitatively delineate tumor from normal tissue. Methods Open-field and a closed-field imaging devices were used to quantify fluorescence in punch biopsy tissues sampled from primary tumors collected during a phase 1 trial evaluating the safety of cetuximab-IRDye800 in patients (n=11) undergoing surgical intervention for head and neck cancer. Fluorescence ratios were calculated using mean fluorescence intensity (MFI) from punch biopsy normalized by MFI of patient-matched tissues. Ratios were compared to pathological assessment and a ratiometric threshold was established to predict presence of cancer. Results During open-field imaging using an intraoperative device, the threshold for muscle normalized tumor fluorescence was found to be 2.7, which produced a sensitivity of 90.5% and specificity of 78.6% for delineating disease tissue. The skin-normalized threshold generated greater sensitivity (92.9%) and specificity (81.0%). Conclusion Successful implementation of a semi-quantitative threshold can provide a scientific methodology for delineating disease from normal tissue during fluorescence-guided resection of cancer. PMID:26074273

A resorbable and rapid method for maxillomandibular fixation in pediatric mandible fractures.

PubMed

Eppley, B L

2000-05-01

Maxillomandibular immobilization in pediatric mandible fractures is accomplished through a resorbable screw placed into the zygomatic body to which is attached a large, monofilament, circummandibular suture. Although the screw must be placed intraoperatively, this method of jaw immobilization is rapid, secure, does not damage the teeth, and can be removed in the office in the older child.

Real-time Visualization and Quantification of Retrograde Cardioplegia Delivery using Near Infrared Fluorescent Imaging

PubMed Central

Rangaraj, Aravind T.; Ghanta, Ravi K.; Umakanthan, Ramanan; Soltesz, Edward G.; Laurence, Rita G.; Fox, John; Cohn, Lawrence H.; Bolman, R. M.; Frangioni, John V.; Chen, Frederick Y.

2009-01-01

Background and Aim of the Study Homogeneous delivery of cardioplegia is essential for myocardial protection during cardiac surgery. Presently, there exist no established methods to quantitatively assess cardioplegia distribution intraoperatively and determine when retrograde cardioplegia is required. In this study, we evaluate the feasibility of near infrared (NIR) imaging for real-time visualization of cardioplegia distribution in a porcine model. Methods A portable, intraoperative, real-time NIR imaging system was utilized. NIR fluorescent cardioplegia solution was developed by incorporating indocyanine green (ICG) into crystalloid cardioplegia solution. Real-time NIR imaging was performed while the fluorescent cardioplegia solution was infused via the retrograde route in 5 ex-vivo normal porcine hearts and in 5 ex-vivo porcine hearts status post left anterior descending (LAD) coronary artery ligation. Horizontal cross-sections of the hearts were obtained at proximal, middle, and distal LAD levels. Videodensitometry was performed to quantify distribution of fluorophore content. Results The progressive distribution of cardioplegia was clearly visualized with NIR imaging. Complete visualization of retrograde distribution occurred within 4 minutes of infusion. Videodensitometry revealed that retrograde cardioplegia primarily distributed to the left ventricle and anterior septum. In hearts with LAD ligation, antegrade cardioplegia did not distribute to the anterior left ventricle. This deficiency was compensated for with retrograde cardioplegia supplementation. Conclusions Incorporation of ICG into cardioplegia allows real-time visualization of cardioplegia delivery via NIR imaging. This technology may prove useful in guiding intraoperative decisions pertaining to when retrograde cardioplegia is mandated. PMID:19016995

Reducing intraoperative red blood cell unit wastage in a large academic medical center

PubMed Central

Whitney, Gina M.; Woods, Marcella C.; France, Daniel J.; Austin, Thomas M.; Deegan, Robert J.; Paroskie, Allison; Booth, Garrett S.; Young, Pampee P.; Dmochowski, Roger R.; Sandberg, Warren S.; Pilla, Michael A.

2015-01-01

BACKGROUND The wastage of red blood cell (RBC) units within the operative setting results in significant direct costs to health care organizations. Previous education-based efforts to reduce wastage were unsuccessful at our institution. We hypothesized that a quality and process improvement approach would result in sustained reductions in intraoperative RBC wastage in a large academic medical center. STUDY DESIGN AND METHODS Utilizing a failure mode and effects analysis supplemented with time and temperature data, key drivers of perioperative RBC wastage were identified and targeted for process improvement. RESULTS Multiple contributing factors, including improper storage and transport and lack of accurate, locally relevant RBC wastage event data were identified as significant contributors to ongoing intraoperative RBC unit wastage. Testing and implementation of improvements to the process of transport and storage of RBC units occurred in liver transplant and adult cardiac surgical areas due to their history of disproportionately high RBC wastage rates. Process interventions targeting local drivers of RBC wastage resulted in a significant reduction in RBC wastage (p <0.0001; adjusted odds ratio, 0.24; 95% confidence interval, 0.15–0.39), despite an increase in operative case volume over the period of the study. Studied process interventions were then introduced incrementally in the remainder of the perioperative areas. CONCLUSIONS These results show that a multidisciplinary team focused on the process of blood product ordering, transport, and storage was able to significantly reduce operative RBC wastage and its associated costs using quality and process improvement methods. PMID:26202213

Multiscale nonlinear microscopy and widefield white light imaging enables rapid histological imaging of surgical specimen margins

PubMed Central

Giacomelli, Michael G.; Yoshitake, Tadayuki; Cahill, Lucas C.; Vardeh, Hilde; Quintana, Liza M.; Faulkner-Jones, Beverly E.; Brooker, Jeff; Connolly, James L.; Fujimoto, James G.

2018-01-01

The ability to histologically assess surgical specimens in real-time is a long-standing challenge in cancer surgery, including applications such as breast conserving therapy (BCT). Up to 40% of women treated with BCT for breast cancer require a repeat surgery due to postoperative histological findings of close or positive surgical margins using conventional formalin fixed paraffin embedded histology. Imaging technologies such as nonlinear microscopy (NLM), combined with exogenous fluorophores can rapidly provide virtual H&E imaging of surgical specimens without requiring microtome sectioning, facilitating intraoperative assessment of margin status. However, the large volume of typical surgical excisions combined with the need for rapid assessment, make comprehensive cellular resolution margin assessment during surgery challenging. To address this limitation, we developed a multiscale, real-time microscope with variable magnification NLM and real-time, co-registered position display using a widefield white light imaging system. Margin assessment can be performed rapidly under operator guidance to image specific regions of interest located using widefield imaging. Using simulated surgical margins dissected from human breast excisions, we demonstrate that multi-centimeter margins can be comprehensively imaged at cellular resolution, enabling intraoperative margin assessment. These methods are consistent with pathology assessment performed using frozen section analysis (FSA), however NLM enables faster and more comprehensive assessment of surgical specimens because imaging can be performed without freezing and cryo-sectioning. Therefore, NLM methods have the potential to be applied to a wide range of intra-operative applications. PMID:29761001

Intraoperative Sedation With Dexmedetomidine is Superior to Propofol for Elderly Patients Undergoing Hip Arthroplasty: A Prospective Randomized Controlled Study.

PubMed

Mei, Bin; Meng, Gaige; Xu, Guanghong; Cheng, Xinqi; Chen, Shishou; Zhang, Ye; Zhang, Ming; Liu, Xuesheng; Gu, Erwei

2018-03-09

Peripheral nerve block is a preferable method for elderly patients receiving hip arthroplasty. Sedation with dexmedetomidine may reduce postoperative delirium. The aim of this study was to investigate whether intraoperative sedation with dexmedetomidine, as a supplementary to peripheral nerve block for elderly patients receiving total hip arthroplasty, can decrease the prevalence of postoperative delirium. A prospective, randomized controlled study was conducted with patients 65 years of age or older who underwent total hip arthroplasty between June 2016 and June 2017. The patients were randomly assigned to receive a lumbosacral plexus plus T12 paravertebral block supplemented with propofol or dexmedetomidine for sedation. Incidence of postoperative delirium was the primary endpoint and was determined with the Confusion Assessment Method, and incidence of postoperative cognitive dysfunction was assessed with the Mini-Mental State Examination. The time of ambulation, discharge time, and complications over a 30-day post-surgery period were also recorded. 296 patients were randomly assigned to two groups. The patients sedated with dexmedetomidine had lower incidences of postoperative delirium and postoperative cognitive dysfunction and were out of bed and discharged sooner than the patients sedated with propofol. There was no difference in complications between the two groups. As a supplementary to peripheral nerve block, intraoperative sedation with dexmedetomidine could be associated with a lower incidence of POD, which may have benefits on reducing the incidence of early postoperative cognitive dysfunction and offering a better short-term recovery for elderly patients receiving hip arthroplasty.

Potential predictors for the amount of intra-operative brain shift during deep brain stimulation surgery

NASA Astrophysics Data System (ADS)

Datteri, Ryan; Pallavaram, Srivatsan; Konrad, Peter E.; Neimat, Joseph S.; D'Haese, Pierre-François; Dawant, Benoit M.

2011-03-01

A number of groups have reported on the occurrence of intra-operative brain shift during deep brain stimulation (DBS) surgery. This has a number of implications for the procedure including an increased chance of intra-cranial bleeding and complications due to the need for more exploratory electrodes to account for the brain shift. It has been reported that the amount of pneumocephalus or air invasion into the cranial cavity due to the opening of the dura correlates with intraoperative brain shift. Therefore, pre-operatively predicting the amount of pneumocephalus expected during surgery is of interest toward accounting for brain shift. In this study, we used 64 DBS patients who received bilateral electrode implantations and had a post-operative CT scan acquired immediately after surgery (CT-PI). For each patient, the volumes of the pneumocephalus, left ventricle, right ventricle, third ventricle, white matter, grey matter, and cerebral spinal fluid were calculated. The pneumocephalus was calculated from the CT-PI utilizing a region growing technique that was initialized with an atlas-based image registration method. A multi-atlas-based image segmentation method was used to segment out the ventricles of each patient. The Statistical Parametric Mapping (SPM) software package was utilized to calculate the volumes of the cerebral spinal fluid (CSF), white matter and grey matter. The volume of individual structures had a moderate correlation with pneumocephalus. Utilizing a multi-linear regression between the volume of the pneumocephalus and the statistically relevant individual structures a Pearson's coefficient of r = 0.4123 (p = 0.0103) was found. This study shows preliminary results that could be used to develop a method to predict the amount of pneumocephalus ahead of the surgery.

Bone quality assessment for total hip arthroplasty with intraoperative trabecular torque measurements.

PubMed

Klotz, Matthias C M; Beckmann, Nicholas A; Bitsch, Rudi G; Seebach, Elisabeth; Reiner, Tobias; Jäger, Sebastian

2014-11-13

In cases of poor bone quality, intraoperative torque measurement might be an alternative to preoperative dual-energy X-ray absorptiometry (DXA) to assess bone quality in total hip arthroplasty (THA). Trabecular peak torque measurement was applied in 14 paired fresh frozen human femurs. Here, a 6.5 × 23 mm wingblade was inserted into the proximal femur without harming the lateral cortical bone. Further tests of the proximal femur also evaluated bone strength (DXA, micro-computed tomography (μCT), monoaxial compression test), and the results were compared to the trabecular torque measurement. Student's t-test was used to compare the values of the groups. Pearson product-moment was applied to correlate the values of the peak torque measurement with the bone strength measured by DXA, μCT, and monoaxial compression test. In the femoral head, the mean trabecular peak torque was 4.38 ± 1.86 Nm. These values showed a strong correlation with the values of the DXA, the μCT, and the biomechanical load test (Pearson's product-moment: DXA: 0.86, μCT-BMD: 0.80, load test: 0.85). Furthermore, the torque measurement showed a more pronounced correlation with the biomechanical load test compared to the DXA. The use of this method provides highly diagnostic information about bone quality. Since the approach was adjusted for THA, no harm of the lateral bone stock will result from this measurement during surgery. The results of this initial study employing small sample sizes indicate that this new method is as sensitive as DXA in predicting bone quality and may function as an intraoperative alternative to DXA in THA. Nevertheless, before this method will turn into clinical use, more research and clinical trials are necessary.

Focal brainstem gliomas

PubMed Central

Sabbagh, Abdulrahman J.; Alaqeel, Ahmed M.

2015-01-01

Improved neuronavigation guidance as well as intraoperative imaging and neurophysiologic monitoring technologies have enhanced the ability of neurosurgeons to resect focal brainstem gliomas. In contrast, diffuse brainstem gliomas are considered to be inoperable lesions. This article is a continuation of an article that discussed brainstem glioma diagnostics, imaging, and classification. Here, we address open surgical treatment of and approaches to focal, dorsally exophytic, and cervicomedullary brainstem gliomas. Intraoperative neuronavigation, intraoperative neurophysiologic monitoring, as well as intraoperative imaging are discussed as adjunctive measures to help render these procedures safer, more acute, and closer to achieving surgical goals. PMID:25864061

Intraoperative serum parathyroid hormone level is an indicator of hypocalcaemia in total thyroidectomy patients.

PubMed

Islam, M S; Sultana, T; Paul, D; Huq, A H M Z; Chowdhury, A A; Ferdous, C; Ahmed, A N N

2012-12-01

Postoperative hypocalcaemia is the most frequent and common complication after total thyroidectomy. It is necessary to diagnose or to predict hypocalcaemia immediately after total thyroidectomy for minimizing complications. A prospective observational study was carried out in the Department of Clinical Pathology in collaboration with Department of Microbiology & Immunology, Department of Surgery, Department of Otolaryngology, Bangabandhu Sheikh Mujib Medical University (BSMMU) and Department of Otolaryngology, Dhaka Medical College & Hospital (DMC&H), Dhaka, during the period of September 2010 to August 2011 to evaluate intraoperative (20 minutes after total thyroidectomy) parathyroid hormone (PTH) measurement as a predictor of post thyroidectomy hypocalcaemia. Total 65 patients were enrolled in this study those came for total thyroidectomy. Postoperative hypocalcaemia developed in 25 cases. Intraoperative PTH was assessed and significant correlation was found between intraoperative PTH level and development of hypocalcaemia. The sensitivity, specificity, accuracy, positive predictive value, negative predictive value of intraoperative serum PTH for prediction of post total thyroidectomy hypocalcaemia were 84.0%, 85.0%, 84.6%, 77.8%, and 89.5% respectively. Because of the high sensitivity, specificity and accuracy of intraoperative serum PTH of this study, the early prediction of hypocalcaemia could be made by single assay of intraoperative serum PTH level at 20 minutes after total thyroidectomy.

Intraoperative magnetic resonance imaging assessment of non-functioning pituitary adenomas during transsphenoidal surgery.

PubMed

Patel, Kunal S; Yao, Yong; Wang, Renzhi; Carter, Bob S; Chen, Clark C

2016-04-01

To review the utility of intraoperative imaging in facilitating maximal resection of non-functioning pituitary adenomas (NFAs). We performed an exhaustive MEDLINE search, which yielded 5598 articles. Upon careful review of these studies, 31 were pertinent to the issue of interest. Nine studies examined whether intraoperative MRI (iMRI) findings correlated with the presence of residual tumor on MRI taken 3 months after surgical resection. All studies using iMRI of >0.15T showed a ≥90% concordance between iMRI and 3-month post-operative MRI findings. 24 studies (22 iMRI and 2 intraoperative CT) examined whether intraoperative imaging improved the surgeon's ability to achieve a more complete resection. The resections were carried out under microscopic magnification in 17 studies and under endoscopic visualization in 7 studies. All studies support the value of intraoperative imaging in this regard, with improved resection in 15-83% of patients. Two studies examined whether iMRI (≥0.3T) improved visualization of residual NFA when compared to endoscopic visualization. Both studies demonstrated the value of iMRI in this regard, particularly when the tumor is located lateral of the sella, in the cavernous sinus, and in the suprasellar space. The currently available literature supports the utility of intraoperative imaging in facilitating increased NFA resection, without compromising safety.

Real-time, label-free, intraoperative visualization of peripheral nerves and micro-vasculatures using multimodal optical imaging techniques

PubMed Central

Cha, Jaepyeong; Broch, Aline; Mudge, Scott; Kim, Kihoon; Namgoong, Jung-Man; Oh, Eugene; Kim, Peter

2018-01-01

Accurate, real-time identification and display of critical anatomic structures, such as the nerve and vasculature structures, are critical for reducing complications and improving surgical outcomes. Human vision is frequently limited in clearly distinguishing and contrasting these structures. We present a novel imaging system, which enables noninvasive visualization of critical anatomic structures during surgical dissection. Peripheral nerves are visualized by a snapshot polarimetry that calculates the anisotropic optical properties. Vascular structures, both venous and arterial, are identified and monitored in real-time using a near-infrared laser-speckle-contrast imaging. We evaluate the system by performing in vivo animal studies with qualitative comparison by contrast-agent-aided fluorescence imaging. PMID:29541506

Margins for Benign Salivary Gland Neoplasms of the Head and Neck.

PubMed

Carlson, Eric R; McCoy, James Michael

2017-08-01

The proper ablation of any neoplasm of the head and neck requires the inclusion of linear and anatomic barrier margins surrounding the neoplasm. Extirpative surgery of the major and minor salivary glands is certainly no exception to this surgical principle. To this end, the selection and execution of the most appropriate ablative surgical procedure for a major or minor benign salivary gland neoplasm is an essential exercise in oral and maxillofacial surgery. Of equal importance is the intraoperative identification and preservation of the pseudocapsule surrounding the benign neoplasm. This article reviews these important elements specifically related to ablative surgery of benign neoplasms of the parotid, submandibular and minor salivary glands with strict attention to observed nomenclature. Copyright © 2017 Elsevier Inc. All rights reserved.

Surgical wound dehiscence: a conceptual framework for patient assessment.

PubMed

Sandy-Hodgetts, Kylie; Carville, Keryln; Leslie, Gavin D

2018-03-02

This paper presents a conceptual framework which outlines the risk factors associated with surgical wound dehiscence (SWD) as identified in the literature. The purpose for the development of the conceptual framework was to derive an evidence-based, informed understanding of factors associated with SWD, in order to inform a programme of research on the aetiology and potential risk factors of SWD. Incorporated within the patient-centric conceptual framework are patient related comorbidities, intraoperative and postoperative risk factors related to SWD. These are categorised as either 'mechanical' or 'physiological mechanisms' posited to influence these relationships. The use of the conceptual model for assessment of patients has particular clinical relevance for identification of risk and the management of patients in the pre-, intra- and postoperative period.

Knowledge modeling in image-guided neurosurgery: application in understanding intraoperative brain shift

NASA Astrophysics Data System (ADS)

Cohen-Adad, Julien; Paul, Perrine; Morandi, Xavier; Jannin, Pierre

2006-03-01

During an image-guided neurosurgery procedure, the neuronavigation system is subject to inaccuracy because of anatomical deformations which induce a gap between the preoperative images and their anatomical reality. Thus, the objective of many research teams is to succeed in quantifying these deformations in order to update preoperative images. Anatomical intraoperative deformations correspond to a complex spatio-temporal phenomenon. Our objective is to identify the parameters implicated in these deformations and to use these parameters as constrains for systems dedicated to updating preoperative images. In order to identify these parameters of deformation we followed the iterative methodology used for cognitive system conception: identification, conceptualization, formalization, implementation and validation. A state of the art about cortical deformations has been established in order to identify relevant parameters probably involved in the deformations. As a first step, 30 parameters have been identified and described following an ontological approach. They were formalized into a Unified Modeling Language (UML) class diagram. We implemented that model into a web-based application in order to fill a database. Two surgical cases have been studied at this moment. After having entered enough surgical cases for data mining purposes, we expect to identify the most relevant and influential parameters and to gain a better ability to understand the deformation phenomenon. This original approach is part of a global system aiming at quantifying and correcting anatomical deformations.

The "right" way is not always popular: comparison of surgeons' perceptions during laparoscopic cholecystectomy for acute cholecystitis among experts from Japan, Korea and Taiwan.

PubMed

Hibi, Taizo; Iwashita, Yukio; Ohyama, Tetsuji; Honda, Goro; Yoshida, Masahiro; Takada, Tadahiro; Han, Ho-Seong; Hwang, Tsann-Long; Shinya, Satoshi; Suzuki, Kenji; Umezawa, Akiko; Yoon, Yoo-Seok; Choi, In-Seok; Huang, Wayne Shih-Wei; Chen, Kuo-Hsin; Miura, Fumihiko; Watanabe, Manabu; Abe, Yuta; Misawa, Takeyuki; Nagakawa, Yuichi; Yoon, Dong-Sup; Jang, Jin-Young; Yu, Hee Chul; Ahn, Keun Soo; Kim, Song Cheol; Song, In Sang; Kim, Ji Hoon; Yun, Sung Su; Choi, Seong Ho; Jan, Yi-Yin; Sheen-Chen, Shyr-Ming; Shan, Yan-Shen; Ker, Chen-Guo; Chan, De-Chuan; Wu, Cheng-Chung; Toyota, Naoyuki; Higuchi, Ryota; Nakamura, Yoshiharu; Mizuguchi, Yoshiaki; Takeda, Yutaka; Ito, Masahiro; Norimizu, Shinji; Yamada, Shigetoshi; Matsumura, Naoki; Shindoh, Junichi; Sunagawa, Hiroki; Gocho, Takeshi; Hasegawa, Hiroshi; Rikiyama, Toshiki; Sata, Naohiro; Kano, Nobuyasu; Kitano, Seigo; Tokumura, Hiromi; Yamashita, Yuichi; Watanabe, Goro; Nakagawa, Kunitoshi; Kimura, Taizo; Yamakawa, Tatsuo; Wakabayashi, Go; Endo, Itaru; Miyazaki, Masaru; Yamamoto, Masakazu

2017-01-01

Generally, surgeons' perceptions of surgical safety are based on experience and institutional policy. Our recent pilot survey demonstrated that the acceptable duration of surgery and criteria for open conversion during laparoscopic cholecystectomy (LC) vary among workplaces. A web-based survey was distributed to 554 expert LC surgeons in Japan, Korea, and Taiwan. The questionnaire covered LC experience, safety measures and recognition of landmarks, decision-making regarding conversion to open/partial cholecystectomy and the implications of this decision. Overall responses were compared among nations, and then stratified by LC experience level (lifetime cases 200-499, 500-999, and ≥1,000). The response rate was 92.6% (513/554); 67 surgeons with ≤199 LCs were excluded, and responses from 446 surgeons were analyzed. We observed significant differences among nations on almost all questions. Differences that remained after stratification by LC experience were on questions related to acceptable duration of surgery, adoption rates of intraoperative cholangiography, the "critical view of safety" technique, identification of Rouvière's sulcus, recognition of the SS-Inner layer theory, and intraoperative judgment to abandon conventional LC. Even among experts, surgeons' perceptions during LC are workplace-dependent. A novel grading system of surgical difficulty and standardized LC procedures are paramount to generate high-level evidence. © 2016 Japanese Society of Hepato-Biliary-Pancreatic Surgery.

Indocyanine green videoangiography (ICGV)-guided surgery of parasagittal meningiomas occluding the superior sagittal sinus (SSS).

PubMed

d'Avella, Elena; Volpin, Francesco; Manara, Renzo; Scienza, Renato; Della Puppa, Alessandro

2013-03-01

Maximal safe resection is the goal of correct surgical treatment of parasagittal meningiomas, and it is intimately related to the venous anatomy both near and directly involved by the tumor. Indocyanine green videoangiography (ICGV) has already been advocated as an intra-operative resourceful technique in brain tumor surgery for the identification of vessels. The aim of this study was to investigate the role of ICGV in surgery of parasagittal meningiomas occluding the superior sagittal sinus (SSS). In this study, we prospectively analyzed clinical, radiological and intra-operative findings of patients affected by parasagittal meningioma occluding the SSS, who underwent ICGV assisted-surgery. Radiological diagnosis of complete SSS occlusion was pre-operatively established in all cases. ICGV was performed before dural opening, before and during tumor resection, at the end of the procedure. Five patients were included in our study. In all cases, ICGV guided dural opening, tumor resection, and venous management. The venous collateral pathway was easily identified and preserved in all cases. Radical resection was achieved in four cases. Surgery was uneventful in all cases. Despite the small number of patients, our study shows that ICG videoangiography could play a crucial role in guiding surgery of parasagittal meningioma occluding the SSS. Further studies are needed to define the role of this technique on functional and oncological outcome of these patients.

Intermittent neural monitoring of the recurrent laryngeal nerve in surgery for recurrent goiter

PubMed Central

Barczyński, Marcin

2016-01-01

Reoperative thyroid surgery is still challenging even for skilled surgeons, and is associated with a higher incidence of complications, such as hypoparathyroidism and recurrent laryngeal nerve (RLN) palsy. Displacement of the RLN, scar tissue from previous neck surgery and difficulty in maintaining good hemostasis are risk factors in reoperations. The prevalence of RLN injury in reoperative thyroid surgery ranges as high as 12.5% for transient injury and up to 3.8% for permanent injury. Bilateral paresis can also occur during reoperations, and is a dangerous complication influencing the quality of life, sometimes requiring tracheostomy. RLN identification is the gold standard during thyroidectomy, and the use of intraoperative neuromonitoring (IONM) can be a valuable adjunct to visual identification. This technique can be used to identify the RLN and the external branch of the superior laryngeal nerve (EBSLN), both of which are standardized procedures. The aim of this review was to evaluate the use of intermittent neural monitoring of the RLN in surgery for recurrent goiter, and to assess the prevalence of RLN injury while using IONM reported in the current literature. PMID:27867862

True duplication of the vas deferens: a case report and review of literature.

PubMed

Liang, Mike K; Subramanian, Anuradha; Weedin, John; Griffith, Donald P; Awad, Samir S

2012-04-01

Duplication of the vas deferens is the identification of a second vas deferens within the spermatic cord; it is a rarely reported congenital anomaly. Duplicate vas deferens should not be confused with double vas deferens that describes ipsilateral renal agenesis with a blind ureter ending in the ejaculatory system. We present a case of duplicated vas deferens, and a PubMed Medline (National Library of Medicine) search was performed using the terms "[duplicated OR double]" and "vas deferens". Nineteen papers for a total of twenty-two cases (including ours) were identified. Duplication of vas deferens is a rare finding; it is likely under-reported and underrecognized. Failure to recognize this variation can result in injury to the vas deferens or an ineffective vasectomy. Following identification of a suspected duplicated vas deferens, the structure should be tracked from the internal ring down to the epididymis and intra-operative Doppler should be performed. Post-operatively, renal and bladder imaging can be considered though there have been no reported cases of non-testicular genito-urinary anomalies associated with duplicated vas deferens.