Improving core surgical training in a major trauma centre.

PubMed

Morris, Daniel L J; Bryson, David J; Ollivere, Ben J; Forward, Daren P

2016-06-01

English Major Trauma Centres (MTCs) were established in April 2012. Increased case volume and complexity has influenced trauma and orthopaedic (T&O) core surgical training in these centres. To determine if T&O core surgical training in MTCs meets Joint Committee on Surgical Training (JCST) quality indicators including performance of T&O operative procedures and consultant supervised session attendance. An audit cycle assessing the impact of a weekly departmental core surgical trainee rota. The rota included allocated timetabled sessions that optimised clinical and surgical learning opportunities. Intercollegiate Surgical Curriculum Programme (ISCP) records for T&O core surgical trainees at a single MTC were analysed for 8 months pre and post rota introduction. Outcome measures were electronic surgical logbook evidence of leading T&O operative procedures and consultant validated work-based assessments (WBAs). Nine core surgical trainees completed a 4 month MTC placement pre and post introduction of the core surgical trainee rota. Introduction of core surgical trainee rota significantly increased the mean number of T&O operative procedures led by a core surgical trainee during a 4 month MTC placement from 20.2 to 34.0 (p<0.05). The mean number of hip hemiarthroplasty procedures led by a core surgical trainee during a 4 month MTC placement was significantly increased (0.3 vs 2.4 [p=0.04]). Those of dynamic hip screw fixation (2.3 vs 3.6) and ankle fracture fixation (0.7 vs 1.6) were not. Introduction of a core surgical trainee rota significantly increased the mean number of consultant validated WBAs completed by a core surgical trainee during a 4 month MTC placement from 1.7 to 6.6 (p<0.0001). Introduction of a departmental core surgical trainee rota utilising a 'problem-based' model can significantly improve T&O core surgical training in MTCs. Copyright © 2016 Elsevier Ltd. All rights reserved.

Model-based surgical planning and simulation of cranial base surgery.

PubMed

Abe, M; Tabuchi, K; Goto, M; Uchino, A

1998-11-01

Plastic skull models of seven individual patients were fabricated by stereolithography from three-dimensional data based on computed tomography bone images. Skull models were utilized for neurosurgical planning and simulation in the seven patients with cranial base lesions that were difficult to remove. Surgical approaches and areas of craniotomy were evaluated using the fabricated skull models. In preoperative simulations, hand-made models of the tumors, major vessels and nerves were placed in the skull models. Step-by-step simulation of surgical procedures was performed using actual surgical tools. The advantages of using skull models to plan and simulate cranial base surgery include a better understanding of anatomic relationships, preoperative evaluation of the proposed procedure, increased understanding by the patient and family, and improved educational experiences for residents and other medical staff. The disadvantages of using skull models include the time and cost of making the models. The skull models provide a more realistic tool that is easier to handle than computer-graphic images. Surgical simulation using models facilitates difficult cranial base surgery and may help reduce surgical complications.

Administrative Costs Associated With Physician Billing and Insurance-Related Activities at an Academic Health Care System.

PubMed

Tseng, Phillip; Kaplan, Robert S; Richman, Barak D; Shah, Mahek A; Schulman, Kevin A

2018-02-20

Administrative costs in the US health care system are an important component of total health care spending, and a substantial proportion of these costs are attributable to billing and insurance-related activities. To examine and estimate the administrative costs associated with physician billing activities in a large academic health care system with a certified electronic health record system. This study used time-driven activity-based costing. Interviews were conducted with 27 health system administrators and 34 physicians in 2016 and 2017 to construct a process map charting the path of an insurance claim through the revenue cycle management process. These data were used to calculate the cost for each major billing and insurance-related activity and were aggregated to estimate the health system's total cost of processing an insurance claim. Estimated time required to perform billing and insurance-related activities, based on interviews with management personnel and physicians. Estimated billing and insurance-related costs for 5 types of patient encounters: primary care visits, discharged emergency department visits, general medicine inpatient stays, ambulatory surgical procedures, and inpatient surgical procedures. Estimated processing time and total costs for billing and insurance-related activities were 13 minutes and $20.49 for a primary care visit, 32 minutes and $61.54 for a discharged emergency department visit, 73 minutes and $124.26 for a general inpatient stay, 75 minutes and $170.40 for an ambulatory surgical procedure, and 100 minutes and $215.10 for an inpatient surgical procedure. Of these totals, time and costs for activities carried out by physicians were estimated at a median of 3 minutes or $6.36 for a primary care visit, 3 minutes or $10.97 for an emergency department visit, 5 minutes or $13.29 for a general inpatient stay, 15 minutes or $51.20 for an ambulatory surgical procedure, and 15 minutes or $51.20 for an inpatient surgical procedure. Of professional revenue, professional billing costs were estimated to represent 14.5% for primary care visits, 25.2% for emergency department visits, 8.0% for general medicine inpatient stays, 13.4% for ambulatory surgical procedures, and 3.1% for inpatient surgical procedures. In a time-driven activity-based costing study in a large academic health care system with a certified electronic health record system, the estimated costs of billing and insurance-related activities ranged from $20 for a primary care visit to $215 for an inpatient surgical procedure. Knowledge of how specific billing and insurance-related activities contribute to administrative costs may help inform policy solutions to reduce these expenses.

Surgical motion characterization in simulated needle insertion procedures

NASA Astrophysics Data System (ADS)

Holden, Matthew S.; Ungi, Tamas; Sargent, Derek; McGraw, Robert C.; Fichtinger, Gabor

2012-02-01

PURPOSE: Evaluation of surgical performance in image-guided needle insertions is of emerging interest, to both promote patient safety and improve the efficiency and effectiveness of training. The purpose of this study was to determine if a Markov model-based algorithm can more accurately segment a needle-based surgical procedure into its five constituent tasks than a simple threshold-based algorithm. METHODS: Simulated needle trajectories were generated with known ground truth segmentation by a synthetic procedural data generator, with random noise added to each degree of freedom of motion. The respective learning algorithms were trained, and then tested on different procedures to determine task segmentation accuracy. In the threshold-based algorithm, a change in tasks was detected when the needle crossed a position/velocity threshold. In the Markov model-based algorithm, task segmentation was performed by identifying the sequence of Markov models most likely to have produced the series of observations. RESULTS: For amplitudes of translational noise greater than 0.01mm, the Markov model-based algorithm was significantly more accurate in task segmentation than the threshold-based algorithm (82.3% vs. 49.9%, p<0.001 for amplitude 10.0mm). For amplitudes less than 0.01mm, the two algorithms produced insignificantly different results. CONCLUSION: Task segmentation of simulated needle insertion procedures was improved by using a Markov model-based algorithm as opposed to a threshold-based algorithm for procedures involving translational noise.

Innovation in internship preparation: an operative anatomy course increases senior medical students' knowledge and confidence.

PubMed

Tocco, Nikki; Brunsvold, Melissa; Kabbani, Loay; Lin, Jules; Stansfield, Brent; Mueller, Dean; Minter, Rebecca M

2013-08-01

An operative anatomy course was developed within the construct of a surgical internship preparatory curriculum. This course provided fourth-year medical students matching into a surgical residency the opportunity to perform intern-level procedures on cadavers under the guidance of surgical faculty members. Senior medical students performed intern-level procedures on cadavers with the assistance of faculty surgeons. Students' confidence, anxiety, and procedural knowledge were evaluated both preoperatively and postoperatively. Preoperative and postoperative data were compared both collectively and based on individual procedures. Student confidence and procedural knowledge significantly increased and anxiety significantly decreased when preoperative and postoperative data were compared (P < .05). Students reported moderate to significant improvement in their ability to perform a variety of surgical tasks. The consistent improvement in confidence, knowledge, and anxiety justifies further development of an operative anatomy course, with future assessment of the impact on performance in surgical residency. Copyright © 2013 Elsevier Inc. All rights reserved.

Teaching surgery takes time: the impact of surgical education on time in the operating room

PubMed Central

Vinden, Christopher; Malthaner, Richard; McGee, Jacob; McClure, J. Andrew; Winick-Ng, Jennifer; Liu, Kuan; Nash, Danielle M.; Welk, Blayne; Dubois, Luc

2016-01-01

Background It is generally accepted that surgical training is associated with increased surgical duration. The purpose of this study was to determine the magnitude of this increase for common surgical procedures by comparing surgery duration in teaching and nonteaching hospitals. Methods This retrospective population-based cohort study included all adult residents of Ontario, Canada, who underwent 1 of 14 surgical procedures between 2002 and 2012. We used several linked administrative databases to identify the study cohort in addition to patient-, surgeon- and procedure-related variables. We determined surgery duration using anesthesiology billing records. Negative binomial regression was used to model the association between teaching versus nonteaching hospital status and surgery duration. Results Of the 713 573 surgical cases included in this study, 20.8% were performed in a teaching hospital. For each procedure, the mean surgery duration was significantly longer for teaching hospitals, with differences ranging from 5 to 62 minutes across individual procedures in unadjusted analyses (all p < 0.001). In regression analysis, procedures performed in teaching hospitals were associated with an overall 22% (95% confidence interval 20%–24%) increase in surgery duration, adjusting for patient-, surgeon- and procedure-related variables as well as the clustering of patients within surgeons and hospitals. Conclusion Our results show that a wide range of surgical procedures require significantly more time to perform in teaching than nonteaching hospitals. Given the magnitude of this difference, the impact of surgical training on health care costs and clinical outcomes should be a priority for future studies. PMID:27007088

Competency-Based Education in Low Resource Settings: Development of a Novel Surgical Training Program.

PubMed

McCullough, Meghan; Campbell, Alex; Siu, Armando; Durnwald, Libby; Kumar, Shubha; Magee, William P; Swanson, Jordan

2018-03-01

The unmet burden of surgical disease represents a major global health concern, and a lack of trained providers is a critical component of the inadequacy of surgical care worldwide. Competency-based training has been advanced in high-income countries, improving technical skills and decreasing training time, but it is poorly understood how this model might be applied to low- and middle-income countries. We describe the development of a competency-based program to accelerate specialty training of in-country providers in cleft surgery techniques. The program was designed and piloted among eight trainees at five international cleft lip and palate surgical mission sites in Latin America and Africa. A competency-based evaluation form, designed for the program, was utilized to grade general technical and procedure-specific competencies, and pre- and post-training scores were analyzed using a paired t test. Trainees demonstrated improvement in average procedure-specific competency scores for both lip repairs (60.4-71.0%, p < 0.01) and palate (50.6-66.0%, p < 0.01). General technical competency scores also improved (63.6-72.0%, p < 0.01). Among the procedural competencies assessed, surgical markings showed the greatest improvement (19.0 and 22.8% for lip and palate, respectively), followed by nasal floor/mucosal approximation (15.0%) and hard palate dissection (17.1%). Surgical delivery models in LMICs are varied, and trade-offs often exist between goals of case throughput, quality and training. Pilot program results show that procedure-specific and general technical competencies can be improved over a relatively short time and demonstrate the feasibility of incorporating such a training program into surgical outreach missions.

Surgical procedures and their cost estimates among women with newly diagnosed endometriosis: a US database study.

PubMed

Fuldeore, M; Chwalisz, K; Marx, S; Wu, N; Boulanger, L; Ma, L; Lamothe, K

2011-01-01

This descriptive study assessed the rate and costs of surgical procedures among newly diagnosed endometriosis patients. Utilizing the Medstat MarketScan database, commercially insured women aged 18-45 with endometriosis newly diagnosed during 2006-2007 were identified. Each endometriosis patient was matched to four women without endometriosis (population controls) based on age and region of residence. Surgical procedures received during the 12 months post-diagnosis were assessed. Costs of surgical procedures were the amount paid by the insurance companies. This study identified 15,891 women with newly diagnosed endometriosis and 63,564 population controls. More than 65% of endometriosis patients received an endometriosis-related surgical procedure within 1 year of the initial diagnosis. The most common procedure was therapeutic laparoscopy (31.6%), followed by abdominal hysterectomy (22.1%) and vaginal hysterectomy (6.8%). Prevalence and type of surgery performed varied by patient age, including a hysterectomy rate of approximately 16% in patients younger than 35 and 37% among patients aged 35-45 years. Average costs ranged from $4,289 (standard deviation [SD]: $3,313) for diagnostic laparoscopy to $11,397 (SD: $8,749) for abdominal hysterectomy. Diagnosis of endometriosis cannot be validated against medical records, and information on the severity of endometriosis-related symptoms is not available in administrative claims data. Over 65% of patients had endometriosis-related surgical procedures, including hysterectomy, within 1 year of being diagnosed with endometriosis. The cost of surgical procedures related to endometriosis places a significant financial burden on the healthcare system.

42 CFR 416.167 - Basis of payment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... classification (APC) groups and payment weights. (1) ASC covered surgical procedures are classified using the APC... section, an ASC relative payment weight is determined based on the APC relative payment weight for each covered surgical procedure and covered ancillary service that has an applicable APC relative payment...

Local antimicrobial administration for prophylaxis of surgical site infections.

PubMed

Huiras, Paul; Logan, Jill K; Papadopoulos, Stella; Whitney, Dana

2012-11-01

Despite a lack of consensus guidelines, local antibiotic administration for prophylaxis of surgical site infections is used during many surgical procedures. The rationale behind this practice is to provide high antibiotic concentrations at the site of surgery while minimizing systemic exposure and adverse effects. Local antibiotic administration for surgical site prophylaxis has inherent limitations in that antibiotics are applied after the incision is made, rather than the current standard for surgical site prophylaxis that recommends providing adequate antibiotic concentrations at the site before the incision. The efficacy and safety of local application of antibiotics for surgical site prophylaxis have been assessed in different types of surgery with a variety of antibiotic agents and methods of application. We identified 22 prospective, randomized, controlled trials that evaluated local application of antibiotics for surgical site prophylaxis. These trials were subsequently divided and analyzed based on the type of surgical procedure: dermatologic, orthopedic, abdominal, colorectal, and cardiothoracic. Methods of local application analyzed included irrigations, powders, ointments, pastes, beads, sponges, and fleeces. Overall, there is a significant lack of level I evidence supporting this practice for any of the surgical genres evaluated. In addition, the literature spans several decades, and changes in surgical procedures, systemic antibiotic prophylaxis, and microbial flora make conclusions difficult to determine. Based on available data, the efficacy of local antibiotic administration for the prophylaxis of surgical site infections remains uncertain, and recommendations supporting this practice for surgical site prophylaxis cannot be made. © 2012 Pharmacotherapy Publications, Inc.

Cleft Lip and Palate Repair Using a Surgical Microscope.

PubMed

Kato, Motoi; Watanabe, Azusa; Watanabe, Shoji; Utsunomiya, Hiroki; Yokoyama, Takayuki; Ogishima, Shinya

2017-11-01

Cleft lip and palate repair requires a deep and small surgical field and is usually performed by surgeons wearing surgical loupes. Surgeons with loupes can obtain a wider surgical view, although headlights are required for the deepest procedures. Surgical microscopes offer comfort and a clear and magnification-adjustable surgical site that can be shared with the whole team, including observers, and easily recorded to further the education of junior surgeons. Magnification adjustments are convenient for precise procedures such as muscle dissection of the soft palate. We performed a comparative investigation of 18 cleft operations that utilized either surgical loupes or microscopy. Paper-based questionnaires were completed by staff nurses to evaluate what went well and what could be improved in each procedure. The operating time, complication rate, and scores of the questionnaire responses were statistically analyzed. The operating time when microscopy was used was not significantly longer than when surgical loupes were utilized. The surgical field was clearly shared with surgical assistants, nurses, anesthesiologists, and students via microscope-linked monitors. Passing surgical equipment was easier when sharing the surgical view, and preoperative microscope preparation did not interfere with the duties of the staff nurses. Surgical microscopy was demonstrated to be useful during cleft operations.

Costs of disposable material in the operating room do not show high correlation with surgical time: Implications for hospital payment.

PubMed

Delo, Caroline; Leclercq, Pol; Martins, Dimitri; Pirson, Magali

2015-08-01

The objectives of this study are to analyze the variation of the surgical time and of disposable costs per surgical procedure and to analyze the association between disposable costs and the surgical time. The registration of data was done in an operating room of a 419 bed general hospital, over a period of three months (n = 1556 surgical procedures). Disposable material per procedure used was recorded through a barcode scanning method. The average cost (standard deviation) of disposable material is €183.66 (€183.44). The mean surgical time (standard deviation) is 96 min (63). Results have shown that the homogeneity of operating time and DM costs was quite good per surgical procedure. The correlation between the surgical time and DM costs is not high (r = 0.65). In a context of Diagnosis Related Group (DRG) based hospital payment, it is important that costs information systems are able to precisely calculate costs per case. Our results show that the correlation between surgical time and costs of disposable materials is not good. Therefore, empirical data or itemized lists should be used instead of surgical time as a cost driver for the allocation of costs of disposable materials to patients. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Classifying breast cancer surgery: a novel, complexity-based system for oncological, oncoplastic and reconstructive procedures, and proof of principle by analysis of 1225 operations in 1166 patients.

PubMed

Hoffmann, Jürgen; Wallwiener, Diethelm

2009-04-08

One of the basic prerequisites for generating evidence-based data is the availability of classification systems. Attempts to date to classify breast cancer operations have focussed on specific problems, e.g. the avoidance of secondary corrective surgery for surgical defects, rather than taking a generic approach. Starting from an existing, simpler empirical scheme based on the complexity of breast surgical procedures, which was used in-house primarily in operative report-writing, a novel classification of ablative and breast-conserving procedures initially needed to be developed and elaborated systematically. To obtain proof of principle, a prospectively planned analysis of patient records for all major breast cancer-related operations performed at our breast centre in 2005 and 2006 was conducted using the new classification. Data were analysed using basic descriptive statistics such as frequency tables. A novel two-type, six-tier classification system comprising 12 main categories, 13 subcategories and 39 sub-subcategories of oncological, oncoplastic and reconstructive breast cancer-related surgery was successfully developed. Our system permitted unequivocal classification, without exception, of all 1225 procedures performed in 1166 breast cancer patients in 2005 and 2006. Breast cancer-related surgical procedures can be generically classified according to their surgical complexity. Analysis of all major procedures performed at our breast centre during the study period provides proof of principle for this novel classification system. We envisage various applications for this classification, including uses in randomised clinical trials, guideline development, specialist surgical training, continuing professional development as well as quality of care and public health research.

An immersive surgery training system with live streaming capability.

PubMed

Yang, Yang; Guo, Xinqing; Yu, Zhan; Steiner, Karl V; Barner, Kenneth E; Bauer, Thomas L; Yu, Jingyi

2014-01-01

Providing real-time, interactive immersive surgical training has been a key research area in telemedicine. Earlier approaches have mainly adopted videotaped training that can only show imagery from a fixed view point. Recent advances on commodity 3D imaging have enabled a new paradigm for immersive surgical training by acquiring nearly complete 3D reconstructions of actual surgical procedures. However, unlike 2D videotaping that can easily stream data in real-time, by far 3D imaging based solutions require pre-capturing and processing the data; surgical trainings using the data have to be conducted offline after the acquisition. In this paper, we present a new real-time immersive 3D surgical training system. Our solution builds upon the recent multi-Kinect based surgical training system [1] that can acquire and display high delity 3D surgical procedures using only a small number of Microsoft Kinect sensors. We build on top of the system a client-server model for real-time streaming. On the server front, we efficiently fuse multiple Kinect data acquired from different viewpoints and compress and then stream the data to the client. On the client front, we build an interactive space-time navigator to allow remote users (e.g., trainees) to witness the surgical procedure in real-time as if they were present in the room.

Fundamental principles in periodontal plastic surgery and mucosal augmentation--a narrative review.

PubMed

Burkhardt, Rino; Lang, Niklaus P

2014-04-01

To provide a narrative review of the current literature elaborating on fundamental principles of periodontal plastic surgical procedures. Based on a presumptive outline of the narrative review, MESH terms have been used to search the relevant literature electronically in the PubMed and Cochrane Collaboration databases. If possible, systematic reviews were included. The review is divided into three phases associated with periodontal plastic surgery: a) pre-operative phase, b) surgical procedures and c) post-surgical care. The surgical procedures were discussed in the light of a) flap design and preparation, b) flap mobilization and c) flap adaptation and stabilization. Pre-operative paradigms include the optimal plaque control and smoking counselling. Fundamental principles in surgical procedures address basic knowledge in anatomy and vascularity, leading to novel appropriate flap designs with papilla preservation. Flap mobilization based on releasing incisions can be performed up to 5 mm. Flap adaptation and stabilization depend on appropriate wound bed characteristics, undisturbed blood clot formation, revascularization and wound stability through adequate suturing. Delicate tissue handling and tension free wound closure represent prerequisites for optimal healing outcomes. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Knowing the operative game plan: a novel tool for the assessment of surgical procedural knowledge.

PubMed

Balayla, Jacques; Bergman, Simon; Ghitulescu, Gabriela; Feldman, Liane S; Fraser, Shannon A

2012-08-01

What is the source of inadequate performance in the operating room? Is it a lack of technical skills, poor judgment or a lack of procedural knowledge? We created a surgical procedural knowledge (SPK) assessment tool and evaluated its use. We interviewed medical students, residents and training program staff on SPK assessment tools developed for 3 different common general surgery procedures: inguinal hernia repair with mesh in men, laparoscopic cholecystectomy and right hemicolectomy. The tools were developed as a step-wise assessment of specific surgical procedures based on techniques described in a current surgical text. We compared novice (medical student to postgraduate year [PGY]-2) and expert group (PGY-3 to program staff) scores using the Mann-Whitney U test. We calculated the total SPK score and defined a cut-off score using receiver operating characteristic analysis. In all, 5 participants in 7 different training groups (n = 35) underwent an interview. Median scores for each procedure and overall SPK scores increased with experience. The median SPK for novices was 54.9 (95% confidence interval [CI] 21.6-58.8) compared with 98.05 (95% CP 94.1-100.0) for experts (p = 0.012). The SPK cut-off score of 93.1 discriminates between novice and expert surgeons. Surgical procedural knowledge can reliably be assessed using our SPK assessment tool. It can discriminate between novice and expert surgeons for common general surgical procedures. Future studies are planned to evaluate its use for more complex procedures.

Estimating times of surgeries with two component procedures: comparison of the lognormal and normal models.

PubMed

Strum, David P; May, Jerrold H; Sampson, Allan R; Vargas, Luis G; Spangler, William E

2003-01-01

Variability inherent in the duration of surgical procedures complicates surgical scheduling. Modeling the duration and variability of surgeries might improve time estimates. Accurate time estimates are important operationally to improve utilization, reduce costs, and identify surgeries that might be considered outliers. Surgeries with multiple procedures are difficult to model because they are difficult to segment into homogenous groups and because they are performed less frequently than single-procedure surgeries. The authors studied, retrospectively, 10,740 surgeries each with exactly two CPTs and 46,322 surgical cases with only one CPT from a large teaching hospital to determine if the distribution of dual-procedure surgery times fit more closely a lognormal or a normal model. The authors tested model goodness of fit to their data using Shapiro-Wilk tests, studied factors affecting the variability of time estimates, and examined the impact of coding permutations (ordered combinations) on modeling. The Shapiro-Wilk tests indicated that the lognormal model is statistically superior to the normal model for modeling dual-procedure surgeries. Permutations of component codes did not appear to differ significantly with respect to total procedure time and surgical time. To improve individual models for infrequent dual-procedure surgeries, permutations may be reduced and estimates may be based on the longest component procedure and type of anesthesia. The authors recommend use of the lognormal model for estimating surgical times for surgeries with two component procedures. Their results help legitimize the use of log transforms to normalize surgical procedure times prior to hypothesis testing using linear statistical models. Multiple-procedure surgeries may be modeled using the longest (statistically most important) component procedure and type of anesthesia.

[Objective surgery -- advanced robotic devices and simulators used for surgical skill assessment].

PubMed

Suhánszki, Norbert; Haidegger, Tamás

2014-12-01

Robotic assistance became a leading trend in minimally invasive surgery, which is based on the global success of laparoscopic surgery. Manual laparoscopy requires advanced skills and capabilities, which is acquired through tedious learning procedure, while da Vinci type surgical systems offer intuitive control and advanced ergonomics. Nevertheless, in either case, the key issue is to be able to assess objectively the surgeons' skills and capabilities. Robotic devices offer radically new way to collect data during surgical procedures, opening the space for new ways of skill parameterization. This may be revolutionary in MIS training, given the new and objective surgical curriculum and examination methods. The article reviews currently developed skill assessment techniques for robotic surgery and simulators, thoroughly inspecting their validation procedure and utility. In the coming years, these methods will become the mainstream of Western surgical education.

A checklist for endonasal transsphenoidal anterior skull base surgery.

PubMed

Laws, Edward R; Wong, Judith M; Smith, Timothy R; de Los Reyes, Kenneth; Aglio, Linda S; Thorne, Alison J; Cote, David J; Esposito, Felice; Cappabianca, Paolo; Gawande, Atul

2016-06-01

OBJECT Approximately 250 million surgical procedures are performed annually worldwide, and data suggest that major complications occur in 3%-17% of them. Many of these complications can be classified as avoidable, and previous studies have demonstrated that preoperative checklists improve operating room teamwork and decrease complication rates. Although the authors' institution has instituted a general preoperative "time-out" designed to streamline communication, flatten vertical authority gradients, and decrease procedural errors, there is no specific checklist for transnasal transsphenoidal anterior skull base surgery, with or without endoscopy. Such minimally invasive cranial surgery uses a completely different conceptual approach, set-up, instrumentation, and operative procedure. Therefore, it can be associated with different types of complications as compared with open cranial surgery. The authors hypothesized that a detailed, procedure-specific, preoperative checklist would be useful to reduce errors, improve outcomes, decrease delays, and maximize both teambuilding and operational efficiency. Thus, the object of this study was to develop such a checklist for endonasal transsphenoidal anterior skull base surgery. METHODS An expert panel was convened that consisted of all members of the typical surgical team for transsphenoidal endoscopic cases: neurosurgeons, anesthesiologists, circulating nurses, scrub technicians, surgical operations managers, and technical assistants. Beginning with a general checklist, procedure-specific items were added and categorized into 4 pauses: Anesthesia Pause, Surgical Pause, Equipment Pause, and Closure Pause. RESULTS The final endonasal transsphenoidal anterior skull base surgery checklist is composed of the following 4 pauses. The Anesthesia Pause consists of patient identification, diagnosis, pertinent laboratory studies, medications, surgical preparation, patient positioning, intravenous/arterial access, fluid management, monitoring, and other special considerations (e.g., Valsalva, jugular compression, lumbar drain, and so on). The Surgical Pause is composed of personnel introductions, planned procedural elements, estimation of duration of surgery, anticipated blood loss and fluid management, imaging, specimen collection, and questions of a surgical nature. The Equipment Pause assures proper function and availability of the microscope, endoscope, cameras and recorders, guidance systems, special instruments, ultrasonic microdoppler, microdebrider, drills, and other adjunctive supplies (e.g., Avitene, cotton balls, nasal packs, and so on). The Closure Pause is dedicated to issues of immediate postoperative patient disposition, orders, and management. CONCLUSIONS Surgical complications are a considerable cause of death and disability worldwide. Checklists have been shown to be an effective tool for reducing preventable errors surrounding surgery and decreasing associated complications. Although general checklists are already in place in most institutions, a specific checklist for endonasal transsphenoidal anterior skull base surgery was developed to help safeguard patients, improve outcomes, and enhance teambuilding.

Multimodal Analgesia in Breast Surgical Procedures: Technical and Pharmacological Considerations for Liposomal Bupivacaine Use

PubMed Central

Newman, Martin I.; Seeley, Neil; Hutchins, Jacob; Smith, Kevin L.; Mena, Gabriel; Selber, Jesse C.; Saint-Cyr, Michel H.; Gadsden, Jeffrey C.

2017-01-01

Enhanced recovery after surgery is a multidisciplinary perioperative clinical pathway that uses evidence-based interventions to improve the patient experience as well as increase satisfaction, reduce costs, mitigate the surgical stress response, accelerate functional recovery, and decrease perioperative complications. One of the most important elements of enhanced recovery pathways is multimodal pain management. Herein, aspects relating to multimodal analgesia following breast surgical procedures are discussed with the understanding that treatment decisions should be individualized and guided by sound clinical judgment. A review of liposomal bupivacaine, a prolonged-release formulation of bupivacaine, in the management of postoperative pain following breast surgical procedures is presented, and technical guidance regarding optimal administration of liposomal bupivacaine is provided. PMID:29062649

Surgical Procedures in Health Professional Shortage Areas: Impact of a Surgical Incentive Payment Plan.

PubMed

Diaz, Adrian; Merath, Katiuscha; Bagante, Fabio; Chen, Qinyu; Akgul, Ozgur; Beal, Eliza; Idrees, Jay; Olsen, Griffin; Gani, Faiz; Pawlik, Timothy M

2018-05-15

The Affordable Care Act established a Center for Medicare/Medicaid Services based 10% reimbursement bonus for general surgeons in Health Professional Shortage Areas. We sought to assess the impact of the Affordable Care Act Surgery Incentive Payment on surgical procedures performed in Health Professional Shortage Areas. Hospital utilization data from the California Office of Statewide Health Planning and Development between January 1, 2006, and December 31, 2015, were used to categorize hospitals according to Health Professional Shortage Area location. A difference-in-differences analysis measured the effect of the Surgery Incentive Payment on year-to-year differences for inpatient and outpatient surgical procedures by hospital type pre- (2006-2010) versus post- (2011-2015) Surgery Incentive Payment implementation. Among 409 unique hospitals that performed surgical procedures for at least 1 year of the study period, 2 performed surgery in a designated Health Professional Shortage Area. The two Health Professional Shortage Area -designated hospitals were located in a rural area, were non-teaching hospitals, and had 196 and 202 hospital beds, respectively. After the enactment of the Surgery Incentive Payment, while non- Health Professional Shortage Areas had only a modest relative decrease in total inpatient procedures (Pre-Surgery Incentive Payment: 4,666,938 versus Post-Surgery Incentive Payment: 4,451,612; Δ-4.6%), the proportional decrease in inpatient surgical procedures at Health Professional Shortage Area hospitals was more marked (Pre-Surgery Incentive Payment: 25,830 versus Post-Surgery Incentive Payment: 21,503; Δ-16.7%). In contrast, Health Professional Shortage Area hospitals proportionally had a greater increase in total outpatient procedures (Pre-Surgery Incentive Payment: 17,840 versus Post-Surgery Incentive Payment: 22,375: Δ+25.4%) versus non- Health Professional Shortage Area hospitals (Pre-Surgery Incentive Payment: 5,863,300 versus Post-Surgery Incentive Payment: 6,156,138; Δ+4.9%). Based on the difference-in-differences analysis, the increase in the trend of surgical procedures at Health Professional Shortage Area hospitals was much more notable after Surgery Incentive Payment implementation (Δ+75.2%). The Medicare Surgery Incentive Payment program was associated with an increase in the number of surgical procedures performed at Health Professional Shortage Area hospitals relative to non-Health Professional Shortage Area hospitals during the study period, reversing the trend from negative to positive. Copyright © 2018 Elsevier Inc. All rights reserved.

Thresholds of Principle and Preference: Exploring Procedural Variation in Postgraduate Surgical Education.

PubMed

Apramian, Tavis; Cristancho, Sayra; Watling, Chris; Ott, Michael; Lingard, Lorelei

2015-11-01

Expert physicians develop their own ways of doing things. The influence of such practice variation in clinical learning is insufficiently understood. Our grounded theory study explored how residents make sense of, and behave in relation to, the procedural variations of faculty surgeons. We sampled senior postgraduate surgical residents to construct a theoretical framework for how residents make sense of procedural variations. Using a constructivist grounded theory approach, we used marginal participant observation in the operating room across 56 surgical cases (146 hours), field interviews (38), and formal interviews (6) to develop a theoretical framework for residents' ways of dealing with procedural variations. Data analysis used constant comparison to iteratively refine the framework and data collection until theoretical saturation was reached. The core category of the constructed theory was called thresholds of principle and preference and it captured how faculty members position some procedural variations as negotiable and others not. The term thresholding was coined to describe residents' daily experiences of spotting, mapping, and negotiating their faculty members' thresholds and defending their own emerging thresholds. Thresholds of principle and preference play a key role in workplace-based medical education. Postgraduate medical learners are occupied on a day-to-day level with thresholding and attempting to make sense of the procedural variations of faculty. Workplace-based teaching and assessment should include an understanding of the integral role of thresholding in shaping learners' development. Future research should explore the nature and impact of thresholding in workplace-based learning beyond the surgical context.

Non-photorealistic rendering of virtual implant models for computer-assisted fluoroscopy-based surgical procedures

NASA Astrophysics Data System (ADS)

Zheng, Guoyan

2007-03-01

Surgical navigation systems visualize the positions and orientations of surgical instruments and implants as graphical overlays onto a medical image of the operated anatomy on a computer monitor. The orthopaedic surgical navigation systems could be categorized according to the image modalities that are used for the visualization of surgical action. In the so-called CT-based systems or 'surgeon-defined anatomy' based systems, where a 3D volume or surface representation of the operated anatomy could be constructed from the preoperatively acquired tomographic data or through intraoperatively digitized anatomy landmarks, a photorealistic rendering of the surgical action has been identified to greatly improve usability of these navigation systems. However, this may not hold true when the virtual representation of surgical instruments and implants is superimposed onto 2D projection images in a fluoroscopy-based navigation system due to the so-called image occlusion problem. Image occlusion occurs when the field of view of the fluoroscopic image is occupied by the virtual representation of surgical implants or instruments. In these situations, the surgeon may miss part of the image details, even if transparency and/or wire-frame rendering is used. In this paper, we propose to use non-photorealistic rendering to overcome this difficulty. Laboratory testing results on foamed plastic bones during various computer-assisted fluoroscopybased surgical procedures including total hip arthroplasty and long bone fracture reduction and osteosynthesis are shown.

Development of a High Resolution 3D Infant Stomach Model for Surgical Planning

NASA Astrophysics Data System (ADS)

Chaudry, Qaiser; Raza, S. Hussain; Lee, Jeonggyu; Xu, Yan; Wulkan, Mark; Wang, May D.

Medical surgical procedures have not changed much during the past century due to the lack of accurate low-cost workbench for testing any new improvement. The increasingly cheaper and powerful computer technologies have made computer-based surgery planning and training feasible. In our work, we have developed an accurate 3D stomach model, which aims to improve the surgical procedure that treats the infant pediatric and neonatal gastro-esophageal reflux disease (GERD). We generate the 3-D infant stomach model based on in vivo computer tomography (CT) scans of an infant. CT is a widely used clinical imaging modality that is cheap, but with low spatial resolution. To improve the model accuracy, we use the high resolution Visible Human Project (VHP) in model building. Next, we add soft muscle material properties to make the 3D model deformable. Then we use virtual reality techniques such as haptic devices to make the 3D stomach model deform upon touching force. This accurate 3D stomach model provides a workbench for testing new GERD treatment surgical procedures. It has the potential to reduce or eliminate the extensive cost associated with animal testing when improving any surgical procedure, and ultimately, to reduce the risk associated with infant GERD surgery.

3D Printing in Surgical Management of Double Outlet Right Ventricle.

PubMed

Yoo, Shi-Joon; van Arsdell, Glen S

2017-01-01

Double outlet right ventricle (DORV) is a heterogeneous group of congenital heart diseases that require individualized surgical approach based on precise understanding of the complex cardiovascular anatomy. Physical 3-dimensional (3D) print models not only allow fast and unequivocal perception of the complex anatomy but also eliminate misunderstanding or miscommunication among imagers and surgeons. Except for those cases showing well-recognized classic surgical anatomy of DORV such as in cases with a typical subaortic or subpulmonary ventricular septal defect, 3D print models are of enormous value in surgical decision and planning. Furthermore, 3D print models can also be used for rehearsal of the intended procedure before the actual surgery on the patient so that the outcome of the procedure is precisely predicted and the procedure can be optimally tailored for the patient's specific anatomy. 3D print models are invaluable resource for hands-on surgical training of congenital heart surgeons.

Standard operating procedures for Peyronie's disease.

PubMed

Levine, Laurence A; Burnett, Arthur L

2013-01-01

Peyronie's disease (PD) refers to a penile deformity that is associated with sexual dysfunction. To provide recommendations and Standard Operating Procedures (SOPs) based on best evidence for diagnosis and treatment of PD. Medical literature was reviewed and combined with expert opinion of the authors. Recommendations and SOPs based on grading of evidence-based medical literature. PD is a fibrotic wound-healing disorder involving the tunica albuginea of the corpora cavernosa. The resulting scar is responsible for a variety of deformities, including curvature, shortening, narrowing with hinge effect, and is frequently associated in the early phase with pain. Patients frequently experience diminished quality erections. All of these conditions can compromise sexual function for the affected male. The etiopathophysiology of PD has yet to be clarified and as a result, effective, reliable, mechanistic directed non-surgical therapy is lacking. The management of PD consists of proper diagnosis and treatment, ranging from non-surgical to surgical interventions. The main state of treatment for PD rests at this time on surgical correction that should be based on clear indications, involve surgical consent, and follow a surgical algorithm that includes tunica plication, plaque incision/partial excision and grafting, and penile prosthesis implantation. © 2012 International Society for Sexual Medicine.

Predicate Argument Structure Frames for Modeling Information in Operative Notes

PubMed Central

Wang, Yan; Pakhomov, Serguei; Melton, Genevieve B.

2015-01-01

The rich information about surgical procedures contained in operative notes is a valuable data source for improving the clinical evidence base and clinical research. In this study, we propose a set of Predicate Argument Structure (PAS) frames for surgical action verbs to assist in the creation of an information extraction (IE) system to automatically extract details about the techniques, equipment, and operative steps from operative notes. We created PropBank style PAS frames for the 30 top surgical action verbs based on examination of randomly selected sample sentences from 3,000 Laparoscopic Cholecystectomy notes. To assess completeness of the PAS frames to represent usage of same action verbs, we evaluated the PAS frames created on sample sentences from operative notes of 6 other gastrointestinal surgical procedures. Our results showed that the PAS frames created with one type of surgery can successfully denote the usage of the same verbs in operative notes of broader surgical categories. PMID:23920664

Medical and surgical treatment of obesity.

PubMed

Kissane, Nicole A; Pratt, Janey S A

2011-03-01

The prevalence of obesity has reached epidemic proportions. Conceptualization of obesity as a chronic disease facilitates greater understanding its treatment. The NIH Consensus Conference on Gastrointestinal Surgery for Severe Obesity provides a framework by which to manage the severely obese--specifically providing medical versus surgical recommendations which are based on scientific and outcomes data. Medical treatments of obesity include primary prevention, dietary intervention, increased physical activity, behavior modification, and pharmacotherapy. Surgical treatment for obesity is based on the extensive neural-hormonal effects of weight loss surgery on metabolism, and as such is better termed Metabolic Surgery. Surgery is not limited to the procedure itself, it also necessitates thorough preoperative evaluation, risk assessment, and counseling. The most common metabolic surgical procedures include Roux-en-Y gastric bypass, adjustable gastric band, sleeve gastrectomy, and biliopancreatic diversion. Surgical outcomes for metabolic surgery are well studied and demonstrate superior long-term weight loss compared to medical management in cases of severe obesity.

Development and validation of trauma surgical skills metrics: Preliminary assessment of performance after training.

PubMed

Shackelford, Stacy; Garofalo, Evan; Shalin, Valerie; Pugh, Kristy; Chen, Hegang; Pasley, Jason; Sarani, Babak; Henry, Sharon; Bowyer, Mark; Mackenzie, Colin F

2015-07-01

Maintaining trauma-specific surgical skills is an ongoing challenge for surgical training programs. An objective assessment of surgical skills is needed. We hypothesized that a validated surgical performance assessment tool could detect differences following a training intervention. We developed surgical performance assessment metrics based on discussion with expert trauma surgeons, video review of 10 experts and 10 novice surgeons performing three vascular exposure procedures and lower extremity fasciotomy on cadavers, and validated the metrics with interrater reliability testing by five reviewers blinded to level of expertise and a consensus conference. We tested these performance metrics in 12 surgical residents (Year 3-7) before and 2 weeks after vascular exposure skills training in the Advanced Surgical Skills for Exposure in Trauma (ASSET) course. Performance was assessed in three areas as follows: knowledge (anatomic, management), procedure steps, and technical skills. Time to completion of procedures was recorded, and these metrics were combined into a single performance score, the Trauma Readiness Index (TRI). Wilcoxon matched-pairs signed-ranks test compared pretraining/posttraining effects. Mean time to complete procedures decreased by 4.3 minutes (from 13.4 minutes to 9.1 minutes). The performance component most improved by the 1-day skills training was procedure steps, completion of which increased by 21%. Technical skill scores improved by 12%. Overall knowledge improved by 3%, with 18% improvement in anatomic knowledge. TRI increased significantly from 50% to 64% with ASSET training. Interrater reliability of the surgical performance assessment metrics was validated with single intraclass correlation coefficient of 0.7 to 0.98. A trauma-relevant surgical performance assessment detected improvements in specific procedure steps and anatomic knowledge taught during a 1-day course, quantified by the TRI. ASSET training reduced time to complete vascular control by one third. Future applications include assessing specific skills in a larger surgeon cohort, assessing military surgical readiness, and quantifying skill degradation with time since training.

Bacterial burden in the operating room: impact of airflow systems.

PubMed

Hirsch, Tobias; Hubert, Helmine; Fischer, Sebastian; Lahmer, Armin; Lehnhardt, Marcus; Steinau, Hans-Ulrich; Steinstraesser, Lars; Seipp, Hans-Martin

2012-09-01

Wound infections present one of the most prevalent and frequent complications associated with surgical procedures. This study analyzes the impact of currently used ventilation systems in the operating room to reduce bacterial contamination during surgical procedures. Four ventilation systems (window-based ventilation, supported air nozzle canopy, low-turbulence displacement airflow, and low-turbulence displacement airflow with flow stabilizer) were analyzed. Two hundred seventy-seven surgical procedures in 6 operating rooms of 5 different hospitals were analyzed for this study. Window-based ventilation showed the highest intraoperative contamination (13.3 colony-forming units [CFU]/h) followed by supported air nozzle canopy (6.4 CFU/h; P = .001 vs window-based ventilation) and low-turbulence displacement airflow (3.4 and 0.8 CFU/h; P < .001 vs window-based ventilation and supported air nozzle canopy). The highest protection was provided by the low-turbulence displacement airflow with flow stabilizer (0.7 CFU/h), which showed a highly significant difference compared with the best supported air nozzle canopy theatre (3.9 CFU/h; P < .001). Furthermore, this system showed no increase of contamination in prolonged durations of surgical procedures. This study shows that intraoperative contamination can be significantly reduced by the use of adequate ventilation systems. Copyright © 2012 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

A surgical support system for Space Station Freedom

NASA Technical Reports Server (NTRS)

Campbell, M. R.; Billica, R. D.; Johnston, S. L.

1992-01-01

Surgical techniques in microgravity are being developed for the Health Maintenance Facility (HMF) on Space Station Freedom (SSF). This will be a presentation of the proposed surgical capabilities and ongoing hardware and procedural investigations. Methods: Procedures and prototype hardware, which include a medical restraint system, a surgical overhead isolation canopy, a suction device, and a regional laminar flow device were evaluated. This was accomplished by realistic sterile surgical simulations involving both mannequins and animals during KC-135 parabolic flight and in a high fidelity ground based HMF mockup. Results: Animal surgery in the environment of microgravity allowed the observation of unique arterial and venous bleeding characteristics for the first time. The ability to control bleeding and to prevent cabin atmosphere contamination was also demonstrated. Conclusions: The procedures and prototype hardware tested provided valuable information and should be investigated and developed further. The use of standard surgical techniques are possible in microgravity if the principles of personnel and supply restraint and operative field containment are adhered to.

Chronic pancreatitis: A surgical disease? Role of the Frey procedure

PubMed Central

Roch, Alexandra; Teyssedou, Jérome; Mutter, Didier; Marescaux, Jacques; Pessaux, Patrick

2014-01-01

Although medical treatment and endoscopic interventions are primarily offered to patients with chronic pancreatitis, approximately 40% to 75% will ultimately require surgery during the course of their disease. Although pancreaticoduodenectomy has been considered the standard surgical procedure because of its favorable results on pain control, its high postoperative complication and pancreatic exocrine or/and endocrine dysfunction rates have led to a growing enthusiasm for duodenal preserving pancreatic head resection. The aim of this review is to better understand the rationale underlying of the Frey procedure in chronic pancreatitis and to analyze its outcome. Because of its hybrid nature, combining both resection and drainage, the Frey procedure has been conceptualized based on the pathophysiology of chronic pancreatitis. The short and long-term outcome, especially pain relief and quality of life, are better after the Frey procedure than after any other surgical procedure performed for chronic pancreatitis. PMID:25068010

Multimedia-based training on Internet platforms improves surgical performance: a randomized controlled trial.

PubMed

Pape-Koehler, Carolina; Immenroth, Marc; Sauerland, Stefan; Lefering, Rolf; Lindlohr, Cornelia; Toaspern, Jens; Heiss, Markus

2013-05-01

Surgical procedures are complex motion sequences that require a high level of preparation, training, and concentration. In recent years, Internet platforms providing surgical content have been established. Used as a surgical training method, the effect of multimedia-based training on practical surgical skills has not yet been evaluated. This study aimed to evaluate the effect of multimedia-based training on surgical performance. A 2 × 2 factorial, randomized controlled trial with a pre- and posttest design was used to test the effect of multimedia-based training in addition to or without practical training on 70 participants in four groups defined by the intervention used: multimedia-based training, practical training, and combination training (multimedia-based training + practical training) or no training (control group). The pre- and posttest consisted of a laparoscopic cholecystectomy in a Pelvi-Trainer and was video recorded, encoded, and saved on DVDs. These were evaluated by blinded raters using a modified objective structured assessment of technical skills (OSATS). The main evaluation criterion was the difference in OSATS score between the pre- and posttest (ΔOSATS) results in terms of a task-specific checklist (procedural steps scored as correct or incorrect). The groups were homogeneous in terms of demographic parameters, surgical experience, and pretest OSATS scores. The ΔOSATS results were highest in the multimedia-based training group (4.7 ± 3.3; p < 0.001). The practical training group achieved 2.5 ± 4.3 (p = 0.028), whereas the combination training group achieved 4.6 ± 3.5 (p < 0.001), and the control group achieved 0.8 ± 2.9 (p = 0.294). Multimedia-based training improved surgical performance significantly and thus could be considered a reasonable tool for inclusion in surgical curricula.

Work domain constraints for modelling surgical performance.

PubMed

Morineau, Thierry; Riffaud, Laurent; Morandi, Xavier; Villain, Jonathan; Jannin, Pierre

2015-10-01

Three main approaches can be identified for modelling surgical performance: a competency-based approach, a task-based approach, both largely explored in the literature, and a less known work domain-based approach. The work domain-based approach first describes the work domain properties that constrain the agent's actions and shape the performance. This paper presents a work domain-based approach for modelling performance during cervical spine surgery, based on the idea that anatomical structures delineate the surgical performance. This model was evaluated through an analysis of junior and senior surgeons' actions. Twenty-four cervical spine surgeries performed by two junior and two senior surgeons were recorded in real time by an expert surgeon. According to a work domain-based model describing an optimal progression through anatomical structures, the degree of adjustment of each surgical procedure to a statistical polynomial function was assessed. Each surgical procedure showed a significant suitability with the model and regression coefficient values around 0.9. However, the surgeries performed by senior surgeons fitted this model significantly better than those performed by junior surgeons. Analysis of the relative frequencies of actions on anatomical structures showed that some specific anatomical structures discriminate senior from junior performances. The work domain-based modelling approach can provide an overall statistical indicator of surgical performance, but in particular, it can highlight specific points of interest among anatomical structures that the surgeons dwelled on according to their level of expertise.

Achievability of 3D planned bimaxillary osteotomies: maxilla-first versus mandible-first surgery.

PubMed

Liebregts, Jeroen; Baan, Frank; de Koning, Martien; Ongkosuwito, Edwin; Bergé, Stefaan; Maal, Thomas; Xi, Tong

2017-08-24

The present study was aimed to investigate the effects of sequencing a two-component surgical procedure for correcting malpositioned jaws (bimaxillary osteotomies); specifically, surgical repositioning of the upper jaw-maxilla, and the lower jaw-mandible. Within a population of 116 patients requiring bimaxillary osteotomies, the investigators analyzed whether there were statistically significant differences in postoperative outcome as measured by concordance with a preoperative digital 3D virtual treatment plan. In one group of subjects (n = 58), the maxillary surgical procedure preceded the mandibular surgery. In the second group (n = 58), the mandibular procedure preceded the maxillary surgical procedure. A semi-automated analysis tool (OrthoGnathicAnalyser) was applied to assess the concordance of the postoperative maxillary and mandibular position with the cone beam CT-based 3D virtual treatment planning in an effort to minimize observer variability. The results demonstrated that in most instances, the maxilla-first surgical approach yielded closer concordance with the 3D virtual treatment plan than a mandibular-first procedure. In selected circumstances, such as a planned counterclockwise rotation of both jaws, the mandible-first sequence resulted in more predictable displacements of the jaws.

Reliable and valid assessment of Lichtenstein hernia repair skills.

PubMed

Carlsen, C G; Lindorff-Larsen, K; Funch-Jensen, P; Lund, L; Charles, P; Konge, L

2014-08-01

Lichtenstein hernia repair is a common surgical procedure and one of the first procedures performed by a surgical trainee. However, formal assessment tools developed for this procedure are few and sparsely validated. The aim of this study was to determine the reliability and validity of an assessment tool designed to measure surgical skills in Lichtenstein hernia repair. Key issues were identified through a focus group interview. On this basis, an assessment tool with eight items was designed. Ten surgeons and surgical trainees were video recorded while performing Lichtenstein hernia repair, (four experts, three intermediates, and three novices). The videos were blindly and individually assessed by three raters (surgical consultants) using the assessment tool. Based on these assessments, validity and reliability were explored. The internal consistency of the items was high (Cronbach's alpha = 0.97). The inter-rater reliability was very good with an intra-class correlation coefficient (ICC) = 0.93. Generalizability analysis showed a coefficient above 0.8 even with one rater. The coefficient improved to 0.92 if three raters were used. One-way analysis of variance found a significant difference between the three groups which indicates construct validity, p < 0.001. Lichtenstein hernia repair skills can be assessed blindly by a single rater in a reliable and valid fashion with the new procedure-specific assessment tool. We recommend this tool for future assessment of trainees performing Lichtenstein hernia repair to ensure that the objectives of competency-based surgical training are met.

[Benefit assessment of operative interventions from the perspective of surgical research].

PubMed

Hüttner, F J; Ulrich, A; Mihaljevic, A L; Probst, P; Rossion, I; Diener, Markus K

2015-03-01

The benefit assessment of surgical procedures serves as the basis for the concept of evidence-based surgery. However, especially in the field of surgery, many interventions are lacking assessment in high-quality clinical trials. Therefore, a well-structured benefit assessment of surgical interventions in the future is imperative. Considering the different perspectives, e.g. of the patients, surgeons, industry or health care investors, the implications of the benefits and risks of a procedure can differ significantly. Researchers have to abide by different regulations, depending on the type of intervention being evaluated in a surgical trial. Furthermore, the benefit assessment of surgical procedures poses specific challenges, from the choice of a relevant endpoint to issues concerning the standardization of the interventions and the impact of learning curves. The IDEAL concept, which was established by a group of international experts in 2009, serves as a framework for the future development and assessment of innovations in the field of surgery. For example, the SDGC (Study Center of the German Society of Surgery) and CHIR-Net (Surgical Studies Network) indicate that such collaborations of clinicians and methodologists can lead to the creation of a qualified structure for the effective benefit assessment of surgical procedures. In the future, the aforementioned evidence gaps must be eliminated and innovations evaluated efficiently by the work of such networks.

Thresholds of Principle and Preference: Exploring Procedural Variation in Postgraduate Surgical Education

PubMed Central

Apramian, Tavis; Cristancho, Sayra; Watling, Chris; Ott, Michael; Lingard, Lorelei

2017-01-01

Background Expert physicians develop their own ways of doing things. The influence of such practice variation in clinical learning is insufficiently understood. Our grounded theory study explored how residents make sense of, and behave in relation to, the procedural variations of faculty surgeons. Method We sampled senior postgraduate surgical residents to construct a theoretical framework for how residents make sense of procedural variations. Using a constructivist grounded theory approach, we used marginal participant observation in the operating room across 56 surgical cases (146 hours), field interviews (38), and formal interviews (6) to develop a theoretical framework for residents’ ways of dealing with procedural variations. Data analysis used constant comparison to iteratively refine the framework and data collection until theoretical saturation was reached. Results The core category of the constructed theory was called thresholds of principle and preference and it captured how faculty members position some procedural variations as negotiable and others not. The term thresholding was coined to describe residents’ daily experiences of spotting, mapping, and negotiating their faculty members’ thresholds and defending their own emerging thresholds. Conclusions Thresholds of principle and preference play a key role in workplace-based medical education. Postgraduate medical learners are occupied on a day-to-day level with thresholding and attempting to make sense of the procedural variations of faculty. Workplace-based teaching and assessment should include an understanding of the integral role of thresholding in shaping learners’ development. Future research should explore the nature and impact of thresholding in workplace-based learning beyond the surgical context. PMID:26505105

SAGES TAVAC safety and effectiveness analysis: da Vinci ® Surgical System (Intuitive Surgical, Sunnyvale, CA).

PubMed

Tsuda, Shawn; Oleynikov, Dmitry; Gould, Jon; Azagury, Dan; Sandler, Bryan; Hutter, Matthew; Ross, Sharona; Haas, Eric; Brody, Fred; Satava, Richard

2015-10-01

The da Vinci(®) Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is a computer-assisted (robotic) surgical system designed to enable and enhance minimally invasive surgery. The Food and Drug Administration (FDA) has cleared computer-assisted surgical systems for use by trained physicians in an operating room environment for laparoscopic surgical procedures in general, cardiac, colorectal, gynecologic, head and neck, thoracic and urologic surgical procedures. There are substantial numbers of peer-reviewed papers regarding the da Vinci(®) Surgical System, and a thoughtful assessment of evidence framed by clinical opinion is warranted. The SAGES da Vinci(®) TAVAC sub-committee performed a literature review of the da Vinci(®) Surgical System regarding gastrointestinal surgery. Conclusions by the sub-committee were vetted by the SAGES TAVAC Committee and SAGES Executive Board. Following revisions, the document was evaluated by the TAVAC Committee and Executive Board again for final approval. Several conclusions were drawn based on expert opinion organized by safety, efficacy, and cost for robotic foregut, bariatric, hepatobiliary/pancreatic, colorectal surgery, and single-incision cholecystectomy. Gastrointestinal surgery with the da Vinci(®) Surgical System is safe and comparable, but not superior to standard laparoscopic approaches. Although clinically acceptable, its use may be costly for select gastrointestinal procedures. Current data are limited to the da Vinci(®) Surgical System; further analyses are needed.

Endoscopic and laparoscopic treatment of gastroesophageal reflux.

PubMed

Watson, David I; Immanuel, Arul

2010-04-01

Gastroesophageal reflux is extremely common in Western countries. For selected patients, there is an established role for the surgical treatment of reflux, and possibly an emerging role for endoscopic antireflux procedures. Randomized trials have compared medical versus surgical management, laparoscopic versus open surgery and partial versus total fundoplications. However, the evidence base for endoscopic procedures is limited to some small sham-controlled studies, and cohort studies with short-term follow-up. Laparoscopic fundoplication has been shown to be an effective antireflux operation. It facilitates quicker convalescence and is associated with fewer complications, but has a similar longer term outcome compared with open antireflux surgery. In most randomized trials, antireflux surgery achieves at least as good control of reflux as medical therapy, and these studies support a wider application of surgery for the treatment of moderate-to-severe reflux. Laparoscopic partial fundoplication is an effective surgical procedure with fewer side effects, and it may achieve high rates of patient satisfaction at late follow-up. Many of the early endoscopic antireflux procedures have failed to achieve effective reflux control, and they have been withdrawn from the market. Newer procedures have the potential to fashion a surgical fundoplication. However, at present there is insufficient evidence to establish the safety and efficacy of endoscopic procedures for the treatment of gastroesophageal reflux, and no endoscopic procedure has achieved equivalent reflux control to that achieved by surgical fundoplication.

Effectiveness of ketamine as an adjuvant to opioid-based therapy in decreasing pain associated with opioid tolerance in adults undergoing orthopedic surgery: a systematic review protocol.

PubMed

Bennett, Marsha; Bonanno, Laura; Kuhn, William

2016-10-01

The objective of this systematic review is to examine the best available evidence on the clinical effectiveness of ketamine as an adjuvant to opioid-based therapy versus opioid-based therapy alone in decreasing perioperative pain associated with opioid tolerance in adult patients, aged 18-70 years, undergoing orthopedic surgical procedures.The following question guides the systematic review: does the administration of ketamine as an adjuvant to opioid-based therapy, compared to opioid-based therapy alone, improve perioperative pain relief in opioid-tolerant adult patients undergoing orthopedic surgical procedures?

Computer based guidance in the modern operating room: a historical perspective.

PubMed

Bova, Frank

2010-01-01

The past few decades have seen the introduction of many different and innovative approaches aimed at enhancing surgical technique. As microprocessors have decreased in size and increased in processing power, more sophisticated systems have been developed. Some systems have attempted to provide enhanced instrument control while others have attempted to provide tools for surgical guidance. These systems include robotics, image enhancements, and frame-based and frameless guidance procedures. In almost every case the system's design goals were achieved and surgical outcomes were enhanced, yet a vast majority of today's surgical procedures are conducted without the aid of these advances. As new tools are developed and existing tools refined, special attention to the systems interface and integration into the operating room environment will be required before increased utilization of these technologies can be realized.

Surgery for children in low-income countries affected by humanitarian emergencies from 2008 to 2014: The Médecins Sans Frontières Operations Centre Brussels experience☆,☆☆,★,★★

PubMed Central

Flynn-O’Brien, Katherine T.; Trelles, Miguel; Dominguez, Lynette; Hassani, Ghulam Hiadar; Akemani, Clemence; Naseer, Aamer; Ntawukiruwabo, Innocent Bagura; Kushner, Adam L.; Rothstein, David H.; Stewart, Barclay T.

2018-01-01

Purpose Pediatric surgical care is deficient in developing countries disrupted by crisis. We aimed to describe pediatric surgical care at Médecins Sans Frontières-Brussels (MSF-OCB) projects to inform resource allocation and define the pediatric-specific skillset necessary for humanitarian surgical teams. Methods Procedures performed by MSF-OCB from July 2008 to December 2014 were reviewed. Project characteristics, patient demographics and clinical data were described. Multivariable logistic regression was performed to determine predictors of perioperative death. Results Of 109,828 procedures, 26,284 were performed for 24,576 children (22% of all procedures). The most common pediatric operative indication was trauma (13,984; 57%). Nine percent of all surgical indications were due to violence (e.g., land mines, firearms, gender-based violence, etc.). The majority of procedures (19,582; 75%) were general surgical, followed by orthopedic (4350; 17%), and obstetric/gynecologic/urologic (2135; 8%). Perioperative death was low (42; 0.17%); independent predictors of death included age <1 year, use of general anesthesia with a definitive airway, and operation during conflict. Conclusion Surgical care for children comprised nearly a quarter of all procedures performed by MSF-OCB between 2008 and 2014. Attention to trauma surgery and infant perioperative care is particularly needed. These findings are important when resourcing projects and training surgical staff for humanitarian missions. PMID:26454469

Surgery for children in low-income countries affected by humanitarian emergencies from 2008 to 2014: The Médecins Sans Frontières Operations Centre Brussels experience.

PubMed

Flynn-O'Brien, Katherine T; Trelles, Miguel; Dominguez, Lynette; Hassani, Ghulam Hiadar; Akemani, Clemence; Naseer, Aamer; Ntawukiruwabo, Innocent Bagura; Kushner, Adam L; Rothstein, David H; Stewart, Barclay T

2016-04-01

Pediatric surgical care is deficient in developing countries disrupted by crisis. We aimed to describe pediatric surgical care at Médecins Sans Frontières-Brussels (MSF-OCB) projects to inform resource allocation and define the pediatric-specific skillset necessary for humanitarian surgical teams. Procedures performed by MSF-OCB from July 2008 to December 2014 were reviewed. Project characteristics, patient demographics and clinical data were described. Multivariable logistic regression was performed to determine predictors of perioperative death. Of 109,828 procedures, 26,284 were performed for 24,576 children (22% of all procedures). The most common pediatric operative indication was trauma (13,984; 57%). Nine percent of all surgical indications were due to violence (e.g., land mines, firearms, gender-based violence, etc.). The majority of procedures (19,582; 75%) were general surgical, followed by orthopedic (4350; 17%), and obstetric/gynecologic/urologic (2135; 8%). Perioperative death was low (42; 0.17%); independent predictors of death included age <1year, use of general anesthesia with a definitive airway, and operation during conflict. Surgical care for children comprised nearly a quarter of all procedures performed by MSF-OCB between 2008 and 2014. Attention to trauma surgery and infant perioperative care is particularly needed. These findings are important when resourcing projects and training surgical staff for humanitarian missions. Copyright © 2016 Elsevier Inc. All rights reserved.

Open surgical simulation--a review.

PubMed

Davies, Jennifer; Khatib, Manaf; Bello, Fernando

2013-01-01

Surgical simulation has benefited from a surge in interest over the last decade as a result of the increasing need for a change in the traditional apprentice model of teaching surgery. However, despite the recent interest in surgical simulation as an adjunct to surgical training, most of the literature focuses on laparoscopic, endovascular, and endoscopic surgical simulation with very few studies scrutinizing open surgical simulation and its benefit to surgical trainees. The aim of this review is to summarize the current standard of available open surgical simulators and to review the literature on the benefits of open surgical simulation. Open surgical simulators currently used include live animals, cadavers, bench models, virtual reality, and software-based computer simulators. In the current literature, there are 18 different studies (including 6 randomized controlled trials and 12 cohort studies) investigating the efficacy of open surgical simulation using live animal, bench, and cadaveric models in many surgical specialties including general, cardiac, trauma, vascular, urologic, and gynecologic surgery. The current open surgical simulation studies show, in general, a significant benefit of open surgical simulation in developing the surgical skills of surgical trainees. However, these studies have their limitations including a low number of participants, variable assessment standards, and a focus on short-term results often with no follow-up assessment. The skills needed for open surgical procedures are the essential basis that a surgical trainee needs to grasp before attempting more technical procedures such as laparoscopic procedures. In this current climate of medical practice with reduced hours of surgical exposure for trainees and where the patient's safety and outcome is key, open surgical simulation is a promising adjunct to modern surgical training, filling the void between surgeons being trained in a technique and a surgeon achieving fluency in that open surgical procedure. Better quality research is needed into the benefits of open surgical simulation, and this would hopefully stimulate further development of simulators with more accurate and objective assessment tools. © 2013 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Haptic interface of web-based training system for interventional radiology procedures

NASA Astrophysics Data System (ADS)

Ma, Xin; Lu, Yiping; Loe, KiaFock; Nowinski, Wieslaw L.

2004-05-01

The existing web-based medical training systems and surgical simulators can provide affordable and accessible medical training curriculum, but they seldom offer the trainee realistic and affordable haptic feedback. Therefore, they cannot offer the trainee a suitable practicing environment. In this paper, a haptic solution for interventional radiology (IR) procedures is proposed. System architecture of a web-based training system for IR procedures is briefly presented first. Then, the mechanical structure, the working principle and the application of a haptic device are discussed in detail. The haptic device works as an interface between the training environment and the trainees and is placed at the end user side. With the system, the user can be trained on the interventional radiology procedures - navigating catheters, inflating balloons, deploying coils and placing stents on the web and get surgical haptic feedback in real time.

Validity evidence for procedural competency in virtual reality robotic simulation, establishing a credible pass/fail standard for the vaginal cuff closure procedure.

PubMed

Hovgaard, Lisette Hvid; Andersen, Steven Arild Wuyts; Konge, Lars; Dalsgaard, Torur; Larsen, Christian Rifbjerg

2018-03-30

The use of robotic surgery for minimally invasive procedures has increased considerably over the last decade. Robotic surgery has potential advantages compared to laparoscopic surgery but also requires new skills. Using virtual reality (VR) simulation to facilitate the acquisition of these new skills could potentially benefit training of robotic surgical skills and also be a crucial step in developing a robotic surgical training curriculum. The study's objective was to establish validity evidence for a simulation-based test for procedural competency for the vaginal cuff closure procedure that can be used in a future simulation-based, mastery learning training curriculum. Eleven novice gynaecological surgeons without prior robotic experience and 11 experienced gynaecological robotic surgeons (> 30 robotic procedures) were recruited. After familiarization with the VR simulator, participants completed the module 'Guided Vaginal Cuff Closure' six times. Validity evidence was investigated for 18 preselected simulator metrics. The internal consistency was assessed using Cronbach's alpha and a composite score was calculated based on metrics with significant discriminative ability between the two groups. Finally, a pass/fail standard was established using the contrasting groups' method. The experienced surgeons significantly outperformed the novice surgeons on 6 of the 18 metrics. The internal consistency was 0.58 (Cronbach's alpha). The experienced surgeons' mean composite score for all six repetitions were significantly better than the novice surgeons' (76.1 vs. 63.0, respectively, p < 0.001). A pass/fail standard of 75/100 was established. Four novice surgeons passed this standard (false positives) and three experienced surgeons failed (false negatives). Our study has gathered validity evidence for a simulation-based test for procedural robotic surgical competency in the vaginal cuff closure procedure and established a credible pass/fail standard for future proficiency-based training.

A primer on standards setting as it applies to surgical education and credentialing.

PubMed

Cendan, Juan; Wier, Daryl; Behrns, Kevin

2013-07-01

Surgical technological advances in the past three decades have led to dramatic reductions in the morbidity associated with abdominal procedures and permanently altered the surgical practice landscape. Significant changes continue apace including surgical robotics, natural orifice-based surgery, and single-incision approaches. These disruptive technologies have on occasion been injurious to patients, and high-stakes assessment before adoption of new technologies would be reasonable. We reviewed the drivers for well-established psychometric techniques available for the standards-setting process. We present a series of examples that are relevant in the surgical domain including standards setting for knowledge and skills assessments. Defensible standards for knowledge and procedural skills will likely become part of surgical clinical practice. Understanding the methodology for determining standards should position the surgical community to assist in the process and lead within their clinical settings as standards are considered that may affect patient safety and physician credentialing.

[The use of synthetic mesh implants in surgical treatment of pelvic organ prolapse].

PubMed

Pastorčáková, M; Huser, M; Belkov, A I; Ventruba, P

2014-04-01

Pelvic organ prolapse (POP) surgical treatment went through major changes thanks to availability and wider expansion of mesh implants (MI). This work is focused on critical analysis of outcomes of these surgical procedures and recommendation prescription for their uses in application pelvic surgery. There was made analysis of published outcomes and experience with MI use in POP surgical treatment. OUTCOMES were analysed separately for each pelvic bottom section. Main criteria were surgical complications and treatment effectivity based on objective measurable parameters and subjective patients evaluation. There are formalized suitable indications and conditions for individual pelvic bottom sections for safe MI use in reconstructive POP surgery. On the basis of objective data authors also define specific situations when MI use doesn't bring any benefit and it is not recommended. Mesh implants have their definite place in POP surgical treatment. Implants with right indication and right surgical technique in comparison with classic surgical procedures have significantly lower recurrence risk with comparable or higher surgical complication rate.

SHOULDER ARTHROPLASTY RECORDS

PubMed Central

Filho, Geraldo Motta; Galvão, Marcus Vinicius; Monteiro, Martim; Cohen, Marcio; Brandão, Bruno

2015-01-01

The study's objective is to evaluate the characteristics and problems of patients who underwent shoulder arthroplasties between July 2004 and November 2006. Methodology: During the period of the study, 145 shoulder arthroplasties were performed. A prospective protocol was used for every patient; demographic, clinical and surgical procedure data were collected. All gathered data were included in the data base. The patients were divided in three major groups: fractures, degenerative diseases and trauma sequels. Information obtained from the data base was correlated in order to determine patients' epidemiologic, injuries, and surgical procedure profiles. Results: Of the 145 shoulder arthroplasties performed, 37% presented trauma sequels, 30% degenerative diseases, and 33% proximal humerus fracture. 12% of the cases required total arthroplasties and 88% partial arthroplasties. Five major complications were observed on early postoperative period. Conclusion: Shoulder arthroplasties have become a common procedure in orthopaedic practice. Surgical records are important in evidencing progressive evolution and in enabling future clinical outcomes evaluation. PMID:26998463

[Obesity surgery in patients suffering from monogenetic adipositas].

PubMed

Korenkov, M; Kohlschmidt, N; Zechner, U; Haaf, T; Junginger, T

2007-06-01

Surgical treatment of patients suffering from monogenetic forms of morbid obesity is considered to be the poorest investigated theme in bariatric surgery. This review article presents aspects of genetic disorders in morbid obesity as well as some aspects of surgical treatment in patients with monogenetic forms of morbid obesity (Prader-Willi-Syndrome). Gastric restrictive procedures such as vertical banded gastroplasty or adjustable gastric banding as well as malabsorptive and mix procedures such as biliopancreatic diversion or Roux-en-Y gastric bypass are used for treatment, similar to polygenetic forms of morbid obesity. Until to now there is no evidence-based data because of the small number of published cases. Decisions about the indication to operation and about the choice of surgical procedures are based on the empiric fundament. It is to suggest that the use of growth hormones in patients with monogenetic forms of morbid obesity could positively influence the results of bariatric surgery in these patients.

Selecting aesthetic gynecologic procedures for plastic surgeons: a review of target methodology.

PubMed

Ostrzenski, Adam

2013-04-01

The objective of this article was to assist cosmetic-plastic surgeons in selecting aesthetic cosmetic gynecologic-plastic surgical interventions. Target methodological analyses of pertinent evidence-based scientific papers and anecdotal information linked to surgical techniques for cosmetic-plastic female external genitalia were examined. A search of the existing literature from 1900 through June 2011 was performed by utilizing electronic and manual databases. A total of 87 articles related to cosmetic-plastic gynecologic surgeries were identified in peer-review journals. Anecdotal information was identified in three sources (Barwijuk, Obstet Gynecol J 9(3):2178-2179, 2011; Benson, 5th annual congress on aesthetic vaginal surgery, Tucson, AZ, USA, November 14-15, 2010; Scheinberg, Obstet Gynecol J 9(3):2191, 2011). Among those articles on cosmetic-plastic gynecologic surgical technique that were reviewed, three articles met the criteria for evidence-based medicine level II, one article was level II-1 and two papers were level II-2. The remaining papers were classified as level III. The pertinent 25 papers met the inclusion criteria and were analyzed. There was no documentation on the safety and effectiveness of cosmetic-plastic gynecologic procedures in the scientific literature. All published surgical interventions are not suitable for a cosmetic-plastic practice. The absence of documentation on safety and effectiveness related to cosmetic-plastic gynecologic procedures prevents the establishment of a standard of practice. Traditional gynecologic surgical procedures cannot be labeled and used as cosmetic-plastic procedures, it is a deceptive practice. Obtaining legal trademarks on traditional gynecologic procedures and creating a business model that tries to control clinical-scientific knowledge dissemination is unethical. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Systematic review of skills transfer after surgical simulation-based training.

PubMed

Dawe, S R; Pena, G N; Windsor, J A; Broeders, J A J L; Cregan, P C; Hewett, P J; Maddern, G J

2014-08-01

Simulation-based training assumes that skills are directly transferable to the patient-based setting, but few studies have correlated simulated performance with surgical performance. A systematic search strategy was undertaken to find studies published since the last systematic review, published in 2007. Inclusion of articles was determined using a predetermined protocol, independent assessment by two reviewers and a final consensus decision. Studies that reported on the use of surgical simulation-based training and assessed the transferability of the acquired skills to a patient-based setting were included. Twenty-seven randomized clinical trials and seven non-randomized comparative studies were included. Fourteen studies investigated laparoscopic procedures, 13 endoscopic procedures and seven other procedures. These studies provided strong evidence that participants who reached proficiency in simulation-based training performed better in the patient-based setting than their counterparts who did not have simulation-based training. Simulation-based training was equally as effective as patient-based training for colonoscopy, laparoscopic camera navigation and endoscopic sinus surgery in the patient-based setting. These studies strengthen the evidence that simulation-based training, as part of a structured programme and incorporating predetermined proficiency levels, results in skills transfer to the operative setting. © 2014 BJS Society Ltd. Published by John Wiley & Sons Ltd.

Implementing Liberia's poverty reduction strategy: An assessment of emergency and essential surgical care.

PubMed

Sherman, Lawrence; Clement, Peter T; Cherian, Meena N; Ndayimirije, Nestor; Noel, Luc; Dahn, Bernice; Gwenigale, Walter T; Kushner, Adam L

2011-01-01

To document infrastructure, personnel, procedures performed, and supplies and equipment available at all county hospitals in Liberia using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. Survey of county hospitals using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. Sixteen county hospitals in Liberia. Infrastructure, personnel, procedures performed, and supplies and equipment available. Uniformly, gross deficiencies in infrastructure, personnel, and supplies and equipment were identified. The World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care was useful in identifying baseline emergency and surgical conditions for evidenced-based planning. To achieve the Poverty Reduction Strategy and delivery of the Basic Package of Health and Social Welfare Services, additional resources and manpower are needed to improve surgical and anesthetic care.

Economic analysis of the future growth of cosmetic surgery procedures.

PubMed

Liu, Tom S; Miller, Timothy A

2008-06-01

The economic growth of cosmetic surgical and nonsurgical procedures has been tremendous. Between 1992 and 2005, annual U.S. cosmetic surgery volume increased by 725 percent, with over $10 billion spent in 2005. It is unknown whether this growth will continue for the next decade and, if so, what impact it will it have on the plastic surgeon workforce. The authors analyzed annual U.S. cosmetic surgery procedure volume reported by the American Society of Plastic Surgeons (ASPS) National Clearinghouse of Plastic Surgery Statistics between 1992 and 2005. Reconstructive plastic surgery volume was not included in the analysis. The authors analyzed the ability of economic and noneconomic variables to predict annual cosmetic surgery volume. The authors also used growth rate analyses to construct models with which to predict the future growth of cosmetic surgery. None of the economic and noneconomic variables were a significant predictor of annual cosmetic surgery volume. Instead, based on current compound annual growth rates, the authors predict that total cosmetic surgery volume (surgical and nonsurgical) will exceed 55 million annual procedures by 2015. ASPS members are projected to perform 299 surgical and 2165 nonsurgical annual procedures. Non-ASPS members are projected to perform 39 surgical and 1448 nonsurgical annual procedures. If current growth rates continue into the next decade, the future demand in cosmetic surgery will be driven largely by nonsurgical procedures. The growth of surgical procedures will be met by ASPS members. However, meeting the projected growth in nonsurgical procedures could be a potential challenge and a potential area for increased competition.

The Spanish national health care-associated infection surveillance network (INCLIMECC): data summary January 1997 through December 2006 adapted to the new National Healthcare Safety Network Procedure-associated module codes.

PubMed

Pérez, Cristina Díaz-Agero; Rodela, Ana Robustillo; Monge Jodrá, Vincente

2009-12-01

In 1997, a national standardized surveillance system (designated INCLIMECC [Indicadores Clínicos de Mejora Continua de la Calidad]) was established in Spain for health care-associated infection (HAI) in surgery patients, based on the National Nosocomial Infection Surveillance (NNIS) system. In 2005, in its procedure-associated module, the National Healthcare Safety Network (NHSN) inherited the NNIS program for surveillance of HAI in surgery patients and reorganized all surgical procedures. INCLIMECC actively monitors all patients referred to the surgical ward of each participating hospital. We present a summary of the data collected from January 1997 to December 2006 adapted to the new NHSN procedures. Surgical site infection (SSI) rates are provided by operative procedure and NNIS risk index category. Further quality indicators reported are surgical complications, length of stay, antimicrobial prophylaxis, mortality, readmission because of infection or other complication, and revision surgery. Because the ICD-9-CM surgery procedure code is included in each patient's record, we were able to reorganize our database avoiding the loss of extensive information, as has occurred with other systems.

[Incidence of surgical site infection in ambulatory surgery: results of the INCISCO surveillance network in 1999-2000].

PubMed

Sewonou, A; Rioux, C; Golliot, F; Richard, L; Massault, P P; Johanet, H; Cherbonnel, G; Botherel, A H; Farret, D; Astagneau, P

2002-04-01

To estimate the incidence of surgical-site infections (SSI) in ambulatory surgery and to identify risk factors based on the surveillance network INCISO in 1999-2000. Annually, during a three-month period, each surgical ward had to include 200 consecutive operations. Patients were surveyed over the month following surgery. For each patient, data including peri-operative factors, type of procedure and SSI occurrence were collected on a standardized form by a surgical staff committed for the study. Of the 5,183 patients who underwent an ambulatory surgery, the SSI incidence ratio was 0.4% (95% CI [0.3-0.7]). Orthopedic, gynecologic/obstetrics, head and neck, skin and soft tissues surgery accounted for 83% of all ambulatory procedures. 93% of patients belonged to the 0 risk category of the National Nosocomial Infections Surveillance system (NNIS) index. Emergency, age, american anesthesia risk score (ASA), Altemeier wound class, and procedure duration were not found to be risk factors for SSI in ambulatory surgery. Based on these surveillance data, infectious risk was low in ambulatory surgery and was not associated with known SSI risk factors.

“Evidence-Based Dentistry in Oral Surgery: Could We Do Better?”

PubMed Central

Nocini, Pier Francesco; Verlato, Giuseppe; Frustaci, Andrea; de Gemmis, Antonio; Rigoni, Giovanni; De Santis, Daniele

2010-01-01

Evidence-based Dentistry (EBD), like Evidence-based Medicine (EBM), was born in order to seek the “best available research evidence” in the field of dentistry both in research and clinical routine. But evidence is not clearly measurable in all fields of healthcare: in particular, while drug effect is rather independent from clinician’s characteristics, the effectiveness of surgical procedures is strictly related to surgeon’s expertise, which is difficult to quantify. The research problems of dentistry have a lot in common with other surgical fields, where at the moment the best therapeutic recommendations and guidelines originates from an integration of evidence-based medicine and data from consensus conferences. To cope with these problems, new instruments have been developed, aimed at standardizing clinical procedures (CAD-CAM technology) and at integrating EBM achievements with the opinions of expert clinicians (GRADE System). One thing we have to remember however: it is necessary to use the instruments developed by evidence-based medicine but is impossible to produce sound knowledge without considering clinical expertise and quality of surgical procedures simultaneously. Only in this way we will obtain an evidence-based dentistry both in dental research and clinical practice, which is up to third millennium standards. PMID:20871758

Middle-ear microsurgery simulation to improve new robotic procedures.

PubMed

Kazmitcheff, Guillaume; Nguyen, Yann; Miroir, Mathieu; Péan, Fabien; Ferrary, Evelyne; Cotin, Stéphane; Sterkers, Olivier; Duriez, Christian

2014-01-01

Otological microsurgery is delicate and requires high dexterity in bad ergonomic conditions. To assist surgeons in these indications, a teleoperated system, called RobOtol, is developed. This robot enhances gesture accuracy and handiness and allows exploration of new procedures for middle ear surgery. To plan new procedures that exploit the capacities given by the robot, a surgical simulator is developed. The simulation reproduces with high fidelity the behavior of the anatomical structures and can also be used as a training tool for an easier control of the robot for surgeons. In the paper, we introduce the middle ear surgical simulation and then we perform virtually two challenging procedures with the robot. We show how interactive simulation can assist in analyzing the benefits of robotics in the case of complex manipulations or ergonomics studies and allow the development of innovative surgical procedures. New robot-based microsurgical procedures are investigated. The improvement offered by RobOtol is also evaluated and discussed.

Middle-Ear Microsurgery Simulation to Improve New Robotic Procedures

PubMed Central

Kazmitcheff, Guillaume; Nguyen, Yann; Miroir, Mathieu; Péan, Fabien; Ferrary, Evelyne; Cotin, Stéphane; Sterkers, Olivier; Duriez, Christian

2014-01-01

Otological microsurgery is delicate and requires high dexterity in bad ergonomic conditions. To assist surgeons in these indications, a teleoperated system, called RobOtol, is developed. This robot enhances gesture accuracy and handiness and allows exploration of new procedures for middle ear surgery. To plan new procedures that exploit the capacities given by the robot, a surgical simulator is developed. The simulation reproduces with high fidelity the behavior of the anatomical structures and can also be used as a training tool for an easier control of the robot for surgeons. In the paper, we introduce the middle ear surgical simulation and then we perform virtually two challenging procedures with the robot. We show how interactive simulation can assist in analyzing the benefits of robotics in the case of complex manipulations or ergonomics studies and allow the development of innovative surgical procedures. New robot-based microsurgical procedures are investigated. The improvement offered by RobOtol is also evaluated and discussed. PMID:25157373

Is There Room for Prevention? Examining the Effect of Outpatient Facility Type on the Risk of Surgical Site Infection.

PubMed

Parikh, Rishi; Pollock, Daniel; Sharma, Jyotirmay; Edwards, Jonathan

2016-10-01

OBJECTIVE We compared risk for surgical site infection (SSI) following surgical breast procedures among 2 patient groups: those whose procedures were performed in ambulatory surgery centers (ASCs) and those whose procedures were performed in hospital-based outpatient facilities. DESIGN Cohort study using National Healthcare Safety Network (NHSN) SSI data for breast procedures performed from 2010 to 2014. METHODS Unconditional multivariate logistic regression was used to examine the association between facility type and breast SSI, adjusting for American Society of Anesthesiologists (ASA) Physical Status Classification, patient age, and duration of procedure. Other potential adjustment factors examined were wound classification, anesthesia use, and gender. RESULTS Among 124,021 total outpatient breast procedures performed between 2010 and 2014, 110,987 procedure reports submitted to the NHSN provided complete covariate data and were included in the analysis. Breast procedures performed in ASCs carried a lower risk of SSI compared with those performed in hospital-based outpatient settings. For patients aged ≤51 years, the adjusted risk ratio was 0.36 (95% CI, 0.25-0.50) and for patients >51 years old, the adjusted risk ratio was 0.32 (95% CI, 0.21-0.49). CONCLUSIONS SSI risk following breast procedures was significantly lower among ASC patients than among hospital-based outpatients. These findings should be placed in the context of study limitations, including the possibility of incomplete ascertainment of SSIs and shortcomings in the data available to control for differences in patient case mix. Additional studies are needed to better understand the role of procedural settings in SSI risk following breast procedures and to identify prevention opportunities. Infect Control Hosp Epidemiol 2016;1-7.

Impact of Medicare payment reductions on access to surgical services.

PubMed Central

Mitchell, J B; Cromwell, J

1995-01-01

OBJECTIVE. This study evaluates the impact of surgical fee reductions under Medicare on the utilization of surgical services. DATA SOURCES. Medicare physician claims data were obtained from 11 states for a five-year time period (1985-1989). STUDY DESIGN. Under OBRA-87, Medicare reduced payments for 11 surgical procedures. A fixed effects regression method was used to determine the impact of these payment reductions on access to care for potentially vulnerable Medicare beneficiaries: joint Medicaid-eligibles, blacks, and the very old. DATA COLLECTION/EXTRACTION METHODS. Medicare claims and enrollment data were used to construct a cross-section time-series of population-based surgical rates from 1985 through 1989. PRINCIPAL FINDINGS. Reductions in surgical fees led to small but significant increases in use for three procedures, small decreases in use for two procedures, and no impact on the remaining six procedures. There was little evidence that access to surgery was impaired for potentially vulnerable enrollees; in fact, declining fees often led to greater rates of increases for some subgroups. CONCLUSIONS. Our results suggest that volume responses by surgeons to payment changes under the Medicare Fee Schedule may be smaller than HCFA's original estimates. Nevertheless, both access and quality of care should continue to be closely monitored. PMID:8537224

The accuracy of an electromagnetic navigation system in lateral skull base approaches.

PubMed

Komune, Noritaka; Matsushima, Ken; Matsuo, Satoshi; Safavi-Abbasi, Sam; Matsumoto, Nozomu; Rhoton, Albert L

2017-02-01

Image-guided optical tracking systems are being used with increased frequency in lateral skull base surgery. Recently, electromagnetic tracking systems have become available for use in this region. However, the clinical accuracy of the electromagnetic tracking system has not been examined in lateral skull base surgery. This study evaluates the accuracy of electromagnetic navigation in lateral skull base surgery. Cadaveric and radiographic study. Twenty cadaveric temporal bones were dissected in a surgical setting under a commercially available, electromagnetic surgical navigation system. The target registration error (TRE) was measured at 28 surgical landmarks during and after performing the standard translabyrinthine and middle cranial fossa surgical approaches to the internal acoustic canal. In addition, three demonstrative procedures that necessitate navigation with high accuracy were performed; that is, canalostomy of the superior semicircular canal from the middle cranial fossa, 1 cochleostomy from the middle cranial fossa, 2 and infralabyrinthine approach to the petrous apex. 3 RESULTS: Eleven of 17 (65%) of the targets in the translabyrinthine approach and five of 11 (45%) of the targets in the middle fossa approach could be identified in the navigation system with TRE of less than 0.5 mm. Three accuracy-dependent procedures were completed without anatomical injury of important anatomical structures. The electromagnetic navigation system had sufficient accuracy to be used in the surgical setting. It was possible to perform complex procedures in the lateral skull base under the guidance of the electromagnetically tracked navigation system. N/A. Laryngoscope, 2016 127:450-459, 2017. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Intermuscular pterygoid-temporal abscess following inferior alveolar nerve block anesthesia–A computer tomography based navigated surgical intervention: Case report and review

PubMed Central

Wallner, Jürgen; Reinbacher, Knut Ernst; Pau, Mauro; Feichtinger, Matthias

2014-01-01

Inferior alveolar nerve block (IANB) anesthesia is a common local anesthetic procedure. Although IANB anesthesia is known for its safety, complications can still occur. Today immediately or delayed occurring disorders following IANB anesthesia and their treatment are well-recognized. We present a case of a patient who developed a symptomatic abscess in the pterygoid region as a result of several inferior alveolar nerve injections. Clinical symptoms included diffuse pain, reduced mouth opening and jaw's hypomobility and were persistent under a first step conservative treatment. Since image-based navigated interventions have gained in importance and are used for various procedures a navigated surgical intervention was initiated as a second step therapy. Thus precise, atraumatic surgical intervention was performed by an optical tracking system in a difficult anatomical region. A symptomatic abscess was treated by a computed tomography-based navigated surgical intervention at our department. Advantages and disadvantages of this treatment strategy are evaluated. PMID:24987612

Intermuscular pterygoid-temporal abscess following inferior alveolar nerve block anesthesia-A computer tomography based navigated surgical intervention: Case report and review.

PubMed

Wallner, Jürgen; Reinbacher, Knut Ernst; Pau, Mauro; Feichtinger, Matthias

2014-01-01

Inferior alveolar nerve block (IANB) anesthesia is a common local anesthetic procedure. Although IANB anesthesia is known for its safety, complications can still occur. Today immediately or delayed occurring disorders following IANB anesthesia and their treatment are well-recognized. We present a case of a patient who developed a symptomatic abscess in the pterygoid region as a result of several inferior alveolar nerve injections. Clinical symptoms included diffuse pain, reduced mouth opening and jaw's hypomobility and were persistent under a first step conservative treatment. Since image-based navigated interventions have gained in importance and are used for various procedures a navigated surgical intervention was initiated as a second step therapy. Thus precise, atraumatic surgical intervention was performed by an optical tracking system in a difficult anatomical region. A symptomatic abscess was treated by a computed tomography-based navigated surgical intervention at our department. Advantages and disadvantages of this treatment strategy are evaluated.

A Descriptive Analysis of the Use of Workplace-Based Assessments in UK Surgical Training.

PubMed

Shalhoub, Joseph; Santos, Cristel; Bussey, Maria; Eardley, Ian; Allum, William

2015-01-01

Workplace-based assessments (WBAs) were introduced formally in the UK in 2007. The aim of the study was to describe the use of WBAs by UK surgical trainees and examine variations by training region, specialty, and level of training. The database of the Intercollegiate Surgical Curriculum Programme was examined for WBAs between August 2007 and July 2013, with in-depth analysis of 2 periods: August 2011 to July 2012 and August 2012 to July 2013. The numbers of validated WBAs per trainee per year increased more than 7-fold, from median 6 per trainee in 2007 to 2008, to 39 in 2011 to 2012, and 44 in 2012 to 2013. In the period 2011 to 2012, 58.4% of core trainees completed the recommended 40 WBAs, with only 38.1% of specialty trainees achieving 40 validated WBAs. In the period 2012 to 2013, these proportions increased to 67.7% and 57.0% for core and specialty trainees, respectively. Core trainees completed more WBAs per year than specialty trainees in the same training region. London core trainees completed the highest numbers of WBAs in both the periods 2011 to 2012 (median 67) and 2012 to 2013 (median 74). There was a peak in WBAs completed by London specialty trainees in the period 2012 to 2013 (median 63). The most validated WBAs were completed by ST1/CT1 (specialty surgical training year, core surgical training year), with a gradual decrease in median WBAs to ST4, followed by a plateau; in the period 2012 to 2013, there was an increase in WBAs at ST8. Core surgical trainees complete ~50% "operative" (procedure-based assessment/direct observation of procedural skills) and ~50% "nonoperative" assessments (case-based discussion/clinical evaluation exercise). During specialty training, procedure-based assessments represented ~46% of WBAs, direct observation of procedural skills 11.2%, case-based discussion ~23%, and clinical evaluation exercise ~15%. UK surgical trainees are, on an average, undertaking 1 WBA per week. Variation exists in use of WBAs between training regions. Core trainees tend to use the spectrum of WBAs more frequently than their senior colleagues do. Further work is required to examine the role of WBAs in assessment, and engagement and training of trainers in processes and validation of WBAs. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

20 CFR 220.60 - Diagnostic surgical procedures.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 20 Employees' Benefits 1 2010-04-01 2010-04-01 false Diagnostic surgical procedures. 220.60... DETERMINING DISABILITY Consultative Examinations § 220.60 Diagnostic surgical procedures. The Board will not order diagnostic surgical procedures such as myelograms and arteriograms for the evaluation of...

20 CFR 220.60 - Diagnostic surgical procedures.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 20 Employees' Benefits 1 2011-04-01 2011-04-01 false Diagnostic surgical procedures. 220.60... DETERMINING DISABILITY Consultative Examinations § 220.60 Diagnostic surgical procedures. The Board will not order diagnostic surgical procedures such as myelograms and arteriograms for the evaluation of...

Short and Long-Term Outcomes After Surgical Procedures Lasting for More Than Six Hours.

PubMed

Cornellà, Natalia; Sancho, Joan; Sitges-Serra, Antonio

2017-08-23

Long-term all-cause mortality and dependency after complex surgical procedures have not been assessed in the framework of value-based medicine. The aim of this study was to investigate the postoperative and long-term outcomes after surgical procedures lasting for more than six hours. Retrospective cohort study of patients undergoing a first elective complex surgical procedure between 2004 and 2013. Heart and transplant surgery was excluded. Mortality and dependency from the healthcare system were selected as outcome variables. Gender, age, ASA, creatinine, albumin kinetics, complications, benign vs malignant underlying condition, number of drugs at discharge, and admission and length of stay in the ICU were recorded as predictive variables. Some 620 adult patients were included in the study. Postoperative, <1year and <5years cumulative mortality was 6.8%, 17.6% and 45%, respectively. Of patients discharged from hospital after surgery, 76% remained dependent on the healthcare system. In multivariate analysis for postoperative, <1year and <5years mortality, postoperative albumin concentration, ASA score and an ICU stay >7days, were the most significant independent predictive variables. Prolonged surgery carries a significant short and long-term mortality and disability. These data may contribute to more informed decisions taken concerning major surgery in the framework of value-based medicine.

Evidence-based value of subcutaneous surgical wound drainage: the largest systematic review and meta-analysis.

PubMed

Kosins, Aaron M; Scholz, Thomas; Cetinkaya, Mine; Evans, Gregory R D

2013-08-01

The purpose of this study was to determine the evidenced-based value of prophylactic drainage of subcutaneous wounds in surgery. An electronic search was performed. Articles comparing subcutaneous prophylactic drainage with no drainage were identified and classified by level of evidence. If sufficient randomized controlled trials were included, a meta-analysis was performed using the random-effects model. Fifty-two randomized controlled trials were included in the meta-analysis, and subgroups were determined by specific surgical procedures or characteristics (cesarean delivery, abdominal wound, breast reduction, breast biopsy, femoral wound, axillary lymph node dissection, hip and knee arthroplasty, obesity, and clean-contaminated wound). Studies were compared for the following endpoints: hematoma, wound healing issues, seroma, abscess, and infection. Fifty-two studies with a total of 6930 operations were identified as suitable for this analysis. There were 3495 operations in the drain group and 3435 in the no-drain group. Prophylactic subcutaneous drainage offered a statistically significant advantage only for (1) prevention of hematomas in breast biopsy procedures and (2) prevention of seromas in axillary node dissections. In all other procedures studied, drainage did not offer an advantage. Many surgical operations can be performed safely without prophylactic drainage. Surgeons can consider omitting drains after cesarean section, breast reduction, abdominal wounds, femoral wounds, and hip and knee joint replacement. Furthermore, surgeons should consider not placing drains prophylactically in obese patients. However, drain placement following a surgical procedure is the surgeon's choice and can be based on multiple factors beyond the type of procedure being performed or the patient's body habitus. Therapeutic, II.

Consumer Choice Between Hospital-Based and Freestanding Facilities for Arthroscopy: Impact on Prices, Spending, and Surgical Complications.

PubMed

Robinson, James C; Brown, Timothy T; Whaley, Christopher; Bozic, Kevin J

2015-09-16

Hospital-based outpatient departments traditionally charge higher prices for ambulatory procedures, compared with freestanding surgery centers. Under emerging reference-based benefit designs, insurers establish a contribution limit that they will pay, requiring the patient to pay the difference between that contribution limit and the actual price charged by the facility. The purpose of this study was to evaluate the impact of reference-based benefits on consumer choices, facility prices, employer spending, and surgical outcomes for orthopaedic procedures performed at ambulatory surgery centers. We obtained data on 3962 patients covered by the California Public Employees' Retirement System (CalPERS) who underwent arthroscopy of the knee or shoulder in the three years prior to the implementation of reference-based benefits in January 2012 and on 2505 patients covered by CalPERS who underwent arthroscopy in the two years after implementation. Control group data were obtained on 57,791 patients who underwent arthroscopy and were not subject to reference-based benefits. The impact of reference-based benefits on consumer choices between hospital-based and freestanding facilities, facility prices, employer spending, and surgical complications was assessed with use of difference-in-differences multivariable regressions to adjust for patient demographic characteristics, comorbidities, and geographic location. By the second year of the program, the shift to reference-based benefits was associated with an increase in the utilization of freestanding ambulatory surgery centers by 14.3 percentage points (95% confidence interval, 8.1 to 20.5 percentage points) for knee arthroscopy and by 9.9 percentage points (95% confidence interval, 3.2 to 16.7 percentage points) for shoulder arthroscopy and a corresponding decrease in the use of hospital-based facilities. The mean price paid by CalPERS fell by 17.6% (95% confidence interval, -24.9% to -9.6%) for knee procedures and by 17.0% (95% confidence interval, -29.3% to -2.5%) for shoulder procedures. The shift to reference-based benefits was not associated with a change in the rate of surgical complications. In the first two years after the implementation of reference-based benefits, CalPERS saved $2.3 million (13%) on these two orthopaedic procedures. Reference-based benefits increase consumer sensitivity to price differences between freestanding and hospital-based surgical facilities. This study shows that the implementation of reference-based benefits does not result in a significant increase in measured complication rates for those subject to reference-based benefits. Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.

Surgery for Gynecomastia in the Islamic Golden Age: Al-Tasrif of Al-Zahrawi (936-1013 AD).

PubMed

Chavoushi, Seyed Hadi; Ghabili, Kamyar; Kazemi, Abdolhassan; Aslanabadi, Arash; Babapour, Sarah; Ahmedli, Rafail; Golzari, Samad E J

2012-01-01

The rise of European science during the Renaissance is greatly indebted to the flourishing of the sciences during the Islamic Golden Age. However, some believe that medieval Islamic physicians and in particular surgeons had been merely a medium for Greco-Roman ideas. Contrarily, in some medieval Islamic medical books, such as Al-Tasrif of Al-Zahrawi (936-1013), the surgical instructions represent a change in the usual techniques or are accompanied by a case history, implying that the procedure was actually undertaken. Along with the hundreds of chapters on different diseases and related medical and surgical treatments, Al-Tasrif includes a chapter on surgical techniques for gynecomastia. The present paper is a review of the description of the surgical management of gynecomastia by Al-Zahrawi as well as that of the ancient Greek, medieval, and modern medicine. Although Al-Zahrawi seemed to base his descriptions of surgery for gynecomastia upon those of Paulus of Aegina, his modification of the procedure and application of the medicinal substances might be indicative of Al-Zahrawi's own practice of the procedure. Al-Zahrawi's surgical procedures remained unchanged for many centuries thenceforward until the technological evolution in the recent centuries.

Surgery for Gynecomastia in the Islamic Golden Age: Al-Tasrif of Al-Zahrawi (936–1013 AD)

PubMed Central

Chavoushi, Seyed Hadi; Ghabili, Kamyar; Kazemi, Abdolhassan; Aslanabadi, Arash; Babapour, Sarah; Ahmedli, Rafail; Golzari, Samad E. J.

2012-01-01

The rise of European science during the Renaissance is greatly indebted to the flourishing of the sciences during the Islamic Golden Age. However, some believe that medieval Islamic physicians and in particular surgeons had been merely a medium for Greco-Roman ideas. Contrarily, in some medieval Islamic medical books, such as Al-Tasrif of Al-Zahrawi (936–1013), the surgical instructions represent a change in the usual techniques or are accompanied by a case history, implying that the procedure was actually undertaken. Along with the hundreds of chapters on different diseases and related medical and surgical treatments, Al-Tasrif includes a chapter on surgical techniques for gynecomastia. The present paper is a review of the description of the surgical management of gynecomastia by Al-Zahrawi as well as that of the ancient Greek, medieval, and modern medicine. Although Al-Zahrawi seemed to base his descriptions of surgery for gynecomastia upon those of Paulus of Aegina, his modification of the procedure and application of the medicinal substances might be indicative of Al-Zahrawi's own practice of the procedure. Al-Zahrawi's surgical procedures remained unchanged for many centuries thenceforward until the technological evolution in the recent centuries. PMID:23050167

Monitoring trends in waiting periods in Canada for elective surgery: validation of a method using administrative data.

PubMed

Shortt, Samuel E D; Shaw, Ralph A; Elliott, David; Mackillop, William J

2004-06-01

Provincial governments require timely, economical methods to monitor surgical waiting periods. Although use of prospective procedure-specific registers would be the ideal method, a less elaborate system has been proposed that is based on physician billing data. This study assessed the validity of using the date of the last service billed prior to surgery as a proxy for the beginning of the post-referral, pre-surgical waiting period. We examined charts for 31,824 elective surgical encounters between 1992 and 1996 at an Ontario teaching hospital. The date of the last service before surgery (the last billing date) was compared with the date of the consultant's letter indicating a decision to book surgery (i.e., to begin waiting). Several surgical specialties (but excluding cardiac, orthopedic and gynecologic) had a close correlation between the dates of the last pre-surgery visit and those of the actual decision to place the patient on the waiting list. Similar results were found for 12 of 15 individually studied procedures, including some orthopedic and gynecological procedures. Used judiciously, billing data is a timely, inexpensive and generally accurate method by which provincial governments could monitor trends in waiting times for appropriately selected surgical procedures.

[Complex surgical procedures in orthopedics and trauma surgery. A contribution to the proposal procedure for the DRG system in 2009].

PubMed

Flohé, S; Nabring, J; Luetkes, P; Nast-Kolb, D; Windolf, J

2008-10-01

Since the DRG system was introduced in 2003/2004 the system for remuneration has been continually modified in conjunction with input from specialized medical associations. As part of this development of the payment system, the criteria for classification of a diagnosis-related group were further expanded and new functions were added. This contribution addresses the importance of the complex surgical procedures as criteria for subdivision of the DRG case-based lump sums in orthopedics and trauma surgery.

Image- and model-based surgical planning in otolaryngology.

PubMed

Korves, B; Klimek, L; Klein, H M; Mösges, R

1995-10-01

Preoperative evaluation of any operating field is essential for the preparation of surgical procedures. The relationship between pathology and adjacent structures, and anatomically dangerous sites need to be analyzed for the determination of intraoperative action. For the simulation of surgery using three-dimensional imaging or individually manufactured plastic patient models, the authors have worked out different procedures. A total of 481 surgical interventions in the maxillofacial region, paranasal sinuses, orbit, and the anterior and middle skull base, in addition to neurotologic procedures were presurgically simulated using three-dimensional imaging and image manipulation. An intraoperative simulation device, part of the Aachen Computer-Assisted Surgery System, had been applied in 407 of these cases. In seven patients, stereolithography was used to create plastic patient models for the preparation of reconstructive surgery and prostheses fabrication. The disadvantages of this process include time and cost; however, the advantages included (1) a better understanding of the anatomic relationships, (2) the feasibility of presurgical simulation of the prevailing procedure, (3) an improved intraoperative localization accuracy, (4) prostheses fabrication in reconstructive procedures with an approach to more accuracy, (5) permanent recordings for future requirements or reconstructions, and (6) improved residency education.

A critical analysis of the surgical outcomes for the treatment of Peyronie’s disease

PubMed Central

Mandava, Sree H.; Trost, Landon W.; Hellstrom, Wayne J.G.

2013-01-01

Peyronie’s disease (PD) is a relatively common condition, which can impair sexual function and result in emotional and psychological distress. Despite an abundance of minimally invasive treatments, few have confirmed efficacy for improving penile curvature and function. Surgical therapies include many different techniques and are reserved for patients with stable disease of ⩾12 months’ duration. We searched PubMed for all articles from 1990 to the present relating to the surgical management of PD. Preference was given to recent articles, larger series, and those comparing various techniques and/or materials. Outcomes were subsequently analysed and organised by surgical technique and the graft material used. Available surgical techniques include plication/corporoplasty procedures, incision and grafting (I&G), and placing a penile prosthesis with or without adjunctive procedures. Although several surgical algorithms have been reported, in general, plication/corporoplasty procedures are reserved for patients with adequate erectile function, simple curvatures of <60°, and with no deformities (hour-glass, hinge). I&G are reserved for complex curvatures of >60° and those with deformities. Penile prostheses are indicated for combined erectile dysfunction and PD. Overall outcomes show high rates of improved curvature and patient satisfaction, with mildly decreased erectile function with both plication and the I&G procedure (I&G >plication) and decreases in penile length (plication >I&G). Surgical management of PD remains an excellent treatment option for patients with penile curvature precluding or impairing sexual activity. Surgical algorithms are available to assist treating clinicians in appropriately stratifying surgical candidates. Additional research is needed to identify optimal surgical techniques and materials based on patient and disease characteristics. PMID:26558094

Post-surgical infections: prevalence associated with various periodontal surgical procedures.

PubMed

Powell, Charles A; Mealey, Brian L; Deas, David E; McDonnell, Howard T; Moritz, Alan J

2005-03-01

Of the various adverse outcomes that may be encountered following periodontal surgery, the risk of infection stands at the forefront of concern to the surgeon, since infection can lead to morbidity and poor healing outcomes. This paper describes a large-scale retrospective study of multiple surgical modalities in a diverse periodontal practice undertaken to explore the prevalence of clinical infections post-surgically and the relationship between diverse treatment variables and infection rates. A retrospective review of all available periodontal surgical records of patients treated in the Department of Periodontics at Wilford Hall Medical Center, San Antonio, Texas, was conducted. The sample comprised 395 patients and included 1,053 fully documented surgical procedures. Surgical techniques reviewed included osseous resective surgery, flap curettage, distal wedge procedures, gingivectomy, root resection, guided tissue regeneration, dental implant surgery, epithelialized free soft tissue autografts, subepithelial connective tissue autografts, coronally positioned flaps, sinus augmentations, and ridge preservation or augmentation procedures. Infection was defined as increasing and progressive swelling with the presence of suppuration. The impact of various treatment variables was examined including the use of bone grafts, membranes, soft tissue grafts, post-surgical chlorhexidine rinses, systemic antibiotics, and dressings. Results were analyzed using Fisher's exact test and Pearson's chi-square test. Of the 1,053 surgical procedures evaluated in this study, there were a total of 22 infections for an overall prevalence of 2.09%. Patients who received antibiotics as part of the surgical protocol (pre- and/ or post-surgically) developed eight infections in 281 procedures (2.85%) compared to 14 infections in 772 procedures (1.81%) where antibiotics were not used. Procedures in which chlorhexidine was used during post-surgical care had a lower infection rate (17 infections in 900 procedures, 1.89%) compared to procedures after which chlorhexidine was not used as part of post-surgical care (five infections in 153 procedures, 3.27%). The use of a post-surgical dressing demonstrated a slightly higher rate of infection (eight infections in 300 procedures, 2.67%) than non-use of a dressing (14 infections in 753 procedures, 1.86%). Despite these trends, no statistically significant relationship was found between post-surgical infection and any of the treatment variables examined, including the use of perioperative antibiotics. The results of this study confirm previous research demonstrating a low rate of postoperative infection following periodontal surgical procedures. Although perioperative antibiotics are commonly used when performing certain regenerative and implant surgical procedures, data from this and other studies suggest that there may be no benefit in using antibiotics for the sole purpose of preventing post-surgical infections. Further large-scale, controlled clinical studies are warranted to determine the role of perioperative antibiotics in the prevention of periodontal post-surgical infections.

Robotic Anterior and Midline Skull Base Surgery: Preclinical Investigations

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

O'Malley, Bert W.; Weinstein, Gregory S.

Purpose: To develop a minimally invasive surgical technique to access the midline and anterior skull base using the optical and technical advantages of robotic surgical instrumentation. Methods and Materials: Ten experimental procedures focusing on approaches to the nasopharynx, clivus, sphenoid, pituitary sella, and suprasellar regions were performed on one cadaver and one live mongrel dog. Both the cadaver and canine procedures were performed in an approved training facility using the da Vinci Surgical Robot. For the canine experiments, a transoral robotic surgery (TORS) approach was used, and for the cadaver a newly developed combined cervical-transoral robotic surgery (C-TORS) approach wasmore » investigated and compared with standard TORS. The ability to access and dissect tissues within the various areas of the midline and anterior skull base were evaluated, and techniques to enhance visualization and instrumentation were developed. Results: Standard TORS approaches did not provide adequate access to the midline and anterior skull base; however, the newly developed C-TORS approach was successful in providing the surgical access to these regions of the skull base. Conclusion: Robotic surgery is an exciting minimally invasive approach to the skull base that warrants continued preclinical investigation and development.« less

Surgical manual of the Korean Gynecologic Oncology Group: ovarian, tubal, and peritoneal cancers.

PubMed

Jeon, Seob; Lee, Sung Jong; Lim, Myong Cheol; Song, Taejong; Bae, Jaeman; Kim, Kidong; Lee, Jung Yun; Kim, Sang Wun; Chang, Suk Joon; Lee, Jong Min

2017-01-01

The Surgery Treatment Modality Committee of the Korean Gynecologic Oncology Group has determined to develop a surgical manual to facilitate clinical trials and to improve communication between investigators by standardizing and precisely describing operating procedures. The literature on anatomic terminology, identification of surgical components, and surgical techniques were reviewed and discussed in depth to develop a surgical manual for gynecologic oncology. The surgical procedures provided here represent the minimum requirements for participating in a clinical trial. These procedures should be described in the operation record form, and the pathologic findings obtained from the procedures should be recorded in the pathologic report form. Here, we describe surgical procedure for ovarian, fallopian tubal, and peritoneal cancers.

Basic research and 12 years of clinical experience in computer-assisted navigation technology: a review.

PubMed

Ewers, R; Schicho, K; Undt, G; Wanschitz, F; Truppe, M; Seemann, R; Wagner, A

2005-01-01

Computer-aided surgical navigation technology is commonly used in craniomaxillofacial surgery. It offers substantial improvement regarding esthetic and functional aspects in a range of surgical procedures. Based on augmented reality principles, where the real operative site is merged with computer generated graphic information, computer-aided navigation systems were employed, among other procedures, in dental implantology, arthroscopy of the temporomandibular joint, osteotomies, distraction osteogenesis, image guided biopsies and removals of foreign bodies. The decision to perform a procedure with or without computer-aided intraoperative navigation depends on the expected benefit to the procedure as well as on the technical expenditure necessary to achieve that goal. This paper comprises the experience gained in 12 years of research, development and routine clinical application. One hundred and fifty-eight operations with successful application of surgical navigation technology--divided into five groups--are evaluated regarding the criteria "medical benefit" and "technical expenditure" necessary to perform these procedures. Our results indicate that the medical benefit is likely to outweight the expenditure of technology with few exceptions (calvaria transplant, resection of the temporal bone, reconstruction of the orbital floor). Especially in dental implantology, specialized software reduces time and additional costs necessary to plan and perform procedures with computer-aided surgical navigation.

A Review of Liposuction as a Cosmetic Surgical Procedure

PubMed Central

Sumrall, Arthur J.

1987-01-01

Liposuction (suction-assisted lipectomy) is today an accepted, closed surgical technique utilized by physicians practicing in a number of different specialties. It is a procedure that can be learned and used as an adjunct to a number of open procedures, including rhytidectomy and abdominoplasty. The two principal keys to successful liposuction procedures are: (1) good patient selection, and (2) realistic expectations. Good selection should be based on physiological skin age of the patient rather than chronological age. Many liposuction procedures can be performed under local anesthesia in an office surgical suite. A conservative approach is always appropriate, as overcorrection is difficult to treat. Areas that can be suctioned effectively include the face, chin, neck, anterior and posterior axilary areas, arms, breasts, abdomen, waist, hips, buttocks, thighs, knees, and ankles. Using the blunt cannula technique pioneered by Fischer and modified and popularized by Illouz and Fournier yields a high percentage of good results. A low percentage of possible complications and undesired sequelae have been documented. PMID:3323540

Fetal Heart Rate Monitoring During Surgical Correction of Spontaneous Pneumothorax During Pregnancy: Lessons in In Utero Resuscitation.

PubMed

Wilson, Bailey; Burt, Bryan; Baker, Byron; Clark, Steven L; Belfort, Michael; Gandhi, Manisha

2016-01-01

Spontaneous pneumothorax during pregnancy has potentially serious implications for the mother and fetus. When surgical correction is required, complex maternal physiologic alterations may significantly affect fetal well-being. A woman underwent thoracoscopic lung resection and pleurodesis at 29 weeks of gestation. At various points during the procedure, maternal hemodynamic and respiratory consequences of anesthetic and surgical management resulted in severe fetal heart rate (FHR) decelerations and bradycardia. In each instance, physiologic manipulations based on an understanding of the likely cause of fetal hypoxia allowed correction of the FHR abnormalities without delivery. Nonsurgical perinatal intervention based on FHR monitoring and analysis of the likely pathophysiologic abnormalities underlying fetal decelerations may allow the gravid woman to undergo complex procedures and continue the pregnancy.

Optimizing preoperative blood ordering with data acquired from an anesthesia information management system.

PubMed

Frank, Steven M; Rothschild, James A; Masear, Courtney G; Rivers, Richard J; Merritt, William T; Savage, Will J; Ness, Paul M

2013-06-01

The maximum surgical blood order schedule (MSBOS) is used to determine preoperative blood orders for specific surgical procedures. Because the list was developed in the late 1970s, many new surgical procedures have been introduced and others improved upon, making the original MSBOS obsolete. The authors describe methods to create an updated, institution-specific MSBOS to guide preoperative blood ordering. Blood utilization data for 53,526 patients undergoing 1,632 different surgical procedures were gathered from an anesthesia information management system. A novel algorithm based on previously defined criteria was used to create an MSBOS for each surgical specialty. The economic implications were calculated based on the number of blood orders placed, but not indicated, according to the MSBOS. Among 27,825 surgical cases that did not require preoperative blood orders as determined by the MSBOS, 9,099 (32.7%) had a type and screen, and 2,643 (9.5%) had a crossmatch ordered. Of 4,644 cases determined to require only a type and screen, 1,509 (32.5%) had a type and crossmatch ordered. By using the MSBOS to eliminate unnecessary blood orders, the authors calculated a potential reduction in hospital charges and actual costs of $211,448 and $43,135 per year, respectively, or $8.89 and $1.81 per surgical patient, respectively. An institution-specific MSBOS can be created, using blood utilization data extracted from an anesthesia information management system along with our proposed algorithm. Using these methods to optimize the process of preoperative blood ordering can potentially improve operating room efficiency, increase patient safety, and decrease costs.

Real-time mandibular angle reduction surgical simulation with haptic rendering.

PubMed

Wang, Qiong; Chen, Hui; Wu, Wen; Jin, Hai-Yang; Heng, Pheng-Ann

2012-11-01

Mandibular angle reduction is a popular and efficient procedure widely used to alter the facial contour. The primary surgical instruments, the reciprocating saw and the round burr, employed in the surgery have a common feature: operating at a high-speed. Generally, inexperienced surgeons need a long-time practice to learn how to minimize the risks caused by the uncontrolled contacts and cutting motions in manipulation of instruments with high-speed reciprocation or rotation. A virtual reality-based surgical simulator for the mandibular angle reduction was designed and implemented on a CUDA-based platform in this paper. High-fidelity visual and haptic feedbacks are provided to enhance the perception in a realistic virtual surgical environment. The impulse-based haptic models were employed to simulate the contact forces and torques on the instruments. It provides convincing haptic sensation for surgeons to control the instruments under different reciprocation or rotation velocities. The real-time methods for bone removal and reconstruction during surgical procedures have been proposed to support realistic visual feedbacks. The simulated contact forces were verified by comparing against the actual force data measured through the constructed mechanical platform. An empirical study based on the patient-specific data was conducted to evaluate the ability of the proposed system in training surgeons with various experiences. The results confirm the validity of our simulator.

Implementation of electronic logbook for trainees of general surgery in Thailand.

PubMed

Aphinives, Potchavit

2013-01-01

All trainees are required to keep a record of their surgical skill and experiences throughout the trainingperiod in a logbook format. Paper-based logbook has several limitations. Therefore, an electronic logbook was introduced to replace the paper-based logbook. An electronic logbook program was developed in November 2005. This program was designed as web-based application based upon PHP scripts beneath Apache web server and MySQL database implementation. Only simpliJfied and essential data, such as hospital number diagnosis, surgical procedure, and pathological findings, etc. are recorded. The electronic logbook databases between Academic year 2006 and 2011 were analyzed. The annual recordedsurgical procedures gradually increasedfrom 41,214 procedures in 2006 to 66,643 procedures in 2011. Around one-third of all records were not verified by attending staffs, i.e. 27.59% (2006), 31.69% (2007), 18.06% (2008), 28.42% (2009), 30.18% (2010), and 31.41% (2011). On the Education year 2011, the three most common procedural groups included colon, rectum & anus group, appendix group, and vascular group, respectively. Advantages of the electronic logbook included more efficient data access, increased ability to monitor trainees and trainers, and analysis of procedural varieties among the training institutes.

Development of a Meso-Scale SMA-Based Torsion Actuator for Image-Guided Procedures.

PubMed

Sheng, Jun; Gandhi, Dheeraj; Gullapalli, Rao; Simard, J Marc; Desai, Jaydev P

2017-02-01

This paper presents the design, modeling, and control of a meso-scale torsion actuator based on shape memory alloy (SMA) for image-guided surgical procedures. Developing a miniature torsion actuator is challenging, but it opens the possibility of significantly enhancing the robot agility and maneuverability. The proposed torsion actuator is bi-directionally actuated by a pair of antagonistic SMA torsion springs through alternate Joule heating and natural cooling. The torsion actuator is integrated into a surgical robot prototype to demonstrate its working performance in the humid environment under C-Arm CT image guidance.

Development of a Meso-Scale SMA-Based Torsion Actuator for Image-Guided Procedures

PubMed Central

Sheng, Jun; Gandhi, Dheeraj; Gullapalli, Rao; Simard, J. Marc; Desai, Jaydev P.

2016-01-01

This paper presents the design, modeling, and control of a meso-scale torsion actuator based on shape memory alloy (SMA) for image-guided surgical procedures. Developing a miniature torsion actuator is challenging, but it opens the possibility of significantly enhancing the robot agility and maneuverability. The proposed torsion actuator is bi-directionally actuated by a pair of antagonistic SMA torsion springs through alternate Joule heating and natural cooling. The torsion actuator is integrated into a surgical robot prototype to demonstrate its working performance in the humid environment under C-Arm CT image guidance. PMID:28210189

Real-time complication monitoring in pediatric cardiac surgery.

PubMed

Belliveau, Daniel; Burton, Hayley J; O'Blenes, Stacy B; Warren, Andrew E; Hancock Friesen, Camille L

2012-11-01

As overall mortality rates have fallen in pediatric cardiac surgical procedures, complication monitoring is becoming an increasingly important metric of patient outcome. Currently there is no standardized method available to monitor severity-adjusted complications in congenital cardiac surgical procedures. Complications associated with pediatric cardiac surgical procedures were prospectively collected from consecutive cases in a single pediatric cardiac surgical unit from October 1, 2009 to September 31, 2011. Complications were accounted for by frequency and severity and then stratified by surgical complexity, using the Risk Adjustment for Congenital Heart Surgery (RACHS) method, giving an average morbidity burden per RACHS category. "Expected" morbidity burden for each RACHS category was derived from year 1 (2009-2010) data. Observed minus expected (O:E) plots were then generated for the entire series of complications from year 2 (2010-2011) data. Separate O:E plots were also created for 5 complication classes and monitored for increases. There were 181 index surgical procedures performed in 178 patients. Two hundred and seventeen complications occurred in 80 procedures. The frequency and severity of complications increased with surgical complexity. The overall O:E plot was flagged twice for unanticipated increases in severity-adjusted complications. When the class-specific O:E plots were monitored for increases, the overall flags were found to originate from increased rates of infections and cardiac/operative complications. The O:E plot provides a simple and effective system to monitor complication rates over time based on severity-adjusted complication data. Grouping complications into classes allows us to identify specific subsets of complications that can be focused on to improve patient outcomes. Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Surgical Instrument Restraint in Weightlessness

NASA Technical Reports Server (NTRS)

Campbell, Mark R.; Dawson, David L.; Melton, Shannon; Hooker, Dona; Cantu, Hilda

2000-01-01

Performing a surgical procedure during spaceflight will become more likely with longer duration missions in the near future. Minimal surgical capability has been present on previous missions as the definitive medical care time was short and the likelihood of surgical events too low to justify surgical hardware availability. Early demonstrations of surgical procedures in the weightlessness of parabolic flight indicated the need for careful logistical planning and restraint of surgical hardware. The consideration of human ergonomics also has more impact in weightlessness than in the conventionall-g environment. Three methods of surgical instrument restraint - a Minor Surgical Kit (MSK), a Surgical Restraint Scrub Suit (SRSS), and a Surgical Tray (ST) were evaluated in parabolic flight surgical procedures. The Minor Surgical Kit was easily stored, easily deployed, and demonstrated the best ability to facilitate a surgical procedure in weightlessness. Important factors in this surgical restraint system include excellent organization of supplies, ability to maintain sterility, accessibility while providing secure restraint, ability to dispose of sharp items and biological trash, and ergonomical efficiency.

Surgical manual of the Korean Gynecologic Oncology Group: ovarian, tubal, and peritoneal cancers

PubMed Central

2017-01-01

The Surgery Treatment Modality Committee of the Korean Gynecologic Oncology Group has determined to develop a surgical manual to facilitate clinical trials and to improve communication between investigators by standardizing and precisely describing operating procedures. The literature on anatomic terminology, identification of surgical components, and surgical techniques were reviewed and discussed in depth to develop a surgical manual for gynecologic oncology. The surgical procedures provided here represent the minimum requirements for participating in a clinical trial. These procedures should be described in the operation record form, and the pathologic findings obtained from the procedures should be recorded in the pathologic report form. Here, we describe surgical procedure for ovarian, fallopian tubal, and peritoneal cancers. PMID:27670260

Anterior mandibular apical base augmentation in the surgical orthodontic treatment of mandibular retrusion.

PubMed

Brusati, R; Giannì, A B

2005-12-01

The authors describe a surgical technique alternative to traditional pre-surgical orthodontics in order to increase the apical base in mandibular retrusion (class II, division I). This subapical osteotomy, optimizing inferior incisal axis without dental extractions and a long orthodontic treatment, associated to genioplasty permits to obtain an ideal labio-dento-mental morphology. This procedure avoids in some cases the need of a mandibular advancement and, if necessary, it reduces his entity with obvious advantages.

Assessment of Anatomical Knowledge and Core Trauma Competency Vascular Skills.

PubMed

Granite, Guinevere; Pugh, Kristy; Chen, Hegang; Longinaker, Nyaradzo; Garofalo, Evan; Shackelford, Stacy; Shalin, Valerie; Puche, Adam; Pasley, Jason; Sarani, Babak; Henry, Sharon; Bowyer, Mark; Mackenzie, Colin

2018-03-01

Surgical residents express confidence in performing specific vascular exposures before training, but such self-reported confidence did not correlate with co-located evaluator ratings. This study reports residents' self-confidence evaluated before and after Advanced Surgical Skills for Exposure in Trauma (ASSET) cadaver-based training, and 12-18 mo later. We hypothesize that residents will better judge their own skill after ASSET than before when compared with evaluator ratings. Forty PGY2-7 surgical residents performed four procedures: axillary artery (AA), brachial artery (BA), femoral artery exposure and control (FA), and lower extremity fasciotomy (FAS) at the three evaluations. Using 5-point Likert scales, surgeons self-assessed their confidence in anatomical understanding and procedure performance after each procedure and evaluators rated each surgeon accordingly. For all the three evaluations, residents consistently rated their anatomical understanding (p < 0.04) and surgical performance (p < 0.03) higher than evaluators for both FA and FAS. Residents rated their anatomical understanding and surgical performance higher (p < 0.005) than evaluators for BA after training and up to 18 mo later. Only for third AA evaluation were there no rating differences. Residents overrate their anatomical understanding and performance abilities for BA, FA, and FAS even after performing the procedures and being debriefed three times in 18 mo.

Operation Sumatra Assist: surgery for survivors of the tsunami disaster in Indonesia.

PubMed

Chambers, Anthony J; Campion, Michael J; Courtenay, Brett G; Crozier, John A; New, Charles H

2006-01-01

The tsunami of 26 December 2004 was one of the deadliest natural disasters recorded, with the Indonesian province of Aceh being the most devastated region. As part of the Australian Government's response to the disaster, the Australian Defence Force deployed personnel from the Sydney-based 1st Health Support Battalion to Banda Aceh, the capital of the province. This unit joined with medical personnel from the New Zealand Defence Force to form the ANZAC field hospital. The mission of this unit as part of Operation Sumatra Assist was to provide medical and surgical care to the people of Aceh during the critical stages of rebuilding of the tsunami-devastated region. Surgical teams of the ANZAC field hospital were some of the first to provide definitive surgical care to the critically injured survivors of the disaster. During the first 4 weeks of the deployment, 173 surgical procedures were carried out for 71 patients in this facility. Thirty patients underwent 119 procedures (69% of total) for injuries sustained in the tsunami. Most of these patients required debridements, dressing changes and wound management procedures for the management of severe soft tissue infections. Three amputations were carried out. The remaining 41 patients underwent 54 procedures (31%) for emergent surgical conditions unrelated to the disaster.

Monitoring trends in waiting periods in Canada for elective surgery: validation of a method using administrative data

PubMed Central

Shortt, Samuel E.D.; Shaw, Ralph A.; Elliott, David; Mackillop, William J.

2004-01-01

Background Provincial governments require timely, economical methods to monitor surgical waiting periods. Although use of prospective procedure-specific registers would be the ideal method, a less elaborate system has been proposed that is based on physician billing data. This study assessed the validity of using the date of the last service billed prior to surgery as a proxy for the beginning of the post-referral, pre-surgical waiting period. Method We examined charts for 31 824 elective surgical encounters between 1992 and 1996 at an Ontario teaching hospital. The date of the last service before surgery (the last billing date) was compared with the date of the consultant's letter indicating a decision to book surgery (i.e., to begin waiting). Results Several surgical specialties (but excluding cardiac, orthopedic and gynecologic) had a close correlation between the dates of the last pre-surgery visit and those of the actual decision to place the patient on the waiting list. Similar results were found for 12 of 15 individually studied procedures, including some orthopedic and gynecological procedures. Conclusion Used judiciously, billing data is a timely, inexpensive and generally accurate method by which provincial governments could monitor trends in waiting times for appropriately selected surgical procedures. PMID:15264378

Surgical informed consent in obstetric and gynecologic surgeries: experience from a comprehensive teaching hospital in Southern Ethiopia.

PubMed

Teshome, Million; Wolde, Zenebe; Gedefaw, Abel; Tariku, Mequanent; Asefa, Anteneh

2018-05-24

Surgical Informed Consent (SIC) has long been recognized as an important component of modern medicine. The ultimate goals of SIC are to improve clients' understanding of the intended procedure, increase client satisfaction, maintain trust between clients and health providers, and ultimately minimize litigation issues related to surgical procedures. The purpose of the current study is to assess the comprehensiveness of the SIC process for women undergoing obstetric and gynecologic surgeries. A hospital-based cross-sectional study was undertaken at Hawassa University Comprehensive Specialized Hospital (HUCSH) in November and December, 2016. A total of 230 women who underwent obstetric and/or gynecologic surgeries were interviewed immediately after their hospital discharge to assess their experience of the SIC process. Thirteen components of SIC were used based on international recommendations, including the Royal College of Surgeon's standards of informed consent practices for surgical procedures. Descriptive summaries are presented in tables and figures. Forty percent of respondents were aged between 25 and 29 years. Nearly a quarter (22.6%) had no formal education. More than half (54.3%) of respondents had undergone an emergency surgical procedure. Only 18.4% of respondents reported that the surgeon performing the operation had offered SIC, while 36.6% of respondents could not recall who had offered SIC. All except one respondent provided written consent to undergo a surgical procedure. However, 8.3% of respondents received SIC service while already on the operation table for their procedure. Only 73.9% of respondents were informed about the availability (or lack thereof) of alternative treatment options. Additionally, a majority of respondents were not informed about the type of anesthesia to be used (88.3%) and related complications (87.4%). Only 54.2% of respondents reported that they had been offered at least six of the 13 SIC components used by the investigators. There is gap in the provision of comprehensive and standardized pre-operative counseling for obstetric and gynecologic surgeries in the study hospital. This has a detrimental effect on the overall quality of care clients receive, specifically in terms of client expectations and information needs.

Lateral Augmentation Procedures in Anterior Cruciate Ligament Reconstruction: Anatomic, Biomechanical, Imaging, and Clinical Evidence.

PubMed

Weber, Alexander E; Zuke, William; Mayer, Erik N; Forsythe, Brian; Getgood, Alan; Verma, Nikhil N; Bach, Bernard R; Bedi, Asheesh; Cole, Brian J

2018-02-01

There has been an increasing interest in lateral-based soft tissue reconstructive techniques as augments to anterior cruciate ligament reconstruction (ACLR). The objective of these procedures is to minimize anterolateral rotational instability of the knee after surgery. Despite the relatively rapid increase in surgical application of these techniques, many clinical questions remain. To provide a comprehensive update on the current state of these lateral-based augmentation procedures by reviewing the origins of the surgical techniques, the biomechanical data to support their use, and the clinical results to date. Systematic review. A systematic search of the literature was conducted via the Medline, EMBASE, Scopus, SportDiscus, and CINAHL databases. The search was designed to encompass the literature on lateral extra-articular tenodesis (LET) procedures and the anterolateral ligament (ALL) reconstruction. Titles and abstracts were reviewed for relevance and sorted into the following categories: anatomy, biomechanics, imaging/diagnostics, surgical techniques, and clinical outcomes. The search identified 4016 articles. After review for relevance, 31, 53, 27, 35, 45, and 78 articles described the anatomy, biomechanics, imaging/diagnostics, surgical techniques, and clinical outcomes of either LET procedures or the ALL reconstruction, respectively. A multitude of investigations were available, revealing controversy in addition to consensus in several categories. The level of evidence obtained from this search was not adequate for systematic review or meta-analysis; thus, a current concepts review of the anatomy, biomechanics, imaging, surgical techniques, and clinical outcomes was performed. Histologically, the ALL appears to be a distinct structure that can be identified with advanced imaging techniques. Biomechanical evidence suggests that the anterolateral structures of the knee, including the ALL, contribute to minimizing anterolateral rotational instability. Cadaveric studies of combined ACLR-LET procedures demonstrated overconstraint of the knee; however, these findings have yet to be reproduced in the clinical literature. The current indications for LET augmentation in the setting of ACLR and the effect on knee kinematic and joint preservation should be the subject of future research.

3D force/torque characterization of emergency cricothyroidotomy procedure using an instrumented scalpel.

PubMed

Ryason, Adam; Sankaranarayanan, Ganesh; Butler, Kathryn L; DeMoya, Marc; De, Suvranu

2016-08-01

Emergency Cricothyroidotomy (CCT) is a surgical procedure performed to secure a patient's airway. This high-stakes, but seldom-performed procedure is an ideal candidate for a virtual reality simulator to enhance physician training. For the first time, this study characterizes the force/torque characteristics of the cricothyroidotomy procedure, to guide development of a virtual reality CCT simulator for use in medical training. We analyze the upper force and torque thresholds experienced at the human-scalpel interface. We then group individual surgical cuts based on style of cut and cut medium and perform a regression analysis to create two models that allow us to predict the style of cut performed and the cut medium.

Challenges in evaluating surgical innovation.

PubMed

Ergina, Patrick L; Cook, Jonathan A; Blazeby, Jane M; Boutron, Isabelle; Clavien, Pierre-Alain; Reeves, Barnaby C; Seiler, Christoph M; Altman, Douglas G; Aronson, Jeffrey K; Barkun, Jeffrey S; Campbell, W Bruce; Cook, Jonathan A; Feldman, Liane S; Flum, David R; Glasziou, Paul; Maddern, Guy J; Marshall, John C; McCulloch, Peter; Nicholl, Jon; Strasberg, Steven M; Meakins, Jonathan L; Ashby, Deborah; Black, Nick; Bunker, John; Burton, Martin; Campbell, Marion; Chalkidou, Kalipso; Chalmers, Iain; de Leval, Marc; Deeks, Jon; Grant, Adrian; Gray, Muir; Greenhalgh, Roger; Jenicek, Milos; Kehoe, Sean; Lilford, Richard; Littlejohns, Peter; Loke, Yoon; Madhock, Rajan; McPherson, Kim; Rothwell, Peter; Summerskill, Bill; Taggart, David; Tekkis, Parris; Thompson, Matthew; Treasure, Tom; Trohler, Ulrich; Vandenbroucke, Jan

2009-09-26

Research on surgical interventions is associated with several methodological and practical challenges of which few, if any, apply only to surgery. However, surgical evaluation is especially demanding because many of these challenges coincide. In this report, the second of three on surgical innovation and evaluation, we discuss obstacles related to the study design of randomised controlled trials and non-randomised studies assessing surgical interventions. We also describe the issues related to the nature of surgical procedures-for example, their complexity, surgeon-related factors, and the range of outcomes. Although difficult, surgical evaluation is achievable and necessary. Solutions tailored to surgical research and a framework for generating evidence on which to base surgical practice are essential.

[Patient's individuality and application of guidelines in surgery].

PubMed

Schulte, Michael

2005-01-01

Individual treatment decisions can become considerably conflictual in view of the co-existence of medical professional guidelines, recommendations based on evidence-based medicine (EBM), and juridical and economical directions. Medical guidelines are not subject to an external review process; also, due to reduced practicability, the surgeons' compliance with guidelines remains relatively low. Surgical treatment strategies can rely on randomized clinical trials (RCTs) in approximately 20% of the surgical procedures and on non-randomized trials in approximately 70% of the cases. No evidence is given in approximately 10% of the cases. Specific problems of implementation of EBM in surgical disciplines are represented by the difficulty of standardized procedures, the heterogeneity of the population, the impossibility to conduct double-blinded RCTs, a low statistical power, and a publication bias. Since individual diseases cannot be reduced to surgical cases manageable only by the application of guidelines, adequate treatment of individual patients requires the critical application of both external evidence and surgeon expertise (internal evidence).

Unusual anchor pins placement and protocol deviations during computer-based implant placement in a patient with severe mandibular bone atrophy. A case report.

PubMed

Pozzi, A; Tallarico, M; Barlattani, A

2012-06-01

The aim of the study was to describe an unusual method to stabilize the surgical template during the treatment of a severely resorbed edentulous mandible by means of computer-guided implant surgery. Pre-operative computer-based planning revealed the difficulty to stabilize the surgical template in a 67-year-old healthy woman. A deviation of the original NobelGuide™ protocol was performed to ensure the stability of the surgical template: four anchor pins were used to stabilize the surgical template, two in the buccal side of the anterior template and two unusual pins were placed in the lingual site. Four straight TiUnite® Nobel Biocare™ implants were then placed, according to a modified All-on-4™ concept procedure, to avoid graft procedures and to reduce the cumulative chair-side treatment time and costs. A temporary restoration was placed immediately after implant placement. Three months later a definitive, full acrylic restoration was delivered.

Designing simulator-based training: an approach integrating cognitive task analysis and four-component instructional design.

PubMed

Tjiam, Irene M; Schout, Barbara M A; Hendrikx, Ad J M; Scherpbier, Albert J J M; Witjes, J Alfred; van Merriënboer, Jeroen J G

2012-01-01

Most studies of simulator-based surgical skills training have focused on the acquisition of psychomotor skills, but surgical procedures are complex tasks requiring both psychomotor and cognitive skills. As skills training is modelled on expert performance consisting partly of unconscious automatic processes that experts are not always able to explicate, simulator developers should collaborate with educational experts and physicians in developing efficient and effective training programmes. This article presents an approach to designing simulator-based skill training comprising cognitive task analysis integrated with instructional design according to the four-component/instructional design model. This theory-driven approach is illustrated by a description of how it was used in the development of simulator-based training for the nephrostomy procedure.

A methodological, task-based approach to Procedure-Specific Simulations training.

PubMed

Setty, Yaki; Salzman, Oren

2016-12-01

Procedure-Specific Simulations (PSS) are 3D realistic simulations that provide a platform to practice complete surgical procedures in a virtual-reality environment. While PSS have the potential to improve surgeons' proficiency, there are no existing standards or guidelines for PSS development in a structured manner. We employ a unique platform inspired by game design to develop virtual reality simulations in three dimensions of urethrovesical anastomosis during radical prostatectomy. 3D visualization is supported by a stereo vision, providing a fully realistic view of the simulation. The software can be executed for any robotic surgery platform. Specifically, we tested the simulation under windows environment on the RobotiX Mentor. Using urethrovesical anastomosis during radical prostatectomy simulation as a representative example, we present a task-based methodological approach to PSS training. The methodology provides tasks in increasing levels of difficulty from a novice level of basic anatomy identification, to an expert level that permits testing new surgical approaches. The modular methodology presented here can be easily extended to support more complex tasks. We foresee this methodology as a tool used to integrate PSS as a complementary training process for surgical procedures.

3D Printed Surgical Instruments Evaluated by a Simulated Crew of a Mars Mission.

PubMed

Wong, Julielynn Y; Pfahnl, Andreas C

2016-09-01

The first space-based fused deposition modeling (FDM) 3D printer became operational in 2014. This study evaluated whether Mars simulation crewmembers of the Hawai'i Space Exploration Analog and Simulation (HI-SEAS) II mission with no prior surgical experience could utilize acrylonitrile butadiene styrene (ABS) thermoplastic surgical instruments FDM 3D printed on Earth to complete simulated surgical tasks. This study sought to examine the feasibility of using 3D printed surgical tools when the primary crew medical officer is incapacitated and the back-up crew medical officer must conduct a surgical procedure during a simulated extended space mission. During a 4 mo duration ground-based analog mission, five simulation crewmembers with no prior surgical experience completed 16 timed sets of simulated prepping, draping, incising, and suturing tasks to evaluate the relative speed of using four ABS thermoplastic instruments printed on Earth compared to conventional instruments. All four simulated surgical tasks were successfully performed using 3D printed instruments by Mars simulation crewmembers with no prior surgical experience. There was no substantial difference in time to completion of simulated tasks with control vs. 3D printed sponge stick, towel clamp, scalpel handle, and toothed forceps. These limited findings support further investigation into the creation of an onboard digital catalog of validated 3D printable surgical instrument design files to support autonomous, crew-administered healthcare on Mars missions. Future work could include addressing sterility, biocompatibility, and having astronaut crew medical officers test a wider range of surgical instruments printed in microgravity during actual surgical procedures. Wong JY, Pfahnl AC. 3D printed surgical instruments evaluated by a simulated crew of a Mars mission. Aerosp Med Hum Perform. 2016; 87(9):806-810.

A review of prophylactic antibiotics use in plastic surgery in China and a systematic review.

PubMed

Li, Ge-hong; Hou, Dian-ju; Fu, Hua-dong; Guo, Jing-ying; Guo, Xiao-bo; Gong, Hui

2014-12-01

The purpose of this study was to investigate the use of antibiotic prophylaxis for plastic surgical procedures at our hospital, and to perform a systematic literature review of randomized controlled trials evaluating the use of prophylactic antibiotics in plastic surgery. The records of patients who received plastic surgical procedures with Class I surgical incisions between 2009 and 2010 were retrospectively reviewed. A systematic literature review was conducted for studies examining the use of prophylactic antibiotics for Class I surgical wounds. A total of 13,997 cases with Class I surgical incisions were included. Prophylactic antibiotics were given in 13,865 cases (99.1%). The antibiotics used were primarily cefuroxime, clindamycin, metronidazole, cefoxitin sodium, and gentamicin. The average duration of administration was 4.84 ± 3.07 (range, 1-51) days. Antibiotics were administered postoperatively in >99% of cases while preoperative antibiotic administration was only given in 32 cases (0.23%). Wound infections occurred in 21 cases for an overall infection rate of 0.15%. Fourteen studies met the inclusion criteria of the systematic review. There was marked variation in the timing of antibiotic administration with antibiotics given pre-, peri-, and postoperatively. Of studies that compared the use of prophylactic antibiotics with placebo, a reduction in wound infections was noted in 4 trials and no difference was noted in 6 trials. No significant difference in infection rates was shown between the prophylactic and postoperative arms. In conclusion, prophylactic antibiotics are overused in plastic surgical procedures. Evidence-based guidelines for the use of prophylactic antibiotics in plastic surgical procedures are needed. Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Explaining the absence of surgical procedure regulation.

PubMed

Darrow, Jonathan J

Each year in the United States, surgeons perform approximately 64 million surgical procedures, ranging from tooth extraction to open heart surgery. Yet, notwithstanding the frequency of surgical procedures and their often critical importance to patient health, no state or federal agency either approves the use of new surgical procedures or directly regulates existing procedures. The absence of surgical procedure regulation differs from the regulation of new pharmaceutical products, which can be introduced into interstate commerce only after the Food and Drug Administration (FDA) has reviewed "adequate and well-controlled [clinical] investigations" and concluded the data from those studies sufficiently establish the drug's safety and efficacy. Surgical procedures, by contrast, are more often conveyed from professor to student, the result being that surgical approaches may vary considerably from one geographic region to another. Whether different techniques produce different outcomes is not always clear, in part because the absence of regulation means that evidence often has not been systematically generated or may be in a form not suitable for comparison. Commentators have noted the differing treatment that persists between surgery and pharmaceuticals and have offered a number of justifications. For example, they have suggested that the surgical profession should self-regulate, that excessive regulation could deter surgeries of unproven benefit even when the surgery may be in the best interest of the patient, and that surgical trials could disrupt the doctor-patient relationship, such as by emphasizing uncertainty in a context where patient trust is important. In the context of innovative (as opposed to established) surgical procedures, controlled trials might be disfavored due to concern that desperate patients might unwisely submit themselves to risky experimental treatments undertaken by overzealous researchers. When commentators advocate for increased surgical regulation, they generally limit their calls for reform to innovative surgical procedures. The absence of direct regulation, however, has implications for the quality of evidence available to support an optimal choice from among all of the alternatives in the surgeon's armamentarium, whether innovative or standard, and whether surgical or non-surgical. This Article first examines the current framework of indirect regulation surrounding surgical procedures and then offers potential explanations as to why surgical procedures themselves are not already subject to direct federal regulation. Finally, it considers possible contributions of increased surgical regulation, including the identification of evidence gaps, the generation or collection of evidence to fill those gaps, and the impact on surgeon decision-making and patient consent.

Evaluation of degenerative disease of the lumbar spine: MR/MR myelography versus conventional myelography/post-myelography CT.

PubMed

Shiban, Ehab; von Lehe, Marec; Simon, Matthias; Clusmann, Hans; Heinrich, Petra; Ringel, Florian; Wilhelm, Kai; Urbach, Horst; Meyer, Bernhard; Stoffel, Michael

2016-08-01

To compare the use of magnetic resonance (MR)/MR myelography (MRM) with conventional myelography/post-myelography CT (convM) for detailed surgery planning in degenerative lumbar disease. Twenty-six patients with suspected complex lumbar degenerative disease underwent MRM in addition to convM as preoperative workup. Surgery was planned based on convM-as usual at our department. Post hoc, surgical planning was repeated planned again-now based on MRM. Furthermore, the MRM-based planning was performed by six independent neurosurgeons (three groups) of different degrees of specialisation. In only 31 % of the patients, post hoc MRM-based planning resulted in the same surgical decision as originally performed, whereas in 69 % (n = 18) a different procedure was indicated. In patients with non-concurring convM- and MRM-based surgical plans, a less extended procedure was the result of MRM in six patients (23 %), a more extended one in five (19 %), and a related to side/level of decompression or nucleotomy different plan in six patients (23 %). In one patient (4 %), the MRM-based planning would have led to a completely different surgery compared to convM. Overall interobserver agreement on the MRM-based planning was substantial. Detailed planning of operative procedures for complex lumbar degenerative disease is highly dependent on the image modality used.

Surgical “Placebo” Controls

PubMed Central

Tenery, Robert; Rakatansky, Herbert; Riddick, Frank A.; Goldrich, Michael S.; Morse, Leonard J.; O’Bannon, John M.; Ray, Priscilla; Smalley, Sherie; Weiss, Matthew; Kao, Audiey; Morin, Karine; Maixner, Andrew; Seiden, Sam

2002-01-01

Objective To set ethical guidelines on the use of surgical placebo controls in the design of surgical trials. Background Data Ethical concerns recently arose from surgical trials where subjects in the control arm underwent surgical procedures that had the appearance of a therapeutic intervention, but during which the essential therapeutic maneuver was omitted. Although there are ethical guidelines on the use of a placebo in drug trials, little attention has been paid to the use of a surgical placebo control in surgical trials. Methods The Council on Ethical and Judicial Affairs developed ethical guidelines based on a wide literature search and consultation with experts. Results Surgical placebo controls should be limited to studies of new surgical procedures aimed at treating diseases that are not amenable to other surgical therapies, and are reasonably anticipated to be susceptible to substantial placebo effects. If the standard nonsurgical treatment is efficacious and acceptable to the patient, then it must be offered as part of the study design. Conclusions Surgical placebo controls should be used only when no other trial design will yield the requisite data and should always be accompanied by a rigorous informed consent process and a careful consideration of the related risks and benefits. The recommended ethical guidelines were adopted as AMA ethics policy and are now incorporated in the AMA’s Code of Medical Ethics. PMID:11807373

A cross sectional study of surgical training among United Kingdom general practitioners with specialist interests in surgery.

PubMed

Ferguson, H J M; Fitzgerald, J E F; Reilly, J; Beamish, A J; Gokani, V J

2015-04-08

Increasing numbers of minor surgical procedures are being performed in the community. In the UK, general practitioners (family medicine physicians) with a specialist interest (GPwSI) in surgery frequently undertake them. This shift has caused decreases in available cases for junior surgeons to gain and consolidate operative skills. This study evaluated GPwSI's case-load, procedural training and perceptions of offering formalised operative training experience to surgical trainees. Prospective, questionnaire-based cross-sectional study. A novel, 13-item, self-administered questionnaire was distributed to members of the Association of Surgeons in Primary Care (ASPC). A total 113 of 120 ASPC members completed the questionnaire, representing a 94% response rate. Respondents were general practitioners practising or intending to practice surgery in the community. Respondents performed a mean of 38 (range 5-150) surgical procedures per month in primary care. 37% (42/113) of respondents had previously been awarded Membership or Fellowship of a Surgical Royal College; 22% (25/113) had completed a surgical certificate or diploma or undertaken a course of less than 1 year duration. 41% (46/113) had no formal British surgical qualifications. All respondents believed that surgical training in primary care could be valuable for surgical trainees, and the majority (71/113, 63%) felt that both general practice and surgical trainees could benefit equally from such training. There is a significant volume of surgical procedures being undertaken in the community by general practitioners, with the capacity and appetite for training of prospective surgeons in this setting, providing appropriate standards are achieved and maintained, commensurate with current standards in secondary care. Surgical experience and training of GPwSI's in surgery is highly varied, and does not yet benefit from the quality assurance secondary care surgical training in the UK undergoes. The Royal Colleges of Surgery and General Practice are well placed to invest in such infrastructure to provide long-term, high-quality service and training in the community. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Inter-rater reliability of surgical reviews for AREN03B2: a COG renal tumor committee study.

PubMed

Hamilton, Thomas E; Barnhart, Douglas; Gow, Kenneth; Ferrer, Fernando; Kandel, Jessica; Glick, Richard; Dasgupta, Roshni; Naranjo, Arlene; He, Ying; Gratias, Eric; Geller, James; Mullen, Elizabeth; Ehrlich, Peter

2014-01-01

The Children's Oncology Group (COG) renal tumor study (AREN03B2) requires real-time central review of radiology, pathology, and the surgical procedure to determine appropriate risk-based therapy. The purpose of this study was to determine the inter-rater reliability of the surgical reviews. Of the first 3200 enrolled AREN03B2 patients, a sample of 100 enriched for blood vessel involvement, spill, rupture, and lymph node involvement was selected for analysis. The surgical assessment was then performed independently by two blinded surgical reviewers and compared to the original assessment, which had been completed by another of the committee surgeons. Variables assessed included surgeon-determined local tumor stage, overall disease stage, type of renal procedure performed, presence of tumor rupture, occurrence of intraoperative tumor spill, blood vessel involvement, presence of peritoneal implants, and interpretation of residual disease. Inter-rater reliability was measured using the Fleiss' Kappa statistic two-sided hypothesis tests (Kappa, p-value). Local tumor stage correlated in all 3 reviews except in one case (Kappa=0.9775, p<0.001). Similarly, overall disease stage had excellent correlation (0.9422, p<0.001). There was strong correlation for type of renal procedure (0.8357, p<0.001), presence of tumor rupture (0.6858, p<0.001), intraoperative tumor spill (0.6493, p<0.001), and blood vessel involvement (0.6470, p<0.001). Variables that had lower correlation were determination of the presence of peritoneal implants (0.2753, p<0.001) and interpretation of residual disease status (0.5310, p<0.001). The inter-rater reliability of the surgical review is high based on the great consistency in the 3 independent review results. This analysis provides validation and establishes precedent for real-time central surgical review to determine treatment assignment in a risk-based stratagem for multimodal cancer therapy. © 2014.

Virtual reality based surgical assistance and training system for long duration space missions.

PubMed

Montgomery, K; Thonier, G; Stephanides, M; Schendel, S

2001-01-01

Access to medical care during long duration space missions is extremely important. Numerous unanticipated medical problems will need to be addressed promptly and efficiently. Although telemedicine provides a convenient tool for remote diagnosis and treatment, it is impractical due to the long delay between data transmission and reception to Earth. While a well-trained surgeon-internist-astronaut would be an essential addition to the crew, the vast number of potential medical problems necessitate instant access to computerized, skill-enhancing and diagnostic tools. A functional prototype of a virtual reality based surgical training and assistance tool was created at our center, using low-power, small, lightweight components that would be easy to transport on a space mission. The system consists of a tracked, head-mounted display, a computer system, and a number of tracked surgical instruments. The software provides a real-time surgical simulation system with integrated monitoring and information retrieval and a voice input/output subsystem. Initial medical content for the system has been created, comprising craniofacial, hand, inner ear, and general anatomy, as well as information on a number of surgical procedures and techniques. One surgical specialty in particular, microsurgery, was provided as a full simulation due to its long training requirements, significant impact on result due to experience, and likelihood for need. However, the system is easily adapted to realistically simulate a large number of other surgical procedures. By providing a general system for surgical simulation and assistance, the astronaut-surgeon can maintain their skills, acquire new specialty skills, and use tools for computer-based surgical planning and assistance to minimize overall crew and mission risk.

42 CFR 416.65 - Covered surgical procedures.

Code of Federal Regulations, 2014 CFR

2014-10-01

... surgical procedures require anesthesia, the anesthesia must be— (i) Local or regional anesthesia; or (ii) General anesthesia of 90 minutes or less duration. (3) Covered surgical procedures may not be of a type...

42 CFR 416.65 - Covered surgical procedures.

Code of Federal Regulations, 2012 CFR

2012-10-01

... surgical procedures require anesthesia, the anesthesia must be— (i) Local or regional anesthesia; or (ii) General anesthesia of 90 minutes or less duration. (3) Covered surgical procedures may not be of a type...

42 CFR 416.65 - Covered surgical procedures.

Code of Federal Regulations, 2013 CFR

2013-10-01

... surgical procedures require anesthesia, the anesthesia must be— (i) Local or regional anesthesia; or (ii) General anesthesia of 90 minutes or less duration. (3) Covered surgical procedures may not be of a type...

Comparative evaluation of stress levels before, during, and after periodontal surgical procedures with and without nitrous oxide-oxygen inhalation sedation.

PubMed

Sandhu, Gurkirat; Khinda, Paramjit Kaur; Gill, Amarjit Singh; Singh Khinda, Vineet Inder; Baghi, Kamal; Chahal, Gurparkash Singh

2017-01-01

Periodontal surgical procedures produce varying degree of stress in all patients. Nitrous oxide-oxygen inhalation sedation is very effective for adult patients with mild-to-moderate anxiety due to dental procedures and needle phobia. The present study was designed to perform periodontal surgical procedures under nitrous oxide-oxygen inhalation sedation and assess whether this technique actually reduces stress physiologically, in comparison to local anesthesia alone (LA) during lengthy periodontal surgical procedures. This was a randomized, split-mouth, cross-over study. A total of 16 patients were selected for this randomized, split-mouth, cross-over study. One surgical session (SS) was performed under local anesthesia aided by nitrous oxide-oxygen inhalation sedation, and the other SS was performed on the contralateral quadrant under LA. For each session, blood samples to measure and evaluate serum cortisol levels were obtained, and vital parameters including blood pressure, heart rate, respiratory rate, and arterial blood oxygen saturation were monitored before, during, and after periodontal surgical procedures. Paired t -test and repeated measure ANOVA. The findings of the present study revealed a statistically significant decrease in serum cortisol levels, blood pressure and pulse rate and a statistically significant increase in respiratory rate and arterial blood oxygen saturation during periodontal surgical procedures under nitrous oxide inhalation sedation. Nitrous oxide-oxygen inhalation sedation for periodontal surgical procedures is capable of reducing stress physiologically, in comparison to LA during lengthy periodontal surgical procedures.

Reducing infection risk in implant-based breast-reconstruction surgery: challenges and solutions

PubMed Central

Ooi, Adrian SH; Song, David H

2016-01-01

Implant-based procedures are the most commonly performed method for postmastectomy breast reconstruction. While donor-site morbidity is low, these procedures are associated with a higher risk of reconstructive loss. Many of these are related to infection of the implant, which can lead to prolonged antibiotic treatment, undesired additional surgical procedures, and unsatisfactory results. This review combines a summary of the recent literature regarding implant-related breast-reconstruction infections and combines this with a practical approach to the patient and surgery aimed at reducing this risk. Prevention of infection begins with appropriate reconstructive choice based on an assessment and optimization of risk factors. These include patient and disease characteristics, such as smoking, obesity, large breast size, and immediate reconstructive procedures, as well as adjuvant therapy, such as radiotherapy and chemotherapy. For implant-based breast reconstruction, preoperative planning and organization is key to reducing infection. A logical and consistent intraoperative and postoperative surgical protocol, including appropriate antibiotic choice, mastectomy-pocket creation, implant handling, and considered acellular dermal matrix use contribute toward the reduction of breast-implant infections. PMID:27621667

The positive impact of structured teaching in the operating room.

PubMed

Leung, Yee; Salfinger, Stuart; Mercer, Annette

2015-12-01

A survey of obstetric and gynaecology trainees in Australia found the trainee's opinion of the consultants' teaching ability for laparoscopic procedures and procedures dealing with complications as 'poor' in 21.2% and 23.4% of responses, respectively (Aust NZ J Obstet Gynaecol 2009; 49: 84). Surgical caseload per trainee is falling for a variety of reasons. Strategies need to be adopted to enhance the surgical learning experience of trainees in the operating room. We describe the use of a structured encounter template to facilitate the teaching of surgery in the operating room and report the response of the trainees to this intervention. Trainees attached to a gynaecologic surgery unit all underwent surgical training using a set format based on the surgical encounter template, including briefing, goal setting and intra-operative teaching aims as well as debriefing. Data on the trainees' experience and perception of their learning experience were then collected and analysed as quantitative and qualitative data sets. The trainees reported satisfaction with the use of a structured encounter template to facilitate the surgical teaching in the operating room. Some trainees had not received such clarity of feedback or the opportunity to complete a procedure independently prior to using the structured encounter template. A structured surgical encounter template based on andragogy principles to focus consultant teaching in the operating room is highly acceptable to obstetric and gynaecology trainees in Australia. Allowing the trainee the opportunity to set objectives and receive feedback empowers the trainee and enhances their educational experience. © 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

A Web Terminology Server Using UMLS for the Description of Medical Procedures

PubMed Central

Burgun, Anita; Denier, Patrick; Bodenreider, Olivier; Botti, Geneviève; Delamarre, Denis; Pouliquen, Bruno; Oberlin, Philippe; Lévéque, Jean M.; Lukacs, Bertrand; Kohler, François; Fieschi, Marius; Le Beux, Pierre

1997-01-01

Abstract The Model for Assistance in the Orientation of a User within Coding Systems (MAOUSSC) project has been designed to provide a representation for medical and surgical procedures that allows several applications to be developed from several viewpoints. It is based on a conceptual model, a controlled set of terms, and Web server development. The design includes the UMLS knowledge sources associated with additional knowledge about medico-surgical procedures. The model was implemented using a relational database. The authors developed a complete interface for the Web presentation, with the intermediary layer being written in PERL. The server has been used for the representation of medico-surgical procedures that occur in the discharge summaries of the national survey of hospital activities that is performed by the French Health Statistics Agency in order to produce inpatient profiles. The authors describe the current status of the MAOUSSC server and discuss their interest in using such a server to assist in the coordination of terminology tasks and in the sharing of controlled terminologies. PMID:9292841

Surgical task-shifting in a low-resource setting: outcomes after major surgery performed by nonphysician clinicians in Tanzania.

PubMed

Beard, Jessica H; Oresanya, Lawrence B; Akoko, Larry; Mwanga, Ally; Mkony, Charles A; Dicker, Rochelle A

2014-06-01

Little is known about the breadth and quality of nonobstetric surgical care delivered by nonphysician clinicians (NPCs) in low-resource settings. We aimed to document the scope of NPC surgical practice and characterize outcomes after major surgery performed by nonphysicians in Tanzania. A retrospective records review of major surgical procedures (MSPs) performed in 2012 was conducted at seven hospitals in Pwani Region, Tanzania. Patient and procedure characteristics and level of surgical care provider were documented for each procedure. Rates of postoperative morbidity and mortality after nonobstetric MSPs performed by NPCs and physicians were compared using multivariate logistic regression. There were 6.5 surgical care providers per 100,000 population performing a mean rate of 461 procedures per 100,000 population during the study period. Of these cases, 1,698 (34.7 %) were nonobstetric MSPs. NPCs performed 55.8 % of nonobstetric MSPs followed by surgical specialists (28.7 %) and medical officers (15.5 %). The most common nonobstetric MSPs performed by NPCs were elective groin hernia repair, prostatectomy, exploratory laparotomy, and hydrocelectomy. Postoperative mortality was 1.7 % and 1.5 % in cases done by NPCs and physicians respectively. There was no significant difference in outcomes after procedures performed by NPCs compared with physicians. Surgical output is low and the workforce is limited in Tanzania. NPCs performed the majority of major surgical procedures during the study period. Outcomes after nonobstetric major surgical procedures done by NPCs and physicians were similar. Task-shifting of surgical care to nonphysicians may be a safe and sustainable way to address the global surgical workforce crisis.

Synframe: a preliminary report.

PubMed

Aebi, M; Steffen, T

2000-02-01

Both endoscopic lumbar spinal surgery and the non-standardized and unstable retractor systems for the lumbar spine presently on the market have disadvantages and limitations in relation to the minimally invasive surgical concept, which have been gradually recognized in the last few years. In an attempt to resolve some of these issues, we have developed a highly versatile retractor system, which allows access to and surgery at the lumbar, thoracic and even cervical spine. This retractor system - Synframe - is based on a ring concept allowing 360 degrees access to a surgical opening in anterior as well as posterior surgery. The ring is concentrically laid over the surgical opening for the approach and is used as a carrier for retractor arms, which are instrumented with either different sizes or types of blades and/or different sizes of Hohmann hooks. In posterior surgery, nerve root retractors can also be installed. This ring also functions as a carrier for fiberoptic illumination devices and different sizes of endoscopes, used to transmit the surgical procedure out of the depth of the surgical exposure for both teaching purposes and for the surgical team when it has no longer direct visual access to the procedure. The ring is stable, being fixed onto the operating table, allowing precise minimally open approaches and surgical procedures under direct vision with optimal illumination. This ring system also opens perspectives for an integrated minimally open surgical concept, where the ring may be used as a reference platform in computer-navigated surgery.

Discharges with surgical procedures performed less often than once per month per hospital account for two-thirds of hospital costs of inpatient surgery.

PubMed

O'Neill, Liam; Dexter, Franklin; Park, Sae-Hwan; Epstein, Richard H

2017-09-01

Most surgical discharges (54%) at the average hospital are for procedures performed no more often than once per month at that hospital. We hypothesized that such uncommon procedures would be associated with an even greater percentage of the total cost of performing all surgical procedures at that hospital. Observational study. State of Texas hospital discharge abstract data: 4th quarter of 2015 and 1st quarter of 2016. Inpatients discharged with a major therapeutic ("operative") procedure. For each of N=343 hospitals, counts of discharges, sums of lengths of stay (LOS), sums of diagnosis related group (DRG) case-mix weights, and sums of charges were obtained for each procedure or combination of procedures, classified by International Classification of Diseases version 10 Procedure Coding System (ICD-10-PCS). Each discharge was classified into 2 categories, uncommon versus not, defined as a procedure performed at most once per month versus those performed more often than once per month. Major procedures performed at most once per month per hospital accounted for an average among hospitals of 68% of the total inpatient costs associated with all major therapeutic procedures. On average, the percentage of total costs associated with uncommon procedures was 26% greater than expected based on their share of total discharges (P<0.00001). Average percentage differences were insensitive to the endpoint, with similar results for the percentage of patient days and percentage of DRG case-mix weights. Approximately 2/3rd (mean 68%) of inpatient costs among surgical patients can be attributed to procedures performed at most once per month per hospital. The finding that such uncommon procedures account for a large percentage of costs is important because methods of cost accounting by procedure are generally unsuitable for them. Copyright © 2017 Elsevier Inc. All rights reserved.

Surgically assisted rapid palatal expansion. An acoustic rhinometric, morphometric and sonographic investigation.

PubMed

Wriedt, S; Kunkel, M; Zentner, A; Wahlmann, U W

2001-03-01

This study aimed to evaluate the effect of surgically assisted rapid palatal expansion on the skeletal structures of the midface. Ten patients (mean age 28.5 years) were investigated by means of acoustic rhinometry, study model analysis and sonography before and after the procedure of surgically assisted rapid palatal expansion. The measurements revealed that surgically assisted rapid palatal expansion not only resulted in transverse expansion of the maxilla, providing dental arch space for lining up the teeth; the procedure also caused a substantial enlargement of the maxillary apical base and of the palatal vault, providing space for the tongue for correct swallowing and thus preventing relapse. There was a distinct subjective improvement in nasal breathing associated with enlargement of the nasal valve towards normal values and with an increase of nasal volume in all compartments. The measurements showed a marked influence of surgically assisted rapid palatal expansion on the skeletal structures of the midface. The significant widening can be demonstrated by non-invasive examination. Success of the osteotomy procedure can be readily monitored by sonographic examination of the expansion and the subsequent ossification, which allows individually adjusted retention periods and avoids frequent radiation exposure.

Temporal bone dissection simulator for training pediatric otolaryngology surgeons

NASA Astrophysics Data System (ADS)

Tabrizi, Pooneh R.; Sang, Hongqiang; Talari, Hadi F.; Preciado, Diego; Monfaredi, Reza; Reilly, Brian; Arikatla, Sreekanth; Enquobahrie, Andinet; Cleary, Kevin

2017-03-01

Cochlear implantation is the standard of care for infants born with severe hearing loss. Current guidelines approve the surgical placement of implants as early as 12 months of age. Implantation at a younger age poses a greater surgical challenge since the underdeveloped mastoid tip, along with thin calvarial bone, creates less room for surgical navigation and can result in increased surgical risk. We have been developing a temporal bone dissection simulator based on actual clinical cases for training otolaryngology fellows in this delicate procedure. The simulator system is based on pre-procedure CT (Computed Tomography) images from pediatric infant cases (<12 months old) at our hospital. The simulator includes: (1) simulation engine to provide the virtual reality of the temporal bone surgery environment, (2) a newly developed haptic interface for holding the surgical drill, (3) an Oculus Rift to provide a microscopic-like view of the temporal bone surgery, and (4) user interface to interact with the simulator through the Oculus Rift and the haptic device. To evaluate the system, we have collected 10 representative CT data sets and segmented the key structures: cochlea, round window, facial nerve, and ossicles. The simulator will present these key structures to the user and warn the user if needed by continuously calculating the distances between the tip of surgical drill and the key structures.

Self-reported "worth it" rating of aesthetic surgery in social media.

PubMed

Domanski, Mark C; Cavale, Naveen

2012-12-01

A wide variety of surveys have been used to validate the satisfaction of patients who underwent aesthetic surgery. However, such studies are often limited by patient number and number of surgeons. Social media now allows patients, on a large scale, to discuss and rate their satisfaction with procedures. The views of aesthetic procedures patients expressed in social media provide unique insight into patient satisfaction. The "worth it" percentage, average cost, and number of respondents were recorded on October 16, 2011, for all topics evaluated on the aesthetic procedure social media site www.realself.com . Procedures were divided into categories: surgical, liposuction, nonsurgical, and dental. For each group, procedures with the most respondents were chosen and ordered by "worth it" score. A literature search was performed for the most commonly rated surgical procedures and the satisfaction rates were compared. A total of 16,949 evaluations of 159 aesthetic surgery topics were recorded. A correlation between cost of the procedure and percentage of respondents indicating that the procedure was "worth it" was not found. The highest-rated surgical procedure was abdominoplasty, with 93 % of the 1,589 self-selected respondents expressing that abdominoplasty was "worth it." The average self-reported cost was $8,400. The highest-rated nonsurgical product was Latisse, with 85 % of 231 respondents reporting it was "worth it" for an average cost of $200. The satisfaction scores in the literature for commonly rated surgical procedures ranged from 62 to 97.6 %. No statistically significant correlations between literature satisfaction scores and realself.com "worth it" scores were found. Abdominoplasty had the highest "worth it" rating among aesthetic surgical procedures. Aesthetic surgeons should be wary that satisfaction scores reported in the literature might not correlate with commonly achieved results. Social media has opened a new door into how procedures are evaluated and perceived. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266 .

Systematic reviews of surgical procedures in children: quantity, coverage and quality.

PubMed

McGee, Richard G; Craig, Jonathan C; Rogerson, Thomas E; Webster, Angela C

2013-04-01

Systematic reviews have the potential to map those areas where children are under-represented in surgical research. We aimed to describe and evaluate the quantity, coverage and the quality of conduct and reporting of systematic reviews of surgical procedures in children. We searched four biomedical databases, a systematic review register, reference lists and conducted hand searching to identify relevant reviews. Two reviewers worked independently to critically appraise included studies and abstract data. We assessed reporting quality using the preferred reporting items for systematic reviews and meta-analysis statement and methodological quality using the Assessment of Multiple SysTemAtic Reviews tool. Fifteen systematic reviews were identified, representing 0.01% of all paediatric surgical citations in MEDLINE and Embase. Thirteen of the reviews were Cochrane reviews, and most reviews (12/15) addressed subspecialty interests such as otorhinolaryngology. The median number of included trials per systematic review was four (interquartile range 1 to 9.5), the median number of primary outcomes was 5.5 (interquartile range 3.5 to 7.5). In general, reporting and methodological quality was good although there were several omissions, particularly around completeness of reporting of statistical methods used, and utilisation of quality assessments in analyses. Outcomes were often not clearly defined and descriptions of procedures lacked sufficient detail to determine the similarities and differences among surgical procedures within the contributing trials. Systematic reviews of surgical procedures in children are rarely published. To improve the evidence base and guide research agendas, more systematic reviews should be conducted, using standard guidelines for conduct and reporting. © 2013 The Authors. Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Safe teleoperation based on flexible intraoperative planning for robot-assisted laser microsurgery.

PubMed

Mattos, Leonardo S; Caldwell, Darwin G

2012-01-01

This paper describes a new intraoperative planning system created to improve precision and safety in teleoperated laser microsurgeries. It addresses major safety issues related to real-time control of a surgical laser during teleoperated procedures, which are related to the reliability and robustness of the telecommunication channels. Here, a safe solution is presented, consisting in a new planning system architecture that maintains the flexibility and benefits of real-time teleoperation and keeps the surgeon in control of all surgical actions. The developed system is based on our virtual scalpel system for robot-assisted laser microsurgery, and allows the intuitive use of stylus to create surgical plans directly over live video of the surgical field. In this case, surgical plans are defined as graphic objects overlaid on the live video, which can be easily modified or replaced as needed, and which are transmitted to the main surgical system controller for subsequent safe execution. In the process of improving safety, this new planning system also resulted in improved laser aiming precision and improved capability for higher quality laser procedures, both due to the new surgical plan execution module, which allows very fast and precise laser aiming control. Experimental results presented herein show that, in addition to the safety improvements, the new planning system resulted in a 48% improvement in laser aiming precision when compared to the previous virtual scalpel system.

Otoplasty: sequencing the operation for improved results.

PubMed

Hoehn, James G; Ashruf, Salman

2005-01-01

: After studying this article, the participant should be able to: 1. Understand the anatomy and embryology of the external ear. 2. Understand the anatomic causes of the prominent ear. 3. Understand the operative maneuvers used to shape the external ear. 4. Be able to sequence the otoplasty for consistent results. 5. Understand the possible complications of the otoplasty procedure. Correction of prominent ears is a common plastic surgical procedure. Proper execution of the surgical techniques is dependent on the surgeon's understanding of the surgical procedure. This understanding is best founded on an understanding of the historical bases for the operative steps and the execution of these operative steps in a logical fashion. This article describes the concept of sequencing the operation of otoplasty to produce predictable results combining the technical contributions from many authors. The historical, embryological, and anatomic bases for the operation are also discussed. Finally, the authors' preferred techniques are presented. Sequencing the steps in the preoperative assessment, preoperative planning, patient management, operative technique, and postoperative care will produce reproducible results for the attentive surgeon. Careful attention to the details of the operation of otoplasty will avoid many postoperative problems.

Postparalysis Facial Synkinesis: Clinical Classification and Surgical Strategies

PubMed Central

Chang, Tommy Nai-Jen; Lu, Johnny Chuieng-Yi

2015-01-01

Background: Postparalysis facial synkinesis (PPFS) can occur after any cause of facial palsy. Current treatments are still inadequate. Surgical intervention, instead of Botox and rehabilitation only, for different degrees of PPFS was proposed. Methods: Seventy patients (43 females and 27 males) with PPFS were enrolled since 1986. They were divided into 4 patterns based on quality of smile and severity of synkinesis. Data collection for clinically various presentations was made: pattern I (n = 14) with good smile but synkinesis, pattern II (n = 17) with acceptable smile but dominant synkinesis, pattern III (n = 34) unacceptable smile and dominant synkinesis, and pattern IV (n = 5) poor smile and synkinesis. Surgical interventions were based on patterns of PPFS. Selective myectomy and some cosmetic procedures were performed for pattern I and II patients. Extensive myectomy and neurectomy of the involved muscles and nerves followed by functioning free-muscle transplantation for facial reanimation in 1- or 2-stage procedure were performed for pattern III and many pattern II patients. A classic 2-stage procedure for facial reanimation was performed for pattern IV patients. Results: Minor aesthetic procedures provided some help to pattern I patients but did not cure the problem. They all had short follow-up. Most patients in patterns II (14/17, 82%) and III (34/34, 100%) showed a significant improvement of eye and smile appearance and significant decrease in synkinetic movements following the aggressively major surgical intervention. Nearly, all of the patients treated by the authors did not need repeated botulinum toxin A injection nor require a profound rehabilitation program in the follow-up period. Conclusions: Treatment of PPFS remains a challenging problem. Major surgical reconstruction showed more promising and long-lasting results than botulinum toxin A and/or rehabilitation on pattern III and II patients. PMID:25878931

Safety and efficacy of noncardiac surgical procedures in the management of patients with trisomy 13: A single institution-based detailed clinical observation.

PubMed

Shibuya, Soichi; Miyake, Yuichiro; Takamizawa, Shigeru; Nishi, Eriko; Yoshizawa, Katsumi; Hatata, Tomoko; Yoshizawa, Kazuki; Fujita, Kenya; Noguchi, Masahiko; Ohata, Jun; Hiroma, Takehiko; Nakamura, Tomohiko; Kosho, Tomoki

2018-05-01

Intensive treatment including surgery for patients with trisomy 13 (T13) remains controversial. This study aimed to evaluate the safety and efficacy of noncardiac surgical intervention for T13 patients. Medical records of patients with karyotypically confirmed T13 treated in the neonatal intensive care unit in Nagano Children's Hospital from January 2000 to October 2016 were retrospectively reviewed, and data from patients who underwent noncardiac surgery were analyzed. Of the 20 patients with T13, 15 (75%) underwent a total of 31 surgical procedures comprising 15 types, including tracheostomy in 10 patients and gastrostomy in 4. Operative time, anesthesia time, and amount of bleeding are described for the first time in a group of children with T13. All the procedures were completed safely with no anesthetic complications or surgery-related death. The overall rate of postoperative complications was 19.3%. Patients receiving tracheostomy had stable or improved respiratory condition. Six of them were discharged home and were alive at the time of this study. These results suggest at least short-term safety and efficacy of major noncardiac surgical procedures, and long-term efficacy of tracheostomy on survival or respiratory stabilization for home medical care of children with T13. Noncardiac surgical intervention is a reasonable choice for patients with T13. © 2018 Wiley Periodicals, Inc.

Estimating Surgical Procedure Times Using Anesthesia Billing Data and Operating Room Records.

PubMed

Burgette, Lane F; Mulcahy, Andrew W; Mehrotra, Ateev; Ruder, Teague; Wynn, Barbara O

2017-02-01

The median time required to perform a surgical procedure is important in determining payment under Medicare's physician fee schedule. Prior studies have demonstrated that the current methodology of using physician surveys to determine surgical times results in overstated times. To measure surgical times more accurately, we developed and validated a methodology using available data from anesthesia billing data and operating room (OR) records. We estimated surgical times using Medicare 2011 anesthesia claims and New York Statewide Planning and Research Cooperative System 2011 OR times. Estimated times were validated using data from the National Surgical Quality Improvement Program. We compared our time estimates to those used by Medicare in the fee schedule. We estimate surgical times via piecewise linear median regression models. Using 3.0 million observations of anesthesia and OR times, we estimated surgical time for 921 procedures. Correlation between these time estimates and directly measured surgical time from the validation database was 0.98. Our estimates of surgical time were shorter than the Medicare fee schedule estimates for 78 percent of procedures. Anesthesia and OR times can be used to measure surgical time and thereby improve the payment for surgical procedures in the Medicare fee schedule. © Health Research and Educational Trust.

Burr Hole Washout versus Craniotomy for Chronic Subdural Hematoma: Patient Outcome and Cost Analysis

PubMed Central

Regan, Jacqueline M.; Worley, Emmagene; Shelburne, Christopher; Pullarkat, Ranjit; Watson, Joseph C.

2015-01-01

Chronic subdural hematomas (CSDH), which are frequently encountered in neurosurgical practice, are, in the majority of cases, ideally treated with surgical drainage. Despite this common practice, there is still controversy surrounding the best surgical procedure. With lack of clear evidence of a superior technique, surgeons are free to base the decision on other factors that are not related to patient care. A retrospective chart review of 119 patients requiring surgical drainage of CSDH was conducted at a large tertiary care center over a three-year period. Of the cases reviewed, 58 patients underwent craniotomy, while 61 patients underwent burr hole washout. The study focused on re-operation rates, mortality, and morbidity, as measured by Glasgow coma scores (GCS), discharge Rankin disability scores, and discharge disposition. Secondary endpoints included length of stay and cost of procedure. Burr hole washout was superior to craniotomy with respect to patient outcome, length of stay and recurrence rates. In both study groups, patients required additional surgical procedures (6.6% of burr hole patients and 24.1% of craniotomy patients) (P = 0.0156). Of the patients treated with craniotomy, 51.7% were discharged home, whereas 65.6% of the burr hole patients were discharged home. Patients who underwent burr hole washout spent a mean of 78.8 minutes in the operating suite while the patients undergoing craniotomy spent 129.4 minutes (P < 0.001). The difference in mean cost per patient, based solely on operating time, was $2,828 (P < 0.001). This does not include the further cost due to additional procedures and hospital stay. The mean length of stay after surgical intervention was 3 days longer for the craniotomy group (P = 0.0465). Based on this retrospective study, burr hole washout is superior for both patients’ clinical and financial outcome; however, prospective long-term multicenter clinical studies are required to verify these findings. PMID:25611468

Burr hole washout versus craniotomy for chronic subdural hematoma: patient outcome and cost analysis.

PubMed

Regan, Jacqueline M; Worley, Emmagene; Shelburne, Christopher; Pullarkat, Ranjit; Watson, Joseph C

2015-01-01

Chronic subdural hematomas (CSDH), which are frequently encountered in neurosurgical practice, are, in the majority of cases, ideally treated with surgical drainage. Despite this common practice, there is still controversy surrounding the best surgical procedure. With lack of clear evidence of a superior technique, surgeons are free to base the decision on other factors that are not related to patient care. A retrospective chart review of 119 patients requiring surgical drainage of CSDH was conducted at a large tertiary care center over a three-year period. Of the cases reviewed, 58 patients underwent craniotomy, while 61 patients underwent burr hole washout. The study focused on re-operation rates, mortality, and morbidity, as measured by Glasgow coma scores (GCS), discharge Rankin disability scores, and discharge disposition. Secondary endpoints included length of stay and cost of procedure. Burr hole washout was superior to craniotomy with respect to patient outcome, length of stay and recurrence rates. In both study groups, patients required additional surgical procedures (6.6% of burr hole patients and 24.1% of craniotomy patients) (P = 0.0156). Of the patients treated with craniotomy, 51.7% were discharged home, whereas 65.6% of the burr hole patients were discharged home. Patients who underwent burr hole washout spent a mean of 78.8 minutes in the operating suite while the patients undergoing craniotomy spent 129.4 minutes (P < 0.001). The difference in mean cost per patient, based solely on operating time, was $2,828 (P < 0.001). This does not include the further cost due to additional procedures and hospital stay. The mean length of stay after surgical intervention was 3 days longer for the craniotomy group (P = 0.0465). Based on this retrospective study, burr hole washout is superior for both patients' clinical and financial outcome; however, prospective long-term multicenter clinical studies are required to verify these findings.

Comparative evaluation of stress levels before, during, and after periodontal surgical procedures with and without nitrous oxide-oxygen inhalation sedation

PubMed Central

Sandhu, Gurkirat; Khinda, Paramjit Kaur; Gill, Amarjit Singh; Singh Khinda, Vineet Inder; Baghi, Kamal; Chahal, Gurparkash Singh

2017-01-01

Context: Periodontal surgical procedures produce varying degree of stress in all patients. Nitrous oxide-oxygen inhalation sedation is very effective for adult patients with mild-to-moderate anxiety due to dental procedures and needle phobia. Aim: The present study was designed to perform periodontal surgical procedures under nitrous oxide-oxygen inhalation sedation and assess whether this technique actually reduces stress physiologically, in comparison to local anesthesia alone (LA) during lengthy periodontal surgical procedures. Settings and Design: This was a randomized, split-mouth, cross-over study. Materials and Methods: A total of 16 patients were selected for this randomized, split-mouth, cross-over study. One surgical session (SS) was performed under local anesthesia aided by nitrous oxide-oxygen inhalation sedation, and the other SS was performed on the contralateral quadrant under LA. For each session, blood samples to measure and evaluate serum cortisol levels were obtained, and vital parameters including blood pressure, heart rate, respiratory rate, and arterial blood oxygen saturation were monitored before, during, and after periodontal surgical procedures. Statistical Analysis Used: Paired t-test and repeated measure ANOVA. Results: The findings of the present study revealed a statistically significant decrease in serum cortisol levels, blood pressure and pulse rate and a statistically significant increase in respiratory rate and arterial blood oxygen saturation during periodontal surgical procedures under nitrous oxide inhalation sedation. Conclusion: Nitrous oxide-oxygen inhalation sedation for periodontal surgical procedures is capable of reducing stress physiologically, in comparison to LA during lengthy periodontal surgical procedures. PMID:29386796

Hands-On Surgical Training Workshop: an Active Role-Playing Patient Education for Adolescents.

PubMed

Wongkietkachorn, Apinut; Boonyawong, Pangpoom; Rhunsiri, Peera; Tantiphlachiva, Kasaya

2017-09-01

Most patient education involves passive learning. To improve patient education regarding surgery, an active learning workshop-based teaching method is proposed. The objective of this study was to assess level of patient surgical knowledge, achievement of workshop learning objectives, patient apprehension about future surgery, and participant workshop satisfaction after completing a surgical training workshop. A four-station workshop (surgical scrub, surgical suture, laparoscopic surgery, and robotic surgery) was developed to teach four important components of the surgical process. Healthy, surgery-naive adolescents were enrolled to attend this 1-h workshop-based training program. Training received by participants was technically and procedurally identical to training received by actual surgeons. Pre- and post-workshop questionnaires were used to assess learning outcomes. There were 1312 participants, with a mean age 15.9 ± 1.1 years and a gender breakdown of 303 males and 1009 females. For surgical knowledge, mean pre-workshop and post-workshop scores were 6.1 ± 1.5 and 7.5 ± 1.5 (out of 10 points), respectively (p < 0.001). Out of 5 possible points, achievement of learning objectives, decreased apprehension about future surgery, and overall workshop satisfaction scores were all higher than 4.5. Active, hands-on patient education is an effective way to improve understanding of surgery-related processes. This teaching method may also decrease apprehension that patients or potential patients harbor regarding a future surgical procedure.

Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires : A Systematic Review of Surgical Never Events.

PubMed

Hempel, Susanne; Maggard-Gibbons, Melinda; Nguyen, David K; Dawes, Aaron J; Miake-Lye, Isomi; Beroes, Jessica M; Booth, Marika J; Miles, Jeremy N V; Shanman, Roberta; Shekelle, Paul G

2015-08-01

Serious, preventable surgical events, termed never events, continue to occur despite considerable patient safety efforts. To examine the incidence and root causes of and interventions to prevent wrong-site surgery, retained surgical items, and surgical fires in the era after the implementation of the Universal Protocol in 2004. We searched 9 electronic databases for entries from 2004 through June 30, 2014, screened references, and consulted experts. Two independent reviewers identified relevant publications in June 2014. One reviewer used a standardized form to extract data and a second reviewer checked the data. Strength of evidence was established by the review team. Data extraction was completed in January 2015. Incidence of wrong-site surgery, retained surgical items, and surgical fires. We found 138 empirical studies that met our inclusion criteria. Incidence estimates for wrong-site surgery in US settings varied by data source and procedure (median estimate, 0.09 events per 10,000 surgical procedures). The median estimate for retained surgical items was 1.32 events per 10,000 procedures, but estimates varied by item and procedure. The per-procedure surgical fire incidence is unknown. A frequently reported root cause was inadequate communication. Methodologic challenges associated with investigating changes in rare events limit the conclusions of 78 intervention evaluations. Limited evidence supported the Universal Protocol (5 studies), education (4 studies), and team training (4 studies) interventions to prevent wrong-site surgery. Limited evidence exists to prevent retained surgical items by using data-matrix-coded sponge-counting systems (5 pertinent studies). Evidence for preventing surgical fires was insufficient, and intervention effects were not estimable. Current estimates for wrong-site surgery and retained surgical items are 1 event per 100,000 and 1 event per 10,000 procedures, respectively, but the precision is uncertain, and the per-procedure prevalence of surgical fires is not known. Root-cause analyses suggest the need for improved communication. Despite promising approaches and global Universal Protocol evaluations, empirical evidence for interventions is limited.

Preoperative surgical rehearsal using cadaveric fresh tissue surgical simulation increases resident operative confidence.

PubMed

Weber, Erin L; Leland, Hyuma A; Azadgoli, Beina; Minneti, Michael; Carey, Joseph N

2017-08-01

Rehearsal is an essential part of mastering any technical skill. The efficacy of surgical rehearsal is currently limited by low fidelity simulation models. Fresh cadaver models, however, offer maximal surgical simulation. We hypothesize that preoperative surgical rehearsal using fresh tissue surgical simulation will improve resident confidence and serve as an important adjunct to current training methods. Preoperative rehearsal of surgical procedures was performed by plastic surgery residents using fresh cadavers in a simulated operative environment. Rehearsal was designed to mimic the clinical operation, complete with a surgical technician to assist. A retrospective, web-based survey was used to assess resident perception of pre- and post-procedure confidence, preparation, technique, speed, safety, and anatomical knowledge on a 5-point scale (1= not confident, 5= very confident). Twenty-six rehearsals were performed by 9 residents (PGY 1-7) an average of 4.7±2.1 days prior to performance of the scheduled operation. Surveys demonstrated a median pre-simulation confidence score of 2 and a post-rehearsal score of 4 (P<0.01). The perceived improvement in confidence and performance was greatest when simulation was performed within 3 days of the scheduled case. All residents felt that cadaveric simulation was better than standard preparation methods of self-directed reading or discussion with other surgeons. All residents believed that their technique, speed, safety, and anatomical knowledge improved as a result of simulation. Fresh tissue-based preoperative surgical rehearsal was effectively implemented in the residency program. Resident confidence and perception of technique improved. Survey results suggest that cadaveric simulation is beneficial for all levels of residents. We believe that implementation of preoperative surgical rehearsal is an effective adjunct to surgical training at all skill levels in the current environment of decreased work hours.

Consumer Choice Between Hospital-Based and Freestanding Facilities for Arthroscopy

PubMed Central

Robinson, James C.; Brown, Timothy T.; Whaley, Christopher; Bozic, Kevin J.

2015-01-01

Background: Hospital-based outpatient departments traditionally charge higher prices for ambulatory procedures, compared with freestanding surgery centers. Under emerging reference-based benefit designs, insurers establish a contribution limit that they will pay, requiring the patient to pay the difference between that contribution limit and the actual price charged by the facility. The purpose of this study was to evaluate the impact of reference-based benefits on consumer choices, facility prices, employer spending, and surgical outcomes for orthopaedic procedures performed at ambulatory surgery centers. Methods: We obtained data on 3962 patients covered by the California Public Employees’ Retirement System (CalPERS) who underwent arthroscopy of the knee or shoulder in the three years prior to the implementation of reference-based benefits in January 2012 and on 2505 patients covered by CalPERS who underwent arthroscopy in the two years after implementation. Control group data were obtained on 57,791 patients who underwent arthroscopy and were not subject to reference-based benefits. The impact of reference-based benefits on consumer choices between hospital-based and freestanding facilities, facility prices, employer spending, and surgical complications was assessed with use of difference-in-differences multivariable regressions to adjust for patient demographic characteristics, comorbidities, and geographic location. Results: By the second year of the program, the shift to reference-based benefits was associated with an increase in the utilization of freestanding ambulatory surgery centers by 14.3 percentage points (95% confidence interval, 8.1 to 20.5 percentage points) for knee arthroscopy and by 9.9 percentage points (95% confidence interval, 3.2 to 16.7 percentage points) for shoulder arthroscopy and a corresponding decrease in the use of hospital-based facilities. The mean price paid by CalPERS fell by 17.6% (95% confidence interval, −24.9% to −9.6%) for knee procedures and by 17.0% (95% confidence interval, −29.3% to −2.5%) for shoulder procedures. The shift to reference-based benefits was not associated with a change in the rate of surgical complications. In the first two years after the implementation of reference-based benefits, CalPERS saved $2.3 million (13%) on these two orthopaedic procedures. Conclusions: Reference-based benefits increase consumer sensitivity to price differences between freestanding and hospital-based surgical facilities. Clinical Relevance: This study shows that the implementation of reference-based benefits does not result in a significant increase in measured complication rates for those subject to reference-based benefits. PMID:26378263

Demographics of patients affected by surgical disease in rural hospitals in two sub-Saharan African countries: a retrospective analysis.

PubMed

Grimes, Caris E; Billingsley, Michael L; Dare, Anna J; Day, Nigel; Mabey, Imogen; Naraghi, Sara; George, Peter M; Murowa, Michael; Kamara, Thaim B; Mkandawire, Nyengo C; Leather, Andy; Lavy, Christopher B D

2015-04-27

Awareness is growing of both the importance of surgical disease as a major cause of death and disability in low-income and middle-income countries (LMICs) and the cost-effectiveness of fairly simple surgical interventions. We hypothesised that surgical disease predominantly affects young adults and is therefore significant in both the macroeconomic effect of untreated disease and the microeconomic effects on patients and families in low-resource settings. We retrospectively reviewed all admission data from two rural government district hospitals, Bo District Hospital in Sierra Leone and Thyolo District Hospital in Malawi. Both hospitals serve a rural population of roughly 600 000. We analysed data from 3 months in the wet season and 3 months in the dry season for each hospital by careful analysis of all hospital logbook data. For the purposes of this study, a surgical diagnosis was defined as a diagnosis in which the patient should be managed by a surgically trained provider. We analysed all surgical admissions with respect to patient demographics (age and sex), diagnoses, and the procedures undertaken. In Thyolo, 835 (12·9%) of 6481 hospital admissions were surgical admissions. In Bo, 427 (19·8%) of 2152 hospital admissions were surgical admissions. In Thyolo, if all patients who had undergone a procedure in theatre were admitted overnight, the total number of admissions would have been 6931, with 1344 (19·4%) hospital admissions being surgical and 1282 (18·5%) hospital patients requiring a surgical procedure. In Bo, 133 patients underwent a surgical procedure. This corresponded to 6·18% of all hospital admissions; although notably many of the obstetric admissions were referred to a nearby Médecins Sans Frontières (MSF) hospital for treatment. Analysis of the admission data showed that younger than 16-year-olds accounted for 10·5% of surgical admissions in Bo, and 17·9% of surgical admissions in Thyolo. 16-35-year-olds accounted for 57·3% of all surgical admissions in Bo and 53·5% of all surgical admissions in Thyolo. Men accounted for 53·7% of surgical admissions in Bo and 46·0% of surgical admissions in Thyolo. Analysis of the procedure data showed that younger than 16-year-olds accounted for 7·0% of procedures in Bo and 4·5% of procedures in Thyolo, with 16-35-year-olds accounting for 65·6% of all procedures in Bo and 84·4% of all procedures in Thyolo. Men underwent 63% of all surgical procedures in Bo, but only 7·7% of surgical procedures in Thyolo. This discrepancy is explained by the high rate of maternal surgery in Thyolo, which was not present in Bo because this service was provided at the nearby MSF hospital. Most people affected by disease requiring surgery are young adults. It would be expected that failure to provide surgical care could have long-term adverse effects on both individual and national wealth. The Sir Ratanji Dalal Scholarship from the Royal College of Surgeons of England. Copyright © 2015 Elsevier Ltd. All rights reserved.

Surgical procedures in liver transplant patients: A monocentric retrospective cohort study.

PubMed

Sommacale, Daniele; Nagarajan, Ganesh; Lhuaire, Martin; Dondero, Federica; Pessaux, Patrick; Piardi, Tullio; Sauvanet, Alain; Kianmanesh, Reza; Belghiti, Jacques

2017-05-01

Pre-existing chronic liver diseases and the complexity of the transplant surgery procedures lead to a greater risk of further surgery in transplanted patients compared to the general population. The aim of this monocentric retrospective cohort study was to assess the epidemiology of surgical complications in liver transplanted patients who require further surgical procedures and to characterize their post-operative risk of complications to enhance their medical care. From January 1997 to December 2011, 1211 patients underwent orthotropic liver transplantation in our center. A retrospective analysis of prospectively collected data was performed considering patients who underwent surgical procedures more than three months after transplantation. We recorded liver transplantation technique, type of surgery, post-operative complications, time since the liver transplant and immunosuppressive regimens. Among these, 161 patients (15%) underwent a further 183 surgical procedures for conditions both related and unrelated to the transplant. The most common surgical procedure was for an incisional hernia repair (n = 101), followed by bilioenteric anastomosis (n = 44), intestinal surgery (n = 23), liver surgery (n = 8) and other surgical procedures (n = 7). Emergency surgery was required in 19 procedures (10%), while 162 procedures (90%) were performed electively. Post-operative mortality and morbidity were 1% and 30%, respectively. According to the Dindo-Clavien classification, the most common grade of morbidity was grade III (46%), followed by grade II (40%). Surgical procedures on liver transplanted patients are associated with a significantly high risk of complications, irrespective of the time elapsed since transplantation. Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Late-in-life surgery associated with Creutzfeldt-Jakob disease: a methodological outline for evidence-based guidance

PubMed Central

2013-01-01

Background There is increasing epidemiological evidence of etiological links between general surgery and sporadic Creutzfeldt-Jakob disease (sCJD) with long incubation periods. The purpose of this study was to identify specific surgical procedures potentially associated with sCJD to be targeted for preventive presurgical-intervention guidance. Results We propose a three-step clinical guidance outline where surgical procedures associated with sCJD clinical onset – potentially more contaminant - are taken into account. Data on hospital discharges and surgical procedures were obtained from Danish and Swedish national in-patient hospital registries for 167 sCJD cases, onset 1987–2003, and for 835 matched and 2,224 unmatched population controls. Surgery was allocated to different life-time periods as previously reported, and frequencies were compared using logistic regression analysis. In the year preceding clinical onset, persons with sCJD underwent a statistically significant higher number of minor surgical interventions (OR (95% CI): 17.50 (3.64-84.24)), transluminal endoscopies (OR: 2.73 (1.01–7.37)) and gastrointestinal operations (OR: 3.51 (1.21–10.19)) compared to matched controls. Surgical discharges clustered towards clinical onset. These differences increased during the clinical period, with statistically significant higher frequencies for both endoscopies and minor surgery (OR: 13.91 (5.87-32.95), and for main surgical procedures (OR: 2.10 (1.00-4.39)), particularly gastrointestinal surgery (OR: 6.00 (1.83-19.66)), and surgery contacting skeletal muscle. Comparisons with unmatched controls yielded similar results for neurosurgery in the clinical period (OR: 19.40 (2.22-168.34)). Conclusions These results suggest that some types of surgical procedures are associated with sCJD, after clinical onset or particularly just before onset. Selective planning of such surgery to minimize instrument/device contamination or quarantining might be feasible. Conditional to progress in sCJD etiological research, results are relevant for guidance development. PMID:23701872

Congenital heart surgery: expected versus observed surgical performance according to the Aristotle complexity score.

PubMed

Photiadis, J; Sinzobahamvya, N; Arenz, C; Sata, S; Haun, C; Schindler, E; Asfour, B; Hraska, V

2011-08-01

The Aristotle score quantifies the complexity involved in congenital heart surgery. It defines surgical performance as complexity score times hospital survival. We studied how expected and observed surgical performance evolved over time. 2312 main procedures carried out between 2006 and 2010 were analyzed. The Aristotle basic score, corresponding hospital survival and related observed surgical performance were estimated. Expected survival was based on the mortality risks published by O'Brien and coauthors. Observed performance divided by expected performance was called the standardized ratio of performance. This should trend towards a figure above 100%. Survival rates and performance are given with 95% confidence intervals. The mean Aristotle basic score was 7.88 ± 2.68. 51 patients died: observed hospital survival was 97.8 % (97.1 %-98.3%). 115 deaths were anticipated: expected survival was 95.2% (93.5%-96.3%). Observed and expected surgical performance reached 7.71 (7.65-7.75) and 7.49 (7.37-7.59), respectively. Therefore the overall standardized ratio of performance was 102.94%. The ratio increased from 2006 (ratio = 101.60%) to 2009 (103.92%) and was 103.42% in 2010. Performance was high for the repair of congenital corrected transposition of the great arteries and ventricular septal defect (VSD) by atrial switch and Rastelli procedure, the Norwood procedure, repair of truncus arteriosus, aortic arch repair and VSD closure, and the Ross-Konno procedure, with corresponding standardized ratios of 123.30%, 116.83%, 112.99%, 110.86% and 110.38%, respectively. With a ratio of 82.87%, performance was low for repair of Ebstein's anomaly. The standardized ratio of surgical performance integrates three factors into a single value: procedure complexity, postoperative observed survival, and comparison with expected survival. It constitutes an excellent instrument for quality monitoring of congenital heart surgery programs over time. It allows an accurate comparison of surgical performance across institutions with different case mixes. © Georg Thieme Verlag KG Stuttgart · New York.

Evaluation of shoulder function in clavicular fracture patients after six surgical procedures based on a network meta-analysis.

PubMed

Huang, Shou-Guo; Chen, Bo; Lv, Dong; Zhang, Yong; Nie, Feng-Feng; Li, Wei; Lv, Yao; Zhao, Huan-Li; Liu, Hong-Mei

2017-01-01

Purpose Using a network meta-analysis approach, our study aims to develop a ranking of the six surgical procedures, that is, Plate, titanium elastic nail (TEN), tension band wire (TBW), hook plate (HP), reconstruction plate (RP) and Knowles pin, by comparing the post-surgery constant shoulder scores in patients with clavicular fracture (CF). Methods A comprehensive search of electronic scientific literature databases was performed to retrieve publications investigating surgical procedures in CF, with the stringent eligible criteria, and clinical experimental studies of high quality and relevance to our area of interest were selected for network meta-analysis. Statistical analyses were conducted using Stata 12.0. Results A total of 19 studies met our inclusion criteria were eventually enrolled into our network meta-analysis, representing 1164 patients who had undergone surgical procedures for CF (TEN group = 240; Plate group = 164; TBW group  =  180; RP group  =  168; HP group  =  245; Knowles pin group  =  167). The network meta-analysis results revealed that RP significantly improved constant shoulder score in patients with CF when compared with TEN, and the post-operative constant shoulder scores in patients with CF after Plate, TBW, HP, Knowles pin and TEN were similar with no statistically significant differences. The treatment relative ranking of predictive probabilities of constant shoulder scores in patients with CF after surgery revealed the surface under the cumulative ranking curves (SUCRA) value is the highest in RP. Conclusion The current network meta-analysis suggests that RP may be the optimum surgical treatment among six inventions for patients with CF, and it can improve the shoulder score of patients with CF. Implications for Rehabilitation RP improves shoulder joint function after surgical procedure. RP achieves stability with minimal complications after surgery. RP may be the optimum surgical treatment for rehabilitation of patients with CF.

Three-dimensional Cross-Platform Planning for Complex Spinal Procedures: A New Method Adaptive to Different Navigation Systems.

PubMed

Kosterhon, Michael; Gutenberg, Angelika; Kantelhardt, Sven R; Conrad, Jens; Nimer Amr, Amr; Gawehn, Joachim; Giese, Alf

2017-08-01

A feasibility study. To develop a method based on the DICOM standard which transfers complex 3-dimensional (3D) trajectories and objects from external planning software to any navigation system for planning and intraoperative guidance of complex spinal procedures. There have been many reports about navigation systems with embedded planning solutions but only few on how to transfer planning data generated in external software. Patients computerized tomography and/or magnetic resonance volume data sets of the affected spinal segments were imported to Amira software, reconstructed to 3D images and fused with magnetic resonance data for soft-tissue visualization, resulting in a virtual patient model. Objects needed for surgical plans or surgical procedures such as trajectories, implants or surgical instruments were either digitally constructed or computerized tomography scanned and virtually positioned within the 3D model as required. As crucial step of this method these objects were fused with the patient's original diagnostic image data, resulting in a single DICOM sequence, containing all preplanned information necessary for the operation. By this step it was possible to import complex surgical plans into any navigation system. We applied this method not only to intraoperatively adjustable implants and objects under experimental settings, but also planned and successfully performed surgical procedures, such as the percutaneous lateral approach to the lumbar spine following preplanned trajectories and a thoracic tumor resection including intervertebral body replacement using an optical navigation system. To demonstrate the versatility and compatibility of the method with an entirely different navigation system, virtually preplanned lumbar transpedicular screw placement was performed with a robotic guidance system. The presented method not only allows virtual planning of complex surgical procedures, but to export objects and surgical plans to any navigation or guidance system able to read DICOM data sets, expanding the possibilities of embedded planning software.

Computer-enhanced visual learning method: a paradigm to teach and document surgical skills.

PubMed

Maizels, Max; Mickelson, Jennie; Yerkes, Elizabeth; Maizels, Evelyn; Stork, Rachel; Young, Christine; Corcoran, Julia; Holl, Jane; Kaplan, William E

2009-09-01

Changes in health care are stimulating residency training programs to develop new methods for teaching surgical skills. We developed Computer-Enhanced Visual Learning (CEVL) as an innovative Internet-based learning and assessment tool. The CEVL method uses the educational procedures of deliberate practice and performance to teach and learn surgery in a stylized manner. CEVL is a learning and assessment tool that can provide students and educators with quantitative feedback on learning a specific surgical procedure. Methods involved examine quantitative data of improvement in surgical skills. Herein, we qualitatively describe the method and show how program directors (PDs) may implement this technique in their residencies. CEVL allows an operation to be broken down into teachable components. The process relies on feedback and remediation to improve performance, with a focus on learning that is applicable to the next case being performed. CEVL has been shown to be effective for teaching pediatric orchiopexy and is being adapted to additional adult and pediatric procedures and to office examination skills. The CEVL method is available to other residency training programs.

Computer-Enhanced Visual Learning Method: A Paradigm to Teach and Document Surgical Skills

PubMed Central

Maizels, Max; Mickelson, Jennie; Yerkes, Elizabeth; Maizels, Evelyn; Stork, Rachel; Young, Christine; Corcoran, Julia; Holl, Jane; Kaplan, William E.

2009-01-01

Innovation Changes in health care are stimulating residency training programs to develop new methods for teaching surgical skills. We developed Computer-Enhanced Visual Learning (CEVL) as an innovative Internet-based learning and assessment tool. The CEVL method uses the educational procedures of deliberate practice and performance to teach and learn surgery in a stylized manner. Aim of Innovation CEVL is a learning and assessment tool that can provide students and educators with quantitative feedback on learning a specific surgical procedure. Methods involved examine quantitative data of improvement in surgical skills. Herein, we qualitatively describe the method and show how program directors (PDs) may implement this technique in their residencies. Results CEVL allows an operation to be broken down into teachable components. The process relies on feedback and remediation to improve performance, with a focus on learning that is applicable to the next case being performed. CEVL has been shown to be effective for teaching pediatric orchiopexy and is being adapted to additional adult and pediatric procedures and to office examination skills. The CEVL method is available to other residency training programs. PMID:21975716

Burn center management of operating room fire injuries.

PubMed

Haith, Linwood R; Santavasi, Wil; Shapiro, Tyler K; Reigart, Cynthia L; Patton, Mary Lou; Guilday, Robert E; Ackerman, Bruce H

2012-01-01

Approximately 100 operating room (OR) fires occur per year in the United States, with 15% resulting in serious injuries. Intraoperative cautery was frequently associated with OR fires before 1994; however, use of supplemental oxygen (O(2)), ethanol-based products, and disposable drapes have been more frequently associated with OR fires. Fires resulting from cosmetic and other small procedures involving use of nasal canula O(2) and electrocautery have been described in six published reports. We report five thermal injury cases admitted to our burn treatment center because of fires during surgical procedures over a 5-year period. Two patients undergoing supraorbital excision experienced 2.5 and 3% TBSA involvement burns; in a third patient surgical excision of a nasal polyp resulted in a 1% TBSA burn; in a fourth patient an excisional biopsy of a lymph node resulted in a 2.75% TBSA burn; and the last patient was burned during placement of a pacemaker, with resulting TBSA of 10.5%. Two of the five patients required intubation for inhalational injury. Two patients required tangential excision and grafting of their thermal injuries. All patients had received local or parenteral anesthesia with supplemental O(2)/nitrous oxide (N(2)O) for surgical procedure. There are a number of ignition sources in the OR, including electrocautery, lasers, and faulty OR equipment. The risk of OR fires increases with surgical procedures involving the face and neck, including tracheostomy and tracheobronchial surgery. The common use of O(2)/N(2)O mixtures or enriched O(2) for minimally complex surgical procedures and disposable drapes adds to the risk of an OR fire: the O(2)/N(2)O provides a fuel source, and the disposable drapes trap thedelivered gas. Electrocautery near an O(2)/N(2)O source resulted in the five thermal injuries and warrants careful reconsideration of technique for surgical procedures.

Contemporary results of surgical repair of recurrent aortic arch obstruction.

PubMed

Mery, Carlos M; Khan, Muhammad S; Guzmán-Pruneda, Francisco A; Verm, Raymond; Umakanthan, Ramanan; Watrin, Carmen H; Adachi, Iki; Heinle, Jeffrey S; McKenzie, E Dean; Fraser, Charles D

2014-07-01

There is a paucity of data on the current outcomes of surgical intervention for recurrent aortic arch obstruction (RAAO) after initial aortic arch repair in children. The goal of this study is to report the long-term results in these patients. All patients undergoing surgical intervention for RAAO at Texas Children's Hospital from 1995 to 2012 were included. The cohort was divided into four groups based on initial procedure: (1) simple coarctation repair, (2) Norwood procedure, (3) complex congenital heart disease, and (4) interrupted aortic arch. A total of 48 patients age 9 months (range, 22 days to 36 years) underwent 49 procedures for RAAO. All patients had an anatomic repair consisting of either patch aortoplasty (n=27, 55%), aortic arch advancement (n=8, 16%), sliding arch aortoplasty (n=6, 12%), placement of an interposition graft (n=2, 17%), reconstruction with donor allograft (n=4, 8%), extended end-to-end anastomosis (n=1, 2%), or redo Norwood-type reconstruction (n=1, 2%). Most procedures (n=46, 94%) were performed through a median sternotomy using cardiopulmonary bypass. At a median follow-up of 6.1 years (range, 9 days to 17 years), only 2 patients required surgical or catheter-based intervention for RAAO. Hypertension was present in 10% of patients at last follow-up. There were no neurologic or renal complications. There was 1 perioperative death after an aortic arch advancement in group 1. Four other patients have died during follow-up, none of the deaths related to RAAO. Anatomic repair of RAAO is a safe procedure associated with low morbidity and mortality, and low long-term reintervention rates. Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Tongue base suspension in children with cerebral palsy and obstructive sleep apnea.

PubMed

Hartzell, Larry David; Guillory, Ryan M; Munson, Patrick David; Dunham, Andrew K; Bower, Charles Michael; Richter, Gresham Thomas

2013-04-01

Children with cerebral palsy (CP) are commonly affected by obstructive sleep apnea (OSA). This study examines the efficacy of combined surgical techniques for OSA including tongue base suspension (TBS), using perioperative polysomnograms (PSG) in pediatric patients with CP. Case series with outcome analysis. University based tertiary care children's hospital. A 7-year retrospective chart review of children with CP who underwent surgical management for OSA. Surgical procedures, postoperative complications, and perioperative PSG data were examined. Only patients with both preoperative and postoperative PSG results were included in the study. Based upon procedures performed patients fell into 2 equal groups for analysis. Fourteen children were identified. Seven patients (mean age = 6.0 years) underwent combined adenotonsillectomy (T&A), uvulopalatopharyngoplasty (UPPP), and tongue base suspension (TBS). Another 7 patients (mean age = 6.3 years) underwent T&A and UPPP alone. Those who received TBS had a mean preoperative AHI of 27.2 compared to 6.8 in the group that did not have TBS. The AHI decreased by a mean of 16.5 in the TBS group and 5.0 in the non-TBS group. The mean oxygen saturation nadir improved in both the TBS (74.0-84.0) and non-TBS (64.8-84.6) groups. The arousal index also improved in the TBS (33.1-20.7) and non-TBS (11.0-5.8) groups. No surgical complications occurred. This study suggests that concomitant surgical approaches for OSA in children with CP are effective. Moderate to severe OSA in this population may safely benefit from the added technique of tongue base suspension. Published by Elsevier Ireland Ltd.

Surgical Care Required for Populations Affected by Climate-related Natural Disasters: A Global Estimation.

PubMed

Lee, Eugenia E; Stewart, Barclay; Zha, Yuanting A; Groen, Thomas A; Burkle, Frederick M; Kushner, Adam L

2016-08-10

Climate extremes will increase the frequency and severity of natural disasters worldwide.  Climate-related natural disasters were anticipated to affect 375 million people in 2015, more than 50% greater than the yearly average in the previous decade. To inform surgical assistance preparedness, we estimated the number of surgical procedures needed.   The numbers of people affected by climate-related disasters from 2004 to 2014 were obtained from the Centre for Research of the Epidemiology of Disasters database. Using 5,000 procedures per 100,000 persons as the minimum, baseline estimates were calculated. A linear regression of the number of surgical procedures performed annually and the estimated number of surgical procedures required for climate-related natural disasters was performed. Approximately 140 million people were affected by climate-related natural disasters annually requiring 7.0 million surgical procedures. The greatest need for surgical care was in the People's Republic of China, India, and the Philippines. Linear regression demonstrated a poor relationship between national surgical capacity and estimated need for surgical care resulting from natural disaster, but countries with the least surgical capacity will have the greatest need for surgical care for persons affected by climate-related natural disasters. As climate extremes increase the frequency and severity of natural disasters, millions will need surgical care beyond baseline needs. Countries with insufficient surgical capacity will have the most need for surgical care for persons affected by climate-related natural disasters. Estimates of surgical are particularly important for countries least equipped to meet surgical care demands given critical human and physical resource deficiencies.

Ontogeny of a surgical technique: Robotic kidney transplantation with regional hypothermia.

PubMed

Sood, Akshay; McCulloch, Peter; Dahm, Philipp; Ahlawat, Rajesh; Jeong, Wooju; Bhandari, Mahendra; Menon, Mani

2016-01-01

Innovation is a hallmark of surgical practice. It is generally accepted that a new procedure will undergo technical changes during its evolution; however, quantitative accounts of the process are limited. Multiple groups, including our own, have recently described a minimally-invasive approach to conventional kidney transplantation (KT) operation. Unique to our experience is a structured development of the technique within the confines of a safe surgical innovation framework - the IDEAL framework (idea, development, exploration, assessment, long-term monitoring; stages 0-4). We here provide a first-hand narrative of the progress of robotic KT operation from preclinical trial to clinical application. Overall, 54 patients underwent robotic KT with regional hypothermia successfully. Major technical changes including selection of optimal patient position (flank vs. lithotomy), robotic instrumentation, vascular occlusion method (bulldog vs. tourniquet) and suture material (prolene vs. GoreTex) occurred early during the procedure development (IDEAL stage 0, preclinical). Minor technical changes such as utilization of the aortic punch for arteriotomy (case 3), use of barbed suture during ureteroneocystostomy (case 6) and extraperitonealization of the graft kidney (case 6) that increased the efficiency and safety of the procedure continued throughout procedure development (IDEAL stages 1-2, clinical stages). We demonstrate that a surgical technique evolves continually; although, the majority of technical alterations occur early in the life-cycle of the procedure. Development of a new technique within the confines a structured surgical innovation framework allows for evidence based progression of the technique and may minimize the risk of harm to the patient. Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

[Current status and changes of metabolic and bariatric surgery in China].

PubMed

Liu, Jingang

2017-04-25

Through continuous development, metabolic and bariatric surgery (MBS) has become widely recognized in academic and medical circles. In China, the volume of MBS operations has increased year by year. Therapeutic goals of MBS have evolved from treating obesity to treating Type 2 diabetes mellitus, and further to treating a series of obesity-associated metabolic diseases (including conditions in the endocrine system, circulatory system, respiratory system, reproductive system, and etc). Surgical approach of MBS has also been evolving continuously. Currently the common surgical procedures include laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), laparoscopic adjustable gastric banding (LAGB) and bilio-pancreatic diversion with duodenal switch (BPD-DS). All surgical procedures have pros and cons, and the choice of surgical procedures should be based on the conditions of patients, the surgeon's technical ability, and benefits and operative risks. With the development of MBS, the proportions of different surgical procedures also changed in China. In recent five years, the proportion of AGB has decreased continuously and LAGB is no longer a common procedure. The proportion of LSG has increased rapidly, rising from 9% in 2010 to 55% in 2015. The proportion of RYGB has increased from 57% to 64% between 2010 and 2013, and remained at 45% afterwards. Since 2010, most MBS operations are laparoscopic surgery. 3D Laparoscopic surgery, laparoendoscopic single-site surgery and da Vinci Robotic Surgery have also been introduced in MBS. This review discusses the status quo and changes of MBS in china, as well as the new technology in MBS, aiming to strengthen the information and comprehension of MBS in china.

Complications associated with surgical treatment of sleep-disordered breathing among hospitalized U.S. adults.

PubMed

Beydoun, Hind A; Beydoun, May A; Cheng, Hong; Khan, Anjum; Eid, Shaker M; Alvarez-Garriga, Carolina; Anderson-Smits, Colin; Zonderman, Alan B; Marinac-Dabic, Danica

2018-05-24

The purpose of this cross-sectional study is to examine the relationship between surgical treatments for sleep-disordered breathing (SDB) and composite measure of surgical complications in a nationally representative sample of hospital discharges among U.S. adults. We performed secondary analyses of 33,679 hospital discharges from the 2002-2012 Nationwide Inpatient Sample that corresponded to U.S. adults (≥18 years) who were free of head-and-neck neoplasms, were diagnosed with SDB and had undergone at least one of seven procedures. Multivariate logistic regression models were constructed to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI), controlling for age, sex, race/ethnicity, obstructive sleep apnea (OSA) and obesity diagnoses. Positive associations were found between composite measure of surgical complications and specific procedures: palatal procedure (aOR = 12.69, 95% CI: 11.91,13.53), nasal surgery (aOR = 6.47, 95% CI: 5.99,6.99), transoral robotic assist (aOR = 5.06, 95% CI: 4.34-5.88), tongue base/hypopharynx (aOR = 4.24, 95% CI: 3.88,4.62), maxillomandibular advancement (MMA) (aOR = 3.24, 95% CI: 2.74,3.84), supraglottoplasty (aOR = 2.75, 95% CI: 1.81,4.19). By contrast, a negative association was found between composite measures of surgical complications and tracheostomy (aOR = 0.033, 95% CI: 0.031,0.035). In conclusion, most procedures for SDB, except tracheostomy, were positively associated with complications, whereby palatal procedures exhibited the strongest and supraglottoplasty exhibited the weakest association. Published by Elsevier Ltd.

Open cholecystectomy: Exposure and confidence of surgical trainees and new fellows.

PubMed

Campbell, Beth M; Lambrianides, Andreas L; Dulhunty, Joel M

2018-03-01

The laparoscopic approach to cholecystectomy has overtaken open procedures in terms of frequency, despite open procedures playing an important role in certain clinical situations. This study explored exposure and confidence of Australasian surgical trainees and new fellows in performing an open versus laparoscopic cholecystectomy. An online survey was disseminated via the Royal Australasian College of Surgeons to senior general surgery trainees (years 3-5 of surgical training) and new fellows (fellowship within the previous 5 years). The survey included questions regarding level of experience and confidence in performing an open cholecystectomy and converting from a laparoscopic to an open approach. A total of 135 participants responded; 58 (43%) were surgical trainees, 58 (43%) were fellows and 19 (14%) did not specify their level of training. Respondents who were involved in more than 20 open cholecystectomy procedures as an assistant or independent operator compared with those less exposed were more likely to feel confident to independently perform an elective open cholecystectomy (87.8% vs. 57.3%, P = 0.001), independently convert from a laparoscopic to open cholecystectomy (87.8% vs. 58.7%, P = 0.001) and independently perform an open cholecystectomy as a surgical consultant based on their level of exposure as a trainee (73.2% vs. 45.3%, P = 0.004). This study suggests the need to ensure surgical trainees are exposed to sufficient open cholecystectomies to enable confidence and skill with performing these procedures when indicated. Greater recognition of the need for exposure during training, including meaningful simulation, may assist. Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.

Support of surgical process modeling by using adaptable software user interfaces

NASA Astrophysics Data System (ADS)

Neumuth, T.; Kaschek, B.; Czygan, M.; Goldstein, D.; Strauß, G.; Meixensberger, J.; Burgert, O.

2010-03-01

Surgical Process Modeling (SPM) is a powerful method for acquiring data about the evolution of surgical procedures. Surgical Process Models are used in a variety of use cases including evaluation studies, requirements analysis and procedure optimization, surgical education, and workflow management scheme design. This work proposes the use of adaptive, situation-aware user interfaces for observation support software for SPM. We developed a method to support the modeling of the observer by using an ontological knowledge base. This is used to drive the graphical user interface for the observer to restrict the search space of terminology depending on the current situation. In the evaluation study it is shown, that the workload of the observer was decreased significantly by using adaptive user interfaces. 54 SPM observation protocols were analyzed by using the NASA Task Load Index and it was shown that the use of the adaptive user interface disburdens the observer significantly in workload criteria effort, mental demand and temporal demand, helping him to concentrate on his essential task of modeling the Surgical Process.

Markov chain decision model for urinary incontinence procedures.

PubMed

Kumar, Sameer; Ghildayal, Nidhi; Ghildayal, Neha

2017-03-13

Purpose Urinary incontinence (UI) is a common chronic health condition, a problem specifically among elderly women that impacts quality of life negatively. However, UI is usually viewed as likely result of old age, and as such is generally not evaluated or even managed appropriately. Many treatments are available to manage incontinence, such as bladder training and numerous surgical procedures such as Burch colposuspension and Sling for UI which have high success rates. The purpose of this paper is to analyze which of these popular surgical procedures for UI is effective. Design/methodology/approach This research employs randomized, prospective studies to obtain robust cost and utility data used in the Markov chain decision model for examining which of these surgical interventions is more effective in treating women with stress UI based on two measures: number of quality adjusted life years (QALY) and cost per QALY. Treeage Pro Healthcare software was employed in Markov decision analysis. Findings Results showed the Sling procedure is a more effective surgical intervention than the Burch. However, if a utility greater than certain utility value, for which both procedures are equally effective, is assigned to persistent incontinence, the Burch procedure is more effective than the Sling procedure. Originality/value This paper demonstrates the efficacy of a Markov chain decision modeling approach to study the comparative effectiveness analysis of available treatments for patients with UI, an important public health issue, widely prevalent among elderly women in developed and developing countries. This research also improves upon other analyses using a Markov chain decision modeling process to analyze various strategies for treating UI.

Quantifying the cognitive cost of laparo-endoscopic single-site surgeries: Gaze-based indices.

PubMed

Di Stasi, Leandro L; Díaz-Piedra, Carolina; Ruiz-Rabelo, Juan Francisco; Rieiro, Héctor; Sanchez Carrion, Jose M; Catena, Andrés

2017-11-01

Despite the growing interest concerning the laparo-endoscopic single-site surgery (LESS) procedure, LESS presents multiple difficulties and challenges that are likely to increase the surgeon's cognitive cost, in terms of both cognitive load and performance. Nevertheless, there is currently no objective index capable of assessing the surgeon cognitive cost while performing LESS. We assessed if gaze-based indices might offer unique and unbiased measures to quantify LESS complexity and its cognitive cost. We expect that the assessment of surgeon's cognitive cost to improve patient safety by measuring fitness-for-duty and reducing surgeons overload. Using a wearable eye tracker device, we measured gaze entropy and velocity of surgical trainees and attending surgeons during two surgical procedures (LESS vs. multiport laparoscopy surgery [MPS]). None of the participants had previous experience with LESS. They performed two exercises with different complexity levels (Low: Pattern Cut vs. High: Peg Transfer). We also collected performance and subjective data. LESS caused higher cognitive demand than MPS, as indicated by increased gaze entropy in both surgical trainees and attending surgeons (exploration pattern became more random). Furthermore, gaze velocity was higher (exploration pattern became more rapid) for the LESS procedure independently of the surgeon's expertise. Perceived task complexity and laparoscopic accuracy confirmed gaze-based results. Gaze-based indices have great potential as objective and non-intrusive measures to assess surgeons' cognitive cost and fitness-for-duty. Furthermore, gaze-based indices might play a relevant role in defining future guidelines on surgeons' examinations to mark their achievements during the entire training (e.g. analyzing surgical learning curves). Copyright © 2017 Elsevier Ltd. All rights reserved.

Causes and Surgical Outcomes of Lower Eyelid Retraction

PubMed Central

Kim, Kun Hae; Baek, Ji Sun; Lee, Saem; Lee, Jung Hye; Choi, Hye Sun; Kim, Sung Joo

2017-01-01

Purpose To investigate the causes of lower eyelid retraction and evaluate the outcomes of various surgical procedures. Methods We conducted a retrospective medical record review of patients who underwent lower eyelid retraction surgery performed by a single surgeon at Kim's Eye Hospital between 2006 and 2013. We investigated the causes of lower eyelid retraction, clinical history, characteristics, treatment, and surgical outcomes. Preoperative and postoperative margin reflex distance 2 and inferior scleral show were measured for each eyelid. Success was defined as a positive eyelid elevation and a decrease in inferior scleral show. Results A total of 19 lower eyelids were treated in 14 patients with lower eyelid retraction. For cosmetic reasons, surgical correction for congenital lower eyelid retraction was performed on seven eyelids (36.8%). Ten eyelids (52.6%) exhibited secondary lower eyelid retraction after surgery. One eyelid (5.3%) was affected by facial palsy and one eyelid (5.3%) exhibited exophthalmos of an unknown origin. We adopted a selective approach based on lower eyelid retraction severity. Spacer grafting via a subconjunctival approach was the most commonly performed surgical technique (13 eyelids, 68.4%). The lateral tarsal strip procedure was used to horizontally tighten three eyelids (15.8%). At the time of the procedure, one of these eyelids (5.3%) also received an adjuvant suborbicularis oculi fat lift. Autogenous dermis fat grafting was performed on two lower eyelids (10.5%), whose retraction was caused by fat and soft tissue loss. Cosmetic outcomes were satisfactory in all cases. Conclusions To achieve satisfactory surgical outcomes, surgeons should adopt an approach based on the severity of lower eyelid retraction. Mild lower eyelid retraction can be corrected without grafts. When retraction is severe and exceeds 2 mm, spacer grafts that push the lower eyelid margin upwards and support it from below are required. PMID:28682021

Causes and Surgical Outcomes of Lower Eyelid Retraction.

PubMed

Kim, Kun Hae; Baek, Ji Sun; Lee, Saem; Lee, Jung Hye; Choi, Hye Sun; Kim, Sung Joo; Jang, Jae Woo

2017-08-01

To investigate the causes of lower eyelid retraction and evaluate the outcomes of various surgical procedures. We conducted a retrospective medical record review of patients who underwent lower eyelid retraction surgery performed by a single surgeon at Kim's Eye Hospital between 2006 and 2013. We investigated the causes of lower eyelid retraction, clinical history, characteristics, treatment, and surgical outcomes. Preoperative and postoperative margin reflex distance 2 and inferior scleral show were measured for each eyelid. Success was defined as a positive eyelid elevation and a decrease in inferior scleral show. A total of 19 lower eyelids were treated in 14 patients with lower eyelid retraction. For cosmetic reasons, surgical correction for congenital lower eyelid retraction was performed on seven eyelids (36.8%). Ten eyelids (52.6%) exhibited secondary lower eyelid retraction after surgery. One eyelid (5.3%) was affected by facial palsy and one eyelid (5.3%) exhibited exophthalmos of an unknown origin. We adopted a selective approach based on lower eyelid retraction severity. Spacer grafting via a subconjunctival approach was the most commonly performed surgical technique (13 eyelids, 68.4%). The lateral tarsal strip procedure was used to horizontally tighten three eyelids (15.8%). At the time of the procedure, one of these eyelids (5.3%) also received an adjuvant suborbicularis oculi fat lift. Autogenous dermis fat grafting was performed on two lower eyelids (10.5%), whose retraction was caused by fat and soft tissue loss. Cosmetic outcomes were satisfactory in all cases. To achieve satisfactory surgical outcomes, surgeons should adopt an approach based on the severity of lower eyelid retraction. Mild lower eyelid retraction can be corrected without grafts. When retraction is severe and exceeds 2 mm, spacer grafts that push the lower eyelid margin upwards and support it from below are required. © 2017 The Korean Ophthalmological Society

Breast Implant-Associated Infections: The Role of the National Surgical Quality Improvement Program and the Local Microbiome.

PubMed

Cohen, Justin B; Carroll, Cathy; Tenenbaum, Marissa M; Myckatyn, Terence M

2015-11-01

The most common cause of surgical readmission after breast implant surgery remains infection. Six causative organisms are principally involved: Staphylococcus epidermidis and S. aureus, Escherichia, Pseudomonas, Propionibacterium, and Corynebacterium. The authors investigated the infection patterns and antibiotic sensitivities to characterize their local microbiome and determine ideal antibiotic selection. A retrospective review of 2285 consecutive implant-based breast procedures was performed. Included surgical procedures were immediate and delayed breast reconstruction, tissue expander exchange, and cosmetic augmentation. Patient demographics, chemotherapy and/or irradiation status, implant characteristics, explantation reason, time to infection, microbiological data, and antibiotic sensitivities were reviewed. Forty-seven patients (2.1 percent) required inpatient admission for antibiotics, operative explantation, or drainage by interventional radiology. The infection rate varied depending on surgical procedure, with the highest rate seen in mastectomy and immediate tissue expander reconstruction (6.1 percent). The mean time to explantation was 41 days. Only 50 percent of infections occurred within 30 days of the indexed National Surgical Quality Improvement Program operation. The most commonly isolated organisms were coagulase-negative Staphylococcus (27 percent), methicillin-sensitive S. aureus (25 percent), methicillin-resistant S. aureus (7 percent), Pseudomonas (7 percent), and Peptostreptococcus (7 percent). All Gram-positive organisms were sensitive to vancomycin, linezolid, tetracycline, and doxycycline; all Gram-negative organisms were sensitive to gentamicin and cefepime. Empiric antibiotics should be vancomycin (with the possible inclusion of gentamicin) based on their broad effectiveness against the authors' unique microbiome. Minor infections should be treated with tetracycline or doxycycline as a second-line agent. National Surgical Quality Improvement Program data are adequate for monitoring and comparing breast infections but certainly not comprehensive. Therapeutic, IV.

Advances in the surgical management of prolapse.

PubMed

Slack, Alex; Jackson, Simon

2007-03-01

Prolapse is an extremely common condition, for which 11% of women will have a surgical procedure at some point in their lives. The recurrence rate after most of the traditional surgical procedures is high and upto 29% of women who have had surgery for prolapse will require a further operation. In order to improve the surgical outcome, there is currently much interest in the use of grafts to augment traditional repairs and new procedures have been developed using specifically developed grafts. These have been combined with minimally invasive surgical techniques in an attempt to reduce surgical morbidity. These procedures may improve the outcome of surgery for prolapse. However, there is currently a lack of long-term data from randomized trials to demonstrate their effectiveness and safety.

Surgical manual of the Korean Gynecologic Oncology Group: classification of hysterectomy and lymphadenectomy

PubMed Central

Choi, Chel Hun; Chun, Yi Kyeong

2017-01-01

The Surgery Treatment Modality Committee of the Korean Gynecologic Oncologic Group (KGOG) has determined to develop a surgical manual to facilitate clinical trials and to improve communication between investigators by standardizing and precisely describing operating procedures. The literature on anatomic terminology, identification of surgical components, and surgical techniques were reviewed and discussed in depth to develop a surgical manual for gynecologic oncology. The surgical procedures provided here represent the minimum requirements for participating in a clinical trial. These procedures should be described in the operation record form, and the pathologic findings obtained from the procedures should be recorded in the pathologic report form. Here, we focused on radical hysterectomy and lymphadenectomy, and we developed a KGOG classification for those conditions. PMID:27670259

Surgical manual of the Korean Gynecologic Oncology Group: classification of hysterectomy and lymphadenectomy.

PubMed

Lee, Maria; Choi, Chel Hun; Chun, Yi Kyeong; Kim, Yun Hwan; Lee, Kwang Beom; Lee, Shin Wha; Shim, Seung Hyuk; Song, Yong Jung; Roh, Ju Won; Chang, Suk Joon; Lee, Jong Min

2017-01-01

The Surgery Treatment Modality Committee of the Korean Gynecologic Oncologic Group (KGOG) has determined to develop a surgical manual to facilitate clinical trials and to improve communication between investigators by standardizing and precisely describing operating procedures. The literature on anatomic terminology, identification of surgical components, and surgical techniques were reviewed and discussed in depth to develop a surgical manual for gynecologic oncology. The surgical procedures provided here represent the minimum requirements for participating in a clinical trial. These procedures should be described in the operation record form, and the pathologic findings obtained from the procedures should be recorded in the pathologic report form. Here, we focused on radical hysterectomy and lymphadenectomy, and we developed a KGOG classification for those conditions.

Providing surgery in a war-torn context: the Médecins Sans Frontières experience in Syria.

PubMed

Trelles, Miguel; Dominguez, Lynette; Tayler-Smith, Katie; Kisswani, Katrin; Zerboni, Alberto; Vandenborre, Thierry; Dallatomasina, Silvia; Rahmoun, Alaa; Ferir, Marie-Christine

2015-01-01

Since 2011, civil war has crippled Syria leaving much of the population without access to healthcare. Various field hospitals have been clandestinely set up to provide basic healthcare but few have been able to provide quality surgical care. In 2012, Medecins Sans Frontieres (MSF) began providing surgical care in the Jabal al-Akrad region of north-western Syria. Based on the MSF experience, we describe, for the period 5th September 2012 to 1st January 2014: a) the volume and profile of surgical cases, b) the volume and type of anaesthetic and surgical procedures performed, and c) the intraoperative mortality rate. A descriptive study using routinely collected MSF programme data. Quality surgical care was assured through strict adherence to the following minimum standards: adequate infrastructure, adequate water and sanitation provisions, availability of all essential disposables, drugs and equipment, strict adherence to hygiene requirements and universal precautions, mandatory use of sterile equipment for surgical and anaesthesia procedures, capability for blood transfusion and adequate human resources. During the study period, MSF operated on 578 new patients, of whom 57 % were male and median age was 25 years (Interquartile range: 21-32 years). Violent trauma was the most common surgical indication (n-254, 44 %), followed by obstetric emergencies (n-191, 33 %) and accidental trauma (n-59, 10 %). In total, 712 anaesthetic procedures were performed. General anaesthesia without intubation was the most common type of anaesthesia (47 % of all anaesthetics) followed by spinal anaesthesia (25 %). A total of 831 surgical procedures were performed, just over half being minor/wound care procedures and nearly one fifth, caesarean sections. There were four intra-operative deaths, giving an intra-operative mortality rate of 0.7 %. Surgical needs in a conflict-afflicted setting like Syria are high and include both combat and non-combat indications, particularly obstetric emergencies. Provision of quality surgical care in a complex and volatile setting like this is possible providing appropriate measures, supported by highly experienced staff, can be implemented that allow a specific set of minimum standards of care to be adhered to. This is particularly important when patient outcomes - as a reflection of quality of care - are difficult to assess.

Surgical Procedures. Second Edition. Teacher Edition.

ERIC Educational Resources Information Center

Baker, Beverly; And Others

This teacher's guide contains 13 units of instruction for a course that will prepare students with the entry-level competencies needed by a surgical technologist. The course covers the following topics: introduction to surgical procedures; diagnostic procedures; general surgery; gastrointestinal surgery; obstetrics and gynecological surgery;…

Peroral Endoscopic Myotomy Versus Heller Myotomy for Achalasia: Pros and Cons.

PubMed

Tefas, Cristian; Ababneh, Rami; Tanţău, Marcel

2018-01-01

Achalasia is an esophageal motor disorder that has multiple endoscopic and surgical methods of treatment. However, there is no consensus on optimal therapy in patients suffering from this disorder. This review discusses two therapies with similar but technically different concepts, peroral endoscopic myotomy and Heller surgical myotomy. After a brief introduction to the basic problems of achalasia, technical considerations, intra and postprocedural complications are presented and the advantages and disadvantages of the two procedures are discussed, based on the relevant articles in the literature. Heller surgical myotomy and peroral endoscopic myotomy appear to be similar in performance with similar results in terms of gastroesophageal reflux rates. However, with experience being gained in the field of endoscopic myotomy, this procedure seems more advantageous, with similar success rates to those of the established surgical technique, but offering shorter operating times, shorter hospitalizations and, ultimately, lower costs. Celsius.

Surgical skills needed for humanitarian missions in resource-limited settings: common operative procedures performed at Médecins Sans Frontières facilities.

PubMed

Wong, Evan G; Trelles, Miguel; Dominguez, Lynette; Gupta, Shailvi; Burnham, Gilbert; Kushner, Adam L

2014-09-01

Surgeons in high-income countries increasingly are expressing interest in global surgery and participating in humanitarian missions. Knowledge of the surgical skills required to adequately respond to humanitarian emergencies is essential to prepare such surgeons and plan for interventions. A retrospective review of all surgical procedures performed at Médecins Sans Frontières Brussels facilities from June 2008 to December 2012 was performed. Individual data points included country of project; patient age and sex; and surgical indication and surgical procedure. Between June 2008 and December 2012, a total of 93,385 procedures were performed on 83,911 patients in 21 different countries. The most common surgical indication was for fetal-maternal pathologies, accounting for 25,548 of 65,373 (39.1%) of all cases. The most common procedure was a Cesarean delivery, accounting for a total of 24,182 or 25.9% of all procedures. Herniorrhaphies (9,873/93,385, 10.6%) and minor surgeries (11,332/93,385, 12.1%), including wound debridement, abscess drainage and circumcision, were also common. A basic skill set that includes the ability to provide surgical care for a wide variety of surgical morbidities is urgently needed to cope with the surgical need of humanitarian emergencies. This review of Médecins Sans Frontières's operative procedures provides valuable insight into the types of operations with which an aspiring volunteer surgeon should be familiar. Copyright © 2014 Mosby, Inc. All rights reserved.

Identification of opportunities for quality improvement and outcome measurement in pediatric otolaryngology.

PubMed

Shah, Rahul K; Stey, Anne M; Jatana, Kris R; Rangel, Shawn J; Boss, Emily F

2014-11-01

Despite increased emphasis on measuring safety outcomes and quality indicators for surgical care, little is known regarding which operative procedures should be prioritized for quality-improvement initiatives in pediatric otolaryngology. To describe the 30-day adverse event rates and relative contributions to morbidity for procedures in pediatric otolaryngology surgery using data from the American College of Surgeons' National Surgical Quality Improvement Program Pediatric database (ACS-NSQIP-P). Analysis of records contained in the ACS-NSQIP-P 2011-2012 clinical database. The ACS-NSQIP-P is a nationwide risk-adjusted, clinical outcomes-based program aimed at measuring and improving pediatric surgical care. Fifty hospitals participated in the 2011-2012 ACS-NSQIP-P program. Medical records of patients who underwent tracked otolaryngologic procedures were accrued in the ACS-NSQIP-P database. These were inclusive of specific otolaryngologic surgical procedures and do not represent the entire spectrum of pediatric otolaryngology surgical procedures. Individual 30-day adverse events, composite morbidity, composite serious adverse events, and composite hospital-acquired infections were compiled. Clinically related procedure groups were used to broadly evaluate outcomes. Procedures and groups were evaluated according to their relative contribution to otolaryngologic morbidity and their incidence of major complications. A total of 8361 patients underwent 1 of 40 selected otolaryngology procedures; 90% were elective; 76% were performed on an outpatient or ambulatory basis; and 46% were American Society of Anesthesiologists (ASA) class 2 cases. Individual 30-day adverse event rates were highest for return to the operating room (4%), surgical site infection (2%), pneumonia (1%), sepsis (1%), and reintubation (1%). The highest rates of composite morbidity were seen for tracheostomy in patients younger than 2 years (23%), airway reconstruction (19%), and tympanoplasty with mastoidectomy (2%). Airway reconstruction procedures had the highest rates of composite serious adverse events (16%), followed by tracheostomy (13%) and abscess drainage (5%). Tracheostomy (31%) and airway reconstruction (16%) made the largest relative contributions to composite morbidity rate of the procedures studied. Tracheostomy in patients younger than 2 years had the highest composite hospital-acquired infection rate (14%), followed by airway reconstruction procedures (11%) and tympanoplasty with mastoidectomy (2%). While the overall rate of major postoperative morbidity in pediatric otolaryngology is low, areas for targeted quality-improvement interventions include tracheostomy, airway reconstruction, mastoidectomy, and abscess drainage. Measurement of outcomes specific to otolaryngologic procedures will be necessary to further identify and measure the impact of quality-improvement initiatives in pediatric otolaryngology.

Paediatric minor oral surgical procedures under inhalation sedation and general anaesthetic: a comparison of variety and duration of treatment.

PubMed

Foley, J

2008-03-01

To develop baseline data in relation to paediatric minor oral surgical procedures undertaken with both general anaesthesia and nitrous oxide inhalation sedation within a Hospital Dental Service. Data were collected prospectively over a three-year period from May 2003 to June 2006 for patients attending the Departments of Paediatric Dentistry, Dundee Dental Hospital and Ninewells Hospital, NHS Tayside, Great Britain, for all surgical procedures undertaken with either inhalation sedation or general anaesthetic. Both operator status and the procedure being undertaken were noted. In addition, the operating time was recorded. Data for 166 patients (F: 102; M: 64) with a median age of 12.50 (inter-quartile range 10.00, 14.20) years showed that 195 surgical procedures were undertaken. Of these 160 and 35 were with general anaesthetic and sedation respectively. The surgical removal of impacted, carious and supernumerary unit(s) accounted for 53.8% of all procedures, whilst the exposure of impacted teeth and soft tissue surgery represented 34.9% and 11.3% of procedures respectively. The median surgical time for techniques undertaken with sedation was 30.00 (inter-quartile range 25.00, 43.50) minutes whilst that for general anaesthetic was similar at 30.00 (inter-quartile range 15.25, 40.00) minutes (not statistically significant, (Mann Whitney U, W = 3081.5, P = 0.331). The majority of paediatric minor oral surgical procedures entail surgical exposure or removal of impacted teeth. The median treatment time for most procedures undertaken with either general anaesthetic or nitrous oxide sedation was 30 minutes.

Skin and Soft Tissue Surgery in the Office Versus Operating Room Setting: An Analysis Based on Individual-Level Medicare Data.

PubMed

Kantor, Jonathan

2018-03-23

The relative volume of skin and soft tissue excision and reconstructive procedures performed in the outpatient office versus facility (ambulatory surgical center or hospital) differs by specialty, and has major implications for quality of care, outcomes, development of guidelines, resident education, health care economics, and patient perception. To assess the relative volume of surgical procedures performed in each setting (office vs ambulatory surgery center [ASC]/hospital) by dermatologists and nondermatologists. A cross-sectional analytical study was performed using the Medicare public use file (PUF) for 2014, which includes every patient seen in an office, ASC, or hospital in the United States billed to Medicare part B. Data were divided by physician specialty and setting. A total of 9,316,307 individual encounters were included in the Medicare PUF. Dermatologists account for 195,001 (2.1%) of the total. Dermatologists were more likely to perform surgical procedures in an office setting only (odds ratio 5.48 [95% confidence interval 5.05-5.95], p < .0001) than other specialists in aggregate. More than 90% of surgical procedures are performed in an office setting, and dermatologists are more than 5 times as likely as other specialists to operate in an office setting.

Hospital profitability for a surgeon's common procedures predicts the surgeon's overall profitability for the hospital.

PubMed

Dexter, F; Macario, A; Cerone, S M

1998-09-01

To evaluate whether a hospital's profitability for a surgeon's common procedures predicts the surgeon's overall profitability for the hospital. Observational study. Community and university-affiliated tertiary hospital with 21,903 surgical procedures performed per year. 7,520 patients having surgery performed by one of 46 surgeons. None. Financial data were obtained for all patients cared for by all the surgeons who performed at least ten cases of one of the hospital's six most common procedures. A surgeon's overall profitability for the hospital was measured using his or her contribution margin ratio (i.e., total revenue for all of the surgeon's patients divided by total variable cost for the patients). Contribution margin was calculated twice: once with all of a surgeon's patients, and second, limiting consideration to those patients who underwent one of the six common procedures. The common procedures accounted for 22 +/- 15% of the 46 surgeons' overall caseload, 29 +/- 10% of their patients' hospital costs, and 30 +/- 12% of the hospital revenue generated by the surgeons. Hospital contribution margin ratios ranged from 1.4 to 4.2. Contribution margin ratios for common procedures and contribution margin ratios for all patients were correlated (tau = 0.58, n = 46, p < 0.0001). Even though most surgical cases were for uncommon procedures, a surgeon's hospital profitability on common procedures predicted the surgeon's overall financial performance. Perioperative incentive programs based on common surgical procedures (clinical pathways) are likely to accurately reflect a surgeon's financial performance on their other surgeries.

Optimizing ACS NSQIP modeling for evaluation of surgical quality and risk: patient risk adjustment, procedure mix adjustment, shrinkage adjustment, and surgical focus.

PubMed

Cohen, Mark E; Ko, Clifford Y; Bilimoria, Karl Y; Zhou, Lynn; Huffman, Kristopher; Wang, Xue; Liu, Yaoming; Kraemer, Kari; Meng, Xiangju; Merkow, Ryan; Chow, Warren; Matel, Brian; Richards, Karen; Hart, Amy J; Dimick, Justin B; Hall, Bruce L

2013-08-01

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) collects detailed clinical data from participating hospitals using standardized data definitions, analyzes these data, and provides participating hospitals with reports that permit risk-adjusted comparisons with a surgical quality standard. Since its inception, the ACS NSQIP has worked to refine surgical outcomes measurements and enhance statistical methods to improve the reliability and validity of this hospital profiling. From an original focus on controlling for between-hospital differences in patient risk factors with logistic regression, ACS NSQIP has added a variable to better adjust for the complexity and risk profile of surgical procedures (procedure mix adjustment) and stabilized estimates derived from small samples by using a hierarchical model with shrinkage adjustment. New models have been developed focusing on specific surgical procedures (eg, "Procedure Targeted" models), which provide opportunities to incorporate indication and other procedure-specific variables and outcomes to improve risk adjustment. In addition, comparative benchmark reports given to participating hospitals have been expanded considerably to allow more detailed evaluations of performance. Finally, procedures have been developed to estimate surgical risk for individual patients. This article describes the development of, and justification for, these new statistical methods and reporting strategies in ACS NSQIP. Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Practice variation in surgical procedures and IUD-insertions among general practitioners in Norway - a longitudinal study.

PubMed

Pahle, Andreas Saxlund; Sørli, Daniel; Kristiansen, Ivar Sønbø; Deraas, Trygve S; Halvorsen, Peder A

2017-01-21

Studies of Primary Health Care (PHC) reveal considerable practice variations in terms of the range of services provided. In Norway, general practitioners (GPs) are traditionally expected to perform IUD-insertions and several surgical procedures as a part of comprehensive PHC. We aimed to investigate variation in the provision of surgical procedures and IUD-insertions across GPs and over time and explore determinants of such variation. Retrospective registry study of Norwegian GPs. From a comprehensive database of GPs' reimbursement claims, we obtained procedure codes and GP characteristics such as age, gender, list size and municipality characteristics from 2006 through 2013. Multivariable logistic regression models were fitted to explore determinants of practice variation. We extracted data from 4,828 GPs. In 2013, 91.0, 76.1 and 74.8% were reimbursed at least once for minor and major surgical procedures and IUD-insertion, respectively. Female GPs had lower odds for performing major surgical procedures (OR 0.38, 95% CI 0.32-0.45) and higher odds for performing IUD-insertions (OR 6.28, 95% CI 4.47-8.82) than male GPs. Older GPs and GPs with shorter patient lists were less likely to perform surgical procedures. GPs with longer patient lists had higher odds for performing IUD-insertions. The proportion of GPs performing surgical procedures increased over time, while the proportion decreased for IUD-insertions. The number of IUD-insertions in specialist care increased from 12,575 in 2011 to 15 216 (+21.0%) in 2014. We observed a large variation in the provision of surgical procedures and IUD-insertions amongst GPs in Norway. The GPs' age, gender, list size and size of municipality were associated with performing the procedures. Our findings suggest a shift of IUD-insertions from primary to specialist care.

Surgical fires: perioperative communication is essential to prevent this rare but devastating complication.

PubMed

Bruley, M E

2004-12-01

A fire on or within a surgical patient is a continuing risk in modern surgery. Unfortunately, the sensitivity of surgical and anaesthesia staff to this hazard has waned over the past 25 years with cessation of the use of flammable anaesthetic agents. Prevention of surgical fires requires understanding the risks and effective communication between surgical, anaesthesia, and operating nursing staffs. Preventive measures exist but have yet to diffuse sufficiently across professional boundaries. Based on a review of relevant databases, decades of experience from field investigations, and a review of the medical literature, this paper discusses the incidence of surgical fires, the responsibility for prevention in the perioperative setting, and the procedures for surgical fire prevention and extinguishment.

Surgical fires: perioperative communication is essential to prevent this rare but devastating complication

PubMed Central

Bruley, M

2004-01-01



 A fire on or within a surgical patient is a continuing risk in modern surgery. Unfortunately, the sensitivity of surgical and anaesthesia staff to this hazard has waned over the past 25 years with cessation of the use of flammable anaesthetic agents. Prevention of surgical fires requires understanding the risks and effective communication between surgical, anaesthesia, and operating nursing staffs. Preventive measures exist but have yet to diffuse sufficiently across professional boundaries. Based on a review of relevant databases, decades of experience from field investigations, and a review of the medical literature, this paper discusses the incidence of surgical fires, the responsibility for prevention in the perioperative setting, and the procedures for surgical fire prevention and extinguishment. PMID:15576710

How can activity-based costing methodology be performed as a powerful tool to calculate costs and secure appropriate patient care?

PubMed

Lin, Blossom Yen-Ju; Chao, Te-Hsin; Yao, Yuh; Tu, Shu-Min; Wu, Chun-Ching; Chern, Jin-Yuan; Chao, Shiu-Hsiung; Shaw, Keh-Yuong

2007-04-01

Previous studies have shown the advantages of using activity-based costing (ABC) methodology in the health care industry. The potential values of ABC methodology in health care are derived from the more accurate cost calculation compared to the traditional step-down costing, and the potentials to evaluate quality or effectiveness of health care based on health care activities. This project used ABC methodology to profile the cost structure of inpatients with surgical procedures at the Department of Colorectal Surgery in a public teaching hospital, and to identify the missing or inappropriate clinical procedures. We found that ABC methodology was able to accurately calculate costs and to identify several missing pre- and post-surgical nursing education activities in the course of treatment.

Are paediatric operations evidence based? A prospective analysis of general surgery practice in a teaching paediatric hospital.

PubMed

Zani-Ruttenstock, Elke; Zani, Augusto; Bullman, Emma; Lapidus-Krol, Eveline; Pierro, Agostino

2015-01-01

Paediatric surgical practice should be based upon solid scientific evidence. A study in 1998 (Baraldini et al., Pediatr Surg Int) indicated that only a quarter of paediatric operations were supported by the then gold standard of evidence based medicine (EBM) which was defined by randomized controlled trials (RCTs). The aim of the current study was to re-evaluate paediatric surgical practice 16 years after the previous study in a larger cohort of patients. A prospective observational study was performed in a tertiary level teaching hospital for children. The study was approved by the local research ethics board. All diagnostic and therapeutic procedures requiring a general anaesthetic carried out over a 4-week period (24 Feb 2014-22 Mar 2014) under the general surgery service or involving a general paediatric surgeon were included in the study. Pubmed and EMBASE were used to search in the literature for the highest level of evidence supporting the recorded procedures. Evidence was classified according to the Oxford Centre for Evidence Based Medicine (OCEBM) 2009 system as well as according to the classification used by Baraldini et al. Results was compared using Χ (2) test. P < 0.05 was considered statistically significant. During the study period, 126 operations (36 different types) were performed on 118 patients. According to the OCEBM classification, 62 procedures (49 %) were supported by systematic reviews of multiple homogeneous RCTs (level 1a), 13 (10 %) by individual RCTs (level 1b), 5 (4 %) by systematic reviews of cohort studies (level 2a), 11 (9 %) by individual cohort studies, 1 (1 %) by systematic review of case-control studies (level 3a), 14 (11 %) by case-control studies (level 3b), 9 (7 %) by case series (type 4) and 11 procedures (9 %) were based on expert opinion or deemed self-evident interventions (type 5). High level of evidence (OCEBM level 1a or 1b or level I according to Baraldini et al. PSI 1998) supported 75 (60 %) operations in the current study compared to 18 (26 %) in the study of 1998 (P < 0.0001). The present study shows that nowadays a remarkable number of paediatric surgical procedures are supported by high level of evidence. Despite this improvement in evidence-based paediatric surgical practice, more than a third of the procedures still lack sufficient evidence-based literature support. More RCTs are warranted to support and direct paediatric surgery practice according to the principals of EBM.

Image-Based Patient-Specific Ventricle Models with Fluid-Structure Interaction for Cardiac Function Assessment and Surgical Design Optimization

PubMed Central

Tang, Dalin; Yang, Chun; Geva, Tal; del Nido, Pedro J.

2010-01-01

Recent advances in medical imaging technology and computational modeling techniques are making it possible that patient-specific computational ventricle models be constructed and used to test surgical hypotheses and replace empirical and often risky clinical experimentation to examine the efficiency and suitability of various reconstructive procedures in diseased hearts. In this paper, we provide a brief review on recent development in ventricle modeling and its potential application in surgical planning and management of tetralogy of Fallot (ToF) patients. Aspects of data acquisition, model selection and construction, tissue material properties, ventricle layer structure and tissue fiber orientations, pressure condition, model validation and virtual surgery procedures (changing patient-specific ventricle data and perform computer simulation) were reviewed. Results from a case study using patient-specific cardiac magnetic resonance (CMR) imaging and right/left ventricle and patch (RV/LV/Patch) combination model with fluid-structure interactions (FSI) were reported. The models were used to evaluate and optimize human pulmonary valve replacement/insertion (PVR) surgical procedure and patch design and test a surgical hypothesis that PVR with small patch and aggressive scar tissue trimming in PVR surgery may lead to improved recovery of RV function and reduced stress/strain conditions in the patch area. PMID:21344066

Accurate multi-robot targeting for keyhole neurosurgery based on external sensor monitoring.

PubMed

Comparetti, Mirko Daniele; Vaccarella, Alberto; Dyagilev, Ilya; Shoham, Moshe; Ferrigno, Giancarlo; De Momi, Elena

2012-05-01

Robotics has recently been introduced in surgery to improve intervention accuracy, to reduce invasiveness and to allow new surgical procedures. In this framework, the ROBOCAST system is an optically surveyed multi-robot chain aimed at enhancing the accuracy of surgical probe insertion during keyhole neurosurgery procedures. The system encompasses three robots, connected as a multiple kinematic chain (serial and parallel), totalling 13 degrees of freedom, and it is used to automatically align the probe onto a desired planned trajectory. The probe is then inserted in the brain, towards the planned target, by means of a haptic interface. This paper presents a new iterative targeting approach to be used in surgical robotic navigation, where the multi-robot chain is used to align the surgical probe to the planned pose, and an external sensor is used to decrease the alignment errors. The iterative targeting was tested in an operating room environment using a skull phantom, and the targets were selected on magnetic resonance images. The proposed targeting procedure allows about 0.3 mm to be obtained as the residual median Euclidean distance between the planned and the desired targets, thus satisfying the surgical accuracy requirements (1 mm), due to the resolution of the diffused medical images. The performances proved to be independent of the robot optical sensor calibration accuracy.

Trends in Gender-affirming Surgery in Insured Patients in the United States

PubMed Central

Ives, Graham C.; Sluiter, Emily C.; Waljee, Jennifer F.; Yao, Tsung-Hung; Hu, Hsou Mei

2018-01-01

Background: An estimated 0.6% of the U.S. population identifies as transgender and an increasing number of patients are presenting for gender-related medical and surgical services. Utilization of health care services, especially surgical services, by transgender patients is poorly understood beyond survey-based studies. In this article, our aim is 2-fold; first, we intend to demonstrate the utilization of datasets generated by insurance claims data as a means of analyzing gender-related health services, and second, we use this modality to provide basic demographic, utilization, and outcomes data about the insured transgender population. Methods: The Truven MarketScan Database, containing data from 2009 to 2015, was utilized, and a sample set was created using the Gender Identity Disorder diagnosis code. Basic demographic information and utilization of gender-affirming procedures was tabulated. Results: We identified 7,905 transgender patients, 1,047 of which underwent surgical procedures from 2009 to 2015. Our demographic results were consistent with previous survey-based studies, suggesting transgender patients are on average young adults (average age = 29.8), and geographically diverse. The most common procedure from 2009 to 2015 was mastectomy. Complications of all gender-affirming procedures was 5.8%, with the highest rate of complications occurring with phalloplasty. There was a marked year-by-year increase in utilization of surgical services. Conclusion: Transgender care and gender confirming surgery are an increasing component of health care in the United States. The data contained in existing databases can provide demographic, utilization, and outcomes data relevant to providers caring for the transgender patient population. PMID:29876180

Uncommon combinations of ICD10-PCS or ICD-9-CM operative procedure codes account for most inpatient surgery at half of Texas hospitals.

PubMed

O'Neill, Liam; Dexter, Franklin; Park, Sae-Hwan; Epstein, Richard H

2017-09-01

Recently, there has been interest in activity-based cost accounting for inpatient surgical procedures to facilitate "value based" analyses. Research 10-20years ago, performed using data from 3 large teaching hospitals, found that activity-based cost accounting was practical and useful for modeling surgeons and subspecialties, but inaccurate for individual procedures. We hypothesized that these older results would apply to hundreds of hospitals, currently evaluable using administrative databases. Observational study. State of Texas hospital discharge abstract data for 1st quarter of 2016, 4th quarter of 2015, 1st quarter of 2015, and 4th quarter of 2014. Discharged from an acute care hospital in Texas with at least 1 major therapeutic ("operative") procedure. Counts of discharges for each procedure or combination of procedures, classified by ICD-10-PCS or ICD-9-CM. At the average hospital, most surgical discharges were for procedures performed at most once a month at the hospital (54%, 95% confidence interval [CI] 51% to 55%). At the average hospital, approximately 90% of procedures were performed at most once a month at the hospital (93%, CI 93% to 94%). The percentages were insensitive to the quarter of the year. The percentages were 3% to 6% greater with ICD-10-PCS than for the superseded ICD 9 CM. There are many different procedure codes, and many different combinations of codes, relative to the number of different hospital discharges. Since most procedures at most hospitals are performed no more than once a month, activity-based cost accounting with a sample size sufficient to be useful is impractical for the vast majority of procedures, in contrast to analysis by surgeon and/or subspecialty. Copyright © 2017 Elsevier Inc. All rights reserved.

Fundamental Use of Surgical Energy (FUSE): An Essential Educational Program for Operating Room Safety

PubMed Central

Jones, Stephanie B; Munro, Malcolm G; Feldman, Liane S; Robinson, Thomas N; Brunt, L Michael; Schwaitzberg, Steven D; Jones, Daniel B; Fuchshuber, Pascal R

2017-01-01

Operating room (OR) safety has become a major concern in patient safety since the 1990s. Improvement of team communication and behavior is a popular target for safety programming at the institutional level. Despite these efforts, essential safety gaps remain in the OR and procedure rooms. A prime example is the use of energy-based devices in ORs and procedural areas. The lack of fundamental understanding of energy device function, design, and application contributes to avoidable injury and harm at a rate of approximately 1 to 2 per 1000 patients in the US. Hundreds of OR fires occur each year in the US, some causing severe injury and even death. Most of these fires are associated with the use of energy-based surgical devices. In response to this safety issue, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) developed the Fundamental Use of Surgical Energy (FUSE) program. This program includes a standardized curriculum targeted to surgeons, other physicians, and allied health care professionals and a psychometrically designed and validated certification test. A successful FUSE certification documents acquisition of the basic knowledge needed to safely use energy-based devices in the OR. By design FUSE fills a void in the curriculum and competency assessment for surgeons and other procedural specialists in the use of energy-based devices in patients. PMID:28241913

The effects of local nitroglycerin on the surgical delay procedure in prefabricated flaps by vascular implant in rats.

PubMed

Sá, Jairo Zacchê de; Aguiar, José Lamartine de Andrade; Cruz, Adriana Ferreira; Schuler, Alexandre Ricardo Pereira; Lima, José Ricardo Alves de; Marques, Olga Martins

2012-12-01

To evaluate the effect of local nitroglycerin on the viable area of a prefabricated flap for vascular implant in rats, and to investigate the surgical delay procedure. A femoral pedicle was implanted under the skin of the abdominal wall in forty Wistar rats. The animals were divided into four groups of ten: group 1 - without surgical delay procedure and local nitroglycerin; group 2 - with surgical delay procedure, but without local nitroglycerin; group 3 - without surgical delay procedure, but with local nitroglycerin; and group 4 - with simultaneous surgical delay procedure and local nitroglycerin. The percentages of the viable areas, in relation to the total flap, were calculated using AutoCAD R 14. The mean percentage value of the viable area was 8.9% in the group 1. 49.4% in the group 2; 8.4% in the group 3 and 1.1% in the group 4. There was significant difference between groups 1 and 2 (p=0.005), 1 and 4 (p=0.024), 2 and 3 (p=0.003), 2 and 4 (p=0.001). These results support the hypothesis that the closure of the arterial venous channels is responsible for the phenomenon of surgical delay procedure. Local nitroglycerin did not cause an increase in the prefabricated viable flap area by vascular implantation and decreased the viable flap area that underwent delay procedures.

Neurological Complications Related to Elective Orthopedic Surgery: Part 1: Common Shoulder and Elbow Procedures.

PubMed

Dwyer, Tim; Henry, Patrick D G; Cholvisudhi, Phantila; Chan, Vincent W S; Theodoropoulos, John S; Brull, Richard

2015-01-01

Many anesthesiologists are unfamiliar with the rate of surgical neurological complications of the shoulder and elbow procedures for which they provide local anesthetic-based anesthesia and/or analgesia. Part 1 of this narrative review series on neurological complications of elective orthopedic surgery describes the mechanisms and likelihood of peripheral nerve injury associated with some of the most common shoulder and elbow procedures, including open and arthroscopic shoulder procedures, elbow arthroscopy, and total shoulder and elbow replacement. Despite the many articles available, the overall number of studied patients is relatively low. Large prospective trials are required to establish the true incidence of neurological complications following elective shoulder and elbow surgery. As the popularity of regional anesthesia increases with the development of ultrasound guidance, anesthesiologists should have a thoughtful understanding of the nerves at risk of surgical injury during elective shoulder and elbow procedures.

Modeling of Tool-Tissue Interactions for Computer-Based Surgical Simulation: A Literature Review

PubMed Central

Misra, Sarthak; Ramesh, K. T.; Okamura, Allison M.

2009-01-01

Surgical simulators present a safe and potentially effective method for surgical training, and can also be used in robot-assisted surgery for pre- and intra-operative planning. Accurate modeling of the interaction between surgical instruments and organs has been recognized as a key requirement in the development of high-fidelity surgical simulators. Researchers have attempted to model tool-tissue interactions in a wide variety of ways, which can be broadly classified as (1) linear elasticity-based, (2) nonlinear (hyperelastic) elasticity-based finite element (FE) methods, and (3) other techniques that not based on FE methods or continuum mechanics. Realistic modeling of organ deformation requires populating the model with real tissue data (which are difficult to acquire in vivo) and simulating organ response in real time (which is computationally expensive). Further, it is challenging to account for connective tissue supporting the organ, friction, and topological changes resulting from tool-tissue interactions during invasive surgical procedures. Overcoming such obstacles will not only help us to model tool-tissue interactions in real time, but also enable realistic force feedback to the user during surgical simulation. This review paper classifies the existing research on tool-tissue interactions for surgical simulators specifically based on the modeling techniques employed and the kind of surgical operation being simulated, in order to inform and motivate future research on improved tool-tissue interaction models. PMID:20119508

Racial/Ethnic Disparities in Perioperative Outcomes of Major Procedures: Results From the National Surgical Quality Improvement Program.

PubMed

Ravi, Praful; Sood, Akshay; Schmid, Marianne; Abdollah, Firas; Sammon, Jesse D; Sun, Maxine; Klett, Dane E; Varda, Briony; Peabody, James O; Menon, Mani; Kibel, Adam S; Nguyen, Paul L; Trinh, Quoc-Dien

2015-12-01

To determine the association between race/ethnicity and perioperative outcomes in individuals undergoing major oncologic and nononcologic surgical procedures in the United States. Prior work has shown that there are significant racial/ethnic disparities in perioperative outcomes after several types of major cardiac, general, vascular, orthopedic, and cancer surgical procedures. However, recent evidence suggests attenuation of these racial/ethnic differences, particularly at academic institutions. We utilized the American College of Surgeons National Surgical Quality Improvement Program database to identify 142,344 patients undergoing one of the 16 major cancer and noncancer surgical procedures between 2005 and 2011. Eighty-five percent of the cohort was white, with black and Hispanic individuals comprising 8% and 4%, respectively. In multivariable analyses, black patients had greater odds of experiencing prolonged length of stay after 10 of the 16 procedures studied (all P < 0.05), though there was no disparity in odds of 30-day mortality after any surgery. Hispanics were more likely to experience prolonged length of stay after 5 surgical procedures (all P < 0.04), and were at greater odds of dying within 30 days after colectomy, heart valve repair/replacement, or abdominal aortic aneurysm repair (all P < 0.03). Fewer disparities were observed for Hispanics, than for black patients, and also for cancer, than for noncancer surgical procedures. Important racial/ethnic disparities in perioperative outcomes were observed among patients undergoing major cancer and noncancer surgical procedures at American College of Surgeons National Surgical Quality Improvement Program institutions. There were fewer disparities among individuals undergoing cancer surgery, though black patients, in particular, were more likely to experience prolonged length of stay.

Surgical correction of the snout suffocation syndrome.

PubMed

Keipper, V L; Chikes, P G

1990-04-01

Two nursing home patients with difficulty breathing because of occlusion of the mouth and nares by an involuntary snout reflex-like mannerism have previously been described. In both cases advanced dementia, edentia, and a downward-angled nasal base were present. Life-threatening hypoxia occurred intermittently in one case, and after becoming severe, was corrected by the surgical procedure described.

Abdominoplasty: Risk Factors, Complication Rates, and Safety of Combined Procedures.

PubMed

Winocour, Julian; Gupta, Varun; Ramirez, J Roberto; Shack, R Bruce; Grotting, James C; Higdon, K Kye

2015-11-01

Among aesthetic surgery procedures, abdominoplasty is associated with a higher complication rate, but previous studies are limited by small sample sizes or single-institution experience. A cohort of patients who underwent abdominoplasty between 2008 and 2013 was identified from the CosmetAssure database. Major complications were recorded. Univariate and multivariate analysis was performed evaluating risk factors, including age, smoking, body mass index, sex, diabetes, type of surgical facility, and combined procedures. The authors identified 25,478 abdominoplasties from 183,914 procedures in the database. Of these, 8,975 patients had abdominoplasty alone and 16,503 underwent additional procedures. The number of complications recorded was 1,012 (4.0 percent overall rate versus 1.4 percent in other aesthetic surgery procedures). Of these, 31.5 percent were hematomas, 27.2 percent were infections and 20.2 percent were suspected or confirmed venous thromboembolism. On multivariate analysis, significant risk factors (p < 0.05) included male sex (relative risk, 1.8), age 55 years or older (1.4), body mass index greater than or equal to 30 (1.3), multiple procedures (1.5), and procedure performance in a hospital or surgical center versus office-based surgical suite (1.6). Combined procedures increased the risk of complication (abdominoplasty alone, 3.1 percent; with liposuction, 3.8 percent; breast procedure, 4.3 percent; liposuction and breast procedure, 4.6 percent; body-contouring procedure, 6.8 percent; liposuction and body-contouring procedure, 10.4 percent). Abdominoplasty is associated with a higher complication rate compared with other aesthetic procedures. Combined procedures can significantly increase complication rates and should be considered carefully in higher risk patients. Risk, II.

Surgical treatment of buried penis.

PubMed

Lipszyc, E; Pfister, C; Liard, A; Mitrofanoff, P

1997-10-01

The buried penis is a rare congenital entity, whose treatment is surgical. There are few publications concerning this matter. The authors report on their experience in 10 cases (1990-1995). In this abnormality, the tip of the glans does not project from the pubic or scrotal skin. It is due to: 1) an excessive development of the penile fascia which retracts the penis; 2) insufficient attachment of the penile skin at the base of the penis; 3) often excessive prepubic fat worsens the appearance of the abnormality but does not by itself totally explain it; 4) a tight phimosis is often present. Surgical treatment is necessary because this aspect tends to persist even after puberty. One cannot indeed count on the development at the age of puberty, neither on the diminution of the fat, nor on the simple cure of the phimosis. One must above all ban circumcision which causes the risk of eliminating the skin necessary for reconstruction. The surgical procedure will comprise: 1) a longitudinal dorsal incision extended circumferentially; 2) resection of the thickened fascia penis; 3) anchoring of the deep face of the dermis to the proximal part of the fascia penis at the base of the penis. This surgical procedure has always brought a significant improvement to the appearance of the penis.

Generating Models of Surgical Procedures using UMLS Concepts and Multiple Sequence Alignment

PubMed Central

Meng, Frank; D’Avolio, Leonard W.; Chen, Andrew A.; Taira, Ricky K.; Kangarloo, Hooshang

2005-01-01

Surgical procedures can be viewed as a process composed of a sequence of steps performed on, by, or with the patient’s anatomy. This sequence is typically the pattern followed by surgeons when generating surgical report narratives for documenting surgical procedures. This paper describes a methodology for semi-automatically deriving a model of conducted surgeries, utilizing a sequence of derived Unified Medical Language System (UMLS) concepts for representing surgical procedures. A multiple sequence alignment was computed from a collection of such sequences and was used for generating the model. These models have the potential of being useful in a variety of informatics applications such as information retrieval and automatic document generation. PMID:16779094

Operating room data management: improving efficiency and safety in a surgical block.

PubMed

Agnoletti, Vanni; Buccioli, Matteo; Padovani, Emanuele; Corso, Ruggero M; Perger, Peter; Piraccini, Emanuele; Orelli, Rebecca Levy; Maitan, Stefano; Dell'amore, Davide; Garcea, Domenico; Vicini, Claudio; Montella, Teresa Maria; Gambale, Giorgio

2013-03-11

European Healthcare Systems are facing a difficult period characterized by increasing costs and spending cuts due to economic problems. There is the urgent need for new tools which sustain Hospitals decision makers work. This project aimed to develop a data recording system of the surgical process of every patient within the operating theatre. The primary goal was to create a practical and easy data processing tool to give hospital managers, anesthesiologists and surgeons the information basis to increase operating theaters efficiency and patient safety. The developed data analysis tool is embedded in an Oracle Business Intelligence Environment, which processes data to simple and understandable performance tachometers and tables. The underlying data analysis is based on scientific literature and the projects teams experience with tracked data. The system login is layered and different users have access to different data outputs depending on their professional needs. The system is divided in the tree profile types Manager, Anesthesiologist and Surgeon. Every profile includes subcategories where operators can access more detailed data analyses. The first data output screen shows general information and guides the user towards more detailed data analysis. The data recording system enabled the registration of 14.675 surgical operations performed from 2009 to 2011. Raw utilization increased from 44% in 2009 to 52% in 2011. The number of high complexity surgical procedures (≥120 minutes) has increased in certain units while decreased in others. The number of unscheduled procedures performed has been reduced (from 25% in 2009 to 14% in 2011) while maintaining the same percentage of surgical procedures. The number of overtime events decreased in 2010 (23%) and in 2011 (21%) compared to 2009 (28%) and the delays expressed in minutes are almost the same (mean 78 min). The direct link found between the complexity of surgical procedures, the number of unscheduled procedures and overtime show a positive impact of the project on OR management. Despite a consistency in the complexity of procedures (19% in 2009 and 21% in 2011), surgical groups have been successful in reducing the number of unscheduled procedures (from 25% in 2009 to 14% in 2011) and overtime (from 28% in 2009 to 21% in 2011). The developed project gives healthcare managers, anesthesiologists and surgeons useful information to increase surgical theaters efficiency and patient safety. In difficult economic times is possible to develop something that is of some value to the patient and healthcare system too.

Operating room data management: improving efficiency and safety in a surgical block

PubMed Central

2013-01-01

Background European Healthcare Systems are facing a difficult period characterized by increasing costs and spending cuts due to economic problems. There is the urgent need for new tools which sustain Hospitals decision makers work. This project aimed to develop a data recording system of the surgical process of every patient within the operating theatre. The primary goal was to create a practical and easy data processing tool to give hospital managers, anesthesiologists and surgeons the information basis to increase operating theaters efficiency and patient safety. Methods The developed data analysis tool is embedded in an Oracle Business Intelligence Environment, which processes data to simple and understandable performance tachometers and tables. The underlying data analysis is based on scientific literature and the projects teams experience with tracked data. The system login is layered and different users have access to different data outputs depending on their professional needs. The system is divided in the tree profile types Manager, Anesthesiologist and Surgeon. Every profile includes subcategories where operators can access more detailed data analyses. The first data output screen shows general information and guides the user towards more detailed data analysis. The data recording system enabled the registration of 14.675 surgical operations performed from 2009 to 2011. Results Raw utilization increased from 44% in 2009 to 52% in 2011. The number of high complexity surgical procedures (≥120 minutes) has increased in certain units while decreased in others. The number of unscheduled procedures performed has been reduced (from 25% in 2009 to 14% in 2011) while maintaining the same percentage of surgical procedures. The number of overtime events decreased in 2010 (23%) and in 2011 (21%) compared to 2009 (28%) and the delays expressed in minutes are almost the same (mean 78 min). The direct link found between the complexity of surgical procedures, the number of unscheduled procedures and overtime show a positive impact of the project on OR management. Despite a consistency in the complexity of procedures (19% in 2009 and 21% in 2011), surgical groups have been successful in reducing the number of unscheduled procedures (from 25% in 2009 to 14% in 2011) and overtime (from 28% in 2009 to 21% in 2011). Conclusions The developed project gives healthcare managers, anesthesiologists and surgeons useful information to increase surgical theaters efficiency and patient safety. In difficult economic times is possible to develop something that is of some value to the patient and healthcare system too. PMID:23496977

Training femoral neck screw insertion skills to surgical trainees: computer-assisted surgery versus conventional fluoroscopic technique.

PubMed

Nousiainen, Markku T; Omoto, Daniel M; Zingg, Patrick O; Weil, Yoram A; Mardam-Bey, Sami W; Eward, William C

2013-02-01

: Femoral neck fractures are among the most common orthopaedic injuries impacting the health care system. Surgical management of such fractures with cannulated screws is a commonly performed procedure. The acquisition of surgical skills necessary to perform this procedure typically involves learning on real patients with fluoroscopic guidance. This study attempts to determine if a novel computer-navigated training model improves the learning of this basic surgical skill. A multicenter, prospective, randomized, and controlled study was conducted using surgical trainees with no prior experience in surgically managing femoral neck fractures. After a training session, participants underwent a pretest by performing the surgical task (screw placement) on a simulated hip fracture using fluoroscopic guidance. Immediately after, participants were randomized into either undergoing a training session using conventional fluoroscopy or computer-based navigation. Immediate posttest, retention (4 weeks later), and transfer tests were performed. Performance during the tests was determined by radiographic analysis of hardware placement. Screw placement by trainees was ultimately equal to the level of an expert surgeon with either training technique. Participants who trained with computer navigation took fewer attempts to position hardware and used less fluoroscopy time than those trained with fluoroscopy. When those trained with fluoroscopy used computer navigation at the transfer test, less fluoroscopy time and dosage was used. The concurrent augmented feedback provided by computer navigation did not affect the learning of this basic surgical skill in surgical novices. No compromise in learning occurred if the surgical novice trained with one type of technology and transferred to using the other. The findings of this study suggest that computer navigation may be safely used to train surgical novices in a basic procedure. This model avoids using both live patients and harmful radiation without a compromise in the acquisition of a 3-dimensional technical skill.

The Met Needs for Pediatric Surgical Conditions in Sierra Leone: Estimating the Gap.

PubMed

Burgos, Carmen Mesas; Bolkan, Håkon Angell; Bash-Taqi, Donald; Hagander, Lars; Von Screeb, Johan

2018-03-01

In low- and middle-income countries, there is a gap between the need for surgery and its equitable provision, and a lack of proxy indicators to estimate this gap. Sierra Leone is a West African country with close to three million children. It is unknown to what extent the surgical needs of these children are met. To describe a nationwide provision of pediatric surgical procedures and to assess pediatric hernia repair as a proxy indicator for the shortage of surgical care in the pediatric population in Sierra Leone. We analyzed results from a nationwide facility survey in Sierra Leone that collected data on surgical procedures from operation and anesthesia logbooks in all facilities performing surgery. We included data on all patients under the age of 16 years undergoing surgery. Primary outcomes were rate and volume of surgical procedures. We calculated the expected number of inguinal hernia in children and estimated the unmet need for hernia repair. In 2012, a total of 2381 pediatric surgical procedures were performed in Sierra Leone. The rate of pediatric surgical procedures was 84 per 100,000 children 0-15 years of age. The most common pediatric surgical procedure was hernia repair (18%), corresponding to a rate of 16 per 100,000 children 0-15 years of age. The estimated unmet need for inguinal hernia repair was 88%. The rate of pediatric surgery in Sierra Leone was very low, and inguinal hernia was the single most common procedure noted among children in Sierra Leone.

Pattern of periodontal treatments performed at the periodontology clinic of the Lagos University Teaching Hospital: 22 months review.

PubMed

Umeizudike, K A; Ayanbadejo, P O; Savage, K O; Taiwo, O A

2012-01-01

A critical evaluation of the pattern of periodontal procedures performed is important in providing useful data to the administrator for proper planning and budgeting for dental health service. To assess the pattern of periodontal treatments performed over a given period of time at the Periodontology clinic of the Lagos University Teaching Hospital, Lagos, Nigeria. This was a twenty two months retrospective study of all periodontal procedures performed on patients seen at the periodontology clinic of the Lagos University Teaching Hospital between January 2006 and October 2007. The periodontology treatment record was used to retrieve information which included the patient's age, gender, diagnosis and periodontal procedures given. The procedures were further categorized into surgical and nonsurgical groups. The information obtained was then analyzed using Epi Info 2007 statistical software. A total of 1,938 patients were seen during this period. Females were 1009 (52.1%) and males were 929 (47.9%). (F/M, 1.1:1). A total of 2,110 periodontal treatments were performed. Majority of the patients received non-surgical periodontal therapy which constituted the bulk (96.3%) of the therapies. Scaling and polishing was the most frequently performed non-surgical procedure accounting for 1261 (62.1%) with slightly more males receiving the treatment. Of the surgical treatment modalities, operculectomy accounted for 65.4% and was carried out on more females than males. Regenerative procedures were the least performed surgical treatments. This study highlighted that non-surgical periodontal therapy, particularly scaling and polishing was the most frequently utilized periodontal procedure. Operculectomy was the predominant surgical procedure performed. The low percentage of regenerative surgical procedures was however below the desired expectation.

Early clinical experience with the da Vinci Xi Surgical System in general surgery.

PubMed

Hagen, Monika E; Jung, Minoa K; Ris, Frederic; Fakhro, Jassim; Buchs, Nicolas C; Buehler, Leo; Morel, Philippe

2017-09-01

The da Vinci Xi Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) has been released in 2014 to facilitate minimally invasive surgery. Novel features are targeted towards facilitating complex multi-quadrant procedures, but data is scarce so far. Perioperative data of patients who underwent robotic general surgery with the da Vinci Xi system within the first 6 month after installation were collected and analyzed. The gastric bypass procedures performed with the da Vinci Xi Surgical System were compared to an equal amount of the last procedures with the da Vinci Si Surgical System. Thirty-one foregut (28 Roux-en-Y gastric bypasses), 6 colorectal procedures and 1 revisional biliary procedure were performed. The mean operating room (OR) time was 221.8 (±69.0) minutes for gastric bypasses and 306.5 (±48.8) for colorectal procedures with mean docking time of 9.4 (±3.8) minutes. The gastric bypass procedure was transitioned from a hybrid to a fully robotic approach. In comparison to the last 28 gastric bypass procedures performed with the da Vinci Si Surgical System, the OR time was comparable (226.9 versus 230.6 min, p = 0.8094), but the docking time significantly longer with the da Vinci Xi Surgical System (8.5 versus 6.1 min, p = 0.0415). All colorectal procedures were performed with a single robotic docking. No intraoperative and two postoperative complications occurred. The da Vinci Xi might facilitate single-setups of totally robotic gastric bypass and colorectal surgeries. However, further comparable research is needed to clearly determine the significance of this latest version of the da Vinci Surgical System.

Povidone-iodine induced post-surgical irritant contact dermatitis localized outside of the surgical incision area. Report of 27 cases and a literature review.

PubMed

Borrego, Leopoldo; Hernández, Noelia; Hernández, Zaida; Peñate, Yeray

2016-05-01

Povidone-iodine solution is an antiseptic that is used worldwide as surgical paint and is considered to have a low irritant potential. Post-surgical severe irritant dermatitis has been described after the misuse of this antiseptic in the surgical setting. Between January 2011 and June 2013, 27 consecutive patients with post-surgical contact dermatitis localized outside of the surgical incision area were evaluated. Thirteen patients were also available for patch testing. All patients developed dermatitis the day after the surgical procedure. Povidone-iodine solution was the only liquid in contact with the skin of our patients. Most typical lesions were distributed in a double lumbar parallel pattern, but they were also found in a random pattern or in areas where a protective pad or an occlusive medical device was glued to the skin. The patch test results with povidone-iodine were negative. Povidone-iodine-induced post-surgical dermatitis may be a severe complication after prolonged surgical procedures. As stated in the literature and based on the observation that povidone-iodine-induced contact irritant dermatitis occurred in areas of pooling or occlusion, we speculate that povidone-iodine together with occlusion were the causes of the dermatitis epidemic that occurred in our surgical setting. Povidone-iodine dermatitis is a problem that is easily preventable through the implementation of minimal routine changes to adequately dry the solution in contact with the skin. © 2015 The International Society of Dermatology.

Economic and organizational sustainability of a negative-pressure portable device for the prevention of surgical-site complications

PubMed Central

Foglia, Emanuela; Ferrario, Lucrezia; Garagiola, Elisabetta; Signoriello, Giuseppe; Pellino, Gianluca; Croce, Davide; Canonico, Silvestro

2017-01-01

Purpose Surgical-site complications (SSCs) affect patients’ clinical pathway, prolonging their hospitalization and incrementing their management costs. The present study aimed to assess the economic and organizational implications of a portable device for negative-pressure wound therapy (NPWT) implementation, compared with the administration of pharmacological therapies alone for preventing surgical complications in patients undergoing general, cardiac, obstetrical–gynecological, or orthopedic surgical procedures. Patients and methods A total of 8,566 hospital procedures, related to the year 2015 from one hospital, were evaluated considering infection risk index, occurrence rates of SSCs, drug therapies, and surgical, diagnostic, and specialist procedures and hematological exams. Activity-based costing and budget impact analyses were implemented for the economic assessment. Results Patients developing an SSC absorbed i) 64.27% more economic resources considering the length of stay (€ 8,269±2,096 versus € 5,034±2,901, p<0.05) and ii) 42.43% more economic resources related to hematological and diagnostic procedures (€ 639±117 versus € 449±72, p<0.05). If the innovative device had been used over the 12-month time period, it would have decreased the risk of developing SSCs; the hospital would have realized an average reduction in health care expenditure equal to −0.69% (−€ 483,787.92) and an organizational saving in terms of length of stay equal to −1.10% (−898 days), thus allowing 95 additional procedures. Conclusion The implementation of a portable device for NPWT would represent an effective and sustainable strategy for reducing the management costs of patients. Economic and organizational savings could be reinvested, thus i) treating a wider population and ii) reducing waiting lists, with a higher effectiveness in terms of a decrease in complications. PMID:28652788

Effects of obesity surgery on non-insulin-dependent diabetes mellitus.

PubMed

Greenway, Scott E; Greenway, Frank L; Klein, Stanley

2002-10-01

Most individuals who have non-insulin-dependent diabetes mellitus are obese. The obese population has proved a frustrating entity regarding weight loss and diabetes control. Results of medical weight loss programs, medications, and behavior therapy have proved disappointing. Bariatric surgery is the most effective method of diabetes management and cure in the morbidly obese population. Surgical procedures to cause malabsorption provide a more dramatic effect on diabetes owing to the imparted bypass of the hormonally active foregut. Pertinent journal articles spanning the last 40 years, as well as textbooks. Bariatric surgical procedures have proven a much more successful method of weight loss and diabetes control in the obese population than conservative methods. These surgical procedures have proven safe with reported mortality rates of 0% to 1.5%. Bariatric operations may be divided based on the method of weight loss and effect on diabetes. The first category is restrictive and includes vertical banded gastroplasty and adjustable silicone gastric banding. These operations improve diabetes by decreasing food intake and body weight with a slowing of gastric emptying. The second category not only contains restrictive components but also elements of malabsorption. This category includes the Roux-en-Y gastric bypass and biliary-pancreatic diversion, which bypass the foregut. Although all of the surgical procedures for obesity offer improved weight loss and diabetes control compared with conservative methods, the Roux-en-Y gastric bypass and biliary-pancreatic diversion offer superior weight loss and resolution of diabetes. The more dramatic effect seen in the surgical procedures to cause malabsorption is likely secondary to the bypass of the foregut resulting in increased weight loss and elevation of the enteroglucagon level.

[Pediatric cardiovascular surgical data base registry in México. First report].

PubMed

Cervantes-Salazar, Jorge; Calderón-Colmenero, Juan; Ramírez-Marroquín, Samuel; Palacios-Macedo, Alexis; Bolio-Cerdán, Alejandro; Vizcaíno Alarcón, Alfredo; Curi-Curi, Pedro; de la Llata, Manuel; Erdmenger-Orellana, Julio; González, Julieta; García-Soriano, Federico; Calderón, Alejandro; Casillas, Luis; Villanueva, Filiberto; Sánchez-Ramírez, Roberto; Osnaya, Héctor; Necoechea, Juan Carlos; Alva-Espinoza, Carlos; Prado-Villegas, Guillermo

2013-01-01

Current world tendency is the detection of health problems in order to offer solution alternatives by means of the development of computarized data bases. To present the results of a computerized data base developed for the registry of pediatric cardiac surgery with the support of Asociación Mexicana de Especialistas en Cardiopatías Congénitas (AMECC, A.C.). A one-year analysis (from August 1, 2011 to July 31, 2012) of a computerized data base was performed with the support of AMECC and the participation of the most important Mexican institutions for pediatric surgical heart disease health care, particularly for the uninsured population. There were 7 health institutions voluntarily incorporated to the national data base registry, and in the first year of observation, 943 surgical procedures in 880 patients and 7% re-operations (n = 63), were reported. Patients up to one-year old accounted for 38%. The most frequent types of operated congenital heart diseases were: patent ductus arteriosus (n = 96), ventricular septal defect (n = 86), tetralogy of Fallot (n = 72), atrial septal defect (n = 68), and aortic coarctation (n = 54). Elective procedures were 90%, and 62% of them were performed with the use of cardiopulmonary bypass. Overall mortality was 7.5% with the following RACHS-1 score risk distribution: 1 (n = 4.2%), 2 (n = 19.6%), 3 (n = 22.8%), 4 (n = 12.19%), 5 (n = 1.25%), 6 (n = 6.44%) and not classifiable (n = 2.9%). Although this analysis gives a representative vision of the cardiovascular surgical health care for the uninsured national pediatric population, the incorporation of other health institutions to this data base may lead us to have a most realistic overview in relation to the surgical cardiovascular health care for the up to 18 year-old population.

Simulation-based otolaryngology - head and neck surgery boot camp: 'how I do it'.

PubMed

Chin, C J; Chin, C A; Roth, K; Rotenberg, B W; Fung, K

2016-03-01

In otolaryngology, surgical emergencies can occur at any time. An annual surgical training camp (or 'boot camp') offers junior residents from across North America the opportunity to learn and practice these skills in a safe environment. The goals of this study were to describe the set-up and execution of a simulation-based otolaryngology boot camp and to determine participants' confidence in performing routine and emergency on-call procedures in stressful situations before and after the boot camp. There were three main components of the boot camp: task trainers, simulations and an interactive panel discussion. Surveys were given to participants before and after the boot camp, and their confidence in performing the different tasks was assessed via multiple t-tests. Participants comprised 22 residents from 12 different universities; 10 of these completed both boot camp surveys. Of the nine tasks, the residents reported a significant improvement in confidence levels for six, including surgical airway and orbital haematoma management. An otolaryngology boot camp gives residents the chance to learn and practice emergency skills before encountering the emergencies in everyday practice. Their confidence in multiple skillsets was significantly improved after the boot camp. Given the shift towards competency-based learning in medical training, this study has implications for all surgical and procedural specialties.

A comparison of case volumes among urologic surgeons identified on an industry-sponsored website to an all provider peer group.

PubMed

See, William A; Jacobson, Kenneth; Derus, Sue; Langenstroer, Peter

2014-11-01

Industry-sponsored websites for robotic surgery direct to surgeons listed as performing specific robotic surgical procedures. The purpose of this study was to compare average annual, surgeon-specific, case volumes for those procedures for which they were listed as performing on the commercial website with the volumes of all providers performing these same procedures across a defined geographic region. A list of providers within the state of Wisconsin cited as performing specific urologic procedures was obtained through the Intuitive Surgical website 〈http://www.davincisurgery.com/da-vinci-urology/〉. Surgeon-specific annual case volumes from 2009 to 2013 for these same cases were obtained for all Wisconsin providers through DataBay Resources (Warrendale, PA) based on International classification of diseases-9 codes. Procedural activity was rank ordered, and surgeons were placed in "volume deciles" derived from the total annual number of cases performed by all surgeons. The distribution of commercially listed surgeon volumes, both 5-year average and most recent year, was compared with the average and 2013 volumes of all surgeons performing a specific procedure. A total of 35 individual urologic surgeons listed as performing robotic surgery in Wisconsin were identified through a "search" using the Intuitive Surgical website. Specific procedure analysis returned 5, 12, 9, and 15 surgeon names for cystectomy, partial nephrectomy, radical nephrectomy, and prostatectomy, respectively. This compared with the total number of surgeons who had performed the listed procedure in Wisconsin at least 1 time during the prior 5 years of 123, 153, 242, and 165, respectively. When distributed by surgeon-volume deciles, surgeons listed on industry-sponsored sites varied widely in their respective volume decile. More than half of site-listed, procedure-specific surgeons fell below the fifth decile for surgeon volume. Data analysis based solely on 2013 case volumes had no effect on the number of website-listed surgeons whose volumes fell below the fifth decile. Surgeons listed on an industry-sponsored website demonstrate wide variation in the actual volume of specific procedures performed. The inferred endorsement of competence by commercial sites has the potential to mislead patients seeking surgical expertise. Providers should consider the ethical and legal implications of these commercial advertising that do not have volume or outcome data. Published by Elsevier Inc.

The efficacy of virtual reality simulation training in laparoscopy: a systematic review of randomized trials.

PubMed

Larsen, Christian Rifbjerg; Oestergaard, Jeanett; Ottesen, Bent S; Soerensen, Jette Led

2012-09-01

Virtual reality (VR) simulators for surgical training might possess the properties needed for basic training in laparoscopy. Evidence for training efficacy of VR has been investigated by research of varying quality over the past decade. To review randomized controlled trials regarding VR training efficacy compared with traditional or no training, with outcome measured as surgical performance in humans or animals. In June 2011 Medline, Embase, the Cochrane Central Register of Controlled Trials, Web of Science and Google Scholar were searched using the following medical subject headings (MeSh) terms: Laparoscopy/standards, Computing methodologies, Programmed instruction, Surgical procedures, Operative, and the following free text terms: Virtual real* OR simulat* AND Laparoscop* OR train* Controlled trials. All randomized controlled trials investigating the effect of VR training in laparoscopy, with outcome measured as surgical performance. A total of 98 studies were screened, 26 selected and 12 included, with a total of 241 participants. Operation time was reduced by 17-50% by VR training, depending on simulator type and training principles. Proficiency-based training appeared superior to training based on fixed time or fixed numbers of repetition. Simulators offering training for complete operative procedures came out as more efficient than simulators offering only basic skills training. Skills in laparoscopic surgery can be increased by proficiency-based procedural VR simulator training. There is substantial evidence (grade IA - IIB) to support the use of VR simulators in laparoscopic training. © 2012 The Authors  Acta Obstetricia et Gynecologica Scandinavica© 2012 Nordic Federation of Societies of Obstetrics and Gynecology.

42 CFR 416.171 - Determination of payment rates for ASC services.

Code of Federal Regulations, 2013 CFR

2013-10-01

... services. (d) Limitation on payment rates for office-based surgical procedures and covered ancillary... nonfacility practice expense relative value units under § 414.22(b)(5)(i)(B) of this subchapter multiplied by... payment rate for covered ancillary radiology services that involve certain nuclear medicine procedures...

42 CFR 416.171 - Determination of payment rates for ASC services.

Code of Federal Regulations, 2012 CFR

2012-10-01

... payment rates for office-based surgical procedures and covered ancillary radiology services... relative value units under § 414.22(b)(5)(i)(B) of this subchapter multiplied by the conversion factor... ancillary radiology services that involve certain nuclear medicine procedures will be the amount determined...

42 CFR 416.171 - Determination of payment rates for ASC services.

Code of Federal Regulations, 2014 CFR

2014-10-01

... services. (d) Limitation on payment rates for office-based surgical procedures and covered ancillary... nonfacility practice expense relative value units under § 414.22(b)(5)(i)(B) of this subchapter multiplied by... payment rate for covered ancillary radiology services that involve certain nuclear medicine procedures...

Extended maxillotomy for skull base access in contemporary management of chordomas: Rationale and technical aspect.

PubMed

Abdul Jalil, Muhammad Fahmi; Story, Rowan D; Rogers, Myron

2017-05-01

Minimally invasive approaches to the central skull base have been popularized over the last decade and have to a large extent displaced 'open' procedures. However, traditional skull base surgery still has its role especially when dealing with a large clival chordoma where maximal surgical resection is the principal goal to maximize patient survival. In this paper, we present a case of a 25year-old male patient with chordoma in the inferior clivus which was initially debulked via a transnasal endoscopic approach. He unfortunately had a large recurrence of tumor requiring re-do resection. With the aim to achieve maximal surgical resection, we then chose the technique of a transoral approach with Le Fort 1 maxillotomy and midline palatal split. Post-operative course for the patient was uneventful and post-operative MRI confirmed significant debulking of the clival lesion. The technique employed for the surgical procedure is presented here in detail as is our experience over two decades using this technique for tumors, inflammatory lesions and congenital abnormalities at the cranio-cervical junction. Copyright © 2017 Elsevier Ltd. All rights reserved.

Identifying gaps in the surgical training curriculum in Rwanda through evaluation of operative activity at a teaching hospital.

PubMed

Rickard, Jennifer L; Ntakiyiruta, Georges; Chu, Kathryn M

2015-01-01

To define the operations performed by surgical residents at a tertiary referral hospital in Rwanda to help guide development of the residency program. Cross-sectional study of all patients operated by surgical residents from October 2012 to September 2013. University Teaching Hospital of Kigali (Centre Hospitalier Universitaire de Kigali [CHUK]), a public, tertiary referral hospital in Kigali, Rwanda. All patient data were entered into the operative database by surgical residents at CHUK. A total of 2833 cases were entered into the surgical database. Of them, 53 cases were excluded from further analysis because no surgical resident was listed as the primary or assistant surgeon, leaving 2780 cases for analysis. There were 2780 operations involving surgical residents. Of them, 51% of procedures were classified under general surgery, 38% orthopedics, 7% neurosurgery, and 4% urology. Emergency operations accounted for 64% of the procedures, with 56% of those being general surgery and 35% orthopedic. Further, 50% of all operations were trauma, with 71% of those orthopedic and 21% general surgery. Surgical faculty were involved in 45% of operations as either the primary or the assistant surgeons, while the remainder of operations did not involve surgical faculty. Residents were primary surgeons in 68% of procedures and assistant surgeons in 84% of procedures. The operative experience of surgery residents at CHUK primarily involves emergency and trauma procedures. Although this likely reflects the demographics of surgical care within Rwanda, more focus should be placed on elective procedures to ensure that surgical residents are broadly trained. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

A pilot survey of pediatric surgical capacity in West Africa.

PubMed

Okoye, Mekam T; Ameh, Emmanuel A; Kushner, Adam L; Nwomeh, Benedict C

2015-03-01

While some data exist for the burden of pediatric surgical disease in low- and middle-income countries (LMICs), little is known about pediatric surgical capacity. In an effort to better plan and allocate resources for pediatric surgical care in LMICs, a survey of pediatric surgical capacity using specific tool was needed. Based on the previously published Surgeons OverSeas Personnel, Infrastructure, Procedure, Equipment, and Supplies (PIPES) survey, a pediatric PIPES (PediPIPES) survey was created. To ensure relevance to local needs and inclusion of only essential items, a draft PediPIPES survey was reviewed by nine pediatric surgeons and modifications were incorporated into a final tool. The survey was then distributed to surgeons throughout sub-Saharan Africa. Data from West Africa (37 hospitals in 10 of the 16 countries in the subregion) were analyzed. Fewer than 50% (18/37) of the hospitals had more than two pediatric surgeons. Neonatal or general intensive care units were not available in 51.4% (19/37) of hospitals. Open procedures such as appendectomy were performed in all the hospitals whereas less-invasive interventions such as non-operative intussusception reduction were done in only 41% (15/37). Life-saving pediatric equipment such as apnea monitors were not available in 65% (24/37) of the hospitals. The PediPIPES survey was useful in documenting the pediatric surgical capacity in West Africa. Many hospitals in West Africa are not optimally prepared to undertake pediatric surgery. Our study showed shortages in personnel, infrastructure, procedures, equipment, and supplies necessary to adequately and appropriately provide surgical care for pediatric patients.

Problems faced by evidence-based medicine in evaluating lymphadenectomy for gastric cancer

PubMed Central

Verlato, Giuseppe; Giacopuzzi, Simone; Bencivenga, Maria; Morgagni, Paolo; De Manzoni, Giovanni

2014-01-01

Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy (D2) is the standard of care in Japan and South Korea since decades, while the majority of United States patients receive at most a limited lymphadenectomy (D1). United States and Northern Europe are considered the scientific leaders in medicine and evidence-based procedures are the cornerstone of their clinical practice. However, surgeons in Eastern Asia are more experienced, as there are more new cases of gastric cancer in Japan (107898 in 2012) than in the entire European Union (81592), or in South Korea (31269) than in the entire United States (21155). For quite a long time evidence-based medicine (EBM) did not solve the question whether D2 improves long-term prognosis with respect to D1. Indeed, eastern surgeons were reluctant to perform D1 even in the frame of a clinical trial, as their patients had a very good prognosis after D2. Evidence-based surgical indications provided by Western trials were questioned, as surgical procedures could not be properly standardized. In the present study we analyzed indications about the optimal extension of lymphadenectomy in gastric cancer according to current scientific literature (2008-2012) and surgical guidelines. We searched PubMed for papers using the key words “lymphadenectomy or D1 or D2” AND “gastric cancer” from 2008 to 2012. Moreover, we reviewed national guidelines for gastric cancer management. The support to D2 lymphadenectomy increased progressively from 2008 to 2012: since 2010 papers supporting D2 have achieved a higher overall impact factor than the other papers. Till 2011, D2 was the procedure of choice according to experts’ opinion, while three meta-analyses found no survival advantage after D2 with respect to D1. In 2012-2013, however, two meta-analyses reported that D2 improves prognosis with respect to D1. D2 lymphadenectomy was proposed as the standard of care for advanced gastric cancer by Japanese National Guidelines since 1981 and was adopted as the standard procedure by the Italian Research Group for Gastric Cancer since the Nineties. D2 is now indicated as the standard of surgical treatment with curative intent by the German, British and ESMO-ESSO-ESTRO guidelines. At variance American NCCN guidelines recommend a D1+ or a modified D2 lymph node dissection. In conclusion, D2 lymphadenectomy, originally developed by Eastern surgeons, is now becoming the procedure of choice also in the West. In gastric cancer surgery EBM is lagging behind national guidelines, rather than preceding and orienting them. To eliminate this lag, EBM should value to a larger extent Eastern Asian literature and should evaluate not only the quality of the study design but also the quality of surgical procedures. PMID:25278685

Problems faced by evidence-based medicine in evaluating lymphadenectomy for gastric cancer.

PubMed

Verlato, Giuseppe; Giacopuzzi, Simone; Bencivenga, Maria; Morgagni, Paolo; De Manzoni, Giovanni

2014-09-28

Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy (D2) is the standard of care in Japan and South Korea since decades, while the majority of United States patients receive at most a limited lymphadenectomy (D1). United States and Northern Europe are considered the scientific leaders in medicine and evidence-based procedures are the cornerstone of their clinical practice. However, surgeons in Eastern Asia are more experienced, as there are more new cases of gastric cancer in Japan (107898 in 2012) than in the entire European Union (81592), or in South Korea (31269) than in the entire United States (21155). For quite a long time evidence-based medicine (EBM) did not solve the question whether D2 improves long-term prognosis with respect to D1. Indeed, eastern surgeons were reluctant to perform D1 even in the frame of a clinical trial, as their patients had a very good prognosis after D2. Evidence-based surgical indications provided by Western trials were questioned, as surgical procedures could not be properly standardized. In the present study we analyzed indications about the optimal extension of lymphadenectomy in gastric cancer according to current scientific literature (2008-2012) and surgical guidelines. We searched PubMed for papers using the key words "lymphadenectomy or D1 or D2" AND "gastric cancer" from 2008 to 2012. Moreover, we reviewed national guidelines for gastric cancer management. The support to D2 lymphadenectomy increased progressively from 2008 to 2012: since 2010 papers supporting D2 have achieved a higher overall impact factor than the other papers. Till 2011, D2 was the procedure of choice according to experts' opinion, while three meta-analyses found no survival advantage after D2 with respect to D1. In 2012-2013, however, two meta-analyses reported that D2 improves prognosis with respect to D1. D2 lymphadenectomy was proposed as the standard of care for advanced gastric cancer by Japanese National Guidelines since 1981 and was adopted as the standard procedure by the Italian Research Group for Gastric Cancer since the Nineties. D2 is now indicated as the standard of surgical treatment with curative intent by the German, British and ESMO-ESSO-ESTRO guidelines. At variance American NCCN guidelines recommend a D1(+) or a modified D2 lymph node dissection. In conclusion, D2 lymphadenectomy, originally developed by Eastern surgeons, is now becoming the procedure of choice also in the West. In gastric cancer surgery EBM is lagging behind national guidelines, rather than preceding and orienting them. To eliminate this lag, EBM should value to a larger extent Eastern Asian literature and should evaluate not only the quality of the study design but also the quality of surgical procedures.

Z-DOC: a serious game for Z-plasty procedure training.

PubMed

Shewaga, Robert; Knox, Aaron; Ng, Gary; Kapralos, Bill; Dubrowski, Adam

2013-01-01

We present Z-DOC, a (prototype) serious game for training plastic surgery residents the steps comprising the Z-plasty surgical procedure. Z-DOC employs touch-based interactions and promotes competition amongst multiple players/users thus promote engagement and motivation. It is hypothesized that by learning the Z-plasty procedure in an interactive, engaging, and fun gaming environment, trainees will have a much better understanding of the procedure than by traditional learning modalities.

Android application for determining surgical variables in brain-tumor resection procedures

PubMed Central

Vijayan, Rohan C.; Thompson, Reid C.; Chambless, Lola B.; Morone, Peter J.; He, Le; Clements, Logan W.; Griesenauer, Rebekah H.; Kang, Hakmook; Miga, Michael I.

2017-01-01

Abstract. The fidelity of image-guided neurosurgical procedures is often compromised due to the mechanical deformations that occur during surgery. In recent work, a framework was developed to predict the extent of this brain shift in brain-tumor resection procedures. The approach uses preoperatively determined surgical variables to predict brain shift and then subsequently corrects the patient’s preoperative image volume to more closely match the intraoperative state of the patient’s brain. However, a clinical workflow difficulty with the execution of this framework is the preoperative acquisition of surgical variables. To simplify and expedite this process, an Android, Java-based application was developed for tablets to provide neurosurgeons with the ability to manipulate three-dimensional models of the patient’s neuroanatomy and determine an expected head orientation, craniotomy size and location, and trajectory to be taken into the tumor. These variables can then be exported for use as inputs to the biomechanical model associated with the correction framework. A multisurgeon, multicase mock trial was conducted to compare the accuracy of the virtual plan to that of a mock physical surgery. It was concluded that the Android application was an accurate, efficient, and timely method for planning surgical variables. PMID:28331887

Android application for determining surgical variables in brain-tumor resection procedures.

PubMed

Vijayan, Rohan C; Thompson, Reid C; Chambless, Lola B; Morone, Peter J; He, Le; Clements, Logan W; Griesenauer, Rebekah H; Kang, Hakmook; Miga, Michael I

2017-01-01

The fidelity of image-guided neurosurgical procedures is often compromised due to the mechanical deformations that occur during surgery. In recent work, a framework was developed to predict the extent of this brain shift in brain-tumor resection procedures. The approach uses preoperatively determined surgical variables to predict brain shift and then subsequently corrects the patient's preoperative image volume to more closely match the intraoperative state of the patient's brain. However, a clinical workflow difficulty with the execution of this framework is the preoperative acquisition of surgical variables. To simplify and expedite this process, an Android, Java-based application was developed for tablets to provide neurosurgeons with the ability to manipulate three-dimensional models of the patient's neuroanatomy and determine an expected head orientation, craniotomy size and location, and trajectory to be taken into the tumor. These variables can then be exported for use as inputs to the biomechanical model associated with the correction framework. A multisurgeon, multicase mock trial was conducted to compare the accuracy of the virtual plan to that of a mock physical surgery. It was concluded that the Android application was an accurate, efficient, and timely method for planning surgical variables.

The Development of Statistical Models for Predicting Surgical Site Infections in Japan: Toward a Statistical Model-Based Standardized Infection Ratio.

PubMed

Fukuda, Haruhisa; Kuroki, Manabu

2016-03-01

To develop and internally validate a surgical site infection (SSI) prediction model for Japan. Retrospective observational cohort study. We analyzed surveillance data submitted to the Japan Nosocomial Infections Surveillance system for patients who had undergone target surgical procedures from January 1, 2010, through December 31, 2012. Logistic regression analyses were used to develop statistical models for predicting SSIs. An SSI prediction model was constructed for each of the procedure categories by statistically selecting the appropriate risk factors from among the collected surveillance data and determining their optimal categorization. Standard bootstrapping techniques were applied to assess potential overfitting. The C-index was used to compare the predictive performances of the new statistical models with those of models based on conventional risk index variables. The study sample comprised 349,987 cases from 428 participant hospitals throughout Japan, and the overall SSI incidence was 7.0%. The C-indices of the new statistical models were significantly higher than those of the conventional risk index models in 21 (67.7%) of the 31 procedure categories (P<.05). No significant overfitting was detected. Japan-specific SSI prediction models were shown to generally have higher accuracy than conventional risk index models. These new models may have applications in assessing hospital performance and identifying high-risk patients in specific procedure categories.

Trends in the surgical management of stress urinary incontinence among female Medicare beneficiaries, 2002-2007.

PubMed

Rogo-Gupta, Lisa; Litwin, Mark S; Saigal, Christopher S; Anger, Jennifer T

2013-07-01

To describe trends in the surgical management of female stress urinary incontinence (SUI) in the United States from 2002 to 2007. As part of the Urologic Diseases of America Project, we analyzed data from a 5% national random sample of female Medicare beneficiaries aged 65 and older. Data were obtained from the Centers for Medicare and Medicaid Services carrier and outpatient files from 2002 to 2007. Women who were diagnosed with urinary incontinence identified by the International Classification of Diseases, Ninth Edition (ICD-9) diagnosis codes and who underwent surgical management identified by Current Procedural Terminology, Fourth Edition (CPT-4) procedure codes were included in the analysis. Trends were analyzed over the 6-year period. Unweighted procedure counts were multiplied by 20 to estimate the rate among all female Medicare beneficiaries. The total number of surgical procedures remained stable during the study period, from 49,340 in 2002 to 49,900 in 2007. Slings were the most common procedure across all years, which increased from 25,840 procedures in 2002 to 33,880 procedures in 2007. Injectable bulking agents were the second most common procedure, which accounted for 14,100 procedures in 2002 but decreased to 11,320 in 2007. Procedures performed in ambulatory surgery centers and physician offices increased, although those performed in inpatient settings declined. Hospital outpatient procedures remained stable. The surgical management of women with SUI shifted toward a dominance of procedures performed in ambulatory surgery centers from 2002 to 2007, although the overall number of procedures remained stable. Slings remained the dominant surgical procedure, followed by injectable bulking agents, both of which are easily performed in outpatient settings. Copyright © 2013 Elsevier Inc. All rights reserved.

Surgical Lasers In Gynecology

NASA Astrophysics Data System (ADS)

Schellhas, Helmut F.; Barnes, Alfonso E.

1982-12-01

Multipurpose surgical CO2 lasers marketed in the USA have been developed to be applicable to a variety of surgical procedures in many surgical fields. They are all suited for endoscopic surgical procedures and can be fitted to all standard surgical microscopes. They all can adjust the focal length of the laser beam to the different standard focal lengths of the surgical microscope which for instance in laryngoscopy is 400 mm and in colposcopy 300 mm. One laser instrument can even change the spot size in a given focal distance which is very advantageous for some microsurgical procedures (Merrimack Laboratories 820). All multipurpose surgical CO2 laser systems provide a multi-articulated surgical arm for free-hand surgery. The surgical arms are cumbersome to use but they are adapted to the surgeons needs with ingenuity. The practicality of the multi-articulated surgical arms depends mostly on the distance of the handpiece from the surgical console which now is also overbridged by the laser tube in most surgical laser system. The spot size of the beam is variable in most handpieces by interchangeable lenses which modify the focal distance of the beam and the power density. Another common feature in all systems is a coaxial He-Ne pilot light which provides a red spot which unfortunately becomes invisible in a bleeding surgical field. Most surgical laser systems have a spacial mode of TEM 00 which is essential for incisional surgery. The continuous mode of beam delivery is used for incisional surgery and also for most endoscopic procedures.

A PC-based Workstation for Robotic Discectomy

NASA Technical Reports Server (NTRS)

Casadei, C.; Fiorini, P.; Martelli, S.; Montanari, M.; Morri, A.

1998-01-01

Ths paper describes a PC-based controller for robot-assisted minimally invasive surgery. The development is motivated by the need of reducing the exposure of operating room personnel to X-rays during surgical procedures such as percutanrous discectomy.

Surgical scheduling categorization system (SSCS): A novel classification system to improve coordination and scheduling of operative cases in a tertiary pediatric medical system.

PubMed

Gantwerker, Eric A; Bannos, Cassandra; Cunningham, Michael J; Rahbar, Reza

2017-01-01

To describe a surgical categorization system to create a universal nomenclature, delineating patient complexity as a first step toward developing a true risk stratification system. Retrospective database review of all otolaryngology surgical procedures performed in a tertiary pediatric hospital system over one academic year (July 2012-June 2013). All otolaryngology surgical procedures were reviewed, encompassing 8478 procedures on 5711 patients. The attending otolaryngologist assigned surgical scheduling category (SSCS) at the time of case booking based on an institution specific guidelines. The guidelines are as follow: Category I was assigned to American Society of Anesthesiologists physical status classification (ASA) I/II patients, designating them appropriate for institution's suburban ambulatory surgery centers; Category II was ASA I/II patients with social or transportation issues; Category III was ASA I/II patients who required case coordination with other medical or surgical departments; Category IV was reserved for patients of any ASA class whom the surgeon designated to be of a higher complexity. 8478 total procedures analyzed with 7198 having complete records. 48% were Category I, 13.6% were Category II, 1.9% were Category III and 36.5% were Category IV. The ASA were 34.7% ASA I, 50% ASA II, 13.39% ASA III, and 1.9% ASA IV. Although the largest proportion of patients were ASA II (50%), 39.6% of all ASA II were Category IV. Category IV was split into 54.2% ASA II and 34% ASA III and shows that peri-operative surgical concerns were not encompassed by the ASA system. This surgical categorization system streamlines surgical scheduling in a tertiary pediatric hospital system, particularly with respect to the designation of cases as ambulatory surgery center or main operating room appropriate. The case mix complexity is also readily apparent, enhancing recognition of the coordination and attention required for the perioperative management of high complexity patients. The SSCS helps convey concerns not addressed by ASA physical status alone. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Surgical management of early endometrial cancer: an update and proposal of a therapeutic algorithm.

PubMed

Falcone, Francesca; Balbi, Giancarlo; Di Martino, Luca; Grauso, Flavio; Salzillo, Maria Elena; Messalli, Enrico Michelino

2014-07-26

In the last few years technical improvements have produced a dramatic shift from traditional open surgery towards a minimally invasive approach for the management of early endometrial cancer. Advancement in minimally invasive surgical approaches has allowed extensive staging procedures to be performed with significantly reduced patient morbidity. Debate is ongoing regarding the choice of a minimally invasive approach that has the most effective benefit for the patients, the surgeon, and the healthcare system as a whole. Surgical treatment of women with presumed early endometrial cancer should take into account the features of endometrial disease and the general surgical risk of the patient. Women with endometrial cancer are often aged, obese, and with cardiovascular and metabolic comorbidities that increase the risk of peri-operative complications, so it is important to tailor the extent and the radicalness of surgery in order to decrease morbidity and mortality potentially derivable from unnecessary procedures. In this regard women with negative nodes derive no benefit from unnecessary lymphadenectomy, but may develop short- and long-term morbidity related to this procedure. Preoperative and intraoperative techniques could be critical tools for tailoring the extent and the radicalness of surgery in the management of women with presumed early endometrial cancer. In this review we will discuss updates in surgical management of early endometrial cancer and also the role of preoperative and intraoperative evaluation of lymph node status in influencing surgical options, with the aim of proposing a management algorithm based on the literature and our experience.

Management options of non-syndromic sagittal craniosynostosis.

PubMed

Lee, Bryan S; Hwang, Lee S; Doumit, Gaby D; Wooley, Joseph; Papay, Francis A; Luciano, Mark G; Recinos, Violette M

2017-05-01

There have been various effective surgical procedures for the treatment of non-syndromic sagittal craniosynostosis, but no definitive guidelines for management have been established. We conducted a study to elucidate the current state of practice and establish a warranted standard of care. An Internet-based study was sent to 180 pediatric neurosurgeons across the country and 102 craniofacial plastic surgeons in fourteen different countries, to collect data for primary indication for surgical management, preference for timing and choice of surgery, and pre-, peri-, and post-operative management options. The overall response rate from both groups was 32% (n=90/284). Skull deformity was the primary indication for surgical treatment in patients without signs of hydrocephalus for both neurosurgeons and craniofacial surgeons (80% and 63%, respectively). Open surgical management was most commonly performed at six months of age by neurosurgeons (46%) and also by craniofacial surgeons (35%). Open surgical approach was favored for patients younger than four months of age by neurosurgeons (50%), but endoscopic approach was favored by craniofacial surgeons (35%). When performing an open surgical intervention, most neurosurgeons preferred pi or reversed pi procedure (27%), whereas total cranial vault remodeling was the most commonly performed procedure by craniofacial surgeons (37%). The data demonstrated a discrepancy in the treatment options for non-syndromic sagittal craniosynostosis. By conducting/comparing a wide survey to collect consolidative data from both groups of pediatric neurosurgeons and craniofacial plastic surgeons, we can attempt to facilitate the establishment of standard of care. Copyright © 2017 Elsevier Ltd. All rights reserved.

Surgical Management of Early Endometrial Cancer: An Update and Proposal of a Therapeutic Algorithm

PubMed Central

Falcone, Francesca; Balbi, Giancarlo; Di Martino, Luca; Grauso, Flavio; Salzillo, Maria Elena; Messalli, Enrico Michelino

2014-01-01

In the last few years technical improvements have produced a dramatic shift from traditional open surgery towards a minimally invasive approach for the management of early endometrial cancer. Advancement in minimally invasive surgical approaches has allowed extensive staging procedures to be performed with significantly reduced patient morbidity. Debate is ongoing regarding the choice of a minimally invasive approach that has the most effective benefit for the patients, the surgeon, and the healthcare system as a whole. Surgical treatment of women with presumed early endometrial cancer should take into account the features of endometrial disease and the general surgical risk of the patient. Women with endometrial cancer are often aged, obese, and with cardiovascular and metabolic comorbidities that increase the risk of peri-operative complications, so it is important to tailor the extent and the radicalness of surgery in order to decrease morbidity and mortality potentially derivable from unnecessary procedures. In this regard women with negative nodes derive no benefit from unnecessary lymphadenectomy, but may develop short- and long-term morbidity related to this procedure. Preoperative and intraoperative techniques could be critical tools for tailoring the extent and the radicalness of surgery in the management of women with presumed early endometrial cancer. In this review we will discuss updates in surgical management of early endometrial cancer and also the role of preoperative and intraoperative evaluation of lymph node status in influencing surgical options, with the aim of proposing a management algorithm based on the literature and our experience. PMID:25063051

Robotic technology in surgery: current status in 2008.

PubMed

Murphy, Declan G; Hall, Rohan; Tong, Raymond; Goel, Rajiv; Costello, Anthony J

2008-12-01

There is increasing patient and surgeon interest in robotic-assisted surgery, particularly with the proliferation of da Vinci surgical systems (Intuitive Surgical, Sunnyvale, CA, USA) throughout the world. There is much debate over the usefulness and cost-effectiveness of these systems. The currently available robotic surgical technology is described. Published data relating to the da Vinci system are reviewed and the current status of surgical robotics within Australia and New Zealand is assessed. The first da Vinci system in Australia and New Zealand was installed in 2003. Four systems had been installed by 2006 and seven systems are currently in use. Most of these are based in private hospitals. Technical advantages of this system include 3-D vision, enhanced dexterity and improved ergonomics when compared with standard laparoscopic surgery. Most procedures currently carried out are urological, with cardiac, gynaecological and general surgeons also using this system. The number of patients undergoing robotic-assisted surgery in Australia and New Zealand has increased fivefold in the past 4 years. The most common procedure carried out is robotic-assisted laparoscopic radical prostatectomy. Published data suggest that robotic-assisted surgery is feasible and safe although the installation and recurring costs remain high. There is increasing acceptance of robotic-assisted surgery, especially for urological procedures. The da Vinci surgical system is becoming more widely available in Australia and New Zealand. Other surgical specialties will probably use this technology. Significant costs are associated with robotic technology and it is not yet widely available to public patients.

A Multispecialty Evaluation of Thiel Cadavers for Surgical Training.

PubMed

Yiasemidou, Marina; Roberts, David; Glassman, Daniel; Tomlinson, James; Biyani, Shekhar; Miskovic, Danilo

2017-05-01

Changes in UK legislation allow for surgical procedures to be performed on cadavers. The aim of this study was to assess Thiel cadavers as high-fidelity simulators and to examine their suitability for surgical training. Surgeons from various specialties were invited to attend a 1 day dissection workshop using Thiel cadavers. The surgeons completed a baseline questionnaire on cadaveric simulation. At the end of the workshop, they completed a similar questionnaire based on their experience with Thiel cadavers. Comparing the answers in the pre- and post-workshop questionnaires assessed whether using Thiel cadavers had changed the surgeons' opinions of cadaveric simulation. According to the 27 participants, simulation is important for surgical training and a full-procedure model is beneficial for all levels of training. Currently, there is dissatisfaction with existing models and a need for high-fidelity alternatives. After the workshop, surgeons concluded that Thiel cadavers are suitable for surgical simulation (p = 0.015). Thiel were found to be realistic (p < 0.001) to have reduced odour (p = 0.002) and be more cost-effective (p = 0.003). Ethical constraints were considered to be small. Thiel cadavers are suitable for training in most surgical specialties.

Surgery of the globe and orbit.

PubMed

Cho, Jane

2008-02-01

Orbital anatomy and the indications and surgical techniques for a variety of small animal orbital/globe surgical procedures are discussed. Details of the more common orbital surgical procedures, including ocular evisceration, intrascleral prosthesis implantation, enucleation, and proptosis repair, are given. Common complications and postoperative considerations for these procedures are also discussed with an emphasis on the practical aspects.

Australian Defence Force surgical support to peacekeeping operations in East Timor.

PubMed

Chambers, Anthony J; Crozier, John A

2004-07-01

The Australian Defence Force (ADF) has provided surgical support to peacekeeping operations in East Timor since September 1999. The aim of the present paper is to document the wide range of surgical procedures performed by the ADF in East Timor from September 1999 to December 2002 on peacekeeping force personnel and the civilian population. Records of all surgical procedures performed by the ADF in East Timor from their arrival in September 1999 to December 2002 were retrospectively reviewed. Details of the type of procedures performed and anaesthetic administered, the age and sex of the patients and whether they were a member of peacekeeping forces or East Timorese civilian were recorded. There were 702 surgical procedures performed by the ADF in East Timor during this period, of which 401 (57%) were for peacekeeping force personnel and 301 (43%) were for East Timorese or other civilians. The most commonly performed procedures were for the management of non-battle wounds, accounting for 181 cases (26%). Battle-type wounds accounted for only 36 procedures (5%). Obstetric and gynaecology cases accounted for 30 procedures (4%). Fifty-six procedures (8%) were on children 12 years or younger. The wide range of surgical procedures performed by the ADF during peacekeeping operations in East Timor highlights the requirement for deployed surgeons to possess a broad range of clinical skills and has implications for their preparation and training. Battle-type wounds accounted for only a small proportion of procedures.

[Interdisciplinary teamwork in the OR: Identification and measurement of teamwork in the operating room].

PubMed

Passauer-Baierl, Stefanie; Baschnegger, Heiko; Bruns, Christiane; Weigl, Matthias

2014-01-01

Effective teamwork is one of the essentials in conducting successful and safe surgical procedures in the operating theatre (OT). The present paper aims to provide a selective review of various approaches describing effective interdisciplinary teamwork in the OT. Furthermore, it covers observational methods to assess OT teamwork with particular focus on Germany. Our definition of successful surgical teamwork is based on an already established classification system considering five criteria for effective and safe OT teams: coordination, communication, cooperation, leadership, and team monitoring. Well-defined and reliable measures are necessary to examine the quality of OT teamwork. Those methods should entail the special characteristics of the OT team. They should include all phases of the surgical procedure and incorporate all the professions involved (surgeons, surgical nurses, and anaesthetic staff). We conclude that research into methods for the assessment of OTs in Germany needs to be undertaken as a prerequisite to investigating the relationship between OT teamwork and its effects on patient safety and surgical quality. Copyright © 2013. Published by Elsevier GmbH.

Surgical rescue: The next pillar of acute care surgery.

PubMed

Kutcher, Matthew E; Sperry, Jason L; Rosengart, Matthew R; Mohan, Deepika; Hoffman, Marcus K; Neal, Matthew D; Alarcon, Louis H; Watson, Gregory A; Puyana, Juan Carlos; Bauzá, Graciela M; Schuchert, Vaishali D; Fombona, Anisleidy; Zhou, Tianhua; Zolin, Samuel J; Becher, Robert D; Billiar, Timothy R; Forsythe, Raquel M; Zuckerbraun, Brian S; Peitzman, Andrew B

2017-02-01

The evolving field of acute care surgery (ACS) traditionally includes trauma, emergency general surgery, and critical care. However, the critical role of ACS in the rescue of patients with a surgical complication has not been explored. We here describe the role of "surgical rescue" in the practice of ACS. A prospective, electronic medical record-based ACS registry spanning January 2013 to May 2014 at a large urban academic medical center was screened by ICD-9 codes for acute surgical complications of an operative or interventional procedure. Long-term outcomes were derived from the Social Security Death Index. Of 2,410 ACS patients, 320 (13%) required "surgical rescue": most commonly, from wound complications (32%), uncontrolled sepsis (19%), and acute obstruction (15%). The majority of complications (85%) were related to an operation; 15% were related to interventional procedures. The most common rescue interventions required were bowel resection (23%), wound debridement (18%), and source control of infection (17%); 63% of patients required operative intervention, and 22% required surgical critical care. Thirty-six percent of complications occurred in ACS primary patients ("local"), whereas 38% were referred from another surgical service ("institutional") and 26% referred from another institution ("regional"). Hospital length of stay was longer, and in-hospital and 1-year mortalities were higher in rescue patients compared with those without a complication. Outcomes were equivalent between "local" and "institutional" patients, but hospital length of stay and discharge to home were significantly worse in "institutional" referrals. We here describe the distinct role of the acute care surgeon in the surgical management of complications; this is an additional pillar of ACS. In this vital role, the acute care surgeon provides crucial support to other providers as well as direct patient care in the "surgical rescue" of surgical and procedural complications. Epidemiological study, level III; therapeutic/care management study, level IV.

Incidence and patterns of surgical glove perforations: experience from Addis Ababa, Ethiopia.

PubMed

Bekele, Abebe; Makonnen, Nardos; Tesfaye, Lidya; Taye, Mulat

2017-03-20

Surgical glove perforation is a common event. The operating staff is not aware of the perforation until the procedure is complete, sometimes in as high as 70% of the incidences. Data from Ethiopia indicates that the surgical workforce suffers from a very surgery related accidents, however there is paucity of data regarding surgical glove perforation. The main objective is to describe the incidence and patterns of surgical glove perforation during surgical procedures and to compare the rates between emergency and elective surgeries at one of the main hospitals in Addis Ababa Ethiopia. This is a prospective study, performed at the Minilik II referral hospital, Addis Ababa. All surgical gloves worn during all major surgical procedures (Emergency and Elective) from June 1-July 20, 2016 were collected and used for the study. Standardised visual and hydro insufflation techniques were used to test the gloves for perforations. Parameters recorded included type of procedure performed, number of perforations, localisation of perforation and the roles of the surgical team. A total of 2634 gloves were tested, 1588 from elective and 1026 from emergency procedures. The total rate of perforation in emergency procedures was 41.4%, while perforation in elective surgeries was 30.0%. A statistically significant difference (P < 0.05) was found in between emergency and elective surgeries. There were a very high rate of perforations of gloves among first surgeons 40.6% and scrub nurses 38.8% during elective procedures and among first surgeons (60.14%), and second assistants (53.0%) during emergency surgeries. Only 0.4% of inner gloves were perforated. The left hand, the left index finger and thumb were the most commonly perforated parts of the glove. Glove perforation rate was low among consultant surgeons than residents. Our reported perforation rate is higher than most publications, and this shows that the surgical workforce in Ethiopia is under a clear and present threat. Measures such as double gloving seems to have effectively prevented cutaneous blood exposure and thus should become a routine for all surgical procedures. Manufacturing related defects and faults in glove quality may also be contributing factors.

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.

Outcomes and Safety of the Combined Abdominoplasty-Hysterectomy: A Preliminary Study.

PubMed

Massenburg, Benjamin B; Sanati-Mehrizy, Paymon; Ingargiola, Michael J; Rosa, Jonatan Hernandez; Taub, Peter J

2015-10-01

Abdominoplasty (ABP) at the time of hysterectomy (HYS) has been described in the literature since 1986 and is being increasingly requested by patients. However, outcomes of the combined procedure have not been thoroughly explored. The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program database and identified each ABP, HYS, and combined ABP-HYS performed between 2005 and 2012. The incidence of complications in each of the three procedures was calculated, and a multiplicative-risk model was used to calculate the probability of a complication for a patient undergoing distinct HYS and ABP on different dates. One-sample binomial hypothesis tests were performed to determine statistical significance. There were 1325 ABP cases, 12,173 HYS cases, and 143 ABP-HYS cases identified. Surgical complications occurred in 7.7 % of patients undergoing an ABP-HYS, while the calculated risk of a surgical complication was 12.5 % (p = 0.0407) for patients undergoing separate ABP and HYS procedures. The mean operative time was significantly lower for an ABP-HYS at 238 vs. 270 min for separate ABP and HYS procedures (p < 0.0001), and the mean time under anesthesia was significantly lower at 295 vs. 364 min (p < 0.0001). A combined ABP-HYS has a lower incidence of surgical complications than separate ABP and HYS procedures performed on different dates. These data should not encourage all patients to elect a combined ABP-HYS, if only undergoing a HYS, as the combined procedure is associated with increased risks when compared to either isolated individual procedure. However, in patients who are planning on undergoing both procedures on separate dates, a combined ABP-HYS is a safe option that will result in fewer surgical complications, less operative time, less time under anesthesia, and a trend towards fewer days in the hospital. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The influence of resident involvement on surgical outcomes.

PubMed

Raval, Mehul V; Wang, Xue; Cohen, Mark E; Ingraham, Angela M; Bentrem, David J; Dimick, Justin B; Flynn, Timothy; Hall, Bruce L; Ko, Clifford Y

2011-05-01

Although the training of surgical residents is often considered in national policy addressing complications and safety, the influence of resident intraoperative involvement on surgical outcomes has not been well studied. We identified 607,683 surgical cases from 234 hospitals from the 2006 to 2009 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Outcomes were compared by resident involvement for all general and vascular cases as well as for specific general surgical procedures. After typical ACS NSQIP comorbidity risk adjustment and further adjustment for hospital teaching status and operative time in modeling, resident intraoperative involvement was associated with slightly increased morbidity when assessing overall general or vascular procedures (odds ratio [OR] 1.06; 95% CI 1.04 to 1.09), pancreatectomy or esophagectomy (OR 1.26; 95% CI 1.08 to 1.45), and colorectal resections (OR 1.15; 95% CI 1.09 to 1.22). In contrast, for mortality, resident intraoperative involvement was associated with reductions for overall general and vascular procedures (OR 0.91; 95% CI 0.84 to 0.99), colorectal resections (OR 0.88; 95% CI 0.78 to 0.99), and abdominal aortic aneurysm repair (OR 0.71; 95% CI 0.53 to 0.95). Results were moderated somewhat after hierarchical modeling was performed to account for hospital-level variation, with mortality results no longer reaching significance (overall morbidity OR 1.07; 95% CI 1.03 to 1.10, overall mortality OR 0.97; 95% CI 0.90 to 1.05). Based on risk-adjusted event rates, resident intraoperative involvement is associated with approximately 6.1 additional morbidity events but 1.4 fewer deaths per 1,000 general and vascular surgery procedures. Resident intraoperative participation is associated with slightly higher morbidity rates but slightly decreased mortality rates across a variety of procedures and is minimized further after taking into account hospital-level variation. These clinically small effects may serve to reassure patients and others that resident involvement in surgical care is safe and possibly protective with regard to mortality. Copyright © 2011 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Modeling surgical tool selection patterns as a "traveling salesman problem" for optimizing a modular surgical tool system.

PubMed

Nelson, Carl A; Miller, David J; Oleynikov, Dmitry

2008-01-01

As modular systems come into the forefront of robotic telesurgery, streamlining the process of selecting surgical tools becomes an important consideration. This paper presents a method for optimal queuing of tools in modular surgical tool systems, based on patterns in tool-use sequences, in order to minimize time spent changing tools. The solution approach is to model the set of tools as a graph, with tool-change frequency expressed as edge weights in the graph, and to solve the Traveling Salesman Problem for the graph. In a set of simulations, this method has shown superior performance at optimizing tool arrangements for streamlining surgical procedures.

Characterisation of Exposure to Ultrafine Particles from Surgical Smoke by Use of a Fast Mobility Particle Sizer.

PubMed

Ragde, Siri Fenstad; Jørgensen, Rikke Bramming; Føreland, Solveig

2016-08-01

Electrosurgery is a method based on a high frequency current used to cut tissue and coagulate small blood vessels during surgery. Surgical smoke is generated due to the heat created by electrosurgery. The carcinogenic potential of this smoke was assumed already in the 1980's and there has been a growing interest in the potential adverse health effects of exposure to the particles in surgical smoke. Surgical smoke is known to contain ultrafine particles (UFPs) but the knowledge about the exposure to UFPs produced by electrosurgery is however sparse. The aims of the study were therefore to characterise the exposure to UFPs in surgical smoke during different types of surgical procedures and on different job groups in the operating room, and to characterise the particle size distribution. Personal exposure measurements were performed on main surgeon, assistant surgeon, surgical nurse, and anaesthetic nurse during five different surgical procedures [nephrectomy, breast reduction surgery, abdominoplasty, hip replacement surgery, and transurethral resection of the prostate (TURP)]. The measurements were performed with a Fast Mobility Particle Sizer (FMPS) to assess the exposure to UPFs and to characterize the particle size distribution. Possible predictors of exposure were investigated using Linear Mixed Effect Models. The exposure to UFPs was highest during abdominoplasty arithmetic mean (AM) 3900 particles cm(-3) and lowest during hip replacement surgeries AM 400 particles cm(-3). The different job groups had similar exposure during the same types of surgical procedures. The use of electrosurgery resulted in short term high peak exposure (highest maximum peak value 272 000 particles cm(-3)) to mainly UFPs. The size distribution of particles varied between the different types of surgical procedures, where nephrectomy, hip replacement surgery, and TURP produced UFPs with a dominating mode of 9nm while breast reduction surgery and abdominoplasty produced UFPs with a dominating mode of 70 and 81nm, respectively. Type of surgery was the strongest predictor of exposure. When only including breast reduction surgery in the analysis, the use of one or two ES pencils during surgery was a significant predictor of exposure. When only including hip replacement surgery, the operating room was a significant predictor of exposure. The use of electrosurgery resulted in short-term high peak exposures to mainly UFPs in surgical smoke. Type of surgery was the strongest predictor of exposure and the different types of surgical procedures produced different sized particles. The job groups had similar exposure. Compared to other occupational exposures to UFPs involving hot processes, the personal exposure levels for UFPs were low during the use of electrosurgery. © The Author 2016. Published by Oxford University Press on behalf of the British Occupational Hygiene Society.

Mapping Population-Level Spatial Access to Essential Surgical Care in Ghana Using Availability of Bellwether Procedures.

PubMed

Stewart, Barclay T; Tansley, Gavin; Gyedu, Adam; Ofosu, Anthony; Donkor, Peter; Appiah-Denkyira, Ebenezer; Quansah, Robert; Clarke, Damian L; Volmink, Jimmy; Mock, Charles

2016-08-17

Conditions that can be treated by surgery comprise more than 16% of the global disease burden. However, 5 billion people do not have access to essential surgical care. An estimated 90% of the 87 million disability-adjusted life-years incurred by surgical conditions could be averted by providing access to timely and safe surgery in low-income and middle-income countries. Population-level spatial access to essential surgery in Ghana is not known. To assess the performance of bellwether procedures (ie, open fracture repair, emergency laparotomy, and cesarean section) as a proxy for performing essential surgery more broadly, to map population-level spatial access to essential surgery, and to identify first-level referral hospitals that would most improve access to essential surgery if strengthened in Ghana. Population-based study among all households and public and private not-for-profit hospitals in Ghana. Households were represented by georeferenced census data. First-level and second-level referral hospitals managed by the Ministry of Health and all tertiary hospitals were included. Surgical data were collected from January 1 to December 31, 2014. All procedures performed at first-level referral hospitals in Ghana in 2014 were used to sort each facility into 1 of the following 3 hospital groups: those without capability to perform all 3 bellwether procedures, those that performed 1 to 11 of each procedure, and those that performed at least 12 of each procedure. Candidates for targeted capability improvement were identified by cost-distance and network analysis. Of 155 first-level referral hospitals managed by the Ghana Health Service and the Christian Health Association of Ghana, 123 (79.4%) reported surgical data. Ninety-five (77.2%) did not have the capability in 2014 to perform all 3 bellwether procedures, 24 (19.5%) performed 1 to 11 of each bellwether procedure, and 4 (3.3%) performed at least 12. The essential surgical procedure rate was greater in bellwether procedure-capable first-level referral hospitals than in noncapable hospitals (median, 638; interquartile range, 440-1418 vs 360; interquartile range, 0-896 procedures per 100 000 population; P = .03). Population-level spatial access within 2 hours to a hospital that performed 1 to 11 and at least 12 of each bellwether procedure was 83.2% (uncertainty interval [UI], 82.2%-83.4%) and 71.4% (UI, 64.4%-75.0%), respectively. Five hospitals were identified for targeted capability improvement. Almost 30% of Ghanaians cannot access essential surgery within 2 hours. Bellwether capability is a useful metric for essential surgery more broadly. Similar strategic planning exercises might be useful for other low-income and middle-income countries aiming to improve access to essential surgery.

Did case-based payment influence surgical readmission rates in France? A retrospective study

PubMed Central

Vuagnat, Albert; Yilmaz, Engin; Roussot, Adrien; Rodwin, Victor; Gadreau, Maryse; Bernard, Alain; Creuzot-Garcher, Catherine; Quantin, Catherine

2018-01-01

Objectives To determine whether implementation of a case-based payment system changed all-cause readmission rates in the 30 days following discharge after surgery, we analysed all surgical procedures performed in all hospitals in France before (2002–2004), during (2005–2008) and after (2009–2012) its implementation. Setting Our study is based on claims data for all surgical procedures performed in all acute care hospitals with >300 surgical admissions per year (740 hospitals) in France over 11 years (2002–2012; n=51.6 million admissions). Interventions We analysed all-cause 30-day readmission rates after surgery using a logistic regression model and an interrupted time series analysis. Results The overall 30-day all-cause readmission rate following discharge after surgery increased from 8.8% to 10.0% (P<0.001) for the public sector and from 5.9% to 8.6% (P<0.001) for the private sector. Interrupted time series models revealed a significant linear increase in readmission rates over the study period in all types of hospitals. However, the implementation of case-based payment was only associated with a significant increase in rehospitalisation rates for private hospitals (P<0.001). Conclusion In France, the increase in the readmission rate appears to be relatively steady in both the private and public sector but appears not to have been affected by the introduction of a case-based payment system after accounting for changes in care practices in the public sector. PMID:29391376

Options to avoid the second surgical site: a review of literature.

PubMed

Ramachandra, Srinivas Sulugodu; Rana, Ritu; Reetika, Singhal; Jithendra, K D

2014-09-01

As esthetics gain importance, periodontal plastic surgical procedures involving soft tissue grafts are becoming commoner both around natural teeth as well as around implants. Periodontal soft tissue grafts are primarily used for the purpose of root coverage and in pre-prosthetic surgery to thicken a gingival site or to improve the crestal volume. Soft tissue grafts are usually harvested from the palate. Periodontal plastic surgical procedures involving soft tissue grafts harvested from the palate have two surgical sites; a recipient site and another donor site. Many patients are apprehensive about the soft tissue graft procedures, especially the creation of the second/donor surgical site in the palate. In the past decade, newer techniques and products have emerged which provide an option for the periodontist/patient to avoid the second surgical site. MucoMatrixX, Alloderm(®), Platelet rich fibrin, Puros(®) Dermis and Mucograft(®) are the various options available to the practicing periodontist to avoid the second surgical site. Use of these soft tissue allografts in an apprehensive patient would decrease patient morbidity and increase patient's acceptance towards periodontal plastic surgical procedures.

Outcomes after salvage procedures for the painful dislocated hip in cerebral palsy.

PubMed

Wright, Patrick B; Ruder, John; Birnbaum, Mark A; Phillips, Jonathan H; Herrera-Soto, Jose A; Knapp, Dennis R

2013-01-01

The painful dislocated hip in the setting of cerebral palsy is a challenging problem. Many surgical procedures have been reported to treat this condition with varying success rates. The purpose of this study is to retrospectively evaluate and compare the outcomes of 3 different surgical procedures performed at our institution for pain relief in patients with spastic quadriplegic cerebral palsy and painful dislocated hips. A retrospective chart review of the surgical procedures performed by 5 surgeons for spastic, painful dislocated hips from 1997 to 2010 was performed. The procedures identified were (1) proximal femoral resection arthroplasty (PFRA); (2) subtrochanteric valgus osteotomy (SVO) with femoral head resection; and (3) proximal femur prosthetic interposition arthroplasty (PFIA) using a humeral prosthesis. Outcomes based on pain and range of motion were determined to be excellent, good, fair, or poor by predetermined criteria. Forty-four index surgeries and 14 revision surgeries in 33 patients with an average follow-up of 49 months met the inclusion criteria. Of the index surgeries, 12 hips were treated with a PFRA, 21 with a SVO, and 11 with a PFIA. An excellent or good result was noted in 67% of PFRAs, 67% of SVOs, and 73% of PFIAs. No statistical significance between these procedures was achieved. The 14 revisions were performed because of a poor result from previous surgery, demonstrating a 24% reoperation rate overall. No patients classified as having a fair result underwent revision surgery. All patients receiving revision surgery were eventually classified as having an excellent or good result. Surgical treatment for the painful, dislocated hip in the setting of spastic quadriplegic cerebral palsy remains unsettled. There continue to be a large percentage of failures despite the variety of surgical techniques designed to treat this problem. These failures can be managed, however, and eventually resulted in a good outcome. We demonstrated a trend toward better outcomes with a PFIA, but further study should be conducted to prove statistical significance. III.

Surgical Treatment for Chronic Pancreatitis: Past, Present, and Future

PubMed Central

Welte, Maria; Izbicki, Jakob R.; Bachmann, Kai

2017-01-01

The pancreas was one of the last explored organs in the human body. The first surgical experiences were made before fully understanding the function of the gland. Surgical procedures remained less successful until the discovery of insulin, blood groups, and finally the possibility of blood donation. Throughout the centuries, the surgical approach went from radical resections to minimal resections or only drainage of the gland in comparison to an adequate resection combined with drainage procedures. Today, the well-known and standardized procedures are considered as safe due to the high experience of operating surgeons, the centering of pancreatic surgery in specialized centers, and optimized perioperative treatment. Although surgical procedures have become safer and more efficient than ever, the overall perioperative morbidity after pancreatic surgery remains high and management of postoperative complications stagnates. Current research focuses on the prevention of complications, optimizing the patient's general condition preoperatively and finding the appropriate timing for surgical treatment. PMID:28819358

Validation of a New Method to Automatically Select Cases With Intraoperative Red Blood Cell Transfusion for Audit.

PubMed

Dexter, Franklin; Epstein, Richard H; Ledolter, Johannes; Dasovich, Susan M; Herman, Jay H; Maga, Joni M; Schwenk, Eric S

2018-05-01

Hospitals review allogeneic red blood cell (RBC) transfusions for appropriateness. Audit criteria have been published that apply to 5 common procedures. We expanded on this work to study the management decision of selecting which cases involving transfusion of at least 1 RBC unit to audit (review) among all surgical procedures, including those previously studied. This retrospective, observational study included 400,000 cases among 1891 different procedures over an 11-year period. There were 12,616 cases with RBC transfusion. We studied the proportions of cases that would be audited based on criteria of nadir hemoglobin (Hb) greater than the hospital's selected transfusion threshold, or absent Hb or missing estimated blood loss (EBL) among procedures with median EBL <500 mL. This threshold EBL was selected because it is approximately the volume removed during the donation of a single unit of whole blood at a blood bank. Missing EBL is important to the audit decision for cases in which the procedures' median EBL is <500 mL because, without an indication of the extent of bleeding, there are insufficient data to assume that there was sufficient blood loss to justify the transfusion. Most cases (>50%) that would be audited and most cases (>50%) with transfusion were among procedures with median EBL <500 mL (P < .0001). Among cases with transfusion and nadir Hb >9 g/dL, the procedure's median EBL was <500 mL for 3.0 times more cases than for procedures having a median EBL ≥500 mL. A greater percentage of cases would be recommended for audit based on missing values for Hb and/or EBL than based on exceeding the Hb threshold among cases of procedures with median EBL ≥500 mL (P < .0001). There were 3.7 times as many cases with transfusion that had missing values for Hb and/or EBL than had a nadir Hb >9 g/dL and median EBL for the procedure ≥500 mL. An automated process to select cases for audit of intraoperative transfusion of RBC needs to consider the median EBL of the procedure, whether the nadir Hb is below the hospital's Hb transfusion threshold for surgical cases, and the absence of either a Hb or entry of the EBL for the case. This conclusion applies to all surgical cases and procedures.

Virtual reality simulation training of mastoidectomy - studies on novice performance.

PubMed

Andersen, Steven Arild Wuyts

2016-08-01

Virtual reality (VR) simulation-based training is increasingly used in surgical technical skills training including in temporal bone surgery. The potential of VR simulation in enabling high-quality surgical training is great and VR simulation allows high-stakes and complex procedures such as mastoidectomy to be trained repeatedly, independent of patients and surgical tutors, outside traditional learning environments such as the OR or the temporal bone lab, and with fewer of the constraints of traditional training. This thesis aims to increase the evidence-base of VR simulation training of mastoidectomy and, by studying the final-product performances of novices, investigates the transfer of skills to the current gold-standard training modality of cadaveric dissection, the effect of different practice conditions and simulator-integrated tutoring on performance and retention of skills, and the role of directed, self-regulated learning. Technical skills in mastoidectomy were transferable from the VR simulation environment to cadaveric dissection with significant improvement in performance after directed, self-regulated training in the VR temporal bone simulator. Distributed practice led to a better learning outcome and more consolidated skills than massed practice and also resulted in a more consistent performance after three months of non-practice. Simulator-integrated tutoring accelerated the initial learning curve but also caused over-reliance on tutoring, which resulted in a drop in performance when the simulator-integrated tutor-function was discontinued. The learning curves were highly individual but often plateaued early and at an inadequate level, which related to issues concerning both the procedure and the VR simulator, over-reliance on the tutor function and poor self-assessment skills. Future simulator-integrated automated assessment could potentially resolve some of these issues and provide trainees with both feedback during the procedure and immediate assessment following each procedure. Standard setting by establishing a proficiency level that can be used for mastery learning with deliberate practice could also further sophisticate directed, self-regulated learning in VR simulation-based training. VR simulation-based training should be embedded in a systematic and competency-based training curriculum for high-quality surgical skills training, ultimately leading to improved safety and patient care.

Depicting surgical anatomy of the porta hepatis in living donor liver transplantation.

PubMed

Kelly, Paul; Fung, Albert; Qu, Joy; Greig, Paul; Tait, Gordon; Jenkinson, Jodie; McGilvray, Ian; Agur, Anne

2017-01-01

Visualizing the complex anatomy of vascular and biliary structures of the liver on a case-by-case basis has been challenging. A living donor liver transplant (LDLT) right hepatectomy case, with focus on the porta hepatis, was used to demonstrate an innovative method to visualize anatomy with the purpose of refining preoperative planning and teaching of complex surgical procedures. The production of an animation-enhanced video consisted of many stages including the integration of pre-surgical planning; case-specific footage and 3D models of the liver and associated vasculature, reconstructed from contrast-enhanced CTs. Reconstructions of the biliary system were modeled from intraoperative cholangiograms. The distribution of the donor portal veins, hepatic arteries and bile ducts was defined from the porta hepatis intrahepatically to the point of surgical division. Each step of the surgery was enhanced with 3D animation to provide sequential and seamless visualization from pre-surgical planning to outcome. Use of visualization techniques such as transparency and overlays allows viewers not only to see the operative field, but also the origin and course of segmental branches and their spatial relationships. This novel educational approach enables integrating case-based operative footage with advanced editing techniques for visualizing not only the surgical procedure, but also complex anatomy such as vascular and biliary structures. The surgical team has found this approach to be beneficial for preoperative planning and clinical teaching, especially for complex cases. Each animation-enhanced video case is posted to the open-access Toronto Video Atlas of Surgery (TVASurg), an education resource with a global clinical and patient user base. The novel educational system described in this paper enables integrating operative footage with 3D animation and cinematic editing techniques for seamless sequential organization from pre-surgical planning to outcome.

Depicting surgical anatomy of the porta hepatis in living donor liver transplantation

PubMed Central

Fung, Albert; Qu, Joy; Greig, Paul; Tait, Gordon; Jenkinson, Jodie; McGilvray, Ian; Agur, Anne

2017-01-01

Visualizing the complex anatomy of vascular and biliary structures of the liver on a case-by-case basis has been challenging. A living donor liver transplant (LDLT) right hepatectomy case, with focus on the porta hepatis, was used to demonstrate an innovative method to visualize anatomy with the purpose of refining preoperative planning and teaching of complex surgical procedures. The production of an animation-enhanced video consisted of many stages including the integration of pre-surgical planning; case-specific footage and 3D models of the liver and associated vasculature, reconstructed from contrast-enhanced CTs. Reconstructions of the biliary system were modeled from intraoperative cholangiograms. The distribution of the donor portal veins, hepatic arteries and bile ducts was defined from the porta hepatis intrahepatically to the point of surgical division. Each step of the surgery was enhanced with 3D animation to provide sequential and seamless visualization from pre-surgical planning to outcome. Use of visualization techniques such as transparency and overlays allows viewers not only to see the operative field, but also the origin and course of segmental branches and their spatial relationships. This novel educational approach enables integrating case-based operative footage with advanced editing techniques for visualizing not only the surgical procedure, but also complex anatomy such as vascular and biliary structures. The surgical team has found this approach to be beneficial for preoperative planning and clinical teaching, especially for complex cases. Each animation-enhanced video case is posted to the open-access Toronto Video Atlas of Surgery (TVASurg), an education resource with a global clinical and patient user base. The novel educational system described in this paper enables integrating operative footage with 3D animation and cinematic editing techniques for seamless sequential organization from pre-surgical planning to outcome. PMID:29078606

Comparing Plastic Surgery and Otolaryngology Management in Cleft Care: An Analysis of 4,999 Cases.

PubMed

Jubbal, Kevin T; Zavlin, Dmitry; Olorunnipa, Shola; Echo, Anthony; Buchanan, Edward P; Hollier, Larry H

2017-12-01

Care for patients with cleft lip and palate is best managed by a craniofacial team consisting of a variety of specialists, including surgeons, who are generally plastic surgeons or otolaryngologists trained in the United States. The goal of this study was to compare the surgical approaches and management algorithms of cleft lip, cleft palate, and nasal reconstruction between plastic surgeons and otolaryngologists. We performed a retrospective analysis of the American College of Surgeons' National Surgical Quality Improvement Program Pediatric database between 2012 and 2014 to identify patients undergoing primary repair of cleft lip, cleft palate, and associated rhinoplasty. Two cohorts based on primary specialty, plastic surgeons and otolaryngologists, were compared in relation to patient characteristics, 30-day postoperative outcomes, procedure type, and intraoperative variables. Plastic surgeons performed the majority of surgical repairs, with 85.5% ( n  = 1,472) of cleft lip, 79.3% ( n  = 2,179) of cleft palate, and 87.9% ( n  = 465) of rhinoplasty procedures. There was no difference in the age of primary cleft lip repair or rhinoplasty. However, plastic surgeons performed primary cleft palate repair earlier than otolaryngologists ( p  = 0.03). Procedure type varied between the specialties. In rhinoplasty, otolaryngologists were more likely to use septal or ear cartilage, whereas plastic surgeons preferred rib cartilage. Results were similar, with no statistically significant difference in terms of mortality, reoperation, readmission, or complications. Significant variation exists in the treatment of cleft lip and palate based on specialty service with regard to procedure timing and type. However, short-term rates of mortality, wound occurrence, reoperation, readmission, and surgical or medical complications remain similar.

Technical skills assessment toolbox: a review using the unitary framework of validity.

PubMed

Ghaderi, Iman; Manji, Farouq; Park, Yoon Soo; Juul, Dorthea; Ott, Michael; Harris, Ilene; Farrell, Timothy M

2015-02-01

The purpose of this study was to create a technical skills assessment toolbox for 35 basic and advanced skills/procedures that comprise the American College of Surgeons (ACS)/Association of Program Directors in Surgery (APDS) surgical skills curriculum and to provide a critical appraisal of the included tools, using contemporary framework of validity. Competency-based training has become the predominant model in surgical education and assessment of performance is an essential component. Assessment methods must produce valid results to accurately determine the level of competency. A search was performed, using PubMed and Google Scholar, to identify tools that have been developed for assessment of the targeted technical skills. A total of 23 assessment tools for the 35 ACS/APDS skills modules were identified. Some tools, such as Operative Performance Rating System (OSATS) and Objective Structured Assessment of Technical Skill (OPRS), have been tested for more than 1 procedure. Therefore, 30 modules had at least 1 assessment tool, with some common surgical procedures being addressed by several tools. Five modules had none. Only 3 studies used Messick's framework to design their validity studies. The remaining studies used an outdated framework on the basis of "types of validity." When analyzed using the contemporary framework, few of these studies demonstrated validity for content, internal structure, and relationship to other variables. This study provides an assessment toolbox for common surgical skills/procedures. Our review shows that few authors have used the contemporary unitary concept of validity for development of their assessment tools. As we progress toward competency-based training, future studies should provide evidence for various sources of validity using the contemporary framework.

The Danish Inguinal Hernia database.

PubMed

Friis-Andersen, Hans; Bisgaard, Thue

2016-01-01

To monitor and improve nation-wide surgical outcome after groin hernia repair based on scientific evidence-based surgical strategies for the national and international surgical community. Patients ≥18 years operated for groin hernia. Type and size of hernia, primary or recurrent, type of surgical repair procedure, mesh and mesh fixation methods. According to the Danish National Health Act, surgeons are obliged to register all hernia repairs immediately after surgery (3 minute registration time). All institutions have continuous access to their own data stratified on individual surgeons. Registrations are based on a closed, protected Internet system requiring personal codes also identifying the operating institution. A national steering committee consisting of 13 voluntary and dedicated surgeons, 11 of whom are unpaid, handles the medical management of the database. The Danish Inguinal Hernia Database comprises intraoperative data from >130,000 repairs (May 2015). A total of 49 peer-reviewed national and international publications have been published from the database (June 2015). The Danish Inguinal Hernia Database is fully active monitoring surgical quality and contributes to the national and international surgical society to improve outcome after groin hernia repair.

Beyond usual care: the economic consequences of expanding treatment options in early pregnancy loss.

PubMed

Dalton, Vanessa K; Liang, Angela; Hutton, David W; Zochowski, Melissa K; Fendrick, A Mark

2015-02-01

The objective of this study was to estimate the economic consequences of expanding options for early pregnancy loss (EPL) treatment beyond expectant management and operating room surgical evacuation (usual care). We constructed a decision model using a hypothetical cohort of women undergoing EPL management within a 30 day horizon. Treatment options under the usual care arm include expectant management and surgical uterine evacuation in an operating room (OR). Treatment options under the expanded care arm included all evidence-based safe and effective treatment options for EPL: expectant management, misoprostol treatment, surgical uterine evacuation in an office setting, and surgical uterine evacuation in an OR. Probabilities of entering various treatment pathways were based on previously published observational studies. The cost per case was US $241.29 lower for women undergoing treatment in the expanded care model as compared with the usual care model (US $1033.29 per case vs US $1274.58 per case, expanded care and usual care, respectively). The model was the most sensitive to the failure rate of the expectant management arm, the cost of the OR surgical procedure, the proportion of women undergoing an OR surgical procedure under usual care, and the additional cost per patient associated with implementing and using the expanded care model. This study demonstrates that expanding women's treatment options for EPL beyond what is typically available can result in lower direct medical expenditures. Copyright © 2015 Elsevier Inc. All rights reserved.

Current Techniques of Teaching and Learning in Bariatric Surgical Procedures: A Systematic Review.

PubMed

Kaijser, Mirjam; van Ramshorst, Gabrielle; van Wagensveld, Bart; Pierie, Jean-Pierre

The gastric sleeve resection and gastric bypass are the 2 most commonly performed bariatric procedures. This article provides an overview of current teaching and learning methods of those techniques in resident and fellow training. A database search was performed on Pubmed, Embase, and the Education Resources Information Center (ERIC) to identify the methods used to provide training in bariatric surgery worldwide. After exclusion based on titles and abstracts, full texts of the selected articles were assessed. Included articles were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. In total, 2442 titles were identified and 14 full text articles met inclusion criteria. Four publications described an ex vivo training course, and 6 focused on at least 1 step of the gastric bypass procedure. Two randomized controlled trials (RCT) provided high-quality evidence on training aspects. Surgical coaching caused significant improvement of Bariatric Objective Structured Assessment of Technical Skills (BOSATS) scores (3.60 vs. 3.90, p = 0.017) and reduction of technical errors (18 vs. 10, p = 0.003). A preoperative warm-up increased global rating scales (GRS) scores on depth perception (p = 0.02), bimanual dexterity (p = 0.01), and efficiency of movements (p = 0.03). Stepwise education, surgical coaching, warming up, Internet-based knowledge modules, and ex vivo training courses are effective in relation to bariatric surgical training of residents and fellows, possibly shortening their learning curves. Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Operationalizing quality improvement in a pediatric surgical practice.

PubMed

Arca, Marjorie J; Enters, Jessica; Christensen, Melissa; Jeziorczak, Paul; Sato, Thomas T; Thielke, Robert; Oldham, Keith T

2014-01-01

Quality improvement (QI) is critical to enhancing patient care. It is necessary to prioritize which QI initiatives are relevant to one's institution and practice, as implementation is resource-intensive. We have developed and implemented a streamlined process to identify QI opportunities in our practice. We designed a web-based Pediatric and Infant Case Log and Outcomes (PICaLO) instrument using Research Electronic Data Capture (REDCap™) to record all surgical procedures for our practice. At the time of operation, a surgeon completes a case report form. An administrative assistant enters the data in PICaLO within 5-7days. Outcomes such as complications, deaths, and "occurrences" (readmissions, reoperations, transfers to ICU, ER visit, additional clinic visits) are recorded at the time of encounter, during M & M Conferences, and during follow-up clinic visits. Variables were chosen and defined based on national standards from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP), and Patient Based Learning Log. Occurrences are queried for potential QI initiatives. In 2012, 3597 patients were entered, totaling 5177 procedures. There were 220 complications, 278 occurrences, and 16 deaths. Specific QI opportunities were identified and put into place. Data on procedures and outcomes can be collected effectively in a pediatric surgery practice to delineate pertinent QI initiatives. PICaLO is recognized by the American Board of Surgery as a mechanism to meet Maintenance of Certification 4 criteria. © 2014.

First metatarsal closing base wedge osteotomy using real-time fluoroscopy.

PubMed

Toepp, F C; Salcedo, M

1991-01-01

A minimal incision surgery approach to metatarsus primus adductus is presented. The percutaneous closing base wedge osteotomy is performed using real-time intraoperative fluoroscopy. The advantages and disadvantages of this minimal incision surgical procedure are discussed.

Monitoring the quality of cardiac surgery based on three or more surgical outcomes using a new variable life-adjusted display.

PubMed

Gan, Fah Fatt; Tang, Xu; Zhu, Yexin; Lim, Puay Weng

2017-06-01

The traditional variable life-adjusted display (VLAD) is a graphical display of the difference between expected and actual cumulative deaths. The VLAD assumes binary outcomes: death within 30 days of an operation or survival beyond 30 days. Full recovery and bedridden for life, for example, are considered the same outcome. This binary classification results in a great loss of information. Although there are many grades of survival, the binary outcomes are commonly used to classify surgical outcomes. Consequently, quality monitoring procedures are developed based on binary outcomes. With a more refined set of outcomes, the sensitivities of these procedures can be expected to improve. A likelihood ratio method is used to define a penalty-reward scoring system based on three or more surgical outcomes for the new VLAD. The likelihood ratio statistic W is based on testing the odds ratio of cumulative probabilities of recovery R. Two methods of implementing the new VLAD are proposed. We accumulate the statistic W-W¯R to estimate the performance of a surgeon where W¯R is the average of the W's of a historical data set. The accumulated sum will be zero based on the historical data set. This ensures that if a new VLAD is plotted for a future surgeon of performance similar to this average performance, the plot will exhibit a horizontal trend. For illustration of the new VLAD, we consider 3-outcome surgical results: death within 30 days, partial and full recoveries. In our first illustration, we show the effect of partial recoveries on surgical results of a surgeon. In our second and third illustrations, the surgical results of two surgeons are compared using both the traditional VLAD based on binary-outcome data and the new VLAD based on 3-outcome data. A reversal in relative performance of surgeons is observed when the new VLAD is used. In our final illustration, we display the surgical results of four surgeons using the new VLAD based completely on 3-outcome data. Full recovery and bedridden for life are two completely different outcomes. There is a great loss of information when different grades of 'successful' operations are naively classified as survival. When surgical outcomes are classified more accurately into more than two categories, the resulting new VLAD will reveal more accurately and fairly the surgical results. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Sexual and functional results after creation of a neovagina in women with Mayer-Rokitansky-Küster-Hauser syndrome: a comparison of nonsurgical and surgical procedures.

PubMed

Morcel, Karine; Lavoué, Vincent; Jaffre, Frédérique; Paniel, Bernard-Jean; Rouzier, Roman

2013-07-01

To compare nonsurgical and surgical procedures for creation of a neovagina in women with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome in terms of sexual satisfaction. We report a cross-sectional study of 91 women with MRKH syndrome undergoing a neovagina creation procedure. They were members of the French National Association of Women with MRKH syndrome. We analyzed all answers to a questionnaire mailed to each woman. The questionnaire solicited short answers concerning the diagnosis and the neovagina procedure, and included the standardized FSFI (Female Sexual Function Index) questionnaire. All analyses were performed using the chi-squared test and Student's t-test. A p-value of <0.05 was considered statistically significant. Forty women answered the questionnaire. Twenty had been treated by Frank's method (non-surgical group) and 20 had undergone a surgical procedure, sigmoid vaginoplasty (12 cases) or Davidov's technique (8 cases) (surgical group). The mean time after neovagina creation was 7 years (range 1-44 years). The population characteristics did not differ significantly between the nonsurgical and surgical groups. The total FSFI score indicated good and similar functional results in the two groups (25.3±7.5 versus 25.3±8.0). Functional sexual outcomes after nonsurgical and surgical methods were similar. Therefore, the Frank's method should be proposed as first line therapy because it is less invasive than surgical procedures. In the case of failure of this technique or of refusal by the patient, surgical reconstruction may then be offered. Copyright © 2013. Published by Elsevier Ireland Ltd.

Application of a Compact High-Definition Exoscope for Illumination and Magnification in High-Precision Surgical Procedures.

PubMed

Krishnan, Kartik G; Schöller, Karsten; Uhl, Eberhard

2017-01-01

The basic necessities for surgical procedures are illumination, exposure, and magnification. These have undergone transformation in par with technology. One of the recent developments is the compact magnifying exoscope system. In this report, we describe the application of this system for surgical operations and discuss its advantages and pitfalls. We used the ViTOM exoscope mounted on the mechanical holding arm. The following surgical procedures were conducted: lumbar and cervical spinal canal decompression (n = 5); laminotomy and removal of lumbar migrated disk herniations (n = 4); anterior cervical diskectomy and fusion (n = 1); removal of intraneural schwannomas (n = 2); removal of an acute cerebellar hemorrhage (n = 1); removal of a parafalcine atypical cerebral hematoma caused by a dural arteriovenous fistula (n = 1); and microsutures and anastomoses of a nerve (n = 1), an artery (n = 1), and veins (n = 2). The exoscope offered excellent, magnified, and brilliantly illuminated high-definition images of the surgical field. All surgical operations were successfully completed. The main disadvantage was the adjustment and refocusing using the mechanical holding arm. The time required for the surgical operation under the exoscope was slightly longer than the times required for a similar procedure performed using an operating microscope. The magnifying exoscope is an effective and nonbulky tool for surgical procedures. In visualization around the corners, the exoscope has better potential than a microscope. With technical and technologic modifications, the exoscope might become the next generation in illumination, visualization, exposure, and magnification for high-precision surgical procedures. Copyright © 2016 Elsevier Inc. All rights reserved.

Comprehensive approach for post-prostatectomy incontinence in the era of robot-assisted radical prostatectomy

PubMed Central

Haga, Nobuhiro; Takinami, Ruriko; Tanji, Ryo; Onagi, Akifumi; Matsuoka, Kanako; Koguchi, Tomoyuki; Akaihata, Hidenori; Hata, Junya; Ogawa, Soichiro; Kataoka, Masao; Sato, Yuichi; Ishibashi, Kei; Aikawa, Ken; Kojima, Yoshiyuki

2017-01-01

Abstract Robot-assisted radical prostatectomy (RARP) has enabled steady and stable surgical procedures due to both meticulous maneuvers and magnified, clear, 3-dimensional vision. Therefore, better surgical outcomes have been expected with RARP than with other surgical modalities. However, even in the RARP era, post-prostatectomy incontinence has a relatively high incidence as a bothersome complication. To overcome post-prostatectomy incontinence, it goes without saying that meticulous surgical procedures and creative surgical procedures, i.e., “Preservation”, “Reconstruction”, and “Reinforcement” of the anatomical structures of the pelvis, are most important. In addition, medication and appropriate pad usage might sometimes be helpful for patients with post-prostatectomy incontinence. However, patients who have 1) BMI > 26 kg/m2, 2) prostate volume > 70 mL, 3) eGFR < 60 mL/min, or a 4) Charlson comorbidity index > 2 have a tendency to develop post-prostatectomy incontinence despite undergoing the same surgical procedures. It is important for patients who have a high risk for post-prostatectomy incontinence to be given information about delayed recovery of post-prostatectomy incontinence. Thus, not only the surgical procedures, but also a comprehensive approach, as mentioned above, are important for post-prostatectomy incontinence. PMID:28747618

Advancing the surgical implantation of electronic tags in fish: a gap analysis and research agenda based on a review of trends in intracoelomic tagging effects studies

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

Cooke, Steven J.; Woodley, Christa M.; Eppard, M. B.

2011-03-08

Early approaches to surgical implantation of electronic tags in fish were often through trial and error, however, in recent years there has been an interest in using scientific research to identify techniques and procedures that improve the outcome of surgical procedures and determine the effects of tagging on individuals. Here we summarize the trends in 108 peer-reviewed electronic tagging effect studies focused on intracoleomic implantation to determine opportunities for future research. To date, almost all of the studies have been conducted in freshwater, typically in laboratory environments, and have focused on biotelemetry devices. The majority of studies have focused onmore » salmonids, cyprinids, ictalurids and centrarchids, with a regional bias towards North America, Europe and Australia. Most studies have focused on determining whether there is a negative effect of tagging relative to control fish, with proportionally fewer that have contrasted different aspects of the surgical procedure (e.g., methods of sterilization, incision location, wound closure material) that could advance the discipline. Many of these studies included routine endpoints such as mortality, growth, healing and tag retention, with fewer addressing sublethal measures such as swimming ability, predator avoidance, physiological costs, or fitness. Continued research is needed to further elevate the practice of electronic tag implantation in fish in order to ensure that the data generated are relevant to untagged conspecifics (i.e., no long-term behavioural or physiological consequences) and the surgical procedure does not impair the health and welfare status of the tagged fish. To that end, we advocate for i) rigorous controlled manipulations based on statistical designs that have adequate power, account for inter-individual variation, and include controls and shams, ii) studies that transcend the laboratory and the field with more studies in marine waters, iii) incorporation of knowledge and techniques emerging from the medical and veterinary disciplines, iv) addressing all components of the surgical event, v) comparative studies that evaluate the same surgical techniques on multiple species and in different environments, vi) consideration of how biotic factors (e.g., sex, age, size) influence tagging outcomes, and vii) studies that cover a range of endpoints over ecologically-relevant time periods.« less

Improving Operating Room Efficiency via Reduction and Standardization of Video-Assisted Thoracoscopic Surgery Instrumentation.

PubMed

Friend, Tynan H; Paula, Ashley; Klemm, Jason; Rosa, Mark; Levine, Wilton

2018-05-28

Being the economic powerhouses of most large medical centers, operating rooms (ORs) require the highest levels of teamwork, communication, and efficiency in order to optimize patient safety and reduce hospital waste. A major component of OR waste comes from unused surgical instrumentation; instruments that are frequently prepared for procedures but are never touched by the surgical team still require a full reprocessing cycle at the conclusion of the case. Based on our own previous successes in the perioperative domain, in this work we detail an initiative that reduces surgical instrumentation waste of video-assisted thoracoscopic surgery (VATS) procedures by placing thoracotomy conversion instrumentation in a standby location and designing a specific instrument kit to be used solely for VATS cases. Our estimates suggest that this initiative will reduce at least 91,800 pounds of unnecessary surgical instrumentation from cycling through our ORs and reprocessing department annually, resulting in increased OR team communication without sacrificing the highest standard of patient safety.

Necrotizing Fasciitis in Aesthetic Surgery: A Review of the Literature.

PubMed

Marchesi, Andrea; Marcelli, Stefano; Parodi, Pier C; Perrotta, Rosario E; Riccio, Michele; Vaienti, Luca

2017-04-01

Necrotizing fasciitis (NF) is a rare, potentially fatal, infective complication that can occur after surgery. Diagnosis is still difficult and mainly based on clinical data. Only a prompt pharmacological and surgical therapy can avoid dramatic consequences. There are few reports regarding NF as a complication after aesthetic surgical procedures, and a systematic review still lacks. We have performed a systematic review of English literature on PubMed, covering a period of 30 years. Keywords used were "necrotising fasciitis" matched with "aesthetic surgery complications", "breast surgery", "mammoplasty", "blepharoplasty", "liposuction", "facelift", "rhinoplasty fasciitis", "arm lift", "thigh lift", "otoplasty" and "abdominoplasty fasciitis". No additional search and temporal limitation were set. Among 3782 papers concerning NF, only 18 were related to NF after an aesthetic surgical procedure. Liposuction was the most affected procedure, with buttocks and lower extremity the most involved anatomical regions. The majority of the infections were monomicrobial, promoted by Streptococcus pyogenes. In most cases, NF occurred within the third post-operative day with non-specific signs and symptoms. In 14 cases, a single or multiple surgical interventions were performed and survival was achieved in 11 patients. In case of infection after aesthetic surgery, we should always bear in mind NF. Clinical hallmarks still guide NF management. Because early signs and symptoms are usually non-specific, a strict clinical control is highly suggested. Once clinical suspicion is raised, prompt antibacterial therapy should be administered, followed by surgical debridement in case of ineffective response. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The effect of economic downturn on the volume of surgical procedures: A systematic review.

PubMed

Fujihara, Nasa; Lark, Meghan E; Fujihara, Yuki; Chung, Kevin C

2017-08-01

Economic downturn can have a wide range of effects on medicine at both individual and national levels. We aim to describe these effects in relation to surgical volume to guide future planning for physician specialization, patient expectations in the face of economic crises, or estimating healthcare expenditure. We hypothesized that because of high out-of-pocket costs, cosmetic procedure volumes would be most affected by economic decline. A systematic review was conducted using MEDLINE, Embase, and ABI/INFORMS. The main search terms were "economic recession" and "surgical procedures, operative". Studies were included if surgical volumes were measured and economic indicators were used as predictors of economic conditions. Twelve studies were included, and the most common subject was cosmetic (n = 5), followed by orthopedic (n = 2) and cardiac surgeries (n = 2). The majority of studies found that in periods of economic downturn, surgical volume decreased. Among the eight studies using Pearson's correlation analysis, there were no significant differences between cosmetic procedures and other elective procedures, indicating that cosmetic procedures may display trends similar to those of non-cosmetic elective procedures in periods of economic downturn. Surgical volume generally decreased when economic indicators declined, observed for both elective and non-elective surgery fields. However, a few specific procedure volumes such as vasectomy and caesarean section for male babies increased during the economic downturn. Knowledge of these trends can be useful for future surgical planning and distribution of healthcare resources. Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Variability in Non-Cardiac Surgical Procedures in Children with Congenital Heart Disease

PubMed Central

Sulkowski, Jason P.; Cooper, Jennifer N.; McConnell, Patrick I.; Pasquali, Sara K.; Shah, Samir S.; Minneci, Peter C.; Deans, Katherine J.

2014-01-01

Background The purpose of this study was to examine the volume and variability of non-cardiac surgeries performed in children with congenital heart disease (CHD) requiring cardiac surgery in the first year of life. Methods Patients who underwent cardiac surgery by 1 year of age and had a minimum 5-year follow-up at 22 of the hospitals contributing to the Pediatric Health Information System database between 2004–2012 were included. Frequencies of non-cardiac surgical procedures by age 5 years were determined and categorized by subspecialty. Patients were stratified according to their maximum RACHS-1 (Risk Adjustment in Congenital Heart Surgery) category. The proportions of patients across hospitals who had a non-cardiac surgical procedure for each subspecialty were compared using logistic mixed effects models. Results 8,857 patients underwent congenital heart surgery during the first year of life, 3,621 (41%) of whom had 13,894 non-cardiac surgical procedures by 5 years. Over half of all procedures were in general surgery (4,432; 31.9%) or otolaryngology (4,002; 28.8%). There was significant variation among hospitals in the proportion of CHD patients having non-cardiac surgical procedures. Compared to children in the low risk group (RACHS-1 categories 1–3), children in the high-risk group (categories 4–6) were more likely to have general, dental, orthopedic, and thoracic procedures. Conclusions Children with CHD requiring cardiac surgery frequently also undergo non-cardiac surgical procedures; however, considerable variability in the frequency of these procedures exists across hospitals. This suggests a lack of uniformity in indications used for surgical intervention. Further research should aim to better standardize care for this complex patient population. PMID:25475794

Short-term complications associated with the use of transvaginal mesh in pelvic floor reconstructive surgery: Results from a multi-institutional prospectively maintained dataset.

PubMed

Caveney, Maxx; Haddad, Devin; Matthews, Catherine; Badlani, Gopal; Mirzazadeh, Majid

2017-11-01

Vaginal reconstructive surgery can be performed with or without mesh. We sought to determine comparative rates of perioperative complications of native tissue versus vaginal mesh repairs for pelvic organ prolapse. Using the National Surgical Quality Improvement Program (NSQIP) database, we concatenated surgical data from vaginal procedures for prolapse repair, including anterior and posterior colporrhaphy, paravaginal defect repair, enterocele repair, and vaginal colpopexy using Current Procedural Terminology (CPT) coding. We stratified this data by the modifier associated with mesh usage at the time of the procedure. We then compared 30-day perioperative outcomes, postoperative complications (bleeding, infection, etc), and readmission rates between women with and without mesh-based repairs. We identified 10 657 vaginal reconstructive procedures without mesh and 959 mesh-based repairs from 2009 through 2013. Patients undergoing mesh repair were more likely to experience at least one complication than native tissue repair (9.28% vs 6.15%, P < 0.001), with the overall complication rate also being higher in the mesh group (11.37% vs 9.39%, P = 0.03). Procedures with mesh had a higher rate of perioperative bleeding requiring transfusion than native tissue repair (2.3% vs 0.49%, P < 0.001), and organ surgical site infection (SSI) (0.52% vs 0.17%, P = 0.02). There were no significant differences in rates of readmission, superficial, or deep SSIs, pneumonia, urinary tract infection, sepsis, or renal failure. The use of vaginal mesh for pelvic organ prolapse repair appears to result in a higher rate of perioperative complications than native tissue repair. Patients undergoing these procedures should be counselled preoperatively concerning these risks. © 2017 Wiley Periodicals, Inc.

Practicing Surgeons Lead in Quality Care, Safety, and Cost Control

PubMed Central

Shively, Eugene H.; Heine, Michael J.; Schell, Robert H.; Sharpe, J Neal; Garrison, R Neal; Vallance, Steven R.; DeSimone, Kenneth J.S.; Polk, Hiram C.

2004-01-01

Objective: To report the experiences of 66 surgical specialists from 15 different hospitals who performed 43 CPT-based procedures more than 16,000 times. Summary Background Data: Surgeons are under increasing pressure to demonstrate patient safety data as quantitated by objective and subjective outcomes that meet or exceed the standards of benchmark institutions or databases. Methods: Data from 66 surgical specialists on 43 CPT-based procedures were accessioned over a 4-year period. The hospitals vary from a small 30-bed hospital to large teaching hospitals. All reported deaths and complications were verified from hospital and office records and compared with benchmarks. Results: Over a 4-year inclusive period (1999–2002), 16,028 elective operations were accessioned. There was a total 1.4% complication rate and 0.05% death rate. A system has been developed for tracking outcomes. A wide range of improvements have been identified. These include the following: 1) improved classification of indications for systemic prophylactic antibiotic use and reduction in the variety of drugs used, 2) shortened length of stay for standard procedures in different surgical specialties, 3) adherence to strict indicators for selected operative procedures, 4) less use of costly diagnostic procedures, 5) decreased use of expensive home health services, 6) decreased use of very expensive drugs, 7) identification of the unnecessary expense of disposable laparoscopic devices, 8) development of a method to compare a one-surgeon hospital with his peers, and 9) development of unique protocols for interaction of anesthesia and surgery. The system also provides a very good basis for confirmation of patient safety and improvement therein. Conclusions: Since 1998, Quality Surgical Solutions, PLLC, has developed simple physician-authored protocols for delivering high-quality and cost-effective surgery that measure up to benchmark institutions. We have discovered wide areas for improvements in surgery by adherence to simple protocols, minimizing death and complications and clarifying cost issues. PMID:15166954

Transferability of laparoscopic skills using the virtual reality simulator.

PubMed

Yang, Cui; Kalinitschenko, Uljana; Helmert, Jens R; Weitz, Juergen; Reissfelder, Christoph; Mees, Soeren Torge

2018-03-30

Skill transfer represents an important issue in surgical education, and is not well understood. The aim of this randomized study is to assess the transferability of surgical skills between two laparoscopic abdominal procedures using the virtual reality simulator in surgical novices. From September 2016 to July 2017, 44 surgical novices were randomized into two groups and underwent a proficiency-based basic training consisting of five selected simulated laparoscopic tasks. In group 1, participants performed an appendectomy training on the virtual reality simulator until they reached a defined proficiency. They moved on to the tutorial procedural tasks of laparoscopic cholecystectomy. Participants in group 2 started with the tutorial procedural tasks of laparoscopic cholecystectomy directly. Finishing the training, participants of both groups were required to perform a complete cholecystectomy on the simulator. Time, safety and economy parameters were analysed. Significant differences in the demographic characteristics and previous computer games experience between the two groups were not noted. Both groups took similar time to complete the proficiency-based basic training. Participants in group 1 needed significantly less movements (388.6 ± 98.6 vs. 446.4 ± 81.6; P < 0.05) as well as shorter path length (810.2 ± 159.5 vs. 945.5 ± 187.8 cm; P < 0.05) to complete the cholecystectomy compared to group 2. Time and safety parameters did not differ significantly between both groups. The data demonstrate a positive transfer of motor skills between laparoscopic appendectomy and cholecystectomy on the virtual reality simulator; however, the transfer of cognitive skills is limited. Separate training curricula seem to be necessary for each procedure for trainees to practise task-specific cognitive skills effectively. Mentoring could help trainees to get a deeper understanding of the procedures, thereby increasing the chance for the transfer of acquired skills.

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.

Surgical resident involvement is safe for common elective general surgery procedures.

PubMed

Tseng, Warren H; Jin, Leah; Canter, Robert J; Martinez, Steve R; Khatri, Vijay P; Gauvin, Jeffrey; Bold, Richard J; Wisner, David; Taylor, Sandra; Chen, Steven L

2011-07-01

Outcomes of surgical resident training are under scrutiny with the changing milieu of surgical education. Few have investigated the effect of surgical resident involvement (SRI) on operative parameters. Examining 7 common general surgery procedures, we evaluated the effect of SRI on perioperative morbidity and mortality and operative time (OpT). The American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2007) was used to identify 7 cases of nonemergent operations. Cases with simultaneous procedures were excluded. Logistic regression was performed across all procedures and within each procedure incorporating SRI, OpT, and risk-stratifying American College of Surgery National Surgical Quality Improvement Program morbidity and mortality probability scores, which incorporate multiple prognostic individual patient factors. Procedure-specific, SRI-stratified OpTs were compared using Wilcoxon rank-sum tests. A total of 71.3% of the 37,907 cases had SRI. Absolute 30-day morbidity for all cases with SRI and without SRI were 3.0% and 1.0%, respectively (p < 0.001); absolute 30-day mortality for all cases with SRI and without SRI were 0.1% and 0.08%, respectively (p < 0.001). After multivariate analysis by specific procedure, SRI was not associated with increased morbidity but was associated with decreased mortality during open right colectomy (odds ratio 0.32; p = 0.01). Across all procedures, SRI was associated with increased morbidity (odds ratio 1.14; p = 0.048) but decreased mortality (odds ratio 0.42; p < 0.001). Mean OpT for all procedures was consistently lower for cases without SRI. SRI has a measurable impact on both 30-day morbidity and mortality and OpT. These data have implications to the impact associated with surgical graduate medical education. Further studies to identify causes of patient morbidity and prevention strategies in surgical teaching environments are warranted. Copyright © 2011 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Development of a patient-specific surgical simulator for pediatric laparoscopic procedures.

PubMed

Saber, Nikoo R; Menon, Vinay; St-Pierre, Jean C; Looi, Thomas; Drake, James M; Cyril, Xavier

2014-01-01

The purpose of this study is to develop and evaluate a pediatric patient-specific surgical simulator for the planning, practice, and validation of laparoscopic surgical procedures prior to intervention, initially focusing on the choledochal cyst resection and reconstruction scenario. The simulator is comprised of software elements including a deformable body physics engine, virtual surgical tools, and abdominal organs. Hardware components such as haptics-enabled hand controllers and a representative endoscopic tool have also been integrated. The prototype is able to perform a number of surgical tasks and further development work is under way to simulate the complete procedure with acceptable fidelity and accuracy.

[Efficacy and limits of the bariatric surgery].

PubMed

Nicolai, Albano; Taus, Marina; Busni, Debora; Petrelli, Massimiliano

2005-01-01

Morbid obesity is associated with and increased risk of serious comorbidities, including type 2 diabetes, sleep apnoea, cardiovascular diseases, and orthopedic disabilities. Not operative treatments for superobese patients have not been shown to produce reliable long-term benefits, therefore surgical therapy has became the treatment of choice. The number of surgical procedures increased in the last year confirm these data. However, before recommended a specific surgical procedures to a superobese patients it is necessary to consider some variables, such as: patient, health structure, and multidisciplinary equipe. Since there are not recommended or condemned surgical procedures, in this paper the Authors tried to evaluate the effectiveness and limits of the most performed surgical procedures for the treatment of pathologic obesity: gastric by-pass, biliopancreatic diversion (duodenal switch), vertical gastroplasty, banding gastric. The Authors used some pointer of outcome to measure effectiveness and limits: five year post-operative percentage excess weight loss >/< 50, peri-operative >/< 1%, early and late complications >/< 15%, reoperation >/< 3%, improvement of quality of life. Thanks to new surgical technique, restrictive options are losing ground, while malabsorbitive bariatric procedures are collecting successful.

Association of Postoperative Readmissions With Surgical Quality Using a Delphi Consensus Process to Identify Relevant Diagnosis Codes.

PubMed

Mull, Hillary J; Graham, Laura A; Morris, Melanie S; Rosen, Amy K; Richman, Joshua S; Whittle, Jeffery; Burns, Edith; Wagner, Todd H; Copeland, Laurel A; Wahl, Tyler; Jones, Caroline; Hollis, Robert H; Itani, Kamal M F; Hawn, Mary T

2018-04-18

Postoperative readmission data are used to measure hospital performance, yet the extent to which these readmissions reflect surgical quality is unknown. To establish expert consensus on whether reasons for postoperative readmission are associated with the quality of surgery in the index admission. In a modified Delphi process, a panel of 14 experts in medical and surgical readmissions comprising physicians and nonphysicians from Veterans Affairs (VA) and private-sector institutions reviewed 30-day postoperative readmissions from fiscal years 2008 through 2014 associated with inpatient surgical procedures performed at a VA medical center between October 1, 2007, and September 30, 2014. The consensus process was conducted from January through May 2017. Reasons for readmission were grouped into categories based on International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes. Panelists were given the proportion of readmissions coded by each reason and median (interquartile range) days to readmission. They answered the question, "Does the readmission reason reflect possible surgical quality of care problems in the index admission?" on a scale of 1 (never related) to 5 (directly related) in 3 rounds of consensus building. The consensus process was completed in May 2017 and data were analyzed in June 2017. Consensus on proportion of ICD-9-coded readmission reasons that reflected quality of surgical procedure. In 3 Delphi rounds, the 14 panelists achieved consensus on 50 reasons for readmission; 12 panelists also completed group telephone calls between rounds 1 and 2. Readmissions with diagnoses of infection, sepsis, pneumonia, hemorrhage/hematoma, anemia, ostomy complications, acute renal failure, fluid/electrolyte disorders, or venous thromboembolism were considered associated with surgical quality and accounted for 25 521 of 39 664 readmissions (64% of readmissions; 7.5% of 340 858 index surgical procedures). The proportion of readmissions considered to be not associated with surgical quality varied by procedure, ranging from to 21% (613 of 2331) of readmissions after lower-extremity amputations to 47% (745 of 1598) of readmissions after cholecystectomy. One-third of postoperative readmissions are unlikely to reflect problems with surgical quality. Future studies should test whether restricting readmissions to those with specific ICD-9 codes might yield a more useful quality measure.

Efficacy of a Procedure-Specific Education Module on Informed Consent in Plastic Surgery.

PubMed

Brandel, Michael G; Reid, Christopher M; Parmeshwar, Nisha; Dobke, Marek K; Gosman, Amanda A

2017-05-01

Truly informed consent is an elusive goal, seldom attained in medical or surgical practice. Patients often do not fully understand procedures and therapies they undergo or the associated sequelae. Historically, informed consent and patient education have been limited to physician discussions, sometimes with the addition of simple visual aids. More recently, there is a growing body of decision aids available, including interactive multimedia patient educational modules that review preoperative through postoperative care, risks, benefits, alternatives, different surgical options, as well as commonly asked questions. We hypothesized that the addition of a Web-based educational tool would positively impact attainment of informed consent and satisfaction in plastic surgery patients. We performed a prospective randomized controlled study comparing patients who presented in consultation for breast reconstruction, breast reduction, and abdominoplasty. Patients received standard patient education along with a procedure-specific (study) or general patient safety (control) Web-based educational module. Informed consent was measured using a surgical-focused, modified version of the Shared Decision-making 25 index tool. Patient demographic information as well as surrogate markers of familiarity with technology were recorded preoperatively and postoperatively. Comparisons were made between study and control groups, procedure subgroups, and preoperative and postoperative time points. Demographic factors and consent variables were compared among experimental and procedure groups. Data were collected from 65 patients preoperatively and 48 patients postoperatively. Thirty patients competed both surveys. Overall, no differences in patient characteristics or familiarity with technology were observed between experimental groups. Demographic characteristics were also similar between groups. No meaningful differences were identified in comparisons between experimental groups on either cross-sectional or longitudinal analyses. Nearly all patient responses were consistent with being well informed and satisfied with the educational process. Overall, patients undergoing plastic surgery procedures are adequately informed and have a high degree of satisfaction regarding their patient education. The addition of a Web-based informed consent tool did not make a demonstrable difference in informed consent.

Video-assisted palatopharyngeal surgery: a model for improved education and training.

PubMed

Allori, Alexander C; Marcus, Jeffrey R; Daluvoy, Sanjay; Bond, Jennifer

2014-09-01

Objective : The learning process for intraoral procedures is arguably more difficult than for other surgical procedures because of the assistant's severely limited visibility. Consequently, trainees may not be able to adequately see and follow all steps of the procedure, and attending surgeons may be less willing to entrust trainees with critical portions of the procedure. In this report, we propose a video-assisted approach to intraoral procedures that improves lighting, visibility, and potential for effective education and training. Design : Technical report (idea/innovation). Setting : Tertiary referral hospital. Patients : Children with cleft palate and velopharyngeal insufficiency requiring surgery. Interventions : Video-assisted palatoplasty, sphincteroplasty, and pharyngoplasty. Main Outcome Measures : Qualitative and semiquantitative educational outcomes, including learner perception regarding "real-time" (video-assisted surgery) and "non-real-time" (video-library-based) surgical education. Results : Trainees were strongly in favor of the video-assisted modality in "real-time" surgical training. Senior trainees identified more opportunities in which they had been safely entrusted to perform critical portions of the procedure, corresponding with satisfaction with the learning process scores, and they showed greater comfort/confidence scores related to performing the procedure under supervision and alone. Conclusions : Adoption of the video-assisted approach can be expected to markedly improve the learning curve for surgeons in training. This is now standard practice at our institution. We are presently conducting a full educational technology assessment to better characterize the effect on knowledge acquisition and technical improvement.

Surgical specialty procedures in rural surgery practices: implications for rural surgery training.

PubMed

Sticca, Robert P; Mullin, Brady C; Harris, Joel D; Hosford, Clint C

2012-12-01

Specialty procedures constitute one eighth of rural surgery practice. Currently, general surgeons intending to practice in rural hospitals may not get adequate training for specialty procedures, which they will be expected to perform. Better definition of these procedures will help guide rural surgery training. Current Procedural Terminology codes for all surgical procedures for 81% of North Dakota and South Dakota rural surgeons were entered into the Dakota Database for Rural Surgery. Specialty procedures were analyzed and compared with the Surgical Council on Resident Education curriculum to determine whether general surgery training is adequate preparation for rural surgery practice. The Dakota Database for Rural Surgery included 46,052 procedures, of which 5,666 (12.3%) were specialty procedures. Highest volume specialty categories included vascular, obstetrics and gynecology, orthopedics, cardiothoracic, urology, and otolaryngology. Common procedures in cardiothoracic and vascular surgery are taught in general surgical residency, while common procedures in obstetrics and gynecology, orthopedics, urology, and otolaryngology are usually not taught in general surgery training. Optimal training for rural surgery practice should include experience in specialty procedures in obstetrics and gynecology, orthopedics, urology, and otolaryngology. Copyright © 2012 Elsevier Inc. All rights reserved.

Estimating procedure times for surgeries by determining location parameters for the lognormal model.

PubMed

Spangler, William E; Strum, David P; Vargas, Luis G; May, Jerrold H

2004-05-01

We present an empirical study of methods for estimating the location parameter of the lognormal distribution. Our results identify the best order statistic to use, and indicate that using the best order statistic instead of the median may lead to less frequent incorrect rejection of the lognormal model, more accurate critical value estimates, and higher goodness-of-fit. Using simulation data, we constructed and compared two models for identifying the best order statistic, one based on conventional nonlinear regression and the other using a data mining/machine learning technique. Better surgical procedure time estimates may lead to improved surgical operations.

Automated Surgical Approach Planning for Complex Skull Base Targets: Development and Validation of a Cost Function and Semantic At-las.

PubMed

Aghdasi, Nava; Whipple, Mark; Humphreys, Ian M; Moe, Kris S; Hannaford, Blake; Bly, Randall A

2018-06-01

Successful multidisciplinary treatment of skull base pathology requires precise preoperative planning. Current surgical approach (pathway) selection for these complex procedures depends on an individual surgeon's experiences and background training. Because of anatomical variation in both normal tissue and pathology (eg, tumor), a successful surgical pathway used on one patient is not necessarily the best approach on another patient. The question is how to define and obtain optimized patient-specific surgical approach pathways? In this article, we demonstrate that the surgeon's knowledge and decision making in preoperative planning can be modeled by a multiobjective cost function in a retrospective analysis of actual complex skull base cases. Two different approaches- weighted-sum approach and Pareto optimality-were used with a defined cost function to derive optimized surgical pathways based on preoperative computed tomography (CT) scans and manually designated pathology. With the first method, surgeon's preferences were input as a set of weights for each objective before the search. In the second approach, the surgeon's preferences were used to select a surgical pathway from the computed Pareto optimal set. Using preoperative CT and magnetic resonance imaging, the patient-specific surgical pathways derived by these methods were similar (85% agreement) to the actual approaches performed on patients. In one case where the actual surgical approach was different, revision surgery was required and was performed utilizing the computationally derived approach pathway.

Cost-effectiveness assessment in outpatient sinonasal surgery.

PubMed

Mortuaire, G; Theis, D; Fackeure, R; Chevalier, D; Gengler, I

2018-02-01

To assess the cost-effectiveness of outpatient sinonasal surgery in terms of clinical efficacy and control of expenses. A retrospective study was conducted from January 2014 to January 2016. Patients scheduled for outpatient sinonasal surgery were systematically included. Clinical data were extracted from surgical and anesthesiology computer files. The cost accounting methods applied in our institution were used to evaluate logistic and technical costs. The standardized hospital fees rating system based on hospital stay and severity in diagnosis-related groups (Groupes homogènes de séjours: GHS) was used to estimate institutional revenue. Over 2years, 927 outpatient surgical procedures were performed. The crossover rate to conventional hospital admission was 2.9%. In a day-1 telephone interview, 85% of patients were very satisfied with the procedure. All outpatient cases showed significantly lower costs than estimated for conventional management with overnight admission, while hospital revenue did not differ between the two. This study confirmed the efficacy of outpatient surgery in this indication. Lower costs could allow savings for the health system by readjusting the rating for the procedure. More precise assessment of cost-effectiveness will require more fine-grained studies based on micro costing at hospital level and assessment of impact on conventional surgical activity and post-discharge community care. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Plastic freezer bags: a cost-effective method to protect extraction sites in laparoscopic colorectal procedures?

PubMed

Huynh, Hai P; Musselman, Reilly P; Trottier, Daniel C; Soto, Claudia M; Poulin, Eric C; Mamazza, Joseph; Boushey, Robin P; Auer, Rebecca C; Moloo, Husein

2013-10-01

To review surgical-site infection (SSI) and retrieval-site tumor recurrence rates in laparoscopic colorectal procedures when using a plastic freezer bag as a wound protector. Laparoscopic colorectal procedures where a plastic freezer bag used as a wound protector at the extraction site were reviewed between 1991 and 2008 from a prospectively collected database. χ test was used to compare SSI and tumor recurrence rates between groups. Costing data were obtained from the operating room supplies department. A total of 936 cases with 51 (5.45%) surgical-site infections were identified. SSI rates did not differ when comparing groups based on demographic factors, diagnosis, or location of procedure. Retrieval-site tumor recurrence rate was 0.21% (1/474). Cost of plastic freezer bags including sterilization ranged from $0.25 to $3. Plastic freezer bags as wound protectors in laparoscopic colorectal procedures are cost effective and have SSI and retrieval-site tumor recurrence rates that compare favorably to published data.

A novel procedure for introducing large sheet-type surgical material with a self-expanding origami structure using a slim trocar (chevron pleats procedure).

PubMed

Nakase, Yuen; Nakamura, Kei; Sougawa, Akira; Nagata, Tomoyuki; Mochizuki, Satoshi; Kitai, Shouzo; Inaba, Seishirou

2017-09-01

Large sheet-type surgical materials (e.g., absorbable hemostat, adhesion barrier membranes, and flat surgical mesh) are difficult to introduce into a corporeal cavity using a 5-mm trocar; however, laparoscopic surgeries that use mainly 5-mm trocars are increasing. Furthermore, it is necessary not only to introduce but also to secure the applied surgical material and expand it from the original surgical site. To address these challenges, we developed a novel procedure for introducing such surgical materials into a corporeal cavity using a 5-mm trocar and a self-expanding origami structure, called the "chevron pleats procedure (CPP)". We used CPP in 114 cases of laparoscopic surgery for gastrointestinal diseases. The chevron folding pattern is an excellent origami structure and compactly folds a large sheet of material for use with a slim trocar. Surgical materials were folded using a chevron pleats pattern and inserted into a novel, slim, long syringe-type device, which was made from a specially ordered precision polypropylene tube, for introduction into a corporeal cavity. When the surgical material was used, the end of the device was placed above the surgical site and the inner rod was pushed. The surgical material was securely injected and expanded over the surgical site. Surgical materials were introduced smoothly and securely using a 5-mm trocar to a site of intraoperative bleeding, the incisional surface of the liver, and defects of the abdominal wall or peritoneum. Efficient hemostasis was attained, the introduction and expansion of surgical mesh was made simpler, and the covering of defects of the peritoneum with adhesion barrier membranes, which is typically difficult during laparoscopic surgery, was easily performed. CPP is a basic utility procedure for introducing several sheet-type surgical materials into a corporeal cavity with a 5-mm trocar and might help ensure efficient and safe laparoscopic surgery.

Large Variability in the Diversity of Physiologically Complex Surgical Procedures Exists Nationwide Among All Hospitals Including Among Large Teaching Hospitals.

PubMed

Dexter, Franklin; Epstein, Richard H; Thenuwara, Kokila; Lubarsky, David A

2017-11-22

Multiple previous studies have shown that having a large diversity of procedures has a substantial impact on quality management of hospital surgical suites. At hospitals with substantial diversity, unless sophisticated statistical methods suitable for rare events are used, anesthesiologists working in surgical suites will have inaccurate predictions of surgical blood usage, case durations, cost accounting and price transparency, times remaining in late running cases, and use of intraoperative equipment. What is unknown is whether large diversity is a feature of only a few very unique set of hospitals nationwide (eg, the largest hospitals in each state or province). The 2013 United States Nationwide Readmissions Database was used to study heterogeneity among 1981 hospitals in their diversities of physiologically complex surgical procedures (ie, the procedure codes). The diversity of surgical procedures performed at each hospital was quantified using a summary measure, the number of different physiologically complex surgical procedures commonly performed at the hospital (ie, 1/Herfindahl). A total of 53.9% of all hospitals commonly performed <10 physiologically complex procedures (lower 99% confidence limit [CL], 51.3%). A total of 14.2% (lower 99% CL, 12.4%) of hospitals had >3-fold larger diversity (ie, >30 commonly performed physiologically complex procedures). Larger hospitals had greater diversity than the small- and medium-sized hospitals (P < .0001). Teaching hospitals had greater diversity than did the rural and urban nonteaching hospitals (P < .0001). A total of 80.0% of the 170 large teaching hospitals commonly performed >30 procedures (lower 99% CL, 71.9% of hospitals). However, there was considerable variability among the large teaching hospitals in their diversity (interquartile range of the numbers of commonly performed physiologically complex procedures = 19.3; lower 99% CL, 12.8 procedures). The diversity of procedures represents a substantive differentiator among hospitals. Thus, the usefulness of statistical methods for operating room management should be expected to be heterogeneous among hospitals. Our results also show that "large teaching hospital" alone is an insufficient description for accurate prediction of the extent to which a hospital sustains the operational and financial consequences of performing a wide diversity of surgical procedures. Future research can evaluate the extent to which hospitals with very large diversity are indispensable in their catchment area.

Femtosecond Lasers and Corneal Surgical Procedures.

PubMed

Marino, Gustavo K; Santhiago, Marcony R; Wilson, Steven E

2017-01-01

Our purpose is to present a broad review about the principles, early history, evolution, applications, and complications of femtosecond lasers used in refractive and nonrefractive corneal surgical procedures. Femtosecond laser technology added not only safety, precision, and reproducibility to established corneal surgical procedures such as laser in situ keratomileusis (LASIK) and astigmatic keratotomy, but it also introduced new promising concepts such as the intrastromal lenticule procedures with refractive lenticule extraction (ReLEx). Over time, the refinements in laser optics and the overall design of femtosecond laser platforms led to it becoming an essential tool for corneal surgeons. In conclusion, femtosecond laser is a heavily utilized tool in refractive and nonrefractive corneal surgical procedures, and further technological advances are likely to expand its applications. Copyright 2017 Asia-Pacific Academy of Ophthalmology.

Clinical Approaches to Breast Reconstruction: What Is the Appropriate Reconstructive Procedure for My Patient?

PubMed

Dieterich, Max; Dragu, Adrian; Stachs, Angrit; Stubert, Johannes

2017-12-01

Breast reconstruction after breast cancer is an emotional subject for women. Consequently, the correct timing and surgical procedure for each individual woman are important. In general, heterologous or autologous reconstructive procedures are available, both having advantages and disadvantages. Breast size, patient habitus, and previous surgeries or radiation therapy need to be considered, independent of the chosen procedure. New surgical techniques, refinement of surgical procedures, and the development of supportive materials have increased the general patient collective eligible for breast reconstruction. This review highlights the different approaches to immediate breast reconstruction using autologous or heterologous techniques.

Spectrum of use and effectiveness of endoscopic and surgical therapies for chronic pancreatitis in the United States.

PubMed

Glass, Lisa M; Whitcomb, David C; Yadav, Dhiraj; Romagnuolo, Joseph; Kennard, Elizabeth; Slivka, Adam A; Brand, Randall E; Anderson, Michelle A; Banks, Peter A; Lewis, Michele D; Baillie, John; Sherman, Stuart; Alkaade, Samer; Amann, Stephen T; Disario, James A; O'Connell, Michael; Gelrud, Andres; Forsmark, Christopher E; Gardner, Timothy B

2014-05-01

This study aims to describe the frequency of use and reported effectiveness of endoscopic and surgical therapies in patients with chronic pancreatitis treated at US referral centers. Five hundred fifteen patients were enrolled prospectively in the North American Pancreatitis Study 2, where patients and treating physicians reported previous therapeutic interventions and their perceived effectiveness. We evaluated the frequency and effectiveness of endoscopic (biliary or pancreatic sphincterotomy, biliary or pancreatic stent placement) and surgical (pancreatic cyst removal, pancreatic drainage procedure, pancreatic resection, surgical sphincterotomy) therapies. Biliary and/or pancreatic sphincterotomy (42%) were the most common endoscopic procedure (biliary stent, 14%; pancreatic stent, 36%; P < 0.001). Endoscopic procedures were equally effective (biliary sphincterotomy, 40.0%; biliary stent, 40.8%; pancreatic stent, 47.0%; P = 0.34). On multivariable analysis, the presence of abdominal pain (odds ratio, 1.82; 95% confidence interval, 1.15-2.88) predicted endoscopy, whereas exocrine insufficiency (odds ratio, 0.63; 95% confidence interval, 0.42-0.94) deterred endoscopy. Surgical therapies were attempted equally (cyst removal, 7%; drainage procedure, 10%; resection procedure, 12%) except for surgical sphincteroplasty (4%; P < 0.001). Surgical sphincteroplasty was the least effective (46%; P < 0.001) versus cyst removal (76% drainage [71%] and resection [73%]). Although surgical therapies were performed less frequently than endoscopic therapies, they were more often reported to be effective.

Surgical site infections in an abdominal surgical ward at Kosovo Teaching Hospital.

PubMed

Raka, Lul; Krasniqi, Avdyl; Hoxha, Faton; Musa, Ruustem; Mulliqi, Gjyle; Krasniqi, Selvete; Kurti, Arsim; Dervishaj, Antigona; Nuhiu, Beqir; Kelmendi, Baton; Limani, Dalip; Tolaj, Ilir

2008-01-01

Abdominal surgical site infections (SSI) cause substantial morbidity and mortality for patients undergoing operative procedures. We determined the incidence of and risk factors for SSI after abdominal surgery in the Department of Abdominal Surgery at the University Clinical Centre of Kosovo (UCCK). Prospective surveillance of patients undergoing abdominal surgery was performed between December 2005 and June 2006. CDC definitions were followed to detect SSI and study forms were based on Europe Link for Infection Control through Surveillance (HELICS) protocol. A total of 253 surgical interventions in 225 patients were evaluated. The median age of patients was 42 years and 55.1% of them were male. The overall incidence rate of SSI was 12%. Follow-up was achieved for 84.1% of the procedures. For patients with an SSI, the median duration of hospitalization was 9 days compared with 4 days for those without an SSI (p < 0.001). Surgical procedures were classified as emergent in 53.3% of cases. Superficial incisional SSI was most common (55%). Clinical infections were culture positive in 40.7% of cases. Duration of operation, duration of preoperative stay, wound class, ASA score > 2, use of antibiotic prophylaxis and NNIS class of > 2 were all significant at p < .001. The SSI rates for the NNIS System risk classes 0, 1 and 2-3 were 4.2%, 46.7% and 100%, respectively. SSI caused considerable morbidity among surgical patients in UCCK. Appropriate active surveillance and infection control measures should be introduced during preoperative, intra-operative, and postoperative care to reduce infection rates.

Comparative Cost Analysis of Surgical and PrePex Device Male Circumcision in Zimbabwe and Mozambique.

PubMed

Schutte, Carl; Tshimanga, M; Mugurungi, Owen; Come, Iotamo; Necochea, Edgar; Mahomed, Mehebub; Xaba, Sinokuthemba; Bossemeyer, Debora; Ferreira, Thais; Macaringue, Lucinda; Chatikobo, Pessanai; Gundididza, Patricia; Hatzold, Karin

2016-06-01

The PrePex device has proven to be safe for voluntary medical male circumcision (VMMC) in adults in several African countries. Costing studies were conducted as part of a PrePex/Surgery comparison study in Zimbabwe and a pilot implementation study in Mozambique. The studies calculated per male circumcision unit costs using a cost-analysis approach. Both direct costs (consumable and nonconsumable supplies, device, personnel, associated staff training) and selected indirect costs (capital and support personnel costs) were calculated. The cost comparison in Zimbabwe showed a unit cost per VMMC of $45.50 for PrePex and $53.08 for surgery. The unit cost difference was based on higher personnel and consumable supplies costs for the surgical procedure, which used disposable instrument kits. In Mozambique, the costing analysis estimated a higher unit cost for PrePex circumcision ($40.66) than for surgery ($20.85) because of higher consumable costs, particularly the PrePex device and lower consumable supplies costs for the surgical procedure using reusable instruments. Supplies and direct staff costs contributed 87.2% for PrePex and 65.8% for surgical unit costs in Mozambique. PrePex device male circumcision could potentially be cheaper than surgery in Zimbabwe, especially in settings that lack the infrastructure and personnel required for surgical VMMC, and this might result in programmatic cost savings. In Mozambique, the surgical procedure seems to be less costly compared with PrePex mainly because of higher consumable supplies costs. With reduced device unit costs, PrePex VMMC could become more cost-efficient and considered as complementary for Mozambique's VMMC scale-up program.

Surgical options for lumbosacral fusion: biomechanical stability, advantage, disadvantage and affecting factors in selecting options.

PubMed

Yoshihara, Hiroyuki

2014-07-01

Numerous surgical procedures and instrumentation techniques for lumbosacral fusion (LSF) have been developed. This is probably because of its high mechanical demand and unique anatomy. Surgical options include anterior column support (ACS) and posterior stabilization procedures. Biomechanical studies have been performed to verify the stability of those options. The options have their own advantage but also disadvantage aspects. This review article reports the surgical options for lumbosacral fusion, their biomechanical stability, advantages/disadvantages, and affecting factors in option selection. Review of literature. LSF has lots of options both for ACS and posterior stabilization procedures. Combination of posterior stabilization procedures is an option. Furthermore, combinations of ACS and posterior stabilization procedures are other options. It is difficult to make a recommendation or treatment algorithm of LSF from the current literature. However, it is important to know all aspects of the options and decision-making of surgical options for LSF needs to be tailored for each patient, considering factors such as biomechanical stress and osteoporosis.

The Gibson and Piggott osteotomy for adult hallux valgus.

PubMed

Rangrez, Arshad Bashir; Dar, Tahir Ahmed; Badoo, Abdul Rashid; Wani, Sharief Ahmed; Dhar, Shabir Ahmed; Mumtaz, Imran; Ahmed, Muzzaffar

2012-01-01

The Gibson and Piggott procedure for hallux valgus is based on sound surgical principles addressing the basic pathologies of this disorder. However, this procedure has not been studied extensively in the literature in comparison to the Mitchell and Chevron osteotomies. We report a prospective study conducted on 50 adult feet with hallux valgus. The Gibson and Piggot osteotomy was done on all the feet. We obtained 76% excellent and 18% good results with this procedure. The results bear out the fact that this procedure is a useful procedure for the management of this disorder.

Noticeable Variations in the Educational Exposure During Residency in Danish Orthopedic Departments.

PubMed

Brand, Eske; Fridberg, Marie; Knudsen, Ulrik Kragegaard; Barfod, Kristoffer Weisskirchner

The objective of the study was to examine the educational exposure during residency in Danish orthopedic departments. Questionnaire-based cross-sectional study. Data were gathered from January 1, 2014 to April 30, 2014 through a nationwide web-based questionnaire containing 15 questions within the areas of workload, surgical procedures, outpatient clinic, and research activities. The residents targeted worked at small-to-large hospitals and in tertiary care centers. Every resident in Denmark (n = 163) with at least 3 active months at a department was included. Questionnaires with less than 80% completion were excluded. In total, 152 entries were registered. Among those, 27 did not meet the inclusion criteria and 29 were excluded, leaving 96 participants, representing 22 of 26 departments, for further analysis. The average number of operative procedures as primary surgeon was 16 (range: 8-35) per month. In all, 18 of 22 (81%) departments offered the possibility to participate in research facilitated by the department and 38 of 96 (40%) worked for free (an average of 10h a month [range: 3-60]) to increase the amount of surgical procedures. A large variation in the educational exposure was found among the Danish orthopedic departments. Numbers indicate that Danish residents, compared with their US counterparts, operate considerably less during residency. Most residents work overtime and many of them work for free to participate in more surgical procedures. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Omega "Ω" Pulley Plasty for Surgical Management of DeQuervain's Disease.

PubMed

Bakhach, Joseph; Chaya, Bachar; Papazian, Nazareth

2018-06-01

DeQuervain tenosynovitis, refractory to medical conservative treatment, has been traditionally treated by a simple division of the pulley, a procedure associated with several complications. Many authors attempted to prevent these complications by describing techniques of pulley reconstruction after its release necessitating suturing the different flaps and subsequently promoting extensor tendons adhesions. The authors present an alternative procedure for the first extensor compartment pulley decompression: "Omegaplasty". 25 Patients with 29 DeQuervain tenosynovitis cases were enrolled in a prospective, nonrandomized clinical trial from 2012 to 2016. At enrollment they were offered the option of Omegaplasty as a surgical treatment modality for their cases. The procedure is based on liberating the anterior attachment of the pulley from the anterior lip of the styloïd process while respecting its continuity with the periosteal flap as well as promoting expansion of the tunnel volume. All operated patients were evaluated using the "Opposition Kapandji Score". The authors present the results of 29 different "Omegaplasty" procedures. Based on the Kapandji opposition score, twenty cases scored 10/10 while the remaining nine cases yielded an 8/10 score each. The described technique is simple, reliable and respects the extensor tendons gliding physiology and biodynamics. By preserving the anatomical continuity of the first extensor compartment pulley at the wrist, the risk of adhesion formation is reduced. The preliminary results are encouraging and provide the "Ω" plasty the potential to be considered as a surgical option for treatment of De Quervain Tenosynovitis.

[Catheter-related bladder discomfort after urological surgery: importance of the type of surgery and efficiency of treatment by clonazepam].

PubMed

Maro, S; Zarattin, D; Baron, T; Bourez, S; de la Taille, A; Salomon, L

2014-09-01

Bladder catheter can induce a Catheter-Related Bladder Discomfort (CRBD). Antagonist of muscarinic receptor is the gold standard treatment. Clonazepam is an antimuscarinic, muscle relaxing oral drug. The aim of this study is to look for a correlation between the type of surgical procedure and the existence of CRBD and to evaluate the efficiency of clonazepam. One hundred patients needing bladder catheter were evaluated. Sexe, age, BMI, presence of diabetes, surgical procedure and existence of CRBD were noted. Pain was evaluated with analogic visual scale. Timing of pain, need for specific treatment by clonazepam and its efficiency were noted. Correlation between preoperative data, type of surgical procedure, existence of CRBD and efficiency of treatment were evaluated. There were 79 men and 21 women (age: 65.9 years, BMI: 25.4). Twelve patients presented diabetes. Surgical procedure concerned prostate in 39 cases, bladder in 19 cases (tumor resections), endo-urology in 20 cases, upper urinary tract in 12 cases (nephrectomy…) and lower urinary tract in 10 cases (sphincter, sub-uretral tape). Forty patients presented CRBD, (pain 4.5 using VAS). This pain occurred 0.6 days after surgery. No correlation was found between preoperative data and CRBD. Bladder resection and endo-urological procedures were surgical procedures which procured CRBD. Clonazepam was efficient in 30 (75 %) out of 40 patients with CRBD. However, it was less efficient in case of bladder tumor resection. CRBD is frequent and occurred immediately after surgery. Bladder resection and endo-urology were the main surgical procedures which induced CRBD. Clonazepam is efficient in 75 %. Bladder resection is the surgical procedure which is the most refractory to treatment. 5. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Malfunction and failure of robotic systems during general surgical procedures.

PubMed

Agcaoglu, Orhan; Aliyev, Shamil; Taskin, Halit Eren; Chalikonda, Sricharan; Walsh, Matthew; Costedio, Meagan M; Kroh, Matthew; Rogula, Tomasz; Chand, Bipan; Gorgun, Emre; Siperstein, Allan; Berber, Eren

2012-12-01

There has been recent interest in using robots for general surgical procedures. This shift in technique raises the issue of patient safety with automated instrumentation. Although the safety of robotics has been established for urologic procedures, there are scant data on its use in general surgical procedures. The aim of this study is to analyze the incidence of robotic malfunction and its consequences for general surgical procedures. All robotic general surgical procedures performed at a tertiary center between 2008 and 2011 were reviewed from institutional review board (IRB)-approved prospective databases. A total of 223 cases were done robotically, including 102 endocrine, 83 hepatopancreaticobiliary, 17 upper gastrointestinal, and 21 lower gastrointestinal colorectal procedures. There were 10 cases of robotic malfunction (4.5%). These failures were related to robotic instruments (n = 4), optical system (n = 3), robotic arms (n = 2), and robotic console (n = 1). None of these failures led to adverse patient consequences or conversion to open. Six (2.7%) cases were converted to open due to bleeding (n = 3), difficult dissection plane (n = 1), invasion of tumor to surrounding structures (n = 1), and intolerance of pneumoperitoneum due to CO(2) retention (n = 1). There was no mortality, and morbidity was 1% (n = 2). To our knowledge, this is the largest North American report to date on robotic general surgical procedures. Our results show that robotic malfunction occurs in a minority of cases, with no adverse consequences. We believe that awareness of these failures and knowing how to troubleshoot are important to maintain the efficiency of these procedures.

A population-based analysis of the drivers of short-term costs after bariatric surgery within a publicly funded regionalized center of excellence system.

PubMed

Doumouras, Aristithes G; Saleh, Fady; Tarride, Jean-Eric; Hong, Dennis

2016-06-01

The most significant driver of healthcare utilization for bariatric surgery is the index admission and readmissions within the first 30 days after a procedure. Identifying areas to create efficiencies during this period is essential to decreasing overall healthcare costs. The objective of the study was to characterize the short-term costs of bariatric surgery within a regionalized center of excellence bariatric care system. The Ontario Bariatric Network is a regionalized bariatric care system with 4 high-volume Bariatric Centers of Excellence. We performed a population-based retrospective analysis including all adult patients who received a bariatric surgical procedure in Ontario from April 2009 until March 2012. Total hospital cost and number of days in hospital was calculated for all index admissions and all readmissions within 30 days of a bariatric surgical procedure. An inverse Gaussian generalized linear model was utilized to model the effect of covariates on costs. A Poisson regression was used to determine the effect on covariates on total days in hospital. After multivariable adjustment, the sleeve gastrectomy procedure decreased costs by $1447 over gastric bypass (95% confidence interval [CI] $1578 to-$1315]); P<.001). This effect increased when adjusting only for preoperative factors with a cost savings of nearly $2000 ($1953) (95% CI-$3250 to-$533; P = .003). Conversely, complications were the major drivers of increased cost as anastomotic leaks added $24,397 (95% CI $20,688-$28,106; P<.001) to healthcare costs. In addition, medical complications, such as respiratory failure/infection ($19,465) (95% CI $11,007-$27,924; P<.001), were also significant cost drivers. Major drivers of increased resource utilization included major surgical and medical complications, such as anastomotic leaks and respiratory failure/infection. Days in hospital were affected more by medical complications than surgical complications. Sleeve gastrectomy resulted in a clear short-term cost advantage over Roux-en-Y gastric bypass (RYGB), and this was likely related to the procedure itself as opposed to differences across procedures in co-morbidity and complication rates. Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Influence of hospital-level practice patterns on variation in the application of minimally invasive surgery in United States pediatric patients.

PubMed

Train, Arianne T; Harmon, Carroll M; Rothstein, David H

2017-10-01

Although disparities in access to minimally invasive surgery are thought to exist in pediatric surgical patients in the United States, hospital-level practice patterns have not been evaluated as a possible contributing factor. Retrospective cohort study using the Kids' Inpatient Database, 2012. Odds ratios of undergoing a minimally invasive compared to open operation were calculated for six typical pediatric surgical operations after adjustment for multiple patient demographic and hospital-level variables. Further adjustment to the regression model was made by incorporating hospital practice patterns, defined as operation-specific minimally invasive frequency and volume. Age was the most significant patient demographic factor affecting application of minimally invasive surgery for all procedures. For several procedures, adjusting for individual hospital practice patterns removed race- and income-based disparities seen in performance of minimally invasive operations. Disparities related to insurance status were not affected by the same adjustment. Variation in the application of minimally invasive surgery in pediatric surgical patients is primarily influenced by patient age and the type of procedure performed. Perceived disparities in access related to some socioeconomic factors are decreased but not eliminated by accounting for individual hospital practice patterns, suggesting that complex underlying factors influence application of advanced surgical techniques. II. Copyright © 2017 Elsevier Inc. All rights reserved.

The intelligent OR: design and validation of a context-aware surgical working environment.

PubMed

Franke, Stefan; Rockstroh, Max; Hofer, Mathias; Neumuth, Thomas

2018-05-24

Interoperability of medical devices based on standards starts to establish in the operating room (OR). Devices share their data and control functionalities. Yet, the OR technology rarely implements cooperative, intelligent behavior, especially in terms of active cooperation with the OR team. Technical context-awareness will be an essential feature of the next generation of medical devices to address the increasing demands to clinicians in information seeking, decision making, and human-machine interaction in complex surgical working environments. The paper describes the technical validation of an intelligent surgical working environment for endoscopic ear-nose-throat surgery. We briefly summarize the design of our framework for context-aware system's behavior in integrated OR and present example realizations of novel assistance functionalities. In a study on patient phantoms, twenty-four procedures were implemented in the proposed intelligent surgical working environment based on recordings of real interventions. Subsequently, the whole processing pipeline for context-awareness from workflow recognition to the final system's behavior is analyzed. Rule-based behavior that considers multiple perspectives on the procedure can partially compensate recognition errors. A considerable robustness could be achieved with a reasonable quality of the recognition. Overall, reliable reactive as well as proactive behavior of the surgical working environment can be implemented in the proposed environment. The obtained validation results indicate the suitability of the overall approach. The setup is a reliable starting point for a subsequent evaluation of the proposed context-aware assistance. The major challenge for future work will be to implement the complex approach in a cross-vendor setting.

Surgical simulation: Current practices and future perspectives for technical skills training.

PubMed

Bjerrum, Flemming; Thomsen, Ann Sofia Skou; Nayahangan, Leizl Joy; Konge, Lars

2018-06-17

Simulation-based training (SBT) has become a standard component of modern surgical education, yet successful implementation of evidence-based training programs remains challenging. In this narrative review, we use Kern's framework for curriculum development to describe where we are now and what lies ahead for SBT within surgery with a focus on technical skills in operative procedures. Despite principles for optimal SBT (proficiency-based, distributed, and deliberate practice) having been identified, massed training with fixed time intervals or a fixed number of repetitions is still being extensively used, and simulators are generally underutilized. SBT should be part of surgical training curricula, including theoretical, technical, and non-technical skills, and be based on relevant needs assessments. Furthermore, training should follow evidence-based theoretical principles for optimal training, and the effect of training needs to be evaluated using relevant outcomes. There is a larger, still unrealized potential of surgical SBT, which may be realized in the near future as simulator technologies evolve, more evidence-based training programs are implemented, and cost-effectiveness and impact on patient safety is clearly demonstrated.

Guideline Implementation: Surgical Smoke Safety.

PubMed

Fencl, Jennifer L

2017-05-01

Research conducted during the past four decades has demonstrated that surgical smoke generated from the use of energy-generating devices in surgery contains toxic and biohazardous substances that present risks to perioperative team members and patients. Despite the increase in information available, however, perioperative personnel continue to demonstrate a lack of knowledge of these hazards and lack of compliance with recommendations for evacuating smoke during surgical procedures. The new AORN "Guideline for surgical smoke safety" provides guidance on surgical smoke management. This article focuses on key points of the guideline to help perioperative personnel promote smoke-free work environments; evacuate surgical smoke; and develop education programs and competency verification tools, policies and procedures, and quality improvement initiatives related to controlling surgical smoke. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures. Copyright © 2017 AORN, Inc. Published by Elsevier Inc. All rights reserved.

30-Day morbidity after augmentation enterocystoplasty and appendicovesicostomy: A NSQIP pediatric analysis.

PubMed

McNamara, Erin R; Kurtz, Michael P; Schaeffer, Anthony J; Logvinenko, Tanya; Nelson, Caleb P

2015-08-01

Augmentation enterocystoplasty and appendicovesicostomy are complex pediatric urologic procedures. Although there is literature identifying long-term outcomes in these patients, the reporting of short-term postoperative outcomes has been limited by small numbers of cases and lack of prospective data collection. Here we report 30-day outcomes from the first nationally based, prospectively assembled cohort of pediatric patients undergoing these procedures. To determine 30-day complication, readmission and reoperation after augmentation enterocystoplasty and appendicovesicostomy in a large national sample of pediatric patients, and to explore the association between preoperative and intraoperative characteristics and occurrence of any 30-day event. We queried the 2012 and 2013 American College of Surgeons National Surgical Quality Improvement Program Pediatric database (ACS-NSQIPP) for all patients undergoing augmentation enterocystoplasty and/or appendicovesicostomy. Surgical risk score was classified on a linear scale using a validated pediatric-specific comorbidity score. Intraoperative characteristics and postoperative 30-day events were reported from prospectively collected data. A composite measure of complication, readmission and/or reoperation was used as primary outcome for the multivariate logistic regression. There were 461 patients included in the analysis: 245 had appendicovesicostomy, 97 had augmentation enterocystoplasty and 119 had both procedures. There were a total of 110 NSQIP complications seen in 87 patients. The most common complication was urinary tract infection (see Table for 30-day outcomes by patient). The composite measure of any 30-day event was seen in 27.8% of the cohort and this was associated with longer operative time, increased number of procedures done at time of primary surgical procedure and higher surgical risk score. The ACS-NSQIPP provides a tool to examine short-term outcomes for these complex urologic procedures that has not been possible before. Although ACS-NSQIP has been used extensively in the adult surgical literature to identify rates of complications, and to determine predictors of readmission and adverse events, its use in pediatric surgery is new. As in the adult literature, the goal is for standardization of practice and transparency in reporting outcomes that may lead to reduction in morbidity and mortality. In this cohort, any 30-day event is seen in almost 30% of the patients undergoing these urologic procedures. Operative time, number of concurrent procedures and higher surgical risk score all are associated with higher odds of the composite 30-day event of complication, readmission and/or reoperation. These data can be useful in counseling patients and families about expectations around surgery and in improving outcomes. Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Achieving Benchmark Results for Neonatal Palliation of Hypoplastic Left Heart Syndrome and Related Anomalies in an Emerging Program.

PubMed

Dodge-Khatami, Ali; Chancellor, William Z; Gupta, Bhawna; Seals, Samantha R; Ebeid, Makram R; Batlivala, Sarosh P; Taylor, Mary B; Salazar, Jorge D

2015-07-01

Results of surgical management of hypoplastic left heart syndrome (HLHS) and related anomalies are often compared to published benchmark data which reflect the use of a variety of surgical and hybrid protocols. We report encouraging results achieved in an emerging program, despite a learning curve at all care levels. Rather than relying on a single preferred protocol, surgical management was based on matching surgical strategy to individual patient factors. From 2010 to 2014, a total of 47 consecutive patients with HLHS or related anomalies with ductal-dependent systemic circulation underwent initial surgical palliation, including 30 Norwood stage I, 8 hybrid stage I, and 9 salvage-to-Norwood procedures. True hybrid procedures entailed bilateral pulmonary artery banding and ductal stenting. In the salvage-to-Norwood strategy, ductal stenting was withheld in favor of continued prostaglandin infusion in anticipation of a deferred Norwood procedure. Cardiac comorbidities (obstructed pulmonary venous return, poor ventricular function, and atrioventricular valve regurgitation) and noncardiac comorbidities influenced the choice of treatment strategies and were analyzed as potential risk factors for extracorporeal membrane oxygenation (ECMO) support or in-hospital mortality. Overall hospital survival was 81% (Norwood 83.3%, hybrid 88%, "salvage" 67%; P = .4942). Extracorporeal membrane oxygenation support was used for eight (17%) patients with two survivors. For cases with obstructed pulmonary venous return (n = 10, 21%), management choices favored a hybrid or salvage strategy (P = .0026). Aortic atresia (n = 22, 47%) was treated by a Norwood or salvage-to-Norwood. No cardiac, noncardiac, or genetic comorbidities were identified as independent risk factors for ECMO or discharge mortality in a multivariable analysis. Our emerging program achieved outcomes that compare favorably to published benchmark data with respect to hospital survival. These results reflect rigorous interdisciplinary teamwork and a flexible approach to surgical palliation based on matching surgical strategy to patient factors. With major associated cardiac/noncardiac comorbidity and antegrade coronary flow, a true hybrid with ductal stenting was our preferred strategy. For high-risk situations such as aortic atresia with obstructed pulmonary venous return, the salvage hybrid-bridge-to-Norwood strategy may help achieve survival albeit with increased resource utilization. © The Author(s) 2015.

The design, production and clinical application of 3D patient-specific implants with drilling guides for acetabular surgery.

PubMed

Merema, B J; Kraeima, J; Ten Duis, K; Wendt, K W; Warta, R; Vos, E; Schepers, R H; Witjes, M J H; IJpma, F F A

2017-11-01

An innovative procedure for the development of 3D patient-specific implants with drilling guides for acetabular fracture surgery is presented. By using CT data and 3D surgical planning software, a virtual model of the fractured pelvis was created. During this process the fracture was virtually reduced. Based on the reduced fracture model, patient-specific titanium plates including polyamide drilling guides were designed, 3D printed and milled for intra-operative use. One of the advantages of this procedure is that the personalised plates could be tailored to both the shape of the pelvis and the type of fracture. The optimal screw directions and sizes were predetermined in the 3D model. The virtual plan was translated towards the surgical procedure by using the surgical guides and patient-specific osteosynthesis. Besides the description of the newly developed multi-disciplinary workflow, a clinical case example is presented to demonstrate that this technique is feasible and promising for the operative treatment of complex acetabular fractures. Copyright © 2017 Elsevier Ltd. All rights reserved.

NIOSH health and safety practices survey of healthcare workers: training and awareness of employer safety procedures.

PubMed

Steege, Andrea L; Boiano, James M; Sweeney, Marie H

2014-06-01

The Health and Safety Practices Survey of Healthcare Workers describes current practices used to minimize chemical exposures and barriers to using recommended personal protective equipment for the following: antineoplastic drugs, anesthetic gases, high level disinfectants, surgical smoke, aerosolized medications (pentamidine, ribavirin, and antibiotics), and chemical sterilants. Twenty-one healthcare professional practice organizations collaborated with NIOSH to develop and implement the web-based survey. Twelve thousand twenty-eight respondents included professional, technical, and support occupations which routinely come in contact with the targeted hazardous chemicals. Chemical-specific safe handling training was lowest for aerosolized antibiotics (52%, n = 316), and surgical smoke (57%, n = 4,747). Reported employer procedures for minimizing exposure was lowest for surgical smoke (32%, n = 4,746) and anesthetic gases (56%, n = 3,604). Training and having procedures in place to minimize exposure to these chemicals is one indication of employer and worker safety awareness. Safe handling practices for use of these chemicals will be reported in subsequent papers. © 2014 Wiley Periodicals, Inc.

10 Years Later: Lessons Learned from an Academic Multidisciplinary Cosmetic Center

PubMed Central

Chen, Jenny T.; Nayar, Harry S.

2017-01-01

Background: In 2006, a Centers for Medicare and Medicaid Services-accredited multidisciplinary academic ambulatory surgery center was established with the goal of delivering high-quality, efficient reconstructive, and cosmetic services in an academic setting. We review our decade-long experience since its establishment. Methods: Clinical and financial data from 2006 to 2016 are reviewed. All cosmetic procedures, including both minimally invasive and operative cases, are included. Data are compared to nationally published reports. Results: Nearly 3,500 cosmetic surgeries and 10,000 minimally invasive procedures were performed. Compared with national averages, surgical volume in abdominoplasty is high, whereas rhinoplasty and breast augmentation is low. Regarding trend data, breast augmentation volume has decreased by 25%, whereas minimally invasive procedural volume continues to grow and is comparable with national reports. Similarly, where surgical revenue remains steady, minimally invasive revenue has increased significantly. The majority of surgical cases (70%) are reconstructive in nature and insurance-based. Payer mix is 71% private insurance, 18% Medicare and Medicaid, and 11% self-pay. Despite year-over-year revenue increases, net profit in 2015 was $6,120. Rent and anesthesia costs exceed national averages, and employee salary and wages are the highest expenditure. Conclusion: Although the creation of our academic cosmetic ambulatory surgery center has greatly increased the overall volume of cosmetic surgery performed at the University of Wisconsin, the majority of surgical volume and revenue is reconstructive. As is seen nationwide, minimally invasive cosmetic procedures represent our most rapidly expanding revenue stream. PMID:29062640

The first successful laparoscopic Whipple procedure at Hat Yai Hospital: surgical technique and a case report.

PubMed

Khaimook, Araya; Borkird, Jumpot; Alapach, Sakda

2010-09-01

Whipple procedure is the most complex abdominal surgical procedure to treat periampullary carcinoma. With the benefit of minimally invasive approach, many institutes attempt to do Whipple procedure laparoscopically. However, only 146 cases of laparoscopic Whipple procedure have yet been reported in the literature worldwide between 1994 and 2008. The authors reported the first laparoscopic Whipple procedure at Hat Yai Hospital in December 2009. The patient was a 40-year-old, Thai-Muslim female, with the diagnosis of ampullary carcinoma. The operating time was 685 minutes. The patient was discharged on postoperative day 14 without serious complication. The surgical technique and postoperative progress of the patient were described.

Incorporating Comorbidity Within Risk Adjustment for UK Pediatric Cardiac Surgery.

PubMed

Brown, Katherine L; Rogers, Libby; Barron, David J; Tsang, Victor; Anderson, David; Tibby, Shane; Witter, Thomas; Stickley, John; Crowe, Sonya; English, Kate; Franklin, Rodney C; Pagel, Christina

2017-07-01

When considering early survival rates after pediatric cardiac surgery it is essential to adjust for risk linked to case complexity. An important but previously less well understood component of case mix complexity is comorbidity. The National Congenital Heart Disease Audit data representing all pediatric cardiac surgery procedures undertaken in the United Kingdom and Ireland between 2009 and 2014 was used to develop and test groupings for comorbidity and additional non-procedure-based risk factors within a risk adjustment model for 30-day mortality. A mixture of expert consensus based opinion and empiric statistical analyses were used to define and test the new comorbidity groups. The study dataset consisted of 21,838 pediatric cardiac surgical procedure episodes in 18,834 patients with 539 deaths (raw 30-day mortality rate, 2.5%). In addition to surgical procedure type, primary cardiac diagnosis, univentricular status, age, weight, procedure type (bypass, nonbypass, or hybrid), and era, the new risk factor groups of non-Down congenital anomalies, acquired comorbidities, increased severity of illness indicators (eg, preoperative mechanical ventilation or circulatory support) and additional cardiac risk factors (eg, heart muscle conditions and raised pulmonary arterial pressure) all independently increased the risk of operative mortality. In an era of low mortality rates across a wide range of operations, non-procedure-based risk factors form a vital element of risk adjustment and their presence leads to wide variations in the predicted risk of a given operation. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Surgical insertions of transmitters and telemetry methods in fisheries research

USGS Publications Warehouse

Wargo Rub, A. Michelle; Jepsen, Niels; Liedtke, Theresa L.; Moser, L; Weber III, E. P. Scott

2015-01-01

Use of electronic transmitter and monitoring systems to track movements of aquatic animals has increased continuously since the inception of these systems in the mid-1950s. The purpose of the present report is to provide information about veterinary principles and their incorporation into surgical implantation procedures for fish. We also intend to provide insight into the unique challenges of field-based aquatic surgical studies. Within this context, 4 aspects of the process for surgical implantation of transmitters in fish (ie, handling, aseptic technique, anesthesia, and implantation) will be described. Effects of surgical insertion of transmitters (ie, tagging) and aspects of the surgical implantation process where collaboration and professional exchanges among nonveterinarian researchers and veterinarians may be most fruitful will be discussed. Although this report focuses on surgical implantation, the principles and protocols described here (other than incision and suture placement) are also applicable to studies that involve injection of transmitters into fish.

Comprehensive evaluation of liver resection procedures: surgical mind development through cognitive task analysis.

PubMed

Ho, Cheng-Maw; Wakabayashi, Go; Yeh, Chi-Chuan; Hu, Rey-Heng; Sakaguchi, Takanori; Hasegawa, Yasushi; Takahara, Takeshi; Nitta, Hiroyuki; Sasaki, Akira; Lee, Po-Huang

2018-01-01

Liver resection is a complex procedure for trainee surgeons. Cognitive task analysis (CTA) facilitates understanding and decomposing tasks that require a great proportion of mental activity from experts. Using CTA and video-based coaching to compare liver resection by open and laparoscopic approaches, we decomposed the task of liver resection into exposure (visual field building), adequate tension made at the working plane (which may change three-dimensionally during the resection process), and target processing (intervention strategy) that can bridge the gap from the basic surgical principle. The key steps of highly-specialized techniques, including hanging maneuvers and looping of extra-hepatic hepatic veins, were shown on video by open and laparoscopic approaches. Familiarization with laparoscopic anatomical orientation may help surgeons already skilled at open liver resection transit to perform laparoscopic liver resection smoothly. Facilities at hand (such as patient tolerability, advanced instruments, and trained teams of personnel) can influence surgical decision making. Application of the rationale and realizing the interplay between the surgical principles and the other paramedical factors may help surgeons in training to understand the mental abstractions of experienced surgeons, to choose the most appropriate surgical strategy effectively at will, and to minimize the gap.

Compact teleoperated laparoendoscopic single-site robotic surgical system: Kinematics, control, and operation.

PubMed

Isaac-Lowry, Oran Jacob; Okamoto, Steele; Pedram, Sahba Aghajani; Woo, Russell; Berkelman, Peter

2017-12-01

To date a variety of teleoperated surgical robotic systems have been developed to improve a surgeon's ability to perform demanding single-port procedures. However typical large systems are bulky, expensive, and afford limited angular motion, while smaller designs suffer complications arising from limited motion range, speed, and force generation. This work was to develop and validate a simple, compact, low cost single site teleoperated laparoendoscopic surgical robotic system, with demonstrated capability to carry out basic surgical procedures. This system builds upon previous work done at the University of Hawaii at Manoa and includes instrument and endoscope manipulators as well as compact articulated instruments designed to overcome single incision geometry complications. A robotic endoscope holder was used for the base, with an added support frame for teleoperated manipulators and instruments fabricated mostly from 3D printed parts. Kinematics and control methods were formulated for the novel manipulator configuration. Trajectory following results from an optical motion tracker and sample task performance results are presented. Results indicate that the system has successfully met the goal of basic surgical functionality while minimizing physical size, complexity, and cost. Copyright © 2017 John Wiley & Sons, Ltd.

Appendicitis with appendicular atresia: a rare presentation

PubMed Central

Masood, Irfan; Majid, Zain; Rafiq, Ali; Fatima, Saba; Siddiqui, Osama Bin Zia

2015-01-01

Acute appendicitis is the most common acute surgical condition; making appendectomy the most commonly performed emergency surgical procedure in the world. Anomalies of the appendix are relatively uncommon. However, their presence may alter the course of pre-operative diagnosis and the surgical treatment provided, leading to medico-legal issues in certain cases as well. We hereby present the case of a 17 year-old female who had the suggestive signs, symptoms and investigations of appendicular lump. She was managed according to the Ochsner-Sherren regimen and then underwent interval open appendectomy 6 weeks later. During the procedure, the findings of a 5 cm long appendix were noted. The base of the appendix was attached to the caecum, however there was complete mucosal discontinuity between the base and the remaining portion of the appendix. A fibrous strand connected the two blind ending parts together. After thorough literature search, the authors concluded that this is only the fourth reported case of appendicular atresia ever to have been reported. Considering the rarity of this finding we feel this could be of valuable interest to surgeons and readers alike PMID:26090015

A tool and index to assess surgical capacity in low income countries: an initial implementation in Sierra Leone.

PubMed

Groen, Reinou S; Kamara, Thaim B; Dixon-Cole, Richmond; Kwon, Steven; Kingham, T Peter; Kushner, Adam L

2012-08-01

A first step toward improving surgical care in many low and middle income countries is to document the need. To facilitate the collection and analysis of surgical capacity data and measure changes over time, Surgeons OverSeas (SOS) developed a tool and index based on personnel, infrastructure, procedures, equipment, and supplies (PIPES). A follow-up assessment of 10 government hospitals in Sierra Leone was completed 42 months after an initial survey in 2008 using the PIPES tool. An index based on number of operating rooms, personnel, infrastructure, procedures, equipment, and supplies was calculated. An index was also calculated, using the 2008 data for comparison. Most hospitals demonstrated an increased index that correlated with site visits that verified improved conditions. Connaught Hospital in Sierra Leone had the highest score (9.2), consistent with its being the best equipped and staffed Ministry of Health and Sanitation facility. Makeni District Hospital had the greatest increase, from 3.8 to 7.5, consistent with a newly constructed facility. The PIPES tool was easily administered at hospitals in Sierra Leone and an index was found useful. Surgical capacity in Sierra Leone improved between 2008 and 2011, as demonstrated by an increase in the overall PIPES indices.

Current state of virtual reality simulation in robotic surgery training: a review.

PubMed

Bric, Justin D; Lumbard, Derek C; Frelich, Matthew J; Gould, Jon C

2016-06-01

Worldwide, the annual number of robotic surgical procedures continues to increase. Robotic surgical skills are unique from those used in either open or laparoscopic surgery. The acquisition of a basic robotic surgical skill set may be best accomplished in the simulation laboratory. We sought to review the current literature pertaining to the use of virtual reality (VR) simulation in the acquisition of robotic surgical skills on the da Vinci Surgical System. A PubMed search was conducted between December 2014 and January 2015 utilizing the following keywords: virtual reality, robotic surgery, da Vinci, da Vinci skills simulator, SimSurgery Educational Platform, Mimic dV-Trainer, and Robotic Surgery Simulator. Articles were included if they were published between 2007 and 2015, utilized VR simulation for the da Vinci Surgical System, and utilized a commercially available VR platform. The initial search criteria returned 227 published articles. After all inclusion and exclusion criteria were applied, a total of 47 peer-reviewed manuscripts were included in the final review. There are many benefits to utilizing VR simulation for robotic skills acquisition. Four commercially available simulators have been demonstrated to be capable of assessing robotic skill. Three of the four simulators demonstrate the ability of a VR training curriculum to improve basic robotic skills, with proficiency-based training being the most effective training style. The skills obtained on a VR training curriculum are comparable with those obtained on dry laboratory simulation. The future of VR simulation includes utilization in assessment for re-credentialing purposes, advanced procedural-based training, and as a warm-up tool prior to surgery.

Successful correction of tibial bone deformity through multiple surgical procedures, liquid nitrogen-pretreated bone tumor autograft, three-dimensional external fixation, and internal fixation in a patient with primary osteosarcoma: a case report.

PubMed

Takeuchi, Akihiko; Yamamoto, Norio; Shirai, Toshiharu; Nishida, Hideji; Hayashi, Katsuhiro; Watanabe, Koji; Miwa, Shinji; Tsuchiya, Hiroyuki

2015-12-07

In a previous report, we described a method of reconstruction using tumor-bearing autograft treated by liquid nitrogen for malignant bone tumor. Here we present the first case of bone deformity correction following a tumor-bearing frozen autograft via three-dimensional computerized reconstruction after multiple surgeries. A 16-year-old female student presented with pain in the left lower leg and was diagnosed with a low-grade central tibial osteosarcoma. Surgical bone reconstruction was performed using a tumor-bearing frozen autograft. Bone union was achieved at 7 months after the first surgical procedure. However, local tumor recurrence and lung metastases occurred 2 years later, at which time a second surgical procedure was performed. Five years later, the patient developed a 19° varus deformity and underwent a third surgical procedure, during which an osteotomy was performed using the Taylor Spatial Frame three-dimensional external fixation technique. A fourth corrective surgical procedure was performed in which internal fixation was achieved with a locking plate. Two years later, and 10 years after the initial diagnosis of tibial osteosarcoma, the bone deformity was completely corrected, and the patient's limb function was good. We present the first report in which a bone deformity due to a primary osteosarcoma was corrected using a tumor-bearing frozen autograft, followed by multiple corrective surgical procedures that included osteotomy, three-dimensional external fixation, and internal fixation.

Surgical management of chronic pancreatitis: current utilization in the United States.

PubMed

Bliss, Lindsay A; Yang, Catherine J; Eskander, Mariam F; de Geus, Susanna W L; Callery, Mark P; Kent, Tara S; Moser, A James; Freedman, Steven D; Tseng, Jennifer F

2015-09-01

Surgical intervention is uncommon in chronic pancreatitis. Literature largely describes single institution or international experiences. This study describes US-based chronic pancreatitis surgical management. Retrospective analysis of chronic pancreatitis patients in the Healthcare Cost and Utilization Project Florida State Inpatient Database 2007-2011. Patients with malignancy or congenital abnormalities were excluded. Univariate analysis using the chi-square test. The number of readmissions, inpatient length of stay and cost using Wilcoxon's signed-rank test. Multivariate analysis of surgery by logistic regression. Twenty-one thousand four hundred and forty-five patients with chronic pancreatitis. 10.8% (2 307) underwent surgery including 1652 cholecystectomies, 564 drainage procedures and 498 pancreatectomies. Procedures decreased from 12.1% to 8.3% over time (P < 0.001), but intervention within 3 months increased (7.2% to 8.4%; P = 0.017). 15.3% (3 278) had pancreatic cysts/pseudocysts and 43.4% (9 312) had diabetes. The median numbers of admissions were 2 [interquartile range (IQR) 1,5] and 3 (IQR 2,7) among non-surgical and surgical patients, respectively (P < 0.001). Predictors of surgery were fewer co-morbidities, private insurance, and either diabetes mellitus or pancreatic cyst/pseudocyst. Chronic pancreatitis leads to numerous inpatient readmissions, but surgical intervention only occurs in a minority of cases. Complicated patients are more likely to undergo surgery. The complexities of chronic pancreatitis management warrant early multidisciplinary evaluation and ongoing consideration of surgical and non-surgical options. © 2015 International Hepato-Pancreato-Biliary Association.

Integration of Surgical Residency Training With US Military Humanitarian Missions.

PubMed

Jensen, Shane; Tadlock, Matthew D; Douglas, Trent; Provencher, Matthew; Ignacio, Romeo C

2015-01-01

To describe how the US Navy integrates surgical resident training during hospital ship-based humanitarian activities and discuss the potential operative and educational benefits during these missions. Retrospective review of predeployment surgical plans, operative case logs, and after-action reports from United States Naval Ship (USNS) Mercy humanitarian deployments from 2006 to 2012. The USNS Mercy hospital ship. We enrolled 24 surgical residents from different surgical specialties including general surgery, obstetrics and gynecology, urology, otolaryngology, and ophthalmology. During 4 planned deployments (2006-2012), 2887 surgical procedures were performed during 20 humanitarian missions conducted by the USNS Mercy in 9 different Southeast Asian countries. Of all the general surgery eligible procedures performed, 1483 (79%) were defined categories under the current general surgery Accreditation Council for Graduate Medical Education guidelines, including abdominal (31%); skin, soft tissue, and breast (21%); ear, nose, and throat (20.5%); plastic surgery (15.5%); and pediatric (12%) cases. The number of surgical cases completed by each resident ranged from 30 to 67 cases over a period of 4 to 6 weeks during the overseas humanitarian rotation. The US Navy's humanitarian experience provides a unique educational opportunity for young military surgeons to experience various global health systems, diverse cultures, and complex logistical planning without sacrificing the breadth and depth of surgical training. This model may provide a framework to develop future international electives for other general surgery training programs. Copyright © 2015. Published by Elsevier Inc.

Complex robotic reconstructive surgical procedures in children with urologic abnormalities.

PubMed

Orvieto, Marcelo A; Gundeti, Mohan S

2011-07-01

Robot-assisted laparoscopic surgery (RALS) is evolving rapidly in the pediatric surgical field. The unique attributes of the robotic interface makes this technology ideal for children with congenital anomalies who often require reconstructive procedures. Furthermore, the system can generate extremely delicate movements in a confined working space such as the one generally found in the pediatric population. Herein, we critically review the current experience with RALS placing a special emphasis in children undergoing complex reconstructive surgical procedures worldwide. A total of 42 original manuscripts on a variety of robot-assisted urologic surgical procedures in children were identified from a MEDLINE database search. Complex reconstructive procedures that are being currently performed include reoperative pyeloplasty, pyeloplasty in infants, pyelolithotomy, ureteropyelostomy/ureterostomy, bladder augmentation with or without appendico-vesicostomy, bladder neck sling procedure, among others. Initial results with robot assistance are encouraging and have demonstrated safety comparable to open procedures and outcomes at least equivalent to standard laparoscopy. Future development of smaller instruments, incorporating tactile feedback, will likely overcome current limitations and spread out the use of this technique in younger children and more advanced procedures.

Unplanned admissions in day-case surgery as a clinical indicator for quality assurance.

PubMed

Margovsky, A

2000-03-01

Day surgery is a modern, effective and economical way to treat patients while maintaining the same level of quality of patient care. Quality improvement in day surgery units, however, continues to be an issue due to high rates of unplanned admissions. The aim of the present retrospective study was to investigate reasons for and methods of preventing unplanned postoperative admissions in a day surgical unit over a 12-month period in respect to different surgical specialties. The study was based on an audit from the Endoscopy and Day Surgery Unit (EDSU) at Launceston General Hospital, which provides health care to a population of more than 120000. For the accounted period 920 outpatients had elective day surgical procedures. Overall the unplanned admission rate was 4.7%, and surgical, anaesthetic and social reasons accounted for 58.2, 37.2 and 4.6% of the unplanned admissions, respectively. The highest rate of unplanned admissions was for plastic and reconstructive surgery (12.8%) and orthopaedic surgery (7.5%) despite the relatively small number of patients who underwent such procedures in the day surgery unit. The results also showed a correlation between age group, pre-operative medical status of the patients found suitable for the day surgical procedure and unplanned admissions. Strategies to reduce the unplanned admission rate which include patient selection and pre-operative assessment, patient waiting time and education, pre-operative anaesthesia, follow-up with nursing care and postoperative analgesia are discussed.

Toward image guided robotic surgery: system validation.

PubMed

Herrell, Stanley D; Kwartowitz, David Morgan; Milhoua, Paul M; Galloway, Robert L

2009-02-01

Navigation for current robotic assisted surgical techniques is primarily accomplished through a stereo pair of laparoscopic camera images. These images provide standard optical visualization of the surface but provide no subsurface information. Image guidance methods allow the visualization of subsurface information to determine the current position in relationship to that of tracked tools. A robotic image guided surgical system was designed and implemented based on our previous laboratory studies. A series of experiments using tissue mimicking phantoms with injected target lesions was performed. The surgeon was asked to resect "tumor" tissue with and without the augmentation of image guidance using the da Vinci robotic surgical system. Resections were performed and compared to an ideal resection based on the radius of the tumor measured from preoperative computerized tomography. A quantity called the resection ratio, that is the ratio of resected tissue compared to the ideal resection, was calculated for each of 13 trials and compared. The mean +/- SD resection ratio of procedures augmented with image guidance was smaller than that of procedures without image guidance (3.26 +/- 1.38 vs 9.01 +/- 1.81, p <0.01). Additionally, procedures using image guidance were shorter (average 8 vs 13 minutes). It was demonstrated that there is a benefit from the augmentation of laparoscopic video with updated preoperative images. Incorporating our image guided system into the da Vinci robotic system improved overall tissue resection, as measured by our metric. Adding image guidance to the da Vinci robotic surgery system may result in the potential for improvements such as the decreased removal of benign tissue while maintaining an appropriate surgical margin.

An introduction to the practical and ethical perspectives on the need to advance and standardize the intracoelomic surgical implantation of electronic tags in fish

USGS Publications Warehouse

Brown, R.S.; Eppard, M.B.; Murchie, K.J.; Nielsen, J.L.; Cooke, S.J.

2011-01-01

The intracoelomic surgical implantation of electronic tags (including radio and acoustic telemetry transmitters, passive integrated transponders and archival biologgers) is frequently used for conducting studies on fish. Electronic tagging studies provide information on the spatial ecology, behavior and survival of fish in marine and freshwater systems. However, any surgical procedure, particularly one where a laparotomy is performed and the coelomic cavity is opened, has the potential to alter the survival, behavior or condition of the animal which can impair welfare and introduce bias. Given that management, regulatory and conservation decisions are based on the assumption that fish implanted with electronic tags have similar fates and behavior relative to untagged conspecifics, it is critical to ensure that best surgical practices are being used. Also, the current lack of standardized surgical procedures and reporting of specific methodological details precludes cross-study and cross-year analyses which would further progress the field of fisheries science. This compilation of papers seeks to identify the best practices for the entire intracoelomic tagging procedure including pre- and post-operative care, anesthesia, wound closure, and use of antibiotics. Although there is a particular focus on salmonid smolts given the large body of literature available on that group, other life-stages and species of fish are discussed where there is sufficient knowledge. Additional papers explore the role of the veterinarian in fish surgeries, the need for minimal standards in the training of fish surgeons, providing a call for more complete and transparent procedures, and identifying trends in procedures and research needs. Collectively, this body of knowledge should help to improve data quality (including comparability and repeatability), enhance management and conservation strategies, and maintain the welfare status of tagged fish. ?? 2010 Springer Science+Business Media B.V.

Past, Present and Future of Surgical Meshes: A Review.

PubMed

Baylón, Karen; Rodríguez-Camarillo, Perla; Elías-Zúñiga, Alex; Díaz-Elizondo, Jose Antonio; Gilkerson, Robert; Lozano, Karen

2017-08-22

Surgical meshes, in particular those used to repair hernias, have been in use since 1891. Since then, research in the area has expanded, given the vast number of post-surgery complications such as infection, fibrosis, adhesions, mesh rejection, and hernia recurrence. Researchers have focused on the analysis and implementation of a wide range of materials: meshes with different fiber size and porosity, a variety of manufacturing methods, and certainly a variety of surgical and implantation procedures. Currently, surface modification methods and development of nanofiber based systems are actively being explored as areas of opportunity to retain material strength and increase biocompatibility of available meshes. This review summarizes the history of surgical meshes and presents an overview of commercial surgical meshes, their properties, manufacturing methods, and observed biological response, as well as the requirements for an ideal surgical mesh and potential manufacturing methods.

Prevalence of Neoplastic Diseases in Pet Birds Referred for Surgical Procedures

PubMed Central

Castro, Patrícia F.; Fantoni, Denise T.; Miranda, Bruna C.; Matera, Julia M.

2016-01-01

Neoplastic disease is common in pet birds, particularly in psittacines, and treatment should be primarily aimed at tumor eradication. Nineteen cases of pet birds submitted to diagnostic and/or therapeutic surgical procedures due to neoplastic disease characterized by the presence of visible masses were retrospectively analyzed; affected species, types of neoplasms and respective locations, and outcomes of surgical procedures were determined. All birds undergoing surgery belonged to the order Psittaciformes; the Blue-fronted parrot (Amazona aestiva) was the prevalent species. Lipoma was the most frequent neoplasm in the sample studied. Most neoplasms affected the integumentary system, particularly the pericloacal area. Tumor resection was the most common surgical procedure performed, with high resolution and low recurrence rates. PMID:26981315

Reduction Mammoplasty: A Comparison Between Operations Performed by Plastic Surgery and General Surgery.

PubMed

Kordahi, Anthony M; Hoppe, Ian C; Lee, Edward S

2015-01-01

Reduction mammoplasty is an often-performed procedure by plastic surgeons and increasingly by general surgeons. The question has been posed in both general surgical literature and plastic surgical literature as to whether this procedure should remain the domain of surgical specialists. Some general surgeons are trained in breast reductions, whereas all plastic surgeons receive training in this procedure. The National Surgical Quality Improvement Project provides a unique opportunity to compare the 2 surgical specialties in an unbiased manner in terms of preoperative comorbidities and 30-day postoperative complications. The National Surgical Quality Improvement Project database was queried for the years 2005-2012. Patients were identified as having undergone a reduction mammoplasty by Current Procedural Terminology codes. RESULTS were refined to include only females with an International Classification of Diseases, Ninth Revision, code of 611.1 (hypertrophy of breasts). Information was collected regarding age, surgical specialty performing procedure, body mass index, and other preoperative variables. The outcomes utilized were presence of superficial surgical site infection, presence of deep surgical site infection, presence of wound dehiscence, postoperative respiratory compromise, pulmonary embolism, deep vein thrombosis, perioperative transfusion, operative time, reintubation, reoperation, and length of hospital stay. During this time period, there were 6239 reduction mammaplasties performed within the National Surgical Quality Improvement Project database: 339 by general surgery and 5900 by plastic surgery. No statistical differences were detected between the 2 groups with regard to superficial wound infections, deep wound infections, organ space infections, or wound dehiscence. There were no significant differences noted between within groups with regard to systemic postoperative complications. Patients undergoing a procedure by general surgery were more likely to experience a failure of skin flaps, necessitating a return to the operative room (P < .05). Operative time was longer in procedures performed by general surgery (P < .05). Several important differences appear to exist between reduction mammaplasties performed by general surgery and plastic surgery. A focused training in reduction mammoplasty appears to be beneficial to the patient. The limitations of this study include a lack of long-term follow-up with regard to aesthetic outcome, nipple malposition, nipple sensation, and late wound sequelae.

Visible Human Project

MedlinePlus

... used for teaching, modeling radiation absorption and therapy, equipment design, surgical simulation, and simulation of diagnostic procedures, ….” ... Project ® " by Michael J. Ackerman, Ph.D. Projects Based on the Visible Human Data Set Applications for ...

High-level virtual reality simulator for endourologic procedures of lower urinary tract.

PubMed

Reich, Oliver; Noll, Margarita; Gratzke, Christian; Bachmann, Alexander; Waidelich, Raphaela; Seitz, Michael; Schlenker, Boris; Baumgartner, Reinhold; Hofstetter, Alfons; Stief, Christian G

2006-06-01

To analyze the limitations of existing simulators for urologic techniques, and then test and evaluate a novel virtual reality (VR) simulator for endourologic procedures of the lower urinary tract. Surgical simulation using VR has the potential to have a tremendous impact on surgical training, testing, and certification. Endourologic procedures seem to be an ideal target for VR systems. The URO-Trainer features genuine VR, obtained from digital video footage of more than 400 endourologic diagnostic and therapeutic procedures, as well as data from cross-sectional imaging. The software offers infinite random variations of the anatomy and pathologic features for diagnosis and surgical intervention. An advanced haptic force feedback is incorporated. Virtual cystoscopy and resection of bladder tumors were evaluated by 24 medical students and 12 residents at our department. The system was assessed by more than 150 international urologists with varying experience at different conventions and workshops from March 2003 to September 2004. Because of these evaluations and constant evolutions, the final version provides a genuine representation of endourologic procedures. Objective data are generated by a tutoring system that has documented evident teaching benefits for medical students and residents in cystoscopy and treatment of bladder tumors. The URO-Trainer represents the latest generation of endoscopy simulators. Authentic visual and haptic sensations, unlimited virtual cases, and an intelligent tutoring system make this modular system an important improvement in computer-based training and quality control in urology.

Management of antithrombotic therapy in patients with coronary artery disease or atrial fibrillation who underwent abdominal surgical operations.

PubMed

Schizas, Dimitrios; Kariori, Maria; Boudoulas, Konstantinos Dean; Siasos, Gerasimos; Patelis, Nikolaos; Kalantzis, Charalampos; Carmen-Maria, Moldovan; Vavuranakis, Manolis

2018-04-02

Patients treated with antithrombotic therapy that require abdominal surgical procedures has progressively increased overtime. The management of antithrombotics during both the peri- and post- operative period is of crucial importance. The goal of this review is to present current data concerning the management of antiplatelets in patients with coronary artery disease and of anticoagulants in patients with atrial fibrillation who had to undergo abdominal surgical operations. For this purpose, incidence of major adverse cardiovascular events (MACE) and risk of antithrombotic use during surgical procedures, as well as the recommendations based on recent guidelines were reported. A thorough search of PubMed, Scopus and the Cochrane Databases was conducted to identify randomized controlled trials, observational studies, novel current reviews, and ESC and ACC/AHA guidelines on the subject. Antithrombotic use in daily clinical practice results to two different pathways: reduction of thromboembolic risk, but a simultaneous increase of bleeding risk. This may cause a therapeutic dilemma during the perioperative period. Nevertheless, careless cessation of antithrombotics can increase MACE and thromboembolic events, however, maintenance of antithrombotic therapy may increase bleeding complications. Studies and current guidelines can assist clinicians in making decisions for the treatment of patients that undergo abdominal surgical operations while on antithrombotic therapy. Aspirin should not be stopped perioperatively in the majority of surgical operations. Determining whether to discontinue the use of anticoagulants before surgery depends on the surgical procedure. In surgical operations with a low risk for bleeding, oral anticoagulants should not be discontinued. Bridging therapy should only be considered in patients with a high risk of thromboembolism. Finally, patients with an intermediate risk for thromboembolism, management should be individualized according to patient's thrombotic and bleeding risk. Management of antithrombotics therapy during the perioperative period in patients undergoing abdominal surgery should follow a patient-centered approach according to a patient's medical history and thrombotic risk weighted for bleeding risk. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

A novel implantable device for the treatment of obstructive sleep apnea: clinical safety and feasibility.

PubMed

Pavelec, Vaclav; Rotenberg, Brian W; Maurer, Joachim T; Gillis, Edward; Verse, Thomas

2016-01-01

Many cases of obstructive sleep apnea (OSA) involve collapse of the tongue base and soft palate during sleep, causing occlusion of the upper airway and leading to oxygen desaturation. Existing therapies can be effective, but they are plagued by patient adherence issues and the invasiveness of surgical approaches. A new, minimally invasive implant for OSA has been developed, which is elastic and contracts a few weeks after deployment, stabilizing the surrounding soft tissue. The device has had good outcomes in preclinical testing; this report describes the preliminary feasibility and safety of its implementation in humans. A prospective, multicenter, single-arm feasibility study was conducted. Subjects were adults with moderate-to-severe OSA who had previously failed or refused conventional continuous positive airway pressure treatment. Intraoperative feasibility data, postoperative pain, and safety information were collected for a 30-day postoperative period. Forty subjects participated (37 men, three women; average age of 46.1 years); each received two tongue-base implants and two soft-palate implants. Surgical procedure time averaged 43 minutes. Postsurgical pain resolved readily in most cases; at 30 days post implantation, <20% of subjects reported pain, which averaged less than two out of ten. Adverse events were generally the mild and expected sequelae of a surgical procedure with general anesthesia and intraoral manipulation. The device was well tolerated. Implant extrusions were reported with soft-palate implants (n=12), while tongue-base implants required few revisions (n=2). Quantitative and qualitative sleep effectiveness outcomes (including full-night polysomnographic and quality-of-life measures) will be presented in a subsequent report. Implantation of the device was feasible. Although a relatively high rate of extrusions occurred in the now-discontinued palate implants, tongue-base implants were largely stable and well tolerated. The minimally invasive and maintenance-free implant may provide a new alternative to higher morbidity surgical procedures.

A comparative analysis of readmission rates after outpatient cosmetic surgery.

PubMed

Mioton, Lauren M; Alghoul, Mohammed S; Kim, John Y S

2014-02-01

Despite the increasing scrutiny of surgical procedures, outpatient cosmetic surgery has an established record of safety and efficacy. A key measure in assessing surgical outcomes is the examination of readmission rates. However, there is a paucity of data on unplanned readmission following cosmetic surgery procedures. The authors studied readmission rates for outpatient cosmetic surgery and compared the data with readmission rates for other surgical procedures. The 2011 National Surgical Quality Improvement Program (NSQIP) data set was queried for all outpatient procedures. Readmission rates were calculated for the 5 surgical specialties with the greatest number of outpatient procedures and for the overall outpatient cosmetic surgery population. Subgroup analysis was performed on the 5 most common cosmetic surgery procedures. Multivariate regression models were used to determine predictors of readmission for cosmetic surgery patients. The 2879 isolated outpatient cosmetic surgery cases had an associated 0.90% unplanned readmission rate. The 5 specialties with the highest number of outpatient surgical procedures were general, orthopedic, gynecologic, urologic, and otolaryngologic surgery; their unplanned readmission rates ranged from 1.21% to 3.73%. The 5 most common outpatient cosmetic surgery procedures and their associated readmission rates were as follows: reduction mammaplasty, 1.30%; mastopexy, 0.31%; liposuction, 1.13%; abdominoplasty, 1.78%; and breast augmentation, 1.20%. Multivariate regression analysis demonstrated that operating time (in hours) was an independent predictor of readmission (odds ratio, 1.40; 95% confidence interval, 1.08-1.81; P=.010). Rates of unplanned readmission with outpatient cosmetic surgery are low and compare favorably to those of other outpatient surgeries.

Control of asthma for reducing the risk of bronchospasm in asthmatics undergoing general anesthesia and/or intravascular administration of radiographic contrast media.

PubMed

Liccardi, Gennaro; Salzillo, Antonello; De Blasio, Francesco; D'Amato, Gennaro

2009-07-01

It is well known that patients suffering from bronchial asthma undergoing surgical procedures requiring general anesthesia (GA) or the administration of water soluble radiographic contrast media (RCM) have an increased risk of potentially severe bronchospasm. Nevertheless, little attention has been devoted to the possible preventive measures to reduce the occurrence of this potentially life-threatening event. It has been shown that the most important risk factor for bronchospasm during GA induction and/or the use of RCM is represented by a high degree of bronchial hyperreactivity with airway instability not adequately controlled by long-term anti-inflammatory treatment. The aim of this commentary is to underline the need for an accurate clinical and functional evaluation of asthmatics undergoing surgical procedures requiring GA or radiological procedures requiring the administration of RCM, as well as to suggest a stepwise preventive pharmacological approach for reducing the risk of bronchospasm. The authors' suggestions represent clinical experience of the respiratory section of an internal hospital-based working group whose aim is the prevention of asthmatic/anaphylactic/anaphylactoid reactions during the administration of anesthetics and/or RCM. The MEDLINE database was searched with a combination of keywords: general anesthesia, radio contrast media [and] bronchial asthma. The main limitation of this commentary is the scarcity of available literature on this topic. The authors suggest a therapeutic approach before surgical procedures requiring GA and/or RCM administration based on the degree of asthma control as assessed by clinical/functional criteria. In this setting, in addition to the necessity of obtaining the best control of airway reactivity, the authors suggest that an optimal control of asthma symptoms in 'real life' conditions might likely constitute a safety issue in asthmatic patients in the case of emergency procedures.

Coracoid bypass procedure: surgical technique for coracoclavicular reconstruction with coracoid insufficiency.

PubMed

Virk, Mandeep S; Lederman, Evan; Stevens, Christopher; Romeo, Anthony A

2017-04-01

Failed acromioclavicular (AC) joint reconstruction secondary to a coracoid fracture or insufficiency of the coracoid is an uncommon but challenging clinical situation. We describe a surgical technique of revision coracoclavicular (CC) reconstruction, the coracoid bypass procedure, and report short-term results with this technique in 3 patients. In the coracoid bypass procedure, reconstruction of the CC ligaments is performed by passing a tendon graft through a surgically created bone tunnel in the scapular body (inferior to the base of the coracoid) and then fixing the graft around the clavicle or through bone tunnels in the clavicle. Three patients treated with this technique were retrospectively reviewed. AC joint reconstruction performed for a traumatic AC joint separation failed in the 3 patients reported in this series. The previous procedures were an anatomic CC reconstruction in 2 patients and a modified Weaver-Dunn procedure in 1 patient. The coracoid fractures were detected postoperatively, and the mean interval from the index surgery to the coracoid bypass procedure was 8 months. The patients were a mean age of 44 years, and average follow-up was 21 months. At the last follow-up, all 3 patients were pain free, with full range of shoulder motion, preserved CC distance, and a stable AC joint. The coracoid bypass procedure is a treatment option for CC joint reconstruction during revision AC joint surgery in the setting of a coracoid fracture or coracoid insufficiency. Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Laser welding in penetrating keratoplasty and cataract surgery of pediatric patients: early results

NASA Astrophysics Data System (ADS)

Rossi, Francesca; Pini, Roberto; Menabuoni, Luca; Malandrini, Alex; Canovetti, Annalisa; Lenzetti, Ivo; Capozzi, Paolo; Valente, Paola; Buzzonetti, Luca

2013-03-01

Diode laser welding of ocular tissues is a procedure that enables minimally invasive closure of a corneal wound. This procedure is based on a photothermal effect: a water solution of Indocyanine Green (ICG) is inserted in the surgical wound, in order to stain the corneal tissue walls. The stained tissue is then irradiated with a low power infrared diode laser, delivering laser light through a 300-μm core diameter optical fiber. This procedure enables an immediate closure of the wounds: it is thus possible to reduce or to substitute the use of surgical threads. This is of particular interest in children, because the immediate closure improves refractive outcome and anti-amblyopic effect; moreover this procedure avoids several general anaesthesia for suture management. In this work, we present the first use of diode laser welding procedure in paediatric patients. 5 selected patients underwent cataract surgery (Group 1), while 4 underwent fs-laserassisted penetrating keratoplasty (Group 2). In Group 1 the conventional surgery procedure was performed, while no stitches were used for the closure of the surgical wounds: these were laser welded and immediately closed. In Group 2 the donor button was sutured upon the recipient by 8 single stitches, instead of 16 single stitches or a running suture. The laser welding procedure was performed in order to join the donor tissue to the recipient bed. Objective observations in the follow up study evidenced a perfect adhesion of the laser welded tissues, no collateral effects and an optimal restoration of the treated tissues.

Restoring tactile and erogenous penile sensation in low-spinal-lesion patients: procedural and technical aspects following 43 TOMAX nerve transfer procedures.

PubMed

Overgoor, Max L E; de Jong, Tom P V M; Kon, Moshe

2014-08-01

The "TOMAX" (TO MAX-imize sensation, sexuality, and quality of life) procedure restores genital sensation in men with low spinal lesions, improving sexual health, as shown previously. It connects the dorsal nerve of the penis to the intact ipsilateral ilioinguinal nerve, unilaterally or bilaterally. This study reports on the technical aspects based on 43 TOMAX nerve transfers. In 40 patients with no penile but intact groin sensation, 43 nerve transfers were performed. Data on patient selection, surgical history, anatomy of the ilioinguinal nerve and dorsal nerve of the penis, unilateral or bilateral surgery, surgical technique, complications, and patient information were collected prospectively. Regardless of origin, all patients with no penile but good groin sensation are eligible for the procedure, provided the ilioinguinal nerve is not damaged because of former inguinal surgery or absent because of anatomical variations. Selection of a unilateral or bilateral procedure depends on the presence or absence of reflex erections and bulbocavernosus reflex. Preliminary experience with the first three bilateral cases shows that it is technically feasible, with encouraging results. The surgical technique has evolved (described in detail, including video) to enhance outcome and reduce complications. Patients are better informed, resulting in realistic expectations. This article synthesizes the procedural and technical experience of 43 TOMAX nerve transfers. Anyone skilled in peripheral nerve surgery and microsurgery can adopt this concept and further develop it. The TOMAX procedure can then be used to restore erogenous penile sensation and improve the quality of sexual health in patients with absent penile but good groin sensation.

E-Cigarettes and Potential Implications for Plastic Surgery.

PubMed

Taub, Peter J; Matarasso, Alan

2016-12-01

The use of tobacco-based products, most notably cigarettes, is related directly to wound healing problems and poorer outcomes in plastic surgery. Current abstracts have highlighted the potential complications from nicotine, specifically following plastic surgery in patients who choose to smoke. Recently, products that use electricity to vaporize liquid nitrogen have been gaining popularity. New rules were recently proposed that would give the federal government authority over electronic cigarettes. However, the health-related issues surrounding e-cigarettes are still largely unknown or misunderstood. These issues also extend to their impact on surgical procedures, notably their effect on plastic surgical procedures that rely heavily on the vascularity of either the host wound bed or the replacement tissue.

Endoscopic colloid cyst excision: surgical techniques and nuances.

PubMed

Azab, Waleed Abdelfattah; Najibullah, Mustafa; Yosef, Waleed

2017-06-01

Endoscopic excision of colloid cysts is currently well established as a minimally invasive and highly effective technique that is associated with less morbidity in comparison to microsurgical resection. Operative charts and videos of patients undergoing endoscopic colloid cyst excision were retrieved from the senior author's database of endoscopic procedures and reviewed. This revealed nine trans-foraminal and three trans-septal procedures. Description of the surgical techniques was then formulated. Variation of the technique is based on the specific patho-anatomical features of the colloid cyst being resected. For the trans-foraminal approach, we think that the rotational technique is associated with a more complete removal of the cyst wall and consequently lower recurrence rate.

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

Brown, Richard S.; Eppard, M. B.; Murchie, Karen J.

The intracoelomic surgical implantation of electronic tags (including radio and acoustic telemetry transmitters, passive integrated transponders and archival biologgers) is frequently used for conducting studies on fish. Electronic tagging studies provide information on the spatial ecology, behavior and survival of fish in marine and freshwater systems. However, any surgical procedure, particularly one where a laparotomy is performed and the coelomic cavity is opened, has the potential to alter the survival, behavior or condition of the animal which can impair welfare and introduce bias. Given that management, regulatory and conservation decisions are based on the assumption that fish implanted with electronicmore » tags have similar fates and behavior relative to untagged conspecifics, it is critical to ensure that best surgical practices are being used. Also, the current lack of standardized surgical procedures and reporting of specific methodological details precludes cross-study and cross-year analyses which would further progress the field of fisheries science. This compilation of papers seeks to identify the best practices for the entire intracoelomic tagging procedure including pre- and post-operative care, anesthesia, wound closure, and use of antibiotics. Although there is a particular focus on salmonid smolts given the large body of literature available on that group, other life-stages and species of fish are discussed where there is sufficient knowledge. Additional papers explore the role of the veterinarian in fish surgeries, the need for minimal standards in the training of fish surgeons, providing a call for more complete and transparent procedures, and identifying trends in procedures and research needs. Collectively, this body of knowledge should help to improve data quality (including comparability and repeatability), enhance management and conservation strategies, and maintain the welfare status of tagged fish.« less

Impact of a surgical site infection (SSI) surveillance program in orthopedics and traumatology.

PubMed

Mabit, C; Marcheix, P S; Mounier, M; Dijoux, P; Pestourie, N; Bonnevialle, P; Bonnomet, F

2012-10-01

Surveillance of surgical site infections (SSI) is a priority. One of the fundamental principles for the surveillance of SSI is based on receiving effective field feedback (retro-information). The aim of this study was to report the results of a program of SSI surveillance and validate the hypothesis that there is a correlation between creating a SSI surveillance program and a reduction in SSI. The protocol was based on the weekly collection of surveillance data obtained directly from the different information systems in different departments. A delay of 3 months was established before extraction and analysis of data and information from the surgical teams. The NNIS index (National Nosocomial Infections Surveillance System) developed by the American surveillance system and the reduction of length of hospital stay index Journées d'hospitalisation évitées (JHE). Since the end of 2009, 7156 surgical procedures were evaluated (rate of inclusion 97.3%), and 84 SSI were registered with a significant decrease over time from 1.86% to 0.66%. A total of 418 days of hospitalization have been saved since the beginning of the surveillance system. Our surveillance system has three strong points: follow-up is continuous, specifically adapted to orthopedic traumatology and nearly exhaustive. The extraction of data directly from hospital information systems effectively improves the collection of data on surgical procedures. The implementation of a SSI surveillance protocol reduces SSI. Level III. Prospective study. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Surgical management of corneal infections.

PubMed

Tuli, Sonal; Gray, Matthew

2016-07-01

The purpose of this review is to discuss the options for, and recent developments in, the surgical treatment of corneal infections. Although the mainstay of treatment of corneal infections is topical antimicrobial agents, surgical intervention may be necessary in a number of cases. These include advanced disease at presentation, resistant infections, and progressive ulceration despite appropriate treatment. Prompt and appropriate treatment can make the difference between a good outcome and loss of vision or the eye. There are a number of surgical therapies available for corneal infections. Preferred therapeutic modalities differ based on the size, causation, and location of the infection but consist of either replacement of the infected tissue or structural support of the tissue to allow healing. Although there are no completely novel therapies that have been developed recently, there have been incremental improvements in the existing treatment modalities making them more effective, easier, and safer. Several options are available for surgically managing corneal infections. Ophthalmologists should select the optimal procedure based on the individual patient's situation. http://links.lww.com/COOP/A20.

Surgical management of corneal infections

PubMed Central

Tuli, Sonal; Gray, Matthew

2016-01-01

Purpose of review The purpose of this review is to discuss the options for, and recent developments in, the surgical treatment of corneal infections. While the mainstay of treatment of corneal infections is topical antimicrobial agents, surgical intervention may be necessary in a number of cases. These include advanced disease at presentation, resistant infections, and progressive ulceration despite appropriate treatment. Prompt and appropriate treatment can make the difference between a good outcome and loss of vision or the eye. Recent findings There are a number of surgical therapies available for corneal infections. Preferred therapeutic modalities differ based on the size, causation, and location of the infection but consist of either replacement of the infected tissue or structural support of the tissue to allow healing. While there are no completely novel therapies that have been developed recently, there have been incremental improvements in the existing treatment modalities making them more effective, easier, and safer. Summary Several options are available for surgically managing corneal infections. Ophthalmologists should select the optimal procedure based on the individual patient’s situation. PMID:27096375

Surgical management of herpetic keratitis.

PubMed

Tuli, Sonal; Gray, Matthew; Shah, Ankit

2018-07-01

The purpose of this review is to discuss the options for, and recent developments in, the surgical treatment of herpes keratitis. Although the mainstay of treatment of herpetic keratitis is topical or oral antiviral agents, surgical intervention may be necessary for corneal melting or long-term complications such as scarring, lipid keratopathy, necrotizing keratitis, and neurotrophic keratitis. There are a number of surgical therapies available for herpes keratitis. Preferred therapeutic modalities differ based on the size, causation, and location of the infection but consist of either replacement of the infected tissue or structural support of the tissue to allow healing. Incremental improvements in the existing treatment modalities have made them more effective, easier, and safer, whereas novel therapies such as corneal neurotization are starting to be described in ophthalmic literature. Several options are available for surgically managing the complications of herpes keratitis. Ophthalmologists should select the optimal procedure based on the individual patient's situation. VIDEO ABSTRACT: http://links.lww.com/COOP/A28.

Use of 0.5% bupivacaine with buprenorphine in minor oral surgical procedures.

PubMed

Nagpal, Varun; Kaur, Tejinder; Kapila, Sarika; Bhullar, Ramandeep Singh; Dhawan, Amit; Kaur, Yashmeet

2017-01-01

Minor oral surgical procedures are the most commonly performed procedures by oral and maxillofacial surgeons. Performance of painless surgical procedure is highly appreciated by the patients and is possible through the use of local anesthesia, conscious sedation or general anesthesia. Postoperative pain can also be controlled by the use of opioids, as opioid receptors exist in the peripheral nervous system and offers the possibility of providing postoperative analgesia in the surgical patient. The present study compares the efficacy of 0.5% bupivacaine versus 0.5% bupivacaine with 0.3 mg buprenorphine in minor oral surgical procedures. The present study was conducted in 50 patients who required minor oral surgical procedures under local anesthesia. Two types of local anesthetic solutions were used- 0.5% bupivacaine with 1:200000 epinephrine in group I and a mixture of 39 ml of 0.5% bupivacaine with epinephrine 1:200000 and 1 ml of 300 μg buprenorphine (3 μg/kg)in group II. Intraoperative and postoperative evaluation was carried out for both the anesthetic solutions. The mean duration of postoperative analgesia in bupivacaine group (508.92 ± 63.30 minutes) was quite less than the buprenorphine combination group (1840.84 ± 819.51 minutes). The mean dose of postoperative analgesic medication in bupivacaine group (1.64 ± 0.99 tablets) was higher than buprenorphine combination group (0.80 ± 1.08 tablets). There was no significant difference between the two groups regarding the onset of action of the anesthetic effect and duration of anesthesia. Buprenorphine can be used in combination with bupivacaine for patients undergoing minor oral surgical procedures to provide postoperative analgesia for a longer duration.

Predictors of Variation in Neurosurgical Supply Costs and Outcomes Across 4904 Surgeries at a Single Institution.

PubMed

Zygourakis, Corinna C; Valencia, Victoria; Boscardin, Christy; Nayak, Rahul U; Moriates, Christopher; Gonzales, Ralph; Theodosopoulos, Philip; Lawton, Michael T

2016-12-01

There is high variability in neurosurgical costs, and surgical supplies constitute a significant portion of cost. Anecdotally, surgeons use different supplies for various reasons, but there is little understanding of how supply choices affect outcomes. Our goal is to evaluate the effect of patient, procedural, and provider factors on supply cost and to determine if supply cost is associated with patient outcomes. We obtained patient information (age, gender, payor, case mix index [CMI], body mass index, admission source), procedural data (procedure type, length, date), provider information (name, case volume), and total surgical supply cost for all inpatient neurosurgical procedures from 2013 to 2014 at our institution (n = 4904). We created mixed-effect models to examine the effect of each factor on surgical supply cost, 30-day readmission, and 30-day mortality. There was significant variation in surgical supply cost between and within procedure types. Older age, female gender, higher CMI, routine/elective admission, longer procedure, and larger surgeon volume were associated with higher surgical supply costs (P < 0.05). Routine/elective admission and higher surgeon volume were associated with lower readmission rates (odds ratio, 0.707, 0.998; P < 0.01). Only patient factors of older age, male gender, private insurance, higher CMI, and emergency admission were associated with higher mortality (odds ratio, 1.029, 1.700, 1.692, 1.080, 2.809). There was no association between surgical supply cost and readmission or mortality (P = 0.307, 0.548). A combination of patient, procedural, and provider factors underlie the significant variation in neurosurgical supply costs at our institution. Surgical supply costs are not correlated with 30-day readmission or mortality. Copyright © 2016 Elsevier Inc. All rights reserved.

Perspectives on procedure-based assessments: a thematic analysis of semistructured interviews with 10 UK surgical trainees.

PubMed

Shalhoub, Joseph; Marshall, Dominic C; Ippolito, Kate

2017-03-24

The introduction of competency-based training has necessitated development and implementation of accompanying mechanisms for assessment. Procedure-based assessments (PBAs) are an example of workplace-based assessments that are used to examine focal competencies in the workplace. The primary objective was to understand surgical trainees' perspective on the value of PBA. Semistructured interviews with 10 surgical trainees individually interviewed to explore their views. Interviews were audio-recorded and transcribed; following this, they were open and axial coded. Thematic analysis was then performed. Semistructured interviews yielded several topical and recurring themes. In trainees' experience, the use of PBAs as a summative tool limits their educational value. Trainees reported a lack of support from seniors and variation in the usefulness of the tool based on stage of training. Concerns related to the validity of PBAs for evaluating trainees' performance with reports of 'gaming' the system and trainees completing their own assessments. Trainees did identify the significant value of PBAs when used correctly. Benefits included the identification of additional learning opportunities, standardisation of assessment and their role in providing a measure of progress. The UK surgical trainees interviewed identified both limitations and benefits to PBAs; however, we would argue based on their responses and our experience that their use as a summative tool limits their formative use as an educational opportunity. PBAs should either be used exclusively to support learning or solely as a summative tool; if so, further work is needed to audit, validate and standardise them for this purpose. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

A new surgical and technical approach in zygomatic implantology

PubMed Central

GRECCHI, F.; BIANCHI, A.E.; SIERVO, S.; GRECCHI, E.; LAURITANO, D.

2017-01-01

SUMMARY Purpose Different surgical approaches for zygomatic implantology using new designed implants are reported. Material and methods The surgical technique is described and two cases reported. The zygomatic fixture has a complete extrasinus path in order to preserve the sinus membrane and to avoid any post-surgical sinus sequelae. Results The surgical procedure allows an optimal position of the implant and consequently an ideal emergence of the fixture on the alveolar crest. Conclusion The surgical procedures and the zygomatic implant design reduce remarkably the serious post-operative sequelae due to the intrasinus path of the zygomatic fixtures. PMID:29876045

Resident versus no resident: a single institutional study on operative complications, mortality, and cost.

PubMed

Hwang, Christine S; Pagano, Christina R; Wichterman, Keith A; Dunnington, Gary L; Alfrey, Edward J

2008-08-01

Previous studies have demonstrated an increase in surgical morbidity, mortality, duration of stay, and costs in teaching hospitals. These studies are confounded by many variables. Controlling for these variables, we studied the effect of surgical residents on these outcomes during rotations with non-academic-based teaching faculty at a teaching hospital. Patients received care at a single teaching hospital from a group of 8 surgeons. Four surgeons did not have resident coverage (group 1) and the other 4 had coverage (group 2). Continuous severity adjusted complications, mortality, length of stay, cost, and hospital margin data were collected and compared. Five common procedures were examined: bowel resection, laparoscopic cholecystectomy, hernia, mastectomy, and appendectomy. Comparing all procedures together, there were no differences in complications between the groups, although there was greater mortality, a greater duration of stay, and higher costs in group 2. When comparing the 5 most common procedures individually, there was no difference in complications or mortality, although a greater length of stay and higher costs in group 2. Comparing the most common procedures performed individually, patients cared for by surgeons with surgical residents at a teaching hospital have an increase in duration of stay and cost, although no difference in complications or mortality compared to surgeons without residents.

J-tube technique for double-j stent insertion during laparoscopic upper urinary tract surgical procedures.

PubMed

Kim, Hyung Suk; Lee, Byung Ki; Jung, Jin-Woo; Lee, Jung Keun; Byun, Seok-Soo; Lee, Sang Eun; Jeong, Chang Wook

2014-11-01

Double-J stent insertion has been generally performed during laparoscopic upper urinary tract (UUT) surgical procedures to prevent transient urinary tract obstruction and postoperative flank pain from ureteral edema and blood clots. Several restrictive conditions that make this procedure difficult and time consuming, however, include the coiled distal ends of the flexible Double-J stent and the limited bending angle of the laparoscopic instruments. To overcome these limitations, we devised a Double-J stent insertion method using the new J-tube technique. Between July 2011 and May 2013, Double-J stents were inserted using the J-tube technique in 33 patients who underwent a laparoscopic UUT surgical procedure by a single surgeon. The mean stent placement time was 4.8±2.7 minutes, and there were no intraoperative complications. In conclusion, the J-tube technique is a safe and time-saving method for Double-J stent insertion during laparoscopic surgical procedures.

Computer aided planning of orthopaedic surgeries: the definition of generic planning steps for bone removal procedures.

PubMed

Putzer, David; Moctezuma, Jose Luis; Nogler, Michael

2017-11-01

An increasing number of orthopaedic surgeons are using computer aided planning tools for bone removal applications. The aim of the study was to consolidate a set of generic functions to be used for a 3D computer assisted planning or simulation. A limited subset of 30 surgical procedures was analyzed and verified in 243 surgical procedures of a surgical atlas. Fourteen generic functions to be used in 3D computer assisted planning and simulations were extracted. Our results showed that the average procedure comprises 14 ± 10 (SD) steps with ten different generic planning steps and four generic bone removal steps. In conclusion, the study shows that with a limited number of 14 planning functions it is possible to perform 243 surgical procedures out of Campbell's Operative Orthopedics atlas. The results may be used as a basis for versatile generic intraoperative planning software.

Critical analysis and systematization of rat pancreatectomy terminology.

PubMed

Eulálio, José Marcus Raso; Bon-Habib, Assad Charbel Chequer; Soares, Daiane de Oliveira; Corrêa, Paulo Guilherme Antunes; Pineschi, Giovana Penna Firme; Diniz, Victor Senna; Manso, José Eduardo Ferreira; Schanaider, Alberto

2016-10-01

To critically analyze and standardize the rat pancreatectomy nomenclature variants. It was performed a review of indexed manuscripts in PUBMED from 01/01/1945 to 31/12/2015 with the combined keywords "rat pancreatectomy" and "rat pancreas resection". The following parameters was considered: A. Frequency of publications; B. Purpose of the pancreatectomy in each article; C. Bibliographic references; D. Nomenclature of techniques according to the pancreatic parenchyma resection percentage. Among the 468, the main objectives were to surgically induce diabetes and to study the genes regulations and expressions. Five rat pancreatectomy technique references received 15 or more citations. Twenty different terminologies were identified for the pancreas resection: according to the resected parenchyma percentage (30 to 95%); to the procedure type (total, subtotal and partial); or based on the selected anatomical region (distal, longitudinal and segmental). A nomenclature systematization was gathered by cross-checking information between the main surgical techniques, the anatomic parameters descriptions and the resected parenchyma percentages. The subtotal pancreatectomy nomenclature for parenchymal resection between 80 and 95% establishes a surgical parameter that also defines the total and partial pancreatectomy limits and standardizes these surgical procedures in rats.

Reducing elective general surgery cancellations at a Canadian hospital

PubMed Central

Azari-Rad, Solmaz; Yontef, Alanna L.; Aleman, Dionne M.; Urbach, David R.

2013-01-01

Background In Canadian hospitals, which are typically financed by global annual budgets, overuse of operating rooms is a financial risk that is frequently managed by cancelling elective surgical procedures. It is uncertain how different scheduling rules affect the rate of elective surgery cancellations. Methods We used discrete event simulation modelling to represent perioperative processes at a hospital in Toronto, Canada. We tested the effects of the following 3 scenarios on the number of surgical cancellations: scheduling surgeons’ operating days based on their patients’ average length of stay in hospital, sequencing surgical procedures by average duration and variance, and increasing the number of post-surgical ward beds. Results The number of elective cancellations was reduced by scheduling surgeons whose patients had shorter average lengths of stay in hospital earlier in the week, sequencing shorter surgeries and those with less variance in duration earlier in the day, and by adding up to 2 additional beds to the postsurgical ward. Conclusion Discrete event simulation modelling can be used to develop strategies for improving efficiency in operating rooms. PMID:23351498

Virtual planning for craniomaxillofacial surgery--7 years of experience.

PubMed

Adolphs, Nicolai; Haberl, Ernst-Johannes; Liu, Weichen; Keeve, Erwin; Menneking, Horst; Hoffmeister, Bodo

2014-07-01

Contemporary computer-assisted surgery systems more and more allow for virtual simulation of even complex surgical procedures with increasingly realistic predictions. Preoperative workflows are established and different commercially software solutions are available. Potential and feasibility of virtual craniomaxillofacial surgery as an additional planning tool was assessed retrospectively by comparing predictions and surgical results. Since 2006 virtual simulation has been performed in selected patient cases affected by complex craniomaxillofacial disorders (n = 8) in addition to standard surgical planning based on patient specific 3d-models. Virtual planning could be performed for all levels of the craniomaxillofacial framework within a reasonable preoperative workflow. Simulation of even complex skeletal displacements corresponded well with the real surgical result and soft tissue simulation proved to be helpful. In combination with classic 3d-models showing the underlying skeletal pathology virtual simulation improved planning and transfer of craniomaxillofacial corrections. Additional work and expenses may be justified by increased possibilities of visualisation, information, instruction and documentation in selected craniomaxillofacial procedures. Copyright © 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Endoscopic duodenal perforation: surgical strategies in a regional centre

PubMed Central

2014-01-01

Background Duodenal perforation is an uncommon complication of endoscopic retrograde cholangio-pancreatography (ERCP) and a rare complication of upper gastrointestinal endoscopy. Most are minor perforations that settle with conservative management. A few perforations however result in life-threatening retroperitoneal necrosis and require surgical intervention. There is a relative paucity of references specifically describing the surgical interventions required for this eventuality. Methods Five cases of iatrogenic duodenal perforation were ascertained between 2002 and 2007 at Cairns Base Hospital. Clinical features were analyzed and compared, with reference to a review of ERCP at that institution for the years 2005/2006. Results One patient recovered with conservative management. Of the other four, one died after initial laparotomy. The other three survived, undergoing multiple procedures and long inpatient stays. Conclusions Iatrogenic duodenal perforation with retroperitoneal necrosis is an uncommon complication of endoscopy, but when it does occur it is potentially life-threatening. Early recognition may lead to a better outcome through earlier intervention, although a protracted course with multiple procedures should be anticipated. A number of surgical techniques may need to be employed according to the individual circumstances of the case. PMID:24461069

Mapping Population-Level Spatial Access to Essential Surgical Care in Ghana Using Availability of Bellwether Procedures

PubMed Central

Stewart, Barclay T.; Tansley, Gavin; Gyedu, Adam; Ofosu, Anthony; Donkor, Peter; Appiah-Denkyira, Ebenezer; Quansah, Robert; Clarke, Damian L.; Volmink, Jimmy; Mock, Charles

2017-01-01

IMPORTANCE Conditions that can be treated by surgery comprise more than 16% of the global disease burden. However, 5 billion people do not have access to essential surgical care. An estimated 90% of the 87 million disability-adjusted life-years incurred by surgical conditions could be averted by providing access to timely and safe surgery in low-income and middle-income countries. Population-level spatial access to essential surgery in Ghana is not known. OBJECTIVES To assess the performance of bellwether procedures (ie, open fracture repair, emergency laparotomy, and cesarean section) as a proxy for performing essential surgery more broadly, to map population-level spatial access to essential surgery, and to identify first-level referral hospitals that would most improve access to essential surgery if strengthened in Ghana. DESIGN, SETTING, AND PARTICIPANTS Population-based study among all households and public and private not-for-profit hospitals in Ghana. Households were represented by georeferenced census data. First-level and second-level referral hospitals managed by the Ministry of Health and all tertiary hospitals were included. Surgical data were collected from January 1 to December 31, 2014. MAIN OUTCOMES AND MEASURES All procedures performed at first-level referral hospitals in Ghana in 2014 were used to sort each facility into 1 of the following 3 hospital groups: those without capability to perform all 3 bellwether procedures, those that performed 1 to 11 of each procedure, and those that performed at least 12 of each procedure. Candidates for targeted capability improvement were identified by cost-distance and network analysis. RESULTS Of 155 first-level referral hospitals managed by the Ghana Health Service and the Christian Health Association of Ghana, 123 (79.4%) reported surgical data. Ninety-five (77.2%) did not have the capability in 2014 to perform all 3 bellwether procedures, 24 (19.5%) performed 1 to 11 of each bellwether procedure, and 4 (3.3%) performed at least 12. The essential surgical procedure rate was greater in bellwether procedure–capable first-level referral hospitals than in noncapable hospitals (median, 638; interquartile range, 440–1418 vs 360; interquartile range, 0–896 procedures per 100 000 population; P = .03). Population-level spatial access within 2 hours to a hospital that performed 1 to 11 and at least 12 of each bellwether procedure was 83.2% (uncertainty interval [UI], 82.2%–83.4%) and 71.4% (UI, 64.4%–75.0%), respectively. Five hospitals were identified for targeted capability improvement. CONCLUSIONS AND RELEVANCE Almost 30% of Ghanaians cannot access essential surgery within 2 hours. Bellwether capability is a useful metric for essential surgery more broadly. Similar strategic planning exercises might be useful for other low-income and middle-income countries aiming to improve access to essential surgery. PMID:27331865

Long term stability following genioplasty: a cephalometric study.

PubMed

Kumar, B Lakshman; Raju, G Kranthi Praveen; Kumar, N Dilip; Reddy, G Vivek; Naik, B Ravindra; Achary, C Ravindranath

2015-04-01

A receding chin associated with an orthognathic mandible is a common situation and surgical changes in chin position are often required to improve the overall harmony of the face. Genioplasty is one such procedure. Stability of hard and soft tissue changes following genioplasty on a long term basis needs to be assessed. Studies on the stability of hard and soft tissue changes following genioplasty on a short term basis have revealed it as a procedure with good stability. This study is done to assess the stability of hard and soft tissue changes following genioplasty on a long term basis. Pre-surgical, postsurgical and long term post-surgical cephalograms of 15 cases treated by vertical reduction augmentation genioplasty were obtained. Paired t-test was used to compare the changes between pre-surgical, postsurgical and long term postsurgical cephalograms. Findings of this study demonstrated that genioplasty is a stable procedure. After long term follow-up period, there was a relapse of 1.5 mm at the pogonion accounting for 24% of the surgical advancement. This is attributed to the remodeling that occurs at the surgical site, but not the instability due to the surgical procedure. With the present study, it can be concluded that vertical reduction and advancement genioplasty can be considered as an adjunctive procedure that produces predictable results and the bony and soft tissue stability were generally very good.

Long Term Stability Following Genioplasty: A Cephalometric Study

PubMed Central

Kumar, B Lakshman; Raju, G Kranthi Praveen; Kumar, N Dilip; Reddy, G Vivek; Naik, B Ravindra; Achary, C Ravindranath

2015-01-01

Background: A receding chin associated with an orthognathic mandible is a common situation and surgical changes in chin position are often required to improve the overall harmony of the face. Genioplasty is one such procedure. Stability of hard and soft tissue changes following genioplasty on a long term basis needs to be assessed. Studies on the stability of hard and soft tissue changes following genioplasty on a short term basis have revealed it as a procedure with good stability. This study is done to assess the stability of hard and soft tissue changes following genioplasty on a long term basis. Materials and Methods: Pre-surgical, postsurgical and long term post-surgical cephalograms of 15 cases treated by vertical reduction augmentation genioplasty were obtained. Paired t-test was used to compare the changes between pre-surgical, postsurgical and long term postsurgical cephalograms. Results: Findings of this study demonstrated that genioplasty is a stable procedure. After long term follow-up period, there was a relapse of 1.5 mm at the pogonion accounting for 24% of the surgical advancement. This is attributed to the remodeling that occurs at the surgical site, but not the instability due to the surgical procedure. Conclusion: With the present study, it can be concluded that vertical reduction and advancement genioplasty can be considered as an adjunctive procedure that produces predictable results and the bony and soft tissue stability were generally very good. PMID:25954070

Transcatheter Aortic Valve-in-Valve Procedure in Patients with Bioprosthetic Structural Valve Deterioration

PubMed Central

Reul, Ross M.; Ramchandani, Mahesh K.; Reardon, Michael J.

2017-01-01

Surgical aortic valve replacement is the gold standard procedure to treat patients with severe, symptomatic aortic valve stenosis or insufficiency. Bioprosthetic valves are used for surgical aortic valve replacement with a much greater prevalence than mechanical valves. However, bioprosthetic valves may fail over time because of structural valve deterioration; this often requires intervention due to severe bioprosthetic valve stenosis or regurgitation or a combination of both. In select patients, transcatheter aortic valve replacement is an alternative to surgical aortic valve replacement. Transcatheter valve-in-valve (ViV) replacement is performed by implanting a transcatheter heart valve within a failing bioprosthetic valve. The transcatheter ViV operation is a less invasive procedure compared with reoperative surgical aortic valve replacement, but it has been associated with specific complications and requires extensive preoperative work-up and planning by the heart team. Data from experimental studies and analyses of results from clinical procedures have led to strategies to improve outcomes of these procedures. The type, size, and implant position of the transcatheter valve can be optimized for individual patients with knowledge of detailed dimensions of the surgical valve and radiographic and echocardiographic measurements of the patient's anatomy. Understanding the complexities of the ViV procedure can lead surgeons to make choices during the original surgical valve implantation that can make a future ViV operation more technically feasible years before it is required. PMID:29743998

Innovating for quality and value: Utilizing national quality improvement programs to identify opportunities for responsible surgical innovation.

PubMed

Woo, Russell K; Skarsgard, Erik D

2015-06-01

Innovation in surgical techniques, technology, and care processes are essential for improving the care and outcomes of surgical patients, including children. The time and cost associated with surgical innovation can be significant, and unless it leads to improvements in outcome at equivalent or lower costs, it adds little or no value from the perspective of the patients, and decreases the overall resources available to our already financially constrained healthcare system. The emergence of a safety and quality mandate in surgery, and the development of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) allow needs-based surgical care innovation which leads to value-based improvement in care. In addition to general and procedure-specific clinical outcomes, surgeons should consider the measurement of quality from the patients' perspective. To this end, the integration of validated Patient Reported Outcome Measures (PROMs) into actionable, benchmarked institutional outcomes reporting has the potential to facilitate quality improvement in process, treatment and technology that optimizes value for our patients and health system. Copyright © 2015 Elsevier Inc. All rights reserved.

[Clinical use of interventional MR imaging].

PubMed

Kahn, Thomas; Schulz, Thomas; Moche, Michael; Prothmann, Sascha; Schneider, Jens-Peter

2003-01-01

The integration of diagnostic and therapeutic procedures by MRI is based on the combination of excellent morphologic and functional imaging. The spectrum of MR-guided interventions includes biopsies, thermal ablation procedures, vascular applications, and intraoperative MRI. In all these applications, different scientific groups have obtained convincing results in basic developments as well as in clinical use. Interventional MRI (iMRI) is expected to attain an important role in interventional radiology, minimal invasive therapy, and monitoring of surgical procedures.

Evaluating the use of preoperative antibiotics in pediatric orthopaedic surgery.

PubMed

Formaini, Nathan; Jacob, Paul; Willis, Leisel; Kean, John R

2012-01-01

To evaluate the rate of infection after minimally invasive procedures on a consecutive series of pediatric orthopaedic patients. We hypothesized that the use of preoperative antibiotics for minimally invasive pediatric orthopaedic procedures does not significantly reduce the incidence of surgical site infection requiring surgical debridement within 30 days of the primary procedure. We retrospectively reviewed 2330 patients having undergone minimally invasive orthopaedic procedures at our institution between March 2008 and November 2010. Knee arthroscopy, closed reduction with percutaneous fixation, soft tissue releases, excision of bony or soft-tissue masses, and removal of hardware constituted the vast majority of included procedures. Two groups, based on whether prophylactic antibiotics were administered before surgery, were created and the incidence of a repeat procedure required for deep infection was recorded. Statistical analysis was performed to determine significance, if any, between the 2 groups. Chart review of the 2330 patients identified 1087 as having received preoperative antibiotics, whereas the remaining 1243 patients did not receive antibiotics before surgery. Only 1 patient out of the 1243 cases in which antibiotics were not given required additional surgery within 30 days of the primary procedure due to a complicated surgical site infection (an incidence of 0.0008%). No patients in the antibiotic group developed a postoperative infection within 30 days requiring a return to the operating room for management. Our data revealed no significant increase in the incidence of complicated infection requiring additional procedures when antibiotics were not administered before surgery. Though prophylactic antibiotics have been shown to confer numerous benefits for patients undergoing relatively major operations, their use in cases of minimally invasive and/or percutaneous orthopaedic surgery is not well defined. Our data suggest that the use of prophylactic antibiotics may not be indicated for many less invasive procedures when performed in a low-risk pediatric population. Future studies are warranted to help establish evidence-based guidelines regarding the routine use of prophylactic antibiotics in this specific population, hopefully resulting in improved cost-effectiveness and safety while slowing the emergence of new drug-resistant organisms. Level III, retrospective comparative.

Epidemiology of Operative Procedures in an NCAA Division I Football Team Over 10 Seasons

PubMed Central

Mehran, Nima; Photopoulos, Christos D.; Narvy, Steven J.; Romano, Russ; Gamradt, Seth C.; Tibone, James E.

2016-01-01

Background: Injury rates are high for collegiate football players. Few studies have evaluated the epidemiology of surgical procedures in National Collegiate Athletic Association (NCAA) Division I collegiate football players. Purpose: To determine the most common surgical procedures performed in collegiate football players over a 10-year period. Study Design: Descriptive epidemiological study. Methods: From the 2004-2005 season through the 2013-2014 season, all surgical procedures performed on athletes from a single NCAA Division I college football team during athletic participation were reviewed. Surgeries were categorized by anatomic location, and operative reports were used to obtain further surgical details. Data collected over this 10-season span included type of injury, primary procedures, reoperations, and cause of reoperation, all categorized by specific anatomic locations and position played. Results: From the 2004-2005 through the 2013-2014 seasons, 254 operations were performed on 207 players, averaging 25.4 surgical procedures per year. The majority of surgeries performed were orthopaedic procedures (92.1%, n = 234). However, there were multiple nonorthopaedic procedures (7.9%, n = 20). The most common procedure performed was arthroscopic shoulder labral repair (12.2%, n = 31). Partial meniscectomy (11.8%, n = 30), arthroscopic anterior cruciate ligament (ACL) reconstruction (9.4% n = 24), and arthroscopic hip labral repair (5.9% n = 15) were the other commonly performed procedures. There were a total of 29 reoperations performed; thus, 12.9% of primary procedures had a reoperation. The most common revision procedure was a revision open reduction internal fixation of stress fractures in the foot as a result of a symptomatic nonunion (33.33%, n = 4) and revision ACL reconstruction (12.5%, n = 3). By position, relative to the number of athletes at each position, linebackers (30.5%) and defensive linemen (29.1%) were the most likely to undergo surgery while kickers (6%) were the least likely. Conclusion: In NCAA Division I college football players, the most commonly performed surgeries conducted for injuries were orthopaedic in nature. Of these, arthroscopic shoulder labral repair was the most common, followed closely by partial meniscectomy. Nonorthopaedic procedures nonetheless accounted for a sizable portion of surgical volume. Familiarity with this injury and surgical spectrum is of utmost importance for the team physician treating these high-level contact athletes. PMID:27504464

42 CFR 405.502 - Criteria for determining reasonable charges.

Code of Federal Regulations, 2011 CFR

2011-10-01

... HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED Criteria for... locality, adjusted by the economic index, for the surgical procedure performed by the primary surgeon... developing limits—(i) Development of a charge base. The carrier establishes a charge base for each service...

The use of a cognitive task analysis-based multimedia program to teach surgical decision making in flexor tendon repair.

PubMed

Luker, Kali R; Sullivan, Maura E; Peyre, Sarah E; Sherman, Randy; Grunwald, Tiffany

2008-01-01

The aim of this study was to compare the surgical knowledge of residents before and after receiving a cognitive task analysis-based multimedia teaching module. Ten plastic surgery residents were evaluated performing flexor tendon repair on 3 occasions. Traditional learning occurred between the first and second trial and served as the control. A teaching module was introduced as an intervention between the second and third trial using cognitive task analysis to illustrate decision-making skills. All residents showed improvement in their decision-making ability when performing flexor tendon repair after each surgical procedure. The group improved through traditional methods as well as exposure to our talk-aloud protocol (P > .01). After being trained using the cognitive task analysis curriculum the group displayed a statistically significant knowledge expansion (P < .01). Residents receiving cognitive task analysis-based multimedia surgical curriculum instruction achieved greater command of problem solving and are better equipped to make correct decisions in flexor tendon repair.

Effect of bariatric surgery on future general surgical procedures.

PubMed

Kini, Subhash; Kannan, Umashankkar

2011-04-01

Bariatric surgery is now accepted as a safe and effective procedure for morbid obesity. The frequency of bariatric procedures is increasing with the adoption of the laparoscopic approach. The general surgeons will be facing many more of such patients presenting with common general surgical problems. Many of the general surgeons, faced with such situations, may not be aware of the changes in the gastrointestinal anatomy following bariatric procedures and management of these clinical situations will therefore present diagnostic and therapeutic challenges. We hereby present a review of management of few common general surgical problems in patients with a history of bariatric surgery.

Incidence of surgical-site infections and the validity of the National Nosocomial Infections Surveillance System risk index in a general surgical ward in Santa Cruz, Bolivia.

PubMed

Soleto, Lorena; Pirard, Marianne; Boelaert, Marleen; Peredo, Remberto; Vargas, Reinerio; Gianella, Alberto; Van der Stuyft, Patrick

2003-01-01

To estimate the frequency of and risk factors for surgical-site infections (SSIs) in Bolivia, and to study the performance of the National Nosocomial Infections Surveillance (NNIS) System risk index in a developing country. A prospective study with patient follow-up until the 30th postoperative day. A general surgical ward of a public hospital in Santa Cruz, Bolivia. Patients admitted to the ward between July 1998 and June 1999 on whom surgical procedures were performed. Follow-up was complete for 91.5% of 376 surgical procedures. The overall SSI rate was 12%. Thirty-four (75.6%) of the 45 SSIs were culture positive. A logistic regression model retained an American Society of Anesthesiologists score of more than 1 (odds ratio [OR], 1.87), a not-clean wound class (OR, 2.28), a procedure duration of more than 1 hour (OR, 1.81), and drain (OR, 1.98) as independent risk factors for SSI. There was no significant association between the NNIS System risk index and SSI rates. However, a "local" risk index constructed with the above cutoff points showed a linear trend with SSI (P < .001) and a relative risk of 3.18 for risk class 3 versus a class of less than 3. SSIs cause considerable morbidity in Santa Cruz. Appropriate nosocomial infection surveillance and control should be introduced. The NNIS System risk index did not discriminate between patients at low and high risk for SSI in this hospital setting, but a risk score based on local cutoff points performed substantially better.

Building a Sustainable Global Surgery Nonprofit Organization at an Academic Institution.

PubMed

Frisella, Margaret M

Surgical Outreach for the Americas is a 501(c)3 nonprofit organization providing surgical care to those in need in developing countries of the Western Hemisphere. Every year since its inception in 2008, teams of surgeons, nurses, and allied health professionals have traveled to areas of need and performed primarily hernia repair surgeries for those without access to affordable health care. Surgical Outreach for the Americas (SOfA) began as a general concept based on World Health Organization statistics claiming that 11% of the global burden of disease can be resolved via surgery. Armed with this information, a group of compassionate and selfless health care professionals planned the first trip, to the Dominican Republic, in January 2009. Building on what was first just an ambition to help others, we now also train surgeons, surgery residents, and nurses in the countries we serve. To date, SOfA has successfully treated 734 patients, with 899 total surgical procedures performed (693 of these under general anesthesia). These procedures include inguinal hernia, umbilical hernia, testicular masses, orchiectomies, and various general surgical procedures. Through the efforts of a great many talented individuals and robust fundraising efforts, the SOfA message continues to gain momentum. SOfA not only considers the health and well-being of the disadvantaged through capacity-building efforts but strives to educate and improve the skills of health care professionals in the countries we visit. Our goal is to increase the number of missions each year and begin a 2-fold educational program that (a) provides surgical resident education through participation in mission work and (b) provides local surgeon education in the areas served. Copyright © 2016. Published by Elsevier Inc.

Advances in diagnosis and treatment of trigeminal neuralgia

PubMed Central

Montano, Nicola; Conforti, Giulio; Di Bonaventura, Rina; Meglio, Mario; Fernandez, Eduardo; Papacci, Fabio

2015-01-01

Various drugs and surgical procedures have been utilized for the treatment of trigeminal neuralgia (TN). Despite numerous available approaches, the results are not completely satisfying. The need for more contemporaneous drugs to control the pain attacks is a common experience. Moreover, a number of patients become drug resistant, needing a surgical procedure to treat the neuralgia. Nonetheless, pain recurrence after one or more surgical operations is also frequently seen. These facts reflect the lack of the precise understanding of the TN pathogenesis. Classically, it has been related to a neurovascular compression at the trigeminal nerve root entry-zone in the prepontine cistern. However, it has been evidenced that in the pain onset and recurrence, various neurophysiological mechanisms other than the neurovascular conflict are involved. Recently, the introduction of new magnetic resonance techniques, such as voxel-based morphometry, diffusion tensor imaging, three-dimensional time-of-flight magnetic resonance angiography, and fluid attenuated inversion recovery sequences, has provided new insight about the TN pathogenesis. Some of these new sequences have also been used to better preoperatively evidence the neurovascular conflict in the surgical planning of microvascular decompression. Moreover, the endoscopy (during microvascular decompression) and the intraoperative computed tomography with integrated neuronavigation (during percutaneous procedures) have been recently introduced in the challenging cases. In the last few years, efforts have been made in order to better define the optimal target when performing the gamma knife radiosurgery. Moreover, some authors have also evidenced that neurostimulation might represent an opportunity in TN refractory to other surgical treatments. The aim of this work was to review the recent literature about the pathogenesis, diagnosis, and medical and surgical treatments, and discuss the significant advances in all these fields. PMID:25750533

[Surgical treatment of blunt liver trauma, indications for surgery and results].

PubMed

Morales Uribe, Carlos H; López, Carolina Arenas; Cote, Juan Camilo Correa; Franco, Sebastián Tobón; Saldarriaga, Maria Fernanda; Mosquera, Jackson; Villegas Lanau, María I

2014-01-01

The liver is the most frequently injured organ in blunt abdominal trauma. Patients that are hemodynamically unstable must undergo inmmediate surgical treatment. There are 2 surgical approaches for these patients; Anatomical Liver resection or non-anatomic liver resection. Around 80-90% of patients are candidates for non-operative management. -Several risk factors have been studied to select the patients most suited for a non operative management. We performed a retrospective study based on a prospective database. We searched for risk factors related to immediate surgical management and failed non-operative management. We also described the surgical procedures that were undertaken in this cohort of patients and their outcomes and complications. During the study period 117 patients presented with blunt liver trauma. 19 patients (16.2%) required a laparotomy during the initial 24h after their admission. There were 11 deaths (58%) amongst these patients. Peri-hepatic packing and suturing were the most common procedures performed. A RTS Score<7.8 (RR: 7.3; IC 95%: 1.8-30.1), and ISS Score >20 (RR 2,5 IC 95%: 1.0-6.7), and associated intra-abdominal injuries (RR: 2.95; IC 95%: 1.25-6.92) were risk factors for immediate surgery. In 98 (83.7%) patients a non-operative management was performed. 7 patients had a failed non-operative management. The need for immediate surgical management is related to the presence of associated intra-abdominal injuries, and the ISS and RTS scores. In this series the most frequently performed procedure for blunt liver trauma was peri-hepatic packing. Copyright © 2013 AEC. Published by Elsevier Espana. All rights reserved.

Implications of a two-step procedure in surgical management of patients with early-stage endometrioid endometrial cancer

PubMed Central

Bleu, Géraldine; Merlot, Benjamin; Boulanger, Loïc; Vinatier, Denis; Kerdraon, Olivier; Collinet, Pierre

2015-01-01

Objective Since European Society for Medical Oncology (ESMO) recommendations and French guidelines, pelvic lymphadenectomy should not be systematically performed for women with early-stage endometrioid endometrial cancer (EEC) preoperatively assessed at presumed low- or intermediate-risk. The aim of our study was to evaluate the change of our surgical practices after ESMO recommendations, and to evaluate the rate and morbidity of second surgical procedure in case of understaging after the first surgery. Methods This retrospective single-center study included women with EEC preoperatively assessed at presumed low- or intermediate-risk who had surgery between 2006 and 2013. Two periods were defined the times before and after ESMO recommendations. Demographics characteristics, surgical management, operative morbidity, and rate of understaging were compared. The rate of second surgical procedure required for lymph node resection during the second period and its morbidity were also studied. Results Sixty-one and sixty-two patients were operated for EEC preoperatively assessed at presumed low-or intermediate-risk before and after ESMO recommendations, respectively. Although immediate pelvic lymphadenectomy was performed more frequently during the first period than the second period (88.5% vs. 19.4%; p<0.001), the rate of postoperative risk-elevating or upstaging were comparable between the two periods (31.1% vs. 27.4%; p=0.71). Among the patients requiring second surgical procedure during the second period (21.0%), 30.8% did not undergo the second surgery due to their comorbidity or old age. For the patients who underwent second surgical procedure, mean operative time of the second procedure was 246.1±117.8 minutes. Third operation was required in 33.3% of them because of postoperative complications. Conclusion Since ESMO recommendations, second surgical procedure for lymph node resection is often required for women with EEC presumed at low- or intermediate-risk. This reoperation is not always performed due to age/comorbidity of the patients, and presents a significant morbidity. PMID:25872893

Inexpensive Monocular Pico-Projector-based Augmented Reality Display for Surgical Microscope

PubMed Central

Shi, Chen; Becker, Brian C.; Riviere, Cameron N.

2013-01-01

This paper describes an inexpensive pico-projector-based augmented reality (AR) display for a surgical microscope. The system is designed for use with Micron, an active handheld surgical tool that cancels hand tremor of surgeons to improve microsurgical accuracy. Using the AR display, virtual cues can be injected into the microscope view to track the movement of the tip of Micron, show the desired position, and indicate the position error. Cues can be used to maintain high performance by helping the surgeon to avoid drifting out of the workspace of the instrument. Also, boundary information such as the view range of the cameras that record surgical procedures can be displayed to tell surgeons the operation area. Furthermore, numerical, textual, or graphical information can be displayed, showing such things as tool tip depth in the work space and on/off status of the canceling function of Micron. PMID:25264542

The importance of improving the quality of emergency surgery for a regional quality collaborative.

PubMed

Smith, Margaret; Hussain, Adnan; Xiao, Jane; Scheidler, William; Reddy, Haritha; Olugbade, Kola; Cummings, Dustin; Terjimanian, Michael; Krapohl, Greta; Waits, Seth A; Campbell, Darrell; Englesbe, Michael J

2013-04-01

Within a large, statewide collaborative, significant improvement in surgical quality has been appreciated (9.0% reduction in morbidity for elective general and vascular surgery). Our group has not noted such quality improvement in the care of patients who had emergency operations. With this work, we aim to describe the scope of emergency surgical care within the Michigan Surgical Quality Collaborative, variations in outcomes among hospitals, and variations in adherence to evidence-based process measures. Overall, these data will form a basis for a broad-based quality improvement initiative within Michigan. We report morbidity, mortality, and costs of emergency and elective general and vascular surgery cases (N = 190,826) within 34 hospitals participating in the Michigan Surgical Quality Collaborative from 2005 to 2010. Adjusted hospital-specific outcomes were calculated using a stepwise multivariable logistic regression model. Adjustment covariates included patient specific comorbidities and case complexity. Hospitals were also compared on the basis of their adherence to evidence-based process measures [measures at the patient level for each case-Surgical Care Improvement Project (SCIP)-1 and SCIP-2 compliance]. Emergency procedures account for approximately 11% of total cases, yet they represented 47% of mortalities and 28% of surgical complications. The complication-specific cost to payers was $126 million for emergency cases and $329 million for elective cases. Adjusted patient outcomes varied widely within Michigan Surgical Quality Collaborative hospitals; morbidity and mortality rates ranged from 16.3% to 33.9% and 4.0% to 12.4%, respectively. The variation among hospitals was not correlated with volume of emergency cases and case complexity. Hospital performance in emergency surgery was found to not depend on its share of emergent cases but rather was found to directly correlate with its performance in elective surgery. For emergency colectomies, there was a wide variation in compliance with SCIP-1 and SCIP-2 measures and overall compliance (42.0%) was markedly lower than that for elective colon surgery (81.7%). Emergency surgical procedures are an important target for future quality improvement efforts within Michigan. Future work will identify best practices within high-performing hospitals and disseminate these practices within the collaborative.

The effect of intensive care unit environments on nurse perceptions of family presence during resuscitation and invasive procedures.

PubMed

Carroll, Diane L

2014-01-01

In a growing number of requests, family members are asking for proximity to their family member during resuscitation and invasive procedures. The objective of this study was to measure the impact of intensive care unit environments on nurse perception of family presence during resuscitation and invasive procedures. The study used a descriptive survey design with nurses from 9 intensive care units using the Family Presence Self-confidence Scale for resuscitation/invasive procedures that measures nurses' perception of self-confidence and Family Presence Risk-Benefit Scale for resuscitation and invasive procedures that measures nurses' perception of risks/benefits related to managing resuscitation and invasive procedures with family present. There were 207 nurses who responded: 14 male and 184 female nurses (9 missing data), with mean age of 41 ± 11 years, with a mean of 15 years in critical care practice. The environments were defined as surgical (n = 68), medical (n = 43), pediatric/neonatal (n = 34), and mixed adult medical/surgical (n = 36) intensive care units. There were significant differences in self-confidence, with medical and pediatric intensive care unit nurses rating more self-confidence for family presence during resuscitation (F = 7.73, P < .000) and invasive procedures (F = 6.41, P < .000). There were significant differences in risks/benefits with medical and pediatric intensive care unit nurses rating lower risk and higher benefit for resuscitation (F = 7.73, P < .000). Perceptions of family presence were significantly higher for pediatric and medical intensive care unit nurses. Further education and support may be needed in the surgical and mixed intensive care units. Evidence-based practice guidelines that are family centered can define the procedures and resources for family presence, to ultimately promote professional practice.

Thoracoscopic anatomical subsegmentectomy of the right S2b + S3 using a 3D printing model with rapid prototyping.

PubMed

Nakada, Takeo; Akiba, Tadashi; Inagaki, Takuya; Morikawa, Toshiaki

2014-10-01

Thoracoscopic segmentectomies and subsegmentectomies are more difficult than lobectomy because of the complexity of the procedure; therefore, preoperative decision-making and surgical procedure planning are essential. In the literature, we could successfully perform thoracoscopic anatomical subsegmentectomy of the right S2b + S3 using a 3D printing model with rapid prototyping. This innovative surgical support model is extremely useful for planning a surgical procedure and identifying the surgical margin. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Quantifying surgical complexity with machine learning: looking beyond patient factors to improve surgical models.

PubMed

Van Esbroeck, Alexander; Rubinfeld, Ilan; Hall, Bruce; Syed, Zeeshan

2014-11-01

To investigate the use of machine learning to empirically determine the risk of individual surgical procedures and to improve surgical models with this information. American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data from 2005 to 2009 were used to train support vector machine (SVM) classifiers to learn the relationship between textual constructs in current procedural terminology (CPT) descriptions and mortality, morbidity, Clavien 4 complications, and surgical-site infections (SSI) within 30 days of surgery. The procedural risk scores produced by the SVM classifiers were validated on data from 2010 in univariate and multivariate analyses. The procedural risk scores produced by the SVM classifiers achieved moderate-to-high levels of discrimination in univariate analyses (area under receiver operating characteristic curve: 0.871 for mortality, 0.789 for morbidity, 0.791 for SSI, 0.845 for Clavien 4 complications). Addition of these scores also substantially improved multivariate models comprising patient factors and previously proposed correlates of procedural risk (net reclassification improvement and integrated discrimination improvement: 0.54 and 0.001 for mortality, 0.46 and 0.011 for morbidity, 0.68 and 0.022 for SSI, 0.44 and 0.001 for Clavien 4 complications; P < .05 for all comparisons). Similar improvements were noted in discrimination and calibration for other statistical measures, and in subcohorts comprising patients with general or vascular surgery. Machine learning provides clinically useful estimates of surgical risk for individual procedures. This information can be measured in an entirely data-driven manner and substantially improves multifactorial models to predict postoperative complications. Copyright © 2014 Elsevier Inc. All rights reserved.

Health expenditures among high-risk patients after gastric bypass and matched controls.

PubMed

Maciejewski, Matthew L; Livingston, Edward H; Smith, Valerie A; Kahwati, Leila C; Henderson, William G; Arterburn, David E

2012-07-01

To determine whether bariatric surgery is associated with reduced health care expenditures in a multisite cohort of predominantly older male patients with a substantial disease burden. Retrospective cohort study of bariatric surgery. Outpatient, inpatient, and overall health care expenditures within Department of Veterans Affairs (VA) medical centers were examined via generalized estimating equations in the propensity-matched cohorts. Bariatric surgery programs in VA medical centers. Eight hundred forty-seven veterans who were propensity matched to 847 nonsurgical control subjects from the same 12 VA medical centers. Bariatric surgical procedures. Health expenditures through December 2006. Outpatient, inpatient, and total expenditures trended higher for bariatric surgical cases in the 3 years leading up to the procedure and then converged back to the lower expenditure levels of nonsurgical controls in the 3 years after the procedure. Based on analyses of a cohort of predominantly older men, bariatric surgery does not appear to be associated with reduced health care expenditures 3 years after the procedure.

Comparison of 368 patients undergoing surgery for lumbar degenerative spondylolisthesis from the SPORT trial with 955 from the NSQIP database.

PubMed

Golinvaux, Nicholas S; Basques, Bryce A; Bohl, Daniel D; Yacob, Alem; Grauer, Jonathan N

2015-03-01

Retrospective cohort. To compare demographics and perioperative outcomes between the Spine Patient Outcomes Research Trial (SPORT) lumbar degenerative spondylolisthesis arm and a similar population from the National Surgical Quality Improvement Program (NSQIP) database. SPORT is a well-known surgical trial that investigated the benefits of surgical versus nonsurgical treatment in patients with various lumbar pathologies. However, the external validity of SPORT demographics and outcomes has not been fully established. Surgical degenerative spondylolisthesis cases were identified from NSQIP between 2010 and 2012. This population was then compared with the SPORT degenerative spondylolisthesis study. These comparisons were based on published data from SPORT and included analyses of demographics, perioperative factors, and complications. The 368 surgical patients with degenerative spondylolisthesis in SPORT were compared with 955 patients identified in NSQIP. Demographic comparisons were as follows: average age and race (no difference; P > 0.05 for each), sex (9.1% more female patients in SPORT; P = 0.002), smoking status (6.6% more smokers in NSQIP; P = 0.002), and average body mass index (1.1 kg/m greater in NSQIP; P = 0.005). Larger differences were noted in what surgical procedure was performed (P < 0.001), with the most notable difference being that the NSQIP population was much more likely to include interbody fusion than the SPORT population (52.4% vs. 12.5%). Most perioperative factors and complication rates were similar, including average operative time, wound infection, wound dehiscence, postoperative transfusion, and postoperative mortality (no differences; P > 0.05 for each). Average length of stay was shorter in NSQIP compared with SPORT (3.7 vs. 5.8 d; P = 0.042). Though important differences in the distribution of surgical procedures were identified, this study supports the greater generalizability of the surgical SPORT degenerative spondylolisthesis study based on similar demographics and perioperative outcomes when compared with patients from the NSQIP database. 3.

Traffic in the operating room: a review of factors influencing air flow and surgical wound contamination.

PubMed

Pokrywka, Marian; Byers, Karin

2013-06-01

Surgical wound contamination leading to surgical site infection can result from disruption of the intended airflow in the operating room (OR). When personnel enter and exit the OR, or create unnecessary movement and traffic during the procedure, the intended airflow in the vicinity of the open wound becomes disrupted and does not adequately remove airborne contaminants from the sterile field. An increase in the bacterial counts of airborne microorganisms is noted during increased activity levels within the OR. Researchers have studied OR traffic and door openings as a determinant of air contamination. During a surgical procedure the door to the operating room may be open as long as 20 minutes out of each surgical hour during critical procedures involving implants. Interventions into limiting excessive movement and traffic in the OR may lead to reductions in surgical site infections in select populations.

Surgical robotics in otolaryngology: expanding the technology envelope.

PubMed

Gourin, Christine G; Terris, David J

2004-06-01

Surgical robotics arose as an extension of virtual reality and robotic technology developed by the United States Department of Defense. Current surgical robotic systems have been used to perform a variety of minimally invasive surgical procedures. The Food and Drug Administration recently granted approval for the clinical use of two surgical robotic systems. Laboratory and clinical experience suggests that the use of surgical robotics is associated with some distinct advantages and disadvantages when compared with conventional open procedures. Robotic surgery has recently been described in the head and neck, and as a result the otolaryngologist should have a basic understanding of the potential applications of surgical robotics in head and neck surgery. Surgical robotic technology is evolving but appears to have a distinct place in the surgical armamentarium.

Essential surgery: key messages from Disease Control Priorities, 3rd edition.

PubMed

Mock, Charles N; Donkor, Peter; Gawande, Atul; Jamison, Dean T; Kruk, Margaret E; Debas, Haile T

2015-05-30

The World Bank will publish the nine volumes of Disease Control Priorities, 3rd edition, in 2015-16. Volume 1--Essential Surgery--identifies 44 surgical procedures as essential on the basis that they address substantial needs, are cost effective, and are feasible to implement. This report summarises and critically assesses the volume's five key findings. First, provision of essential surgical procedures would avert about 1·5 million deaths a year, or 6-7% of all avertable deaths in low-income and middle-income countries. Second, essential surgical procedures rank among the most cost effective of all health interventions. The surgical platform of the first-level hospital delivers 28 of the 44 essential procedures, making investment in this platform also highly cost effective. Third, measures to expand access to surgery, such as task sharing, have been shown to be safe and effective while countries make long-term investments in building surgical and anaesthesia workforces. Because emergency procedures constitute 23 of the 28 procedures provided at first-level hospitals, expansion of access requires that such facilities be widely geographically diffused. Fourth, substantial disparities remain in the safety of surgical care, driven by high perioperative mortality rates including anaesthesia-related deaths in low-income and middle-income countries. Feasible measures, such as WHO's Surgical Safety Checklist, have led to improvements in safety and quality. Fifth, the large burden of surgical disorders, cost-effectiveness of essential surgery, and strong public demand for surgical services suggest that universal coverage of essential surgery should be financed early on the path to universal health coverage. We point to estimates that full coverage of the component of universal coverage of essential surgery applicable to first-level hospitals would require just over US$3 billion annually of additional spending and yield a benefit-cost ratio of more than 10:1. It would efficiently and equitably provide health benefits, financial protection, and contributions to stronger health systems. Copyright © 2015 Elsevier Ltd. All rights reserved.

Can surgical simulation be used to train detection and classification of neural networks?

PubMed

Zisimopoulos, Odysseas; Flouty, Evangello; Stacey, Mark; Muscroft, Sam; Giataganas, Petros; Nehme, Jean; Chow, Andre; Stoyanov, Danail

2017-10-01

Computer-assisted interventions (CAI) aim to increase the effectiveness, precision and repeatability of procedures to improve surgical outcomes. The presence and motion of surgical tools is a key information input for CAI surgical phase recognition algorithms. Vision-based tool detection and recognition approaches are an attractive solution and can be designed to take advantage of the powerful deep learning paradigm that is rapidly advancing image recognition and classification. The challenge for such algorithms is the availability and quality of labelled data used for training. In this Letter, surgical simulation is used to train tool detection and segmentation based on deep convolutional neural networks and generative adversarial networks. The authors experiment with two network architectures for image segmentation in tool classes commonly encountered during cataract surgery. A commercially-available simulator is used to create a simulated cataract dataset for training models prior to performing transfer learning on real surgical data. To the best of authors' knowledge, this is the first attempt to train deep learning models for surgical instrument detection on simulated data while demonstrating promising results to generalise on real data. Results indicate that simulated data does have some potential for training advanced classification methods for CAI systems.

Pediatric emergency and essential surgical care in Zambian hospitals: a nationwide study.

PubMed

Bowman, Kendra G; Jovic, Goran; Rangel, Shawn; Berry, William R; Gawande, Atul A

2013-06-01

Pediatric surgical care in developing countries is not well studied. We sought to identify the range of pediatric surgery available, the barriers to provision, and level of safety of surgery performed for the entire pediatric population in Zambia. In cooperation with the Ministry of Health, we validated and adapted a World Health Organization instrument. During onsite visits, the availability of 32 emergency and essential surgical procedures relevant to children was surveyed. The availability of basic World Health Organization surgical safety criteria was determined. A single interviewer visited 103 (95%) of 108 surgical hospitals in Zambia and carried out 495 interviews. An average of 68% of the 32 emergency and essential surgical procedures was available (range 32%-100%). Lack of surgical skill was the primary reason for referral in 72% of procedure types, compared with 24%, 2% and 3% due to lack of equipment, supplies and anesthesia skills, respectively (p<0.001). Minimum pediatric surgical safety criteria were met by 14% of hospitals. The primary limitation to providing pediatric surgical care in Zambia is lack of surgical skills. Minimum safety standards were met by 14% of hospitals. Efforts to improve pediatric surgery should prioritize teaching surgical skills to expand access and providing safety training, equipment and supplies to increase safety. Copyright © 2013 Elsevier Inc. All rights reserved.

Economic Valuation of the Global Burden of Cleft Disease Averted by a Large Cleft Charity.

PubMed

Poenaru, Dan; Lin, Dan; Corlew, Scott

2016-05-01

This study attempts to quantify the burden of disease averted through the global surgical work of a large cleft charity, and estimate the economic impact of this effort over a 10-year period. Anonymized data of all primary cleft lip and cleft palate procedures in the Smile Train database were analyzed and disability-adjusted life years (DALYs) calculated using country-specific life expectancy tables, established disability weights, and estimated success of surgery and residual disability probabilities; multiple age weighting and discounting permutations were included. Averted DALYs were calculated and gross national income (GNI) per capita was then multiplied by averted DALYs to estimate economic gains. 548,147 primary cleft procedures were performed in 83 countries between 2001 and 2011. 547,769 records contained complete data available for the study; 58 % were cleft lip and 42 % cleft palate. Averted DALYs ranged between 1.46 and 4.95 M. The mean economic impact ranged between USD 5510 and 50,634 per person. This corresponded to a global economic impact of between USD 3.0B and 27.7B USD, depending on the DALY and GNI values used. The estimated cost of providing these procedures based on an average reimbursement rate was USD 197M (0.7-6.6 % of the estimated impact). The immense economic gain realized through procedures focused on a small proportion of the surgical burden of disease highlights the importance and cost-effectiveness of surgical treatment globally. This methodology can be applied to evaluate interventions for other conditions, and for evidence-based health care resource allocation.

Development of a surgical site infection (SSI) surveillance system, calculation of SSI rates and specification of important factors affecting SSI in a digestive organ surgical department.

PubMed

Kimura, Koji; Sawa, Akihiro; Akagi, Shinji; Kihira, Kenji

2007-06-01

We have developed an original system to conduct surgical site infection (SSI) surveillance. This system accumulates SSI surveillance information based on the National Nosocomial Infections Surveillance (NNIS) System and the Japanese Nosocomial Infections Surveillance (JNIS) System. The features of this system are as follows: easy input of data, high generality, data accuracy, SSI rate by operative procedure and risk index category (RIC) can be promptly calculated and compared with the current NNIS SSI rate, and the SSI rates and accumulated data can be exported electronically. Using this system, we monitored 798 patients in 24 operative procedure categories in the Digestive Organs Surgery Department of Mazda Hospital, Mazda Motor Corporation, from January 2004 through December 2005. The total number and rate of SSI were 47 and 5.89%, respectively. The SSI rates of 777 patients were calculated based on 15 operative procedure categories and Risk Index Categories (RIC). The highest SSI rate was observed in the rectum surgery of RIC 1 (30%), followed by the colon surgery of RIC3 (28.57%). About 30% of the isolated infecting bacteria were Enterococcus faecalis, Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli. Using quantification theory type 2, the American Society of Anesthesiology score (4.531), volume of hemorrhage under operation (3.075), wound classification (1.76), operation time (1.352), and history of diabetes (0.989) increased to higher ranks as factors for SSI. Therefore, we evaluated this system as a useful tool in safety control for operative procedures.

Past, Present and Future of Surgical Meshes: A Review

PubMed Central

Baylón, Karen; Rodríguez-Camarillo, Perla; Elías-Zúñiga, Alex; Díaz-Elizondo, Jose Antonio; Gilkerson, Robert; Lozano, Karen

2017-01-01

Surgical meshes, in particular those used to repair hernias, have been in use since 1891. Since then, research in the area has expanded, given the vast number of post-surgery complications such as infection, fibrosis, adhesions, mesh rejection, and hernia recurrence. Researchers have focused on the analysis and implementation of a wide range of materials: meshes with different fiber size and porosity, a variety of manufacturing methods, and certainly a variety of surgical and implantation procedures. Currently, surface modification methods and development of nanofiber based systems are actively being explored as areas of opportunity to retain material strength and increase biocompatibility of available meshes. This review summarizes the history of surgical meshes and presents an overview of commercial surgical meshes, their properties, manufacturing methods, and observed biological response, as well as the requirements for an ideal surgical mesh and potential manufacturing methods. PMID:28829367

Telepresence and telementoring in surgery.

PubMed

Latifi, Rifat; Peck, Kim; Satava, Richard; Anvari, Mehran

2004-01-01

Telesurgical mentoring has evolved as an important subset of telemedicine, yet has remained an underutilized technique when all its potential is considered. As applied to surgery, telementoring is used when an experienced surgeon assists or directs another less experienced surgeon who is operating at a distance. Two- and three-dimensional, video-based laparoscopic procedures are an ideal platform for real-time transmission and thus for applying telementoring to surgery. The images viewed by the operating surgeon can easily be transmitted to a central "telesurgical mentor" and permit an intraoperative interaction. Several studies have demonstrated the practicality, effectiveness and safety of surgical telementoring. The goal of this application of telemedicine is to improve surgical education and training, expand patient care and improve health care delivery by allowing access to surgical specialists. Eventually, surgical telementoring could assist in the provision of surgical care to underserved areas and potentially facilitate the teaching of advanced surgical skills worldwide.

Surgical innovation: the ethical agenda: A systematic review.

PubMed

Broekman, Marike L; Carrière, Michelle E; Bredenoord, Annelien L

2016-06-01

The aim of the present article was to systematically review the ethics of surgical innovation and introduce the components of the learning health care system to guide future research and debate on surgical innovation.Although the call for evidence-based practice in surgery is increasingly high on the agenda, most surgeons feel that the format of the randomized controlled trial is not suitable for surgery. Innovation in surgery has aspects of, but should be distinguished from both research and clinical care and raises its own ethical challenges.To answer the question "What are the main ethical aspects of surgical innovation?", we systematically searched PubMed and Embase. Papers expressing an opinion, point of view, or position were included, that is, normative ethical papers.We included 59 studies discussing ethical aspects of surgical innovation. These studies discussed 4 major themes: oversight, informed consent, learning curve, and vulnerable patient groups. Although all papers addressed the ethical challenges raised by surgical innovation, surgeons hold no uniform view of surgical innovation, and there is no agreement on the distinction between innovation and research. Even though most agree to some sort of oversight, they offer different alternatives ranging from the formation of new surgical innovation committees to establishing national registries. Most agree that informed consent is necessary for innovative procedures and that surgeons should be adequately trained to assure their competence to tackle the learning curve problem. All papers agree that in case of vulnerable patients, alternatives must be found for the informed consent procedure.We suggest that the concept of the learning health care system might provide guidance for thinking about surgical innovation. The underlying rationale of the learning health care system is to improve the quality of health care by embedding research within clinical care. Two aspects of a learning health care system might particularly enrich the necessary future discussion on surgical innovation: integration of research and practice and a moral emphasis on "learning activities." Future research should evaluate whether the learning health care system and its adjacent moral framework provides ethical guidance for evidence-based surgery.

Mixed reality simulation of rasping procedure in artificial cervical disc replacement (ACDR) surgery.

PubMed

Halic, Tansel; Kockara, Sinan; Bayrak, Coskun; Rowe, Richard

2010-10-07

Until quite recently spinal disorder problems in the U.S. have been operated by fusing cervical vertebrae instead of replacement of the cervical disc with an artificial disc. Cervical disc replacement is a recently approved procedure in the U.S. It is one of the most challenging surgical procedures in the medical field due to the deficiencies in available diagnostic tools and insufficient number of surgical practices For physicians and surgical instrument developers, it is critical to understand how to successfully deploy the new artificial disc replacement systems. Without proper understanding and practice of the deployment procedure, it is possible to injure the vertebral body. Mixed reality (MR) and virtual reality (VR) surgical simulators are becoming an indispensable part of physicians' training, since they offer a risk free training environment. In this study, MR simulation framework and intricacies involved in the development of a MR simulator for the rasping procedure in artificial cervical disc replacement (ACDR) surgery are investigated. The major components that make up the MR surgical simulator with motion tracking system are addressed. A mixed reality surgical simulator that targets rasping procedure in the artificial cervical disc replacement surgery with a VICON motion tracking system was developed. There were several challenges in the development of MR surgical simulator. First, the assembly of different hardware components for surgical simulation development that involves knowledge and application of interdisciplinary fields such as signal processing, computer vision and graphics, along with the design and placements of sensors etc . Second challenge was the creation of a physically correct model of the rasping procedure in order to attain critical forces. This challenge was handled with finite element modeling. The third challenge was minimization of error in mapping movements of an actor in real model to a virtual model in a process called registration. This issue was overcome by a two-way (virtual object to real domain and real domain to virtual object) semi-automatic registration method. The applicability of the VICON MR setting for the ACDR surgical simulator is demonstrated. The main stream problems encountered in MR surgical simulator development are addressed. First, an effective environment for MR surgical development is constructed. Second, the strain and the stress intensities and critical forces are simulated under the various rasp instrument loadings with impacts that are applied on intervertebral surfaces of the anterior vertebrae throughout the rasping procedure. Third, two approaches are introduced to solve the registration problem in MR setting. Results show that our system creates an effective environment for surgical simulation development and solves tedious and time-consuming registration problems caused by misalignments. Further, the MR ACDR surgery simulator was tested by 5 different physicians who found that the MR simulator is effective enough to teach the anatomical details of cervical discs and to grasp the basics of the ACDR surgery and rasping procedure.

Mixed reality simulation of rasping procedure in artificial cervical disc replacement (ACDR) surgery

PubMed Central

2010-01-01

Background Until quite recently spinal disorder problems in the U.S. have been operated by fusing cervical vertebrae instead of replacement of the cervical disc with an artificial disc. Cervical disc replacement is a recently approved procedure in the U.S. It is one of the most challenging surgical procedures in the medical field due to the deficiencies in available diagnostic tools and insufficient number of surgical practices For physicians and surgical instrument developers, it is critical to understand how to successfully deploy the new artificial disc replacement systems. Without proper understanding and practice of the deployment procedure, it is possible to injure the vertebral body. Mixed reality (MR) and virtual reality (VR) surgical simulators are becoming an indispensable part of physicians’ training, since they offer a risk free training environment. In this study, MR simulation framework and intricacies involved in the development of a MR simulator for the rasping procedure in artificial cervical disc replacement (ACDR) surgery are investigated. The major components that make up the MR surgical simulator with motion tracking system are addressed. Findings A mixed reality surgical simulator that targets rasping procedure in the artificial cervical disc replacement surgery with a VICON motion tracking system was developed. There were several challenges in the development of MR surgical simulator. First, the assembly of different hardware components for surgical simulation development that involves knowledge and application of interdisciplinary fields such as signal processing, computer vision and graphics, along with the design and placements of sensors etc . Second challenge was the creation of a physically correct model of the rasping procedure in order to attain critical forces. This challenge was handled with finite element modeling. The third challenge was minimization of error in mapping movements of an actor in real model to a virtual model in a process called registration. This issue was overcome by a two-way (virtual object to real domain and real domain to virtual object) semi-automatic registration method. Conclusions The applicability of the VICON MR setting for the ACDR surgical simulator is demonstrated. The main stream problems encountered in MR surgical simulator development are addressed. First, an effective environment for MR surgical development is constructed. Second, the strain and the stress intensities and critical forces are simulated under the various rasp instrument loadings with impacts that are applied on intervertebral surfaces of the anterior vertebrae throughout the rasping procedure. Third, two approaches are introduced to solve the registration problem in MR setting. Results show that our system creates an effective environment for surgical simulation development and solves tedious and time-consuming registration problems caused by misalignments. Further, the MR ACDR surgery simulator was tested by 5 different physicians who found that the MR simulator is effective enough to teach the anatomical details of cervical discs and to grasp the basics of the ACDR surgery and rasping procedure PMID:20946594

Patient use of social media to evaluate cosmetic treatments and procedures.

PubMed

Schlichte, Megan J; Karimkhani, Chante; Jones, Trevor; Trikha, Ritika; Dellavalle, Robert P

2015-04-16

With a growing sphere of influence in the modern world, online social media serves as a readily accessible interface for communication of information. Aesthetic medicine is one of many industries increasingly influenced by social media, as evidenced by the popular website, "RealSelf," an online community founded in 2006 that compiles ratings, reviews, photographs, and expert physician commentary for nearly 300 cosmetic treatments. To investigate the current preferences of patients regarding cosmetic non-surgical, surgical, and dental treatments on RealSelf and in the documented medical literature. On a single day of data collection, all cosmetic treatments or procedures reviewed on the RealSelf website were tabulated, including name, percent "worth it" rating, total number of reviews, and average cost. Patient satisfaction rates documented in the current medical literature for each cosmetic treatment or procedure were also recorded. Statistical t-testingcomparing RealSelf ratings and satisfaction rates in the literature was performed for each category-non-surgical, surgical, and dental. The top ten most-commonly reviewed non-surgical treatments, top ten most-commonly reviewed surgical procedures, and top 5 most-commonly reviewed dental treatments, along with documented satisfaction rates in the medical literature for each treatment or procedure were recorded in table format and ranked by RealSelf "worth it" rating. Paired t-testing revealed that satisfaction rates documented in the literature were significantly higher than RealSelf "worth it" ratings for both non-surgical cosmetic treatments (p=0.00076) and surgical cosmetic procedures (p=0.00056), with no statistically significant difference for dental treatments. For prospective patients interested in cosmetic treatments or procedures, social media sites such as RealSelf may offer information helpful to decision-making as well enable cosmetic treatment providers to build reputations and expand practices. "Worth it" ratings on RealSelf may, in fact, represent a more transparent view of cosmetic treatment or procedural outcomes relative to the high satisfaction rates documented in medical literature. Massive online communication of patient experiences made possible through social media will continue to influence the practice of medicine, both aesthetic and otherwise.

German Association of Endocrine Surgeons practice guideline for the surgical management of malignant thyroid tumors.

PubMed

Dralle, Henning; Musholt, Thomas J; Schabram, Jochen; Steinmüller, Thomas; Frilling, Andreja; Simon, Dietmar; Goretzki, Peter E; Niederle, Bruno; Scheuba, Christian; Clerici, Thomas; Hermann, Michael; Kußmann, Jochen; Lorenz, Kerstin; Nies, Christoph; Schabram, Peter; Trupka, Arnold; Zielke, Andreas; Karges, Wolfram; Luster, Markus; Schmid, Kurt W; Vordermark, Dirk; Schmoll, Hans-Joachim; Mühlenberg, Reinhard; Schober, Otmar; Rimmele, Harald; Machens, Andreas

2013-03-01

Over the past years, the incidence of thyroid cancer has surged not only in Germany but also in other countries of the Western hemisphere. This surge was first and foremost due to an increase of prognostically favorable ("low risk") papillary thyroid microcarcinomas, for which limited surgical procedures are often sufficient without loss of oncological benefit. These developments called for an update of the previous practice guideline to detail the surgical treatment options that are available for the various disease entities and tumor stages. The present German Association of Endocrine Surgeons practice guideline was developed on the basis of clinical evidence considering current national and international treatment recommendations through a formal expert consensus process in collaboration with the German Societies of General and Visceral Surgery, Endocrinology, Nuclear Medicine, Pathology, Radiooncology, Oncological Hematology, and a German thyroid cancer patient support organization. The practice guideline for the surgical management of malignant thyroid tumors includes recommendations regarding preoperative workup; classification of locoregional nodes and terminology of surgical procedures; frequency, clinical, and histopathological features of occult and clinically apparent papillary, follicular, poorly differentiated, undifferentiated, and sporadic and hereditary medullary thyroid cancers, thyroid lymphoma and thyroid metastases from primaries outside the thyroid gland; extent of thyroidectomy; extent of lymph node dissection; aerodigestive tract resection; postoperative follow-up and surgery for recurrence and distant metastases. These evidence-based recommendations for surgical therapy reflect various "treatment corridors" that are best discussed within multidisciplinary teams and the patient considering tumor type, stage, progression, and inherent surgical risk.

Virtual Reality: Teaching Tool of the Twenty-First Century?

ERIC Educational Resources Information Center

Hoffman, Helene; Vu, Dzung

1997-01-01

Virtual reality-based procedural and surgical simulations promise to revolutionize medical training. A wide range of simulations representing diverse content areas and varied implementation strategies are under development or in early use. The new systems will make broad-based training experiences available for students at all levels without risks…

Risk analysis based on the timing of tracheostomy procedures in patients with spinal cord injury requiring cervical spine surgery.

PubMed

Galeiras, Rita; Mourelo, Mónica; Bouza, María Teresa; Seoane, María Teresa; Ferreiro, María Elena; Montoto, Antonio; Salvador, Sebastián; Seoane, Leticia; Freire, David

2018-05-19

To determine the optimal moment to carry out a tracheostomy in a patient requiring anterior cervical fixation. A retrospective observational study was carried out over an 18-year period on 56 patients who had been admitted to the ICU with acute spinal cord injury (SCI), and who underwent a tracheostomy and surgical fixation. The sample was divided into two groups: An at-risk group (31 patients, who had undergone a tracheostomy prior to the cervical surgery or <4 days after the procedure), and a not at-risk group (25 patients, who had undergone a tracheostomy >4 day following the fixation surgery). Both a descriptive and a comparative study were carried out. The overall trend of the collected data was analysed using cubic splines (graphic methods). The only infectious complications diagnosed as related to the surgical procedure were infection of the surgical wound in two patients of the not at-risk group (12%) and deep-tissue infection in one patient of the at-risk group (3.2%). During the study period, we identified a tendency towards the conduct of early tracheostomies. Our results suggest that the presence of a tracheostomy stoma prior to, or immediately after surgery, is associated with a low risk of infection of the cervical surgical wound in instrumented spinal fusion. Copyright © 2018 Elsevier Inc. All rights reserved.

ASERNIP-S: international trend setting.

PubMed

Maddern, Guy; Boult, Margaret; Ahern, Eleanor; Babidge, Wendy

2008-10-01

The Australian Safety and Efficacy Register of New Interventional Procedures--Surgical (ASERNIP-S) came into being 10 years ago to provide health technology assessments specifically tailored towards new surgical techniques and technologies. It was and remains the only organisation in the world to focus on this area of research. Most funding has been provided by the Australian Government Department of Health, and assessments have helped inform the introduction of new surgical techniques into Australia. ASERNIP-S is a project of the Royal Australasian College of Surgeons. The ASERNIP-S program employs a diverse range of methods including systematic reviews, technology overviews, assessments of new and emerging surgical technologies identified by horizon scanning, and audit. Support and guidance for the program is provided by Fellows of the Royal Australasian College of Surgeons. ASERNIP-S works closely with consumers to produce health technology assessments and audits, as well as consumer information to keep patients fully informed of research. Since its inception, the ASERNIP-S program has developed a strong international profile through the production of over 60 reports on evidence-based surgery, surgical technologies and audit. The work undertaken by ASERNIP-S has evolved from assessments of the safety and efficacy of procedures to include guidance on policies and surgical training programs. ASERNIP-S needs to secure funding so that it can continue to play an integral role in the improvement of quality of care both in Australia and internationally.

Learning surgically oriented anatomy in a student-run extracurricular club: an education through recreation initiative.

PubMed

Ullah, Shahnoor M; Bodrogi, Andrew; Cristea, Octav; Johnson, Marjorie; McAlister, Vivian C

2012-01-01

Didactic and laboratory anatomical education have seen significant reductions in the medical school curriculum due, in part, to the current shift from basic science to more clinically based teaching in North American medical schools. In order to increase medical student exposure to anatomy, with clinical applicability, a student-run initiative called surgically oriented anatomy prosectors (SOAP) club was created within the extracurricular program at the Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Canada. SOAP invites surgeons and residents from various surgical specialties to demonstrate, on a cadaver, a surgical procedure of their choosing. During the demonstration, the anatomy, as it relates to the surgical procedure, is discussed. The students then break into smaller groups to examine the relevant anatomy on the cadavers, during which time the discussion is broadened. The group continues the conversation in a social environment with refreshments. SOAP is one of the most popular extracurricular clubs with 65% of first and second year medical students registered as members. The high demand for SOAP, along with the positive participant feedback, may be due to its utilization of the principle of education through recreation, which seeks to provide opportunities for learning seamlessly throughout all facets of life. It also demonstrates the desire, amongst certain medical students, to learn applied anatomy, particularly within a surgical context. Copyright © 2012 American Association of Anatomists.

Comparing Pre- and Post-Operative Fontan Hemodynamic Simulations: Implications for the Reliability of Surgical Planning

PubMed Central

Haggerty, Christopher M.; de Zélicourt, Diane A.; Restrepo, Maria; Rossignac, Jarek; Spray, Thomas L.; Kanter, Kirk R.; Fogel, Mark A.; Yoganathan, Ajit P.

2012-01-01

Background Virtual modeling of cardiothoracic surgery is a new paradigm that allows for systematic exploration of various operative strategies and uses engineering principles to predict the optimal patient-specific plan. This study investigates the predictive accuracy of such methods for the surgical palliation of single ventricle heart defects. Methods Computational fluid dynamics (CFD)-based surgical planning was used to model the Fontan procedure for four patients prior to surgery. The objective for each was to identify the operative strategy that best distributed hepatic blood flow to the pulmonary arteries. Post-operative magnetic resonance data were acquired to compare (via CFD) the post-operative hemodynamics with predictions. Results Despite variations in physiologic boundary conditions (e.g., cardiac output, venous flows) and the exact geometry of the surgical baffle, sufficient agreement was observed with respect to hepatic flow distribution (90% confidence interval-14 ± 4.3% difference). There was also good agreement of flow-normalized energetic efficiency predictions (19 ± 4.8% error). Conclusions The hemodynamic outcomes of prospective patient-specific surgical planning of the Fontan procedure are described for the first time with good quantitative comparisons between preoperatively predicted and postoperative simulations. These results demonstrate that surgical planning can be a useful tool for single ventricle cardiothoracic surgery with the ability to deliver significant clinical impact. PMID:22777126

Combined operative technique with anterior surgical approach and video-assisted thoracoscopic surgical lobectomy for anterior superior sulcus tumours.

PubMed

Yokoyama, Yuhei; Chen, Fengshi; Aoyama, Akihiro; Sato, Toshihiko; Date, Hiroshi

2014-11-01

Video-assisted thoracoscopic surgery (VATS) has been widely used, but surgical resections of superior sulcus tumours remain challenging because of their anatomical location. For such cases, less-invasive procedures, such as the anterior transcervical-thoracic and transmanubrial approaches, have been widely performed because of their excellent visualization of the subclavian vessels. Recently, a combined operative technique with an anterior surgical approach and VATS for anterior superior sulcus tumours has been introduced. Herein, we report three cases of anterior superior sulcus tumours successfully resected by surgical approaches combined with a VATS-based lobectomy. In all cases, operability was confirmed by VATS, and upper lobectomies with hilar and mediastinal lymph node dissections were performed. Subsequently, dissections of the anterior inlet of the tumours were performed using the transmanubrial approach in two patients and the anterior trans-cervical-thoracic approach in one patient. Both approaches provided excellent access to the anterior inlet of the tumour and exposure of the subclavian vessels, resulting in radical resection of the tumour with concomitant resection of the surrounding anatomical structures, including the chest wall and vessels. In conclusion, VATS lobectomy combined with the anterior surgical approach might be an excellent procedure for the resection of anterior superior sulcus tumours. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Natural language generation of surgical procedures.

PubMed

Wagner, J C; Rogers, J E; Baud, R H; Scherrer, J R

1999-01-01

A number of compositional Medical Concept Representation systems are being developed. Although these provide for a detailed conceptual representation of the underlying information, they have to be translated back to natural language for used by end-users and applications. The GALEN programme has been developing one such representation and we report here on a tool developed to generate natural language phrases from the GALEN conceptual representations. This tool can be adapted to different source modelling schemes and to different destination languages or sublanguages of a domain. It is based on a multilingual approach to natural language generation, realised through a clean separation of the domain model from the linguistic model and their link by well defined structures. Specific knowledge structures and operations have been developed for bridging between the modelling 'style' of the conceptual representation and natural language. Using the example of the scheme developed for modelling surgical operative procedures within the GALEN-IN-USE project, we show how the generator is adapted to such a scheme. The basic characteristics of the surgical procedures scheme are presented together with the basic principles of the generation tool. Using worked examples, we discuss the transformation operations which change the initial source representation into a form which can more directly be translated to a given natural language. In particular, the linguistic knowledge which has to be introduced--such as definitions of concepts and relationships is described. We explain the overall generator strategy and how particular transformation operations are triggered by language-dependent and conceptual parameters. Results are shown for generated French phrases corresponding to surgical procedures from the urology domain.

The effect of implementing cognitive load theory-based design principles in virtual reality simulation training of surgical skills: a randomized controlled trial.

PubMed

Andersen, Steven Arild Wuyts; Mikkelsen, Peter Trier; Konge, Lars; Cayé-Thomasen, Per; Sørensen, Mads Sølvsten

2016-01-01

Cognitive overload can inhibit learning, and cognitive load theory-based instructional design principles can be used to optimize learning situations. This study aims to investigate the effect of implementing cognitive load theory-based design principles in virtual reality simulation training of mastoidectomy. Eighteen novice medical students received 1 h of self-directed virtual reality simulation training of the mastoidectomy procedure randomized for standard instructions (control) or cognitive load theory-based instructions with a worked example followed by a problem completion exercise (intervention). Participants then completed two post-training virtual procedures for assessment and comparison. Cognitive load during the post-training procedures was estimated by reaction time testing on an integrated secondary task. Final-product analysis by two blinded expert raters was used to assess the virtual mastoidectomy performances. Participants in the intervention group had a significantly increased cognitive load during the post-training procedures compared with the control group (52 vs. 41 %, p  = 0.02). This was also reflected in the final-product performance: the intervention group had a significantly lower final-product score than the control group (13.0 vs. 15.4, p  < 0.005). Initial instruction using worked examples followed by a problem completion exercise did not reduce the cognitive load or improve the performance of the following procedures in novices. Increased cognitive load when part tasks needed to be integrated in the post-training procedures could be a possible explanation for this. Other instructional designs and methods are needed to lower the cognitive load and improve the performance in virtual reality surgical simulation training of novices.

Adjunctive intracardiac echocardiography imaging from the left ventricle to guide percutaneous mitral valve repair with the MitraClip in patients with failed prior surgical rings.

PubMed

Saji, Mike; Rossi, Ann M; Ailawadi, Gorav; Dent, John; Ragosta, Michael; Lim, D Scott

2016-02-01

We evaluated intracardiac echocardiography (ICE) for adjunctively guiding the MitraClip procedure in patients with prior surgical rings. Transesophageal echocardiography (TEE) is the standard imaging modality used to guide the MitraClip procedure (Abbott Vascular, CA). However, in patients with post-surgical anatomy, clear imaging of the mitral valve leaflets may be complex because of shadowing from the surgical ring. In these patients, TEE may be suboptimal for guiding the procedure, even using three-dimensional imaging. This retrospective analysis included data from 121 consecutive patients with mitral regurgitation who underwent MitraClip procedures at the University of Virginia. ICE was used adjunctively when there was difficulty with TEE, particularly for assessing the insertion of the posterior leaflet into the MitraClip's arms. The ICE catheter was introduced transarterially into the left ventricle and flexed to obtain the short-axis view. Six patients had prior surgical rings, and in five, we used adjunctive ICE. The etiology of the mitral regurgitation was prolapse of the posterior leaflet in one patient and restriction of the posterior leaflet due to ischemic tethering in the remainder. All images were obtained from the left ventricle, and were adequate for assessing posterior leaflet insertion and the perpendicularity of the MitraClip arms. The procedural success rate was 80%. There was no adverse event related to the ICE procedure. Mitral valve repair with the MitraClip system assisted by ICE is feasible in patients with prior surgical rings, achieving an excellent risk profile and satisfactory procedural success. © 2015 Wiley Periodicals, Inc.

42 CFR 416.75 - Performance of listed surgical procedures on an inpatient hospital basis.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Scope of Benefits for Services Furnished Before January 1, 2008 § 416.75 Performance of listed surgical... 42 Public Health 3 2014-10-01 2014-10-01 false Performance of listed surgical procedures on an inpatient hospital basis. 416.75 Section 416.75 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES...

iROLL: does 3-D radioguided occult lesion localization improve surgical management in early-stage breast cancer?

PubMed

Bluemel, Christina; Cramer, Andreas; Grossmann, Christoph; Kajdi, Georg W; Malzahn, Uwe; Lamp, Nora; Langen, Heinz-Jakob; Schmid, Jan; Buck, Andreas K; Grimminger, Hanns-Jörg; Herrmann, Ken

2015-10-01

To prospectively evaluate the feasibility of 3-D radioguided occult lesion localization (iROLL) and to compare iROLL with wire-guided localization (WGL) in patients with early-stage breast cancer undergoing breast-conserving surgery and sentinel lymph node biopsy (SLNB). WGL (standard procedure) and iROLL in combination with SLNB were performed in 31 women (mean age 65.1 ± 11.2 years) with early-stage breast cancer and clinically negative axillae. Patient comfort in respect of both methods was assessed using a ten point scale. SLNB and iROLL were guided by freehand SPECT (fhSPECT). The results of the novel 3-D image-based method were compared with those of WGL, ultrasound-based lesion localization, and histopathology. iROLL successfully detected the malignant primary and at least one sentinel lymph node in 97% of patients. In a single patient (3%), only iROLL, and not WGL, enabled lesion localization. The variability between fhSPECT and ultrasound-based depth localization of breast lesions was low (1.2 ± 1.4 mm). Clear margins were achieved in 81% of the patients; however, precise prediction of clear histopathological surgical margins was not feasible using iROLL. Patients rated iROLL as less painful than WGL with a pain score 0.8 ± 1.2 points (p < 0.01) lower than the score for iROLL. iROLL is a well-tolerated and feasible technique for localizing early-stage breast cancer in the course of breast-conserving surgery, and is a suitable replacement for WGL. As a single image-based procedure for localization of breast lesions and sentinel nodes, iROLL may improve the entire surgical procedure. However, no advantages of the image-guided procedure were found with regard to prediction of complete tumour resection.

Intraocular robotic interventional surgical system (IRISS): Mechanical design, evaluation, and master-slave manipulation.

PubMed

Wilson, Jason T; Gerber, Matthew J; Prince, Stephen W; Chen, Cheng-Wei; Schwartz, Steven D; Hubschman, Jean-Pierre; Tsao, Tsu-Chin

2018-02-01

Since the advent of robotic-assisted surgery, the value of using robotic systems to assist in surgical procedures has been repeatedly demonstrated. However, existing technologies are unable to perform complete, multi-step procedures from start to finish. Many intraocular surgical steps continue to be manually performed. An intraocular robotic interventional surgical system (IRISS) capable of performing various intraocular surgical procedures was designed, fabricated, and evaluated. Methods were developed to evaluate the performance of the remote centers of motion (RCMs) using a stereo-camera setup and to assess the accuracy and precision of positioning the tool tip using an optical coherence tomography (OCT) system. The IRISS can simultaneously manipulate multiple surgical instruments, change between mounted tools using an onboard tool-change mechanism, and visualize the otherwise invisible RCMs to facilitate alignment of the RCM to the surgical incision. The accuracy of positioning the tool tip was measured to be 0.205±0.003 mm. The IRISS was evaluated by trained surgeons in a remote surgical theatre using post-mortem pig eyes and shown to be effective in completing many key steps in a variety of intraocular surgical procedures as well as being capable of performing an entire cataract extraction from start to finish. The IRISS represents a necessary step towards fully automated intraocular surgery and demonstrated accurate and precise master-slave manipulation for cataract removal and-through visual feedback-retinal vein cannulation. Copyright © 2017 John Wiley & Sons, Ltd.

Patterns and Variations in Microvascular Decompression for Trigeminal Neuralgia

PubMed Central

TODA, Hiroki; GOTO, Masanori; IWASAKI, Koichi

2015-01-01

Microvascular decompression (MVD) is a highly effective surgical treatment for trigeminal neuralgia (TN). Although there is little prospective clinical evidence, accumulated observational studies have demonstrated the benefits of MVD for refractory TN. In the current surgical practice of MVD for TN, there have been recognized patterns and variations in surgical anatomy and various decompression techniques. Here we provide a stepwise description of surgical procedures and relevant anatomical characteristics, as well as procedural options. PMID:25925756

Association between hospital procedure volume and early complications after pacemaker implantation: results from a large, unselected, contemporary cohort of the German nationwide obligatory external quality assurance programme.

PubMed

Nowak, Bernd; Tasche, Karl; Barnewold, Linda; Heller, Günther; Schmidt, Boris; Bordignon, Stefano; Chun, K R Julian; Fürnkranz, Alexander; Mehta, Rajendra H

2015-05-01

Several studies demonstrated an inverse relationship between cardioverter-defibrillator implantation volume and complication rates, suggesting better outcomes for higher volume centres. However, the association of institutional procedural volume with patient outcomes for permanent pacemaker (PPM) implantation remains less known, especially in decentralized implantation systems. We performed retrospective examination of data on patients undergoing PPM from the German obligatory quality assurance programme (2007-12) to evaluate the relationship of hospital PPM volume (categorized into quintiles of their mean annual volume) with risk-adjusted in-hospital surgical complications (composite of pneumothorax, haemothorax, pericardial effusion, or pocket haematoma, all requiring intervention, or device infection) and pacemaker lead dislocation. Overall 430 416 PPM implantations were documented in 1226 hospitals. Systems included dual (72.8%) and single (25.8%) chamber PPM and cardiac resynchronization therapy (CRT) devices (1.1%). Complications included surgical (0.92%), and ventricular (0.99%), and atrial (1.22%) lead dislocation. Despite an increase in relatively complex procedures (dual chamber, CRT), there was a significant decrease in the procedural and fluoroscopy times and complications from lowest to highest implantation volume quintiles (P for trend <0.0001). The greatest difference was observed between the lowest (1-50 implantations/year-reference group) and the second-lowest (51-90 implantations/year) quintile: surgical complications [odds ratio (OR) 0.69; confidence interval (CI) 0.60-0.78], atrial lead dislocations (OR 0.69; CI 0.59-0.80), and ventricular lead dislocations (OR 0.73; CI 0.63-0.84). Hospital annual PPM volume was directly related to indication-based implantation of relatively more complex PPM and yet inversely with procedural times and rates of early surgical complications and lead dislocations. Thus, our data suggest better performance and lower complications with increasing procedural volume. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

Experiential learning not enough for organ procurement surgery: implications for perioperative nursing education.

PubMed

Smith, Zaneta; Leslie, Gavin; Wynaden, Dianne

2015-12-01

Perioperative nurses play a vital role in assisting in surgical procedures for multiorgan procurement, receiving little education apart from on-the-job experiential learning when they are asked to participate in these procedures. Within an Australian context and as part of a larger study, this article describes issues that hindered perioperative nurses' participatory experiences as a result of lacking education, previous exposure, and preparation for assisting in surgical procedures for organ procurement. The grounded theory method was used to develop a substantive theory of perioperative nurses' experiences of participating in surgical procedures for multiorgan procurement. Thirty-five perioperative nurses who had experience in surgical procedures for organ procurement from regional, rural, and metropolitan hospitals of 2 Australian states, New South Wales and Western Australia, participated in the research. Levels of knowledge and experience emerged from the data as an influencing condition and was reported to affect the perioperative nurses' participatory experiences when assisting in procurement surgical procedures. Six components of levels of knowledge and experience were identified and are described. The findings from this study provide a unique contribution to the existing literature by providing an in-depth understanding of the educational needs of perioperative nurses in order to assist successfully in multiorgan procurement procedures. These findings could guide further research with implications for clinical initiatives or education programs specifically targeting the perioperative nursing profession both locally and internationally.

Procedure-specific Surgical Site Infection Incidence Varies Widely within Certain National Healthcare Safety Network Surgery Groups

PubMed Central

Saeed, Mohammed J; Dubberke, Erik R; Fraser, Victoria J; Olsen, Margaret A

2015-01-01

Background The National Healthcare Safety Network (NHSN) classifies surgical procedures into 40 categories. The objective of this study was to determine surgical site infection (SSI) incidence for clinically defined subgroups within 5 heterogeneous NHSN surgery categories. Methods This is a retrospective cohort study using the longitudinal State Inpatient Database. We identified 5 groups of surgical procedures (amputation; biliary, liver and pancreas [BILI]; breast; colon and hernia) using ICD-9-CM procedure codes in community hospitals in California, Florida and New York from January 2009 through September 2011 in persons aged ≥18 years. Each of these 5 categories was classified to more specific surgical procedures within the group. 90-day SSI rates were calculated using ICD-9-CM diagnosis codes. Results There were 62,901 amputation, 33,358 BILI, 72,058 breast, 125,689 colon and 85,745 hernia surgeries in 349,298 people. 90-day SSI rates varied significantly within each of the 5 subgroups. Within the BILI category, bile duct, pancreas and laparoscopic liver procedures had SSI rates of 7.2%, 17.2%, and 2.2%, respectively (p<0.0001 for each) compared to open liver procedures (11.1% SSI). Conclusion 90-day SSI rates varied widely within certain NHSN categories. Risk adjustment for specific surgery type is needed in order to make valid comparisons between hospitals. PMID:25818024

Hospitals with greater diversities of physiologically complex procedures do not achieve greater surgical growth in a market with stable numbers of such procedures.

PubMed

Dexter, Franklin; Epstein, Richard H; Lubarsky, David A

2018-05-01

Although having a large diversity of types of procedures has a substantial operational impact on the surgical suites of hospitals, the strategic importance is unknown. In the current study, we used longitudinal data for all hospitals and patient ages in the State of Florida to evaluate whether hospitals with greater diversity of types of physiologically complex major therapeutic procedures (PCMTP) also had greater rates of surgical growth. Observational cohort study. 1479 combinations of hospitals in the State of Florida and fiscal years, 2008-2015. The types of International Classification of Diseases, Ninth revision, Clinical Modification (ICD-9-CM) procedures studied were PCMT, defined as: a) major therapeutic procedure; b) >7 American Society of Anesthesiologists base units; and c) performed during a hospitalization with a Diagnosis Related Group with a mean length of stay ≥4.0days. The number of procedures of each type of PCMTP commonly performed at each hospital was calculated by taking 1/Herfindahl index (i.e., sum of the squares of the proportions of all procedures of each type of PCMTP). Over the 8 successive years studied, there was no change in the number of PCMTP being performed (Kendall's τ b =-0.014±0.017 [standard error], P=0.44; N=1479 hospital×years). Busier and larger hospitals commonly performed more types of PCMTP, respectively categorized based on performed PCMTP (τ=0.606±0.017, P<0.0001) or hospital beds (τ=0.524±0.017, P<0.0001). There was no association between greater diversity of types of PCMTP commonly performed and greater annual growth in numbers of PCMTP (τ=0.002±0.019, P=0.91; N=1295 hospital×years). Conclusions were the same with multiple sensitivity analyses. Post hoc, it was recognized that hospitals performing a greater diversity of PCMTP were more similar to the aggregate of other hospitals within the same health district (τ=0.550±0.017, P<0.0001). During a period with no overall growth in PCMTP, hospitals with greater diversities of types of PCMTP had growth that was, at most, minimally larger than that of the smaller hospitals, and vice-versa. Diversity is important operationally. From the perspective of delivering surgical care within a market, the unique contributions of each large teaching hospital performing many different types of PCMTP needs to be considered relative to the combined capabilities of other hospitals in its region. Copyright © 2018 Elsevier Inc. All rights reserved.

Cognitive Task Analysis: Bringing Olympic Athlete Style Training to Surgical Education.

PubMed

Wingfield, Laura R; Kulendran, Myutan; Chow, Andre; Nehme, Jean; Purkayastha, Sanjay

2015-08-01

Surgical training is changing and evolving as time, pressure, and legislative demands continue to mount on trainee surgeons. A paradigm change in the focus of training has resulted in experts examining the cognitive steps needed to perform complex and often highly pressurized surgical procedures. To provide an overview of the collective evidence on cognitive task analysis (CTA) as a surgical training method, and determine if CTA improves a surgeon's performance as measured by technical and nontechnical skills assessment, including precision, accuracy, and operative errors. A systematic literature review was performed. PubMed, Cochrane, and reference lists were analyzed for appropriate inclusion. A total of 595 surgical participants were identified through the literature review and a total of 13 articles were included. Of these articles, 6 studies focused on general surgery, 2 focused on practical procedures relevant to surgery (central venous catheterization placement), 2 studies focused on head and neck surgical procedures (cricothyroidotomy and percutaneous tracheostomy placement), 2 studies highlighted vascular procedures (endovascular aortic aneurysm repair and carotid artery stenting), and 1 detailed endovascular repair (abdominal aorta and thoracic aorta). Overall, 92.3% of studies showed that CTA improves surgical outcome parameters, including time, precision, accuracy, and error reduction in both simulated and real-world environments. CTA has been shown to be a more effective training tool when compared with traditional methods of surgical training. There is a need for the introduction of CTA into surgical curriculums as this can improve surgical skill and ultimately create better patient outcomes. © The Author(s) 2014.

Patient selection for day case-eligible surgery: identifying those at high risk for major complications.

PubMed

Mathis, Michael R; Naughton, Norah N; Shanks, Amy M; Freundlich, Robert E; Pannucci, Christopher J; Chu, Yijia; Haus, Jason; Morris, Michelle; Kheterpal, Sachin

2013-12-01

Due to economic pressures and improvements in perioperative care, outpatient surgical procedures have become commonplace. However, risk factors for outpatient surgical morbidity and mortality remain unclear. There are no multicenter clinical data guiding patient selection for outpatient surgery. The authors hypothesize that specific risk factors increase the likelihood of day case-eligible surgical morbidity or mortality. The authors analyzed adults undergoing common day case-eligible surgical procedures by using the American College of Surgeons' National Surgical Quality Improvement Program database from 2005 to 2010. Common day case-eligible surgical procedures were identified as the most common outpatient surgical Current Procedural Terminology codes provided by Blue Cross Blue Shield of Michigan and Medicare publications. Study variables included anthropometric data and relevant medical comorbidities. The primary outcome was morbidity or mortality within 72 h. Intraoperative complications included adverse cardiovascular events; postoperative complications included surgical, anesthetic, and medical adverse events. Of 244,397 surgeries studied, 232 (0.1%) experienced early perioperative morbidity or mortality. Seven independent risk factors were identified while controlling for surgical complexity: overweight body mass index, obese body mass index, chronic obstructive pulmonary disease, history of transient ischemic attack/stroke, hypertension, previous cardiac surgical intervention, and prolonged operative time. The demonstrated low rate of perioperative morbidity and mortality confirms the safety of current day case-eligible surgeries. The authors obtained the first prospectively collected data identifying risk factors for morbidity and mortality with day case-eligible surgery. The results of the study provide new data to advance patient-selection processes for outpatient surgery.

Concentric Tube Robot Design and Optimization Based on Task and Anatomical Constraints

PubMed Central

Bergeles, Christos; Gosline, Andrew H.; Vasilyev, Nikolay V.; Codd, Patrick J.; del Nido, Pedro J.; Dupont, Pierre E.

2015-01-01

Concentric tube robots are catheter-sized continuum robots that are well suited for minimally invasive surgery inside confined body cavities. These robots are constructed from sets of pre-curved superelastic tubes and are capable of assuming complex 3D curves. The family of 3D curves that the robot can assume depends on the number, curvatures, lengths and stiffnesses of the tubes in its tube set. The robot design problem involves solving for a tube set that will produce the family of curves necessary to perform a surgical procedure. At a minimum, these curves must enable the robot to smoothly extend into the body and to manipulate tools over the desired surgical workspace while respecting anatomical constraints. This paper introduces an optimization framework that utilizes procedureor patient-specific image-based anatomical models along with surgical workspace requirements to generate robot tube set designs. The algorithm searches for designs that minimize robot length and curvature and for which all paths required for the procedure consist of stable robot configurations. Two mechanics-based kinematic models are used. Initial designs are sought using a model assuming torsional rigidity. These designs are then refined using a torsionally-compliant model. The approach is illustrated with clinically relevant examples from neurosurgery and intracardiac surgery. PMID:26380575

Intra-operative disruptions, surgeon's mental workload, and technical performance in a full-scale simulated procedure.

PubMed

Weigl, Matthias; Stefan, Philipp; Abhari, Kamyar; Wucherer, Patrick; Fallavollita, Pascal; Lazarovici, Marc; Weidert, Simon; Euler, Ekkehard; Catchpole, Ken

2016-02-01

Surgical flow disruptions occur frequently and jeopardize perioperative care and surgical performance. So far, insights into subjective and cognitive implications of intra-operative disruptions for surgeons and inherent consequences for performance are inconsistent. This study aimed to investigate the effect of surgical flow disruption on surgeon's intra-operative workload and technical performance. In a full-scale OR simulation, 19 surgeons were randomly allocated to either of the two disruption scenarios (telephone call vs. patient discomfort). Using a mixed virtual reality simulator with a computerized, high-fidelity mannequin, all surgeons were trained in performing a vertebroplasty procedure and subsequently performed such a procedure under experimental conditions. Standardized measures on subjective workload and technical performance (trocar positioning deviation from expert-defined standard, number, and duration of X-ray acquisitions) were collected. Intra-operative workload during simulated disruption scenarios was significantly higher compared to training sessions (p < .01). Surgeons in the telephone call scenario experienced significantly more distraction compared to their colleagues in the patient discomfort scenario (p < .05). However, workload tended to be increased in surgeons who coped with distractions due to patient discomfort. Technical performance was not significantly different between both disruption scenarios. We found a significant association between surgeons' intra-operative workload and technical performance such that surgeons with increased mental workload tended to perform worse (β = .55, p = .04). Surgical flow disruptions affect surgeons' intra-operative workload. Increased mental workload was associated with inferior technical performance. Our simulation-based findings emphasize the need to establish smooth surgical flow which is characterized by a low level of process deviations and disruptions.

Surgical management of abnormal uterine bleeding in fertile age women.

PubMed

Finco, Andrea; Centini, Gabriele; Lazzeri, Lucia; Zupi, Errico

2015-07-01

Abnormal uterine bleeding is a common gynecological disease and represents one of the most frequent reasons for hospital admission to a specialist unit, often requiring further surgical treatment. Following the so-called PALM-COEIN system we will attempt to further clarify the surgical treatments available today. The first group (PALM) is characterized by structural lesions, which may be more appropriately treated by means of surgical management. Although hysterectomy remains the definitive and decisive choice, there are many alternative techniques available. These minimally invasive procedures offer the opportunity for a more conservative approach. Precise and accurate counseling facilitates better patient selection, based on the patient's desires, age and disease type, allowing treatment to be individually tailored to each woman.

Is Office-Based Surgery Safe? Comparing Outcomes of 183,914 Aesthetic Surgical Procedures Across Different Types of Accredited Facilities.

PubMed

Gupta, Varun; Parikh, Rikesh; Nguyen, Lyly; Afshari, Ashkan; Shack, R Bruce; Grotting, James C; Higdon, K Kye

2017-02-01

There has been a dramatic rise in office-based surgery. However, due to wide variations in regulatory standards, the safety of office-based aesthetic surgery has been questioned. This study compares complication rates of cosmetic surgery performed at office-based surgical suites (OBSS) to ambulatory surgery centers (ASCs) and hospitals. A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 were identified from the CosmetAssure database (Birmingham, AL). Patients were grouped by type of accredited facility where the surgery was performed: OBSS, ASC, or hospital. The primary outcome was the incidence of major complication(s) requiring emergency room visit, hospital admission, or reoperation within 30 days postoperatively. Potential risk factors including age, gender, body mass index (BMI), smoking, diabetes, type of procedure, and combined procedures were reviewed. Of the 129,007 patients (183,914 procedures) in the dataset, the majority underwent the procedure at ASCs (57.4%), followed by hospitals (26.7%) and OBSS (15.9%). Patients operated in OBSS were less likely to undergo combined procedures (30.3%) compared to ASCs (31.8%) and hospitals (35.3%, P < .01). Complication rates in OBSS, ASCs, and hospitals were 1.3%, 1.9%, and 2.4%, respectively. On multivariate analysis, there was a lower risk of developing a complication in an OBSS compared to an ASC (RR 0.67, 95% CI 0.59-0.77, P < .01) or a hospital (RR 0.59, 95% CI 0.52-0.68, P < .01). Accredited OBSS appear to be a safe alternative to ASCs and hospitals for cosmetic procedures. Plastic surgeons should continue to triage their patients carefully based on other significant comorbidities that were not measured in this present study. LEVEL OF EVIDENCE 3. © 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.

The Aristotle score: a complexity-adjusted method to evaluate surgical results.

PubMed

Lacour-Gayet, F; Clarke, D; Jacobs, J; Comas, J; Daebritz, S; Daenen, W; Gaynor, W; Hamilton, L; Jacobs, M; Maruszsewski, B; Pozzi, M; Spray, T; Stellin, G; Tchervenkov, C; Mavroudis And, C

2004-06-01

Quality control is difficult to achieve in Congenital Heart Surgery (CHS) because of the diversity of the procedures. It is particularly needed, considering the potential adverse outcomes associated with complex cases. The aim of this project was to develop a new method based on the complexity of the procedures. The Aristotle project, involving a panel of expert surgeons, started in 1999 and included 50 pediatric surgeons from 23 countries, representing the EACTS, STS, ECHSA and CHSS. The complexity was based on the procedures as defined by the STS/EACTS International Nomenclature and was undertaken in two steps: the first step was establishing the Basic Score, which adjusts only the complexity of the procedures. It is based on three factors: the potential for mortality, the potential for morbidity and the anticipated technical difficulty. A questionnaire was completed by the 50 centers. The second step was the development of the Comprehensive Aristotle Score, which further adjusts the complexity according to the specific patient characteristics. It includes two categories of complexity factors, the procedure dependent and independent factors. After considering the relationship between complexity and performance, the Aristotle Committee is proposing that: Performance = Complexity x Outcome. The Aristotle score, allows precise scoring of the complexity for 145 CHS procedures. One interesting notion coming out of this study is that complexity is a constant value for a given patient regardless of the center where he is operated. The Aristotle complexity score was further applied to 26 centers reporting to the EACTS congenital database. A new display of centers is presented based on the comparison of hospital survival to complexity and to our proposed definition of performance. A complexity-adjusted method named the Aristotle Score, based on the complexity of the surgical procedures has been developed by an international group of experts. The Aristotle score, electronically available, was introduced in the EACTS and STS databases. A validation process evaluating its predictive value is being developed.

Smartphone, Smart Surgeon, what about a 'Smart Logbook'?

PubMed

Adam, A; Spencer, K; Moon, S; Jacub, I

2016-06-01

Mobile phone applications (Apps) have become a vital assistant to medical personnel in today's technologically advanced era. The utility of Apps with case logbook capabilities has not yet been explored. To assess and evaluate all currently available surgical and procedural case logbook Apps. A comprehensive search was conducted in April 2015 on the Android Play Store, iTunes (Apple App Store, iOS), and BlackBerry World for surgical and/or procedural logbooks. The search terms'surgical logbook', 'logbook', 'procedure logbook' and 'surgical log' were used. Apps which could not be utilized as a surgical/procedural logbook were excluded. Each App was individually assessed and rated using preset criteria, by the unit consultant, registrars, and medical officer. In total, 2 740 Apps were assessed. After applying our exclusion criteria, only 16 Apps were relevant, and 11 suitable for critical review. Data sizes ranged from 510Kb to 12.2Mb. Costing of the Apps ranged from ZAR 0.00 to ZAR 105.32. The overall study scores revealed the following top five rated Apps: Surgical Logbook by Surgilog ; Surgeon Logbook Pro ; Surgery Notebook , Surgical Logbook , and Universal Logbook . The current mobile Apps available are efficient in replacing traditional case logbooks. The use of the 'Smart Logbook' may become common practice in the life of the modern-day surgeon.

Early-onset scoliosis: current treatment.

PubMed

Cunin, V

2015-02-01

Early-onset scoliosis, which appears before the age of 10, can be due to congenital vertebral anomalies, neuromuscular diseases, scoliosis-associated syndromes, or idiopathic causes. It can have serious consequences for lung development and significantly reduce the life expectancy compared to adolescent scoliosis. Extended posterior fusion must be avoided to prevent the crankshaft phenomenon, uneven growth of the trunk and especially restrictive lung disease. Conservative (non-surgical) treatment is used first. If this fails, fusionless surgery can be performed to delay the final fusion procedure until the patient is older. The gold standard delaying surgical treatment is the implantation of growing rods as described by Moe and colleagues in the mid-1980s. These rods, which are lengthened during short surgical procedures at regular intervals, curb the scoliosis progression until the patient reaches an age where fusion can be performed. Knowledge of this technique and its complications has led to several mechanical improvements being made, namely use of rods that can be distracted magnetically on an outpatient basis, without the need for anesthesia. Devices based on the same principle have been designed that preferentially attach to the ribs to specifically address chest wall and spine dysplasia. The second category of surgical devices consists of rods used to guide spinal growth that do not require repeated surgical procedures. The third type of fusionless surgical treatment involves slowing the growth of the scoliosis convexity to help reduce the Cobb angle. The indications are constantly changing. Improvements in surgical techniques and greater surgeon experience may help to reduce the number of complications and make this lengthy treatment acceptable to patients and their family. Long-term effects of surgery on the Cobb angle have not been compared to those involving conservative "delaying" treatments. Because the latter has fewer complications associated with it than surgery, it should be the first-line treatment for most cases of early-onset scoliosis. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Comprehensive evaluation of liver resection procedures: surgical mind development through cognitive task analysis

PubMed Central

Wakabayashi, Go; Yeh, Chi-Chuan; Hu, Rey-Heng; Sakaguchi, Takanori; Hasegawa, Yasushi; Takahara, Takeshi; Nitta, Hiroyuki; Sasaki, Akira; Lee, Po-Huang

2018-01-01

Background Liver resection is a complex procedure for trainee surgeons. Cognitive task analysis (CTA) facilitates understanding and decomposing tasks that require a great proportion of mental activity from experts. Methods Using CTA and video-based coaching to compare liver resection by open and laparoscopic approaches, we decomposed the task of liver resection into exposure (visual field building), adequate tension made at the working plane (which may change three-dimensionally during the resection process), and target processing (intervention strategy) that can bridge the gap from the basic surgical principle. Results The key steps of highly-specialized techniques, including hanging maneuvers and looping of extra-hepatic hepatic veins, were shown on video by open and laparoscopic approaches. Conclusions Familiarization with laparoscopic anatomical orientation may help surgeons already skilled at open liver resection transit to perform laparoscopic liver resection smoothly. Facilities at hand (such as patient tolerability, advanced instruments, and trained teams of personnel) can influence surgical decision making. Application of the rationale and realizing the interplay between the surgical principles and the other paramedical factors may help surgeons in training to understand the mental abstractions of experienced surgeons, to choose the most appropriate surgical strategy effectively at will, and to minimize the gap. PMID:29445607

Surgical site infections in an abdominal surgical ward at Kosovo Teaching Hospital.

PubMed

Raka, Lul; Krasniqi, Avdyl; Hoxha, Faton; Musa, Ruustem; Mulliqi, Gjyle; Krasniqi, Selvete; Kurti, Arsim; Dervishaj, Antigona; Nuhiu, Beqir; Kelmendi, Baton; Limani, Dalip; Tolaj, Ilir

2007-12-01

Abdominal surgical site infections (SSI) cause substantial morbidity and mortality for patients undergoing operative procedures. We determined the incidence of and risk factors for SSI after abdominal surgery in the Department of Abdominal Surgery at the University Clinical Centre of Kosovo (UCCK). Prospective surveillance of patients undergoing abdominal surgery was performed between December 2005 and June 2006. CDC definitions were followed to detect SSI and study forms were based on Europe Link for Infection Control through Surveillance (HELICS) protocol. A total of 253 surgical interventions in 225 patients were evaluated. The median age of patients was 42 years and 55.1% of them were male. The overall incidence rate of SSI was 12%. Follow-up was achieved for 84.1% of the procedures. For patients with an SSI, the median duration of hospitalization was 9 days compared with 4 days for those without an SSI (p2, use of antibiotic prophylaxis and NNIS class of >2 were all significant at p < .001. The SSI rates for the NNIS System risk classes 0, 1 and 2-3 were 4.2%, 46.7% and 100%, respectively. SSI caused considerable morbidity among surgical patients in UCCK. Appropriate active surveillance and infection control measures should be introduced during preoperative, intra-operative, and postoperative care to reduce infection rates.

Virtual Whipple: preoperative surgical planning with volume-rendered MDCT images to identify arterial variants relevant to the Whipple procedure.

PubMed

Brennan, Darren D; Zamboni, Giulia; Sosna, Jacob; Callery, Mark P; Vollmer, Charles M V; Raptopoulos, Vassilios D; Kruskal, Jonathan B

2007-05-01

The purposes of this study were to combine a thorough understanding of the technical aspects of the Whipple procedure with advanced rendering techniques by introducing a virtual Whipple procedure and to evaluate the utility of this new rendering technique in prediction of the arterial variants that cross the anticipated surgical resection plane. The virtual Whipple is a novel technique that follows the complex surgical steps in a Whipple procedure. Three-dimensional reconstructed angiographic images are used to identify arterial variants for the surgeon as part of the preoperative radiologic assessment of pancreatic and ampullary tumors.

Perspectives on the management of antiplatelet therapy in patients with coronary artery disease requiring cardiac and noncardiac surgery.

PubMed

Franchi, Francesco; Rollini, Fabiana; Angiolillo, Dominick J

2014-11-01

To provide an updated overview on the management of antiplatelet therapy in patients with coronary stents undergoing cardiac and noncardiac surgery. Surgical procedures are frequently performed in patients with coronary stents and are associated with an increased risk of ischemic and bleeding complications in the perioperative period. Given the lack of well-designed prospective randomized trials, guidelines recommendations are currently derived from observational studies and expert consensus. Defining the optimal balance between the risk of thrombotic events following discontinuation of antiplatelet therapy and the risk of hemorrhagic complications of having a surgical procedure while on antiplatelet therapy is pivotal. Elective surgery should be postponed for at least 4 weeks after bare metal stent implantation and 6-12 months after drug-eluting stent. If this is not possible, aspirin should be continued in the perioperative period, although the management of P2Y₁₂ inhibitors should be individualized according to the individual patient and type of surgery. In the absence of well-defined recommendations deriving from prospective randomized clinical trials, the perioperative management of antiplatelet therapy should be based on the balance between the specific thrombotic and hemorrhagic risks that characterize each patient and each surgical procedure.

Rational decision making in a wide scenario of different minimally invasive lumbar interbody fusion approaches and devices.

PubMed

Pimenta, Luiz; Tohmeh, Antoine; Jones, David; Amaral, Rodrigo; Marchi, Luis; Oliveira, Leonardo; Pittman, Bruce C; Bae, Hyun

2018-03-01

With the proliferation of a variety of modern MIS spine surgery procedures, it is mandatory that the surgeon dominate all aspects involved in surgical indication. The information related to the decision making in patient selection for specific procedures is mandatory for surgical success. The objective of this study is to present decision-making criteria in minimally invasive surgery (MIS) selection for a variety of patients and pathologies. In this article, practicing surgeons who specialize in various MIS approaches for spinal fusion were engaged to provide expert opinion and literature review on decision making criteria for several MIS procedures. Pros, cons, relative limitations, and case examples are provided for patient selection in treatment with MIS posterolateral fusion (MIS-PLF), mini anterior lumbar interbody fusion (mini-ALIF), lateral interbody fusion (LLIF), MIS posterior lumbar interbody fusion (MIS-PLIF) and MIS transforaminal lumbar interbody fusion (MIS-TLIF). There is a variety of aspects to consider when deciding which modern MIS surgical approach is most appropriate to use based on patient and pathologic characteristics. The surgeon must adapt them to the characteristic of each type of patients, helping them to choose the most effective and efficient therapeutic option for each case.

Systematic extrahepatic Glissonean pedicle isolation for anatomical liver resection based on Laennec's capsule: proposal of a novel comprehensive surgical anatomy of the liver

PubMed Central

Sugioka, Atsushi; Kato, Yutaro; Tanahashi, Yoshinao

2017-01-01

Abstract Anatomical liver resection with the Glissonean pedicle isolation is widely approved as an essential procedure for safety and curability. Especially, the extrahepatic Glissonean pedicle isolation without parenchymal destruction should be an ideal procedure. However, the surgical technique has not been standardized due to a lack of anatomical understanding. Herein, we proposed a novel comprehensive surgical anatomy of the liver based on Laennec's capsule that would give a theoretical background to the extrahepatic Glissonean pedicle isolation. Laennec's capsule is the proper membrane that covers not only the entire surface of the liver including the bare area but also the intrahepatic parenchyma surrounding the Glissonean pedicles. Consequently, there exists a gap between the Glissonean pedicle and Laennec's capsule that could be reached extrahepatically and allows us to isolate the extrahepatic Glissonean pedicle without parenchymal destruction systematically. For standardization, it is essential to approach the “six gates” indicated by the “four anatomical landmarks”: the Arantius plate, the umbilical plate, the cystic plate and the Glissonean pedicle of the caudate process (G1c). This novel anatomy would contribute to standardize the surgical techniques of the systematic extrahepatic Glissonean pedicle isolation for anatomical liver resection including laparoscopic or robotic liver resection and to bring innovative changes in hepatobiliary surgery for spreading safe and curable liver resection. PMID:28156078

'It is Time to Prepare the Next patient' Real-Time Prediction of Procedure Duration in Laparoscopic Cholecystectomies.

PubMed

Guédon, Annetje C P; Paalvast, M; Meeuwsen, F C; Tax, D M J; van Dijke, A P; Wauben, L S G L; van der Elst, M; Dankelman, J; van den Dobbelsteen, J J

2016-12-01

Operating Room (OR) scheduling is crucial to allow efficient use of ORs. Currently, the predicted durations of surgical procedures are unreliable and the OR schedulers have to follow the progress of the procedures in order to update the daily planning accordingly. The OR schedulers often acquire the needed information through verbal communication with the OR staff, which causes undesired interruptions of the surgical process. The aim of this study was to develop a system that predicts in real-time the remaining procedure duration and to test this prediction system for reliability and usability in an OR. The prediction system was based on the activation pattern of one single piece of equipment, the electrosurgical device. The prediction system was tested during 21 laparoscopic cholecystectomies, in which the activation of the electrosurgical device was recorded and processed in real-time using pattern recognition methods. The remaining surgical procedure duration was estimated and the optimal timing to prepare the next patient for surgery was communicated to the OR staff. The mean absolute error was smaller for the prediction system (14 min) than for the OR staff (19 min). The OR staff doubted whether the prediction system could take all relevant factors into account but were positive about its potential to shorten waiting times for patients. The prediction system is a promising tool to automatically and objectively predict the remaining procedure duration, and thereby achieve optimal OR scheduling and streamline the patient flow from the nursing department to the OR.

Surgical treatment for hypopharyngeal cysts with a side-opened direct laryngoscope.

PubMed

Kawaida, M; Fukuda, H; Shiotani, A; Kohno, N

1994-01-01

Two cases of hypopharyngeal cyst are reported. Both cysts occurred in the piriform sinus of the hypopharynx. Histopathological examination indicated that both were retention cysts. These cysts were removed by laryngomicrosurgical technique using a side-opened direct laryngoscope. In the cyst with a distinct base, a laryngomicrosurgical snare was used for removal. In the wide-based cyst, the mucous membrane around the cyst was incised with an electrosurgical instrument and then detached to facilitate removal. In this paper, we describe our surgical procedure for removing hypopharyngeal cysts and discuss the causes of such cysts.

Doctors' perspectives of informed consent for non-emergency surgical procedures: a qualitative interview study.

PubMed

Wood, Fiona; Martin, Sean Michael; Carson-Stevens, Andrew; Elwyn, Glyn; Precious, Elizabeth; Kinnersley, Paul

2016-06-01

The need to involve patients more in decisions about their care, the ethical imperative and concerns about ligation and complaints has highlighted the issue of informed consent and how it is obtained. In order for a patient to make an informed decision about their treatment, they need appropriate discussion of the risks and benefits of the treatment. To explore doctors' perspectives of gaining informed consent for routine surgical procedures. Qualitative study using semi-structured interviews selected by purposive sampling. Data were analysed thematically. Twenty doctors in two teaching hospitals in the UK. Doctors described that while consent could be taken over a series of consultations, it was common for consent to be taken immediately prior to surgery. Juniors were often taking consent when they were unfamiliar with the procedure. Doctors used a range of communication techniques to inform patients about the procedure and its risks including quantifying risks, personalizing risk, simplification of language and use of drawings. Barriers to effective consent taking were reported to be shortage of time, clinician inexperience and patients' reluctance to be involved. Current consent processes do not appear to be ideal for many doctors. In particular, junior doctors are often not confident taking consent for surgical procedures and require more support to undertake this task. This might include written information for junior staff, observation by senior colleagues when undertaking the task and ward-based communication skills teaching on consent taking. © 2014 John Wiley & Sons Ltd.

Perioperative Management of Sickle Cell Disease

PubMed Central

Adjepong, Kwame Ofori; Otegbeye, Folashade

2018-01-01

Over 30 million people worldwide have sickle cell disease (SCD). Emergent and non-emergent surgical procedures in SCD have been associated with relatively increased risks of peri-operative mortality, vaso-occlusive (painful) crisis, acute chest syndrome, post-operative infections, congestive heart failure, cerebrovascular accident and acute kidney injury. Pre-operative assessment must include a careful review of the patient’s known crisis triggers, baseline hematologic profile, usual transfusion requirements, pre-existing organ dysfunction and opioid use. Use of preoperative blood transfusions should be selective and decisions individualized based on the baseline hemoglobin, surgical procedure and anticipated volume of blood loss. Intra- and post-operative management should focus on minimizing hypoxia, hypothermia, acidosis, and intravascular volume depletion. Pre- and post-operative incentive spirometry use should be encouraged. PMID:29755709

First impressions about Adherus, a new dural sealant.

PubMed

Zoia, Cesare; Bongetta, Daniele; Lombardi, Francesco; Custodi, Viola Marta; Pugliese, Raffaelino; Gaetani, Paolo

2015-12-18

The aim of the study is to report our first impressions about Adherus, a novel dural sealant, used in neurosurgical endoscopic transnasal procedures. We retrospectively reviewed the clinical and surgical records of the first 11 patients with intraoperative high-flow cerebrospinal fluid leak treated with the aid of Adherus at our center between February and October 2014. The healing at the level of the dural plasty was monitored and evaluated radiologically and with regular endoscopic inspections. With a median follow-up of 210 days, no postoperative CSF leak or surgical site infections were found in any of the cases. Based on our preliminary experience, this new dural sealant seems to provide an effective aid in dural plasty during endoscopic transphenoidal procedures.

Perioperative Management of Sickle Cell Disease.

PubMed

Adjepong, Kwame Ofori; Otegbeye, Folashade; Adjepong, Yaw Amoateng

2018-01-01

Over 30 million people worldwide have sickle cell disease (SCD). Emergent and non-emergent surgical procedures in SCD have been associated with relatively increased risks of peri-operative mortality, vaso-occlusive (painful) crisis, acute chest syndrome, post-operative infections, congestive heart failure, cerebrovascular accident and acute kidney injury. Pre-operative assessment must include a careful review of the patient's known crisis triggers, baseline hematologic profile, usual transfusion requirements, pre-existing organ dysfunction and opioid use. Use of preoperative blood transfusions should be selective and decisions individualized based on the baseline hemoglobin, surgical procedure and anticipated volume of blood loss. Intra- and post-operative management should focus on minimizing hypoxia, hypothermia, acidosis, and intravascular volume depletion. Pre- and post-operative incentive spirometry use should be encouraged.

See, Do, Teach? A Review of Contemporary Literature and Call to Action for Communication Skills Teaching in Urology.

PubMed

Kieran, Kathleen; Jensen, Norman M; Rosenbaum, Marcy

2018-04-01

To assess the current state of published literature on communication skills teaching in urology to inform future directions for research and teaching. Excellent patient-physician communication skills increase understanding of medical conditions, facilitate shared decision-making regarding treatment planning, improve clinical outcomes, and decrease lawsuits. Surgical and procedure-based subspecialties, including urology, have generally been slow to incorporate formal communication skills teaching into curricula for postgraduate trainees. We performed a PubMed literature search using multiple keywords, selecting and reviewing articles published in English, and addressing 1 of 3 domains (curriculum development, teaching methods, and assessment methods) of communication skills teaching. The distribution of articles within the urology-specific literature was compared with that of procedure-based specialties as a whole. Eight articles were found in the urology literature, and 24 articles were found in other procedure-based specialties. Within the urology-specific literature, all 8 articles (100%) acknowledged the need for communication curriculum development, 1 article (12.5%) described how communication skills were taught, and 1 article (12.5%) discussed how communication skills were assessed. Fewer articles in other procedure-based specialties acknowledged the need to develop curricula (29.2%, P = .0007) but were equally likely to discuss communication skills teaching (37.5%, P = .63) and assessment (33.3%, P = .73). Orthopedic surgery is the only surgical subspecialty with ongoing, adaptable, formal training for physicians. Most current publications addressing communication skills in procedure-based specialties are specialty specific and focus on only 1 of the 3 communication domains. Opportunities exist to share information and to create more integrated models to teach communication skills in urology. Copyright © 2018 Elsevier Inc. All rights reserved.

Intraoperative monitoring technician: a new member of the surgical team.

PubMed

Brown, Molly S; Brown, Debra S

2011-02-01

As surgery needs have increased, the traditional surgical team has expanded to include personnel from radiology and perfusion services. A new surgical team member, the intraoperative monitoring technician, is needed to perform intraoperative monitoring during procedures that carry a higher risk of central and peripheral nerve injury. Including the intraoperative monitoring technician on the surgical team can create challenges, including surgical delays and anesthesia care considerations. When the surgical team members, including the surgeon, anesthesia care provider, and circulating nurse, understand and facilitate this new staff member's responsibilities, the technician is able to perform monitoring functions that promote the smooth flow of the surgical procedure and positive patient outcomes. Copyright © 2011 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Increased anaesthesia duration increases venous thromboembolism risk in plastic surgery: A 6-year analysis of over 19,000 cases using the NSQIP dataset.

PubMed

Mlodinow, Alexei S; Khavanin, Nima; Ver Halen, Jon P; Rambachan, Aksharananda; Gutowski, Karol A; Kim, John Y S

2015-01-01

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality, particularly in the postoperative setting. Various risk stratification schema exist in the plastic surgery literature, but do not take into account variations in procedure length. The putative risk of VTE conferred by increased length of time under anaesthesia has never been rigorously explored. The goal of this study is to assess this relationship and to benchmark VTE rates in plastic surgery. A large, multi-institutional quality-improvement database was queried for plastic and reconstructive surgery procedures performed under general anaesthesia between 2005-2011. In total, 19,276 cases were abstracted from the database. Z-scores were calculated based on procedure-specific mean surgical durations, to assess each case's length in comparison to the mean for that procedure. A total of 70 patients (0.36%) experienced a post-operative VTE. Patients with and without post-operative VTE were compared with respect to a variety of demographics, comorbidities, and intraoperative characteristics. Potential confounders for VTE were included in a regression model, along with the Z-scores. VTE occurred in both cosmetic and reconstructive procedures. Longer surgery time, relative to procedural means, was associated with increased VTE rates. Further, regression analysis showed increase in Z-score to be an independent risk factor for post-operative VTE (Odds Ratio of 1.772 per unit, p-value < 0.001). Subgroup analyses corroborated these findings. This study validates the long-held view that increased surgical duration confers risk of VTE, as well as benchmarks VTE rates in plastic surgery procedures. While this in itself does not suggest an intervention, surgical time under general anaesthesia would be a useful addition to existing risk models in plastic surgery.

National Hospital Discharge Survey: 2003 annual summary with detailed diagnosis and procedure data.

PubMed

Kozak, Lola Jean; Lees, Karen A; DeFrances, Carol J

2006-05-01

This report presents 2003 national estimates and trend data on the use of non-Federal short-stay hospitals in the United States. Estimates are provided by patient and hospital characteristics, diagnoses, and surgical and nonsurgical procedures performed. Estimates of diagnoses and procedures are presented according to the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. The estimates are based on data collected through the National Hospital Discharge Survey (NHDS). The survey has been conducted annually since 1965. In 2003, data were collected for approximately 320,000 discharges. Of the 479 eligible non-Federal short-stay hospitals in the sample, 426 (89 percent) responded to the survey. An estimated 34.7 million inpatients were discharged from non-Federal short-stay hospitals in 2003. They used 167.3 million days of care and had an average length of stay of 4.8 days. Females used almost one-third more days of hospital care than males. Patients with five or more diagnoses rose from 29 percent of discharges in 1990 to 57 percent in 2003. The leading diagnostic category was respiratory diseases for children under 15 years, childbirth for 15-44 year olds, and circulatory diseases for patients 45 years of age and over. Only surgical procedures were performed for 27 percent of discharges, 18 percent had surgical and nonsurgical procedures, and 16 percent had only nonsurgical procedures. A total of 664,000 coronary angioplasties were performed, and stents were inserted during 86 percent of these procedures with drug-eluting stents used in 28 percent. The number and rate of total and primary cesarean deliveries rose from 1995 to 2003. The rate of vaginal birth after cesarean delivery dropped 58 percent, from 35.5 in 1995 to 14.8 in 2003.

Does simulation-based training facilitate the integration of human anatomy with surgery? A report of a novel Surgical Anatomy Course.

PubMed

Torres, K; Denisow-Pietrzyk, M; Pietrzyk, Ł; Maciejewski, R; Torres, A

2018-01-01

Knowledge of gross anatomy, as a basic core subject, is fundamental for medical students and essential to medical practitioners, particularly for those intending a surgical career. However, both medical students and clinical teachers have found a significant gap in teaching basic sciences and the transition into clinical skills. The authors present a Surgical Anatomy Course developed to teach the anatomical basis of surgical procedures with particular emphasis on laparo-scopic skills while incorporating medical simulation. An evaluation of the students' satisfaction of the Surgical Anatomy Course was completed using a mix of multiple choice and open-ended questions, and a six-point Likert Scale. Questions were asked about the students' perceived improvement in surgical and laparoscopic skills. Manual skills were assessed using a laparoscopic simulator. Both evaluation of the course structure and the general impression of the course were positive. Most students believed the course should be an integral part of a modern curriculum. The course supported the traditional surgical classes and improved anatomical knowledge and strengthened students' confidentiality and facilitated understanding and taking surgical rotations. A medical course combining the practical learning of anatomy and surgical-based approaches will bring out the best from the students. Medical students positively evaluated the Surgical Anatomy Course as useful and benefi-cial regarding understanding anatomical structure and relationship necessary for further surgical education. (Folia Morphol 2018; 77, 2: 279-285).

Efficiency of Core Biopsy for BI-RADS-5 Breast Lesions.

PubMed

Wolf, Ronald; Quan, Glenda; Calhoun, Kris; Soot, Laurel; Skokan, Laurie

2008-01-01

Stereotactic biopsy has proven more cost effective for biopsy of lesions associated with moderately suspicious mammograms. Data regarding selection of stereotactic biopsy (CORE) instead of excisional biopsy (EB) as the first diagnostic procedure in patients with nonpalpable breast lesions and highest suspicion breast imaging-reporting and data system (BI-RADS)-5 mammograms are sparse. Records from a regional health system radiology database were screened for mammograms associated with image-guided biopsy. A total of 182 nonpalpable BI-RADS-5 lesions were sampled in 178 patients over 5 years, using CORE or EB. Initial surgical margins, number of surgeries, time from initial procedure to last related surgical procedure, and hospital and professional charges for related admissions were compared using chi-squared, t-test, and Wilcoxon Mann-Whitney tests. A total of 108 CORE and 74 EB were performed as the first diagnostic procedure. Invasive or in situ carcinoma was diagnosed in 156 (86%) of all biopsies, 95 in CORE and 61 in EB groups. Negative margins of the first surgical procedure were more frequent in CORE (n = 70, 74%) versus EB (n = 17, 28%), p < 0.05. Use of CORE was associated with fewer total surgical procedures per lesion (1.29 +/- 0.05 versus 1.8 +/- 0.05, p < 0.05). Time of initial diagnostic procedure to final treatment did not vary significantly according to group (27 +/- 2 days versus 22 +/- 2 days, CORE versus EB). Mean charges including the diagnostic procedure and all subsequent surgeries were not different between CORE and EB groups ($10,500 +/- 300 versus $11,500 +/- 500, p = 0.08). Use of CORE as the first procedure in patients with highly suspicious mammograms is associated with improved pathologic margins and need for fewer surgical procedures than EB, and should be considered the preferred initial diagnostic approach.

Utilization of the NASA Robonaut as a Surgical Avatar in Telemedicine

NASA Technical Reports Server (NTRS)

Dean, Marc; Diftler, Myron

2015-01-01

The concept of teleoperated robotic surgery is not new; however, most of the work to date has utilized specialized robots designed for specific set of surgeries. This activity explores the use of a humanoid robot to perform surgical procedures using the same hand held instruments that a human surgeon employs. For this effort, the tele-operated Robonaut (R2) was selected due to its dexterity, its ability to perform a wide range of tasks, and its adaptability to changing environments. To evaluate this concept, a series of challenges was designed with the goal of assessing the feasibility of utilizing Robonaut as a telemedicine based surgical avatar.

Characterization of aerosols produced by surgical procedures

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

Yeh, H.C.; Muggenburg, B.A.; Lundgren, D.L.

1994-07-01

In many surgeries, especially orthopedic procedures, power tools such as saws and drills are used. These tools may produce aerosolized blood and other biological material from bone and soft tissues. Surgical lasers and electrocautery tools can also produce aerosols when tissues are vaporized and condensed. Studies have been reported in the literature concerning production of aerosols during surgery, and some of these aerosols may contain infectious material. Garden et al. (1988) reported the presence of papilloma virus DNA in the fumes produced from laser surgery, but the infectivity of the aerosol was not assessed. Moon and Nininger (1989) measured themore » size distribution and production rate of emissions from laser surgery and found that particles were generally less than 0.5 {mu}m diameter. More recently there has been concern expressed over the production of aerosolized blood during surgical procedures that require power tools. In an in vitro study, the production of an aerosol containing the human immunodeficiency virus (HIV) was reported when power tools were used to cut tissues with blood infected with HIV. Another study measured the size distribution of blood aerosols produced by surgical power tools and found blood-containing particles in a number of size ranges. Health care workers are anxious and concerned about whether surgically produced aerosols are inspirable and can contain viable pathogens such as HIV. Other pathogens such as hepatitis B virus (HBV) are also of concern. The Occupational Safety and Health funded a project at the National Institute for Inhalation Toxicology Research Institute to assess the extent of aerosolization of blood and other tissues during surgical procedures. This document reports details of the experimental and sampling approach, methods, analyses, and results on potential production of blood-associated aerosols from surgical procedures in the laboratory and in the hospital surgical suite.« less

Gastric cancer perforation: experience from a tertiary care hospital.

PubMed

Kandel, Bishnu Prasad; Singh, Yogendra; Singh, Keshav Prasad; Khakurel, Mahesh

2013-01-01

Gastric cancer perforation can occurs in advanced stage of the disease and is often associated with a high morbidity and mortality. Peritonitis due to perforation needs emergency laparotomy and different surgical procedures can be performed for definitive treatment. Surgical procedures largely depend on the stage of the disease and general condition of the patient. This study was carried out to evaluate the outcome and role of different surgical procedures in gastric cancer perforation. Medical record of patients with gastric perforation, who were treated during ten years period, was reviewed retrospectively. Data regarding clinical presentation, surgical procedures, staging and survival of patients were obtained. Features suggestive of diffuse peritonitis were evident in all cases. The majority of the patients underwent emergency surgery except one who died during resuscitation. The majority of patients were in stage III and stage IV. Surgical procedure includes simple closure and omental patch in five patients, simple closure and gastrojejunostomy in nine patients, gastrectomy in six patients and Devine's antral exclusion in one patient. Surgical site infection was the most common (45.5%) postoperative complication. Four patients died within one month of the surgery. Three patients who underwent gastrectomy survived for one year and one patient survived for five years. Although gastric cancer perforation usually occurs in advanced stage of the disease, curative resection should be considered as far as possible.

Perioperative mortality: Analysis of 3 years of operative data across 7 general surgical projects of Médecins Sans Frontières in Democratic Republic of Congo, Central African Republic, and South Sudan.

PubMed

Davies, Jessica F; Lenglet, Annick; van Wijhe, Marten; Ariti, Cono

2016-05-01

The African continent has the greatest burden of surgical disability-adjusted life years, yet the least is known about operative care here. This analysis describes the surgical patients admitted to 7 hospitals supported by the Médécins Sans Frontières (MSF) over 3 years in 3 conflict-affected countries-Eastern Democratic Republic of Congo, Central African Republic, and South Sudan. A standardized operative data collection tool was used for routine collection of operative inpatient data between 2011 and 2013 at 7 MSF surgical facilities. Surgical records of 14,482 patients were analyzed to describe surgical epidemiology, major procedures, and perioperative mortality. The perioperative mortality rate (POMR) was calculated within 2 days of admission (POMR2) and within 30 days from admission (POMR30). The POMR is used as a marker of quality of operative care. Caesarean delivery was the most common major procedure performed and had a POMR30 of 5.28 per 1,000 admissions. The overall inpatient mortality was 19.67 per 1,000 admissions. Children had greater POMR than adults for the same procedure types (47.97 vs 15.89 deaths per 1,000 admissions, P < .001); 85.1% of all major procedures were emergency procedures and between 3 and 30% of admissions were related to violence. After adjustment, perioperative death was associated with emergency surgery, violence, and age younger than 15 years. POMRs varied by age group and type of major procedure performed. Collecting surgical data is achievable and can inform future planning and support for national surgical programs. More information is needed on operative outcomes in adults and children in low-resource settings to improve quality and access to care. Copyright © 2016 Elsevier Inc. All rights reserved.

Toolbox of assessment tools of technical skills in otolaryngology-head and neck surgery: A systematic review.

PubMed

Labbé, Mathilde; Young, Meredith; Nguyen, Lily H P

2017-10-08

To support the development of programs of assessment of technical skills in the operating room (OR), we systematically reviewed the literature to identify assessment tools specific to otolaryngology-head and neck surgery (OTL-HNS) core procedures and summarized their characteristics. We systematically searched Embase, MEDLINE, PubMed, and Cochrane to identify and report on assessment tools that can be used to assess residents' technical surgical skills in the operating room for OTL-HNS core procedures. Of the 736 unique titles retrieved, 16 articles met inclusion criteria, covering 11 different procedures (in otology, rhinology, laryngology, head and neck, and general otolaryngology). The tools were composed of a task-specific checklist and/or global rating scale and were developed in the OR, on human cadavers, or in a simulation setting. Our study reports on published tools for assessing technical skills for OTL-HNS residents during core procedures conducted in the OR. These assessment tools could facilitate the provision of timely feedback to trainees including specific goals for improvement. However, the paucity of publications suggests little agreement on how to best perform work-based direct-observation assessment for core surgical procedures in OTL-HNS. The sparsity of tools specific to OTL-HNS may become a barrier to a fluid transition to competency-based medical education. Laryngoscope, 2017. © 2017 The American Laryngological, Rhinological and Otological Society, Inc.

Does intraoperative fluid management in spine surgery predict intensive care unit length of stay?

PubMed

Nahtomi-Shick, O; Kostuik, J P; Winters, B D; Breder, C D; Sieber, A N; Sieber, F E

2001-05-01

To determine whether intraoperative fluid management in spine surgery predicts postoperative intensive care unit length of stay (ICU LOS). Retrospective case series. University-affiliated medical center. 103 adult ASA physical status I, II, and III patients undergoing spine surgery. Patients were divided into three LOS groups: no ICU stay (LOS0) (n = 26), 1 day ICU stay (LOS1) (n = 48), and ICU stay > 1 day (LOS2) (n = 29). Measurements were analyzed by groups using the Kruskal-Wallis and Mann-Whitney tests, and linear regression. Demographics, comorbidity, length of surgery, surgical procedure, and intraoperative fluids were recorded. The important differences in perioperative fluid management among the three groups included estimated blood loss (612 +/- 480 mL, 1853 +/- 1175 mL, 2702 +/- 1771 mL, means +/- SD); total crystalloid administration (2715 +/- 1396 mL, 5717 +/- 2574 mL, 7281 +/- 3417 mL); and total blood administration (92 +/- 279 mL, 935 +/- 757 mL, 1542 +/- 1230 mL) in LOS0, LOS1, and LOS2, respectively. The mixture of surgical procedures was similar in LOS1 and LOS2; and differed from LOS0. Predictors of ICU LOS included age, ASA physical status, surgical procedure, total crystalloid administration, and platelet administration. Surgical procedure and total crystalloid administration correlated (Pearson correlation coefficient = 0.441; p = 0.000) and were not related to age or ASA physical status. Total crystalloid administration during spine surgery does predict ICU LOS. In addition, total crystalloid administration is closely related to the surgical procedure. Given that the mixture of surgical procedures was similar in LOS1 and LOS2, but differed in estimated blood loss, total crystalloid administration, and total blood administration; intraoperative fluid management during spine surgery only predicts ICU LOS insofar as total crystalloid administration is related to the surgical procedure.

Cost analysis of robotic versus laparoscopic general surgery procedures.

PubMed

Higgins, Rana M; Frelich, Matthew J; Bosler, Matthew E; Gould, Jon C

2017-01-01

Robotic surgical systems have been used at a rapidly increasing rate in general surgery. Many of these procedures have been performed laparoscopically for years. In a surgical encounter, a significant portion of the total costs is associated with consumable supplies. Our hospital system has invested in a software program that can track the costs of consumable surgical supplies. We sought to determine the differences in cost of consumables with elective laparoscopic and robotic procedures for our health care organization. De-identified procedural cost and equipment utilization data were collected from the Surgical Profitability Compass Procedure Cost Manager System (The Advisory Board Company, Washington, DC) for our health care system for laparoscopic and robotic cholecystectomy, fundoplication, and inguinal hernia between the years 2013 and 2015. Outcomes were length of stay, case duration, and supply cost. Statistical analysis was performed using a t-test for continuous variables, and statistical significance was defined as p < 0.05. The total cost of consumable surgical supplies was significantly greater for all robotic procedures. Length of stay did not differ for fundoplication or cholecystectomy. Length of stay was greater for robotic inguinal hernia repair. Case duration was similar for cholecystectomy (84.3 robotic and 75.5 min laparoscopic, p = 0.08), but significantly longer for robotic fundoplication (197.2 robotic and 162.1 min laparoscopic, p = 0.01) and inguinal hernia repair (124.0 robotic and 84.4 min laparoscopic, p = ≪0.01). We found a significantly increased cost of general surgery procedures for our health care system when cases commonly performed laparoscopically are instead performed robotically. Our analysis is limited by the fact that we only included costs associated with consumable surgical supplies. The initial acquisition cost (over $1 million for robotic surgical system), depreciation, and service contract for the robotic and laparoscopic systems were not included in this analysis.

Prospective, randomized in vivo comparison of a dual-active waterless antiseptic versus two alcohol-only waterless antiseptics for surgical hand antisepsis.

PubMed

Olson, Linda K M; Morse, Dan J; Duley, Collette; Savell, Brenon K

2012-03-01

This study aimed to demonstrate the value of adding an active level of a persistent antimicrobial agent, such as chlorhexidine gluconate (CHG), to an alcohol-based surgical hand antiseptic. The persistence of 3 waterless, brushless alcohol-based surgical hand antiseptics, including one product containing CHG, was compared. The test products were applied a total of 12 times over 5 days. Samples of aerobic bacteria were collected on days 1 and 5, on both days immediately after drying and 6 hours later, using the glove juice technique. Relative suppression of regrowth was compared using t tests. Using an equivalence margin of 20%, the alcohol plus CHG product showed noninferiority to the alcohol-only products at all sampling points and, based on significantly lower bacterial regrowth (P = .026), superior persistence to the alcohol-only products after 6 hours of glove wear. Given the primary objective of surgical hand antisepsis of reducing resident skin flora for the duration of the surgical procedure, using an alcohol-based hand antiseptic containing CHG appears to be the most appropriate choice for maintaining microbial levels as low as possible for as long as possible. Copyright © 2012 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

Clean and Green: Saving Water in the Operating Theatre

PubMed Central

Jehle, Karlheinz; Jarrett, Nick; Matthews, Shaun

2008-01-01

INTRODUCTION There is a growing trend to use alcohol-based hand disinfectants in clinical practice. In addition to their antibacterial efficacy, these disinfectants offer an alternative to traditional surgical hand disinfection agents that can save water in the operating theatre. MATERIALS AND METHODS The amounts of water and soap used during traditional surgical hand disinfection with antiseptic soap preparations were measured and water usage over a 1-year period was estimated. Costs of traditional disinfection agents were compared with alcohol-based agents. RESULTS One surgical hand disinfection episode with traditional agents used 18.5 l of water. During 15,500 procedures performed at our institution over a 1-year period, 931,938 l of water were used which could have been saved had alcohol-based agents been used. Cost per episode of hand disinfection depends on the amounts used and is not higher compared to traditional agents. CONCLUSIONS The benefits of using an alcohol-based surgical hand disinfectant may include significant water savings, in addition to previously published advantages of improved efficacy. When deciding on the method of surgical hand disinfection, careful thought should be given to the use of water as a resource. Surgeons should be aware of the environmental impact of their profession. PMID:18201493

[Anopexy according to Longo for hemorrhoids].

PubMed

Ruppert, R

2016-11-01

The treatment for hemorrhoids ranges from conservative management to surgical procedures. The procedures are tailored to the individual grading of hemorrhoids and the individual complaints. The standard Goligher classification of the hemorrhoids is the basis for further treatment and no differentiation is made between segmental hemorrhoids and circular hemorrhoids. In the case of advanced circular hemorrhoid disease the surgical procedure with a stapler, so-called stapler anopexy, is the procedure of choice.

Implementation of transcatheter aortic valve replacement in California: Influence on aortic valve surgery.

PubMed

Maximus, Steven; Milliken, Jeffrey C; Danielsen, Beate; Shemin, Richard; Khan, Junaid; Carey, Joseph S

2018-04-01

Transcatheter aortic valve replacement (TAVR) procedures were introduced in 2011. Initially, procedures were limited to patients who were not surgical candidates, but subsequently high-risk surgical candidates were considered for TAVR. The influence on aortic valve surgery in California is unknown. The California Office of Statewide Health Planning and Development hospitalized patient discharge database was queried for the years 2009 through 2014. isolated surgical aortic valve and aortic valve/coronary artery bypass graft (SAVR) and TAVR procedures were identified by International Classification of Diseases-9th revision clinical modification procedure codes. Seven TAVR programs were introduced in 2011, 12 in 2012, 3 in 2013, and 6 in 2014. SAVR procedure volumes were compared from the 2 years before institution with SAVR volumes during the year(s) after institution of the TAVR program in these 28 hospitals. Overall, surgical volumes increased during the first, second, and third years after implementation of TAVR procedures. Among 7 hospitals with 4-year programs, surgical volumes increased to a maximum of 15.5% during the third year, then began to decrease. The hospital performing the largest number of TAVR procedures showed a marked decrease in SAVR volume by the fourth year, suggesting a shift of SAVR candidates to TAVR. Among all hospitals with 4-year programs, TAVR exceeded SAVR procedures by the fourth year. In California overall, SAVR increased during 2011 through 2013, due primarily to increasing volume of isolated SAVR procedures. Statewide, isolated SAVR increased from a yearly average of 3111 procedures during 2009-2010 to 3592 (+15.5%) in 2013, then decreased slightly in 2014. SAVR plus coronary artery bypass graft procedures decreased during the same time period. After implementation of TAVR, hospital SAVR volumes increased moderately, then began to decrease by the fourth year, when TAVR volume exceeded SAVR. Surgical candidates may be identified during evaluation for TAVR, resulting in increased SAVR volume. Increasing SAVR volume may also be related to improved patient and provider awareness of aortic valve disease. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Assessing the surgical skills of trainees in the operating theatre: a prospective observational study of the methodology.

PubMed

Beard, J D; Marriott, J; Purdie, H; Crossley, J

2011-01-01

To compare user satisfaction and acceptability, reliability and validity of three different methods of assessing the surgical skills of trainees by direct observation in the operating theatre across a range of different surgical specialties and index procedures. A 2-year prospective, observational study in the operating theatres of three teaching hospitals in Sheffield. The assessment methods were procedure-based assessment (PBA), Objective Structured Assessment of Technical Skills (OSATS) and Non-technical Skills for Surgeons (NOTSS). The specialties were obstetrics and gynaecology (O&G) and upper gastrointestinal, colorectal, cardiac, vascular and orthopaedic surgery. Two to four typical index procedures were selected from each specialty. Surgical trainees were directly observed performing typical index procedures and assessed using a combination of two of the three methods (OSATS or PBA and NOTSS for O&G, PBA and NOTSS for the other specialties) by the consultant clinical supervisor for the case and the anaesthetist and/or scrub nurse, as well as one or more independent assessors from the research team. Information on user satisfaction and acceptability of each assessment method from both assessor and trainee perspectives was obtained from structured questionnaires. The reliability of each method was measured using generalisability theory. Aspects of validity included the internal structure of each tool and correlation between tools, construct validity, predictive validity, interprocedural differences, the effect of assessor designation and the effect of assessment on performance. Of the 558 patients who were consented, a total of 437 (78%) cases were included in the study: 51 consultant clinical supervisors, 56 anaesthetists, 39 nurses, 2 surgical care practitioners and 4 independent assessors provided 1635 assessments on 85 trainees undertaking the 437 cases. A total of 749 PBAs, 695 NOTSS and 191 OSATSs were performed. Non-O&G clinical supervisors and trainees provided mixed, but predominantly positive, responses about a range of applications of PBA. Most felt that PBA was important in surgical education, and would use it again in the future and did not feel that it added time to the operating list. The overall satisfaction of O&G clinical supervisors and trainees with OSATS was not as high, and a majority of those who used both preferred PBA. A majority of anaesthetists and nurses felt that NOTSS allowed them to rate interpersonal skills (communication, teamwork and leadership) more easily than cognitive skills (situation awareness and decision-making), that it had formative value and that it was a valuable adjunct to the assessment of technical skills. PBA demonstrated high reliability (G > 0.8 for only three assessor judgements on the same index procedure). OSATS had lower reliability (G > 0.8 for five assessor judgements on the same index procedure). Both were less reliable on a mix of procedures because of strong procedure-specific factors. A direct comparison of PBA between O&G and non-O&G cases showed a striking difference in reliability. Within O&G, a good level of reliability (G > 0.8) could not be obtained using a feasible number of assessments. Conversely, the reliability within non-O&G cases was exceptionally high, with only two assessor judgements being required. The reasons for this difference probably include the more summative purpose of assessment in O&G and the much higher proportion of O&G trainees in this study with training concerns (42% vs 4%). The reliability of NOTSS was lower than that for PBA. Reliability for the same procedure (G > 0.8) required six assessor judgements. However, as procedure-specific factors exerted a lesser influence on NOTSS, reliability on a mix of procedures could be achieved using only eight assessor judgements. NOTSS also demonstrated a valid internal structure. The strongest correlations between NOTSS and PBA or OSATS were in the 'decision-making' domain. PBA and NOTSS showed better construct validity than OSATS, the year of training and the number of recent index procedures performed being significant independent predictors of performance. There was little variation in scoring between different procedures or different designations of assessor. The results suggest that PBA is a reliable and acceptable method of assessing surgical skills, with good construct validity. Specialties that use OSATS may wish to consider changing the design or switching to PBA. Whatever workplace-based assessment method is used, the purpose, timing and frequency of assessment require detailed guidance. NOTSS is a promising tool for the assessment of non-technical skills, and surgical specialties may wish to consider its inclusion in their assessment framework. Further research is required into the use of health-care professionals other than consultant surgeons to assess trainees, the relationship between performance and experience, the educational impact of assessment and the additional value of video recording.

Financial modeling of current surgical robotic system in outpatient laparoscopic cholecystectomy: how should we think about the expense?

PubMed

Schwaitzberg, S D

2016-05-01

More than 500,000 robotically assisted procedures were performed worldwide in 2013. Despite broad adoption, there remains a lack of clarity concerning the added cost of the robotic system to the procedure especially in light of an increasing number of ambulatory procedures which are now marketed by hospitals, surgeons and the manufacturer. These procedures are associated with much less reimbursement than inpatient procedures. It is unclear whether these added expenses can be absorbed in these scenarios. Reports vary in opinion concerning the added net costs during robotically assisted laparoscopic hernia or cholecystectomy. The worldwide revenues, procedures, and the installed base of robotic system data were reviewed and reanalyzed from the 2013 Intuitive Surgical Investors report. This provided an opportunity to look cost per case projections from the vantage point of actual revenue. This analysis was based on revenue of 2.27 billion US dollars in the three categories of capital acquisition, instrumentation and accessories, and service revenue. These revenues were then spread across 523,000 cases with varying assumptions. Without regard to expense offsets, the additional cost ranges from $2908 to $8675 depending on what system was purchased and the ability to distribute costs against case volume. Estimates of commercial and government revenue were then compared against these expenses. The use of the extraordinary technology in the face of low-morbidity low-cost established minimally invasive procedures needs to withstand scrutiny of outcome assessment, revenue and expense considerations and appropriateness review in order to create financially viable approaches to high-volume minimally invasive procedures. Revenue estimates associated with outpatient reimbursement make it difficult to support these expenses, recognizing inpatient procedures represent a different net financial picture.

Learning intervention-induced deformations for non-rigid MR-CT registration and electrode localization in epilepsy patients

PubMed Central

Onofrey, John A.; Staib, Lawrence H.; Papademetris, Xenophon

2015-01-01

This paper describes a framework for learning a statistical model of non-rigid deformations induced by interventional procedures. We make use of this learned model to perform constrained non-rigid registration of pre-procedural and post-procedural imaging. We demonstrate results applying this framework to non-rigidly register post-surgical computed tomography (CT) brain images to pre-surgical magnetic resonance images (MRIs) of epilepsy patients who had intra-cranial electroencephalography electrodes surgically implanted. Deformations caused by this surgical procedure, imaging artifacts caused by the electrodes, and the use of multi-modal imaging data make non-rigid registration challenging. Our results show that the use of our proposed framework to constrain the non-rigid registration process results in significantly improved and more robust registration performance compared to using standard rigid and non-rigid registration methods. PMID:26900569

Treating Voice Disorders in the School-Based Setting: Working within the Framework of IDEA

ERIC Educational Resources Information Center

Ruddy, Bari Hoffman; Sapienza, Christine M.

2004-01-01

The role of the speech-language pathologist (SLP) has developed considerably over the last 10 years given the medical and technological advances in life-sustaining procedures. Over time, children born with congenital, surgical, or "medically fragile" conditions have become mainstreamed into regular school-based settings, thus extending…

Cervical degenerative disease: systematic review of economic analyses.

PubMed

Alvin, Matthew D; Qureshi, Sheeraz; Klineberg, Eric; Riew, K Daniel; Fischer, Dena J; Norvell, Daniel C; Mroz, Thomas E

2014-10-15

Systematic review. To perform an evidence-based synthesis of the literature assessing the cost-effectiveness of surgery for patients with symptomatic cervical degenerative disc disease (DDD). Cervical DDD is a common cause of clinical syndromes such as neck pain, cervical radiculopathy, and myelopathy. The appropriate surgical intervention(s) for a given problem is controversial, especially with regard to quality-of-life outcomes, complications, and costs. Although there have been many studies comparing outcomes and complications, relatively few have compared costs and, more importantly, cost-effectiveness of the interventions. We conducted a systematic search in PubMed/MEDLINE, EMBASE, the Cochrane Collaboration Library, the Cost-Effectiveness Analysis registry database, and the National Health Service Economic Evaluation Database for full economic evaluations published through January 16, 2014. Identification of full economic evaluations that were explicitly designed to evaluate and synthesize the costs and consequences of surgical procedures or surgical intervention with nonsurgical management in patients with cervical DDD were considered for inclusion, based on 4 key questions. Five studies were included, each specific to 1 or more of our focus questions. Two studies suggested that cervical disc replacement may be more cost-effective compared with anterior cervical discectomy and fusion. Two studies comparing anterior with posterior surgical procedures for cervical spondylotic myelopathy suggested that anterior surgery was more cost-effective than posterior surgery. One study suggested that posterior cervical foraminotomy had a greater net economic benefit than anterior cervical discectomy and fusion in a military population with unilateral cervical radiculopathy. No studies assessed the cost-effectiveness of surgical intervention compared with nonoperative treatment of cervical myelopathy or radiculopathy, although it is acknowledged that existing studies demonstrate the cost-effectiveness of surgical intervention for these 2 clinical entities. A paucity of high-quality economic literature exists regarding cost-effectiveness of surgical intervention for cervical DDD. Future research is necessary to validate the findings of the few studies that do exist to guide decisions for surgery by the physician and patient with respect to cost-effectiveness. 2.

Antibiotic stewardship in the newborn surgical patient: A quality improvement project in the neonatal intensive care unit.

PubMed

Walker, Sarah; Datta, Ankur; Massoumi, Roxanne L; Gross, Erica R; Uhing, Michael; Arca, Marjorie J

2017-12-01

There is significant diversity in the utilization of antibiotics for neonates undergoing surgical procedures. Our institution standardized antibiotic administration for surgical neonates, in which no empiric antibiotics were given to infants with surgical conditions postnatally, and antibiotics are given no more than 72 hours perioperatively. We compared the time periods before and after implementation of antibiotic protocol in an institution review board-approved, retrospective review of neonates with congenital surgical conditions who underwent surgical correction within 30 days after birth. Surgical site infection at 30 days was the primary outcome, and development of hospital-acquired infections or multidrug-resistant organism were secondary outcomes. One hundred forty-eight infants underwent surgical procedures pre-protocol, and 127 underwent procedures post-protocol implementation. Surgical site infection rates were similar pre- and post-protocol, 14% and 9% respectively, (P = .21.) The incidence of hospital-acquired infections (13.7% vs 8.7%, P = .205) and multidrug-resistant organism (4.7% vs 1.6%, P = .143) was similar between the 2 periods. Elimination of empiric postnatal antibiotics did not statistically change rates of surgical site infection, hospital-acquired infections, or multidrug-resistant organisms. Limiting the duration of perioperative antibiotic prophylaxis to no more than 72 hours after surgery did not increase the rate of surgical site infection, hospital-acquired infections, or multidrug-resistant organism. Median antibiotic days were decreased with antibiotic standardization for surgical neonates. Copyright © 2017 Elsevier Inc. All rights reserved.

The impact of intra-operative interruptions on surgeons' perceived workload: an observational study in elective general and orthopedic surgery.

PubMed

Weigl, Matthias; Antoniadis, Sophia; Chiapponi, Costanza; Bruns, Christiane; Sevdalis, Nick

2015-01-01

Surgeons' intra-operative workload is critical for effective and safe surgical performance. Detrimental conditions in the operating room (OR) environment may add to perceived workload and jeopardize surgical performance and outcomes. This study aims to evaluate the impact of different intra-operative workflow interruptions on surgeons' capacity to manage their workload safely and efficiently. This was an observational study of intra-operative interruptions and self-rated workload in two surgical specialties (general, orthopedic/trauma surgery). Intra-operative interruptions were assessed via expert observation using a well-validated observation tool. Surgeons, nurses, and anesthesiologists assessed their intra-operative workload directly after case completion based on three items of the validated Surgery Task Load Index (mental demand, situational stress, distraction). A total of 56 elective cases (35 open, 21 laparoscopic) with 94 workload ratings were included. Mean intra-operative duration was 1 h 37 min. Intra-operative interruptions were on average observed 9.78 times per hour. People who entered/exited the OR (30.6 %) as well as telephone-/beeper-related disruptions (23.6 %) occurred most often. Equipment and OR environment-related interruptions were associated with highest interference with team functioning particularly in laparoscopic procedures. After identifying task and procedural influences, partial correlational analyses revealed that case-irrelevant communications were negatively associated with surgeons' mental fatigue and situational stress, whereas surgeons' reported distraction was increased by case-irrelevant communication and procedural disruptions. OR nurses' and anesthesiologists' perceived workload was also related to intra-operative interruption events. Our study documents the unique contribution of different interruptions on surgeons' workload; whereas case-irrelevant communications may be beneficial for mental fatigue and stress in routine cases, procedural interruptions and case-irrelevant communication may contribute to surgeons' mental focus deteriorating. Well-designed OR environments, surgical leadership, and awareness can help to control unnecessary interruptions for effective and safe surgical care.

Medical Engineering and Microneurosurgery: Application and Future.

PubMed

Morita, Akio; Sora, Shigeo; Nakatomi, Hirofumi; Harada, Kanako; Sugita, Naohiko; Saito, Nobuhito; Mitsuishi, Mamoru

2016-10-15

Robotics and medical engineering can convert traditional surgery into digital and scientific procedures. Here, we describe our work to develop microsurgical robotic systems and apply engineering technology to assess microsurgical skills. With the collaboration of neurosurgeons and an engineering team, we have developed two types of microsurgical robotic systems. The first, the deep surgical systems, enable delicate surgical procedures such as vessel suturing in a deep and narrow space. The second type allows for super-fine surgical procedures such as anastomosing artificial vessels of 0.3 mm in diameter. Both systems are constructed with master and slave manipulator robots connected to local area networks. Robotic systems allowed for secure and accurate procedures in a deep surgical field. In cadaveric models, these systems showed a good potential of being useful in actual human surgeries, but mechanical refinements in thickness and durability are necessary for them to be established as clinical systems. The super-fine robotic system made the very intricate surgery possible and will be applied in clinical trials. Another trial included the digitization of surgical technique and scientific analysis of surgical skills. Robotic and human hand motions were analyzed in numerical fashion as we tried to define surgical skillfulness in a digital format. Engineered skill assessment is also feasible and should be useful for microsurgical training. Robotics and medical engineering should bring science into the surgical field and training of surgeons. Active collaboration between medical and engineering teams and academic and industry groups is mandatory to establish such medical systems to improve patient care.

Medical Engineering and Microneurosurgery: Application and Future

PubMed Central

MORITA, Akio; SORA, Shigeo; NAKATOMI, Hirofumi; HARADA, Kanako; SUGITA, Naohiko; SAITO, Nobuhito; MITSUISHI, Mamoru

2016-01-01

Robotics and medical engineering can convert traditional surgery into digital and scientific procedures. Here, we describe our work to develop microsurgical robotic systems and apply engineering technology to assess microsurgical skills. With the collaboration of neurosurgeons and an engineering team, we have developed two types of microsurgical robotic systems. The first, the deep surgical systems, enable delicate surgical procedures such as vessel suturing in a deep and narrow space. The second type allows for super-fine surgical procedures such as anastomosing artificial vessels of 0.3 mm in diameter. Both systems are constructed with master and slave manipulator robots connected to local area networks. Robotic systems allowed for secure and accurate procedures in a deep surgical field. In cadaveric models, these systems showed a good potential of being useful in actual human surgeries, but mechanical refinements in thickness and durability are necessary for them to be established as clinical systems. The super-fine robotic system made the very intricate surgery possible and will be applied in clinical trials. Another trial included the digitization of surgical technique and scientific analysis of surgical skills. Robotic and human hand motions were analyzed in numerical fashion as we tried to define surgical skillfulness in a digital format. Engineered skill assessment is also feasible and should be useful for microsurgical training. Robotics and medical engineering should bring science into the surgical field and training of surgeons. Active collaboration between medical and engineering teams and academic and industry groups is mandatory to establish such medical systems to improve patient care. PMID:27464471

ANAESTHESIA FOR OPHTHALMIC SURGICAL PROCEDURES.

PubMed

Onakpoya, O H; Asudo, F D; Adeoye, A O

2014-03-01

Ophthalmic surgical procedures are performed under anaesthesia to enhance comfort and cooperation of patient. To review factors influencing the choice of anaesthesia for ophthalmic surgical procedures. Restrospective descriptive study. Eye unit of a tertiary hospital. All patients who had ophthalmic surgeries in the operating theatre from January 2002 to December 2009. Two hundred and ninety ophthalmic surgeries were carried out during the study period. Age range was 1-95 years and mean of 61.0 ± 1.9; most (55%) were elderly while 4.8% were children. One hundred and fourty seven (50.7%) were males, 143(49.3%) females; male:female of 1.03:1. Local anaesthesia was the more commonly (92.1%) employed while general anaesthesia was used in 23(7.9%) patients. General anaesthesia was used more frequently (71.4%) in children compared to other age groups; the mean age and standard error of means for patients who had general anaesthesia (27.2 /5.4 years) is smaller compared to 63.9/0.93 years for patients who had local anaesthesia (p < 0.0001). Regional anaesthesia was the most frequently used for all types of procedures except for eye wall repairs in which general anaesthesia was used for 71.4% of patients (p < 0.0001). General anaesthesia was indicated in seven (41.2%) of emergency ophthalmic surgical procedures as compared to 16 (5.9%) of elective ophthalmic procedures P < 0.0001. General anaesthesia was more commonly employed in children, eye wall repairs and emergency ophthalmic surgical procedures.

Development of virtual environments for training skills and reducing errors in laparoscopic surgery

NASA Astrophysics Data System (ADS)

Tendick, Frank; Downes, Michael S.; Cavusoglu, Murat C.; Gantert, Walter A.; Way, Lawrence W.

1998-06-01

In every surgical procedure there are key steps and skills that, if performed incorrectly, can lead to complications. In conjunction with efforts, based on task and error analysis, in the Videoscopic Training Center at UCSF to identify these key elements in laparoscopic surgical procedures, the authors are developing virtual environments and modeling methods to train the elements. Laparoscopic surgery is particularly demanding of the surgeon's spatial skills, requiring the ability to create 3D mental models and plans while viewing a 2D image. For example, operating a laparoscope with the objective lens angled from the scope axis is a skill that some surgeons have difficulty mastering, even after using the instrument in many procedures. Virtual environments are a promising medium for teaching spatial skills. A kinematically accurate model of an angled laparoscope in an environment of simple targets is being tested in courses for novice and experienced surgeons. Errors in surgery are often due to a misinterpretation of local anatomy compounded with inadequate procedural knowledge. Methods to avoid bile duct injuries in cholecystectomy are being integrated into a deformable environment consisting of the liver, gallbladder, and biliary tree. Novel deformable tissue modeling algorithms based on finite element methods will be used to improve the response of the anatomical models.

Training Surgical Residents With a Haptic Robotic Central Venous Catheterization Simulator.

PubMed

Pepley, David F; Gordon, Adam B; Yovanoff, Mary A; Mirkin, Katelin A; Miller, Scarlett R; Han, David C; Moore, Jason Z

Ultrasound guided central venous catheterization (CVC) is a common surgical procedure with complication rates ranging from 5 to 21 percent. Training is typically performed using manikins that do not simulate anatomical variations such as obesity and abnormal vessel positioning. The goal of this study was to develop and validate the effectiveness of a new virtual reality and force haptic based simulation platform for CVC of the right internal jugular vein. A CVC simulation platform was developed using a haptic robotic arm, 3D position tracker, and computer visualization. The haptic robotic arm simulated needle insertion force that was based on cadaver experiments. The 3D position tracker was used as a mock ultrasound device with realistic visualization on a computer screen. Upon completion of a practice simulation, performance feedback is given to the user through a graphical user interface including scoring factors based on good CVC practice. The effectiveness of the system was evaluated by training 13 first year surgical residents using the virtual reality haptic based training system over a 3 month period. The participants' performance increased from 52% to 96% on the baseline training scenario, approaching the average score of an expert surgeon: 98%. This also resulted in improvement in positive CVC practices including a 61% decrease between final needle tip position and vein center, a decrease in mean insertion attempts from 1.92 to 1.23, and a 12% increase in time spent aspirating the syringe throughout the procedure. A virtual reality haptic robotic simulator for CVC was successfully developed. Surgical residents training on the simulation improved to near expert levels after three robotic training sessions. This suggests that this system could act as an effective training device for CVC. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

The change in upper tract urolithiasis composition, surgical treatments and outcomes of para and quadriplegic patients over time.

PubMed

Clifton, Marisa M; Gettman, Matthew T; Patterson, David E; Rangel, Laureano; Krambeck, Amy E

2014-10-01

Stone disease in patients with spinal cord injury is a source of morbidity and mortality. Previous studies have indicated a decrease in infection-based urolithiasis in recent decades. We aimed to identify changes in stone composition and surgical outcomes in patients with para and quadriplegia over time. A retrospective review of para and quadriplegic patients from 1986 to 2011 who underwent surgical intervention for urolithiasis was performed, identifying 95 patients. The Mantel-Haenszel Chi square test was used to compare change in stone composition over time. The mean patient age was 44.0 years (range 18-88) and treatment included percutaneous nephrolithotomy (PCNL) 40 (42.1 %), ureteroscopy 28 (29.5 %), shock wave lithotripsy (SWL) 26 (27.4 %), and nephrectomy 1 (1 %). Overall stone-free status was found in 47.4 % with 19.0 % requiring a repeat procedure. The median hospital stay for patients undergoing SWL was 2.5 days, ureteroscopy 5 days, and PCNL 6 days. Infection-based stone composition was identified in 23 patients (36.5 %). We evaluated the linear change in percent of each stone component over time and identified increasing components of calcium oxalate dihydrate (p = 0.002) and calcium carbonate (p = 0.009). However, over a period of 25 years, the incidence of infection-based stone did not change (p = 0.57). Para and quadriplegic patients with urolithiasis can be difficult to treat surgically with prolonged hospitalizations, low stone-free status, and often require additional procedures. Despite improvements in antibiotic agents and management of neurogenic bladders, infection-based calculi continue to be a significant source of morbidity to this patient population.

Management of mechanical ventilation during laparoscopic surgery.

PubMed

Valenza, Franco; Chevallard, Giorgio; Fossali, Tommaso; Salice, Valentina; Pizzocri, Marta; Gattinoni, Luciano

2010-06-01

Laparoscopy is widely used in the surgical treatment of a number of diseases. Its advantages are generally believed to lie on its minimal invasiveness, better cosmetic outcome and shorter length of hospital stay based on surgical expertise and state-of-the-art equipment. Thousands of laparoscopic surgical procedures performed safely prove that mechanical ventilation during anaesthesia for laparoscopy is well tolerated by a vast majority of patients. However, the effects of pneumoperitoneum are particularly relevant to patients with underlying lung disease as well as to the increasing number of patients with higher-than-normal body mass index. Moreover, many surgical procedures are significantly longer in duration when performed with laparoscopic techniques. Taken together, these factors impose special care for the management of mechanical ventilation during laparoscopic surgery. The purpose of the review is to summarise the consequences of pneumoperitoneum on the standard monitoring of mechanical ventilation during anaesthesia and to discuss the rationale of using a protective ventilation strategy during laparoscopic surgery. The consequences of chest wall derangement occurring during pneumoperitoneum on airway pressure and central venous pressure, together with the role of end-tidal-CO2 monitoring are emphasised. Ventilatory and non-ventilatory strategies to protect the lung are discussed.

Assessing unmet anaesthesia need in Sierra Leone: a secondary analysis of a cluster-randomized, cross-sectional, countrywide survey.

PubMed

Harris, Mark J; Kamara, Thaim B; Hanciles, Eva; Newberry, Cynthia; Junkins, Scott R; Pace, Nathan L

2015-09-01

To determine the unmet anaesthesia need in a low resource region. Surgery and anæsthesia services in low- and middle-income countries (LMICs) are under-equipped, under-staffed, and unable to meet current surgical need. There is little objective measure as to the true extent and nature of unmet need. Without such an understanding it is impossible to formulate solutions. Therefore, we re-examined Surgeons OverSeas (SOSAS) unmet surgical need data to extrapolate unmet anaesthesia need. For the untreated surgical conditions identified by SOSAS, we assigned anaesthetic technique required to carry out the procedure. The chosen anaesthetic was based on common practice in the region. Procedures were categorized into minimal anaesthesia, spinal anæsthesia, regional anaesthesia, ketamine/monitored anaesthesia care (MAC), and general endotracheal anæsthesia (GETA). Ninety-two per cent (687 of 745) of untreated surgical conditions in Sierra Leone would require some form of anaesthesia. Seventeen per cent (125 of 745) would require MAC, 22% (167 of 745) would require spinal anaesthesia, and 53% (395 of 745) would require GETA. Analyses such as this can provide guidance as to the rational and efficient production and distribution of personnel, drugs and equipment.

[Surgical treatment of children with brachial plexus paralysis].

PubMed

Grossman, J A; Ramos, L E; Tidwell, M; Price, A; Papazian, O; Alfonso, I

1998-08-01

A variety of surgical procedures exist for early repair of the nerve injury in obstetrical brachial plexus palsy, including neuroma excision and nerve grafting, neurolysis and neurotization. Secondary deformities of the shoulder, forearm, and hand can similarly be reconstructed using soft tissue and skeletal procedures. This review describes our surgical approach to maximize the ultimate functional outcome in infants and children with obstetrical brachial plexus palsy.

Preoperative Screening.

PubMed

Marwell, Julianna G; Heflin, Mitchell T; McDonald, Shelley R

2018-02-01

Older adults undergoing elective surgical procedures suffer higher rates of morbidity and mortality than younger patients. A geriatric-focused preoperative evaluation can identify risk factors for complications and opportunities for health optimization and care coordination. Key components of a geriatric preoperative evaluation include (1) assessments of function, mobility, cognition, and mental health; (2) reviews of medical conditions and medications; and (3) discussion of risks, preferences, and goals of care. A geriatric-focused, team-based approach can improve surgical outcomes and patient experience. Published by Elsevier Inc.

Meniere's disease: A surgeon's tactics

NASA Technical Reports Server (NTRS)

Soldatov, I.

1980-01-01

Surgical procedures for treating Meniere's disease are discussed. Based on the results of 250 operations, it is concluded that interventions are sufficiently effective not only with vestibular dysfunction, but also with hearing disorders. In surgical treatment of Meniere's disease, it is expedient to adhere to by-stage tactics: to start with the simplest and least traumatic interventions - operations on the nerves of the tympanic cavity, and if these are ineffective to use more complex methods, including drainage or shunting of the endolymphatic sac.

Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008.

PubMed

Wright, Tina I; Baddour, Larry M; Berbari, Elie F; Roenigk, Randall K; Phillips, P Kim; Jacobs, M Amanda; Otley, Clark C

2008-09-01

Antibiotic prophylaxis is an important component of dermatologic surgery, and recommendations in this area should reflect the updated 2007 guidelines of the American Heart Association, the American Dental Association with the American Academy of Orthopaedic Surgeons guidelines, and recent prospective studies on surgical site infection. To provide an update on the indications for antibiotic prophylaxis in dermatologic surgery for the prevention of infective endocarditis, hematogenous total joint infection, and surgical site infection. A literature review was performed, expert consensus was obtained, and updated recommendations were created, consistent with the most current authoritative guidelines from the American Heart Association and the American Dental Association with the American Academy of Orthopaedic Surgeons. For patients with high-risk cardiac conditions, and a defined group of patients with prosthetic joints at high risk for hematogenous total joint infection, prophylactic antibiotics are recommended when the surgical site is infected or when the procedure involves breach of the oral mucosa. For the prevention of surgical site infections, antibiotics may be indicated for procedures on the lower extremities or groin, for wedge excisions of the lip and ear, skin flaps on the nose, skin grafts, and for patients with extensive inflammatory skin disease. These recommendations are not based on multiple, large-scale, prospective trials. There is a strong shift away from administration of prophylactic antibiotics in many dermatologic surgery settings, based on updated authoritative guidelines. These recommendations provide guidance to comply with the most current guidelines, modified to address dermatology-specific considerations. Managing physicians may utilize these guidelines while individualizing their approach based on all clinical considerations.

Elective ambulatory surgical care in Ireland-why it needs to be better coded, classified and managed.

PubMed

Keane, Frank; Hammond, Laura; Kelliher, Gerry; Mealy, Ken

2017-12-12

In the year to July 2017, surgical disciplines accounted for 73% of the total national inpatient and day case waiting list and, of these, day cases accounted for 72%. Their proper classification is therefore important so that patients can be managed and treated in the most suitable and efficient setting. We set out to sub-classify the different elective surgical day cases treated in Irish public hospitals in order to assess their need to be managed as day cases and the consistency of practice between hospitals. We analysed all elective day cases that came under the care of surgeons between January 2014 and December 2016 and sub-classified them into those that were (A) true day case surgical procedures; (B) minor surgery or outpatient procedures; (C) gastrointestinal endoscopies; (D) day case, non-surgical interventions and (E) unclassified or having no primary procedure identified. Of 813,236 day case surgical interventions performed over 3 years, 26% were adjudged to accord with group A, 41% with B, 23% with C, 5% with D and 5% with E. The ratio of A to B procedures did not vary significantly across the range of hospital types. However, there were some notable variations in coding and practices between hospitals. Our findings show that many day cases should have been performed as outpatient procedures and that there were variations in coding and practices between hospitals that could not be easily explained. Outpatient procedure coding and a better, more consistent, classification of day cases are both required to better manage this group of patients.

Supportive psychotherapy or client education alongside surgical procedures to correct complications of female genital mutilation: A systematic review.

PubMed

Abayomi, Olukayode; Chibuzor, Moriam T; Okusanya, Babasola O; Esu, Ekpereonne; Odey, Edward; Meremikwu, Martin M

2017-02-01

Supportive psychotherapy, in individual or group settings, may help improve surgical outcomes for women and girls living with female genital mutilation (FGM). To assess whether supportive psychotherapy given alongside surgical procedures to correct complications of FGM improves clinical outcomes. We searched major databases including CENTRAL, Medline, African Index Medicus, SCOPUS, PsycINFO, and others. There were no language restrictions. We checked the reference lists of retrieved studies for additional reports of relevant studies. We included studies of girls and women living with any type of FGM who received supportive psychotherapy or client education sessions alongside any surgical procedure to correct health complications from FGM. Two team members independently screened studies for eligibility. There were no eligible studies identified. There is no direct evidence for the benefits or harms of supportive psychotherapy alongside surgical procedures for women and girls living with FGM. Research evidence is urgently needed to guide clinical practice. 42015024639. © 2017 International Federation of Gynecology and Obstetrics. The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.

General surgery graduates may be ill prepared to enter rural or community surgical practice.

PubMed

Gillman, Lawrence M; Vergis, Ashley

2013-06-01

Rural/community surgery presents unique challenges to general surgeons. Not only are they required to perform "classic" general surgery procedures, but they are also often expected to be competent in other surgical disciplines. Final-year Canadian-trained residents in general surgery were asked to complete the survey. The survey explored chief residents' career plans for the following year and whether or not they would independently perform various procedures, some general surgical, and others now considered within the domain of the subspecialties. Sixty-four residents (71%) completed the survey. Twenty percent planned to undertake a rural surgical practice, 17% an urban community practice, and 55% had confirmed fellowships. Most residents (>90%) expressed comfort with basic general surgical procedures. However, residents were less comfortable with subspecialty procedures that are still performed by general surgeons in many rural practices. More than half of graduating general surgery residents are choosing subspecialty fellowship training over proceeding directly to practice. Those choosing a rural or community practice are likely to feel ill prepared to replace existing surgeons. Copyright © 2013 Elsevier Inc. All rights reserved.

Establishment of Next-Generation Neurosurgery Research and Training Laboratory with Integrated Human Performance Monitoring.

PubMed

Bernardo, Antonio

2017-10-01

Quality of neurosurgical care and patient outcomes are inextricably linked to surgical and technical proficiency and a thorough working knowledge of microsurgical anatomy. Neurosurgical laboratory-based cadaveric training is essential for the development and refinement of technical skills before their use on a living patient. Recent biotechnological advances including 3-dimensional (3D) microscopy and endoscopy, 3D printing, virtual reality, surgical simulation, surgical robotics, and advanced neuroimaging have proved to reduce the learning curve, improve conceptual understanding of complex anatomy, and enhance visuospatial skills in neurosurgical training. Until recently, few means have allowed surgeons to obtain integrated surgical and technological training in an operating room setting. We report on a new model, currently in use at our institution, for technologically integrated surgical training and innovation using a next-generation microneurosurgery skull base laboratory designed to recreate the setting of a working operating room. Each workstation is equipped with a 3D surgical microscope, 3D endoscope, surgical drills, operating table with a Mayfield head holder, and a complete set of microsurgical tools. The laboratory also houses a neuronavigation system, a surgical robotic, a surgical planning system, 3D visualization, virtual reality, and computerized simulation for training of surgical procedures and visuospatial skills. In addition, the laboratory is equipped with neurophysiological monitoring equipment in order to conduct research into human factors in surgery and the respective roles of workload and fatigue on surgeons' performance. Copyright © 2017 Elsevier Inc. All rights reserved.

Sedation with intranasal midazolam of Angolan children undergoing invasive procedures.

PubMed

Kawanda, Lumana; Capobianco, Ivan; Starc, Meta; Felipe, Daniel; Zanon, Davide; Barbi, Egidio; Munkela, Nadine; Rodrigues, Verónica; Malundo, Lúis; Not, Tarcisio

2012-07-01

Ambulatory surgery is a daily requirement in poor countries, and limited means and insufficient trained staff lead to the lack of attention to the patient's pain. Midazolam is a rapid-onset, short-acting benzodiazepine which is used safely to reduce pain in children. We evaluated the practicability of intranasal midazolam sedation in a suburban hospital in Luanda (Angola), during the surgical procedures. Intranasal midazolam solution was administered at a dose of 0.5 mg/kg. Using the Ramsay's reactivity score, we gave a score to four different types of children's behaviour: moaning, shouting, crying and struggling, and the surgeon evaluated the ease of completing the surgical procedure using scores from 0 (very easy) to 3 (managing with difficulty). Eighty children (median age, 3 years) were recruited, and 140 surgical procedures were performed. Fifty-two children were treated with midazolam during 85 procedures, and 28 children were not treated during 55 procedures. We found a significant difference between the two groups on the shouting, crying and struggling parameters (p < 0.001). The mean score of the ease of completing the procedures was significantly different among the two groups (p < 0.0001). These results provide a model of procedural sedation in ambulatory surgical procedures in poor countries, thus abolishing pain and making the surgeon's job easier. © 2012 The Author(s)/Acta Paediatrica © 2012 Foundation Acta Paediatrica.

Robotic Whipple Procedure for Pancreatic Cancer: The Moffitt Cancer Center Pathway.

PubMed

Rashid, Omar M; Mullinax, John E; Pimiento, Jose M; Meredith, Kenneth L; Malafa, Mokenge P

2015-07-01

Resection of malignancies in the head and uncinate process of the pancreas (Whipple procedure) using a robotic approach is emerging as a surgical option. Although several case series of the robotic Whipple procedure have been reported, detailed descriptions of operative techniques and a clear pathway for adopting this technology are lacking. We present a focused review of the procedure as it applies to pancreatic cancer and describe our clinical pathway for the robotic Whipple procedure used in pancreatic cancer and review the outcomes of our early experience. A systematic review of the literature is provided, focusing on the indications, variations in surgical techniques, complications, and oncological results of the robotic Whipple procedure. A clinical pathway has been defined for preoperative training of surgeons, the requirements for hospital privileges, patient selection, and surgical techniques for the robotic Whipple procedure. The robotic technique for managing malignant lesions of the pancreas head is safe when following well-established guidelines for adopting the technology. Preliminary data demonstrate that perioperative convalescence may exceed end points when compared with the open technique. The robotic Whipple procedure is a minimally invasive approach for select patients as part of multidisciplinary management of periampullary lesions in tertiary centers where clinicians have developed robotic surgical programs. Prospective trials are needed to define the short- and long-term benefits of the robotic Whipple procedure.

[Surgical techniques in liver transplantation].

PubMed

Chan, Carlos; Plata-Muñoz, Juan José; Franssen, Bernardo

2005-01-01

Liver transplantation (LT) is probably the biggest surgical aggression that a patient can endure. It was considered only as a last option in the era of experimental LT, yet it evolved into the definitive treatment for some types of acute and chronic end stage liver disease. In terms of technique LT is the most complex of all types of transplantations. The surgical procedure in itself is well established and has changed little through time. Liver transplantation owes its improvement to better and more systematic anesthetic procedures and to perioperative care more than being due to improvement of the surgical technique. The first surgical procedure was described by Thomas Starzl in 1969. His initial work has been strengthened with the development of venous bypass, the refinement in vascular and biliary reconstruction technique and the development of the split liver. Up to date technical aspects of orthotopic liver transplantation are described in the present article.

The Utilization of Rehabilitation in Patients with Hemophilia A in Taiwan: A Nationwide Population-Based Study

PubMed Central

Yang, Yao-Hsu; Chang, Chia-Hao; Chen, Chih-Cheng; Chen, Pau-Chung

2016-01-01

Introduction Rehabilitation plays an important role in the physical health of patients with hemophilia. However, comprehensive information regarding the utilization of rehabilitation for such patients remains scarce. Aim This population-based study aimed to examine the characteristics, trends, and most important factors affecting rehabilitation usage in patients with hemophilia A using a nationwide database in Taiwan. Methods Data from 777 patients with hemophilia A who were registered in the National Health Insurance Research Database between 1998 and 2008 were analyzed using SAS 9.0. Results Musculoskeletal or nervous system-related surgical procedures and clotting factor VIII concentrate costs were identified as factors affecting rehabilitation usage; musculoskeletal or nervous system-related surgical procedures (odds ratio = 3.788; P < 0.001) were the most important predictor of whether a patient with hemophilia A would use rehabilitation services. Joint disorders, arthropathies, bone and cartilage disorders, intracranial hemorrhage, and brain trauma were common diagnoses during rehabilitation use. The costs of physical therapy (physiotherapy) comprised the majority (71.2%) of rehabilitation therapy categories. Increasingly, rehabilitation therapy was performed at physician clinics. The total rehabilitation costs were <0.1% of the total annual medical costs. Conclusion Musculoskeletal or nervous system-related surgical procedures and increased use of clotting factor VIII concentrate affect the rehabilitation utilization of patients with hemophilia A the most. The findings in this study could help clinicians comprehensively understand the rehabilitation utilization of patients with hemophilia A. PMID:27690229

[Clinical study on vocal cords spontaneous rehabilitation after CO2 laser surgery].

PubMed

Zhang, Qingxiang; Hu, Huiying; Sun, Guoyan; Yu, Zhenkun

2014-10-01

To study the spontaneous rehabilitation and phonation quality of vocal cords after different types of CO2 laser microsurgery. Surgical procedures based on Remacle system Type I, Type II, Type III, Type IV and Type V a respectively. Three hundred and fifteen cases with hoarseness based on strobe laryngoscopy results were prospectively assigned to different group according to vocal lesions apperence,vocal vibration and imaging of larynx CT/MRI. Each group holded 63 cases. The investigation included the vocal cords morphological features,the patients' subjective feelings and objective results of vocal cords. There are no severe complications for all patients in perioperative period. Vocal scar found in Type I ,1 case; Type II, 9 cases ;Type III, 47 cases; Type IV, 61 cases and Type Va 63 cases respectively after surgery. The difference of Vocal scar formation after surgery between surgical procedures are statistical significance (χ2 = 222.24, P < 0.05). Hoarseness improved after the surgery in 59 cases of Type I , 51 cases of Type II, 43 cases of Type III, 21 cases of Type IV and 17 cases of Type Va. There are statistically significance (χ2 = 89.46, P < 0.05) between different surgical procedures. The parameters of strobe laryngoscope: there are statistical significance on jitter between procedures (F 44.51, P < 0.05), but without difference within Type I and Type II (P > 0.05). This happened in shimmer parameter and the maximum phonation time (MPT) as jitter. There are no statistical significance between Type IV and Type Va on MPT (P > 0.05). Morphological and functional rehabilitation of vocal cord will be affected obviously when the body layer is injured. The depth and range of the CO2 laser microsurgery are the key factors affecting the vocal rehabilitation.

Medical Abortion Provided by Nurse-Midwives or Physicians in a High Resource Setting: A Cost-Effectiveness Analysis.

PubMed

Sjöström, Susanne; Kopp Kallner, Helena; Simeonova, Emilia; Madestam, Andreas; Gemzell-Danielsson, Kristina

2016-01-01

The objective of the present study is to calculate the cost-effectiveness of early medical abortion performed by nurse-midwifes in comparison to physicians in a high resource setting where ultrasound dating is part of the protocol. Non-physician health care professionals have previously been shown to provide medical abortion as effectively and safely as physicians, but the cost-effectiveness of such task shifting remains to be established. A cost effectiveness analysis was conducted based on data from a previously published randomized-controlled equivalence study including 1180 healthy women randomized to the standard procedure, early medical abortion provided by physicians, or the intervention, provision by nurse-midwifes. A 1.6% risk difference for efficacy defined as complete abortion without surgical interventions in favor of midwife provision was established which means that for every 100 procedures, the intervention treatment resulted in 1.6 fewer incomplete abortions needing surgical intervention than the standard treatment. The average direct and indirect costs and the incremental cost-effectiveness ratio (ICER) were calculated. The study was conducted at a university hospital in Stockholm, Sweden. The average direct costs per procedure were EUR 45 for the intervention compared to EUR 58.3 for the standard procedure. Both the cost and the efficacy of the intervention were superior to the standard treatment resulting in a negative ICER at EUR -831 based on direct costs and EUR -1769 considering total costs per surgical intervention avoided. Early medical abortion provided by nurse-midwives is more cost-effective than provision by physicians. This evidence provides clinicians and decision makers with an important tool that may influence policy and clinical practice and eventually increase numbers of abortion providers and reduce one barrier to women's access to safe abortion.

Major and Minor Classifications for Surgery in People With Hemophilia: A Literature Review.

PubMed

Solimeno, Luigi Piero; Escobar, Miguel A; Krassova, Snejana; Seremetis, Stephanie

2018-05-01

Agents that control bleeding and the usage of bypassing agents have made surgery an option to consider in people with hemophilia. However, the lack of consistent definitions for major or minor surgery may lead to inconsistencies in patient management. This literature review has evaluated how surgical procedures in people with hemophilia were categorized as major or minor surgery and assessed the consistency across publications. After screening 926 potentially relevant articles, 547 were excluded and 379 full-text articles were reviewed. Ninety-five articles categorized major or minor surgical procedures; of these, 35 publications categorized three or more major or minor surgical procedures and were included for analysis. Seven (20%) publications provided varying criteria for defining major or minor surgery, five of which defined surgery according to the level of surgical invasiveness. Across all 35 publications, there was considerable variance in the categorization of major and minor surgical procedures and some overlap in surgical nomenclature (eg, type of synovectomy, arthroscopy, and central venous access device insertion/removals). The lack of consistent guidance when referring to major or minor surgery in people with hemophilia needs to be addressed. Clear and consistent definitions, achieved by consensus and promoted by relevant international hemophilia committees, are desirable, to provide guidance on appropriate treatment, to increase the accuracy of trial data and may confound the interpretation of surgical outcomes.

Surgical team turnover and operative time: An evaluation of operating room efficiency during pulmonary resection.

PubMed

Azzi, Alain Joe; Shah, Karan; Seely, Andrew; Villeneuve, James Patrick; Sundaresan, Sudhir R; Shamji, Farid M; Maziak, Donna E; Gilbert, Sebastien

2016-05-01

Health care resources are costly and should be used judiciously and efficiently. Predicting the duration of surgical procedures is key to optimizing operating room resources. Our objective was to identify factors influencing operative time, particularly surgical team turnover. We performed a single-institution, retrospective review of lobectomy operations. Univariate and multivariate analyses were performed to evaluate the impact of different factors on surgical time (skin-to-skin) and total procedure time. Staff turnover within the nursing component of the surgical team was defined as the number of instances any nurse had to leave the operating room over the total number of nurses involved in the operation. A total of 235 lobectomies were performed by 5 surgeons, most commonly for lung cancer (95%). On multivariate analysis, percent forced expiratory volume in 1 second, surgical approach, and lesion size had a significant effect on surgical time. Nursing turnover was associated with a significant increase in surgical time (53.7 minutes; 95% confidence interval, 6.4-101; P = .026) and total procedure time (83.2 minutes; 95% confidence interval, 30.1-136.2; P = .002). Active management of surgical team turnover may be an opportunity to improve operating room efficiency when the surgical team is engaged in a major pulmonary resection. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Systematic review of general thoracic surgery articles to identify predictors of operating room case durations.

PubMed

Dexter, Franklin; Dexter, Elisabeth U; Masursky, Danielle; Nussmeier, Nancy A

2008-04-01

Previous studies of operating room (OR) information systems data over the past two decades have shown how to predict case durations using the combination of scheduled procedure(s), individual surgeon and assistant(s), and type of anesthetic(s). We hypothesized that the accuracy of case duration prediction could be improved by the use of other electronic medical record data (e.g., patient weight or surgeon notes using standardized vocabularies). General thoracic surgery was used as a model specialty because much of its workload is elective (scheduled) and many of its cases are long. PubMed was searched for thoracic surgery papers reporting operative time, surgical time, etc. The systematic literature review identified 48 papers reporting statistically significant differences in perioperative times. There were multiple reports of differences in OR times based on the procedure(s), perioperative team including primary surgeon, and type of anesthetic, in that sequence of importance. All such detail may not be known when the case is originally scheduled and thus may require an updated duration the day before surgery. Although the use of these categorical data from OR systems can result in few historical data for estimating each case's duration, bias and imprecision of case duration estimates are unlikely to be affected. There was a report of a difference in case duration based on additional information. However, the incidence of the procedure for the diagnosis was so uncommon as to be unlikely to affect OR management. Matching findings of prior studies using OR information system data, multiple case series show that it is important to rely on the precise procedure(s), surgical team, and type of anesthetic when estimating case durations. OR information systems need to incorporate the statistical methods designed for small numbers of prior surgical cases. Future research should focus on the most effective methods to update the prediction of each case's duration as these data become available. The case series did not reveal additional data which could be cost-effectively integrated with OR information systems data to improve the accuracy of predicted durations for general thoracic surgery cases.

An improved method of electrode placement in configuration Lead II for the reliable ECG recording by telemetry in the conscious rat.

PubMed

Tontodonati, Marcello; Fasdelli, Nicola; Dorigatti, Roberto

2011-01-01

Telemetry represents the gold standard technique for the acquisition of animal haemodynamic signals in the pharmaceutical preclinical development of new chemical entities. In terms of electrocardiographic signal recording, the quality is well established in large animals, mainly dog, non human primates and minipig, whereas it is still lacking in terms of satisfactory results in rodents (mouse and rat in particular). In very recent times, an increasing interest in early safety prediction for the reduction of cardiovascular attrition has been raised in all the major pharmaceutical companies, focusing in particular, on in vivo models. Crl:CD(SD) and Wistar Han rats (Crl:WI[Han], Charles River) underwent surgery for the implantation of telemetry devices (Data Science International, USA) for the acquisition of blood pressure and electrocardiogram (ECG). A group of male CD rats (N=6) was implanted using the standard procedure as described by DSI technical documentation; another male CD group (N=3) was implanted using the technique described by Sgoifo et al. (1996); a third group (total of N=46, N=26 male CD rats, and N=10 male WI and N=10 female WI) was implanted using an alternative approach developed in our laboratory. The new surgical procedure was analysed based on technical difficulties, time to complete the surgery, time to recover, animal care, survival time after surgery and quality of telemetry signal recordings. Although a quantitative and qualitative comparison with other techniques described in literature was beyond the scope of the present work, based on our laboratory experience, Sgoifo's methodology showed better results compared to DSI standard approach, but surgical procedure was not easy to perform and more invasive. The novel approach described in the present paper was characterised by simplicity, repeatability, high rate of survival and improved quality of ECG signals for all the implanted rats. Telemetry in small rodents became of particular interest in the early safety assessment of cardiovascular liability during the development of new chemical entities. Although several surgical procedures are well described in literature, none seem to offer high standard electrocardiography signals in order to reliably detect intervals or arrhythmias. In the Safety Pharmacology Laboratory at GlaxoSmithKline, Verona (Italy), a novel and alternative surgical placement of the electrocardiographic electrodes in Lead II configuration was developed, in the rat. The scope of the present paper is to illustrate that this alternative surgical procedure is easily reproducible, minimally invasive and gives high standard quality ECG signals. Copyright © 2010 Elsevier Inc. All rights reserved.

Treatment Patterns for Cervical Carcinoma In Situ in Michigan, 1998-2003

PubMed Central

Patel, Divya A.; Saraiya, Mona; Copeland, Glenn; Cote, Michele L.; Datta, S. Deblina; Sawaya, George F.

2015-01-01

Objective To characterize population-level surgical treatment patterns for cervical carcinoma in situ (CIS) reported to the Michigan Cancer Surveillance Program (MCSP), and to inform data collection strategies. Methods All cases of cervical carcinoma in situ (CIS) (including cervical intraepithelial neoplasia grade 3 and adenocarcinoma in situ [AIS]) reported to the MCSP during 1998–2003 were identified. First course of treatment (ablative procedure, cone biopsy, loop electrosurgical excisional procedure [LEEP], hysterectomy, unspecified surgical treatment, no surgical treatment, unknown if surgically treated) was described by histology, race, and age at diagnosis. Results Of 17,022 cases of cervical CIS, 82.8% were squamous CIS, 3% AIS/adenosquamous CIS, and 14.2% unspecified/other CIS. Over half (54.7%) of cases were diagnosed in women under age 30. Excisional treatments (LEEP, 32.3% and cone biopsy, 17.3%) were most common, though substantial proportions had no reported treatment (17.8%) or unknown treatment (21.1%). Less common were hysterectomy (7.2%) and ablative procedures (2.6%). LEEP was the most common treatment for squamous cases, while hysterectomy was the most treatment for AIS/adenosquamous CIS cases. Across histologic types, a sizeable proportion of women diagnosed ≤30 years of age underwent excision, either LEEP (20%–38.7%) or cone biopsy (13.7%–44%). Conclusion Despite evidence suggesting it may be safer and equally effective as excision, ablation was rarely used for treating cervical squamous CIS. These population-based data indicate some notable differences in treatment by histology and age at diagnosis, with observed patterns appearing consistent with consensus guidelines in place at the time of study, but favoring more aggressive procedures. Future data collection strategies may need to validate treatment information, including the large proportion of no or unknown treatment. PMID:24002133

[Surgical smoke: risks and preventive measures].

PubMed

Carbajo-Rodríguez, Hilario; Aguayo-Albasini, José Luis; Soria-Aledo, Víctor; García-López, Concepción

2009-05-01

The application of the advanced technologies in medicine has led to the appearance of new risk factors for health personnel. One of these could be the surgical smoke produced by electrosurgical instruments, ultrasounds or laser. However, there is still insufficient evidence in the published population studies on the detrimental effects of chronic exposure to surgical smoke. The main concern on the possible damage to the health of operating room staff is mainly based on the components currently detected until the date and laboratory experiments. Caution must also be used when extrapolating the results of in vitro studies to daily clinical practice. The organisations responsible for protecting the health of the workers in different countries have still not issued guidelines for the treatment and removal of the surgical smoke generated in both open and laparoscopic procedures. In this article we try to present a view of the consequences that surgical smoke has on health and the preventive measures that can be adopted.

[Estimation of surgical treatment capacity for managing mass casualty incidents based on time needed for life-saving emergency operations].

PubMed

Kanz, K-G; Huber-Wagner, S; Lefering, R; Kay, M; Qvick, M; Biberthaler, P; Mutschler, W

2006-04-01

The surgical treatment capacity of a hospital constitutes a significant restriction in the capability to deal with critically injured patients from multiple or mass casualty incidents (MCI). With regard to the time needed for life-saving operative interventions there are no basic reference values available in the literature, which can aid in detailed planning for management of mass casualty incidents. The data of 20,815 trauma patients, recorded in the trauma registry hosted by the German Association for Trauma Surgery DGU, were analyzed to extract the median duration of life-saving surgical interventions carried out in an operating theatre. Inclusion criteria were an ISS > or = 16 and the performance of relevant ICPM coded procedures within 6 h after trauma room admission. Orthopedic procedures as well as the placement of ICP catheters and chest tubes or performance of laparoscopies were not included. Complete data sets with the required variables were available from 9,988 trauma patients with an ISS > or = 16, and included 7,907 interventions that took place within 6 h after hospital admission. From among 1,228 patients 1,793 operations could be identified as relevant life-saving emergency operations. Acute injury to the abdomen was the major cause accounting for 54.1% of all emergency surgical procedures with a median intervention duration of 137 min followed by head injuries accounting for 26.3% with a median duration of 110 min. Interventions in the pelvis amounted to 11.5% taking an average of 136 min, 5.0% were in the thorax requiring 91 min and 3.1% major amputations with 142 min. The average cut to suture time for all emergency surgical interventions was 130 min. A prerequisite for estimating the surgical operation capacity for critically injured patients of an MCI is the number of OR teams available during and outside of the normal working hours of the hospital. The average operation time of 130 min calculated from investigation of 1,793 emergency life-saving surgical procedures provides a realistic guideline. Used in combination with the number of available OR teams the prospective treatment capacity can be estimated and projected into an actual incident admission capacity. The identification and numerical value of such significant variables are the basis for operations research and realistic planning in emergency and disaster medicine.

Traumatic Extensor Tendon Injuries to the Hand: Clinical Anatomy, Biomechanics, and Surgical Procedure Review.

PubMed

Colzani, Giulia; Tos, Pierluigi; Battiston, Bruno; Merolla, Giovanni; Porcellini, Giuseppe; Artiaco, Stefano

2016-04-01

The extensor apparatus is a complex muscle-tendon system that requires integrity or optimal reconstruction to preserve hand function. Anatomical knowledge and the understanding of physiopathology of extensor tendons are essential for an accurate diagnosis of extensor tendon injuries (ETIs) of the hand and wrist, because these lesions are complex and commonly observed in clinical practice. A careful clinical history and assessment still remain the first step for the diagnosis, followed by US and MR to confirm the suspect of ETI or to investigate some doubtful conditions and rule out associate lesions. During last decades the evolution of surgical techniques and rehabilitative treatment protocol led to gradual improvement in clinical results of ETI treatment and surgical repair. Injury classification into anatomical zones and the evaluation of the characteristics of the lesions are considered key points to select the appropriate treatment for ETI. Both conservative and surgical management can be indicated in ETI, depending on the anatomical zone and on the characteristics of the injuries. As a general rule, an attempt of conservative treatment should be performed when the lesion is expected to have favorable result with nonoperative procedure. Many surgical techniques have been proposed over the time and with favorable results if the tendon injury is not underestimated and adequately treated. Despite recent research findings, a lack of evidence-based knowledge is still observed in surgical treatment and postoperative management of ETI. Further clinical and biomechanical investigations would be advisable to clarify this complex issue.

Traumatic Extensor Tendon Injuries to the Hand: Clinical Anatomy, Biomechanics, and Surgical Procedure Review

PubMed Central

Colzani, Giulia; Tos, Pierluigi; Battiston, Bruno; Merolla, Giovanni; Porcellini, Giuseppe; Artiaco, Stefano

2016-01-01

The extensor apparatus is a complex muscle-tendon system that requires integrity or optimal reconstruction to preserve hand function. Anatomical knowledge and the understanding of physiopathology of extensor tendons are essential for an accurate diagnosis of extensor tendon injuries (ETIs) of the hand and wrist, because these lesions are complex and commonly observed in clinical practice. A careful clinical history and assessment still remain the first step for the diagnosis, followed by US and MR to confirm the suspect of ETI or to investigate some doubtful conditions and rule out associate lesions. During last decades the evolution of surgical techniques and rehabilitative treatment protocol led to gradual improvement in clinical results of ETI treatment and surgical repair. Injury classification into anatomical zones and the evaluation of the characteristics of the lesions are considered key points to select the appropriate treatment for ETI. Both conservative and surgical management can be indicated in ETI, depending on the anatomical zone and on the characteristics of the injuries. As a general rule, an attempt of conservative treatment should be performed when the lesion is expected to have favorable result with nonoperative procedure. Many surgical techniques have been proposed over the time and with favorable results if the tendon injury is not underestimated and adequately treated. Despite recent research findings, a lack of evidence-based knowledge is still observed in surgical treatment and postoperative management of ETI. Further clinical and biomechanical investigations would be advisable to clarify this complex issue. PMID:27616821

Standard operating procedures for vascular surgery in erectile dysfunction: revascularization and venous procedures.

PubMed

Sohn, Michael; Hatzinger, Martin; Goldstein, Irwin; Krishnamurti, Sudhakar

2013-01-01

The impact of penile blood supply on erectile function was recognized some 500 years ago. At the turn of the 20th century first results of penile venous ligation were published and in 1973 the first surgical attempts to restore penile arterial inflow were undertaken. Numerous techniques were published in the meantime, but inclusion criteria, patient selection, and success evaluation differed extremely between study groups. To develop evidence-based standard operating procedures (SOPs) for vascular surgery in erectile dysfunction, based on recent state of the art consensus reports and recently published articles in peer-reviewed journals. Based on the recent publication of the consensus process during the 2009 International Consultation on Sexual Medicine in Paris, recommendations are derived for diagnosis and surgical treatment of vascular erectile dysfunction. In addition several recent publications in this field not mentioned in the consensus statements are included in the discussion. The Oxford system of evidence-based review was systematically applied. Due to the generally low level of evidence in this field expert opinions were accepted, if published after a well-defined consensus process in peer-reviewed journals. Referring to penile revascularization it may be concluded, that in the face of missing randomized trials, only recommendations grade D may be given: this kind of surgery may be offered to men less than 55 years, who are nonsmokers, nondiabetic, and demonstrate isolated arterial stenoses in the absence of generalized vascular disease. The evidence level for recommendations concerning penile venous ligations may be even lower. Too many unsolved controversies exist and universal diagnostic criteria for patient selection as well as operative technique selection have not been unequivocally established. This kind of surgery is still considered investigational but may be offered in special situations on an individualized basis in an investigational or research setting after obtaining written consent, using both pre- and postoperatively validated measuring instruments of success evaluation. SOPs for penile revascularization procedures can be developed, concerning a highly selected patient group with isolated arterial stenoses. Based on the available data it is not yet possible to define SOPs for surgical treatment of corporal veno-occlusive dysfunction. © 2012 International Society for Sexual Medicine.

Designing safety into the minimally invasive surgical revolution: a commentary based on the Jacques Perissat Lecture of the International Congress of the European Association for Endoscopic Surgery.

PubMed

Clarke, John R

2009-01-01

Surgical errors with minimally invasive surgery differ from those in open surgery. Perforations are typically the result of trocar introduction or electrosurgery. Infections include bioburdens, notably enteric viruses, on complex instruments. Retained foreign objects are primarily unretrieved device fragments and lost gallstones or other specimens. Fires and burns come from illuminated ends of fiber-optic cables and from electrosurgery. Pressure ischemia is more likely with longer endoscopic surgical procedures. Gas emboli can occur. Minimally invasive surgery is more dependent on complex equipment, with high likelihood of failures. Standardization, checklists, and problem reporting are solutions for minimizing failures. The necessity of electrosurgery makes education about best electrosurgical practices important. The recording of minimally invasive surgical procedures is an opportunity to debrief in a way that improves the reliability of future procedures. Safety depends on reliability, designing systems to withstand inevitable human errors. Safe systems are characterized by a commitment to safety, formal protocols for communications, teamwork, standardization around best practice, and reporting of problems for improvement of the system. Teamwork requires shared goals, mental models, and situational awareness in order to facilitate mutual monitoring and backup. An effective team has a flat hierarchy; team members are empowered to speak up if they are concerned about problems. Effective teams plan, rehearse, distribute the workload, and debrief. Surgeons doing minimally invasive surgery have a unique opportunity to incorporate the principles of safety into the development of their discipline.

Handling topological changes during elastic registration : Application to augmented reality in laparoscopic surgery.

PubMed

Paulus, Christoph J; Haouchine, Nazim; Kong, Seong-Ho; Soares, Renato Vianna; Cazier, David; Cotin, Stephane

2017-03-01

Locating the internal structures of an organ is a critical aspect of many surgical procedures. Minimally invasive surgery, associated with augmented reality techniques, offers the potential to visualize inner structures, allowing for improved analysis, depth perception or for supporting planning and decision systems. Most of the current methods dealing with rigid or non-rigid augmented reality make the assumption that the topology of the organ is not modified. As surgery relies essentially on cutting and dissection of anatomical structures, such methods are limited to the early stages of the surgery. We solve this shortcoming with the introduction of a method for physics-based elastic registration using a single view from a monocular camera. Singularities caused by topological changes are detected and propagated to the preoperative model. This significantly improves the coherence between the actual laparoscopic view and the model and provides added value in terms of navigation and decision-making, e.g., by overlaying the internal structures of an organ on the laparoscopic view. Our real-time augmentation method is assessed on several scenarios, using synthetic objects and real organs. In all cases, the impact of our approach is demonstrated, both qualitatively and quantitatively ( http://www.open-cas.org/?q=PaulusIJCARS16 ). The presented approach tackles the challenge of localizing internal structures throughout a complete surgical procedure, even after surgical cuts. This information is crucial for surgeons to improve the outcome for their surgical procedure and avoid complications.

Radiofrequency-Based Identification Medical Device: An Evaluable Solution for Surgical Sponge Retrieval?

PubMed

Lazzaro, Alessandra; Corona, Arianna; Iezzi, Luca; Quaresima, Silvia; Armisi, Luca; Piccolo, Ilaria; Medaglia, Carlo Maria; Sbrenni, Sergio; Sileri, Pierpaolo; Rosato, Nicola; Gaspari, Achille Lucio; Di Lorenzo, Nicola

2017-06-01

A retained surgical item in patients (gossypiboma) is a persisting problem, despite consistent improvements and existing guidelines in counting instruments and sponges. Previous experiences with radiofrequency identification technology (RFID) tracking sponges show that it could represent an innovation, in order to reduce the criticism and increase the effectiveness during surgical procedures. We present an automated system that allows reduction of errors and improves safety in the operating room. The system consists of 3 antennas, surgical sponges containing RFID tags, and dedicated software applications, with Wi-Fi real-time communication between devices. The first antenna provides the initial count of gauzes; the second a real-time counting during surgery, including the sponges thrown into the kick-bucket; and the third can be used in the event of uneven sponge count. The software allows management at all stages of the process. In vitro and in vivo tests were performed: the system provided excellent results in detecting sponges in patients' body. Hundred percent retained sponges were detected correctly, even when they were overlapped. No false positive or false negative was recorded. The counting procedure turned out to be more streamlined and efficient and it could save time in a standard procedure. The RFID system for sponge tracking was shown to be experimentally a reliable and feasible method to track sponges with a full detection accuracy in the operating room. The results indicate the system to be safe and effective with acceptable cost-effective parameters.

[Strategies and surgical management of endometriosis: CNGOF-HAS Endometriosis Guidelines].

PubMed

Roman, H; Ballester, M; Loriau, J; Canis, M; Bolze, P A; Niro, J; Ploteau, S; Rubod, C; Yazbeck, C; Collinet, P; Rabischong, B; Merlot, B; Fritel, X

2018-03-01

The article presents French guidelines for surgical management of endometriosis. Surgical treatment is recommended for mild to moderate endometriosis, as it decreases pelvic painful complaints and increases the likelihood of postoperative conception in infertile patients (A). Surgery may be proposed in symptomatic patients with ovarian endometriomas which diameter exceeds 20mm. Cystectomy allows for better postoperative pregnancy rates when compared to ablation using bipolar current, as well as for lower recurrences rates when compared to ablation using bipolar current or CO 2 laser. Ablation of ovarian endometriomas using bipolar current is not recommended (B). Surgery may be employed in patients with deep endometriosis infiltrating the colon and the rectum, with good impact on painful complaints and postoperative conception. In these patients, laparoscopic route increases the likelihood of postoperative spontaneous conception when compared to open route. When compared to conservative rectal procedures (shaving or disc excision), segmental colorectal resection increases the risk of postoperative stenosis, requiring additional endoscopic or surgical procedures. In large deep endometriosis infiltrating the rectum (>20mm length of bowel infiltration), conservative rectal procedures do not improve postoperative digestive function when compared to segmental resection. In patients with bowel anastomosis, placing anti-adhesion agents on contact with bowel suture is not recommended, due to higher risk of bowel fistula (C). Various other recommendations are proposed in the text, however, they are based on studies with low level of evidence. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

Surgical treatment of obesity.

PubMed

Puzziferri, Nancy; Blankenship, Jeanne; Wolfe, Bruce M

2006-02-01

The surgical treatment of obesity has existed for over 50 yr. Surgical options have evolved from high-risk procedures infrequently performed, to safe, effective procedures increasingly performed. The operations used today provide significant durable weight loss, resolution or marked improvement of obesity-related comorbidities, and enhanced quality of life for the majority of patients. The effect of bariatric surgery on the neurohormonal regulation of energy homeostasis is not fully understood. Despite its effectiveness, less than 1% of obese patients are treated surgically. The perception that obesity surgery is unsafe remains a deterrent to care.

Voice tuning with new instruments for type II thyroplasty in the treatment of adductor spasmodic dysphonia.

PubMed

Sanuki, Tetsuji; Yumoto, Eiji; Toya, Yutaka; Kumai, Yoshihiko

2016-10-01

Adductor spasmodic dysphonia is a rare voice disorder characterized by strained and strangled voice quality with intermittent phonatory breaks and adductory vocal fold spasms. Type II thyroplasty differs from previous treatments in that this surgery does not involve any surgical intervention into the laryngeal muscle, nerve or vocal folds. Type II thyroplasty intervenes in the thyroid cartilage, which is unrelated to the lesion. This procedure, conducted with the aim of achieving lateralization of the vocal folds, requires utmost surgical caution due to the extreme delicacy of the surgical site, critically sensitive adjustment, and difficult procedures to maintain the incised cartilages at a correct position. During surgery, the correct separation of the incised cartilage edges with voice monitoring is the most important factor determining surgical success and patient satisfaction. We designed new surgical instruments: a thyroid cartilage elevator for undermining the thyroid cartilage, and spacer devices to gauge width while performing voice monitoring. These devices were designed to prevent surgical complications, and to aid in selecting the optimal size of titanium bridges while temporally maintaining a separation during voice monitoring. We designed new surgical instruments, including a thyroid cartilage elevator and spacer devices. Precise surgical procedures and performing voice tuning during surgery with the optimal separation width of the thyroid cartilage are key points for surgical success. We introduce the technique of voice tuning using these surgical tools in order to achieve a better outcome with minimal surgical complications. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Management of acute unstable acromioclavicular joint injuries.

PubMed

Cisneros, Luis Natera; Reiriz, Juan Sarasquete

2016-12-01

Surgical management of acute unstable acromioclavicular joint injuries should be focused on realigning the torn ends of the ligaments to allow for healing potential. The most widely utilized treatment methods incorporate the use of metal hardware, which can alter the biomechanics of the acromioclavicular joint. This leads to a second surgical procedure for hardware removal once the ligaments have healed. Patients with unstable acromioclavicular joint injuries managed with arthroscopy-assisted procedures have shown good and excellent clinical outcomes, without the need for a second operation. These procedures incorporate a coracoclavicular suspension device aimed to function as an internal brace, narrowing the coracoclavicular space thus allowing for healing of the torn coracoclavicular ligaments. The lesser morbidity of a minimally invasive approach and the possibility to diagnose and treat concomitant intraarticular injuries; no obligatory implant removal, and the possibility of having a straight visualization of the inferior aspect of the base of the coracoid (convenient when placing coracoclavicular fixation systems) are the main advantages of the arthroscopic approach over classic open procedures. This article consists on a narrative review of the literature in regard to the management of acute acromioclavicular joint instability.

“Reality Surgery” — A Research Ethics Perspective on the Live Broadcast of Surgical Procedures

PubMed Central

Williams, Judson B.; Mathews, Robin; D'Amico, Thomas A.

2013-01-01

In recent years, the live broadcasting of medical and surgical procedures has gained worldwide popularity. While the practice has appropriately been met with concerns for patient safety and privacy, many physicians tout the merits of real time viewing as a form of investigation, accelerating the process leading to adoption or abolition of newer techniques or technologies. This view introduces a new series of ethical considerations that need to be addressed. As such, this article considers, from a research ethics perspective, the use of live surgical procedure broadcast for investigative purposes. PMID:21292217