Flexible ureteropyeloscopy with modular, "disposable" endoscope

A flexible modular ureteropyeloscope has been utilized in 36 patients. The flexible tips of this instrument can be replaced and have been available in sizes 6.0F, 8.5F, and 11.0F. The instrument was passed successfully into the ureter in 37 of 38 patients. The most frequent indications were surveillance for fragments after lithotripsy and for diagnosis of radiographic abnormalities in the upper tracts. The high success rate in these patients supports wider application of these techniques and indicates the potential for therapeutic procedures through flexible ureteroscopes.     

The argon "contact" laser scalpel: technical considerations

The authors describe the use of a new contact argon laser scalpel designed specifically for hand-controlled cutting and hemostasis. This instrument delivers energy precisely to targeted tissue and produces minimal damage to adjacent healthy structures. Potential clinical applications are discussed.     

Measuring of the human body with the "Differentiometer" (author's transl)]

The "Differentiometer" is a handy instrument suitable for many measurements of the human body. Many important parts of the human body in their length, in their geometrical position and in their relation to each other can be measured on the lying as well as on the standing patient. Some of these measurements could not be done clinically until now. With these measurements investigation by X-ray sometimes can be spared.     

Instantaneous "video photography" with a low-cost black-and-white video printer: its value in otolaryngology and head and neck surgery

Despite its shortcomings in black-and-white imagery and its print quality, the video printer described here is an inexpensive and convenient video image-printing instrument and is useful for documentation of anatomy and pathologic conditions of otolaryngologic structures. It is of great value in patient counselling and in development of a permanent pictorial record.     

"Quality of life" for patients with end-stage renal failure

The assessment of health status and quality of life among chronically ill patients is an area of current scientific interest. This paper considers the utility of a short but comprehensive instrument to assess the quality of life for end-stage renal failure patients. the Spitzer QL-Index was completed by 8 nurses for all patients in the Wellington region currently being treated with home hemodialysis (n = 58); hospital hemodialysis (n = 13); and continuous ambulatory peritoneal dialysis (n = 37). Results indicated that home hemodialysis patients achieve the highest quality of life in comparison to the other two treatment modalities. It is concluded that the QL-Index has some discriminative validity for this patient population, and its use may contribute to informed decision making by both patients and doctors.     

"Wallstent" endo-urethral prosthesis in recurrent stenoses of the urethra

Urethral strictures recur in about 30% of the cases whatever the treatment. We describe a new urethral stent, originally developed in our Institution for vascular use after transluminal angioplasty. Since January 1986, we have controlled the biocompatibility and tolerance in the normal urethra of dogs with a one year follow-up. The stent has a braided structure, made of fine stainless steel wires and is self-expanding when released from a special endoscopic instrument. From November 1987, we have implanted the stent into 11 males (mean age 54 years), after previous urethrotomy. In two patients a second stent was implanted for incomplete result. Now, with a mean follow-up of 12 months, all patients have recovered normal micturition and only two complain slight stress incontinence.     

A "last ditch" airway.

In a patient whose airway is in jeopardy after unsuccessful attempts at conservative measures to clear it and after failed attempts at intubation, the intravenous tubing connector spike may be considered as an emergency percutaneous tracheostomy device. It is readily available wherever physicians have intravenous solutions at hand. It is inserted through the cricothyroid space with the help of a scalpel blade or other sharp instrument such as a pair of scissors. A severed spike can be as easily carried in a pocket, purse or medical bag as can an intravenous cannula. A number 11 scalpel blade fits neatly between two credit cards. The shape of the spike makes it fortuitously adaptable to intermittent positive pressure ventilation by mouth or standard resuscitation equipment. If the patient is otherwise well enough, it is of sufficient bore to allow spontaneous respiration. I have been fortunate not to have had the opportunity to use this device in an emergency situation as of the time of the submission of this paper.     

Pressure-controlled hydraulic dilation of the ureter: "one-step" ureteroscopy

A controlled pressure pump was used to dilate the ureteral orifice hydraulically with irrigant flow through the ureteroscope in 50 ureters in 48 patients. The method was successful in all but 1 patient, who had a dense, fibrotic intramural segment that required extensive ureteral meatotomy before the instrument could be inserted. All subsequent procedures (stone removal, relief of obstruction or diagnostic evaluation) were successful, and there were no cases of sepsis or signs of excessive intraureteral or intrapelvic pressure. Hydraulic dilation drastically reduced the time required for ureteroscopy and probably reduced the frequency of complications. Details of the technique and the precautions are provided.     

A new instrument,the "Perfore-Aspirator" for laparoscopic treatment of hydatid cysts of the liver

The authors introduce a new instrument functioning as both perforator and aspirator in the laparoscopic management of hepatic hydatid cysts. Between January 1998 and January 2002, 11 laparoscopic cystotomy + partial cystectomy + drainage procedures were performed for eight consecutive patients. Eight of the cysts were located in the right lobe, and the remaining three in the left. The average diameter (+/-SD) of the cysts was 9.6 +/- 3.66 cm, and the mean age of the patients was 31.3 +/- 7.24 years. The diagnosis was confirmed by ultrasonography and/or computerized tomography. The procedure was performed with the help of three ports. The "perfore-aspirator" instrument (Bahadir Tibbi Aletler A. S., Samsun, Turkey) was introduced through the 10-mm trocar at the subcostal area, and the cystotomy procedure was done with success. Then, a partial cystectomy procedure was performed with the use of a grasper and scissors attached to an electrocautery device. The average hospitalization period was 5 +/- 1.69 days. No major morbidity or mortality was seen. All patients were treated with albendazole preoperatively and postoperatively.     

Laparoscopic cholecystectomy and the "soft trocar".

We have devised a new "soft trocar" for laparoscopic surgery. This translucent trocar, made of silicon, has a flexible sleeve that permits a curved instrument to pass through. Eighteen patients underwent laparoscopic cholecystectomy with the use of the soft trocar. There were no complications related to its use. The soft trocar is useful during laparoscopic cholecystectomy because it is radiolucent, a curved forceps can be inserted, and it is potentially less traumatic to the abdominal viscera than a standard trocar.     

"Side table assembly"--an adjuvant to craniofacial reconstruction

Plates and screws are used extensively in craniofacial surgery; they have increased the speed of this surgery, but this can be made even more efficient. Utilising an adjacent instrument table, the rearrangement and reassembly of bone segments resulting from osteotomy or fracture can be performed by a second surgical team using plates and screws. At the conclusion of the operation, the reassembled bony reconstruction can rapidly be placed in position with a minimum of additional screws. This technique has been found to be technically easier and to afford a considerable saving of operating time.     

"Insitutom RC": a new instrument for valve incision in in-situ vein bypass

The "in situ" bypass technique was first used by Cartier in 1960. It has only slowly gained acceptance among vascular surgeons. In part this can be explained by the lack of an easy and reliable method to render vein valves incompetent. The instruments most widely used for this purpose have been developed by Hall, Gruss and Leather ("Valve Stripper", "Insitucut" and "Valve Cutter", respectively). Based on theoretical considerations and practical experience, we have developed a new instrument for the incision of vein valves: the Insitutom RC. Unlike other instruments, it allows rotation control of the cutting blade and thus enables the surgeon to incise the valve cusps more precisely and reliably.     

"Bidirectional tunneler": an improved tunneler and shunt instrument for vascular surgery

When autologous veins or vascular prostheses are implanted for bypass operations or hemodialysis shunts, the use of an appropriate tunneling device is recommended. In order to avoid perigraft hemorrhage and allow undelayed graft incorporation, the tunneler should match the diameter of the implant. Interchangeable shafts with various lengths and blunt tips of various diameters are prerequisites for versatile applicability. The tunneling instrument designed by Kelly and Wick was until now the most versatile on the market. Its main drawback is a handle that is welded to one end of the shaft thus preventing "bi-directional" use. We therefore developed a modified "Bi-directional Tunneler". Its handle can be attached to both ends of the shaft and allow at the same time torsional rigidity for directional guiding. Thus, e.g. in a femoro-popliteal bypass, the distal anastomosis can be accomplished first, followed by the introduction of the "Bi-directional Tunneler" from the knee to the groin. In a further step the tip and handle are interchanged and the graft is also passed from the knee to the groin. Thus, the "Bi-directional Tunneler" offers hitherto unknown versatility in bypass as well as in hemodialysis shunt surgery.     

Hand surgery on patients who are "high risk" for blood-borne viruses

There is a risk of transmission of blood-borne viruses (BBV) to health-care workers when performing hand surgery on intravenous drug abusers and other patients known to have BBV. This review summarises methods and procedures that may be employed to help reduce this risk to a minimum. High-risk patients should be identified early and a non-invasive procedure considered. Only experienced staff should scrub and appropriate clothing should be worn. Sharp instrument use should be kept to a minimum and only instrument retraction and suturing should be employed. When possible, wounds should be closed with staples, glue or absorbable sutures. Appropriate steps must be taken to reduce the risk of injuries from sharp bone ends, K-wires and splash exposure during irrigation.     

Initial experimental experience with a "replaceable" cardiac valve prosthesis

An easily "replaceable" cardiac valve prosthesis has been designed. It consists of two parts: (1) a sewing ring incorporating a circlip and (2) a functioning valve (either mechanical or tissue). The circlip is encased in a sewing ring, which is sutured into the natural valve annulus, and grips the functional part of the prosthesis, thereby preventing dislodgment. A simple instrument has been designed to open the circlip a few millimeters to allow easy removal or insertion of the functional element. This sewing ring/circlip with the functional element of a Bj?rk-Shiley prosthesis was used in 10 baboons undergoing mitral valve replacement. Removal and replacement of the functional element was carried out at a second operation between 1 and 12 weeks later. There were no operative deaths. Baboons were electively killed one day to twelve months after the second operation. There were no complications related to the prosthesis; cardiac catheterization showed normal hemodynamics before and after the second operative procedure.     

Hand-assisted laparoscopic esophagojejunostomy using newly developed purse-string suture instrument "Endo-PSI"

Although there are several reports on the esophagojejunostomy during laparoscopy-assisted total gastrectomy, the procedures still remain to be established. We report hand-assisted laparoscopic esophagojejunostomy using circular stapler and newly developed instrument "Endo-PSI." Between April 2005 and April 2006, 13 patients received these products during laparoscopy-assisted total gastrectomy. The Endo-PSI was attached to the abdominal esophagus using hand-assisted laparoscopic surgery. The insertion of the straight needle with 2-0 polypropylene into the device and the cutting of the esophagus were also performed using hand-assisted laparoscopic surgery. The insertion of the anvil head into the esophagus and the ligation of the purse-string suture were performed laparoscopically. After the jejuno-jejunal anastomosis was performed extracorporeally, the combination of the circular stapler for esophagojejunostomy and the closure of the stump of the jejunum were performed laparoscopically. There were no complications attributable to this procedure and there were no cases that required conversion to conventional open procedure or required extension of median incision. This newly developed Endo-PSI was useful for laparoscopic purse-string suture.     

Endoscopic neurosurgery "around the corner" with a rigid endoscope. Technical note.

Endoscopically "working around the corner" is presently restricted to the use of flexible endoscopes or an endoscope-assisted microneurosurgical (EAM) technique. In order to overcome the limitations of these solutions, endoscopic equipment and techniques were developed for "working around the corner" with rigid endoscopes. A steering insert with a 5 French working channel is capable of steering instruments around the corner by actively bending the guiding track and consecutively the instrument. A special fixation device enables strict axial rotation of the endoscope in the operating field. Endoscopic procedures "around the corner", including aqueductal stenting, pellucidotomy, third ventriculostomy and biopsy were performed in human cadavers. Special features of the used pediatric neuroendoscope system, i.e., reliable fixation, axial rotation, and controlled steering of instruments, increase the safety and reduce the surgical traumatization in selected cases, such as obstructive hydrocephalus due to a mass lesion in the posterior third ventricle, since endoscopic third ventriculostomy and biopsy can be performed through the same burr hole trephination. Limitations of this technique are given by the size of the foramen of Monro and the height of the third ventricle as well as by the bending angle of the instruments (40-50 degrees).     

Validation of the Spanish version of the "Bladder control Self-Assessment Questionnarie" (B-SAQ). A new screening instrument for lower urinary tract dysfunction

BackgroundTaking into account the high prevalence in our country of Overactive Bladder Syndrome (OAB) (“urgency”, with or without incontinence, sometimes associated to an increase in frequency and/or nocturia) and the difficulty to identify it, it would be interesting to have a short patient self assessment screening questionnarie for the evaluation of lower urinary tract symptoms. The objective of the study is to evaluate the psychometric properties of the Spanish version of the Bladder control Self-Assessment Questionnaire (B-SAQ).Patients and methods133 women consulting due to lower urinary tract symptoms in a health care centre specialised on uroginecology. The subjects filled the B-SAQ (scales “symptoms” and “discomfort”) and the ICIQ-UI SF, and underwent the usual protocol: uroginecologic history, pelvic examination and urodynamic study. Feasibility, validity, and reliability of the B-SAQ were assessed, as well as the ROC curve for the scores of both BCSEQ scales regarding the urodynamic diagnosis of Detrusor Overactivity (DO).Results: FeasibilityAverage administration time, 3.5 (1.5) minutes; 2 women did not answer any of the questionnaires. Validity: the scores for “symptoms” and “discomfort” were higher in those women with a DO diagnosis: “symptoms” = 7.8 (2.6) vs 6.2 (2.3) (p=0.0002); “discomfort” = 9.1 (3) vs 7.8 (3.6) (p=0.03); the Spearman’s correlation coefficient between “discomfort” scale and item 3 of the ICIQ-UI SF (affection) was 0.65 (p < 0.001). Feasibility: Cronbach’s alpha for “symptoms” was 0.722 and 0,889 for “discomfort”. According to the COR curve for both scales, a score greater than or equal to 6 showed adequate sensibility and specificity for the DO diagnosis.ConclusionsThe B-SAQ is an easy-use instrument which shows adequate feasibility, validity and reliability for its use in clinical practice as screening instrument for OAB.     

Use of the Endoholder device during robotic-assisted laparoscopic radical prostatectomy: the "poor man's" fourth arm equivalent

PURPOSE: During standard, six-port set-up, robotic-assisted laparoscopic radical prostatectomy (RLRP) using a three-arm daVinci system (DVS), two assistants are routinely required. The role of the second assistant is often limited to isometric traction during prostate dissection. Due to muscle fatigue and inability of the operator to see the operative field, frequent repositioning of the second assistant is often required. MATERIALS AND METHODS: In an attempt to improve efficiency in such surgical situations, we describe the use of the Endoholder, an adjustable articulating instrument holder, to assist during RLRP. RESULTS: During 100 consecutive cases, the Endoholder provided quick, reproducible retraction to facilitate exposure. No complications occurred with its use. The device reduced the need for a dedicated second assistant to stand bedside. CONCLUSIONS: We have achieved significant improvements in the safety and efficiency of retraction of the rectum, bladder, and prostate during RLRP with the Endoholder. For urologists working with a three-armed DVS, use of the Endoholder may help facilitate tissue retraction during dissection.     

Incorrect vector after calibration of surgical instruments for image guidance. The problem and the solution: technical note.

Recently, the use of intra-operative image guidance has gained an increasing role in neurosurgery for both spinal and cerebral interventions. Some modern neuronavigation systems are able to register any surgical instrument and create a virtual pointer. A virtual elongation of the digitized instrument is frequently used for neuroendoscopic procedures and spinal instrumentation. The instrument is equipped with a universal instrument adapter clamp and digitized by touching the tip of the instrument into a calibration cone. An algorithm calculates the vector of the instrument using two points: the tip of the instrument, and the geometrical center of the instrument adapter geometry. If a virtual elongation of the calibrated instrument is performed, the neuronavigation software may calculate an incorrect virtual target point. We developed an instrument calibration matrix (ICM) that automatically calibrates the correct vector, tip, and diameter of the instrument used for image-guided surgery. The ICM is easy to handle and does not cause a time delay during surgery. Virtual elongation of the surgical instruments shows correct anatomic data, which are fundamental for planning ventricular tapping and spinal screw placement in particular. The instrument calibration matrix is essential if surgical instruments are digitized and used for neuronavigation. It helps to avoid mis-planning of surgical vectors and mis-placement of the used instruments.