Semiautomatic suturing device (Maniceps®) for laparoscopic surgery

The only automatic device now available to laparoscopic surgeons is Endo-Stitch?, which is costly for single use and has the disadvantage of leaving a large needle hole in the tissue. A semiautomatic suturing device (Maniceps?) for laparoscopic use was developed from a forceps-type of needle holder for open pelvic surgery. The first generation of the instrument was designed for use with the abdominal wall-lift method of laparoscopic surgery, whereas the second generation can be applied for gas insufflation as well. Exchange of the needle is done by an automatic grasping action of a resilient slit in one jaw and by manual pull-down of the needle via the thread onto the other jaw. The new instrument was employed in 10 cases of laparoscopic surgery for various procedures including suture of the perforated gallbladder wall and running suture of the peritoneum after mesh placement in transabdominal repair of inguinal hernia. Maniceps? provides an economic advantage and has the merit of a smaller needle hole. Received: 4 February 1998/Accepted: 18 March 1998     

Recovery after stabilising surgery for ‘flail chest’

Background/Purpose

There is a lack of knowledge on respiratory and physical function, mobility and pain following stabilising surgery for ‘flail chest’. The purpose of this study was, therefore, to evaluate pain, respiratory function, range of motion and physical function/activity 3 and 6 months after stabilising surgery in patients with ‘flail chest’ due to trauma.

Method

Twenty-four patients diagnosed with ‘flail chest’ were, 3 and 6 months after the trauma, measured with regard to remaining pain, lung volume, breathing movements, and range of motion in the rib cage and thoracic spine. Physical function and level of physical activity were also estimated.

Results

Approximately 50 % of the patients had remaining pain after 3 months and 35 % had remaining pain after 6 months. Vital capacity was significantly decreased after 3 and 6 months compared to predicted values: >83 % after 3 months and >86 % after 6 months. There were no significant differences between the injured versus non-injured side in breathing movements, nor between the values of the range of motion between the two test occasions. The results of physical function showed mild to moderate disability 3 months after surgery and some or mild disability at 6 months. The patients were active, performing moderate exercise 1–2 h/week or light physical activities more than 4 h/week at 3 and 6 months.

Conclusions

Patients who had undergone stabilising surgery due to ‘flail chest’ showed decreased range of motion 3 and 6 months after surgery. Despite decreased range of motion and remaining pain, the breathing movements are synchronic.     

The ‘Saw Tooth’ operation for giant fibroadenomas

Fibroadenomas are the most common benign breast lesions affecting adolescents and young women. Cosmesis is an important factor when considering surgical management for these masses.Giant fibroadenomas (>5 cm), because of their size, may require larger incisions resulting in significant scarring and scar complications in these young women. Several approaches have been employed, usually involving large incisions, when performing a lumpectomy for giant fibroadenomas. In this report, we highlight a new technique for removal of these masses, which allows the removal of large fibroadenomas through a relatively small, cosmetically acceptable, circumareolar incision.     

Anaesthesia for ‘off-pump’ coronary artery bypass grafts

There has been renewed interest in carrying out coronary artery bypass grafts without the use of cardiopulmonary bypass, both through the usual sternotomy incision, and also using smaller intercostal incisions that avoid sternotomy completely. Avoiding cardiopulmonary bypass has several advantages, including reduced incidence of stroke and neuro-psychiatric disorders, reduced blood loss, reduced incidence of renal problems, earlier extubation and shorter hospital stay. Although there are few randomized controlled trials, early published results are very encouraging. The use of this technique looks set to continue to increase facilitated by the development of specialized equipment that stabilizes the coronary artery during anastomosis. The use of this technique creates a variety of challenges for the anaesthetist. This article explores the surgical and anaesthetic management of ‘off-pump’ cardiac surgery.     

Ten years’ experience of free flaps for breast reconstruction in a Danish microsurgical centre: An audit

We have done a total of 292 breast reconstructions using a free flap over a period of 10 years (1994–2003). During the last five years the number of deep inferior epigastric perforator (DIEP) flaps has increased. However, to secure an optimal blood supply we still use a muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flap sometimes. Our results with the two flaps were identical as far as operating time and length of hospital stay were concerned, but the DIEP flap has less donor site morbidity. Our results are influenced by our selection of patients and our technique but we think that muscle-sparing TRAM flaps may be used as an alternative to DIEP flaps.     

Challenges for ‘diastology’: contributions from Japanese researchers

Diastology is a study to treat diastole of the heart. Transmitral flow and pulmonary venous flow velocities recorded by pulsed Doppler echocardiography provide more important information about left ventricular (LV) diastolic dysfunction [left atrial (LA)?LV coupling] than cardiac catheterization in clinical practice; however, these waveforms are influenced by loading conditions, particularly preload. The early diastolic mitral annular and LV wall motion indices measured by tissue Doppler echocardiography can evaluate LV relaxation abnormality and filling pressure by being relatively preload independent. In addition, the role of concomitant systolic longitudinal dysfunction is well characterized in asymptomatic patients and in patients with heart failure and preserved ejection fraction. Two-dimensional speckle tracking echocardiography is an angle-independent method, and has the potential to evaluate the contraction and relaxation abnormalities in the longitudinal, circumferential, and radial directions of the LV myocardium as well as LV torsion/untwisting and, moreover, deformation of the LA myocardium and large arterial wall. As a result, this new technique can facilitate the early detection of impaired LA?LV?arterial coupling in patients before occurrence of overt heart failure symptoms.     

Macroscopic and microsurgical varicocelectomy: what’s the intraoperative difference?

Purpose

Many authors reported that microsurgical varicocelectomy was among the best treatment modalities for varicocele. However, the difference in intraoperative anatomic detail between macroscopic and microsurgical varicocele repair in the same spermatic cord has not been critically discussed.

Methods

Between August 2010 and February 2011, 32 men with 42 sides’ grade 2–3 varicocele were enrolled in this study. One surgeon firstly mimicked the modified open varicocelectomy by identifying, isolating, and marking the presumed internal spermatic veins, lymphatics, and arteries. Another surgeon then checked the same spermatic cord using operating microscope to investigate the number of missed veins, to be ligated lymphatics and arteries in the “imitative” open varicocelectomy.

Results

There were significant differences in the average number of internal spermatic arteries (1.67 vs. 0.91), internal spermatic veins (6.45 vs. 4.31), and lymphatics (2.93 vs. 1.17) between microscopic and macroscopic procedure (P < 0.001, P < 0.001, P < 0.001, respectively). Meanwhile, an average of 2.14 ± 1.26 internal spermatic veins was missed; among them, 1.63 ± 1.32 internal spermatic veins adherent to the preserved testicular artery were overlooked. The number of 0.69 ± 0.84 lymphatics and 0.74 ± 0.74 arteries were to be ligated in “macroscopic varicocelectomy.” A number of 1.07 ± 1.11 lymphatics were neither identified nor ligated. In addition, in 2 cases, the vasal vessels of the vas deferens were to be ligated at macroscopic procedure.

Conclusions

Microsurgical varicocelectomy could preserve more internal spermatic arteries and lymphatic and ligate more veins which may interpret the superiority of microsurgical varicocele repair.     

Should ‘smart phones’ be used for patient photography?

BACKGROUND:

Within the field of plastic surgery, clinical photography is an essential tool. ‘Smart phones’ are increasingly being used for photography in medical settings.

OBJECTIVE:

To determine the prevalence of smart phone use for clinical photography among plastic surgeons and plastic surgery residents in Canada.

METHODS:

In 2014, a survey was distributed to all members of the Canadian Society of Plastic Surgeons. The questions encompassed four main categories: smart phone use for clinical photos; storage of photos; consent process; and privacy issues. The survey participation rate was 27% (147 of 545) with 103 surgeons and 44 residents. In total, 89.1% (131 of 147) of respondents have taken photographs of patients using smart phones and 57% (74 of 130) store these photos on their phones. In addition, 73% (74 of 102) of respondents store these photos among personal photos. The majority of respondents (75% [106 of 142]) believe obtaining verbal consent before taking clinical photographs is sufficient to ensure privacy is respected. Written consent is not commonly obtained, but 83% (116 of 140) would obtain it, if it could be done more efficiently. Twenty-six percent (31 of 119) of respondents have accidentally shown a clinical photograph on their phone to friends or family. A smart phone application that incorporates a written consent process, and allows photos to be immediately stored externally, is perceived by 59% (83 of 140) to be a possible way to address these issues.

CONCLUSION:

Smart phones are commonly used to obtain clinical photographs in plastic surgery. There are issues around consent process, storage of photos and privacy that need to be addressed.     

The ‘antiphospholipid syndrome’ and the ‘lupus anticoagulant’

In recent years an association has been described between, on the one hand, an in vitro prolongation of phospholipid-dependent coagulation tests (the lupus anticoagulant) or the demonstration of antiphospholipid antibodies and, on the other, clinical events, particularly recurrent thrombosis (usually venous but sometimes arterial), thrombocytopenia, and also recurrent mid-term fetal loss. Other less well-documented associations with haemolytic anaemia, livedo reticularis, strokes and other neurological syndromes have been suggested. The antibodies are present temporarily in many infections, are usually of IgM isotype and thrombosis does not occur. However, they are persistently present and mainly of IgG isotype in a number of auto-immune disorders associated with thrombosis, in particular systemic lupus erythematosus, in which 50% of patients will show antibody of one isotype or another. The strongest association is with antinuclear factor-negative lupus and lupus-like disorders in which a full diagnosis of classical lupus cannot be made. The clotting test abnormality and antiphospholipid antibodies may be found also in otherwise normal individuals suffering thrombosis or fetal loss — the so-called primary antiphospholipid syndrome. These data raise important questions for management, but many details are controversial despite a decade's work; this review examines the present position and outlines some of the difficulties, particularly from the point of view of nephrology and paediatrics.     

A new assessment for syndesmosis injury – The ‘Chertsey test’

IntroductionIf a syndesmosis injury is not detected, or not treated appropriately, it can lead to pain and arthritis. Various techniques have been described to look for the presence of a syndemosis injury. If concern is raised regarding malreduction, the most recognised way of checking accuracy of the reduction (of the fibula into the incisura) is bilateral postoperative ankle CT scans. This not only exposes the patient to further radiation, but can normally only be done once the surgery is completed and so if adjustment is needed, this requires a further operation, encompassing further surgical risks.We developed a simple assessment, which both gives accurate intra-operative demonstration of an injury to the syndesmosis and also can check how well the fibula has been reduced (if required), without the need for further radiological investigation or surgical intervention.The objectives were to test how easy it was to perform the test and apply it to a number of different ankle fractures.MethodsPeri-operatively, 2–4 ml of contrast medium was injected into the ankle joint in cases where there was concern about injury to the syndesmosis. If there was a ‘positive’ test, and a ‘blush’ of dye leaked into the surrounding soft tissues, then fixation of the syndesmosis was performed (as per the surgeon's preferred technique). After fixation was completed, a further injection of contrast medium was injected to see if the fibular had been anatomically reduced into its incisura. The test was performed on 15 ankles.ResultsThere were no difficulties in performing the test and no complications reported. The test clearly demonstrated where there had been an injury to the syndesmosis and also confirmed the accurate reduction of the fibula when there had been stabilisation of the syndesmosis.ConclusionsIt has proved to be an easy and reliable adjunct to ankle fixation surgery and may have further indications.