Axillobrachial artery bypass grafting with in situ cephalic vein for axillary artery occlusion: a case report

The cephalic vein has been reported to be a suitable vascular conduit for arterial reconstructive surgery, but its use remains controversial. When used for lower extremity revascularization, its use has been complicated by elongation and dilation. Its use for upper extremity revascularization has only been rarely reported. This article represents the first published use of the cephalic vein with the in situ technique for upper extremity occlusive disease. This technique may avoid some of the complications noted when used in the reverse fashion.     

The agents used for sedation in neurointensive care unit

Sedation and analgesia can be routinely prescribed in head injury patients. The goals of such sedation are three: brain protection, prevention and treatment of intracranial hypertension and therapeutic facilitation. In such situation, the use of sedative and analgesic therapy should respect the rate of cerebral blood flow/cerebral oxygen consumption coupling while preserving cerebral perfusion pressure and decreasing the intracranial pressure. This treatment should have an analgesic and myorelaxing action with short and predictable time of action. The ideal sedation agent with all these properties does not exist. Only the combination of several different pharmacological classes of compounds may reach this goal. Benzodiazepines are the most frequently used agents. In most of the cases they are associated with analgesic agents such as opioid or ketamine. Opioids may be the basic analgesic agents because they do not produce brain haemodynamic modifications if arterial pressure is maintained. Among them, sufentanil, thanks to its pharmacokinetics properties, remains the most prescribed opioid. However, in the future, remifentanil that presents a fast elimination may be more frequently used for neurological follow up of patients. Ketamine whose use is subject of debate, has the main advantage of maintaining haemodynamic status. Ketamine has no side effects on brain haemodynamic when used with propofol or midazolam. Taking into account their deleting effect on haemodynamic status and immune system, barbituric are no longer used as long term sedative agents. However, their use is still recommended in the cases of refractory intracranial hypertension. Propofol remains the ideal sedative agent because of its short duration action but its use is limited by its cost. Its use may be recommended for short time sedations with or without an opioid drug. The curare use should be restrain to refractory intracranial hypertension to usual treatments and happening during stimulation.     

PARAMIS parallel robot for laparoscopic surgery

The paper presents the parallel robot, which has been developed in Romania and it is used for laparoscope camera positioning. Based on its mathematical modeling, the first low-cost experimental model of the PARAMIS surgical robot has been built. The system has been built in such a way that it has the possibility to transform it in a multiarm robot controlled from the console. The control input allows the user to give commands in a large area for the positioning of the laparoscope using different interfaces: joystick, microphone, keyboard & mouse and haptic device. The first results have been obtained through the performing of an experimental laparoscopic cholecystectomy using PARAMIS surgical robot. The model which was used was a porcine liver, removed with the gall-bladder and the bile ducts. Due to its very easy use control system, surgeons have adapted rapidly to the use of PARAMIS in surgical procedures. Some of its advantages could be emphasized: precision of the movements; absence of the laparoscope operator's natural tremor, direct control over a smooth, precise, stable view of the internal surgical field for the surgeon; no fatigue; allows the use of both hands for the actual procedure; reduces eye fatigue; eliminates the need for a second surgeon to be present for the entire procedure.     

Trochanteric Osteotomy for Total Hip Arthroplasty: Six Variations and Indications for Their Use

Trochanteric osteotomy of the femur in total hip replacement used to be a simple, stereotyped technique and was declining in frequency of use. Many variations in the technique have evolved recently, including the trochanteric slide and the extended trochanteric osteotomy, which have increased the flexibility and utility of trochanteric osteotomy and the frequency of its application. The authors describe six trochanteric osteotomies and discuss the indications for their use.     

Unicompartmental knee arthroplasty for younger patients: an alternative view

Unicompartmental knee arthroplasty has been a controversial operation for the past 3 decades. Many surgeons in the 1980s and 1990s found little or no indication for the procedure. Others were enthusiastic for its use in selected patients with osteoarthritis who had unicompartmental disease. Initially, unicompartmental knee arthroplasty was thought to be appropriate for the elderly patient who was sedentary. With the advent of minimally invasive techniques, indications have expanded to include its use in younger patients (especially females) as an alternative to osteotomy or tricompartmental knee arthroplasty. Advantages over osteotomy include higher initial success, greater longevity, and fewer early complications. If done conservatively, salvage is not difficult. The extent of safe postoperative activity levels has yet to be established. Failure rates seem to be higher in heavy active males. A metallic interposition hemiarthroplasty in the form of a McKeever or Macintosh prosthesis has been available for 50 years as a unicompartmental arthroplasty, but with limited use. It still may have a role in selected patients as a conservative temporizing procedure.     

Sedation and analgesia for the brain-injured patient

Sedation-analgesia occupies an essential place in the specific therapeutic arsenal of the brain-injured patients. The maintenance of the perfusion of the brain, its relaxation and its protection are the fundamental objectives whose finality is to avoid the extension of the lesions and to preserve the neuronal capital. Sedation is instituted when patients are severely agitated or present a deterioration of their state of consciousness (GCS< or =8). Under cover of mechanical ventilation, sedation is the first line treatment of intracranial hypertension, a common pathway of various acute brain diseases of traumatic, vascular or other origin. The use of the combination of hypnotic and opioids is the rule. The combined action of these two classes reinforces and improves their sedative effects. Midazolam is the 2 benzodiazepine of reference. Propofol is more and more frequently added to the combination of hypnotic and opioids. The "propofol infusion syndrome" is a severe limitation to its long term administration in particular among patients presenting a severe septic or inflammatory state. Propofol will be imperatively stopped in the event of metabolic acidosis, rhabdomyolysis, acute renal insufficiency, hyperkaliemia or increase in the blood triglyceride levels. The use of thiopental is restricted to the most severe cases. Its use as a monotherapy at high doses is abandoned to the profit of a co-administration with midazolam or even with the combination of midazolam and propofol. Thiopental overdose is very frequent in the event of associated hypothermia. Etomidate does not have its place apart from induction in fast sequence. The neuro-protective effects of ketamine require to be demonstrated in man before being recommended routinely. Withdrawal of sedation can be responsible for a state of agitation which can be controlled by neuroleptics.     

Safe sedation for surgeons

Sedation, with or without the use of local anaesthetic, is a commonly used technique to allow patients to tolerate uncomfortable or unpleasant surgical procedures, avoiding the requirement for a general anaesthetic. Prevention of significant morbidity and mortality during sedation requires individuals to be appropriately trained in its use. This article aims to provide information into the techniques used, it discusses the generic principles and risks of sedation and should not be seen as a substitute for formal training. Attention is also drawn to the currently existing guidelines for various procedures.     

Unfractionated heparin for hemodialysis: still the best option

Unfractionated heparin (UFH) is the anticoagulant of choice for most maintenance hemodialysis units in the United States. Low molecular weight heparin (LMWH) is the norm in Western Europe, but is not approved for this indication in the United States. UFH is likely to remain the agent of choice in the United States because of its relative ease of use, safety, and low cost. Coating tubing and dialyzers with heparin is now possible, but systemic anticoagulation with heparin is usually still required. The additional cost of this innovation does not yet justify its use. Side effects of both UFH and LMWH include heparin-induced thrombocytopenia, hypertriglyceridemia, and hyperkalemia. It is uncertain whether osteoporosis is an important side effect, as vitamin D deficiency, secondary hyperparathyroidism, age, and debility are confounding factors. When UFH poses a risk or its use is contraindicated, e.g., after development of heparin-induced thrombocytopenia, the use of direct thrombin inhibitors, regional citrate anticoagulation, citrate dialysate, and heparin-free dialysis may be appropriate.     

Safe sedation for surgeons

Sedation, with or without the use of local anaesthetic, is a commonly used technique to allow patients to tolerate uncomfortable or unpleasant surgical procedures, avoiding the requirement for a general anaesthetic. Prevention of significant morbidity and mortality during sedation requires individuals to be appropriately trained in its use. This article aims to provide information into the techniques used. It discusses the generic principles and risks of sedation and should not be seen as a substitute for formal training. Attention is also drawn to the currently existing guidelines for various procedures.     

Microvascular free musculocutaneous flaps for the treatment of avulsion injuries of the lower leg

Microvascular free flap transfer has added new dimensions in reconstructive surgery. The use uf musculocutaneous units as free flap donors may have additional advantages over skin units. Microvascular free musculocutaneous flaps were utilized to cover avulsion wounds in the lower leg of six patients and satisfactory results were obtained. The latissimus dorsi musculocutaneous flap proved to be well suited for free transfer to the traumatized lower extremity, because of its long dominant vascular pedicle, its large size, and the minimal functional problems that result from its use.     

Cloning and transgenesis in mammals: Implications for xenotransplantation

Availability of suitable organs for transplantation remains of major concern and projections indicate that the problem will continue to increase. Therefore, alternatives to the use of human organs for transplantation, continue to be explored including use of stem cells, artificial organs, and organs from other species (xenotransplantation). In xenotransplantation, the species of choice remains the pig due to its physiological similarities to humans, reduced costs, ease of manipulation, and reduced ethical concerns to its use. However, in order to develop pig organs that are suitable for xenotransplantation, complex genetic modification need to be undertaken. These modifications require the introduction of precise genetic changes into the pig that can only be accomplished at this time using somatic cell nuclear transfer. We cover in this review advances in transgenic manipulation and cloning in swine and how the development of these two technologies is critical to the eventual utilization of the pig as a human organ donor.     

Nitrous oxide: a unique drug of continuing importance for anaesthesia

Early attempts to use nitrous oxide as a sole anaesthetic foundered because of its low potency. It has been used successfully as an adjunct to more potent anaesthetics, however, since 1868. By enabling reduced doses of more potent anaesthetics, nitrous oxide reduces the cost of anaesthesia and limits cardiorespiratory side effects. Nitrous oxide does increase the incidence of postoperative nausea and vomiting in cases where risk of this side effect is increased, but it seems likely that use of antiemetics prophylactically will negate this factor. Perhaps the greatest argument for the continued use of nitrous oxide is that it reduces the incidence of recall of intraoperative awareness. Reduced pharmacokinetic variability compared with other anaesthetics, especially intravenous agents, is likely to be a most important reason for this, although evidence is emerging that nitrous oxide also has pharmacodynamic advantages. There are specific situations in which nitrous oxide should not be used, but in the absence of these, its use can be favourably recommended.     

Shell tamponade in filtering surgery for glaucoma

The glaucoma shell tamponade technique in filtering surgery for glaucoma is a technique for (1) decreasing the incidence of flat anterior chamber and choroidal separation postoperatively, (2) promoting the development of a low diffuse filtration area, and (3) increasing the possibility of achieving very low resulting postoperative pressure. The glaucoma shell technique is applicable to all types of filtration procedures, including conventional filtering procedures utilizing no scleral flap and those utilizing a scleral flap, such as trabeculectomy. It can be used at surgery or can be applied in the postoperative period to deal with flat or shallow anterior chambers immediately at the time of onset. The shell tamponade technique can be utilized to aid in the management of some cases of leaking bleb in the early postoperative period or in the late postoperative period. The technique for operative and postoperative use of the glaucoma shell tamponade technique and its closely related pressure dressing is a demanding and exacting art. Because the technique increases the possibility of very low resulting tensions, its use should be considered especially for cases in which very low pressures are desired, such as some cases of extremely advanced cupping and field loss and low-tension glaucoma.     

Surgical indications for fasciocutaneous flaps

The development of the fasciocutaneous flap, its relationship to the musculocutaneous flap, and the surgical indications for its use in various areas of the body are discussed. The precise vascular architecture has not yet been described, nor have reliable guidelines been established for the safe use of these flaps, but some clinical observations are made and related to the anatomical findings of other workers.     

Total intravenous anesthesia with propofol for thymectomy in a patient with myasthenia gravis.

Experience with the use of propofol for induction and maintenance of anesthesia in patients with myasthenia gravis is limited. This case report documents the safe use of propofol in a patient with myasthenia gravis. Because of its unique pharmacodynamic and pharmacokinetic profile, propofol may be an ideal agent for safe use in the young patient with myasthenia gravis.     

The modified bitemporal flap for the treatment of bitemporal recessions

A modified version of the bitemporal flap can be used effectively for the treatment of bitemporal recessions in one step. The geometry of this flap is discussed along with several precautionary points concerning its use.     

Silicone foam dressing for penis after reconstructive pediatric surgery

Although silicone foam has been used abroad as an effective means to dress the penis after hypospadias surgery, its use has not been widespread in the United States. We have modified the method to apply the foam in order to facilitate its use. We used this method to dress the penis with silicone foam in 50 boys after reconstructive surgery. The dressing appeared to be effective in restricting edema and hematoma formation. Also, the dressing stabilized the indwelling urethral catheter thereby preventing disruption of the glansplasty. The urethrocutaneous fistula rate (10%) was not reduced by use of the foam. The dressings uncommonly fell off prematurely. The boys appeared to experience little discomfort while the foam was in place and during its removal.     

Graft selection for anterior cruciate ligament reconstruction

The ideal anterior cruciate ligament (ACL) graft substitute would have no morbidity associated with its procurement, be readily available for use, and be capable of strong fixation with sufficient inherent strength to withstand an accelerated postoperative rehabilitation program. In addition, the long-term results of ACL reconstruction using the graft substitute should be favorable. Unfortunately, such an ideal graft material does not currently exist. At present, available choices for ACL graft substitutes include autograft tissue, allograft tissue, and synthetic devices. This article presents the reader with a review of the factors involved in selecting a material to serve as a graft substitute for ACL reconstruction and explores the advantages and disadvantages associated with the use of various graft tissues.     

Proposal for a new classification of prostheses used in the repair of abdominal wall hernial defects

Research and development in new biomaterials is currently increasing. The greater use of prostheses for the repair of abdominal wall defects has meant that new designs incorporating novel materials are constantly emerging. Today's surgeon needs to be aware of these novel designs and become familiar with their use. In the present article, we classify the prostheses currently available on the market for the repair of abdominal wall defects, mostly hernias. The new classification scheme we propose takes into account the type of prosthesis, its components, and its ideal site of placement in the abdominal wall.