Use of the site percutaneous breast biopsy device

A new technique is described for image guided percutaneous diagnostic excision biopsy of non-palpable mammographically detected breast lesions. This method involves insertion of a localizing guide wire under stereotactic guidance followed by insertion of the 15 mm diameter biopsy device which is positioned within the breast immediately proximal to the target lesion. A cylindrical cannula is advanced over the lesion which is then separated from the surrounding breast tissue by deploying a garrote wire at the distal end of the cannula. The biopsy device is then removed with the target lesion contained within the cannula. The mammographic lesion is excised without removing any excess adjacent breast tissue, and in one piece, so allowing histological examination of the whole lesion. The experience of the first three cases is described with imaging and histological correlation.     

Treatment with Ultrasound-Assisted Liposuction of Accessory Axillary Breast Tissues

Supernumerary nipples and breast tissue often are dismissed as cosmetic curiosities. These structures have the potential for pathologic degeneration and may be associated with significant congenital abnormalities. In a prospective comparison of 100 Native American women with 100 non-Native American women, these accessory organs were found much more commonly among Native American women. Careful attention should be given to thorough evaluation and long-term follow-up evaluation of any patient with this anomaly. This study investigated a patient who underwent surgical removal of her axillary breast tissue with ultrasound-assisted liposuction. The advantages of this method include a minimal incision scar from the liposuction cannula and the ability to detect residual axillary breast by ultrasound.     

Multimodality gynecomastia repair by cross-chest power-assisted superficial liposuction combined with endoscopic-assisted pull-through excision

Numerous methods of gynecomastia repair have been described to accomplish removal of breast tissue. Our multimodality surgical approach for the treatment of gynecomastia combines the use of power-assisted superficial cross-chest liposuction with direct pull-through excision of the breast parenchyma under endoscopic supervision. Seventeen patients, aging 17-39, underwent this multimodality approach. According to Simon's grading, 3 patients had grade 1, 5 had grade 2a, 6 had grade 2b, and 3 had grade 3 gynecomastia. Power-assisted liposuction was performed with a 3- or 4-mm triple-hole cannula inserted through the contralateral periareolar medial incision to suction the contralateral prepectoral fatty breast. At the end of the liposuction, the fibrous tissue was easily pulled through the ipsilateral stab wound and excised under endoscopic control. Follow-up time ranged from 6 to 34 months. The amount of fat removed by liposuction varied from 100-800 mL per breast, and the amount of breast parenchyma removed by excision varied from 20-110 g. All patients recovered remarkably well. No complications were recorded. All patients were satisfied with their results. This technique enables an effective treatment of both the fatty and fibrous tissue of the male breast and avoids skin redundancy due to skin contraction. A smooth masculine breast contour is consistently achieved without the stigma of this type of surgery.     

The forked liposuction cannula: a novel approach to the correction of cicatricial contracture deformities in breast reconstruction

Cicatricial contracture deformities in breast reconstruction can result from delayed wound healing, fat necrosis, or chest wall radiation. Secondary revision can be difficult as these contour deformities compromise the final result. The authors describe correction of these scar deformities with a forked liposuction cannula in 38 breast reconstructions (32 patients). Mean follow-up time was 6 months, and no complications resulted from the use of the forked cannula. In 33 reconstructions (86.8%), autologous fat grafting was performed simultaneously. Multiple revisions were required in 8 reconstructions (23.7%). Three patients had a residual contracture after treatment; all 3 had a history of radiation therapy. This early experience demonstrates that use of a forked liposuction cannula for cicatricial breast deformities is both easy and safe. This technique can be a useful adjunct, especially in patients undergoing autologous fat grafting; however, residual contracture may be observed in patients with a history of radiation therapy.     

Tissue suction of the male and female breast

Liposuction has been used either alone or combined with resection for the correction of male and female breast deformities. The majority of the 32 patients in our study were treated for gynecomastia (69%). Other indications were Madelung's disease, gender dysphoria, asymmetry, hypertrophy, postburn and postreconstruction deformities. In 54% of the gynecomastia cases, suction alone gave a satisfactory result. In all but one male patient suction permitted us to avoid incisions other than periareolar incisions. Thirteen aspirates from gynecomastias and three glands resected secondarily after suction were examined histologically. All aspirates included glandular tissue. We conclude that breast tissue is accessible to the suction cannula, and that this is a valuable tool for correcting gynecomastia and for use in many aesthetic procedures on female patients.Presented at the Annual Scientific Meeting of the Lipoplasty Society of North America, Seattle, WA, September 21–22, 1991     

Suction lipectomy: an excellent adjutant to improve the results of breast reconstruction with RAM flaps

It has been said about breast reconstruction with implants that a patient should not expect more than a mound that will fill out her brassiere or bathing suit. Autogenous tissue breast reconstruction has changed this. One of the great advantages of autogenous reconstruction over implants is that the breast remains soft, supple, and warm, improving with time as the scars begin to fade and becoming more natural and pendulous. Furthermore, since the new breast is made of fat, we can change its size, enhance its shape, and sculpture it with a suction lipectomy cannula to make it look practically identical to the opposite. We look upon breast reconstruction with rectus abdominis myocutaneous (RAM) flaps as a torsoplasty because of the improvements to the two areas involved: the reconstructed breast and the resulting abdominal lipectomy. This torsoplasty is done in two stages: One is the actual transfer of the rectus abdominis flap in which the skin and fat involved is designed to try to give an aesthetic dermolipectomy but without compromising the vascularity of the flap. Three or four months later, we perform the second-stage torsoplasty where the suction-assisted lipectomy plays a fundamental role and which is the subject of this article.     

REMOVAL OF BULKY TISSUE AT LAPAROSCOPIC SURGERY

A technique for extraction of bulky tissue during laparoscopic surgery is presented. One laparoscopic cannula is replaced with a sigmoidoscope which acts as a wide-bore cannula. At laparoscopic cholecystectomy, 22 of 60 (38%) patients were. found to require wound enlargement to remove a grossly diseased gall-bladder. Use of a sigmoidoscope as a cannula was associated with fewer technical complications than surgical wound extension. At laparoscopic appendicectomy, the appendix could not be removed through the standard laparoscopic cannula in 16 of 46 (31 %) cases. The incidence of wound infection was significantly lower after laparoscopic appendicectomy than among a group of 98 patients having conventional appendicectomy (P= 0.024). It is concluded that a sigmoidoscope can be used as a replacement cannula allowing uncomplicated removal of bulky tissue and reducing wound contamination.     

An improved system for surgical excision of needle-localized nonpalpable breast lesions

A technique for improved localization and surgical excision of nonpalpable breast lesions is described. The method employs an atraumatic outer stiffening cannula which is available in a variety of lengths and eliminates several of the technical difficulties encountered during these procedures. Successful initial excision of over 50 consecutive nonpalpable breast lesions has been obtained with this technique.     

Suction lipectomy: An excellent adjutant to improve the results of breast reconstruction with RAM flaps

It has been said about breast reconstruction with implants that a patient should not expect more than a mound that will fill out her brassiere or bathing suit. Autogenous tissue breast reconstruction has changed this. One of the great advantages of autogenous reconstruction over implants is that the breast remains soft, supple, and warm, improving with time as the scars begin to fade and becoming more natural and pendulous. Furthermore, since the new breast is made of fat, we can change its size, enhance its shape, and sculpture it with a suction lipectomy cannula to make it look practically identical to the opposite. We look upon breast reconstruction with rectus abdominis myocutaneous (RAM) flaps as a torsoplasty because of the improvements to the two areas involved: the reconstructed breast and the resulting abdominal lipectomy. This torsoplasty is done in two stages: One is the actual transfer of the rectus abdominis flap in which the skin and fat involved is designed to try to give an aesthetic dermolipectomy but without compromising the vascularity of the flap. Three or four months later, we perform the second-stage torsoplasty where the suction-assisted lipectomy plays a fundamental role and which is the subject of this article.Presented at the Lipoplasty Society of North America, 7th Annual Meeting, San Francisco, October 1989     

Stereotactic technique and pathophysiological mechanisms of neurotransplantation in Huntington's chorea.

In Huntington's chorea, embryonal brain tissue (striatum) was implanted in the caudate nucleus bilaterally, using stereotaxy assisted by CT. A special cannula allowed the placement into the brain of 3 or 4 grafts of embryonal tissue along the determined trajectory by one introduction of the cannula. The pathophysiological mechanism of neurotransplantation in Huntington's chorea is to compensate for the degenerated striatal tissue by embryonal striatum, so it is necessary to supply a quantity of embryonal striatal tissue which enables the whole functional integrity. Therefore, we use material from several embryos.     

Is There any Real Advantage in the Double-Lumen Cannula?

The author demonstrates one of liposuction's great problems, what he calls the ``contra-vacuum,' which forms inside the cannula while it is inserted under the skin. To keep liposuction effective, an ascending pressure is needed while the holes of the cannula are deep inside the tissues. The results are higher pressure, more tissue trauma, less effectiveness. To prevent these problems, the author developed a double-lumen cannula in 1983; because of a secondary tube outside it, there is no contra-vacuum formation. He presents here his experience in large liposuctions with a new cannula model, thinner than the first one, but also very effective.     

A new suction cannula

A new cannula has been designed that facilitates liposuction procedures by increasing the amount of fat tissue breakdown before aspiration. The cannula allows for greater application and opens up new horizons in aspirative surgery.     

A femoral artery cannula that allows distal blood flow

OBJECTIVE: A femoral artery cannula is used for certain types of circulatory support but can cause ischemia, especially during prolonged perfusion. This study tests the function of a femoral cannula designed to allow proximal and distal blood flow. METHODS: Five pigs were used in the study. In each animal a distal-flow cannula was implanted in the femoral artery of one leg, and the same-sized standard cannula was implanted in the other. Blood was drained from the left atrium and delivered to the femoral artery through the distal-flow cannula or standard cannula by using a centrifugal pump. An ultrasonic flow probe and microspheres were used to quantify flow and perfusion distal to the cannula. RESULTS: Distal femoral flow and tissue perfusion were present in all animals (5/5) with the distal-flow cannula but only in 1 of 5 animals with the standard cannula (P < .048). Distal flow did not change with pump flow. Mean distal flow at each level of pump flow was higher with the distal-flow cannula (P < .05). Tissue perfusion was also higher with the distal-flow cannula (0.052 +/- 0.028 vs 0.010 +/- 0.022 mL x min(-1) x g(-1), P < .03). CONCLUSIONS: In the swine model the distal-flow cannula allowed greater and more consistent distal flow than the standard cannula. The use of a distal-flow cannula for circulatory support might reduce the risk of distal limb ischemia.     

Multimodality stereotactic brain tissue identification: the NASA smart probe project

Real-time tissue identification can benefit procedures such as stereotactic brain biopsy, functional neurosurgery and brain tumor excision. Optical scattering spectroscopy has been shown to be effective at discriminating cancer from noncancerous conditions in the colon, bladder and breast. The NASA Smart Probe extends the concept of 'optical biopsy' by using neural network techniques to combine the output from 3 microsensors contained within a cannula 2. 7 mm in diameter (i.e. the diameter of a stereotactic brain biopsy needle). Experimental data from 5 rats show the clear differentiation between tissues such as brain, nerve, fat, artery and muscle that can be achieved with optical scattering spectroscopy alone. These data and previous findings with other modalities such as (1) analysis of the image from a fiberoptic neuroendoscope and (2) the output from a microstrain gauge suggest the Smart Probe multiple microsensor technique shows promise for real-time tissue identification in neurosurgical procedures.     

The technic for the reoptimization of laryngeal cannulae by recoating them with a silicone material

In the laryngeal surgical pathology area, the application of a cannula with temporary or long term indications is necessary for ensuring the respiratory function troubled by various causes (inflammatory, tumor or traumatic) that obstruction the respiratory tract. The most frequently used standard cannula is rigid and does not show proper adaptation for every clinical situation, thus leading to local troubles. In this paper, the realization technique of a rigid/flexible and individual cannula applied after the tracheotomy is presented. In order to carry out the cannula, a rigid material is utilized (acrylic resin) for maintaining the shape and dimensions of the laryngeal stoma. It is also utilized an elastically material (acrylic resin with a retard plug--Simpa) that ensures the optimal adaptation, tight close and tissue protection around the stoma. In co-operation with the ORL Clinic--Recuperation Hospital, these cannulae were applied to fifteen patients pursuing their evolution in time.     

Arthroscopic Technique of Interposition Arthroplasty of the Glenohumeral Joint

Arthroscopic glenohumeral interposition arthroplasty is performed with the patient placed in the lateral decubitus position. Standard posterior, anterior, and anterosuperior portals are created, a routine diagnostic arthroscopy is performed, and the joint is débrided with the use of an arthroscopic shaver. An arthroscopic burr is used to resect prominent osteophytes, to alter the version of the glenoid if necessary, and to create microfractures on the glenoid surface. Next, 3 absorbable sutures are passed percutaneously with a 30° angled suture grasper from 3 different sites posteriorly through the posterior capsular–labral tissue and into the anterior portal cannula, where they are isolated by means of the suture saver kit. The prepared interposition membrane/tissue (GRAFTJACKET Regenerative Tissue Matrix, Wright Medical Technology, Inc., Arlington, TN) is tagged with the 3 sutures in the anterior cannula before it is introduced into the joint. Three additional sutures are attached to the membrane anteriorly at 1, 3, and 5 o’clock positions and are isolated with suture savers. The membrane is next introduced into the joint through the anterior cannula and is aligned with the glenoid rim. The anterior sutures are rerouted through the anterior capsular–labral tissue with a 70° angled suture grasper, and they are retrieved through the anterior cannula. Intra-articular nonsliding knots are used anteriorly to anchor the interposition tissue to the anterior glenoid labrum and capsule. The posterior sutures are knotted intra-articularly, or they may be tied extra-articularly; the proximal and distal posterior sutures are retrieved subcutaneously out through the skin tract of the posterior portal and are knotted with the suture present in this portal, with the use of nonsliding knots. Stability of the interposition tissue is assessed by movement of the glenohumeral joint through its entire range of motion. The postoperative protocol consists of early passive exercises, active exercises after 3 weeks, and muscle-strengthening exercises after 6 weeks.     

锐性吸脂针腋皱襞入路肿胀抽吸法治疗男性乳房发育症

目的:改良目前治疗男性乳房发育症的手术方法,观察其效果。方法:术前应用高频超声探头选择脂肪和乳腺组织均有增生的男性乳房发育症患者18例,以腋皱襞前端为入路,单纯应用锐性吸脂针对增大的乳房进行肿胀抽吸治疗,吸出物送病理学检查。结果:乳房胸部塑形良好,无血肿、乳头乳晕感觉障碍等并发症。胸部无手术痕迹残留。随访3～18月无复发。病理检查结果显示吸出物中有增生的乳腺组织,病理特点符合男性乳腺发育症。结论:对于脂肪和乳腺组织均有增生的男性乳房发育症,锐性吸脂针腋皱襞入路单纯肿胀抽吸术是一种可选的有效手术方法。     

Arthroscopic Anterior Diskectomy of the Cervical Spine

We describe a minimally invasive arthroscopic technique for anterior diskectomy of the cervical spine. Fingertip pressure is applied between the carotid sheath laterally and the pharynx medially. The trachea and esophagus are displaced to the contralateral side. The disk level, soft-tissue thickness, and midline are verified with image intensification. A spinal needle is inserted through the soft tissue into the disk space at the midline. Contrast is injected to facilitate visualization. While maintaining displacement of the pharynx, a 4-mm vertical incision is made to incorporate the needle and is enlarged bluntly. A guidewire is passed through the needle. A dilator is passed over the guidewire, through the soft tissue, and usually into the disk, stopping posterior to the mid-vertebral body, as verified with lateral imaging. A cannula is placed over the dilator, and the dilator and wire are removed. Occasionally, the cannula is passed over the dilator to the anterior aspect of the disk, and the dilator is replaced with a trephine to penetrate the anterior spinal ligament, osteophytes, and annulus. The cannula seated in the middle of the disk allows diskectomy to commence with small rongeurs through the cannula, followed by a cervical spine arthroscope with a working channel. The arthroscope is removed, and further diskectomy is performed under fluoroscopic guidance with a motorized shaver and radiofrequency probe.     

Education and engineering solutions for potential problems with laparoscopic monopolar electrosurgery.

The potential problems of monopolar electrosurgery relate to unrecognized energy transfer ("stray current") outside the view of the laparoscope. Mechanisms of stray current and unrecognized tissue injury include: (1) insulation breaks in electrodes; (2) capacitive coupling, or induced currents through the intact insulation of the active electrode to surrounding cannulas or other instruments; and (3) direct coupling (or unintended contact) between the active electrode and other metal instruments or cannulas within the abdomen. Capacitive coupling poses the greatest risk for injury when the outer conductor (trocar cannula or irrigation cannula) is electrically isolated from the abdominal wall by a plastic nonconductor. Capacitive coupling is increased by the coagulation mode (versus cut), open circuit (versus tissue contact with the electrode), 5-mm cannulas (versus 11 mm), and higher voltage generators. The safety of electrosurgery can be enhanced by surgical education regarding the biophysics of radio frequency electrical energy, technical choices in instruments using all-metal cannula systems, and engineering developments with a dynamically monitored system for insulation failure and capacitive coupling.