Surgery 2001

Prologue It has become apparent over the past few years that technology is advancing at a rate beyond even the wildest expectations. It is difficult to keep up with all the aspects of a changing surgical practice let alone those technologies which promise to change the future of surgery. An example of this rapid change is laparoscopic surgery. The technologies behind this innovation have been in place in academia, business, and industry for a decade or two, even though they appear new to physicians. And when we are introduced to a new technology, it is usually difficult to completely understand and to put it into the perspective of a busy surgical practice.The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense     

The nature of surgical error A cautionary tale and a call to reason

Errors and “patient safety” have taken on monumental importance for surgery. Like all things new, there is an initial over-reaction before a return to a balanced perspective. The current response to the global interest in error has been to seize on the latest reports that are focusing on the “systemic nature” of errors, which is also being referred to as “the new look.” There has been an unintentional ignoring of the actual error, referred to as the coface error, that the surgeon commits. It is time to put the approach to errors into perspective and redefine errors within the context of the surgical community, which can result in a balance of the surgeon’s position in regard to systemic and personal responsibility. The opinions or assertions contained herein are the private views of the author and are not to be construed as official, or as reflecting the views of the Department of the Army, Department of the Navy, the Defense Advanced Research Projects Agency, or the Department of Defense.     

An alternative use for a nasotracheal tube

The opinions and assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense.     

Hyperthermia after cardiopulmonary bypass in a child

The opinions or assertions contained herein are the private views of the authors and are not to be construed as reflecting the view of the Department of the Army or the Department of Defense     

Virtual reality surgical simulator

Summary The virtual-reality surgical simulator signals the beginning of an era of computer simulation for surgery. The surgical resident of the future will learn new perspectives on surgical anatomy and repeatedly practice surgical procedures until they are perfect before performing surgery on patients. Primitive though these initial steps are, they represent the foundation for an educational base that will be as important to surgery as the flight simulator is to aviation. It is anticipated that the full development of the surgical simulator will take less than the 40 years which was required for flight simulators to become an indispensable ingredient of pilot training. As the system evolves, many new and yet-to-be-imagined applications will arise, but we must have understanding and patience as we wait for computer power to improve to a point where VR surgical simulation can emerge from its PacMan era.The opinions or assertions contained herein are the private views of the author and are not to be construed as official, or as reflecting the views of the Department of the Army or the Department of Defense     

Historical Review of Surgical Simulation—A Personal Perspective

Although simulation is relatively new to surgical education, there is a long history in many other disciplines, such as military, aviation, and nuclear power plant operations, among others. In the late 1980s these technologies began to be adapted to the surgical world, along with the new technology of virtual reality. This is a review of the introduction of manikins, computers, and virtual reality into education and training for surgical skills. Two concomitant revolutions occurred: objective assessment of surgical skills and converting training from the apprenticeship model to one of criterion-based training. A personal perspective on these developments adds information not previously published. Opinions or assertions contained herein are the private views of the author(s) and are not to be construed as official, or as reflecting the views of the Departments of the Army, Navy or Air Force, the Defense Advanced Research Projects Agency, or the Department of Defense. This is a declared work of the U. S. Government and as such is not subject to copyright protection in the United States.     

Disruptive visions: surgical education

Technological change, decreased financial support for medical education, and social oversight (in the form of the To Err Is Human report, HIPPA, and reduced work hours) are forcing a rethinking of the traditional model of surgical education to improve patient safety. New approaches to evaluating surgical competence, such as objective assessment, in combination with new technologies, such as the Internet and surgical simulators, provide the tools to effect a revolution in surgical education and training. Competency based upon quantifiable criteria measures must replace the traditional subjective assessment. The implementation requires accurately defining the elements of training, establishing new quantifiable metrics, stringently measuring performance against criterion, and reporting outcomes throughout the career of a surgeon. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official, or as reflecting the views of the Department of the Army, Department of the Navy, the Advanced Research Projects Agency, or the Department of Defense.     

A quick and simple method to close vascular, biliary, and urinary tract incisions using the new Vascular Closure Staples

Traditional suture reconstruction of tubular organs creates a perforating needle injury, leaves suture material on the endothelial or mucosal surfaces, and is cumbersome when done endoscopically. One alternative method of reconstruction of tubular organs could use the new non-penetrating clip to create an everted closure. In five pigs, a longitudinal incision of the infrarenal aorta, inferior vena cava, left ureter, gallbladder, and the common bile duct (in two) was closed with Vascular Closure Staples (VCS-clips). Four weeks after surgery, all ten blood vessels remained patent with no thrombosis. There was a well-healed wound with continuous intimal layer. The ureteral, gallbladder, and common bile duct wounds healed without leakage or obstruction in all animals. There was complete mucosal bridging of the wound, although in some specimens one or two clips were exposed to the lumen. The VCS-clips are easily and quickly applied and are safe insofar as can be determined by short-term follow-up. Disclaimer: The opinions expressed herein are those of the authors and are not to be construed as reflecting the views of the Uniformed Services University of the Health Sciences, the Department of the Army, or the Department of Defense.     

Disruptive visions: Biosurgery

There are a number of new therapeutic options generated by the biotechnology, bioengineering, and bioimaging revolutions in terms of organ-specific designer drugs, genetically engineered cells, cell-specific proteins and drugs, directed energy instruments, therapeutic microdevices, etc. Many of these new therapies need to be placed exactly on, within, or adjacent to an organ, and many others are delivered by endoluminal or endovascular approaches. The common requirements are (1) the accurate delivery of the modality and (2) the functional importance of targeting the biologic basis rather than the anatomic structure—hence the term biosurgery. As more of these therapies achieve clinical applicability and FDA approval, there will be the need for the precision of delivery to be at the micro- and nanoscale, which is well beyond human physical limitations. The surgeon of the future must be able to identify those therapeutic modalities that would benefit from such exact placement or implantation and acquire the skills, training, and equipment to use surgical expertise to deliver these new modalities. A review of some of the emerging opportunities is presented. Ignoring these challenges will relinquish these new procedures to other nonsurgical interventionalists, perhaps to the detriment of patient safety. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official, or as reflecting the views of the Department of the Army, Department of the Navy, the Advanced Research Projects Agency, or the Department of Defense.     

Free tissue transfer at an army medical center

Free tissue transfer has been demonstrated to be an effective modality of treating a variety of wounds and conditions in the civilian population. The use of these procedures has been underreported by American military surgeons. Military surgeons face unique hurdles that make the effective performance of these procedures difficult. We report our experience with free flap reconstruction at an American Army medical center. We performed 44 free flaps in 38 patients; although operative times and hospital length of stay were comparatively long, our success rates were excellent with only one partial flap loss. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Army or the Department of Defense.     

The optimal treatment of lymphoceles following renal transplantation

Lymphoceles are well-recognized complications following kidney transplantation. The authors describe their experience with the treatment of eight clinically significant lymphoceles (incidence 2.7%). In seven patients percutaneous needle aspiration was attempted, often repeatedly, both for diagnostic and therapeutic purposes. In all of the patients the lymphocele recurred within days and internal marsupialization was therefore performed, in the last two patients utilizing minimal access surgery through laparoscopy. There were no postoperative complications or signs of a recurrence of the lymphocele. Patients following the laparoscopic marsupialization had a much briefer hospital stay and postoperative convalescence. Our results confirm that internal marsupialization is the procedure of choice for most post-transplant lymphoceles. Internal marsupialization through laparoscopy should be used in patients who meet the standard criteria for laparoscopy.This is a United States government work. There are no restrictions in its use. The opinions and assertions contained herein are the private view of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.     

Successful treatment of early postoperative aortic graft infection by percutaneous catheter drainage

Successful treatment by percutaneous catheter drainage of an acute aortic graft infection with an associated pancreatic fistula is reported. Percutaneous catheter drainage can be considered in selected patients when the risk of reoperation is deemed unacceptable or when other reasonable treatment options do not exist.The views expressed herein are those of the authors and do not represent the views of the Department of Defense or other departments of the U.S. government.     

Flap techniques as an adjunct in vaginal fistulectomy

This paper reviews the method of vaginal fistulectomy as currently practiced worldwide. In addition, the tissue flap techniques available for repair of extensive injuries not amenable to primary multilayer closure are presented. Specific optional flap procedures proposed in fistula closure include: random tissue flaps, the labial fat pad (Martius graft), the bulbocavernosus muscle flap and the gracilis or rectus abdominis myocutaneous tissue flaps. The uses and advantages of each procedure and a comparison with split-thickness skin grafts are discussed.The opinions and assertions contained herein are those of the authors and are not to be construed as official or as representing the views of the Department of the Army or the Department of Defense.     

Acetabular Fractures in the Elderly: Treatment Recommendations

Acetabular fractures in the elderly population are marked by a high degree of variability in terms of patient and fracture characteristics. Successful outcomes depend on application of highly individualized management principles by experienced teams. Reviewed are indications and outcomes associated with various management options, including closed treatment, open reduction internal fixation, and acute or staged total hip arthroplasty. Proper initial management choices are critical, as early failures and subsequent salvage surgery can be accompanied by significant morbidity. Clinical results after ORIF closely follow the quality of articular reduction and the ability to maintain a congruent reduction of the hip joint. Fracture characteristics predictive of anatomic articular reduction should be treated with ORIF. Fracture characteristics predictive of early post-traumatic arthritis should be treated with simultaneous ORIF and THA. Presented is one referral institution’s treatment algorithm and management approach.The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.     

FatalPneumocystis pneumonia in a child treated for focal segmental glomerulosclerosis

A 4-year-old female with nephrotic syndrome secondary to focal segmental glomerulosclerosis (FSGS) was treated with pulse methylprednisolone and chlorambucil therapy. She subsequently developed fatalPneumocystis carinii pneumonia (PCP). This is the first report of a pediatric patient whose treatment for FSGS resulted in PCP raising the issue of PCP prophylaxis for these patients.The views expressed in this material are those of the authors and do not reflect the official policy or position of the United States government, the Department of Defense, or the Department of the Air Force.     

T-tube placement during laparoscopic cholecystectomy

Summary The management of common bile duct stones during laparoscopic cholecystectomy can pose a challenge to the surgeon as no definitive management plan is universally accepted at this time. We present a case where a common bile duct exploration was performed through a choledochotomy, describing how the t-tube was placed.The contents of this article do not necessarily reflect the views of the Department of the Army or the Department of Defense     

Q-angle: a factor in peak torque occurrence in isokinetic knee extension*

* This study was conducted in partial fulfillment for the requirements the U.S. Any-Baylor University Program in Physical Therapy, Academy of Health Sciences, Fort Sam Houston, TX. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the U.S. Army or the Department of the Defense. The purpose of this study was to examine the differences in peak torque occurrence during knee extension range of motion between groups of subjects with varying quadriceps-angle (Q-angle). Fifty-six female subjects, aged 18 to 35, participated in the study. The subjects were separated into three groups: low (N = 12) consisted of subjects with Q-angles <11 degrees ; moderate (N = 27), 13-17 degrees ; and high (N = 17), > 19 degrees . Three sets of subjects, grouped according to Q-angle, were evaluated using the Cybex II Isokinetic Dynamometer. Each subject was tested at three isokinetic speeds (30, 60, and 180 degrees /sec) utilizing only the right lower extremity. The results suggest that the point at which peak torque occurs within knee extension range of motion is not significantly different between the three groups of subjects tested at the three test speeds.J Orthop Sports Phys Ther 1988;9(7):250-253.     

Investigation of the flexible ruler as a noninvasive measure of lumbar lordosis in black and white adult female sample populations

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Army, the Department of Defense, or the U.S. Government. The purpose of this study was to investigate the validity of the flexible ruler as a noninvasive measure of lumbar lordosis in black and white adult females. The bony landmarks of the second lumbar vertebra (L2) and the intersection of the posterior superior iliac spines (PSIS) were palpated and marked on 45 adult females (21 blacks, 24 whites). Potential subjects with a previous history of activity-limiting low-back pain, spinal surgery, or spinal anomaly were excluded from the study. A lateral lumbosacral roentgenograph was taken of each subject, and an actual (skeletal) lumbosacral lordosis angle (ALS) was calculated from the roentgenograph. A flexible ruler was then molded to the contour of the subject's lumbosacral spine, and the previously marked L2 and PSIS intersection bony landmarks were located on the flexible ruler. The flexible ruler lordosis angle (FRA) was then calculated and correlated to the subject's ALS. The criterion validity of the flexible ruler as a measure of actual lumbosacral lordosis was poor (Pearsons' Correlation Coefficient = 0.30, N = 45). Because of the poor criterion validity of the flexible ruler compared to roentgenographically confirmed lumbar lordosis, the flexible ruler has questionable clinical value in the assessment of lumbar lordosis. J Orthop Sports Phys Ther 1989;11(1):3-7.     

Complications following needle bladder-neck suspension

Urinary incontinence affects over ten million Americans, and 75 000 surgeries are performed annually to correct this problem. Complications following bladder-neck suspension are uncommon, but when a complication does occur it generates concern from both patient and physician. In patients with anatomically correctable stress urinary incontinence who opt for surgery, preoperative counseling should include the likelihood of failure, postoperative urinary retention, hemorrhage and the other complications discussed. With adequate counseling and appropriate management, complications following bladder-neck suspension can be handled without significant trauma to either patient or physician.The opinions or assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Departments of the Army, Air Force or Defense.