Lloyd-davies position with trendelenburg—A disaster waiting to happen?

PURPOSE: Lower limb compartment syndrome has been reported to occur after colorectal, urological, and gynecological procedures during which the patient's lower limbs are elevated for prolonged periods of time. METHOD: We investigated lower limb perfusion in a group of patients undergoing prolonged pelvic surgery both during and immediately after surgery, using intra-arterial blood pressure monitoring, laser doppler flowmetry, and pulse oximetry. RESULTS: Use of the modified lithotomy position was not associated with any demonstrable decrease in lower limb perfusion. The addition of 15° head-down tilt, however, during pelvic dissection, led to an immediate and significant drop in lower limb perfusion (P<0.05; Mann-WhitneyU test). The subgroup of patients analyzed postoperatively showed a ten-fold increase (P<0.01) in perfusion that was confined to the muscle compartment with no demonstrable increase in skin perfusion or intra-arterial pedal blood pressure. CONCLUSION: The use of the modified lithotomy position during pelvic surgery is not associated with lower limb ischemia. Addition of Trendelenburg position, however, causes profound ischemia of the lower limbs, and this is followed during the recovery period by hyperperfusion that is confined to the muscle compartments, which may put patients at risk of developing lower limb compartment syndrome.Presented at The Association of Surgeons of Great Britain and Ireland, Edinburgh, United Kingdom, May 13 to 15, 1998.     

Laparoscopic Surgical Skills Assessment: Can Simulators Replace Experts?

Introduction  Global Rating Scales (GRS) quantify and structure subjective expert assessment of skill. Hybrid simulators measure performance during physical laparoscopic tasks through instrument motion analysis. We assessed whether motion analysis metrics were as accurate as structured expert opinion by using GRS. Methods  A random sample of 10 consultant laparoscopic surgeons, 10 senior trainees, and 10 novice students were assessed on a Sharp Dissection task. Coded video footage was reviewed by two blinded assessors and scored using a Likert Scale. Correlation with metrics was tested using Spearman’s rho. Inter-rater reliability was measured using intraclass correlation coefficient (ICC). Results  Strongest GRS–Metric correlations were found for Time/Motion/Progress with Time (Spearman’s rho 0.88; p < 0.05) and Instrument Handling with Path Length (Spearman’s rho 0.8; p < 0.05). Smoothness correlated with Respect for Tissue in Rater 1 (rho 0.68) but not Rater 2 (rho 0.18). Mean GRS showed stronger inter-rater agreement than individual scale components (ICC 0.68). Correlation coefficients with actual experience group were 0.58–0.74 for mean GRS score and 0.67–0.78 for metrics (Spearman’s rho, p < 0.05). Conclusions  Metrics correlate well with GRS assessment, supporting concurrent validity. Metrics predict experience level as accurately as global rating and are construct valid. Hybrid simulators could provide resource-efficient feedback, freeing trainers to concentrate on teaching.     

Nd:YAG laser capsulotomy in the prone position under general anesthesia.

Neodymium:YAG (Nd:YAG) capsulotomy is the most common treatment for posterior capsule thickening. Occasionally, patients are unsuitable for receiving this treatment by slit lamp and require alternative surgical options. A technique enabling patients to undergo Nd: YAG laser capsulotomies while under general anesthesia is described. After induction of anesthesia in the supine position, the patient is transferred into the prone position and his or her neck is extended with the chin supported onto the Nd:YAG laser delivery slit lamp before the administration of the laser treatment. The procedure was performed in three individuals, who experienced good outcomes.     

Factors associated with community ambulation in chronic stroke

Purpose: Loss of independent community ambulation is one of the most disabling consequences of stroke. The aim of this study was to investigate the association of multiple personal and post-stroke factors with community ambulation in persons between 1- and 3-year post-stroke. Methods: This was a cross-sectional study of 40 community-dwelling stroke patients, >18 years, between 1- and 3-year post-stroke. The main outcome measures used were self-report community ambulation questionnaire, demographic information, 10-M Walk Test, Timed Up and Go test, Activities-Specific Balance Confidence Scale, Fatigue Severity Scale, Hospital Anxiety and Depression Scale, Trail-Making Test-Part B, Single Letter Cancellation Test. Results: Age, number of medications and use of a walking aid were found to be significantly associated with community ambulation (p?≤?0.05). Gait speed, walking balance and balance self-efficacy were also found to be significantly associated with community ambulation (p?≤?0.05). Balance self-efficacy was the only factor independently associated with community ambulation post-stroke (p?≤?0.05). Conclusion: Balance self-efficacy may be a significant determinant in the attainment of independent community ambulation post-stroke. This suggests that physical aspects such as gait speed and walking balance should not be considered in isolation when addressing community ambulation post-stroke.

• Implications for Rehabilitation

• Balance self-efficacy may play a significant role in the attainment of independent community ambulation in a chronic stroke population.

• Physiotherapy interventions addressing community ambulation post-stroke should consider methods for improving balance self-efficacy in chronic stroke, such as self management programmes.

     

Indocyanine green fluorescence-guided parathyroidectomy for primary hyperparathyroidism

Background

Our aim was to evaluate the ease and utility of using indocyanine green fluorescence angiography for intraoperative localization of the parathyroid glands.