Changes In Surgical Technique Research Articles

The Learning Curve for Surgical Margins After Open Radical Prostatectomy: Implications for Margin Status as an Oncological End Point

Surgical margin status is commonly used as an end point for surgical learning. We examined the surgical margin learning curve and investigated whether surgical margins are a good marker for oncological outcome. The study cohort included 7,765 patients with prostate cancer treated with radical prostatectomy by 1 of 72 surgeons at a total of 4 major American academic medical centers. We calculated the learning curve for surgical margins and a concordance probability between the surgeon rates of positive surgical margins and 5-year biochemical recurrence. A positive surgical margin was identified in 2,059 patients (27%). On multivariate analysis surgeon experience was strongly associated with surgical margin status (p = 0.017). The probability of a positive surgical margin was 40% for a surgeon with 10 prior cases, which decreased to 25% for a surgeon with 250 (absolute difference 15%, 95% CI 11 to 18). Learning curves differed dramatically among surgeons. For surgeon pairs the surgeon with the superior positive surgical margin rate also had the better biochemical recurrence rate only 58% of the time. We noted a learning curve for surgical margins after open radical prostatectomy. The poor concordance between surgeon margin and recurrence rates suggests that while margins clearly matter and efforts should be made to decrease positive margin rates, surgical margin status is not a strong surrogate for cancer control. These results have implications for using the margin rate to evaluate changes in surgical technique and as surgeon feedback.

Reduction of Biliary Complication Rate Using Continuous Suture and No Biliary Drainage for Duct-to-Duct Anastomosis in Whole-Organ Liver Transplantation

Biliary complications (BC) following orthotopic liver transplantation (OLT) are related to various factors including surgical technique and use of biliary drains for a duct-to-duct (DD) anastomosis. Herein we have reported the influence of changes in surgical technique on BC following OLT in our center. From February 2002 to February 2007, we performed 101 whole-organ OLT with a DD anastomosis in 99 adults, of whom we analyzed 84 subjects. We excluded recipients who died within 30 days of OLT without any evidence of BC and 1 patient with a biliary stricture secondary to a hepatic artery thrombosis. Until late 2004, a DD anastomosis with interrupted sutures over an external biliary drain (DD/BD) was performed in 35 patients (Group I). Subsequently, no biliary drain was used for the DD anastomosis (DD/non-BD), using a continuous suture in 49 patients (Group II). The DD anastomosis with interrupted sutures over a biliary drain was associated with a higher incidence of both total (31% vs 8%; P = .008) and late BC (>30 days; 20% vs 2%; P = .008) with a trend toward more leaks (17% vs 4%; P = .06). All biliary leaks in patients with DD/BD reconstruction occurred at the exit site of the biliary drain following its removal. No significant differences were observed when we compared the incidence of biliary strictures and the necessity for surgical intervention. One patient died due to a BC. Our results indicated that a DD anastomosis performed with a continuous suture technique and no external biliary drainage reduced the incidence of BC after whole-organ OLT.

Metal-on-Metal Hip Resurfacing and Total Hip Arthroplasty in the Same Patient: A Case Series Comparison

Early outcomes for metal-on-metal total hip resurfacing (MOMHR) suggest that it may have a role as a bone-sparing alternative to total hip arthroplasty (THA) in younger patients. The possible biomechanical advantages of MOMHR over THA have been extensively discussed in the published data and have been clinically examined. However, few studies have offered a direct, controlled comparison of patients' experiences after MOMHR and THA. To more accurately describe differences in patient outcomes between MOMHR and THA in comparable patients, we present a report of 8 patients who had both MOMHR and a contralateral THA. This report included a patient-completed hip comparison questionnaire that assessed hip pain, stiffness, surgical recovery, proprioception, hip strength, and overall preference. Most patients preferred MOMHR, citing reasons such as better range of motion, improved proprioception, and a faster, easier recovery. These preferences may likely be related to the biomechanical advantages of a larger femoral head. However, it is important to consider how differences in the time elapsed since the patients' index surgeries, changes in surgical technique and differences in rehabilitation affect patients' preferences. At this point, there are on-going prospective clinical trials comparing MOMHR to THA, and only after long-term reports are critically examined there may be more definitive recommendations.

Intraoperative detection of left atrial clot using transoesophageal echocardiography in a patient undergoing off-pump coronary artery bypass grafting

Intraoperative detection of left atrial clot using transoesophageal echocardiography in a patient undergoing off-pump coronary artery bypass grafting

Best Practice Updates for Surgical Care in Weight Loss Surgery

To update evidence-based best practice guidelines for surgical care in weight loss surgery (WLS). Systematic search of English-language literature on WLS in MEDLINE, EMBASE, and the Cochrane Library between April 2004 and May 2007. Use of key words to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. Evidence-based best practice recommendations from the most recent literature on surgical methods and technologies, risks and benefits, outcomes, and surgeon qualifications and credentialing. We identified >135 articles; the 65 most relevant were reviewed in detail. Regular updates of evidence-based recommendations for best practices in WLS are required to address rapid changes in surgical techniques and patient demographics. Key factors in patient safety include surgical risk factors, type of procedure, surgeon training, and facility certification.

Prevention of adhesions in surgery of the flexor tendons of the hand: what is the evidence?

Despite advances in knowledge and refinements of technique, the management of flexor tendon injuries within the digital sheath continues to present a formidable challenge. This in turn has led to a massive expansion in search of modified surgical therapies and various adjuvant therapies, which could prevent adhesion formation without compromising digital function. A search of PubMed, Medline, CINAHL and Embase databases was performed using the keywords 'tendon adhesion prevention', 'tendon healing', 'adhesion prevention in tendons' and 'adjuvants for adhesion prevention'. Studies detailing the use of surgical, pharmacological and non-pharmacological agents for adhesion prevention in digital flexor tendons were identified, and their bibliographies were thoroughly reviewed to identify further related articles. This search identified 41 studies, which investigated the use of various pharmacological agents in adhesion prevention in digital tendons. There is a need to develop and utilize an optimal method for the prevention of adhesions in the flexor tendons of the hand, due to post-surgical complications. Even though there have been significant advances in the prevention of adhesions in flexor tendons, it remains to be proved which, if any, of the current methods are the most beneficial. The only thing that appears clinically justified in adhesion prevention is the need for early post-operative mobilization of digits after tendon injury or repair but the best method of mobilization remains controversial. Suggested changes in surgical techniques and various proposed pharmacological and non-pharmacological modalities need to withstand the test of adequately powered human trials, before their justification for potential benefit in clinical practice is accepted.

Complete obstetric brachial plexus palsy: Surgical improvement to recover a functional hand

Complete obstetrical brachial plexus palsy remains a difficult situation for the child and his/her family. The quality of spontaneous reinnervation is rarely good and always leads to a non-sensitive and non-functional hand, even if abduction of the shoulder and elbow flexion do spontaneously recover. The aim of this study was to assess the results from nerve reconstruction in cases of complete palsy and to demonstrate the effect of a change in surgical technique on the outcome of hand function. Thirty pediatric patients with complete obstetric brachial plexus palsy were operated on in our department between 1987 and 2003. Twenty-five of these patients were clinically reviewed and evaluated by a physiotherapist and a surgeon (not the surgeon who performed the surgery). Functional assessment was based on the Gilbert shoulder score, the Gilbert-Raimondi score for elbow function and the Raimondi hand score. All children underwent a nerve reconstruction as graft and/or intra- or extra-plexual neurotization. Our neural surgical strategy changed between 1995 and 1996 to one that addresses the function of the hand and the wrist. A secondary surgical intervention was required in 18 cases. The most frequent procedures were a radial rotation osteotomy and a tendon transfer restoring wrist extension. Mean follow-up was 7 years and 10 months. Among children operated on with the first surgical strategy-the pre-1995-1996 period-hand function was good in three cases, satisfactory in four cases and unsatisfactory in one case. Among children for whom the second surgical strategy was used-1995-1996 and later-hand function was good or very good in eight cases, satisfactory in four cases and unsatisfactory in two cases. When the 25 patients were assessed for shoulder function, the functional result was good or very good in 12 cases, satisfactory in seven cases and unsatisfactory in six cases. In terms of elbow function, the results were good or very good in 14 cases, satisfactory in eight cases and unsatisfactory in three cases. All hands recovered sensation to a certain degree. The surgical results are encouraging in terms of shoulder and elbow function, but not as good for hand function. With the change in neural surgical strategy in 1995-1996, when more focus was placed on the hand (second surgical strategy), the results on hand function improved relative to those obtained with the first surgical strategy. It must also be noted that hand recovery requires more time, which may partially explain why functional results are not as good for the hand as for the shoulder and elbow. These results demonstrate that early surgical exploration is useful in complete obstetrical brachial plexus palsies and that there is a need for neural reconstruction of the lower trunk.

Robot-Assisted Laparoscopic Prostatectomy: The First 100 Patients—Improving Patient Safety and Outcomes

Patient safety and outcomes are paramount when using new technology. We report our initial experience of 100 patients with robot-assisted laparoscopic prostatectomy (RALP) with a focus on patient safety and outcomes. Data were prospectively collected from the first 100 consecutive patients who underwent RALP for localized prostate cancer from October 2004 to August 2007. To determine our learning curve, the cases were divided into quarters of 25 patients and stratified to identify trends. Mean age was 59.4 years (range 44.5-72.6 yrs), body mass index was 28.4 (range 20.4-40.1), preoperative prostate-specific antigen (PSA) level was 5.7 ng/mL (range 0.4-15.0 ng/mL), and follow-up was 12.7 months (range 7 days-38 mos). Mean operative time was 5.9 hours (range 3.7-10.9 hr), and estimated blood loss (EBL) was 218 mL (range 25-600 mL). Thirty bilateral pelvic lymphadenectomies were performed. Twelve patients had pT(2a) disease, 3 had T(2b), 61 had T(2c), 22 had T(3a)N(0), and 1 had T(3b)N(1). Positive surgical margin rate was 23%. Overall complication rate was 26%. At last follow-up, 88% (76/86) of patients had undetectable PSA levels, and 80% (70/87) of patients were using no pads. Improvement in EBL and operative time was noted throughout the series, and changes in surgical technique and perioperative management were made to improve patient safety and outcomes. RALP perioperative parameters improved throughout the first 100 cases, while postoperative outcomes remained acceptable. Methods to improve patient safety and outcome occurred throughout the series. Even during the initial learning curve for this procedure, RALP appears to be another alternative for achieving prostate cancer control.

Sport Activity after Total Hip Arthroplasty: Changes in Surgical Technique, Implant Design, and Rehabilitation

Over the past 10-15 years, many aspects of total hip arthroplasty (THA) have changed. First and foremost, the patients themselves have changed. Since 1990, the age group that has demonstrated the greatest increase in THA was patients between the ages of 45 and 64. As younger, healthier patients are having surgery, a greater emphasis is being placed on postoperative function, activity, and exercise. The rationale for increased postoperative activity is 2-fold: the obvious cardiovascular benefits of exercise and greater patient desire to return to recreational sporting activities. The purpose of this review is to discuss how recent changes in surgical technique, implant design, and pre- and postoperative rehabilitation have affected postoperative athletic activity for THA patients. Although these topics have been addressed often in the orthopedic literature, to our knowledge no published articles have summarized this information for a targeted audience of rehabilitation specialists.

Abdominal Surgery Impact Scale (ASIS) is Responsive in Assessing Outcome Following IPAA

PurposeVarious generic and disease-specific quality of life instruments are available to assess outcome following surgery. However, they may not be sensitive to changes in outcome in the early postoperative period, which is important when assessing changes in surgical technique and perioperative care. The Abdominal Surgery Impact Scale (ASIS) is a validated instrument designed to assess short-term outcome following surgery. Thus, the aims of this study were to assess the impact of surgery on patients undergoing ileal pouch anal anastomosis (IPAA), assess factors which might impact on outcome, and lastly, further evaluate the reliability and internal consistency of the ASIS. MethodsPatients over the age of 18 who had an IPAA between March 2005 and October 2007 completed the ASIS on postoperative day 3 and at the time of discharge. The ASIS contains 18 items within six domains with possible scores ranging from 18 to 126. Demographic, clinical and surgical data, postoperative complications, and length of stay were also recorded. Internal reliability of the ASIS was measured using Cronbach’s alpha coefficient. ResultsNinety-two patients (36 female, 56 male, mean age = 36.8 ± 10.8) completed the ASIS at two time intervals (mean 3 days and mean 7 days postoperatively). Forty-seven patients had an IPAA performed with an ileostomy; 11 patients had the IPAA performed laparoscopically. The mean hospital stay was 10.8 days. The overall mean ASIS score significantly increased over the two time periods (mean 56.9±18.3 vs. 81.8 ± 17.3, p < 0.001). Patients who had an ileostomy had a significantly lower mean score at discharge (77.32 vs. 86.82), secondary to lower scores on the physical limitations, functional impairment, and visceral function domains. Seven (7.8%) patients had ileo-anal anastomotic leaks, and seven (7.8%) patients had small bowel obstructions. These patients had an increased length of stay, whereas patients having laparoscopic surgery had a significantly shorter length of stay (8.8 days vs. 11.1 days), but there was no significant difference in mean ASIS scores. Cronbach’s alpha coefficient was 0.94 overall and ranged from 0.69 to 0.91 for subscales indicating internal reliability. ConclusionsASIS is a valid instrument for measuring quality of life in the postoperative period and is responsive to changes over time. Although quality of life increases postoperatively during hospital stay, at discharge, patients with IPAA still have decreased quality of life. Patients with ileostomies have further decreased scores.

Lip adhesion revisited: A technical note with review of literature.

Context (Background):Lip adhesion is a direct edge approximation without changing lip landmarks or disturbing tissue required for definitive closure. This converts a complete cleft into an incomplete cleft, facilitating and enhancing subsequent definitive lip and nose repair.Aim:The study aims to describe our technique of lip adhesion and its morbidity, and discuss the rationale for its use.Settings and Design:Retrospective follow-up study of complete clefts operated upon in the Bruges Cleft and Craniofacial Centre, at the supra regional teaching hospital AZ St. Jan, Bruges, between June 1, 1991 and May 1, 2009.Methods and Material:The group comprised 33 unilateral and 24 bilateral lip adhesion procedures. The medical files were reviewed for changes in surgical technique, morbidity, and complications and their treatment.Results:The lip adhesion procedure was performed at the age of two to eight weeks postnatal, and definitive lip closure, at the age of four to six months. In all cases, segment repositioning was further controlled by a palatal guidance plate. Wound dehiscence occurred in eight patients (14.0%), and three patients (5.3%) required reoperation.Conclusions:Although complications occurred, the beneficial effects of lip adhesion in combination with a guidance plate outweighed the risks for anatomical reconstruction of a platform for definitive lip and nose repair. Modifications are suggested to reduce these complications.

The Specific Definition of High Risk Prostate Cancer Has Minimal Impact on Biochemical Relapse-Free Survival

Accurate categorization of high risk prostate cancer cases remains elusive. Various schemes based on clincopathological criteria have been proposed to stratify cases by presumed recurrence risk. We determined whether survival outcomes are dependent on the specific definition. The study population included men who underwent radical prostatectomy from 1987 to 1995 (708) and 1996 to 2007 (3,351). Patients who received adjuvant therapy or had no postoperative prostate specific antigen were excluded from analysis. High risk patients were identified based on 6 commonly used definitions. Biochemical failure was defined as a prostate specific antigen of 0.4 ng/ml or greater and increasing or initiation of salvage therapy. Estimates of biochemical relapse-free survival were generated with the Kaplan-Meier method. Hazard ratios for disease recurrence were estimated using Cox proportional hazards analysis. High risk patients determined by the 6 definitions demonstrated a 2.7 to 5.3-fold increased hazard of biochemical relapse, and 5 and 10-year biochemical relapse-free survival rates were 36% to 58% and 25% to 43%, respectively. When stratified by date of treatment high risk patients from 1987 to 1995 generally had worse biochemical relapse-free survival compared to those treated after 1996. Within each era the variation in biochemical relapse-free survival among various high risk definitions was not substantial. Biochemical relapse-free survival after radical prostatectomy does not vary substantially based on the specific definition of high risk prostate cancer. There is a trend toward improved biochemical relapse-free survival in patients treated more recently, perhaps reflecting stage migration or changes in surgical technique. The data suggest that high risk prostate cancer may represent a relatively homogeneous population.

Neurological Complications of Cardiac Surgery

Neurological injury resulting from cardiac surgery has a range of manifestations from focal neurological deficit to encephalopathy or coma. As the safety of drug-eluting stents comes into question, more patients will likely undergo coronary artery bypass graft surgery. These projections, along with the growing proportions of elderly patients and those with comorbidities, portend the potential for rising rates of perioperative neurological complications. The risk for neurological injury may be determined by the type of procedure, by patient-specific characteristics, and by the extent of cerebral embolization and hypoperfusion during and after surgery. Changes in surgical techniques, including the use of off-pump surgery, have not decreased rates of brain injury from cardiac surgery. When appropriate, modern neuroimaging techniques should be used in postoperative patients to confirm diagnosis, to provide information on potential etiology, to direct appropriate therapy, and to help in prognostication. Management of postoperative medications and early use of rehabilitation services is a recommended strategy to optimize the recovery for individuals with neurological injury after cardiac surgery.

Lymphedema after breast cancer in a prospective cohort study

20736 Background: Breast cancer-related lymphedema (BCRL) is a chronic, debilitating condition that may occur among breast cancer survivors after surgery and/or radiation therapy to the axilla. BCRL patients can experience overall decreased quality of life. Reports of the true incidence of lymphedema vary widely, and no large, population-based studies have been conducted with standardized diagnosis, measurement, and follow-up. Methods: In an ongoing, prospective study of recently-diagnosed breast cancer survivors at Kaiser Permanente Northern California (KPNC), we ascertained the incidence of BCRL based on electronic medical records. Cases were identified by ICD-9 code 4571.0, outpatient procedures for manual lymph drainage, or durable medical equipment orders after breast cancer diagnosis. We compared demographic, medical care utilization, and cancer characteristics among BCRL and non-BCRL women using Pearson’s chi- square test and Satterthwaite t-test. A brief questionnaire about BCRL education was administered at cohort entry among a sample of women. Results: As of 16 October 2007, 111 out of 1,176 breast cancer patients were diagnosed with BCRL (9.4% incidence with up to 22 months of follow-up). The mean time to diagnosis after cancer diagnosis was 6.2 months with the majority (37.9%) diagnosed in the first three months. BCRL patients were younger, had significantly more physical therapy and surgery visits, and had more advanced cancer stage than non-BCRL patients (p<0.05). No differences were observed by BMI at cancer diagnosis. Among 332 respondents, 67.8% reported having received BCRL educational materials from KPNC. Awareness of risk reduction strategies was poor, with only 60.5% and 57.8% reporting avoidance of trauma/injury and arm constriction, respectively. Suggestions for improving BCRL education included a discussion with the surgeon pre- and post-surgery and a mandatory physical therapy meeting post-surgery. Conclusions: Within a large HMO setting, BCRL remains an important health issue despite recent changes in surgical technique to remove positive lymph nodes. More improvements are needed for disseminating BCRL information to breast cancer patients due to mounting evidence that progression can be prevented through early treatment. No significant financial relationships to disclose.

No improvement in neurocognitive outcomes after off-pump versus on-pump coronary revascularisation: a meta-analysis

The popularity of off-pump (beating heart) coronary artery bypass grafting (CABG) was initially stimulated by numerous theoretical benefits including lower incidence of stroke and neurocognitive dysfunction. With a postoperative stroke rate of less than 1% for elective CABG, it has been very difficult to demonstrate any significant differences in this outcome between techniques. However, changes in neurocognitive function are more common in the postoperative setting and thus provide greater power for demonstrating improvement with changes in surgical technique. The aim of this meta-analysis was to assess whether there were significant differences in neurocognitive outcomes in patients after undergoing off-pump versus on-pump CABG. A database search for prospective randomised controlled trials of off-pump versus on-pump CABG in any language was conducted. Eight trials incorporating 892 patients fulfilled all the inclusion criteria for reporting of neurocognitive outcomes, and were able to be included in this meta-analysis. Sufficient data were available across the seven studies to combine results for five neurocognitive tests (Rey Auditory Verbal Learning, Grooved Pegboard, Trail A and B, and Digit Symbol). Overall there were no convincing differences in outcomes in neurocognitive testing between off-pump and on-pump CABG groups. The results of this meta-analysis show that there are no significant neurocognitive benefits when comparing off-pump versus on-pump CABG.

Positive Margins: The Challenge Continues for Breast Surgeons

Positive Margins: The Challenge Continues for Breast Surgeons

Infant Tracheotomy

To identify practice patterns regarding tracheotomy technique among pediatric otolaryngologists. Survey of physicians. Academic medical center. Members of the American Society of Pediatric Otolaryngology (ASPO) residing in the United States. Physician responses to survey questions, including both multiple choice and free-text responses. We used chi(2) tests to determine if demographic factors (pediatric otolaryngology fellowship training, the number of tracheotomies performed yearly) correlated with differences in the technique used to perform infant tracheotomies. A total of 168 of 225 surveys mailed to ASPO members (75%) were completed and returned. Most respondents (87%) report that they make a simple vertical incision in the trachea. An even greater number (94%) use stay sutures routinely. On other technical points, such as management of the thyroid gland, the subcutaneous fat, and the method of securing the tracheostomy tube, there was much greater variability: 22% of respondents reported having had a serious tracheotomy-related complication in the immediate postoperative period, and 58% of these physicians changed their technique as a result. In several areas, chi(2) analysis revealed statistically significant differences in technique that were dependent on both fellowship training and the number of tracheotomies performed (P < or = .05). Among ASPO members practicing in the United States, there is near-unanimity on certain technical points, with considerable divergence on others. A substantial percentage of our colleagues have experienced a tracheotomy-related complication in the early postoperative period. In many cases, these incidents led to changes in surgical technique.

Late Bacterial Keratitis After Intracorneal Ring Segments (Ferrara Ring) Insertion for Keratoconus

To report a case of late bacterial keratitis after intrastromal corneal ring segments (ICRSs; Ferrara ring; Ferrara Ophthalmics, Belo Horizonte, Brazil). Review the clinical findings in a 42-year-old woman with bilateral keratoconus who underwent implantation of Ferrara ring segments in her left eye and 4 months later presented with corneal infiltrates and hypopyon. Bacterial staining, culture, and antibiotic sensitivities were done. Medical treatment and rings explantation were performed. The cultures revealed growth of vancomycin-oxacillin sensible coagulase-positive Staphylococcus aureus. Treatment with topical moxifloxacin, topical imipenem, and systemic intravenous and topical vancomycin was kept for two weeks. Corneal inflammation and hypopyon resolved, leaving a minimal residual leucoma. Infectious keratitis is an uncommon complication of ICRS and it may be late in presentation, even months after implantation. Importance of patient education about alarm symptoms and the need for long-term close postoperative follow-up cannot be underestimated. If a change in surgical technique, i.e., suturing the incision, has an influence in this complication's incidence, it will require further studies.

Telesurgery System with Original-Quality Moving Images over High-Speed Internet: Expansion Within the Asia-Pacific Region

Amid rapid changes in surgical techniques and patient care, education and training for the new generation of health care providers is of utmost importance. An international telesurgical system, which we established between Japan and Korea through super-fast broadband Internet without any loss of quality, was shown to be a powerful tool for this purpose. We attempted to expand our advanced system throughout the Asia-Pacific region and studied its usefulness. Kyushu University Hospital (Fukuoka, Japan) was linked to 33 medical institutions and meeting venues in China, Taiwan, Thailand, Vietnam, Singapore, and Australia by academic optic fiber network. Digital video signals were directly converted into Internet protocol, and cipher security programs were used to protect patient privacy. Of 49 international surgical teleconferences conducted, 16 were real-time demonstrations of surgery, and 33 involved recorded videos. For 37 events, two stations were connected pier-to-pier, and for the remaining 12, multiple stations were connected. The network remained stable, and the time delay between stations was restricted to 0.3-1.0 seconds. Responding to questionnaires, 70.6% of participants rated the image quality as "very good," and 22.5% rated it "good." We succeeded in establishing a high-quality telesurgical system in a wide area of the Asia-Pacific region, and this is the first time high-speed Internet technology has been applied to surgery on such a large scale. Because it is not only of high quality but also economical and easy to set up, we believe this system will promote efficient remote surgical education and active academic exchange worldwide.

Sedation and Anesthesia Care for Ophthalmologic Surgery during Local/Regional Anesthesia

Anesthesia care for the patients undergoing ophthalmologic surgical procedures during local/regional anesthesia balances goals of patient comfort with safety and an optimal outcome in a highly cost-conscious environment. This article discusses current practices and trends in anesthesia care with respect to sedation for eye surgery during local/regional anesthesia. Although there is no evidence that one local/regional anesthesia technique or sedation analgesia regimen is superior to the others, this review highlights important differences between these varied approaches. The type of block used for the ophthalmologic surgery alters the sedation requirements. Changes in surgical techniques have increased the popularity of topical anesthesia, which reduces the need for sedation analgesia and may lessen the need for an anesthesia practitioner. The involvement of an anesthesia practitioner in eye surgery varies from facility to facility based on costs, anesthesiologist availability, and local standards. Anesthesia care choices are often made based on surgeon skill and anesthesiologist comfort, as well as the expectations and needs of the patient.