Clear Surgical Field Research Articles

A new technique for treating hiatal hernia with gastroesophageal reflux disease: the laparoscopic total left-side surgical approach

IntroductionAlthough the traditional bilateral surgical approach to treat hiatal hernia (HH) with gastroesophageal reflux disease (GERD) can provide local protection of the vagus nerve, the integrity of the entire vagus nerve cannot be evaluated. Therefore, we developed and described the total left-side surgical approach (TLSA), which theoretically reduces injury to the vagus nerve, and described the detailed surgical procedure.MethodsInitially, we performed a cadaver study to explore the characteristics of the vagus nerve. Then, we prospectively evaluated the TLSA in 5 patients with HH and GERD between June 2020 and September 2020. Demographic characteristics, surgical parameters, perioperative outcomes, and follow-up findings were analyzed.ResultsThe TLSA was successfully used in five patients (40–64 years old), and no major complications were noted. The median total operative time was 114 min, median blood loss was 50 mL, and median postoperative hospital stay was 3.8 days. Gastrointestinal function recovered within 4 days of surgery in all the patients. The 6-month follow-up gastroscopy examination showed well-established gastroesophageal flap valves. Compared with the baseline results, the 6-month follow-up results showed lower values for the total GerdQ score (12.4 vs. 6.2) and the total esophageal acid exposure time (3.48% vs. 0.38%). Based on the European Organization for Research and Treatment of Cancer quality of life questionnaire-stomach module 52 results, the incidence of dysphagia and flatulence decreased over time after the TLSA.ConclusionsThe TLSA provides a clear and broad surgical field, less trauma, and rapid recovery; moreover, it is technically simple. Although our results suggest that the TLSA provides safety and short-term efficacy and is feasible for patients with HH and GERD, long-term results from a larger clinical trial are needed to validate these findings.Trial registration ChiCTR2000034028, registration date is June 21, 2020. The study was registered prospectively

Bleeding Control with Warm Saline Irrigation during Functional Endoscopic Sinus Surgery

Background: Functional endoscopic sinus surgery is a surgical technique that requires a clear surgical field in which bleeding occurs during surgery may become obstacle for surgeon. Warm saline irrigation produce hemostasis to control mucosal bleeding during surgery. Objective: To demonstrate the effectiveness of warm saline irrigation as mucosal bleeding control during FESS. Cases: There were four cases, two male and one female with chronic rhinosinusitis (CRS) with nasal polyps and one male with allergic fungal rhinosinusitis (AFRS) underwent a FESS. A warm saline irrigation was administered during all procedures, Boezaart score was used to assessed bleeding grade during surgery. Methods: Literature search found 86 journals from Pubmed and Springer database, and there were three articles met the criteria. Results: Three articles obtained were met the criteria in term of study providing warm saline irrigation at temperatures up to 50o C as a mucosal bleeding control during FESS able to be effective in more than two hours surgical time. Conclusion: Warm saline irrigation for FESS can reduce bleeding thereby affecting a better surgical field.

Effect of tranexamic acid on blood loss, coagulation profile, and quality of surgical field in intracranial meningioma resection: A prospective randomized, double-blind, placebo-controlled study.

Background: Resection of intracranial meningioma has been associated with significant blood loss. Providing a clear surgical field and maintaining hemodynamic stability are the major goals of anesthesia during meningioma surgery. Tranexamic acid has been used to reduce blood loss in various neurosurgical settings with limited evidence in literature. A randomized, double-blind, and placebo-controlled trial was conducted to evaluate the efficacy of tranexamic acid on blood loss, coagulation profile, and quality of surgical field during resection of intracranial meningioma.Methods: Thirty patients aged 18–65 years undergoing elective meningioma resection surgery were given either tranexamic acid or placebo (0.9% saline), tranexamic acid at a loading dose of 20 mg/kg, and infusion of 1 mg/kg/h during surgery. The intraoperative blood loss, coagulation profile, and the surgical field using Likert scale were assessed.Results: The patients in tranexamic group had significantly decreased intraoperative blood loss compared to the placebo group (616.42 ± 393.42 ml vs. 1150.02 ± 416.1 ml) (P = 0.02). The quality of the surgical field was better in the tranexamic group (median score 4 vs. 2 on Likert Scale) (P < 0.001). Patients in tranexamic group had an improved coagulation profile and decreased blood transfusion requirement (p=0.016). The blood collected in closed suction drain in 24 h postsurgery was less in the tranexamic acid group compared to placebo group (84.7 ± 50.4 ml vs. 127.6 ± 62.2 ml) (P = 0.047).Conclusion: Tranexamic acid bolus followed by infusion reduces perioperative blood loss by 46.43% and blood transfusion requirement with improved surgical field and coagulation profile in patients undergoing intracranial meningioma resection surgery.

Tension-Free Anterior Rerouting of the Facial Nerve in Management of Jugular Foramen Paragangliomas.

Tension-Free Anterior Rerouting of the Facial Nerve in Management of Jugular Foramen Paragangliomas.

Application of Percutaneous Holmium Laser Lithotripsy in the Treatment of Bladder Calculi with Lower Urinary Tract Obstruction or Pelvic Joint Disease

Objective: The aim was to summarize the experience of percutaneous holmium laser lithotripsy in the treatment of bladder calculi with lower urinary tract obstruction or pelvic joint disease in our hospital, explore its efficacy and safety, and improve the minimally invasive surgical technique for bladder calculi. Methods: The clinical data of 61 patients with bladder calculi combined with lower urinary tract obstructive diseases, including urethral stricture, benign prostatic hyperplasia, and bladder neck contracture or pelvic joint diseases in our hospital from 2017 to 2019 were retrospectively analyzed. All patients with bladder stones measuring 1.5–9 cm were placed in supine or lithotomy position. B-scan was conducted to locate the puncture above the pubic symphysis, establishing a 16–30 Fr bladder channel, and Lumenis holmium laser lithotripsy was subsequently performed through a Li Xun Nephroscope. The crushed stones were flushed out through the percutaneous bladder channel or taken out with foreign body forceps. After surgery, the cystostomy tube was indwelled for 3 days. Results: All the 61 cases were operated successfully with an average lithotripsy time of 25 min, and there was no conversion to open surgery. Postoperative reexamination showed neither residual calculi nor complications such as severe infection, massive hemorrhage, and intestinal injury. Conclusion: Percutaneous holmium laser lithotripsy is an improved minimally invasive surgical technique for the treatment of bladder calculi with the advantages of clear surgical field, high stone removal efficiency, less trauma, low-pressure bladder perfusion, and low incidence of accessory injury and infection. For patients with lower urinary tract obstructive disease resulting in obstruction of transurethral surgery and patients with pelvic joint disease resulting in difficult lithotomy position placement, this procedure is more advantageous than transurethral surgery. It is also suitable for bladder calculus with a long diameter >5 cm or multiple calculi.

Hybrid Surgical and Endovascular Approach via the Contralateral Superficial Middle Cerebral Vein to Occlude Cavernous Sinus Dural Arteriovenous Fistula in a Hybrid Operating Room: A Case Report

Most cases of cavernous sinus dural arteriovenous fistula (CS-dAVF) are treated via the inferior petrous sinus (IPS) through the transfemoral vein approach, but there are cases where treatment through the superficial middle cerebral vein (SMCV) is required. A hybrid operating room (OR) is useful because it allows for smooth direct surgery and endovascular treatment in a clean surgical field. We herein report a case of simultaneous treatment for CS-dAVF by coil embolization via a contralateral SMCV and middle cerebral artery (MCA) aneurysm by clipping in a hybrid OR. A 68-year-old woman had been suffering from left chemosis and ptosis for 2 months before visiting our hospital. Digital subtraction angiography (DSA) revealed Borden type II and Cognard type II a+b CS dAVF with parenchymal hemorrhaging and an unruptured left M1/M2 junction aneurysm. Since passing through the CS via the femoral vein was unsuccessful, we decided to access the right CS via the left CS through the intercavernous sinus (ICS) via the left SMCV by the pterional approach in a hybrid OR equipped with a multi-axis working system angiography machine. Endovascular treatment via direct cannulation into the contralateral SMCV following craniotomy in a hybrid OR is an optional strategy for treating complicated CS-dAVF.

A case series of treatment of oral mucosal lesions using diode lasers

Background: Einstein's photoelectric amplification theory provided the template for the development of lasers. With recent technological advancements, the increasing use of lasers in dentistry has had a meaningful impact on the diagnosis and management of oral mucosal lesions. This case series highlights lasers' impact. Case Reports: Five patients with diagnoses of arteriovenous malformation, homogeneous leukoplakia, mucocele, traumatic fibroma, and erosive lichen planus were treated with a diode laser (1,200 J/s; wavelength of 940 nm; 1.5 W; pulse mode). The patients were followed up to evaluate lesion healing and complete healing of the lesion was rapidly achieved with minimal discomfort. Conclusion: Soft-tissue lasers are trending in the management of various oral mucosal lesions due to their advantages of providing higher precision, a clean surgical field with minimal blood loss, accelerated wound healing, and fewer postoperative complications.

Anatomical and Clinical Implication of Corona Mortis in the Anterior Approaches of Pelvis in Sudanese Patient

Background: Corona Mortis is an abnormal blood vessels connecting Between obturator and external iliac systems of vessels and inferior epigastric vessels. It is located behind the superior public ramus at a variable distance from the symphysis pubis. Orthopaedic surgeons and obestitrtion found these vessels in the field of surgery. So displaced fractures or iatrogenic injury, can cause life threatening bleeding and hence these vascular anomalies are referred to us crown of death. The bulk of the studies about the corona mortise were conducted in the cadavers or 3D CT angiography and there was no studies were conducted about corona mortise in Sudan. The purpose of this study was to study the corona mortis anatomical and clinical implication in the anterior approaches to the pelvis and acetabulum in Sudanese patient. Methodology: Hospital based descriptive cross-sectional study was conducted among patients sustaining anterior pelvic anterior acetabulum fracture and underwent open reduction internal fixation by reconstruction plates. This study was conducted in Bahri Teaching Hospital from June 2017 to June 2018. Through the most common anterior approaches to the pelvis and acetabulum (Stoppa-modified stoppa-ilioinguinal), done by single surgeon and fulfil data sheet intra-operatively. Results: In a total of 30 pelvic halves corona mortis was detected in 13 patients (43%).The Majority in the Rt.hemipelvies 7 (53.8%) specimens: arterial 4/13 (30.8%), venous 1/13 (7.7%) and both arterial and venous in 8/13 (61.5%) specimens respectively. Of these (53.9%) had a large Diameter > 5 mm and the largest one measure 80 mm, with mean distance From the symphysis 5.8 + 1.6 mm. Conclusion: Only 13 patients have corona mortis, 12 of them were arterial with diameter more than 5 mm (53%), and thus surgeon should exercise caution during Surgery and secure its site to help minimizing surgery time, Clear surgical field and prevent iatrgenic injury.

An easy way to tidy up long hair with rubber bands during scalp surgery.

One of the most challenging steps in preparing for dermatologic operations on the scalp can be securing a clean surgical field without long and messy hair. We present a simple and painless way to remove hair from the scalp surgical field utilizing three rubber bands.

Endoscopic Vascular Decompression for the Treatment of Trigeminal Neuralgia: Clinical Outcomes and Technical Note.

PurposeMicrovascular decompression (MVD) surgery is considered as an effective method with which to treat trigeminal neuralgia (TN). However, sometimes MVD surgery fails due to incomplete decompression of the responsible vessels caused by a poor visual field. In this study, we evaluated the benefits of endoscopic visualization and the value of full endoscopic vascular decompression (EVD) by describing the surgical results of 20 patients with TN after EVD.Patients and MethodsThis was a retrospective study in a single institution of 20 patients with TN who received EVD between April 2018 and October 2019. All patients underwent EVD via the suboccipital retrosigmoid approach without microscopy at any stage. Abnormal muscle response (AMR) and brainstem auditory evoked potentials (BAEPs) were routinely monitored throughout the procedure. Follow-up was conducted by outpatient and telephone interviews. The degree of facial pain was graded using the Barrow Neurological Institute (BNI) pain intensity score; a BNI of 1 was considered as the best result while a BNI of 2 or 3 was considered as a satisfactory result. Follow-up time ranged from 8 to 24 months, with a mean of 18±4.36 months.ResultsAll 20 patients with severe preoperative pain (BNI of 5) achieved immediate relief or complete control of pain after surgery (BNI of 1 to 2). Vascular conflicts were observed during surgery in all of the patients. None of the patients experienced hearing loss, facial paralysis, intracranial infection, cerebrospinal fluid leakage, cerebral hemorrhage, or death, following the operation.ConclusionWhen carried out by surgeons with endoscopic experience, EVD can provide a clear surgical field of view and reduce the risk of surgical injury. Our findings indicate that EVD is a safe and effective surgical method for the treatment of TN.

Dr. Ahila's Conchal Crusher for Concha Bullosa.

Endoscopic Sinus Surgery is evolving day by day, there is a constant need for improvisation in terms of instrumentation with clear bloodless surgical field and good postoperative results. The applications of Dr. Ahila's Conchal Crusher for managing Concha bullosa in Functional Endoscopic Sinus Surgery (FESS) Surgery are presented. The creation/innovation of Dr. Ahila's conchal crusher will prevent rawmucosal surface area, bleeding and scope fogging with blood during FESS surgery after traditional conchoplasty. This new instrument makes it easy to reduce concha bullosa during nose and sinus surgery creating a bloodless field, no risk of destabilization or fracture of middle turbinate hence no postoperative synechiae which may otherwise lead to iatrogenic frontal sinusitis. Surgical instruments represent a major financial asset to the healthcare facility. Single instrumentation is essential to avoid costly replacements, surgeon satisfaction, reduce costs and delays in the Operating room and enhance patient safety. Dr. Ahila's conchal crusher may facilitate the performance of concha bullosa surgery and advance the art of Endoscopic Sinus surgery to a better level.

Comparative Evaluation of Hypotensive and Normotensive Anesthesia on LeFort I Osteotomies: A Randomized, Double-Blind, Prospective Clinical Study.

Orthognathic surgery can account for a considerable amount of blood loss since the vascularization of maxillofacial region is such that major bleeding can occur. Intra-bony bleed is often involved as a major aspect of blood loss associated with osteotomies, especially LeFort I osteotomy when performed during orthognathic surgery. This study evolved as a result of the increasing concern to attain a clear surgical field and reduce the duration of surgical procedure and the amount of blood loss associated with orthognathic surgery with the use of controlled hypotension. Twenty patients planned for undergoing LeFort I osteotomy were randomly allocated into two groups (Group 1-normotensive anesthesia; Group 2-hypotensive anesthesia). The amount of blood loss, mean difference between hemoglobin and hematocrit in the preoperative and postoperative period, and quality of surgical field were evaluated for patients in the two groups. Comparative analysis of the various parameters showed a statistically significant improvement in the hypotensive group when compared to normotensive group, although the duration of surgery and postoperative morbidity were not significantly affected when controlled hypotension was used.

A case report on the excision of irritational fibroma using the diode laser

Irritational fibroma is a commonly occurring oral lesion, which may mimic many other pathological conditions. In this case report, we present a case of a 15-year-old male with an ill-defined overgrowth on the gingiva which was diagnosed with an irrational fibroma due to the presence of calculus. This was then excised using biolase laser, and uneventful healing was noted postoperatively. The advantage of laser over conventional treatment is that it helps in better precision, clean surgical field, and lesser postoperative complications.

An Innovative Technique to Maintain a Clear Surgical Field During Venous Anastomosis in Free Flap Transfer for Head and Neck Reconstruction

Authors proposed a simple innovative technique that helps in achieving a clear surgical field at the time of venous repair by diverting the venous bleeding through a glove finger and at the same time preventing venous congestion of the flap.

Coblation Assisted Endoscopic Excision of Juvenile Nasopharyngeal Angiofibroma- An Institutional Observational Study

Objective: The purpose of our case series is to highlight the role of coblation in endoscopic JNA excision in terms of blood loss, duration of surgery and hospital stay. This was a Retrospective study done at Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha between January 2014 to June 2019 which includes 12 patients of JNA. Material and Method: The present case series was of 12 cases of JNA removal by endoscopic approach using coblation. Proper history taking and clinical examination was done in all cases. All patients were male between age group 5 to 20 years in the present series. In all patients preoperative CECT and MRI was done and staged according to Radkowski staging system. Out of 12 patients, 9 patients (Radkowski stage IB, IIA &amp; IIB) were operated without embolization &amp; 3 patients (Radkowski stage IIB &amp; IIIA) were embolized 24 hr before operation. Result: The present study suggests that coblation decreases the chances of intraoperative bleeding, provides clear surgical field thus reduces operative time. Coblation helps in debulking of tumor, preserving anatomical integrity, increases chance of complete removal and reduces the recurrence. Coblation decreases use of frequent and multiple instrumentation. So use of coblation in JNA removal (with or without preoperative embolization) gives advantage of safe and effective results. Conclusion: Hence, none of the 12 patients required post-operative blood transfusion and follow-up showed no complications in any of the cases.

Clinical efficacy of laparoscopic stomach intestinal pylorus sparing surgery in the treatment of severe obesity

Objective To investigate the clinical efficacy of laparoscopic stomach intestinal pylorus sparing surgery (SIPS) in the treatment of severe obesity. Methods The retrospective and descriptive study was conducted. The clinical data of 5 patients with severe obesity who were admitted to the China-Japan Union Hospital Affiliated to Jilin University from October to November 2018 were collected. There was 1 male and 4 females, aged from 18 to 55 years, with an average age of 33 years. All the 5 patients underwent laparoscopic SIPS. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Follow-up was performed by outpatient examination, telephone interview and Wechat up to February 2019, including general condition, changes in body weight, body mass index, waistline, blood pressure, percentage of excess weight loss, fasting plasma glucose, glycosylated hemoglobin, blood lipid, and uric acid at 3 months after surgery. Measurement data with normal distribution were represented as Mean±SD, and they were tested with Hotelling T2 test. Measurement data with skewed distribution were represented as M (range). Results (1) Surgical situations: 5 patients underwent successfully laparoscopic SIPS under clear surgical field, without obvious bleeding, conversion to open surgery or perioperative death. The operation time was 240 minutes (range, 165-345 minutes). (2) Postoperative situations: the time to initial out-of-bed activity, time to first and flatus, and time to initial drinking and liquid intake were 2 days (range, 2-3 days), 3 days (range, 2-3 days), and 3 days (range, 3-4 days), respectively. On the third day after surgery, all the 5 patients were confirmed anastomotic patency, without gastric leakage, stenosis, or obstruction by upper gastrointestinal contrast. The abdominal drainage-tube was removed on the fourth day after feeding without obvious discomfort and foreign substances extraction from the drainage-tube. The duration of postoperative hospital stay was 6 days (range, 6-7 days). (3) Follow-up: 5 patients with severe obesity were successfully followed up for 3 months. During the follow-up, one patient had significantly increased frequency of defecation, roughly 5-8 times a day, especially after eating greasy food. According to the dietary guidance of the case manager, diarrhea was improved significantly after reducing the intake of oily food. Of the 5 patients with severe obesity, color doppler ultrasonography examination revealed that cholestasis was found in 2 patients at 3 months after operation, which may be related to significant weight loss, ratio imbalance of bile acid to and cholesterol, intestinal microbiota, injury of vagus nerve, significant increasing in mucin of gallbladder, and without oral ursodeoxycholic acid as prescribed by the doctor. The body weight, body mass index, waistline, systolic blood pressure, and diastolic blood pressure of 5 patients with severe obesity were (100±15)kg, (36±4)kg/m2, (111±10)cm, (130±12)mmHg (1 mmHg=0.133 kPa), and (78±14)mmHg at 3 months after operation, respectively, showing significant differences compared with these of preoperation (F=61.631, 75.558, 87.045, 9.501, 16.248, P<0.05). The percentage of excess weight loss was 44%±9%. Among the 5 patients with severe obesity, the fasting plasma glucose of 2 patients with type 2 diabetes mellitus decreased from 9.55 mmol/L and 13.49 mmol/L to 5.18 mmol/L and 5.62 mmol/L after operation, respectively. Level of glycated hemoglobin decreased from 10.0% and 9.9% to 5.2% and 6.2% after operation, respectively. In the 2 patients with hyperlipidemia, one patient with hypertriglyceride had level of triglyceride, total cholesterol, and low density lipoprotein increased from preoperative 2.24 mmol/L, 4.84 mmol/L and 2.92 mmol/L to 2.47 mmol/L, 6.68 mmol/L and 5.51 mmol/L after operation, another patient with hypercholesterol had cholesterol level decreased from preoperative 5.97 mmol/L to postoperative 5.75 mmol/L after operation. In the 3 patients with hyperuricemia, two patients had the uric acid decreased from 404 μmol/L and 484 μmol/L to 319 μmol/L and 417 μmol/L after operation, respectively, one had the uric acid increased from 531 μmol/L to 674 μmol/L after operation. Conclusions Laparoscopic SIPS has a significant short-term effect on patients with severe obesity, but its long-term safety and efficacy need to be further followed up. Key words: Obesity; Type 2 diabetes mellitus; Stomach intestinal pylorus sparing surgery; Biliopancreatic diversion surgery; Laparoscopy

Laparoscopic Right Posterior Sectionectomy Under Single Incision Plus One Port for Hemangioma

Introduction: Laparoscopic right posterior sectionectomy is one of the most technically challenging laparoscopic liver resections.1–5 The single-incision laparoscopic surgery is known to have a highly cosmetic effect, less pain, and shorter hospital stay, but with technical difficulties.6–13 For single incision plus one port surgery, the additional port can be utilized for drainage as well an additional access route for laparoscopic procedures to overcome the technical difficulties. This video demonstrates a laparoscopic right posterior sectionectomy using a single incision plus one port technique. Materials and Methods: A 32-year-old male was evaluated for right upper quadrant pain with a computed tomogram that showed a 9.5 cm sized exophytic hemangioma in segment 6 of the liver. Based on the size and his symptom, surgical resection was recommended. Operatively, the patient was placed in a supine position with the legs split. After making a 3 cm incision through the umbilicus, an additional 12 mm port for the assistant was placed in the right upper abdomen. The surgeon stood between the legs of the patient, while the assistant stood on the right side of the patient. After dividing the cystic duct and artery, the gallbladder and round ligament were fixed to the abdominal wall using Endo-graps (Port-Free Endocavity Retractor; Virtual Ports, Misgav, Israel). The hepatic hilum was dissected bluntly using suction. Then the right posterior Glissonean pedicle was ligated. Without doing the Pringle maneuver, the hepatic parenchyma was dissected meticulously. The additional assistant port was used for liver retraction during deeper parenchyma dissection. After completing the dissection of the liver, the specimen and gallbladder were removed through the umbilical wound. Finally, a Jackson–Pratt drain was placed at the hepatic resection margin through the additional assistant port. Results: This operation took 220 minutes and the estimated blood loss was 100 mL. The Jackson–Pratt drain was removed 2 days after the operation. The patient was discharged 3 days after the operation without any postoperative complications. The final histopathologic report showed a cavernous hemangioma. Conclusions: Although single-incision techniques have been attempted for hepatectomy, posterior sectionectomy is still a technically difficult procedure. Because the posterosuperior part of the liver is difficult to access, any significant bleeding during parenchymal transections can be difficult to control laparoscopically.14 When posterior sectionectomy is performed using a single-incision technique, one additional port can assist to retract the liver and to make clean surgical field by suctioning effectively. Ultimately, this additional port can then be used for the insertion of a drain. Overall, the single incision plus one port laparoscopic surgery can be a new option in right posterior sectionectomy. Acknowledgment: The authors thank Woo Chul Kim, MD, for help in improving the use of English in the article and recording a narration. This video was presented at the Video Exhibition in the HBP Surgery Week 2018, Korea. No competing financial interests exist. Runtime of video: 5 mins 28 secs

The efficacy of esmolol, remifentanil and nitroglycerin in controlled hypotension for functional endoscopic sinus surgery

IntroductionControlled hypotension is a reversible procedure in which the patient’s baseline mean arterial blood pressure is reduced by 30% and sustained at 60–70 mmHg during the procedure. It decreases blood loss and provides clear surgical field during the procedures. ObjectivesThe purpose of this study was to compare the efficacy of controlled hypotension agents esmolol, remifentanil, and nitroglycerin in functional endoscopic sinus surgery, in terms of hemodynamic changes and impact on the surgical efficiency. MethodsThe research was carried out as a cohort study. Patients who underwent functional endoscopic sinus surgery were randomized into 3 groups. Controlled hypotension was achieved with remifentanil (Group R), esmolol (Group E) and nitroglycerin (Group N). The efficacy of the drugs was tested by comparing the length of time with the targeted mean arterial pressure, the amount of anesthetics used, surgical field bleeding score and surgeon’s satisfaction. ResultsBetween May to December 2015, 60 patients were included and randomized equally into 3 different study groups. The median of the length of time with the targeted mean arterial pressure was shorter in the Group R when compared with Group E (p = 0.01) and Group N (p = 0.14). The amount of volatile anesthetics used was 25.0 mL (15–51), 43.0 mL (21–105) and 40.0 mL (26–97) in Groups R, E and N, respectively (p < 0.001). While there was more bleeding with nitroglycerin, surgical field bleeding scores were lower in Group R when compared with esmolol (p = 0.001) and nitroglycerin (p < 0.001). The analysis of surgeon’s satisfaction scores concluded that surgeons were more satisfied with the group R (100%), when compared with group E (60%) and group N (30%) (p < 0.001). ConclusionLess volatile agent, short time to achieve controlled hypotension, stable blood pressure, lower surgical field bleeding scores and larger length of time with the targeted mean arterial pressure were found as the advantages of Remifentanil. Less costly, efficiency of achieving the targeted median arterial pressure and less postoperative complications were the advantages of nitroglycerin. In functional endoscopic sinus surgery procedures, appropriate controlled hypotensive agents should be selected according to the patients’ characteristics and advantages/disadvantages of the drugs.

The cheek expander enables tonsillectomy with a wide view and working space

ObjectiveTonsillectomy is the most commonly performed otolaryngological surgeries.Although a surgical method had been established, obtaining a clear surgical field still remains problematic, and injury to the corners of the mouth may occur. For safer tonsillectomy, we use a cheek expander coupled with a Davis mouth gag. The devise retract both corners of the mouth to a wide lateral position. We report here our investigation in the application of a cheek retractor for tonsillectomy and also report the advantages of this device. MethodsA series of 13 tonsillectomies (7 adults and 6 children) using the cheek retractor from November 2017 to March 2018 were enrolled for this study. The cheek retractor was applied after the Davis mouth-opening device was in place. We measured the oral angle diameter before and after placement of the cheek retractor. ResultsThis devise increases the width of the visual field 1.6 times and provides a good surgical field. In addition, this device covers the mouth fully and safely, so no lip injury develops ConclusionThe cheek retractor is useful for improving the narrow working space in tonsillectomy.

More pain and slower functional recovery when a tourniquet is used during total knee arthroplasty.

Although a tourniquet can effectively control intraoperative blood loss and offer clear surgical field in total knee arthroplasty (TKA), its optimal usage has been controversial. The aim of this research was to perform a systematic review and meta-analysis to compare and explore the best application of a tourniquet in TKA. MEDLINE, PubMed, EMBASE, the Cochrane Library, Wanfang database, and Web of Science were searched for randomized controlled trials (RCTs) comparing the four different strategies of tourniquet application in TKA. In Group I, a tourniquet was not used and was called the non-tourniquet (NT) group. In Group II, a tourniquet was only used during the cementation of implants and was called the specific duration tourniquet (SDT) group. In Group III, the tourniquet was only released before wound closure to control the bleeding sources and was called the majority duration tourniquet (MDT) group. In Group IV, a tourniquet was used throughout the procedure, from skin incision to wound closure and was called the whole duration tourniquet (WDT) group. Forty-six RCTs were included in this systematic review and meta-analysis. In a comparison between the NT and WDT groups (25 RCTs), intraoperative blood loss (IBL) (P = 0.0001) and range of motion (ROM) (P = 0.0001) were significantly increased in the NT group, while the visual analog score (VAS) (P = 0.0001), rate of deep vein thrombosis (DVT) (P = 0.01), and all complications (AC) (P = 0.0001) were significantly decreased in the NT group. In a comparison between the SDT and WDT groups (10 RCTs), IBL (P = 0.0001), TBL (P = 0.009), and ROM (P = 0.0001) were significantly increased in the SDT group, while thigh pain (P = 0.04) and the rate of DVT (P = 0.03) were significantly decreased in the SDT group. There were no significant differences between the MDT and WDT groups (12 RCTs) except for the rate of all complications (P = 0.01). Despite the decrease in IBL with a tourniquet, no difference was found in TBL. In conclusion, not using a tourniquet or only using it during the cementation of implants was preferable based on the faster functional recovery, lower rate of DVTs and complications compared with using a tourniquet throughout the TKA procedure. I.