Consent For Surgery Research Articles

Microsurgical Clipping of an Unruptured Basilar Apex Aneurysm: 2-Dimensional Operative Video.

Aneurysms of the basilar artery apex are generally at an increased risk of rupture compared with aneurysms in other locations, and the risk of rupture increases with increasing aneurysm size. Therefore, these lesions necessitate treatment to decrease the risk of rupture. The location, size, and directionality of dome projection influence the difficulty of microsurgical treatment. The patient presented with an incidental basilar apex aneurysm identified on workup for headaches. The aneurysm projected superoposteriorly into the interpeduncular cistern. The surgical approach involved a wide exposure of the basilar apex complex and meticulous identification and preservation of P1 perforators during clip applications. It was imperative to visualize all perforators on both sides of the clip prior to application, given the severe morbidity associated with a perforator infarct. The patient tolerated the procedure well and remained neurologically intact after the operation. This video is an exemplary demonstration of basilar apex aneurysm clip application for an incidentally discovered aneurysm. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Optic Nerve Decompression from Coil Mass Impingement and Adhesion Following Large Internal Cerebral Artery Aneurysm Coil Embolization: 2-Dimensional Operative Video.

Aneurysmal mass effect is a consideration for treatment modality selection, particularly in the setting of cranial neuropathy or obstructive hydrocephalus. However, the extent of consequences related to mass effect is not always apparent periprocedurally from the original treatment. This unique video highlights a patient who underwent previous coil occlusion of a supraclinoid internal carotid artery (ICA) aneurysm with subsequent occlusion of the ipsilateral ICA who presented 16 yr later with progressive worsening hemianopsia. The preoperative imaging was suggestive of coil mass impingement prompting operative intervention for decompression. Intraoperative inspection demonstrated that the coil mass was exerting mass effect on the optic nerve and had partially migrated out of the aneurysm dome into the optic nerve. The ICA was also transected and mobilized to further reduce mass effect. Careful microsurgical decompression was achieved and prevented further visual compromise. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Treatment of a Fusiform Anterior Cerebral Artery Aneurysm With an A3-A3 Bypass: 2-Dimensional Operative Video.

Distal anterior cerebral artery (ACA) aneurysms remain a relatively rare and challenging entity for both open microsurgical and endovascular treatments. These lesions provide a significant surgical challenge because of the narrow interhemispheric surgical field, limited proximal control, common fixation of the aneurysm to the adjacent cingulate gyrus, and possible involvement of an unpaired azygos A2. These challenges result in a known association between distal ACA aneurysms and higher operative morbidity. This video demonstrates indirect obliteration of a prior ruptured fusiform right A2 aneurysm utilizing an A3-to-A3 side-to-side anastomotic bypass with aneurysm trapping. An anterior interhemispheric approach was used for exposure of bilateral ACAs, arteriotomies, microanastomosis, and trapping of the aneurysmal right A2 segment. Postoperatively, the patient's neurological status returned to baseline, and imaging demonstrated evidence of bypass patency with no residual filling of the fusiform aneurysmal segment. This video verifies the feasibility and efficacy of the A3-to-A3 anastomotic bypass for treatment of distal ACA aneurysms. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Hunterian Ligation With Distal Revascularization for Management of a Previously Coiled Giant Internal Cerebral Artery Aneurysm: 2-Dimensional Operative Video.

Unclippable giant aneurysms pose a significant microsurgical challenge. Options for management are highly dependent on the aneurysm characteristics and cerebrovascular anatomy. Hunterian (proximal) ligation with either high-flow or low-flow distal revascularization is an option for the treatment of aneurysms of the internal carotid artery (ICA). This patient had a multiply recurrent supraclinoid ICA aneurysm following endovascular treatment and progressive ipsilateral homonymous hemianopsia. In preparation for the clip occlusion of the proximal ICA, the patient underwent a balloon test occlusion of the ICA, which had a negative result, indicative of tolerance. A pterional craniotomy was used to perform a low-flow bypass, superficial temporal artery to M2, and clip occlusion of the proximal ICA. The patient tolerated the procedure well with some pressure-dependent contralateral symptoms, which resolved. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Consent in forefoot surgery; What does it mean to the patient?

AimsThis study aimed to assess patient risk recall and find risk thresholds for patients undergoing elective forefoot procedures. MethodsPatients were interviewed in the pre-assessment clinic (PAC) or on day of surgery (DOS); some in both settings. A standardised questionnaire was used for all interviews, regardless of setting. Patients were tested on which risks they recalled from their consent process, asked for thresholds for five pre-chosen risks and asked about a sham risk. ResultsAcross all interviews, risk recall on DOS (2.34 risks/patient interview) was significantly lower (p=.05) than in PAC (2.95 risks/patient interview) – this was repeated when comparing results from patients interviewed in both settings only with PAC mean recall of 2.93 risks/patient interview and DOS mean recall of 2.57 risks/patient interview. The mean reported risk thresholds greatly exceeded NHS Lothian’s observed complication rates for forefoot procedures. The five risks tested for thresholds produced the same order in each interview setting, suggesting a patient-perceived severity ranking. Patients answering the sham risk question incorrectly tended to recall fewer risks across all interviews. ConclusionsThis study shows that patient risk recall is poor, as previous literature outlines, reinforcing that consent process improvements could be made. It also illustrates the value of PAC visits in patient education, as shown by higher levels of recall when compared to DOS.

Pictorial Consent in Cardiac Surgery: A far better option rather than Standard Informed Written Consent

Pictorial Consent in Cardiac Surgery: A far better option rather than Standard Informed Written Consent

Response to: ‘Montgomery in, Bolam out: are trainee surgeons “material risks” when taking consent for cataract surgery?’

Response to: ‘Montgomery in, Bolam out: are trainee surgeons “material risks” when taking consent for cataract surgery?’

Clipping of Basilar and Middle Cerebral Artery Aneurysms: 2-dimensional operative video.

Careful preoperative planning for patients with multiple intracranial aneurysms is paramount given the importance of an appropriate trajectory and exposure for each aneurysm that will be clipped. The general principle is to clip aneurysms in a retrograde manner, such that more distal aneurysms are clipped earlier, and more superficial aneurysms are clipped later. This patient had unruptured middle cerebral artery (MCA) and basilar artery (BA) apex aneurysms and elected for surgical clipping of both lesions. An orbitozygomatic craniotomy ipsilateral to the MCA aneurysm was performed to permit clipping of both lesions. The dissection initially focused on exposure of the MCA aneurysm and then focused on the carotid-oculomotor triangle to permit basilar apex exposure and aneurysm clipping. The MCA aneurysm was clipped second. Postoperative imaging demonstrated complete obliteration of both aneurysms. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Intraoperative Rerupture and Surgical Clipping of a Small Superiorly Projecting Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video.

Anterior communicating artery (ACoA) aneurysms are prone to rupture even at smaller sizes. The surgical management of ACoA aneurysms is highly dependent on the spatial orientation of the saccular projection, categorized as inferior, superior, anterior, or posterior. Superior projecting aneurysms constitute approximately one-third of all aneurysms involving the ACoA. These aneurysms commonly project within the interhemispheric fissure; however, if the aneurysm is not high-riding, it can often be approached via a transsylvian trajectory. The patient presented after subarachnoid hemorrhage with a 3-mm superiorly projecting ACoA aneurysm. The lesion was approached via a right modified orbitozygomatic craniotomy with a transsylvian trajectory. The aneurysm reruptured after minimal manipulation of the dome. Mitigation of the intraoperative rupture was achieved through temporary clip application to bilateral A1 vessels. Bipolar coagulation and placement of 2 permanent clips facilitated final aneurysm occlusion. Postoperative imaging demonstrated patent bilateral A2 flow and no residual aneurysm filling. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Surgical Challenges Associated With Anterior Choroidal Artery Aneurysm Clipping: 2-Dimensional Operative Video.

Surgical treatment of anterior choroidal artery (AChA) aneurysms is challenging because of the constrained operative corridor and limitations imparted by the surrounding rigid structures during the exposure. The AChA most commonly arises as a single branch from the communicating (C7) segment of the internal carotid artery but has 2 to 4 branches in approximately one-third of cases, and aneurysms generally arise from the parent vessel interface with these branches. This patient experienced a sentinel headache 4 d before presenting with subarachnoid hemorrhage. The patient had a large right AChA aneurysm with a unique configuration in which the parent vessel was located anterior to the aneurysm. Endovascular therapy was aborted because there was an AChA branch at the base of the aneurysm. An orbitozygomatic craniotomy was performed that provided transsylvian access to the region of interest. Clip application was challenging because of the close proximity of the branch vessels. Intraoperative indocyanine green evaluation and postoperative angiogram showed patency of the AChA and posterior communicating artery. This video demonstrates the surgical challenge associated with AChA aneurysms because of the proximity of adjacent structures and highlights the importance of meticulous technique during clip application. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

An a3-Anterior Inferior Cerebellar Artery to p3-Posterior Inferior Cerebellar Artery Bypass With Thrombectomy and Trapping of an Anterior Inferior Cerebellar Artery Aneurysm: 3-Dimensional Operative Video.

In situ bypasses to the anterior inferior cerebellar artery (AICA) are unusual because, with only one artery in the cerebellopontine angle (CPA), no natural intracranial donors parallel its course. In rare cases, the posterior inferior cerebellar artery (PICA) may have the tortuosity or redundancy to be mobilized to the AICA to serve as a donor. This video demonstrates this p3 PICA-to-a3 AICA in situ side-to-side bypass. A 75-yr-old woman presented with ataxia and hemiparesis from a large thrombotic right AICA aneurysm compressing the brainstem. Strategy consisted of bypass, trapping, and brainstem decompression. Written informed consent for surgery was obtained from the patient. A hockey-stick incision was made to harvest the occipital artery as a backup donor, but its diminutive caliber precluded its use. The bypass was performed through an extended retrosigmoid craniotomy. The aneurysm was trapped completely and thrombectomized to relieve the pontine mass effect. Indocyanine green videoangiography confirmed patency of the bypass, retrograde filling of the AICA to supply pontine perforators, and no residual aneurysmal filling. This unusual in situ bypass is possible when redundancy of the AICA and PICA allow their approximation in the CPA. The anastomosis is performed lateral to the lower cranial nerves in a relatively open and superficial plane. The extended retrosigmoid approach provides adequate exposure for both the bypass and aneurysm trapping. In situ AICA-PICA bypass enables anterograde and retrograde AICA revascularization with side-to-side anastomosis. The occipital artery-to-AICA bypass and the V3 vertebral artery-to-AICA interpositional bypass are alternatives when intracranial anatomy is unfavorable for this in situ bypass.1-6 Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Clipping of Complex Internal Cerebral Artery Terminus Aneurysm: 2-Dimensional Operative Video.

Internal carotid artery (ICA) bifurcation, or terminus, aneurysms are uncommon, and although they can be accessed with relative ease, clip occlusion of such aneurysms is often challenging due to the close proximity of basal forebrain perforator vessels. This patient had an incidentally discovered ICA terminus aneurysm and elected for microsurgical clipping. A modified orbitozygomatic approach was used to approach the aneurysm. The clipping was significantly complicated by the adherence and close proximity of the recurrent artery of Heubner to the aneurysm dome. Following successful dissection of the artery from the aneurysm dome and complete visualization of the aneurysm neck to avoid violation of perforator flow, successful clip occlusion of the aneurysm was achieved. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Informed Consent for Surgery During COVID-19: Some Important Issues.

Informed Consent for Surgery During COVID-19: Some Important Issues.

Transpetrous Clip Occlusion of a Giant Midbasilar Aneurysm Using Hypothermic Cardiac Arrest: 2-Dimensional Operative Video.

Basilar trunk aneurysms are historically associated with extremely high morbidity. The complexity of circumflex perforator arteries responsible for the perfusion of the brainstem makes surgical intervention for these lesions particularly challenging. This patient had a giant midbasilar aneurysm that encompassed multiple perforators but was associated with progressive mass effect and debilitating morbidity. Therefore, a transpetrous approach was used with transposition of the facial nerve and sacrifice of the vestibulocochlear nerve to permit access to the aneurysm. Hypothermic cardiac arrest was used to permit dome manipulation with a tandem fenestrated clipping of the aneurysm. Postoperative imaging demonstrated a reduction in mass effect attributable to the significantly reduced dome size and persistence of flow via a reconstructed basilar trunk. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Left A2 Fusiform Aneurysm: 2-Dimensional Operative Video.

Anterior cerebral artery aneurysms within the A2 segment that are fusiform or giant A2 aneurysms with a wide neck often are not candidates for endovascular treatment and require surgical intervention. These lesions necessitate a bypass procedure to preserve distal flow along the anterior cerebral artery. This patient demonstrated a left-sided unruptured A2 fusiform aneurysm that necessitated a bypass procedure for management. The patient was positioned with the head rotated laterally to permit orientation of the interhemispheric fissure within the horizontal plane and achieve gravity retraction of the dependent hemisphere. The bilateral pericallosal branches were exposed and liberated from arachnoid adhesions to permit mobilization necessary for the side-to-side anastomosis. While the anastomosis was performed, the continuous suture loops were left loose to permit complete visualization of the inner and outer walls prior to the final tightening and tying of the anastomotic suture. Following the completion of the anastomosis, the temporary clips were removed. A permanent clip was placed on the distal A2 to prevent outflow from the parent artery and thereby allow for aneurysm thrombosis. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Kickstand Rod Technique for Correcting Coronal Imbalance in Adult Scoliosis: 2-Dimensional Operative Video.

Restoration of spinal alignment and balance is a major goal of adult scoliosis surgery. In the past, sagittal alignment has been emphasized and was shown to have the greatest impact on functional outcomes. However, recent evidence suggests the impact of coronal imbalance on pain and functional outcomes has likely been underestimated.1,2 In addition, iatrogenic coronal imbalance may be common and frequently results from inadequate correction of the lumbosacral fractional curve.2,3 The "kickstand rod" is a recently described technique to achieve and maintain significant coronal-plane correction.4 Also, of secondary benefit, the kickstand rod may function as an accessory supplemental rod to offload stress and bolster primary instrumentation. This may reduce occurrence of rod fracture (RF) or pseudarthrosis (PA).5 Briefly, this technique involves positioning the kickstand rod on the side of coronal imbalance (along the major curve concavity or fractional curve convexity in our video demonstration). The kickstand rod spans the thoracolumbar junction proximally to the pelvis distally and is secured with an additional iliac screw placed just superior to the primary iliac screw. By using the iliac wing as a base, powerful distraction forces can reduce the major curve to achieve more normal coronal balance. This operative video illustrates the technical nuances of utilizing the kickstand rod technique for correction of severe lumbar scoliosis and coronal malalignment in a 60-yr-old male patient. Alignment correction was achieved and maintained without evidence of RF/PA after nearly 6 mo postoperatively. The patient gave informed consent for surgery and to use imaging for medical publication.

Surgical Clipping of an Unruptured Large Inferiorly Projecting Anterior Communicating Artery Aneurysm With Chiasmopathy: 2-Dimensional Operative Video

Anterior communicating artery (ACoA) aneurysms are a frequently encountered cerebrovascular entity that is associated with a high rupture rate at a smaller size and debilitating morbidity and mortality following rupture. The surgical management of ACoA aneurysms is highly dependent on the spatial orientation of the saccular projection, which is categorized as inferior, superior, anterior, or posterior. The inferiorly projecting aneurysms constitute a minority of all aneurysms involving the ACoA. The adherence of the aneurysm dome near the chiasm predisposes these patients to dome avulsion during frontal lobe retraction. This patient presented with a 1-mo history of progressive vision loss and was found to have a large inferiorly projecting ACoA saccular aneurysm measuring 2.04 cm×1.54 cm with resultant chiasmopathy. The lesion was approached via a right modified orbitozygomatic craniotomy, which can provide a more favorable maximal angle of approach to the ACoA complex to avoid brain retraction. Intraoperative adenosine was administered to provide relaxation of the aneurysm dome to augment clip placement. Postoperatively, the patient's chiasmopathy demonstrated near-complete resolution. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Excision of a Large Complex Left Middle Cerebral Artery Aneurysm With a Middle Cerebral Artery-Middle Cerebral Artery and Superficial Temporal Artery-Middle Cerebral Artery Bypass: 2-Dimensional Operative Video.

Revascularization techniques for microsurgical manage-ment of middle cerebral artery (MCA) bifurcation aneurysms are often necessary for treatment of fusiform or giant aneurysms. Augmentation of the standard pterional approach to include an extended orbitozygomatic or modified orbitozygomatic approach provides a wider and more favorable approach to the MCA when attempting revascularization. Direct excision of a giant aneurysm (aneurysmectomy) with mobilization and reanastomosis of the MCA afterward has been reported. This patient had a giant MCA bifurcation aneurysm for which aneurysmectomy and distal reanastomosis were performed between the M1 and two M2 branches via a modified orbitozygomatic craniotomy. A second bypass between a third M2 branch at the ipsilateral superficial temporal artery was performed. Postoperative angiography confirmed patency of the bypasses. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

What's Important: What I Learned as My Spouse's "Recovery Partner" Following Rotator Cuff Surgery.

What's Important: What I Learned as My Spouse's "Recovery Partner" Following Rotator Cuff Surgery.

Outcome and complications following transrectal and transabdominal large intestinal trocarization in equids with colic: 228 cases (2004-2015).

To describe outcome and complications after large intestinal trocarization in equids with colic and identify factors associated with nonsurvival and clinically relevant peritonitis (CRP). 228 (198 horses, 24 ponies, and 6 donkeys and mules) equids with colic that underwent large intestinal trocarization. Medical records from 2004 through 2015 were reviewed for equids with colic that underwent large intestinal trocarization. Factors associated with nonsurvival in all (ie, surgically and medically treated) equids and with CRP in medically only treated equids were identified. Medically only treated equids with a high peritoneal fluid cell count (ie, > 10,000 cells/μL) after large intestinal trocarization were classified as having CRP if they met ≥ 2 of the following clinical criteria: anorexia, fever, lethargy, abnormal oral mucous membrane color, abnormal WBC count, or high blood fibrinogen concentration (> 5 g/L). Transabdominal large intestinal trocarization was performed in 190 (83%) equids, transrectal trocarization in 17 (7%), and both procedures in 21 (9%). Of 228 equids, 167 (73%) survived to hospital discharge. None died or were euthanized because of complications from large intestinal trocarization. Nonsurvival was associated with an increasing number of trocarization procedures and diagnosis of a large intestinal strangulating lesion. A diagnosis of nephrosplenic ligament entrapment of the large colon decreased the odds of nonsurvival. Twelve of 60 (20%) equids that received medical treatment only had CRP following large intestinal trocarization. Large intestinal trocarization could be considered for equids with colic and large intestinal gas distension. More than one trocarization procedure was associated with an increase in nonsurvival, which should be considered for equids for which consent for surgery has been obtained.