French Surgeons Research Articles

Reply to: Re: “NOTES: Where have we been and where are we going” (2008; 22(5):1143–1145) and “Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES, world’s first” (2008; 22(5):1343–1347)

Dear Editor, We welcome the interesting comments made by the French surgeons. The idea of the article was to show that the transvaginal route is a feasible alternative in Natural Orifice Translumenal Endoscopic Surgery (NOTES). The fact that it can only be applied in females is definitely a limiting factor. Until safer routes for NOTES are described, at least female patients can benefit. Several surgeons have used the transvaginal approach, and have found it viable [1–6]. I do not know if it is fair enough to say that all female patients do not prefer the transvaginal route based on a questionnaire answered by just 125 subjects. As the article states, the inherent danger of a potentially fatal gastric perforation is always present in the transgastric approach, especially since there is no foolproof method of gastrotomy closure as yet. Were the dangers of the transgastric approach clearly explained to these 125 subjects? In the transvaginal route, postoperative pain during sexual intercourse is an issue to contend with, but this was not a problem in any of our patients. Besides, only randomized controlled trials comparing the different routes can provide solid evidence, and I dare say that human trials would currently be premature. For now, we have to be satisfied with small case series. Yes, the debate continues. References

Patellar instability: the Lyon experience

During the past 3 decades, the surgeons of Lyon have developed a vast experience dealing with patellofemoral problems. The “Lyon School,” as it may be called, addresses episodic patellar instability using anatomical principles based on the teachings of Dejour and Walch. Under this theory, trochlear dysplasia is the fundamental anatomical abnormality, without which recurrent patellar instability is very rare. Trochlear dysplasia causes a flat upper portion of the trochlear groove, usually because of a prominent floor as opposed to deficient sidewalls, so that joint reaction forces are increased but lateral constraint is reduced. But the dysplasia itself is rarely addressed directly. Instead, surgical treatment addresses each of 3 principal factors whenever it is present: tibial tubercle–trochlear groove offset, patella alta, and patella tilt. This article presents an algorithm for treating episodic patellar instability based on the teachings of the Lyon School. Although the specifics of the treatment protocol remain subjects of discussion, debate, and study, the protocol has been very successful in the hands of French surgeons.

NOTES: because we can or because we should?

NOTES: because we can or because we should?

Cheeverʼs Double Operation: The First Le Fort I Osteotomy

In 1868, David Williams Cheever of Boston performed a daring operation, now known as a Le Fort I osteotomy, to expose and remove a large nasopharyngeal polyp. His published account described osteotomies 31 years before Le Fort's articles on experimental facial fracture lines, and remains the earliest description of this procedure. German and French surgeons had been treating similar polyps via hemimaxillary osteotomy. Because Cheever performed bilateral osteotomies, his technique became known as Cheever's "double operation." Cheever went on to become a prominent Boston surgeon, playing a pivotal role in the development of Boston City Hospital. He eventually became chair in surgery at Harvard Medical School, succeeding Bigelow and preceding J. Collins Warren at the Massachusetts General Hospital. He was also editor of the Boston Medical and Surgical Journal (a predecessor of the New England Journal of Medicine) and president of the American Surgical Association. Although Cheever's contributions have been recognized, little has been written about the life of this forgotten pioneer in American craniofacial surgery, nor the surgical and historical context in which his "double operation" was developed.

The Introduction of Ether in Paris Revisited**A version of this material was presented by the first author at the annual meeting of the Anesthesia History Association, Nashville, Tennessee, May, 2007.

Modern accounts of the introduction of ether anesthesia in France are mainly based on a letter written in February 1947 to the editor of the Boston Medical and Surgical Journal by Francis Willis Fisher, a young Boston surgeon at that time a student in Paris. Fisher's letter hints that his efforts were the main impetus to the acceptance of ether by the French academic surgeons. The authors have reviewed the contemporary medical literature, especially the numerous French journals, relative to that event. Their review suggests that Fisher was largely ignored by the French surgeons and by his young competitors then studying in Paris. He seems to have exaggerated his role in the acceptance of ether anesthesia in France. The reviewed literature also provides some additional details and some corrections to Fisher's account. Modern accounts of the introduction of ether in France have relied heavily on a letter sent in February 1847 to the editor of the Boston Medical & Surgical Journal by Francis W. Fisher, a young Boston physician then studying in Paris. Fisher's report is often vague, occasionally incorrect, and probably exaggerates his role in the acceptance of anesthesia in Paris. This review attempts to complement and correct Fisher's account.

Penile Surgery for ED, Urologists and Sexologists

Currently available options for patients with ED include, in addition to sextherapies, oral pharmacotherapy, intraurethral and intracavernous PGE1, vacuum devices and penile implants. Phosphodiesterase 5 inhibitors offer the less invasive and the most manageable option but their efficacy is limited in patients with severe organic factors. Intraurethral and intracavernous PGE1 and vacuum devices represent powerful second line therapies. However some patients fail with PGE1 and vacuum and should be referred to urologists for penile implants. The first penile implant procedure has been described in 1936 by Bogoras who inserted a section of rib cartilage into a reconstructed penis. Penile prosthetic surgery became popular in the early 1970s when Scott introduced the first inflatable penile prosthesis. Numerous papers in the last recent years have stigmatized visible improvements in materials and surgical techniques. Antibioprophyllaxy, use of specific surgical areas and sterile ways have produced very significant reductions in complications rates as infections, cylinders extrusions and urethral perforations. Patients with working devices have reported very high satisfaction, better quality of life and improvements in self esteem and partner relationship. However some studies indicate reasonable level of satisfaction post-operatively, although success rate in term of satisfaction are not as high as success rate in term of a good surgical result. Presumably, the patient or couple who is dissatisfied post-operatively yet has a good surgical result did not have expectations met. Ideally, penile prosthesis implantation should include at least one preoperatively counseling visit with a sex therapist and one or more visits as needed postoperatively. Some surgeons and particularly some urologists are interested in and well trained on penile surgery. However, country differences in penile implants surgical activities can be very important. Thus, the ratio for penile prosthesis implantations between US and France is close to 1 to 10. Such variation cannot be explained only by cultural differences and lead us to consider that penile implants image is not very positive in France. It is never easy for the patients and their general practitioners to accept the proposition of prosthetic implantations. It is common in France that, when sex therapists give information to the patient or couple, when they explain that there are various treatment options for erectile dysfunction, they don’t include penile prosthesis implantation or they discussed very strongly of complications. Sometimes, the patient is referred to a urologists that decline the prosthetic surgery because of insufficient training. Urologists and sexologists organized a round table in the French sexological meeting in Marseille on 2006. As it has been previously reported in UK, only a few French surgeons implanted more than 10 or 20 prostheses per year. They decided together that the first step to develop penile prosthesis implantations in France was to increase the surgical level of French urologists. A national 2 years post-graduate training and academic certification has been proposed. First sessions will start on November 2008. The program include not only surgical indications and techniques but also sexological evaluation and management of the couple.

Patellar Instability

ABSTRACT During the past 3 decades, the surgeons of have developed a vast experience dealing with patellofemoral problems. The Lyon School, as it may be called, addresses episodic patellar instability using anatomical principles based on the teachings of Dejour and Walch. Under this theory, trochlear dysplasia is the fundamental anatomical abnormality, without which recurrent patellar instability is very rare. Trochlear dysplasia causes a flat upper portion of the trochlear groove, usually because of a prominent floor as opposed to deficient sidewalls, so that joint reaction forces are increased but lateral constraint is reduced. But the dysplasia itself is rarely addressed directly. Instead, surgical treatment addresses each of 3 principal factors whenever it is present: tibial tubercle-trochlear groove offset, patella alta, and patella tilt. This article presents an algorithm for treating episodic patellar instability based on the teachings of the School. Although the specifics of the treatment protocol remain subjects of discussion, debate, and study, the protocol has been very successful in the hands of French surgeons.

Neck dissection in the nineteenth century

The nineteenth century brought great progress in several Welds of surgery and medicine. In addition to the fact that insights, which were gained in the laboratory or during anatomic dissection studies, were, for the Wrst time, correlated to bedside Wndings and could then be used to improve the treatment of patients, the medical world struggled to discard the baggage of useless and counterproductive traditional treatments such as venesection (bleeding) and purging, previously employed to treat almost any ailment. It was the beginning of modern, science-based medicine. The Wrst half of nineteenth century medicine was dominated by the “Paris School” of French physicians and surgeons. Dominique Jean Larrey (1766–1842) and Pierre Francois Percy (1754–1825) accompanied Napoleon through many of his campaigns while acquiring extensive military surgical experience. Guillaume Dupuytren (1777–1835) accomplished numerous surgical innovations as chief surgeon at the Hotel Dieu. Laennec, Bretonneau and Bouillaud among many others developed a scientiWc basis of examination of patients and explanation of the cause of many diseases. In the second half of the nineteenth century while Paris was still paramount in the world of medicine, the “New Vienna School” as well as a generation of German surgeons were instrumental in the development of modern surgical treatment as well as understanding of the cellular basis of disease. The English speaking world produced pioneers of medicine throughout the nineteenth century including the “Irish School” of Graves, Stokes and Corrigan, and the great physicians of Guy’s Hospital in London including Bright, Addison,

Total hip arthroplasty through an anterior Hueter minimally invasive approach

The anterior access of the hip was described more than 50 years ago by Robert Judet. These past ten years, several French surgeons familiar with this technique have attempted to reduce the size of the scar while preserving the muscles in the same manner. The technique which is described hereafter is characterized by a complete preservation of gluteal muscle integrity. Only the tensor fascia lata is detached from the medial aponeurosis. The psoas major muscle is no longer separated from the capsule, as previously recommended, and the capsule is no longer “sacrificed” since its full preservation is one of the components of this technique. The use of an orthopaedic extension table and a modified Charnley retractor is indispensable and useful for efficient exposure of the hip bones. Thus, the orthopaedic table may constitute a worthwhile alternative to operative assistance. As an illustration to this novel approach, we describe a surgical series of 80 consecutive patients having undergone hip arthroplasty using this technique. For about 10 years, we have been routinely using this technique with a very low rate of complications. Almost all patients with hip arthrosis may benefit from such surgical method.

Tolstoy’s Report of Five Cases of Chest Trauma: Its Relevance to Contemporary Military Surgical Experience

Fragments of the history of trauma care, an important part of our surgical heritage, can offer a relevant message to contemporary science, even at the level of statistical evaluations. A surprisingly good match of results using two distinctively different approaches for calculating survival after a chest injury is reported in a historical model. Statistical data published by French and British surgeons serving in the Crimean War (1853-1856) were found to conform with the analysis of literary observations in Leo Tolstoy's Sebastopol Sketches. The nearly complete agreement on survival probabilities from two sources so different in their nature highlights the question of the relevance of nonstatistical methods in other fields of surgery as well.

Pyogenic Granuloma of the Colon in Children

Pyogenic Granuloma of the Colon in Children

The Classic: Injuries of the Wrist

The Classic: Injuries of the Wrist

Le risque thrombo-embolique en chirurgie plastique et esthétique : enquête de pratique, conséquences et recommandations

This first French national survey of the deep vein thrombosis and embolism risk during plastic and aesthetic surgery shows the reality of this complication. Eighty percent of the french plastic surgeons had deep vein thrombosis in their patients and 53% had pulmonary embolism. There are no guidelines in our speciality in French. The author reviews the bibliography and guidelines of all the other societies around the world as experts' recommendations during the national congress of the French Plastic Reconstructrice and Aesthetic Surgery (SOF.CPRE) in 2004.

Surgical emergencies of the new-born, and hiatus hernia. By Seven French Surgeons

Surgical emergencies of the new-born, and hiatus hernia. By Seven French Surgeons

The first facial transplant

Last week, French surgeons performed the first partial facial transplant, using the nose, lips, and chin from a brain-dead living donor to repair the face of a 38-year-old woman who had been mauled by a dog. Initial reports indicate that the recipient is doing well.Over the past several years, there has been intense debate over whether enough is known of the risks and benefits of facial transplantation to allow such an operation to be done. The procedure, though technically demanding, does not carry a great risk in itself. The risk comes from the threat of graft rejection and the immunosuppressive regimen given to prevent rejection. During the first year, the risk of acute rejection is estimated to be about 10%, and the risk of loss of graft function due to scarring from chronic rejection is predicted to be 30–50% over 2–5 years. The risks due to immunosuppressive treatment include life-threatening infections, cancers, and organ damage. And, because the surgery involves the face, there are concerns that patients will experience psychological trauma that could be profound.Solid organ transplantation carries similar risks but is considered justified because it is life-saving. A key question, then, is whether a facial transplant patient should undergo a potentially life-threatening procedure to treat a disfigurement, albeit a major one. Indeed, because so much is uncertain about the true risks and benefits of facial transplantation, it has been argued that it is impossible to provide a prospective patient with the information needed to give truly informed consent.But the time comes when enough is known to do an experiment and when an experiment may be the only way to answer the questions that remain. According to press reports, the French surgical team took care to select a patient who was unlikely to benefit substantially from standard restorative surgery and prepared her psychologically for the operation and its aftermath. They proceeded with the approval of French medical and ethical authorities. Although the decision to operate will no doubt be debated, the French team has taken a cautious and justifiable first step. Last week, French surgeons performed the first partial facial transplant, using the nose, lips, and chin from a brain-dead living donor to repair the face of a 38-year-old woman who had been mauled by a dog. Initial reports indicate that the recipient is doing well. Over the past several years, there has been intense debate over whether enough is known of the risks and benefits of facial transplantation to allow such an operation to be done. The procedure, though technically demanding, does not carry a great risk in itself. The risk comes from the threat of graft rejection and the immunosuppressive regimen given to prevent rejection. During the first year, the risk of acute rejection is estimated to be about 10%, and the risk of loss of graft function due to scarring from chronic rejection is predicted to be 30–50% over 2–5 years. The risks due to immunosuppressive treatment include life-threatening infections, cancers, and organ damage. And, because the surgery involves the face, there are concerns that patients will experience psychological trauma that could be profound. Solid organ transplantation carries similar risks but is considered justified because it is life-saving. A key question, then, is whether a facial transplant patient should undergo a potentially life-threatening procedure to treat a disfigurement, albeit a major one. Indeed, because so much is uncertain about the true risks and benefits of facial transplantation, it has been argued that it is impossible to provide a prospective patient with the information needed to give truly informed consent. But the time comes when enough is known to do an experiment and when an experiment may be the only way to answer the questions that remain. According to press reports, the French surgical team took care to select a patient who was unlikely to benefit substantially from standard restorative surgery and prepared her psychologically for the operation and its aftermath. They proceeded with the approval of French medical and ethical authorities. Although the decision to operate will no doubt be debated, the French team has taken a cautious and justifiable first step.

Augmentation mammaire par implants : études des pratiques chirurgicales: Étude réalisée auprès des chirurgiens plasticiens français

In the framework of the 2005 report on mammary implants prepared by the Société française de chirurgie plastique reconstructrice et esthétique (SOF.CPRE), we conducted a survey among french plastic surgeons involved in the field. We elaborated a questionnaire that we distributed twice to the 600 members of the society; a total of 261 responded. Analysis of the data collected provides information on the socioprofessional characteristics of the responding surgeons, and on the devices, products and techniques they use. Finally, the survey has permitted to identify their qualitative perception of breast implant products currently available. Ranking these items by order of frequency provides a snapshot of the current procedures and practices in use for breast augmentation surgery in France.

Le gantage chirurgical en France : une évolution lente mais nécessaire

Since the end of the 19 th century, surgeons have used gloves to prevent infectious complications to the patient. The AIDS epidemic of the 1980's sparked the use of universal precautions to protect the surgeon from infection and vice-versa. The interface between surgeon and patient is in effect a two-way street. Surgical techniques must be modified and barrier protection optimized to minimize these risks. A single layer glove is a fragile barrier to blood exposure ; unrecognized glove perforations may lead to unrecognized and prolonged exposure. Double gloving, though far from being a widespread practice in France, seems to be the best protection from pathogen exposure. Glove powder and latex allergies have their own inherent risks to both surgeon and patient in the form of latex allergies and adhesive peritonitis. New institutional protocols will be necesssary in order to make powder-free non-latex gloves available to French surgeons.

Hospital at War: The 95th Evacuation Hospital in World War II (review)

Reviewed by: Hospital at War: The 95th Evacuation Hospital in World War II Joseph W. Sokolowski Jr. Hospital at War: The 95th Evacuation Hospital in World War II. By Zachary B. Friedenberg. College Station: Texas A&M University Press, 2004. ISBN 1-58544-379-4. Maps. Photographs. Appendixes. Index. Pp. x, 158. $32.50. Zachary Friedenberg, an orthopedic surgeon at the University of Pennsylvania, has written a memoir of his experiences as a general surgeon with the 95th Evacuation Hospital in the European Theater of Operations during the Second World War. He describes his colleagues as " civilians in uniform" with limited instruction in the customs of military life at the time of their entry into military service. Over time they demonstrated adaptability to professional military life without losing sight of their goal of providing quality care to the sick and injured regardless of national origin, military or civilian status, friend or foe. The initial chapter describes the organizational structure of an evacuation hospital and its personnel. The staff is composed of surgical teams, who operate simultaneously on a rotational basis. Staff is also assigned to provide care for medical problems, such as malaria, trenchfoot, and respiratory infections, etc. Support functions are provided in the areas of administration, logistics, technology, and personnel by nonmedical officers, and enlisted personnel. The campaign experiences of the author are interspersed with those of nurses and enlisted personnel. They provide a personal perspective to a hostile environment where death is a daily occurrence to those who are non-combatants. This is poignantly brought home when a hospital ship, HMS Newfoundland, is bombed, resulting in a significant loss of injured and killed off the Salerno landing beaches. At Anzio, the 95th Evacuation Hospital was [End Page 877] bombed by a German fighter, resulting in a major death toll among the staff and patients. We have learned that the Red Cross emblem on the uniform does not guarantee the safety of medical personnel. As the war progresses, reorganization of the hospital occurs, resulting in a greater efficiency in delivery of surgical and medical care. Emphasis is placed on proper positioning of the facility in relation to the battle front, described as within the sound of cannon fire. Following the invasion of southern France in August of 1944, French surgeons joined the surgical teams and French civilians served as litter bearers. The rapport that the author experienced with the French people remains a life-long, cherished memory for him. Hospital at War provides limited information for the scholarly military historian. However, it will interest anyone who has served in a military medical unit. The major thrust of the book is that, as the author so aptly points out, the military medical profession needs to relearn the lessons of prior conflicts., e.g., the necessity of leaving soft tissue wounds of the extremities open after debridement of devitalized tissue in the initial surgical management. Joseph W. Sokolowski Jr. Medford Lakes, New Jersey Copyright © 2005 Society for Military History

Apport de la France à la microchirurgie

The authors report the contribution of French surgeons and particularly the plastic surgeons to the reconstructive microsurgery since 1972. Different domains are reviewed: animal experimentation, anatomical studies, reimplantations, free tissular transfer, free bone transfer, strategic original concept of transfer, free toes transfer, microsurgical reconstruction of malformative hand, free lymphatic transfer, nervous microsurgery, flap prefabrication, allotransplantations and the future of microsurgery. Three societies have the place of honour: the French Society of Plastic Reconstructive and Aesthetic Surgery, the Group for Advancement of Microsurgery and the World Society for Reconstructive Microsurgery.

Retromuskuläre Kunststoffnetz-Implantation von Narbenhernien

Retromuscular Prosthetic Mesh Implant of Incisional Hernias It is widely accepted that the implant of prosthetic meshes is the method of choice for the treatment of incisional hernias. However, there is still controversy about the specific surgical procedure to be used. The present article gives an overview about the retromuscular (underlay, sublay) technique first presented by the French surgeons Rives and Stoppa. The anatomic and physiologic backgrounds are described as well the potential complications, the available long-term results and the reasons for possible recurrence.