Intraoperative Considerations Research Articles

299 Intra-operative Use of Betadine Is Associated with an Increased Rate of Penile Prosthesis Infections

Inflatable penile prostheses (IPP) remain the gold standard for medically refractory erectile dysfunction (ED). Despite high overall success and satisfaction rates, infections remain a persistent and significant complication. In our clinical practice, we continued to experience high rates of infections despite use of a no-touch technique, voluminous irrigation, antibiotic-impregnated devices, post-op antibiotics, and multiple other intra-operative considerations. However, after switching from Betadine irrigation to Vancomycin / Gentamicin, we anecdotally noted an immediate reduction in infections, which prompted the current analysis. To compare the rate of IPP infections based on the type of intra-operative irrigation utilized: Betadine versus Vancomycin / Gentamicin. We reviewed a detailed, prospective database of men undergoing primary, revision, and salvage penile prostheses at our institution. The primary outcome was rate of penile prosthesis infection prior to and following change of intra-operative irrigation. It is notable that no other changes to operative or perioperative techniques occurred following the change in irrigation solution. Multiple variables were reviewed as potential confounders including patient demographics, comorbidities, type of surgery (primary, revision, salvage), number of prior prostheses, and adjunctive techniques. Univariate analysis was performed to evaluate for differences in rate of infection with use of Betadine versus Vancomycin / Gentamicin irrigation. Regression analysis was performed to control for variables noted to significantly impact infection rate.

Laparoscopic totally extra-peritoneal (TEP) inguinal hernia repair

Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is an effective minimally invasive method for treating hernias that avoids entry into the abdomen. Its indications have developed and broadened over time to encompass almost the whole spectrum of groin hernias. A detailed description of the procedure is presented focusing on seven key steps. Moreover, pre- and intra-operative considerations, pearls and pitfalls are highlighted in order to maximize efficiency and safety when performing this procedure. The attached figures and accompanying narrated videos complement this manuscript by providing an audiovisual adjunct and to clarify technical and anatomical descriptions.

Laparoscopic totally extra-peritoneal (TEP) inguinal hernia repair

Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is an effective minimally invasive method for treating hernias that avoids entry into the abdomen. Its indications have developed and broadened over time to encompass almost the whole spectrum of groin hernias. A detailed description of the procedure is presented focusing on seven key steps. Moreover, pre- and intra-operative considerations, pearls and pitfalls are highlighted in order to maximize efficiency and safety when performing this procedure. The attached figures and accompanying narrated videos complement this manuscript by providing an audiovisual adjunct and to clarify technical and anatomical descriptions.

Modified Bianchi pyloromyotomy versus laparoscopic pyloromyotomy for patients with infantile hypertrophic pyloric stenosis: Intraoperative considerations and parents satisfaction

Introduction Infantile hypertrophic pyloric stenosis is a common cause of persistent nonbilious vomiting during infancy. Ramstedt pyloromyotomy through right upper quadrant transverse incision is the conventional treatment. The laparoscopic and Tan-Bianchi approaches were introduced to improve the cosmesis and decrease postoperative morbidity. In this study, we compared between laparoscopic and modified Bianchi approaches regarding intraoperative technical considerations and postoperative outcomes.Patients and methods The study included 40 patients with infantile hypertrophic pyloric stenosis. Overall, 20 patients underwent laparoscopic pyloromyotomy (LP) and the other 20 patients underwent modified Bianchi pyloromyotomy (MBP). Patients’ characteristics, including age, sex, gestational age, and associated comorbidities, were documented. Intraoperative details and complications and postoperative outcomes were recorded.Results The operative time and intraoperative complications including mucosal perforation and bleeding did not significantly differ between both the groups. From the laparoscopic group, one (5%) case was complicated by mucosal perforation and converted to open and another case (5%) developed hypercapnia. There was no statistically significant difference between the two groups regarding time till full feed (P=0.648) and postoperative hospital stay (P=0.082). In addition, there was no statistically significant difference between the two groups regarding postoperative complications, with one (5%) case from the laparoscopic group underwent incomplete myotomy and required redo-operation and another case (5%) developed wound infection. MBP had a significantly more parent satisfaction regarding cosmesis than LP (P=0.016).Conclusion MBP is comparable to LP regarding intraoperative complications and postoperative outcomes; however, the modified Bianchi approach offered more parent satisfaction than laparoscopic approach. Keywords: laparoscopic, modified Bianchi, pyloric stenosis, pyloromyotomy

Noncardiac surgery in the congenital heart patient

More children with congenital heart disease are surviving and require noncardiac surgery. A high-yield summary of congenital heart anatomy and pathophysiology is presented to contextualize these patients for surgeons. Preoperative planning including risk stratification, anesthetic management and timing of elective surgery are discussed. Specific intraoperative considerations for particular cases, such as the use of laparoscopy and thoracic surgery, are reviewed. Postoperative outcomes and recommended management required to mitigate complications are summarized.

Current understanding and perioperative management of pediatric pulmonary hypertension.

Pediatric pulmonary hypertension is a complex disease with multiple, diverse etiologies affecting the premature neonate to the young adult. Pediatric pulmonary arterial hypertension, whether idiopathic or associated with congenital heart disease, is the most commonly discussed form of pediatric pulmonary hypertension, as it is progressive and lethal. However, neonatal forms of pulmonary hypertension are vastly more frequent, and while most cases are transient, the risk of morbidity and mortality in this group deserves recognition. Pulmonary hypertension due to left heart disease is another subset increasingly recognized as an important cause of pediatric pulmonary hypertension. One aspect of pediatric pulmonary hypertension is very clear: anesthetizing the child with pulmonary hypertension is associated with a significantly heightened risk of morbidity and mortality. It is therefore imperative that anesthesiologists who care for children with pulmonary hypertension have a firm understanding of the pathophysiology of the various forms of pediatric pulmonary hypertension, the impact of anesthesia and sedation in the setting of pulmonary hypertension, and anesthesiologists' role as perioperative experts from preoperative planning to postoperative disposition. This review summarizes the current understanding of pediatric pulmonary hypertension physiology, preoperative risk stratification, anesthetic risk, and intraoperative considerations relevant to the underlying pathophysiology of various forms of pediatric pulmonary hypertension.

Intraoperative Considerations of the Suprascapular Nerve Block.

Intraoperative Considerations of the Suprascapular Nerve Block.

Intraoperative Considerations for Treatment/Prevention of Prosthetic Joint Infection.

Innovative measures have recently been proposed to prevent periprosthetic joint infection following total hip and knee arthroplasty. We sought to review these recent innovations to determine the reported reduction in periprosthetic joint infection. The most recent literature demonstrates promising results in regard to hydrofiber dressings as an independent risk factor for primary prosthetic joint infection reduction, which in turn is also linked with cost savings. As our understanding of safe yet effective concentrations of antiseptic solutions develops, dilute betadine in particular has demonstrated encouraging efficacy which warrants continued investigation through controlled trials. In summary, we found that the application of a hydrofiber dressing may prove beneficial in decreasing the risk of prosthetic joint infection following primary total hip and knee arthroplasty. The gold standard for an infection prevention protocol continues to be explored and optimized.

Risk factors for conversion surgery to total hip arthroplasty of a hemiarthroplasty performed for a femoral neck fracture

The purpose of this study was to determine risk factors for conversion to total hip arthroplasty (THA) in patients originally treated with hemiarthroplasty (HA) for displaced femoral neck fractures. In this case-controlled study, we identified 54 patients who were treated with HA for femoral neck fracture (FNF) who subsequently underwent conversion to THA at our institution between 2003 and 2013. We randomly selected 142 control patients who underwent HA for a displaced FNF without conversion surgery during the same time period. We compared demographic data, implant parameters, and radiographic data between the groups to identify risk factors for conversion surgery. In the univariate analysis, younger age at index surgery (mean 75 vs. 80 years, p = 0.006), higher body mass index (26.1 vs. 23.7, p = 0.031), bipolar prosthesis (20% vs. 36%, p = 0.024), absence of dementia (6% vs. 23%, p = 0.01), increased leg length compared to contralateral limb (6.5 mm vs. 0.2 mm, p<0.001), and increased HA femoral head size compared to the contralateral femoral head (2.7 mm vs. 1.5 mm, p = 0.02) were associated with a significantly increased risk of conversion surgery. In the multivariate logistic regression, decreased age at index surgery, no dementia, use of a bipolar head, and increased leg length discrepancy (LLD) were associated with risk of conversion. Patient characteristics, including younger age, increased BMI, and absence of dementia can lead to increased risk for conversion of HA to THA. Intraoperative considerations of head size and increase in ipsilateral LLD may increase the risk of conversion surgery. These factors should be considered by surgeons who employ HA for displaced FNFs.

Hints and tips in revision hip surgery

Revision total hip arthroplasty has excellent results but is challenging surgery. A myriad of considerations and complications face the surgeon but careful planning and careful execution of that plan can reduce the likelihood of failure. This review article attempts to give practical advice on managing preoperative planning, intraoperative considerations and postoperative complications for the reader.

Minimally Invasive Approaches to the Surgical Management of Fibroids.

AbstractUterine fibroids, as the most common benign neoplasm of the female reproductive tract, can significantly impact a woman's quality of life through abnormal uterine bleeding, infertility, and bulk symptoms. When medical therapy for symptomatic fibroids fails, surgery is the recommended treatment. While a hysterectomy through laparotomy was historically the first-line surgical approach for fibroids, multiple minimally invasive and uterine-sparing techniques are now available. An evidence-based literature review of the following minimally invasive approaches is detailed in this article: hysteroscopic myomectomy, laparoscopic and robotically assisted myomectomy, laparoscopic and robotically assisted hysterectomy, and ultrasound-guided radiofrequency ablation. For each approach, this review discusses the indications, patient selection, adjunct preoperative treatment modalities, instrumentation, techniques, and pertinent intraoperative considerations such as fluid management, interventions to reduce blood loss, antiadhesion barriers, and tissue extraction. Perioperative benefits, long-term outcomes including recurrence and fertility, and comparisons of outcomes among the various approaches are outlined as well. With continued technological advancements and surgical innovations, minimally invasive techniques will become the mainstay of surgical management for symptomatic fibroids to provide high-quality patient-centered care.

Anaesthetic considerations in spinal deformity surgery

Surgery for scoliosis is a significant operation and requires thorough anaesthetic planning. Idiopathic scoliosis accounts for the majority of patients who can have sequelae resulting from a long-term deformity. Patients with non-idiopathic deformities can have organ dysfunction which will impact anaesthetic management and so preoperative assessment is very important, with particular emphasis on cardiopulmonary function. A multidisciplinary approach is the key to successful treatment with the involvement of surgeons, anaesthetists, paediatricians and specialist nurses. Positioning, potential haemmorhage and the ability to monitor nerve function are important intraoperative considerations and postoperatively, a multimodal analgesic regime and level 1 monitoring are required.

Risk factors for conversion surgery to total hip arthroplasty of a hemiarthroplasty performed for a femoral neck fracture.

The purpose of this study was to determine risk factors for conversion to total hip arthroplasty (THA) in patients originally treated with hemiarthroplasty (HA) for displaced femoral neck fractures. In this case-controlled study, we identified 54 patients who were treated with HA for femoral neck fracture (FNF) who subsequently underwent conversion to THA at our institution between 2003 and 2013. We randomly selected 142 control patients who underwent HA for a displaced FNF without conversion surgery during the same time period. We compared demographic data, implant parameters, and radiographic data between the groups to identify risk factors for conversion surgery. In the univariate analysis, younger age at index surgery (mean 75 vs. 80 years, p = 0.006), higher body mass index (26.1 vs. 23.7, p = 0.031), bipolar prosthesis (20% vs. 36%, p = 0.024), absence of dementia (6% vs. 23%, p = 0.01), increased leg length compared to contralateral limb (6.5 mm vs. 0.2 mm, p<0.001), and increased HA femoral head size compared to the contralateral femoral head (2.7 mm vs. 1.5 mm, p = 0.02) were associated with a significantly increased risk of conversion surgery. In the multivariate logistic regression, decreased age at index surgery, no dementia, use of a bipolar head, and increased leg length discrepancy (LLD) were associated with risk of conversion. Patient characteristics, including younger age, increased BMI, and absence of dementia can lead to increased risk for conversion of HA to THA. Intraoperative considerations of head size and increase in ipsilateral LLD may increase the risk of conversion surgery. These factors should be considered by surgeons who employ HA for displaced FNFs.

Robotic-assisted thoracoscopic lung surgery: anesthetic impact and perioperative experience.

Anesthesiologists and the perioperative team have a tremendous impact upon clinical outcomes in robotic-assisted thoracoscopic surgery. As anesthesiology is developing its role outside the operating room, the patient population benefits from an expanded focus on perioperative critical care and pain management. This article focuses upon the preoperative optimization, unique intraoperative considerations for surgeons and anesthesiologists, and postoperative management of patients undergoing robotic-assisted thoracoscopic surgery.

Pituitary and skull-base lesions and the litigious patient.

The objective of this research was to evaluate litigation relating to the diagnosis and management of pituitary and ventral skull base lesions and delineate allegations involved in the decision to pursue medicolegal proceedings. Publically available federal and court records were accessed via the Westlaw Next database. Jury verdict and settlement reports relevant to pituitary and anterior skull-base lesions were accessed, and litigation was reviewed for alleged injuries, defendant specialty, patient demographics, and other factors raised in proceedings. Of 75 cases included, 50.7% were resolved in the defendant's favor. The most frequent physician specialties cited as defendants included primary care (20%), neurosurgery (17%), and radiology (16%), while otolaryngologists were defendants in only 5% of cases. Fifty-two (69%) did not involve surgical intervention; the most common allegations in these proceedings were misdiagnosis, permanent injury (19%), requiring additional procedures as a result of misdiagnosis (17%), permanent endocrine dysfunction (14%), and visual sequelae (12%). Among surgical cases, the most common allegations raised included permanent injury (17%), postoperative complications (14%), intraoperative complications (13%), and death (10%). Among cases resolved with payment, there was no statistical difference in payment between surgical cases ($5.7M) and nonsurgical cases ($4.8M). Misdiagnosis of endocrinopathy, failure to appropriately workup patients presenting with neurologic complaints, and radiologic misdiagnosis play important roles in the pursuit of litigation in nonsurgical cases. Sustaining permanent sequelae including endocrine and visual injury play an important role in surgical cases. Postoperative management appears to play just as important a role in the decision to pursue litigation as intraoperative considerations.

Bilateral Free Flap Breast Reconstruction Outcomes: Do Abdominal Scars Affect Bilateral Flaps?

The incidence of bilateral mastectomies is increasing along with the rates of breast reconstructions. A substantial number of patients will present with abdominal scars after Cesarean section, laparoscopy, laparotomy, and so on. The aim of this study was to evaluate the impact of prior abdominal scars on complication rates in abdominal bilateral free flap breast reconstruction. All consecutive patients with autologous free flap breast reconstruction between 2007 and 2014 were eligible. The relevant demographic and clinical data were prospectively collected into a study-specific database. Complications and reoperations were prospectively registered after postoperative outpatient visits. Overall, 493 patients underwent abdominally based breast reconstruction during the study period: unilateral (n = 250; 50.7%) or bilateral (n = 243; 49.3%). In the bilateral group, the abdominal scar locations were Pfannenstiel (n = 73; 30.1%), midline (n = 16; 6.6%), lower oblique (n = 17; 7.0%), upper oblique (n = 5; 2.1%), and laparoscopic (n = 69; 28.4%). Four (1.7%) flap failures (including 1 converted to a pedicled transverse rectus abdominis flap) were registered, all occurring in patients from the scar group: 3 with Pfannenstiel incision and 1 patient with prior laparoscopy. Pfannenstiel scar was associated with higher risk of hematoma at the recipient site when compared with no scar group (13.7% versus 2.2%; P = 0.006). Partial flap necrosis, infection, and seroma occurred in 14 (5.9%), 8 (3.4%), and 5 (2.1%) patients, respectively, and no differences between the scar groups were identified. Surgical outcomes of bilateral reconstructions in patients with abdominal scars are generally comparable with ones in patients without prior surgery; however, some problems have been identified. These procedures might have some intraoperative considerations and often require increased operative times. Apart from the traditional preoperative computed tomography angiography, intraoperative imaging (e.g., fluorescence angiography) may be advocated in patients with abdominal scars.

Vertebral column resection for complex spinal deformity

Vertebral column resection is a powerful tool in the management of complex spinal deformity. Indications for VCR include rigid or focal, angular kyphosis or coronal deformity, hemivertebrae, and post-tuberculous spinal deformity. We review the approach to the patient with complex spinal deformity, VCR surgical technique, intraoperative considerations and outcomes reported in the literature.

Falla hepática y anestesia: un enfoque práctico

IntroductionTerminal liver disease is an important public health problem and an interesting challenge for the anesthetic management of these patients due to the number of risk factors present. The main objective of this article is to provide a practical approach regarding the anesthetic management of patients with hepatic failure. Materials and methodsA comprehensive review of the literature was done in databases such as UpToDate, PubMed and ScienceDirect. DiscussionWe present the factors that increase the surgical risk of patients with liver disease as well as the strategies to reduce them in addition to the systemic effects of the same, the pre-surgical anesthetic management as well as the intraoperative considerations and the postoperative care. ConclusionLiver disease has a high surgical morbidity and mortality, however, performing a pre-anesthetic evaluation could identify and correct the risk factors of the patient with the purpose of performing a safe surgical act taking into account the pharmacodynamic alterations of the medications.

Robot-assisted ureteroureterostomy in pediatric patients: current perspectives.

Developments in pediatric robotic surgery have increased the feasibility of minimally invasive surgery for complex urinary tract reconstruction. Ureteroureterostomy is a commonly employed strategy for the management of a duplicated ureteral system with either upper pole obstruction or lower pole vesicoureteral reflux, and this approach minimizes the risk to a healthy ureter as might be seen in a common sheath ureteral reimplant and avoids complex dissection around the renal hilum as with a heminephrectomy. The robotic platform enables optimum instrument manipulation for an end-to-side ureteral anastomosis as well as excellent visualization deep into the pelvis for excision of the distal ureteral stump. In this study, the indications and preoperative evaluation for pediatric robotic ureteroureterostomy (RUU) were described and intraoperative considerations for a successful repair were highlighted. In order to assess the outcomes, a PubMed search was performed to find the articles focusing on RUU in the pediatric population. The institutional experience of the authors was also reviewed. As with an open procedure, both minimizing dissection on the recipient ureter and ensuring a tension-free, watertight anastomosis are key principles to minimize complications. Although port placement is similar to that in robotic pyeloplasty, small adjustments may need to be made to ensure access to the pelvis. An assistant port and/or traction sutures is often used to aid in the dissection and anastomosis. RUU was first described in 2008, and several reports have demonstrated positive short-term results. However, median follow-up times are limited with most series reporting outcomes <1 year postoperatively. A future study is required to establish the long-term efficacy of this procedure and define the optimum patient population for a robotic approach.

Role of Segmentectomy in Treatment of Early-Stage Non-Small Cell Lung Cancer.

Standard treatment for early-stage non-small cell lung cancer has traditionally involved lobectomy. Historical data that demonstrates suboptimal results for sublobar resection compared to lobectomy have been challenged in recent years with retrospective data for patients with T1a disease. For patients who are not candidates for lobectomy, options for sublobar resection include wedge resection or anatomic segmentectomy. Segmentectomy has long been held to be a better cancer operation than wedge resection, and its role in treating early-stage lung cancer remains controversial in patients who are candidates for lobectomy. A review of available literature involving segmentectomy and possible predictors of failure for segmentectomy was performed in an attempt to clarify the role of segmentectomy for early-stage lung cancer. Current evidence is conflicting regarding the optimal scenario for sublobar resection with segmentectomy. Two large-scale randomized trials are currently addressing the question. In the meantime, certain preoperative and intraoperative considerations should be taken into account when considering segmentectomy for the treatment of early-stage non-small cell lung cancer.