Intraoperative Displacement Research Articles

Left-Sided Double-Lumen Tube vs EZ-Blocker for One-Lung Ventilation in Thoracic Surgery: A Systematic Review and Meta-Analysis.

Background. The EZ-Blocker is the newest generation of bronchial blocker and offers a potential alternative to left-sided double lumen tubes for lung isolation and one-lung ventilation during thoracic surgery. Methods. Databases were searched for randomized controlled trials comparing left-sided double lumen tube to the EZ-Blocker for one-lung ventilation during thoracic surgery. The time for placement, incidence of intraoperative displacement, and surgeons' rating of lung collapse quality were designated as coprimary outcomes. The safety profiles of the two devices, including the incidence of airway trauma and post-extubation discomfort were also examined. Results. Six randomized controlled trials (495 patients) were analyzed. Compared to the EZ-Blocker, the left-sided double lumen tube was faster to place by a weighted mean difference of [95% CI] of -61.24 seconds [-102.48, -20.00] (P = .004) and was much less likely to become displaced during lung isolation with an odds ratio [95% CI] of .56 [.34, .91] (P = .02). The left-sided double lumen tube and the EZ-Blocker provided similar surgeon-rated quality of lung isolation. Although the left-sided double lumen tube caused a greater degree of post-extubation sore throat, there was a similar incidence of carinal trauma and post-extubation hoarseness compared to the EZ-Blocker. Conclusion. Our analysis suggests that the left-sided double lumen tube can be placed more quickly and is less prone to intraoperative displacement compared to the EZ-Blocker; the quality of lung collapse is similar. Thus, evidence appears to support the continued utilization of the left-sided double lumen tube for routine thoracic surgery requiring one-lung ventilation.

Predictive factors and visual outcomes after immediate pars plana vitrectomy for posteriorly dislocated lens fragments during complicated phacoemulsification surgery.

To investigate the prognostic factors for visual outcome in patients undergoing immediate pars plana vitrectomy (PPV) for posteriorly dislocated lens fragments during phacoemulsification surgery. This was a single-center, retrospective, cross-sectional study of 37 eyes of 37 patients undergoing immediate PPV for posteriorly dislocated lens fragments from 2015 to 2021. The primary outcome measure was changes in the best-corrected visual acuity (BCVA). Additionally, we analyzed the predictive factors for poor visual outcomes (BCVA <20/40) and perioperative complications. The mean (±standard deviation [SD]) age of the patients was 66.57 (±10.86) years, with an almost identical gender profile (M: F = 18/19 [48.64%:51.36%]). The median (interquartile range [IQR]) log of minimum angle of resolution (logMAR) BCVA improved significantly from the baseline (1 [0.6-1.48], ~20/200) to the final visit (0.3 [0.2-0.6], ~20/40) (P < 0.0001) after a mean (±SD) follow-up of 6.35 (±6.32) months. The final BCVA was 20/40 or better in 59.5% of the eyes. Poor final BCVA (<20/40) was associated with small preoperative pupillary size (P = 0.02), presence of preoperative ocular pathology (P = 0.02) including uveitis, glaucoma, and clinically significant macular edema (CSME), intraoperative displacement of >50% of lens matter into the vitreous (P < 0.001), use of iris-claw lens (P < 0.001), and postoperative cystoid macular edema (CME; P = 0.007). The postoperative complications included CME (13.51%), retinal detachment (10.81%), chronic uveitis (8.11%), glaucoma (8.11%), iritis (2.7%), posterior chamber IOL (PCIOL) dislocation (2.7%), and vitreous hemorrhage (2.7%). For retained lens fragments in complicated phacoemulsification surgery, immediate PPV is a viable approach with the potential for a good visual outcome. The important predictors for poor visual outcomes include a small preoperative pupil size, preexisting ocular pathology, displacement of significant volume of lens matter (>50%), use of an iris-claw lens, and CME.

The first experience of robot-assisted bariatric surgery using the Senhance system in patients with morbid obesity

To study the results of robot-assisted bariatric surgery using the Senhance system in patients with morbid obesity. A prospective cohort study included 74 patients who underwent bariatric surgery (Senhance digital laparoscopy system) between January 2022 and May 2023. Of these, 12 patients underwent robot-assisted longitudinal gastrectomy, 20 patients - robot-assisted Roux-en-Y gastric bypass, 36 patients - robot-assisted gastric bypass with one anastomosis/mini-gastric bypass, 6 patients - surgical exploration. We assessed duration of surgery, docking, placement of trocars and robotic manipulators, the need for their intraoperative displacement, incidence of intraoperative complications and conversions to laparoscopic surgery, intraoperative blood loss and early postoperative complications, severity of pain syndrome on the 1st day after surgery. Mean surgery time was 87 [67, 120], 116 [78, 139], 96 [79, 125] and 141 [112, 184] min, respectively. Intraoperative blood loss was less than 50 ml. There were no complications requiring surgical treatment, cardiovascular, respiratory and other complications within 1 month. Robot-assisted bariatric surgery using the Senhance system is feasible and safe for patients. Immediate results of robotic surgery are comparable to those after laparoscopy. However, large experience and cost-effectiveness analysis are required to assess the feasibility of robotic systems in bariatric surgery.

Intraoperative Displacement of a Radiofrequency Identifier Tag into the Proximal Bronchus Requiring Extension of Lung Resection—Report of a Case—

Intraoperative Displacement of a Radiofrequency Identifier Tag into the Proximal Bronchus Requiring Extension of Lung Resection—Report of a Case—

Silicone oil migration into the anterior chamber in a phakic eye

We describe a novel technique to manage silicone oil (SO) migration into the anterior chamber (AC) in a phakic eye. A 57-year-old female patient underwent right lens-sparing pars plana vitrectomy for diabetic tractional retinal detachment with SO tamponade. Postoperatively, a large bubble of SO was detected in the AC. The case was managed with the intraoperative displacement of the SO bubble using an ophthalmic viscoelastic device, phacoemulsification, and insertion of a capsular tension ring with an opening directed toward 6 o'clock position. The insertion of the capsular tension ring in this particular position prevented further migration of SO into the AC.

A particle filter approach to dynamic kidney pose estimation in robotic surgical exposure.

Traditional soft tissue registration methods require direct intraoperative visualization of a significant portion of the target anatomy in order to produce acceptable surface alignment. Image guidance is therefore generally not available during the robotic exposure of structures like the kidneys which are not immediately visualized upon entry into the abdomen. This paper proposes guiding surgical exposure with an iterative state estimator that assimilates small visual cues into an a priori anatomical model as exposure progresses, thereby evolving pose estimates for the occluded structures of interest. Intraoperative surface observations of a right kidney are simulated using endoscope tracking and preoperative tomography from a representative robotic partial nephrectomy case. Clinically relevant random perturbations of the true kidney pose are corrected using this sequence of observations in a particle filter framework to estimate an optimal similarity transform for fitting a patient-specific kidney model at each step. The temporal response of registration error is compared against that of serial rigid coherent point drift (CPD) in both static and simulated dynamic surgical fields, and for varying levels of observation persistence. In the static case, both particle filtering and persistent CPD achieved sub-5mm accuracy, with CPD processing observations 75% faster. Particle filtering outperformed CPD in the dynamic case under equivalent computation times due to the former requiring only minimal persistence. This proof-of-concept simulation study suggests that Bayesian state estimation may provide a viable pathway to image guidance for surgical exposure in the abdomen, especially in the presence of dynamic intraoperative tissue displacement and deformation.

Прогностичні критерії судово-медичної оцінки ступеня тяжкості тілесних ушкоджень при закритих переломах кісток нижніх кінцівок

Currently, to determine the severity of injuries in case of adverse effects of subcutaneous fractures of the lower extremities, several forensic examinations are conducted at the stage of treatment, which may lead to loss of confidence in the results of forensic expert opinion of the victims, accompanied by economic losses. Therefore, predicting the consequences of such injuries is an urgent scientific and practical problem of forensic medicine. The purpose of the study is to develop prognostic criteria for forensic assessment of the severity of injuries in fractures of the femur and tibia. Materials and methods. The object of the research was 180 "Expert conclusions (examination of the case file)" with the establishment of the severity of injuries in victims of road accidents: subcutaneous isolated and fractures of the femur (24; 13.3%), tibia – (64; 35.6%); fractures of these bones as the leading injury in polytrauma – (92; 51.1%). In 120 (66.7%) expert opinions the average degree of severity of bodily injuries was established as favorable consequences of road accidents (main sample). In 60 (33.3%) cases, adverse effects of injury were observed with the establishment of severe injuries (a control sample). Research methods which were used are expert examination of the victim with anthropometric studies; radiation diagnostics; alternative computational forecasting. Results and discussion. According to the results of retrospective analysis of the results of treatment, 25 risk factors for adverse effects of subcutaneous fractures of the femur and tibia were identified. The main ones are: passive participation in a road traffic injury as a pedestrian (87.5% in the main sample and 91.7% in the control); combined trauma (70.8% and 75.0%, respectively), multifracture (66.7% and 95.0%, respectively); age &gt;41 years old (48.3% and 81.7%, respectively) and a frontal collision with a car (51.7% and 70.0%, respectively). Risk factors such as intraoperative misalignment of the fragments of the femur and violation of the terms of postoperative X-ray control (23.8% in the main group and absence in the control group) were relatively uncommon. Conclusion. Numerical values of prognostic coefficients of the most probable factors potentiating adverse effects of subcutaneous fractures of long bones of the lower extremities are established. The most informative are: intra-articular multifracture fracture (prognostic coefficient equals -9; I=1.44); multifragmental diaphyseal fracture (prognostic coefficient equals -7; I=1.20); non-elimination of intraoperative displacement of long bone fragments (prognostic coefficient equals -6; I=1.04); discrepancy of the sizes of a clamp to anatomic sizes of the damaged bone (prognostic coefficient equals -6; I=1,04); violation of the terms of postoperative X-ray control (prognostic coefficient equals -4; I=0.50)

A Comparison Between Selective Lobar Bronchial Blockade and Main Bronchial Blockade in Pediatric Thoracoscopic Surgery: A Retrospective Cohort Study

The primary objective of this study was to assess the effect of selective lobar blockade on the risk of hypoxemia during one-lung ventilation in pediatric patients undergoing thoracoscopic surgery. This was a retrospective matched case-control cohort study. The study was performed in a teaching hospital. A total of 60 pediatric patients who underwent thoracoscopic surgery in the authors' hospital from March 2020 to March 2021 were analyzed. The authors examined their electronic medical records and found 30 patients in whom selective lobar blockade was used. These patients then were matched to 30 other patients in whom routine main bronchial blockade was performed in the authors' center based on age, weight, sex, side of surgery, and type of surgery. The inclusion criteria were four-fold: (1) pediatric patients with scheduled thoracoscopic resection of the middle and lower lobe lesions; (2) no obvious anesthesia or surgical contraindications; (3) American Society of Anesthesiologists class I to II; and (4) age younger than one year old. The exclusion criteria were as follows: (1) pediatric patients whose trachea was intubated with a size less than 3.0 mm; (2) a difficult airway; (3) changes in ventilation patterns during surgery; and (4) severe pneumonia and respiratory and circulatory system dysfunction. The following patient data were collected: (1) general clinical information; (2) mean arterial blood pressure, heart rate, central venous pressure, airway peak pressure (Ppeak), oxygenation index (PaO2/FIO2 ratio), and alveolar-arterial oxygen differential pressure (AaDO2) at different time points; that is, before one-lung ventilation (OLV) (T1), ten minutes after OLV (T2), and ten minutes after the end of OLV (T3); (3) degree of lung collapse ten minutes after OLV; (4) operative duration; and (5) the prevalence of hypoxemia, the number of adjustments required for intraoperative displacement of the bronchial blocker, and pulmonary atelectasis. A total of 135 patients were selected, and 60 pediatric patients (30 in group S and 30 in group R) were included in this study. There were no significant differences in age, sex, weight, general preoperative data, degree of lung collapse, or operative duration (p > 0.05). The perioperative hemodynamics between the two groups were not statistically significant (p > 0.05). The oxygenation index, AaDO2, and Ppeak were not significantly different between the two groups at the T1 time point (p > 0.05). However, the oxygenation index was higher, and AaDO2 and Ppeak were lower in group S than in group R at the T2 and T3 time points (p < 0.05). The incidence of atelectasis, the prevalence of hypoxemia, and the number of adjustments required for intraoperative displacement of the bronchial blocker in group S were lower than those in group R (p < 0.05). Selective lobar bronchial blockade, using a bronchial blocker in pediatric thoracoscopic surgery, may represent an alternative to excluding the main bronchial blockade for patients undergoing middle and lower lobe procedures, which may improve intraoperative oxygenation and reduce postoperative atelectasis.

Every Inch Counts: A Prospective Randomized Trial of Anti-Slip Surfaces in Minimally Invasive Gynecologic Surgery

Study Objective To assess the effectiveness of common anti-slip surfaces on reducing intra-operative patient displacement while in Trendelenburg Design Prospective randomized controlled trial with a minimum 6-week post-operative follow up Setting Patient positioning with Trendelenburg Patients or Participants Patients undergoing major laparoscopic or vaginal surgery (hysterectomy or surgery >2 hours) were randomly assigned to one of three anti-slip surfaces: Pink Pad, Action O.R. Overlay (gelpad) or Olympic Vac-Pac (beanbag) from 6/2018-12/2019. 159 patients were enrolled with 148 found to be eligible. Interventions Patients were randomized 1:1:1 one of the three anti-slip surfaces. Measurements and Main Results Patients were pre-operatively assigned to one of three anti-slip surfaces. Intra-operative displacement was assessed by measuring multiple anatomic landmarks [perineum, anteriorsuperior iliac spine (ASIS), umbilicus, acromion and the head] at three times during the case: 1) pre-op, 2) when placed in Trendelenburg, and 3) prior to leveling. Positioning time and time added due to obstructed uterine manipulation were recorded. There was significantly less total movement on the Pink Pad at all anatomic landmarks compared to the gelpad (2.75-5.66cm) and for the torso (ASIS & perineum) compared to the beanbag (1.22-2.69cm). The most consistent predictors of movement included: height, weight, and body mass distribution. Obesity increased displacement by 32-55%. Surgery type, length of surgery, and maximum Trendelenburg did not predict displacement. Laparoscopic surgery with robotic assistance had greater displacement than without (p Conclusion Patients on the Pink Pad had significantly less displacement with Trendelenburg and faster positioning compared to the other surfaces. Obesity is a major predictor of movement. Uterine manipulation was easier on the Pink Pad than the beanbag.

The Stabilization of Lower Lateral Cartilage in Rhinoplasty: A New Control Suture Technique.

Abstract Objective: Reposition of malpositioned lateral crura to normal position in rhinoplasty is important both functionally and aesthetically. The aim of this study is to describe a lateral cruras reposition suture technique for supplying tip symmetry and avoiding crural displacement. Patient and Method: Sixteen primary rhinoplasty cases with malpositioned lateral crura underwent lateral crural control suture (LCCS) were reported. In this technique dissected and released lateral crura were fixed to cheek skin with a suture. Those cases were assessed with FACE-Q rhinology module both aesthetically and functionally. Result: Intraoperative or postoperative lateral crural displacement can be prevented and nasal tip symmetry can be supplied easily with LCCS. Results were satisfactory both functionally and aesthetically. Conclusion: LCCS is a good alternative to correct lateral crural malposition and obtain a tip symmetry.

A historical cohort study of anesthetic methods for percutaneous left atrial appendage closure

Objective To explore the appropriate anesthetic method of percutaneous left atrial appendage closure by comparing the safety and feasibility of the different anesthetic methods. Methods Ninety nine patients with percutaneous left atrial appendage closure were divided into three groups according to anesthetic scheme by using a method of Historical Cohort Research: laryngeal mask general anesthesia without muscle relaxant (L group, n=19), endotracheal intubation general anesthesia with muscle relaxation antagonist (S group, n=40), and endotracheal intubation general anesthesia without muscle relaxation antagonist (G group, n=40). Target controlled infusion(TCI) of propofol and remifentanil for anesthesia induction and maintenance were used in L group and S group. The laryngeal mask was used in L group without muscle relaxants. Rocuronium was used for endotracheal intubation in S group, but the muscle relaxation was antagonized by sugammadex at the end of operation. Endotracheal intubation was performed after TCI propofol, intravenous sufentanil and cisatracurium in G group, but the muscle relaxation was not antagonized at the end of the operation. The outcome indexes were as follows: the time of spontaneous respiration, the time of consciousness recovery, the time of extubation, the time of staying at the postanesthesia care unit (PACU), the successful rate of esophageal ultrasonic probe placement, the incidence of displacement and air leakage of laryngeal mask, the incidence of replacement of a laryngeal mask with tracheal intubation during operation, and the adverse events after awakening. Results The recovery time of autonomic respiration in S group and L group were significantly shorter than that in G group[(2.5±0.5), (1.9±0.6) min vs (22.2±7.1) min, P<0.05]. The recovery time of consciousness was (3.4±0.6), (2.7±0.6) min in L group and S group respectively, both which were significantly shorter than that in G group[(28.8±12.9) min, P<0.05]. The time of extubation in L and S group was (4.5±1.0), (3.6±1.0) min respectively, both which were significantly shorter than that in G group [(34.6±16.0) min, P<0.05]. The time of staying at PACU in L group and S group was (28±4), (26±5) min respectively, which were significantly shorter than that in G group[(65±20) min, P<0.05]. The successful rate of one-time placement of TEE was 42.1% in L group, but that in S group and G group was more than 95% respectively(P<0.05). The intraoperative displacement rate in L group was 36.8%. The incidence of replacement of a laryngeal mask with tracheal intubation during operation was 21.1% in L group(P<0.05). The incidence of transient hypoxemia, agitation, nausea and vomiting and urinary retention were lower in S group and L group than in G group after awakening(P<0.05). Conclusions Endotracheal intubation general anesthesia was performed by combined intravenous injection of rocuronium with TCI propofol and remifentanil and reversal of rocuronium by sugammadex, which have the advantages of safe airway controllability, recovery rapidly after operation, extubation earlier, the lower incidence of hypoxemia and the lower incidence of agitation. Therefore, this anesthetic pattern is an ideal anesthetic method for percutaneous left atrial appendage closure. Key words: Left atrial appendage closure; General anesthesia; Sugammadex

Iatrogenic Fracture Gapping During Fixation of Jones Fractures

Category: Trauma Introduction/Purpose: Surgical fixation of Jones fractures is often recommended to facilitate recovery and achieve union. Iatrogenic fracture displacement during intramedullary screw fixation is a commonly encountered technical issue. This may be related to fracture location in relation to the surrounding ligamentous attachments, namely the robust intermetatarsal ligaments found at the proximal articulation of the 4th and 5th metatarsals. This study examines the relationship between fracture line and its location in regards to the surrounding ligamentous structures and its effect on Jones fracture displacement, reduction and fixation in a cadaveric model. Methods: Eighteen fresh-frozen cadaveric feet were dissected with preservation of all ligamentous attachments. Given the similar anatomic distal extent of the dorsal and plantar intermetatarsal ligaments on the 5th metatarsal, measurements were obtained detailing the anatomic position of the dorsal intermetatarsal ligament (DIL) only. The specimens were divided into two groups with modelled fractures created at the 4th &amp; 5th metatarsal articulation proximal to the distal extent of the DIL (Group 1) or just distal to the DIL (Group 2). Fractures were fixed in standard fashion with serial fluoroscopic images obtained to study fracture gapping and rotation. Results: There was approximately 5 mm of fracture gapping created iatrogenically during tapping with no statistically significant differences between Group 1 and Group 2 (4.53 mm versus 5.25 mm, p=0.5430). The distal aspect of the DIL was anatomically located 2.77 mm (Range 1.58 mm – 4.46 mm) distal to the 4th &amp; 5th metatarsal articulation. Conclusion: Considerable iatrogenic fracture gapping occurs during intramedullary screw fixation of Jones fractures in a cadaveric model regardless of fracture location in relation to the intermetatarsal ligamentous attachments. Intraoperative displacement may be related to iatrogenic distraction caused by canal tapping when utilizing a common surgical method. Specific techniques may be required to maintain anatomic alignment during tapping and screw fixation to prevent iatrogenic displacement.

A Survey of Current Practice of Supraglottic Airway Devices in Pediatric Anesthesia from India.

Background and Objectives:Supraglottic airway devices (SADs) have revolutionized the pediatric anesthetic practice and got a key role in difficult airway (DA) management. Several modifications of SADs design had come up to improve their safety.Aim:The aim of this survey was to determine the current usage of SADs in pediatric anesthetic practice, their availability, and to know any difficulties noted in practice.Methods:It was a questionnaire survey among the anesthesiologists who attended the National Pediatric Anesthesia Conference-2016. The questionnaire assessed the current practice preferences of SADs in routine pediatric cases and DA management, availability of various devices, and any difficulties noted in their usage.Results:First-generation SADs were widely available (97%), and 64% of respondents preferred to use it for pediatric short cases. 64% felt the use of SADs free their hands from holding the facemask and 58% found better airway maintenance with it. Intraoperative displacement (55%) was the common problem reported and only 11% felt aspiration as a problem. Most of the respondents (73%) accepted its use as rescue device in airway emergency, and 84% felt the need of further randomized controlled studies on safety of SADs in children. The majority were not confident to use SADs in neonates.Interpretation and Conclusions:The key role of SADs in DA management was well accepted, and aspiration was not a major problem with the use of SADs. Although many newer versions of SADs are available, classic laryngeal mask remains the preferred SAD for the current practitioner. Further, RCTs to ensure the safety of SADs in children are warranted.

Rate and Risk Factors for Delayed Healing Following Surgical Treatment of Lateral Condyle Humerus Fractures in Children.

Lateral condyle humerus fracture nonunion after surgical fixation has been reported to be <1%. The purpose of this study was to evaluate the rate and risk factors for delayed healing of pediatric lateral condyle fractures after surgical fixation. Retrospective study of all operatively treated lateral condyle fractures at a single institution from 2006 to 2013 was performed. Radiographic evaluation included: measured fracture displacement at both presentation and after surgical fixation, fracture classification, and multiple parameters of pin configuration. Patients who had delayed healing were defined as those not healed by the eighth week of follow-up and were compared with those fractures that healed in <8 weeks to identify risk factors associated with delayed healing. Purposeful selection was utilized to identify factors for entry into a multivariate binary logistic regression model. A total of 210 children were evaluated. Mean follow-up was 25 weeks (4 wk to 5 y). Distribution of Weiss classification was as follows: type 1, 8 (4%); type 2, 61 (29%); and type 3, 141 (67%). There were 33 (16%) delayed unions and 7 of these (3% of the entire cohort) required further surgery to achieve healing. Weiss classification, intraoperative fluoroscopy time, and intraoperative displacement after fixation met criteria for entry into the regression. While Weiss classification did not remain significant within the model, its removal resulted in a 30% change in the parameter estimate for intraoperative fluoroscopy time. For each second increase in fluoroscopy time, there is a 3% increase in the risk of delayed healing. Patients with >1 mm displacement of the lateral cortex after fixation had an increased risk of delayed healing (OR=4.78, P=0.007). Delayed union of lateral condyle fractures is a matter of concern, and the rate of secondary surgery to achieve healing appears to be higher than previously reported. Risks for delayed healing include amount of residual displacement after reduction and the difficulty in attaining that reduction, as defined by fluoroscopy time. Level IV-therapeutic study, case series.

Effect of Pneumoperitoneum and Lateral Position on Oropharyngeal Seal Pressures of Proseal LMA in Laparoscopic Urological Procedures.

A sustained and effective oropharyngeal sealing with supraglottic airway is required to maintain the ventilation during laparoscopic surgery. Previous studies have observed the Oropharyngeal Seal Pressure (OSP) for Proseal Laryngeal Mask Airway (PLMA) after pneumoperitoneum in supine and trendelenburg position, where PLMA was found to be an effective airway device. This study was conducted with ProSeal LMA, for laparoscopic Urologic procedures done in lateral position. To measure OSP in supine and lateral position and to observe the effect of pneumoperitoneum in lateral position on OSP. Secondary objectives were to assess adequacy of ventilation and incidence of adverse events. A total number of 25 patients of American Society of Anaesthesiologists (ASA) physical status II and I were enrolled. After induction of anaesthesia using a standardized protocol, PLMA was inserted. Ryle's tube was inserted through drain tube. The position of PLMA was confirmed with ease of insertion of Ryle's tube and fibreoptic grading of vocal cords. Patients were then put in lateral position. The OSP was measured in supine position. This value was baseline comparison for OSP in lateral position and that after pneumoperitoneum. We assessed the efficacy of PLMA for ventilation, after carboperitoneum in lateral position (peak airway pressure, End Tidal Carbon dioxide (EtCO2), SPO2). Incidence of adverse effects (displacement of device, gastric insufflation, regurgitation, coughing, sore throat, blood on device, trauma) was also noted. The OSP was above Peak Airway Pressure (PAP) in supine (22.1±5.4 and 15.4±4.49cm of H2O) and lateral position (22.6±5.3 and 16.1±4.6). After pneumoperitoneum, which was in lateral position, there was statistically significant (p-value <0.05) increase in both PAP (19.96±4.015) and OSP (24.32±4.98, p-value 0.03). There was no intraoperative displacement of PLMA. There was no event of suboptimal oxygenation. EtCO2 was always within normal limits. Gastric insufflation was present in one patient. One patient had coughing and blood was detected on device. Three patients had throat discomfort post-operatively. In this study, Oropharyngeal seal pressures with PLMA were found to increase after pneumoperitoneum in lateral position. PLMA forms an effective seal around airway and is an efficient and safe alternative for airway management in urological laparoscopic surgeries done in lateral position.

Posterior Malleolar Fractures Associated With Tibial Shaft Fractures and Sequence of Fixation.

The purpose of this study was to evaluate posterior malleolar injuries associated with nailed tibial fractures and to determine the quality of reduction based on the sequence of fixation in associated fracture patterns. Retrospective cohort study. 1113 tibia fractures treated with an intramedullary nail at 3 level I trauma centers. Tibial shaft fractures with posterior malleolar injury were analyzed regarding type of fracture, mechanism of injury, energy of injury, fracture characteristic, surgical characteristics including sequence of fixation, obvious intraoperative displacement of the posterior malleolar fragment, and the quality of reduction. One group ("malleolus-first") consisted of patients in whom the posterior malleolus was fixed before tibial nailing and the other group ("tibia-first") included patients in whom tibial nailing was done before posterior malleolus fixation. Intraoperative displacement, quality of reduction. Ninety-six of 1113 (9%) nailed tibial shaft fracture patients had a concomitant posterior malleolus fracture (9%). Of the 96 posterior malleolar fracture patients, 70 patients were operatively treated (73%). In the malleolus-first group (54 patients), intraoperative displacement of the posterior malleolar fragment was observed in 1 patient, and 1 case of poor reduction of the posterior malleolar fragment was observed (2%). In the tibia-first group (16 patients), obvious intraoperative displacement of the posterior malleolar fragment was observed in 5 patients (31%), and poor reduction of the posterior malleolar fragment was observed in 7 patients (44%). These percentages of patients with poor quality of reduction were statistically significantly different (p ≤ 0.01). Many low-energy tibia fractures with a spiral configuration do have an associated posterior malleolus fracture. In order to avoid intraoperative displacement and poor reduction, we recommend fixation of the posterior malleolar fragment before nailing of the tibia in associated fracture pattern. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Edema and Seed Displacements Affect Intraoperative Permanent Prostate Brachytherapy Dosimetry

We sought to identify the intraoperative displacement patterns of seeds and to evaluate the correlation of intraoperative dosimetry with day 30 for permanent prostate brachytherapy. We analyzed the data from 699 patients. Intraoperative dosimetry was acquired using transrectal ultrasonography (TRUS) and C-arm cone beam computed tomography (CBCT). Intraoperative dosimetry (minimal dose to 40%-95% of the volume [D40-D95]) was compared with the day 30 dosimetry for both modalities. An additional edema-compensating comparison was performed for D90. Stranded seeds were linked between TRUS and CBCT using an automatic and fast linking procedure. Displacement patterns were analyzed for each seed implantation location. On average, an intraoperative (TRUS to CBCT) D90 decline of 10.6%±7.4% was observed. Intraoperative CBCT D90 showed a greater correlation (R(2)=0.33) with respect to Day 30 than did TRUS (R(2)=0.17). Compensating for edema, the correlation increased to 0.41 for CBCT and 0.38 for TRUS. The mean absolute intraoperative seed displacement was 3.9±2.0mm. The largest seed displacements were observed near the rectal wall. The central and posterior seeds showed less caudal displacement than lateral and anterior seeds. Seeds that were implanted closer to the base showed more divergence than seeds close to the apex. Intraoperative CBCT D90 showed a greater correlation with the day 30 dosimetry than intraoperative TRUS. Edema seemed to cause most of the systematic difference between the intraoperative and day 30 dosimetry. Seeds near the rectal wall showed the most displacement, comparing TRUS and CBCT, probably because of TRUS probe-induced prostate deformation.

Diagnostic Performance of Radiographs and Computed Tomography for Displacement and Instability of Acute Scaphoid Waist Fractures

Fracture displacement is the most important factor associated with nonunion of a scaphoid waist fracture.We evaluated the performance characteristics of radiographs and computed tomography (CT) in the diagnosis of intraoperative displacement and instability of scaphoid waist fractures using wrist arthroscopy as the reference standard. During a six-year period (2004 to 2010) at two institutions, forty-four adult patients with a scaphoid waist fracture underwent arthroscopy-assisted operative fracture treatment at a mean of nine days (range, two to twenty-two days) after injury. Subjects included all of those with a displaced scaphoid fracture seen on radiographs and a selection of patients with a nondisplaced scaphoid fracture. All patients had preoperative radiographs and CT. Arthroscopy with up to 5 kg of traction was the reference standard for fracture displacement and instability. The reference standard (arthroscopy) led to a diagnosis of twenty-two displaced fractures (all unstable) and twenty-two nondisplaced fractures (seven unstable). Displacement was diagnosed in eleven patients (25%) with the use of radiographs and in twenty (45%) with CT. The sensitivity, specificity, and accuracy for diagnosing intraoperative displacement were 45%, 95%, and 70%, respectively, with the use of radiographs and 77%, 86%, and 82%, respectively, with CT. The sensitivity, specificity, and accuracy for diagnosing intraoperative instability were 34%, 93%, and 55%, respectively,with the use of radiographs and 62%, 87%, and 70%, respectively, with CT. Assuming a 10% prevalence of fracture displacement and instability among all scaphoid waist fractures, the positive and negative predictive values for displacement were 53% and 94%, respectively, with the use of radiographs and 39% and 97% with CT whereas the positive and negative predictive values for instability were 36% and 93%, respectively, with radiographs and 34% and 95% with CT. Radiographs and CT scans cannot be relied on to accurately diagnose intraoperative scaphoid fracture displacement or instability compared with arthroscopic examination. The influence, with regard to the risk of nonunion, of intraoperative instability of a scaphoid fracture that is seen to be nondisplaced on radiographs or CT is currently unknown. Diagnostic Level III.

Usefulness of Cone-Beam Computed Tomography in Determining the Position of Ossicular Prostheses

Cone-beam computed tomography (CT) is proving useful in various operative settings. We hypothesize that it has great potential as an intraoperative assessment tool for ossicular prosthesis positioning. Results from prosthetic ossiculoplasty are frequently disappointing. Undetected intraoperative displacement of the prosthesis may be caused, and obscured, by placement of an overlying cartilage graft. A cadaveric right temporal bone was prepared with a tympanomeatal flap, and an extended posterior tympanotomy through a cortical mastoidectomy. Each of 3 commercially available prostheses was positioned in 3 different locations: (1) optimal, (2) grossly displaced, and (3) marginally displaced. The intended prosthetic positions were confirmed by endoscopy before and after cone-beam CT image acquisition. The primary outcome measure was the position of the prosthesis in relation to the stapes and tympanic membrane, as assessed by 5 expert reviewers blinded to the study. Secondary outcome measures included optimal dosing for adequate image resolution and radiographic scatter associated with different prosthetic materials. Cone-beam CT accurately demonstrated the position of ossicular reconstruction prostheses with respect to the stapes and tympanic membrane. Prosthesis displacement, whether minimally or marked, was also accurately demonstrated. Interobserver agreement among the 5 reviewers, measured using a Fleiss κ statistic, ranged from 0.4 to 0.8 (fair to substantial agreement depending on type and position of the prosthesis). Cone-beam CT is a useful tool for determining the position of ossicular reconstruction prostheses in situ. We suggest it has potential for intraoperative assessment, to check positioning after the prosthesis has been covered with a cartilage graft and tympanomeatal flap.

Lumbar Plexus Anatomy within the Psoas Muscle: Implications for the Transpsoas Lateral Approach to the L4-L5 Disc

The transpsoas lateral surgical approach has been advocated as an alternative to direct anterior approaches for less invasive or minimally invasive access to the spine. Postoperative thigh pain, paresthesia, and/or weakness have been described after the use of this surgical approach. The purpose of this cadaveric anatomic study is to provide a description of the lumbar plexus as it relates to the transpsoas lateral surgical approach. Dissection of the lumbar plexus was performed in eighteen cadaveric specimens. Needle markers were placed in the L2-L3, L3-L4, and L4-L5 discs in the midcoronal plane. The anatomic structures were surveyed, and the proximity of the needle to the neural structures was observed. In thirteen of the eighteen specimens, the femoral nerve received its contributions from the L2 to L4 nerve roots and was formed at the L4-L5 disc space. In all specimens, the femoral nerve passed dorsal to or directly at the midpoint of the disc. In three specimens, the needle displaced or was immediately adjacent to the femoral nerve. The femoral nerve was found between the needle and the posterior aspect of the L4-L5 disc space in thirteen of the eighteen specimens. Because of the proximity of the neural elements, in particular the femoral nerve, to the center of the disc space, the transpsoas lateral surgical approach to the L4-L5 disc space will likely cause intraoperative displacement of neural structures from their anatomic course during retractor dilation. Careful attention should be paid to retractor placement and dilation time during transpsoas lateral access surgery, particularly at the L4-L5 disc.