Intraoperative Steps Research Articles

Targeting repeatability of a less obtrusive surgical navigation procedure for total shoulder arthroplasty.

Surgical navigation systems have demonstrated improvements in alignment accuracy in a number of arthroplasty procedures, but they have not yet been widely adopted for use in total shoulder arthroplasty (TSA). We believe this is due in part to the obtrusiveness of conventional optical tracking systems, as well as the need for additional intraoperative steps such as calibration and registration. The purpose of this study is to evaluate the feasibility of adapting a less-intrusive dental navigation system for use in TSA. We developed a proof-of-concept system based on validated laser-engraved surgical tools recently introduced for use in dental surgery that are calibrated once when manufactured and not recalibrated at time of use. The design also features a notably smaller bone-mounted tracker that can be tracked from a wide range of viewing angles. To assess our system's performance, we modified the dental surgical software to support guidance of a TSA procedure. We then conducted a user study in which three participants with varying surgical experience used the system to drill 30 holes in a glenoid model. Using a coordinate measuring machine, we determined the resulting drilled trajectory and compared this to the pre-planned trajectory. Since we used a model glenoid rather than anatomical specimens, we report on targeting precision rather than overall procedure precision or accuracy. We found targeting precision < 1mm (standard deviation) for locating the entry hole and < ~ 1° (SD) for both version and inclination. The latter value was markedly lower than the end-to-end angular precision achieved by previously reported TSA navigation systems (approximately 3°-5° SD). We conclude that variability during the targeting phase represents a small fraction of the overall variability exhibited by existing systems, so a less obtrusive navigation system for TSA based on laser-engraved tooling is likely feasible, which could improve the uptake rates of surgical navigation for TSA, thereby potentially leading to improved overall surgical outcomes.

Extended Anterior Inferior Approach to Endoscopic Medial Maxillectomy for Maxillary Sinus Lesions.

Myriad open and endoscopic approaches are employed to resect maxillary sinus lesions, each with associated advantages and disadvantages. The inferior and anterior portion of the sinus remains a challenging space to access. To describe the extended anterior inferior approach to endoscopic medial maxillectomy (EAMM) as a novel and valuable addition to a stepwise approach for minimizing surgical morbidity without compromising tumor outcomes. To report the outcomes of patients treated with this approach. A retrospective case series study of 9 patients who underwent EAMM between 2016 and 2019 at a tertiary care referral center was performed. The endoscopic technique is described. The duration of follow-up ranged from 1 to 53 months. Intraoperative steps, including transection of the nasolacrimal duct and execution of an intraoperative dacryocystorhinostomy, were reviewed. Postoperative outcomes, including patient symptoms at follow-up and tumor recurrence, were recorded. Adequate exposure with gross total tumor resection or margin-negative tumor resection was achieved in all cases. Sparing of the nasolacrimal duct was achieved in 2 patients. No patients reported persistent epiphora, empty nose syndrome, or changes in cosmesis such as alar or nasal tip collapse. One patient reported unilateral V2 hypoesthesia at 6 months postoperatively that had resolved by his next follow-up 18 months after surgery. Postoperative tumor surveillance was achieved by endoscopic examinations in all patients and there was no evidence of tumor recurrence at a median follow-up of 22 months. The EAMM provides improved access to the inferior-posterior-medial maxillary sinus. This approach minimizes the risk of hypoesthesia and change in cosmesis present in other approaches, and obviates division of the nasolacrimal duct for inferior, posterior-medial attached lesions. This progressive escalation of approach for maxillary sinus lesions minimizes injury to nasal and nasolacrimal structures without compromising tumor outcomes.

179 Improving Operative Notes in Upper GI Surgery: An Innovative QI Project Utilising Existing Electronic Hospital Systems

Abstract Introduction Operative notes play a valuable role in ensuring that surgical patients receive consistent and adequate care. There are many inherent difficulties affecting their quality. We performed a QI project to improve surgical operative notes at our centre. Method A questionnaire assessing subjective quality of operative notes was sent to all foundation doctors delivering post-operative care. Compliance to each inclusion recommendation in the RCS guidelines was analysed. A standardised template for operative notes was incorporated into the hospital’s electronic records system, compliance was then reassessed. Results Questionnaire responses (16) were better for typed vs hand-written notes in all domains: ease of accessing notes, following intra-operative steps, following post-operative plans and frequency of asking for additional information regarding plans. After implementation of the template, mean compliance across 19 RCS parameters improved from 69% (55 operations) to 89% (46 operations). Number of parameters with 100% compliance improved from 2/19 to 8/19. Compliance increased in 14/19 parameters, there was no change in 2/19 (already 100%) and a reduction was seen in 3/19. Conclusions Results from our analysis and questionnaire showed that typed notes were favourable when compared to hand-written. The introduction of a standardised electronic template, without investment in new software, improved compliance to RCS guidelines.

Intraoperative strategies to overcome difficulties in laparoscopic cholecystectomy for chronic calculous cholecystitis

Background: Surgery in chronic cholecystitis is very challenging because of inability to hold the gall bladder, dense adhesions, frozen Calot’s triangle and difficulty in applying clips. Precise and meticulous dissection is required to establish critical view of safety. There is no consensus among surgeons about appropriate intraoperative steps in difficult gall bladder (GB) surgery. The authors aim to present various intraoperative difficulties and strategies to overcome them. Methods: A prospective study of 81 patients of chronic cholecystitis was done in our institution. They were divided in two groups. Group A in which surgery could be done easily. Group B in which surgery was difficult and different intraoperative strategies were applied to overcome them. Results: Total 42 patients were included in group A and 39 patients in group B. Various difficulties encountered while performing laparoscopic cholecystectomy in group B were adhesions (53.8 %), inability to grasp the fundus of GB (15.3%), frozen Calot’s triangle (15.3%), inability to grasp the Hartmann’s pouch (12.8%) and cystic duct edema (2.5%). Conclusions: Intraoperative technique of identification of Rouviere′s sulcus first, followed by high peritoneal incision on the GB body. Subsequently blunt dissection of Calot’s triangle using gauze piece and hydro dissection by suction irrigation canula ventral to the sulcus. It created a retro gall bladder tunnel safely. It established the critical view of safety in all our cases.

Can diagnostic changes caused by cone beam computed tomography alter the clinical decision in impacted lower third molar treatment plan?

This study observed whether changes in diagnosis caused by analysis of three-dimensional images can lead to alterations in the treatment plans of impacted lower third molars (ILTMs). Sets of panoramic (PAN) - cone beam computed tomography (CBCT) of 218 patients were assessed for ILTM classification, contact with mandibular canal, contact and resorption of the lower second molar (LSM), intraoperative planning and post-operative expectations. Percentage agreement and McNemar test compared PAN vs CBCT assessments. Logistic regression analyzed the dependency of change in surgical planning considering the changes in diagnostic features; descriptive statistics was used to observe the expectation of post-operative complications and paresthesia. Differences were found between PAN vs CBCT for classification of impaction and positioning, LSM relationship, choice for crown and root sectioning and expectation of post-operative complications (all with p < 0.001). Logistic regression indicated that the change in diagnosis caused by CBCT examination did not change the clinical decision to extract ILTM but altered the planning of intraoperative steps such as osteotomy, crown sectioning and relaxing incision. The expectation of post-operative complications decreased when professionals planned the ILTM removal using tri-dimensional images. We concluded that changes in the diagnosis after CBCT examination can lead to alterations in the treatment plan of impacted lower third molar.

Introduction of the Operating Room Black Box in Gynecology: Development of a Procedural Framework for Total Laparoscopic Hysterectomy

Study Objective Operating room (OR) delays due to inefficiency can result from a chain of intraoperative events including technical factors, equipment failures or unavailability, and non-technical human factors. The newly developed Operating Room Black Box (ORBB) technology can be used to capture information during surgery which can be analyzed to potentially identify the root causes of delays and inefficiencies. We aimed to develop a procedural framework for total laparoscopic hysterectomy (TLH) in order to accurately and consistently capture the essential time points that occur during this complex laparoscopic procedure. Design Multi-disciplinary collaborative working group. Setting Canadian tertiary care academic hospital. Patients or Participants Team consisted of gynecologic surgeons, an anesthetist, an OR nurse and systems analysts. Interventions Multi-disciplinary working group collaborated to develop a procedural framework encompassing the critical steps and check points occurring during the course of a TLH. All phases of the operation were considered including pre-operative, intra-operative, and post-operative steps. Measurements and Main Results The completed framework consists of a series of procedural steps divided into three time phases: pre-operative, intraoperative and post-operative. Consensus from the group led to the identification of 7 discrete steps during the pre-operative phase, 11 intra-operative steps and 6 post-operative steps. Conclusion The development of a standardized procedural framework for TLH is the first step towards capturing data with the ORBB technology. The analysis of the captured data will allow us to analyze the non-technical skills and team performance in the OR, and ultimately develop a multi-disciplinary operating room “playbook” that can be utilized to minimize time delays and maximize OR utilization.

Utility of Tokyo guidelines and intraoperative safety steps in improving the outcome of laparoscopic cholecystectomy in complex acute calculus cholecystitis: a prospective study

Laparoscopic cholecystectomy (LC) in complicated acute calculus cholecystitis (ACC) poses multiple challenges. This prospective, observational study assessed the utility and safety of a set protocol and intraoperative steps in LC for complex ACC. All cases of ACC from 2008 to 2018 were graded asper Tokyo guidelines; moderate and severe ACC were termed as 'complex ACC (CACC).' Patients were subjected to upfront LC or percutaneous drainage (PCD) followed by LC. Seven intraoperative safety steps were used to achieve critical view of safety (CVS). Use of safety steps, duration of surgery, and length of hospital stay were compared between moderate and severe ACC; complications were classified using Clavien-Dindo classification. We analyzed 145 patients with moderate (74.5%) and severe (25.5%) ACC. There were significantly more male (p = 0.0059) and older (p = 0.0006) patients with severe ACC. Upfront LC was performed in 81.4%; PCD required in 6.9%. Timing of LC from symptom onset was < 1week (53.1%), 2-5weeks (28.3%), and ≥ 6weeks (18.6%). CVS was achieved in 97.2%, subtotal cholecystectomy performed in 2.8%, conversion rate was 1.4%, major postoperative complications (Clavien-Dindo Grade IIIa and IIIb) were seen in 4.1%, no bile duct injury, and mortality was 0.7%. The outcomes were similar irrespective of timing of intervention. The study concludes that preoperative assessment by Tokyo guidelines, algorithmic plan of treatment and use of intraoperative safety steps results in favorable outcome of LC in ACC.

Role of Microscope-Intraoperative Optical Coherence Tomography in Pediatric Keratoplasty: AComparative Study

We evaluate the role of microscope-integrated intraoperative optical coherence tomography (i-OCT) in pediatric keratoplasty. Combined prospective and retrospective, comparative, interventional study conducted at the Dr Rajendra Prasad Center for Ophthalmic Sciences in New Dehli, India. Seventy-five children ≤16 years of age undergoing planned keratoplasty were divided into 2 groups and compared regarding intraoperative course and postoperative outcome. In group 1 (prospective group, n= 56), preoperative anterior segment visualization was performed clinically, with ultrasound biomicroscopy (UBM) and i-OCT and keratoplasty was commenced under i-OCT microscope. In group 2 (retrospective group, n= 19), a conventional microscope was used during keratoplasty. In group 1, i-OCT, UBM, and clinical examination detected retrocorneal membrane in 10%, 7.5%, and 5% (P= .005), iris adhesions in 62.5%, 57.5%, and 20% (P= .02), iris stump in aniridia 15%, 10%, and 0% (P= .001), shallow central anterior chamber in 22.5%, 22.5%, and 7.5% (P= .003), and shallow peripheral anterior chamber in 65%, 60%, and 17.5% (P= .004) of children, respectively. The use of i-OCT affected intraoperative surgeon decision making in 45% and 33% of cases of anterior and posterior lamellar keratoplasty, respectively. During penetrating keratoplasty, concomitant intraoperative procedures were higher in group 1 than in group 2, namely synechiolysis (19/40 vs 2/15; P= .1), pupilloplasty (4/40 vs 0/15; P= .02), lens extraction (4/40 vs 1/15; P= .5), and anterior vitrectomy (2/40 vs 1/15; P= .4). Postoperative secondary interventions were lower (P= .04) in group 1 (48.21% vs 94.74%). Anterior segment imaging with i-OCT and UBM immediately before surgery improves the surgical planning of children with corneal opacities. In addition, the use of i-OCT refines intraoperative steps, thereby optimizing the postoperative outcome of pediatric keratoplasty.

Laparoscopic Right Hepatectomy

Laparoscopic right hepatectomy (LRH) is an important technique in a modern hepatobiliary surgeon’s arsenal. It’s application extends to many different disease processes including both malignant and benign tumors as well as infections and in trauma. The procedure involves using minimally invasive methods to remove Couinaud segments 5-8 delineated by the portion of the liver right and lateral to Cantlie’s line. In this chapter, we explain the approach to performing this operation by delving into preoperative considerations with a focus on high quality imaging, 3D reconstruction, and virtual hepatectomy, optimizing the future liver remnant (FLR) with PVE and use of parenchymal sparing methods, and detailed intraoperative steps emphasizing caudal view, Glissonian approach, MHV roadmap, and communication with anesthesia. We also give context to LRH by discussing the two most common diseases addressed by it, namely colorectal liver metastases (CRLM) and hepatocellular carcinoma (HCC), as well as historical perspectives and how LRH use has evolved. We also address complication management such as post-operative liver failure and intra-operative bleeding accidents, variants on exposure with hand assist and transthoracic view, and comparing the advantages and disadvantages between open and laparoscopic right hepatectomy. This review contains 12 figures, 4 tables, and 111 references. Keywords: augmented reality, laparoscopic right hepatectomy, laparoscopic PVE and ALPPS, low CVP anesthesia, MHV roadmap, minimally invasive liver resection, parenchymal sparing right hepatectomy, Takasaki caudal approach, virtual hepatectomy,

Laparoscopic Right Hepatectomy

Laparoscopic right hepatectomy (LRH) is an important technique in a modern hepatobiliary surgeon’s arsenal. It’s application extends to many different disease processes including both malignant and benign tumors as well as infections and in trauma. The procedure involves using minimally invasive methods to remove Couinaud segments 5-8 delineated by the portion of the liver right and lateral to Cantlie’s line. In this chapter, we explain the approach to performing this operation by delving into preoperative considerations with a focus on high quality imaging, 3D reconstruction, and virtual hepatectomy, optimizing the future liver remnant (FLR) with PVE and use of parenchymal sparing methods, and detailed intraoperative steps emphasizing caudal view, Glissonian approach, MHV roadmap, and communication with anesthesia. We also give context to LRH by discussing the two most common diseases addressed by it, namely colorectal liver metastases (CRLM) and hepatocellular carcinoma (HCC), as well as historical perspectives and how LRH use has evolved. We also address complication management such as post-operative liver failure and intra-operative bleeding accidents, variants on exposure with hand assist and transthoracic view, and comparing the advantages and disadvantages between open and laparoscopic right hepatectomy. This review contains 12 figures, 4 tables, and 111 references. Keywords: augmented reality, laparoscopic right hepatectomy, laparoscopic PVE and ALPPS, low CVP anesthesia, MHV roadmap, minimally invasive liver resection, parenchymal sparing right hepatectomy, Takasaki caudal approach, virtual hepatectomy,

3D Printing for scaphoid-reconstruction with medial femoral condyle flap

Three-dimensional (3D) printing has emerged as an innovative technology to derive a maximum benefit from high-resolution tomography images and virtual 3D reconstructions.The present study describes a novel technique using a 3D printed model for harvesting osteochondral medial femur condyle (MFC) flap to replace the proximal pole of the scaphoid in case of proximal avascular pole. MFC bone grafting has already proved to be reasonable surgical method for this indication. To refine this technique, we introduce a 3D model of the proximal scaphoid pole on a handlebar with anatomic orientation marks on its surface, which was virtually planned via 3D imaging and finally 3D printed. This 3D model was sterilized and facilitated several intraoperative steps, such as resecting the proximal pole, simulating the alignment of the future MFC flap, detecting the most feasible harvest site, reducing the donor site morbidity and precisely modeling the graft. In summary, 3D printing is an innovative, feasible technology to aid in various surgical steps while performing a MFC flap for posttraumatic avascular proximal scaphoid pole. It enhances the surgeon's perception of complex patient-specific pathologies and intraoperative accuracy. Especially, we emphasize the benefit of a handlebar on the 3D model, because it enormously improves its maneuverability and usability.

Evolution of Principles of Transmetatarsal Amputations: How We Do It Today

Transmetatarsal amputation (TMA) aims to preserve the length of the foot as much as possible in patients with traumatic mangled foot injuries or diabetic foot. In this article, we give an overview of the evolution of technique of TMA, management of complications, its postoperative care, with utmost emphasis on preoperative and intraoperative steps to achieve best results. We have formulated a treatment algorithm as per our institutional practice for systematic application of principles for the management of TMA. How to cite this article: Kumar D, Hooda A, Thami T. Evolution of Principles of Transmetatarsal Amputations: How We Do It Today. J Foot Ankle Surg (Asia Pacific) 2020;7(2):73–76.

Role of Doppler ultrasound and Creatine Kinase as a Biochemical Marker in Diagnosis of Placenta Accreta

Placenta accreta is a life-threatening obstetric condition requiring cesarean hysterectomy for management. Placenta accreta was diagnosed by gray-scale ultrasonography, color Doppler imaging, and magnetic resonance imaging. Creatine kinase (CK) is an enzyme expressed by various tissues and cell types. This study compared between creatine kinase as biological marker and ultrasound and Doppler findings for prenatal detection of morbid placentation in anterior placenta on scar of previous cesarean section. The current study is a prospective cohort observational study, Led In Benha educating support doctor's facility on 50 pregnant ladies Hosting placenta accreta coating scar about past uterine surgery. Every one incorporated ladies were conveyed Eventually Tom's perusing caesarian segments for intend gestational agdistis during conveyance might have been 34. 5 ± 2 weeks. Done ladies with low parity, youthful age, or the individuals who wanted to preserve their fertility, preservationist methodology might have been trailed. Cs hysterectomy might have been performed over 28 (90. 32%) ladies. There might have been a noteworthy Acquaintanceship between 2D-GS ultrasonography discoveries Also troublesome placental separation, need for included intraoperative steps, necessity to cs hysterectomy What's more bladder damage with affectability 90% and specificity 60%. CK distinguished 10 patients crazy about 31 with placenta accreta Also 18 patients crazy about 19 without placental invasion, its affectability 30% and specificity. Joining 2DGS with CK test demonstrated huge change to auc worth about CK. 2D grayscale U/S required a great screening ability for those prediction of sequele from claiming dismal placentation in ladies for placenta previa. CK it is questionable test alone for antenatal finding from claiming morbidly follower placenta.

Resection of a Type III Leiomyoma

Video Objective To demonstrate the appropriate preoperative evaluation and intraoperative steps for the management of a type III leiomyoma for fertility enhancement. Setting A 33-year-old G2P0020 with recurrent miscarriages and a recently identified type 3 leiomyoma on pelvic ultrasound desiring hysteroscopic myomectomy prior to undergoing in vitro fertilization. Interventions Hysteroscopic resection of a type III fibroid Conclusion The association between intramural fibroids and infertility remains a controversial area of investigation. Recent evidence demonstrating that intramural fibroids without any intracavity component may still negatively impact both clinical pregnancy rates and live birth rates following in vitro fertilization has reignited this debate (Behbehani et al). We hope to demonstrate that in the hands of a skilled surgeon, hysteroscopic resection of type 3 leiomyoma can be carefully performed for the purposes of fertility enhancement. The goal for hysteroscopic myomectomy should include complete removal of all fibroid tissue. Preoperative imaging is critical in correctly identifying appropriate surgical candidates with intraoperative review of the imaging as needed to safely identify the type III leiomyoma. Careful resection of the fibroid within the boundaries of the pseudo-capsule to help reduce the risk of uterine perforation.

Devising the guidelines: the concept of uniportal video-assisted thoracic surgery-instrumentation and operatory room staff.

In the last years, uniportal video-assisted thoracic surgery (VATS) has been gaining more and more popularity, becoming a common procedure in several thoracic centers all over the world not only for minor procedures but also for major and complex cases. This technique combines the advantages of the less invasiveness with the oncological principles of open surgery. A standardization of the different peri- and intraoperative steps can help in the establishment and development of this technique. The aim of this paper is to set the basic steps for operating room set-up and instrumentation for starting or improving a uniportal VATS program in thoracic surgery centers.

Optimal mobilization of the stomach and the best place in the gastric tube for intrathoracic anastomosis.

Esophagectomy with gastric tube reconstruction is a highly complex surgical procedure. With regard to mobilization of the stomach and optimal gastric tube preparation and anastomosis, there are several important intraoperative steps that can influence the outcome of the operation. This study aims to describe the optimal mobilization of the stomach for gastric tube reconstruction and explore the best place in the gastric tube for intrathoracic anastomosis after esophagectomy. A search of the literature was performed and results are described in a descriptive review. Based on literature and our own experience we describe important operating steps for laparoscopic stomach mobilisation for gastric tube reconstruction. Steps to create additional length include preserving the left gastroepiploic artery, transecting the right gastric artery, extended duodenal mobilization, and duodenal diversion with roux-Y reconstruction. Several techniques for intrathoracic anastomosis are described in literature. Several imaging techniques, of which fluorescence imaging is the most commonly used, are available to assess the vascularization of the gastric tube and to assist in determining the best place in the gastric tube for intra thoracic anastomosis. Although there is little evidence of exact technique on stomach mobilization and location for an intrathoracic anastomosis, many techniques are used by different authors with varying results.

Kinematic alignment is bone and soft tissue preserving compared to mechanical alignment in total knee arthroplasty

BackgroundKinematically aligned (KA) total knee arthroplasty (TKA) has emerged as an alternative approach to the intraoperative alignment targets of mechanically aligned (MA) TKA. While the clinical outcomes of the two philosophies have been investigated, further investigation is required to quantify exactly how the two philosophies differ in their approach to correcting the deformities encountered in osteoarthritic knees such as fixed flexion deformities (FFD) and coronal malalignment. The aim of this paper was to compare MA and KA philosophies in TKA in terms of the intra-operative correction of FFD and coronal malalignment and quantify the way in which each philosophy achieves a well-balanced knee that can reach full extension. MethodsA retrospective review of prospective data collected from 210 consecutive TKAs performed by a single surgeon between March 2015 and May 2017 was undertaken. MA and KA cases were compared in terms of pre-operative patient deformity and characteristics, intraoperative steps taken to correct FFD (including bony resections, soft tissue releases and components used) and postoperative alignment achieved. ResultsOne hundred twenty MA and 90 KA TKAs were analysed. There was no significant difference in terms of patient age, gender and preoperative coronal and sagittal deformity between the two cohorts. KA TKAs were able to achieve the same degree of sagittal correction as MA TKAs with less total bony resection (16.7 mm vs. 18.9 mm, p < 0.0001), less soft tissue releases (10% vs. 49.2%, p < 0.0001). This was achieved with a difference in component alignment. The femur was in more valgus (−2.5 vs. −0.03°, p < 0.0001), the tibia in more varus (2.3 vs. 0.3°, p < 0.0001), and the overall alignment slightly more varus in the KA group (1.1 vs. 0.4°, p = 0.007), without significant difference in the proportion of patients within three degrees of a neutral axis. ConclusionThis study shows that using a kinematic alignment philosophy in total knee arthroplasty results in the achievement of extension range-of-motion and soft tissue balance goals with less bone resection and less soft tissue release. This allows for bone stock preservation and minimization of trauma due to soft tissue release. Further study is required to correlate these results with patient reported outcomes and determine their clinical significance. Level of evidenceIII — retrospective cohort study.

Procedure and step-based analysis of the occupational radiation dose during endovascular aneurysm repair in the hybrid operating room

ObjectiveThis study measured the cumulative occupational X-ray radiation dose received by support staff during endovascular aortic procedures and during additional intraoperative steps in the hybrid operating room. MethodsRadiation dose measurements were performed during interventions on 65 patients receiving 90 stent grafts during endovascular aneurysm repair (EVAR), bifurcated EVAR, thoracic EVAR, iliac branched device deployment, aortouni-iliac stenting, and fenestrated/branched EVAR (F/BrEVAR). X-ray imaging was acquired using the Philips Allura FD20 Clarity System (Philips Medical Systems, Best, The Netherlands). The occupational radiation dose (also referred to as the estimated effective dose, E, measured in millisieverts) was measured with the DoseAware Xtend system (Philips Medical Systems) personal dosimeters. E was reported per staff member (ESTAFF), where “staff” was a generic term for each staff member included in the study: the first operator (FO), the second operator (ESO), a virtual maximum operator (MO), and all additional supporting staff, including the sterile nurse, nonsterile nurse, anaesthesiologist, and radiation technician. The primary outcome was the median cumulative ESTAFF (or EFO, EMO, and so on), which was presented as the median cumulative dose per intervention and stratified for several within-interventional EVAR and F/BrEVAR steps or stents. The second outcome was the percentage of the absorbed E by a supporting staff member in relation to the E measured by the reference badge attached on the C-arm (ESTAFF% or EFO%, EMO%, and so on). All outcomes are presented as median with interquartile range, unless stated differently. ResultsThe occupational effective dose in millisieverts of the MO (EMO) was 0.055 (0.029-0.082) for aortouni-iliac stenting (n = 6), 0.084 (0.054-0.141) during thoracic EVAR (n = 14), 0.036 (0.026-0.068) during bifurcated EVAR (n = 38), 0.054 (0.035-0.126) during iliac branched device deployment (n = 8), and 0.345 (0.235-0.757) during F/BrEVAR (n = 24). The median EMO in millisieverts was 0.025 (0.012-0.062) per renal target vessel (TV) and 0.146 (0.07-0.315) for a nonrenal visceral TV. During all noncomplex interventions, the EMO% was 4.4% (2.7%-7.3%), with the lowest median rate at 3.5% (2.5%-5%) for EVAR. The highest median rate EMO% was found for F/BrEVAR procedures: 8.2% (5.0%-14.4%). ConclusionsWith maximum operator shielding during femoral access, relative occupational radiation risk can be minimized. However, digital subtraction angiography image acquisition, recanalization of TVs, recanalization of superior mesenteric artery or celiac artery, and recanalization of branched TVs are predictors for increased occupational radiation dose risks caused by increased radiation doses to the patient and reduced options for shielding of the operator.

Supraorbital Approach for Resection of Clinoidal Meningioma

Meningiomas of the clinoid region pose a formidable surgical challenge. Pterional craniotomy is the traditional approach and is often associated with high-risk postsurgical morbidities. In the current presentation, we describe an elderly male with a clinoidal meningioma who underwent a minimally invasive supraorbital craniotomy for tumor resection. Patient presentation, neuroimaging, and surgical techniques (patient position, incision, anatomic consideration, and surgical steps) are described meticulously. Initial intraoperative steps include dissection via the corridor between the carotid artery and the tentorium, as well as exposing the tumor in the opticocarotid triangle, followed by tumor dissection using microsurgical techniques. Care must be taken to preserve the supraorbital nerve to prevent frontal numbness and avoid violation of the frontal sinus to prevent postoperative cerebrospinal fluid leak. Emphasis on using this minimally invasive procedure for clinoidal meningiomas over the pterional approach for a select cohort of patients is laid, considering the cosmetic merits and adequate extent of tumor resection.

Entrustment Evidence Used by Expert Gynecologic Surgical Teachers to Determine Residents' Autonomy.

To identify entrustment evidence used by expert gynecologic surgical teachers to determine obstetrics and gynecology residents' level of autonomy in the operating room. A qualitative interview study was undertaken from March to November 2016. Four selection criteria were used to define and purposefully sample expert gynecologic surgical teachers across the United States to represent all four geographic regions. All interviews were audio-recorded and transcribed. We applied the Framework Method of content analysis. Transcripts were iteratively analyzed and emergent themes identified. Twenty-seven expert gynecologic surgical teachers from 15 institutions across the United States participated in 30-minute interviews. We identified four domains of entrustment evidence (resident characteristics, medical knowledge, technical performance, and "beyond current surgical case") commonly reported by expert gynecologic surgical teachers to determine residents' autonomy as well as the particular evidence associated with expert gynecologic surgical teachers' determination of resident autonomy at two decision-making points (surgical time-out and taking over certain intraoperative steps) in the operating room. Onsite direct observation and conversation were two common methods used by expert gynecologic surgical teachers to obtain this evidence. Entrustment evidence from resident characteristics, medical knowledge, and technical performance domains and from "beyond current surgical case" was commonly used by expert gynecologic surgical teachers to determine residents' autonomy. Our findings provide a potential framework for designing educational interventions that aim to increase residents' readiness for autonomy and entrustment in the operating room.