Minimal Blood Loss Research Articles

Surgical Management of Second Trimester Cesarean Scar Ectopic Pregnancy with Laparoscopic Wedge Resection

<h3>Study Objective</h3> To review the case of a second trimester cesarean scar ectopic pregnancy managed with laparoscopic resection in a patient with a history of renal transplant. <h3>Design</h3> Video demonstration of surgical technique with narrated description. <h3>Setting</h3> Academic tertiary care site. <h3>Patients or Participants</h3> 36yo G5P0221 found to have a 14-week cesarean scar ectopic pregnancy, desiring fertility sparing intervention. <h3>Interventions</h3> In this video, we demonstrate the case of a second trimester cesarean scar ectopic pregnancy resected laparoscopically. We illustrate several key points including: - Safe port placement in the setting of prior renal transplant - Preemptive hemostasis management with temporary uterine artery ligation - Intraoperative strategies for reducing blood loss - Considerations for management of gestational sac rupture and abdominal spill of fetal contents <h3>Measurements and Main Results</h3> A 14-week cesarean scar ectopic pregnancy was successfully resected with minimal blood loss and excellent recovery. <h3>Conclusion</h3> Laparoscopic resection can be safely and effectively utilized even for cesarean scar ectopic pregnancies of more advanced gestational ages.

Robotic Management of Large and Ruptured Interstitial Ectopic Pregnancy

<h3>Study Objective</h3> To describe management of very advanced and ruptured interstitial ectopic pregnancy, including minimally invasive technique for fertility sparing large wedge resection and surgical techniques to reduce morbidity and mortality <h3>Design</h3> Video Presentation. <h3>Setting</h3> University tertiary care hospital. <h3>Patients or Participants</h3> 22-year-old patient, 12 weeks and 2 days who presented to the emergency department with severe abdominal pain, imaging showed large and viable right interstitial ectopic pregnancy. <h3>Interventions</h3> Interstitial ectopic pregnancies are not common and account for 2-4% of ectopic pregnancies, management of interstitial ectopic pregnancy is a constant challenge due to the lack of general guidelines, a large and viable interstitial ectopic pregnancy could be life threatening due to hemorrhage and delayed diagnosis, The patient underwent Robotically assisted laparoscopic fertility sparing wedge resection and chromopertubation. <h3>Measurements and Main Results</h3> at 1 week follow up patient did well without complications. <h3>Conclusion</h3> Interstitial ectopic pregnancy is not common and a viable and advanced gestational age interstitial ectopic pregnancy is even less common, but robotically assisted laparoscopic fertility sparing wedge resection with surgical techniques to minimize blood loss decrease the risk of infertility and the morbidity associated with large blood loss, patient was counseled regarding the need for cesarean section in future pregnancies due to the increased risk of uterine rupture.

Strategies to Minimize Blood Loss during Laparoscopic Hysterectomy for Management of Cesarean Scar Ectopic Pregnancy

<h3>Study Objective</h3> Demonstrate techniques to minimize blood loss during laparoscopic hysterectomy for management of cesarean scar ectopic pregnancy. <h3>Design</h3> Stepwise demonstration using narrated video footage. <h3>Setting</h3> An academic tertiary care hospital. <h3>Patients or Participants</h3> 33-year-old G5P4004 with one prior cesarean delivery presented to the ER with abdominal pain and vaginal spotting in early pregnancy. Her vital signs were normal with a Hemoglobin of 8.9. Ultrasound revealed a ∼6-week cesarean scar ectopic pregnancy. She was counseled on management options including laparoscopic resection of the ectopic with repair of uterine defect or laparoscopic hysterectomy. The patient was satisfied with her parity and opted for hysterectomy. <h3>Interventions</h3> The patient underwent total laparoscopic hysterectomy, bilateral pelvic wall dissection, bilateral salpingectomy, and cystoscopy. Various considerations and techniques were used intraoperatively to minimize blood loss. 1. Major vasculature (uterine and utero-ovarian arteries) was interrupted before placement of uterine manipulator 2. Uterine manipulator was placed under laparoscopic guidance in a retroverted fashion to avoid disruption of pregnancy 3. The correct plane was identified during dissection between the bladder and pregnancy to avoid injury or bleeding 4. Additional bleeding was anticipated and encountered even after major blood supply was interrupted, likely related to collateral vasculature to the pregnancy <h3>Measurements and Main Results</h3> Successful management of cesarean scar ectopic pregnancy was performed via laparoscopic hysterectomy. Estimated blood loss was 100cc and the surgery was uncomplicated. <h3>Conclusion</h3> Cesarean scar ectopic pregnancy is more common with the rising rate of cesarean deliveries. Risk of hemorrhage in this scenario is higher due to possible trophoblastic involvement up to level of uterine arteries. However, various techniques may be used to decrease blood loss during definitive surgical treatment.

Management of Gestational Choriocarcinoma with Combined Robotic Surgery and Suction D&C to Minimize Blood Loss

<h3>Study Objective</h3> Use of combined surgical techniques to minimize blood loss. <h3>Design</h3> video case report of one patient <h3>Setting</h3> OR setting, low lithotomy position. <h3>Patients or Participants</h3> one female patient from clinical practice setting with gestational choriocarcinoma. <h3>Interventions</h3> Combined minimally invasive techniques, in this case robotic surgery and suction D&C. <h3>Measurements and Main Results</h3> With combined surgical techniques the EBL was 350 ml, there were no short- or long-term complications and patient was discharged same day. <h3>Conclusion</h3> Combined minimally invasive techniques can be used to minimize blood loss or other unwanted surgical outcomes.

Laparoscopic Excision of Retroperitoneal Adnexal Cyst

<h3>Study Objective</h3> To demonstrate the laparoscopic excision of a retroperitoneal adnexal cyst and describe the advanced surgical techniques and anatomic considerations in a patient with prior abdominopelvic surgery. <h3>Design</h3> Stepwise demonstration of advanced laparoscopic techniques with narrated video footage. <h3>Setting</h3> Adnexal masses after hysterectomy are a common reason for repeat abdominal surgery. Up to 9% of patients may require future adnexal surgery if ovarian preservation was chosen at the time of hysterectomy. Indications for surgery can include persistent adnexal masses, masses with concern for malignancy, chronic pelvic pain, and risk-reducing surgery. <h3>Patients or Participants</h3> 53-year-old post-menopausal female with a history of a total abdominal hysterectomy and left salpingectomy who underwent the excision of an 8-centimeter retroperitoneal left adnexal cyst. <h3>Interventions</h3> Excision of a retroperitoneal adnexal cyst can be performed through a laparoscopic approach with several key strategies: 1. Use of advanced laparoscopic techniques, such as the "push and spread" method and quick bursts of bipolar energy to prevent injury to vessels, bowel and bladder 2. Use of traction and counter-traction techniques to aid in dissection 3. Knowledge of retroperitoneal anatomy and avascular spaces to assist with dissection 4. Early ligation of the infundibulopelvic ligament to minimize blood loss 5. High ligation of the infundibulopelvic ligament and complete ureterolysis from the level of the pelvic brim to bladder to completely excise ovarian tissue <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Knowledge of retroperitoneal anatomy is crucial in the surgical management of retroperitoneal adnexal masses as dissection can be technically challenging and anatomy may be distorted due to pelvic adhesive disease. Use of advanced laparoscopic techniques and understanding surgical planes are important for safe dissection. High ligation of the infundibulopelvic ligament at the pelvic brim and a complete ureterolysis with parametrial excision are often necessary to remove all ovarian tissue to prevent an ovarian remnant.

8499 Laparoscopic Myomectomy for Symptomatic Pedunculated Fibroid with Degeneration and Subserous Fibroids in Second Trimester of Pregnancy

Study Objective To demonstrate the feasibility of emergency laparoscopic myomectomy for a large pedunculated fibroid (FIGO type 7) with degeneration and multiple subserous fibroids (FIGO type 6) in a patient with pregnancy of 12.4 weeks. Design Stepwise demonstration of laparoscopic myomectomy in a patient with gravid uterus with narrated video footage with sonographic images. Setting Tertiary care hospital. Patients or Participants A 27 years primigravida with 12.4 weeks of gestation presented with severe pain in right lower abdomen and vomiting for three days. Abdominal ultrasound showed gravid uterus with multiple subserous fibroids of size 30 × 30mm, 23 × 26mm, 24 × 21mm and a large avascular lesion showing central degeneration of size 117 × 93 mm in right hypochondriac region separately from uterine fundus suggestive of pedunculated fibroid. Patient counselling was done about the risks and benefits of surgery during pregnancy. Interventions Laparoscopic myomectomy of a large pedunculated myoma and other multiple subserous fibroids was done. The base of pedunculated fibroid ligated with two sutures and rest of fibroids enucleated out. Myometrial walls sutured. Use of vasopressin was avoided during myomectomy. The fibroids were removed by in bag morcellation with morcellator. Measurements and Main Results The myomas were removed with very minimal blood loss of 50 ml. The pedunculated large myoma measured 10 × 12 cm and six subserosal fibroids measured 2 × 2 cm to 2 × 3 cm each. Histopathological reports revealed degeneration in large pedunculated fibroid. The patient had complete resolution of right lower abdominal pain and recovered well post operatively and underwent vaginal delivery at term with healthy baby. Conclusion Laparoscopic myomectomy can be done selectively for patients with only symptomatic pedunculated and subserous fibroids. Minimal handling of the gravid uterus is necessary to minimize the chances of abortion and preterm delivery. Proper selection of patients for this type of surgery during pregnancy is very important and requires surgical expertise. To demonstrate the feasibility of emergency laparoscopic myomectomy for a large pedunculated fibroid (FIGO type 7) with degeneration and multiple subserous fibroids (FIGO type 6) in a patient with pregnancy of 12.4 weeks. Stepwise demonstration of laparoscopic myomectomy in a patient with gravid uterus with narrated video footage with sonographic images. Tertiary care hospital. A 27 years primigravida with 12.4 weeks of gestation presented with severe pain in right lower abdomen and vomiting for three days. Abdominal ultrasound showed gravid uterus with multiple subserous fibroids of size 30 × 30mm, 23 × 26mm, 24 × 21mm and a large avascular lesion showing central degeneration of size 117 × 93 mm in right hypochondriac region separately from uterine fundus suggestive of pedunculated fibroid. Patient counselling was done about the risks and benefits of surgery during pregnancy. Laparoscopic myomectomy of a large pedunculated myoma and other multiple subserous fibroids was done. The base of pedunculated fibroid ligated with two sutures and rest of fibroids enucleated out. Myometrial walls sutured. Use of vasopressin was avoided during myomectomy. The fibroids were removed by in bag morcellation with morcellator. The myomas were removed with very minimal blood loss of 50 ml. The pedunculated large myoma measured 10 × 12 cm and six subserosal fibroids measured 2 × 2 cm to 2 × 3 cm each. Histopathological reports revealed degeneration in large pedunculated fibroid. The patient had complete resolution of right lower abdominal pain and recovered well post operatively and underwent vaginal delivery at term with healthy baby. Laparoscopic myomectomy can be done selectively for patients with only symptomatic pedunculated and subserous fibroids. Minimal handling of the gravid uterus is necessary to minimize the chances of abortion and preterm delivery. Proper selection of patients for this type of surgery during pregnancy is very important and requires surgical expertise.

Temporary Occlusion of the Uterine Artery at the Origin Using Titanium Clips for Laparoscopic Myomectomy

<h3>Study Objective</h3> To demonstrate retroperitoneal dissection to skeletonize and temporarily occlude the uterine arteries at the origin using titanium clips at the time of a laparoscopic myomectomy and to demonstrate simulation of clip application and removal. <h3>Design</h3> N/A. <h3>Setting</h3> Robotic-assisted pelvic laparoscopy. <h3>Patients or Participants</h3> Patient with large fibroid uterus undergoing myomectomy. <h3>Interventions</h3> Placement of titanium clips on the uterine arteries at the origin. <h3>Measurements and Main Results</h3> Minimization of blood loss at the time of myomectomy. <h3>Conclusion</h3> Temporary occlusion of the uterine arteries at the origin with titanium clips can be used to minimize blood loss at the time of laparoscopic myomectomy and other laparoscopic pelvic and uterine surgeries where high blood loss is expected or for patients with a low starting hemoglobin or other pertinent medical co-morbidities.

Laparoscopic hepatectomy for hepatocellular carcinoma in a patient with congenital factor V deficiency: a case report

BackgroundFactor V (FV) deficiency is an extremely rare disease, with an incidence of 1 in 1 million. The bleeding symptoms are mild, and the prognosis is good; however, the safety of surgical treatment is unclear, because there are few available reports. Herein, we report a case of hepatocellular carcinoma with congenital FV deficiency in a patient who safely underwent laparoscopic hepatectomy.Case presentationA 79-year-old man, diagnosed with hepatocellular carcinoma of liver segment 5, with type C cirrhosis and sustained virological response visited our hospital. He had congenital FV deficiency, and blood tests showed coagulation deficiencies with an FV activity of < 2.6%, prothrombin time activity of 11%, and activated partial thromboplastin time of 100.3 s. Surgery and radiofrequency ablation were considered for treatment. Since the tumor was in contact with the Glissonean pedicle 5 + 6, surgery was judged to be superior from the viewpoint of safety and curability. After discussing the safety of the surgery with a hematologist, it was determined that the operation could be performed safely by transfusing sufficient fresh frozen plasma (FFP). Laparoscopic hepatic segment 5 + 6 subsegmental resection was performed with FFP transfusion, fluid restriction, airway pressure control, and central venous pressure reduction to control the bleeding. Bleeding was minimized during the transection of the liver parenchyma and no bleeding tendency was observed. The operative time was 445 min, and the amount of intraoperative bleeding was 171 mL. No complications, such as postoperative bleeding, were observed, and the patient was discharged on the eighth postoperative day.ConclusionsLiver surgery can be performed safely in FV-deficient patients with strict coagulation capacity monitoring and appropriate transfusion of FFP. Preoperative evaluation of cardiac function to determine tolerance to high doses of FFP and ingenuity of surgery and intraoperative management to minimize blood loss are important.

Introduction of Spring-Assisted Cranioplasty for Sagittal Craniosynostosis in a Craniofacial Service: A Report of Early Experience.

Spring-assisted cranioplasty (SAC) for the treatment of craniosynostosis uses internal springs to produce dynamic changes in cranial shape over several months before its removal. The purpose of this study was to report the first Egyptian experiences with SAC in the treatment of children with sagittal synostosis and evaluate the preliminary outcome. A total of 17 consecutive patients with scaphocephaly underwent SAC with a midline osteotomy along the fused sagittal suture and insertion of 3 springs with bayonet-shaped ends across the opened suture. Operative time, blood transfusion requirements and length of ICU, total hospital stay, and complications graded according to Oxford protocol classification were recorded. Spring removal was performed once re-ossification of the cranial defect occurred. All patients successfully underwent SAC without significant complications. The mean age at surgery was 6.8 months. The mean time of the spring insertion surgery was 63 minutes (SD 9.7). Blood transfusion was needed in less than half of the patients (41.2%).The mean duration of hospital stay was 3.2 days. The mean timing of spring removal was 5.5 months (SD 0.4). The mean time of the second surgery (spring removal) was 22.8 minutes (SD 3.6). In conclusion, SAC can easily be incorporated into the treatment armamentarium of craniofacial surgeons. The technique offers a safe and minimally invasive option for the treatment of sagittal craniosynostosis with the benefit of limited dural undermining, minimal blood loss, operative time, anesthetic time, ICU stay, and hospital stay.

Modified anterior transarticular C1/2 fixation for odontoid fractures: An approach with high complication rate in geriatric population

In patients over 75 years of age, we applied a modified anterior transarticular C1/2 fixation with reduced pharyngeal mobilization versus the standard anterior triple/quadruple osteosynthesis procedures. From 2010 to 2018, 29 patients underwent a modified anterior transarticular C1/2 fixation utilizing single odontoid screw fixation through a right-sided Smith-Robinson - (i.e., short and steep screw trajectory for the right and long trajectory for the left side) approach. All the patients were 75 years of age or older (mean age 82.6) and had sustained odontoid Type II fractures. In addition, a subset exhibited further ligamentous injuries and/or atlas fractures. Their Mean Age-adjusted Charlson Comorbidity Index was 5.3 points (range 3-12), while mean American Society of Anesthesiologists scores averaged 2.9 (range 2-4). The mean operating time was 55.8 min, there were no intraoperative complications, and there was minimal blood loss in all cases. The most common medical complications included aspiration pneumonia (24.1%, n = 7), altered mental status (17.2%, n = 5), and cardiac decompensation (6.9%, n = 2). One patient with delayed dysphagia and an infected implant resulting in loosening/dislocation required implant removal and long-term antibiotic therapy. The 30-day mortality rate was 13.8% (four patients) and the 1-year mortality rate was 27.6% (eight patients). Anterior transarticular C1/2/odontoid fixation with reduced pharyngeal mobilization and shorter operative times was associated with high morbidity/mortality rates. Dysphagia/aspiration was the major postoperative complications leading to some deaths especially in patients with dementia/Parkinsonism.

Technical aspect in renal artery embolization in renal tumors: A case series.

IntroductionRenal artery embolization aims to reduce blood loss during surgery. Various embolizing agents are available, each of which has its own indications appropriate for various vascular anatomy and renal pathology.Presentation of caseWe report three cases of renal artery embolization prior to surgical nephrectomy using vascular plug and other embolizing agents. In two cases, complete blood flow occlusion was achieved with minimal blood loss during the subsequent surgery. One case only achieved reduced blood flow, but subsequent nephrectomy and patient recovery was successful.DiscussionRenal artery embolization prior to malignant mass resection is a well-known, potentially beneficial procedure. The rationale that supports this procedure is clear, but its reported outcome in the literature is still inconclusive. It is important to understand its benefits, complications, and pitfalls to achieve better outcome.ConclusionIn our cases, renal artery embolization provided satisfactory reduction in bleeding during nephrectomy, and therefore has the potential to be employed as a standard procedure for future surgeries.

Rectal Artery Embolization for Hemorrhoidal Disease: Anatomy, Evaluation, and Treatment Techniques.

Chronic hemorrhoidal disease is a common anorectal condition that leads to hemorrhoidal hyperplasia, which affects millions of people worldwide and is a significant medical and socioeconomic issue. Rectal bleeding is one of the main chronic symptoms. Recurrent rectal bleeding can alter an individual's quality of life and, more rarely, cause anemia. Pain is less common, occurring only in the event of complications such as congestive exacerbation, external hemorrhoidal thrombosis, or fissures. The most standard treatment involves dietary and hygiene measures, use of phlebotonic drugs, and nonsurgical treatment such as infrared photocoagulation or elastic band ligation. Excisional treatments such as hemorrhoidectomy and hemorrhoidopexy are the reference standards for treatment of hemorrhoidal disease. Embolization of the rectal arteries (ie, emborrhoid) has recently emerged as an effective treatment option, with few reported adverse effects, minimal blood loss, and a same-day hospital procedure. Hemorrhoid embolization is performed by using femoral or radial access. The inferior mesenteric artery and then the superior rectal arteries are catheterized with a microcatheter. Embolization can be performed by using different agents. Studies have shown improvement in symptoms and high technical success rates after treatment. The basic principles of hemorrhoid embolization that must be understood to achieve effective treatment, including those related to patient evaluation, the arterial anatomy, basic embolization, and published results, are reviewed. An invited commentary by Thompson and Kelley is available online. ©RSNA, 2022.

Робот-ассистированная цистэктомия с ортотопической везикопластикой при раке мочевого пузыря.

Introduction. Bladder cancer is the 10th most common cancer worldwide. Radical cystectomy remains the gold standard for muscle invasive bladder cancer. The active use of robot-assisted cystectomy for treating patients with bladder cancer allows considering it as an alternative surgical option. The review is aimed at collecting and systematizing the evidence base for intracorporeal robot-assisted cystectomy. Materials and methods. MEDLINE, Scopus, Clinicaltrials.gov, Google Scholar, and Web of Science databases were used with the PICO (Patient-InterventionComparison-Outcome) search strategy to identify research articles published between 2000 and 2022. The following keywords were used to search the medical literature: «robot-assisted cystectomy», «RARC», «orthotopic neobladder», «intracorporeal RARC», «extracorporeal RARC», «bladder cancer», «functional outcomes», and «clinical outcomes». The review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist. Exclusion criteria: abstracts, review articles, editor's notes and comments, book chapters; experimental and laboratory studies on animals or cadavers. Results and disscussion. A total of 475 original articles were retrieved from the databases. Of them, 71 original articles were included in the analysis. The benefits and advantages of intracorporeal RARC at the intraoperative and postoperative period in comparison with RCE and extracorporeal RARC were reported. Functional and oncological outcomes following intracorporeal RARC are also comparable with RCE and extracorporeal RARC, suggesting the effectiveness and safety of the new surgical technology for treating patients with bladder cancer. Conclusions. The last decade has been marked with an active transition from traditional surgical techniques to robot-assisted surgery, enabling the precise performance, minimal trauma, and minimal intraoperative blood loss.

Use of Medical Robots in Allowing Surgeons to More Dexterous Manipulate Surgical Instruments or Catheters Inside the Patient's Body During Minimally Invasive Surgeries

Robots are used in surgery to improve the entire surgery process. Most surgery robots are able to do open surgery and have different kinds of benefits such as shorter hospitalization, quick recovery, reduction of pain, little incision, less possibility of infection, minimal blood loss and minimum scarring. Surgery robots are able to do fast surgery and as a result the patients recover quickly. Surgical robots have been developed to overcome the surgical limitations [1]. Long time hospitalization is not needed for the patient's surgery by robots. Mostly the patients return to normal conditions quickly due to fast surgery and for this reason short hospitalization is possible in robot surgery. Currently robots are used to do surgery and mostly medical experts control the robots to do surgery with robots. Robotics technology has improved and the development has helped to make surgical robots in the field of medical care. Surgical robots have a long history in the medical field. This kind of robot was started to be used in the medical field in the year 1985 with the Puma 560. Stanford Research Institute has started research on developing robots which have surgical senses that can help to do various critical surgeries. Keywords : Catheters, Invasive, Robots, Surgeons, Surgery robots

Robotic assisted cholecystectomy – A retrospective cohort study of experience of 106 first robotic cholecystectomies in versius robotic platform

IntroductionLaparoscopic cholecystectomy is currently the standard of care for symptomatic cholelithiasis as well as for chronic and acute cholecystitis. The incidence of bile duct injury in laparoscopic cholecystectomy is still higher than that in open surgery. Surgical robots aim to bridge this gap. With the greater availability of surgical robots and cheaper alternatives to the Da Vinci system, surgeons can take advantage of the better manoeuvrability and better vision that a surgical robot offers. This is likely to make robotic assisted cholecystectomy a very safe option. Here, we present our early data on the robotic procedures performed by the Versius robotic system by CMR (Cambridge Medical Robotics). MethodsIt is a retrospective study, with data collected from our prospectively maintained database at Swagat Super Speciality Surgical Institute and NH, maintained collectively by CMR and our surgical residents. The first consecutive 106 planned robotic cholecystectomies that were performed by a single surgeon were included in the study. ResultsOut of 106 serial planned robotic assisted cholecystectomies (101 robotic assisted cholecystectomies + 5 combined with other procedures), no bile duct injury was reported, with a mean console time of 54.16 min and a mean setup time of 9.29 min. One procedure had to be converted to open for malignancy, and another patient had to be converted to laparoscopy due to dense adhesions with the duodenum. Three chronic liver disease (CLD) patients underwent partial cholecystectomy. A total of 70.75% of patients had no pain – visual analogy scale (VAS) pain score of 0 at POD 1 with minimal blood loss in most of the procedures. No learning curve for robotic assisted cholecystectomy was seen. ConclusionAlthough robotic assisted cholecystectomy was mostly chosen for patients in whom difficult cholecystectomy was clinically anticipated, it fared quite well. The learning curve was essentially non-existent. Robotic assisted cholecystectomy is a safe and feasible option in both simple and difficult cases of gallbladder disease.

Indications and hemoglobin thresholds for red blood cell transfusion and iron replacement in adults with gastrointestinal bleeding: An algorithm proposed by gastroenterologists and patient blood management experts.

Gastrointestinal (GI) bleeding is associated with considerable morbidity and mortality. Red blood cell (RBC) transfusion has long been the cornerstone of treatment for anemia due to GI bleeding. However, blood is not devoid of potential adverse effects, and it is also a precious resource, with limited supplies in blood banks. Nowadays, all patients should benefit from a patient blood management (PBM) program that aims to minimize blood loss, optimize hematopoiesis (mainly by using iron replacement therapy), maximize tolerance of anemia, and avoid unnecessary transfusions. Integration of PBM into healthcare management reduces patient mortality and morbidity and supports a restrictive RBC transfusion approach by reducing transfusion rates. The European Commission has outlined strategies to support hospitals with the implementation of PBM, but it is vital that these initiatives are translated into clinical practice. To help optimize management of anemia and iron deficiency in adults with acute or chronic GI bleeding, we developed a protocol under the auspices of the Spanish Association of Gastroenterology, in collaboration with healthcare professionals from 16 hospitals across Spain, including expert advice from different specialties involved in PBM strategies, such as internal medicine physicians, intensive care specialists, and hematologists. Recommendations include how to identify patients who have anemia (or iron deficiency) requiring oral/intravenous iron replacement therapy and/or RBC transfusion (using a restrictive approach to transfusion), and transfusing RBC units 1 unit at a time, with assessment of patients after each given unit (i.e., “don’t give two without review”). The advantages and limitations of oral versus intravenous iron and guidance on the safe and effective use of intravenous iron are also described. Implementation of a PBM strategy and clinical decision-making support, including early treatment of anemia with iron supplementation in patients with GI bleeding, may improve patient outcomes and lower hospital costs.

The Renaissance of the Vaginal Hysterectomy-A Due Act.

For many years, vaginal and abdominal hysterectomies were part of the routine procedures in many departments. Both of them lost their priority due to the introduction of endoscopy and robotic surgery. The disappearing abdominal hysterectomy is certainly reasonable, but the decline of using vaginal hysterectomy seems not to be justified, and it is an optimal example of the recent emergence of the Natural Orifice Surgery discipline. A modified method for vaginal hysterectomy is presented in order to encourage gynecologists to reconsider vaginal hysterectomy as a valid method. This method is the outcome of critical analyses of different vaginal hysterectomy methods. It is simple, reasonable, only ten steps, easy to learn, perform and teach, and proven to be a shorter operation with minimal blood loss and reduced need for analgesics when compared to the traditional way. Endoscopy or robotic surgery is not available everywhere. Therefore, it is important that gynecologists in low-resource settings be familiar with this simple method.

Modified Borggreve–Van Nes-Winkelmann rotationplasty for surgery in developing countries

BackgroundAmputation is still the most common therapy for patients suffering from osteosarcoma in Myanmar, despite the fact that limb salvage surgery e.g. Borggreve–Van Nes-Winkelmann rotationplasty for malignant tumors located within the distal femur or proximal tibia is the current state-of-the-art reconstructive procedure. A safe and reliable operation technique is crucial in order to perform a complex surgical procedure like the rotationplasty in lower-middle income economies with limited infrastructure and resources. The authors present seven cases of patients with osteosarcomas that received a Borggreve–Van Nes-Winkelmann rotationplasty with an evaluation of the procedures focusing on safety and sustainability.MethodsFrom 2019 until 2020, seven young patients with osteosarcomas of the distal femur or proximal tibia were treated with Borggreve–Van Nes-Winkelmann rotationplasties in the Orthopaedic Hospital in Mandalay, Myanmar. As modification of the standard procedure the dissection and subsequent clamping of the femoral artery in order to minimize blood loss as well as the formation of an adipocutaneous flap that minimizes swelling and decreases the pressure on the vessels were successfully performed. This modified procedure resembles a safe and simplified surgical technique that is feasible under the circumstances of lower-middle income economies with good outcomes.ResultsAll patients showed good functional and aesthetic results. One of the seven patients needed secondary wound closure due to wound dehiscence.ConclusionsA simplified and safe operation technique for the performance of the Van Nes-Borggreve rotationplasty was adapted to the given constraints in lower-middle income economies and proved to be successful.Trial registration All patients approved to participate in the study and have given consent to publication.

FUNCTIONAL OUTCOME OF DISPLACED CLAVICLE FRACTURE TREATED BY INTRAMEDULLARY NAILING: A PROSPECTIVE STUDY

Background:Clavicle fracture is one of the most common injury.Despite the high incidence, the choice of proper treatment is still controversial. This prospective study was done to evaluate functional outcome of displaced clavicle fracture treated by intramedullary nailing. Material and methods:The study was conducted on 30 patients(25 males and 5 females) with displaced/comminuted clavicle fracture treated by either elastic intramedullary nails or elastic intramedullary nails with endcap.Followupexamination for functional and radiological evaluationwas done at 1 month,3 months and 6 months. Results: Mean duration of clinical union in comminuted and transverse/oblique fracture was 6.41 weeks and 6.89 weeks respectively while the mean duration of radiological union in comminuted and transverse/oblique fracture was 8 weeks and 8.5 weeks respectively.In co-relation between functional outcome and fracture pattern we obtained P-value 0.418,0.842 and 0.453 for Constant shoulder,DASH and VAS scores respectively which was statically not significant that means there was no relation between fracture pattern and functional outcome. Conclusion:- The intramedullary fixation of displaced clavicle fracture is a safe minimally invasive technique. The intramedullary nailing holds advantages of high union rate, minimal periosteal stripping and soft tissue damage, minimal blood loss and relatively less complications. This technique provides faster return to daily and professional activities with excellent functional results. Implant removal is easier and can be done as day care procedure under local anesthesia.

The effect of iv tranexamic acid on blood loss during myomectomy

Uterine leiomyomas are benign gynecological tumors of the uterus which are commonly seen in women under 50 years of age and they are one of the common reasons of abnormal uterine bleeding. Myomectomy is the most common treatment method among women who want to remain fertile and/or to protect the uterus. Approximately 1-4% of myomectomy operations end up with hysterectomy due to uncontrollable bleeding. Many different methods are used in order to reduce the incidence of uncontrollable bleeding and minimize blood loss. In this study, we have examined the effect of intraoperative intravenous tranexamic acid on blood loss on type 3, 4, 5, and 6 myomas during myomectomy according to FIGO grading and its postoperative results.