Modern Surgical Practice Research Articles

TOPOGRAPHIC AND ANATOMICAL RELATIONSHIPS OF INTRAMUSCULAR ARTERIES AND NERVES IN THE SHOULDER REGION OF HUMAN FETUSES

In modern surgical practice, there is a growing need to improve techniques of operative interventions. Despite advancements in diagnosis and treatment, combined shoulder injuries remain a pressing problem. In the past, surgical intervention for combined trauma primarily focused on saving the patient's life. However, today it is essential not only to preserve life but also to restore the function of the injured structures. Humerus fractures are observed in 27.9% of polytrauma cases, significantly complicating urgent diagnostic and treatment procedures and worsening the patient's condition. A comprehensive study of the topographical and anatomical relationships of intramuscular arteries and nerves at the shoulder level can facilitate the selection of optimal surgical approaches, prevent iatrogenic damage, and contribute to the patient's rapid rehabilitation.
 The objective of this study was to identify the distribution patterns of arteries and nerves at different levels of the shoulder in human foetuses.
 Materials and Methods. The study involved the examination of upper limb preparations from 48 human foetuses, ranging from 81.0 to 370.0 mm in parietal-caudal length without external signs of anatomical deviations or anomalies in the development of the skeletal and muscular structures of the upper limbs. Macromicroscopic dissection, vessel injection, and morphometry techniques were employed.
 Results and Discussion. In human foetuses, the upper and middle thirds of the shoulder were found to have the highest concentration of intramuscular arteries and nerves. The entry points of arteries and nerves, their topography and branching patterns within the shoulder muscles did not always align. Arterial branches generally entered the muscles at slightly more distal locations than the nerve trunks, following the shortest path to reach the muscles.
 The levels at which arteries and nerves start branching to supply and innervate the muscles of the anterior and posterior shoulder groups, vary in human foetuses. This variation depends on the individual anatomical variability of the major vascular and nerve trunks.
 Conclusion: The levels of arterial and nerve abduction are related to the topographic and anatomical features of a particular shoulder muscle. Considering the topography of intramuscular arteries and nerves, it is advisable to perform incisions along the direction of muscle bundles, particularly near the lower border of the neurovascular unit of the brachial biceps. This approach can offer higher clinical and surgical effectiveness.

Simulation training to retool practicing orthopedic surgeons is rare.

Modern surgical practice is continuously changing as technology develops. New techniques are often implemented after a surgeon has made the transition to independent clinical practice. There is therefore a need to 'retool' technical skills. Additionally, practicing surgeons must maintain and develop skills such as leadership, communication, critical thinking, teaching, and mentoring. Our aim was to perform a scoping review to assess the current status of simulation education for practicing Orthopedic Surgeons (OS). A 10year search of PubMed, ERIC, and Web of Science was performed with a medical librarian. Controlled vocabulary Medical Subject Headings terms and natural language were developed with subject matter experts describing simulation, training and OS. Two trained reviewers evaluated all abstracts for inclusion. Exclusion criteria were articles that did not assess simulation education involving practicing OS. Data were extracted from the included full text articles by two reviewers: details of study design, type of participants, type of simulation and role of OS in the educational event. Initial search identified 1824 articles of which 443 were duplicates, and 1381 articles were further screened. Of these, 1155 were excluded, 226 full text articles were assessed for eligibility and 80 included in analysis. Most were published in the last 6years and from the United States. The majority (99%) described technical skill simulations (arthroscopy 56%, screw placement 23%, ligament reconstruction 19%). OS were rarely the only learners with 91% studies also having residents participate. OS were the targeted learner in 6% studies. OS provided content validity for 15 (19%) and construct validity in 59 (74%) studies. Simulation training to educate practicing OS is rare. OS are often used to validate work rather than being the center of an educational endeavor. A refocusing is needed to provide adequate training for practicing surgeons to retool skills as new techniques become available.

Functional outcomes after transanal ileal pouch-anal anastomosis for ulcerative colitis: narrative review of the current literature.

The transanal approach to ileal pouch-anal anastomosis (Ta-IPAA) for ulcerative colitis was introduced in 2015 and has since been shown to be a safe and feasible technique, although the impact of this approach on patient function remains unclear. A systematic literature review was performed to identify studies exploring functional outcomes and quality of life after Ta-IPAA. Seven papers were identified, which all demonstrated satisfactory functional outcomes after Ta-IPAA as measured by tools such as Cleveland Global Quality of Life (CGQOL), Oresland Score (OS), Pouch Functional Score (PFS), and Inflammatory Bowel Disease Questionnaire (IBDQ). Many gaps in the literature were identified including paucity of follow-up data beyond the 1-year mark, lack of fertility and fecundity assessment as functional outcomes, and limited evaluation of objective physiologic anal sphincter function. The Ta-IPAA therefore shows promise for good functional results in the short-term, although further research will be required to evaluate the stability of function over time as the technique becomes increasingly integrated into modern surgical practice.

The effects of propofol anaesthesia on molecular-enriched networks during resting-state and naturalistic listening

Placing a patient in a state of anaesthesia is crucial for modern surgical practice. However, the mechanisms by which anaesthetic drugs, such as propofol, impart their effects on consciousness remain poorly understood. Propofol potentiates GABAergic transmission, which purportedly has direct actions on cortex as well as indirect actions via ascending neuromodulatory systems. Functional imaging studies to date have been limited in their ability to unravel how these effects on neurotransmission impact the system-level dynamics of the brain. Here, we leveraged advances in multi-modal imaging, Receptor-Enriched Analysis of functional Connectivity by Targets (REACT), to investigate how different levels of propofol-induced sedation alter neurotransmission-related functional connectivity (FC), both at rest and when individuals are exposed to naturalistic auditory stimulation. Propofol increased GABA-A- and noradrenaline transporter-enriched FC within occipital and somatosensory regions respectively. Additionally, during auditory stimulation, the network related to the dopamine transporter showed reduced FC within bilateral regions of temporal and mid/posterior cingulate cortices, with the right temporal cluster showing an interaction between auditory stimulation and level of consciousness. In bringing together these micro- and macro-scale systems, we provide support for both direct GABAergic and indirect noradrenergic and dopaminergic-related network changes under propofol sedation. Further, we delineate a cognition-related reconfiguration of the dopaminergic network, highlighting the utility of REACT to explore the molecular substrates of consciousness and cognition.

Evaluating the Efficacy of Surgical Consent.

Patient autonomy is the most important of the core values of medical ethics, yet the process of obtaining surgical consent remains a lesser scrutinized area of modern surgical practice. Informed consent implies a patient's understanding of nature of the operation, indications, risks, benefits, and alternatives. Surgical consent has traditionally been obtained through verbal communication and formalized by signing a legal document. This process oftentimes leaves patients unequipped with adequate knowledge about the procedure they just consented to. In most cases, it is simply impossible for the non-medically trained layperson to fully understand the nuances of surgery in a conversation. Some may argue a degree of paternalism may be inevitable; we believe there is room for improvement. We chose to examine English-speaking adult patients undergoing common procedures (laparoscopic cholecystectomy, open inguinal hernia repair, and skin mass/soft tissue excision). We asked 71 patients to complete a free response survey on the risks, benefits, and alternatives to the operation they had just consented to. The patients were administered the survey either in the outpatient clinic or in the preoperative area. Our analysis showed that most of our patients understand the inherent risks, benefits, and alternatives when being consented but that less than 50% of those consented were considered to have adequate understanding of the procedures they were consented for. This study highlights key deficits and potential areas of improvement in the informed consent process. Based on the results, we have significant room for improvement and the responsibility to do so.

Mixed Reality in Modern Surgical and Interventional Practice: Narrative Review of the Literature.

Mixed reality (MR) and its potential applications have gained increasing interest within the medical community over the recent years. The ability to integrate virtual objects into a real-world environment within a single video-see-through display is a topic that sparks imagination. Given these characteristics, MR could facilitate preoperative and preinterventional planning, provide intraoperative and intrainterventional guidance, and aid in education and training, thereby improving the skills and merits of surgeons and residents alike. In this narrative review, we provide a broad overview of the different applications of MR within the entire spectrum of surgical and interventional practice and elucidate on potential future directions. A targeted literature search within the PubMed, Embase, and Cochrane databases was performed regarding the application of MR within surgical and interventional practice. Studies were included if they met the criteria for technological readiness level 5, and as such, had to be validated in a relevant environment. A total of 57 studies were included and divided into studies regarding preoperative and interventional planning, intraoperative and interventional guidance, as well as training and education. The overall experience with MR is positive. The main benefits of MR seem to be related to improved efficiency. Limitations primarily seem to be related to constraints associated with head-mounted display. Future directions should be aimed at improving head-mounted display technology as well as incorporation of MR within surgical microscopes, robots, and design of trials to prove superiority.

Диагностическая лапароскопия в современной хирургии (обзор литературы)

The research presents a review of the current state of the method of diagnostic laparoscopy in modern clinical practice. In modern medicine, there is a tendency to minimize injuries to the patient in diagnostic search to achieve a compensatory state as soon as possible, to improve the quality of life, and to maintain working capacity. All these conditions meet the requirements of the method of diagnostic laparoscopy. The purpose of this research is to assess the current state of the scope and prevalence of diagnostic laparoscopy in modern surgery. Materials and methods: the search was carried out in the open electronic scientific databases PubMed and the databases of the Russian scientific electronic library eLibrary using keywords and phrases: laparoscopy, diagnostic laparoscopy, surgical intervention, current trends, abdominal cavity. Results. In modern surgical practice, diagnostic laparoscopy is considered as a highly informative preoperative method for detecting intra-abdominal pathologies and postoperative complications. This technique is widely used in gynecological practice, oncogynecology, in acute and chronic surgical pathologies in patients of various ages in order to assess the state of the intra-abdominal space and determine the correct tactics and extent of surgical intervention in the earliest possible time. In urgent abdominal pathology, laparoscopy remains the leading minimally invasive technique that allows assessing the extent and prevalence of the process. Conclusion: the vector of development of modern clinical medical practice creates all the conditions for the regular development and active growth of the possibilities of carrying out the presented diagnostic technique in various areas of surgical profiles.

Robert Lawson Tait (1845-1899): The true innovator of aseptic surgery?

Robert Lawson Tait was an original thinker, a surgical innovator, a controversialist and an iconoclast. He made important contributions to surgery, was an eloquent supporter of Darwinian evolution and women in medicine and opposed vivisection. He is probably best remembered for his high-profile opposition to Listerian antisepsis which continued until his death. While Lister went on to receive the country's highest honours and was lauded throughout the world, Tait received much more modest honours and little subsequent recognition by historians. Yet it could be argued that Tait's system rather than Lister's was the basis of modern aseptic surgery. Tait never changed his views on asepsis over his lifetime and relied on surgical cleanliness, which, combined with his extensive clinical experience, enabled him to achieve outcomes as good or better than with antisepsis. By contrast, Listerism evolved over 30 years, claimed to be based on laboratory data and adopted the new discoveries of the germ theory of disease as they emerged. We compare the systems of Tait and Lister, explore the basis of Tait's opposition to Listerian methods and conclude that Tait's thinking underlies modern surgical practice and that he should receive greater acknowledgement for his contribution to the prevention of surgical infections.

Role of Acharya Sushruta in Ophthalmology Surgery - Arma Chhedana (Pterygium Excision)

Background: Acharya Sushruta, being the father of surgery has described various surgical disorders with their respective detailed interventions. He described 76 Netra Rogas, including 40 diseases which are surgically curable and with elaborative depiction of indications, contra-indications, pre-para-post operatives of Utsangini (Trachoma), Arma (Pterygium), Pakshmakopa (Trichiasis), Lingnasha (Cataract) etc. is practiced in contemporary science with similar concepts that are mentioned by Acharya Sushruta. Till now, there is less work done on Arma Chhedana (Pterygium excision), so this topic has been selected. Aims and Objectives: To study the concepts of Acharya Sushruta and correlate with modern surgical practice of ophthalmology. Materials and Methods: Arma described in Sushruta Samhita with various commentaries and Pterygium with available sources of modern literatures is studied and analyzed. Result: If the root of surgery is traced, Acharya Sushruta is the pioneer of the various surgeries, that can be seen through the comparison of Arma Chhedana with Pterygium excision.

Oral Hydration Before and After Hip Replacement: The Notion Behind Every Action.

Even though nearly 20 patients undergo hip replacement every hour just in Italy and the United Kingdom, it is unclear what are the most appropriate oral hydration practices that patients should follow before and after surgery. Improper administration can cause postoperative fluid disturbances or exacerbate pre-existing conditions, which are not an uncommon find in older subjects. Considering that the number of hip operations is expected to increase in the next years as well as the age of patients, it is important to recall the notions behind water balance, especially in light of modern surgical and anesthetic practices. This technical perspective discusses the perioperative changes in the hydration status that occur during hip replacement and provides the concepts that help clinicians to better manage how much water the patient can drink. The points of view of the surgeon, the anesthetist, and the nurse are offered together with the description of mineral waters intended for human consumption. Before surgery, water should be always preferred over caffeinated, sugar-sweetened, and alcoholic beverages. The drinking requirements on the day of surgery should consider the water output from urine, feces, respiration, exudation, and bleeding along with the water input from metabolic production and intravenous administration of fluids and medications. Healthy eating habits provide water and should be promoted before and after surgery. The judgment on which is the most appropriate approach to oral hydration practices must be the responsibility of the multidisciplinary perioperative team. Nevertheless, it is reasonable to argue that, in the presence of a patient with no relevant illness and who follows a healthy diet, it is more appropriate to stay closer to dehydration than liberalizing water intake both prior to surgery and in the early postoperative hours until the resumption of normal physiological functions.

Integrative Surgery: Embedding Complementary and Nonpharmacologic Therapies into Surgical Pain Management Strategies.

There has been a growing interest in the use of complementary and alternative medicine in modern pain management strategies on behalf of both patients and clinicians. Nonpharmacologic modalities such as cryotherapy, acupuncture, music, and mind-body therapies have been shown to aid in symptom control and improve quality of life in patients suffering from acute and chronic pain, and there is a growing body of literature demonstrating their feasibility, acceptability, and efficacy in the perioperative period. Here, we provide a brief review of the current evidence supporting the use of complementary therapies within existing perioperative pain management strategies and highlight evidence-based protocols to facilitate implementation into modern surgical practice.

Diathermy smoke induced asthmatic attack during transurethral resection of prostate

The use of diathermy and other electrosurgical devices have become an indispensible and integral part of modern surgical practice. This revolutionary benefit to surgery have been associated with the release of toxic agents that represents a potential health risk. A 79 year old who had an asthmatic attack during transurethral resection of prostate (TURP) on account of benign prostate enlargement. He was a known asthmatic, incidence of attacks had become infrequent over the years, and the last asthmatic attack was over 10 years ago. Triggers for attacks were strong smell, smoke and dusty environment. He had no other systemic disease of note. The procedure was done under subarachnoid block. Thirty minutes into the procedure, he was noticed to have difficulty in breathing and coughing, there was tachycardia and elevated blood pressure. The patient oxygen saturation was between 88-92% on room air, chest auscultation revealed a wide spread rhonchi. Oxygen via a non-rebreather face mask with reservoir bag at 10L/min was commenced and intravenous hydrocortisone 200mg was given. Forty minutes into the procedure, patient’s condition did not improve. Procedure was discontinued and patient moved to the ward, patient was nebulized, intravenous aminophylline 250 mg given slowly, with repeated nebulization and continued oxygenation, patient condition improved. An immediate postoperative serum electrolyte, urea and creatinine done showed normal values to rule out TURP syndrome.

"More or less": management of type A aortic dissections in the endovascular era.

The management of type A aortic dissection presents a major therapeutic challenge in modern surgical practice. Whilst the traditional dictum, to provide timely surgical interventionwith the minimum treatment needed to repair the ascending aorta as well as the primary tear, may be a reasonable strategy in older patients, a tailored approach is desired for younger patients to manage the immediate life-threatening condition, as well as for the management of lifelong complications of the residual dissected aorta. Endovascular technology continues to advance, providing an adjunctive role to open cardiac repair presently to manage downstream aortic pathology, with the aim of striving towards a complete endovascular solution for type A aortic dissections.

59 Robotic-Assisted Knee Replacement Surgery & Infection: A Systematic Review and Meta-Analysis

Abstract Aim An increasing proportion of knee arthroplasties are performed using robotic-assisted surgical techniques. While these techniques are associated with shorter lengths of stay, better patient outcomes and lower revision rates, the increase in intra-operative time and requirement for extra instrumentation, such as array pins, may lead to an increased risk of infection. Therefore, this review reports summary rates of surgical site infection (SSIs) in robotic-assisted knee arthroplasties. Method The protocol for this review was prospectively registered on PROSPERO. Embase, PubMed/MEDLINE, Cochrane and CINAHL databases were searched from 2004 to November 2020 to reflect modern robotic surgical practice. The primary outcome was overall number of SSIs that occurred within one year of the primary operative procedure, which was sub-classified into either deep or superficial and pin-site infections. Risk of bias was assessed via the Cochrane RoB2 tool. Conventional Q and I2 tests for heterogeneity were performed with subsequent meta-analysis using a DerSimonian-Laird random-effects model. Results From 1052 studies identified, 17 were included, of which 13 were deemed to have an overall ‘low’ risk of bias. This review included 4400 unicompartmental and 1883 total knee arthroplasties. The summary rate of overall SSIs within one year of primary robotic knee arthroplasty was 0.568% (SE=0.183, 95% CI=0.209–0.927). This rate fell to 0.154% (SE=0.069, 95% CI=0.018–0.290) for deep infections and 0.347% (SE=0.109, 95% CI=0.133–0.561) for superficial and pin-site infections. Conclusions The rates of surgical site infection were found to be low in robotic knee arthroplasty, however, further research is required to compare outcomes with conventional knee arthroplasty.

Patient-specific simulation for tracheobronchial reconstruction procedures using 3-dimensional operable models: A proof-of-concept study.

Patient-specific simulation for tracheobronchial reconstruction procedures using 3-dimensional operable models: A proof-of-concept study.

Advances and future directions in the care of patients with facial paralysis

Advances and future directions in the care of patients with facial paralysis

Teaching in Orthopaedic Surgery: Effective Strategies for Educating the Modern Learner in a Modern Surgical Practice.

Prioritizing the education of orthopaedic surgery residents and fellows is essential for the future of the field. This review highlights strategies that educators may find useful in improving their teaching skills for the modern orthopaedic surgery learner. Educators may benefit from focusing on active, effortful, and repetitive engagement in lecture; setting clear expectations to help track progress in clinic; and breaking skills into smaller steps in context of a framework when teaching procedural skills. Providing objective assessment and growth-oriented feedback helps establish a close rapport between educator and trainee while encouraging personal development. Through a remediation process that examines deficiency in core areas and equitability of the learning environment, the trainee and the educator may engage in a fair discussion that prevents trainees from falling behind. Finally, in the era of COVID-19, e-learning and virtual simulations have become increasingly used as effective modalities for teaching clinical knowledge and procedures to trainees. The medical education landscape has been changing at a rapid pace, and by evaluating and adapting to the novel educational models of today, the modern orthopaedic surgeon ensures a learning environment that is equitable, effective, and inspiring for the orthopaedic surgeon of tomorrow.

Transarticular gunshot injuries: a systematic review of 150 years of management

ABSTRACT BACKGROUND: This review aims to collate all published work on the management of transarticular gunshot injuries to better inform decision-making when managing these injuries METHODS: A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was undertaken. A literature search of major electronic databases was conducted to identify journal articles relating to the management of transarticular gunshot injuries published from database inception until 31 January 2021 RESULTS: Sixty-eight publications reporting on the management of 544 patients were included. Injuries to the lower limbs were reported in 438 cases (81%), while injuries to the upper limb accounted for 106 cases (19%). A total of 145 patients (27%) developed a deep infection. Following the routine use of antibiotics, 6% of patients (14/251) developed an infection. A significantly higher hip joint infection rate was seen in patients who sustained associated hollow viscus injury (11/30, 37% CONCLUSION: The management of transarticular gunshot injuries is currently based on limited high-quality evidence. Modern antibiotic and surgical management practices have resulted in low overall septic complications; however, different joints have different injury and complication profiles. Future research should be aimed at identifying joint-specific evidence-based care pathways Level of evidence: Level 4 Keywords: gunshot, ballistic, joint, transarticular, intra-articular

Most Preoperative Consultations Need Improvement

Although obtaining informed consent has long been a necessary part of modern surgical practice, experts recently have begun to wonder if it is

The Role of 3D Exoscope Systems in Neurosurgery: An Optical Innovation.

The development of the three-dimensional (3D) exoscope is a marvel of technological innovation in modern surgical practice. While its predecessor, the operating microscope (OM), has long been the gold-standard surgical visualization modality, its particular limitations in terms of accessibility and ergonomic demand have led to the development of a more sophisticated, 3D model. Specifically, the 3D exoscope allows for an enhanced image quality of the surgical field, while also being more ergonomically favorable. Moreover, this device’s ability to handle delicate microsensitve procedures, along with its alleviation of surgeon fatigue, indicates great potential for neurosurgical application. For this narrative review, the authors queried PubMed database using the keyword “exoscope” to identify relevant studies involving the specialty of neurosurgery that were published in English language full text. The search yielded full-text English language-related articles regarding neurosurgical exoscope, its applications and limitations. The 3D exoscope uniquely allows for enhanced surgeon comfort and superior imaging of the patient’s real-time anatomy. However, the OM was described to having a slight image favorability with fusion and decompression surgery. Cost analysis is highlighted for its potential disparity. 3D exoscopes will potentially be incorporated with intelligent carriers and robotic surgical systems. Ultimately, with further studies highlighting its use, the 3D exoscope is expected to continue to imprint its status as one of the most efficient technological visualization tools in the future of neurosurgical practice.