Modern Surgical Practice Research Articles

Awareness of Surgical Costs: A Multicenter Cross-Sectional Survey

Resource scarcity continues to be an important problem in modern surgical practice. Studies in North America and Europe have found that medical professionals have limited understanding of the costs of medical care. No cost awareness studies have been undertaken in Australasia or specifically focusing on the surgical team. This study determined the cost of a range of commonly used diagnostic tests, procedures, and hospital resources associated with care of the surgical patient. The surgical teams' awareness of these costs was then assessed in a multicenter cross-sectional survey. In total, 14 general surgical consultants, 14 registrars, and 25 house officers working in three New Zealand hospitals were asked to estimate the costs of 14 items commonly associated with patient care. Cost estimations were considered correct if within 25% plus or minus of the actual cost. Accuracy was assessed by calculating the median, mean, and absolute percentage discrepancy. A total of 57 surveys were completed. Of which, four were incomplete and were not included in the analysis. Cost awareness was generally poor, and members of the surgical team were rarely able to estimate the costs to within 25%. The mean absolute percentage error was 0.87 (95% CI: 0.58-1.18) and underestimates were most common. There was no significant difference in estimate accuracy between consultants, registrars, or house officers, or between consultants working in both public/private practice compared with those working in public practice alone. There is poor awareness of surgical costs among consultant surgeons, registrars, and junior physicians working in Australasia.

The Chloroform Controversies

It was the introduction of ether by Morton in 1846 that provided the necessary conditions for the development of Modern Surgical practice. Previous to its use Surgery was swift and brutal, its scope confined to the body surface, i.e. the evacuation of pus, amputation of limbs, excision of superficial tumours. It is revealing to examine the operations performed in the Royal Infirmary, Edinburgh, in the years 1831-34, a total of one hundred and forty, an average of thirty-five a year. Hovell remarks, “Although in 1829 the staff of the Royal Infirmary included surgeons of great reputation, very few operations were performed, and the operation theatre served little purpose.”It is hard today to realise the impact of the new discovery on the medical profession, yet in a very short time ether was to be supplanted by chloroform. I have often wondered why this happened. History is rather vague on this point. The major objection appears to have been its unpleasant smell. I suspect there were other reasons. The entrepreneurs of the time, realising the importance of the event, were anxious to participate in it. A frantic search for new drugs began and in November 1847 Simpson of Edinburgh used chloroform, first in obstetrics and then nearly six months later in general surgery.

Recubrimiento de la superficie radicular expuesta (Parte II). Tratamiento quirúrgico y no quirúrgico

El tratamiento de la recesión gingival puede ser realizado quirúrgicamente con una alta predecibilidad de éxito debido al gran avance durante los últimos de las técnicas quirúrgicas mucogingivales. El uso de injertos de tejido conectivo para cubrimiento radicular ha obtenido altas tasas de éxito por lo que estos procedimientos son actualmente comunes dentro de la práctica quirúrgica pcriodontal. Conociendo que no todos los pacientes aceptan el tratamiento quirúrgico. se ha venido estudiando la posibilidad de tratar la recesión gingival desde un punto de vista no quirúrgico mediante raspaje y alisado radicular, pulido y terapia de mantenimiento mostrando resultados prometedores.

Informed consent in surgery.

The year 2014 marks the 100th anniversary of the famous decision made in New York by Justice Benjamin Cardozo in the Mary Schloendorff case [1]. His decision, condemning the surgeon for the removal of an abdominal fibroid tumor without the expressed consent of the patient, paved the way, together with other sentences [2–7] (Table 1), for the development of the defense of patients’ rights, in tandem with major developments in the fields of surgery and anesthesia during the 20th century. In the field of twenty-first century, it is wholly accepted that the traditional paternalist relationship between the patient and his or her surgeon has been superseded by a new type of relationship in which the patient has to play a participative role, with the aim of the patient-physician relationship a more interactive dialog that makes it possible to provide the patient with the information they need prior to being operated on, and to allow the surgeon to receive feedback from the patient. This new concept of the patientphysician relationship has come about because the users of healthcare systems are more mature, are more informed by different sources, in which the Internet plays an increasingly significant role, and wish to participate actively in their healthcare. For this reason, it is essential to establish a more fluid dialog between the patient and physician. Within this new context of the patient-surgeon relationship, informed consent plays a highly significant role. For patients waiting to undergo surgery, obtaining informed consent is the final step in the information process for the surgeon, and giving informed consent is an important decision that the patient must make freely and independently. For informed consent in surgery, the legal principle emphasizes that the patient is an independent adult who has the capacity and the competence to authorize what is going to be done to their body and mind. Therefore, any operation that may infringe upon this principle is not only considered illegal and liable to result in lawsuits for unlawful injury caused to the patient, it is also ethically unacceptable. In Spain, Law 41/2002 [8] defines informed consent as ‘‘the free, voluntary and conscious agreement of a patient, stated in the full use of their faculties after being suitably informed, so that an action may be undertaken that affects their health.’’ The general concept of this Law is similar in all Western nations. It is a legal term that underlines the voluntary authorization granted by a patient who fully understands the risks involved in the performance of a medical or surgical treatment. Thus, the former paternalistic relationship with the physician gave way during the 20th century to the current situation whereby patients are able to make decisions characterized by patient autonomy, shared decision-making, self-determination, and patient value system. The aim of the patient-physician relationship is to respect the patient’s interests and system of values and, in general, guarantee the patient’s rights. Experts increasingly agree that informed consent is a process in which the surgeon plays a truly important role. This role has been called ‘‘the art of obtaining informed consent in the clinical setting’’ [9]. All surgeons, including those in training, must know this art, and, in the opinion of Childers et al. [9], ‘‘informed consent must be an integral part of every surgeon’s daily practice.’’ This process has significant ethical and legal aspects, but it also plays an important role in modern surgical practice. The surgeon is M. A. Cainzos (&) S. Gonzalez-Vinagre Department of Surgery, Hospital Clinico Universitario, c/Vidan, s.no, 15706 Santiago de Compostela, Spain e-mail: miguelangel.cainzos@usc.es

Are plain abdominal and erect chest radiographs still diagnostically useful, cost-effective and relevant in acute admissions in modern surgical practice?

Are plain abdominal and erect chest radiographs still diagnostically useful, cost-effective and relevant in acute admissions in modern surgical practice?

An evaluation of embolisation in the management of haemorrhage from traumatic solid organ injury at a level 1 major trauma centre

An evaluation of embolisation in the management of haemorrhage from traumatic solid organ injury at a level 1 major trauma centre

Etiopathogenesis of midfacial fractures in patients treated at Maxillofacial Surgery Clinic , Medical University of Lublin in 2007–2011

Introduction: With the growing industrialization and the increasingly rapid pace of life the number and variety of injuries are growing higher. In the midst of injuries, the midfacial injuries constitute a considerable part and pose a huge therapeutic challenge. The presence of life sustaining organs in the area of midfacial injuries require use of modern surgical and diagnostic methods and practices implemented by multi-specialty operative teams. Objective: The purpose of the work is the analysis of clinical documentation of patients who had been treated in 2007 – 2011 at Maxillofacial Surgery Clinic, Medical University of Lublin due to midfacial injury. Materials and Method: A subject of the analysis is a group of 424 patients examined at Maxillofacial Surgery Clinic, Medical University of Lublin in the years 2007–2011 due to midfacial injury. Medical documentation in the form of case history and radiological images were analyzed and reported in a special form of Microsoft Excel Program. Wanyjura’s classification of fracture was used in the study. The most common reasons of midfacial fractures are batteries and traffic accidents. Men aged 20 to 40 years old prevailed among all patients. The number of surgically treated patients was growing in the recent years and it accounted for 75.2%. Indications for surgical treatment were visual, aestetics and stomatognatic disturbances. Conclusions: In the recent years, an increase in midfacial fractures may be discerned among other types of fractures of maxillofacial area. Thorough radiologic analysis of injuries using up-to-date research methods allows to establish the most efficient method of therapeutical conduct. An appropriate education, observance of traffic as well as health and safety regulations allows to decrease the number and causes of midfacial injuries.

The Surgically Induced Stress Response

The stress response to surgery, critical illness, trauma, and burns encompasses derangements of metabolic and physiological processes that induce perturbations in the inflammatory, acute phase, hormonal, and genomic responses. Hypermetabolism and hypercatabolism result, leading to muscle wasting, impaired immune function and wound healing, organ failure, and death. The surgery-induced stress response is largely similar to that triggered by traumatic injuries; the duration of the stress response, however, varies according to the severity of injury (surgical or traumatic). This spectrum of injuries and insults ranges from small lacerations to severe insults such as large poly-traumatic and burn injuries. Burn injuries provide an extreme model of trauma induced stress responses that can be used to study the long-term effects of a prolonged stress response. Although the stress response to acute trauma evolved to confer improved chances of survival following injury, in modern surgical practice the stress response can be detrimental.

Postoperative pain is undertreated: results from a local survey at Jordan university hospital

Postoperative pain management is nowadays considered an integral part of modern surgical practice. An audit was made in 2010 to assess the status of acute postoperative pain management at Jordan University Hospital. Data were collected from patients' files and through face-to-face interviews of all patients aged over 16 years who underwent general, gynaecological, ear-nose-throat and orthopaedic surgery. Of 275 patients, 72.0% experienced moderate to severe pain postoperatively at rest and 89.3% on movement. No analgesics were prescribed to 4.7% of the patients and of the remainder, a single analgesic was prescribed to 51.5%. Pethidine and paracetamol were the drugs most commonly prescribed (to 66.9% and 42.5% of patients respectively), most often on a regular schedule rather than on-demand. Despite improvements in pain management worldwide, patients at this hospital were still suffering from postoperative pain. Awareness among professionals and the public is needed and a structured acute pain management programme is essential.

Imparting Surgical Training in Private Practice

Imparting Surgical Training in Private Practice

Evolving Patterns of Vascular Surgery Care in the United States: A Report from the American Board of Surgery

The purpose of this study was to analyze the distribution of major vascular procedures among general and vascular surgeons and to compare the evolution of vascular surgical practice of general and vascular surgeons at specific points in their careers. Case logs of surgeons seeking recertification in surgery from 2007 to 2009 were reviewed. Data from 3,362 physicians certified only in surgery (GS) were compared with 363 additionally certified in vascular surgery (VS). Independent variables were compared using factorial ANOVA. The mean numbers of major vascular procedures (±SD) were 10 ± 51 for GS and 192 ± 209 for VS (p < 0.001). Thirty-three percent of the total vascular procedures reported were performed by GS. Compared with VS, GS performed significantly fewer vascular procedures in all major procedure categories, and GS certifying at 10 years performed fewer vascular procedures (6.7 ± 47) than those recertifying at 20 years (11.5 ± 48) and 30 years (13.6 ± 59) (p < 0.01). In contrast, VS certifying at 10 years performed more vascular procedures (235 ± 237) compared with those recertifying at 20 years (157 ± 173) and 30 years (104 ± 115). The mean number of vascular procedures was not different for sex, geographic location, or practice type, after controlling for other variables in the study. The majority of GS currently do not perform any major vascular procedures, and younger GS are performing fewer such procedures than their older counterparts. The opposite is true for VS. These opposing trends indicate that vascular procedures are shifting from GS to VS in modern surgical practice, and this may have important implications for patient access to vascular surgery care, considering the limited capacity for VS to assume the excess case load.

Newly entered medical students’ views on an Information Communication Technology course

Even though Information and Communication Technology (ICT) has a relatively short history, it has become a part of the medical industry, not only in selected areas of high technology medicine, but throughout the industry. Apart from using IT for medical education, it has become a mandatory element in modern medical and surgical practice. Therefore, an ICT course was designed for the new entrants of the Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka and the perception of students on the course was evaluated using a validated questionnaire. The results of this study confirmed that the course was well organised and interesting but the time allocated for the course needs to be increased. Sri Lanka Journal of Bio-Medical Informatics 2012; 3 (3): 97-100 DOI: http://dx.doi.org/10.4038/sljbmi.v3i3.5280

Aortic valve sparing operations in aortic root aneurysms: remodeling or reimplantation?

Over the past two decades, there has been a significant paradigm shift towards aortic valve sparing (AVS) operations over the more traditional method of prosthetic replacement for suitable aortic pathologies. Such operations, by virtue of preserving the patient’s native aortic valvular anatomy, carry numerous benefits, most notably the obviation of life-long anticoagulation medication and the reduced need for reoperation when compared to mechanical and biosynthetic valves. Two main valve-sparing operations have dominated modern surgical practice: the David ‘reimplantation’ technique, whereby the entire aortic valve is preserved and securely sewn within a synthetic tube graft (1), and the Yacoub ‘remodeling’ technique, which replaces all three sinuses by means of a triple-tongue-shaped graft (2). Whether one technique is superior than the other has polarised the surgical community. The present article summarises the recent evidence comparing remodelling and reimplantation techniques (3).

Sabiston Textbook of Surgery The Biological Basis of Modern Surgical Practice 19th Edition 2012

The 19th&nbsp;edition of the Sabiston Textbook of Surgery includes fundamental medical knowledge which is tremendous useful to all. It begins, as is traditional, with a history of surgery and ethics, and then gives an overview of molecular and cellular biology before moving on to customary surgical tenets such as metabolic support and wound healing. Subsequent sections deal with perioperative management, trauma and transplantation and oncology, breast, endocrine, and abdominal procedures before dividing into surgery subspecialties such as head and neck, thoracic, vascular, urology and neurosurgery.

MSc in surgical technology

This postgraduate degree offered by Imperial College London is aimed not only at surgeons hoping to further their knowledge in the subject but also at healthcare professionals interested in the fields of surgery and technology—for example, operating department practitioners and theatre staff. I did this course at the start of my core training year 1, opting to do the course part time over two years. I decided to study for an MSc relevant to my chosen field of specialisation to enhance my CV before applying for higher surgical training. The MSc in surgical technology gave me an opportunity to learn and explore new and different aspects of modern surgical practice and to gain a better understanding of the potential future direction of the specialty. Having …

Fast‐Track for the Modern Colorectal Department

In recent years, fast-track or enhanced recovery after surgery (ERAS) colorectal pathways have been utilized to achieve faster recovery and discharge from hospital with swift resumption of normal activities of daily living without an increase in complications or readmissions. Despite the large body of evidence available, however, adoption of the fast-track methodology in current surgical practice has been slow and sporadic. As outlined by a recent Cochrane review, practice uptake has mostly focused on individual component uptake. Therefore, instead of repeating what already has been established in the literature pertaining to colorectal fast-track surgery, the aim of this article is to interrogate the evidence concerning the individual components of ERAS pathways as they relate to a contemporary surgical department to determine the most relevant critical components for patients undergoing colorectal surgery in modern surgical practice.

Combined Intraperitoneal Monitoring and Total Extraperitoneal Repair of McBurney’s Incisional Hernia

McBurney's incisional hernia after appendectomy is rare. Although the open surgical approach, either through direct suturing or through mesh repairs, mostly achieves a satisfactory outcome, postoperative wound pain usually impedes patient's early ambulation. Accordingly, laparoscopic ventral hernia repair has emerged as a minimally invasive technique in modern surgical practice. We described a different approach of laparoscopic incisional hernia repair. A 76-year-old woman with a history of appendectomy presenting with a bulging mass over the right lower quadrant of the abdomen beneath the operation scar was admitted to our hospital. Computed tomography revealed defects in the abdominal muscle layers without evidence of bowel incarceration. The patient was diagnosed with postappendectomy incisional hernia for which laparoscopic hernia repair was performed through a combined intraperitoneal and extraperitoneal approach. The patient's postoperative course was excellent. Combined extraperitoneal approach and intraperitoneal monitoring for McBurney's incisional hernia is feasible in selected cases.

Continuous Veno-Venous Haemofiltration in the Management of Severe Hyponatraemia Associated with Transurethral Resection of Prostate Syndrome

Modern surgical practice and anaesthetic vigilance has reduced the incidence of profound metabolic disturbance associated with absorption of irrigation fluid during endoscopic transurethral resection (TUR) of the prostate. We describe the critical care management of a patient with severe TUR syndrome, who was successfully managed with continuous veno-venous haemofiltration for the treatment of profound electrolyte disturbance, intravascular volume correction, and treatment of irrigation-fluid glycine toxicity. We examine the rationale for rapid and controlled correction of hyponatraemia in TUR syndrome.

Comparison Between Effect of Lidocaine, Morphine and Ketamine Spray on Post-Tonsillectomy Pain in Children

BackgroundAn effective pain therapy to block or modify the physiological responses to stress has become an essential component of modern pediatric anesthesia and surgical practice.ObjectivesThe goal of this study was to compare the analgesic effects of the spray forms of; lidocaine, morphine, ketamine, and normal saline on post-tonsillectomy pain scores in children.Patients and MethodsA total of 120 children, American Society of Anesthesiologist (ASA) class I–II, scheduled for elective tonsillectomy were enrolled in this double-blind, clinical trial study. They were randomly divided into 4 groups, each receiving one of the following drugs at the end of operation; lidocaine spray (2 mg/kg); morphine spray (0.05 mg/kg); ketamine spray (0.5 mg/kg); or normal saline spray (8 puffs). For comparison of postoperative pain; the face, legs, activity, cry, consolability (FLACC) pain scale was evaluated during the first one hour of recovery period at 20 minutes intervals. The data was transferred to SPSS-10 software and analyzed statistically with the Scheffe test and Dunnett’s T3 test. P value less than 0.05 was considered significant.ResultsIn the early postoperative period (time: 0) and at 20, 40 and 60 minutes of recovery time, FLACC scale scores in the control group were higher than in the three other groups. At 20 minutes, the FLACC scale score in the lidocaine group was lower than in the other groups. At 40 minutes, the statistical differences between FLACC scales of the lidocaine, morphine and ketamine groups were not significant (P > 0.05). Finally, at 60 minutes, the FLACC scale scores of the ketamine and morphine groups were lower than in the other groups.ConclusionsThe results of this study showed that lidocaine spray had the best pain controlling effect at 20 minutes in the recovery room, but after 40 minutes, ketamine and morphine sprays were more effective than the lidocaine spray.

From Leonardo to da Vinci: the history of robot‐assisted surgery in urology

What's known on the subject? and What does the study add? Numerous urological procedures can now be performed with robotic assistance. Though not definitely proven to be superior to conventional laparoscopy or traditional open surgery in the setting of a randomised trial, in experienced centres robot-assisted surgery allows for excellent surgical outcomes and is a valuable tool to augment modern surgical practice. Our review highlights the depth of history that underpins the robotic surgical platform we utilise today, whilst also detailing the current place of robot-assisted surgery in urology in 2011. The evolution of robots in general and as platforms to augment surgical practice is an intriguing story that spans cultures, continents and centuries. A timeline from Yan Shi (1023-957 bc), Archytas of Tarentum (400 bc), Aristotle (322 bc), Heron of Alexandria (10-70 ad), Leonardo da Vinci (1495), the Industrial Revolution (1790), 'telepresence' (1950) and to the da Vinci(®) Surgical System (1999), shows the incredible depth of history and development that underpins the modern surgical robot we use to treat our patients. Robot-assisted surgery is now well-established in Urology and although not currently regarded as a 'gold standard' approach for any urological procedure, it is being increasingly used for index operations of the prostate, kidney and bladder. We perceive that robotic evolution will continue infinitely, securing the place of robots in the history of Urological surgery. Herein, we detail the history of robots in general, in surgery and in Urology, highlighting the current place of robot-assisted surgery in radical prostatectomy, partial nephrectomy, pyeloplasty and radical cystectomy.