Operating Table Research Articles

Lateral Decubitus Positioning For Shoulder Arthroscopy

Background: Lateral decubitus positioning is a frequently employed technique to perform shoulder arthroscopy. Proper patient positioning and equipment setup is crucial to ensure a safe and efficient surgery. Indications: The common indications for performing a shoulder arthroscopy in the lateral decubitus position include anterior shoulder stabilization, posterior shoulder stabilization, superior labrum anterior to posterior (SLAP) repair, diagnostic arthroscopy for internal impingement, and arthroscopic capsular release for adhesive capsulitis. Technique Description: After undergoing general endotracheal anesthesia in the supine position on a standard operating room table, the patient is rotated into the lateral decubitus position with the operative arm facing upward. The patient’s head is supported with a pillow to ensure a neutral position. The nonoperative arm is flexed forward and rests on a padded arm board. The sides of a bean bag are applied to the patient’s torso to maintain the lateral decubitus position, and the bean bag is deflated to remain rigid. An axillary roll is placed under the axilla, and foam pads are placed below the “down leg” and between both legs. A commercial arm jack is positioned on the anterior, proximal side of the operating room table to allow for 20° of shoulder abduction, which maximizes the glenohumeral joint space. Results: Advantages of the lateral decubitus position over the beach chair position include improved access to the anterior, inferior, and posterior glenoid; more ergonomic positioning for the operating surgeon; lower risk for patient cerebral hypoperfusion; and reduced rates of recurrent instability following arthroscopic stabilization in comparison to procedures performed in the beach chair position. Disadvantages of the lateral decubitus position include risk of traction-related neurovascular injury, requirement of an arm suspension device, and increased difficulty in rotating the shoulder intraoperatively. Discussion/Conclusion: Lateral decubitus positioning is commonly used to achieve a circumferential view of the glenohumeral joint in shoulder arthroscopy. This surgical position yields several advantages for the operating surgeon and has been shown to be associated with improved clinical outcomes after shoulder instability surgery. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Anesthetic concerns for robotic-assisted laparoscopic radical prostatectomy: an update.

The anesthetic concerns of patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP) are primarily related to the use of pneumoperitoneum in the steep Trendelenburg position. This combination will affect cerebrovascular, ocular, respiratory, and hemodynamic homeostasis. Possible non-surgical complications range from mild subcutaneous emphysema to devastating ischemic optic neuropathy. The anesthetic management of RALP patients involves a thorough preoperative evaluation, careful positioning on the operative table, managing ventilation issues, and appropriate fluid management. Close coordination between the anesthesia and surgical teams is required for a successful surgery. This updated review will discuss the anesthetic concerns and perioperative management of patients presenting for RALP.

Colorectal awareness in March, are we really marching?

Colorectal diseases, which impose a significant global burden, have been growing daily throughout the world, and low-income countries like Nepal are not immune to them1. A relatively low burden of colorectal carcinoma (CRC) seems to be reported from low and middle-income countries (LMIC), which could be due to underdiagnosis and there is a dearth of publications related to CRC from LMICs2. The age-standardized incidence rates of CRC reported in LMICs such as India are 7.2 and 5.1 per 100,000 population for men and women in comparison with global CRC incidence rates of 20.6 and 14.3 per 100,000 population, respectively3. But, the mortality rates reported have been higher compared with global north nations, which can be attributed to limited access to health care facilities, cancer screenings, and advanced illness4. The similar lifestyles, cultural beliefs, and geographical similarities between Nepal and India imply similar incidences, as no data-driven research has come to light regarding colorectal lesions from our country. The changing lifestyles, westernization of the population groups, and dietary modifications prevalent today have contributed to the increase in disease conditions related to the colon and rectum5. Screening for colorectal cancers is the most effective way to catch the lesions in the early stage, which might be deemed curable after necessary surgical intervention. However, the lack of adequate screening facilities in low-income countries has contributed to the excessive burden of the disease, being diagnosed at late stages. The available screening programs can be characterized by a lack of a qualified, robust workforce, a few well-trained, specialized surgeons, a backlog in screening centers and cancer registries, and limited access to care outside of the capital6. Some factors that challenge the already compromised system include constraints in the availability of well-furnished operation tables, appropriate retractors, adjuvant chemotherapy centers/units, or colonoscopy facilities; limited training in minimally invasive surgery, pelvic floor repairs, laparoscopic colorectal surgeries, or treatment pursued at local levels as hemorrhoids for rectal malignancies; and less awareness among consumer groups and even health care professionals at the peripheries7. The global incidences of young-onset colorectal cancers are rising. The transition of disease prevalence from elderly populations to the younger generation has been overlooked, albeit a change in behaviors related to obesity, physical activity, and smoking can be speculated as potential factors3. The other possibilities remain the 3 intercalated factors: diet, bacteria in the gut, and inflammation. Diets high in processed meat and fats while being low in fruits and vegetables generally deteriorate gut health; chiefly, some gut bacteria strains intensify inflammation by recruiting immune cells that help cancer grow and block the defensive immune cells that fight cancer. Further, inflammation has been attributed to chronic diseases like irritable bowel syndrome, diabetes, and Crohn disease5. Colorectal screening modalities ought to be enacted in low and LMICs, and if feasible, the screening age can be reduced from 50 to 45 with a screening interval of every 10 years or more frequently depending on the patient’s history. Tailoring or precision CRC screening should be especially adopted for younger high-risk patients8. In addition to strategizing national guidelines for the general population, subsidizing noninvasive screening modalities like fecal occult blood test (FOBT) and fecal immunochemical test will ameliorate access-to-care disparities among high-risk groups. The fecal immunochemical test is better and more specific than FOBT, uses antibodies to detect blood in the stool, and has high sensitivity and specificity for lower colorectal lesions whereas FOBT consumes guaiac chemical for blood detection in stool determines the bleed from upper and lower gastrointestinal tract requiring restricted diet before the procedure6. Increasing access to invasive sigmoidoscopy/colonoscopy among suspected groups would be the subsequent goal, which would have to be approached cognizant of the predominant logistic issues in countries like Nepal1. Holistically, the formula for decreasing the incidence of CRC in LMICs would not be complete without enhancing public awareness: awareness campaigns can address knowledge deficiencies among the population regarding risk factors, symptomatology, warning signs, and treatment modalities6. To shift the focus towards primordial prevention, patients and physicians alike need to retire the notion of CRC as an “old man’s disease.” A data-driven, evidence-based approach should be done in collaboration with high-income countries from the southeast. The BLUE MARCH should be the defining ideal year-round in the fight to conquer this gruesome disease, such that no portion of this earth is left behind. Let us ask ourselves: Are we all truly aware? Are we truly “marching,” collectively? Ethical approval None. Sources of funding None. Author contributions S.B.: Wrote the article, conducted literature search and finalised the manuscript. B.P., S.B. and V.N.: Copyedited and reviewed the manuscript. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantor Suman Baral.

OVARIAN CYST MASQUERADING AS CERVICAL STUMP LEIOMYOMA IN A WOMAN AFTER SUBTOTAL HYSTERECTOMY: AN UNUSUAL PRESENTATION.

Introduction: Pelvic masses that seem to be ovarian masses on imaging are many times, actually broids, which can be subserosal, or true/ false broad ligament broids. Many cases of broids mimicking ovarian masses/ malignancy have been reported, but rarely any case can be found where an ovarian mass, especially a hemorrhagic cyst mimicked a broid. We present a case of a woman who, was post subtotal hysterectomy, presented with a midline homogenous mass suggesting a cervical stump broid but on operation table was diagnosed to be an ovarian mass. 47years old P2L2 woman presented with insidious dull aching lower abdominal p Case report: ain and an ultrasound report showing a midline 10 x 10cm pelvic mass. She had undergone a subtotal abdominal hysterectomy 15 years ago for symptomatic uterine broid. Examination and higher imaging suggested a cervical stump broid. On laparotomy, it was a well-circumscribed oval mass with a smooth surface, stuck in the pouch of Douglas originating from the right infundibulopelvic ligament with torsion (one twist). It was a thick-walled cyst with dried spongy hemorrhagic content. Histopathology conrmed the diagnosis of hemorrhagic cyst. A mass that is likely broid on imag Conclusion: ing preoperatively rarely turns out to be an ovarian mass during surgery. A hemorrhagic ovarian cyst can present in a subacute form mimicking a solid neoplasm or a solid broid.

Cervical spine fractures in ankylosing spondylitis patients: an analysis of the presentation and clinical results of 110 surgically managed patients in two spine centers.

In this work, a two-center study was performed to study the clinical presentation of cervical spine fractures in ankylosing spondylitis (AS) patients and assess the surgical management of these fractures. A retrospective analysis of prospectively collected data in two level-1 spine surgery centers was performed. Both spine centers have a standard database for all admitted patients. Inclusion criteria were surgically treated AS with cervical spine fracture diagnosis (from C1 to Th3) and postoperative follow-up minimum of 12months. One hundred ten patients (105 male/5 female) were included. The mean age was 62 ± 10years. The mean time between trauma and surgery was 49 ± 42days. There was a history of mild trauma in 72 patients (65.4%). The clinical presentation was a pain in all patients. Twenty-seven (24.6%) had a neurological deficit at admission. The most common fracture level was C6/7 in 63 patients (57.23%). The VAS was 7 ± 1, and NDI was 34 ± 8 in the preoperative assessment. The mean preoperative kyphosis angle was 48 ± 26° between C2 and C7. Positioning and preparing of the patients on the operation table took a mean of 57 ± 28min. The surgical approach was dorsal in 59 patients (53.6%), combined in 45 patients (40.9%), and ventral in 6 patients (6,5%). The mean number of the fixed levels was 6 ± 2 levels. Intraoperative complications occurred in 9 patients (8.2%). Postoperative Cobb angle improved to a mean of 17 ± 9 degrees. Neurological improvement occurred in 20/27 patients. In 12 patients, the recovery was complete. The mean postoperative follow-up was 46 ± 18months. VAS improved to 3 ± 1, and NDI improved to 14 ± 6 at the last postoperative visit. The improvement was clinically significant (p = 0.01 and 0.00, respectively). High suspicion of cervical spine fractures is necessary for patients with AS. CT and MRI images are necessary to rule out cervical spine fractures in AS patients, especially to detect occult fractures. Surgical treatment is safe, and the posterior approach with long-segment fusion is the approach of choice in this group of patients.

Relevance of Project Evaluation and Review Technique (PERT) for Procurement of Equipments in a Government Medical College and Hospital in North-East India

Introduction: Continuous procurement of various equipments in the hospitals is essential to keep up with global progress of healthcare services. In public sectors, procurement process largely depends on budget sanctions and also by a number of formal procedures and rules which leads to delayed procurement. With this prevalent scenario, the present study was carried out to evaluate the procurement of two major equipments in an apex tertiary care institute using Project Evaluation and Review Technique (PERT). Objective: This study was done to evaluate the procurement of two major equipments using PERT in a tertiary care institute. Method: This study was conducted using Operational Research technique in an apex tertiary care institute i.e., medical college and hospital, in one of the North Eastern states of India. All the procurements related to equipments in that teaching hospital initiated in the financial year 2021 were listed. Out of them, two procurement files were selected by simple random sampling; procurement of Operating Table and Bio Safety cabinet Level – III. Project Evaluation and Review Technique (PERT) was applied to calculate the possible reduction in time in the whole procurement process. Results: The present study showed that procurement of Operating table took 185 days where minimum 8 days could have been saved and procurement of Bio-Safety cabinet Level-III was completed by 702 days where minimum 196 days could have been saved. Conclusion: Application of PERT in this procurement evaluation process can play significant role by calculating critical path and predicting the possible delay.

Threat Assessment and Risk Analysis (TARA) for Interoperable Medical Devices in the Operating Room Inspired by the Automotive Industry.

Prevailing trends in the automotive and medical device industry, such as life cycle overarching configurability, connectivity, and automation, require an adaption of development processes, especially regarding the security and safety thereof. The changing requirements imply that interfaces are more exposed to the outside world, making them more vulnerable to cyberattacks or data leaks. Consequently, not only do development processes need to be revised but also cybersecurity countermeasures and a focus on safety, as well as privacy, have become vital. While vehicles are especially exposed to cybersecurity and safety risks, the medical devices industry faces similar issues. In the automotive industry, proposals and draft regulations exist for security-related risk assessment processes. The medical device industry, which has less experience in these topics and is more heterogeneous, may benefit from drawing inspiration from these efforts. We examined and compared current standards, processes, and methods in both the automotive and medical industries. Based on the requirements regarding safety and security for risk analysis in the medical device industry, we propose the adoption of methods already established in the automotive industry. Furthermore, we present an example based on an interoperable Operating Room table (OR table).

Do On-Table Radiographs Predict Postoperative Sagittal Alignment after Posterior Lumbar Fusion?

To determine if intraoperative on-table lumbar lordosis and segmental lordosis correlate with postoperative lordosis following single-level posterolateral decompression and fusion (PLDF) or transforaminal lumbar interbody fusion (TLIF). Electronic medical records were reviewed for patients ≥18 years old who underwent PLDF or TLIF between 2012 and 2020. Lumbar lordosis and segmental lordosis were compared between pre-, intra-, and postoperative radiographs using paired t tests. Significance was set at P < 0.05. A total of 200 patients met inclusion criteria. No significant differences in preoperative, intraoperative, or postoperative measurements were found between groups. Patients who underwent PLDF experienced less disc height loss over 1 year postoperatively (PLDF: 0.45 ± 0.9 mm vs. TLIF: 1.2 ± 1.4 mm, P < 0.001). Lumbar lordosis significantly decreased between intraoperative to postoperative radiographs at 2-6 weeks for PLDF (Δ: -4.0°, P<0.001) and TLIF (Δ: -5.6°, P < 0.001), but no change was identified between the intraoperative and >6 month postoperative radiographs for PLDF (Δ: -0.3°, P= 0.634) or TLIF (Δ: -1.6°, P= 0.087). Segmental lordosis significantly increased from the preoperative to post-instrumentation intraoperative radiographs for PLDF (Δ: 2.7°, P < 0.001) and TLIF (Δ: 1.8°, P < 0.001), but it subsequently decreased at the final follow up for PLDF (Δ: -1.9°, P < 0.001) and TLIF (Δ: -2.3°, P < 0.001). Subtle decreases in lumbar lordosis may be noticed in early postoperative radiographs compared with intraoperative images on Jackson operative tables. However, these changes are not present at 1-year follow-up as lumbar lordosis increases to a similar level as intraoperative fixation.

Excision of a Superior Ramus Osteochondroma Through the Modified Stoppa Approach

Excision of a Superior Ramus Osteochondroma Through the Modified Stoppa Approach

Modified Direct Anterior Approach for Total Hip Arthroplasty in an Indonesian Population with Primary Standard Instruments of Total Hip Arthroplasty: Our Experiences and Short-term Follow-up

AbstractIntroduction: The direct anterior approach (DAA) for total hip arthroplasty (THA) is a very sophisticated and complicated surgery typically performed using a specialized operating room table and instruments. In our clinic, this procedure was performed with a modified incision to avoid dependence on a special operating room table and we could use ordinary THA instruments. There is an obvious absence of literature regarding this subject.Methods: A total of 31 patients (31 hips) were recruited for primary THAs from January 1, 2020 to December 31, 2021 who underwent THAs using the DAA in the supine position with modified incision. The technical feasibility and early results were evaluated.Results: The orientation of the acetabular component average cup inclination was 41.57o ±6.7o, (23o-57o) and the mean cup anteversion was 17.36o ± 5o, (11o-38o). The incidence of neutral coronal femoral stem alignment were 30 hips (97%), varus was 1 (3%), neutral sagittal alignment were 30 hips (97%), and flexion was 1 (3%). The preoperative Harris Hip Score (HHS) was 57.89 points (range: 17-68 points), whereas the postoperative HHS was 89.97 points (range: 82-100 points). There were no postoperative problems such as proximal femur fracture, hematoma, superficial wound complications, deep vein thrombosis, lateral femoral cutaneous nerve damage, heterotopic ossification, loosening of the acetabular component, loosening of the stem, dislocation, infection, or postoperative periprosthetic fracture.Conclusion: The DAA supine for THA with modified incision may be a valuable alternative in the absence of a special operating room table or special instruments for DAA. This technique also seems to provide satisfactory clinical and radiographic outcomes with acceptable complications in our early follow-up.

The Prone Lateral Approach for Lumbar Fusion—A Review of the Literature and Case Series

Lateral lumbar interbody fusion is an evolving procedure in spine surgery allowing for the placement of large interbody devices to achieve indirect decompression of segmental stenosis, deformity correction and high fusion rates through a minimally invasive approach. Traditionally, this technique has been performed in the lateral decubitus position. Many surgeons have adopted simultaneous posterior instrumentation in the lateral position to avoid patient repositioning; however, this technique presents several challenges and limitations. Recently, lateral interbody fusion in the prone position has been gaining in popularity due to the surgeon's ability to perform simultaneous posterior instrumentation as well as decompression procedures and corrective osteotomies. Furthermore, the prone position allows improved correction of sagittal plane imbalance due to increased lumbar lordosis when prone on most operative tables used for spinal surgery. In this paper, we describe the evolution of the prone lateral approach for interbody fusion and present our experience with this technique. Case examples are included for illustration.

Surgical Technique of Direct Anterior Approach for Primary Total Hip Arthroplasty Using a Leg Positioning Traction System.

Through the use of a natural intramuscular and internervous interval, the direct anterior approach (DAA) for total hip arthroplasty (THA) has been suggested to have several advantages over other popular arthroplasty approaches. The usage of DAA for THA has considerably grown in the West in recent years due to the emphasis on tissue preservation and minimally invasive joint replacements. However, due to the long learning curve, literature on this approach originating from India has been inadequate, suggesting a limited adoption of this surgical technique by the Indian diaspora of practicing surgeons. The DAA for THA is reliable and suitable to all conventional primary and revision THA cases. In the surgical procedure, the patient is positioned supine on the standard operating room (OR) table with the legs positioned in the Leg Positioning Traction System. The OR table may rotate, which enables the surgeon to perform the surgery more conveniently as it covers the majority of the patient's center of gravity. The incision is made over the tensor fascia lata. After femoral neck osteotomy, the head is removed, and traction is applied to the operative leg followed by acetabular cup insertion. The femoral stem is inserted after releasing soft tissues around the proximal femur using the leg positioning traction system. Using traction, flexion, and internal rotation, the femoral head is pushed into the acetabulum at the same time, and reduction is achieved. DAA for THA technique offers patients the advantage of minimally invasive surgery compared to other approaches. Many authors have published their experiences and technical keys to successfully completing this procedure, and several variations of the procedure have been described. The approach described is implemented utilizing specifically developed instruments, including a specialized table and intraoperative fluoroscopy while employing the standard surgical incision. This article attempts to outline the authors' technique for performing the DAA in the supine position for a primary THA using a Leg Positioning Traction System, with a focus on technical details in assisting an early DAA convert in making a safe transition.

Effect of an Adjustable Hinged Carbon Fiber Operating Table on Sagittal Alignment of the Lumbar Spine

This is a prospective study that has been done to assess the lumbar sagittal alignment of patients positioned prone over an adjustable hinged carbon fiber operating table. The following three variations of table position have been considered: neutral, 20° convex, and 20° concave bending. A total of 33 patients who underwent lumbar disc herniation and lumbar canal stenosis surgery were enrolled. Patients who presented with spinal deformity akin to lumbar scoliosis or spondylolisthesis were excluded. For the surgical procedure, following the induction of endotracheal general anesthesia, patients were positioned prone on the adjustable hinged carbon fiber operating table. Radiographs of the lateral view of the lumbar spine were acquired for the three table positions, i.e., neutral, 20° convex, and 20° concave. The lumbar lordosis was measured on radiographs. The lumbar lordosis presented divergently in all three variations of the table (p &lt; 0.01): 45.2 ± 11.0° in neutral; 52.0 ± 10.7° in 20° lumbar extension bending; and 35.9 ± 10.8° in 20° lumbar flexion bending. The efficacy of table bending was 46.5% in convex and 34.0% in concave bending. In conclusion, the lumbar lordosis in three different table positions were 35.9° in 20° convex bending, 45.2° in neutral, and 52.0° in concave bending. The efficacy of table bending was 46.5% in convex and 34.0% in concave bending.

A prospective randomized study of different height of operation table for tracheal intubation with videolaryngoscopy in ramped position

BackgroundPrevious studies have reported that the ramped position provides a better laryngoscopic view, reduces tracheal intubation time, and increases the success rate of endotracheal intubation. However, the patient’s head height changes while in the ramped position, which in turn changes the relative positions of the patient and intubator. Thus, making these changes may affect the efficiency of tracheal intubation; however, few studies have addressed this problem. This study analyzed intubation time and conditions during tracheal intubation using videolaryngoscope in the ramped position.MethodsThis prospective study included 144 patients who were scheduled to receive general anesthesia for surgeries involving orotracheal intubation. The participants were randomly allocated to either the nipple or umbilical group according to the table height. Mask ventilation was assessed using the Warters grading scale. Tracheal intubation was performed using a McGrath MAC laryngoscope. The total intubation time, laryngoscopy time, tube insertion time, and difficulty of intubation (IDS score) were measured.ResultsThe umbilical group had a significantly shorter laryngoscopy time (10 ± 3 vs. 16 ± 4 s), tube insertion time (18 ± 4 vs. 24 ± 6 s), and total intubation time (28 ± 5 vs. 40 ± 7 s) compared to the nipple group. No significant difference in the difficulty of mask ventilation was observed between the two groups. The IDS score was higher in the nipple than umbilical group.ConclusionThe lower (umbilical) table level reduced the intubation time and difficulty of videolaryngoscopy compared to the higher (nipple) table level.Trial registrationThis study was registered at KCT0005987, 11/03/2021, Retrospectively registered.

A Mixed E/E-Architecture for Interconnected Operating Tables Inspired by the Automotive Industry

Since interoperability in the operating room (OR) is considered a main factor to increase safety and improve the quality of surgeries, new challenges arise for the medical device industry in this increasingly connected environment. Therefore, new architectural approaches are needed, some of which may be inspired by other domains. In the meantime, novel communication paradigms are also gaining practical relevance in the automotive industry, which faces similar challenges. As a result, service-oriented architectures (SOAs) are often considered to provide a higher degree of flexibility for changes during the development and after product deployment. In this paper, we derive requirements of future networked OR tables from challenges and trends ahead. Based on these requirements, we propose a mixed electric and electronic architecture (E/E-architecture) inspired by the state-of-the-art measures from automotive domain and present an Identity and Access Management (IAM) approach to improve system security. In addition, a prototypical implementation is used to demonstrate the practicality of the proposed solution and to discuss necessary adjustments to the development process resulting from a mixed E/E-architecture approach.

Assessment of the urinary bladder prior to cesarean delivery in women with multiple abdominal scars through operation table ultrasonography: a case report

Bladder injury is a rare but serious complication that can occur during cesarean deliveries with an incidence of between 0.25% and 0.9%. Most bladder injuries (53%) occur upon entering the peritoneal cavity as a consequence of either extensive adhesions, a distorted pelvic anatomy, or an unexpectedly high-situated bladder owing to previous operations including a previous cesarean delivery. Patients with a previous abdominal operation can benefit from a preoperative ultrasound to identify the upper limits of an unexpectedly enlarged urinary bladder, even after preoperative catheterization. A modified surgical approach can then be applied to allow entry into the peritoneum above the bladder, thus preventing severe bladder injury. Surgeons may consider the use of preoperative sonography before operating on women with a previous abdominal surgery, especially following midline incisions, to improve safety and to potentially modify abdominal entry into the peritoneal cavity to avoid bladder injury.

Lower leg blood pressure decreases while calf external pressure increases with the angulation of the Trendelenburg position in the lithotomy position with calf- and foot-supported leg holders.

Patients who underwent lower abdominopelvic surgeries in the lithotomy position (LP) and the Trendelenburg position (TP) with the leg holder are at risk of developing well leg compartment syndrome (WLCS). However, contributing factors related to the LP with TP associated with WLCS are unknown. This study aimed to investigate the associations between external pressure at the calf in the LPs at different angulations of the TP and physiological characteristics. Eighty-four university students (age, 21.7 ± 0.9; 42 men and 42 women) voluntarily participated in the study. The awake participants were placed in the LPs using the calf- and foot-supported leg holder at 0° (horizontal level), 5°, 10°, and 20° head-down tilts by moving the electric operating table. The peak contact pressure (pCP) was measured at the calf as a representative external pressure using the pressure distribution measurement system BIG-MAT®. Lower leg blood pressure significantly decreased with TP angulation, while calf pCP significantly increased with it at 0°, 5°, 10°, and 20° head-down tilts (39.4 ± 15.2, 46.5 ± 17.7, 47.2 ± 16.9, and 50.3 ± 17.6mmHg, respectively). The calf pCP with a 10° head-down tilt was correlated positively with the calf total force (P < 0.001) and negatively with the calf contact area (P < 0.001). Blood hypoperfusion due to low lower leg blood pressure secondary to lower leg elevation and head-down tilt, and high calf external pressure due to direct external compression from the leg holder where it is loaded may contribute to WLCS.

Evaluating the Optimal Operating Table Height for ProSeal-LMA™ Insertion.

ProSeal-Laryngeal Mask Airway™ (P-LMA™) is one of the commonly used laryngeal mask airways. Despite the proper insertion technique, suboptimal positioning and airway morbidity still occurs. This study explored the possibility of the operating table height position affecting successful P-LMA™ placement. A total of 138 patients aged between 18 and 65 years old with the American Society of Anesthesiologists (ASA) I or II status, who required general anaesthesia and had no contraindication towards the use of P-LMA™, were recruited. They were randomly positioned into three anatomical landmarks, which were umbilicus, lowest rib margin, and xiphoid. P-LMA™ was inserted following muscle paralysis, and the first successful placement was evaluated using positional and performance tests. Duration, ease of P-LMA™ insertion, and airway complications were compared. Demographic and airway features were comparable among all groups. The P-LMA™ placement success rate improved when the table height was positioned at the lowest rib margin (p=0.002). All three positions were comparable in terms of duration, ease of insertion, and airway morbidities. The lowest rib margin anatomical landmark can be used as a guide in achieving the optimal operating table height for successful P-LMA™ placement.

Preoperative CT Scanning in Hemodynamically Stable Thoracoabdominal Gunshot Wounds: Outcomes from a Long-Term Single-Institution Pilot Study

INTRODUCTION: Emergent operative exploration is the standard of care for penetrating thoracoabdominal trauma. With advanced CT imaging, preoperative scans may be obtained efficiently for operative planning. This study aims to determine if CT imaging before operative exploration for hemodynamically stable thoracoabdominal gunshot wound injuries adversely affects patient outcomes. METHODS: This was a retrospective chart review was performed between 2014 and 2019 at an urban trauma center to identify hemodynamically stable patients who suffered penetrating thoracoabdominal gunshot wound and had operative intervention. Patients were then stratified into 2 groups: (1) those who received CT imaging before operative intervention, and (2) those who went straight to the operating room (OR). RESULTS: A total of 113 patients were identified. A total of 64 (56.6%) received CT imaging, and 49 (43.4%) went straight to the OR (Table). There were no differences in mortality (p = 0.25), hospital length of stay (p = 0.17), ICU length of stay (p = 0.14), ventilator days (p = 0.37), and postoperative complications (p > 0.05). Time spent in the OR and time from emergency department to end of operation were similar between groups (p = 0.051). Multivariable analysis demonstrated risk factors for time greater than 150 minutes includes Injury Severity Score, age, sex, and blood product administration. Multivariate regression displayed that for each unit of PRBC given, OR time were more likely to increase (p < 0.001). Table. - Patient Demographics and Outcome Data Demographics Overall Sample (N = 113) Group A: CT Scan before Going to the Operating Room (N = 64) Group B: Straight to the Operating Room (N = 49) p Value Age, y, mean (SD) 25.57 (7.60) 24.30 (6.74) 27.22 (8.38) 0.042 Race, % (White, Black, other, unknown) 8.0, 86.7, 1.8, 3.5 3.1, 92.2, 1.6, 3.1 14.3, 79.6, 2.0, 4.1 0.175 Sex, % (male, female) 92, 8 90.6, 9.4 93.9, 6.1 0.530 Injury Severity Score, mean (SD) 16.95 (9.42) 16.34 (8.76) 17.73 (10.26) 0.220 Hospital days, mean (SD) 11.06 (8.12) 10.42 (7.87) 11.90 (8.44) 0.142 Ventilator days, mean (SD) 2.07 (4.15) 1.95 (4.65) 2.22 (3.43) 0.370 MTP activation, n (%) 31.9% 17.2% 51% <0.0001 Total number of blood products, mean (SD) 4.00 (6.24) 2.09 (3.26) 6.49 (8.11) <0.0001 Mortality, n (%) 0.9% 0% 2.0% 0.251 CONCLUSION: Obtaining a CT scan before operative intervention in hemodynamically stable patients with thoracoabdominal gunshot wound did not affect mortality, hospital length of stay, or ventilator days, indicating that obtaining CT scans before operative intervention may be safe in select patients. This pilot serves as the basis for an ongoing regional multi-institutional study.

SYNTHESIS OF THE FINITE STATE MACHINE WITH DATAPATH OF TRANSITIONS ACCORDING TO THE OPERATIONAL TABLE OF TRANSITIONS

Context. The problem of formalizing the description of a microprogram finite state machine based on the principle of operational transformation of state codes with the help of a modified transition table is considered. The object of research was a model of a microprogram finite state machine with datapath of transitions.&#x0D; Objective. The goal of the work is development and research of a method for formally specifying a microprogram finite state machine with datapath of transitions in the form of a modified table of transitions containing sufficient information for synthesizing the logic circuit of the finite state machine in the basis of programmable logic devices.&#x0D; Method. A new way of representing the formal solution of the problem of algebraic synthesis of a microprogram finite state machine with datapath of transitions in the form of an operational table of transitions is proposed. This table is a modification of the direct structural table traditionally used in the synthesis of microprogram finite state machines. The use of the previously known representation of the formal solution of the problem of algebraic synthesis in the form of a system of isomorphisms of automaton algebras is too formalized and makes it difficult to synthesize the logical circuit of the finite state machine due to the separate description of the transition and output functions. It is shown that the structure of a microprogram finite state machine with datapath of transitions requires information about the set of interpretations of state codes and the transition operations used to be entered into the traditional table of transitions. It is noted that the proposed operational table of transitions contains sufficient information for the synthesis of the logical circuit of the finite state machine. An example of constructing an operational table of transitions for a finite state machine given by a graph-scheme of the implemented control algorithm is shown. The example demonstrates various ways to interpret state codes. The procedure for synthesizing the circuit for generating codes of transition operations and the circuit for generating microoperations according to the operational table of transitions is proposed.&#x0D; Results. An example of the implementation of the main stages of the synthesis of a finite state machine with datapath of transitions according to the operational table of transitions is considered. Examples of synthesized finite state machine models in the VHDL language are given, which take into account the peculiarities of the representation of finite state machine models in Xilinx Vivado CAD. The results of the synthesis of the finite state machine according to VHDL models in FPGA basis are shown.&#x0D; Conclusions. The experiments carried out confirmed the sufficiency of the operational table of transitions for describing a microprogram finite state machine with operational transformation of state codes for the purpose of further synthesizing its logic circuit. Prospects for further research are the use of the proposed operational table of transitions in the development of various methods for the synthesis and optimization of microprogram finite state machine with operational transformation of state codes.