Laceration Repair Research Articles

Are We on the Same Page? A Multi-Institutional Evaluation of Faculty and Resident Training Needs

BACKGROUND: Resident and faculty needs are important in guiding the educational agenda; studies demonstrate that these groups do not always agree on needs. A previously piloted 50-item needs assessment evaluating content areas of feedback, the 15 Ob-Gyn milestone procedures, and simulation was used to assess and compare faculty and resident needs. METHODS: The needs assessment was administered electronically to two academic Ob-Gyn residency programs (located in South Carolina and Texas) in June 2016; all items were ranked on a 5-point agreement scale. Equivalent versions were written to capture resident and faculty perceptions of the training program; results were anonymous and participation was voluntary. RESULTS: Forty-two surgical faculty (52.5%) and 47 residents (62.5%) completed the needs assessment; t tests compared resident/faculty group differences. Both groups agreed on the adequacy of surgical content, however, faculty consistently self-reported delivering feedback at a significantly higher level than residents' perceived receiving it (P<.05) for 8/16 feedback items. Overall, both groups were least satisfied with training in breech vaginal delivery, 3rd/4th-degree laceration repair and operative vaginal delivery; residents were most satisfied with training in cesarean delivery while faculty were most satisfied with laparoscopy. Both groups agreed simulation can improve procedure performance; no significant differences existed. These findings were consistent between institutions, although each institution's levels of agreement differed for individual items. DISCUSSION: Although residents and faculty agree on areas of strengths and weaknesses, significant differences exist in perception of feedback delivery and reception.

278 Intranasal Ketamine for Procedural Sedation in Children: A Randomized Controlled Pilot Study

The pain of intravenous (IV) insertion is rated by children as second only to disease-related pain. Procedural sedation and analgesia (PSA) is a common indication for IV insertion in the emergency department (ED). Ketamine is the most frequently used agent for PSA in children. Intranasal ketamine (INK) has shown effectiveness for PSA in a limited number of painful procedures (IV insertion, gastric aspiration, and laceration repair) but no studies have explored INK for fracture reduction in children. Our objective was to evaluate the feasibility of INK for PSA in children who sustained a fracture requiring a closed reduction. This was a randomized, blinded, controlled, trial comparing the effectiveness of INK versus intravenous ketamine (IVK). We included children 4-17 years, < 40 kg with a non-shortened distal forearm fracture requiring PSA for closed reduction. Participants were randomized using a double-dummy approach to receive single dose (i) INK 8 mg/kg (maximum 320 mg) + 0.9% IV normal saline OR (ii) IVK 1 mg/kg (maximum of 40 mg) + IN 0.9% normal saline. The primary outcome was the proportion of participants with adequate sedation during closed reduction as defined by a University of Michigan Sedation Scale (UMSS) score of > 3 of 4. Secondary outcomes included need for additional IV sedation, adverse effects, time to sedation defined as a UMSS score of > 3 of 4, and length of stay. Fifteen participants were consecutively recruited from March 1, 2016 to Feb 1, 2017. Seven children (3 females) received INK and the mean (SD) age was 6.6 (3.1) years. Eight children (3 females) received IVK and the mean (SD) age was 5.9 (2) years. Adequate sedation was achieved by 4/7 (57.1%) versus 7/8 (87.5%) participants in the INK and IVK groups, respectively (p = 0.28). The median (IQR) time to sedation was 10 (11.3) versus 5 (0) minutes in the INK and IVK groups, respectively (p = 0.23). Additional IVK was required by 5/7 (71.4%) versus 2/8 (25%) of participants in the INK and IVK groups, respectively (p = 0.13). Adverse effects consisting of nausea, vomiting, or dizziness were seen in 4/7 (57.1) versus 2/8 (25%) of participants in the INK and IVK groups, respectively (p = 0.32). No participants experienced emergence agitation and there were no serious adverse events. The median (IQR) length of stay in the INK and IVK groups was 364 (153) versus 290 (113) minutes, respectively (p = 0.13). The adequacy of sedation for INK 8 mg/kg is inconsistent for closed reduction of distal forearm fractures in children. Greater sedative efficacy may be achieved with a higher INK dose (9-10 mg/kg), consistent with demonstrated effectiveness in other studies of PSA in children undergoing painful procedures.

Evaluating Clinical Effectiveness and Pharmacokinetic Profile of Atomized Intranasal Midazolam in Children Undergoing Laceration Repair

BackgroundAtomized intranasal midazolam is a common adjunct in pediatrics for procedural anxiolysis. There are no previous studies of validated anxiety scores with pharmacokinetic data to support optimal procedure timing. ObjectivesWe describe the clinical and pharmacokinetic profile of atomized intranasal midazolam in children presenting for laceration repair. MethodsChildren 11 months to 7 years of age and weighing <26 kg received 0.4 mg/kg of atomized intranasal midazolam for simple laceration repair. Blood samples were obtained at 3 time points in each patient, and the data were fit with a 1-compartment model. Patient anxiety was rated with the Observational Scale of Behavioral Distress. Secondary outcomes included use of adjunctive medications, successful completion of procedure, and adverse events. ResultsSixty-two subjects were enrolled, with a mean age of 3.3 years. The median time to peak midazolam concentration was 10.1 min (interquartile range 9.7–10.8 min), and the median time to the procedure was 26 min (interquartile range 21–34 min). There was a trend in higher Observational Scale of Behavioral Distress scores during the procedure. We observed a total of 2 adverse events, 1 episode of vomiting (1.6%) and 1 paradoxical reaction (1.6%). Procedural completion was successful in 97% of patients. ConclusionsAtomized intranasal midazolam is a safe and effective anxiolytic to facilitate laceration repair. The plasma concentration was >90% of the maximum from 5 to 17 min, suggesting this as an ideal procedural timeframe after intranasal midazolam administration.

Early Versus Late Canalicular Laceration Repair Outcomes

To determine whether delayed repair of traumatic canalicular laceration affects the final outcome. Retrospective case series. The medical records of 334 patients who underwent primary traumatic canalicular laceration repair were retrospectively reviewed. Patients were divided into 2 groups according to the surgical timing within 48 hours (early) or after 48 hours (delayed). The anatomic results were compared between these 2 groups. The causes of delayed repair and the mean operation time were also analyzed. There were 23 failed cases among 301 patients (7.6%) who had a repair within 48 hours and 3 failed cases among 33 patients (9.1%) who had a repair after 48 hours (P= .732). The mean operation time was 62minutes in the early group and 66.3minutes in the delayed group, which showed no significant difference (P= .371). The major cause of delayed surgery was traumatic brain injury, followed by facial or orbital fracture, long bone fracture, and chest injury. Delayed canalicular repair in unstable patients did not lead to poor results. An elective scheduling surgery, instead of an urgent repair, is feasible for an experienced surgeon.

A new method for locating the proximal lacerated bicanalicular ends in Chinese preschoolers and long-term outcomes after surgical repair.

This report is to explore the long-term outcomes of surgical repair of bicanalicular lacerations in Chinese preschool patients. In this report, 12 patients with bicanalicular lacerations were studied between September 2010 and September 2015. The distance from the punctum to the distal canalicular lacerated end was recorded before surgery to classify different types of trauma. All patients underwent surgical repair of the lacerated canaliculi by 1 surgeon within 48 hours after the trauma occurred. After treatment, the lesions were divided into 3 types according to the distance from the punctum to the distal lacerated canalicular end as follows: lateral, medial, and the central. Based on this classification, each lacerated canaliculus was successfully repaired. Nearly half of the lesions (46%) were lateral, 42% were central, and 12% were medial. The average time for locating the proximal lacerated end of the canaliculus was 3.33 ± 1.52 minutes (range, 1.0–7.0 minutes). The follow-up time ranged from 6.0 months to 4.5 year (median, 25 months). Our study showed that 96% (23) of the canaliculi were completely patent. One lateral lesion presented with residual outdoor epiphora in cold weather secondary to left lower canalicular stenosis. All 12 patients had excellent cosmetic results. Our study displayed a surgical management based on the 3 types of lesions helped to find the proximal lacerated end of the canaliculus, and provided excellent long-term outcomes of drainage function.

Topical antibiotics to prevent surgical site infection after minor surgery in primary care.

BackgroundSurgical site infection (SSI) after minor surgery in primary care can compromise cosmetic outcomes, delay wound healing and increase costs. In addition to efficacy, adverse effects must be considered when considering antibiotic prophylaxis. There is no prior published literature regarding the proportion of general practitioners (GPs) who use topical antibiotics as SSI prophylaxis following minor surgery.ObjectivesTo identify the proportion of GPs in a regional center in Queensland, Australia who apply topical antibiotics to wounds prevent SSIs after minor surgery.MethodA database of 90 GPs was established, and they were invited to complete a questionnaire.ResultsThe response rate was 62% (56/90). Topical antibiotics prophylaxis was reported as being used always or sometimes in routine practice by 18% (10/56) of participants after both skin lesion excision and repair of lacerations. In the context of high-risk situations, on the other hand, use was higher. They were more likely to be used in high-risk situations, most frequently in diabetic patients (41.0% [23/56]) and immunocompromised patients (46.5% [26/56]).ConclusionsEvidence-based prescribing of antibiotics is vital. Topical antibiotic prophylaxis is often prescribed excessively after clean dermatological surgery, however, in our sample of GPs, only 18% used topical antibiotics always or sometimes in their practice.

Consultation for Simple Laceration Repair When On-Call in the Emergency Department: Potential Quagmire.

Summary:What are the forces obligating a plastic surgeon who is on-call for the emergency department to respond to a consultation request for repair of a simple laceration? Although the duties are clear in cases of obvious surgical emergency, ambiguity and subsequent conflict may arise when the true nature of the emergency is less clear. Does the consultant’s clinical discretion dictate the obligation in the case of a simple laceration; or is it subservient to either the discretion of the requesting health-care provider or even the patient? Do federal statutes such as the Emergency Medical Treatment and Labor Act, or perhaps more local rules apply, such as the by-laws of the hospital? It would behoove all medical practitioners to familiarize themselves with both the legal and moral implications of these issues. Having legitimate policies in place which actively address those situations where the consultative obligation is unclear is critical to resolve potential conflict.

A Simulation-Based Longitudinal Procedural Curriculum for Pediatric Residents Improves Self-Perceived Competence (Research Abstract)

Studies have shown that both residents and program directors perceive procedural competence to be poor due to the general low volume of pediatric procedures. We developed a novel, longitudinal, simulation-based procedural curriculum to teach procedures required by the Accreditation Council of Graduate Medical Education (ACGME) including lumbar puncture (LP), simple laceration repair, bag mask ventilation (BMV), intubation, fracture splinting, abscess incision and drainage (I&D), foreign body removal and dislocation reduction as well as other procedures routinely performed during residency including nasogastric (NG) tube placement, nasointestinal (NI) tube bridling, and tracheostomy-and gastrostomy-tube management. We aimed to assess the change in self-perceived procedural competence as a result of this curriculum.

Old canalicular laceration repair: a retrospective study of the curative effects and prognostic factors.

To investigate the epidemiology and surgical outcomes of old canalicular laceration and analyze the variables impacting on the prognosis of reparation. A retrospective review of all old canalicular laceration repairs from Jan. 1, 2008 to Dec. 30, 2015 was performed. Analyzed data included demographics, mechanisms of injury, the time from injury to repair, causes for delayed repair, old associated injuries, the types of surgery, and the effects of repair using canaliculus anastomosis combined with bicanalicular stent intubation. Totally 148 patients with old canalicular laceration received surgical repair and were enrolled. The mean age at presentation was 32.52 years old (ranged from 3 to 63 years old). The 110 patients (74.32%) were male and 127 patients (85.81%) were adults (≥18 years old). The old upper, lower, and bicanalicular lacerations were found in 5 (3.38%), 39 (26.35%), and 104 patients (70.27%), respectively. The mechanism of old injury was primarily due to motor vehicle accidents (n=53, 35.81%). The mean time from injury to repair was 43.61mo (ranged from 1 to 360mo). Associated old ocular and orbit injuries were found in 65 patients (43.92%), and chronic dacryocystitis in 18 patients (12.16%). The main cause of delayed repair was that doctors or patients didn't pay attention to the canalicular laceration because of the concurrent severe injuries (n=71, 47.97%). Totally 136 patients (91.89%) with old canalicular laceration underwent canaliculus anastomosis combined with bicanalicular stent intubation. In all of them, 20 patients (13.51%) were combined with dacryocystorhinostomy. In these cases, 132 patients (97.06%) attained anatomic success, 121 patients (88.97%) reported no epiphora (functional success), 11 patients (8.09%) reported significant epiphora anesis (functional improvement), and 4 (2.94%) reported no significant anesis (functional failure). Rates of anatomic success and functional success were significantly correlated with different canaliculus involved. However, rates of anatomic success and functional success were not significantly affected by the time from injury to repair. The canalicular anastomosis combined with bicanalicular stent intubation could act as an effective therapeutics for old canalicular laceration.

Variation in Emergency Department vs Internal Medicine Excess Charges in the United States

Uninsured and insured but out-of-network emergency department (ED) patients are often billed hospital chargemaster prices, which exceed amounts typically paid by insurers. To examine the variation in excess charges for services provided by emergency medicine and internal medicine physicians. Retrospective analysis was conducted of professional fee payment claims made by the Centers for Medicare & Medicaid Services for all services provided to Medicare Part B fee-for-service beneficiaries in calendar year 2013. Data analysis was conducted from January 1 to July 31, 2016. Markup ratios for ED and internal medicine professional services, defined as the charges submitted by the hospital divided by the Medicare allowable amount. Our analysis included 12 337 emergency medicine physicians from 2707 hospitals and 57 607 internal medicine physicians from 3669 hospitals in all 50 states. Services provided by emergency medicine physicians had an overall markup ratio of 4.4 (340% excess charges), which was greater than the markup ratio of 2.1 (110% excess charges) for all services performed by internal medicine physicians. Markup ratios for all ED services ranged by hospital from 1.0 to 12.6 (median, 4.2; interquartile range [IQR], 3.3-5.8); markup ratios for all internal medicine services ranged by hospital from 1.0 to 14.1 (median, 2.0; IQR, 1.7-2.5). The median markup ratio by hospital for ED evaluation and management procedure codes varied between 4.0 and 5.0. Among the most common ED services, laceration repair had the highest median markup ratio (7.0); emergency medicine physician review of a head computed tomographic scan had the greatest interhospital variation (range, 1.6-27.7). Across hospitals, markups in the ED were often substantially higher than those in the internal medicine department for the same services. Higher ED markup ratios were associated with hospital for-profit ownership (median, 5.7; IQR, 4.0-7.1), a greater percentage of uninsured patients seen (median, 5.0; IQR, 3.5-6.7 for ≥20% uninsured), and location (median, 5.3; IQR, 3.8-6.8 for the southeastern United States). Across hospitals, there is wide variation in excess charges on ED services, which are often priced higher than internal medicine services. Our results inform policy efforts to protect uninsured and out-of-network patients from highly variable pricing.

Anatomical and functional outcomes of canalicular laceration repair with self retaining mini-MONOKA stent

AimTo evaluate the anatomical and functional outcomes of canalicular laceration repair with self retaining monocanalicular intubation system (Mini-MONOKA). Materials and methodsThe data of 29 patients undergoing canalicular laceration repair from 2010 to 2014 were retrospectively analyzed. Operative details and complications were noted. The stent was removed earliest at 3months. Anatomical and functional success was defined by a patent syringing and the absence of epiphora respectively. ResultsOut of 29 patients, 23 (79.3%) were males. Mean age at presentation was 19.3 ±13.8years. Lower canaliculus was involved in 19 (65.5%), upper in 8 (27.5%) and both canaliculi in 2 (6.8%). Ten patients presented later than 11days after trauma (range 12–168days), and repair was attempted successfully in all.Fourteen (48.2%) cases reported for stent removal, at a mean follow-up period of 4.64 ±2.12months. Anatomical success was noted in 12 (85.71%) and functional success in 13 (92.85%) cases. Four patients had stent related complications. ConclusionCanalicular injuries are more common in young males. Mini-MONOKA stents are easy to insert and retrieve, and yield excellent anatomical and functional outcome. Canalicular laceration repair can be attempted successfully irrespective of the delay in presentation.

Validation of the Pediatric Sedation State Scale.

Development and validation of the Pediatric Sedation State Scale (PSSS) is intended to specifically meet the needs of pediatric procedural sedation providers to measure effectiveness and quality of care. The PSSS content was developed through Delphi methods utilizing leading pediatric sedation experts and published guidelines on procedural sedation in children. Video clips were created and presented to study participants, who graded the state of patients during procedures by using the PSSS to evaluate inter- and intrarater reliability by determining the intraclass correlation coefficient. We also compared the PSSS to the Observational Scale of Behavioral Distress-revised during 4 clinically relevant phases of a laceration repair procedure. Six sedation states were defined for the PSSS. Each state was assigned a numerical value with higher numbers for increasing activity states. We included behaviors associated with adequate and inadequate sedation and adverse events associated with excessive sedation. Analysis of interrater and intrarater reliability revealed an intraclass correlation coefficient of 0.994 (95% confidence interval: 0.986-0.998) and 0.986 (95% confidence interval: 0.970-0.995), respectively. Criterion validity was confirmed with respect to the Observational Scale of Behavioral Distress-revised (Spearman r = 0.96). Construct validity was indicated by significant differences in PSSS scores (P < .001) between 4 phases of a procedure, each having a different degree of painful or distressing stimuli. The PSSS is a 6-point scale that is a valid measure of the effectiveness and quality of procedural sedation in children within the limits of the testing method used in this study.

Transverse process anatomy as a guide to vertebral artery exposure during anterior cervical spine approach: A Cadaveric Study.

Safe exposure of the vertebral artery (VA) is needed during resection of tumors close to the artery and during repair of lacerations. We defined the anatomy of the anterior root of each transverse process (TP) from C3 to C6 for identification and exposure of the VA during the anterior approach. We examined the anatomy of the TP and assessed two approaches for safe identification of the VA, lateral to medial and medial to lateral dissection of the TP, in 20 cadavers. The safe zone at each level of the cervical spine was defined as an area in which the surgeon can start to dissect at the midline of that level on the TP and safely cross the VA laterally. For the lateral to medial approach the surgical safe zone lies between the mid axis of the TPs and a line 2 mm parallel to and above it. The average TP angle was 11 ± 10.2 degrees. The mean distance of the lateral border of the VA from the TP tip was 3.78-5.28 mm. For the medial to lateral approach, staying at the level of the upper vertebral end plate will lead the surgeon to the tip of the TP. From that point, dissection can be carried out as described above. This study examined the anatomy of the TP and defined the approach to expose the VA safely during anterior cervical spine exposure. Clin. Anat. 30:492-497, 2017. © 2017 Wiley Periodicals, Inc.

PD63-06 NONOPERATIVE MANAGEMENT HAS SIGNIFICANTLY INCREASED FOR BOTH BLUNT AND PENETRATING RENAL TRAUMA: DATA FROM THE NATIONAL TRAUMA DATA BANK

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) II1 Apr 2017PD63-06 NONOPERATIVE MANAGEMENT HAS SIGNIFICANTLY INCREASED FOR BOTH BLUNT AND PENETRATING RENAL TRAUMA: DATA FROM THE NATIONAL TRAUMA DATA BANK Marc Colaco, Susan MacDonald, and Ryan Terlecki Marc ColacoMarc Colaco More articles by this author , Susan MacDonaldSusan MacDonald More articles by this author , and Ryan TerleckiRyan Terlecki More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2930AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Management of blunt renal trauma has evolved to favor a conservative approach. Penetrating trauma, however, has traditionally involved surgical intervention. The purpose of this study is to compare the trends in operative and nonoperative management following blunt and penetrating renal trauma. METHODS A retrospective cross sectional analysis was performed using data from 2002-2012 within the National Trauma Data Bank (NTDB). Cases were identified by ICD-9 diagnosis codes. Codes 866.00 through 866.03 and 866.10 through 866.13 were queried for blunt and penetrating renal trauma, respectively. Only cases requiring interventions were included. Treatments were identified using ICD-9 procedure codes for nephrectomy (55.5x), renal laceration repair (55.81), arteriography (88.45) or endovascular repair (39.79). RESULTS 4296 cases were reported during the study period. Of these, 2635 involved blunt trauma and 1661 involved penetrating injury. Following blunt trauma, there was a significant increase in the percentage of cases managed by endovascular means (R2=0.92, p<0.01) with a corresponding decrease in the amount of patients undergoing both nephrectomy (R2=0.32, p=0.068) and laceration repair (R2=0.54, p<0.01) [Figure 1a]. Following penetrating trauma, there was also a significant decrease in nonoperative management (R2=0.69, p<0.01) largely explained by a decline in nephrectomy (###). Endovascular interventions significantly increased (R2=0.87, p<0.01) [Figure 1b]. These cases, however, were predominantly managed with laceration repair with no significant change over the study period. CONCLUSIONS Surgical intervention for blunt and penetrating trauma continues to decrease. Procedural intervention for blunt renal trauma largely consists of endovascular management. Although most interventions for penetrating trauma involve repair, nephrectomy has significantly decreased while endovascular management has increased. Future efforts should aim to characterize whether the current trends in surgical intervention following penetrating renal injuries is appropriate and if outcomes data warrants a change in guidelines that may allow for quality improvement and decreased morbidity. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1256 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Marc Colaco More articles by this author Susan MacDonald More articles by this author Ryan Terlecki More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Nitrous Oxide Utility in Labor and Birth: A Multipurpose Modality.

The use of nitrous oxide (N2O) for labor and birth has very recently emerged as a viable modality in the United States, despite a long history of use in Canada and Europe. Usually associated with dental procedures, there are significant differences between dental and parturition utility, efficacy, and staff exposure. In addition to using it for pain relief and anxiolysis, those centers utilizing it have noted it to be multipurpose and useful for such situations as: external cephalic version, manual removal of placenta, intravenous starts, during placement of urinary catheters and intracervical Foley bulbs. Nitrous oxide has proven to be especially helpful for repair of lacerations under local anesthesia and is a multiuse modality that should be available to women in all birth settings. This article explores the history of N2O use, provides a comparison of obstetrical use to use in the dental industry, examines the contraindications to, and implications for usage, and discusses logistical points of consideration for clinicians working with women using N2O for labor and birth.

Collagen cross-linking as an adjunct for repair of corneal lacerations: a cadaveric study

ObjectiveTo determine the efficacy of collagen cross-linking (CXL) as an adjunct to suturing in the repair of corneal lacerations. MethodsA cadaveric study was undertaken in which a linear 5 mm corneal laceration was created in the central cornea of 20 eyes. The eyes were then randomized to receive 1 (n = 8), 2 (n = 8), or 3 (n = 4) standard corneal sutures. The burst pressure of the wound was then measured. All eyes in the 1- and 2-suture group then underwent standard CXL, with burst pressure repeated afterward. ResultsThe initial wound burst pressure in the 1-, 2-, and 3-suture groups was 54.9, 74.0, and 201.2 mm Hg, respectively. After CXL, wound burst pressure increased by a mean of 3.2 and 62.3 mm Hg in the 1- and 2-suture groups, respectively. This change was statistically significant in the 2-suture group (p = 0.017). After CXL, the 2-suture group still had a significantly lower burst pressure compared with the 3-suture group (p = 0.011). ConclusionsThe study highlights a potential novel application for CXL to strengthen corneal wounds. Provided that suture density is sufficient to appose the wound edges, CXL may result in short-term wound strengthening. This could potentially allow for decreased corneal suture density and a corresponding decrease in suture-related complications.

Improving Resident Performance in Oculoplastic Surgery: A New Curriculum Using Surgical Wet Laboratory Videos

To develop a new oculoplastic curriculum that incorporates learning theory of skill acquisition. To develop and evaluate the effectiveness of instructional videos for an oculoplastic surgical wet laboratory. Proof of concept, randomized controlled trial. New York Eye and Ear Infirmary of Mount Sinai-tertiary care academic institution. In total, 16 ophthalmology residents were randomly assigned to 1 of 2 groups and given either video and text or text instructions alone for the following 2 procedures: blepharoplasty and eyelid laceration repair. Operating time and esthetic result were measured, and the groups were statistically compared. A brief survey was administered. We developed a new 6 component oculoplastics curriculum that incorporates concepts of the Fitts and Posner skill acquisition model and mental imagery. In the wet laboratory pilot study, the group that watched the video of the laceration repair showed better esthetic grades than the group that received text alone (p = 0.038). This difference was not found for the blepharoplasty (p = 0.492). There was no difference between groups in operating time for the laceration repair (p = 0.722), but the group that watched the blepharoplasty video required more time to complete the task than those that reviewed text only (p = 0.023). In total, 100% of residents reported the videos augmented their learning. Methods to optimize surgical education are important given limited operating room time in oculoplastics, a subspecialty in which the number of surgeries performed during residency is relatively low. We developed a curriculum based on learning theory and sought to formally test one important aspect, surgical video for wet laboratories. Our pilot study, despite its limitations, showed that wet laboratory surgical videos can be effective tools in improving motor skill acquisition for oculoplastic surgery.

Modified Beef Tongue Model for Fourth-Degree Laceration Repair Simulation.

An existing model for fourth-degree laceration repair uses beef tongue with plastic or vinyl tubing. This modified model substitutes beef tripe for the anal mucosa and chicken leg muscles for the anal sphincter muscle analogs to create a realistic model. Tripe is tunneled through the body of the trimmed beef tongue and sutured like an ostomy to simulate the anal canal. The tongue is incised toward the tripe "anal canal." Chicken leg muscles are tunneled from the incision out to the cut edges of the beef tongue to create anal sphincter muscle analogs. Procedures can be repeated on the opposite side. Two double-sided models can be made per tongue. The model can be refrigerated or frozen and thawed before use. A fourth-degree laceration can be cut immediately before use. Materials were obtained at a local supermarket for $5-7 per half-tongue, double-sided model. Residents responded positively to the model and stated that animal tissue provided realistic haptic simulation. The modified beef tongue model utilizing tripe and chicken leg muscles as anal mucosa and anal sphincter muscle analogs, respectively, provided excellent perceived haptic fidelity. Moreover, it is an innovative, inexpensive, and well-received teaching tool to augment resident education.

A new method for identifying the cut ends in canalicular laceration

To locate the proximal and distal cut ends of the canaliculus following trauma is the most difficult part of canalicular repair, especially in patients with complex acute canalicular lacerations and late presenting canalicular lacerations. Previously, irrigation and air-injection technique are reported and widely used to locate the cut ends of lacerated canaliculus. However, we have developed a novel technique in which with a 23 Ga fiber optic light pipe is used to identify the cut ends of the canaliculus allowing silicone tube intubation of the lacrimal system. The mean time from initiation of the identification of the cut ends of the canaliculus to insertion of the silicone tube was 5 minutes. In this study, the cut ends were successfully identified by using this novel method in 33 cases of acute and late presenting canalicular laceration for canalicular reconstruction without any complications. This light-guided technique may represent an improvement in the surgical repair of canalicular lacerations.

Topical anaesthetics for pain control during repair of dermal laceration.

Topical local anaesthetics provide effective analgesia for patients undergoing numerous superficial procedures, including repair of dermal lacerations. The need for cocaine in topical anaesthetic formulations has been questioned because of concern about adverse effects, thus novel preparations of cocaine-free anaesthetics have been developed. This review was originally published in 2011 and has been updated in 2017. To assess whether benefits of non-invasive topical anaesthetic application occur at the expense of decreased analgesic efficacy. To compare the efficacy of various single-component or multi-component topical anaesthetic agents for repair of dermal lacerations. To determine the clinical necessity for topical application of the ester anaesthetic, cocaine. For this updated review, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 2010 to December 2016), Embase (2010 to December 2016) and MEDLINE (2010 to December 2016). We did not limit this search by language or format of publication. We contacted manufacturers, international scientific societies and researchers in the field. Weemailed selected journalsand reviewed meta-registers of ongoing trials. For the previous version of this review, we searched these databases to November 2010. We included randomized controlled trials (RCTs) that evaluated the efficacy and safety of topical anaesthetics for repair of dermal laceration in adult and paediatric participants. Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information when needed. We collected adverse event information from trial reports. We assessed methodological risk of bias for each included study and employed the GRADE approach to assess the overall quality of the evidence. The present updated review included 25 RCTs involving 3278 participants. The small number of trials in each comparison group and the heterogeneity of outcome measures precluded quantitative analysis of data for all but one outcome: pain intensity. In two pooled studies, the mean self-reported visual analogue scale (VAS; 0 to 100 mm) score for topical prilocaine-phenylephrine (PP) was higher than the mean self-reported VAS (0 to 100 mm) score for topical tetracaine-epinephrine-cocaine (TAC) by 5.59 points (95% confidence interval (CI) 2.16 to 13.35). Most trials that compared infiltrated and topical anaesthetics were at high risk of bias, which is likely to have affected their results. Researchers found that several cocaine-free topical anaesthetics provided effective analgesic efficacy. However, data regarding the efficacy of each topical agent are based mostly on single comparisons in trials with unclear or high risk of bias. Mild, self-limited erythematous skin induration occurred in one of 1042 participants who had undergone application of TAC. Investigators reported no serious complications among any of the participants treated with cocaine-based or cocaine-free topical anaesthetics. The overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well-designed RCTs with low risk of bias are necessary before definitive conclusions can be reached. We have found two new studies published since the last version of this review was prepared. We have added these studies to those previously included and have conducted an updated analysis, which resulted in the same review conclusions as were presented previously.Mostly descriptive analysis indicates that topical anaesthetics may offer an efficacious, non-invasive means of providing analgesia before suturing of dermal lacerations. Use of cocaine-based topical anaesthetics might be hard to justify, given the availability of other effective topical anaesthetics without cocaine. However, the overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well-designed RCTs with low risk of bias are necessary before definitive conclusions can be reached.