Safe Insertion Research Articles

Pediatric atlas anatomy and its implications for fracture treatment: an anatomical and radiological study

Introduction and objectivesThe objective of the study was: (1) to describe changes in the shape of the atlas during growth, including gender and side differences; (2) to assess the dimension essential for identification of the optimal entry point; (3) to determine the age limit for a safe insertion of 3.5-mm screws into the lateral masses according to our own limiting parameters. Materials and methodsDimensions of the atlas were measured on 200 CT scans of the craniocervical junction in individuals aged 0–18 years and on 34 anatomical specimens of the first cervical vertebra (aged 2.5–18 years). Both series were divided according to the gender and age. The values measured on CT scans were used for statistical comparison of data in boys and girls and comparison of the right and left sides. ResultsThe atlas reaches its maximum growth rate between 0 and 2 years of age, then the growth decelerates and continues until the age of 18 years. The proportion of dimensions of C1 vertebral foramens changes with age. The youngest children show a relatively greater distance from the left to the right medial pedicle; around the age of 5 the values get even and subsequently the distance from the inner wall of anterior to posterior arch gets relatively greater. The transverse foramen has a slightly oval shape throughout the period of growth. Statistically significant differences between boys and girls were observed primarily between 12 and 18 years of age. ConclusionThe study has proved adequate size of lateral masses for insertion of 3.5-mm screws in all patients from the age of 5 years. In younger children, the patient´s anatomy should be respected and the surgical technique tailored accordingly.

Optimal retractor insertion point for nerve safety during total hip arthroplasty: an anatomical study on the femoral and sciatic nerves in relation to hip motion.

Nerve injury is one of the most serious complications of total hip arthroplasty (THA). It is suspected to be a result from nerve compression or direct injury caused by an acetabular retractor. The anatomical relationship between the acetabular rim and the femoral and sciatic nerves, including hip motion, has not been investigated. This study aimed to identify the optimal position for retractor insertion during THA to prevent nerve damage. A total of 28 hip joints from 14 freshly frozen cadavers were used. Using an anterolateral approach, each cadaver was immobilised in the lateral decubitus position and deployed to measure the distance between the nerves and the acetabular rim, while the hip joint was changed to the extension, neutral, and flexion positions. Three femoral nerves were closest to the anterior margin of the acetabulum at 90° and 120° of extension and farthest away at 30° of flexion. The sciatic nerve was closest to the posterior margin of the acetabulum at 90° and 120° of flexion and farthest away at 30° and 150° of extension compared with the other points. To prevent nerve damage during THA, we suggest that the retractor be inserted at the points where the nerves are the farthest away, such as at 30° and 150°. The femoral and sciatic nerves vary in their movements depending on the hip position. Therefore, the safe insertion of a retractor is recommended for hip flexion of the femoral nerve and extension of the sciatic nerve. Additionally, it is important to carefully insert the retractor along the acetabular margin without penetrating the joint capsule. Overall, this study provides valuable insights into the anatomical location and movement of the femoral and sciatic nerves in relation to hip motion and can help inform surgical techniques for safer THA.

Mini-Implant Insertion Using a Guide Manufactured with Computer-Aided Design and Computer-Aided Manufacturing in an Adolescent Patient Suffering from Tooth Eruption Disturbance.

Due to dental diseases, anatomical restrictions, and mixed dentition, the reduction in the number of teeth and the displacement of tooth germs pose challenges in orthodontic treatment, limiting anchorage options. The presented case demonstrates an advanced treatment solution using digital CAD/CAM-technologies and medical imaging for the creation of a mini-implant template. A 12-year-old male patient experiencing delayed tooth eruption, multiple impacted germs, and maxillary constriction underwent intraoral scanning and CBCT. Utilizing coDiagnostiXTM Version 10.2 software, the acquired data were merged to determine the mini-implant placement and to design the template. The template was then manufactured through stereolithography using surgical-guide material. Mini-implants were inserted using the produced appliance, enabling safe insertion by avoiding vital structures. Surgically exposed displaced teeth were aligned using a Hyrax screw appliance anchored on the mini-implants for rapid palatal expansion (RPE) and subsequently used as fixed orthodontics to align impacted teeth. The screw was activated daily for 10 weeks, resulting in a 7 mm posterior and 5 mm anterior maxillary transversal increase. Skeletal anchorage facilitated simultaneous RPE and tooth alignment, ensuring accuracy, patient safety, and appliance stability. The presented case shows a scenario in which computer-aided navigation for mini-implant positioning can enhance precision and versatility in challenging anatomical cases.

A Wire Guide for Transosseous Osteosynthesis of the Lumbar Spine in Dogs

Introduction. The transosseous osteosynthesis method is actively used both for pathologies of limb bones and for pathologies of the axial skeleton in dogs. The insertion of the fixators through the bodies of the lumbar vertebrae requires the surgeon’s skill and precision in determining the insertion point and direction. To help novice traumatologists, a wire guide has been developed to insert the wires through the structures of the lumbar spine.Materials and Methods. The study was performed on the basis of the experimental laboratory of the Ilizarov Centre (Kurgan city). As part of the state task, lateral interbody fusion was performed at the L4–L6 level with simultaneous bilateral posterior arthrodesis of the sacroiliac joint and external controlled transosseous osteosynthesis of the lumbar spine in 12 adult mongrel dogs. The insertion of wires through the lumbar vertebrae was performed using a wire guide for osteosynthesis of the spinal column, which was assembled from parts of the Ilizarov fixator. The wire guide consists of standard parts of the Ilizarov apparatus: a beam, one radius bar and nine short bars, threaded rods, bolts, flange nuts and two frame dismountable wire clamps. Next, the fixation of wires on the external supports was carried out according to the accepted method. After osteosynthesis, clinical and neurological studies were performed.Results. After the dog was placed on the operating table, the distances from the external cues to the wire insertion points were calculated according to the radiographs. Two wires were put in the fixator at the required levels and, following the technique, a wire was inserted through the structures of the lumbar vertebra using a wire guide. No iatrogenic injuries were observed when using the wire guide. Clinically, after application of the external fixation device on the lumbar spine, on the next day after surgery and thereafter, preservation of all reflexes and functions of the pelvic limbs was observed. Clinical and neurological studies have confirmed the safe insertion of wires through the bodies of the lumbar vertebrae.Discussion and Conclusion. The use of the wire guide is recommended for a novice traumatologist, proficient in the method of transosseous osteosynthesis. The wire guide allows the doctor to orientate himself when inserting the wires through the structures of the spine, in order to avoid iatrogenic damage to the spinal cord and abdominal organs.

Design, fabrication, and evaluation of single- and multi-level 3D-printed non-covering cervical spinal fusion surgery templates.

Cervical spinal fusion surgeries require accurate placement of the pedicle screws. Any misplacement/misalignment of these screws may lead to injuries to the spinal cord, arteries and other organs. Template guides have emerged as accurate and cost-effective tools for the safe and rapid insertions of pedicle screws. Novel patient-specific single- and multi-level non-covering templates for cervical pedicle screw insertions were designed, 3D-printed, and evaluated. CT scans of two patients were acquired to reconstruct their 3D spine model. Two sets of single-level (C3-C7) and multi-level (C4-C6) templates were designed and 3D-printed. Pedicle screws were inserted into the 3D-printed vertebrae by free-hand and guided techniques. For single-level templates, a total of 40 screws (2 patients × 5 vertebrae × 2 methods × 2 screws) and for multi-level templates 24 screws (2 patients × 3 vertebrae × 2 methods × 2 screws) were inserted by an experienced surgeon. Postoperative CT images were acquired to measure the errors of the entry point, 3D angle, as well as axial and sagittal plane angles of the inserted screws as compared to the initial pre-surgery designs. Accuracy of free-hand and guided screw insertions, as well as those of the single- and multi-level guides, were also compared using paired t-tests. Despite the minimal removal of soft tissues, the 3D-printed templates had acceptable stability on the vertebrae during drillings and their utilization led to statistically significant reductions in all error variables. The mean error of entry point decreased from 3.02mm (free-hand) to 0.29mm (guided) using the single-level templates and from 5.7mm to 0.76mm using the multi-level templates. The percentage reduction in mean of other error variables for, respectively, single- and multi-level templates were as follows: axial plane angle: 72% and 87%, sagittal plane angle: 56% and 78%, and 3D angle: 67% and 83%. The error variables for the multi-level templates generally exceeded those of the single-level templates. The use of single- and multi-level templates also considerably reduced the duration of pedicle screw placements. The novel single- and multi-level non-covering templates are valuable tools for the accurate placement of cervical pedicle screws.

A GAVeCeLT bundle for PICC-port insertion: The SIP-Port protocol.

In the last decade, a new type of brachial port has been introduced in clinical practice, the so-called "PICC-port." This is a brachial port, but inserted according to the methodologies and technologies currently adopted for the insertion of peripherally inserted central catheters (PICCs). Several studies have shown that PICC-port insertion is safe, not associated with any relevant immediate or early complication, and that the expected incidence of late complications is significantly lower if compared to "traditional" brachial ports (i.e. inserted without ultrasound guidance). Furthermore, PICC-ports yield excellent esthetic results and are associated with optimal patient compliance. This paper describes an insertion bundle-developed by GAVeCeLT, the Italian Group of Long Term Venous Access Devices, and nicknamed "SIP-Port" (Safe Insertion of PICC-Ports)-which consists of few evidence-based strategies aiming to further minimize all immediate, early, or late complications potentially associated with PICC-port insertion. Also, this insertion bundle has been developed for the purpose of defining more closely the differences between a traditional brachial port and a PICC-port. The SIP-Port bundle is currently adopted by all training courses on PICC-port insertion held by GAVeCeLT. It includes eight steps: (1) preprocedural ultrasound assessment utilizing the RaPeVA (Rapid Peripheral Venous Assessment) protocol; (2) appropriate skin antiseptic technique and maximal barrier precautions; (3) choice of appropriate vein, in terms of caliber and site; (4) clear identification of the median nerve and of the brachial artery during the venipuncture; (5) ultrasound-guided puncture and cannulation of the vein; (6) ultrasound-guided tip navigation; (7) intra-procedural assessment of tip location by intracavitary ECG or by trans-thoracic echocardiography; (8) appropriate creation and closure of the subcutaneous pocket.

Carbonylative Transformations Using a DMAP-Based Pd-Catalyst through Ex Situ CO Generation.

A phosphine-free, efficient protocol for aminocarbonylation and carbonylative Suzuki-Miyaura coupling has been developed using a novel palladium complex, [PdII(DMAP)2(OAc)2]. The complex was successfully synthesized using a stoichiometric reaction between PdII(OAc)2 and DMAP in acetone at room temperature and characterized using single-crystal X-ray analysis. Only 5 mol % catalyst loading was sufficient for effective carbonylative transformations. "Chloroform-COware" chemistry was utilized for safe and facile insertion of the carbonyl unit using chloroform as an inexpensive CO source in a two-chamber setup. Various value-added pharmaceutically relevant compounds such as CX-516, CX-546, and farampator were synthesized using the technique. Furthermore, the commercially designed COware was engineered to COware-RB setup for sequential one-pot synthesis of indenoisoquinolines (topoisomerase I inhibitors).

Patent umbilical artery in medial umbilical fold: Cadaveric study and clinical implications

Minimally invasive surgery has become one of the most accepted surgical options across the globe. In most laparoscopic surgeries, medial umbilical fold (MUF) containing the umbilical artery (UA) serves as an important landmark for creation of peritoneal flap. 50% of gynaecological laparoscopic injuries occur at the time of entry into the anterior abdominal wall, as it involves blind insertion of the trochar or veress needle in the peritoneal cavity. Any variation in the structures of the anterior abdominal wall may affect the placement location of the trocar, which is a crucial aspect to ease the surgeon’s ability to manoeuvre the abdominal cavity. The presence of cords and/or dense ligamentous structures in the anterior abdominal wall may complicate trocar insertion and restrict the probe movement during laparoscopic procedures. Hence, the aim of the present study was to classify and observe the variations in the MUF in the anterior abdominal wall.The cadavers in the study were formalin fixed through femoral artery perfusion method. Out of the 35 (23 males; 12 female) cadavers (70 MUF), studied, 34 cadavers (69 MUF) followed the pattern of the existing classification proposed by Tokar and Yucel, (2009). However, the right MUF of one male cadaver presented, patent umbilical artery (PUA) associated with a long mesentery. Based on safe presentations for laparoscopic exploration, MUF was given grades. Grades 0 and 1 were categorised as safe as compared to grade 2 and the novel variant observed, based on the morphology of MUF. No significant difference was noted in the occurrence of safe presentations of MUF amongst males and females.MUF with a patent vessel and a mesentery may cause technical difficulties to the surgeon by decreasing the laparoscopic port work space and obscuring the view of lateral pelvic wall during surgeries. Furthermore, persistent UA can compress the ureter and vas deferens resulting in myriad of symptoms ranging from unexplainable flank pain, hydronephrosis to male infertility. Awareness of such variants is of relevance to urologists in determining the cause of these unexplained symptoms and to surgeons in determining the site of safe trocar insertion. The findings also, highlight the fact that anterior abdominal wall anatomy is not mirror image on both the sides.

The relevance of reducing Veress needle overshooting

Safe insertion of the Veress needle during laparoscopy relies on the surgeons’ technical skills in order to stop needle insertion just in time to prevent overshooting in the underlying organs. To reduce this risk, a wide variety of Veress needle systems were developed with safety mechanisms that limit the insertion speed, insertion depth or decouple the driving force generated by the surgeon’s hand on the needle. The aim of this study is to evaluate current surgeons’ perceptions related to the use of Veress needles and to investigate the relevance of preventing overshooting of Veress needles among members of the European Association of Endoscopic Surgery (EAES). An online survey was distributed by the EAES Executive Office to all active members. The survey consisted of demographic data and 14 questions regarding the use of the Veress needle, the training conducted prior to usage, and the need for any improvement. A total of 365 members residing in 58 different countries responded the survey. Of the responding surgeons, 36% prefer the open method for patients with normal body mass index (BMI), and 22% for patients with high BMI. Of the surgeons using Veress needle, 68% indicated that the reduction of overshoot is beneficial in normal BMI patients, whereas 78% indicated that this is beneficial in high BMI patients. On average, the members using the Veress needle had used it for 1448 (SD 3031) times and felt comfortable on using it after 22,9 (SD 78,9) times. The average years of experience was 17,6 (SD 11,1) and the surgeons think that a maximum overshoot of 9.4 (SD 5.5) mm is acceptable before they can safely use the Veress needle. This survey indicates that despite the risks, Veress needles are still being used by the majority of the laparoscopic surgeons who responded. In addition, the surgeons responded that they were interested in using a Veress needle with an extra safety mechanism if it limits the risk of overshooting into the underlying structures.

Safe range of femoral neck system insertion and the risk of perforation

BackgroundInternal fixation of the femoral neck carries a risk of perforation due to the presence of the isthmus of the femoral neck. At present, there are few studies on the safe and risk zones of the femoral neck system (FNS) implantation. This study aimed to recommend the safe range of injection of FNS in the lateral wall of the proximal femur, parallel to the axis of the femoral neck, during FNS treatment of femoral neck fracture (FNF).MethodsFemoral computed tomography (CT) data of 80 patients (male: 40; female: 40) who met the inclusion criteria were collected. Mimics 21.0 software was used to complete the modeling. 3-Matic 13.0 software was used to establish the axis of the femoral neck and its vertical plane, perform the cutting of the femoral neck, and project it on the vertical plane of the femoral neck axis. After matching a rectangle for each projection map, all sample sizes (80 cases) were standardized and superimposed to obtain gradient maps of the safe zone (SZ) and dangerous zone (RZ), thereby securing edge key points and safe FNS insertion range.ResultsIn the 80 samples, the mean diameter of the smallest femoral neck section was 33.87 ± 2.32 mm for men and 29.36 ± 1.92 mm for women. All 80 femoral necks had safe and risky areas. The SZ/S × 100% was 77.59 (± 2.22%), and the RS/S × 100% was 22.39% (± 2.22%). The risk area was composed of four parts: (1), (2), (3), and (4), respectively, corresponding to 3.45 ± 1.74%, 5.51 ± 2.63%, 6.22 ± 1.41%, and 7.22 ± 1.39%. Four marginal key points, perforation risk, and safe ranges (SR) of FNS were analyzed on the lateral wall of the femoral neck.ConclusionsThe SR of FNS placement was recommended by digital simulation. In addition, Regions (3) and (4) posed a higher risk of penetrating the cortex. Using the gradient map of RZ for preoperative evaluation is recommended to avoid iatrogenic perforation.

Acetabular Revision with McMinn Cup: Development and Application of a Patient-Specific Targeting Device.

Surgeries of severe periacetabular bone defects (Paprosky ≥ 2B) are a major challenge in current practice. Although solutions are available for this serious clinical problem, they all have their disadvantages as well as their advantages. An alternative method of reconstructing such extensive defects was the use of a cup with a stem to solve these revision situations. As the instrumentation offered is typically designed for scenarios where a significant bone defect is not present, our unique technique has been developed for implantation in cases where reference points are missing. Our hypothesis was that a targeting device designed based on the CT scan of a patient's pelvis could facilitate the safe insertion of the guiding wire. Briefly, our surgical solution consists of a two-step operation. If periacetabular bone loss was found to be more significant during revision surgery, all implants were removed, and two titanium marker screws in the anterior iliac crest were percutaneously inserted. Next, by applying the metal artifact removal (MAR) algorithm, a CT scan of the pelvis was performed. Based on that, the dimensions and positioning of the cup to be inserted were determined, and a patient-specific 3D printed targeting device made of biocompatible material was created to safely insert the guidewire, which is essential to the implantation process. In this study, medical, engineering, and technical tasks related to the design, the surgical technique, and experiences from 17 surgical cases between February 2018 and July 2021 are reported. There were no surgical complications in any cases. The implant had to be removed due to septic reasons (independently from the technique) in a single case, consistent with the septic statistics for this type of surgery. There was not any perforation of the linea terminalis of the pelvis due to the guiding method. The wound healing of patients was uneventful, and the implant was fixed securely. Following rehabilitation, the joints were able to bear weight again. After one to four years of follow-up, the patient satisfaction level was high, and the gait function of the patients improved a lot in all cases. Our results show that CT-based virtual surgical planning and, based on it, the use of a patient-specific 3D printed aiming device is a reliable method for major hip surgeries with significant bone loss. This technique has also made it possible to perform these operations with minimal X-ray exposure.

Hearing rehabilitation in children with malformed ears: The endoscopic-assisted approach for cochlear implantation

BackgroundCochlear implantation (CI) in children with malformed ears can be challenging through the standard surgical technique. Several alternative approaches have been described. The endoscopic-assisted approach can be chosen as an effective and safe surgical technique, overcoming the drawbacks of the traditional approach. MaterialWe further describe a combined technique based on a limited mastoidectomy with no posterior tympanotomy and an endoscopic transmeatal approach to the round window (RW): the electrode is driven from the mastoid to the middle ear through the attic. ResultsThe concomitant endoscopic assistance allows for improved surgical vision, reducing the risk of major complications. The main advantages of this technique are related to better visualization of the RW for safe insertion of the electrode; avoidance of damage to the facial nerve (FN), due to direct visualization, and sparing the posterior tympanotomy; avoidance of subtotal petrosectomy, if not necessary. ConclusionThe purpose of this article, supported with a video file, is to describe step by step this endoscopic-assisted procedure in a patient with middle ear malformation.

Autonomous medical needle steering in vivo.

The use of needles to access sites within organs is fundamental to many interventional medical procedures both for diagnosis and treatment. Safely and accurately navigating a needle through living tissue to a target is currently often challenging or infeasible because of the presence of anatomical obstacles, high levels of uncertainty, and natural tissue motion. Medical robots capable of automating needle-based procedures have the potential to overcome these challenges and enable enhanced patient care and safety. However, autonomous navigation of a needle around obstacles to a predefined target in vivo has not been shown. Here, we introduce a medical robot that autonomously navigates a needle through living tissue around anatomical obstacles to a target in vivo. Our system leverages a laser-patterned highly flexible steerable needle capable of maneuvering along curvilinear trajectories. The autonomous robot accounts for anatomical obstacles, uncertainty in tissue/needle interaction, and respiratory motion using replanning, control, and safe insertion time windows. We applied the system to lung biopsy, which is critical for diagnosing lung cancer, the leading cause of cancer-related deaths in the United States. We demonstrated successful performance of our system in multiple in vivo porcine studies achieving targeting errors less than the radius of clinically relevant lung nodules. We also demonstrated that our approach offers greater accuracy compared with a standard manual bronchoscopy technique. Our results show the feasibility and advantage of deploying autonomous steerable needle robots in living tissue and how these systems can extend the current capabilities of physicians to further improve patient care.

Computed tomography in measuring electrode insertion angle and depth for cricopharyngeal muscle electromyography.

Electromyography of the cricopharyngeal muscle (CP-EMG) is one of many assessment tools for dysphagia. The key to performing EMG and BTX injections is to precisely locate the cricopharyngeal muscle with an electrode. One of the main difficulties of electrode insertion is the fact that the CP muscle is located deep within the neck. Since a neck computed tomography (CT) can clearly display the CP muscle, thyroid, and blood vessels in the neck, we speculate that a safe concentric needle electrode insertion path to the cricopharyngeal muscle can be simulated with the assistance of the patient's neck CT which clearly marks the angle and depth of concentric needle electrode insertion. The purpose of this study was to explore simulated electrode insertion angles and insertion depths for cricopharyngeal electromyography based on retrospective CT data and present a method of percutaneous localization of the cricopharyngeal muscle based on CT images of the neck. One hundred and forty-three neck CT scans performed between January 2019 and November 2020 were included in this study. With the assistance of the angle and straight-line tools found in the Advantage Workstation 4.4 (GE, HealthCare), simulated insertion angles and depths from the anterior border of the sternocleidomastoid muscle to the cricopharyngeal muscle were obtained. The 143 CT images originated from participants that included 63 males (44.1%) with an average age of 46.2±13.9 years old. The insertion angle, insertion depth, and neck thickness measured on the CT images were 53.2±10.7˚, 24.2±4.1 mm, and 130.1±17.7 mm, respectively. The insertion angle and depth were significantly greater in males than in females (P<0.05), and the insertion angle increased with the age of participants (P<0.05). A generalized linear model (GLM) showed that insertion angle was positively correlated with neck thickness (β=0.14; 95% CI: 0.03 to 0.25) and gender (β=5.08; 95% CI: 1.31 to 8.85), and negatively correlated with age (β=-5.88; 95% CI: -9.54 to -1.62). Insertion depth was only positively correlated with the neck thickness (β=0.11; 95% CI: 0.07 to 0.15). This study indicates that age, gender, and neck thickness are influencing factors for insertion angle, while neck thickness is the influencing factor for insertion depth. The simulated concentric needle electrode insertion method based on CT can assist clinical operation to ensure safety and effectiveness of cricopharyngeal electromyography.

Development of a deep learning model for safe direct optical trocar insertion in minimally invasive surgery: an innovative method to prevent trocar injuries.

Direct optical trocar insertion is a common procedure in laparoscopic minimally invasive surgery. However, misinterpretations of the abdominal wall anatomy can lead to severe complications. Artificial intelligence has shown promise in surgical endoscopy, particularly in the employment of deep learning models for anatomical landmark identification. This study aimed to integrate a deep learning model with an alarm system algorithm for the precise detection of abdominal wall layers during trocar placement. Annotated bounding boxes and assigned classes were based on the six layers of the abdominal wall: subcutaneous, anterior rectus sheath, rectus muscle, posterior rectus sheath, peritoneum, and abdominal cavity. The cutting-edge YOLOv8 model was combined with a deep learning detector to train the dataset. The model was trained on still images and inferenced on laparoscopic videos to ensure real-time detection in the operating room. The alarm system was activated upon recognizing the peritoneum and abdominal cavity layers. We assessed the model's performance using mean average precision (mAP), precision, and recall metrics. A total of 3600 images were captured from 89 laparoscopic video cases. The proposed model was trained on 3000 images, validated with a set of 200 images, and tested on a separate set of 400 images. The results from the test set were 95.8% mAP, 89.8% precision, and 91.7% recall. The alarm system was validated and accepted by experienced surgeons at our institute. We demonstrated that deep learning has the potential to assist surgeons during direct optical trocar insertion. During trocar insertion, the proposed model promptly detects precise landmark references in real-time. The integration of this model with the alarm system enables timely reminders for surgeons to tilt the scope accordingly. Consequently, the implementation of the framework provides the potential to mitigate complications associated with direct optical trocar placement, thereby enhancing surgical safety and outcomes.

Is fluoroscopy-free single-use flexible ureteroscopy a feasible treatment for kidney stones with abnormal renal anatomy?

ObjectiveTo evaluate the feasibility of fluoroscopy-free single-use flexible ureteroscopy procedure in the treatment of kidney stones with abnormal renal anatomy compared to normal renal anatomy. MethodsForty patients with abnormal (Group A) and 80 patients with normal (Group B) renal anatomy who had 10–20 mm renal stones were included. They were treated with LithoVue single-use flexible ureteroscopy (Boston Scientific, Marlborough, MA, USA) after ureteric dilatation by two different size semi-rigid ureteroscopes. This technique was chosen as the aim was to exclude any ureteric pathology (e.g., stone or stricture), confirm the placement of a safe guidewire, avoid balloon dilatation of the ureter, and achieve safe insertion of a 12 Fr, 35/45 cm ureteric access sheath with optical and tactile sign and without fluoroscopy image for guidance. ResultsThe mean ages were 43 years and 45 years in group A and group B, respectively. The mean stone burden was 14.62 (standard deviation: 5.35) mm3 and 14.79 (standard deviation: 4.58) mm3 in Group A and Group B, respectively. There is no significant difference between both groups according to the mean operative time, hospital stay, or stone-free rate. The stone-free rate was about 93% in both groups when the stone size was between 10 mm and 15 mm, and less than 54% when the stone size was more than 15 mm to 20 mm. In the majority of cases (80% in Group A and 92.5% in Group B), we completed the procedure without fluoroscopy. The perioperative complication rates were comparable in the two groups. ConclusionFluoroscopy-free single-use flexible ureteroscopy, when performed by expert urologist, is a feasible treatment for pre-stented patients with kidney calculi of ≤15 mm with abnormal renal anatomy.

Safe Insertion of Arterial Catheters (SIA): An ultrasound-guided protocol to minimize complications for arterial cannulation.

Direct puncture and cannulation of peripheral arteries is frequently performed in critical care and in emergency settings, mainly for hemodynamic monitoring and blood sampling. While there is abundant literature on peripheral arterial cannulation in children and adults, there is still scope for clinical improvements which may impact on patient safety. Although the radial artery is the most frequently utilized access site today, due to its superficial proximity, ease of access, and low risk of adverse events, other sites are sometimes chosen. The authors propose the Safe Insertion of Arterial Catheters (SIA) protocol, an ultrasound-guided insertion bundle applying a systematic approach to arterial cannulation, with a focus on improving insertion practices, reducing procedural complications, increasing the patient safety profile, and improving device performance.

Safe insertion of Veress needle for the induction of pneumoperitoneum: a technical note.

Techniques for the induction of pneumoperitoneum for laparoscopic surgery remain varied as complication risk remains with all techniques. Veress needle is used for the induction of pneumoperitoneum as a technique of preference or when an open technique is considered challenging as in obese patients. We present a novel safe technique for insertion of Veress needle by measuring the depth of the anterior abdominal wall prior to insertion. Accurate measurements help in the safe insertion of the Veress needle for inducing pneumoperitoneum and hence reduce the incidence of intra-abdominal injuries.

How far is the endoscopist to blame for a percutaneous endoscopic gastrostomy complication?

Percutaneous endoscopic gastrostomy (PEG) is a well-established, minimally invasive, and easy to perform procedure for nutrition delivery, applied to individuals unable to swallow for various reasons. PEG has a high technical success rate of insertion between 95% and 100% in experienced hands, but varying complication rates ranging from 0.4% to 22.5% of cases. To discuss the existing evidence of major procedural complications in PEG, mainly focusing on those that could probably have been avoided, had the endoscopist been more experienced, or less self-confident in relation to the basic safety rules for PEG performance. After a thorough research of the international literature of a period of more than 30 years of published "case reports" concerning such complications, we critically analyzed only those complications which were considered - after assessment by two experts in PEG performance working separately - to be directly related to a form of malpractice by the endoscopist. Malpractice by the endoscopist were considered cases of: Gastrostomy tubes passed through the colon or though the left lateral liver lobe, bleeding after puncture injury of large vessels of the stomach or the peritoneum, peritonitis after viscera damage, and injuries of the esophagus, spleen, and pancreas. For a safe PEG insertion, the overfilling of the stomach and small bowel with air should be avoided, the clinician should check thoroughly for the proper trans-illumination of the light source of the endoscope through the abdominal wall and ensure endoscopically visible imprint of finger palpation on the skin at the center of the site of maximum illumination, and finally, the physician should be more alert with obese patients and those with previous abdominal surgery.

Morphometry around Cochleostomy Site to Aid Safe Cochlear Implantation.

In morphologically normal-appearing inner ears, measurements of the distance between the round window and carotid canal (RCD), the maximum diameter of the basal turn of the cochlea next to the round window (BD), and the thickness of the promontory (PT) just lateral to the basal turn may be used as guide for safe cochleostomy and implant placement. From January to March 2022, a cross-sectional observational study was carried out in a tertiary care hospital. The round window to carotid canal distance (RCD), the largest diameter of the cochlea's basal turn next to the round window (BD), and the thickness of the promontory immediately lateral to the basal turn (PT) were measured using CT temporal bone images of 150 persons without cochlear abnormalities. The values obtained were compared using Paired T-test for significance of difference between both genders and sides. A total of 150 participants-75 men and 75 women-with a mean age of 37.5 years were enrolled in the study. With a range of 7.18 mm to 10.52 mm, the mean RCD was 8.84 mm (SD 0.8 mm). The mean BD was 2.27 mm (SD 0.4 mm), while the mean PT was 1.15 mm (SD 0. mm). The values obtained did not differ significantly in both the genders and the right and left sides (p = 0.37 and 0.24, respectively). The present study has defined and calculated pertinent measures at cochleostomy site that will aid safe electrode insertion and prevent misplacement.