Scalpel Incision Research Articles

Endoscopic Closure of Duodenal Perforations By Means of An Over the Scope Clip (OTSC): A Randomized Controlled Porcine Study

Background and study aims: Duodenal perforations during upper endoscopy are rare. However, since invasive endoscopic techniques like EMR, ESD, and EUS are increasingly used, so may the incidence of duodenal perforations. Surgical repair is still the mainstay of therapy but associated with significant morbidity and mortality. Endoscopic closure of such perforations would represent a minimal invasive alternative and was therefore evaluated in a randomized controlled animal study. Material and Methods: In 24 domestic pigs a 1cm large duodenal perforation was endoscopically created using needle knife incision with the animals under general anaesthesia. After randomisation pigs were assigned to either surgical repair (n=12) or endoscopic closure (n=12). Endoscopic repair was performed using a 2T160 double channel upper endoscope (Olympus, Hamburg, Germany), a Twin Grasper and 12mm traumatic Over The Scope Clips (OTSC, Ovesco, Germany). Surgical repair was achieved by open laparotomy. Pressurized leak tests of the perforation closures were performed following necropsy. Additionally pressurized leak test were performed in an ex vivo evaluation of hand-sewn closures of 1cm large scalpel incisions (n=18) and of healthy duodenal tissue (n=18). Tissue for ex vivo evaluation was obtained from freshly killed pigs. Results: Mean time for endoscopic closure was 5 min. (Range 3-8 min., SD 2). No complication occurred during any of the closure procedures. At necropsy and macroscopic examination all OTSC and surgical closures showed complete incorporation and closure of the duodenal needle-knife incisions. Pressurized leak test showed a mean burst pressure of 166 mmHg (Range 80-260, SD 65) for OTSC closures and a mean burst pressure of 143 mmHg (Range 30-300, SD 83) for surgical sutures. Ex vivo hand-sewn sutures of 1cm scalpel incisions exhibited a mean burst pressure of 81 mmHg (Range 43-140, SD 31) and ex vivo duodenal tissue exhibited a burst pressure of 247 mmHg (Range 200-300, SD 35). Ex vivo duodenal tissue burst pressure was significantly higher compared to OTSC closure (p<0.01), in vivo surgical closures (p<0.01), and ex vivo hand-sewn closures (p<0.01). OTSC closures were comparable to surgical closures (p=0.461) and superior to ex vivo hand-sewn closures (p<0.01). In vivo surgical closures were superior to ex vivo hand-sewn closures (p<0.01). Conclusions: Endoscopic closure by means of the OTSC system exhibits comparable results to in vivo surgical sutures and seems suitable to attempt closure of 1cm large duodenal perforations.

Emergency cricothyroidotomy: training is paramount and oxygenation is the aim

We read with great interest Dimitriadis and Paoloni’s [1] study examining the use of four methods of cricothyroid access. The ‘can’t intubate, can’t ventilate’ (CICV) scenario is a rare but potentially devastating one and research aimed at improving its management is welcome. The study raises issues that need highlighting. The authors correctly point out that training in the management of the CICV scenario is likely to have been remote in time and poorly remembered by clinicians. It would be easy for the reader to ignore this issue and concentrate instead on the authors’ findings regarding the optimum device to use without refresher training. The anaesthetic community must not lose focus; training aimed at managing the CICV situation should be the priority [2]. Unfortunately, the authors make no mention of narrow-bore cannula (or ‘needle’) cricothyroidotomy. In a study aimed at determining which method of emergency cricothyroidotomy is the easiest and quickest to perform without refresher training, we find this surprising. Although the study’s participants were emergency physicians, the readership consists predominantly of anaesthetists. Most anaesthetists are more familiar with the use of simple intravenous cannulae than devices such as the Quicktrach (VBM Medizintechnik GmbH, Sulz, Germany) or Minitrach (Smiths Medical Ltd, Hythe, UK) and insertion involves fewer steps. The skills of anaesthetists also favour the use of a cannula over the use of a scalpel [3]. Moreover, intravenous cannulae are ubiquitous in the operating theatre and Emergency Department. The 14G Insyte Cannula (Becton Dickinson UK Ltd, Oxford, UK) is ideally suited as its trochar is sharp and the cannula has a memory allowing the lumen to reform after kinking. Thus, cannula cricothyroidotomy is likely to be an easier and quicker technique for anaesthetists to use than the four techniques evaluated in Dimitriadis and Paoloni’s study [1]. Ideally cannula cricothyroidotomy should be followed by high pressure source oxygenation using a device such as the Manujet III (VBM Medizintechnik GmbH). We feel that such a device should be immediately available in areas where advanced airway management occurs, however oxygen tubing connected to a three-way tap, sourced from an oxygen cylinder or pipeline can maintain oxygenation and thus the patient’s life, if this is not available [4]. It is of course true that needle cricothyroidotomy followed by high pressure source oxygenation does not provide a cuffed large bore airway, an important endpoint in many CICV scenarios. However, the likelihood is that, when a clinician feels that emergency cricothyroid access is necessary, the patient will be critically hypoxic, and cardiac arrest will be imminent. The priority in this situation is rapid oxygenation and conversion to a cuffed airway is of secondary importance. To make an incision in the cricothyroid membrane with a device but then not use that device to oxygenate is to waste valuable time, with potentially fatal consequences. Once the patient has been re-oxygenated, conversion to a cuffed larger bore airway can occur using a Seldinger technique via the cricothyroid cannula. A further limitation of Dimitriadis and Paoloni’s study is that it was performed using an artificial model. Experience in the use of both live animal and artificial models for the CICV situation (personal communication, AMB Heard) makes us feel that plastic models positively discriminate towards large bore cricothyroidotomy cannulae and surgical techniques. For instance while the Quicktrach cuts and dilates easily through synthetic ‘tissues’ in artificial models, it is very difficult to insert through the skin and subcutaneous tissue overlying the cricothyroid membrane of live animals. Also, making a scalpel incision in synthetic tissue leaves a readily identifiable hole in the tracheal wall that is easy to dilate for surgical cricothyroidotomy; but in the live animal model the tissues move relative to each other, thus the hole is difficult to identify and may be obscured by blood. In summary we believe that it is not acceptable for the anaesthetic fraternity to accept the status quo of infrequent training in management of the CICV scenario. In addition we believe that, in this scenario, a narrow bore cricothyroid cannula is the device most likely to save the critically hypoxic patient’s life.

Clinicopathologic Comparison of Radiofrequency Versus Scalpel Incision for Upper Blepharoplasty

To compare the sensation recovery, scar formation, and histopathologic aspects of upper blepharoplasty eyelid incision performed with radiofrequency or scalpel. In a prospective, randomized, blind, comparative, interventional study, 46 eyelids from 23 subjects underwent upper blepharoplasty using radiofrequency incision on one side and a scalpel on the other side. Exclusion criteria were diseases resulting in peripheral neuropathy such as diabetes mellitus, previous upper eyelid surgery or trauma, and history of skin disease. Eyelid sensation was measured preoperatively and 1 week, 1 month, and 6 to 7 months after surgery by a masked observer. Eyelid scar was evaluated by 2 masked observers at final follow-up. Histologic examination for zone and depth of tissue damage, hemorrhage, and inflammatory cell reaction was performed in a masked fashion on 16 eyelids. The mean patient age was 52 years (SD, 5.48 years). Mean aesthesiometry reading significantly decreased in both groups at all follow-up visits in comparison with preoperative measurement (p = 0.000). Mean sensation recovery was insignificantly (0.2 < p < 0.6) higher in the radiosurgery group at all follow-up visits. Mean scar score was insignificantly (p = 0.055 for observer 1, and 0.241 for observer 2) less in the radiosurgery group. The scar score was not significantly different between Fitzpatrick skin types 3 and 4, scored by either observer. The zone and depth of tissue damage on histopathologic examination was greater in the radiofrequency group. However, the hemorrhage and infiltration of inflammatory cells were the same. There was no significant difference between radiofrequency and scalpel incision in upper blepharoplasty with regard to sensation recovery and scar formation. Histologic zone and depth of tissue damage were greater in the radiofrequency group.

Comparison Between Co2Laser and 4.0 MHz Radiosurgery for Incising Skin in White Carneau Pigeons (Columba Livia)

To objectively evaluate the collateral damage associated with radiosurgical and carbon dioxide (CO2) laser devices, a comparative surgical and histologic study was undertaken in white Carneau pigeons (Columba livia). Ten pigeons were anesthetized, and a series of 3 skin incisions were made in the pectoral region by using a 4.0-MHz radiosurgical unit, a CO2 laser, and a scalpel blade (control). A total of 90 skin incisions were microscopically evaluated, and their associated mechanical- and thermal-induced tissue lesions were measured in micrometers. Scalpel incisions invariably resulted in hemorrhage, whereas all laser and radiosurgical skin incisions were essentially bloodless. Scalpel blade incisions were least traumatic (mean [SD] 18 +/- 15 microm) followed by incisions created with radiosurgery (mean [SD] 94 +/- 60 microm) and CO2 laser (mean [SD] 150 +/- 64 microm). Radiosurgery was significantly less traumatic than CO2 laser (P = .003). Radiosurgery appears to offer significant benefits over CO2 laser for avian surgery.

Topical Anesthesia With EMLA does Not Decrease Pain During Vasectomy

Previous studies show conflicting results of the ability of EMLA (eutectic mixture of local anesthetics) to decrease pain during vasectomy. We examined the effectiveness of EMLA cream to decrease pain in patients undergoing bilateral percutaneous no-scalpel vasectomy. A prospective study was performed in which 316 patients used EMLA cream (178) or no topical anesthesia (138) before vasectomy. EMLA cream was applied by patients 1 hour before the scheduled time of surgery. Bilateral percutaneous no-scalpel vasectomy was then performed in the 2 groups with local infiltration of 1% lidocaine into the scrotal wall and vasal sheath. Following the procedure patients were asked to rate their associated pain using a visual analog scale. Statistical analysis was performed using the 2-sided Student t test. Mean patient age was similar in the groups with and without EMLA (39.1 and 39.0 years, respectively). No significant difference in mean visual analog pain scores were noted between the EMLA and control groups (21.5 vs 21.0, p = 0.8). Topical anesthesia with EMLA did not significantly decrease the pain associated with percutaneous vasectomy.

Diathermy versus scalpel incisions for hemiarthroplasty for hip fracture: a randomised prospective trial.

As the age profile of our population expands, we can expect subsequent increase in patients presenting with intracapsular fracture. The onus remains on the surgeon to make all reasonable efforts to find new and innovative means of reducing associated morbidity and mortality of the treatment of these injuries. This challenge is particularly relevant in the elderly and in patients with multiple co-morbidities. In this study, 100 patients were randomly allocated into two groups. One group had dissection to the level of the hip joint under direct diathermy control; the other group had dissection using a scalpel with supplementary electrocautery. Intraoperative total blood loss prior to dissection of the abductors was measured by collecting blood using wound swabs using a local protocol and results were statistically analysed using PROC GLM SAS. We demonstrate a clear advantage in the use of diathermy to create a hip incision showing a significant reduction in wound-related blood loss and a reduction, whilst not statistically significant, in total operative blood loss using diathermy incision. Larger randomised prospective trials are necessary to study the effects of this intervention in a larger patient population so that these end-points can be adequately assessed.

Diathermy versus scalpel incisions for hemiarthroplasty for hip fracture: a randomised prospective trial

Diathermy versus scalpel incisions for hemiarthroplasty for hip fracture: a randomised prospective trial

A preliminary study of healing of diode laser versus scalpel incisions in rat oral tissue: a comparison of clinical, histological, and immunohistochemical results

The aim of this preliminary study was to compare wound healing of rat oral tissues after surgical procedure with diode laser or scalpel. Healing was evaluated histologically, immunohistochemically, and by measurement of 2 nitric oxide synthase isoforms (eNOS and iNOS) as intracellular messenger molecules with important immune functions. The instruments were also evaluated for performance and ease of use. Twenty-four standardized incisions were performed in the hard palate of 12 male Wistar rats. Each rat received 2 incisions on the opposite sides of the palate by using a steel scalpel (control group) and a diode laser (808 nm) at a power output of 4 W and 6 W (test group). Histological and immunohistochemical analyses were performed on tissue samples after 7 and 14 days. The expression of eNOS and iNOS was confirmed by RT-PCR (reverse transcriptase-polymerase chain reaction) and Western blot analysis. Scalpel repair was found to be equivalent to or better than laser repair at the intervals measured. Histological analysis showed that incision wound repair after laser surgical procedure was related to parameters and beam characteristics. Diode laser at a power output of 6 W showed the worst results of tissue repair, especially after 7 days. On the contrary, the extent of epithelial damage lateral to the wound edge and the extent of collagen denaturation were near equal with scalpel incision and laser irradiation at 4 W after 14 days. Biochemical analysis of RT-PCR and Western blots also confirmed histological results with a greater concentration of eNOS and iNOS after 7 days of laser surgical procedure. Clinical and histological findings change over time for different treatments. Diode laser tends to produce more pronounced changes than conventional scalpel surgical procedure (due to tissue thermal damage), with corresponding greater inflammatory reaction and delay in tissue organization only at the initial stage. Thus, long-term histology is critical for predicting treatment results. The clinical use of low-level diode laser for tissue welding of oral mucosa should be investigated further, since it appears to be a good alternative to scalpel incision and suture repair.

Hindlimb Withdrawal Reflexes Evoked by Er:YAG Laser and Scalpel Incisions in Rats

In this study, we assessed the magnitudes of nociceptive withdrawal reflexes evoked by skin and muscle incisions made with steel scalpel and erbium:yttrium-aluminum-garnet (Er:YAG) laser. A few studies have suggested that laser incisions would be less painful than conventional scalpel incisions. Twenty adult male Sprague-Dawley rats were used. Under light barbiturate anesthesia, graded incisions were made into the plantar surface of the animals' hindpaws. Electromyographic (EMG) recordings from a hamstring muscle were used to estimate the nociceptive response. The mean amplitude of EMG activity was significantly higher during incisions made with steel scalpel than with any of the laser irradiation parameters. All laser irradiation parameters produced similar nociceptive responses. Er:YAG laser incisions may be less painful, albeit considerably slower, than scalpel incisions. Laser incisional pain would be more closely related to the mechanical rather than the thermal effect of laser ablation.

Needle vs surgical cricothyroidotomy: a short cut to effective ventilation

Cricothyroidotomy can be performed using three techniques. This literature review seeks to determine which is more appropriate for use in prehospital can't intubate/can't ventilate scenarios where laryngeal mask airways prove ineffective. The common approach of inserting a 14-gauge cannula and using low-pressure ventilation via intermittent occlusion of an opening in oxygen tubing (15 l x min(-1) flow) results in ineffective ventilation within 60 s or less, depending on the degree of airway obstruction. In the absence of a high degree of upper airway obstruction, ventilation can be effective if the cannula is attached to a high pressure (45 psi) jet ventilator, but such devices are rare in UK prehospital practice. A self-inflating bag used with a cuffed tube inserted through a horizontal scalpel incision provides sustained adequate ventilation, has a relatively low complication rate compared to needle cricothyroidotomy and is a skill that can be easily taught to paramedics, nurses and doctors.

Epidermal Development and Wound Healing in Matrix Metalloproteinase 13-Deficient Mice

Degradation of the extracellular matrix, which is an indispensable step in tissue remodelling processes such as embryonic development and wound healing of the skin, has been attributed to collagenolytic activity of members of the matrix metalloproteinase family (MMPs). Here, we employed mmp13 knockout mice to elucidate the function of MMP13 in embryonic skin development, skin homeostasis, and cutaneous wound healing. Overall epidermal architecture and dermal composition of non-injured skin were indistinguishable from wild-type mice. Despite robust expression of MMP13 in the early phase of wound healing, wild-type and mmp13 knockout animals did not differ in their efficiency of re-epithelialization, inflammatory response, granulation tissue formation, angiogenesis, and restoration of basement membrane. Yet, among other MMPs also expressed during wound healing, MMP8 was found to be enhanced in wounds of MMP13-deficient mice. In summary, skin homeostasis and also tissue remodelling processes like embryonic skin development and cutaneous wound healing are independent of MMP13 either owing to MMP13 dispensability or owing to functional substitution by other collagenolytic proteinases such as MMP8.

Lateral thermal damage to rat abdominal wall after harmonic scalpel application

Use of the Harmonic Scalpel transduces a lower amount of energy to tissues, thereby limiting the potential for lateral thermal damage and deep penetration because only low temperatures are reached. The working principle of the Harmonic Scalpel is the transformation of electric power into the longitudinal mechanical movement of the instrument tip. This study aimed to determine the effects from varying durations of Harmonic Scalpel application on the experimental model of rat abdominal wall without skin. After the rats had been anesthetized, and a laparotomy was performed. The Harmonic Scalpel shears were used on the muscular part of the abdominal wall without skin. Different durations of output power 3 were applied: a single 5-s application, a single 10-s application, and a regimen of two sequential 5-s applications. Each animal in each group of 10 received five individual activations, after which the animals were killed. Tissue samples were fixed and embedded in paraffin before sections were taken and stained. Using light microscopy and morphometric imaging analysis, the width of tissue lateral thermal damage was measured from the point of Harmonic Scalpel incision. The rat abdominal wall showed lateral thermal damage over a mean width of 0.0522 +/- 0.0097 mm after a 5-s Harmonic Scalpel application, a damage width of 0.1544 +/- 0.0419 mm after a 10-s application, and a damage width of 0.1020 +/- 0.0430 mm after a 5-s application followed by 5 s of inactivity and another 5 s of activity. These differences in thermal damage width between all the groups are statistically significant. The findings lead to the conclusion that tissue lateral thermal damage after Harmonic Scalpel application at standard output power is greater when a longer sustained period of application is used. Lateral thermal damage also is greater if the Harmonic Scalpel application time is continuous rather than of the same total duration with a brief midpoint interruption.

ELECTRO-CAUTERY VERSUS SCALPEL INCISION IN ABDOMINAL SURGERY

Electrocautery is used increasingly for tissue dissection; fears of excessive scaring and poor wound healing curtailed its use for skin incisions. This study compared electrocautery incision with traditional scalpel incision for abdominal operations in general surgery. Two groups of 62 patients in each were compared prospectively, in one of them electrocautery knife used and in the other traditional scalpel used to incised the abdominal wall layers starting from the skin. Parameters measured included, the time needed to complete the incision with all the necessary hemostasis, the wound length, the macroscopic tissue response, the incidence of infection, the final tissue scar. The electrocautery knife is quicker than the traditional scalpel 4.2Cm/Minute in electrocautery knife versus 2.7Cm/Minute in scalpel; there was little increase in macroscopic tissue response in the first 3-4 days, which do not differ in both groups in the 4th5th day. There was no difference in the incidence of infection and the final scar after one year between the two groups. Electrocautery can be used as alternative to scalpel in creating abdominal skin incisions, with the advantages of shortening the time, and decreasing the blood loss without affecting wound healing or incidence of infection and the scar formation. Incidence.

Comparison of jaw-opening reflexes evoked by Er:YAG laser versus scalpel incisions in rats

Anecdotal remarks suggest that incisions in oral soft tissue would be less painful if performed with laser rather than with scalpel, but such an argument remains to be scientifically validated. Twelve rats received graded incisions to lip, gingiva, mucosa, and tongue with either a pulsed Er:YAG laser (65 mJ/pulse at 10 Hz) or a stainless steel scalpel. The amplitude of the jaw-opening reflex, as measured by the digastric muscle electromyogram, was used to quantify the nociceptive response evoked by the surgical incisions. Except for lip, mean reflex amplitudes evoked by laser were significantly smaller (P < .05) than those evoked by scalpel in all other incision sites. Er:YAG laser surgery may be less painful and therefore require less use of anesthesia and sedation than conventional scalpel surgery in oral soft tissue procedures.

Chondrocyte Death Associated with Human Femoral Osteochondral Harvest as Performed for Mosaicplasty

Autologous osteochondral transfer is an option for the treatment of articular defects. However, there are concerns about graft integration and the nature of the tissue forming the cartilage-cartilage bridge. Chondrocyte viability at graft and recipient edges is thought to be an important determinant of the quality of repair. The purpose of the present study was to evaluate early cell viability at the edges of osteochondral grafts from ex vivo human femoral condyles. Fresh human tissue was obtained from eleven knees at the time of total knee arthroplasty for the treatment of osteoarthritis. Osteochondral cylinders were harvested with use of a 4.5-mm-diameter mosaicplasty osteotome from regions of the anterolateral aspect of the femoral condyle that were macroscopically nondegenerate and histologically nonfibrillated. Plugs were assessed for marginal cell viability by means of confocal laser scanning microscopy. The diameter of the cartilaginous portion of the osteochondral plugs was a mean (and standard error of the mean) of 4.84 +/- 0.12 mm (as determined on the basis of three plugs). This value was approximately 300 microm greater than the measured internal diameter of the osteotome. There was a substantial margin of superficial zone cell death (mean thickness, 382 +/- 68.2 microm), with >99% cell viability seen more centrally (as determined on the basis of five plugs). Demiplugs were created by splitting the mosaicplasty explants with a fresh number-11 scalpel blade. The margin of superficial zone cell death at the curved edge was significantly greater than that at the site of the scalpel cut (390.3 +/- 18.8 microm compared with 34.8 +/- 3.2 microm; p = 0.0286). Similar findings were observed when the cartilage alone was breached and the bone was left intact, with the margin of superficial zone cell death being significantly greater than that obtained in association with the straight scalpel incision (268 +/- 38.9 microm compared with 41.3 +/- 13.4 microm; p = 0.0286). The margin of superficial zone cell death showed no increase during the time-period between fifteen minutes and two hours after plug harvest. A mathematical approximation of the mosaicplasty region suggested that early cell death of this magnitude affects about one third of the superficial graft area. The results of the present study suggest that mosaicplasty, while capable of transposing viable hyaline cartilage, is associated with an extensive margin of cell death that is likely to compromise lateral integration and articular reconstruction.

CHONDROCYTE DEATH ASSOCIATED WITH HUMAN FEMORAL OSTEOCHONDRAL HARVEST AS PERFORMED FOR MOSAICPLASTY

Background: Autologous osteochondral transfer is an option for the treatment of articular defects. However, there are concerns about graft integration and the nature of the tissue forming the cartilage-cartilage bridge. Chondrocyte viability at graft and recipient edges is thought to be an important determinant of the quality of repair. The purpose of the present study was to evaluate early cell viability at the edges of osteochondral grafts from ex vivo human femoral condyles. Methods: Fresh human tissue was obtained from eleven knees at the time of total knee arthroplasty for the treatment of osteoarthritis. Osteochondral cylinders were harvested with use of a 4.5-mm-diameter mosaicplasty osteotome from regions of the anterolateral aspect of the femoral condyle that were macroscopically nondegenerate and histologically nonfibrillated. Plugs were assessed for marginal cell viability by means of confocal laser scanning microscopy. Results: The diameter of the cartilaginous portion of the osteochondral plugs was a mean (and standard error of the mean) of 4.84 ± 0.12 mm (as determined on the basis of three plugs). This value was approximately 300 μm greater than the measured internal diameter of the osteotome. There was a substantial margin of superficial zone cell death (mean thickness, 382 ± 68.2 μm), with >99% cell viability seen more centrally (as determined on the basis of five plugs). Demiplugs were created by splitting the mosaicplasty explants with a fresh number-11 scalpel blade. The margin of superficial zone cell death at the curved edge was significantly greater than that at the site of the scalpel cut (390.3 ± 18.8 μm compared with 34.8 ± 3.2 μm; p = 0.0286). Similar findings were observed when the cartilage alone was breached and the bone was left intact, with the margin of superficial zone cell death being significantly greater than that obtained in association with the straight scalpel incision (268 ± 38.9 μm compared with 41.3 ± 13.4 μm; p = 0.0286). The margin of superficial zone cell death showed no increase during the time-period between fifteen minutes and two hours after plug harvest. A mathematical approximation of the mosaicplasty region suggested that early cell death of this magnitude affects about one third of the superficial graft area. Conclusions: The results of the present study suggest that mosaicplasty, while capable of transposing viable hyaline cartilage, is associated with an extensive margin of cell death that is likely to compromise lateral integration and articular reconstruction. Clinical Relevance: The data suggest that there is a need to improve the plug-harvest technique, which may improve graft-recipient healing and clinical outcomes.

To compare the superiority of electrocautery over the traditional scalpel for skin incisions

Background. This study was designed to assess whether electrocautery can be used for incising skin in various abdominal operations. To date, many trials have been conducted to this regard, but drew inconclusive. Methods. A prospective analysis of 60 patients was done. The age of the patients included in the trial ranged from age 15 to 60 years. The patients were randomized into two groups, namely “incision by scalpel” and “incision by electrocautery.” These populations were further subgrouped into those receiving Flank incisions, those receiving Kocher’s incisions, and those receiving Midline incisions. The parameters used to compare the two primary groups were pain (on the visual analog scale), blood loss from the incision, time taken to make the incision, incidence of postoperative wound infection, and finally the cosmetic appeal upon follow-up. Results. The results showed significantly less blood loss as well as less pain scores associated with electrocautery incisions over scalpel incisions. The electrocautery incisions also took less time to make. Although the time taken and the blood loss did not attain statistical significance in the Midline abdominal incisions, the results still favored use of electrocautery in midline as well as other incisions. Postoperatively, the rates of wound infection were comparable in both techniques (3 in scalpel and 2 in cautery incision.). The cosmetic appeal was superior in the incisions that employed use of electrocautery. Conclusions. The method of electrosurgical incision is seen to be an easily learned, safe, highly effective technique associated with lesser complications. Comparing the three incisions, less pain and less bleed was noted with use of electrocautery. Additionally, there was no incidence of postoperative hematomas, no delay in healing of wounds incised by diathermy and the aesthetic results obtained were superior with minimal scarring. The difference in the incidence of wound infections was not significant. We concluded that use of electrocautery is a suitable method of skin incision; especially when employed for Kocher’s abdominal incision and abdominal flank incisions, although its use in Midline abdominal incisions did not show significant superiority.

Comparison of Mouse Matrix Metalloproteinase 13 Expression in Free-Electron Laser and Scalpel Incisions During Wound Healing

Collagenase-3 (matrix metalloproteinase 13, MMP-13) was employed as a surrogate marker to compare the characteristics of incisional wound repair after surgery with the free-electron laser at 6.1 microm and the scalpel. Using a transgenic mouse strain with the MMP-13 or the COL1A2 promoter driving luciferase expression, we observed MMP-13 and COL1A2 expression, tensile strength, macrophage infiltration, and wound histology for up to 62 d. The scalpel incisions showed higher tensile strength than free-electron laser wounds from days 10 to 22 postwounding, despite minimal collateral thermal damage. After 45 d healing was similar. Trichrome staining confirmed that the scalpel incisions had more dense collagen deposition than free-electron laser incisions up to 36 d postinjury, but at day 45 they became similar. MMP-13 expression was biphasic, with peak activities at days 15 and 37 after injury, whereas free-electron laser wounds showed greater luciferase activity than scalpel wounds. Peak COL1A2 activity preceded the MMP-13 maximum. MMP-13 expression localized predominantly to dermal fibroblasts near the epidermis at day 15, and in the region of the deep dermis, muscle, and fascia at day 37 postwounding. Migrating muscle cells, but not all skeletal muscle cells, also expressed MMP-13. Free-electron laser incisions contained more macrophages than scalpel wounds at days 2 and 7 postinjury, suggesting that free-electron laser irradiation exacerbated the inflammatory response and thereby stimulated MMP-13 expression. These results revealed that MMP-13 was involved in a series of coordinated events during wound healing, not only the long-term remodeling of wound connective tissue, but also skeletal muscle repair. MMP-13 activity in vivo may correlate with the extent of tissue damage.

Ventriculosagittal Sinus Shunt Placement: Technical Case Report

Determining an appropriate site for distal catheter placement for ventricular shunting for some hydrocephalic patients can be difficult. We describe a simplification of the technique for sagittal sinus shunt placement using a guidewire. A 20-month-old infant with hydrocephalus secondary to Alexander's disease developed erosion of her parieto-occipital ventriculoperitoneal shunt reservoir through an occipital decubitus scalp ulceration. Her hydrocephalus was temporarily treated with a ventriculostomy; however, she developed pneumatosis intestinalis while in the hospital. The patient underwent placement of a ventriculosagittal sinus shunt. The ventricular catheter and shunt valve were placed through a burr hole at Kocher's point, and the distal end of the catheter was placed in the superior sagittal sinus by using the Seldinger technique. Ventriculosagittal sinus shunting may be used as an alternative to traditional methods for patients for whom distal shunt placement is problematic. Our technique has the theoretical advantage of reducing the risks of blood loss or air embolism by not requiring a scalpel incision into the sinus.

The role of large extracellular matrix glycoproteins in regenerating laser-treated tissue

The distribution of large extracellular matrix glycoproteins tenascin, cellular fibronectin and laminin was studied in healing CO 2 laser, scalpel incision and excision wounds of rat tongue dorsal mucosa in 153 rats over a period of 42 days by indirect immunofluorescence microscopy using mono- and polyclonal antibodies. A local increase in tenascin distribution in the basement membrane zone indicated that this protein was important to epithelial cell proliferation and movement. The increased amount of cellular fibronectin in the provisional stromal matrix showed that this protein was a crucial component in healing wounds. An increased expression of laminin in the basement membranes of the wound borders, blood vessel walls and nerve structures suggested that this protein could guide and stimulate the regenerating epithelial cells. In laser wounds, re-epithelialization seemed to progress upon the laminin-containing structures, although the formation and subsidation of laminin back to normal seemed to be somewhat slower. The results show that long observation times are needed when studying laser wound healing.