Standard Surgical Instruments Research Articles

Fibrin hydrogels as a xenofree and rapidly degradable support for transplantation of retinal pigment epithelium monolayers

Stem cell-derived retinal pigment epithelial (RPE) cell transplantation is currently in phase 1 clinical trials for macular degeneration (MD). A major obstacle in these studies is delivering the RPE as a living, flat sheets without leaving behind foreign materials in the retina. Here we investigate the suitability of using hydrogels made from human blood-derived proteins for RPE transplant. Our data shows that these fibrin hydrogels are rigid enough for use in surgery, support growth of stem cell-derived RPE, and are easily degraded within hours without damage to the RPE sheet. These fibrin hydrogels offer a promising solution to transplant RPE for patients with MD.

Pediatric laryngeal simulator using 3D printed models: A novel technique.

Simulation to acquire and test technical skills is an essential component of medical education and residency training in both surgical and nonsurgical specialties. High-quality simulation education relies on the availability, accessibility, and reliability of models. The objective of this work was to describe a practical pediatric laryngeal model for use in otolaryngology residency training. Ideally, this model would be low-cost, have tactile properties resembling human tissue, and be reliably reproducible. Pediatric laryngeal models were developed using two manufacturing methods: direct three-dimensional (3D) printing of anatomical models and casted anatomical models using 3D-printed molds. Polylactic acid, acrylonitrile butadiene styrene, and high-impact polystyrene (HIPS) were used for the directly printed models, whereas a silicone elastomer (SE) was used for the casted models. The models were evaluated for anatomic quality, ease of manipulation, hardness, and cost of production. A tissue likeness scale was created to validate the simulation model. Fleiss' Kappa rating was performed to evaluate interrater agreement, and analysis of variance was performed to evaluate differences among the materials. The SE provided the most anatomically accurate models, with the tactile properties allowing for surgical manipulation of the larynx. Direct 3D printing was more cost-effective than the SE casting method but did not possess the material properties and tissue likeness necessary for surgical simulation. The SE models of the pediatric larynx created from a casting method demonstrated high quality anatomy, tactile properties comparable to human tissue, and easy manipulation with standard surgical instruments. Their use in a reliable, low-cost, accessible, modular simulation system provides a valuable training resource for otolaryngology residents. N/A. Laryngoscope, 127:E132-E137, 2017.

Analyse fonctionnelle après implantation d’une prothèse d’épaule inversée – comparaison d’une méthode traditionnelle et d’une méthode avec guides personnalisés

Recent studies reported the use of patient-specific guides in aim to improve accuracy in glenoid component positioning for RSA. Most of the guides assessed in the literature have shown promising results on following preoperative plans. However, there are no direct comparisons for glenoid placement and functional outcomes of a standard RSA surgery to a guided RSA surgery. This study was designed to perform RSA surgery from a single surgeon in 20 cadaveric specimens with two methodologies for glenoid baseplate placement: – traditional procedure in using a standard surgical instrumentation; – assisted procedure with a specific-guide according to a preoperative plan. The Biomet Comprehensive RSA was used. In both methods, the surgeon aimed to achieve glenoid baseplate version and tilt placement to anatomical values (0 to 5°). For the guided surgeries, a preoperative plan was performed using an interactive shoulder model (Newcastle Shoulder Model). The plan aimed to maximize impingement free range of motion (abduction, internal and external rotation). Specific guides were manufactured based on these plans by a 3D printer. Pre- and postoperative CTs were used to assess the glenoid orientation as well as the position of the baseplate. The impingement free range of motion was evaluated with a motion analysis system postoperatively. In average both standard and guided RSA surgeries changed the postoperative glenoid version and tilt, but none of the changes were statistically significant (P > 0.05). The guided surgery had a significant impact on the placement of the glenoid baseplate, which was in average 4.2 mm (SD 4.0) more inferiorly compared to the standard procedure (P < 0.05). This difference in baseplate placement had also an effect on the impingement results. The average inferior impingement was recorded at 10.4° (SD 4.3) and superior impingement averaged at 67.9° (SD 4.3) for the guide surgery specimens. It was better than the cadavers that received traditional procedure (average inferior and superior impingement - 29.6° (SD 13.7), 59.3° (SD 1.54), respectively, P < 0.05). Rotation range of motion was 113° (SD 15.0) for the specific guide group and 63.3° (SD 27.4) for the standard guide group (P < 0.05). The specific guides allowed to achieve a more inferior glenoid placement compared to the standard instrumentation. The latter translated in a better functional outcome with a larger free impingement range of motion. The guided surgeries had no effect on the postoperative glenoid alignment but this was expected since the cadaveric specimens had no arthritis or abnormal glenoid deformities.

Subretinal implantation surgery and follow up in pig model

SummaryThe dimension of the porcine eye is similar to the human eye. Combined with an almost identical anatomy to the human eye, the porcine eye makes an excellent model for surgical eye studies. Standard surgical instruments can be used in the pig model, and thereby can new surgical techniques be tested before they are introduced into the human.Evaluation of the surgical outcome can be performed both in vivo, with fundus photo, OCT and mfERG, and ex vivo with histology, immunohistochemistry and molecular technologies.Retinal pigment epithelium cells, biological membranes, artificial polymers and stem cells can be implanted in the pig, but the overall idea with subretinal implantation surgery is to regain function in diseased retina. There are transgenic porcine models of known retinal degenerative diseases and different iatrogenic traumas can simulate retinal disease, but there still need for development of new models.For long time studies mini pigs are essential as modern pigs have been refined to gain weight quickly. Spontaneous regenerative potential and a remarkable resistance to retinal trauma can also invalidate interpretation of the surgical outcome.

New software applications for interchangeable instrumentation in spinal stereotaxis.

Computer image-guided surgery has been widely accepted because it allows the surgeon to track an instrument through unvisualized critical structures of a patient in real-time, thus minimizing the risk of injury. Current spinal and cranial image-guided surgery is, however, limited by the lack of surgical instruments and software applications that would allow rapid interchange of useful instruments to perform the procedures. Most image-guided systems utilize a single standard probe or a few pre-defined instruments that are not necessarily useful for performing the actual surgical procedure. Present image-guided technology for screw placement in spinal surgery utilizes the standard probe only to confirm the entry point location and view the planned trajectory of the screw. The surgeon then resumes the procedure using standard surgical instruments to drill, tap and place screws without the benefit of image guidance. Our clinical laboratory experience with spinal image-guided surgery indicates that there is potential for error between each of these procedural steps of screw placement. Despite accurately locating an entry point, any deviation in the trajectory during drilling of a pilot hole, tapping or screw placement may result in significant errors in screw placement and potential neurovascular injury. We have developed custom software applications and universal hardware adaptation devices for spinal image-guided surgery that allow the use of standard instruments for intraoperative guidance. Utilizing universal dynamic registration hardware and software, standard surgical instruments are adapted for real-time image guided surgery. An array of light emitting diodes can be attached to essentially any rigid instrument with a definable tip and then calibrated to the system for intraoperative use. Laboratory tests using a cadaveric model indicate a difference in accuracy of less than 1.0 mm between the standard probe and a dynamically registered custom instrument and an absolute mean error of less than 2.0 mm for the image-guided system which is clinically insignificant in most cases. This technology is a significant step forward as it allows the surgeon to use a full array of instruments with image guidance and will ultimately make spinal and intracranial surgery safer and more accurate.

A Safe, Effective, and Alternative Technique for Fascial Port Site Closure

Background and Objectives: Fascial closure of the 10-mm and 12-mm port sites is mostly recommended to avoid port site incisional herniation. However, it is often difficult and time-consuming. The aim of this study is to describe a novel technique for fascial closure of laparoscopic port sites. Methods: The fascial closure was performed using straight needle and standard surgical instruments under the laparoscopic visualization in 100 patients. The time duration of the closure, intraoperative and postoperative complications, and patient characteristics were recorded. All patients were examined at postoperative third and sixth months. Results: Intraoperative or postoperative complications were not observed. The mean time for fascial closure was 90 seconds. No port site hernia was encountered at the third month and sixth month postoperative examinations. Discussion: The present technique is safe, effective, easy, and does not require any special instruments. Our technique should be kept in mind during fascial closure of the laparoscopic port sites.

Computer navigation and patient-specific instrumentation in shoulder arthroplasty.

Longevity of total anatomic and reversed shoulder arthroplasty largely depends on accurate correction of glenoid deformity and correct positioning and fixation of the glenoid component. However, the morphology of the scapula is inconsistent, varying degrees of osteoarthritis cause numerous anatomic changes, and standard 2-dimensional imaging and standard surgical instrumentation are imprecise for preoperative planning and execution of glenoid reconstruction. Recently, various authors have shown that preoperative 3-dimensional surgical planning and computer navigation technology may increase the accuracy and repeatability of the implantation of the glenoid component, especially for the position and orientation of the glenosphere and screws in reversed arthroplasty. These novel techniques may allow the surgeon to better define the preoperative deformity, select the optimal implant position, and then accurately execute the plan at the time of surgery. Future studies are needed to determine the long-term effect on functional outcome and cost-effectiveness of computer-assisted technology in shoulder arthroplasty.

Biomechanical analysis of spinal instrumentation systems dedicated to stabilise thoracolumbar fractures: comparison between standard open surgical instrumentation and percutaneous techniques

Thoracolumbar burst fractures represent an important part of spine injuries. Burst fractures are usually caused by dynamic axial compression of spine segments. This leads to an inherent instability and then a spinal cord compression. A surgical treatment is needed for most of the cases to restore bone stability, prevent neurological deterioration and provide pain relief. Classically, posterior instrumentations using rods and pedicle screws are performed under open surgical approaches and eventually associated with corpectomy and/or anterior fixation, in case of anterior column threatening instability. However, the choice of the type of surgery might progressively change in favour of minimally invasive techniques. Indeed, burst fracture stabilization using a short posterior instrumentation and/or vertebral balloon expansion followed by an injection of cement (kyphoplasty), with a pure percutaneous approach, can help to reduce morbidity for these patients. However some keypoints need to be clarified about these techniques with a focus on their biomechanical effectiveness. The purpose of this study was to compare mechanical behaviour under physiological loadings of four types of stabilizations devices, including 2 open instrumentations and 2 percutaneous techniques: classical Posterior Fixation standalone (PF); Posterior Fixation associated with anterior screwed Cage-Plate, following a corpectomy of the fractured vertebra (PF-CP); percutaneous Kyphoplasty standalone (K); percutaneous Kyphoplasty and Posterior Fixation (K-PF).

Clinical application of CO2laser in dentistry: A case series

Surgical lasers have been well accepted by all disciplines of healing arts as useful adjunct to care of patients. The attitude toward their use has changed from one of gee-whiz appreciation for modern technology to that of acceptance of lasers as standard surgical instruments. The applications of Laser technology in dentistry and medicine have now entered the age of sophisticated and rational treatment. This presentation is an attempt to distil our experience with the patients in various periodontal soft and hard tissue procedures such as biopsies, frenectomies, white lesions, vesicullobulous lesions, preprosthetic surgery and dentinal hypersensitivity with the use of Carbon dioxide laser. Laser device used for all intra oral procedures in the presentation is LASERSAT TM Carbon dioxide Laser Manufactured by SATELAC R . Dental Laser safety and protection protocol was strictly followed. All patients responded well to Laser treatment with complete healing of lesions with no post operative complications. No recurrence of any lesion was reported at follow up visits. Lasers have become an integral part of periodontal surgeons' armamentarium. They have proved to be useful as adjunct to conventional treatment modalities in various soft and hard tissue intraoral procedures with better patient acceptance.

Comparison of Acetabular Shell Position Using Patient Specific Instruments vs. Standard Surgical Instruments: A Randomized Clinical Trial

Total hip arthroplasty (THA) survivorship relies largely upon appropriate acetabular cup placement. The purpose of this prospective randomized controlled trial was to determine whether the use of a preoperative 3D planning software in combination with patient specific instrumentation (PSI) results in improved cup placement compared with traditional techniques. Thirty-six THA patients were randomized into standard (STD) or PSI technique. Standard approach was completed using traditional techniques, while PSI cases were planned and customized surgical instruments were manufactured. Postoperative CT scans were used to compare planned to actual results. Differences found between planned and actual anteversion were −0.2°±6.9° (PSI) and −6.9°±8.9° (STD) (P=0.018). Use of 3D preoperative planning along with PSIs resulted in significantly greater anteversion accuracy than traditional planning and instrumentation.

88. Technical aspects and patient’s safety in an OR with a 1.5 T MR

BrainSUITE is equipped with a magnetic resonance machine, a ceiling-linked, last-generation microscope and a suspended and rotating operatory bed that allows real-time evaluations and tests during surgery. The room is designed so that the surgical field is situated outside the 5 Gauss (black) line, allowing the use of standard surgical instruments. Yet an OR provided with a 1.5 Tesla NMR machine poses problems such as the exposure of the surgical personnel to magnetic fields, the set-up of the dedicated materials and the neuroradiological management of the images acquired before, during and after the procedure. The neurophysiology machinery is composed by a work station, the main amplifier and the recording and stimulating needles with cables protected by plastic cable strips. A careful evaluation of the technical aspects during the procedures in BrainSUITE decreases the issues related to personnel and patient’s safety and results in less postoperative complications.

Benefits of using customized instrumentation in total knee arthroplasty: results from an activity-based costing model

The growing demand for total knee arthroplasty (TKA) associated with the efforts to contain healthcare expenditure by advanced economies necessitates the use of economically effective technologies in TKA. The present analysis based on activity-based costing (ABC) model was carried out to estimate the economic value of patient-matched instrumentation (PMI) compared to standard surgical instrumentation in TKA. The costs of the two approaches, PMI and standard instrumentation in TKA, were determined by the use of ABC which measures the cost of a particular procedure by determining the activities involved and adding the cost of each activity. Improvement in productivity due to increased operating room (OR) turn-around times was determined and potential additional revenue to the hospital by the efficient utilization of gained OR time was estimated. Increased efficiency in the usage of OR and utilization of surgical trays were noted with patient-specific approach. Potential revenues to the hospital were estimated with the use of PMI by efficient utilization of time saved in OR. Additional revenues of <euro>78,240 per year were estimated considering utilization of gained OR time to perform surgeries other than TKA. The analysis suggests that use of PMI in TKA is economically effective when compared to standard instrumentation.

Comparison of Patient-Specific Instruments with Standard Surgical Instruments in Determining Glenoid Component Position

Glenoid component malposition for anatomic shoulder replacement may result in complications. The purpose of this study was to define the efficacy of a new surgical method to place the glenoid component. Thirty-one patients were randomized for glenoid component placement with use of either novel three-dimensional computed tomographic scan planning software combined with patient-specific instrumentation (the glenoid positioning system group), or conventional computed tomographic scan, preoperative planning, and surgical technique, utilizing instruments provided by the implant manufacturer (the standard surgical group). The desired position of the component was determined preoperatively. Postoperatively, a computed tomographic scan was used to define and compare the actual implant location with the preoperative plan. In the standard surgical group, the average preoperative glenoid retroversion was -11.3° (range, -39° to 17°). In the glenoid positioning system group, the average glenoid retroversion was -14.8° (range, -27° to 7°). When the standard surgical group was compared with the glenoid positioning system group, patient-specific instrumentation technology significantly decreased (p < 0.05) the average deviation of implant position for inclination and medial-lateral offset. Overall, the average deviation in version was 6.9° in the standard surgical group and 4.3° in the glenoid positioning system group. The average deviation in inclination was 11.6° in the standard surgical group and 2.9° in the glenoid positioning system group. The greatest benefit of patient-specific instrumentation was observed in patients with retroversion in excess of 16°; the average deviation was 10° in the standard surgical group and 1.2° in the glenoid positioning system group (p < 0.001). Preoperative planning and patient-specific instrumentation use resulted in a significant improvement in the selection and use of the optimal type of implant and a significant reduction in the frequency of malpositioned glenoid implants. Novel three-dimensional preoperative planning, coupled with patient and implant-specific instrumentation, allows the surgeon to better define the preoperative pathology, select the optimal implant design and location, and then accurately execute the plan at the time of surgery.

A comparative evaluation of ablations produced by high-frequency coagulation-, argon plasma coagulation-, and cryotherapy devices in porcine liver

Hepatic resection is the only curative treatment option for primary or metastatic malignancies of the liver. Although R1 resections can also lead to prolonged survival, the main surgical goal is complete tumor resection (R0). To achieve this, additional treatment of the resection margin with ablation devices is discussed. Using a porcine in vivo model, we therefore analyzed the effect of different ablation devices on depth and completeness of hepatic parenchymal cell destruction. Swabian-Hall strain pigs underwent ablation on the surface of the right, middle, or left liver lobe using seven different types of high-frequency (HF)-, cryotherapy (Cryo)-, or argon plasma coagulation (APC) devices. Penetration depth and volume were analyzed from histological sections. Severity of parenchymal cell destruction was assessed by a histomorphological score. The greatest penetration depth was achieved with Cryo (10.4 ± 1.7 mm), whereas HF and APC exhibited a smaller penetration depth. However, HF and APC compared to Cryo achieved complete destruction of the intralobular architecture and hepatocellular morphology depending on the application time and the adjusted power. HF, APC, and Cryo applied to the liver surface induce different parenchymal penetration depth and cell destruction. HF and APC are considered to be standard surgical instruments and therefore recommended as standard treatment, whereas Cryo may be used only if particularly deep penetration is required.

Selective automation and skill transfer in medical robotics: a demonstration on surgical knot‐tying

Transferring non-trivial human manipulation skills to robot systems is a challenging task. There have been a number of attempts to design research systems for skill transfer, but the level of the complexity of the actual skills transferable to the robot was rather limited, and delicate operations requiring a high dexterity and long action sequences with many sub-operations were impossible to transfer. A novel approach to human-machine skill transfer for multi-arm robot systems is presented. The methodology capitalizes on the metaphor of 'scaffolded learning', which has gained widespread acceptance in psychology. The main idea is to formalize the superior knowledge of a teacher in a certain way to generate support for a trainee. In our case, the scaffolding is constituted by abstract patterns, which facilitate the structuring and segmentation of information during 'learning by demonstration'. The actual skill generalization is then based on simulating fluid dynamics. The approach has been successfully evaluated in the medical domain for the delicate task of automated knot-tying for suturing with standard surgical instruments and a realistic minimally invasive robotic surgery system.

The Value of Patient-Matched Instrumentation in Total Knee Arthroplasty

The purpose of the current prospective, randomized study was to compare the value of a new mechanically aligned patient-matched instrument system for total knee arthroplasty (TKA) (Visionaire; Smith & Nephew, Inc, Memphis, Tenn) (VIS) to that of standard TKA surgical instrumentation (STD). Twenty-nine primary TKA patients were enrolled and completed surgery (15 VIS and 14 STD). Postoperatively, mechanical alignment was significantly closer to neutral zero in the VIS group (1.7° vs 2.8°; P = .03). Furthermore, the VIS group demonstrated significant reductions in duration of hospital stay, operative time, incision length, and number of used instrument trays ( P < .05). Although additional research is underway to confirm these preliminary results, this evidence suggests that patient-matched instrumentation may support repeatable improvements in surgical accuracy and hospital efficiency.

Faculty evaluation of simulation-based modules for assessment of intraoperative decision making

Previous studies using simulation-based curricula have focused largely on technical skills. We developed a set of simulation-based modules that focus on intraoperative decision making. The objective of this study was to conduct a faculty evaluation of: (1) the usefulness of 4 newly developed, simulation-based modules; (2) the curricular need to train and assess intraoperative decision making skills of the residents; and (3) potential for resident benefit. Simulation-based modules were developed using a cognitive task analysis (CTA) framework. The CTA framework involved faculty interviews focusing on 4 operative tasks that span a range of complexity: (1) creation of small and large bowel stoma, (2) laparoscopic ventral hernia repair, (3) pancreaticojejunostomy, and (4) lymph node biopsy during a mediastinoscopy. An experienced psychologist conducted task-specific, one-on-one interviews with fellowship-trained specialists who perform these operations in their practice. Two faculty were interviewed for each procedure. The interviews lasted a minimum of 1 hour and focused on critical decisions, error prevention, error recognition, and error rescue strategies. The coded interview summaries were used as development guides for the simulation-based learning modules. Each module included locally developed physical models for the simulated operative tasks combined with oral and paper-based questions. The physical models were fabricated in such a way that simulated operative tasks could be performed using standard surgical instruments. To assess the newly developed simulation-based modules, 8 volunteer faculty (50% overlap with the interview pool) participated in a simulation-based exercise during a one-on-one session and then completed an 8-item survey cast on a 5-point Likert agreement scale (1 = strongly disagree, 5 = strongly agree). One of the items was worded negatively to ensure internal consistency. An independent observer recorded faculty session times and assessed faculty engagement in the task (1 = not engaged, 5 = extremely engaged). On average, faculty spent 60 minutes completing each simulation-based exercise. Over 80% of this time was spent performing the operative tasks as they would during a real-life procedure. Mean engagement rating was 4.9 (maximum 5.0, SD = 0.3). Survey results show strong agreement on the importance of training and assessing intraoperative decision making, and that residents would likely benefit from the simulation-based modules. We developed 4 high-fidelity simulation-based modules to assess intraoperative decision making. Faculty agree strongly on the importance and need for additional modules.

A Simple, Effective Technique for Port-Site Closure After Laparoscopy

Fascial closure of port sites represents a challenging issue in laparoscopic surgery. The aim of this article is to introduce a procedure that allows the safe suturing of the abdominal fascia in these wounds. We herein describe a simple technique for fascial closure after laparoscopy using a transcutaneous approach and standard surgical instruments for suture. The method was used in 34 patients with no intraoperative incidents and no port-site hernias during a mean follow-up of 23.9 months (median 20.5, range 5 to 47). The procedure is easy to perform, safe, fast, and inexpensive.

Single Access Laparoscopic Ileocecal Resection in Complicated Crohn’s Disease

Laparoscopic approach to Crohn’s disease has gained good acceptance in selected, high-volume centers. Natural orifice transluminal endoscopic surgery and single access laparoscopic surgery are, at the moment, the latest frontier of minimally invasive surgery. The single laparoscopic access offers excellent cosmetic results (the umbilicus will hide a surgical scar) and may be associated with decreased postoperative pain, shortened postoperative hospitalization, and retains the ability to be converted to standard multiport laparoscopic surgery if needed. It allows to perform surgical procedure with standard surgical instruments although the complexity of the procedure may increase because of the reduced possibility of triangulation. We hereby report the first case of complicated Crohn’s disease approached with this new technique at our institution last September 2009.

Video-assisted mini-thoracoscopy for complete resection of 28 cases of pleomorphic carcinoma of the lung

背景与目的胸腔镜辅助小切口（video-assisted mini-thoracoscopy, VAMT）下完成肺叶切除已有二十年的历史，具有创伤小、术后疼痛轻、肺功能损失少、恢复快等优点，是目前微创胸部外科的发展趋势。本研究旨在探讨胸腔镜辅助小切口肺叶切除术在多形性肺癌治疗中的应用价值。方法应用VAMT行根治性肺叶切除术治疗28例多形性肺癌。采用常规器械与胸腔镜器械相结合直视操作处理肺血管、支气管行肺叶切除，胸腔镜、直视下行纵隔、肺门区淋巴结清扫。结果28例均获成功。无围手术期死亡，术中出血量200 mL-450 mL，平均300 mL；胸管留置时间3 d-8 d，平均5 d，术后总引流量300 mL-800 mL，平均460 mL；术后住院7 d-14 d，平均12 d。随访28例，其中2例患者于术后2个月死亡，其余患者生存均超过1年，3年生存率为60.7%（95%CI: 40.3%-81.1%）。结论VAMT治疗多形性肺癌近期疗效良好，既发挥了微创外科的优越性，又达到了传统开胸手术安全、可靠的效果，清扫淋巴结符合肿瘤手术原则，有很好的应用前景。