Surgeon Comfort Research Articles

Microvascular decompression in trigeminal neuralgia using a robot-assisted exoscope and head-mounted display.

Microvascular decompression (MVD) in trigeminal neuralgia (TN) is currently managed using an operating microscope (OM). Recent experiences with endoscopy-assisted, fully endoscopic, and exoscopic surgery have been described, aiming to improve ergonomics and image quality. The aim of this study was to report the first series of patients operated on with the aid of a robotic binocular exoscope using a head-mounted display (RoboticScope). From September 2023 to March 2024, 9 patients with TN were treated using the RoboticScope. A classic mini-retrosigmoid approach was performed and standard microsurgical techniques were applied. Surgical timing, ergonomics, visual performances, adverse events, and 1-month postoperative pain outcomes were evaluated. All surgeries were completed without shifting to the OM. Surgeon comfort with the RoboticScope was better compared with the OM and visualization was good. No intraoperative adverse events were recorded. The duration of the procedure was significantly shorter with the RoboticScope compared to those using the OM (median 18 vs 34 minutes, p = 0.0001). MVD can be safely and effectively performed using the RoboticScope. Surgeons benefit from better ergonomics, stereoscopic image quality, and shorter surgical duration.

Protocol for Comparing Benzodiazepine-Ketamine and Benzodiazepine-Fentanyl Sedation in Phacoemulsification (BEKEF): A Double-Blind Crossover Non-Inferiority Clinical Trial Study.

Cataract surgery, particularly phacoemulsification, often requires sedation alongside topical anesthesia to manage patient anxiety and discomfort. This protocol proposes a study comparing the efficacy of ketamine and fentanyl, both combined with benzodiazepine, as sedation options for patients undergoing bilateral phacoemulsification. In a randomized, double-blind, crossover clinical trial, at least 48 patients scheduled for bilateral cataract surgery will receive fentanyl with midazolam for one eye and ketamine with midazolam for the other. Sedation levels will be assessed using the Ramsay Sedation Scale, and the SURG-TLX Scale will measure intraoperative difficulties. Secondary outcomes include anesthesia-related complications, pain scores, and patient satisfaction. The primary outcomes, utilizing the Ramsay Sedation Scale, will determine if ketamine combined with a benzodiazepine is non-inferior to fentanyl combined with a benzodiazepine for sedation during phacoemulsification. Secondary outcomes will provide insight into complications, patient and surgeon comfort, and overall satisfaction. This trial will evaluate whether ketamine offers a safe and effective alternative to fentanyl for sedation in cataract surgery, potentially optimizing sedation protocols to enhance patient and surgeon experiences.

Comparison of low-pressure and standard-pressure pneumoperitoneum laparoscopic cholecystectomy in patients with cardiopulmonary comorbidities: a double blinded randomized clinical trial

BackgroundThe benefits of low-pressure laparoscopic cholecystectomy (LPLC) in patients with cardiopulmonary comorbidities remain unclear. This study aimed to explore the feasibility and pulmonary effects of LPLC in patients with cardiopulmonary comorbidities.MethodsThis was a multicenter, parallel, double-blind, randomized controlled trial. Eligible patients included patients with cardiac or pulmonary comorbidities, who were randomly assigned (1:1) to undergo LPLC (10 mmHg) or standard-pressure laparoscopic cholecystectomy (SPLC) (14 mmHg). The primary outcome was postoperative partial pressure of carbon dioxide (CO2). Surgical safety variables, patient recovery, pulmonary function parameters, and surgeon comfort were also compared between groups.ResultsThis study enrolled 144 participants, with 124 participants extracted for the final analysis (62 in LPLC and 62 in SPLC group, respectively). The median postoperative PaCO2 was similar in the LPLC (43.3 mmHg) and SPLC (43.0 mmHg) groups (p = 0.988). Pulmonary parameters including postoperative pH, PaCO2, HCO3, and lactate levels were similar between the two groups. Postoperative base excess was significantly higher in the LPLC group (− 0.6 mmol/L [− 6.9 ~ 7.5] vs. −1.9 mmol/L [− 6.6 ~ 5.4]; p = 0.031). There was no between-group difference regarding intraabdominal operative time, rate of intraoperative bile spillage, blood loss, surgeon comfort during surgery, and conversion rate. Moreover, postoperative major complication rates, the median time to the first flatus, postoperative hospital stay, or mean postoperative visual analog scale score for pain were similar in both groups.ConclusionsThis study found no reduction of partial pressure of CO2 with LPLC compared with SPLC for patients with cardiopulmonary comorbidities. LPLC with a pneumoperitoneum pressure of 10 mmHg may be safe and feasible for these patients when performed by experienced surgeons, although it does not improve pulmonary parameters.RegistrationThe trial is retrospectively registered at ClinicalTrials.gov (NCT04670952) on December 17, 2020.

Neurosurgical applications of the exoscope: from in vitro studies to real-life surgical use in selective dorsal rhizotomy

BackgroundThe microscope has been the gold standard in neurosurgical practice due to its ability to magnify anatomical structures. However, it has limitations, including restricted visual fields and ergonomic challenges that can lead to surgeon fatigue and musculoskeletal issues. The exoscope is an emerging technology that may address these limitations by offering comparable magnification with improved ergonomics. MethodsThis study compares the traditional microscope (KINEVO 900) with a 3D digital exoscope (Aeos Digital Microscope) in visual field width, image sharpness, and ergonomic impact. Visual field assessments were conducted using millimeter paper at a fixed distance, while image sharpness was evaluated using graph paper with pins at different depths. Ergonomic evaluation involved simulating surgical positions using a spine anatomical model. The practical applicability was tested during Selective Dorsal Rhizotomy (SDR) procedures, comparing the surgeon's experience with both devices over 20 consecutive cases. ResultsThe exoscope provided a larger visual field (81.18 cm2) compared to the microscope's (54.10 cm2). Image sharpness was similar for both devices across various depths and zoom levels. Ergonomically, the exoscope allowed the surgeon to maintain a neutral posture while visualizing extreme angles, unlike the microscope, which required significant upper body movement. In SDR procedures, the exoscope improved surgeon comfort and interaction with the operating team, despite an initial learning curve. ConclusionsThe exoscope presents notable advantages in terms of visual field and ergonomics. The exoscope’s ability to facilitate better posture and team communication without compromising image quality makes it an addition to neurosurgical practice, as in SDR.

Fenestrating Versus Reconstituting Subtotal Cholecystectomy: Systematic Review and Meta-Analysis on Bile Leak, Bile Duct Injury, and Outcomes.

Symptoms of gallstone disease are the most common reason for cholecystectomy. Fenestration reduces the likelihood of severe inflammation or scarring after normal treatments are used, and it also enhances control over bile outflow. The goal of reconstituted cholecystectomy is to lessen symptoms like pain and jaundice without undergoing the high-risk procedures associated with more invasive procedures. The reconstituted and fenestrated procedures were assessed by a meta-analysis and systematic review. Of the five studies, 189 (34.2%) had a reconstituted subtotal cholecystectomy, and 363 (65.8%) had a fenestrated subtotal cholecystectomy, which had populations from the United States of America, the United Kingdom, Japan, and Turkey. Two individuals from three trials had bile duct injury, according to three studies. Whereas the fenestrated group reported no bile injury from 236 individuals (0%), the reconstituted group reported two bile duct injuries from 100 patients (2%). The incidence was found to be lower in the fenestrated group (OR 10.81; CI 95% 1.03-113.65; p = 0.39; I2 = 0%) than in the reconstituted group. Four studies revealed 92 cases of bile leaks: 19 out of 155 cases (12.3%) were reconstituted, and 73 out of 351 cases (20.8%) were fenestrated. Between the two groups, there was a significant difference in bile leakage (OR 0.72; CI 95% 0.23-2.32; p = 0.03; I2 = 66%). Two studies reported the establishment of fistulas following surgery in 58 patients in the reconstituted group (5.2%) and 120 patients in the fenestrated group (2.5%) (p = 0.56, I2 = 0%, and OR 0.65; CI 95% 0.12-3.38); however, there was no statistically significant difference between the groups. Following a fenestrated partial cholecystectomy, postoperative bile leakage, fistula development, wound infection, and retained stones are more prevalent. Additionally, we saw that the fenestrated method was being used more frequently for post-operative endoscopic retrogradecholangiopancreatography (ERCP). The subtotal cholecystectomy technique used should be chosen according to the surgeon's comfort level and experience with the various techniques and intraoperative findings, even if the reconstituted procedure could be preferred when feasible. To completely understand the role of each method in the general surgeon's toolkit for treating complex gallbladder (GB) patients, longer-term follow-up studies are still necessary.

Comparison of the effectiveness of 0.5% and 0.25% proparacaine hydrochloride eye drops as topical anesthetics in routine ocular investigations and procedures.

To compare the effectiveness of 0.5% and 0.25% proparacaine eye drops in providing topical anesthesia for routine ocular procedures. 137 patients (274 eyes) were included in this study. They were categorized into two groups. Group A patients received 0.5% and Group B received 0.25% proparacaine drops. A single surgeon performed all the procedures. Intraprocedural and postprocedural pain scores, surgeon comfort, supplemental anesthesia, and vital parameters, were noted. The mean age of the participants was 69.42 years (±12.05). An equal number of procedures were performed (n = 30) for applanation tonometry, lacrimal sac syringing, and A-scan biometry. The other procedures performed were removal of the conjunctiva (n = 5) and corneal foreign bodies (n = 16 per group), corneal scraping (n = 8 per group), and corneal suture removal (n = 18 per group).The mean visual analog pain score during the procedure was 6.9663 in Group A and 8.0803 in Group B (P = 0.66). The mean postprocedural pain score was not significant (P = 0.21). None of the patients required any additional anesthesia during or after the procedure. The average surgeon's experience was 0.152±0.507 in Group A and 0.111±0.402 in Group B (P = 0.07).In Group A, 133 of 137 patients (97.08%), and in Group B, 132 out of 137 patients (96.35%) preferred to use the same anesthetic for future procedures. None of the patients experienced a vasovagal attack or any change in vital parameters. The present study aimed to establish equivalence between two concentrations of proparacaine hydrochloride in which false positive and false negative errors were expected. This is the inherent challenge in the equivalence and inferiority trials. To mitigate these risks, the present study was carefully designed with specific statistical methods, sample size calculation, and rigorous methodology. Nevertheless, it is crucial to recognize that the risk of false positive errors remains, and the results should be interpreted with this in mind. These findings indicated that 0.25% proparacaine is a viable alternative to the standard 0.5% concentration in routine ophthalmic procedures, with the potential for improved patient comfort.

The Effect of Operative Time on Short Term Total Ankle Arthroplasty Outcomes

Category: Ankle; Ankle Arthritis Introduction/Purpose: The incidence of total ankle arthroplasty (TAA) continues to increase as outcomes and surgeon comfort with the procedure improve. There is a paucity of literature investigating the association between operative time (case duration) and postoperative outcomes following TAA. Thus, this study seeks to evaluate the relationship between total operative time and postoperative outcomes following TAA. We hypothesize that increased operative time is statistically significantly associated with an increased risk of 30-day postoperative complications in patients undergoing total ankle arthroplasty. Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried from 2007-2020 to identify 2,133 patients undergoing TAA. Demographics, medical comorbidities, concomitant procedures, hospital length of stay (LOS), and 30-day complication, readmission, and reoperation rates were compared between groups. Patients were excluded based on an operative time greater than 290 minutes (based on Inter-Quartile Range [IQR] proximity rule) to limit the influence of extreme outliers. The cohort was predominantly male (53.8%) and mean patient age was 64.10 (range 19-87) years with a mean BMI of 31.00 (range 17.14-57.78) m/kg2. The mean operative time of the cohort was 149.56 (standard deviation [SD]=49.60) minutes. Results: Demographic characteristics associated with increased operative time were younger age (p <.001), functionally dependent status (p=.041), general anesthesia instead of spinal (p <.001), not having diabetes (p <.001), and not having COPD (p=.005). Multivariate analysis, accounting for these variables, revealed that a 15-minute increase in operative time led to an increase in risk of any complication by 10% (p=.019), wound dehiscence by 30% (p=.005), urinary tract infection by 38% (p=0.009), readmission by 16% (p=0.003), reoperation by 16% (p=0.048), and extended length of stay by 6% (p=0.023). Increased operative (>1 SD above the mean), independently predicted readmission (OR=2.817; 95%CI=1.334-5.951; p=0.007), urinary tract infection (OR=6.410; 95%CI=1.384-29.6866; p=0.018), wound dehiscence (OR=5.127; 95%CI=1.282-20.508; p=0.021), and bleeding requiring transfusion (OR=18.364; 95%CI=1.846-182.682; p=0.013). Conclusion: The study found longer operative time during TAA is associated with a statistically significant increase in complications, including wound dehiscence, urinary tract infection, readmission, reoperation, and increased length of stay. Therefore, surgeons should prioritize measures to reduce operative time when appropriate while optimizing implant placement, deformity correction, and implant stability in TAA.

Third generation versus fourth generation percutaneous hallux valgus correction: A radiographic analysis of outcomes

Percutaneous hallux valgus correction is gaining popularity with foot and ankle surgeons. Various studies have found that the percutaneous approach has increased patient satisfaction and outcomes. The technique of the procedure has some variability with the geometry of the distal osteotomy being the most scrutinized. As of this publication, there has been no comparative studies on the geometry of the distal metatarsal osteotomy. This is a retrospective study of 50 patients who underwent percutaneous correction of a hallux valgus deformity with either a percutaneous transverse or modified chevron osteotomy. The two groups were compared radiographically, preoperatively, and postoperatively using both the intermetatarsal and hallux valgus angles. There is no difference in radiographic outcomes when comparing pre and post-operative IM and HAV angles, and it is the surgeon's comfort levels with a particular geometry of the osteotomy that should determine the approach.

Intraoperative Electromyogram Analysis of Postural Musculature With Three-dimensional Screen Display Versus Operating Microscope in Ophthalmic Surgery: A Clinical Methods Study.

To objectively analyze the effect of three-dimensional screen-based surgery (3D SBS) versus traditional operating microscope (TOM) on operating surgeon posterior chain postural musculature during ophthalmic surgery. We hypothesized an increase in median amplitude of electromyography (EMG) signals when using a TOM compared to 3D SBS. The goal was to assess surgical ergonomics that may contribute to cervical and lumbar spine pathology. EMG analysis was conducted at the University of Cincinnati Medical Center Epilepsy Monitoring Unit. Data were collected in the private practice setting at Cincinnati Eye Institute. This was an institutional review board exempt, nonrandomized, prospective, single center, n = 1 clinical methods study. EMG surface electrodes were affixed to the bilateral splenius capitis, sternocleidomastoid, upper trapezius, anterior deltoid, and quadratus lumborum musculature. EMG data were collected across four sessions consisting of one day each using 3D SBS or a TOM, and two cross-over days. A survey regarding surgeon comfort was administered before, during, and after each surgery, and at the end of each day. EMG cross-over data demonstrated an increase in muscle activation in all measured muscles except the anterior deltoids and right quadratus lumborum with use of a TOM. Survey data showed increased fatigue when using a TOM relative to 3D SBS. EMG demonstrated increased postural muscle activation when utilizing TOM relative to 3D SBS. Similar to previous studies, our survey data suggest inferior ergonomics of TOM relative to 3D SBS. [Ophthalmic Surg Lasers Imaging Retina 2024;55:628-636.].

Short term temporal outcomes after intramedullary fixation of lateral malleolus fractures

Ankle fractures are a common intra-articular trauma. The gold standard treatment for unstable ankle fractures has been Open Reduction Internal Fixation with plating and lag screw(s). Advocates for intramedullary nailing of the fibula note decreased wound complications and greater biomechanical strength. We hypothesized that time to union and time to weight bearing would be decreased with a fibular intramedullary nail compared to prior ankle ORIF literature. A retrospective cohort study was conducted of 65 consecutive ankle fracture patients treated with a fibular nail. The median follow-up time was 18.3 months (IQR: 55.4 – 97.6 days). All patients (100%) achieved clinical and radiographic union at a median of 9.6 (IQR: 54 – 78 days) and 10.8 weeks (IQR: 58 – 95 days), respectively. Post-operatively patients bore weight in walking boot and athletic shoe at a median 6.1 and 9.4 weeks, respectively. Fifteen patients suffered complications (23.1%). Patients with history of prior or active smoking were significantly correlated to longer time to union (p=0.016). Time to union also took 0.43 days longer for each additional year of age (t-value 2.13, p-value = 0.038). Nineteen out of 65 patients (29.2%) participated in the Olerud-Molander Ankle Scoring and the median functional outcome score was 71 (IQR: 56 – 93). While fibular nailing has advanced passive range of motion and weight bearing in our institution, time to weight bearing is clouded by surgeon comfort. Further study comparing fibular fracture healing and weight bearing status in regards to intramedullary and plate fixation in needed. Level of EvidenceIV

Recent patterns in minimally invasive colectomies: Where are we now?

ObjectiveMinimally invasive surgery (MIS) techniques such as laparoscopy and robotic surgery for colorectal resection have been cited as superior to traditional open surgery because of their associations with decreased operating room time, hospital stay length, and postoperative morbidity. Despite these benefits, the open approach remains a common surgical method for colorectal resection procedures. We aim to evaluate the most recent yearly trends in open, laparoscopic, and robotic approaches to provide insight into uptake and present the status of MIS in the field of colorectal surgery. MethodsData were collected from the American College of Surgeons National Surgical Quality Improvement Program targeted colectomy database for the years 2014–2020. The surgical approach was classified as either open, laparoscopic, or robotic. Analysis was performed to identify trends in colorectal surgery categorized by year, patient age, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), and emergency status. ResultsThere was an overall decline in both open and laparoscopic surgery cases (from 38.4% to 34.4% and from 57.4% to 50.8%, respectively) and an overall increase in robotic surgery cases (from 4.2% to 14.8%) from 2014 through 2020. Open surgery was the most common approach for the lowest BMI category (<18.5), highest risk ASA classes (4–5) and most emergent surgeries, whereas robotic surgery rates were negligible for these groups. Laparoscopy was the most prevalent approach for all other categories. ConclusionLaparoscopy was the most prevalent approach in colorectal surgery, although the total case proportions generally tended to decrease. While open surgery remains the approach of choice for emergent procedures, laparoscopic case proportions increased marginally in this category, likely owing to increases in surgeon comfort and continued expansion of laparoscopic training efforts. Importantly, the total prevalence of robotic surgery increased significantly between 2014 and 2020, which may be attributable to advancements in the robotic platform and increases in familiarity and competence with the technology. We anticipate a continuation of these trends in the future and recommend the creation of a national robotic surgery training standard.

Efficacy and safety of Adrenaline-augmented subconjunctival anesthesia in phacoemulsification: A randomized controlled trial.

Cataract surgery, particularly phacoemulsification, has evolved significantly, benefiting millions worldwide. The choice of anesthesia technique impacts patient comfort and procedural efficacy. Subconjunctival anesthesia has emerged as an attractive alternative due to its potential to provide effective pain relief and surgeon comfort during surgery. A different aspect of this study is the inclusion of 1:100,000 adrenaline in 2% lignocaine for subconjunctival anesthesia, which has not been previously studied. A prospective, randomised, comparative study involving 196 eyes evaluated the safety and efficacy of subconjunctival anesthesia in phacoemulsification surgery. Pain scores during surgery and one hour post-surgery, surgeon discomfort, postoperative corneal clarity, complications, and additional anesthesia requirement were assessed. Statistical analysis employed descriptive statistics, t-tests, chi-squared tests, and correlations. Subconjunctival anesthesia significantly lowered pain scores during surgery (p < 0.001) and one hour post-surgery (p < 0.001) compared to topical anesthesia. Surgeon discomfort was notably reduced with subconjunctival anesthesia (p < 0.001). Subconjunctival hemorrhage (p = 0.012) and redness (p = 0.024) were more prevalent postoperatively. No significant difference was observed in intraoperative complications (p = 0.573) or postoperative corneal clarity (p = 0.347). Subconjunctival anesthesia, with the inclusion of 1:100,000 adrenaline in 2% lignocaine, provides effective pain relief and reduces surgeon discomfort during phacoemulsification surgery. The addition of adrenaline extends anesthesia duration. While immediate postoperative effects exist, subconjunctival anesthesia holds promise for enhanced patient comfort and procedural efficiency. Further research is needed to validate its long-term benefits and broader implications in evolving ophthalmic surgical practices.

Non-surgical (liquid) rhinoplasty

Non-surgical (liquid) rhinoplasty (LR) is a common and expanding cosmetic procedure. The use and safety of in-office injectables, as well as surgeon comfort, has led to substantial growth with the procedure. Knowledge of nasal structural and vascular anatomy, injectable filler properties and in situ behavior, and procedural technique are all required for the application of non-surgical rhinoplasty. There is consensus regarding common indications for the procedure, including dorsal augmentation, correction of post-surgical deformities, and improvement of nasal tip symmetry. However, there is substantial variability in filler usage, technique, and patient selection. As with surgical rhinoplasty, the risk of patient dissatisfaction with LR remains high. It is of utmost importance to consider the rise of non-surgeon providers performing these procedures. A thorough understanding of the risks, benefits, and proper patient selection are key for any facial plastic surgeon utilizing LR.

Use of Color Channel Optimization in 3D Heads-Up Vitrectomy vs Standard Operating Microscope for Macular Surgeries.

Purpose: To compare the efficacy and safety of color channel optimization with 3-dimensional (3D) heads-up vitrectomy (3D HUD group) vs standard operating microscope vitrectomy (control group) for macular surgery. Methods: This retrospective multicenter comparative study comprised patients having 25-gauge pars plana vitrectomy for macular hole, epiretinal membrane (ERM), or vitreomacular traction. The minimum follow-up was 6 months. Surgeons completed a subjective questionnaire after each case. The main outcome measures were safety related (dye reinjection rate, macular ERM or internal limiting membrane [ILM] peeling time, endoillumination intensity). Other outcome measures included total surgical time, surgical outcomes, and subjective surgeon-related parameters. Results: The study included 74 eyes (36 in 3D HUD group; 38 in control group). There were no statistical differences in baseline parameters between groups. Significantly more eyes in the control group than in the 3D HUD group required dye reinjection (23.7% vs 5.6%; P = .03). Less time was required for ERM and ILM peeling in the 3D HUD group (both P < .01); however, the total surgical time was the same between groups. Eyes in the 3D HUD group required lower endoillumination (P < .001). There were no between-group differences in the rates of complications. Surgeons said depth perception was better in the control group (P < .001), with no differences in comfort or visibility. Conclusions: 3D heads-up-based color channel optimization for macular surgeries is safe and effective. Although it may have safety advantages, it did not affect the visual or anatomic outcomes or total surgical time and did not improve surgeon comfort or visibility.

Robotically assisted outflow graft anastomosis in minimally invasive left-ventricular assist device implantation: feasibility, surgeon comfort, and operative times in an anatomical study.

Upper hemi-sternotomy is a common approach for outflow graft anastomosis to the ascending aorta in minimally invasive left-ventricular assist device implantation. Right mini-thoracotomy may also be used, but use of robotic assistance has been reported only anecdotally. The aim of our study was to confirm the feasibility of robotically assisted suturing of the outflow graft anastomosis and to assess performance metrics for the robotic suturing part of the procedure. The procedure was carried out in eight cadaver studies by two surgeons. The assist device pump head was inserted through a left-sided mini-thoracotomy and the outflow graft was passed toward a right-sided second interspace mini-thoracotomy through the pericardium. After placement of a partial occlusion clamp on the ascending aorta, a longitudinal aortotomy was performed and the outflow graft to ascending aorta anastomosis was carried out robotically. The procedure was feasible in all eight attempts. The mean outflow graft anastomotic time was 20.1 (SD 6.8) min and the mean surgeon confidence and comfort levels to complete the anastomoses were 8.3 (SD 2.4) and 6.9 (SD2.2), respectively, on a ten-grade Likert scale. On open inspection of the anastomoses, there was good suture alignment in all cases. We conclude that suturing of a left-ventricular assist device outflow graft to the human ascending aorta is very feasible with good surgeon comfort. Anastomotic times are acceptable and suture placement can be performed with appropriate alignment.

Endoscopic transorbital approach to the petrous apex: is orbital rim removal worthwhile for the exposure? An anatomical study with illustrative case.

The endoscopic transorbital approach (ETOA) has been demonstrated to be a feasible ventral route to the petrous apex. Yet, it has been pointed to as a deep and narrow corridor for anterior petrosectomy; particularly, medialization of the instruments can become an issue when targeting the petroclival area. To overcome this limitation, an ETOA with orbital rim removal (ETOA-OR) has been suggested, but not de facto compared, with a transorbital approach without removal of the rim. This addition could augment the surgical exposure and freedom of movement when accessing the petrous apex area. Five human cadaveric heads (10 sides) were dissected. First, anterior petrosectomy was performed via a conventional ETOA (without orbital rim removal). Second, en bloc removal of the orbital rim was performed, with enlargement of the orbital craniectomy and, subsequently, further drilling of the medial petrous apex. Qualitative and quantitative comparisons are provided. An illustrative surgical case is also shown. The transorbital route allowed the authors to perform an anterior petrosectomy in all specimens. The landmarks of bone removal are superposed onto those in the transcranial route. The ETOA-OR increased the volume of craniectomy (from 4.0 mL to 5.5 mL), the lateromedial angulation, and superoinferior angulation of the instruments within the petrous area. Thus, this approach improved the exposure of the medial petroclival area, allowing for an augmented petrosectomy (from 1.4 mL to 2.0 mL, 39.5% increase) and for increased maneuverability, both in the petrous area (from 44.1 cm2 to 76.5 cm2, 73.3% increase) and in the posterior fossa (from 20.2 cm2 to 52.0 cm2, 158% increase). The ETOA-OR was also pragmatically applied to treat a recurrent petroclival meningioma. Complete removal was achieved, the abducens nerve palsy improved, and the trigeminal neuralgia decreased in severity, yet still required medication. The authors provide the first formal anatomical comparison between the transorbital approach with preservation of the orbital rim and a transorbital approach with removal of the rim to access the petrous apex. In addition, an illustrative case is used as a proof of concept and feasibility. According to the authors' data, the ETOA-OR significantly improves surgical exposure and the surgeon's comfort in this deep region. The bony defect can be reconstructed to avoid cosmetic deformities, maintaining the minimally disruptive concept of transorbital surgery.

Fasciotomy following North American pit viper envenomation in Texas 2004–2021

Introduction North American pit viper envenomation occurs over 4,000 times annually in the United States, with polyvalent Fab antivenom being the primary treatment. Fasciotomy is occasionally performed due to concerns about compartment syndrome. We utilized our direct access to Texas Poison Center Network data to create a new snakebite abstraction form and database on relevant available information between 2004 and 2021 and to identify, describe, and estimate the incidence of fasciotomy following pit viper envenomation in Texas. Methods We searched the Texas Poison Center Network database for cases during 2004–2021 using keywords such as fasciotomy, surgery, compartment pressure, and compartment syndrome. Descriptive statistics summarized the data. Results Of 16,911 reported envenomations, 0.69 percent involved fasciotomies (n = 117). Most common bite sites were digits/hands and lower extremities. Patients who underwent fasciotomy were typically male, aged 20–59, and 10 years younger than the total snakebite population. Only 6 percent of reported compartment syndrome cases had a compartment pressure measurement. Antivenom was administered in 101 (86.3 percent) cases, 92 (91.1 percent) of which received only Fab antivenom product. Patients with bites from rattlesnakes (47.9 percent) were associated with most fasciotomies Discussion Our findings suggest a potential increase in snakebite exposures, accompanied by a decrease in fasciotomies. Overall, copperheads constituted the majority of snakebites, but most fasciotomies were from rattlesnake envenomations (47.9 percent). In this cohort, compartment syndrome diagnosis and decisions regarding fasciotomy were primarily based on clinical evaluation/surgeon expertise without compartment pressure measurements. Despite the efficacy of antivenom, only 86.3 percent of patients in our study received antivenom. Conclusions Fasciotomy after North American pit viper envenomation in Texas is uncommon (0.69 percent) and has decreased over time, possibly due to increased antivenom use or surgeon comfort with nonsurgical management.

Is Resectoscopic Hysteroscopy a Dying Art? Creation of an Educational Instructional Video [ID 2683474

INTRODUCTION: Resectoscopic hysteroscopy is a valuable surgical technique for addressing intrauterine pathology. Within our institution, most operative hysteroscopies are performed using newer non-resectoscopic systems, potentially creating a gap in resident surgical education. We developed a novel instructional video demonstrating the components and capabilities of the resectoscopic hysteroscope. Our aim is to assess whether the instructional video increased surgeon comfort using the resectoscopic hysteroscope. METHODS: A pilot cohort study was performed with gynecologic surgery and obstetrics (GS&amp;O) residents and staff physicians at Brooke Army Medical Center. Participants were provided access to the resectoscope surgical set throughout the study, completed a baseline survey assessing surgeon comfort, and then repeated the survey after watching the instructional video. The survey used a 5-point Likert scale with 1) very uncomfortable, 3) neutral, and 5) very comfortable. RESULTS: Of the 20 participants, 85% lacked formal resectoscope training and 45% had no prior resectoscope experience. Prior experience was limited: 55% used it less than five times and 64% had no use in the last year. At baseline, few were comfortable with setup (15%) and troubleshooting (5%). The instructional video significantly increased surgeon comfort with resectoscope setup (P&lt;.001) and troubleshooting (P&lt;.001). Surgeon comfort supervising a resident doubled after the instructional video (33–66%). All participants felt the video was helpful and would recommend it to others (100%; P&lt;.01). Finally, 80% of participants would like more formal training opportunities for other surgical devices. CONCLUSION: This survey demonstrated a gap in surgical experience and comfort using the resectoscope at our institution. The novel instructional resectoscope video improved GS&amp;O resident and staff comfort with setting up and troubleshooting the resectoscope. Staff comfort with supervising a resident using the resectoscope also increased. Future directions include expanding study population to include operating room staff and assessing post-intervention resectoscope utilization rates.

Study of safety and efficacy of sub-Tenon and subconjunctival anesthesia in manual small-incision cataract surgery for hard-grade cataracts.

The purpose was to study the safety and efficacy of sub-Tenon and subconjunctival anesthesia in manual small-incision cataract surgery (MSICS) in patients with hard-grade cataracts. The design of the study was a prospective, observational, and randomized control study. A total of 196 eyes, including 98 eyes in the subconjunctival anesthesia group (group A) and 98 eyes in the sub-Tenon anesthesia group (Group B), undergoing MSICS were enrolled in the study. A single surgeon performed all the surgeries. Intraoperative and postoperative pain scores, patient comfort, surgeon's satisfaction, and intraoperative complications were examined. The mean age of patients in Group A was 66.64 ± 9.95 years and that of patients in Group B was 64.52 ± 9.46. No statistically significant difference was noted in the intraoperative (P = 0.54) and postoperative pain (P = 0.66) scores between the two groups. There was no pain (0 score) in 30% of patients in Group A and 35% of patients in Group B intraoperatively. The average surgical time (P = 0.66) and surgeon's comfort (P = 0.34) were not statistically significant. The mean corneal haze was 0.054 ± 0.12 in group A and 0.065 ± 0.22 in group B (P = 0.45). Two patients in group A required supplemental anesthesia. There were no surgical complications that could compromise visual outcomes. No patients in either group showed alterations in vital parameters or required intravenous sedation. Both techniques of anesthesia are safe and effective for performing MSICS in hard-grade cataracts. However, it is prudent to choose a technique according to the surgeon's requirements.

Single-Center Experience of Resection of 120 Cases of Intradural Spinal Tumors

Our study presents a single-center experience of resection of intradural spinal tumors either with or without using intraoperative computed tomography-based registration and microscope-based augmented reality (AR). Microscope-based AR was recently described for improved orientation in the operative field in spine surgery, using superimposed images of segmented structures of interest in a two-dimensional or three-dimensional mode. All patients who underwent surgery for resection of intradural spinal tumors at our department were retrospectively included in the study. Clinical outcomes in terms of postoperative neurologic deficits and complications were evaluated, as well as neuroradiologic outcomes for tumor remnants and recurrence. 112 patients (57 female, 55 male; median age 55.8 ± 17.8 years) who underwent 120 surgeries for resection of intradural spinal tumors with the use of intraoperative neuromonitoring were included in the study, with a median follow-up of 39 ± 34.4 months. Nine patients died during the follow-up for reasons unrelated to surgery. The most common tumors were meningioma (n= 41), schwannoma (n= 37), myopapillary ependymomas (n= 12), ependymomas (n= 10), and others (20). Tumors were in the thoracic spine (n= 46), lumbar spine (n= 39), cervical spine (n= 32), lumbosacral spine (n= 1), thoracic and lumbar spine (n= 1), and 1 tumor in the cervical, thoracic, and lumbar spine. Four biopsies were performed, 10 partial resections, 13 subtotal resections, and 93 gross total resections. Laminectomy was the common approach. In 79 cases, patients experienced neurologic deficits before surgery, with ataxia and paraparesis as the most common ones. After surgery, 67 patients were unchanged, 49 improved and 4 worsened. Operative time, extent of resection, clinical outcome, and complication rate did not differ between the AR and non-AR groups. However, the use of AR improved orientation in the operative field by identification of important neurovascular structures. High rates of gross total resection with favorable neurologic outcomes in most patients as well as low recurrence rates with comparable complication rates were noted in our single-center experience. AR improved intraoperative orientation and increased surgeons' comfort by enabling early identification of important anatomic structures; however, clinical and radiologic outcomes did not differ, when AR was not used.