Surgeon Comfort Research Articles

Displaced Clavicle Fractures in Adolescents

There is an increasing trend toward stabilization and fixation of markedly displaced midshaft clavicle fractures in adolescents. Recent studies in the adult literature have shown a greater prevalence of symptomatic malunion, nonunion, and poor functional outcomes after nonsurgical management of displaced fractures. Fixation of displaced midshaft clavicle fractures can restore length and alignment, resulting in shorter time to union. Symptomatic malunion after significantly displaced fractures in adolescents may be more common than previously thought. Adolescents often have high functional demands, and their remodeling potential is limited. Knowledge of bone biology and the effects of shortening, angulation, and rotation on shoulder girdle mechanics is critical in decision making in order to increase the likelihood of optimal results at skeletal maturity. Selection of fixation is dependent on many factors, including fracture type, patient age, skeletal maturity, and surgeon comfort.

Retraction Note: Graft fixation alternatives in anterior cruciate ligament reconstruction

Reconstruction of the anterior cruciate ligament is a frequently performed procedure that has had outstanding results. Outcomes are dependent upon an early postoperative physical therapy program that stresses early motion. Early rehabilitation demands rigid intraoperative mechanical fixation of the graft since therapy begins before biologic incorporation of the graft in the bone tunnels. Regardless of the graft substitute chosen, many methods of fixation are available. The best fixation technique depends on several factors, including graft choice and surgeon comfort. The figures are not documented in this paper. We review current methods available for graft fixation in anterior cruciate ligament surgery.

Editorial Comment

The authors presented a manuscript looking at outcomes between live robotic surgery and “standard” robotic cases, here, robot-assisted partial nephrectomy (RAPN). This is a timely manuscript given the increasing number of broadcast surgeries through meetings and courses in urology as well as other fields. The literature dealing with this issue is quite thin with just a few studies, mainly in the gastrointestinal and cardiovascular fields (as referenced by the authors). The study is well framed and the variables controlled as much as possible in this retrospective study. The first issue the article addresses is the concept that cases selected to be broadcast are carefully selected, thus not comparable to “everyday” practice. Table 1 demonstrates that the live broadcast group was quite similar to the standard group in important details, such as R.E.N.A.L. nephrometry score, body mass index (BMI), lesion size, sex ratio, etc. The “standard” cases were part of a consecutive series by the authors. So, whereas certainly some bias may exist in selecting these patients for live surgery, the groups seem comparable. It is also noted that all surgeons had performed over 100 RAPNs. What we do not know is when, in each surgeon's experience, that the live cases were performed. The number of cases to reach a comfort level high enough to do live surgery will likely be different for each surgeon, but knowing a “number” may be helpful for insight into the learning curve for this procedure. Live Robotic Surgery: Are Outcomes Compromised?UrologyVol. 80Issue 3PreviewTo determine the outcomes of patients undergoing robotic partial nephrectomy as a live broadcast surgery compared to a cohort treated without observers. Full-Text PDF ReplyUrologyVol. 80Issue 3PreviewWe thank Dr. Strup for his insightful comments. As discussed in the article, surgeon comfort with the proceedings surrounding a live surgical demonstration is paramount to its success. While obtaining this level of confidence may be a trait inherent to a given surgeon, it is certainly influenced by experience. In the present series, the average number of robot-assisted partial nephrectomies (RAPNs) performed before a live surgery was 51.3 cases. However, one must use caution when viewing any number as a surgical benchmark to be achieved before performing live surgery. Full-Text PDF

Reply

We thank Dr. Strup for his insightful comments. As discussed in the article, surgeon comfort with the proceedings surrounding a live surgical demonstration is paramount to its success. While obtaining this level of confidence may be a trait inherent to a given surgeon, it is certainly influenced by experience. In the present series, the average number of robot-assisted partial nephrectomies (RAPNs) performed before a live surgery was 51.3 cases. However, one must use caution when viewing any number as a surgical benchmark to be achieved before performing live surgery. All 5 participating surgeons have extensive experience in laparoscopic partial nephrectomy and robot-assisted radical prostatectomy, which certainly augmented their comfort while performing live RAPNs. Therefore, their “learning curve” to performing a successful live RAPN may have been significantly truncated. Ultimately, it is our belief that live surgery should be reserved for experienced surgeons who are equipped to deal with the increased tension and emotional stress inherent to such demonstrations. Editorial CommentUrologyVol. 80Issue 3PreviewThe authors presented a manuscript looking at outcomes between live robotic surgery and “standard” robotic cases, here, robot-assisted partial nephrectomy (RAPN). This is a timely manuscript given the increasing number of broadcast surgeries through meetings and courses in urology as well as other fields. The literature dealing with this issue is quite thin with just a few studies, mainly in the gastrointestinal and cardiovascular fields (as referenced by the authors). The study is well framed and the variables controlled as much as possible in this retrospective study. Full-Text PDF

Comparison of Breast Augmentation Incisions and Common Complications

Incisions for insertion of breast implants are most commonly placed in the inframammary fold, areola, or axilla. Previous studies have evaluated selection of incision location preoperatively and for nipple-areola complex sensation retention after primary augmentation mammaplasty. This study compares the most common postoperative complications for each incision location in patients who underwent primary breast augmentation. A retrospective chart review was performed on 619 patients who underwent primary breast augmentation, excluding simultaneous mastopexy, within a single group practice from July 1994 to June 2009. Incision location, postoperative complications (capsular contracture, hematoma formation, rippling, infection, and rupture), and total reoperation rates were recorded. Incision locations were also compared with respect to implant fill type (saline or silicone gel) and pocket location (subglandular or submuscular). A statistically significant association was identified between total reoperation and incision location (p = 0.0054). The highest rate of total reoperation occurred when using an inframammary fold incision compared to either the transaxillary or periareolar. This relationship with total reoperation was not attributed to the five complications analyzed, but rather with patient desire for size/style change, asymmetry, or ptosis. No statistically significant association was observed between incision location and specific complications such as capsular contracture, rippling, implant rupture, hematoma, or infection. None of the five complications analyzed correlated with incision location. The data generated from this study will assure the surgeon that all three incision locations are safe. Preoperative examination, patient preference, and surgeon comfort should remain the mainstays of incision planning in augmentation mammaplasty. This journal requires that authors assign a level of evidence to each article.

Graft Patency After Off-Pump Coronary Artery Bypass Surgery

For the past few decades, coronary artery bypass grafting (CABG) using cardiopulmonary bypass and cardioplegic arrest (ONCAB) has been considered the standard for surgical coronary revascularization. Since the mid-1990s, there has been increased interest in avoiding the use of extracorporeal circulation and the bypass circuit during construction of the distal anastomoses. This interest in off-pump coronary artery bypass grafting (OPCAB) has, in large part, been because of the detrimental effects of cardiopulmonary bypass; specifically the inflammation response, adverse neurological outcomes, and the multi-system organ injury that may occur. Importantly, OPCAB has been associated with reduced myocardial enzyme release, lower transfusion requirement, reduced pulmonary and renal complications, shorter length of stay, and lower cost.1,2 Article see p 2827 Currently, OPCAB accounts for approximately 20% to 25% of coronary artery bypass cases in the United States and has not changed significantly for ≈5 years. It is plausible that the lack of compelling evidence for a mortality benefit of OPCAB in randomized, controlled trials has been an impediment to broader adoption of this strategy in routine practice.3 Furthermore, many surgeons consider OPCAB more technically challenging, especially when grafting the lateral wall. For certain subgroups of patients, such as patients undergoing single- and double-vessel coronary bypass or high-risk candidates, it would appear intuitive that avoiding the systemic effects of cardiopulmonary bypass, as well as aortic manipulation, would reduce the incidence of specific complications.4 However, until definitive studies prove an advantage of one technique over the other, the preferred approach will ultimately be dictated by the surgeon's comfort level and expertise. Patient outcomes with the use of OPCAB techniques have been studied in numerous prospective randomized trials1–2,5–7 and in retrospective reviews of individual institutions and large society- and Veterans Affairs–based databases reporting that …

Ropivacaine for Unilateral Spinal Anesthesia; Hyperbaric or Hypobaric?

The aim of this study was to compare the unilaterality of subarachnoid block achieved with hyperbaric and hypobaric ropivacaine. The prospective, randomized trial was conducted in an orthopedics surgical suite. In all, 60 ASA I-III patients scheduled for elective total knee arthroplasty were included in the study. Group Hypo (n=30) received 11.25mg of ropivacaine (7.5mg.mL(-1)) + 2mL of distilled water (density at room temperature was 0.997) and group Hyper (n=30) received 11.25mg of ropivacaine (7.5mg.mL(-1)) + 2mL (5mg.mL(-1)) of dextrose (density at room temperature was 1,015). Patients in the hyperbaric group were positioned with the operated side down and in the 15° Fowler position, versus those in the hypobaric group with the operated side facing up and in the 15° Trendelenburg position. Combined spinal epidural anesthesia was performed midline at the L(3-4) lumbar interspace. Hemodynamic and spinal block parameters, regression time, success of unilateral spinal anesthesia, patient comfort, surgical comfort, surgeon comfort, first analgesic requirement time, and adverse effects were assessed. Time to reach the T10 dermatome level on the operated side was shorter in group Hyper (612.00±163.29s) than in group Hypo (763.63±208.35s) (p<0.05). Time to 2-segment regression of the sensory block level on both the operated and non-operated sides was shorter in group Hypo than in group Hyper. Both hyperbaric and hypobaric ropivacaine (11.25mg) provided adequate and dependable anesthesia for total knee replacement surgery, with a high level of patient and surgeon comfort. Hypobaric local anesthetic solutions provide a high level of unilateral anesthesia, with rapid recovery of both sensory and motor block, and therefore may be preferable in outpatient settings.

Current Status of Robot-Assisted Laparoscopic Ureteral Reimplantation and Reconstruction

We reviewed the literature on robot-assisted laparoscopic ureteral reimplantation and provide general considerations for indications, perioperative management, and steps of the case. Robot-associated laparoscopic procedures are becoming more common in urologic surgery. The uses of the da Vinci robot (Intuitive Surgical, Sunnyvale, CA) are expanding as well. We examine the use of the robot in distal ureteral reconstruction. A PubMed search was performed using keywords "robot" and "ureter," "distal ureter," "ureteral reimplant," "psoas," and "Boari." Papers that discussed proximal ureteral reconstruction and nephroureterectomy were excluded. A total of nine papers were relevant. Personal experience was also drawn upon. Distal ureteral reconstruction using the robotic technique is feasible, safe, and becoming more and more prevalent as surgeon comfort with the robot increases.

Qualitative and Quantitative Differences between 2 Robotic Thyroidectomy Techniques

Two distinct remote access robotic thyroidectomy techniques were implemented in a high-volume endocrine surgery practice. Important technical and clinical differences were observed and are described. Cross-sectional study with planned data collection. Thyroid center. A panel of demographic and clinical parameters was captured in a series of patients undergoing 1 of 2 robotic thyroidectomy techniques (robotic axillary thyroidectomy [RAT] or robotic facelift thyroidectomy [RFT]). Particular attention was paid to time of surgery, ease of dissection, complications, use of drains, and length of stay. Fifteen robotic hemithyroidectomies were accomplished by either RAT (n = 5) or RFT (n = 10). The duration of surgery for RAT averaged 196 ± 38.1 minutes, with no clear downward trend observed. The mean time of surgery for RFT was 156.9 ± 16.3 minutes, with a steady trend toward shorter surgical times. All 5 RAT patients were managed with drains and as inpatients (length of stay = 1.0 days); 9 of 10 RFT patients were managed without drains and on an outpatient basis (the first patient had a drain and was observed for 1 night in the hospital; P < .001). Ease of surgery, familiarity with anatomic dissection planes, and surgeon comfort level all favored RFT. In an early experience of a small series of patients, a more rapid learning curve reflected by shorter operative times was observed with robotic facelift thyroidectomy compared with robotic axillary thyroidectomy. Furthermore, the vast majority of patients could be managed as outpatients, which represents one of several apparent advantages.

Surgery of the Chin

With a clear understanding of the anatomy and thorough patient evaluation, a safe and effective surgical plan can be constructed. There are several options available to reduce or augment the chin, and often the choice is based on patient presentation and surgeon comfort and familiarity with a given procedure.

Regional anaesthesia for surgical repair in selected open globe injuries in adults

PurposeTo determine whether the combination of topical, intracameral and facial nerve blocks would produce adequate analgesia for repair of open globe injuries without increasing intraocular tension. MethodsA comparison of combined O’Brien’s block (facial nerve block), topical ropivacaine and intracameral lignocaine versus peribulbar block in 100 randomly selected cases of traumatic corneal rupture. Patients were randomly divided in two groups of 50 each based on those receiving the combined approach (Group T) and those undergoing peribulbar block (Group P). Patients were excluded if there was rupture with significant scleral extension, the interval between trauma and presentation greater than 2h, presence of hypopyon, rupture with significant corneal oedema, expulsion of intraocular contents with a collapsed globe and monocular cases.The effect of the anaesthetic was compared by patient comfort and surgeon comfort, the incidence of vitreous prolapse and the requirement of incremental sedation. The Student’s “t” test, the “Z” test, and Chi Square tests were used where appropriate. P<0.05 was considered statistically significant. ResultsThe average patient comfort in Group P was 5.67% greater than Group T (P>0.05). The average surgeon comfort and patient comfort between groups were similar (P>0.05, both comparisons). Incremental sedation was required in 16% of patients in Group T compared to 8% in Group P (P=0.218363). The total sedation dosage required for each group was similar. The incidence of vitreous prolapse was statistically significantly higher by 14% in Group P compared to Group T (P=0.03731). ConclusionsOur combined technique proved as efficacious as peribulbar block in providing adequate local anaesthesia and reducing the incidence of vitreous prolapse. We recommend greater use of this technique for repair of open globe injuries especially in locations where full time anaesthesia services are not available.

Successful Descemet’s stripping automated endothelial keratoplasty for congenital hereditary endothelial dystrophy in a pediatric patient

Endothelial keratoplasty, particularly Descemet’s stripping automated endothelial keratoplasty (DSAEK), has quickly become the standard of care for adult endothelial dysfunction [1–4]. As long-term follow-up data becomes available and surgeon comfort with the procedure increases, DSAEK is continually being applied to new diseases. Pediatric cases of endothelial dysfunction treated by DSAEK have already been reported for the treatment of bullous keratopathy following cataract surgery and Descemet’s membrane damage due to traumatic birth injury [5, 6]. Pineda et al. [7] reported a single case of attempted DSAEK in a 7-year-old boy with congenital hereditary endothelial dystrophy (CHED) which was converted to penetrating keratoplasty due to poor visualization and difficulty stripping the host Descemet’s membrane. The authors questioned whether DSAEK could be successfully performed for CHED. Mittal et al. [8] recently reported the first successful case of DSAEK in a 19-year-old male with CHED. To date, no successful reports of DSAEK as treatment for CHED in the pediatric age group have been published. In this paper, we report our successful technique and results in performing DSAEK for each eye of an eight-yearold child with CHED.

Phacoemulsification under topical anesthesia alone versus topical anesthesia with intracameral lodocaine injection

Purpose: goal was to study the intra-operative pain experienced by patients when topical alone was used compared with topical anesthesia with intracameral lidocaine injection. To study the patient and surgeon satisfaction when the two different types of anesthesia are used. Setting/Venue: Regional Institute of Medical Sciences, Imphal, India. Methods: 40 patients of cataract divided into two groups, A and B each containing 20 patients were included in the study. phacoemulsification was performed on group A under topical anesthesia with proparacaine hydrochloride 0.5% and on group B under topical anesthesia along with intracameral infiltration of 2% lidocaine. Un co-operative patients, those with previous ocular trauma and corneal opacities were excluded from the study. All patients in both groups were operated by the same surgeon. The surgeon and patient satisfaction score was entered in a standardized proforma. Results: 6 patients in group A felt no pain while 3 patients felt pain upto the extent that 0.5 cc of 2% lidocaine was needed to infiltrate at the phaco port site. Thereafter the procedure was competed comfortably and pain free. Mean phacoemulsification time was 2.5 minutes and mean operation time was 30 minutes. In group B, the patients were operated after infiltration of 0.5 cc 2% lidocaine injection. 16 patients were operated pain free and 4 patients had mild pain. The mean phacoemulsification time was 2.2 minutes and the mean operation time was 30 minutes Conclusions: The intracameral infiltration of 2% lidocaine injection with topical anesthesia is superior to topical anesthesia with proparacaine hydrochloride alone during phacoemulsification ensuring patients and surgeons comfort. None of the patients in any group showed the complication as sometimes seen in periocular and retrobulbar anesthesia

Infratentorial supracerebellar resection of a pineal tumor using a high definition video exoscope (VITOM®)

A telescope based high definition (HD) video system (VITOM®, Karl Storz GmBH & Co., Tuttlingen, Germany) has recently been proposed as an alternative to the operating microscope for microneurosurgery. It remains unclear which clinical situations will benefit from its advantages. In light of the uncomfortable surgeon position and fatigue often associated with pineal region surgery, we used the VITOM® HD exoscope system to perform an infratentorial supracerebellar resection of a pineal tumor. The VITOM® dramatically improved surgeon comfort and ease of operating by permitting the surgeon to stand upright and in a comfortable position and avoid the need to extend the arm or assume an awkward. position commonly encountered when using the microscope for these approaches. The marked improvement in surgeon comfort afforded by the VITOM® exoscope indicates that this system may have significant advantages over traditional microscope based surgery for tumors of the pineal region approached using an infratentorial supracerebellar approach.

Ophthalmic viscosurgical device–assisted incision modification for the big-bubble technique in deep anterior lamellar keratoplasty

We describe several simple modifications of the big-bubble technique to improve surgeon comfort and reduce the risk for complications, with emphasis on our ophthalmic viscosurgical device (OVD)-assisted incision technique. By coating the overlying stroma with OVD prior to entering the big bubble, space is maintained in the pre-Descemet plane. This prevents collapse of the big bubble and allows an air-OVD exchange. We have successfully used this technique in 72 consecutive cases without a perforation during the entry incision to the bubble space of the DALK procedure. No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Simple, Effective, Supine Positioning for the Retrosigmoid Approach

The retrosigmoid approach is often used for posterior fossa pathology. Many variations of positioning exist. Here, we report a simple, safe, and quick positioning technique which maximizes patient safety, surgeon comfort, and intraoperative view. We reviewed the senior author's prospective surgical database for retrosigmoid approaches to the posterior fossa and noted any complications or difficult exposures. Over 970 retrosigmoid operations were performed over the course of 19 years. There were no positioning-related complications and no aborted surgeries due to inadequate exposure. No normal cerebellum was ever resected to increase exposure and no retractor was ever used in the posterior fossa. Supine positioning for the retrosigmoid approach is an excellent and safe positioning alternative.

Differences between 2 Robotic Thyroidectomy Techniques

Objective: Two distinct remote access robotic thyroidectomy techniques were implemented in a high-volume endocrine surgery practice. Important technical and clinical differences were observed and are described. Method: Demographic and clinical parameters were prospectively captured in a series of patients undergoing 1 of 2 robotic thyroidectomy techniques (robotic axillary thyroidectomy [RAT] or robotic facelift thyroidectomy [RFT]). Attention was paid to time of surgery, ease of dissection, complications, use of drains, and length of stay. Results: Fifteen robotic hemithyroidectomies were accomplished by either RAT (n = 5) or RFT (n = 10). The duration of surgery for the 5 RATs averaged 196 ± 38.1 minutes, with no clear downward trend observed; time of surgery for RFT was 156.9 ± 16.3 minutes with a steady trend towards shorter surgical times. All 5 RAT patients were managed with drains and on an inpatient basis (LOS = 1.0 days); 9 of 10 RFT patients were managed without drains and on an outpatient basis. Ease of surgery, familiarity with anatomic dissection planes, and surgeon comfort level all favored RFT. Conclusion: In the implementation phase, a more rapid learning curve, reflected by shorter operative times, was observed with RFT compared with RAT. Furthermore, the vast majority of patients could be managed as outpatients even early in the experience, which represents one of several apparent advantages.

Robotically Assisted Totally Endoscopic Coronary Bypass Surgery

Nearly all surgical disciplines have developed endoscopic operations over the last 2 decades that have become the standard of care. In cardiac surgery and specifically for coronary artery bypass grafting (CABG), the adoption of minimally invasive techniques was challenging for the following reasons: First, most procedures are already complex, and endoscopic approaches further increase the degree of complexity; second, the cardiac surgery community had until recently no endoscopic surgical tradition; and finally, early attempts to perform CABG with the use of conventional thoracoscopic instrumentation failed completely.1 Cardiac surgeons have standardized open operations for acquired heart disease, and despite low mortality and excellent results, CABG outcomes are heavily scrutinized. Consequently, the bar has been raised for any new competing technology, which has slowed its adoption. Robotic surgical technology was developed with the idea of performing remote operations and procedures in difficult spaces. These machines allow surgical maneuvers to be performed by instruments on robotic arms that are controlled by the operator from a console situated away from the operating table. This technology is well suited for completely endoscopic suturing inside the chest. In 1998, Loulmet et al2 performed the world's first totally endoscopic coronary artery bypass (TECAB) procedure using robotic assistance. The patient who received a single left internal mammary artery (IMA) to left anterior descending artery graft remains alive and free from angina 12 years postoperatively. During subsequent years, development has been slow but significant. TECAB developed from a single-vessel procedure to complex endoscopic robotic multivessel revascularization (Figure 1). The third generation of surgical telemanipulators is now available, with technological improvements in the areas of high-definition video, robotic arm mobility, instrument reach, surgeon comfort, and capability for intraoperative surgical endoscopic teaching with a dual-console system.3 Figure 1. Development of robotic totally endoscopic coronary artery bypass grafting from 1998 to …

Pure endoscopic removal of pineal region tumors

Endoscopic resection of pineal tumors using an endoscope with a mounted rigid suction that allows bimanual handling of the tumor for resection. This contrasts to the established method of biopsy of pineal tumors through intraventricular approach. Two patients, one with a cystic lesion in the pineal region and one with a large pineal tumor, were operated in sitting position through a subtorcular approach. Endoscope was held in the left hand with suction tip extending beyond the tip through its instrument channel. Regular microsurgical instrumentation/CUSA/Nico Aspirator was used with the right hand for dissection, cutting, and removing the tumor under endoscopic vision. Surgeon comfort was superior to when microscope is used in sitting position. Complete resection was achieved in all cases. The two-handed endoscopic technique using a mounted suction on the endoscope as described is a safe and effective strategy for resecting pineal region tumors.

RETRACTED ARTICLE: Graft fixation alternatives in anterior cruciate ligament reconstruction

Reconstruction of the anterior cruciate ligament is a frequently performed procedure that has had outstanding results. Outcomes are dependent upon an early postoperative physical therapy program that stresses early motion. Early rehabilitation demands rigid intraoperative mechanical fixation of the graft since therapy begins before biologic incorporation of the graft in the bone tunnels. Regardless of the graft substitute chosen, many methods of fixation are available. The best fixation technique depends on several factors, including graft choice and surgeon comfort. The figures are not documented in this paper. We review current methods available for graft fixation in anterior cruciate ligament surgery.