Surgeon's Point Research Articles

Preoperative assessment of thyroid nodules: the surgeon's point of view

A selective approach to patients with thyroid nodules, in order to differentiate between negative findings and uncertain or positive results requiring surgery, has been outlined. Fine needle aspiration biopsy (FNAB) is the most reliable and cost-effective technique currently available to distinguish benign from malignant thyroid disease. In those lesions diagnosed by FNAB as 'follicular lesions', radionuclide scanning, serum calcitonin and CEA determination, color doppler ultrasonography and the response to TSH suppressive therapy may be of assistance. Despite such screening procedures, the majority of follicular lesions remain indeterminate, and surgery is therefore necessary before a correct diagnosis can be made.

Infection after total knee prosthesis - The surgeon's point of view

Infection of a knee prosthesis leads to specific problems in relation to the function of the knee joint and its superficial location in comparison with the better known infection after total hip replacement. Every joint replacement is a foreign body which promotes a reaction of the host organism. The important and dangerous period for infection is the initial period after foreign body implantation, until all its adherence receptors are inactivated by the normal biological host response. The presence of a foreign body decreases the local immune response of the host, and especially the phagocytosis mechanisms and antibiotic effectiveness, due to anaerobic conditions. The surgical debridement of a joint prosthesis is ineffective because it is unable to debride the prosthesis-host interface, which is always contaminated in a per-operatively acquired infection. The only effective treatment is then removal of the foreign body. Results of the treatment of infected knee arthroplasties are very different in the literature. Medical treatment alone, surgical debridement alone, arthrodesis or amputation should only be used in cases where the optimal treatment, i.e. one or two-stage exchange, is contra-indicated. There is no evidence for the superiority of one or two-stage exchange in curing infection, but the functional results of the former treatment should be better. The choice of the prosthesis must be made on mechanical considerations only, as for aseptic revisions. Primary fixation is mandatory, and cemented fixation often offers the best cost-benefit ratio.

Zanoli's procedure for overlapping fifth toe: retrospective study of 18 cases followed for 4-17 years.

Digitus quintus superductus pedis (overlapping fifth toe) is a congenital deformity, often bilateral, in which the fifth toe is medially directed, rotated and hyperextended. There is no consensus regarding the best treatment. We describe our experience using Zanoli's procedure, which is a tenodesis procedure using the extensor tendon of the fifth toe. Between 1979 and 1993, we operated on 16 patients (7 bilateral, total 23 feet). 13 (10 women) patients (18 feet), with a mean age of 26 (19-40) years, were seen on follow-up. The mean follow-up time was 8 (4-17) years. Pain relief was achieved in all patients. From the surgeon's point of view, 3 toes overcorrected due to technical errors were considered unsatisfactory. All patients, however, were satisfied with the result and would advise other patients to undergo the same operation.

Tissue repair after Mohs surgery. A plastic surgeon's view.

Goals of the treatment for skin cancer include completeness of removal of the lesion, minimal functional disability, and a good aesthetic result. With increasing standards for the quality assurance and the demand for cost-effectiveness, assessment of resource-consuming treatment modalities, especially those involving multidisciplinary approaches, seems appropriate. The purpose of this study was to review the strategy of management and the approaches to tissue repair following cutaneous micrographic surgery from the plastic surgeon's point of view. Retrospective review of personal experience based on approximately 800 patients treated between 1989 and 1996 and current plastic surgery literature. Teamwork with the Mohs surgeon, recognition of the post-Mohs' procedure wound components, and familiarity with reconstructive techniques are essential for the multidisciplinary practice success. The pitfalls of the reconstructive approaches are discussed.

Carotid stenosis and coronary artery disease in the elderly: the vascular surgeon's point of view.

Surgical prevention of stroke is justified only when the perioperative morbidity and mortality rates are very low. Therefore, an accurate cardiac evaluation is essential for patients with a vascular disease like carotid stenosis, to reduce the surgical risk and improve prognosis. The aim of our retrospective study was to characterize subgroups of patients with high cardiac risk. From 1986 to 1993 at the Vascular Surgery Unit of the Department of Surgery and Surgical Emergencies at the University of Perugia, 857 carotid endarterectomies were performed on 739 patients. The stroke/death rate, at 30 days after surgery, was 2.16% per patient and 1.86% per procedure; cardiac mortality was 0. However, during follow-up 58 patients died: 55% of these deaths could be attributed to cardiac disease. No statistically significant differences emerged in cardiac mortality of patients with a positive history of cerebral vascular accident with respect to asymptomatics, neither among patients with carotid stenosis associated with complete contralateral occlusion nor among those without. Our group of patients had a 76% survival rate at 7 years after surgery, which is different from that reported by other studies. This may be due to some bias associated with the preoperative selection of the patients and the retrospective nature of our study. Nevertheless, in patients with carotid stenosis, the most important cause of death is cardiac ischemia, therefore a rigorous preoperative selection is mandatory particularly in elderly asymptomatic patients.

Dissection of the anterior abdominal wall and the deep inguinal region from a laparoscopis perspective

The usual dissection by medical students of the anterior abdominal wall and the inguinal region proceeds from superficial to deep; special emphasis is placed on the sheath of the rectus abdominis muscle and lateral muscular layers. We suggest an alternate approach to dissection of this region that has the following advantages: (1) sparing of delicate deep structures not often fully appreciated by students; (2) provision of an opportunity to visualize the region from a laparoscopic surgeon's vantage point; (3) considerably reduced time spent dissecting and identifying structures and relationships, especially peritoneal reflections important in laparoscopic procedures. Our dissection begins with bilateral subcostal incisions through the entire thickness of the anterior abdominal wall and peritoneum, which extend laterally and inferiorly to the level of the anterior superior iliac spines, thereby forming a large, inverted, U-shaped flap. This flap is reflected inferiorly, allowing abdominal viscera to be dissected, and ultimately removed en bloc. The flap is then drawn cranially and stretched somewhat to approximate its position when the abdomen is inflated with CO2 during laparoscopic procedures. Major landmarks, including the deep inguinal ring, are noted and the flap is again reflected inferiorly for dissection beginning with the peritoneum and transversalis fascia. This method of dissecting the anterior abdominal wall and inguinal region results in more facile and timely identification of both superficial and deep structures of the anterior abdominal wall and inguinal region, and provides a clinically relevant demonstration of anatomy from a laparoscopic perspective.

A clinically relevant variation of the superior thyroid artery

Usually the superior thyroid artery is a branch of the external carotid artery. During a functional neck dissection in order to remove a metastasis of a tongue cancer we observed a variation of the origin of the vessel that was interesting from the surgeon's point of view. The artery rose from the A. carotis communis 3.5 cm below the bifurcation of the common carotid artery. Normally in this region no vessels leave the common carotid artery and therefore the knowledge of such variations is important for the exact identification of the neck vessels during surgery to avoid a fatal mix-up with the internal carotid artery.

What is Needed from Imaging? The Surgeon's Point of View

Abdominal sepsis after surgery is decreasing in incidence but has a high mortality, especially in those with other complicating factors. The most difficult abscesses to localize are those in intermesenteric folds. Pyrexia of unknown origin is much less of a clinical problem since the advent of ultrasound and computerized tomography (CT) scanning. Laparotomy still has an occasional role but laparoscopy should precede it and may be therapeutic using minimally invasive surgical techniques; for example, in appendicitis and cholecystitis. Pancreatitis remains a serious clinical problem in which imaging plays an important role. Percutaneous drainage has a similar morbidity and success rate to open drainage. In certain cases of diverticular disease it may obviate altogether the need for surgical resection. The differentiation between abscess and necrotic tumour is important, and CT is most helpful in this area.

Group a streptococci infections. The surgeon's point of view

Group a streptococci infections. The surgeon's point of view

Studies to be Conducted Before Projected Operations from the Pediatric Surgeon's Point of View

To rationally discuss the "need for preoperative laboratory investigations prior to performing an operation that can be pre-planned", two questions must be considered: 1. What kind of complications were encountered during or after 25,872 anesthesias performed in a 20-year period? 2. What kind of diseases were recognized only postoperatively which apparently could not be diagnosed preoperatively via case history and clinical examination? The results of these analyses are tabulated and assessed. It could be shown that the case history and the clinical examination of the patient on the day of surgery rank before all laboratory tests. With regard to peroperative respiratory disturbances it could be proven that children within the first trimester are particularly susceptible to such alterations. Furthermore, it could be demonstrated that within this group premature babies are more susceptible to this kind of complication than babies born at date. With regard to the incidence of preoperative respiratory disturbances in children with or without infection of the upper respiratory tract, it was shown that children without such symptoms who had however undergone an infection three to four weeks before the operation, were more susceptible to peroperative respiratory disturbances than children without any infection or even children suffering from an acute infection. Taking the physiological Hb decrease at the end of the first trimester as an example, questions on the optimal date for surgery are discussed. Preoperative handling is discussed on the basis of the blood glucose level of 500 children after a fasting period of 3-4 hours.

Hidradenitis Suppurativa

Ariyan and Krizek, in 1976, reported on three patients with perineal hidradenitis suppurativa who, following excision, achieved satisfactory closure allowing spontaneous wound healing by secondary intention. We have used this approach and have considered it very satisfactory from the surgeon's point of view. We now report from the point of view of patients and review the records of 20 consecutive patients with perineal hidradenitis treated by excision and secondary healing. Surgical results and patient satisfaction were assessed 1 year following complete wound closure. All patients reported minimal inconvenience and interruption of daily activities from this method of management. Analgesic requirements were minimal, and little reinforcement was necessary to maintain vigorous wound care. Uncomplicated wound closure was uniformly achieved with unrestrictive, stable scars providing long-term relief of this disabling disease. Two patients expressed dissatisfaction as a result of a new onset of disease in previously uninvolved and therefore unresected apocrine tissue. With this exception, patient satisfaction has been great and hospitalization time and costs reduced.

A pattern for the establishment of a unit for the dental treatment of the handicapped patient in the community based on such a unit in Hertfordshire.

In 1978 the Hertfordshire Area Health Authority converted a ground floor dental surgery with the specific aim of providing a comprehensive dental service to the handicapped in the Community. This article describes the criteria used in the design and location of the unit and, briefly, how an efficient patient flow is achieved. The routine dental treatment of the handicapped patient has always posed problems real and artificial for the dental surgeon. Problems can be simply classified into: (1) Medical. (2) Management from the patient's point of view, including access to surgery, dental chair, and transportation. (3) Management from the Dental Surgeon's point of view. (4) Economics. (5) Time, which is closely related to economics. The Community Dental Service is responsible, as part of its duties, for the provision of dental care for both physically and mentally handicapped children and adults living in the Community. In 1978 the Hertford shire Area Health Authority decided that dental facilities for these children and adults were inadequate and began work on the conversion of a ground floor dental surgery to cope with their special needs. The following criteria were considered to be basic essen tials : Situation of Unit (1) The site of the surgery would have to be centrally located in the county with good road and public transport access. (2) As some patients would be treated under general anaesthetic on a day-care basis good access to a nearby General Hospital would be essential in case of emergency and possible utilization of in-patient facilities. (3) The unit must be on the ground floor with adequate access for wheelchairs. The standard wheelchair is 42 inches long, 25 inches wide, 36 inches high (handles to floor) and 20 inches high from seat to floor. Hence to turn a wheelchair through 360 degrees needs 54 inches clearance. Using figures for an average adult, the average reach of such an adult in a wheelchair is 60 inches vertically, 30 inches long and 48 inches diagonally from the floor. Therefore for wheel chair manoeuverability a hall way would have to be at least 60 inches wide in order to allow two way traffic, and doors would have to be 30 inches wide to allow adequate access 1-3.

Manual of Cardiac Surgery

TheComprehensive Manuals of Surgical Specialtiesrepresent the ongoing best efforts of series editor Richard H. Egdahl and the publishers (Springer-Verlag) to present the operative techniques employed in each of the surgical disciplines in full color, from the surgeon's point of view, and in perspective, beginning with the basics and advancing to highly sophisticated techniques. The first volume in the series,Manual of Endocrine Surgery, appeared six years ago at a price of $40; the page size was smaller (10 1/2×7 1/2 in) but there were more of them (274), so the amount of information contained is similar to the newest volume in the series, with its 204 pages (12×9 in), and comparisons are appropriate. TheManual of Endocrine Surgery, by Edis, Ayala, and Egdahl, remains the single most useful reference to this topic. Logically organized, superbly illustrated, and impeccably detailed, it unravels all the mysteries of surgical approaches to

Legal aspects of patient enlightenment (therapeutic consent) from a surgeon's point of view (German): Magistris, F. Chir. Abt., Allg. Krankenh., Hollabrunn Wien. Klin. Wochenschr. 90(17), 639–647, 1978

Legal aspects of patient enlightenment (therapeutic consent) from a surgeon's point of view (German): Magistris, F. Chir. Abt., Allg. Krankenh., Hollabrunn Wien. Klin. Wochenschr. 90(17), 639–647, 1978

Aesthetic judgment in the surgery of appearance

The aesthetic judgment of human appearance differs from that of the visual arts in that the former is determined not only by the degree of balance and harmony of proportions of its component parts, but also by such factors as body posture and movement and facial expression. Since these are influenced by ethnic background, environment, education, health, and mood of the individual, human appearance from the surgeon's point of view cannot be judged solely on its relationship to the proportions of a classic beauty ideal. From the patient's point of view, judgment of his own appearance introduces a subjective element and involves the way he sees himself in relation to his social environment. His aesthetic judgment is thus rooted in social psychology and modified by certain aspects of his individual psychologic makeup. As far as the patient's daily contacts are concerned, their judgment of his appearance is based on criteria similar to those of the surgeon, but perhaps more strongly influenced by the psychology of interpersonal relationships.

The second‐opinion case‐(3) the referring Veterinary Surgeon's point of view

The second‐opinion case‐(3) the referring Veterinary Surgeon's point of view

The medico-legal aspects of emergency surgery: the surgeon's point of view.

The medico-legal aspects of emergency surgery: the surgeon's point of view.

Electrolyte Imbalance

The subject of this paper is Electrolyte Imbalance. Unqualified, such a title may sound like an overambitious attempt to embrace within the span of forty-five minutes the whole gamut of the disordered physiology of the anions and cations. Mindful of the penalty of such vaulting ambition which would, I think, without doubt "fall on the other" its content will be limited largely to some of the more acute and dramatic examples of disturbances of body fluid that are commonly encountered in surgical patients. Surgery deals with the sort of patients of whom John Donne might well have been thinking when he said "this minute I was well and I am ill this minute " and consequently the pattern of electrolyte imbalance encountered by the surgeon is usually drawn in starker and bolder lines than is the more subtle, long drawn out problem with which the physician is often confronted. This makes life considerably easier for the surgeon who is not uncommonly a simple man of action rather than a profound thinker; an extrovert rather than an introvert, a Roman rather than a Greek. Therefore, this account is mainly from a surgeon's point of view with an occasional digression.

Selection of patients for haemodialysis. Surgeon's point of view.

Selection of patients for haemodialysis. Surgeon's point of view.

Alveoloplasty—the oral surgeon's point of view

Alveoloplasty—the oral surgeon's point of view