Toothed Forceps Research Articles

A case report on use of ivermectin as nasal drop in a case of nasal myiasis

We describe a case of nasal myiasis due to in a 52-year-old Hindu priest with a previously known case of right sided hemiparesis with diabetes mellitus. Initial attempts to remove the fly larvae using manual extraction with a toothed forceps and normal saline irrigation were unsuccessful. On subsequent nasal irrigation after instillation of ivermectin tabs crushed in normal saline as nasal drops, the patient self-expulsed some larvae, and rest larvae were cleared on subsequent nasal suction and clearance. He also received a course of oral ivermectin. Here, we propose that the antiparasitic oral tablet ivermectin can be used in a nasal drop formulation for the aid of nasal myiasis.

Flexible bronchoscopy for removal of airway foreign bodies: A single center experience

Background: Airway foreign bodies are rare in occurrence and challenging to manage. The presentation varies depending upon the size, site, and nature of the aspirated material. Although rigid bronchoscopy is the preferred choice in children; distally lodged foreign bodies in adults have high success rate of extraction with flexible bronchoscope. Objective: The aim of this study is to evaluate the utility of flexible bronchoscopy for removal of airway foreign bodies in adolescents and adults. Methods: In a retrospective study conducted between January 2018 to March 2024 at National Academy of Medical Sciences, Bir hospital; medical records of patients undergoing bronchoscopy for airway foreign bodies were extracted. Methods and Material: Demographic parameters, type and location of foreign body, extraction procedure, accessory equipment used, and the success rates were analyzed. Complications during and after the procedure were also recorded. Results: During the study period, a total of 3143 bronchoscopies were performed, of which 18 (0.57%) were done for foreign body extraction. Patients were aged between 12 to 89 years; cough was the commonest symptom and lobar collapse was the commonest radiological sign. Organic foreign bodies accounted for 61% cases and inorganic 39%. Right lower lobe was the commonest site. Successful flexible bronchoscopy assisted extraction was achieved in 89%. Of the 18 patients, 12 (67%) were successfully removed with rat toothed forceps and five (28%) with basket device. No major complications were noted. Conclusions: Flexible bronchoscopy has a high success rate in management of airway foreign bodies and should always be considered as first line in adults.

Four-Point Refixation for In-the-Bag Intraocular Lens Dislocation Into Vitreous Cavity With Implantable Capsular Hooks.

Four-Point Refixation for In-the-Bag Intraocular Lens Dislocation Into Vitreous Cavity With Implantable Capsular Hooks.

The Effect of The Topical Application of Eurycoma Longifolia Jack (TA) Root Extract Hydrogel on Vascular Endothelial Growth Factor (VEGF) Expression During Wound Healing in vivo Excisional Wound Model

INTRODUCTION: Medicinal plants are known for their positive impacts on wound healing by stimulating angiogenesis in the skin. Eurycoma longifolia Jack locally known as Tongkat Ali (TA), is a medicinal plant characterised by anti-inflammatory and antioxidant effects. MATERIALS AND METHODS: Excisional wound (15mm × 15mm) in diameter and (2mm) depth was created at the back of 20 male Sprague Dawley rats by incising the marked skin with sterilized surgical scalpel blade then excised the skin by surgical scissors and toothed forceps. The wounded rats were divided into 4 groups, each group contained 5 rats (n=5). Experimental groups were formed as follows: untreated (-ve) control, Hydrocyn® aqua gel (+ve) control, vehicle hydrogel, and TA hydrogel. All the treatments were applied twice daily for 5 days starting on the first day (wounding day). On Day 5 post-wounding, the granulation tissue was harvested from all groups and evaluated by immunohistochemistry assay for Vascular endothelial growth factor (VEGF) expression. RESULTS: VEGF expression in granulation tissue of rat’s skin treated with TA hydrogel and vehicle hydrogel increased significantly compared to that in the untreated (-ve) control group with p-values of 0.040 and 0.029, respectively. Although there was no significant difference in VEGF expression in granulation tissue of rat’s skin treated with the TA group, Hydrocyn® aqua gel (+ve) control, and vehicle hydrogel groups, our study group showed higher expression of VEGF. CONCLUSION: Our study showed that the topical application of TA hydrogel increased the VEGF expression in granulation tissue of rat’s skin, which is an essential growth factor for wound healing. Thus, there is great potential for TA hydrogel to be an effective wound-healing agent for managing cutaneous wounds.

S2352 No Soup for You: The Case of an Intramucosal Hematoma Found During Endoscopy for an Esophageal Food Impaction

Introduction: Esophageal food impaction (EFI) is third most common gastrointestinal emergency, which is commonly associated with obstructive lesions such as peptic strictures and Schatzki rings, eosinophilic esophagitis and rarely motility disorders. Endoscopic therapy is the mainstay option for the management of EFI if medical therapy fails. The most commonly impacted foods include beef, chicken, pork, and undercooked vegetables with liquids rarely causing an impaction. Complications from a prolonged EFI can result in mucosal disruption to an esophageal perforation. We present an unusual case of an esophageal intramucosal hematoma found in a during endoscopic retrieval of an esophageal impaction. Case Description/Methods: An 80-year-old male presented with a 2-hour history of foreign body sensation in his throat that began while eating hamburger meat and soup with potatoes. He began coughing up a large amount of mucus at symptom onset and was unable to finish his meal. He has been unable to swallow solids or liquids. History was significant for esophageal peptic strictures in the past requiring dilations. After 2 doses of glucagon failed to help pass the bolus, the patient underwent endoscopic removal of the esophageal food impaction. During the procedure, food was found in the middle and lower thirds of the esophagus and was subsequently removed with suction cap and rat toothed forceps. The esophagus was tortious and was noted to have decreased and abnormal movement throughout with a moderate stenosis found at the gastroesophageal junction. The middle and lower third of the esophagus had localized severe erythema, suspicious for the presence of intramucosal hemorrhage (Figure). The patient tolerated a diet after endoscopy and discharged home. Discussion: Esophageal food impactions are uncommon and are commonly associated with stricture and rings. Complications from a prolonged food impaction include mucosal disruption however findings of an intramucosal hematoma are rare. Intramucosal hematoma present with chest pain, dysphagia, and hematemesis. This patient presented with dysphagia however had no other pain or episodes of hematemesis. In this patient it is unclear whether his presentation was due to an acute EFI causing an intramucosal hematoma or whether the ingestion of soup caused an intramucosal hematoma resulting in an EFI. Nevertheless, one should take caution during endoscopic evaluation for patients who presented with an EFI.Figure 1.: Localized severe erythema suspicious for intramucosal hemorrhage. (1a., 1b., 1c.), Lower third of the esophagus. (1d.)- Gastroesophageal junction.

Pronounced squamous cell contamination in biliary tract cytology: A diagnostic pitfall.

Squamous cells are rarely found in biliary tract cytology specimens, and when present are typically scant in quantity. Over an 8-year time period, two cases at our institution reporting abundant squamous cells were identified. Both patients underwent endoscopic retrograde cholangiopancreatography with bile duct brushings and removal of a migrated biliary stent. The migrated stents were retrieved using rat toothed forceps and required removal of the endoscope through the esophagus with the stent exposed to esophageal and oral mucosa outside of the endoscope. Cytologic examination of the accompanying biliary stent material accordingly revealed abundant benign squamous cells. However, bile duct brushings showed benign ductal epithelial cells without squamous cells. Prior and subsequent cytology and bile duct surgical pathology specimens did not show squamous metaplasia. Migrated biliary stents that require endoscopic withdrawal increase the risk of contaminating samples with squamous cells. Recognition of this unique scenario is important, as the differential diagnosis includes squamous metaplasia and squamous neoplasia.

A simple modified surgical technique combined with tissue adhesive for steatocystoma multiplex.

Steatocystoma multiplex (SM) is a disorder of the pilosebaceous unit characterized by multiple sebum-containing dermal cysts. Psychological distress of patients is always derived from these undesirable lesions. Although various treatments have been attempted to improve cosmetic outcomes, no optimal treatment strategy has been established to date.. To provide a facile and practical surgical technique combined with tissue adhesive for the treatment of steatocystoma multiplex. Forty patients diagnosed as SM were treated with simple modified surgical technique. After local anesthesia, the surface skin was incised about 1-2mm using a No. 11 blade. When the wall was punctured, the cyst should be squeezed to cause the contents to come out first. Then, we used single toothed forceps which were inserted through the narrow incision. When the cyst was exposed, the mosquito forceps grasp the portion of the cyst and pull it out gently. Then, the incisions were pressed locally, and tissue adhesive was employed to align them when there was no bleeding. We just took approximately 1-2minutes to excise one cyst completely. We successfully treated forty SM patients with our simple modified surgical technique. After treatment, excellent clinical outcomes and minimal adverse effects were observed in this study. And more importantly, no recurrence was found 12months after the surgery. Our simple modified surgical technique was proved to be practical and have excellent results in the long run. We highly recommend this treatment technique as the first-line therapy for SM.

Permeability of the porcine iris stroma

Current literature has not considered or provided any data on the permeability of the iris stroma. In this study, we aimed to determine the hydraulic permeability of porcine irides from the isolated stroma. Fifteen enucleated porcine eyes were acquired from the local abattoir. The iris pigment epithelium was scraped off using a pair of forceps and the dilator muscles were pinched off using a pair of colibri toothed forceps. We designed an experimental setup, based on Darcy's law, and consisting of a custom 3D-printed pressure column using acrylonitrile butadiene styrene (ABS) plastic. PBS solution was passed through the iris stroma in a 180° arc shape, with a column height of approximately 204 mm (2000 Pa). Measurements of iris stromal thickness were conducted using optical coherence tomography (OCT). To measure flow rate, we measured the mass (volume) of PBS solution using a mass balance in approximately 1 min. Histology was performed using hematoxylin and eosin (H&E) and anti-smooth muscle antibody (anti-α-SMA) for validation. The permeability experiments demonstrated that the iris stroma is a biphasic tissue that allows fluid flow. Our image processing results determined the area of flow to be 7.55 mm2 and the tissue thickness to be between 180 and 430 μm. The hydraulic permeability of the porcine stroma, calculated using Darcy's law, was 5.13 ± 2.39 × 10−5 mm2/Pa•s. Histological and immunochemical studies confirmed that the tissues used for this permeability study were solely iris stroma. Additionally, anti-α-SMA staining revealed staining specific for stromal blood vessels, with the notable absence of dilator and sphincter muscle staining. Our study combined experimental microscopic data with the theory of biphasic materials to investigate the hydraulic permeability of the iris stroma. This work will serve as a basis on which to validate future biomechanical studies of human irides with which may ultimately aid disease diagnosis and inform the design of novel treatments.

Removal of intraocular foreign body in anterior chamber angle with prism contact lens and 23-gauge foreign body forceps.

To introduce a novel approach in removal of anterior chamber angle foreign body (ACFB) using a prism contact lens and 23-gauge foreign body forceps. Data of 42 eyes of 42 patients who had undergone removal of ACFB using a prism contact lens and 23-gauge foreign body forceps from January 2008 to October 2013 were collected and analyzed. Twenty eyes in group A received the conventional approach by using toothed forceps through corneal limbus incision, and 22 eyes in group B underwent the novel method through the opposite corneal limbus incision. The success rate of ACFB once removal was 75% (15/20) in group A, and 100% (22/22) in group B. The average operation time of group A was significantly longer compared with group B (34.9±9.88min vs 22.13±8.85min; P<0.05). The average size of corneal limbus incision in group A was significantly larger than that of group B (4.85±1.89 mm vs 3.95±1.17 mm; P<0.05). The corneal limbus incision suturing were conducted in all eyes in group A, and only 5 eyes in group B. Removal of ACFB using a prism contact lens and 23-gauge foreign body forceps is a safer, more effective, and convenient technique compared with the conventional approach.

A novel technique for diaphragm biopsies in human patients

BackgroundThe diaphragm is difficult to biopsy because of its anatomic location. We describe a new laparoscopic diaphragm biopsy technique. Material and methodsFifty one patients with amyotrophic lateral sclerosis gave their consent to diaphragm biopsy in the context of an implanted phrenic nerve stimulation protocol (NCT01583088). The biopsy was taken from the costal diaphragm, after opening the parietal peritoneum with scissors, and by grasping the diaphragmatic muscle over the rib with toothed laparoscopy forceps. ResultsThe first four electrocoagulation biopsies were unsuitable for morphologic examination. The following 47 biopsies were therefore performed without electrocoagulation. The mean size of the biopsy fragments obtained after preparation was 3 ± 1 × 2 ± 1 × 1 ± 1 mm (maximum: 4 × 3 × 2 mm). A diaphragmatic injury occurred during the section in three cases requiring immediate suture without causing pneumothorax. A small pleural effusion was observed on the postoperative chest x-ray in one patient with a spontaneously favorable outcome. Numerous stains were able to be performed on the fragments obtained. ConclusionsDiaphragm biopsy can be safely performed by laparoscopy and yields tissue suitable for our future histologic evaluation.

3D Printing of Surgical Instruments for Long-Duration Space Missions

The first off-Earth fused deposition modeling (FDM) 3D printer will explore thermoplastic manufacturing capabilities in microgravity. This study evaluated the feasibility of FDM 3D printing 10 acrylonitrile butadiene styrene (ABS) thermoplastic surgical instruments on Earth. Three-point bending tests compared stiffness and yield strength between FDM 3D printed and conventionally manufactured ABS thermoplastic. To evaluate the relative speed of using four printed instruments compared to conventional instruments, 13 surgeons completed simulated prepping, draping, incising, and suturing tasks. Each surgeon ranked the performance of six printed instruments using a 5-point Likert scale. At a thickness of 5.75 mm or more, the FDM printing process had a less than 10% detrimental effect on the tested yield strength and stiffness of horizontally printed ABS thermoplastic relative to conventional ABS thermoplastic. Significant weakness was observed when a bending load was applied transversely to a 3D printed layer. All timed tasks were successfully performed using a printed sponge stick, towel clamp, scalpel handle, and toothed forceps. There was no substantial difference in time to completion of simulated surgical tasks with control vs. 3D printed instruments. Of the surgeons, 100%, 92%, 85%, 77%, 77%, and 69% agreed that the printed smooth and tissue forceps, curved and straight hemostats, tissue and right angle clamps, respectively, would perform adequately. It is feasible to 3D print ABS thermoplastic surgical instruments on Earth. Loadbearing structures were designed to be thicker, when possible. Printing orientations were selected so that the printing layering direction of critical structures would not be transverse to bending loads.

Theoretical and experimental study on lipophilicity and wound healing activity of ginger compounds

To correlate the chromatographic and computational method to calculate lipophilicity of selected ginger compounds and to observe the effects of log P on wound healing. Mixtures of acetonitrile and water with acetonitrile content between 95% and 50% v/v in 5% increments were kept separately in 10 different chromatographic chambers, saturated with solvent for 2 h. Spots were observed under UV light at λ=254 nm p-anisaldehyde used as a spraying reagent. Theoretical calculation was done using the Alogps 2.1 online program at www.vcclab.org/lab/alogps. For percentage wound contraction, five groups of animal (mice) (25-30 g) of either sex were selected. Wound were created on dorsal surface of animals using toothed forceps, scalpel and pointed scissors. The wound areas were calculated using vernier caliper. After making wound mice were orally administered 35 mg/kg 6-shogoal, 6-gingerol, 8-gingerol and 10-gingerol respectively. Group E as the control group received tap water. The lipophilicity values determined in thin layer chromatography were correlated with the theoretically calculated various log P by linear regression analysis. Significant correlations were found between log P values calculated by software program and the experimental reversed-phase thin-layer chromatography data. Order of wound healing property of ginger compounds is directly dependent on lipophilicity i.e. more lipophilic compound has highest activity. Experimentally determined lipophilicity (R MO) values were correlated with log P determined by software's and found satisfactory. Lipophilicity (R MO) is a useful parameter for the determination and prediction of biological activity of ginger compounds.

Histological and ultrastructural findings of corneal tissue after failed descemet membrane endothelial keratoplasty

To investigate in a retrospective review the histological and ultrastructural findings after failed primary and early Descemet membrane endothelial keratoplasty (DMEK), propose possible pathomechanisms of graft failure and give clinical implications. The explanted grafts underwent light- and electromicroscopical investigations in eight failed DMEK cases. Haematoxylin - Eosin, periodic acid Schiff and Alcian blue stainings were performed. Special note was given to any residual stromal remnants, absence of endothelial cells, lamellar structure and 'activation' of keratocytes. Of the eight cases, six were re-DMEKs and two penetrating keratoplasties. Partial graft separation was seen in six and no graft separation in two of the cases. The average time-interval to the re-DMEK or penetrating keratoplasty was 4.6 months. Light and electron microscopy of the two explanted stromal specimens showed varying degrees of keratocyte activation. Endothelial cell loss was observed in essentially all explants with varying degrees and positive correlation with intraoperative difficulty. Assumed upside-down situations showed large areas of intact endothelial cells. In addition, a new layer, situated between the endothelial cell layer and the posterior nonbanded layer, was observed with loose intercellular structure. A loss of the endothelial cell layer of varying degrees and positive correlation with intraoperative difficulty are the prominent feature of primary and early DMEK graft failure. Of note is the upside-down situation, in which in some cases, the endothelial cell layer not only remains intact but also demonstrates metabolical activity in forming a novel cellular layer.

New strabismus surgical techniques

Five new strabismus surgical procedures were developed by the authors and were presented as a workshop at the AAPOS annual meeting of the American Association for Pediatric Ophthalmology and Strabismus. They are summarized here to introduce these methods to the reader and provide surgeons with more options in approaching difficult strabismus problems. Diagnosis and correction of consecutive strabismus attributable to stretched scar is discussed. The pulley posterior fixation procedure is a unique approach to correct high accommodative convergence or to augment a maximal medial rectus recession. Diagnosis and repair of the partial avulsion (flap tear) of a rectus muscle allows correction of some restrictive strabismus following blunt trauma. The nasal myectomy of the inferior oblique muscle corrects persistent inferior oblique overaction without sacrificing the tether effect gained by a previous anterior transposition of the inferior oblique. The full advancement of the superior oblique tendon offers another option to strengthen a weak superior oblique muscle.

Transumbilical Single-Port Splenectomy

Laparoscopic approach is now considered the gold standard technique for the treatment for many hematologic diseases requiring splenectomy, both in case of a normal or enlarged spleen. During the last few years, new surgical approaches such as natural orifice transluminal endoscopic surgery and single-port laparoscopic surgery have been described. We describe details of the surgical technique for transumbilical single-port splenectomy. A 55-year-old man was referred to our department for spleen removal, a treatment of idiopathic thrombocytopenia and immune anemia. He had no previous significant medical history. Reusable single-port device and coaxial curved instruments were used to perform splenectomy, reproducing the same technique used in the standard laparoscopic approach. For single-port laparoscopic splenectomy, we use a reusable single-port access system (Endocone® Karl Storz GmbH & Co. KG) that was designed to enable instrument triangulation. The proximal conical section of the Endocone® is capped with a separate seal cap (bulkhead), which houses eight valved instrument seals: two along large midline (for instruments up to 15 mm in diameter) and six (three on either side) for instruments up to 5 mm in diameter. The patient is placed in right lateral decubitus as in standard laparoscopic splenectomy, and the surgeons second the camera assistant stand on the side of the bed. The pneumoperitoneum is established using a Veress needle inserted in the umbilicus; at this point, a 5-mm-longitudinal incision is performed right through the umbilical scar and a standard trocar inserted for exploration of the abdominal cavity to evaluate the local condition and contraindications to the single-port approach such as severe adhesions and abnormal anatomy. At this point, the umbilical scar is pulled out using toothed forceps, and the incision is enlarged for up to 3 cm longitudinally: this technique will later allow to hide the scar inside umbilicus itself. A size small surgical wound protector (Alexis O; Applied Medical Rancho Santa Margarita) is inserted through the incision to protect the abdominal wall as well as to improve the stability of the port system and facilitate its introduction. As in standard laparoscopic splenectomy, the procedure starts with division of the small vessels of the lower pole of the spleen by means of combination of bipolar electrocautery and harmonic scalpel (Ethicon Endosurgery). The procedure carries on with the isolation of the main splenic artery that can be then closed by endoscopic clips and divided; surgical stapler can also be used according to surgeon's preferences. Once the artery is divided, the main vein is dissected gently and then closed and divided with an endoscopic surgical stapler with a vascular cartridge (Ethicon Endosurgery). At this point, the short gastric vessels are divided using the harmonic scalpel, and finally the spleen is mobilized by division of the splenodiaphragmatic, splenogastric, and splenocolic ligaments. A large endobag is then introduced through the Endocone®, and the spleen retrieved inside it through the incision. The surgical filed is finally checked for hemostasis, and the incision is carefully closed with an interrupted reabsorbable suture. The operative time was 95 minutes, and there were no intra- or postoperative complications. The patient was discharged on postoperative day 2. No competing financial interests exist. Runtime of video: 6 mins 11 secs

Intraocular Lens Explantation Technique for One-piece Acrylic Lenses

To present a simple technique to remove a one-piece, acrylic AcrySof (Alcon Laboratories Inc) intraocular lens (IOL) via the original incision. The AcrySof IOL is removed via the original (2.75-mm) incision, without cutting or folding the IOL or widening the incision. After the IOL is viscodissected from the capsular bag and brought into the anterior chamber, toothed forceps hold the optic through the incision while the manipulator enters the side-port incision and hooks onto the optic 180° away. With the forceps pulling and the lens manipulator pushing the IOL toward the incision, the IOL will fold and be delivered. A one-piece, acrylic (Acrysof) IOL can be removed without cutting or folding the lens and without widening the original 2.75-mm incision.

Sp699 Pancreatic Necrosectomy via Percutaneous Self-Expandable Metal Stent Placement

gastric wall to adhere to the abdominal wall before proceeding with ERCP. At our institution we have developed a novel way of EUS guided, fluoroscopic assisted access of gastric remnant followed by sutured gastropexy and subsequent ERCP, all in one session. We describe a series of three such cases. Endoscopic methods: The echo-endoscope was inserted trans-orally and advanced to the gastric pouch or the Roux limb. The remnant stomach was identified using sonographic features and was punctured across the pouch or roux limb wall using a 19G needle pre-loaded with 0.025 guidewire. Radioopaque contrast injection and fluoroscopy were used to confirm needle position. After advancing guidewire the remnant stomach was maximally inflated with air injection through the needle and the best point of percutaneous entry on the abdominal wall was chosen. An 18-gauge introducer needle was inserted into the lumen of the gastric remnant and a 0.035 wire advanced. The wire track was serially dilated and a gastroscope inserted into the remnant. The gastric wall was now secured to the anterior abdominal wall using full thickness sutures. The gastroscope was removed and a 15mm laproscopy port inserted for duodenoscope access. Clinical implications: This novel, one setting minimally invasive approach allows access to remnant stomach and upper GI tract for the purposes of diagnostic and therapeutic endoscopy/ERCP. It allows the use of duodenoscope for difficult cannulation and precise therapeutic ERCP manouvers such as bliary and pancreatic sphioncterotomy. As the gastric wall is secured to anterior abdominal wall with full thickness sutures, one does not run into the risk of dehisence and intra-peritoneal leakage of gastric contents. The use of EUS to access gastric remnant and maximal insufflation alllows for identification of the best point of per cutaneous puncture for gastrostomy tube thus reducing post operative complications and pain. This technique allows the gastrostomy placement and ERCP to be done in the same setting thus reducing health care costs and patient visits.

A rose by any other name - Hasson's technique and its modifications.

We read with interest the article by Dr Sadhu and colleagues [1] that details a technique of open insertion of laparosocpic cannula very much similar to the one we described and published in the Indian Journal of Surgery well over 9 years ago [2]. Both of us have since used it in more than 5000 patients without any instance of bowel or vascular injury. Having also taught the technique to several surgeon and gynecologist colleagues, we can vouch for its safety, simplicity and reproducibility. Over the years we have refined our technique to make it applicable in patients of all body habitus. Some of the technical aspects are highlighted below. 1 In thin patients and in those with a lax abdominal wall (e.g. multi-parous women) it is easy to evert the umbilicus completely by grasping the bottom of the umbilical pit with a towel clip. After a vertical incision on the umbilical cicatrix or the “umbilical tube” a cannula with a blunt inner trocar can then be guided into the peritoneal cavity directly.2 In most patients with a deep umbilicus and particularly in the obese, however, it is not always possible to evert the umbilicus. In these patients we place a towel clip on one lip of the umbilicus that has been everted with a toothed forceps, and apply a strong upward traction. This produces the desired effect of making the umbilical tube prominent allowing its easy identification after the skin has been incised. 3 We have observed that the umbilical tubes vary greatly in their texture, toughness and the amount of extraperitoneal fat they cover. Muscular and obese men often have a fibrous tube. After its incision, it is essential to grasp the cut edges with toothed instruments (our preference is single-toothed, straight Kocher’s forceps) to provide counter traction that allows a blunt-tipped hemostat to gently pierce and stretch the posterior rectus sheath/peritoneum underneath. 4 If the hemostat fails to gain easy entry into the peritoneal cavity, the incision on the umbilical tube needs to be extended onto the area where the umbilical tube merges with the horizontally placed linea alba. During this step, the short curved end of a baby Deaver’s retractor retracts and protects the skin to avoid a “T” extension of the incision. 5 A fair proportion of obese patients (and some not so obese ones) have a thick pad of extraperitoneal fat beneath the umbilical tube. If the tip of the hemostat does not “walk into” the peritoneal cavity after the tube is incised and its edges are lifted upwards, it is unwise to use force for the fear of causing injury to a loop of bowel lying under the incision. In such instances, we advance the blades of Deaver’s retractors to the depth of the extraperitoneal fat so as to identify and pick up the posterior sheath/peritoneum with two Kocher’s forceps. This layer is then incised. Additional manoeuvres such slightly extending the transverse skin incision, insertion of a third retractor

Modified Deep Lamellar Keratoplasty for the Treatment of Advanced-Stage Keratoconus with Steep Curvature

To determine the clinical efficacy of modified deep lamellar keratoplasty for the treatment of advanced-stage keratoconus with steep curvature. Retrospective, noncomparative clinical trial. Fifty-nine keratoconus patients with a curvature of more than 60 diopters (D) in 65 eyes were studied. All affected eyes were in the advanced stage with typical clinical characteristics, and 31 of the eyes had midstromal scars in the central cornea. All patients were treated with modified deep lamellar keratoplasty. Briefly, four-fifths thickness of the corneal lamellae was cut using a Hessburg-Barron vacuum trephine (with a diameter of 7.75 mm). The incisal edge of the cornea was drawn using toothed forceps, and the lamellae were cut with a diamond knife along the stromal fibers. At the top of the cone, 2 mm (in diameter) of Descemet's membrane was left. A corneal graft (8.0 mm in diameter) was sutured to the recipient using a gradual pressure technique to decrease the occurrence of folds in the central cornea. Complications during and after the surgery were recorded. The transparency of the graft, eye vision, and cornea curvature were monitored during follow-ups. Surgical effect and visual acuity after modified deep lamellar keratoplasty in patients with keratoconus. No corneal perforation occurred during the operations. Nine patients had mild liquid accumulation underneath the graft, but it disappeared 1 to 2 days after the surgery. The corneal graft attached to the patient's eye well, and there was no obvious fold in the center. The average best-corrected visual acuity was 20/32 between 3 months and 1 year after surgery and reached 20/25 at 1 year after the operation. There was no detectable corneal graft rejection during the follow-ups. This modified deep lamellar keratoplasty procedure for the treatment of keratoconus in patients with advanced-stage disease and steep curvature seems to provide similar efficacy to penetrating keratoplasty and may decrease the risk of immune rejection when compared with historical outcomes.

Discharge patterns of nociceptive primary afferent fibres in the rat coccygeal nerve after UV A-light exposure

We have shown that administration of the local anaesthetic bupivacaine into the base of rats’ tails prevents the development of hyperalgesia induced by UV A-light to a noxious thermal challenge, but not to noxious mechanical challenges. The aim of this study was to determine whether exposure of rats’ tails to UV A-light altered the responses of Aδ- and C-fibres innervating the tail to noxious mechanical and noxious thermal challenges. We dissected the right ventral coccygeal nerve in Sprague–Dawley rats that had their tails exposed to, or shielded from, UV A-light 24-h earlier. Single afferent Aδ- and C-fibres receptive fields were located and the response of a fibre to noxious blunt (3.9 N bar algometer) and punctate (rat toothed forceps) mechanical challenges, as well as a noxious thermal (49 °C) challenge was measured. In rats exposed to UV A-light, the peak firing rates and areas under the curve of post-challenge histograms of Aδ- and C-fibres evoked neural activity were increased when noxious blunt and punctate challenges were applied to the rats’ tails. However, the peak firing rate and areas under the curve of post-challenge histograms of C-fibre evoked neural activity, which were responsive to noxious thermal challenges, were not increased after UV A-light exposure. We have shown that the Aδ- and C-fibres that encode for noxious punctate and blunt challenges were sensitized after UV A-light exposure, but C-fibres responsible for encoding noxious thermal challenges were not sensitized by UV A-light exposure.