Towel Clamp Research Articles

Investigation the Frequency of Fungal Contamination in Surgical Instruments

Background: Fungal contamination of surgical instruments poses a significant risk to patient safety, potentially leading to surgical site infections and other severe complications. By examining contamination levels both immediately after opening sterile sets and after two hours of environmental exposure, it becomes possible to assess contamination reduction strategies. Objectives: The aim of this study was to identify which instruments and operating rooms were most affected by fungal contamination. Understanding the extent of this contamination is critical to developing more effective sterilization protocols, improving infection control practices, and ultimately enhancing patient safety in surgical settings. Methods: This study was conducted on surgical instruments at Ali ebn Abi Talib Zahedan Hospital in 2023, across seven operating rooms (emergency, general surgery, gynecology, and urology). Samples were randomly collected under sterile conditions to prevent external contamination. The collected samples were cultured in Sabouraud Dextrose Agar (SDA), and data were analyzed using SPSS version 26. Results: The findings revealed that different surgical instruments, such as Pinzette (without teeth), Allis forceps, Babcock forceps, curved clamps, Gully pots, receivers, retractors, ring forceps, and towel clamps, were contaminated with fungal pathogens within two hours of opening the sterile sets. The highest contamination rates were observed in general surgery (39%), followed by emergency (29%), urology (21%), and gynecology (11%) rooms. The most common fungal contaminants were Aspergillus spp., yeast, and Penicillium spp. Conclusions: This study highlights the challenge of maintaining sterility in surgical environments post-sterilization, as fungal contamination reappeared on surgical instruments within two hours despite the initial sterilization. These findings emphasize the need for enhanced infection control measures, advanced environmental controls, and regular monitoring to reduce the risks associated with fungal contamination in surgical settings.

A novel electroencephalographic evaluation of noxious stimulation during isoflurane anesthesia in dogs.

In veterinary clinical medicine, evaluating the balance between nociception and antinociception presents a great challenge for anesthesiologists during canine surgeries. Heart rate (HR) and mean arterial pressure (MAP) are suitable indexes for monitoring noxious stimuli during anesthesia. Frontal electroencephalography (EEG) records, including processed parameters, are recommended for evaluating nociceptive balance in anesthetized unconscious human patients, which is unexplored in veterinary medicine. Therefore, the objective is to explore the response of processed EEG parameters to noxious stimulation and elucidate the impact of noxious stimulation on frontal cortical activity in dogs anesthetized with 1.5% isoflurane. Fourteen dogs were included and underwent frontal EEG monitoring, measuring the patient state index (PSI) and spectral edge frequency (SEF) before and after administering noxious stimulation using the towel clamp method on the tail of each 1.5% isoflurane-anesthetized dog. As the noxious stimulation was applied, there was a simultaneous increase in PSI, HR, and MAP, with PSI exhibiting a drastic response. SEF, especially on the left side, also increased with noxious stimulation. In EEG power spectral analysis, the delta band was decreased, and the alpha and beta bands showed an increase following noxious stimulation, with a more profound elevation of beta bands on the left side. This study suggests that noxious stimulation brings asymmetric frontal cortical arousal, changing brain activity by suppressing delta waves and augmenting alpha and beta waves. Consequently, PSI seems to be a potential indicator for detecting stimuli in canine isoflurane anesthesia.

Extension block pinning combined with traction using towel clamps for effective reduction of mallet fracture: a technical tip

Purpose: Although closed reduction and extension block pinning have been widely used for acute mallet finger fracture, the problem of reduction remains a concern. We describe a tip for the reduction technique using a towel clamp, which provides a longitudinal traction force to the distal phalanx, and report the results of the technique.Methods: The medical records of 14 consecutive cases from 12 patients with acute mallet fractures were retrospectively reviewed. Reduction was achieved using the towel clamp reduction technique. The radiologic results were evaluated by simple radiographs, the functional results were analyzed in terms of range of motion, and remaining pain was assessed using Crawford criteria.Results: The mean follow-up period was 8.4 months. The mean union duration was 6 weeks. The mean range of motion was 73°. Eight cases had excellent outcomes, one had good outcomes, four had fair outcomes, and one had poor outcomes. One case of superficial infection and one case of skin necrosis developed, and three cases showed arthritic changes in the distal interphalangeal joint.Conclusion: The towel clamp technique can provide good reduction during surgery, with favorable radiologic and clinical results.

Comparison Between Cotton Test and Tap Test for the Assessment of Coronal Syndesmotic Instability: A Cadaveric Study

Category:Ankle; Basic Sciences/Biologics; Sports; TraumaIntroduction/Purpose:Diagnosis of subtle instability of the distal tibiofibular syndesmosis is challenging. In surgically treated rotational malleolar fractures, instability is typically assessed with the intraoperative Cotton test. However, this test can be unreliable due to its dynamic nature and uncontrolled distraction force. The Tap test is an alternative test where a cortical tap is advanced through the fibula with a progressive, stable, and unidirectional distraction force. The objective of this cadaveric study was to compare the DTFS widening when using the Cotton and Tap tests as diagnostic tools for coronal plane syndesmotic instability.Methods:Ten below-knee cadaveric specimens were tested in intact non-stressed, intact stressed, injured non-stressed, and injured stressed conditions, with stressed conditions utilizing both Cotton and Tap tests. In injured conditions, the syndesmotic ligamentous complex was sectioned (anterolateral longitudinal approach). Perfect fluoroscopic Mortise images were acquired for all conditions. For the Tap test, a 2.5 drill bit was used to drill a hole through both distal fibular cortices. A blunt-edged 3.5mm cortical tap was advanced toward the tibia. For the Cotton test, a lateral distraction force was applied to the distal fibula with a towel clamp. Two observers measured Tibiofibular Clear Space (TFCS) 1cm proximal to the ankle joint line. Intra and interobserver reliabilities were assessed by Intraclass Correlation Coefficient (ICC). Syndesmotic TFCS values for all conditions were compared by paired Wilcoxon. Diagnostic performance of the Cotton and Tap tests was assessed (a relative increase of TFCS>2mm). P-values <0.05 were considered significant.Results:The intraclass correlation coefficient (ICC) for intraobserver and interobserver reliability was respectively, 0.96 and 0.78.TFCS measurements were similar in intact non-stressed, intact stressed (both Cotton and Tap tests) and injured non- stressed conditions: intact non-stressed, 3.5mm (CI, 3.0 to 3.9mm); intact stressed, 3.6mm (CI, 3.1 to 4.1mm) (Cotton test) and 4.0mm (CI, 3.5 to 4.5mm) (Tap test); injured non-stressed, 3.8mm (CI, 3.3 to 4.3mm). TFCS was significantly increased (p<0.0001) in injured and stressed ankles for both Cotton and Tap tests, with values of respectively, 6.2mm (CI, 5.8 to 6.7mm) and 6.1mm (CI, 5.7 to 6.6mm). The Cotton test had 73.3% sensitivity, 100% specificity, and 86.7% diagnostic accuracy. The Tap test had 70% sensitivity, 90% specificity, and 80% diagnostic accuracy.Conclusion:Our cadaveric study compared the Cotton and Tap tests for detection of coronal plane syndesmotic instability. Both tests demonstrated similar increases in TFCS measurements in stressed injured conditions when compared to intact and injured non-stressed conditions. Additionally, both tests demonstrated similar diagnostic accuracy for coronal plane syndesmotic instability, with slight favor for the Cotton test. In our experience, the Cotton test can be unreliable due to the difficulty in applying a steady distraction force while maintaining a perfect Mortise view. We recommend the Tap test as a more stable, controlled, and reproducible intraoperative diagnostic test for coronal plane syndesmotic instability.

Maintained skin distension with a towel clamp for direct closure defects

Maintained skin distension with a towel clamp for direct closure defects

Treatment strategy of unstable atlas fracture: A retrospective study of 21 patients.

At present, the posterior cervical approach with open reduction and internal fixation (ORIF) remains a commonly effective treatment for unstable Atlas fracture. However, the inserted screws into the C1 lateral mass of some unstable atlas fracture are very difficult, so that the operation is forced to change into C0 to C2 fusion. In order to improve the successful rate of lateral mass screw placement, we introduced a method of fixing lateral mass with a towel clamp in posterior transpedicular fixation, and explore the efficacy and feasibility.Twenty-one consecutive patients with unstable atlas fracture were treated via this method from October 2012 to July 2017. All cases had neck pain and restricted motion of neck movement on admission. Electronic medical records and pre- and postoperative radiographs were reviewed. Screw and rod placement, bone fusion, and spinal cord integrity were assessed via long-term follow-up with anteroposterior and lateral radiographs and computed tomography. Follow-up included clinical assessment of neurological function, assessment of pain using the visual analog scale (VAS), and assessment of the activities of daily living using the neck disability index (NDI).The mean follow-up duration was 22.1 months (range: 12–54 months). No screw loosening or breakage, plate displacement, neurovascular injury, and severe complications occurred during follow-up. The mean operative time was 112.4 ± 14.9 min (range: 82–135 min), and mean blood loss was 386.2 ± 147.9 mL (range: 210–850 mL). One patient experienced continuous neck pain postoperatively, but this gradually disappeared with analgesic administration. At final follow-up, all patients had bone fusion, the VAS scores and NDI were significantly improved compared with preoperatively.Fixing the C1 lateral mass with a towel clamp during posterior transpedicular fixation for unstable atlas fracture appears to be a safe and reliable method, with the advantages of being a simple technique with few complications.

Combination hand–instrument tension suture tie

Tying sutures under tension is a common challenge in surgery. Various solutions to this problem include pulley sutures, buried mattress sutures, hand tension ties, towel clamps, and surgical assistant to physically relieve tension on the closure. Disadvantages of these techniques include increased suture waste and additional time involved in suture placement.1 Penetrating towel clamps cause tissue trauma and require an extra instrument on the tray. For various reasons, support staff are not always readily available.

Surface adhesive and hand-aided needle-assisted biopsy technique (SAHNA).

We describe a novel and efficient CT biopsy technique that we have termed 'skin adhesive and hand-aided biopsy technique', shortened to the acronym SAHNA. This technique is ideal for biopsying surface osseous lesions where there is a lack of subcutaneous fat. This avoids the need for the radiologist's hand to be in close proximity to the CT scanner beam at the time of intervention. The SAHNA technique uses a plastic surgical forceps towel clamp to stabilise the biopsy needle just proximal to the lesion after piercing through the skin. The clamp itself is stabilised via a self-adhesive dressing which is stuck down to the skin at its shank. In our institution, we have already used the SAHNA technique successfully in over 5 cases. The SAHNA technique is a widely accessible and effective way of stabilising the CT biopsy needle in technically challenging superficial bony lesions.

A novel three-dimensional strapping reduction for the treatment of patellar fractures

ObjectiveThis study aimed to investigate the effectiveness of a three-dimensional strapping reduction in the treatment of patellar fractures.MethodsBetween January 2015 and June 2017, a total of 56 patients were randomly allocated to the three-dimensional strapping reduction group (trial group) and towel clamp reduction group (control group). There were no significant differences in age, gender, injury side, the interval time from injury to surgery, fracture pattern, and cause of injury (P > 0.05). The operation time, fluoroscopy time, bone union time, postoperative Hospital for Special Surgery (HSS) scores, and complications were recorded and analyzed.ResultsAll incisions achieved primary union. All patients in both groups completed a follow-up with an average of 12.5 months (range 11–15 months). Both operation time and fluoroscopy time in the trial group were significantly shorter than those in the control group (P < 0.001). All patellar fractures achieved bone union, and there was no significant difference in bone union time between the two groups (P > 0.05). Bone nonunion, infection, and fixation failure were not found in both groups. HSS scores of the trial group (90.9 ± 4.2) were higher than those of the control group (86.6 ± 5.2) (P < 0.01).ConclusionCompared with towel clamp reduction, the three-dimensional strapping reduction in the treatment of patellar fractures has advantages of shorter operation time and fluoroscopy time, better knee function after surgery, and satisfactory fracture healing.

Direct Trocar Insertion with Elevation of the Rectus Sheath in Bariatric Surgery: A Novel Technique.

Initial trocar entry, the first step in laparoscopic surgery, is associated with several complications. In morbidly obese patients, initial trocar placement is associated with a greater number of complications compared to non-obese patients. Materials and Surgical Technique. In this study, we describe our use of an initial trocar entry technique which is direct trocar insertion with elevation of the rectus sheath by a single Backhaus towel clamp and we would like to evaluate the sa fety and efficacy of its administration in bariatric surgery. Our results indicate that gaining initial trocar entry using our technique leads to successful laparoscopic bariatric surgery. Our technique is a safe, effective, and reliable first step in successful laparoscopic surgery for almost all patients, and is only contraindicated in patients with severe hepatomegaly.

Is there any difference between the distances created by towel clamp lifting and towel clamp plus manual lifting of the anterior abdominal wall for direct trocar entry in laparoscopic gynecologic surgery? A prospective interventional study.

Objective:Most surgeons prefer to perform anterior abdominal wall lifting during abdominal entry to avoid damage to intestines or main vessels. Anterior abdominal wall lifting is assumed to prevent vital organ injuries by creating an adequate distance prior to entry into the peritoneal cavity. In this study, we compared the distance created for trocar entry into the peritoneal cavity with towel clamp lifting and towel clamp plus manual elevation of the anterior abdominal wall.Material and Methods:Forty patients who underwent various laparoscopic procedures were enrolled. The study was performed in two steps: first the anterior abdominal wall was lifted using towel clamps (TC group), next the anterior abdominal wall was lifted via maximal manual elevation from the lower abdomen in addition to towel clamps (TCM group). The insertion distance of a plastic ruler into the abdomen was measured from the parietal peritoneum to the intra-abdominal structure in both groups.Results:There was a statistically significant difference between the two groups (TC group 3.9±1.5 cm vs. TCM group 4.5±1.5 cm, p<0.001). Correlation analysis of the relationship of distance with BMI in the study groups revealed a strong negative linear correlation [TC group vs. body mass index (BMI); r=-0.719, p<0.001 and TCM group vs. BMI, r=-0.749, p<0.001]. Correlation analysis of the relationship between the study groups and parity number revealed a weak negative linear correlation (TC group vs. parity number, r=-0.071, p=0.76 and the TCM group vs. parity number, p=0.61), which did not reach statistical significance.Conclusion:The recruitment of both towel clamps and manual elevation in anterior abdominal wall lifting provides significantly greater distance for trocar entry in laparoscopic surgery.

Minimum alveolar concentration of isoflurane in dogs administered two morphine doses

ABSTRACT: This study aimed to evaluate the effects of intramuscular 0.5mg kg-1 (MOR0.5) and 1.0mg kg-1 (MOR1.0) morphine premedication on the minimum alveolar concentration of isoflurane (ISOMAC) in dogs. Eighteen client-owned female dogs were scheduled for elective ovariohysterectomy. Dogs received intramuscular MOR0.5 or MOR1.0 as premedication and propofol IV for induction of anesthesia. Isoflurane was delivered for maintenance of anesthesia and dogs were maintained under normocapnia and normothermia. Determinations of the ISOMAC were conducted by use of the “up-and-down” method. Noxious stimulus (placement of Backhaus towel clamps, a midline skin incision and subcutaneous tissue dissection) was delivered approximately 50 minutes after premedication with MOR0.5 or MOR1.0. The calculated ISOMAC was 0.98±0.15% in MOR0.5 and 0.80±0.08% in MOR1.0. The ISOMAC was significantly lower in MOR1.0 compared with MOR0.5 (P=0.010). Results of this study suggested that intramuscular premedication with morphine 0.5 and 1.0mg kg-1 decreases the ISOMAC in a dose-related manner in dogs.

Clinical study of three-dimensional strapping reduction in treatment of patellar fracture

To investigate the effectiveness of three-dimensional strapping reduction in treatment of patellar fracture. Between January 2015 and June 2015, thirty-two patients were randomly allocated to three-dimensional strapping reduction group (trial group) and towel clamp reduction group (control group). There was no significant difference in age, gender, damage side, interval from injury to opreration, fracture pattern, and cause of injury ( P>0.05). The operation time, fluoroscopy time, fracture healing time, postoperative Hospital for Special Surgery (HSS) scores, and complications were collected and analysed. All incisions healed at stage I. All patients of 2 groups were followed up 10-14 months (mean, 12.4 months). The operation time and fluoroscopy time of trial group were both shorter than those of control group ( t=6.212, P=0.000; t=6.585, P=0.000). X-ray films showed that the fractures in both groups healed successfully and there was no significant difference in healing time between groups ( t=1.973, P=0.058). Bone nonunion, infection, and failure fixation were not found in both groups. HSS scores of trial group (91.6±3.8) was higher than that of control group (86.4±5.5) ( t=-3.105, P=0.004). Compared with towel clamp reduction, the three-dimensional strapping reduction in treatment of patellar fracture has the advantages of shorter operation time and fluoroscopy time, better knee function after operation, and satisfactory fracture healing.

Surgical Treatment of Ankle Syndesmosis Injuries with Syndesmosis Elastic Hook.

Surgical Treatment of Ankle Syndesmosis Injuries with Syndesmosis Elastic Hook.

3D Printed Surgical Instruments Evaluated by a Simulated Crew of a Mars Mission.

The first space-based fused deposition modeling (FDM) 3D printer became operational in 2014. This study evaluated whether Mars simulation crewmembers of the Hawai'i Space Exploration Analog and Simulation (HI-SEAS) II mission with no prior surgical experience could utilize acrylonitrile butadiene styrene (ABS) thermoplastic surgical instruments FDM 3D printed on Earth to complete simulated surgical tasks. This study sought to examine the feasibility of using 3D printed surgical tools when the primary crew medical officer is incapacitated and the back-up crew medical officer must conduct a surgical procedure during a simulated extended space mission. During a 4 mo duration ground-based analog mission, five simulation crewmembers with no prior surgical experience completed 16 timed sets of simulated prepping, draping, incising, and suturing tasks to evaluate the relative speed of using four ABS thermoplastic instruments printed on Earth compared to conventional instruments. All four simulated surgical tasks were successfully performed using 3D printed instruments by Mars simulation crewmembers with no prior surgical experience. There was no substantial difference in time to completion of simulated tasks with control vs. 3D printed sponge stick, towel clamp, scalpel handle, and toothed forceps. These limited findings support further investigation into the creation of an onboard digital catalog of validated 3D printable surgical instrument design files to support autonomous, crew-administered healthcare on Mars missions. Future work could include addressing sterility, biocompatibility, and having astronaut crew medical officers test a wider range of surgical instruments printed in microgravity during actual surgical procedures. Wong JY, Pfahnl AC. 3D printed surgical instruments evaluated by a simulated crew of a Mars mission. Aerosp Med Hum Perform. 2016; 87(9):806-810.

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.

Post castration evisceration

See also article by Torre et al.

EComment. Efforts to further enhance the safety of sternal re-opening in the paediatric age group

We thank Gandolfo et al. for their effective and easy reproducible technique for managing major vessel injuries during chest re-entry in children [1]. As diagnostic and therapeutic interventions in congenital heart diseases advance progressively, cardiac surgeons have begun to deal with chest re-opening more frequently. Although major venous damages like innominate vein can be managed by a Fogarty catheter, cardiac surgeons are still facing challenging problems, such as damage of cardiac chambers, retrosternal right ventricle to pulmonary artery conduits and ascending aortic aneurysms during the re-sternotomy procedures performed in children. In such cases, we believe that the inflation of Fogarty catheters may even enlarge the defect and make it more uncontrollable in an incomplete sternotomy. In our practice, patients with a sternotomy history are carefully evaluated before the operation. Although the best option in imaging work-up is computed tomography, its routine usage is avoided so as not to increase the exposure of ionizing radiation in the paediatric age group. In most of the patients with redo cardiac surgery, magnetic resonance angiography or lateral projection of cardiac cine-angiography studies demonstrate the potential adhesions of the anatomic structures to the posterior part of the sternum. At the operation, we regularly mark the femoral vessels with Doppler ultrasonography and prepare a cardiopulmonary bypass (CPB) set-up before initiating the incision. The skin incision is performed subsequently, the sternal wires are untwisted and an oscillating saw is used to open the anterior table of the sternum until contact with the sternal wires at the posterior side is felt. The untwisted wires are held with clamps and the sides of the sternum are pulled upwards in which a lateral retraction force is strictly avoided. Afterwards, the posterior table of the sternum is carefully opened starting with xiphoid process towards the jugular fossa with the aid of Mayo scissors. We believe hyperinflation of the lungs, which decompresses the right atrium and ventricle, is a safe and easy measure during this part of the re-entry process [2]. We neither use electrocautery nor blunt digital manipulation for the dissection of the mediastinum. As described by Holst et al. we can clinically group cardiac injuries during sternal re-entry procedures into two categories [3]. A cardiac injury in re-sternotomy is an anticipated (i.e. expected) injury when there is a conduit, an aortic aneurysm, an enlarged right atrium or ventricle which is adherent to the posterior surface of the sternum. In such cases, we prefer to initiate CPB with femoral arterial and venous cannulation before sternal re-entry. This provides us with a safer re-entry process in the mediastinum with decompressed cardiac chambers. The main disadvantage of initiating CPB at the early stage of surgery is the prolonged duration of CPB and uneasiness of controlling the haemostasis in a heparinized patient. CPB may be discontinued after the safe entry to the mediastinum and dissection may be completed off-pump in order to shorten the CPB time. In unanticipated injuries, when a massive bleeding occurs, we discontinue the re-sternotomy and join the two sides of the sternum with two towel clamps. The femoral artery and vein are then promptly cannulated before further dissection at the mediastinum after which CPB is initiated. As a result, besides meticulous surgical technique and judicious usage of CPB, we believe that simple and easily applicable precautions can decrease the incidence of cardiac injuries being encountered during sternal re-opening procedures. These precautions will obviously stipulate a prudent, safe and bloodless operative field for the surgical team. Conflict of interest: none declared.

Technical Facilitation of the Fleur-de-Lis Abdominoplasty for Symmetrical Resection Patterns in Massive Weight Loss Patients

Sir:FigureThe vertical skin excision in fleur-de-lis abdominoplasty1 can complicate the preoperative planning and the procedure itself compared with traditional abdominoplasty techniques. Irregularities caused by asymmetrical skin resections can lead to unfavorable results and have to be avoided. In this communication, we describe a novel technical method of facilitating symmetrical resection patterns in fleur-de-lis abdominoplasty. Unlike in other previously described techniques,2–5 the vertical and horizontal resection patterns are defined not preoperatively but during the operation after mobilization of the tissue with the help of a “plumb-line” suture stretching from the xiphoid to the mons pubis. Marking is performed preoperatively with the patient standing and begins by drawing a line between the xiphoid appendix and the pubic symphysis (median line), which marks the vertical incision line. Then, the lower abdominal skin is stretched cranially and the horizontal incision line is marked. The horizontal incision is carried out first. Sharp dissection is performed up to the level of the umbilicus. The lower flap is split in the midline and the umbilicus transected and preserved on a stalk. Supraumbilically, the vertical incision is now continued approximately up to the level of the xiphoid process. Epifascial dissection is continued in an inverted V shape (Fig. 1). The skin flaps are left attached to the underlying fascia, except in the areas that are contained within the fleur-de-lis excision. If necessary, a wide abdominal rectus plication is performed. The operating table is flexed at the patient's waist to reduce tension.Fig. 1: Tissue mobilization and definition of the new flap tip A′.At this stage, the point of confluence of the horizontal and vertical incisions is defined. This new flap tip is marked as A′ in Figures 1 and 2 [the blue cross (A) marks the flap tip before excision]. Using a sharp towel clamp placed subcutaneously caudally in the middle of the horizontal incision (red cross), the remaining mons pubis is moderately pulled upward (Fig. 1, left) and the mobilized flaps are pulled inferomedially (to obtain an oblique vector, indicated by the upper arrow in Fig. 1) over the towel clamp, which can be palpated through the flaps, and the point is marked as new flap tip A′.Fig. 2: Use of the plumb-line suture for intraoperative marking of the resection margins. Note the symmetrical markings. The preoperatively marked supraumbilical horizontal lines are matching each other and facilitate symmetrical closure.A suture is placed at the level of the xiphoid process in the midline and is pulled toward the marking of the midline caudally of the horizontal incision (Fig. 2). This suture is used as a plumb-line. Now, both flaps are pulled inferomedially under the suture so that the newly defined point of confluence A′ is met by the suture that is marking the midline, and tissue exceeding the midline indicated by the plumb-line suture is marked for resection on both sides (Fig. 2). To define the horizontal resection line, three sharp towel clamps are placed along the caudal incision on either side of the midline subcutaneously and pulled cranially, and the mobilized flaps are pulled inferomedially again, and the points on which the clamps can be palpated are marked. En bloc resection is carried out and hemostasis is achieved by electrocautery. Now, the inferomedial edges of the skin flaps are fixed to the suprapubic skin at the midline with a strong suture. Two Redon drains are placed under the skin flaps and the incisions are closed by a single running subcuticular layer using 2-0 polypropylene suture. The umbilicus is inset into the vertical incision. This novel approach simplifies the fleur-de-lis technique and allows for the intraoperative determination of the resection margins with symmetrical resection patterns. Steffen U. Eisenhardt, M.D. Sebastian M. Goerke Holger Bannasch G. Björn Stark Nestor Torio-Padron Department of Plastic and Hand Surgery, University of Freiburg Medical Centre, Freiburg, Germany

Sedative, analgesic, cardiopulmonary and haemodynamic effects of medetomidine-butorphanol and midazolam-butorphanol on thiopental-propofol anaesthesia in water buffaloes (Bubalus bubalis)

The sedative, dose sparing, cardiopulmonary and haemodynamic effects of medetomidine-butorphanol and midazolam-butorphanol, on thiopental-propofol anaesthesia were evaluated in six healthy male water buffaloes (2 to 3 years; 290 to 325 kg). Group P1 received medetomidine (2.5 µg/kg) + butorphanol (0.05 mg/kg) intravenously, while in group P2 midazolam (0.25 mg/kg) + butorphanol (0.05 mg/kg) were used intravenously at 7 days interval. After 15 min of premedication, anaesthesia was induced by 5% thiopental sodium intravenously. The anaesthesia was maintained with continuous intravenous infusion (CII) of 1% propofol in both groups up to 120 min and the depth was determined by towel clamp method. Cardio-respiratory and haemodynamic parameters were assessed up to 120 min after preanaesthetic administration. Medetomidine-butorphanol produced better sedation in comparison to midazolam-butorphanol. However, this combination produced more depression of cardiovascular system during preanaesthetic period but lesser depression of cardiorespiratory dynamics in post-induction and during maintenance period and quicker recovery was observed. Significantly lesser doses of thiopental sodium were required in the animals of group P1. It can be concluded that medetomidine–butorphanol produced better quality sedation and analgesia and quicker recovery with significantly more reduction in the induction dose of thiopental sodium and propofol and lesser cardiopulmonary effects than midazolam-butorphanol in buffaloes.