Use Of Loupe Magnification Research Articles

Loupe Assisted Thyroidectomy: A Tool for Reducing Complications.

The objective of this study is to assess if the use of magnification can reduce the incidence of hypocalcemia and vocal cord palsy in thyroid surgery. Data of patients who underwent total thyroidectomy (N = 50) for thyroid malignancy were analyzed retrospectively for 1year. The patients were divided into two groups based on surgery with and without loupes. Hypocalcemia and Vocal cord palsy was assessed pre as well as post-operatively and the observations were noted. Descriptive statistics were performed to assess the proportion of the respective groups. Inferential statistics to find out the difference between the groups was done using the chi-square test. Significance level was kept at 5%. The incidence of hypocalcemia was 36.9% in the group done without loupes compared to 7.6% with loupes. The event of vocal cord injury though transient was 33% when done without loupes (p < 0.05). Magnification is crucial for the visualization of the neurovascular anatomy which is depicted in our study. Although the study includes less number of cases, it is evident that the use of loupe magnification can reduce the morbidity associated with thyroid surgery to a great extent. We recommend the use of loupe magnification during surgery whenever possible.

Dental Magnification Loupes: An Update of the Evidence

To overview dental magnification loupes and to present the updated scientific evidence supporting its use. The practice of dentistry places considerable stress on the operators' visual acuity and musculoskeletal system. The use of magnification loupes has spanned many decades with claims of supporting visual and postural capacities of dental professionals and enhancing diagnostic and procedural accuracy. Galilean and prismatic loupes both provide lightweight and clinically appropriate magnifications between 2.5× and 5.0×, with beneficial features such as a fixed working distance and downward lens inclinations. Studies have found significantly increased detection and diagnostic abilities due to enhanced visibility and improved treatment outcomes for some investigated procedures. Postural studies have found improved positioning of the upper body when using loupes as compared to the positioning when using the naked eye, with practitioners experiencing reductions in musculoskeletal symptoms when using magnification loupes. The current evidence supports the presence of some visual advantages of loupe magnification in diagnosis and treatment delivery. However, more clinical trials are needed to investigate different procedure outcomes over the long term. Further, there is robust scientific evidence advocating the use of loupe magnification for postural and musculoskeletal support. Dentistry is a visually and physically demanding profession with a high prevalence of musculoskeletal disorders among dental professionals. The use of loupe magnification potentially benefits both the dental healthcare provider and patients. Therefore, there is reason to consider the use of loupe magnification as an integral part of dental education and training, as well as a tool in the dental clinician's armamentarium.

No Longer a Pain in the Neck: Use of Operating Microscope for Palatoplasty.

For craniofacial surgeons, cleft palate repair is an intricate and difficult operation positionally. Historically, use of loupe magnification and a headlight can cause significant strain to the surgeon's neck and, at times, subpar optics for both the operator and the assistant. The use of an operating microscope was first advocated by Sommerlad in 2003. By using the operating microscope for cleft palate closure, there are improved ergonomics for the surgeon and assistant by allowing for straight in-line back and neck posture with excellent visualization of the surgical field for the entire surgical team. The available zoom and focus improve the ability to isolate and repair the levator veli palatini muscle. Proper posture with a neutral cervical spine will help prolong a surgeon's career and ability to care for their patients.

Global incidence of incomplete surgical excision in adult patients with non-melanoma skin cancer: study protocol for a systematic review and meta-analysis of observational studies

BackgroundNon-melanoma skin cancer, which includes basal cell carcinoma and cutaneous squamous cell carcinoma, is the commonest malignancy worldwide. The mainstay of treatment is surgical excision. Despite this being an exceptionally common procedure, it is not known what the accepted standard is for incomplete excision. Multiple single-centre, regional and national studies have previously reported their incidence of incomplete excision in isolation. Furthermore, is it not known what effect potential risk factors such as the operating group, location of lesions, type of reconstruction, histological components or use of loupe magnification have on the incidence of incomplete excisions. The objective of this study will be to systematically evaluate observational data that present incidence of incomplete surgical excision amongst adult patients with non-melanoma skin cancer worldwide.MethodsWe designed and registered a study protocol for a systematic review and meta-analysis of descriptive epidemiology data. A comprehensive literature search will be conducted (from January 2000 onwards) in MEDLINE, EMBASE, Scopus, CINAHL, EMCare and Cochrane Library. Grey literature will be identified through searching Open Grey, dissertation databases (e.g. Open Access Theses and Dissertations) and clinical trial registers (e.g. WHO ICTRP). Observational studies (cohort, cross-sectional, case series and clinical audits) reporting the incidence of incomplete surgical excision and conducted in adult patients with non-melanoma skin cancer will be included. The primary outcome will be the incidence of incomplete surgical excision (defined as residual tumour at either the peripheral or deep margin). Secondary outcomes will be risk factors that may affect incomplete excision (e.g. operating group, location of lesions, types of reconstruction, histological components). Data will not be extracted if the study uses other surgical techniques such as Mohs micrographic surgery, intra-operative frozen section, incision, shave or punch biopsies. Two investigators will independently screen all citations, full-text articles and abstract data. Potential conflicts will be resolved through discussion. No limitations will be imposed on publication status or language of publication. The study methodological quality (or bias) will be appraised using an appropriate tool. If feasible, we will conduct a random effect meta-analysis of observational data. Incidence estimates will be stratified according to cancer type (e.g. basal cell carcinoma vs squamous cell carcinoma) and operating group (e.g. dermatology, plastic surgery and general practice). Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g. methodological quality, sample size).DiscussionThis systematic review will summarise the best available evidence and definitively establish the incidence of incomplete surgical excision in non-melanoma skin cancer. It will determine if there is variation observed amongst different operating groups and provide some evidence for potential other factors causing this difference. This knowledge will provide a standard for future audits and will contribute to improving the treatment of non-melanoma skin cancer treatment.Systematic review registrationPROSPERO CRD42019157936

Comparative evaluation of second mesiobuccal canal detection in maxillary first molars using magnification and illumination

Aim: This in vitro study evaluated the effectiveness of detecting the presence of second mesiobuccal (MB2) canal in the maxillary first molars, using magnification and illumination. Materials and Methods: Access cavities of fifty extracted human maxillary first molars were prepared, and the floor of the pulp chamber was then explored to locate the MB2 canal in five stages: Stage I (direct vision), Stage II (under ×2.5 magnifying loupes without light-emitting diode [LED] light), Stage III (under ×2.5 magnifying loupes with LED light), Stage IV (under operating microscope at ×5), and Stage V (under operating microscope at ×12.8). Statistical Analysis: The descriptive statistics were tabulated using the kappa statistic to check the association between the five groups. Results: The operating microscope at ×5 and ×12.8 gave a diagnostic accuracy of 100%, followed by magnifying loupes with LED light which gave a diagnostic accuracy of 90% in detecting the presence of MB2 canal. The use of magnifying loupes without LED light and plain eyesight gave a comparatively lesser diagnostic accuracy, i.e., 76% and 68%, respectively. Conclusion: The operating microscope with a sensitivity and diagnostic accuracy of 100% was most effective in the detection of MB2 canals followed by magnifying loupes with LED light.

Can the operating time be reduced by use of magnification in Total Thyroidectomy? A preliminary Study

Introduction: Total thyroidectomy is a major surgical procedure which is becoming increasingly popular. Operating Time taken for total thyroidectomy can be approximately 3- 4 hours. Thyroidectomy surgeries still occupy a significant portion of busy general surgical lists in high volume thyroid centers such as Surgical Professorial Unit of Teaching Hospital Karapitiya. With resource constrains this implies much theatre time, staff and costs with significant bearing on health care demands. Reduction in operating time with consequent reduction in time under anesthesia is beneficial to patient too. This study was carried out to explore whether the surgical time is reduced by using magnification by the surgeon for total thyroidectomy. Methods: The operating procedure of total thyroidectomy was divided in to 10 phases for the purpose of study. Surgeon A, who has been doing thyroid surgery for last 10 years without any magnification, was selected as the object of the study. Three total thyroidectomies performed by surgeon A was observed and records were made by surgeon B for timing of each phase and for any other significant events occurred during the operation. Surgeon A has been using magnification for next 10 thyroidectomies which allowed him to get over the steepest part of the learning curve. This was not included in the study. Subsequently surgeon A performed 14 thyroidectomies over next two months and 11 of them were observed by the other surgeon B. Results: Results of the three observed thyroidectomies done without magnification: Control Group (CG) was compared with the group in which thyroidectomies were done under magnification: Study Group (SG). There were no significant difference between SG and CG with regard to time taken during the path from skin incision to isthmus (S1). During the dissection over anterolateral surface of the left lobe (S2) significant difference was observed with CG gaining 1.91 minute average time advantage. More deliberations were observed over small strands containing minute blood vessels which were usually dissected bluntly in CG. Total operating time (Skin to skin) was 109.76 minutes for SG and 146.67 for CG. Conclusion: The study shows that approximately 45 minute reduction in operating time can be achieved with use of loupes. This preliminary study has given an insight in to how and why operating time for total thyroidectomy can be reduced by the use of loupe magnification.

Does Loupe Magnification Reduce the Gap Between the Macroscopic and Microscopic Border of a Basal Cell Carcinoma?

Incomplete excision of a basal cell carcinoma (BCC) remains a frustrating problem. Various attempts have been made to decrease the rate of incomplete excisions, including the use of loupe magnification. A prospective, controlled study is presented, which was designed to evaluate whether loupe magnification (×3.5) leads to a more accurate determination of the clinical border of primary facial BCCs. The objectives of this study were 4-fold: to analyze if there was a statistically significant difference when using a loupe magnifier or not in (1) rate of incomplete excisions, (2) width of histologic margins, (3) excised surface areas, and (4) types of closure. Ninety primary facial BCCs in 81 patients were treated by conventional surgical excision. Forty-five BCCs (40 patients) were excised with loupe magnification, and 45 (41 patients), without. Although the number of incomplete excisions was equal in both groups (n=3), the mean histologic margin was larger in the study group (2.4 mm) compared with the control group (2.1 mm). This could illustrate the enhanced visualization by using a magnifier, which consequently results in excising a lesion with excessive unaffected skin, after adding a standard surgical margin. Furthermore, the mean surface area of BCCs was larger in the study group (103.7 mm) compared with that in the control group (76.1 mm). More defects were closed in a nonprimary fashion in the study group (n=14) compared with the control group (n = 10). However, none of these differences did reach statistical significance. Our results could implicate that the determination of the surgical margin might be influenced not only by size, location, and histologic subtype of the tumor but also by the method of tumor assessment. This means that deciding on the appropriate surgical margin might be adapted according to the method of preoperative evaluation of tumor extensions.

Video-microscopy for use in microsurgical aspects of complex hepatobiliary and pancreatic surgery: a preliminary report

BackgroundThe use of loupe magnification during complex hepatobiliary and pancreatic (HBP) surgery has become routine. Unfortunately, loupe magnification has several disadvantages including limited magnification, a fixed field and non-variable magnification parameters. The aim of this report is to describe a simple system of video-microscopy for use in open surgery as an alternative to loupe magnification. MethodsIn video-microscopy, the operative field is displayed on a TV monitor using a high-definition (HD) camera with a special optic mounted on an adjustable mechanical arm. The set-up and application of this system are described and illustrated using examples drawn from pancreaticoduodenectomy, bile duct repair and liver transplantation. ResultsThis system is easy to use and can provide variable magnification of ×4–12 at a camera distance of 25–35cm from the operative field and a depth of field of 15mm. This system allows the surgeon and assistant to work from a HD TV screen during critical phases of microsurgery. ConclusionsThe system described here provides better magnification than loupe lenses and thus may be beneficial during complex HPB procedures. Other benefits of this system include the fact that its use decreases neck strain and postural fatigue in the surgeon and it can be used as a tool for documentation and teaching.

Robotic vasovasostomy: description of technique and review of initial results.

Vasovasostomy (VV) for iatrogenic infertility is commonly employed for patients with obstructive intervals of less than 15years, with the microsurgical technique gaining favor over use of loupe magnification due to precision suture placement. We present our technique of a robot-assisted VV and compare surgical times of staff to resident. Twenty patients with iatrogenic infertility and obstructed intervals of less than 10years underwent robot-assisted VV, 17 utilizing a single-layer reapproximation and 3 using a double-layer reapproximation. Average patient age was 32.9years. Following vasal exposure, the staff performed the robot-assisted anastomosis on one side followed by the resident on the opposite side. Reanastomosis times and semen analyses were recorded. Twenty patients underwent successful single- or double-layer robot-assisted vasovasostomy. Mean console time for staff to complete the vasal reconstruction was 37.6min compared to the resident time of 54min. Mean total operative time for all procedures was 187min (single-layer procedure averaged 182min compared to double-layer repair which averaged 238min). Thirteen patients returned for follow-up semen analysis, with twelve patients demonstrating sperm within the ejaculate. Additionally, two patients reported pregnancies for a patency rate of 93%. Mean sperm density was 14 million/ml with motility of 26.4%. Robot-assisted vasovasostomy is a technically feasible procedure demonstrating adequate results on follow-up semen analysis, and can be included in training residents in robotic surgery. Additional data are needed to determine its role in the management of iatrogenic infertility.

A Survey Study of Occupational Pain and Injury in Ophthalmic Plastic Surgeons

To determine factors associated with pain/injury related to practicing ophthalmic plastic and reconstructive surgery. A 29-question electronic survey was sent to the American Society of Ophthalmic Plastic and Reconstructive Surgery's listserv. The Chi-Squared Automatic Interaction Detector technique was used to generate a decision tree using SPSS software. The levels of dendograms were limited to 8. Significance was pre-established at α = 0.05. One hundred thirty surveys were completed, and 72.5% reported pain associated with operating, 80.9% reported use of loupe magnification, 68.7% reported use of a headlight, 42.5% reported modification of their operating room practice, and 9.2% reported stopping operating due to pain or spine injury. Most respondents regularly exercise, with 55.7% characterizing the amount of exercise as less than necessary; 60.8% and 57.3% agreed that loupe use and headlamp use, respectively, can lead to spine problems.Chi-Squared Automatic Interaction Detector analysis found that 62.7% (n = 47) with neck pain had modified their operating room practice, compared with 13.5% (n = 7) without pain (χ = 30.42; df = 1; p < 0.001); All surgeons that had to stop operating (n = 9) had tried modifying their operating room practice; over half (57.6%, n = 38) of practicing surgeons had changed their operating room practice (χ = 6.09; df = 1; p = 0.014). The majority who exercised 5 hours or less had modified their operating room practice (70.2%, n = 33), compared with 26.3% (n = 5) who exercised more. Many oculoplastic surgeons experience discomfort due to operating, and an alarming minority have stopped operating due to pain or neck injury. Participants identified loupe and headlamp use as a special concern.

The Utility of Optical Loupe Magnification for Testis Sperm Extraction in Men With Nonobstructive Azoospermia

The testis of patients with nonobstructive azoospermia (NOA) harbors sperm in approximately 30% to 60% of cases. Use of an operating microscope has been shown to result in better sperm retrieval rates. This investigation was undertaken to evaluate the ability of a modified microsurgical approach using magnifying loupes (3.5x) to improve the rates of sperm retrieval during testis sperm extraction (TESE). The study group consisted of patients with NOA who underwent TESE. Before December 1998, TESE was conducted in a standard fashion, and from 1999 on, loupe magnification was used. Comparison was made between the 2 groups with regard to sperm retrieval rates, need for bilateral TESE, and number of tunical incisions. Overall sperm retrieval rates did not differ between the 2 groups (45% vs 50%). However, in patients with testicular volumes of 10 mL or less, patients who underwent standard TESE had a retrieval rate of 27% compared with 42% when using the optical loupe magnification (P = .025). The use of loupe magnification may permit surgeons without access to or experience using an operating microscope to obtain better rates of sperm retrieval in men with NOA who have testicular volumes of 10 mL or less.

Dupuytren???s Fasciectomies in 60 Consecutive Digits Using Lidocaine with Epinephrine and No Tourniquet

Dupuytren's contracture is a common hand problem. Its treatment, other than percutaneous fasciectomy, is an outpatient operation performed with the patient under regional or general anesthesia. If local anesthetics are used, they are used without epinephrine, and an arm or forearm tourniquet is essential. Multiple reviews have described the safety of local anesthetics with epinephrine in the digits. This study is a retrospective review of operations performed by the same surgeon in the hospital (43 digits) versus the office using local anesthetics with epinephrine and no tourniquet (60 digits). Results and complications were compared and tabulated. The hospital and epinephrine groups were comparable regarding preoperative measurements. Postoperative improvement in extension at the metacarpophalangeal and proximal interphalangeal joints was similar in both the hospital and epinephrine groups. Complications, including digital nerve and artery injuries, infections, and hematomas, were similar between the groups. There were no cases of digital necrosis or gangrene in the epinephrine group, even though one patient sustained a transection of a digital artery at the proximal interphalangeal joint. Because of the similarities in results and complications, there does not seem to be an advantage to performing Dupuytren's excisions with full arm tourniquet and outpatient admission in many cases. Local anesthetics with epinephrine are safe in the treatment of Dupuytren's contracture, although both the use of digital epinephrine and the use of mechanical tourniquets carry the potential for complications. Visibility is similar to that for facial or head and neck surgery and is aided by the use of loupe magnification. The old dogma against its use in the fingers is refuted, as seen by the results in these 60 consecutive Dupuytren's fasciectomies and the results of other authors.

COMPLICATIONS OF ARTERIAL RECONSTRUCTION AND A NEWLY-DEVISED RELIABLE TECHNIQUE OF ARTERIAL ANASTOMOSIS IN LIVING DONOR LIVER TRANSPLANTATION

P548 Aims: In living donor liver transplantation (LDLT), microsurgical reconstruction of fine hepatic arteries has been introduced to reduce surgical complications such as hepatic artery thrombosis (HAT). We reviewed arterial reconstructions in 72 LDLTs and analyzed its complications and devised the anastomosis skill to reduce technical errors. Methods: From August 1996 to March 2004, we performed a series of 72 LDLTs on 54 adults and 18 children under 18 years old. They received 33 extra-right lobe grafts (16 lateral segment grafts, 10 left lobe grafts and 7 extended left lobe grafts) and 39 right lobe grafts. Results: Hepatic arterial reconstruction was performed by an end-to-end anastomosis under an operating microscope except for 3 adult cases who received right lobe grafts with the use of loupe magnification. The complication rate was lower in the right lobe graft group (2 / 39, 5.1%) compared with that in the extra-right lobe graft group (4 / 33, 12.1%). The child cases (3/18,16.7%) increased the complication rate compared with the adult cases (3/54, 5.6%). 3 cases required a reanastomosis in primary operation due to HAT or poor arterial flow caused by kinking at anastomosis. We observed 4 postoperative complications which included 2 cases of anastomotic stenosis, a rupture of hepatic artery pseudoaneurysm treated by embolization, and an anastomotic kinking revised by a reanastomosis. Only the case of pseudoaneurysm died of arterial complications. In the use of extra-right lobe graft, especially in pediatric recipients, arterial reconstruction was difficult, because anastomosed arteries in small diameter often ran vertically parallel with the direction of the operator’s eyes. To overcome the difficulty, we have improved the anastomosis technique using a untied-two stay suture method. As a result, surgical experiences significantly improved the incidence of complications chronologically between the early cases up to 1999 (4/13, 30.8%) and the late cases from 2000 (2/59, 3.4%, P=0.0041). Conclusions: The use of the extra-right lobe graft especially on children was the major risk factor of arterial complications in LDLT. Case number-dependent anstomotic reliability and device of anastomosis skills is also important on performance of safer arterial reconstruction..

Living-related liver transplantation.

Living-related liver transplantation.

Hepatic artery thrombosis in living related liver transplantation.

Hepatic artery thrombosis (HAT) after orthotopic liver transplantation remains a significant cause of graft loss in pediatric patients. We previously reported that the microsurgical techniques for arterial anastomosis can reduce the incidence of HAT in living related liver transplantation (LRLT). The purpose of this study is to analyze the risk factors for HAT after LRLT. A total of 245 patients received 250 liver transplants. Eight arteries in eight patients, reconstructed with the use of loupe magnification (HAT; 1/8, 12.5%), were excluded from this study. We observed HAT in 4 patients of the 242 transplants (1.7%, HAT group). Seventeen factors were compared between the HAT and the control group (those without HAT). HAT occurred in 3 of 33 grafts (9%) from ABO-incompatible donors, whereas it occurred in 1 of 209 grafts (0.5%) from identical or compatible donors (P=0.008). The corrected volume of fresh-frozen plasma intraoperatively transfused in the HAT group (46.9+/-30.3 ml/kg) was significantly (P=0.015) different from that in the control group (10.2+/-1.9 ml/mg). In all four patients with HAT, emergent revisions of the anastomosis were performed. Two patients with ABO-incompatible grafts died of hepatic failure and sepsis. Although microsurgical techniques can minimize the surgical risk factors for HAT, overtransfusion of fresh-frozen plasma in high-risk patients (ABO incompatible) may be a critical factor in the development of HAT in LRLT.

The introduction of microvascular surgery to hepatic artery reconstruction in living-donor liver transplantation--its surgical advantages compared with conventional procedures.

Microvascular surgery for the reconstruction of the graft artery has been used since the 8th case in our series of 14 liver transplantations using living-related donors, and the clinical results have been compared between the first seven cases (the Loupe group) and the last seven cases (the Micro group). Seven arteries in 7 grafts were reconstructed with the use of loupe magnification in the Loupe group, while 8 arteries in 7 grafts were anastomosed with microscopic techniques in the Micro group. Statistically, there was no difference between the two groups in general background, including age, body weight and primary disease of the recipient, and in medical and surgical factors possibly relating to postoperative thrombosis of the hepatic artery. In two cases in the Loupe group, one or two additional reconstructions were necessary to obtain sufficient blood flow, while 8 arteries were anastomosed in the Micro group without any arterial complication in the postoperative period. There was no difference in time required for completing the arterial reconstruction (45.1 +/- 18.1 min in the Loupe versus 44.4 +/- 6.9 min in the Micro [mean +/- SEM]). Postoperative ultrasonic Doppler duplex study demonstrated a temporary decrease in the arterial flow in 2 cases of the Loupe group, and partial thrombosis of the artery was suspected. Additionally there were two episodes of hepatic artery thrombosis in 1 case of the Loupe group, in which emergent revision for thrombectomy and reanastomosis was performed at the first episode. This illustrated the higher incidence of arterial complications in the Loupe group compared with the Micro group (4 episodes/7 arteries in the Loupe versus 0/8 arteries in the Micro, P less than 0.05). In the present series there were no graft failures or arterial complications in the three deaths in the series. The clinical improvements achieved by microvascular surgery in living-donor liver transplantation suggest an alternative technical strategy for dealing with problematic arterial reconstruction in adult liver transplantation.