Efficacy of Ring Drape and Unused Sterile Instruments for Incisional SSI After Hepatectomy.

BACKGROUND/AIM: The aim of this study was to verify the efficacy of wound protection with a plastic ring wound protector (ring drape) and using new sterile instruments when closing the abdominal wall (wound closure set), both of which were used to prevent incisional surgical site infection (SSI) after hepatectomy. PATIENTS AND METHODS: The incidence of incisional SSIs and the clinical courses of 572 patients who underwent hepatectomy between January 2010 and December 2015 were studied retrospectively. The patients were divided into three period groups according to the period when each infection countermeasure was started. RESULTS: Incisional SSI incidence decreased significantly with additional countermeasures: 1st period 10.1%; 2nd period 2.08% (p=0.0114); 3rd period, 1.63% (1st vs. 3rd period, p=0.0016). A multivariate analysis showed that postoperative bile leakage [odds ratio (OR)=4.12, p=0.012] and not using a ring drape (OR=0.176, p=0.003) were independent factors for incisional SSI. CONCLUSION: Incisional SSI incidence was significantly reduced by using ring drape after hepatectomy.

[Respiratory and Facial Protection: Current Perspectives in the Context of the COVID-19 Pandemic]. / Proteção Facial e Respiratória: Perspetivas Atuais no Contexto da Pandemia por COVID-19.

The new SARS-CoV-2 pandemic is an example of an international public health emergency, which is associated with considerable social and economic challenges. At the healthcare level there is the risk that nosocomial outbreaks can be local amplifiers. Adequate infection control practices are of critical importance, which include proper use of personal protective equipment. This equipment must be appropriate to the pathogen transmission route that, in the case of SARS-CoV-2, occurs through droplet and contact routes. The infected individual, when talking, coughing or sneezing, spreads droplets containing the virus, directly contaminating other individuals within one to two meters of distance, as well as the surrounding environment. Airborne transmission may occur when aerosol-generating procedures are performed. Concerning respiratory protection, there is currently weak evidence that the use of respirators provides better protection than surgical masks for SARS-CoV-2 or other viruses (with the exception of aerosol-generating procedures, in which case the use of a respirator is recommended). Eye protection should be guaranteed whenever there is a risk of splashes, droplets or aerosols. The use of different, or higher than necessary, level of personal protective equipment, for the transmission route of the agent, is a form of misuse and can affect its supply for situations when it is clearly indicated. The adequate provision of protective equipment, as well as training of healthcare professionals in its correct use, is highly recommended to ensure safety of care.

A nova pandemia por SARS-CoV-2 é um exemplo de uma emergência de saúde pública de âmbito internacional, associada a consideráveis desafios sociais e económicos. A nível das unidades de saúde há o risco que surtos nosocomiais sejam amplificadores locais. Perante tal, práticas de controlo de infeção são de importância crítica no funcionamento destes serviços, de que faz parte a utilização adequada de equipamento de proteção individual. Este deve ser adequado à via de transmissão do agente que, no caso do SARS-CoV-2, é através de gotícula e contacto. O indivíduo infetado, ao falar, tossir ou espirrar, dissemina gotículas que contêm o vírus, contaminando diretamente outros indivíduos, que estão num raio de um a dois metros, assim como o ambiente. A transmissão por via aérea também poderá ocorrer, no caso de procedimentos geradores de aerossóis. A nível da proteção respiratória existe, atualmente, fraca evidência que a utilização de respiradores permita maior proteção que máscara cirúrgica para o SARS-CoV-2 ou outros vírus(com exceção dos procedimentos geradores de aerossóis, em que a utilização de um respirador é recomendada). A proteção ocular deverá ser garantida sempre que houver risco de salpicos, gotículas ou aerossóis. A utilização incorreta de equipamento de proteção individual, para a via de transmissão do agente ou superior ao necessário, é uma forma de uso indevido e pode afetar o seu suprimento para as situações em que é realmente indicado. A disponibilização deste equipamento de proteção, e formação dos profissionais de saúde na sua correta utilização, é fortemente recomendado para garantir a prestação de cuidados seguros.

In Vitro Leakage Testing of Tissue Containment Bags When Subjected to Power Morcellation Forces.

STUDY OBJECTIVE: To determine the ability of tissue containment systems to prevent leakage of cancer cell surrogates when subjected to forces encountered during power morcellation procedures. DESIGN: In vitro study. SETTING: Medical device research laboratory. INTERVENTIONS: Samples from 7 different legally marketed tissue containment bags (1 of which is indicated for power morcellation) were subjected to dye and bacteriophage penetration tests at pressures ranging from 0.5 to 50 times the insufflation pressure. The minimum pressure required to cause bag leakage was measured. Subsequently, the morcellation leakage safety factor for each bag was determined as the ratio of the minimum leakage pressure of the bag to the total pressure contributed from insufflation pressure and mechanical forces acting during the power morcellation procedure. MEASUREMENT AND MAIN RESULTS: The leakage performance of the bags varied markedly from brand to brand. No correlation was found between leakage pressure and the bag material or the total bag thickness. The leakage pressures ranged from 26 mmHg to >1293 mmHg for the 7 bags, and safety factors ranged from 1 to 50 when only the insufflation pressure was considered. However, if the morcellation forces were included in the calculation, the safety factor dropped by 6-fold for all brands and dropped below 1, indicating likelihood of leakage, for 2 of the 7 brands. CONCLUSION: This study provides a mechanism for more realistically simulating the conditions experienced by containment bags during morcellation and quantifying the level of safety provided by the bags.

Role of Preoperative Dexamethasone Nebulization in Reducing Bougie Complications Encountered After Sleeve Gastrectomy: a Prospective Double-Blind Control Interventional Study.

INTRODUCTION: The usage of bougie devices in guiding the extent of sleeve gastrectomies has been associated with several laryngeal and pharyngeal complications. Despite these being distressing for patients, they draw little attention in current literature. OBJECTIVES: To study the role of preoperative nebulized dexamethasone in relieving the symptoms related to bougie insertion during laparoscopic sleeve gastrectomy postoperatively. MATERIALS AND METHODS: A prospective interventional study that included 80 patients. The patients were assigned to two groups, 40 patients in each group: the dexamethasone group (D) which received nebulized dexamethasone 8 mg 1 h before surgery and the control group (S) which received saline nebulizer instead. Assessment of postoperative sore throat, nausea and vomiting, odynophagia, and change of voice was used as an outcome comparative tool. RESULTS: The patient's age ranged from 17 to 61 years, and the mean age of patients was 34.51 (± 9.5) years. Patients were composed of 13 (16.3%) males and 67 (83.8%) females. The study found a significant preference of outcome values in the dexamethasone group. Sore throat mean and medians were less at all-time intervals: 0 h (p < 0.001), 1 h (p < 0.001), 6 h (p < 0.004), and 24 h (p < 0.001). Nineteen patients of the saline group suffered from a change of voice (p < 0.001), compared to only 4 patients in the dexamethasone group. On the contrary, no significant differences are noted in the incidences of PONV and odynophagia. CONCLUSION: Preoperative nebulized dexamethasone was found to be an effective measure in reducing bougie insertion complications in laparoscopic sleeve gastrectomy.

The safety wire with a ureteral access sheath - does it hurt more than it helps?

INTRODUCTION: Studies indicate that with a safety wire in the ureter, an increased amount of force is necessary to advance ureteral access sheaths up to the proximal ureter. Theoretically, the compression of the ureter with the wire could lead to an increase in number and severity of ureteral injuries secondary to placement of a sheath. This prospective study aims to evaluate if there is a correlation between the use of a safety wire and ureteral injury from sheath placement by evaluating the location of the wire in relation to the injury after ureteroscopy. MATERIALS AND METHODS: Fifty-nine consecutive patients underwent ureteroscopy for upper tract urinary stone disease. A 12/14 French ureteral access sheath was used with a safety wire in place. Ureteroscopy during withdrawal of the sheath was video recorded and reviewed by a blinded observer. Visible ureteral injuries were graded per the Traxer ureteral injury scale and the proximity of the wire to the injury was noted. RESULTS: Thirty-one of 59 patients (52.4%) had a ureteral injury secondary to access sheath placement. Eighteen (30.5%) injuries were low-grade, 13 (22.0%) were high-grade (grade 2 and 3) and there were no grade 4 injuries. A total of 10 (32.3%) injuries occurred on the same side as the wire while 67.7% were on the contralateral side of the ureter. Of the injuries that occurred on the same side as the wire, 80% were grade 1 injuries and 2 (20%) were grade 3. Statistical analysis did not show a significant relationship between high/low injury grade and side of injury (p value = 0.088). This suggests that there is no association of between the safety wire and development of high injury. CONCLUSION: There is no association between the location of the safety wire and ureteral injury if injury occurs during the placement of a ureteral access sheath. This suggests that the use of a safety wire does not add significant morbidity to the procedure.

Imaging of Usual and Unusual Complication of Rotator Cuff Repair.

Several complications may be encountered after rotator cuff (RC) repair. A thorough knowledge of surgical interventions, normal postoperative findings, and postoperative complications is crucial to provide a timely diagnosis, improving the clinical outcome of patients. Postoperative complications may involve RC, implanted device, osteochondral tissue, surgical-site infection, peripheral nerves, soft tissues, and vascular structures. In this review, we discuss the usual and unusual complications detectable after RC repair.

Neurosurgical Device-Related Infections.

In this review article, we discuss the epidemiology, microbiology, diagnosis, treatment and prevention of infections associated with cerebrospinal fluid shunts, cerebrospinal fluid drains, and deep brain stimulators. We also briefly discuss prevention strategies with appropriate antibiotics, devices, and operating room practices to decrease the risk of these infections.

Dual Ring Wound Protector Reduces Circular Stapler Related Surgical Site Infections in Patients Undergoing Laparoscopic Roux-En-Y Gastric Bypass.

BACKGROUND: While there are various techniques to create the gastrojejunostomy during a laparoscopic Roux-en-Y gastric bypass (LRYGB), many surgeons prefer using a circular stapler. One drawback of this method, however, is the higher incidence of surgical site infections (SSIs). To investigate the effect of a dual ring wound protector on SSIs during LRYGB. METHODS: In April 2016, our bariatric surgical group implemented an intervention whereby a dual ring wound protector in conjunction with a conical EEA stapler introducer was used when creating the gastrojejunostomy. SSIs from pre- and post-intervention were compared using Fisher's exact test. Only LRYGBs performed with a circular stapler were included in our analysis. Student's t test and χ2 were used to compare pre- and post-intervention groups with respect to demographics and co-morbidities. RESULTS: Between April 2015 and January 31st, 2017, our surgeons performed 158 LRYGBs using a circular stapler for the gastrojejunostomy. There were 84 patients (53%) in the pre-intervention group and 74 (47%) in the post-intervention group. The pre- and post-intervention groups were not statistically different. The SSI rate for the pre-intervention group was 9.5% while the SSI rate was 1.35% in the post-intervention group (p = 0.0371). The use of a dual ring wound protector for LRYGBs with circular stapled gastrojejunostomy was associated with an 86% relative risk reduction in SSIs. CONCLUSION: Using a dual ring wound protector in conjunction with a conical EEA introducer for LRYGBs with circular stapled gastrojejunostomy significantly decreased SSIs.

Surgical trainees and powered-drill use do not affect type I tympanoplasty hearing outcomes.

The purposes of this study were to determine if use of a powered drill or trainee involvement during tympanoplasty is associated with a decline in sensorineural hearing, as well as to examine whether trainee involvement affected tympanic membrane (TM) closure rates. This study was a chart review (February 2006 to October 2011) of 172 pediatric otolaryngology patients undergoing type I tympanoplasty for TM perforation of any etiology at a tertiary-care pediatric otolaryngology practice. Data collected included air conduction (AC) at 250 to 8,000 Hz, speech reception thresholds, bone conduction (BC) at 500 to 4,000 Hz, and air-bone gap (ABG) at 500 to 4,000 Hz. Rates of surgical success did not change significantly if a trainee assisted during surgery (69.6% with an assistant vs. 77.4% without; p = 0.297). AC hearing was not found to be significantly different between the two groups preoperatively or postoperatively at 250, 500, 1,000, 2,000, 4,000, or 8,000 Hz (p > 0.05). There were no significant differences in AC hearing outcomes between patients in whom a surgical drill was used and those in whom no drill was used (p > 0.05). BC and ABG did not change significantly at any frequency (p > 0.05). In conclusion, no correlation between high-frequency hearing loss and use of a powered drill for canalplasty during type I tympanoplasty was found in this pediatric population. No significant difference was found in surgical success rates or AC hearing outcomes when a surgical trainee was present.

[Surgical Removal of Migrated Coil after Embolization of Jejunal Variceal Bleeding: A Case Report].

Jejunal variceal bleeding is less common compared with esophagogastric varices in patients with portal hypertension. However, jejunal variceal bleeding can be fatal without treatment. Treatments include surgery, transjugular intrahepatic porto-systemic shunt (TIPS), endoscopic sclerotherapy, percutaneous coil embolization, and balloon-occluded retrograde transvenous obliteration (BRTO). Percutaneous coil embolization can be considered as an alternative treatment option for those where endoscopic sclerotherapy, surgery, TIPS or BRTO are not possible. Complications of percutaneous coil embolization have been reported, including coil migration. Herein, we report a case of migration of the coil into the jejunal lumen after percutaneous coil embolization for jejunal variceal bleeding. The migrated coil was successfully removed using surgery.

Surgical Fires and Operative Burns: Lessons Learned From a 33-Year Review of Medical Litigation.

OBJECTIVE: We aimed to understand the setting and litigation outcomes of surgical fires and operative burns. METHODS: Westlaw, an online legal research data-set, was utilized. Data were collected on patient, procedure, and case characteristics. RESULTS: One hundred thirty-nine cases were identified; 114 (82%) operative burns and 25 (18%) surgical fires. Median plaintiff (patient) age was 46 (IQR:28-59). Most common site of operative burn was the face (26% [n = 36]). Most common source of injury was a high energy device (43% [n = 52]). Death was reported in 2 (1.4%) cases. Plaintiff age <18 vs age 18-50 and mention of a non-surgical physician as a defendant both were shown to be independently associated with an award payout (OR = 4.90 [95% CI, 1.23-25.45]; p = .02) and (OR = 4.50 [95% CI, 1.63-13.63]; p = .003) respectively. Plaintiff award payment (settlement or plaintiff verdict) was reported in 83 (60%) cases; median award payout was $215,000 (IQR: $82,000-$518,000). CONCLUSION: High energy devices remain as the most common cause of injury. Understanding and addressing pitfalls in operative care may mitigate errors and potentially lessen future liability. LEVEL OF EVIDENCE: III.

Iatrogenic surgical microscope skin burns: A systematic review of the literature and case report.

Cutaneous burns associated with microscope-use are perceived to be uncommon adverse events in microsurgery. Currently, it is unknown what factors are associated with these iatrogenic events. In this report, we describe the case of a 1-year-old patient who suffered a full thickness skin burn from a surgical microscope after a L4-S1 laminectomy. Additionally, we present a systematic review of the literature that assessed the preoperative risk, outcome, and management of iatrogenic microscope skin burns. Lastly, a summary of the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database of voluntary adverse events was reviewed and analyzed for clinical cases of microscope thermal injuries. The systematic literature review identified only seven articles related to microsurgery-related cutaneous burns. From these seven studies, 15 clinical cases of iatrogenic skin burns were extracted for analysis. The systematic review of the FDA MAUDE database revealed only 60 cases of cutaneous burns associated with surgical microscopes since 2004. Few cases of microscope burns have been described in the literature; this report is, to our knowledge, one of the first comprehensive reports of this iatrogenic event in the literature.

Greater auricular nerve palsy after arthroscopic anterior-inferior and posterior-inferior labral tear repair using beach-chair positioning and a standard universal headrest.

Shoulder arthroscopy is a common treatment for numerous different pathologies. An iatrogenic nerve injury that occurs during shoulder arthroscopy is more common than previously recognized. However, though many nerve pathologies are increasingly being recognized, reported cases of greater auricular nerve injury are limited. For instance, a case of greater auricular nerve palsy was reported in only 2 series that used a horseshoe headrest. One set of authors discontinued and recommended against use of this headrest, and the other recommended a headrest redesign. Here we report on a case of greater auricular nerve palsy that occurred after the patient's anterior-inferior and posterior-inferior labral tear was arthroscopically repaired using beach-chair positioning and a standard universal headrest. The palsy resulted in numbness and dysesthesia, which lessened gradually over 3 months after surgery and was completely resolved by 6 months.

Imaging of abdominal and pelvic surgical and postprocedural foreign bodies.

Every form of medical and surgical treatment, even the most trivial one, carries with it some chance of complications. This risk is usually small, and the benefit of the treatment should clearly outweigh the risk. Treatment-related complications may occur, however, presenting either soon after the intervention or remote from it. In this review, the focus is on imaging findings of surgical materials used in abdominal surgery, and of a wide array of implanted abdominal devices. The pertinent complications of these devices and of retained surgical objects are highlighted and illustrated.

Femoral nerve injury complicating surgery for gynecologic cancer.

OBJECTIVE: The aim of this study was to report the incidence, severity, and factors associated with femoral nerve injury during gynecologic cancer surgery. METHODS: All patients who underwent abdominal surgery for gynecologic cancer entered the study. A retrospective review of the medical records was carried out for patients operated on from 2003 to April 2011. After this analysis, the use of the Bookwalter retractor was modified and the data were prospectively recorded. RESULTS: In the first period, femoral nerve injury was observed in 11 (2.7%) of 406 patients, occurring with a significantly higher frequency when the Bookwalter retractor was used (5.1% vs 0%, P < 0.01) and when pelvic lymphadenectomy was performed (5.1% vs 0.9%, P < 0.01). The analysis of the 212 patients (52.2%) in the Bookwalter group showed higher frequency of nerve injury in the patients undergoing pelvic lymphadenectomy (7.8% vs 2.0%, P = 0.05). In the second period, femoral nerve injury was observed in 1 (0.7%) of 132 patients operated on and in 1 (2.3%) of 43 patients (32.6%) in the Bookwalter group. When comparing the 2 periods, the lesser use of the Bookwalter retractor and the reduced time of maximal traction of the pelvic blades decreased the nerve injury rate from 2.7% to 0.7% and, in the Bookwalter group, from 5.1% to 2.3%. These results, although not statistically significant, are clinically relevant. CONCLUSIONS: Femoral nerve injury during gynecologic cancer surgery was associated with the Bookwalter retractor. The pelvic blades of the retractor may exert a compression on the nerve. The weakened muscles suggest that the nerve compression occurred intrapelvically over the iliacus muscle. Shortening the time of maximal traction of the pelvic blades reduced the incidence of femoral nerve injury. When performing gynecologic surgery with the use of the Bookwalter retractor, care must taken with the placement of the pelvic blades.

Phototoxic effects of an operating microscope on the ocular surface and tear film.

PURPOSE: We evaluated light exposure-induced dry eye syndrome by investigating the phototoxic effects of an operating microscope on the ocular surface and tear film in rabbits. METHODS: Sixty eyes of 30 rabbits were divided into 3 groups based on the intensity of light exposure received from an operating microscope: Control group, no exposure to light; group A, 40,000-lx intensity for 30 minutes; and group B, 100,000-lx intensity for 30 minutes. To evaluate the potential damage to the ocular surface and tear film, Schirmer tests, rose bengal staining, and conjunctival impression cytology were performed before the light exposure and at 1, 3, and 5 days afterward. In addition, the expression of interleukin 1-beta was analyzed in tear samples. The expression of mucin 5AC was evaluated using immunofluorescence staining, and periodic acid-Schiff staining was conducted on conjunctival tissues. Corneal and conjunctival tissues were observed by means of electron microscopy. RESULTS: Potential damage to the ocular surface and tear film was found in the light-exposed groups as evidenced by decreased aqueous tear production, devitalized corneal and conjunctival epithelial cells, squamous metaplasia of conjunctival epithelial cells, decreased conjunctival goblet cell density, decreased expression of mucin 5AC, ultrastructural cellular damage to corneal and conjunctival tissues, and increased interleukin 1-beta expression in tears. This damage was more noticeable in group B than in group A (P < 0.05). CONCLUSIONS: Light exposure from an operating microscope had phototoxic effects on the ocular surface and tear film in this in vivo experiment. These changes seemed to intensify as the intensity of the light increased. Therefore, excessive light exposure during ophthalmic procedures could be a pathogenic factor in dry eye syndrome after a surgery is performed.