Effect of Changing Surgical Instruments Before Wound Closure to Prevent Wound Infection in Lower GI Surgery: A Randomized Controlled Trial.

BACKGROUND: Surgical site infection is a major surgical complication and has been studied extensively. However, the efficacy of changing surgical instruments before wound closure remains unclear. OBJECTIVE: The aim of this study was to investigate the efficacy of changing surgical instruments to prevent incisional surgical site infection during lower GI surgery. DESIGN: This was a randomized controlled trial. SETTINGS: This study was conducted at the Hyogo College of Medicine in Japan. PATIENTS: Patients undergoing elective lower GI surgery with open laparotomy were included. INTERVENTIONS: Patients were randomly assigned to 1 of 2 groups. In group A, the surgeon changed surgical instruments before wound closure, and in group B, the patients underwent conventional closure. MAIN OUTCOME MEASURES: The primary end point was the incidence of incisional surgical site infection. The secondary end point was the incidence of surgical site infection restricted to clean-contaminated surgery. RESULTS: A total of 453 patients were eligible for this trial. The incidence of incisional surgical site infection was not significantly different between group A (18/213; 8.5%) and group B (24/224; 10.7%; p = 0.78). In the clean-contaminated surgery group, the incidence of incisional surgical site infection was 13 (6.8%) of 191 in group A and 9 (4.7%) of 190 in group B (p = 0.51). LIMITATIONS: This was a single-center study. CONCLUSIONS: Changing surgical instruments did not decrease the rate of incisional surgical site infection in patients undergoing lower GI surgery in either all wound classes or clean-contaminated conditions. See Video Abstract at http://links.lww.com/DCR/B701. EFECTO DE REALIZAR CAMBIO DE LOS INSTRUMENTOS QUIRRGICOS ANTES DEL CIERRE DE LA INCISIN EN LA INFECCIN DE LA HERIDA DEL SITIO QUIRRGICO EN CIRUGA DEL TUBO DIGESTIVO BAJO ESTUDIO ALEATORIO CONTROLADO: ANTECEDENTES:La infección del sitio quirúrgico es una complicación importante y se ha estudiado ampliamente. Sin embargo, la eficacia de cambiar los instrumentos quirúrgicos antes del cierre de la herida sigue sin estar clara.OBJETIVO:El objetivo de este estudio es investigar la eficacia de cambiar el instrumental quirúrgico en la prevención de la infección del sitio quirúrgico en cirugía gastrointestinal inferior.DISEÑO:Estudio aleatorio controlado.AJUSTE:Este estudio se realizó en la Facultad de Medicina de Hyogo en Japón.PACIENTES:Se incluyeron pacientes sometidos a cirugía electiva de tubo digestivo bajo con laparotomía abierta.INTERVENCIONES:Los pacientes fueron asignados aleatoriamente a uno de dos grupos. En el grupo A, el cirujano cambió el instrumental quirúrgico antes del cierre de la herida, y en el grupo B, los pacientes se sometieron a un cierre convencional.PRINCIPALES MEDIDAS DE RESULTADO:El criterio de valoración principal fue la incidencia de infección del sitio quirúrgico de la incisión. El criterio de valoración secundario fue la incidencia de infección del sitio quirúrgico restringida a la cirugía limpia contaminada.RESULTADOS:Un total de 453 pacientes fueron elegibles para este ensayo. La incidencia de infección del sitio quirúrgico no fue significativamente diferente entre el grupo A (18/213; 8,5%) y el grupo B (24/224; 10,7%) (p = 0,78). En el grupo de cirugía limpia-contaminada, la incidencia de infección del sitio quirúrgico incisional fue 13/191 (6,8%) en el grupo A y 9/190 (4,7%) en el grupo B (p = 0,51).LIMITACIÓN:Estudio de un solo centro.CONCLUSIÓNES:El cambio de instrumentos quirúrgicos no disminuyó la tasa de infección del sitio quirúrgico en todas las clases de heridas o condiciones limpias-contaminadas. Consulte Video Resumen en http://links.lww.com/DCR/B701.

Utilization fraction of rhinoplasty instrument sets: Model for efficient use of surgical instruments.

OBJECTIVES: Recognize the avoidable costs incurred due to overpacking of rhinoplasty instrument trays. Reduce rhinoplasty instrument trays by including only instruments used frequently. Establish methods to reduce trays prepared for other otolaryngologic procedures. METHODS: This is a prospective study. The study evaluates the specific use of instruments opened for rhinoplasty procedures at the New York Eye & Ear Infirmary of Mount Sinai. Instruments were counted in 10 rhinoplasty cases. Usage rate was calculated for each instrument. Additionally, all instruments used in at least 20% of cases were noted. This "20%" threshold was used to create new rhinoplasty tray inventories more reflective of actual instrument usage. Some instruments above the 20% threshold were included in multiples (i.e. two Adson Brown forceps vs. one curved iris scissor). RESULTS: 189 instruments were opened, and 32 instruments were used on average in each rhinoplasty. 55 instruments were used in at least 20% of cases. The 55 "high usage" instruments were used to create new, reduced rhinoplasty tray inventory lists. Based on our analysis, a new rhinoplasty tray inventory was created comprised of 68 instruments, a 64% reduction from 189. CONCLUSION: Instruments are sterilized and packed in gross excess for rhinoplasty procedures. Previously published figures estimate re-sterilization costs of $0.51 to $0.77 per instrument. Reduction in instruments opened from 189 to 68 is expected to lead to cost savings ranging from $62 to $93 per case, yielding a savings between $6200 and $9300 per 100 cases performed. LEVEL OF EVIDENCE: II-3.

Colonic transendoscopic tube-delivered enteral therapy (with video): a prospective study.

BACKGROUND: Colonic transendoscopic enteral tubing (TET) refers to colonic transendoscopic tube-delivered enteral therapy. Colonic TET has been successfully used for frequent colonic administration of drugs or multiple fecal microbiota transplantations (FMTs). This prospective observational study aimed to evaluate possible factors affecting methodology, feasibility and safety of colonic TET. METHODS: Patients who underwent colonic TET at our center from October 2014 to November 2018 were included. The feasibility, efficacy, and safety of TET were evaluated. RESULTS: In total, 224 patients were analyzed. The success rate of TET was 100%. The median retention time of TET tube within the colonic lumen was 8.5 (IQR 7-11) days in 158 patients with tube falling out spontaneously, and the maximum retention time was up to 28 days. These patients were divided into the short-retention group (≤ 8.5 days) and the long-retention group (> 8.5 days). Univariate and multivariate analysis demonstrated that the type of endoscopic clip (p = 0.001) was an independent factor for the retention time. The larger clips as well as a greater number of clips significantly affected the retention time (p = 0.013). No severe adverse event was observed during and after TET. CONCLUSIONS: Colonic TET is a feasible, practical, and safe colon-targeted drug delivery technique with a high degree of patients' satisfaction. Two to four large endoscopic clips are recommended to maintain stability of the TET tube within the colon for over 7 days.

The effect of scissor-type versus non-scissor-type knives on the technical outcomes in endoscopic submucosal dissection for superficial esophageal cancer: a multi-center retrospective study.

The Clutch Cutter was invented as a scissor-type knife for endoscopic submucosal dissection (ESD) of gastrointestinal neoplasms. ESD with the scissor-type knife (ESD-S) may be considered a technically easier procedure than ESD with non-scissor-type knives (ESD-NS). Therefore, this study aimed to compare the technical outcomes of ESD-S with those of ESD-NS for superficial esophageal cancer. This was a multicenter retrospective study. Patients with superficial esophageal cancer treated with ESD between October 2015 and March 2018 at three hospitals were retrospectively reviewed. The ESD-S group had 48 patients and the ESD-NS group had 114 patients. A propensity score matching analysis was performed to compensate for the confounding bias between both groups. Multivariate analyses and propensity score matching were used to adjust for age, sex, the tumor size, tumor location, tumor depth, degree of tumor circumference, operator level, usage of the traction method, and the sedation method. The primary outcome was the procedure time of the ESD. Secondary outcomes were the rate of en-bloc/complete resection and the rate of complications including perforation, delayed bleeding, and stricture. Propensity score matching analysis provided 36 matched pairs. Median procedure time in the ESD-S group was significantly shorter than that in the ESD-NS group (44.0 min vs. 66.5 min, P = 0.020). In addition, the treatment outcomes were similar in both groups (en-bloc resection: 100% vs. 97.2%, P = 1; complete resection: 88.9% vs. 86.1%, P = 1; curative resection: 80.6% vs. 77.8%, P = 1; perforation: 0% vs. 5.6%, P = 0.49; delayed bleeding: 0% in both groups; stricture: 2.8% vs. 8.3%, P = 0.61). ESD-S was associated with a shorter procedure time than ESD-NS, without an increase in the incidence of complications. Therefore, the scissor-type knife should be considered as an endo-knife for ESD of superficial esophageal cancers.

A qualitative content analysis of retained surgical items: learning from root cause analysis investigations.

OBJECTIVE: To describe incidents of retained surgical items, including their characteristics and the circumstances in which they occur. DESIGN: A qualitative content analysis of root cause analysis investigation reports. SETTING: Public health services in Victoria, Australia, 2010-2015. PARTICIPANTS: Incidents of retained surgical items as described by 31 root cause analysis investigation reports. MAIN OUTCOME MEASURE(S): The type of retained surgical item, the length of time between the item being retained and detected and qualitative descriptors of the contributing factors and the circumstances in which the retained surgical items occurred. RESULTS: Surgical packs, drain tubes and vascular devices comprised 68% (21/31) of the retained surgical items. Nearly one-quarter of the retained surgical items were detected either immediately in the post-operative period or on the day of the procedure (7/31). However, about one-sixth (5/31) were only detected after 6 months, with the longest period being 18 months. Contributing factors included complex or multistage surgery; the use of packs not specific to the purpose of the surgery; and design features of the surgical items. CONCLUSION: Retained drains occurred in the post-operative phase where surgical counts are not applicable and clinician situational awareness may not be as great. Root cause analysis investigation reports can be a valuable means of characterizing infrequently occurring adverse events such as retained surgical items. They may detect incidents that are not detected by other data collections and can inform the design enhancements and development of technologies to reduce the impact of retained surgical items.

The Impact of Breast Lumpectomy Tray Utilization on Cost Savings.

BACKGROUND: Right-sizing instrument trays reduce processing and replacement costs, physical strain, and turnover times. Historically, a 98-instrument head and neck tray has been used for breast lumpectomy cases at our institution. Observations revealed that many instruments on the tray were not used during the breast cases. With the significant number of surgical breast lumpectomies performed annually, tray downsizing could significantly reduce costs and physical strain. METHODS: Surgical technicians identified instruments needed for a standard breast lumpectomy. Breast surgeons reviewed the list and made final recommendations. Three of 13 existing head and neck trays were converted to breast lumpectomy trays. The number of breast lumpectomies in 2017 was pulled from the institution's health information system. Instrument quantities were verified using instrument management software. Weights were taken on a digital scale, and processing cost was estimated by a consultant. RESULTS: The new breast trays included 51 instruments rather than the standard 98-instrument trays. Reprocessing cost decreased from $49.98 to $26.01. With 449 breast lumpectomies performed at the institution in 2017, the annual reprocessing savings totaled $10,763. The tray weight was reduced from 27 to 16 pounds. Setup time decreased from 7 to 4 min per use (22.5 h saved annually). CONCLUSIONS: Downsizing from a head and neck tray to a specific breast lumpectomy tray demonstrated a reduction in reprocessing cost, tray weight, and setup time. Lighter trays allow for safer handling and transport by surgical personnel. In the current health-care environment, it is important to maximize operating room efficiency and minimize cost.

Prediction of the service life of surgical instruments from the surgical instrument management system log using radio frequency identification.

BACKGROUND: Bar code- or radio frequency identification (RFID)-based medical instrument management systems have gradually been introduced in the field of surgical medicine for the individual management and identification of instruments. We hypothesized that individual management of instruments using RFID tags can provide previously unavailable information, particularly the precise service life of an instrument. Such information can be used to prevent medical accidents caused by surgical instrument failure. This study aimed to predict the precise service life of instruments by analyzing the data available in instrument management systems. METHODS: We evaluated the repair history of instruments and the usage count until failure and then analyzed the data by the following three methods: the distribution of the instrument usage count was determined, an instrument failure probability model was generated through logistic regression analysis, and survival analysis was performed to predict instrument failure. RESULTS: The usage count followed a normal distribution. Analysis showed that instruments were not used uniformly during surgery. In addition, the Kaplan-Meier curves plotted for five types of instruments showed significant differences in the cumulative survival rate of different instruments. CONCLUSIONS: The usage history of instruments obtained with RFID tags or bar codes can be used to predict the probability of instrument failure. This prediction is significant for determining the service life of an instrument. Implementation of the developed model in instrument management systems can help prevent accidents due to instrument failure. Knowledge of the instrument service life will also help in developing a purchase plan for instruments to minimize wastage.

Rotational component alignment in patient-specific total knee arthroplasty compared with conventional cutting instrument.

BACKGROUND: Although many studies investigated the accuracy of customized cutting block (CCB), the data on rotational alignment are still lacking. The study aimed to assess whether CCB improved the component rotational position compared with conventional cutting instrument (CCI) using computed tomography scanning. METHODS: Eighty-six of 102 total knee arthroplasties from the previous randomized study were analyzed. The outcomes were rotational position of the femoral and tibial components, frequency of outliers and intra-class correlation coefficient. RESULTS: The mean femoral component rotation was not different between CCB versus CCI: 0.9° ± 0.8° versus 1.1° ± 1.1° (P = 0.29). Both groups had similar outlier frequencies: 2% (CCB) versus 2% (CCI) (P = 0.74). CCB had nearly 1° less mean tibial component deviation compared with CCI (P < 0.001): (1) dorsal tangent reference (DTR): 0.7° ± 0.8° versus 1.5° ± 1.0°, and (2) tibial trans-epicondylar reference (TTR): 0.5° ± 0.9° versus 1.4° ± 1.1°. Outlier frequencies were similar: (1) DTR: 0% CCB versus 5% CCI (P = 0.24), and (2) TTR: 5% in CCB versus 12% CCI (P = 0.20). Measurements based on tibial tubercle showed that CCB had ~ 1.4° less mean tibial component deviation compared with CCI: 0.3° ± 1.4° versus 1.7° ± 1.6° (P < 0.001) with a corresponding, less frequency of outliers: 0% versus 19% (P = 0.002). However, there was poor intra-observer reproducibility (0.61). CONCLUSIONS: CCB did not improve femoral component rotational alignment compared with CCI nor affect outlier frequency, but it marginally improved the accuracy of tibial rotational alignment. The tibial tubercle reference point had poor intra-observer reproducibility.

Transcatheter Treatment of Severe Tricuspid Regurgitation With the Edge-to-Edge MitraClip Technique.

BACKGROUND: Current surgical and medical treatment options for severe tricuspid regurgitation (TR) are limited, and additional interventional approaches are required. In the present observational study, the safety and feasibility of transcatheter repair of chronic severe TR with the MitraClip system were evaluated. In addition, the effects on clinical symptoms were assessed. METHODS: Patients with heart failure symptoms and severe TR on optimal medical treatment were treated with the MitraClip system. Safety, defined as periprocedural adverse events such as death, myocardial infarction, stroke, or cardiac tamponade, and feasibility, defined as successful implantation of 1 or more MitraClip devices and reduction of TR by at least 1 grade, were evaluated before discharge and after 30 days. In addition, functional outcome, defined as changes in New York Heart Assocation class and 6-minute walking distance, were assessed. RESULTS: We included 64 consecutive patients (mean age 76.6±10 years) deemed unsuitable for surgery who underwent MitraClip treatment for chronic, severe TR for compassionate use. Functional TR was present in 88%; in addition, 22 patients were also treated with the MitraClip system for mitral regurgitation as a combined procedure. The degree of TR was severe or massive in 88% of patients before the procedure. The MitraClip device was successfully implanted in the tricuspid valve in 97% of the cases. After the procedure, TR was reduced by at least 1 grade in 91% of the patients, thereof 4% that were reduced from massive to severe. In 13% of patients, TR remained severe after the procedure. Significant reductions in effective regurgitant orifice area (0.9±0.3cm2 versus 0.4±0.2cm2; P<0.001), vena contracta width (1.1±0.5 cm versus 0.6±0.3 cm; P=0.001), and regurgitant volume (57.2±12.8 mL/beat versus 30.8±6.9 mL/beat; P<0.001) were observed. No intraprocedural deaths, cardiac tamponade, emergency surgery, stroke, myocardial infarction, or major vascular complications occurred. Three (5%) in-hospital deaths occurred. New York Heart Association class was significantly improved (P<0.001), and 6-minute walking distance increased significantly (165.9±102.5 m versus 193.5±115.9 m; P=0.007). CONCLUSIONS: Transcatheter treatment of TR with the MitraClip system seems to be safe and feasible in this cohort of preselected patients. Initial efficacy analysis showed encouraging reduction of TR, which may potentially result in improved clinical outcomes.

Reducing cost and improving operating room efficiency: examination of surgical instrument processing.

BACKGROUND: Operating room efficiency can be compromised because of surgical instrument processing delays. We observed that many instruments in a standardized tray were not routinely used during thyroid and parathyroid surgery at our institution. Our objective was to create a streamlined instrument tray to optimize operative efficiency and cost. MATERIALS AND METHODS: Head and neck surgical instrument trays were evaluated by operating room team leaders. Instruments were identified as either necessary or unnecessary based on use during thyroidectomies and parathyroidectomies. The operating room preparation time, tray weights, number of trays, and number of instruments were recorded for the original and new surgical trays. Cost savings were calculated using estimated reprocessing cost of $0.51 per instrument. RESULTS: Three of 13 head and neck trays were converted to thyroidectomy and parathyroidectomy trays. The starting head and neck surgical set was reduced from two trays with 98 total instruments to one tray with 36 instruments. Tray weight decreased from 27 pounds to 10 pounds. Tray preparation time decreased from 8 min to 3 min. The new tray saved $31.62 ($49.98 to $18.36) per operation in reprocessing costs. Projected annual savings with hospitalwide implementation is over $28,000.00 for instrument processing alone. Unmeasured hospital savings include decreased instrument wear and replacement frequency, quicker operating room setup, and decreased decontamination costs. CONCLUSIONS: Optimizing surgical trays can reduce cost, physical strain, preparation time, decontamination time, and processing times, and streamlining trays is an effective strategy for hospitals to reduce costs and increase operating room efficiency.

With a new clip technique surgically inducing varicocele in Sprague-Dawley rats.

BACKGROUND: We introduced and recreated a more consistent and effective experimental varicocele rat model by a new clip technique. METHODS: A total of 40 rats were numbered and randomly assigned to 5 groups of 8 each, including sham surgery (Group I), conventional (Group II) and clip groups with 0.7, 0.8, 0.9 mm gap widths, respectively (Group III, IV, V). All of the rats in each group were sacrificed at 8 weeks after initial surgery, and the rats forming out with less than 1 mm diameter of left spermatic vein or no presence of the pampiniform plexus dilation were excluded from the experimental groups. The left spermatic vein (LSV) diameter, testicular weight, left kidney weight to body weight coefficients, kidney and testicular histology were determined. RESULTS: The baseline mean diameter of the LSV in Group I, II and III was 0.22 ± 0.02, 0.23 ± 0.02 and 0.22 ± 0.03 mm, respectively (P = 0.7504). At 8 weeks after initial surgery, varicocele was successfully created in 6/8 (75%), 7/8 (87.5%), 3/8 (37.5%), 3/8 (37.5%) in GroupII-V, no varicocele was observed in Group I. In Group I, II and III, no pathological changes were observed and the left kidney weight to body weight coefficients showed no significant differences. The diameter of LSV was remarkably increased both in Group II and III compared to Group I (1.72 ± 0.13, 1.57 ± 0.19 and 0.25 ± 0.02, respectively), and Group II and III had a smaller testicular weight than the rats in Group I (1.67 ± 0.05, 1.62 ± 0.06, and 1.92 ± 0.12, respectively). CONCLUSIONS: With a new clip technique, surgically inducing varicocele rat model becomes convenient and safe. This appears to improve the effectiveness of the model and this innovation may allow us to further understand the pathophysiology of varicocele.

Comparison of the Thermal Spread of Three Different Electrosurgical Generators on Rat Uterus: A Preliminary Experimental Study.

BACKGROUND/AIMS: The objective of this study was to compare the depth and width of thermal spread caused on rat uterine tissue after application of 3 different electrosurgical generators. METHODS: Alsa Excell 350 MCDSe (Unit A), Meditom DT-400P (Unit M), and ERBE Erbotom VIO 300 D (Unit E) electrosurgical units (ESUs) were used. The number of Wistar Hannover rats required to obtain valid results was 10. The primary objective of the study was to compare the 3 ESUs using the same instrument and the same waveform. The secondary objective of the study was to compare the differences between monopolar and bipolar systems of each ESU separately using the same waveform. RESULTS: The thermal spread caused by each ESU using monopolar instruments with continuous and interrupted waveforms was significantly different. Among the 3 devices, Unit A caused the largest thermal uterine tissue spread. On the other hand, Unit E caused the most superficial thermal tissue spread, and the smallest thermal spread among all ESUs. CONCLUSIONS: Surgeons should note that different ESUs used with the same power output might create different thermal effects especially in the monopolar configuration within the same waveform, for the same duration, and with the same instrument.

Temporal trends in peripheral arterial interventions: Observations from the blue cross blue shield of michigan cardiovascular consortium (BMC2 PVI).

OBJECTIVES: The aim is to examine trends in procedural indication, arterial beds treated, and device usage in peripheral arterial interventions (PVIs). BACKGROUND: There is little data on indication, vascular beds treated and devices utilized for peripheral arterial interventions. METHODS: We used data from 43 hospitals participating in the BMC2 VIC registry. PVIs were separated by year and divided by arterial segment. Lower extremity PVIs were subclassified as having been performed for claudication or critical limb ischemia (CLI). Yearly device usage was also included. A repeated measure ANOVA was used to determine trends. RESULTS: 44,650 PVIs were performed from 2006 to 2013. Renal interventions decreased from 18% of interventions in 2006 to 5.6% in 2013 (P < 0.001) and femoral-popliteal increased from 54.9% in 2006 to 64.5% in 2013 (P < 0.001). No significant trend was seen for aorta-iliac or below-the-knee interventions. 58.6% of PVIs were performed for claudication in 2006 and this decreased to 44.6% in 2013 (P = 0.025). Indications for CLI were 24.1% in 2006 and 47.5% in 2013 (P < 0.001). There were significant increases in the use of balloon angioplasty (P = 0.029) and cutting/scoring balloons (P < 0.001) while cryoballoon usage decreased (P < 0.001). No significant changes were found with stenting, atherectomy, and laser. CONCLUSIONS: There is a significant increase in patients presenting with CLI. Renal artery intervention rates are decreasing while femoral-popliteal interventions are increasing. Additionally, balloon angioplasty and cutting/scoring balloon usage is increasing. © 2017 Wiley Periodicals, Inc.

The Efficacy of a Novel Tissue Grasper-Clips Technique for Large Perforations of the Sigmoid Colon in an Experimental Animal Model (Video).

BACKGROUND: The incidence of iatrogenic colonic perforation has been gradually increasing. In particular, sigmoid colon perforations are difficult to handle because of excess mobility. AIM: The aim of this study was to evaluate the efficacy of the twin grasper-clips technique for large perforations of the sigmoid colon. METHODS: This study was designed as a prospective, randomized, experimental study using ex vivo porcine colorectal specimens. Thirty standardized and variable artificial perforations were closed in the hemoclip group (hemoclips) and twin grasper group (hemoclips with a novel tissue grasper). We counted the number of hemoclips used per case to assess the cost and efficacy of the procedure. RESULTS: In the hemoclip group (n = 15), among the 20-, 25-, and 30-mm defects, the mean number of clips (4.8 ± 0.8, 6.0 ± 1.6, and 8.4 ± 2.1, respectively, p = 0.011) and closure time (7.6 ± 0.5, 9.9 ± 3.3, and 13.9 ± 4.1 min, respectively, p = 0.020) differed significantly. In the twin grasper group (n = 15), among the 20-, 25-, and 30-mm defects, the mean number of clips (4.0 ± 1.0, 5.0 ± 0.7, and 5.4 ± 1.1, respectively, p = 0.101) and closure time (7.7 ± 0.6, 8.3 ± 1.9, and 9.1 ± 2.7 min, respectively, p = 0.506) did not differ significantly. In 30-mm defects, the mean number of hemoclips used per case and total closure time were significantly lower in the twin grasper group than the hemoclip group. CONCLUSIONS: The twin grasper-clips technique seems to reduce the use of hemoclips and to result in more effective and rapid closure than does the conventional technique in large perforations of the ex vivo porcine sigmoid colon.

Independent Roll-Down Ring for Contained Tissue Extraction.

An independent roll-down ring can be used to improve exposure during contained tissue extraction. We have used this technique in approximately 50 cases to date with good success. In this article we briefly describe our technique.

Physician Engagement in Improving Operative Supply Chain Efficiency Through Review of Surgeon Preference Cards.

STUDY OBJECTIVE: To reduce operative costs involved in the purchase, packing, and transport of unnecessary supplies by improving the accuracy of surgeon preference cards. STUDY DESIGN: Quality improvement study (Canadian Task Force classification II-3). SETTING: Gynecologic surgery suite of an academic medical center. PARTICIPANTS: Twenty-one specialized and generalist gynecologic surgeons. INTERVENTIONS: The preference cards of up to the 5 most frequently performed procedures per surgeon were selected. A total of 81 cards were distributed to 21 surgeons for review. Changes to the cards were communicated to the operating room charge nurse and finalized. MEASUREMENTS AND MAIN RESULTS: Fourteen surgeons returned a total of 48 reviewed cards, 39 of which had changes. A total of 109 disposable supplies were removed from these cards, at a total cost savings of $767.67. The cost per card was reduced by $16 on average for disposables alone. Three reusable instrument trays were also eliminated from the cards, resulting in savings of approximately $925 in processing costs over a 3-month period. Twenty-two items were requested by surgeons to be available on request but were not routinely placed in the room at the start of each case, at a total cost of $6,293.54. The rate of return of unused instruments to storage decreased after our intervention, from 10.1 to 9.6 instruments per case. CONCLUSIONS: Surgeon preference cards serve as the basis for economic decision making regarding the purchase, storing, packing, and transport of operative instruments and supplies. A one-time surgeon review of cards resulted in a decrease in the number of disposable and reusable instruments that must be stocked, transported, counted in the operating room, or returned, potentially translating into cost savings. Surgeon involvement in preference card management may reduce waste and provide ongoing cost savings.

Locking compression plate distal ulna hook plate fixation versus intramedullary screw fixation for displaced avulsion fifth Metatarsal Base fractures: a comparative retrospective cohort study.

BACKGROUND: Intramedullary screw (IMS) fixation was wildly used in fifth metatarsal base fractures (FMBFs) and the results were satisfactory. However, in the comminuted osteoporosis or small displaced avulsion FMBFs, anatomical reduction and stable fixation could not be achieved with IMS. The Locking Compression Plate (LCP) distal ulna hook plate fixation was a novel alternative fixation method. The aim of this retrospective cohort study was to determine if LCP distal ulna hook plate fixation resulted in improved outcomes compared to the traditional IMS fixation in displaced avulsion FMBFs. METHODS: Of 43 patients with displaced avulsion FMBFs, 18 patients were treated with LCP distal ulna hook plate fixation and 25 were treated with IMS fixation. The patients were evaluated clinically and radiographically and followed up to 12 months. The surgery time, time for hospital stay, time for weight-bearing, time for bony union, time for return to daily life, pain relief, functional outcome and complications after treatment with LCP distal ulna hook plate fixation or IMS fixation were compared. The functional outcome was assessed by the AOFAS (American Orthopedic Foot and Ankle Society) mid-foot score at 3, 6, 9, and 12 months after surgery. Meanwhile, pain scores were obtained at 3, 6, 9, and 12 months after surgery. RESULTS: The two cohorts had similar baseline characteristics. Surgery time was less in LCP distal ulna hook plate fixation cohort compare to IMS fixation cohort (p < 0.0001). Time for partial weight-bearing (p < 0.0001) and full weight-bearing (p < 0.0001) also demonstrated significant improvements in patients with LCP distal ulna hook plate fixation compared to IMS fixation. Patients in the LCP distal ulna hook plate fixation cohort had significantly increased AOFAS at 9 months (p < 0.0001) and 12 months (p < 0.0001) after surgery compared to the IMS fixation cohort. CONCLUSION: In this retrospective cohort study, LCP distal ulna hook plate fixation as an alternative fixation method was better therapy for the displaced avulsion FMBFs compared to IMS fixation. LCP distal ulna hook plate fixation had a short surgery time and improved functional performance.

Trocar Site Hernia After Gastric Bypass.

BACKGROUND: The 5.2% rate of trocar site incisional hernia (TSIH) reported appears low in view of the proportion of TSIH repairs being performed. Detecting TSIH by clinical examination may be difficult in the obese. The correlation between clinical examination and a novel radiological examination for the detection of TSIH in obese patients was studied. MATERIALS AND METHODS: Twenty-six patients subjected to laparoscopic gastric bypass in 2010 underwent clinical and radiological examination by three independent assessors for each method, after a mean follow-up time of 33 months. The computed tomography was in the prone position upon a ring. RESULTS: At clinical examination, a TSIH was regarded to be present in six out of 26 patients and at CT scan in four. The Fleiss' Kappa for multiple raters was 0.40 (p = 0.184) with clinical examination and 1 (p <0.05) with CT scan. With CT scan, herniation was diagnosed in three of 26 umbilical trocar sites that had been closed at the index operation, and in one of the 130 other trocar sites that had not been closed. CONCLUSIONS: Clinical examination is not reliable when detecting TSIH in the obese. A CT scan in the prone position was extremely reliable and seems to have the potential of becoming the standard method for detecting TSIH in obese patients.

Surgical count process: evidence for patient safety. / Processo de contagem cirúrgica: evidências para a segurança do paciente.

OBJECTIVE: To analyze the surgical count process according to reports of nurses working in surgical centers of a city in the state of São Paulo. METHODS: Cross-sectional study with a sample of 55 nurses. Data collection occurred from August to December 2013, with application of an instrument submitted to face and content validation, composed of data on variables regarding characteristics of nurses, hospital, and surgical count process. RESULTS: Fifty-two (94.5%) nurses reported that the surgical count process was carried out in their workplaces. A statistically significant association was found between the surgical count process and the type of institution (P=0.046), and between the presence of a surgical technologist and the processes for counting surgical instruments (P<0.001) and sponges (P=0.016). CONCLUSION: The results found contributed to understand how, by whom, and when the surgical count process was carried out in the studied hospital.

Costs associated with instrument sterilization in gynecologic surgery.

BACKGROUND: With rising health care expenditures, hospitals must contain costs in ways that maintain high-quality patient care. A significant portion of perioperative costs are associated with materials and supplies; many reusable instruments on surgical trays go unused, which may account for significant annual excess processing costs. Reorganizing gynecologic trays to contain fewer instruments can result in significant cost savings. In the field of operative gynecology, there has been considerable attention to the various costs and surgical outcomes that are associated with hysterectomy performed in the abdominal, vaginal, and laparoscopic approaches; however, little research has been done on the cost differences that are associated with the reusable instruments that are used in these approaches. OBJECTIVES: This study aimed to identify the percent usage of instruments within gynecologic surgery and to identify differences by surgical approach. We further aimed to estimate the costs of sterilizing surgical instruments and estimate the excess costs that are associated with processing unused instruments. STUDY DESIGN: This was a single site observational study. Specific instruments that were used from incision to closure were recorded on operating room count sheets via direct observation of surgeries that were performed in the gynecologic operating rooms by a trained investigator. Cost data on instrument transportation, employee wages, and instrument replacement was obtained from institutional supply chain management. RESULTS: In total, 28 surgical cases (5 abdominal, 11 laparoscopic, and 12 vaginal) were analyzed, with an average of 2 hours 37 minutes operating room time and 5.4 instrument trays for each case. One hundred fifty trays were observed. Trays had an average of 38 instruments per tray (range, 1-141). Surgeons used an average of 36.7 instruments of 184 available instruments per case, for a usage rate of 20.5±2.8%. A significant difference was noted between usage rates in abdominal cases (26.3±6.5%) and vaginal cases (13.6±3.3%) but not between laparoscopic (19.4±4.2%) vs other approaches. Instrument use was correlated inversely with the number of instruments, with an average usage rate of 18.7% for trays that contained ≥10 instruments. Total annual institutional cost associated with instrument processing was estimated at $3.19 per instrument. CONCLUSION: Instrument usage in the gynecologic operating room is low, and the cost of processing instruments is significant. Availability of certain instruments is necessary for patient safety in the event of rare unexpected events. However, given that less than one quarter of the instruments pulled for surgery are used and that total processing cost per instrument exceeds $3.00, careful review of what instruments are included in each tray is warranted. Clearly, significant cost-savings are possible while concurrently balancing safety concerns.