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.

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.

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.

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.

[Robotic-enhanced percutaneous coronary revascularization].

Percutaneous revascularization (PCI) has made significant technological progress in the last four decades. Despite advances in the safety and efficacy of the coronary revascularization, interventional cardiologists have to cope with occupational hazards including exposure to radiation, cataract, and orthopedic problems. Robotic systems that enable distant navigation were developed to address the risks and challenges that are associated with percutaneous revascularization. The PRECISE multi-center study with robotic-enhanced PCI demonstrated technical success of 98.7% and clinical success of 97.5%. The use of the robotic-enhanced PCI system reduced operator radiation exposure by 95%. Patient benefits include precise segment measurements, improved stability of the intracoronary devices, and reduction of contrast media volume. Robotic-enhanced PCI is a promising advancement in interventional cardiology.

A newly developed drill with a polished tip for the anterior cervical approach in spinal canal stenosis: a technical note.

PURPOSE: The goal of our efforts was to develop a modified drill that allows a safe milling of the dorsal osteophytes located close to the dura. METHODS: Usually a normal high-speed drill is used for the resection of uncarthrotic and spondylophytic bone. In one patient, we used our new high-speed drill close to the dura in an area, which is not easy reachable with a normal drill or a rongeur. RESULTS: Employing the new drill with a polished tip, the spine surgeon is able to overcome the anatomical restrictions, which he has to face when the anterior approach to the cervical spine. The resection of dorsal osteophytes is easy and safe. CONCLUSION: The newly developed drill with the polished tip is a safe and high-quality alternative to conventional drills. Further investigations have to be done, to proof the advantages of the new drill.

Comparison between the intraoperative use of polyvinyl chloride cover and surgical compresses for preventing postoperative adhesions.

BACKGROUND/PURPOSE: Surgical compresses used for retraction during major abdominal and pelvic procedures lead to postoperative adhesion formation resulting from damage to the visceral peritoneum. This study investigates whether polyvinyl chloride (PVC) covers cause less postsurgical adhesion and inflammation than surgical compresses in an animal model. METHODS: Female Wistar albino rats (n = 160) were divided into three groups (compress, PVC cover and control), which were then divided into 16 subgroups (n = 10/group). All animals underwent midline laparotomy and cecal abrasion. A metal retractor, which applies a constant force, was then placed on the small intestine for 2 h. In the control group, no material was placed under the retractor, whereas a surgical compress or PVC cover was placed in the experimental animals. Full-thickness small intestinal biopsies were obtained and examined by light and electron microscopy. The following parameters were evaluated: congestion, mesothelial proliferation, leukocyte migration and collagenization. Adhesions were scored according to the Nair, Knightly and Mazuji scoring systems. RESULTS: All inflammation scores were significantly higher in the compress group than in the other two groups. However, no significant difference was observed between the PVC cover and control groups. Adhesions were more frequent in the compress group than in the other two groups, regardless of the scoring system used. CONCLUSIONS: Surgical compresses used in abdominal and pelvic surgeries cause inflammation and adhesion. Contrary to surgical compresses, PVC covers do not cause inflammation and adhesion, which may considerably reduce adhesion-related complications in abdominopelvic surgeries.

Noise exposure of care providers during otosurgical procedures.

OBJECTIVE: To monitor the noise exposure of care providers during otological surgery due to drilling and suction in the operating room. METHODS: A clinical study monitoring different standard otosurgical procedures was conducted; cochlear implantation (CI), mastotympanoplasty, and mastoidectomy alone. Noise exposure to the surgeon and assistant were monitored with wireless personal noise dosimetry and stationary sound monitoring. Both maximum peak level in dBC (Lpeak) and time-average sound pressure level in dBA (equivalent level or Leq) were measured during drilling episodes. Frequency analysis in one third octaves covering the frequency bands 6.3 Hz to 20 k Hz was performed using a sound analyzing program. RESULTS: When averaged over the entire procedure, the sound pressure level was highest for the surgeon and the assistant with values of 76.0 dBA and 72.5 dBA, respectively, during CI. Lpeak was 135.9 dBC. Leq for the stationary sound measurement was 74.2 dBA. During cortical bone work using a cutting burr, 84.6 dBA was measured. Mean values of L95% (estimation of the background noise) were between 55.8 dBA and 61.2 dBA. Frequency analysis showed the highest sound pressure level for all procedures was between 2.5 kHz and 3.15 kHz. CONCLUSION: This is the first study to use personal sound dosimetry to monitor noise exposure during otosurgical drilling. In accordance with other studies, the results presented show sound levels below international occupational noise level regulations. However, the measured noise exposure during drilling could have negative effects on care providers based on unfavorable acoustical comfort.

[Compression of facial skin by headrest in prone position].

The higher body pressures of patients compared to their capillary blood pressures in the limited areas of their skin induced peripheral blood flow disturbances, thus causing skin injuries. Use of horseshoe-shaped headrest for prone-positioning during surgeries can induce blood flow occlusion, skin ischemia, and skin injury due to high pressure and shear stress on the forehead and both cheeks, which are protrusions on facial bone. The use of pressure dispersion headrests is preferred, redistributing the body pressure equally and absorbing pressure from the entire head in the prone position for surgery.

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.

Intra-operative 3.0 T magnetic resonance imaging using a dual-independent room: long-term evaluation of time-cost, problems, and learning-curve effect.

We present a short and comprehensive report of our 39-month experience using a 3.0 T intra-operative magnetic resonance imaging (ioMRI) neurosurgical-MR twin room, including a description of the problems encountered and the associated time-delays. Forty-seven problems were experienced during the 189 ioMRI procedures (two ioMRI were performed in five of the 184 surgical procedures) performed in the 39-month period, including a blocked transfer table, failure of anesthetic monitoring material, and specific MRI-related problems, such as head and coil positioning difficulties, artefacts, coil malfunctions and other technical difficulties. None of these problems prevented the ioMRI procedure from taking place or affected image interpretation, but they sometimes caused a significant delay. Fifteen (32%) of these problems occurred during the initial learning curve period. The mean duration of the ioMRI procedure was 75 min, which decreased slightly with experience, although an average waiting-for-access time of 24 min could not be avoided. These results illustrate that although performing ioMRI at 3.0 T with the dual room is a challenging procedure, it remains safe and feasible and associated with only minor dysfunctions while offering optimal image quality and standard surgical conditions.

Transition to reprocessing: one OR's success.

This article tells the story of an OR staff that achieved a successful implementation of reprocessing 6 years ago, ultimately resulting in a culture change. The transition to the use of reprocessed Food and Drug Administration-approved single-use surgical devices is described as it occurred. Consideration of the human factors, change management, and culture change are included in this tale of transition. This change occurred organically within the team, rather than being forced by organizational hierarchy. The telling of this experience speaks to the effectiveness of change initiated at the bedside by motivated staff, which then evolved into a culture change for this OR.

[Advantages and disadvantages of the application of endoscopic techniques at different stages of tympanoplasty].

The objective of this work was to evaluate advantages and disadvantages of selected tympanoplastic stages under the endoscopic control during the surgical treatment of 93 patients presenting with chronic otitis media. The endoscopic techniques has indisputable advantages over traditional surgical microscopy when applied to elucidate the character and extent of the pathological process in the middle ear. This method allows to reveal granulation and cholesteatoma in difficult of access pockets and folds of the middle ear without enlargement of the extent of surgical intervention, to evaluate the "continuity" of the chain of auditory ossicles, etc. At the same time the use of an endoscope during performance of the majority of tympanoplastic procedures creates some difficulties related to the necessity of regular cleaning of the instrument and the impossibility of application of the bimanual technique.

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.

[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.

Hazard report. Overlap of surgical lighthead beams may present burn risk.

The heat created when the beams from multiple surgical lightheads overlap can sometimes present the risk of patient burns during a procedure. Safe use of multiple heads requires limiting the total light intensity to acceptable levels.

Outbreak of diffuse lamellar keratitis caused by marking-pen toxicity.

PURPOSE: To examine the evidence that a series of cases of diffuse lamellar keratitis (DLK) after laser in situ keratomileusis (LASIK) was caused by a type of marker pen. SETTING: Eye Institute, Auckland, New Zealand. METHODS: During a 10-week period, 522 consecutive LASIK procedures were performed using a 60 Hz IntraLase femtosecond laser (IntraLase Corp.) to create the LASIK flap and a 217Z 100 Hz excimer laser (Bausch & Lomb) to perform the refractive ablation. As standard practice, a marking pen was used to enable accurate flap realignment. Three weeks after a sudden increase in the incidence of DLK was identified, one of the 5 surgeons performed 5 consecutive bilateral cases using the marking pen in the right eyes but not in the left eyes. RESULTS: Of the 522 LASIK cases (119 without marking pen, 403 with marking pen), DLK developed in 49 (9.4%). No eye treated without the marking pen developed DLK; of those in which the marking pen was used, 49 (12.2%) developed DLK (P<0.0001, Fischer exact test; odds ratio, 27). In the 5 consecutive bilateral cases in which the marking pen was used in the right eye but not the left eye, 4 right eyes and no left eye developed DLK (P=0.03). Forty-five of the 49 eyes with DLK quickly recovered. The other 4 developed central toxic keratopathy. CONCLUSION: There is strong statistical evidence that the marking pen was a factor in the occurrence of DLK.

Diffuse lamellar keratitis after laser in situ keratomileusis associated with surgical marker pens.

PURPOSE: To describe a series of cases of diffuse lamellar keratitis (DLK) after laser in situ keratomileusis (LASIK) associated with intraoperative use of a surgical marker pen. SETTING: Singapore National Eye Centre, Singapore, Singapore. METHODS: A review of all 115 patients (125 eyes) who had myopic LASIK from July 23 to July 26, 2007, was performed to determine whether eyes in which the Codman surgical marker pen (Johnson & Johnson Medical) was used intraoperatively developed postoperative DLK. RESULTS: Nine of 12 eyes that had LASIK or flap relifting with a Codman surgical marker pen developed grade 1 to grade 3 DLK on the first postoperative day. The 113 other eyes that had LASIK in the same week with another brand of surgical marker pen (Securline, Precision Dynamics Corp.) did not develop DLK. All eyes with DLK were treated with intensive topical steroid therapy. The DLK resolved in 2 eyes after the steroid treatment; 7 eyes required flap relifting with interface irrigation. One month postoperatively, 6 eyes with DLK had an uncorrected visual acuity of 6/7.5 or better. Two eyes developed central corneal scarring with consecutive hyperopia with a best corrected visual acuity of 6/12 after 1 month. CONCLUSIONS: There was a strong association between the occurrence of DLK after LASIK with the use of the Codman surgical marker pen. One or more constituents of the ink in the Codman pen may have been responsible for this series of cases.