Access to Technology and Education for the Development of Minimally Invasive Spine Surgery Techniques in Latin America.

OBJECTIVE: To evaluate access to the technologies and education needed to perform minimally invasive spine surgery (MISS) in Latin America. METHODS: We designed a questionnaire to evaluate surgeons' practice characteristics, access to different technologies, and training opportunities for MISS techniques. The survey was sent to members and registered users of AO Spine Latin from January 6-20, 2020. The major variables studied were nationality, specialty (orthopedics or neurosurgery), level of hospital (primary, secondary, tertiary), number of surgeries performed per year by the spine surgeon, types of spinal pathologies commonly managed, and number of MISS performed per year. Other variables involved specific access to different technologies: intraoperative fluoroscopy, percutaneous screws, cages, tubular retractors, microscopy, intraoperative computed tomography, neuronavigation imaging, and bone morphogenetic protein. Finally, participants were asked about main obstacles to performing MISS and their access to education on MISS techniques in their region. RESULTS: The questionnaires were answered by 306 members of AO Spine Latin America across 20 different countries. Most answers were obtained from orthopedic surgeons (57.8%) and those with over 10 years of experience (42.4%). Most of the surgeons worked in private practice (46.4%) and performed >50 surgeries per year (44.1%), but only 13.7% performed >50 MISS per year, mainly to manage degenerative pathologies (87.5%). Most surgeons always had access to fluoroscopy (79%). Only 26% always had access to percutaneous screws, 24% to tubular retractors, 34.3% to cages (anterior lumbar interbody fusion, lateral lumbar interbody fusion, or transforaminal lumbar interbody fusion), and 43% to microscopy. Regarding technologies, 71% reported never having access to navigation, 83% computed tomography, and 69.3% bone morphogenetic protein. The main limitations expressed for widely used MISS technologies were the high implant costs (69.3%) and high navigation costs (49.3%). Most surgeons claimed access to online education activities (71%), but only 44.9% reported access to face-to-face events and 28.8% to hands-on activities, their limited access largely because the courses were expensive (62.7%) or few courses were available on MISS in their region (51.3%). CONCLUSIONS: Most surgeons in Latin America have limited resources to perform MISS, even in private practice. The main constraints are implant costs, access to technologies, and limited face-to-face educational opportunities.

[Reduced climate impact by resource-efficient surgeries]. / Resurssmarta operationer för lägre klimatpåverkan - Projekt i Västra Götalandsregionen minskade avfallet samtidigt som arbetet blev effektivare.

The Västra Götaland region carried out a project to develop resource-efficient surgeries using standardized hip prosthesis surgery as case. The purpose was to reduce and streamline the use of consumables and thus reduce the climate impact. At the surgery departments of three hospitals, significant variations were found in the supply and use of consumables during operations for total hip replacement (5.0-6.6 kg dry weight/operation). The major part of disposables consisted of surgery textiles, and choosing fossil-free products has the beneficial impact on a carbon footprint. Customized surgical procedure trays significantly reduce the number of packages and result in reduced work load for the staff. However, since there is a long term trend to increase the use of consumables in such sets, there is a need of continuous monitoring of such choices. In summary, a critical review of routines for care and use of materials is a powerful tool for streamlining healthcare and reducing its climate impact.

Reprocessing Single-Use Devices in the Ambulatory Surgery Environment.

Reprocessing single-use surgical supplies and devices is an option for hospitals and ambulatory surgery centers (ASCs). The US Federal Government has recognized the practice since 2000, and regulatory oversight has increased dramatically since that time. Reprocessing single-use devices is safe when personnel use approved methods, and health care facilities can experience significant cost savings by participating in this type of initiative. This article explores reprocessing and its benefits in ASCs, including a review of the oversight that the US Food and Drug Administration currently has for reprocessing and a discussion of the results of studies pertaining to this practice. The article also describes some issues that ASC leaders need to be aware of when considering the implementation of a reprocessing program. Single-use device reprocessing can be an effective tool for ASC leaders to conserve and manage resources.

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 Procedure Characteristics and Risk of Sharps-Related Blood and Body Fluid Exposure.

OBJECTIVE To use a unique multicomponent administrative data set assembled at a large academic teaching hospital to examine the risk of percutaneous blood and body fluid (BBF) exposures occurring in operating rooms. DESIGN A 10-year retrospective cohort design. SETTING A single large academic teaching hospital. PARTICIPANTS All surgical procedures (n=333,073) performed in 2001-2010 as well as 2,113 reported BBF exposures were analyzed. METHODS Crude exposure rates were calculated; Poisson regression was used to analyze risk factors and account for procedure duration. BBF exposures involving suture needles were examined separately from those involving other device types to examine possible differences in risk factors. RESULTS The overall rate of reported BBF exposures was 6.3 per 1,000 surgical procedures (2.9 per 1,000 surgical hours). BBF exposure rates increased with estimated patient blood loss (17.7 exposures per 1,000 procedures with 501-1,000 cc blood loss and 26.4 exposures per 1,000 procedures with >1,000 cc blood loss), number of personnel working in the surgical field during the procedure (34.4 exposures per 1,000 procedures having ≥15 personnel ever in the field), and procedure duration (14.3 exposures per 1,000 procedures lasting 4 to <6 hours, 27.1 exposures per 1,000 procedures lasting ≥6 hours). Regression results showed associations were generally stronger for suture needle-related exposures. CONCLUSIONS Results largely support other studies found in the literature. However, additional research should investigate differences in risk factors for BBF exposures associated with suture needles and those associated with all other device types. Infect. Control Hosp. Epidemiol. 2015;37(1):80-87.

Prevention of medical accidents caused by defective surgical instruments.

BACKGROUND: The malfunctioning of surgical instruments may lead to serious medical accidents. Limited information is available on the risk of defective instruments. The purpose of these study is to demonstrate the features of defective surgical instruments, to establish a strategy to reduce the risk of medical accidents. METHODS: We studied 19,474 consecutive operations during 2007 to 2009 at our hospital. The data on defective instruments were collected based on the orders for repair of broken instruments and reports of near-miss incidents. Adverse events caused by defective instruments were also identified from reports of near-miss incidents. RESULTS: A total of 1,775 nonfunctioning instruments were identified during the study period. Of these, 112 were found during operation. More than half of the defective instruments were tissue-grasping instruments, bone-boring/gnawing instruments, and instruments for endoscopic surgery. Wearing out and inappropriate use of instruments were 2 major causes of defects. The rest of the causes consisted of inadequate inspection and factory defects. Two near-miss incidents (incidence 10 per 100,000 operations) in endoscopic surgery were potentially critical, but the postoperative course was uneventful in each patient. The incidence of defects adjusted by the number of operations demonstrated that bone-boring/gnawing instruments and instruments for endoscopic surgery tend to be broken during surgery. Without inspection by the manufacturer, the incidence would be much higher for endoscopic instruments. CONCLUSION: Our data suggest that the appropriate use and adequate inspection of particular types of instruments are key for reducing the risk of medical accidents caused by defective surgical instruments.

Indicating shortcomings in surgical lighting systems.

Ergonomic problems of surgical lighting systems have been indicated by surgeons; however, the underlying causes are not clear. The aim of this study is to assess the problems in detail. Luminaire use during 46 hours of surgery was observed and quantified. Furthermore, a questionnaire on perceived illumination of and usability problems with surgical luminaires was issued among OR-staff in 13 hospitals. The results showed that every 7.5 minutes a luminaire action (LA) takes place, intended to reposition the luminaire. Of these LAs, 74% were performed by surgeons and residents. For 64% of these LAs the surgical tasks of the OR-staff were interrupted. The amount of LAs to obtain a well-lit wound, the illumination level, shadows, and the illumination of deep wounds were most frequently indicated lighting aspects needing improvement. Different kinematic aspects of the pendant system of the lights that influence usability were also mentioned: High forces for repositioning, ease of focusing and aiming, ease of moving, collisions of the luminaire, entangling of pendant arms, and maneuverability. Based on these results conclusions regarding the improvement of surgical lighting systems are formulated. Focus for improvements should be on minimizing the need for repositioning the luminaire, and on minimizing the effort for repositioning.

Microdebrider-assisted endoscopic marsupialization for the nasolabial cyst: Comparisons between sublabial and transnasal approaches.

BACKGROUND: The incidence of nasolabial cysts is very low. Simple excision through a sublabial approach is the treatment of choice. The aim of this study was to evaluate the microdebrider as a tool in transnasal endoscopic marsupialization for nasolabial cysts and compare it with conventional instruments and a sublabial approach for cyst removal. METHODS: Retrospective chart review of 30 patients (31 cysts) with a mean age of 46.9 years received surgical treatments for nasolabial cysts. We performed three types of surgical procedures including the sublabial approach (10 cysts), conventional transnasal marsupialization (13 cysts), and microdebrider-assisted marsupialization (8 cysts). RESULTS: Patients that received surgery with the sublabial approach experienced significant increases in operation time, blood loss, and hospitalized time compared with those treated with transnasal marsupialization. However, the number of postoperative stoma stenoses was higher for conventional transnasal marsupialization (two cases). No recurrences or other postoperative complications were found during the follow-up. CONCLUSION: The transnasal marsupialization of nasolabial cysts has remarkable benefits compared with sublabial cyst excision during operation. Microdebriders can be used safely and effectively in endoscopic marsupialization without stoma stenosis.

The development of a material model and wheel-tissue interaction for simulating wheeled surgical robot mobility.

In vivo surgical robot wheel and tissue interaction was studied using a nonlinear finite element model. A liver material model, derived from laboratory experiments, was implemented as a viscoelastic material. A finite element simulation of this laboratory test confirmed the accuracy of the liver material model. This material model was then used as the tissue model to study wheel performance. A helical wheel moving on the liver model was used to replicate laboratory experiments that included several different slip ratios and applied loads. The drawbar force produced in this model showed good agreement with the physical tests. These results have provided the baseline for studying how changes in wheel geometry, such as tread height, tread spacing and wheel diameter, affect drawbar force and ultimately wheel performance. These results will be used in future surgical robot wheel designs.

Noise in the operating rooms of Greek hospitals.

This study is an evaluation of the problem of noise pollution in operating rooms. The high sound pressure level of noise in the operating theatre has a negative impact on communication between operating room personnel. The research took place at nine Greek public hospitals with more than 400 beds. The objective evaluation consisted of sound pressure level measurements in terms of L(eq), as well as peak sound pressure levels in recordings during 43 surgeries in order to identify sources of noise. The subjective evaluation consisted of a questionnaire answered by 684 operating room personnel. The views of operating room personnel were studied using Pearson's X(2) Test and Fisher's Exact Test (SPSS Version 10.00), a t-test comparison was made of mean sound pressure levels, and the relationship of measurement duration and sound pressure level was examined using linear regression analysis (SPSS Version 13.00). The sound pressure levels of noise per operation and the sources of noise varied. The maximum measured level of noise during the main procedure of an operation was measured at L(eq)=71.9 dB(A), L(1)=84.7 dB(A), L(10)=76.2 dB(A), and L(99)=56.7 dB(A). The hospital building, machinery, tools, and people in the operating room were the main noise factors. In order to eliminate excess noise in the operating room it may be necessary to adopt a multidisciplinary approach. An improvement in environment (background noise levels), the implementation of effective standards, and the focusing of the surgical team on noise matters are considered necessary changes.

Safety, hazards and ergonomics in the operating room.

OBJECTIVE: The objective for this study was to address the lack of information regarding the working conditions in the operating room (OR). Safety issues in the OR need to be discussed not only for the sake of patients, but also for personnel, as hazards may occur for all persons within the OR. METHODS: To evaluate the workplace conditions in the operating room, a survey was conducted among surgeons working in German hospitals. Sixty questions were asked regarding the personal profile, the architectural situation, the devices and instruments as well as working posture and associated pain. RESULTS: The survey showed elementary ergonomic deficiencies within all fields. Surgeons stated that these deficiencies lead to potential hazards for patients and personnel, potentially on a frequent basis. 97% of the surveyed surgeons see ergonomic improvement in the operating room as necessary. CONCLUSION: The survey results display a high potential for improvement within all fields. Therefore, industry, surgeons and their professional organizations are asked to work on the optimization of the workplace conditions in the operating room in terms of improvement of quality and efficiency.

Actual and estimated costs of disposable materials used during surgical procedures.

It is difficult to estimate precisely the costs of disposable materials used during surgical operations. To evaluate the actual costs of disposable materials, we calculated the actual costs of disposable materials used in 59 operations by taking account of costs of all disposable materials used for each operation. The costs of the disposable materials varied significantly from operation to operation (US$ 38-4230 per operation), and the median [25-percentile and 75-percentile] of the sum total of disposable material costs of a single operation was found to be US$ 686 [205 and 993]. Multiple regression analysis with a stepwise regression method showed that costs of disposable materials significantly correlated only with operation time (p<0.001). Based on the results, we propose a simple method for estimating costs of disposable materials by measuring operation time, and we found that the method gives reliable results. Since costs of disposable materials used during surgical operations are considerable, precise estimation of the costs is essential for hospital cost accounting. Our method should be useful for planning hospital administration strategies.

Endoscopic palliation for pancreatic cancer with expandable metal stents.

Pancreatic cancer is generally not amenable to curative resection. Consequently, therapeutic efforts for these patients are most commonly directed at palliation of symptoms. Historically, surgery has been considered the most effective method of providing relief for biliary and/or enteric obstruction. However, less invasive methods have become available that can provide effective relief of jaundice and duodenal obstruction. Surgeons should still play an integral role in the management of these patients. We present a case report in which self-expanding metallic stents were used to relieve obstruction of the bile duct and duodenum in a patient with unresectable pancreatic cancer.

Open MRI-guided neurosurgery.

OBJECTIVES: A number of different image-guided surgical techniques have been developed during the past decade. None of these methods can provide the surgeon with information about the dynamic changes that occur intra-operatively. MATERIAL AND METHOD: The first vertical open 0.5T MRI-scanner for intra-operative MRI-guided neurosurgery in Germany was installed at the University of Leipzig during the summer 1996. Since autumn 1996 a number of surgical procedures including biopsies (n = 31), craniotomies (n = 32), transsphenoidal procedures (n = 8) and interstitial lasertherapies (n = 3) have been performed using intra-operative MR image guidance. RESULTS: The development of MR-compatible and MR-safe non-magnetic instruments and components had to be solved. Specific surgical instruments were developed to perform biopsies, craniotomies, microsurgical tumour resections and transsphenoidal procedures in the 0.5-T open MRI. Several components required adaptation including the head holder the stereotactic navigation device, the high speed drill, the suction unit, the ultrasonic aspirator, the bipolar coagulation, the laser probe and the surgical microscope. All these newly developed technical features enable the neurosurgeon to perform a large number of surgical procedures under direct control and guidance of intra-operative MR imaging. In contrast to frame-based for framless navigation systems, intra-operative MRI provides accurate and immediate information during the progress of surgery. These intra-operative images allow definitive localization and targeting of the lesions and accommodate anatomical changes that may occur during surgery. CONCLUSION: Intra-operative MRI is helpful for navigation as well as determining of tumour margins to achieve a complete and safe resection of intracranial lesions. Complications related to the surgical procedure are reduced and the risk of neurological deterioration due to tumour removal and postoperative complications is minimized. It can be concluded that the intra-operative application of interventional MRI technology may represent a major step forward in the field of neurosurgery.

Focused versus operating room-wide recovery of unused supplies for overseas reconstructive surgery.

Proliferation of programs that recover surplus operating room supplies may effectively address the needs of volunteer overseas surgical efforts. However, these programs tend to garner supplies highly heterogeneous in nature. In order to evaluate the nature and quantity of supplies generated by plastic and reconstructive procedures, we extrapolated the inventory of 71 consecutive cases from our 33,000-case database. Additionally, we examined the recovery of 7 specific supplies from all cases performed at Yale-New Haven Hospital over a 3-year period. Though consistency is unlikely when only plastic and reconstructive surgical cases are examined, operating room-wide recovery may be a reliable source of usable materials.