Anterior approach to total hip replacement: surgical technique and clinical results of our first one thousand cases using non-cemented prostheses.

Total hip replacement has evolved into one of the most frequently performed reconstructive procedures in orthopaedic surgery today. A modified anterior approach developed by the senior surgeon has been utilized in performing over 3,000 operations in the past two decades. It is a unique and facile exposure. It can be easily applied to primary and revision surgery. Noncemented prostheses have been used in over 1,000 of these operations. This article details the surgical exposure, acetabular and femoral preparation for both non-cemented and cemented prostheses, special considerations for revision surgery, and the clinical results of the experience with noncemented prostheses to date.     

Advanced techniques in abdominal surgery.

Almost every abdominal organ is now amenable to laparoscopic surgery. Laparoscopic appendicectomy is a routine procedure which also permits identification of other conditions initially confused with an inflamed appendix. However, assessment of appendiceal inflammation is more difficult. Almost all colonic procedures can be performed laparoscopically, at least partly, though resection for colonic cancer is still controversial. For simple patch repair of perforated duodenal ulcers laparoscopy is ideal, and inguinal groin hernia can be repaired satisfactorily with a patch of synthetic mesh. Many upper abdominal procedures, however, still take more time than the open operations. These techniques reduce postoperative pain and the incidence of wound infections and allow a much earlier return to normal activity compared with open surgery. They have also brought new disciplines: surgeons must learn different hand-eye coordination, meticulous haemostasis is needed to maintain picture quality, and delivery of specimens may be problematic. The widespread introduction of laparoscopic techniques has emphasised the need for adequate training (operations that were straight-forward open procedures may require considerable laparoscopic expertise) and has raised questions about trainee surgeons acquiring adequate experience of open procedures.     

Minimally invasive surgery. Future developments.

The rapid development of minimally invasive surgery means that there will be fundamental changes in interventional treatment. Technological advances will allow new minimally invasive procedures to be developed. Application of robotics will allow some procedures to be done automatically, and coupling of slave robotic instruments with virtual reality images will allow surgeons to perform operations by remote control. Miniature motors and instruments designed by microengineering could be introduced into body cavities to perform operations that are currently impossible. New materials will allow changes in instrument construction, such as use of memory metals to make heat activated scissors or forceps. With the reduced trauma associated with minimally invasive surgery, fewer operations will require long hospital stays. Traditional surgical wards will become largely redundant, and hospitals will need to cope with increased through-put of patients. Operating theatres will have to be equipped with complex high technology equipment, and hospital staff will need to be trained to manage it. Conventional nursing care will be carried out more in the community. Many traditional specialties will be merged, and surgical training will need fundamental revision to ensure that surgeons are competent to carry out the new procedures.     

Minimally invasive surgery in the field of gynecologic oncology

The aim of this paper was to present the results in minimal invasive surgery in the field of gynecologic oncology at General hospital Zabok, Croatia. 381 laparoscopic procedures were performed between 1994 and 1998. There were 263 operations of the benign adnexal masses, and 107 operations due to benign tumors of corpus uteri (there were 18 LAVH, 12 LH and 77 TLH). There were 11 laparoscopic operations due to carcinoma (1 ovary, 6 corpus and 4 cervix). Operations were: 3 LAVH (laparoscopically assisted vaginal hysterectomy), 5 TLH (total laparoscopic hysterectomy) with pelvic lymphadenectomy, 1 LAVH with pelvic lymphadenectomy, 1 coelio Shauta operation with laparoscopic pelvic lymphadenectomy and paraaortal lymphadenectomy, and 1 laparoscopic adnexectomy. Among laparoscopic procedures in 370 patients operations were successfully performed as planed, while in 11 patients it was necessary to switch to laprotomy. Among serious complications of laparscopic operations it is necessary to note 2 lesions of the ureter and 1 lesion of the bladder. Laparoscopic lymphadenectomies were performed successfully; there were no serious early or late postoperative complications. There was no operative mortality. Even though many authors claim that laparoscopic operations in the field of gynecologic oncology are safe and have the same results as in open surgery, patients benefit from shorter recovery and better quality of life during laparoscopic procedures.     

General anesthesia in an office-based plastic surgical facility: a report on more than 23,000 consecutive office-based procedures under general anesthesia with no significant anesthetic complications

The popularity of elective office-based plastic surgery has increased significantly over the past two decades. The continuing demand for improved aesthetic results has stimulated the development of ever more complex plastic surgical techniques. These techniques may require extended periods of operative time spent under anesthesia. Patients have come to expect an almost perfect anesthetic and surgical experience, with safety and comfort being their foremost concerns. Because of increasingly complex and lengthy operations, the authors believe that intravenous sedation, used for many years in their plastic surgery practice, is now suboptimal for most longer and complex surgical procedures. In their experience, under most circumstances, general anesthesia provides the optimal anesthetic experience for the patient, anesthesiologist, and surgeon. The authors present a consecutive 18-year study of general anesthesia in more than 23,000 procedures in an accredited, office-based plastic surgical facility that offers a very safe and uniformly pleasant anesthesia experience for patients. There were no intraoperative or postoperative deaths and no significant complications. The authors' experience differs from the common perception that general anesthesia is too risky for aesthetic surgery procedures.     

Evaluation of results in aesthetic plastic surgery: preliminary observations on mammaplasty

Aesthetic plastic surgery has received wide public attention in the past few years. Expectations of patients regarding results have been exaggerated; the real place and medical importance of the procedures are still not clear because of a lack of more objective evidence. This study discusses the difficulties encountered related to the scientific evaluation of the aesthetic operations and proposes alternatives for assessment. A frequently performed procedure, reduction mammaplasty, is presented as an example, with its specific evaluation.     

Changing patterns in iatrogenic ureteral injuries

Advances in laparoscopic and endoscopic surgery over the past 25 years have changed the preferred methods for performing many operations. We previously reported an increase in the number of patients treated for ureteral injury at our institution that paralleled the introduction of minimally invasive techniques. Since that report, more advanced endoscopic procedures have been introduced. We sought to determine whether the latter influenced the number of ureteral injuries managed at our institution. Reported here are the results of our retrospective study, which sought to determine if the rate of treatment of major iatrogenic ureteral injuries has changed.     

Surgery and anesthesia in Ontario.

Operative and case-fatality rates in Ontario for eight elective (discretionary) and seven nonelective (nondiscretionary) operations and the proportions of these operations and their anesthetic procedures performed by general practitioners were calculated. Cholecystectomy increased in frequency 32% from 1968 through 1973, tonsillectomy and adenoidectomy decreased 37%, and hysterectomy increased 41%. Except for colectomy the rates for nonelective operations changed only slightly over the 6 years. Case-fatality rates (hospital deaths per 10000 operations) for the discretionary operations in 1973 were as follows: extraction of lens, 23.1; tonsillectomy and adenoidectomy, 0.4 (2 deaths among 52938 operations); varicose vein stripping, 6.1; nonrecurrent inguinal herniorrhaphy, 21.9; cholecystectomy, 61.0; hemorrhoidectomy, 9.8; prostatectomy, 115.9; and hysterectomy, 9.6. In 1973 general practitioners did 32% of tonsillectomies and adenoidectomies (61% in 1971), 10 to 20% of inguinal herniorrhaphies, hemorrhoidectomies and appendectomies and 6% or less of the other operations. However, they performed 35% or more of the anesthetic procedures for these four operations as well as for varicose vein stripping, cholecystectomy and hysterectomy. Rates of general-practice surgery and anesthesia in an urban centre in Ontario were substantially less than those for the province as a whole.     

Incidence and pathophysiological relevance of postoperative endotoxemia

Abstract Patients who underwent surgical procedures usually develop elevated body temperature, changes of plasma levels of some proteins, and leucocytosis. These alterations are summarized as the postoperative acute-phase reaction. Also endotoxin can induce the described phenomena suggesting that endotoxin may play a role concerning the induction of the acute phase reaction. In order to test that hypothesis we determined endotoxin plasma levels preoperatively and daily postoperatively in patients who were operated on because of goiter ( n = 20), colonic, pancreatic and gastric diseases ( n = 58). A significant increase of endotoxin plasma levels was found at the first and third day after abdominal surgery whereas after goiter surgery the increase revealed to be only very slight. However, the decrease between the first and second postoperative day in the latter group was again statistically significant suggesting postoperative endotoxemia even after minor operations. Furthermore a correlation between the amount of circulating endotoxin and pulmonary or infectious complications could be established in patients after major operations even at the first postoperative day suggesting a pathogenetic relevance of postoperative endotoxemia.     

Increasing use of private practice by patients in Oxford requiring common elective surgical operations.

A random sample of 6000 people from eight general practices in and around Oxford was studied to ascertain their surgical histories and method of care received. The proportion of operations that were performed privately had increased with time and had a steep gradient according to social class. Different procedures had different likelihoods of being performed privately, but the age and sex of the patient had a non-significant association with private surgery. Adjustment for possible confounding variables using logistic analysis indicated that in the 1980s elective surgery is five times more likely to be performed privately than it was at the institution of the National Health Service.     

Paediatric cardiac surgical mortality in England after Bristol: descriptive analysis of hospital episode statistics 1991-2002

Objective To describe trends in mortality of open cardiac surgery in children in Bristol and England since 1991.Design Retrospective analysis of hospital episode statistics data.Setting All open cardiac surgery of children in England.Population Patients younger than 16 undergoing open cardiac surgical procedures in England between April 1991 and March 2002. Three time periods were defined: epoch 3 (April 1991 to March 1995), epoch 5 (April 1996 to March 1999), epoch 6 (April 1999 to March 2002).Main outcome measure Mortality in hospital within 30 days of a cardiac procedure.Results We identified 5221 open operations between April 1996 and March 2002 in children under 1 year and 6385 in children aged 1-15 years. Mortality for all centres combined fell from 12% in epoch 3 to 4% in epoch 6. Mortality in children under 1 year at Bristol fell from 29% (95% confidence interval 21% to 37%) in epoch 3 to 3% (1% to 6%) in epoch 6, below the national average. The reduction in mortality did not seem to be due to fewer high risk procedures or an increase in the numbers of low risk cases. Oxford had a significantly higher mortality than the national average in all three epochs (11% (5% to 18%) in epoch 6), which was not affected by adjusting for procedure or the inclusion of cases with missing outcomes.Conclusions At Bristol, mortality for open operations in children aged under 1 year has fallen markedly, to below the national average. Nationwide mortality has also fallen. Improved quality of care may account for the drop in mortality, through new technologies or improved perioperative and postoperative care, or both.     

Clearing the smoke: the scientific rationale for tobacco abstention with plastic surgery

The use of tobacco is a significant contributor to preventable morbidity and mortality in the United States. A significant proportion of cardiovascular diseases, various oral and pulmonary neoplasms, nonmalignant respiratory diseases, and peripheral vascular disorders can be attributed to the use of cigarettes. Surgical outcomes can also be adversely affected as a result of cigarette smoking with intraoperative and postoperative pulmonary, cardiovascular, and cerebrovascular complications as well as increased wound healing complications. These are found across the entire spectrum of surgical specialties. Tissue ischemia and wound-healing impairment secondary to the influence of tobacco is particularly problematic for the plastic surgeon, especially during elective facial aesthetic procedures, cosmetic and reconstructive breast operations, abdominoplasty, free-tissue transfer, and replantation procedures. By educating and providing guidelines to those patients who smoke and by refusing to operate on individuals who fail to abstain, tobacco-associated surgical morbidity in the plastic and reconstructive surgery patient can be eliminated.     

Secondary abdominal contour surgery: a review of early and late reoperative surgery

A retrospective chart review of 400 abdominal contour operations produced a series of 24 patients who underwent both their primary and then their secondary abdominal contour surgeries with the senior author (Matarasso). The majority of patients were classified and treated according to the abdominoplasty classification system previously described; however, a subgroup could not be categorized according to this system. In this study, the authors identified the secondary abdominal contour surgical experience of one surgeon. A comparison was made between two groups of patients treated for both primary and secondary operations: group I, considered early, less than 18 months after the previous operation; and group II, considered late, 18 or more months after the previous operation. There was a significant difference between groups I and II (chi2 = 4.12, p = 0.05); most patients had their surgical procedures before 18 months. For patients who underwent either a miniabdominoplasty or a full primary abdominoplasty, there was a statistically significant difference between the number of patients treated in group I and the number in group II (Fisher's exact test, D = 0, p = 0.05). Next, the nature of the secondary procedure was determined to be either a revisional procedure or a completely new reoperative procedure. The majority of patients underwent revision or "touch-ups," accomplished with either liposuction alone or in combination with scar revision. There was no significant difference between types of primary and secondary procedures performed in group I or group II. Secondary abdominal contour surgery accounted for 6 percent (24 of 400) of all abdominal contour procedures performed by one surgeon. Complete secondary surgery, performing an additional open procedure, occurred in 21 percent of cases (five of 24). Revision surgery (scar revision or removal of dog-ears) was performed in 29 percent of all cases (seven of 24). There was a 4 percent (one of 24) complication rate requiring operative intervention. This rate is consistent with that reported in the literature for primary abdominal contour surgery. With the overall acceptance of aesthetic surgery increasing, the number of patients undergoing abdominoplasty increasing, an aging population, and the safety of secondary abdominal contour surgery suggested from this review, it is likely that plastic surgeons will see more patients requesting secondary abdominal contour surgery in the future.     

A palm-sized high-sensitivity near-infrared fluorescence imager for laparotomy surgery

In laparotomy surgery guided by near-infrared fluorescence imaging, the access to the field of operation is limited by the illumination and/or the imaging field. The side of cavities or organs such as the liver or the heart cannot be examined with the systems available on the market, which are too large and too heavy. In this article, we describe and evaluate a palm sized probe, whose properties, weight, size and sensitivity are adapted for guiding laparotomy surgery.Different experiments have been performed to determine its main characteristics, both on the illumination and imaging sides. The device has been tested for fluorescent molecular probe imaging in preclinical procedures, to prove its ability to be used in cancer nodule detection during surgery. This system is now CE certified for clinical procedures and Indocyanine Green imaging has been performed during clinical investigations: lymphedema and surgical resection of liver metastases of colorectal cancers.     

Safety and efficacy of office-based surgery with monitored anesthesia care/sedation in 4778 consecutive plastic surgery procedures

Office-based surgery has several potential benefits over hospital-based surgery, including cost containment, ease of scheduling, and convenience to both patients and surgeons. Scrutiny of office-based surgery by regulators and state-licensing agencies has increased and must be addressed by improved documentation of safety and efficacy. To evaluate the safety and efficacy of the authors' office-based plastic surgery, a review was undertaken of 3615 consecutive patients undergoing 4778 outpatient plastic surgery procedures under monitored anesthesia care/sedation in a single office. The charts of 3615 consecutive patients who had undergone office-based surgery with monitored anesthesia care/sedation between May of 1995 and May of 2000 were reviewed. In all cases, the anesthesia protocol used included sedation with midazolam, propofol, and a narcotic administered by a board-certified registered nurse anesthetist with local anesthesia provided by the surgeon. Charts were reviewed for patient profile, types of procedures, multiple procedures, duration of anesthesia, American Society of Anesthesiologists class, and complications related to anesthesia. Outcomes measured included death, airway compromise, dyspnea, hypotension, venous thrombosis, pulmonary emboli, protracted nausea and vomiting lasting more than 24 hours, and unplanned hospital admissions. Statistical analyses were performed using the Microsoft Excel program and the SAS package. Results were as follows: 92.3 percent of the patients were female and 7.7 percent were male, with a mean age of 42.7 years (range, 3 to 83 years). Patients underwent aesthetic (95.6 percent) and reconstructive (4.4 percent) plastic surgery procedures. Same-session multiple procedures occurred in 24.8 percent of patients. The vast majority of patients were healthy: 84.3 percent of patients were American Society of Anesthesiologists class I, 15.6 percent were class II, and 0.1 percent were class III. The operations required a mean of 111 minutes. There were no deaths, ventilator requirements, deep venous thromboses, or pulmonary emboli. Complications were as follows: 0.05 percent (n = 2) of patients had dyspnea that resolved, 0.2 percent (n = 6) of patients had protracted nausea and vomiting, and 0.05 percent (n = 2) of patients had unplanned hospital admissions (<24 hours). One patient had an emergent intubation. No prolonged adverse effects were noted. There was a 30-day follow-up minimum. Outpatient surgery is an important aspect of plastic surgery. It was shown that office-based surgery with intravenous sedation, performed by board-certified plastic surgeons and nurse anesthetists, is safe. Appropriate accreditation, safe anesthesia protocols, and proper patient selection constitute the basis for safe and efficacious office-based outpatient plastic surgery.     

Acute hepatitis B in patients in Britain related to previous operations and dental treatment.

The frequency of transmission of hepatitis B virus infection from health service staff to patients was assessed from reports of confirmed cases of acute clinical hepatitis in 1980-3. During the four years 4505 reports (91% of the total) included replies to a question about recent operations; 153 patients (3.4%) had this history. Transfused blood or blood products were considered the source for 27 cases (0.06%). Eleven patients (0.02%) were infected in two clusters, both in cardiac surgery units; six were caused by a perfusion technician, who was a symptomless carrier, and five by a surgical registrar during the incubation period of an acute hepatitis B infection. The estimated average annual risk of a patient developing acute hepatitis B as part of a cluster caused by staff during surgical procedures was one in a million operations. For another 11 patients blood transfusion could not be excluded as a source. Where no association between surgery and hepatitis was found the incidence of a history, lay between 2.3 and 2.6%. The Hospital In-Patient Enquiry data showed that about 2.4% of the population had had operations in a six month period. These findings suggest that transmission of hepatitis B infection from staff to patients is rare in Britain and that the small risk could be eliminated by attention to measures to preserve asepsis and by immunising staff at risk.     

The Controversy Over Pediatric Bariatric Surgery

Despite the reported limited success of conventional treatments and growing evidence of the effectiveness of adult bariatric surgery, weight loss operations for (morbidly) obese children and adolescents are still considered to be controversial by health care professionals and lay people alike. This paper describes an explorative, qualitative study involving obesity specialists, morbidly obese adolescents, and parents and identifies attitudes and normative beliefs regarding pediatric bariatric surgery. Views on the etiology of obesity—whether it should be considered primarily a medical condition or more a psychosocial problem—seem to affect the specialists’ normative opinions concerning the acceptability of bariatric procedures as a treatment option, the parents’ feelings regarding both being able to influence their child’s health and their child being able to control their own condition, and the adolescents’ sense of competence and motivation for treatment. Moreover, parents and adolescents who saw obesity as something that they could influence themselves were more in favor of non-surgical treatment and vice versa. Conflicting attitudes and normative views—e.g., with regard to concepts of disease, personal influence on health, motivation, and the possibility of a careful informed consent procedure—play an important role in the acceptability of bariatric surgery for childhood obesity.     

Paulus Aegineta, a seventh century encyclopedist and surgeon: his role in the history of plastic surgery.

Paulus Aegineta (625-690 ad), born on the island of Aegina, practiced medicine at Alexandria. The last of the eclectic Greek compilers in the Byzantine period, he wrote an Epitome of medicine in seven books. The sixth book, which is considered the best section of his work, is devoted mainly to surgery. The first edition, "editio princeps," of his Epitome was published in Greek by the Aldine press in Venice in 1528 and later translated into English for the Sydenham Society by Francis Adams of Banchory (1844-1847). Paulus was not only a compiler but also a competent and skillful surgeon. In addition to his achievements in general surgical progress, Paulus Aegineta, especially in the book on surgery, made valuable contributions in the history of plastic surgery. He may be considered as one of the originators of plastic surgery as it is known today. He described procedures varying from the treatment of nasal and jaw fractures to operations for gynecomastia, ganglion, and hypospadias. This Grecian master influenced not only his own but also the subsequent ages. Rhazes, Haly Abbas, Albucasis, Avicenna, and Fabricius ab Aquapendente were the greatest physicians influenced by Paulus Aegineta. Because the work of Paulus Aegineta was the only source for many of the surgical treatises of Arabian authors, his Epitome bridged Western and Eastern medicine and conveyed surgical experience and knowledge, including several plastic surgery procedures, to the subsequent ages.     

Simplified oesophageal transection for bleeding varices.

Thirty patients with bleeding oesophageal varices were treated by oesophageal transection using the SPTU gun. Any form of shunt was contraindicated in all the patients. Twelve operations were done as urgent procedures within 36 hours of haemorrhage. The overall operative mortality rate was 10%, and there were two late deaths during follow-up, which has so far extended from two months to two years. Three of the patients had recurrent bleeding, and residual varices were probably the source in two. There were no cases of portal systemic encephalopathy. Although the follow-up is too short to allow any definite conclusions, these early results suggest that oesophageal transection with the SPTU gun may be useful in the large proportion of patients in whom injection sclerotherapy, shunt surgery, or conservative treatment is inappropriate.     

SOME RECENT ADVANCES IN THORACIC SURGERY

In this brief presentation of some recent advances in thoracic surgery a number of miscellaneous topics which deserve consideration at this time are discussed. Among these are acidosis during anesthesia for thoracic operations, the problem of esophagitis in relation to surgery, recent improvements and reorientations in pulmonary operations, and some comments on operations upon the heart and great vessels.