The number of surgical procedures performed each year to treat
femoroacetabular impingement (FAI) continues to rise. Although there
is evidence that surgery can improve symptoms in the short-term,
there is no evidence that it slows the development of osteoarthritis
(OA). We performed a feasibility study to determine whether patient
and surgeon opinion was permissive for a Randomised Controlled Trial
(RCT) comparing operative with non-operative treatment for FAI.
Surgeon opinion was obtained using validated questionnaires at
a Specialist Hip Meeting (n = 61, 30 of whom stated that they routinely
performed FAI surgery) and patient opinion was obtained from clinical
patients with a new diagnosis of FAI (n = 31).
Clinical equipoise was demonstrated when surgeons were given
clinical scenarios and asked whether they would manage a patient
operatively or non-operatively. A total of 23 surgeons (77%) who
routinely perform FAI surgery were willing to recruit patients into
a RCT, and 28 patients (90%) were willing to participate. 75% of
responding surgeons believed it was appropriate to randomise patients
to non-operative treatment for ≥ 12 months. Conversely, only eight
patients (26%) felt this was acceptable, although 29 (94%) were
willing to continue non-operative treatment for six months. More
patients were concerned about their risk of developing OA than their
current symptoms, although most patients felt that the two were
of equal importance.
We conclude that a RCT comparing operative and non-operative
management of FAI is feasible and should be considered a research
priority. An important finding for orthopaedic surgical trials is
that patients without life-threatening pathology appear willing
to trial a treatment for six months without improvement in their
Femoroacetabular impingement; Randomised controlled trial; Hip; Feasibility; Equipoise; Trial design
A prospective comparative study was undertaken to compare the patients’ pain experience, surgical outcome and surgeon’s experience in phacoemulsification and manual small incision cataract surgery (MSICS) under topical anesthesia supplemented with intracameral lignocaine (TASIL). In Group 1 (n=88) phacoemulsification was done and in Group 2 (n=92) MSICS was done. Pain scores were marked by the patients on a Visual analog scale (VAS) after the surgery. The surgical experience was noted on a questionnaire by the operating surgeon. Descriptive analysis and one-tailed Mann-Whitney test were used to draw results. The average VAS score in Group 1 was 0.65 (SD 1.31) and in Group 2 it was 0.90 (SD 1.22). This difference in the average was not statistically significant with P=0.09. The study demonstrates that MSICS and phacoemulsification both can be done safely under TASIL with acceptable patient comfort, and the pain experienced by the patients during the procedures is comparable.
Manual small incision cataract surgery; phacoemulsification; topical anesthesia; Visual analog scale; pain evaluation; gender; cataract. intracameral lignocaine
Maintaining patient safety in the operating room is a major concern of surgeons, hospitals, and surgical facilities. Circumventing preventable complications is essential, and the pressure to avoid these complications during elective cosmetic surgery is especially important. Traditionally, nursing and anesthesia staff have managed patient positioning and most safety issues in the operating room. As the number of office-based procedures in the plastic surgeon's practice increases, understanding and implementation of patient safety guidelines by the plastic surgeon is of increasing importance.
Key aspects of patient safety in the operating room include thoughtful patient positioning, ocular protection, proper handling of electrocautery, and airway management. If performed correctly with attention to certain anatomic landmarks, preoperative positioning of the patient can prevent nerve injury and postoperative joint or muscle pain. In this article we discuss proper patient positioning with attention to protection against nerve palsy. Further, we discuss common patient positions on the operative table and highlight special concerns associated with each position. Other safety issues including prevention of ocular injury and proper management of electrocautery are discussed.
Responsibility of postoperative complications ultimately lies with the surgeon. Careful attention to patient safety guidelines is of paramount importance to surgeons, especially during elective cosmetic procedures. Attention to detail in patient positioning, eye protection, and bovie use can help avoid unnecessary perioperative complications and significantly improve the patient's cosmetic surgery experience.
Patient safety; operating room; patient positioning; ocular injury; electrosurgery; nerve injury
Postpartum hemorrhage is one of the rare occasions when a general or acute care surgeon may be emergently called to labor and delivery, a situation in which time is limited and the stakes high. Unfortunately, there is generally a paucity of exposure and information available to surgeons regarding this topic: obstetric training is rarely found in contemporary surgical residency curricula and is omitted nearly completely from general and acute care surgery literature and continuing medical education.
The purpose of this manuscript is to serve as a topic specific review for surgeons and to present a surgeon oriented management algorithm. Medline and Ovid databases were utilized in a comprehensive literature review regarding the management of postpartum hemorrhage and a management algorithm for surgeons developed based upon a collaborative panel of general, acute care, trauma and obstetrical surgeons' review of the literature and expert opinion.
A stepwise approach for surgeons of the medical and surgical interventions utilized to manage and treat postpartum hemorrhage is presented and organized into a basic algorithm.
The manuscript should promote and facilitate a more educated, systematic and effective surgeon response and participation in the management of postpartum hemorrhage.
A properly conducted surgical informed consent process (SIC) allows patients to authorize an invasive procedure with full comprehension of relevant information including involved risks. Current practice of SIC may differ from the ideal situation. The aim of this study is to evaluate whether SIC practiced by Dutch general surgeons and residents is adequate with involvement of all required elements.
All members of the Dutch Society of Surgery received an online multiple choice questionnaire evaluating various aspects of SIC.
A total of 453 questionnaires obtained from surgeons and residents representing >95% of all Dutch hospitals were eligible for analysis (response rate 30%). Knowledge on SIC was limited as only 55% was familiar with all three basic elements (‘assessment of preconditions’, ‘provision of information’ and ‘stage of consent’). Residents performance was inferior compared to surgeons regarding most aspects of daily practice of SIC. One in 6 surgeons (17%) had faced a SIC-related complaint in the previous five years possibly illustrating suboptimal SIC implementation in daily surgical practice.
The quality of the current SIC process is far from optimal in the Netherlands. Surgical residents require training aimed at improving awareness and skills. The SIC process is ideally supported using modern tools including web-based interactive programs. Improvement of the SIC process may enhance patient satisfaction and may possibly reduce the number of complaints.
Informed consent; Surgery; Patient education; Questionnaire; Interactive tools; Training
This paper reviews the current status of bilateral breast reduction surgery in the UK and Ireland. It examines the pre-operative, operative and postoperative management of women.
PATIENTS AND METHODS
A questionnaire established information about surgeons' experience, bilateral breast reduction work-load, pre-operative assessment, selection criteria, issues of operative technique and postoperative management. This was sent to 230 consultant plastic surgeons working in the NHS in the UK and Ireland.
There was a 61% response rate. Of respondent surgeons, 82% always perform pre-operative photography, 71% never do a mammogram even in patients above the age of 50 years. Body mass index (BMI) is the most commonly used criteria for patient selection (60%). Two-thirds of the surgeons use an inferior pedicle technique and 75% of surgeons work in health authorities that restrict breast reduction surgery.
There was significant variation in practice among surgeons performing bilateral breast reduction. This may reflect a lack of evidence base for practise. Published literature focuses almost exclusively on the description of different techniques. Further work is required to evaluate the role of pre-operative mammography, specimen mammography, antibiotics and selection criteria for surgery.
Bilateral breast reduction; Audit; Pre-operative assessment; Selection criteria; Operative technique; Postoperative management
Informed consent is perhaps more relevant to surgical specialties than to other clinical disciplines. Fundamental to this concept is the provision of relevant information for the patient to make an informed choice about a surgical intervention. The opinions of surgeons in Nigeria about informed consent in their practice were surveyed.
A cross-sectional survey of surgeons in Nigeria was undertaken in 2004/5 using self-administered semistructured questionnaires.
There were 102 respondents, 85.3% of whom were men and 58.8% were aged 31–40 years. 43.1% were consultants and 54.0% were surgical trainees. 27.4% were in surgical subspecialties, 26.5% in general surgery and 21.6% were obstetricians and gynaecologists. 54.9% agreed that sufficient information is not provided to patients while obtaining their consent for surgical procedures. They listed medicolegal reasons (70.6%), informing patients about benefits, risks and alternatives (64.7%) and hospital policy (50.0%) as some reasons for obtaining consent for surgical procedures. When patients decline to give consent for surgery, 84.3% of them thought that poor communication between surgeons and patients may be contributory. They identified taking a course in bioethics during surgical training and compulsory communication skills course as some ways to improve communication between surgeons and patients.
Most Nigerian surgeons seemed to have a good knowledge of the informed consent requirements and process but fall short in practice. There is a need to improve the surgeon–patient relationship in line with modern exigencies to provide interactive environments for fruitful patient communication and involvement.
To assess surgical team members’ differences in perception of non-technical skills.
Operating theatres (OTs) at one university hospital, three teaching hospitals and one general hospital in the Netherlands.
Sixty-six surgeons, 97 OT nurses, 18 anaesthetists and 40 nurse anaesthetists.
All surgical team members, of five hospitals, were asked to complete a questionnaire and state their opinion on the current state of communication, teamwork and situation awareness at the OT.
Ratings for ‘communication’ were significantly different, particularly between surgeons and all other team members (P ≤ 0.001). The ratings for ‘teamwork’ differed significantly between all team members (P ≤ 0.005). Within ‘situation awareness’ significant differences were mainly observed for ‘gathering information’ between surgeons and other team members (P < 0.001). Finally, 72–90% of anaesthetists, OT nurses and nurse anaesthetists rated routine team briefings and debriefings as inadequate.
This study shows discrepancies on many aspects in perception between surgeons and other surgical team members concerning communication, teamwork and situation awareness. Future research needs to ascertain whether these discrepancies are linked to greater risk of adverse events or to process as well as systems failures. Establishing this link would support implementation and use of complex team interventions that intervene at multiple levels of the healthcare system.
patient safety; quality of care; teamwork; communication; surgery
Neck or back problems are experienced at some time by many Americans and many patients receive recommendations for spinal surgery. Patients naturally seek another opinion to confirm the need for surgery, or for the particular procedure recommended.
Over approximately a 14-month period, the author prospectively collected data regarding 240 consecutive patients seeking a surgical opinion regarding a spine problem. Imaging studies were reviewed and patients were asked to comment on the consultation experience.
Of the 240 patients, 155 (65%) came for a second, third, or fourth surgical opinion following an earlier opinion from a surgeon who recommended an operation. Of these patients, the author recommended no surgery for 69 (44.5%) patients. The remaining 85 (35%) were referred by primary care doctors or neurologists for initial surgical (first) opinions because of magnetic resonance imaging (MRI) or computed tomography (CT) reports indicating the presence of surgical lesions. The author recommended no surgery for 37 (43%) of these 85 patients.
Patients request and deserve the attention of a physician who will listen to their history and perform a careful neurological examination. The results of the neurological examination and the imaging studies must then be carefully integrated and correlated with the patient's complaints. The results should be explained to the patient so that he or she will understand the surgical or non surgical nature of his or her problem.
Imaging studies; not satisfied; spinal surgery; very helpful
Maintaining patient safety in the operating room is a major concern of surgeons, hospitals and surgical facilities. Circumventing preventable complications is essential, and pressure to avoid these complications in cosmetic surgery is increasing. Traditionally, nursing and anesthesia staff have managed patient positioning and safety issues in the operating room. As the number of office-based procedures in the plastic surgeon’s practice increases, understanding and implementing patient safety guidelines by the plastic surgeon is of increasing importance.
A review of the Joint Commission’s Universal Protocol highlights requirements set forth to prevent perioperative complications. In the present paper, the importance of implementing these guidelines into the cosmetic surgery practice is reviewed. Key aspects of patient safety in the operating room are outlined, including patient positioning, ocular protection and other issues essential for minimization of postoperative morbidity. Additionally, as the demand for body contouring surgery in the cosmetic practice continues to increase, special attention to safety considerations specific to the obese and massive weight loss patients is mandatory.
After review of the present paper, the reader should be able to introduce the Joint Commission’s Universal Protocol into their daily practice. The reader will understand key aspects of patient positioning, airway management and ocular protection in cosmetic surgery. Finally, the reader will have a better understanding of the perioperative care of unique populations including the morbidly obese, massive weight loss patients and the elderly. Attention to detail in these aspects of patient safety can help avoid unnecessary complication and significantly improve the patient’s experience and surgical outcome.
Body contouring surgery; Cosmetic surgery; Patient safety
This observational study was carried out to establish how surgeons performing laparoscopic cholecystectomy currently deal with the issue of spilled gallstones.
MATERIALS AND METHODS
A questionnaire was circulated amongst laparoscopic surgeons attending the annual conference of the Association of Laparoscopic Surgery of Great Britain and Ireland in November 2006.
Eighty-two surgeons completed the questionnaire. Only half of surgeons inform patients when gallstones are spilled. Less than 30% of surgeons inform general practitioners (GPs) of this complication, when it occurs. Less than a quarter of surgeons include this information in the consent literature provided to patients.
We recommend that trusts review their policy towards spilled stones either by local audit or adopt the guidance given by the UK Healthcare Commission. While some surgeons feel informing patients and GPs may unnecessarily heighten anxiety from an uncommon complication, our review of the literature suggests this position is not tenable in the current medicolegal climate.
Laparoscopic cholecystectomy; Spilled gallstones
Obesity has become a major issue for healthcare providers as its prevalence continues to increase throughout the world. The literature suggests that increased body mass index (BMI) is associated with the development of certain cancers such as colorectal cancer (CRC). Consequently, CRC surgeons are now encountering an increasing number of obese patients which may influence the technical aspects and outcomes of surgical treatment. For instance, obese patients present with greater comorbidities preoperatively, which adds increasing complexity and risks to surgical management. Recent literature also suggests that obesity may increase operating time and conversion rates to open colorectal surgery. Postoperative outcomes may also be influenced by obesity; however, this currently remains controversial. There is evidence that survival rates after CRC surgery are not influenced by obesity. In summary, obesity presents challenges to CRC surgeons, and further research will be needed to show how this important characteristic influences the outcomes for CRC patients.
A questionnaire was given to 37 members of staff of the Department of Surgery, Addenbrooke's Hospital, Cambridge, in order to determine whether their knowledge was adequate to give accurate information to patients regarding operations and thus to obtain properly informed consent for that operation. Each participant was asked to estimate the 24-h and 30-day mortality for five common elective operations. A wide range of answers was given for operations by all groups. Estimates of 24-h mortality after unilateral inguinal herniorrhaphy differed between staff grades by a factor of 3, but estimates of 24-h mortality after thyroidectomy differed by a factor of 100 between consultant surgeons and staff nurses. Our findings suggest that some members of the surgical team have insufficient knowledge about common operations to obtain properly informed consent from patients.
Prior studies have suggested that biomodels enhance patient education, preoperative planning and intra-operative stereotaxy; however, the usefulness of biomodels compared to regular imaging modalities such as X-ray, CT and MR has not been quantified. Our objective was to quantify the surgeon’s perceptions on the usefulness of biomodels compared to standard visualisation modalities for preoperative planning and intra-operative anatomical reference. Physical biomodels were manufactured for a series of 26 consecutive patients with complex spinal pathologies using a stereolithographic technique based on CT data. The biomodels were used preoperatively for surgical planning and customising implants, and intra-operatively for anatomical reference. Following surgery, a detailed biomodel utility survey was completed by the surgeons, and informal telephone interviews were conducted with patients. Using biomodels, 21 deformity and 5 tumour cases were performed. Surgeons stated that the anatomical details were better visible on the biomodel than on other imaging modalities in 65% of cases, and exclusively visible on the biomodel in 11% of cases. Preoperative use of the biomodel led to a different decision regarding the choice of osteosynthetic materials used in 52% of cases, and the implantation site of osteosynthetic material in 74% of cases. Surgeons reported that the use of biomodels reduced operating time by a mean of 8% in tumour patients and 22% in deformity procedures. This study supports biomodelling as a useful, and sometimes essential tool in the armamentarium of imaging techniques used for complex spinal surgery.
Biomodelling; Complex spinal surgery; Rapid prototyping; Stereolithography; Spinal deformity; Spine surgery planning
This survey aimed to validate the English version of the multidimensional Leiden Perioperative Patient Satisfaction questionnaire (LPPSq) and use it to assess patient satisfaction with perioperative care and the influence of type of anesthesia. One hundred patients having orthopedic surgery under regional and general anesthesia verbally consented to participate. Different aspects of satisfaction were assessed (eg, provision of information, and staff-patient relationship). The reliability estimate of the LPPSq (Cronbach’s-α) was good (0.94). Overall, patient satisfaction score was 86.7%, lowest was for information (80.8%) and highest for staff-patient relationships (90.3%). Patients were more satisfied with the provision of information regarding regional anesthesia.
Leiden Perioperative Patient Satisfaction questionnaire; orthopedic; anesthesia; information
Following surgery for rectal cancer, two unfortunate outcomes for patients are permanent colostomy and local recurrence of cancer. We tested whether a quality-improvement strategy to change surgical practice would improve these outcomes.
Sixteen hospitals were cluster-randomized to the intervention (Quality Initiative in Rectal Cancer strategy) or control (normal practice) arm. Consecutive patients with primary rectal cancer were accrued from May 2002 to December 2004. Surgeons at hospitals in the intervention arm could voluntarily participate by attending workshops, using opinion leaders, inviting a study team surgeon to demonstrate optimal techniques of total mesorectal excision, completing postoperative questionnaires, and receiving audits and feedback. Main outcome measures were hospital rates of permanent colostomy and local recurrence of cancer.
A total of 56 surgeons (n = 558 patients) participated in the intervention arm and 49 surgeons (n = 457 patients) in the control arm. The median follow-up of patients was 3.6 years. In the intervention arm, 70% of surgeons participated in workshops, 70% in intraoperative demonstrations and 71% in postoperative questionnaires. Surgeons who had an intraoperative demonstration provided care to 86% of the patients in the intervention arm. The rates of permanent colostomy were 39% in the intervention arm and 41% in the control arm (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.63–1.48). The rates of local recurrence were 7% in the intervention arm and 6% in the control arm (OR 1.06, 95% CI 0.68–1.64).
Despite good participation by surgeons, the resource-intense quality-improvement strategy did not reduce hospital rates of permanent colostomy or local recurrence compared with usual practice. (ClinicalTrials.gov trial register no. NCT00182130.)
With recent advances in minimally invasive techniques, many surgeons are favoring laparoscopic over traditional “open” pyloromyotomy for hypertrophic pyloric stenosis. The results of few studies, however, exist in the literature adequately comparing surgical outcome. We present a retrospective analysis of 56 consecutive patients who underwent laparoscopic or open pyloromyotomy.
A retrospective chart review of 56 consecutive infants (ages: 2 to 9 weeks; weights: 2.2 to 5.4 kilograms) who underwent laparoscopic (Group A-28) vs open (Group B- 28) pyloromyotomy between January 2000 and May 2001 was performed. Preoperative (age, sex, weight, HCO3, and K values) and postoperative (operating time, time to full feedings, persistence of emesis, and hospital stay) parameters were compared. Statistical analysis was performed via the Student t test and chisquare/Fischer analysis where appropriate. A P value <0.05 was considered significant.
Preoperative parameters of both groups were similar (P >0.05). In Group A, 26/28 (92.9%) were completed successfully with 2 open conversions. Group A versus Group B average operating times (36.1 vs 32.5 minutes), time to full feedings (24.1 vs 27.0 hours), and hospital stay (2.5 vs 2.6 days) were similar (P >0.05). Persistent vomiting was observed in Group A, 25.0% (day 1)/3.5% (day 2) vs Group B, 39.3% (day 1)/10.7% (day 2). One infant in Group B required operative drainage of a wound abscess 1 week after surgery.
Laparoscopic pyloromyotomy can be performed with similar efficiency and surgical outcome as traditional open pyloromyotomy. Improved cosmesis and avoidance of wound complications are major benefits of this procedure, and a tendency towards less postoperative emesis is a potential benefit that deserves further investigation.
Laparoscopic; Pyloromyotomy; Hypertrophic; Stenosis
To survey clinical practice and opinions of consultant surgeons and anaesthetists caring for children to inform the needs for training, commissioning and management of children's surgery in the UK.
The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) hosted an online survey to gather data on current clinical practice of UK consultant surgeons and anaesthetists caring for children.
The questionnaire was circulated to all hospitals and to Anaesthetic and Surgical Royal Colleges, and relevant specialist societies covering the UK and the Channel Islands and was mainly completed by consultants in District General Hospitals.
555 surgeons and 1561 anaesthetists completed the questionnaire.
32.6% of surgeons and 43.5% of anaesthetists considered that there were deficiencies in their hospital's facilities that potentially compromised delivery of a safe children's surgical service. Almost 10% of all consultants considered that their postgraduate training was insufficient for current paediatric practice and 20% felt that recent Continued Professional Development failed to maintain paediatric expertise. 45.4% of surgeons and 39.2% of anaesthetists considered that the current specialty curriculum should have a larger paediatric component. Consultants in non-specialist paediatric centres were prepared to care for younger children admitted for surgery as emergencies than those admitted electively. Many of the surgeons and anaesthetists had <4 h/week in paediatric practice. Only 55.3% of surgeons and 42.8% of anaesthetists participated in any form of regular multidisciplinary review of children undergoing surgery.
There are significant obstacles to consultant surgeons and anaesthetists providing a competent surgical service for children. Postgraduate curricula must meet the needs of trainees who will be expected to include children in their caseload as consultants. Trusts must ensure appropriate support for consultants to maintain paediatric skills and provide the necessary facilities for a high-quality local surgical service.
Accurate preoperative and postoperative risk assessment has been critical for counseling patients regarding radical prostatectomy for clinically localized prostate cancer. In addition to other treatment modalities, neoadjuvant or adjuvant therapies have been considered. The growing literature suggested that the experience of the surgeon may affect the risk of prostate cancer recurrence. The purpose of this study was to develop and internally validate nomograms to predict the probability of recurrence, both preoperatively and postoperatively, with adjustment for standard parameters plus surgeon experience.
The study cohort included 7724 eligible prostate cancer patients treated with radical prostatectomy by 1 of 72 surgeons. For each patient, surgeon experience was coded as the total number of cases conducted by the surgeon before the patient’s operation. Multivariable Cox proportional hazards regression models were developed to predict recurrence. Discrimination and calibration of the models was assessed following bootstrapping methods, and the models were presented as nomograms.
In this combined series, the 10-year probability of recurrence was 23.9%. The nomograms were quite discriminating (preoperative concordance index, 0.767; postoperative concordance index, 0.812). Calibration appeared to be very good for each. Surgeon experience seemed to have a quite modest effect, especially postoperatively.
Nomograms have been developed that consider the surgeon’s experience as a predictor. The tools appeared to predict reasonably well but were somewhat little improved with the addition of surgeon experience as a predictor variable.
prostate cancer; surgeon experience; recurrence; predictive value; nomogram
To assess the impact of subspecialisation on surgical and oncological outcomes after rectal cancer surgery in a single surgical unit within a district general hospital.
PATIENTS AND METHODS
A total of 207 patients with rectal cancer treated surgically by two colorectal surgeons and four experienced general surgeons at the Royal Berkshire Hospital, Reading, England between January 1995 and December 1999 were studied. A retrospective case-note review of each patient's personal details, operative and histological findings, their subsequent clinical progress and oncological outcomes, including 5-year survival were recorded.
In the study group, 127 patients were treated by a colorectal surgeon and 80 by general surgeons. Pre-operative radiotherapy was more likely to be given to patients treated by a colorectal surgeon. Fewer permanent stomas were performed by colorectal surgeons. Postoperative morbidity, transfusion requirements, anastomotic leak rates and 30-day mortality were not significantly different. Tumour-involved circumferential resection margins, local recurrence rates and risk of distant metastases were similar between the two groups of surgeons.
Colorectal subspecialisation has resulted in an increased use of pre-operative radiotherapy and fewer permanent stomas. No significant improvement in surgical or oncological outcomes after rectal cancer surgery have been observed.
Rectal cancer; Outcomes after surgery; Subspecialisation
A cross-sectional study of 100 surgeons and 370 patients awaiting primary total hip or knee replacement was carried out. Oxford hip or knee score questionnaires were sent to the surgeons and patients. They were asked to predict the level of symptoms expected 6 months following surgery. The Oxford scores derive a value of 12-60, with a greater score indicating worsening symptoms. The mean pre-operative score was 45.12 for the hip patients and 42.96 for the knee patients, and the patients expected this to drop to 23.70 and 25.66, respectively, 6 months' postoperatively. This was a significant difference for both groups. The surgeons expected the patients to have a mean postoperative score of 20.91 for the hip group and 22.19 for the knee group. The surgeons' scores were significantly lower than those from the patients. There was a significant difference between the patients' and surgeons' expectations of the results of total knee and hip replacement surgery. The surgeons expected better results than the patients. We believe that this is the first study that directly compares surgeon and patient expectations of lower limb arthroplasty.
The authors here describe manual small incision cataract surgery (MSICS) by using topical anesthesia with intracameral 0.5% lignocaine, which eliminates the hazards of local anesthesia, cuts down cost and time taken for the administration of local anesthesia.
To evaluate the patients' and surgeons' experience in MSICS using topical anesthesia with intracameral lignocaine in terms of pain, surgical complications, and outcome.
Settings and Design
Prospective interventional case series.
Materials and Methods
Ninety-six patients of senile cataract were operated by MSICS under topical anesthesia with intracameral lignocaine using “fish hook technique.” The patients and the single operating surgeon were given a questionnaire to evaluate their experience in terms of pain, surgical experience, and complications.
Statistical Analysis Used
Statistical analysis software “Analyseit.”
There were 96 patients enrolled in the study. The mean pain score was 0.7 (SD ± 0.97, range 0–5, median 0.0, and mode 0.0). Fifty-one patients (53%) had pain score of zero, that is, no pain. Ninety-one patients (˜95%) had a score of less than 3, that is, mild pain to none. All the surgeries were complication-free except one and the surgeon's experience was favorable in terms of patient's cooperation, anterior chamber stability, difficulty, and complications. The ocular movements were not affected, and hence, the eye patch could be removed immediately following the surgery.
MSICS can be performed under topical anesthesia with intracameral lignocaine, which makes the surgery patient friendly, without compromising the outcome.
Anesthesia; intracameral lignocaine; pain evaluation; manual small incision cataract surgery; topical
To identify and quantify factors causing stress in the operating room (OR) and evaluate the relationship between these factors and surgeons’ stress level.
This is a prospective observational study from 32 elective surgical procedures conducted in the OR of King Khalid University Hospital, Riyadh, Saudi Arabia. Before each operation, each surgeon was asked of stressors. Two interns observed 16 surgeries each, separately. The interns watched and took notes during the entire surgical procedure. During each operation, the observer recorded anxiety-inducing activities and events that occurred in real time by means of a checklist of 8 potential stressors: technical, patient problems, teamwork problems, time and management issues, distractions and interruptions, equipment problems, personal problems, and teaching. After each operation, surgeons were asked to answer the validated State-Trait Anxiety Inventory questionnaire and self-report on their stress level from the 8 sources using a scale of 1–8 (1: stress free, 8: extremely stressful). The observer also recorded perceived stress levels experienced by the surgeons during the operation.
One hundred ten stressors were identified. Technical problems most frequently caused stress (16.4%) and personal issues the least often (6.4%). Frequently encountered stressors (teaching and distractions/interruptions) caused less stress to the surgeons. Technical factors, teamwork, and equipment problems occurred frequently and were also a major contributor to OR stress. All patients were discharged in good health and within 1 week of surgery.
Certain stressful factors do occur among surgeons in the OR and can increase the potential for errors. Further research is required to determine the impact of stress on performance and the outcome of surgery.
Operating room; stressful events; surgeon
Background: Recurrence of trichiasis following surgery remains unacceptably high, regardless of the surgical procedure. Few prospective studies of sufficient size are available to assess the rate of recurrence and the factors contributing to recurrence. A prospective study of the modified Cuenod Nataf surgical procedure was conducted in Vietnam to determine recurrence and co-factors.
Methods: The prospective study of Cuenod Nataf surgery for trachomatous trichiasis took place in four districts of Vietnam. All patients from identified villages who had surgery were followed for a period of 1 year. 10 Surgeons using standard techniques and recording procedures carried out the surgery. The presence of an eyelash touching the eyeball in the operated eye was considered as recurrence. Information on all subjects was recorded preoperatively, intraoperatively, and postoperatively. An independent examiner recorded postoperative information. Relative risks were calculated to assess the contribution of various risk factors to recurrence (by eye and by person). Cox proportional hazards modelling was used to assess the independent contribution of relevant factors to the outcome.
Results: 471 individuals had trichiasis surgery; 463 were followed for a period of 1 year. Overall, the recurrence rate was 10.8% (95% CI 8.0 to 13.6). Among people having surgery recurrence (one or both eyes) was most common in the most elderly (relative risk (RR) 2.49) and among those with a history of previous surgery (RR = 2.49). Cox proportional hazards analysis (by eye) revealed that visual acuity, conjunctival scarring, and suture adjustment were associated with recurrence at 1 year.
Conclusion: The Cuenod Nataf procedure, which is well accepted in the community and by eye care providers in Vietnam, has an acceptable 1 year success rate. Individuals with severe conjunctival scarring have the highest rate of recurrence suggesting that other surgical approaches are needed to manage these patients or that these patients need to be educated regarding the risk of recurrence. Active follow up of these patients would be warranted. The association with suture adjustment requires further investigation.
trachomatous trichiasis; Cuenod Nataf lid surgery; Vietnam
CT and MR imaging give spatial information of patient’s disease and anatomy. They help in preoperative surgical planning and guide the surgeon during operation. In conventional Functional Endoscopic Sinus Surgery (FESS), surgeon mentally correlates the information of CT and MR with the direct sinuscopic view of operative field. In Computer-Assisted Functional Endoscopic Sinus Surgery ( C-A FESS), computer provides image guidance for the surgeon. Surgeon can appreciate ike immediate surrounding structures outside the direct endoscopic vision of the surface. Thus widely enhancing the field of endoscopic mage. The overall accuracy of 1 to 2 mm has been reported. Many systems of tracing are being developed and tested far. Each system has its own advantages and disadvantages. It is now possible to guide mrgery with intraoperatively acquired MR images. The real-time imaging shows the tissue changes occurring during the operation. Surgeon can safely operate the lesions of optic nerve, sphenoid sinuses, pituitary gland, and cranial base.
Computer-Assisted Surgery; Computer-Aided Surgery; Computer-Augmented Surgery; Image-Guided Surgery; Functional Endoscopic Sinus Surgery; Endoscopic Sinus Surgery