Abstract:

Conventional, pointer-based navigated Functional Endoscopic Sinus Surgery (FESS) has been shown to have certain limitations: necessity of instrument change for navigation, changes in the surgeon's line-of-sight axis, and limited length of use of the navigation information. These limitations result in negative consequences regarding the surgeon's attentiveness in any given situation, as well as in his cognitive work-load. The principle of Navigated Control offers advantages concerning these problems and limitations of the conventionally navigated FESS. This Chapter analyzes the first clinical deployment of a navigation-controlled shaver in FESS on the basis of the following questions: (1) Is clinical deployment of the navigation-controlled shaver possible with the pre-clinic evaluated set-up? (2) What information relevant to the surgery is relayed in an intraoperative setting by the navigation-controlled shaver? (3) How does deployment of the navigation-controlled shaver affect the ergonomics of the surgery? Ten patients with chronic sinusitis ethmoidalis were included in the study (average age: 48 [22-71], m:w=4:6). The preoperative and intraoperative workflow was documented according to the Innovation Center Computer Assisted Surgery (ICCAS) Workflow protocol. Data regarding the surgical validity of the information and ergonomic characteristics were recorded by means of questionnaires. The average time required for segmentation of the workspace was 14.2 minutes. The shaver switched off through Navigated Control an average 16.5 times during an FESS. From this amount, five shutdowns on average were initiative and six were determined to be provoked. The shutdowns were indicated by the operators to be correct in 199 of 220 (90.5%) events and in agreement with the actual position and planned resection borders. The quality of the relayed navigation information was indicated with an average Level of Quality (LOQ) of 56.4 [50-80]. The most favorable evaluation was attained for navigation in the area of the sphenoid sinus with 71 points on average [60-80]. During an FESS, the navigation information led to a change in the planned surgical strategy an average of 0.9 [0-3] times. Throughout all surgical procedures, the situation awareness was assessed an average of 2.7 points better than with the conventionally navigated FESS. This also was the case for the cognitive workload (Workload shift) with 2.8 [1-3.5] points. This Chapter proves the clinical applicability of a navigation-controlled instrument by means of a shaver in Ears, Nose, and Throat (ENT) surgery for the first time. Reproduction of the dental splint registration, manual segmentation of the working space, and attachment of the registration star still prove to be critical aspects. Data regarding quality of the information relayed by the navigation system and resulting change in surgical strategy lead to the conclusion that the authors are dealing with, in the overall evaluation, supplementary and surgically relevant information. This information is more efficiently transferred to the surgeon by means of Navigated Control that allows, according to the following results, both an improved understanding of the information and cognitive easing of stress for the surgeon.

Authors:

Gero Strauss, M.D., Ph.D., Department of ENT, University Hospital Leipzig, Germany, Mathias Hofer, M.D., Department of ENT, University Hospital Leipzig, Germany, Milos Fischer, M.D., Department of ENT, University Hospital Leipzig, Germany, Kirill Koulechov, Ph.D., Micro- and Medical Devices, Technical University Munich, Germany, Christos Trantakis, M.D., Department of Neurosurgery, University of Leipzig, Germany, Dittrich Manzey, Ph.D., Professor, Institute of Human-Machine-Interface, Technical University of Munich, Germany, Juergen Meixenberger, M.D., Ph.D., Professor, Head of the Department Department of Neurosurgery, University Hospital Leipzig, Germany Andreas Dietz, M.D., Ph.D., Professor, Head of Department, Department of ENT, University Hospital Leipzig, Germany, Tim C. Lueth, Ph.D., Professor, Head of the Department, Micro- and Medical Devices, Technical University Munich, Germany, H.U. Klapper, M.D., Department of Dental Surgery, University Hospital Leipzig, Germany

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Abstract:

To prevent unnecessary mistakes and avoidable complications in laparoscopic surgery, there has to be proper training. A safe way to train surgeons for laparoscopy is simulation. This study addresses the face validity of ProMIS, an Augmented Reality laparoscopic simulator, as a tool for training suturing skills in laparoscopic surgery. A two-paged, 12-item structured questionnaire, using a five-point-Likert scale, was presented to 50 surgeons/surgical interns. The participants were allotted to two groups: an "expert" (>50 procedures; N=23) and a "referent" group (<50 procedures; N=27). Non-parametric statistics were used to determine statistical differences. General consensus existed in both "expert" and "referent" groups, delineating ProMIS as a useful tool in teaching suturing skills surgeons/surgical interns (mean ± st dev, resp, score 4.91 ± 0.42 and 4.93 ± 0.38) with regard to realism, tactile feedback, and suturing techniques. Significant differences in opinion regarding the ergonomics and design of ProMIS between the "expert" and "referent" groups existed. The ProMIS Augmented Reality laparoscopic simulator is regarded as a useful tool in laparoscopic training in both "expert" and "referent" groups. Although significant differences in opinion existed with regards to ergonomics and design of ProMIS, they were present between experts and novices.

Authors:

S.M.B.I. Botden, M.Sc., Ph.D., Candidate/Medical Intern, Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands, J.T.M. Berlage, M.D., Surgical Resident, Department of Surgery, Maxima Medisch Centrum, Eindhoven, The Netherlands, M.P. Schijven, M.D., Ph.D., Surgeon, Department of Surgery, University Medical Centre, Utrecht, The Netherlands, J.J. Jakimowicz, M.D., Ph.D., Surgeon, Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands

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Abstract:

The principal cause of perioperative morbidity and mortality following hepatic resection is excessive intraoperative hemorrhage. This study evaluates the operative use of the LigaSure™ device in sealing ductal structures during major and minor hepatic resections. Patients were analyzed between June 1994 and December 2005, comparing 89 randomly selected cases undergoing hepatic resections using the clamp-crushing technique with LigaSure™ electrocautery and hepatic inflow occlusion where appropriate with 70 patients undergoing various hepatic resections using the clamp-crushing technique alone with hepatic inflow occlusion where appropriate. Intraoperative blood loss and perioperative blood transfusion requirements were significantly less for patients in the LigaSure™ group. LigaSure™-assisted hepatic resection was generally performed more quickly than the conventional clamp-crushing technique. The overall maximum postoperative AST, ALT, and bilirubin serum levels were similar in the two groups, as was the incidence of major postoperative complications. The LigaSure™ device in this randomized study is safe and simple to use, resulting in less perioperative blood loss and transfusion requirement during hepatic parenchymal transection.

Authors:

Antonio Chiappa, M.D., F.A.C.S., Professor of Surgery, Vice Director, Department of General Surgery, European Institute of Oncology, University of Milan, Milan, Italy, Emilio Bertani, M.D., Senior Assistant, Department of General Surgery, European Institute of Oncology, University of Milan, Milan, Italy, Roberto Biffi, M.D., Co-Director, Department of General Surgery, European Institute of Oncology University of Milan, Milan, Italy, Andrew P Zbar, M.D., F.R.C.S., F.R.A.C.S., Professor of Surgery, Director, Professorial Department of General Surgery, University of the West Indies, School of Clinical Medicine and Research, Cave Hill Campus, Barbados, Giuseppe Viale, M.D., F.R.C.P. (Path), Professor of Pathology, Director, Division of Pathology, European Institute of Oncology, University of Milan, Milan, Italy, Giancarlo Pruneri, M.D., Assistant Professor, Division of Pathology, European Institute of Oncology, University of Milan, Milan, Italy, Massimo Bellomi, M.D., Professor of Radiology, Director, Division of Radiology, European Institute of Oncology, University of Milan, Milan, Italy, Marco Venturino, M.D., Director, Division of Anesthesiology, European Institute of Oncology, University of Milan, Milan, Italy, Bruno Andreoni, M.D., Professor of Surgery, Director, Department of General Surgery, European Institute of Oncology, University of Milan, Milan, Italy

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Abstract:

Surgical, post-surgical deep vein thrombosis (DVT), or thromboembolism is common and potentially catastrophic. Surgical DVT may lead to either immediate post-surgical morbidity or long-term morbidity by way of post-phlebitic syndrome and chronic venous insufficiency. In addition, surgery-associated pulmonary embolism (PE) may lead to significant morbidity or post-surgical mortality. As this surgical complication is so common, both the North American Consensus Conference Committee, sponsored by the American College of Chest Physicians, and the International Consensus Conference Committee, sponsored by the International Society of Angiology, have convened periodically during the past two decades to analyze the highest-quality published studies and publish clear standards and guidelines for prevention and treatment of surgical DVT and thromboembolism. The latest North American Recommendations were published in 2004 and the latest International Committee recommendations were released in 2006. These recommendations are summarized in this chapter, which offers the clinician the latest guidelines for prevention and treatment of surgery-associated DVT and thromboembolism.

Authors:

Shirisha Reddy, M.D., Senior Fellow, Yu-Min Shen, M.D., Assistant Professor, Division of Hematology/Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas Dallas, Texas, USA

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