Atraumatic Instability and Surgical Technique

The term “atraumatic surgical technique” was probably first used by the American surgeon Sterling Bunnell [1]. He described the particularly careful handling of the various anatomic structures with the goal of minimizing trauma, which is known today as “minimally invasive surgical technique.”

Embolization during carotid reconstruction is the most frequent cause of neurologic complications. Atraumatic surgical technique, intraoperative monitoring of the cerebral circulation and completion imaging all contribute to reduce the risks of embolization. Data from the literature suggest that the incidence of perioperative neurologic events correlate with the number of microemboli demonstrated by transcranial Doppler. Cerebral protection for percutaneous angioplasty with stenting of the carotid artery needs to be introduced, since without protection devices endovascular techniques are associated with > 8 times the rate of microemboli seen during carotid endarterectomy.

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1013 Abstract The normal hip has a natural tendency to stability due to its depth, congruency, and surrounding contractile and inert tissues. Hip instability may occur either with or without trauma. Hip microinstability may also occur with or without trauma. However, microinstability is a concept that is currently unproven, but sound anatomically, biomechanically, and radiographically, and with limited in vivo clinical studies. In the absence of other clear sources for persistent hip symptoms despite treatment, the astute clinician may diagnose microinstability. However, microinstability may also be the cause or the effect of other concomitant hip pathologies. If prior surgery has been performed, the operative report, photographs, and videos should be scrutinized in detail, especially in regard to osseous, chondrolabral, and capsuloligamentous management. Patients should be assessed for generalized hypermobility. Certain subjects (such as young female gymnasts, ballet, dance, yoga) may be at particular risk. Impingement-induced instability may also be an underlying contributor, especially in males with cam deformities. The examiner must assess the difference between laxity (asymptomatic) and instability (symptomatic). The true location of pain and tenderness, motion, and strength should be evaluated. Both radiographic and advanced imaging may be indicated. Initial management of microinstability J.D. Harris (*) Houston Methodist Center for Orthopaedics & Sports Medicine, Houston, TX, USA

In an effort to substantiate the efficacy of adenotonsillectomy in very young children, 108 procedures in one and two-year-old children were reviewed. After rigid preoperative criteria are met, a meticulous, conservative adenotonsillectomy is performed. A review of all hospital and office records shows the procedure can be safely and simply performed without significant complications. Seventy-nine parents were questioned regarding postoperative problems and results. Of the parents, 96% were satisfied and would have the procedure done again if they had the chance. Eighty-four referring physicians were polled and 87% thought the procedure solved the children's problem altogether or mostly. In conclusion, the results of this study show that, in carefully selected young children using expert anesthesia and atraumatic surgical technique, adenotonsillectomy under the age of three is a safe and gratifying procedure.

BackgroundZone 2 flexor tendon injuries still represent a challenging problem to hand surgeons despite the well developed surgical techniques and suture materials. Meticulous surgical repair with atraumatic handling of the severed tendon stumps and minimal damage to the tendon sheath are particularly important to prevent postoperative adhesions and ruptures in this area.In zone 2 flexor tendon injuries proximal to the vinculas, the cut ends of the flexor tendons retract to the palm with muscle contraction. To retrieve the severed proximal flexor tendon under tendon sheath and pulley system is very difficult without damaging these structures. Many techniques are described in the literature for the delivery of the retracted proximal tendon stump to the repair site.MethodsIn this report we would like to present a simple and relatively atraumatic technique that facilitates passing of the retracted flexor tendon through the pulleys in zone 2. We sutured the proximal tendon stump at the distal palmar crease with 3–0 polypropylene suture and used a 14 gauge plastic feeding tube, acting like a conduit for the passage of straightened needle to the finger.ResultsWe have used this technique 21 times without any complication in our clinic. We have not seen any suture breakage during the passage or needle breakage due to the bending of the needle.ConclusionsWe have found this technique is very simple and very effective in retrieving the retracted tendon stump without causing undue damage to the tendon stump or tendon sheath.

To collect data on the current practice and knowledge about surgical techniques for prevention of adhesions and types of surgical gloves used by Swedish obstetricians and gynaecologists. Postal questionnaire during 1995. Sweden. All 1200 Swedish gynaecologists were invited to participate. Methods in use to prevent the formation of adhesions such as glove selection criteria, operative techniques, and laparoscopic surgery. At this time there were 72 hospitals in Sweden carrying out gynaecological operations and responses were received from obstetricians and gynaecologists at 61 of these hospitals. The response rate was 27% of gynaecologists routinely carrying out such operations. There were no consistent methods in use to prevent the formation of adhesions. The most common method used was the atraumatic technique. For laparotomy 19.5% always used powdered gloves whereas half had changed to powder-free gloves. The use of powdered gloves was highest in the university hospitals (62%). 95% always closed the visceral peritoneum for gynaecological or obstetric procedures although there is no documentation to support the benefit of doing so. There was a low percentage response, probably indicating lack of interest. Swedish gynaecologists seem unaware of the need to prevent adhesions.

Dental autotransplantation is defined as the movement of one tooth from one position to another, within the same patient. Autotransplantation has predictable results; in fact, many studies describe a success rate of over 90%. This article describes a case report concerning the surgical management of this surgical technique. An 18-year-old patient comes for the treatment of her left first mandibular molar (3.6) involved in decay process. An accurate radiological analysis (periapical X-ray and orthopantomographic evaluation) showed an immature left mandibular third molar (3.8), suitable as donor tooth. The mandibular first molar was extracted in an atraumatic way. The intra-alveolar septum was modified with a piezoelectric device. The tooth was slightly depressed in the socket and remained in infra-occlusion. It was stabilized by sutures and a metallic splint. Then, the autotransplanted molar was fixed with a double splinting for 4 weeks. In conclusion, the autotransplantation was followed by endodontic treatment. After 36 months of follow-up, wisdom tooth showed an improvement in clinical features in agreement with radiological examination. The success of this case can be attributed to the atraumatic surgical technique and the immature stage of the transplanted element.

Connecting Art and Science: How Far Have We Come?

BackgroundPerfluorocarbon liquid (PFCL) is an effective surgical adjuvant in performing vitrectomy for severe vitreoretinal pathologies such as proliferative vitreoretinopathy and giant retinal tears. However, subretinal retention of PFCL can occur postoperatively and retained PFCL causes severe visual disorders, particularly when PFCL was retained under the fovea. Although several procedures have been proposed for subfoveal PFCL removal, such as direct aspiration or submacular injection of balanced salt solution (BSS) to dislodge the subfoveal PFCL, the retinal damage associated with these procedures has been a major problem. Here, we report a case of subfoveal retention of PFCL for which we performed a novel surgical technique that attempts to minimize retinal damage.Case presentationA 69-year-old man presented with subfoveal retained PFCL after surgery for retinal detachment. To remove the retained PFCL, the internal limiting membrane overlying the subretinal injection site is first peeled to allow low-pressure (8 psi) transretinal BSS infusion, using a 41-gauge cannula, to slowly detach the macula. A small drainage retinotomy is created with the diathermy tip at the inferior position of the macular bleb, sized to be slightly wider than that of the PFCL droplet. The head of the bed is then raised, and the surgeon gently vibrates the patient’s head to release the PFCL droplet to allow it to migrate inferiorly towards the drainage retinotomy. The bed is returned to the horizontal position, and the PFCL, now on the retinal surface, can be aspirated. The subfoveal PFCL is removed while minimizing iatrogenic foveal and macular damage. One month after PFCL removal, the foveal structure showed partial recovery on optical coherence tomography, and BCVA improved to 20/40.ConclusionCreating a macular bleb with low infusion pressure and using vibrational forces and gravity to migrate the PFCL towards a retinotomy can be considered as a relatively atraumatic technique to remove subfoveal retained PFCL.

Implant-retained craniofacial prostheses (or epitheses) made of silicone are state of the art for prosthetic rehabilitation of facial defects. With the modern extraoral implant systems, prostheses may be securely anchored to the bone regardless of size and location of the defect. Prerequisite for successful implantation is the classical atraumatic surgical technique with avoidance of any thermal trauma to the bone. The treatment intention may be atemporary measure, arescue procedure after failed (re)construction, or adefinitive treatment option. This article gives an overview of the strategies in various facial regions stratified according to the age of the patient and the etiology of the defect. Moreover, prosthetic rehabilitation offers additional options for septal perforations, distorted and leaky tracheostomies, and treatment-resistant tracheoesophageal fistula.

A laparoscopic method of managing macroscopically benign, unilateral, unilocular, mobile, translucent, and smooth-walled ovarian cysts in women of reproductive age is described. The method requires the cutting of a window in the cyst wall through the laparoscope fenestration. In preference to aspiration at laparoscopy or removal at laparotomy, this method has the advantage of ensuring histologic material as well as permanent drainage by the use of atraumatic surgical technique. Nineteen cysts were fenestrated laparoscopically. Four cysts could not be classified, two owing to lack of histologic material, two owing to malpreparation of the selected cyst tissue. In one case an epithelial cyst--a mucinous cystadenoma, being laparoscopically unsuspected--was fenestrated. One cyst recurred. By observing the above criteria it is possible and tolerably safe to select non-neoplastic cysts, for which fenestration should be reserved.