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Surgical Techniques - Science topic

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Endoscopic middle meatal surgery is commonly associated with post-op adhesions. I my self use different techniqs.
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I use plastic splint for 9 days to prevent adhesion.
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Perhaps surgical techniques have changed and some are allowed but a good proportion are not allowed to weightbear. May I know the reasons or indications to keep a patient non-weightbearing? Noted a previous discussion on load bearing and sharing differences a few years back. Noted for IM Nailing, which is load sharing, patients are allowed to weight-bear early. Noted also that a dynamic hip screw is load bearing but weight bearing is allowed since stability is achieved. Thanks!
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It is a bespoke scenario but we tend to let them weight bear. There are multiple factors to consider. Internal fixation is not a new science. The first half
of the twentieth century has provided us with ample documentation of the results of unstable internal fixation. Surgery has frequently proved to be the worst
form of treatment. It destroyed the soft tissue hinges, interfered with biological factors such as the blood supply and the periosteum, and was never sufficiently strong or stable to permit active mobilization of the limbs with partial loading. Supplemental external plaster fixation was often necessary. The emphasis
was on bone healing and not on soft tissue rehabilitation. Healing became evident when callus appeared. Unfortunately, unstable internal fixation was unpredictable
and uncertain, and it frequently resulted in delayed union, nonunion, or deformity. When union did occur, instead of signifying the end of treatment it merely signaled the beginning of a prolonged phase of rehabilitation designed to regain motion in the soft tissue envelope and in the stiff joints. The ravages
of this prolonged nonfunctional form of treatment were such that open reduction and internal fixation were looked upon as the last resort in the treatment of a fracture.
Neutralization plates or protection plates are used to protect the primary lag screw fixation. They conduct part or all of the forces from one fragment to
the other. In this way they protect the fracture fixation from the forces of bending shear and rotation
In metaphyseal areas the cortex is very thin, and if subjected to load it can fail. Such failures result in deformity and axial overload of the joint. Therefore, internal fixation in metaphyseal areas requires protection with plates that support the underlying cortex. These are referred to as buttress plates. Buttressing
may also be achieved with external fixation.
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Dear all,
For some time, we have been working with Stata metaprop in order to analyse our results from our review on two surgical techniques (for now A and B).
Through the metaprop command (Metaprop: a Stata command to perform meta-analysis of binomial data, by Nyaga et al.) we were able to perform a meta-analysis of our data.
However, where the 'normal' Stata program for meta-analysis has a test for group differences ( Qb with corresponding p value) to compare overall effect sizes of the two groups.
Metaprop gives a significance test with hypothesis effect size = 0 (ES = 0).
This results in tree Z values and their p values, one for each group and one overall outcome.
Eg. outcome A : z= 7.68, p=0.00
outcome B: z= 8.77, p=0.00
Overall: z =9.79, p=0.00
Is there a way of telling or calculating the group difference between the effect sizes of group A versus group B?
Thanks in advance,
Regards,
Iris Hochstenbach
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My study has 2 components:
1)
I have 10 organ and I want to find how accurate surgeons are using 2 seperate measurement techniques for measuring an angle on the organ compared to a gold standard.
4 surgeons each generate 1 measurement per organ per technique.
I want to pool the surgeons data together, making the asumption that they are representive, and then get some sort of value on the accuracy of the 2 techniques compared to gold standard.
Would a Lin's Concordance Correlation Coefficient for each technique be appropriate? Would that tell me how "good" each technique is in some sense?
Then, would it be appropriate to run ICC to see what the inter-observer agreement is for each of the 2 measurement techniques?
2)
I also have 1010 organs that were operated on by each surgeon 3 times using 3 different techniques.
After each "surgery" I measured the change in angle from pre to post surgery (if surgery was perfect, change would be 0)
I want to find some way of estimating the "accuracy" or "effectiveness" in some way of each of the 3 surgical techiques, pooling the data from the 4 surgeons.
could I do some sort of regression analysis to see overall how each technique performed in terms of having the smallest overall change in angle?
Could I also run an ICC to get a sense of the inter-observer variability for each surgical technique?
Thanks for reading
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If your "angle" variable is continuous, then ICC is appropriate. However, if you categorize it in groups (ordinal variable), Cohen's kappa will be more suitable.
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If there are two surgeons in two different institutions and both are mastered in two different surgical techniques, can we compare the outcome of their patients to understand the value of each intervention? Let me also put this; when I mean "mastered" learning curve for the intervention is suggested as 100 cases and each had done that intervention for more than 500. I am asking this question as we have a study like this and it has been rejected for this limitation. However, I have encountered similar studies in the literature and would like to know how to respond or how to make a revision in our study.
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Good Answer Om Prakash Sudrania
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Looking for any approaches, SOPs or anatomical landmarks people use to conduct a gonadectomy of immature male rats (this is for epigenetic analysis of reproductive cells as young as 10 days). Looking for a method to minimize the time and damage to the area while removing the immature testes.
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Thanks! I have done gonadectomies with adult animals using a similar procedure, but am uncertain about doing them in animals where the testes have not descended yet. If I am following your guide, you make two incisions on the lower belly (one on either side), then go through the muscle. Are the testes easily visible from there? Once I find them, I can use the same general procedure used for adults for tying them off and suturing the incisions
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I am considering the surgical technique during thoracic surgery concerning phrenic nerve and laryngeal recurrent nerve injury.
What's the outcome after the reconstruction of these nerves?
Do any endeavors have related experience?
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Sorry for the delayed response. Well the phrenic nerve is a peripheral nerve, so it should behave almost the same way. Like the extracranial part of facial nerve. Thanks
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HelIo everyone, Currently I am working on systematic review and meta-analysis of a surgical technique ( Posterior Scleral Reinforcement in high myopia and complications of high myopia ) to observe its effect. As there is no comparator in my study. So my question is,which type of study model I should apply and which software is most reliable for Meta-analysis?
Regards.
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State your research question. Use PICO format. Based on your comment, I do not expect a "C" component. What is the rationale for not having a comparator?
What do you mean by "study model"? Fixed-effect model? Random-effects model?
I doubt that you are truly concerned about the reliability of a software. Reliability of an instrument assesses the reproducibility of the instrument, an issue I would not think a software program would have a problem with. Also remember that an instrument can have perfect reliability and be wrong 100% of the time. Validity (aka accuracy) would be more likely to be a problem. Still, I doubt that it would be an issue for any of the major meta-analysis packages. The "best" meta-analysis software is largely a matter of opinion. You pretty much get what you pay for, noting that several packages are free. The following URL shows six head-to-head comparisons of various meta-analysis packages to Comprehensive Meta-Analysis. It may be useful to you. The URL is at the CMA website so beware. (https://www.meta-analysis.com/pages/comparisons.php)
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Can anyone recommend any recent research that supports or disproves standard precautions such as double gloving and PPE in surgery?
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Yes , I am
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Nasalisation is a french surgical technique for massive excision of sinus polyposis, aiming to make all sinuses & nostrils as one cavity. Majority of sinus surgeons prefer FESS. Of my gathered experience during working with different sinus surgeons, I noted that FESS is lesser aggressive than Nasalisation but followed by recurrence of polyposis requiring multiple revision FESS which gave finally a sinus condition resembling that of post-Nasalisation.  Would you give your own experience, if possible with research study. 
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FESS  is defined as functional ESS , NASELIZATION IS NOT FESS BUT ESS, and this is it's main problem: not functional wit severe dryness and crustatiobs . Patients would develop atrophic rhinitis or Emty nose syndrome.
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From time to time, I meet cases of bilateral choanal adenoids causing mouth breathing, snoring +/- disturbed sleep according to severity. I found that both x-ray of postnasal space and flexible fibreoptic nasal scope can preoperatively diagnose this unusual type of adenoids. Surgical technique varies according to size & extension of this adenoid. If it is limited at choana but bulged intranasally, then I use an endonasal approach to remove it by depriding (preferable to me) or by suction diathermy (vallylab). If it is limited at choana but bulged into nasopharynx, then it can be removed through nasopharynx under mirror vision using suction diathermy (vallylab). If it is prominent intranasal & into nasopharynx, then combined approach can be used. I found that choanal adenoids is preoperatively misdiagnosed by geniors as classic nasopharyngeal adenoids hypertrophy if they depends on endoscope alone. Also, x-ray alone when revealed empty nasopharynx does not mean absent choanal adenoids in case of presence of symptoms (mouth breathing, snoring +/- disturbed sleep). Also, choanal adenoids is perioperatively misdiagnosed by geniors as inferior turbinate tail hypertrophy. So, to diagnose choanal adenoids, you would put it in your consideration & you would request x-ray with endoscopic examination. This is my own experience regarding choanal adenoids management. Would you add your experience?
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Thank you Dr. Viswanatha for  your sharing but my topic is about bilateral choanal adenoids & not nasopharyngeal adenoids.
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what is your experience with sternal cable system for sternal closure? is it better than ordinary stainless steel wire? is it cost effective? 
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HI.
I prefer to use the ordinary stainless steel wire. It´s coste-effective, easy to use and replace, and I dont like the "figure 8" made by the cables (we use 8 or 9 parallel wires, twisted each one).
Last time I had demo of sternal closure systems, they were at least 70-100 times expensive than ordinary closure.
Best regards
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32 year old women with a BMI of 60 presented with severe Gallstone disease.ERCP was performed to clear the Bile duct 2days prior to her admission.GallBladder was gangrenous and full of pus.Lap chole was difficult but no adverse events.Her temperature was swinging at 101 which is settling.She has no other comorbidities.
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The main issue about the timing of bariatric and biliary surgery is the possible need to endoscopically access the biliary tree after the bariatric procedure, in particular after a RY gastric bypass. When you feel confident that this risk is minimized (and your patient already had a laparoscopic cholecystectomy and a ERCP with a probable sphyncterotomy) you could plan her bariatric surgery. Of course, I agree with Guido Jutten that bariatric surgery is not urgent and a patient with a BMI of 60 should undergo a preoperative weight reduction plan, and a gastric balloon should be considered along with a period of ketogenic diet: another problem you are going to face is the technical difficulty of performing bariatric surgery due to the liver enlargement, visceral fat along with the adhesions of the previous inflammatory state. Of course, you want to operate after having maximized the preoperative weight loss and liver size reduction.
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I am conducting meta-analysis on complication outcomes related to a rather new surgical technique. Hence, published studies contain rather small study samples. Is there a minimum to the number of participants in a study for it to be eligible for inclusion in meta-analysis?
Thank you
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i trhink you will find an answer for your question in Chapter 16:  Special topics in statistics(chocrane handbook for interventions systematic review)
Cochrane Handbook for Systematic Reviews of Interventions
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40 years old female patient with a 3,5 cm solitary nodule on left thyroid lobe.fine needle aspiration biopys confirmed atypia with undetermined significance. Which type of surgery do you prefer? Total thyroidectomy? Left lobectomy or frozen section biopsy directed surgery?
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Why to do this dr khaled where the risk of malignancy is 5 to 15 % only ?!! Frozen section isnot reliable in such cases 
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Can anyone suggest me any article highlighting steps in costotransversectomy?
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The costotransversectomy is a classic operation for spinal tuberculosis that is aimed at curettage and plumbage of the TB focus or abscess through a sophisticated postero-lateral approach. It is introduced by the French surgeon Menard some 100 years ago. You can find the separate surgical steps for costotransversectomy ih the excellent surgical atlas "Orthopaedische Operations-Lehre" (Becken & Wirbelsaule) by Rathke&Schlegel.
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Any advice, tips and tricks on how to best perform the surgery and how to set up this model would be greately appreciated.
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You can find the answer in the following research :
Y. Li, J.-G. Wang, Y.-P. Li, Z.-F. Lin, A MODIFIED RAT MODEL FOR CANNULATION AND COLLECTION OF THORACIC DUCT LYMPH. Lymphology 44 (2011) 82-88
You can also contact :
 Zhao-fen Lin, PhD, Professor, Emergency Department
Changzheng Hospital Second Military Medical University
No. 415 Fengyang Road- Shanghai 200003, China
Tel: +8613601605100
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Dear Colleagues,
Good day. Laparoscopic PIRS is a procedure that closes the patent deep inguinal ring mainly in paediatric indirect hernia without posterior wall weakness. No mesh is used in this procedure. 
Upon my brief literature review, patients that have underwent Lap PIRS ranges 4 weeks old to 17 years old have been reported.
May I know anyone has any experience on performing Lap PIRS on older teenage or young adult?
Is there a limit to the size of the deep ring defect? How do we check for posterior wall weakness in laparoscopy?
Many thanks in advance.
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The important thing is to asses the  posterior inguinal wall weakness for the percutaneous inguinal ring suturing rather than taking a decision on the basis of age limit. suturing can be done even in the age of 17 or 18 years of age if there is no posterior inguinal wall weakness
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Assuming H.pylori eradicated and NSAIDs/antiplatelet risk factor withdrawn
Is it 6 weeks, the same duration recommended as for non perforated ulcer healing?
Do we routinely perform gastroduodenoscopy to confirm ulcer healing?
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In my practice 6 weeks is the minimum duration as well. At this moment I will perform an upper endoscopy especially to rule out any malignancy. During the initial procedure in the acute setting, the biopsy is not always performed/ recommended. After this period the PPI therapy will be prolonged depending on the Endoscopy findings.
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It is known that Hippocrates had developed a "surgical" technique to stabilise the commonly presented anterior dislocation of the shoulder. In the modern medical era we have developed and abandoned many procedures. Which of them do you think imitates the original Hippocratic technique?
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Thermal capsuloraphy is usually performed arthroscopically now days. In my humble opinion the ancient technique cannot be compared totally with this.
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Does anyone use Definity contrast agent as a continuous infusion? We have had to manually continuously rotate the syringe pump during use to keep the solution mixed. Any ideas on a better method of mixing during infusion? Thanks in advance.
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Please also the attachment added.
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Literature is rife with many surgical techniques for obese diabetics. Is duodeno-jejunal bypass + sleeve gastrectomy superior to Roux-en-Y gastric bypass regarding T2DM control ?
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Thanks for your input sir. But what  about the nutritional complications associated with such a long limb? 
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One of the commonly performed minimal access procedure is Lap mesh ventral hernia repair.we started with plain polypropylene grafts and now we are using composite mesh grafts.The market is flooded with variety of expensive grafts.Most of them are good. It is always a difficult task to choose.One such is symbotex which has been recently introduced in India.
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I have no experience in their use
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Acid burns of upper gastrointestinal tract produce a complex combination of lesions which can be grouped into five types, and existing surgical techniques have proved inadequate in treating some of these lesions. Over the past 25 years 72 patients have needed operative treatment since they could not be managed by more conservative measures; the anatomical lesions in the five types and their surgical management are described.
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Yes, the treatment protocol varies with the lesion. Acute gastric bleeding may be life threatening needing immediate surgical intervention, usually partial gastrectomy. Esophagial stricture does not always need excision or bypass, dilatation with bougie after the acute stage is followed by self bouginage at home and cure many patients. The surgical treatment is reserved for the severe and extensive burns. Majority patients in our experience are females and care has been taken that the surgical technique was cosmetic without leaving ugly visible scars that will be embarrassing throughout life. Use of right colon and terminal small intestine make the conduit isoperistaltic however long the conduit is and can be done through a small incision and it is a pleasure to see the radioactive bolus passing smoothly as in normal esophagus and the girls getting married and leading a happy life. We have never seen any carcinoma developing in the injured esophagus over the last decades.
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the safest  and reproducible technique
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Here's a link from Arie Blitz on handling the big MAC (mitral annular calcification).  Hope it is useful.
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A 55 year old obese female patient has undergone Open Mesh Repair for Ventral Hernia (Onlay Technique) about 45 days back. It was a large hernia with defect size of about 20 x 15 cm. Mesh was placed and vacuum suction placed over it. Even after 45 days drain output is about 100 ml per day. There is no evidence of infection and the suture line has healed well. Do i have to wait till output comes to less than 30 ml per day or remove it now and use compression dressing?
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Very difficult situation. I would keep close contact with the patient after removal of the drain, and then see 1) how big the seroma gets and 2) how much it bothers the patient. Aspiration is not, in my opinion, necessary if it does not bother the patient. Within a year seromas can regress and some may even disappear completely.
Word of caution though: Onlay repair for such a large hernia? Why not go retromuscular, then you reduce the risk of seroma and recurrence. And if you really want to avoid these problems, demand that the patient lose weight before surgery. Probably makes both patient and surgeon happy if no complications are encountered.
Hope the best for the patient -- I am very interested in what happens next!
Regards
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I need to know which cyanoacrylate tissue adhesive is better to use in oral and maxillofacial surgical procedure instead of suturing?
[email removed by admin]
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I would agree on the n-butyl-2-cyanoacrylate, have used it extensively on laparoscopic inguinal hernia repair with good results. 
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long surgery
cancer surgery
 hepatic surgery
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Clotting powders are only ment for superficial outside use and have not approved for internal application. Their temperature is high, so they are able to result in burns. Nevertheless, chitosan has been used by Kenji Inaba in the swine model in liver injury, and was found to be a good adjunct to packing. There is a certain degree of embolism risk not yet quantified. If a patient dies in localised profuse bleeding, you may save the patient. If you have a bleeding disorder and erythrocytes are appearing from everywhere, physiology is the key to survival. Try rewarming, coag factors, thrombocytes, high dose calcium.....But it may be too late at that stage.
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We are planning some studies assaying tissue collected by a minimally invasive muscle biopsy method. We have two scientists and a clinician working on this project. The clinician is not in a position to perform these biospsies on our patients. We are unclear as to the relevant regultion surrounding the ability of non-clinically trained scientific personnel to peform these tasks as ideally the two scientists would perform the biopsies. Further what are the costs involved in this proceedure (per patient) and what other consumables are needed?
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Currently our muscle biopsies involve a significant incision in the thigh, any advance on this would be welcome. Certainly the procedure as it stands has to be done by a surgeon. Can you describe your minimally invasive method?
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Often comparisons between different surgical techniques for assessing the effectiveness of a method are performed. That experience is with the use of the same technique as Tector today?
Thank you very much in advance
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Colleagues of this forum:
I beg your pardon for the time that has passed and I have not thanked them their appropriate comments. I was not connected these days.
I thank them suggestions and makes them personally extend my thanks to each of you.
I fraternally a shipment from Havana, Cuba
Dr.Nizahe Estevez Alvarez. MD
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Intraoperatively, what is the best surgical technique to fin intramyocardial LAD
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thank you very much Dr Ugurlucan and Dr Holubec for the valuable answer
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The therapy involves the use of stem cells derived from the patient’s own fat (adipose tissue) obtained using liposuction.
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I conducted Autologous Adipose Derived Stem Cell (AADSC) application in thirty-four patients. Most of them had Buerger Disease and the rest had inoperable distal arterial occlusive diseases. In both groups, including local distal phalangeal necroses, we obtained good results. I personally think that, this method has a promising future. However, clinical evidence and the statistical data are not sufficient so far. But, it often elongate the claudication distance and providing increased comfort to these patients. If anyone interested, I can send the before-after photos of the ischemic limbs!
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I've not been able to locate any evidence for or against warming patients intraoperatively as a prevention measure for postoperative delirium in elderly patients. 
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Delirium wasn't recognized as a common and serious postoperative complication until well after the major hypothermia studies were conducted in the 1990s. It thus wasn't included as an outcome in any of them. I don't believe that there is any substantive information about hypothermia and delirium. My guess, though, is that hypothermia is not a major contributor. 
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In trans abdominal proproteinial hernioplasty, is it important to fix the mesh??
Have you any experience in , not fixing the mesh??
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I do mostly TEP. I switched from TAP to TEP after doing 61 TAPS and rarely have to do TAP. Started in 1991. I use 7 to 10 pro-tacks per side. I always worry about recurrences on directs that have not had fixation. I find my recurrence rate to be 1 percent or less
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Although most surgeons may claim to master all current hernia surgery techniques, a recent analysis show that outcomes of hernia surgery in different hospitals show a large variability. Additionally to two major problems of groin hernia surgery (chronic pain and hernia recurrence) remain a continuous challenge. A few networks (e.g. Denmark, Germany) have come up with a hernia database to monitor surgical quality and set benchmarks. 
Do you think we need more quality management in hernia surgery?
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The RCS England have published a document which includes at the end some 'quality' specifications.   
Its not amazing, but these criteria are designed to be easily obtained using administrative databases.
Cheers
Ewen
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what education medication can cut down on ileostomy output
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The patient should measure ileostomy output for 2 days. If over 1200 ml per day, start taking loperamide  up to 16 mg (8 tablets) per day, taken in divided doses before meals and at bedtime.
Eat 6 small meals per day rather than 3 larger ones.
Try limiting fluid intake with meals. Still make sure you are drinking 8-10  cups of fluid per day.
Avoid high fiber foods.
Limit or avoid caffeine and high fat foods.
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Inguinal seems to be safer but less effective. Is this true?
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I agree with Darby
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Madelung's deformity is a rare disease of the wrist which affects mainly females during the adolescence growth spurt. Clinical presentation: radial deviation of the hand with prominence of distal end of ulna and a volar subluxation of the carpus. Various techniques for surgical management have been described until now, but still clear evidence to support the use of any single approach is lacking. 
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Epiphysiolysis is only useful when you expect the growth plate is intact and will correct the deficit. In most cases this is not possible. You can correct the deficit much better by correction osteotomy. With computer you can do a mathematical - theoretical correction but in the patient there are so many limiting structures as tendons, nerves, ligaments, vessels, and so on. In most cases the mathematical aim will not be achieved. and a complete anatomical correctionis not possible if there is a deformation in the distal radius and the proximal row.
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Elective orthopeadics, OA , post op athroplasty.
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I agree with the previous comments and i want to add some others. Indeed the time required to obtain a muscle strength at 4 or 5/5 depends on the joint and the location of the muscle. globally the mean recovery period is of 4 weeks for the hip and 6 weeks for the knee. Special attention should be given to hip stabilizers (specially the gluteus medius) that take longer to recover.   
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the indication is cardiac arrest usually or tamponade which is not giving us time enough to shift the patient back to theater. but when exactly should we say lets re-open the patient and stop defibrillating etc any more.? 
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Massive bleeding 300 ml or more/h,3 or 4 consecutive hours is reason for reopen patients after cardiac surgery. Second reason is clinical signs of cardiac tamponade with hemodynamic unstabile patients.To reduce te risk of infection surgeon reopen patients in operating room. Some times ,very poor LVEDP end EF requires a reopen patients.
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SILS cholecystectomy concept is not popular in the UK,most Lap.Chole operations are performed by traditional 4,or 3 ports lap.chole. One study from the UK showed comparable results for SILS cholecystectomy but the time is longer.(.Chow A, et al.)
Appendicectomy and cholecystectomy using single-incision laparoscopic surgery (SILS): the first UK experience.Surg Innov. 2009 .
The review showed comparable safety (Markar SR, Karthikesalingam A,et al.Single-incision laparoscopic surgery (SILS) vs. conventional multiport cholecystectomy: systematic review and meta-analysis.Surg Endosc. 2012.
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Dear Deepraj,
Many thanks for your expert input,
I'm a fan of minimal access surgery and I think we should offer this kind of operation on condition that safety is not going to be less than traditional lap.chole and also resources and operative time are not going to be stretched!!.
I agree there are many ways to do cholecystectomy.The chosen technique will depends on surgeons' experience,local setting and some unavoidable politics within each department.
I'm aware of your technique and agree its cheap and no extra instruments cost is warranted.
My questions to you:
1.If you see this patient 2-5 years later and compare to another patient who have been done by traditional 3 or 4 ports technique ,what is the difference or the advantage from your perspective?by that time the traditional ports are inconspicuous.
2.The operative time : Most surgeons can do easy gall bladder in 20-25 minutes.What is your average operative time from pneumoperitoneum to closure of your single port?
3.What is your incidence of clinical umbilical hernia[this is the major concern of SILS].Studies quoting 2-3%.
4.What is your bile injury &bile leak incidence over the last 5 years? the field in the video you put on you tube is not comfortable for surgeons who are not SILS fan.
5.Are you applying SILS for each gall bladder?how would manage difficult gall bladder?what is the incidence of conversion to traditional lap.chole and to open chole?
6.Are comfortable with bile leak+/_ bleeding from your retraction stitch through the gall bladder and are you giving prophylactic antibiotics for each patient as you expect bile leak anyway?
I would be very grateful for your answers to these questions.
Thanks again
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I am trying to perform a surgery for 2k1c method. Does the kidney size gets reduced after clipping it or does it remains same. Can we use some other thing to occlude renal artery other them silver clip and do we need to partially or completely block the artery.
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The best person in my mind would be Dr. L. Gabriel Navar, who is the Chair of the Department of Physiology at Tulane University School of Medicine. His group developed and used the 2K1C hypertensive rat and mouse models for a long time, and has published extensively. I am sure he will give you very sound advice, as I know that he is one of best mentors and teachers in the field. His e-mail is Navar, Luis G navar@tulane.edu.
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We're planning a trial on patients choosing CAM from aversion to surgery due to fear-avoidance beliefs and catastrophizing, and we are looking for fear-specific psychiatric assessment tools for treatment interventions (esp. surgery). Any ideas would be most welcome, Thank you :)
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Here's a good article assessing the "Amsterdam Preoperative Anxiety and Information Scale," which includes fear of anesthetic, fear of surgery, and informational desire:
Pritchard, M. J. (2008). Identifying and assessing anxiety in pre-operative patients. Nursing standard (Royal College of Nursing (Great Britain): 1987), 23(51), 35-40.
Good luck with your important research!
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Is this necessary? What is the rationale? Is not the spacer another foreign body that could maintain the infection?
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If you have an acute infection with a sensitive bacteria and no osteoarthritis we always were successful by doing an arthroscopic synovectomy and parallel antibiotic treatment.
In cases with osteoarthritis we carried out an open synovectomy as we expected, that there would be an chance to do a second operation ( TKA).
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Traditionally, we use a 11 x 6cm in open hernia repair. In laparoscopic repair, most surgeons use one of these sizes: 15 x 10cm, 15 x 12cm or 15 x 7.5cm. The recommendation is to adequately cover the myopectineal orifice of Fruchaud, so what size mesh will do this?
Is there a consensus?
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Ferdinando, I'm glad to read the same newspapers.
If you want to predict the future, try to create it yourself (with a little help of all friends) 
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I remember during my training days, how difficult it is to inject local anesthetic for corn excision. Where the local spilt all over.
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I use a posterior tibial nerve block with lidocaine 2%. It is quite simple. Find the artery and leave a depot near the artery. Take care not to puncture the artery. With this technique the whole foot sole is numb. A number 11 blade is ideal to remove the corn with an elliptical excision. Sharp spoons are also useful. I close the skin with an absorbable suture.
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We usually enter the saphenous vein below the knee level and place in upwards to the saphenofemoral junction. In 2 cases of mine, who were morbid obese, I tried this method and I thought it may be helpful in some cases. Especially in patients who can not be cannulated from below the knee level due to various reasons.
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We often use this technique for venous ulcers.
Unsure of benefit in morbidly obese - we usually find the apron to be more difficult than a thick leg.  However interesting - variation of cryostripping really
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After disconnecting the uterus, I think suturing is faster and easier if its done transvaginally. Laparoscopy & CO2 insufflation times can be reduced as well. Is there any specific advantage of suturing intracorporeally?
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Intracorporeal suturing of the vaginal cuff is directly under laparoscopic vision and so is technically safer. The introduction of new sutures like Stratfix and V-lock sutures have revolutionised laparoscopic intracorporeal suturing with minimal morbidity .
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I think the opening for organ extraction should be mede at the beginning in the umbilicus.
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I think I will. Thanks
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There seems to be a lot of doubt and confusion as to whether anything works at all, and which option is the most effective. If anyone can answer one or both parts of my question, that would be quite helpful.
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Answering both questions:
Hyaluronic acid (eg Sepra) is the best choice, based on empirical and scientific grounds.
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What are your opinions and suggestion about treatment? VAC therapy? Total Parenteral Nutrition? Wait and watch? Planned delayed new laparotomy?
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I am sorry, I don't entirely agree that high output fistulas "in the majority of the cases" will close. Moreover, I don't think there is any evidence that somatostatin is able to turn a high output fistula into a low output fistula, and if this treatment is just a try it's an expensive and often an useless try.
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The motion capture data is needed to train classification models which could basically help surgical trainees to improve their body posture and manual techniques applying motion capture technology. The data would be recorded during exercises on surgery training system like CAST (see attached link) or similar systems. After classifiers have been trained using different algorithms and different sets of extracted features, their performance and reliability will be evaluated in order to find the best combination of classification algorithm and feature extraction. The final goal is a reliable classifier which tells trainees what exactly they have to improve in their movements and maybe even how to. Of course that's easier said than done though - and there are many intermediate steps to accomplish prior to that.
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Dear Tobias,
If it is helpfull, i did a lot of those measurements in the Netherlands in multiple hospitals ( see publications). You may find it interesting to know how we used classifiers to determine the skills levels of surgeons. If so, you can always contact me. And if you are willing to come to the NL, i know some surgeons that can participate as well.
Good luck and kind regards,
Tim
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There are concerns regarding mesh infection during emergency hernia repair especially if a segment of bowel has compromised blood supply requiring resection. On the other hand, anatomical repair of these hernias will lead to a high recurrence rate. In these circumstances, what is your preferred technique of repair?
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we are loosing the core of disease. In strangulated inguinal, crural or incisional hernias the real problem is quoad vitam. The hernia recurrence is secondary. I confirm that is better a recurrence in an healthful patient than the risk of infected mesh. i'll read with interest the article you cited but i think that in in emergency surgery the common sense should prevail
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I have changed my practise over the years. While training in HPB, as a protocol were putting T tubes across all HJ's performed(Whipple's, biliary strictures etc). I did not see any complication related to the T tube( no leaks because of T tube, no infection etc). The advantages were to monitor the colour of the bile, output, could flush the tube if there was thick infected bile or sludge etc and we would perform cholangiogram always before removal of the T tube. Patients who had cholangitis preop or had thick sludge in the bile duct where the tissues were friable and thin, putting a stent gave a sense of relief even if there was leak(controlled fistula). However the disadvantage from patients perspective was a tube sticking out and the need for a visit to pull the tube out.
I changed and started putting T tubes selectively in patients with cholangitis and who had thick infected bile. The size of the duct was not a criteria to decide regarding T tube insertion. In living donor liver transplant, where the ducts are small, many times more than one duct, I never place a T tube(except in post transplant situation if there was a need for HJ - reason being while on steroids and other immunosuppressants tissue healing is compromised and here the stent would stay for a long period).
As far as transhepatic stents are concerned, if there were PTBD catheters placed preoperatively for any reason( hilar cholangio- biliary decompression etc), these catheters were placed across the anastomosis, otherwise I do not feel the need to place transhepatic catheters preoperatively.
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Nowadays it's possible to achieve real time control of surgical resections, like in neuro and orthopedic surgery. In liver surgery this new technology is still experimental. The question is if we will gain clinical application of such a technology and more important if we really need it.
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Yes I think we need it, because liver anatomy is not as simple as it is on graphics about liver anatomy especially segment anatomy. This is shown in anatomically reconstructions as the commercially available MEVIS program in Germany. But we all have the problem that different diagnostic modalities show different metastases in e.g colorectal cancer surgery and we cannot use these different modalities during surgery. So I think in critical cases (small remnant of liver, perhaps to small) these techniques will help us in planing and conducting liver surgery
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Despite the impressive scientific and technological progress of modern surgery, many general surgeons, whether community- or academic-based, continue to follow some of the traditional surgical myths (changing the scalpel blade after the skin incision to limit contamination, drainage as an attribute of operations, antibiotics in irrigation solution, midline incisions are the best, wound dressings should be changed under sterile conditions etc.). Everyone of us has heard them before - they have been trusted for years. Some of these myths are actually based on fact, but most of them are based on archaic or obsolete scientific concepts. What do we do with these myths: not notice and continue to live with them or to try to verify or disprove them?
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A physicean has to master the statistical methods of investigation, lest he or she being a blind instrument in other person's hands. He or she was educated at university and must know the bases of Statistics, Phylosophy along with the own specialization. A meta-analysis is only a tool that one can use on this way or that, fruitefully, or vice versa.
Any way, thanks to Dr.Bonanno for this wise, enthusiastic speech! Agree completely, save one thing: I did not understand the abbreviations he used:
LDV
PRCT
NEJM.
What are their meanings?
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I wrote two articles (a meta-analysis and a systematic review) on two different topics regarding the surgical technique of open appendicectomy. I'm finding it difficult to publish them because the Editors of various journals claim that nowadays open appendicectomy is a procedure almost abandoned in "developed" countries which favour laparoscopic appendicectomy. What do you think about this statement? Can you also suggest any journal that could possibly be interested?
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I look forward to reading the national audit mentioned above. Personally I feel that comparison between open and laparoscopic appendiectomy is a valid study, I see little benefit in the laparoscopic approach apart from marginal improvement in cosmesis.
Open surgery can be done through a very small incision and would be much cheaper than laparoscopically. Comparative wound infection rates are also debatable. One particular benefit of laparoscopy of course is the ability to examine the rest of the abdomen.