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Craniotomy

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Intervention:
Craniotomy

ICD-10 code:

ICD-9 code: 01.2

Other codes:
A craniotomy is a surgical operation in which part of the skull, called a bone flap, is removed in
order to access the brain. Craniotomies are often a critical operation performed on patients
suffering from brain lesions or traumatic brain injury (TBI), and can also allow doctors to
surgically implant deep brain stimulators for the treatment of Parkinson's disease, epilepsy and
cerebellar tremor. The procedure is also widely used in neuroscience for extracellular recording,
brain imaging, and for neurological manipulations such as electrical stimulation and chemical
titration.
Human craniotomy is usually performed under general anesthesia but can be also done with the
patient awake using a local anaesthetic; the procedure generally does not involve significant
discomfort for the patient. In general, a craniotomy will be preceded by an MRI scan which
provides a picture of the brain that the surgeon uses to plan the precise location for bone removal
and the appropriate angle of access to the relevant brain areas. The amount of skull that needs to
be removed depends to a large extent on the type of surgery being performed. Most small holes
can heal with no difficulty. When larger parts of the skull must be removed, surgeons will usually
try to retain the bone flap and replace it immediately after surgery. It is held in place temporarily
with metal plates and rather quickly reintegrates with the intact part of the skull, at which point
the metal plates are removed.
Craniotomy is distinguished from craniectomy, in which the skull flap is not replaced, and from
trepanation, which is performed voluntarily without medical necessity.

Decompressive craniectomy
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Intervention:
Decompressive craniectomy
ICD-10 code:

ICD-9 code: 01.2

Other codes:

Decompressive craniectomy is a neurosurgical procedure in which part of the skull is removed


to allow a swelling brain room to expand without being squeezed. It is performed on victims of
traumatic brain injury and stroke. Use of the surgery is controversial.[1]

[edit] Results of clinical trials


[edit] Reduction of intracranial pressure
Though the procedure is considered a last resort, some evidence suggests that it does improve
outcomes by lowering intracranial pressure (ICP), the pressure within the skull.[1][2][3] Raised
intracranial pressure is very often debilitating or fatal because it causes compression of the brain
and restricts cerebral blood flow. The aim of decompressive craniectomy is to reduce this
pressure. The part of the skull that is removed is called a bone-flap. A study has shown that the
larger the removed bone-flap is, the more ICP is reduced.[4]
[edit] Other effects
In addition to reducing ICP, studies have found decompressive craniectomy to improve cerebral
perfusion pressure[1][3] and cerebral blood flow in head injured patients.[1]
Decompressive craniectomy is also used to manage major strokes, associated with "malignant"
edema and intracranial hypertension. The pooled evidence from three randomised controlled
trials in Europe supports the retrospective observations that early (within 48 hours) application of
decompressive craniectomy after "malignant" stroke may result in improved survival and
functional outcome in patients under the age of 55, compared to conservative management
alone.[5]
The procedure is recommended especially for young patients in whom ICP is not controllable by
other methods.[1] Age of greater than 50 years is associated with a poorer outcome after the
surgery.[3]
[edit] Complications
Infections such as meningitis or brain abscess can occur after decompressive craniectomy.[6]
[edit] Children
In severely head injured children, a study has shown that decompressive craniectomy resulted in
good recovery in all children in the study, suggesting the procedure has an advantage over non-
surgical treatment in children.[7] In one of the largest studies on pediatric patients, Jagannathan et
al. found a net 65% favorable outcomes rate in pediatric patients for accidental trauma after
craniectomy when followed for more than five years. Only three patients were dependent on
caregivers.[8] This is the only prospective randomised controlled study to date to support the
potential benefit of decompressive craniectomy following traumatic brain injury.[9]
[edit] Follow-up treatment
After a craniectomy, the risk of brain injury is increased, particularly after the patient heals and
becomes mobile again. Therefore, special measures must be taken to protect the brain, such as a
helmet or a temporary implant in the skull [10].
When the patient has healed sufficiently, the opening in the skull is usually closed with a
cranioplasty. If possible, the original skull fragment is preserved after the craniectomy in
anticipation of the cranioplasty[11].

[edit] Ongoing Trials


Two prospective randomised controlled trials are currently being run in an attempt to provide
Class I evidence on the role of surgical decompression in the treatment of raised intracranial
pressure after severe head injury. The RESCUEicp study[1] is an international multicentre trial,
coordinated by the University of Cambridge Academic Neurosurgery Unit[2] and the European
Brain Injury Consortium (EBIC)[3] and the DECRA trial[4] is run and coordinated by the
Australian centres[5].
thoracic
Lung volume reduction surgery for chronic obstructive pulmonary
disease (COPD)
In lung volume reduction surgery (LVRS), a large area of damaged lung is removed to allow the remaining
lung tissue to expand when you breathe in. This surgery sometimes is done if you have severe chronic
obstructive pulmonary disease (COPD) with severe emphysema.1

The National Emphysema Treatment Trial has examined the results of LVRS. The results of this study
report that people not considered good candidates for this surgery include people who have:2

• Severely impaired lung function as measured by breathing tests or a uniform pattern of emphysema
throughout the lungs.
• Largely non-upper lung emphysema and who are able to exercise for a longer time than other people with
COPD.
• Certain other serious medical problems.
For other people LVRS, compared to medical treatment, may provide an increased ability to exercise and
may result in fewer symptoms. LVRS also can reduce the number of COPD exacerbations for some
people.3 But it does not improve the survival rate compared to medical treatment, except for people who
have emphysema mainly in the upper portion of the lungs and who are not able to exercise well even
after pulmonary rehabilitation.4
Although selecting candidates for LVRS is subjective, criteria identifying good candidates for LVRS
include people:5

• Who have severe emphysema that does not respond to medical therapy.
• Who are younger than 75 to 80 years old.
• Who have not smoked for at least 4 months.
• Who have reasonable expectations of surgery results.
• Who have areas of the lung that can be targeted.
• Who have severe difficulty breathing, as determined by breathing tests.
Decision to have the surgery
The decision to have this surgery is not an easy one. Not all patients who have emphysema or COPD will
benefit from this surgery. Detailed testing is needed to find out if a person is likely to be helped by LVRS.
Talk with your doctor about all of the treatment options available for COPD.

Lung transplant for chronic obstructive pulmonary disease (COPD)


Although uncommon, lung transplants are sometimes used in chronic obstructive pulmonary disease
(COPD). During a lung transplant, you are given a lung from a donor who has recently died. A single-lung
transplant (receiving one lung) is done more often than a double-lung transplant (receiving two lungs).
Improvement in the ability to exercise is nearly as good in people who have a single-lung transplant as it
is in those who have a double-lung transplant.

Lung transplant surgery has been found to help people with COPD for at least 3 to 4 years after surgery.
A transplant can improve breathing and quality of life. But the long-term benefit of lung transplant for
people with COPD is not yet known.

Criteria have not been firmly established for selecting people with COPD to have a lung transplant. Lung
transplant for people with COPD may be considered for those who:

• Have severe lung disease.


• Are younger than age 65.
• Have stopped smoking.
• Have family and friends who will help and encourage them during and after the surgery.
• Do not currently have a drug or alcohol abuse problem.
Other considerations for lung transplant include the following:
• It can take a long time to find a donor whose blood and tissue types match yours.
• You will have to take medicine for the rest of your life to prevent rejection of the new lung. Even then,
there is a chance that rejection will occur.
• The medicines you must take suppress your immune system, resulting in an increased risk of developing
severe and life-threatening infections.
If you are interested in lung transplants, you may be referred to a transplant center, where you will have
extensive physical and psychological testing to see whether you are a good candidate for a lung
transplant. The testing includes exercise tests, lung function tests, heart function tests, numerous blood
tests, psychological profiles, and other specialized testing. In addition, you need to demonstrate mental
stability and the commitment that is needed to follow up with the medical demands after the transplant.
If you become a candidate for a transplant, you are placed on a waiting list. Depending on where the
transplant center is located, the wait for a lung transplant can be from 1 year to over 2 years.

Bullae and bullectomy for chronic obstructive pulmonary disease


(COPD)
Chronic obstructive pulmonary disease (COPD) weakens the structure of the lung and may also damage
the tiny air sacs (alveoli) in the lung. When these air sacs break down, larger airspaces known as bullae
are formed.

Bullae sometimes can become so large that they interfere with breathing and may cause complications:

• They can burst, leading to a collapsed lung (pneumothorax). A collapsed lung will often need treatment
with a chest tube.
• They can become infected, leading to an abscess in the lung that can spread to the pleural cavity (the
space between the lung and the membrane that surrounds it). This condition (empyema) can be difficult
to resolve and often requires extensive treatment with antibiotics.
For some people, surgically removing the enlarged air sacs-known as a bullectomy-makes breathing
easier. However, few people are considered good candidates for a bullectomy. It may work best for
people with COPD who are young, have large bullae that are grouped in just one area of the lung, and do
not have severe blockage in their airways.1 A bullectomy may be considered if the bullae:
• Are larger than one-third of a lung.
• Prevent the lung from expanding so the person cannot move enough air into his or her lungs.
Bullectomy may make the lungs work better so more oxygen gets into the blood.
If there are many bullae spread throughout the lungs, surgery is not likely to be helpful. In this case, other
areas of the lung often become damaged after the surgery. The best surgical results are obtained when
there is only one bulla or only a few that are all clustered in one area.

Long-term follow-up studies have begun to show that within 3 to 5 years after surgery, lung function
deteriorates to the level it was before surgery.2

The decision about whether to perform the surgery is difficult and usually is based on the doctor's
experience and the person's overall condition.

Bullae can be removed using a laser, but this method has not been found to have an advantage over
traditional surgery.

Lumpectomy
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Lumpectomy is a common surgical procedure designed to remove a discrete lump, usually a
tumor, benign or otherwise, from an affected man or woman's breast. As the tissue removed is
generally quite limited and the procedure relatively non-invasive, compared to a mastectomy, a
lumpectomy is considered a viable means of "breast conservation" or "breast preservation"
surgery with all the attendant physical and emotional advantages of such an approach.

Mastectomy
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In medicine, mastectomy is the medical term for the surgical removal of one or both breasts,
partially or completely. Mastectomy is usually done to treat breast cancer; in some cases, women
and some men believed to be at high risk of breast cancer have the operation prophylactically,
that is, to prevent cancer rather than treat it. It is also the medical procedure carried out to
remove breast cancer tissue in males. Alternatively, certain patients can choose to have a wide
local excision, also known as a lumpectomy, an operation in which a small volume of breast
tissue containing the tumor and some surrounding healthy tissue is removed to conserve the
breast. Both mastectomy and lumpectomy are what are referred to as "local therapies" for breast
cancer, targeting the area of the tumor, as opposed to systemic therapies such as chemotherapy,
hormonal therapy, or immunotherapy.
Traditionally, in the case of breast cancer, the whole breast was removed. Currently the decision
to do the mastectomy is based on various factors including breast size, number of lesions,
biologic aggressiveness of a breast cancer, the availability of adjuvant radiation, and the
willingness of the patient to accept higher rates of tumor recurrences after lumpectomy and
radiation. Outcome studies comparing mastectomy to lumpectomy with radiation have suggested
that routine radical mastectomy surgeries will not always prevent later distant secondary tumors
arising from micro-metastases prior to discovery, diagnosis, and operation.

Contents
[hide]
• 1 Rates
• 2 Mastectomy
indications
• 3 Types of mastectomy
• 4 Gallery
• 5 See also
• 6 References
• 7 External links

[edit] Rates

Mastectomy patient

Mastectomy rates vary tremendously world-wide, as was documented by the 2004 'Intergroup
Exemestane Study',[1] an analysis of surgical techniques used in an international trial of adjuvant
treatment among 4,700 women with early breast cancer in 37 countries. The mastectomy rate
was highest in central and eastern Europe at 77%. The USA had the second highest rate of
mastectomy with 56%, western and northern Europe averaged 46%, southern Europe 42% and
Australia and New Zealand 34%.

[edit] Mastectomy indications


Despite the increased ability to offer breast-conservation techniques to patients with breast
cancer, there exist certain groups who may be better served by traditional mastectomy procedures
including:
• women who have already had radiation therapy to the affected breast
• women with 2 or more areas of cancer in the same breast that are too far
apart to be removed through 1 surgical incision, while keeping the
appearance of the breast satisfactory
• women whose initial lumpectomy along with (one or more) re-excisions has
not completely removed the cancer
• women with certain serious connective tissue diseases such as scleroderma,
which make them especially sensitive to the side effects of radiation therapy
• pregnant women who would require radiation while still pregnant (risking
harm to the fetus)
• women with a tumor larger than 5 cm (2 inches) that doesn't shrink very
much with neoadjuvant chemotherapy
• women with a cancer that is large relative to her breast size
• Women who have tested positive for a deleterious mutation on the BRCA1 or
BRCA2 gene and opt for prophylactic removal of the breasts
• male breast cancer patients.

[edit] Types of mastectomy


There are a variety of types of mastectomy in use, and the type that a patient decides to undergo
(or whether he or she will decide instead to have a lumpectomy) depends on factors such as size,
location, and behavior of the tumor (if there is one), whether or not the surgery is prophylactic,
and whether or not the patient intends to undergo reconstructive surgery.
• Simple mastectomy (or "total mastectomy"): In this procedure, the entire
breast tissue is removed, but axillary contents are undisturbed. Sometimes
the "sentinel lymph node"--that is, the first axillary lymph node that the
would be expected to drain into—is removed. This surgery is sometimes done
bilaterally (on both breasts) on patients who wish to undergo mastectomy as
a cancer-preventative measure. Patients who undergo simple mastectomy
can usually leave the hospital after a brief stay. Frequently, a drainage tube is
inserted during surgery in their chest and attached to a small suction device
to remove subcutaneous fluid. These are usually removed several days after
surgery as drainage decrease to less than 20-30 ml per day.
• Modified radical mastectomy: The entire breast tissue is removed along with
the axillary contents (fatty tissue and lymph nodes). In contrast to a radical
mastectomy, the pectoral muscles are spared.
• Radical mastectomy (or "Halsted mastectomy"): First performed in 1882, this
procedure involves removing the entire breast, the axillary lymph nodes, and
the pectoralis major and minor muscles behind the breast. This procedure is
more disfiguring than a modified radical mastectomy and provides no survival
benefit for most tumors. This operation is now reserved for tumors involving
the pectoralis major muscle or recurrent breast cancer involving the chest
wall.
• Skin-sparing mastectomy: In this surgery, the breast tissue is removed
through a conservative incision made around the areola (the dark part
surrounding the nipple). The increased amount of skin preserved as
compared to traditional mastecomy resections serves to facilitate breast
reconstruction procedures. Patients with cancers that involve the skin, such
as inflammatory cancer, are not candidates for skin-sparing mastectomy.
• Subcutaneous mastectomy: Breast tissue is removed, but the nipple-areola
complex is preserved. This procedure was historically done only
prophylactically or with mastecomy for benign disease over fear of increased
cancer development in retained areolar ductal tissue. Recent series suggest
that it may be an oncologically sound procedure for tumors not in the
subareolar position.[2][3][4]

Cardiac surgery is surgery on the heart and/or great vessels performed by a cardiac surgeon.
Frequently, it is done to treat complications of ischemic heart disease (for example, coronary
artery bypass grafting), correct congenital heart disease, or treat valvular heart disease created by
various causes including endocarditis. It also includes heart transplantation.
Open heart surgery
This is a surgery in which the patient's chest is opened and surgery is performed on the heart. The
term "open" refers to the chest, not to the heart itself. The heart may or may not be opened
depending on the particular type of surgery. Surgeons realized the limitations of hypothermia -
complex intracardiac repairs take more time and the patient needs blood flow to the body (and
particularly the brain); the patient needs the function of the heart and lungs provided by an
artificial method, hence the term cardiopulmonary bypass. Dr. John Heysham Gibbon at
Jefferson Medical School in Philadelphia reported in 1953 the first successful use of
extracorporeal circulation by means of an oxygenator, but he abandoned the method,
disappointed by subsequent failures. In 1954 Dr. Lillehei realized a successful series of
operations with the controlled cross-circulation technique in which the patient's mother or father
was used as a 'heart-lung machine'. Dr. John W. Kirklin at the Mayo Clinic in Rochester,
Minnesota started using a Gibbon type pump-oxygenator in a series of successful operations, and
was soon followed by surgeons in various parts of the world.
Dr. Nazih Zudhi worked for four years under Drs. Clarence Dennis, Karl Karlson, and Charles
Fries, who built an early pump-oxygenator. Zudhi and Fries worked on several designs and re-
designs of Dennis' earlier model from 1952-1956 at the Brooklyn Center. Zuhdi then went to
work with Dr. C. Walton Lillehei at the University of Minnesota. Lillehei had designed his own
version of a cross-circulation machine, which came to become known as the DeWall-Lillehei
heart-lung machine. Zudhi worked on perfusion and blood flow trying to solve the problem of air
bubbles while bypassing the heart so the heart could be stopped for the operation. Zudhi moved
to Oklahoma City, OK, in 1957, and began working at the Oklahoma University College. Zudhi,
the heart surgeon, teamed up with Dr. Allen Greer, a lung surgeon and Dr. John Carey, forming a
three man open heart surgery team. With the advent of Dr. Zudhi's heart-lung machine which was
modified in size, being much smaller than the DeWall-Lillhei heart-lung machine, and with other
modifications, reduced the need for blood down to a minimal amount, and the cost of the
equipment down to $500.00 and also reduced the prep time from two hours to 20 minutes. Dr.
Zudhi performed the first Total Intentional Hemodilution open heart surgery on Terry Gene Nix,
age 7, on February 25, 1960, at Mercy Hospital, Oklahoma City, OK. The operation was a
success; however, Nix died three years later in 1963.[7] In March, 1961, Zudhi, Carey, and Greer,
performed open heart surgery on a child, age 3 1/2, using the Total Intentional Hemodilution
machine, with success. That patient is still alive.[8]
[edit] Modern beating-heart surgery
Since the 1990s, surgeons have begun to perform "off-pump bypass surgery" - coronary artery
bypass surgery without the aforementioned cardiopulmonary bypass. In these operations, the
heart is beating during surgery, but is stabilized to provide an almost still work area. Some
researchers believe this approach results in fewer post-operative complications (such as
postperfusion syndrome) and better overall results (study results are controversial as of 2007, the
surgeon's preference and hospital results still play a major role).
[edit] Minimally invasive surgery
A new form of heart surgery that has grown in popularity is robot-assisted heart surgery. This is
where a machine is used to perform surgery while being controlled by the heart surgeon. The
main advantage to this is the size of the incision made in the patient. Instead of an incision being
at least big enough for the surgeon to put his hands inside, it does not have to be bigger than 3
small holes for the robot's much smaller hands to get through. Also, a major advantage to the
robot is the recovery time of the patient, instead of months of recovery time, some patients have
recovered and resumed playing athletics in a matter of weeks.[citation needed]

[edit] Risks
The development of cardiac surgery and cardiopulmonary bypass techniques has reduced the
mortality rates of these surgeries to relatively low levels. For instance, repairs of congenital heart
defects are currently estimated to have 4-6% mortality rates.[9][10]
A major concern with cardiac surgery is the incidence of neurological damage. Stroke occurs in
2-3% of all people undergoing cardiac surgery, and is higher in patients at risk for stroke.[citation
needed]
A more subtle constellation of neurocognitive deficits attributed to cardiopulmonary bypass
is known as postperfusion syndrome (sometimes called 'pumphead'). The symptoms of
postperfusion syndrome were initially felt to be permanent,[11] but were shown to be transient
with no permanent neurological impairment.[12]
Cardiopulmonary bypass

Cardiopulmonary bypass (CPB) is a technique that temporarily takes over the function of the
heart and lungs during surgery, maintaining the circulation of blood and the oxygen content of
the body. The CPB pump itself is often referred to as a Heart-Lung Machine or the Pump.
Cardiopulmonary bypass pumps are operated by allied health professionals known as
perfusionists in association with surgeons who connect the pump to the patient's body. CPB is a
form of extracorporeal circulation.

[edit] Uses of cardiopulmonary bypass


Cardiopulmonary bypass is commonly used in heart surgery because of the difficulty of
operating on the beating heart. Operations requiring the opening of the chambers of the heart
require the use of CPB to support the circulation during that period.
CPB can be used for the induction of total body hypothermia, a state in which the body can be
maintained for up to 45 minutes without perfusion (blood flow). If blood flow is stopped at
normal body temperature, permanent brain damage normally occurs in three to four minutes —
death may follow shortly afterward.
Extracorporeal membrane oxygenation (ECMO) is a simplified form of CPB sometimes used as
life-support for newborns with serious birth defects, or to oxygenate and maintain recipients for
organ transplantation until new organs can be found.
CPB mechanically circulates and oxygenates blood for the body while bypassing the heart and
lungs. It uses a heart-lung machine to maintain perfusion to other body organs and tissues while
the surgeon works in a bloodless surgical field. The surgeon places a cannula in right atrium,
vena cava, or femoral vein to withdraw blood from the body. The cannula is connected to tubing
filled with isotonic crystalloid solution. Venous blood that is removed from the body by the
cannula is filtered, oxygenated, cooled or warmed, and then returned to the body. The cannula
used to return oxygenated blood is usually inserted in the ascending aorta, but it may be inserted
in the femoral artery. The patient is administered heparin to prevent clotting, and protamine
sulfate is given after to reverse effects of heparin. During the procedure, hypothermia is
maintained; body temperature is usually kept at 28ºC to 32ºC (82.4-89.6ºF). The blood is cooled
during CPB and returned to the body. The cooled blood slows the body’s basal metabolic rate,
decreasing its demand for oxygen. Cooled blood usually has a higher viscosity, but the
crystalloid solution used to prime the bypass tubing dilutes the blood.
[edit] Surgical procedures in which cardiopulmonary bypass is used
• Coronary artery bypass surgery
• Cardiac valve repair and/or replacement (aortic valve, mitral valve, tricuspid
valve, pulmonic valve)
• Repair of large septal defects (atrial septal defect, ventricular septal defect,
atrioventricular septal defect)
• Repair and/or palliation of congenital heart defects (Tetralogy of Fallot,
transposition of the great vessels)
• Transplantation (heart transplantation, lung transplantation, heart-lung
transplantation)
• Repair of some large aneurysms (aortic aneurysms, cerebral aneurysms)
• Pulmonary thromboendarterectomy
• Pulmonary thrombectomy
[edit] Complications
CPB is not benign and there are a number of associated problems:
• Postperfusion syndrome (also known as Pumphead)
• Hemolysis
• Capillary Leak Syndrome
• Clotting of blood in the circuit - can block the circuit (particularly the
oxygenator) or send a clot into the patient.
• Air embolism
• Leakage - a patient can rapidly exsanguinate (lose blood perfusion of tissues)
if a line becomes disconnected.
As a consequence, CPB is preferentially only used during the up to several hours a cardiac
surgery may take. The longest time anyone has survived on CPB is 16 days.[4]

Coronary artery bypass surgery, also coronary artery bypass graft surgery, and colloquially
heart bypass or bypass surgery is a surgical procedure performed to relieve angina and reduce
the risk of death from coronary artery disease. Arteries or veins from elsewhere in the patient's
body are grafted to the coronary arteries to bypass atherosclerotic narrowings and improve the
blood supply to the coronary circulation supplying the myocardium (heart muscle). This surgery
is usually performed with the heart stopped, necessitating the usage of cardiopulmonary bypass;
techniques are available to perform CABG on a beating heart, so-called "off-pump" surgery.

[edit] Indications for CABG


Several alternative treatments for coronary artery disease exist. They include:
• Medical management (anti-anginal medications plus statins,
antihypertensives, smoking cessation, tight blood sugar control in diabetics)
• Percutaneous coronary intervention (PCI)
Both PCI and CABG are more effective than medical management at relieving symptoms,[9] (e.g.
angina, dyspnea, fatigue). CABG is superior to PCI for some patients with multivessel CAD[10][11]
The Surgery or Stent (SoS) trial was a randomized controlled trial that compared CABG to PCI
with bare-metal stents. The SoS trial demonstrated CABG is superior to PCI in multivessel
coronary disease.[10]
The SYNTAX trial was a randomized controlled trial of 1800 patients with multivessel coronary
disease, comparing CABG versus PCI using drug-eluting stents (DES). The study found that
rates of major adverse cardiac or cerebrovascular events at 12 months were significantly higher
in the DES group (17.8% versus 12.4% for CABG; P=0.002). [11] This was primarily driven by
higher need for repeat revascularization procedures in the PCI group with no difference in repeat
infarctions or survival. Higher rates of strokes were seen in the CABG group.
The FREEDOM (Future Revascularization Evaluation in Patients With Diabetes Mellitus—
Optimal Management of Multivessel Disease) trial will compare CABG and DES in patients
with diabetes. The registries of the nonrandomized patients screened for these trials may provide
as much robust data regarding revascularization outcomes as the randomized analysis.[12]
A study comparing the outcomes of all patients in New York state treated with CABG or
percutaneous coronary intervention (PCI) demonstrated CABG was superior to PCI with DES in
multivessel (more than one diseased artery) coronary artery disease (CAD). Patients treated with
CABG had lower rates of death and of death or myocardial infarction than treatment with a
coronary stent. Patients undergoing CABG also had lower rates of repeat revascularization.[13]
The New York State registry included all patients undergoing revascularization for coronary
artery disease, but was not a randomized trial, and so may have reflected other factors besides the
method of coronary revascularization.
The 2004 ACC/AHA CABG guidelines state CABG is the preferred treatment for:[14]
• Disease of the left main coronary artery (LMCA).
• Disease of all three coronary vessels (LAD, LCX and RCA).
• Diffuse disease not amenable to treatment with a PCI.
The 2005 ACC/AHA guidelines further state: CABG is the likely the preferred treatment with
other high-risk patients such as those with severe ventricular dysfunction (i.e. low ejection
fraction), or diabetes mellitus.[14]

Complications
People undergoing coronary artery bypass are at risk for the same complications as any surgery,
plus some risks more common with or unique to CABG.
[edit] CABG associated
• Postperfusion syndrome (pumphead), a transient neurocognitive impairment
associated with cardiopulmonary bypass. Some research shows the incidence
is initially decreased by off-pump coronary artery bypass, but with no
difference beyond three months after surgery. A neurocognitive decline over
time has been demonstrated in people with coronary artery disease
regardless of treatment (OPCAB, conventional CABG or medical
management).
• Nonunion of the sternum; internal thoracic artery harvesting devascularizes
the sternum increasing risk.
• Myocardial infarction due to embolism, hypoperfusion, or graft failure.
• Late graft stenosis, particularly of saphenous vein grafts due to
atherosclerosis causing recurrent angina or myocardial infarction.
• Acute renal failure due to embolism or hypoperfusion.
• Stroke, secondary to embolism or hypoperfusion.
[edit] General surgical
• Infection at incision sites or sepsis.
• Deep vein thrombosis (DVT)
• Anesthetic complications such as malignant hyperthermia.
• Keloid scarring
• Chronic pain at incision sites
• Chronic stress related illnesses
• Death
General

[edit] Risks
The development of cardiac surgery and cardiopulmonary bypass techniques has reduced the
mortality rates of these surgeries to relatively low levels. For instance, repairs of congenital heart
defects are currently estimated to have 4-6% mortality rates.[9][10]
A major concern with cardiac surgery is the incidence of neurological damage. Stroke occurs in
2-3% of all people undergoing cardiac surgery, and is higher in patients at risk for stroke.[citation
needed]
A more subtle constellation of neurocognitive deficits attributed to cardiopulmonary bypass
is known as postperfusion syndrome (sometimes called 'pumphead'). The symptoms of
postperfusion syndrome were initially felt to be permanent,[11] but were shown to be transient
with no permanent neurological impairment.[12]

Thoracic surgery
Thoracic surgery is the field of medicine involved in the surgical treatment of diseases affecting
organs inside the thorax (the chest). Generally treatment of conditions of the lungs, [[chest wall],
and diaphragm.
Thoracic surgery is often grouped with cardiac surgery and called cardiothoracic surgery.
"According to a June, 2003 article in the Annals of Thoracic Surgery, the workforce currently
appears "right sized," although the workforce survey cited indicates significant retirement during
the next 10 to 15 years. The annual salary for thoracic surgeons ranges from $218,550 to
$533,000".

Indication for spinal fusion surgery


Proper patient selection for lumbar spine fusion surgery
Spinal fusion is best for treating low back pain caused by severe degenerative disc changes and is best
for treating one, or maybe two, levels of the lower spine (typically the L4-L5 level and/or L5-S1 level).
Prior to recommending or offering spine surgery, a surgeon must also consider other causes of low back
pain that can closely mimic the symptoms of degenerative disc disease. These conditions include:
• Sacroiliac joint dysfunction
• Piriformis syndrome
• Facet osteoarthritis
• Muscle strain
• Hip osteoarthritis
If a patient’s low back pain and other symptoms do not improve with extensive conservative treatment
and other causes of low back pain have been ruled out, then he or she may be considered for a spine
fusion surgery. Importantly, while failing conservative treatment is a necessary prerequisite for spine
fusion surgery, it is not sufficient. Prior to recommending spine fusion surgery, a spine surgeon has to be
confident that he or she is fusing the segment of the spine that is generating the patient’s pain (the “pain
generator”). Obviously, fusing a structure that does not cause pain will not reduce the patient’s low back
pain or lead to a successful outcome.
MRI scans have greatly increased the spine surgeon’s ability to diagnose degenerative disc disease.
Unfortunately, a lot of the changes that are seen on MRI scans are more related to normal aging than to a
pathologic and painful disc. Differentiating a painful disc from an aging disc is often difficult but there are
some clues that help. In general, a painful disc will be severely degenerated whereas the rest of the discs
will be well preserved. Other characteristics of a painful disc on an MRI scan include:
• Disc space collapse (see figure 1), which means that the disc has gotten shorter/flatter
• Endplate erosion, which is erosion of the top and bottom outer material of the disc
• Edematous changes in the vertebral body (Modic changes), which is when the MRI shows irritation
of the bone marrow, may be an indicator of a painful disc. There is a characteristic bright signal on
the MRI scan when this occurs.
If a spine surgeon is uncertain as to whether or not a disc is painful, a CT-discogram may be ordered. A
discogram is a direct pain provocation test that is designed to try to elicit the patient’s pain by injecting a
dye into the disc space. If the test creates the patient’s normal pain, it can be assumed that the test is
positive and the disc is generating the patient’s pain. Some major drawbacks of the procedure are:
• It involves an injection into the spine, which has several risks (albeit rare)
• It is usually painful
• It is a subjective test, and both false positives and false negatives can occur
• Accuracy of the test is largely dependent on the skill of the discographer
Discograms are used by some surgeons before every spine fusion, and it is certainly warranted to gather
as much information as possible before undergoing a fusion procedure. However, discograms are
probably not necessary on a routine basis, and the test itself is somewhat controversial. The test should
only be used if the results are going to change the surgeon’s recommendations (e.g. if negative, spine
surgery will not be recommended). If the results are ignored and the surgical choice is made off of the
MRI findings, then a discogram does not serve any useful purpose.
Abdominal

Abdominal surgery
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The term abdominal surgery broadly covers surgical procedures that involve opening the
abdomen. Surgery of each abdominal organ is dealt with separately in connection with the
description of that organ (see stomach, kidney, liver, etc.) Diseases affecting the abdominal
cavity are dealt with generally under their own names (e.g. appendicitis).

Contents
[hide]
• 1 Types
• 2 Complications
• 3 See also
• 4 References

[edit] Types
The three most common abdominal surgeries are described below.
• Exploratory Laparotomy -- This refers to the opening of the abdominal cavity
for direct examination of its contents, for example, to locate a source of
bleeding or trauma. It may or may not be followed by repair or removal of the
primary problem.
• Appendectomy -- Surgical opening of the abdominal cavity and removal of
the appendix. Typically performed as definitive treatment for appendicitis,
although sometimes the appendix is prophylactically removed incidental to
another abdominal procedure.
• Laparoscopy -- A minimally invasive approach to abdominal surgery where
rigid tubes are inserted through small incisions into the abdominal cavity. The
tubes allow introduction of a small camera, surgical instruments, and gases
into the cavity for direct or indirect visualization and treatment of the
abdomen. The abdomen is inflated with carbon dioxide gas to facilitate
visualization and, often, a small video camera is used to show the procedure
on a monitor in the operating room. The surgeon manipulates instruments
within the abdominal cavity to perform procedures such as cholecystectomy
(gallbladder removal), the most common laparoscopic procedure. The
laparoscopic method speeds recovery time and reduces blood loss and
infection as compared to the traditional "open" cholecystectomy.

[edit] Complications
Complications of abdominal surgery include
• bleeding,
• infection,
• post-surgical adhesions
• shock, and
• ileus, or more commonly Paralytic ileus (short-term paralysis of the bowel)
Sterile technique, aseptic post-operative care, antibiotics, and vigilant post-operative monitoring
greatly reduce the risk of these complications. Planned surgery performed under sterile
conditions is much less risky than that performed under emergency or unsterile conditions. The
contents of the bowel are unsterile, and thus leakage of bowel contents, as from trauma,
substantially increases the risk of infection

Laparotomy
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Intervention:
Laparotomy

Abdominal cavity

ICD-10 code:

ICD-9 code: 54.1

Other codes:

A laparotomy is a surgical procedure involving an incision through the abdominal wall to gain
access into the abdominal cavity. It is also known as coeliotomy.

Contents
[hide]
• 1 Terminology
• 2 Spaces accessed
• 3 Types of incisions
○ 3.1 Midline
○ 3.2 Other
• 4 Related procedures
• 5 References
• 6 External links

[edit] Terminology
In diagnostic laparotomy (most often referred to as an exploratory laparotomy and abbreviated
Ex-Lap), the nature of the disease is unknown, and laparotomy is deemed the best way to identify
the cause.
In therapeutic laparotomy, a cause has been identified (e.g. peptic ulcer, colon cancer) and
laparotomy is required for its therapy.
Usually, only exploratory laparotomy is referred to as a surgical operation by itself; and when a
specific operation is already planned, laparotomy is considered merely the first step of the
procedure.

[edit] Spaces accessed


Depending on incision placement, it may give access to any abdominal organ or space, and is the
first step in any major diagnostic or therapeutic surgical procedure of these organs, which
include:
• the lower part of the digestive tract (the stomach, duodenum, jejunum, ileum
and colon)
• the liver, pancreas and spleen
• the bladder
• the female reproductive organs (the uterus and ovaries)
• the retroperitoneum (the kidneys, the aorta, abdominal lymph nodes
• the appendix

Appendicectomy
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(Redirected from Appendectomy)

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An appendicectomy in progress

An appendicectomy (or appendectomy) is the surgical removal of the vermiform appendix.


This procedure is normally performed as an emergency procedure, when the patient is suffering
from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to
delay or avoid the onset of sepsis; it is now recognized that many cases will resolve when treated
non-operatively. In some cases the appendicitis resolves completely; more often, an
inflammatory mass forms around the appendix. This is a relative contraindication to surgery.
Appendicectomy may be performed laparoscopically (this is called minimally invasive surgery)
or as an open operation. Laparoscopy is often used if the diagnosis is in doubt, or if it is desirable
to hide the scars in the umbilicus or in the pubic hair line. Recovery may be a little quicker with
laparoscopic surgery; the procedure is more expensive and resource-intensive than open surgery
and generally takes a little longer, with the (low in most patients) additional risks associated with
pneumoperitoneum (inflating the abdomen with gas). Advanced pelvic sepsis occasionally
requires a lower midline laparotomy.
In general terms, the procedure for an open appendicectomy is as follows.
Antibiotics are given immediately if there are signs of sepsis, otherwise a single dose of
prophylactic intravenous antibiotics is given immediately prior to surgery.
General anaesthesia is induced, with endotracheal intubation and full muscle relaxation, and the
patient is positioned supine.
The abdomen is prepared and draped and is examined under anesthesia. If a mass is present, the
incision is made over the mass; otherwise, the incision is made over McBurney's point, one third
of the way from the anterior superior iliac spine (ASIS) and the umbilicus; this represents the
position of the base of the appendix (the position of the tip is variable). The various layers of the
abdominal wall are then opened. The effort is always to preserve the integrity of abdominal wall.
Therefore, the External Oblique Aponeurosis is slitted along its fiber, and the internal oblique
muscle is split along its length, not cut. As the two run at right angles to each other, this prevents
later Incisional hernia.
On entering the peritoneum, the appendix is identified, mobilized and then ligated and divided at
its base. Some surgeons choose to bury the stump of the appendix by inverting it so it points into
the caecum. Each layer of the abdominal wall is then closed in turn.

Contents
[hide]
• 1 Prophylactic
appendicectomy
• 2 Pregnancy
• 3 Recovery
• 4 References
• 5 External links

[edit] Prophylactic appendicectomy


This article does not cite any references or sources. Please help improve this
article by adding citations to reliable sources. Unverifiable material may be
challenged and removed. (February 2008)
To find the cause of unexplained abdominal pain, exploratory surgery is sometimes performed. If
the appendix is not the cause of symptoms, the surgeon will thoroughly check the other
abdominal organs and remove the appendix anyway, to prevent it from becoming a problem in
the future.
When abdominal surgery is performed for an entirely different reason (e.g. hysterectomy or
bowel resection), the surgeon sometimes decides to perform an appendicectomy in addition to
the intended procedure, to eliminate the possible need of a future surgery just to remove the
appendix. However, recent findings on the possible usefulness of the appendix has led to an
abatement of this practice.

[edit] Pregnancy
If appendicitis develops in a pregnant woman, an appendicectomy is usually performed and
should not harm the fetus.[1] The risk of fetal death in the perioperative period after an
appendectomy for early acute appendicitis is 3% to 5%. The risk of fetal death is 20% in
perforated appendicitis. [2]

[edit] Recovery
This section does not cite any references or sources. Please help improve this
article by adding citations to reliable sources. Unverifiable material may be
challenged and removed. (February 2008)

Scar and Bruise 2 days after operation.

Recovery time from the operation varies from person to person. Some will take up to three
weeks before being completely active; for others it can be a matter of days. In the case of a
laparoscopic operation, the patient will have three stapled scars of about an inch in length,
between the navel and pubic hair line. When a laparotomy has been performed the patient will
have a 2-3 inch scar, which will initially be heavily bruised.

Laparoscopic surgery
From Wikipedia, the free encyclopedia
(Redirected from Laparoscopy)

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challenged and removed. (February 2008)
Cholecystectomy as seen through a laparoscope

Laparoscopic surgery, also called minimally invasive surgery (MIS), bandaid surgery, keyhole
surgery is a modern surgical technique in which operations in the abdomen are performed
through small incisions (usually 0.5-1.5cm) as compared to larger incisions needed in traditional
surgical procedures. Laparoscopic surgery includes operations within the abdominal or pelvic
cavities, whereas keyhole surgery performed on the thoracic or chest cavity is called
thoracoscopic surgery. Laparoscopic and thoracoscopic surgery belong to the broader field of
endoscopy.
The key element in laparoscopic surgery is the use of a laparoscope. There are two types: 1)a
telescopic rod lens system, that is usually connected to a video camera (single chip or three chip)
or a digital laparoscope where the charge-coupled device is placed at the end of the laparoscope,
eliminating the rod lens system.[1] Also attached is a fiber optic cable system connected to a 'cold'
light source (halogen or xenon), to illuminate the operative field, inserted through a 5 mm or 10
mm cannula or trocar to view the operative field. The abdomen is usually insufflated with carbon
dioxide gas to create a working and viewing space. The abdomen is essentially blown up like a
balloon (insufflated), elevating the abdominal wall above the internal organs like a dome. The
gas used is CO2, which is common to the human body and can be absorbed by tissue and
removed by the respiratory system. It is also non-flammable, which is important because
electrosurgical devices are commonly used in laparoscopic procedures.

Contents
[hide]
• 1 History
• 2 Procedures
• 3 Advantages
• 4 Risks
• 5 Robotics and technology
• 6 Non-robotic hand guided assistance
systems
• 7 See also
• 8 References
• 9 External links

[edit] History
It is difficult to credit one individual with the pioneering of laparoscopic approach. In 1902
Georg Kelling, of Dresden, Saxony, performed the first laparoscopic procedure in dogs and in
1910 Hans Christian Jacobaeus of Sweden reported the first laparoscopic operation in humans. In
the ensuing several decades, numerous individuals refined and popularized the approach further
for laparoscopy. The introduction of computer chip television camera was a seminal event in the
field of laparoscopy. This innovation in technology provided the means to project a magnified
view of the operative field onto a monitor, and at the same time freed both the operating
surgeon's hands, thereby facilitating performance of complex laparoscopic procedures. Prior to
its conception, laparoscopy was a surgical approach with very limited application and used
mainly for purposes of diagnosis and performance of simple procedures in gynecologic
applications.
The introduction in 1990 of a laparoscopic clip applier with twenty automatically advancing
clips (rather than a single load clip applier that would have to be taken out, reloaded and
reintroduced for each clip application) made surgeons more comfortable with making the leap to
laparoscopic cholecystectomies (gall bladder removal). On the other hand, some surgeons
continue to use the single clip appliers as they save as much as $200 per case for the patient,
detract nothing from the quality of the clip ligation, and add only seconds to case lengths.

[edit] Procedures
Laparoscopic cholecystectomy is the most common laparoscopic procedure performed. In this
procedure, 5-10mm diameter instruments (graspers, scissors, clip applier) can be introduced by
the surgeon into the abdomen through trocars (hollow tubes with a seal to keep the CO2 from
leaking). Rather than a minimum 20cm incision as in traditional cholecystectomy, four incisions
of 0.5-1.0cm will be sufficient to perform a laparoscopic removal of a gallbladder. Since the gall
bladder is similar to a small balloon that stores and releases bile, it can usually be removed from
the abdomen by suctioning out the bile and then removing the deflated gallbladder through the
1cm incision at the patient's navel. The length of postoperative stay in the hospital is minimal,
and same-day discharges are possible in cases of early morning procedures.
In certain advanced laparoscopic procedures where the size of the specimen being removed
would be too large to pull out through a trocar site, as would be done with a gallbladder, an
incision larger than 10mm must be made. The most common of these procedures are removal of
all or part of the colon (colectomy), or removal of the kidney (nephrectomy). Some surgeons
perform these procedures completely laparoscopically, making the larger incision toward the end
of the procedure for specimen removal, or, in the case of a colectomy, to also prepare the
remaining healthy bowel to be reconnected (create an anastomosis). Many other surgeons feel
that since they will have to make a larger incision for specimen removal anyway, they might as
well use this incision to have their hand in the operative field during the procedure to aid as a
retractor, dissector, and to be able to feel differing tissue densities (palpate), as they would in
open surgery. This technique is called hand-assist laparoscopy. Since they will still be working
with scopes and other laparoscopic instruments, CO2 will have to be maintained in the patient's
abdomen, so a device known as a hand access port (a sleeve with a seal that allows passage of
the hand) must be used. Surgeons that choose this hand-assist technique feel it reduces operative
time significantly vs. the straight laparoscopic approach, as well as providing them more options
in dealing with unexpected adverse events (i.e. uncontrolled bleeding) that may otherwise require
creating a much larger incision and converting to a fully open surgical procedure.
Conceptually, the laparoscopic approach is intended to minimise post-operative pain and speed
up recovery times, while maintaining an enhanced visual field for surgeons. Due to improved
patient outcomes, in the last two decades, laparoscopic surgery has been adopted by various
surgical sub-specialties including gastrointestinal surgery (including bariatric procedures for
morbid obesity), gynecologic surgery and urology. Based on numerous prospective randomized
controlled trials, the approach has proven to be beneficial in reducing post-operative morbidities
such as wound infections and incisional hernias (especially in morbidly obese patients), and is
now deemed safe when applied to surgery for cancers such as cancer of colon.
The restricted vision, the difficulty in handling of the instruments (new hand-eye coordination
skills are needed), the lack of tactile perception and the limited working area are factors which
add to the technical complexity of this surgical approach. For these reasons, minimally invasive
surgery has emerged as a highly competitive new sub-specialty within various fields of surgery.
Surgical residents who wish to focus on this area of surgery gain additional training during one
or two years of fellowship after completing their basic surgical residency.
The first transatlantic surgery (Lindbergh Operation) ever performed was a laparoscopic
gallbladder removal.
Laparoscopic techniques have also been developed in the field of veterinary medicine. Due to the
relative high cost of the equiment required, however, it has not become commonplace in most
traditional practices today but rather limited to specialty-type practices. Many of the same
surgeries performed in humans can be applied to animal cases - everything from an egg-bound
tortoise to a German Shepherd can benefit from MIS. A paper published in JAVMA (Journal of
the American Veterinary Medical Association) in 2005 showed that dogs spayed laparoscopically
experienced significantly less pain (65%)than those that were spayed with traditional 'open'
methods. Arthroscopy, thoracoscopy, cystoscopy are all performed in veterinary medicine today.
The University of Georgia School of Veterinary Medicine and Colorado State University's
School of Veterinary Medicine are two of the main centers where veterinary laparoscopy got
started and have excellent training programs for veterinarians interested in getting started in MIS.

[edit] Advantages
There are a number of advantages to the patient with laparoscopic surgery versus an open
procedure. These include:
• reduced haemorrhaging , which reduces the chance of needing a blood
transfusion.
• smaller incision, which reduces pain and shortens recovery time.
• less pain, leading to less pain medication needed.
• Although procedure times are usually slightly longer, hospital stay is less, and
often with a same day discharge which leads to a faster return to everyday
living.
• reduced exposure of internal organs to possible external contaminants
thereby reduced risk of acquiring infections.
• can be used in Gamete intrafallopian transfer (GIFT) surgery to put the eggs
back into the fallopian tubes
[edit] Risks
Some of the risks are briefly described below:
• The most significant risks are from trocar injuries to either blood vessels or
small or large bowel. The risk of such injuries is increased in patients who are
obese or have a history of prior abdominal surgery. The initial trocar is
typically inserted blindly. While these injuries are rare, significant
complications can occur. Vascular injuries can result in hemorrhage that may
be life threatening. Injuries to the bowel can cause a delayed peritonitis. It is
very important that these injuries be recognized as early as possible.[2]
• Some patients have sustained electrical burns unseen by surgeons who are
working with electrodes that leak current into surrounding tissue. The
resulting injuries can result in perforated organs and can also lead to
peritonitis.
• There may be an increased risk of hypothermia and peritoneal trauma due to
increased exposure to cold, dry gases during insufflation. The use of heated
and humidified CO2 may reduce this risk.[3]
• Many patients with existing pulmonary disorders may not tolerate
pneumoperitoneum (gas in the abdominal cavity), resulting in a need for
conversion to open surgery after the initial attempt at laparoscopic approach.
• Not all of the CO2 introduced into the abdominal cavity is removed through
the incisions during surgery. Gas tends to rise, and when a pocket of CO2 rises
in the abdomen, it pushes against the diaphragm (the muscle that separates
the abdominal from the thoracic cavities and facilitates breathing), and can
exert pressure on the phrenic nerve. This produces a sensation of pain that
may extend to the patient's shoulders. For an appendectomy, the right
shoulder can be particularly painful. In some cases this can also cause
considerable pain when breathing. In all cases, however, the pain is transient,
as the body tissues will absorb the CO2 and eliminate it through respiration. [4]
• Coagulation disorders and dense adhesions (scar tissue) from previous
abdominal surgery may pose added risk for laparoscopic surgery and are
considered relative contra-indications for this approach.
• Patients can often have trouble walking after surgery for a few days
[edit] Robotics and technology

A laparoscopic robotic surgery machine.

The process of minimally invasive surgery has been augmented by specialized tools for decades.
However, in recent years, electronic tools have been developed to aid surgeons. Some of the
features include:
• Visual magnification - use of a large viewing screen improves visibility
• Stabilization - Electromechanical damping of vibrations, due to machinery or
shaky human hands
• Simulators - use of specialized virtual reality training tools to improve
physicians' proficiency in surgery
• Reduced number of incisions
Robotic surgery has been touted as a solution to underdeveloped nations, whereby a single
central hospital can operate several remote machines at distant locations. The potential for
robotic surgery has had strong military interest as well, with the intention of providing mobile
medical care while keeping trained doctors safe from battle.

[edit] Non-robotic hand guided assistance systems


There are also user-friendly non robotic assistance systems that are single hand guided devices
with a high potential to save time and money. These assistance devices are not bound by the
restrictions of common medical robotic systems. The systems enhance the manual possibilities of
the surgeon and his team, regarding the need of replacing static holding force during the
intervention.
Some of the features are:
• The Stabilisation of the camera picture because the whole static workload is
conveyed by the assistance system.
• Some systems enable a fast repositioning and very short time for fixation of
less than 0.02 seconds at the desired position. Some systems are lightweight
constructions (18kg) and can withstand a force of 20 N in any position and
direction.
• The benefit – a physically relaxed intervention team can work concentrated
on the main goals during the intervention.
• The potentials of these systems enhance the possibilities of the mobile
medical care with those lightweight assistance systems. These assistance
systems meet the demands of true solo surgery assistance systems and are
robust, versatile and easy to use.

Cholecystectomy
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Laparoscopic Cholecystectomy as seen through laparoscope


X-Ray during Laparoscopic Cholecystectomy

Cholecystectomy (pronounced /ˌkɒləsɪsˈtɛktəmi/, plural: cholecystectomies) is the surgical


removal of the gallbladder. Despite the development of non-surgical techniques, it is the most
common method for treating symptomatic gallstones, although there are other indications for the
procedure, including carcinoma. Surgery options include the standard procedure, called
laparoscopic cholecystectomy, and an older more invasive procedure, called open
cholecystectomy. A cholecystectomy is performed when attempts to treat gallstones with
ultrasound to shatter the stones (lithotripsy) or medications to dissolve them have not proved
feasible.

Contents
[hide]
• 1 Open surgery
• 2 Laparoscopic surgery
○ 2.1 Procedural Risks and Complications
○ 2.2 Biopsy
• 3 Long-Term Prognosis
• 4 References

[edit] Open surgery


Traditional open cholecystectomy is a major abdominal surgery in which the surgeon removes
the gallbladder through a 10 to 18 cm (4- to 7-inch) incision. Patients usually remain in the
hospital overnight and may require several additional weeks to recover at home. It takes a
minimum of 7 to 15 days to complete the treatment. or as long as 30 days[citation needed]
[edit] Laparoscopic surgery
Laparoscopic cholecystectomy has now replaced open cholecystectomy as the first-choice of
treatment for gallstones and inflammation of the gallbladder unless there are contraindications to
the laparoscopic approach. Sometimes, a laparoscopic cholecystectomy will be converted to an
open cholecystectomy for technical reasons or safety.

A US Navy general surgeon and an operating room nurse discuss proper procedures
while performing a laparoscopic cholecystectomy surgery.

Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the
insertion of operating ports, small cylindrical tubes approximately 5-10 mm in diameter, through
which surgical instruments and a video camera are placed into the abdominal cavity. The camera
illuminates the surgical field and sends a magnified image from inside the body to a video
monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the
monitor and performs the operation by manipulating the surgical instruments through the
operating ports.
To begin the operation, the patient is anesthetized and placed in the supine position on the
operating table. A scalpel is used to make a small incision at the umbilicus. Using either a Veres
needle or Hassan technique the abdominal cavity is entered. The surgeon inflates the abdominal
cavity with carbon dioxide to create a working space. The camera is placed through the umbilical
port and the abdominal cavity is inspected. Additional ports are placed inferior to the ribs at the
epigastric, midclavicular, and anterior axillary positions. The gallbladder fundus is identified,
grasped, and retracted superiorly. With a second grasper, the gallbladder infundibulum is
retracted laterally to expose and open Calot's Triangle (the area bound by the liver, cystic duct,
and common hepatic duct). The triangle is gently dissected to clear the peritoneal covering and
obtain a view of the underlying structures. The cystic duct and the cystic artery are identified,
clipped with tiny titanium clips and cut. Then the gallbladder is dissected away from the liver
bed and removed through one of the ports. This type of surgery requires meticulous surgical
skill, but in straightforward cases can be done in about an hour.
Recently, this procedure is performed through a single incision in the patient's umbilicus. This
advanced technique is called Single Incision laparoscopic Surgery or "SILSTM".
[edit] Procedural Risks and Complications
Laparoscopic cholecystectomy does not require the abdominal muscles to be cut, resulting in less
pain, quicker healing, improved cosmetic results, and fewer complications such as infection and
adhesions. Most patients can be discharged on the same or following day as the surgery, and
most patients can return to any type of occupation in about a week.
An uncommon but potentially serious complication is injury to the common bile duct, which
connects the gallbladder and liver. An injured bile duct can leak bile and cause a painful and
potentially dangerous infection. Many cases of minor injury to the common bile duct can be
managed non-surgically. Major injury to the bile duct, however, is a very serious problem and
may require corrective surgery. This surgery should be performed by an experienced biliary
surgeon.[1]
Abdominal peritoneal adhesions, gangrenous gallbladders, and other problems that obscure
vision are discovered during about 5% of laparoscopic surgeries, forcing surgeons to switch to
the standard cholecystectomy for safe removal of the gallbladder. Adhesions and gangrene, of
course, can be quite serious, but converting to open surgery does not equate to a complication.
A Consensus Development Conference panel, convened by the National Institutes of Health in
September 1992, endorsed laparoscopic cholecystectomy as a safe and effective surgical
treatment for gallbladder removal, equal in efficacy to the traditional open surgery. The panel
noted, however, that laparoscopic cholecystectomy should be performed only by experienced
surgeons and only on patients who have symptoms of gallstones.
In addition, the panel noted that the outcome of laparoscopic cholecystectomy is greatly
influenced by the training, experience, skill, and judgment of the surgeon performing the
procedure. Therefore, the panel recommended that strict guidelines be developed for training and
granting credentials in laparoscopic surgery, determining competence, and monitoring quality.
According to the panel, efforts should continue toward developing a noninvasive approach to
gallstone treatment that will not only eliminate existing stones, but also prevent their formation
or recurrence.
One common complication of cholecystectomy is inadvertent injury to an anomalous bile duct
known as Ducts of Luschka, occurring in 33% of the population. It is non-problematic until the
gall bladder is removed, and the tiny supravesicular ducts may be incompletely cauterized or
remain unobserved, leading to biliary leak post operatively. The patient will develop biliary
peritonitis within 5 to 7 days following surgery, and will require a temporary biliary stent. It is
important that the clinician recognize the possibility of bile peritonitis early and confirm
diagnosis via HIDA scan to lower morbidity rate. Aggressive pain management and antibiotic
therapy should be initiated as soon as diagnosed.
[edit] Biopsy
After removal, the gall bladder should be sent for biopsy (pathological examination) to confirm
the diagnosis and look for an incidental cancer. If cancer is present, a reoperation to remove part
of liver and lymph nodes will be required in most cases. [2]

[edit] Long-Term Prognosis


Bile is crucial to fat digestion, and after removal of a gallbladder, normal digestion can be
adversely affected. Bile is still produced by the liver, but rather than being stored in a reservoir
which releases large quantities when needed, bile is released in a continuous, slow trickle into the
intestine. Thus, when eating a meal that is high in fat content, there may not be an adequate
amount of bile in the intestine to properly handle the normal absorption process. Your doctor
may prescribe medications to control the availability of bile salts.
As many as twenty percent of patients develop chronic diarrhea. The cause is unclear and the
condition may last for many years. [3]
A significant proportion of the population, between 5-40%, develop a condition called
postcholecystectomy syndrome, or PCS.[4] Symptoms include gastrointestinal distress and
persistent pain in the upper right abdomen. The cause is uncertain.
extremities

Orthopedic surgery
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(Redirected from Orthopaedic Surgery)
Jump to: navigation, search

This fracture of the lower cervical vertebrae, known as a 'teardrop fracture' is one of the
conditions treated by orthopedic surgeons.

This image, taken in September 2006, shows extensive repair work to the right acetabulum 6
years after it was carried out (2000). Further damage to the joint is visible due to the onset of
arthritis.
Orthopedic surgery or orthopedics (also spelled orthopaedics) is the branch of surgery
concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both
surgical and non-surgical means to treat musculoskeletal trauma, sports injuries, degenerative
diseases, infections, tumors, and congenital conditions.
Nicholas Andry coined the word "orthopaedics", derived from Greek words for orthos ("correct",
"straight") and paideia ("rearing" (usually of child)), in 1741, when at the age of 81 he published
Orthopaedia: or the Art of Correcting and Preventing Deformities in Children.
In the US the spelling orthopedics is standard[citation needed], although the majority of university and
residency programs[citation needed], and even the AAOS, still use Andry's spelling. Elsewhere, usage
is not uniform; in Canada, both spellings are common; orthopaedics usually prevails in the rest
of the Commonwealth, especially in Britain.

[edit] Training
In the United States and Canada, orthopedic surgeons have typically completed 4 years of
undergraduate education and 4 years of medical school. Subsequently, orthopedic surgeons
undergo residency training in orthopedic surgery. The five-year residency consists of one year of
general surgery training followed by four years of training in orthopedic surgery.
Selection for residency training in orthopedic surgery is extremely competitive--candidates for
orthopedic residencies generally graduate at the top of their medical school classes.
Approximately 650 physicians complete orthopedic residency training per year in the US. About
7 percent of current orthopaedic surgery residents are women; about 20 percent are members of
minority groups. There are approximately 20,400 actively practicing orthopaedic surgeons and
residents in the United States.[1] According to the latest Occupational Outlook Handbook (2006–
2007) published by the US Department of Labor, between 3–4% of all practicing physicians are
orthopedic surgeons.
Many orthopedic surgeons elect to do further subspecialty training, or 'fellowships', after
completing their residency training. Fellowship training in an orthopedic subspeciality is
typically one year in duration (sometimes two) and sometimes has a research component
involved with the clinical and operative training. Examples of orthopedic subspecialty training in
the US are:
• Hand surgery
• Shoulder and elbow surgery
• Total joint reconstruction (arthroplasty)
• Pediatric orthopedics
• Foot and ankle surgery
• Spine surgery
• Musculoskeletal oncology
• Surgical sports medicine
• Orthopedic trauma
These specialty areas of medicine are not exclusive to Orthopaedic Surgery. For example, Hand
surgery is practiced by some plastic surgeons and spine surgery is practiced by most
neurosurgeons. Additionally, foot and ankle surgery is practiced by board certified Doctors of
Podiatric Medicine (D.P.M.) in the United States. Some family practice physicians practice
sports medicine, however their scope of practice is non-operative..
After completion of specialty residency/registrar training, an orthopedic surgeon is then eligible
for board certification. Certification by the American Board of Orthopaedic Surgery means that
the orthopaedic surgeon has met the specified educational, evaluation, and examination
requirements of the Board[2]. The process requires successful completion of a standardized
written exam followed by an oral exam focused on the surgeon's clinical and surgical
performance over a 6 month period. In Canada, the certifying organization is the Royal College
of Physicians and Surgeons of Canada; in Australia and New Zealand it is the Royal Australasian
College of Surgeons.
In the US, specialists in hand surgery and sports medicine may obtain a Certificate of Added
Qualifications (CAQ) in addition to their board certification by successfully completing a
separate standardized examination. There is no additional certification process for the other
subspecialties.

[edit] Practice
According to applications for board certification from 1999 to 2003, the top 25 most common
procedures (in order) performed by orthopedic surgeons are as follows[3]:
• Knee arthroscopy and meniscectomy
• Shoulder arthroscopy and decompression
• Carpal tunnel release
• Knee arthroscopy and chondroplasty
• Removal of support implant
• Knee arthroscopy and anterior cruciate ligament reconstruction
• Knee replacement
• Repair of femoral neck fracture
• Repair of trochanteric fracture
• Debridement of skin/muscle/bone/fracture
• Knee arthroscopy repair of both menisci
• Hip replacement
• Shoulder arthroscopy/distal clavicle excision
• Repair of rotator cuff tendon
• Repair fracture of radius (bone)/ulna
• Laminectomy
• Repair of ankle fracture (bimalleolar type)
• Shoulder arthroscopy and débridement
• Lumbar spinal fusion
• Repair fracture of the distal part of radius
• Low back intervertebral disc surgery
• Incise finger tendon sheath
• Repair of ankle fracture (fibula)
• Repair of femoral shaft fracture
• Repair of trochanteric fracture
A typical schedule for a practicing orthopedic surgeon involves 50–55 hours of work per week
divided among clinic, surgery, various administrative duties and possibly teaching and/or
research if in an academic setting. In 2007, the median salary for an orthopedic surgeon in the
United States is $388,784.[4]

[edit] History

Orthopedic implants to repair fractures to the radius and ulna. Note the visible
break in the ulna. (right forearm)

Jean-Andre Venel established the first orthopedic institute in 1780, which was the first hospital
dedicated to the treatment of children's skeletal deformities. He is considered by some to be the
father of orthopedics or the first true orthopedist in consideration of the establishment of his
hospital and for his published methods.
Antonius Mathysen, a Dutch military surgeon, invented the plaster of Paris cast in 1851.
Many developments in orthopedic surgery resulted from experiences during wartime. On the
battlefields of the Middle Ages the injured were treated with bandages soaked in horses' blood
which dried to form a stiff, but unsanitary, splint. Traction and splinting developed during World
War I. The use of intramedullary rods to treat fractures of the femur and tibia was pioneered by
Gerhard Küntscher of Germany. This made a noticeable difference to the speed of recovery of
injured German soldiers during World War II and led to more widespread adoption of
intramedullary fixation of fractures in the rest of the world. However, traction was the standard
method of treating thigh bone fractures until the late 1970s when the Harborview Medical Center
in Seattle group popularized intramedullary fixation without opening up the fracture. External
fixation of fractures was refined by American surgeons during the Vietnam War but a major
contribution was made by Gavril Abramovich Ilizarov in the USSR. He was sent, without much
orthopedic training, to look after injured Russian soldiers in Siberia in the 1950s. With no
equipment he was confronted with crippling conditions of unhealed, infected, and malaligned
fractures. With the help of the local bicycle shop he devised ring external fixators tensioned like
the spokes of a bicycle. With this equipment he achieved healing, realignment and lengthening to
a degree unheard of elsewhere. His Ilizarov apparatus is still used today as one of the distraction
osteogenesis methods.
David L. MacIntosh pioneered the first successful surgery for the management of the torn
anterior cruciate ligament of the knee. This common and serious injury in skiers, field athletes,
and dancers invariably brought an end to their athletics due to permanent joint instability.
Working with injured football players, Dr. MacIntosh devised a way to re-route viable ligament
from adjacent structures to preserve the strong and complex mechanics of the knee joint and
restore stability. The subsequent development of ACL reconstruction surgery has allowed
numerous athletes to return to the demands of sports at all levels.
Modern orthopaedic surgery and musculoskeletal research has sought to make surgery less
invasive and to make implanted components better and more durable.
Additionally, there is currently under development highly promising research involving the
regrowth of Anterior Cruciate Ligament Tissue by the use of scaffolding around the Ligament,
thereby providing an environment in which the tissue can clot and heal like other areas of the
body which are not surrounded by the clot-preventing liquids which surround the major
ligaments. This research among others conducted at the Sports Medicine Research Laboratory is
still in the Research and Development stage.

[edit] Arthroscopy
The use of arthroscopic tools has been particularly important for injured patients. Arthroscopy
was pioneered in the early 1950's by Dr. Masaki Watanabe of Japan to perform minimally
invasive cartilage surgery and re-constructions of torn ligaments. Arthroscopy helped patients
recover from the surgery in a matter of days, rather than the weeks to months required by
conventional, 'open' surgery. Knee arthroscopy is one of the most common operations performed
by orthopedic surgeons today and is often combined with meniscectomy or chondroplasty.

[edit] Joint replacement


The modern total hip replacement was pioneered by Sir John Charnley in England in the 1960s.[5]
He found that joint surfaces could be replaced by metal or high density polyethylene implants
cemented to the bone with methyl methacrylate bone cement. Since Charnley, there have been
continuous improvements in the design and technique of joint replacement (arthroplasty) with
many contributors, including W. H. Harris, the son of R. I. Harris, whose team at Harvard
pioneered uncemented arthroplasty techniques with the bone bonding directly to the implant.
Knee replacements using similar technology were started by McIntosh in rheumatoid arthritis
patients and later by Gunston and Marmor for osteoarthritis in the 1970s.developed by Dr. John
Insall and Dr. Chitranjan Singh Ranawat in New York utilizing a fixed bearing,[6] and by Dr
Frederick Buechel and Dr Michael Pappas utilizing a mobile bearing.[7] Uni-compartment knee
replacement, in which only one side of an arthritic knee is replaced, is a smaller operation and
has become popular recently.
Joint replacements are available for other joints on a limited basis, most notably shoulder, elbow,
wrist, ankle, and fingers.
In recent years, surface replacement of joints, in particular the hip joint, have become more
popular amongst younger and more active patients. This type of operation delays the need for the
more traditional and less bone-conserving total hip replacement, but carries significant risks of
early failure from fracture and bone death.
One of the main problems with joint replacements is wear of the bearing surfaces of components.
This can lead to damage to surrounding bone and contribute to eventual failure of the implant.
Use of alternative bearing surfaces has increased in recent years, particularly in younger patients,
in an attempt to improve the wear characteristics of joint replacement components. These include
ceramics and all-metal implants (as opposed to the original metal-on-plastic). The plastic
(actually ultra high molecular weight polyethylene) can also be altered in ways that may improve
wear characteristics.

Bone grafting
From Wikipedia, the free encyclopedia
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Bone grafting is a surgical procedure that replaces missing bone with material from the patient's
own body, an artificial, synthetic, or natural substitute. Bone grafting is used to repair bone
fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal
properly.

Contents
[hide]
• 1 Types and Tissue Sources
○ 1.1 Autologous bone grafting
○ 1.2 Allograft bone grafting
○ 1.3 Demineralized Bone Matrix
○ 1.4 Synthetic variants
○ 1.5 Xenografts
○ 1.6 Alloplastic Grafts
○ 1.7 Growth Factors
• 2 Uses
• 3 Procedure
• 4 Risks
○ 4.1 Risks for grafts from the iliac crest
• 5 Recovery and Aftercare
• 6 Costs
• 7 References
• 8 See also

[edit] Types and Tissue Sources


[edit] Autologous bone grafting
Autologous (or autogenous) bone grafting is the most desired. Autogenous bone grafting
involves taking the patient's own bone from a part of the body where it is not essential (typically
from the pelvis or iliac crest), and placing it where it's needed. Autogenous bone grafts are the
most preferred by surgeons because there is less risk of the bone being rejected due to the fact
that the bone originated in the patient's body [1], and therefore has the most abundant "amount of
the patient's bone growing cells and proteins" and is a kind of "outline" for the new bone that is
growing. One negative aspect of the procedure would be that the surgeon has to make more
incisions than are required for the surgical site; he or she must make an extra incision to extract
the bone that is being used for the surgery. An effect of this is "another location for postoperative
pain" and it may increase the price of the procedure.[2]
Autologous bone is typically harvested from intra-oral sources as the chin or extra-oral sources
as the iliac crest, the fibula, the ribs, the mandible and even parts of the skull.
All bone requires a blood supply in the transplanted site. Depending on where the transplant site
is and the size of the graft, an additional blood supply may be required. For these types of grafts,
extraction of the part of the periosteum and accompanying blood vesels along with donor bone is
required. This kind of graft is known as a free flap graft.
[edit] Allograft bone grafting
Allograft bone grafting is similar to the autogenous bone graft in that it is still harvested from
people. Allograft bone in bone taken from cadavers or deceased people that have donated their
bone so that it can be used for living people who are in need of it; it is typically sourced from a
bone bank. The bone is disinfected and then frozen or lyophilized (freeze-dried).[2] It helps
minimize problems that come with taking the patient's bone and takes the place of a bone graft
extender or replacement in the procedure. A disadvantage of this type of graft is that it is not very
successful; it is fairly useful in several types of spinal fusions, but because it is not a very
powerful "biological stimulant", it cannot, when used as the only grafting material, typically
achieve a good fusion in procedures such as a lumbar spinal fusion.[1]
[edit] Demineralized Bone Matrix
To demineralize bone, proteins that help with bone formation are taken from bones and are
processed. Demineralized bone is suggested as only a bone graft extender because there really
isn't much proof that it is "powerful enough" to fuse a human spine.[1]
[edit] Synthetic variants
Artificial bone can be created from ceramics such as calcium phosphates (e.g. hydroxyapatite
and tricalcium phosphate), Bioglass and calcium sulphate; all of which are biologically active to
different degrees depending on solubility in the physiological environment (see: Hench
'Bioceramics: From Concept to Clinic' 1991, Journal of the American Ceramic Society). These
materials can be doped with growth factors, ions such as strontium or mixed with bone marrow
aspirate to increase biological activity. Some authors believe this method is inferior to
autogenous bone grafting [1] however infection and rejection of the graft is much less of a risk,
the mechanical properties such as Young's modulus are comparable to bone. The presence of
elements such as strontium can result in higher bone mineral density and enhanced osteoblast
proliferation in vivo.
[edit] Xenografts
Xenograft bone substitute has its origin from a species other than human, such as bovine.
Xenografts are usually only distributed as a calcified matrix.
[edit] Alloplastic Grafts
Alloplastic grafts may be made from hydroxylapatite, a naturally occurring mineral that is also
the main mineral component of bone. They may be made from bioactive glass. Hydroxylapetite
is a Synthetic Bone Graft, which is the most used now among other synthetic due to its
osteoconduction, hareness and acceptability by bone there are also calcium carbonate which start
to decrease in usage because it is completely resorbable in short time which make the bone easy
to break again finally used is the tricalcium phosphate which now used in combination with
hydroxylapatite thus give both effect osteoconduction and resorbsbility.
[edit] Growth Factors
Growth Factor enhanced grafts are produced using recombinant DNA technology. They consist
of either Human Growth Factors or Morphogens (Bone Morphogenic Proteins in conjunction
with a carrier medium, such as collagen).

[edit] Uses
The most common use of bone grafting is in the application of dental implants, in order to restore
the edentulous area of a missing tooth. Dental implants require bones underneath them for
support and to have the implant integrate properly into the mouth. People who have been
edentulous (without teeth) for a prolonged period may not have enough bone left in the necessary
locations. In this case, bone can be taken from the chin or from the pilot holes for the implants or
even from the iliac crest of the pelvis and inserted into the mouth underneath the new implant.
In general, bone grafts are either used en block (such as from the chin or the ascending ramus
area of the lower jaw) or particulated, in order to be able to adapt it better to a defect.
Another common bone graft, which is more substantial than those used for dental implants, is of
the fibular shaft. After the segment of the fibular shaft has been removed normal activities such
as running and jumping are permitted on the leg with the bone deficit. The grafted, vascularized
fibulas have been used to restore skeletal integrity to long bones of limbs in which congenital
bone defects exist and to replace segments of bone after trauma or malignant tumor invasion.
The periosteum and nutrient artery are generally removed with the piece of bone so that the graft
will remain alive and grow when transplanted into the new host site. Once the transplanted bone
is secured into its new location it generally restores blood supply to the bone in which it has been
attached.
Besides the main use of bone grafting--dental implants--this procedure is used to fuse joints to
prevent movement, repair broken bones that have bone loss, and repair broken bone that has not
yet healed.[3]
Bone grafts are used in hopes that the defective bone will be healed or will regrow with little to
no graft rejection.[3]
[edit] Procedure
Depending on where the bone graft is needed, a different doctor may be requested to do the
surgery. Doctors that do bone graft procedures are commonly orthopedic surgeons,
otolaryngology head and neck surgeons, neurosurgeons, craniofacial surgeons, oral and
maxillofacial surgeons, and periodontists.[4]

[edit] Risks
As with any procedure, there are risks involved; among these include reactions to medicine and
problems breathing, bleeding, and infection.[3]Infection is reported to occur in less than 1% of
cases and is curable with antibiotics. Overall, patients with a preexisting illness are at a higher
risk of getting an infection as opposed to those who are overall healthy.[5]
[edit] Risks for grafts from the iliac crest
Some of the potential risks and complications of bone grafts employing the iliac crest as a donor
site include[5][6][7]:
• acquired bowel herniation (this becomes a risk for larger donor sites
(>4 cm))[5]. About 20 cases have been reported in the literature from 1945 till
1989[8] and only a few hundred cases have been reported worldwide[9]
• meralgia paresthetica (injury to the lateral femoral cutaneous nerve also
called Bernhardt-Roth's syndrome)
• pelvic instability
• fracture (extremely rare and usually with other factors[10][11])
• injury to the clunial nerves (this will cause posterior pelvic pain which is
worsened by sitting)
• injury to the ilioinguinal nerve
• infection
• minor hematoma (a common occurrence)
• deep hematoma requiring surgical intervention
• seroma
• ureteral injury
• pseudoaneurysm of iliac artery (rare)[12]
• tumor transplantation
• cosmetic defects (chiefly caused by not preserving the superior pelvic brim)
• chronic pain
Bone grafts harvested from the posterior iliac crest in general have less morbidity, but depending
on the type of surgery, may require a flip while the patient is under general anesthesia.[13][14]
[edit] Recovery and Aftercare
The amount of time it takes for an individual to recovery depends on the severity of the injury
being treated and lasts anywhere from 2 weeks to 2 months with a possibility of vigorous
exercise being barred for up to 6 months.[3]

[edit] Costs
This section may require cleanup to meet Wikipedia's quality standards.
Please improve this section if you can. (January 2009)
Bone graft procedures consist of more than just the surgery. The average cost of bone graft
procedures ranges from approximately $33,860 to $37,227.[15] Besides the cost of the bone graft
itself (ranging from $250 to $900) other expenses for the procedure include: surgeon's fees (these
vary), anesthesiologist fees (approximately $350 to $400 per hour), hospital charges (these vary;
averaging about $1,500 to $1,800 a day), medication charges ($200 to $400), and additional fees
for services such as medical supplies, diagnostic procedures, equipment use fees, etc.[16]
Hand surgery
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This article does not cite any references or sources. Please help improve this
article by adding citations to reliable sources. Unverifiable material may be
challenged and removed. (June 2007)
The field of hand surgery deals with both surgical and non-surgical treatment of conditions and
problems that may take place in the hand or upper extremity (commonly from the tip of the hand
to the shoulder). Hand surgery may be practiced by graduates of general surgery, orthopedic
surgery and plastic surgery. Plastic surgeons and orthopedic surgeons receive significant training
in hand surgery during their residency training, with some graduates continuing on to do an
additional one year hand fellowship. These fellowships are sometimes also pursued by general
surgeons. Plastic surgeons are particularly well suited to handle traumatic hand and digit
amputations that require a "replant" operation. Orthopedic surgeons are trained to reconstruct all
aspects to salvage the appendage: tendons, muscle, bone. Orthopedic surgeons are particularly
well suited to handle complex fractures of the hand and injuries to the carpal bones that alter the
mechanics of the wrist. Hand surgeons perform a wide variety of operations such as fracture
repairs, releases, transfer and repairs of tendons and reconstruction of injuries, rheumatoid
deformities and congenital defects.

[edit] Indications
The following conditions can be indications for hand surgery:
• Hand injuries
• Carpal tunnel syndrome
• Carpometacarpal bossing
• Rheumatoid arthritis
• Dupuytren's contracture
• Congenital defects

Unicompartmental knee arthroplasty


From Wikipedia, the free encyclopedia
(Redirected from Partial knee replacement)

Jump to: navigation, search

Unicompartmental knee arthroplasty is a surgical procedure used to relieve arthritis in one of


the knee compartments in which the damaged parts of the knee are replaced. UKA surgery may
reduce post-operative pain and have a shorter recovery period than a total knee replacements.[1]
Also, UKA may have a smaller incision because the implants may be smaller.[1]
In the United States, this procedure constitutes approximately 8% of knee arthroplasty.[2]

Contents
[hide]
• 1 Background
• 2 Indications and
Contraindications
• 3 History and physical
examination
• 4 Surgical information
• 5 Benefits
• 6 Risks
• 7 Long-term results
• 8 External links
• 9 References

[edit] Background
In the early 1950s, Duncan C. McKeever theorized that osteoarthritis could be isolated to only
one compartment of the knee joint,[1] and that replacement of the entire knee might not be
necessary if only one knee compartment was affected.[1] The UKA concept was designed to cause
less trauma or damage than traditional total knee replacement by removing less bone and trying
to maintain most of the patient’s bone and anatomy.[1] Also, the concept was designed to use
smaller implants and thereby keep most of the patient’s bone; this can help patients return to
normal function faster.[1]
Initially, UKAs were not always successful, because the implants were poorly designed, patients
weren't thoroughly screened for suitability, and optimal surgical techniques were not
developed.[3][4][5][6][7] Recent advancements have been made to improve the design of the
implants.[7] Also, choosing the best-suited patients was emphasized to ensure that surgeons
followed the indications and contraindications for partial replacement. Proper patient selection[8],
following the indications/contraindications, and performing the surgery well are key factors for
the success of UKA.[1]

[edit] Indications and Contraindications


UKA may be suitable for patients with moderate joint disease caused by painful osteoarthritis or
traumatic injury, a history of unsuccessful surgical procedures or poor bone density that
precludes other types of knee surgery.[9] Patients that may not be eligible for a UKA include
patients that have an active or suspected infection in or about the knee joint, may have a known
sensitivity to device materials, have bone infections or disease that result in an inability to
support or fixate the new implant to the bone, have inflammatory arthritis, have major
deformities that can affect the knee mechanical axis, have neuromuscular disorders that may
compromise motor control and/or stability, have any mental neuromuscular disorder, patients
who are not skeletally mature, are obese[10], have lost a severe amount of bone from the shin
(tibia) or have severe tibial deformities, have recurring subluxation of the knee joint, have
untreated damage to the knee cap and thigh bone joint (patellofemoral joint), have untreated
damage to the opposite compartment or the same side of the knee not being replaced by a device,
and/or have instability of the knee ligaments such that the postoperative stability the UKA would
be compromised[11].
The anterior cruciate ligament (ACL) should be intact.[12] Although, this is debated by clinicians
for patients that need a medial compartment replacement.[1] For patients that need a lateral
compartment replacement, the ACL should be intact and is contraindicated for patients that have
ACL-deficient knees because the lateral component has more motion than the medial
compartment.[1]

[edit] History and physical examination


A physical examination and getting the patient’s history is performed before getting surgery.[1] A
doctor may ask the patient to identify their pain with one finger.[1] If the patient has pain in one
area of the knee, he or she may be a candidate for UKA.[1] But if the patient has pain in more
than one area of the knee, he or she may not be a good candidate for UKA.[1] The doctor may
take some radiographs (e.g., x-rays) to check for degeneration of the other knee compartments
and evaluate the knee.[1] The physical exam may also include special tests designed to test the
ligaments of the knee and other anatomical structures.[8] Most likely, the surgeon will decide to
do a UKA during surgery where he/she can directly see the status of the other compartments.[1]

[edit] Surgical information


The surgeon may choose which type of incision and implant he or she should use for the patient’s
knee. During the surgery, the surgeon may align the instruments to determine the amount of bone
that should be removed.[7] The surgeon will remove bone from the shin bone (tibia) and thigh
bone (femur).[7] The surgeon may decide to check if he or she removed the proper amount of
bone during the surgery.[7] In order to make sure that the proper size implant is used, a surgeon
may choose to use a temporary trial. After making sure the proper size implant is selected, the
surgeon will put the implant on the ends of the bone and secure it with pegs. Finally, the surgeon
will close the wound with sutures.[7]

The uni-compartmental replacement is a minimally invasive option for patients whose arthritis is
isolated to either the medial or the lateral compartment. The procedure offers several benefits for
patients with a moderately active lifestyle, who have arthritis in just one knee compartment, and
who are within normal weight ranges. The surgeon uses an incision of just 3-4 inches; a total
knee replacement typically requires an incision of 8-12 inches. According to Dr. Howard J.
Luks,[13] Associate Professor of Orthopedic Surgery at New York Medical College, the partial
replacement does not disrupt the knee cap, which makes for a shorter rehabilitation period. A
partial replacement also causes minimal blood loss during the procedure, and results in
considerably less post-operative pain. The hospitalization time compared with a total knee
replacement is also greatly reduced.

[edit] Benefits
The potential benefits of UKA include a smaller incision because the UKA implants are smaller
than the total knee replacements, and the surgeon may make a smaller incision.[1] This may lead
to a smaller scar.[1] Another potential benefit is less post-operative pain because less bone is
removed. Also, a quicker operation and shorter recovery period may be a result of less bone
being removed during the operation and the soft tissue may sustain less trauma.[14] Also, the
rehabilitation process may be more progressive.[15] More specific benefits of UKA are it may
improve range of motion, reduce blood loss during surgery, reduce the patient’s time spent in the
hospital, and decrease costs.[10]

[edit] Risks
Blood clots (also known as deep vein thrombosis) are a common complication after surgery.[16][17]
However, a doctor may prescribe certain medications to help prevent blood clots.[16][17] Infection
may occur after surgery.[18] However, antibiotics may be prescribed by a doctor to help prevent
infections.[17] Individual patient factors (i.e., anatomy, weight, prior medical history, prior joint
surgeries) should be addressed with the patient’s doctor. There is some evidence that the rate of
complications may be higher than with total knee arthroplasty.[19] The causes of long-term failure
of UKAs include polyethylene wear, loosening of the implant, and degeneration of the adjacent
knee compartment.[1]

[edit] Long-term results


Long term studies reported excellent outcomes for UKA and the authors credit it to picking the
proper patients[20], minimizing the amount of bone that is removed[21], and using the proper
surgical technique[20]. One study found that at a minimum of 10 years follow up time after the
initial surgery, the overall survival rate of the implant was 96%.[20] Also, 92% of the patients in
this study had excellent or good outcome.[20] Another study, reported that at 15 years follow up
time after the initial surgery, the overall rate of the implant was 93% and 91% of these patients
reported good or excellent outcomes.[21]

Epiphysiodesis
From Wikipedia, the free encyclopedia
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This article is an orphan, as few or no other articles link to it. Please introduce
links to this page from other articles related to it. (February 2009)
This article may require cleanup to meet Wikipedia's quality standards. Please
improve this article if you can. (August 2008)
Epiphysiodesis is a Pediatric surgical procedure in which the epiphyseal (growth) plate of a
bone is removed.
This procedure is used to:
• Lengthen an abnormally short leg
• Shorten an abnormally long leg
• Limit growth of a normal leg to allow a short leg to grow to a matching
length[1] This can incorporate a bone graft to produce fusion of the epiphysis
or premature cessation of the epiphyseal plate's growth.
The epiphysis can be removed in one of the bone's end to slow down the growth, or in both ends
to stop growth of that bone completely.

[edit] Limitations
The surgery must also be carefully planned with regard to timing, as it is non-reversible, so that
the limbs are at near-equal length at end of growth.
Back
Laminectomy/Laminotomy

Spinal surgery usually involves either a laminotomy


or laminectomy. First, the surgeon will make an incision in the midline of the back. Next, a
"window" is made in the lamina, the portion of the vertebrae that forms the roof of the spinal
canal. Bone is removed to relieve pressure on the nerve and to allow the surgeon access to the
spinal canal.
A laminotomy removes a portion of the lamina and is performed
when the surgeon needs access to a small part of the spinal canal.
A laminectomy removes the entire lamina and is performed to create more room for the nerves
and allows the surgeon greater access to the spinal canal. The bone removed does not grow back.

Discectomy

With access to the nerve and disc areas gained through the
laminotomy or laminectomy, further corrections can be made. The surgeon uses small
instruments to remove the damaged disc material that is pressing on a nerve root.
Fusion
For patients with instability, a spinal fusion may be recommended. A spinal fusion involves
placing bone grafts between vertebrae. Frequently only two lumbar vertebrae are fused.
However, multiple vertebrae may be included. Bone grafts may be taken from the pelvic bone
and placed in a hollow, porous implant that is placed between two vertebrae or the bone is placed
along side the vertebrae on the transverse processes. As the body heals, the bone graft and the
vertebrae grow into one unit or become fused. This stabilizes the vertebrae reducing pain caused
by too much movement between vertebrae.

Before Surgery
Before performing surgery, your physician will study your back by means of X-ray or other tests
such as magnetic resonance imaging (MRI), myelography or a CT scan. Testing will help the
physician determine what procedure will be best for you. Your doctor will discuss whether your
procedure will be performed on an outpatient basis or if a hospital stay will be required; fully
explain the procedure; and explain the risks and benefits of surgery.
To prepare yourself for surgery, you may be asked to do a number of things. You may be asked to
lose weight if you are overweight. If you smoke, it is important for you to stop several weeks
prior to surgery. If you are taking aspirin or certain anti-inflammatory medications, inform your
surgeon; you may need to stop taking these two weeks before surgery.

What to Expect After Surgery


You will be monitored as you recover from your procedure and you will be given medication to
relieve pain. As you prepare to go home, you will be given instructions about physical therapy
and a prescription for pain medication. You will also be instructed about follow up visits to your
physician.
Your active role in your recovery will continue once you are home by following your
rehabilitation plan. Call your doctor if you have any of the following:
• new pain, weakness or numbness that begins after you return home

• fever, headache or extreme fatigue

• bladder or bowel problems

Recuperation will depend on the type of procedure performed and varies with each patient. Ask
your doctor when it is safe to resume regular activities, including house work, returning to work,
and athletic activities.
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Doctors will almost always try non-surgical back pain treatments before
recommending surgery. People with chronic (recurring) back pain are often good
candidates for back surgery, as are people who have lower back pain without leg
pain. Some of the diagnoses that may need surgery include herniated discs,
spinal stenosis, spondylolisthesis, vertebral fractures, and discogenic low back
pain.
Back Surgery: An Introduction
Depending on the diagnosis, back surgery is sometimes used when other non-
surgical treatments have failed. People who may be candidates for back surgery
have:

• Constant pain
• Pain that recurs frequently and interferes with their ability to sleep
• Pain that prevents them from functioning at their job
• Pain that makes it difficult to perform daily activities.

In general, there are two groups of people who may require back surgery to treat
their spinal problems. People in the first group may have:

• Chronic low back pain


• Sciatica
• A herniated disc
• Spinal stenosis
• Spondylolisthesis
• Vertebral fractures with nerve involvement.
People in the second group may have predominant lower back pain without leg
pain. These are people with discogenic low back pain (also called degenerative disc
disease), in which discs wear out with age. In most cases, the outcome of back
surgery is much more predictable in people with sciatica than in those with
predominant low back pain.

(Click Lower Back Pain for more information.)

Some of the diagnoses that may require back surgery include:

• Herniated discs
• Spinal stenosis
• Spondylolisthesis
• Vertebral fractures
• Discogenic low back pain.

Back Surgery for Herniated Discs


Herniated discs are a potentially painful problem in which the hard outer coating of
the discs, which are the circular pieces of connective tissue that cushion the bones
of the spine, are damaged, allowing the discs' jelly-like center to leak, irritating
nearby nerves. This causes severe sciatica and nerve pain down the leg. A
herniated disc is sometimes called a ruptured disc.

Back surgery options for a herniated disc include:

• Laminectomy/discectomy
• Microdiscectomy
• Laser surgery.

Laminectomy/Discectomy

In this type of back surgery, part of the lamina (a portion of the bone on the back
of the vertebrae) is removed, as well as a portion of a ligament. The herniated disc
is then removed through the incision, which may extend two or more inches.
Microdiscectomy

As with traditional discectomy, this back surgery involves removing a herniated disc
or damaged portion of a disc through an incision in the back. The difference is that
the incision is much smaller and the doctor will use a magnifying microscope or lens
to locate the disc through the incision. The smaller incision may reduce pain and
the disruption of tissues, and it will reduce the size of the surgical scar. It appears
to take about the same time to recuperate from a microdiscectomy as from a
traditional discectomy.

Laser Surgery

Technological advances in recent decades have led to the use of lasers for operating
on people with herniated discs accompanied by lower back and leg pain. During this
back surgery, the surgeon will insert a needle into the disc, which will deliver a few
bursts of laser energy to vaporize the tissue in the disc. This will reduce its size and
relieve pressure on the nerves. Although many people return to daily activities
within three to five days after laser surgery, pain relief may not be apparent until
several weeks, or even months, after the surgery. The usefulness of laser
discectomy is still being debated.

Back Surgery for Spinal Stenosis


Spinal stenosis is the narrowing of the spinal canal, through which the spinal cord
and spinal nerves run. This condition is often caused by the overgrowth of bone
resulting from osteoarthritis of the spine. Compression of the nerves caused by
spinal stenosis can lead to:

• Pain
• Numbness in the legs
• Loss of bladder and/or bowel control.

People may have difficulty walking any distances and may also have severe pain in
their legs, as well as numbness and tingling.

The only back surgery option for spinal stenosis is a laminectomy. In this
procedure, the doctor will make a large incision down the affected area of the spine
and remove the lamina and any bone spurs (overgrowths of bone) that may have
formed in the spinal canal as the result of osteoarthritis. A laminectomy is a major
back surgery that requires a short hospital stay and physical therapy afterwards to
help regain strength and mobility.

(Click Spinal Stenosis Surgery for more information.)

Back Surgery for Spondylolisthesis


Spondylolisthesis is a condition in which a vertebra of the lumbar spine slips out of
place. As the spine tries to stabilize itself, the joints between the slipped vertebra
and adjacent vertebrae can become enlarged, pinching nerves as they exit the
spinal column. Spondylolisthesis may cause low back pain and severe sciatica leg
pain.

The back surgery option for spondylolisthesis is spinal fusion. When a slipped
vertebra leads to the enlargement of adjacent facet joints, surgical treatment
generally involves both laminectomy and spinal fusion. In spinal fusion, two or more
vertebrae are joined together using bone grafts, screws, and rods to stop slippage
of the affected vertebrae. Bone that is used for grafting comes from another area of
the body, usually the hip or pelvis. In some cases, donor bone is used.

Although the back surgery is generally successful, either type of graft has its
drawbacks. Using your own bone means surgery at a second site on your body, and
with donor bone, there is a slight risk of disease transmission or rejection. In recent
years, a new development -- bone morphogenic proteins -- has eliminated these
risks for some people undergoing spinal fusion. Bone morphogenic proteins
are used to stimulate bone generation, thereby eliminating the need for grafts. The
proteins are placed in the affected area of the spine, often in collagen putty or
sponges. Regardless of how spinal fusion is performed, the fused area of the spine
becomes immobilized.

Back Surgery for Vertebral Fractures


Vertebral fractures are caused by trauma to the vertebrae of the spine or by
crumbling of the vertebrae resulting from osteoporosis. This causes mostly
mechanical back pain, but it may also put pressure on the nerves, creating leg pain.
Back surgery options for osteoporotic fractures include:
• Vertebroplasty
• Kyphoplasty.

Vertebroplasty

When back pain is caused by a compression fracture of a vertebra due to


osteoporosis or trauma, a doctor generally makes a small incision in the skin over
the affected area. The doctor will then inject a cement-like mixture called
polymethyacrylate into the fractured vertebra to relieve pain and stabilize the spine.
This back surgery is generally performed on an outpatient basis under a mild
anesthetic.

Kyphoplasty

Much like vertebroplasty, kyphoplasty is used to relieve pain and stabilize the spine
following fractures due to osteoporosis. Kyphoplasty is a two-step process. In the
first step, the doctor will insert a balloon device to help restore the height and
shape of the spine. In the second step, the doctor will inject polymethyacrylate to
repair the fractured vertebra. This back surgery is done under anesthesia, and in
some cases it is performed on an outpatient basis.

Back Surgery for Discogenic Low Back Pain


Most people's discs degenerate over a lifetime, but in some, this aging process can
become chronically painful, severely interfering with their quality of life. Back
surgery options for discogenic low back pain (also called degenerative disc disease)
include:

• Intradiscal electrothermal therapy


• Spinal fusion
• Disc replacement.
• Intradiscal Electrothermal
Therapy (IDET)
• One of the newest and least
invasive therapies for low back pain
involves inserting a heating wire
through a small incision in the back
and into a disc. An electrical current
is then passed through the wire to
strengthen the collagen fibers that
hold the disc together. This back
surgery is done on an outpatient
basis, often under local anesthesia.
The usefulness of IDET, however, is
debatable, and further studies on its
effectiveness are needed.

• Spinal Fusion
• When the degenerated disc is
extremely painful, the surgeon may
recommend removing it and fusing
the disc to help with the pain. This
fusion can be done through the
abdomen (stomach) in a type of
back surgery known as anterior
lumbar interbody fusion, or through
the back in a procedure called
posterior fusion. Theoretically,
fusion surgery should eliminate the
source of pain. This back surgery is
successful in about 60 to 70 percent
of cases, and fusion for low back
pain or any spinal surgeries should
only be done as a last resort, and
the person should be fully informed
of risks.

• Disc Replacement
• When a disc is herniated, one
alternative to a discectomy -- in
which the disc is simply removed --
is removing it and replacing it with a
synthetic or artificial disc. Replacing
the damaged one with an artificial
one restores disc height and
movement between the vertebrae.
Artificial discs come in several
designs. Although doctors in Europe
have performed this type of back
surgery for more than a decade, the
procedure had only been
experimental in the United States
until the U.S. Food and Drug
Administration (FDA) approved the
Charité artificial disc.