Clips Can be Safely Used for Vascular Control of the Renal Vessels During Laparoscopic Donor Nephrectomy

OBJECTIVE

To review our experience using clips to control the renal vessels during laparoscopic donor nephrectomy (LDN) and determine the safety of this practice.

METHODS

We performed a retrospective review of patients who underwent LDN at our centre January 1, 2007-September 17, 2019. The primary outcome was the rate of complication associated with vascular control of the renal vessels, which included (1) conversion to open to manage bleeding, (2) additional procedures for bleeding, and (3) major bleeding requiring blood transfusion. Secondary outcomes included the rate of renal artery/vein clip dislodgement or crossing, change in hemoglobin, warm ischemia time and the incidence of intra-operative complications and postoperative in-hospital complications.

RESULTS

We included 503 patients who underwent LDN, of which 497 were left sided. The main renal artery was controlled with 3 titanium clips in 489 (97%) cases. The main renal vein was controlled with 2 polymer-locking clips in 478 (95%) cases. For our primary outcome, there were no conversions to open to manage bleeding, no secondary procedures due to bleeding and no major bleeding requiring blood transfusion. Additionally, there were no donor deaths. Regarding our secondary outcomes, there were 5 intraoperative events related to the titanium clips being placed on the renal artery and 1 intraoperative event related to the polymer-locking clips on the renal vein, none of which resulted in any morbidity.

CONCLUSION

Using 3 titanium clips on the renal artery and 2 polymer-locking clips on the renal vein during left LDN is safe and provides excellent vascular control.

Feasibility of bilateral internal thoracic artery harvesting using the da Vinci SP system

PURPOSE

We conducted this study to investigate the feasibility of mobilizing the bilateral internal thoracic arteries (ITAs) using the da Vinci SP through a single intercostal incision and to compare the amount of rib spreading with that required for mini-thoracotomy procedures. We also evaluated the construction of an intrathoracic T-graft anastomosis using existing instrumentation of the SP system.

METHODS

We harvested bilateral ITAs from two male cadavers via a single incision made in the fifth intercostal space using the da Vinci SP. A T-graft end-to-side anastomosis was created in one cadaver.

RESULTS

The bilateral ITAs were harvested in less than 60 min and a T-graft was completed. No additional rib spreading was required. Intraoperative adjustments of the da Vinci SP were necessary to maintain alignment with the surgical targets.

CONCLUSIONS

Bilateral ITA harvest using the da Vinci SP through a single intercostal incision was feasible, with less rib spreading than in mini-thoracotomy procedures. Thus, creating an intrathoracic T-graft with the existing da Vinci SP instruments is possible.

Laparoscopic myomectomy using self-made retrieval bag to contain tissue extraction

OBJECTIVE

To introduce an effective approach using a self-made retrieval bag during laparoscopic myomectomy to contain tissue extraction.

DESIGN

Step-by-step video explanation of the surgical procedure with still pictures and surgical video clips to demonstrate the detailed technique, approved by the Shengjing Hospital of China Medical University.

SETTING

University hospital.

PATIENT(S)

A 32-year-old woman diagnosed with a uterine myoma (diameter, 6 cm). She had endured 5 years of intermittent lower abdominal pain and 2 years of infertility.

INTERVENTION(S)

A self-made retrieval bag during laparoscopic myomectomy was used (consists of four steps) to contain tissue extraction. 1. Self-made retrieval bag using a sterile medical bag. 2. Inspect the pelvic cavity, evaluate and determine the location and number of myomas. 3. Resect the myoma. 4. Morcellate the myoma into pieces inside the retrieval bag using laparoscopic power morcellation.

MAIN OUTCOME MEASURE(S)

Value and feasibility of using a self-made retrieval bag in laparoscopic myomectomy.

RESULT(S)

The myoma was successfully and completely resected by laparoscopy using a self-made retrieval bag to contain tissue extraction. Operative time was 93 minutes. In the follow-up period, the patient did not report any symptom of iatrogenic parasitic myoma. The woman had a pregnancy at month 26 after operation and underwent a cesarean section. This resulted in a full-term baby.

CONCLUSION(S)

Our surgical approach demonstrated a number of noteworthy advantages. The use of retrieval bag to contain tissue extraction during laparoscopic morcellation can avoid the risk of iatrogenic parasitic myoma. The retrieval bag is self-made using a sterile packing bag, which is cost free and also reduces operative expenses.

Dermatome-Induced Lacerations: An Unspoken Problem in Burn Surgery

BACKGROUND

Dermatome-induced lacerations are a known complication; however, there is a paucity of literature discussing the incidence and predisposing factors. The aim of this study was to determine the incidence and risk factors to develop a preventive algorithm.

METHODS

An 18-question survey was sent to all US and Canadian burn unit directors. Surgeons were queried about type and location of their practices, average annual caseload of skin graft harvesting, and number of dermatome-induced lacerations. The survey also asked about donor site location, harvesting technique and equipment, laceration severity, and causative factors. An algorithm was developed based on the results.

RESULTS

Fifty-six responses (42% response rate) were received from the burn unit directors. They reported an estimated 133 lacerations over the past 5 y. The overall incidence of dermatome-induced lacerations was approximately 0.1% per year (1.3 per 1000 cases). The most commonly attributed causes were excessive pressure (25.0%) and patient factors (18.4%). Most lacerations occurred when using air dermatomes (73.0%) with a 4-inch guard (63.5%), 0.010- to 0.015-inch thickness (78.4%), and 30°-45° angulation (47.3%); the most common brand was Zimmer (71.6%). The dermatome was typically set up by a scrub tech or nurse (48.6%), whereas the skin harvesting was performed by residents (39.2%) or attendings (35.1%). Lacerations typically extended to subcutaneous tissue (70.3%), with no neurovascular injury (86.5%).

CONCLUSIONS

Our study showed that dermatome-induced lacerations are rare events and that certain factors predispose patients to injury. An algorithm was developed to provide guidance on risk factor identification and the set up and use of dermatomes.

Naturally Adipose Stromal Cell-Enriched Fat Graft: Comparative Polychromatic Flow Cytometry Study of Fat Harvested by Barbed or Blunt Multihole Cannula

Background

Fat grafts enriched with cells of the stromal vascular fraction (SVF), especially adipose-derived stromal cells (ASCs), exhibit significantly improved retention over non enriched, plain fat. Different types of liposuction cannulae may yield lipoaspirates with different subpopulations of cells. Moreover, preparation of adipose tissue for transplantation typically involves centrifugation, which creates a density gradient of fat.

Objectives

The authors sought to determine whether liposuction with a barbed or smooth cannula altered the enrichment of the SVF, and specifically ASCs, in low-density (LD) and high-density (HD) fractions of centrifuged adipose tissue.

Methods

Fat was harvested from 2 abdominal sites of 5 healthy women with a barbed or smooth multihole blunt-end cannula. After centrifugation, LD and HD fat fractions were digested with collagenase and analyzed by polychromatic flow cytometry to identify and enumerate distinct populations of cells.

Results

Overall cell yield and the number of immune cells were consistently higher in HD fractions than in LD fractions, regardless of the cannula employed. More living cells, and specifically more ASCs, populated the HD fractions of lipoaspirates obtained with a barbed cannula than with a smooth cannula.

Conclusions

In this study, lipoaspiration with a barbed cannula and isolation of the HD layer of centrifuged adipose tissue yielded maximal amounts of SVF cells, including ASCs.

Spray Diathermy Versus Harmonic Scalpel Technique for Hepatic Parenchymal Transection of Living Donor

BACKGROUND

Liver parenchymal transection is the most invasive and challenging part in the living donor operation. The study was planned to compare the safety, efficacy, and outcome of harmonic scalpel versus spray diathermy as a method of parenchymal liver transection in donor hepatectomy.

PATIENT AND METHOD

Eighty consecutive patients, who were treated by living donor liver transplantation (LDLT), were included in the study. The study population was divided into two groups according to the method of liver transection: group A by harmonic scalpel (HS) and group B by spray diathermy (SD). The primary outcome was the volume of blood loss during transection. Secondary outcomes were time of transection, number of ligatures needed during transection, pathological changes at cut surface, postoperative morbidities, cost, and hospital stay RESULTS: Blood loss during overall liver transection and in each zone was significantly less in the SD than in the HS group (P = 0.015). The number of ligatures was significantly less in the SD than in the HS group (P = 0.0001). The SD group had significantly higher level of serum bilirubin, serum glutamic pyruvic transaminase (SGPT), and international normalized ratio (INR) levels on postoperative day 3 than the HS group. Lateral tissue coagulation and hepatic necrosis are significantly less in HS group. The overall incidence of postoperative morbidities was the same in both groups. The cost was higher in HS group than SD group (US$760 vs. US$40 P = 0.0001).

CONCLUSION

Spray diathermy is an effective method of parenchymal transection with significantly lower blood loss and lower cost compared to HS with no increase in morbidity. HS is associated with earlier recovery of liver functions.

Experimental Hepatocyte Transplantation in Pigs

Technical issues of experimental hepatocyte transplantation in pigs, i.e., selection of animals, anesthesia, route of transplantation, and segment-specific transplantation have described.

The use of Reamer-irrigator-aspirator in the management of long bone osteomyelitis: an update

Purpose

Reamer–irrigator–aspirator (RIA) is an innovative device that its indications have recently been expanded to the management of long bone infections.

Methods

In this narrative review, we summarise the most important studies in the field and we present the current open questions pertaining to the use of RIA in the management of osteomyelitis of long bones.

Results

The relevant literature is sparse and low quality. Nevertheless, the use of RIA for infected cases has yielded promising outcomes in specialised centres. Technical aspects that merit special attention in osteomyelitis of long bones are its inapplicability in small diameter long bones, the inadequate debridement of wide metaphyseal areas and the potential bleeding sequelae. The use of RIA in open fracture management to reduce infection risk has not gained acceptance. The antibiotic impregnated nails and rods constitute a complimentary strategy for the management of infections.

Conclusions

The use of RIA for the management of long bone infections is an innovative and promising strategy. High quality studies are needed to shed light in its efficacy compared to conventional methods of management of osteomyelitis of long bones.

Advantages of the Ultrasonic Harmonic Scalpel for Radial Artery Harvesting

The aim of the study was to examine the safety and effectiveness of the Harmonic Scalpel® for reducing spasm caused by thermal injury during radial artery harvesting. The study sample included 100 candidates undergoing coronary artery bypass grafting. In half the patients, radial artery harvesting was performed using the ultrasonic Harmonic Scalpel equipped with coagulating curved shears and a 14 cm scissor-grip handle and in the other half, hemostatic clips, scissors, and minimal electrocautery were employed. Comparison of outcome between the groups showed that radial artery harvesting with the Harmonic Scalpel was associated with a shorter harvesting time, lower frequency of spasm, larger internal diameter of the radial artery graft, and a significantly reduced need for clips to control bleeding than the standard method. In addition, there were no cases of hematoma or superficial wound infection in the arm, and no postoperative reduction in soft touch sensation or objective pin-prick sensation. In conclusion, the Harmonic Scalpel provides excellent control of bleeding without the need for potentially damaging electrocautery, and with a markedly decreased use of hemostatic clips. Harvesting time is also shorter. The minimized thermal injury decreases the rate of radial artery spasm. Further studies using additional objective measures are currently underway to confirm these findings.

Histologic and Radiographic Comparison of Bone Scraper and Trephine Bur for Autologous Bone Harvesting in Maxillary Sinus Augmentation

PURPOSE

The aims of this study were to investigate the best two of five common methods of collecting autologous bone (preliminary study [PS]) and to test clinically the effects of autografts harvested using a trephine bur or bone scraper for sinus augmentation surgery (main study [MS]).

MATERIALS AND METHODS

In the PS, five autograft samples from five patients (n = 25) were harvested with a bone scraper, round bur, piezoelectric device, implant bur, and trephine bur and were processed for histomorphometric analysis. In the MS, sinus augmentation was performed on 20 patients using bovine-derived bone substitute and autograft collected with a trephine bur (group A, n = 10) or collected with a bone scraper (group B, n = 10). Narrow implants were also placed. At 6 months, changes in graft volume were evaluated with cone beam computed tomography. The amounts of regenerated bone, residual graft, and osseointegration of the implants were assessed histologically.

RESULTS

In the PS, the trephine bur and bone scraper harvested bone chips that were medium to large and more vital than those obtained with the other tools. In the MS, no significant differences were seen between groups in terms of the amount of residual biomaterial, regenerated bone, change in graft volume, and osseointegration.

CONCLUSION

Biologic differences between these two bone particulates may not influence regeneration and implant osseointegration in sinus augmentation when mixed with xenograft bone.

[DELAYED PORT DEPLOYMENT FOR HAND-ASSISTED LAPAROSCOPIC DONOR NEPHRECTOMY. CASE REPORT AND LITERATURE REVIEW]

The standard method of surgical treatment of end-stage renal failure is kidney transplantation. A laparoscopic method of organ retrieval from a living donor is currently preferred. The techniques of laparoscopic surgery include hand-assisted nephrectomy and "pure" laparoscopic nephrectomy. We present analysis of the literature data and our own data on the use of the advantages of each of the techniques. A case of complication associated with the use of hand-port from our own practice is described.

Volumetric comparison of three different innovative bone collecting devices for autogenous bone grafts

OBJECTIVE

The aim of this study was to evaluate the clinical relevance of three different bone collecting devices in a volumetric comparison.

METHOD AND MATERIALS

Bone harvesting for the collection of bone particles was performed on bovine mandibles. Three different types of bone collecting devices (Tests 1, 2, and 3) were used. Ten drilling sites in each group were prepared and bone particles were collected. Bone particles were sieved twice in sieves with 500 μm and 1,000 μm openings. The bone particles were divided into three groups: < 500 μm (SP), 500-1,000 μm (MP), and >1,000 μm (LP). Total wet volume, fractional wet volume, fractional dry volume, and weight were measured. The shape of the dried particles was examined using a microscope.

RESULTS

All particles in all three groups had a wood shaving-like appearance. With Test 1 and Test 2, LP were the most common (0.510 ± 0.064 mL, 0.430 ± 0.067 mL), and in Test 3, MP was the most common (0.112 ± 0.019 mL). Among the SP and MP, the wet volume of Test 3 was significantly greater than those of Tests 1 and 2 (P < .001). However, among the LP, the wet volume sequentially increased from Test 1, to Test 2, and Test 3 (P < .001). The proportion of dry volume was similar to that of wet volume.

CONCLUSION

Three innovative bone collecting devices could collect comparable amounts of bone particles to commercially available bone graft materials.

Retrograde reamer/irrigator/aspirator technique for autologous bone graft harvesting with the patient in the prone position

In recent years, the Reamer/Irrigator/Aspirator (RIA) system (Synthes, West Chester, Pennsylvania) has emerged as an extremely effective alternative in harvesting large volumes of autologous bone graft through reaming of the femoral intramedullary canal. The technique has been described in the literature as using an antegrade approach to the femur with the patient in the supine or prone position. It has also been described as a retrograde approach in the supine position. In this article, we describe a new technique-a retrograde femoral approach with the patient in the prone position. This technique allows for more efficient preparation by eliminating the need to reposition, reprepare, and redrape the extremity, thus decreasing operative time and risk of infection. Although we present this technique for use in ankle and hindfoot arthrodesis, we think it can be valuable in any prone-position procedure, including spine surgery.

The increasing role of epidermal grafting utilizing a novel harvesting system in chronic wounds

Skin grafting techniques range from harvesting full-thickness to split-thickness grafts to grafts containing only epidermis. All of these autologous tissues have their place on the reconstructive ladder. However, the use of full-thickness and split-thickness grafts as coverage over chronic wounds remains limited by a number of factors, including the need for anesthesia, a surgically trained physician, and an operating room in which to perform the procedure; pain and damage associated with the donor site; and severe patient comorbidities. Epidermal grafting offers an option for autografts and uses only a minimal amount of superficial epidermis from the donor site. Although successful use of epidermal grafting has been reported in pigmentation disorders, as well as burns and chronic wounds, previous harvesting methods have been described as cumbersome and time consuming. An automated epidermal harvesting system is now commercially available and involves a tool that applies both heat and suction concurrently to normal skin to induce epidermal micrograft formation. The new tool allows quick harvest and transfer of the epidermal micrografts at the bedside without anesthesia, with minimal donor site healing time and patient discomfort. The use of epidermal grafts in chronic wounds and the harvesting technique are reviewed here.

Increased osteogenic capacity of Reamer/Irrigator/Aspirator derived mesenchymal stem cells

INTRODUCTION

Donor-site morbidity, complications and availability remain concerns in autologous bone grafting today. The Reamer/Irrigator/Aspirator system (RIA) provides an alternative method to overcome these problems. According to literature, RIA graft possesses a higher osteogenic potency. This study compares iliac crest and RIA graft performance by determining their in vitro osteogenic capacity in a porcine model.

METHODS

Osteogenic capacity and cell content was determined in RIA and iliac crest bone grafts harvested from six female domestic white pigs. Cells initially washed off, and cells harvested with collagenase were analysed separately and in combination. Alkaline phosphatase expression (ALP) and cell numbers were evaluated after 7 and 14 days of culture. Matrix mineralisation was quantified after 14 days.

RESULTS

Cell cultures showed a significant increase of matrix mineralisation by RIA-derived cells compared to iliac crest bone graft (p = 0.0313). The yield of collagenase derived cells was increased in the RIA group and a synergy between washed off and collagenase derived cells was observed. Cell proliferation was similar in both groups.

DISCUSSION

The osteogenic differentiation capacity of cell populations isolated from the RIA derived bone graft surpasses that of iliac crest derived cells. It is proposed that the observed effect can be attributed to the origin of the cells and to the specific action of the RIA system. This study provides further evidence indicating that RIA bone graft provides superior osteogenic properties compared to iliac crest bone graft.

[Surgical technique of saphenous vein harvesting using a Cusco vaginal speculum]

We used Cusco vaginal speculum in harvesting saphenous vein graft (SVG) as an assist device for making a skin tunnel. After making 2 incisions of 3 to 4 cm, the SVG was dissected in a usual procedure. Then Cusco vaginal speculum was inserted into the skin tunnel between the 2 incisions. The SVG was dissected in a usual fashion under direct vision with the speculum. This procedure requires only small incisions, short learning curve and low cost. The new technique using Cusco vaginal speculum can be a reliable option for harvesting SVG.

Sequential harvesting of bone graft from the intramedullary canal of the femur

The effectiveness of using the Reamer/Irrigator/Aspirator (RIA) System (Synthes, Inc, West Chester, Pennsylvania) to obtain bone graft from the intramedullary canal of long bones for the treatment of bone defects and nonunions has been previously documented. However, there is nothing in the literature discussing the potential for reaming the same canal at subsequent surgeries. The authors detail their experience of 8 instances of sequential reaming in 7 patients. Six patients were harvested twice, and 1 patient was harvested 3 times. In each patient, the bone graft was obtained from the same canal. The main outcome measurements were time interval between reamings, reamer head size, indication for reaming, volume of harvested bone graft, and complications. Average volume of graft obtained in the first reaming procedure was 34 mL (range, 25-50 mL). After an average of 9 months (range, 3-16 months), the subsequent reaming was performed. Average volume of graft obtained in the second procedure was 45 mL (range, 28-65 mL). In the authors' series, no reaming-related complications were observed. The graft volume was the same or increased during the subsequent intramedullary reaming in all but 1 case, suggesting that the intramedullary canal is a potentially renewable source for bone graft. There were no complications related to the sequential reaming procedure. Overall, the authors' data suggest that sequential reaming with the RIA has the potential to safely and effectively provide a large quantity of bone graft on multiple occasions.

Harmonic Scalpel versus electrocautery and surgical clips in head and neck free-flap harvesting

We sought to determine the safety and utility of Harmonic Scalpel-assisted free-flap harvesting as an alternative to a combined electrocautery and surgical clip technique. The medical records of 103 patients undergoing radial forearm free-flap reconstruction (105 free flaps) for head and neck surgical defects between 2006 and 2008 were reviewed. The use of bipolar electrocautery and surgical clips for division of small perforating vessels (n = 53) was compared to ultrasonic energy (Harmonic Scalpel; Ethicon Endo-Surgery, Inc., Cincinnati, Ohio) (n = 52) free-tissue harvesting techniques. Flap-harvesting time was reduced with the use of the Harmonic Scalpel when compared with electrocautery and surgical clip harvest (31.4 vs. 36.9 minutes, respectively; p = 0.06). Two patients who underwent flap harvest with electrocautery and surgical clips developed postoperative donor site hematomas, whereas no donor site complications were noted in the Harmonic Scalpel group. Recipient site complication rates for infection, fistula, and hematoma were similar for both harvesting techniques (p = 0.77). Two flap failures occurred in the clip-assisted radial forearm free-flap harvest group, and none in the Harmonic Scalpel group. Median length of hospitalization was significantly reduced for patients who underwent free-flap harvest with the Harmonic Scalpel when compared with the other technique (7 vs. 8 days; p = 0.01). The Harmonic Scalpel is safe, and its use is feasible for radial forearm free-flap harvest.

Harvest of superficial layers of fat with a microcannula and isolation of adipose tissue-derived stromal and vascular cells

BACKGROUND

Adipose tissue is a source of stromal and vascular cells suitable for regenerative medical applications. Cell recovery depends on several factors, including the characteristics of the cannula used to harvest tissue.

OBJECTIVES

The authors assess whether aspiration of superficial layers of adipose tissue performed with a microcannula, rather than a standard cannula, allows for improved isolation of stromal and vascular cells, and they evaluate the angiogenic potential of the isolated cells in vitro and in vivo.

METHODS

Adipose-derived stromal and stem cells (ADSC) were collected from the lipoaspirate of the abdomen and hip regions of 6 healthy female donors. For adipose tissue harvest, several options were compared: (1) a rounded-tip cannula with a length of 170 mm, a diameter of 3 mm, and a single elliptic suction port on the side near its distal end (port diameter: 3 × 9 mm) or (2) a rounded-tip infiltration cannula with a length of 170 mm, a diameter of 2 mm, and 5 round ports placed spirally along the sides of the distal cannula shaft (each port diameter: 1 mm) (Shipper Medical Technologies Corporation, Centennial, Colorado). Isolated cells were characterized for (1) expression of the endothelial specific marker CD31 by immunohistochemical and cytofluorimetric analyses and (2) tubular-like structure formation using a 3-dimensional angiogenesis assay on Matrigel. Human ADSC were transduced to express firefly luciferase as a marker suitable for bioluminescent tracking and transplantation studies into immunosuppressed mice were performed.

RESULTS

ADSC yield was determined to be significantly higher in samples collected with the microcannula (P = .04). Moreover, isolated cells acquired typical endothelial-like morphology in vitro, formed capillary-like structures, and expressed the distinctive endothelial cell marker CD31. Cells implanted into immunosuppressed mice persisted for several weeks in areas undergoing neovascularization.

CONCLUSIONS

These results suggest that aspiration of adipose tissue with a microcannula can be a minimally invasive method to obtain clinically relevant numbers of stromal and vascular cells useful for autologous transplant procedures and for promoting tissue regeneration and neovascularization.

Follicular unit extraction hair transplant harvest: a review of current recommendations and future considerations

Alopecia affects many individuals worldwide. Owing to the large role that hair loss plays in self-image and self-confidence, an increasing number of these men and women seek options for hair restoration. Major considerations and sources of hesitation for strip surgical restoration are the visible linear scar, prolonged downtime, and other expected side effects of invasive procedures. These problems can be circumvented by smaller harvest approaches. However, the traditional punch harvest, which produces no linear scar, does leave patients with an often-unsatisfactory "doll hair" appearance. Follicular Unit Extraction (FUE) is a minimally invasive surgical procedure that utilizes a punch device to harvest occipital follicular units that are later transplanted in areas of loss to restore hair growth. FUE captures the benefit of multiple available restoration techniques and avoids the disadvantages of traditional strip surgery. A number of variations on the procedure are currently in practice and many more exciting advances are underway.

[Endoscopic saphenous vein harvesting with non-disposable device]

Endoscopic vein harvesting (EVH) for coronary artery bypass grafting has been proved to be effective in reduced wound complications, without compromising long-term mortality or composite of death, myocardial infarction and repeat revascularization. However, only disposable devices that are costly and raise environmental problems, have been obtained on the market in Japan. Now, a non-disposable device for EVH is available. With this equipment, a 50 cm-long great saphenous vein can be obtained with a single 3 cm-long incision. We demonstrate how to use this device and show its tips and pitfall.

Total anterior corneal surface and epithelial stem cell harvesting: current microkeratomes and beyond

Currently, most corneal lamellar allografts are performed by manually dissecting donor corneoscleral material for transplantation. Manual dissection is technically challenging and time intensive, and excessive handling of tissue may decrease the likelihood of obtaining viable grafts. These mechanical factors, along with problems controlling immune rejection, have prevented limbal stem cell lamellar allografts in particular from becoming more widely used. Anterior lamellar keratoplasty is gaining in clinical importance and usage but is still only practiced by a limited number of surgeons. Recently, new mechanical and femtosecond laser microkeratomes have been adapted to harvest the anterior corneal surface, including the limbal stem cell region. Preliminary results have been encouraging and give hope that this technique may prove to be of benefit to patients in the future.

Comparison of adipocyte viability and fat graft survival in an animal model using a new tissue liquefaction liposuction device vs standard Coleman method for harvesting

BACKGROUND

The use of autologous fat for augmentation has become common practice among plastic surgeons for both cosmetic and reconstructive procedures. Previously reported data suggest that the method of fat extraction can have profound effects on adipocyte viability and subsequent fat graft survival.

OBJECTIVE

The authors describe a pilot study comparing a new tissue liquefaction liposuction device (TLL; HydraSolve Lipoplasty System; Andrew Technologies, Irvine, California) with a standard syringe aspiration method with respect to adipocyte viability, fat graft survivability, and fat graft quality.

METHODS

Lipoaspirate from 5 patients was harvested using either TLL or the standard method. Samples were centrifuged and assayed for cell viability. All lipoaspirate samples were grafted into nude rats and harvested 42 and 84 days later. Graft survival and quality were assessed.

RESULTS

There was no difference in adipocyte viability between the lipoaspirate conditions. At 42 days, there was no significant difference in fat graft weight and the TLL grafts were more fibrotic than the standard control grafts, but this was improved with the increased centrifuge rate. At 84 days, fat grafts were equivalent with respect to graft weight and histology.

CONCLUSIONS

Lipoaspirate harvested with the TLL device and centrifuged at 3000 rpm resulted in fat grafts that were equivalent in weight and histology to those from lipoaspirate harvested with the standard syringe aspiration technique.

Endoscopic conduit harvesting and conventional conduit harvesting for coronary artery bypass graft surgery

Conventional conduit harvesting used for coronary artery bypass graft for many decades but there has been some wound complication problem. Endoscopic conduit harvesting is a minimal invasive surgery for reduced wounds complication. The authors aimed to compare the result between two techniques.

MATERIAL AND METHOD

Prospective enroll of 100 patients for elective coronary artery bypass graft surgery. Divided in 2 groups. The first groups was a convention conduit harvesting (C groups) and the second groups was endoscopic conduit harvesting (E groups). The endoscopic conduit harvesting performed using the Maquet Vasoview system under CO2 inflation assisted.

RESULTS

Endoscopic conduit harvesting was successful 94%. Harvest time C group 32.4 mins E group 48.9 mins, ET CO2 C group 40.3, E group 50.9, Wounds infection C group 6% E group O, wounds echymosis C group 6% E group 44%.

CONCLUSION

Endoscopic conduit harvesting showed better results with conventional conduit harvesting in wounds with serious complications but they need more harvest time and risk of CO2 embolism. However a long term graft patency needs more investigation.

Lung transplantation with uncontrolled non-heart-beating donor. Review

The discrepancy between organ availability and the increasing amount of patients on the waiting list has prompted the development of medical strategies to increase the usable organs, including the search for alternative sources of donation, organ optimization and extension of the criteria for donation. The recovery of lungs from non-heart-beating donors (NHBD) is a concept in which death is declared based on cardiopulmonary criteria rather than the currently used definition of "brain death." Obtaining NHBD lungs is currently practiced in many centers. In this review we discuss the current state of lung transplantation from uncontrolled NHBD.

A novel device for minimally invasive harvest of the sural nerve

The sural nerve is ideal for autologous nerve reconstruction. Traditional open harvest techniques result in a large prominent scar, delayed ambulation and poor patient satisfaction. Accordingly, we have designed a neurotome device to exclusively harvest the sural nerve as a safe and effective alternative to traditional techniques. Five patients underwent sural nerve harvest using our neurotome device. Scanning electron microscopy confirmed the preservation of histological nerve architecture when compared to nerves harvested by traditional open technique. Patients who underwent traditional open harvest of the sural nerve were asked to fill out a questionnaire to assess patient satisfaction. Ninety-three percent preferred a shorter scar, 20% complained of difficult ambulation, while 50% found troubling sensory deficits. Patients undergoing sural nerve harvest by our novel technique were satisfied with the cosmetic results and had less difficulty in ambulation. To optimize operative technique, cadaveric dissection of 15 limbs was done to further define the anatomic relationship of the sural nerve to the short saphenous vein. Minimally invasive harvest of sural nerve through our novel technique yields good cosmetic and functional results.

Complications following autologous bone graft harvesting from the iliac crest and using the RIA: a systematic review

Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the 'gold standard' and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device. We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis. Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant (p=0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection (p=0.016), haematoma formation (p=0.002), fracture (p=0.017), and hyperthrophic scar (p=0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain (p=0.004) and sensory disturbances (p=0.003) were significantly lower. The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate.

The mandibular retromolar area as a donor site in maxillofacial bone grafting: surgical notes

Bone harvesting from the mandibular retromolar area represents an attractive approach to obtaining corticocancellous bone blocks for reconstruction of a deficient alveolar ridge. Knowledge of the local anatomy, adherence to proper surgical techniques, and judicious use of appropriate surgical armamentarium are paramount to minimizing operative hazards. The objective of this article is to review pertinent surgical notes related to the safe harvesting of corticocancellous bone blocks from the retromolar area using a trephine bur technique.

Maquet Vasoview Hemopro VH-3000 vessel harvesting system may self-activate or fail to deactivate, potentially resulting in injury

The Harvesting Tool component of the Maquet Vasoview Hemopro VH-3000 vessel harvesting system may self-activate or may fail to deactivate, increasing the chance of thermal injury to the patient or staff, or of igniting a fire. Users of this product must be aware of the potential for either of the unintended activation problems to occur and must be familiar with Maquet's recommendations for dealing with the issue, which are provided in the system's instructions for use.

[Clinical application of a self-developed bone collector in dental implantation]

OBJECTIVE

To introduce a self-developed bone collector designed by the authors and evaluate its effect in clinical application.

METHODS

A self-developed bone collector was used in 38 patients who underwent the dental implant operation from May 2008 to October 2009. During the operation the bone particles were harvested, which was used for the reconstruction of the bone defects around the implant simultaneously. The defects were fenestrate in 29 regions and triangle in 23 regions on buccal or lingual side of the dental implants.

RESULTS

All cases had no surgical wound infection and dehiscence 7 - 10 days after operation. Three to six months after implantation, the X-ray showed that all the dental implants had perfect osseointergration and the alveolar bone were successfully augmented.

CONCLUSIONS

Bone debris harvested by self-developed bone collector could repair small peri-implant bone defects, which is simple to use in clinic.

Use of the novel ANSPACH bone collector for bone autograft in anterior cervical discectomy and cage fusion

BACKGROUND

The use of interbody cages with bone autograft following anterior cervical discectomy is well documented. The use of high-speed drills in the drilling of the posterior osteophyte results in the production of bone dust with viable osteophytes. We report the use of the ANSPACH bone collector device, which can be connected to standard suction circuitry and used to collect this bone dust.

METHOD/RESULTS

A group of six patients undergoing anterior cervical discectomies at one (4) or two levels (2). The bone collector was attached to the suction system. Following collection of the desired bone dust from the devices' collection chambers, it was fitted into the previously sized interbody cages and impacted into the disc spaces. The bone collector is a single-use, disposable device, delivered sterile, designed to connect to standard 6-mm suction tubing. The use of the bone collector provided sufficient bone material for complete filling of the interbody cages in all of the patients.

DISCUSSION

The use of autogenous cancellous bone material is the gold standard with regards to bone graft. The collection of bone dust during the use of high-speed drills has a number of applications and could provide a useful source of viable osteogenic material in spinal, cranial and craniofacial procedures.

CONCLUSION

The use of the ANSPACH bone collector incorporated into a standard suction system provides an efficient method of autograft collection, removing the need for an adjunctive procedure with associated donor-site morbidity.

[Anesthetic management for robot assisted off-pump construction of composite graft using the da Vinci surgical system]

Robot-assisted minimally invasive surgery has become common in recent years. We used the da Vinci surgical system and managed anesthesia in 6 cases of bilateral internal mammary artery dissection and construction of a composite graft using the radial artery. To ensure vision inside the thoracic cavity, endoscopic robotic surgery employs the inflation of the thoracic cavity with carbon dioxide, producing a pneumothorax and turning the thoracic cavity into a positive pressure chamber. Thus, marked acidosis and circulatory changes manifest during anesthetic management. Although robotic surgery is considered "minimally invasive, such surgery involves a number of problems in terms of anesthetic management, and these problems must be examined.

Description and validation of a navigation system for intra-operative evaluation of knee laxity

This paper describes the features of KIN-nav, a navigation system specifically dedicated to intra-operative evaluation of knee laxity, and assesses the reliability of the system during surgery. The acquisition protocol for its intra-operative use, the original user interface, and the computational methods for elaboration of kinematic data are described in detail. Moreover, an extensive and specific validation of the system was performed in order to evaluate its intra-operative performance and usability. KIN-nav's reliability and accuracy were analyzed in a series of 79 patients undergoing ACL reconstruction. The intra-surgeon repeatability computed for ACL-deficient and reconstructed knees at different flexion angles was less than 0.6 degrees for varus-valgus (VV) rotation, less than 1 mm for AP translation, and less than 1.6 degrees for IE rotation. The inter-surgeon repeatability is less than 2 degrees for VV rotation, 5 degrees for internal-external rotation, and less than 3 mm for AP translation. The proposed method was fast (requiring an additional 10 minutes of surgical time on average), required only a short learning period (5 cases), was minimally invasive, and was robust from the numerical perspective. Our system clearly shows that the use of navigation systems for kinematic evaluation provides useful and complete information on the knee state and test performance, and is simple and reliable to use. The good repeatability in manual kinematic tests is an improvement on the present ability to discriminate knee kinematics intra-operatively, and thus offers the possibility of better discrimination between knee pathologies and the prospect of new surgical applications.

The Healing of Free Gingival Autografts for Socket-seal Surgery: a Case Report

Tooth extraction will be followed by marked alterations to the tissue volume, in particular in the anterior zone, which may jeopardize the esthetic outcome of any dental treatment involving tooth extraction. If, however, ridge collapse can eb prevented or minimized after tooth extraction, more predictable outcomes with superior esthetics can be accomplished along with fewer surgical procedures. Therefore, it was proposed that stabilizing the soft tissue architecture with a free gingival graft could minimize the soft tissue shrinkage. The following case report describes some surgical modifications and refinements in order to enhance the predictability of the socket-seal surgery.

An analysis of partial width flexor tendon graft preparation on porcine models: the optimal split?

Partial width tendon grafts are commonly used in upper limb reconstructive surgery. Different techniques are described to harvest the graft including a "cheese wire" technique to split the tendon along its fibres with a filament. However no study has looked at the best material for this purpose. Fresh flexor tendons from pigs' trotters were used to analyse the splitting qualities of 11 different suture materials. The qualities assessed were: whether the suture material was successful in splitting the tendon, the average force required to split the tendon and the resulting quality of the spilt tendon graft. Whilst wire sutures produced a high quality of graft, they were awkward to use as they necessitated handling with a holder due to the higher forces required to split the tendon. Fibrewire provided the best result with respect to graft quality and ease of method as it combined the cutting strength of wire with the handling characteristics of a braided suture.

[Erythrocyte removal from bone marrow by density gradient separation using the COBE 2991 cell processor with the triple-bag processing set]

ABO-incompatible bone marrow transplantation requires red blood cell depletion. Lots of laboratory adopted the technique of density gradient centrifugation (Ficoll-hypaque) using the COBE 2991 cell processor with simple-bag processing set. However, tubing of this set is not adapted to the currently available peristaltic pumps. Moreover, two other sets are required: one for the buffy-coat and one for postgradient cell washing. We developed a method using triple-bag processing set to conduct whole-step procedure (concentration, Ficoll and washing). Peristaltic PVC tubing is provided in one line of the set allowing a safe processing without several connections thus reducing risks of microbial contamination. First, we used buffy-coat of total blood for training, then, we carried out red cell depletion of healthy bone marrow donors. The red blood cell depletion was 97.9+/-1.1% and CD34+ recovery was 89.6+/-8.7%. These results are very close to those obtained with the simple-bag set (red cell depletion.=94.0+/-6.8% and CD34+ recovery=95.9+/-20.3%). We conclude that the triple-bag system, very little used in France, is practical, simplified the manipulation and is more safety than the simple-bag set.

Harvesting technique using a mucotome and modified surgical procedure for root coverage with enamel matrix derivatives with and without a connective tissue graft

The aim of this clinical study was to evaluate the coverage of gingival recession defects with enamel matrix derivatives (EMD) with or without a connective tissue graft (CTG). Twenty-five patients (16 female, 9 male) from 16 to 58 years of age (mean: 32.2; SD: 11.2) with 92 gingival recessions (Miller Class I and II) and with at least 4.0 mm of clinical attachment loss were treated with a modified surgical technique for root coverage by CTG with EMD (45 recession defects) or EMD only (47 recession defects). Vertical recession depth, probing depth, clinical attachment level, dehiscence depth, width of keratinized gingiva (vertical), and recession coverage were recorded before surgery (baseline) and at 12 and 24 months. The average presurgical recession depth was 4.4 mm (SD: 1.3) with EMD and CTG versus 3.2 mm (SD: 1.1) with EMD only. Both treatment modalities led to a significant decrease in recession and a gain in attachment. Mean root coverage 12 months postoperatively was 92.7% (SD: 13.5) (EMD and CTG) versus 96.3% (SD: 11.5) (EMD only). Compared to the mean root coverage of recession after 24 months, the change was not significant. The results confirmed that the applied modified surgical techniques are safe and predictable, with better clinical outcomes at the donor and recipient sites.

Harvesting bone in the recipient sites for ridge augmentation

A modified ridge augmentation technique is introduced for augmenting deficient alveolar ridges in preparation for endosseous implant placement. The technique is based on the principles for guided bone regeneration, in which a created space is kept isolated from the surrounding soft tissues by a resorbable membrane with an excellent extended resorption profile, thus permitting the accrual of bone-formative elements into the graft site. The absorbable membrane is propped up by an autogenous mixture of native corticocancellous bone cores taken in the graft site and reduced to smaller particle sizes and osseous coagulum collected in bone traps and with a special bone scraper. The major advantage of this technique is that all the autogenous bone graft material is obtained from the actual graft site, avoiding second remote intra- or extraoral surgical sites and attendant morbidities. Ridges augmented with this technique permit optimal endosseous implant placement.

Orthogonal cutting of cancellous bone with application to the harvesting of bone autograft

Autogenous bone graft harvesting results in cell death within the graft and trauma at the donor site. The latter can be mitigated by using minimally invasive tools and techniques, while cell morbidity may be reduced by improving cutter design and cutting parameters. We have performed orthogonal cutting experiments on bovine cancellous bone samples, to gain a basic understanding of the cutting mechanism and to determine design guidelines for tooling. Measurements were performed at cutting speeds from 11.2 to 5000 mm/min, with tool rake angles of 23 degrees, 45 degrees and 60 degrees, and depths of cut in the range of 0.1-3.0 mm. Horizontal and vertical cutting forces were measured, and the chip formation process video recorded. Continuous chip formation was observed for rake angles of 45 degrees and 60 degrees , and depths of cut greater than 0.8 mm. Chip formation for depths of cut greater than 1.0 mm was accompanied by bone marrow extruding out of the free surfaces and away from the rake face. Specific cutting energies decreased with increasing rake angle, increasing depth of cut and increasing cutting speed. Our orthogonal cutting experiments showed that a rake angle of 60 degrees and a depth of cut of 1mm, will avoid excessive fragmentation, keep specific cutting energy low and promote bone marrow extrusion, which may be beneficial for cell survival. We demonstrate how drill bit clearance angle and feed rate can be calculated facilitating a 1mm depth of cut.

New Methodology and Instrumentation for Follicular Unit Extraction: Lower Follicle Transection Rates and Expanded Patient Candidacy

BACKGROUND

Follicular unit extraction (FUE), as described in the literature for harvesting follicular units, is technically demanding, has limited patient candidacy, and can potentially result in high rates of follicle transection. Although FUE has potential advantages, such as faster surgical recovery, less postoperative pain, less noticeable scarring, and possible expansion of the donor area, the acceptance of the technique is limited by the problems noted above. The proposed methodology and instrumentation may allow widespread adoption of FUE.

OBJECTIVE

To present the SAFE (Surgically Advanced Follicular Extraction) System, a new methodology and novel instrumentation for FUE. This article presents the efficacy of this methodology and addresses patient candidacy.

METHODS

Twenty-two patients undergoing standard strip excision were enrolled in a pilot study to assess follicle transection rates using the SAFE System. Based on the success of the pilot study, an additional 37 patients receiving a total of 6,947 grafts were examined. Transection rates were recorded, and patients were examined for complications or adverse reactions.

RESULTS

The average follicle transection rate was 6.14%, with a range of 1.7 to 15%. The only adverse reaction was the occurrence of two buried grafts, resulting in inflammatory subcutaneous cysts requiring excision.

CONCLUSION

It appears that the SAFE System provides the methodology and instrumentation to enhance current FUE techniques and expand patient candidacy. The transection rate of this method compares favorably with traditional microscope graft dissection. Physicians with a modicum of technical skills can use the technique, and there does not appear to be a significant adverse reaction rate.