Surgical technology international
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Different factors (strategic, anatomical, instrumental, etc.) can cause difficult surgical situations, especially in bariatric surgery. In a difficult surgical situation, the surgeon faces a dilemma as to whether to continue the intended operation "at all costs" or to deviate from the initially planned surgical procedure to some alternative technique or procedure. The dilemmatic nature of the difficult surgical situation in bariatric surgery has motivated us to discuss the following aspects because they all contribute to the problem: standards in bariatric surgery, deviation from standards, the role of experts, and the focus of research. ⋯ We discuss the establishment of a registry of difficult surgical situations including the possibilities of deviating from the standard. Scientific analyses of such registries should focus on patients with apparent modifications in treatment (process deviations), but might also look at those with surprisingly good or bad results (outcome deviations). The technical steps of laparoscopic adjustable gastric banding (LAGB) have been chosen to illustrate this concept.
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Laparoscopy was considered marginal to surgical specialties before 1990. Rare innovations in instruments were done. With the realization of the first laparoscopic hysterectomy, this surgical route gained wide acceptance during the 1990s. ⋯ Also, it is useful to avoid carbon dioxide leakage at the vaginal opening and to retrieve the surgical specimen. Each step is shown in a photograph with the specific hand movements corresponding to the manipulator's handling. We think that the use of manipulators during laparoscopic surgery is very useful and helps to reduce operative time.
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Concerns about blood loss and the safety of allogenic blood transfusion have led to the development of many transfusion options for lower extremity joint arthroplasty. Techniques for dealing with such blood loss include allogenic blood transfusion, autologous donation and transfusion, hemodilution, perioperative blood salvage, intraoperative cell savers, bipolar sealers, and pharmacological agents. A blood management strategy must consider both the patient and the surgical procedure, assess the transfusion risks, and formulate a plan to address them appropriately. ⋯ The purpose of this review is to report our opinion regarding the use of alternative blood management strategies and to discuss the possible advantages and disadvantages of each technique. The results of this review indicate that a patient-focused algorithm using one or more strategies such as preoperative administration of erythropoietin, preoperative autologous blood donation, use of a bipolar sealer, intraoperative blood collection and reinfusion, as well as postoperative reinfusion drains may reduce the need for allogenic blood transfusions in patients undergoing primary and revision lower-extremity joint arthroplasties. The authors believe that a patient-specific algorithm utilizing the aforementioned techniques can lead to a substantial decrease in morbidity and mortality and an overall cost saving for both patients and medical institutions.