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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Lisfranc injuries are not very common. Surgical options available for treatment of Lisfranc injuries have produced chronic pain and disability due to the damage to the articular surface, leading to early arthritis. We describe the technique of extra-articular fixation using dorsal plates for Lisfranc injury, avoiding any damage to the articular surface.
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Brain tissue retraction is frequently required to reach deep intra-axial lesions, and the quest for an ideal retractor that would protect the underlying brain tissue continues. Despite the availability of multiple retractors, the incidence of brain retraction injury remains high and has been reported to be 5% to 10%. A recently developed transparent tubular retractor appears to provide several advantages in surgery for deep intra-axial tumors and intracerebral hematomas. ⋯ Transparent tubular retractors provide a unique means of deep visualization and even force distribution at the retracted brain tissue. Although these retractors were originally designed for the removal of deep subcortical tumors, they may be used to access and evacuate intracerebral hematomas. In our experience, the use of tubular retractors allows one to achieve safe access to deep intracerebral lesions and decreases the rate of retraction-related complications.
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Neurophysiological investigations and neurosurgical procedures of the sacral plexus are not especially well developed, because the sacral plexus is difficult to access. Awareness that sacral radiculopathies may exist is still lacking and the incidence of these pathologies is widely underestimated. ⋯ Regarding the dramatically increased incidence of sacral radiculopathies, especially secondary to pelvic prolaps surgeries by blind mesh-material implantation, this field of pathologies has to come in the focus of medical interests. Also, physicians involved in pelvic pathologies/surgeries have to be trained in clinical neuropelveology.
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Despite the advancement of surgical techniques in endoscopic spine surgeries, treatment of central and paracentral disc herniations, especially disc extrusions and disc sequestrations, remains challenging. On the basis of our experience with treating disc tears, disc herniations, and other spinal diseases, we have developed a new technique we call the "between" technique. This technique involves positioning the opening of the endoscope access cannula at the edge of the targeted disc with half of the opening being positioned inside the disc and the other half positioned in the epidural space. ⋯ The technique is safe, effective, and easy to use. It has been proven particularly efficacious for the treatment of central and paracentral extruded disc herniations and sequestered disc herniations. The purpose of this Chapter is to describe this technique and introduce its application in removing central and paracentral disc extrusions and sequestrations.