Atlas Of Surgical Techniques In Trauma

[Dot Liljenquist]

Thisthoroughly revised and expanded atlas is the ideal reference for residents, fellows, and clinicians to review surgical procedures before entering the operating room. The authors provide step-by-step descriptions of techniques, clearly delineating indications and contraindications, goals, operative preparation and anesthesia, and postoperative management. The main focus of this book is on teaching neurosurgical techniques at the most detailed level.

This book should be read cover to cover by young practitioners several times during their residency, and it will keep more experienced neurosurgeons up-to-date on the latest surgical techniques in the field.

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This atlas is the collaborative work of surgeons from Latin America and North America and describes techniques that can aid in the treatment of trauma patients. Trauma surgeons need to perform procedures efficiently and expeditiously for patients that are crashing. The surgeries and exposures are narrated by experts in the field, and include pitfalls and complications, as well as ways to avoid and treat them. Detailed illustrations add clarity to each procedure and help surgeons improve their technique when treating trauma patients.

Brainlab is committed to software innovation and, over the last decades, has continuously refined spinal and trauma surgical navigation. This focus on core competencies has resulted in powerful and innovative navigation and visualization technology that helps surgeons effectively plan and execute spine procedures and place pedicle screws more accurately. Compared to conventional surgical techniques, our technology also helps minimize X-Ray exposure.

The basis for accurate and reliable digital spine surgery starts with the intelligence of our software. Brainlab Universal Atlas functions as the heart of modern spine surgery by providing software intelligence for automatic and enhanced planning and navigation features.

Brainlab Spine Navigation is suited for a wide variety of indications, such as tumors and deformities, as well as routine surgeries of cervical, thoracic and lumbar spine. Beneficial for both less invasive as well as open approaches, the software continuously tracks surgical instruments in relation to patient anatomy, helping surgeons to avoid critical structures. A broad range of image registration options and compatible imaging devices provides great freedom to the surgeon to tailor the surgical procedure.

The enriched intraoperative data provided to clinicians by Brainlab software have the potential to minimize complications, increase precision and improve patient outcomes compared to conventional surgery techniques.

With our vision for the future of digital spine surgery, Brainlab is expanding and diversifying our spine and trauma portfolio with robotic imaging and surgical assistance as well as mixed reality to support all spinal surgeries. Our ultimate goal is to provide powerful digital data, building the foundation to facilitate new possibilities for spine and trauma treatments and enhance outcomes for patients.

Minimally-invasive mitral valve surgery was introduced into the surgical routine by Alain Carpentier, one of the pioneers of mitral valve surgery, in 1996 (1). It was at this time that minimally-invasive access was also performed at the Leipzig Heart Center for the first time. Since then, this technique has become routine at our institution with an annual number of up to 400 cases (2). It has been shown to be a safe technique not only in patients with impaired left ventricular function (3) and in patients of advanced aged (4), but also in selected patients who have had a previous sternotomy (5). In the majority of cases, the mitral valve is operated under direct vision. However, some cases are performed using pure videoscopic vision, as it has been promoted by Hugo Vanerman and others (6).

The goal of minimally-invasive mitral valve surgery is to perform the operation with the same high repair rate compared to conventional mitral valve surgery through a median sternotomy and without putting the patient at a higher surgical risk. Avoiding sternotomy has major advantages for the patient, such as decreased surgical trauma and therefore improved recovery, less postoperative pain and improved cosmesis. These issues are of major importance for patients. There are, however, specific contraindications to this access, which have to be taken into account. In particular, a heavily calcified mitral valve annulus or severe annular abscess formation with the need to perform extensive annular reconstruction techniques should necessitate a conventional approach. Previous right chest surgery with severe adhesions of the right lung to the chest wall is an additional contraindication to minimally-invasive access. In addition, aortic valve regurgitation >I is in our experience also a reason to perform a conventional sternotomy, in order to avoid insufficient administration of cardioplegia.

The first additional incision should be positioned anteriorly in a safe distance to the right internal thoracic artery. This incision will be used for the holder of the left atrial retractor blade and may also be used for getting the cardioplegia line/root vent out. The incision for the cross-clamp should be directed towards the ascending aorta, without putting any force onto the aorta after the left atrium has been retracted. Care must be taken to avoid interference with the camera, which should be inserted anterior and superior to the cross-clamp, achieving a direct view of the mitral valve. One or two of these additional incisions can be used later for getting the chest drains out.

Following incision of the pericardium about 3 cm above the phrenic nerve, pericardial retraction sutures may be applied and brought out laterally. Using a purse string suture, a needle vent is brought into the aortic root for application of cardioplegia and later venting of the aortic root.

After aortic cross clamping, the left atrium is entered through the interatrial groove. It is advisable to apply the cross-clamp during a short duration of complete circulatory arrest to avoid the potential risk of aortic dissection. The left atrium is lifted up using a retractor blade, which is available in different sizes and lengths. In some cases, the blade used for pushing the diaphragm away can also be used to improve visualization of the mitral valve by pushing the inferior part of the left atrial incision downwards.

After assessing mitral valve pathology, adequate lengths of premanufactured Gore Tex loops are placed onto the specific papillary muscle (PM). The lengths of the loops are calculated using a special measuring caliper. The measuring device is placed onto the tip of the relevant PM and at the free edge of the leaflet to measure the adequate length of the neo-chords. On average, the mean length for the posterior leaflet is between 12-14 mm and for the anterior leaflet between 22-24 mm. Each set of neo-chords is composed of four loops, which are anchored to the specific PM by getting two sutures through the muscle, which are then knotted over two teflon pledgets. The free edges of the loops are then positioned at the corresponding free edges of the leaflets using an additional 4-0 Gore suture for each loop. It is important to anchor the loops in the body of the PM to prevent tearing of the loops and to grasp enough leaflet tissue. If less than four neo-chords are necessary, two loops may be sutured to the leaflet at once. The maximum number of loops is therefore 16, with eight loops to each leaflet and eight loops coming from each PM. For a simple posterior leaflet prolapse P2, loops in the majority of cases coming from the postero-medial PM are enough to accomplish an adequate reconstructive result.

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