Clinical assessment of a radiolucent cushion for mammography.

PURPOSE: To determine whether use of a radiolucent cushion could significantly decrease pain during screening mammography without compromising image quality or other technical factors. MATERIAL AND METHODS: 838 patients presenting for routine screening mammography were evaluated. The radiolucent cushions were placed on the compression surfaces of the mammographic equipment and were used while imaging the right breast. No pads were used while imaging the left breast. Patient age, hormonal status, compression force, and radiation dose values were collected on all patients. Each subject completed a visual analog pain scale (VAS) rating the degree of pain experienced with and without the cushions. All mammographic images obtained (CC and MLO views) were compared, side by side (cushioned versus non-cushioned) by the readers. RESULTS: Use of radiolucent cushions reduced pain by 10% or more in 66% (555/838) of women. Patients in this "benefited group" experienced an average pain reduction of 53%. No compromise of image quality was observed. Compression force and radiation dose values were highly correlated between the cushioned and non-cushioned sides. CONCLUSION: Two-thirds of women experienced a significant reduction of pain when the radiolucent cushions were used during mammography. Pain reduction was accomplished without any clinically significant change in compression force, radiation dose values, or image quality.

Transballoon trocar insertion during preperitoneal hernia repair.

Trocar insertion during laparoscopic preperitoneal hernia repair (TEP) can be troublesome because the space into which the trocars are inserted is smaller than that available for transabdominal approaches. Insertion of the trocars directly into the balloon used to dissect the preperitoneal space can facilitate this process. The insertion of a 5-mm trocar into the balloon does not usually result in balloon deflation, and a second trocar can be placed into the balloon as well. Removing the balloon, despite the trocars inside it, is straightforward, allowing the placement of a cannula at the balloon insertion site and initiation of the hernia repair.

Endoscopic technique for subfascial perforating vein interruption.

Surgical treatment of incompetent perforating veins of the lower leg performed openly carries considerable morbidity associated with wound healing. Newer minimally invasive techniques offer an effective treatment alternative that avoids the lengthy incisions of the classical subfascial ligation techniques. The authors report a simple and quick two-port endoscopic method for clipping incompetent perforating veins of the lower leg using commonly available endoscopic instrumentation. The technique is unique in its use of a balloon dissector to rapidly establish the subfascial working space.

Selected applications of balloon dissection.

Historically, balloons have been used in surgery for a variety of applications. Over the past decades, balloons have been used by surgeons for retaining means (Foley catheter), extraction and occlusion (Fogarty catheter), tamponade (Sengstaken-Blakemore tube) as well as other uses such as dilation and calibration. The pioneering efforts of Gauer and Kieturakis have broadened the use of balloons for a new surgical application - dissection. An important feature of balloon dissection is that it allows the surgeon to create a new operative working space in which a surgical procedure can be performed. Currently, a particularly useful working space is the region immediately outside the peritoneum, frequently termed the extraperitoneal space. A variety of procedures can be performed laparoscopically in the extraperitoneal space such as herniorrhaphy, bladder neck suspension, lymph node dissection, and varicocelectomy.

Monitoring Distal Extremity Perfusion with the Pulse Amplitude Monitor during Vascular Reconstruction.

One problem in vascular surgery today is the effective monitoring of blood flow to distal extremities before, during, and after a surgical reconstruction. Current methods of blood flow assessment such as periodic pulse palpation, skin signs, Doppler sounds, and capillary refill are neither continuous nor objectively comparable. Because of the qualitative nature of these methods, it is difficult to compare measurements taken by different people at different times, making a quick and appropriate response to changing perfusion requirements difficult. In order to address these problems, a system has been designed to monitor and document pulse amplitudes non-invasively. A pulse amplitude monitor system (Figure 1) consists of a pulse sensor and a waveform monitor (Impra, Tempe, AZ). The sensor (Figure 2) contains a piezoelectric film which is used to detect the slight mechanical oscillations of the arterial wall beneath the skin surface. This film is mounted on a compressible foam block which isolates the vibrations and maintains constant force on the skin. The sensor is taped over a distal pulse, typically that of the dorsalis pedis.

The guide-eye ureteral access system.

Equipping ureteral instruments with the guide-eye feature has expanded the instrumentation options available to urologists. The guide-eye facilitates repetitive instrument access, allows coordinated instrument combinations, and enhances sequential placement of a series of instruments. We believe this concept increases the safety and efficacy of our present instruments and clearly encourages innovative designs for the future.

Assessment of transmural force during application of vascular occlusive devices.

An in vivo system was established whereby the transmural forces exerted across the arterial wall during vascular occlusion were directly measured. Evaluation of various currently available vascular occlusive devices was conducted and transmural force transmission data were recorded. The clamps were classified according to their mechanical design characteristics. The magnitude of force required to obtain cessation of distal flow varied significantly among devices of differing mechanical design but correlated well when compared with clamps of similar design. This information was then compared with graded analysis of the degree of intimal injury created by these specific devices as assessed with scanning electron microscopy. The amount of transmural force exerted by each individual device correlated with the grade of intimal injury created by that device. We conclude that fundamental clamp design dictates the magnitude of applied transmural force, that force and the vectors of the application of that force are directly responsible for the degree of resultant intimal injury, and that the intima appears to possess an injury threshold of approximately 5 x 10(4) dynes/cm2. Intimal injury may determine success or failure of vascular surgical procedures; therefore it is prudent to seek the least traumatic means of vascular occlusion.

A new vascular clamp.

A new vascular clamp called the occluder pad is described. It has significant utility when used in a variety of anatomic sites in either normal or diseased vessels. It possesses suitable tractive and occlusive forces while minimizing the mechanical forces applied to the vessel walls.

Coaxial balloon dilation and calibration of urethral strictures.

New coaxial balloon dilators with standard urologic tip configurations have been designed for use in urethral strictures. Balloon dilatation provides several advantages over conventional dilatation of strictures including improved access and decreased mucosal trauma due to a low silhouette, adjustability of diameter and rigidity, decreased instrumentation, and facilitation of intermittent self-dilation by the patient. The instruments were evaluated in 51 strictures (41 patients) as both a dilator and a calibrator. All catheters were located across the stricture easily (although two required filiform attachments). All clinical goals were achieved, and no complications were identified. Two patients were started on a program of intermittent self-dilation after internal urethrotomy with good results. It is our initial clinical impression that slow, gradual dilation of strictures is superior to rapid, abrupt dilation. This can only be practically achieved with balloon dilators.