New Frontiers in Wide-Awake Surgery.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Explain the most important benefits of wide-awake surgery to patients. 2. Tumesce large parts of the body with minimal pain local anesthesia injection technique to eliminate the need for sedation for many operations. 3. Apply tourniquet-free surgery to upper and lower limb operations to avoid the sedation required to tolerate tourniquet pain. 4. Move many procedures out of the main operating room to minor procedure rooms with no increase in infection rates to decrease unnecessary cost and solid waste in surgery. SUMMARY: Three disruptive innovations are changing the landscape of surgery: (1) minimally painful injection of large-volume, low-concentration tumescent local anesthesia eliminates the need for sedation for many procedures over the entire body; (2) epinephrine vasoconstriction in tumescent local anesthesia is a good alternative to the tourniquet and proximal nerve blocks in extremity surgery (sedation for tourniquet pain is no longer required for many procedures); and (3) evidence-based sterility and the elimination of sedation enable many larger procedures to move out of the main operating room into minor procedure rooms with no increase in infection rates. This continuing medical education article explores some of the new frontiers in which these changes affect surgery all over the body.

Below-knee Amputation with Minimally Painful Injection of Tumescent Local Anesthesia.

We successfully performed minimally painful injection of tumescent local anesthesia to eliminate the need for the tourniquet and sedation for a below-knee amputation in a frail patient with multiple medical comorbidities in Mombasa, Kenya. Minimal pain injection of WALANT (wide awake local anesthesia no tourniquet) pure local anesthesia can be a good alternative for lower limb amputation in frail patients when safe sedation services are unavailable or unaffordable in many countries.

Clinically Important Pharmacologic Considerations for Wide Awake Local No Tourniquet (WALANT) Hand Surgery.

Understanding the clinically important pharmacokinetics (what the body does to the drug) and pharmacodynamics (what the drug does to the body) of medications utilized in surgery will help surgeons to utilize them more safely and effectively. The goal of this article is to provide an overview of these considerations for the two medications, lidocaine, and epinephrine, utilized in Wide Awake Local Anesthesia No Tourniquet (WALANT) upper extremity surgery. After review of this article, the reader should have a better understanding of lidocaine and epinephrine for tumescent local anesthesia, as well as adverse reactions and how to manage them.

The Medial Sural Artery Perforator Flap versus Other Free Flaps in Head and Neck Reconstruction: A Systematic Review.

The medial sural artery perforator (MSAP) flap is a versatile fasciocutaneous flap, and yet is less commonly utilized than other free flaps in microvascular reconstructions of the head and neck. The aim is to conduct a high-quality Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)- and Assessment of Multiple Systematic Reviews 2 (AMSTAR 2)-compliant systematic review comparing the use of the MSAP flap to other microvascular free flaps in the head and neck. Medline, Embase, and Web of Science databases were searched to identify all original comparative studies comparing patients undergoing head and neck reconstruction with an MSAP flap to the radial forearm free flap (RFFF) or anterolateral thigh (ALT) flap from inception to February 2021. Outcome studied were the recipient-site and donor-site morbidities as well as speech and swallow function. A total of 473 articles were identified from title and abstract review. Four studies met the inclusion criteria. Compared with the RFFF and the ALT flaps, the MSAP flap had more recipient-site complications (6.0 vs 10.4%) but less donor-site complications (20.2 vs 7.8%). The MSAP flap demonstrated better overall donor-site appearance and function than the RFFF and ALT flaps ( p = 0.0006) but no statistical difference in speech and swallowing function following reconstruction ( p = 0.28). Although higher quality studies reviewing the use of the MSAP flap to other free flaps are needed, the MSAP flap provides a viable and effective reconstructive option and should be strongly considered for reconstruction of head and neck defects.

Tips to Successful Flexor Tendon Repair and Reconstruction with WALANT.

WALANT has generated many changes that have improved flexor tendon repair and reconstruction in the last 10 years. Seeing awake unsedated educable patients move repaired reconstructed tendons during the surgery has changed how we do surgery and therapy in many ways for the better. This article offers many tips on how to get better results in using these new techniques with the help of WALANT.

Internal mammary vein diameter - Is the left side really smaller? A study of 105 bilateral free flap breast reconstruction patients.

INTRODUCTION: Autologous free flap breast reconstruction is currently considered as the gold standard in breast reconstruction as it provides a durable, natural result. The internal mammary vessels are the most commonly used recipient vessels in free flap breast reconstruction, and anecdotally we have often observed that the left internal mammary vein (IMV) appears smaller than the right IMV. The aim of this study is to compare the diameters of the right and left IMVs by recording the size of the venous coupler used on each side in a large series of bilateral free flap breast reconstructions. METHODS: We searched our free flap database for patients who had breast reconstruction between October 2018 and August 2021. Inclusion criteria for this study were bilateral breast reconstruction patients, where the internal mammary vessels were used. We used a paired t-test for statistical analysis of the data. RESULTS: A total of 105 patients who had bilateral breast reconstruction were included in this study. Their mean age was 48.4 years. The mean venous coupler size used on the right was 2.64 mm (SD 0.35), whilst the mean left IMV coupler size was 2.48 (SD 0.32). Using a paired t-test, the p value for the comparison of the right and left IMV size in the cohort was 0.00032, demonstrating a statistically significant difference. CONCLUSION: We have confirmed that the right IMV is larger in diameter than the left side, and demonstrated that this translates into a recordable practical difference in the coupler size used. Despite this, we experienced no venous congestion or flap failures in our left-sided flaps, indicating that the IMVs remain a safe choice of recipient vein.

Quadrant Excision of Benign Lesions: A Prospective Outcome Study of Pediatric Patients.

ABSTRACT: Serial excision is a commonly used technique for the excision of large lesions. The procedure in children is challenging due to different skin quality and unpredictable scar patterns compared to adults. Quadrant excision is a modification of serial excision. The authors report quadrant excisions in 3 pediatric cases with facial congenital melanocytic naevi in aesthetically challenging areas. Based on our results we recommend the use of this technique in similar cases.

Objective Scoring of Information Websites for Vascular Anomalies.

ABSTRACT: One of the challenging aspects of caring for patients with vascular anomalies has been the use of inconsistent terminologies which has resulted in inconsistencies with treatment, miscommunication between clinicians, and subsequently patient misinformation and confusion. In this study, we objectively assessed the quality of online information on vascular anomalies. Our results emphasize the crucial role of vascular anomaly services in the communication and provision of patient information.

Life expectancy in elderly patients following burns injury.

INTRODUCTION: Burn injuries commonly occur in vulnerable age and social groups. Previous research has shown that frailty may represent a more important marker of adverse outcome in healthcare rather than chronological age (Roberts et al., 2012). In this paper we determined the relationship between burn injury, frailty, co-morbidities and long-term survival. METHODOLOGY: Retrospective data collection from patients aged 75 with burns injuries, treated and discharged at Queen Victoria Hospital. The Clinical Frailty Scale (Rockwood et al., 2005) was used to calculate frailty at the time of admission. The expected mortality age (life expectancy) of deceased patients was obtained from two survival predictors. RESULTS: The data shows a statistically significant correlation between frailty score and complications and a statistically significant correlation between total body surface area percentage and complications. No significant difference was found between expected and observed age of death or life expectancy amongst the deceased (p value of 0.109). CONCLUSIONS: Based on the data from our unit, sustaining a burn as an elderly person does not reduce life expectancy. Medical and surgical complications, immediate, early and late, although higher with greater frailty and TBSA of burn, but do not adversely affect survival in this population.

Surrogate Outcome Measures for Corneal Neurotization in Infants and Children.

BACKGROUND: Corneal anesthesia is a rare and challenging condition, particularly in young children. The insensate cornea leads to abnormal epithelial cell metabolism and loss of trophic influences supplied by the corneal nerve fibers. This results in recurrent spontaneous epithelia erosion and eventual loss of sight. Corneal reinnervation is a definitive treatment option for neuropathic keratitis. The outcome measures in young children following corneal sensitization are different to adults as esthesiometry is unachievable. METHODS: The authors have undertaken corneal reinnervation in a young patient using a sural nerve graft. Surrogate measures suitable for pediatric patients were used for assessment of the outcome. RESULTS: Postoperatively there was evidence of improved corneal healing and function after 8 weeks. At 10 months postprocedure, the cornea was completely free of vascularization. CONCLUSION: Resensitization of the cornea using nerve grafts has previously been reported in older children and adults. This is the first time the procedure has been undertaken in a young child. Although the technique is still in its infancy with only 4 patients reported worldwide including our report, it seems to hold promise of improvement to this challenging cohort of patients.

Microtia and Social Media: Patient Versus Physician Perspective of Quality of Information.

INTRODUCTION: Previous research demonstrates that patients seek high-quality information on the World Wide Web, especially in rare conditions such as microtia. Social media has overtaken other sources of patient information but quality remains untested. This study quantifies the quality of information for patients with Microtia on social media compared with nonsocial media websites and compares physician and patient scoring on quality using the DISCERN tool. METHODS: In phase 1, quality of the top 100 websites featuring information "Microtia" was ranked according to quality score and position on Google showing the position of social media websites among other nonsocial media websites. Phase 2 involved independent scoring of websites on microtia compared with a patient group with microtia to test whether physicians score differently to patients with t test comparison. RESULTS: Social media websites account for 2% of the scored websites with health providers linking to social media. Social media websites were among the highest ranked on Google. No correlation was found between the quality of information and Google rank. Social media scored higher than nonsocial media websites regarding quality of information on microtia. No significant difference existed between physician and patient quality of information scores on social media and nonsocial media websites (p 1.033). CONCLUSION: Physicians and patients objectively score microtia websites alike. Social media websites have higher use despite being few in number compared with nonsocial media websites. Physicians providing links to social media on information websites on rare conditions such as microtia are engaging in current information-seeking trends.

How not to bite the bullet: A novel technique for intra operative handling of bullets.

Ballistic trauma caused by bullets can be fatal or cause serious injury. Despite the abundance in literature in management of bullet injuries, there is paucity in describing how the operating surgeon should handle the bullet intra operatively. Bullets are important pieces of evidence and evidence preservation becomes the responsibility of the surgeon. We suggest a novel technique in handling bullets intraoperatively which, to the best of our knowledge, has not been published before. We also suggest general recommendations in handling bullets intraoperatively.