A history of surgery in the instrument tray: eponymous tools used in hand surgery

Hand surgery emerged as a specialty after World War II, and early hand surgeons borrowed tools from established fields of the time. These tools remain in common use today, and many are identified by the names of the men who created them. Because these men did not specialize in surgery of the hand, their history remains obscure to modern surgeons who do. We have investigated the history of eponymous instruments developed before 1945 and used widely today in American hand surgery. Reflection on these eponymous instruments reveals the rich and diverse history of hand surgery.     

手部创面的细菌分布研究

目的 探讨开放性手外伤创面常见污染细菌的种类及敏感抗生素。方法 200例开放性手外伤，于急诊室、手术室刷洗创面后、清创后、关闭伤口前分四次取材，作细菌培养及药敏试验。结果 急诊室、手术室刷洗创面后，清创后及关闭伤口前的细菌检出率分别为71.5%（143／200）、74.0%（148／200）、33.5%（67／200）及25.50%（51／200）。术后伤口感染率为3.5%（7／200）。对环丙沙星及头孢噻肟敏感性最高。结论 开放性手外伤创面菌种分布广泛，以革兰氏阳性菌为主，彻底的清创及保持手术室常用器具的清洁是降低术后感染的有效措施。     

Hand Surgery in Different Countries: Hand Surgery in Japan

Japan has faced the most challenging times in the past. Through precise diligence by stalwarts and doyens of initial hand surgeons, it led an incredible path for the most significant moments of hand surgery. This article describes the early phase of development of Japanese Society for Surgery of the hand, substantial and innovative contributions from surgeons. A noteworthy and significant achievement in the hand surgery is microsurgery and its utilities for all hand-related diseases. The first replantation of the thumb, toe transfers and wrap-around flaps are the effective surgical techniques developed and imparted to the fellow hand surgeons worldwide. We had a particular interest in congenital hand surgery and developed a modification of congenital hand classifications and introduced many surgical techniques. Besides, we grew ourselves refining more in hand and microsurgery, innovating flexor tendon repair, peripheral nerve surgeries, wrist arthroscopy, joint replacements, external fixators, and implant arthroplasty for rheumatoid hand. We share our health care information, insurance working model and hand surgery training schedule in Japan.     

The relationship between hand size and difficulty using surgical instruments: A survey of 726 laparoscopic surgeons

Background: Hand size is an important variable to consider when designing hand tools. Laparoscopic surgical instruments have been reported to cause hand and upper extremity discomfort. This study investigates the correlation between surgical glove size, preexisting musculoskeletal problems, and difficulty using laparoscopic instruments. Methods: Approximately 11,000 questionnaires were sent to SAGES, AAGL, and AWS members. Questions included basic demographic and practice data, surgical glove size, the presence of musculoskeletal problems, and the perceived difficulty using several types laparoscopic instruments. There were 726 responses (from 159 women and 567 men). Subjects were grouped by hand size (Small 6.5, Medium 7.0–7.5, Large >7.5; female group only: Small 6.0, Medium 6.5, Large >6.5). ANOVA was used to test for differences between groups. Results: The percentage of time subjects reported having difficulty using all laparoscopic instruments was greater for the Small glove size group compared to both the Medium and Large groups (p < 0.001). In females, the scissors and staplers were more difficult to use for the Small and Medium glove size group compared to the Large group (p < 0.001). Subjects who reported musculoskeletal problems (n = 145) performed a significantly greater percent of laparoscopic cases and found the stapler and graspers difficult to use for a greater percentage of time than those not reporting problems (n = 559). Conclusion: Hand size is a significant determinant of difficulty using laparoscopic surgical instruments. Individuals using glove sizes 6.5 or smaller experience significantly more difficulty using common laparoscopic instruments, and in particular laparoscopic staplers. Manufacturers of surgical hand tools should consider hand size when designing future surgical instruments.     

Hand Surgery in Different Countries: Hand Surgery in Cambodia

As a lower middle-income nation, Cambodia has made significant improvements in basic health but hand surgery development continues to lag behind due to scarcity of trained and quality surgical manpower. Most of the hand surgery development locally has been due to surgical volunteers from Asia, Europe, and the United States. The introduction of a structured and systematic community-oriented hand surgery training over a 5-year period was successful in producing local surgeons to meet the basic needs of hand surgery patients. Brachial plexus surgery has benefited significantly, with local surgeons able to independently manage cases with minimal support. With the expansion of local surgical manpower and guidance, motivation, and assistance of regional hand surgeons, the future of hand surgery in Cambodia looks promising.     

MINIMAL ACCESS GASTRODUODENAL SURGERY

Considerable advances are occurring in the application of laparoscopic techniques to gastrointestinal and hepatobiliary disorders. Following studies in experimental animals, surgeons with an interest in gastroduodenal disease have now introduced laparoscopic techniques into current surgical practice. Elective intervention for peptic ulcer disease is currently being established, particularly in patients with proven negative Helicobacter pylori (HP) status, or when eradication has proved unsuccessful with various drug regimens. In addition, emergency laparoscopic intervention for perforation is gaining acceptance, with or without a definitive anti-ulcer procedure. Therapeutic endoscopy for bleeding peptic ulcer may well be followed by anti-ulcer laparoscopic surgery in selected patients. Laparoscopic techniques have been utilized for the treatment of Mallory Weiss tear, congenital hypertrophic pyloric stenosis, Dieulafoy's lesion, gastric trauma or volvulus and benign gastric tumours. More ergonomic instruments are required before laparoscopic gastric resection becomes more widely acceptable. It is essential that objective evaluation of variations on vagotomy themes be undertaken in prospective clinical trials and that the safety and efficacy of gastric resection procedures be substantiated if this renaissance is to revolutionize gastroduodenal surgical practice.     

Community-Acquired Methicillin-Resistant <Emphasis Type="Italic">Staphylococcus aureus</Emphasis> in the Suburban Hand Surgery Patient Population

Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause for patients to present to a physician’s office or emergency department. We observed increasing numbers of community-acquired MRSA infections in patients admitted to the hand surgery service at our suburban academic center. It is an important issue as unsuspected community-acquired MRSA hand infections can be admitted to the hospital, inadequately treated, and allowed for nosocomial spread. This study was performed to examine the trend in the incidence of community-acquired MRSA infections in patients admitted to the hand surgery service in order to sensitize practitioners to have a high index of suspicion for this entity and promote early recognition and treatment of this organism. A multihospital retrospective chart review was undertaken to compare the total number of community-acquired MRSA infections in our hospital as well as the number in patients admitted to the hand surgery service with community-acquired MRSA from 2000 through 2008. Statistical analysis was provided by linear regression. Two community-acquired hand MRSA infections were treated in 2000, as compared to three in 2001 and 2002, four in 2003, five in 2004, six in 2005, 14 in 2006, 13 in 2007, and ten in 2008. This increase was statistically significant (p = 0.038). This retrospective review documents a rapidly rising number of community-acquired MRSA hand infections in the suburban environment. The hand surgeon must be aware of the increased prevalence of this entity to adequately combat this organism and prevent prolonged hospital stays, expanded morbidity, and inflated treatment costs.     

A protocol for wide awake local anaesthetic no tourniquet (WALANT) hand surgery in the context of the coronavirus disease 2019 (COVID-19) pandemic

There are new and unique challenges to emergency surgery service provision posed by the Coronavirus disease 2019 global pandemic. It is in the best interests of patients for care providers to streamline services where possible to maximise the number of cases that can be performed by limited surgical and anaesthetic teams, as well as minimising patient interactions and admission times to reduce potential spread of the virus.There is evidence that wide awake local anaesthetic no tourniquet (WALANT) hand and upper limb surgery can meet this need in a number of ways, including reduced pre-operative work up, the lack of a need for an anaesthetist or ventilator, shorter inpatient stays and improved cost efficiencies.Though updated national guidelines exist that advocate increased use of WALANT surgery in response to the pandemic there are not yet clear protocols to facilitate this.We outline a protocol being developed at one UK Major Trauma Centre tailored to the expansion of WALANT hand and upper limb emergency surgery with particular emphasis on facilitating timely surgical care while minimising healthcare encounters pre and post-operatively. This will serve to reduce potential transmission of the virus and create cost efficiencies to free funding for COVID-19 related care.Our protocol is easily replicable and may be of benefit to other centres dealing with emergency upper limb surgery in the new climate of COVID-19.     

SINGLE-INCISION VIDEOLAPAROSCOPIC APPENDECTOMY WITH CONVENTIONAL VIDEOLAPAROSCOPY EQUIPMENT

Background

Acute appendicitis is the most common surgical emergency in daily practice, and is approached laparoscopically in many centers. Efforts have been undertaken for the development of minimally invasive techniques that reduce tissue trauma and offer improved cosmetic results, one of such being the single-incision laparoscopic surgery (SILS).

Aim

To present a minimally invasive technique for appendectomy (SILS) undertaken with conventional instruments.

Method

Eleven patients were treated in the emergency care center presenting abdominal pain in the right iliac fossa that was suggestive of appendicitis. Diagnostic investigation was subsequently conducted, including physical examination, laboratory and imaging exams (CT scan with intravenous contrast or total abdominal ultrasound), and the results were consistent with acute appendicitis. Thus, after consent, these patients underwent SILS appendectomy under general anesthesia with three trocars (two 10 mm and one 5 mm), using conventional and optical laparoscopic tweezers (10 mm, 30º). The base and pedicle of the appendix were ligated with titanium LT 400 clips. The procedure occurred uneventfully. Inclusion criteria were absence of diffuse peritonitis, BMI (body mass index) less than 35 and absence of serious comorbidities or sepsis.

Results

Seven men and four women were operated with average age of 25.7 years and underwent appendectomy through this technique. Mean procedure duration was of 37.2 min. Regarding surgical findings, three had appendicitis in stage 1, four in stage 2 and four in stage 3. All patients improved well, without surgical complications, and did not require conversion to open surgery or conventional laparoscopy technique.

Conclusion

Appendectomy conducted through Single Incision Laparoscopic Surgery is a feasible and promising technique that can be performed with conventional laparoscopic instruments.     

In-use efficacy of a chlorhexidine in alcohol surgical rub: a comparative study

BACKGROUND: Although full surgical scrubs are performed prior to each case on an operating list, optimum regimens for hand cleaning have yet to be determined, and in-use efficacy evaluations are very limited. METHODS: A crossover study was undertaken comparing a chlorhexidine in detergent/alcohol regimen with povidine-iodine detergent scrub, within an orthopaedic operating environment. Depending on the skin asepsis regimen used, five surgical team members scrubbed or rubbed prior to each case for a complete operating list. Bactericidal efficacy was measured using the 'glove-juice' technique before and after hand asepsis, and at the completion of each case. RESULTS: The chlorhexidine regimen caused substantial and sustained reductions in hand bacterial counts (>50-fold prior to case 1) during surgical cases. Application of alcoholic chlorhexidine prior to each subsequent case reduced bacterial counts to the same level as the original scrub. In contrast, the povidine-iodine scrub reduced counts <3-fold prior to the first case and <2-fold in subsequent cases. The chlorhexidine regimen also resulted in persistent bactericidal effects between cases, as counts prior to application of cases 2 and higher were significantly lower than prior to case 1 (>7-fold for case 2 vs case 1). CONCLUSIONS: The chlorhexidine regimen demonstrated excellent bactericidal efficacy throughout an operating list, and was superior to povidine-iodine scrubbing in all aspects. The alcoholic chlorhexidine regimen is simpler and should have wide surgical application.     

Colorectal surgeons should be open to modern surgical technologies for challenging cases

Today, colorectal surgeons globally are practicing in an exciting era where surgical technologies are constantly emerging. Most of these cutting‐edge technologies are readily available in Australia and New Zealand at present. Thus the ‘modern surgeon’ should always be defined by this open‐minded attitude towards these new and emerging surgical technologies. This review article highlights current modalities that we have been using in our north‐Brisbane public and private hospitals for cases predicted to be technically challenging using minimally invasive approaches for most of them. We examined the current evidence regarding the following modalities and critiqued their use in clinical practice: lighted ureteric stents, minimally invasive surgery approaches of laparoscopy and robotic surgery, pressure barrier insufflation devices, 3D camera systems, hand‐assist device ports and indocyanine green dye fluorescence angiography. The objective of this review paper is to alert colorectal surgeons to new surgical technologies available to them, to encourage colorectal surgeons' familiarization with these many technologies, and to support evidence‐based consideration for the clinical use of such. These technologies should be supplemental aides to the safe, oncologically adequate and efficient operation that they already routinely perform.     

Can Brief Interventions by Hand Surgeons Influence Medical Students Toward a Career in Hand Surgery?

PURPOSE: In 2004, the American Society for Surgery of the Hand and the American Association for Hand Surgery formed a joint task force to deal with the difficulty of promoting hand surgery as a career choice to medical students. The purpose of this study was to use a previously validated format to expose medical students to a brief intervention early in their medical education that might influence their perceptions of hand surgery as a career choice. METHODS: First-year medical students were asked to rank 11 items on a Likert scale from 1 (not important) to 5 (very important) regarding their beliefs about hand surgery as a career before and after a brief 1-hour presentation by a hand surgeon. Additional information about career choice and prior exposure to hand surgery was obtained before the intervention, and student interest in hand surgery was measured after the intervention. RESULTS: Of 110 first-year medical students, 72 (65%) students completed both the pre-lecture survey and the post-lecture survey. Of the 72 students with matched responses, 8 (11%) ranked surgery as their first career choice, whereas 13 (18%) ranked a surgical subspecialty as their first choice. Thirty-nine (54%) students stated that the lecture raised their interest in hand surgery as a possible career, and 36 (50%) were interested in doing an elective in it while in medical school. Nonparametric tests showed improvement in knowledge after the lecture for length of training, technical aspects, intellectual challenge, and fellowship requirements. CONCLUSIONS: A positive information-providing encounter with a hand surgeon may favorably influence the perceptions of first-year medical students toward hand surgery.     

A novel technique of finger-assisted laparoscopic surgery

BACKGROUND: Although advanced and complex laparoscopic procedures are now being performed, tactile sensation is limited with available laparoscopic instrumentation. For immediate hemostasis, it sometimes is necessary to convert laparoscopic into open surgery. METHODS: We improved the procedure with the aid of an abdominal wall sealing device, a Lap protector, and a surgical grove. With this simple apparatus, we can easily switch from laparoscopic to open surgery and vice versa. RESULTS: Only 4 cm of skin incision was made. The operator can use his or her finger and most of the usual surgical instruments during the laparoscopic surgery. CONCLUSIONS: Finger-assisted laparoscopic surgery is affordable to perform the advanced laparoscopic procedure. This new technique made laparoscopic abdominal surgery easier and safer for beginners in laparoscopic surgery and skilled surgeons in open surgery. For the experts, this technique set up the safety door for the emergency in laparoscopic surgery.     

Economic analysis in hand surgery

Economic analysis is a method for allocating resources among competing alternatives. Four techniques commonly used in an economic analysis are cost-minimization analysis, cost-effectiveness analysis, cost-benefit analysis, and cost-utility analysis. These analyses provide information to guide medical decisions and to set funding priorities. Understanding the differences between the techniques allows for better decision making. Although economic analysis is used widely in other fields of medicine, its use in studies of disorders of the hand has been sparse. Only recently has economic analysis been included in studies focused on the care of the upper-extremity patient. As such, to interpret the results of these studies better, hand surgeons need to understand the similarities and differences and the strengths and weaknesses of the different techniques. Such an understanding will allow hand surgeons to know when economic analyses are comparable. Furthermore it will aid them in providing their patients not only medically sound care, but also economically efficient care. This article provides a synopsis of the most widely used and accepted techniques for performing an economic analysis. The key concepts of each of the 4 techniques are shown by using the small number of studies that are available in the upper-extremity literature.     

Comparing sterile bag rubbing and paint on technique in skin preparation of the hands

Background: The aim of this study was to compare two techniques for surgical site skin preparation in hand surgery. Methods: We compared the standard sponge paint technique versus a plastic bag immersion technique using a 10% povidone–iodine with alcohol solution (Betadine, ORION Laboratories Pty Ltd, Balcatta, WA, Australia) to prepare surgical site skin for hand surgery. This sterile bag rubbing technique involves using a sterile plastic bag filled with 60 mL of Betadine solution to immerse the subjects' hand. Samples were taken from 10 subjects for bacteria colony‐forming unit (CFU) counts before and 3 min after surgical site preparation in each group. Outcome measures were preparation time and CFU reduction with a plate impression test using commercially available agar slides. Results: The sterile bag rubbing technique significantly reduced (P < 0.0001) the time required for surgical site skin preparation (28 s) compared with the standard technique (86 s). Both techniques were found to have similar efficacy in the reduction of CFU. Conclusions: The sterile bag rubbing technique is a quicker alternative method for surgical site preparation in hand surgery and has comparable efficacy to the widely practised standard paint‐on technique.     

The cutaneous innervation of the dorsal hand: detailed anatomy with clinical implications

PURPOSE: Detailed knowledge of the anatomy of the cutaneous innervation to the dorsal surface of the hand is valuable information. Because surgical access to the wrist often is obtained via the dorsal skin it would be helpful particularly to delineate an area where surgical incisions would not injure underlying nerves. METHODS: Thirty cadaver forearms were dissected carefully to examine in detail the anatomy of the lateral antebrachial cutaneous nerve, the superficial branch of the radial nerve, and the dorsal branch of the ulnar nerve. Each hand then was evaluated for an area free of any major nerve branches over the dorsal wrist. RESULTS: Although the innervation to the dorsal hand varies certain patterns exist. The innervation pattern between the superficial branch of the radial nerve and the dorsal branch of the ulnar nerve is distributed evenly, dual innervation is frequent between the 2 nerves, and the lateral antebrachial cutaneous nerve is a common contributor to the innervation of the thumb. The superficial branch of the radial nerve and the dorsal branch of the ulnar nerve have identifiable branching patterns and have been classified according to a system developed for this study. CONCLUSIONS: Two classification systems based on detailed dorsal hand cutaneous innervation patterns can be used to specify the placement of a safe dorsal skin incision away from major nerve branches.     

Retained surgical sponges,needles and instruments

Introduction

Retained sponges and instruments (RSI) due to surgery are a recognised medical ‘never event’ and have catastrophic implications for patients, healthcare professionals and medical care providers. The aim of this review was to elucidate the extent of the problem of RSI and to identify preventative strategies.

Methods

A comprehensive literature search was performed on MEDLINE^®, Embase™, the Science Citation Index and Google™ Scholar for articles published in English between January 2000 and June 2012. Studies outlining the incidence, risk, management and attempts to prevent RSI following surgical intervention were retrieved.

Results

The overall incidence of RSI is low although its incidence is substantially higher in operations performed on open cavities. Sponges are the most commonly retained item when compared with needles and instruments. Clinical presentation is varied, leading to avoidable morbidity, and the error is indefensible medicolegally. Risk factors include emergency operations, operations involving unexpected change in procedure, raised body mass index, and a failure to perform accurate sponge and instrument counts. The existing strategy for prevention is manual counting of sponges and instruments undertaken by surgical personnel. This, however, is fallible. Computer assisted counting of sponges using barcodes and gauze sponges tagged with a radiofrequency identification device aiding manual counting have been trialled recently, with success.

Conclusions

Vigilance among operating theatre personnel is paramount if RSI is to be prevented. Prospective multicentre trials to assess efficacy of new technologies aiding manual counting should be undertaken if this medical error is to be eliminated completely.     

Comparison of instruments to assess hand function in children with radius deficiencies

PURPOSE: For treatment evaluation of children with radius deficiencies (RDs), standardized assessment of hand function in performing activities is required. Instruments to measure hand function have been developed for other diagnoses. The current study aimed to find additional evidence for validity, reliability, and usefulness of these instruments for children with RDs. METHODS: In this study, 20 children with RDs (aged 4-12 years) participated; 16 were boys, and 13 children were unilaterally affected. Children were assessed using the Assisting Hand Assessment, the Unilateral Below Elbow Test, the Prosthetic Upper Extremity Functional Index, and ABILHAND-Kids. Construct and convergent validity of the instruments were studied focusing on predefined hypotheses and relationships with other instruments and the therapist's global assessment. Test-retest reliability was assessed in 10 children by means of the intraclass correlation coefficients and the smallest detectable differences. RESULTS: For children with RDs, the Assisting Hand Assessment and the Prosthetic Upper Extremity Functional Index appeared to be the most valid function test and questionnaire according to the relationships found with type of RD, functional hand grips, and the therapist's global assessment of hand function. Regarding test-retest reliability, intraclass correlation coefficients ranged from 0.82 to 0.91, and smallest detectable differences were acceptably small. CONCLUSIONS: The current results contribute to the evidence that the instruments, especially the Assisting Hand Assessment and the Prosthetic Upper Extremity Functional Index, provide valid and reliable results in children with RDs. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic I.     

Hand Surgery in Different Countries: Hand Surgery in New Zealand

Hand surgery in New Zealand has steadily grown from its origins in plastic surgery and orthopaedic surgery into its own discipline. There has been much progress and innovation in hand surgery that has originated from New Zealand and this review acknowledges the historical figures and events that have led to our present position. The current and future directions of hand surgery in our country are also discussed. As a small and remote country, we are very fortunate to have close relationships with other international hand societies. Through these relationships and the efforts of committed regional hand surgeons, the art and science of hand surgery in New Zealand continues to progress.     

Can Open Hand Injuries Wait for Their Surgery in a Tertiary Hospital?

Objective  Open hand injuries are routinely admitted and planned for surgery acutely, competing with other surgical emergencies. This retrospective study aims to evaluate if a delay in timing to surgery for open hand injuries led to an increased rate of infection. Materials and Methods  All patients who sustained open hand injuries and underwent semi-emergent day surgery from January 1, 2015 to December 31, 2016 were included. Outcome of postoperative infection was analyzed against demographic data, injury details, and delay from trauma to therapy. Results  There were 232 cases (91% males) included, with 92.0% performed under local anesthesia. Deep seated postoperative infection was seen in 1.3%, which was not significantly associated with delay to surgery. Conclusion  We had comparable infection rates as compared with published literature. Delayed timing of surgical treatment in open hand injuries was not associated with increased rates of deep-seated infection. Managing open hand injuries as semi-emergent surgeries may be acceptable given the low infection rates.