TECHNICAL SECTION
Anal retraction sutures as an alternative to Lone Star® retractor R Durai, R Makhija Peterborough and Stamford Hospitals NHS Foundation Trust, UK
reproducible, simple and does not require any specialist equipment. In our experience, it is safer than the Lone Star®. Very occasionally, it may cause skin laceration that can be minimised by tying the sutures over a bolster of cotton gauze.
CORRESPONDENCE TO Rohit Makhija, E: [email protected]
Transinguinal laparoscopy during emergency open inguinal hernia repair BACKGROUND
Various anal retractors are available to facilitate retraction of the anus. Commonly used retractors include Parks’, Eisenhammer and Lone Star®. The Lone Star® retractor provides stable retraction without needing an assistant to hold it. We describe an alternative method when a Lone Star® is unavailable. TECHNIQUE
The patient is positioned appropriately for the operation (ie LloydDavies or jack-knife). Thick suture material such as size 0 polypropylene or silk is used to suture the perianal skin to the anal skin/ mucosa (Fig 1). The amount of perianal skin and anal mucosa that is included should be based on the size of the anal canal, the thickness of the skin/mucosa and the purpose of anal retraction. We use six sutures, corresponding to the even numbers of the clock (2, 4, 6, 8, 10 and 12 o’clock positions). DISCUSSION
Lone Star® retractors are very useful for anal retraction but the hooks may prick the surgeon or assistant while inserting or removing them. Sometimes it is hard to find them in operating theatres. The technique described here is not our invention: the senior author learnt it while working in Cleveland, OH, US. It is a useful technique, easily
PW Waterland, L Bone, M Zilvetti Worcestershire Acute Hospitals NHS Trust, UK CORRESPONDENCE TO Peter Waterland, E: [email protected]
On occasion, the contents of the hernia sac may slip back into the peritoneal cavity or it may not be possible to assess bowel viability adequately during emergency open inguinal hernia repair. In this situation, a simple tip is to establish pneumoperitoneum and perform laparoscopy through the deep ring or medial defect with a modified glove port. In the Trendelenburg position, a small Alexis® (Applied Medical, Rancho Santa Margarita, CA, US) wound protector is inserted through the defect, a glove is attached and two or three 5mm trocars are secured with Vicryl® (Ethicon, Somerville, NJ, US) through the digits. Insufflation of the abdomen allows the returned contents to be seen and assessed safely without the need for further abdominal access.
How to safely remove ceramic bearings from the metal shell without expensive tools or the risk of shattering A Memarzadeh, J Jeffery Queen Elizabeth Hospital, Kings Lynn, United Kingdom CORRESPONDENCE TO A Memarzadeh, E: [email protected]
BACKGROUND
Figure 1 Anal retraction sutures stitching the perianal skin to the anal mucosa
Removal of an intact ceramic bearing from a securely fixed acetabular shell during revision surgery can be very difficult. Removing screws before removal of the shell may be crucial. Breaking the bearing also results in considerable ceramic debris and stops employment of other bearing surfaces. Various techniques have been devised for this task. One technique is to hit the metal shell with hard blows, the resonation of which loosens the ceramic bearing. Despite such loosening, the bearings often sit almost flush with the shell, and are difficult to retrieve. Implant companies1 have devised specialised tools to remove ceramic bearings. However, such tools are expensive and can attract further loan charges if they are not deemed to be ‘essential instruments’ that should be purchased.
Ann R Coll Surg Engl 2015; 97: 476–479
477
TECHNICAL SECTION
Kocher forceps assisted pedicle screw insertion as an aid to the trainee spinal surgeon MK Shahid, AJ Marino Royal Wolverhampton NHS Trust, UK CORRESPONDENCE TO Mohammad Shahid, E: [email protected]
BACKGROUND
Figure 1 A Sterling punch is used to hit the metal shell of the acetabular component
The reported incidence of misplaced spinal screws using uniplanar fluoroscopic guidance varies widely.1 In addition to anteroposterior fluoroscopic screening, obtaining a true lateral image of the pedicles is the key to optimum screw placement but this can be difficult to achieve.2 When difficulties arise in identifying the endplates (such as in the presence of significant osteopenia, degenerative scoliosis or high body mass index), screws can be inserted with increased confidence with the technique described. We describe a simple technique to improve intraoperative pedicle visualisation for the trainee surgeon. TECHNIQUE
Kocher forceps are applied loosely to each of the two transverse processes of the vertebra to be instrumented and both are held together in position with a swab tie to avoid crushing the transverse processes (Fig 1). The image intensifier C-arm is adjusted until the two forceps are seen to overlap, thereby achieving a true lateral view with sharper definition of the pedicles (Fig 2). DISCUSSION
Figure 2 Suction from a pulse lavage gun is used to form a seal around the ceramic bearing
This technique enables quicker and easier ‘true lateral’ visualisation of the pedicles, especially in the setting of degenerative lumbar
TECHNIQUE
Our technique uses instruments available in all arthroplasty sets. Once adequate exposure of the entire cup is achieved, a Sterling punch is used to direct a forceful blow on the metallic shell only (Fig 1). Such action resonates the bearing and deforms the taper, causing loosening of the ceramic. The force must be applied to the metal shell only, and not the bearing, to avoid ceramic shattering. The tip from a pulse lavage gun, with integrated vacuum suction, is then used to create a seal around the periphery of the bearing. The suction creates a vacuum strong enough to pull the bearing out of the shell readily (Fig 2). We use this technique routinely when removing hard bearings from a securely fixed shell. DISCUSSION
We have described a reliable technique that allows for safe extraction of ceramic bearings without the risk of shattering or the high costs associated with the loaning/purchasing of specialised equipment.
Reference 1.
478
Zimmer. www.zimmer.co.uk/en-GB/hcp/hip/product/continuum-acetabularsystem.jspx. Accessed 18 May 2015.
Ann R Coll Surg Engl 2015; 97: 476–479
Figure 1 Spinal column sawbone model demonstrating placement of Kocher forceps on each transverse process to help facilitate fluoroscopic pedicle screw placement
Anal retraction sutures as an alternative to Lone Star® retractor R Durai, R Makhija Peterborough and Stamford Hospitals NHS Foundation Trust, UK
reproducible, simple and does not require any specialist equipment. In our experience, it is safer than the Lone Star®. Very occasionally, it may cause skin laceration that can be minimised by tying the sutures over a bolster of cotton gauze.
CORRESPONDENCE TO Rohit Makhija, E: [email protected]
Transinguinal laparoscopy during emergency open inguinal hernia repair BACKGROUND
Various anal retractors are available to facilitate retraction of the anus. Commonly used retractors include Parks’, Eisenhammer and Lone Star®. The Lone Star® retractor provides stable retraction without needing an assistant to hold it. We describe an alternative method when a Lone Star® is unavailable. TECHNIQUE
The patient is positioned appropriately for the operation (ie LloydDavies or jack-knife). Thick suture material such as size 0 polypropylene or silk is used to suture the perianal skin to the anal skin/ mucosa (Fig 1). The amount of perianal skin and anal mucosa that is included should be based on the size of the anal canal, the thickness of the skin/mucosa and the purpose of anal retraction. We use six sutures, corresponding to the even numbers of the clock (2, 4, 6, 8, 10 and 12 o’clock positions). DISCUSSION
Lone Star® retractors are very useful for anal retraction but the hooks may prick the surgeon or assistant while inserting or removing them. Sometimes it is hard to find them in operating theatres. The technique described here is not our invention: the senior author learnt it while working in Cleveland, OH, US. It is a useful technique, easily
PW Waterland, L Bone, M Zilvetti Worcestershire Acute Hospitals NHS Trust, UK CORRESPONDENCE TO Peter Waterland, E: [email protected]
On occasion, the contents of the hernia sac may slip back into the peritoneal cavity or it may not be possible to assess bowel viability adequately during emergency open inguinal hernia repair. In this situation, a simple tip is to establish pneumoperitoneum and perform laparoscopy through the deep ring or medial defect with a modified glove port. In the Trendelenburg position, a small Alexis® (Applied Medical, Rancho Santa Margarita, CA, US) wound protector is inserted through the defect, a glove is attached and two or three 5mm trocars are secured with Vicryl® (Ethicon, Somerville, NJ, US) through the digits. Insufflation of the abdomen allows the returned contents to be seen and assessed safely without the need for further abdominal access.
How to safely remove ceramic bearings from the metal shell without expensive tools or the risk of shattering A Memarzadeh, J Jeffery Queen Elizabeth Hospital, Kings Lynn, United Kingdom CORRESPONDENCE TO A Memarzadeh, E: [email protected]
BACKGROUND
Figure 1 Anal retraction sutures stitching the perianal skin to the anal mucosa
Removal of an intact ceramic bearing from a securely fixed acetabular shell during revision surgery can be very difficult. Removing screws before removal of the shell may be crucial. Breaking the bearing also results in considerable ceramic debris and stops employment of other bearing surfaces. Various techniques have been devised for this task. One technique is to hit the metal shell with hard blows, the resonation of which loosens the ceramic bearing. Despite such loosening, the bearings often sit almost flush with the shell, and are difficult to retrieve. Implant companies1 have devised specialised tools to remove ceramic bearings. However, such tools are expensive and can attract further loan charges if they are not deemed to be ‘essential instruments’ that should be purchased.
Ann R Coll Surg Engl 2015; 97: 476–479
477
TECHNICAL SECTION
Kocher forceps assisted pedicle screw insertion as an aid to the trainee spinal surgeon MK Shahid, AJ Marino Royal Wolverhampton NHS Trust, UK CORRESPONDENCE TO Mohammad Shahid, E: [email protected]
BACKGROUND
Figure 1 A Sterling punch is used to hit the metal shell of the acetabular component
The reported incidence of misplaced spinal screws using uniplanar fluoroscopic guidance varies widely.1 In addition to anteroposterior fluoroscopic screening, obtaining a true lateral image of the pedicles is the key to optimum screw placement but this can be difficult to achieve.2 When difficulties arise in identifying the endplates (such as in the presence of significant osteopenia, degenerative scoliosis or high body mass index), screws can be inserted with increased confidence with the technique described. We describe a simple technique to improve intraoperative pedicle visualisation for the trainee surgeon. TECHNIQUE
Kocher forceps are applied loosely to each of the two transverse processes of the vertebra to be instrumented and both are held together in position with a swab tie to avoid crushing the transverse processes (Fig 1). The image intensifier C-arm is adjusted until the two forceps are seen to overlap, thereby achieving a true lateral view with sharper definition of the pedicles (Fig 2). DISCUSSION
Figure 2 Suction from a pulse lavage gun is used to form a seal around the ceramic bearing
This technique enables quicker and easier ‘true lateral’ visualisation of the pedicles, especially in the setting of degenerative lumbar
TECHNIQUE
Our technique uses instruments available in all arthroplasty sets. Once adequate exposure of the entire cup is achieved, a Sterling punch is used to direct a forceful blow on the metallic shell only (Fig 1). Such action resonates the bearing and deforms the taper, causing loosening of the ceramic. The force must be applied to the metal shell only, and not the bearing, to avoid ceramic shattering. The tip from a pulse lavage gun, with integrated vacuum suction, is then used to create a seal around the periphery of the bearing. The suction creates a vacuum strong enough to pull the bearing out of the shell readily (Fig 2). We use this technique routinely when removing hard bearings from a securely fixed shell. DISCUSSION
We have described a reliable technique that allows for safe extraction of ceramic bearings without the risk of shattering or the high costs associated with the loaning/purchasing of specialised equipment.
Reference 1.
478
Zimmer. www.zimmer.co.uk/en-GB/hcp/hip/product/continuum-acetabularsystem.jspx. Accessed 18 May 2015.
Ann R Coll Surg Engl 2015; 97: 476–479
Figure 1 Spinal column sawbone model demonstrating placement of Kocher forceps on each transverse process to help facilitate fluoroscopic pedicle screw placement
