TRAM flap perforator ligation and the delay phenomenon: development of an endoscopic/laparoscopic delay procedure

Despite its versatility in breast reconstruction, the TRAM flap is at times subject to ischemic compromise, especially in certain high risk populations. A preoperative delay procedure can decrease the likelihood of TRAM flap failure or fat necrosis, but the required extent of this delay procedure is not clearly defined. In an attempt to augment flap vascularity while reducing surgical dissection and morbidity, six distinct delay procedures and a nondelayed control were compared in a rat TRAM flap model (n = 8 for all groups). An important feature that was incorporated into several groups was the ligation of the contralateral rectus perforators through minimal skin incisions (endoscopic analogy, groups 4 to 7). The most effective delay procedure was the combination of contralateral rectus perforator ligation and ipsilateral dominant pedicle ligation (group 7), which was achieved with two minimal skin incisions and no significant flap undermining. This procedure reduced the flap necrosis from 63.2 +/- 5.8 percent (control) to 13.5 +/- 3.3 percent (p < 0.001). After completion of the animal studies, clinical application of a "minimally invasive" TRAM flap delay procedure was then undertaken in eight high risk patients with only modest ischemic compromise. Although the clinical experience is too early to draw definite conclusions, we feel that "endoscopic delay" has potential as a modality that will increase flap vascularity but minimize the morbidity of the preliminary procedure.

Developing information materials to present the findings of technology assessments to consumers. The experience of the NHS Centre for Reviews and Dissemination

We discuss some of the issues that have arisen during the development and introduction into practice of information materials for health professionals and patients that aim to promote clinical effectiveness and informed patient participation in clinical decision making.

Measurement of the effective size of the input phosphor of an x-ray image intensifier

A technique is described, using a mobile radiographic x-ray unit, for determining the effective size of the input phosphor of an image intensifier (I.I.), in particular for a unit with over-table x-ray tube, under-table II, and with the I.I. physically inaccessible. The techniques described also enable (1) locating the central axis of the I.I.; (2) the ratio, R, of the dimensions of the radiological image incident upon the front of the I.I. to the dimensions of the image on the monitor screen; and (3) the distance between the input phosphor and the table top, which is needed to determine the distance from focal spot to input phosphor.

Informed choice for users of health services: views on ultrasonography leaflets of women in early pregnancy, midwives, and ultrasonographers

With the aim of promoting the informed choice of pregnant women, staff and pregnant women at two urban hospitals were offered leaflets summarising the best available evidence about the effectiveness of routine ultrasonography in early pregnancy. Ultrasonographers doubted the credibility of the evidence and were concerned that the leaflets would raise women's anxiety, reduce uptake of scans, disrupt hospital organisation, and reinforce media messages about the poor safety record of ultrasonography. Midwives thought that the leaflets would inform women, help them to talk about their care with health professionals, and help them to get better care. Women were shocked at some of the contents but thought that it was appropriate to include both advantages and disadvantages of routine scanning in the leaflet. This case study highlights the resistance of some health professionals to evidence based health care; underlying conflicts with the principle of professional autonomy; concern that informed choice may create anxiety; and professional and organisational barriers to allowing informed choice.

CD-ROM multimedia. The step before virtual reality

Applications developed using key multimedia elements are finding their way into a number of training and information exchange environments including the laparoscopy training market. Emerging multimedia-based applications range from procedural information for patients to interactive CD-ROM-based applications used to train highly skilled surgeons. These products are designed with a high level of interactivity that allows the surgeon to plan a surgical procedure, review detailed patient information and then merge that information into the surgical planning process. Using this new technology, a surgeon now has the ability to review CD-ROM-based course materials and efficiently meet continuing education requirements. The factor found most limiting in the development of multimedia-based applications for laparoscopy training is generally not the technology, but the limits placed on the technology because of one's reluctance to think beyond what is accepted as the norm. Properly implemented, multimedia applications developed for laparoscopy training reduce the cost and time associated with learning new materials, assist a user in retaining more of the information reviewed, and in many cases make the learning experience much more enjoyable.

The anatomical basis for laparoscopic hernia repair revisited

With the development of the transabdominal preperitoneal secured prosthetic mesh repair, many laparoscopic surgeons feel not only that they have a procedure with a low recurrence rate, but that the procedure also has historic academic credibility. This repair emulates well-established open procedures. Shortcomings of this repair include a demand for more precise identification of structures, more careful dissection, and a higher risk of injury to important anatomical entities. There have been anecdotal reports of injuries to nerves such as the lateral femoral cutaneous nerve, the femoral nerve, and the genital branch of the genital-femoral nerve. This article reviews inguinal anatomy from the laparoscopic vantage point and identifies the areas where injury to nerves can occur.

The development of auditory temporal acuity in children

The development of auditory temporal acuity was studied in 56 children aged 6-12 years and compared with that of 8 adults. Acuity was measured by determining the minimum detectable duration of a brief cessation in a noise band with the 2-alternative forced-choice method. For detection of gaps in a broadband noise, acuity improved significantly with age and reached adult values by 11 years. The minimum detectable duration was significantly shorter at higher levels of the noise. For narrow-band noises, acuity also improved significantly with age and depended on the center frequency of the band. The improvement in temporal acuity with age was attributed to the development of sensory processes and not to age-related changes in nonsensory factors.