Surgical instrument wrap: a pilot recycling initiative

BACKGROUND

Seven per cent of general waste and 20% of healthcare risk waste produced in acute hospitals in Ireland comes from operating theatres. Surgical wrap comprises 11% of operating theatre waste.

AIMS

The primary aim of this study was to pilot the implementation of a recycling initiative for surgical instrument set wrap in an operating theatre in Ireland. Secondary aims included quantification of the surgical wrap diverted from general waste to recycling streams over a 5-week period and estimation of the annual carbon emissions associated with gynaecology surgical wrap use in Cork.

METHODS

The amount of polypropylene surgical wrap generated by a single gynaecology theatre at Cork University Maternity Hospital was prospectively quantified from 24/1/22 to 1/3/22. At the end of the study period, individual sheets of polypropylene wrap were counted and dimensions were measured to calculate the total surface area of surgical wrap saved for recycling.

RESULTS

A total of 66 surgeries were performed over the 5-week study period. Two hundred twenty-one individual sheets of surgical wrap were collected, equating to 282.1 m2 of polypropylene wrap. An estimated 11,564 m2 of surgical wrap could be recycled annually from the gynaecology theatre service in Cork with an associated annual carbon emissions equivalent of at least 2.2 tonnes of CO2.

CONCLUSION

Diversion of surgical wrap from general waste and clinical waste streams to the recycling stream is achievable in every operating theatre. Small changes to operating theatre waste disposal practices have the potential to yield significant reductions to theatre waste outputs and to hospital carbon emissions.

Double covering with amniotic membrane in restrictive strabismus

A case of severe restrictive strabismus after a consecutive exotropia surgery is presented. We describe the exitous managment through a technique consist of wrapping with amniotic membrane (AM) the affected muscle where we add a second AM graft in the reconstruction of the ocular Surface.

Wrap choice during fundoplication

Gastro-oesphageal reflux disease is an increasing health burden. The mainstay of treatment has conventionally been medical therapy but since the introduction of laparoscopic surgery laparoscopic anti-reflux surgery has been increasingly used for intractable symptoms or in patients unwilling to take long term medication. The Nissen 360 degree wrap has traditionally been considered the gold standard operation but can be associated with significant complications. These complications include “gas bloat” and dysphagia and can occur relatively frequently. Various modifications have been described to the original operation and some of these have been described. In addition alternative wraps have been described which seem to have a reduced incidence of complications associated with their use. This editorial discusses the various types of wrap that can be performed and the minimum requirements of the surgical technique. The evidence from a recent meta-analysis of the randomised data has suggested that an anterior wrap is associated with a lower rate of complications and gives just as good control of reflux symptoms. The advantages and disadvantages of an anterior wrap are discussed. The lack of long term follow up data concerns some practitioners and at the moment the choice of wrap carried out still rests with the individual surgeon.

Evaluation of canine prostate volume in calculated tomographic images - comparison of two assessment methods

BACKGROUND

Since most prostatic diseases are associated with the organ's enlargement, evaluation of prostatic size is a main criterion in the diagnosis of prostatic state of health. While enlargement is a non-uniform process, volumetric measurements are believed to be advantageous to any single dimensional parameter for the diagnosis of prostatomegaly. In a previous study, volume was analysed with a slice addition technique (SAT), which was validated as highly accurate. Irrespective of high accuracy, SAT represents a complex and time-consuming procedure, which limits its clinical use. Thus, demand exists for more practical volume assessment methods. In this study, the prostatic volume of 95 canine patients (58 intact males, 37 neutered males) were analysed retrospectively by using the ellipsoid formula (Formula) and an imaging "wrap" function tool (Wrap) to help assess accuracy and applicability. Accuracy was checked against phantom measurements and results were compared to SAT measurements of the same patient pool obtained from a previously published paper. Patients were grouped according to prostatic structure (H = homogeneous, I = inhomogeneous, C = cystic) and volume using the SAT (volume group = vg: 1, 2 and 3).

RESULTS

High correlation between the Formula or Wrap volume and the phantom volume was found, the values being higher for the Formula. Mean Formula volumes (vg 1: 2.2 cm³, vg 2: 14.5 cm³, vg 3: 109.4 cm³, respectively) were significantly underestimated, while mean Wrap volumes (vg 1: 3.8 cm³, vg 2: 19.5 cm³, vg 3: 159.2 cm³) were statistically equivalent to SAT measurements (vg 1: 3.1 cm³, vg 2: 18.6 cm³, vg 3: 157.2 cm³, respectively). Differences between Formula and SAT volumes ranged from 22.4-31.1%, while differences between Wrap and SAT volumes were highest in small prostates (vg 1: 22.1%) and fell with increasing prostatic size (vg 3: 1.3%).

CONCLUSION

The Wrap function is highly accurate, less time-consuming and complex compared to SAT and could serve as beneficial tool for measuring prostatic volume in clinical routine after further validation in future studies. The Formula method cannot be recommended as an alternative for volumetric measurements of the prostate gland due to its underestimation of volumes compared to SAT results.

Vancomycin-soaked wrapping of harvested hamstring tendons during anterior cruciate ligament reconstruction. A review of the 'vancomycin wrap'

The practice of 'vancomycin wrapping' of harvested hamstring autografts during Anterior Cruciate Ligament Reconstruction (ACLR) surgery has gathered recent interest. This practice involves the wrapping of harvested grafts in a vancomycin-soaked swab during the preparatory phase. Different techniques are observed, and a small number of studies have shown that pre-soaking hamstring ACLR grafts in this manner dramatically reduces the post-surgical infection rate compared with standard intravenous antibiotic prophylaxis alone. However, the literature surrounding this practice is surprisingly limited and thus the basis and rationale of the 'vancomycin wrap' has established itself largely without question. The exact popularity of this practice is difficult to establish but there has been increasing disclosure of its efficacy in reducing post-operative infection in ACLR since 2012. We provide a synopsis of the current literature surrounding vancomycin and its use in 'wraps' in ACLR to help apprise the surgeon of the nature of infection in ACLR, the rationale for vancomycin, whilst considering evidence to support alternatives and discussing potential ramifications for future practice.

Traction reinforcement in prehensile feet of harvestmen (Arachnida, Opiliones)

Prehensile and gripping organs are recurring structures in different organisms that enhance friction by the reinforcement and redirection of normal forces. The relationship between organ structure and biomechanical performance is poorly understood, despite a broad relevance for microhabitat choice, movement ecology and biomimetics. Here, we present the first study of the biomechanics of prehensile feet in long-legged harvestmen. These arachnids exhibit the strongest sub-division of legs among arthropods, permitting extreme hyperflexion (i.e. curling up the foot tip). We found that despite the lack of adhesive foot pads, these moderately sized arthropods are able to scale vertical smooth surfaces, if the surface is curved. Comparison of three species of harvestmen differing in leg morphology shows that traction reinforcement by foot wrapping depends on the degree of leg sub-division, not leg length. Differences are explained by adaptation to different microhabitats on trees. The exponential increase of foot section length from distal to proximal introduces a gradient of flexibility that permits adaptation to a wide range of surface curvature while maintaining integrity at strong flexion. A pulley system of the claw depressor tendon ensures the controlled flexion of the high number of adesmatic joints in the harvestman foot. These results contribute to the general understanding of foot function in arthropods and showcase an interesting model for the biomimetic engineering of novel transportation systems and surgical probes.

Gastroesophageal reflux

Gastroesophageal reflux disease (GERD) is a very common condition and affects approximately 7-20% of the pediatric population. Symptoms from pathological GERD include regurgitation, irritability when feeding, respiratory problems, and substernal pain. Treatment typically starts with dietary modifications and postural changes. Antireflux medications may then be added. Indications for operative management in the pediatric population include failure of medical therapy with poor weight gain or failure to thrive, continued respiratory symptoms, and complications such as esophagitis. Laparoscopic Nissen fundoplication has become the standard of care for surgical treatment of children with GERD. The key technical aspects of laparoscopic Nissen fundoplication include creation of an adequate intra-abdominal esophagus, minimal dissection of the hiatus with exposure of the right crus to identify the gastroesophageal junction, crural repair, and creation of floppy, 360° wrap that is oriented at the 11 o׳clock position.

Perivascular medical devices and drug delivery systems: Making the right choices

Perivascular medical devices and perivascular drug delivery systems are conceived for local application around a blood vessel during open vascular surgery. These systems provide mechanical support and/or pharmacological activity for the prevention of intimal hyperplasia following vessel injury. Despite abundant reports in the literature and numerous clinical trials, no efficient perivascular treatment is available. In this review, the existing perivascular medical devices and perivascular drug delivery systems, such as polymeric gels, meshes, sheaths, wraps, matrices, and metal meshes, are jointly evaluated. The key criteria for the design of an ideal perivascular system are identified. Perivascular treatments should have mechanical specifications that ensure system localization, prolonged retention and adequate vascular constriction. From the data gathered, it appears that a drug is necessary to increase the efficacy of these systems. As such, the release kinetics of pharmacological agents should match the development of the pathology. A successful perivascular system must combine these optimized pharmacological and mechanical properties to be efficient.

Periadventitial drug delivery for the prevention of intimal hyperplasia following open surgery

BACKGROUND

Intimal hyperplasia (IH) remains a major cause of poor patient outcomes after surgical revascularization to treat atherosclerosis. A multitude of drugs have been shown to prevent the development of IH. Moreover, endovascular drug delivery following angioplasty and stenting has been achieved with a marked diminution in the incidence of restenosis. Despite advances in endovascular drug delivery, there is currently no clinically available method of periadventitial drug delivery suitable for open vascular reconstructions. Herein we provide an overview of the recent literature regarding innovative polymer platforms for periadventitial drug delivery in preclinical models of IH as well as insights about barriers to clinical translation.

METHODS

A comprehensive PubMed search confined to the past 15years was performed for studies of periadventitial drug delivery. Additional searches were performed for relevant clinical trials, patents, meeting abstracts, and awards of NIH funding.

RESULTS

Most of the research involving direct periadventitial delivery without a drug carrier was published prior to 2000. Over the past 15years there have been a surge of reports utilizing periadventitial drug-releasing polymer platforms, most commonly bioresorbable hydrogels and wraps. These methods proved to be effective for the inhibition of IH in various animal models (e.g. balloon angioplasty, wire injury, and vein graft), but very few have advanced to clinical trials. There are a number of barriers that may account for this lack of translation. Promising new approaches including the use of nanoparticles will be described.

CONCLUSIONS

No periadventitial drug delivery system has reached clinical application. For periadventitial delivery, polymer hydrogels, wraps, and nanoparticles exhibit overlapping and complementary properties. The ideal periadventitial delivery platform would allow for sustained drug release yet exert minimal mechanical and inflammatory stresses to the vessel wall. A clinically applicable strategy for periadventitial drug delivery would benefit thousands of patients undergoing open vascular reconstruction each year.

Unilateral versus bilateral wrap crural fixation in laparoscopic Nissen fundoplication for children

Introduction:

Gastroesophageal reflux (GERD) is common in neurologically impaired (NI) children. Fundoplication and gastrostomy have previously been indicated in NI children with GERD who have not responded to medical treatment. The most common reason for fundoplication failure is intrathoracic migration of the wrap.

Objective:

The aim of the study is to measure the effect of wrap fixation on the final outcome of laparoscopic Nissen fundoplication in NI children.

Patients and Methods:

A retrospective file review was conducted for all NI children who underwent laparoscopic Nissen fundoplication in 2 tertiary pediatric surgery centers in the United Arab Emirates from February 15, 2006 to February 15, 2013. Redo fundoplication patients were excluded from the study. Patients were divided into 2 groups: group 1 in which the fundoplication wrap was fixed to the right crus only, and group 2 in which the wrap was fixed to the right and left crus simultaneously.

Results:

The study population included 68 patients; there were 47 male and 21 female children. Mean age at time of surgery was 8.2 years. Recurrent GERD at 1 year postoperatively was 26% versus 7% in group 1 and group 2, respectively, by upper contrast study. Redo surgery was required in 21% versus 3% in group 1 and group 2, respectively.

Conclusions:

Bilateral fixation of the wrap to diaphragmatic crura significantly reduced recurrent GERD, in laparoscopic Nissen fundoplication for neurologically impaired children, with no increased risk of morbidities. Future prospective studies should be conducted with larger patient populations and longer follow-up periods.

Mesh wrapping for severe hepatic injury: a beneficial option in the trauma surgeon's armamentarium

BACKGROUND

The purpose of this study was to assess the efficacy of absorbable mesh wrapping (MW) versus perihepatic packing (HP) for severe hepatic injury.

METHODS

From January 2001 to December 2012, data were collected for MW patients with hepatic injury. Patients who underwent HP were matched with MW patients by injury mechanism, liver injury grade, Injury Severity Score, and age.

RESULTS

Twenty-six MW and twenty-six HP patients were matched. Eighteen blunt and 8 penetrating injuries were present in each group. There were 9 (35%) mortalities in the MW group and 16 (62%) in the HP groups (P = .03). Average transfusions were 12.0 and 24.5 (P = .03) packed red blood cells in the MW and HP groups, respectively. Average laparotomies per survivors were 1.3 for the MW and 3.1 for the HP groups (P = .01). Average length of stay for survivors was 19 and 47 (P = .04) days in the MW and HP groups, respectively.

CONCLUSION

MW for hepatic injuries can significantly decrease mortality, transfusions, laparotomies, and length of stay.