Closer Look: Anterior Cruciate Ligament (ACL) Reconstruction

Never in my whole stay in the operating room have I assisted in an ACL Reconstruction and Mam G knows it. I'd rather scrubbed in shoulder or knee arthroscopy because at least there I know I already mastered it, but in ACL, God knows that I don't know what to do. So when Mam G assigned me in ACL reconstruction, I didn't know what to do, so I just prayed that Dr. M (one of the best ortho surgeon in our hospital) won't be mad at me and throw me the OR instruments that I will be passing to him. And to think I need to endure all three cases of ACL.

Anyways, it's a good thing that all of my senior co-staff helped me to understand the process of ACL reconstruction and with all three cases being assigned to me, now I'm proud to say I already knew how to do it. Here's the closer look of the surgery.

ANTERIOR CRUCIATE LIGAMENT (ACL) RECONSTRUCTION

Definition: Anterior cruciate ligament reconstruction (ACL reconstruction) is a surgical tissue graft replacement of the anterior cruciate ligament, located in the knee, to restore its function after anterior cruciate ligament injury. The torn ligament is removed from the knee before the graft is inserted through a hole created by a single hole punch. The surgery is performed arthroscopically.

Procedure:

This surgical technique uses three very small incisions that are about 1/4 of an inch in length to create "portals" into the knee. A fiber-optic light source illuminates the inside of the knee and a video camera feeds an image to a monitor so that the surgeon can see inside the knee. A sterile saline solution is continuously pumped through the knee via a cannula so that the operative field is always clear.

After the surgeon inspects the knee for damage to the cartilage or the menisci, the remnants of the torn ACL are removed with a high-speed shaver. This tool is a very specialized device that is used to remove torn ligaments or torn pieces of cartilage from the knee. The surface of the intercondylar notch where the ACL normally attaches to the femur is then prepared with a high-speed burr so that the proper location for the tunnel for femoral fixation can be seen clearly. 

Tunnels are then drilled through the bone in the femur and the tibia so that the graft can be placed in the center of the knee in the same position as the original ACL. A separate incision that is about 2 to 3 inches long also has to be made in order to harvest the graft from either the patellar tendon or the hamstring tendons. After the graft has been harvested, it is then prepared by placing several very strong surgical sutures through the graft that are used to fix it in place. Some surgeons will also braid the graft before passing it through the tunnels.

After the graft is passed through the tunnels, it is then tensioned and fixed in place. A variety of fixation techniques have been developed to anchor the graft to the bone. Different techniques are used for different types of grafts, and today, fixation failures, though possible, are very rare.

Once the graft has been fixed in place and any additional damage has been addressed, the incisions are closed and a sterile dressing is used to cover the knee. This dressing will usually stay on for several days while the wound begins to heal.

Instruments and Supplies:

• Sharps
• Tonsil/Adson Curve Clamp
• Mixter
• Mosquito Curve
• blade 15/11
• myerding retractor
• ticron 2-0
• vicryl 0
• vicryl 2-0
• vicryl 4-0
• EB 6" # 2
• Band-aid
• Wadding sheet for pneumatic tourniquet
• pneumatic tourniquet
• camera (scope)
• light source
• water tubings
• suction tubing
• shaver
• RF
• arthroscopic hand instruments (grasper, straight biting, right biting, left biting punchers)
• drill and hose
• endobutton c/o company (as well as instruments for grafting)

Source: ACL Solutions, Wikipedia, Physio4life

Closer Look: Scoliosis Surgery

, c;lToday, I was able to assist in a Scoliosis Surgery. I was only able to assist in this surgery once and in what I remember, it's one of the long surgeries done in OR. Anyways, here's a closer look in this surgery.

SCOLIOSIS SURGERY

Definition: Surgery for adolescents with scoliosis is only recommended when their curves are greater than 40 to 45 degrees and continuing to progress, and for most patients with curves that are greater than 50 degrees. Scoliosis surgery is designed to reduce the patients curvature and fuse the spine to prevent any further progression of the deformity.

Besides preventing further curvature, scoliosis surgery can also reduce the amount of deformity. Usually, about a 50% correction can be obtained with surgery using modern instrumentation systems in which hooks and screws are applied to the spine to anchor long rods. The rods are then used to reduce and hold the spine while bone that is added fuses together.

 

Procedure:

Surgery involves an incision in the posterior aspect of the spine. The child lies on their stomach as the procedure is performed. The length of the incision will be based on the location and extent of the curvature. The muscles of the spine are moved in order for the surgeon to access the spinal column. 

Surgery for scoliosis is a form of spinal fusion. Rods and screws are connected to the individual vertebrae and a wire is often used to help realign and straighten the curve. The use of Harrington rods are a common fixation device for this type of fusion.

In many cases, a bone graft is used to connect one vertebra to another to form one segment and provide additional strength to keep the bones in place. Although donor bone material may be used, the surgeon may harvest bone to be used for this bone graft from the child’s pelvis (called an autograft). Generally bone that comes from a synthetic form or donor is not as successful as the autograft. Scoliosis surgery is involved and generally takes 4 to 6 hours to perform, depending on the specific case.

Instruments and Supplies:

• Sharps
• Kelly
• ochsner straight
• freer
• wetlainer (curve)
• adson-beckman retractor
• rongeur/ gooseneck
• mallet
• harrington/cobbs
• cottonoids
• 2/3s
• rubber sheet
• bone wax
• cautery tip
• NST
• Suction tube
• curette
• sterile cover for C-arm
• PDS OCT1
• Vicryl OCT1
• Vicryl 2-0
• Prolene 4-0
• osteotome
• bone gouge

Sources: Scoliosis Surgery, Spine Health

Closer Look: Laparoscopic Appendectomy

Today was my first time to assist in Laparoscopic Appendectomy and I'm glad that finally I was able to assist in such procedure. This kind of surgery is rarely done in our institution due to different reasons but because primarily the cost of the procedure is not that affordable compared to the open approach and secondly the incision of laparoscopic and open approach are nearly the same.

Anyways, here's the closer look of the surgery:

Laparoscopic Appendectomy

Definition:  A laparoscopic appendectomy is a surgical procedure that removes the appendix from the body through a small incision. During this procedure, small incisions are made in the abdomen so a surgeon can insert a small camera and surgical instrument. With the camera in the right place, the surgeon can watch what he is doing on a video screen, while he is removing the appendix.

Position: The patient is in supine position, arms tucked at the side. The surgeon stands on the left side of the patient with the camera holder-assistant. For maintaining co-axial alignment surgeon should stand near left shoulder and monitor should be placed near right hip facing towards surgeon.

Procedure:

A small incision will be made for insertion of the laparoscope. Additional incisions may be made so that other instruments can be used during the procedure. Carbon dioxide gas will be introduced into the abdomen to inflate the abdominal cavity so that the appendix and other structures can be easily visualized. The laparoscope will be inserted and the appendix will be located. The appendix will be tied off with sutures and removed. When the procedure is completed, the laparoscope will be removed.  A small tube may be placed in the incision to drain out fluids.

Instruments and Supplies: Lap Chole Set (consists of: allis #6, towel clips #6 , kelly #6 , tissue #2, thumb #1, needle holder #3) Trochars: 5mm #2, 11mm/10mm #1 Hand Instruments: grasper, dissector, needle holder, mixter/ hook, scissors, extractor, suction tip Silk 2-0 Prolene 2-0 Prolene 4-0 betadine (for betadine wash) asepto Sources: Lap AP,  World Laparoscopy Hospital

Closer Look: Cochlear Implant Surgery

To avoid being asked to do an overtime and to reserve my energy as well considering I still have 7 days left to work, I asked the HNOD if I could have a 5-1 shift instead and fortunately she granted it to me.

Anyways, my case for today is Cochlear Implant Surgery. It is not a frequent surgery done in our hospital so I'm really lucky to assist in this kind of surgery. Anyways, here's a closer look in this surgery.

COCHLEAR IMPLANT SURGERY

Definition: A cochlear implant is a small, complex electronic device that can help to provide a sense of sound to a person who is profoundly deaf or severely hard-of-hearing. The implant consists of an external portion that sits behind the ear and a second portion that is surgically placed under the skin.

Procedure:

The actual surgical procedure, which takes 2 to 4 hours and uses general anesthesia, involves securing the implant package under the skin and inside the skull, and then threading the wires containing the electrodes into the spirals of the cochlea.

To secure the implant, the surgeon first drills a 3- to 4-millimeter bed in the temporal bone (the skull bone that contains part of the ear canal, the middle ear, and the inner ear). Next the surgeon opens up the mastoid bone behind the ear to allow access to the middle ear. Then, a small hole is drilled in the cochlea and the wires containing the electrodes are inserted. The implant package is then secured and the incision is closed.

Instruments and Supplies:

• Plastic Set
• freer/dissector
• wetlainer
• periosteal elevator
• gentian violet
• cotton applicator
• cotton balls
• PNSS 500ml (for irrigating)
• suction tube
• NST
• Leica machine
• Leica cover
• rubber band
• extra bowl
• iris scissor

Sources:  Cochlear Implants, Cochlear Implant Surgery - Intraoperative Details, http://kidshealth.org