Search results for: orthopaedic surgery

Authors: Aisling Eves, Andrew Pieri, Ross McLean, Nerys Forester

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Background: DCIS accounts for 20% of malignancies diagnosed by the breast screening programme and is primarily managed by surgical excision. There is variable guidance on defining excision margins, and adjuvant treatments vary widely. This study aimed to investigate the clinical outcomes for patients following surgical excision of small volume DCIS. Methods: This single-centreretrospective cohort study of 101 consecutive breast screened patients diagnosed with DCIS who underwent surgical excision. All patients diagnosed with DCIS had radiological abnormalities <15mm. Clinical, radiological, and histological data were collected from patients who had been diagnosed within a 5 year period, and ASCO guidelines for margin involvement of <2mm was used to guide the need for re-excision. Outcomes included re-excision rates, radiotherapy usage, and the presence of invasive cancer. Results: Breast conservation surgery was performed in 94.1% (n=95). Following surgical excision, 74(73.27%)patients had complete DCIS excision (>2mm margin), 4(4.0%) had margins 1-2mm, and 17(16.84%)had margins <1mm. The median size of DCIS in the specimen sample was 4mm. In 86% of patients with involved margins (n=18), the mammogram underestimated the DCIS size by a median of 12.5mm (range: 1-42mm). Of the patients with involved margins, 11(10.9%)had a re-excision, and 6 of these (50%) required two re-excisions to completely excise the DCIS. Post-operative radiotherapy was provided to 53(52.48%)patients. Four (3.97%) patients were found to have invasive ductal carcinoma on surgical excision, which was not present on core biopsy – all had high-grade DCIS. Recurrence of DCIS was seen in the same site during follow-up in 1 patient (1%), 1 year after their first DCIS diagnosis. Conclusion: Breast conservation surgery is safe in patients with DCIS, with low rates of re-excision, recurrence, and upstaging to invasive cancer. Furthermore, the median size of DCIS found in the specimens of patients who had DCIS fully removed in surgery was low, suggesting it may be possible that total removal through VAE was possible for these patients.

Keywords: surgical excision, breast conservation surgery, DCIS, Re-excision, radiotherapy, invasive cancer

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Authors: Zengmin Tian, Bin Lv, Rui Hui, Yupeng Liu, Chuan Wang, Qing Liu, Hongyu Li, Yan Qi, Li Song

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Objective Robot was used for replacement of the frame in recent years. The paper is to investigate the safety and effectiveness of frameless stereotactic surgery in the treatment of children with cerebral palsy. Methods Clinical data of 425 children with spastic cerebral palsy were retrospectively analyzed. The patients were treated with robot-assistant frameless stereotactic surgery of nuclear mass destruction. The motor function was evaluated by gross motor function measure-88 (GMFM-88) before the operation, 1 week and 3 months after the operation respectively. The statistical analysis was performed. Results The postoperative CT showed that the destruction area covered the predetermined target in all the patients. Minimal bleeding of puncture channel occurred in 2 patient, and mild fever in 3 cases. Otherwise, there was no severe surgical complication occurred. The GMFM-88 scores were 49.1±22.5 before the operation, 52.8±24.2 and 64.2±21.4 at the time of 1 week and 3 months after the operation, respectively. There was statistical difference between before and after the operation (P<0.01). After 3 months, the total effective rate was 98.1%, and the average improvement rate of motor function was 24.3% . Conclusion Replaced the traditional frame, the robot-assistant frameless stereotactic surgery is safe and reliable for children with spastic cerebral palsy, which has positive significance in improving patients’ motor function.

Keywords: cerebral palsy, robotics, stereotactic techniques, frameless operation

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Authors: Paul J Yazaki, Michael Bouvet, John Shively

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Surgery for solid gastrointestinal (GI) cancers such as pancreatic, colorectal, and gastric adenocarcinoma remains the mainstay of curative therapy. Complete resection of the primary tumor with negative margins (R0 resection), its draining lymph nodes, and distant metastases offers the optimal surgical benefit. Real-time fluorescence guided surgery (FGS) promises to improve GI cancer outcomes and is rapidly advancing with tumor-specific antibody conjugated fluorophores that can be imaged using near infrared (NIR) technology. Carcinoembryonic Antigen (CEA) is a non-internalizing tumor antigen validated as a surface tumor marker expressed in >95% of colorectal, 80% of gastric, and 60% of pancreatic adenocarcinomas. Our humanized anti-CEA hT84.66-M5A (M5A) monoclonal antibody (mAb)was conjugated with the NHS-IRDye800CW fluorophore and shown it can rapidly and effectively NIRoptical imageorthotopically implanted human colon and pancreatic cancer in mouse models. A limitation observed is that these NIR-800 dye conjugated mAbs have a rapid clearance from the blood, leading to a narrow timeframe for FGS and requiring high doses for effective optical imaging. We developed a novel antibody-fluorophore conjugate by incorporating a PEGylated sidearm linker to shield or mask the IR800 dye’s hydrophobicity which effectively extended the agent’s blood circulation half-life leading to increased tumor sensitivity and lowered normal hepatic uptake. We hypothesized that our unique anti-CEA linked to the fluorophore, IR800 by PEGylated sidewinder, M5A-SW-IR800 will become the next generation optical imaging agent, safe, effective, and widely applicable for intraoperative image guided surgery in CEA expressing GI cancers.

Keywords: optical imaging, anti-CEA, cancer, fluorescence-guided surgery

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Authors: Conor Mccartney, Mark Lee

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Background: An essential component in ambulatory breast augmentation surgery is good analgesia. The demographic undergoing this operation is usually fit, low risk with few comorbidities. These patients do not require long-term hospitalization and do not want to spend excessive time in the hospital for financial reasons. Opiate analgesia can have significant side effects such as nausea, vomiting and sedation. Reducing volumes of postoperative opiates allows faster ambulation and discharge from day surgery. We have developed two targeted nerve blocks that can be applied by the operating surgeon in a matter of seconds under direct vision, not requiring imaging. Anecdotally we found that these targeted nerve blocks reduced opiate requirements and allowed accelerated discharge and faster return to normal activities. This was then tested in a prospective randomized, double-blind trial. Methods: 20 patients were randomized into saline (n = 10) or Ropivicaine adrenaline solution (n = 10). The operating surgeon and anesthetist were blinded to the solution. All patients were closely followed up and morphine equivalents were accurately recorded. Follow-up pain scores were recorded using the Overall Benefit of Analgesia pain questionnaire. Findings: The Ropivicaine nerve blocks significantly reduced opiate requirements postoperatively (p<0.05). Pain scores were significantly decreased in the study group (p<0.05). There were no side effects attributable to the nerve blocks. Conclusions: Intraoperative targeted nerve blocks significantly reduce postoperative opiate requirements in breast augmentation surgery. This results in faster recovery and higher patient satisfaction.

Keywords: breast augmentation, nerve block, postoperative recovery, opiate analgesia, inter pectoral block, sub serratus block

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Authors: Davender Kumar, Virender Singh, Rekha Sharma

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Correction of skeletal deformities in adult patients with orthodontics is limited. In adult severe cases, the combined approach, orthodontic and orthognathic surgery, is always the treatment of choice, and the results obtained usually ensure a better esthetic, functional, and stable results Orthognathic surgery is the best option for cases when camouflage treatment is questionable and growth modulation is not possible. This case report illustrates the benefit of the team approach in correcting mandible retrusion along with class II skeletal deformity with 100% deep bite. Correction was achieved by anterior repositioning of mandible osteotomy along with orthodontic treatment. The patient's facial appearance was markedly improved along with functional and stable occlusion.

Keywords: camouflage, skeletal, orthognathic, dental

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Authors: Fatma Ahmed, Heba Mostafa, Bassem Ramdan, Azza El-Soussi

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Background: World Health Organization stated that by 2020 cardiac disease will be the number one cause of death worldwide and estimates that 25 million people per year will suffer from heart disease. Cardiac surgery is considered an effective treatment for severe forms of cardiovascular diseases that cannot be treated by medical treatment or cardiac interventions. In spite of the benefits of cardiac surgery, it is considered a major stressful experience for patients who are candidate for surgery. Prehabilitation can decrease incidences of postoperative complications as it prepares patients for surgical stress through enhancing their defenses to meet the demands of surgery. When patients anticipate the postoperative sequence of events, they will prepare themselves to act certain behaviors, identify their roles and actively participate in their own recovery, therefore, anxiety levels are decreased and functional capacity is enhanced. Prehabilitation programs can comprise interventions that include physical exercise, psychological prehabilitation, nutritional optimization and risk factor modification. Physical exercises are associated with improvements in the functioning of the various physiological systems, reflected in increased functional capacity, improved cardiac and respiratory functions and make patients fit for surgical intervention. Prehabilitation programs should also prepare patients psychologically in order to cope with stress, anxiety and depression associated with postoperative pain, fatigue, limited ability to perform the usual activities of daily living through acting in a healthy manner. Notwithstanding the benefits of psychological preparations, there are limited studies which investigated the effect of psychological prehabilitation to confirm its effect on psychological, quality of life and physiological outcomes of patients who had undergone cardiac surgery. Aim of the study: The study aims to determine the effect of prehabilitation interventions on outcomes of patients undergoing cardiac surgeries. Methods: Quasi experimental study design was used to conduct this study. Sixty eligible and consenting patients were recruited and divided into two groups: control and intervention group (30 participants in each). One tool namely emotional, physiological, clinical, cognitive and functional capacity outcomes of prehabilitation intervention assessment tool was utilized to collect the data of this study. Results: Data analysis showed significant improvement in patients' emotional state, physiological and clinical outcomes (P < 0.000) with the use of prehabilitation interventions. Conclusions: Cardiac prehabilitation in the form of providing information about surgery, circulation exercise, deep breathing exercise, incentive spirometer training and nutritional education implemented daily by patients scheduled for elective open heart surgery one week before surgery have been shown to improve patients' emotional state, physiological and clinical outcomes.

Keywords: emotional recovery, clinical recovery, coronary artery bypass grafting patients, prehabilitation

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Authors: Ana Claudia Muniz Rennó, Karina Nogueira

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This study aimed to investigate the in vivo tissue response of the introduction of the bioactive mesh (BM) scaffolds using a model of tibial bone defect implants in rats. Although a previous in vivo study demonstrated a highly positive response of particulate bioactive materials in the morphological and biomechanical properties of the bone callus, the effects of material with superior bioactivity, present in form of meshes have not been studied yet. Eighty male Wistar rats with 3 mm tibial defects were used. Animals were divided into four groups: intact group (IG) – tibia without any injury; bone defect day zero (0dD) – bone defects, sacrificed immediately after injury; bone defect control group (CG) – bone defects without any filler and bone defect filled with BM scaffold. The animals of BM and CG groups were sacrificed 15, 30 and 45 days post-injury to compare the temporal-special effects of the scaffolds on bone healing. The histological analysis revealed an organized newly formed bone at 30 and 45 days post-surgery in the BM. Also, this group presented an increased COX-2 expression on days 15 and 30 post-surgery. Furthermore, the immunohistochemistry analysis revealed that, BM presented a positive immunoexpression of RUNX-2 during all periods evaluated. The biomechanical analysis revealed that at 15 day after surgery, no significant statistically difference was observed between BM and CG and both groups had significantly higher values of maximal load compared to 0dG and significantly lower values than IG. On days 30 and 45 post-surgery, BM presented statistically lower values of maximal load compared to the CG. Nevertheless, at the same periods, BM did not show statistically significant difference compared to the IG maximal load values (p > 0, 05). Our results revealed that the implantation of the BM scaffolds was effective in stimulating newly bone formation.

Keywords: bone, biomaterials, scaffolds, cartilage

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Authors: M. Sulieman, H. Arabiyat, H. Ali, K. Potiszil, I. Abbas, R. English, P. King, I. Brown, P. Drew

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Introduction: The incidence of breast ductal Carcinoma in Situ (DCIS) has been increasing; it currently represents up 20-25% of all breast carcinomas. Some aspects of DCIS management are still controversial, mainly due to the heterogeneity of its clinical presentation and of its biological and pathological characteristics. In DCIS, histological diagnosis obtained preoperatively, carries the risk of sampling error if the presence of invasive cancer is subsequently diagnosed. The mammographic extent over than 4–5 cm and the presence of architectural distortion, focal asymmetric density or mass on mammography are proven important risk factors of preoperative histological under staging. Intracystic papillary cancer (IPC) is a rare form of breast carcinoma. Despite being previously compared to DCIS it has been shown to present histologically with invasion of the basement membrane and even metastasis. SLNB – Carries the risk of associated comorbidity that should be considered when planning surgery for DCIS and IPC. Objectives: The aim of this Audit was to better define a ‘high risk’ group of patients with pre-op diagnosis of non-invasive cancer undergoing breast conserving surgery, who would benefit from sentinel node biopsy. Method: Retrospective data collection of all patients with ductal carcinoma in situ over 5 years. 636 patients identified, and after exclusion criteria applied: 394 patients were included. High risk defined as: Extensive micro-calcification >40mm OR any mass forming DCIS. IPC: Winpath search from for the term ‘papillary carcinoma’ in any breast specimen for 5 years duration;.29 patients were included in this group. Results: DCIS: 188 deemed high risk due to >40mm calcification or a mass forming (radiological or palpable) 61% of those had a mastectomy and 32% BCS. Overall, in that high-risk group - the number with invasive disease was 38%. Of those high-risk DCIS pts 85% had a SLN - 80% at the time of surgery and 5% at a second operation. For the BCS patients - 42% had SLN at time of surgery and 13% (8 patients) at a second operation. 15 (7.9%) pts in the high-risk group had a positive SLNB, 11 having a mastectomy and 4 having BCS. IPC: The provisional diagnosis of encysted papillary carcinoma is upgraded to an invasive carcinoma on final histology in around a third of cases. This has may have implications when deciding whether to offer sentinel node removal at the time of therapeutic surgery. Conclusions: We have defined a ‘high risk’ group of pts with pre-op diagnosis of non-invasive cancer undergoing BCS, who would benefit from SLNB at the time of the surgery. In patients with high-risk features; the risk of invasive disease is up to 40% but the risk of nodal involvement is approximately 8%. The risk of morbidity from SLN is up to about 5% especially the risk of lymphedema.

Keywords: breast ductal carcinoma in Situ (DCIS), intracystic papillary carcinoma (IPC), sentinel node biopsy (SLNB), high-risk, non-invasive, cancer disease

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Authors: Rassoli Aisa, Abrishami Movahhed Arezu, Faturaee Nasser, Seddighi Amir Saeed, Shafigh Mohammad

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Cardiovascular diseases are one of the most common causes of mortality in developed countries. Coronary artery abnormalities and carotid artery stenosis, also known as silent death, are among these diseases. One of the treatment methods for these diseases is to create a deviatory pathway to conduct blood into the heart through a bypass surgery. The saphenous vein is usually used in this surgery to create the deviatory pathway. Unfortunately, a re-surgery will be necessary after some years due to ignoring the disagreement of mechanical properties of graft tissue and/or applied prostheses with those of host tissue. The objective of the present study is to clarify the viscoelastic behavior of human saphenous tissue. The stress relaxation tests in circumferential and longitudinal direction were done in this vein by exerting 20% and 50% strains. Considering the stress relaxation curves obtained from stress relaxation tests and the coefficients of the standard solid model, it was demonstrated that the saphenous vein has a non-linear viscoelastic behavior. Thereafter, the fitting with Fung’s quasilinear viscoelastic (QLV) model was performed based on stress relaxation time curves. Finally, the coefficients of Fung’s QLV model, which models the behavior of saphenous tissue very well, were presented.

Keywords: Viscoelastic behavior, stress relaxation test, uniaxial tensile test, Fung’s quasilinear viscoelastic (QLV) model, strain rate

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Authors: Keiko Yamauchi, Motoyuki Nakao, Yoko Ishihara

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The increase in the number of women with breast cancer in Japan has required hospitals to provide a higher quality of medicine so that patients are satisfied with the treatment they receive. However, patients’ satisfaction following breast cancer treatment has not been sufficiently studied. Hence, we investigated the factors influencing patient satisfaction following breast cancer treatment among Japanese women. These women underwent either breast-conserving surgery (BCS) (n = 380) or total mastectomy (TM) (n = 247). In March 2016, we conducted a cross-sectional internet survey of Japanese women with breast cancer in Japan. We assessed the following factors: socioeconomic status, cancer-related information, the role of medical decision-making, the degree of satisfaction regarding the treatments received, and the regret arising from the medical decision-making processes. We performed logistic regression analyses with the following dependent variables: extreme satisfaction with the treatments received, and regret regarding the medical decision-making process. For both types of surgery, the odds ratio (OR) of being extremely satisfied with the cancer treatment was significantly higher among patients who did not have any regrets compared to patients who had. Also, the OR tended to be higher among patients who chose to play a wanted role in the medical decision-making process, compared with patients who did not. In the BCS group, the OR of being extremely satisfied with the treatment was higher if, at diagnosis, the patient’s youngest child was older than 19 years, compared with patients with no children. The OR was also higher if patient considered the stage and characteristics of their cancer significant. The OR of being extremely satisfied with the treatments was lower among patients who were not employed on full-time basis, and among patients who considered the second medical opinions and medical expenses to be significant. These associations were not observed in the TM group. The OR of having regrets regarding the medical decision-making process was higher among patients who chose to play a role in the decision-making process as they preferred, and was also higher in patients who were employed on either a part-time or contractual basis. For both types of surgery, the OR was higher among patients who considered a second medical opinion to be significant. Regardless of surgical type, regret regarding the medical decision-making process decreases treatment satisfaction. Patients who received breast-conserving surgery were more likely to have regrets concerning the medical decision-making process if they could not play a role in the process as they preferred. In addition, factors associated with the satisfaction with treatment in BCS group but not TM group included the second medical opinion, medical expenses, employment status, and age of the youngest child at diagnosis.

Keywords: medical decision making, breast-conserving surgery, total mastectomy, Japanese

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Authors: Rajib Husain, Munirujzaman Osmani, Mohammad Shamsal Islam

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Purpose: To compare the safety, efficacy and visual outcome of phacoemulsification vs. manual small-incision cataract surgery (SICS) for the treatment of cataract in Bangladesh. Objectives: 1. To assess the Visual outcome after cataract surgery 2. To understand the post-operative complications and early rehabilitation 3. To identified which surgical procedure more attractive to the patients 4. To identify which surgical procedure is occurred fewer complications. 5. To find out the socio-economic and demographic characteristics of study patients Setting: Chittagong Eye Infirmary and Training Complex, Chittagong, Bangladesh. Design: Retrospective, randomised comparison of 300 patients with visually significant cataracts. Method: The present study was designed as a retrospective hospital-based research. The sample size was 300 and study period was from July, 2012 to July, 2013 and assigned randomly to receive either phacoemulsification or manual small-incision cataract surgery (SICS). Preoperative and post-operative data were collected through a well designed collection format. Three follow-up were done; i) during discharge ii) 1-3 weeks & iii) 4-11 weeks post operatively. All preoperative and surgical complications, uncorrected and best-corrected visual acuity (BCVA) and astigmatism were taken into consideration for comparison of outcome Result: Nearly 95% patients were more than 40 years of age. About 52% patients were female, and 48% were male. 52% (N=157) patients came to operate their first eye where 48% (N=143) patients were visited again to operate their second eye. Postoperatively, five eyes (3.33%) developed corneal oedema with >10 Descemets folds, and six eyes (4%) had corneal oedema with <10 Descemets folds for Phacoemulsification surgeries. For SICS surgeries, seven eyes (4.66%) developed corneal oedema with >10 Descemets folds and eight eyes (5.33%) had corneal oedema with < 10 descemets folds. However, both the uncorrected and corrected (4-11 weeks) visual acuities were better in the eyes that had phacoemulsification (p=0.02 and p=0.03), and there was less astigmatism (p=0.001) at 4-11 weeks in the eye that had phacoemulsification. Best-corrected visual acuity (BCVA) of final follow-up 95% (N=253) had a good outcome, borderline 3.10% (N=40) and poor outcome was 1.6% (N=7). The individual surgeon outcome were closer, 95% (BCVA) in SICS and 96% (BCVA) in Phacoemulsification at 4-11 weeks follow-up respectively. Conclusion: outcome of cataract surgery both Phacoemulsification and SICS in CEITC was more satisfactory according to who norms. Both Phacoemulsification and manual small-incision cataract surgery (SICS) shows excellent visual outcomes with low complication rates and good rehabilitation. Phacoemulsification is significantly faster, and modern technology based surgical procedure for cataract treatment.

Keywords: phacoemulsification, SICS, cataract, Bangladesh, visual outcome of SICS

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Authors: Yu-Chieh Chen, Kuei-Feng Shen, Chia-Ling Chao

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The purpose of this report was to present the nursing experience and case of an unexpected cerebellar hemorrhagic stroke with acute hydrocephalus patient after lumbar spine surgery. The patient had been suffering from an emergent external ventricular drainage and stayed in the Surgical Intensive Care Unit from July 8, 2016, to July 22, 2016. During the period of the case, the data were collected for attendance, evaluation, observation, interview, searching medical record, etc. An integral evaluation of the patient's physiological 'psychological' social and spiritual states was also noted. The author noticed the following major nursing problems including ineffective cerebral perfusion 'physical activity dysfunction' family resource preparation for disability. The author provided nursing care to maintain normal intracranial pressure, along with a well-therapeutic relationship and applied interdisciplinary medical/nursing team to draft an individualized and appropriate nursing plan for them to face the psychosocial impact of the patient disabilities. We also actively participated in the rehabilitation treatments to improve daily activity and confidence. This was deemed necessary to empower them to a more positive attitude in the future.

Keywords: family resourace preparation inability, hemorrhagic sroke, ineffective tissue cerebral perfusion, lumbar spine surgery

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Authors: Khosro Barkhordari, Fateme Sadr, Mina Pashang

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Back ground: Blood transfusion is one of the major issues in cardiac surgery patients. Transfusing patients based on fixed cut-off points of hemoglobin is the current protocol in most institutions. The hemoglobin level of 7- 10 has been suggested for blood transfusion in cardiac surgery patients. We aimed to evaluate if blood transfusion based on change in percentage of hematocrit has different outcomes. Methods: In this retrospective cohort study, we investigated the early postoperative outcome of cardiac surgery patients who received blood transfusions at Tehran Heart Center Hospital, IRAN. We reviewed and analyzed the basic characteristics and clinical data of 700 patients who met our exclusion and inclusion criteria. The two groups of blood transfused patients were compared, those who have 30-50 percent decrease in basal hematocrit versus those with 10 -29 percent decrease. Results: This is ongoing study, and the results would be completed in two weeks after analysis of the date. Conclusion: Early analysis has shown no difference in early post-operative outcomes between the two groups, but final analysis will be completed in two weeks. 1-Department of Anesthesiology and Critical Care, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, IRAN 2- Department of Research, Tehran Heart Center, Tehran, IRAN Quantitative variables were compared using the Student t-test or the Mann‐Whitney U test, as appropriate, while categorical variables were compared using the χ2 or the Fisher exact test, as required. Our intention was to compare the early postoperative outcomes between the two groups, which include 30 days mortality, Length of ICU stay, Length of hospital stay, Intubation time, Infection rate, acute kidney injury, and respiratory complications. The main goal was to find if transfusing blood based on changes in hematocrit from a basal level was better than to fixed cut-off point regarding early post-operative outcomes. This has not been studied enough and may need randomized control trials.

Keywords: post-operative, cardiac surgery, outcomes, blood transfusion

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Authors: Rafael Ricieri, Rogerio Barros

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Objective: This study is to report a case of massive necrotizing enterocolitis in a six-month-old patient, requiring ileostomy and protective jejunostomy as a damage control measure in the first exploratory laparotomy surgery in massive enterocolitis without a previous diagnosis. Methods: This study is a case report of success in making and closing a protective jejunostomy. However, the low number of publications on this staged and risky measure of surgical resolution encouraged the team to study the indication and especially the correct time for closing the patient's protective jejunostomy. The main study instrument will be the six-month-old patient's medical record. Results: Based on the observation of the case described, it was observed that the time for the closure of the described procedure (protective jejunostomy) varies according to the level of compromise of the health status of your patient and of an individual of each person. Early closure, or failure to close, can lead to a favorable problem for the patient since several problems can result from this closure, such as new intestinal perforations, hydroelectrolyte disturbances. Despite the risk of new perforations, we suggest closing the protective jejunostomy around the 14th day of the procedure, thus keeping the patient on broad-spectrum antibiotic therapy and absolute fasting, thus reducing the chances of new intestinal perforations. Associated with the closure of the jejunostomy, a gastric tube for decompression is necessary, and care in an intensive care unit and electrolyte replacement is necessary to maintain the stability of the case.

Keywords: jejunostomy, ileostomy, enterocolitis, pediatric surgery, gastric surgery

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Authors: C. Kuoh, C. Lucas, T. Lopes, I. Mechie, J. Yoong, W. Yoong

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For all surgeons, there is one preventable but still highly occurring complication – wrong site surgeries. They can have potentially catastrophic, irreversible, or even fatal consequences on patients. With the exponential development of microsurgery and the use of advanced technological tools, the consequences of operating on the wrong side, anatomical part, or even person is seen as the most visible and destructive of all surgical errors and perhaps the error that is dreaded by most clinicians as it threatens their licenses and arouses feelings of guilt. Despite the implementation of the WHO surgical safety checklist more than a decade ago, the incidence of wrong-site surgeries remains relatively high, leading to tremendous physical and psychological repercussions for the clinicians involved, as well as a financial burden for the healthcare institution. In this presentation, the authors explore various factors which can lead to wrong site surgery – a combination of environmental and human factors and evaluate their impact amongst patients, practitioners, their families, and the medical industry. Major contributing factors to these “never events” include deviations from checklists, excessive workload, and poor communication. Two real-life cases are discussed, and systems that can be implemented to prevent these errors are highlighted alongside lessons learnt from other industries. The authors suggest that reinforcing speaking-up, implementing medical professional trainings, and higher patient’s involvements can potentially improve safety in surgeries and electrosurgeries.

Keywords: wrong side surgery, never events, checklist, workload, communication

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Authors: Rona Lee Suelo-Calanao, Mahmoud Loubani

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Objective: Sternal wound infection (SWI) following cardiac operation has a significant impact on patient morbidity and mortality. It also contributes to longer hospital stays and increased treatment costs. SWI management is mainly focused on treatment rather than prevention. This study looks at the effect of closed incision negative pressure therapy (ciNPT) dressing to help reduce the incidence of superficial SWI in high-risk patients after cardiac surgery. The ciNPT dressing was evaluated at 3 cardiac hospitals in the United Kingdom". Methods: All patients who had cardiac surgery from 2013 to 2021 were included in the study. The patients were classed as high risk if they have two or more of the recognised risk factors: obesity, age above 80 years old, diabetes, and chronic obstructive pulmonary disease. Patients receiving standard dressing (SD) and patients using ciNPT were propensity matched, and the Fisher’s exact test (two-tailed) and unpaired T-test were used to analyse categorical and continuous data, respectively. Results: There were 766 matched cases in each group. Total SWI incidences are lower in the ciNPT group compared to the SD group (43 (5.6%) vs 119 (15.5%), P=0.0001). There are fewer deep sternal wound infections (14(1.8%) vs. 31(4.04%), p=0.0149) and fewer superficial infections (29(3.7%) vs. 88 (11.4%), p=0.0001) in the ciNPT group compared to the SD group. However, the ciNPT group showed a longer average length of stay (11.23 ± 13 days versus 9.66 ± 10 days; p=0.0083) and higher mean logistic EuroSCORE (11.143 ± 13 versus 8.094 ± 11; p=0.0001). Conclusion: Utilization of ciNPT as an approach to help reduce the incidence of superficial and deep SWI may be effective in high-risk patients requiring cardiac surgery.

Keywords: closed incision negative pressure therapy, surgical wound infection, cardiac surgery complication, high risk cardiac patients

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Authors: Arun Prasad

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Introduction: Laparoscopic surgery of hernia started in early 1990 and has had a mixed acceptance across the world, unlike laparoscopic cholecystectomy that has become a gold standard. Laparoscopic hernia repair claims to have less pain, less recurrence, and less wound infection compared to open hernia repair leading to early recovery and return to work. Materials and Methods: Laparoscopic hernia repair has been done in 2100 patients from 1995 till now with a follow-up data of 1350 patients. Data was analysed for results and satisfaction. Results: There is a recurrence rate of 0.1%. Early complications include bleeding, trocar injury and nerve pain. Late complications were rare. Conclusion: Laparoscopic inguinal hernia repair has a steep learning curve but after that the results and patient satisfaction are very good. It should be the procedure of choice in all bilateral and recurrent hernias.

Keywords: laparoscopy, hernia, mesh, surgery

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Authors: Saman Namvarrechi, Armin A. Dormeny, Javad Dargahi, Mojtaba Kahrizi

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Since last two decades, minimally invasive surgery (MIS) has grown significantly due to its advantages compared to the traditional open surgery like less physical pain, faster recovery time and better healing condition around incision regions; however, one of the important challenges in MIS is getting an effective sensing feedback within the patient’s body during operations. Therefore, surgeons need efficient tactile sensing like determining the hardness of contact tissue for investigating the patient’s health condition. In such a case, MIS tactile sensors are preferred to be able to provide force/pressure sensing, force position, lump detection, and softness sensing. Among different pressure sensor technologies, the piezoelectric operating principle is the fittest for MIS’s instruments, such as catheters. Using PVDF with its copolymer, TrFE, as a piezoelectric material, is a common method of design and fabrication of a tactile sensor due to its ease of implantation and biocompatibility. In this research, PVDF-TrFE polymer is deposited via spin-coating method and treated with various post-deposition processes to investigate its piezoelectricity and amount of electroactive β phase. These processes include different post thermal annealing, the effect of spin-coating speed, different layer of deposition, and the presence of additional hydrate salt. According to FTIR spectroscopy and SEM images, the amount of the β phase and porosity of each sample is determined. In addition, the optimum experimental study is established by considering every aspect of the fabrication process. This study clearly shows the effective way of deposition and fabrication of a tactile PVDF-TrFE based sensor and an enhancement methodology to have a higher β phase and piezoelectric constant in order to have a better sense of touch at the end effector of biomedical devices.

Keywords: β phase, minimally invasive surgery, piezoelectricity, PVDF-TrFE, tactile sensor

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Authors: Palaniraj Rama Raj, Himeesh Kumar, Paul Adler

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Purpose: To investigate the effect of ultrasound energy, expressed as cumulative dissipated energy (CDE), on short and long-term outcomes after uncomplicated cataract surgery by phacoemulsification. Methods: In this single-surgeon, two-center retrospective study, non-glaucomatous participants who underwent uncomplicated cataract surgery were investigated. Best-corrected visual acuity (BCVA) and intraocular pressure (IOP) were measured at 3 separate time points: pre-operative, Day 1 and ≥1 month. Anterior chamber (AC) inflammation and corneal odema (CO) were assessed at 2 separate time points: Pre-operative and Day 1. Short-term changes (Day 1) in BCVA, IOP, AC and CO and long-term changes (≥1 month) in BCVA and IOP were evaluated as a function of CDE using a multivariate multiple linear regression model, adjusting for age, gender, cataract type and grade, preoperative IOP, preoperative BCVA and duration of long-term follow-up. Results: 110 eyes from 97 non-glaucomatous participants were analysed. 60 (54.55%) were female and 50 (45.45%) were male. The mean (±SD) age was 73.40 (±10.96) years. Higher CDE counts were strongly associated with higher grades of sclerotic nuclear cataracts (p <0.001) and posterior subcapsular cataracts (p <0.036). There was no significant association between CDE counts and cortical cataracts. CDE counts also had a positive correlation with Day 1 CO (p <0.001). There was no correlation between CDE counts and Day 1 AC inflammation. Short-term and long-term changes in post-operative IOP did not demonstrate significant associations with CDE counts (all p >0.05). Though there was no significant correlation between CDE counts and short-term changes in BCVA, higher CDE counts were strongly associated with greater improvements in long-term BCVA (p = 0.011). Conclusion: Though higher CDE counts were strongly associated with higher grades of Day 1 postoperative CO, there appeared to be no detriment to long-term BCVA. Correspondingly, the strong positive correlation between CDE counts and long-term BCVA was likely reflective of the greater severity of underlying cataract type and grade. CDE counts were not associated with short-term or long-term postoperative changes in IOP.

Keywords: cataract surgery, phacoemulsification, cumulative dissipated energy, CDE, surgical outcomes

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Authors: Amrit Vasdev, Edwin Rho, Gurinder Vasdev

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Robotic surgery has enabled a new spectrum of minimally invasive breast reconstruction by improving visualization, surgeon posturing, and improved patient outcomes.1 The DaVinci robot system can be utilized in nipple sparing mastectomies and reconstructions. The process involves the insufflation of the subglandular space and a dissection of the mammary gland with a combination of cautery and blunt dissection. This case outlines a 35-year-old woman who has a long-standing family history of breast cancer and a diagnosis of a deleterious BRCA2 genetic mutation. She has decided to proceed with bilateral nipple sparing mastectomies with implants. Her perioperative mammogram and MRI were negative for masses, however, her left internal mammary lymph node was enlarged. She has taken oral contraceptive pills for 3-5 years and denies DES exposure, radiation therapy, human replacement therapy, or prior breast surgery. She does not smoke and rarely consumes alcohol. During the procedure, the patient received a standardized anesthetic for out-patient surgery of propofol infusion, succinylcholine, sevoflurane, and fentanyl. Aprepitant was given as an antiemetic and preoperative Tylenol and gabapentin for pain management. Concerns for the patient during the procedure included CO2 insufflation into the subcutaneous space. With CO2 insufflation, there is a potential for rapid uptake leading to severe acidosis, embolism, and subcutaneous emphysema.2To mitigate this, it is important to hyperventilate the patient and reduce both the insufflation pressure and the CO2 flow rate to the minimal acceptable by the surgeon. For intraoperative monitoring during this 6-9 hour long procedure, it has been suggested to utilize an Arterial-Line for end-tidal CO2 monitoring. However, in this case, it was not necessary as the patient had excellent cardiovascular reserve, and end-tidal CO2 was within normal limits for the duration of the procedure. A BIS monitor was also utilized to reduce anesthesia burden and to facilitate a prompt discharge from the PACU. Minimal Invasive Robotic Surgery will continue to evolve, and anesthesiologists need to be prepared for the new challenges ahead. Based on our limit number of patients, robotic mastectomy appears to be a safe alternative to open surgery with the promise of clearer tissue demarcation and better cosmetic results.

Keywords: anesthesia, mastectomies, robotic, hypercarbia

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Authors: J. R. Ashrapov, G. A. Alihodzhaeva, D. E. Abdullaev, N. R. Kadirbekov

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Diagnosis of brain tumors is one of the challenges, as several central nervous system diseases run the same symptoms. Modern diagnostic techniques such as CT, MRI helps to significantly improve the surgery in the operating period, after surgery, after allowing time to identify postoperative complications in neurosurgery. Purpose: To study the MRI characteristics and localization of brain tumors in children and to detect the postoperative complications in the postoperative period. Materials and methods: A retrospective study of treatment of 62 children with brain tumors in age from 2 to 5 years was performed. Results of the review: MRI scan of the brain of the 62 patients 52 (83.8%) case revealed a brain tumor. Distribution on MRI of brain tumors found in 15 (24.1%) - glioblastomas, 21 (33.8%) - astrocytomas, 7 (11.2%) - medulloblastomas, 9 (14.5%) - a tumor origin (craniopharyngiomas, chordoma of the skull base). MRI revealed the following characteristic features: an additional sign of the heterogeneous MRI signal of hyper and hypointensive T1 and T2 modes with a different perifocal swelling degree with involvement in the process of brain vessels. The main objectives of postoperative MRI study are the identification of early or late postoperative complications, evaluation of radical surgery, the identification of the extended-growing tumor that (in terms of 3-4 weeks). MRI performed in the following cases: 1. Suspicion of a hematoma (3 days or more) 2. Suspicion continued tumor growth (in terms of 3-4 weeks). Conclusions: Magnetic resonance tomography is a highly informative method of diagnostics of brain tumors in children. MRI also helps to determine the effectiveness and tactics of treatment and the follow up in the postoperative period.

Keywords: brain tumors, children, MRI, treatment

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Authors: Hsiao-Yung Wang

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This essay aims to examine how the discursive formation of the 'transing-nationalism' (which is extended and slightly modified from 'homonationalism') had been constructed in the Taiwanese news media before the legalization of 'sex reassignment surgery (SRS)' in 1988. Samples for rhetorical analysis were selected from two mainstream newspapers, including China Times, and United Daily. The time frame for sample selection is from August 1953 (when the first transgender case was reported) to 1988, while the SRS was legalized in Taiwan. To enhance understanding of media representation as contextualized-based, the author refers to the representative of spatial rhetoric Mikhail Bakhtin for his late study on 'emergence' and 'visualization of time' in Bildungsroman; thereby categorizing the media discourse of transgender into two critical period: (1) transgender as 'misrecognized' and 'included' into the rhetoric of modern medical space; (2) transgender as 'institutionalized' into discourse of protection and salvation by the reified sympathy of nation-state. These two periods and relevant spatial rhetoric were of no immediate concern on the vital interest of transgender individuals; therefore constructed the imagery of transgender for the service of nationalism rather than gender consciousness or human right rhetoric. Based on the research findings, this essay concludes that 'queer multiplicity' should be regarded as not only the guideline for the amendment of the gendered policies and laws but the rhetorical resources for the mobilization of transgender movement in Taiwan from now on.

Keywords: Bakhtin, legalization, rhetoric, sex reassignment surgery, transgender, transing-nationalism

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Authors: A. V. Alabut, V. D. Sikilinda, N. J. Nelasov, O. L. Eroshenko, M. N. Morgunov, I. V. Koroleva

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We have analyzed the results of treatment of 204 patients with knee prosthetic arthroplasty. For the purpose of active delineation of vascular pathology triplex sonography of arterial and venous vessels of low extremities was performed in all cases in the preoperative period. When it was necessary, reconstructive vascular surgery was implemented to improve peripheral circulation and reduce the hazard of thrombosis after knee replacement. The combination of specific and nonspecific methods of thromboprophylaxis was used in perioperative period. On 7-10 day and 2.5-3 month after prosthetic arthroplasty, all patients iteratively underwent triple sonography. In case of detection of floating thrombus, urgent venous ligation was performed. Active diagnostics of venous thrombosis gave the opportunity to avoid fatal pulmonary embolism.

Keywords: knee replacement, venous thrombosis, pulmonary embolism, vascular surgery

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Authors: Waleed Jarjoura

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In various cases of visual impairments, the individuals are referred to expert Ophthalmologists in order to establish a correct diagnosis. Children with visual-impairments confront various challenging experiences in life since early childhood throughout lifespan. In some cases, blind infants, especially due to congenital hydrocephalus, suffer from high intra-cranial pressure and, consequently, go through a ventriculo-peritoneal shunt surgery in order to limit the neurological symptoms or decrease the cognitive impairments. In this article, a detailed description of numerous crucial implications of the V/P shunt surgery, through the right posterior-inferior parieto-temporal cortex, on the observed preliminary capabilities that are pre-requisites for the acquisition of literacy skills in braille, basic Math competencies, braille printing which suggest Gerstmann syndrome in the blind. In addition, significant difficultiesorientation and mobility skills using the Cane, in general, organizational skills, and social interactions were observed. The primary conclusion of this report focuses on raising awareness among neuro-surgeons towards the need for alternative intracranial routes for V/P shunt implantation in blind infants that preserve the right posterior-inferior parieto-temporal cortex that is hypothesized to modulate the tactual-spatial cues in braille discrimination. A second conclusion targets educators and therapists that address the acquired dysfunctionsin blind individuals due to V/P shunt surgeries.

Keywords: congenital blindness, hydrocephalus, shunt surgery, spatial orientation

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Authors: Mohammad Tayefeh Norooz, Amirhossein Kargarzadeh

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Overweight and obesity as an abnormality are health threatening factors. Body mass index (BMI) above 25 is referred to as overweight and above 30 as obese. Apollo Endosurgery, Inc., a pioneering company in endoscopy surgeries, is poised to revolutionize patient care with its minimally invasive treatment options. Some product solutions are designed to improve patient outcomes and redefine the future of healthcare. Weight gain post-weight-loss surgery may stem from an enlarged stomach opening, reducing fullness and increasing food intake. Apollo Endosurgery's OverStitch system, a minimally invasive approach, addresses this by using sutures to reduce stomach opening size. This reflects Apollo's commitment to transformative improvements in healing endoscopy, emphasizing a shift towards minimally invasive options. The system's versatility and precision in full-thickness suturing offer treatment alternatives, exemplified in applications like Endoscopic Sleeve Gastroplasty for reshaping obesity management. Apollo’s dedication to pioneering advancements suggests ongoing breakthroughs in minimally invasive surgery, positioning the OverStitch systems as a testament to innovation in patient care.

Keywords: apollo endosurgery, endoscopic sleeve gastroplasty, weight loss system, overstitch endoscopic suturing system, therapeutic, perforations, fistula

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Authors: Thaminda Liyanage, Chamila Shamika Kurukulasuriya

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Introduction: Morbid obesity has been successfully treated with bariatric surgery for over 60 years. Although operative procedures have improved and associated complications have reduced substantially, surgery still carries the risk of post-operative malabsorption, malnutrition and a range of gastrointestinal disorders. Overweight by itself can impair libido in both sexes and cause erectile dysfunction in males by inducing a state of hypogonadotropic hypogonadism, proportional to the degree of obesity. Impact of weight reduction on libido and sexual activity remains controversial, however it is broadly accepted that weight loss improves sexual drive. Zinc deficiency, subsequent to malabsorption, may lead to impaired testosterone synthesis in men while excessive and/or rapid weight loss in females may result in reversible amenorrhoea leading to sub-fertility. Methods: We describe a 37 year old male, 6 years post Roux-en-Y gastric bypass surgery, who presented with erectile dysfunction, loss of libido, worsening fatigue and generalized weakness for 4 months. He also complained of constipation and frequent muscle cramps but denied having headache, vomiting or visual disturbances. Patient had lost 38 kg of body weight post gastric bypass surgery over four years {135kg (BMI 42.6 kg/m2) to 97 kg (BMI 30.6 kg/m2)} and the weight had been stable for past two years. He had no recognised co-morbidities at the time of the surgery and noted marked improvement in general wellbeing, physical fitness and psychological confident post surgery, up until four months before presentation. Clinical examination revealed dry pale skin with normal body hair distribution, no thyroid nodules or goitre, normal size testicles and normal neurological examination with no visual field defects or diplopia. He had low serum testosterone, follicular stimulating hormone (FSH), luteinizing hormone (LH), T3, T4, thyroid stimulating hormone (TSH), insulin like growth factor 1 (IGF-1) and 24-hour urine cortisol levels. Serum cortisol demonstrated an appropriate rise to ACTH stimulation test but growth hormone (GH) failed increase on insulin tolerance test. Other biochemical and haematological studies were normal, except for low zinc and folate with minimally raised liver enzymes. MRI scan of the head confirmed a solid pituitary mass with no mass effect on optic chiasm. Results: In this patient clinical, biochemical and radiological findings were consistent with anterior pituitary dysfunction. However, there were no features of raised intracranial pressure or neurological compromise. He was commenced on appropriate home replacement therapy and referred for neurosurgical evaluation. Patient reported marked improvement in his symptoms, specially libido and erectile dysfunction, on subsequent follow up visits. Conclusion: Sexual dysfunction coupled with non specific constitutional symptoms has multiple aetiologies. Clinical symptoms out of proportion to nutritional deficiencies post bariatric surgery should be thoroughly investigated. Close long term follow up is crucial for overall success.

Keywords: obesity, bariatric surgery, erectile dysfunction, loss of libido

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Authors: Shang Yee Chong

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Perioperative pain is a complex mechanism activated by various nociceptive, neuropathic, and inflammatory pathways. Opioids have long been a mainstay for analgesia in this period, even as we are continuously moving towards a multimodal model to improve pain control while minimising side effects. Dexmedetomidine, a potent alpha-2 agonist, is a useful sedative and hypnotic agent. Its use in the intensive care unit has been well described, and it is increasingly an adjunct intraoperatively for its opioid sparing effects and to decrease pain scores. We describe a case of a general surgical patient in whom minimal opioids was required with dexmedetomidine use. The patient was a 61-year-old Indian gentleman with a history of hyperlipidaemia and type 2 diabetes mellitus, presenting with rectal adenocarcinoma detected on colonoscopy. He was scheduled for a robotic ultra-low anterior resection. The patient was induced with intravenous fentanyl 75mcg, propofol 160mg and atracurium 40mg. He was intubated conventionally and mechanically ventilated. Anaesthesia was maintained with inhalational desflurane and anaesthetic depth was measured with the Masimo EEG Sedline brain function monitor. An initial intravenous dexmedetomidine dose (bolus) of 1ug/kg for 10 minutes was given prior to anaesthetic induction and thereafter, an infusion of 0.2-0.4ug/kg/hr to the end of surgery. In addition, a bolus dose of intravenous lignocaine 1.5mg/kg followed by an infusion at 1mg/kg/hr throughout the surgery was administered. A total of 10mmol of magnesium sulphate and intravenous paracetamol 1000mg were also given for analgesia. There were no significant episodes of bradycardia or hypotension. A total of intravenous phenylephrine 650mcg was given throughout to maintain the patient’s mean arterial pressure within 10-15mmHg of baseline. The surgical time lasted for 5 hours and 40minutes. Postoperatively the patient was reversed and extubated successfully. He was alert and comfortable and pain scores were minimal in the immediate post op period in the postoperative recovery unit. Time to first analgesia was 4 hours postoperatively – with paracetamol 1g administered. This was given at 6 hourly intervals strictly for 5 days post surgery, along with celecoxib 200mg BD as prescribed by the surgeon regardless of pain scores. Oral oxycodone was prescribed as a rescue analgesic for pain scores > 3/10, but the patient did not require any dose. Neither was there nausea or vomiting. The patient was discharged on postoperative day 5. This case has reinforced the use of dexmedetomidine as an adjunct in general surgery cases, highlighting its excellent opioid-sparing effects. In the entire patient’s hospital stay, the only dose of opioid he received was 75mcg of fentanyl at the time of anaesthetic induction. The patient suffered no opioid adverse effects such as nausea, vomiting or postoperative ileus, and pain scores varied from 0-2/10. However, intravenous lignocaine infusion was also used in this instance, which would have helped improve pain scores. Paracetamol, lignocaine, and dexmedetomidine is thus an effective, opioid-sparing combination of multi-modal analgesia for major abdominal surgery cases.

Keywords: analgesia, dexmedetomidine, general surgery, opioid sparing

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Authors: Alasdair Warwick, Luna Dhir

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Aim: To ascertain the efficacy of overcorrecting minus lens therapy in intermittent distance exotropia. Methods: Retrospective audit of all intermittent distance exotropia patients seen in the Chelsea and Westminster Hospital pediatric eye clinic between 1st January 2014 and 1st March 2016. Change in LogMAR visual acuity, stereopsis, near and distance angles of deviation, as well as the proportions of patients converting to exophoria or undergoing strabismus surgery, were recorded. Results: 22 patients were identified, 45% male, mean age 5 years (range 0.6 to 18.5 years). The median overminus prescription was -1.0 dioptres (range -0.5 to -1.75 dioptres) and mean follow-up was 15 months (range 3 to 54 months). Visual acuity, near and distance angles of deviation improved but were not statistically significant: -0.15 LogMAR, -0.2 prism dioptres and -1.2 prism dioptres respectively (p>0.05). However, a significant change in stereopsis was observed: -74'' (p<0.01). 27% underwent strabismus surgery and 36% converted to exophoria whilst wearing their overminus prescription. Conclusions: Overcorrecting minus lens therapy is an effective therapy for intermittent distance exotropia. There was no deterioration in visual acuity and a significant improvement in stereopsis was seen in our cohort, with many patients converting to an exophoria. The proportion of patients requiring strabismus surgery was comparable to other studies. Further, follow-up is needed to ascertain long-term outcomes.

Keywords: exotropia, overcorrecting minus lens, refraction, strabismus

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Authors: Wisam Ismail, Brendan Wooler, Penelope McManus

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Introduction: The public perception of implants has been damaged in the wake of recent negative publicity and increasingly we are finding patients wanting to avoid them. Planned lipo-modelling to enhance the volume of a Latissimus dorsi flap is a viable alternative to silicone implants and maintains a Totally Autologous Technique (TAT). Here we demonstrate that when compared to an Implant Assisted Technique (IAT), a TAT offers patients many benefits that offset the requirement of more operations initially, with reduced short and long term complications, reduced symmetrisation surgery and reduced revision rates. Methods. Data was collected prospectively over 7 years. The minimum follows up was 3 years. The technique was generally standardized in the hand of one surgeon. All flaps were extended LD flaps (ELD). Lipo-modelling was performed using standard techniques. Outcome measures were unplanned secondary procedures, complication rates, and contralateral symmetrisation surgery rates. Key Results Were: Lower complication rates in the TAT group (18.5% vs. 33.3%), despite higher radiotherapy rates (TAT=49%, IAT=36.8%), TAT was associated with lower subsequent symmetrisation rates (30.6% vs. 50.9%), IAT had a relative risk of 3.1 for subsequent unplanned procedure, Autologous patients required an average of 1.76 sessions of lipo-modelling, Conclusions: Using lipo-modelling to enable totally autologous LD reconstruction offers significant advantages over an implant assisted technique. We have shown a lower subsequent unplanned procedure rate, lower revision surgery, and less contralateral symmetrisation surgery. We anticipate that a TAT will be supported by patient satisfaction surveys and long-term patient-reported cosmetic outcome data and intended to study this.

Keywords: breast, Latissimus dorsi, lipomodelling, reconstruction

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Authors: Charles A. Khamala

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In 2003, constrained by an absent “rule of law culture” and negative economic growth, the new Kenyan government chose to pursue incremental judicial reforms rather than comprehensive constitutional reforms. President Mwai Kibaki’s first administration’s judicial reform strategy was two pronged. First, to implement unprecedented “radical surgery,” he appointed a new Chief Justice who instrumentally recommended that half the purportedly-corrupt judiciary should be removed by Presidential tribunals of inquiry. Second, the replacement High Court judges, initially, instrumentally-endorsed the “radical surgery’s” administrative decisions removing their corrupt predecessors. Meanwhile, retention of the welfare-reducing Constitution perpetuated declining public confidence in judicial institutions culminating in refusal by the dissatisfied opposition party to petition the disputed 2007 presidential election results, alleging biased and corrupt courts. Fatefully, widespread post-election violence ensued. Consequently, the international community prompted the second Kibaki administration to concede to a new Constitution. Suddenly, the High Court then adopted a non-instrumental interpretation to reject the 2003 “radical surgery.” This paper therefore critically analyzes whether the Kenyan court’s inconsistent interpretations–pertaining to the constitutionality of the 2003 “radical surgery” removing corruption from Kenya’s courts–was predicated on political expediency or human rights principles. If justice “must also seen to be done,” then pursuit of the CJ’s, Judicial Service Commission’s and president’s political or economic interests must be limited by respect for the suspected judges and magistrates’ due process rights. The separation of powers doctrine demands that the dismissed judges should have a right of appeal which entails impartial review by a special independent oversight mechanism. Instead, ignoring fundamental rights, Kenya’s new Supreme Court’s interpretation of another round of vetting under the new 2010 Constitution, ousts the High Court’s judicial review jurisdiction altogether, since removal of judicial corruption is “a constitutional imperative, akin to a national duty upon every judicial officer to pave way for judicial realignment and reformulation.”

Keywords: administrative decisions, corruption, fair hearing, judicial review, (non) instrumental

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