Bombay Hospital Journal EDITOR'S CHOICEContentsHomeArchivesSearchBooksFeedback


Arthroscopic Day Care Surgery An Approach to New Millennium
Sanjeev Jain
In 1912, the Swedish internist, Jacobeus, was the first to write about laparoscopy. He used a special endoscope developed for him by the Wolf Company in Germany. In his book about laparoscopy and thoracoscopy, he mentioned the possibility of also looking into the joints. As far as we know, he never did.

The father of Swiss surgeon, Eugen Bircher, acquired a Jacobeus laparoscope at about the same time, and Eugen Bircher tried it in the cadaver knees around 1913 to 1914. Eugen Bircher was also the first to publish about arthroscopy in living patients in 1921. It had earlier been believed that the Japanese researcher, Takagi, in 1918 was the first to inspect a knee through a cystoscope. Eugen Bircher must be given credit for having performed the first-known arthroscopy. In the last 25 years, there has been enormous development of operative arthroscopy. Watanabe in Japan should be credited with performing the first operative arthroscopy in 1957 and for developing the No. 21 arthroscope. Had not the British physicist, Hopkins, invented the rod lens and had Karl Storz in Tuttlingen, Germany, not been smart enough to realize how revolutionary these optics were, operative arthroscopy would never have developed the way it is. John McGinty of USA introduced the use of television into arthroscopy.

Arthroscopy and arthroscopic surgery are among the most rapidly growing techniques developed in the twentieth century. As a technique, arthroscopy is continuing to expand at a rapid rate. During the 1970s the entire emphasis was on the knee. It was in this joint that basic surgical skills were honed; the use of television was developed, and operating from a television monitor, rather than under direct vision, was learned. In the knee, basic procedures were learned: joint inspection, removal of loose bodies, menisectomy meniscal repair, synovectomy, lateral release, abrasion arthroplasty, treatment of osteochondritis dessicans, and management of some fractures. As we moved into the 1980s, these techniques were applied first to the shoulder and then to other joints. Now there is no joint in the body that has not been invaded by arthroscope. Not only are the new procedures being developed, but also techniques with new instrumentation are constantly changing. We are seeing new and different power tools, new and updated video equipment for both viewing and recording, and introduction and refining of laser technology applied to arthroscopy.

During the last three decades, the evolution of arthroscopy has been mercurial. This progress has led us to the threshold of Day Care Arthroscopic Surgery (Office arthroscopy). The first office arthroscopy was performed in December 1989, when a small flap tear of the posterior horn of medial meniscus was removed using basket forceps. Day care arthroscopic surgery is the demand of the day and could be performed for any of the problem of most of the joints of the body.

Day Care (Office) operator, must have room to accommodate video equipment, recording equipment, monitoring equipment, a crash cart with cardiopulmonary resuscitation equipment, an operating room table with leg holder, an autoclave, a Cidex basin, nitrogen and oxygen tanks, and suction equipment. All arthroscopic instruments and good tourniquet is must. Patient can walk into the operating room from office examination table and can be discharged from there as well.

Basic minimal blood investigations are required.
For diagnostic arthroscopy: local anaesthesia, may be a little sedation, is the only thing required. Patient may need short general anaesthesia, especially of shoulder procedure and knee intervention. One shot of intra-operative antibiotics is usually used. Patients are discharged with compression dressings, which is changed on second postoperative day. Pain management is simple. For routine procedure of knee and shoulder usually local anaesthetic agent is injected into the joint, which gives good relief and if needed NSAID could be given as per requirement. For major procedures pain is taken care by pain management team headed by anaesthesiologist.

Gradual physiotherapy and rehabilitation programme is used as per individual patient. Physiotherapy programme is to be followed rigidly during postoperative period. The entire success of these procedures depends on good rehabilitation.

Depending on the nature of procedure, a patient returns to the office in two to three weeks time. The emotional maturity and stability of the patient is an important consideration when deciding whether the procedure should be performed in the office or in the hospital. Preventing complication in the office environment is of paramount importance and can, in most incidents, be directly controlled by the surgeon and his team. Record of office arthroscopy should be in detail, similar to those kept in the hospital. Documentation of every arthroscopic procedure performed, regardless of its complexity or simplicity is of paramount importance. Computerized management of images, videotaping and compact disc [CD] recording are good tools.

Basically, most of the joint can be looked into through arthroscope but this is commonly done for knee and shoulder in more than 95 times. Surgeons should perfect basic technique and any advances must be updated. In the knee, apart from routine diagnostic procedure, treating meniscal and chondral injuries, patellar disorders, synovial biopsy and synovectomy, adhesiolysis, and other many basic procedures are performed as day care surgery. Cruciate reconstruction and any other arthroscopic procedure done along with corrective bony surgery needs more than a day stay in the hospital. In shoulder all kind of procedures are performed as a day care surgery.

As arthroscopy has grown rapidly in geometric proportions with increasing demands of patients expecting decreased morbidity, out patient procedure, more speedy return to work and recreation, media response to use these techniques in sports medicine was an accelerating factor in growth. Instruments to do specific tasks are more advanced; arthroscopy has grown out of the hospital into the surgeon’s office (Day Care); methods of documentations are easier; and the orthopaedic learning centre has realized the need to enhance education.

When doing this, three caveats must be remembered by a surgeon to be an arthroscopic surgeon:
First, a learning curve to all these techniques must be mastered by the surgeon before using them as treatment methods on his patients.

Second, as these procedural techniques develop, their results must be seriously compared with those of other methods before adopting them. It is not advisable for practising surgeon to adopt a new procedure before its results have been established to be comparatively reliable and its efficacy has been proven by one or a group of surgeons who have performed a large number of arthroscopic operations.

Finally, we are in an era when the medical profession is scrutinized under a magnifying glass by the public, the media and the for-profit health care providers. Cost containment has become the by-word for health care. Before undertaking new expensive procedures with expensive instrumentation, we must be able to justify the additional expense. Therefore, we must be sure that as a whole, our efforts result in saving and not in an increase of health care costs.

Office operative arthroscopy is obviously an efficient method of performing arthroscopic surgery for patient and surgeon. The cost saving of the third party payer and the patient are quite significant when compared to the traditional arthroscopic environment such as the hospital operating room and ambulatory surgery centre operating room. The advent of arthroscopic technique made rehabilitation easier and at least early in the course of recovery, because of a resultant decrease in postoperative pain and morbidity of adjacent tissues.

Botulin Toxin-in Day Care Plastic Surgery
Viraj S Tambwekar*, Suresh R Tambwekar**, Kumkum Khadalia***, Rustom P Ginwala+
In recent years, Botulin toxin has been a topic of fervent research, and as with all great discoveries, its use to enhance facial features was discovered more by accident than by intention. Since then, it has gained in popularity and indication. This article gives a brief overview of the clinical application of Botulin toxin in the practise of a plastic surgeon.

Botulin toxin is a neurotoxin, produced by an obligate bacterium, Clostridium botulinum. Botulinum toxin type-A, is a very potent exotoxin and has been used clinically in neuromuscular diseases due to its high potency. It produces its effect by preventing the release of acetylcholine from the pre-synaptic neuron of striated muscles. Simply put-it relaxes the concerned muscle completely, but temporarily, thus abolishing wrinkles / lines that are seen on the skin as a result of the contraction of the muscle.

This principle has been carried further: to use Botulin toxin (BTX-A) to reduce the size and secretions of glands as well.
The use of Botulinum toxin has become one of the most commonly performed office-based procedures in plastic surgery clinics in recent times.

Common indications for the use of this drug are forehead and glabellar frown lines, baggy eyelids, crow’s feet around the eyes, peri-oral frown lines, nasolabial frown lines, dorsal nasal, mental and submental frown lines, wrinkles in the neck, masseter hypertrophy, hyperadenitis suppuritava, hyperhidrosis (with or without osmidrosis) of the axilla, palms and feet.
It is also used to enhance and produce specific features in facial expression such as the shape of the eyebrows.

It is beyond the purview of this article to describe in detail the method of using this drug in all of the above indications; however, it is important to understand the basic principles that need to be followed in order to gain optimum advantage from its use.

A thorough clinical examination is a must to decide the indication (e.g. botulin toxin is contraindicated for baggy eyelids if the snap test is negative).

In all of the above cases, it is of paramount importance to be very familiar with the detailed anatomy of the region, the action of the muscle/s in the region and their nerve supply (to prevent complications such as drooping of eyebrows).
BTX-A should always be diluted before use (4 ml. is a good dilution), however, it should be remembered that increasing the volume of diluted toxin will increase its spread in the muscle and may result in unwanted side effects such as ptosis.
More often than not, to achieve optimum results, this drug is used as an adjuvant to surgical therapy or concomitantly with biological filler substances.

The Effect
The effect of BTX-A is seen in a couple of days and is transient. The effect typically wears off in 6-8 months time and varies from case to case. However, this procedure is gaining in popularity with people who want a quick and cheap solution to enhancing their appearance for a specific cause, such as, a marriage or a modelling assignment. When I say cheap, I am comparing cost to that involved with a surgical procedure, such as, a blepharoplasty or a face-lift or brow lift.
Patients may require a touch up if the desired result is not obtained with the first injection, especially if a low dose has been used initially to “err on the side of safety.”

Side Effects
Side effects if any are minimal and transient, with the exception of ptosis.
The most common are pain, minor local swelling, ecchymosis, headache, nausea, and a small area of transitory numbness.

One patient had a vasovagal attack; however that was attributed to the fact that he was extremely anxious and was fasting as well, thus making it difficult to rule out hypoglycaemia as the cause of giddiness, profuse sweating and a drop in his blood pressure.

Dilution of the toxin is very important and has to be done with extreme gentleness as any vigorous movements bring down the potency of the drug.

The area to be injected should be free of any inflammation (pimples, etc.), or any kind of skin lesion.
It is necessary to inject a small amount of the drug in specific areas and then, to spread it around gently with even pressure, to achieve good results.

Most importantly, adequate training is necessary before commencing practice, as this is not “just another injection”.
The undiluted drug should be stored in a freezer and once it has been diluted, on the shelf of the fridge door. It can be stored for between eight and ten days in such a fashion. (In a personal communication with Dr. Woffles Wu, who has been using this drug for quite a while now, and is one of the foremost plastic surgeons using it, we were made to understand that the reconstituted drug may be used for up to two weeks, with a marginal decrease in its potency).
There are many companies worldwide that manufacture this drug, and it is marketed under various trade names. It is important to choose a company whose drug potency and purity can be relied on and not necessarily the cheapest available.

Yes, botulin toxin has arrived and the results achieved are akin to a miracle of sorts. We must remember that the goal of treatment is to make the face appear more youthful and fresh, as opposed to mask like, which might be the case if the treating plastic surgeon is too enthusiastic and aggressive.

Great maturity is to be exercised while planning the procedure and the patient properly counselled to avoid dissatisfaction.

1. Christos Naoum, Dimitra Dasiou - Plakida. Dermal Filler Materials and Botulin Toxin. International Journal of Dermatology 2001; 40 : 609-621.
2. K. Pavithran. Botulinum Toxin in Dermatology. What’s New? In Dermatology, STDs and Leprosy. 2003; 34 : 2-8.
3. Alan Matarasso, Olivia H. Z. Hutchinson. Evaluating Rejuvenation of the Forehead and Brow: An Algorithm for Selecting the Appropriate Technique. 2000; 106 (3) : 687-694.
4. Steven Silberstein, Ninan Mathew, Joel Saper, Stephen Jenkins, for BOTOX Migraine Clinical Research Group. Headache 2000; 40 : 445-450.
5. Alister Carruthers, Ki Young Ahn, Mee Young Park, Sung Hai Park. The Advanced use of BOTOX in the Face and Neck, presented at Seoul, Korea. 9/12/01.

Daycare Coronary Angioplasty
BK Goyal, Ramesh Kawar, BC Kalmath, Anil Sharma

Twenty-five years have passed since the beginning of clinical interventional cardiology, the first human coronary angioplasty was procedure performed by Andreas Gruentzig on 16th September 1977, at Zurich. Percutaneous transluminal coronary angioplasty (PTCA), usually simply called angioplasty, involves opening the blocked coronary artery. Before the advent of coronary angioplasty, CABG (coronary artery bypass surgery) was the only hope for patients with coronary artery disease.

Indications for coronary angioplasty have been dramatically changed during the last 25 years. Initially coronary angioplasties were feasible in limited number of cases with discrete block in one vessel, with good pumping of heart, CABG for the rest. Presently, most of the blocks can be removed with angioplasty including complex lesions like totally occluded artery, multiple blocks in multiple vessels, post CABG grafts, and acute myocardial infarction (heart attack).

Day Care procedure
Plain balloon angioplasty has limitations, the risk of acute closure of artery, need for urgent CABG and re-stenosis rate up to 50%. To combat these complications, Puel and Ulrich Sigwart used coronary stents first time in 1986. Stent is a slotted tube or ring like structure, made up of stainless steel or nitinol and it acts as a scaffold. Presently the restenosis rate of stents (non drug eluting) is around 15%. Radiation therapy has been used to reduce the restenosis rate. Recently developed drug eluting stents are claiming nearly 0% restenosis. Hopefully this may bypass the bypass surgery (CABG).
During coronary angiography and angioplasty the patient remains fully conscious. It is done under local anaesthesia given at groin or hand, unlike bypass surgery, which requires general anaesthesia. A small tube (sheath) is inserted in the femoral artery (groin) or radial artery (hand). Through this sheath, long tube (catheter) of about 2 mm diameter is passed and kept at the mouth of the coronary artery. Coronary arteries are visualized by injecting dye through these catheters.
For coronary angioplasty thin wire is passed in the coronary artery via the catheter. The deflated balloon is passed over the wire and inflated at the site of coronary artery block to compress the plaque against the wall of the artery. In the same way coronary stent is deployed at the site of block to keep the artery open afterwards.

Unlike bypass surgery (CABG), which requires two weeks hospitalization and six weeks for full recovery with significant loss of manpower, in angioplasty most of the patients can be discharged from hospital same day (transradial) or next day (transfemoral) to resume full duty with no scar. In angiography patient can be discharged either in 2 hrs. (transradial) or in 6 hrs. (transfemoral).

The femoral artery, the traditional entry site, is the most appealing approach for coronary angioplasty, because of ease of arterial cannulation and catheter manipulation. However, there are several important limitations associated with this entry site. The femoral artery usually runs deep under the skin, especially in obese patients, close to the femoral vein and nerve. Following removal of the arterial sheath, after angioplasty, bleeding complications are difficult to prevent, despite careful haemostasis techniques and prolonged immobilization of the patient.

On the contrary, the radial artery is a potentially safer entry site for several reasons. The superficial course of this artery facilitates haemostasis, by simple application of a pressure bandage over the puncture site. Important bleeding is immediately noticed by the patient, who can at least temporarily address this problem by himself. This is one of the reasons that blood loss is usually minimal. Since the median nerve is well separated from the artery, this structure is usually not damaged during puncturing or during bleeding. The absence of major veins makes the incidence of arteriovenous fistula rare.

Lucien Campeau, pioneered this transradial technique for diagnostic coronary studies. Kiemeneij performed the first coronary angioplasty in 1992 by transradial approach.

However, this transradial coronary angioplasty technique appeared to be technically more demanding compared to the traditional femoral technique, since smaller guiding catheters have to be used. In addition, these catheters are approaching the coronary arteries from the right side instead of left side making adequate coronary cannulation a greater challenge. Downsized angioplasty equipments have to be selected, requiring more delicate handling.
The price to pay for this safe and elegant technique is a new learning curve. The reward of this effort will be apparent after the procedure, since no manpower is required to obtain haemostasis and since bleeding complications are very uncommon.

One of the most striking advantages is the free and immediate ambulation of the patients, which is greatly appreciated in most instances. Free mobilization, without additional risk for bleeding, opens the way to outpatient or daycare coronary angioplasty, reducing costs and increasing efficiency of coronary angioplasty and patient comfort. Waiting lists can be shortened, by increased turnover on the cardiology ward.
Lately, we are performing angiographies and angioplasties through radial artery regularly at Bombay Hospital, which avoids a lot of discomfort to the patient, as he is fully mobile after the procedure, and can be discharged the same day.

To Section TOC
Sponsor-Dr.Reddy's Lab