A collection of recent journal abstracts and other references from the veterinary and human surgical laparoscopy and endosurgery literature

Recent Veterinary Laparoscopy References

Canine and Feline Laparoscopy

Making a rational choice between ovariectomy and ovariohysterectomy in the dog: a discussion of the benefits of either technique.
van Goethem B, Schaefers-Okkens A, Kirpensteijn J. Vet Surg. 2006 Feb;35(2):136-43.
OBJECTIVE: To determine if ovariectomy (OVE) is a safe alternative to ovariohysterectomy (OVH) for canine gonadectomy. STUDY DESIGN: Literature review. METHODS: An on-line bibliographic search in MEDLINE and PubMed was performed in December 2004, covering the period 1969-2004. Relevant studies were compared and evaluated with regard to study design, surgical technique, and both short-term and long-term follow-up. CONCLUSIONS: OVH is technically more complicated, time consuming, and is probably associated with greater morbidity (larger incision, more intraoperative trauma, increased discomfort) compared with OVE. No significant differences between techniques were observed for incidence of long-term urogenital problems, including endometritis/pyometra and urinary incontinence, making OVE the preferred method of gonadectomy in the healthy bitch. CLINICAL RELEVANCE: Canine OVE can replace OVH as the procedure of choice for routine neutering of healthy female dogs.

Prospective Evaluation of Laparoscopic Pancreatic Biopsies in 11 Healthy Cats
K.L. Cosford, C.L. Shmon, S.L. Myers, S.M. Taylor, A.P. Carr, J.M. Steiner, J.S. Suchodolski,F. Mantovani, Journal of Veterinary Internal Medicine, 2010, Volume 24 Issue 1, Pages 104 - 113
BACKGROUND: Definitive diagnosis of feline pancreatic disease is dependent on histologic examination of biopsies. HYPOTHESIS: Laparoscopic punch biopsy of the pancreas does not significantly affect pancreatic health or clinical status of healthy cats, and provides an adequate biopsy sample for histopathology. ANIMALS: Eleven healthy female domestic shorthair cats. METHODS: Effects of laparoscopic pancreatic visualization alone in 5 cats compared with laparoscopic pancreatic visualization and punch biopsy in 6 cats were studied. Temperature, pulse, and respiratory rate, physical examination, and daily caloric intake were evaluated for 1 week before and 1 week after the procedure. Pain scores (simple descriptive score and dynamic interactive visual assessment score) were evaluated hourly during the 1st 6 hours postprocedure. Complete blood cell counts, serum biochemical profiles, serum feline pancreatic lipase immunoreactivity, and urine specific gravity were evaluated before the procedure and at 6, 24, and 72 hours postprocedure. One month postprocedure, during sterilization, the pancreas was reassessed visually in all cats, and microscopically in the biopsy group. RESULTS: For all variables evaluated, there were no significant differences between biopsy and control cats. Re-evaluation of the pancreatic biopsy site 1 month later documented a normal tissue response to biopsy. The laparoscopic punch biopsy forceps provided high-quality pancreatic biopsy samples with an average size of 5 mm × 4 mm on 2-dimensional cut section. CONCLUSIONS: Laparoscopic pancreatic biopsy is a useful and safe technique in healthy cats.

Laparoscopic ovariectomy in dogs: comparison between single portal and two-portal access.
Dupré G, Fiorbianco V, Skalicky M, Gültiken N, Ay SS, Findik M. Vet Surg. 2009 Oct;38(7):818-24.
OBJECTIVE: To compare surgical times and perioperative complication rates of single portal access and 2-portal laparoscopic ovariectomy (LapOVE) in dogs using a bipolar vessel sealer/divider device, and to evaluate the performance of novice laparoscopists for right ovariectomy. STUDY DESIGN: Controlled clinical trial. ANIMALS: Female dogs (n=42). METHODS: Dogs were divided into groups: 1=single portal and 2=2 portal. LapOVE was performed using a 5 mm vessel sealer/divider device and a 10 mm operating laparoscope (Group 1) or a 5 mm laparoscope (Group 2). Dog characteristics (weight, body condition score, ovarian ligament fat score), operative time, and perioperative complication rate were compared between groups. Right ovariectomy duration was evaluated for 2 novice laparoscopists. RESULTS: No significant difference was found in mean total surgical time between group 1 (21.07 min/s) and group 2 (19.06 min/s). Factors significantly affecting times included body condition scores, ovarian ligament fat score, ovarian bleeding, and surgeon expertise. Minor complications (bleeding from ovaries or after splenic trauma) occurred and were similar in both groups. Bleeding was correlated to body condition score and ovarian ligament fat score. Interindividual differences were found among surgeons for right ovariectomy time. CONCLUSIONS: Single portal access LapOVE using vessel sealer/divider device is feasible, safe, and does not significantly increase total surgical time in comparison with 2-portal approach. Laparoscopic skills may play a role in ability to perform single portal LapOVE. CLINICAL RELEVANCE: LapOVE can be performed using single portal access.

The effect of laparoscopic versus open ovariectomy on postsurgical activity in small dogs.
Culp WT, Mayhew PD, Brown DC. Vet Surg. 2009 Oct;38(7):811-7.
OBJECTIVE: To describe a technique for laparoscopic ovariectomy (LapOVE) in small dogs, and compare the surgical time, complications, and postoperative activity of dogs undergoing LapOVE to those undergoing conventional traditional open ovariectomy (OOVE). STUDY DESIGN: A randomized, controlled clinical trial. ANIMALS: Intact small breed (<10 kg) female dogs (n=20). METHODS: Ventral median celiotomy was performed for OOVE. A 2-midline portal technique using a 3.5 mm laparoscope port and a 6 mm instrument portal was used for LapOVE. An accelerometer was attached to the collar of each dog to record 24-hour preoperative and 48-hour postoperative activity. Total activity counts recorded before surgery were compared with total counts recorded after surgery. The percent change in counts after surgery was compared between OOVE- and LapOVE-treated dogs. RESULTS: No major complications occurred and surgical time for LapOVE was significantly longer than for OOVE cases (P=.005). Dogs in the LapOVE group had a 25% decrease in total activity counts after surgery (95% confidence interval [CI]: 11-38%), whereas dogs in the OOVE group had a 62% decrease in total activity counts after surgery (95% CI: 48-76%). CONCLUSIONS: Both procedures were performed with reasonable surgical times and without major complication. Postoperative activity, as measured by accelerometry, was significantly different between the 2 groups. CLINICAL RELEVANCE: Laparoscopy is a safe method for ovariectomy in small dogs and results in increased postoperative activity counts when compared with an open technique.

Prospective evaluation of two intracorporeally sutured prophylactic laparoscopic gastropexy techniques compared with laparoscopic-assisted gastropexy in dogs.
Mayhew PD, Brown DC. Vet Surg. 2009 Aug;38(6):738-46.
OBJECTIVE: To report technique, surgical time, complication rate, and postoperative activity in dogs undergoing 2 intracorporeally-sutured total laparoscopic gastropexy (TLG) techniques compared with a laparoscopic-assisted gastropexy (LAG) technique. STUDY DESIGN: Randomized clinical trial. ANIMALS: Dogs (n=30) weighing >25 kg. Methods: Dogs were randomly assigned to 1 of 3 groups. Two TLG techniques were performed using a median 3 portal technique. One of 2 suturing techniques was used to approximate corresponding incisions made in the stomach and body wall; using intracorporeal hand-suturing or a suture-assist device (Endostitch). In a 3rd group, a previously reported LAG technique was used. All dogs had an activity monitor placed for 7 days pre- and postoperatively. Linear regression analyses were performed to evaluate the association of surgical procedure on gastropexy time and the percentage change in activity counts. RESULTS: Median gastropexy time was 28 minutes (range, 20-41 minutes) for LAG, 48 minutes (range, 39-61 minutes) for the hand suture TLG technique, and 56 minutes (range, 30-90 minutes) for the Endostitch TLG technique. LAG was performed faster than TLG (P<.05). LAG dogs had a greater decrease in postoperative activity than TLG dogs (P=.005); however there was no difference in surgical time or postoperative activity between TLG techniques. CONCLUSIONS: TLG can be performed safely and effectively in dogs and although it takes longer, it has less impact on postoperative activity compared with LAG. CLINICAL RELEVANCE: TLG techniques may have advantages over LAG as measured by a greater willingness of dogs to move around postoperatively.

Evaluation of creatine kinase (CK) and aspartate aminotransferase (AST) activities after laparoscopic or conventional ovariectomy in queens.
Alves AE, Ribeiro AP, Filippo PA, Apparicio MF, Motheo TF, Mostachio GQ, Vicente WR, Hotston Moore A. Schweiz Arch Tierheilkd. 2009 May;151(5):223-7.
Creatine kinase (CK) and aspartate aminotransferase (AST) are mainly muscle-specific enzymes, which can be associated with muscle tissue damage. The aim of this study was to assess the activities of CK and AST during the postoperative period, after conventional (G1) and videolaparoscopic ovariectomy (G2), in queens. A further group (G3) was subjected to anaesthesia only. Results demonstrate that there were significant differences between groups. The highest levels of CK were recorded in G1, however at a confidence level of p<0.05 there was no significant difference between groups during the first 6 hours after surgery. A significant (p<0.05) increase of CK values was identified between 0 h and 3 h in both groups (G1 and G2). Regarding AST activity there was no significant variation between groups, but again there was a significant difference between values at 0 h and 3h after surgery. In conclusion, ovariectomy performed by videolaparoscopy seems to cause less muscle damage when compared to the conventional method.

Laparoscopic cholecystectomy for management of uncomplicated gall bladder mucocele in six dogs.
Mayhew PD, Mehler SJ, Radhakrishnan A. Vet Surg. 2008 Oct;37(7):625-30.
OBJECTIVES: To describe a technique for, and outcome after, laparoscopic cholecystectomy (LC) for management of uncomplicated gall bladder mucocele (GBM) in dogs. STUDY DESIGN: Case series. ANIMALS: Dogs (n=6) with uncomplicated GBM. METHODS: Dogs with ultrasonographic evidence of GBM but without imaging or laboratory signs of gall bladder rupture, peritonitis, or extra-hepatic biliary tract rupture that had LC were included. A 4 portal technique was used. A fan retractor was used to retract the gall bladder to allow dissection around the cystic duct with 5 or 10 mm right-angle dissecting forceps. The cystic duct was ligated using extracorporeally tied ligatures supplemented sometimes with hemostatic clips. A harmonic scalpel was used to dissect the gall bladder from its fossa. The gall bladder was placed into a specimen retrieval bag and after bile aspiration the bag was withdrawn through the 11 mm portal incision. RESULTS: Five dogs had mild intermittent clinical signs including vomiting, inappetence, and lethargy. All dogs had successful LC without conversion to an open approach. All dogs with clinical signs had improvement or resolution of signs postoperatively. No important perioperative complications occurred and all dogs were alive at a median of 8 months postoperatively (range, 3-14 months). CONCLUSIONS: LC can be accomplished safely and effectively in dogs with uncomplicated GBM. CLINICAL RELEVANCE: A minimally invasive approach for cholecystectomy can be used for the treatment of GBM in dogs.

Laparoscopic diagnosis of pancreatic disease in dogs and cats.
Webb CB, Trott C. J Vet Intern Med. 2008 Nov-Dec;22(6):1263-6. Epub 2008 Aug 25.
BACKGROUND: Histopathology is the gold standard for the diagnosis of pancreatic disease. Laparoscopy offers a minimally invasive route by which to obtain pancreatic biopsies. HYPOTHESIS: Laparoscopy is a safe and effective technique for evaluating the pancreas in small animal patients. ANIMALS: Medical records of 18 dogs and 13 cats examined between 1999 and 2007 that underwent laparoscopy during which observation or biopsy of the pancreas was recorded. METHODS: The database for the Laparoscopy Laboratory at Colorado State University was searched for records that contained "pancreatitis,""pancreas," or "pancreatic." The presenting complaints, imaging studies, and histopathologic findings of animals were recorded. All hospital admissions were searched for animals with the same presenting complaints and of those it was determined which animals had exploratory surgery and their pancreas biopsied. RESULTS: Thirteen cats and 18 dogs underwent laparoscopy for presumptive pancreatic disease or had the appearance of the pancreas described, pancreatic biopsies obtained, or both. In 14 animals a laparoscopic biopsy of the pancreas resulted in a histopathologic diagnosis when the sonographic findings or the gross assessment failed to do so. In 35% of the animals a biopsy of the pancreas was not obtained despite findings consistent with pancreatic disease. Those animals examined for vomiting or anorexia were significantly more likely to have a biopsy of the pancreas obtained through laparoscopy versus surgery (P < .0001). CONCLUSIONS AND CLINICAL IMPORTANCE: Laparoscopy and pancreatic biopsy is useful for evaluation of pancreatic disease.

Comparison of three techniques for ovarian pedicle hemostasis during laparoscopic-assisted ovariohysterectomy.
Mayhew PD, Brown DC. Vet Surg. 2007 Aug;36(6):541-7.
OBJECTIVE: To describe the safety, surgical time, and complications associated with 3 techniques for achieving hemostasis during laparoscopic-assisted ovariohysterectomy (LAOVH). STUDY DESIGN: Prospective, randomized clinical trial. ANIMALS: Female dogs (n=30). METHODS: Dogs were randomly assigned to 1 of 3 methods for achieving ovarian pedicle hemostasis during LAOVH: extracorporeal modified Roeder knot application (suture group), metal clip application using a multifire 10 mm laparoscopic clip applier (clip group), or use of a novel 5 mm bipolar vessel-sealing device (vessel-sealing group). In all dogs a 3 median portal technique was used. RESULTS: Controlling for the dogs' bodyweights, there was a significant association between surgical time and which method for hemostasis was used. This association was different when comparing the first 5 procedures using each method to the second 5. For a 20 kg dog, the surgical time (95% CI) for the first 5 procedures was 80 (69-91), 68 (57-79), and 33 (21-45) minutes for the suture, clip, and vessel-sealing groups, respectively. For the second 5 procedures surgical time was 71 (60-81), 50 (39-60), and 40 (29-51) minutes. Pedicle hemorrhage occurred in all dogs in the clip group, 3 dogs in the suture group, and none of the dogs in the vessel-sealing group although in all cases was considered hemodynamically inconsequential. All dogs recovered uneventfully. CONCLUSIONS: All methods of hemostasis were safe for pedicle sectioning. A learning curve exists for clip and suture methods. CLINICAL RELEVANCE: Use of a vessel-sealing device significantly shortens surgical time and provides excellent hemostasis during LAOVH.

Equine & Bovine Laparoscopy

Laparoscopic mesh incisional hernioplasty in five horses.
Caron JP, Mehler SJ. Vet Surg. 2009 Apr;38(3):318-25.
OBJECTIVE: To report a technique for incisional hernioplasty in horses using laparoscopic placement of a prosthetic mesh. STUDY DESIGN: Case series. ANIMALS: Horses (n=5) with ventral median abdominal incisional hernia. METHODS: A telescope and 2 instrument portals were established bilaterally, lateral to and distant from the hernia margins. After exposure of the internal rectus sheath by removal of retroperitoneal fat with endoscopic scissors and monopolar cautery, a prosthetic mesh was introduced into the abdomen and secured intraperitoneally using transfascial sutures with or without supplemental endoscopic hernia fixation devices. RESULTS: Successful placement of the prostheses was achieved without major intra- or postoperative complications. Repairs were intact in all horses (follow-up range: 6-23 months) without evidence of adhesion formation. Cosmetic results compared favorably with those typically achieved using conventional, open hernioplasty techniques. CONCLUSION: Incisional hernia repair in horses can be successfully achieved with a laparoscopic intraperitoneal mesh onlay technique. CLINICAL RELEVANCE: Laparoscopic mesh hernioplasty has promise as a safe and effective method for repair of incisional hernias in horses.

Unilateral and bilateral laparoscopic ovariectomy of mares by electrocautery.
Smith LJ, Mair TS. Vet Rec. 2008 Sep 6;163(10):297-300.
Twelve horses underwent standing laparoscopic ovariectomy using electrocoagulation and fine dissection as the only means of achieving haemostasis of the severed ovarian pedicle. Four mares had bilateral ovariectomy performed as a treatment for aggressive behaviour thought to be associated with the oestrous cycle. Eight mares had unilateral ovariectomy performed for removal of a granulosa thecal cell tumour (GCT). Electrocoagulation provided an effective means of haemostasis in both normal and pathological ovaries. Only one case (removal of a GCT) had mild haemorrhage following electrocoagulation, necessitating the need for the application of endoscopic clips to achieve haemostasis. Six of the horses developed minor wound complications (none of them requiring any additional treatment). Long-term follow-up information showed complete resolution of abnormal behaviour in all eight horses with GCTs, but in one of the four horses with normal ovaries the aggressive behaviour had not been completely resolved.

Evaluation of a laparoscopic technique for collection of serial full-thickness small intestinal biopsy specimens in standing sedated horses.
Bracamonte JL, Bouré LP, Geor RJ, Runciman JR, Nykamp SG, Cruz AM, Teeter MG, Waterfall HL. Am J Vet Res. 2008 Mar;69(3):431-9.
OBJECTIVE: To assess a technique for laparoscopic collection of serial full-thickness small intestinal biopsy specimens in horses. ANIMALS:13 healthy adult horses. PROCEDURES: In the ex vivo portion of the study, sections of duodenum and jejunum obtained from 6 horses immediately after euthanasia were divided into 3 segments. Each segment was randomly assigned to the control group, the double-layer hand-sewn closure group, or the endoscopic linear stapler (ELS) group. Bursting strength and bursting wall tension were measured and compared among groups; luminal diameter reduction at the biopsy site was compared between the biopsy groups. In the in vivo portion of the study, serial full-thickness small intestinal biopsy specimens were laparoscopically collected with an ELS from the descending duodenum and distal portion of the jejunum at monthly intervals in 7 sedated, standing horses. Biopsy specimens were evaluated for suitability for histologic examination. RESULTS: Mean bursting strength and bursting wall tension were significantly lower in the ELS group than in the hand-sewn and control groups in both the duodenal and jejunal segments. Use of the hand-sewn closure technique at the biopsy site reduced luminal diameter significantly more than use of the stapling technique. In the in vivo part of the study, all 52 biopsy specimens collected during 26 laparoscopic procedures were suitable for histologic examination and no clinically important perioperative complications developed. CONCLUSIONS AND CLINICAL RELEVANCE: Laparoscopic collection of serial full-thickness small intestinal biopsy specimens with a 45-mm ELS may be an effective and safe technique for use in healthy adult experimental horses.

Left- and right-sided laparoscopic-assisted nephrectomy in standing horses with unilateral renal disease.
Röcken M, Mosel G, Stehle C, Rass J, Litzke LF. Vet Surg. 2007 Aug;36(6):568-72.
OBJECTIVE: To describe a technique for, and outcome after, left- or right-sided laparoscopic-assisted nephrectomy in standing horses with unilateral renal disease. STUDY DESIGN: Clinical report. ANIMALS: Horses (n=3) with unilateral renal disease. METHODS: Horses were sedated with detomidine (0.01 mg/kg intravenously [IV]) and levomethadone (0.05 mg/kg IV). Paravertebral anesthesia and infiltration-anesthesia with 2% lidocaine were used to create a surgical field incorporating the 17th intercostal space and paralumbar fossa. Two separate, ipsilateral portals and a mini-laparotomy were used. The perirenal peritoneum was horizontally incised (10-15 cm) using endoscissors and the incision digitally enlarged for manual dissection of the perirenal fat and kidney mobilization. The renal vessels and ureter were individually dissected, ligated, and transected under laparoscopic observation and the kidney removed. The perirenal and laparotomy peritoneal defects were not closed; and the laparotomy was closed in a multilayered fashion. The transverse abdominal muscle was apposed in a continuous pattern using 1 polyglactin 910, the subcutaneous tissue (simple continuous pattern) and skin (simple interrupted pattern) with 2-0 polyglactin 910. RESULTS: Left (2) and right (1) sided laparoscopic-assisted nephrectomy (1 nephrolithiasis, 2 hydronephrosis) was performed successfully. Sedation and local anesthesia was adequate for intraoperative immobilization and analgesia. No intraoperative complications occurred. Incisional seroma formation and fever occurred on days 3 and 4 in 1 horse and resolved with medical management. CONCLUSION: Laparoscopic-assisted nephrectomy can be used for removal of the left or right kidney in standing horses with unilateral kidney disease. CLINICAL RELEVANCE: To avoid risks associated with general anesthesia and to reduce surgical trauma, laparoscopic-assisted nephrectomy can be performed in the standing sedated horse using a 2 portal technique and a mini-laparotomy.

Laparoscopic hernioplasty in recumbent horses using transposition of a peritoneal flap.
Rossignol F, Perrin R, Boening KJ. Vet Surg. 2007 Aug;36(6):557-62.
OBJECTIVE: To evaluate the efficacy of a laparoscopic peritoneal flap hernioplasty (PFH) to close anatomically the vaginal ring and to evaluate its protective effect in horses with a history of strangulated inguinal hernia (SIH) against future herniation. STUDY DESIGN: Prospective study. ANIMALS: A first group of 5 ponies, 3 horses and 1 donkey with no history of SIH and a second group of 4 horses 'clinical cases' with a history of SIH. METHODS: A laparoscopic PFH was effected on all horses under general anaesthesia. Peritoneum ventro-lateral to the vaginal ring was elevated and cut on 3 sides, separated from the underlying muscle, then inverted and attached dorso-medially and laterally to the parietal wall using intra-corporeal stitches (6 cases) or laparoscopic staples (7 cases). Animals of the first group (n=9) underwent a standing laparoscopy 7 days post-operatively to visualize the vaginal rings. Horses of the second group were followed to confirm the absence of re-herniation. RESULTS: The laparoscopic check-up showed that the vaginal ring had been effectively and completely covered in all cases except the first one. No adhesions was observed. In the four clinical cases, none of the horses have had a reccurence of SIH at the time of writing (6 months to 4 years). CONCLUSION: Laparoscopic hernioplasty on a recumbent horse is feasible by closing the vaginal ring with a peritoneal flap. This technique was efficient in our cases to prevent recurrence of SIH but more cases are needed. This technique may reduce inflammation and irritation of the spermatic cord, which could otherwise jeopardise the animal's breeding career. CLINICAL RELEVANCE: Laparoscopic PFH coud be used in horses with a history of SIH.

Laparoscopic reposition and fixation of the left displaced abomasum in cattle. [Article in German]
Janowitz H. Tierarztl Prax Ausg G Grosstiere Nutztiere. 1998 Nov;26(6):308-13.
Abstract: This article explains a minimally invasive technique for surgical correction of the left displaced abomasum in cattle. Endoscopic photographs show how the abomasum will be deflated, replaced and percutaneously fixed. Laparoscopy makes it possible to fix the fundus of the abomasum in all clinical conditions, independent of size, gas filling and fluid in abomasum and rumen. Especially cases with extremely dilated abomasum and cases with small quantity of gas within the abomasum are no problem in percutaneous abomasopexy. Fixation of the pyloric part of the abomasum or other abdominal structures are avoided. Adhesions of the abomasum to the rumen or the left body wall and other pathologic conditions can be seen.

Bird and Reptile Endosurgery

An endoscopic method for identifying sex of hatchling Chinese box turtles and comparison of general versus local anesthesia for coelioscopy.
Hernandez-Divers SJ, Stahl SJ, Farrell R.J Am Vet Med Assoc. 2009 Mar 15;234(6):800-4.
OBJECTIVE: To establish a safe and effective endoscopic method for visualizing the gonads and identifying the sex of hatchling Chinese box turtles and to compare the effects of general versus local anesthesia during coelioscopy. DESIGN: Clinical trial. ANIMALS: 58 hatchling Chinese box turtles (Cuora flavomarginata). PROCEDURES: Turtles were randomly assigned to be anesthetized with a mixture of ketamine, medetomidine, and morphine (n = 29) or to receive local anesthesia with lidocaine in the prefemoral region (29). Coelioscopy was performed with a rigid 1.9- or 2.7-mm telescope following insufflation with sterile lactated Ringer's solution. Ease of endoscopic sex identification and quality of anesthesia were scored. Body weights were recorded before and 7 and 14 days after surgery. RESULTS: Gonads were easily visualized and sex was easily identified in all 58 turtles without complications. Endoscopy scores and pre- and postoperative weights did not differ significantly between groups. However, anesthesia scores were significantly worse for animals that received local anesthesia alone, compared with those that underwent general anesthesia. All anesthetized turtles recovered within 21 minutes after administration of the reversal agents, atipamezole and naloxone. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested that coelioscopy with a rigid endoscope and lactated Ringer's solution for insufflation was a safe and effective method for identifying the sex of hatchling Chinese box turtles. General anesthesia was effective and effects were rapidly reversible; local anesthesia with lidocaine alone was considered insufficient for coelioscopy.

Endoscopic orchidectomy and salpingohysterectomy of pigeons (Columba livia): an avian model for minimally invasive endosurgery.
Hernandez-Divers SJ, Stahl SJ, Wilson GH, McBride M, Hernandez-Divers SM, Cooper T, Stedman N.J Avian Med Surg. 2007 Mar;21(1):22-37.
To evaluate a minimally invasive endosurgical system in birds, endoscopic orchidectomy and salpingohysterectomy were evaluated in 11 male and 14 female pigeons (Columba livia). Anesthesia was maintained by using isoflurane delivered by a pressure-cycle ventilator and produced good to excellent anesthesia during 96% of procedures. Endosurgery was performed with a 2.7-mm telescope system, 3-mm human pediatric laparoscopy instruments, and a 4.0-MHz radiofrequency device. Mean +/- SD surgery times for bilateral orchidectomy and salpingohysterectomy procedures were 39 +/- 18 minutes and 34 +/- 15 minutes, respectively. Procedures were generally straightforward, with any minor complications easily overcome. Surgical complications were generally minor, with mild hemorrhage and focal coagulative damage to the kidney being most common. All pigeons recovered quickly (20 +/- 11 minutes), with 95% displaying good to excellent recoveries. No birds exhibited any clinically apparent morbidity or mortality associated with endosurgery. At least 1 male and 1 female bird were subjected to elective euthanasia and necropsy on postoperative days 1, 3, 5, 10, 20, and 90 to determine the success and side effects of surgery. Gross and histologic abnormalities, when observed, were generally mild, with hemorrhage and partial necrosis of the cranial kidney present in 27% of males. Mild damage or hematoma associated with the left kidney was also reported in 28% of females. The surgical objectives were achieved in 23 of 25 pigeons. The 2 surgical failures (regenerated testes in a male and large oviductal remnant in a female) were attributed to endosurgical inexperience and occurred during the first procedures. Salpingohysterectomy does not appear to prevent ovarian development and ovulation in the pigeon, at least not during the first 3 postoperative months. Orchidectomy and salpingohysterectomy appear to be safe procedures when performed using appropriate equipment and techniques. Endosurgery offers a valuable, minimally invasive alternative to the standard coeliotomy techniques commonly used in birds.

Zoo and Wildlife Laparoscopy

Laparoscopic cholecystectomy under field conditions in Asiatic black bears (Ursus thibetanus) rescued from illegal bile farming in Vietnam.
Pizzi R, Cracknell J, David S, Laughlin D, Broadis N, Rouffignac M, Duong DV, Girling S, Hunt M. Vet Rec. 2011 Oct 29;169(18):469. Epub 2011 Sep 6.
Nine adult Asiatic black bears (Ursus thibetanus) previously rescued from illegal bile farming in Vietnam were examined via abdominal ultrasound and exploratory laparoscopy for liver and gall bladder pathology. Three bears demonstrated notable gall bladder pathology, and minimally invasive cholecystectomies were
performed using an open laparoscopic access approach, standard 10 to 12 mmHg carbon dioxide pneumoperitoneum and a four-port technique. A single bear required insertion of an additional 5 mm port and use of a flexible liver retractor due to the presence of extensive adhesions between the gall bladder and quadrate and left and right medial liver lobes. The cystic duct was dissected free and this and the cystic artery were ligated by means of extracorporeal tied Meltzer knot sutures. The gall bladder was dissected free of the liver by blunt and sharp dissection, aided by 3.8 MHz monopolar radiosurgery. Bears that have had open abdominal cholecystectomies are reported as taking four to six weeks before a return to normal activity postoperatively. In contrast, these bears demonstrated rapid unremarkable healing, and were allowed unrestricted access to outside enclosures to climb trees, swim and interact normally with other bears within seven days of surgery.

Laparoscopic-Assisted Cryptorchidectomy in an Adult Reindeer (Rangifer tarandus)
R Pizzi, S Girling, A Bell, A Tjolle, D Brown, C Devine. Veterinary Medicine International, vol. 2011, Article ID 131368, 4 pages, 2011. doi:10.4061/2011/131368
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A successful laparoscopic-assisted cryptorchidectomy is reported in a novel species, the reindeer (Rangifer tarandus). The procedure was performed in an 8-year-old adult positioned in dorsolateral oblique recumbency, with an open approach midline subumbilical placement of the primary 10 mm optical port and carbon dioxide insufflation at 12 mmHg. Three 5 mm instrument ports were inserted under visualization in the left caudal abdomen as the retained testicle was localized to the internal inguinal ring. A 5 mm flexible organ retractor was used to assist in localizing the retained testicle. This procedure provided a less invasive alternative to open laparotomy. The authors are unaware of any published reports of laparoscopy in reindeer, or of laparoscopic assisted cryptorchidectomy in deer species.

Laparoscopic ovariohysterectomy in a brown bear (Ursus arctos) with pyometra.
K. G. Friedrich, L. Pazzaglia, M. Valente, G. Costamagna, Proceedings of the International Conference on Diseases of Zoo and Wild Animals, 1999, pp.85-89.
Abstract: In September 2008 an adult female brown bear (Ursus arctos), one of the five brown bears living in the bear area of the Rome Zoological Garden (Fondazione Bioparco di Roma) showed apathy and slight purulent discharge from the reproductive tract. The diagnosed pyometra was approached by laparoscopic ovariohysterectomy. The access to the abdominal cavity was performed through 4 access ports (trocars) and the organs were manipulated with endosurgery instruments and by moving the animal into the Trendelenburg's position and laterally. Rapid and exact dissection and haemostasis of the blood vessels in the mesovarium and in the mesometrium was possible with the use of a harmonic scalpel (Harmonic Scalpel LCSC-5, Harmonic Scalpel, Ethicon Endosurgery, U.S.A) and ultrasonic generator (Harmonic Scalpel, Ethicon Endosurgery, U.S.A.). Time of surgery was limited to 51 minutes. The retrieval of the dissected reproductive tract was achieved through one enlarged access port (35 mm) performing a mini-laparotomy. The recovery of the animal was uneventful and the day after the bear was released again in the exhibit. In consequence, the laparoscopic surgical approach can be performed safely not only in healthy animals as described in literature previously, but also in the case of an old animal in critical health conditions. General advantages of minimally invasive surgery are reduced tissue trauma, less pain and short recovery after surgery, with reduced postoperative care requirements.

Post-mortem evaluation of left flank laparoscopic access in an adult female giraffe (Giraffa camelopardalis)
R. Pizzi, J. Cracknell, L. Dalrymple, Veterinary Medicine International, 2010, doi: 10.4061/2010/789465 
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There are still few reports of laparoscopy in megavertebrates. The giraffe (Giraffa camelopardalis) is the tallest land mammal, and the largest ruminant species. An 18 year old multiparous female hybrid giraffe, weighing 650kg was euthanized for chronic health problems, and left flank laparoscopy performed less than 30 minutes after death. Safe primary access was achieved under visualisation using an optical bladed trocar (Visiport Plus, Tyco healthcare UK Ltd) without prior abdominal insufflation. A left paralumbar fossa approach allowed access to the spleen, rumen, left kidney, and intestines, but did not allow access to the reproductive tract which in non-gravid females is intrapelvic in nature.

Surgical technique for tubal ligation in white-tailed deer (Odocoileus virginianus).
MacLean RA, Mathews NE, Grove DM, Frank ES, Paul-Murphy J.J Zoo Wildl Med. 2006 Sep;37(3):354-60.
Surgical tubal ligation was used to sterilize urban free-ranging white-tailed deer (Odocoileus virginianus) as a methodology of a larger study investigating the influences of intact, sterile females on population dynamics and behavior. Deer were either trapped in clover traps (n = 55) and induced with an i.m. injection of xylazine and tiletamine/zolazepam or induced by a similar protocol by dart (n = 12), then intubated and maintained on isoflurane in oxygen. Over 3 yr, individual female deer (n = 103) were captured in Highland Park, Illinois, with a subset of females sterilized using tubal ligation by ventral laparotomy (n = 63). Other sterilization procedures included tubal transection by ventral (n = 1) or right lateral (n = 2) laparoscopy and ovariohysterectomy by ventral laparotomy (n = 1). One mortality (1/ 67, 1.5%) of a doe with an advanced pregnancy was attributed to a lengthy right lateral laparoscopic surgery that was converted to a right lateral laparotomy. The initial surgical modality of laparoscopy was altered in favor of a ventral laparotomy for simplification of the project and improved surgical access in late-term gravid does. Laparotomy techniques included oviductal ligation and transection (n = 14), application of an oviductal mechanical clip (n = 9), ligation and partial salpingectomy (n = 40), and ovariohysterectomy (n = 1). As of 2 yr poststerilization, no surgical does were observed with fawns, indicating that these procedures provide sterilization with low mortality in urban white-tailed deer.

Anesthesia and use of a sling system to facilitate transvaginal laparoscopy in a black rhinoceros (Diceros bicornis minor).
Portas TJ, Hermes R, Bryant BR, Göritz F, Thorne AR, Hildebrandt TB.J Zoo Wildl Med. 2006 Jun;37(2):202-5.
Transvaginal laparoscopy to allow assessment of ovarian pathology and to attempt retrieval of oocytes was facilitated in a captive, female black rhinoceros (Diceros bicornis minor) through the use of a sling on two separate occasions. Following induction of anesthesia with an opioid-based combination, the rhinoceros was intubated and maintained on isoflurane in oxygen. The use of the sling and volume controlled inhalation anesthesia allowed for maintenance of appropriate anatomic positioning, analgesia, and insufflation of the abdominal cavity for laparoscopy during both procedures.

Recent Human Laparoscopy Abstracts

Laparoscopic entry techniques
Ahmad G, O'Flynn H, Duffy JM, Phillips K, Watson A.Cochrane Database Syst Rev. 2012 Feb 15;2:CD006583
BACKGROUND: Laparoscopy is a common procedure in gynaecology. Complications associated with laparoscopy are often related to entry. Life-threatening complications include injury to the bowel, bladder, major abdominal vessels, and an anterior abdominal-wall vessel. Other less serious complications can also
occur, such as post-operative infection, subcutaneous emphysema and extraperitoneal insufflation. There is no clear consensus as to the optimal method of entry into the peritoneal cavity. This is an update of a Cochrane review first published in 2008.
OBJECTIVES: To evaluate the benefits and risks of different laparoscopic techniques in gynaecological and non-gynaecological surgery.
SEARCH METHODS: This review has drawn on the search strategy developed by the Cochrane Menstrual Disorders and Subfertility Group. In addition, MEDLINE, EMBASE, CENTRAL and PsycINFO were searched through to February 2011.
SELECTION CRITERIA: Randomised controlled trials were included when one laparoscopic entry technique was compared with another.
DATA COLLECTION AND ANALYSIS: Data were extracted independently by the first three authors. Differences of opinion were registered and resolved by the fourth author. Results for each study were expressed as odds ratio (Peto OR) with 95% confidence interval (CI).
MAIN RESULTS: The review included 28 randomised controlled trials with 4860 individuals undergoing laparoscopy and evaluated 14 comparisons. Overall there was no evidence of advantage using any single technique in terms of preventing major vascular or visceral complications. Using an open-entry technique compared to a Veress Needle demonstrated a reduction in the incidence of failed entry, Peto OR 0.12 (95% CI 0.02 to 0.92). There were three advantages with direct-trocar entry when compared with Veress Needle entry, in terms of lower rates of failed entry (Peto OR 0.21, 95% Cl 0.14 to 0.31), extraperitoneal insufflation (Peto OR 0.18, 95% Cl 0.13 to 0.26), and omental injury (Peto OR 0.28, 95% CI 0.14 to 0.55).There was also an advantage with radially expanding access system (STEP) trocar entry when compared with standard trocar entry, in terms of trocar site bleeding (Peto OR 0.31, 95% Cl 0.15 to 0.62). Finally, there
was an advantage of not lifting the abdominal wall before Veress Needle insertion when compared to lifting in terms of failed entry, without an increase in the complication rate (Peto OR 4.44, 95% CI 2.16 to 9.13). However, studies were limited to small numbers, excluding many patients with previous abdominal surgery
and women with a raised body mass index who may have unusually high complication  rates.
AUTHORS' CONCLUSIONS: An open-entry technique is associated with a significant reduction in failed entry when compared to a closed-entry technique, with no difference in the incidence of visceral or vascular injury.Significant benefits were noted with the use of a direct-entry technique when compared to the Veress
Needle. The use of the Veress Needle was associated with an increased incidence of failed entry, extraperitoneal insufflation and omental injury; direct-trocar entry is therefore a safer closed-entry technique.The low rate of reported complications associated with laparoscopic entry and the small number of participants within the included studies may account for the lack of significant difference in terms of major vascular and visceral injury between entry techniques. Results should be interpreted with caution for outcomes where only single studies were included.

Measuring mental workload during the performance of advanced laparoscopic tasks
Bin Zheng, Maria A Cassera, Danny V Martinec, Georg O Spaun, Lee L Swanström. Surgical Endoscopy. 2010. Vol. 24, Iss. 1; pg. 45
Mental workload is a finite resource and is increased while learning new tasks and performing complex tasks. Measurement of a surgeon's mental workload may therefore be an indication of expertise. We hypothesized that surgeons who were expert at laparoscopic suturing would have more spare mental resources to perform a secondary task, compared with surgeons who had just started to learn suturing.
Standardized suturing tasks were performed on a bench-top model. Twelve junior residents (novices) and nine fellows and attending surgeons (experts) were instructed to perform as many sutures as possible in 6 min. An adjacent monitor was placed 15° off axis to the first and randomly displayed 30 true visual signals among 90 false ones. Participants were required to identify the true signals while continuing to suture. Laparoscopic sutures were evaluated using the Fundamentals of Laparoscopic Surgery (FLS) scoring system. The secondary (visual detection) task was evaluated by calculating the rate of missed true signals or detection of false signals. Experts completed significantly more secure sutures (6 ± 2) than novices (3 ± 1; p = 0.001). The suture performance score was 50 ± 20 for experts, significantly higher than for novices (29 ± 10; p = 0.005). The rate for detecting visual signals was higher for experts (98%) compared with for novices (93%; p = 0.041). Practice develops automaticity, which reduces the mental workload and allows surgeons to have sufficient spare mental resources to attend to a secondary task. Visual detection provides a simple and reliable way to assess mental workload and situation awareness abilities of surgeons during skills training, and may be an indirect measure of expertise.

Seasoned surgeons assessed in a laparoscopic surgical crisis.
Powers K, Rehrig ST, Schwaitzberg SD, Callery MP, Jones DB.J Gastrointest Surg. 2009 May;13(5):994-1003.
OBJECTIVE: Maintenance of certification is a relatively new concept in the United States, and there is no mandatory retirement for surgeons. Our aim was to compare technical and team performance of surgeons of different ages in a simulated laparoscopic surgical crisis and validate a potential recredentialing tool for surgeons. METHODS: Using a single-blinded protocol, the performance of six "Seasoned" surgeons >55 years (mean 64, range 55-83) was compared to six "control" surgeons <55 years (mean 46, range 34-53) in a simulation. Surgical teams established pneumoperitoneum, trocar access, and managed intraabdominal hemorrhage in a simulated laparoscopic cholecystectomy while videotaped as part of an IRB protocol. Surgeons' performance was scored using validated technical and team performance scales. RESULTS: All of the "seasoned" surgeons relegated the use of unfamiliar technology to their assistants. All control surgeons achieved intraabdominal pneumoperitoneum themselves. Mean blood loss for seasoned surgeons and control surgeons was 2,555 versus 2,725 ml (NS), respectively. After recognition of bleeding in the unstable patient, senior surgeons converted to an urgent laparotomy case after 2.4 vs. 3.3 min for control group (NS). No difference was observed in overall technical and team abilities (p = NS). On debriefing, 85% of surgeons recommended simulation for training and recertification. CONCLUSIONS: Seasoned surgeons can use their assistant surgeon well to assure a safe and effective operation. Mandatory operating room retirement based on age may be arbitrary and should be replaced by performance measures. Simulation may prove a valuable tool for self -assessment and recredentialing.

Other Human Surgical References

Laparoscopic Entry Techniques
Ahmad G, Duffy JMN, Phillips K, Watson A. 2008. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD006583. DOI: 10.1002/14651858.CD006583.pub2.
Background: Laparoscopy is a very common procedure in gynaecology. Complications associated with laparoscopy are often related to entry. The life-threatening complications include injury to the bowel, bladder, major abdominal vessels, and anterior abdominal-wall vessel. Other less serious complications can also occur, such as post-operative infection, subcutaneous emphysema and extraperitoneal insufflation. There is no clear consensus as to the optimal method of entry into the peritoneal cavity.
Objectives: The objective of this study was to compare the different laparoscopic entry techniques in terms of their influence on intra-operative and post-operative complications.
Search strategy: This review has drawn on the search strategy developed by the Menstrual Disorders and Subfertility Group. In addition MEDLINE and EMBASE were searched through to July, 2007.
Selection criteria: Randomised controlled trials were included when one laparoscopic primary-port-entry technique was compared with another.
Data collection and analysis: Data were extracted independently by the first two authors. Differences of opinion were registered and resolved by the fourth author. Results for each study were expressed as odds ratio (Peto version) with their 95% confidence intervals.
Main results: The 17 included randomised controlled trials concerned 3,040 individuals undergoing laparoscopy. Overall there was no evidence of advantage using any single technique in terms of preventing major complications. However, there were two advantages with direct-trocar entry when compared with Veress-Needle entry, in terms of avoiding extraperitoneal insufflation (OR 0.06, 95%CI 0.02, 0.23) and failed entry (OR 0.22, 95%CI 0.08, 0.56). There was also an advantage with radially expanding access system (STEP) trocar entry when compared with standard trocar entry, in terms of trocar site bleeding (OR 0.06, 95%CI 0.01, 0.46). Finally, there was an advantage of not lifting the abdominal wall before Veress-Needle insertion when compared to lifting in terms of failed entry without an increase in the complication rate (OR 5.17, 95%CI 2.24, 11.90). However, studies were limited to small numbers, excluding many patients with previous abdominal surgery and women with a raised body mass index, who often had unusually high complication rates.
Authors' conclusions On the basis of evidence investigated in this review, there appears to be no evidence of benefit in terms of safety of one technique over another. However, the included studies are small and cannot be used to confirm safety of any particular technique

Abdominal access in gynaecological laparoscopy: a comparison between direct optical and blind closed access by Verres needle.
Tinelli A, Malvasi A, Istre O, Keckstein J, Stark M, Mettler L.
OBJECTIVE: : Complications associated with initial abdominal entry are a prime concern for laparoscopic surgeons. In order to minimize first access-related complications in laparoscopy, several techniques and technologies have been introduced in the past years. This investigation compares two laparoscopic access techniques. STUDY DESIGN: : 194 women underwent laparoscopic surgery for simple ovarian cysts: 93 were assigned to direct optical access (DOA) abdominal entry (group I), and 101 women to classical closed method by Verres needle, pneumoperitoneum and trocar entry (group II). The following parameters were compared: time required for entry into abdomen, occurrence of vascular and/or bowel injury, blood loss. The results were analyzed using SAS software. p-value<0.05 was considered as significant. RESULTS: : No statistically significant differences were observed in the occurrence of blood loss and minor vascular injury between the two techniques, as well as minor bowel injuries; time for of abdominal entry, instead, were significantly reduced in the DOA group. CONCLUSIONS: : The results of the preliminary comparison between the DOA and the Verres methods, commonly used by gynecologists, suggests that the visual entry system confers a statistical advantage over closed entry technique with Verres needle, in terms of time saving and due to the minor vascular and bowel injuries, thus enabling a safe and expeditious, visually-guided, entry for surgeons.

Primary access-related complications in laparoscopic cholecystectomy via the closed technique: experience of a single surgical team over more than 15 years.
Sasmal PK, Tantia O, Jain M, Khanna S, Sen B. Surg Endosc. 2009 Mar 19.
BACKGROUND: Laparoscopic cholecystectomy (LC), a common laparoscopic procedure, is a relatively safe invasive procedure, but complications can occur at every step, starting from creation of the pneumoperitoneum. Several studies have investigated procedure-related complications, but the primary access- or trocar-related complications generally are underreported, and their true incidence may be higher than studies show. Major vascular or visceral injury resulting from blind access to the abdominal cavity, although rare, has been reported. Of the two methods for creating pneumoperitoneum, the open access technique is reported to have the lower incidence of these injuries. The authors report their experience with the closed method and show that if performed with proper technique, it can be as rapid and safe as other techniques. However, injuries still happen, and the search for the predisposing factors must be continued. METHODS: Between January 1992 and December 2007, a retrospective study examined 15,260 cases of LC performed for symptomatic gallstone disease in the authors' institution by a single team of surgeons. The primary access-related injuries in these cases were retrospectively analyzed. RESULTS: In 15,260 cases of LC, 63 cases of primary access-related complications were identified, for an overall incidence of 0.41%. Major injuries in 11 cases included major vascular and visceral injuries, and minor injuries in 52 cases included omental and subcutaneous emphysema. For the closed method, the findings showed an overall incidence of 0.14% for primary access-related vascular injuries and 0.07% for visceral injuries. CONCLUSION: Primary access-related complications during LC are common and can prove to be fatal if not identified early. The incidence of these injuries with closed methods is no greater than with open methods. No evidence suggests abandonment of the closed-entry method in laparoscopy.

Open laparoscopic access technique: review of 2010 patients.
Long JB, Giles DL, Cornella JL, Magtibay PM, Kho RM, Magrina JF. JSLS. 2008 Oct-Dec;12(4):372-5.
OBJECTIVE: We assessed safety and efficacy of an open laparoscopic entry technique. METHODS: A retrospective review of all patients undergoing laparoscopy via open laparoscopic access over an 8-year period from January 1, 1998 to December 31, 2006 is presented. RESULTS: During the study period, 2010 consecutive subjects underwent laparoscopy. Recorded intraoperative complications include enterotomy (0.1%) and failure to enter (0.1%). There were no instances of vascular injury related to entry. Recorded postoperative complications include hernia (0.9%), infection (2.5%), hematoma (0.05%), and noncosmetic healing (0.4%). A statistically significant association existed between obesity and postoperative hernia, and between previous abdominal surgery and postoperative infection. CONCLUSION: Though typically straightforward, initial entry is one of the most common causes of injury in laparoscopy. The predominant entry method of entry in gynecologic surgery remains a closed technique. This technique has unfortunately been demonstrated in multiple series to have the potential for visceral and vascular injury due to its blind insertion of Veress needles and trocars. The open laparoscopic technique is a safe and effective method of obtaining access to the abdominal cavity with no associated vascular injury.

Disposable surgical face masks for preventing surgical wound infection in clean surgery.
Lipp A, Edwards P,Cochrane Database Syst Rev. 2002;(1):CD002929.
Surgical face masks were originally developed to contain and filter droplets of microorganisms expelled from the mouth and nasopharynx of healthcare workers during surgery, thereby providing protection for the patient. However, there are several ways in which surgical face masks could potentially contribute to contamination of the surgical wound. Surgical face masks have recently been advocated as a protective barrier between the surgical team and the patient, but the role of the surgical face mask as an effective measure in preventing surgical wound infections is questionable. The aim of the systematic review is to identify and review all randomised controlled trials evaluating disposable surgical face masks worn by the surgical team during clean surgery to prevent postoperative surgical wound infection. All relevant publications about disposable surgical face masks were sought through the Specialised Trials Register of the Cochrane Wounds Group (March 2001). Manufacturers and distributors of disposable surgical masks as well as professional organisations including the National Association of Theatre Nurses and the Association of Operating Room Nurses were contacted for details of unpublished and ongoing studies. Randomised controlled trials (RCTs) and quasi-randomised controlled trials comparing the use of disposable surgical masks with the use of no mask were included. Main results: Two randomised controlled trials were included involving a total of 1453 patients. In a small trial there was a trend towards masks being associated with fewer infections, whereas in a large trial there was no difference in infection rates between the masked and unmasked group. Neither trial accounted for cluster randomisation in the analysis. Reviewers' conclusions: From the limited results it is unclear whether wearing surgical face masks results in any harm or benefit to the patient undergoing clean surgery.

Does evidence based medicine support the effectiveness of surgical facemasks in preventing postoperative wound infections in elective surgery?
Bahli ZM. J Ayub Med Coll Abbottabad. 2009 Apr-Jun;21(2):166-70.
BACKGROUND: The incidence of postoperative wound infection is usually not the cause of death but it increases the length of hospital stay and cost of care and morbidity. Since their introduction a century ago there is still controversy about primary purpose of the facemasks as whether they provide protection for the patient from surgical team or weather they protect surgical team from the patient? The Objectives of this study were to critically analyze and systematically review the randomized trials regarding effectiveness of surgical facemasks in preventing post operative wound infection in elective surgery. METHOD: Systematic literature review and analysis of all available trials (randomized controlled trials) regarding use of surgical face masks in elective surgeries. Medline (1966-2007), Embase (1996-2007), Cochrane database, Pubmed, Google Scholar, were searched for the selection of literature for the review. RESULTS: No significance difference in the incidence of postoperative wound infection was observed between masks group and groups operated with no masks (1.34, 95% CI, 0.58-3.07). There was no increase in infection rate in 1980 when masks were discarded. In fact there was significant decrease in infection rate (p < 0.05). CONCLUSION: From the limited randomized trials it is still not clear that whether wearing surgical face masks harms or benefit the patients undergoing elective surgery.

A surgical safety checklist to reduce morbidity and mortality in a global population.
Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA; Safe Surgery Saves Lives Study Group. N Engl J Med. 2009 Jan 29;360(5):491-9. Epub 2009 Jan 14.
BACKGROUND: Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. Surgical complications are common and often preventable. We hypothesized that a program to implement a 19-item surgical safety checklist designed to improve team communication and consistency of care would reduce complications and deaths associated with surgery.
METHODS: Between October 2007 and September 2008, eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) representing a variety of economic circumstances and diverse populations of patients participated in the World Health Organization's Safe Surgery Saves Lives program. We prospectively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing noncardiac surgery. We subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist. The primary end point was the rate of complications, including death, during hospitalization within the first 30 days after the operation.
RESULTS: The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001).
CONCLUSIONS: Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals