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Temperature probes in bladder or rectum purchase tamoxifen 20 mg with visa menopause vitamin e, esophageal order tamoxifen with amex womens health redding ca, and pulmonary artery for simultaneous temperature measurements purchase 20mg tamoxifen visa menstruation app. Side effects include postoperative respiratory depression (12–24 hr) purchase generic tamoxifen on-line menopause vitamins supplements, a high incidence of recall, or failure to control the hyper- tensive response to stimulation. Opioids (fentanyl, maximum of 5 µg/kg or sufentanil 15 µg/kg) and volatile agent (0. Muscle relaxants: Rocuronium, vecuronium, and cisatracurium have almost no hemodynamic effects on their own. Pancuronium may be used in β-blocked patients with marked bradycardia because of its vagolytic effects. Judicious dosing and nerve stimulator monitoring should be used to avoid prolonged muscle paralysis. Serial hematocrit with goal hematocrit between 20% and 25% and red blood cell transfusion into pump reservoir when necessary. Persistent and excessive decreases (<30 mm Hg) should prompt a search for unrecognized aortic dissection. Blood glucose should be checked at least once in patients without diabetes and hourly in patients with dia- betes. Sodium concentration in cardioplegic solutions is usually less than in plasma (<140 mEq/L) because ischemia tends to increase intracellular sodium content. A buffer—most commonly bicarbonate—is necessary to prevent excessive buildup of acid metabolites; alkalotic perfusates are reported to produce better myocardial preservation. Recovery from cardioplegia: Inadequate “washout” and recovery from cardioplegia can result in an absence of electrical activity, atrioventricular conduction block, or a poorly contracting heart at the end of bypass. Calcium administration improves hyperkalemia; excessive calcium can promote and enhance myocardial damage. Myocardial performance generally improves with time as the contents of the cardioplegia are cleared from the heart. Metabolic oxygen requirements are approximately halved with each 10°C change in body temperature. Profound hypothermia: Temperatures of 15° to 18°C allow total circulatory arrest for complex repairs for durations of as long as 60 minutes. Side effects: The adverse effects of hypothermia include platelet dysfunction, reversible coagulopathy, and depression of myocardial contractility. Patients at greatest risk are those with poor preoperative ventricular function, ventricular hypertrophy, or severe coronary artery disease. Myocardial ischemia can result from low arterial pressures, coronary embolism, reperfusion injury, coronary artery or bypass graft vasospasm, and contortion of the heart causing compression or distortion of the coronary vessels. Ventricular fibrillation and distention are important causes of increased myocar- dial oxygen demand and decreased oxygen supply. Methods for preservation: Decrease cellular energy requirements to minimal levels, initially by potassium car- dioplegia either hypothermic or progressively cooler. Then maintain myocardial temperature 10° to 15°C by topi- cal cardiac hypothermia (ice slush). Myocardial hypothermia reduces basal metabolic oxygen consumption, and the potassium cardioplegia minimizes energy expenditure by arresting both electrical and mechanical activity. To prevent cardiac distention, vents placed in the right superior pulmonary vein and left atrium drain the left ventricle. To prevent coronary air emboli, cardiac chambers and coronary artery grafts are carefully deaired at the end of repair. Pulmonary artery catheterization: In general, pulmonary artery catheterization has been most often used in patients with compromised ventricular function (ejection fraction <40%–50%) or pulmonary hypertension and in those undergoing complicated procedures. The use of pulmonary artery catheterization is largely dependent on institutional practices. Anesthetic doses: Severely compromised patients should be given anesthetic agents in incremental, small doses. Reduce systemic perfusion pressure just before clamp release; then increase initially to 40 mm Hg before being gradually increased and maintained at about 70 mm Hg. Administer lidocaine 100 to 200 mg and magnesium sulfate 1 to 2 g before aortic cross-clamp removal to decrease the likelihood of fibrillation. Atrioventricular pacing is often necessary to get the heart rate 80 to 100 beats/min, and supraventricular tachycardias generally require cardioversion. If drug therapies fail to provide adequate cardiac output, use an intraaortic balloon pump. Administering protamine too rapidly may result in severe hypotension or pulmonary hypertension. Persistent bleeding after bypass: Often occurs after prolonged durations of bypass (>2 hr) and usually is caused by inadequate surgical control of bleeding sites, incomplete reversal of heparin, thrombocytopenia, platelet dysfunction, hypothermia-induced coagulation defects, undiagnosed preoperative hemostatic defects, newly acquired factor deficiency, or hypofibrinogenemia. Platelet, fresh-frozen plasma, or cryopre- cipitate transfusion should be considered. Accelerated fibrinolysis confirmed by elevated fibrin degradation products (>-32 mg/mL) or evidence of clot lysis should be treated with ε-aminocaproic acid or tranexamic acid. Chest tube drainage: In the first 2 hours after surgery of more than 250 to 300 mL/hr (10 mL/kg/hr)—in the absence of a hemostatic defect—is excessive and may require surgical reexploration. Intrathoracic bleed- ing at a site not adequately drained may cause cardiac tamponade, requiring immediate reopening of the chest, and is associated with severe hypotension on anesthetic induction. For asymptomatic lesions with greater than 60% stenosis, stenting is generally recommended. Neurologic deficits should be defined, and other disease states should be optimized. Most patients are elderly, have hypertension, have general- ized arteriosclerosis, and often have diabetes. Regional anesthesia with superficial cervical plexus blocks allow the patient to be awake and neuro- logically examined during surgery. Intraoperative hypertension is common and should be treated with a vasodilator like nitroglycerin, nicardipine, or nitroprusside; phenylephrine is used for hypotension. Bradycardia or complete heart block can be caused by manipulation of the carotid baroreceptor and is treated with atropine. Complications The perioperative mortality rate is 1% to 4% and is primarily attributable to cardiac complications. Damage to the recurrent laryngeal nerve can cause hoarseness, and damage to the hypoglossal nerve can cause ipsilateral deviation of the tongue. Denervation of the ipsilateral carotid baroreceptor can cause postop- erative hypertension, and denervation of the carotid body can blunt the ventilatory response to hypoxemia. Acute cardiac tamponade usually presents as sudden hypotension, tachycardia, and tachypnea. Physical examination may show jugular venous distention, narrowed arterial pulse pressure, muffled heart sounds, friction rub, or pul- sus paradoxus. Anesthetic considerations: Symptomatic cardiac tamponade requires evacuation either by pericardiocente- sis or surgically (usually for postoperative cardiac tamponade or for large recurrent pericardial effusions).
The support of the urethra does not depend on attachments of the urethra itself to adjacent structures buy discount tamoxifen menopause goddess, but on the connection of the vagina and periurethral tissues to the muscles and fasciae of the pelvic wall purchase tamoxifen 20 mg women's health clinic queen elizabeth. Surgeons are most familiar with seeing this anatomy through the space of Retzius buy genuine tamoxifen line pregnancy first trimester symptoms, and this view is also helpful in understanding urethral support (Figure 21 generic 20 mg tamoxifen visa breast cancer ultrasound imaging. The layer of tissue that provides urethral support has two lateral attachments: a fascial attachment and a muscular attachment (Figure 21. The muscular attachment connects these same periurethral tissues to the medial border of the levator ani muscle. These attachments allow the normal resting tone of the levator ani to maintain the position of the vesical neck, supported by the fascial attachments (Figure 21. When the muscle relaxes at the onset of micturition, it allows the vesical neck to rotate downward to the limit of the elasticity of the fascial attachments; at the end of micturition, contraction allows it to resume its normal position. Pubovesical muscle can be seen going from vesical neck to arcus tendineus fasciae pelvis and running over the paraurethral vascular plexus. Note that windows have been cut in the levator ani muscles, vagina, and endopelvic fascia so that the urethra and anterior vaginal walls can be seen. Also within this region are the pubovesical muscles, which are extensions of the detrusor muscle [1,68,69]. They lie within the connective tissue; when both muscular and fibrous elements are considered together, they are termed the “pubovesical ligaments,” in much the same way that the smooth muscle of the ligamentum teres is referred to as the round ligament (see Figures 21. Although the terms “pubovesical ligament” and “pubourethral ligament” have sometimes been considered to be synonymous, the pubovesical ligaments are different structures from the urethral supportive tissues. Fibers of the detrusor muscle are able to undergo great elongation, and these weak tissues are, therefore, not suited to maintain urethral position under stress. In addition, they run in front of the vesical neck rather than underneath it, where one would expect supportive tissues to be found. It is not surprising, therefore, that these detrusor fibers do not differ, in stress-incontinent patients, from those in patients without this condition . The tissues that support the urethra are separated from the pubovesical ligaments by a prominent vascular plexus and are easily parted from them. Rather than supporting the urethra, the pubovesical muscles may be responsible for assisting in vesical neck opening at the onset of micturition by contracting to pull the anterior vesical neck forward, as some have suggested . This mechanism influences incontinence by determining how the urethra is supported, not by how high or low the urethra is in the pelvis. In examining anatomic specimens, simulated increases in abdominal pressure reveal that the urethra lies in a position where it can be compressed against the supporting hammock by rises in abdominal pressure (Figure 21. In this model, it is the stability of this supporting layer under the urethra rather than the height of the urethra that determines stress continence. In an individual with a firm supportive layer, the urethra would be compressed between abdominal pressure and pelvic fascia (Figure 21. If, however, the layer under the urethra becomes unstable and does not provide a firm backstop against which the urethra can be compressed by abdominal pressure, the opposing force that causes closure is lost and the occlusive action is diminished. This latter situation is similar to an attempt to stop the flow of water through a garden hose by stepping on it while it lies on soft soil. As new functional observations are made of the lower urinary tract, it will be necessary to reexamine our anatomic concepts; doubtless, some of the structural arrangements described in this chapter will be corrected, expanded upon, and improved. This will continue to enhance our ability to understand the variety of patients with lower urinary tract dysfunction and will improve our ability to restore normal urinary control. Aspects on the anatomy of the female urethra with special relation to urinary continence. Stress urinary incontinence relative importance to urethra support and urethra closure pressure. Anatomy of the perineal membrane as seen in magnetic resonance images of nulliparous women. A comparative study of the human external sphincter and periurethral levator ani muscles. Quantification of intramuscular nerves within the female striated urogenital sphincter muscle. Change in urethral sphincter neuromuscular function during pregnancy persists after delivery. Observations on the musculature of the urinary bladder and urethra in the human foetus. Effects of aging on lower urinary tract and pelvic floor function in nulliparous women. The corpus spongiosum of the urethra: Its possible role in urinary control and stress incontinence in women. Location of maximum intraurethral pressure related to urogenital diaphragm in the female subject as studied by simultaneous urethrocystometry and voiding urethrocystography. Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse. Quantitative analysis of uterosacral ligament origin and insertion points by magnetic resonance imaging. Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Levator contraction strength and genital hiatus as risk factors for recurrent pelvic organ prolapse. Experimental study of the reflex mechanism controlling muscles of the pelvic floor. Interaction among apical support, levator ani impairment, and anterior vaginal wall prolapse. A 3-D finite element model of anterior vaginal wall support to evaluate mechanisms underlying cystocele formation. Urethral pressure measurement by microtransducer: The results in symptom-free women and in those with genuine stress incontinence. Resting and stress urethral pressures as a clinical guide to the mechanism of continence in the female patient. Relationship between the pubo-urethral ligaments and the urogenital diaphragm in the human female. Structural support of the urethra as it relates to stress urinary incontinence: The hammock hypothesis. Vaginal birth and de novo stress incontinence: Relative contributions of urethral dysfunction and mobility. Pubovesical ligament: A separate structure from the urethral supports (pubo-urethral ligaments). Posterior pubo-urethral ligaments in normal and genuine stress 311 incontinent women. An anatomical contribution to the problem of continence and incontinence in the female.
The degree of overlap obviously indicates that the predictive value of a short refractory 64 period for the development of cardiac arrest would be low generic tamoxifen 20mg with visa women's health center tampa florida. No sudden cardiac death occurred in asymptomatic patients generic 20mg tamoxifen otc women's health lemon zucchini bars, and only two symptomatic patients died suddenly purchase 20mg tamoxifen visa menstruation discharge, one of whom was an athlete with a grossly enlarged and hypertrophied heart (520 g) at autopsy buy cheap tamoxifen line menstruation girl. He divided the patients into 52 with effective refractory periods ≤240 msec and 90 patients with effective refractory periods >240 msec and followed them for more than 20 years. Only two patients in both groups died suddenly, and in only one patient in each group did atrial fibrillation seem a likely cause. Thus, the overwhelming evidence suggests that one cannot use the antegrade effective refractory period measurements to predict patients at risk for development of sudden death. It also does not appear that the use of the ventricular response during induced atrial fibrillation, particularly in asymptomatic patients, is useful. It is my personal bias that regardless of the presence or absence of symptoms, these measurements are poor predictors of patients at risk. Patients with syncope do not have distinct clinical or electrophysiologic features that differ from P. Thus, I believe that we cannot predict patients at high risk for sudden death but we are able to select patients at low risk for sudden death. This is useful because it has implications for lifestyle recommendation for these patients. The widespread use of electrophysiologic studies to predict patients who are likely to die, and therefore have limitations placed on their life-style, seems totally unjustified at this point. The only things we can do are (a) assure people who are totally asymptomatic that they are unlikely to experience sudden cardiac death and, if less than 30 years old, are likely to remain asymptomatic regardless of their effective refractory periods and (b) reassure those patients who have prolonged refractory periods as assessed by any method that they are extremely unlikely to develop ventricular fibrillation regardless of whether symptoms are present or not. Finally, one must remember that freedom from developing life- threatening ventricular response during atrial fibrillation or the demonstration of a long antegrade refractory period of the bypass tract is of no value in predicting the likelihood of developing orthodromic tachycardia. A: A single atrial stimulus terminates the tachycardia by blocking in the A-V node. The tachycardia is terminated when the early atrial impulse attempts to return to the ventricle but blocks antegradely in the A-V node. Termination of Orthodromic Tachycardia Because the reentrant circuit in orthodromic tachycardia is large and incorporates both the atrium and ventricles, premature stimuli from either chamber can almost always penetrate the circuit, even during tachycardias with rapid rates. More rapid rates may necessitate the introduction of multiple electrical stimuli to reach either the normal A-V conducting system or the bypass tract during its refractory state. Thus, in most tachycardias with cycle lengths exceeding 300 msec, single atrial and/or ventricular extrastimuli can terminate the arrhythmia (Fig. The faster the rate, and the farther the extrastimulus is from the site of the bypass tract, the more premature or the greater the number of stimuli required to terminate the arrhythmia. Thus, in patients with right-sided or septal bypass tracts, single premature stimuli from the right atrium or the right ventricle will almost always terminate tachycardias with cycle lengths >300 msec. Ventricular extrastimuli then can result in termination of the tachycardia even when delivered when the His bundle is refractory (Fig. The response to ventricular extrastimuli, however, can vary greatly, depending on the coupling interval and number of ventricular extrastimuli needed. Thus, ventricular extrastimuli can terminate the tachycardia by (a) blocking retrogradely in the bypass tract; (b) conducting retrogradely up the normal A-V conducting system, with or without retrograde conduction up the bypass tract; or (c) retrograde conduction over the bypass tract with subsequent antegrade block in the A-V node, or occasionally below the His bundle (Fig. A–C demonstrate orthodromic circus movement tachycardia using a left-sided bypass tract, each of which is terminated by ventricular extrastimuli. A: The first of three ventricular extrastimuli blocks retrogradely in the bypass tract and collides with the impulse in the normal His–Purkinje system. The third extrastimulus blocks retrogradely in both the bypass tract and the His–Purkinje system. B: The first extrastimulus, which is delivered when the His bundle is refractory, blocks in the bypass tract. The third extrastimulus blocks in the bypass tract and conducts retrogradely up the normal A-V conducting system to depolarize the atrium and terminate the tachycardia. C: The first extrastimulus is delivered while the His bundle is refractory and preexcites the atrium. The second extrastimulus blocks in the bypass tract, conducts up the His– Purkinje system, blocks in the node, and terminates the tachycardia. Multiple Bypass Tracts Because A-V bypass tracts appear to be a congenital abnormality that is due to developmental defects in the A-V rings, it is not surprising that multiple A-V bypass tracts can be present in the same patient. In the preablation era we recognized nearly one-third of the bypass tracts, unsuspected during the preoperative electrophysiology study, at the time of surgery. The wide range of incidence in multiple bypass tracts probably stems from differences in patient populations and methodologic differences in determining the presence of such bypass tracts. The observation of changing antegrade delta waves – that is, changing patterns of preexcitation – is uncommon during sinus rhythm. Occasionally, following the use of Type I agents or amiodarone, block in one accessory pathway can lead to manifestation of antegrade conduction over a second 38 accessory pathway. Atrial fibrillation (either spontaneous or induced) may provide the opportunity to see different patterns of preexcitation, thereby allowing one to document the presence of multiple bypass tracts. This has been suggested as an indication for the deliberate induction of atrial fibrillation during an electrophysiologic study. Because multiple bypass tracts are often located in the free walls of the right and left A-V grooves, the use of both right and left atrial pacing occasionally can document the presence of additional bypass tracts that are not manifested if only pacing from the one atrium is performed. This can be seen in Figure 10-95, where right atrial pacing produces ventricular activation over a right-sided bypass tract, and coronary sinus pacing produces ventricular activation over a left-sided bypass tract. In addition, the tachycardias initiated by stimulation at different sites can vary, resulting in two retrograde activation sequences, which document the presence of multiple bypass tracts (see following discussion). If a single bypass tract was present, the V-A interval should be fixed and the retrograde P-wave morphology constant during orthodromic tachycardia. If the V-A interval or P- wave morphology changes during orthodromic tachycardia, the presence of an additional bypass tract should be suspected. During the electrophysiology study, the presence of two distinct retrograde atrial activation patterns documents the presence of multiple bypass tracts and explains changing P-wave morphology and V-A intervals (see Fig. In other cases, during orthodromic tachycardia, a single, fixed retrograde atrial activation pattern is observed in the presence of two or more bypass P. In this instance, additional bypass tracts can be recognized by the appearance of more than one atrial breakthrough site. This is demonstrated in Figure 10-96, where the earliest retrograde atrial activation occurs in the distal coronary sinus, compatible with a left lateral bypass tract. In this instance, atrial activation in the His bundle recording precedes atrial activation of the os by 30 msec, suggesting a second pathway in the anterior septum. With the introduction of a ventricular extrastimulus, retrograde activation may proceed over one bypass tract to initiate orthodromic tachycardia with retrograde conduction over an additional bypass tract (Fig. The site of ventricular pacing is critical because retrograde atrial activation will preferentially proceed over a bypass tract adjacent to the site of stimulation as long as that bypass tract is capable of retrograde conduction.
Of 322 women in the study cheap tamoxifen 20mg with visa menopause young living, 19 had symptoms of possible ileus or small bowel obstruction; of these cheap 20mg tamoxifen free shipping menstrual not flowing, 4 had reoperation for small bowel obstruction order 20 mg tamoxifen amex women's health clinic sf, 11 were readmitted for medical management buy 20mg tamoxifen otc menopause kidney pain, and 4 had a prolonged initial hospitalization for gastrointestinal symptoms . In a recent publication comparing robotic and laparoscopic approach to sacral colpopexy, again where closure of peritoneum was optional, the rate of small bowel obstruction was 2. The question raised is whether the relatively simple task of closing the peritoneum after sacral colpopexy has a role in minimizing postoperative bowel complications and would be easily answered by a subanalysis of these two papers. Brosens reported that a gynecologist performing less than 100 laparoscopies a year had a five times higher rate of bowel injuries than those performing more than 100 laparoscopies a year . Operating time declined rapidly after the first 30 cases and continued to decline before plateauing after 90 cases. Skills can be improved in a variety of means including training programs, skills workshops, and operating with colleagues. A gas filled urinary bag or blood in the urine means bladder trauma till proven otherwise and warrants careful laparoscopic inspection of the bladder distended to 300 mL and cystoscopy. Cystotomies should be repaired in two layers so that the bladder is watertight at 300 mL. After repair, cystoscopy should be performed with the laparoscope in place, to ensure that there are no other unrecognized injuries and that the ureters are patent. After a watertight cystotomy repair, the catheter can safely be removed at 4 days . If concomitant continence surgery is performed, the nursing staff and the patient should be vigilant during the trial of void to ensure the bladder is not grossly over distended. Postoperative cystoscopy is vital to minimize lower urinary tract complications following pelvic floor surgery as it is the unrecognized cystotomy that may cause vesicovaginal fistula . In the first layer, care is taken to ensure that the mucosa and detrusor muscle are included. Problems can also be encountered during the repair of a large cystotomy at the time of a difficult hysterectomy. The morbidity associated with ureteric injury can be dramatically reduced if identified intraoperatively using postoperative cystoscopy and intravenous indigo carmine [64,65]. If indigo carmine is not clearly visible following laparoscopic pelvic floor repair, the injury is likely to be related to kinking of the ureter in the lateral retropubic space or in relation to the uterosacral/cardinal ligament sutures during sacral colpopexy or vault suspending procedures. Lateral retropubic or vault suspending sutures should be removed one at a time till the ureteric patency is obtained. The sutures are then replaced at a lower level and ureteric patency is again confirmed. If patency is not confirmed with the removal of the sutures, retrograde dye studies and intraoperative urological consultation are required. Ureteric injuries related to concomitant laparoscopic hysterectomy usually require ureteric reimplantation by urological colleagues. One small study retrospectively compared laparoscopic hysterectomy performed with and without ureteric catheters and suggested that ureteric catheters may decrease the risk of ureteric injury . Just less than 10 minutes was required to place the catheters, but no other prospective evaluation of routine ureteric catheters at laparoscopic pelvic floor surgery is available. The presacral fascia covers and protects the underlying plexus, which consists of venous network both on and beneath the surface of the sacral periosteum as seen in Figure 102. Inadvertent manipulation outside this avascular presacral space may tear the fascia and cause damage of underlying thin-walled veins, which are devoid of valves. It is well documented that conventional measures for hemostasis are ineffective in managing presacral hemorrhage . Coagulation and suturing should be avoided because they can aggravate bleeding resulting in significant blood loss. Surgeons should have a planned approach to this problem, and the author initially applies immediate direct pressure over the bleeding site using small tampon gauze for 5 minutes to temporarily control the bleeding. If bleeding persists, traditionally pelvic packing and the use of sterile metallic or titanium thumbtacks are employed (Figure 102. Packing has the disadvantage of reoperation for removing the packs and risk of rebleeding . More recently, surgeons have reported successfully using a hemostatic matrix agent such as FloSeal (Baxter, United States) or Surgicel Fibrillar (Ethicon, United States) followed by gauze pressure for 5 minutes  (Figure 102. Although a rare condition, it has been reported after the use of both sutures and tacks into the sacrum and after open laparoscopic and robotic approaches. Potential exacerbating factors include concomitant hysterectomy, mesh exposure, the use of braided sutures or the placement of sutures and tackers deep into the periosteum at robotic sacral colpopexy without tactile feedback , and fixation into the L5–S1 intervertebral disc . We perform minimal sacral dissection and simply attach the mesh at the most prominent site on the sacral promontory that appears to compliment Good’s recommendation. Some surgeons attach the mesh to the lower part of the body of the L5 because of easier access. Leaks to the extraperitoneal tissues can occur at entry, with opening of extraperitoneal spaces or through existing undetected hernia. Significant or sudden subcutaneous emphysema around the face, neck, and chest must alert to the possibility of mediastinal emphysema. This usually arises from a congenital defect of the diaphragm but can also occur after trauma associated with upper abdominal surgery. Gas embolism can occur if gas enters the vascular system and usually occurs during or shortly after insufflation. The sudden development of hypotension, bradycardia, or arrhythmias at this time should immediately raise suspicion of gas embolism. The pneumoperitoneum should be released and the procedure abandoned as soon as feasible. Most of the changes are due to establishment and maintenance of pneumoperitoneum or Trendelenburg positioning. Carbon dioxide remains the most widely used distension media but is rapidly absorbed from the peritoneum and may cause hypercarbia and acidosis. Hypercarbia is associated with arrhythmias, increased cardiac output, and decreased systemic vascular resistance. Steep Trendelenburg may be required for posterior compartment or vault suspending procedures and results in increased central venous pressure and decreased arterial pressure and cardiac output. Atelectasis and decreased pulmonary compliance can occur but are usually well controlled with general anesthesia, neuromuscular blockade, endotracheal intubation, and controlled ventilation. Both pneumoperitoneum and Trendelenburg position reduce femoral venous flow increasing the risk of thrombotic complications. The judicious use of open approach or access via the left upper quadrant may be beneficial in minimizing access-related complications. Newer optical entry trocars may serve to decrease morbidity associated with closed or open access techniques. Careful dissection during adhesiolysis and cautious and appropriate use of electrical current will decrease bowel injuries. Vigilance during surgery is required to detect and manage complications intraoperatively, rather than postoperatively. An experienced operating room staff including assistants, scrub sisters, and anesthetists, who are enthusiastic regarding laparoscopic surgery, is vital to minimize complications associated with laparoscopic pelvic floor surgery. Finally, following surgical complication, it is vital to investigate the clinical and surgical decisions that may have led to an unwanted outcome.
Restoring eyelids to their nor- mal shape became an accepted procedure buy generic tamoxifen pills breast cancer mammogram, so that the Parisian surgeon Pierre Dionis (1643–1718) in his treatise “Cours d’Opérations de Chirurgie” purchase 20 mg tamoxifen mastercard menopause 3 months no period, published in 1707  20mg tamoxifen overnight delivery women's health bendigo vic, included a plate discount 20mg tamoxifen mastercard menopause age, which depicts an operating table with the instruments necessary to perform eyelid operations (Fig. Bartisch, in the form of a guillo- tine, for excising the excess of upper eyelid skin Jacques Croissant de Garengeot (1688–1759) illustrates an upper eyelid incision, using a ﬁne scalpel, in his “Traité des Opérations de Chirurgie”, issued in 1731  (Fig. Signiﬁcant improvements were also achieved in the ﬁeld of correction of ectropion. In 1866, the French surgeon Pierre- Édouard Cruveilhier (1835–1906) summarized the different 6 The Nineteenth Century or causes of the disease, analyzed the various procedures avail- the Golden age of Plastic Surgery: able at that time and wrote a well-documented thesis “De The Beginning of Cosmetic Surgery l’Ectropion” (On Ectropion) . About the same period, the Latvian Julius von Szymanowski (1829–1868) published The great majority of plastic surgery operations were con- “Handbuch der operativen Chirurgie” [ 17], where besides ceived in the nineteenth century, this is the reason why this an array of plastic surgery operations for closing various period is recognized as the golden age of Plastic Surgery. Croissant de Garengeot (1731)  ) ectropion correction, which is still used nowadays (Fig. In 1817, the eyeball appears ﬂaccid and swollen and presents a tumor Viennese George Joseph Beer (1763–1821) in his Lehre von even elastic on palpation. Most often this tumor is encircled den Augenkrankheiten als Leitfaden öffentlichen Vorlesungen between the border adhering to the eyeball and its wide entworfen  was among the ﬁrst to describe fat herniation transversal fold. Its weight, more important than the simple skin fold, illustration of orbital fat herniation: “(fatty ptosis) is pro- makes the movements of the lid more difﬁcult…” duced by a certain amount of fat deposited between the skin One of the ﬁrst surgical approaches to upper eyelid relax- and the orbicularis,…most often in continuity with cellular ation was by Baron Guillaume Dupuytren (1777–1835), the orbital adipose tissue… Frequently this fat is located under most brilliant leader of surgery in France. In the a pioneering work on aesthetic procedures, where facial oper- second edition of “Leçons orales de Clinique Chirurgicale ations, such as double-chin excision and upper eyelid modiﬁ- faites à l’Hôtel Dieu de Paris” (Clinical lectures on sur- cations, were illustrated . Miller wrote: “these conditions gery delivered at Hôtel Dieu of Paris), compiled by two of may be easily overcome by simple surgical procedures, Dupuytren’s pupils and posthumously published [21 ], one which are performed painlessly. In the second edition, published 17 years later , drooping of the skin of that region in the long run, that it falls he made considerable improvements, at least judging from down in front of the eyeball and, more or less completely, the variety of incisions illustrated, more than 13! However, interferes with vision… As it has been said, all internal ther- despite the lower eyelid approach, no fat removal is reported, apeutic means and topical remedies praised in similar cases only skin excision and no pre- and postoperative photo is sup- are ineffectual. Kolle (1872–1929) published excision of a part of the distended skin would be necessary, “Plastic and Cosmetic Surgery” the second book on cos- succeeded by a scar that would put an end to deformity. Under the heading operation which one uses in this case is wholly analogous to “wrinkled eyelids” he advocated the removal of “the redun- the one employed to remedy trichiasis. Cosmetic surgery developed at the turn of the century, On the other side of the Ocean, at the end of the First although its explosion occurred during the interwar period. Miller (1880–1950), from Chicago, with leading personalities, for example, Suzanne Noel, regarded as an “unscrupulous charlatan” by some, or “the Julien Bourguet, Raymod Passot and many others. His book “La Rôle Sociale ” [ 27], one of the ﬁrst textbooks on this topic Chirurgie Esthétique pure”, dating from 1931 , shows a and the ﬁrst written by a woman (Fig. In Vienna, Ernst Eitner (1867–1955) was among the ﬁrsts to illustrate excision of fat herniation from lower eyelid  (Fig. A great breakthrough in the knowledge of fat herniation of the eyelids was provided in 1951 by S. A great change in aesthetic surgery operative techniques has taken place after the Second World War and in recent years. Correction of upper and lower blepharoplasty became more precise and sophisti- cated. A good review of the literature on blepharoplasty and cosmetic surgery is supplied by Dupuis and Rees [34 ], Fig. Hunt for upper and lower eyelid correction in 1926  History of Cosmetic Eyelid Surgery 729 a b c Fig. Nöel for upper and lower eyelid correction (From: La Chirurgie Esthétique (1926)  ) a b Fig. Published Wien kl Wochenschr 9:109–110 in facsimile and hieroglyphic transliteration with translation and 23. The correction of featural a venerabili D’Hanvantare demonstratum a Susruta discipulo com- imperfections, 2nd edn. Lascaratos J, Cohen M, Voros D (1998) Plastic surgery of the Paris face in Byzantium in the fourth century. Bourguet J (1928) Notre traitement chirurgical de « poches » sous 1274–1280 les yeux sans cicatrice. Technique et century encyclopedist and surgeon: his role in the history of plastic Résultats. Kestenbaum A (1935) Modiﬁcation of ectropion operation accord- ing to Kuhnt-Szymanowski procedure. Klin Montatsbl f Augenheilk 95:51–53 Anatomy of the Orbitopalpebral Region Paolo Persichetti , Stefania Tenna , and Annalisa Cogliandro 1 Introduction medial third and middle third of the upper edge is located the supraorbital foramen through which pass the external frontal The orbitopalpebral region is a complex anatomofunctional nerve – also named supraorbital nerve – and the supraorbital unit, formed by several structures to support, protect, and artery. In the middle part of the lower edge there is the infra- assist the eye in performing the visual function. This chapter aims to point out the anatomical basis of the orbitopalpebral region and systematically give the new morphological concepts whose knowledge has become of great signiﬁcance for a correct surgical approach. Its base corresponds with the anterior opening; it has a quadrangular shape and consists of the fron- tal bone at the top, the orbital part of the maxillary bone at the bottom and the inner side, and the zygomatic bone at the bottom and the outer side. The optic nerve together with the oph- and the greater wing of the sphenoid ; ﬁnally the inner or thalmic artery, which is located below and lateral to the nerve nasal wall constituted forward reverse by the orbital part of itself, passes through these structures. The orbit is also related in the upper part with the anterior 3 Eyeball cranial fossa, at the back with the middle cranial fossa and the sphenoid sinus, inferiorly with the maxillary sinus, later- The eyeball has an ovoid shape to the most anteroposterior ally with the temporal fossa and medially, through the eth- axis and occupies the anterior prefascial portion of the orbital moidal cells, with the nasal cavity. It adheres to the posterior hemi- the greater wing of the sphenoid that gives passage to the sphere of the eyeball and separates it from the adipose body frontal, lacrimal, trochlear, common oculomotor, abducens of the orbit; it extends forward, behind the conjunctival for- nerves, to the nasociliary branch of the ophthalmic nerve, the nix, until the sclerocorneal margin and backwards it wraps sympathetic root of the ciliary ganglion and to the upper and around the optic nerve. It is connected to the edges of the lower ophthalmic veins; and the inferior orbital ﬁssure or orbit by means of a funnel-shaped extension through the sphenomaxillary between the orbital portions of the maxilla, peribulbar adipose tissue. This connective funnel-shaped tis- the greater wing of the sphenoid and the zygomatic bone that sue, thanks to a non-uniform thickness, very thin in some gives passage to the zygomatic nerve, the maxillary nerve, points, allows the passage of the neurovascular structures the orbital branches of the sphenopalatine ganglion, as well anteriorly. The capsule has a special relationship with the as to an anastomosis between the inferior ophthalmic vein ocular muscles forming a sheath such as a ﬁnger glove for and the venous pterygoid plexus (Figs. These sheaths, more developed forward, Finally in the posterior side of the orbit at its apex, is located thinner and transparent behind, are connected by a very thin the optic foramen followed by the optic canal, which has close connective lamella in the peribulbar portion called Anatomy of the Orbitopalpebral Region 735 Fig. It goes sideways, backward, and upward, all contained in the orbital cavity and are classiﬁed into two describing a loop around the eyeball and folding obliquely groups: the rectus muscles (superior, inferior, lateral, and from below the inferior rectus muscle, so that the two sheaths medial) and the oblique ones (upper and lower) (Fig. The most developed stretched, ribbon-shaped muscles, narrower behind, and arrest tendon is the lateral rectus muscle, which joins on the wider forward where by means of a long, ﬂattened tendon, outer wall of the orbit at the level of the lateral retinaculum thin and wider than the muscular body, attach themselves to near the tubercle of Whitnall. The biggest tendon of the medial rectus muscle is inserted on the poste- and strongest is the medial rectus. The insertion line of the rior lacrimal crest, behind the deep insertion of the medial rectus muscles is called spiral of Tillaux. The superior rectus muscle has two There are two oblique muscles: the upper one is the lon- orbital tendons that arise from the medial and lateral edge of gest and thinnest of the ocular muscles; it arises with a short its sheath and are inserted in the upper, medial, and lateral tendon from the medial edge of the optic foramen and the corners of the orbit. They also send numerous ﬁbers to the optic nerve sheath and is linked at the top of the orbit with tarsus and the conjunctival fornix mingling in part with the the insertion of the levator muscle of the upper eyelid. In collateral expansions of the levator muscle tendon of the eye- proximity of the base of the orbital pyramid it is transformed lid (Fig. These relationships justify a sort of functional into a cylindrical tendon that joins a ﬁbrocartilagineous eye- solidarity between the superior rectus muscle and elevating let, the trochlea , ﬁxed to the dimple or the trochlear spine of muscle of upper eyelid strengthened by the merger of the the frontal bone, where it is reﬂected to head sideways and sheaths of the two muscles, and explain why the upper lid is back towards the eyeball inserting on the sclera, in the super- lifted, when the superior rectus muscle is contracted making olateral part of the posterior hemisphere of the eye. It arises from the anteromedial part of inferior oblique muscle, the sheath of the two muscles the lower wall of the orbit in the jawbone below the fossa of appears thickened and sends prolongations towards the walls 736 P. The main functions of the intraorbital adipose tissue are those of protection, sup- port, and reduced friction of the eyeball.
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