Surgery Encyclopedia

thopedic injuries. Many of these injuries heal without treatment and go undetected. Many people with multiple WHO PERFORMS traumas in accidents have knee dislocations that go undi- THE PROCEDURE AND agnosed. Knee dislocations are of special concern, espe- WHERE IS IT PERFORMED? cially in traumatic injury, because their early diagnosis is Knee arthroscopic surgery required if surgery is to be effective. Knee dislocations in Surgery is performed by an orthopedic surgeon, the morbidly obese individuals often occur spontaneous- a specialist in joint and bone surgery, trained in ly and may be associated with artery injury. This surgery arthroscopic surgery. Arthoscopic surgery is involves complications related to the obesity. Finally, usually performed in a general hospital with an knee dislocations have been reported to occur in up to outpatient operating suite. 6% of trampoline-associated accidents. Description PCL is rare, because the tear can usually be treated with Arthroscopic surgery for acute injuries rest and with rehabilitation. If surgery is required, it is usually to reattach the PCL to the tibia bone. The knee bone sits between the femur and the tibia, attached by four ligaments that keep the knee stable as • Medial collateral ligament (MCL). This is an inside lat- the leg moves. These ligaments can be damaged or torn eral ligament connecting the femur and tibia and stabi- through injuries and accidents. Once damaged, they do lizing the knee against lateral dislocation to the left or not offer stability to the knee and can cause buckling, or to the right. The injury is usually due to external pres- allow the knee to “give way.” Ligaments can also “catch” sure against the inside of the knee. In the case of a and freeze the knee or make the knee track in a different grade I or II collateral ligament tear, doctors are likely direction than its leg movement, causing the knee to dis- to brace the knee for four to six weeks. A grade III tear locate. Traumatic injuries such as automobile accidents may require surgery to repair ligament tear and is fol- may cause more than one ligament injury, necessitating lowed by three months of bracing. Physical therapy multiple repairs to ligaments. may be necessary before resuming full activity. Four arthroscopic procedures relate to damage to • Lateral collateral ligament (LCL). An outside lateral each of the four ligaments that stabilize the knee joint ligament connecting the femur and tibia and stabilizing movement. The four procedures are: the knee against lateral dislocation. In the case of a grade I or II collateral ligament tear, doctors are likely • Anterior cruciate ligament (ACL). A front-crossing lig- to brace the knee for four to six weeks. A Grade III tear ament attaching the femur to the tibia through the knee; may require surgery to reattach the ligament to bone. this ligament keeps the knee from hyperextension or Surgery will be followed by three months of bracing. being displaced back from the femur. The ACL is a Physical therapy may be necessary before resuming rather large ligament that can withstand 500 lb (227 kg) full activity. of pressure. If it is torn or becomes detached, it remains that way and surgery is indicated. In the most severe cases, a graft to the ligament is necessary to reattach it Patello-femoral syndrome (PFS) to the bone. The surgery can use tissue from the pa- The patella rests in a groove on the femur. Anything tient, called an autograft, or from a cadaver, called an but a good fit can cause the patella to be unstable in its allograft. The patella tendon, which connects the patel- movement and very painful. Some individuals have la to the tibia, is the most commonly used autograft. chronic problems with the proper tracking of the patella ACL reconstructive surgery involves drilling a tunnel with the femur. This may be associated with conditions into the tibia and the femur. The graft is then pushed related to physical features like foot pronation, or to types through the tunnels and secured by stapling or sutures. of body development in exercising or overuse of muscles. • Posterior cruciate ligament (PCL). A back-crossing lig- In the case of damage, an examination of the cartilage ament that attaches the front of the femur to back of the surrounding the patella can identify cartilage that increas- tibia behind the knee that keeps the knee from hyperex- es friction as the patella moves. Smoothing the damaged tension or being displaced backward. PCL injuries are cartilage can increase the ease of movement and elimi- not as frequent as ACL injuries. These injuries are large- nate pain. Finally, a tendon can occasionally make the ly due to falls directly on the knee or hitting the knee on patella track off center of the femur. By moving where the dashboard of a car in an accident. Both displace the the tendon is attached through lateral release surgery, the tibia too far back and tear the ligament. Surgery to the patella can be forced back into its groove. GALE ENCYCLOPEDIA OF SURGERY 793

Knee arthroscopic surgery Knee arthroscopic surgery Patella Light enters arthroscope here Femur Posterior crutiate ligament ligament Medial collateral Anterior cruciate ligament Lateral collateral Fluid can be Instrument ligament added or removed from this tube Lateral meniscus Medial meniscus Tibia Fibula Drainage needle A. B. Torn meniscus Anterior meniscus horn Sutures Posterior Sutures meniscus horn C. D. Step A shows the anatomy of the knee from the front with the leg bent.To repair a torn meniscus, three small incisions are made into the knee to admit laparoscopic instruments (B). Fluid is injected into the joint to aid in the operation.The injury is visualized via the instruments, and the torn area is removed (C). (Illustration by GGS Inc.) Pain management with lavage and debridement smoothes the surface of bone to decrease pain. These two surgical treatments are controversial because re- In addition to the ligament and patella surgeries that search has not indicated that alternatives to surgery are are largely required for traumatic injuries, arthroscopic not as successful. surgery treats the wear and tear injuries related to a torn meniscus, which is the crescent-shaped cartilage that All of the above procedures are conducted through cushions the knee, as well as injuries to the surface of the visualization offered by the lighted arthroscope that bone that makes joint movement painful. These are relat- allows the surgeon to follow the surgery on a television ed to osteoarthritis and rheumatoid arthritis. monitor. Instruments only about 0.15 in (4 mm) thick are In lavage and debridement, the surgeon identifies inserted in a triangular fashion around the knee. The floating or displaced tissue pieces and either flushes arthroscope goes in one incision, and instruments to cut them out with a solution applied with arthroscopy or and/or smooth and to engage in other maneuvers are put 794 GALE ENCYCLOPEDIA OF SURGERY

through the other incisions. In this fashion, the surgeon has magnification, perspective, and the ability to make QUESTIONS TO ASK tiny adjustments to the tissue without open surgery. The THE DOCTOR triangular approach is highly effective and safe. • Are there rehabilitation alternatives to this Knee arthroscopic surgery Diagnosis/Preparation surgery? • Will this surgery allow me to return to sports? Disease and injury can damage joints, ligaments, cartilage, and bone surfaces. Because the knee carries • How much success have you had with this most of the weight of the body, this damage occurs al- surgery in eliminating pain? most inevitably as people age, due to sports injuries and • Is this injury one that I can live with if I pur- through accidents. sue a change in lifestyle? The diagnosis of knee injuries or damage includes a • How long will post-operative rehabilitation medical history, physical examination, x rays, and the take and how can I help in moving it along additional, more detailed imaging techniques with MRI faster? or CT scan. Severe or chronic pain and/or knee instability initially brings the patient to an orthopedic physician. From there, the decision is made for surgery or for reha- bilitation. Factors that influence the decision for surgery is usually suggested. Recovery times for resumed athlet- are the likelihood for repair and recovery of function, the ic activity are highly dependent on age and health. The patient’s health and age, and, most importantly, the will- surgeon often makes very careful assessments about re- ingness of the patient to consider changes in lifestyle, es- covery and the need for rehabilitation. pecially as this relates to sport activity. Arthroscopic Patella-tracking surgeries offer about a 90% chance viewing is the most accurate tool for diagnosis, as well as that the patella will no longer dislocate. However, many for some repairs. The surgeon may provide only a provi- people have continued swelling and pain after surgery. sional diagnosis until the actual surgery but will apprise These seem to be dependent upon how carefully the reha- the patient of the most likely course the surgery will take. bilitation plan is developed and/or adhered to by the patient. Arthroscopic surgery can be performed under local, regional, or general anesthetic. The type used depends Lavage and debridement surgeries largely upon the severity of damage, the level of pain Elevation of the leg after surgery is usually required after surgery, patient wishes, and patient health. The for a short period. A crutch or knee immobilizer adds ad- surgery is brief, less than two hours. After closing the in- ditional stability and assurance when walking. Physical cisions, the leg will be wrapped tightly and the patient is therapy is usually recommended to strengthen the mus- taken to recovery. For most same-day surgeries, individ- cles around the knee and to provide extra support. Special uals are allowed to leave once the anesthetic effects have attention should be paid to any changes to the leg a few worn off. Patients are not allowed to drive. Arrangements days after surgery. Swelling and pain to the leg can mean for pick up after surgery are mandated. a blood clot has been dislodged. If this occurs, the physi- Unlike open surgery, arthroscopic surgery generally cian should be notified immediately. Getting out of bed does not require a hospital stay. Patients usually go home shortly after surgery decreases the risk of blood clots. the same day. Any crutches or canes required prior to surgery will be needed after surgery. Follow-up visits Risks will be scheduled within about a week, at which point dressings will be removed. The risks of arthroscopic surgery are much less than open surgery, but they are not nonexistent. The risk of Aftercare any surgery carries with it danger in the use of anesthe- sia, including heart attacks, strokes, pneumonia, and Ligament- and patella-tracking surgeries blood clots. The risks are rare, but they increase with the age of the patient. Blood clots are the most common dan- Arthroscopic surgery for severe ligament damage or gers, but they occur infrequently in arthroscopic surgery. knee displacement often involves ligament grafting. In Other risks include infections at the surgery site or at the some cases, this includes taking tissue from a tendon to skin level, bleeding, and skin scars. use for the graft and drilling holes in the femur or tibia or both. Aftercare involves the use of crutches for six to Risks related specifically to arthroscopic surgery are eight weeks. A rehabilitation program for strengthening largely ones related to injury at the time of surgery. Arter- GALE ENCYCLOPEDIA OF SURGERY 795

Knee arthroscopic surgery ies, veins, and nerves can be injured, resulting in discom- Anterior cruciate ligament (ACL)—A crossing liga- KEY TERMS fort in minor cases and leg weakness or decreased sensa- tion in more serious complications. These injuries are rare. One major risk of arthropscopic surgery to the knee for ment that attaches the femur to the tibia and stabi- conditions related to tissue tears is that the pain may not lizes the knee against forward motion of the tibia. be relieved by the operation; it may even become worse. Knee surgery—Refers primarily to knee repair, re- placement or revision of parts of the knee, both Normal results Normal results of ligament surgery are pain, initial and open surgeries. immobility and inflexibility, bracing of the leg, crutch tissue and bond, and includes both arthroscopic Lateral release surgery—Release of tissues in the dependence, with increasing mobility and flexibility knee that keep the kneecap from tracking properly with rehabilitation. Full recovery to the level of prior in its groove (sulcus) in the femur; by realigning or physical activity can take up to three months. With ACL tightening tendons, the kneecap can be forced to surgery, pain in the front of the knee occurs in 10–20% track properly. of individuals. Limited range of motion occurs in less than 5% due to inadequate placement of the graft. A sec- Meniscus—The fibrous cartilage within the knee ond surgery may be necessary. joint that covers the surfaces of the femur and the tibia as they join the patella. Research indicates that the pain-relieving effects for arthroscopic partial menisectomy (removal of torn parts of cartilage) and debridement (the abrasion of cartilage to make it smooth) are not very reliable. Pain relief the degree of injury or damage are key to deciding varies between 50% and 75%, depending upon the age, whether to have surgery or rehabilitation. The physician activity level, degree of damage, and extent of follow-up. calibrates the severity of acute injuries and either pro- One study indicates that the two surgical procedures, ceeds to a determined treatment plan immediately or rec- lavage and debridement, fared no better than no surgical ommends surgery. Alternatives for acute ligament injuries procedure in relieving pain. The participants were divid- depend on the severity of injury and whether the patient ed into three groups for arthroscopic surgery: one third can make lifestyle changes and is willing to move away underwent debridement, a second third underwent from athletic activities. This decision becomes paramount lavage, and the remaining third likewise were anes- for many people with collateral and cruciate injuries. thetized and had three incisions made in the knee area, According to the American Association of Orthope- though no procedure was performed. All three groups re- dic Surgeons, conservative treatment for acute injuries ported essentially the same results. Each had slightly less involves RICE: Rest, Ice, Compression, Elevation, as pain and better knee movement. The non-procedure had well as a follow-up rehabilitation plan. The RICE proto- the best results. Debates about normal expectations from col involves resting the knee to allow the ligament to minor arthroscopic surgery continue with many surgeons heal, applying ice two or three times a day for 15–20 believing that arthroscopic surgery of the knee should be minutes, compression with a bandage or brace, and ele- restricted to acute injuries. vation of the knee whenever possible. Rehabilitation re- quires range-of-motion exercises to increase flexibility, Morbidity and mortality rates braces to control joint immobility, exercise for quadri- ceps to support the front of the thigh, and upper thigh ex- Complications occur in less than 1% of arthroscopic ercise with a bicycle. surgeries. Different procedures have different complica- tions. In general, morbidity results mostly from medically For arthritis-related damage and pain management, induced nerve and vascular damage; death or amputations anti-inflammatory medication, weight loss, and exercise almost never occur. Graft infection may occur, along with can all be crucial to strengthening the knee to relieve other types of infection largely due to microbes introduced pain. Evidence suggests that these alternatives work as with instruments. The latter cases are becoming increas- well as surgery. ingly rare as the science of arthroscopic surgery develops. Resources Alternatives BOOKS Canale, S. Terry. “Arthroscopic Surgery of Meniscus.” In Whether or not surgical treatment is the best choice Campbell’s Operative Orthopaedics. 9th ed. St. Louis: depends on a number of factors and alternatives. Age and Mosby, Inc., 1998. 796 GALE ENCYCLOPEDIA OF SURGERY

PERIODICALS Alleyne, K. R., and M. T. Galloway. “Osteochondral Injuries of WHO PERFORMS the Knee.” Clinics in Sports Medicine 20, no. 2 (April 2001). THE PROCEDURE AND Brown, C. H., and E. W. Carson. “Revision Anterior Cruciate WHERE IS IT PERFORMED? Knee osteotomy Ligament Surgery.” Clinics in Sports Medicine 18, no. 1 (January 1999). An orthropedic surgeon speciliazing in knee re- Heges, M. S., M. W. Richardson, and M. D. Miller. “The Dislo- construction surgery performs the operation. cated Knee.” Clinics in Sports Medicine 19, no. 3 (July Surgery takes place in a general hospital. 2000). Moseley, J. B, et al. “A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee.” New England Journal of Medicine 347, no. 2 (July 11, 2002): 81–88. Vangsness, C. T., Jr. “Overview of Treatment Options for the knee at the top of the tibia. Valgus osteotomy in- Arthritis in the Active Patient.” Clinical Sports Medicine volves the lateral (outer) compartment of the knee by 18, no. 1 (January 1999): 1–11. shaping the bottom of the femur. ORGANIZATIONS American Academy of Orthopaedic Surgeons (AAOS). 6300 Purpose North River Rd. Suite 200, Rosemont, IL 60018. (847) 823-7186 or (800) 346-2267; Fax: (847) 823-8125. Osteotomy surgery changes the alignment of the <http://www.aaos.org>. knee so that the weight-bearing part of the knee is shift- Arthritis Foundation. P.O. Box 7669, Atlanta, GA 30357-0669. ed off diseased or deformed cartilage to healthier tissue (800) 283-7800. <http://www.arthritis.org>. in order to relieve pain and increase knee stability. Os- National Institute of Arthritis and Musculoskeletal and Skin teotomy is effective for patients with arthritis in one Diseases Information Clearinghouse. 1 AMS Circle, compartment of the knee. The medial compartment is on Bethesda, MD 20892-3675. (301) 495-4484 or (877) 226- the inner side of the knee. The lateral compartment is on 4267; Fax: (301) 718-6366; TTY: (301) 565-2966. <http:// the outer side of the knee. The primary uses of osteoto- www.nih.gov/niams>. my occur as treatment for: OTHER • Knee deformities such as bowleg in which the knee is “Arthroscopic Knee Surgery No Better Than Placebo Surgery.” varus-leaning (high tibia osteotomy, or HTO) and Medscape Medical News. July 11, 2002. <http://www. knock-knee (tibial valgus osteotomy), in which the medscape.com>. knee is valgus leaning. “Arthroscopic Surgery.” Harvard Medical School Consumer Health. InteliHealth. <http://www.intelihealth.com>. • A torn anterior cruciate ligament (ACL), which is a “Knee Arthroscopy Summary.” Patient Education Institute, Na- set of ligaments that connects the femur to the tibia tional Library of Medicine/NIH/MedlinePlus. <http:// behind the patella and offers stability to the knee on www.nlm.nih.gov/medlineplus/tutorials/kneearthroscopy>. the left-right or medial-lateral axis. If this ligament is injured, it must be repaired by surgery. Many ACL Nancy McKenzie, PhD injuries cause inflammation of the cartilage of the knee and result in bones extrusions, as well as insta- bility of the knee due to malalignment. Osteotomy is performed to cut cartilage and increase the fit and alignment of the ends of the femur and tibia for Knee osteotomy smooth articulation. As one very common knee in- jury that often occurs in athletic activity, HTO is Definition often performed when ACL surgery is used to repair the ligament. The combination of the two surgeries Knee osteotomy is surgery that removes a part of the occurs primarily in young people who wish to return bone of the joint of either the bottom of the femur (upper to a highly athletic life. leg bone) or the top of the tibia (lower leg bone) to in- crease the stability of the knee. Osteotomy redistributes • Osteoarthritis that includes loss of range of motion, the weight-bearing force on the knee by cutting a wedge stiffness, and roughness of the articular cartilage in the of bone away to reposition the knee. The angle of defor- knee joint secondary to the wear and tear of motion, es- mity in the knee dictates whether the surgery is to correct pecially in athletes, as well as cartilage breakdown re- a knee that angles inward, known as a varus procedure, sulting from traumatic injuries to the knee. Surgery for or one that angles outward, called a valgus procedure. progressive osteoarthritis or injury-induced arthritis is Varus osteotomy involves the medial (inner) section of often used to stave off total joint replacement. GALE ENCYCLOPEDIA OF SURGERY 797

Diagnosis/Preparation Knee osteotomy • Are there lifestyle changes, weight, diet, or the patient to an orthopedic physician. From there, the QUESTIONS TO ASK Severe or chronic pain and/or knee instability brings THE DOCTOR decision is made for surgery or for rehabilitation. Pa- rehabilitative factors that can help avoid this physician. Once rehabilitation or other treatments are surgery? tients will undergo an examination and history with their ruled out and surgery is indicated, the physician must as- • How many of your patients have been able to sess for three factors: pain, instability, and knee align- return to normal activities such as walking, ment. Osteotomy is indicated if malalignment is a factor. running, and climbing stairs after surgery? Debridement, or the shaving of cartilage on the articu- • How many of your patients have been able to late femur or tibia, can usually resolve pain with instabil- return to exercise and to other athletic activi- ity problems. It must be determined whether the instabil- ties? ity is related to malalignment and not to other sources such as ACL injury. Since the goal of osteotomy is to • Is this surgery just putting off my need for shift weight from a symptomatic cartilage to an unsymp- knee replacement surgery? tomatic area to relieve both an instability and pain due to • How many of these surgeries have you per- excessive contact, alignment of the knee is assessed for formed? pressure distribution along the mechanical axis and the loading axis. This requires an analysis of gait pattern, range of motion, localized areas of pain, and neurologi- cal factors, as well as other technical tests for anterior in- Demographics stability. A diagnostic arthroscopy—examination of the According to Healthy People 2000, Final Review, knee joint with a long tube attached to a video camera— published by the Centers for Disease Control and Pre- is usually indicated before all knee osteotomies. Carti- vention, the various forms of arthritis “the leading cause lage surfaces are examined for degenerative or late-stage of disability in the United States” affect more than 15% arthritis. Magnetic resonance imaging (MRI) is useful of the total U.S. population (43 million persons) and in evaluating any intra-articular pathology such as bone more than 20% of the adult population. Osteoarthritis chips, padding tears, or injuries to ligaments. (OA) is the most common form of knee arthritis and in- volves a slowly progressive degenerative disease in Aftercare which the joint cartilage gradually wears away. It most After surgery, patients are placed in a hinged brace. often affects middle-aged and older people. The most Toe-touching is the only weight-bearing activity al- common source of ACL injury is skiing. Approximately lowed for four weeks in order to allow the osteotomy to 250,000 people sustain a torn or ruptured ACL in the hold its place. Continuous passive motion is begun im- United States each year. Research indicates that ACL in- mediately after surgery and physical therapy is used to juries are on the rise in the United States due to the in- establish full range of motion, muscle strengthening, crease in sport activity. and gait training. After four weeks, patients can begin weight-bearing movement. The brace is worn for eight Description weeks or until the surgery site is healed and stable. X Osteotomy is performed as open surgery to the knee rays are performed at intervals of two weeks and eight assisted by pre-operative arthropscopic diagnostic tech- weeks after surgery. niques. Surgery takes place on the tibia end or the femoral end at the knee according to whether the Risks malalignment to be corrected is varus, or inward leaning, The usual general surgical risks of thrombosis and or valgus, outward leaning. The surgery involves the heart attack are possible in this open surgery. Osteotomy gaping or wedging of a piece of bone and its removal to surgery itself involves some risk of infection or injury change the pressure points of weight-bearing activity. during the procedure. Combined surgery for ACL and The cut surfaces of the bone are held together with two osteotomy has higher morbidity rates. staples, or a plate and screws. Other devices may be used, especially in tibial osteotomy where a fracture is involved. After surgery, a small plastic suction drain is Normal results left in the wound during recovery and early postopera- Varus malalignment correction with osteotomy tive hospitalization. through the high tibia (HTO) is a proven and satisfacto- 798 GALE ENCYCLOPEDIA OF SURGERY

trauma to knee cartilage, complete knee replacement KEY TERMS may be suggested. High tibial osteotomy (HTO)—The tibial bone is Resources Knee replacement cut to redistribute weight on the knee for varus BOOKS alignment deformities or injuries. Ruddy, Shaun, et al., eds. Ruddy: Kelly’s Textbook of Rheuma- Osteotomy of the knee—Realignment of the tology, 6th Edition. Philadelphia: WB Saunders Publish- knee, using bone cutting to shift weight bearing ing, 2001. from damaged cartilage to healthier cartilage. PERIODICALS Valgus alignment—Alignment of the knee that an- Alleyne, K. R., and M. T. Galloway. “Management of Os- gles outward due to injury or deformity. teochrondral Injuries of the Knee.” Clinics in Sports Med- Varus alignment—Alignment of the knee that an- icine 20, No. 2 (April 2001). gles inward due to injury or deformity. Shubin Stein, B. E., R. J. William, and T. L. Wickiewicz. “Arthritis and Osteotomies in Anterior Cruciate Ligament Reconstruction.” Orthopedic Clinics of North America 34, no. 1 (January 2003). ry operation. Success rates are high when the patient has ORGANIZATIONS a small angle deformity (<10°). Knees with more severe American Academy of Orthopaedic Surgeons (AAOS). 6300 deformity have less satisfactory results. Tibial osteoto- North River Rd., Suite 200, Rosemont, IL 60018. (847) my for the less common valgus deformity is less satis- 823-7186. (800) 346-2267, Fax (847) 823-8125. <http:// factory. Research indicates that only a few individuals www.aaos.org/>. are able to return to their previous level of high sports Arthritis Foundation. P.O. Box 7669, Atlanta, GA 30357-0669. activity after a knee osteotomy, whether done with an (800) 283-7800. <http://www.arthritis.org>. ACL repair or not. However, more than half of patients National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse. 1 AMS Circle, in one study were able to return to leisure sports activi- Bethesda, MD 20892-3675. (301) 495-4484, Toll-Free ties. Reports also indicate that those individuals who (877) 226-4267. Fax: (301) 718-6366. TTY: (301) 565- had osteotomy without ACL reconstruction had no dif- 2966. <www.nih.gov/niams>. ferences in results with respect to measures of stability. It may take up to a year for the knee to be fully aligned OTHER and adapted to its new position after surgery. Most pa- “Osteotomy for Osteoarthritis.” WebMD Health. <http://www. tients, more than 50%, gain stability and are able to webmd.com.>. walk further than they could walk before osteotomy. However, according to one report, 13% of patients had Nancy McKenzie, PhD severe pain or needed a total knee replacement after five years. In one European review, the results were bet- ter. Osteoarthritis was arrested in 105 cases (69%), with Knee prosthesis surgery see Knee revision 47 cases showing deterioration. The main factors associ- surgery ated with further deterioration were insufficient correc- tion and persistence of malalignment. Morbidity and mortality rates Knee replacement Morbidity rates include bleeding, inflammation of Definition joint tissues, nerve damage, and infection. Knee replacement is a procedure in which the sur- geon removes damaged or diseased parts of the patient’s Alternatives knee joint and replaces them with new artificial parts. For those individuals suffering from osteoarthritis, The operation itself is called knee arthroplasty. Arthro- muscle-strengthening exercise, weight loss, and rehabili- plasty comes from two Greek words, arthros or joint tation can be helpful in relieving pain and gaining stabil- and plassein, “to form or shape.” The artificial joint it- ity. Anti-inflammatory medications can also be effective self is called a prosthesis. Most knee prostheses have in helping pain and stability. For severe varus or valgus four components or parts, and are made of a combina- deformities, osteotomy or knee replacement may be indi- tion of metal and plastic, or metal and ceramic in some cated. For those with severe ACL injury with secondary newer models. GALE ENCYCLOPEDIA OF SURGERY 799

Purpose Knee replacement relief and improved functioning of the knee joint. Be- is sometimes called the shinbone; and the fibula, a small- er bone on the outside of the lower leg. There are two col- Knee arthroplasty has two primary purposes: pain lateral ligaments on the outside of the knee joint that con- nect the femur to the tibia and fibula respectively. These cause of the importance of the knee to a person’s ability ligaments help to control the stresses of side-to-side to stand upright, improved joint functioning includes movements on the knee. The patella—a triangular bone at greater stability in the knee. the front of the knee—is attached by tendons to the quadriceps muscles of the thigh. This tendon allows a Pain relief person to straighten the knee. Two additional tendons in- side the knee stretch between the femur and the tibia to Total knee replacement, or TKR, is considered prevent the tibia from moving out of alignment with the major surgery. Therefore, it is usually not considered a femur. Cartilage, which is a whitish elastic tissue that al- treatment option until the patient’s pain cannot be man- lows bones to glide smoothly against each other, covers aged any longer by more conservative treatment. Alter- the ends of the femur, tibia, and fibula as well as the sur- natives to surgery are described below. faces of the patella. In addition to the cartilage that covers Pain in the knee may be either a sudden or gradual the bones, the knee joint also contains two crescent- development, depending on the cause of the pain. Knee shaped disks of cartilage known as menisci (singular, pain resulting from osteoarthritis and other degenerative meniscus), which lie between the lower end of the femur disorders may develop gradually over a period of years. and the upper end of the tibia and act as shock absorbers On the other hand, pain resulting from an athletic injury or cushions. The entire joint is surrounded by a thick or other traumatic damage to the knee, or from such con- layer of protective tissue known as the joint capsule. ditions as infectious arthritis or gout, may come on sud- Disorders and conditions that may lead to knee re- denly. Because the structure of the knee is complex and placement surgery include: many different disorders or conditions can cause knee pain, the cause of the pain must be diagnosed before • Osteoarthritis (OA). Osteoarthritis is a disorder in joint replacement surgery can be discussed as an option. which the cartilage in the knee joint gradually breaks down, allowing the surfaces of the bones to rub directly Joint function against each other. The patient experiences swelling, pain, inflammation, and increasing loss of mobility. OA Restoration of joint function and stability is the most often affects adults over age 45, and is thought to other major purpose of knee replacement surgery. It is result from a combination of wear and tear on the joint, helpful to have a brief outline of the major structures in lifestyle, and genetic factors. As of 2003, OA is the the knee joint in order to understand the types of disor- most common cause of joint damage requiring knee re- ders and injuries that can make joint replacement neces- placement. sary as well as to understand the operation itself. • Rheumatoid arthritis (RA). Rheumatoid arthritis is a The knee is the largest joint in the human body, as disease that begins earlier in life than OA and affects well as one of the most vulnerable. Unlike the hip joint, the whole body. Women are three times as likely as which is partly protected by the bony structures of the men to develop RA. Its symptoms are caused by the pelvis, the knee joint is not shielded by any other parts of immune system’s attacks on the body’s own cells and the skeleton. In addition, the knee joint must bear the tissues. Patients with RA often suffer intense pain even weight of the upper body as well as the stresses and when they are not putting weight on the affected joints. shocks carried upward through the feet when a person walks or runs. Moreover, the knee is essentially a hinge • Trauma. Damage to the knee from a fall, automobile joint, designed to move primarily backwards and for- accident, or workplace or athletic injury may trigger wards; it is not a ball-and-socket joint like the hip, which the process of cartilage breakdown inside the joint. can swivel and rotate in a variety of directions. Many Trauma is a common cause of damage to the knee joint. knee injuries result from stresses caused by twisting or Some traumatic injuries are caused by repetitive mo- turning movements, particularly when the foot remains tion or overuse of the knee joint; these types of injury in one position while the upper body changes direction include bursitis, or housemaid’s knee, and so-called rapidly, as in basketball, tennis, or skiing. runner’s knee. Other traumatic injuries are caused by sudden twisting of the knee, a direct blow to a bent The normal knee joint consists of a bone, the patella knee, or being tackled from the side in football. or kneecap, and a set of tendons, ligaments, and cartilage disks that connect the femur, or thighbone, to the lower There are several factors that increase a person’s leg. There are two bones in the lower leg, the tibia, which risk of eventually requiring knee replacement surgery. 800 GALE ENCYCLOPEDIA OF SURGERY

While some of these factors cannot be avoided, others as measuring the forces that affect the operation of a Knee replacement can be corrected through lifestyle changes: joint. Biomechanical studies have shown that people with certain types of leg or foot deformities, such as • Genetic. Both OA and RA tend to run in families. One bowlegs or difference in leg length, are at increased study done in France reported that the genetic factors risk of knee disorders because the stresses on the knee affecting osteoarthritis in the knee can be traced back joint are not distributed normally. almost 8,000 years. Both OA and RA, however, are polygenic disorders, which means that more than one • Gait-related factors. Gait refers to a person’s pattern of gene is involved in transmitting susceptibility to these motion when walking or running. Some people walk forms of arthritis. with their feet turned noticeably outward or inward; • Age. Knee cartilage becomes thinner and weaker with others tend to favor either the heel or the toe when they age, even in people who have no family history of walk, which makes their gait irregular. Any of these arthritis. factors can increase strain on the knee joint. • Sex. Women athletes have three times as many knee in- • Shoes. Poorly fitted or worn-out shoes contribute to juries as men. At present, orthopedic specialists are knee strain by increasing the force transmitted upward conducting studies to determine the cause(s) of this dif- to the knee when the foot strikes the sidewalk or other ference. Some doctors think it is related to the fact that hard surface. They also introduce or increase irregulari- most women have wider hips than most men, which re- ties in gait. Women’s high-heeled shoes are particularly sults in a different pattern of stresses on the knee joint. harmful to the knee joint because they do not cushion Others think that the ligaments in women’s knees tend the foot; and they cause prolonged tightening and fa- to loosen more easily. tigue of the leg muscles. • Biomechanical. Biomechanics refers to the study of • Work or other activities that involve jumping, jogging, body structures in terms of the laws of mechanics, such or squatting. Jogging tends to loosen the ligaments that GALE ENCYCLOPEDIA OF SURGERY 801

Knee replacement hold the parts of the knee joint in alignment, while on the second knee. The disadvantages of bilateral knee jumping increases the shock on the knee joint and the replacement include a longer period of time under anes- thesia; a longer hospital stay and recovery period at risk of twisting or tearing the knee joint when the per- home; and a greater risk of severe blood loss and other son lands. Squatting can increase the forces on the knee complications during surgery. joint as much as eight times body weight. If the operation is on only one knee, it will take two Demographics to four hours. The patient may be given a choice of gen- eral, spinal, or epidural anesthesia. An epidural anesthet- According to the American Academy of Or- ic, which is injected into the space around the spinal cord thopaedic Surgeons (AAOS), there are about 270,000 to block sensation in the lower body, causes less blood knee replacement operations performed each year in the loss and also lowers the risk of blood clots or breathing United States. Although about 70% of these operations problems after surgery. After the patient is anesthetized, are performed in people over the age of 65, a growing the surgeon will make an incision in the skin over the number of knee replacements are being done in younger knee and cut through the joint capsule. He or she must be patients. A Canadian survey released in January 2003 careful in working around the tendons and ligaments in- stated that the number of knee replacements performed side the joint. Knee replacement is a more complicated in patients younger than 55 rose 90% between 1994 and operation than hip replacement because the hip joint 2001. Most surgeons expect to see the proportion of knee does not depend as much on ligaments for stability. The arthroplasties performed in younger patients continue to next step is cutting away the damaged cartilage and bone rise. One reason for this trend is improvements in surgi- at the ends of the femur and tibia. The surgeon reshapes cal technique, as well as the design and construction of the end of the femur to receive the femoral component, knee prostheses since the first knee replacement was per- or shell, which is usually made of metal and attached formed in 1968. Although most knee prostheses are still with bone cement. cemented in place as of 2003, cementless prostheses were introduced in the 1980s. A second reason is peo- After the femoral part of the prosthesis has been at- ple’s changing attitudes toward aging and their expecta- tached, the surgeon inserts a metal component into the tions of an active life after retirement. Fewer are willing upper end of the tibia. This part is sometimes pressed to endure years of discomfort or resign themselves to a rather than cemented in place. If it is a cementless pros- restricted level of activity. thesis, the metal will be coated or textured so that new bone will grow around the prosthesis and hold it in In terms of gender and racial differences, women are place. A plastic plate called a spacer is then attached to slightly more likely to seek knee replacement surgery than the metal component in the tibia. The plastic allows the men, and Caucasians in the United States are more likely femur and tibia to move smoothly against each other. to have the operation than African Americans. Re- searchers have suggested that one reason for the racial dif- Lastly, another plastic component is glued to the ference is a difference in social networks. People in gener- rear of the patella, or kneecap. This second piece of plas- al are influenced in their health care decisions by the ex- tic prevents friction between the kneecap and the other periences and opinions of friends or family members, and parts of the prosthesis. After all the parts of the prosthe- Caucasians are more likely than African Americans to sis have been implanted, the surgeon will check them for know someone who has had knee replacement surgery. proper positioning, make certain that the tendons and lig- aments have not been damaged, wash out the incision with sterile saline solution, and close the incision. Description The length and complexity of a total knee replace- ment operation depend in part on whether both knee Diagnosis/Preparation joints are replaced during the operation or only one. Patient history Such disorders as osteoarthritis usually affect both knees, and some patients would rather not undergo The first part of a diagnostic interview for knee pain surgery twice. Replacement of both knees is known as is the careful taking of the patient’s history. The doctor bilateral TKR, or bilateral knee arthroplasty. Bilateral will ask not only for a general medical history, but also knee replacement seems to work best for patients whose about the patient’s occupation, exercise habits, past in- knees are equally weak or damaged. Otherwise most sur- juries to the knee, and any gait-related problems. The geons recommend operating on the more painful knee doctor will also ask detailed questions about the patient’s first so that the patient will have one strong leg to help ability to move or flex the knee; whether specific move- him or her through the recovery period following surgery ments or activities make the pain worse; whether the 802 GALE ENCYCLOPEDIA OF SURGERY

Knee replacement Saw Knee replacement Incision Femur Patella Tibia A. B. Tibial plateau Prosthetic button Femoral prosthesis Repaired patella Tibial prosthesis C. D. Patellar tendon Sutures E. In a total knee replacement, an incision is made to expose the knee joint (A).The surfaces of the femur are cut with a saw to receive the prosthesis (B).The tibia is cut to create a plateau (C).The prostheses for the femur, tibia, and patella are put in place (D).The incision is closed (E). (Illustration by GGS Inc.) GALE ENCYCLOPEDIA OF SURGERY 803

Knee replacement pain is sharp or dull; its location in the knee; whether the geon will make two to four small incisions known as ports. One port is used to insert the arthroscope; the sec- knee ever buckles or catches; and whether there are ond port allows insertion of miniaturized surgical instru- clicking or popping sounds inside the joint. ments; the other ports drain fluid from the knee. Sterile saline fluid is pumped into the knee to enlarge the joint Diagnostic tests PHYSICAL EXAMINATION OF THE KNEE. Following structures and to cut, smooth, or repair damaged tissue. the history, the doctor will examine the knee itself. The space and make it easier for the surgeon to view the knee knee will be checked for swelling, reddening, bruises, Preoperative preparation breaks in the skin, lumps, or other unusual features while the patient is standing. The doctor will also make note of Knee replacement surgery requires extensive and the patient’s posture, including whether the patient is detailed preparation on the patient’s part because it af- bowlegged or knock-kneed. The patient may be asked to fects so many aspects of life. walk back and forth so that the doctor can check for gait LEGAL AND FINANCIAL CONSIDERATIONS. In the abnormalities. United States, physicians and hospitals are required to In the second part of the physical examination, the verify the patient’s insurance benefits before surgery and patient lies on an examining table while the doctor pal- to obtain precertification from the patient’s insurer or pates (feels) the structures of the knee and evaluates the from Medicare. Without health insurance, the total cost strength or tightness of the tendons and ligaments. The of a knee replacement as of early 2003 can run as high as patient may be asked to flex one knee and straighten the $38,000. In addition to insurance documentation, pa- leg or turn the knee inward and outward so that the doc- tients are legally required to sign an informed consent tor can measure the range of motion in the joint. The form prior to surgery. Informed consent signifies that the doctor will also ask the patient to lie still while he or she patient is a knowledgeable participant in making health- moves the knee in different directions. care decisions. The doctor will discuss all of the follow- ing with the patient before he or she signs the form: the IMAGING STUDIES. The doctor will order one or nature of the surgery; reasonable alternatives to the more imaging studies in order to narrow the diagnosis. A surgery; and the risks, benefits, and uncertainties of each radiograph or x ray is the most common, but is chiefly option. Informed consent also requires the doctor to useful in showing fractures or other damage to bony struc- make sure that the patient understands the information tures. X-ray studies are usually supplemented by other that has been given. imaging techniques in diagnosing knee disorders. A com- puted tomography, or CAT scan, which is a specialized MEDICAL CONSIDERATIONS. Patients are asked to type of x ray that uses computers to generate three-dimen- do the following in preparation for knee replacement sional images of the knee joint, is often helpful in evaluat- surgery: ing malformations of the joint. Magnetic resonance • Get in shape physically by doing exercises to strength- imaging (MRI) uses a large magnet, radio waves, and a en or increase flexibility in the knee joint. Specific ex- computer to generate images of the knee joint. The advan- ercises are described in the books listed below. Many tage of an MRI is that it reveals injuries to ligaments, ten- clinics and hospitals also distribute illustrated pam- dons, and menisci as well as damage to bony structures. phlets of preoperation exercises. ASPIRATION. Aspiration is a procedure in which • Lose weight if the surgeon recommends it. fluid is withdrawn from the knee joint by a needle and • Quit smoking. Smoking weakens the cardiovascular sent to a laboratory for analysis. It is done to check for system and increases the risks that the patient will have infection in the joint and to draw off fluid that is causing breathing difficulties under anesthesia. pain. Aspiration is most commonly done when the knee has swelled up suddenly, but may be performed at any • Make donations of one’s own blood for storage in case a time. Blood in the fluid usually indicates a fracture or transfusion is necessary during surgery. This procedure torn ligament; the presence of bacteria indicates infec- is known as autologous blood donation; it has the ad- tion; the presence of uric acid crystals indicates gout. vantage of avoiding the risk of transfusion reactions or Clear, straw-colored fluid suggests osteoarthritis. transmission of diseases from infected blood donors. ARTHROSCOPY. Arthroscopy can be used to treat • Check the skin of the knee and lower leg for external knee problems as well as diagnose them. An arthroscope infection or irritation, and check the lower leg for signs consists of a miniature camera and light source mounted of swelling. If either is noted, the surgeon should be on a flexible fiberoptic tube. It allows the surgeon to look contacted for instructions about preparing the skin for into the knee joint. To perform an arthroscopy, the sur- the operation. 804 GALE ENCYCLOPEDIA OF SURGERY

• Have necessary dental work completed before the oper- ation. This precaution is necessary because small num- WHO PERFORMS bers of bacteria enter the bloodstream whenever a den- THE PROCEDURE AND tist performs any procedure that causes the gums to WHERE IS IT PERFORMED? Knee replacement bleed. Bacteria from the mouth can be carried to the knee area and cause an infection. Knee replacement surgery is performed by an • Discontinue taking birth control pills and any anti-in- orthopedic surgeon, who is an MD who has re- flammatory medications (aspirin or NSAIDs) two ceived advanced training in surgical treatment weeks before surgery. Most doctors also recommend of disorders of the musculoskeletal system. As discontinuing any alternative herbal preparations at this of 2002, qualification for this specialty in the time, as some of them interact with anesthetics and United States requires a minimum of five years pain medications. of training after medical school. Most orthope- dic surgeons who perform joint replacements LIFESTYLE CHANGES. Knee replacement surgery re- have had additional specialized training in quires a long period of recovery at home after leaving these specific procedures. the hospital. Since the patient’s physical mobility will be Knee replacement surgery can be performed limited, he or she should do the following before the op- in a general hospital with a department of ortho- eration: pedic surgery, but is also performed in special- • Arrange for leave from work, help at home, help with ized clinics or institutes for joint disorders. driving, and similar tasks and commitments. • Obtain a handicapped parking permit. • Check the house or apartment thoroughly for needed and antibiotic medications intravenously to prevent in- adjustments to furniture, appliances, lighting, and per- fection. Medications for pain will be given every three to sonal conveniences. People recovering from knee re- four hours, or through a device known as a PCA (patient- placement surgery must avoid kneeling, and minimize controlled anesthesia). The PCA is a small pump that de- bending, squatting, and any risk of falling. There are livers a dose of medication into the IV when the patient several good guides available that describe household pushes a button. To get the lungs back to normal func- safety and comfort considerations in detail. tioning, a respiratory therapist will ask the patient to • Stock up on nonperishable groceries, cleaning supplies, cough several times a day or breathe into blow bottles. and similar items in order to minimize shopping. Aftercare during the hospital stay is also intended to • Have a supply of easy-care clothing with elastic waist- lower the risk of a venous thromboembolism (VTE), or bands and simple fasteners in front rather than compli- blood clot in the deep veins of the leg. Prevention of cated ties or buttons in the back. Women may find knit VTE involves medications to thin the blood; exercises dresses that pull on over the head or wraparound skirts for the feet and ankles while lying in bed; and wearing easier to put on than slacks or skirts that must be pulled thromboembolic deterrent (TED) or deep vein thrombo- up over the knees. Shoes should be slip-ons or fastened sis (DVT) stockings. TED stockings are made of nylon with Velcro. (usually white) and may be knee-length or thigh-length; they help to reduce the risk of a blood clot forming in the Many hospitals and clinics now have “preop” class- leg vein by putting mild pressure on the veins. es for patients scheduled for knee replacement surgery. These classes answer questions about the operation and Physical therapy is also begun during the patient’s what to expect during recovery, but in addition they pro- hospital stay, often on the second day after the operation. vide an opportunity for patients to share concerns and The physical therapist will introduce the patient to using experiences. Studies indicate that patients who have at- a cane or crutches and explain how to manage such activ- tended preop classes are less anxious before surgery and ities as getting out of bed or showering without dislocat- generally recover more rapidly. ing the new prosthesis. In most cases the patient will spend some time each day on a continuous passive mo- tion (CPM) machine, which is a device that repeatedly Aftercare bends and straightens the leg while the patient is lying in Aftercare following knee replacement surgery be- bed. In addition to increasing the patient’s level of physi- gins while the patient is still in the hospital. Most pa- cal activity each day, the physical therapist will help the tients will remain there for five to 10 days after the oper- patient select special equipment for recovery at home. ation. During this period the patient will be given fluids Commonly recommended devices include tongs or reach- GALE ENCYCLOPEDIA OF SURGERY 805

Knee replacement • How many knee replacements have you per- • Deep vein thrombosis (DVT). There is some risk (about 1.5% in the United States) of a clot developing QUESTIONS TO ASK in the deep vein of the leg after knee replacement THE DOCTOR surgery because the blood supply to the leg is cut off by a tourniquet during the operation. The blood-thinning medications and TED stockings used after surgery are formed? intended to minimize the risk of DVT. • Should I consider bilateral knee replacement? • Will I benefit from arthroscopy or should I • Infection. The risk of infection is minimized by storing have knee replacement surgery now? autologous blood for transfusion and administering in- • What activities will I have to give up perma- travenous antibiotics after surgery. The rate of infec- nently if I have TKR? tion following knee replacement is about 1.89%. Fac- tors that increase the risk of infection after TKR in- • Does the hospital or clinic have preop class- clude poor nutritional status, diabetes, obesity, a weak- es to help me prepare for the operation? If ened immune system, and a history of smoking. not, are there knee exercises you would rec- ommend before the surgery? • Heterotopic bone. Heterotopic bone is bone that devel- ops at the lower end of the femur after knee replace- ment surgery. It is most likely to develop in patients ers for picking up objects without bending too far; a sock whose knee joints developed an infection. Heterotopic cone and special shoehorn; and bathing equipment. bone can cause stiffness and pain, and usually requires revision surgery. Following discharge from the hospital, the patient may go to a skilled nursing facility, rehabilitation center, or home. Patients who have had bilateral knee replace- Normal results ment are unlikely to be sent directly home. Ongoing Normal results include relief of chronic pain in the physical therapy is the most important part of recovery knee and greater range of motion in the knee joint. Real- for the first four to five months following surgery. Most istically, however, the patient should not expect complete HMOs in the United States allow home visits by a home restoration of function in the knee, and will usually be health aide, visiting nurse, and physical therapist for three advised to avoid contact sports, skiing, jogging, or other to four weeks after surgery. Some hospitals allow patients athletic activities that strain the knee joint. to borrow a CPM machine for use at home for a few Mild swelling of the leg may occur for as long as weeks. The physical therapist will monitor the patient’s three to six months after surgery. It can be treated by ele- progress as well as suggest specific exercises to improve vating the leg, applying an ice pack, and wearing com- strength and range of motion. After the home visits, the pression stockings. patient is encouraged to take up other forms of low-im- pact physical activity in addition to the exercises; swim- One commonplace side effect of TKR is that knee ming, walking, and pedaling a stationary bicycle are all prostheses sometimes set off metal detectors in airports good ways to speed recovery. The patient may take a mild and high-security buildings because of their large metal medication for pain (usually aspirin or ibuprofen) 30–45 content. Patients who fly frequently or whose occupations minutes before an exercise session if needed. require security clearance should ask their doctor for a wallet card certifying that they have a knee prosthesis. The patient will be instructed to notify his or her den- tist about the knee replacement so that extra precautions can The patient can expect a cemented knee prosthesis be taken against infection resulting from bacteria getting to last about 10–15 years, although many still function into the bloodstream during dental work. Some surgeons well as long as 20 years later. Cementless prostheses ask patients to notify them whenever the dentist schedules a have not been in use long enough for reliable evaluations tooth extraction, root canal, or periodontal work. of their long-term durability. When the prosthesis wears out or becomes loose, it is replaced in a procedure Risks known as knee revision surgery. Serious risks associated with TKR include the fol- lowing: Morbidity and mortality rates • Loosening or dislocation of the prosthesis. The risk of A study published in 2002 reported that the 30-day dislocation varies, depending on the type of prosthesis mortality rate following total knee arthroplasty was used, the patient’s level of activity, and the previous 0.5%. The overall frequency of serious complications in condition of the knee joint. this time period was 2.2%. This figure included 0.4% 806 GALE ENCYCLOPEDIA OF SURGERY

heart attack; 0.7% pulmonary embolism; and 1.5% deep are related to their gait. Orthotics are designed either to venous thrombosis. The rate of complications was high- correct the position of the foot in order to keep it from est in patients over 70, and male patients were more like- turning too far outward or inward, or to correct problems ly to have heart attacks than women. in the arch of the foot. Some orthotics are made of soft Knee replacement material that cushions the foot and are particularly help- A 2001 study published by the Mayo Clinic re- ful for patients with osteoarthritis or diabetes. viewed the records of 22,540 patients who had had knee replacements between 1969 and 1997. The mortality rate within 30 days of surgery was 0.21%, or 47 patients. Complementary and alternative Forty-three of the 47 patients had had preexisting cardio- (CAM) approaches vascular or lung disease. Patients who had had bilateral Complementary and alternative therapies are not knee operations had a higher mortality rate than those substitutes for arthroscopy or joint replacement surgery, who had not. but some have been shown to relieve physical pain before or after surgery, or to help patients cope more effectively Alternatives with the emotional and psychological stress of a major operation. Acupuncture, chiropractic, hypnosis, and Nonsurgical alternatives mindfulness meditation have been used successfully to relieve the pain of osteoarthritis as well as postoperative MEDICATION. The most common conservative al- discomfort. According to Dr. Marc Darrow, author of The ternatives to knee replacement surgery are analgesics,or Knee Sourcebook, a plant extract called RA-1, which is painkilling medications. Most patients who try medica- used in Ayurvedic medicine to treat arthritis, relieved pain tion for knee pain begin with an over-the-counter and leg swelling in patients participating in a randomized NSAID such as ibuprofen (Advil). If the pain cannot be trial. Alternative approaches that have helped patients controlled by nonprescription analgesics, the doctor may maintain a positive mental attitude include meditation, give the patient cortisone injections, which relieve the biofeedback, and various relaxation techniques. pain of arthritis by reducing inflammation. Unfortunate- ly, the relief provided by cortisone tends to diminish with each injection; moreover, the drug can produce seri- Alternative surgical procedures ous side effects. Arthroscopy is the most common surgical alterna- If the knee pain is caused by rheumatoid arthritis, a tive to knee replacement. It should be understood, how- group of medications known as disease-modifying an- ever, as a way to postpone TKR rather than avoid it com- tirheumatic drugs, or DMARDs, may help to slow or stop pletely. The arthroscopic procedure most often used to the progress of the disease. They work by suppressing or treat knee pain from osteoarthritis is debridement, in interfering with the immune system. DMARDs include which the surgeon cuts or scrapes away damaged struc- such drugs as penicillamine, methotrexate, oral or in- tures or tissues until healthy tissue is reached. Most pa- jectable gold, hydroxychloroquine, leflunomide, and sul- tients who have had arthroscopic débridement have been fasalazine. DMARDs are not suitable for all patients with able to postpone TKR for three to five years. RA, however, as they sometimes have serious side effects. Cartilage transplantation is a procedure in which In addition, some of them are slow-acting and may take small bone plugs with cartilage are removed from a part several months to work before the patient feels some relief. of the patient’s knee where the cartilage is still healthy LIFESTYLE CHANGES. A second alternative to knee and transplanted to the area in which cartilage has been surgery is lifestyle changes. Losing weight helps to re- damaged. Another form of cartilage transplantation in- duce stress on the knee joint. Giving up specific sports or volves two operations, one to remove cartilage cells from other activities that damage the knee, such as jogging, the patient’s knee for culture in a laboratory, and a sec- tennis, high-impact aerobics, or stair-climbing exercise ond operation to place the new cells within the damaged machines, may control the pain enough to make surgery part of the knee. The cultured cells are covered with a unnecessary. Wearing properly fitted shoes and avoiding thin layer of tissue to hold them in place. After surgery, high heels and other extreme styles can also help to con- the cartilage cells multiply to form new cartilage inside trol pain and minimize further damage to the knee. the knee. Unfortunately, as of 2003 neither form of carti- lage transplantation is usually beneficial to patients with BRACES AND ORTHOTICS. Some patients with un- osteoarthritis; transplantation has been most successful stable knees are helped by functional braces or knee sup- in treating patients whose knee cartilage was damaged ports that are designed to keep the kneecap from slipping by sudden trauma rather than by gradual degeneration. out of place. Orthotics, which are inserts placed inside shoes, are often helpful to patients whose knee problems See also Arthroscopic surgery; Knee revision surgery. GALE ENCYCLOPEDIA OF SURGERY 807

Knee replacement Analgesic—A medication given to relieve pain. Fibula—The smaller of the two bones in the lower KEY TERMS leg. Arthroplasty—The medical term for surgical re- placement of a joint. Arthroplasty can refer to hip as well as knee replacement. Ligament—A band of fibrous tissue that connects bones to other bones or holds internal organs in Arthroscope—An instrument that contains a place. miniature camera and light source mounted on a Meniscus (plural, menisci)—One of two crescent- flexible tube. It allows a surgeon to see the inside shaped pieces of cartilage attached to the upper of a joint or bone during surgery. surface of the tibia. The menisci act as shock ab- Autologous blood—The patient’s own blood, sorbers within the knee joint. drawn and set aside before surgery for use during Nonsteroidal anti-inflammatory drugs (NSAIDs)— surgery in case a transfusion is needed. A term used for a group of analgesics that also re- Biomechanics—The application of mechanical laws duce inflammation when used over a period of to the structures in the human body, such as mea- time. NSAIDs are often given to patients with os- suring the force and direction of stresses on a joint. teoarthritis. Bursitis—Inflammation of a bursa, which is a sac- Orthopedics (sometimes spelled orthopaedics)— like cavity filled with fluid that protects the tissues The branch of surgery that treats deformities or dis- around certain joints in the body from friction. orders affecting the musculoskeletal system. Bursitis of the knee frequently develops as a result Orthotics—Shoe inserts that are intended to cor- of activities requiring frequent bending and kneel- rect an abnormal or irregular gait or walking pat- ing, such as housecleaning. tern. They are sometimes prescribed to relieve gait- Cartilage—A whitish elastic connective tissue that related knee pain. allows the bones forming the knee joint to move Patella—The medical term for the knee cap. The smoothly against each other. patella is a triangular bone located at the front of Cortisone—A steroid compound used to treat au- the knee. toimmune diseases and inflammatory conditions. It is sometimes injected into a joint to relieve the Prosthesis (plural, prostheses)—An artificial de- pain of arthritis. vice that substitutes for or supplements a missing or damaged body part. Prostheses may be either Debridement—The surgical removal of foreign external or implanted inside the body. material and dead or contaminated tissue from a wound or the area of an incision. Quadriceps muscles—A set of four muscles on each leg located at the front of the thigh. The Disease-modifying antirheumatic drugs (DMA quadriceps straighten the knee and are used every RDs)—A group of medications that can be given to time a person takes a step. slow or stop the progression of rheumatoid arthri- tis. DMARDs include such drugs as oral or in- Tibia—The larger of two leg bones that lie beneath jectable gold, methotrexate, leflunomide, and the knee. The tibia is sometimes called the shin penicillamine. bone. Resources PERIODICALS Alemparte, J., G. V. Johnson, R. L. Worland, et al. “Results of BOOKS Simultaneous Bilateral Total Knee Replacement: A Study Darrow, Marc, MD, JD. The Knee Sourcebook. Chicago and of 1208 Knees in 604 Patients.” Journal of the Southern New York: Contemporary Books, 2002. Orthopaedic Association 11 (Fall 2002): 153–156. Nohava, Ann. My Bilateral Knee Replacement: A Personal Story. San Jose, CA and New York: Writers Club Press, 2001. Blake, V. A., J. P. Allegrante, L. Robbins, et al. “Racial Differ- Silber, Irwin. A Patient’s Guide to Knee and Hip Replacement: ences in Social Network Experience and Perceptions of Everything You Need to Know. New York: Simon & Benefit of Arthritis Treatments Among New York City Schuster, 1999. Medicare Beneficiaries with Self-Reported Hip and Knee 808 GALE ENCYCLOPEDIA OF SURGERY

Pain.” Arthritis and Rheumatism 47 (August 15, 2002): Canadian Institute for Health Information/Institut canadien 366–371. d’information sur la santé (CIHI). 377 Dalhousie Street, Chernajovsky,Y., P. G. Winyard, and P. S. Kabouridis. “Advances Suite 200, Ottawa, ON K1N 9N8. (613) 241-7860. in Understanding the Genetic Basis of Rheumatoid Arthritis <http://secure.cihi.ca/cihiweb>. and Osteoarthritis: Implications for Therapy.” American National Center for Complementary and Alternative Medicine Knee revision surgery Journal of Pharmacogenomics 2 (2002): 223–234. (NCCAM) Clearinghouse. P.O. Box 7923, Gaithersburg, Crubezy, E., J. Goulet, J. Bruzek, et al. “Epidemiology of Os- MD 20898. (888) 644-6226. TTY: (866) 464-3615. Fax: teoarthritis and Enthesopathies in a European Population (866) 464-3616. <http://www.nccam.nih.gov.>. Dating Back 7700 Years.” Joint, Bone, Spine: Revue du National Institute of Arthritis and Musculoskeletal and Skin Rhumatisme 69 (December 2002): 580–588. Diseases (NIAMS) Information Clearinghouse. National Gunther, K. P. “Surgical Approaches to Osteoarthritis.” Best Institutes of Health, 1 AMS Circle, Bethesda, MD 20892. Practice and Research: Clinical Rheumatology 15 (Octo- (301) 495-4484. TTY: (301) 565-2966. <http://www. ber 2001): 627–643. niams.nih.gov>. Rush Arthritis and Orthopedics Institute. 1725 West Harrison Hasegawa, M., T. Ohashi, and A. Uchida. “Heterotopic Ossifi- cation Around Distal Femur After Total Knee Arthroplas- Street, Suite 1055, Chicago, IL 60612. (312) 563-2420. ty.” Archives of Orthopaedic and Trauma Surgery 122 <http://www.rush.edu>. (June 2002): 274–278. OTHER Johnson, L. L. “Arthroscopic Abrasion Arthroplasty: A Re- American Academy of Orthopaedic Surgeons (AAOS) Patient view” Clinical Orthopaedics and Related Research 391 Education Booklet #03057. Total Knee Replacement. Supplement (October 2001): S306–S317. Rosemont, IL: AAOS, 2001. Lombardi, A. V., T. H. Mallory, R. A. Fada, et al. “Simultane- Canadian Institute for Health Information/Institut canadien ous Bilateral Total Knee Arthroplasty: Who Decides?” d’information sur la santé (CIHI). Total Hip and Total Clinical Orthopaedics and Related Research 392 (No- Knee Replacements in Canada, 2000/01. Toronto, ON: vember 2001): 319–329. Canadian Joint Replacement Registry, 2003. Mantilla, C. B., T. T. Horlocker, D. R. Schroeder, et al. “Fre- Questions and Answers About Knee Problems. Bethesda, MD: quency of Myocardial Infarction, Pulmonary Embolism, National Institutes of Health, 2001. NIH Publication No. Deep Venous Thrombosis, and Death Following Primary 01-4912. Hip or Knee Arthroplasty.” Anesthesiology 96 (May University of Iowa Department of Orthopaedics. Total Knee 2002): 1140–1146. Replacement: A Patient Guide. Iowa City, IA: University Parvisi, J., T. A. Sullivan, R. T. Trousdale, and D. G. Lewallen. of Iowa Hospitals and Clinics, 1999. “Thirty-Day Mortality After Total Knee Arthroplasty.” Journal of Bone and Joint Surgery, American Volume 83- Rebecca Frey, Ph.D. A (August 2001): 1157–1161. Peersman, G., R. Laskin, J. Davis, and M. Peterson. “Infection in Total Knee Replacement: A Retrospective Review of 6489 Total Knee Replacements.” Clinical Orthopaedics and Related Research 392 (November 2002): 15–23. Shah, S. N., D. J. Schurman, and S. B. Goodman. “Screw Mi- Knee revision surgery gration from Total Knee Prostheses Requiring Subsequent Surgery.” Journal of Arthroplasty 17 (October 2002): Definition 951–954. Knee revision surgery, which is also known as revi- Silva, M., R. Tharani, and T. P. Schmalzried. “Results of Direct Exchange or Debridement of the Infected Total Knee sion total knee arthroplasty, is a procedure in which the Arthroplasty.” Clinical Orthopaedics and Related Re- surgeon removes a previously implanted artificial knee search 404 (November 2002): 125–131. joint, or prosthesis, and replaces it with a new prosthesis. Wai, E. K., H. J. Kreder, and J. I. Williams. “Arthroscopic De- Knee revision surgery may also involve the use of bone bridement of the Knee for Osteoarthritis in Patients Fifty grafts. The bone graft may be an autograft, which means Years of Age or Older: Utilization and Outcomes in the that the bone is taken from another site in the patient’s Province of Ontario.” Journal of Bone and Joint Surgery, own body; or an allograft, which means that the bone tis- American Volume 84-A (January 2002): 17–22. sue comes from another donor. ORGANIZATIONS American Academy of Orthopaedic Surgeons (AAOS). 6300 Purpose North River Road, Rosemont, IL 60018. (847) 823-7186 or (800) 346-AAOS. <http://www.aaos.org>. Knee revision surgery has three major purposes: re- American Physical Therapy Association (APTA). 1111 North lieving pain in the affected hip; restoring the patient’s Fairfax Street, Alexandria, VA 22314. (703) 684-APTA or mobility; and removing a loose or damaged prosthesis (800) 999-2782. <http://www.apta.org>. before irreversible harm is done to the joint. Knee pros- GALE ENCYCLOPEDIA OF SURGERY 809

A knee prosthesis that has become infected or com- Knee revision surgery Knee revision surgery is performed by an ortho- pletely dislocated must be removed and replaced to pre- WHO PERFORMS THE PROCEDURE AND vent permanent damage to the patient’s knee. WHERE IS IT PERFORMED? Demographics The demographics of knee revision surgery are pedic surgeon, who is an MD and who has re- somewhat difficult to evaluate because the procedure is ceived advanced training in surgical treatment of performed much less frequently than total knee replace- disorders of the musculoskeletal system. As of ment (TKR). TKR itself is a relatively new operation; 2002, qualification for this specialty in the Unit- the first total knee replacement was performed in the ed States requires a minimum of five years of United Kingdom in 1968 and the first TKR in the United training after medical school. Most orthopedic States in 1970. As of 2003, it is estimated that 98% of surgeons who perform joint replacements and knee prostheses are still functioning well 10 years after revision operations have had additional special- surgery, with 94% still working after 20 years. Because ized training in these specific procedures. of this high success rate, the number of patients who In many cases, knee revision surgery is have had knee revision surgery yields a much smaller done by the surgeon who performed the origi- database than those who have had TKR. It is estimated nal knee replacement operation. Some sur- that about 22,000 knee revision operations are performed geons, however, refer patients to colleagues in the United States each year; over half of them are who specialize in revision procedures. done within two years of the patient’s TKR. Knee revision surgery can be performed in Another difficulty in evaluating the demographics of a general hospital with a department of ortho- knee revision surgery is the growing trend toward TKR pedic surgery, but is also performed in special- in younger patients. A Canadian survey released in Janu- ized clinics or institutes for joint disorders. ary 2003 stated that the number of knee replacements performed in patients below the age of 55 rose 90% be- tween 1994 and 2001. As the number of knee replace- ment procedures done in younger patients continues to theses can come loose for one of two reasons. One is me- rise, the number of revision surgeries will increase as chanical and is related to the fact that the knee joint well. A study done in the United States in 1996 reported bears a great deal of weight when a person is walking or that women were almost twice as likely as men to have running. It is unusual for the metal part of a knee pros- knee revision surgery, and that Caucasians were 1.5 thesis to simply break. This part, however, is inserted times as likely as African Americans to have the proce- into the upper part of the tibia, the larger of the two dure. This study, however, was limited to patients over bones in the lower leg, after the surgeon has removed the the age of 65, so that its findings are not likely to be an upper surface of the tibia. The bone tissue that receives accurate picture of younger patient populations. the metal implant is softer than the bone that was re- moved, which means that the metal implant may sink Description into the softer bone and gradually loosen. Most knee revision operations take about three The second reason for loosening of a knee prosthesis hours to perform and are similar to knee replacement is related to the development of inflammation in the knee procedures. After the patient has been anesthetized, the joint. The plastic part of a knee prosthesis is made of a surgeon opens the knee joint by cutting through the joint material called polyethylene, which can form small parti- capsule. The first step in revision surgery is the removal cles of debris as a result of wear on the prosthesis over of the old femoral component of the knee prosthesis. time. If the patient has an uneven gait, or pattern of walk- After the metal shell has been removed, the damaged ing, the debris particles tend to form at a faster rate be- bone at the end of the femur is scraped off and the femur cause one side of the prosthesis will tend to pull away is reshaped. If the bone is weak, the surgeon may decide from the bone and the other side will be pushed further to fill the cavity inside the femur with bone grafts. In into the bone. These tiny fragments of plastic are ab- some cases, metal wedges may be used to strengthen the sorbed by tissue cells around the knee joint, which be- attachment of the new femoral component. come inflamed. The inflammatory response begins to dis- solve the bone around the prosthesis in a process known After the new femoral component has been glued in as osteolysis. As the osteolysis continues, bone loss ac- place with bone cement, the old implant in the tibia is re- celerates and the prosthesis eventually comes loose. moved and the bone is reshaped to receive a new implant. 810 GALE ENCYCLOPEDIA OF SURGERY

If the old implant had loosened because it had moved downward into the softer tissue inside the tibia, the sur- QUESTIONS TO ASK geon will pack the space with morselized bone from a THE DOCTOR donor before putting in the new implant. This technique is known as impaction grafting. The impaction grafting • How many knee revision operations do you Knee revision surgery may be reinforced with wire mesh. If the tibia has been perform each year? shortened by the removal of damaged bone, the surgeon • Would I be likely to benefit from arthroscopy? will insert a wedge along with the new tibial implant and • What lifestyle changes can I make to extend secure them to the end of the tibia with bone cement. A the life of the new prosthesis? new plastic plate will be fastened to the tray at the top of the tibial implant so that the patient’s femur can move • What are my chances of needing another re- smoothly over the tibia. If the patient’s patella (kneecap) vision operation in the future? has been damaged, the surgeon will resurface its back surface and attach a plastic component to protect the patella from further bone loss. The tibial and femoral components of the prosthesis are then fitted together, the • age (Younger patients tend to be more active and to kneecap is replaced, and the knee tendons reattached with wear out knee prostheses more rapidly than older ones.) surgical wire. The knee joint is washed out with sterile • a long hospital stay for the original knee surgery saline fluid and the various layers of the incision closed. • concurrent diseases or disorders Revision surgery on an infected knee requires two • any type of arthritis separate operations. In the first operation, the old pros- thesis is taken out and a block of polyethylene cement • surgical complications during the first knee operation known as a spacer block is inserted in the joint. The • having the first knee operation performed at an urban spacer block has been treated with antibiotics to fight hospital the infection. The incision is closed and the spacer block The doctor will then usually order a series of imag- remains inside the patient’s knee for about six weeks. ing tests to determine the location of the problem and the The patient is also given intravenous antibiotics during extent of bone loss. X-ray studies can be used to check this period. After the infection has cleared, the knee is for complete dislocation of the prosthesis as well as loos- reopened and the new revision prosthesis is implanted. ening. Computed tomography appears to be more effec- tive in detecting the early stages of osteolysis than x-ray Diagnosis/Preparation studies. If the doctor suspects that the knee prosthesis has become infected, he or she will aspirate the joint. As- In most cases, increasing pain, stiffness, and loss of piration is a procedure in which fluid is withdrawn from mobility in the knee joint are early indications that the pa- a joint through a needle and sent to a laboratory for tient may benefit from revision surgery. The location of analysis. The fluid will be cultured in order to identify the pain may point to the part of the prosthesis that has the specific organism causing the infection. been affected by osteolysis. Pain around or in the kneecap is not always significant by itself because many TKR pa- Aftercare tients have occasional discomfort in that area after their knee replacement. If the pain is diffuse (felt throughout Aftercare following knee revision surgery is essen- the knee rather than in only one part of the knee), it may tially the same as for knee replacement, consisting of a indicate either an infection or loosening of the prosthesis. combination of physical therapy, rehabilitation exercises, Pain felt throughout the knee accompanied by tissue fluid pain medication when necessary, and a period of home accumulating in the joint points to a problem with the health care or assistance. polyethylene part of the prosthesis. Pain in the lower The length of recovery after revision knee surgery thigh or in the part of the leg just below the knee suggests varies in comparison to the patient’s first knee replace- that the metal plate attached to the femur or the metal im- ment. Some patients take longer to recover from revision plant in the tibia may have come loose. surgery, but others recover more rapidly than they did The doctor may take risk factors into account in as- from TKR, and they experience less discomfort. The rea- sessing the likelihood of a failed knee prosthesis. Six sons for this variation are not yet known. As of 2003, the factors have been identified as increasing a patient’s risk Hip and Knee Center at Columbia University is conduct- of needing revision surgery within two years of knee re- ing a study of 100 knee revision patients at five different placement surgery: sites in the United States in order to evaluate the out- GALE ENCYCLOPEDIA OF SURGERY 811

Knee revision surgery comes of revision surgery. The patients will be examined • deep infection: 0.97% at three-month, six-month, 12-month, and 24-month in- • loosening of the new prosthesis: 10–15%. tervals in order to measure their progress after surgery. • dislocation of the new prosthesis: 2–5%. Risks • deep venous thrombosis: 1.5% The complications that may follow knee revision surgery are similar to those for knee replacement. They include: Alternatives Nonsurgical alternatives • Deep vein thrombosis. • Infection in the new prosthesis. LIFESTYLE CHANGES. The American Association of Orthopaedic Surgeons (AAOS) has published a fact • Loosening of the new prosthesis. The risk of this com- sheet about the effects of aging on the knee joint aimed plication is increased considerably if the patient is at the baby boomer generation. Many adults in their 40s overweight. and 50s have been influenced by the contemporary em- • Formation of heterotopic bone. Heterotopic bone is phasis on youthfulness to keep up athletic activities and bone that develops at the lower end of the femur fol- forms of exercise that are hard on the knee joint. Some lowing knee replacement or knee revision surgery. Pa- of them try to return to a high level of activity even after tients who have had an infection in the joint have an in- TKR. As a result, some surgeons are suggesting that creased risk of heterotopic bone formation. adults in this age bracket scale back their athletic work- • Bone fractures during the operation. These are caused outs or substitute low-impact forms of exercise. Good by the force or pressure that the surgeon must some- choices include water aerobics, tai chi, yoga, swimming, times apply to remove the old prosthesis and the ce- cycling, and walking. ment that may be attached to it. COMPLEMENTARY AND ALTERNATIVE (CAM) AP- • Dislocation of the new prosthesis. The risk of disloca- PROACHES. Complementary and alternative therapies are tion is twice as great for revision surgery as for TKR. not substitutes for knee revision surgery, but some have • Difference in leg length resulting from shortening of been shown to relieve physical pain before or after the leg with the prosthesis. surgery, or to help patients cope more effectively with • Additional or more rapid loss of bone tissue. the emotional and psychological stress of a major opera- tion. Acupuncture, chiropractic, hypnosis, and mindful- Normal results ness meditation have been used successfully to relieve Normal results of knee revision surgery are quite postoperative discomfort following revision surgery. Al- similar to those for TKR. Patients have less pain and ternative approaches that have helped patients maintain a greater mobility in the affected knee, but not complete positive mental attitude include meditation, biofeedback, restoration of the function of a normal knee. Between and various relaxation techniques. 5% and 20% of patients report some pain following ei- ther TKR or revision surgery for several years after their Alternative surgical procedures operation. Most patients, however, have considerably Arthroscopy is the most common surgical alterna- less discomfort in the knee after surgery than they did tive to knee revision surgery. It is a procedure in which a before the procedure. A recent British study found that surgeon makes three or four small incisions in the knee revision knee surgery patients had the same positive re- in order to insert a device that allows him or her to see sults at six-month follow-up as patients who had had pri- the inside of the joint, insert miniaturized instruments to mary knee replacement surgery. remove or repair damaged tissue, and drain fluid from As with knee replacement surgery, patients who the joint. Arthroscopy has been used successfully to treat have had revision surgery may experience mild swelling stiffness in the knee following TKR and improve range of the leg for as long as three to six months after surgery. of motion in the joint. It is not successful in treating in- Swelling can be treated by elevating the leg, applying an fected prostheses unless it is used very early. ice pack, and wearing compression stockings. Other surgical alternatives to knee revision surgery include manipulation of the joint while the patient is Morbidity and mortality rates under general anesthesia, and arthrodesis of the knee. The 30-day mortality rate following knee revision Arthrodesis is a procedure in which the joint is fixed in surgery is low, between 0.1% and 0.2%. The estimated place with a long surgical nail until the growth of new rates of complications are as follows: bone tissue fuses the knee. It is generally considered a 812 GALE ENCYCLOPEDIA OF SURGERY

less preferable alternative to knee revision surgery, but is sometimes used in the treatment of elderly patients with KEY TERMS infected prostheses or weakened bone structure. Arthrodesis—A procedure that is sometimes used See also Arthroscopic surgery. Knee revision surgery as an alternative to knee revision surgery, in which Resources the joint is first fixed in place with a surgical nail and then fused as new bone tissue grows in. BOOKS Arthroscope—An instrument that contains a Darrow, Marc, MD, JD. The Knee Sourcebook. Chicago and New York: Contemporary Books, 2002. miniature camera and light source mounted on a Silber, Irwin. A Patient’s Guide to Knee and Hip Replacement: flexible tube. It allows a surgeon to see the inside Everything You Need to Know. New York: Simon & of a joint or bone during surgery. Schuster, 1999. Femur—The medical name for the thighbone. PERIODICALS Gait—A person’s habitual pattern of walking. An Barrack, R. I., C. S. Brumfield, C. H. Rorabeck, et al. “Hetero- irregular gait is a risk factor for knee revision topic Ossification After Revision Total Knee Arthroplas- surgery. ty.” Clinical Orthopaedics and Related Research 404 (No- Heterotopic bone—Bone that develops as an ex- vember 2002): 208–213. cess growth around a joint following joint re- Djian, P., P. Christel, and J. Witvoet. “Arthroscopic Release for Knee Joint Stiffness After Total Knee Arthroplasty.” [in placement surgery. French] Revue de chirurgie orthopedique et reparatrice de Impaction grafting—The use of crushed bone l’appareil moteur 88 (April 2002): 163–167. from a donor to fill in the central canal of the tibia Hartley, R. C., N. G. Barton-Hanson, R. Finley, and R. W. during knee revision surgery. Parkinson. “Early Patient Outcomes After Primary and Osteolysis—Dissolution and loss of bone resulting Revision Total Knee Arthroplasty. A Prospective Study.” Journal of Bone and Joint Surgery, British Volume 84 from inflammation caused by particles of polyeth- (September 2002): 994–999. ylene debris from a prosthesis. Hasegawa, M., T. Ohashi, and A. Uchida. “Heterotopic Ossifi- Patella—The medical term for the knee cap. The cation Around Distal Femur After Total Knee Arthroplas- patella is a triangular bone located at the front of ty.” Archives of Orthopaedic and Trauma Surgery 122 the knee. (June 2002): 274–278. Heck, D. A., C. A. Melfi, L. A. Mamlin, et al. “Revision Rates Prosthesis (plural, prostheses)—An artificial de- After Knee Replacement in the United States.” Medical vice that substitutes for or supplements a missing Care 36 (May 1998): 661–669. or damaged body part. Prostheses may be either Incavo, S. J., J. W. Lilly, C. S. Bartlett, and D. L. Churchill. external or implanted inside the body. “Arthrodesis of the Knee: Experience with Intramedullary Tibia—The larger of two leg bones that lie be- Nailing.” Journal of Arthroplasty 15 (October 2000): neath the knee. The tibia is sometimes called the 871–876. shin bone. Katz, B. P., D. A. Freund, D. A. Heck, et al. “Demographic Variation in the Rate of Knee Replacement: A Multi-Year Analysis.” Health Services Research 31 (June 1996): 125–140. Lonner, J. H., P. A. Lotke, J. Kim, and C. Nelson. “Impaction Teng, H. P., Y. C. Lu, C. J. Hsu, and C. Y. Wong. “Arthroscopy Grafting and Wire Mesh for Uncontained Defects in Revi- Following Total Knee Arthroplasty.” Orthopedics 25 sion Knee Arthroplasty.” Clinical Orthopaedics and Re- (April 2002): 422–424. lated Research 404 (November 2002): 145–151. Vidil, A., and P. Beaufils. “Arthroscopic Treatment of Peersman, G., R. Laskin, J. Davis, and M. Peterson. “Infection Hematogenous Infected Total Knee Arthroplasty: 5 in Total Knee Replacement: A Retrospective Review of Cases.” [in French] Revue de chirurgie orthopedique et 6489 Total Knee Replacements.” Clinical Orthopaedics reparatrice de l’appareil moteur 88 (September 2002): and Related Research 392 (November 2002): 15–23. 493–500. Shah, S. N., D. J. Schurman, and S. B. Goodman. “Screw Mi- ORGANIZATIONS gration from Total Knee Prostheses Requiring Subsequent Surgery.” Journal of Arthroplasty 17 (October 2002): American Academy of Orthopaedic Surgeons (AAOS). 6300 951–954. North River Road, Rosemont, IL 60018. (847) 823-7186 Sharkey, P. F., W. J. Hozack, R. H. Rothman, et al. “Insall or (800) 346-AAOS. <http://www.aaos.org>. Award Paper: Why Are Total Knee Arthroplasties Failing American Physical Therapy Association (APTA). 1111 North Today?” Clinical Orthopaedics and Related Research 404 Fairfax Street, Alexandria, VA 22314. (703)684-APTA or (November 2002): 7–13. (800) 999-2782. <http://www.apta.org>. GALE ENCYCLOPEDIA OF SURGERY 813

Kneecap removal Canadian Institute for Health Information/Institut canadien WHERE IS IT PERFORMED? d’information sur la santé (CIHI). 377 Dalhousie Street, WHO PERFORMS Suite 200, Ottawa, ON K1N 9N8. (613) 241-7860. THE PROCEDURE AND <http://secure.cihi.ca/cihiweb>. Center for Hip and Knee Replacement, Columbia University. Department of Orthopaedic Surgery, Columbia Presbyter- ian Medical Center, 622 West 168th Street, PH11-Center, in an outpatient setting and hospital stays, if New York, NY 10032. (212) 305-5974. <www.hipnknee. Kneecap removal surgery is usually performed org>. any, are short, not exceeding more than a day. National Center for Complementary and Alternative Medicine An orthopedic surgeon performs the surgery. (NCCAM) Clearinghouse. P.O. Box 7923, Gaithersburg, Orthopedics is the medical specialty that focus- MD 20898. (888) 644-6226. TTY: (866) 464-3615. Fax: es on the diagnosis, care, and treatment of pa- (866) 464-3616. <http://www.nccam.nih.gov.>. tients with disorders of the bones, joints, mus- National Institute of Arthritis and Musculoskeletal and Skin cles, ligaments, tendons, nerves, and skin. Diseases (NIAMS) Information Clearinghouse. National Institutes of Health, 1 AMS Circle, Bethesda, MD 20892. (301) 495-4484. TTY: (301) 565-2966. <http://www. niams.nih.gov>. Dislocation of the kneecap is most common in Rothman Institute of Orthopaedics. 925 Chestnut Street, young girls between the ages of 10–14. Initially, the Philadelphia, PA 19107-4216. (215) 955-3458. <http:// kneecap will pop back into place of its own accord, but www.rothmaninstitute.com>. pain may continue. If dislocation occurs too often, or the OTHER kneecap does not go back into place correctly, the patella Questions and Answers About Knee Problems. Bethesda, MD: may rub the other bones in the knee, causing an arthritis- National Institutes of Health, 2001. NIH Publication No. like condition. Some people are also born with birth de- 01-4912. fects that cause the kneecap to dislocate frequently. University of Iowa Department of Orthopaedics. Total Knee Replacement: A Patient Guide. Iowa City, IA: University Degenerative arthritis of the kneecap, also called of Iowa Hospitals and Clinics, 1999. patellar arthritis or chondromalacia patellae, can cause so much pain that it becomes necessary to remove the Rebecca Frey, Ph.D. kneecap. As techniques of joint replacement have im- proved, arthritis in the knee is more frequently treated with total knee replacement. People who have had their kneecap removed for de- generative arthritis and then later require a total knee re- Kneecap removal placement are more likely to have problems with the sta- Definition bility of their artificial knee than those who only have total knee replacement. This occurs because the re- Kneecap removal, or patellectomy, is the partial or aligned muscles and tendons provide less support once total surgical removal of the patella, commonly called the kneecap is removed. the kneecap. Description Purpose General anesthesia is typically used for kneecap re- Kneecap removal is performed under three circum- moval surgery, though in some cases a spinal or epidural stances: anesthetic is used. The surgeon makes a linear incision • The kneecap is fractured or shattered. over the front of the kneecap. The damaged kneecap is • The kneecap dislocates easily and repeatedly. examined. If a part or the entire kneecap is so severely damaged that it cannot be repaired, it may be partially • Degenerative arthritis of the kneecap causes extreme removed (partial patellectomy) or totally removed (full pain. patellectomy). If kneecap removal is total, the muscles and tendons attached to the kneecap are cut and the Demographics kneecap is removed. However, the quadriceps tendon A person of any age can break a kneecap in an acci- above the kneecap, the patellar tendon below, and the dent. When the bone is shattered beyond repair, the other soft tissues around the kneecap are preserved so kneecap has to be removed. No prosthesis or artificial re- that the patient may still be able to extend the knee after placement part is put in its place. surgery. Next, the muscles are sewn together, and the 814 GALE ENCYCLOPEDIA OF SURGERY

QUESTIONS TO ASK KEY TERMS THE DOCTOR Degenerative arthritis, or osteoarthritis—A non- Kneecap removal • How is the kneecap removed? inflammatory type of arthritis, usually occurring in older people, characterized by degeneration of • What type of anesthesia will be used? cartilage, enlargement of the margins of the bones, • How long will it take for the knee to recover and changes in the membranes in the joints. from the surgery? Patella—The knee cap; the quadriceps tendon at- • When will I be able to walk without crutches? taches to it above and the patellar tendon below. • What are the risks associated with kneecap Patellectomy—Surgical removal of the patella, or removal surgery? kneecap removal. • How many kneecap removal procedures do you perform in a year? kneecap is removed, the extensor assembly becomes more lax, and it may be impossible to ever regain full extension. skin is closed with sutures or clips that stay in place for about two weeks. Normal results Diagnosis/Preparation People who undergo kneecap removal because of a Prior to surgery, x rays and other diagnostic tests are broken bone or repeated dislocations have the best done on the knee to determine if removing the kneecap is chance for complete recovery. Those who have this oper- the appropriate treatment. Preoperative blood and urine ation because of arthritis may have less successful re- tests are also done. sults, and later need a total knee replacement. Patients are asked not to eat or drink anything after midnight on the night before surgery. On the day of Resources surgery, patients are directed to the hospital or clinic BOOKS holding area where the final preparations are made. The Harner, C. D., K. G. Vince, and F. H. Fu, eds. Techniques in knee area is usually shaved and the patient is asked to Knee Surgery. Philadelphia: Lippincott, Williams & change into a hospital gown and to remove all jewelry, Wilkins, 2001. watches, dentures, and glasses. Winter Griffith, H., et al., eds. “Kneecap Removal.” In The Complete Guide to Symptoms, Illness and Surgery, 3rd Aftercare edition. New York: Berkeley Publishing, 1995. Pain medication may be prescribed for a few days. PERIODICALS The patient will initially need to use a cane or crutches to Juni, P., et al. “Population Requirement for Primary Knee Re- walk. Physical therapy exercises to strengthen the knee placement Surgery: A Cross-sectional Study.” Rheumatol- should start as soon as tolerated after surgery. Driving ogy 42 (April 2003): 516–521. should be avoided for several weeks. Full recovery can Meijer, O. G., and Van Den Dikkenberg. “Levels of Analysis in take months. Knee Surgery.” Knee Surgery Sports Traumatology Arthroscopy 11 (January 2003): 53–54. Risks Petersen, W., C. Beske, V. Stein, and H. Laprell. “Arthroscopi- cal Removal of a Projectile from the Intra-articular Cavity Risks involved with kneecap removal are similar to of the Knee Joint.” Archives of Orthopaedic Trauma those associated with any surgical procedure, mainly al- Surgery 122 (May 2002): 235–236. lergic reaction to anesthesia, excessive bleeding, and in- ORGANIZATIONS fection. The American Academy of Orthopaedic Surgeons. 6300 North Kneecap removal is very delicate surgery because the River Road, Rosemont, IL 60018-4262. (847) 823-7186, kneecap is part of the extensor mechanism of the leg, (800) 346-AAOS. <http://www.aaos.org>. meaning the muscles and ligaments, the patella, the quadri- The American Association of Hip and Knee Surgeons ceps tendon, and the patellar tendon; which all allow the (AAHKS). 704 Florence Drive, Park Ridge, IL 60068- knee to extend and remain stable when extended. When the 2104. (847) 698-1200. <hhtp://www.aahks.org>. GALE ENCYCLOPEDIA OF SURGERY 815

Kneecap removal OTHER “Patellectomy.” The Knee Guru Page. <http://www.kneeguru. co.uk/html/step_05_patella/step_05_patellectomy.html>. “Patellectomy or Partial Patellectomy.” Pro Team Physicians. <http://www.proteamphysicians.com/Patient/Treat/knee/ kneefracture/patellectomy_procedure.asp>. Tish Davidson, AM Monique Laberge, PhD 816 GALE ENCYCLOPEDIA OF SURGERY

L Laceration repair WHO PERFORMS THE PROCEDURE AND Definition WHERE IS IT PERFORMED? Laceration repair includes all the steps required to treat a wound in order to promote healing and minimize Primary care physicians, emergency room the risks of infection, premature splitting of sutures (de- physicians, and surgeons usually repair lacera- hiscence), and poor cosmetic result. tions. All physicians are trained in the basics of wound assessment, cleansing, and anesthesia. They are also familiar with the basic suturing Purpose techniques and have the experience required to A laceration is a wound caused by a sharp object attend to the details of wound repair, such as producing edges that may be jagged, dirty, or bleeding. proper selection and preparation of equipment, Lacerations most often affect the skin, but any tissue careful wound preparation, appropriate use of may be lacerated, including subcutaneous fat, tendon, specific closure methods, and effective patient muscle, or bone. education, required to avoid wound infection and excessive scarring. A laceration should be repaired if it: Laceration repair is routinely performed in • Continues to bleed after application of pressure for hospitals and clinics on an outpatient basis. 10–15 minutes. • Is more than one-eighth to one-fourth inch deep. • Exposes fat, muscle, tendon, or bone. The laceration is cleaned by removing any foreign • Causes a change in function surrounding the area of the material or debris. Removing foreign objects from pene- laceration. trating wounds can sometimes cause bleeding, so this type of wound must be cleaned very carefully. The wound is • Is dirty or has visible debris in it. then irrigated with saline solution and a disinfectant. The • Is located in an area where an unsightly scar is undesir- disinfecting agent may be mild soap or a commercial able. preparation. An antibacterial agent may be applied. Lacerations are less likely to become infected if they Once the wound has been cleansed, the physician are repaired soon after they occur. Many physicians will anesthetizes the area of the repair. Most lacerations are not repair a laceration that is more than eight hours old anesthetized by local injection of lidocaine, with or with- because the risk of infection is too great. out epinephrine, into the wound edges. Lidocaine with- out epinephrine is used in areas with limited blood sup- ply such as fingers, toes, ears, penis, and nose, because Description epinephrine could cause constriction of blood vessels Laceration repair mends a tear in the skin or other (vasoconstriction) and interfere with the supply of blood tissue. The four goals of laceration repair are to stop to the laceration site. Alternatively, a topical anesthetic bleeding, prevent infection, preserve function, and re- combination such as lidocaine, epinephrine, and tetra- store appearance. caine may also be used. GALE ENCYCLOPEDIA OF SURGERY 817

The repair should be examined frequently for signs Laceration repair • How will my wound be repaired? of infection, which include redness, swelling, tender- QUESTIONS ness, drainage from the wound, red streaks in the skin TO ASK THE DOCTOR surrounding the repair, chills, or fever. If any of these occur, the physician should be contacted immediately. • Will the procedure hurt? • How can I avoid infection after surgery? Risks The most serious risk associated with laceration re- • Will I be able to wash the wound? pair is infection. Risk of infection depends on the nature • What are the possible complications? of the wound and the type of injury sustained. Infection • How long will it take to heal? risks are increased in wounds that are contaminated with • Will there be a scar? soil or fecal matter, are the result of bites, have been open longer than one hour, or are located on the extremities or • When can the sutures be removed? on the region between the thighs, genitalia, or other areas where opposing skin surfaces touch and may rub. The physician may trim edges that are jagged or ex- Normal results tremely uneven. Tissue that is too damaged to heal must All lacerations will heal with a scar. Wounds that are be removed (debridement) to prevent infection. If the repaired with sutures are less likely to develop scars that laceration is deep, several absorbable stitches (sutures) are unsightly, but it cannot be predicted how wounds will are placed in the tissue under the skin to help bring the heal and who will develop unsightly scars. Plastic tissue layers together. Suturing also helps eliminate any surgery can improve the appearance of many scars. pockets where tissue fluid or blood can accumulate. The skin wound is closed with sutures. Suture material used Alternatives on the surface of a wound is usually non-absorbable and The only alternative to laceration repair is to leave will have to be removed later. A light dressing or an ad- the wound without medical treatment. This increases the hesive bandage is applied for 24–48 hours. In areas risk of infection, poor healing, and an undesirable cos- where a dressing is not feasible, an antibiotic ointment metic result. can be applied. If the laceration is the result of a human or animal bite, if it is very dirty, or if the patient has a See also Debridement. medical condition that alters wound healing, a broad- spectrum antibiotic may be prescribed. Resources BOOKS Diagnosis/Preparation Snell, George. “Laceration Repair.” In Procedures for Primary Care Physicians, edited by John L. Pfenninger and Grant Preparation for laceration repair involves inspecting C. Fowler. St. Louis: Mosby, 1994. the wound and the underlying tendons or nerves to eval- PERIODICALS uate the risk of infection, the degree of tissue damage, Beredjiklian, P. K. “Biologic Aspects of Flexor Tendon Lacera- the need for debridement, and its complexity. If hair is tion and Repair.” The Journal of Bone and Joint Surgery located in or around the wound, it is usually removed to 85-A (March 2003): 539–550. minimize contamination and allow for good visibility of Gordon, C. A. “Reducing Needle-stick Injuries with the Use of the wound. If nerves or tendons have been injured, a sur- 2-octyl Cyanoacrylates for Laceration Repair.” Journal of geon may be needed to complete the repair. the American Academy of Nurse Practitioners 13 (January 2001): 10–12. Klein, E. J., D. S. Diekema, C. A. Paris, L. Quan, M. Cohen, Aftercare and K. D. Seidel. “A Randomized, Clinical Trial of Oral Midazolam Plus Placebo Versus Oral Midazolam Plus The laceration is kept clean and dry for at least 24 Oral Transmucosal Fentanyl for Sedation during Lacera- hours after the repair. Light bathing is generally permit- tion Repair.” Pediatrics 109 (May 2002): 894–897. ted after 24 hours if the wound is not soaked. The physi- Pratt, A. L., N. Burr, and A. O. Grobbelaar. “A Prospective Re- cian will provide directions for any special wound care. view of Open Central Slip Laceration Repair and Rehabil- Sutures are removed three to 14 days after the repair is itation.” The Journal of Hand Surgery: Journal of the completed. Timing of suture removal depends on the lo- British Society for Surgery of the Hand 27 (December cation of the laceration and physician preference. 2002): 530–534. 818 GALE ENCYCLOPEDIA OF SURGERY

on the dorsal surface of a vertebra, which is one of the KEY TERMS bones that make up the human spinal column. It is done to relieve back pain that has not been helped by more Laminectomy Debridement—The act of removing any foreign conservative treatments. In most cases a laminectomy is material and damaged or contaminated tissue from an elective procedure rather than emergency surgery. A a wound to expose surrounding healthy tissue. laminectomy for relief of pain in the lower back is called Dehiscence—A premature bursting open or split- a lumbar laminectomy or an open decompression. ting along natural or surgical suture lines. A com- plication of surgery that occurs secondary to poor Purpose wound healing. Structure of the spine Laceration—A torn, ragged, mangled wound. In order to understand why removal of a piece of Sutures—Materials used in closing a surgical or traumatic wound. bone from the arch of a vertebra relieves pain, it is help- ful to have a brief description of the structure of the Vasoconstriction—The diminution of the diameter spinal column and the vertebrae themselves. In humans, of blood vessels, leading to decreased blood flow the spine comprises 33 vertebrae, some of which are to a part of the body. fused together. There are seven vertebrae in the cervical (neck) part of the spine; 12 vertebrae in the thoracic (chest) region; five in the lumbar (lower back) region; five vertebrae that are fused to form the sacrum; and Singer, A. J., J. V. Quinn, H. C. Thode Jr., and J. E. Hollander. four vertebrae that are fused to form the coccyx, or tail- “Determinants of Poor Outcome after Laceration and Sur- gical Incision Repair.” Plastic and Reconstructive Surgery bone. It is the vertebrae in the lumbar portion of the 110 (August 2002): 429–437. spine that are most likely to be affected by the disorders that cause back pain. ORGANIZATIONS The Association of Perioperative Registered Nurses, Inc. The 24 vertebrae that are not fused are stacked verti- (AORN). 2170 South Parker Rd, Suite 300, Denver, CO cally in an S-shaped column that extends from the tail- 80231-5711. (800) 755-2676. <http://www.aorn.org/>. bone below the waist up to the back of the head. This column is held in alignment by ligaments, cartilage, and OTHER muscles. About half the weight of a person’s body is car- “Cuts and Scrapes.” Mayo Clinic Online. <http://www.may- ried by the spinal column itself and the other half by the oclinic.com/invoke.cfm?objectid=FDEFD23A-F29F- 47FB-9A7CD4CF4427D590>. muscles and ligaments that hold the spine in alignment. “A Systematic Approach to Laceration Repair.” Postgraduate The bony arches of the laminae on each vertebra form a Medicine Page. <http://www.postgradmed.com/issues/ canal that contains and protects the spinal cord. The 2000/04_00/wilson.htm>. spinal cord extends from the base of the brain to the “Wound Repair.” Family Practice Notebook. <http://www.fp- upper part of the lumbar spine, where it ends in a collec- notebook.com/SUR18.htm>. tion of nerve fibers known as the cauda equina, which is a Latin phrase meaning “horse’s tail.” Other nerves Mary Jeanne Krob, MD, FACS branching out from the spinal cord pass through open- Monique Laberge, PhD ings formed by adjoining vertebrae. These openings are known as foramina (singular, foramen). Between each vertebra is a disk that serves to cush- Lactate dehydrogenase isoenzymes test see ion the vertebrae when a person bends, stretches, or Liver function tests twists the spinal column. The disks also keep the forami- na between the vertebrae open so that the spinal nerves can pass through without being pinched or damaged. As people age, the intervertebral disks begin to lose mois- ture and break down, which reduces the size of the foramina between the vertebrae. In addition, bone spurs Laminectomy may form inside the vertebrae and cause the spinal canal itself to become narrower. Either of these processes can Definition compress the spinal nerves, leading to pain, tingling sen- A laminectomy is a surgical procedure in which the sations, or weakness in the lower back and legs. A lum- surgeon removes a portion of the bony arch, or lamina, bar laminectomy relieves pressure on the spinal nerves GALE ENCYCLOPEDIA OF SURGERY 819

Laminectomy by removing the disk, piece of bone, tumor, or other • Herniated disk. The disks between the vertebrae in the spine consist of a fibrous outer part called the annulus structure that is causing the compression. and a softer inner nucleus. A disk is said to herniate when the nucleus ruptures and is forced through the Causes of lower back pain The disks and vertebrae in the lower back are partic- outer annulus into the spaces between the vertebrae. The material that is forced out may put pressure on the ularly vulnerable to the effects of aging and daily wear nerve roots or compress the spinal cord itself. In other and tear because they bear the full weight of the upper cases, the chemicals leaking from the ruptured nucleus body, even when one is sitting quietly in a chair. When a may irritate or inflame the spinal nerves. More than person bends forward, 50% of the motion occurs at the 80% of herniated disks affect the spinal nerves associ- hips, but the remaining 50% involves the lumbar spine. ated with the L5 vertebra or the first sacral vertebra. The force exerted in bending is not evenly divided • Osteoarthritis (OA). OA is a disorder in which the car- among the five lumbar vertebrae; the segments between tilage in the hips, knees, and other joints gradually the third and fourth lumbar vertebrae (L3-L4) and the breaks down, allowing the surfaces of the bones to rub fourth and fifth (L4-L5) are most likely to break down directly against each other. In the spine, OA may result over time. More than 95% of spinal disk operations are in thickening of the ligaments surrounding the spinal performed on the fourth and fifth lumbar vertebrae. column. As the ligaments increase in size, they may Specific symptoms and disorders that affect the begin to compress the spinal cord. lower back include: Factors that increase a person’s risk of developing • Sciatica. Sciatica refers to sudden pain felt as radiating pain in the lower back include: from the lower back through the buttocks and down • Hereditary factors. Some people are born with relative- the back of one leg. The pain, which may be experi- ly narrow spinal canals and may develop spinal steno- enced as weakness in the leg, a tingling feeling, or a sis fairly early in life. “pins and needles” sensation, runs along the course of • Sex. Men are at greater risk of lower back problems the sciatic nerve. Sciatica is a common symptom of a than women, in part because they carry a greater pro- herniated disk. portion of their total body weight in the upper body. • Spinal stenosis. Spinal stenosis is a disorder that re- • Age. The intervertebral disks tend to lose their mois- sults from the narrowing of the spinal canal surround- ture content and become thinner as people get older. ing the spinal cord and eventually compressing the • Occupation. Jobs that require long periods of driving cord. It may result from hereditary factors, from the (long-distance trucking; bus, taxi, or limousine opera- effects of aging, or from changes in the pattern of tion) are hard on the lower back because of vibrations blood flow to the lower back. Spinal stenosis is some- from the road surface transmitted upward to the spine. times difficult to diagnose because its early symptoms Occupations that require heavy lifting (nursing, child can be caused by a number of other conditions and be- care, construction work, airplane maintenance) put cause the patient usually has no history of back prob- extra stress on the lumbar vertebrae. Other high-risk lems or recent injuries. Imaging studies may be neces- occupations include professional sports, professional sary for accurate diagnosis. dance, assembly line work, foundry work, mining, and • Cauda equina syndrome (CES). Cauda equina syn- mail or package delivery. drome is a rare disorder caused when a ruptured disk, • Lifestyle. Wearing high-heeled shoes, carrying heavy bone fracture, or spinal stenosis put intense pressure on briefcases or shoulder bags on one side of the body, or the cauda equina, the collection of spinal nerve roots at sitting for long periods of time in one position can all the lower end of the spinal cord. CES may be triggered throw the spine out of alignment. by a fall, automobile accident, or penetrating gunshot • Obesity. Being overweight, particularly if the extra injury. It is characterized by loss of sensation or altered pounds are concentrated in the abdomen, adds to the sensation in the legs, buttocks, or feet; pain, numbness, strain on the muscles and ligaments that support the or weakness in one or both legs; difficulty walking; or spinal column. loss of control over bladder and bowel functions. Cauda equina syndrome is a medical emergency re- • Trauma. Injuries to the back from contact sports, falls, quiring immediate treatment. If the pressure on the criminal assaults, or automobile accidents may lead to nerves in the cauda equina is not relieved quickly, per- misalignment of the vertebrae or a ruptured disk. Trau- manent paralysis and loss of bladder or bowel control matic injuries may also trigger the onset of cauda may result. equina syndrome. 820 GALE ENCYCLOPEDIA OF SURGERY

Laminectomy Laminectomy L2 L1 L2 Incision L3 L3 L4 L5 Sacrum A. B. Spinal cord Back Area to be removed by laminectomy Lamina Body of vertebra Front C. D. Herniated portion of disk E. Spinal nerves In this posterior (from the back) lumbar laminectomy, an incision is made in the patient’s back over the lumbar vertebrae (A). The wound is opened with retractors to expose the L2 and L3 vertebrae (B). A piece of bone at the back of the vertebrae is removed (C and D), allowing a damaged disk to be repaired (E). (Illustration by GGS Inc.) GALE ENCYCLOPEDIA OF SURGERY 821

Laminectomy WHERE IS IT PERFORMED? the bony arch in order to expose the ligamentum flavum, which is a band of yellow tissue attached to the vertebra WHO PERFORMS THE PROCEDURE AND that helps to support the spinal column and closes in the spaces between the vertebral arches. The surgeon then reach the spinal canal and expose the compressed nerve. A lumbar laminectomy is performed by an or- cuts an opening in the ligamentum flavum in order to thopedic surgeon or a neurosurgeon. It is per- At this point the cause of the compression (herniated formed as an inpatient procedure in a hospital disk, tumor, bone spur, or a fragment of the disk that has with a department of orthopedic surgery. Mini- separated from the remainder) will be visible. mally invasive laminotomies and microdiscec- Bone spurs, if any, are removed in order to enlarge tomies are usually performed in outpatient the foramina and the spinal canal. If the disk is herniat- surgery facilities. ed, the surgeon uses the retractor to move the com- pressed nerve aside and removes as much of the disk as necessary to relieve pressure on the nerve. The space that was occupied by the disk will be filled eventually by new Demographics connective tissue. Pain in the lower back is a chronic condition that has If necessary, a spinal fusion is performed to stabi- been treated in various ways from the beginnings of lize the patient’s lower back. A small piece of bone taken human medical practice. The earliest description of dis- from the hip is grafted onto the spine and attached with orders affecting the lumbar vertebrae was written in metal screws or plates to support the lumbar vertebrae. 3000 B.C. by an ancient Egyptian surgeon. In the modern Following completion of the spinal fusion, the sur- world, back pain is responsible for more time lost from geon closes the incision in layers, using different types work than any other cause except the common cold. Be- of sutures for the muscles, connective tissues, and skin. tween 10% and 15% of workers’ compensation claims The entire procedure takes one to three hours. are related to chronic pain in the lower back. It is esti- mated that the direct and indirect costs of back pain to the American economy range between $75 and $80 bil- Diagnosis/Preparation lion per year. Diagnosis In the United States, about 13 million people seek medical help each year for the condition. According to The differential diagnosis of lower back pain is the Centers for Disease Control, 14% of all new visits to complicated by the number of possible causes and the primary care doctors are related to problems in the lower patient’s reaction to the discomfort. In many cases the back. The CDC estimates that 2.4 million adults in the patient’s perception of back pain is influenced by poor- United States are chronically disabled by back pain, with quality sleep or emotional issues related to occupation or another 2.4 million temporarily disabled. About 70% of family matters. A primary care doctor will begin by tak- people will experience pain in the lower back at some ing a careful medical and occupational history, asking point in their lifetime; on a yearly basis, one person in about the onset of the pain as well as its location and every five will have some kind of back pain. other characteristics. Back pain associated with the lum- bar spine very often affects the patient’s ability to move, Back pain primarily affects the adult population, and the muscles overlying the affected vertebrae may most commonly people between the ages of 45 and 64. It feel sore or tight. Pain resulting from heavy lifting usual- is more common among men than women, and more ly begins within 24 hours of the overexertion. Most pa- common among Caucasians and Hispanics than among tients who do not have a history of chronic pain in the African Americans or Asian Americans. lower back feel better after 48 hours of bed rest with pain medication and either a heating pad or ice pack to relax Description muscle spasms. A laminectomy is performed with the patient under If the patient’s pain is not helped by rest and other general anesthesia, usually positioned lying on the side conservative treatments, he or she will be referred to an or stomach. The surgeon begins by making a small orthopedic surgeon for a more detailed evaluation. An or- straight incision over the damaged vertebra. thopedic evaluation includes a physical examination, The surgeon next uses a retractor to spread apart the neurological workup, and imaging studies. In the physi- muscles and fatty tissue overlying the spine. When the cal examination, the doctor will ask the patient to sit, laminae have been reached, the surgeon cuts away part of stand, or walk in order to see how these functions are af- 822 GALE ENCYCLOPEDIA OF SURGERY

fected by the pain. The patient may be asked to cough or to lie on a table and lift each leg in turn without bending QUESTIONS the knee, as these maneuvers can help to diagnose nerve TO ASK THE DOCTOR Laminectomy root disorders. The doctor will also palpate (feel) the pa- tient’s spinal column and the overlying muscles and liga- • What conservative treatments would you rec- ments to determine the external location of any tender ommend for my lower back pain? spots, bruises, thickening of the ligaments, or other struc- • How much time should I allow for conserva- tural abnormalities. The neurological workup will focus tive therapies to demonstrate effectiveness on the patient’s reflexes and the spinal nerves that affect before considering surgery? the functioning of the legs. Imaging studies for lower • Am I a candidate for a laminotomy and mi- back pain typically include an x ray study and CT scan of crodiscectomy? the lower spine, which will reveal bone deformities, nar- rowing of the intervertebral disks, and loss of cartilage. • How many laminectomies have you per- An MRI may be ordered if spinal stenosis is suspected. In formed? some cases the doctor may order a myelogram, which is an x ray or CT scan of the lumbar spine performed after a special dye has been injected into the spinal fluid. to three days after the procedure. During this period the Lower back pain is one of several common general patient will be given fluids and antibiotic medications in- medical conditions that require the doctor to assess the travenously to prevent infection. Medications for pain possibility that the patient has a concurrent psychiatric will be given every three to four hours, or through a de- disorder. Such diagnoses as somatization disorder or vice known as a PCA (patient-controlled anesthesia). The pain disorder do not mean that the patient’s physical PCA is a small pump that delivers a dose of medication symptoms are imaginary or that they should not receive into the IV when the patient pushes a button. To get the surgical or medical treatment. Rather, a psychiatric diag- lungs back to normal functioning, a respiratory therapist nosis indicates that the patient is allowing the back pain will ask the patient to do some simple breathing exercises to become the central focus of life or responding to it in and begin walking within several hours of surgery. other problematic ways. Some researchers in Europe as well as North America think that the frequency of lower Aftercare during the hospital stay is also intended to back problems in workers’ disability claims reflect emo- lower the risk of a venous thromboembolism (VTE), or tional dissatisfaction with work as well as physical blood clot in the deep veins of the leg. Prevention of stresses related to specific jobs. VTE involves medications to thin the blood and wearing compression stockings or boots. Preparation Most surgeons prefer to see patients one week after surgery to remove stitches and check for any postoperative Most hospitals require patients to have the following complications. Patients should not drive or return to work tests before a laminectomy: a complete physical exami- before their checkup. A second follow-up examination is nation; complete blood count (CBC); an electrocardio- usually done four to eight weeks after the laminectomy. gram (EKG); a urine test; and tests that measure the speed of blood clotting. Patients can help speed their recovery by taking short walks on a daily basis; avoiding sitting or standing Aspirin and arthritis medications should be discontin- in the same position for long periods of time; taking ued seven to 10 days before a laminectomy because they brief naps during the day; and sleeping on the stomach thin the blood and affect clotting time. Patients should pro- or the side. They may take a daily bath or shower with- vide the surgeon and anesthesiologist with a complete list out needing to cover the incision. The incision should be of all medications, including over-the-counter and herbal carefully patted dry, however, rather than rubbed. preparations, that they take on a regular basis. The patient is asked to stop smoking at least a week Risks before surgery and to take nothing by mouth after mid- night before the procedure. Risks associated with a laminectomy include: • bleeding Aftercare • infection • damage to the spinal cord or other nerves Aftercare following a laminectomy begins in the hospital. Most patients will remain in the hospital for one • weakening or loss of function in the legs GALE ENCYCLOPEDIA OF SURGERY 823

Laminectomy Cauda equina—The collection of spinal nerve Dorsal—Referring to a position closer to the back KEY TERMS roots that lie inside the spinal column below the end of the spinal cord. The name comes from the than to the stomach. The laminae in the spinal col- umn are located on the dorsal side of each vertebra. Latin for “horse’s tail.” Dura—A tough fibrous membrane that covers and Cauda equina syndrome (CES)—A group of symp- protects the spinal cord. toms characterized by numbness or pain in the legs and/or loss of bladder and bowel control, caused Foramen (plural, foramina)—The medical term for by compression and paralysis of the nerve roots in a natural opening or passage. The foramina of the the cauda equina. CES is a medical emergency. spinal column are openings between the vertebrae Chiropractic—A system of therapy based on the no- for the spinal nerves to branch off from the spinal tion that health and disease are related to the inter- cord. actions between the brain and the nervous system. Treatment involves manipulation and adjustment of Laminae (singular, lamina)—The broad plates of the segments of the spinal column. Chiropractic is bone on the upper surface of the vertebrae that considered a form of alternative medicine. fuse together at the midline to form a bony cover- ing over the spinal canal. Decompression—Any surgical procedure done to relieve pressure on a nerve or other part of the Laminotomy—A less invasive alternative to a body. A laminectomy is sometimes called an open laminectomy in which a hole is drilled through the decompression. lamina. • blood clots Alternatives • leakage of spinal fluid resulting from tears in the dura, Conservative treatments the protective membrane that covers the spinal cord Surgery for lower back pain is considered a treat- • worsening of back pain ment of last resort, with the exception of cauda equina syndrome. Patients should always try one or more con- Normal results servative approaches before consulting a surgeon about a Normal results depend on the cause of the patient’s laminectomy. In addition, most health insurers will re- lower back pain; most patients can expect considerable quire proof that the surgery is necessary, since the aver- relief from pain and some improvement in functioning. age total cost of a lumbar laminectomy is $85,000. There is some disagreement among surgeons about the success rate of laminectomies, however, which appears Some conservative approaches that have been found to be due to the fact that the operation is generally done to relieve lower back pain include: to improve quality of life—cauda equina syndrome is the only indication for an emergency laminectomy. Different • Analgesic or muscle relaxant medications. Analgesics sources report success rates between 26% and 99%, with are drugs given to relieve pain. The most commonly 64% as the average figure. According to one study, 31% prescribed pain medications are aspirin or NSAIDs. of patients were dissatisfied with the results of the opera- Muscle relaxants include methocarbamol, cyclobenza- tion, possibly because they may have had unrealistic ex- prine, or diazepam. pectations of the results. • Epidural injections. Epidural injections are given di- rectly into the space surrounding the spinal cord. Cor- Morbidity and mortality rates ticosteroids are the medications most commonly given The mortality rate for a lumbar laminectomy is be- by this route, but preliminary reports indicate that tween 0.8% and 1%. Rates of complications depend epidural injections of indomethacin are also effective in partly on whether a spinal fusion is performed as part of relieving recurrent pain in the lower back. the procedure; while the general rate of complications following a lumbar laminectomy is given as 6–7%, the • Rest. Bed rest for 48 hours usually relieves acute lower rate rises to 12% of a spinal fusion has been done. back pain resulting from muscle strain. 824 GALE ENCYCLOPEDIA OF SURGERY

KEY TERMS (contd.) Ligamenta flava (singular, ligamentum flavum)—A made worse by psychological factors. The lower Laminectomy series of bands of tissue that are attached to the verte- back is one of the most common sites for pain re- brae in the spinal column. They help to hold the spine lated to this disorder. straight and to close the spaces between the laminar Retractor—An instrument used during surgery to arches. The Latin name means “yellow band(s).” hold an incision open and pull back underlying Lumbar—Pertaining to the part of the back be- layers of tissue. tween the chest and the pelvis. Sciatica—Pain in the lower back, buttock, or leg Myelogram—A special type of x ray study of the along the course of the sciatic nerve. spinal cord, made after a contrast medium has Somatization disorder—A chronic condition in been injected into the space surrounding the cord. which psychological stresses are converted into Osteopathy—A system of therapy that uses stan- physical symptoms that interfere with work and re- dard medical and surgical methods of diagnosis lationships. Lower back pain is a frequent com- and treatment while emphasizing the importance plaint of patients with somatization disorder. of proper body alignment and manipulative treat- Spinal stenosis—Narrowing of the canals in the ment of musculoskeletal disorders. Osteopathy is vertebrae or around the nerve roots, causing pres- considered mainstream primary care medicine sure on the spinal cord and nerves. rather than an alternative system. Vertebra (plural, vertebrae)—One of the bones of Pain disorder—A psychiatric disorder in which the spinal column. There are 33 vertebrae in the pain in one or more parts of the body is caused or human spine. • Appropriate exercise. Brief walks are recommended as cine and surgery as MDs; however, they are also trained a good form of exercise to improve blood circulation, to evaluate postural and spinal abnormalities and to per- particularly after surgery. In addition, there are several form several different manual techniques for relief of simple exercises that can be done at home to strengthen back pain. An article published in the New England the muscles of the lower back. A short pamphlet enti- Journal of Medicine in 1999 reported that OMT was as tled Back Pain Exercises may be downloaded free of effective as physical therapy and standard medication in charge from the American Academy of Orthopedic Sur- relieving lower back pain, with fewer side effects and geons (AAOS) web site. lower health care costs. OMT is recommended in the United Kingdom as a very low-risk treatment that is • Losing weight. People who are severely obese may more effective than bed rest or mild analgesics. wish to consider weight reduction surgery to reduce the stress on their spine as well as their heart and respirato- • Transcutaneous electrical nerve stimulation (TENS). ry system. TENS is a treatment technique developed in the late • Occupational modifications or change. Lower back 1960s that delivers a mild electrical current to stimulate pain related to the patient’s occupation can sometimes nerves through electrodes attached to the skin overly- be eased by taking periodic breaks from sitting in one ing a painful part of the body. It is thought that TENS position; by using a desk and chair proportioned to works by stimulating the production of endorphins, one’s height; by learning to use the muscles of the which are the body’s natural painkilling compounds. thighs when lifting heavy objects rather than the lower back muscles; and by maintaining proper posture when Surgical alternatives standing or sitting. In some cases the patient may be helped by changing occupations. The most common surgical alternative to laminecto- my is a minimally invasive laminotomy and/or microdis- • Physical therapy. A licensed physical therapist can be cectomy. In this procedure, which takes about an hour, helpful in identifying the patient’s functional back the surgeon makes a 0.5-in (1.3-cm) incision in the lower problems and planning a course of treatment to im- back and uses a series of small dilators to separate the prove flexibility, strength, and range of motion. layers of muscle and fatty tissue over the spine rather • Osteopathic manipulative treatment (OMT). Osteopath- than cutting through them with a scalpel. A tube-shaped ic physicians (DOs) receive the same training in medi- retractor is inserted to expose the part of the lamina over GALE ENCYCLOPEDIA OF SURGERY 825

Laminectomy the nerve root. The surgeon then uses a power drill to “Osteoarthritis.” In The Merck Manual of Diagnosis and Ther- apy, edited by Mark H. Beers, MD, and Robert Berkow, make a small hole in the lamina to expose the nerve itself. MD. Whitehouse Station, NJ: Merck Research Laborato- After the nerve has been moved aside with the retractor, a ries, 1999. small grasping device is used to remove the herniated Pelletier, Kenneth R., MD. “Acupuncture.” In The Best Alter- portion or fragments of the damaged spinal disk. native Medicine. New York: Simon & Schuster, 2002. The advantages of these minimally invasive proce- Pelletier, Kenneth R., MD. “Chiropractic.” In The Best Alterna- dures are fewer complications and a shortened recovery tive Medicine. New York: Simon & Schuster, 2002. time for the patient. The average postoperative stay is PERIODICALS three hours. In addition, 90% of patients are pleased with Aldrete, J. A. “Epidural Injections of Indomethacin for Post- the results. laminectomy Syndrome: A Preliminary Report.” Anesthe- sia and Analgesia 96 (February 2003): 463–468. Complementary and alternative Braverman, D. L., J. J. Ericken, R. V. Shah, and D. J. Franklin. (CAM) approaches “Interventions in Chronic Pain Management. 3. New Frontiers in Pain Management: Complementary Tech- Two alternative methods of treating back disorders niques.” Archives of Physical Medicine and Rehabilitation that have been shown to help many patients are acupunc- 84 (March 2003) (3 Suppl 1): S45–S49. ture and chiropractic. Chiropractic is based on the belief Carlsson, C. P., and B. H. Sjolund. “Acupuncture for Chronic that the body has abilities to heal itself provided that Low Back Pain: A Randomized Placebo-Controlled Study nerve impulses can move freely between the brain and with Long-Term Follow-Up.” Clinical Journal of Pain 17 the rest of the body. Chiropractors manipulate the seg- (December 2001): 296–305. ments of the spine in order to bring them into proper Harvey, E., A. K. Burton, J. K. Moffett, and A. Breen. “Spinal alignment and restore the nervous system to proper func- Manipulation for Low-Back Pain: A Treatment Package Agreed to by the UK Chiropractic, Osteopathy and Phys- tioning. Many are qualified to perform acupuncture as iotherapy Professional Associations.” Manual Therapy 8 well as chiropractic adjustments of the vertebrae and (February 2003): 46–51. other joints. Several British and Swedish studies have re- Hurwitz, E. L., H. Morgenstern, P. Harber, et al. “A Random- ported that acupuncture and chiropractic are at least as ized Trial of Medical Care With and Without Physical effective as other conservative measures in relieving pain Therapy and Chiropractic Care With and Without Physical in the lower back. Modalities for Patients with Low Back Pain: 6-Month Fol- low-Up Outcomes from the UCLA Low Back Pain Movement therapies, including yoga, tai chi, and Study.” Spine 27 (October 15, 2002): 2193–2204. gentle stretching exercises, may be useful in maintaining Nasca, R. J. “Lumbar Spinal Stenosis: Surgical Considera- or improving flexibility and range of motion in the spine. tions.” Journal of the Southern Orthopedic Association 11 A qualified yoga instructor can work with the patient’s (Fall 2002): 127–134. doctor before or after surgery to put together an individ- Pengel, H. M., C. G. Maher, and K. M. Refshauge. “Systematic ualized set of beneficial stretching and breathing exercis- Review of Conservative Interventions for Subacute Low es. The Alexander technique is a type of movement ther- Back Pain.” Clinical Rehabilitation 16 (December 2002): apy that is often helpful to patients who need to improve 811–820. their posture. Sleigh, Bryan C., MD, and Ibrahim El Nihum, MD. “Lumbar Laminectomy.” eMedicine. August 8, 2002 [cited May 3, See also Disk removal. 2003]. <http://www.emedicine.com/aaem/topic500.htm>. Wang, Michael Y., Barth A. Green, Sachin Shah, et al. “Com- Resources plications Associated with Lumbar Stenosis Surgery in Patients Older Than 75 Years of Age.” Neurosurgical BOOKS Focus 14 (February 2003): 1–4. American Psychiatric Association. “Somatoform Disorders.” In Diagnostic and Statistical Manual of Mental Disorders. ORGANIZATIONS 4th ed. Revised text. Washington, DC: American Psychi- American Academy of Neurological and Orthopedic Surgeons atric Association, 2000. (AANOS). 2300 South Rancho Drive, Suite 202, Las “Low Back Pain.” In The Merck Manual of Diagnosis and Vegas, NV 89102. (702) 388-7390. <http://www.aanos. Therapy, edited by Mark H. Beers, MD, and Robert org>. Berkow, MD. Whitehouse Station, NJ: Merck Research American Academy of Neurology. 1080 Montreal Avenue, Laboratories, 1999. Saint Paul, MN 55116. (800) 879-1960 or (651) 695- “Nerve Root Disorders.” In The Merck Manual of Diagnosis 2717. <http://www.aan.com>. and Therapy, edited by Mark H. Beers, MD, and Robert American Academy of Orthopedic Surgeons (AAOS). 6300 Berkow, MD. Whitehouse Station, NJ: Merck Research North River Road, Rosemont, IL 60018. (847) 823-7186 Laboratories, 1999. or (800) 346-AAOS. <http://www.aaos.org>. 826 GALE ENCYCLOPEDIA OF SURGERY

American Chiropractic Association. 1701 Clarendon Blvd., Ar- lington, VA 22209. (800) 986-4636. <http://www.amer chiro.org>. Laparoscopy American Osteopathic Association (AOA). 142 East Ontario Street, Chicago, IL 60611. (800) 621-1773 or (312) 202- 8000. <http://www.aoa-net.org>. American Physical Therapy Association (APTA). 1111 North Fairfax Street, Alexandria, VA 22314. (703)684-APTA or (800) 999-2782. <http://www.apta.org>. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) Information Clearinghouse. National Institutes of Health, 1 AMS Circle, Bethesda, MD 20892. (301) 495-4484. TTY: (301) 565-2966. <http://www. niams.nih.gov>. OTHER American Academy of Orthopedic Surgeons (AAOS). Back Pain Exercises. March 2000 [cited May 5, 2003]. <http:// www.orthoinfo.aaos.org>. American Physical Therapy Association. Taking Care of Your Back. 2003 [cited May 4, 2003]. <http://www.apta. org/Consumer/ptandyourbody/back>. Waddell, G., A. McIntosh, A. Hutchinson, et al. Clinical Guide- This surgeon is performing a laparoscopic procedure on a lines for the Management of Acute Low Back Pain. Lon- patient. (Photo Researchers, Inc. Reproduced by permission.) don, UK: Royal College of General Practitioners, 2000. where the underlying cause cannot be determined using Rebecca Frey, Ph.D. diagnostic imaging (ultrasound and computed tomogra- phy). Examples of gynecologic conditions diagnosed using laparoscopy include endometriosis, ectopic preg- Laparoscopic cholecystectomy see nancy, ovarian cysts, pelvic inflammatory disease [PID], Cholecystectomy infertility, and cancer. Laparoscopy is used in general surgery to examine the abdominal organs, including the gallbladder, bile ducts, the liver, the appendix, and the intestines. During the laparoscopic surgical procedure, certain Laparoscopy conditions can be treated using instruments and devices specifically designed for laparoscopy. Medical devices Definition that can be used in conjunction with laparoscopy include surgical lasers and electrosurgical units. Laparoscopic Laparoscopy is a minimally invasive procedure used surgery is now preferred over open surgery for several as a diagnostic tool and surgical procedure that is per- types of procedures because of its minimally invasive na- formed to examine the abdominal and pelvic organs, or ture and its association with fewer complications. the thorax, head, or neck. Tissue samples can also be col- Microlaparoscopy can be performed in the physi- lected for biopsy using laparoscopy and malignancies cian’s office using smaller laparoscopes. Common clini- treated when it is combined with other therapies. La- cal applications in gynecology include pain mapping (for paroscopy can also be used for some cardiac and vascu- endometriosis), sterilization, and fertility procedures. lar procedures. Common applications in general surgery include evalua- tion of chronic and acute abdominal pain (as in appen- Purpose dicitis), basic trauma evaluation, biopsies, and evaluation of abdominal masses. Laparoscopy is performed to examine the abdomi- nal and pelvic organs to diagnose certain conditions Laparoscopy is commonly used by gynecologists, and—depending on the condition—can be used to per- urologists, and general surgeons for abdominal and pelvic form surgery. Laparoscopy is commonly used in gyne- applications. Laparoscopy is also being used by orthope- cology to examine the outside of the uterus, the fallopian dic surgeons for spinal applications and by cardiac sur- tubes, and the ovaries—particularly in pelvic pain cases geons for minimally invasive heart surgery. As of 2003, GALE ENCYCLOPEDIA OF SURGERY 827

Laparoscopy procedures under investigation for possible laparoscopy mm for hospital laparoscopy), with the patient undergo- ing local anesthesia with conscious sedation (during included thyroidectomy and parathyroidectomy. which the patient remains awake but very relaxed) in a physician’s office. Video and photographic equipment, Demographics At first, laparoscopy was only been performed on previously explained, may be used. Laparoscopy has been explored in combination with young, healthy adults, but the use of this technique has other therapies for the treatment of certain types of malig- greatly expanded. Populations on whom laparoscopies nancies, including pelvic and aortic lymph node dissec- are now performed include infants, children, the elderly, tion, ovarian cancer, and early cervical cancer. Laparo- the obese, and those with chronic disease states, such as scopic radiofrequency ablation is a technique whereby cancer. The applications of this type of surgery have laproscopy assists in the delivery of radiofrequency grown considerably over the years to include a variety of probes that distribute pulses to a tumor site. The pulses patient populations, and will continue to do so with the generate heat in malignant tumor cells and destroys them. refinement of laparascopic techniques. The introduction of items such as temperature-con- trolled instruments, surgical instruments with greater Description rotation and articulation, improved imaging systems, and Laparoscopy is typically performed in the hospital multiple robotic devices will expand the utility of laparo- under general anesthesia, although some laparoscopic pro- scopic techniques in the future. The skills of surgeons cedures can be performed using local anesthetic agents. will be enhanced as well with further development of Once under anesthesia, a urinary catheter is inserted into training simulators and computer technology. the patient’s bladder for urine collection. To begin the pro- cedure, a small incision is made just below the navel and a Diagnosis/Preparation cannula or trocar is inserted into the incision to accommo- date the insertion of the laparoscope. Other incisions may Before undergoing laparoscopic surgery, the patient be made in the abdomen to allow the insertion of addition- should be prepared by the doctor for the procedure both al laparoscopic instrumentation. A laparoscopic insuffla- psychologically and physically. It is very important that tion device is used to inflate the abdomen with carbon the patient receive realistic counseling before surgery dioxide gas to create a space in which the laparoscopic and prior to giving informed consent. This includes dis- surgeon can maneuver the instruments. After the laparo- cussion about further open abdominal surgery (laparoto- scopic diagnosis and treatment are completed, the laparo- my) that may be required during laparoscopic surgery, scope, cannula, and other instrumentation are removed, information about potential complications during and the incision is sutured and bandaged. surgery, and the possible need for blood transfusions. In the case of diagnostic laparoscopy for chronic pelvic Laparoscopes have integral cameras for transmitting pain, the procedure may simply indicate that all organs images during the procedure, and are available in various are normal and the patient should be prepared for this sizes depending upon the type of procedure performed. possibility. The surgery may be explained using pictures, The images from the laparoscope are transmitted to a models, videotapes, and movies. It is especially impor- viewing monitor that the surgeon uses to visualize the in- tant for the patient to be able to ask questions and ex- ternal anatomy and guide any surgical procedure. Video press concerns. It may be helpful, for the patient to have and photographic equipment are also used to document a family member or friend present during discussions the surgery, and may be used postoperatively to explain with the doctor. Such conversations could understand- the results of the procedure to the patient. ably cause anxiety, and information relayed may not be Robotic systems are available to assist with la- adequately recalled under such circumstances. paroscopy. A robotic arm, attached to the operating table There is usually a presurgical exam two weeks before may be used to hold and position the laparoscope. This the surgery to gather a medical history and obtain blood serves to reduce unintentional camera movement that is and urine samples for laboratory testing. It is important common when a surgical assistant holds the laparoscope. that the patient inform the doctor completely about any The surgeon controls the robotic arm movement by foot prior surgeries, medical conditions, or medications taken pedal with voice-activated command, or with a handheld on a regular basis, including such nonsteroidal anti-in- control panel. flammatory drugs (NSAIDs) as aspirin. Patients taking Microlaparoscopy has become more common over blood thinners like Coumadin or Heparin (generic name: the past few years. The procedure involves the use of warfarin) should not adjust their medication themselves, smaller laparoscopes (that is, 2 mm compared to 5–10 but should speak with their prescribing doctors regarding 828 GALE ENCYCLOPEDIA OF SURGERY

Laparoscopy Laparoscopy Pneumoperitoneum Lung Incision Bladder Incision A. B. Uterus CO 2 To video monitor gallbladder Pneumoperitoneum Camera Lung Gallbladder Laparoscope Stomach Rib Intestines Liver Spleen C. Kidney Liver Cystic duct Spine D. Spine of gallbladder The surgeon has a choice of incision options for laparoscopy, depending on the needs of the procedure (A). In this abdomi- nal procedure, carbon dioxide is pumped into the cavity to create a condition called pneumoperitoneum, which allows the surgeon easier access to internal structures.The laparoscope is connected to a video monitor, and special forceps are used to carry out any necessary procedure (C and D) (Illustration by GGS Inc.) their upcoming surgery. (Patients should never adjust anesthesia in most cases, the patient may be asked to eat dosage without their doctors’ approval. This is especially lightly 24 hours prior to surgery and fast at least 12 hours important for elderly patients, asthmatics, those with hy- prior to surgery. Bowel cleansing with a laxative may also pertension, or those who are on ACE inhibitors.) If a tubal required, allowing the it to be more easily visualized and dye study is planned during the procedure, the patient may to prevent complications in the unlikely event of bowel in- also be required to provide information on menstrual his- jury. Those who are have diabetes or have hypoglycemia tory. For some procedures, an autologous (self) blood do- may wish to schedule their procedures early in the morn- nation may be suggested prior to the surgery to replace ing to avoid low blood sugar reactions. The patient should blood that may be lost during the procedure. Chest x rays follow the directions of the hospital staff, arriving early on may also be required. For some obese patients, weight the day of surgery to sign paperwork and to be screened loss may be necessary prior to surgery. by the anesthesiology staff. Questions will be asked re- garding current medications and dosages, allergies to Immediately before to surgery, there are several pre- medication, previous experiences with anesthesia (that is, operative steps that the patient may be advised to take. allergic reactions, and previous experiences regarding The patient should shower at least 24 hours prior to the time-to-consciousness), and a variety of other questions. It surgery, and gently but thoroughly cleanse the umbilicus is often helpful for the patient to make a list of this infor- (belly button) with antibacterial soap and water using a mation beforehand so that the information can be easily cotton-tipped swab. Because laparoscopy requires general retrieved when requested by the hospital staff. GALE ENCYCLOPEDIA OF SURGERY 829

Aftercare Laparoscopy main in a recovery area until the immediate effects of signs that should be watched for and reported immedi- ately include: Following laparoscopy, patients are required to re- • fever and chills anesthesia subside and until normal voiding is accom- plished (especially if a urinary catheter was used during • abdominal distension • vomiting the surgery). Vital signs are monitored to ensure that there are no reactions to anesthesia or internal injuries • difficulty urinating present. There may be some nausea and/or vomiting, • sharp and unusual pain in the abdomen or bowel which may be reduced by the use of the propofol anes- • redness at the incision site, which indicate infection thetic for healthy patients undergoing elective procedures such as tubal ligation, diagnostic laparoscopy, or hernia • discharge from any places where tubes were inserted or repair. Laparoscopy is usually an outpatient procedure incisions were made and patients are discharged from the recovery area within Additional complications may include a urinary a few hours after the procedure. For elderly patients and tract infection (resulting from catheterization) and minor those with other medical conditions, recovery may be infection of the incision site. An injury to the ureter may slower. Patients with more serious medical conditions, or be indicated by abdominal distention or a pain in the patients undergoing emergency laparoscopy, an overnight flank. Additional testing may be required if a complica- hospital stay or a stay of several days may be required. tion is suspected. Discharged patients will receive instructions regard- ing activity level, medications, postoperative dietary Risks modifications, and possible side effects of the procedure. Complications may be associated with the la- It may be helpful to have a friend or family member pre- paroscopy procedure in general, or may be specific to the sent when these instructions are given, as the after- type of operation that is performed. Patients should con- effects of anesthesia may cause some temporary confu- sult with their doctors regarding the types of risks that are sion. Postoperative instructions may include information specific for their procedures. The most serious complica- on when one might resume normal activities such as tion that can occur during laparoscopy is laceration of a bathing, housework, and driving. Depending on the na- major abdominal blood vessel resulting from improper ture of the laparoscopic procedure and the patient’s med- positioning, inadequate insufflation (inflation) of the ab- ical condition, daily activity may be restricted for a few domen, abnormal pelvic anatomy, and too much force ex- days and strenuous during administration of anesthesia erted during scope insertion. Thin patients with well-de- may cause some soreness. Additionally, shoulder pain veloped abdominal muscles are at higher risk, since the may persist as long as 36 hours after surgery. Pain-re- aorta may only be an inch or so below the skin. Obese pa- lieving medications and antibiotics may be prescribed tients are also at higher risk because more forceful and for several days postoperatively. deeper needle and scope penetration is required. During Patients will be instructed to watch for signs of a uri- laparoscopy, there is also a risk of bleeding from blood nary tract infection (UTI) or unusual pain; either may in- vessels, and adhesions may require repair by open dicate organ injury. It is important to understand the dif- surgery if bleeding cannot be stopped using laparoscopic ference between normal discomfort and pain, because instrumentation. In laparoscopic procedures that use elec- pain may indicate a problem. Patients may also experience trosurgical devices, burns to the incision site are possible an elevated temperature, and occasionally “postla- due to passage of electrical current through the laparo- paroscopy syndrome”; this condition is similar in appear- scope caused by a fault or malfunction in the equipment. ance to peritonitis (marked by abdominal pain, constipa- Complications related to insufflation of the abdomi- tion, vomiting, and fever) that disappears shortly after nal cavity include gas inadvertently entering a blood ves- surgery without antibiotics. However, any postoperative sel and causing an embolism, pneumothorax, or subcuta- symptoms that cause concern for the patient should be dis- neous emphysema. One common but not serious side ef- cussed with the doctor, so that any fears can be alleviated fect of insufflation is pain in the shoulder and upper and recovery can be accomplished. Due to the after-effects chest area for a day or two following the procedure. of anesthesia, patients should not drive themselves home. Any abdominal surgery, including laparoscopy, car- It is advisable for someone to stay with the patient ries the risk of unintentional organ injury (punctures and for a few hours following the procedure, in case compli- perforations). For example, the bowel, bladder, ureters, cations arise. Injury to an organ might not be readily ap- or fallopian tubes may be injured during the laparoscopic parent for several days after the procedure. The physical procedure. Many times these injuries are unavoidable 830 GALE ENCYCLOPEDIA OF SURGERY

due to the patient’s anatomy or medical condition. Pa- tients at higher risk for bowel injury include those with QUESTIONS chronic bowel disease, PID, a history of pervious ab- TO ASK THE DOCTOR Laparoscopy dominal surgery, or severe endometriosis. Some types of laparoscopic procedures have a higher risk of organ in- • Will this surgery be covered by my insur- jury. For instance, during laparoscopic removal of en- ance? Will any postsurgical care that I require dometriosis adhesions or ovaries, the ureters may be in- also be covered? jured due to their proximity to each other. • What do I need to do to prepare for the Several clinical studies have shown that the compli- surgery? Are there any restrictions on diet, cation rate during laparoscopy is associated with inade- fluid intake, or other measures? quate surgeon experience. Surgeons who are more expe- • Are there any medications that should be rienced in laparoscopic procedures have fewer complica- stopped prior to the surgery? tions than those performing their first 100 cases. • Does my medical history pose any potential problems that need to be considered before Normal results undergoing this procedure? In diagnostic laparoscopy, the surgeon will be able to • What is your (the doctor’s) training in per- see signs of a disease or condition (for example, en- forming this surgery? Will you perform the dometriosis adhesions; ovarian cysts; diseased gallblad- actual surgery or will a trainee? der)immediately, and can either treat the condition surgi- • What aftereffects can I expect? cally or proceed with appropriate medical management. In • Are there any post-surgical symptoms that diagnostic laparoscopy, biopsies may be taken of tissue in might indicate a complication that I should questionable areas, and laboratory results will govern report, and to whom should these questions medical treatment. In therapeutic laparoscopy, the surgeon be directed? What post-surgical symptoms performs a procedure that rectifies a known medical prob- should be considered “normal” and how lem, such as hernia repair or appendix removal. Because might discomfort be relieved? laparoscopy is minimally invasive compared to open • What is the expected recovery period from surgery, patients may experience less trauma and postop- this procedure? erative discomfort, have fewer procedural complications, have a shorter hospital stay, and return more quickly to • What special care or self-care is required fol- daily activities. The results will vary, however, depending lowing this surgery? on the patients’s condition and type of treatment. Morbidity and mortality rates secondary trocars may be of particular interest as a risk factor. There is still some debate, however, as to which Laparoscopic surgery, like most surgeries, is not method of trocar insertion is most appropriate in a partic- without risk. Risks should be thoroughly explained to the ular situation, as no technique is without risk. The most patient. Complications from laparoscopic surgeries arise commonly cited injury in laparoscopic malpractice in 1–5% of the cases, with a mortality of about 0.05%. claims has been injury to the bile duct (66%). Proper Complications may arise from the laparoscopic entry identification of this structure by an experienced sur- during procedure, and the risks vary depending on the el- geon, or by a cholangiogram, may reduce this type of in- ements specific to a particular procedure. For example, jury. Other areas of the body may be injured during ac- the risk of injury to the common bile duct in laparoscop- cess including the stomach, bladder, and liver. Hemor- ic biliary surgery is 0.3–0.6% of cases. The factors that rhages may also occur during the operation. contribute to morbidity are currently under study and de- bate. Injury may occur to blood vessels and internal or- gans. Some studies examining malpractice data indicate Laparoscopic entry injuries have been the subject of that trocar injury to the bowel or blood vessels may ac- recent study. Data collected from insurance companies count up to one-fourth of laparoscopic medical claims. It and medical device regulation indicate that bowel and has been suggested that these injuries can be reduced by vascular injuries may account for 76% of the injuries alterations in the placement and use of the Verses needle, that occur when a primary port is created. Delayed or by using an open technique of trocar insertion in recognition of bowel injuries was noted to be an impor- which a blunt cannula (non-bladed) is inserted into the tant factor in mortality. The risk of possible injury or abdominal cavity through an incision. The insertion of death in laparoscopy depends on such factors as the GALE ENCYCLOPEDIA OF SURGERY 831

Laparoscopy WHERE IS IT PERFORMED? Ascites—Accumulation of fluid in the abdominal KEY TERMS WHO PERFORMS THE PROCEDURE AND cause. Laparoscopy may be performed by a gynecolo- cavity; laparoscopy may be used to determine its gist, general surgeon, gastroenterologist, or other Cholecystitis—Inflammation of the gallbladder, physician—depending upon the patient’s condi- often diagnosed using laparoscopy. tion. An anesthesiologist is required during the Electrosurgical device—A medical device that procedure to administer general and/or local uses electrical current to cauterize or coagulate anesthesia and to perform patient monitoring. tissue during surgical procedures; often used in Nurses and surgical technicians/assistants are conjunction with laparoscopy. needed during the procedure to assist with scope Embolism—Blockage of an artery by a clot, air or positioning, video system adjustments and image gas, or foreign material. Gas embolism may occur recording, and laparoscopic instrumentation. as a result of insufflation of the abdominal cavity during laparoscopy. Endometriosis—A disease involving occurrence of anatomy of the patient, the force of entry, and the type endometrial tissue (lining of the uterus) outside operative procedure being performed. the uterus in the abdominal cavity; often diag- nosed and treated using laparoscopy. Alternatives Hysterectomy—Surgical removal of the uterus; often performed laparoscopically. The alternatives to laparoscopy vary, depending on the medical condition being treated. Laparotomy (open abdom- Insufflation—Inflation of the abdominal cavity inal surgery with larger incision) may be pursued when fur- using carbon dioxide; performed prior to la- ther visualization is needed to treat the condition, such as in paroscopy to give the surgeon space to maneuver the case of pain of severe endometriosis with deeper le- surgical equipment. sions. For those female patients with pelvic masses, trans- Oophorectomy—Surgical removal of the ovaries; vaginal sonography may be a helpful technique in obtaining often performed laparoscopically. information about whether such masses are malignant, as- Pneumothorax—Air or gas in the pleural space sisting in the choice between laparoscopy or laparotomy. (lung area) that may occur as a complication of la- paroscopy and insufflation. Resources Subcutaneous emphysema—A pathologic accu- BOOKS mulation of air underneath the skin resulting from Merrell, Ronald C., ed. Laparoscopic Surgery. New York: improper insufflation technique. Springer-Verlag New York, Inc., 1999. Trocar—A small sharp instrument used to punc- Pasic, Resad P., Ronald L. Levine. A Practical Manual of La- ture the abdomen at the beginning of the laparo- paroscopy: A Clinical Cookbook. New York: The scopic procedure. Parthenon Publishing Group, 2002. Schier, Felix. Laparoscopy in Children. Berlin: Springer, 2003. Soderstrom, Richard M., ed. Operative Laparoscopy, 2nd ed. Philadelphia: Lippincott-Raven, 1998. Chandler, J.G., S.L. Corson, L.W. Way. “Three Spectra of La- Webb, Maurice, ed. J. Mayo Clinic Manual of Pelvic Surgery, paroscopic Entry Access Injuries.” Journal of American 2nd ed. Philadelphia, 2000. College of Surgeons 192, no.4 (April 2001):478–490. Zucker, Karl A., ed. Surgical Laparoscopy, 2nd ed. Philadel- ORGANIZATIONS phia, 2001. American College of Obstetricians and Gynecologists. 409 PERIODICALS 12th Street SW, P.O. Box 96920, Washington, DC 20090- Abu-Rustum, Nadeem R. “Laparoscopy 2003: Oncologic Per- 6920. <http://www.acog.org>. spective.” Clinical Obstetrics and Gynecology 46, no.1 Society of American Gastrointestinal Endoscopic Surgeons (March 2003): 61-69. (SAGES). 2716 Ocean Park Boulevard, Suite 3000, Santa Bieber, Eric. “Laparoscopy: Past, Present, and Future.” Clinical Monica, CA 90405. (310) 314-2404. <http://www.endo Obstetrics and Gynecology 46, no.1 (March 2003): 3–14. scopy-sages.com>. Boike, Guy M., and Brian Dobbins. “New Equipment for Oper- Society of Laparoendoscopic Surgeons. 7330 SW 62nd Place, ative Laparoscopy.” Contemporary OB/GYN, no. 2 (April Suite 410, Miami, FL 33143-4825. (305) 665-9959. <http:// 1998). <http://consumer.pdr.net/consumer/psrecord.htm>. www.sls.org>. 832 GALE ENCYCLOPEDIA OF SURGERY

OTHER Agency for Healthcare Research and Quality. <http://www. WHO PERFORMS webmm.ahrq.gov/cases.aspx?ic=3>. THE PROCEDURE AND “Diagnostic Laparoscopy.” Society of Gastrointestinal Endo- WHERE IS IT PERFORMED? scopic Surgeons. <http://www.sages.org/pi_diaglap.html>. “Laparoscopy.” WebMD.com. October 24, 2002). <http://my. Laparoscopy for endometriosis is performed by Laparoscopy for endometriosis webmd.com/content/healthwise/21/5199.htm?lastselected a surgeon or gynecologist who has been guid={5FE84E90-BC77-4056-A91C-9531713CA348>. trained in laparoscopic techniques. A gynecol- Jennifer E. Sisk, M.A. ogist is a medical doctor who has completed Jill Granger, M.S. specialized training in the areas of women’s general and reproductive health, pregnancy, labor and delivery, and prenatal testing. La- paroscopy is usually performed in a hospital on an outpatient basis. Laparoscopy for endometriosis Definition and examine them for endometrial growths) and as an op- Laparoscopy is a surgical procedure in which a la- erative tool (to excise or destroy endometrial growths). A paroscope, a telescope-like instrument, is inserted into patient’s recovery time following laparoscopic surgery is the abdomen through a small incision and used to diag- shorter and less painful than following a traditional la- nose or treat various diseases. Specifically, laparoscopy parotomy (a larger surgical incision into the abdominal may be used to diagnose and treat endometriosis, a con- cavity). A disadvantage to laparoscopy is that some dition in which the tissue that lines the uterus grows else- growths may be too large or extensive to remove with la- where in the body, usually in the abdominal cavity. paroscopic instruments, necessitating a laparotomy. Purpose Demographics The endometrium is the inner lining of the uterus; it Endometriosis has been estimated to affect up to is where a fertilized egg will implant during the early 10% of women. Approximately four out of every 1,000 days of pregnancy. The endometrium normally sheds women are hospitalized as a result of endometriosis each during each menstrual cycle if the egg released during year. Women ages 25–35 are most affected, with 27 ovulation has not been fertilized. Endometriosis is a con- being the average age at diagnosis. The incidence of en- dition that occurs when cells from the endometrium dometriosis is higher among white women and among begin growing outside the uterus. The outlying endome- women who have a family history of the disease. trial cells respond to the hormones that control the men- strual cycle, bleeding each month the way the lining of the uterus does. This causes irritation of the surrounding Description tissue, leading to pain and scarring. The patient is given anesthesia before the procedure Endometrial growths are most commonly found on commences. The method of anesthesia depends on the the pelvic organs, including the ovaries (the most com- type and duration of surgery, the patient’s preference, mon site), fallopian tubes, bladder, rectum, cervix, vagi- and the recommendation of the physician. General anes- na, and the outer surface of the uterus. Growths are also thesia is most common for operative laparoscopy, while sometimes found in other areas of the body, including diagnostic laparoscopy is often performed under regional the skin, lungs, brain, or surgical scars. There are numer- or local anesthesia. A catheter is inserted into the bladder ous theories as to the cause of endometriosis; these in- to empty it of urine; this is done to minimize the risk of clude retrograde menstruation (movement of menstrual injury to the bladder. blood up through the fallopian tubes), movement of en- A small incision is first made into the patient’s ab- dometrial tissue through the blood or lymph system, or domen in or near the belly button. A gas such as carbon surgical transplantation (when endometriosis is found in dioxide is used to inflate the abdomen to allow the sur- surgical scars). geon a better view of the surgical field. The laparoscope is There are a number of reasons why laparoscopy is a thin, lighted tube that is inserted into the abdominal cav- used to treat endometriosis. It is useful as both a diagnos- ity through the incision. Images taken by the laparoscope tic tool (to visualize structures in the abdominal cavity may be seen on a video monitor connected to the scope. GALE ENCYCLOPEDIA OF SURGERY 833

Laparoscopy for endometriosis Laparoscopy for endometriosis Lung Pneumoperitoneum Bladder Incision A. B. Uterus CO 2 To video monitor Fallopian tube Laparoscope Bladder Rectum C. Ovary Uterus For this procedure, three or four incisions may be made in the woman’s lower abdomen (A). Carbon dioxide is pumped into the abdomen to create a condition called pneumoperitoneum, which gives the surgeon more room to work (B). A laparo- scope with video monitor is used to view the internal structures, while endometrial growths are removed with other tools (C). (Illustration by GGS Inc.) The surgeon will examine the pelvic organs for en- Prior to surgery, the patient may be asked to refrain dometrial growths or adhesions (bands of scar tissue that from eating or drinking after midnight on the day of may form after surgery or trauma). Other incisions may surgery. An intravenous (IV) line will be placed for ad- be made to insert additional instruments; this would ministration of fluids and/or medications. allow the surgeon to better position the internal organs for viewing. To remove or destroy endometrial growths, Aftercare a laser or electric current (electrocautery) may be used. After the procedure is completed, the patient will Alternatively, implants may be cut away with a scalpel usually spend several hours in the recovery room to en- (surgical knife). After the procedure is completed, any sure that she recovers from the anesthesia without com- incisions are closed with stitches. plication. After leaving the hospital, she may experience soreness around the incision, shoulder pain from the gas used to inflate the abdomen, cramping, or constipation. Diagnosis/Preparation Most symptoms resolve within one to three days. Some of the symptoms of endometriosis include pelvic pain (constant or during menstruation), infertility, Risks painful intercourse, and painful urination and/or bowel Risks that are associated with laparoscopy include movements during menstruation. Such symptoms, how- complications due to anesthesia, infection, injury to or- ever, are also exhibited by a number of other diseases. A gans or other structures, and bleeding. There is a risk that definitive diagnosis of endometriosis may only be made endometriosis will reoccur or that not all of the endome- by laparoscopy or laparotomy. trial implants will be removed with surgery. 834 GALE ENCYCLOPEDIA OF SURGERY

QUESTIONS KEY TERMS TO ASK THE DOCTOR Acupuncture—The insertion of tiny needles into • Why is laparoscopic surgery recommended the skin at specific spots on the body for curative for my particular case? purposes. Laparoscopy for endometriosis • Will operative laparoscopy be performed if Fallopian tubes—The structures that carry a ma- endometriosis is diagnosed? ture egg from the ovaries to the uterus. • What options do I have in terms of anesthesia Ovulation—A process in which a mature female and pain relief? egg is released from one of the ovaries (egg- • What are the risks if I decide against surgical shaped structures located to each side of the treatment? uterus) every 28 days. • What alternatives to laparoscopy are avail- Sub-fertility—A decreased ability to become able to me? pregnant. with or without removal of bowel that is involved by the Normal results disease. Semi-conservative surgery involves removing After laparoscopy for endometriosis, a woman some of the pelvic organs; examples are hysterectomy should recover quickly from the surgery and experience (removal of the uterus) and oophorectomy (removal of a significant improvement in symptoms. Some studies the ovaries). Radical surgery involves removing the suggest that surgical treatment of endometriosis may im- uterus, cervix, ovaries, and fallopian tubes (called a total prove a sub-fertile woman’s chance of getting pregnant. hysterectomy with bilateral salpingo-oophorectomy). See also Laparoscopy. Morbidity and mortality rates Resources The overall rate of risks associated with laparoscopy is approximately 1–2%, with serious complications oc- PERIODICALS curring in only 0.2% of patients. The rate of reoccur- Prentice, Andrew. “Endometriosis.” British Medical Journal rence of endometrial growths after laparoscopic surgery 323 (July 14, 2001): 93–95. is approximately 19%. The mortality rate associated with Wellbery, Caroline. “Diagnosis and Treatment of Endometrio- laparoscopy is less than five per 100,000 cases. sis.” American Family Physician 60 (October 1, 1999): 1753–68. Alternatives ORGANIZATIONS American Association of Gynecologic Laparoscopists. 13021 While laparoscopy remains the definitive approach East Florence Ave., Sante Fe Springs, CA 90670-4505. to diagnosing endometriosis, some larger endometrial (800) 554-AAGL. <http://www.aagl.com>. growths may be located by ultrasound, a procedure that Endometriosis Association. 8585 North 76th Place, Milwaukee, uses high-frequency sound waves to visualize structures WI 53223. (414) 355-2200. <http://www.endometriosis in the human body. Ultrasound is a noninvasive tech- assn.org>. nique that may detect endometriomas (cysts filled with OTHER old blood) larger than 0.4 in (1 cm). “Endometriosis.” UC Davis Health System. 2002 [cited March 22, 2003]. <http://www.ucdmc.ucdavis.edu/ucdhs/health/ A physician may recommend noninvasive measures to a-z/74Endometriosis__/>. treat endometriosis before resorting to surgical treatment. Hurd, William W., and Janice M. Duke. “Gynecologic Laparo- Over-the-counter or prescription pain medications may be scopy.” eMedicine. November 27, 2002 [cited March 22, recommended to relieve pain-related symptoms. Oral con- 2003]. <http://www.emedicine.com/med/topic3299.htm>. traceptives or other hormone drugs may be prescribed to Kapoor, Dharmesh. “Endometriosis.” eMedicine. September suppress ovulation and menstruation. Some women seek 17, 2002 [cited March 22, 2003]. <http://www.emedicine. alternative medical therapies such as acupuncture, manage- com/med/topic3419.htm>. ment of diet, or herbal treatments to reduce pain. “What is Endometriosis?” Endometriosis Association. 2002 [cited March 22, 2003]. <http://www.endometriosisassn. Severe endometriosis may need to be treated by more org/endo.html>. extensive surgery. Conservative surgery consists of exci- sion of all endometrial implants in the abdominal cavity, Stephanie Dionne Sherk GALE ENCYCLOPEDIA OF SURGERY 835

Laparotomy, exploratory domen. Exploratory laparotomy is used to visualize and Depending on the reason for performing an ex- Laparotomy, exploratory WHO PERFORMS THE PROCEDURE AND Definition WHERE IS IT PERFORMED? A laparotomy is a large incision made into the ab- examine the structures inside of the abdominal cavity. ploratory laparotomy, the procedure may be performed by a general or specialized surgeon in a hospital operating room. In the case of Purpose trauma to the abdomen, laparotomy may be Exploratory laparotomy is a method of abdominal performed by an emergency room physician. exploration, a diagnostic tool that allows physicians to examine the abdominal organs. The procedure may be recommended for a patient who has abdominal pain of unknown origin or who has sustained an injury to the ab- • adhesions (bands of scar tissue that form after trauma domen. Injuries may occur as a result of blunt trauma or surgery) (e.g., road traffic accident) or penetrating trauma (e.g., • diverticulitis (inflammation of sac-like structures in the stab or gunshot wound). Because of the nature of the ab- walls of the intestines) dominal organs, there is a high risk of infection if organs • intestinal perforation rupture or are perforated. In addition, bleeding into the abdominal cavity is considered a medical emergency. Ex- • ectopic pregnancy (pregnancy occurring outside of the ploratory laparotomy is used to determine the source of uterus) pain or the extent of injury and perform repairs if needed. • foreign bodies (e.g., a bullet in a gunshot victim) Laparotomy may be performed to determine the • internal bleeding cause of a patient’s symptoms or to establish the extent of a disease. For example, endometriosis is a disorder in which cells from the inner lining of the uterus grow else- Demographics where in the body, most commonly on the pelvic and ab- Because laparotomy may be performed under a dominal organs. Endometrial growths, however, are dif- number of circumstances to diagnose or treat numerous ficult to visualize using standard imaging techniques conditions, no data exists as to the overall incidence of such as x ray, ultrasound technology, or computed to- the procedure. mography (CT) scanning. Exploratory laparotomy may be used to examine the abdominal and pelvic organs (such as the ovaries, fallopian tubes, bladder, and rec- Description tum) for evidence of endometriosis. Any growths found The patient is usually placed under general anesthe- may then be removed. sia for the duration of surgery. The advantages to general Exploratory laparotomy plays an important role in the anesthesia are that the patient remains unconscious dur- staging of certain cancers. Cancer staging is used to de- ing the procedure, no pain will be experienced nor will scribe how far a cancer has spread. A laparotomy enables the patient have any memory of the procedure, and the a surgeon to directly examine the abdominal organs for patient’s muscles remain completely relaxed, allowing evidence of cancer and remove samples of tissue for fur- safer surgery. ther examination. When laparotomy is used for this use, it is called staging laparotomy or pathological staging. Incision Some other conditions that may be discovered or in- Once an adequate level of anesthesia has been vestigated during exploratory laparotomy include: reached, the initial incision into the skin may be made. A scalpel is first used to cut into the superficial layers of • cancer of the abdominal organs the skin. The incision may be median (vertical down the • peritonitis (inflammation of the peritoneum, the lining patient’s midline), paramedian (vertical elsewhere on the of the abdominal cavity) abdomen), transverse (horizontal), T-shaped, or curved, • appendicitis (inflammation of the appendix) according to the needs of the surgery. The incision is then continued through the subcutaneous fat, the abdom- • pancreatitis (inflammation of the pancreas) inal muscles, and finally, the peritoneum. Electrocautery • abscesses (a localized area of infection) is often used to cut through the subcutaneous tissue as it 836 GALE ENCYCLOPEDIA OF SURGERY

Laparotomy Linea alba Incision fascia Laparotomy, exploratory B. A. Peritoneum Interrupted sutures C. C. Linea alba fascia Skin Scarpa's fascia Fat Rectus muscle E. Linea alba Peritoneum During a laparotomy, and an incision is made into the patient’s abdomen (A). Skin and connective tissue called fascia is di- vided (B).The lining of the abdominal cavity, the peritoneum, is cut, and any exploratory procedures are undertaken (C).To close the incision, the peritoneum, fascia, and skin are stitched (E). (Illustration by GGS Inc.) has the ability to stop bleeding as it cuts. Instruments Any fluid surrounding the abdominal organs will be in- called retractors may be used to hold the incision open spected; the presence of blood, bile, or other fluids may once the abdominal cavity has been exposed. indicate specific diseases or injuries. In some cases, an abnormal smell encountered upon entering the abdomi- Abdominal exploration nal cavity may be evidence of infection or a perforated gastrointestinal organ. The surgeon may then explore the abdominal cavity for disease or trauma. The abdominal organs in question If an abnormality is found, the surgeon has the op- will be examined for evidence of infection, inflamma- tion of treating the patient before closing the wound or tion, perforation, abnormal growths, or other conditions. initiating treatment after exploratory surgery. Alterna- GALE ENCYCLOPEDIA OF SURGERY 837

Laparotomy, exploratory • Why is exploratory laparotomy being recom- the anesthesiologist to go over details of the method of anesthesia to be used. QUESTIONS TO ASK THE DOCTOR Aftercare The patient will remain in the postoperative recov- mended? ery room for several hours where his or her recovery can • What diagnostic tests will be performed to be closely monitored. Discharge from the hospital may determine if exploratory laparotomy is neces- occur in as little as one to two days after the procedure, sary? but may be later if additional procedures were performed • Are any additional procedures anticipated? or complications were encountered. The patient will be • What type of incision will be used and where instructed to watch for symptoms that may indicate in- will it be located? fection, such as fever, redness or swelling around the in- cision, drainage, and worsening pain. Risks tively, samples of various tissues and/or fluids may be removed for further analysis. For example, if cancer is Risks inherent to the use of general anesthesia in- suspected, biopsies may be obtained so that the tissues clude nausea, vomiting, sore throat, fatigue, headache, can be examined microscopically for evidence of abnor- and muscle soreness; more rarely, blood pressure prob- mal cells. If no abnormality is found, or if immediate lems, allergic reaction, heart attack, or stroke may occur. treatment is not needed, the incision may be closed with- Additional risks include bleeding, infection, injury to the out performing any further surgical procedures. abdominal organs or structures, or formation of adhe- sions (bands of scar tissue between organs). During exploratory laparotomy for cancer, a pelvic washing may be performed; sterile fluid is instilled into the abdominal cavity and washed around the abdominal Normal results organs, then withdrawn and analyzed for the presence of The results following exploratory laparotomy de- abnormal cells. This may indicate that a cancer has pend on the reasons why it was performed. The proce- begun to spread (metastasize). dure may indicate that further treatment is necessary; for example, if cancer was detected, chemotherapy, radiation Closure therapy, or more surgery may be recommended. In some Upon completion of any exploration or procedures, cases, the abnormality is able to be treated during laparo- the organs and related structures are returned to their tomy, and no further treatment is necessary. normal anatomical position. The incision may then be sutured (stitched closed). The layers of the abdominal Morbidity and mortality rates wall are sutured in reverse order, and the skin incision The operative and postoperative complication rates closed with sutures or staples. associated with exploratory laparotomy vary according to the patient’s condition and any additional procedures Diagnosis/Preparation performed. Various diagnostic tests may be performed to deter- mine if exploratory laparotomy is necessary. Blood tests Alternatives or imaging techniques such as x ray, computed tomogra- Laparoscopy is a relatively recent alternative to la- phy (CT) scan, and magnetic resonance imaging (MRI) parotomy that has many advantages. Also called mini- are examples. The presence of intraperitoneal fluid (IF) mally invasive surgery, laparoscopy is a surgical proce- may be an indication that exploratory laparotomy is nec- dure in which a laparoscope (a thin, lighted tube) and essary; one study indicated that IF was present in nearly other instruments are inserted into the abdomen through three-quarters of patients with intra-abdominal injuries. small incisions. The internal operating field may then be Directly preceding the surgical procedure, an intra- visualized on a video monitor that is connected to the venous (IV) line will be placed so that fluids and/or med- scope. In some patients, the technique may be used for ications may be administered to the patient during and abdominal exploration in place of a laparotomy. La- after surgery. A Foley catheter will be inserted into the paroscopy is associated with faster recovery times, short- bladder to drain urine. The patient will also meet with er hospital stays, and smaller surgical scars. 838 GALE ENCYCLOPEDIA OF SURGERY

Demographics KEY TERMS The American Cancer Society estimates that, in 2003, about 9,500 people in the United States will be Laryngectomy Intestinal perforation—A hole in the intestinal wall. found to have laryngeal cancer. Laryngeal cancer occurs 4.4 times more frequently in men than in women, al- Subcutaneous—Under the skin. though, like lung cancer, it is becoming increasingly common in women. Tobacco smoking is by far the great- est risk factor for laryngeal cancer. Others include alco- Resources hol abuse, radiation exposure, asbestos exposure, and ge- netic factors. In the United Kingdom, cancer of the lar- BOOKS ynx is quite rare, affecting under 3,000 people each year. Marx, John A., et al. Rosen’s Emergency Medicine. St. Louis, MO: Mosby, Inc., 2002. Description PERIODICALS Hahn, David D., Steven R. Offerman, and James F. Holmes. Laryngectomies may be total or partial. In a total la- “Clinical Importance of Intraperitoneal Fluid in Patients ryngectomy, the entire larynx is removed. If the cancer with Blunt Intra-abdominal Injury.” American Journal of has spread to other surrounding structures in the neck, Emergency Medicine 20, no. 7 (November 2002). such as the lymph nodes, they are removed at the same OTHER time. If the tumor is small, a partial laryngectomy is per- Awori, Nelson, et al. “Laparotomy.” Primary Surgery. [cited formed, by which only a part of the larynx, usually one April 6, 2003]. <http://www.meb.uni-bonn.de/dtc/prim- vocal chord, is removed. Partial laryngectomies are also surg/index.html>. often performed in conjunction with other cancer treat- “Surgery by Laparotomy.” Stream OR. 2001 [cited April 6, ments, such as radiation therapy or chemotherapy. 2003]. <http://www.streamor.com/opengyn/openindex. html>. During a laryngectomy, the surgeon removes the lar- ynx through an incision in the neck. The procedure also requires the surgeon to perform a tracheotomy, because Stephanie Dionne Sherk air can no longer flow into the lungs. He makes an artifi- cial opening called a stoma in the front of the neck. The upper portion of the trachea is brought to the stoma and Large bowel resection see Bowel resection secured, making a permanent alternate way for air to get to the lungs. The connection between the throat and the esophagus is not normally affected, so after healing, the person whose larynx has been removed (called a laryn- gectomee) can eat normally. Laryngectomy Diagnosis/Preparation Definition A laryngectomy is performed after cancer of the lar- A laryngectomy is the partial or complete surgical ynx has been diagnosed by a series of tests that allow the removal of the voice box (larynx). otolaryngologist (a physician often called an ear, nose & throat or ENT specialist) to examine the throat and take Purpose tissue samples (biopsies) to confirm and stage the cancer. People need to be in good general health to undergo a la- Because of its location, the voice box, or larynx, ryngectomy, and will have standard pre-operative blood plays a critical role in breathing, swallowing, and speak- work and tests to make sure they are able to safely with- ing. The larynx is located above the windpipe (trachea) stand the operation. and in front of the food pipe (esophagus). It contains two small bands of muscle called the vocal cords that close to As with any surgical procedure, the patient is re- prevent food from entering the lungs and vibrate to pro- quired to sign a consent form after the procedure is thor- duce the voice. If cancer of the larynx develops, a laryn- oughly explained. Blood and urine studies, along with gectomy is performed to remove tumors or cancerous chest x ray and EKG may be ordered as required. If a tissue. In rare cases, the procedure may also be per- total laryngectomy is planned, the patient meets with a formed when the larynx is badly damaged by gunshot, speech pathologist for discussion of post-operative ex- automobile injuries, or other traumatic accidents. pectations and support. GALE ENCYCLOPEDIA OF SURGERY 839

Laryngectomy WHERE IS IT PERFORMED? TO ASK THE DOCTOR WHO PERFORMS QUESTIONS THE PROCEDURE AND tion? A laryngectomy is usually performed by an oto- • Is laryngectomy my only viable treatment op- laryngologist in a hospital operating room. In the • How will drinking and eating be affected? case of trauma to the throat, the procedure may • How will I talk without my larynx? be performed by an emergency room physician. • How will my breathing be affected? • What about my usual activities? • Is there a support group in the area that can Aftercare assist me after surgery? A person undergoing a laryngectomy spends several • How long will it be until I can verbally com- days in intensive care (ICU) and receives intravenous municate? What are my options? (IV) fluids and medication. As with any major surgery, • What is the risk of recurring cancer? blood pressure, pulse, and respiration are monitored reg- ularly. The patient is encouraged to turn, cough, and deep-breathe to help mobilize secretions in the lungs. One or more drains are usually inserted in the neck to re- method depends on several factors including the age move any fluids that collect. These drains are removed and health of the laryngectomee, and whether other after several days. parts of the mouth, such as the tongue, have also been removed (glossectomy). It takes two to three weeks for the tissues of the throat to heal. During this time, the laryngectomee can- not swallow food and must receive nutrition through a Risks tube inserted through the nose and down the throat into Laryngectomy is often successful in curing early- the stomach. Normal speech is also no longer possible stage cancers. However, it requires major lifestyle and patients are instructed in alternate means of vocal changes and there is a risk of severe psychological stress communication by a speech pathologist. from unsuccessful adaptations. Laryngectomees must When air is drawn in normally through the nose, learn new ways of speaking, they must be constantly it is warmed and moistened before it reaches the concerned about the care of their stoma. Serious prob- lungs. When air is drawn in through the stoma, it does lems can occur if water or other foreign material enters not have the opportunity to be warmed and humidi- the lungs through an unprotected stoma. Also, women fied. In order to keep the stoma from drying out and who undergo partial laryngectomy or who learn some becoming crusty, laryngectomees are encouraged to types of artificial speech will have a deep voice similar breathe artificially humidified air. The stoma is usual- to that of a man. For some women this presents psycho- ly covered with a light cloth to keep it clean and to logical challenges. As with any major operation, there is keep unwanted particles from accidentally entering a risk of infection. Infection is of particular concern to the lungs. Care of the stoma is extremely important, laryngectomees who have chosen to have a voice pros- since it is the person’s only way to get air to the lungs. thesis implanted, and is one of the major reasons for hav- After a laryngectomy, a health-care professional will ing to remove the device. teach the laryngectomee and his or her caregivers how to care for the stoma. Normal results There are three main methods of vocalizing after a Ideally, removal of the larynx will remove all cancer- total laryngectomy. In esophageal speech, patients ous material. The person will recover from the operation, learn how to “swallow” air down into the esophagus make lifestyle adjustments, and return to an active life. and create sounds by releasing the air. Tracheoe- sophageal speech diverts air through a hole in the tra- Morbidity and mortality rates chea made by the surgeon. The air then passes through an implanted artificial voice. The third method in- For 2003, the American Cancer Society estimates a volves using a hand-held electronic device that trans- 40% mortality rate for laryngeal cancer, meaning that lates vibrations into sounds. The choice of vocalization about 3,800 people will die of this disease. 840 GALE ENCYCLOPEDIA OF SURGERY

Alternatives KEY TERMS There are two alternatives forms of treatment: • Radiation therapy, a treatment that uses high-energy Larynx—Also known as the voice box, the larynx rays (such as x rays) to kill or shrink cancer cells. is composed of cartilage that contains the appara- tus for voice production. This includes the vocal • Chemotherapy, a treatment that uses drugs to kill can- cords and the muscles and ligaments that move cer cells. Usually the drugs are given into a vein or by the cords. Laser in-situ keratomileusis (LASIK) mouth. Once the drugs enter the bloodstream, they spread throughout the body to the cancer site. Lymph nodes—Accumulations of tissue along a lymph channel, which produce cells called lym- See also Glossectomy; Tracheotomy. phocytes that fight infection. Resources Tracheotomy—A surgical procedure in which an artificial opening is made in the trachea (wind- BOOKS pipe) to allow air into the lungs. Algaba, J., ed. Surgery and Prosthetic Voice Restoration after Total and Subtotal Laryngectomy. New York: Excerpta Medica, 1996. Casper, J. K. and R. H. Colton. Clinical Manual For Laryngec- tomy And Head/Neck Cancer Rehabilitation. Indepen- The Voice Center at Eastern Virginia Medical School. Norfolk, dence, KY: Singular Publishing, 1998. VA 23507. <http://www.voice-center.com>. Singer, M. I. and R. C. Hamaker. Tracheoesophageal Voice Restoration Following Total Laryngectomy. Independence, OTHER KY: Singular Publishing, 1998. “Laryngectomy: The Operation.” The Voice Center. <http:// Weinstein, G. S., O. Laccourreye, D. Brasnu, and H. Laccourr- www.voice-center.com/laryngectomy.html>. eye. Organ Preservation Surgery For Laryngeal Cancer. Independence, KY: Singular Publishing, 1999. Kathleen Dredge Wright PERIODICALS Tish Davidson, A.M. King, A. I., B. E. Stout, and J. K. Ashby. “The Stout prosthesis: Monique Laberge, Ph.D. an alternate means of restoring speech in selected laryn- gectomy patients.” Ear Nose and Throat Journal 82 (Feb- ruary 2003): 113–116. Landis, B. N., R. Giger, J. S. Lacroix, and P. Dulguerov. Larynx removal see Laryngectomy “Swimming, snorkeling, breathing, smelling, and motor- Laser coagulation therapy see cycling after total laryngectomy.” American Journal of Photocoagulation therapy Medicine 114 (March 2003): 341–342. Nakahira, M., K. Higashiyama, H. Nakatani, and T. Takeda. “Staple-assisted laryngectomy for intractable aspiration.” American Journal of Otolaryngology 24 (January-Febru- ary 2003): 70–74. ORGANIZATIONS Laser in-situ keratomileusis American Academy of Otolaryngology - Head and Neck Surgery. One Prince Street, Alexandria, VA 22314. (703) (LASIK) 806-4444. <http://www.entnet.org>. Definition American Cancer Society. National Headquarters. 1599 Clifton Road NE, Atlanta, GA 30329. (800) ACS -2345. <http:// Laser in-situ keratomileusis (LASIK) is a non-re- www.cancer.org>. versible refractive procedure performed by ophthalmolo- Cancer Information Service. National Cancer Institute. Build- gists to correct myopia, hyperopia, or astigmatism. The ing 31, Room 10A19, 9000 Rockville Pike, Bethesda, MD surgeon uses an excimer laser to cut or reshape the 20892. (800)4-CANCER. <http://www.nci.nih.gov/cancer cornea so that light will focus properly on the retina. info/index.html> . International Association of Laryngectomees (IAL). <http:// www.larynxlink.com/>. Purpose National Institute on Deafness and Other Communication Dis- orders. National Institutes of Health. 31 Center Drive, LASIK is an elective surgery for patients who want MSC 2320, Bethesda, MD 20892-2320. <http://www. to permanently correct myopia (nearsightedness), hyper- nidcd.nih.gov> . opia (farsightedness), or astigmatism without eyeglasses, GALE ENCYCLOPEDIA OF SURGERY 841

The first LASIK patients in the late 1990s were in Laser in-situ keratomileusis (LASIK) the upper class, or upper middle class, and in their early 30s to mid-40s. The market was limited for the elective procedure that at first could range as expensive as $5,000 per eye. The number of younger patients receiving LASIK (in their early to mid-20s) was expected to rise in 2003 and beyond. The number of procedures also was expected to increase as prices continued to stabilize, and surgery centers and physicians offered payment plans. Description LASIK is a relatively new procedure. In April 1985, German physician Theo Seiler was the first to use an ex- cimer laser to attempt to correct astigmatism in blind eyes. Experiments with excimer lasers on blind eyes were also completed in the United States in the mid- 1980s. The term LASIK was invented by Greek ophthal- mologist Ioannis Pallikari, the first surgeon to use the hinged flap technique. Dr. Stephen Brint, as part of a clinical trial in 1991, performed the first LASIK proce- dure in the United States. As of 2003, there are two types of LASIK. The stan- contact lenses, or refractive surgical procedures. The dard LASIK procedure and custom LASIK, which rela- goal for most patients is to be free of any type of correc- tively few surgeons have the technology to perform. tive lenses. Some patients may find wearing eyeglasses or contact lenses interferes with their careers or hobbies. Standard LASIK Many professional athletes have chosen LASIK to im- Standard LASIK takes from 10 to 20 minutes to per- prove their performance. However, patients with higher form and the results are immediate. It’s standard practice degrees of refractive error will still need some type of in LASIK operating rooms to have a clock on the wall so corrective lens. patients immediately can note they are able to read a LASIK is most commonly performed on myopes. clock face or other items that previously were blurry. For myopia, the surgeon flattens the cornea; for hyper- Immediately before the procedure, the ophthalmolo- opia, the surgeon steepens the cornea. Surgeons correct gist may request corneal topography (a corneal map) to astigmatism by creating a normally shaped cornea with compare with previous maps to ensure the treatment plan the excimer laser. is still correct. The surgeon may also measure the A new type of LASIK also can treat contrast sensi- cornea’s thickness if he didn’t previously. After these tivity as well as refractive error. Custom LASIK incorpo- tests, a technician or co-managing optometrist will per- rates new eye mapping technology into standard LASIK. form a refraction to make sure the refractive correction The surgeon measures the eye from front to back creat- the surgeon will program into the laser is correct. ing a three dimensional corneal map. This much-more Three sets of eye drops will be administered twice detailed map gives surgeons more specific information before surgery. The first drop anesthetizes the cornea, the for the excimer laser and enables them to correct other second drop prevents infection and the third drop controls abnormalities besides refractive error. inflammation after LASIK. Patients may be given a seda- tive, such as Valium. This is administered to calm nervous Demographics patients or to help patients sleep after the procedure. LASIK candidates have myopia, hyperopia, or astig- After the prep work is completed, the patient re- matism; are 18 or older; and have had stable vision for at clines on a laser bed and the surgeon is seated directly least two years. The American Academy of Ophthalmol- behind the patient. If the procedure is being done on both ogy (AAO) estimated that 1.8 million refractive surgery eyes on the same day, the surgeon will patch the second procedures were performed in 2002. LASIK was esti- eye. An eyelid speculum is inserted in the eye to be treat- mated to account for 95% of those procedures. ed first to hold the eyelids apart. The patient stares at the 842 GALE ENCYCLOPEDIA OF SURGERY