FROZEN SECTION -Examining histologic sections few minutes after removing from the patient -frozen sections must

be quick -Indications: diagnostic. -Procedure: FROZEN SECTION PROCEDURE 1. Obtain frozen tissue, preferably frozen in liquid nitrogen. It is imperative that the tissue be frozen as quickly as possible in order to avoid ice crystal formation resulting in artifact and poor morphological preservation. 2. Make sure the cryostat is at proper operating temperature -20 C to -30 C. Place a small amount of OCT or other suitable frozen section embedding medium on a cryostat object disk (make sure the disk is at room temp. before mounting the specimen). 3. Position the frozen specimen in the center of the object disk and place the disk on the cryobar in the cryostat to begin the quick freeze process. 4. Using "Histo-Freeze" or other appropriate aerosol refrigerant, spray around the periphery of the object disk, as the OCT freezes it will begin to turn from a clear gel to white solid substance. Proceed quickly to step # 5. 5. Before the disk is frozen solid add enough OCT to cover the top the specimen and quickly place a heat extractor on top of the specimen. The heat extractor serves two purposes, (1) rapidly freezes the OCT and tissue and (2) produces a flat embedded surface for easy cutting. 6. Spray with refrigerant if necessary to expedite the freezing process. 7. Place the object disk in the microtome object disk holder and tighten the set screw or clamp. 8. Make sure that there is enough clearance between the block and the microtome knife. 9. Move the block toward the knife edge. Make sure the ratchet is disengaged from the micrometer gear. Turn the flywheel with the right hand and begin turning the gross adjust wheel (on the down stoke) slowly with the left hand. Face off enough OCT until a full section of the specimen is visible. 10. Engage the ratchet on the micrometer gear, cut and discard the first two or three sections. 11. Have the proper fixative (95% ETOH for H&E) and slides ready. Turn the flywheel with the right hand. As the block comes in contact with the knife edge the section will move down the blade and begin to curl. Hold the section down with as little force as possible and guide in along the blade using a camel hair paint brush in the left hand. Continue the cut until a full specimen section has been obtained, but

stop before passing through the remaining OCT. One edge of the section is held flat with the paint bush and the other with the knife edge. 12. Pick up the slide with the right hand and turn it so that the top side is facing toward the knife blade. 13. Carefully lower the slide onto the blade, keeping the slide parallel to the section. As the tissue comes into contact with the slide the OCT and tissue will melt causing the tissue to adhere to the slide. 14. Place the slide in fixative. If staining H&E sections, use 95% ETOH and fix for 30 sec. ADHESIOLYSIS -surgical lysis of adhesions by laparoscopy or laparotomy -Goal: eliminate pain caused by adhesion or scar tissue -adhesions can cause abdominal pain, discomfort, bloating and difficulty in bowel movements TUMOR DEBULKING -performed to remove as much of the tumor as possible. - factors that influence way procedure is performed: type of tumor, location, px's general health. -can be performed by oncology surgeon or surgical specialist, general surgeons -steps: tumor identified; screening to find out type of tumor/staging, origin, location, size and degree of spread. -for cancerous tumors: removal of entire tumor with healthy margin. designed to take out all malignant material and remove pre-malignant cells that would later divide and be cancerous. -sometimes taking out wholee tumor is not possible. goal is to take out as much as possible. -can increase comfort for the patient. improve QOL. -advantages:allows for some reduction in size of tumor. -goal(ovarian cancer): excise a sufficient amount of tumor so that the remaining cancerous tissue is no larger than 1cm in size -considerations: to be effective, must be combined with other CA treatments BILATERAL LYMPH NODE DISSECTION - lymph nodes are removed -Description
Lymph node dissection is usually done by a surgeon in a hospital setting, under general anesthesia. An incision is made and tissue is pulled back to reveal the lymph nodes. The surgeon is guided in what to remove by the location of the original cancer. Sample lymph nodes may be sent to the laboratory for examination. If the excised nodes do contain malignant cells, this would indicate that the cancer has spread beyond the original site, and recommendations can then be made regarding further therapy.

Preparation
Tests may be done before the operation to determine the location of the cancer and which nodes should be removed. These tests may include lymph node biopsies, CT (computed tomography) scans, and MRI scans. In addition, standard pre-operative blood and liver function tests are performed. The patient will meet with an anesthesiologist before the operation, and should notify the anesthesiologist about all drug allergies and all medication (prescription, non-prescription, or herbal) that he or she is taking.

Aftercare
How long a person stays in the hospital after lymph node dissection depends on how many lymph nodes were removed, their location, and whether surgery to remove the primary tumor or other structures was performed at the same time. Drains are inserted under the skin to remove the fluid that accumulates after the lymph nodes have been removed, and patients are usually able to return home with the drains still in place. Some patients are able to leave the same day or the day following the procedure. An accumulation of lymph fluid that causes swelling, a condition known as lymphedema, is the most feared side effect of lymph node dissection. If swelling occurs, patients should consult their doctors immediately. Swelling may indicate that a new tumor is blocking a lymph vessel, or that a side effect of lymph node dissection is present. Treatment for lymphedema in people with cancer is different than treatment of lymphedema that arises from other causes. In cancer patients, it is essential to alleviate swelling without spreading cancer cells to other parts of the body, therefore an oncologist (cancer specialist) should be consulted before beginning any treatment.

Risks
People who have lymph nodes removed are at increased risk of developing lymphedema, which can occur in any part of the body where lymph accumulates in abnormal quantities. When the amount of fluid exceeds the capacity of the lymph system to move it through the body, it leaks into the tissues and causes them to swell. Removing lymph nodes and lymph vessels through lymph node dissection increases the likelihood that the capacity of the lymph transport system will be exceeded. Lymphedema can occur days or weeks after lymph node dissection. Radiation therapy also increases the chance of developing lymphedema, so those people who have radiation therapy following lymph node dissection are at greatest risk of experiencing this side effect. Lymphedema slows healing, causes skin and tissue damage, and when left untreated can result in the development of hard or fibrous tissue. People with lymphedema are also at risk for repeated infection, because pools of lymph in the tissues provide a perfect spot for bacteria to grow. In severe cases, untreated lymphedema can develop into a rare form of cancer called lymphangiosarcoma. Other risks associated with lymph node dissection are the same as for all major surgery: potential bleeding, infection, and allergic reaction to anesthesia.

PERITONECTOMY -peritonectomy procedures There are six different peritonectomy procedures that are used to resect cancer on visceral intra-abdominal surfaces or to strip cancer from parietal peritoneal surfaces. One or all six of these procedures may be required, depending on the distribution and volume of peritoneal disease. 1. Abdominal exposure The abdomen is opened from xiphoid to pubis and the xiphoid excised. Generous abdominal exposure is achieved through the use of a Thompson self-retaining retractor. First step of operation will be the resection of the central peritoneal compartment. Here it is necessary to cut out scars of previous laparotomies as well as the peritoneum beneath rectus abdominis mussels from xyphoid area to symphysis. 2. 3. 4. Greater omentectomy and splenectomy To free the mid-abdomen of a large volume of tumor, a complete greater omentectomy is performed. The greater omentum is elevated and then separated from the transverse colon using ball-tip electrosurgery. This dissection continues beneath the peritoneum that covers the transverse mesocolon so as to expose the pancreas. The gastroepiploic vessels on the greater curvature of the stomach are ligated and divided. In addition, the short gastric vessels are transsected. The mound of tumor that covers the spleen is identified. The peritoneum on the anterior surface of the pancreas may need to be elevated from the gland. Working from the anterior and posterior aspect, the splenic artery and vein at the tail of the pancreas are exposed. These vessels are ligated in continuity and proximally suture-ligated. This allows the greater curvature of the stomach to be reflected anteriorly from pylorus to gastroesophageal junction. Greater omentectomy is usually combined with splenectomy to achieve a complete cytoreduction. If the spleen is free of tumor, it is left in situ. 5. 6. 7. Peritoneal stripping from beneath the left hemidiaphragm To begin exposure of the left upper quadrant, the peritoneum beneath the epigastric fat pad that constitutes the edge of the abdominal incision

is stripped off the posterior rectus sheath. Traction is to be achieved on the tumor specimen throughout the left upper quadrant. The left upper quadrant peritonectomy involves a stripping of all tissue from beneath the left hemidiaphragm to expose diaphragmatic muscle, left adrenal gland, and the cephalad half of the perirenal fat. To achieve a full exposure of the left upper quadrant, the splenic flexure of the colon is released from the left paracolic sulcus and moved medially by dividing tissue along Toldt's line. The dissection beneath the left hemidiaphragm is performed with ball-tip electrosurgery. 8. 9. 10. Peritoneal stripping from beneath the right hemidiaphragm The peritoneum and epigastric fat pad are stripped away from the right posterior rectus sheath to begin the peritonectomy in the right upper quadrant of the abdomen. Strong traction on the specimen is used to elevate the hemidiaphragm into the operative field. Ball-tip electrosurgery on pure cut is used to dissect at the interface of mesothelioma infiltrating the peritoneum and the muscle of the right hemidiaphragm. 11. 12. 13. Dissection beneath the tumor through Glisson's capsule The stripping of the tumor from the muscular surface of the diaphragm continues until the area the liver is encountered. Tmor formations on the superior surface of the liver will be electroevaporated . With blunt and ball-tip electrosurgical dissection, the tumor is lifted off the dome of the liver by moving through or beneath Glisson's capsule. Hemostasis is achieved as the dissection proceeds, using coagulation electrosurgery on the liver surface. Ball-tip electrosurgery is also used to extirpate the tumor from and around the falciform ligament, round ligament, and umbilical fissure of the liver. 14. 15. 16. Removal of tumor from beneath the right hemidiaphragm, from the right subhepatic space, and from the surface of the liver Tumor from beneath the right hemidiaphragm, from the right subhepatic space, and from the surface of the liver forms an envelope as it is removed en bloc. The dissection is simplified greatly if the tumor specimen can

be maintained intact. The dissection continues laterally on the right to encounter the fat covering the right kidney. The right adrenal gland is visualized as the tumor is stripped from Morrison's pouch. Care is taken not to traumatize the vena cava or to disrupt caudate lobe veins that pass between the vena cava and segment 1 of the liver. lesser omentectomy and cholecystectomy The gallbladder is removed in a routine fashion from its fundus toward the cystic artery and cystic duct. These structures are ligated and divided. The plate of tissue that covers the structures that constitute the porta hepatis is usually infiltrated heavily by tumor. Using strong traction, the cancerous tissue that covers the structures is stripped from the base of the gallbladder bed toward the duodenum stripping of the omental bursa As one clears the left part of the caudate liver segment of tumor, the vena cava is visualized directly beneath. To strip the floor of the omental bursa, strong traction is maintained on the tumor. Ball-tip electrosurgery is used to divide the peritoneum joining the caudate lobe of the liver to the vena cava. Division of the phrenoesophageal ligament allows the crus of the right hemidiaphragm to be stripped of peritoneum. 17. 18. 19. Pelvic peritonectomy The peritoneum is stripped from the posterior surface of the lower abdominal incision, exposing the rectus muscle. The muscular surface of the bladder is seen as ball-tip electrosurgery strips tumor-bearing peritoneum and preperitoneal fat from this structure. The urachus must be divided and is placed on upward traction as the leading point for dissection of the visceral surface of the bladder. Round ligaments are divided as they enter the internal inguinal ring on both the right and left in the female patient. The peritoneal incision around the pelvis is completed by dividing peritoneum along the pelvic brim. Right and left ureters are identified and preserved. In women, the right and left ovarian veins are ligated and divided at the level of the lower portion of the kidney. A linear stapler is used to divide the colon at the junction of sigmoid and descending colon. The vascular supply of the distal portion of the bowel is traced back to its origin on the aorta. The inferior mesenteric artery is ligated and divided. This allows one to

pack all of the viscera, including the proximal descending colon in the upper abdomen. Ball-tip electrosurgery is used to dissect beneath the mesorectum. An extraperitoneal suture ligation of the uterine arteries occurs just above the ureter and close to the base of the bladder. In women, the bladder is moved gently off the cervix, and the vagina is entered. The vaginal cuff anterior and posterior to the cervix is divided using ball-tip electrosurgery, and the perirectal fat inferior to the posterior vaginal wall is encountered. All the tumor that occupies the cul-de-sac should be removed intact with the specimen. The mid-portion of the rectal musculature is skeletonized and a roticulator stapler is used to staple the rectal stump closed. INFRACOLIC OMENTECTOMY - Omentectomy- procedure when a part or all of the abdominal lining is removed. Tissue removed is the OMENTUM. May involve the complete removal of the momentum(supracolic omentectomy). Removal of momentum may reduce the chances of cancer spreading from nearby organs to the stomach. - omentectomy done during staging procedure for ovarian cancer - omentum resected from the transverse colon - initiated on the underside of the greater omentum PERITONEAL FLUID CYTOLOGY Cytology - branch of biology dealing with structure, function, multiplication, pathology and life history of cells - study of the structure and function of the cells used in the diagnosis of cancer - cells are continually shed from tissues that line the cavities and hollow body organs of the body. Cells are examined microscopically to determine tissue of origin and whether or not they are malignant. -Technique: Washing - removal of fluid from a hollow organ or structure for the purpose of collecting any cells in the fluid TAHBSO -surgical procedure involving removal of the uterus, both ovaries and fallopian tubes. lymph nodes may also be removed. -treatment for endometrial cancer and uterine sarcoma -oopherectomy = removal of the ovaries -salpingo-oopherectomy = removal of the ovary and its adjacent fallopian tube - dx procedure before tahbso: complete pelvic exam, pap smear, pelvic utz, cbc -complications: hemorrhage, infix, constipation, urinary retention more common in vaginal hysterectomy resolves within 24-48hrs, blood clots, damage to adjacent organs

LOW TRANSVERSE CERVICAL CESAREAN SECTION a surgical procedure to deliver a baby through a transverse incision in the thin supracervical part of the lower uterine segment, behind the bladder and the bladder flap. This incision bleeds less during surgery and heals with a stronger scar than the higher vertical scar of the classic cesarean section Cervical meaning a transverse (horizontal) or vertical incision in the lower uterus. Cesarean Childbirth Causes Some of the reasons for the increased use of cesarean childbirth include the following: Use of heart rate monitors to evaluate the fetal heart rate pattern Baby positioned in a manner other than head first Womans preference or repeat cesarean sections Labor does not progress to delivery Mother has an active genital herpes infection (baby needs to avoid potential exposure through the birth canal) Mother has HIV infection Malpractice concerns Birth in a private, for-profit hospital Womans higher level of education and social status Obesity The most frequent reasons for performing a cesarean delivery are discussed below. Repeat cesarean delivery: There are 2 types of uterine incisionsa

low transverse incision and a vertical uterine incision. The direction of the incision on the skin (up and down or side to side) does not necessarily match the direction of the incision made in the uterus. As the name implies, the low transverse incision is a horizontal cut across the lower part of the uterus. In the United States, whenever possible, a low skin incision below or at the bikini line with a low transverse uterine incision is the approach of choice. A vertical incision on the uterus may be used for delivering preterm babies, abnormally positioned placentas, pregnancies with more than one fetus, and in extreme emergencies. In the last 20 years, studies have shown that women who have had a prior cesarean section with a low transverse incision may safely and successfully go through labor and have a vaginal delivery in later pregnancies. The same, however, cannot be said of women who have had vertical incisions on the uterus. In about 10% of women with vertical uterine incisions, their uterus will rupture (break open). The uterus may rupture even before labor begins in up to 50% of these women. Uterine rupture can be dangerous to the fetus even if delivery is accomplished immediately after a uterine rupture. Diagnosing a uterine rupture can be difficult, and signs of a rupture can include increased bleeding, increased pain, or an abnormal fetal heart rate tracing. Previous cesarean deliveries: Women with a prior history of more than 1 low transverse cesarean section are at slightly increased risk for uterine rupture. This risk increases significantly when the woman has had 3 cesarean deliveries. If an abdominal delivery is planned and a trial of labor is not an option, the best time for delivery is determined when the lungs of the fetus are mature. Lack of labor progression: If the woman is having adequate contractions but no change in the cervix (opening to the uterus)

beyond 3 centimeters dilation or the woman is unable to deliver the fetus despite complete dilation of the cervix and "adequate" pushing for 2-3 hours, cesarean delivery may be performed. Abnormal position of the fetus: In a normal delivery, the baby presents head first. In this positionas it is in most birthsthe smallest diameter of the human skull is presented to the pelvis in the best way. This, of course, increases the success of a vaginal delivery. There are, however, various other presentations of the fetus, which make vaginal delivery difficult, including the commonly known breech position (when the babys buttocks are in the lower portion of the uterus). Certain forms of breech delivery have a very low increased risk to the fetus. But, as a rule, breech deliveries may cause more complications, including death and neurologic disability. Careful counseling, analysis of the exact type of breech position, and an estimate of the babys weight are required before making any decision about an attempted vaginal delivery or delivery by cesarean section. Fetal status: Although an attractive and much-used tool, the fetal heart rate monitor has not improved birth outcomes as once expected. Some believe the lack of improved outcomes is because many current practicing doctors are poorly trained in interpreting the subtleties of fetal heart rate patterns. Since the use of continuous fetal heart rate monitoring in labor was begun, however, birth experts say death of a fetus during labor is much more rare than in the past. Emergency situations: If the woman is severely ill or has a life-threatening injury or illness with interruption of the normal heart or lung function, she may be a candidate for an emergency cesarean section. When performed within 6-10 minutes of the onset of cardiac arrest, the procedure may save the newborn and improve the resuscitation rate for the mother. This procedure, obviously, is performed only in the direst circumstances. Elective sterilization: A desire for elective sterilization is not an indication for cesarean delivery. Sterilization after a vaginal

delivery can be performed via a tiny 3-cm incision along the lower edge of the umbilicus or as a delayed procedure 6 weeks after delivery with laparoscopic surgery or vaginal surgery. repeat Caesarean section is done when a patient had a previous Caesarean section. Typically it is performed through the old scar. BILATERAL TUBAL LIGATION -Laparoscopic bilateral tubal ligation is a surgical procedure to occlude the fallopian tubes, which prevents pregnancy. It is a permanent form of birth control. There are different methods of occluding the fallopian tubes. The common methods used are clips, rings and diathermy. The procedure is simple, safe and usually does not require hospitalisation. The procedure is done under general anaesthesia An instrument is inserted through the vagina to move the uterus into position during the operation. A small incision is made at the umbilicus (navel). Gas is introduced to distend your abdomen A laparoscope (telescope-like instrument) is inserted through the incision Another small incision may be made in the lower abdomen to insert a surgical instrument to apply clips, rings or diathermies the tubes. PHACOEMULSIFICATION In cataract surgery, the cloudy natural lens must be removed from the eye. After that, in most cases a permanent intraocular lens (IOL) implant replaces the natural lens to restore focusing power. When to have cataract surgery often is a subjective decision, based on how well you are able to see during routine activities. You might be able to drive, watch television and work at a computer for quite a few years, even after you are first diagnosed with cataracts. However, if you have cataracts, you may eventually start to notice "ghost" images and declining visual clarity, which can't be corrected with glasses or contacts. Colors may begin to look faded, too. If your functional vision is impaired significantly and it becomes difficult for you to perform your normal daily activities, it may be time for cataract surgery. Preparing for Cataract Surgery Once you and your eye doctor have decided that you will have your cataract removed, the eye surgeon will examine you. For the immediate time period before and after cataract surgery, ask your surgeon if you should continue your usual medications and nutritional supplements. As an example, a common drug that treats men with enlarged prostates Flomax and similar medications known as alpha-blockers could cause

problems associated with intraoperative floppy iris syndrome (IFIS) during cataract surgery. Patients on Flomax or similar medications should notify their eye surgeon before undergoing cataract surgery. You may be given a choice of implantation with a regular single-vision (monofocal) intraocular lens or a presbyopia-correcting intraocular lens for replacement of your eye's natural lens. Determining the right IOL for you can be based on many factors, including your lifestyle and ability to pay. If you are interested in correcting presbyopia, which all people have beginning at around age 40, you potentially could restore your ability to see at all distances with a multifocal IOL or accommodating IOL. However, you must consider that extra cataract surgery costs do occur with "premium" IOLs, even though they may reduce or eliminate dependency on eyeglasses. Before cataract surgery, your eye will be thoroughly measured in a preliminary eye exam to determine the proper power of the intraocular lens that will be placed in your eye. If you choose a premium IOL, you may need extra tests to make sure measurements are exact and that you don't have other vision problems that might hamper the performance of the IOL. If you need cataracts removed from both eyes, surgery usually will be done on only one eye at a time. An uncomplicated surgical procedure lasts only about 10 minutes. However, you may be in the outpatient facility for 90 minutes or longer, because extra time will be needed for preparation and recovery. At least a few days to weeks typically will be needed between surgeries, so that your first eye has the chance to heal and be evaluated in a follow-up exam for any possible problems. What Happens During Cataract Surgery? Cataract surgery usually is done on an outpatient basis. You may be asked to skip breakfast and avoid drinking liquids, depending on the time of your surgery. Also, do not wear eye makeup on the day of surgery. Upon arrival at the facility, you will be given eye drops to dilate your pupils and perhaps a sedative to help you relax. A local or topical anesthetic will make the operation painless. The skin around your eye will be thoroughly cleansed, and sterile coverings will be placed around your eye and head. Under an operating microscope, at least one small incision is made into the eye. The surgeon will then remove your cloudy lens (the cataract). This procedure can be performed using an ultrasound-driven instrument that "sonically" breaks up the cataract (phacoemulsification) as it is suctioned (aspirated) out of the eye. In another surgical method, special instruments are used to

mechanically break up the cloudy lens into small pieces (phacofracture) and remove them directly from the eye through a small incision. The surgeon will insert a plastic or silicone IOL inside the eye to replace the natural lens that was removed. Most incisions used for cataract surgery are self-sealing. However, on occasion, incisions may need to be sutured. When stitches are used, they rarely need to be removed. Cataract Surgery Recovery When the operation is over, the surgeon will usually place a protective shield over your eye. After a short stay in the outpatient recovery area, you will be ready to go home. Plan to have someone else drive you home.You will need to administer eye drops, as prescribed by your surgeon, several times daily during the next few weeks. You also will need to wear your protective eye shield while sleeping or napping, for about a week after surgery. You will be given sun shades to help protect your eye in bright light. While your eye heals, you might experience some blurred vision during the first few days or even weeks following the procedure. During at least the first week of your recovery, it is essential that you avoid: Strenuous activity and heavy lifting (nothing over 25 pounds). Bending, exercising and similar activities that might stress your eye while it is healing. Water that might splash into your eye and cause infection. Keep your eye closed while showering or bathing. Also, avoid swimming or hot tubs for at least two weeks. Any activity (such as changing cat litter boxes) that would expose your healing eye to dust, grime or other infection-causing contaminants. Although the basic postoperative instructions are similar among most eye surgeons, each surgeon may have specific recovery instructions depending on the outcome of your surgery. Always follow your surgeon's specific instructions, which you will receive prior to your discharge from the outpatient facility. Complications of Cataract Surgery Glaucoma or a buildup of pressure within the eye (intraocular pressure) also occurs sometimes after cataract surgery. If your eye pressure remains high, you may need additional treatment such as eye drops, a laser procedure, pills or additional surgery. Far more rarely, you might experience problems such as a decentered intraocular lens that might need to be repositioned or replaced in a second surgery. Various complications, ranging from minor to serious, also can take place as a direct result of the surgical procedure, including tearing of the posterior capsule holding the intraocular lens in place.

Phacoemulsification in cataract surgery involves insertion of a tiny, hollowed tip that uses high frequency (ultrasonic) vibrations to "break up" the eye's cloudy lens (cataract). The same tip is used to suction out the lens. After the eye's natural lens is removed during cataract surgery, an artificial or intraocular lens is implanted to take its place. Detached retinas also are possible in a small percentage of people who have undergone cataract surgery, particularly if they have unusually long eyes associated with higher degrees of nearsightedness.* Some eye surgeons dispute this direct association with cataract surgery, because highly nearsighted people already are at risk of getting a detached retina with or without cataract surgery. Cumulative rates of detached retinas occurring in highly myopic general populations who underwent cataract surgery or refractive lens exchange are roughly 1 percent in some studies, which is about the same risk if you never underwent a procedure. However, a common complication that creates a "secondary cataract" may require a YAG laser capsulotomy procedure. A high myope who undergoes both cataract surgery and a subsequent YAG laser capsulotomy may have a significantly greater risk of developing a detached retina.** Endophthalmitis causing widespread inflammation or infection of the eye can be a serious side effect of cataract surgery that can lead to permanent vision loss and even blindness. Various studies indicate that endophthalmitis occurs in about one out of every thousand cataract surgeries. Endophthalmitis also is more likely to be seen in people with compromised immune systems associated with conditions such as diabetes. However, even serious cataract surgery complications often can be resolved with appropriate follow-up treatments. Cataract Surgery Outcomes A comprehensive study reported in Archives of Ophthalmology in 1994 noted that 95.5 percent of healthy eyes achieved 20/40 uncorrected vision (legally acceptable for driving) or better outcomes following cataract surgery. Of the more than 17,000 eyes evaluated, fewer than 2 percent had sight-threatening complications. Bruising or a black eye can result from cataract surgery, if an injection is used to numb the eye. Remember that sight-threatening complications often are associated with individuals who are much older or who already have poor underlying health affecting how their eyes heal. Also, some people have complications because their cataracts are far more advanced or

"hardened" at the time of surgery, making them difficult to remove. A Swedish study published in the British Journal of Ophthalmology in November 1999 found that self-reported outcomes among people who had undergone cataract surgery were less satisfactory when other eye problems were present. Younger people undergoing cataract surgery reported the highest satisfaction levels. The British journal also reported study results in December 2000 indicating that people in their 60s undergoing cataract surgery were 4.6 percent more likely to achieve 20/40 uncorrected vision or better than people in their 80s Definition Phacoemulsification cataract surgery is a procedure in which an ultrasonic device is used to break up and then remove a cloudy lens, or cataract, from the eye to improve vision. The insertion of an intraocular lens (IOL) usually immediately follows phacoemulsification. PURPOSE Phacoemulsification, or phaco, as surgeons refer to it, is used to restore vision in patients whose vision has become cloudy from cataracts. In the first stages of a cataract, people may notice only a slight cloudiness as it affects only a small part of the lens, the part of the eye that focuses light on the retina. As the cataract grows, it blocks more light and vision becomes cloudier. As vision worsens, the surgeon will recommend cataract surgery, usually phaco, to restore clear vision. With advancements in cataract surgery such as the IOL patients can sometimes experience dramatic vision improvement. Demographics As people age, cataracts are likely to form. The National Eye Institute (NEI) reports in a 2002 study that more than half of all United States residents 65 and older have a cataract. People who smoke are at a higher risk for cataracts. Increased exposure to sunlight without eye protection may also be a cause. Cataracts also can occur anytime because of injury, exposure to toxins, or diseases such as diabetes. Congenital cataracts are caused by genetic defects or developmental problems, or exposure to some contagious diseases during pregnancy. However, the most common form of cataract in the United States is age related. According to the NEI, cataracts are more common in women than in men, and Caucasians have cataracts more frequently than other races, especially as people age. People who live close to the equator also are at higher risk for cataracts because of increased sunlight exposure. More than 1.5 million cataract surgeries are performed in the United

States each year. The NEI reports that the federal government, through Medicare , spends more than $3.4 billion each year treating cataracts. Cataract surgery is one of the most common surgeries performed, and also one of the safest and most effective. Phaco is currently the most popular version of cataract surgery. Description Phacoemulsification is a variation of extracapsular cataract extraction , a procedure in which the lens and the front portion of the capsule are removed. Formerly the most popular cataract surgery, the older method of extracapsular extraction involves a longer incision, about 0.4 in (10 mm), or almost half of the eye. Recovery from the larger incision extracapsular extraction also requires almost a week-long hospital stay after surgery, and limited physical activity for weeks or even months. Charles Kelman created phacoemulsification in the late 1960s. His goal was to remove the cataract with a smaller incision, less pain, and shorter recovery time. He discovered that the cataract could be broken up, or emulsified, into small pieces using an ultrasound tip. At first, phaco was slow to catch on because of its high learning curve. With its success rate and shorter recovery period, surgeons slowly learned the technique. Over the past decades, surgeons have constantly refined phaco to make it even safer and more successful. Innovations in technology such as the foldable IOL also have helped improve outcomes by allowing surgeons to make smaller incisions. During surgery, the patient will probably breathe through an oxygen tube because it might be difficult to breathe with the draping. The patient's blood pressure and heart rate also are likely to be monitored. Before making the incision, the surgeon inserts a long needle, usually through the lower eyelid, to anesthetize the area behind the eyeball. The surgeon then puts pressure on the eyeball with his or her hand or a weight to see if there is any bleeding (possibly caused by inserting the anesthetic). The pressure will stop this bleeding. This force also decreases intraocular pressure, which lowers the chances of complications. After applying the pressure, the surgeon looks through a microscope and makes an incision about 0.1 in (3 mm) on the side of the anesthetized cornea. As of 2003, surgeons are beginning to favor the temporal location for the incision because it has proved to be safer. The incision site also varies depending on the size and denseness of the cataract. Once the incision is made, a viscoelastic fluid is injected to reduce shock to the intraocular tissues. The surgeon then

makes a microscopic circular incision in the membrane that surrounds the cataract; this part of the procedure is called capsulorhexis. A water stream then frees the cataract from the cortex. The surgeon inserts a small titanium needle, or phaco tip, into the cornea. The ultrasound waves from the phaco tip emulsify the cataract so that it can be removed by suction. The surgeon first focuses on the cataract's central nucleus, which is denser. While the cataract is being emulsified, the machine simultaneously aspirates the cataract through a small hole in the tip of the phaco probe. The surgeon then removes the cortex of the lens, but leaves the posterior capsule, which is used to support the intraocular lens. The folded IOL is inserted by an injector. The folded IOL means that a larger incision is not required. After the IOL is inserted into the capsular bag, the viscoelastic fluid is removed. No sutures are usually required after the surgery. Some surgeons may recommend that patients wear an eye shield immediately after the surgery. The entire procedure takes about 20 minutes. The phaco procedure itself takes only minutes. Most surgeons prefer a certain technique for the procedure, although they might vary due to the cataract's density and size. The variations on the phaco procedure lie mostly on what part of the nucleus the surgeon focuses on first, and how the cataract is emulsified. Some surgeons In a phacoemulsification procedure, an incision is first made in the cornea, the outer covering of the eye (A). A phacoemulsification instrument uses ultrasonic waves to break up the cataract (B). Pieces of the cataract are then suctioned out (C). To repair the patient's vision, a folded intraocular lens is pushed through the same incision (D) and opened in place (E). ( Illustration by GGS Inc. ) prefer a continuous "chop," while others divide the cataract into quadrants for removal. One procedure, called the "phaco flip," involves the surgeon inverting and then rotating the lens for removal. Advances in technology also may allow for even smaller incisions, some speculate as small as 0.05 in (1.4 mm). Diagnosis/Preparation People might have cataracts for years before vision is impaired enough to warrant surgery. Eye doctors may first suggest eyeglasses to temporarily help improve vision. But as the lens grows cloudier, vision deteriorates. As cataracts develop and worsen, patients may notice these common symptoms: gradual (and painless) onset of blurry vision poor central vision

 frequent changes in prescription for corrective lenses increased glare from lights near vision improvement to the point where reading glasses may no longer be needed poor vision in sunlight Cataracts grow faster in younger people or diabetics, so doctors will recommend surgery more quickly in those cases. Surgery may also be recommended sooner if the patient suffers from other eye diseases such as agerelated macular degeneration and if the cataract interferes with complete eye examination. When symptoms worsen to the point that everyday activities become problematic, surgery becomes necessary. A complete ocular exam will determine the severity of the cataract and what type of surgery the patient will receive. For some denser cataracts, the older method of extracapsular extraction is preferred. The diagnostic exam should include measurement of visual acuity under both low and high illumination, microscopic examination of eye structures and pupil dilation, assessment of visual fields, and measurement of intraocular pressure (IOP). If cataracts are detected in both eyes, each must be treated separately. Overall patient health must also be considered, and how it will affect the surgery's outcome. Surgeons may recommend a complete physical examination before surgery. Although preoperative instructions may vary, patients are usually required not to eat or drink anything after midnight the day of the surgery. Patients must disclose all medications to determine if they must be discontinued before surgery. Patients taking aspirin for blood thinning usually are asked to stop for two weeks before surgery. Blood-thinning medications may put patients at risk for intraocular bleeding or hemorrhage. Coumadin, the prescription medicine for blood thinning, might still be taken if the risk for stroke is high. People should consult with their eye doctor and internist to decide the best course of action. An A-scan measurement, which determines the length of the eyeball, will be performed. This helps determine the refractive power of the IOL. Other pre-surgical testing such as a chest x ray , blood work, or urinalysis may be requested if other medical problems are an issue. The surgeon may also request patients begin using antibiotic drops before the surgery to limit the chance of infection. Cataract surgery is done on an outpatient basis, so patients must arrange for someone to take them home after surgery. On the day of the surgery, doctors will review the pre-surgical tests and insert dilating eye drops, antibiotic drops, and a corticosteriod or nonsteroidal anti-inflammatory drop. Anesthetic eye drops will be given in both eyes to keep both eyes comfortable during surgery. A

local anesthetic will be administered. Patients are awake for the surgery, but are kept in a relaxed state. The patient's eye is scrubbed prior to surgery and sterile drapes are placed over the shoulders and head. The patient is required to lie still and focus on the light of the operating microscope. A speculum is inserted to keep the eyelids open. Aftercare Immediately following surgery, the patient is monitored in an outpatient recovery area. The patient is advised to rest for at least 24 hours, until he or she returns to the surgeon's office for follow-up. Only light meals are recommended on the day of surgery. The patient may still feel drowsy and may experience some eye pain or discomfort. Usually, over-the-counter medications are advised for pain relief, but patients should check with their doctors to see what is recommended. Other side effects such as severe pain, nausea, or vomiting should be reported to the surgeon immediately. There will be some changes in the eye during recovery. Patients may see dark spots, which should disappear a few weeks after surgery. There also might be some discharge and itching of the eye. Patients may use a warm, moist cloth for 15 minutes at a time for relief and to loosen the matter. All matter should be gently cleared away with a tissue, not a fingertip. Pain and sensitivity to light are also experienced after surgery. Some patients may also have slight drooping or bruising of the eye which will improve as the eye heals. Patients have their first postoperative visit the day after surgery. The surgeon will remove the eye shield and prescribe eye drops to prevent infections and control intraocular pressure. These eye drops are used for about a month after surgery. Patients are advised to wear an eye shield while sleeping, and refrain from rubbing the eye for at least two weeks. During that time, the doctor will give the patient special tinted sunglasses or request that he or she wear current prescription eyeglasses to prevent possible eye trauma from accidental rubbing or bumping. Unlike other types of cataract extraction, patients can resume normal activity almost immediately after phaco. Subsequent exams are usually at one week, three weeks, and six to eight weeks following surgery. This can change, however, depending on any complications or any unusual postoperative symptoms. After the healing process, the patient will probably need new corrective lenses, at least for close vision. While IOLs can remove the need for myopic correction, patients will probably need new lenses for close work. Risks

Complications are unlikely, but can occur. Patients may experience spontaneous bleeding from the wound and recurrent inflammation after surgery. Flashing, floaters, and double vision may also occur a few weeks after surgery. The surgeon should be notified immediately of these symptoms. Some can easily be treated, while others such as floaters may be a sign of a retinal detachment. Retinal detachment is one possible serious complication. The retina can become detached by the surgery if there is any weakness in the retina at the time of surgery. This complication may not occur for weeks or months. Infections are another potential complication, the most serious being endophthalmitis, which is an infection in the eyeball. This complication, once widely reported, is much more uncommon today because of newer surgery techniques and antibiotics . Patients may also be concerned that their IOL might become displaced, but newer designs of IOLs also have limited reports of intraocular lens dislocation. Other possible complications are the onset of glaucoma and, in very rare cases, blindness. It is possible that a secondary cataract may develop in the remaining back portion of the capsule. This can occur for as long as one to two years after surgery. YAG capsulotomy, using a laser, is most often used for the secondary cataract. This outpatient procedure requires no incision. The laser makes a small opening in the remaining back part of the lens to allow light to penetrate. Normal results Most patients have restored visual acuity after surgery, and some will have the best vision of their lives after the insertion of IOLs. Some patients will no longer require the use of eyeglasses or contact lenses after cataract surgery. Patients will also have better color and depth perception and be able to resume normal activities they may have stopped because of impaired vision from the cataract, such as driving, reading, or sports. Morbidity and mortality rates Phacoemulsification has taken the previous risks from cataract surgery, making it a much safer procedure. Before phacoemulsification, death after cataract surgery was still rare, but usually stemmed from the possible complications of general anesthesia. Phaco is performed under local anesthesia, limiting the risk of general anesthetic use. Other serious complications such as blindness also have been reduced with the widespread use of phaco. Better antibiotics have enabled physicians to combat former debilitating infections that previously would have caused blindness.

Alternatives Some older methods of cataract surgery may have to be used if the cataract is too large to remove with a small incision, including: Extracapsular cataract extraction. While phaco is considered a type of extracapsular extraction, the older version of this technique requires a much larger incision and does not use the phaco machine. It is similar in that the lens and the front portion of the capsule are removed and the back part of the capsule remains. The surgeon might consider this technique if the patient has corneal disease or if the pupil becomes too small during the first stages of surgery. Intracapsular cataract extraction. This also requires a larger incision than phaco. It differs in that the lens and the entire capsule are removed. While it is the easiest cataract surgery for the surgeon technically, this method carries an increased risk for the patient with increased potential for detachment of the retina and swelling after surgery. Recovery is long and most patients will have to use large "cataract glasses" to see. The incision size for phaco surgery The incision size for phaco surgery is 3.0 - 3.2mm, however foldable iols are in the market which can be inserted through a 1.6 - 3.0mm incision. If a lens implant that can be folded is used following removal of the cataract, this incision may not have to be enlarged. If a conventional PMMA iol is used, which can not be folded, the incision must be enlarged to minimal 5.5mm and sutured for closure after insertion of the intraocular lens. he technique of phaco surgery The technique of phacoemulsification surgery utilizes a small incision. The tip of the U/S hand piece instrument is introduced into the eye through this small incision. Localized high frequency waves are generated through this tip to break the cataract into very tiny fragments and pieces, which are then sucked out through the same tip in a controlled manner. A thin 'capsule' or shell is left behind after cleaning up of the entire opaque cataract. ECCE Extracapsular cataract extraction (ECCE) is a category of eye surgery in which the lens of the eye is removed while the elastic capsule that covers the lens is left partially intact to allow implantation of an

intraocular lens (IOL). This approach is contrasted with intracapsular cataract extraction (ICCE), an older procedure in which the surgeon removed the complete lens within its capsule and left the eye aphakic (without a lens). The patient's vision was corrected after intracapsular extraction by extremely thick eyeglasses or by contact lenses. There are two major types of ECCE: manual expression, in which the lens is removed through an incision made in the cornea or the sclera of the eye; and phacoemulsification, in which the lens is broken into fragments inside the capsule by ultrasound energy and removed by aspiration. In extracapsular cataract extraction, an incision is made in the eye just beneath the iris, or colored part (A). The diseased lens is pulled out (B). A prosthetic intraocular lens is placed through the incision (D), and is opened to replace the old lens (E). ( Illustration by GGS Inc. Conventional extracapsular cataract extraction Although phacoemulsification has become the preferred method of extracapsular extraction for most cataracts in the United States since the 1990s, conventional or standard ECCE is considered less risky for patients with very hard cataracts or weak epithelial tissue in the cornea. The ultrasound vibrations that are used in phacoemulsification tend to stress the cornea. A conventional extracapsular cataract extraction takes less than an hour to perform. After the area around the eye has been cleansed with antiseptic, sterile drapes are used to cover most of the patient's face. The patient is given either a local anesthetic to numb the tissues around the eye or a topical anesthetic to numb the eye itself. An eyelid holder is used to hold the eye open during the procedure. If the patient is very nervous, the doctor may administer a sedative intravenously. After the anesthetic has taken effect, the surgeon makes an incision in the cornea at the point where the sclera and cornea meet. Although the typical length of a standard ECCE incision was 1012 mm in the 1970s, the development of foldable acrylic IOLs has allowed many surgeons to work with incisions that are only 56 mm long. This variation is sometimes referred to as small-incision ECCE. After the incision is made, the surgeon makes a circular tear in the front of the lens capsule; this technique is known as capsulorrhexis. The surgeon then carefully opens the lens capsule and removes the hard nucleus of the lens by applying pressure with special instruments. After the nucleus has been expressed, the surgeon uses suction to remove the softer cortex of the lens. A special viscoelastic material

is injected into the empty lens capsule to help it keep its shape while the surgeon inserts the IOL. After the intraocular lens has been placed in the correct position, the viscoelastic substance is removed and the incision is closed with two or three stitches. Phacoemulsification In phacoemulsification, the surgeon uses an ultra-sound probe inserted through the incision to break up the nucleus of the lens into smaller pieces. The newer technique offers the advantages of a smaller incision than standard ECCE, fewer or no stitches to close the incision, and a shorter recovery time for the patient. Its disadvantages are the need for specialized equipment and a steep learning curve for the surgeon. One study found that surgeons needed to perform about 150 cataract extractions using phacoemulsification before their complication rates fell to a baseline level. Diagnosis/Preparation Diagnosis The diagnosis of cataract is usually made when the patient begins to notice changes in his or her vision and consults an eye specialist. In contrast to certain types of glaucoma, there is no pain associated with the development of cataracts. The specific changes in the patient's vision depend on the type and location of the cataract. Nuclear cataracts typically produce symptoms known as myopic shift (in nearsighted patients) and second sight (in farsighted patients). What these terms mean is that the nearsighted person becomes more nearsighted while the farsighted person's near vision improves to the point that there is less need for reading glasses. Cortical and posterior subcapsular cataracts typically reduce visual acuity; in addition, the patient may also complain of increased glare in bright daylight or glare from the headlights of oncoming cars at night. Because visual disturbances may indicate glaucoma as well as cataracts, particularly in older adults, the examiner will first check the intraocular pressure (IOP) and the anterior chamber of the patient's eye. The examiner will also look closely at the patient's medical history and general present physical condition for indications of diabetes or other systemic disorders that affect cataract development. The next step in the diagnostic examination is a test of the patient's visual acuity for both near and far distances, commonly known as the Snellen test. If the patient has mentioned glare, the Snellen test will be conducted in a brightly lit room. The examiner will then check the patient's eyes with a slit lamp in order to evaluate the location and size of the cataract. After the patient's eyes have been dilated with eye drops, the slit lamp can also be used to check the other structures of the eye for any indications of metabolic disorders or previous eye injury. Lastly, the

examiner will use an ophthalmoscope to evaluate the condition of the optic nerve and retina at the back of the eye. The ophthalmoscope can also be used to detect the presence of very small cataracts. Imaging studies of the eye (ultrasound, MRI, or CT scan) may be ordered if the doctor cannot see the back of the eye because of the size and density of the cataract. Preparation ECCE is almost always elective surgeryemergency removal of a cataract is performed only when the cataract is causing glaucoma or the eye is severely injured or infected. After the surgery has been scheduled, the patient will need to have special testing known as keratometry if an IOL is to be implanted. The testing, which is painless, is done to determine the strength of the IOL needed. The ophthalmologist measures the length of the patient's eyeball with ultrasound and the curvature of the cornea with a device called a keratometer. The measurements obtained by the keratometer are entered into a computer that calculates the correct power for the IOL. The IOL is a substitute for the lens in the patient's eye, not for corrective lenses. If the patient was wearing eyeglasses or contact lenses before the cataract developed, he or she will continue to need them after the IOL is implanted. The lens prescription should be checked after surgery, however, as it is likely to need adjustment. Aftercare Patients can use their eyes after ECCE, although they should have a friend or relative drive them home after the procedure. The ophthalmologist will place some medicationsusually steroids and antibioticsin the operated eye before the patient leaves the office. Patients can go to work the next day, although the operated eye will take between three weeks and three months to heal completely. At the end of this period, they should have their regular eyeglasses checked to see if their lens prescription should be changed. Patients can carry out their normal activities within one to two days of surgery, with the exception of heavy lifting or extreme bending. Most ophthalmologists recommend that patients wear their eyeglasses during the day and tape an eye shield over the operated eye at night. They should wear sunglasses on bright days and avoid rubbing or bumping the operated eye. In addition, the ophthalmologist will prescribe eye drops for one to two weeks to prevent infection, manage pain, and reduce swelling. It is important for patients to use these eye drops exactly as directed. Patients recovering from cataract surgery will be scheduled for frequent checkups in the first few weeks following ECCE. In most cases, the ophthalmologist will check the patient's eye the day after

surgery and about once a week for the next several weeks. About 25% of patients who have had a cataract removed by either extracapsular method will eventually develop clouding in the lens capsule that was left in place to hold the new IOL. This clouding, which is known as posterior capsular opacification or PCO, is not a new cataract but may still interfere with vision. It is thought to be caused by the growth of epithelial cells left behind after the lens was removed. PCO is treated by capsulotomy, which is a procedure in which the surgeon uses a laser to cut through the clouded part of the capsule. Risks The risks of extracapsular cataract extraction include: Edema (swelling) of the cornea. A rise in intraocular pressure (IOP). Uveitis. Uveitis refers to inflammation of the layer of eye tissue that includes the iris. Infection. Infection of the external eye may develop into endophthalmitis, or infection of the interior of the eye. Hyphema. Hyphema refers to the presence of blood inside the anterior chamber of the eye and is most common within the first two to three days after cataract surgery. Leaking or rupture of the incision. Retinal detachment or tear. Malpositioning of the IOL. This complication can be corrected by surgery. Cystoid macular edema (CME). The macula is a small yellowish depression on the retina that may be affected after cataract surgery by fluid collecting within the tissue layers. The patient typically experiences blurring or distortion of central vision. CME rarely causes loss of sight but may take between two and 15 months to resolve completely. Normal results Extracapsular cataract extraction is one of the safest and most successful procedures in contemporary eye surgery; about 95% of patients report that their vision is substantially improved after the operation. In the words of a British ophthalmologist, "The only obstacle lying between cataract sufferers and surgical cure is resource allocation." Morbidity and mortality rates Mortality as a direct result of cataract surgery is very rare. On the other hand, several studies have indicated that patients over the age of 50 who undergo cataract extraction have higher rates of mortality in the year following surgery than other patients in the same age group who have other types of elective surgery . Some researchers have

interpreted these data to imply that cataracts related to the aging process reflect some kind of systemic weakness rather than a disorder limited to the eye. About 23% of patients who have undergone cataract extraction have a postoperative complication. The majority of these, however, are not vision-threatening. The most common complication is swelling of the cornea (9.5%), followed by raised IOP (7.9%); uveitis (5.6%); leaking from the incision (1.2%); hyphema (1.1%); external eye infection (0.06%); endophthalmitis (0.03%); retinal detachment (0.03%); retinal tear (0.02%), and CME (0.017%). Of these complications, only endophthalmitis and retinal detachment or tear are considered potentially vision-threatening. Standard ECCE and phacoemulsification have very similar success rates and complication rates when performed by surgeons of comparable skill and length of experience. Alternatives Medical treatment As of 2003 there are no medications that can prevent or cure cataracts. Many ophthalmologists, however, recommend a well-balanced diet as beneficial to the eyes as well as the rest of the body, on the grounds that some studies suggest that poor nutritional status is a risk factor for cataract. While vitamin supplements do not prevent cataracts, there is some evidence that an adequate intake of vitamins A, C, and E helps to slow the rate of cataract progression. Elderly people who may be at risk of inadequate vitamin intake due to loss of appetite and other reasons may benefit from supplemental doses of these vitamins. Watchful waiting Not all cataracts need to be removed. A patient whose cataracts are not interfering with his or her normal activities and are progressing slowly may choose to postpone surgery indefinitely. It is important, however, to have periodic checkups to make sure that the cataract is not growing in size or density. In the recent past, surgeons often advised patients to put off surgical treatment until the cataract had "ripened," which meant that the patient had to wait until the cataract had caused significant vision loss and was interfering with reading, driving, and most daily activities. At present, ophthalmologists prefer to remove cataracts before they get to this stage because they are harder and consequently more difficult to remove. In addition, a rapidly growing cataract that is not treated surgically may lead to swelling of the lens, secondary glaucoma, and eventual blindness. In most cases, however, it is up to the patient to decide when the cataract is troublesome enough to schedule surgery.

Surgical alternatives The major surgical alternative to ECCE is intracapsular cataract extraction, or ICCE. It is rarely performed at present in Europe and North America, but is still done in countries where operating microscopes and high-technology equipment are not always available. In ICCE, the surgeon makes an incision about 150 degrees of arc, or about half the circumference of the cornea, in order to extract the lens and its capsule in one piece. The surgeon then inserts a cryoprobe, which is an instrument for applying extreme cold to eye tissue. The cryoprobe is placed on the lens capsule, where it freezes into place. It is then used to slowly pull the capsule and lens together through the long incision around the cornea. Because of the length of the incision needed to perform ICCE and the pressure placed on the vitreous body, the procedure has a relatively high rate of complications. In addition, the recovery period is much longer than for standard ECCE or phacoemulsification. CLOSED REDUCTION - reduction of a fractured bone by manipulation without incision into the skin Reduction is the positioning a bone or bones to their normal position after a fracture or dislocation. The goals of a reduction are to restore position (alignment, rotation, and length) to the bone or joint, to decrease pain, to prevent later deformity, and to encourage healing and normal use of the bone and limb. In the case of a fracture, it is also important for the bone ends to meet correctly (apposition). If a fracture is described as "nondisplaced" or in "anatomic position," no reduction maneuver to improve position can be performed, since the fracture is already in perfect position. When a bone breaks, a blood clot (hematoma) forms around the ends of the fragments. The tough outer sheath of the bone (periosteum) is usually intact on one side of the fracture, forming a hinge between the fragments, unless the bone has broken through the skin (open fracture or compound fracture). The muscles that are attached to the bone contract or shorten during the early period after a fracture causing the bones to overlap and rotate. Contraction usually continues to hold the fragments out of position. A closed reduction is accomplished by applying traction at or across the fracture to relax and lengthen the muscles then manipulating the bone fragments back into position and holding this newly achieved position with a cast or splint. No skin incision is required in the closed reduction procedure. Although many fractures are reduced using sedation or local or regional anesthesia in an emergency department or physician office, some individuals must be given general anesthesia in the operating room in

order to provide pain control and muscle relaxation. An open reduction involves the same concepts but is done as a surgical procedure for fractures that cannot be reduced or held in reduced position by closed reductions. Usually internal fixation of the fracture is performed during the same operation as the open reduction. Open reductions are also necessary to treat an open fracture or compound fracture, as open wounds must be cleaned, dead tissue and foreign material removed (dbridement), and then repaired. Sometimes fractures that are initially reduced in a closed procedure need to be reduced again in an open procedure and then stabilized with hardware (open reduction, internal fixation) because a cast or splint cannot maintain the desired position. If the bones in a joint are intact but out of position (dislocated), a closed reduction is usually attempted first. When traction is applied to overcome muscle spasm and regain muscle length, the bone will often slip back into place (closed reduction). Sometimes pressure must also be applied to guide the bones into correct position (manipulative reduction). Muscle spasm is often difficult to overcome without pain control (analgesia) and/or sedation, including sedation in an emergency room or the use of general anesthesia in the operating room. Some dislocated joints commonly require open reduction (e.g., finger MCP joints, hip joints with fracture fragments in the joint). The longer a joint is dislocated, the more difficult it is to reduce due to muscle spasm. Fractures and dislocations often occur at the same time (fracture-dislocation), and both problems must be addressed. Spontaneous reductions can occur with partial dislocation (subluxation) of a joint in which contact between joint surfaces remains, but not with fractures or complete dislocations such as shoulder dislocations and patella dislocations. An example of a spontaneous reduction is when the individual is able to relax the area and allow the bones to slip back into position, as occurs commonly with a shoulder subluxation. Individuals can also do self-reduction by learning maneuvers that physicians do to reduce dislocations. After returning the joint to anatomical alignment, joint reductions can be stable or unstable. With stable reductions, the joint does not re-dislocate when performing joint range of motion. This type of injury is often maintained with brief immobilization and gradual return to activities. Both rest and immobilization can be obtained with devices ranging from slings, casts, and traction, to internal or external fixation. With unstable reductions, the joint continues to pop out or re-dislocate after the reduction. This type of injury may require surgery or special splints to maintain reduction and allow for healing.

Fractures almost always require some type of support, splinting, or surgery to maintain alignment and allow for healing. The need for a fracture reduction or reduction of a dislocation is not sex or age specific, but rather is dependent on the severity of the injury. Care must be taken not to overlook the need for correct restoration of bone and joint position (reduction) to ensure complete return of function. Seemingly minor injuries to toes and fingers for example can be debilitating if not managed correctly. Reason for procedure Reductions are performed to restore anatomical position of bones and soft tissue after a fracture or dislocation. This promotes normal function after the fractured bone or dislocated joint and/or the supporting tissue heals. Attention is given to the nerves and blood vessels in the injured area as these can be damaged during the injury or during reduction. Treatment of the fracture or dislocation may involve treatment of damaged nerves and blood vessels as well How Procedure is performed In a closed fracture reduction, after examination of the skin, nerve function, and circulation, an x-ray is taken to determine the current position of the fracture fragments. Often an x-ray of the opposite or uninjured side is also taken and used as a guide during the reduction. Local or regional anesthesia, or sedation, may be used to control pain and to promote muscle relaxation. The physician applies pressure above and below the fracture, often with assistance by a person or device to maintain traction on the muscles around the fracture. First, the fragments are bent in the direction of the fracture (slightly exaggerating the deformity) and then lifted into correct position. Position is first maintained manually while nerve and tendon function and circulation are checked. A cast or splint is then used to hold the bone fragments in correct position. A final x-ray confirms position of the fragments. If alignment is not correct, the procedure may be repeated or the individual scheduled for an open reduction with possible fixation of the fragments. Repeat x-rays and changes of the cast are done over the next several weeks because the reduction may move out of position (slip) or the bone may begin to heal incorrectly. Initially a splint or half cast may be used to avoid problems with swelling. A full cast is applied after the swelling has decreased, often after 7 to 10 days. Closed reductions are most often done in the emergency room, physician's office, or outpatient surgical setting. An open reduction or open reduction, internal fixation (ORIF) is done when

a closed reduction is not possible or when the fracture is complicated by a wound. This is an in-patient or outpatient surgical procedure performed in the operating room. An incision is made over the fracture, wounds are cleaned, and the fracture position is corrected with pressure. Sometimes the reduced position is maintained with orthopedic hardware such as screws, plates and rods, placed through or around the fracture fragments (internal fixation). An external fixator device may be used to maintain position. The fixator is composed of pins or rods through the skin and bone, and the free end of the rods are then attached to a long bar on the outside of the skin. This device can allow for early motion of the joints above and/or below the fracture. It is always eventually removed, often in the physician's office, while internal hardware may be left in place. If internal hardware is to be removed, another surgical procedure is required. In reducing dislocations, x-rays are done first to confirm position of the bones and to rule out a fracture combined with the dislocation. If there is only a dislocation, medication is given to control pain and relax the muscles around the dislocation. Gentle stretch or traction is then applied to the muscles, and the bones either slip into position or are eased into place with pressure from the physician's hands. These techniques can be done in the emergency room or doctor's office. Sometimes, it is necessary to take the individual to the operating room for general anesthesia to obtain enough muscle relaxation to manipulate the bones into correct position. Slings or braces are used to rest the joint after reduction. If the reduction is not maintained, surgery (open reduction) may be required to tighten or strengthen surrounding tissue. External fixation rarely is used to maintain the corrected position, employing the open reduction, internal fixation (ORIF) procedure, which is more commonly used for fracture fixation. Prognosis The outcome of a closed or open reduction depends on the type of injury and the treatment needed to maintain the reduction and the healing of bone and supporting tissue (joint capsule, tendons, ligaments, and muscles). Generally, fractures and dislocations can be re-positioned (reduced) but this may not always be a simple, straightforward procedure. Once the reduction is complete, the healing phase may involve treatment over several months. Any complication regarding nerves or blood vessels will delay healing and may contribute to a poor outcome. For fractures that involve joints (intra-articular fractures), the more comminuted (broken into multiple fracture pieces) the joint surface and the greater joint surface deformity present after the fracture has healed, the worse the prognosis for the development of late post-traumatic arthritis of the joint. Fractures that do not involve joints but that heal with significant deformity change biomechanics of the limb and may lead to post-traumatic

arthritis of adjacent joints. Some bones such as those in the wrist (scaphoid and lunate) and hip (femoral head) have a poor blood supply to begin with and historically do not heal well. Individuals with loose tissue (laxity) have a higher incidence of recurrent dislocation, as do those with anatomical variations such as tilted kneecaps (patellar misalignment). Joints that remain dislocated for a long time have a less successful outcome. Rehabilitation Rehabilitation after reduction of a fracture or dislocation begins after some healing has occurred. The primary focus is to restore function, regain strength, and relieve pain. The time and techniques involved are dependent upon the location and type of injury, treatment used, and stability of the fracture/dislocation. Once the dislocation or fracture has been reduced, the therapist may utilize modalities, such as heat or cold, to decrease pain and edema (Braddom). Exercises are initiated according to the recommendations of the treating physician and based on tissue healing. Therapy should begin with gentle range of motion and progress to strengthening exercises as tolerated. Intensity and duration of exercises should be advanced as indicated. A home exercise program should be taught to the individual to complement supervised rehabilitation. All rehabilitation should be directed toward returning the individual to preinjury status. Additional information may provide insight into the rehabilitation needs of these individuals (Chapman). Complications Complications associated with reductions of fractures and dislocations include failure to obtain reduction, nerve or blood vessel damage, puncture of the skin, infection of the fracture wound or surgical wound, infection in the bone or bone marrow (osteomyelitis), and reflex sympathetic dystrophy (complex regional pain syndrome). Blood clots formed at the site of injury can dislodge and migrate to the lung (embolism). An open fracture is at greater risk of development of complications than a fracture that does not break the skin or a dislocation. Any complication involving nerves or blood vessels will delay healing and may contribute to a poor outcome. Knee dislocations with vascular complications may result in leg amputation. Advanced age and pre-existing chronic conditions (e.g., diabetes,

osteoarthritis, or osteoporosis) can complicate and/or delay healing. Reactions to anesthesia may occur in some individuals. Repeat surgery sometimes is needed if healing does not occur properly. Fractures that have not healed in the expected time period for the fracture in question are called "delayed union." Fractures that have not healed, and that are no longer biologically active in the healing process are called "non union."
Discussion: (distal radius fracture menu) - closed reduction & immobilization in plaster cast remains accepted method of treatment for majority of stable distal radius frx; - unstable fractures will often lose reduction in the cast and will slip back to the pre-reduction position; - patients should be examined for carpal tunnel symptoms before and after reduction; - carpal tunnel symptoms that do not resolve following reduction will require carpal tunnel release; - cautions: - The efficacy of closed reduction in displaced distal radius fractures. - Technique: - anesthesia: (see: anesthesia menu) - hematoma block w/ lidocaine; - w/ hematoma block surgeon should look for "flash back" of blood from hematoma, prior to injection; - references: - Regional anesthesia preferable for Colles' fracture. Controlled comparison with local anesthesia. - Neurological complications of dynamic reduction of Colles' fractures without anesthesia compared with traditional manipulation after local infiltration anesthesia. - methods of reduction: - Jones method: involves increasing deformity, applying traction, and immobilizing hand & wrist in reduced position; - placing hand & wrist in too much flexion (Cotton-Loder position) leads to median nerve compression & stiff fingers; - Bohler advocated longitudinal traction followed by extension and realignment; - consider hyper-extending the distal fragment, and then translating it distally (while in extended position) until it can be "hooked over" proximal fragment; - subsequently, the distal fragment can be flexed (or hinged) over the proximal shaft fragment; - closed reduction of distal radius fractures is facilitated by having an assistant provide counter traction (above the elbow) while the surgeon controls the distal fragment w/ both hands (both thumbs over the dorsal surface of the distal fragment); - flouroscopy:

- it allows a quick, gentle, and complete reduction; - prepare are by prewrapping the arm w/ sheet cotton and have the plaster or fibroglass ready; - if flouroscopy is not available, then do not pre-wrap the extremity w/ cotton; - it will be necessary to palpate the landmarks (outer shaped of radius, radial styloid, and Lister's tubercle, in order to judge success of reduction; - casting: - generally, the surgeon will use a pre-measured double sugar sugar tong splint, which is 6-8 layers in thickness; - more than 8 layers of plaster can cause full thickness burns: - references: Setting temperatures of synthetic casts. - position of immobilization: - follow up: - radiographs: - repeat radiographs are required weekly for 2-3 weeks to ensure that there is maintenance of the reduction; - a fracture reduction that slips should be considered to be unstable and probably require fixation with (pins, or ex fix ect.) - there is some evidence that remanipulation following fracture displacement in cast is not effective for these fractures; - ultimately, whether or not a patient is satisfied with the results of non operative treatment depends heavily on their personal expectations, non dominant side, and functional status; - hence, younger patients w/ involvement of dominant side, moderately high functional demands, and high expections for outcome may not be satisfied with non operative care;

Closed reduction is a method used for treating fractures in which the physician manipulates the fractured bones from the outside of the body to correctly position them without making an incision to access the site of the fracture. This method of fracture treatment is preferred in many settings and it will be tried first in some cases even if a doctor fears that surgical treatment may be required. Closed reductions can be used to treat not just fractures, but also dislocations. In a closed reduction, the physician takes x-rays to visualize the bone and to determine the nature and position of the fracture. Analgesic medications are given to the patient to make him or her more comfortable, and then the doctor, usually an orthopedic surgeon, carefully manipulates the bones to fit them back together. Once the surgeon is satisfied that the bones are aligned properly, they are immobilized so that they can begin the process of knitting back together. Once a closed reduction is complete, a second x-ray is taken to confirm that the bones

are properly placed. This is important because if they are not positioned appropriately they will heal improperly. The bones may still heal improperly or shift during healing, which usually leads to a situation in which a patient must have surgery. Poorly healed fractures can cause complications such as limb shortening and joint weakness. Patients usually experience a significant reduction in pain once a fracture has been reduced. There are a number of advantages to a closed reduction. This type of treatment is less invasive, which can speed healing time. It is less likely to expose the patient to the risk of infection, because the skin is not broken, and it will not leave scars behind, which can be a concern for some patients. However, closed reduction is not always appropriate. Sometimes a fracture needs to be repaired surgically because it is complex. Usually a surgeon can determine from x-rays whether or not surgery is necessary. If the surgeon is not sure, a closed reduction may be attempted first to see if the situation can be resolved that way. Before doing this, the surgeon has to weigh the risks and benefits of attempting a closed reduction. One risk may be the risk of increased injuries to the patient incurred during a closed fracture reduction. If this risk is high, the surgeon may suggest proceeding directly to surgery.

OPEN REDUCTION -reduction of a fractured bone by manipulation after incision into skin and muscle over site of fracture