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An effective self-retaining retractor for limb surgery
Short reports and correspondence
705
flap is difficult. This device can be bent and shaped to match the lower incision (Fig. 1). Following the dissection, the upper flap is pulled caudally, the ruler is placed on the upper flap and the incision site is marked. Thereby, the correct excision is performed. 2. The ruler has printed millimetric markings; therefore it can be used to measure curved surfaces. 3. In breast operations, the ruler can be used to make measurements (Fig. 2) or to squeeze the breast (as a mammostat) and enable easier de-epithelisation under tension.
References
The ruler can be sterilised repeatedly with ethylene oxide, maintaining its flexibility and the printed markings. It can be obtained from many shops that sell equipment for engineering or architecture.
An effective self-retaining retractor for limb surgery
Yours faithfully, O r h a n (~izmeci MD, Professor in Plastic and Reconstructive Surgery Ufuk Emekli MD, Associate Professor in Plastic and Reconstructive Surgery Serdar Tuncer MD, Resident in Plastic and Reconstructive Surgery Department of Plastic and Reconstructive Surgery, University of Istanbul Medical Faculty, Istanbul, Turkey.
1. Georgeu G, Putnis S, Pereira J. Gillies forceps diathermy burns. Br J Plast Surg 2002; 55: 263. 2. Willson PD, van der Walt JD, Moxon D, Rogers J. Port site electrosurgical (diathermy) burns during surgical laparoscopy. Surg Endosc 1997; 11: 653--4.
doi: 10.1054/bjps.2002.3945 i
Sir, A simple retractor to facilitate exposure for limb surgery can be readily and cheaply made from 1 mm-thick malleable copper sheet, using the design shown in Fig. 1. The tips of the arms are thinned to about 0.5mm to increase their malleability, allowing them to be bent into broad hooks which retract the wound edges in the appropriate directions with minimal trauma. The stern prevents the retractor from twisting and dislocating the tips out of the wound. The instrument can be easily moulded to fit specific sites, and, unlike hand-held or scissoraction retractors, has limbs that can be pressed flush with the
References 1. Erk Y, Kaytkcm~lu A. A method for developing individualized wise keyhole patterns: an aid in reduction mammaplasty for asymmetric breast. Plast Reconstr Surg 2000; 106: 226-7. 2. Giraldo F, Bergero T, Esteva I. A simple way to make a vaginal measurer. Plast Reconstr Surg 2001; 107:2170-1.
doi:10.1054/bjps.2002.3954
Capacitance coupling and diathermy burns
Figure 1--The retracto~
Sir, I read with interest the recent article describing Gillies forceps puncturing operating gloves, resulting in diathermy burns when using them to hold blood vessels. 1 I thank the authors for bringing this to our attention. I would like to propose a different theory to explain the 'hole in the glove and the diathermy burn' scenario. When using non-insulated forceps, such as Gillies forceps, to pick up blood vessels, which are then 'touched' with a diathermy probe, a phenomenon known as capacitance coupling may occur. This is where two conductors (forceps and the surgeon's fingers) are separated by an insulator (the surgical glove), with a resultant build-up of charge, leading to current passing into the finger of the user. This may cause a hole to be 'blown' in the glove, leading the surgeon to believe that the glove was punctured prior to the burn. The phenomenon of capacitance coupling is well known in laparoscopic surgery, where insulated diathermy probes are used inside metal cannulae, and may result in skin burns.2 For this reason, many surgeons in our unit use insulated forceps rather than Gillies forceps to pick up vessels, which can then be safely 'touched' by the diathermy probe. Yours faithfully, D a r r e n L. Chester MRCS, Registrar in Plastic Surgery Department of Plastic Surgery, Selly Oak Hospital, Raddlebarn Road, Selly Oak, Birmingham B29 6JD, UK.
Figure 2--Retraction of the skin edges during dissection of a wrist.
706 skin so that there are no projections to snag sutures or obstruct access (Fig. 2). This is particularly important in microsurgery, where instruments are wielded close to the surface of the wound. Copper is inert, cheap, easily autoclaved and has long been used in the production of malleable spatulas for retraction of the brain during neurosurgical procedures, and the soft tissues during maxillofacial procedures. Suzuki et al. described moulding a copper spatula into a self-retaining arch, the limbs of which push the intracranial and extracranial structures away from each other) Doi and Ogawa attached malleable copper spatulas to the limbs of a traditional self-retainer.2 However, the bodies of these retractors compromise access to the surgical site. In our design, as with the 'lead hand' commonly used as a digital retractor, the body of the instrument is held out of the way beneath the limb. Contact allergy is unlikely to a problem. 3 We have used the retractor to good effect in the upper limb, particularly when exploring traumatic wounds and performing microsurgery. A larger version has also proved useful in exposure and microsurgery of the posterior tibial vessels. Yours faithfully,
Dominique Moloney, DPhil, FRCS, Specialist Registrar in Plastic Surgery,
Peter Arnstein, FRCS (Plast,), Consultant Plastic Surgeon, Department of plastic and reconstructive surgery, Queen Victoria Hospital, Holteye Road, East Grinstead, West Sussex RH19 3DZ, UK.
References 1. Suzuki S, Sobata E, Ogane K, Sekiya T, Iwabuchi T. A simple self-retaining cerebral retractor. Acta Neurochir (Wien) 1989; 100: 87-8. 2. Doi H, Ogawa Y. A new malleable self-retaining retractor. Ann Plast Surg 1997; 38: 543-5. 3. Morris A, English J. Copper is unlikely to cause contact allergy. BMJ 1998; 316: 1902-3.
doi:10.1054/bjps.2002.3944
UK guidelines for the management of cutaneous melanoma Sir, We read with interest the recent article 'UK guidelines for the management of cutaneous melanoma'. 1 We are, however, surprised at some of the recommendations. The recommendation for a 1-2 cm excision margin in the 1-2 mm turnout-thickness group has level 1, grade A evidence. We believe that this is still controversial. The 1991 World Health Organization Melanoma Group study by Veronesi and Cascinelli involved a prospective randomised trial of 612 patients with stage I cutaneous melanoma not greater than 2 mm thick, comparing 1 cm and 3 cm excision margins. They noted increased local recurrence in the narrow-margin group. 2'3 It is also unclear how one should decide whether to use a 1 cm or a 2 cm excision margin in this group. Perhaps the most worrying recommendation in the new guidelines is that patients with disease stage IIb and over should have the following staging investigations: chest X-ray; liver ultrasound or CT scan with contrast of chest, abdomen _+ pelvis; liver function tests/lactate dehydrogenase (LDH) and full blood count. No reference is given to justify these
British Journal of Plastic Surgery investigations, which have significant resource implications, and there is good evidence to question their value. In 1998, Terhune et al published a series of 876 stage UII patients who underwent staging chest X-rays within 6 months of diagnosis. 4 Although 130 patients (15%) had suspicious findings, only one patient had a true positive pulmonary metastasis. Whilst most of the patients in this series had stage I disease, and the study was retrospective, it nevertheless suggests a lack of usefulness of chest X-rays as a staging tool. Liver ultrasound detects large hepatic lesions only, and, in any case, CT scanning of the abdomen is more accurate at detecting intra-abdominal disease. 5 However, CT scanning is poor at detecting visceral disease in asymptomatic patients with stage I, II or III disease. 6 In a series of 151 patients, Buzaid found that CT scanning detected 29 suspicious cases (19%) but 24 were false positives, three were second primary malignancies and only two were true positive findings. The low detection rate and the high rate of false positives in melanoma in patients with both local disease and regional disease suggests a lack of usefulness of CT scanning as a staging tool. 7 LDH is a highly significant prognostic factor, and its elevation upstages the patient to stage IV disease, s'9 However, only 12% of patients have an elevated LDH as the first sign of distant metastasis. 1~ By the time LDH and other blood tests become abnormal, the patient has obvious metastases, and 74% of patients have clinical symptoms or signs as the first indicators of disseminated disease.1~ The UK guidelines recommend staging investigations on patients with stage IIb disease and over, but these will primarily detect stage IV disease. Stages I and II patients usually present with subsequent nodal disease (stage II/) rather than with widespread disease (stage IV). We feel, therefore, that it is more sensible to perform investigations that will upstage patients from stage II to IlL As the most reliable means of detecting nodal disease, sentinel-node biopsy should be the investigation of choice in stage II patients. This is reflected by the inclusion of the Na category of the new American Joint Committee on Cancer (AJCC) guidelines to denote micrometastasis, s'9 Stage III patients should have investigations according to their clinical picture if symptomatic, or if required for inclusion in a clinical trial of adjuvant treatment. Yours faithfully,
Taimur Shoaib FRCSEd, Specialist Registrar in Plastic Surgery
Roderick Dunn MBBS, DMCC, FRCS, FRCS(Plast), Specialist Registrar in Plastic Surgery
David Soutar FRCS(Glas), FRCSEd, Consultant Plastic Surgeon Canniesburn Hospital, Switchback Road, Bearsden, Glasgow G61 IQL, UK.
References 1. Newton Bishop JA, Corrie PG, Evans J, et al. UK guidelines for the management of cutaneous melanoma. Br J Plast Surg 2002; 55: 46-54. 2. Veronesi U, Cascinelli N. Narrow excision (1 cm margin): a safe margin for thin cutaneous melanoma. Arch Surg 1991; 126: 438--41. 3. Marsden JR. Malignant melanoma excision margins. Lancet 1993; 341: 184. 4. Terhune MH, Swanson N, Johnson TM. Use of chest radiography in the initial evaluation of patients with localized melanoma. Arch Dermatol 1998; 134: 569-72. 5. Kuan AK, Jackson FI, Hanson J. Mtflfimodality detection of metastatic melanoma. J R Soc Med 1988; 81: 579-82.
705
flap is difficult. This device can be bent and shaped to match the lower incision (Fig. 1). Following the dissection, the upper flap is pulled caudally, the ruler is placed on the upper flap and the incision site is marked. Thereby, the correct excision is performed. 2. The ruler has printed millimetric markings; therefore it can be used to measure curved surfaces. 3. In breast operations, the ruler can be used to make measurements (Fig. 2) or to squeeze the breast (as a mammostat) and enable easier de-epithelisation under tension.
References
The ruler can be sterilised repeatedly with ethylene oxide, maintaining its flexibility and the printed markings. It can be obtained from many shops that sell equipment for engineering or architecture.
An effective self-retaining retractor for limb surgery
Yours faithfully, O r h a n (~izmeci MD, Professor in Plastic and Reconstructive Surgery Ufuk Emekli MD, Associate Professor in Plastic and Reconstructive Surgery Serdar Tuncer MD, Resident in Plastic and Reconstructive Surgery Department of Plastic and Reconstructive Surgery, University of Istanbul Medical Faculty, Istanbul, Turkey.
1. Georgeu G, Putnis S, Pereira J. Gillies forceps diathermy burns. Br J Plast Surg 2002; 55: 263. 2. Willson PD, van der Walt JD, Moxon D, Rogers J. Port site electrosurgical (diathermy) burns during surgical laparoscopy. Surg Endosc 1997; 11: 653--4.
doi: 10.1054/bjps.2002.3945 i
Sir, A simple retractor to facilitate exposure for limb surgery can be readily and cheaply made from 1 mm-thick malleable copper sheet, using the design shown in Fig. 1. The tips of the arms are thinned to about 0.5mm to increase their malleability, allowing them to be bent into broad hooks which retract the wound edges in the appropriate directions with minimal trauma. The stern prevents the retractor from twisting and dislocating the tips out of the wound. The instrument can be easily moulded to fit specific sites, and, unlike hand-held or scissoraction retractors, has limbs that can be pressed flush with the
References 1. Erk Y, Kaytkcm~lu A. A method for developing individualized wise keyhole patterns: an aid in reduction mammaplasty for asymmetric breast. Plast Reconstr Surg 2000; 106: 226-7. 2. Giraldo F, Bergero T, Esteva I. A simple way to make a vaginal measurer. Plast Reconstr Surg 2001; 107:2170-1.
doi:10.1054/bjps.2002.3954
Capacitance coupling and diathermy burns
Figure 1--The retracto~
Sir, I read with interest the recent article describing Gillies forceps puncturing operating gloves, resulting in diathermy burns when using them to hold blood vessels. 1 I thank the authors for bringing this to our attention. I would like to propose a different theory to explain the 'hole in the glove and the diathermy burn' scenario. When using non-insulated forceps, such as Gillies forceps, to pick up blood vessels, which are then 'touched' with a diathermy probe, a phenomenon known as capacitance coupling may occur. This is where two conductors (forceps and the surgeon's fingers) are separated by an insulator (the surgical glove), with a resultant build-up of charge, leading to current passing into the finger of the user. This may cause a hole to be 'blown' in the glove, leading the surgeon to believe that the glove was punctured prior to the burn. The phenomenon of capacitance coupling is well known in laparoscopic surgery, where insulated diathermy probes are used inside metal cannulae, and may result in skin burns.2 For this reason, many surgeons in our unit use insulated forceps rather than Gillies forceps to pick up vessels, which can then be safely 'touched' by the diathermy probe. Yours faithfully, D a r r e n L. Chester MRCS, Registrar in Plastic Surgery Department of Plastic Surgery, Selly Oak Hospital, Raddlebarn Road, Selly Oak, Birmingham B29 6JD, UK.
Figure 2--Retraction of the skin edges during dissection of a wrist.
706 skin so that there are no projections to snag sutures or obstruct access (Fig. 2). This is particularly important in microsurgery, where instruments are wielded close to the surface of the wound. Copper is inert, cheap, easily autoclaved and has long been used in the production of malleable spatulas for retraction of the brain during neurosurgical procedures, and the soft tissues during maxillofacial procedures. Suzuki et al. described moulding a copper spatula into a self-retaining arch, the limbs of which push the intracranial and extracranial structures away from each other) Doi and Ogawa attached malleable copper spatulas to the limbs of a traditional self-retainer.2 However, the bodies of these retractors compromise access to the surgical site. In our design, as with the 'lead hand' commonly used as a digital retractor, the body of the instrument is held out of the way beneath the limb. Contact allergy is unlikely to a problem. 3 We have used the retractor to good effect in the upper limb, particularly when exploring traumatic wounds and performing microsurgery. A larger version has also proved useful in exposure and microsurgery of the posterior tibial vessels. Yours faithfully,
Dominique Moloney, DPhil, FRCS, Specialist Registrar in Plastic Surgery,
Peter Arnstein, FRCS (Plast,), Consultant Plastic Surgeon, Department of plastic and reconstructive surgery, Queen Victoria Hospital, Holteye Road, East Grinstead, West Sussex RH19 3DZ, UK.
References 1. Suzuki S, Sobata E, Ogane K, Sekiya T, Iwabuchi T. A simple self-retaining cerebral retractor. Acta Neurochir (Wien) 1989; 100: 87-8. 2. Doi H, Ogawa Y. A new malleable self-retaining retractor. Ann Plast Surg 1997; 38: 543-5. 3. Morris A, English J. Copper is unlikely to cause contact allergy. BMJ 1998; 316: 1902-3.
doi:10.1054/bjps.2002.3944
UK guidelines for the management of cutaneous melanoma Sir, We read with interest the recent article 'UK guidelines for the management of cutaneous melanoma'. 1 We are, however, surprised at some of the recommendations. The recommendation for a 1-2 cm excision margin in the 1-2 mm turnout-thickness group has level 1, grade A evidence. We believe that this is still controversial. The 1991 World Health Organization Melanoma Group study by Veronesi and Cascinelli involved a prospective randomised trial of 612 patients with stage I cutaneous melanoma not greater than 2 mm thick, comparing 1 cm and 3 cm excision margins. They noted increased local recurrence in the narrow-margin group. 2'3 It is also unclear how one should decide whether to use a 1 cm or a 2 cm excision margin in this group. Perhaps the most worrying recommendation in the new guidelines is that patients with disease stage IIb and over should have the following staging investigations: chest X-ray; liver ultrasound or CT scan with contrast of chest, abdomen _+ pelvis; liver function tests/lactate dehydrogenase (LDH) and full blood count. No reference is given to justify these
British Journal of Plastic Surgery investigations, which have significant resource implications, and there is good evidence to question their value. In 1998, Terhune et al published a series of 876 stage UII patients who underwent staging chest X-rays within 6 months of diagnosis. 4 Although 130 patients (15%) had suspicious findings, only one patient had a true positive pulmonary metastasis. Whilst most of the patients in this series had stage I disease, and the study was retrospective, it nevertheless suggests a lack of usefulness of chest X-rays as a staging tool. Liver ultrasound detects large hepatic lesions only, and, in any case, CT scanning of the abdomen is more accurate at detecting intra-abdominal disease. 5 However, CT scanning is poor at detecting visceral disease in asymptomatic patients with stage I, II or III disease. 6 In a series of 151 patients, Buzaid found that CT scanning detected 29 suspicious cases (19%) but 24 were false positives, three were second primary malignancies and only two were true positive findings. The low detection rate and the high rate of false positives in melanoma in patients with both local disease and regional disease suggests a lack of usefulness of CT scanning as a staging tool. 7 LDH is a highly significant prognostic factor, and its elevation upstages the patient to stage IV disease, s'9 However, only 12% of patients have an elevated LDH as the first sign of distant metastasis. 1~ By the time LDH and other blood tests become abnormal, the patient has obvious metastases, and 74% of patients have clinical symptoms or signs as the first indicators of disseminated disease.1~ The UK guidelines recommend staging investigations on patients with stage IIb disease and over, but these will primarily detect stage IV disease. Stages I and II patients usually present with subsequent nodal disease (stage II/) rather than with widespread disease (stage IV). We feel, therefore, that it is more sensible to perform investigations that will upstage patients from stage II to IlL As the most reliable means of detecting nodal disease, sentinel-node biopsy should be the investigation of choice in stage II patients. This is reflected by the inclusion of the Na category of the new American Joint Committee on Cancer (AJCC) guidelines to denote micrometastasis, s'9 Stage III patients should have investigations according to their clinical picture if symptomatic, or if required for inclusion in a clinical trial of adjuvant treatment. Yours faithfully,
Taimur Shoaib FRCSEd, Specialist Registrar in Plastic Surgery
Roderick Dunn MBBS, DMCC, FRCS, FRCS(Plast), Specialist Registrar in Plastic Surgery
David Soutar FRCS(Glas), FRCSEd, Consultant Plastic Surgeon Canniesburn Hospital, Switchback Road, Bearsden, Glasgow G61 IQL, UK.
References 1. Newton Bishop JA, Corrie PG, Evans J, et al. UK guidelines for the management of cutaneous melanoma. Br J Plast Surg 2002; 55: 46-54. 2. Veronesi U, Cascinelli N. Narrow excision (1 cm margin): a safe margin for thin cutaneous melanoma. Arch Surg 1991; 126: 438--41. 3. Marsden JR. Malignant melanoma excision margins. Lancet 1993; 341: 184. 4. Terhune MH, Swanson N, Johnson TM. Use of chest radiography in the initial evaluation of patients with localized melanoma. Arch Dermatol 1998; 134: 569-72. 5. Kuan AK, Jackson FI, Hanson J. Mtflfimodality detection of metastatic melanoma. J R Soc Med 1988; 81: 579-82.