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Microsurgery without a microscope
Letters to the Editor
261
References 1. Foster RD, Anthony JR Mathes SJ, Hoflman WY. Ischial pressure sore coverage: a rationale for flap selection. Br J Plast Surg 1997; 50: 374-79. 2. Foster RD, Anthony JR Mathes SJ, Hoffman WY, Young D, Eshima I. Flap selection as a determinant of success in pressure sore coverage. Arch Surg 1997; 132: 868-73. 3. Wechselberger G, Schoeller T, Schwabegger A, Ninkovic M, Papp C, Anderl H. Plastic surgery treatment of extensive decubitus ulcers of the pelvic area. Chirurg 1996; 67:1147-51. 4. Nola GT, Vistnes LM. Differential response of skin and muscle in the experimental production of pressure sores. Plast Reconstr Surg 1980; 66: 728-33.
Regression in keloid scar by intralesional injection of papaya milk Fig. 1 Sir, Unripe papaya juice is in common use to digest muscle fibres prior to roasting mutton and kawab. Papaya juice seems to have some effect on connective tissues and the question arises as to whether this property could be utilised in the treatment of keloid scars. The precise cause of keloid scarring remains unknown although there appears to be increased cellularity and overproduction of matrix components. The unripe papaya fruit was plucked and washed with Savlon solution and hand scrubbed. Using a sterile disposable blade, three or four cuts were made on the outer wall and milk was collected in a sterile vial. Using a disposable syringe and needle, the juice was diluted 1:2 with distilled water for injection. Two millilitres of the diluted solution was injected intralesionallyusing a dermojet injector at 21-day intervals. Up to six sittings were required and 10 patients have been treated in this way. Although the substance has not been subjected to a controlled trial, there appears to be a marked regression of up to 90% in the keloid size. Systemic effects have not been noted. There may be slight burning on injection as papaya juice contains an alkaloid, karpain. Rare allergy to papaya is recognised. These preliminary results deserve further scientific study.
Fig. 2
Yours faithfully,
Dr Khursid Ahmad Consultant Plastic Surgeon, Deoria Plastic Surgery Centre, Deoria, UP 274001, India.
Microsurgery without a microscope Sir, In British Journal of Plastic Surgery April 1997 Ramakrishnan et al described the use of endoscopic systems and video imaging as a possible substitute for the operating microscope.' They used an available endoscopic system and performed 20 anastomoses in vitro. The idea to disconnect the surgeon and his assistant from the microscope and to perform (micro) surgery using a known endoscopic or a developed camera video system is very promising and can have a great future. But why should we leave the conventional, well known surgical light microscope with its very high optical resolution and clear view? In microvascular surgery, however, procedures may be both technically and physically demanding. Precise movements sustained over long hours in addition to typically compromised surgeon and assistant positioning lead quickly
Fig. 3 Figure 1--A child with a large left pre-auricular keloid. Figure 2--The keloidat 42 daysafter two injectionsand prior to the tNrd. Figure 3~The keloid at 84 days. to physical and mental fatigue. Many of the positioning problems encountered are related to the fact that the eyes of the surgeon must be continually fixed to the microscope
262 eyepieces. Our studies/research performed in 1994 and 1995 explored possible solutions; for example, a microscope system that eliminates the need to view the operative field through the microscope eyepieces. A Three-dimensional On-screen Microsurgical System (TOMS) was used and contrasted with conventional operative microvascular surgery in the laboratory setting. The surgeon's comfort, his ability to instruct microsurgical techniques, pertinent technological performance, and the procedure itself were evaluated using a standardised questionnaire. Based on data collected in those studies, we concluded thal separating the surgeon's eyes from the microscope eyepieces using TOMS may make prolonged microvascular procedures less physically demanding and may increase the comfort level of both the surgeon and his assistant? 3 At the end of 1994. we performed the first microvascular end-to-end anastomoses of less than 1 mm without looking through a microscope, using TOMS. TOMS is a computerassisted videomicroscopy setup, which projects a stereoscopic 3-D magnified image on one or more monitors, similar to t3D) laparoscopic surgical systems (Fig. 1). The two cameras. mounted on custom fit eyepiece adapters, were connected to the camera controller which served as the interface to the image processor. The processor then sequentially output the right and left eyepiece camera images alternating at 120 cycles per second. This alternating signal was output to both the monitor and the emitter, which synchronised the right and left output with the opening and closing of the right and left lenses of the shutter glasses. Thus, the right lens (right eye of the surgeon) was open to see only the output from the right eyepiece of the 'microscope', and the left lens (left eye) only saw the output from the left eyepiece (Fig. 2). This method of achieving true stereoscopic vision reproduced the stereoscopy viewed through a conventional binocular microscope. Using prototype equipment, we compared TOMS to conventional operative microvascular surgery in both the clinical (3-5 cases) and laboratory (I 5-20 cases) situation. 3,4 Currently we are developing the computer-assisted 3-D camerascope with a single 3-chip videocamera. The special computer between the live-view and record processor and the monitor provides alternating images for both eyes with a frequency of at least 120 Hz (pseudo 3-D). The small optomechanic camerascope with focusing and magnification possibilities can be mounted on the ceiling, 3 feet above the patient and is controlled by a footpedal. Problems with sterilisation will belong to the past as the camerascope is extracted from the surgical field; probably the only equipment needed for this instrument will be some sterile handles. 4 As did Ramakrishnan, we concluded that video microsurgery is encouraging, although refinements to the used technology/systems are required. Using the computerassisted digital data, great educational possibilities, videoconference, and even telepresence and telerobotics, may be envisaged in the near future.
British Journal of Plastic Surgery J. H. Barker, MD, PhD Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA. J. C. Banis Jr, MD Division Of Plastic and Reconstructive Surgery and Division of Microsurgery and Microsurgical Research, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA.
References 1. Ramakrishnan VV, Villavane O, Southern S. Video microsurgery: a substitute for the operating microscope? Br J Plast Surg 1997; 50: 294. 2. Gupta SC, Klein SA, Barker JH, Franken RJPM, Banis JC Jr. Introduction of new technology to clinical practice: a guide for assessment of new VR applications. J Med VR 1995; 1: 16-20. 3. Franken RJPM, Gupta SC, Rod SR, et al. Microsurgery without a microscope: development of a Three-dimensional On-screen Microsurgery System (TOMS). J Med VR 1995; l: 26-32. 4. Franken RJPM, Gupta SC, Banis JC, et ai. Microsurgery without a microscope: laboratory evaluation of a Three-dimensional On-screen Microsurgery System. Microsurg 1995; 16:746-51.
Dual Camera Controller
Callo~rascope
View~RecordProcessor
VCR []ram
Emitter Monitor(s) Glasses Operative FieM
Fig, 1
Yours faithfully, R. J. P. M. Franken, MD Plastic Surgery Resident, Department of Plastic, Reconstructive & Hand Surgery, University Hospital of Utrecht, Utrecht, The Netherlands and Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA. M. Kon, MD, PhD Department of Plastic, Reconstructive & Hand Surgery, University Hospital of Utrecht, Utrecht, The Netherlands.
Fig. 2 Figure 1--Schematic configuration of the prototype ThreedimensionaI On-screen Microsurgery System (TOMS). Figure 2--The pilot studies. The senior author, wearing the active polarising glasses, performs an end-to-end anastomosis of an artery less than 1 ram, without looking through the microscope, using the prototype/pilot equipment of TOMS (October 1994). For further explanations see Figure 1.
261
References 1. Foster RD, Anthony JR Mathes SJ, Hoflman WY. Ischial pressure sore coverage: a rationale for flap selection. Br J Plast Surg 1997; 50: 374-79. 2. Foster RD, Anthony JR Mathes SJ, Hoffman WY, Young D, Eshima I. Flap selection as a determinant of success in pressure sore coverage. Arch Surg 1997; 132: 868-73. 3. Wechselberger G, Schoeller T, Schwabegger A, Ninkovic M, Papp C, Anderl H. Plastic surgery treatment of extensive decubitus ulcers of the pelvic area. Chirurg 1996; 67:1147-51. 4. Nola GT, Vistnes LM. Differential response of skin and muscle in the experimental production of pressure sores. Plast Reconstr Surg 1980; 66: 728-33.
Regression in keloid scar by intralesional injection of papaya milk Fig. 1 Sir, Unripe papaya juice is in common use to digest muscle fibres prior to roasting mutton and kawab. Papaya juice seems to have some effect on connective tissues and the question arises as to whether this property could be utilised in the treatment of keloid scars. The precise cause of keloid scarring remains unknown although there appears to be increased cellularity and overproduction of matrix components. The unripe papaya fruit was plucked and washed with Savlon solution and hand scrubbed. Using a sterile disposable blade, three or four cuts were made on the outer wall and milk was collected in a sterile vial. Using a disposable syringe and needle, the juice was diluted 1:2 with distilled water for injection. Two millilitres of the diluted solution was injected intralesionallyusing a dermojet injector at 21-day intervals. Up to six sittings were required and 10 patients have been treated in this way. Although the substance has not been subjected to a controlled trial, there appears to be a marked regression of up to 90% in the keloid size. Systemic effects have not been noted. There may be slight burning on injection as papaya juice contains an alkaloid, karpain. Rare allergy to papaya is recognised. These preliminary results deserve further scientific study.
Fig. 2
Yours faithfully,
Dr Khursid Ahmad Consultant Plastic Surgeon, Deoria Plastic Surgery Centre, Deoria, UP 274001, India.
Microsurgery without a microscope Sir, In British Journal of Plastic Surgery April 1997 Ramakrishnan et al described the use of endoscopic systems and video imaging as a possible substitute for the operating microscope.' They used an available endoscopic system and performed 20 anastomoses in vitro. The idea to disconnect the surgeon and his assistant from the microscope and to perform (micro) surgery using a known endoscopic or a developed camera video system is very promising and can have a great future. But why should we leave the conventional, well known surgical light microscope with its very high optical resolution and clear view? In microvascular surgery, however, procedures may be both technically and physically demanding. Precise movements sustained over long hours in addition to typically compromised surgeon and assistant positioning lead quickly
Fig. 3 Figure 1--A child with a large left pre-auricular keloid. Figure 2--The keloidat 42 daysafter two injectionsand prior to the tNrd. Figure 3~The keloid at 84 days. to physical and mental fatigue. Many of the positioning problems encountered are related to the fact that the eyes of the surgeon must be continually fixed to the microscope
262 eyepieces. Our studies/research performed in 1994 and 1995 explored possible solutions; for example, a microscope system that eliminates the need to view the operative field through the microscope eyepieces. A Three-dimensional On-screen Microsurgical System (TOMS) was used and contrasted with conventional operative microvascular surgery in the laboratory setting. The surgeon's comfort, his ability to instruct microsurgical techniques, pertinent technological performance, and the procedure itself were evaluated using a standardised questionnaire. Based on data collected in those studies, we concluded thal separating the surgeon's eyes from the microscope eyepieces using TOMS may make prolonged microvascular procedures less physically demanding and may increase the comfort level of both the surgeon and his assistant? 3 At the end of 1994. we performed the first microvascular end-to-end anastomoses of less than 1 mm without looking through a microscope, using TOMS. TOMS is a computerassisted videomicroscopy setup, which projects a stereoscopic 3-D magnified image on one or more monitors, similar to t3D) laparoscopic surgical systems (Fig. 1). The two cameras. mounted on custom fit eyepiece adapters, were connected to the camera controller which served as the interface to the image processor. The processor then sequentially output the right and left eyepiece camera images alternating at 120 cycles per second. This alternating signal was output to both the monitor and the emitter, which synchronised the right and left output with the opening and closing of the right and left lenses of the shutter glasses. Thus, the right lens (right eye of the surgeon) was open to see only the output from the right eyepiece of the 'microscope', and the left lens (left eye) only saw the output from the left eyepiece (Fig. 2). This method of achieving true stereoscopic vision reproduced the stereoscopy viewed through a conventional binocular microscope. Using prototype equipment, we compared TOMS to conventional operative microvascular surgery in both the clinical (3-5 cases) and laboratory (I 5-20 cases) situation. 3,4 Currently we are developing the computer-assisted 3-D camerascope with a single 3-chip videocamera. The special computer between the live-view and record processor and the monitor provides alternating images for both eyes with a frequency of at least 120 Hz (pseudo 3-D). The small optomechanic camerascope with focusing and magnification possibilities can be mounted on the ceiling, 3 feet above the patient and is controlled by a footpedal. Problems with sterilisation will belong to the past as the camerascope is extracted from the surgical field; probably the only equipment needed for this instrument will be some sterile handles. 4 As did Ramakrishnan, we concluded that video microsurgery is encouraging, although refinements to the used technology/systems are required. Using the computerassisted digital data, great educational possibilities, videoconference, and even telepresence and telerobotics, may be envisaged in the near future.
British Journal of Plastic Surgery J. H. Barker, MD, PhD Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA. J. C. Banis Jr, MD Division Of Plastic and Reconstructive Surgery and Division of Microsurgery and Microsurgical Research, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA.
References 1. Ramakrishnan VV, Villavane O, Southern S. Video microsurgery: a substitute for the operating microscope? Br J Plast Surg 1997; 50: 294. 2. Gupta SC, Klein SA, Barker JH, Franken RJPM, Banis JC Jr. Introduction of new technology to clinical practice: a guide for assessment of new VR applications. J Med VR 1995; 1: 16-20. 3. Franken RJPM, Gupta SC, Rod SR, et al. Microsurgery without a microscope: development of a Three-dimensional On-screen Microsurgery System (TOMS). J Med VR 1995; l: 26-32. 4. Franken RJPM, Gupta SC, Banis JC, et ai. Microsurgery without a microscope: laboratory evaluation of a Three-dimensional On-screen Microsurgery System. Microsurg 1995; 16:746-51.
Dual Camera Controller
Callo~rascope
View~RecordProcessor
VCR []ram
Emitter Monitor(s) Glasses Operative FieM
Fig, 1
Yours faithfully, R. J. P. M. Franken, MD Plastic Surgery Resident, Department of Plastic, Reconstructive & Hand Surgery, University Hospital of Utrecht, Utrecht, The Netherlands and Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA. M. Kon, MD, PhD Department of Plastic, Reconstructive & Hand Surgery, University Hospital of Utrecht, Utrecht, The Netherlands.
Fig. 2 Figure 1--Schematic configuration of the prototype ThreedimensionaI On-screen Microsurgery System (TOMS). Figure 2--The pilot studies. The senior author, wearing the active polarising glasses, performs an end-to-end anastomosis of an artery less than 1 ram, without looking through the microscope, using the prototype/pilot equipment of TOMS (October 1994). For further explanations see Figure 1.