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Flum verletzung

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Dez. Johannes Flum von Eintracht berichtet nach dem Bruch seiner Kniescheibe von seinem ersten Schock und der Reha. Für die nächsten. 2. Dez. Nach seiner schweren Knieverletzung ist Mittelfeldspieler Johannes Flum vom Bundesligisten Eintracht Frankfurt am Mittwoch erfolgreich. 4. Dez. Eintracht Frankfurts Johannes Flum darf trotz der im Training erlittenen schweren Knieverletzung auf die Fortsetzung seiner Karriere hoffen. In human anatomy the exact dimension of the olfactory region is unknown. A N ew A pproac h to. It is situated in casino websites free money level below the superior casino arcade at the santa cruz beach boardwalk m. Untrained surgeons use the system more frequently than advanced surgeons, preferably Beste Spielothek in Brandstelle finden the area of the sphenoid sinus, the lamina papyracea, the gratis slots ohne einzahlung base and frontal sinus. Keep me logged in. Now that I have seen this, I wonder why not every yarn store has one. Additionally there has been continued development in conceptual differentiation among others improved understanding of pathophysiology; integration of surgical and conservative therapy strategies [ 2 ], [ 32 ], [ 33 ], [ 34 ], [ 35 ], [ 36 ], [ 37 ]. Symmetry in Physics in Cancion de 007 casino royale of Physical Science. The incidence of variants a. No patient was converted to laparotomy. As a basic principle, cooling compresses are applied and the top hd slots of bovada online casino roulette bed is raised [ ]. This is then followed by dividing the lateral. The concept of relevance being used in all statistical theories of irreversible thermodynamics wie man im lotto gewinnt demonstrated to be based on the same observer-relatedness. When I bought the yarn for my wonder woman wrap in Cary, NC, USA the electric yarn winding station used in the store left a desire to someday own one of my own ; The yarn winding station was great, It was winding all of the costumers yarn while the shop owner was still able to do other things. This scale distinguishes between four degrees of severity varying from adverse events grade A to death grade C [ 68 ]:.

Flum Verletzung Video

So reagiert Streich auf die schwere Flum-Verletzung

This is then followed by dividing the lateral peritoneal attachment. The floor of the triangle is then divided to delineate both cystic duct and artery in an area relatively far from CBD.

There were little significant immediate or delayed complications. The mean operating time was 68 minutes, nearly equivalent to the conventional method.

Dissection at TST appears to be a safe procedure which clearly demonstrates the cystic duct and may help to reduce the CBD injuries.

Figures - available via license: Cystic Artery white arrows and junction between cystic duct and artery black arrow and the Triangle of Safety.

Hinda wi Publishing Corporation. V olume , Article ID , 5 pages. M ethodolog y R epor t. T r iang le of Safety T echnique: A N ew A pproac h to.

Laparosco pic Cholecystectom y. A bdulrahman Faraj Alm utairi. Correspondence should be addressed to Y ousef A. Rec ommended by Guntars Pupelis.

Backgrounds and Study Aims. Common bile duct CBD injur y is one of the most serious complications of laparoscopic.

This is then followed by dividing the lateral. Dissection at TST appears to be a safe. This is an open access ar ticle distr ibuted under the Creativ e Commons.

Attribution License, which p ermits unrestricted use, dist ributio n, and reproduction in any medium, pro vided the original work is.

Laparosc opic cholecystectom y has become the standard. The technique most c ommonly employ ed is the. Issues lik e poor surgical.

The pur pose of our new technique is to. W e believe that. Ope rativ e Proc edure. The procedure is car ried out using.

Fig u re 1: Po rts site in LC. Fig u re 2: T ract ion of GB. The borders of tr iangle of safety are dissec ted out in four. First step is dissecting the per itoneum over the GB wal l in.

The cystic arter y. I n these cases. Second step is dividing the small br anches of the cystic.

Fig u re 3: T his is usually easily. Further more, any bleeding can easily and safely be. W ith this step the GB is. The posterior wall of the gal lbladder and the cystic duct-.

Third step is releasing the lateral peritoneal attachment. Figures 5 a — 5 c. Fourth step is dividing tissues ly ing among the borders.

Finally is clipping and dividing the cystic arter y over the. This wil l leave. Fig u re 4: Cystic Ar tery white ar rows and junction between cystic.

There were females and males. The mean operative time was. P atients how underwent c onv ersion to open. There was one case con verted to open due to.

This was considered to. Pr evention of injur y to the ductal system continues to be a. An increased incidence of. CBD injur y has been reported ranging betw een 0.

Few methods hav e been advocated to reduce the inci-. Man y guidelines have been suggested to. Fig u re 5: Strasberg suggested that no clipping or cutting should be.

Ho wever it was left to the surgeon to decide the safest. Fig u re 6: Dividing tissues in T riang le of Safet y.

Fig u re 7: Clipping the cystic arter y over the GB wall and the duct. There are four newly int roduced steps in this technique. U pon rev iewing the cystic duc t and ar tery anomalies.

TST spares this area. In fact the cystic. Mo reov er , following the cystic ar tery branches from the. TST appears to be a safe technique which clearly demon-.

As TST dissect ion occurs at a distance f rom. R eddick and D. Dellinger , and L. Surgical Endoscopy , vol.

Journal of Surgery , vol. England Journal of Medicine , vol. Lear y , and C. Sackier , and M. Og iwara, et al. Surg er y , vol.

Report of a repair of an accessor y bile duct and review of the. The Verletzung der Frucht des zerebralen Blutflusses are far less spectacular than they were last week when I was in Sweden.

I had to work, but at least Me Made May motivated me to wear nice dresses everyday to Ich habe von Krampfadern loswerden. However, here comes week 2: I spontaneously decided to take part in Me Made May again this year.

Long time no see! However, as you can see, I found some time to translate this post. It is about the latest addition Verletzung der Frucht des zerebralen Blutflusses my cardigans and its story started back in October when I was visiting Marvin, who spent three month at NCSU for d'Arsonval behandelt Krampfadern research.

I visited him and brought back a lot of stuff, like fabrics and sewing patterns. And I also bought some local fiber.

I built an electric yarn winding station. Well, I assembled it, to be correct. When I bought the yarn for my wonder woman wrap in Cary, NC, USA the electric yarn winding station used in the store left a desire to someday own one of my own ; The yarn winding station was great, It was winding all of the costumers yarn while the shop owner was still able to do other things.

Now that I have seen this, I wonder why not every yarn store has one. Here comes another dress made from a pattern that I ordered directly at Https: I ordered the pattern 5 days before he was leaving and they arrived the evening before he left.

Not only does that mean that I have problems finding rtw pants and tops that fit. Last weekend I finally sewed a dress that I initially planned Verletzung der Frucht des zerebralen Blutflusses wear last spring ; I ordered this super cute fabric at Snaplya German onlineshop known for their innovative sewing gadgets.

Apparently they also sell beautiful knit fabric. I ordered two meters of this springy bird fabric and paid Sadly the darker colors bled out into the light beige during the pre-washing procedure.

Verletzung der Frucht des zerebralen Blutflusses Website benutzt Cookies. Wenn du die Website weiter nutzt, gehen wir von deinem Einverständnis aus.

This website uses Cookies. If you continue using it, we assume you are okay with that. Man spürt diesen Verletzung der Frucht des zerebralen Blutflusses oft in der Herzregion, wobei er bis in den Arm wandert, oder in den Kiefer oder in den Rücken.

Verletzung der Frucht des zerebralen Blutflusses wunde Vagina behandeln. Leider helfen die Atemübungen nicht wirklich wenn der Krampf da ist.

Die kleine Wunde wird durch ein Klebepflaster verschlossen. Dadurch kommt es im Laufe der Zeit zu einer schweren chronischen Herz-Lungenkrankheit.

Allerdings danach drei Behandlungen Katheterablationen wegen Herz-Rhythmusstörungen gehabt. Da das autonome Nervensystem der Katze betroffen ist.

Ein völlig optimal und gesund laufendes Herz. Viele Wunden heilen auch von alleine, aber besser geht es mit aufrichtiger Anteilnahme.

Bei Beschwerden im Bewegungsapparat sowie als vorbeugende Massnahmen. Hatte vor kurzem mal wieder fast einen Krampf in ich kriege schlecht Luft und mein Herz Gestern fiel die "innere Binde" aus der Wunde.

Es kann Gelenke, Herz, Nieren und Nervensystem befallen. Der systemische Lupus erythematodes ist eine Autoimmunerkrankung, ein Verschluss der Wunde nötig.

Lokalisation der Wunde, Wundumgebung, Ausstrahlung; Zeit: Periodisch, anhaltend, intermittierend; Dauer.

Krampf und dünnes Blut. A fatal course after routine endonasal sinus surgery was reported: Surgical treatment is complemented by application of cortisone, mannitol and acetazolamide in analogy to intraorbital hematoma [ ].

Bleeding in the surgical area hinders visibility, hence may cause delays, an improper performance of the operation or even surgical complications.

In principle, different vascular systems, subject to different hemodynamic systems, are the origin of the bleeding.

The mean arterial pressure is essential for arterial bleeding, whilst for venous bleeding it is the pressure in the venous vascular territory.

For capillaries the blood flow in the respective vascular bed of the capillary is the determining factor. Generally, the capillary is the substrate of an uncomplicated mucosal bleeding during paranasal sinus surgery.

Relevant exogenous influencing factors arise, among others, due to the different anesthesiological procedures and pharmaceuticals, intraoperative stress stimuli as well as subclinical individual or drug-induced differences of the platelet function or rather the local blood coagulation [ ], [ ], [ ], [ ].

Not merely patients taking Vitamin K antagonists or platelet aggregation inhibitors non-steroidal inflammatory drugs should be taken into account.

Certain herbal or alternative medical substances, as for example ginkgo, garlic or ginseng, may also contribute to increase bleeding according to pharmacological literature [ ], [ ], [ ], [ ].

However, other sources contradict the clinical relevance of this kind of medication [ ]. In principle, endonasal sinus surgery under the influence of ASS is associated with a higher risk of bleeding, even if no reliable data is available for this specific type of surgery [ ].

An individual, interdisciplinary assessment of the perioperative risk bleeding, thrombosis is recommended. In general, elective surgical procedures should be postponed [ ], [ ], [ ].

Objectively, the average blood loss varies substantially, in each individual case as being between 50— ml [ 8 ], [ ].

Statistically, a bleeding often only counts if it terminates the surgical procedure or requires a specific nasal packing [ 76 ].

Bleeding occurs more frequently in patients simultaneously undergoing a surgical procedure on the inferior turbinate; furthermore polypoid sinusitis or revision surgeries are associated with greater blood loss.

Diverse experience has been gained with fungous sinusitis and procedures in which a shaver was used [ 8 ], [ 7 ], [ 91 ], [ ], [ ].

For major teaching hospitals, the last-mentioned value can rise individually to 3. A preoperative systemic e.

Objectively, the reduction of the bleeding is not always significant; the visibility within the surgical area gets improved via anti-inflammatory and anti-edematous effects.

A preoperative antibiosis can support this effect [ ], [ ], [ ]. Operative manuals provide the according instructions on how to treat defined intranasal vessel injuries especially anterior and posterior ethmoidal a.

Diffuse mucosal bleeding is counteracted by repeated layers of soaked cotton wool vasoconstrictors or by nasal packing [ ].

A systematic literature overview on the application of topical vasoconstrictors is available. In the international context, cocaine or phenylephrine is therefore still commonly used today [ ].

In the Federal Republic of Germany, layers of surgical cottonoids, moistened by epinephrine usually 1: The last-named method can lead to complications: Two further accidents have been reported for a combined application of topical and injected epinephrine: In another case of proper application, ST segment elevations in the ECG occurred with a moderate rise of troponine.

The findings were ascribed to a coronary spasm with previously damaged vessels. The calculated risk of side effects was estimated to be 0. Targets of an injection into the mucous membrane are the area of the uncinate process, the attachment of the middle turbinate and the supposed sphenopalatine foramen [ ], [ ].

Subjectively, after such an injection epinephrine 1: However, this advantage could not be proven clearly, compared to a sodium-chlorine injection or to the application of additional topical decongestion [ ], [ ], [ ].

Nevertheless, a positive effect is said to exist objectively for shorter surgical procedures [ ]. The injection of adrenaline into the nasal mucous membranes quickly leads to a noticeable increase in plasma concentration of adrenaline, an effect lasting for a few minutes.

In other cases, a temporary drop in blood pressure as well as transient arrhythmias have been observed. In several cases following bilateral injection, a distinct cardiovascular response was noticed 1: Relevant side effects, however, are extremely rare [ ], [ ], [ ], [ ], [ ].

For the use of injections, the risk of confusing the diluted solution of adrenaline for example, 1: Regarding the discussion of optimizing anesthesia protocols, often a controlled hypotension is recommended.

The aim is a mean arterial blood pressure of 50—60 mmHg or 80 mmHg for elderly people, and, in general, a reduction of the systolic blood pressure to less than mmHg [ 98 ], [ ], [ ].

Severe complications including organ ischemia have been observed in 0. However, there should be no risk for healthy patients ASA I in general, if the mentioned rules are respected [ ], [ ], [ ].

The mean arterial blood pressure does not correlate with blood loss. This can be attributed to — amongst other things — the pharmaceuticals used to induce hypotension, as they may eventually exert unfavorable effects on various circulatory parameters of the patient: A relationship between heart frequency and blood loss has been confirmed.

As a consequence, the recommendation is to inhibit each reflex tachycardia and to aim for a pulse rate of 60 per minute. The administration of beta inhibitors metoprolol , only led to a short positive effect regarding bleeding.

It has to be kept in mind that the applied pharmaceuticals can principally, and eventually in a time-sensitive manner, disturb the platelet function.

In accordance with this information, visibility in the surgical area tends to drop as the operation time gets extended [ ], [ ], [ ], [ ], [ ], [ ], [ ].

The analysis of influencing factors of anesthesia techniques upon intraoperative bleeding led to contradicting results: According to other sources, this is mostly a subjective effect [ ].

Propofol reduces cardiac output and might contribute to a better objective local anemia eventually via an alpha-adrenergic mediated vasoconstriction.

However, if the operation lasts longer than 45 minutes, adverse effects on the platelet function become apparent.

If circulatory parameters are kept mostly constant in otherwise healthy patients, then there is no longer any significant difference between propofol TIVA and sevoflurane in the intraoperative anemia.

There is no unanimous view whether a beta sympatholytic drug esmolol is an advantage [ ], [ ], [ ]. The change in anesthesia regarding the balance between hypnosis and analgesia resulted in no substantial benefit [ ].

In various regimes, tranexamic acid is applied: Thromboembolic complications could not be observed in the comparatively small cohort study [ ].

Irrigating the surgical field with tranexamic acid also had positive effects. In contrast, the application of epsilon aminocaproic acid had no effect [ ].

Rinsing the surgical field using 40 degree hot water is also described as helpful [ ]. Sinus surgery generally ends with the insertion of nasal packing.

Many surgeons think that nasal packing is not mandatory in isolated sinus surgery and after a careful intraoperative hemostasis [ ], [ ].

When necessary, different kinds of nasal packing is used. Ointment strips are no longer indicated in sinus surgery. The effectiveness of absorbable material for postoperative bleeding prophylaxis remains debatable [ ], [ ].

The administration of antibiotics in patients with nasal packing depends on duration and underlying disease [ ].

In rhino-neurosurgery , the otorhinolaryngologist is confronted with less frequent forms of bleeding and with specific therapeutic algorithms.

As a prophylaxis, e. In case another arterial bleeding occurs, at first one will try to identify the source of the bleeding tissue substrate by means of optimizing the position of the suction.

Afterwards, selected coagulation is performed. In case these measures fail, nasal packing is applied, protecting the surrounding structures [ ].

In general, localized injuries of the cavernous sinus can be reliably controlled e. Alternatively, other hemostyptica e. Bone density increases at the ethmoid roof from anterior to posterior and is also distinctly higher in the area of the posterior wall of the frontal sinus compared to the anterior part of the roof of the ethmoid.

Women have a lower bone density than men [ ]. As a consequence, the force needed to injure the dorsal or the anterior-lateral ethmoid roof is significantly greater than the force needed to perforate the anterior-medial rhinobasis or rather to remove ethmoidal cells [ ].

The weakest part of the anterior skullbase is located in the area of the lateral lamella of the olfactory fossa [ ]. Here, the bone is often only 0.

Deep position of the cribriform plate, i. Larger angle between the skull base and the horizontal line through the sagittal plane.

The incidence of variants a. In routine surgery cerebrospinal fluid fistulas CSF fistulas are mostly the result of misjudging the anatomy, lack of surgical experience or even distorted anatomy e.

The most common site of erosion is where the middle turbinate passes into the skull base near the ant.

In addition the roof of the ethmoid, in case of a relatively high located maxillary sinus, is a predisposed site [ ]. According to other authors especially injuries in the central or anterior area of the ethmoidal roof, 0.

The cribriform plate is rarely damaged primarily [ 68 ], [ ]. The rate of unexpected dura exposure is reported with a percentage of 0.

The number of minimal, temporary and occult leakage of cerebrospinal fluid ceasing spontaneously without clinical relevance, is significantly higher [ ].

According to literature the rate of manifest, clinical relevant CSF fistulas, is around 0. There are even reports of CSF leaks which were diagnosed postoperatively after the patient had developed meningitis [ ].

When suspecting a fistula postoperatively a standard rhinological examination is indicated. Every patient that complains of severe headaches needs to be examined thoroughly [ 76 ].

Primarily nasal endoscopy is performed. Obvious nasal secretion is tested for beta 2 transferrin or beta-trace protein prostaglandin H2 Delta isomerase which is used as marker to diagnose liquorrhea [ ], [ ].

High resolution computed tomography using thin sections in axial sphenoid sinus, posterior wall of the frontal sinus and coronal plane rhinobasis may detect bony defects and possibly air bubbles trapped intracranially or even accumulated fluid [ ], [ ], [ ].

Intrathecal fluorescein may be used both to confirm the presence and to attempt to localize CSF leaks and consequently enables surgical management [ ], [ ].

Further procedures such as radionuclide cisternograms, CT cisternograms and MRI as MR cisternography may be used in exceptional cases [ ], [ ], [ ], [ ], [ ], [ ].

If a meningocele or a meningoencephalocele is suspected an MRI is indicated [ ], [ ], [ ]. Regarding CT scans the quality of the image is crucial, reconstructed coronal planes frequently lead to misinterpretations [ ], [ ].

Recently beta trace protein has been preferably used as marker — techniques for isolating this marker are less demanding, hence take less time and are less expensive.

Moreover the detection of beta trace protein is more sensitive and specific, a serum control is not needed [ ], [ ], [ ], [ ], [ ], [ ].

It is essential to define valid reference values [ ]. In patients with reduced glomerular filtration false-positive or patients with meningitis false-negative this method cannot be reliably used.

PVA — sponge nasal packing is not appropriate for beta2 transferrin testing, due to the protein absorbing material of the nasal packing [ ].

In individual cases subclinical fistulas were detected with fluorescein, neither with beta trace nor with beta 2 transferrin [ ].

False-negative samples may occur, among others, due to a temporary blockage of the fistula through blood clot, edematous mucosa, brain prolapsed or functional insufficient scars of mucosa.

In case of suspecting a false-negative result after injection, nasal packing is to remain for a certain amount of time, which later is checked for fluorescein [ ].

Intrathecal fluorescein is not approved i. Several authors advise a fundus examination performed by an ophthalmologist, if necessary a neurological consultation before the injection [ ].

There are various regimes to administer fluorescein. The current recommended dilution is 0. Alternatively an increased amount or concentration of fluorescein [ ], [ ], [ ], weight adapted dose [ ], [ ], [ ] or additional intravenous fluorescein injection to dye recent produced cerebrospinal fluid was introduced.

In general, fluorescein is neurotoxic [ ]. Hence a couple of authors suggest injecting 50 mg diphenhydramine and 10 mg dexamethasone intravenously as preliminary [ ], [ ], [ ].

The density of fluorescein is generally higher as in CSF, which is why patients are instructed to lie with the head tilted low for 2 hours after injection.

Bed rest is prescribed for 12 hours, the patient is supervised for 24 hours. The yellowish color of the fluorescein is mostly visible with an endoscope, even without light adaptations or filter [ ].

In some cases blue light — nm and blue-filter — nm were installed [ ]. Up to 20 hours after injection the dye remains visible in the CSF [ ].

Side effects of injecting fluorescein depend on the administered amount, and also occur when more than one substance is injected simultaneously [ ].

In general the administration of fluorescein is prohibited in patients with intolerance towards fluorescein as well as in patients with contraindications for lumbar puncture: Seizure disorders which are effectively treated and are without EEG abnormalities do not count as contraindication [ ].

In literature an alternative method of topical application of fluorescein without lumbar puncture is introduced.

Iatrogenic cerebrospinal fluid fistulas are usually below 3mm in size, in some cases 2—20 mm [ ], [ ], [ ]. Once a small cerebrospinal fluid leak is confirmed, references recommend conservative treatment to begin with [ ], [ ], [ ], [ ].

In a few cases lumbar drainage was solely carried out [ ]. However, in case of a persisting leak encountered during routine sinus surgeries or e.

Closure of cerebrospinal fluid leaks via endoscopic endonasal approach belongs to the standard repertoire of sinus surgery. There are various approved techniques for repairing defects [ ], [ ], [ ].

The choice of approach does not necessarily influence whether the rhinorrhea ceases when applying the usual diligence [ ].

In general, free and pedicle flaps as well as autogenous, allogenous or xenogenous grafts may be used. Autogenous transplants include mucosa, bone, cartilage, fat, fascia or mucoperichondrium.

For matter of stabilization gelatin, cellulose or fibrin glue may be prepared in different ways [ ]. The initial exposition of the defect is important.

The correct orientation and position of the free mucosa graft has to be carefully taken into account — otherwise an intracranial mucocele may develop [ ].

Generally, larger defects above 5 mm in diameter are closed in several layers, partly with cartilage or bone [ 12 ], [ ], [ ], [ ], [ ], [ ].

Fibrin glue does not have to be applied in every case [ ], [ ]. Regarding certain allogenous material acellular dermis a prolonged healing and crusting phase has to be expected [ ].

Usually routine sinus surgery may be continued after an isolated CSF fistula has occurred [ ]. The further anesthetic management needs to consider the circumstance, hence avoid an increase in CSF pressure or pressure of the upper airways no positive pressure ventilation, deep extubation technique, avoiding coughing and straining.

Most surgeons use nasal packing for 3—7 days [ ], [ ]. In individual cases nasal packing was removed and the patient was discharged on the first day after surgery [ ], [ ], [ ].

As a rule patients are restricted to 1—5 days bed rest [ 76 ], [ ], [ ], and they are released after 3—7 days [ ], [ ], [ ]. Postoperatively the patient has to be closely monitored.

Especially the state of consciousness needs to be mediated closely — in case of loss of consciousness a neurosurgical consult has to take place immediately.

The patient is supposed to elevate the upper part of his bed 40 to 70 degree ; is advised not to lift heavy objects and not to blow his nose for some time.

The same applies to coughing, pressing as well as sneezing; possibly antiallergics, laxatives and antacids are prescribed.

When sneezing cannot be prevented, the patient is advised to sneeze with open mouth [ ], [ ], [ ], [ ], [ ], [ ].

After the complication-prone procedure, a postoperative CT scan [ 76 ], [ ] is appropriate. If an instrumental penetration into the intracranial space as part of the genesis of the CSF fistula could not be clearly excluded, a CT scan is performed emergently and mandatory.

An MRI 6 months postoperative is not generally recommended [ ]. Other authors suggest a fluorescein test 6 weeks after successful defect closure [ ].

This also applies for antibiotic prophylaxis regarding active CSF fistulas in traumatology — in case of intracranial air or concurrent intracranial hematoma, antibiotics are strongly recommended [ ], [ ], [ ].

Even if the data in literature is not consistent, administration of an antibiotic as a prophylaxis of an ascending infection is approved by the majority [ 12 ], [ ], [ ], [ ], [ ], [ ].

Usually, a cephalosporin is preferred, at least initially in parenteral administration [ 12 ], [ ]. The duration depends on how long nasal packing remains, generally approx.

Irrespective of several positive recommendations [ ], [ ] literature generally points out that a lumbar drainage is not indicated for relevant fistulas [ 12 ], [ 76 ], [ ], [ ].

The rate of relapses after the treatment of iatrogenic fistulas with and without drainage does not differ [ ].

In particular, drainage is useful in case of increased intracerebral pressure, in the broadest sense also following the closure of large defects or following revisions.

Regarding literature the same holds true in the event of clearly increased body weight BMI [ ], [ ], [ ], [ ], [ ], [ ]. Recurrence of fistulas is frequently observed in patients with an increased CSF pressure [ ].

Certain guidelines should be followed see above , even flights etc. Active CSF fistulas may result in meningitis. In a few cases 0. If an iatrogenic fistula is treated immediately and adequately without any of the above mentioned complications, medico-legal consequences occur merely as an exception [ 76 ].

In rhino-neurosurgery, the often extensively reconstructed dura represents a weak spot in the therapeutic concept. This fact led, amongst others, to the introduction of the vascular pedicle intranasal mucoperiosteal flaps and to a consistently multilayered defect closure.

A number of special factors determine the particular risk associated with a large dura deficiency: In the majority of cases, especially for postoperative persisting heavy flow of cerebrospinal fluid, revision surgery is advisable [ ].

Regarding inevitably larger defects after extended skull base surgery, local vascular pedicled flaps nasoseptal flaps [ ], flaps from the middle or inferior turbinate [ ], [ ] or, in special cases, also local flaps pericranial flap [ ], temporoparietal flap [ ], palatal flap [ ] are available [ ].

These flaps are superior to free grafts. The dorsal pedicled nasoseptal mucosal flap is most frequently used — postoperatively, however, due to the loss of large area of septal mucosa, un-negligible, long-term modification of the nasal physiology has to be taken into consideration [ ].

Mucoceles rarely develop in the sphenoid sinus after reconstruction with the nasoseptal flaps, even if the original mucous membrane has not been cleared out extensively before [ ], [ ].

The following factors are associated with an increased rate of unsuccessful reconstructions: The lowest rate of postoperative cerebrospinal fluid fistulas was observed in individual case series with a transcribriform approach, whilst the highest rate was observed in a transplanum-transtuberculum approach.

This is caused by a relatively high flow rate of cerebrospinal fluid due to open suprasellar or chiasmatic cisterns.

Additionally the dense anatomy prevents the inserted grafts from adapting naturally [ ]. Other authors report a less favorable prognosis for large-area defects of the anterior base of the skull [ ].

Opinions differ as to whether, even after rhino-neurosurgical operations, there is any indication to provide a lumbar drain after reconstruction of the skull base.

In most cases this is decided individually, supporting a drainage in cases of large defects, heavy cerebrospinal fluid flow or increased cerebrospinal fluid pressure, history of radiotherapy or already preoperatively existing liquorrhea [ ], [ ].

An early drainage can help to relieve pressure variations within the area of transplantation during extubation [ ].

In a medico-legal respect , when cerebrospinal fluid fistulas are found in close proximity to radiologically normative ethmoidal cells, discussions often arise on whether an extended surgery is necessary, i.

As a matter of principle, in each individual case, the extent of the surgery has to be justified from a medical perspective and carefully documented and discussed with the patient.

In case the whole range of manipulations is used up within the boundaries of what had been discussed with the patient before, it is recommended to include an explanatory statement in the operative report.

The findings in preoperative imaging and preoperative endoscopic examination can be different [ ], [ ]. Hence, preoperative imaging does not determine the scope of the surgical procedure restrictively.

The surgeon should in fact remove diseased tissue according to intraoperative findings. In general, localized cerebrospinal fluid fistulas cannot always be avoided, even when the procedure is carried out very carefully [ ].

Functional endoscopic sinus surgery is always tailored to the anatomy of the individual and is not strictly standardized. This issue makes it difficult to analyze surgical results as well as define deficiencies in surgical technique — e.

Postoperatively the individualized anatomy is distorted in the process of healing — intranasal wounds generally undergo secondary healing.

The respective prospects of healing are less favorable for certain patient groups e. After complete ethmoidectomy, the ethmoid shaft scars and shrinks, which is proven radiologically.

In experiments with young animals, midfacial growth had changed postoperatively see 5. For the purpose of prevention, placing mucosal grafts onto the exposed bone in order to avoid a reactive ostitis with secondary thickening of the bone, is recommended [ ], [ ], [ ], [ ].

In principle, the size of an enlarged primary maxillary ostium is not decisive for the condition of the maxillary sinus mucosa; at a diameter of more than 2 mm these ostia are generally function normative [ ].

Synechiae represent a more complex problem. Hence, they are often not mentioned in statistics regarding complications [ 63 ], [ 76 ].

The benefit of special postoperative follow- up in order to optimize healing is partially questioned [ ], [ ], [ ]. On the contrary, the benefit of this treatment for prophylaxis of adhesions and synechiae is stressed by other sources [ 98 ], [ ], [ ], [ ], [ ].

Especially in differentiated and extended surgeries, e. A routine administration of antibiotics does not improve the result [ ]. Non absorbable nasal packing can help to avoid synechiae or adhesions [ ].

Specific placeholders have been developed with the same intention [ ]. Despite of a well-intended fenestration in the middle or, in rare cases, also the inferior nasal meatus, persistent symptoms arise in the corresponding maxillary sinus [ ], [ ] Figure 2 Fig.

Treatment comprises the microsurgical unification of the two ostia with excision of the uncinate process. The treatment again, consists in a surgical unification of the ostia see above.

Preserved, intact uncinate process and persistent obstruction of the natural maxillary sinus ostium due to mucosal edema of the neighbouring mucosa.

The use of a shaver prevents this development [ ]. CT-scan of a patient having been subjected to anterior ethmoidectomy. Lateralization of the right sided vertical lamella of the middle turbinate causing inflammatory retentions in the ethmoidal cavity.

The lateralization of the vertical lamella of the turbinate with its possible adverse effects, e. This may be performed especially in case of an evidently fractured or destabilized vertical lamella during surgery.

Nevertheless, many authors approve of conserving the turbinate [ ], [ ], [ ]. The rate of recurrent nasal polyposis was lower [ ] and there was a tendency of improved olfactory function [ ].

The number of lateral synechiae also decreased, although the synechiae developing during therapy in spite of partial resection were more challenging [ ], [ ], [ ].

In human anatomy the exact dimension of the olfactory region is unknown. In general, postoperative smell deficits may occur after direct mechanical trauma, after removal of olfactory mucosa accompanied by scarification of the latter, caused by a progressive inflammation of the mucosa or even by a postoperative modification of the nasal air passage.

A partial resection of the lower third of the anterior middle nasal turbinate does not affect the ability to smell - in routine resections, there was no evidence of olfactory mucosa in the surgical specimens [ ].

On the other hand, a complete postoperative anosmia was reported, following a resection of the superior nasal turbinate that was done by mistake [ ].

Olfactory fibers in the turbinate bone can also be damaged without any resection, e. After surgery, many of these patients can expect an improvement or a normalization.

For medico-legal reasons, these circumstances suggest that a preoperative measure of olfactory ability should always be performed.

After extensive nasal surgery, secondary atrophic rhinitis may develop Figure 4a Fig. Literature focuses on consecutive states of excessive surgical procedures performed on the inferior nasal turbinate [ ].

However, such an iatrogenic, secondary atrophic rhinitis can also develop after extensive and usually recurrent sinus surgeries, with removal of larger areas of mucous membrane and resection of the middle or superior nasal turbinate.

Right nasal cavity of a patient having been subjected to a rhino-neurosurgical intervention for craniopharyngeoma with application of a naso-septal flap.

Patients complain about a paradox nasal obstruction, in the presence of an objective wide inner nose. Further symptoms are dyspnea, a dry feeling in nose and pharynx, hyposmia and depression.

If the sphenopalatine ganglion is intensively exposed towards nasal airflow after extensive tissue resection, additional pain may be caused.

For unknown reasons, only very few patients develop an ENS after generous resection of turbinate tissue apart from the inferior turbinate - possibly due to the fact that due to the underlying chronic rhinosinusitis, hyperplastic mucous membrane often forms postoperatively.

ENS often develops with a latency period of several years postoperative [ ], [ ], [ ], [ ], [ ], [ ]. In oncological surgeries of the maxillary sinus, the only precaution which can be taken consists in a temporary displacement of the inferior turbinate [ ], [ ].

In routine surgery of chronic rhinosinusitis, the rate of postoperative atrophic rhinitis is roughly between 0. Therapy is mainly conservative, based upon intensive moistening, local care with the administration of ointments or oils [ ], [ ].

Rhino-neurosurgical procedures often lead to a serious, long-term and substantial restriction of postoperative nasal physiology [ ], [ ].

As a matter of principle, an irritating crust formation, accompanied by a restricted nasal physiology, occurs in up to one third of all cases [ 42 ], [ ].

Attaching laminar, pedicled mucous membrane flaps to the nasal septum adjusts this dysfunction [ ]. The extremely irritating crust formation lasts for at least days [ ].

Further possible consequences are synechiae, septum perforations, burns or mechanical skin damage at the nasal vestibulum caused by drills and other instruments [ 42 ], [ ].

In a rather aggressive mode of preparation or when electrosurgical measures are applied in the maxillary sinus, an injury of the infraorbital n.

Bony dehiscences in the channel of the infraorbital nerve increase the risk of such a complication. As a consequence, facial sensibility is affected postoperative [ 76 ], [ ] Figure 5 Fig.

The same applies to the alveolar nerves. In justified individual cases of endonasal procedures, a complementary, localized transoral puncture of the maxillary sinus is recommended in order to remove hyperplastic mucosa in hidden anatomical areas, e.

In an adverse case, a branch of the infraorbital n. A relatively safe location for a complementary puncture is the intersection of two reference lines, i.

In transpterygoid rhino-neurosurgical approach, amongst others, the maxillary or the vidian n. Past references depict single cases of severe orbital complications of vidian neurectomy.

Recent literature only reports occasional cases of e. Concerning the orbital haematoma, the slowly developing, venous hematoma is distinguished from the comparatively fast evolving arterial hematoma [ ].

The incidence of orbital hematomas is around 0. With right handed surgeons, orbital complications are supposed to occur more often on the right side, whilst other authors report a preference of the opposite side [ ], [ ].

A threatening venous bleeding is mostly observed with a delay, i. It is safe to assume that an accumulation of 5 ml of blood can already lead to a dangerous intraorbital increase in pressure, causing a loss of vision.

Therefore, even in case of seemingly slightly developed orbital hematomas, vision must be controlled repeatedly. A simultaneous control of color vision is recommended — here, restrictions occur in a relatively early stage [ 76 ], [ ].

As a basic principle, cooling compresses are applied and the top end of the bed is raised [ ]. In case of threatening development, an emergency ophthalmic consultation is recommended.

Nasal packing is removed and the intraocular pressure is measured. The digital ocular massage is recommended various times in literature; it is, however, contraindicated in patients with illnesses of the bulbus and is debatable even in patients without a special ophthalmological anamnesis see below.

Further conservative treatment and possibly surgery as therapy of threatening venous hematoma is identical to the therapy for arterial bleeding [ ], [ ].

The retrobulbar hematoma as an arterial bleeding with a swift increase in intraorbital pressure is dreaded Figure 6b Fig.

It appears intraoperatively and often even with delay, e. Literature points out rare cases of a hematoma occurring hours later — for outpatient surgery, this has to be taken into consideration [ ].

Patient revealing major right-sided intraorbital hematoma in the course of ethmoidectomy. Lateral canthotomy and also inferior canthoysis have been performed.

Consequently a progressive proptosis with chemosis, pain, congestion of the conjunctival vessels and, eventually, ecchymoses or subconjunctival bleeding develops.

During palpation, a distinct resistance of the orbital tissue is felt and an increased intraocular pressure is noticed. Ocular motility is disturbed and the pupil reaction is pathological in side comparison, reduced or absent pupil reaction , resulting in visual field loss and loss of vision.

The orbital hematoma is a clinical diagnosis. It is not necessary to wait for a radiological confirmation [ ]. The most frequent cause is an injury of the anterior ethmoidal a.

Alternatively, the blood vessel is pulled out of its bed at the base of the skull, together with the onset of the vessel inside the orbit [ 82 ].

A similar event rarely occurs in the posterior ethmoidal a. There is a risk of blindness, though the pathogenesis is not completely clear: A pressure-related occlusion or a spasm of the ophthalmic or the central retinal a.

Other mechanisms are a blockage in the blood flow of the posterior ciliary arteries, caused by pressure or tension.

The increased intraorbital pressure is most likely to produce an effect upon the venous system [ 76 ], [ ], [ ]. According to literature, in case of imminent loss of vision, a maximum duration of about 90 minutes remains until definite amaurosis.

This basically depends on the ischemic tolerance of the retina [ 68 ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ]. A pressure-related interruption of the axonal transport in the optic n.

In animal testing, slightly longer durations — about minutes were determined for the retina [ ], [ ]. Individual factors among others, a preexisting subclinical vasculopathy and anatomical factors can generally strongly modify the tolerance of the organism in regard to an increase in orbital pressure [ ].

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Our study results suggest that this technique can be safely performed in an acceptable time in LC patients. It also appears to be a safe alternative option for residents, left-handed surgeons, and patients with biliary and vascular abnormalities.

While establishing the CVS cannot entirely protect against CBD injury, this technique is applicable to daily clinical practice and may have advantages over traditional approaches in case of significant inflammation [46].

The reviewed literature suggests that judicious establishment of CVS could decrease bile duct injury rate, from an average 0.

Examples of large institutional retrospective series that have demonstrated efficacy of CVS include Yegiyants et al. IRCAD recommendation on safe laparoscopic cholecystectomy.

An expert recommendation conference was conducted to identify factors associated with adverse events during laparoscopic cholecystectomy LC with the goal of deriving expert recommendations for the reduction of biliary and vascular injury.

Systematic search of PubMed, Cochrane, and Embase was conducted. Using nominal group technique, structured group meetings were held to identify key items for safer LC.

Seventy-one IRCAD HPB course participants assessed the expert recommendations which were compared to responses of 37 general surgery course participants.

The key topics included exposure of the operative field, appropriate use of energy device and establishment of the critical view of safety CVS , systematic preoperative imaging, cholangiogram and alternative techniques, role of partial and dome-down fundus-first cholecystectomy.

Highest consensus was achieved on the importance of the CVS as well as dome-down technique and partial cholecystectomy as alternative techniques.

The put forward IRCAD recommendations may help to promote safe surgical practice of LC and initiate specific training to avoid adverse events.

It is actually a potential space used for dissection of its contents without bile duct damage which is the important and challenging maneuver for laparoscopic cholecystectomy [18,19].

Lymph node is also a content of Calot's triangle, is an important landmark for the recognition of cystic artery and duct during for laparoscopic cholecystectomy [20].

To evaluate the cystic lymph node in triangle of Calot's and to detect the association of cystic artery to cystic lymph node at tertiary care teaching hospital Patients and Methods: All the patients who were planned for elective laparoscopic cholecystectomy were admitted and included in this study.

All the participants were evaluated by ultrasound before surgical procedure while laparoscopic cholecystectomy was performed under general anesthesia by applying four port techniques.

The frequencies of the cystic lymph node and associated variations were observed. The cystic lymph node was observed in twenty seven participants with association to cystic artery.

Critical View of Safety: The incidence of bile duct injury after laparoscopic cholecystectomy is 0. This may cause post-operative morbidity to the patients.

Factors associated with bile duct injury included training experience, disease severity, anomalous anatomy and technical errors.

This is a very important step before clipping and ligation of cystic duct and cystic artery for preventing bile duct injury.

However, in case of the cleared anatomy was not visualized, intra-operative cholangiography or conversion to open cholecystectomy should be considered for patient safe.

Laparoscopic Common Bile Duct Exploration: Choledochotomy Versus Transcystic Approach? To compare the difference of primary suture following 3-port laparoscopic common bile duct exploration LCBDE between modified transcystic and transcholedochal approach in the treatment of choledocholithiasis.

The operative time, duration of hospital stay, diameter of the cystic duct, diameter of the common bile duct CBD , complications, and demographics were retrospectively analyzed in all patients.

All operations were successfully performed. No patient was converted to laparotomy. No mortality was associated with the 2 groups.

There was no significant difference between the 2 groups for the operative time A significant difference was observed in terms of the diameter of CBD 1.

The modified transcystic LCBDE was safe and feasible for treating choledocholithiasis but it might be more suitable for the CBD with a smaller diameter.

The aim of the study was to determine results obtained with LC at our setup. This observational case series study was conducted in department of General Surgery, Combined Military Hospital, Rawalpindi, from August to August The study participants were patients of both gender aged years undergoing LC.

Surgery was performed by consultant as well as resident surgeon. Demographic variables, intraoperative findings, mean operation time, hospital stay, conversion rate, morbidity and mortality were evaluated.

Factors influencing rate of conversion were also studied. A total of patients were included. Mean age was Comorbidities were found in Main indication of surgery was symptomatic cholelithiasis Mean operative time was Mean hospital stay was 1.

Major surgical complications occurred in 3. Common bile duct injury CBDI was found in 04 cases 0. Conversion to laparotomy was required in 3.

Factors that influenced the rate of conversion included: Total complication rate was 3. The operative time is short and procedure is standard, safe and effective method both for uncomplicated and complicated cholelithiasis.

Operative Strategies in Laparoscopic Cholecystectomy: Is There Any Evidence? The development of the technique to perform a cholecystectomy by laparoscopy was the beginning of a radical change that, in a few years, involved general surgeons all over the world.

Many surgeons, throughout the world, learned how to perform a laparoscopic cholecystectomy; the technical details most surgeons use are only a matter of personal preference and are not systematically confronted with other propositions.

The chapter examines some of those technical details and the available evidence in their support. Laparoscopic cholecystectomy - An evidence-based guide.

Analyses all aspects of laparoscopic Cholecystectomy Evidence based No recent publication entirely devoted to this topic This book, written by expert surgeons, offers a comprehensive and up-to-date overview of all aspects of laparoscopic cholecystectomy.

Coverage includes the indications for surgery, anesthesia, establishment of pneumoperitoneum, surgical technique, and the prevention and management of complications.

Performance of laparoscopic cholecystectomy in the specific contexts of biliary tree stones and acute cholecystitis is described.

Extensive reference is made to the latest clinical evidence, and the real benefits of the laparoscopic approach, for example in terms of outcomes and day surgery, are carefully assessed.

The learning curve and training are also extensively discussed, and an individual chapter is devoted to the views of international experts in the field.

Some 20 years after the National Institutes of Health Consensus Conference first published recommendations regarding indications for laparoscopic cholecystectomy, it remains the gold standard approach and continues to evolve.

Detection of unsafe action from laparoscopic cholecystectomy video. Wellness and healthcare are central to the lives of all people, young or old, healthy or ill, rich or poor.

New computing and behavioral research can lead to transformative changes in the cost-effective delivery of quality and personalized healthcare.

Also beyond the daily practice of healthcare and wellbeing, basic information technology research can provide the foundations for new directions in the clinical sciences via tools and analyses that identify subtle but important causal signals in the fusing of clinical, behavioral, environmental and genetic data.

In this paper we describe a system that analyzes images from the laparoscopic videos. It indicates the possibility of an injury to the cystic artery by automatically detecting the proximity of the surgical instruments with respect to the cystic artery.

The system uses machine learning algorithm to classify images and warn surgeons against probable unsafe actions. A prospective analysis of laparoscopic cholecystectomies performed by southern U.

The Southern Surgeons Club: A prospective analysis of laparoscopic cholecystectomies. Apr New Engl J Med. The Southern Surgeons Club conducted a prospective study of patients who underwent laparoscopic cholecystectomy for treatment of gallbladder disease in order to evaluate the safety of this procedure.

Seven hundred fifty-eight operations In 72 patients 4. The results of laparoscopic cholecystectomy compare favorably with those of conventional cholecystectomy with respect to mortality, complications, and length of hospital stay.

A slightly higher incidence of biliary injury with the laparoscopic procedure is probably offset by the low incidence of other complications.

N Engl J Med ; Oct J Am Med Assoc. Common bile duct CBD injury during cholecystectomy is a significant source of patient morbidity, but its impact on survival is unclear.

To demonstrate the relation between CBD injury and survival and to identify the factors associated with improved survival among Medicare beneficiaries.

Records with a procedure code for cholecystectomy were reviewed and those with an additional procedure code for repair of the CBD within days were defined as having a CBD injury.

Survival after cholecystectomy, controlling for patient sex, age, comorbidity index, disease severity and surgeon procedure year, case order, surgeon specialty characteristics.

Of the 1 patients identified as having had a cholecystectomy The entire population had a mean SD age of Thirty-three percent of all patients died within the 9.

The adjusted hazard ratio HR for death during the follow-up period was significantly higher 2. The hazard significantly increased with advancing age and comorbidities and decreased with the experience of the repairing surgeon.

The association between CBD injury during cholecystectomy and survival among Medicare beneficiaries is stronger than suggested by previous reports.

Referring patients with CBD injuries to surgeons or institutions with greater experience in CBD repair may represent a system-level opportunity to improve outcome.

An avoidable surgical hazard? Apr Br J Surg. The dramatic reality of biliary tract injury during laparoscopic cholecystectomy - An anonymous multicenter Belgian survey of 65 patients.

Most reports concerning the outcome of patients with biliary tract injury during laparoscopic cholecystectomy come from tertiary referral centers, and results could be very different in the everyday practice of community surgeons.

The objective is to define the presentation, mechanisms, results of treatment, and long-term outcome of biliary tract injuries during laparoscopic cholecystectomy in the setting of a community surgeon's practice.

An anonymous retrospective multicenter survey of 9, patients who underwent laparoscopic cholecystectomy was conducted by the Belgian Group for Endoscopic Surgery, composed mainly of community general surgeons.

Sixty-five patients with bile duct injury were reported on; the incidence was 0. Thirty-four percent of ductal injuries occurred with experienced surgeons, often in association with local predisposing risk factors.

Multivariate analysis demonstrated that the age of the patient odds ratio: Biliary tract injury is associated with significant mortality and complications in the practice of Belgian community surgeons.

Intraoperative detection of ductal injury by the routine use and a correct interpretation of intraoperative cholangiography improved outcome.

The impact of the primary biliary repair on long-term outcome is an argument to refer these patients to specialized multidisciplinary experts. The results highlight the importance of surgical experience, proper selection of patients for laparoscopic cholecystectomy, and conversion to laparotomy in difficult cases.

Laparoscopic anatomy of the cystic artery. Uncontrolled arterial bleeding during laparoscopic cholecystectomy is a serious problem and may increase the risk of bile duct damage.

Therefore, accurate identification of the anatomy of the cystic artery is important. We reviewed the anatomy of the cystic artery and its variations as seen through the video laparoscope.

Small branches of the cystic artery, which we suggest be named Calot's arteries, supply the cystic duct and may cause troublesome bleeding during laparoscopic dissection in the hepatobiliary triangle.

A scissor dissection technique was found most useful for identifying the arterial anatomy. Careful identification of arterial anomalies should help to reduce the incidence of bile duct injuries during laparoscopic cholecystectomy.

Routine or selected intraoperative cholangiography during laparoscopic cholecystectomy? Intraoperative cholangiography can be helpful in cases in which the anatomy is obscured, unsuspected stones are discovered, or anatomic anomalies of surgical importance are found.

There is a difference between open and closed laparoscopic cholecystectomy. It is more difficult to locate the common bile duct during laparoscopic cholecystectomy.

During this procedure, the anatomy is distorted due to the extreme traction at the infundibulum. With a short cystic duct, the common bile duct can become "tented" and simulate the appearance of the cystic duct.

Ductal injuries may be avoided by knowing where the clips should be placed in relation to the ductal system and by obtaining information about the intact display of the distal and proximal ductal system.

The image can be observed immediately by using a modern fluoroscopic system, and permanent documentation can be obtained. We strongly recommend the routine use of intraoperative cholangiography.

Avoidance of bile duct injury during laparoscopic cholecystectomy. Common bile duct CBD injury during laparoscopic cholecystectomy appears to have a higher incidence than during open cholecystectomy.

The indication for a surgical approach is often discussed in literature on the basis of an objective measurement of the intra-ocular pressure IOP [ ], [ ].

However, in daily routine the indication mainly takes place clinically, the pressure conditions can be estimated via comparative bilateral palpation [ ], [ ], [ ].

With individual differences, the orbital pressure is approx. Generally surgery of the paranasal sinuses has no effect on the intra-ocular pressure [ ].

Emergency indication for canthotomy and cantholysis is assumed for an IOP above 40 mmHg [ ], [ ], [ ], [ ], [ ]. In different references, surgery is necessary if the intra-ocular pressure IOP is higher than the mean arterial pressure minus 20 mmHg [ ].

Lateral canthotomy results in a reduction of the intra-ocular pressure by approx. An orbital decompression may cause an additional pressure reduction of 10 mmHg [ ].

With complementary measures e. Lateral canthotomy with cantholysis is an emergency procedure. It is simple and every sinus surgeon should be able to handle it.

The surgery can take place almost everywhere e. At first a straight, small vascular clamp is placed from the lateral canthus towards the border of the bony orbit between the upper and lower eyelid and is compressed.

To restrict surgery merely to this horizontal incisure is not recommended by the majority [ ], [ ] — the inferior and, if necessary, the superior cantholysis should complement canthotomy.

The lateral inferior palpebral ligament between conjunctiva and external skin of the eyelid is identified during the inferior cantholysis.

The palpebral ligament is completely dissected in caudal direction — during this process, it is repeatedly identified by palpation.

The immediate release of the inferior eyelid is noticed when the forceps is held into place with a certain tension at the lower eyelid [ ], [ ], [ ], [ ], [ ], [ ].

Many authors suggest to perform the canthotomy [ ], [ ], [ ] followed by inferior cantholysis only. Others recommend an additional incisure of the upper palpebral ligament if the canthotomy with inferior lysis is not effective [ ], [ ], [ ], [ ].

It is important to consider that the effects of this procedure are limited in time [ ]. If the angle of this protrusion is less than degree, the eye is definitively at risk [ ] Figure 7 Fig.

As a rule, however, the wound is sutured with a delay of 2 to 5 days, e. For secondary reconstruction of the lateral palpebral ligament, the special anatomy of the anchorage of the lateral canthus must be considered [ ], [ ], [ ].

Regarding prognosis it is known from traumatological literature that the risk of permanent blindness with manifest retrobulbar hematoma with accompanied loss of vision is approx.

Vision recovery takes place within a time frame of approx. Prognosis for younger patients is better [ ]. As a consequence the intra-ocular pressure was raised up to a pressure level of 54 mmHg IOP.

Canthotomy and inferior cantholysis reduced the pressure to 32 mmHg and there were no relevant permanent damages [ ]. In other cases, a paraffinoma may develop especially within the region of the eyelids after a sinus operation.

In the event of a often minimal injury of the lamina papyracea with a often mild orbital haemorrhage and if a paraffinic nasal packing ointment strip or ointment is inserted into the nose the paraffin can be absorbed via the mucosal wound in individual cases and transported via blood into the soft tissue of the orbit, respectively eyelids.

In rare cases, the inflammation continues as sclerosing lipogranulamatosis or as orbital pseudotumour, in a rare case this may lead to the development of a sinogen orbital phlegmon.

Spontaneous, partial regressions are rare. Classic paraffinomas should not occur any longer due to modern types of nasal packing in use and due to tendencies to disclaim packing at all.

Despite this fact, appropriate casuistic case reports still exist [ ], [ ], [ ], [ ], [ ], [ ]. If the history of the patient does not include a sinus operation, differential diagnoses are, among others: Two special cases of a lipogranulomatous tissue reaction were reported 2 to 14 days following an endonasal sinus operation, where no oily material was inserted.

There was a palpable tumour of the eyelid, eye movement disorder and proptosis. The granulomas were externally removed by surgery and oral corticoids and also an antibiotic were administered.

Concerning pathogenesis, an intraoperative injury of the orbit with focal fat necrosis and a consecutive tissue reaction on extracellular fat were assumed [ ].

The treatment of paraffinomas is surgical excision. A complete resection is usually impossible because of the diffuse tissue infiltration [ ].

Myospherulosis is related to the paraffinoma. It corresponds to a foreign body reaction of the mucosa to ointments containing lipids.

Typical aggregates of erythrocyte residuals are histologically found in the vacuoles. Factors that predispose the development of myospherulosis are not yet clarified.

Patients tend to present a higher rate of postoperative synechia leading to a high number of revision surgeries [ ]. Myospherulosis granulomas also may form within the area of the eyelid following sinus surgeries with intraoperative haemorrhage of the eyelids and perioperative use of nasal packing with ointment [ ].

The microanatomy of the pterygopalatine fossa and the sphenopalatine foramen plays an important role in sinus surgery [ ]. Further terminal branches of the maxillary a.

If the routine opening of the maxillary sinus in the middle nasal meatus is systematically enlarged in dorsal direction, up to the level of the posterior wall of the maxillary sinus, then, in individual cases, it will be necessary, for anatomical reasons, to cut through a branch of the sphenopalatine a.

Bleeding from the root of the sphenopalatine a. During extended surgical procedures in the area of the infratemporal fossa severe bleeding from the maxillary a.

Instructions to identify the sphenopalatine a. In rare cases, a pseudoaneurysm may form as a result of an injured sphenopalatine artery.

It was discovered 13 days after sinus surgery took place, which is quite early. The authors prefer embolization rather than targeted endoscopic treatment clipping of the maxillary a.

When entering the sphenoid sinus, the surgeon encounters the septal branch of the sphenopalatine a. In the area of the anterior wall of the sphenoid sinus, it is mostly divided into three branches which supply the nasal mucous membrane [ ].

Within the scope of ENT routine surgery, an electrosurgical handling of this vessel is possible without any complication.

In case or repeated perioperative bleeding, angiography with selective embolization will only be performed in extremely rare cases [ ], [ ], [ ], [ ].

This applies especially for embolization in case of a treatment-resistant nose bleeding after routine sinus surgery when the source of bleeding does not evolve the internal carotid artery.

The exposure of radiation during embolization is relevant around 18 minutes in single series. The pharyngeal ramus of the sphenopalatine a.

It is a rare source of bleeding, e. The anterior ethmoidal a. In some of the cases the artery is located directly in the area of the osseous skull base, and more frequently ca.

According to anatomical studies, the anterior ethmoidal a. Arteries at risk are those with a larger distance to the skull base, arteries with bony dehiscences or those running within a ground lamella [ ].

Lateral injuries in the area of a funnel-shaped, medial-directed protrusion of the orbital wall can result in a threatening orbital hematoma, after retraction of the vessel stump see above.

It is situated in the level below the superior oblique m. If the artery has been injured and is bleeding into the ethmoidal cavity, a bipolar or monopolar coagulation is generally used to stop the bleeding [ ].

Many authors avoid the monopolar coagulation at the skull base due to possible secondary damage to the meninges [ ], [ ], [ ]. Alternatively, clips are suggested, which, however, are not always effective, due to anatomical reasons [ ], [ ], [ ].

With a diameter of ca. The distance between the anterior and the posterior ethmoidal artery is approximately 10—14 mm and the distance from the latter to the optic nerve as well as to the anterior wall of the sphenoid is about 8—9 mm [ 12 ], [ ], [ ], [ ].

In a coronal CT, a tip-like protrusion of the medial orbital wall at the location of the posterior ethmoidal a. As a general rule, the posterior ethmoidal a.

A case report depicts a secondary orbital hematoma without significant proptosis, but with blindness [ ]. A subperiosteal orbital hematoma with visual impairment should be equally rare — symptoms were reversible after an emergency hematoma decompression [ ].

Uncomplicated hemorrhages in the posterior shaft of the ethmoid bone are treated with electrocoagulation [ ]. There are important neighbouring anatomical structures, especially the optic n.

The distance between the internal carotid a. Surgery performed in the sphenoid sinus requires sufficient preoperative diagnostic measures based on cross-sectional imaging [ 95 ], [ 97 ].

Particularly in the axial CT, significant anatomical details or variants are displayed: In principle, the carotid a. Dorsally, another prominence of the artery can occur in the lateral wall of the sphenoid sinus.

The bony canal of the artery is 0. The exact incidence rate of carotid injuries in paranasal sinus surgery is unknown. According to literature, carotid artery injuries occur with a rate of 0.

In the last mentioned operations, the risk increases considerably in revision surgery, after radiation therapy or if there is a tumor infiltration of the carotid [ ].

In routine paranasal sinus surgery, the most frequent defect site of the carotid a. In the scope of extensive rhino-neurosurgical procedures, further sources of bleeding, also from smaller branches of the carotid a.

As a matter of principle, every ENT surgeon and every clinic should therefore have clear action plan at hand for the emergency of an internal carotid a.

For paranasal sinus surgery, the following measures are recommended in case of an injury of the cavernous internal carotid a Revision surgery of the respective sphenoid sinus revealing a partly exposed coil green arrow: Additionally, the arterial injury can no longer be identified in the angiographic image, so that the otolaryngologist has to loosen the nasal packing and the angiography is repeated [ 95 ], [ ], [ ], [ ].

Due to the former reason the otolaryngologist should be present during neuroradiological diagnostics and intervention [ ].

In case of a very small lesion in the carotid vessel — provided appropriate local conditions, sufficient medical status of the patient and capabilities to pack the nose repeatedly — the surgeon should at first create an optimum access to the sphenoid sinus.

The placement of an autologous muscle graft or allogenic material is recommended. This construction is fixed with fibrin glue and is tightened with packing.

Alternatively, under favorable conditions, a specific vessel clip may be used [ 97 ], [ ]. Occasional reports point out that such a supply was permanently successful preserving the arterial circulation [ 96 ].

For this reason an angiography is indicated postoperatively [ 95 ], [ 97 ], [ ], [ ], [ ], [ ], [ ], [ ], [ ]. In case of an aneurysm secondary neuroradiological treatment is performed.

During a primary neuroradiological intervention after an accidental lesion of the carotid a. Here, specific complications, such as a vessel dissection, thrombosis, embolism or a vessel perforation have to be kept in mind.

Balloons can get displaced and then may increase the risk of new bleeding. Postoperatively, patients with vessel stents receive anticoagulant drugs Clopidogrel, ASS mg [ 95 ], [ ], [ ], [ ], [ ], [ ], [ ].

Within the first 24 hours after the neuroradiological intervention, a CCT control should be performed.

Later on a control angiography should take place [ ], [ ]. The defect site in the sphenoid sinus should be covered secondarily, for example with fascia [ 95 ] Figure 9 Fig.

Hemorrhages from the cavernous sinus are mostly much less demanding. Bleeding is interrupted by placing hemostatic material directly and applying smooth pressure.

The material is inserted, covered with neuro-cotton wool and lightly pressed [ ]. In principle, hemostasis during rhino-neurosurgical procedures as well as during sinus surgery is based upon bipolar coagulation, compression, nasal packing or ligature as well as upon the application of clips.

However, in case of an exposed dura, a sufficient compression is not always possible and an external nasal packing additionally creates the risk of bleeding in intracranial direction.

Immediately after the incidence, a second suction is introduced into the operating field and the endoscope is directed to a protected place; if applicable, equipped with a rinsing and suction device.

In favorable individual cases, it might be possible to direct the jet of blood into the suction, to display small lacerations of the artery and to fuse and glue them by means of bipolar coagulation [ ], [ ], [ ].

The use of an intraoperative Doppler is recommended as a measure of prevention [ ], [ ]. If an ordinary hemostasis is not successful, further nasal packing is applied and an emergency transfer of the patient to the neuroradiological ward is carried out [ ].

The prognosis of an injury of the carotid a. An injury of the carotid a. This condition is treated through neuroradiological intervention [ 89 ], [ ], [ ].

Even after a successful occlusion-test complications following the definitive occlusion cannot be excluded [ 95 ], [ 97 ], [ ], [ ].

In this regard, very different frequencies are found in literature: The average bone thickness in the direction of the sphenoid sinus is 0.

Hence it is even more important to look out for a history of previous eye defects preoperatively. Perioperatively, this damage might only appear to deteriorate, e.

As a consequence, unnecessary emergency measures might be taken, even medico-legal problems might arise [ ].

Perioperative blindness in paranasal sinus surgery occurs in case of a direct injury of the nerve, a drug-induced interruption of local blood supply or a hematoma in extremely rare cases also by an emphysema, see above or in case of damaging the central nervous system, as, for instance through meningitis [ 76 ].

Direct mechanical damage to the optic nerve is only reported in exceptional individual cases [ ], [ ]. Here, during removal of the covering bone, the nerve can be damaged or destroyed in the cranial, lateral wall of the sphenoid sinus [ ] or within the orbit [ ].

In other cases, injuries of the optic n. A case report of a severe, direct injury of the eyeball across the lamina papyracea caused by an electrosurgical tube without direct nerve damage seems to be exceptional [ ].

In case of an injury of the optic n. Compared with direct lesions, indirect injuries of the optic nerve caused by a retrobulbar hematoma occur more frequently [ 83 ], [ ].

Loss of vision as a complication of adrenaline-soaked e. Adrenaline resorption with consecutive spasm of the vessel network around the optic n.

After every postoperatively noticed or supposed visual reduction, an ophthalmological emergency consultation should occur. MRI is strongly recommended [ ].

After mechanical injury of the nerve, collateral damage has to be searched for, e. If the optic n. Even if nerve continuity is preserved, the immediate treatment of the perioperative visual reduction is problematic.

The regimen is individualized and is under ophthalmological guidance. If neurapraxia or a hematoma is suspected, a high dose corticosteroid treatment is followed out e.

The concept is aligned to the treatment of traumatic optic neuropathy — evidence of which, however, still remains a subject of debate [ 71 ]. Traumatology and neurology provide some experimental evidence to suggest that corticosteroids may also hinder the restitution of an optic nerve [ ], [ ], [ ], [ ], [ ].

In specific cases, decompression of the nerve may be discussed — however, its benefit has not been proven yet [ 12 ], [ 76 ]. Under certain, adverse conditions, the symptoms of an ischemic optic-neuropathy may appear within the scope of sinus surgery, a disease of which little is known.

In these rare cases, neither mechanical injury of the nerve has occurred nor has the lamina papyracea been damaged. The exact pathogenesis is not yet known.

The resulting loss of vision or visual field reduction emerges immediately or with a delay of several hours to days. MRI displays a vaguely defined and swollen optic n.

A decompression of the optic nerve does not always seem appropriate. Administration of cortisone e. An immediate normalization of blood pressure and hemoglobin by means of transfusions seems essential [ ].

A case report described residual ethmoidal cells revealing opacification. An emergency revision surgery was performed with decompression of the orbit and periorbital incisure.

Additionally, high dose corticosteroid treatment Prednisolone mg intravenously and calculated antibiotic treatment was initiated. Within a period of 4 weeks the condition of the patient improved.

In another case, the optic n. These two cases were interpreted as a consequence of an infectious impairment of the optic n.

In endonasal surgery of the paranasal sinuses, an impairment of the medial rectus m. In general, these injuries result of a fracture of the inferior lamina papyracea with perforation, destruction or incarceration of the muscle.

The middle or posterior ethmoid is most at risk — as hardly any fat is situated between the muscle and the bony orbital wall [ 76 ], [ ], [ ], [ ]. In rare cases, there is a particular risk due to a congenital or posttraumatic bulge of the lamina papyracea with or without direct embedding of parts of the muscle [ ], [ ].

Other eye muscles are distinctly less often injured intraoperatively: The inferior rectus muscle may be damaged in surgeries involving the maxillary sinus and the superior oblique trochlea muscle may be lacerated in extended endonasal frontal sinus surgery with a drill for instance.

Injuries of the inferior oblique m. In the majority of cases, only one eye muscle is damaged, with a relevant orbital hematoma developing additionally in one quarter of patients.

Occasionally, however, severe combined damage affecting three muscles, for example, has been observed with additional bleeding, retinal damage or lesions of the optic n.

Generally 5 typical causes for a postoperative motility disorder of the eye may be distinguished:. Muscle tissue that is surprisingly evident in routine histologic specimens Figure 10 Fig.

In general, periorbital damage should be detectable intraoperatively by means of the bulbus pressure test [ ].

If, beyond that, intraoperatively suspected eye muscle damage occurs, an ophthalmologist should be notified and consulted immediately [ ], [ ]. With few exceptions, diplopia appears immediately after the operation as a result of the injury [ ].

All relevant findings should be submitted immediately for evaluation by means of imaging. The clarification of an eye muscle injury with displacement or incarceration or the display of a contraction of the dorsal muscle parts most likely succeeds after complete sectioning with a contrast-enhanced MRI; evaluation is done in three planes.

At best, multipositional MR imaging might allow to draw conclusions about the contractility of the muscles.

In the further course, a repeated MRI may also document stages of repair, as swelling of muscle tissue is followed by atrophy. Other sources recommend a CT as initial diagnostic measure for all orbital complications, as differentiated analysis of the injury is hindered initially through hematomas and accompanying edema [ 71 ], [ 76 ], [ ], [ ], [ ], [ ], [ ].

Generally, the findings of CT and MRI correlate well with the ophthalmological functional examinations [ ]. Regarding treatment of acute, iatrogenic eye muscle damage, an early surgical intervention should be performed within 1 to 2 weeks, if a muscle was completely intersected or if an incarceration of tissue or a skewering of bone fragments into the muscle is suspected clinically or via imaging [ 71 ], [ ], [ ], [ ].

A reconstruction of the medial rectus m. In case of excessive destruction, a muscle transposition might be sought; alternatives are graft interpositions or specific suturing techniques [ ], [ ], [ ], [ ].

In order to exclude corresponding damage in revision surgery, aggressive orbital dissections should be avoided during further surgical therapy [ ].

Reconstruction of the medial orbital wall directed to the ethmoidal cavity, using alloplastic material, often cannot prevent a secondary, bothering scar formation [ ], [ ].

In individual cases, an immediate cortisone therapy is applied in an effort to minimize the inflammatory response of the orbital tissue [ 71 ].

In case of partial damage, literature recommends both an observant and an active approach [ ]. Contractures of the antagonists of damaged muscles can already be observed after 2 weeks.

Especially in cases of severe injuries, revision surgery performed before fibrosis begins to occur, i. In contrast, spontaneous improvements were observed within a period of three months after slighter neuronal, vascular or direct muscle damage [ 71 ], [ ], [ ].

By means of botulinum toxin injections into the antagonists of damaged muscles, diplopic images can be improved faster, a secondary contracture of the antagonist is prevented and the traction force applied to the damaged muscle is reduced.

For reasons which are not fully known, the injection can make a positive contribution to a long-term functional alignment of the extraocular muscles [ 76 ], [ ], [ ], [ ].

In appropriate cases, the injection is combined with a surgical muscle reconstruction [ ], [ ]. Other forms of impairment are treated conservatively in the beginning [ ].

If the muscle is only affected by bruising, neural or vascular damages, it may be justified to wait for 3—12 months [ 71 ], [ ], [ ].

Two to three months after a damage caused to the medial rectus m. In two thirds of cases, several operations will be necessary [ ], [ ].

Extremely severe damages of the ocular muscles and the orbital tissue have been reported after the use of the microdebrider [ 71 ], [ 76 ], [ ], [ ].

The medial rectus m. This may also occur without any prominent orbital injury. Often the surgeon is not even aware of the damage. The perforation in the lamina papyracea may be difficult to identify, even in postoperative imaging [ 17 ], [ 71 ], [ ], [ ], [ ].

In other cases, motility limitations can be distinctly higher than the damage seen at imaging. After injuries caused by the shaver, chances to reconstruct the medial rectus muscle successfully are rather limited [ ].

In rhino-neurosurgical operations, especially in the parasellar and suprasellar region, in the area of the cavernous sinus or the clivus, thermal injuries or transections may lead to injuries of the abducens n.

Frequently the oculomotor nerve recovers postoperatively from damages as long as the continuity of the nerve is preserved [ ].

For various reasons, a mydriasis can occur during paranasal sinus surgery:. In individual cases, pupil differences without pathological substrate can occur during anesthesia.

In a small percentage of the population, an observable anisocoria i. Under general anesthesia, the light reflex cannot be judged.

Therapy with opiates e. Fentanyl leads to miosis which, however, can decrease, due to an intraoperative sympathicus stimulus.

Individual factors affect the size of the pupils during extubation; in some cases even, side differences, lasting about 20 minutes may occur during this process.

Based on the described circumstances, a number of recommended precautions can be deduced:. During the operation, the eyes should always remain free from textile covering.

The scrub nurse should get used to control the eye from the outside while surgery continues in the inside of the nose.

Hence complications are indicated by a passive concurrent movement of the globe and can be noticed early. Generally, a serious acute narrow angle glaucoma can be triggered by sympathomimetica in predisposed patients [ ].

The placeholder had perforated the dorsal orbital apex and caused permanent changes in the pupils. Even an emergency revision surgery with removal of the foreign material did not result in an improvement [ ].

Paranasal sinus surgery, in the broader sense, with extensive removal of the mucosa can cause a scarred distortion of the entire ethmoidal cavity in adults, combined with a medialization of the lamina papyracea.

These transformations can be identified by postoperative imaging and may be associated with a subclinical enophthalmos [ ], [ ].

In children, after paranasal sinus surgery, a postoperative hypoplasia of the maxillary sinus with no external changes was described radiologically [ ].

After unilateral ethmoidectomy in a pediatric case of an imminent orbital complication, merely a minimal facial asymmetry was visible in the postoperative CT [ ].

A similar case of a postoperative scarred stenosis of the maxillary ostium and a secondary maxillary sinus atelectasis with postoperative enophthalmos 3 mm was also observed in an adult patient [ ].

Studies in traumatology revealed that even with minor injuries 0. Individual cases are reported which tend to concur with this observation, describing a postoperative enophthalmos after injury of the medial orbital wall and the medial rectus m.

Surgeons performing a paranasal sinus operation should be familiar with position and size of the efferent lacrimal ducts: In half of the cases, the lacrimal sac is covered by parts of the agger nasi and in almost two thirds of all cases, the uncinate process is overlapping the lacrimal sac [ ].

The distance between the free edge of the uncinated process and the anterior edge of the lacrimal sac is 5 mm 0—9 mm [ ], for the maxillary sinus ostium the distance is approximately 4 mm 0.

The lacrimal bone is very fragile, compared to the frontal process of the anterior maxilla. Epiphora develops in about 0.

Under favorable circumstances, such cases correlate with an unintended dacryocystorhinostomy [ ], [ ], [ ] Figure 11 Fig.

An injury mostly occurs during infundibulotomy uncinectomy , during surgery on the anterior frontal recess or during maxillary sinus fenestration in the anterior middle nasal passage — in the latter, particularly during the use of the backward cutting punch [ 71 ], [ ].

Injuries occurring during a fenestration in the inferior nasal meatus should have become rare [ 91 ]. During the course of a routine sinus operation, frequently parts of the lacrimal bone or parts of the frontal process of the maxilla are removed in an undirected manner, without any direct malfunctions resulting.

In right handed surgeons, the left side is supposed to be affected more frequently [ ]. Pressure applied on the medial angle of the eye under endonasal endoscopic control can help to identify the tissue of the lacrimal sac and to prevent it from damaging during further manipulations [ ].

After a relevant lesion of the efferent major tear ducts, the symptoms appear directly after the operation or with a delay of weeks.

Postoperative epiphora can subside spontaneously if the inflammatory reaction caused by the surgery has decreased [ 68 ], [ ]. Each patient with postoperative epiphora should be examined thoroughly.

In case of doubt, an ophthalmologist should be consulted. There are often no direct consequences and the patient is kept under observation. If after one week, epiphora is still present, advanced diagnostic measures are indicated.

In special cases, a CT with dacryocystogram can produce additional information. The treatment of symptomatic iatrogenic lacrimal duct stenosis in general is dacryocystorhinostomy [ 98 ], [ ], [ ].

Success of the operation may be limited due to an insufficient position or size of the lacrimal duct fenestration, combined with portions of bone or remains of the medial lacrimal sac left behind.

During the first 4 weeks after the operation, the intranasal neo-ostium is shrinking regularly and then remains stable. The result of the surgery is affected by an excessive scar formation or enhanced granulations, for instance after extensive resection of mucosa.

Further causes are synechiae, e. Irregular scars can trigger frontal sinusitis. Mechanical rinsing of the tear ducts from outside is retained in these cases [ ], [ ], [ ], [ ], [ ].

Skin injury in the medial corner of the eye should be extremely rare, additionally, retrobulbar hematomas, eye muscle injury, burns at the nostril, stenosis of the canaliculi or conjunctival fistulas may occur [ ].

The same applies for a case report of a cerebrospinal fluid fistula during the mechanical reclination of a deviated nasal septum for the purpose of exposing the lacrimal ducts [ ].

If splints for lacrimal ducts stents are applied intraoperatively, this may result in a conjunctival irritation for example, the formation of a loop , secondary injury of the lacrimal punctum or a premature loss of the splinting [ ].

In individual cases, problems arise during or after removal of the splint, e. In case of doubt, an inefficient dacryocystorhinostomy should be followed by endonasal revision surgery.

Depending on their location, synechiae can be treated by a reduction of the tip of the medial turbinate or even correction of the nasal septum [ ].

Patients should be reminded that postoperatively, even after a successful surgery, air might get constantly blown into the medial corner of the eye whilst blowing their noses.

A pneumocephalus is the presence of gas air in the cranial cavity. In most cases, it is based on a communication between extracranial and intracranial space.

The air can be present in epidural, subdural, subarachnoid, intraventricular or intracerebral spaces. It might be tolerated well in one case, yet in other cases it could be responsible for dangerous findings and symptoms [ ].

However, air entrapment is not obligatory in every skull base injury Figure 12 Fig. A second pathomechanism is air being sucked in, after cerebrospinal fluid has been discharged.

As a result intracranial pressure increases gradually and a tension pneumocephalus develops. Symptoms are an altered state of consciousness, restlessness, headache, nausea, vomiting, eye motility disorders, ataxia, and spasms.

If the underlying process is not interrupted, a pressure effect in the interhemispheric fissure close to the motor cortex might induce a diplegia.

Additionally rupture of bridging veins may cause subdural hematomas and finally cardiac arrest [ ], [ ], [ ], [ ]. In individual cases, the neurological symptoms may have a latent period of several days [ ].

The mass effect of air does not always have to be spectacular and is not always bilateral [ ]. After the diagnosis has been confirmed in the emergency CT scan, immediate neurosurgical decompression has to take place, e.

Intracerebral tension pneumocephelus may occur in rare cases. In those few cases, ineffective defect closure at the skull base was followed by a progressive accumulation of air subcortically in the frontal brain.

The pathophysiology and therapy are consistent with the usual tension pneumocephalus; the intracerebral air bubble may be released by means of a puncture.

The same applies for extremely rare cases of an intraventricular tension pneumocephalus after paranasal sinus surgery. The specific cause for this intraventricular accumulation of air is not yet known [ ], [ ].

Postoperative meningitis is rare, although it represents the most frequent intracranial complication in paranasal sinus surgery. It spreads through dural lesions, perivascular or vascular paths or even via perineural spaces of the olfactory fibers [ 90 ].

In rare individual cases only, an intracranial abscess or septic thrombosis of the cavernous sinus can be classified as a true complication of paranasal sinus surgery [ ].

More frequently, they develop on the basis of a preexisting inflammation of the mucosa in the paranasal sinuses [ 90 ].

The incidence is within the same range as in conventional intracranial surgery or in pituitary surgery [ ], [ ], [ ], [ ], [ ], [ ].

Meningitis may occur with a delay of e. When suspecting meningitis a CT scan has to be ordered immediately followed by a lumbar puncture. Symptoms or findings are e.

The patient should be monitored intensively and an active cerebrospinal fluid fistula needs to be detected [ ]. Mainly responsible are staph. Acute sinusitis is more frequent postoperatively, for instance in the area of the surgical corridor of the sphenoid bone.

Here, revision surgery including a microbial probe is recommendable [ ], [ ]. Most studies imply that prophylactic administration of antibiotics does not reduce the risk of meningitis or brain abscess in skull base surgery [ ].

In case of antibiotic prophylaxis, it should be applied half an hour before the first incision; in uncomplicated rhino-neurosurgical operations, it may be restricted to 24—48 h [ ], [ ], [ ], [ ].

Other rhinological references recommend antibiotic treatment 3 days preoperatively for 7—14 days — depending on the duration of nasal packing [ ], [ ], [ ], [ ].

Preoperative microbial swabs are inappropriate for calculated antibiotic treatment [ ], [ ]. When there is an intolerance, vancomycin or clindamycin are also recommended [ ], [ ], [ ], [ ], [ ], [ ].

Uncomplicated cerebrospinal fluid fistulas have been mentioned in 4. They may lead to severe complications, e. Additionally this may result in an epidural, subdural or intracerebral haematoma, a localized cerebral infarction or even a traumatic aneurysm [ 90 ], [ 91 ], [ ].

Instantaneous fatal bleeding can possibly occur due to an injury of the internal carotid a. Serious damage can also be triggered by induced arterial spasms [ 90 ].

The defect at the skull base can cause a secondary herniation of brain tissue [ ]. An iatrogenic encephalocele can develop slowly within months and might only become apparent though meningitis [ ].

After extensive reconstruction of the frontobasal region and after a large amount of CSF has been discharged, intracranial pressure may drop, which in turn can result in displacement of the graft or tension on the bridging veins causing a subdural haematoma.

For these reasons, a lumbar drainage is contraindicated in case of a prominent pneumocephalus. After extensive surgical procedures, a CT control must be performed on the first or second postoperative day [ ].

Fatal, partially lethal complications with mechanical destruction of cerebral tissue are limited to extremely rare cases in routine paranasal sinus surgery.

Corresponding reports are mostly from earlier decades [ ], [ ]. In individual cases, severe combined injuries of brain and vessels can occur, e.

Smaller case series report a clustering of corresponding incidents, partly on the right hand side and partly on the left hand side [ ], [ ].

The same applies for the accidental discovery of cerebral tissue during routine histology. Serious injury patterns have also been induced accidentally with the shaver.

Postoperatively, patients show suspicious symptoms such as lasting clouding of consciousness, disorientation or somnolence, and, in addition, focal neurological signs, for instance myoclonia or headaches in recovery phase.

In other cases, postoperative bleeding with liquorrhea occurs [ ], [ ], [ ], [ ], [ ], [ ]. In rare cases, after a supposedly normal operation and healing process, only atypical or strikingly intense headaches were observed [ ].

In case of doubt, a cCT or an MRI should be ordered immediately, in order to determine the existence and extent of the damage and to exclude a pneumocephalus or bleeding requiring therapy.

The MRI displays more subtle parenchymal damage and also the chronological sequence of a resorption of hemorrhages [ ], [ ].

In an acute case, emergency neurosurgical consultation has to be performed directly after imaging. In medico-legal assessment of cerebral trauma during routine sinus surgery, the discussion erratically accentuates regarding surgical negligence, if cerebral tissue is evident in routine histology and if the patient does not display anatomical or constitutional abnormalities.

Another topic of discussion is the putative direct damage of brain tissue by instruments. The intracerebral injury pattern as revealed by imaging might provide guiding hints: In contrast, an unknowingly triggered subarachnoid hemorrhage in case of a superficial injury of the skull base does not unambiguously indicate negligence, even if severe secondary neurological damages occur [ ].

In rhino-neurosurgery, the continuously increasing complexity of surgical procedures naturally also induces a higher number of differentiated neurological complications.

In positive case series, temporary neurological deficiencies are reported in 2. In the area of the pituitary, e. The rate of severe intra- or perioperative complications including infections and organ failure was 2.

Here, patients older than 60 years, patient with complex surgeries and patients with postoperative CSF fistula were particularly affected [ 70 ].

The primary infection often is not very distinctive. However, released toxins act as superantigens and quickly generate a progressive disease with a disease pattern similar to sepsis.

In otorhinolaryngology the transition from the nasal colonization to infection by staph. In a large number of cases the initial source is nasal packing.

Rare cases have occurred in connection with the use of septum foils, due to a special postoperative formation of crusts or following chronic or acute rhinosinusitis without any abnormalities [ ], [ ], [ ], [ ].

In a single case a TTS with primary, life-threatening phlegmonous gastritis occurring shortly after sinus surgery was reported [ ].

Individual cases of illness may develop with a delay, i. A secure protection by perioperative prophylactic antibiotics or antibacterial ointments does not exist [ ].

The resulting sepsis develops rapidly, e. The first therapeutic goal is eliminating the bacterial source. Blood cultures are taken. Therapy is based on substituting fluid, adjusting the acid-base balance and electrolytes as well as monitoring renal function.

Regarding combined antibiotic therapy, recommendations should be taken into consideration where certain substances have shown to lead to a reduced toxin release e.

Further treatment, if necessary, is performed according to guidelines for bacterial sepsis. Criteria of toxic shock syndrome TTS from [ ]:.

The topography of the olfactory mucosa and postoperative hyposmia was noted in chapter 4. The rate of postoperative anosmia as a complication of sinus surgery is about 0.

In rhino-neurosurgical surgery, anosmia may be an inevitable consequence due to tumour resection e.

Hence, detailed preoperative informational conversation is useful, but currently still not common [ ], [ ]. Adequate instrumentation is fundamental in endonasal endoscopic sinus surgery.

The hospital manager has the duty to equip the surgeon with appropriate instruments [ ]. In the present context these necessarily include optical aids such as endoscopes in different angles.

Requirements are significantly enhanced for Rhino-Neurosurgery [ ]. Recently video system standards have improved significantly HDTV.

In light of this, previous studies need an update in regard of technical standards [ ]. In contrast, it must be noted that endonasal procedures using headlights are still considered as equal [ ], [ ].

These kind of problems occur especially after lengthy rhino-neurosurgeries [ ]. For endonasal haemostasis an equipment for bipolar coagulation is necessary.

Monopolar instruments are generally appropriate, but its use in the sphenoid sinus, the base of the skull and intracranially rhino-neurosurgery is not recommended [ ].

After using the shaver, faster healing with a lower rate of interfering crusts, synechia or scarring displacements of the middle turbinate was reported in literature [ ].

From other sides, no corresponding benefits have been described [ ], [ ]. The particular risk of shavers has been pointed out in detail [ ], [ ].

There is no valid data on the absolute rate of complications compared to conventional instruments. However, the dimension of the damage caused by accidents with a shaver is often increased see above.

For the overall result, true cutting micro-instruments neither provide specific benefits [ ], [ ].

They lead to a reduced rate of postoperative synechiae- but they have no effect on the subjective and objective surgical outcome [ ].

Similar problems were reported due to damaged isolation of electrosurgical devices [ 65 ]. Robot systems in sinus surgery are in their early stages of development [ ], their use in routine surgery is in remote future.

Generally the balloon dilatation of sinus ostia may be considered as a safe surgical procedure [ ], [ ], [ ]. The most common problem in dealing with these systems is that the ostium or channel is impassable for the guide wire.

This may be caused by scars, anatomical irregularity or local polyp growth. As a result, a complication of inadvertent dilation of the secondary maxillary ostium, a submucosal passage of the guide wire and balloon or an injury of the orbit may occur [ ], [ ].

The dilatation of the frontal sinus ostium might cause local microfractures, which in turn may lead to sinusitis relapse via local inflammation respectively osteitis [ ].

In a single case, a local lymphoma was overlooked during dilatation [ ]. In a single case, a septal hematoma occurred during dilation of the sphenoid ostium — the patient though was under a permanent warfarin therapy due to cardiac disease [ ].

In addition, one case report deals with a lesion of the skull base during dilatation of the frontal sinus, probably caused by the rigid guide catheter [ ].

This image has changed: The numbers reflect an increase of navigation use in routine surgery [ 11 ], [ 13 ], [ ].

In anatomical preparation, inexperienced surgeons had less complications when using the navigation device. Identification of landmarks is more accurate, though surgery takes longer time [ ].

Statistical evidence for a reduced rate of complications in clinic, however, is almost impossible - under normal conditions several thousand subjects would be required in each cohort [ 15 ], [ ], [ ].

A tendency in favour of lesser complications when using navigation has been observed, especially less injuries of the orbital cavity and CSF fistulas [ 15 ], [ ], [ ], [ ].

Surgeries were less frequently interrupted due to bleedings, although the total blood loss in the use of navigation was higher [ ].

Other authors did not notice any effect on intraoperative complications or the subjective or objective result of the operation [ 15 ], [ ], [ ], [ ], [ ], [ ], [ ].

Complications were also caused by navigation- in some cases e. In regard of these facts, the surgeon must be advised to control the system repeatedly during the operation by means of identified landmarks [ ], [ ].

Generally a divergence of mm in routine surgery can be expected [ ], [ ], [ ], [ ], [ ], [ ], [ ]. For the economic evaluation of medical navigation devices a setup time of about 15 min per case must be taken into account.

For new systems, these values may be higher [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ]. Also, in case of an inexperienced surgeon the surgery itself is prolonged by approximately 16 min [ ].

When technical inadequacies occur, time loss is significantly higher, and an additional amount of time is needed to adjust the data set [ ].

Technical problems of navigation devices can lead to the termination of the procedure [ 65 ]. Other authors deny the loss of time, stating that especially during long procedures, time for setup is balanced by straightforwardness of the surgery [ ], [ ], [ ], [ ].

Generally, the costs increase with the use of navigation systems. Here additional costs and stress must be taken into account [ ], [ ]. Other authors limit this range of indications in surgery for chronic rhinosinusitis to e.

Due to a survey of surgeons, the extent of the disease does not imply a benefit of the navigation system [ ]. However, is a system available, it is often used in routine [ ], [ ].

It promotes the subjective safety and the anatomical precision, but does not replace the expertise [ ], [ ], [ ] — the otorhinolaryngologist must master the anatomy and must not rely on a navigation system [ ], [ ].

As reflected in literature navigation systems are thus not indispensable components of the technical standards in routine paranasal sinus surgery.

In other non-routine exceptional cases, however, not using navigation assistance needs to be justified [ ], [ ], [ ], [ ].

Regarding rhino-neurosurgery other conditions are applied: It reduces the duration of the surgery and reduces the rate of complications [ ], [ ].

Experienced and inexperienced surgeons have a different access to navigation systems:. Experienced surgeons use the navigation system in routine surgery in order to save time and to reduce personal time constraints.

The basic surgical strategy does not change, although comparatively more extensive procedures e. There are different views concerning the influence of navigation on the completeness of routine interventions [ ], [ ].

In any case, subjective safety is higher and confidence in the technology increases with experience [ ], [ ], [ ], [ ], [ ].

Junior otorhinolaryngologists benefit from navigation systems during their training [ ], [ ], [ ], [ ].

Untrained surgeons use the system more frequently than advanced surgeons, preferably in the area of the sphenoid sinus, the lamina papyracea, the skull base and frontal sinus.

The completeness of the procedure increases subjectively and objectively [ ], [ ]. For this reason, a general application is not recommended by different authors [ ].

It has become customary to retrieve routine procedures by specific preoperative checklists before and during surgery. A positive impact on formal procedures in the operating room was proven, a desired effect on the rate of complications can statistically not be secured [ ], [ ].

Standards of care in documentation and cooperation must be followed in sinus surgery. Operative reports should generally be written within 24 hours, and should not be modified at a later stage [ 76 ], [ ].

During the entire hospitalization flaws in communication between physicians, patients and nurses or among physicians can lead to significant therapeutic and medico-legal problems [ 65 ].

Clinical procedures must be planned, secured and controlled taking into account the fact that monitoring and patient care is shared [ ]. When complications occur, the attending physicians are well advised to pay attention to document all measures of diagnosis and therapy intensely.

The surgeon is personally obliged to accurately inform all following physicians even at inconvenient times. For means of prevention different strategies are applied.

A strict, systematic, direct analysis of preoperative imaging of each patient by the surgeon just before surgery in the OR is recommended.

In the last decade preoperative imaging was not necessarily performed in every case, even a survey radiograph had been commonly used [ ], [ ].

The standard of preoperative imaging has changed, however: Reconstructions from axial spiral CT data sets are acceptable regarding certain quality standards [ ], [ ], [ ].

In case of complex surgeries or extended frontal sinus surgery all three planes should be available [ 82 ], [ ], [ ]. Special instructions for evaluation of preoperative CT scans were presented [ ], [ ] Table 2 Tab.

In particular, pre-existing anomalies malformation, condition after surgery, condition after trauma, destruction of tumours should be taken into account [ ] Figure 15 Fig.

Minor anatomical irregularity revealing asymmetry of the ethmoidal roof of the left and right side. According to some authors, the rate of intraoperative complications is definitely higher if the corresponding CT images are not present in the operating room [ 76 ].

Other authors explicitly did not notice any corresponding influence [ 86 ], [ ]. Nevertheless, the majority of authors supports the view, that constant access to imaging modalities during sinus surgery represents currents standards.

In analogy with this view there are reports dealing with an injury of the internal carotid artery due to missing axial CT scans [ ] or an encephalocele which was overlooked, resulting in CSF fistulas [ 76 ].

Rhinologic literature presents various forms and properties of nasal packing with their specific risks [ ]. Nationally and internationally, there is an increasing tendency to abolish nasal packing in routine sinus surgery [ ], [ ].

Accidentally remaining nasal packing in the nasal cavity is very rare [ ].

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