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opinion Uncategorized

Top Ten Things -Tech Gadgets- That Have Grabbed My Attention, 2021

Okay, so I have made this intermittent list of top ten gadgets and gewgaws which I used to to call “Top Ten Things to Get Your Favorite Vascular Surgeon” but even in jest, over the years that I have been publishing this blog, the world has changed. As a watcher of technology, I have always had my eye out for the next great thing, and here is my list. I hope you all have a great Christmas and a wonderful New Year.

  1. Giant Laptops with Complications -old automatic watches with complications are still coveted, and the tech space is no different. Whereas, Apple has always veered to minimalism, there is an exuberance to adding “stuff” in among the Chinese manufacturers and ASUS is no different.

This laptop, the ASUS ZenBook Pro UX581 is a perfect example of innovation by jamming as much possible onto your ADHD-addled field of view. What would I use it for? Who knows, but I want!

2. Timex watches retroversions. Like automakers making updated versions of classic muscle cars, the old standby Timex, has launched watches that that make you want to party like it’s 1979.

The Navi XL Automatic 41mm by Timex is beautiful to look at and of all the knockoff Omega Seamasters out there, it is nice to see a classic American branded offering. Cheaper watches are a smart thing for surgeons in that it’s easy to lose them when you take them off to scrub for a case. While Apple watches are popular, the only square watches I like are Cartier Tanks, and for health data, I wear a Fitbit on my right wrist.

3. Entertainment tablets have made the large family TV obsolete. Add in good audio, and you have that weird future that they promised back in the 1980’s when they swindled your parents to buy a $3000 computer that really couldn’t do anything.

The Lenovo Yoga Tab is an incredible value for what you get which is a bright screen, fast enough processor, long battery life and great sound (JBL speakers with Dolby Atmos processing). It comes in 8, 10, and 13 inch sizes. Coupled with a keyboard and mouse, and an Office or Drive account, and you have a very portable workstation. The only thing missing is the ability to draw as it does not pair with a stylus.

4. E-ink based tablets. If you have ever had a Kindle, you know what an E-Ink based tablet is like. Viewable in direct light, these displays have the advantage of minimizing fatigue in the same way paper does compared to staring at a monitor. These 3rd generation tablets run full Android and can run the Kindle app, as well as advanced note taking and PDF markup software, and have that warm backlighting that comes with the modern Kindles.

The Boox Max Lumi does all of that. Paired with a keyboard, it recreates a basic typewriter well. It also functions as a second screen, allowing you to stare at and markup documents driven by a laptop computer. I want.

5. The modern update to the Psion Series 5mx. The Psion Series 5mx was a pocketable computer that ran a very efficient operating system, powered by two AA cells which lasted up to 40 hours, and had a tiny keyboard that with practice was fine for authoring chart notes that I would then print out to HP printers that that infrared ports (IrDA). This allowed me over a three year period of residency, to collect my personal EMR that I kept on a huge for that time 32mB flash drive. I sold my 5mx, along with a considerable box of hard to find accessories, to a journalist in Mexico who needed to author articles and fax them to his paper in 2007.

The Gemini PDA was made by a group of engineers and programmers who remember that time and updated the Psion Series 5mx form factor, down to the legendary keyboard. Available in Android and a Linux, it is a pocketable microlaptop.

6. Asian stationary, notebooks and pens, are next level. In certain malls in coastal cities in the US, you can find the odd Japanese store that has a section for stationary. The bindings are fantastic and the pens work forever. My favorites are mechanical pencils and fountain pens, which despite the incredible builds, are really affordable.

For example, the Planting Tree Paper Bind Ruled Notebook 5 Piece Set, available from Muji, is available for 2.99 on line and are great looking and durable.

7. Instant Coffee is anathema to serious coffee snobs. I have a friend who keeps a water heater, lab style glassware, digital food scale, and grinder to make a perfect cup of drip brewed coffee for himself -a fifteen minute process. The disposable pod coffees -blurgh. In Abu Dhabi, I got introduced to high end instant coffees at the grocery -the packaging and brands oozed luxury, and the coffee was much better than the instant coffee I grew up with.

Mount Hagen Fairtrade Organic Freeze Dried Coffee is what I found as an alternative to the old instant brands that represented bad instant coffee. This stuff mixes well with cold water as well, and delivers a bright kick of caffeine. It lets me make a to-go cup of coffee, well, instantly.

8. Headlights are always fun, but running in them is challenging because they sit off the center axis and tend to drop down. I have tried many times to incorporate them as cheap operating room headlamps, but failed largely as they are not bright enough. These light band headlamps which popped up in my Facebook were intriguing.

These lights (link) have both the light band which is amazingly bright and a regular flash light on the side, both of which can be turned on by waving your hand by a sensor next to your head. I thought this was the answer to my search for a cheap OR headlamp (the regular ones cost way over 1500USD), but the problem is that anyone looking at you is immediately blinded and their retinas seared. But for running, these forehead based high beams are amazing.

9. If you are surprised at the lack of Apple products, it’s because I typically aren’t in the market for them. They last forever. My 2007 Macbook Pro still runs, survived a major upgrade which included maxing out RAM and swapping the spinning platter hard drive for an SSD, resulting in lightning speed. Unfortunately, they are exhorbitantly expensive and so I find myself hesitating at purchasing a 2500USD laptop, especially one that I can no longer upgrade and maintain as I could the older Apple laptops. The problem is the battery and the SSD. They have finite lives. You can still buy batteries for the 2007 Macbook Pro, and get all day work from several batteries. Apple solves the problem of owners keeping their Apple gear for decades by imposing obsolescence, and recently even slowing down the performance of older machines to get owners to buy new iPhones.

So this makes the purchase of iPad, Macbook Pro, and even the iMac problematic in that they are all closed box systems with limited lifespans. Of the recent Apple products, the best bang for the buck comes from the Mac Mini. The older ones from 2012 can be found in droves, refurbished, and can still be upgraded, but the new ones with the blisteringly fast M1 chip that can run iOS apps is worthy of my consideration. It may be the last Mac that I ever purchase. My 2007 MacBook no longer runs the latest OS version, and I will be turning it into a Chromebook.

10. Typewriters are a fantastic way to write. They don’t let you check social media or email, and encourage that focused state where words just flow. That is the concept behind the Freewrite and its special edition Hemigwrite.

Whatever you type gets stored in you choice of cloud account, including Google, Dropbox, and Evernote. You can work on 3 different files, and as you type, the Wifi connection updates your file in the cloud. The keys are that clickety clack mechanism reminiscent of original keyboards from the 80’s, and the E-Ink screen, now backlit on this beautiful aluminum clad Hemingway edition of the Freewrite, makes it easy on the eyes. The great American novel awaits to come erupting out of your head.

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Describe vascular surgery without saying it in one sentence…

Too much blood, not enough blood.

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Editorial Board

So honored to be on the editorial board of JVSVL

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AAA complications Endoleak EVAR imaging open aneurysm surgery opinion ruptured AAA Uncategorized

Off the guidelines: type II endoleak can derail the perfect EVAR

Every once in a while, I will make an exception to the SVS guidelines on AAA repair with regard to size at time of repair (link). I have a bunch of excuses. When I trained in 2000-2002 with several giants of vascular surgery, there was some controversy when the first guidelines came out in 2003 (link). The board answer became 5.5cm that year, but where I trained, it was a minority opinion held by Dr. Jeb Hallett. The majority was in the belief that as long as operative mortality was low, even high risk AAA repair could be undertaken (link). The published risk for Mayo was low, and that came from both technical excellence and high volume (more on that later). The criteria during my fellowship was 4.5cm in good risk patients for open repair based on data generated in the 1980’s and 90’s during Dr. Hollier’s tenure.

Then as now, the debate centered around the balance of risk. At specialty centers that achieved less than 1% mortality rate for elective open AAA repair, 4.5cm in good risk patients would seem perfectly reasonable. But given the 5-10% mortality seen in the Medicare database at that time for community practice, the 5.5 cm criteria was not only good science, it was prudent. The first set of guidelines held off the contentious volume recommendations that was the nidus of conflict within other surgical societies.

The advent of endovascular was a game changer -the mortality rate in the Medicare databases was 1-2% for EVAR in the community setting, meaning more surgeons in most hospitals could achieve tertiary center levels of mortality with this new technology. The issue was never really settled in my mind through the 2000’s, even with the PIVOTAL Study. I enrolled patients into the PIVOTAL Study (link) at that 4.5cm threshold during my time in Iowa. Eventually I lost equipoise and I stopped enrolling after a handful of patients. It had to do with graft durability.

Around that time, I took two patients in a row to the operating room for sac expansion without identifiable endoleak. They were Dacron and stent-based endografts placed about 5-7 years before by another surgeon and aortography failed to show type I or III endoleak. Sac growth was over a centimeter in 6 months and the aneurysm size was over 6cm in both. I chose to marsupialize the sac and oversew any leaks, with the plan to replace the graft if there was a significant leak. On opening the sac, no significant lumbar or IMA leaks were encountered but in these patients a stream of blood could be seen coming from the sutures securing the stents. It was the same graft that was in the trial, the AneuRx, and that was when I realized that these grafts have the potential to fail in the same way that patio umbrellas leak after years of use -cloth sewn to rigid metal with movement wears open the cloth wherever there is stitching. This did not happen with open repair. I lost enthusiasm for the trial as I lost faith in this graft which was retired from the market. I placed pledgetted sutures to close the leaks on both patients, and closed the aneurysm sac tightly around the graft in one patient who was higher risk, and replaced the stent graft in the other.

There are some exceptions to justify repair of 4.5-5.5cm AAA. During my time in practice, there were patients who lived far away from major medical centers who would not survive a ruptured AAA even if the rupture rate was low and who confessed they only came into town every five years or so. There were patients who suffered from clinical anxiety whose AAA was documented by a psychiatrist to amplify their anxiety. There were patients with vague abdominal pain for whom thorough workup have ruled out gastrointestinal causes and every visit to the ER triggered a CT scan to rule out AAA rupture. And there seemed to be some patients who seemed to have such perfect anatomy for EVAR, whose risks were low, and whose growth rates were so consistent that their repairs could be timed on the calendar. Some combination of these factors and lobbying on the part of the patient got them their repair in the 5cm range. And they still do.

The patient is a man in his sixties with hypertension who presented with a 4.7cm AAA which in various reports he came with described 5.2×4.7cm. After review of his images, it was clear it was 4.7cm. If measured on a typical axial cut CT scan or a horizontally oriented ultrasound probe, a cylindrical aortic aneurysm will be seen as an ellipse in cross section. A radiology report will typically report an aneurysms length and the anteroposterior and lateral dimensions. If you cut a sausage at an angle, the ovals you cut can be quite wide but the smaller length of the oval reflects the diameter of the sausage.

Looking back at his records, for three years he had multiple CT scans for abdominal  pain showing the AAA and a well documented record of growth of about 2-3mm annually -the normal growth rate. He asked me to prognosticate and so I relayed that 4.7cm in 2017 with a 3mm growth rate, we would be operating in 2020. The anatomy was favorable with a long infrarenal neck and good iliac arteries for distal seal and access. He was quite anxious as whenever he had abdominal pain, his local doctors would discuss the AAA and its risks or order a CT. After a long discussion and considerable lobbying by the patient and family, I agreed to repair his 4.7cm AAA.

The EVAR was performed percutaneously. No endoleak was detected by completion arteriography (figure). He was soon discharged and was grateful. In followup, CT scan showed excellent coverage of the proximal and distal zones and absence of type III endoleaks. There was increased density to suggest a type II leak, but his inferior mesenteric artery was not the source of it. over a three year period, his aneurysm sac continued its 2-3mm of annual growth despite the presence of the the stent graft.

While CT failed to locate this endoleak, abdominal duplex ultrasound did showing flow from a small surface vessel (duplex below, figure at beginning of post). It was not the inferior mesenteric artery which can be treated endovascularly (link) or laparoscopically (link). CT scan suggested that it was one of those anterior branch vessels that one would encounter in exposing the aorta. Usually these were higher up as accessory phrenic arteries, but these fragile vessels, larger than vasovasorum, but smaller than named aortic branches, are seen feeding the tissues of the retroperitoneum.

Ultrasound revealed the type II endoleak from an anterior retroperitoneal branch artery.

Type II endoleaks are not benign. The flow of blood into the aneurysm sac after stent graft repair is almost never benign. It is a contained hemorrhage. There are three components to the pressure signal  seen by the aortic aneurysmal wall that could trigger breakdown, remodeling, and aneurysm growth. They include pressure, heart rate, and the rate of change of pressure. The presence of fresh thrombus may play an inflammatory role. Some endoleaks clearly have a circuit and others are sacs at the terminus of their feeding vessels, never shutting down because the AAA sac can both accept and eject the blood flow. Changes in AAA sac morphology due to sac growth can cause problems with marginal seals, component separation, and component wear. Sac growth can cause pain. Ruptures, while rare, can cause death. Mostly, type II endoleaks generate more procedures because it is hard to ignore continued growth.

Review of aortogram from device implantation showed a small anterior artery arising from the proximal aortic sac (arrow)

Three years of followup showed growth of the AAA sac to 5.5cm, which ironically threshold for repair. Again, no type I or III endoleak could be seen. He reached his calculated repair date, and I discussed our options in detail.

1. Do nothing, keep following

2. Endovascular attempt

3. Open surgery, marsupialization

4. Laparoscopic ligation of target vessel

Doing nothing hasn’t worked for 3 years. What would more time buy? Endovascular -to where. The IMA is the usual target for an endovascular attempt, although iliolumbar access is possible (link), we really needed to fix this with one attempt. Open surgery is a great option -a short supraumbilical incision is all that would be needed to open the AAA sac and oversew the collaterals. The patient did not want a laparotomy. There are reports of laparoscopic guided endovascular access with endovascular coiling of the remnant sac with fluoroscopy. This adheres to the letter of the claim of minimal access, but really?

I compromised with the patient and offered laparoscopy. I have ligated the IMA a handful of times laparoscopically -these are relatively fast and straightforward cases. As I had the location of the endoleak, I felt it should be straighforward to dissect out the anterior sac much as in open repair and clip this vessel.

Use of ultrasound allowed localization of the leak and identification of the artery for clipping.

Of course, what should have been a 30 minute procedure through a minilaparotomy became a two hour enterprise getting through scar tissue (not the first time encountering this after EVAR) while pushing away retroperitoneum. I recruited the help of general surgery to get extra hands, but the patient was well aware that there was a good chance of conversion. Patience won out as the artery was ultimately clipped and endoleak no longer seen on ultrasound.

I waited a year before putting this together as I wanted CT followup. The sac stopped growing and has shrunk a bit back to 5cm or so. There will be those who argue that nothing needed to have been done about this leak as it would have stopped growing eventually, but I would counter that an aneurysm sac that kept growing like the stent graft never went in is one demanding attention. The key role of duplex ultrasound cannot be minimized. We have an excellent team of vascular scientists (their title in Europe), and postop duplex confirmed closure of the leak.

Not seeing the leak anymore is a positive, but the stent graft remains.

The patient is quite satisfied having avoided laparotomy. His hospital stay was but a few days. During my conversations with our general surgeons who are amazing laparoscopists, that this would have been a nice case with the robot. That’s a post for another day.

The definition of success in this case and many EVAR’s plagued by type II leaks leaves me wondering. Excellent marketing of the word “minimally invasive” has subtly defined laparotomy as failure, and not just in vascular surgery. When costs and efficacy are reviewed as we come out of this pandemic, I suspect that open surgery will selectively have its day in the sun. A ten blade, a retractor, a 3-0 silk is so much more cost effective than five ports and disposable instruments. And a stent graft system?

Maybe I am just a dinosaur.

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Golf Lessons from the Operating Room – Golfism -life is a metaphor for golf

Golf Lessons from the Operating Room – Golfism -life is a metaphor for golf
— Read on www.google.com/amp/s/golfism.org/2008/09/06/golf-lessons-from-the-operating-room/amp/

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skunk works techniques Technology Uncategorized

Distraction free writing used to be the norm with technology

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Distraction Free Writing: Portable, Disconnected, AA Battery Powered

Distraction free writing has been a buzzword. It used to be the norm with computers by their limitations and design to focus you on writing. Today, technology is increasingly put in front of you to entertain and distract. The problem for students and writers is that your computer and phone are gateways to music, video, and communication in ways that were only dreams twenty years ago. The key elements of distraction free writing are a decent keyboard, extended battery life, simple interfaces, lack of connectivity, and   absence of party line operators. Each of these elements formed the core of our computers back in the 1980’s, when computers were rarely networked, they were all monochrome, and your words were all that you saw. This desire is driving the market for distraction free writing software and hardware, but you can find ways to create your own portable distraction free writing tools without dropping a fortune. And distraction-free writing is also intrusion-free -something to consider in today’s shifting privacy boundaries. At the end, the best distraction free options may be in reconsidering decades old devices that may be picked up cheaply used or at greatly reduced prices for new. Most current devices are made to last about a thousand recharges, and struggle with purposeful obsolescence. You may find that there are many fine older options that will suit your writing needs while greatly increasing your productivity while avoiding costs.

Consider the keyboards we had back in 1985. They were all mechanical spring keyboards which made a nice click sound. Writing was a tactile pleasure. This was in contrast to the membrane based keys seen on games and toys, and mistakes like the PCjr. You see them today as controls for microwave ovens. The moving keys send a message of accomplishment to your brain. Despite this, flat keyboards with no physical component  are still being thrown up to see if they would stick. The smartphone keyboard on the first iPhone killed the physical ones on Blackberry and the Treo’s after all. Manufacturers are still experimenting with flat keyboards such as on the latest Yoga Book’s e-ink keyboard, and the upcoming Microsoft Surface Duo devices.

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flat screen based keys like on the latest Yoga Book takes some getting used to

These software and touch display based keyboards rely on spelling correction and ultimately constant connectivity to minimize error. The push for ultra-portability means dispensing with the original mechanical keyboard which was descended from electric typewriters like the IBM Selectric. This resulted in the terribly mushy, mass produced keyboards introduced in the 1990’s, getting ever worse. The high point of this design viewpoint was introduced in the 2015 MacBook and recently retired in the 2019 Macbook Pro when Apple realized everyone hated typing on superflat keys meant to accommodate flatness over functionality. There is a welcome movement back to reasonable keyboards. I would even claim that the persistent life and value of the Thinkpad line is the focus on the keyboard that remains preserved after IBM sold it to Lenovo. The new-old keyboard on the 2019 MacBook Pro 16’s are a concession to the realization that typing is a core function of these machines.

There is a push back as writers, office workers, and gamers have created a market for mechanical keyboards. These are usually Bluetooth connected devices, and typically paired to tablets for writing. Unfortunately, separate keyboards connected to tablets are not as portable as a laptop.

QWERKYwriter is a retro mechanical keyboard for tablets but try taking that onto an airplane

I would argue that laptops are not as portable as they could be. The Freewrite (link) was designed with writers in mind as an update to electric typewriters with cloudbased file management and an e-ink display with days of battery life on a single charge. I almost bought one but the small display and the relatively bulky size kept me from springing. I have ordered a Freewrite Traveler (link) which is their mini-laptop version, but since I ordered one last spring, it has remained vaporware with its delivery date pushed back from summer 2019 to spring 2020.

Battery life is a sore point for me. Laptops are now expected to be wonderful if they exceed 8 hours of battery life, but I remember that the original portable computers like the Radio Shack 100 series could go days on AA batteries. Writing appliances were introduced in the 80’s including electric typewriters with single line LCD displays and single file memory which would allow you to compose and edit. I had such a device from Japan in high school that had a four line LCD display, built in thermoelectric (fax paper) printer, and battery life that went several days on 4 AA batteries.

By using computers and smartphones, which function as portable televisions and multi-function, shopping kiosks which use Watts of power, the trade off is battery life and constantly worrying about plugging in for a recharge. We forgot the days of battery life and are happy with 8 hours. The battery power bar is terribly distracting for me and I tend to stop working to find an outlet to recharge when it inevitably drops and when my productivity is nearly always highest. If I’m traveling, this means carrying the power brick, another injury to this one who remembers AA battery powered writing tools.

In 2017, the Samsung Galaxy Note 7 was famously recalled after spontaneously combusting and were banned from airplanes. All Lithium batteries must now be hand carried. Just recently, I was told while checking in that Apple Macbooks could not be turned on during flight because of heating issues. This is a consequence of the greatly increased energy densities of Lithium cells and their chemical volatility. AA batteries and their nickel metal hydride (NiMH) rechargeable variants suffer from no such problem.

Even with great battery life, you have to remember most of that power, and therefore bulk and weight of the Lithium batteries is devoted to painting vivid colors on the screen, communicating via radio signal to the world, and keeping dozens of apps updated on your activities, and not to writing.

The Lithium battery which can power a car because of its energy density is overkill if all you want is to write. The modern computer operating systems, Windows, MacOS, iOS, and Android, are all over-powered for the simple act of preserving words. Consider the lowly text file to a modern Word file. The text file for a novel might take kilobytes of memory, but the same Office Word file is measured in megabytes -thousands of times bigger. Try emailing a fully formatted Word file through your corporate firewalls if it exceeds your company’s limits on attachment file sizes. The size and complexity of information that is exchanged burns power. Compare that to the notes you might write onto paper. The few microcalories used to power your neurons and move pencil on paper, the motor and optics circuitry processing the information at a speed suitable for your ape brain.

My friend and early mentor, Professor David Tilson, refused to relinquish his DOS based word processor even well into the Windows era. And I understood. The monochrome and monotype letters forced you to look at the words and not the style of the words. While I admire Steve Jobs, and his introduction of fonts to our everyday lives, the ability to shape the look of your writing intrudes on its composition. Monochrome does not mean monotonous, and modern distraction-free software efforts like IA Writer embrace simplicity. The emergence of dark mode is another effort at rolling back the clock. When you enable it for your iPhone, it reaffirms the utility and critical need for focus and simplicity. Do you need millions of colors or just letters on a simple background? While you can change the color setting of your laptop screen or your writing software, the ultimate in monochrome experience is an e-ink display.

The e-ink display is what you see on Amazon Kindles. Originally meant for low power usage, high contrast functions like in store signs, e-Ink is currently used for e-Readers, although there is a niche market for e-ink based displays and tablets which do offer the low power hi contrast display perfect for a focused writing work station – you can find them on Amazon and eBay. Unfortunately, because these e-Ink tablets are run typically on Android, there is no escaping the internet on these, and because they do so, their battery lives are not that much different from standard tablets. What the we need is for Amazon to gift the writers of the world with Bluetooth or wired keyboard functionality to their Kindles and offer a text writer that can be synced to their cloud..

What the we need is for Amazon to gift the writers of the world with bluetooth or wired keyboard functionality to their Kindles and offer a text writer that can be synced to their cloud.

The constant need for connectivity drives software and hardware inefficiency. Writing requires intimacy and privacy. Just as you cannot write while engaged in a shouting match with someone, you cannot write with notifications of arriving messages, pictures, and videos. I cannot write while watching a movie or listening to certain music, but all of these distractions are baked into the function of modern computers and smartphones. This uses up battery life. The devices are in a race to maximize the battery and screen size at the cost of purpose and meaning aside from commerce.

Party line operators were a feature of the early telephone systems. Your locality was serviced by an operator that routed your calls and inevitably your conversations were open to intrusion both intentional and unintentional. When all your work is kept on a cloud server, it really is no different. And it isn’t that hackers that may take all your work. My generation grew up with the Cold War, and its dark tales of thought crimes and writers imprisoned for samizdat -ideas forbidden by a state entity. In a time when your social media is a subject for governmental and not just consumer interest, returning to off line options is something to consider seriously. The meaning of party line operators is in this context wholly changed.

The one feature of cloud based options is the convenience of accessing it across all of your devices. But are you really going to be writing on your iPhone, then on your desktop, then on your laptop, then from an airport kiosk? Your file can be lost during the sync process or changed to a competing version from another computer you were working on. And goodbye work if you get hacked or if your cloud service shuts you down or out. While you write, you have to keep a local version and back up to a nonvolatile storage option.

Not connecting to the internet saves you battery life. It also frees you from taking deep YouTube dives into funny cat videos or answering emails or Facebook posts. The stillness you need to just write is difficult to achieve with a modern laptop, tablet or smartphone. It can be attained with these older devices which people in the know still value decades after they left their boxes. I suggest these options if you are thinking of trying a focused writing appliance (a typewriter!).

Option 1: King Jim Pomera DM100  (link) is best described as a writing appliance designed in Japan adapted for the English speaking market. It is a sleek thin portable that allows one to type words unencumbered by internet. The files on it can be transferred to another computer by Bluetooth, and to smart phones by QR code which is cool. It runs for days on AA batteries, and has a backlit monochrome LCD screen. It is priced on th high end at 392.61, but receives the best rating on Amazon which to me is a 4.5. I never come across 5 star reviews that aren’t fake. One reviewers comment that the keyboard is cramped and takes getting used to. It can be used as a Bluetooth keyboard and stand for iOS devices.

Option 2: Neo 2 Alphasmart Word Processor with Full Size Keyboard,, Calculator

The Alphasmart Neo2 (link) was the last of a line of writing appliances put out by a pair of former Apple engineers who wanted to provide affordable word processing options on a full mechanical keyboard. The Neo2 is the most available and apparently the most usable, allowing one to type out hundreds of pages and transfer to a computer via USB connection. The screen is an LCD screen like on a calculator. The killer feature on this device is nearly forever battery life on AA cells. It has a rabid following of professional writers who appreciate the pared down experience for productive writing. It achieves that perfect 4.5 star rating. This is for a device discontinued in 2007 and sells for about 40-50USD in used condition. Reviewers rave about turning it on and instantly being able to type without bootup, and avoiding distraction by email, notifications, social media etc.

Option 3: Psion Series 5MX

The Psion Series 5MX represented the apex of portable computer design in the late 1990s. It was a computer made from the ground up from circuits, hardware, operating system, and apps by British engineers and it was a thing of beauty. Made in the late 1990’s, this device’s killer features, long battery life via AA cells, ultraportabiity, and lack of easy internet access puts it in a separate class. Not everyone like the keyboard, but I have long been able to type on it without difficulty with average to large sized hands. I had one during residency in the 1990’s and it followed me into fellowship. Before EHR, I composed full consultation notes and H&Ps on it and filed them on my password protected CF drive for later retrieval and update for frequent flyer patients. I picked up a pair of these for about 90USD from the Netherlands, but the going priced varies from about 70 to 200USD for a used one in good condition. New ones pop up but they go for nearly their original price -they are that good. I suspect I got a deal because they were Ericsson MC218, a Swedish licensed clone.

It has a compact flash drive, and with the save as text file function in the built-in word processor which works fast and reliably, it is possible to back up to a nonvolatile memory (the CF drive) and transfer to a regular computer. The one caveat is that the maximum size of CF drive it will see seems to be 128mB -that is megabytes which is hard to find. In certain older industrial machinery, instructions are uploaded via CF cards of these size, and so these cards are available on Amazon. Or look in a drawer for an old unused CF card.

I wrote this post on the Psion, and never once looked at emails, social media, or Youtube.

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I wrote this post on the Psion, and never once looked at emails, social media, or Youtube.

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Our mesenteric stent paper goes on line

https://www.jvascsurg.org/article/S0741-5214(19)30530-0/fulltext

Improving midterm results justify the continued use of bare-metal stents for endovascular therapy for chronic mesenteric ischemia

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Top 12 Things to Get Your Favorite Surgeon in 2018

1. Microsoft Surface Book 2. It comes in two flavors, Large (13.5inch) and Supersize (15 inch).

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Surface Book 2 13.5 Inch

Like Apple and their Macbook Pros, Microsoft decided to price it out of the reach of most people. In my opinion, it is worth it because of the versatility of popping off the screen and using as a tablet. Reading a journal articles is unmatched at 13.5 inch size.

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The Surface Book 2 13.5 Inch Detached as a Giant Tablet

The other feature is the 12 plus hours of battery life for both sizes although results may vary. The keyboard part has a second large battery and an NVIDIA graphics processor which makes short order of Fortnite Battle Royale. The storage options come steeply priced, but there is an SD slot -with a half height MicroSD adapter (link)and some fiddling with DiskManagement (link), you can trick the computer to thinking the SD card slot is onboard hard drive, so you can add 200-400gB for dumping pictures, media, and Dropbox onto it.

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Sketched on Tablet Using Sketchbook

Low usage apps can also be installed onto this drive. The pen allows you create nice artwork -something that I have always needed for my blogging.  And it plays nice with Apple -you can run iTunes (yes it sucks), and link iCloud to your calendar, photos, iPhone, and Mac desktop. The sweetspot is the Core i5 with 256gB SSD in the 13.5 inch version for about $1400, but if you can swing it, the Core i7 with a 1tB SSD and 15 inch screen (with listed 17hr battery life) is the way to go, but be prepared for sticker shock

2. Samsung Galaxy Note 8/9 Smartphone. I know, I have been a lifelong Apple user, but I wearied of the closed nature of the Apple ecosystem. Get a Note 8 and you can add as much memory as you need via the MicroSD slot (remember to change settings on your apps to make use of this). The AMOLED screens are gorgeous, the pen (pens are back!) lets you scratch down patients MRNs during phone calls and sign PDFs. Google services are great for a lot of things. Add a folding bluetooth keyboard and you have an ultraportable solution to avoiding the giant corporate laptop. The imminent release of the 9 should give you pause, but given the incremental changes under the hood, buy if you find a deal on the 8. The battery life is sufficient for all day use, plays nice with iTunes music, and takes some of the greatest phone pictures I have ever taken (below).

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3. Bluetooth Keyboards -I know they are incredibly boring and utilitarian, but hear me out. There are two form factors that bear consideration. First, the folding keyboards that in combination with a large screen smartphone, give you 95% of the capabilities of a laptop, letting you travel with bare minimum of items. The EC Techology Folding Blue Tooth Keyboard (link) is smaller, and likely not suitable for people with giant paws, but for me, who used to write long form essays and papers on a Psion Series 5MX, this keyboard works well, particularly because it has the phone/tablet stand built into it.

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Samsung Galaxy Note 8 and EC Technology Folding Bluetooth Keyboard

For several months last year, TSA restricted travel to the US with anything bigger than a smartphone. My workaround then was digging up an old Palm Bluetooth keyboard, but the modern stuff is far better. The EC keyboard is sturdier, rechargeable, usable with multiple devices (the one above links to 3 devices). It isn’t backlit but you can find those that are.

The other kind of Bluetooth keyboard that I love are the ones that incorporate retro keys -there are several that have old typewriter keys and others that have the large IBM keys -these both share the clicky key mechanism that were lost when island type chiclet keyboards became the norm. While I love the Macbook, and tolerate the keys, for long typing, I need a real keyboard, and lately, I am willing to spend on mechanical keys.

Why do I like them? For focused writing, the chunky keys with a loud clickety clack sound is incredibly comforting -it sounds like intense work to spit out words on these keyboards. I recently purchased a Bastron Wireless Mechanical Keyboard (link) which looks and feels like an IBM Thinkpad keyboard circa 1995. It is backlit and has a groove for placing tablets and smartphones, although I use it as the center keyboard of my writing station between my laptop and a large second screen. It is backlit which is a plus. Most of you are familiar with the bluetooth keyboards that are like mechanical typewriter keyboards, but I think aside from the asthetics, they are generally very costly and I don’t feel compelled to get one. This Bastron Keyboard is a keeper at the 35 dollars on Amazon (a clearance price). Some people have a difficult time managing the wonky Bluetooth and therefore it gets a 3-ish rating. Just sit tight and follow the instructions and you will be fine. Mine came with a free Bluetooth mouse. I give it a 4 -taking off a point because it uses AA batteries.

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Bastron Wireless Mechanical Keyboard

4. Smartwatches. Sure, go ahead and get a fancy automatic watch, but be prepared to pay through the nose in maintenance and repair fees as when five to ten years out, you notice the watch not keeping time well.

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The watch is round, the way it should be…

The repair fees may actually come out to the same price as getting a new watch. The newer generation of smartwatches offer so many useful functions that they trump their general fugliness. The Apple Watch and the Samsung Gear 3 both hit the right pricepoint for not crying when the inevitable better and newer versions come out. My Gear 3 offers customizable faces and quick swapouts of bands to match my wardrobe. It tracks my activity and measures my heartbeat, and can record my runs. The battery is good for 3 days and recharges in about an hour wirelessly. Unlike the Apple watch, it is round.
5. A two week vacation in the middle of nowhere. All surgeons want out of a vacation is to be completely away from work and preferably with a stunning view. I suggest the following. A two week cruise with a private balcony and view of the ocean and never getting off the boat for excursions. A cabin/house rental off season -that means going to Vail or Aspen in the summer or Martha’s Vineyard or the Hamptons in the winter. Bring food for the apocalypse -Spam, pasta, rice, canned vegetables, oatmeal, powdered milk, sack of potatoes. The ultimate lonely vacation destinations are British microcolonies -the Falklands, the Hebrides, Prince Edward Island, Bermuda, Pitcairn. Unfortunately, they probably all have internet. Bring a couple bottles of whiskey and a box of cigars. Go shoot something with a local. Or spend two weeks on the transcontinental train across Russia from St. Petersburg to Vladivostok in a premier car.

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Go far away, eg. Maldives

6. Blank sheet journal of high quality. Moleskine makes a nice one, but when I travel, I always drop in on local stationers and arts stores for unusual blank books to write in. The Japanese in their infinite wisdom offer a cheap but high quality bound notebook of blank paper that you can find in Japanese bric-brac stores that are cheap but wonderful.

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From local Japanese Store (Daiso), for 10AED (about 3 dollars US), Personalized

I think that all surgeons need to keep notes on what makes their operations fail or work, and imagine what would make things better, but writing about your passions or scratching travel notes is great brain exercise. The bottom line is that an idea needs to be written down as much as a seed needs to be placed into soil.
7. Large capacity battery for recharging -I carry two of these Anker beasts (link). They will charge my Macbook and Surfacebook, and my smartphones multiple times. I can’t tell you how useful it is to not worry about low charges during travel. I bought mine 3 years ago and they are still going strong. They don’t need to be fancy, just incredibly reliable and able to recharge at the higher amperage required by tablets and computers. My MacBook will typically go from 25% to 100% on one of these power banks -nothing to sniff at when you want to write any where any time. Mine are 20100 mAh, but larger ones are available. They do get heavy and they must be on the carry on luggage.
8. Small bluetooth speaker. Not all operating rooms have good sound systems, but you don’t want to lug a huge speaker either. Most tablets will be sufficient for playing music at volume but without sufficient bass. You can play around with the acoustics by placing your smartphone or tablet in a large metal basin, but you want speakers if you want to hear the bottom half of your music, whether it be Vivaldi or Childish Gambino.

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Harman/Kardon makes a supercompact speaker that also is an excellent speakerphone and in a pinch will recharge your phone (link). It’s is plenty loud and gives a nice balanced sound. If you want more bass, you want something like the Bang and Olufson of bluetooth speakers. Again, there are larger speakers, but I’m focusing on ones that will fit nicely in a laptop bag, and I’m happy with my Harman Kardon’s.
9. Giant E-Ink Tablet. Imagine reading journal articles in original A4 size. While it is possible to do this with a standard tablet, the screen will cause eye fatigue. Printing this out means carrying heavy paper copies that are easily lost.

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Boox Max 2 In Monitor Mode. It’s also an Android 6.0 Tablet

You might remember that Amazon once had a Brobdingnagian Kindle -the Kindle DX, but has focused on ever smaller form factors. I had the DX and reading PDFs on it in normal size was a pleasure. Unfortunately, the DX was an early Kindle and not particularly fast nor high resolution. While it was excellent for its time, it has comparatively a muddy low resolution screen when compared to modern Kindles. So you would think in the effort to go paperless that modern hardware and software would combine with state of the art E-ink to create a great reader. Well, Sony put out the Sony DPT-RP1/B 13” Digital Paper, but based on feedback on Amazon, it is clear that Sony hasn’t shaken off their great handicap which is putting out great looking products with terrible names that fail in crucial fashion either in software or hardware. In this case, the proprietary software cuts the legs off this device. The Chinese on the other hand, have put out what appears to be an excellent 13-inch E-Ink tablet running Android (link), the Boox Max 2  and allowing for direct wired second monitor function. This is the sweet spot, but unfortunately is quite pricey. That said, if you really want to make your surgeon smile, this is the gadget. It has that modern high resolution E-ink screen that is close to paper linked to a touch screen and medium range Android hardware. The reviews say that it works well as a second monitor, but I would use it in combination with my bluetooth keyboard and IAWriter (link) to create a focused writing station.
10. Japanese massage chair. My father got one a couple of years back, and now whenever I visit him, I have to wake him up and shoo him out of this chair to get an intense deep tissue massage. The calf and forearm massage function is a must. When I get my forever house, a dark room with several large screens and this chair will be the core of this home. Put on golf or an animal documentary with Attenborough and you get the best nap of your life!

11. Audible.com Subscription. While commuting or long haul driving, catching up with the latest business managment book or historical non-fiction tome makes the 10 minute red lights in Abu Dhabi a pleasure. While there are free podcasts galore, audiobooks lets you get through the latest materials with minimal fuss. There are often free books with coupon codes from some podcasts. Suggested listening -Norse Mythology by Neil Gaiman, 1453: Holy War for Constantinople and the Clash of Islam and the West by Roger Crowley, How to American: An Immigrant’s Guide to Disappointing Your Parents by Jimmy O. Yang, and Ready Player One by Ernest Cline.

12. Ichiran Ramen Instant Noodles. If you haven’t been, you need to go to Ichiran Ramen in Brooklyn, NY. There you will be seated in a single booth, solo with a small cryptic order slip. You choose the texture of your ramen -basically under or over al dente, the add ons like fish cake, seasoned egg, pork belly, and some sides and ring a bell. The roll up shades peak and a hand, no face, reaches in and gets your order. You wait about 5 minutes, and the shade opens and your ramen is placed in front of you. One slurp and you are transported to a kind of ramen induced rapture. It is that good. The noodles are great -they invested a serious amount of time to create a noodle factory out in Brooklyn, but it is the soup that brings you to your knees. The donkotsu broth is made from pork shoulder and bones and has character, depth, and a lingering finish that burnishes itself into your memories. You can’t eat at a normal table and get the same effect -hence the flavor concentration booths. As you walk out, you can purchase boxes of packaged instant Ichiran Ramen which cost as much as buying one fresh, but lets you enjoy the noodles and broth at home or far away like here in Abu Dhabi. You can buy them on Amazon (link) but it looks to be overstock. 20180727_144208They opened a branch in Manhattan, but my kids say it wasn’t as good as in Brooklyn. I can’t imagine what it must be like at the original store in Japan, but I am planning an entire trip just to eat ramen.

Addendum

This post is meant to be a review of items and satirical in presentation. It is not a demand for gifts or services in kind. Anything sent from anonymous sources will not be acknowledged. Please consider donations to your local charity -in Cleveland, the United Way offers services to the needs of the community. Surgeons are perfectly fine getting these things for themselves.

Categories
edema interstitium Lymphatic lymphedema Uncategorized

The Interstitial

https://opmed.doximity.com/new-interest-in-the-interstitium-is-like-people-suddenly-obsessing-about-the-stuffing-in-sofas-308b1336a317

By Woosup Park, MD

A recently published paper caused breathless worldwide headlines about a “new” human organ hiding in plain site — the interstitium. It had me smiling because vascular surgeons, the good ones, recognize it and have been managing it for a long time. The interstitium is described as the space outside the cells. The new interest in it is like people suddenly obsessing about the stuffing in sofas. It is the body’s contained negative space and it is the most important organ because it was the first. It has been there all the while.

The genome and its expression, the organism, carry the past like hoarders. Look at a skin cell, and you see a nucleus and a cell membrane, the hallmark of the eukaryote, and the mitochondria that it took captive in eons past when it was a sea bacteria that was eaten and refused to be digested. The next most important step in evolution was multicellularity and specialization of these cells. The earliest efforts started as clumps of cells, but clumps have a limit — every cell had to have exposure to the outside and eventually these became spheres with a hollow internal space. Here was the first interstitium — the first inside, the first not-outside.

To these first animals, segregating an internal space different from the outer sea had advantages. You can concentrate nutrients inside when the seas outside are plentiful and use these when they are not. Add some structure and you have an endoskeleton — we share this with sponges inside this interstitium. As the organism became larger, this sphere flattened and some became animals with one pore ingesting and ejecting and others with two holes. We fall into a lineage that found transiting food through a cylinder to be advantageous. The nutrients were digested and absorbed from the worm into this internal space. The interstitial waters needed to be mixed as food came not from the outside but from this internal protodigestive tract, to have currents and streams. This was done with the development of tubes lined with smooth muscles that beat, interspaced with one way tricuspid valves. This primitive circulatory system is seen in many of our spiny sea cousins like starfish and sea cucumber, and lives in us as the lymphatics.

The interstitium is the remnants of this primitive sea creature that we carry with us, carrying within this pouch of internal sea. The fluid that fills blisters is a kind of briny sea water. When you see an edematous patient, observe the level of this sea by seeing where the edema ends. See how easy it is to milk out this edema out of a hand or foot, just as it is to squeeze the water out of a sponge. Edema is so common that it is easy to forget that so many diseases cause failure of the lymphatics — the bilge pumps of the body, and that on this tide may come many other things that makes the problem worse. In other instances, it may be just high tide in Venice, right before all the sewage gets washed out into the Adriatic.

The interstitium, as much as it was the progenitor of the circulatory system, is likely the foundational element of the nervous system. The various ion pumps are highly conserved and are useful only when concentration gradients are stable. The bioluminescent jellyfish is testament to this. Without the interstitium, cross membrane voltage potentials cannot be maintained. It is the bioelectric spark that life motion. If a planaria, a flatworm, is to have a soul, it resides in the interstitium. It is the spiritual ether bottled inside us. The ghost in our machine swims our portable primordial sea.

These old parts and compartments are hiding in plain site. The lymphatics beat and spread some of the nutrients from the gut into the venous system in connections up at the base of the neck. Both have been superseded by the portal venous system and the circulatory system but the lymphatics persist because there was no reason to abandon it, but possibly it is critical to our existence. The interstitium must play a critical role in homeostasis in the same way that the older autonomic nervous system plays critical subliminal roles by being both a buffer and a store. Every cell in our body is in contact with this inner sea as much as the first cell was afloat in the primordial one.

The interstitium is the final contact point between each cell and the organism as a whole. Oxygen does not go from alveoli to the skin without transiting the interstitium. Just as we are only beginning to grasp the complexity of genetics and the heredity of epigenetics, we are just noticing the interstitium. Up to now, it is as if we have been studying the outlines and histories of Byzantium, Rome, and Carthage, in isolation without studying the depth, composition, and currents of the Mediterranean.

Categories
amputation aortoiliac occlusive disease (AIOD) BKA bypass Commentary complications limb salvage Lymphatic techniques tibial revascularization training Uncategorized Wounds

Exovascularist’s Dilemma: Where Is Our LIMA to LAD

During our daily morning huddles, peopled by cardiologists and cardiac surgeons, one thing impresses me more than anything else. The assembled interventional cardiologists, world class and renown, they who can place a stent in any part of the body, will defer to the unassailable superiority of the LIMA to LAD bypass over any existing intervention. I am always a little sad that the analog for this, the vein bypass in the leg does not get the same love. The open surgical bypass of the leg is the great straw man at international symposia. It is fast becoming a diminishing and curious habit of a fading generation.

The acknowledged superior hemodynamics and patency of the bypass is diminished in the literature by pooling patency loss with other factors such as amputation, heart attacks, and death. Some vascular surgeons dogmatically cling to habits learned in training that favor complications, making themselves their own worst enemies both in the literature and in the marketplace. These bad habits involve long incision length, closure techniques that do not anticipate edema, and wound orientation that makes failure more likely.

Operations require far more support and resources to succeed than do interventions that soon go home. Brilliant operations alone will not heal the patient. It is pathways and postoperative care infrastructure and staff that prevent these secondary complications -the very complications that keep the leg vein bypass from being as respected, if not loved, as the LIMA to LAD.

The postoperative care of these patients devolves to management of leg edema. No medical or nursing school adequately teaches the basic science nor management of edema, which is the most common vascular condition

The incisions are too long in the classic vein bypass. When you create and then close an incision, the inflammation drives the accumulation of fluid in the extracellular space – creating edema. This postoperative edema, poorly managed, results in complications that leave the patient hobbled with time lost to healing wound complications, pain, and excess limb weight. Additionally, vein bypasses usually involve groin exposure and the delicate lymphatics that coalesce there are perturbed or destroyed during exposure. Postop, this damage and the inflammation rapidly overcomes the capacity of a lymphatic system. The traditional vein harvest also involves cutting through deep layers of fat. The fat is typically closed by broad sutures that create areas of fat necrosis -potential fodder for bacteria. The best ways the complications of long and deep incisions is to avoid them altogether. The calculus of the operative moment – “I must see the vein,” must include the vision of a patient losing months to wound therapies to heal a gaping, necrotic, infected wound. I recommend skip incisions or adopting in-situ bypass technique with endovascular management of fistulae. Or corral your cardiac PA to harvest the vein segment in the thigh after mobilizing the vein in the leg with the endoscope.

The incisions are often closed with Nylon sutures and skin clips which can become potential foci of infection. With edema, they create zones of ischemia around them, killing skin and creating entry points for skin flora as the skin expands under an unyielding clip or suture. Placed under a pannus, these sutures or clips fester in an anaerobic environment. Closure should adhere to anatomy. The body relies on connective tissue planes to keep itself together. In the groin, these are Scarpa’s layer and the dermis. They should be closed with absorbable monofilament in a buried interrupted fashion at the dermis with a final running subcuticular layer of 4-0 absorbable monofilament. Steristrips or glue at the skin finishes the job. If you use sutures, particularly at the distal anastomotic site, take care to realize that you have about 12 hours before the skin dies in the best of circumstances, and less with microangiopathy of diabetes and ESRD. Squeezing out the edema before closure with a sterile Esmarch or short counterincisions or even a large one to allow for tension free closure over an anastomosis will prevent wound complications over your graft.

The classic longitudinal groin incisions that cut across the inguinal crease divides a tension point -that crease is like a cord that supports the pannus that is slung over it and when divided and then closed with a stitch, that stitch then bears the weight of that pannus every time the patient sits up or stands. If you are observant, wound necrosis typically starts at the groin crease under a surgical clip or suture. Incisions in the groin should be obqlique and parallel to this crease, or if you can, even inside this crease. When these wounds are closed, the natural lines of tension are in line with the incision rather than orthogonal to it. The natural forces keep the wound shut.

This is only the first step. The next is keeping the wound clean and dry for at least 5 days. At the Mayo Clinic, where I trained, the nurses up on 5 Mary Brigh were trained to blow dry the groin wounds every few hours on cool setting and redressing the wound with dry gauze. You can get something close to it by ensuring the wounds painted with betadine, allowed to air dry, and dressed with dry gauze. If there is a constant leak of fluid, you have a serious problem as there is too much edema in the leg, or the wound isn’t closed, or there is a lymph leak. It needs to be actively dried out or you get a wet, macerated, infected wound like a grenade went off in the groin.

They don’t teach compression wrap techniques in medical or nursing school

The simplest thing to avoid lymph leaks is to not make them. Cutting near lymph nodes is hazardous, and once below Scarpa’s you have to orient your dissection directly over the femoral artery. Stray horizontally and you will undoubtedly cut one of the 4 to 10 invisible lymph channels.

They are invisible but detectable -after you break them, you will see a constant wetness in the wound. Think about injecting a cc or two of Lymphazurin (Isosulfan Blue, for those not allergic to Sulfa) into the intertriginous space on the same foot and you will see the lymph channel in bright blue, or stare carefully at the likely spots for a lymph leak and clip it, burn it, Ligasure or Harmonic scalpel it.

Lymph leak identified from saphenectomy incision (for CABG)

So how did we get to a rather dry discussion about edema? Wound complications are tremendously debilitating and offset any benefit from vein bypass operations. These long incisions become terrible big wounds if not prevented. It takes the concerted effort of a team and particularly nursing in actively managing edema. And at the end, the patient too must be included in this discussion. For the vein bypass of the leg to get the same respect and love as the LIMA to LAD bypass, surgical wound complications must become never events.

Water goes downhill