and advance an 11 blade to make the portal incision right where the
mark is. It's a technique that eliminates guesswork.
• Fluid pressure. As every orthopedic surgeon knows, main-
taining optimal fluid pressure is an extremely important component of
visualization. But it can be challenging to strike the right balance
between controlling bleeding and pumping too much fluid into the
joint. You don't want to over-pressurize and have the area around the
joint blow up like a water balloon.
Here's where I stumbled upon an old-fashioned technique that for
me works better than fluid pumps. And Isaac Newton would have
loved it.
That's right, gravity. I'd tried a couple of pumps, but they didn't
always seem accurate to me, and occasionally my joints were getting
over-pressurized. Then I happened to observe a surgeon who was
doing a posterolateral corner reconstruction, and I noticed he wasn't
using a pump. When I asked about it, he said he'd given it up 5 years
earlier, because he'd had the same complaint I'd had. Get your hospi-
tal to buy an irrigation tower, he said, and you'll never go back. That
was 7 years ago, and he was right: I haven't gone back.
Some surgeons will say it's absurd — that they would never give up
their pumps, and that I must be stuck in a different century. But for
me, simple gravity works better. The tower is like a giant rolling IV
pole with a pulley system, so the circulating nurse doesn't have to lift
multiple 10-pound bags of fluid way up over her head several times
throughout a procedure. You just hook up the fluid bag, plug it into
the hoses, raise it up with the pulleys and use the height of the bag to
regulate the flow, lowering it when you want to decrease the flow. You
can have 2 bags going at once, or you can clamp one and just keep the
other one going. My tower has places for 4 bags, so they can be
changed out without having to stop, and we can always stay ahead.
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