Optimizing Working Space in Laparoscopy: Studies in a porcine model

__Abstract__ Adequate working space is essential for safe and effective laparoscopic surgery. However, the factors that determine working space have not been sufficiently studied. Working space can be very limited, especially in children. A literature review was undertaken to search for factors that can be influenced to increase working space in laparoscopy

Optimizing working-space in laparoscopy: Measuring the effect of mechanical bowel preparation in a porcine model

Background: Adequate working space is a prerequisite for safe and efficient minimal access surgery. No objective data exist in literature about the effect of mechanical bowel preparation (MBP) on working space in laparoscopic surgery. We objectively measured this effect with computed tomography in a porcine laparoscopy model. Methods: Using standardized anesthesia, twelve 20-kg pigs without MBP and eight 20-kg pigs with MBP were studied with computed tomography at intra-abdominal pressure (IAP) levels of 0, 5, 10, and 15 mmHg. Volumes and dimensions of the pneumoperitoneum were measured on reconstructed CT images and compared between the pigs with and those without MBP. Results: A reproducible and statistically significant increase of approximately 500 ml in pneumoperitoneum volume was found in the MBP group at all levels of IAP. This represents a 43 % relative increase at a pneumoperitoneum pressure of 5 mmHg, 21 % at IAP 10 mmHg, and 18 % at IAP 15 mmHg. Peak inspiratory pressure was lower at IAP 0 and 5 mmHg in the MBP group. Anteroposterior diameter in the group with MBP was lower at 0 mmHg, but abdominal dimensions were similar in both groups at all other IAPs. This shows that the gain in working space is due to a diminished volume of the intra-abdominal content and not to compression or displacement of the bowel. Conclusions: MBP increases working space by reducing bowel content. Especially at low intra-abdominal working pressures, the increase in working space associated with MBP could represent an important benefit in challenging laparoscopic surgery

The Acute Compartment Syndrome of the Lower Leg: A Difficult Diagnosis?

Three patients, two adults and one child, developed an acute compartment syndrome of the lower leg. Due to delay in diagnosis, severe complications developed, resulting in two transfemoral amputations. In the youngest patient, the lower leg was able to be saved after extensive reconstructive surgery. In most cases, acute compartment syndrome of the lower leg is seen in combination with a fracture (40%), although other causes (minor trauma or vascular surgery) are also known. Moreover, patient history (pain out of proportion to the associated injury) and physical examination are central to the diagnosis. In some cases, however, a reliable diagnosis cannot be made clinically, as in the case of unconscious, intoxicated or intubated patients, as well as small children. Under these circumstances, intra-compartmental pressure measurement can be of great assistance. After confirmation of the diagnosis, immediate fasciotomy of all lower leg compartments should be performed. The eventual outcome of this syndrome is directly related to the time elapsed between diagnosis and definitive treatment. Although the diagnosis can be difficult, delays in treatment should be avoided at all costs. The acute compartment syndrome of the lower leg is a surgical emergency and should be dealt with immediately

Exploring views on medical care for people with intellectual disabilities: an international concept mapping study

Contains fulltext : 253060.pdf (Publisher’s version ) (Open Access

Thoracoscopic versus open repair of CDH in cardiovascular stable neonates

Background: Thoracoscopic surgery is an increasingly popular surgical technique to repair congenital diaphragmatic hernia (CDH). However, acidosis during surgery and the higher recurrence rate are considerable risk factors. The aim of this retrospective study is to compare the outcome of open versus thoracoscopic repair of the diaphragm in neonates with CDH with the same degree of cardiovascular and pulmonary illness who meet the criteria for thoracoscopic repair. Methods: Retrospective analysis of all patients of two large national reference centers for CDH born in the years 2008 through 2012, and meeting the criteria for surgical repair on cardiopulmonary and physiological criteria according to the CDH EURO consortium consensus and meeting the criteria for thoracoscopic repair according to the review by Vijfhuize et al. The surgical technical aspects were comparable in both centers. Results: 108 patients were included, of whom 75 underwent thoracoscopic repair and 34 underwent open repair. The gestational age and lung-to-head ratio were significantly lower and stay on the ICU significantly longer in the open-repair group. The operation time was longer (178 vs. 150 min, p = .012) and the recurrence rate higher (18.9 vs. 5.9 %, p = .036) in the thoracoscopic-repair group. The arterial pH, pO2, pCO2 and base excess before and after thoracoscopic repair were all significantly different. Conclusion: After critical selection for thoracoscopic repair of left-sided CDH based on the patient’s preoperative condition, the outcomes of open repair were almost identical to those of thoracoscopic repair. A notable exception is the recurrence rate, which was significantly higher in the thoracoscopic-repair group. For the time being, thoracoscopic primary closure seems a safe and effective procedure, but efficacy of thoracoscopic patch repair has not been established

Optimizing working space in laparoscopy: CT-measurement of the effect of neuromuscular blockade and its reversal in a porcine model

Objective: The objective of this paper was to determine the effect of neuromuscular blockade (NMB) on working space in a porcine laparoscopy model. Background: Conflicting results on the effect of NMB on laparoscopic working space are found in literature. Almost all studies are limited by absence of objective assessment of working space or use surrogate outcomes. Methods: In a standardized porcine laparoscopy model, laparoscopic working-space dimensions with and without NMB were investigated in 16 animals using computed tomography at intra-abdominal pressures of 0, 5, 10, and 15 mmHg during multiple runs of abdominal insufflation. Results: No statistically significant effect of NMB on abdominal dimensions and laparoscopic working-space volume was found during CO2 pneumoperitoneum. In contrast, the effect of pre-stretching of the abdominal wall by a previous abdominal insufflation was found to be significant. Conclusions: This experimental study confirms the results from several clinical studies that NMB does not influence laparoscopic working space. Studies dealing with working space during laparoscopy should take note of pre-stretching bias

Impact damage characteristics of carbon fibre metal laminates : experiments and simulation

In this work, the impact response of carbon fibre metal laminates (FMLs) was experimentally and numerically studied with an improved design of the fibre composite lay-up for optimal mechanical properties and damage resistance. Two different stacking sequences (Carall 3–3/2–0.5 and Carall 5–3/2–0.5) were designed and characterised. Damage at relatively low energy impact energies (≤30 J) was investigated using Ultrasonic C-scanning and X–ray Computed Tomography (X-RCT). A 3D finite element model was developed to simulate the impact induced damage in both metal and composite layers using Abaqus/Explicit. Cohesive zone elements were introduced to capture delamination occurring between carbon fibre/epoxy plies and debonding at the interfaces between aluminium and the composite layers. Carall 5–3/2–0.5 was found to absorb more energy elastically, which indicates better resistance to damage. A good agreement is obtained between the numerically predicted results and experimental measurements in terms of force and absorbed energy during impact where the damage modes such as delamination was well simulated when compared to non-destructive techniques (NDT)

Bidirectional and passive optical field to microwave field quantum converter with high bandwidth

The conversion between microwave photons and optical photons with quantum coherence is important for quantum communication and computation. In this paper, we report a proposal using an ensemble of atoms coupled to microwave and optical resonators. Input photons to one resonator are converted into output photons in the other resonator without active operation. Usually the conversion is only optimized at certain frequency. In our proposal, we find that the efficiency is almost a constant and can be close to 100% in a large interval of frequency, i.e. a high-bandwidth conversion can be realized with our proposal.Comment: 6 pages, 4 figure

Bacteriophage DNA glucosylation impairs target DNA binding by type I and II but not by type V CRISPR-Cas effector complexes

Prokaryotes encode various host defense systems that provide protection against mobile genetic elements. Restriction-modification (R-M) and CRISPR-Cas systems mediate host defense by sequence specific targeting of invasive DNA. T-even bacteriophages employ covalent modifications of nucleobases to avoid binding and therefore cleavage of their DNA by restriction endonucleases. Here, we describe that DNA glucosylation of bacteriophage genomes affects interference of some but not all CRISPR-Cas systems. We show that glucosyl modification of 5-hydroxymethylated cytosines in the DNA of bacteriophage T4 interferes with type I-E and type II-A CRISPR-Cas systems by lowering the affinity of the Cascade and Cas9-crRNA complexes for their target DNA. On the contrary, the type V-A nuclease Cas12a (also known as Cpf1) is not impaired in binding and cleavage of glucosylated target DNA, likely due to a more open structural architecture of the protein. Our results suggest that CRISPR-Cas systems have contributed to the selective pressure on phages to develop more generic solutions to escape sequence specific host defense systems