12 research outputs found
Liquid Chromatography-Mass Spectrometry-Based Parallel Metabolic Profiling of Human and Mouse Model Serum Reveals Putative Biomarkers Associated with the Progression of Nonalcoholic Fatty Liver Disease
Keywords: NAFLD, steatosis, NASH, metabolomics, biomarkers. FOOTNOTE
Relations entre différents scores tomodensitométriques et l'obésité morbide
REIMS-BU Santé (514542104) / SudocSudocFranceF
Complicated diverticular disease: the changing paradigm for treatment
The term "complicated" diverticulitis is reserved for inflamed diverticular disease complicated by bleeding, abscess, peritonitis, fistula or bowel obstruction. Hemorrhage is best treated by angioembolization (interventional radiology). Treatment of infected diverticulitis has evolved enormously thanks to: 1) laparoscopic colonic resection followed or not (Hartmann's procedure) by restoration of intestinal continuity, 2) simple laparoscopic lavage (for peritonitis +/- resection). Diverticulitis (inflammation) may be treated with antibiotics alone, anti-inflammatory drugs, combined with bed rest and hygienic measures. Diverticular abscesses (Hinchey Grades I, II) may be initially treated by antibiotics alone and/or percutaneous drainage, depending on the size of the abscess. Generalized purulent peritonitis (Hinchey III) may be treated by the classic Hartmann procedure, or exteriorization of the perforation as a stoma, primary resection with or without anastomosis, with or without diversion, and last, simple laparoscopic lavage, usually even without drainage. Feculent peritonitis (Hinchey IV), a traditional indication for Hartmann's procedure, may also benefit from primary resection followed by anastomosis, with or without diversion, and even laparoscopic lavage. Acute obstruction (nearby inflammation, or adhesions, pseudotumoral formation, chronic strictures) and fistula are most often treated by resection, ideally laparoscopic. Minimal invasive therapeutic algorithms that, combined with less strict indications for radical surgery before a definite recurrence pattern is established, has definitely lead to fewer resections and/or stomas, reducing their attendant morbidity and mortality, improved post-interventional quality of life, and less costly therapeutic policies
Problems associated with education and teaching laparoscopic surgery: the role of the European Association for Endoscopic Surgery
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Optimal trocar placement for ergonomic intracorporeal sewing and knotting in laparoscopic hiatal surgery
BACKGROUND: Trocar placement presently is mostly empiric. Our goal was
to define simple distances from bony landmarks to locate the optimal
ergonomic placement of manipulation trocars for access to the lower
esophagus and hiatal orifice, for suture placement, and knotting of the
gastric fundus and crura. Hypothesizing that the ideal ergonomic
principles of a manipulation angle of 60 degrees, an elevation angle
(alpha(e)) of 30 degrees to 60 degrees, and an
intracorporeal/extracorporeal length ratio (TIE) of working instruments
close to 1:1 are interrelated by simple trigonometric functions, the
variations of each of these parameters were calculated in a dependent
manner for 2 standard lengths of needle holders: 48.5 cm and 58.5 cm.
RESULTS: Trocar placement can be calculated easily according to simple
formulas dependent on the alpha(e), the distance from the sternoxiphoid
junction to the median of the intertrocar span (d) and the vertical
distance from the stenoxiphoid junction to the average distance between
the apex of the hiatal orifice and the anterior aspect of the esophagus
(XHâ): when the alpha(e) is 30 degrees: d is XHâ root 2 and when
alpha(e) is 45 degrees, d is XHâ/root 2. Likewise, when alpha(e) is 30
degrees the intertrocar span (LR) is 2XHâ, half on either side of the
optical axis (d), and when alpha(e) is 45 degrees, LR is XHâ root 2,
XHâ/root 2 on either side of the optical axis. The most ergonomic
solution is to work with an alpha(e) of 40 degrees to 45 degrees by
placing the 2 working (manipulation) trocars, between 10 and 14 cm
caudad from the sternoxiphoid junction, between 10 and 12 cm on either
side of the longitudinal axis corresponding to the optic-target axis.
The shorter needle holder works best in this configuration because the
I/E ratio will be between .8 and 1. If, however, the surgeon wants to
work with an alpha(e) closer to 30 degrees, then the longer needle
holder should be used, and the trocars should be placed between 20 and
21 cm from the sternoxiphoid junction, 14.5 to 15 cm on either side of
the optical axis. The I/E ratio will vary between 1 and 1.1. When a 1/1
I/E ratio was prioritized, the alpha(e) would be 40 degrees and 32
degrees, for the shorter and longer instruments, respectively. The
deeper crural closure requires increasing the alpha(e) by 2 degrees and
3 degrees, respectively. Hyperlordosis, as obtained by placing a cushion
under the patientâs back, shortens the distances, allowing placement of
the trocars closer to the sternoxiphoid junction.
CONCLUSIONS: Based on ergonomic principles (manipulation angle, 60
degrees; alpha(e), 40 degrees-45 degrees; and an I/E ratio of working
instruments, close to 1:1), simple trigonometric considerations allow
easy calculation of the ideal placement of trocars corresponding to
working instruments in hiatal surgery necessary for ergonomic
dissection, suturing, and intracorporeal knotting. Ideal trocar
placement is dependent only on the vertical depth of the target organ.
(C) 2010 Elsevier Inc. All rights reserved