Implementation of robotic laparoscopic cholecystectomy in a university hospital.

BACKGROUND: Robot surgery is a further step towards new potential developments in minimally invasive surgery. Surgeons must keep abreast of these new technologies and learn their limits and possibilities. Robot-assisted laparoscopic cholecystectomy has not yet been performed in our institution. The purpose of this report is to present the pathway of implementation of robotic laparoscopic cholecystectomy in a university hospital. METHODS: The Zeus(R) robot system was used. Experimental training was performed on animals. The results of our experimental training allowed us to perform our first two clinical cases. RESULTS: Robot arm set-up and trocar placement required 53 and 35 minutes. Operative time were 59 and 45 minutes respectively. The overall operative time was 112 and 80 minutes, respectively. There were no intraoperative complications. Patients were discharged from the hospital after an overnight stay. CONCLUSION: Robotic laparoscopic cholecystectomy is safe and patient recovery similar to those of standard laparoscopy. At present, there are no advantages of robotic over conventional surgery. Nevertheless, robots have the potential to revolutionise the way surgery is performed. Robot surgery is not reserved for a happy few. This technology deserves more attention because it has the potential to change the way surgery is performed

Neural fate of seen and unseen faces in visuospatial neglect: A combined event-related functional MRI and event-related potential study

This is a post print version of the article. The official published version can be obtained from the link below.To compare neural activity produced by visual events that escape or reach conscious awareness, we used event-related MRI and evoked potentials in a patient who had neglect and extinction after focal right parietal damage, but intact visual fields. This neurological disorder entails a loss of awareness for stimuli in the field contralateral to a brain lesion when stimuli are simultaneously presented on the ipsilateral side, even though early visual areas may be intact, and single contralateral stimuli may still be perceived. Functional MRI and event-related potential study were performed during a task where faces or shapes appeared in the right, left, or both fields. Unilateral stimuli produced normal responses in V1 and extrastriate areas. In bilateral events, left faces that were not perceived still activated right V1 and inferior temporal cortex and evoked nonsignificantly reduced N1 potentials, with preserved face-specific negative potentials at 170 ms. When left faces were perceived, the same stimuli produced greater activity in a distributed network of areas including right V1 and cuneus, bilateral fusiform gyri, and left parietal cortex. Also, effective connectivity between visual, parietal, and frontal areas increased during perception of faces. These results suggest that activity can occur in V1 and ventral temporal cortex without awareness, whereas coupling with dorsal parietal and frontal areas may be critical for such activity to afford conscious perception. Right parietal damage may cause a loss of awareness for contralateral (left) sensory inputs, such as hemispatial neglect and extinction (1–3). Visual extinction is the failure to perceive a stimulus in the contralesional field when presented together with an ipsilesional stimulus (bilateral simultaneous stimulation, BSS), even though occipital visual areas are intact and unilateral contralesional stimuli can be perceived when presented alone. It reflects a deficit of spatial attention toward the contralesional side, excluding left inputs from awareness in the presence of competing stimuli (2, 3). Spatial attention involves a complex neural network centered on the right parietal lobe (4, 5), but how parietal and related areas interact with sensory processing in distant cortices is largely unknown. Here we combined event-related functional MRI (fMRI) and event-related potentials (ERPs) to study the regional pattern and temporal course of brain activity produced by seen and unseen stimuli in a patient with chronic neglect and extinction caused by parietal damage. In keeping with intact early visual areas in such patients, behavioral studies suggest that some residual processing may still occur for contralesional stimuli without attention, or without awareness, including “preattentive” grouping (e.g., refs. 6 and 7) and semantic priming (e.g., ref. 8). It has been speculated (3, 9) that such effects might relate to separate cortical visual streams, with temporal areas extracting object features for identification, and parietal areas encoding spatial locations and parameters for action (10). Because neglect and extinction follow parietal damage, residual perceptual and semantic processing still might occur in occipital and temporal cortex without awareness, in the absence of normal integration with concomitant processing in parietal regions. Our study tested this hypothesis by using event-related imaging and electrophysiology measures, which are widely used to study mechanisms of normal attention (11, 12). There have been few imaging (e.g., ref. 13) or ERP (e.g., ref. 14) studies in neglect, and most examined activity at rest or during passive unilateral visual stimulation, rather than in relation to awareness or extinction on bilateral stimulation. However, a recent ERP study (15) found signals evoked by perceived, but not extinguished, visual stimuli in a parietal patient. By contrast, functional imaging in another patient (16) showed activation of striate cortex by extinguished stimuli, although severe extinction on all bilateral stimuli precluded any comparison with normal perception. In our patient we used both fMRI and ERPs during a similar extinction task to determine the neural correlates of two critical conditions: (i) when contralesional stimuli are extinguished, and (ii) when the same stimuli are seen. Stimulus presentation was arranged so as to obtain a balanced number of extinguished and seen contralesional events across all bilateral trials. Like Rees et al. (16), we used face stimuli to exploit previous knowledge that face processing activates fusiform areas in temporal cortex (e.g., refs. 17 and 18), and elicits characteristic potentials 170–200 ms after stimulus onset (e.g., refs. 19–21) in addition to other visual components such as P1 and N1 (e.g., ref. 11). We reasoned that such responses might help trace the neural fate of contralesional stimuli (seen or extinguished) at both early and later processing stages in the visual system

Investigations of fast neutron production by 190 GeV/c muon interactions on different targets

The production of fast neutrons (1 MeV - 1 GeV) in high energy muon-nucleus interactions is poorly understood, yet it is fundamental to the understanding of the background in many underground experiments. The aim of the present experiment (CERN NA55) was to measure spallation neutrons produced by 190 GeV/c muons scattering on carbon, copper and lead targets. We have investigated the energy spectrum and angular distribution of spallation neutrons, and we report the result of our measurement of the neutron production differential cross section.Comment: 19 pages, 11 figures ep

Laparoscopic cholecystectomy as a day surgery procedure: implementation and audit of 136 consecutive cases in a university hospital

Laparoscopic cholecystectomy (LC) has been routinely performed since 1989 at our institution, and patients were traditionally admitted for 2 days. In 1996 we implemented a protocol for LC as a day surgery procedure at our center. Although initially reported by others, it has not yet been introduced as routine in Switzerland. The objective of this prospective study was to determine acceptability and safety of LC as an outpatient procedure in a university hospital. Data were collected prospectively for 136 LCs between January 1996 and December 2001. Patients were selected for the study if they wanted to go home within less than 24 hours, had no previous jaundice, and had no anesthetic contraindication. Systematic preoperative liver function tests and hepatic ultrasonography were performed. All patients were admitted on the day of operation. LC was performed using a three-trocar technique. Systematic cholangiography was performed, and all the procedures were completed laparoscopically. There were no common bile duct explorations. Postoperative complications were the following: nausea in seven patients, a minor umbilical hematoma in two. According to patient preference, 101 (74%) were discharged after an overnight stay (less than 24 hours) and 32 (24%) on the same day. The unplanned admission rate was 2%, and none of the patients was subsequently readmitted. The reasons for unplanned admissions were two patients with persistent nausea and one patient for whom an overnight stay was scheduled who presented with a ruptured subcapsular hematoma of the liver. Altogether, 97% of the patients were satisfied with the care they received. Operative costs were not significantly different when comparing inpatient and outpatient LC. The main postoperative savings were in the postoperative costs. Our results confirm that LC as a day surgery procedure is safe, effective, and acceptable to patients and their relatives. These results were achieved by using selection criteria that considered not only the surgical pathology but also the individual and by using appropriate techniques and planned postoperative analgesi

Automated Incubation and Digital Image Analysis of Chromogenic Media Using Copan WASPLab Enables Rapid Detection of Vancomycin-Resistant Enterococcus.

Objective: The aim of the present study was to assess whether the WASPLab automation enables faster detection of vancomycin-resistant Enterococcus (VRE) on chromogenic VRE-specific plates by shortening the incubation time. Methods: Ninety different VRE culture negative rectal ESwab specimens were spiked with various concentrations (ranging from 3 × 10 <sup>2</sup> to 3 × 10 <sup>7</sup> CFU/ml) of 10 Enterococcus faecium strains (vancomycin MICs ranging from 32 to >256 mg/l), 3 E. faecium VanB strains (vancomycin MICs: 4, 8, and 16 mg/l), and 2 E. faecium VanB strains displaying vancomycin heteroresistance (vancomycin MICs: 64 and 96 mg/l). Results: Besides the two strains exhibiting vancomycin heteroresistance, all the other 13 VRE strains included in this study were detected as early as 24 h on the WASPLab even if the inoculum was low (3 × 10 <sup>3</sup> CFU/ml). When the vancomycin MICs were high, all strains were detected as early as at 18 h. However, 30 h was a conservative time point for finalizing the analysis of chromogenic cultures. Conclusion: These results suggested that the WASPLab automated incubation could allow decreasing the initial incubation time to 18 h, followed by an intermediate time at 24 h and a final incubation period of 30 h for VRE culture screening, to deliver rapid results without affecting the analytical sensitivity

Solar irradiances measured using SPN1 radiometers: uncertainties and clues for development

International audienceThe fast development of solar radiation and energy applications, such as photovoltaic and solar thermodynamic systems, has increased the need for solar radiation measure-ment and monitoring, for not only the global but also the diffuse and direct components. End users look for the best compromise between getting close to state-of-the-art mea-surements and keeping low capital, maintenance and operat-ing costs. Among the existing commercial options, SPN1 is a relatively low cost solar radiometer that estimates global and diffuse solar irradiances from seven thermopile sensors under a shading mask and without moving parts. This work presents a comprehensive study of SPN1 accu-racy and sources of uncertainty, drawing on laboratory ex-periments, numerical modelling and comparison studies be-tween measurements from this sensor and state-of-the art in-struments for six diverse sites. Several clues are provided for improving the SPN1 accuracy and agreement with state-of-the art measurements

Hourly resolved cloud modification factors in the ultraviolet

Cloud impacts on the transfer of ultraviolet (UV) radiation through the atmosphere can be assessed by using a cloud modification factor (CMF). CMF, which is based on total global solar irradiation (SOL<sub>CMF</sub>), has proved to be a solid basis to derive CMFs for the UV radiation (UV<sub>CMF</sub>). This is an advantage, because total global irradiance, the basis for SOL<sub>CMF</sub>, is frequently measured and forecasted by numerical weather prediction systems and includes all relevant effects for radiation transmission, such as cloud optical depth, different cloud layers, multiple reflection, as well as the distinct difference as to whether the solar disc is obscured by clouds or not. In the UV range clouds decrease the irradiance to a lesser extent than in the visible and infrared spectral range. Thus the relationship between CMFs for solar radiation and for UV-radiation is not straight forward, but will depend on whether, for example, the solar zenith angle (SZA) and wavelength band or action spectrum in the UV have been taken into consideration. Den Outer et al. provide a UV<sub>CMF</sub> algorithm on a daily basis, which accounts for these influences. It requires as input a daily SOL<sub>CMF</sub> and the SZA at noon. The calculation of SOL<sub>CMF</sub> uses the clear-sky algorithm of the European Solar Radiation Atlas to account for varying turbidity impacts. The algorithm's capability to derive hourly UV<sub>CMFs</sub> based on the SZA at the corresponding hour and its worldwide applicability is validated for erythemal UV using observational data retrieved from the databases of the COST-Action 726 on "Long-term changes and climatology of UV radiation over Europe" and the USDA UV-B Monitoring Program. The clear-sky part of the models has proved to be of good quality. Accumulated to daily doses it forms a tight cluster of points to the highest measured daily sums. All sky model performances for hourly resolution are shown to be comparable in accuracy with the well performing daily models of the COST-726 model intercomparison

Redistribution of gastric blood flow by embolization of gastric arteries before esophagectomy.

Background. Anastomotic leak remains a common and potentially deleterious complication after esophagectomy. Preoperative embolization of the left gastric artery and splenic artery (PAE) has been suggested to lower anastomotic leak rates. We present the results of our 5-year experience with this technique.Methods. All patients undergoing PAE before esophagectomy since introduction of this technique in 2004 were compared in a 1: 2 matched-pair analysis with patients without PAE. Matching criteria were type of anastomosis, neoadjuvant treatment, comorbidity, and age. Data were derived from a retrospective chart review from 2000 to 2006 that was perpetuated as a prospective database up to date. Outcome measures were anastomotic leak, overall complications, and hospital stay.Results. Between 2000 and 2009, 102 patients underwent esophagectomy for cancer in our institution with an overall leak rate of 19% and a mortality of 8%. All 19 patients having PAE since 2004 were successfully matched 1: 2 to 38 control patients without PAE; both groups were similar regarding demographics and operation characteristics. Two PAE (11%) and 8 control patients (21%) had an anastomotic leak, but the difference was statistically not significant (p = 0.469). Overall and major complication rates for PAE and control group were 89% versus 79% (p = 0.469) and 37% versus 34% (p = 1.000), respectively. Median intensive care unit and hospital stay were 3 versus 3 days (p = 1.000) and 22 versus 17 days (p = 0.321), respectively.Conclusions. In our experience, PAE has no significant impact on complications and anastomotic leak in particular after esophagectomy. (Ann Thorac Surg 2011;91:1556-61) (C) 2011 by The Society of Thoracic Surgeon