A new technique of extreme lateral positioning for laparoscopic splenic flexure mobilization.

AIM: This aim of this study was to describe a novel positioning technique that assists in the expeditious mobilization of the splenic flexure without the need for redraping or compromise of port placement. METHOD: A prospective case series was studied to evaluate the technique and its ability to facilitate splenic flexure mobilization. RESULTS: The technique was used in 12 patients. There were no adverse intra- or postoperative events. The median time (interquartile range) for laparoscopic splenic flexure mobilisation was 10 (9-11.25). CONCLUSION: This novel positioning technique is safe and feasible. We include a detailed video that describes and demonstrates the requisites for its safe conduct. We also include intra-operative footage demonstrating the benefits of the patient's position.

Abdominal injury due to a hand held flare: an ongoing insult.

Although traumatic abdominal missile injuries have been previously widely reported, there are no reports on penetrating hand held flare injuries. We report a case of a penetrating abdominal flare injury and the subsequent complications that occurred as a result of this unique injury.

Technical skills examination for general surgical trainees.

BACKGROUND: The technical skills of surgical trainees are difficult to assess and compare objectively. This study involved a structured, multistation, technical skills examination that enables the stratification of surgical trainees. METHODS: Twenty-two surgeons (five basic surgical trainees, eight junior specialist trainees, four senior specialist trainees and five consultants) participated in the study. All undertook a five-station technical skills examination consisting of three synthetic simulations (bowel anastomosis, vascular anastomosis, saphenofemoral dissection) and two virtual reality-based (flexible sigmoidoscopy and laparoscopy) assessment stations. Video-based analyses and in-built computer scoring were used to measure each surgeon's performance. The mean rank was determined for each variable, and the sum of the mean ranks produced a total score. RESULTS: There was a significant improvement in overall performance with increasing seniority (P<0.001). Significant differences were observed between basic surgical trainees and junior specialist trainees (P=0.019), and between junior and senior specialist trainees (P=0.048), but not between senior trainees and consultants. CONCLUSION: This examination successfully differentiated surgical skill, both between surgeons with different grades of experience and within the target study group of specialist trainees. The examination is feasible in terms of the timeframe needed to complete tasks, cost, and efficiency in performing video-based assessments.

Virtual reality simulation training can improve inexperienced surgeons' endovascular skills.

PURPOSE: The aim of this study was to evaluate virtual reality (VR) simulation for endovascular training of surgeons inexperienced in this technique. METHODS: Twenty consultant vascular surgeons were divided into those who had performed >50 endovascular procedures (e.g. aortic and carotid stent) as primary operator (n=8), and those having performed <10 procedures (n=12). To test for endovascular skill rather than procedural knowledge, all subjects performed a renal artery balloon angioplasty and stent procedure. The simulator uses real tools with active force feedback, and provides a realistic image of the virtual patient. Surgeons with endovascular skills performed two repetitions and those without completed six repetitions of the same task. The simulator recorded time taken for the procedure, the amount of contrast fluid used and total fluoroscopy time. RESULTS: Initially, surgeons with endovascular skills were significantly faster (median 571.5 vs. 900.0 s, p=0.039) and used less contrast fluid (19.1 vs. 42.9 ml, p=0.047) than inexperienced operators, though differences for fluoroscopy time were not significant (273 vs. 441 s, p=0.305). Over the six sessions, the inexperienced group made significant improvements in performance for time taken (p=0.007) and contrast fluid usage (p=0.021), achieving similar scores at the end of the training program to the experienced group. CONCLUSIONS: Surgeons with minimal endovascular experience can improve their time taken and contrast usage during short-phase training on a VR endovascular task. VR simulation may be useful for the early part of the learning curve for surgeons who wish to expand their endovascular interests.

Skills training in telerobotic surgery.

Surgical robots have the potential to expand the repertoire of minimally invasive surgery resulting in more patients benefiting from lower operative morbidity and shorter hospital stays. However, in a similar manner to all new surgical interventions it necessary to explore the learning curves of practitioners as they adopt this new technology to enable optimisation of future training programs. Only when the standard of practice is firmly established, should the proliferation of robotic practitioners be encouraged thus ensuring patient safety is not compromised.

Evaluation of the benefit of VR simulation in a multi-media web-based educational tool.

WebSET is an Internet based educational tool that can be used on any standard personal computer. It has been developed by a European collaboration and integrates high quality multimedia learning materials with VR simulation. The aim of this study was to evaluate the benefit of the VR simulation on the learning of procedure based psychomotor skills. Subjects were divided into three groups. The group that used the entire package including the VR simulation were superior to the group that used only the multimedia component in terms of the their procedural skills in the post-training assessment. Both groups performed better than the controls.

Robot-assisted laparoscopic Heller cardiomyotomy: preliminary UK results.

BACKGROUND/AIM: Laparoscopic Heller cardiomyotomy is an established modality in the surgical treatment of patients having achalasia cardia. We present our initial experience in robot-assisted laparoscopic Heller cardiomyotomy without addition of an antireflux procedure and discuss the relative merits and disadvantages of the procedure. PATIENTS AND METHODS: Five patients underwent robot-assisted laparoscopic Heller cardiomyotomy between August 2001 and October 2002. The diagnosis had been confirmed by radiology and manometry in all patients prior to surgery. RESULTS: All procedures were completed successfully using the robotic system, without conversion to open procedure. Mucosal perforation occurred in 1 patient and was sutured robotically. The average operative time was 114.8 (range 65-160) min which is comparable to laparoscopic procedures. After a mean follow-up period of 9.4 (range 3-17) months, 4 patients remained completely asymptomatic, and 1 patient has benefited from symptomatic improvement. CONCLUSIONS: The enhanced dexterity and the high-quality three-dimensional vision available with robot-assisted surgery make the application of this technology highly suitable for Heller cardiomyotomy. The minimal lateral and posterior dissection due to the wristed instruments avoids the need for an antireflux procedure.

Robotics and surgery: a long-term relationship?

This article introduces robotic surgical systems by explaining the shortcomings of traditional laparoscopic surgery, and how these new systems have been developed to address them. This is followed by a descriptive section of robotic systems past and present and their use in different surgical specialities. Finally, we discuss advances that are planned for the development of current systems and the future role of robotics in surgery.

Robotics in colorectal surgery.

Minimally invasive surgery has been shown to offer many advantages to general surgical patients but has not been widely adopted for colorectal disease. Initial fears surrounding the oncological safety of laparoscopic colectomies have largely subsided but the technical challenges still remain. Surgical robots or telemanipulators present the laparoscopic surgeon with unrivaled dexterity and vision, which may allow colonic resections to be completed with greater ease. Although initial studies suggest promising results using currently available systems, it will take further time for patient benefits to be proven, therefore justifying the greater expense of operating with this new technology.

RED: the analysis, management and dissemination of expressed sequence tags.

The Rancourt EST Database (RED) is a web-based system for the analysis, management, and dissemination of expressed sequence tags (ESTs). RED represents a flexible template DNA sequence database that can be easily manipulated to suit the needs of other laboratories undertaking mid-size sequencing projects.

The influence of early and frequent use of marijuana on the risk of desistance and of progression to marijuana-related harm.

BACKGROUND: A significant minority of lifetime marijuana users will eventually receive a diagnosis of abuse or dependence. Yet little is known regarding the effect of age at onset and frequency of lifetime marijuana use on desistance from use and on progression to marijuana disorders. METHODS: To address this issue, data were obtained from a community sample of 2,729 lifetime marijuana users participating in the Ontario Mental Health Supplement. RESULTS: Early and frequent lifetime marijuana use was associated with highly persistent use and rapid progression to marijuana-related harm. Multivariate analyses revealed a monotonic increase in the risk of desistance with less frequent categories of use and later ages of onset. Results also indicated a threshold of use (100-199 times) associated with an elevated risk of developing marijuana disorders. A lower threshold of risk for marijuana problems was observed for females (50-99 times). CONCLUSIONS: Early and frequent marijuana use are potent risk factors for prolonging desistance and hastening marijuana-related harm. Required are prevention programs aimed at delaying the onset of first use as well as harm reduction strategies that encourage cessation or reduced levels of consumption among those already using.

ES cell neural differentiation reveals a substantial number of novel ESTs.

We have used a method for synchronously differentiating murine embryonic stem (ES) cells into functional neurons and glia in culture. Using subtractive hybridization we isolated approximately 1200 cDNA clones from ES cell cultures at the neural precursor stage of neural differentiation. Pilot studies indicated that this library is a good source of novel neuro-embryonic cDNA clones. We therefore screened the entire library by single-pass sequencing. Characterization of 604 non-redundant cDNA clones by BLAST revealed 96 novel expressed sequence tags (ESTs) and an additional 197 matching uncharacterized ESTs or genomic clones derived from genome sequencing projects. With the exception of a handful of genes, whose functions are still unclear, most of the 311 known genes identified in this screen are expressed in embryonic development and/or the nervous system. At least 80 of these genes are implicated in disorders of differentiation, neural development and/or neural function. This study provides an initial snapshot of gene expression during early neural differentiation of ES cell cultures. Given the recent identification of human ES cells, further characterization of these novel and uncharacterized ESTs has the potential to identify genes that may be important in nervous system development, physiology and disease.

alpha-actinin-2 is a new component of the dystrophin-glycoprotein complex.

The human skeletal muscle yeast two-hybrid cDNA library was screened with the carboxyl-terminal region (the last 200 amino acids) of dystrophin. Two interacting clones were identified corresponding to alpha-actinin-2 and actin. Interactions between alpha-actinin, actin, and dystrophin were confirmed by the ligand-blotting technique, by colocalization of dystrophin and alpha-actinin-2 to the isolated skeletal muscle sarcolemmal vesicles and to the plasma membranes isolated from C2C12 myoblasts, and by indirect immunolocalization of dystrophin and alpha-actinin-2 in skeletal muscle cells. This is the first identification of a direct interaction between alpha-actinin, actin, and the carboxyl-terminal region of dystrophin. We propose that dystrophin forms lateral, multicontact association with actin and that binding of alpha-actinin-2 to the carboxyl-terminus of dystrophin is the communication link between the integrins and the dystrophin/dystrophin-glycoprotein complex.

Phosphorylation of the carboxyl-terminal region of dystrophin.

Dystrophin is a protein product of the gene responsible for Duchenne and Becker muscular dystrophy. The protein is localized to the inner surface of sarcolemma and is associated with a group of membrane (glyco)proteins. Dystrophin links cytoskeletal actins via the dystrophin-associated protein complex to extracellular matrix protein, laminin. This structural organization implicates the role of dystrophin in stabilizing the sarcolemma of muscle fibers. Precisely how dystrophin functions is far from clear. The presence of an array of isoforms of the C-terminal region of dystrophin suggests that dystrophin may have functions other than structural. In agreement, many potential phosphorylation sites are found in the C-terminal region of dystrophin, and the C-terminal region of dystrophin is phosphorylated both in vitro and in vivo by many protein kinases, including MAP kinase, p34cdc2 kinase, CaM kinase, and casein kinase, and is dephosphorylated by calcineurin. The C-terminal domain of dystrophin is also a substrate for hierarchical phosphorylation by casein kinase-2 and GSK-3. These observations, in accordance with the finding that the cysteine-rich region binds to Ca2+, Zn2+, and calmodulin, suggest an active involvement of dystrophin in transducing signals across muscle sarcolemma. Phosphorylation-dephosphorylation of the C-terminal region of dystrophin may play a role in regulating dystrophin-protein interactions and (or) transducing signal from the extracellular matrix via the dystrophin molecule to the cytoskeleton.