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We propose an approach for emptying of bin using a combination of Image and Range sensor. Offering a complete solution: calibration, segmentation and pose estimation, along with approachability analysis for the estimated pose. The work is novel in the sense that the objects to be picked are featureless and uniformly black in colour, hence existing approaches are not directly applicable. A key point involves optimal utilization of range data acquired from the laser scanner for 3-D segmentation using localized geometric information. This information guides segmentation of the image for better object pose estimation, used for pick-and-drop. We analytically assure the approachability of the object to avoid collision of the manipulator with the bin. Disturbance of objects caused during pick up has been modelled, which allows pickup of multiple pellets based on information from a single range scan. This eliminates the necessity of repeated scanning and data conditioning. The proposed method offers high object detection rate and pose estimation accuracy. The innovative techniques aimed at reducing the average pickup time makes it suitable for robust industrial operation.

Intraoperative incisionless fluorescent cholangiogram (IOIFC) has been demonstrated to be a useful tool to increase the visualization of Calot’s triangle. This study evaluates the identification of extrahepatic biliary structures with IOIFC by medical students and surgery residents. Two pictures were taken, one with xenon light and one with near-infrared (NIR) light, at the same stage during dissection of Calot’s triangle in ten different cases of laparoscopic cholecystectomy (LC). All twenty pictures were organized in a random fashion to remove any imagery bias. Twenty students and twenty residents were asked to identify the biliary anatomy. Medical students were able to accurately identify the cystic duct on an average 33.8 % under the xenon light versus 86 % under NIR light (p = 0.0001), the common hepatic duct (CHD) on an average 19 % under the xenon light versus 88.5 % under NIR light (p = 0.0001), and the junction on an average 24 % under xenon light versus 80.5 % under NIR light (p = 0.0001). Surgery residents were able to accurately identify the cystic duct on an average 40 % under the xenon light versus 99 % under NIR light (p = 0.0001), the CHD on an average 35 % under the xenon light versus 96 % under NIR light (p = 0.0001), and the junction on an average 24 % under the xenon light versus 95.5 % under NIR light (p = 0.0001). IOIFC increases the visualization of Calot’s triangle structures when compared to xenon light. IOIFC may be a useful teaching tool in residency programs to teach LC.

BACKGROUND: Paraesophageal hernia patients are often elderly with complicating medical comorbidities, making surgical management complex in formulating a management strategy. METHODS: Between January 2005 and July 2009, 93 patients underwent surgical treatment of paraesophageal hernia, including 8 recurrent cases after multiple repairs. Open transabdominal surgeries were performed in 14 (15%) patients, and combined thoracotomy was performed in 1 (1%). Laparoscopic surgeries were performed in 78 (84%) patients with 4 (5%) conversions. Artificial prosthetics were used in 27 (29%) patients. Fundoplication was performed in 82 (88%) patients. Gastropexy or feeding tube gastrostomy was performed in 10 (11%) patients. RESULTS: The average length of the surgery was 125 minutes (range, 51‐304 min). The mean blood loss was 100 mL. The average length of stay was 4 days (range, 1‐14 d). There were 2 mortalities (2%) and 4 re-operations, with a recurrence rate of 2%. CONCLUSIONS: Laparoscopic paraesophageal hernia repair can be performed safely with acceptable results when following a standard approach.

Laparoscopic sleeve gastrectomy is a viable option that is becoming common in the management of morbid obesity. The aim of this study was to examine the effectiveness and safety of laparoscopic sleeve gastrectomy as a primary step for rapid weight loss in patients who required a second non-bariatric procedure.After Internal Review Board approval and with adherence to HIPAA guidelines, we conducted a retrospective review of a prospectively collected database of all patients who underwent laparoscopic sleeve gastrectomy as a primary procedure for a second non-bariatric operation from November 2004 to September 2008 at the Bariatric and Metabolic Institute at Cleveland Clinic Florida. The data was reviewed for age, gender, percentage of excess weight loss (%EWL), preoperative and postoperative body mass index (BMI), morbidity, and mortality. Mean follow-up time was 7 months (range, 2 weeks-12 months).Laparoscopic sleeve gastrectomy was performed in 18 patients who needed a second non-bariatric procedure such as knee replacement surgery, recurrent incisional hernia repair, laminectomy of the lumbar spine, kidney transplant, anterior cervical discectomy, and nephrectomy. Mean preoperative weight and BMI were 124.9 kg (range, 95.5-172.3 kg) and 44.87 kg/m2 (range, 33.36-58.87 kg/m2), respectively. Mean postoperative weight and BMI were 99.2 kg (range, 68.2-132.2 kg) and 35.79 kg/m2 (range, 23.46-48.97 kg/m2), respectively. There were no conversions to an open procedure in this series. There was no morbidity or mortality in this series.In this small group, laparoscopic sleeve gastrectomy appears to be an effective and safe first surgical approach for rapid weight loss in high-risk patients that require a second non-bariatric procedure.

Bezoar is a rare cause of small bowel obstruction after Roux-en-Y gastric bypass (RYGB). We report the case of a 34-year-old man who developed small bowel obstruction secondary to a phytobezoar at the jejunojejunal anastomosis, 5½ years after the patient underwent RYGB for morbid obesity. The phytobezoar developed in the background of recurring abdominal pain. Imaging studies suggested complete obstruction of the alimentary limb. Laparoscopic exploration demonstrated complete obstruction of the alimentary and biliopancreatic limb. Patient had successful treatment with laparoscopic enterototomy. Six months after the laparoscopic removal of phytobezoar, patient remained asymptomatic. Phytobezoar formation must be considered in the differential diagnosis when postgastric bypass patients present late with obstructive symptoms. We believe that this is the first report of a phytobezoar obstructing at the jejunojejunal anastomosis after RYGB.

Intraoperative incisionless fluorescent cholangiography (IOIFC) has been described to identify extrahepatic biliary anatomy. Potential advantages of the routine use of intraoperative incisionless fluorescent cholangiography were evaluated in a consecutive series of cases. A total of 45 patients undergoing laparoscopic cholecystectomy between January and July 2013 were consented and included in this study. We analyzed a prospectively collected database for feasibility, cost, time, usefulness, teaching tool, safety, learning curve, X-ray exposure, complexity, and real-time surgery of IOIFC. A single dose of 0.05 mg/kg of Indocyanine green was administered prior to surgery. During the procedure, a laparoscopic fluorescence system was used. IOIFC could be performed in all 45 patients, whereas intraoperative cholangiography could be performed in 42 (93 %). Individual median cost of performing IOFC was cheaper than IOC (13.97 ± 4.3 vs 778.43 ± 0.4 USD) per patient, p = 0.0001). IOFC was faster than IOC (0.71 ± 0.26 vs 7.15 ± 3.76 minutes, p

Identification of adrenal glands from the surrounding structures during laparoscopic surgery can be challenging especially in obese individuals. This can increase the chances for hemorrhage and conversion to open surgery. We present the first report of fluorescent infrared visualization of the adrenal glands in a large animal model. Five adult Yorkshire pigs were utilized for the study, in compliance with the animal study regulations. After an intravenous bolus administration of 3 mL of indocyanine green (ICG), visualization was performed with a xenon/infrared light source and a laparoscope with a charge-coupled filter device. Activation of the device was done with a foot pedal. Images were analyzed using histogram software and the difference of enhancement was statistically analyzed using unpaired two-tailed t test. The right adrenal glands were visualized in all five animals immediately after administering ICG. Fluorescence facilitated demarcation of adrenal gland tissue from surrounding adipose tissue. Peritoneum and fat was visualized in black color. Adrenal enhancement lasted for 4 h in all cases. The mean value for adrenal fluorescence using histogram count was 71.75 pixels, and for adrenal xenon was 168.87 pixels (p = 0.0002; 95 % CI −130.93 to −0.63). The mean value for fat fluorescence using histogram count was 5.54 pixels and fat xenon was 187.15 pixels (p = 0.0001; 95 % CI −199.39 to −163.82). Although there was no significant difference between adrenal and fat enhancement with xenon light (p = 0.24; 95 % CI −15.53 to 52.09), the difference became significant between adrenal and fat fluorescence (p = 0.0001; 95 % CI 48.51–83.9). Fluorescence imaging appears to be a feasible and easy method to differentiate adrenal glands from the surrounding tissue in a large animal model. Further studies are necessary to investigate the real application of this method during laparoscopic adrenalectomy in humans.

The prevalence and severity of obesity in children and adolescents has been increasing in recent years at an unprecedented rate. Morbidly obese children will almost certainly develop severe comorbidities as they progress to adulthood, and bariatric surgery may provide the only alternative for achieving a healthy weight. The aim of this study was to assess the long-term outcomes and safety of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) as new treatment modalities for morbidly obese adolescents. We conducted a retrospective review of a prospectively collected database of all adolescent patients who underwent LSG and RYGB under IRB protocol at the Bariatric and Metabolic Institute in Cleveland Clinic Florida between 2002 and 2011. Patients were also contacted by phone, adhering to HIPAA regulations, and were asked to answer a survey. Eighteen adolescents had a bariatric procedure performed at this institution. The mean age was 17.5 years, the average weight was 293.1 lbs, and the average BMI was 47.2 kg/m2. The mean follow-up period consisted of 55.2 months. The postoperative weight at 55 months follow-up was 188.4 lbs and average BMI was 30.1 kg/m2. Fifteen of the patients were available for follow-up. Thirteen out of 16 (81%) comorbidities in patients available for follow-up were in remission following rapid weight loss. The long-term follow-up and perioperative morbidity shown in this study suggest that LSG and LRYGB appear to be safe and effective operations in morbidly obese adolescents.

The Rhodococcus species rarely cause musculoskeletal infections, with only two cases reported in the literature. We report the case of a 53-year-old woman who had an infection develop after first metatarsophalangeal joint fusion. A year after surgery, she continued to have pain and swelling with nonunion. She underwent revision of the arthrodesis and tissue samples from surgery revealed Rhodococcus erythropolis. The patient's symptoms improved with oral antibiotics. One year after the revision surgery, the fusion had united. We believe this is the first report of a case of a musculoskeletal infection caused by Rhodococcus erythropolis.

The term osteomyelitis encompasses a broad group of infectious diseases characterized by infection of the bone and/or bone marrow. The pathogenesis of these diseases can follow acute, subacute or chronic courses and involves a range of contributory host and pathogen factors. A commonly used aetiological classification distinguishes between three types of osteomyelitis: acute or chronic haematogenous disease seeded by organisms in the bloodstream, local spread from a contiguous source of infection and secondary osteomyelitis related to vascular insufficiency.

Background The aim of the present study was to report the outcomes of bariatric surgery in patients >70 years of age at a community hospital in the United States. Methods A retrospective review was performed of prospectively collected data from patients aged >70 years who had undergone bariatric surgery at a single institution from 2002 to 2008. The data analyzed included age, preoperative and postoperative weight and body mass index, postoperative complications, and co-morbidities. Results Of 42 patients aged >70 years who underwent bariatric surgery, 22 patients (52.4%) had undergone laparoscopic gastric banding, 12 patients (28.6%) laparoscopic sleeve gastrectomy, and 8 patients (19%) laparoscopic Roux-en-Y gastric bypass. The mean preoperative weight and body mass index was 127.4 ± 25.5 kg and 46.8 ± 9.3 kg/m 2 , respectively. The mean postoperative weight and body mass index was 100.2 ± 17 kg and 35.5 ± 5.4 kg/m 2 , respectively. The median length of follow-up was 12 months (range 1–66). The mean percentage of excess weight loss was 47.7% at 12 months, with 73.1% follow-up data. Complications included wound infections in 4 patients (9.5%), band removal in 3 patients (7.1%), anastomotic leak in 1 patient (2.3%), and megaesophagus in 1 patient (2.3%). No mortality occurred. The postoperative use of medications for hypertension, hyperlipidemia, diabetes mellitus, and degenerative joint disease were reduced by 56%, 54%, 53%, 66%, and 50%, respectively. Conclusion Bariatric surgery in carefully screened patients aged >70 years can be performed safely and can achieve modest improvement in co-morbidities.

Making telephone referrals from A&E can be a daunting process, especially for a complicated case and to specialties where it is difficult to refer. The voice on the other end of the phone might sound much more experienced and knowledgeable than you, but remember that you always have an added advantage—the patient is in front of you. Here are a few tips to help …

After working hard to find a clinical attachment you will want to make sure that you get a job at the end of it. Here are a few tips on how you should use your time in your clinical attachment as effectively as possible.