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The study is concerned with the development, encouragement and use of more environment-friendly forms of alternative fuels for transport. These innovative solutions encompass new more environment-friendly transport technologies (and also innovative transport concepts with potential for lowering environmental impacts, such as minimizing exhaust emissions).

Single-incision laparoscopic cholecystectomy (SILC) is a relatively new technique that is being increasingly used by surgeons around the world. Unlike the multi-port cholecystectomy, a standardised technique and detailed description of the operative steps of SILC is lacking in the literature. This article provides a stepwise account of the technique of SILC aimed at surgeons wishing to learn the procedure. A brief review of the current literature on SILC follows.

We read with interest the article by Dr Sadhu and colleagues [1] that details a technique of open insertion of laparosocpic cannula very much similar to the one we described and published in the Indian Journal of Surgery well over 9 years ago [2]. Both of us have since used it in more than 5000 patients without any instance of bowel or vascular injury. Having also taught the technique to several surgeon and gynecologist colleagues, we can vouch for its safety, simplicity and reproducibility. Over the years we have refined our technique to make it applicable in patients of all body habitus. Some of the technical aspects are highlighted below. 1 In thin patients and in those with a lax abdominal wall (e.g. multi-parous women) it is easy to evert the umbilicus completely by grasping the bottom of the umbilical pit with a towel clip. After a vertical incision on the umbilical cicatrix or the “umbilical tube” a cannula with a blunt inner trocar can then be guided into the peritoneal cavity directly.2 In most patients with a deep umbilicus and particularly in the obese, however, it is not always possible to evert the umbilicus. In these patients we place a towel clip on one lip of the umbilicus that has been everted with a toothed forceps, and apply a strong upward traction. This produces the desired effect of making the umbilical tube prominent allowing its easy identification after the skin has been incised. 3 We have observed that the umbilical tubes vary greatly in their texture, toughness and the amount of extraperitoneal fat they cover. Muscular and obese men often have a fibrous tube. After its incision, it is essential to grasp the cut edges with toothed instruments (our preference is single-toothed, straight Kocher’s forceps) to provide counter traction that allows a blunt-tipped hemostat to gently pierce and stretch the posterior rectus sheath/peritoneum underneath. 4 If the hemostat fails to gain easy entry into the peritoneal cavity, the incision on the umbilical tube needs to be extended onto the area where the umbilical tube merges with the horizontally placed linea alba. During this step, the short curved end of a baby Deaver’s retractor retracts and protects the skin to avoid a “T” extension of the incision. 5 A fair proportion of obese patients (and some not so obese ones) have a thick pad of extraperitoneal fat beneath the umbilical tube. If the tip of the hemostat does not “walk into” the peritoneal cavity after the tube is incised and its edges are lifted upwards, it is unwise to use force for the fear of causing injury to a loop of bowel lying under the incision. In such instances, we advance the blades of Deaver’s retractors to the depth of the extraperitoneal fat so as to identify and pick up the posterior sheath/peritoneum with two Kocher’s forceps. This layer is then incised. Additional manoeuvres such slightly extending the transverse skin incision, insertion of a third retractor

Hemangiomas are the most common type of tumor in infants. As they are endothelial cell–derived neoplasias, their growth can be regulated by the autocrine-acting Tie2 ligand angiopoietin 2 (Ang2). Using an experimental model of human hemangiomas, in which polyoma middle T–transformed brain endothelial (bEnd) cells are grafted subcutaneously into nude mice, we compared hemangioma growth originating from bEnd cells derived from wild-type, Ang2+/–, and Ang2–/– mice. Surprisingly, Ang2-deficient bEnd cells formed endothelial tumors that grew rapidly and were devoid of the typical cavernous architecture of slow-growing Ang2-expressing hemangiomas, while Ang2+/– cells were greatly impaired in their in vivo growth. Gene array analysis identified a strong downregulation of NADPH oxidase 4 (Nox4) in Ang2+/– cells. Correspondingly, lentiviral silencing of Nox4 in an Ang2-sufficient bEnd cell line decreased Ang2 mRNA levels and greatly impaired hemangioma growth in vivo. Using a structure-based approach, we identified fulvenes as what we believe to be a novel class of Nox inhibitors. We therefore produced and began the initial characterization of fulvenes as potential Nox inhibitors, finding that fulvene-5 efficiently inhibited Nox activity in vitro and potently inhibited hemangioma growth in vivo. In conclusion, the present study establishes Nox4 as a critical regulator of hemangioma growth and identifies fulvenes as a potential class of candidate inhibitor to therapeutically interfere with Nox function.

I read with interest the letter to the editor by Dr Lakhotia in a previous issue of IJS [1]. His letter clearly brings out the anguish that the surgical trainees (ST) today experience when they attend a conference or a workshop. There is perhaps an urgent need for the organisers of surgical conferences to take a fresh look at why, how and for whose benefi t are the conferences being conducted. It is essential that the interests of the ST and the young surgeons be kept in mind while preparing the scientifi c programme of any conference. I would like to put before the readers some of my thoughts on the matter and encourage them to use the IJS as a forum to debate these as well as other related issues. 1. Registration All conferences should carry a subsidized registration for the ST and in fact most do. However, this fact should be highlighted prominently to encourage participation of the young surgeons. 2. Providing content of interest to the ST Scientific programme committee of any conference should dwell seriously upon the topics which would be of interest to the ST and ensure that there are enough sessions/lectures which would make it worthwhile for the ST to attend a conference. 3. Guidelines to speakers Most conferences today provide “guidelines” to the speakers and the invited faculty; unfortunately very few organisers seriously enforce them. The speakers should be requested to have clear and practical “take home points” for the ST in their presentations. Also, they should be urged to project a healthy mix of “evidence base” and “experience base” in their lectures rather than the emphasis being on the latter. 4. Allocation of adequate time for audience participation There is nothing more disheartening during a conference than to see presenter and hearing the moderators announcing, “for lack of time no questions would be permitted” after presenter delivering their talks. Free exchange of ideas and generation of interaction and debate should form the core of any scientifi c meeting. This would be possible only if: a) the speakers are instructed to fi nish their talks in the allotted time, b) the moderators are empowered to be strict in enforcing the time limit (even at the cost of appearing rude to a “distinguished” speaker) and c) the time allowed for audience interaction is at least 50% of that allotted to the speaker. A conference is likely to be benefi cial not only to the ST but also to all the delegates only if it fosters an interactive atmosphere. 5. “Meet the expert” sessions These are very useful sessions in which a small group of ST is allowed to interact with an expert. The opportunity for group interaction that such gatherings provide would certainly help the ST. 6. Live surgery There is little doubt that in recent times live surgical workshops have become an essential part of most conferences and also a popular mode of teaching technical aspects of surgery. However, delegates often come away from a live surgical workshop with the same “feel good” facD. Bhandarkar ( ) Department of Minimal Access Surgery, P. D. Hinduja National Hospital, Veer Savarkar Marg, Mahim, Mumbai 400 016, India

Purpose: Melanoma is a solid tumor that is notoriously resistant to chemotherapy, and its incidence is rapidly increasing. Recently, several signaling pathways have been shown to contribute to melanoma tumorigenesis, including constitutive activation of mitogen-activated protein kinase, Akt, and Stat-3. The activation of multiple pathways may account in part for the difficulty in treatment of melanoma. In a recent screen of compounds, we found that an organopalladium compound, Tris (dibenzylideneacetone) dipalladium (Tris DBA), showed significant antiproliferative activity against melanoma cells. Studies were carried out to determine the mechanism of action of Tris DBA.Experimental Design: Tris DBA was tested on efficacy on proliferation of human and murine melanoma cells. To find the mechanism of action of Tris DBA, we did Western blot and gene array analyses. The ability of Tris DBA to block tumor growth in vivo was assessed.Results: Tris DBA has activity against B16 murine and A375 human melanoma in vivo. Tris DBA inhibits several signaling pathways including activation of mitogen-activated protein kinase, Akt, Stat-3, and S6 kinase activation, suggesting an upstream target. Tris DBA was found to be a potent inhibitor of N-myristoyltransferase-1, which is required for optimal activity of membrane-based signaling molecules. Tris DBA showed potent antitumor activity in vivo against melanoma.Conclusion: Tris DBA is thus a novel inhibitor of N-myristoyltransferase-1 with significant antitumor activity and is well tolerated in vivo. Further preclinical evaluation of Tris DBA and related complexes is warranted.

Melanoma is a common malignancy which is poorly responsive to chemotherapy and radiation. One of the major reasons melanoma responds poorly to these modalities is constitutive expression of Akt, which protects against apoptosis. The antidepressant sertraline was found to be a potent cytotoxic agent against A375 human melanoma. To determine the mechanism by which sertraline kills melanoma cells, Western blot analysis of signaling molecules, including phosphorylated Akt, caspase 9 and phospho-p70 S6 kinase was performed. Finally, the effects of sertraline on A375 xenografts in mice were assessed. Sertaline potently inhibited the phosphorylation of Akt, and caused cell death through induction of endoplasmic reticulum in vitro. Sertraline monotherapy demonstrated activity against A375 xenografts in vivo. Akt is a major cause of resistance of melanoma to current therapy. Antidepressants are commonly used to prevent interferon-induced depression. Use of antidepressants that decrease Akt may improve the efficacy of interferon and other therapies against melanoma. Further studies are needed to elucidate whether sertraline acts as an Akt inhibitor in melanoma.

Scleroderma is a common autoimmune disorder with no effective therapy. Current concepts of scleroderma include the hypothesis that scleroderma results from excess conversion of endothelial cells to fibroblast like cells, called endothelial mesenchymal transformation. This process is thought to be mediated by cytokines including transforming growth factor beta (TGFb), which causes increased collagen synthesis, resulting in fibrosis, the hallmark of the disease. In vitro studies have hypothesized that rapamycin may be of benefit in scleroderma due to antagonism of collagen synthesis. Given that rapamycin has antiangiogenic activities, inhibits wound healing, and prevents the synthesis of collagen in vivo, we tried rapamycin in a patient with scleroderma. We observed rapid improvement in skin stiffness and mobility. Our results provide the rationale for larger clinical trials of rapamycin in scleroderma and other fibrotic disorders.

Since skin is the largest organ in the body, skin-based diseases are among the most common diseases in the human population, ranging from cancerous to noncancerous diseases caused by infection, inflammation, and autoimmune disorders. The occurrence of skin diseases varies between continents with people being exposed to different elements. These different skin diseases have individualized diagnoses, treatments, and a unique social traumatic aspect. Given the abundance of dermatological diseases, this article only focuses on the most common skin diseases found around the world.

Objective To examine the potential role of angiogenesis in leprosy. Design Immunohistochemical analysis of leprosy lesions. Setting Department of Dermatology, Venereology, and Leprology, Kasturba Medical College; Division of Dermatology, University of California at Los Angeles; and Departments of Dermatology and Pathology, Emory University. Patients Thirty-two cutaneous lesions that represented the spectrum of leprosy were obtained from 32 patients. Main Outcome Measure CD31 microvessel counts. Results The mean CD31 microvessel count in borderline tuberculoid, midborderline, and lepromatous leprosy lesions was significantly higher than in indeterminate leprosy lesions. Conclusions Increased bacterial load is associated with increased angiogenesis. Angiogenesis inhibitors may be of benefit in the treatment of leprosy.

Angiogenesis, the formation of new blood vessels from host vasculature, is critical for tumor growth and metastases. -Curcumin, a novel small-molecular-weight compound, has been shown to inhibit carcinogenesis in different organs and the common link between these actions is its antiangiogenic effect. Curcumin is a direct inhibitor of angiogenesis and also downregulates various proangiogenic proteins like vascular endothelial growth factor and basic fibroblast growth factor. Curcumin's antiangiogenic effect is also in part due to its inhibitory effect on signal transduction pathways, including those involving protein kinase C and the transcription factors NF-kappaB and AP-1. Curcumin has an inhibitory effect on two groups of proteinases involved in angiogenesis that are the members of the matrix metalloproteinase family and the urokinase plasminogen activator family. Cell adhesion molecules are upregulated in active angiogenesis and curcumin can block'this effect, adding further dimensions to curcumin's antiangiogenic effect. Curcumin shows a dose-dependent inhibition on tumor necrosis factor, a versatile cytokine, which has its effect on angiogenesis through the signal transduction pathways, expression of proangiogenic factors, and cell adhesion molecules. Curcumin's effect on the overall process of angiogenesis compounds its enormous potential as an antiangiogenic drug.

Angiogenesis, the formation of new blood vessels from host vasculature, is critical for tumor growth and metastases. -Curcumin, a novel small-molecular-weight compound, has been shown to inhibit carcinogenesis in different organs and the common link between these actions is its antiangiogenic effect. Curcumin is a direct inhibitor of angiogenesis and also downregulates various proangiogenic proteins like vascular endothelial growth factor and basic fibroblast growth factor. Curcumin's antiangiogenic effect is also in part due to its inhibitory effect on signal transduction pathways, including those involving protein kinase C and the transcription factors NF-kappaB and AP-1. Curcumin has an inhibitory effect on two groups of proteinases involved in angiogenesis that are the members of the matrix metalloproteinase family and the urokinase plasminogen activator family. Cell adhesion molecules are upregulated in active angiogenesis and curcumin can block'this effect, adding further dimensions to curcumin's antiangiogenic effect. Curcumin shows a dose-dependent inhibition on tumor necrosis factor, a versatile cytokine, which has its effect on angiogenesis through the signal transduction pathways, expression of proangiogenic factors, and cell adhesion molecules. Curcumin's effect on the overall process of angiogenesis compounds its enormous potential as an antiangiogenic drug.

A 16-year-old boy presented with flank pain and was found to have right-sided hydronephrosis and hydroureter on ultrasonography and an intravenous urogram. A retrograde pyelogram revealed a tight, short-segment, non-negotiable stricture in the midureter. A CT scan excluded extrinsic compression. In the absence of any other pathology, the stricture was considered to be congenital. The diseased segment of the ureter was resected laparoscopically, and an intracorporeally sutured ureteroureterostomy was fashioned over a double- J stent. The patient made an uneventful recovery and was well at follow-up 18 months later. To the best of our knowledge, this is the first reported case of laparoscopic resection of a congenital midureteral stricture.

A 28-year-old woman presented with abdominal pain, anorexia, low-grade pyrexia, and a palpable abdominal lump. An abdominal CT scan revealed a mass in the region of the pancreatic head comprised of enlarged lymph nodes interspersed with loculi of pus. Because a fine-needle aspiration failed to establish a diagnosis, the abscess was drained laparoscopically and biopsy specimens were obtained; the specimens confirmed lymph nodal tuberculosis. Postoperatively, the patient received a 9-month course of antitubercular therapy; she remains asymptomatic on follow-up. To the best of our knowledge, this is the first report describing the use of laparoscopy for the drainage of a peripancreatic tuberculous abscess.

We report two newborns each detected to have a large intra-abdominal cyst on antenatal ultrasonography. Postnatal imaging confirmed presence of the cysts and showed a complex cyst with multiple septae in the first patient and evidence of bleeding in both. Laparoscopy performed on the 14th and 19th day of life, respectively, showed ovarian cysts with hemorrhage and torsion. The cysts were treated successfully by laparoscopic oopherectomy. Histopathology revealed an ovarian gonadoblastoma in the first patient and a simple cyst with calcification in the second. Both patients remain well at a follow up of six and four months. Laparoscopic treatment of antenatally detected cystic abdominal masses is a feasible option in the newborn.