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Minimally invasive surgery (MIS) has been proven feasible and safe for gastrointestinal surgery. Since its introduction, robotic surgery has not been as widely adopted for small bowel as for other procedures, due to difficulty in working in multiple abdominal quadrants and lack of tactile feedback.

Introduction: The penetration of chemotherapeutic drugs into peritoneal nodules remains at levels well below 1 mm, thus significantly limiting the antitumor effect of intraperitoneal chemotherapy (IPC). Recently, high-Intensity ultrasound (HIUS) has been discovered as a potential tool to significantly improve peritoneal diffusion rates. Despite promising preliminary data, basic aspects regarding its technical feasibility, safety and possible limitations remain unclear. This study aims to enhance our current understanding of HIUS and test its applicability using an ex-vivo swine model. Methods: Three postmortem swine were subject to laparotomy and consecutive lavage with 0.9%NaCl saline and HIUS application. For this purpose, a large HIUS radiating pen was introduced into the abdominal cavity and HIUS was applied on two of the four abdominal quadrants for 300 seconds each at an output power of 70 W, 50 % amplitude and 20 kHz frequency. Following the procedure, small intestinal tissue samples were retrieved for further analyses. Results: Peritoneal and subperitoneal layers showed structural changes only visible on a microscopic level. The peritoneal layer was transformed into a mesh-like structure while the subperitoneal layer (depth of 142 +/- 28 µm) exhibited microcavities and vascular detachment from surrounding tissues. No bowel rupture or vascular perforations were observed. Conclusions: Our data indicate that HIUS is a technically feasible and safe add-on procedure for intraperitoneal chemotherapy (IPC) with measurable microscopic changes on the peritoneal surface. Pretreatment of the abdominal cavity with HIUS could significantly improve IPC efficacy. Further studies are required to optimize and evaluate this novel approach.

The use of the da Vinci robotic platform for total colectomy has been limited by the need to reposition the surgical cart from one side of the patient to the other, which increases operative time. Nevertheless, the new da Vinci Xi model offers a rotating boom-mounted system and laser-targeted trocar positioning which facilitates the application of the robotic approach to all abdominal quadrants with relocation of the arms in the ports but without re-docking or relocation of the patient-side surgical cart. In this chapter, we describe total abdominal colectomy with a robotic approach.

Laparoscopic colonic resections often require manipulation and surgical action in all abdominal quadrants. Port placement, a fundamental part of a successful procedure, often varies widely among surgeons and is currently dictated by individual experience and preference. This variability may be suboptimal for the operation at hand, can be confusing for trainees and many times provide inadequate working posture for the surgeons, resulting in discomfort due to muscular fatigue in the hands, arms, shoulders and cervical spine. This article is protected by copyright. All rights reserved.

This review looks at the implementation of magnetic-based approaches in surgical instruments for abdominal surgeries. As abdominal surgical techniques advance toward minimizing surgical trauma, surgical instruments are enhanced to support such an objective through the exploration of magnetic-based systems. With this design approach, surgical devices are given the capabilities to be fully inserted intraabdominally to achieve access to all abdominal quadrants, without the conventional rigid link connection with the external unit. The variety of intraabdominal surgical devices are anchored, guided, and actuated by external units, with power and torque transmitted across the abdominal wall through magnetic linkage. This addresses many constraints encountered by conventional laparoscopic tools, such as loss of triangulation, fulcrum effect, and loss/lack of dexterity for surgical tasks. Design requirements of clinical considerations to aid the successful development of magnetic surgical instruments, are also discussed.

Introduction: Isomerism is a rare congenital condition in which one side of the body is a mirror image of the opposite side of the body. Abdominal manifestations include abnormal stomach positioning with possible malrotation of the intestines.1 If malrotation occurs, a laparoscopic Ladd procedure is performed. Materials and Methods: This video shows a laparoscopic Ladd procedure done in a 9-month-old male with right-sided isomerism and asymptomatic intestinal malrotation. Access to the right lower quadrant was achieved by a modified Hasson technique with a Step™ trocar (Auto-Suture) placed through a 5 mm incision in the umbilicus. Pneumoperitoneum was established using 5 L/minute of carbon dioxide under 12 mm Hg of pressure. A 30° telescope camera was inserted into the peritoneal cavity for proper observation. Next, two 3 mm incisions were made in the lower right and left abdominal quadrants. A 3 mm port was placed on the right and a 5 mm port was placed on the left with Step trocars (Auto-Suture...

Strategic trocar placement remains an essential component of safe laparoscopy and is responsible for almost half of the complications related to minimally invasive surgical interventions. The surgeon usually prefers to use the dominant hand to achieve the desired porting precision and comfort even for ancillary trocars. However, this tends to limit the operator’s dexterity in introducing laparoscopic ports, particularly for contralateral abdominal quadrants, and coerces him/her to undertake a number of insecure and haphazard manoeuvres towards its completion. Furthermore, in contrast to primary trocar placement, there is hardly any dedicated research available pertaining to secondary trocar insertion. We describe a simple technique of securing ancillary port using the surgeon’s nondominant hand in a systematic and controlled manner. It is an ergonomically comfortable practice wherein the operator does not need to shuffle his/her position. Having utilized this method on over 5000 occasions without any complication, we propose its wider usage by minimal access surgeons. To our knowledge, such a technique has yet to be described in the literature.

Background A retained surgical sponge is a serious medical error that results in negative patient outcomes. Radiofrequency (RF) technology has recently been introduced to evaluate for the presence of a retained sponge. The aim of this study was to evaluate the sensitivity and specificity of the detection of surgical sponges embedded with an RF chip through the torsos of subjects of varying body habitus, including the morbidly obese. Methods A prospective, crossover, and observer blinded study design was used. Subjects served as their own controls. With the subject supine, 4 surgical sponges were sequentially placed behind the subject's torso in locations approximating abdominal quadrants. Results Two hundred ten subjects were enrolled in the study. Nearly half (n = 101) were morbidly obese. Eight hundred forty readings were taken. There were no false-positive or false-negative readings. The sensitivity and specificity of detection of the RF sponges through the torsos of subjects of varying body habitus were 100%. Conclusions The sensitivity and specificity of RF sponge technology are much higher than published reports of surgical counts or published findings of intraoperative radiographs for retained sponges.

Summary Introduction This feasibility study aimed to establish if retrieval physicians can overcome the transport environment and obtain F.A.S.T. (focused assessment by sonography in trauma) images of suitable quality during patient retrieval in rotary wing aircraft such that diagnostic interpretation of free intra-abdominal fluid or pericardial fluid would be possible. Materials and methods During a 6-month trial period, one of three retrieval physicians attempted to obtain the standard four quadrant F.A.S.T. views using a portable ultrasound on patients they retrieved. Ultrasound images where obtained whilst in-flight in a rotary wing aircraft. Image adequacy was assessed by the retrieval physician and by an independent blinded physician using strict clinical criteria. Results Thirty-eight patients were enrolled. Thirty-six patients had a complete F.A.S.T. scan attempted whilst a further two patients had their abdominal quadrants scanned without a pericardial view being attempted. Independent blinded physician review of scans agreed with the scanning retrieval physician that images were adequate for showing the F.A.S.T. quadrants appropriately in 143 of 150 quadrants imaged and inadequate in two. Blinded physician review disagreed with scanning physician regarding adequacy of image in 5 of 150 quadrants imaged. Scanning physicians were happy with adequacy of the view in all F.A.S.T. quadrants in 34 of the 36 patients in whom a complete F.A.S.T. was performed. Blinded physician review agreed in 30 of those cases. Discussion The physicians performing the F.A.S.T. examination, all incorporate ultrasound into their daily clinical practice thereby maintaining their skill level. This is likely to contribute to the high level of view adequacy. Independent blinded image review controlled for bias regarding view adequacy. Disagreement between scanning physician and reviewing physician assessment of view adequacy in 5 of the 150 views obtained is likely to relate to the difficulties in interpreting still ultrasound images, compared to interpreting real time images at point-of-care. There were no machine limitations. Conclusion This study demonstrates that it is possible for critical care retrieval physicians to obtain adequate ultrasound F.A.S.T. images on patients using a portable ultrasound machine en-route to definitive care, in a rotary wing aircraft.

We describe a standarized eight-step technique to perform sigmoid colectomy using the da Vinci robot (Intuitive Surgical, Sunnyvale, CA) in both the left upper and lower abdominal quadrants.Between March 2005 and June 2006, 11 robotic sigmoid colectomies were performed on patients with diverticulitis or cancer. The procedures were performed through 4 ports, using a medial to lateral approach and involved moving the robot during the procedure.We describe the data and results from our first 11 robotically performed sigmoid colectomies using this technique. Operative times during each step of the procedure were collected and reported. By the eighth case, our team required only 4 minutes to undock, move, and redock the robot. The average operative time was 197 minutes and the average length of hospital stay was 3.4 days. There were no complications and no conversions to open colectomy.Robotically performed sigmoid colectomy is a feasible and safe procedure. The robot can be moved efficiently during surgery to allow a totally robotically performed sigmoid colectomy. The three-dimensional view, articulating instruments, intuitive movement, motion scaling, stable camera platform, and comfortable surgeon ergonomics facilitate splenic flexure mobilization and dissection and division of the inferior mesenteric artery and inferior mesenteric vein. Further studies will be needed to determine clinical benefit and economic feasibility.

OBJECTIVE: To identify any systemic effects of topical and subconjunctival administration of atropine sulfate in the horse. Animals studied Six mature grade horses were treated hourly in one eye with topical ophthalmic atropine drops for 24 h. Five horses were treated subconjunctivally in one eye with 3 mg of atropine sulfate. Procedures Pupillary light reflexes, pupil size, electrocardiographic parameters, girth measurements, intestinal motility, and clinical signs of abdominal pain were monitored. RESULTS: Alteration in auscultated gut motility and clinical signs of abdominal pain were the most sensitive indicators of the systemic manifestations of the topically applied atropine. Gut motility was absent in all horses for periods of 2-18 h in all four abdominal quadrants in horses given topically administered atropine. Signs of abdominal pain were observed in four of six horses that received topical atropine. In the subconjunctival test study, gut motility was absent in three horses for periods of 3-7 h. Uniocular subconjunctival injection of 3 mg atropine sulfate produced signs of abdominal pain in one of six horses. Conclusion The ophthalmic administration of atropine can affect gut motility and induce signs of colic in selected horses.

Background. This study was undertaken to compare the efficacy of a novel synthetic material (TMS-1) with polytetrafluoroethylene, polypropylene, and primary closure of experimentally fashioned clean and contaminated abdominal wounds. Methods. One square centimeter full-thickness abdominal wall defects were created in each of the four abdominal quadrants of anesthetized rats (n=6). Patches of polytetrafluoroethylene, polypropylene, and a polyurethane-polypropylene composite material (TMS-1) were used to repair three of these defects; the fourth was primarily closed. A second group of rats (n=9) underwent the same operative protocol; however, peritonitis was induced at the time of operation by using the fecal inoculation technique. Animals were killed 2 to 3 weeks later, and surface area and severity of formed adhesions were assessed. Results. By all methods of assessment, primary closure proved significantly superior to all other methods of closure in clean and contaminated conditions. The three synthetic materials were equally matched for surface area involved in adhesion formation. When compared with the other synthetic materials, TMS-1 was associated with significantly milder adhesions in uninfected (p Conclusions. The clear superiority of TMS-1 over other nonabsorbable synthetic materials shown in this pilot study warrants further investigation relative to its use to close large abdominal wall defects.

Objective Foreign body ingestion is common and potentially lethal. This study evaluates the use of low-dose Statscans (LODOX) in emergency departments. Design This comparative cross-sectional study retrospectively assessed 28 289 digital chest x-rays and 2301 LODOX scans performed between 2006 and 2010 at a tertiary emergency centre. The radiographic appearance, image quality and location of ingested foreign bodies were evaluated in standard digital chest and LODOX radiography. The mean irradiation (μSv) and cumulative mean radiation dose per patient with the ingested foreign body were calculated according to literature-based data, together with the sensitivity and specificity for each modality. Results A total of 62 foreign bodies were detected in 39 patients, of whom 19 were investigated with LODOX and 20 with conventional digital chest radiography. Thirty-three foreign bodies were located in the two upper abdominal quadrants, 21 in the lower quadrants—which are not visible on conventional digital chest radiography—seven in the oesophagus and one in the bronchial system. The sensitivity and specificity of digital chest radiography were 44.4% and 94.1%, respectively, and for the LODOX Statscan 90% and 100%, respectively. The calculated mean radiation dose for LODOX investigations was 184 μS, compared with 524 μS for digital chest radiography. Conclusions LODOX Statscan is superior to digital chest radiography in the diagnostic work-up of ingested foreign bodies because it makes it possible to enlarge the field of view to the entire body, has higher sensitivity and specificity, and reduces the radiation dose by 65%.

To characterize normal patterns of intestinal motility by ultrasound (US) in the preterm neonate during the first 5 days of life. Bowel US examinations were performed with an US machine (Vivid-i, General Electric) equipped with a 13-MHz linear and 7 MHz sector transducer. Still images and clips were taken from all abdominal quadrants along with Doppler of the superior mesenteric artery. Cumulative motility (CM) was quantified for each patient. Comparisons were made between CM for each day of life. Inter-observer correlations were made using the intra-class correlation coefficient. Notation was made of feeding status, bowel sounds and clinical demographics. Twenty infants were enrolled in the study. Seventeen infants had 5 days of complete US results available. Mean CM visualized on day of life (DOL) 1 was 28±12. By DOL 4 (38±17, P=0.006) and DOL 5 (41±20, P=0.008) mean CM increased. There was no difference in the resistance index on days imaged. Mean CM correlated with days to reach full feeds and gestational age, but gestational age was a stronger predictor of days to reach full feeds. Intra-observer correlation coefficient was 0.84. Real-time US provides a quantitative measure of intestinal motility in the preterm infant. Further studies are needed to establish the link between bowel US findings and feeding tolerance.

Presentation of Case An 80-year-old man was admitted to the hospital because of repeated bouts of hematochezia during several hours before entry. The patient was in stable health until two or three days earlier, when he experienced crampy pain in both lower abdominal quadrants that lasted for several minutes. At 4 a.m. on the day of admission he passed a stool and observed gross blood in the toilet. Later in the morning he passed four more semiformed stools, each accompanied by gross blood, and in addition soiled his undergarments twice with blood that he passed without ability to control his . . .

The authors describe the case of a large hepatocellular adenoma diagnosed in a 30-year old woman who came to us complaining of acute pain in the upper abdominal quadrants. The patient had been taking an oral contraceptive pill for the last ten years. We present the clinical features, the diagnostic work-up and the treatment prescribed.

The laparoscopic approach to total abdominal colectomy is especially attractive as there are a variety of benign indications for this procedure and a previously necessary long midline incision for surgery in all four abdominal quadrants is avoided and replaced by a short suprapubic incision of a few centimeters in length with all the favorable postoperative effects of minimally invasive surgery.

Since the first description by Jacobs [1], laparoscopic colorectal surgery has gained popularity over the past years. The acceptance of this approach has not been as fast as it was for laparoscopic cholecystectomy and other laparoscopic operations, owing to several differences: a steep learning curve of procedures that requires working in multiple abdominal quadrants, control of vascular structures, creation of intestinal anastomoses and sometimes retrieving large specimens [2, 3]. Other concerns have focused on the compliance of oncologic principles of radicality and the presumed increased incidence of port-site metastases described in early series [4]. Several advantages of laparoscopic colorectal surgery have been reported, including reduction of postoperative pain, shortened postoperative ileus and hospital stay, and recently a potential benefit in immune response and oncologic results [5–7]. The objective of this review is to describe the technical issues of laparoscopic-assisted colectomy (LAC) for malignancies, making special reference to the data available on the achievement of oncological principles and the comparison of results with open techniques [8].

Advances in laparoscopic surgical procedures will facilitate the solution of specific problems, especially in emergency surgery. A simple technique of intracorporeal finger assistance, which permits a fast and safe solution in selected cases involving right and left lower abdominal quadrants, is described. The forefinger, introduced like a cannula, can be used to complete laparoscopic procedures in which there is potential risk for bowel injury or failure in using laparoscopic instruments.

Pseudocysts of the pancreas are a rare cause of a mediastinal mass. They are clinically characterized by the combination of thoracic symptoms (shortness of breath, dysphagia, pleural effusions) with complaints in the upper abdominal quadrants and weight loss. The diagnosis is usually made by CT scan or MRI including upper abdominal views. Internal drainage via an abdominal route performed either as cystogastrostomy or cystojejunostomy is the treatment of choice.

Presentation of Case A 35-year-old woman was admitted to the hospital because of a pelvic mass, a productive cough, and known pulmonary adenocarcinomatous metastases. She was well until two months earlier, when a cough developed, worsened progressively, and became productive of frothy mucoid sputum. She observed painless swelling of the right leg and had diarrhea of three weeks' duration. Seven weeks before admission the patient consulted a physician, who found a tender mass in the pelvis and both lower abdominal quadrants. An x-ray film of the chest was reported to be normal. An ultrasonographic examination of the abdomen was reported . . .

Presentation of Case A 25-year-old woman was admitted to the hospital because of syncope. She was well until five days earlier, when she began to experience orthostatic dizziness, nausea, and sweating, accompanied by the passage of tarry stools. Crampy pain in both lower abdominal quadrants prompted the removal of an intrauterine device, which had been inserted one month earlier; there was no improvement in the symptoms. On the day of admission she lost consciousness while walking to work and was brought to the Emergency Ward. Grand-mal seizures developed when the patient was 11 years of age and were controlled with . . .

Presentation of Case A 71-year-old woman was admitted to the hospital because of abdominal pain, fever, and bloody stools. She was well until six weeks earlier, when abdominal cramps and distention developed, accompanied by obstipation and fever. Ten days later she entered another hospital, where examination revealed tenderness in both lower abdominal quadrants, especially the left; no mass was palpated on abdominal or rectal examination. An x-ray film of the abdomen showed a normal gas pattern; no masses were visible. Results of liver-function tests were abnormal, with persistent elevation of the alkaline phosphatase level and hyperglobulinemia. A barium-enema examination and . . .

Presentation of Case* A seventeen-year-old boy was admitted to the hospital because of abdominal pain. Three days before entry, soon after pushing an automobile, the patient experienced the onset of steady periumbilical pain and nausea. The pain increased in severity during the day, and vomiting began. A physician gave him meperidine (Demerol), which afforded temporary relief, but the pain recurred and persisted and was centered largely in the upper portion of the abdomen. On the following day the pain migrated to the right middle portion of the abdomen and left lower quadrant and then to the lower abdominal quadrants. The . . .

To the Editor: —In an earlier paper (June, 1922), I mentioned the frequency of changes in the abdominal reflex in epidemic encephalitis, and stated that I felt this had not been sufficiently emphasized. With this thought in mind, the last fifty cases examined (most of them seen during the epidemic of the past winter), have been carefully studied with reference to this symptom, with these findings: The abdominal reflex was normal only eight times, or in 16 per cent, of the cases, and in the patients seen within one month of the onset of the disease only three presented normal abdominal reflexes in all quadrants. Of the remaining five patients, one had developed the infection six months previous to the examination, one eight months, two two years and one three years. To offset this, the reflex was absent in all of the abdominal quadrants in patients as late as one