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Popliteal vascular trauma has historically been an urban phenomenon. We hypothesized that rural popliteal artery injury would result more often from blunt mechanisms of injury (MOI), have a longer time to operation, and result in a higher amputation rate. We retrospectively reviewed all cases of popliteal artery injury from December 1994 to May 2001 at our rural trauma center. Age, gender, Injury Severity Score (ISS), MOI, scene transport versus transfer from a referring hospital, time to operation, and operative times were studied. Significance was determined by Student's t test with a P value < or = 0.05. Thirty-two popliteal artery injuries were found. Blunt trauma accounted for 50 per cent of the injuries. Eighty-eight per cent of the patients were transferred from a referring hospital. Patients transported directly from the scene had a higher ISS. Longer operative times translated into an increased need for fasciotomy. The amputation rate was 19 per cent. This is the first attempt to delineate the specific nature of rural popliteal artery trauma. The amputation rate was not different between the two different MOI and was independent of the time to operation. Of those patients receiving an amputation 83 per cent were transferred from another hospital and despite a statistically lower ISS still required an amputation.

Laparoscopic splenectomy has become the standard of care for the surgical treatment of idiopathic thrombocytopenic purpura (ITP). The minimally invasive approach to splenic disorders such as ITP clearly results in the same benefits to the patients as have been demonstrated with the laparoscopic cholecystectomy techniques. New technologies in minimally invasive surgery have resulted in the development of robotic devises that assist the surgeon during the procedures. Robotic surgery is in its infancy at this point in time. Herein, we report a splenectomy performed with the assistance of the da Vinci surgical robot. With advancement of technology, robotic systems will play an integral role in future minimally invasive surgery.

The Greenville version of the gastric bypass induced long-term remission of type II diabetes mellitus in 121 of 146 (82.9%) morbidly obese patients. Similarly, the operation returned 150 of 152 (98.7%) morbidly obese patients with impaired glucose tolerance to euglycemia. These outcomes were not merely changes in glucose levels; the operation also reduced the mortality and morbidity of the disease. Diabetic patients submitted to surgery had a 1.0% chance of dying during a 10-year period of follow-up compared to a mortality rate of 4.5% in a matched group (p = 0.0003). These results, the best therapeutic outcomes for type II diabetes ever reported, suggest that the disease is not an untreatable, hopeless illness but one that can be treated successfully with better understanding of the pathophysiology of these surgical remissions. The mechanism of the improvement is not yet clear. The rapidity of the correction to euglycemia, usually a matter of days, suggests that the reason is not the loss of weight (i.e., reduction in fat mass) but, rather, the result of the exclusion of food and a secondary alteration in incretin signals from the antrum, duodenum, and proximal jejunum to the islets.

The first robotic Nissen fundoplication using the da Vinci robotic surgical system was performed on a 56-year-old woman with a 20-year history of severe gastroesophageal reflux disease refractory to medical management. The recovery was uneventful, and follow-up continues.

Severe obesity is a grave disease in the U.S. as well as other industrialized nations. This disease has many ramifications on both an individual and social levels. It affects 12.5 million people in the U.S., according to national survey data. The health risks of severe obesity include hypertension, hyperlipidaemia, cardiomyopathy, diabetes, hypoventilation disorders, increased risk of malignancy, cholelithiasis, degenerative arthritis, infertility, and psychosocial impairments. Medical weight reduction programmes have rarely achieved long-term success. Most authorities now agree that bariatric surgery is the treatment of choice for well-informed and motivated obese patients with acceptable operative risks, who strongly desire substantial weight loss or who have severe impairments because of their weight. Surgery is indicated for patients with a BMI greater than 40 kg/m2, or for those with serious medical co-morbidities and a BMI greater than 35 kg/m2. Three procedures, the adjustable silicone gastric banding (ASGB), vertical gastric banding (VBG), and gastric bypass (GB), have produced the best results to date. Each of these procedures is much more effective than dietary therapies. Each has advantages and disadvantages, with GB producing greater sustained weight loss in the long-term, with a slightly higher risk of metabolic complications. All can be done with surprisingly low operative mortality. The pronounced weight loss induced with these operations can relieve and bring co-morbid diseases, such as diabetes and hypertension, once thought to be only barely controllable, into full long-term remission.