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Government funding and policies are critical to academic medicine. Publicfunds sustain the education, research, and patient care missions of medical schools and teaching hospitals, and regulations govern the fulfillment of those missions. Consequently, both individuals and institutions often need to engage with those who develop these policies, including through lobbying. Lobbying fulfills a constitutionally protected right to petition the government for a redress of grievances, despite perceptions that it is instead only back-room dealing and insider influence. As an important part of the system of government in the United States, lobbying is subject to complex regulations, and failure to comply can result in substantial penalties, particularly for tax-exempt entities, of which almost all medical schools and the large majority of teaching hospitals are. In this Invited Commentary, the author briefly summarizes these regulations to complement the article in this issue by Lynch and colleagues. He then argues that while regulatory compliance is essential, it is not the same as lobbying effectively. For individual academic researchers to do that involves a number of considerations, including whether to coordinate their efforts with those of their institution to leverage the expertise and resources of the institution, to maximize their chances for success with policymakers.

Uterine leiomyomas (fibroids) are seen in up to 4% of pregnancies, and most commonly present with pain in pregnancy, which can be due to red degeneration or torsion. Most cases previously have been managed with open resection. We report the case of a 35-y-old primagravida woman, presenting with acute lower abdominal pain at 11 wk gestation. Ultrasound demonstrated an 8-cm fibroid only. She demonstrated features of lower abdominal peritonitis and was scheduled for a diagnostic laparoscopy. At operation, a torsed subserosal fibroid was found. She successfully underwent laparoscopic myomectomy with the endoGIA vascular stapler and subsequent Pfannenstiel delivery. The patient was discharged 48 h postoperatively to continue her pregnancy. This case demonstrates the safe application of laparoscopic excisional myomectomy in the first trimester of pregnancy. Previously reported cases in the literature have focused on open resection or bipolar diathermy enucleation and morcellation. A high degree of suspicion should be maintained for the diagnosis in patients presenting to the surgical service with acute lower abdominal peritoneal signs during pregnancy.

A 21-year-old female presented with left-sided loin pain and profound circulatory shock. After emergency laparotomy, angiography, embolisation and histological investigation, a diagnosis of spontaneous rupture of a benign non-secretory adrenal cortical tumour was made. To our knowledge, this is the only reported case of this diagnosis.

Background: Acute abdominal pain is a common cause for presentation to the emergency room and hospital admission. Many of these patients will undergo exploration for suspected appendicitis, but in 20-35% of cases a normal appendix is found. Because of the limited access provided by the gridiron incision, a definitive diagnosis may not be found. Other patients may be treated conservatively and discharged, only to return with recurrent pain or more definitive symptoms of pathology. In patients with acute abdominal pain, early laparoscopy is an accurate means of both making a definitive diagnosis and avoiding a delay in the diagnosis., Methods: We performed a retrospective analysis of 1,320 consecutive patients with acute abdominal pain over a 62-month period. All patients underwent diagnostic laparoscopy within 48 h of admission. We evaluated the initial clinical diagnosis, the laparoscopic diagnosis, and the subsequent outcome in this group of patients. Individuals with abdominal trauma were excluded from the study, and all patients were >12 years of age., Results: A definitive diagnosis was made in 90% of patients after diagnostic laparoscopy. Laparoscopy changed the clinical diagnosis in 30% of cases. (83%) of patients underwent a laparoscopic operation for management of their condition at the time of diagnosis. In 92 patients (7%), conversion to laparotomy was required to manage their condition. Peritonitis was present in 180 patients; of 110 of them had appendicitis. Twelve patients developed complications related to the diagnostic laparoscopy or the laparoscopic operation, and there was one postoperative death due to a perforated gastric malignancy. Mean operating time was 30 min (range, 17-90)., Conclusion: Early diagnostic laparoscopy and treatment results in the accurate, prompt, and efficient management of acute abdominal pain. This technique reduces the rate of unnecessary laparotomy and right iliac fossa gridiron incisions and increases the diagnostic accuracy in these patients. This treatment method is feasible where facilities are available to accommodate the workload and there are practitioners with the requisite expertise.

UK Government guidelines state that single use instruments, including those used in minimal access surgery, should not be reprocessed because of the risk of-patient injury. In order to determine the incidence of this practice in minimal access surgery a questionnaire was issued to all participants of an Advanced Laparoscopy for Theatre Personnel course between 1994 and 1996. There was a 55% response rate. 27% of respondents had resterilised an instrument within the past year. More senior nurses resterilised more often and the request was usually made by Senior Registrars and Consultants, 52% of resterilised instruments were used with diathermy, the commonest being scissors. The practice was almost exclusive to the NHS. Since the course 44% of respondents have changed their practice. These results have implications for patient safety, staff indemnity, education and training for nurses and surgeons involved in minimal access surgery.

Background: Direct and capacitive coupling of diathermy current have been reported as causes of occult injury during surgical laparoscopy., Methods: In order to determine the incidence of electrosurgical injury adjacent to metal and plastic cannulas, skin biopsies at 19 port sites used for monopolar electrosurgery were analyzed for coagulative necrosis. Prior to surgery the cannulas were randomized to either metal or plastic., Results: Coagulative necrosis was observed at nine electrosurgery port sites compared to only one control (chi2 = 4.872; df = 1; 0.05 > p > 0.02). Plastic cannulas afforded no greater protection from skin burns than metal cannulas., Conclusions: Burns may be the result of direct or capacitive coupling to metal cannulas or capacitive coupling to the skin edge across plastic cannulas. The potential exists for burns to other tissues also in close proximity to a cannula used for electrosurgery.

Pharyngolaryngoesophagectomy (PLO) for post-cricoid tumour offers opportunity for cure or reasonable paliation. However, it carries significant morbidity and mortality. We present two patients with post-cricoid carcinomas who underwent laparoscopically-assisted total PLO with gastric transposition without a laparotomy, thoracotomy or thoracoscopy. This technique appears promising for patients with post-cricoid or hypopharyngeal malignancy in reducing operative morbidity, and may represent improvement on conventional open and thoracoscopic techniques in selected patients.

Rectal prolapse is a distressing condition often affecting elderly patients. Open rectopexy has a proven track record in the treatment of this condition but may be complicated by significant morbidity. The benign nature of the disease and reduced pain and pulmonary complications of the laparoscopic approach makes this an attractive operation in this patient group. Laparoscopic prosthesis fixation rectopexy and lateral ligament suspension with and without colectomy have been described with low recurrence rates, good patient acceptance, improvement in symptoms, and both radiological and physiological assessments, although these initial findings require further evaluation with prospective controlled trials.

The complications of open antireflux operations may be reduced by laparoscopic techniques. Fifteen patients of median age 42 (range 16-79) years with gastro-oesophageal reflux underwent laparoscopic fundoplication. Preoperative and postoperative assessment was by clinical scoring, oesophageal pH measurement and manometry. Median (range) operating time was 115 (60-210) min and hospital stay 3 (1-6) days, with no conversions to open operation and only one minor wound infection. Four patients had occasional reflux symptoms on postoperative assessment at a median of 7 weeks and nine had occasional dysphagia. Median DeMeester symptom scores improved from 4 to 1.5 (P = 0.001). There were significant increases in both lower oesophageal sphincter pressure and length. The nocturnal proportion of time at pH < 4 decreased from 9.6 to 0.05 per cent (P = 0.02), although the drop in total proportion of time at pH < 4 (10.4 to 2.2 per cent) was not statistically significant (P = 0.08). Early objective results of laparoscopic fundoplication show improved symptoms, decreased acid reflux and altered lower sphincter function. The procedure combines the benefits of early mobilization and reduced morbidity with the efficacy of the traditional open operation.

Continued haemorrhage from oesophageal varices despite adequate injection sclerotherapy and tamponade has a high mortality rate. Such patients are usually referred for surgery. Over a 10-year period, 30 patients (21 men and nine women of median age 52 (range 21-70) years) with acute variceal haemorrhage uncontrolled by initial treatment underwent early emergency oesophageal transection. Portal hypertension was caused by alcoholic cirrhosis in 22 patients; other forms of cirrhosis were present in seven and portal vein thrombosis in one. Hepatic function immediately before operation was Pugh grade A in two patients, B in six and C in 22. Deterioration between admission and transection from grade A to B occurred in one patient and from B to C in five. Oesophageal transection stopped variceal haemorrhage in 29 of the 30 patients. Rebleeding from gastric varices within 35 days of surgery occurred in five patients. Postoperative haemorrhage also occurred from perioesophageal vessels (two patients), a gastrotomy (one) and oesophageal ulceration (two). Hepatic failure developed in seven patients, renal failure in five and both hepatic and renal failure in four. Mortality at 30 days occurred in neither of the two patients with liver function of grade A, in one of six of grade B and in 18 of 22 of grade C. The overall 30-day mortality rate was thus 63 per cent. Mortality was related to the preoperative Pugh grade (hazard ratio 3.95 per grade; P = 0.013) and preoperative blood transfusion (hazard ratio 1.37 per unit; P = 0.035). Four of six patients with grade B liver function died within 3 months and 21 of 22 with grade C disease within 1 year. Oesophageal transection is effective at stopping variceal bleeding but does not modify the underlying disease. Caution is urged for patients with grade C hepatocellular impairment proceeding to acute oesophageal transection after initial sclerotherapy. Such patients may benefit more from treatment with somatostatin or an intrahepatic porta-systemic stent shunt while awaiting definitive therapy.

Laparoscopic appendicectomy for acute appendicitis has been promulgated in many European countries during the 1980s. The introduction of the microchip camera and visual assistance on a monitor has increased the appeal of laparoscopic appendiceal resection. It carries a unique appeal in that the extent of inflammation and the presence of other pathological conditions are readily identified. This approach does not prevent the surgeon proceeding to open surgery if appropriate, and will aid in defining the site of incision. Prospective analyses (McAnena et al, 1992; Attwood et al, 1992) have shown that this approach shortens hospital stay, decreases wound infection rates and provides excellent cosmetic results. It also hastens return to full activity. It requires experience and, as with cholecystectomy, the option of converting to an open procedure should not be considered a failure of the approach. Details of approaches to the inflamed appendix are described. Caution in the use of diathermy is needed (particularly at the base of the appendix), as it may cause necrosis of the caecum or dissolution of the ties at the appendix base. Control of the appendicular artery by clip ligation is preferable to diathermy. The training of surgical residents will be enhanced rather than diminished if, under close, experienced supervision, they are taught to perform appendicectomy laparoscopically, as the essentials of anatomic dissection of the appendix are perhaps better appreciated on a video screen than at open surgery through a small incision.

It is shown that the deconvolution method of Van Cittert can be used reliably to enhance the effective spectral resolution by a factor of ~3 with data that exhibit a high SNR (~10(3)) and in which base line variations have been eliminated. Deconvolution of a Doppler-limited spectrum of C(6)H(6) measured on a difference-frequency laser system yielded linewidths of ~1.2 x 10(-3) cm(-1) (compared with the Doppler width of 3.6 x 10(-3) cm(-1) at 203 K). Extensive reliability tests of the deconvolution technique have been performed.