Khalafzai, Rida Usman Obesity is the bane of modern times. Its ever-rising incidence and the frequent lack of success of conventional weight loss methods, has lead to the evolution of surgical weight loss techniques. Laparoscopic Adjustable Gastric Banding (LAGB) is one such procedure aimed at assisting in the loss of weight in obese individuals for whom traditional methods have failed.

Bulang He,1,2 Jeffrey M Hamdorf2 1Liver and Kidney Transplant Unit, Sir Charles Gairdner Hospital, Perth, WA, Australia; 2School of Surgery, The University of Western Australia, Perth, WA, Australia Aims: The aim of this paper was to review the current status of laparoscopic/robotic kidney transplant and evaluate its feasibility and safety in comparison with conventional standard "open" kidney transplant. Methods: An electronic search of PubMed, Embase, and the Cochrane library database was performed to identify the papers between January 1980 and (...) June 2013 that reported on laparoscopic/robotic kidney transplantation. The terms "laparoscopic kidney/renal transplant" and "robotic kidney/renal transplant " were used. Cross-referencing was also used to find the further publications. Only English language reports were selected and accepted for descriptive analysis. Results: A total of 17 papers and abstracts were retrieved. There were two case-control studies of small volume. High-level evidence comparing the safety and efficacy of laparoscopic/robotic kidney transplant with conventional open kidney transplant was not available at the time of this review. Conclusion: The limited published data have suggested that laparoscopic/robotic kidney transplant may offer the advantages of less pain, better cosmesis, possible shorter hospital stay, and fewer wound complications, without compromising graft function. Accordingly, some immunosuppressive agents, such as sirolimus, might be able to be commenced earlier, after laparoscopic/robotic kidney transplant. The techniques are various at this early stage. A uniformed operative technique may be established in the near future. With refinement of laparoscopic devices, this technique may be widely employed. Further studies will be needed to demonstrate the advantages of laparoscopic/robotic kidney transplant over the conventional open kidney transplant. Keywords: laparoscopic surgery, robotic surgery. (shrink)

One of the main challenges in medicine is to guarantee an appropriate drug supply according to the real needs of patients. Closed-loop strategies have been widely used to develop automatic solutions based on feedback variables. However, when the variable of interest cannot be directly measured or there is a lack of knowledge behind the process, it turns into a difficult issue to solve. In this research, a novel algorithm to approach this problem is presented. The main objective of this study (...) is to provide a new general algorithm capable of determining the influence of a certain clinical variable in the decision making process for drug supply and then defining an automatic system able to guide the process considering this information. Thus, this new technique will provide a way to validate a given physiological signal as a feedback variable for drug titration. In addition, the result of the algorithm in terms of fuzzy rules and membership functions will define a fuzzy-based decision system for the drug delivery process. The method proposed is based on a Fuzzy Inference System whose structure is obtained through a decision tree algorithm. A four-step methodology is then developed: data collection, preprocessing, Fuzzy Inference System generation, and the validation of results. To test this methodology, the analgesia control scenario was analysed. Specifically, the viability of the Analgesia Nociception Index as a guiding variable for the analgesic process during surgical interventions was studied. Real data was obtained from fifteen patients undergoing cholecystectomy surgery. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Practice of SurgeryKaren DevonThere’s no one on the snowy road driving beside me. It’s Christmas Eve, the night the newest attending surgeon on staff gets to be on call. Tonight feels like an anniversary of sorts. The first time I performed an appendectomy “alone” was on Christmas Eve. I can’t recall if it was snowing back then since I hadn’t left the hospital in days. I had assumed (...) that while I was operating on that 26–year–old woman with new abdominal pain that moved towards the left lower quadrant, my attending staff on call was sleeping soundly. I didn’t even know where he lived, or how long it would take if something catastrophic were to happen. I phoned the white–haired man to get his blessing just before midnight. “Have you done this operation before?” he asked. “Yes, several, but not completely alone” I confessed. “Go for it and call me when you are done. Oh, and be safe!” Click. Gulp.As I drive in tonight, again past midnight, I reflect upon that night. Was it practice? A right of passage? The most appropriate treatment for the patient? Perhaps it was even safer this way since my attending really had never done this operation the way it is now done—laparoscopically—by residents. I clearly recall telling the patient and her mother, “We do this all the time! The staff surgeon on call will come in if I need him, but the chief residents always do this operation and I feel comfortable taking care of you.” Sign on the dotted line and make sure you read the part where you are told this is a teaching hospital. Not only was independence an expectation, but I was also supposed to teach the more junior house staff how to emulate what I was so expertly performing.That night I took out the rotting appendix without incident and called the grey haired surgeon in the wee hours. “Merry Christmas Doctor. Sorry to bother you. I just wanted to let you know that the patient is awake and doing well.” “Yes I know. Good work” he replied. “I was in my office. Just in case.”As a resident, I was often torn between the need to gain independence in order to learn and grow as a surgeon, and the idea that I was practicing. As most budding surgeons do, I wanted to be the person doing the surgery. Working on my technical skills was clearly an important part of expertise. Surgery is inherently different than other types of medicine. It seemed slightly more difficult for someone to stop my cutting, than to catch the error in a prescription, before some damage is done. Perhaps a little more like driving a car, than learning to use a calculator. Recently a more modern surgical education is evolving, whereby students practice by simulations on machines. Yet educators know that ultimately many “firsts” need to occur with real patients. That proficiency and expertise are more than a diagnosis, a steady hand, or even the two combined. If the experience of operating as the primary surgeon without immediate supervision, on a patient with acute appendicitis never occurred until we passed licensing exams wouldn’t that be more harmful? I may have been the least legally responsible for outcomes, that night of my own first, when the grey–haired surgeon took the [End Page E1] responsibility of trusting me. But in fact, the obligation I felt was enormous. We cannot simulate the weight of responsibility that comes when responsible for another human being, who you have met and who provides their trust in you. Furthermore, as the teachers of this art and science, we need to balance our obligations to each individual patient with our obligation to society to train competent and caring future surgeons. Surgery would have no history if the “practice” of surgery had nothing to do with practice, defined in its simplest form, yet how do we cover all of this during the late night conversation that is called informed consent. Interestingly since that December evening and for the next 200 laparoscopic appendectomies before my graduation in to... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Removing the Mask: Hopeless Isolation to Intersex AdvocacyAlexandra von KlanStrangers undoubtedly perceive me as female, but I identify as an intersex woman. My karyotype is 46,XY, a typically defined marker of male biological sex, and I was born with undeveloped, non–functioning gonads. As an intersex person, I know firsthand the negative consequences of pathologizing intersex people’s lived experience by categorizing otherwise healthy, functioning organs and bodies as abnormal. The (...) following narrative recounts conversations and interactions with medical providers during my diagnosis and subsequent treatment of pure XY gonadal dys-genesis, sometimes referred to as Swyer Syndrome. I hope to elaborate upon emotionally significant actions and inactions of medical care providers to expose consequential effects on my emotional processing, physical health, and self–actualization.In December 1988, I was born with “typical” female genitalia. No one knew I was an intersex woman with 46,XY karyotype. Thus, there was no hesitation in the announcement of the birth of a girl in the delivery room or later, on my birth certificate. My parents raised me as a girl and dressed their firstborn in culturally normative feminine garments and accessories: lace frilly frocks, oversized bows, white stockings, and black patent leather Mary Jane’s. I embraced femininity and expressed this gender identity throughout my childhood and adolescence. I’m the eldest of six children split between two households.In January 2005, a month after my sixteenth birthday, delayed puberty and absent menstruation prompted an appointment to a local women’s health center. Nurses collected blood samples and administered an MRI scan on my pelvic region. A week later, my father received a perplexing phone call. An inexperienced doctor told him “there must be something wrong” with me, because lab results revealed I was “chromosomally male.” My father recalls the information presented like, based on the evidence, “your daughter may not be completely female,” and that is that. His impression was that she knew little about the subject and was a bit clueless. She did not mention Swyer Syndrome, or any diagnosis for that matter.Up to this point, I was unaware that a member of my extended family also had Swyer Syndrome. Born in the 1950s, secrecy engulfed her medical treatment and doctors warned her parents against revealing her true chromosomal sex in order to prevent the hysterical panic and depression they [End Page E14] thought the truth would bring. Years later, she sought her medical records and unearthed the truth. Shortly after my father received that dubious phone call, my relative’s endocrinologist provided a referral to his mentor, “Doctor A,” a clinical reproductive endocrinologist.Under Doctor A’s care, I experienced the first of many pelvic exams. Much to my discomfort, Doctor A inspected my semi–clothed body with a male resident in the room. As a people–pleasing teen, I granted permission for his presence; I didn’t voice my preference for a female alternative. Doctor A’s cold hands pressed around each undeveloped breast, pulled a gown away from my hips to inspect a sparse patch of pubic hair, and conducted an examination of my vaginal canal.Shortly after the examination, Doctor A charted Swyer Syndrome as the official diagnosis. Speaking to my father and me, he described my condition as an extremely rare genetic mutation. He told us that Swyer Syndrome was an intersex condition, a group of congenital disorders impacting a person’s internal or external reproductive systems, including endocrine function and genitalia. He explained I had atypical streak gonads instead of ovaries and that, despite having typical male sex chromosomes, I was still very much a girl. He disclosed that my vaginal canal was moderate in length, perhaps further evidence—or consolation—that my body possessed normative female reproductive attributes after all.Next, Doctor A identified a pressing medical concern—golf–ball–sized benign tumors had developed on each streak gonad; if allowed to remain, they would pose an increasing risk of malignancy. We scheduled an appointment for laparoscopic gonadectomy six months later. I left his office with a 3–month prescription for estrogen and progesterone oral tablets. On the way home, we drove to an electronics store where my father... (shrink)

Living donor kidney transplantation has increased significantly in the past 10 years. Currently it accounts for 41% of all kidney transplants in the USA.1 While the percentage is lower in the United Kingdom and other European countries, the number of living compared with cadaveric kidney donors will probably continue to increase globally. Mortality associated with surgery on live donors is low, thanks largely to the success of laparoscopic nephrectomy. Kidney transplantation from a living donor is preferable to that from (...) a cadaveric, or deceased, donor because of its superior graft and patient survival outcomes. It also preempts the need for or reduces the duration of dialysis for individuals with end-stage renal disease and therefore greatly improves their quality of life.Some who donate kidneys to anonymous recipients are motivated by altruism, with no direct benefit and only an indirect psychological benefit as a consequence of donating. Those who donate may be motivated by prudential reasons involving shared interests, or by a sense of obligation grounded in emotional relations. This includes donations between spouses, siblings, parents and children and may also include donations between intimate friends. Others may be motivated to donate by the prospect of financial gain. In a recent article on kidney markets, The Economist claimed that those who donate one of their healthy kidneys do so at “very little risk to their health”.2 Presumably, this provides support for these markets. In 2004, Zell Kravinsky, an American in his early 40s, gave away one of his healthy kidneys to a stranger as part of a utilitarian obligation to help other people and maximise the good by saving or improving the quality of their lives.3 He estimated that this entailed a statistically insignificant risk to his health. In a lecture to an ethics class at …. (shrink)

Surgical expertise does not have a clear definition and is often culturally associated with power, authority, prestige, and case number rather than more objective proxies of excellence. Multiple models of expertise progression have been proposed including the Dreyfus model, however, they all currently require subjective evaluation of skill. Recently, efforts have been made to improve the ways in which surgical excellence is measured and expertise is defined using artificial intelligence, video recordings, and accelerometers. However, these aforementioned methods of assessment are (...) still subjective or indirect proxies of expertise, thus uncovering the neural mechanisms that differentiate expert surgeons from trainees may enhance the objectivity of surgical expertise validation. In fact, some researchers have already suggested that their neural imaging-based expertise classification methods outperform currently used methods of surgical skill certification such as the Fundamentals of Laparoscopic Surgery scores. Such imaging biomarkers would not only help better identify the highest performing surgeons, but could also improve residency programs by providing more objective, evidence-based feedback and developmental milestones for those in training and perhaps act as a marker of surgical potential in medical students. Despite the potential advantages of using neural imaging in the assessment of surgical expertise, this field of research remains in its infancy. This systematic review identifies studies that have applied neuromonitoring in assessing surgical skill across levels of expertise. The goals of this review are to identify the strongest neural indicators of surgical expertise, the limitations of the current literature on this subject, the most sensible future directions for further study. We found substantial evidence that surgical expertise can be delineated by differential activation and connectivity in the prefrontal cortex across multiple task and neuroimaging modalities. Specifically, novices tend to have greater PFC activation than experts under standard conditions in bimanual and decision-making tasks. However, under high temporal demand tasks, experts had increased PFC activation whereas novices had decreased PFC activation. Common limitations uncovered in this review were that task difficulty was often insufficient to delineate between residents and attending. Moreover, attending level involvement was also low in multiple studies which may also have contributed to this issue. Most studies did not analyze the ability of their neuromonitoring findings to accurately classify subjects by level of expertise. Finally, the predominance of fNIRS as the neuromonitoring modality limits our ability to uncover the neural correlates of surgical expertise in non-cortical brain regions. Future studies should first strive to address these limitations. In the longer term, longitudinal within-subjects design over the course of a residency or even a career will also advance the field. Although logistically arduous, such studies would likely be most beneficial in demonstrating effects of increasing surgical expertise on regional brain activation and inter-region connectivity. (shrink)

The current study examined youths’ and their parents’ perceptions concerning participation in an investigation of spontaneous and induced pain during recovery from laparoscopic appendectomy. Youth and their parents independently completed surveys about their study participation. On a scale from 0 to 10, both parents and youth rated their experience as positive. Among youth, experience ratings did not differ by pain severity and survey responses did not differ by age. Most youth reported that they would tell another youth to participate. (...) Ethical issues regarding instigation of pain in youth for research purposes are examined. (shrink)

This work focuses on the application of machine learning techniques to assist the clinicians in the administration of analgesic drug during general anaesthesia. Specifically, the main objective is to propose the basis of an intelligent system capable of making decisions to guide the opioid dose changes based on a new nociception monitor, the analgesia nociception index. Clinical data were obtained from 15 patients undergoing cholecystectomy surgery. By means of an off-line study, machine learning techniques were applied to analyse the (...) possible relationship between the analgesic dose changes performed by the physician due to the hemodynamic activity of the patients and the evolution of the ANI. After training different classifiers and testing the results under cross validation, a preliminary relationship between the evolution of ANI and the dosage of remifentanil was found. These results evidence the potential of the ANI as a promising index to guide the infusion of analgesia. (shrink)

Information on the risks and benefits related to surgical procedures is essential for patients in order to obtain their informed consent. Some disciplines, such as sociolinguistics, offer insights that are helpful for patient—professional communication in both written and oral consent. Communication difficulties become more acute when patients make decisions through an informed consent document because they may sign this with a lack of understanding and information, and consequently feel deprived of their freedom to make their choice about different treatments or (...) surgery. This article discusses findings from documentary analysis using the sociolinguistic SPEAKING model, which was applied to the general and specific informed consent documents required for laparoscopic surgery of the bile duct at Torrecárdenas Hospital, Almería, Spain. The objective of this procedure was to identify flaws when information was provided, together with its readability, its voluntary basis, and patients’ consent. The results suggest potential linguistic communication difficulties, different languages being used, cultural clashes, asymmetry of communication between professionals and patients, assignment of rights on the part of patients, and overprotection of professionals and institutions. (shrink)

A clinical scenario is described where an anaesthetist is concerned about the seemingly high risk/benefit ratio relating to laparoscopic versus standard inguinal hernia operations. Some options for further action by the anaesthetist are introduced. The remainder of the paper explores the question of who can legitimately assess the acceptability of risk/benefit ratios, and defends the use of practice guidelines at the expense of so called clinical freedom. It is argued that respect for persons is not breached by limiting the (...) treatment options offered to patients to those therapies which have a ‘reasonable’ risk/benefit ratio. This ‘reasonableness’ is context dependent, and should be properly decided by those with expertise in the field. (shrink)

A clinical scenario is described where an anaesthetist is concerned about the seemingly high risk/benefit ratio relating to laparoscopic versus standard inguinal hernia operations. Some options for further action by the anaesthetist are introduced. The remainder of the paper explores the question of who can legitimately assess the acceptability of risk/benefit ratios, and defends the use of practice guidelines at the expense of so called clinical freedom. It is argued that respect for persons is not breached by limiting the (...) treatment options offered to patients to those therapies which have a ‘reasonable’ risk/benefit ratio. This ‘reasonableness’ is context dependent, and should be properly decided by those with expertise in the field. (shrink)

A clinical scenario is described where an anaesthetist is concerned about the seemingly high risk/benefit ratio relating to laparoscopic versus standard inguinal hernia operations. Some options for further action by the anaesthetist are introduced. The remainder of the paper explores the question of who can legitimately assess the acceptability of risk/benefit ratios, and defends the use of practice guidelines at the expense of so called clinical freedom. It is argued that respect for persons is not breached by limiting the (...) treatment options offered to patients to those therapies which have a ‘reasonable’ risk/benefit ratio. This ‘reasonableness’ is context dependent, and should be properly decided by those with expertise in the field. (shrink)

This paper discusses spatial cognition in the domain of minimally invasive surgery. It draws on studies from this domain to shed light on a range of spatial cognitive processes and to consider individual differences in performance. In relation to modeling, the aim is to identify potential opportunities for characterizing the complex interplay between perception, action, and cognition, and to consider how theoretical models of the relevant processes might prove valuable for addressing applied questions about surgical performance and training.