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fold.A 5mm trocar is inrted under direct visualization in the mid-line.Insufflation is initiated and the abdomen inspected.The abdo-men is desufflated and two very low profile trocars are then inrted superiolaterally within this incision.Alternately,the apex of the tri-angulated inrtion of trocars can be rotated within this incision de-pending on the procedure.Additionally,a third instrument via a transfascial incision without a trocar may be inrted to assist in re-traction to u for the entire ca.Results:In the first 30months of experience,we have performed general and gynecologic procedures using this technique including cholecystectomy,fundoplication,colon mobilization,adhesiolysis,ventral hernia repair,splenectomy,hys-terectomy,and oopherectomy.We do not have a lection bias.All pa-tients are connted for SPA with the potential to conversion to multiple ports or open surgery.Although initial operative times were extended,with modifications in technique and experience,the learning curve has decread.In some cas,such as colectomies,SPA is ud for mobilization even if the procedure then is planned to progress to an extracorporeal anastomosis.SPA enables multiple quadrants to be accesd during the same procedure,also permitting pelvic and upper quadrant procedures to be performed together.Conclusions:We have developed a reproducible alternative tech-nique of abdominal entry in laparoscopic surgery.This technique has proven versatile in its applicability to multiple procedures and surgical specialties.This technique is a safe alternative to multiport laparoscopy.Safe disction principles such as obtaining a critical view in cholecystectomy and traction/
细胞结构counter-traction during disc-tion are maintained.Furthermore,standard rigid instrumentation and trocars are ud,maintaining familiarity of equipment and costs.In most cas,there is a cost reduction by using a reduced number of very low profile trocars.Although potential benefits related to incision reduction have not been proven,this may be a stepping stone in the development of future technology and innovations in minimally invasive
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53.11.Multi-Scale Dynamic Knowledge Reprentation of Pul-monary Inflammation with an Agent-Bad Model:from Gene Regulation to Clinical Phenomenon.M.Wandling G.An;Northwestern University Feinberg School of Medicine,Chicago,IL Introduction:The inflammatory respon is a critical component of surgical dia,both in a positive n,through its role in healing and fighting infection,and a negative n,through its role in psis and multiple organ failure.The multi-scale complexity of inflamma-tory process creates challenges in preventing,diagnosing,and treating nosocomial infections in post-operative surgical patients.Dynamic knowledge reprentation (DKR)with computational modeling can be ud to evaluate the mechanistic interactions of the inflammatory respon from the transcriptional level to their
systemic conquences.To demonstrate the utility of this method,we ud agent-bad modeling (ABM)to generate a multi-scale model to characterize key dynamic patterns of immune responsiveness and suppression in the development of nosocomial pneumonia in the post-operative patient.In-silico DKR of clinical scenarios can provide a pre-viously unattainable understanding of the physiological dynamics in-volved in the pathogenesis of nosocomial pneumonia and can rve as a guide to managing this significant cau of morbidity and mortality.Methods:An abstract multi-scale A
工程管理毕业论文BM of the lung was developed us-ing NetLogo,an ABM development software package.An initial sur-gical insult and subquent inflammatory respon were modeled,and the pulmonary conquences of systemic inflammation were eval-uated.Knowledge of inflammatory signaling pathways and gene reg-ulation were derived from a thorough literature review of the cellular respon to damage,and was ud to generate the rule-ts for compu-tational cellular agents.The cellular behaviors included cytokine re-spon and relea,alterations in membrane permeability,and changes in movement and localization patterns.Output measure-ments of the model included levels of tissue damage,bacterial load,levels of inflammatory mediators,and profiles of the activation state of the inflammatory cell populations.Results:The ABM reproduced clinically recognizable dynamics of surgical dia and the sub-quent development of nosocomial pneumonia.There was a positive correlation between the verity of initial insult and the development of nosocomial pneumonia.The ABM also reproduced trajectories of pro-and anti-inflammatory cytokines,and demonstrated recognized alterations in intracellular transcription factors and signaling com-pounds.Discussion:In-silico reproduction of the inflammatory re-spon in surgical patients provides a uful platform for evaluating dynamic states of the system that may not be identified using stan-dard experimental techniques.The identification and characteriza-tion of the patterns of behavior may help refine the diagnosis of surgical dia to include the dynamic patterns of multiple bio-markers in the definition of different dia states.M
ulti-scale DKR of this type may also play an esntial translational role in link-ing detailed molecular knowledge to clinical phenomena.The execu-tion of the in-silico experiments allows for the discovery of general principles of the inflammatory respon,which are of vital impor-tance,as they may guide the testing of new hypothes,the modifica-tion of diagnostic criteria,and the development of new mechanism-bad interventions.
53.13.The Role of a Robotic-Assisted Approach to Distal Pan-createctomy.J.R.Aguilar Saavedra,J.A.Waters,J.D.Beane, D. F.Canal, C.M.Schmidt;Indiana University Department of Surgery,Indianapolis,IN Background:Since the introduction of minimally invasive surgery,surgeons have sought to optimize the efficiency and safety of the techniques.Recently,robotic assistance devices have been employed in conjunction with standard laparoscopic techniques to further refine minimally invasive surgery.The advantages of the laparoscopic ap-proach to distal pancreatectomy are well documented,but any added safety or efficacy of robotic surgery has not been demonstrated in the literature.In this ries we compare the outcomes of distal pancrea-tectomy utilizing the robotic-assisted approach with its conventional laparoscopic counterpart.Methods:From February 2004to August 2009,39minimally invasive distal pancreatic rections were per-formed by a single pancreaticobiliary trained surgeon at Indiana Uni-versity Hospital.All rections were performed eithe
r using standard laparoscopic or robotic-assisted approach using the da Vinci Robotic Surgical system (Intuitive Surgical,Sunnyvale,CA).Retrospective statistical analysis of a prospectively collected group of patients was performed.Results:Thirty-ven patients underwent distal pancre-atectomy using conventional laparoscopic (22)versus robotic-assisted (15)approaches.Average age was 65.9and 60.0years in robotic and laparoscopic groups (p ¼0.34).Indications included,adenocarcinoma (6.7%and 4.5%),IPMN (40.0%and 40.9%),and other (53.3%and 54.6%)in robotic and laparoscopic groups respectively.There was
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ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
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