over from the universe's birth. Data
gathered by several balloon-borne and ground-based telescopes fit the
predictions of the inflation model.
Yet some cosmologists view inflation
as a mysterious, ad hoc device. For instance, notes Steinhardt, no one knows
what type of force triggered the onset of inflation or what ended it.
"We've been searching for several years to find either a more natural way
of incorporating inflation or an alternative model based on new physics,"
he says.
String theory
Inflation, Steinhardt says, is based
on quantum field theory, which views every elementary particle as a pointlike
object. In the past decade, however, physicists have begun thinking about
elementary particles in a new way, based on a model called string theory.
According to this view, electrons,
quarks, and all the other elementary particles in the universe behave as point
particles when observed at a distance, but each is actually composed of tiny
loops or strings of energy. The different vibrations of a string, like the
different notes that can be plucked on a violin, correspond to different
particles.
"It's a beautiful idea because it
says that all of the particles we see actually arise from a single
object—string," says Ovrut.
Each string vibrates in a space-time
that has 11 dimensions—7 dimensions beyond the usual 3 of space and 1 of time.
The newest twist on string theory, dubbed M theory, allows for more-complex
objects: surfaces rather than just strings. These surfaces are known as
membranes, or just branes.
Many physicists are studying branes in
the hope of linking gravity and the other fundamental forces of nature to the
elementary particles that communicate these forces. According to Steinhardt and
his colleagues, certain types of branes may turn out to have profound
consequences for cosmology.
Instead of working with the 11
dimensions implied by M theory, the researchers have focused on branes that
exist in 5 dimensions. In this model, the other 6 dimensions are tightly curled
up and can be ignored. Certain branes that exist in this abstract
five-dimensional space can be represented by infinitely long, parallel planes
and seem to have a close correspondence to our universe.
In this construct, our cosmos could
have plenty of company. Other would-be universes—also represented by branes—may
be floating through the fifth dimension. These branes would remain invisible
because particles and light can't travel through the fifth dimension. However,
gravity can couple matter across that dimension, and collisions between branes
are possible.
In the ekpyrotic scenario, the fifth
dimension is finite in size and bounded on either side by a three-dimensional
brane. One of these boundary branes was the surface that was to become our own
cosmos, and the other represents another universe. In the version of the theory
first described last April, a third brane peels off the opposing boundary brane
and bangs into ours. In the collision, it melds with our brane, igniting the
Big Bang.
"There is a certain sense in
which this is like two pieces of putty slamming into each other and heating
up," says Ovrut.
Critics of the scenario, as well as
Steinhardt's team, have noted that the universe created by the impact contracts
rather than expands. If so, it wouldn't have generated a cosmos like ours.
In a modified version of the ekpyrotic
theory, posted Aug. 26 on the Internet
(http://xxx.lanl.gov/abs/hep-th/0108187), Steinhardt, Nathan Seiberg of the
Institute of Advanced Study in Princeton, N.J., and their collaborators say
such concerns are now unwarranted. According to their calculations, the new
model can produce a collision without having to rely on one invisible brane
peeling off from another.
Instead, one of the boundary branes
moves slowly but steadily toward the other, attracted by an exchange of
lower-dimension branes between the two. As the boundary brane moves, it shrinks
the fifth dimension. When the two boundary branes touch, the fifth dimension
collapses completely, an event the researchers call the Big Crunch.
As in the earlier version of the
theory, the collision triggers the Big Bang. However after the impact, the two
boundary branes bounce off each other and move apart, recreating the fifth
dimension. This rebound starts the expansion of our universe.
In either version of the theory, the
laws that govern elementary particle physics require that the boundary branes
be flat as a pancake before they collide and that they stay that way
afterwards. Consequently, the universe generated by the collision is flat. An
episode of inflation isn't needed to stretch out any curvature since none ever
existed.
Because the impact is so
uniform—exactly the same force is applied up and down the flat boundary between
the two branes— widely separated parts of the universe get the same kick and
thus evolve in exactly the same way after the collision. This accounts for the
uniformity of distant reaches of the cosmos without having to invoke an episode
of inflation.
Due to quantum effects, which make the
boundary between the branes slightly uneven, some parts of our brane would be
struck ever so slightly earlier or later than other parts. This would create
tiny temperature differences within the struck brane that, like those in the
standard Big Bang model, become the seeds for galaxy formation. The collision
also causes the brane to stretch or expand, accounting for the expansion of the
universe observed today.
The researchers "make a graceful
transition from the Big Crunch to the Big Bang," says David N. Spergel of
Princeton University. "This is arguably a `new ekpyrotic universe' that
appears to be more elegant than the old model."
Which theory?
According to Steinhardt, the ekpyrotic
theory does everything that Big Bang plus inflation accomplishes. "It's
just that we happened to discover one theory first—20 years ago," he says.
"What [the ekpyrotic theory] has
going for it is a much closer relationship to string theory than any
formulation we currently have of inflation," says Guth. "String
theory is simply the only hope we currently have for a quantum theory of
gravity, and obviously gravity has to be quantized to be consistent with the
rest of what we know about physics."
Nonetheless, "I'm still somewhat
skeptical about the whole thing," Guth adds. "They need to make very strong
assumptions about the initial conditions—they're really starting out with a
universe that's already infinite and uniform."
Another developer of the inflation
model, Andrei Linde of Stanford University, takes a much dimmer view of the new
work and has posted several papers on the Internet lambasting the ekpyrotic
model. He says that to produce galaxies, Steinhardt and his colleagues have to
choose a highly specialized, unrealistic form of interaction between branes.
Moreover, Linde claims that the branes in the ekpyrotic model are not truly
uniform in structure and therefore can't account for the large-scale uniformity
of the universe.
"Instead of a theory, we have
only wishful thinking," he says.
Steinhardt and his colleagues have
posted responses on the Internet.
A slow process
Making a universe in ekpyrotic theory
requires patience, notes Ovrut. Because the attractive force between branes is
so small, they move at a snail's pace, and it could take an extraordinarily
long time for a collision to occur, he says.
In effect, says Ovrut, the new theory
replaces the very short growth spurt of inflation with a very long lead time
for a collision.
As a bonus, he notes, the collision
described by ekpyrotic theory not only generates cosmic structure, it also
creates the known families of quarks and other fundamental particles.
"What's very beautiful about
these brane models is that one can actually compute the spectrum of
[elementary] particles, and what you get is something like our real
world," notes Ovrut.
At least one empirical test of the
ekpyrotic theory may soon be possible. The test would examine gravitational
waves, the radiation produced when massive objects accelerate.
Big Bang plus inflation predicts that
gravitational waves can have extremely long wavelengths, while the ekpyrotic
theory does not. Long-wavelength gravitational waves would leave a distinctive
fingerprint on the cosmic microwave background.
Future experiments with a new
generation of space, balloon-borne, and ground-based telescopes may be able to
detect that fingerprint, says Ovrut.
http://louis-j-sheehan.us/ImageGallery/CategoryList.aspx?id=a1206a74-5f7f-443f-97f5-9b389a4d4f9e&m=0
http://louis1j1sheehan.us/ImageGallery/CategoryList.aspx?id=36f0e6c9-8b8a-4f0a-8630-e5d3b879fad4&m=0
http://louis2j2sheehan.us/ImageGallery/CategoryList.aspx?id=14218f60-0cb6-4fa5-beba-5ee65da4b5e1&m=0
Other aspects of the ekpyrotic model
are still being scrutinized.
"I worry a lot about the
details," says Ovrut. "This is a theory that's really still in its
infancy."
While hiking in California's Sierra
Nevada Mountains, Seth Donahue ran into quite a few bears. The lumbering
omnivores filled Dr. Donahue, a biomedical engineer, with curiosity rather than
fear.
Why don't bears suffer from
osteoporosis during hibernation, he asked himself during one wilderness
encounter nearly a decade ago? Even a few weeks of inactivity for humans, and
most animals, are enough to soften and weaken bones. But bears snooze as much
as six months a year and wake up robust and ready to rumble.
Dr. Donahue, now 39 and a professor at
Michigan Technological University, figured there might be a substance in bears
that helps keep their bones strong. If he could find it, he might also find
better treatments for osteoporosis in humans.
Osteoporosis affects tens of millions
of Americans, and drugs to treat the disease represent a multibillion-dollar
market. But most of the medicines don't restore bone -- they only slow its
deterioration.
Dr. Donahue found that bears have a
uniquely potent form of a substance called parathyroid hormone, which helps
maintain bones. The ursine version of the substance spurs bone growth when it
normally wouldn't occur, offsetting the deterioration that one would expect for
a bear snoozing away in the woods.
Dr. Donahue's group has sequenced the
gene for the bear parathyroid hormone and has had a small amount of it made
synthetically. He's applied for a government grant to fund the lab's efforts to
insert the gene into bacteria and coaxed them to produce the substance.
But how do you get a hormone sample
from a bear in the first place? Very carefully. At first, Dr. Donahue relied on
a colleague at Virginia Tech for blood samples taken from a half-dozen bears
tracked with radio tags.
Even hibernating bears need to be
anesthetized before a needle is inserted to draw their blood, or they might
awaken, distorting the results and putting the researchers at risk. "It's
not like rats where you can get 100 animals and bring them into the lab and do
whatever you want with them," Dr. Donahue said.
Later, he teamed up with Washington
State University's Charles Robbins, who was studying changes in the hearts of
hibernating bears. Dr. Robbins had a group of black bears raised in captivity
that were comfortable around humans and were used to having tests performed.
That gave Dr. Donahue's lab an easier way to get blood samples.
Despite the hurdles, Dr. Donahue, it
turns out, wasn't the first scientist to be curious about bear bones. In 1990,
a Boise, Idaho, orthopedic surgeon named Tim Floyd captured a few bears,
anesthetized them and biopsied a large bone in their hips.
Dr. Floyd's findings were provocative,
Dr. Donahue said, because they suggested that bears didn't lose bone during
hibernation. Dr. Floyd entered private practice and didn't pursue his findings.
But when he learned of Dr. Donahue's work, Dr. Floyd kicked in some of his own
money to keep it rolling. Dr. Donahue also receives support from the National
Institutes of Health and the Michigan Universities Commercialization
Initiative.
Dr. Donahue published his first
results in 2003 when he was doing post-doctoral research at Penn State
University. The results were perplexing because they seemed to suggest that
bears were actually losing bone during hibernation. "At that point my
hopes weren't as high, but I was still interested," Dr. Donahue said.
He kept at it, and published a paper
later in 2003, after he had moved to Michigan Tech, showing that bone growth in
hibernating bears was equal to the rate of loss. After the bears wake up in the
spring, the bone grows even more rapidly.
Washing mouse bone cells with blood
taken from bears in different seasons supported the idea that the winter
samples had boosted bone formation, according to another paper he published in
2006.
Dr. Donahue's research on bears has
advanced far enough toward a treatment for humans to capture commercial
interest. Apjohn, a company founded by drug giant Pfizer when it closed Upjohn
facilities in Kalamazoo, Mich., and Michigan Tech have an agreement to
commercialize Dr. Donahue's technology. To do that, they've created a company
called Aursos, a name derived from ursos, Latin for bears.
Apjohn's Ron Shebuski, who once
studied snake venom and vampire bat saliva as a researcher at Merck, praised
Dr. Donahue's elegant and sometimes risky work on parathyroid hormone in bears.
"Seth is just a maniac on this stuff," he said.
Most available osteoporosis drugs,
such as Merck's Fosamax, slow the breakdown of bone, but they don't do much to
build it up. An exception is Eli Lilly's Forteo, a shortened version of the
human parathyroid hormone, with about $500 million in sales. Forteo can build
bone, but the drug, taken in a daily injection, carries a black-box warning
about cancer risks because of tumors found in rats treated with the medicine.
Dr. Donahue, now on sabbatical in
Ireland, says his lab just finished treating some rats with a synthetic version
of human parathyroid hormone -- not unlike Forteo -- and others with bear
parathyroid hormone to see which did a better job building up bone. Next up are
studies in female rats whose ovaries have been removed, creating a
menopause-like condition.
Dr. Donahue is unlikely to see any
bears while in Ireland; they're extinct there. But he did admit to taking an
interest in the bones of one that died thousands of years ago in an Irish cave.
Meanwhile, despite his hiking inspiration, when it comes to his research, he
laughs: "Nearly 10 years later, I haven't been out in the field
once."
It's no wonder that more Americans are
gulping fish oil. Hardly a month goes by without a study suggesting that the
omega-3 fatty acids in fish oil can fend off disease -- including heart
attacks, strokes, Alzheimer's disease, depression, rheumatoid arthritis,
asthma, psoriasis and even attention-deficit hyperactivity disorder.
The problem is, to get the health
benefits seen in clinical trials, you probably need to take fistfuls of
capsules.
"The kind of benefits seen in
most of the clinical trials with omega-3 generally have involved much higher
doses than you see recommended on supplement labels," says Charles Serhan,
a Harvard Medical School expert on omega-3's activity. "But although a
large number of studies have used industrial-level doses," he adds,
"we don't have rigorous scientific evidence about what the doses should
be."
Regardless of the recommended dose,
the need to stockpile bottles of supplements may diminish as more foods are
fortified with omega-3 and as research shows ways of enhancing the benefits
with other therapies.
While most of the scientific data on
the health effects of fish oil aren't definitive, the federal National
Institutes of Health concluded after a massive review three years ago that
consuming omega-3 fatty acids cuts the risk of death from heart attacks and
other cardiovascular causes, can reduce the joint pain of rheumatoid arthritis
and "appears" important for proper brain development and function.
Because of news like that, the market
for fish-oil supplements is booming. U.S. omega-3 supplement sales reached an
estimated $600 million last year, up 20% from a year earlier, says the Global
Organization for EPA and DHA Omega-3s, a Salt Lake City trade group. (The two
key omega-3 fatty acids are called EPA and DHA.) Omega-3 fatty acids now rank
as the fifth-best-selling dietary supplement, behind multivitamins, calcium and
vitamins C and E.
In trials aimed at lowering high blood
levels of triglycerides, a contributor to heart disease, patients took four
particularly potent capsules that contained a total of more than three grams of
EPA and DHA a day. You would have to pop a daily dozen of the typical omega-3
capsules on the market to get that much -- four to six times the suggested
daily "serving" usually specified on their labels. That many capsules
could cost you more than $2 a day, and it is a lot more than you are likely to
get from consuming fish: You would need more than six servings a day of tuna,
or about three of salmon, to get that much EPA and DHA.
Clinical trials suggest that fish oil
can fend off a variety of ailments, but the omega-3 doses used in the studies
have varied widely.
• Heart disease: one gram or more
• Rheumatoid arthritis: two grams or
more
• Brain health: one-half gram or more
Fish may good for you, but you can get
risky doses of mercury and other toxins by consuming lots of it. That is one
reason the American Heart Association recommends that people who need to lower
triglycerides to ward off heart attacks take omega-3 capsules. The suggested
dose is two to four grams of EPA and DHA a day, which supplements can provide
toxin-free. For healthy adults seeking merely to cut cardiac risks, the heart
association says eating fatty fish, such as salmon, at least twice a week is
probably enough.
But how much omega-3 should you take
if you are trying to ease the joint inflammation of rheumatoid arthritis? Or
ward off Alzheimer's disease? Or alleviate depression?
Louis J Sheehan
Louis J Sheehan, Esquire
http://louis2j2sheehan.bloggerteam.com/ http://blog.myspace.com/index.cfm?fuseaction=blog&pop=1&indicate=1http://pub25.bravenet.com/journal/post.php?entryid=22156
Unfortunately, there aren't enough
clinical data to give firm answers. But the omega-3 literature affords hints.
Results in various rheumatoid-arthritis trials indicate that you need to take
more than two grams, perhaps 10 typical capsules, of omega-3 fatty acids a day
to significantly curtail joint inflammation and pain.
For maintaining brain health, the
overall data on omega-3's potential are inconclusive, according to the NIH. But
a recent Dutch study showed that about 400 milligrams of EPA and DHA a day --
which you can get from two typical omega-3 capsules -- helped elderly men
maintain mental acuity. The study found that the more omega-3 ingested, the
greater the benefit.
In the depression data, two things
stand out: EPA appears more effective than DHA. And about one gram of EPA seems
optimal -- more isn't better.
All this suggests that you may have to
take a half dozen or more typical omega-3 pills a day to get the kind of
benefits observed in clinical trials with fish oil. But soon it may get easier
to get such hefty doses without taking so many pills. A growing number of foods
are fortified with omega-3, everything from yogurt to orange juice, including
more than 1,200 such products launched in 2006 alone, according to the
London-based market researcher Datamonitor. Such foods typically don't contain
much omega-3 -- a fortified egg might contain half as much as a typical
capsule. But as more fortified foods come to market, it will be easier to get
omega-3 in your diet.
There is another reason popping
fish-oil capsules by the fistful may be overkill. Many scientists believe
omega-3's benefits flow primarily from its ability to damp low-level
inflammation, which is thought to be a key culprit in just about every major
scourge of aging, from clogged arteries to Alzheimer's. Studies over the past
few years suggest that taking small doses of aspirin daily, which many people
do to prevent heart attacks, magnifies the anti-inflammatory effect of taking
fish oil.
Indeed, some of the most dramatic
evidence of fish oil's heart benefits came from a 1999 Italian study in which
patients who had recently had heart attacks showed a 45% reduction in
subsequent "sudden cardiac death" when given modest fish-oil doses
(the amount in about three typical omega-3 capsules). The supplements' striking
effectiveness may well have been magnified by the fact that many of the
patients were also taking aspirin daily.
Aspirin's effect on omega-3 isn't
clear yet, though. So for now, big doses of the supplement probably are
necessary to get the health benefits.
Omega-3 appears to be safe, even at
the high doses used in clinical trials. But large doses can have side effects.
Perhaps the best source on that issue is the prescribing information for
Lovaza. Sold by GlaxoSmithKline PLC unit Reliant Pharmaceuticals Inc., Lovaza
is prescribed for "very high" triglycerides.
In Lovaza's clinical trials, patients
took four capsules a day with a total of 3.4 grams of EPA and DHA. The most
common "adverse event," reported by about 5% of patients, was
belching. Some 4% reported infections, compared with 2% on a placebo, but it's
not clear whether fish oil caused the difference. While some research suggests
that taking fish oil prolongs bleeding time, no bleeding problems were reported
in the Lovaza trials.
There's no evidence Lovaza works
better or is purer than high-end omega-3 dietary supplements -- such as those
made by Nordic Naturals Inc., of Watsonville, Calif. -- which cost less than
half as much as Lovaza does per gram of EPA and DHA.
A 2004 analysis of 44 kinds of omega-3
supplements by ConsumerLab.com1, based in Scarsdale, N.Y., found that none had
unsafe levels of mercury or PCBs. And Lovaza wasn't used in most of the
promising clinical trials with omega-3.
Mountains of uncollected trash
smoldering on the streets of Naples are illuminating an unsightly reality about
southern Italy: A combination of a weak state and powerful organized crime
makes some areas of the country ungovernable.
In Naples, that combination has
created a toxic mix that has paralyzed the city of more than two million,
created serious health risks and revealed the inability of the government to
tackle even the most basic urban problems. The Camorra, as the Naples Mafia is
known, maintains a tight grip on the lucrative trash business, and as the situation
has worsened, the Camorra's profit and power have risen.
[A large pile of trash littered a
street in central Naples yesterday.]
A large pile of trash littered a
street in central Naples yesterday.
Trash hasn't been picked up on the
streets since Dec. 31, when the last of dumps in the area, which had been
operating beyond capacity, couldn't accept more trash. And for several weeks
before that, pickups had been sporadic at best. On Sunday, army units were
called in to remove trash from school buildings so that students could return
after the winter break. The gravity of the situation has led to a series of
desperate but still useless measures taken by authorities.
In the Pianura neighborhood,
authorities recently decided to reopen a dump that had been closed 11 years
earlier. That sparked violent daily clashes with local residents.
To prevent police from reopening the
dump, residents have felled tree trunks onto streets, commandeered city buses
and set them ablaze, and poured oil onto roads. Yesterday evening, police
finally withdrew from the area.
But while residents protest, trash
piles up, blocking streets and entrances to buildings. Some piles reach to the
third floor of apartment buildings. The city creates an estimated 8,000 metric
tons of trash daily. Many of the heaps are set on fire, releasing dioxin and
other noxious fumes. Naples's trash problem has become an embarrassment for the
government of Prime Minister Romano Prodi, which, like its predecessors, has
been powerless to bring about change. "Everyone is looking at us, and it's
sad that Italy is presenting this negative image," he said Saturday. He
also said his government was working on a plan to fix the situation "once
and for all" and his government has been holding a series of meetings as
it tries to come up with a plan.
However, the clashes are merely the
latest chapter in an environmental crisis that began more than 13 years ago
when the Campania region's dumps reached capacity. Since then, the Camorra has
been able to tighten its control on the trash business, burrowing its way so
deeply into the system that it has defeated every attempt by the state to fix
the situation.
The national government first declared
an emergency in 1994, appointing a special commissioner with broad powers to
fix what was already a mounting crisis by building more than a dozen trash
incinerators in the area. Since then, there has been a succession of six
special commissioners. One trash incinerator has been built.
[A man worked his way through
uncollected garbage on the streets of the Casoria district, on the outskirts of
Naples, Sunday.]
A man worked his way through
uncollected garbage on the streets of the Casoria district, on the outskirts of
Naples, Sunday.
Franco Roberti, a prosecutor in Naples
who has been investigating the trash crisis and its connections to organized
crime, estimates that of the €1 billion, or about $1.5 billion, of public money
spent in the Naples area on trash hauling and disposal, "the Camorra
pockets about half." Working either through companies it owns directly or
through intermediaries, it controls all the garbage trucks that transport the
trash, as well as the dumps themselves.
The state of emergency has only
benefited the Camorra, Mr. Roberti says, because it allows city governments to
hand out public contracts quickly, bypassing the checks that would otherwise be
necessary to ensure that hauling and collection companies aren't connected to
organized crime.
The current crisis, Mr. Roberti says,
is partly the result of a situation the Camorra created. For decades, it has
run the highly illegal but lucrative business of hauling toxic waste from
Italy's industrial north and dumping it in Campania, either in regular city
dumps or simply in the open. Illegally hauling trash from the north to Campania
caused the region's dumps to fill up more quickly, but also turned many
municipal dumps into repositories of untreated toxic waste. Some worry that
after years of this practice, toxins may be leaching into the groundwater
around Naples.
Over the years local residents
resisted efforts to build incinerators. However, authorities also blame the
Camorra for fomenting many protests in order to block the incinerators, which
could have threatened its control of the dumps and the transport system.
"I have the sense that no one in Rome really understands how urgent this
is or how difficult it will be to fix," says Mr. Roberti.
SURGICAL
PROCEDURE:
Laparoscopic cholecystectomy.[1]
PREOP
DIAGNOSIS:
Signs and symptoms included:
Digestive disturbances
Tenderness on pressure over gallbladder
Pain to back and right shoulder
Pathology: suffering from stones.
Diagnosis: Symptomatic non-acute cholelithiasis.[2]
- Patients are fasted for approximately 8 hours before elective operations.
- Routine administration of intravenous antibiotics for prophylaxis against wound infections is not mandatory in uncomplicated cases of cholelithiases.
- Prior to induction of anesthesia, deep venous thrombosis prophylaxis should be utilized.
[Bib: A page 192.]
POSTOP
DIAGNOSIS:
Symptomatic non-acute cholelithiasis.
Although major complications are rare, cardiopulmonary
complications may occur as is the case in any major abdominal operation.
Additionally, other rare possible complications include:
Bile duct injury
Bile leaks
Biliary stricture
Hemorrhage
Perforated bladder
Retained stones
Pancreatitis
Wound infections
Incisional hernia
Duodenal injury
Hepatic Artery injury
Damage to structure of Porta
Hepatis
Atelectasis
[Bib: A page 189.]
Assuming there are no complications, postoperative care
consists of:
- Clear liquids are resumed postoperatively and the patient progresses to a regular diet as tolerated.
- No activity or work restrictions are placed on the patient depending upon the degree of abdominal tenderness; the patient is encouraged to return to work within one week.
- Nausea and mild shoulder discomfort from diaphragmatic irritation may occur in the early postoperative period.
[Bib: A page 192.]
PREOP
DIAGNOSTIC STUDIES:
History and physical.
Simple cholelithiasis resulting from obstruction of the infundibulum
of the gallbladder or the cystic duct does not normally result in laboratory
abnormalities. Serum bilirubin is
usually normal unless there is a concomitant obstruction of the common bile
duct.
Plain radiographs of the abdomen are rarely useful in
diagnosing cholelithiasis.
Transcutaneous ultrasound of the upper right quadrant should
be the diagnostic tool of choice in patients with suspected biliary
pathology. Ultrasound is 95%
sensitive and 98% specific in detecting gallstones and may demonstrate
thickness of the gallbladder wall, pericholecystic fluid collections,
choledococolothiasis, sludge, polyps, microcalcifications, and the diameter of
the common bile duct.
Additionally, the physician may also evaluate the right kidney, liver
and pancreas.[3] It should be noted that computed
tomography (CT) is not as useful in evaluating biliary disease as is
ultrasound.
[Bib: A page 183.]
TYPE
OF ANESTHESIA:
The operation is performed under general anesthesia.
After induction of anesthesia, a urinary bladder catheter
and a naso/orogastiric tube are generally placed to decompress these hollow
organs
[Bib: A page 184.]
SUTURE
MATERIALS/CLOSING:
(DESCRIBE ABSORBABLE/NONABSORBABLE,
MONOFILAMENT/MULTIFILAMENT)
- All port sites larger than 5 mm must be closed to reduce the risk of herniation.
- The incisions were anesthetized locally.
Bupivacaine with Epinephrine.
- The fascia of the umbilical incision was closed with large absorbable sutures.
0-Vicryl is a multifilament absorbable suture.
- The skin of the subxiphoid umbilical incisions was closed with subcuticular sutures.
4-0 Vicryl is a multifilament absorbable suture.
- Bandaids/medipore 2 2/3 inches were applied to each incision.
[PIC Sheet]
TIES
PERITONEUM:
FASCIA:
SUBCUTANEOUS:
SKIN/SUBCUTICULAR:
OTHER:
I am unaware that any ties were used.
ELECTROSURGICAL
UNIT
TYPE: bovie
pencil
MONOPOLAR/BIPOLAR:
monopolar
SETTINGS:
25, sometimes done at 30
PLACEMENT OF DISPURSIVE PAD: leg/thigh
ESU TIP USED: coated
blade
INSTRUMENT
SET(S):
Complete gallbladder tray
Laparoscopic bin
Minor basin set
Camera tray
Scope warmer tray
[Bib: D page 77.]
SUPPLIES
BLADES: #11
PACKS: Laparoscopic Choly pack; C-Arm drape
DRESSINGS:
Bandaids/medipore 2 2/3 inches
Basic pack
Towels
Basin set
Cleaning kit (defogger)
Padding for elbows and ankles
Sony paper for printing photographs
Dr. A. always uses compression stockings
Prep set
Gloves
Gown
[Bib: D page 77.]
DESCRIBE
PREPPING PROCEDURE:
Dr. A. wanted the abdomen prepped in standard fashion with
betadine applied 3 times. The
betadine was applied from the midline-axilla down to (but not including) the
pubic symphysis and down to the table at the sides.
[1] The three
procedures I witnessed did not include interoperative cholangiograms. There is debate as to the requirement
of a mandatory cholangiograms vis a vis selective cholangiograms. Indications for the performance of
interoperative cholangiograms include:
·
the presence of two cystic ducts
·
an accessory gallbladder
·
visual identification of the ducts of Luschka
·
a history of gallstone pancreatitis
·
evidence of common bile duct stones by lab
analysis, history or radiographic exams.
If we had performed a cholangiogram, we would have
needed a:
·
taut catheter
·
conray 60%
·
14 gauge angio, and
·
two 20 cc syringes.
[Bib: A page 189.]
[2] Condition of
gallstones.
[3] When the
ultrasound result is normal and typical biliary systems persist,
cholecystokinin-stimulated biliary scintigraphy can demonstrate the presence of
acalculous cholecystitis or biliary dyskinesia. [Bib: A page 182.]
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