Towards no-scar cardiac surgery - minimally invasive access through umbilicus for aortic valve replacement.

There is an ever-growing trend towards less-invasive procedures in all fields of medicine. We designed an animal study to prove the concept that trans-apical aortic valve replacement from an incision within the umbilicus through a single channel for instruments is feasible, which would be a major leap towards no-scar cardiac surgery. In three adult pigs, after creating a single 3-cm incision at a place where the human umbilicus would be, we introduced a 30F sheath through a tunnel created by an endoscopic vein-harvesting device up to the cardiac apex, through it and up to the left ventricle simulating the approach for trans-apical aortic valve replacement. We used a standard Amplatz nitinol occluder to seal the defect in ventricle wall later. The animals were followed up for 1h. Blood loss was minimal, and no tamponade occurred in any of the animals. In addition, we performed a test with water column static pressure to evaluate the impact of preclotting on the sealing properties of the occluders: 1 min flow-through was 2860+/-176 ml for the standard occluders and 348+/-56 ml for preclotted occluders (p<0.001).

Teaching video neuroimages: Beevor sign: when the umbilicus is pointing to neurologic disease

A 57-year-old man with genetically proven facioscapulohumeral muscular dystrophy (FSHMD 1A) demonstrated Beevor sign (video on the Neurology Web site at www.neurology.org). The upward movement of the umbilicus in a supine patient flexing the neck or sitting up is named after the British neurologist Charles Edward Beevor (1854-1908). He described a "marked elevation of the umbilicus in the act of sitting up" due to a paralyzed infraumbilical part of the rectus abdominis muscle, indicating a lesion of the spinal cord between the segments T10 and T12 or its nerve roots.(1) Beevor sign may also be present, as in our patient, in myopathies affecting the abdominal muscles, particularly in FSHMD, in which predominant involvement of the lower part of the rectus abdominis muscle is typical.(2).

Biomechanical analysis of sutures used for mesh fixation in the donor area after removal of the rectus abdominis muscle

Background: The use of synthetic mesh for abdominal wall closure after removal of the rectus abdominis is established but not standardised. This study compares two forms of mesh fixation: a simple suture, which fixes the mesh to the edges of the defect on the anterior rectus abdominis fascia; and total fixation, which incorporates the fasciae of the internal oblique, external oblique and transverse muscles in the suture, anchoring the mesh in the position of the removed muscle. Method: A total of 16 fresh cadavers were dissected. Two sutures were compared: simple and total. Three different sites were analysed: 5 cm above, 5 cm below and at the level of the umbilicus. The two sutures compared were tested in each region using a standardised technique. All sutures were performed with nylon 0, perpendicular to the linea alba. Each suture was secured to a dynamometer, which was pulled perpendicularly towards the midline until the rupture of the aponeurosis. `Rupture resistance` was measured in kilogram force. The mean among the groups was compared using the paired Student`s t-test to a significance level of 1% (p < 0.01). Results: The mean rupture resistance of the total suture was 160% higher than that of the simple suture. Conclusion: The total suture includes the external oblique, internal oblique and transverse fasciae, which are multi-directional, and creates a much higher resistance when compared with the simple suture. Total suture may reduce the incidence of bulging and hernias of the abdominal wall after harvesting the rectus abdominis muscle, but comparative clinical studies are necessary. (C) 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Bupivacaine 0.25% and methylene blue spread with epidural anesthesia in dog

Objective To evaluate the extent sensory and motor blocks produced by the epidural injection of different volumes of 0.25% bupivacaine (Bu) with methylene blue (MB), in dogs. Study design Prospective experimental trial. Animals Twenty healthy adult mongrel dogs, weighing 9.9 +/- 1.9 kg. Methods Dogs were randomly allocated into one of four groups that received 0.2, 0.4, 0.6 or 0.8 mL kg-1 of an epidural solution containing 0.25% Bu and MB. Sensory block was evaluated against time by pinching the tail, hind limb interdigital web, toenail bases and the skin over the vertebral dermatomes. Motor block was assessed by ataxia, hind limb weight-bearing ability and by loss of muscle tone of the tail and pelvic limbs. Data were collected at 2, 5, 10, 15 and 30 minutes after the end of epidural injection. After the final time point, dogs were euthanatized and laminectomies were conducted to expose the extent of the dural dye staining. Results The volumes 0.2, 0.4, 0.6 and 0.8 mL kg-1 of 0.25% Bu and MB blocked a mean of 5, 14.2, 20.2 and 21 dermatomes, respectively. The extent of the senory block increased up to a volume of 0.6 mL kg-1. Motor block was longer-lasting and more intense than sensory block. Complete dyeing of the spinal cord with MB was achieved in some dogs at 0.4 mL kg-1 and all dogs at 0.6 mL kg-1. Conclusions The volume of anesthetic injected into the epidural space plays an important role in the quality of the epidural anesthesia. At 0.25%, bupivacaine provided an efficient sensory block at 0.6 mL kg-1. Clinical relevance Relatively high volumes (0.6 mL kg-1) of 0.25%, BU and MB were needed to produce an effective sensory and motor block caudal to the umbilicus, but all spinal cord segments were reached by MB at this dose.

Induction of birth in the bandicoot (Isoodon macrourus) with prostaglandin and oxytocin

As in eutherians, maturation of the fetal pituitary and adrenal glands together with an increase in prostaglandin and mesotocin or oxytocin production initiates birth in marsupials. in this study, prostaglandin (Lutalyse) or oxytocin (Syntocinon) were administered to pregnant bandicoots at 05:00 h on the calculated day of birth and the resultant effects were filmed for analysis. The administration of prostaglandin caused the bandicoot to adopt the birth position several minutes after injection (n = 2). However, the bandicoot did not give birth for several hours. Birth occurred at a similar time of day to that observed for untreated bandicoots (n = 7), between 08:00 h and 12:00 h. After an injection of oxytocin, the bandicoot assumed the birth position and birth occurred within several minutes. The young were alive while still connected to their allantoic stalks. However, they were unable to attach to the teats and did not survive (n = 4). The induced young were the colour of venous blood and died soon after the umbilicus was separated, indicating that the cardiopulmonary system of these neonates was underdeveloped and inadequate to maintain life. The results from this study demonstrate that prostaglandin is required to prepare the bandicoot for birth, and mesotocin is required for contraction of the uterus and for birth to occur.

Fauna de Dissomphalus Ashmead (Hymenoptera, Bethylidae) da Mata Atlântica Brasileira, com descrição de 23 espécies novas

Foram realizadas coletas padronizadas em 18 pontos ao longo da Mata Atlântica Brasileira no escopo do Programa BIOTA/FAPESP usando-se varredura de vegetação, e armadilhas Malaise e Möricke. Foi coletado um total de 2.811 exemplares de Dissomphalus. Foram reconhecidas 30 espécies descritas, a saber: Dissomphalus conicus Azevedo, 2003, D. h-ramus Redighieri & Azevedo, 2004, D. laminaris Redighieri & Azevedo, 2004, D. manus Azevedo, 2003, D. umbilicus Azevedo, 2003, D. verrucosus Redighieri & Azevedo, 2004, D. alticlypeatus Azevedo, 2003, D. bicerutus Azevedo, 2003, D. gilvipes Evans, 1979, D. krombeini Azevedo, 1999, D. gordus Azevedo, 2003, D. undatus Azevedo, 2003, D. cristatus Redighieri & Azevedo, 2004, D. laticephalus Azevedo, 2003, D. lobicephalus Azevedo, 2003, D. completus Azevedo, 1999, D. gigantus Azevedo, 1999, D. scamatus Azevedo, 1999, D. napo Evans, 1979, D. punctatus (Kieffer, 1910), D. infissus Evans, 1969, D. plaumanni Evans, 1964, D. concavatus Azevedo, 1999, D. rectilineus Azevedo, 1999, D. bifurcatus Azevedo, 1999, D. extrarramis Azevedo, 1999, D. strictus Azevedo, 1999, D. connubialis Evans, 1966, D. microstictus Evans, 1969, D. scopatus Redighieri & Azevedo, 2004. Além disso, foram descritas e ilustradas 23 espécies novas: Dissomphalus inclinatus sp. nov., D. divisus sp. nov., D. distans sp. nov., D. crassus sp. nov., D. filiformis sp. nov., D. inflexus sp. nov., D. spissus sp. nov., D. firmus sp. nov., D. setosus sp. nov., D. tubulatus sp. nov., D. differens sp. nov., D. lamellatus sp. nov., D. fimbriatus sp. nov., D. magnus sp. nov., D. trilobatus sp. nov., D. amplifoveatus sp. nov., D. personatus sp. nov., D. excellens sp. nov., D. peculiaris sp. nov., D. bahiensis sp. nov., D. amplexus sp. nov., D. elegans sp. nov. e D. amplus sp. nov.. Foram propostos 2 grupos novos de espécies, brasiliensis com duas espécies e setosus com oito espécies. Dissomphalus connubialis Evans, 1966 foi revalidado a partir de D. brasiliensis Kieffer, 1910. Dissomphalus bispinulatus Evans, 1969 foi considerado sinônimo junior de D. brasiliensis. Foi proposto para o gênero uma chave de espécies Neotropicais baseada em machos. Algumas espécies como Dissomphalus rectilineus, D. plaumanni, D. connubialis e D. gigantus são amplamente distribuídos ao longo deste bioma. Por outro lado, espécies como Dissomphalus completus, D. bifurcatus, D. napo, D. gilvipes, D. microstictus, D. brasiliensis, D. scamatus, D. strictus, D. undatus, D. alticlypeatus, D. laticephalus, D. verrucosus, D. extrarramis, D. concavatus, D. krombeini, D. gordus, D. lobicephalus e 13 espécies novas são restritas a regiões específicas, apresentando congruência com os subcentros deste bioma.

Elimination of biliary stones through the urinary tract: a complication of the laparoscopic cholecystectomy

The introduction and popularization of laparoscopic cholecystectomy has been accompanied with a considerable increase in perforation of gallbladder during this procedure (10%--32%), with the occurrence of intraperitoneal bile spillage and the consequent increase in the incidence of lost gallstones (0.2%--20%). Recently the complications associated with these stones have been documented in the literature. We report a rare complication occurring in an 81-year-old woman who underwent laparoscopic cholecystectomy and developed cutaneous fistula to the umbilicus and elimination of biliary stones through the urinary tract. During the cholecystectomy, the gall bladder was perforated, and bile and gallstones were spilled into the peritoneal cavity. Two months after the initial procedure there was exteriorization of fistula through the umbilicus, with intermittent elimination of biliary stones. After eleven months, acute urinary retention occurred due to biliary stones in the bladder, which were removed by cystoscopy. We conclude that efforts should be concentrated on avoiding the spillage of stones during the surgery, and that no rules exist for indicating a laparotomy simply to retrieve these lost gallstones.

Scarless laparoscopic repair of epigastric hernia in children

Background Despite the small size of the incision, the scar left by open repair of epigastric hernia in children is unaesthetic. Few laparoscopic approaches to epigastric hernia repair have been previously proposed, but none has gain wide acceptance from pediatric surgeons. In this study, we present our experience with a scarless laparo- scopic approach using a percutaneous suturing technique for epigastric hernia repair in children. Methods Ten consecutive patients presenting with epi- gastric hernia 15 mm or further from the umbilicus were submitted to laparoscopic hernia repair. A 5-mm 308-angle laparoscope is introduced through a umbilical trocar and a 3-mm laparoscopic dissector is introduced through a stab incision in the right flank. After opening and dissecting the parietal peritoneum, the fascial defect is identified and closed using 2–0 polyglactin thread through a percutaneous suturing technique. Intraoperative and postoperative clinical data were collected. Results All patients were successfully submitted to la- paroscopic epigastric hernia repair. Median age at surgery was 79 months old and the median distance from the um- bilicus to the epigastric defect was 4 cm. Operative time ranged from 35 to 75 min. Every hernia was successfully closed without any incidents. Follow-up period ranges from 2 to 12 months. No postoperative complications or recurrence was registered. No scar was visible in these patients. Conclusion This scarless laparoscopic technique for epi- gastric hernia repair is safe and reliable. We believe this technique might become gold standard of care in the near future.

Impact of Different Obesity Assessment Methods after Acute Coronary Syndromes

Background: Abdominal obesity is an important cardiovascular risk factor. Therefore, identifying the best method for measuring waist circumference (WC) is a priority. Objective: To evaluate the eight methods of measuring WC in patients with acute coronary syndrome (ACS) as a predictor of cardiovascular complications during hospitalization. Methods: Prospective study of patients with ACS. The measurement of WC was performed by eight known methods: midpoint between the last rib and the iliac crest (1), point of minimum circumference (2); immediately above the iliac crest (3), umbilicus (4), one inch above the umbilicus (5), one centimeter above the umbilicus (6), smallest rib and (7) the point of greatest circumference around the waist (8). Complications included: angina, arrhythmia, heart failure, cardiogenic shock, hypotension, pericarditis and death. Logistic regression tests were used for predictive factors. Results: A total of 55 patients were evaluated. During the hospitalization period, which corresponded on average to seven days, 37 (67%) patients had complications, with the exception of death, which was not observed in any of the cases. Of these complications, the only one that was associated with WC was angina, and with every cm of WC increase, the risk for angina increased from 7.5 to 9.9%, depending on the measurement site. It is noteworthy the fact that there was no difference between the different methods of measuring WC as a predictor of angina. Conclusion: The eight methods of measuring WC are also predictors of recurrent angina after acute coronary syndromes.

Observations on the morphology of Pomacea lineata (Spix, 1827) (Mollusca, Ampullariidae)

This paper deals with the morpholgy of Pomacea lineata (Spix, 1827) collected at its type locality. The shell is globose, moderately heavy, horn-colored with brown spiral bands; apex subelevated; 4 - 5 rounded whorls increasing in diameter rather rapidly, separated by deep suture. Aperture large and ovoid; outer lip sharp; umbilicus narrow and deep; operculum concentric, corneous. Ratios: shell width/shell length = 0.74 - 0.83 (mean 0.78); spire length/shell length = 0.10 - 0.18 (mean 0.13); aperture length/shell length = 0.70 - 0.77 (mean 0.73). The animal is longisiphonate. Renal organ brownish with marked invagination at its right edge. Ureter elongated with its long axis transverse to the main axis of the kidney. The radula is taenioglossate (2.1.1.1.2) and has on average 35 transverse rows of teeth. The form and arrangement of the radula teeth are nearly the same as in other Ampullariidae. The testis is cream-colored and lies in the first three whorls of the spire. Spermiduct uniformly narrow, running to the base of the spire. Seminal vesicle whitish, slightly pressed dorsoventrally. Prostate cylindric and thick, similar in color to the testis. Penis whiplike, with a closed circular spermiduct. Penis pouch ovoid completely envelping the penis. Penis sheath elongated, broad prosimally, tapering distally. Its inner surface shows a longitudinal channel along its proximal half and two glands, one on the middle and the other apical. Ovary composed of branched whitish tubules situated on the surface of the digestive gland. Oviduct slender running along the columellar axis toward the base of the spire. Seminal receptalble tubiform, thick-walled and rounded proximally. Albumen gland large, pink, enclosing the receptacle and the spiral capsule gland. Vestigial male copulatory apparatus (penis and its sheath) present in all females examined.

On Pomacea sordida (Swainson, 1823) (Prosobranchia, Ampullariidae)

A description of Pomacea sordida (Swainson, 1823) collected in Caxias and Nova Iguaçu, state of Rio de Janeiro, is presented. The shell is globose, heavy, whith greenish or horn-colored periostracum and dark spinal bands; apex subelevated, 4-5 moderately shoudered whorls, increasing rather rapidly and separated by deep suture. Aperture large, moderately round, yellowish or violaceous; lip thick and sometimes dark brown; umbilicus large and deep; operculum corneous and heavy, entirely closing the aperture. Ratios: shell width/shell length = 0.81-0.91 (mean 0.86); aperture length/shell length = 0.66-0.75 (mean 0.70). Testis, spermiduct and penis pouch as in Pomacea lineata (Spix, 1827). Seminal vesicle whitish and bean-shaped. Prostate cylindric and narrow, cream in coloar as the testis. Penis whiplike whith a closed circular spermiduct. Penial sheath elongated and tapered, with its distal tip turned to the right; outer basal gland situated on the left; inner median gland rounded; apical gland elongated and wrinkled. Ovary composed of branched whitish tubules lying superficially on the digestive gland; oviduct and seminal receptacle as in P. lineata; albumen gland yellowish - orange. Vestigial male copulatory apparatus (penis and its sheath) present in all females examined.

On Pomacea canaliculata (Lamarck, 1822) (Mollusca; Pilidae: Ampullariidae)

This paper deals with the morphology of Pomacea caniculata (Lamarck, 1822) collected at Corrientes, Argentina. Comparison is made with Pomacea lineata (Spix, 1827) and Pomacea sordida (Swainson, 1823). The shell is globose, heavy, with greenish or horn-colored periostracum and dark spiral bands; apex subelevated, 5-6 whorls increasing rather rapidly and separated by very deep suture. Aperture large, rounded to subelongated; lip sometimes reddish; umbilicus large and deep; operculum corneous, entirely closing the aperture. Ratios: shell width/shell length = 0.78-0.96 (mean 0.86); aperture length/shell length = 0.68-0.77 (mean 0.72). Radula similar to other congeneric species. Testis and spermiduct as in P. lineata and P. sordida; prostate cylindric and short, cream in color as the testis. Penial sheath straight bearing a central outer gland deeply embedded in the tissue of its basal portion and a large wrinkled gland occupying 2/3 of the distal tip of its inner surface; the rigth margin of the sheath overlaps the left one until 2/3 of its proximal end. Female reproductive apparatus similar to that P. lineata; vestigial male copulatory apparatus (penis and its sheath) present in all females examined.

Fauna de Dissomphalus Ashmead (Hymenoptera, Bethylidae) da Mata Atlântica Brasileira, com descrição de 23 espécies novas

Foram realizadas coletas padronizadas em 18 pontos ao longo da Mata Atlântica Brasileira no escopo do Programa BIOTA/FAPESP usando-se varredura de vegetação, e armadilhas Malaise e Möricke. Foi coletado um total de 2.811 exemplares de Dissomphalus. Foram reconhecidas 30 espécies descritas, a saber: Dissomphalus conicus Azevedo, 2003, D. h-ramus Redighieri & Azevedo, 2004, D. laminaris Redighieri & Azevedo, 2004, D. manus Azevedo, 2003, D. umbilicus Azevedo, 2003, D. verrucosus Redighieri & Azevedo, 2004, D. alticlypeatus Azevedo, 2003, D. bicerutus Azevedo, 2003, D. gilvipes Evans, 1979, D. krombeini Azevedo, 1999, D. gordus Azevedo, 2003, D. undatus Azevedo, 2003, D. cristatus Redighieri & Azevedo, 2004, D. laticephalus Azevedo, 2003, D. lobicephalus Azevedo, 2003, D. completus Azevedo, 1999, D. gigantus Azevedo, 1999, D. scamatus Azevedo, 1999, D. napo Evans, 1979, D. punctatus (Kieffer, 1910), D. infissus Evans, 1969, D. plaumanni Evans, 1964, D. concavatus Azevedo, 1999, D. rectilineus Azevedo, 1999, D. bifurcatus Azevedo, 1999, D. extrarramis Azevedo, 1999, D. strictus Azevedo, 1999, D. connubialis Evans, 1966, D. microstictus Evans, 1969, D. scopatus Redighieri & Azevedo, 2004. Além disso, foram descritas e ilustradas 23 espécies novas: Dissomphalus inclinatus sp. nov., D. divisus sp. nov., D. distans sp. nov., D. crassus sp. nov., D. filiformis sp. nov., D. inflexus sp. nov., D. spissus sp. nov., D. firmus sp. nov., D. setosus sp. nov., D. tubulatus sp. nov., D. differens sp. nov., D. lamellatus sp. nov., D. fimbriatus sp. nov., D. magnus sp. nov., D. trilobatus sp. nov., D. amplifoveatus sp. nov., D. personatus sp. nov., D. excellens sp. nov., D. peculiaris sp. nov., D. bahiensis sp. nov., D. amplexus sp. nov., D. elegans sp. nov. e D. amplus sp. nov.. Foram propostos 2 grupos novos de espécies, brasiliensis com duas espécies e setosus com oito espécies. Dissomphalus connubialis Evans, 1966 foi revalidado a partir de D. brasiliensis Kieffer, 1910. Dissomphalus bispinulatus Evans, 1969 foi considerado sinônimo junior de D. brasiliensis. Foi proposto para o gênero uma chave de espécies Neotropicais baseada em machos. Algumas espécies como Dissomphalus rectilineus, D. plaumanni, D. connubialis e D. gigantus são amplamente distribuídos ao longo deste bioma. Por outro lado, espécies como Dissomphalus completus, D. bifurcatus, D. napo, D. gilvipes, D. microstictus, D. brasiliensis, D. scamatus, D. strictus, D. undatus, D. alticlypeatus, D. laticephalus, D. verrucosus, D. extrarramis, D. concavatus, D. krombeini, D. gordus, D. lobicephalus e 13 espécies novas são restritas a regiões específicas, apresentando congruência com os subcentros deste bioma.