Alistair Dick

Multidetector-row computed tomography three-dimensional volume reformatted 'transparency' images to define an upper pouch fistula in oesophageal atresia

Oesophageal atresia (OA) is an important congenital malformation in which prompt diagnosis and appropriate management can significantly improve outcome. The surgical approach to repair of OA and associated tracheo-oesophageal fistulae (TOF) depends upon correct evaluation of the tracheobronchial tree. Three-dimensional imaging of the tracheobronchial tree using CT data to produce shaded surface displays and virtual bronchoscopy has been reported in paediatric and neonatal patients with OA and TOF and is described as accurate and helpful, non-invasively facilitating the appreciation of complex anatomy prior to surgery. We describe the technique of reconstructing 3D volume-reformatted ‘transparency’ images using insufflated air as a negative contrast medium. This technique is fast, accurate and produces high-quality images that are easy to reproduce.

Interactive force sensing feedback system for remote robotic laparoscopic surgery

This paper presents hardware and software systems which have been developed to provide haptic feedback for teleoperated laparoscopic surgical robots. Surgical instruments incorporating quantum tunnelling composite force measuring sensors have been developed and mounted on a pair of Mitsubishi PA-10 industrial robots. Feedback forces are rendered on pseudo-surgical instruments based on a pair of PHANTOM Omnis, which are also used to remotely manipulate the robotic arms. The paper describes the measurement of forces applied to surgical instruments during a teleoperated procedure, in order to provide a haptic feedback channel. This force feedback channel is combined with a visual feedback channel to enable a surgeon to better perform a two-handed surgical procedure on a remote patient by more accurately controlling a pair of robot arms via a computer network.

Peritoneography in the assessment of peritoneal cerebrospinal fluid absorption potential for distal ventriculoperitoneal shunt catheter placement: technical case report.

OBJECTIVE AND IMPORTANCE Distal ventriculoperitoneal shunt failure has been associated with absorption failure secondary to previous peritonitis. This assumption has caused surgeons to seek alternate sites for distal catheter placement. We propose that the absorptive potential of the peritoneal cavity should be assessed before that site is discounted for catheter placement. CLINICAL PRESENTATION The case of a 14-month-old male patient is presented, demonstrating multiple ventriculoperitoneal shunt placement procedures and a diagnostic dilemma with respect to distal shunt placement. Peritoneography was performed to demonstrate peritoneal fluid absorption, allowing subsequent placement of a new distal shunt catheter with good clinical results. TECHNIQUEUsing aseptic technique, a 24-gauge spinal needle was inserted in the midline of the abdomen and water-soluble contrast material was instilled. Delayed radiographs delineated peritoneal adhesions and demonstrated renal excretion of the contrast material, confirming peritoneal absorption. CONCLUSIONThe peritoneal cavity remains the site of choice for distal shunt catheter placement. If failure of peritoneal cerebrospinal fluid absorption is suspected as a cause of shunt failure, then peritoneography with water-soluble contrast material may be safely used to demonstrate the adequacy of fluid absorption before a secondary site is chosen.

The need for preoperative α-adrenergic blockade for ganglioneuroma excision

ting position, arms rested on a table. When she reported fullness in her back and easing of pressure behind her eyes, further injection of blood in the epidural space was stopped. After the blood patch, she reported that her double vision resolved completely in standing position and she was discharged home without any complications. Abducens nerve, which has a long intracranial course, is often stretched with caudal sagging of brain structures due to intracranial hypotension. Prolonged stretching of abducent nerve can result in ischemia, palsy, and persistent diplopia despite correction of intracranial hypotension. Although adult literature reports that epidural blood patch consistently fails to relieve diplopia when performed more than 1 day after the onset of sixth cranial nerve palsy (2), we report an adolescent who developed diplopia for 3 days without positional headache following multiple lumbar punctures, having complete resolution of diplopia immediately after epidural blood patch. Clinicians need to be aware of atypical symptoms of intracranial hypotension such as positional diplopia in the absence of spinal headache following intentional (e.g. diagnostic lumbar punctures) or accidental (e.g. epidural catheter placement) dural punctures as these procedures are frequently carried out in children and adolescents. In children, lumbar epidural blood patches might be useful in relieving diplopia following intracranial hypotension due to CSF leak following dural punctures. Learning points

A severe bleeding diathesis in a 6-year-old girl secondary to a composite diagnosis of splenic hemangiomatosis and small bowel lymphangiomatosis.

A 6-year-old girl presented with presumed relapse of childhood immune thrombocytopenia. Investigations revealed deranged coagulation parameters, abnormal small bowel thickening, and splenomegaly. A clinically significant bleeding diathesis emerged which was refractory to most hemostatic interventions. Laparatomy revealed a composite diagnosis of splenic hemangiomatosis and small bowel lymphangiomatosis. Splenectomy resulted in complete resolution of the coagulopathy. The diagnosis and management of these conditions is inherently complex and without clear guidance. We discuss our perioperative management of the bleeding diathesis. There is a need for long-term follow-up of the underlying pathologies particularly as potentially useful therapeutic agents have emerged.

Infected transverse colonic cystic duplication simulating pelvic appendicular abscess

A 23-month-old girl presented with 5 days of lower abdominal pain, lethargy, anorexia, reduced wet nappies and high fever not responding to a 5-day course of amoxicillin. On examination, she had a pulse rate of 179, respiratory rate 32, temperature 39.2°C and a tender mass in the lower abdomen. A urine dipstick was normal. White cell count was 30.36 × 109/L, neutrophils 24.59×109/L and C reactive protein 34.9 mg/L. An abdominal ultrasound scan showed a 5.7 cm long cystic mass on the left side of the pelvis with a thin septae, layering of the debris within …

Interactive force-sensing feedback system for remote robotic laparoscopic surgery

This paper presents the details of a combined hardware/software system, which has been developed to provide haptic feedback for teleoperated laparoscopic surgical robots. Surgical instruments incorporating quantum tunnelling composite (QTC) force measuring sensors have been developed and mounted on a pair of Mitsubishi PA-10 industrial robots. Feedback forces are rendered on pseudo-surgical instruments based on a pair of PHANTOM Omni devices, which are also used to remotely manipulate the robotic arms. Measurements of the behaviour of the QTC sensors during a simulated teleoperated procedure are given. In addition, a method is proposed that can compensate for their non-linear characteristics in order to provide a ‘realistic feel’ to the surgeon through the haptic feedback channel. The paper concludes by explaining how the force feedback channel is combined with a visual feedback channel to enable a surgeon to perform a two-handed surgical procedure better on a remote patient by more accurately controlling a pair of robot arms via a computer network.