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There are different shapes of the snare such as oval symptoms for pink eye lumigan 3 ml cheap, hexagon and crescent, and different structure of wire such as single wire, double wire, and wire with or without thorn. The metal snare are commonly used for polyps with pedicle or polyps without pedicle but larger than 0. If resection is difficult or with high risks of bleeding, nylon loop is applied to the pedicle of the polyps until the polyps get avascular necrosis and falls off, but the specimens is usually lost. Careful endoscopic suction is applied to reduce the size of the perforation before nylon snare is applied. Generally, the resected pieces can be collected into the cap and retrieved from the patient after the cap-assisted. We can also use some retrieval devices to collect the tissue for the purpose of keeping the integrity of the samples, for example Roth Net. We usually use metal clips for hemostasis particularly if wall is thin or the bleeding is brisk from arteriole or venule with large diameter, because coagulation in this situation can result in delayed perforation. However, the clips for hemostasis may influence the view of the operation field if used during the dissection. This clip is also commonly used in full-thickness resection to close the perforation. The clips can be used to help the surgeon locate the exact position of lesion, sometime assisted with X-ray. Area suitable for skilled doctor: angular part in stomach, upper and middle part of great curvature of stomach body and pylorus ring. When finishing about 2030 cases, the beginner can try some difficult areas such as angle of stomach. Advantage of hook knife: (1) Hook knife is rotatable so that it is suitable for all direction dissection. Disadvantage of hook knife: (1) It needs experienced assistants for rotating the knife tip to a proper direction. Advantage of flex knife: (1) Easy control and faster dissection as the tip of the sheath is thick and functions as a stopper (2) It can produce marking, cutting and all-oriented dissection. Disadvantage of flex knife: (1) It is hard for beginner to adjust the length of the knife tip. The knife sheath extension out of the endoscopy should be adjusted under the direct vision. Less extension of the sheath is used for marking and greater extension for complete circumferential cut and submucosal dissection. Area suitable for flex knife dissection: lesser curvature of the middle gastric body, greater curvature, anterior and back wall of antrum. The characteristics of this device is that we can dissect the mucosa for ideal direction without rotating the knife tip. The flexible, multi-function probe combines both technology, electrosurgrey and waterjet surgery, in one instrument-hybrid knife.
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Note medications restless leg syndrome lumigan 3 ml buy with mastercard, the length of I band decreases (without change in A band) during contraction that decreases in sarcomeric length. A cross section through the overlap region of A band shows that each thick filament is surrounded by a hexagonal array of six thin filaments, and each thin filament is surrounded by a triangular arrangement of three thick filaments. Once initiated, an action potential is rapidly conducted along the sarcolemma over the surface of the muscle fiber as well as into the interior of the muscle cell by the way of the T-tubules so that deep lying myofibrils are fast activated. The junctional feet involve two integral membrane proteins, one in the T-tubule membrane, and the other in the membrane of the terminal cistern. The portion of the terminal cisternae membrane that faces the T-tubules contains proteins known as the ryanodine receptors. It forms an elaborate membranous network having extensive anastomosis around each myofibril and runs parallel to the myofilaments. Note the relationship of sarcoplasmic reticulum and T tubules with I and A bands of sarcomere, in a myofibrils. Mechanism of Calcium Release Following depolarization at the motor end plate, action potentials propagate along the sarcolemma and down the T-tubule membrane. The entire process, starting from depolarization of the T-tubule membrane to the initiation of the cross-bridge cycling is termed excitation-contraction coupling. Increase in Ca2+ concentration near the sarcoplasmic reticulum is known as calcium spark. In the terminal cisternae, a Ca2+ binding protein called calsequestrin, favors storage of calcium at high concentration. With decrease in cytoplasmic calcium concentration, contractile activity ceases and relaxation process begins (Flowchart 26. This is so named as it is present in all cells in connection with the endoplasmic reticulum. It transfers action potential from the surface of the muscle fiber to the interior, closer to the myofibrils. Sarcomere, the functional unit of muscle fibril, is the distance between two Z lines. During muscle contraction, the length of the sarcomere decreases, due to shortening of I band, but the length of A band remains unchanged. The globular heads of myosin project from the thick filaments toward the thin filaments and bridge the gap between them. During muscle contraction, cross bridge attach to the thin filaments and pull them. T tubule of sarcotubular system that invaginates into the myofibril transmits action potential to the contractile machinery.
Under the guidance of colonoscopy medications memory loss 3 ml lumigan with mastercard, laparoscopy can help to locate intestinal segment and the lesion. Once the penetrating injury or bleeding occurs, laparoscopy can immediately be used to suture or pin up on the weak part of intestinal wall. Colonoscopy Assisted with Laparoscopic Treatment It is applied for high-grade intraepithelial neoplastic or malignant lesions. During the process of operation, colonoscopy needs to find location and continue to go further to surpass the polyp part (for cecal lesions, it needs to enter the terminal ileum), linear cutting anastomosis needs to be applied for wedge resection with laparoscopy. Presence colonoscopy prevents damage to opposite wall during laparoscopic cutting and prevents collapse of lumen. Under a general anesthetic, an on table colonoscopy was performed to identify and reassess the polyp, whilst a laparoscopy was performed to excise the polyp via wedge resection, using the endoscopic view as guidance. Laparoscopic Resection of Intestinal Segments When the lesions are located in mesenteric border or they cannot be resected by the above two methods, corresponding intestinal segment resection operation is carried out in accordance with their locations. Ligate and transect the arterioles, mobilize the relevant intestinal segments and mesentery. Depending on the situations to do intracorporal or extracorporeal intestinal removal and anastomosis, colonoscopy has following two functions, a. Intraoperative frozen section is performed, once the suspected malignance is found, additional operation may not be required in the case of pre-invasive carcinoma. But laparoscopic colorectal cancer radical operation is required for patients with infiltrating cancer. Since then, many different operation methods been reported and demonstrated the safety and reliability of combined approach. A total of 209 polyps were resected, 59 % of the polyps were located in the right hemicolon, 4 % in transverse colon, 8 % in the left hemicolon and 19 % of the polyps were located in rectum and sigmoid colon. Histology showed that 43 % of polyps were villous canalicular adenoma, 19 % villous adenoma, 17 % canalicular adenoma, 7 % of the patients were pre-invasive carcinoma. Reported complications included nine cases of atelectasis, three cases of haematoma, four cases of transient intestinal obstruction, managed conservatively and death occurred. Malignant lesion identified during this procedure can be dealt with laparoscopic resection at the same time. Laparoscopic colectomy for colorectal cancer by colonoscopic positioning It is indicated for patients who are diagnosed to have invasive colorectal cancer; Lesion extension should be less than 1/3 circumference. During the operation, the principles are (a) to ensure sufficient tumor-free margins, (b) cut off blood vessel via root ligation of blood vessels, clean lymphoid tissue, and stick to the principle of no contact with tumor. Colonoscopy examination in laparoscopic colectomy to rule out synchronous multiple primary carcinomas For the patient who fails to have a total colonoscopy due to blocked lumen, colonoscopy can be conducted during laparoscopic operation to eliminate the possibility of multiple primary carcinomas. Surgeons used to operate emergency surgery of exploratory laparotomy for those patients to remove obstruction and create a stoma. The operation may result in large wound and a high occurrence rate of complications. Endoscopic metal stent drainage makes the emergency operation turn into selective operation, which can avoid creating stoma.
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