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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
\n\n\n\n\n'}],latestNews:[{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"},{slug:"intechopen-identified-as-one-of-the-most-significant-contributor-to-oa-book-growth-in-doab-20210809",title:"IntechOpen Identified as One of the Most Significant Contributors to OA Book Growth in DOAB"}]},book:{item:{type:"book",id:"11072",leadTitle:null,fullTitle:"Sample Preparation Techniques for Chemical Analysis",title:"Sample Preparation Techniques for Chemical Analysis",subtitle:null,reviewType:"peer-reviewed",abstract:"Despite having powerful software, microchips, and solid-state detectors that enable analytical chemists to achieve fast, stable, and accurate signals from their instruments, sample preparation is the most important step in chemical analysis. Issues can arise at this step for various reasons, including a low concentration of analytes, incompatibility of the sample with the analytical instrument, and matrix interferences. This volume discusses the basics of sample preparation and examines modern techniques that can be used by both novice and expert analytical chemists. Chapters review microextraction, surface spectroscopy analysis, and techniques for particle, tissue, and cellular separation.",isbn:"978-1-83969-215-4",printIsbn:"978-1-83969-214-7",pdfIsbn:"978-1-83969-216-1",doi:"10.5772/intechopen.96639",price:119,priceEur:129,priceUsd:155,slug:"sample-preparation-techniques-for-chemical-analysis",numberOfPages:108,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"38fecf7570774c29c22a0cbca58ba570",bookSignature:"Massoud Kaykhaii",publishedDate:"December 22nd 2021",coverURL:"https://cdn.intechopen.com/books/images_new/11072.jpg",numberOfDownloads:818,numberOfWosCitations:0,numberOfCrossrefCitations:2,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:3,numberOfDimensionsCitationsByBook:0,hasAltmetrics:0,numberOfTotalCitations:5,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 26th 2021",dateEndSecondStepPublish:"May 6th 2021",dateEndThirdStepPublish:"July 5th 2021",dateEndFourthStepPublish:"September 23rd 2021",dateEndFifthStepPublish:"November 22nd 2021",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,7",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"349151",title:"Prof.",name:"Massoud",middleName:null,surname:"Kaykhaii",slug:"massoud-kaykhaii",fullName:"Massoud Kaykhaii",profilePictureURL:"https://mts.intechopen.com/storage/users/349151/images/system/349151.png",biography:"Massoud Kaykhaii has been a Professor of Analytical Chemistry at the University of Sistan and Baluchestan (USB), Zahedan, Iran, since 1989. His research work focuses on modern sample preparation techniques including miniaturized solid and liquid phase microextraction and stir bar sorptive extraction. He has written 150 research articles, 5 books, and 22 national standard procedures of analysis. He has three patents to his credit. He has presented at 150 seminars/conferences and (co)supervised 106 MSc and Ph.D. theses. He is a member of the editorial advisory board of ninety-eight journals and acted as secretary of three national mirror committees of ISO/TC. Professor Kaykhaii was recognized as the best researcher at USB and as being in the top 1 percent of reviewers in chemistry by Publons.",institutionString:"University of Sistan and Baluchestan",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"University of Sistan and Baluchestan",institutionURL:null,country:{name:"Iran"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"81",title:"Analytical Chemistry",slug:"chemistry-analytical-chemistry"}],chapters:[{id:"79484",title:"Introductory Chapter: Evolution of Sample Preparation",doi:"10.5772/intechopen.101434",slug:"introductory-chapter-evolution-of-sample-preparation",totalDownloads:148,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:null,signatures:"Massoud Kaykhaii",downloadPdfUrl:"/chapter/pdf-download/79484",previewPdfUrl:"/chapter/pdf-preview/79484",authors:[{id:"349151",title:"Prof.",name:"Massoud",surname:"Kaykhaii",slug:"massoud-kaykhaii",fullName:"Massoud Kaykhaii"}],corrections:null},{id:"79034",title:"Modern Sample Preparation Techniques: A Brief Introduction",doi:"10.5772/intechopen.100715",slug:"modern-sample-preparation-techniques-a-brief-introduction",totalDownloads:204,totalCrossrefCites:2,totalDimensionsCites:3,hasAltmetrics:0,abstract:"Due to fast growth in microprocessors, analytical instrumentations in spectroscopy, chromatography, microscopy, sensors and microdevices have been subjected to significant developments. Despite these advances, a sample preparation step is indispensable before instrumental analysis. Main reasons are low sensitivity of the instruments, matrix interferences and incompatibility of the sample with the analytical device. Most of the time spent and most of the errors occurring during a chemical analysis is on sample preparation step. As a result, any improvements in this essential process will have a significant effect on shortening the analysis time and its precision and accuracy and lowering the cost. This introductory chapter intends to draw the readers’ attention to the importance of sample preparation, the procedures of sampling and the source of errors that occur in the course of sampling. The chapter then continues with a heading on sample preparation techniques, including exhaustive and non-exhaustive methods of extraction. Microwave, sonication and membrane-based extraction techniques are more emphasized as exhaustive methods and under a new title, miniaturized methods are discussed. Automation, on-line compatibility and simplification is an important aspect of any sample preparation and extraction which is discussed at the end of this chapter.",signatures:"Mona Sargazi, Sayyed Hossein Hashemi and Massoud Kaykhaii",downloadPdfUrl:"/chapter/pdf-download/79034",previewPdfUrl:"/chapter/pdf-preview/79034",authors:[{id:"349151",title:"Prof.",name:"Massoud",surname:"Kaykhaii",slug:"massoud-kaykhaii",fullName:"Massoud Kaykhaii"},{id:"356813",title:"Dr.",name:"Mona",surname:"Sargazi",slug:"mona-sargazi",fullName:"Mona Sargazi"},{id:"426250",title:"Dr.",name:"Sayyed Hossein",surname:"Hashemi",slug:"sayyed-hossein-hashemi",fullName:"Sayyed Hossein Hashemi"}],corrections:null},{id:"78687",title:"Advanced Sample Preparation Techniques for Surface Spectroscopy Analysis of Organic: Inorganic Hybrid Silica Particles",doi:"10.5772/intechopen.100118",slug:"advanced-sample-preparation-techniques-for-surface-spectroscopy-analysis-of-organic-inorganic-hybrid",totalDownloads:157,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Silica due to its large inorganic amorphous wall and hydrophilic surface properties renders its suitability for designing different varieties of organic–inorganic silica-based materials. Characterization of such hybrid silica-based materials is one of the fascinating as well as challenging topics to be covered. Surface analysis of these hybrid materials can be done utilizing various techniques, out of which X-ray photoelectron spectroscopy (XPS), 29Si Solid-state Nuclear magnetic resonance (NMR) spectroscopy, and Fourier-transform infrared spectroscopy (FTIR) is the most ideal ones. Thus, before analyzing these silica materials, it requires a massive study on its sample preparation for appropriate characterization of the organic molecules present in the inorganic network. Hence, this chapter will give a brief elucidation of the sample preparation techniques for analyzing the hybrid materials utilizing the above instrumentation techniques.",signatures:"Harekrishna Panigrahi, Smrutirekha Mishra and Suraj Kumar Tripathy",downloadPdfUrl:"/chapter/pdf-download/78687",previewPdfUrl:"/chapter/pdf-preview/78687",authors:[{id:"419009",title:"Dr.",name:"Smrutirekha",surname:"Mishra",slug:"smrutirekha-mishra",fullName:"Smrutirekha Mishra"},{id:"419124",title:"Mr.",name:"Harekrishna",surname:"Panigrahi",slug:"harekrishna-panigrahi",fullName:"Harekrishna Panigrahi"},{id:"427165",title:"Dr.",name:"Suraj Kumar",surname:"Tripathy",slug:"suraj-kumar-tripathy",fullName:"Suraj Kumar Tripathy"}],corrections:null},{id:"78769",title:"Preparation of Tissues and Heterogeneous Cellular Samples for Single-Cell Analysis",doi:"10.5772/intechopen.100184",slug:"preparation-of-tissues-and-heterogeneous-cellular-samples-for-single-cell-analysis",totalDownloads:160,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"While sample preparation techniques for the chemical and biochemical analysis of tissues are fairly well advanced, the preparation of complex, heterogenous samples for single-cell analysis can be difficult and challenging. Nevertheless, there is growing interest in preparing complex cellular samples, particularly tissues, for analysis via single-cell resolution techniques such as single-cell sequencing or flow cytometry. Recent microfluidic tissue dissociation approaches have helped to expedite the preparation of single cells from tissues through the use of optimized, controlled mechanical forces. Cell sorting and selective cellular recovery from heterogenous samples have also gained traction in biosensors, microfluidic systems, and other diagnostic devices. Together, these recent developments in tissue disaggregation and targeted cellular retrieval have contributed to the development of increasingly streamlined sample preparation workflows for single-cell analysis technologies, which minimize equipment requirements, enable lower processing times and costs, and pave the way for high-throughput, automated technologies. In this chapter, we survey recent developments and emerging trends in this field.",signatures:"E. Celeste Welch and Anubhav Tripathi",downloadPdfUrl:"/chapter/pdf-download/78769",previewPdfUrl:"/chapter/pdf-preview/78769",authors:[{id:"355954",title:"Prof.",name:"E.",surname:"Celeste Welch",slug:"e.-celeste-welch",fullName:"E. Celeste Welch"}],corrections:null},{id:"78143",title:"Particle and Cell Separation",doi:"10.5772/intechopen.99635",slug:"particle-and-cell-separation",totalDownloads:149,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Many processors are available for separating particles and/or cells, but few can match the capacity of flow cytometry – in particular the sorting component. Several aspects unique to cell sorting give it such power. First, particles can be separated based on size, complexity, fluorescence, or any combination of these parameters. Second, it is entirely possible to separate particles under sterile conditions, making this technology very advantageous for selecting cells for culture. Third, when this sterile environment is combined with a highly controlled safety system, it is possible to safely sort and separate highly pathogenic organisms or even cells containing such pathogens. The very latest instruments available add even more power by introducing the ability to sort cells based on spectral unmixing. This last option requires incredible computer power and very-high-speed processing, since the sort decision is based on computational algorithms derived from the spectral mixture being analyzed.",signatures:"J. Paul Robinson",downloadPdfUrl:"/chapter/pdf-download/78143",previewPdfUrl:"/chapter/pdf-preview/78143",authors:[{id:"357422",title:"Prof.",name:"J. Paul",surname:"Robinson",slug:"j.-paul-robinson",fullName:"J. 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\r\n\tThe development of RNA therapeutics has been an intense journey, with numerous stories of success and failure. The potential, and suitability, of recently discovered RNAs (for therapeutics), stemmed from several Nobel Prize-winning discoveries. Currently, novel RNA drugs are entering clinical trials almost daily. RNA therapeutics are chemically synthesized biomolecules with broad clinical applications, ranging from correcting inherited mutations, to treating cancer, and chronic conditions, improving organ transplant outcomes, and infectious disease prophylaxes.
\r\n\tRNA therapies evolved as profitable and widely applicable individualized treatment solutions. Moreover, RNA-based therapeutic vaccines (e.g., against SARS-CoV-2 infection) have been proven to be safe and effective, and several of them are approved by the United States Food and Drug Administration (FDA).
\r\n\tThis book aims to present distinct classes of RNA therapeutics, ranging from single-stranded antisense oligonucleotides (ASOs), and subclasses of RNA interferences (miRNAs and other RNAi), to in vitro transcribed mRNAs and RNA vaccines. Also, it will present some of the challenges in RNA drug engineering, delivery, and specificity. Additionally, the improvement of pharmacological effectiveness will be discussed. Monumental breakthroughs in molecular biology, computational chemistry, bioinformatics, and individualized genomics, which undoubtedly propelled RNA therapeutics through the commercialization stage, will also be examined in this book.
\r\n\tRNA therapeutics have had a significant impact on medicine, the economy, and overall public health; they are becoming prescription drugs, and this holds great promise for modernizing healthcare.
In 1495 Leonardo Da Vinci designed what was to be the first automated humanoid and it is speculated that this was to be for the entertainment of royalty. It is not known whether an actual prototype was ever built. The word robot was first introduced by the Czech writer Karel Capek in his play
Robotic technology is now incorporated into our everyday life which can range from the large manufacturing assembly lines to everyday household chores. The field of Medicine is no exception where robotic applications are gaining momentum.
One of the first robotic applications came from the Stanford Artificial Intelligence Lab (SAIL) in 1969. They designed a robotic arm with 6 degrees of freedom (6-dof) all-electric mechanical manipulator exclusively for computer control. The Stanford Arm and SAIL helped to develop the knowledge base which has been applied in essentially all the industrial robots.
The first commercially available robotic system was the ROBODOC which was used for orthopedic surgery. AESOP was designed to allow the surgeon greater control over visualization and to eliminate the need for an assistant holding the scope. The ZEUS robot was then developed which had a two-dimensional imaging system. Intuitive Surgical Inc (Intuitive Surgical Inc, Moutain View, CA) developed the Da Vinci robotic system and the first successful surgery was performed in 1997 in Belgium.
The Da Vinci Robotic system is now also utilized by gynecologists to perform a number of procedures including hysterectomy myomectomy, tubal reversal and sacrocolpopexy as well as cancer surgeries. This chapter will discuss the use of robotic technology during hysterectomy procedures for benign conditions.
With more than 600,000 procedures performed annually in the US, hysterectomy is by far one of the most common procedures in women’s health and the most common in the non-pregnant women. [1] Traditionally this procedure is performed through 3 routes which include abdominal, vaginal and laparoscopic. The abdominal route is considered to be the most invasive while the vaginal route is the least invasive. The laparoscopic approach is considered minimally invasive and sort of in between those two ends of the spectrum.
Even though the vaginal route is considered the least invasive on the patients, still around 65-70% of hysterectomy procedures are performed via the abdominal route.[1] The decision on the route is multifaceted. It includes the anticipated complexity of the surgery, size of the uterus, presence of adhesions, vaginal exposure, concomitant procedures such as oophorectomy and the surgeon’s skill level. In addition, vaginal hysterectomy does not allow adequate inspection of the pelvis and abdomen.
It has been over 20 years since Reich performed the first laparoscopic hysterectomy. 2 Since then laparoscopic hysterectomy has undergone many changes and tools have been developed to assist with this procedure. This procedure has gained much attention and popularity. A trend toward higher rate of laparoscopic hysterectomy was observed in the 1990s with an increase from 0.3% to 9.9% and a drop in abdominal hysterectomy rates from 73.6% to 63.0% over a period of 7 years.[1] Vaginal hysterectomy remained stable at around 23-24%. Some of the reasons behind the added interest in the laparoscopic approach include the ability to survey the pelvis and easy access to the infundibulo-pelvic ligaments as compared to the vaginal route, and the potential for benefits of a minimally invasive procedure as compared to the abdominal route. Especially considering that the ovaries are concomitantly removed in 73% of these procedures. [3] When compared to abdominal hysterectomy, the laparoscopic route results in a shorter hospital stay, less abdominal wound morbidity, quicker return to normal daily activity and decreased blood loss, however at the cost of increased surgical time and urinary tract injuries. [4, 5] Similar to Vaginal hysterectomy, this procedure is highly dependent on the skill and experience of the surgeon.
The straight laparoscopic hysterectomy is limited by the 2-dimensional view and four degrees of freedom and the most significant recent addition to the laparoscopic armamentarium is the robotic assistance. The Da Vinci Robotic System has three main components: the robotic cart (actual robot with arms), the operating console (which contains the surgeon’s hand controls and foot pedals) and the endoscopic stack (or tower). With multiple arms, seven degrees of freedom and 3-dimension high definition magnified image inside the peritoneal cavity, the potential is there to complete the most daunting procedure with ease and precision. The robot will also automatically filter out any tremors in the hand of the surgeon and scale the movements to a smooth single motion. The lack of tactile feedback which the surgeon would have otherwise obtained from the laparoscopic instruments is replaced by visual feedback. Finally the surgeon is seated in an ergonomically comfortable console which makes the prolonged cases more tolerable.
Robot assisted laparoscopic hysterectomy (RALH) has been shown to be safe and effective. [6-11] A recent study by Payne et al comparing straight laparoscopic hysterectomy to RALH, noted that the robotic cohort was associated with significantly less blood loss, decreased hospital stay, but longer operative time. The intra-operative conversion rate to abdominal route from laparoscopic dropped from 9% to 4% when the robot assistance was introduced and there were no post-operative exploratory laparatomy in the robotic cohort as compared to 11% in the straight laparoscopic. [12] In another similar study by Sakhel et al, RALH was associated with less total operative room time, less blood loss and no conversion to laparatomy as compared to 11% conversion rate with straight laparoscopic hysterectomy. [13]
As with any procedure, the preoperative preparations are of utmost importance and can help make it a success. Some form of mechanical bowel preparation should be used the day before surgery while the patient is on clear liquid diet. Even though strong data to support the practice of mechanical bowel preparation does not exist, [14] we believe this helps to deflate the bowels for visualization and also decrease the risk of contamination should the bowel be injured accidentally. On the other hand, it may be advisable to discuss this with the team who would be performing any bowel repair should you encounter bowel injury.
The patients should also be instructed to refrain from taking anything by mouth past midnight. All patients should be screened for blood thinners and medical conditions that require further workup and management. The need for pneumo-peritoneum and steep Trendelenburg may make some patients poor candidates for laparoscopic procedures. In the preoperative holding area the patients are given antibiotic prophylaxis (2 grams of cefazolin intravenously) and some form of an anti-emetic regimen especially if the patient is to be discharged the same day.
After general endotracheal anesthesia is induced, the patient is positioned in the dorsal lithotomy position with the buttock just off the table. The patient must be securely positioned on the OR table with the use of shoulder braces, chest straps, underbody foam “egg-crate” mattress or a combination of those. It is advisable to use stirrups that allow for leg repositioning as this will facilitate adequate visualization of the cervix for the insertion of the uterine manipulator. The arms are padded and tucked in on the side of the patient in the neutral position with the thumb pointing up. Some form of protection of the face may be utilized and this can be in the form of a foam or gel pad. An Oro-gastric tube may be inserted to deflate the stomach especially if a left upper quadrant trocar insertion is contemplated.
The patient may be placed in some Trendelenburg and the legs may be elevated with the use of the stirrups. An examination under anesthesia is performed to estimate the size and position of the uterus. A speculum is inserted, the cervix is held using a single tooth tenaculum and the uterus is sounded. If the cervix is to be excised with the uterus then a uterine manipulator is a must for successful colpotomy and completion of the surgery. Currently there are 3 commonly used uterine manipulators which have a colpotomy ring. They are the Vcare Uterine Manipulator (ConMed Corporation, Utica, N.Y.), the Rumi and the Zumi Uterine Manipulators (Cooper Surgical, Trumbull, CT) with a Koh ring and balloon pneumo-occluder attached. The uterine manipulator of choice is inserted into the uterus and the uterine balloon is insufflated. The single tooth tenaculum is removed. The colpotomy ring is placed ensuring that is fits well all around the cervix by a sweep of the index and middle fingers (Fig. 1). The speculum is removed. A Foley catheter is then inserted into the bladder.
Uterine Manipulator (Courtesy of Intuitive Surgical)
At this point the Trendelenburg is reversed, the patient is placed in the neutral position and the legs are put down. A pneumo-peritoneum is secured in the usual manner. This can be achieved with a Veress needle, direct umbilical trocar insertion or left upper quadrant trocar insertion. Alternatively an open technique with a Hasson trocar may be used. We prefer the direct insertion with a bladeless trocar that allows visualization of the tip. The first trocar to be inserted is the umbilical trocar. This is a 12mm bladeless to be used for the camera arm and may be placed higher in the midline abdomen to ensure a distance of 10 cm from the fundus of the uterus. The patient is then placed in maximal Trendelenburg. This is a must for procedures that involve the pelvis as this will allow the bowels to migrate into the abdomen for visualization. This should not increase the risk of the patient sliding back down the OR table nor affect oxygenation even in the morbidly obese, if the patient is securely positioned. The left and right 8mm robotic arm trocars are placed 10cm lateral and 3cm inferior to the umbilical trocar under direct laparoscopic visualization. This ensures an arc across the fundus of the uterus. If the 4th arm is needed, it is placed 10cm lateral and 3cm inferior to the left robotic trocar. A 10-12mm bladeless surgeon’s assistant trocar is placed about 5-7cm superior and midway between the umbilical trocar and the right or left upper robotic trocar (Fig. 2). The robot is then docked (Fig. 3).
Port Placement (Courtesy of Intuitive Surgical)
Da Vinci Robotic System docked (Courtesy of Intuitive Surgical)
After the docking of the robot is completed, the surgeon may then leave the sterile field and move over to the surgeon console. The surgeon’s assistant will then insert the camera and Endowrist instruments of choice into the robotic ports. This is performed under direct vision of the trocar by the robotic camera. Our preferred instruments include the monopolar Hot Shears on the right, the fenestrated bipolar on the left and if the 4th arm is needed a Cobra Grasper or a Tenaculum is inserted. A common variation to this set up is to use the PK Dissecting Forceps in place of the bipolar fenestrated while that is used for retraction.
The hysterectomy described is the AAGL type IVE which is defined as a totally laparoscopic removal of the uterus and cervix including vaginal cuff closure. [15]
\tStep 1. Survey of the Pelvis
A comprehensive survey of the pelvic and lower abdominal structures is performed. The ureters and identified on either side.
\tStep 2. Opening of the broad ligament.
The round ligament is identified, cauterized using the fenestrated bipolar and cut using the monopolar Hot shears. The anterior leaf of the broad ligament is then incised towards the bladder and the vesicouterine reflection (bladder flap) is started. The surgical assistant will either be retracting from above with a tenaculum or using the suction irrigation to provide adequate exposure and removing excess surgical smoke (Fig. 4).
\tStep 3. The ovaries
If the ovaries are to be removed, the infundibulopelvic ligament is then cauterized with bipolar and cut with shears ensuring the safety of the ureter. If the ovaries are to be conserved then the utero-ovarian ligament is cauterized and cut (Fig.5).
\tStep 4. The contra lateral side
In a similar fashion the contra lateral side is secured.
\tStep 5. The Vesico-uterine reflection
At this point a 30º down camera may be used for adequate visualization anteriorly especially if the uterus is enlarged. The anterior leaf of the broad ligament is completely incised creating the vesicouterine reflection anteriorly. The vesicouterine reflection is tented up using the fenestrated bipolar and the bladder is gently dissected off the uterus and cervix using mostly sharp dissection with the shears. This will ensure adequate visualization of the colpotomy ring (Fig. 6).
A few common variations to the above noted steps include starting with the Infundibulopelvic or Utero-ovarian ligament and working caudal toward the round ligament. This ensures adequate visualization of the broad ligament. In addition, other vessel occluding devices may be inserted from the surgeon assistant port for securing pedicles.
\tStep 6. Uterine Vessels
Once the vesico-uterine reflection is completed, the uterine arteries can be skeletonized adequately. This will ensure that the ureters are sufficiently lateral and out of harms way. The uterine arteries can then be coagulated using the bipolar and cut with the shears. It is advisable to begin coagulation at the ascending branch of the uterine artery and move caudal along the cardinal ligaments (Fig. 7).
\tStep 7. Colpotomy
The colpotomy is performed using the monopolar Hot Shears and taken all around. At one point the uterine manipulator will no longer suffice for retraction as the colpotomy progresses. At that point either the 4th arm or the surgeon assistant may grasp the uterus and provide tension for completion of the colpotomy. The specimen can be pulled through the incision if it is small enough to pass through vaginal cuff or it can be divided or morcellated first. The uterus can serve as a pneumo-occluder in the vagina or the balloon occluder can be replaced into the vagina (Fig. 8).
\tStep 8. Vaginal cuff closure
Irrigation is performed and any significant bleeding is controlled. Minimal oozing from the vaginal cuff can be controlled with the closure. Excessive cautery should be avoided at the vaginal cuff as this may predispose the patient to cuff dehiscence. The bipolar fenestrated and shears are replaced with needle holders. The vaginal cuff can then be closed with interrupted figure of eight stitches using 2-0 Vicryl incorporating the uterosacral ligaments. The needle is passed in and out of the abdomen by the surgeon assistant. Alternatively, the vaginal cuff can be closed with a running stitch and the use of Lapra-ty clips (Ethicon Endosurgery, Cincinnati, OH) (Fig. 9, 10).
\tStep 9. Repair of the trocar sites
Once the vaginal cuff repair is completed, the pelvis is irrigated and inspected for hemostasis. The instruments are then removed under vision, the robot is undocked, the trocars are removed and the abdomen is deflated. The sites of the trocars are repaired in the usual manner as per the surgeon’s preference. The rate of bowel herniation at the 12mm bladeless trocar sites has been reported to be 0.7% [16] and therefore we prefer to re-approximate the fascia of those sites separately using the Carter-Thomason Closure system XL (Inlet Medical, Eden Prairie, Minnesota) or the EndoClose (Tyco International, Inc. Norwalk, CT).
\tStep 10. Cystoscopy
While the repair of the skin incisions is being performed, the patient is given indigo carmine intravenously. Cystoscopy is then performed to ensure patency of the uteters and the integrity of the bladder. The rate of bladder and ureteral injury during laparoscopic has been reported to be 2.9% and 1.7% respectively. [17] Only one fourth of injuries to the urinary tract are detected by visual inspection. For this purpose a 30 or 70 scope can be used with saline for distention medium.
Securing the round ligament
Securing the infundibulo-pelvic ligament.
Opening the broad ligament and developing the vesico-uterine reflection.
Securing the ascending branch of the uterine artery
Performing the colpotomy (green).
Vaginal cuff closure.
Completion of the procedure with the vaginal cuff closed.
Postoperatively the patient may be placed on a diet of her choice and this can be started immediately after surgery. The Foley catheter may be removed immediately especially if the patient is to be discharged. Even though abdominal trocar wound site infections are rare the patients are advised to keep them clean. The rate of vaginal cuff evisceration is 2.9% for RALH. [18] For this reason we recommend that they refrain from vaginal intercourse for 6-8 weeks. We have found that patients can be discharged the day of the procedure if she is noted to be stable 4-6 hours later or early the next day.
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When deciding the most effective non-pharmacological technique, take into consideration the patient’s age, developmental level, medical history and prior experiences, current degree of pain and/or anticipated pain. The advantage of non-pharmacological treatments is that they are relatively inexpensive and safe.",book:{id:"7289",slug:"pain-management-in-special-circumstances",title:"Pain Management in Special Circumstances",fullTitle:"Pain Management in Special Circumstances"},signatures:"Ahmed El Geziry, Yasser Toble, Fathi Al Kadhi, Muhammad Pervaiz\nand Mohammad Al Nobani",authors:null},{id:"63463",title:"Clinical Classification of Cerebral Palsy",slug:"clinical-classification-of-cerebral-palsy",totalDownloads:2575,totalCrossrefCites:1,totalDimensionsCites:2,abstract:"The classification of cerebral palsy (CP) remains a challenge; hence the presence of so many classifications and a lack of consensus. Each classification used alone is incomplete. 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A viral disease can be defined as an infectious disease that has recently appeared within a population or exists in nature with the rapid expansion of incident or geographic range. 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The combination of electronics and computer science with biology and medicine has improved patient diagnosis, reduced rehabilitation time, and helped to facilitate a better quality of life. Nowadays, all medical imaging devices, medical instruments, or new laboratory techniques result from the cooperation of specialists in various fields. The series of Biomedical Engineering books covers such areas of knowledge as chemistry, physics, electronics, medicine, and biology. 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The applications of this research cover many related fields, such as biotechnology and medicine, where, for example, Bioinformatics contributes to faster drug design, DNA analysis in forensics, and DNA sequence analysis in the field of personalized medicine. Personalized medicine is a type of medical care in which treatment is customized individually for each patient. Personalized medicine enables more effective therapy, reduces the costs of therapy and clinical trials, and also minimizes the risk of side effects. Nevertheless, advances in personalized medicine would not have been possible without bioinformatics, which can analyze the human genome and other vast amounts of biomedical data, especially in genetics. The rapid growth of information technology enabled the development of new tools to decode human genomes, large-scale studies of genetic variations and medical informatics. 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