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Health Scan: Looking through the surgical keyhole
By JUDY SIEGEL-ITZKOVICH
02/04/2012
Study could help develop better surgical training techniques for laparoscopy, a minimally invasive operation.
Keyhole surgery – laparoscopy – requires a surgeon with a high level of eye-hand coordination, motor skills, perception and sensitivity; older doctors tend to find it more difficult to perform than do younger ones who grew up with computer games that require the same skills.

Now Ben-Gurion University of the Negev researchers have discovered that novices’ sense of perception is substantially different from experts’ when it comes to laparoscopy. Their work could help develop better surgical training techniques in this type of minimally invasive operation.

In laparoscopy, the surgeon operates with elongated instruments through a small incision in the patient’s abdominal wall. Reduced blood loss, pain, complications and hospitalization time are just a few examples of the vast advantages of keyhole surgery over traditional open surgery.

However, when doctors perform surgical maneuvers through the laparoscope, they face various challenges due to the “fulcrum effect” of the mechanical constraint at the incision point – that is, because the doctors are not viewing the surgical site directly, but via a miniature camera, and because the device is balanced on the point of incision, it is difficult for the surgeons to assess the effect of their external movements on the surgical tools inside the patient. These challenges include inversion and scaling of movements and forces (similar to what happens when children use a seesaw at a playground).

Researchers have studied extensively how the fulcrum effect changes the motion of surgeons. But haptic perception – related to the sense of touch and including the sensation of forces as well as textures, humidity and temperature – through the laparoscopic device has not received as much attention.

The study is a collaboration among Dr. Ilana Nisky, a post-doctoral research fellow at Stanford University who received her three degrees from BGU; Dr. Felix Huang (Rehabilitation Institute of Chicago, RIC); Amit Milstein (BGU); Prof. Carla Pugh (Northwestern University); Prof. Sandro Mussa-Ivaldi (RIC); and Dr. Amir Karniel (BGU). It will be presented at the MMVR19/NextMed conference in California next month.

In the study, Nisky said, the team focused on forces and explored the effect of the fulcrum on the perception of tissue stiffness.

“To systematically study this effect, we connected a mechanical simulator – a box with a hole through which a mockup of a surgical instrument was inserted, to a robotic system that can apply forces as a function of its position,” Nisky explained. “The participants interacted with virtual tissues and were asked to compare between pairs of different tissues and say which felt stiffer. Based on their answers in different experimental conditions, we extracted the bias in perception due to the fulcrum,” Both novice BGU students and haptic experts from BGU’s computational motor control laboratory participated.

According to Nisky, the difficulties involved in scaling of movement and the reciprocal scaling of forces due to the fulcrum affected the novices’ perception of stiffness, and consequently their ability to operate. “Interestingly, the haptic experts were affected by this bias to a much smaller extent,” Nisky said. These findings could aid in the development of training techniques for future surgeons and could contribute to improving surgical outcomes.

INTERNET ADDICTION MAY AFFECT BRAIN
Internet addiction disorder (IAD) may be associated with abnormal white matter structure in the brain, as reported in the January 11 issue of the online journal PLoS ONE. These structural features may be linked to behavioral impairments and may also help study and treat the disorder. Addiction to the Internet can affect people of all ages. Previous studies of IAD have focused mostly on psychological questionnaires. A new study from the Chinese Academy of Sciences in Wuhan used magnetic resonance imaging (MRI) to investigate specific features of the brain in 18 teens suffering from the addiction. The researchers found that in IAD, white matter fibers connecting brain regions that are involved in emotional generation and processing, executive attention, decision-making and cognitive control are impaired. IAD may share psychological and neural mechanisms with other types of impulse control disorders and substance addiction, they said.

CHINESE MEDICINE FOR EASIER CONCEPTION?
Traditional Chinese medicine (TCM), which includes the use of herbal preparations and acupuncture, has long been used to ease pain, treat disease, boost fertility and prevent miscarriage. Now Tel Aviv University researchers say that a combination of TCM therapy and intrauterine insemination (IUI) is a winning solution for women having trouble conceiving.

In the first study that measures the effectiveness of both herbs and acupuncture in combination with IUI infertility treatment, Dr. Shahar Lev- Ari and Keren Sela of TAU’s Sackler Faculty of Medicine and the Tel Aviv Sourasky Medical Center say that the results, recently published in the Journal of Integrative Medicine, show a significant increase in fertility when the therapies are given side by side.

When combining IUI with TCM treatments, 65.5 percent of the test group was able to conceive, compared with 39.4% of the control group, which received no herbal or acupuncture therapy. The method is as “close to nature” as possible and can be used by women getting sperm donations or after a partner’s sperm is centrifuged to enhance its motility in the uterus.

Lev-Ari, a cellular biologist and head of the integrative medicine unit, works with both medical doctors and TCM practitioners at the Tel Aviv hospital’s fertility research institute.

He and Sela, a TCM practitioner specializing in women’s health, have long been wondering if Chinese herbal and acupuncture therapies could raise the success rates of Western- style fertility treatments.

In a retrospective study, Lev-Ari and Sela followed the progress of 29 women between the ages of 30 and 45 who were receiving IUI treatment combined with TCM therapy, and compared their results to a control group of 94 women between the ages of 28 and 46 who were undergoing IUI treatment alone. In addition to their IUI treatments, the 29 women in the first group received weekly sessions of acupuncture and a regime of Chinese medicines, which consisted of powdered or raw Chinese herbs such as PeoniaAlbae and Chuanxiong. All herbal preparations had Health Ministry approval.

In terms of both conception and take-home baby rates, the test group fared far better than the control group. Out of the 29 women in the test group, 65.5% conceived, and 41.4% delivered healthy babies. In the control group, only 39.4% conceived and 26.9% gave birth. The large gap in success rates is even more surprising when the age of the average participant was taken into account, Lev-Ari and Sela note. “The average age of the women in the study group was 39.4, while that of the control group was 37.1. Normally, the older the mother, the lower the pregnancy and delivery rates,” they explain.

According to the researchers, TCM is aimed at correcting imbalances in the body’s natural energy flow, promoting an overall sense of wellbeing.

There are several theories why Chinese medicine can be beneficial to fertility rates, including the possibility that herbal remedies and acupuncture can affect the ovulation and menstrual cycle, enhance blood flow to the uterus and enhance endorphin production and secretion to inhibit the central nervous system and induce calm – all of which can contribute to successful conception.

Now that the researchers have shown that TCM can have a major impact on the success of fertility treatments, they plan to design randomized clinical trials, including placebos, to further validate their findings.
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