O primeiro desses, o título da história, "Strange Highways" aparece pela primeira vez aqui. É um dos meus empreendimentos rara na ficção sobrenatural: Finalmente romance, a lista de contos sobrenaturais no meu currículo inclui apenas Darkfall, The Funhouse, The Mask, Hideaway, e talvez Os Servos de Twilight. Embora, como um leitor Adoro essas histórias, eu tendo a não Cialis masculino escrever sobre vampiros, lobisomens, casas mal-assombradas, ou animais de estimação casa que morrer e depois voltar a partir do outro lado com uma determinação maníaca de vingança por ter sido forçado a comer fora de um bacia no chão todos os anos em vez de na mesa com o resto da família. "Strange Highways", foi uma idéia que eu não poderia agitar, no entanto, e eu tenho que admitir que um certo poder inerente histórias do sobrenatural torna divertido óptimo para escrever.
A peça romance de comprimento outras incluído aqui é Chase. Uma versão desta história foi publicada pela Random House, sob o pseudônimo de KR Dwyer, quando eu era apenas um filhote. Como Dwyer, eu também escreveu Shattered, que foi disponibilizado sob meu nome cialis genérico verdadeiro por anos. Quando releio Chase para possível inclusão nesta coleção, eu corou e gemia sem parar porque tinha iniciante escrito tudo sobre ele, também sinuoso "e desleixado, embora tenha sido bem comentado em muitos lugares no momento da publicação. O personagem de Ben Chase ainda me intrigou, no entanto, a história básica ainda tinha poder. Então, antes de embalar-lo e enviá-lo fora a Warner Books, eu revisei-o.
A revisão resultou no corte de pelo menos 25 por cento do texto original, a adição de novas cenas, e uma limpeza completa da prosa e do diálogo.
Como sempre acontece quando eu revisitar um trabalho desde o início da minha carreira, eu estava tentado a mudar toda a intenção da história, o estilo, os personagens, a trama e transformá-lo em uma peça que iria ler exatamente como se eu tivesse levitra onde comprar escrito hoje. Que não é o ponto de coleta de trabalhos anteriores, é claro, um livro como Strange Highways é suposto mostrar o alcance do autor de interesses e abordagens diferentes ao longo dos anos. Conseqüentemente, eu me contive.
Chase é suspense psicológico em linha reta, sem nenhum traço do sobrenatural, é também personagem driven, confiando quase inteiramente sobre o caráter de Benjamin Chase por seu efeito, então se ele não intriga você, eu estou em apuros. Um aviso: Esta é uma peça bastante escuro, e algumas das escolhas morais Ben Chase pode assustar você, leitor suave, embora eles são praticamente os únicos que ele poderia ter feito.
วันอาทิตย์ที่ 30 ตุลาคม พ.ศ. 2554
วันเสาร์ที่ 19 มีนาคม พ.ศ. 2554
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วันพฤหัสบดีที่ 10 มีนาคม พ.ศ. 2554
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However if you have symptoms your doctor may recommend medications or surgery depending on the severity of your condition. These drugs help prevent irregular heartbeats by making your heat beat more slowly and with less force which reduces your blood pressure. These medications &mdash warfarin (Coumadin) is commonly used &mdash prevent your blood from clotting. They can have dangerous side effects however and must be taken exactly as prescribed. Severe mitral valve regurgitation can eventually cause heart failure preventing it from effectively pumping blood.
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วันอาทิตย์ที่ 6 มีนาคม พ.ศ. 2554
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วันพุธที่ 26 มกราคม พ.ศ. 2554
Figure
A comparative analysis of the results in the first two groups can be assumed that the excess value of APACHE II score of 14 is responsible for at least 10%-ing mortality, but at the same time, the lack of classic symptoms of SIRS is not determinative in the choice of tactics. Perhaps there was an element of overdiagnosis, or to determine the half-open tactics of increasing importance given to the visual characteristics of the fluid, rather than the symptoms pointing to the generalization of the inflammatory process. Thus, from this group of patients could be treated effectively using semi-method. The presence of preoperative dysfunction of one of the systems at the most seemingly uncompromising - half-open method determines the death of a quarter of patients. On the other hand the presence of symptoms of SIRS can be observed before the operation and fibrinous and serous fluid. Therefore, to better forecast should have a value of resistance in negative symptoms and treatment efficacy in the first (how?) Days after the operation. Application landmark rehabilitation can be considered progressive method with purulent peritonitis due to many reasons, but that does not mean that the determination of indications for repeated operations do not need to fight.
Postoperative peritonitis leads to 47% mortality. The most important factor contributing to this figure is the late diagnosis. In the event of Poland after the planned operations average time to re-intervention was 28 hours, and after the operations brand viagra undertaken at the ER re-intervention was performed after an average of 150 hours. Preoperative patient's condition was not significantly different from patients whose treatment was half-closed manner. The main indications for repeated operations were: in 56% of the further development of common inflammation of the peritoneum (the inadequate evaluation of the reorganization of the abdominal cavity, the underestimation of the activity of microorganisms, inadequate drainage, etc.) and in 14% necrosis of the walls of the hollow body, a 21% failure of the anastomosis in 4 % otgranichenny peritonitis. The greatest diagnostic difficulties encountered by 3-4 days after the first operation, when uncomplicated RP is to be expected the effect of all previous therapeutic interventions. Treatment of patients in this group after repeated operations conducted mostly semi-open way. Significant importance in determining the indications for repeated operations is deontological factor.
Thus, these data suggest that the definition of indications and complications of diagnostic quality still presents considerable difficulties. To this end, one of the main problems in the treatment of peritonitis is a qualitative monitoring of the patient based on the well-established criteria for the severity of his condition, as well as development of algorithms for selection of tactical schemes. The presence of dysfunction of two or more organ systems is an opportunity for a semi-open way of managing patients with RP. Monoorgannaya dysfunction, pronounced by indicators such as respiratory rate, Glasgow Coma Scale, and mean arterial pressure in the presence of high activity of the microflora can define complicated postoperative course in the application of a half-closed technique. The undoubted effectiveness of bowel decompression and peritoneal-enteral lavage in purulent peritonitis promotes simplification of the indications for this method and makes giperdiagnosticheskie trends. Diagnosis of prolonged inflammation of the peritoneum, even on the basis of informative clinical data still presents considerable difficulties. In these cases, greater informational value to buy the tests for the maintenance of pro-inflammatory cytokines of peripheral blood, tumor markers, procalcitonin.
microadenomas
wrong interpretation
stable remission
placebo
metabolism
Postoperative peritonitis leads to 47% mortality. The most important factor contributing to this figure is the late diagnosis. In the event of Poland after the planned operations average time to re-intervention was 28 hours, and after the operations brand viagra undertaken at the ER re-intervention was performed after an average of 150 hours. Preoperative patient's condition was not significantly different from patients whose treatment was half-closed manner. The main indications for repeated operations were: in 56% of the further development of common inflammation of the peritoneum (the inadequate evaluation of the reorganization of the abdominal cavity, the underestimation of the activity of microorganisms, inadequate drainage, etc.) and in 14% necrosis of the walls of the hollow body, a 21% failure of the anastomosis in 4 % otgranichenny peritonitis. The greatest diagnostic difficulties encountered by 3-4 days after the first operation, when uncomplicated RP is to be expected the effect of all previous therapeutic interventions. Treatment of patients in this group after repeated operations conducted mostly semi-open way. Significant importance in determining the indications for repeated operations is deontological factor.
Thus, these data suggest that the definition of indications and complications of diagnostic quality still presents considerable difficulties. To this end, one of the main problems in the treatment of peritonitis is a qualitative monitoring of the patient based on the well-established criteria for the severity of his condition, as well as development of algorithms for selection of tactical schemes. The presence of dysfunction of two or more organ systems is an opportunity for a semi-open way of managing patients with RP. Monoorgannaya dysfunction, pronounced by indicators such as respiratory rate, Glasgow Coma Scale, and mean arterial pressure in the presence of high activity of the microflora can define complicated postoperative course in the application of a half-closed technique. The undoubted effectiveness of bowel decompression and peritoneal-enteral lavage in purulent peritonitis promotes simplification of the indications for this method and makes giperdiagnosticheskie trends. Diagnosis of prolonged inflammation of the peritoneum, even on the basis of informative clinical data still presents considerable difficulties. In these cases, greater informational value to buy the tests for the maintenance of pro-inflammatory cytokines of peripheral blood, tumor markers, procalcitonin.
microadenomas
wrong interpretation
stable remission
placebo
metabolism
วันพฤหัสบดีที่ 20 มกราคม พ.ศ. 2554
Weak zones
Diaphragmatic hernia (DH) 2% of all hernias. This disease occurs in 5-7% of patients with gastric complaints during a radiological investigation.
The first description of diaphragmatic hernia belongs to Ambroise Pare (1579). Under diaphragmatic hernia should be understood penetration of internal organs through a defect in the diaphragm from one cavity to another.
It should be recalled brand viagra online that the development of the diaphragm is due to the connection on both sides plevroperitonealnoy membrane, transverse septum and mezoezofagusa.
Disorders arising from complications of embryonic development, can lead to newborn partial or complete defect of the diaphragm. When violations occur before the formation of membrane aperture, then the hernia is not a hernia sac (correct to speak of eventration). At later stages of development, when it was formed membranous diaphragm and only generic viagra delayed the development of muscle, a muscle containing no penetration occurs hernial hernial sac, consisting of two serous films.
Site of entry sternocostal hernias (sternokostalnyh) is devoid of muscle area connection with the sternum and ribs. This place is known as the triangle sternokostalnogo Larrea, and such hernias are known as the triangle hernia Larrea. In the absence of serous cover a hole sternokostalnoe Morgan.
In connection with the anatomical location of the front and back muscles within the lumbar costal triangle Bochdalek in this place might hernial protrusion.
Classification of diaphragmatic hernia in Petrovsky:
I. Traumatic hernia:
* True;
* False.
II. Nontraumatic:
* False congenital hernia;
* True hernia weak zones diaphragm;
* True hernia atypical localization;
* Hernia orifices Aperture:
a) the esophageal opening;
b) rare hernia orifices diaphragm.
Traumatic hernia due to injuries mostly false, indoor injuries - true and false.
When only non-traumatic hernia false hernia is congenital - a defect the diaphragm, spina between the thoracic and abdominal cavities.
Of the weak zones diaphragm - a hernia zone generic levitra sternocostal triangle (the gap Bogdaleka). Thorax in these areas is separated from the abdominal cavity of a thin plate of connective tissue between the pleura and peritoneum.
Underdeveloped area of the chest diaphragm - retrosternal hernia
Rare (extreme) hernia gap sympathetic nerve, vena cava, the aorta. In frequency in the first place - hiatal hernia (HH), they constitute 98% of all non-traumatic diaphragmatic hernia of origin.
Hiatal hernia
Anatomical features. The esophagus passes from the chest cavity through the abdominal hiatus oesophagcus, formed from the muscles that make up the diaphragm. Muscle fibers, which form the right and left legs of the diaphragm, formed as the front loop, which in most cases is derived from the right leg. Behind the legs of the diaphragm of the esophagus are not connected intimately, forming a V-shaped defect. In normal esophageal opening is wide enough diameter, at approximately 2.6 cm through which food passes freely. The esophagus goes through the hole obliquely, above the hole he is in front of the aorta below the holes left her somewhat. Described 11 different anatomical muscles in the esophageal opening. In 50% of the oesophageal hiatus is formed from the right crus of diaphragm, 40% are the inclusion of muscle fibers of the left leg. Both diaphragmatic legs start at the lateral surfaces of I-IV of the lumbar vertebrae. Oesophageal ring slightly decreases during inspiration, resulting in increased bending of the esophagus in the esophageal opening. Abdominal segment of the esophagus is small, its length is variable, averaging about 2 cm esophagus enters the stomach at an acute angle. The bottom of the stomach is located above and left of the esophageal-gastric connection, occupying almost all the space under the left dome of the diaphragm. Acute angle between the left edge of the abdominal esophagus and the medial edge of the bottom of the stomach is called the angle of branch block. Folds of mucous membrane of the esophagus, descending into the lumen of the stomach from the top angle (valve Gubareva), play a role of an additional valve. With the rise of pressure in the stomach, especially in the area of its bottom, the left half of the semiring of esophageal-gastric connection shifts to the right, overlapping with the entrance into the esophagus. Fore-stomach at the junction of the esophagus is a narrow ring about 1 cm in diameter. The structure of this department is very similar to the structure of the pyloric stomach. Submucosa is loose, parietal and chief cells are absent. The eye can see the connection of esophageal mucosa to gastric mucosa. The junction is located near the mucosal anastomosis, but not necessarily be consistent with it.
conduct group
no significant effect
daily diet
a peck of salt
The first description of diaphragmatic hernia belongs to Ambroise Pare (1579). Under diaphragmatic hernia should be understood penetration of internal organs through a defect in the diaphragm from one cavity to another.
It should be recalled brand viagra online that the development of the diaphragm is due to the connection on both sides plevroperitonealnoy membrane, transverse septum and mezoezofagusa.
Disorders arising from complications of embryonic development, can lead to newborn partial or complete defect of the diaphragm. When violations occur before the formation of membrane aperture, then the hernia is not a hernia sac (correct to speak of eventration). At later stages of development, when it was formed membranous diaphragm and only generic viagra delayed the development of muscle, a muscle containing no penetration occurs hernial hernial sac, consisting of two serous films.
Site of entry sternocostal hernias (sternokostalnyh) is devoid of muscle area connection with the sternum and ribs. This place is known as the triangle sternokostalnogo Larrea, and such hernias are known as the triangle hernia Larrea. In the absence of serous cover a hole sternokostalnoe Morgan.
In connection with the anatomical location of the front and back muscles within the lumbar costal triangle Bochdalek in this place might hernial protrusion.
Classification of diaphragmatic hernia in Petrovsky:
I. Traumatic hernia:
* True;
* False.
II. Nontraumatic:
* False congenital hernia;
* True hernia weak zones diaphragm;
* True hernia atypical localization;
* Hernia orifices Aperture:
a) the esophageal opening;
b) rare hernia orifices diaphragm.
Traumatic hernia due to injuries mostly false, indoor injuries - true and false.
When only non-traumatic hernia false hernia is congenital - a defect the diaphragm, spina between the thoracic and abdominal cavities.
Of the weak zones diaphragm - a hernia zone generic levitra sternocostal triangle (the gap Bogdaleka). Thorax in these areas is separated from the abdominal cavity of a thin plate of connective tissue between the pleura and peritoneum.
Underdeveloped area of the chest diaphragm - retrosternal hernia
Rare (extreme) hernia gap sympathetic nerve, vena cava, the aorta. In frequency in the first place - hiatal hernia (HH), they constitute 98% of all non-traumatic diaphragmatic hernia of origin.
Hiatal hernia
Anatomical features. The esophagus passes from the chest cavity through the abdominal hiatus oesophagcus, formed from the muscles that make up the diaphragm. Muscle fibers, which form the right and left legs of the diaphragm, formed as the front loop, which in most cases is derived from the right leg. Behind the legs of the diaphragm of the esophagus are not connected intimately, forming a V-shaped defect. In normal esophageal opening is wide enough diameter, at approximately 2.6 cm through which food passes freely. The esophagus goes through the hole obliquely, above the hole he is in front of the aorta below the holes left her somewhat. Described 11 different anatomical muscles in the esophageal opening. In 50% of the oesophageal hiatus is formed from the right crus of diaphragm, 40% are the inclusion of muscle fibers of the left leg. Both diaphragmatic legs start at the lateral surfaces of I-IV of the lumbar vertebrae. Oesophageal ring slightly decreases during inspiration, resulting in increased bending of the esophagus in the esophageal opening. Abdominal segment of the esophagus is small, its length is variable, averaging about 2 cm esophagus enters the stomach at an acute angle. The bottom of the stomach is located above and left of the esophageal-gastric connection, occupying almost all the space under the left dome of the diaphragm. Acute angle between the left edge of the abdominal esophagus and the medial edge of the bottom of the stomach is called the angle of branch block. Folds of mucous membrane of the esophagus, descending into the lumen of the stomach from the top angle (valve Gubareva), play a role of an additional valve. With the rise of pressure in the stomach, especially in the area of its bottom, the left half of the semiring of esophageal-gastric connection shifts to the right, overlapping with the entrance into the esophagus. Fore-stomach at the junction of the esophagus is a narrow ring about 1 cm in diameter. The structure of this department is very similar to the structure of the pyloric stomach. Submucosa is loose, parietal and chief cells are absent. The eye can see the connection of esophageal mucosa to gastric mucosa. The junction is located near the mucosal anastomosis, but not necessarily be consistent with it.
conduct group
no significant effect
daily diet
a peck of salt
วันอาทิตย์ที่ 9 มกราคม พ.ศ. 2554
Treatment inherent
Extracorporeal lithotripsy
Noninvasive method of crushing konkrementov gall bladder went into medical practice in 1985, the emergence of this method led to the doctors hope to the possibility of its widespread use that would allow many patients to avoid surgery. However, early observations showed that not every patient can recommend this treatment and not in all cases achieved positive results. To obtain the therapeutic effect required a rigorous selection of patients. Experience shows that the effectiveness of extracorporeal lithotripsy (EKLT) depends on the properties of concretions in the success of their fragmentation and elimination, as well as the functional state of the gallbladder, which determines the frequency of complications and side effects of the elimination period and early recurrence of stone formation.
The selection criteria for patients with brand viagra cholecystolithiasis (symptomatic and asymptomatic forms of the disease) for EKLT are: single and few (2-4) concretions, which occupy less than 1 / 2 volume of the gallbladder, the preservation of contractile-evacuation function of the gallbladder. Treatment success depends largely on the presence of concrements calcium salts and their degree of calcification. Good treatment results are achieved in patients with ehopronitsaemymi and ehoneplotnymi (not containing calcium salts), radiolucent concrements, an increase in their ehonepronitsaemosti and ehoplotnosti signs of radiopacity efficiency of crushing falls.
Contraindications EKLT are: multiple cholecystolithiasis, which occupies more than 1 / 2 volume of the gallbladder, calcified stones, decrease contractility-evacuation function of the gallbladder, and disabled gallbladder; concretions of bile ducts and biliary obstruction, the impossibility of enteral litolizisa after crushing concretions (gastroduodenal ulcer , allergy), pregnancy.
About rezultath lithotripsy judged by 3-18 months, when there is a release from the gall bladder stone fragments. To expedite the process of elimination and reduction of the size of fragments of patients prescribed oral litoliticheskuyu therapy. In the short and long periods of process of elimination of the fragments can produce complications in the form of attacks of biliary colic, acute cholecystitis, obstructive jaundice and acute pancreatitis. It should be noted that these complications are rare. With strict selection of patients with good outcomes (full exemption from the gall bladder concretions) occurs in 65-70% of patients. Unsatisfactory results EKLT when fragments do not come out of the gallbladder or, alternatively, increase in size, associated with either incorrect estimation of the function of the gallbladder or from the qualitative composition of the stones. After successful lithotripsy possible recurrence of stone formation, were observed in 20-23% of patients who underwent this procedure (most of them have lipid metabolism). Measure to prevent the recurrence of the disease in such patients is to conduct a corrective holesterinsnizhayuschey therapy.
Non-operational methods of treatment inherent in one drawback nepatogenetichnost therapy. Expect good outcomes when applied in the late period is not necessary, because if you can not work on all the links in the pathogenesis of the disease remains the gallbladder body, forming concretions. That is why surgical removal of the gall bladder is seen as a radical method of treatment of gallstone disease, relieving the patient of biliary colic and dangerous complications. Currently, hospitals use three ways to remove the gallbladder: laparoscopic, surgery of the minimal surgical approach and the standard laparotomy.
Laparoscopic cholecystectomy
Appearance in the medical practice of the method of laparoscopic cholecystectomy (LCE) was a new landmark in the development of surgery of cholelithiasis. For a little more than 10-year existence it has won wide recognition and has been further improved. Endoscopic method began to produce 70-80% of cholecystectomy.
By the indications for LCE include symptomatic uncomplicated gallstone disease, asymptomatic form of the disease and cholesterosis gallbladder. Improved technology in endoscopic surgery has allowed to expand indications for intervention in combined lesions of the bile ducts. Among the contraindications for this operation produce a dense inflammatory infiltrate in the Viagra an epidemic neck of the gallbladder and gepatoduodenalnoy ligament, pregnancy, deferred laparotomy, obesity, liver cirrhosis, intrahepatic location of the gallbladder, obstructive jaundice and acute pancreatitis. Some authors consider these contraindications, except for the first two, relative and at the same time stressed that the operation's success is largely determined by the level of training of surgeon and technical equipment of the operating room. However, these contraindications can not be underestimated, since in these situations there is a risk of intraoperative complications and, moreover, there is a need for conversion (transition to a laparotomy), which extends the operation time by 2-3 times.
LCE operation is usually carried out under general anesthesia, while ensuring that the deep relaxation of the abdominal wall. The main steps of endoscopic surgery are: the creation of pneumoperitoneum, the introduction of trocars and instruments, inspection of the abdominal cavity, the selection of the gall bladder adhesions, cystic duct and cystic artery with subsequent clipping and intersection, the selection of the gallbladder from liver bed and removed from the abdominal cavity (sometimes with the use of container) and installation of the control of drainage in podpechenochnom space. For the introduction of trocars into the abdominal cavity produce arcuate incision length 1,5-2 cm above or below the navel and three cut length of 56 mm in the right upper quadrant.
Some patients
diabetes prevention
Statement
Noninvasive method of crushing konkrementov gall bladder went into medical practice in 1985, the emergence of this method led to the doctors hope to the possibility of its widespread use that would allow many patients to avoid surgery. However, early observations showed that not every patient can recommend this treatment and not in all cases achieved positive results. To obtain the therapeutic effect required a rigorous selection of patients. Experience shows that the effectiveness of extracorporeal lithotripsy (EKLT) depends on the properties of concretions in the success of their fragmentation and elimination, as well as the functional state of the gallbladder, which determines the frequency of complications and side effects of the elimination period and early recurrence of stone formation.
The selection criteria for patients with brand viagra cholecystolithiasis (symptomatic and asymptomatic forms of the disease) for EKLT are: single and few (2-4) concretions, which occupy less than 1 / 2 volume of the gallbladder, the preservation of contractile-evacuation function of the gallbladder. Treatment success depends largely on the presence of concrements calcium salts and their degree of calcification. Good treatment results are achieved in patients with ehopronitsaemymi and ehoneplotnymi (not containing calcium salts), radiolucent concrements, an increase in their ehonepronitsaemosti and ehoplotnosti signs of radiopacity efficiency of crushing falls.
Contraindications EKLT are: multiple cholecystolithiasis, which occupies more than 1 / 2 volume of the gallbladder, calcified stones, decrease contractility-evacuation function of the gallbladder, and disabled gallbladder; concretions of bile ducts and biliary obstruction, the impossibility of enteral litolizisa after crushing concretions (gastroduodenal ulcer , allergy), pregnancy.
About rezultath lithotripsy judged by 3-18 months, when there is a release from the gall bladder stone fragments. To expedite the process of elimination and reduction of the size of fragments of patients prescribed oral litoliticheskuyu therapy. In the short and long periods of process of elimination of the fragments can produce complications in the form of attacks of biliary colic, acute cholecystitis, obstructive jaundice and acute pancreatitis. It should be noted that these complications are rare. With strict selection of patients with good outcomes (full exemption from the gall bladder concretions) occurs in 65-70% of patients. Unsatisfactory results EKLT when fragments do not come out of the gallbladder or, alternatively, increase in size, associated with either incorrect estimation of the function of the gallbladder or from the qualitative composition of the stones. After successful lithotripsy possible recurrence of stone formation, were observed in 20-23% of patients who underwent this procedure (most of them have lipid metabolism). Measure to prevent the recurrence of the disease in such patients is to conduct a corrective holesterinsnizhayuschey therapy.
Non-operational methods of treatment inherent in one drawback nepatogenetichnost therapy. Expect good outcomes when applied in the late period is not necessary, because if you can not work on all the links in the pathogenesis of the disease remains the gallbladder body, forming concretions. That is why surgical removal of the gall bladder is seen as a radical method of treatment of gallstone disease, relieving the patient of biliary colic and dangerous complications. Currently, hospitals use three ways to remove the gallbladder: laparoscopic, surgery of the minimal surgical approach and the standard laparotomy.
Laparoscopic cholecystectomy
Appearance in the medical practice of the method of laparoscopic cholecystectomy (LCE) was a new landmark in the development of surgery of cholelithiasis. For a little more than 10-year existence it has won wide recognition and has been further improved. Endoscopic method began to produce 70-80% of cholecystectomy.
By the indications for LCE include symptomatic uncomplicated gallstone disease, asymptomatic form of the disease and cholesterosis gallbladder. Improved technology in endoscopic surgery has allowed to expand indications for intervention in combined lesions of the bile ducts. Among the contraindications for this operation produce a dense inflammatory infiltrate in the Viagra an epidemic neck of the gallbladder and gepatoduodenalnoy ligament, pregnancy, deferred laparotomy, obesity, liver cirrhosis, intrahepatic location of the gallbladder, obstructive jaundice and acute pancreatitis. Some authors consider these contraindications, except for the first two, relative and at the same time stressed that the operation's success is largely determined by the level of training of surgeon and technical equipment of the operating room. However, these contraindications can not be underestimated, since in these situations there is a risk of intraoperative complications and, moreover, there is a need for conversion (transition to a laparotomy), which extends the operation time by 2-3 times.
LCE operation is usually carried out under general anesthesia, while ensuring that the deep relaxation of the abdominal wall. The main steps of endoscopic surgery are: the creation of pneumoperitoneum, the introduction of trocars and instruments, inspection of the abdominal cavity, the selection of the gall bladder adhesions, cystic duct and cystic artery with subsequent clipping and intersection, the selection of the gallbladder from liver bed and removed from the abdominal cavity (sometimes with the use of container) and installation of the control of drainage in podpechenochnom space. For the introduction of trocars into the abdominal cavity produce arcuate incision length 1,5-2 cm above or below the navel and three cut length of 56 mm in the right upper quadrant.
Some patients
diabetes prevention
Statement
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