U.S. patent application number 12/590105 was filed with the patent office on 2010-05-27 for methods and apparatus for image recognition and dictation.
Invention is credited to Leonard S. Schultz.
Application Number | 20100131532 12/590105 |
Document ID | / |
Family ID | 25333889 |
Filed Date | 2010-05-27 |
United States Patent
Application |
20100131532 |
Kind Code |
A1 |
Schultz; Leonard S. |
May 27, 2010 |
Methods and apparatus for image recognition and dictation
Abstract
The present invention relates to methods of and apparatus for
producing and digitizing a number of images to create a digital
library of images, providing an image from outside the digital
library, digitizing it and comparing it to the digital images in
the digital library, and providing a text descriptive of the image
from outside the digital library.
Inventors: |
Schultz; Leonard S.;
(Bloomington, MN) |
Correspondence
Address: |
David E. Bruhn;Dorsey & Whitney LLP
Suite 1500, 50 South Sixth Street
Minneapolis
MN
55402-1498
US
|
Family ID: |
25333889 |
Appl. No.: |
12/590105 |
Filed: |
November 2, 2009 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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10827558 |
Apr 19, 2004 |
7613336 |
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12590105 |
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PCT/US02/15545 |
May 16, 2002 |
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10827558 |
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09860728 |
May 18, 2001 |
6735329 |
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PCT/US02/15545 |
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Current U.S.
Class: |
707/758 ;
382/306; 707/E17.019 |
Current CPC
Class: |
G16H 30/40 20180101;
G06F 16/38 20190101; G16H 50/70 20180101; Y10S 128/923 20130101;
G06F 16/532 20190101; G16H 20/40 20180101 |
Class at
Publication: |
707/758 ;
382/306; 707/E17.019 |
International
Class: |
G06F 17/30 20060101
G06F017/30 |
Claims
1-4. (canceled)
5. A device for producing a text suitable for use in a record
concerning a surgical procedure, comprising: a library of digital
images drawn from surgical procedures; a microprocessor; a digital
image from outside said library; and a digital library of texts,
wherein the microprocessor is adapted to compare at least a portion
of the image from outside the library to the images in the library,
and wherein, based on the comparison, one of none, one or more
portions of one or more of said texts, and one or more of said
texts is selected for use in the record.
6. (canceled)
7. The device according to claim 5, wherein the image from outside
the library is a recorded image.
8. The device according to claim 5, wherein the image from outside
the library is a real-time image.
9-10. (canceled)
11. The apparatus according to claim 5, further comprising means
for communicating said images and texts.
12-37. (canceled)
38. The device according to claim 11, further comprising one or
more remote accesses.
39. The device according to claim 38, wherein said remote accesses
comprise an in-wall or wireless connector.
40-42. (canceled)
Description
BACKGROUND
[0001] The present invention relates to methods of and apparatus
for making a history or record, particularly, but not exclusively,
of medical treatments or procedures, and to methods of and
apparatus for using the history or record. More particularly, it
relates to producing and digitizing a number of images to create a
digital library of images, producing and providing a digital
library of texts corresponding to the images in the library of
images, providing an image from outside the digital library,
digitizing it and comparing it to the digital images in the digital
library, and selecting from the digital library of texts a text
which corresponds to the outside image, and using the selected text
to produce at least a portion of a record.
[0002] In many fields and technologies it is important to create
and maintain a record, or history or narrative, of situations,
facts, operations or procedures. Such records are important for
achieving repeatability and accuracy, for educational or evaluative
purposes, and/or for reconstructive purposes. For example, in
industrial production, they may be used to detect deviations from
specifications and production standards, and/or they may be used to
create a "standard operating procedure" ("SOP"). In the legal
field, transcripts or records of legal proceedings may be used to
revisit or review the propriety of proceedings and decisions. In
research or experimental science, laboratory notebooks or journals
may reflect and/or evidence results of chemical combinations or
hypothesis. In medicine, medical records and transcripts of
surgical procedures may be used for diagnosis, to determine
subsequent treatments, and/or to determine or assess prognoses. In
each of these examples, and in many other instances and fields,
records provide a database or library of knowledge, teach, instruct
or inform about past practices or products, and/or aid in the
detection and elimination of anomalies and inaccuracies.
[0003] Making and keeping a record has been, and is, a painstaking
process. Typically, it has involved an individual hand writing a
description or narrative, which may then be archived or preserved
for reference by the individual who created it, or others.
Developments in recording technologies, e.g., photography, sound
and voice recording and storage, digital storage of information,
etc., have somewhat eased the burden of creating a record, but
there is room for further improvement.
[0004] Turning to the field of medicine, in which the present
invention finds particular, but not exclusive, applicability,
medical records were typically produced by the care giver writing
by hand, for example, in a patient's chart. More recently, a care
giver or physician may speak into a sound recording machine, or
dictate, a description of a treatment or procedure. The recording
or "tape" is then transcribed by others into a written record or
chart. Also more recently, photographic records may be used. For
example, a surgical procedure may be filmed, and the film may be
accompanied by a verbal description dictated or spoken by the
surgeon or attending physician while the procedure is taking place.
Notwithstanding these advances, problems and inefficiencies
remain.
[0005] One problem stems from outsourcing dictated medical records,
even when such outsourcing is to organizations or people
specializing in the transcription of medical records. The dictated
item must be communicated to the transcriptionist, and back, and
physicians and care givers must review and edit the transcription,
leading to inefficiencies in time and handling, and increased
costs. Another problem is the time interval or delay between the
procedure and the availability of the transcript. This is true even
when a physician dictates during a procedure, which itself may
interfere with the concentration or performance of the physician.
Typically, current medical record procedures still require a
physician or surgeon to go to a workstation to dictate a
description of a procedure or treatment after it is completed, at
least to review a transcript, but in most instances, to dictate a
description as well.
[0006] There are some attempts to improve the efficiency of
producing medical records. For example, there are service
providers, e.g., Speech Machines, Inc. and MedQuist, Inc., which
specialize in transcribing dictated descriptions of medical
treatments. They may use voice or term recognition systems (e.g.,
Dragon System's "Naturally Speaking," IBM's "ViaVoice" and Lernout
& Hauspie's "VoiceXpress") wherein a vocal term or phrase is
recognized by a computer which then converts it into a
word-processing result. U.S. Pat. No. 6,031,526 discloses a system
wherein generating electronic and printed medical records provides
automatic integration of captured video still images and voice
dictated information concerning the image, and wherein a voice
recognition module allows the system to respond to voice commands
and automatically transcribe the dictated text into a word
processing document. Another, generally similar example of such
systems is that provided by cMore Medical Solutions, Inc. of
Minneapolis, Minn. Although efficiency of making a record may be
increased, there are still transmission and handling delays, even
when use is made of browser or internet-based systems.
[0007] One way to relieve physicians' dictation burden would be to
film or photograph a treatment or surgical procedure and use the
recorded images to trigger a descriptive text. Such a solution
would likely involve a computer or computers. U.S. Pat. No.
4,996,707 (O'Malley et al.) discloses a computer system having the
capability to receive and store graphic images which might be
useful in such a solution. The system includes software that can
digitize images, enabling them to be stored in memory and then
accessed and used for various purposes, including identification,
printing, or converting the digitized images to speech using a
"text-to-speech" module. There is no disclosure or suggestion of
digitizing a large number of images to create a digital library of
images, providing an image from outside the digital library,
digitizing it and comparing it to the digital images in the digital
library, and providing for the production of a descriptive text
associated with the image from outside the digital library.
[0008] Computers and storage and manipulation of data using
computers hold promise for improving medical record creation,
record keeping and use of stored medical records. For example, U.S.
Pat. No. 5,050,220 involves an optical fingerprint correlator
wherein a fingerprint is digitized, and then may be compared to a
database of fingerprints to try to find a match. Such a correlator
could be adapted to identify a patient, pull up the patient's
medical record, and compare a current or recent diagnostic image
(e.g., an MRI image) to the record. U.S. Pat. No. 5,031,228
discloses another image recognition system and method for
identifying a pattern in images, and U.S. Pat. No. 5,668,897
discloses a method and apparatus for imaging and image processing,
including digitizing an image and comparing the digitized image
against a codebook of stored digital images. None of these patents
discloses using an image to select or create a text describing an
image.
[0009] The use of microprocessors, computers and computer
management of data, including images, in the field of medicine is
reflected in U.S. Pat. Nos. 5,241,472; 5,261,404; 5,740,802;
5,951,571; 5,961,456 and 6,024,695, the disclosures of which
patents are incorporated herein by reference. Typically, the
systems and methods disclosed in these patents involve obtaining
images, digitizing the images and storing and/or manipulating or
using the images, e.g., in U.S. Pat. No. 5,241,472 to create a text
file. In U.S. Pat. No. 5,951,571 a computer is used to access a
data storage unit containing previously acquired and digitally
stored images of a patient. U.S. Pat. No. 5,961,456 is directed to
a system and method for using current actual images and computer
generated reference images, and the U.S. Pat. Nos. 5,261,404 and
6,024,695 patents use computer technologies to use images to
position or guide surgical procedures. The U.S. Pat. No. 5,740,802
patent involves interactive computer generated models obtained from
medical diagnostic imaging data to allow a surgeon to view internal
and external patient structures and their relation to adjust the
surgery accordingly. None of these patents discloses or suggests
the use of the disclosed technologies to facilitate dictation,
i.e., to help a physician create a medical record describing an
administered treatment or procedure by using an image drawn from
the treatment or procedure to trigger or select a text descriptive
of the image, wherein the text then becomes at least part of a
medical record.
[0010] U.S. Pat. Nos. 5,704,371 and 6,026,363 disclose a medical
history documentation system and method which may involve a
microprocessor to collect data and down load it to a computer which
may store and process the data to provide a patient history text.
There is no disclosure of using images to provoke the selection of
a text corresponding to the image, wherein the selected text may
become the record, or portion of the record, of a medical treatment
or surgical procedure.
[0011] Notwithstanding the advances represented by the above
mentioned technology and patents, it would be advantageous if there
were a method and apparatus for more efficiently and accurately
making a history or record, particularly, but not exclusively, a
medical record.
SUMMARY
[0012] In one embodiment, the present invention provides methods
and apparatus for making a history or record, particularly, but not
exclusively, of a medical treatment or surgical procedure.
[0013] In one embodiment, the present invention relates to
producing and digitizing a number of images to create a digital
library of images, providing an image from outside the digital
library, digitizing it and comparing it to the digital images in
the digital library, and producing a text associated with the image
from outside the digital library.
[0014] In one embodiment, the present invention comprises a visual
input device, a processor, a visual output device, and a
transmission system linking the input device, the processor and the
output device.
[0015] In one embodiment, the present invention relates to the
capture, recognition and manipulation of data.
[0016] In one embodiment, the present invention relates to the
capture, recognition and manipulation of data, particularly data
concerning medical treatment, wherein the treatment may be broken
down into a series of steps, and wherein each step may be described
by standard language understood by one skilled in the art. This
feature of the present invention is well-suited to use in surgical
procedures, wherein any one procedure may be accomplished in one of
usually several or so standard or routine ways, wherein any one
procedure may be broken down into steps or milestones, and wherein
any one procedure usually involves encountering the same or similar
physical structures.
[0017] An advantage of the present invention is that it facilitates
creating a record, particularly, but not exclusively, a medical
record.
[0018] In one embodiment, the present invention relates to
producing and digitizing a number of images, related to a medical
treatment, particularly a surgical procedure, to create a digital
library of images, providing an image from outside the digital
library, digitizing it and comparing it to the digital images in
the digital library, and producing a text associated with the image
from outside the digital library. In some embodiments, an image of
an unusual, atypical and/or anomalous medical condition or
situation may provoke, trigger or provide a "blank" text to be
filled in later by the treating person. An advantage is better
coordination of procedures and respective outcomes, as well as
improving the time it takes for comparative or analytical
information to become available. In some embodiments, the image
from outside the digital library may be a real time image.
[0019] A feature of the present invention is image recognition,
wherein a collection of images is available, each having an
associated descriptive text, and wherein an image not in the
collection is compared to images in the collection to find a
comparable or matching image, and associated text. The collection
of images may be created by accumulating images originally not in
the collection.
[0020] Another feature of the present invention is providing a
library of descriptions or texts, each associated, related to
and/or describing a structure, step or quality depicted or captured
as an image. In some embodiments, the structure, step or quality is
an aspect of a medical treatment or surgical procedure.
[0021] Another feature of the present invention is providing
coordination of procedures and outcomes, e.g., the outcome of a
medical treatment may be compared to outcomes of similar
procedures, anomalies or abnormalities may be compared and/or
identified, a record of a procedure may be available for
consideration more quickly, etc.
[0022] In one embodiment of the method and apparatus of the present
invention, a live or real-time image obtained during a surgical
procedure is compared to stored images of previous surgical
procedures to find a stored image similar or substantially
identical to the live image, whereupon a script or text describing
the live image is produced.
[0023] In some embodiments, the method of the present invention
involves creating a collection or library of images drawn from
surgical procedures, e.g., laparoscopic gallbladder procedures,
cholecystectomy, hernia procedures, etc., wherein the individual
images comprise pictorial representations of anatomy or structures
encountered and steps undertaken during the procedures. In some
embodiments, the collection of images may be sorted or indexed into
sets or groups, wherein a set or group may be comprised of any
number of generally similar images depicting a step or action which
is typically common to a selected procedure, e.g., a step in a
laparoscopic gallbladder procedure.
[0024] In one embodiment, the present invention encompasses
breaking a surgical procedure into a series of steps, capturing or
representing each step in an image, each image depicting the step
and structures and qualities associated with the step, digitizing
the images, and creating a text respectively descriptive of a step
and images of that step, wherein the text comprises standard
language understood by one skilled in the art, and may be selected,
without substantial change, to describe the similar step of another
generally similar surgical procedure, the text selection being
accomplished on the basis of comparing images from the generally
similar surgical procedure to the previously acquired images.
[0025] In one embodiment, the present invention relates to
producing a number of digital images to create a digital library of
images, providing an image from outside the digital library,
digitizing it (if it is not already digital) and comparing it to
the digital images in the digital library, and producing a text
associated with the image from outside the digital library, wherein
the digital images and text may be considered data and may be
analyzed and/or manipulated to provide likely or actual: diagnostic
outcome information; a classification or sort of procedures by
type; possible therapeutic, corrective or repair steps; and a
recommendation of optional, and/or the optimal, therapeutic,
corrective or repair steps. In one embodiment, the present
invention may provide for statistical analysis of subject
procedures and outcomes, for example, surgical procedures, whereby
the optimum or best step or action within a given procedure may be
identified.
[0026] In one embodiment of the present invention, data may be
accumulated, analyzed and reported.
[0027] In one embodiment, the present invention relates to methods
and apparatus for viewing and taking an image or picture of a
number of objects or situations, processing the images, including
digitizing and storing them and creating a text describing each of
them, viewing and taking another image or picture, processing the
another image, including digitizing and storing it, and selecting
one of the texts which corresponds to the another image.
[0028] An advantage of the present invention is the creation and
use of a world-wide network of procedural information, including,
but not limited to medical and/or surgical information, wherein the
information may be accessed by those engaged in similar procedures
and/or wherein the information may evolve, e.g., the data
comprising the information may increase, both in number and
sophistication.
[0029] Another advantage of the methods and apparatus of the
present invention is that they may be used to create an "early
warning" system wherein a real-time image is compared to a library
of images which includes images of anomalous, abnormal and/or
dangerous structures, situations and/or qualities and, if a
similarity is detected, a warning or alert is provided. In one
embodiment, the present invention takes advantage of the routine,
repetitive or common steps typical of a given procedure, for
example, a surgical procedure, to provide for the early warning
system, and/or to provide for a predictive and/or educational
system, wherein a accessible and/or searchable database comprising
a collection of images and texts to provided for consideration
before undertaking a procedure.
[0030] Other features and advantages of methods and apparatus of
the present invention will become more fully apparent and
understood with reference to the accompanying description, drawings
and claims.
BRIEF DESCRIPTION OF THE DRAWINGS
[0031] This patent and/or patent application file contains
photographs executed in color. Copies of this patent or patent
application publication with color photographs will be provided by
the Office upon request and payment of the necessary fee.
[0032] FIG. 1 comprises representative images exemplifying images
for use in embodiments of the present invention.
[0033] FIG. 2 comprises representative images exemplifying images
for use in embodiments of the present invention.
[0034] FIG. 3 comprises representative images exemplifying images
for use in embodiments of the present invention.
[0035] FIG. 4 comprises representative images exemplifying images
for use in embodiments of the present invention.
[0036] FIG. 5 comprises representative images exemplifying images
for use in embodiments of the present invention.
[0037] FIG. 6 comprises representative images exemplifying images
for use in embodiments of the present invention.
[0038] FIG. 7 comprises representative images exemplifying images
for use in embodiments of the present invention.
[0039] FIG. 8 comprises representative images exemplifying images
for use in embodiments of the present invention.
[0040] FIG. 9 comprises representative images exemplifying images
for use in embodiments of the present invention.
[0041] FIG. 10 comprises representative images exemplifying images
for use in embodiments of the present invention.
[0042] FIG. 11 comprises representative images exemplifying images
for use in embodiments of the present invention.
[0043] FIG. 12 comprises representative images exemplifying images
for use in embodiments of the present invention.
[0044] FIG. 13 comprises representative images exemplifying images
for use in embodiments of the present invention.
[0045] FIG. 14 depicts one embodiment of a computer or processing
system of the present invention.
[0046] FIG. 15 depicts an embodiment of the process or method of
the present invention.
[0047] FIG. 16 depicts another embodiment of the present
invention
[0048] FIG. 17 depicts another embodiment of the present
invention
DETAILED DESCRIPTION
[0049] The accompanying figures and this description depict and
describe embodiments of a process or method and apparatus in
accordance with the present invention, and features, steps and
components thereof. As used herein, the terms "medical treatment",
"surgery" and "surgical procedure" are intended to encompass any
medical care giver/patient interaction, including, but not limited
to office examinations, surgical procedures, physical therapy,
administration of medication, consults, diagnostic procedures, etc.
In some embodiments, the methods and apparatus of the present
invention may comprise integrated structures or features, such as a
network of microprocessors, communication links and the like, at
various locations, including a central station, and the steps may
be performed at various locations. Although electronic, e.g.,
digital, apparatus and methods are contemplated, the present
invention is also intended to encompass "hard copy," e.g., video
images, photographs, printed documents, including directories or
indices, and the like.
[0050] Unless specifically disclosed or taught, any suitable
electronic devices and coupling or linking methods and apparatus
may be used in the present invention, for example, the present
invention may incorporate appropriate microprocessors, integrated
circuits, chips, memory structures, wireless links, internet links,
telephony, optical fiber technology, data storage technology,
etc.
[0051] Any references to positional and/or temporal locations,
e.g., the location of microprocessors and/or the order of
processing or steps, are intended for convenience of description,
not to limit the present invention to any one positional or
temporal orientation.
[0052] Although the microprocessor or controller, or
microprocessors, for the present invention can be any controller or
microprocessor-based system, and more than one may be involved, in
one embodiment of the invention, the controller comprises a
suitable central processing unit and suitable peripheral devices.
In one embodiment, a suitable peripheral device may be a field
programmable micro-controller peripheral device that includes, like
the processing unit, programmable logic devices, EPROMs, and
input-output ports. Typically, instructions are stored in the
controller as program logic, which might be found as RAM or ROM
hardware in the processing unit or peripheral device. (Since the
processing unit may have some memory capacity, it is possible that
some of the instructions are stored in the processing unit.) As one
skilled in the art will recognize, various implementations of
program logic are possible. The program logic could be either
hardware, software, or a combination of both. Hardware
implementations might involve hardwired controller logic or
instructions stored in a ROM or RAM device. Software
implementations would involve instructions stored on a magnetic,
optical, or other media that can be accessed by the processing
unit. Communication implementations may be wired, optical or
wireless.
[0053] FIG. 14 depicts one embodiment of the processing system of
the present invention where an apparatus 100 is used to process the
images received from inputs 112 and generate text output also
depicted at block 112 and which may be stored in a text library. A
central processing unit or CPU 102 utilizes appropriate software to
operate the system. The image library 107 contains the images and
is stored in the memory 106. The image recognition device 108
compares a newly acquired image to the images in the library. Once
the image is recognized the computer will select the text
corresponding to the recognized image. The apparatus 100 can be
connected to appropriate interfaces 104 and/or to a remote computer
or interface 114 and/or other suitable remotes or peripherals
116.
[0054] The following examples reflect one embodiment of the present
invention wherein at least a portion of a dictation record
regarding a surgical procedure corresponds to an image captured
during that procedure and during other similar procedures. In other
words, each of the following examples of dictation records
concerning actual surgical procedures includes certain steps or
elements in common, and those elements or steps, and the entire
procedure, may be photographed during the procedures of the
examples. The examples are generally typical of such procedures
and, thus, the pictures of common elements or steps will be
generally typical. The pictures may be digitized using a suitable
method, and stored in a digital library. Pictures taken during
another (e.g., real time) procedure, not one of the examples, but
another similar procedure, may be digitized and compared to the
pictures in the digital library. Because the another procedure is
similar to the procedures already represented in the digital
library, pictures of steps from it will correspond or match closely
pictures of steps from the previous similar procedures. The
corresponding or matching picture(s) in the digital library may be
used to trigger a text descriptive of the picture(s) which will
also be descriptive of the step of the another (or real time)
procedure.
[0055] FIGS. 1-13, including FIGS. 1a-1e, 2a-2c, 3a-3d, 4a-4i,
5a-5f, 6a-6c, 7a-7g, and 8a-8b, 9a-9c, 10a-10i, 11a-11e, 12a-12e,
and 13a-13j, are actual images taken from the procedures of the
following Examples 1-6 (gallbladder) and Examples 1-4 (hernia) or
from generally similar procedures. Any surgical procedure,
including those of the examples, may be imagined as a film or
movie, i.e., a continuous series of images, and FIGS. 1-13 comprise
selected stills or individual images clipped or selected from the
film. Images identified as Figures corresponding to the steps of
the procedures of Examples 1-6 (gallbladder) and Examples 1-4
(hernia) have been referenced in the dictation text of those
examples. It should be appreciated that other and/or additional
common, routine and/or similar steps, dictation portions and images
may be identified. In the following examples, grammatical and
typographical errors from the original transcribed dictation record
have been corrected.
[0056] The following six examples are actual dictated records of
gallbladder procedures. It should be understood that an advantage
of the present invention derives from the fact that surgical
procedures are repetitive in terms of what is seen, and the words
used to describe what is seen. Indeed, routinization in procedures
is important to surgeons and patients because anatomy usually
conforms from patient to patient. Although a surgeon may slightly
vary steps and/or the order of steps in a procedure, and although
there may be some slight variations in the angle of vision, color,
etc., there will be steps and images which are substantially
similar from procedure to procedure. Again, the parenthetical
reference to a figure or figures following each step is to link the
step with various corresponding sample figures and are outlined by
bold lettering.
Example 1
Gallbladder
Operative Procedure: Laparoscopic Cholecystectomy,
Cholangiography.
Description of Procedure:
[0057] Introduction [0058] After satisfactory endotracheal
anesthesia was obtained the patient's abdomen was prepped and
draped in the usual fashion. A CO2 pneumoperitoneum was instilled
through a 10 mm trocar placed cephalad to the umbilicus at 4 liters
per minute of flow pressure equal to or less than 17 mmHg to a
total of 4.5 liters. A 45.degree. angle laparoscope was introduced.
Examination of the abdomen was unremarkable except for the
gallbladder which showed multiple adhesions. These were of a
chronic type. Under direct vision a 5 mm trocar was placed along
the right anterior axillary line. [0059] Step 1: Fundus of the
gallbladder was grasped. (FIGS. 1, 1a-1e) [0060] Step 2: A # 17
gauge pericardial needle was passed percutaneously into the
gallbladder. Then 30 cc of bile was aspirated and replaced with 60
cc of 50 percent Hypaque and two separate aliquots of 50 and 10 cc
each with x-rays taken at the conclusion of infusion of each
aliquot. After x-rays were taken and examined excess Hypaque was
aspirated and the needle removed under direct vision. (FIGS. 2,
2a-2c) [0061] Step 3: Two 5 mm and a 12 mm trocars were placed in
the right mid abdomen. The patient was placed in reversed
Trendelenburg's position. (FIGS. 3, 3a-3d) [0062] Step 4: The neck
of the gallbladder was grasped and dissected out from surrounding
tissue. The junction of the cystic duct, common duct, and common
hepatic duct was visualized. (FIGS. 4, 4a-4i) [0063] Step 5: The
cystic duct was dissected free, clipped proximally and distally,
divided. (FIGS. 5, 5a-5f) [0064] Step 6: The cystic artery was
electrocoagulated with bipolar cautery. (FIGS. 6, 6a-6c) [0065]
Step 7: The gallbladder was removed off the liver bed with bipolar
cautery in retrograde fashion. (FIGS. 7, 7a-7g) [0066] Step 8: The
gallbladder was led out of the abdomen through the 12 mm trocar.
(FIGS. 8, 8a-8b)
CONCLUSION
[0066] [0067] The abdomen was irrigated with saline and the
irrigant suctioned out. Trocars were removed. The deep tissue was
closed with interrupted #2 Vicryl to the fascia, continuous running
#4 Vicryl subcuticular to reapproximate the skin. Closure was
reinforced with Steri-Strips. Gauze bandage and paper tape with
dressings were applied. Blood loss was negligible. She left the
Operating Room in satisfactory condition. (End of Example 1)
Example 2
Gallbladder
Operative Procedure:
[0067] [0068] 1. Laparoscopic cholecystectomy with cholecyst
cholangiography. [0069] 2. Excision of chronic infected, nonhealing
cyst of the back with conversion from transverse to oblique
orientation using Z-plasty technique.
Description of Procedure:
[0070] Introduction [0071] After satisfactory endotracheal
anesthesia was obtained, the patient's abdomen was prepped and
draped in the usual fashion, after which CO2 pneumoperitoneum
instilled through a 10 mm Innerdyne trocar placed cephalad to the
umbilicus and 4 L/min flow, pressures equal to or less than 17 mm
Hg to a total of 5 L. A 45-degree angle laparoscope introduced.
Thorough examination of the abdomen revealed a right inguinal
hernia. Otherwise, there were a few adhesions to the gallbladder, a
few stones in the gallbladder of cholesterol origin, and at the
time of cholangiography, one was able to see a normal anatomical
pattern. No defects in the common duct with dye entering freely
into the duodenum. Under direct vision, a 5 mm trocar placed along
the right anterior axillary line. [0072] Step 1: Bi-toothed biopsy
forceps used to grab the fundus of the gallbladder for upward
retraction. (FIGS. 1, 1a-1e) [0073] Step 2: A 17 gauge pericardial
needle passed percutaneously into the gallbladder, excess bile
aspirated, replaced with 60 cc of 50% Hypaque, delivered in two
aliquots of 50 and 10 cc each. At the end of infusion of each
aliquot, x-rays were taken. These were examined. Findings as listed
above. Excess dye was then aspirated, the needle removed. (FIGS. 2,
2a-2c) [0074] Step 3: Additional 5 mm and 12 mm trocar placed in
the right mid abdomen. Patient placed in reversed Trendelenburg
position. (FIGS. 3, 3a-3d) [0075] Step 4: The neck of the
gallbladder was elevated, the cystic duct dissected from the
gallbladder to junction with the common bile duct, cystic artery
identified along with the lymph node of Calot. (FIGS. 4, 4a-4i)
[0076] Step 5: The cystic duct was clipped.times.3 proximally,
distally, the cystic duct divided. (FIGS. 5, 5a-5f) [0077] Step 7:
The gallbladder dissected off the liver bed with bipolar cautery.
(FIGS. 7, 7a-7g) [0078] Step 6: The cystic artery was
electrocoagulated with bipolar cautery. (FIGS. 6, 6a-6c) [0079]
Step 8: The gallbladder was then delivered out of the abdomen
through the leading edge of the 12 mm trocar. (FIGS. 8, 8a-8b)
CONCLUSION
[0079] [0080] The stones were removed before the entire gallbladder
could be removed from the abdominal cavity. Once done, the 12 mm
trocar was replaced, the right upper quadrant irrigated with saline
until clear. No bile or blood was noted. Irrigant suctioned out
along the right lateral sulcus of the liver. Instruments removed,
CO2 let out through open valves and external massage. Trocars
removed, deep tissue closed with 2-0 Vicryl, skin with continuous
running 4-0 Vicryl and 1/2 inch Steri-Strips. Tegaderm dressings
applied. Tolerated well. At that point, we placed the patient
prone. The lesion in the upper mid back measured approximately 3/4
to 1 inch in transverse diameter. The cyst was partially filled
with material. It was opened and chronically fistulized to the
skin. Actually, the cyst traveled cephalad a fair distance
underneath the skin. The area was locally infiltrated with 0.25%
Marcaine with epinephrine as were the previous sites of the
gallbladder trocars. A Z-plasty was marked on the skin. The mass
itself was first excised. Z-plasty flaps were dissected out.
Bleeding controlled with electrocoagulation. After the flaps were
completed, they were placed in the proper orientation, allowing a
central vertical incision and two adjacent oblique incisions. The
closure was completed with interrupted 4-0 Vicryl to the
subcutaneous tissue. It should be mentioned a #7 round
Jackson-Pratt drain was placed into the depths of the incision,
brought out through a lateral stab wound, tied to the skin with 2-0
silk. After stabilization of the flaps, the skin was reapproximated
with continuous running 5-0 Vicryl. Sterile compressive dressing
applied. Tolerated well. Blood loss negligible. Left the operating
room now in satisfactory condition. (End of Example 2)
Example 3
Gallbladder
[0081] Operative Procedure: Laparoscopic Cholecystectomy with
Cholecyst Cholangiography.
Description of Procedure:
[0082] Introduction [0083] After satisfactory endotracheal
anesthesia was obtained, the patient's abdomen was prepped and
draped in the usual fashion after which CO2 pneumoperitoneum
instilled with a Veress needle placed cephalad to the umbilicus at
2.5 L full to pressures equal to or less than 16 mmHg to a total of
6 L. The Veress needle then removed and replaced with a 10-mm
InnerDyne trocar. A 45-degree-angle laparoscope introduced. General
examination of the abdomen. Findings as listed above. No adhesions
were present to the gallbladder. The gallbladder appeared gray in
color. Under direct vision, a 5-mm trocar was placed along the
right anterior axillary line. [0084] Step 1: The bitoothed biopsy
forceps were used to grab the fundus of the gallbladder with upward
retraction. (FIGS. 1, 1a-1e) [0085] Step 2: A 17-gauge pericardial
needle passed percutaneously into the gallbladder. Approximately 30
cc of dark brown bile was aspirated and 60 cc of 50% Hypaque
instilled in two separate aliquots of 50 and 10 cc each. At the end
of the infusion of each of the two aliquots, x-rays were taken and
examined in the operating room, with the findings as listed above.
The excess Hypaque was then aspirated, the needle removed. (FIGS.
2, 2a-2c) [0086] Step 3: Under direct vision a 5-mm and 12-mm
trocar were placed in the right midabdomen. (FIGS. 3, 3a-3d) [0087]
Step 4: Bitooth biopsy forceps used to place the neck of the
gallbladder on stretch after placing the patient in reverse
Trendelenburg position. Everest Medical bipolar curved scissors and
forceps used to uncover the cystic duct and the cystic artery. The
cystic duct was followed to its junction with the common bile duct.
(FIGS. 4, 4a-4i) [0088] Step 5: The cystic duct was clipped times 2
proximally and once distally, divided. (FIGS. 5, 5a-5f) [0089] Step
6: The cystic artery electrocoagulated with bipolar cautery. (FIGS.
6, 6a-6c) [0090] Step 7: Gallbladder dissected off the liver bed
with bipolar cautery aided by bipolar scissors dissection. (FIGS.
7, 7a-7g) [0091] Step 8: After removal of the gallbladder from the
liver, the gallbladder fossa was examined for bile or blood. There
was none. The gallbladder then placed into a bag which was then
brought out half way through the abdomen and ring forceps used to
extract whatever was left of the gallbladder itself and the bag as
well. (FIGS. 8, 8a-8b)
CONCLUSION
[0091] [0092] With all of this removed, the 12-mm trocar was placed
back into the abdomen, the right upper quadrant irrigated with
saline until clear, and the instruments then removed. CO2 let out
through external massage. The trocars were removed. The deep tissue
was closed with 2-0 Vicryl, the skin with continuous running 4-0
Vicryl, with 1/2 inch Steri-Strips. Each puncture site was locally
infiltrated with 0.25% Marcaine with epinephrine for postoperative
pain relief. A Tagaderm dressing was applied. Tolerated well. Blood
loss negligible. (End of Example 3)
Example 4
Gallbladder
Operative Procedure: Laparoscopic Cholecystectomy
Description of Procedure:
[0093] Introduction [0094] After satisfactory endotracheal
anesthesia was obtained, the patient's abdomen was prepped and
draped in the usual fashion, after which CO2 pneumoperitoneum was
instilled through a 10-mm InnerDyne trocar placed cephalad to the
umbilicus at 4 L per minute flow pressures equal to or less than 16
mmHg to a total of 5 L. A 45-degree-angle laparoscope was
introduced. Sterile examination of the abdomen and findings as
listed above. [0095] Step 3: Under direct vision, 5-mm trocars
times two were placed in the right midabdomen along with the 12-mm
InerDyne trocar. (FIGS. 3, 3a-3d) [0096] Multiple adhesions were
present on the gallbladder. These were taken down with bipolar
cautery. The gallbladder was then elevated out of the wound after
being freed of adhesions. [0097] Step 4: Careful dissection of the
gallbladder as it narrowed down into the cystic duct was noted.
Medial dissection was unremarkable. (FIGS. 4, 4a-4i) [0098] Step 5:
Once the dissection was completed, the clips were placed proximally
on the cystic duct times three, one distally, the cystic duct
divided. (FIGS. 5, 5a-5f) [0099] Then dissected off in a retrograde
fashion using bipolar cautery. The gallbladder represented an
intrahepatic gallbladder as well as subacute. The dissection went
very smoothly without any bleeding. [0100] Step 6: The cystic
artery had been identified and electrocoagulated. (FIGS. 6, 6a-6c)
[0101] Step 7: We located the anterior cystic artery. The
dissection continued smoothly off the liver bed. (FIGS. 7, 7a-7g)
[0102] The liver bed was then inspected for any residual bleeding
or bile staining and none was evident except some bleeding, a very
minimal amount, toward the bottom of the liver bed, and a piece of
Surgicel was placed here for control. This was then re-examined
after total removal of the gallbladder and again no blood or bile
was now present. [0103] Step 8: The gallbladder after being removed
was then led partially out of the abdomen through the 12-mm trocar
and grabbed with clamps, incised, the bile suctioned out, and small
stones were then removed with a ring forceps until the gallbladder
was small enough in size to pop through the opening. (FIGS. 8,
8a-8b)
CONCLUSION
[0103] [0104] The trocar was then replaced, the right upper
quadrant irrigated with saline, some irrigant suctioned off, and
the procedure terminated with removal of instruments. Open valves
on the trocars. External massage to remove CO2 gas. The trocars
were removed and the tissue closed with interrupted 2-0 Vicryl
sutures, the skin with continuous running 4-0 Vicryl and 1/2-inch
Steri-Strips. Tegaderm dressing was applied. Tolerated well. Left
the operating room in satisfactory condition. (End of Example
4)
Example 5
Gallbladder
Operative Procedure: Laparoscopic Cholecystectomy and
Cholecyst-Cholangiography.
Description of Procedure:
[0105] Introduction [0106] After satisfactory, endotracheal
inhalation anesthesia was obtained, the patient's abdomen was
prepped and draped in the usual fashion, after which CO2
pneumoperitoneum was instilled through a 10 mm Innerdyne trocar
placed cephalad to the umbilicus at a 4 L/min flow with pressures
equal to or less than 17 mmHg to a total of five liters. A 45
degree angle laparoscope was introduced into the abdomen and
general examination of the abdomen unremarkable except for findings
as listed above. Under direct vision, a 5 mm trocar was placed
along the right anterior axillary line. [0107] Step 1: Bi-toothed
biopsy forceps grasped the fundus of the gallbladder with upward
retraction. (FIGS. 1, 1a-1e) [0108] Step 2: A 17 gauge pericardial
needle was passed percutaneously into the gallbladder, excess bile
aspirated and 60 cc of 50% Hypaque introduced in 50 and 10 cc
aliquots. At the end of each aliquot x-rays were taken and cystic
duct obstruction was noted. Excess dye was then removed, the needle
removed. (FIGS. 2, 2a-2c) [0109] Step 3: A 5 mm and 12 mm trocars
placed in the right mid abdomen under direct vision. The patient
was placed in reverse Trendelenburg position. (FIGS. 3, 3a-3d)
[0110] Step 4: The gallbladder was then grabbed just above the
stone which was impacted in the neck. The cystic duct was fully
dissected away from the gallbladder and the anterior and posterior
cystic artery noted. (FIGS. 4, 4a-4i) [0111] Step 5: After all
three structures were identified clearly, they were clipped,
appropriately divided. (FIGS. 5, 5a-5f) [0112] Step 7: The
gallbladder then dissected off the liver bed with bipolar cautery
and scissors. (FIGS. 7, 7a-7g) [0113] Step 8: It was then put into
an extraction bag, brought half way out of the abdomen through the
12 mm trocar and piecemeal we were able to remove the gallbladder
bag intact. (FIGS. 8, 8a-8b)
CONCLUSION
[0113] [0114] The puncture site was irrigated with saline. The
abdomen was copiously irrigated until clear. No drains were placed.
The trocars were removed, the deep tissue closed with interrupted
2-0 Vicryl and the skin with continuous running 4-0 Vicryl
subcuticular. Half inch Steri-Strips were applied, Tegaderm
dressings applied, the wounds locally infiltrated with 0.25%
Marcaine with epinephrine for postoperative pain relief and the
procedure terminated. The patient tolerated it well and left the
operating room in satisfactory condition. (End of Example 5)
Example 6
Gallbladder
Operative Procedure: Laparoscopic Cholecystectomy,
Cholangiography.
Description of Procedure:
[0115] Introduction [0116] After a satisfactory endotracheal
anesthesia was obtained the abdomen was prepped and draped in the
usual fashion. A CO2 pneumoperitoneum was instilled through a 10 mm
innerdyne trocar placed cephalad to the umbilicus at four liters
per minute flow. Flow pressures were equal to or less than 17 mmHg
to a total of five liters. The 45.degree. angle laparoscope was
introduced. General examination of the abdomen showed findings as
described above. [0117] Step 3: Under direct vision a 5 mm and 12
mm disposable trocar was placed in the right upper quadrant along
with a third trocar, 5 mm. (FIGS. 3, 3a-3d) [0118] Step 1: Bitooth
biopsy forceps were used to grasp the fundus of the gallbladder.
(FIGS. 1, 1a-1e) [0119] Step 2: A #17 gauge pericardial needle was
passed percutaneously into the gallbladder and 30 cc of dark bile
was aspirated. Then 60 of 50% Hypaque was instilled through
separate aliquots, and 50 and 10 cc each. X-rays were taken at the
conclusion of each aliquot infusion. Findings are as noted above.
Excess Hypaque was aspirated and the needle removed. The patient
was placed in reversed Trendelenburg position. (FIGS. 2, 2a-2c)
[0120] Step 4: The gallbladder was grasped at the neck. Moderate
amount of inflammation was noted in the wall with edema. The lymph
node of Calot was identified and stripped off the gallbladder. The
gallbladder junction with the cystic duct was identified which was
then traced down to the common bile duct. The cystic artery was
identified and all these structures lay in normal anatomic
position. The cystic duct was dissected free of surrounding tissue.
(FIGS. 4, 4a-4i) [0121] Step 5: Two clips were then placed
proximally and two distally. The duct was divided. (FIGS. 5, 5a-5f)
[0122] Step 6: The cystic artery was electrocoagulated with bipolar
cautery and divided. (FIGS. 6, 6a-6c) [0123] Step 7: The
gallbladder was then dissected off the liver bed with bipolar
cautery in a retrograde fashion until it was free from the liver.
(FIGS. 7, 7a-7g) [0124] Step 8: It was then brought partially out
of the abdomen through the 12 mm trocar. (FIGS. 8, 8a-8b)
CONCLUSION
[0124] [0125] The instrument was then placed within the gallbladder
to crush the stone into multiple small pieces which were then
removed piecemeal until the gallbladder popped through the hole.
Some fragments got loose but were retrieved both intra-abdominal
with a pelviscopic scoop and within the wound itself while pulling
the gallbladder through the wound with pickups. The whole tract was
irrigated copiously with saline until all fragments were cleaned
up. The inside of the abdomen was irrigated with saline, especially
the gallbladder fossa and along the right lateral sulcus of the
liver, all of which was aspirated. No evidence of any bleeding,
bile leakage was noted. Instruments were removed. Trocars were
removed after expelling co2 gas with external massage. After
removal of the trocars the deeper tissue was reapproximated with
#2-0 Vicryl and skin with continuous running #4 Vicryl. Half-inch
Steri-Strips were placed. Tegaderm dressing was applied. The
patient tolerated the procedure well. Blood loss was negligible. No
complications were apparent. (End of Example 6)
[0126] The present invention can be used for various types of
procedures in addition to the prior 6 examples just discussed.
Another example is for use in hernia procedures. The following four
examples are dictation records from left inguinal hernia repair
procedures. References have been inserted in each example to refer
to FIG. 1 and FIGS. 9-13, including FIGS. 1a-1e, 9a-9c, 10a-10i,
11a-11e, 12a-12e, 13a-13j which comprise images actually captured
during the procedure of Example 1-4 (hernia).
Example 1
Hernia
[0127] Operative Procedure: Laparoscopic Repair of Left Inguinal
Hernia with Polypropylene Mesh
Description of Procedure:
[0128] Introduction [0129] After satisfactory endotracheal
anesthesia was obtained, patient's abdomen was prepped and draped
in the usual fashion after which CO2 peritoneum instilled through a
10 mm trocar placed cephalad to the umbilicus at 4 liters/minute
flow of pressures equal to or less than 16 mmHg to a total of 5
liters. The 45 degree angle laparoscope introduced. General
examination of the abdomen with findings as listed above. [0130]
Step 1: Under direct vision, a 5 mm and 12 mm trocar placed in
right and left mid abdomen respectively. (FIGS. 1, 1a-1e) [0131]
Step 2: Patient placed in Trendelenburg position. Everest medical
curved scissors and bitooth biopsy forceps used to develop a left
curvilinear peritoneal flap directed posteriorly which allowed
entry into the preperitoneal space. (FIGS. 9, 9a-9c) [0132] Step 3:
Dissection of the space curved from the line of Douglas above to
Cooper's ligament below beyond the midline and lateral to the
internal ring. (FIGS. 10, 10a-10i) [0133] Step 4: Direct space
hernia was evident. A very small amount of fat was contained within
the internal ring which was essentially normal in size and this was
not reduced. A piece of polypropylene mesh measuring 6.times.5
inches was tightly rolled up into 10/11 mm trocar, placed on the 12
mm trocar and popped into the preperitoneal space on the left. This
was unfurled, covered with the inguinal femoral area. (FIGS. 11,
11a-11e) [0134] Step 5: Stapled in place. (FIGS. 12, 12a-12e)
[0135] Step 6: Pressure was then reduced to 5-6 mmHg, the leaves of
peritoneum then reapproximated with closely placed staples. (FIGS.
13, 13a-13j)
CONCLUSION
[0135] [0136] When complete, instruments were removed, CO2 let out
through open valves and external massage. Trocar was removed, deep
tissue closed with interrupted 2-0 Vicryl, skin with continuous
running 4-0 Vicryl, Steri-Strips applied, Tegaderm placed.
Tolerated well. Blood loss negligible. Left the operating room in
satisfactory condition. (End of Example 1)
Example 2
Hernia
[0137] Operative Procedure: Laparoscopic Repair of Recurrent Left
Inguinal Hernia with Polypropylene Mesh
Description of Procedure:
[0138] Introduction [0139] After satisfactory general endotracheal
anesthesia was obtained, the patient's abdomen was prepped and
draped in the usual fashion after which CO2 pneumoperitoneum was
instilled through a 10 mm Interdyne trocar placed cephalad to the
umbilicus, 4 liters/minute flow and pressures equal to or less than
16 mmHg to a total of 4 liters. A 25 degree angle laparoscope was
introduced and examination of the abdomen was unremarkable. A left
inguinal hernia was noted. There is minimal weakness on the right
and no additional surgery was done for that. [0140] Step 1: Under
direct vision, a 5 mm and 12 mm trocars were placed in right and
left midabdomen, respectively. (FIGS. 1, 1a-1e) [0141] Step 2: The
patient was placed in Trendelenburg position and a bitooth biopsy
forceps and Everest Medical curved forceps and scissors used to
develop a left curvilinear peritoneal flap directed posteriorly
allowing entry into the preperitoneal space. (FIGS. 9, 9a-9c)
[0142] Step 3: The space was dissected completely beyond the
midline to the line of Douglas above to Cooper's ligament below.
(FIGS. 10, 10a-10i) [0143] The hernia could be seen in the direct
space constituting herniated fat, which was then reduced out of the
hole, which could clearly be seen. The dissection carried well
beyond the internal ring. A search for lipoma was negative. With
the flap nicely developed. [0144] Step 4: A piece of polypropylene
mesh measuring 15.times.11.5 cm was placed into the preperitoneal
space and used to cover the inguinal femoral area. (FIGS. 11,
11a-11e) [0145] Step 5: Staples were placed at all but the volar
inferior portion mesh because of underlying nerve tissue in this
region. (FIGS. 12, 12a-12e) [0146] Step 6: Pressure then reduced to
8 mmHg and leaves of peritoneum reapproximated with closely placed
staples. (FIGS. 13, 13a-13j)
CONCLUSION
[0146] [0147] Instruments were removed and CO2 removed through open
valves. Trocars were removed. Deep tissue was closed with
interrupted #2-0 Vicryl and skin with running #4-0 Vicryl and 1/2
inch Steri-Strips. Tegaderm dressings applied. Marcaine 0.25% with
epinephrine was instilled in puncture sites for postoperative pain
relief. Blood loss was minimal. The patient tolerated the procedure
well and left the operating room in satisfactory condition. (End of
Example 2)
Example 3
Hernia
[0148] Operative Procedure: Laparoscopic Repair of Left Direct
Space Weakness with Excision of Left Inguinal Lipoma Using
Polypropylene Mesh.
Description of Procedure:
[0149] Introduction [0150] After satisfactory endotracheal
anesthesia was obtained, the patient's abdomen was prepped and
draped in the usual fashion after which CO2 pneumoperitoneum was
instilled through a 10-mm InnerDyne trocar placed cephalad to the
umbilicus at 4 L per minute flow pressures equal to less than 16
mmHg. A 45-degree angle laparoscope introduced into the abdomen.
The left inguinal hernia and weakness were noted, primarily over
the direct space. The right inguinal area was unremarkable. [0151]
Step 1: Under direct vision, a 5-mm and 12-mm trocar was placed in
the right and left midabdomen respectively. (FIGS. 1, 1a-1e) [0152]
Step 2: The patient placed in Trendelenburg position and a
45-degree-angle laparoscope introduced. General examination of the
abdomen as noted above. Using a bitooth biopsy forceps, the Everett
Medical curved scissors and Kleptinger bipolar cautery, a left
curvilinear peritoneal flap was directed posteriorly. (FIGS. 9,
9a-9c) [0153] Step 3: The preperitoneal space dissected thoroughly
from beyond the midline to below. (FIGS. 10, 10a-10i) [0154] An
extremely weak posterior space was noted. A lipoma of the cord was
noted. In addition, there were multiple and enlarged lymph nodes
present at the mouth of the slightly dilated internal ring. This
site is considered to be unusual and is not customarily found,
although such nodes are found in the region of the femoral ring.
For that reason, a biopsy was taken of one of these nodes and sent
for pathologic examination. [0155] Step 4: After thorough
dissection of the preperitoneal space, polypropylene mesh measuring
15.times.11.5 was rolled up in a 10-11 trocar placed down a 12-mm
trocar and placed into the preperitoneal space. This was unfurled
over the inguinal femoral area. (FIGS. 11, 11a-11e) [0156] Step 5:
Held in place with staples. (FIGS. 12, 12a-12e) [0157] Step 6: The
pressure was then reduced to 8 mmHg and the leaves of peritoneum
reapproximated with closely placed staples. (FIGS. 13, 13a-13j)
CONCLUSION
[0157] [0158] The instruments were removed and CO2 let out through
open valves and external massage. The trocar was removed. The deep
tissue was closed with interrupted 2-0 Vicryl, the skin with
continuous running 4-0 Vicryl, with 1/2 inch Steri-Strips. A
Tegaderm dressing was applied. Tolerated well. Blood loss
negligible. Left the operating room in satisfactory condition. (End
of Example 3)
Example 4
Hernia
[0159] Operative Procedure: Laparoscopic Repair of Indirect Right
Inguinal Hernia with Polypropylene Mesh
Description of Procedure:
[0160] Introduction [0161] After satisfactory endotracheal
inhalation anesthesia was obtained, the patient's abdomen was
prepped and draped in the usual fashion, after which CO2
pneumoperitoneum was instilled through a 10 mm Innerdyne trocar
placed cephalad to the umbilicus at 4 L/min flow with pressures
equal to or less than 17 mmHg to a total of 4.5 liters. A 45 degree
angle laparoscope was introduced. General examination of the
abdomen revealed findings as listed above. [0162] Step 1: Under
direct vision, 5 mm and 12 mm trocars were placed in the right and
left mid abdomen respectively. (FIGS. 1, 1a-1e) [0163] Step 2: The
patient was placed in Trendelenburg position. A curvilinear flap
was developed in the right inguinal area using Everest Medical
bipolar curved scissors and forceps and bi-toothed biopsy forceps.
(FIGS. 9, 9a-9c) [0164] Step 3: As the flap was developed it
allowed entry into the preperitoneal space, which was dissected
from the line of Douglas above to Cooper's ligament below lateral
to the internal ring and medial to the midline. (FIGS. 10, 10a-10i)
[0165] Step 4: Once fully developed and the extraneous sac removed
from the internal ring, a piece of polypropylene mesh measuring
6.times.5 inches was rolled up into a 10-11 mm trocar, popped down
the 12 mm trocar and then into the preperitoneal space. This was
unfurled over the inguinal-femoral area. (FIGS. 11, 11a-11e) [0166]
Step 5: Held in place with staples. (FIGS. 12, 12a-12e) [0167] Step
6: Pressure was then reduced to 6 mmHg and the leaves of peritoneum
reapproximated with closely placed staples. (FIGS. 13, 13a-13j)
CONCLUSION
[0167] [0168] When this was completed, instruments were removed,
the CO2 let out through open valves and external massage, the
trocars removed, the deep tissue closed with interrupted 2-0 Vicryl
suture to the fascia and subcutaneous tissue, the skin closed with
continuous running 4-0 Vicryl with half inch Steri-Strips. Tegaderm
dressings were applied, 0.25% Marcaine with epinephrine instilled
in the puncture sites for postop pain relief and the procedure
terminated. (End of Example 4)
[0169] The preceding examples are intended to be exemplary, and the
present invention is not limited to the preceding examples.
[0170] FIG. 15 depicts one embodiment of the method, process and/or
functional flow of present invention. The images are obtained and
stored in the image library, 200. First the image is obtained, 202,
and then appropriately digitized, 204. The digitized images are
then added to the image library 206 and compared to the images in
the library, 208. Corresponding to the images or to groups of
similar images (e.g. Figures) is the respective text descriptions
of the steps and/or of the image, 400. The text is created, 402,
and then added to a text library 404. Text creation, editing, and
storage can be either a separate or concurrent function of the
image processing.
[0171] The text and the images are combined together, 600, after
the obtained image is compared to images from the image library
602. Similar images in the image library may be grouped together
with a descriptive text associated with each grouping. Subgroups of
the grouped images may be created to provide further descriptive
detail to the step (e.g., the color of organ, the position of the
organ, etc.). After the comparison of the images has been made and
the obtained image is associated with a group and/or related
subgroup, the obtained image is labeled with the corresponding text
from the text library 604. The text that is selected from the text
library is used to create a record 606 or part of a record. The
record or portion there of that is created can then be
communicated, displayed, or manipulated, 608.
[0172] The following are "stylized" descriptive texts based on the
steps and images from the above examples. These stylized texts are
examples of language which may be descriptive of the various steps,
procedures, functions, physiology, physiological conditions, and
the like generally typical of gallbladder and hernia procedures,
respectively. The process outlined in FIG. 15 may be used to create
a record comprising the following stylized steps. The text for the
steps of the procedure may be set or read only; however, a doctor
or other person creating a record may insert patient specific
details in the introduction and conclusion of the record to account
for problems, deviations or additions to the set-up or closing
procedures.
Gallbladder (Stylized Text)
[0173] Step 1: The bitoothed biopsy forceps were used to grab the
fundus of the gallbladder with upward retraction. (FIGS. 1, 1a-1e)
[0174] Step 2: A 17 gauge pericardial needle was passed
percutaneously into the gallbladder. Excess bile was aspirated and
replaced with 60 cc of 50% Hypaque instilled in two separate
aliquots of 50 and 10 cc each. At the end of the infusion of each
of the two aliquots, x-rays were taken and examined in the
operating room with the findings as listed above. The excess
Hypaque was aspirated and the needle removed under direct vision.
(FIGS. 2, 2a-2c) [0175] Step 3: A 5-mm and 12-mm trocar were placed
in the right mid-abdomen. The patient was placed in reversed
Trendelenburg position. (FIGS. 3, 3a-3d) [0176] Step 4: The
gallbladder was grasped at the neck and dissected out from
surrounding tissue. The gallbladder junction with the cystic duct
was identified. The cystic duct was fully dissected away from the
gallbladder and the cystic artery noted. (FIGS. 4, 4a-4i) [0177]
Step 5: The cystic duct was dissected free, and clipped proximally
and distally, divided. (FIGS. 5, 5a-5f) [0178] Step 6: The cystic
artery was electrocoagulated with bipolar cautery. (FIGS. 6, 6a-6c)
[0179] Step 7: The gallbladder was dissected off the liver bed with
bipolar cautery. (FIGS. 7, 7a-7g) [0180] Step 8: The gallbladder
was led out of the abdomen through the 12-mm trocar. (FIGS. 8,
8a-8b)
Hernia (Stylized Text)
[0180] [0181] Step 1: Under direct vision, 5-mm and 12-mm trocars
were placed in the right and left midabdomen, respectively. (FIGS.
1, 1a-1e) [0182] Step 2: The patient was placed in the
Trendelenburg position. A curvilinear flap was developed using
Everest Medical curved scissors and forceps and bitoothed biopsy
forceps. (FIGS. 9, 9a-9c) [0183] Step 3: The space was dissected
from the line of Douglas above to Cooper's ligament below. (FIGS.
10, 10a-10i) [0184] Step 4: A piece of polypropylene mesh was
tightly rolled up and placed into the preperitoneal space. This was
unfurled over the inguinal femoral area. (FIGS. 11, 11a-11e) [0185]
Step 5: The mesh was stapled in place. (FIGS. 12, 12a-12e) [0186]
Step 6: Pressure was then reduced and the leaves of the peritoneum
then reapproximated with closely placed staples. (FIGS. 13,
13a-13j)
[0187] In one embodiment, the apparatus of the present invention
may further comprise an input/output device 112 located in or just
outside an operating room. In this example, a surgeon could perform
a procedure while it is being filmed and while the film (image) is
processed to produce a record in accordance with the present
invention. Upon finishing the procedure and leaving the operating
room, the record could be accessed in hard or electronic form by
the surgeon, e.g., at a terminal 112 outside the operating room.
The surgeon could then immediately review the text, edit it if
desirable or necessary and sign it. In some embodiments, the
signature may be electronic, and the record may be immediately
placed in an electronic chart or patient record.
[0188] One example of using the apparatus and methods of the
present invention in fields other than medicine is their use in
mass or batch manufacturing or production of parts. In this
example, the parts are typically subjected to a number of steps or
processes to provide a raw, or stock, material with selected
features. Images of the steps, and the part during and/or after the
steps, can be captured. These images, which may be digital
initially or digitized, may be stored in a library of images,
and/or may be immediately or at a later time compared to other
images in the library or to real time images or the process as it
occurs. This comparison could be used, for example, to assess the
repeatability of the process, and/or that the finished parts meet
required tolerances. Stored images from the library could be used
for educational purposes, e.g., to train production line workers,
and/or for assessments of the cost and/or time efficiency of the
process. The images also could be used to create a record of
production, required tolerances, standard operation procedure
and/or testing. For example, images could be compared to assess
tolerances of finished parts and, if an "out-of-tolerance" part or
feature is detected, a warning message or text could be produced
and recorded and/or sent to a monitoring location; the images of
the steps could be used to trigger a written standard operating
procedure and/or portions thereof; and/or the images could be used
to trigger a written or textual production and/or quality control
record. Similarly, the methods and apparatus of the present
invention could be used in assembly line settings, wherein a final
product is built or assembled.
[0189] Another example of using the apparatus and methods of the
present invention in fields other than medicine is their use in
athletic or sports training in improving techniques, for example,
in improving a golf swing. A golf swing involves various body and
club positions and movements. A person trying to improve his or her
golf swing may stand at a tee with his club and swing at a ball
while a camera, video camera or the like photographs the golfer.
The camera obtains images of various parts and aspects of the
golfer's swing, positioning, and movement. Such images may be saved
or stored in an image library, which may thus comprise images
and/or groups of similar images of the various golfers and/or
images of various golf swings, including stylized or ideal golf
swings. A processing unit could digitize the obtained images from
the golfer's swing and compare the images obtained to the images in
the library, for example, to the ideal swing images. The obtained
images may then identified, and/or added to the images library, and
a text from a text library, may be added to create a report
identifying, for example, what is incorrect with the golfer's swing
and suggestions on how to correct it.
[0190] Referring to FIGS. 16 and 17, one example would be that the
camera could focus on the position of the club head on the golfer's
back swing. The images in the library would have various images of
an "open" and "closed" back swing as depicted by the possible
representative images in FIG. 16. The obtained image would be
compared to the images in the image library and identified as
either "open" or "closed". FIG. 17 shows representative figures of
possible images for the library of images. If the back swing is
"closed" a text statement would be added to the report identifying
the golfer's back swing as "closed", stating the problems of having
a "closed" back swing, stating how to change the back swing to
"open", and how an "open" back swing should improve their swing.
The report may be available in hard or electronic form, and may be
available to the golfer and/or a teaching pro.
[0191] The methods and apparatus of the present invention may be
used for any medical treatment or surgical procedure, and may be
used in fields other than medicine. Suitable computer and/or
microprocessing equipment and systems, including suitable software,
may be used to accomplish the methods of the present invention,
along or in conjunction with suitable image capturing and
processing equipment or systems and communication systems. In some
embodiments, the present invention may comprise a dispersed library
of information, i.e., there is no "central station," central
library, central server or central repository, but rather a
substantially instantaneous communication or flow of information
over the Internet or the like. The present invention encompasses
taking, transmitting and processing digital images, wherein the
digital images can be placed into a digital library of images
directly. It encompasses a digital library of digital or digitized
images and texts, wherein the digital library may be accessed
and/or manipulated from a central and/or one or more remote
locations.
[0192] The present invention may be embodied in other specific
forms without departing from the essential spirit or attributes
thereof, and it may be used in applications outside the medical
field. Described embodiments should be considered in all respects
as illustrative, not restrictive.
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