The seeder is integral to smallholder agricultural production. This technology seeks to lessen farmer labor requirements, meter seeds accurately, and minimize excessive soil disturbance. Hand seeders play a central role in conservation agriculture (CA) for the smallholder farmer as a means to plant through residue cover and penetrate non-tilled soil surfaces. Two trials in maize (Zea mays, L.) residue and soybean (Glycine max, L.) residue were conducted to test seven seeders of increasing mechanization levels: five hand operated, one mechanized, and one tractor-drawn control. The experiment site was in Mt. Gilead, Ohio, at the Eastern end of the US “Corn Belt” that had been under continuous no-till production for seven years. Experimental conditions at the site sought to mimic smallholder conditions through seeding and hand harvesting. Seeders were evaluated based on plant population establishment, crop growth stage, crop heights and final maize grain yield. The hand seeders were further evaluated based on their economic viability and usability – key challenges to the ultimate adoption of new seeding technologies. The study found that the seeders tested performed equally to the control, the John Deere MaxEmerge Conservation planter, the crop-seeding capacity and price evaluation identified the Haraka rolling planter ill-suited for smallholders while the OSU Greenseeder proved highest qualitative performance. In conclusion, all evaluations indicate that a medium level of mechanization is appropriate and necessary to be successful in a smallholder CA system although continued research is necessary.

Spent microbial biomass (SMB), a nutrient-rich co-product of industrial white biotechnology processes, is produced in substantial quantities alongside high-value products and most often disposed of in landfills or incinerated. Alternatively, SMB could be reused as a land-applied N source in agricultural crop production, reducing the environmental and economic footprint of synthetic fertilizers. This research compares SMB applied at different rates to current farmer practice (FP) fertilizer use in tall fescue (Festuca arundinacea Schreb.) and corn (Zea mays L.) production on a Dewey silty clay in Lenoir City, TN. The effect of SMB on tall fescue was measured over three harvests through plant biomass production, crop N status using the normalized difference vegetation index (NDVI), and forage quality by near-infrared reflectance spectroscopy (NIRS). Corn productivity was measured by crop height, leaf chlorophyll content using a handheld meter, and grain yield. Tall fescue data showed the mineralization and release of SMB N over time compared with the rapidly available fertilizer N, and the highest SMB application rate in tall fescue was not statistically different from the FP in plant biomass, leaf NDVI, or any measured forage quality parameters. Despite differences in corn leaf chlorophyll contents between SMB and fertilizer treatments during the growing season, no differences in final grain yields were found. This research substantiates the potential of SMB as a soil N amendment from a nutrient source and yield perspective. Additional studies are needed to understand SMB mineralization rates and to confirm the material's nutrient contribution to crop production.

Background To review our case series regarding the effectiveness, postprocedure pain, and cost of totally extraperitoneal (TEP) procedure for inguinal hernia repair, using a preformed polyester mesh (PEM), without fixation with additional anchoring devices. Methods Prospective evaluation of all patients from March 2001 to July 2005 who underwent the above-described procedure in an outpatient setting in the rural southern United States using a preformed anatomic Parietex PEM with a minimum 1-year follow-up. All patients were evaluated at 1, 3-week, and 1-year postprocedure for recurrence, complications, and pain level assessment using a standardized questionnaire employing visual analog scale. Results A series of 108 patients consisting of 95 males and 13 females were operated on with a total of 157 hernias being repaired using laparoscopic techniques. The 1-year follow-up rate was 88.9% (n=96/108). Only 1 followed-up patient (n=1/96; 1.04%) or 0.71% (n=1/140) followed-up hernia repair had a recurrence after TEP repair noted at 1-week postoperative. Two patients had temporary urinary retention and there were no infectious complications or readmissions to the hospital. Visual analog scale pain score (0 to 10) at 1-month postprocedure averaged 0.37 and decreased to 0.03 at 1 year. The cost difference in our institution for all nonreusable material used in laparoscopic hernia repair was US $ 116.77 more than for an open procedure. This was primarily caused by higher costs for the laparoscopic mesh. Conclusions Laparoscopic TEP inguinal hernia repair with preformed PEM without additional fixation can be performed in a rural community hospital setting with minimal long-term postoperative pain and the procedure results are comparable with larger centers with only marginally increased costs over open hernia repair.

Objective To compare institutional costs for open versus laparoscopic inguinal hernia repair and its relationship to reimbursement in an ambulatory surgery center in the United States. Method Analysis of institutional costs in US$ of 2006 for all nonreusables used in a laparoscopic total extraperitoneal (TEP) hernia repair using a polyester mesh compared with open hernia repair using polypropylene mesh. A comparison of the institution's disposable costs related to reimbursement at an ambulatory surgery center in Southeastern United States was performed to identify the most cost-effective procedure for the outpatient facility. Results As fixed and indirect costs of the ambulatory surgery center are similar for both procedures, a cost difference can only be found in direct disposable costs with that being US$ 235.57 for the procedure-specific disposables in the laparoscopic hernia repair as compared with US$ 117.15 for the open hernia repair. Cost for identical disposables used in both procedures amounted to US$ 32.57. Laparoscopic TEP hernia repair has a higher cost for procedure related disposables versus the open hernia repair at +US$ 118.42 mainly being due to the more costly polyester mesh. A flat rate reimbursement of US$ 1800 for a laparoscopic procedure compared with only US$ 950 for the open procedure minus all disposable cost results in a higher institutional income of +US&$ 731.58 (US$ 1531.86 vs. US$ 800.28), from which other institutional costs can be paid. Conclusions Despite marginally higher procedure-related disposable costs for laparoscopic TEP hernia repair, the institutional income is remarkably higher owing to a better reimbursement for this procedure in ambulatory surgery centers. From the institution's point of view, laparoscopic hernia repair is by far the more cost-effective procedure when compared with an open hernia procedure at the present time.

A 69-year-old female patient underwent a standard laparoscopic Nissen fundoplication for repair of a hiatal hernia and correction of reflux. A Harmonic scalpel was used as the only energy source intraoperatively. The operation was uneventful until the middle of the procedure when a significant amount of blood was noted in the left upper quadrant. After aspiration and careful inspection, a 5-cm irregular vertical laceration was found on the posterior and lateral aspect of the spleen, far away from the operative field and any previous instrumentation. Control of bleeding from the spleen was unsuccessful, so a laparoscopic splenectomy was performed, and the procedure was finished without further incident. Histologic examination revealed a normal spleen with no pathologic alterations accounting for the laceration. After comprehensive evaluation of this case to assess a potential cause of the complication, the question arose as to whether the energy produced by the Harmonic scalpel could have caused this splenic laceration.

Study objectiveTo compare 5 laparoscopic insufflators with different gas flow rates with regard to accuracy of preset pressure setting versus real intraoperative intraabdominal pressure.DesignProspective study (Canadian Task Force classification II-2).SettingFayette Medical Center, Alabama.PatientsFive patients undergoing laparoscopic cholecystectomy.InterventionsIntraoperative intraabdominal and system pressure measurements during comparable laparoscopic procedures.Measurements and main resultsActual intraabdominal pressure was measured and compared between 5 different 10 to 20 L/min insufflators (Storz Laparoflator and Endoflator, Richard Wolf, BEI Medical and Snowden & Pencer) with a computer-based online data acquisition system. At a nominal pressure of 10 mm Hg, the mean intraabdominal pressure during the entire procedure was measured to be between 9.68 and 11.45 mm Hg. The mean intraabdominal pressure during laparoscopy for the insufflators showed a margin of error of 14.5%, with maximum intraabdominal pressure peaks measured between 14.65 and 17.87 mm Hg.ConclusionsWithin an error margin of <15% of the preset intraabdominal pressure setting, the insufflators evaluated can be considered pressure reliable. Although intraabdominal pressure peaks exceeding the nominal pressure temporarily reached up to 78.7% of the setting, no apparent complications were observed. Excessive pressure peaks seen in the previous reported laboratory model could not be confirmed during in vivo application.

Objective-Postoperative pain management is important, especially in cancer patients. We describe our experience with the application of a locally placed continuous local anesthetic-releasing catheter for wound pain reduction after mastectomy for breast cancer. Materials and Methods-Retrospective evaluation of a continuous series of 41 patients at Fayette Medical Center, AL, USA, receiving an anesthetic-releasing catheter from January 2000 until June 2004. We used a pain management system with 270 ml volume of 0.25 % Sensorcaine (bupivacaine and epinephrine) and a release rate through dual catheter ends of 2 ml/h each, lasting for approx. 67.5 h post op. Results-41 patients, age 67.0 (42-84) years, height 164.5 (152.4-177.8) cm, weight 71.1 (45.4-129.4) kg were treated after mastectomies (n=43; two bilateral) for breast cancer (n=30) and carcinoma in situ (CIS) (n=11) with a local anesthetic wound catheter (n=43). The following procedures were performed: 31 modified radical mastectomies, 10 simple mastectomies and 2 simple mastectomies with sentinel lymph nodes. Intraoperative application of such a catheter system took less than 3 minutes. No intra- or postoperative complication or infection occurred within a follow up time of 30.3 months (0.2-52.4). Conclusion-Application of this temporary anesthesia catheter after mastectomy is easy and safe and reduces postoperative pain.

Study objectiveTo compare laparoscopic insufflators with different insufflation characteristics and evaluate the effects of resistance and leakage on maintenance of nominal pressure.DesignProspective study (Canadian Task Force classification II-2).SettingLaboratory of university clinic.InterventionsMeasurement in an abdomen box model of insufflator response to different resistance and leakage combinations during steady state while attempting to maintain a nominal set pressure of 12 mm Hg.Measurements and main resultsAn abdomen box model for laboratory measurements was designed with differing entrance and exit diameters simulated by hole disks of 0.5 mm to 7.6 mm. With a computer-based data-acquisition model, five insufflators (Olympus 9L and 16L, Storz 10L and 30L, HiTec 16L) were evaluated with 150 disk combinations. Average abdominal box pressures were recorded in three-dimensional (3-D) profiles showing different nominal pressure maintenance response for all insufflators regarding the resistance and leakage combination, maximum flow performance, and insufflation principle of the device. Average abdomen model box pressure can increase up to 26.57 mm Hg at 12 mm Hg nominal pressure setting (+121.4%). Insufflators with high flow rates (Storz 30L) tend to compensate leakage better but with the risk of higher intraabdominal pressure peaks. Insufflators with low-pressure principle (HiTec 16L) have limited pressure compensation but are safer for the patient.ConclusionsNominal pressure maintenance of insufflators is mainly dependent on flow resistance and leakage rate and less on potential insufflator flow capacity. With this 3-D model, the nominal pressure maintenance of different insufflators can be described for the first time regarding these main factors.

BACKGROUND AND OBJECTIVES:Within recent years, the insufflation technique for laparoscopy has become more important with high flow insufflators (> or = 30 L/min) and high gas turn over (> or = 800 L/procedure). Increased amounts of carbon dioxide (CO2) gas used can lead to laparoscopic hypothermia. We studied the insufflator with versus insufflators without internal gas heating (inside insufflator) as a sufficient method of hypothermia prevention at different flow rates.METHODS:With a computer-based data acquisition model, different standard insufflators with internal gas heating (Snowden Pencer) vs. without (Storz Endoflator, Storz Laparoflator, Richard Wolf, and BEI Medical) were compared regarding CO2 gas temperature at different points in the insufflation system (insufflator exit, insufflation hose end).RESULTS:Gas temperature of the Snowden Pencer insufflator, which is flow-rate dependent, increases at the exit (max. 35.4 degrees C). However, gas temperature is back to room temperature (-0.22 to +1.10 degrees C) at the end of the insufflation hose (10 ft or 3 m) for all 5 insufflators studied. Even at high gas flow rates (< or = 20 L/min), CO2 gas is at room temperature when it reaches the patient.DISCUSSION:No difference was noted regarding gas temperature between the insufflators compared. Insufflator internal gas heating, such as the Snowden Pencer insufflator, can not have a clinically significant effect because it is too far away from the patient to raise the gas temperature in the abdomen. Purchasers are misled because the gas-heating device has no measurable benefit for the patient.

The yeast Saccharomyces cerevisiae is recognized as an ideal eukaryotic microorganism for biological studies. Although yeasts have greater genetic complexity than bacteria, they share many of the technical advantages that permitted rapid progress in the molecular genetics of prokaryotes and their viruses. Some of the properties that make yeast particularly suitable for biological studies are rapid growth, a budding pattern resulting in dispersed cells, the ease of replica plating and mutant isolation, a well-defined genetic system, and a highly versatile DNA transformation system. Being nonpathogenic, yeast can be handled with few precautions. Strains of Saccharomyces cerevisiae—unlike most other microorganisms—have both a stable haploid and diploid state and are viable with many markers. The development of DNA transformation has made yeast particularly accessible to gene cloning and genetic engineering techniques. Structural genes corresponding to virtually any genetic trait can be identified by complementation from plasmid libraries. Plasmids can be introduced into yeast cells either as replicating molecules or by integration into the genome. Integrative recombination of transforming DNA in yeast proceeds exclusively via homologous recombinations, in contrast to other organisms.

OBJECTIVE:Patients demand that health care and procedures in rural areas be provided by ambulatory surgery centers close to home. However, the reimbursement rate for such procedures in ambulatory centers is extremely low, so a standard classic intrafascial supracervical hysterectomy procedure needs to be more cost effective to be performed there. Instruments and disposable devices can make up > or = 50% of hospital costs for this procedure, so any cost reduction has to focus on this aspect.METHODS:We identified the 3 most expensive disposable devices: (1) an Endostapler, 498 US dollars and 3 staple reloads, 179 US dollars each; (2) a calibrated uterine resection tool 15 mm for encoring of the endocervical canal, 853 US dollars; and (3) a serrated edged macro morcellator for intraabdominal uterus morcellation, 321 US dollars, and substituted them using classic conservative surgical techniques.RESULTS:From September 2001 to September 2002, we performed 26 procedures with this modified technique at an ambulatory surgery center with a follow-up of 6.7 (2 to 14) months. This modified operative technique was feasible; no conversions were necessary, and no complications occurred. Cost savings were 2209 US dollars per procedure; additional costs were 266.33 US dollars for suture material and an Endopouch, resulting in an overall savings of 50 509.42 US dollars. The disadvantage was an increase in operating room time of about 1 hour 20 minutes per case.CONCLUSION:These modifications in the classic intrafascial supracervical hysterectomy technique have proven to be feasible, safe, and highly cost effective, especially for a rural ambulatory surgery center. Long-term follow-up is necessary to further evaluate these operative modifications.

Piercing is an increasingly popular fashion trend mainly among adolescents. Umbilical piercing in particular can cause perioperative problems during laparoscopic procedures. We describe how to deal with this fashion trend in our institutions. First, any piercing needs to be documented during preoperative physical examination. During preoperative informed consent, patients are told that all pierced jewelry needs to be removed, preferably by the patient before the procedure. For the operation, patients may be offered the use of sterile “sleepers,” which are substitutes made of plastic to avoid closure of the wound canal perioperatively. Postoperatively, most pierced jewelry can be put back into position after anesthesia has completely worn off. Only jewelry for piercings close to wounds (e.g., navel piercings) should not be reinserted until the skin is closed. Careful observation and increased hygienic effort to prevent local infection is necessary. To date, we have not seen any severe umbilical infection after laparoscopy. However, in several patients the umbilical pierced jewelry was back in the navel on the same day of surgery, sometimes immediately after waking from anesthesia. Hospital staff should know how to remove and substitute piercing jewelry as well as how to optimize hygienic care perioperatively to prevent umbilical wound infections. Time and effort for patient teaching and hygienic care are slightly increased.

Study Objective. To evaluate a cost-optimized operative technique for outpatient laparoscopic hysterectomy in a rural ambulatory surgery center focusing on shortening hospital stay and substitution of expensive disposable laparoscopic instruments with standard surgical techniques.Design. Prospective feasibility and observational study (Canadian Task Force classification 11-3).Setting. Rural ambulatory surgery center in Lamar, Alabama.Patients. Fifty-two women.Intervention. Outpatient laparoscopic hysterectomy.Measurements and Main Results. From September 2001 through September 2003, 52 consecutive procedures with a modified classical intrafascial supracervical hysterectomy (CISH) technique without disposable instruments have been performed on patients with an average age of 42.2 years (range 25-62 years) and a follow-up of 12.5 months (range 0.4-23.6 months). Mean postoperative length of stay was 6 hours, 19 minutes (range 3 hours, 10 minutes-17 hours, 30 minutes), and overall length of stay was 11 hours, 37 minutes (range 6 hours, 45 minutes-22 hours, 50 minutes). Five patients (9.6%) stayed overnight, three for medical and two for social reasons. With an average of 2 hours, 14 minutes, the operating room time was about 1 hour longer than with disposable instruments. Health insurance reimbursement for the ambulatory surgery center was on average $1814.11. No complications occurred, and no readmission to the hospital was necessary.Conclusion: Outpatient laparoscopic hysterectomy is feasible and safe and can be performed cost effectively in ambulatory surgery centers, even in rural areas. Development of a protocol with patient selection, preoperative and postoperative patient teaching, caring family environment, and round-the-clock medical telephone backup is necessary.

Technical aspects of laparoscopic insufflation technique and interaction among patient, technique, and physician can affect the performance of laparoscopy and patient safety. A variety of laparoscopic equipment was evaluated regarding insufflation performance in laboratory measurements and/or in an intraoperative computer-based data-acquisition model for intraabdominal pressure, gas flow, and temperature. In this article, we present 25 suggestions for improving insufflation performance and increasing patient safety. These tips may help avoid and solve insufflation problems and malfunction, over- and under-pressure peaks, laparoscopic hypothermia, and gas embolism, and shorten operation room and anesthesia time, thereby saving time, money, and physician stress.

OBJECTIVE:We report and review herein our 10-year experience with classic intrafascial supracervical hysterectomy focusing on our long-term experience, evolution of the operative technique, and increased use of this technique.METHOD:We performed a parallel, observational study with retrospective data to evaluate classic intrafascial supracervical hysterectomy, a laparoscopic hysterectomy technique, at Fayette Medical Center, a community hospital in Northwestern Alabama, USA. Patients comprised a consecutive series of 579 over a 10-year period from November 1992 through November 2002.RESULTS:The classic intrafascial supracervical hysterectomy technique, similar to standard supracervical hysterectomy, leaves the cardinal ligament, uterosacral ligament, vascular supply, and innervation to the upper vagina and cervix intact, but unlike supracervical hysterectomy removes the transition zone and endocervical canal. For 579 patients, the average age was 45.4 years (range, 22 to 92), follow-up was 75.3 months (range, 17 to 137), operating room time was 69 minutes (range, 44 to 370), blood loss was 72 mL (range, 10 to 765), length of hospital stay was 23.2 hours (range, 14 hours to 5 days), time to return to work was 13.2 days (range, 3 to 28). Complications include 11 cervical bleedings, 1 uterine artery bleeding, 1 pelvic hematoma, 1 postoperative ileus, and 16 mucoceles of the cervical stump. Three patients were converted from a laparoscopic to an open procedure (0.52%). Long-term follow-up of up to 137 months shows no adverse events thus far.CONCLUSIONS:Classic intrafascial supracervical hysterectomy is a safe procedure with a low short- and long-term complication rate. It has a short recuperation period and high patient satisfaction. It is the procedure of choice when hysterectomy is indicated for benign disease.

Study Objective. To report technical aspects and practical long-term experience with classic intrafascial supracervical hysterectomy (CISH).Design. Retrospective evaluation (Canadian Task Force Classification II-2).Setting. Local community hospital in rural northwest Alabama.Patients. Four hundred thirty-seven women.Intervention. The procedure was performed as described originally but with slight modifications (vaginal manipulator, ETS stapler).Measurements and Main Results. Follow-up was 44.7 months (range 3-97 mo). Average operating time was 1 hour 70 minutes (range 46 min-6 hrs, 70 min), average blood loss was 68 ml (range 10-765 ml), average length of hospital stay was 22 hours (range 10 hrs-5 days), and average return to work was 14 days (range 3-28 days). Complications were 11 bleeding cervices (7 occurring within 21 days after surgery, and 4 between 2 and 4 yrs after surgery), 7 case of uterine artery bleeding, 7 ileus, 1 pelvic hematoma, and 5 mucoceles between 2 and 27 months postoperatively. There were three conversions, one because of morbid obesity (185 kg) and two because of large uterus.-pelvis ratio.Conclusion. CISH leaves the pelvic floor intact, has short recuperation and high patient satisfaction, and is cost effective at a low complication rate. It is an advanced laparoscopic procedure, is initially technically challenging, and has a learning curve.

Study Objective. To characterize insufflator CO2 gas flow performance to predict gas flow rate with standard cannulas.Design, Prospective, observational study (Canadian Task Force classification IL-2).Setting. Laboratory of university clinic.Patients, None.Intervention. Gas flow (L/min) and average pressure (mm Hg) inside an abdomen model were measured at 12 mm Hg nominal pressure during steady state.Measurements and Main Results. An abdomen box model for laboratory measurements was designed with different entrance and exit diameters simulated with hole disks from 0.5 to 7.6 mm. With a computer-based data-acquisition model, five insufflators (Olympus 9L and 16L, Storz 10L and 30L, HiTec 16L) were evaluated with 150 disk combinations. Flow performance in three-dimensional profiles showed different flow, rates for all insufflators depending on resistance and leakage combination, maximum flow rare, and insufflation principle. Maximum flow was reached without resistance only in the insufflation system at high leakage rates. Low-pressure principle is more affected by resistance. Cannula flow rates at 12 mm Hg and 15 L/minute leakage ranged from 4.8 (Origin) to 6.0 L/minute (Storz HiCap) for Olympus 9-L insufflators and from 5.4 (Origin) to 15.10 L/minute (Storz HiCap) for Storz 30-L Thermoflator. Reusable cannulas have more flow efficacy than disposable ones, especially with high-flow insufflators, because of larger diameter at insufflation supply.Conclusion. Gas flow depends not only on maximum Now of insufflators but also on resistance of cannulas and leakage rate. With this model it is possible to predict the real, available flow of insufflator-cannula combinations for the first time. Improved resistance of all components can save insufflation time.