Léonard de Vinci (1452–1519): andrologue avant la lettre

Leonardo da Vinci devoted 41 years of his lifetime to anatomy and anatomical drawing and opened new horizons in these two disciplines. He is therefore justly considered to be the father of modern anatomy. Considering the great number of his anatomical drawings dealing with the male urogenital tract and its function, Leonardo da Vinci can also be considered to be the father of andrology.     

Thoracoscopic lobectomy with the da vinci surgical system

Thoracoscopic upper lobectomy has been performed with the da Vinci surgical system in human cadavers. A minithoracotomy and two additional thoraco ports provided access to the thoracic cavity. An auxiliary port was used for both retraction of the lung and suction. The pulmonary vessels were ligated by robotic instruments, and the bronchi were divided after suturing robotically or with automatic staplers. A standard lymph node dissection was performed. The current da Vinci surgical system provided superior optics and enhanced dexterity. The application of the system for minimally invasive lobectomy may add benefits for both surgeon and patients.     

Left atrial myxoma: extraction by robotic and vacuum assistance

We report a single case of left atrial giant myxoma excision using the da Vinci S surgical system in a 47-year-old woman. A vacuum extractor device was designed to avoid tumor fragmentation or embolization. The myxoma was entirely removed under aspiration through the extractor device, achieving all the surgical tenets of myxoma excision.     

Leonardo da Vinci on atherosclerosis and the function of the sinuses of Valsalva

Although well studied by a medical scholar like Kenneth D. Keele, Leonardo da Vinci’s elaborate study of the heart is not generally known. This article focuses on two of Leonardo’s achievements concerning atherosclerosis and the sinuses of Valsalva. The first is his post-mortem observation on the degeneration of the vascular system in an old man, an early case history.     

BOOK REVIEWS

Book reviewed in this article:
Guide to the Botanical Gardens of Britain. Michael Young
An Irish Florilegium 11. Wendy Walsh, with introduction and notes by Charles Nelson.
The Gardens of Provence and the French Riviera. Michael Racine, Ernest J.-P. Boursier-Mougenot and Franqoise Binet
Collins Photoguide to Wild Flowers of Britain and Northern Europe. Oleg Polunin
Leonardo da Vinci on Plants and Gardens. William A. Emboden     

The Oberlin procedure for restoration of elbow flexion with the da Vinci robot: four cases

Robotics allows up to 40× visual magnification and 10× magnification of the surgeon's movements, and eliminates physiologic tremors. These properties should allow the development of mini-invasive limb surgery, especially of the brachial plexus. The purpose of this work was to test the feasibility of the restoration of elbow flexion according to the technique of Oberlin using a da Vinci robot. The authors' series included four patients (average age, 31 years) presenting with elbow flexion paralysis. They were operated on 8 months after injury using a da Vinci S robot. In three patients, the open technique (technique 1) was used, and the mini-invasive approach (technique 2) was used for the last one. Strength of elbow flexion was measured. After 1-year follow-up, all of the patients had recovered elbow flexion. No sensory or motor deficit was found in the ulnar nerve territory. There was no difficulty with technique 1; technique 2, however, required a conversion to technique 1 because of difficulty visualizing the operative field. The results of the authors' series show the feasibility of the robot-assisted technique for the Oberlin procedure. The lack of sensory feedback was not an issue. The development of specific retractors and instruments should improve the mini-invasive technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.     

Complex Bileaflet Mitral Valve Repair (Barlow's) Using the da Vinci Robotic Surgical System

Robotic mitral valve repair (RMVR) is less invasive and potentially more precise. However, RMVR lengthens both cardiopulmonary bypass and arrested heart times. In our initial experience, only posterior leaflet repair and/or annuloplasty were performed. With increasing experience, we have performed more complex bileaflet RMVR. A 50-year-old man presented with severe mitral regurgitation. Transesophageal echocardiography (TEE) demonstrated a complex bileaflet prolapse and preserved left ventricular function. Through a 4 cm working port and with the da Vinci Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA) RMVR was performed. Details of the technique and patient's hospital course are described. The repair comprised closure of clefts between A3 and P3, quadrangular resection of P2, transfer of multiple chords from P2 to A2/A3 and a #38 Cosgrove-Edwards (Edwards Lifesciences, Irvine, CA) band annuloplasty. Nitinol U-Clips (Medtronic, Minneapolis, MN) were used to complete the annuloplasty. Postoperative TEE showed no mitral regurgitation. The patient was discharged on the third postoperative day. Cardiopulmonary bypass and arrested heart times were 3 hours and 29 minutes and 2 hours and 59 minutes, respectively. Complex bileaflet repair of mitral valve with Barlow's disease can be successfully performed with the da Vinci Robotic Surgical System. Long-term follow-up is needed to assess the durability of repair.     

A laminar cortical model of stereopsis and 3D surface perception: closure and da Vinci stereopsis

A laminar cortical model of stereopsis and 3D surface perception is developed and simulated. The model describes how monocular and binocular oriented filtering interact with later stages of 3D boundary formation and surface filling-in in the LGN and cortical areas V1, V2, and V4. It proposes how interactions between layers 4, 3B, and 2/3 in V1 and V2 contribute to stereopsis, and how binocular and monocular information combine to form 3D boundary and surface representations. The model includes two main new developments: (1) It clarifies how surface-to-boundary feedback from V2 thin stripes to pale stripes helps to explain data about stereopsis. This feedback has previously been used to explain data about 3D figure-ground perception. (2) It proposes that the binocular false match problem is subsumed under the Gestalt grouping problem. In particular, the disparity filter, which helps to solve the correspondence problem by eliminating false matches, is realized using inhibitory interneurons as part of the perceptual grouping process by horizontal connections in layer 2/3 of cortical area V2. The enhanced model explains all the psychophysical data previously simulated by Grossberg and Howe (2003), such as contrast variations of dichoptic masking and the correspondence problem, the effect of interocular contrast differences on stereoacuity, Panum's limiting case, the Venetian blind illusion, stereopsis with polarity-reversed stereograms, and da Vinci stereopsis. It also explains psychophysical data about perceptual closure and variations of da Vinci stereopsis that previous models cannot yet explain.     

Generation and visualization of root-like structures in a three-dimensional space

In his Notebooks Leonardo da Vinci describes his diameter squared rule for the branching of above-ground tree parts. We now apply this branching-rule to the study of root-branching. Repeated application of this rule in a recursive computer program (ArtRoot) produces the diameters of the branches. An algorithm in this recursive program calculates the orientation of the branches in a three-dimensional space. From these data three-dimensional root-like structures are visualized by a computer program (PLUTON) designed to draw three-dimensional molecular structures. The visualization shows that starting from a relatively simple, symmetrical structure of dichotomous branching, more complex, asymmetrical root-like structures arise even if only a few parameter values are changed. The introduction of randomness into parameter values produces structures that differ considerably in their architecture. An extra force has been added in order to influence the orientation of new branches in space and to increase the flexibility of the structure formation.     

Mechanics of blood flow

The historical development of the mechanics of blood flow can be traced from ancient times, to Leonardo da Vinci and Leonhard Euler and up to the present times with increasing biological knowledge and mathematical analysis. In the last two decades, quantitative and numerical methods have steadily given more complete and precise understanding. In the arterial system wave propagation computations based on nonlinear one-dimensional modeling have given the best representation of pulse wave propagation. In the veins, the theory of unsteady flow in collapsible tubes has recently been extensively developed. In the last decade, progress has been made in describing the blood flow at junctions, through stenoses, in bends and in capillary blood vessels. The rheological behavior of individual red blood cells has been explored. A working model consists of an elastic membrane filled with viscous fluid. This model forms a basis for understanding the viscous and viscoelastic behavior of blood.     

流程再造在达芬奇机器人辅助手术中的应用

目的探讨达芬奇机器人辅助手术中应用流程再造对患者的影响。方法对我院实施达芬奇机器人辅助手术患者108例进行流程再造,观察流程再造前后手术开台时间,医护人员以及患者满意度,术后并发症和住院时间情况。结果流程再造后手术开台时间和并发症均有降低,医护人员满意度和患者满意度均有提高,与流程再造前比较差异均有统计学意义(均P0.05);流程再造前后患者的住院时间比较,差异无统计学意义(P0.05)。结论在达芬奇机器人辅助手术中应用流程再造,能缩短达芬奇机器人辅助手术开台时间,提高医护人员以及患者满意度,减少了患者术后并发症。     

Robotic-assisted cryosurgical treatment of atrioventricular node reentrant tachycardia

Atrioventricular nodal reentrant tachycardias typically arise from the existence of variable refractoriness in fast and slow conduction pathways within the triangle of Koch, which provide input to the atrioventricular node. Standard therapy includes medical management and catheter-based ablation procedures. Robotic-assisted, minimally invasive cryosurgical modification of the atrioventricular node can provide definitive therapy for patients who fail traditional therapy. A 65-year-old man presented with a several-year history of recurrent atrioventricular nodal reentrant tachycardia. Despite medical management and attempted percutaneous ablation, the patient remained symptomatic with weekly episodes. Access was via a 4-cm right anterolateral thoracotomy and peripheral perfusion. The da Vinci S robotic system was used to manipulate the cryoprobe (CryoMaze Probe; ATS Medical, Plymouth, MN USA). A series of spot freezes (tip 60°C) were made along the boundaries of the triangle of Koch until transient complete heart block was achieved and nodal rhythm was recovered. At follow-up 3 weeks postoperatively, the patient was asymptomatic in first-degree heart block. Robotic-assisted cryosurgical atrioventricular node ablation is an effective, minimally invasive treatment for patients with atrioventricular nodal reentrant tachycardia.     

Computer assisted laparoscopic pneumovesical ureter reimplantation a.m. Cohen: initial experience in a pig model

To assess the feasibility of a new variant of laparoscopic Cohen cross-trigonal ureter reimplantation in vesico-ureteral reflux (VUR) using telesurgical equipment. VUR was induced in 8 female pigs by transurethral unroofing of the ureteric orifices. Three months later the reflux was verified by a cystography. A cross-trigonal ureter reimplantation a.m. Cohen was performed by laparoscopic access to the bladder using the da Vinci telesurgical system. The 12 mm camera port was placed below the umbilicus, two 8 mm working ports for the robotic system were placed lateral to the rectus muscles and an additional port for assistance between camera and right working port. The outcome was assessed 3 months later by a new cystography. The operative time for a single reimplantation varied from 45 to 90 minutes. In all pigs the reflux disappeared after the procedure, which was complicated by a postoperative port hernia in two animals. Laparoscopic transvesical ureter reimplantation using telesurgical equipment is a feasible method in the few cases this procedure is indicated. The advantage of the robotic equipment is the better access to submucosal tunneling of the ureter and the intravesical suturing of the anastomosis indicated by shorter operative time and success rates similar to the open procedure.     

The Renaissance or the cuckoo clock

‘…in Italy, for thirty years under the Borgias, they had warfare, terror, murder and bloodshed, but they produced Michelangelo, Leonardo da Vinci and the Renaissance. In Switzerland, they had brotherly love, they had five hundred years of democracy and peace—and what did that produce? The cuckoo clock’.Orson Welles as Harry Lime: The Third Man

Orson Welles might have been a little unfair on the Swiss, after all cuckoo clocks were developed in the Schwartzwald, but, more importantly, Swiss democracy gives remarkably stable government with considerable decision-making at the local level. The alternative is the battling city-states of Renaissance Italy: culturally rich but chaotic at a higher level of organization. As our understanding of the cell cycle improves, it appears that the cell is organized more along the lines of Switzerland than Renaissance Italy, and one major challenge is to determine how local decisions are made and coordinated to produce the robust cell cycle mechanisms that we observe in the cell as a whole.     

达芬奇机器人与腹腔镜手术治疗胰腺癌的近期疗效比较及对血清CRP、PCT及肿瘤标志物的影响

摘要 目的：探讨达芬奇机器人与腹腔镜手术治疗胰腺癌的近期疗效比较及对血清C-反应蛋白（CRP）、降钙素原（PCT）及肿瘤标志物的影响。方法：选择2019年1月至2020年1月在我院接受治疗的61例胰腺癌患者,根据手术方法分为机器人组（n=26）和腹腔镜组（n=35）。腹腔镜组给予腹腔镜手术治疗,机器人组给予达芬奇机器人辅助治疗。比较两组围术期情况、CRP 、PCT、糖类抗原19-9（CA19-9）、糖类抗原125（CA125）、术后恢复情况及并发症发生情况。结果：机器人组禁食时间及排气时间显著低于腹腔镜组,差异显著（P<0.05）;治疗前,两组血清CA19-9、CA125水平无明显差异;治疗后,两组血清CA19-9、CA125水平治疗后较治疗前均显著下降差异显著（P<0.05）;两组治疗后血清CA19-9、CA125水平比较无显著差异（P>0.05）;治疗前,两组CRP、PCT水平无明显差异;治疗后,两组CRP、PCT明显升高,且机器人组低于腹腔镜组差异显著（P<0.05）;机器人组和腹腔镜组术后下床活动时间、拔尿管时间、术后住院时间比较无显著差异;机器人组术后重症监护时间显著低于腹腔镜组,差异显著（P<0.05）;两组患者治疗期间并发症总发生率分别为4.44%、6.67%,无显著差异（P>0.05）。结论：达芬奇机器人辅助能够显著提高胰腺癌手术质量,且对血清CRP 、PCT的影响较小,且对肿瘤标志物的影响与腹腔镜手术较为接近,为患者提供机器人微创治疗是未来临床的必然发展趋势。     

Valéry et l’automatisme psychologique

While the name of Paul Valery is usually associated with that of Leonardo da Vinci or the character, Monsieur Teste, most people are unaware of Valery’s posthumous work, which he considered the most significant of his writings: Cahiers/Notebooks, a voluminous and dense work, in its dimensions (around 30,000 pages) as well as in what it discloses about the daily ponderings of a man who considered himself — in spite of himself — a philosopher. It is a multifaceted work, touching on all fields of thought: history, politics, and the sciences, in all their diversity, from mathematics to physics, and biology to the theory of evolution. Neither philosophy, nor theology, nor linguistics is left in the dark. But he clearly expressed a preference for psychology and, more specifically, the question of mental function: What is it to think? How does the mind link ideas? What is abstraction? What role do feelings play? What is the relationship between the mind and the machine? Must we concede the existence of the unconscious mind. These are some of the questions we address in elucidating the concept of automatism through what makes it work as well as its failings.     

喀斯特峰丛洼地不同植被恢复阶段优势种根系构型特征

以喀斯特峰丛洼地不同植被恢复阶段灌丛、次生林、原生林为研究对象,采用全挖法分析了各阶段4个优势种的根系构型参数,探讨该特殊生境条件下植物根系构型的差异性、相似性以及资源合理高效的利用方式。结果表明:(1)各个植被恢复阶段优势种拓扑指数TI均趋向于0.5,呈叉状分支结构,并表现为次生林(0.57)原生林(0.49)灌丛(0.46),有利于根系在贫瘠且浅薄的土壤环境中拓展生存空间。(2)3种植被恢复阶段优势种的根系平均连接长度在34.29cm以上,平均为37.01cm,增加连接长度对植物在养分贫瘠的喀斯特土壤环境的生存有利。(3)次生林根系分支率低于灌丛和原生林,这是不同植被恢复阶段优势种对环境所采取的不同适应策略。(4)3种植被恢复阶段优势种根系的横截面积比均符合Leonardo da Vinci法则,且不随直径的变化而变化。(5)3种植被恢复阶段优势种在土壤养分、水分获取及土壤空间拓展方面没有显著差异性。研究认为,在喀斯特峰丛洼地异质性很强的生境下,3种植被恢复阶段优势种的根系均为叉状分支结构,且均以较长的连接长度和较低的分支率策略适应其特殊的生态环境。     

Mediastinal parathyroidectomy with the da Vinci robot

Mediastinal parathyroid glands are often located in a position which is inaccessible through a cervical approach. Because of the significant morbidity of open surgery, the need for minimal invasive approaches is high. More recently, robotic systems have been introduced to refine the dissection and optimize the view in the mediastinal region. We present two cases. The first case is a 34-year-old woman who was diagnosed with primary hyperparathyroidism. Because a bilateral neck dissection disclosed no parathyroid adenoma, we performed a parathyroid sestamibi scan and computed tomographic scan of neck and mediastinum to look for aberrant parathyroid glands. Both showed a parathyroid adenoma in the mediastinum on the left side. The second case is a 66-year-old man. A sestamibi scan showed a parathyroid adenoma of 3 cm in the superior mediastinum which was confirmed by and computed tomographic scan. In both cases, we performed a parathyroidectomy with the da Vinci robotic system through a left-sided approach. Three thoracoports were inserted around the mammary gland for the robot and a fourth auxiliary port was positioned in between. Single-lung ventilation was installed, and the mediastinum was entered by opening the parietal pleura along the left phrenic nerve. The upper margin for dissection was the left brachiocephalic vein that was followed until the right pleura. All the tissue in front of the pericardium was dissected en bloc. The sinking test of the nodule and a preoperative frozen section analysis confirmed the diagnosis of parathyroid adenoma, which was also proven by rapid parathyroid hormone analysis. The resection of a parathyroid adenoma from the aortopulmonary window represents an ideal case for robotic surgery.