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Morning Five: 03.13.13 EditionPosted by nvr1983 on March 13th, 2013
- The swag that college football teams get at bowl games may garner plenty of attention, but they are not the only college athletes to receive significant amounts of swag. Participants in the NCAA Tournament will receive an estimated $750,000 in gifts with the value of the gifts escalating if teams make it to the Final Four. Unlike college football (at least to our knowledge) the gifts are not limited to just teams that make the equivalent of a bowl game (the NCAA Tournament) as players in nearly every conference tournament will be taking home gifts ranging for t-shirts to televisions. We won't try to argue that this is comparable to a stipend that many are advocating, but it is a nice bonus.
- All programs are subject to up and down periods, but mid-majors are more subject to these extremes than most teams in power conferences and Siena is a prime example. It was not that long ago that the Saints made three straight NCAA Tournaments (2008-10), but once Fran McCaffery left things went downhill quickly as they went 35-59 in the following three seasons and yesterday that led to the firing of Mitch Buonaguro, McCaffery's lead assistant and replacement. Given the sudden drop-off that the program experienced and the lack of progress the team showed in regaining its former glory the decision should not be too surprising. We doubt that we will see Siena reach the heights they saw under McCaffery, but the initiative the administration has shown and the tradition that McCaffery built should make it an appealing destination for a long-time assistant looking for his first job or a coach at a mid-major looking to move up in the college basketball world.
- We wish we could say the same about UMKC, which fired Matt Brown yesterday, but we are must more skeptical that the Kangaroos (yes, that is actually their nickname) will become a real mid-major threat. Even that lowered expectation was not enough to save the job of Brown, who went 64-122 in six seasons including 8-24 this season. Looking through Brown's record at UMKC it is not hard to see why Brown was fired even with what we would expect are fairly low expectations at a school that has the misfortune of being surrounded by three basketball powerhouses.
- We have not seen many significant recruits opt to go the overseas rather than head to college (Brandon Jennings is the most notable exception), but Seton Hall commit Aquille Carr appears to joining that small group. The decision is not exactly shocking for people who have followed Carr closely as the 5'6″ guard had previously mentioned playing in Europe and his arrest last summer for assault and reckless endangerment raised further questions about whether he would end up on a college campus. Still Carr's decision is the latest in a series of blows for Seton Hall coach Kevin Willard, who went 3-15 in the Big East this season and now has lost two of the guards he was looking forward to bringing to campus next season (both also already carried criminal charges).
- With the regular season winding down every analyst's rankings becomes a little less hot debated as we are finally getting to the point of the season where teams control their "ranking" based on what they do on the court rather than how impressive they are in doing so. That does not mean that Luke Winn's Power Rankings are not as useful as ever with their usual wealth of information. Winn decided to go a little heavier in terms of subjective rankings than usual to offer his Player of the Year, Coach of the Year, and Freshman of the Year ballots, but he still has plenty of other interesting data including an analysis of how unique Gonzaga's offensive distribution is and showing just how badly Florida's guards are shooting.

subset: commoncrawl


text: Create die-cut gift boxes and party favors in seconds with Thinlits dies and the Big Shot. The delicate design provides a peek of what's inside. Thinlits Dies help you create detailed die-cuts with just a few turns of the Big Shot handle. Detailed dies include ejection holes so you can remove the paper easily.* 9 dies* Largest image: 6" x 5-9/16" (15.2 x 14.1 cm)* Use with Big Shot* Use Precision Base Plate with detailed images


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If, on initial entry into an alliance program, you receive $30/head above Certified Angus Beef "TM" (CAB) cattle, you'll sit up and take notice. Burlington, OK, producer Kent Kisling did. He became a member of the Farmland Supreme Beef Alliance (FSBA) early on and benefited by receiving a premium on his calves based on the FSBA grid.
Formed in September 1995, FSBA is a collaborative effort of Farmland Industries, Agri Beef Company and Farmland National Beef Packing Co. FSBA targets production for products within the Farmland Black Angus Beef(tm) and CAB labels.
To date, about 270 producers have placed nearly 140,000 head at Supreme Feeders, the sole feedyard for FSBA, and the alliance is experiencing continual growth. Nearly 112,000 head have been slaughtered at National Beef. As of June 1997, FSBA had paid $1 million in producer premiums.
Kisling says because the program feeds with a goal of achieving a Prime grade, it pays off at slaughter. He and his partner, John Schupbach are using involvement in FSBA to improve their cow herd and management practices, including making cull decisions, better bull selection and using artificial insemination (AI).
"We AI'd 20 heifers last year. This year we'll do 67 heifers and 16 cows," Kisling says. Bull and semen selection are based on a combination of factors from information provided on the first set of slaughtered calves and the advice of Butch and Mike McCracken, fellow producers experienced with AI.
In addition, Kisling leans heavily on Expected Progeny Differences (EPDs). He's running a majority of Angus-based cows and heifers, consisting of about 250 cows plus a group of heifers. The bulls they've bought have come from herds also involved in FSBA.
"When we get data back on the group we're feeding now, I hope we can make even more effective breeding decisions," Kisling says. Breeding is just one area the alliance has helped Kisling improve. It's also created a varied income source.
"Our alliance involvement allows us to diversify our stocker operation," Kisling says. "Basically, it takes all of our eggs out of one basket, primarily stockers."
What opened his eyes, says Kisling, was a Farmland-sponsored conference that brought producers together with foreign meat buyers. "We had the opportunity to talk about what they (buyers) needed. Farmland is providing a way to supply their needs while allowing us to enhance our product in the U.S. We need the organization and structure it offers. We can't do it all ourselves," Kisling says.
For information contact Jim Norwood, CEO of FSBA, at 816/891-3644 or Julie Kistler at 816/891-3645.


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Select the offers that interest you!
The clown Mauro has passed, but his spirit is still with us. Instead of mourning, the funeral cortege celebrates the here and hereafter with laughter and exuberance. Rich, extravagant memories frolic with the senses. The sound of laughter peals around the stage, visions of joyous tumblers and players fascinate the eyes. Regret and melancholy retreat in the face of a cavalcade of lively recollections of a life gloriously lived. A festive parade that entertains; the perfect accolade for an artist whose life was dedicated to revelry and making merry.
DisclaimerDue to the nature of the acts in the show, changes in the cast may occur. In addition, the content and duration of the show may differ from time to time. Although we try to keep this information up to date, we cannot guarantee its accuracy.


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Verizon: We Protect Our Customers' Data... Until The Government Asks For It
from the um,-that's-not-protecting deptSo, Verizon has finally come out with a statement about the fact that they're handing over all data on every call anyone on its network makes to the government. And the response is just as ridiculous as you'd expect:
You may have seen stories in the news about a top secret order Verizon allegedly received to produce certain calling information to the U.S. government.Let's parse that a bit. First, to "not comment" on it is ridiculous. This is the same issue I had with the government pretending that leaked Wikileaks documents had never leaked. It's not reality-based. In the business world, if you sign a non-disclosure agreement, it only applies to information that remains private. If the same information becomes public through other means, it's recognized that the non-disclosure agreement no longer applies. Because that's living in reality. Pretending you can't comment on the document is not reality-based.
We have no comment on the accuracy of The Guardian newspaper story or the documents reference, but a few items in these stores are important. The alleged court order that The Guardian published on its website contains language that:
Verizon continually takes steps to safeguard its customers' privacy. Nevertheless, the law authorizes the federal courts to order a company to provide information in certain circumstances, and if Verizon were to receive such an order, we would be required to comply.
- compels Verizon to respond;
- forbids Verizon from revealing the order's existence; and
- excludes from production the "content of any communication . . . or the name, address, or financial information of a subscriber or customer."
Second, the claim that "Verizon continually takes steps to safeguard its customers' privacy" is completely meaningless when they're handing every bit of that data over to the government. Third, the idea that this order "excludes" information like someone's name is pretty silly. Don't you think that the federal government might have a giant database, in the form of a basic phone book that lets them look up the name associated with each number?
But, most importantly, this whole claim that Verizon is compelled to obey is silly and ignores some of the history. When the government asks you to break the law, you have the right to say no. And here's the big thing: even if this is legal today, that only came about because various telcos worked with the government on broad lawbreaking in the past, only to have the government paper that over with new laws that made such things "legal" and included retroactive immunity. And, really, that's all that Verizon really cares about (and you'll note they don't mention it): that they have no liability for coughing up everyone's information.
Filed Under: data, government, privacy


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Boulder Brands, a Boulder County-based natural products company that owns brands such as Smart Balance and Udi's, announced Thursday it acquired Davies Bakery, a United Kingdom-based gluten-free bakery.
As a result of the acquisition, Boulder Brands (Nasdaq: BDBD, $9.30) will establish a subsidiary, Boulder Brands UK, and expand its Udi's Gluten Free Foods to the United Kingdom.
Boulder Brands paid 2.5 million pounds, or nearly $3.9 million, for Davies Bakery, which recorded approximately $2 million in sales last year, according to Boulder Brands' first-quarter earnings report that was also released Thursday
During the quarter that ended March 31, 2013, Boulder Brands posted a net income of $3.96 million, or 7 cents per share, on revenue of $106.65 million. In the comparable year-ago period, the company — then known as Smart Balance Inc. — made $3.7 million, or 6 cents per share on revenue of $79.29 million.
Smart Balance completed its acquisition of Udi's in July of last year.
Net sales increased nearly 35 percent, officials said, adding that assuming Boulder Brands owned Udi's for the first quarter of 2012, sales would have increased 9.5 percent.
Smart Balance Inc. formally changed its name to Boulder Brands Inc. earlier this year. The company has announced its intentions to move its headquarters to Boulder.
Boulder Brands' quarterly earnings were boosted by gains in its Natural segment, which includes the gluten-free category. The company's Smart Balance segment experienced a 16 percent sales decline, which company officials attributed to a "strategic plan to improve profitability."
The company plans to discontinue some categories including Bestlife spreads and Smart Balance Butter Blends.


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And I haven't seen the pilot... should I buy the tape or an import DVD?
okay i know i keep talking about this and not really saying anything, but !!!! OH MY GOD! second episode of season two was great! the goddamn last 5 minutes after they sing that song and lauras cousin 'sees' the guy walking towards her from behind the couch, is the absolute scariest thing ive seen since the girl climbing out of the tv at the end of the ring. TERRIFYING.
I had to cover my eyes. No lie.


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Program Overview
The Rural Underserved Opportunities Program (RUOP) is a four-week, elective immersion experience in community medicine for students between their first and second years of medical school. During their 4-week rotation, students live in rural or urban underserved communities throughout Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI). They work side-by-side with local physicians providing health care to underserved populations. Administered by the Office of Rural Programs, RUOP is a collaborative effort of the UW School of Medicine, WWAMI campuses and the Area Health Education Centers. It is also supported by the Washington and Idaho Academies of Family Physicians. For more information, contact the RUOP Administrative Office.
Program Goals
- Provide students with an early exposure to the challenges and rewards of practicing primary care medicine in a rural or urban underserved setting.
- Promote in students a positive attitude toward rural and urban underserved community medicine.
- Provide students with an opportunity to learn how community health care systems function.


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The House Ethics Committee said Monday it will not appoint a special panel to investigate allegations that Rep. Cathy McMorris Rodgers, the fourth-highest ranking House Republican, improperly combined campaign and official funds in a GOP leadership race and her re-election campaign.
The committee's top two leaders, Reps. Michael Conaway, R-Texas, and Linda Sanchez, D-Calif., said they will not formally drop the case against McMorris Rodgers, but will continue to review the matter under their own authority. In practical terms, the decision means it is unlikely that McMorris Rodgers will face charges or sanctions.
Separately, the ethics panel said it also will not appoint a special panel to investigate Republican Rep. Markwayne Mullin of Oklahoma. Mullin was alleged to have improperly received outside income totaling $600,000 last year from a weekly radio talk show and family-owned plumbing business. Both cases were forwarded to the Ethics Committee's attention by the independent Office of Congressional Ethics, which reviews complaints against House members.
The ethics office said it found "substantial reason to believe" the allegations in both cases.
McMorris Rodgers, 44, of Washington state, is the highest-ranking Republican woman in the House. She delivered the GOP response to President Barack Obama's State of the Union address in January.
Her attorney, Elliot Berke, said the complaint against her was based on "frivolous allegations from a single source — a former employee who then discredited himself by admitting to his own improper conduct."
The onetime employee was Todd Winer, a former spokesman for McMorris Rodgers who told the ethics office that he wrote campaign speeches for her on his work computer during business hours, and that he and other staffers frequently wrote news releases and did other work for the campaign on government time.
But Berke said other staffers contradicted Winer, telling investigators that debate prep and other campaign work was done on a voluntary basis and on their own time. On one occasion, McMorris Rodgers recalled that some "conversation" about a debate was held in her Capitol Hill office "because she knew her home was noisy with her young children," Berke said.
"Neither Congresswoman McMorris Rodgers nor any other staff members were aware of" Winer's actions, Berke said. "At no time did they improperly mix official and campaign resources."
Berke said he is confident the ethics panel ultimately will dismiss the complaint.
Winer, in lengthy testimony to the ethics office, said he and several staffers attended a debate prep session at the congresswoman's office in the Rayburn building on a weekday in October 2012, in apparent violation of House rules. Staffers also traveled to a debate in Spokane, Wash., later that month and attended other campaign events over several days, all on official time, Winer said. Such actions would violate House rules that require campaign activities be separated from official duties.
Winer, who now serves as spokesman for Rep. Raul Labrador, R-Idaho, did not return a telephone call or email Monday.
The report by the ethics office was forwarded to the House Ethics panel in December. The committee made it public Monday.
Winer told investigators that he was uncomfortable performing campaign work on staff time, but was told by the congresswoman's former chief of staff, Jeremy Deutsch, that he "wanted to keep down costs" for the campaign so McMorris Rodgers would have more money to contribute to other GOP candidates and build support for her race for GOP leadership. McMorris won election as GOP Conference chairwoman in 2012.
The report also says that McMorris paid a campaign consultant with official funds, a violation of House rules.


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The Lamar County Trojans (13-3) host Wesleyan (11-8-1) at Trojan Field in the Elite 8 round of the GHSA Class AA state soccer playoffs.
Match time is 6:30 p.m.
Realtime scoring from the game by Walter Geiger
Wesleyan 1-0. Goal Benji Johnson on header off corner kick.
Wesleyan 2-0. Goal Cort Cockshead
Wesleyan 3-0. Goal Sam Straker off corner kick
Wesleyan 4-0. Goal Straker
Wesleyan 5-0. Goal Cort Cockshead
Wesleyan 6-0. Goal Cockshead
Wesleyan. 7-0. Goal Straker
Trojans fall hard in Elite 8
No Trackbacks


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Precious few things in sports are as clear-cut as a single-elimination playoff.
Win and advance, or lose and go home.
At this point in the season, when stakes are multiplied and mistakes are magnified, pure ecstasy and utter despair share the same field.
OCVarsity photographers have captured both ends of the spectrum all season, and they'll continue to do so 'til the joyous (or bitter) end.


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Fluid operated retractors
A fluid operated retractor for use in surgery. The retractor has a portion which is expandable upon the introduction of fluid under pressure. The expandable portion is made of a material strong enough, and is inflated to enough pressure, to spread adjoining tissues within the body. The retractor is especially useful in fiber optic surgery because it can be inserted percutaneously through a small opening then expanded to a much larger dimension when in the desired location, to retract tissue from within. The retractor may be used to spread a joint such as a knee joint or a shoulder joint, or may be used to separate tissue planes generally, to improve visualization and create a working space for the surgeon.
1. Technical Field
The present invention relates to tissue retractors for use in medicine. More particularly, the present invention relates to fluid operated apparatus for use in moving apart abutting tissues, during surgery, in order to create a space between the tissues to improve visualization and for increased working space during open surgery and fiberoptic assisted surgery.
2. Description of the Prior Art
Current methods used for retracting tissue and improving visualization are mechanical separation using metal retractors during open surgery, or the direct pressure of an unconfined flow of fluid such as water or CO.sub.2 during fiberoptic surgery. A typical mechanical external fixator has pins driven through the bones and mechanically distracts the elements of the joint. Problems with the water method include fluid extravasation including into and through the tissue itself. Increased pressure and swelling result in the area, resulting in edematous or swollen tissue. Excess pressure from mechanical retractors may cause necrosis or tissue death. With these methods, it is impossible to monitor the pressure being applied to the body tissues, and tissue damage or necrosis can result.
While operating from within the body, i.e., fiber optic assisted surgery as opposed to open surgery, there is no known way to selectively move or retract tissue, either hard tissue such as bone or soft tissue, out of the way to improve visualization. No device in use adequately allows a surgeon to create an actual space or expand a potential space in the body, by separating adjacent layers of tissue. The prior art does not disclose a retractor which is powerful enough and made of a material which is strong and resilient enough to, for example, separate tissue planes from within. Such a device, especially in the field of fiber optic surgery, would allow a surgeon to visualize and operate without using the conventional bulky and awkward mechanical retractors which require large open incisions. Such a device would also permit working within the body without damaging a great deal of tissue in the path between the skin opening and the working area, by minimizing the external orifice or skin incision.
The present invention is a system of retractors which a surgeon can use to take potential spaces within the body and turn them into existing spaces safely and easily and controllably in order to safely visualize appropriate tissue and operate. The retractor selectively moves appropriate tissue out of the way to enable a surgeon to see and work better within the body, and selectively moves body parts such as joint parts or soft tissue planes in order to create a space between the tissues for visualization and for working.
The retractor of the present invention includes a fluid-operated portion such as a balloon or bladder to retract tissue, not merely to work in or dilate an existing opening as for example an angioscope does. The fluid-filled portion is flexible, and thus there are no sharp edges which might injure tissue being moved by the retractor. The soft material of the fluid-filled portion, to an extent desired, conforms to the tissue confines, and the exact pressure can be monitored so as not to damage tissue. The expanding portion is less bulky and more compact, and the pressure it applies at the tissue edges can stop bleeding of cut tissue. These are all features not possessed by a conventional mechanical retractor.
With a typical mechanical retractor, the opening in the skin and thence inwardly must be larger than the surgical area being worked upon, in order to be able to get the mechanical retractor into position. The surgeon must damage a large amount of tissue which may be healthy, in order to expose the tissue to be worked on. The retractor of the present invention minimizes damage to tissue in the way of the tissue the surgeon needs to expose, which was previously cut in a large open exposure. With the retractor of the present invention, the opening at the skin is smaller at the skin where the device is inserted, and wider at the location inside the body where the retractor is expanded. The retractor is first placed into the body in an unexpanded condition, and then, as it is expanded, pushes tissue out of the way in deeper layers of the body one can see and safely operate on affected tissue. Thus, less undesired tissue damage occurs.
The bladder is pressurized with air or with water or another fluid. The fluid used in the bladder must be safe if it accidentally escapes into the body. Thus, besides air, such other fluids as dextrose water, normal saline, CO.sub.2, and N.sub.2 are safe. The pressure in the bladder is monitored and regulated to keep the force exerted by the retractor at a safe level for tissue to prevent tissue necrosis. The retractor can exert a pressure on the tissues of as high as the mean diastolic pressure of 100 mm of mercury, or higher for shorter periods of time, while still being safely controlled. Typical inflatable devices such as angioscopes do not have anywhere near the strength, or the ability to hold enough fluid pressure, or shapes to retract tissue as described herein. As compared to prior art devices, the retractor of the present invention operates with greater pressure within the bladder, since it is made of stronger materials such as Kevlar or Mylar which may be reinforced with stainless steel, nylon, or other fiber to prevent puncturing and to provide structural shape and support as desired. Such materials are strong enough to hold the necessary fluid pressure of about several pounds or up to about 500 mg Hg or more and exert the needed force on the tissue to be moved. The choice of material is well within the ability of one familiar with such materials and accordingly will not be gone into in further detail herein. The present retractor is thus able to exert substantially more force on adjoining tissues than a prior art device. The shapes of the retractors are specific for each application, and may include separate variable chambers which are sequentially controllable, to control the direction of tissue retraction.
The fluid-filled portion of the retractor is preferably a unitary portion such as a bladder. In this case, the bladder is expanded with the introduction of fluid under pressure. Alternatively, the fluid-filled portion of the retractor may include a series of prongs or filaments which expand radially outwardly upon the introduction of fluid under pressure. The prongs themselves may be expandable, or there may be an expandable portion located centrally of all the prongs which, when it expands, forces the prongs outwardly.
Typically, the height of the bladder, that is, its width or transverse dimension, is significantly greater than its length (axial or longitudinal dimension). The bladder expands primarily in width only, not in length, although the shape will vary with the application. This is in accordance with the purpose of the device which is to enable the separation of adjacent tissue layers to, for example, allow improved visualization in front of a scope inserted between the tissue layers.
The retractor of the present invention can be used to direct or position the end of a scope relative to the tissue walls. The retractor can also be used to stabilize the end of a scope. When a camera is being used via the scope, the scope often moves or jumps around because of the flexibility of the end of the scope. This is prevented by inflating bladders at the tip or along the shaft of the fiberoptic scope to control the direction of the tip of the scope and thus stabilize the scope, leaving both hands free to work and providing a stable image for the surgeon.
Surgeons operate along tissue planes. Once a surgeon finds a tissue plane, he dissects along it, starting the separation process with the knife. The retractor holds the tissue layers apart and helps and eases in defining and further separating the tissue layers as the surgeon operates along the tissue planes, helping to spread and define the planes. The retractor helps to separate the tissue layers, increasing the space for operating, and improving the surgeon's ability to separate and visualize, leading to better and safer surgical technique.
A preferred use for the present retractor is in the field of fiber optic surgery, including endoscopy, arthroscopy, laparoscopy, etc. which require looking into and operating within a limited space with a fiber optic light and camera. The open or existing spaces in joints are generally too small to permit easy operation and visualization. In the prior art, only direct (unconfined) water or air pressure is used to expand the joint capsule or tissue in the joint. This may actually push tissue in front of the scope, obscuring vision. The present retractor distracts a joint directly to make it easier to see inside (around) the joint. A sleeve which can be a malleable or rigid sheath may optionally be provided to protect the tissue as the bladder is slid in and out of the end of the cannula once in the work area within the joint. The bladder expands into an area of soft tissue--for example the bursa--and pushes it out of the way. The bladder can be left in place during the operation, or it can be deflated and removed, and the arthroscope and other instruments can be put into the space created.
An alternative preferred use for the retractor of the present invention is to operate in a joint of the spine, and specifically between two vertebrae. The retractor is used to spread two vertebrae apart to enable removal of the spinal disc from between the vertebrae.
Other uses of the retractor are as an occluding device to stop blood flow from an anastomosis or angioscopic procedure, or to stop backflow (retrograde flow) of stomach or colon contents. The retractor of the present invention is also suitable for use in the tempomandibular joint. Specifically, a dentist or oral surgeon uses an appropriately shaped retractor to hold open the jaw of a patient while the dentist or oral surgeon works on the mouth of the patient. The inflatable retractor is much more comfortable to the patient than a rigid metal or plastic device, it conforms to the jaw structure rather than pressing unevenly against it, and lessens fatigue. Thus, it is safer for the dentist by safely maintaining the two rows of teeth spaced apart and by increasing visibility for working, while at the same time being easier for the patient.
The retractor can also be a useful diagnostic tool. The strength or pressure or resistance of tissue can be measured by the pressure required to move it.
The bladder may be a bellows type device in which the material does not stretch but which expands when pressurized from within and which is collapsed by the use of suction. In this case, it would preferably be made of a polymer of the class including Kevlar or Mylar fabric for strength and structural integrity. The bladder may generally also be made from any very thin walled polymer.
The bladder may also be made from a biocompatible and/or biodegradable material, so that if it can not be removed from the body for some reason, or if the surgeon desires to keep the bladder in place in the body for a period of time, it will not damage the tissue and may eventually be resorbed into the body. Such a biodegradable bladder may be left under the skin postoperatively to stop postoperative bleeding or to keep tissue expanded. Alternatively, the bladder may made of a stretchable material which stretches when pressurized from within, and then collapses partially of its own accord when depressurized or also with the help of suction. The retractor may be transparent for better visibility, but it need not be for some applications. Also, the retractor can be disposable. The material choice is within the skill of the art. One surface of the bladder may be made of or have thereon a reflective surface to reflect light to see around a corner.
The retractor can be used as a joint jack----that is, to distract a joint from within in one area and provide ease of access through the joint. Less damage to the joint occurs if the tissue edges are spaced apart during a procedure. When placed between two joint surfaces it pushes them apart from within, increasing the space available for visualization and/or the working space. The retractor stabilizes a joint when expanded because it forces the tissues to remain in one place.
Another use is to look directly at a neurovascular bundle, retract it out of the way, and then operate around it. For example, the surgeon can go into the back of a knee, inflate the retractor, identify the neurovascular bundle and then be able to work around it. The task is made easier by the ability to separate tissue layers from within. One may cup the tissue then push it out of the way, in the nature of an umbrella opening, to protect vital tissues to operate safely around them.
Depending on the application, the retractor can be left in place while the work (or looking) is being done, or it can be deflated and then taken out to allow a scope or other instrument to be put in. Some tissues will stay in place to allow this latter function, after the space has been created with the retractor.
A most typical construction for the retractor of the present invention is an inflatable bladder situated on the end of a shaft, which may be flexible or rigid, which is pushed through an extra opening in a scope or cannula or through a separate portal, and which expands at the end of the shaft.
The retractor can be located on a scope, either on the end thereof or movable axially through a channel along the length of the scope. The retractor can alternatively be mounted on a cannula. The retractor can be mounted on a separate shaft passing through an existing channel in a cannula; it can be inserted through a separate hole in the cannula or the scope; or it can be inserted through a separate opening in the body. The shaft with a retractor on the end can be pushed or slid through the cannula, side by side with a scope. Alternatively, the bladder can expand out of, then recess back into, a groove on a cannula or scope. The retractor can be used to create a space right by the scope, or possibly at a location spaced from the end of the scope.
The bladder itself can be round, eccentric, oval, conical, wedge-shaped, U-shaped, curved, angled, or it may be in any shape desirable to optimize the particular application. The bladder may be irregularly shaped when inflated, that is, it may expand to a greater radius in the area where it is desired to look (where greater exposure space is needed).
Vacuum can be used to deflate the bladder. The bladder may then be romoved by sliding it out the portal directly.
In one embodiment the retractor includes a spring loaded sleeve which slides axially over a plurality of plates or prongs, plastic or metal. A centrally located motive force is provided to move the prongs outwardly to retract the tissue, which force may be mechanical or a separate inflatable device. Alternatively, each filament is a tube which expands and straightens out as air pressure is added (as it is inflated) and thus moves radially outwardly to retract adjoining tissue. The filaments plates or prongs are controllable and covered by a sheath, which slides off them proximally axially to allow them to be inflated and expand, and then, after they have been deflated, slides distally along the shaft over the filaments to cover them and allow the device to be moved through the body. When the sleeve retracts the prongs or filaments expand radially outwardly to push tissue away from the scope to improve visualization.
The retractor can be disposed at the end of a flexible sheath. The retractor can be directable with cables, or with compressed air, to turn or bend in a certain direction.
The present invention also provides a new type of self retaining retractor which is more compact and is disposable for use in open surgery. The retractor is used to hold tissues laterally, pushing tissue edges apart. For such an application, the retractor includes a U-shaped bladder which is a tube which acts like a spring and under high pressure attempts to straighten itself out when inflated. The deflated tube-like structure is first properly positioned within the wound. As the retractor is inflated, it tries to straighten out, and thus opens the wound. As it presses on the edges of the wound, it compresses tissue edges, giving a hemostatic effect. For example, if the retractor is put vertically into a wound, it expands the deep tissues. The retractor can also use the inflatable bladder to push apart metal or plastic plates to push apart tissue.
Further features of the present invention will become apparent to those skilled in the art to which the present invention relates from reading the following specification with reference to the accompanying drawings, in which:
FIG. 1 is a schematic view of a retractor in accordance with the present invention shown in the unexpanded and expanded conditions;
FIG. 2 is a schematic view of a retractor extending through a cannula and mounted on the end of a separate shaft;
FIG. 3 is a schematic view similar to FIG. 2 illustrating the use of a fiber optic scope with the retractor;
FIG. 4 is a schematic view showing a retractor inserted through a separate side opening in a cannula;
FIGS. 5A-5E are schematic views of a few of the many and various shapes in which the inflatable portion of the retractor may be formed;
FIG. 6 is a schematic view of a retractor shown mounted on the end of a cannula and having an opening therein for a scope to pass through;
FIG. 7 is a diagram of a fluid supply system for operating a retractor;
FIGS. 8 and 8A are views illustrating the use of a retractor to position the end of a scope;
FIG. 9 is a schematic view illustrating the retraction of soft tissue from bone;
FIG. 10 is a schematic view of a retractor shown in use in a shoulder joint;
FIGS. 11 and 11A are schematic views of a retractor shown in use in a knee joint;
FIGS. 12 and 12A are schematic views of a second embodiment of a retractor shown in use in a knee joint;
FIG. 13 is a schematic view illustrating the simultaneous use of two retractors to retract tissue;
FIG. 14 is a schematic view illustrating the simultaneous use of two retractors to create an open working space in a digestive tract;
FIG. 15 is a schematic view showing two retractors being used together to create an open working space in a blood vessel, or a working space from potential space created between the two expanded bladders;
FIG. 16 is a schematic view illustrating the relatively large size of an expanded retractor compared to the relatively small size of the percutaneous incision;
FIGS. 17 and 17A-17C are schematic views showing a retractor used for percutaneous bone access;
FIGS. 18 and 18A-18C are a series of schematic views illustrating another embodiment of the fluid-expandable portion of the retractor of the present invention;
FIGS. 19 and 19A-19C are a series of schematic views illustrating a retractor of the present invention suitable for use in open surgery.
FIGS. 20A-20D are a series of illustrating the provision of a plurality of separately inflatable bladders on one supporting structure;
FIGS. 21 and 21A are a schematic views illustrating the use of retractors of a certain shape to create a visualization and working space;
FIGS. 22 and 22A are schematic views illustrating the use of retractors of a certain shape to create a visualization and working space;
FIG. 23 is a schematic view illustrating a retractor having a reflective surface thereon; and
FIGS. 24 and 24A are a series of views illustrating a retractor of the present invention suitable for use in carpal tunnel surgery.
FIG. 1 illustrates schematically a retractor 10 in accordance with the present invention. The retractor 10 includes a fluid supply structure and 12 and an expandable balloon or bladder 14 located at or near the end of the structure 12. The bladder is expandable, under the force of fluid under pressure, from an unexpanded condition as indicated in full lines at 14 to an expanded condition as shown in broken lines at 16. In the expanded condition, the transverse dimension 18 of the bladder 14 is significantly greater than its transverse dimension before expansion. The longitudinal dimension 20. Also, in the expanded condition, the transverse dimension 18 of the bladder 14 is significantly greater than its longitudinal dimension 20.
When the bladder of the retractor is expanded inside the body, it retracts tissue. As seen in FIG. 2, a bladder 22 is mounted on the end of a separate shaft 24 within a cannula or scope 26. The cannula or scope 26 has been inserted into the body through an opening 28 in the skin (either pre-existing or made in situ) which has a transverse dimension 30. The bladder 22 when in its unexpanded condition as shown in broken line is smaller than the dimension 30 of the body opening, but when expanded, it expands to a dimension 32 which is significantly greater than the dimension 30. An actual space or working space 34 is formed which was not present before the expansion of the bladder.
The newly-formed working space may be used, for example, for better use of a fiber optic scope as illustrated in FIG. 3. In FIG. 3, retractor 10 is passed through an opening 36 in a cannula 38. A fiber optic scope shown schematically at 40 is also passed through the cannula 38. The cannula 38 is inserted into the body through an opening in the body tissues 42 which is only as large as the outer diameter of the cannula 38. The retractor 10 is then inflated, with air or another fluid being supplied through a rigid or flexible shaft 44 to an expandable bladder 46. The bladder 46 expands transversely, retracting the tissues 42 transversely and creating a working space 34. By axial manipulation of the shaft 44, the bladder 46 is movable either toward the end of the scope 40 in the direction as indicated by the arrow 48, or away from the end of the scope 40 as indicated by the arrow 50, as desired. Such manipulation of the retractor can selectively move and place the adjoining body tissues where the surgeon wants them to enable better use of the scope 40 by the surgeon.
As shown in FIG. 4, the retractor 10 may be inserted into a cannula 52 through a separate opening 54 therein. The opening 54 is shown on the side of the cannula 52, although, of course, it may be on the end of the cannula as is typical. Alternatively, the retractor 10 may be inserted into the body through an opening in the body tissues separate from the opening through which the fiber optic scope is inserted. Either of these options allows for greater flexibility in the insertion and positioning of the retractor 10 relative to the other instruments being used such as the arthroscope.
Also as indicated in FIG. 4, the bladder 58 may be eccentric or eccentrically located relative to the opening 60 at the junction between the bladder 58 and the shaft 62. This is accomplished by using known techniques to form the bladder 58 of a material, construction, and shape such that it expands into the eccentric shape as illustrated in FIG. 4 when inflated by fluid under pressure through the shaft 62. In this manner, an improved visualization and working space 34 is created which is eccentrically located relative to the other instruments being used. This may be preferable when the surgeon is using an angled scope.
FIG. 4 is illustrative of the fact that the bladder of the retractor of the present invention may be formed so as to expand into any particular shape as desired for the particular application. This feature is also shown schematically in FIGS. 5A through 5E which illustrate, respectively, retractor bladders which assume in their expanded states in round, oval, eccentric, blong, and conical shapes. Such shapes may generally be called "non-uniform" shapes for purposes of the present invention, and retractors with such a shape will expand in a "non-uniform" manner. Such shapes may include, for example, wedge- or U-shaped filaments which collapse at the skin, then expand at deep tissue planes for visualization and working space. The bladder may also cup and protect vital tissues such as nerves and arteries while working on other tissues such as muscle.
Another typical form of construction is illustrated on FIG. 6, which shows a bladder 64 which in its expanded condition assumes a toroidal shape. Again, the width 66 of the bladder 64 is significantly greater than its length 68. The bladder 68 is expanded by fluid under pressure received through a fluid channel 70 formed between a cannula or scope outer wall 72 and inner wall 73. By virtue of the toroidal shape of the bladder 68, the leading end 74 of the scope 76 may be passed axially completely through the retractor into the working space 34 which has been created in the tissues 78. Such a bladder 64 may also be mounted on a separate shaft inserted through the scope of cannula.
In all cases, the fluid pressure within the bladder of the retractor is monitored and controlled to keep the force exerted by the retractor at a safe level for tissue tp prevent tissue necrosis. As indicated schematically in FIG. 7, a retractor 10 is supplied with fluid under pressure from a fluid pressure source 80 via a fluid supply line 82. A regulator 84 controls the supply of fluid to the retractor 10. A pressure sensor 86 is located within the retractor 10 and senses the pressure of the fluid within the retractor 10. The pressure sensor 86 sends a signal which is representative of the fluid pressure within the retractor 10, via wiring 88, to a monitor 90. The monitor 90 is connected via control wiring 92 to the pressure regulator 84. The pressure of the fluid within the retractor 10 may thus be monitored and controlled either manually or automatically, by means which are well known in the art and so need not be described further herein. The source 80 of fluid supply may be, for example, the air pressure supply which is commonly found in hospital operating rooms.
By virtue of this ability to monitor the pressure within the retractor 10, the retractor 10 can also be a useful diagnostic tool. The strength or pressure or resistance of tissue to movement can be measured by the pressure require to move it.
FIGS. 8 and 8A illustrate the use of a retractor of the present invention to stabilize a fiber optic scope. The retractor 10 (FIG. 8) includes a bladder 94 which retracts the body tissues 96 away from the scope 98. Since the bladder 94 engages and pushes radially outwardly on body tissues 96 all around the scope 98, the retractor becomes fixed in position when it is so expanded. If the bladder 94 is fixed to the end of the scope 98, the retractor 10 thereby fixes the end of the scope 98 in position relative to the body tissues 96. When a camera is being used with the scope 98, the picture normally moves or jumps around because of the movability of the end of the scope 98. This is prevented by so using the retractor 10 to stabilize the scope 98, leaving the surgeon with both hands free to work and a steady view of the work area.
FIGS. 8 and 8A also illustrate how the retractor of the present invention can be used to control the placement of the tip of a fiber optic scope. The retractor 10 is formed with an eccentric bladder 94 which retracts the body tissues 96 away from the scope 98 to a greater distance in one direction than in another. Thus, by rotating the retractor 10, the surgeon can place the tip of the scope 96 closer to the body tissue 100 (FIG. 8) on one side of the working space 34, or to the body tissue 102 (FIG. 8A) on the other side of the working space 34. Such variable placement can, of course, also be attained via use of a retractor 10 which includes a bladder which can be expanded to varying shapes.
The retractor of the present invention has many uses in the surgical field. FIG. 9 illustrates the use of a retractor 10 to retract soft tissue from bone, for example within a joint. The retractor 10 is inserted between the bone 110 and the soft tissue 112. The bladder 104 is then expanded. The soft tissue 106 is forced away from the bone 104. The surgeon may then use a fiber optic scope or other instrument to work within the working space 34 created by the retractor 10. The retractor of the present invention can provide the force needed to move the soft tissue 112 away from the bone 110 may vary between about 100 and 1000 mm Hg, and thus, it is important to maintain the proper pressure between the two. The retractor 10 can do this since it operates on high fluid pressures of about 10 to 1000 mm Hg and it utilizes a high strength material such as Kevlar, Mylar, or another durable polymer such as Polylite.RTM., a product of Reichhold Chemicals, Inc. This simple retraction of soft tissue from bone would otherwise be impossible.
FIG. 10 illustrates the use of a retractor 10 to enable a surgeon to work within a shoulder joint. The joint includes the humeral head 114, the glenoid 116, the acromium 118, and the acromium joint 120. The rotator cuff 122 is attached to the humeral head 114. A scope 124 is inserted preferably from the back of the shoulder joint. In the prior art method, the acromium 118 can be separated from the bone from within the joint, in order to gain access to the rotator cuff, only be introducing an unconfined stream of water into the joint as indicated at 126. This method leads to the presence of water everywhere, including within the tissues themselves, and is not a desirable method. In accordance with the present invention, a retractor 10 with an expandable bladder 128 is simply inserted through a small incision in the skin and inflated to expand in the direction indicated by the arrow 130, thus retracting the tissue space. There is no unconfined fluid introduced into the tissue space, and the degree of separation of the joint is easily and safely controlled by controlling the pressure within the retractor 10.
FIGS. 11, 11A, 12, and 12A illustrate the use of a retractor 10 to enable a surgeon to better work within a knee joint. The joint includes femur 132 and tibia 134 and between them a neurovascular bundle 136 which the surgeon wishes to work on (or work around). However, the normal space 138 within the tissue space is so small as to make working within the joint very difficult or impossible. Accordingly, a retractor which is in the form of a wedge-shaped bladder 140 (FIGS. 11 and 11A) is inserted on one or both sides of the knee joint and expanded. The retractor expands in a straight or curved shpae depending on its dimensions and easily separates the joint, creating a much enlarged working space 142 (FIG. 11A), enabling the surgeon to operate via any instrument such as the scope illustrated schematically at 144. In a similar manner, a surgeon can easily spread adjacent vertebrae in a spine to work on the spinal column, for example to remove a spinal disc or any other tissue or bone. The bladder 140 may also be formed with a curved shape or otherwise cutom-fit for the particular application.
The retractor 10 shown in FIGS. 12 and 12A operates similarly, with the exception that the bladder 146 is formed as a bellows-type device which expands in an accordion-like manner. The material of which the bellows-type bladder 146 is made does not necessarily stretch although it may somewhat, but rather the expansion comes primarily when the various surfaces are repositioned relative to each other. The accordion-like ridges 148 may be made of differing degrees of resistance to straightening and flexing, in order to vary the rate and/or sequence of inflation of various portions of the bladder 146. Alternatively, the material of which the bladder 146 is made has areas of rigidity interleaved with areas of more elasticity, to provide the desired expansion effect. The ridges 148 may also be closure members which divide the bladder 146 into a plurality of separate inflatable chambers with valving therebetween, for sequential inflation. Such an accordion-like or bellows construction can provide greater stability in intermediate (partially expanded) positions, and can have greater structural integrity.
FIG. 13 illustrates how a pair of retractors in accordance with the present invention can be used together to create an working space between them. In the operation illustrated schematically in FIG. 13, the surgeon desires to retract a fat pocket or tissue 150 away from a knee 152 in order to provide a working space 34 between them in which he can operate. A cannula 154 is inserted through a small opening 156 in the skin 158 and through the fat pocket or tissue 150. An inner bladder 160 is inflated inside the fat pocket or tissue 150, while an outer bladder 164 is inflated on the outside of the skin 158. Drawing the two bladders toward each other pulls the fat pocket or tissue 150 toward the skin and away from the knee 152, thus creating the enlarged working space 34. This enables the surgeon to operate comfortably with a scope or other instrument 166, while still performing the entire operation percutaneously as is, of course, desired, meanwhile stabilizing the instrument.
In a somewhat similar manner, two separate retractors can be used to create a working space in between the two retractors. For example, FIG. 14 illustrates the use of a pair of retractors to create and maintain an open working space in a duodenum 170. A first retractor 172 is inserted through the stomach 174 on a scope or cannula 176 and is inflated at the upper end of the duodenum 170 to block it off from the stomach 174. A second retractor 178 is inserted through the stomach 174 on the scope or cannula 176 and is inflated lower on the duodenum 170 to block it off from the small intestine. An open working space 34 is thus created between the retractors 172 and 178. The working space may be maintained as long as both retractors 172 and 178 remain inflated. Such an open working space is advantageous to enable a surgeon to better work on, for example, a growth 180 in the duodenum 170. The retractor may also be used to block off an artery in a bleeding area of the bowel by direct pressure.
Similarly, FIG. 15 illustrates the use of a pair of retractors in accordance with the present invention to create a working space in a blood vessel. A first retractor 182 is inserted through a main blood vessel 184 on a cannula 186 and is inflated to block the vessel 184 from blood flow in one direction. A second retractor 188 is inserted through the vessel 184 on a separate shaft 190 through the cannula 186 and is inflated farther along the vessel 184 to block blood flow from a branch blood vessel 192. An open working space 34, free of blood, is thus created and is maintained as long as both retractors 182 and 188 remain inflated. Such an open working space can advantageously be used to enable a surgeon to better work, for example, with a scope 194 within the main vessel 184.
As noted above, an important advantage of the retractor of the present invention is that it can be used percutaneously to create a large actual space within the body while making only a small opening in the skin. This allows for percutaneous or fiber optic surgery in locations where heretofore only open surgery with its attendant disadvantages was possible. This feature is illustrated in FIG. 16 which shows in solid lines a retractor 10 for insertion through a cannula 196 into an opening 198 in skin 200. The retractor 10 is, at the time of insertion, no larger in diameter than the opening 198. However, once inserted into location subcutaneously, the retractor 10 can be expanded to the condition shown in broken lines to create a working space which as illustrated by the relative size of the arrow 202 is significantly larger than the opening 198 in the skin 200.
The retractor illustrated in FIGS. 17-17C uses a bladder which is longer than it is wide but which is hollow. To gain access to the surface 204 of a bone 206, a small opening 208 is formed extending through the skin 210 and the muscle 212. The opening 208 extends down to the surface 204 of the bone 206. A retractor 214 (FIG. 17A) is then inserted, in an unexpanded condition, into the opening 208 and down into contact with the surface of the bone. The retractor has an inner wall 215 and an outer wall 217 with a fluid space 219 between. The retractor 214 is then inflated, as seen in FIG. 17B, retracting the adjoining skin 210 and muscle 212 radially outwardly. The retractor 214 has a hollow cylindrical shape with an opening 216 in the middle (see FIG. 17C). The opening 216 is significantly larger than the opening 208. A surgical or other instrument can be inserted through the opening 216 from outside the body, into contact with the surface 204 of the bone 206, while the opening 216 is being maintained. Thus, a large opening can be temporarily created with only a small opening in the body tissue.
In a variation on the retractor shown in FIGS. 17-17C, a retractor like the retractor 214 is shorter and has a ring shape when expanded. The retractor is slid into the body tissue over a small pin such as a K-wire which has been used to pinpoint the desired area. The retractor is slid in while deflated, then expanded when at the desired location inside the body. The inner diameter when expanded, though slightly less than the outer diameter, is still much larger than the size of the pin, forming a large working and visualization space for the surgeon. The surface of the retractor may be roughened, ribbed, or serrated for better gripping power to keep the retractor in place while expanded.
In another embodiment of the invention illustrated in FIGS. 18-18C, the one piece bladder of the retractor 10 is replaced by a series of plates or filaments which are expanded radially or conically outwardly to retract the adjoining tissue. These plates or filaments may, as illustrated in FIGS. 18 and 18a, be rigid or semi-rigid elements 218 which are expanded radially outwardly by a centrally located positioner 220 which may be mechanical or which may be air-operated such as an expandable bag. This is in the nature of a spring loaded umbrella with a sleeve which slides over the ribs of the umbrella, which ribs open and expand outwardly when the sleeve is pulled back. Alternatively, as illustrated in FIGS. 18B and 18C, the filaments 222 are hollow inflatable elements which themselves inflate upon application of fluid under pressure to the retractor 10, straightening out as they fill with pressurized fluid. In either case, a sleeve 224 is preferably provided to protect and help locate or position the radially movable elements. The sleeve 224 slides axially. The plates or filaments are covered by sheath 224, which slides off them proximally axially to allow them to be expanded radially outwardly to push tissue away from the scope to improve visualization. After deflation, the sleeve 224 slides distally along the shaft over the filaments to cover them and allow the retractor 10 to be moved through the body. A sleeve such as the sheath 224 can also be employed in conjunction with a unitary bladder. In either event, the sleeve can be rigid or can be flexible.
Retractors in accordance with the present invention can also be used for open surgery. FIGS. 19-19C are a series of schematic views illustrating the use of a retractor of the present invention in open surgery. The retractor is used to hold tissues laterally, pushing tissue edges apart. FIG. 19 shows the edges 226 and 228 on either side of an open surgical incision or opening 230. As seen in FIG. 19A, an open surgery retractor 232 has been inserted down into the incision 230. The retractor 232 is in the form of a hollow expandable tube which is bent into a V-shape or a U-shape for insertion into the incision 230. It may have a lip or ridge on the surface engaging the tissue to better hold it in place. The deflated tube-like structure is first properly positioned within the wound 230. Upon inflation, the tube under fluid pressure attempts to straighten itself out, and thus opens the wound 230 (FIG. 19B) for easier access by the surgeon. As the retractor 232 presses on the edges 226 and 228 of the wound, it also compresses the tissue edges, giving a hemostatic effect. The retractor may be a bladder which pushes two metal or plastic pieces out to the sides, rather than pushing directly on the tissue itself. If the retractor is put vertically into a wound (see FIG. 19C) it expands the deep tissues. The depending legs 234 and 236 push outwardly as more fluid is admitted into the retractor, thus pushing the deep tissues apart. This is accomplished without making a correspondingly large opening in the skin.
As seen in FIG. 20A, a plurality of separately inflatable radially spaced bladders 246, 248, 250, 252, etc. can be located on one scope or cannula or rod 254. The bladders 246, 248, 250, 252 can be selectively inflated, possibly in a given sequence, to selectively retract tissue.
Alternatively, as seen in FIG. 20B a plurality of separately inflatable axially spaced bladders 240, 242, etc. can be located on one scope or cannula or rod 244. The bladders 240, 242 can be selectively inflated to selectively retract tissue. One particular use for such a capability is to push a tube or other device down the stomach without it curling back up. FIG. 20C illustrates such a tube 260 having a plurality of bladders 262A through 262F which are deflated. When it is desired to selectively rigidify a portion of the tube 260, the bladders 262C through 262F are inflated (FIG. 20D), providing support for the tube at their corresponding axial locations and rigidifying the corresponding portion of the tube 260 as desired.
When a plurality of separately inflatable bladders are located on the same supporting device, suitable apparatus is provided for their inflation. Such apparatus may be, when only a few bladders are present, a simple mechanical valving apparatus. When more bladders are present, or more sophisticated or complex control thereof is desired, a microprocessor may be used to control the inflation. In such case, the control signals may be multiplexed down the structure via optical fiber or wire, for example.
As further illustration of the variety of shapes of retractors which can be used, FIGS. 21 and 21A illustrate the provision of pie-shaped retractors which create a working space between the edges of the pie. The supporting structure carries a pie-shaped retractor 272 which, when inflated as shown, provides a space 274 for visualization and working. If two such retractors 272 are spaced axially as seen in FIG. 21A, an extended working and visualization area 272 is provided for the surgeon.
In the embodiment shown in FIG. 22, a bladder 280 is split at two locations 282, 284 so that when inflated it provides working and visualization areas between the lobes 286 and 288. Any number of such lobes may be provided, as seen in FIG. 22A showing a bladder 290 having four such lobes.
A surface of the retractor may be reflective, to allow the surgeon to see within the opening created by the retractor at different angles rather than merely straight in. The retractor 292 (FIG. 23) has a reflective surface or mirror 294 which enables visualization at an angle .alpha. which may be varied through inflation of the bladder 292 by various amounts. This is an especially appropriate use for the bellows type construction of the bladder as described above, wherein the surface of the bladder has a plurality of ridges 296. The retractor may thus be used to reflect light or a laser beam for visualization with a camera.
Another suitable use for the retractors of the present invention is in carpal tunnel surgery which can be otherwise quite difficult. The retractors are used to cup, move, and protect the nerves during the operation. FIG. 24 illustrates schematically a sectional view through a wrist 300 and showing the radius 302, ulna 304, median nerve 306, and tendons 308 and 310. A retractor 312 is inflatable radially outwardly in the directions indicated by the arrows 314, to push the tendons 310 in the direction indicated by the arrow 316 and away from the median nerve 306. Thus, space is created adjacent the tendons and median nerve, at a location axially from the retractor 312, for visualization and working. A second retractor 318 may be simultaneously used to create a longer working and visualization space 320, as seen in FIG. 24A.
From the foregoing description of preferred embodiments of the invention, those skilled in the art will perceive improvements, changes and modifications in the invention. Such improvements, changes and modifications within the skill of the art are intended to be covered by the appended claims.
1. A surgical retractor for insertion between adjoining tissue masses to move tissue to provide working space and visualization space in endoscopic surgery, comprising:
- a longitudinally extending support member having proximal and distal ends;
- a plurality of rigid plastic plates pivotally connected to said support member and insertable between the adjoining tissue masses;
- a sleeve member coaxial with said support member and slidably supported on said support member for movement between a first position blocking movement of said plates radially outwardly and a second position in which said plates are exposed to allow movement of said plates radially outwardly; and
- a radially centrally located inflatable positioner expandable when inflated to move said exposed plates radially outwardly to move tissue radially outwardly to separate the adjoining tissue masses.
2. Apparatus as defined in claim 1 wherein said inflatable positioner comprises balloon means capable of moving said exposed plates radially outwardly to move tissue radially outwardly with a pressure of approximately 500 mm of mercury.
3. Apparatus as defined in claim 1 wherein said positioner expands into a condition in engagement with radially inner surfaces of said plates to move said plates radially outwardly.
4. A method of providing working space and visualization space between adjoining tissue masses in endoscopic surgery, comprising the steps of:
- providing a surgical retractor having a longitudinally extending support member having proximal and distal ends, a plurality of rigid arms pivotally connected to the support member and insertable between the adjoining tissue masses, a sleeve member coaxial with the support member and slidably supported on the support member for movement between a first position blocking movement of the arms radially outwardly and a second position in which the arms are exposed to allow movement of the arms radially outwardly, and a radially centrally located positioner actuatable to engage radially inner surfaces of the arms to move the exposed arms radially outwardly to thereby move tissue radially outwardly to thereby separate the adjoining tissue masses;
- inserting the retractor between adjoining tissue masses;
- moving the sleeve from its first position to its second position to allow radial outward movement of the arms; and
- actuating the positioner by inflating a balloon to engage radially inner surfaces of the arms to move the exposed retractor arms radially outwardly to separate adjoining tissue masses to provide the desired working space and visualization space.
Referenced Cited
U.S. Patent Documents
|August 1929
|March 20, 1990
|Taguchi et al.
Foreign Patent Documents
|November 1933
|February 1903
|October 1986
Patent History
Type: Grant
Filed: Jul 17, 1991
Date of Patent: Nov 17, 1992
Inventor: Peter M. Bonutti (Watson, IL)
Primary Examiner: Michael H. Thaler
Law Firm: Tarolli, Sundheim & Covell
Application Number: 7/731,534
International Classification: A61M 2902;


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OpenStack, Cisco ONE and You
So, with our announcements around OpenStack this week a few folks have asked me how OpenStack fits into our broader strategies like Cisco Open Network Environment. The short answer is "quite well, actually", the longer answer follows. 🙂
If you look back our original introduction of the Cisco Open Network Environment, we made a couple of points—there is a plurality of use cases and as a result, there need to be a plurality of enabling technologies. While there are common objectives such as agility and programmability to better handle the macro trends like cloud and virtualization, the truth is, everyone has their own design objectives and priorities. To that sentiment, I might add that folks have varying operational objectives and priorities—the appetite for the amount of risk and complexity they want to take on.
With the three-pillar structure of the Open Network Environment, we feel like we have given folks the flexibility to choose the right technologies for the job. With initiatives like OpenStack we now support a different kind of flexibility.
While a segment of the market seems to want to start writing their own protocols and hand-wiring flow tables, a different segment of the market is moving in the other direction, expressing a desire to get out of the infrastructure business and focus their time and efforts on their apps and their users—this has traditionally been the Vblock and FlexPod crowd. With OpenStack, they now have another option—they get the programmability we talk about with the Open Network Environment, but at the stack level, instead of at the box level. The idea behind something like the Cisco Edition of OpenStack is simplify the task and reduce the risks of standing up a cloud stack. You have the full Folsom release of OpenStack, some Puppet recipes to simplify deployment and validation against the relevant Cisco hardware (follow that last link for details).
To get more insights into our OpenStack announcements this week, check our this blog by Lew Tucker, our VP/CTO for Cloud Computing and this post by Kyle Mestery, one of the many Cisco folks who has invested a great deal of time and effort in OpenStack.
One final thought. We are a long way from being done yet. In just the last few days, I blogged about how our Virtuata and vCider acquisitions fit into a multi-cloud strategy, we have had the aforementioned posts related to this week's OpenStack announcements, and Rodrigo Flores just posted about our Multi-Cloud Acceleration Kits for our Intelligent Automation for Cloud solution. While cloud is the destination, there are many ways to get there as we have customers and we will continue to innovate and partner on a number of fronts and in a number of ways that will likely surprise some folks. Stay tuned.
In an effort to keep conversations fresh, Cisco Blogs closes comments after 60 days. Please visit the Cisco Blogs hub page for the latest content.


text:
Williams Sonoma Peppermint Cremes
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- Summary
Our Peppermint Cremes are made with old-fashioned care by a family-owned company. Their creamy fondant centers are delicately infused with natural peppermint oil and covered with Guittard bittersweet chocolate, for an irresistibly fresh flavor and light texture.
- Perfect for treating holiday guests, or for tucking into children's Christmas stockings, and a delightful addition to a batch of chocolate brownies.
- Made in small batches using traditional candy-making techniques.
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- Each creamy fondant center is enrobed with a generous layer of premium Guittard bittersweet chocolate.
- 1 lb. (48 cremes).
- Made in USA.
- This item cannot be shipped to Hawaii but is available for purchase at our Honolulu retail store.
- Ingredients
- Mint fondant: sugar, invert sugar, coconut oil, modified food starch, dried egg whites, salt, invertase, citric acid, peppermint oil.
- Dark chocolate: sugar, chocolate liquor processed with potassium carbonate, cocoa butter, butter oil, soy lecithin, pure vanilla.
- Shipping
Shipping Information
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Alto, Texas is preparing for a crime wave, after the small East Texas town put its entire police force on furlough, the Wall Street Journal reports today.
In an effort to save money, the city has laid off its police chief and four police officers for six months — longer if Alto's finances don't improve.
In the meantime, the county sheriff's department will take over law enforcement duties for the town of 1,200, according to the AP. The sheriff's department is already responsible for policing the nearby city of Wells, which laid off its sole police officer last year.
Alto residents fear that crime will rise in the absence of a local police force. The town's crime rate is already above the state average; there were 66 crimes in Alto last year, according to the WSJ, compared to 51 the previous year.
"Everybody's talking about 'bolt your doors, buy a gun,'" Alto Mayor Monty Collins told the WSJ.
Across the country, cash-strapped cities like Alto are making public safety cuts in the face of revenue losses and growing personnel costs. Small towns have found that law enforcement is easier to pass off to county or state agencies than other city services.
In Alto, reduced sales and property tax revenue, have tightened the city's budget. City officials project a budget deficit of about $185,000 for the fiscal year ending Sept. 30. The City Council was forced to choose between funding the police department and making much needed repairs on the city-owned natural gas distribution system, which generates most of the city's revenue.


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On Jan. 22, the staff of the SEC delivered to Congress a report called the "Study on Investment Advisors and Broker-Dealers" that was mandated under Section 913 of 2010's Dodd-Frank financial services reform law. The report is the most significant, if not final, step in the long debate over whether the fiduciary standard should apply to all who provide investment and financial advice to individual investors.
Dodd Frank and the Fiduciary Standard
For a moment in fall 2009, it seemed that the Democratic controlled U.S. House of Representatives and Senate would duel over who could pass a stronger fiduciary standard for those who provide financial advice to individual investors. The House proposed treating all who provide advice to investors as fiduciaries, no matter their affiliation. The Senate went a step further, proposing that advice providers would have to register as investment advisors and thereby act with the fiduciary duty imposed by the Investment Adviser Act of 1940.
When the House passed its version of financial reform legislation in December 2009, the bill included the requirement for a fiduciary standard of care for all who provide advice. This was due, in large part, to efforts of then-House Financial Services Committee Chairman Barney Frank, D-Mass., who rebuffed big financial services' lobbying efforts to excise the fiduciary standard and other provisions from the bill.
The SEC's chairman, Mary Schapiro, became a frequent visitor to Capitol Hill during the financial reform's discussions, testifying before Congress and various committees including the Financial Crisis Inquiry Commission (FCIC), before which in January 2010 she clearly stated the need for the fiduciary standard for investors. Schapiro compared the FCIC's work to the investigation of the stock market crash in 1929: "Ferdinand Pecora uncovered widespread fraud and abuse on Wall Street," Schapiro said then, recalling the 1930s-era investigation by the Senate Banking and Currency Committee whose chief counsel was Pecora, "including self-dealing and market manipulation among investment banks and their securities affiliates."
Politically, though, the atmosphere in Washington more than 75 years later regarding financial services legislation was a bitter tug-of-war between the big Wall Street companies who were more focused on issues that loomed larger in the press than the fiduciary standard, like murmurs of a Glass-Steagall redux, executive compensation issues and derivatives legislation. On the other side of the argument were consumer lobbying groups that wanted an extension of the fiduciary standard and a regulatory entity of some kind that would better protect consumers from financial predators. The partisan feeling was evident.
In the midst of this battle, Senate Banking Committee Chairman Chris Dodd, D-Conn., a strong proponent of extending the fiduciary standard, announced he would retire at the end of his term.
Disagreement in the Senate on Dodd's View
By February 2010, there were indications that not all senators shared Dodd's view. Some senators led by Sen. Tim Johnson, D-S.D.,—who was in line to chair the Senate Banking Committee after Dodd retired—moved to amend the strong fiduciary provision in the Senate's proposal by substituting instead a call for a two-year SEC study of broker and advisor obligations, with no provision for the SEC to enact rules unless the Commission went back to Congress for that power. Thought by many advocates of a broader application of the fiduciary standard as a prelude to cutting such a fiduciary duty entirely out of the final law, the Johnson Amendment had support from the insurance and bank-wirehouse camps.
The Committee for the Fiduciary Standard (of which this writer was a member) published a statement arguing that the proposed Johnson study was unnecessary. Much of the information it requested was already known to regulators, the Committee argued. Johnson's office called and invited the Committee to discuss his proposal in person. His staff asked the Committee to analyze the research that had already been conducted and point out what was already known to regulators. The Committee conducted its own analysis and provided that to the senator. The meetings on Capitol Hill with the Committee continued.
Meanwhile, several Nobel laureates, prominent academics and investment industry leaders became involved, advocating for extending the fiduciary duty to all those who advise investors. The battle over what to retain and what to exclude from what would eventually come to be known as the Dodd-Frank bill continued.
In mid-April 2010, the SEC charged Goldman Sachs with fraud in connection with a CDO deal. The case underscored the conflicts of interest and lack of transparency that investors—even large, sophisticated institutional investors—can face under the broker-dealer suitability standard instead of a fiduciary standard. Goldman executives testified at Congressional hearings. (A video excerpt from the 13 hours of Goldman testimony is posted on the Committee for the Fiduciary Standard website.) Goldman Sachs settled the charges with the SEC in July 2010, paying a record $550 million fine.
As much as in fall 2009 the contest appeared to be over on who could extend the fiduciary standard most strictly, in spring 2010 the situation with the Senate's version seemed tenuous. This uncertainty would continue until the Senate's version of Dodd-Frank passed in June 2010. Now the reconciliation of the two bills in Congressional conference would offer another opportunity to the interest groups on both sides: those who wanted to strip the fiduciary standard from the final bill and those who wanted to extend the standard to all advice givers.
The road to passage of the final bill was like a roller coaster. As the Senate and House versions of financial reforms became reconciled, it seemed that the fiduciary standard might get swapped out in return for retaining larger pieces of reform. While the debate continued, the SEC geared up for an enormous set of studies and rulemakings—including one on whether investment advisors should be regulated by an SRO like FINRA, which it delivered to Congress on Jan. 19, and one on the fiduciary standard.
The final Dodd-Frank bill, signed into law by President Obama on July 21, 2010, did, indeed, contain a provision for the SEC to study the fiduciary standard for six months and then commence rulemaking according to its findings. Public comment and meetings commenced.
The SEC continued a series of meetings with many groups of various points of view, including meetings with members of the Committee for the Fiduciary Standard. Other groups who met with the SEC on the issue were: the Investment Advisers Association (IAA); the Consumer Federation of America (CFA); Fund Democracy; the National Association of Personal Financial Advisors (NAPFA); the Certified Financial Planning Board of Standards (CFP Board); the Financial Planning Association (FPA); and the North American Securities Administration Association (NASAA), the state securities regulators group.
FINRA, the broker-dealer SRO that is supervised by the SEC but funded by its self-regulated membership, occupies an unusual place in the regulatory sphere. As the self-run group of brokerage firms that supervises brokers, it must balance investors' needs with its members' desires to distribute products to investors and maintain its commission- and fee-based business models.
The SEC and legislators also met with SIFMA, the broker-dealer lobbyist, the Financial Services Institute (FSI), the Financial Services Forum, The Financial Services Roundtable, The American Council of Life Insurers, the National Association of Insurance and Financial Advisors (NAIFA), as well as many individual banks, broker-dealers, and insurance companies and their advocates.
Most independent broker-dealer leaders argued that they were in effect already operating under a fiduciary standard, in no small measure because IBDs do not, for the most part, manufacture and distribute their own investment products, thus limiting some conflicts of interest.
History and Suggestions for Regulation
The Committee called for academic papers from all points of view on application of the fiduciary standard in a brokerage setting, and held a Fiduciary Forum in Washington. The Committee provided the SEC with The Fiduciary Reference, a 1,100-page compendium of the best fiduciary papers and articles published over the prior seven decades, and responded to requests from senators for analyses and assistance.
The Financial Planning Association (FPA) proposed a professional regulatory organization (PRO) for financial planners, some of whom fall under no regulatory body presently.
Many RIAs share the view that the SEC still is the best entity to regulate investment advisors. In part because it oversees BD-RIA firms, FINRA's desire to regulate RIA firms, as well as BDs, is on the record, and the independent broker-dealer group FSI in January formally endorsed FINRA as its preferred SRO. Both the SEC and FINRA recognize the differences between the ways these very different professionals operate, and one would hope a thoughtful and pragmatic approach will be taken with this very sensitive issue.
In the end, the SEC on Jan. 19 presented Congress with its report on an SRO for advisors, leaving it to Congress to decide on whether there should be an SRO such as FINRA, or institute a different funding mechanism for the SEC under which RIAs would be charged a fee to help support the SEC's Office of Compliance, Inspections and Examinations. Specifically, three options were given to Congress:
- Authorize the Commission to impose user fees on SEC-registered investment advisors to fund their examinations by OCIE;
- Authorize one or more SROs to examine, subject to SEC oversight, all SEC-registered investment advisors; or
- Authorize FINRA to examine dual registrants for compliance with the Advisers Act.
The Fiduciary Study Is Released, and Next Steps
The SEC sent its report on the Fiduciary Study to Congress late Jan. 21, and released it to the public on Saturday, Jan. 22. The report contains SEC staff recommendations on whether to extend the fiduciary standard to brokers. In reporting about the fiduciary report, AdvisorOne Washington Bureau Chief Melanie Waddell writes that the SEC decided to "move forward in creating a new uniform fiduciary standard of care for broker-dealers and investment advisors when providing advice to retail customers."
The report, however, isn't the final word on the fiduciary standard.
In part three of our special report on the process of Dodd-Frank, we will discuss the next steps on the issue: how the SEC rulemakings are likely to play out, and how politics are not out of the equation yet. In fact, the two Republican members of the SEC issued a joint dissent statement, writing that the staff report "fails to adequately justify its recommendation that the Commission embark on fundamentally changing the regulatory regime for broker-dealers and investment advisers providing personalized investment advice to retail investors."
We will also discuss the SEC's recommendations and suggest the next rulemaking and business steps that extending such a standard might entail for brokers, RIAs and their affiliated partners. Stay tuned.
Kathleen McBride is wealth editor in chief at AdvisorOne.com and a member of The Committee for the Fiduciary Standard. She can be reached at firstname.lastname@example.com.


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0333 772 0796
Local Auto LocksmithsWhen you need an auto locksmith for lost car keys, vehicle unlocking, car key repairs, transponder programming or a full Eeprom job on your vehicle, then look no further as we have 24 hour auto locksmiths on call to help with all your needs.
Lost Car Keys ReplacedCar key replacements can be done at the side of the road by auto locksmith professionals who have the correct tools, software and the knowhow to unlock your vehicle, code the lock, then program the transponder so that it tarts the vehicle.
Locked Vehicles UnlockedWhen your car keys have been locked inside your vehicle, you can employ a professional auto locksmith to pick open your vehicle locks and retrieve the key from inside. If the vehicle has faulty locks, then a professional auto locksmith can unlock your vehicle with the least chance of any damage being caused to the vehicle and its paintwork.
Damaged Car Keys RepairedWhen a car key has been damaged or gets snapped by accident, a professional auto locksmith can come to where the vehicle is parked and make either a new key or repair the damaged car key at the side of the road. A snapped car key blade can usually be repaired quite quickly.
New Key By EepromIn some cases a car key cant be replaced by simply plugging into the OBD and pulling the pin, and sometimes precode data. In this circumstance an auto locksmith will have to remove the immobiliser from your vehicle, locate the transponder chip on the circuit board, de solder the chip and then insert it into a special machine which pulls the pin code and if required pre code data for the vehicle enabling an auto locksmith to then re solder the chip and then make a key that starts the car.
Because of the level of difficulty and the time taken to undertake a full Eeprom, the procedure will be much more expensive than a simple OBD car key replacement service.
Full lock set replacementIf a car key has been stolen, then a customer may choose to completely remove all the locks and the ignition from the vehicle to ensure the thief has no chance of accessing the car with the old key. This process can take half a day to complete and can be quite costly. In some cases the customer may choose to simply have the auto locksmith delete the stolen key from the cars memory. This will stop the thief from starting the vehicle, but unfortunately they will still be able to unlock the vehicle with the old key.
Vehicle Security BypassingWhen a vehicle is locked and the locks are faulty an auto locksmith may choose to unlock your vehicle by implementing bypass techniques. These techniques are learned by all professional auto locksmiths and they should only ever be used in the event that the vehicles locks are not pickable due to the lock being faulty or seized.
The Complete Auto Locksmith ServiceWe provide a comprehensive auto locksmith service for all our clients from a simple vehicle unlocking to a full scale Eeprom of your car or van to get you back on the road. No matter what you are looking for from an auto locksmith, simply pick up the phone and give us a call for a first class auto locksmith service 24 hours a day 365 days a year.
Vehicle Locksmiths Portsmouth
50.79685; -1.09117
Site by Mike Martin


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Title: Arborist Crew Leader
West Chester, PA
Date Listed: 1/16/2018
Application Deadline: 3/31/2018
Reports to: Arborist Representative & Local Manager
Summary :
For over 100 years, Bartlett Tree Experts has been providing residential and commercial property owners science-based solutions and expert care for trees and shrubs. Our growing 1,600-person team encompasses highly skilled, knowledgeable professionals, who are dedicated to delivering quality service.
We are continually recognized as an industry leader, with a safety record that is unsurpassed in the arboricultural profession. We are seeking experienced Arborist Crew Leaders who have a passion for preserving and caring for trees. This position will involve pruning and general maintenance of trees and shrubs on commercial and residential properties.
Supervises: Crew members
- Qualifications & Responsibilities
- Benefits
- Apply
- At least 3 years of climbing (DdRT or SRT) and bucket operation experience in the tree care industry
- A current commercial driver's license or ability to attain a CDL is a must
- Degree in Arboriculture, Forestry, Horticulture, Plant Science, Landscape Management, or a related field
- ISA Arborist Certification is preferred but not required
- Supervises and manages tree care crew while performing all aspects of tree care services, as directed by the Arborist Representative and Local Manager
- Reviews scope of work and safety issues with the Arborist Representative prior to beginning each work assignment
- Ensures that each crew member is trained appropriately for each designated job assignment
- Demonstrates the ability to manage a crew safely
- Ensures that all tree care work is performed in accordance with industry and company standards
- Interacts with clientele in order to help ensure job satisfaction
- Brings a cooperative and enthusiastic attitude to the job site
Bartlett Tree Experts offers competitive compensation, medical and dental benefits, 401K, life insurance, flexible spending account, and paid vacation and holidays. Employees have access to continuing education programs, professional development training materials, and a variety of resources provided by the Bartlett Tree Experts Research Laboratories.
Bartlett Tree Experts is an Equal Opportunity Employer
To submit your résumé, you can do any of the following:
- Apply online
- Fax your résumé to


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Servicios Personalizados
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PER: Potchefstroomse Elektroniese Regsblad
versión On-line ISSN 1727-3781
PER vol.12 no.3 Potchefstroom ene. 2009
We are pleased to publish here, as an oratio, the Ebsworth Memorial Lecture delivered by Mr Justice Louis Harms in February 2007. In his lecture he addressed a range of contentious issues regarding the challenges of judging under a (new) Bill of Rights and he inter alia raises, "without answering, the question of whether a bill of rights should reflect existing societal values or whether it should create them." He also spoke candidly of judicial activism, verbosity emanating from the bench, the judiciary and the separation of powers and (in-)consistency in constitutional adjudication. Among his conclusions he states that a Bill of Rights "is supposed to remove arbitrariness, not only of legislation but also of adjudication."
Corlia van Heerden and André Boraine of the University of Pretoria examine the relationship between debt relief legislation and insolvency law. At the heart of the inquiry lies the question whether the South African Insolvency Act 24 of 1936 is in conflict with the principle of full satisfaction of all responsible financial obligations by an over-indebted consumer.
Najma Moosa of the University of the Western Cape investigates the question whether there is a relationship in South Africa between the institution of (particularly Islam) polygynous marriages and the incidence or spread of HIV/AIDS. In this regard she advocates "an informed approach to HIV and an enlightened approach to the application of Islamic values."
Hannelie Crous of the Potchefstroom Campus of the North-West University considers the utilization of medical screening panels in the expected rising trend of medical malpractice complaints in South Africa, and concludes with reference to the American experience that making use of such panels, usually consisting of a medical practitioner, a lawyer and a member of the public, is indeed to be recommended.
In a case note, Boitumelo Mmusinyane of UNISA discusses some of the implications of the supremacy of the South African Constitution for customary systems of succession with specific reference to male primogeniture. He argues that the appointment of women as traditional chiefs should be considered to be in accordance with the boni mores test.
Francois Venter
21 September 2009
Edition Editor:
Dr Anel du Plessis


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Heartfulness Meditation – Learn How to Meditate
Sep 27, 2018 @ 10:00 am - 10:30 am
| Free
|Recurring Event (See all)
An event every week that begins at 10:00am on Thursday, repeating until Oct 25, 2018
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Experience simple and effective ways to meditate to reduce stress, calm your mind, and improve quality of life.
Please bring to class if you can; a mat or towel to sit on, wear comfortable clothes and socks if this is more comfortable with your shoes off.
For more information call Chris 775-982-4352 or email firstname.lastname@example.com
*Registration required. To attend, please RSVP below or call 775-982-RSVP (7787)
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