Secondary Ports Research Articles

705 Assessment of a Novel Low-Cost Abdominal Box Simulator for Laparoscopic Skills Training

Abstract Aim To create a low-cost abdominal box simulator and assess its validity for Hassan’s entry technique and visiport. Method A low-cost abdominal box simulator was created using a metal box skeleton. This was covered in a layer of cling-film simulating the peritoneum. Red and blue tubing was placed over this creating the inferior epigastric vessels. A posterior rectus sheath was created on either side using a white cotton sheet whilst thick red woollen socks were used to simulate the rectus abdominus muscles. The entire surface was then wrapped in a thick canvas to simulate the anterior rectus sheath. Finally, a commercial skin with subcutaneous tissue was affixed and the umbilicus demarcated using a pen. This simulator was used by 30 surgical trainees (ST3 to ST7) attending a laparoscopic skills course who were asked to provide feedback on the simulator for both Hassan’s entry technique, visiport entry and the introduction of secondary ports. Results The simulator was rated 10/10 for validity as well as ease of use for Hassan’s open entry technique, visiport and secondary port insertion by all 30 of the trainees. Feedback highlighted that using the simulator trainees were able to see all layers of the abdomen and gain excellent haptic feedback. The model was described as realistic as trainees were able to identify each layer of the abdomen as they performed open or visiport entry. Conclusions A low-cost abdominal box simulator can easily be reproduced using our technique and used to train trainees effectively.

Role of laparoscopic surgery in gynecology.

Objective: Technological advancements extend the range of indications for gynecological laparoscopy. We are presenting the outcome of our experiences with gynaecological laparoscopies and assessed rate, indications, complications and its benefits in a teaching hospital. Study Design: Retrospective Observational study. Setting: MTI Hayatabad Medical Complex Peshawar. Period: January 2021 to December 2021. Material & Methods: we performed laparoscopic procedure for a total of 222 patients and all were included in the study. Laparoscopic surgeries were performed under general anesthesia. Successful creation of the pneumoperitoneum was done with the help of Veress needle, mostly by closed access technique and occasionally with the open method. Secondary ports were introduced under direct vision. After completing the surgery laparoscope and secondary ports were removed under direct vision to minimize any iatrogenic insult. Results: During the study period, 908 major gynaecological operations including 222 laparoscopies were performed. This gave the rate of 24.45% laparoscopies per 100 operations. Diagnostic laparoscopies were performed in 195 (87.84%) cases and operative were in 27 (12.16%) cases. Complications were only in 5 of the cases, two being of major nature. A ureteric ligation occurred during laparoscopic hysterectomy resulting in conversion of laparoscopic surgeries into open surgery and another was during cystectomy due to excessive bleeding. Conclusion: Laparoscopic surgery propounds unique benefits including definite diagnosis, mobilization and speedy recovery, minimal complications, less cost and shorter hospital stay. In young patients, laparoscopy helps in preserving their fertility with better prognosis in contrast to open surgery.

O-232 Art of fibroid removal in patients with infertility

Abstract Aim of myomectomy in infertile patient is to preserve and improve fertility, minimising excessive bleeding and pain. Relation ship of myoma and fertility remains debatable moreover removal of all myomas may not be helpful in improving fertility outcome thus it becomes important to decide which fibroid should be removed and which one shouldn’t be touched. Principle of minimal damage and complication should be kept in mind. Mapping of fibroid is an important step in planning the route of operation.Number and site of myoma decides the approach. A preoperative meticulous TVS examination supplemented by TAS specially in large and multiple fibroids is extremely helpful in decision making. it is also important to preoperative differentiation of adenomyosis and fibroid to avoid a surprise element and excessive bleeding during removal. Use of colour flow may be helpful in differentiating. Use of 3-D is important specially in borderline sub mucous myoma. Extent of myoma in to uterine cavity is very important to decide the route of operation. various classifications have attempted to simplify the decision making but combining usg and hysteroscopy is the best way to decide. it is also important to diagnose a large intramural myoma touching the junctional zone. Instilling methylene blue before operation to outline the cavity during surgery in case of accidental entry is a good practice. using intraoperative ultrasound while tackling a large intracavitary fibroid having more than 75% extent in intra myometrial region may be helpful in complete removal. The placement of the optical and secondary ports determines the degree of ergonomic surgery performance, time and difficulty of myoma enucleation, and the ease of suturing. reducing the bleeding during enucleation, dissection in the right plane, minimal use of cautery and proper suturing and closure avoiding any haematoma formation are key points for a successful myomectomy. Use of diluted vasopressin is very effective in making the surgery blood less. So also the use of bipolar in coagulating the large blood vessels. Using bipolar diathermy, a dissecting grasper, and a suction cannula, meticulous exploration of the dissection field can more efficiently detect and coagulate any actively bleeding vessels. Slow rotation of the bevelled morcellator and good control of the bag could reduce de novo myoma and endometriosis. The surgery outcome and the risk of intraoperative complications are highly dependent on trocar placement, finding of the correct cleavage plane, haemostasis, and suturing technique. Flap technique is an innovative approach for removing small fibroid near junctional zone. Good surgery with respect to minimal destruction and handling of the healthy tissue, avoiding unnecessary organ manipulation, controlled bleeding, minimal coagulation, and reasonable operating time remain the best ways to diminish the risk of adhesion formation.It is very important to preserve the cavity, minimal adhesion formation and perfect suturing avoiding dead spaces and haematoma formation for a successful out come in infertile patient.

053 Totally extraperitoneal approach (TEP) for gonadectomy for differences in sex development (DSD): Report of 2 cases

Introduction: 17-β-hydroxysteroid dehydrogenase type-3 deficiency (17βHSD-3) is a rare cause of 46XY DSD. Gonadectomy is often offered to prevent further virilization and to continue living in a female gender role [ [1] Chuang J. Vallerie A. Breech L. Saal H.M. Alam S. Crawford P. Rutter M.M. Complexities of gender assignment in 17β-hydroxysteroid dehydrogenase type 3 deficiency: is there a role for early orchiectomy?. Int J Pediatr Endocrinol. 2013; 12: 15 Crossref Google Scholar ]. Both laparotomic and laparoscopic approaches to gonadectomy had been described for DSDs [ [2] Dellaportas D. Chatzipapas I. Pandraklakis A. Michala L. Laparoscopic bilateral gonadectomy and inguinal hernia repair with mesh for complete androgen insensitivity syndrome: A case report. J Pediatr Adolesc Gynecol. 2019; 32 (Epub 2019 Feb 27): 443-445 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar ]. Retrieval and removal of testes located in the inguinal canal can be technically challenging and requires collaboration with surgical colleagues. Cases: We present 2 cases of DSD with 17βHSD-3. One of them is 16 years old, while the other one is 20 years old. Both cases presented with amenorrhea and clitoral enlargement, whereas the second case also had deepening of voice. Blood tests for both revealed elevated testosterone and androstenedione. MRI findings were similar showing bilateral gonads located in the inguinal canals. Genetic tests revealed 46 XY karyotype and HSD17B3 gene mutation. Both subjects opted to continue with a female gender role and opted for gonadectomy to prevent further virilization. Gonadectomy was performed with a totally extraperitoneal laparoscopic approach. An infraumbilical incision was made and care was taken to enter the potential space above the rectus sheath. Then a balloon was placed via the port to distend the extraperitoneal space and then the laparoscope was inserted. Secondary ports at the suprapubic region and the left lower quadrant were placed. The gonads were mobilized and gonadectomy performed. Gonadectomy was successfully performed for the first case, but for the second case, there was failure to mobilize the gonad and operation was completed with inguinal incisions. Conclusion: Totally extraperitoneal laparoscopic approach for hernia repair is a well-established technique familiar to surgeons [ [3] McKernan J.B. Laws H.L. Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc. 1993; 7: 26-28 Crossref PubMed Scopus (264) Google Scholar ]. This was the first time the TEP approach has been described for gonadectomy for DSD. By cooperating with surgeons who has abundant experience in operating in this region, one can allow utilization of techniques which were already commonly used. It raises the importance as gynecologists, we should be mindful of technological advances in other specialties as with other aspects of DSD, collaboration with other specialties may lead to advances in patient management.

A port attractiveness assessment framework: Chittagong Port’s attractiveness from the users’ perspective

This study evaluates the attractiveness of the Chittagong Port of Bangladesh from the port users’ perspective. Existing maritime literature is focused on major ports of Europe, East Asia and North America, but many secondary ports of the mainline maritime network, which play a crucial role in their countries, are overlooked. Chittagong Port is such a port having an enormous impact on the economy of Bangladesh. The perceived attractiveness of this port to its users is assessed in this study based on six factors: port connectivity, facilities, costs, service quality, policy and management, and green port management practices. Data are collected on a 7-point Likert scale for 25 measurement items, and the port attractiveness measurement model is validated using Confirmatory Composite Analysis (CCA). The results indicate that the port users’ find the port’s connectivity most attractive and green port management practices least attractive. We also observe that port users with a high frequency of port usage find Chittagong Port less attractive compared to less frequent users. These findings have significant policy implications for the port authority and policymakers to enhance the port’s attractiveness, which is in a monopolistic position handling more than 90% of international trade for Bangladesh. Further, a validation of the port attractiveness assessment framework enables researchers and practitioners to use it as a standard instrument for assessing the attractiveness of ports having similar characteristics globally.

Modular DC‐DC auto‐transformer: Topology, operation, and system design

Here, a modular DC-DC auto-transformer is proposed with a developed scheme of two-port submodules. The proposed two-port submodule is composed of six switches and single capacitor, and it is featured with three general working states. In the proposed DC-DC auto-transformer, all two-port submodules are connected in the input-series-output-series structure. Then the general primary and secondary ports of the submodules of the proposed DC-DC auto-transformer are connected in series to achieve the auto-transformer operation capability. All submodule capacitors are actively connected in the transformer to form the primary and secondary side voltages. The capacitor utilization is increased therefore. Different voltage ratios can be achieved by arranging different submodule numbers in each working state simultaneously. The volume is reduced due to the developed two-port submodule which eliminates of AC transformers. Detailed topology, working principles, modulation method, and control strategy are provided in the paper. Voltage and current fluctuations are analysed, and the system parameter design method is proposed in detail. Both a simulation system with 40 submodules and a down-scaled experimental system with three submodules were set up and verified the proposed approach.

A quantitative research on the level of disturbance to secondary signal ports of electronic voltage transformers under the operation of gas‐insulated switchgear

The collectors of electronic transformers has the problem of electromagnetic incompatibility under the operation of disconnecting switches, which limits their wide application in smart grids. To evaluate the maximum level of disturbance that collectors are able to withstand in the stochastic process of switching operation, this work introduces a quantitative approach based on limited test measurements, which can quantify the level of disturbance in the signal acquisition ports of electronic voltage transformers (EVT) in different gas-insulated switchgears (GIS). Based on large numbers of experimental statistical data of the true type simulation experimental platform, the Spearman rank correlation coefficient is used to prove that the amplitude of the disturbance voltage pulse at the secondary side port and the breakdown voltage between the primary side fracture approximately satisfy a linear relationship. Subsequently, the quantile regression model is used to quantify and verify the maximum disturbance level of the secondary side port. Moreover, a solution is proposed to tackle the difficulty in obtaining the breakdown voltage at breaks in the GIS substation field applicatvion, under which the quantified maximum disturbance voltage deviation of secondary ports is only −4.34% by comparison. The research work can further explore the practical value of the measured data in a few tests under GIS substation field conditions and provide references for the subsequent revision of EVT-related standards.

Biomass Sea-Based Supply Chains and the Secondary Ports in the Era of Decarbonization

One of the tools to attain the goal of climate-neutrality by 2050 by the European Union is increasing the share of renewable energy sources (RESs) in the energy mix of member states. A major part of the future bioenergy mix is to be played by biomass. As many hazards have been pointed out when using forest biomass, particular attention is paid to the potential of agro biomass. However, as agro biomass is sourced mostly locally, the supply may not be sufficient to meet the growing demand. Therefore, international trade (including overseas) might become increasingly important to meet the EU renewable energy targets. In this context, it is seaports that may play a major part in developing biomass supply chains. The main purpose of the article is to fill the research gap by identifying the pros and cons for the development of biomass sea-based supply chains through secondary ports and specifying their relevance from the perspective of major stakeholders in the context of decarbonization processes. The supplementary purpose of the study was the verification of the environmental sustainability of biomass sea-based supply chains through secondary ports versus land transport (carbon footprint). This study applied the single case study method (the case of the secondary port in Szczecin). The case study strategy involved qualitative and quantitative research techniques. Our research study showed that (1) overseas agro biomass (wastes and residues) may become a significant tool in the process of decarbonization of economies that are heavily reliant on coal as a transition fuel and as a stable RES in the structure of the future energy mix; and (2) biomass sea-based supply chains may be an attractive alternative for secondary ports affected by negative outcomes of decarbonization. However, a dedicated biomass terminal would make the secondary ports more attractive for this type of cargo. A biomass terminal may provide sufficient port service efficiency and enable harmonization of deliveries. Additionally, the carbon footprint analysis performed in this study has shown that biomass sea-based supply chains generate lower CO2 emissions than alternative land deliveries.

Port choice problem in a linear city: Application to Manila and Batangas ports in the Philippines

Global maritime container trade has increased during the past two decades. In many developing countries, secondary ports have been developed to complement primary ports. However, primary ports are still being used even after the development of a secondary port, notwithstanding heavy congestion at the former. Construction of new port infrastructure demands several important decisions such as port capacity and number of gantry cranes and berths, which significantly affect shippers’ port choice. This study aims to develop a port choice model in a multiple-port region as a linear city and observe the improvement in port-related factors, that is, container allocation and catchment areas of the two ports. We present a spatial model in which the hinterland is expressed as a linear city to describe the behaviors of shippers and shipping lines. As a case study, the model is applied to the Manila metropolitan area (i.e., the Manila and Batangas ports) where secondary port utilization is not as expected. Three significant insights are obtained: (i) hourly container handling volume of gantry cranes at the port is the most influential factor regarding container allocation, (ii) port-related factors affecting shipping lines are more effective than those of shippers for increasing the container volume at the port, and (iii) geographical disadvantages are limiting the increase in container volume at the Batangas port.

Dhows in Doldrums: a Spotlight on an Informal Segment of Pakistan’s Maritime Economy

This paper elaborates upon the challenges faced by Dhow making industry in Pakistan, where dhows have always served as the traditional means of cargo transportation. Dhows have also been useful in trade especially with secondary ports and war -torn countries of the Middle East and Africa. The decreasing trend in trade through dhows is affecting not only the maritime economy but also may lead to the extinction of traditional and customary knowledge of dhow making industry. Pakistan needs to ensure that policy gaps are filled to address the concerns of all stakeholders and steps may be taken to identify it as a formal industry in the maritime economy. Moreover, training and capacity building programs will also play an eminent role in generating relevant workforce for boosting the growth of the boat making industry. Active efforts are needed for Public Private Partnership and incentivizing dhow trade also with the assurance of the availability of required raw materials that would help in the revival of the industry. The utilization of modern technology, adequate facilities such as revision of port charges and availability of basic infrastructure are recommended to excel the growth of this vital segment of maritime economy.

Seaports as Nodal Points of Circular Supply Chains: Opportunities and Challenges for Secondary Ports

This paper focuses on the development of secondary ports in the circular economy model (as a node of circular supply chains) to implement sustainable seaports in the context of the structural changes taking place in the global economy, trade, and maritime transport. The purpose of this article is to identify the opportunities, challenges, and key actions to be taken by secondary ports in circular supply chains. The research method applied was a single case study. The object of the study was the seaport of Szczecin (Poland). Our study showed that the secondary ports lacking technical conditions to serve large vessels, but with available space to develop their transshipment, storage, industrial, distribution, and logistics activities, may become major participants in circular supply chains. Taking advantage of the opportunities associated with participating secondary ports in the circular supply chain requires facing a number of challenges identified in the current literature, such as return-flow uncertainty, transport and infrastructure, the availability of suitable supply chain partners, coordination and information sharing, product traceability, and cultural issues. Our study partially confirms the significance of these challenges for secondary ports. The significance of these challenges depends on the kind of circular supply chain, i.e., whether the supply chain is a producer or a consumer chain. Our study shows that a very important challenge for both types of chains is the problem of internal resistance to change. This still-unsolved issue involves the persistent linear mindset of the port authority, which is manifested mainly as investor evaluation policy based exclusively on the declared annual transshipment volume, which fails to take actions to provide the available land plots with the infrastructure necessary for the terminals and industrial plants that participate in circular supply chains. Simultaneously, for secondary ports, we proved that it is stevedores (who are flexible and fast in adapting to new market conditions, strongly determined to search for new cargo types to replace those that have vanished, and who adapt the scope of their services) who play a key role in stimulating the development of circular supply chains. As a main managerial implication for the authorities of secondary ports, such authorities should create appropriate policies for investor assessments and the utilisation of available areas within the port premises to encourage the enterprises engaged in circular supply chains to invest in and develop their businesses within the port’s premises. It is also necessary to develop appropriate communication between port authorities and their external stakeholders. As a managerial implication for the stevedores in secondary ports, these entities should first develop their service offers to address cargo as part of the circular supply chains (with more comprehensive service offers and added-value services, such as freight forwarding services, stuffing, packing, and mixing of cargo) and develop cooperation with other stakeholders of circular supply chains.

Multiport Isolated link with Current-Fed Z-Source Converters to Manage Power Imbalance in PV Applications

In order to address power imbalance in large-scale PV systems, this paper presents a multiport isolated medium-frequency (MF) link to process different power levels from PV arrays, using current-fed Z-source inverters (CZSI) modules to drive the energy from the PV array to the MF link in a single power stage. The MF link provides the galvanic isolation required by many codes and standards to integrate a system to the grid. The multiport configuration of the MF link allows the system to process different power levels on each primary port and, being all ports magnetically coupled, provide balanced power levels on secondary ports which can be used for multilevel converters applications. Additionally, the current-fed version of the Z-source topology offers natural protection against short-circuit damage enhancing reliability of the system. The analysis of CZSI cells and the study of asymmetrical power levels transference, as well as simulation and experimental results are presented.

Reconstruction of marine small-scale fisheries captures in the Canary Islands (NE Atlantic Ocean) from 1950 to 2010

Total marine fisheries catches within the exclusive economic zone of the Canary Islands, Spain, were reconstructed to include catches from the various small-scale artisanal fleets and their discards, as well as subsistence, recreational and other unreported catch. Total reconstructed catch was estimated at 38600 t in 1950, increasing to 81200 t in 1985, declining to approximately 43700 t year–1 in the early 2000s, and finally spiking to about 65300 t year–1 by the late 2000s. These catches coincide with a severe depletion of fish stocks, especially those of demersal species, due in part to fishing overcapacity in the artisanal sector, despite attempts to limit effort by the government. Spain only started to report catches to the FAO in 2006, and from 2006 to 2010 reconstructed catch was seven times the reported catch. Nearly 70% of this catch was from the recreational fishing sector, due in part to technological advancements and increased investments in the construction and improvement of secondary ports.

Biofilms shaping compositions of macrofouling assemblages: An initial barrier against NIS settlement?

Biofilms shaping compositions of macrofouling assemblages: An initial barrier against NIS settlement?

Study of Transient Enclosure Voltage Coupling to Secondary Cables in a Gas-Insulated Substation

Transient enclosure voltage (TEV) induces a relative potential difference between grounding conductors and then couples to secondary cables and may cause malfunction and even damage to secondary equipment. This study investigates the coupling mechanism of TEV to secondary cables from an experimental point of view and presents a cable model suitable for calculation. Experiments are carried out on test platforms established in a laboratory. The experimental results indicate that the magnitudes of port voltages are roughly 1.5‰ of TEV magnitudes, and the waveform of the start port voltage has the same profile but in antiphase with that of the end port voltage. Moreover, only common-mode voltage with no differential-mode voltage exists for the twin core cable. Based on these results, an equivalent circuit for a secondary cable is proposed. This circuit can generate similar waveforms as those measured in the experiment. The experimental and theoretical results presented in this paper should prove helpful for evaluating the interference severity of secondary cables resulting from TEV for the electromagnetic protection of secondary ports.

Decision making technique for analysing performance of Malaysian secondary ports

This paper aims to study the performance of the secondary ports in the East Coast Economic Region (ECER) of Malaysia by analysing the selected criteria and sub-criteria involved. A total of 12 respondents were selected as the sample for the study and the data were analysed using a decision-making method that incorporated an analytical hierarchy process, fuzzy-link based approach and evidential reasoning. To analyse the performance of the secondary ports, five criteria were considered, which include: 1) operational; 2) physical; 3) shipping demand; 4) financial and 5) manpower performances. To realise this performance benchmarking, two secondary ports that were positioned on the ECER, namely, the Kemaman Port (Kemaman Supply Base) and Kertih Port were used as the case studies. The findings of this study showed that the operational and physical performances played a significant role in contributing to benchmark the performance of the secondary ports.

Prevention and Management of Complications in Laparoscopic Myomectomy.

Myomectomy aims to preserve fertility, treat abnormal uterine bleeding, and alleviate pain. It should cause minimal damage to the endometrium, while being tolerable and durable, and reduce the incidence of myoma recurrence and complications including bleeding, hematoma, adhesions, and gravid uterus perforation. Training and experience are crucial to reduce complications. The surgical strategy depends on imaging information on the myomas. The position of the optical and secondary ports will determine the degree of ergonomic surgery performance, time and difficulty of myoma enucleation, and the suturing quality. Appropriate hysterotomy length relative to myoma size can decrease bleeding, coagulation, and suturing times. Bipolar coagulation of large vessels, while avoiding carbonization and myometrium gaps after suturing, may decrease the risk of myometrial hematoma. Quality surgery and the use of antiadhesive barriers may reduce the risk of postoperative adhesions. Slow rotation of the beveled morcellator and good control of the bag could reduce de novo myoma and endometriosis. Low intra-abdominal CO2 pressure may reduce the risk of benign and malignant cell dissemination. The benefits a patient gains from laparoscopic myomectomy are greater than the complication risks of laparoscopic morcellation. Recent publications on laparoscopic myomectomies demonstrate reduced hospitalization stays, postoperative pain, blood loss, and recovery compared to open surgery.

Decision making technique for analysing performance of Malaysian secondary ports

Decision making technique for analysing performance of Malaysian secondary ports

Intraoperative safety of low pressure pneumoperitoneum cholecystectomy: a comparative study

Background: With the establishment of laparoscopic cholecystectomy as gold standard for management of cholelithiasis, the current stress is on increasing patient safety. Hence, this study was undertaken to compare the effect of low pressure pneumoperitoneum (LPP <10mm Hg) versus high pressure pneumoperitoneum (HPP >14mm Hg) in a prospective randomized manner on intraoperative safety, assessing the working space and safety by seeing contact of parietal peritoneum to underlying viscera during secondary port insertion.Methods: 120 patients undergoing laparoscopic cholecystectomy were randomized into the LPP (<10mm Hg) group (n=60) and the HPP (>14mm Hg) group (n=60) prospectively. Available working space assessed directly, safety by contact of parietal peritoneum to underlying viscera during secondary port insertion and operative difficulty assessed by visualization, dissection and grasping, total duration of surgery; intra-operative gas consumption, and bile spillage were assessed.Results: There was no significant difference in terms of available working space, operative duration, consumption of carbon dioxide, surgeon’s operative difficulty and intraoperative bile spillage. Out of 180 secondary ports inserted, there was evident contact of 20 (11.1%) secondary ports in high pressure groups and 14 (7.7%) secondary ports in low pressure group, which is suggestive of adequate exposure and working space available for surgery at both pressures.Conclusions: Low-pressure cholecystectomy did not compromise intraoperative safety and should be the standard of care in day care surgery.

Flights of fancy: The bird of paradise and its cultural impact

The aim of this essay is to show through just one greatly valued trade item — in this case, the bird of paradise — how even the most distant and apparently isolated areas of the world could be linked to the major metropoles through trade. Yet this trade was anything but a simple bilateral exchange. It involved a complex series of networks that extended from the collectors to various levels of intermediaries and secondary ports, and then to foreign shippers bringing the desired product to its ultimate destination in various world markets. There is, however, another aspect of this essay which focuses not on the economic but the cultural value of trade. Most studies of the bird of paradise have commented on the cultural impact of its feathers on Western fashion, yet few have examined other cultural interpretations of the feathers that are closely associated with authority, fertility, and even invulnerability. These attitudes found in eastern Indonesia and New Guinea continue a tradition that has its roots in Southeast Asia in the early centuries of the Common Era.