Lone Star 150/galvani

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Jessie's land is up for grabs, and so is her neck! Finding the Circle Star ranch besieged by a gang of trigger-happy claim jumpers and their leader Pleas Barstow, a bloodthirsty rustler who kills for his own glory, Jessie and Ki plan to retaliate with a Gatling gun. An assassin blazes a bloody trail headed straight for Jessie and Ki! Jessica Starbuck, a woman fighting for justice on the American frontier, and Ki, a martial arts expert devoted to her protection, return in an adventure that brings them face to face with a mystery killer named "The Scorpion.

A con man plans an all-out border war—and makes Jessie a deal to die for! When Colonel Edgar Perry rides into the Circle Star ranch with a get-rich-quick scheme to extend the border of Texas into Mexico, Jessie's refusal to go along leads to her abduction, sending Ki on their trail. The triumphant final ride of the Lone Star legend! Jessie and Ki are on a train to Laredo with Jessie's new thoroughbred, Lucifer, when the train is ambushed.

Natural orifice transluminal endoscopic surgery NOTES techniques are developing worldwide to perform intraabdominal operations without a skin incision; however, concerns about safety and technical limitations have slowed its introduction into mainstream clinical practice. For these reasons, single-incision laparoscopic techniques have gained in popularity, in addition to the ability to reproduce the same surgical procedures with a less invasive approach.

Clearly, the high-risk patient population, the complexity of the procedures, and the current instrumentation are some of the major impediments to the wide implementation of these techniques. To date, only a handful of reports on this topic are available in the literature. Several techniques for replacing the liver retractor have been described in the literature.

Later, Reavis et al 10 reported their first case using a single paramedian incision. In this case, no liver retractor was required. Both reports concluded that the operation was safe and technically feasible. The purpose of this report is to evaluate the safety and feasibility of our initial clinical experience with single-incision laparoscopic sleeve gastrectomy using a novel technique for retraction of the liver.

We prospectively studied 7 consecutive patients who underwent single-incision laparoscopic sleeve gastrectomy between March and May All patients underwent a routine preoperative evaluation before being considered for sleeve gastrectomy and met the criteria for bariatric surgery according to the NIH. Two techniques of liver retraction were used for the procedure.

In the first patient in the series, the Nathanson liver retractor was used. For the rest of the group, an internal liver retractor was utilized. For this purpose, the back of the bulldog clamp is encircled with the Lone Star retractor, and then the retractor is tied to itself with 2 silk sutures. The bulldog was then introduced into the abdomen and attached to the pars flaccida. The elastic portion of the Lone Star retractor was used to retract the liver, while the hook was secured to the parietal peritoneum or the falciform ligament as needed.

If additional retraction of the liver is necessary, a second laparoscopic bulldog could be used. All the cases were performed through a left paramedian incision Figure 2. In addition, the first 4 cases were carried out with a single incision, and the insertion of 3 separate trocars single-incision laparoscopic surgery , as opposed to the last 3 cases in which a single port with 3 working channels was used SILS port, Covidien, Norwalk, CT.

Tape is used as an additional measure to support the patient in this position. Split-leg table attachments are used to allow the operating surgeon to stand between the patient's legs. Pneumatic compression stockings are routinely placed on both of the patient's legs. A Foley catheter is inserted, and an orogastric tube is placed at the beginning of the case to decompress the stomach. A 4-cm incision is made superior and left of the umbilicus Figure 2. This incision is carried down to the fascia, and superior and inferior flaps are formed to create an adequate working space. For the 3-trocar technique, a 5-mm optical trocar is inserted under direct vision in the external aspect of the space, and the abdomen is insufflated to 20mm Hg.

A mm trocar is inserted on the medial aspect of the incision, and a 5-mm low profile trocar is placed inferiorly in between the previous 2 trocars. For the single-port technique, after the flaps are created, the anterior sheath of the rectus muscle is incised for about 3-cm, and the muscle fibers are spread in a vertical direction to expose the posterior rectal sheath.

A 2-cm incision is carried down on the posterior rectal sheath and peritoneum. Then, two 5-mm and one mm trocar are introduced into the working channels of the SILS port. A 5-mm, degree laparoscope is used for the entire case. Standard extra long laparoscopic instruments were used in all cases. The laparoscopic bulldog clamp Aesculap, Tuttlingen, Germany is inserted through the mm trocar and attached to the pars flaccida with the bulldog applicator. This provides adequate visualization of the entire stomach, gastroesophageal junction, and the angle of His Figure 3. Left lobe of the liver before and after placement of the internal liver retractor.

The bulldog is introduced into the abdomen and attached to the pars flaccida, while the hook is secured to the parietal peritoneum or the falciform ligament as needed. The operation begins with mobilization of the greater curve of the stomach. This is performed with the use of the Harmonic scalpel.

Lone Star 150/galvani

A Raytec sponge is inserted and used for lateral retraction of the gastrosplenic omentum. Dissection of the greater curve and division of the short gastric vessels is performed all the way up to the angle of His. The dissection is stopped once the fundus is completely mobilized and the left crura are exposed.

The dissection is then continued distally along the greater curvature, until the stomach is fully mobilized to a point approximately 2cm to 3cm proximal to the pylorus. Posterior adhesions to the pancreas are divided using medial retraction of the stomach. At this point, the greater curvature of the stomach is folded medially to help guide the bougie placement.

A 40 French bougie is inserted by the anesthesia team and guided along the lesser curvature towards the antrum of the stomach. The articulating linear cutting stapler with mm, 4. Gore and Associates, Flagstaff, AZ is then used to begin division of the antrum.

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After the first 2 fires, 3. Once the stomach is completely divided, the staple line and divided omentum are checked for hemostasis. The bougie is removed and an orogastric tube is inserted by anesthesia. The staple line is checked for leaks by occluding the prepyloric region with a bowel clamp and instilling mL of dilute methylene blue via the orogastric tube.

The stomach is then placed in a mm retrieval bag and removed from the abdomen at the end of the procedure. The abdomen is deflated and either trocars or the SILS port are removed. If the single-incision technique was used, the mm trocar site is enlarged to allow the extraction of the surgical specimen. On the other hand, with the single-port technique, the fascial incision is enlarged to about 2cm to 2. The fascial defect is closed with a running 1 Maxon suture. No nasogastric tube is placed, and no drains are used. Tolbert wanted Liberia to be a force for African unity and civil rights.

His vice president and successor, William R. Tolbert, attempted to improve the economic and political climate by introducing many new changes. But the damage of the past seemed irreparable. The majority of the population was poor and lacked basic amenities such as access to safe water and electricity. Tolbert's attempt to liberalize Liberian society backfired -- some thought he was moving too quickly, while others thought he wasn't moving quickly enough. Many could no longer bear the political dominance of the descendants of American settlers. At the same time, Tolbert's own administration opposed his efforts to bring more indigenous Liberians into the upper echelons of government.

Tolbert's proposal in to increase the price of imported rice, a basic part of the Liberian diet, as a tactic to encourage local production was interpreted negatively, and this provided the spark for demonstrations which rapidly turned violent. Doe led the coup that resulted in the assassination of Tolbert.

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Some soldiers in the army sympathized with the demonstrators, but others strongly believed in the power of the military. In , a group of enlisted men led by Samuel K.

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Doe, a year-old indigenous master sergeant, fought their way into the presidential mansion and shot Tolbert to death. Shortly afterwards, 13 members of the Cabinet were publicly executed. Hundreds of government workers fled the country, while others were imprisoned.



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Many people welcomed Doe's takeover as a shift favoring the majority of the population that had been excluded from power. Soon there were internal rifts, and Doe began to systematically eliminate Council members who challenged his authority. Paranoid about the possibility of a counter-coup, Doe began to favor people of his own ethnic background, the Krahns, placing them in key positions.

Among ordinary Liberians, support for Doe's government soon dampened. In , Doe declared himself the winner of a presidential election he had actually lost. His corrupt government became more repressive, shutting down newspapers and banning political activity. The government's mistreatment of certain ethnic groups, particularly the Gio or Dan and the Mano in the north, resulted in divisions and violence among indigenous populations who until then had coexisted relatively peacefully.

Rebels were ready to be organized by Taylor. The brutal treatment they faced at the hands of the Liberian army drove some indigenous northerners across the border to the Ivory Coast. There, a man named Charles Taylor organized and trained many of them. Taylor had previously served as deputy minister of commerce under Doe, but was imprisoned for allegedly transferring millions of government funds into his own account.

He was reported to have bribed his way out of a Massachusetts jail. When Taylor and his force of rebels reentered Liberia in , on Christmas Eve, thousands of Gio and Mano joined them. While they formed the core of his rebel army, there were many Liberians of other ethnic backgrounds who joined as well.

A brutal civil war ensued.

The Galvanized Yankees (Lone Star, book ) by Wesley Ellis

Military peacekeeping forces gave a fragile sense of security. Entire villages were emptied as people fled. Soldiers, some of them still children, committed unspeakable atrocities, raping and murdering people of all ages, in what became one of the world's worst episodes of ethnic cleansing. In a climate hardly conducive to free movement and security of persons, he won a presidential election against 12 other candidates.