text: Planning & Investing Plan your financial future with Essex Financial. Essex Financial at Farmington Bank in CT and MA provides investment and wealth management solutions with a personal, collaborative and customized approach. Request an AppointmentContact Us Personalized wealth management The advisors for Essex Financial pride themselves on exceeding expectations to address their customers' unique needs. By working closely with a client's legal counsel, accountants, other trusted advisors and key family members, they can create and manage an investment strategy that caters to complex and changing necessities. Core investment strategies are based on the input of a team of our top financial advisors and members of senior management. Essex Financial has been recognized by Barron's in their annual ranking of "The Top 100 Independent Advisors" in the United States every year since 2004. In 2015, the firm was named the top independent financial advisory firm in Connecticut by Barron's. Essex Financial Advisors will guide you through every stage, providing expert insight that can help you reach your goals. Beginning Understanding your portfolio Designing a plan based on your needs Building Saving for education and retirement Preparing for illness or injury Building for the future Preserving Managing your estate Maximizing your assets Minimizing estate taxes Evaluating life insurance Eldercare Enjoying Transitioning to retirement Traveling and leisure time Giving Philanthropy Inheritance Special bequests Request a confidential appointment with a Financial Advisor today. David C. Donaldson Jr., MBA, CRPC® Financial Advisor 282 Scott Swamp Rd Farmington, CT 06032 firstname.lastname@example.com Anthony Fortuna, CRPC® Financial Advisor 73 Broad Street New Britain, CT 060533 email@example.com Anthony G. Russo, CRPC® Financial Advisor 962 Farmington Ave West Hartford, CT 06107 firstname.lastname@example.com Nathaniel Morris Financial Advisor 32 Main Street Farmington, CT 06032 firstname.lastname@example.com Adam Brown Financial Advisor 32 Main Street Farmington, CT 06032 firstname.lastname@example.com Essex Financial Services, Inc., member FINRA/SIPC, is a subsidiary of Essex Savings Bank. Essex Savings Bank and Farmington Bank are not affiliated. Investments and insurance are offered through Essex Financial Services, Inc. Member FINRA/SIPCProducts and services made available through Essex Financial Services, Inc. are not insured by the FDIC or any other agency of the United States and are not deposits or obligations of nor guaranteed or insured by any bank or bank affiliate. These products are subject to investment risk, including possible loss of original investment and may go down in value. Home Equity Lines


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Patagonia Women's Regular Rise Bootcut Jeans - $89.00
Free Shipping. Patagonia Women's Regular Rise Bootcut Jeans DECENT FEATURES of the Patagonia Women's Regular Rise Bootcut Jeans Organic cotton denim with stretch for fit and comfort Classic 5-pocket-jean styling Zip fly with button shank closure Pocket bags are made of an organic cotton, polyester twill with a bandana-style indigo print These denim jeans will fit snug initially, but will stretch and conform to your body with wear The SPECS Slim fit Weight: 21.7 oz / 615 g Regular rise Boot cut Inseam: regular: 32in., long: 34in. 11 oz 98% organic cotton 2% spandex denim This product can only be shipped within the United States. Please don't hate us. - $89.00

subset: commoncrawl


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Peppermint - 10 Pack | Product code: 15813
A Soothing & Uplifting Infusion
Soothing & uplifting pure Peppermint Infusion with invigorating minty freshness. Known for its digestive health benefits and naturally caffeine free.
per pack
We are pleased to announce that Dualit Fine Tea Peppermint Infusion and Green Tea have won the Great Taste Award.
We are pleased to announce that Dualit Fine Tea Peppermint Infusion has been shortlisted in The Grocer New Product Awards 2015.
Dualit's Fine Tea capsules reduce brew time by up to 90%. Enjoy refreshing tea in seconds, mess free and perfect every time.
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How to use Nespresso® compatible tea pods & capsules – Dualit
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Dualit are excited to announce that the Intense Espresso capsule from the NX® coffee capsule...
We were delighted to welcome BBC Radio 4 journalist, Peter White, to Dualit recently. Peter spent...


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Schlock and Awe
There are the books you proudly display volumes by Steinbeck, Mailer, and Twain. Then there are the well-thumbed ones you stash under your bed. The location of your copies of Jacqueline Susanns Valley of the Dolls and Dominick Dunnes People Like Us doesnt mean those books are anything less than timeless classics. The brilliant minds behind the NADA Art Fair plan to celebrate lowbrow entertainment during this frenetic art season with Readings in Classic American Schlock. Brought to Miami by Altoids and the New Museum of Contemporary Art, the five-day public readings will feature notable curators, critics, and artists like Katherine Bernhardt, Mario Ybarra Jr., Philippe Vergne, and José Freire.
We naturally wanted to create an alternative, more intimate environment to offer respite from the madness of the art fair, explains Richard Flood, chief curator of the New Museum. Early visitors to the complimentary readings will receive a limited-edition tote bag designed by up-and-coming artist Adam Helms. Stop by the NADA Art Fair at he Ice Palace for enlightening excerpts from Diana Vreelands D.V. every hour today from 11:30 a.m. to 5:30 p.m.
Sat., Dec. 9, 11:30 a.m.-5:30 p.m.
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Northwestern U. Press Acquires Curbstone Press
December 11, 2009
Northwestern University Press on Thursday announced that it has acquired the publishing assets of Curbstone Press and that as of Jan. 1, it will publish new titles under the Curbstone imprint. Curbstone and Northwestern are both known for publishing literature from around the world in translation. Curbstone's current publishing list includes work by Luis Rodríguez, Martín Espada, Claribel Alegria, Salah Al Hamdani, Ana Castillo, Wayne Karlin, E. Ethelbert Miller, Sergio Ramírez and Jean-Marie Gustave Le Clézio, winner of the 2008 Nobel Prize in Literature.
Opinions on Inside Higher Ed
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Disney's Pete's Dragon New Zealand Explorer from $2299*
Hotel, Sightseeing and transfers
New Zealand is renowned for its stunning scenery so it is easy to see why it was chosen as a the official location and backdrop for Disney's Pete's Dragon movie. This New Zealand vacation package showcases some of the country's beautiful regions in both the north and south islands.
North Island
- 1 night Auckland
- Full day sightseeing tour from Auckland to Rotorua including the Waitomo Caves glow worm grotto with a boat ride through the caverns
- 3 nights Rotorua
- The Redwood forest in Rotorua is where most of the forest scenes in Disney's Pete's Dragon were filmed. You will experience an exhilirating mountain bike ride through the redwoods and see some of the magnificent views of the area
- Also included is a half day sightseeing including some of Rotorua's top attractions including Te Puia, Whakarewarewa Thermal Valley, the Agrodome and also Rainbow Springs Nature Park
South Island
- 4 nights Queenstown
- Scenic helicopter ride high above Queenstown, Lake Whakatipu and the Remarkables mountains for a different view of this stunning region where a lot of the aerial sequences were filmed for Disney's Pete's Dragon
- Travel up the scenic Shotover river on a jetboat adventure
- Transfers to/from airports in Auckland, Rotorua and Queenstow
- Travelscene After Hours Emergency Travel Assistance
|Travel Dates
|10/10/2016 - 12/22/2016
|2/13/2016 - 3/31/2017
|Book by
|Price per person from
|Terms and Conditions - Tour Code: SN16049
|*Terms & Conditions: All prices are land only, 'from' per person, double occupancy and travel between 10 October and 22 December 2016 or 13 February and 31 March 2017 ; otherwise supplements will apply. Book by 19 March 2017. Flights not included, unless otherwise stated. Seasonal surcharges and additional surcharges apply over weekends, special events and holiday periods. No refunds or changes are allowed and space is strictly limited. Not combinable with any other special or discounted vacation package. Prices may differ when you book your travel and are not guaranteed until full payment is received. All prices are in US dollars and correct at time of posting (3 August 2016). All prices, itineraries and routings are subject to change. Please call for our current prices. Hearing impaired persons may dial 711 (National Relay Service) to contact us at the above number. Tour Code: SN16049. CST#2001136-50
Prices subject to change without notice. Please click here to read our terms and conditions.


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Angel PuddingAngel food cake, pudding and candy all in one!
One (10-inch) angel food cake, cut in cubes
6 cups cold milk
One (6 serving) package instant chocolate pudding mix
One (6 serving) package instant vanilla pudding mix
Five (2.1 ounce) bars chocolate-covered crispy peanut butter flavored candy (ie: Butterfinger), crushed
Place half of cake cubes in the bottom of a 9x13 inch dish. Prepare chocolate and vanilla puddings with cold milk according to package directions. Spread prepared chocolate pudding over cake cubes in dish. Top with half the crushed candy. Distribute remaining cake cubes over candy and top with vanilla pudding and remaining candy. Chill until serving.
Recipe makes ten servings.
Nutritional Information:
Calories 263
Protein 7g
Total Fat 3g
Sodium 735mg
Cholesterol 11
Carbohydrates 52g
Fiber 0


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Page 15 (Chapter 4)Mature
Chapter 4
The marble floors of the palace's hallway clicked and clacked as hard leather riding boots strode briskly across it. Armand Velarois, the Captain of the Guard, was rarely one to break schedule, and the recent events had given him much more reason than usual to keep on pace.
Accompanied by three other guardsmen, the captain's entourage loudly announced its presence via the hard stone floor. Armand looked to the officer to his left. The officer was one of his close friends, Absolon Beaumont. Absolon and Armand had both been trained together in apprenticeship. However, while Armand was trained as a cavalry officer due to his combat prowess, Absolon had shown a gifted ability in the application of magic with warfare. He even had developed a personal style of fighting that blended magic with conventional close quarters combat. However, these days he rarely saw action: ever since Armand had promoted him to Major and made him his head of the BattleMage Corp, Absolon spent most of his days approving military research particularly in magical fields and developing tactics in the war room.
To his other side was his right hand man, Commander Hayes Strider. Whereas Armand and Absolon were both Mages and members of the aristocracy, Hayes had grown up in an entirely different case. He was a rough and tumble woodsman from the frontier territory in his natural element as an earthborn. Even as a young boy, he spent more time exploring and living off the land than he did in his hometown of Dunwoodton. His career had started when that same town and the territory around it had been threatened in the second Shifter war by the raiders sweeping through the countryside. Knowing it was for his home, Hayes put his skills to use as a marksman and soldier for the army. No man could outshoot him with a crossbow, nor could they do better as a tracker than him. He often chose not to wear the cuirass and flashy uniform officers often were equipped with because he found the uniform was too noticeable and the cuirass weighed him down unnecessarily. Instead, his standard field dress as he wore it now was a long duster coat and a wide brimmed hat tapered to one side over normal utility wear. It made sense; Hayes was a simple sort of person like that. That's what made him the perfect person for commanding the Infantry Corp of the royal guards.
The third and final officer was by far the one that stood out most among the bunch, and given Strider was with them that said a lot. The third man was Alwyn "Croen Pren", a title that translated to "Bark Skinned" in Alwyn's native language. He had been a servant of Armand's family for quite some time, since long before Armand was born. Apparently he had sworn allegiance to the Velarois house for some reason unknown to Armand decades ago. In spite of his age, however, Alwyn looked very young. While his actual age was almost a century, his status as a Coeden gave him a remarkably long life. At one point he had told Armand that he likely would outlive him just from his blood. Something about the tribes' genetics made them age much slower, nearly stopping aging altogether at the peak of adulthood.
Regardless, Alwyn was a natural at scouting. He could disappear in the forest before your very eyes and new every trail, plant, animal, and item in Deyras' wilderness. He was nominally the leader of the Recon Corp, containing all of the scouts and rangers employed by the army, but given the natures of such guardsmen to work independently aside from checking in, Alwyn had little work to his title. That was fine by him of course; Alwyn worked similarly and was best at his job when unfettered by busy work to focus on real issues


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Clyde North - Clyde Growth Area
Overseas arrivals
191 people who were living in Clyde North - Clyde Growth Area in 2011 were born overseas, and 18% arrived in Australia within 5 years prior to 2011.
The Year of Arrival data records when the overseas born population arrived in Australia. The data shows the degree to which areas are 'ports' for new overseas arrivals and reveals the role of Clyde North - Clyde Growth Area in housing the overseas-born. The number of recent overseas arrivals in an area is often determined by housing affordability, employment opportunities and pre-existing communities located in the area.
Clyde North - Clyde Growth Area's Year of Arrival data, when used with Birthplace, Religion and Language Spoken at Home data, is a good indicator of the likely need for services in migrant communities.
Derived from the Census question:
'In what year did the person first arrive in Australia to live here for one year or more?'
Overseas born population
Source: Australian Bureau of Statistics, Census of Population and Housing (opens a new window) 2006 and 2011. Compiled and presented by .id (opens a new window), the population experts.
(Usual residence data)
Compiled and presented in profile.id by .id, the population experts.
Dominant groups
Analysis of the year of arrival for the overseas born population of Clyde North - Clyde Growth Area in 2011 compared to the City of Casey shows that there was a larger proportion of people who arrived before 2001, and a smaller proportion of recent overseas arrivals (those who arrived between 2006 and 2011).
Overall, 68.7% of the overseas born population arrived before 2001, and 17.7% arrived during or after 2006, compared with 60.4% and 20.8% respectively for the City of Casey.
The major differences in year of arrival data in the population between Clyde North - Clyde Growth Area and the City of Casey are:
- A larger percentage of arrivals between 1961 and 1970 (25.2% compared to 9.0%)
- A larger percentage of arrivals between in 1960 or earlier (15.1% compared to 5.4%)
- A smaller percentage of arrivals between 1981 and 1990 (8.7% compared to 17.6%)
- A smaller percentage of arrivals between 1991 and 2000 (10.5% compared to 18.9%)


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LeBron James 2013 NBA Finals MVP!
Geege Schuman stashed this in Basketball
Stashed in: Basketball, Haters!, LeBron James
To save this post, select a stash from drop-down menu or type in a new one:
LeBron James and the Miami Heat won their second straight NBA championship. And after the game, James was named NBA Finals MVP.
While first receiving the trophy, LeBron first called out his critics, yelling "hate now!"
Afterwords, LeBron reflected on his place in the NBA by saying "I'm LeBron James, from Akron, Ohio. From the inner city. I am not even supposed to be here." It was a heart-felt moment from a true superstar...
Read more: http://www.businessinsider.com/video-lebron-james-gives-epic-speech-after-winning-nba-finals-mvp-2013-6#ixzz2Wp1gc2RK


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Need an Ovulation Test in Bloomsburg, PA? Simply order online 24/7 and get a fast, affordable Ovulation Test at a lab near you (Find More Locations):
What is an Ovulation Test?
The Ovulation Test helps check for ovulation using blood markers. The Ovulation Test is used to help guide decisions for people trying to get pregnant in Bloomsburg, PA.
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Our Ovulation Test price includes the doctor's order that you need to get tested in Bloomsburg, PA, all lab fees and taxes, and a pdf copy of your results. For current prices, CLICK HERE.
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Sands House
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TripAdvisor Reviews Sands House Brampton
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Bum Slitherin
We started our walk from Littletown. The church and schoolroom attached was quaint. Our walk was the ascent of Hindsgarth (2400 ft). This was a tricky climb with lots of scrambles. The sun was shining and the ground dry so that made it straight forward. The views were stunning in the bright sunshine as we looked across at our other walks on Cats Bells, Blencathra and High Rigg. It must ...
Lots of Walking
We arrived last Friday and are sharing a cottage with fellow trippers, Dick and Mags, Rob and Di. I am a bit late getting this started so I'm going to list a few thinks we've done then upload some photos so I can remember what we did. Friday - went to the pub, the Dog And Gun, met Will & Gill Sat - Judy and Di went to the market we walked up Latrigg 5 miles. Pub and chilli Sunday - ferry to the other side of Derwent Water and ...
Day 8
Another cold start, looks like we are going swimming again, rain due about 09.00, all of us are feeling it this morning. Hallelujah the rain has stopped, not so cool is a 792 metre hill climb with our 18 miles. Some sore limbs were gained today, I think we nearly killed Martin, but we all achieved ...
Making the Most of it...
... o)
We mooched for a few hours around the city while the car was being fixed. We eventually worked our way over there to see if we could get on the road again. Another stroke of luck when just as we arrived, they were tightening the last screw ;o)
Back on the road to Ardrossan now and driving like a bat out of hell to get to the ferry on time.
When we got there, we immediately noticed the ...
Cumbria Way - High Brandlehow to Keswick.
High Brandlehow to Keswick.
4 miles
2.5 hours.
88m ascent
A better night less wind and rain. We waited until gone 8 for mum and dad to move.
Slow morning but we all got the 10:30 bus from Keswick via Catbells to be dropped on the road above the jetty at High Brandlehow. The bus driver wasn't quite sure where ...


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A girl without influence wakes me. Her face, framed by two long braids, is the first picture that registers in my hazy mind. She is young enough to have clear skin, bronzed by time outdoors. I should know her name, but the morning has swept it from me. By the time my awareness returns, she has skittered out the door, her leather shoes whispering wind.
I am alone in the first light, greeted by stillness. I feel nothing, the same nothing I have felt for years. It is almost a comfort; almost a tragedy.
Low voices soon filter in from the outside, the same three men who take the back path each morning. Their conversations are predictable, but comforting. I sit up and ease to the edge of my bed.
"I've made thousands of mistakes, but I believe everyone has, and that's how I live with myself." This voice is Grath's, the youngest, the least headstrong. He is hardly a man of age, and yet. A beat of silence marks a shift in conversation.
"You can feel the world turn today," he says. "The wind!"
There is laughter, indulging him. I make a point to keep my eyes from them, but I hope he is spreading his arms like wings. Their voices turn to other things, to rains and harvests and families, and they continue beyond the point that I can hear.
The rising sun draws me out of doors, and I feel the wind dashing over my skin, too. A deep breath is all I need for now. Yesterday, when I walked out of this same door, I could not name the feeling as well as I can now.
Paths crisscross across the land near our home. We could have been in the middle of a budding town, but we are seated on the very edge, growing over. The straight and narrow path goes back the way we came, to the rest of the world. Mom spent months digging up that ground, but it trails into nothing. I turn to the other path. This one leads to the young town, and my feet begin up the trail.


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Raksha ShettySingapore, SG
Hindi, English, English (Indian), Gujarati
British, India (Hindi), Indian (Gujarati)
Child, Teen, Young Adult
Special Skills
Audiobooks, Business, Cartoons, Documentaries, Educational, Internet, Jingles, Movie Trailers, Music, Podcasting, Radio, Telephone, Television, Videogames
I am a singer, a voice artist and a radio presenter.
i have sung for private albums and radio and tv jingles in hindi language.
I have lent my voice for radio spots and tv advertisements in hindi and kannada language.
I have dubbed for Disney series and movies in hindi.
I have lent my voice for IVRs for all major service providing companies like vodafone, airtel,reliance etc in languages like hindi, english, marathi, kannada and gujrathi.
I have also given my voice for e learning projects in english.
I have presented shows as a radio jockey for the hindi radio station called "Zee radio" in london and have also been the presenter for the inflight radios of Kingfisher airlines and Etihad airways
I have also lent my voice for a hindi internet radio as a radio jockey.
(Website hidden)
(Website hidden)
Payment Terms
Hire Raksha as a voice actor. Payment is made through Voices.com SurePay, an escrow service that guarantees your work is done to your satisfaction. Send payment securely by Visa, Mastercard or PayPal through Voices.com then download your files from the website.
Watch a video to see how to make a payment
Next Steps
To contact Raksha Shetty about your project, request a quote today. We'll walk you through the process step-by-step. It's fast and easy.
Hire Raksha Shetty as a voice actor. Working with Raksha Shetty is fast and easy. We'll walk you through the process step-by-step.
Request a quote for your project today.


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|Publication number
|Publication type
|Application number
|Publication date
|Aug 22, 2000
|Filing date
|Sep 24, 1997
|Priority date
|Jun 23, 1994
|Fee status
|Also published as
|Publication number
|Paul F. Zupkas
|Original Assignee
|Situs Corporation
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (67), Non-Patent Citations (60), Referenced by (57), Classifications (23), Legal Events (7)
|External Links: USPTO, USPTO Assignment, Espacenet
This application is a continuation of U.S. patent application Ser. No. 08/468,717, filed Jun. 6, 1995, now U.S. Pat. No. 5,672,172, which is a file wrapper continuation of U.S. patent application Ser. No. 08/265,666, filed Jun. 23, 1994.
The present invention relates to the field of medical surgical instruments. More particularly, it relates to a medical surgical probe having an ultrasound transducer operatively incorporated into the tip of the probe. The probe having manipulating means for manipulating tissue within the human body in a minimally invasive manner. The visualization and localization of the probe tip and the tissue manipulation is enhanced by ultrasound pulses generated at the tip of the probe.
The development of medical surgical instruments has focused on providing surgeons and physicians with safer and more effective tools to diagnose and treat patients. One area receiving considerable recent attention is the development of tools providing the capability of operating on a patient in a minimally invasive manner. In contrast to conventional surgical methods, these tools reduce morbidity, the time and trauma of surgery, postoperative pain and recovery time. These tools make surgery safer and less costly. Examples of tools developed to operate in this manner include laparoscopic, thoracoscopic, endoluminal, perivisceral endoscopic, and intra-articular joint instruments. The role of minimally invasive surgery in medicine is presented in Minimally Invasive Surgery, by J. Hunter, and J. Sackier, New York:McGraw Hill, Inc. 1993, and Advances in Minimally Invasive Surgery, New York:New World Press, 1993).
Minimally invasive surgery uses a variety of methods to manipulate tissue within the body. These methods include lasers, electromagnetic energy, mechanical manipulation, and freezing. The freezing of tissue or cryosurgery was practiced as early as 1850 for treating breast and uterine cancers. More recently, cryosurgery has been used in a minimally invasive manner to treat carcinoma of the prostate, breast, colon and other organs. The objective of the physician in treating carcinoma is to effectively destroy all cancer cells in the patient's body. Cancer cells left alive after treatment are future sites for recurrence of the disease.
A major hurdle facing the surgeon or radiologist in using minimally invasive surgical instruments has been the difficulty in visualizing and positioning instruments. Decreasing instrument size and increasing complexity of operations have placed greater demands on the surgeon to accurately identify the position of instruments and details of the surrounding tissue. Visualization is a critical component to the successful use of minimally invasive surgical or diagnostic instruments. In laparoscopic surgery, visualization is accomplished by using fiber optics. A bundle of microfilament plastic fibers is incorporated in the instrument and displays a visible image of the field of interest to the surgeon. The quality of this image directly impact the surgeons ability to successfully manipulate tissue within the patient's body. An overview of laparoscopy is presented in New Applications in Laparoscopy by David W. Easter. Other visualization methods include fluoroscopy, magnetic resonance imaging, thermal imaging, and ultrasound.
Ultrasound imaging is based on the reflection of high frequency ultrasound energy from tissue surfaces within the body. Modern B-mode ultrasound imaging systems are capable of noninvasively scanning an area deep within the body and displaying a two dimensional image of the area, typically a transverse or lateral plane relative to the position of the ultrasound scanner (see Ultrasound Physics and Instrumentation, D. Hykes, New York:Churchill Livingston, 1985). Reflection of ultrasound energy occurs at tissue interfaces as a result of a mismatch in the acoustic impedance between the tissues. This makes visualization of soft tissues possible, establishing ultrasound imaging as an important tool for visualizing organs and locating and guiding surgical instruments during minimally invasive procedures.
The last two decades have seen tremendous advances in the sophistication of ultrasound imaging technology. Improved signal processing techniques and transducer construction and design have lead to imaging systems that resolve details of internal tissues of under 1 mm. Visualization of the internal structure of organs by B-mode imaging systems improved greatly with the introduction of grey scale imaging in the early 1970s. This method enables different echo amplitudes to be displayed in varying shades of grey. The sophistication of present ultrasound imaging systems has lead to the evolution of ultrasound into a specialty of its own. This specialty focuses on training personnel to operate modern ultrasound systems and interpret and understand ultrasound images.
Ultrasound imaging plays a very important role in the use of cryosurgery to treat carcinoma, tumors, cyts and other soft tissue masses in a minimally invasive manner. The present state of the art in cryosurgery employs the placement of cryoprobes into tissue beneath the surface of the skin through small incisions. Ultrasound imaging is used as the visualization means for guiding and positioning the tip of the cryoprobe beneath the skin surface. The cryoprobe freezes tissue in the region surrounding the probe tip, preventing undesirable damage to tissue contacting the cryoprobe between the skin surface and the cryoprobe tip. The cryoprobe manipulates or destroys tissue by creating a freeze zone or iceball that starts and grows radially from the cryoprobe tip. Ultrasound imaging is used to visualize the extent of the freezing process by displaying the acoustic interface between frozen and nonfrozen tissue.
Although the use of cryosurgery in a minimally invasive manner would not be possible without the visualization provided by ultrasound imaging, there are problems and limitations with present cryosurgical procedures. Two major difficulties the surgeon faces with present cryosurgical procedures are, (1) properly locating the cryoprobe tip in the desired position within a tissue, (2) insuring that all diseased tissue is destroyed while healthy surrounding tissue is not damaged or affected by the freezing process.
The position of the cryoprobe at the start of the freezing process, determines the center of the formation of the iceball. The iceball radiates outward in a spherical pattern. Tissue within the sphere is frozen and destroyed. The objective of the surgeon is to position the cryoprobe tip to maximize the destruction of diseased tissue and preserve healthy surrounding tissue. The cryoprobe tip represents a single point in the two dimensional display created by a B-mode ultrasound imaging system. Identifying and guiding a single point, represented by the cryoprobe tip, in a three dimensional body space using a two dimensional image is a daunting task for even the trained operator.
Visualization of the iceball and its progression are critical steps in validating the destruction of diseased tissue and the safety of surrounding healthy tissues. The interface between the tissue frozen by the cryoprobe and nonfrozen tissue appears as a white border in the CRT display of an ultrasound image of tissue manipulated during a cryosurgical procedure. This border radiates out from the cryoprobe tip in the display of an ultrasound image as the freezing progresses. Because the acoustic impedance of frozen tissue is more than double nonfrozen tissue, little, if any, ultrasound energy is transmitted through the interface. This makes it difficult to visualize areas of nonfrozen tissue within the border of the iceball or in close proximity to the border.
The difficulties with visualizing small objects or areas in the body that are not good reflectors of ultrasound energy is well recognized. Many methods are known in the art of ultrasonography for enhancing the visualization of objects or areas within the body by ultrasound imaging systems (Diagnostic Ultrasound by F. Kremkau, Philadelphia:W. B. Saunders Co. 1993 and Diagnostic Sonography by A. Fleischer and A. James, Philadelphia: W. B. Saunders 1989). These methods are either passive, enhancing the reflection of ultrasound, or active, generating or receiving an ultrasound pulse, in nature. Two areas where enhancement of visualization has received considerable attention has been tissue biopsy and cardiac catheterization (Advances in Ultrasound Techniques and Instrumentation, Well, P. New York; Churchill Livingstone, 1993).
Passively enhancing the visualization of a tissue biopsy needle in an ultrasound image is described in Elkins, U.S. Pat. No. 4,869,259, Echogenically Enhanced Surgical Instrument and Method for Production Thereof. Enhancement is accomplished by roughening a portion of the surface of a needle to improve the scattering or nonspecular reflection of ultrasound energy from the roughened surface. Van Wormer, U.S. Pat. No. 5,259,837, Acoustically Enhanced Catheter, describes the use of coils of metal wire around a portion of a cardiac catheter to enhance scattering of ultrasound energy from that portion of the catheter. Both methods of marking surgical instruments improve visualization by passively enhancing the reflected ultrasound energy and are relatively inexpensive to implement and support. However, both method also depend upon reflection of ultrasound energy, making them liable to visualization problems associated with signal attenuation. In addition, the passive nature of both methods limits the information on surrounding tissue available to the operator in contrast to active marking methods.
U.S. Pat. No. 3,556,079 describes a device generating an ultrasound beam to describe the position of a surgical instrument relative to a blood vessel deep within the body and guide the instrument towards a puncture site on the vessel. The ultrasound beam is transmitted through the instrument towards the vessel. The backscatter of the beam is received by a transducer on the skin surface. The Doppler shift of the beam is measured and converted to an audible sound. The volume of the sound guides the operator in manipulating the instrument to the vessel for puncture. However, the device cannot visualize the exact position of the instrument within the body. It provides a relative position of the instrument in relation to the vessel, making it inappropriate for locating a fixed position within the body. At the same time, this device and method cannot visualize or describe features or status of tissue surrounding the surgical instrument.
The use of an omni-directional ultrasound transducer is described by Vilkomerson, U.S. Pat. No. 4,249,539, Ultrasound Needle Tip Localization System. The transducer, located at the tip of a hollow needle, generates a ultrasound wave or pulse that is sensed by the transducer of a B-mode pulse echo ultrasound imaging system. The signal appears as a point source on the display of the imaging system, revealing the position of the needle tip. Placing the needle in the proper position for tissue sampling, the transducer is removed and tissue is aspirated through the needle for the purpose of testing. This device has the disadvantage of requiring the removal of the ultrasound transducer to allow for aspirating or manipulating tissue. Removing the transducer eliminates the locating method for identifying the probe tip and the ability of using the transducer to provide information on the status of the probe or surrounding tissue during the manipulation process.
The use of ultrasound transducers actively incorporated into a surgical instrument that does not require the removal of the transducer to manipulate surrounding tissue is described by Breyer in U.S. Pat. No. 4,697,595, Ultrasonically Marked Cardiac Catheter. Ultrasonic transducers are permanently embedded within the wall of the lumen of a cardiac catheter. The embedded transducers receive ultrasound pulses from a commonly used B-mode ultrasound imaging system causing the transducers to generate an electrical signal. This electrical signal is processed and incorporated into the display of the imaging system, thereby locating the position of the catheter within the vessel. Although this method does not require the removal of the ultrasound transducer to manipulate tissue, its does depend on receiving ultrasound energy to localize the catheter. This is a disadvantage if the manipulation of tissue by a surgical instrument changes the ultrasound transmission properties of the tissue surrounding the device. This change can block any signal from reaching the device or effect the signal in such a way to render it useless in localizing the device.
A method for locating the tip of a catheter using an ultrasound transducer to transmit a pulse is described in U.S. Pat. No. 5,042,486, Pfeiler, Catheter Locatable with Non-ioning Field and Method for Locating Same. The tip transducer, described as an antenna to transmit or receive ultrasound pulses, a non-ionizing form of energy, is coupled with a second series of antennas located on the surface of the skin. The combination of the two series of antennas, one series acting as transmitters and the other series acting as receivers, locate the tip of the catheter by measuring the transit time of the pulses. The location of the tip is superimposed on a radiologically acquired image of the vessel. This image defines the path of the catheter by precisely defining the structure and topology of the vessel in which the catheter is confined to move. The operator can then monitor the real-time movement of the catheter within the vessel using ultrasound without exposing the operator or patient to continuous and potentially harmful ionizing radiation. However, radiologic imaging cannot visualize structural details of soft tissues. This makes the device and method inappropriate for locating a surgical instrument within soft tissue. Without the ability to adequately visualize details of soft tissue structures, it is impossible to identify a single point or position an instrument within a soft tissue mass.
In accordance with the present invention, a surgical instrument is provided that overcomes the above-mentioned problems, providing a safer and more effective method for performing minimally invasive surgery. The claimed instrument is a surgical probe adapted for insertion into the body of a patient and includes means for manipulating the tissue of the host. Manipulation means are typically, but not restricted to, a freezing or heating element for destroying diseased or aberrant tissue.
An ultrasound transducer that actively emits ultrasound pulses is operatively incorporated into the instrument. The ultrasound transducer element of the instrument provides a means for locating and positioning the manipulation means within the body of the host or patient. Furthermore, the ultrasound transducer provides a means for visualizing tissue within the target or manipulation zone and identifying variations in the status of the manipulated tissue, i.e. the effect of the manipulation means on said tissue.
The invention further provides a method for manipulating target tissue of a host. The method involves contacting the host with a scanner of an ultrasound imaging system. The scanner operates to create an image of a target zone within target tissue for placing a surgical instrument, the instrument comprising the claimed probe with ultrasound transducer. The ultrasound transducer element of the probe is operatively connected with an ultrasound imaging system. With the aid of the image provided by the scanner with further image input from the ultrasound transducing element, the manipulation means of the probe is guided by an operator into the target zone tissue. The method involves manipulating the tissue in the target zone, and further involves manipulation of the target zone tissue with the aid of images which identify and locate target zone tissue which is destroyed by the step of manipulating the tissue in the target zone.
In use, the claimed method involves using an ultrasound imaging system to create an image of the target zone within the soft tissue for placing a surgical instrument, the instrument comprising the claimed probe with ultrasonic transducer. The imaging system and ultrasonic transducer element of the probe are operatively connected. The image created by the imaging system with further input from the ultrasound transducer in the claimed probe, enables the operator to guide the manipulation means of the probe to a position within the target zone to optimize the destruction of diseased tissue. The method further optimizes the destruction of diseased tissue by enhancing the image or visualization of the manipulated tissue by the claimed probe.
FIG. 1 is a longitudinal cross-section of a surgical instrument in accordance with the present invention portrayed as a cryosurgical probe constructed with an ultrasound transducer at the probe tip;
FIG. 2 is a perspective view of the probe placed within the prostate under guidance of an ultrasound imaging system using a scanner placed in the rectum to visualize the prostate;
FIG. 3 is a perspective view of the probe generating ultrasound pulses at the probe tip and received by a scanner of an ultrasound imaging system in the rectum to localize the position of the tip of the probe in the prostate;
FIG. 4 is a perspective view of the probe manipulating the prostate by freezing visualized by a scanner of an ultrasound imaging system placed in the rectum;
FIG. 5 is the same perspective as FIG. 4 with the probe generating ultrasound pulses at the tip during the manipulation process to enhance the visualization of the extent of the manipulation process by a scanner of an ultrasound imaging system placed in the rectum;
FIG. 6 is a perspective of the probe surrounded by frozen tissue during the manipulation process, generating ultrasound pulses at the probe tip that enhance the visualization of variations of the freezing process within the manipulated zone by a scanner of an ultrasound imaging system placed in the rectum;
FIG. 7 is a perspective view of the surgical procedure employing the present invention and an ultrasound imaging system to treat prostate cancer using cryosurgery in a minimally invasive manner;
FIG. 8 is a cross-sectional view of the prostate showing the desired position of the placement of the probes within the prostate for the treatment of prostate cancer using cryosurgery in a minimally invasive manner;
Objectives of the present invention include providing a surgical instrument that can safely and effectively manipulate tissue in a minimally invasive manner, and a method of manipulating tissues of a host which involves using the claimed surgical instrument. The unique features of the present invention are to provide the surgeon or physician with a means to clearly and easily localize the tissue manipulation portion of the probe and enhance the visualization of the extent and effect of the manipulation process. The present invention is particularly beneficial when the manipulation portion of the instrument is adapted to freezing tissue, but may also be adapted to heat tissue using thermal or electromagnetic energy.
An ultrasound transducer is actively incorporated into the tip of the present invention. This provides the operator (generally a surgeon or physician) an advantage when visualizing the instrument and the manipulation of the surrounding tissue by the probe using an ultrasound imaging system. When used in this manner, the present invention overcomes many of the problems inherent in visualizing surgical instruments during minimally invasive procedures.
In operation, the transducer element of the claimed instrument is made to appear as a point source in the CRT display of a standard commercially available B-mode ultrasound imaging system. This facilitates locating and positioning the manipulating portion of the instrument within the body. The transducer also serves to enhance the visualization of tissue within the zone manipulated by the instrument by emitting ultrasound pulses during the manipulation process.
The ultrasound transducer in the present invention is supported by a system of external electronics that serves to determine when to generate ultrasound pulses and provide the power to drive the transducer. It is well understood in the art of ultrasound imaging that the image of an object created by an imaging system is the result of the reflection of ultrasound pulses or echos from the surface of the object in the scanned area. To visualize and localize an object, the imaging system generates ultrasound pulses and uses the transit time of the returning echos to create an image of the area scanned. The external electronics supporting the present invention serve to determine when to power the transducer to generate pulses that appear as echos of the imaging system pulses or to provide feedback to the imaging system of the transit time of the imaging system pulses. Employing either method, the ultrasound transducer incorporated in the claimed instrument must sense the arrival of the pulses from the imaging system to enable the transducer to appear in the image of the area scanned by the imaging system. The principles governing the design and function of ultrasound imaging systems and the requirements of the external electronics to function with these systems are well understood and documented in the literature (Ultrasound Physics and Instrumentation by D. Hykes, New York:Churchill Livingston 1985).
As the instrument manipulates the surrounding tissue, the pulses transmitted by the transducer enhance the visualization of the extent of the manipulation process. In this manner, the present invention improves the safety and efficacy of minimally invasive surgery procedures, in contrast to surgical instruments relying upon the passive reflection of ultrasound pulses from an ultrasound imaging system to visualize the instrument and the extent of the manipulation of tissue by the instrument. In review of prior art presented above, the method for using an actively incorporated ultrasound transducer to identify and guide the manipulation portion of a surgical instrument and enhance the visualization of the extent of the manipulation process is unique.
The claimed surgical instrument is shown in a prefer red embodiment as a cryoprobe in FIG. 1. Shown in cross-section, the cryoprobe 10 possesses a shaft portion 11 and a handle portion 12. The cryoprobe 10 utilizes a typical concentric tube construction for delivery and removal of refrigerant to an expansion chamber 24 at the tip of the cryoprobe 20. Incorporated in the tip of the cryoprobe is an omnidirectional ultrasound transducer 29 with conductors 19 from the transducer to external electronics 110. The ultrasound transducer 29 (available from American Piezo Ceramics, Inc. Mackeyville, Pa.) emits ultrasound pulses, preferably in the range 2-10 MHz. Commercially available transducers are constructed of ceramic materials, typically barium titanate or lead titanate zirconate. The ultrasound transducer 29 is impedance matched at approximately 2-5 ohms to the external electronics 110.
The probe shaft 11 is constructed of three concentric tubes. The inner tube defines an inlet channel 15 for refrigerating fluid through the shaft. The middle tube defines an outlet channel 16 for refrigerating fluid through the shaft. The outer tube forms the cryoprobe shaft 11 and the surface contacting tissue when inserted in the body. The space 17 between the middle and outer tubes is vacuum sealed 18 at the tip of the shaft 20, preventing the space 17 from communicating with inlet 15 or outlet 16 channels. This space serves to insulate the outer tube from the flow of refrigerant except at the tip of the shaft 20.
The refrigerating fluid, typically liquid nitrogen, flows through the inlet channel 15 into the tip expansion chamber 24 and expands, causing a reduction in temperature through a Joules-Thompson effect in the chamber. The expansion of the fluid in the chamber 24 and the insulation of the cryoprobe shaft from the flow of refrigerant, cause tissue surrounding only the tip portion of the cryoprobe shaft to freeze. The zone of frozen tissue radiates outward from the cryoprobe tip, as the refrigerant flows through the expansion chamber 24.
The pulses emitted by the transducer 29 enhances the visualization of the cryoprobe 10 when placed in an area scanned by a standard medical ultrasound imaging system (available from General Electric Medical Systems, Milwaukee, Wis. or Brauel & Kjaer, Naerum, Denmark). FIG. 2 shows the present invention as a cryoprobe inserted into the prostate gland 120 under the guidance of transrectal ultrasonography (TRUS). The TRUS scanner 101 creates an image of the prostate gland 120, generating ultrasound pulses 102 that are received by the transducer 29 and converted into an electrical signal. The electrical signal is transmitted to external electronics 110. When the electronics 110 determines the pulses were generated by the TRUS scanner 101, it powers the transducer 29 to emit ultrasound pulses. The pulses are generated at the same instant the pulses 102 are reflected by the cryoprobe tip 20, enhancing the strength of the reflected pulses or echos. Shown in FIG. 3, the enhanced echos 103 are received by the TRUS scanner 101 and incorporated into the scan of the area displayed by the imaging system 105.
The enhanced echos 103 localize the cryoprobe tip 20 and the manipulation portion of the cryoprobe, the expansion chamber 24, in the prostate 120 and in relation to healthy tissue surrounding the prostate. Because the echos 103 are displayed real time, the movement of the cryoprobe tip can be viewed. This allows the surgeon or physician to precisely position the cryoprobe as to maximize the destruction of the prostate 120 and the safety of healthy surrounding tissue, such as the bladder 121, rectum 122 or urethra 123.
As heretofore used, ultrasonography provides a method for visualizing the growth of the zone of frozen tissue or iceball. Waves or pulses of ultrasound energy are nearly totally reflected at the interface between frozen and nonfrozen tissue due to the acoustic impedance mismatch between the tissues. The small portion of the pulses transmitted through the interface between frozen and nonfrozen tissue face the same impedance mismatch when reflected back to the imaging system. The result is the imaging system is unable to visualize tissue details within the iceball and can only define the extent of the freezing process from the outside border of the iceball. The present invention uses the transducer 29 to improve the safety and efficacy of the present application by enhancing the visualization of the extent of the freezing process and providing greater definition of tissue within the iceball.
FIG. 4 shows the function of the present invention during the freezing process. When the manipulation portion 24 of the cryoprobe 10 is positioned in the optimum location in the prostate 120, the freezing process begins. Refrigerant enters the expansion chamber 24 freezing the tissue surrounding the tip 20. The iceball 30 radiates outward from the tip 20 in approximately a spherical pattern. The pulses 102 from the TRUS scanner 101 are reflected 106 at the acoustic interface 31 between the frozen and nonfrozen tissue. The reflected pulses or echos define the position of the outer border of the iceball 30 in the image of the prostate 120 displayed by the imaging system 105. Because only a small portion of the pulses 102 are transmitted through the border 31, the imaging system 101 is unable to visualize tissue within the iceball 30. At the same time, the tip transducer 29 is unable to detect the arrival of the pulses 102 from the TRUS scanner 101.
Without the detection of the arrival of pulses 102 by the tip transducer 29, the external electronics 110 are unable to time the generation of the ultrasound pulses 103 by the tip transducer 29. However, the freezing process immobilizes the cryoprobe, making the transit time of the pulses from the TRUS scanner 101 to the tip transducer 29 constant. Using the time constant and input from the imaging system 105 through a connecting line 111 informing the external electronics 110 of the generation of an ultrasound pulse by the scanner 101, the external electronics 110 can time the generation of ultrasound pulses 104 by the tip transducer 29 during the manipulation of the prostate, as shown in FIG. 5. Although the pulses 104 will be reflected at the inner border of the interface 31, the portion of the pulses 104 transmitted through the interface 31 will significantly enhance the visualization of the tip transducer 29 and details of tissue within the manipulated zone or iceball. Additionally, the pulses 104 reflected at the inner border of the interface 31 or echoes are detected by the transducer 29. The transit time of these pulse-echo combinations provides information to the extent of the freezing process. This information can be incorporated into the image of the iceball 30 created and displayed by the imaging system 101 to enhance visualization by defining the extent of the freezing process by the cryoprobe 10.
The generation of ultrasound pulses 104 by the tip transducer 29 also enhances the visualization of details of tissue areas within the iceball 30. The reflection of ultrasound pulses from the TRUS scanner 101 at the outer border of the iceball 30 as a result of an acoustic impedance mismatch between frozen and nonfrozen tissue prevents the imaging system 105 from directly visualizing details of tissue areas within the iceball 30. As shown in FIG. 6, areas 40 of tissue that are denser or possess greater vascularization will freeze slower than surrounding tissue. As the iceball 30 radiates outward from the tip 20, these area may be encapsuled by frozen tissue without being properly frozen. The generation of ultrasound pulses by the tip transducer 29 enhances the visualization of areas 40 within the iceball 30 that would not otherwise be discernible by the imaging system 101. The surgeon or physician can then alter the freezing process by freezing a second time or extending the freezing time to guarantee that all tissue within the iceball 30 is destroyed.
The incorporation of an ultrasound transducer element in a surgical instrument in the claimed invention provides a method for performing minimally invasive surgery in a safer and more effective manner. A standard commercially available ultrasound imaging system (General Electric Medical Systems, Milwaukee, Wis., or Brauel & Kjaer, Naerum, Denmark) is used to visualize a target zone within the body. As used herein, the term "target zone" or "target zone tissue" refers to tissue within the host or body of a patient that is intended to be manipulated with the claimed method. The method for localizing the claimed invention in the target zone is facilitated by the enhancement of the visualization of the claimed invention by the imaging system as a result of ultrasound pulses generated by the transducer element in the tip of the probe.
The claimed method for manipulating target tissue of a host involves contacting the host with the scanner of an ultrasound imaging system. The scanner operates to create an image of a target zone within the host for placing the claimed surgical instrument. Accordingly, an initial step in the claimed method involves contacting the host with a scanner to visualize the target zone and surrounding tissue.
In the claimed method, the ultrasound transducer element of the probe is operatively connected with an ultrasound imaging system. The manipulation means of the probe is guided into the target zone tissue with the aid of visualization of the target zone provided by the scanner and with further image input from the ultrasound transducing element. The method involves manipulating the tissue in the target zone, and further involves manipulation of the target zone tissue with the aid of images which visualize and identify target zone tissue with reference to surrounding tissue. The effects of manipulating the target zone tissue include, but are not restricted to, destruction of the tissue, depending on the duration and intensity of the manipulation as medically indicated.
In a typical use of the claimed method, the second step of the claimed method would involve the localization of the claimed instrument in the target zone using the imaging system to guide the placement of the instrument. The ultrasound pulses generated by the transducer element, typically located on the tip of the claimed instrument, facilitate its placement by enhancing the visualization of the claimed instrument.
The third step of the claimed method typically involves the manipulation of the target zone by the claimed instrument and visualization of the extent and effectiveness of the manipulation process using the imaging system. The tip transducer element of the claimed surgical instrument is operatively connected to the ultrasound imaging system. The connection provides the means to exchange input between the transducer element and imaging system. The input allows the tip transducer element to generate ultrasound pulses during the manipulation process that enhances the extent of the manipulation process and the effect of the manipulation process in the target zone. So described, the claimed method provides a means to perform minimally invasive surgery in a manner that is safer and more effective than existing procedures.
The cryosurgical probe embodiments of the claimed surgical instrument would typically be used in a cryosurgical procedure to treat carcinoma of the prostate using the following detailed procedure, which procedure embodies the method of the invention:
Preparation of the patient
The patient is prepared f or sterile surgery in the dorsal lithotomy position 150 using accepted surgical procedures, as shown in FIG. 7. The scrotum is secured and the perineum, the area between the scrotum and the rectum is exposed.
A small incision approximately 4-5 mm in size is made over the pubic bone. At the same time, a cystoscope is placed in the bladder through the urethra. The cystoscope allows the surgeon to visualize the placement of a trocar through a suprapubic incision into the bladder. A Foley catheter is inserted through the trocar into the lumen of the bladder and the balloon of the catheter inflated with approximately 10 cc of fluid.
A guidewire is placed through the cystoscope into the bladder and the cystoscope removed leaving the guidewire in place. A Coude tipped Foley catheter is inserted into the bladder over the guidewire and the balloon of the catheter is inflated with 10 cc of water.
An ultrasound scanner 101, operating at approximately 7.5 MHZ, is inserted in th e rectum 122 and the prostate 120 and surrounding tissue is displayed by an ultrasound imaging system 105, a process described as transrectal ultrasonography or TRUS. Size of the prostate 120, which contains the target zones, is estimated by taking measurements of length, width and height from the ultrasound image. These measurements are used to calculate prostatic volume. The volume is used to determine the number of cryoprobes 10 required to manipulate the prostate 120, i.e. freeze the prostate 120, as well as the number of freeze cycles that will be required to complete the surgical procedure. Cryoprobes typically freeze tissue in a zone 1 centimeter in radius around the tip of the probe. If the prostate 120 is 4 centimeters long, two freezing cycles would be required, one for the proximal 2 centimeters and another for the distal 2 centimeters.
Insertion of claimed CryoProbes,
Depending on prostatic volume, four or five of the present cryoprobes 10 would be placed in the prostate 120 in positions shown in FIG. 8 following the described procedure. A locating needle 82 is inserted percutaneously via the perineum into the prostate 120. The first locating needle 82 is placed in the anterior aspect of the prostate 120 on the left or right side. The locating needle is placed up to within 0.5 cm of the proximal portion of the prostatic capsule. The TRUS scanner 101 is used to properly position the needles in the prostate 120.
Following the placement of the locating needles in the left 82 and right 83 anterior aspect of the prostate 120, a third 84 and fourth 85 needles are placed in the left and right posterior aspect of the prostate. If required, a fifth needle 86 is placed underneath the urethra 123. All needles are placed approximately 0.5 cm from the proximal prostatic capsule as determined by TRUS. The use of needles as a first step is to minimize the trauma of multiple attempts of locating the proper position, that is, the target zones within the prostate 120 for placing the cryoprobes.
The next step in the procedure is to replace the needles with the claimed surgical instrument, the cryoprobes. This involves guiding the placement of the manipulation means into the target zone with the aid of the image created by the ultrasound imaging system and with the aid of pulses generated by the ultrasound transducer in the cryoprobe. The pulses generated by the transducer enhance the ultrasound image of the location of the manipulation means within the target tissue, as the manipulation means is guided toward the target zone. Small puncture wounds are made around the needles before removal to facilitate the passage of the cryoprobes through the skin. The cryoprobes are inserted in the same order as the locating needles.
During the placement of the cryoprobes, a catheter is inserted over the guidewire through the urethra into the bladder. This catheter controls a continuous flow of warm water (30-36� C.) through the urethra, keeping it warm and preventing damage to the urethral wall. After establishing a flow of warm water through the urethra, the temperature of each cryoprobe tip is reduced to approximately -20� C., freezing the tissue surrounding the cryoprobe tip 20. This immobilizes the cryoprobe, locking it in position and preventing accidental displacement of the cryoprobe. When all cryoprobes are properly located and frozen in good position, approximately 0.5 cm from the prostatic capsule as displayed by the TRUS image, the freezing of the prostate is started.
The freezing process begins by reducing the temperature of the anterior cryoprobe tips to below -180� C. The transit time between the tip transducer 29 and the TRUS scanner 101 is measured at the start of the freezing process. The progression of freezing of prostate tissue is visualized using TRUS with the aid of pulses generated by the ultrasound transducer 29 of the cryoprobe 10. Accordingly, the method of the invention achieves concurrently with manipulation, an ultrasound image that visualizes and identifies tissue within the target destroyed by the step of manipulating the tissue in said target zone. The outer border of the target zone or iceball 30, the acoustic interface between frozen and nonfrozen tissue, is displayed as an arc radiating outward from the cryoprobe tip 24 in the display of the imaging system. Areas 40 of nonuniform freezing within the iceball 30 appear as darker than surrounding tissue as a result of the reflection of ultrasound energy at the surface of the nonuniformity. Detection of the reflected energy or echos 107 of the pulses 104 generated by the tip transducer 29 is input into the imaging system 105 through the connecting line 111 to enhance the details of the extent of the freezing process and details of the uniformity of freezing within the iceball 30.
As the freezing process continues, it spreads through the anterior portion of the prostate and progresses towards the posterior portion of the prostate. The temperature of the posterior cryoprobe tips is reduced to below -180� C. as the freezing process continues into the posterior prostate. Finally, if present, the temperature of the fifth cryoprobe tip underneath the urethra is reduced to below -180� C. and the entire prostate is frozen.
Damage to tissues and organs bordering the prostate as a result of the freezing process is a major concern for the physician or surgeon. The urethra is protected from damage during the freezing process by providing heat to the urethral wall. The anterior portion of the prostate is surrounded by loose fat which acts to insulate the prostate from other organs and tissues. The posterior portion of the prostate rests on the rectum separated from the prostate by a thin layer of perirectal fat. The extent of the freezing process is carefully monitored in accordance with the claimed method. The freezing process is not allowed to progress beyond the perirectal fat lest damage to the rectal wall occur.
Upon termination of the freezing process, a thaw cycle is started. The thaw cycle is accomplished by pumping heated gas through the cryoprobe, increasing the temperature at the cryoprobe tip and the surrounding tissue. When the tissue surrounding the cryoprobe tips sufficiently thaws to loosen the probes, they are removed and the operation is completed.
Although the present invention has been described in considerable detail with regards to certain preferred embodiments, other embodiments are possible. For example, the claimed surgical instrument can be embodied as a surgical probe incorporating a microwave antenna for manipulating tissue and an ultrasound transducer for precisely placing the probe in a breast tumor under ultrasound imaging guidance. With the portion of the probe containing the antenna in the center of the tumor, microwave energy can be delivered to the tissue surrounding the antenna. This heats the surrounding tissue causing it to die, thus destroying the tumor. Positioning the probe is critical to ensure that the heat zone encompasses the entire tumor, but does not include healthy tissue or organs surrounding the tumor.
At the same time, pulses from the transducer enhance the visualization of tissue within the heat zone that are not discernible by ultrasound imaging from outside the zone due to reflection, absorption, refraction, or diffraction of the imaging pulses outside the zone of manipulated tissue. The heating of the tumor surrounding the probe depends on the vascularization of the tissue. Areas more highly vascularized will heat slower than areas less vascularized. When scanned with an ultrasound imaging system from outside the heated zone, areas more highly vascularized may be shielded from the imaging system by areas less vascularized that heat quicker. The inability to identify highly vascularized tissue areas may lead the operator to assume tumor destruction when areas within the tumor are still viable. The pulses generated by the ultrasound transducer on the probe at the center of the heated zone enhance the visualization of non-uniform heating, revealing areas within the zone that had not reached sufficient temperature to destroy the tissue.
Having thus disclosed exemplary embodiments of the present invention, it should be noted by those skilled in the art that the disclosures herein are exemplary only and that various other alternatives, adaptions, and modifications may be made within the scope of the present invention. Accordingly, the present invention is only limited by the following claims.
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|U.S. Classification
|606/20, 600/443, 600/462, 606/27
|International Classification
|Cooperative Classification
|European Classification
|Oct 22, 1999
Owner name: SITUS CORPORATION, CALIFORNIA
Free format text: PROOF OF NAME CHANGE;ASSIGNOR:UROS CORPORATION;REEL/FRAME:010331/0680
Effective date: 19990513
|Apr 18, 2003
Owner name: PARSONS, C. LOWELL, CALIFORNIA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:SITUS CORPORATION;REEL/FRAME:014043/0751
Effective date: 20010209
Owner name: ZUPKAS, PAUL F., CALIFORNIA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:SITUS CORPORATION;REEL/FRAME:014043/0751
Effective date: 20010209
|Jan 21, 2004
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Year of fee payment: 4
|Jan 25, 2008
|Fee payment
Year of fee payment: 8
|Apr 2, 2012
|Maintenance fee reminder mailed
|Aug 22, 2012
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|Oct 9, 2012
|Expired due to failure to pay maintenance fee
Effective date: 20120822


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Add some sparkle to her day with this Sean John top!
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TripAdvisor Reviews Daniela Garden Hotel Gela
Travel Blogs from Gela
The Incredible Sicilian Countryside
... grapes, which have been at their peak during our visit - haven't been able to get enough) and olive trees as far as the you can see. The lack of large trees mean the vistas from the winding and mountainous country roads are astounding.
We are navigating from village to village, avoiding the more significant highways. The backroads are narrow, winding and with sometimes pretty poor pavement. Because there have ...
First ride of the trip - Short warm-up
Friday [October 9th - Day 5]
TaiChi @6am, breakfast at 7am. Packed and ready for the transfer bus @8:30 in the lobby.
Driver called running 30 min late. We were met by the same VBT person from the airport, who got our luggage & us on the bus for a 2.5hr drive to Poggio Del Sol Resort in Ragusa. All 15 VBT participants headed south and were detained for an hour by a tractor trailer that had burnt . On the way we noticed that all drivers ...
Ciao from Sicily
... was important back in the day as it was the Sicily's main defence from attacking ships. The harbour was pretty impressive and a huge golden statue of the Virgin Mary overlooks it. We drove to see a few lakes and this part of Sicily is really close to the Italian mainland and the region of Calabria.
Sicily is officially part if Italy – a bit like Tasmania I guess – and the symbol for the town of Messina is a picture ...
Same berth as last year. Had great bacon and egg breakfast and went for walk then slept in arvo. Diff people at hotel but looked same. Happy hour for yachties at Las Vegas bar near bike shop. Was like a reunion party. Mostly poms but all with an interesting story to tell. The Germans and French had their own little group inside. The good pizza shops were closed for the weekend for a religious festival so we had pizza around the corner- not so ...
Making new friends in Delia
... dresser that I just wanted my hair "adjusted"... spiffied up would be another way to put it! I ended up getting it washed , dried and straightened.. nothing fancy, but in the heat and humidity it is aways nice tp have someone else do the work. See my nice straight hair in next blog entry : )
We are looking forward to seeing them again in Edmonton when they come for a visit over Christmas and New Years.


text:
2013 Canada World Junior team - anyone care to take a stab?
View Single Post
Join Date: Dec 2011
Posts: 794
vCash: 500
Originally Posted by
Team Canada could use someone like him. Big and mean
, plus he shut down Yakupov while playing along side Murray. Siemens isn't given enough credit, its not like Dumba was super awesome in the Subway Series. Siemens was solid, especially on the penalty kill plus he's not exactly an offensive black hole. He's picked up his game so lets see how he does. If he lays out another teammate in tryouts all the better. Bring some grit to this team.
Oh Yes, Finally someone sees what i see. MEAN!!! we currently have a D that is NOT mean, we have an abundance of puck moving D's on this team but lack the MEANNESS that seimens brings...We will need it against those nasty americans and russian + swedes...He can go as the 7th D...He played very well in the SSS better than Dumba...
Murphy <- ???? good puck movement
Ouelette <- good puck movement + Good shutdown
Harington <- Good shutdown
Hamilton <- puck moving + Good shutdown
Reilly <- puck moving
Reinhart <- Good shutdown (interchange with Ceci ??? maybe ?? not)
Seimens <- Good shutdown + MEAN Mother F***cr
3 - 4 puck moving D
3 shut down D (You will need in case 1 gets hurt like last year)
1 Mean Mother F***r
View Public Profile
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Probably not. Here he helpfully corrects wingnuts who equate Obama with Hitler when, actually, Obama is the new Neville Chamberlain. (Who hasn't been accused of being Chamberlain these days? Nous sommes tous Chamberlain!) Still, there are some signs that Horowitz may climb down from his lunacy to become a mere run-of-the-mill asshole. After watching Obama's Cairo speech, I raced to the Frontpage website for what I had hoped would be some top-shelf, sputtering apoplexy (Frontpage is basically what you'd get if a Maoist newsletter adopted the politics of Fox News). Instead I found a Horowitz piece titled "An American Leader Stands Up for His Country." David the Lionheart Horowitz, Foe of the Saracens, loved the speech and interpreted it, correctly I think, as a beautifully argued case for the legitimacy and goodness of American power and supremacy. Horowitz:
Conservatives will make a great mistake if they fail to see this speech for what it was, and treat it as another round in the partisan food fight. It was not an appeasement our enemies. It was a forthright statement by an American leader in a Muslim capital explaining why America is in fact the global leader in those battles that matter most to people everywhere: freedom, equality, and peace.
Also worth reading is Horowitz's moving tribute to his late daughter Sarah, who seems to have been a very remarkable person.


text:
The Los Angeles Kings are three wins away from winning their first Stanley Cup and a computerized simulation of the series says they will get there but it won't be as easy as the previous three rounds were for L.A.
EA Sports recently conducted a computerized simulation of the 2012 Stanley Cup Final using their video game, NHL 12. The simulation used artificial intelligence based on real-life data from each team, such as player ratings and line combinations, and includes variances such as injuries and hot streaks to predict a realistic outcome of each game and series.
NHL 12 correctly predicted that the Kings would win Game 1 of the series but has the Devils winning Games 2 and 3 before the Kings take three straight to close out the series in six games at Staples Center. Kings goaltender Jonathan Quick is the projected Conn Smythe Trophy winner, according to the simulation, after recording a shutout and not allowing more than two goals in a game against the Devils.
Here is how NHL 12 sees the rest of the 2012 Stanley Cup Final unfolding:
Game 2: Devils 2, Kings 0
GWG: Adam Henrique (NJD)
Game 3: Devils 2, Kings 1
GWG: Ilya Kovalchuk (NJD)
Game 4: Kings 2, Devils 0
GWG: Dustin Penner (LAK)
Game 5: Kings 3, Devils 2 (OT)
GWG: Dustin Brown (LAK)
Game 6: Kings 3, Devils 1
GWG: Drew Doughty (LAK)