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Before explaining these methods let us recall exactly the conditions of the problem which we are attempting to solve. Our purpose is to be able to measure the intellectual capacity of a child who is brought to us in order to know whether he is normal or retarded. We should therefore, study his condition at the time and that only. We have nothing to do either with his past history or with his future; consequently we shall neglect his etiology, and we shall make no attempt to distinguish between acquired and congenital idiocy; for a stronger reason we shall set aside all consideration of pathological anatomy which might explain his intellectual deficiency. So much for his past. As to that which concerns his future, we shall exercise the same abstinence; we do not attempt to establish or prepare a prognosis and we leave unanswered the question of whether this retardation is curable, or even improvable. We shall limit ourselves to ascertaining the truth in regard to his present mental state.Furthermore, in the definition of this state, we should make some restrictions. Most subnormal children, especially those in the schools, are habitually grouped in two categories, those of backward intelligence, and those who are unstable. This latter class, which certain alienists call moral imbeciles, do not necessarily manifest inferiority of intelligence; they are turbulent, vicious, rebellious to all discipline; they lack sequence of ideas, and probably power of attention. It is a matter of great delicacy to make the distinction between children who are unstable, and those who have rebellious dispositions. Elsewhere we have insisted upon the necessity of instructors not treating as unstable, that is as pathological cases, those children whose character is not sympathetic with their own. It would necessitate a long study, and probably a very difficult one, to establish the distinctive signs which separate the unstable from the undisciplined. For the 37

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• What are the incidences of bowel injury, and what are the safest techniques for avoiding them? • What is the safest management for bowel injury, and do alternatives exist?Electronic supplementary material The online version of this article (doi:10.1007/s00464-013-3171-5) contains supplementary material, which is available to authorized users. Bowel injuries are classified in one of three categories. Immediately recognized injuries result either from bowel trauma during initial port insertion or from bowel manipulation, especially adhesiolysis. Bowel injuries sustained during adhesiolysis may be missed, to be recognized postoperatively by the development of sepsis during the first 24 h. Delayed injuries occur from progression of a thermal injury caused by energized dissection such as monopolar electrosurgery or ultrasonic dissection. These present within the first 5 days postoperatively [7][8][9]. R. Bittner (&)HerniaAvoiding bowel injury is of utmost importance during LVHR. It is advisable to gain access to the abdominal cavity via an open technique far removed from the hernia or scar. Sharp dissection should always be used in areas of dense adhesions, particularly when the presence of bowel is suspected. Again, the use of energized dissection close to bowel may cause delayed injuries, with significantly increased morbidity and mortality [7]. An alternative is to repair the bowel and delay the hernia repair until after a period of inpatient observation and administration of parenteral antibiotics [7, 10]. If the surgeon lacks experience with laparoscopic bowel repair, an immediate conversion to a laparotomy is advisable. In such a case, the bowel injury is repaired and the hernia defect managed according to the extent of contamination. In the presence of gross spillage and contamination, the hernia should be repaired primarily without the use of mesh [6, 11].In 2010, Itani et al.[3] reported a series of 73 patients who underwent conversion to an open technique for bowel injury with minimal contamination during LVHR. In three patients, the enterotomy was repaired, and the herniorrhaphy was performed with polypropylene (PP) mesh laparoscopically. None of the patients who underwent conversion to laparotomy, including those in whom mesh was placed, experienced a surgical-site infection.Alternative methods for dealing with bowel injury during LVHR In the event of a bowel injury, there are several alternatives to conversion to laparotomy. Carbajo et al. [11] and Heniford et al.[6] both have described a case in which a minilaparotomy was performed to repair the bowel injury. The incision was made away from the hernia and under direct visualization with the laparoscope. The injured bowel was exteriorized through the incision and repaired extracorporeally. The incision then was closed, and the LVHR was resumed.In the presence of gross contamination, another valid option entails laparoscopic repair of the injury, with postponement of the herniorrhaphy to a later date. Lederman and Ramshaw [5] reported a series of nine ...

Section 7: Mesh technology Do we have an ideal mesh in terms of prevention of adhesions? Are coated meshes really necessary? Are there data to support the manufacturers' claims of superiority? Is a permanent or absorbable barrier preferred?