This research was not supported by any grants.

The protocol was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Meizhou People&#39;s Hospital. (MS-2023-C-95). Informed consent was obtained from patients for this study.
1. Patient selection
<ol>
	<li>Use the following inclusion criteria for patients: meet the clinical diagnosis of acute pancreatitis; age between 18 and 80 years; have a CT-enhanced scan grade D/E; and a substantial amount of necrotic tissue and fluid accumulation around the body and tail of the pancreas, as well as in the retroperitoneal area4.</li>
	<li>Use the following exclusion criteria: exclude patients with severe cardiopulmonary dysfunction or coagulation disorders and preoperative percutaneous drainage (PCD) who had digestive fluid or abdominal bleeding in cases where gastrointestinal fistulas had occurred.</li>
</ol>
2. Preoperative preparation
<ol>
	<li>Ask patients to abstain from food for 6 h and refrain from consuming any liquids for 2 h before the scheduled surgery.</li>
	<li>Prepare concentrated red blood cells and fresh frozen plasma for patients with hemoglobin (HGB) &#8804; 80 g/L. Briefly, upon obtaining a doctor&#39;s order and patient consent, collect blood samples from the patient and label them. Send this sample to the hospital&#39;s blood bank. Conduct tests to determine the patient&#39;s blood type and Rh factor, check for any antibodies, and confirm compatibility with donor blood.</li>
	<li>Administer intravenous antibiotics (such as 2.0 g of ceftriaxone) 30 min before anesthesia induction and proton pump inhibitors (such as omeprazole 40 mg).</li>
	<li>Administer general anesthesia and perform endotracheal intubation. Following required assessments, the anesthesiologist first administers sedatives and then general anesthesia. After the patient is unconscious, the anesthesiologist inserts an endotracheal tube through the mouth into the trachea, guided by a laryngoscope. The tube is then connected to a ventilator to manage the patient&#39;s breathing. Throughout this process, the anesthesiologist continuously tailors anesthesia delivery and closely monitors its depth.</li>
</ol>
3. Surgical procedure
<ol>
	<li>Review CT scans carefully to evaluate the severity of pancreatic necrosis and fluid distribution around the pancreas and retroperitoneum (Figure 1).</li>
	<li>After successful anesthesia induction, position the patient in the right lateral decubitus position, elevate the hip bridge, and perform routine draping.</li>
	<li>Arrange the three-port trocar as in laparoscopic retroperitoneal adrenal surgery8. In brief, make a 2 cm-long skin incision below the left axillary posterior line and rib margin using a scalpel. Separate the subcutaneous tissue and muscles with fingers, extend the fingers to push apart the lumbar fascia and peritoneum, and widen the retroperitoneal space.</li>
	<li>Place a 10 mm trocar, a 5 mm trocar, and another 10 mm trocar 2 cm above the iliac crest on the left midline, below the left anterior axillary line, and 2 cm above the iliac spine on the left midaxillary line, respectively. Inject CO2 gas and maintain the gas pressure at 12 mmHg. The trocar distribution is shown in Figure 2.</li>
	<li>Explore the retroperitoneal tissues laparoscopically, employing a sharp dissection method to clear perirenal fat tissue and expose the perirenal fascia with dissecting forceps and an ultrasonic scalpel.</li>
	<li>On the lateral side of the peritoneal reflection, use an ultrasonic scalpel to open the perirenal fascia. Use a suction device and blunt dissection to access the perirenal space between the descending colon and the left kidney. Due to inflammation and edema in the perirenal space, the process is prone to bleeding. Use bipolar electrocoagulation and an ultrasonic scalpel to achieve hemostasis.</li>
	<li>Incise the anterior renal fascia and extend the retroperitoneal front space of the kidney (Figure 3). Aspirate the pus and send a portion of the sample for bacterial culture. Enlarge the incision, enter the abscess cavity, and remove the black necrotic tissue carefully and repeatedly using tissue forceps (Figure 3).</li>
	<li>Rinse the abscess cavity with hydrogen peroxide-povidone-iodine-normal saline solution, in this order, until the rinsing fluid becomes relatively clear.</li>
	<li>To achieve thorough hemostasis in the surgical area, place drainage tubes below and front of the pancreas and lead the tubes through the abdominal punctures (Figure 2).</li>
	<li>After confirming that there was no bleeding at the incision site, remove the trocars, intermittently suture the incisions with 4-0 silk sutures, and terminate the surgery.</li>
</ol>
4. Postoperative management
<ol>
	<li>Considering the severity and high mortality of necrotizing pancreatitis, transfer patients to the intensive care unit (ICU) for further observation after surgery.</li>
	<li>Based on the bacterial culture results, initiate an appropriate antibiotic treatment regimen in accordance with the identified bacteria and its sensitivity profile.
	<ol>
		<li>Administer the selected antibiotic at regular intervals, as prescribed by the treating physician. During this time, periodically monitor serum procalcitonin levels, a biomarker for bacterial infection, with blood tests. Continue the antibiotic treatment until these levels return to normal, indicating resolution of the infection. All procedures were performed following established protocols and guidelines for management of bacterial infections9.</li>
		<li>Administer intravenous proton pump inhibitors (PPIs) for at least 1 week before the patients are switched to oral PPIs (single dose) for 4 weeks. If complications such as gastrointestinal or intra-abdominal bleeding occur, extend the duration of intravenous PPI usage.</li>
	</ol>
	</li>
	<li>Perform daily peritoneal lavage with 3000-6000 mL of normal saline solution with low central negative pressure suction, ensuring the drainage tubes remain unobstructed.</li>
	<li>Recover patients from a liquid diet 24 h after surgery, gradually progressing to a regular diet based on gastrointestinal function recovery. Pay careful attention to maintaining regular bowel movements.</li>
</ol>
5. Follow-up procedures
<ol>
	<li>Conduct outpatient visits and telephone interviews at 1 month, 3 months, 6 months, and 1 year after surgery.</li>
	<li>In follow-up, assess the patient&#39;s diet and weight changes and schedule examinations, including enhanced abdominal CT, complete blood count, PCT, pancreatic enzymes, and liver function.</li>
</ol>

Laparoscopic Retroperitoneal Treatment of Necrotizing Pancreatitis Complications

<ol>
	<li>Wang, S. Q., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+day+when+infection+is+confirmed+is+a+better+time+point+for+mortality+prediction+in+patients+with+severe+acute+pancreatitis.">The day when infection is confirmed is a better time point for mortality prediction in patients with severe acute pancreatitis.</a> Pancreas. 41 (4), 605-610 (2012).</li><li>Zou, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+Study+on+the+related+factors+of+severe+pancreatitis+complicated+with+early+infection.">A Study on the related factors of severe pancreatitis complicated with early infection.</a> Modern Chinese Doctor. 45 (20), 13-14 (2007).</li><li>Shen, Y. F., Cui, N. Q. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+observation+of+immunity+in+patients+with+secondary+infection+from+severe+acute+pancreatitis.">Clinical observation of immunity in patients with secondary infection from severe acute pancreatitis.</a> Inflammation Res. 61 (7), 743-748 (2012).</li><li>Chen, G. D., Huang, Y. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+analysis+of+ten+cases+of+severe+acute+pancreatitis+complicated+with+peripancreatic+necrosis+with+minimally+invasive+treatment+via+retroperitoneal+pathway.">Clinical analysis of ten cases of severe acute pancreatitis complicated with peripancreatic necrosis with minimally invasive treatment via retroperitoneal pathway.</a> Chinese J Pancreatol. 17 (4), 228-230 (2017).</li><li>Working Group IPA/APA Acute Pancreatitis. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Working+Group+IPA/APA+Acute+Pancreatitis+Guidelines.+IAP/APA+evidence+-+based+guidelines+for+the+management+of+acute+pancreatitis.">Working Group IPA/APA Acute Pancreatitis Guidelines. IAP/APA evidence - based guidelines for the management of acute pancreatitis.</a> Pancrcatology. 13 (4), 15 (2013).</li><li>Chen, P., Tang, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+of+severe+acute+pancreatitis+with+laparoscopic+drainage+via+posterior+approach.">Treatment of severe acute pancreatitis with laparoscopic drainage via posterior approach.</a> Chinese J Curr Adv Gen Surg. 12 (11), 928-930 (2009).</li><li>Sileikis, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Three-port+retroperitoneoscopic+necrosectomy+in+management+of+acute+necrotic+pancreatitis.">Three-port retroperitoneoscopic necrosectomy in management of acute necrotic pancreatitis.</a> Medicina. 46 (3), 176-179 (2010).</li><li>Zhang, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technique+of+anatomical+retroperitoneoscopic+adrenalectomy+with+report+of+800+cases.">Technique of anatomical retroperitoneoscopic adrenalectomy with report of 800 cases.</a> J Urol. 177 (4), 1254-1257 (2007).</li><li>Chinese Society of Surgical Infection and Intensive Care, Chinese Society of Surgery, Chinese Medical Association, Chinese College of Gastrointestinal Fistula Surgeons, Chinese College of Surgeons, Chinese Medical Doctor Association. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Chinese+guidelines+for+the+diagnosis+and+management+of+intra-+abdominal+infection.">Chinese guidelines for the diagnosis and management of intra- abdominal infection.</a> Chinese J Pract Surg. 40 (1), 1-16 (2020).</li><li>Banks, P. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Classification+of+acute+pancreatitis-2012:+revision+of+the+Atlanta+classification+and+definitions+by+international+consensus.">Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus.</a> Gut. 62, 102-111 (2013).</li><li>Hong, C., Sun, B., Lu, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preliminary+exploration+of+basic+treatment+principles+for+severe+acute+pancreatitis.">Preliminary exploration of basic treatment principles for severe acute pancreatitis.</a> Chinese J Surg. 45 (1), 6-8 (2007).</li><li>Adler, D. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Conservative+management+of+infected+necrosis+complicating+severe+acute+pancreatitis.">Conservative management of infected necrosis complicating severe acute pancreatitis.</a> Am J Gastroenterol. 98 (1), 98-103 (2003).</li><li>Yao, J. R., Tian, Y. Z., Liu, S. Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Incremental+trauma+surgical+mode+for+the+treatment+of+severe+acute+pancreatitis.">Incremental trauma surgical mode for the treatment of severe acute pancreatitis.</a> Chinese J Joint Surg. 9 (3), 213-215 (2020).</li><li>Penghao, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+versus+minimally+invasive+surgical+approach+for+infected+necrotizing+pancreatitis:+a+systematic+review+and+meta-analysis+of+randomized+controlled+trials.">Endoscopic versus minimally invasive surgical approach for infected necrotizing pancreatitis: a systematic review and meta-analysis of randomized controlled trials.</a> Ann Med. 55 (2), 1-13 (2023).</li><li>Pancreatic Surgery Group, Surgery Branch, Chinese Medical Association. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Guidelines+for+the+diagnosis+and+treatment+of+acute+pancreatitis.">Guidelines for the diagnosis and treatment of acute pancreatitis.</a> Chinese J Digest Surg. 20 (7), 730-739 (2021).</li><li>Van Santvoort, H. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+conservative+and+minimally+invasive+approach+to+necrotizing+pancreatitis+improves+outcome.">A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome.</a> Gastroenterology. 141 (4), 1254-1263 (2011).</li></ol>

The authors declare that they have nothing to disclose.

The optimal timing of surgical intervention for SAP has been a subject of ongoing debate. In the past, surgical intervention was assumed to be performed immediately upon the occurrence of pancreatic infection-related necrosis. However, since 2000, an increasing number of experts have suggested that the timing of surgical intervention for SAP should be postponed as much as possible11,12,13. Aseptic peripancreatic necrosis may not...

The treatment of severe acute pancreatitis (SAP) complicated by peripancreatic infection and necrosis has long been a difficult problem to solve1,2. Pancreatic infection and necrosis are serious complications of severe acute pancreatitis3. Reducing abdominal and retroperitoneal pressure, removing necrotic tissue as much as possible, and reducing the absorption of toxic substances are the main surgical principles for successfully treating SAP4. Traditional open surgery and continuous postoperative lavage have saved the lives of many SAP patients. However, the transabdominal approach requires perforation of the gastrocolic ligament, entry into the minor omental sac, and subsequent invasion of all segments of the pancreas, which inevitably interferes with various abdominal organs and might introduce retroperitoneal bacteria into the abdominal cavity, increasing the risk of abdominal infection. In addition, the drainage tube is drained from the retroperitoneal cavity to the outside of the abdominal wall. Owing to poor drainage, compression of the intestinal tube may also cause intestinal fistula and abdominal bleeding. In 2013, the Evidence-based Guidelines for the Treatment of Acute Pancreatitis issued by the International Society of Pancreatology and the American Society of Pancreatology noted that minimally invasive debridement of necrotic tissue was superior to open debridement for patients with symptomatic infectious necrosis5. Chen et al.6 used peritoneal laparoscopy to reach the peritoneum, remove necrotic pancreatic tissue, and place the drainage tube, achieving satisfactory results. However, theoretically, problems such as bacterial displacement and peritoneal infection caused by communication between the peritoneum and retroperitoneum are inevitable. Sileikis et al.7 used three-hole laparoscopic retroperitoneal resection of pancreatic necrotic tissue and catheter drainage from 2007 to 2009 and cured 8 SAP patients.
Since 2016, we have adopted retroperitoneal laparoscopy to remove necrotic pancreatic tissue through a retroperitoneal approach. Compared to other minimally invasive surgeries, this method is more direct and safer. It provides direct access to the retroperitoneal space, allowing direct visualization and removal of necrotic tissue in the renal capsule. The field of view is clear, bleeding is easily controlled, and a drainage tube can be placed as needed, ensuring effective drainage. The drainage tube does not pass through the abdominal cavity, causing minimal disturbance to the cavity and reducing the risk of abdominal infection. The necrosis and infection of SAP occur mostly in the tail of the pancreas. There is often necrosis of the peripancreatic fatty tissue, which sometimes extends into the left colonic sulcus. Therefore, we utilized a left-sided approach in all patients, and typically, a single surgery was sufficient to thoroughly remove the necrotic tissue. We believe that retroperitoneal laparoscopic surgery via a left-sided approach is particularly suitable for patients with necrosis of the pancreatic body and tail combined with massive effusion.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Dissecting forceps</td>
			<td>KANGJI</td>
			<td>ZP485RB 330mm&#215;&#934;5</td>
			<td></td>
		</tr>
		<tr>
			<td>Drainage tube</td>
			<td>Kang-Li</td>
			<td>QH-F28</td>
			<td></td>
		</tr>
		<tr>
			<td>Grasping forceps</td>
			<td>KANGJI</td>
			<td>ZP531RB 330mm&#215;&#934;5</td>
			<td></td>
		</tr>
		<tr>
			<td>Laparoscope</td>
			<td>STORZ</td>
			<td>26003BA</td>
			<td></td>
		</tr>
		<tr>
			<td>Normal Saline 3000ml</td>
			<td>Ke-Lun</td>
			<td>3000ml:27g</td>
			<td></td>
		</tr>
		<tr>
			<td>Suction and Irrigation</td>
			<td>KANGJI</td>
			<td>&#934;5/&#934;10&#215;330mm</td>
			<td></td>
		</tr>
		<tr>
			<td>Suture</td>
			<td>ETHICON</td>
			<td>SA86G</td>
			<td></td>
		</tr>
		<tr>
			<td>Trocar</td>
			<td>KANGJI</td>
			<td>ZP015RN &#934;5.5/ ZP018RN &#934;12.5</td>
			<td></td>
		</tr>
		<tr>
			<td>Ultrasonic knife</td>
			<td>An-He</td>
			<td>AH-600</td>
			<td></td>
		</tr>
		<tr>
			<td>Veress needle</td>
			<td>KANGJI</td>
			<td>ZP001RN &#934;2.5&#215;100mm</td>
			<td></td>
		</tr>
	</tbody>
</table>

retroperitoneal laparoscopic debridement and drainage for pancreatic abscess

In patients with severe necrotizing pancreatitis, pancreatic necrosis and secondary infection of surrounding tissues can quickly spread to the whole retroperitoneal space. Treatment of pancreatic abscess complicating necrotizing pancreatitis is difficult and has a high mortality rate. The well-accepted treatment strategy is early debridement of necrotic tissues, drainage, and postoperative continuous retroperitoneal lavage. However, traditional open surgery has several disadvantages, such as severe trauma, interference with abdominal organs, a high rate of postoperative infection and adhesion, and hardness with repeated debridement. The retroperitoneal laparoscopic approach has the advantages of minimal invasion, a better drainage route, convenient repeated debridement, and avoidance of the spread of retroperitoneal infection to the abdominal cavity. In addition, retroperitoneal drainage leads to fewer drainage tube problems, including miscounting, displacement, or siphon. The debridement and drainage of pancreatic abscess tissue via the retroperitoneal laparoscopic approach plays an increasingly irreplaceable role in improving patient prognosis and saving healthcare resources and costs. The main procedures described here include laying the patient on the right side, raising the lumbar bridge and then arranging the trocar; establishing the pneumoperitoneum and cleaning the pararenal fat tissues; opening the lateral pyramidal fascia and the perirenal fascia outside the peritoneal reflections; opening the anterior renal fascia and entering the anterior pararenal space from the rear; clearing the necrotic tissue and accumulating fluid; and placing drainage tubes and performing postoperative continuous retroperitoneal lavage.

A total of six patients received this surgical treatment (Table 1). Preoperatively, all patients were assessed based on PaO2/FiO2, systolic blood pressure, and creatinine levels and were assigned modified Marshall score10 and APACHE II scores (Table 2). All patients underwent surgery smoothly, and the duration of surgery ranged from 75 to 100 min, with an average of 84 &#177; 6.7 min. Preoperative bacterial cultures obtained through PCD tubes...

Read this Scientific Article Protocol about Author Spotlight: Advancements in Retroperitoneal Approach for Necrotizing Pancreatitis at JoVE.com

Author Spotlight: Advancements in Retroperitoneal Approach for Necrotizing Pancreatitis

To improve the drainage of patients with necrotizing pancreatitis complicated with peripancreatic abscess and reduce the mortality of patients with necrotizing pancreatitis, we adopted a retroperitoneal approach for peripancreatic abscess debridement and drainage by laparoscopy.

Retroperitoneal Laparoscopic Debridement and Drainage for Pancreatic Abscess

In patients with severe necrotizing pancreatitis, pancreatic necrosis and secondary infection of surrounding tissues can quickly spread to the whole ...

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317 Views.  Meizhou People’s Hospital. To improve the drainage of patients with necrotizing pancreatitis complicated with peripancreatic abscess and reduce the mortality of patients with necrotizing pancreatitis, we adopted a retroperitoneal approach for peripancreatic abscess debridement and drainage by laparoscopy.

Video: Author Spotlight: Advancements in Retroperitoneal Approach for Necrotizing Pancreatitis

Staining Protocols for Human Pancreatic Islets

Estimates of islet area and numbers and endocrine cell composition in the adult human pancreas vary from several hundred thousand to several million and beta mass ranges from 500 to 1500 mg 1-3. With this known heterogeneity, a standard processing and staining procedure was developed so that pancreatic regions were clearly defined and islets characterized using rigorous histopathology and immunolocalization examinations. 
Standardized procedures for processing human pancreas recovered from organ donors are described in part 1 of this series. The pancreas is processed into 3 main regions (head, body, tail) followed by transverse sections. Transverse sections from the pancreas head are further divided, as indicated based on size, and numbered alphabetically to denote subsections. This standardization allows for a complete cross sectional analysis of the head region including the uncinate region which contains islets composed primarily of pancreatic polypeptide cells to the tail region.
The current report comprises part 2 of this series and describes the procedures used for serial sectioning and histopathological characterization of the pancreatic paraffin sections with an emphasis on islet endocrine cells, replication, and T-cell infiltrates. Pathology of pancreatic sections is intended to characterize both exocrine, ductular, and endocrine components. The exocrine compartment is evaluated for the presence of pancreatitis (active or chronic), atrophy, fibrosis, and fat, as well as the duct system, particularly in relationship to the presence of pancreatic intraductal neoplasia4. Islets are evaluated for morphology, size, and density, endocrine cells, inflammation, fibrosis, amyloid, and the presence of replicating or apoptotic cells using H&amp;E and IHC stains. 
The final component described in part 2 is the provision of the stained slides as digitized whole slide images. The digitized slides are organized by case and pancreas region in an online pathology database creating a virtual biobank. Access to this online collection is currently provided to over 200 clinicians and scientists involved in type 1 diabetes research. The online database provides a means for rapid and complete data sharing and for investigators to select blocks for paraffin or frozen serial sections.

This video demonstrates procedures for characterization of human pancreatic islets using hematoxylin and eosin (H&E) and immunohistochemistry (IHC). Pancreatic sections from head, body, and tail regions are stained by both H&amp;E and IHC to determine islet endocrine composition (insulin, glucagon, and pancreatic polypeptide), cell replication (Ki67), and inflammatory infiltrates (H&E, CD3). The uncinate region is localized using IHC for pancreatic polypeptide.

Estimates of islet area and numbers and endocrine cell composition in the adult human pancreas vary from several hundred thousand to several million and ...

Ovine Lumbar Intervertebral Disc Degeneration Model Utilizing a Lateral Retroperitoneal Drill Bit Injury

Intervertebral disc degeneration is a significant contributor to the development of back pain and the leading cause of disability worldwide. Numerous animal models of intervertebral disc degeneration have been developed. The ideal animal model should closely mimic the human intervertebral disc with regard to morphology, biomechanical properties and the absence of notochordal cells. The sheep lumbar intervertebral disc model fulfils these criteria. We present an ovine model of intervertebral disc degeneration utilizing a drill bit injury through a lateral retroperitoneal approach. The lateral approach significantly reduces the incision and potential morbidity associated with the traditional anterior approach to the ovine spine. Utilization of a drill-bit method of injury affords the ability to produce a consistent and reproducible injury, of precise dimensions, that initiates a consistent degree of intervertebral disc degeneration. The focal nature of the annular and nucleus pulposus defect more closely mimics the clinical condition of focal intervertebral disc herniation. Sheep recover rapidly following this procedure and are typically mobile and eating within the hour. Intervertebral disc degeneration ensues and sheep undergo necropsy and subsequent analysis at periods from eight weeks. We believe that the drill bit injury model of intervertebral disc degeneration offers advantages over more conventional annular injury models.

Intervertebral disc degeneration is a significant contributor to back pain and a leading cause of disability worldwide. Numerous animal models of intervertebral disc degeneration exist. We demonstrate an ovine model of intervertebral disc degeneration, utilizing a drill bit, which achieves a consistent disc injury and reproducible level of disc degeneration.

Intervertebral disc degeneration is a significant contributor to the development of back pain and the leading cause of disability worldwide. Numerous ...

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The recent rise of robotic and laparoscopic pancreatic surgery has found benefits such as reduced time to functional recovery. Few studies have reported on the feasibility, technique and outcome of robotic LPJ, especially including transection of the gastroduodenal artery. The present study describes the main steps for robotic LPJ in a patient with painful chronic pancreatitis with a dilated main pancreatic duct. The patient underwent robotic LPJ. The LPJ anastomosis is performed using a running suture technique in a longitudinal side-to-side manner. Routinely, the gastroduodenal artery is transected to drain the entire length of the main pancreatic duct. The patient is in French position; 7 trocars are placed (4 robotic, 2 laparoscopic assistants, 1 liver-retractor). After docking of the robot system, the omental bursa is opened, and the right gastroepiploic artery and vein are ligated at their base at the lower border of the pancreas. Intraoperative ultrasonography is performed in order to determine trajectory of the dilated main pancreatic duct which is opened for its entire length after the gastroduodenal artery has been suture ligated both cranially and caudally from the main pancreatic duct. A Roux limb is created, and a latero-lateral PJ is fashioned using several 3-0 barbed sutures. A stapled jejuno-jejunostomy is created at sufficient distance from the pancreatic anastomosis, aided by a 50 cm suture. The described technique for robotic LPJ is a complex but feasible operation for patients with treatment refractory CP and a dilated main pancreatic duct. Due to its complexity, implementation in high volume centers with extensive experience with CP surgery may improve outcomes.

Robotic lateral pancreaticojejunostomy (RLPJ) may be used in patients with painful, morphine dependent, chronic pancreatitis and a dilated main pancreatic duct. We describe a standardized and reproducible technique for RLPJ, which includes transection of the gastroduodenal artery.

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The ...

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota&#39;s fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota&#8217;s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (&#62;1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota&#8217;s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...

Posterior Approach for Debridement of the Psoas Abscess

This method focuses on outlining a safe zone for irrigation and debridement of a psoas abscess through a posterior approach. Initially, an anterior approach to the spine was performed to ensure that the anterior longitudinal ligament and the psoas muscle could be visualized. All the abdominal organs were removed. Subsequently, a posterior approach was performed to remove the paraspinal muscles from L1&#8211;L5. The transverse processes, pars interarticularis and lamina of L1&#8211;L5 were identified. The exiting nerve root was identified between the transverse processes and followed into the substance of the psoas muscle. Using the anterior and posterior approach, the lumbar plexus was isolated from the substance of the psoas muscle. Before and after various steps of dissection, digital photographs were obtained. These images were uploaded into ImageJ and multiple measurements, including the distance between the lateral superior and inferior tip of each TP to the most lateral region of the plexus, the distance between the lateral superior and inferior tip of the TP to the lateral edge of the psoas, and the width of the lumbar plexus were recorded. The safe zone for entering the substance of the psoas muscle was defined between the lateral edge of the psoas muscle and the lateral edge of the lumbar plexus. The relationship of this interval to the tip of the transverse process at each level was measured and reported.

This is a cadaveric study investigating the landmarks for the posterior approach for irrigation and debridement of the psoas abscess. The interval between the transverse processes (TP) was used to access the substance of the psoas muscle.

This method focuses on outlining a safe zone for irrigation and debridement of a psoas abscess through a posterior approach. Initially, an anterior ...

Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing pancreatitis, if it does not resolve or is accompanied with infected necrosis in the retroperitoneum. As there are rarely any visually clear separating surface in white light image between necrotic debris and adjacent inflammatory normal tissues due to extensive retroperitoneal adhesions, VARD is accompanied with the risk of vascular injury, external pancreatico-cutaneous or enterocutaneous fistulae. In view of the above disadvantages, we apply real-time intraoperative near-infrared fluorescence imaging with indocyanine green (ICG) during VARD, which enables visualization of the well-perfused adjacent normal tissues. This modified technique (ICG-guided VARD) can provide a clear separating surface during debridement and reduce the risk of vascular or enteric injury. ICG-guided VARD may facilitate surgeons to perform safer debridement in treating severe acute necrotizing pancreatitis.

This protocol presents Indocyanine Green-guided video-assisted retroperitoneal debridement (ICG-guided VARD) for treating severe acute necrotizing pancreatitis.

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing ...

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein&#160;(SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore apical support for treating POP. Sacrocolpopexy and pectopexy are indicated for apical prolapse. Using a synthetic mesh in these techniques increases success by enhancing apical support. However, the implantation of synthetic mesh is associated with mesh-related complications. In addition, the exorbitant cost of synthetic mesh and lack of universal access limit the popularity of these procedures. The current study develops a unique technique known as laparoscopic non-mesh cerclage pectopexy (LNMCP), in which permanent cervical cerclage sutures are embedded in the round ligament until the iliopectineal ligament. The iliopectineal ligament was sutured, resulting in a firm cervical suspension. The procedure was successfully performed in 16 cases in the hospital. The surgical duration was 67.8 min &plusmn; 15.5 min, and the blood loss was 73.1 mL &plusmn; 51.1 mL. No procedural complications were seen. LNMCP is associated with an objective success rate of 100% and a subjective success rate of 93.8%. LNMCP for patients with apical prolapse obviates the need for a mesh, thereby avoiding complications associated with mesh erosion and reducing medical costs. In addition, it is easy to perform even in resource-poor areas without access to synthetic mesh.

The present pilot study describes the development of laparoscopic non-mesh cerclage pectopexy to treat pelvic organ prolapse. The procedure can be used to prevent any complications associated with the use of mesh.

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore ...

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope.
The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

With advancements in laparoscopic techniques, laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been widely recognized. However, owing to several technical difficulties in this procedure, the artery-first approach in L-RAMPS still remains uncommon. Here, we developed the dorsal-caudal artery approach for L-RAMPS, which might be safe and beneficial for pancreatic neck tumors.

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who ...

Application of Laparoscopic Hepatectomy Combined with Intraoperative Microwave Ablation in Colorectal Cancer Liver Metastasis

Laparoscopic hepatectomy is a common treatment for colorectal cancer liver metastasis. Previously, a sufficient number of functional liver masses had to be maintained during laparoscopic hepatectomy, with a residual liver volume of &gt;40% in cirrhotic patients and &gt;30% in non-cirrhotic patients. The high incidence of complications such as bleeding, bile leakage, or liver failure due to the exposure and difficulty of the resection of specific liver segments such as S2 and S7 reduces the success rate of liver resection. At present, microwave ablation is mainly applied in the treatment of liver metastasis using a percutaneous approach, which makes it difficult to identify hidden parts or small lesions. For some liver segments, the percutaneous puncture of liver segment 7 (S7) is likely to pass through the thoracic cavity, and the percutaneous puncture of liver segment 2 (S2) adjacent to the diaphragm is likely to injure the diaphragm and heart; these issues restrict the application of percutaneous ablation in colorectal cancer liver metastasis. Considering multiple lesions, laparoscopic microwave ablation combined with hepatectomy was performed in this study. The location of the lesions was determined by contrast-enhanced ultrasound under laparoscopy, and small lesions that were difficult to detect before the operation were identified. For the scattered lesions, which had diameters less than 3 cm and were difficult to resect, ablation was adopted to substitute hepatectomy. This technique helped to more explicitly locate the tumors, simplified the operation procedures, reduced the risk of complications such as bleeding and bile leakage, shortened the operation time, accelerated the postoperative recovery, significantly improved the success rate of operation, and enhanced the clinical prognosis of colorectal cancer liver metastasis by surgical resection.

This protocol describes the laparoscopic resection of colorectal cancer liver metastases combined with ultrasound-guided microwave ablation. This technique can safely, effectively, and accurately treat refractory liver metastases &lt;3 cm, reduce postoperative complications, and accelerate the postoperative rehabilitation of patients.

Laparoscopic hepatectomy is a common treatment for colorectal cancer liver metastasis. Previously, a sufficient number of functional liver masses had to ...