Name: techniques of laparoscopic right posterior sectionectomy: glissonian approach and a parenchymal transection technique
Uploaded: 2023-10-06T12:10:00
Description: Watch this Scientific Journal Video about Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique at JoVE.com

The study is self-sponsored.

The protocol follows the guidelines of Kwong Wah Hospital&#39;s human research ethics committee.
1. Pre-operative workup
<ol>
	<li>Check triphasic CT scans to evaluate the extent of disease and vascular anatomy.</li>
	<li>Perform an indocyanine green (ICG) retention test to assess liver function properly. Preferably, ICG retention of less than 15% is required for patients to undergo major liver resection13.</li>
	<li>Perform CT volumetry to ensure ade...

Advancing LRPS: Optimal Techniques for Challenging Liver Resections

<ol>
	<li>van der Heijde, N., 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=Laparoscopic+versus+open+right+posterior+sectionectomy:+an+international,+multicenter,+propensity+score-matched+evaluation.">Laparoscopic versus open right posterior sectionectomy: an international, multicenter, propensity score-matched evaluation.</a> Surgical Endoscopy. 35 (11), 6139-6149 (2021).</li><li>Cheng, K. C., Yeung, Y. P., Ho, K. M., Chan, F. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+right+posterior+sectionectomy+for+malignant+lesions:+An+anatomic+approach.">Laparoscopic right posterior sectionectomy for malignant lesions: An anatomic approach.</a> Journal of Laparoendoscopic &amp; Advanced Surgical Techniques. Part A. 25 (8), 646-650 (2015).</li><li>Fretland, A. 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=Laparoscopic+versus+open+resection+for+colorectal+liver+metastases:+The+OSLO-COMET+randomized+controlled+trial.">Laparoscopic versus open resection for colorectal liver metastases: The OSLO-COMET randomized controlled trial.</a> Annals of Surgery. 267 (2), 199-207 (2018).</li><li>Landi, F., 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=Short-term+outcomes+of+laparoscopic+vs.+open+liver+resection+for+hepatocellular+adenoma:+a+multicenter+propensity+score+adjustment+analysis+by+the+AFC-HCA-2013+study+group.">Short-term outcomes of laparoscopic vs. open liver resection for hepatocellular adenoma: a multicenter propensity score adjustment analysis by the AFC-HCA-2013 study group.</a> Surgical Endoscopy. 31 (10), 4136-4144 (2017).</li><li>Cho, 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=Safe+and+feasible+extrahepatic+Glissonean+access+in+laparoscopic+anatomical+liver+resection.">Safe and feasible extrahepatic Glissonean access in laparoscopic anatomical liver resection.</a> Surgical Endoscopy. 25 (4), 1333-1336 (2011).</li><li>Oztas, M., Lapsekili, E., Fatih Can, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+liver+right+posterior+sectionectomies;+surgical+technique+and+clinical+results+of+a+single+surgeon+experience.">Laparoscopic liver right posterior sectionectomies; surgical technique and clinical results of a single surgeon experience.</a> Turkish Journal of Surgery. 38 (1), 18-24 (2022).</li><li>Siddiqi, N. N., 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=Laparoscopic+right+posterior+sectionectomy+(LRPS):+surgical+techniques+and+clinical+outcomes.">Laparoscopic right posterior sectionectomy (LRPS): surgical techniques and clinical outcomes.</a> Surgical Endoscopy. 32 (5), 2525-2532 (2018).</li><li>Machado, M. A., Makdissi, F. F., Galvao, F. H., Machado, M. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intrahepatic+Glissonian+approach+for+laparoscopic+right+segmental+liver+resections.">Intrahepatic Glissonian approach for laparoscopic right segmental liver resections.</a> The American Journal of Surgery. 196 (4), e38-e42 (2008).</li><li>Machado, M. A., Kalil, A. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Glissonian+approach+for+laparoscopic+mesohepatectomy.">Glissonian approach for laparoscopic mesohepatectomy.</a> Surgical Endoscopy. 25 (6), 2020-2022 (2011).</li><li>Topal, B., Aerts, R., Penninckx, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+intrahepatic+Glissonian+approach+for+right+hepatectomy+is+safe,+simple,+and+reproducible.">Laparoscopic intrahepatic Glissonian approach for right hepatectomy is safe, simple, and reproducible.</a> Surgical Endoscopy. 21 (11), 2111 (2007).</li><li>Park, J., 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=Safety+and+Risk+factors+of+pure+laparoscopic+living+donor+right+hepatectomy:+Comparison+to+open+technique+in+propensity+score-matched+analysis.">Safety and Risk factors of pure laparoscopic living donor right hepatectomy: Comparison to open technique in propensity score-matched analysis.</a> Transplantation. 103 (10), e308-e316 (2019).</li><li>Yang, Y., 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=Laparoscopic+liver+resection+with+&amp;#34;ultrasonic+scalpel+mimic+CUSA&amp;#34;+technique.">Laparoscopic liver resection with &amp;#34;ultrasonic scalpel mimic CUSA&amp;#34; technique.</a> Surgical Endoscopy. 36 (12), 8927-8934 (2022).</li><li>Kitano, S., Kim, Y. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=ICG+clearance+in+assessing+cirrhotic+patients+with+hepatocellular+carcinoma+for+major+hepatic+resection.">ICG clearance in assessing cirrhotic patients with hepatocellular carcinoma for major hepatic resection.</a> HPB Surgery. 10 (3), 182-183 (1997).</li><li>Lim, M. C., Tan, C. H., Cai, J., Zheng, J., Kow, A. W. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=CT+volumetry+of+the+liver:+Where+does+it+stand+in+clinical+practice.">CT volumetry of the liver: Where does it stand in clinical practice.</a> Clinical Radiology. 69 (9), 887-895 (2014).</li><li>Sachdeva, A., Dalton, M., Lees, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Graduated+compression+stockings+for+prevention+of+deep+vein+thrombosis.">Graduated compression stockings for prevention of deep vein thrombosis.</a> Cochrane Database of Systematic Reviews. 11 (11), CD001484 (2018).</li><li>Liu, T. S., 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=Application+of+controlled+low+central+venous+pressure+during+hepatectomy:+A+systematic+review+and+meta-analysis.">Application of controlled low central venous pressure during hepatectomy: A systematic review and meta-analysis.</a> Journal of Clinical Anesthesia. 75, 110467 (2021).</li><li>Ellison, E. C., Zollinger, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Zollinger's Atlas of Surgical Operations. , (2016).</li><li>Kato, Y., 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=Minimally+invasive+anatomic+liver+resection+for+hepatocellular+carcinoma+using+the+extrahepatic+Glissonian+approach:+Surgical+techniques+and+comparison+of+outcomes+with+the+open+approach+and+between+the+laparoscopic+and+robotic+approaches.">Minimally invasive anatomic liver resection for hepatocellular carcinoma using the extrahepatic Glissonian approach: Surgical techniques and comparison of outcomes with the open approach and between the laparoscopic and robotic approaches.</a> Cancers (Basel). 15 (8), 2219 (2023).</li><li>Kamiyama, T., Kakisaka, T., Orimo, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Current+role+of+intraoperative+ultrasonography+in+hepatectomy.">Current role of intraoperative ultrasonography in hepatectomy.</a> Surgery Today. 51 (12), 1887-1896 (2021).</li><li>Huang, J. W., Su, W. L., Wang, S. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Alternative+laparoscopic+intracorporeal+Pringle+maneuver+by+Huang's+loop.">Alternative laparoscopic intracorporeal Pringle maneuver by Huang's loop.</a> World Journal of Surgery. 42 (10), 3312-3315 (2018).</li><li>. Laparoscopes articulating HD 3D videoscope ENDOEYE FLEX 3D (LTF-190-10-3D) Available from: <a target="_blank" href="https://medical.olympusamerica.com/products/laparoscopes/endoeye-flex-3d">https://medical.olympusamerica.com/products/laparoscopes/endoeye-flex-3d</a> (2023)</li><li>Welling, A., Scoggins, P., Cummings, J., Clymer, J., Amaral, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Superior+dissecting+capability+of+a+new+ultrasonic+device+improves+efficiency+and+reduces+adhesion+formation.">Superior dissecting capability of a new ultrasonic device improves efficiency and reduces adhesion formation.</a> Global Surgery. 3 (1), (2017).</li><li>Lortat-Jacob, J. L., Robert, H. G., Henry, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Case+of+right+segmental+hepatectomy.">Case of right segmental hepatectomy.</a> Memoires. Academie de Chirurgie (Paris). 78 (8-9), 244-251 (1952).</li><li>Takasaki, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Glissonean+pedicle+transection+method+for+hepatic+resection:+a+new+concept+of+liver+segmentation.">Glissonean pedicle transection method for hepatic resection: a new concept of liver segmentation.</a> Journal of Hepato-Biliary-Pancreatic Surgery. 5 (3), 286-291 (1998).</li><li>Ramacciato, 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=Effective+vascular+endostapler+techniques+in+hepatic+resection.">Effective vascular endostapler techniques in hepatic resection.</a> International Surgery. 83 (4), 317-323 (1998).</li><li>Figueras, J., 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=Hilar+dissection+versus+the+&amp;#34;glissonean&amp;#34;+approach+and+stapling+of+the+pedicle+for+major+hepatectomies:+a+prospective,+randomized+trial.">Hilar dissection versus the &amp;#34;glissonean&amp;#34; approach and stapling of the pedicle for major hepatectomies: a prospective, randomized trial.</a> Annals of Surgery. 238 (1), 111-119 (2003).</li><li>Jegadeesan, M., Jegadeesan, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anatomical+basis+of+approaches+to+liver+resection.">Anatomical basis of approaches to liver resection.</a> Acta Scientific Gastrointestinal Disorders. 3 (12), 17-23 (2020).</li><li>Eikermann, M., 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=Prevention+and+treatment+of+bile+duct+injuries+during+laparoscopic+cholecystectomy:+the+clinical+practice+guidelines+of+the+European+Association+for+Endoscopic+Surgery+(EAES).">Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES).</a> Surgical Endoscopy. 26 (11), 3003-3039 (2012).</li><li>Imamura, H., 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=Prognostic+significance+of+anatomical+resection+and+des-gamma-carboxy+prothrombin+in+patients+with+hepatocellular+carcinoma.">Prognostic significance of anatomical resection and des-gamma-carboxy prothrombin in patients with hepatocellular carcinoma.</a> British Journal of Surgery. 86 (8), 1032-1038 (1999).</li><li>Lee, N., 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=Application+of+temporary+inflow+control+of+the+Glissonean+pedicle+method+provides+a+safe+and+easy+technique+for+totally+laparoscopic+hemihepatectomy+by+Glissonean+approach.">Application of temporary inflow control of the Glissonean pedicle method provides a safe and easy technique for totally laparoscopic hemihepatectomy by Glissonean approach.</a> Annals of Surgical Treatment and Research. 92 (5), 383-386 (2017).</li><li>Otsuka, Y., 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=What+is+the+best+technique+in+parenchymal+transection+in+laparoscopic+liver+resection?+Comprehensive+review+for+the+clinical+question+on+the+2nd+International+Consensus+Conference+on+Laparoscopic+Liver+Resection.">What is the best technique in parenchymal transection in laparoscopic liver resection? 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The critical components of the surgery include the intrahepatic Glissonian approach for inflow control, a &#39;ultrasonic scalpel mimic CUSA&#39; parenchymal transection technique, early identification of right hepatic vein and meticulous bleeding control by bipolar diathermy.
The first critical step in this protocol is identifying and controlling the right posterior pedicle. The Glissonian approach was first introduced as extrahepatic Glissonian pedicle control in open liver surgery<sup class...

Laparoscopic liver surgery has been shown to have several advantages over open liver resection, including reduced blood loss, decreased wound pain, and shorter hospital stay while maintaining comparable oncological outcomes1,2,3,4. Although LRPS was previously considered a relative contraindication due to its deep-seated anatomic location and challenges in bleeding control, recent advancements have proven its safety and feasibility2,5,6,7. Various strategies and surgical devices have been developed to overcome these challenges. However, no consensus exists on the best surgical technique and devices for LRPS.
In this article, we aim to provide a detailed description of the steps involved in LRPS at our centre, with a specific focus on the intrahepatic Glissonian approach for inflow control, a novel technique called the &#39;ultrasonic scalpel mimic Cavitron ultrasonic surgical aspirator (CUSA)&#39; for parenchymal transection, early identification of the right hepatic vein, and meticulous bleeding control using bipolar diathermy. Machado et al. and Topal et al. reported the feasibility and safety of the laparoscopic intrahepatic Glissonian approach8,9,10. Laparoscopic techniques offer improved visualization and precision in dissecting the Glissonian pedicle. The approach maintains the blood flow to the remnant liver, reducing the risk of ischaemic injury. Additionally, this approach allows for the exact demarcation of liver segments that are being resected, making the surgery more precise and reducing the risk of bleeding. Professor Kwon introduced the &#39;ultrasonic scalpel mimic CUSA&#39; technique in 201911, which has been shown to reduce intraoperative blood loss and operative time11,12.
A representative case is discussed in this study to detail the steps performed in the protocol. The patient is a 54-year-old man who is a chronic carrier of hepatitis B. During screening ultrasonography, a liver mass was identified in segment 6. A pre-operative triphasic computed tomography (CT) scan was performed, which revealed a 5.7 cm hypervascular tumor with arterial enhancement and portovenous washout in segment 7 (Figure 1).&#160;The alpha-fetoprotein (AFP) level was 2 ng/ml. The Child-Pugh score was 5 (Grade A). The indocyanine green retention at 15 min was 7.5%. The residual liver volume (RLV) was 45%. Based on the patient&#39;s hepatitis status and the radiological features of the tumor, the mass was treated as hepatocellular carcinoma. The patient was offered a laparoscopic right posterior sectionectomy, including the right hepatic vein.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>3D ENDOEYE Flex</td>
			<td>Olympus&#160;</td>
			<td>LTF-S190-10-3D</td>
			<td>Flexible tip laparoscopic camera</td>
		</tr>
		<tr>
			<td>5 mm ROBI Bipolar Grasping Forceps</td>
			<td>KARL STORZ</td>
			<td>38851 ON</td>
			<td>atraumatic, fenestrated forceps</td>
		</tr>
		<tr>
			<td>AESCULAP Challenger Ti-P</td>
			<td>Barun</td>
			<td>PL520L</td>
			<td>Pneumatic driven multi-fire clip applicator. 5 mm metal clips</td>
		</tr>
		<tr>
			<td>Endo GIA Reloads with Tri-Staple Technology, 30 mm, Tan colour</td>
			<td>Medtronic&#160;</td>
			<td>SIG30AVM</td>
			<td>Tristaple system that has stepped cartridge face that delivers graduated compression and three rows of varied height staples. Staple height 2 mm, 2.5 mm, 3 mm.</td>
		</tr>
		<tr>
			<td>Endo GIA Ultra Universal Stapler</td>
			<td>Medtronic&#160;</td>
			<td>EGIAUSTND</td>
			<td>Manual stapler that compresses tissue while it simultaneously lays down a staple line and transects the tissue</td>
		</tr>
		<tr>
			<td>HARMONIC ACE+7 Shears</td>
			<td>Ethicon</td>
			<td>HARH36</td>
			<td>Curved tip, energy sealing and dissecting, diameter 5 mm, length 36 cm</td>
		</tr>
		<tr>
			<td>Hem-o-lok Clips L</td>
			<td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td>
			<td>544240</td>
			<td>Vascular clip 5&#8211;13 mm Size Range</td>
		</tr>
		<tr>
			<td>Hem-o-lok Clips ML</td>
			<td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td>
			<td>544230</td>
			<td>Vascular clip 3&#8211;10 mm Size Range</td>
		</tr>
		<tr>
			<td>Hem-o-Lok Polymer Ligation System</td>
			<td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td>
			<td>544965</td>
			<td></td>
		</tr>
		<tr>
			<td>Profocus 2202 Ultraview 800</td>
			<td>BK Medical&#160;</td>
			<td>N/A</td>
			<td>Intraoperative Ultrasonography</td>
		</tr>
	</tbody>
</table>

techniques of laparoscopic right posterior sectionectomy: glissonian approach and a parenchymal transection technique

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver resections, including less blood loss, reduced wound pain, and shorter hospital stays with a comparable oncological outcome. However, laparoscopic resection of lesions in the right posterior section of the liver is challenging due to difficulties in bleeding control and visualizing the surgical field. In the past, laparoscopic right posterior sectionectomy (LRPS) was still in the exploration phase, with undefined risks in the Second International Consensus Conference on LLR in 2014. However, recent technological advancements and increased surgical experience have shown that LRPS can be safe and feasible. It has been found to reduce hospital stay and blood loss compared to open surgery. This manuscript aims to provide a detailed description of the steps involved in LRPS. The key factors contributing to our success in this challenging procedure include proper liver retraction and exposure, the use of an intrahepatic Glissonian approach for inflow control, a technique called the 'ultrasonic scalpel mimic Cavitron ultrasonic surgical aspirator (CUSA)' for parenchymal transection, early identification of the right hepatic vein, and meticulous bleeding control using bipolar diathermy.

In the representative case, the total operative time was 738 min, with an estimated blood loss of 400 mL. The patient was nursed in the intensive care unit for 2 days. The recovery was uneventful, and the patient was discharged on postoperative day 5. Histopathological examination of the specimen revealed moderately differentiated cholangiocarcinoma measured 8.0 cm x 5.5 cm x 4.5 cm. There was no perineural or lymphovascular permeation. The resection margin was 14 mm. The American Joint Committee on Cancer (AJCC) staging...

Watch this Scientific Journal Video about Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique at JoVE.com

Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique

Here, we present a protocol to perform laparoscopic right posterior sectionectomy, focusing on two key aspects: the intrahepatic Glissonian approach for inflow control and a parenchymal transection technique using an ultrasonic surgical aspirator.

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver ...

After inserting the laparoscope ports in the patient, complete the division of the triangular ligament until the bare area of the liver is exposed. Expose the groove that lies between the right hepatic veins and the common trunk of the middle and left hepatic veins. Then, incise the inferior peritoneal attachment and gently lower the adrenal gland to the retroperitoneum.Divide the short hepatic veins and the ligament connecting to the vena cava until the inferior border of the right hepatic vein becomes visible. Carefully dissect along the superior border of the right posterior Glissonean pedicle along the Rouviere's sulcus, while ensuring the integrity of the Laennec capsule. Then transect the caudate process to reveal the inferior margin of the right posterior Glissonean pedicle.Dissect along the inferior border of the right posterior Glissonean pedicle along the Rouviere's sulcus. Using a bulldog clamp, control the right posterior pedicle. With the help of an ultrasonic scalpel, carefully open the liver capsule.Make the incision at the dome of the liver, precisely along the left margin of the right hepatic vein, ensuring a secure and accurate transection plane. Then use diathermy to mark the remainder of the transection line along the ischemic line. Using Huang's loop and a shortened Foley catheter, prepare an intracorporeal tourniquet for the laparoscopic Pringle maneuver.Carefully open the liver capsule along the predetermined transection line. Heat both arms of the ultrasonic scalpel in the open position. Utilize the active blade of the ultrasonic scalpel for tissue dissection.Activate the ultrasonic scalpel at its maximum power setting, and move the active blade in a horizontal swinging motion parallel to the vasculobiliary structures. Then dissect the liver parenchyma while exposing individual intrahepatic vessels and ensuring their preservation. Employ a suction device with the left hand to maintain a dry surgical field continually.And then use either plastic clips or metal clips to divide large vessels or pedicle structures. Use an ultrasonic scalpel to divide small vessels. To address bleeding, use bipolar diathermy while simultaneously using suction to maintain a clear surgical field.Wrap vascular tape around the right posterior pedicle before cutting with a vascular stapler. Use intracorporeal sutures for significant bleeding, such as bleeding from the right hepatic vein. Transect the right hepatic vein using a vascular stapler.Finally, place the specimen into a plastic bag and retrieve the specimen through the Pfannenstiel incision. In the representative case, the total operative time was 738 minutes, with an estimated blood loss of 400 milliliters. The patient was discharged on post-operative day five.The resection margin was 14 millimeters.

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Laparoscopic Technique for Serial Collection of Liver and Mesenteric Lymph Nodes in Macaques

The mesenteric lymph nodes (MLN) and the liver are exposed to microbes and microbial products from the gastrointestinal (GI) tract, making them immunologically unique. The GI tract and associated MLN are sites of early viral replication in human immunodeficiency virus (HIV) infection and the MLN are likely important reservoir sites that harbor latently-infected cells even after prolonged antiretroviral therapy (ART). The liver has been shown to play a significant role in immune responses to lentiviruses and appears to play a significant role in clearance of virus from circulation. Nonhuman primate (NHP) models for HIV and Acquired Immunodeficiency Syndrome (AIDS) closely mimic these aspects of HIV infection and serial longitudinal sampling of primary sites of viral replication and the associated immune responses in this model will help to elucidate critical events in infection, pathogenesis, and the impact of various intervention strategies on these events. Current published techniques to sample liver and MLN together involve major surgery and/or necropsy, which limits the ability to investigate these important sites in a serial fashion in the same animal. We have previously described a laparoscopic technique for collection of MLN. Here, we describe a minimally invasive laparoscopic technique for serial longitudinal sampling of liver and MLN through the same two port locations required for the collection of MLN. The use of the same two ports minimizes the impact to the animals as no additional incisions are required. This technique can be used with increased sampling frequency compared to major abdominal surgery and reduces the potential for surgical complications and associated local and systemic inflammatory responses that could complicate interpretation of results. This procedure has potential to facilitate studies involving NHP models while improving animal welfare.

Here, we describe a minimally invasive laparoscopic technique for serial sampling of liver and mesenteric lymph nodes (MLN) in macaques that allows for increased sampling frequency, and reduces the potential for surgical complications when compared to performing a laparotomy.

The mesenteric lymph nodes (MLN) and the liver are exposed to microbes and microbial products from the gastrointestinal (GI) tract, making them ...

Posterior Semicircular Canal Approach for Inner Ear Gene Delivery in Neonatal Mouse

Inner ear gene therapy offers great promise as a potential treatment for hearing loss and dizziness. One of the critical determinants of the success of inner ear gene therapy is to find a delivery method which results in consistent transduction efficiency of targeted cell types while minimizing hearing loss. In this study, we describe the posterior semicircular canal approach as a viable method for inner ear gene delivery in neonatal mice. We show that gene delivery through the posterior semicircular canal is able to perfuse the entire inner ear. The easy anatomic identification of the posterior semicircular canal, as well as minimal manipulation of the temporal bone required, make this surgical approach an attractive option for inner ear gene delivery.

In this study, we describe the posterior semicircular canal approach as a reliable method for inner ear gene delivery in neonatal mice. We show that gene delivery through the posterior semicircular canal is able to perfuse the entire inner ear.

Inner ear gene therapy offers great promise as a potential treatment for hearing loss and dizziness. One of the critical determinants of the success of ...

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.

The goal of this protocol is to describe in detail the technique of minimally invasive aortic valve replacement through a right anterior mini-thoracotomy and central aortic cannulation. This technique can potentially enhance patients&#39; comfort and, by reducing post-operative morbidity, promote lowering the length of stay and global costs.

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. 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 ...

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts to spare normal ovarian cortex. Optimization of tubal anatomy is another frequent consideration. Fertility-sparing laparoscopic techniques at the time of cystectomy for ovarian endometrioma seek to limit iatrogenic surgical damage to the ovarian cortex and strategically assess and respond to genital tract patency. Surgical candidates frequently desire relief from endometriosis-associated pain while also seeking to optimize spontaneous or assisted conception rates. Operative benefits include potential for surgical and histopathologic diagnosis of endometriosis, evaluation of genital tract patency, and treatment of visualized lesions. Resection of ovarian endometrioma nonetheless poses significant risks, including surgical injury, blood loss, post-surgical decline in ovarian reserve and post-operative inflammation with adhesion formation, both of which may impair folliculogenesis.
We present the case of a 32-year-old woman with known endometriosis and continued pain refractory to medical management who opted for surgical management of her disease tailored toward optimizing her chances at future conception. Using this case as an example, we describe techniques and considerations for diagnostic laparoscopy, adhesiolysis, ovarian cystectomy, chromopertubation, and salpingectomy with a focus on maintaining a fertility-preserving approach.

This protocol presents techniques to laparoscopically excise ovarian endometrioma, to perform adhesiolysis with sparing electrosurgical application, and to employ intraoperative chromopertubation to assess for genital tract patency. This systematic approach will facilitate optimal endometriosis management, guide concomitant adnexal surgeries, and enhance post-surgical fertility outcomes.

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...

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 ...

Arthroscopic Double Posteromedial Approach for PCL Cyst Excision

Arthroscopic Excision of Posterior Cruciate Ligament Cysts Using a Double Posteromedial Approach

Cruciate ligament cysts of the knee are a rare condition. Posterior cruciate ligament cysts of the knee are less common than anterior cruciate ligament cysts. In patients with asymptomatic isolated cruciate ligament cysts of the knee, conservative treatment is recommended. Symptomatic cruciate ligament cysts of the knee are mostly manifested as knee hyperflexion pain, straightening pain, knee discomfort after standing for a long time or walking for a long time, etc., which seriously affects the quality of life, surgical treatment can be performed. The surgical treatments can be divided into ultrasound-guided cyst puncture and fluid extraction procedure and arthroscopic cystectomy. Cysts are mostly lobulated with a multi-layer cyst wall, cyst fluid extraction does not remove the cyst wall completely but simply extracts cyst fluid, leading to a high recurrence rate. Arthroscopic surgery can completely remove the cyst wall with little trauma, a low recurrence rate, and fast postoperative recovery, so arthroscopic resection is the most common and preferred method of treatment. Since posterior cruciate ligament cysts mostly occur posterior to the ligament, we remove the cyst wall by adding a double posteromedial approach to the knee joint, and the cyst wall is removed under direct vision, which is simple to operate, the cyst wall is completely cleared, the trauma is small, the postoperative recovery is fast, and there is no recurrence. Here, 8 posterior cruciate ligament cysts were removed with complete postoperative symptom relief, no surgical complications, and no recurrence at 1-year follow-up.

Author Spotlight: Double Posteromedial Approach for Treating Posterior Cruciate Ligament Cysts

We present a surgical approach to treat posterior cruciate ligament cysts by an arthroscopic double posteromedial approach.

Cruciate ligament cysts of the knee are a rare condition. Posterior cruciate ligament cysts of the knee are less common than anterior cruciate ligament ...

Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic capsule to infiltrate surrounding tissues. In conventional distal pancreatosplenectomy (DPS), tumor cells are prone to spread along the direction of blood and lymphatic reflux due to surgical compression. Additionally, inflammation makes it challenging to achieve R0 resection, leading to a lower patient survival rate. To address these limitations, radical antegrade modular pancreatosplenectomy (RAMPS) was developed, emphasizing deeper excision, including the left anterior renal fascia, the left anterior renal adipose sac, and even the left adrenal gland, to improve the R0 resection rate. With the advancement of minimally invasive surgical techniques, laparoscopic RAMPS (L-RAMPS) is being considered technically safe and feasible in oncology. However, due to technical difficulties and a lack of supporting evidence for clinical application, only a few institutions are currently conducting L-RAMPS. In this context, this article presents detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy (L-pRAMPS), offering promise for future clinical applications.

Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) is currently considered technically safe and feasible. However, due to technical challenges and a lack of supporting evidence for widespread clinical applications, only a limited number of institutions are currently conducting L-RAMPS. This article aims to provide detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy.

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic ...

Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic pancreatoduodenectomy (LPD), laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has not yet obtained wide acceptance. This could be attributed to the technical challenges involved in preserving the blood supply of the duodenum and bile duct.
This study describes and demonstrates all the steps of LDPPHR. A 48-year-old woman was diagnosed with a 3.0 cm x 2.5 cm pancreatic head cystic mass, which was detected unexpectedly. The surgery was performed using the 3D laparoscopy via an inferior infracolic approach. The operation lasted approximately 310 min with 100 mL of blood loss. Postoperatively, the patient experienced no complications and was discharged 5 days later. Pathology revealed intraductal papillary mucinous neoplasms.
LDPPHR via an inferior infracolic approach is feasible and safe when performed by experienced surgeons in selected patients with thin mesenteric fat layers. The described technique for LDPPHR via inferior infracolic approach should be well standardized and performed at high-volume centers with experienced surgeons in both open and laparoscopic pancreatology.

This article provides a whole technical process of laparoscopic duodenum-preserving pancreatic head resection via an inferior infracolic approach. This is a surgical approach for benign tumors without intraoperative fluorescence image guidance.