Name: laparoscopic repair of para-esophageal hernia using absorbable biosynthetic mesh
Uploaded: 2021-09-11T13:00:00
Description: Watch this Scientific Journal Video about Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh at JoVE.com

The authors have no acknowledgements.

The protocol follows the guidelines of the authors&#8217; institution&#8217;s human research ethics committee (South-Western Health District).
1. Pre-operative preparation
<ol>
	<li>Place the patient on low calorie high protein nutritional diet for a week to reduce the liver size and facilitate improved access to the hiatus hernia.</li>
	<li>Under general anesthesia, place the patient in lithotomy and reverse Trendelenburg position.</li>
	<li>Intra-operatively, prescribe first-generation cep...

<ol>
	<li>Sathasivam, R., 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=Mesh+hiatal+hernioplasty'+versus+'suture+cruroplasty'+in+laparoscopic+para-oesophageal+hernia+surgery;+a+systematic+review+and+meta-analysis.">Mesh hiatal hernioplasty' versus 'suture cruroplasty' in laparoscopic para-oesophageal hernia surgery; a systematic review and meta-analysis.</a> Asian Journal of Surgery. 42 (1), 53-60 (2018).</li><li>Olson, M. 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=Primary+paraesophageal+hernia+repair+with+Gore&#174;+Bio-A&#174;+tissue+reinforcement:+long-term+outcomes+and+association+of+BMI+and+recurrence.">Primary paraesophageal hernia repair with Gore&#174; Bio-A&#174; tissue reinforcement: long-term outcomes and association of BMI and recurrence.</a> Surgical Endoscopy. 32 (11), 4506-4516 (2018).</li><li>K&#246;ckerling, F., Schug-Pass, C., Bittner, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+word+of+caution:+never+use+tacks+for+mesh+fixation+to+the+diaphragm.">A word of caution: never use tacks for mesh fixation to the diaphragm.</a> Surgical Endoscopy. 32 (7), 3295-3302 (2018).</li><li>Asti, E., 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=Crura+augmentation+with+Bio-A&#174;+mesh+for+laparoscopic+repair+of+hiatal+hernia:+single-institution+experience+with+100+consecutive+patients.">Crura augmentation with Bio-A&#174; mesh for laparoscopic repair of hiatal hernia: single-institution experience with 100 consecutive patients.</a> Hernia. 21 (4), 623-628 (2017).</li><li>Berselli, 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=Laparoscopic+repair+of+voluminous+symptomatic+hiatal+hernia+using+absorbable+synthetic+mesh.">Laparoscopic repair of voluminous symptomatic hiatal hernia using absorbable synthetic mesh.</a> Minimally Invasive Therapy and Allied Technology. 24 (6), 372-376 (2015).</li><li>Priego, P., 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=Long-term+results+and+complications+related+to+Crurasoft((R))+mesh+repair+for+paraesophageal+hiatal+hernias.">Long-term results and complications related to Crurasoft((R)) mesh repair for paraesophageal hiatal hernias.</a> Hernia. 21 (2), 291-298 (2017).</li><li>Alicuben, E. T., Worrell, S. G., DeMeester, S. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Resorbable+biosynthetic+mesh+for+crural+reinforcement+during+hiatal+hernia+repair.">Resorbable biosynthetic mesh for crural reinforcement during hiatal hernia repair.</a> American Journal of Surgery. 80 (10), 1030-1033 (2014).</li><li>Massullo, J. M., Singh, T. P., Dunnican, W. J., Binetti, B. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preliminary+study+of+hiatal+hernia+repair+using+polyglycolic+acid:+trimethylene+carbonate+mesh.">Preliminary study of hiatal hernia repair using polyglycolic acid: trimethylene carbonate mesh.</a> Journal of the Society of laproscopic and Robotic Surgeons. 16 (1), 55-59 (2012).</li><li>Palmer, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+in+laparoscopy.">Safety in laparoscopy.</a> Journal of Reproductive Medicine. 13 (1), 1-5 (1974).</li><li>Owens, M., Barry, M., Janjua, A. Z., Winter, D. 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+systematic+review+of+laparoscopic+port+site+hernias+in+gastrointestinal+surgery.">A systematic review of laparoscopic port site hernias in gastrointestinal surgery.</a> Surgeon. 9 (4), 218-224 (2011).</li><li>Kohn, G. P., 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=Guidelines+for+the+management+of+hiatal+hernia.">Guidelines for the management of hiatal hernia.</a> Surgical Endoscopy. 27 (12), 4409-4428 (2013).</li><li>Luketich, J. D., 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+repair+of+giant+paraesophageal+hernia:+100+consecutive+cases.">Laparoscopic repair of giant paraesophageal hernia: 100 consecutive cases.</a> Annals of Surgery. 232 (4), 608-618 (2000).</li><li>Wiechmann, R. 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=Laparoscopic+management+of+giant+paraesophageal+herniation.">Laparoscopic management of giant paraesophageal herniation.</a> The Annals of Thoracic Surg. 71 (4), 1080-1086 (2001).</li><li>Zaninotto, 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=Objective+follow-up+after+laparoscopic+repair+of+large+type+III+hiatal+hernia.+Assessment+of+safety+and+durability.">Objective follow-up after laparoscopic repair of large type III hiatal hernia. Assessment of safety and durability.</a> World Journal of Surgery. 31 (11), 2177-2183 (2007).</li><li>Powell, B. S., Wandrey, D., Voeller, G. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+technique+for+placement+of+a+bioabsorbable+prosthesis+with+fibrin+glue+fixation+for+reinforcement+of+the+crural+closure+during+hiatal+hernia+repair.">A technique for placement of a bioabsorbable prosthesis with fibrin glue fixation for reinforcement of the crural closure during hiatal hernia repair.</a> Hernia. 17 (1), 81-84 (2013).</li><li>Asti, E., 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+management+of+large+hiatus+hernia:+five-year+cohort+study+and+comparison+of+mesh-augmented+versus+standard+crura+repair.">Laparoscopic management of large hiatus hernia: five-year cohort study and comparison of mesh-augmented versus standard crura repair.</a> Surgical Endoscopy. 30 (12), 5404-5409 (2016).</li><li>Lee, C. 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=Nationwide+survey+of+partial+fundoplication+in+Korea:+comparison+with+total+fundoplication.">Nationwide survey of partial fundoplication in Korea: comparison with total fundoplication.</a> Annals of Surgical Treatment and Research. 94 (6), 298-305 (2018).</li><li>Muller-Stich, B. P., 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=Repair+of+Paraesophageal+Hiatal+Hernias-Is+a+Fundoplication+Needed?+A+Randomized+Controlled+Pilot+Trial.">Repair of Paraesophageal Hiatal Hernias-Is a Fundoplication Needed? A Randomized Controlled Pilot Trial.</a> Journal of the American College of Surgery. 221 (2), 602-610 (2015).</li><li>Broeders, J. 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+anterior+180-degree+versus+nissen+fundoplication+for+gastroesophageal+reflux+disease:+systematic+review+and+meta-analysis+of+randomized+clinical+trials.">Laparoscopic anterior 180-degree versus nissen fundoplication for gastroesophageal reflux disease: systematic review and meta-analysis of randomized clinical trials.</a> Annals of Surgery. 257 (5), 850-859 (2013).</li></ol>

The key steps in para-esophageal hernia repair include port placement, total excision of the hernia sac, intra-abdominal esophageal lengthening, identification of both vagus nerves, atraumatic mesh reinforcement of the crus, and anterior fundoplication with gastroplasty.
This protocol highlights a 4-port method (one camera, three working ports) which uses only one assistant. Safe insufflation is achieved through a Veress needle inserted at Palmer&#8217;s point. An optical bladeless access syst...

The most recent meta-analysis review on para-esophageal hernia repair concluded that mesh reinforcement was superior and was associated with lower recurrence rates compared to the suture repair1. However, the preferred type of mesh remains controversial due to the study heterogeneity. Some included in the review had inconsistent definitions not only of para-esophageal hernias (which were either determined pre-operatively or intra-operatively) or hernia recurrences (which were based, either on symptoms or investigations), but also unspecified loss to follow-up. This manuscript highlights successful repair of a large hiatus hernia using biosynthetic mesh.
The most common biosynthetic mesh used is composed of 67% polyglycolic acid and 33% trimethylene carbonate. This prosthesis is gradually absorbed over 6 months and is replaced by the vascularized soft tissue and collagen. This biosynthetic mesh has been studied in 395 patients and in this large study, 16.1% of them experienced recurrent symptoms at 24 months (range, 2-69 months) and 7.3% had objective recurrence2. Only one patient had a major post-operative complication (esophageal stenosis) that required percutaneous endoscopic gastrostomy tube insertion and subsequently, re-operation with no recurrence at 44 months. Similar smaller studies reported symptom recurrence rates ranging from 0%-9%, objective recurrence rates 0.9%-25%, and re-operations ranging from 0%-10%4,5,6,7,8. None of the studies reported mesh-related complications.
The protocol detailed below was performed on a 68-year-old female who presented with a one-year history of severe reflux symptoms unresponsive to medical treatment and iron deficiency anemia, in the setting of previous Helicobacter pylori gastritis and NSAID-induced gastric ulcer. Pre-operative gastroscopy demonstrated Cameron&#39;s ulcers, large linear erosions in the gastric body and a 10 cm rolling hiatus hernia (compared to 4 cm in the previous gastroscopy one year earlier). Chest CT-scan confirmed the diagnosis of intra-thoracic para-esophageal hernia.

<table border="0" cellpadding="0" cellspacing="0" style="width:683px;" width="684">
	<tbody>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">1.0 non-absorbable suture</td>
			<td style="width:125px;"></td>
			<td style="width:165px;"></td>
			<td style="width:171px;"></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">10 mm port</td>
			<td style="width:125px;"></td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">3.0 absorbable suture</td>
			<td style="width:125px;"></td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">5mm port</td>
			<td style="width:125px;"></td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">Biosynthetic mesh</td>
			<td style="width:125px;">GORE BIO-A</td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:221px;">Bladeless optical access entry system</td>
			<td style="width:125px;">Kii</td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">Drain&#160;</td>
			<td style="width:125px;"></td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">Fibrin glue</td>
			<td style="width:125px;">Tiseel</td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">Laparoscopic grasper</td>
			<td style="width:125px;">Ethicon</td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">Laparoscopic harmonic&#160; scalpel</td>
			<td style="width:125px;">Ethicon</td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">Nathan liver retractor</td>
			<td style="width:125px;"></td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">Sling</td>
			<td style="width:125px;"></td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">Veress needle</td>
			<td style="width:125px;"></td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
	</tbody>
</table>

laparoscopic repair of para-esophageal hernia using absorbable biosynthetic mesh

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been associated with lesser hernia recurrence when compared to the primary suture repair. The type of mesh that is most appropriate is still debatable. Synthetic and biosynthetic materials have been studied in the literature. It is well documented that a synthetic mesh is associated with esophageal erosion and migration into the stomach. Though there are limited long-term data on biosynthetic mesh, the short-term results are excellent and promising.
This paper illustrates how a biosynthetic prosthesis can be safely used with fibrin glue fixation and anterior Dor fundoplication to repair any para-esophageal defect. The absorbable biosynthetic mesh has been shown to produce good long-term patient satisfaction outcomes and low recurrence rates compared to conventional methods including repair with synthetic mesh. This technique also avoids the risk of esophageal erosion whilst strengthening the repair. Tacks that are still widely used to secure the mesh can be abandoned due to the associated risk of developing cardiac tamponade, or other disastrous consequences. This repair method, also, highlights how the prosthesis can be fashioned into a V-shape and easily placed in an onlay fashion behind the esophagus. The protocol demonstrates an alternative and safer method for mesh fixation using fibrin glue.

Post-operatively the patient remained symptom free. Routine gastroscopies at 4, 12 and 24&#160;months respectively showed that the cardio-esophageal junction remained at 38 cm from the dental arcade with no evidence of early recurrence or reflux esophagitis. There was mild gastritis of the antrum.
This technique has been performed in 32&#160;patients using&#160;absorbable biosynthetic mesh. Only one patient reported complication (Table 1).
<table border="1" fo:keep-togethe...

Watch this Scientific Journal Video about Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh at JoVE.com

Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh

Presented here is a protocol of para-esophageal hernia repair. Use of absorbable biosynthetic mesh avoids the risk of erosion through the esophagus whilst reinforcing the repair. Glue fixation is preferred to avoid the risk of trauma such as bleeding or cardiac tamponade, which are associated with stitches or tacks.

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been ...

This is a video showing laparoscopic mesh repair of a large, defined as greater than seven centimeters in length, sliding hiatus hernia using Gore Bio-A Mesh. This patient is a 68-year-old who presented with reflux symptoms, unresponsive to medical treatment and iron-deficiency anemia. Subsequent gastroscopy found Cameron lesions, large linear erosions in the gastric body and a 10 centimeter rolling hiatus hernia, compared to four centimeters in the previous gastroscopy a year ago.Prior to surgery, the patient was given Optifast for one week to reduce the liver size and assist the liver retraction intraoperatively. Establish pneumoperitoneum of 12 millimeters of mercury via a left subcostal Veress needle at Palmer's point. defined as three centimeters below the subcostal margin in the left midclavicular line.Using a direct bladeless optical access entry system, insert the port, which is supraumbilical, one hand span from the costal margin and to the left of the midline for the camera. Elevate the left lobe of the liver with a Nathanson liver retractor through a small left paraxiphoid incision. Place two further five millimeter ports under direct vision alongside the camera port.One at the level of the right midclavicular line. The second port on the left anterior auxiliary line. Insert a 10 millimeter port that is more cephalad at the left midclavicular line to create an ideal working triangulation.At this stage, most of the stomach will be herniating into the mediastinum. Therefore, pull the incarcerated stomach back into their abdominal cavity with continuous traction from the assistant to view the gastroesophageal junction. Enter the lesser curvature at the level of the pars flaccida of the gastrohepatic ligament and progressively dissect, reduce and excise the hernia sac using cauterization.This will lead to gradual exposure of both diaphragmatic crura. Note is made of the inferior vena cava and the caudate lobe of the liver in relation to the right crus. Mobilize the esophagus circumferentially by dividing all the congenital paraesophageal adhesions within the hiatus.Continue mobilizing the hiatus hernia off the bilateral crura to assist in retracting the hernia sac into the abdominal cavity. Identify and preserve the vagus nerves and both pleura. Create a window posteriorly between esophagus and thoracic aorta and place tape around the distal esophagus to allow gentle retraction.Mobilize the distal esophagus proximally, about 10 centimeters in distance, until there is adequate intraabdominal esophageal length, which is about three to four centimeters and so the esophagus lies free of tension. Approximate the diaphragmatic crura with three or four interrupted 1-O nonabsorbable braided sutures and reinforce the repair with a pre-shaped biosynthetic mesh that is introduced behind the esophagus in an onlay fashion. The right edge of the mesh should slide under the caudate lobe of the liver.If necessary, divide the left triangular ligament to accommodate the mesh. No pledgets are required if the quality and the tension of the crura is adequate. The extent of the crura closure should not cause narrowing or compression on the lower esophagus.A rough guide to adequate closure is being able to pass a grasper through the remaining gap. Secure the biosynthetic mesh with four mLs of fibrin glue. Perform a modified 180 degree anterior Dor fundoplication using 2-O nonabsorbable braided sutures by suturing the gastric fundus to the left crus, then sequentially fixing the folded greater curvature of the stomach anteriorly to the diaphragm and all the way to the proximal right crus.Four sutures are usually required. Incorporate the mesh into the first suture. Take care not to injure the pericardium during the fundoplication.A Bougie is not used. Insert a closed suction drain. Close skin with subcuticular 3-O synthetic absorbable and monofilament sutures.Postoperatively, the patient is nursed with the head elevated to 30 degrees to avoid aspiration. The patient was placed on regular antiemetics. The patient is allowed sips of water overnight followed by clear fluids if tolerated.The drain is usually removed after two days. The patient is advised to have a puree diet for four to six weeks.Results. 32 patients have undergone this technique.Of this, 26 were female and six were male. The median follow-up was 19 months. The median age for this group was 72 years of age.Of these 32 patients, four were type one, all of these were greater than seven centimeters, 23 would type three, of which three were recurrent, and lastly, four were type four. Of these patients, there was one recurrence and one mortality. This patient had a recurrent type three hiatus hernia, and this was a difficult dissection.Postoperatively, this patient was quite well and tolerated fluids well for the first 48 hours. She then unexpectedly rapidly decompensated from unrecognized cardiac tamponade.Conclusion. The key points for this procedure includes one, complete and circumferential mobilization of the hiatus hernia with excision of the sac.Two, adequate exposure and crura repair. Three, reinforcement of the cruroplasty with biosynthetic mesh. Four, further reinforcement of the repair with a modified 180 degree anterior Dor fundoplication.Using this technique, a low recurrence rate can be achieved. However, the patient should have ongoing followup with regular endoscopy. A healthier lifestyle is also encouraged.

laparoscopic-repair-para-esophageal-hernia-using-absorbable

Research

JoVE Journal

Medicine

A Contusive Model of Unilateral Cervical Spinal Cord Injury Using the Infinite Horizon Impactor

While the majority of human spinal cord injuries occur in the cervical spinal cord, the vast majority of laboratory research employs animal models of spinal cord injury (SCI) in which the thoracic spinal cord is injured. Additionally, because most human cord injuries occur as the result of blunt, non-penetrating trauma (e.g. motor vehicle accident, sporting injury) where the spinal cord is violently struck by displaced bone or soft tissues, the majority of SCI researchers are of the opinion that the most clinically relevant injury models are those in which the spinal cord is rapidly contused.1 Therefore, an important step in the preclinical evaluation of novel treatments on their way to human translation is an assessment of their efficacy in a model of contusion SCI within the cervical spinal cord. Here, we describe the technical aspects and resultant anatomical and behavioral outcomes of an unilateral contusive model of cervical SCI that employs the Infinite Horizon spinal cord injury impactor.
Sprague Dawley rats underwent a left-sided unilateral laminectomy at C5. To optimize the reproducibility of the biomechanical, functional, and histological outcomes of the injury model, we contused the spinal cords using an impact force of 150 kdyn, an impact trajectory of 22.5&deg; (animals rotated at 22.5&deg;), and an impact location off of midline of 1.4 mm. Functional recovery was assessed using the cylinder rearing test, horizontal ladder test, grooming test and modified Montoya's staircase test for up to 6 weeks, after which the spinal cords were evaluated histologically for white and grey matter sparing.
The injury model presented here imparts consistent and reproducible biomechanical forces to the spinal cord, an important feature of any experimental SCI model. This results in discrete histological damage to the lateral half of the spinal cord which is largely contained to the ipsilateral side of injury. The injury is well tolerated by the animals, but does result in functional deficits of the forelimb that are significant and sustained in the weeks following injury. The cervical unilateral injury model presented here may be a resource to researchers who wish to evaluate potentially promising therapies prior to human translation.

A reliable and repeatable way to produce a cervical unilateral spinal cord injury using the Infinite Horizon impactor is described. The method takes advantage of a custom designed frame and clamp to stabilize the spine. The standardized procedure and biomechanical injury parameters result in sufficient and sustained injuries.

While the majority of human spinal cord injuries occur in the cervical spinal cord, the vast majority of laboratory research employs animal models of ...

Development of an Algorithm to Perform a Comprehensive Study of Autonomic Dysreflexia in Animals with High Spinal Cord Injury Using a Telemetry Device

Spinal cord injury (SCI) is a debilitating neurological condition characterized by somatic and autonomic dysfunctions. In particular, SCI above the mid-thoracic level can lead to a potentially life-threatening hypertensive condition called autonomic dysreflexia (AD) that is often triggered by noxious or non-noxious somatic or visceral stimuli below the level of injury. One of the most common triggers of AD is the distension of pelvic viscera, such as during bladder and bowel distension or evacuation. This protocol presents a novel pattern recognition algorithm developed for a JAVA platform software to study the fluctuations of cardiovascular parameters as well as the number, severity and duration of spontaneously occurring AD events. The software is able to apply a pattern recognition algorithm on hemodynamic data such as systolic blood pressure (SBP) and heart rate (HR) extracted from telemetry recordings of conscious and unrestrained animals before and after thoracic (T3) complete transection. With this software, hemodynamic parameters and episodes of AD are able to be detected and analyzed with minimal experimenter bias.

The catheter of a telemetry device is implanted into the abdominal aorta in order to continuously collect beat-by-beat hemodynamic data from animals pre and post-high thoracic spinal cord transection. A novel JAVA software was employed to analyze hemodynamic parameters as well as frequency and intensity of spontaneous episodes of autonomic dysreflexia.

Spinal cord injury (SCI) is a debilitating neurological condition characterized by somatic and autonomic dysfunctions. In particular, SCI above the ...

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during totally laparoscopic gastrectomy (TLG). The aim of this protocol is to introduce a procedure for intraoperative gastroscopy, in order to directly mark tumors during TLG for gastric cancer in the middle third of the stomach. Patients who were diagnosed with adenocarcinoma in the middle third of the stomach were enrolled in this case series. Before surgery, additional gastroscopy for tumor localization is not performed. Under general anesthesia, laparoscopic mobilization of the stomach is performed first. After the first portion of the duodenum is mobilized from the pancreas and clamped, the surgeon moves to the other side for the gastroscopic procedure. On the insertion of a gastroscope through the oral cavity into the stomach, 2 - 3 cc of indigo carmine is administered via an endoscopic injector into the gastric muscle layer at the proximal margin of the stomach. The location of stained serosa in the laparoscopic view is used to guide distal subtotal gastrectomy, however, total gastrectomy is performed if the tumor is too close to the esophagogastric junction. A specimen is sampled after distal gastrectomy to confirm sufficient length from resection margin to tumor before reconstruction. In our case series, all patients had tumor-free margins and required no additional resection. There was no morbidity related to the gastroscopic procedure, and the time required for the procedure has gradually decreased to about five minutes. Intraoperative gastroscopy for tumor localization is an accurate and tolerated method for gastric cancer patients undergoing totally laparoscopic distal gastrectomy.

In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during ...

Transvaginal Mesh Insertion in the Ovine Model

This protocol describes mesh insertion into the rectovaginal septum in sheep using a single vaginal incision technique, with and without the trocar-guided insertion of anchoring arms. Parous sheep underwent the dissection of the rectovaginal septum, followed by the insertion of an implant with or without four anchoring arms, both designed to fit the ovine anatomy. The anchoring arms were put in place using a trocar and an "outside-in" technique. The cranial arms were passed through the obturator, gracilis, and adductor magnus muscles. The caudal arms were fixed near the sacrotuberous ligament, through the coccygeus muscles. This technique allows for the mimicking of surgical procedures performed in women suffering from pelvic organ prolapse. The anatomical spaces and elements are easily identified. The most critical part of the procedure is the insertion of the cranial trocar, which can easily penetrate the peritoneal cavity or the surrounding pelvic organs. This can be avoided by a more extensive retroperitoneal dissection and by guiding the trocar more laterally. This approach is designed only for experimental testing of novel implants in large animal models, as trocar-guided insertion is currently not used clinically.

This protocol describes mesh implantation in the ovine rectovaginal septum using a single vaginal incision technique, with and without the trocar-guided insertion of anchoring arms.

This protocol describes mesh insertion into the rectovaginal septum in sheep using a single vaginal incision technique, with and without the trocar-guided ...

Operating Transverse Aortic Constriction with Absorbable Suture to Obtain Transient Myocardial Hypertrophy

Based on twice transverse aortic constrictions (TACs) in mice, it is proved that myocardial hypertrophic preconditioning (MHP) could attenuate cardiomyocyte hypertrophy and slow down progression to heart failure. For novices, however, the MHP model is usually quite difficult to establish because of the technical obstacles in ventilator operation, opening the chest repeatedly, and bleeding caused by debanding. To facilitate this model, to increase the surgical success rate and to reduce the incidence of bleeding, we switched to absorbable sutures for the first TAC combing with a ventilator-free technique. Using a 2-week absorbable suture, we demonstrated that this procedure could cause significant myocardial hypertrophy in 2 weeks; and 4 weeks after surgery, myocardial hypertrophy was almost completely regressed to the baseline. Using this protocol, the operators could master the MHP model easily with a lower operation mortality.

This protocol presents an improved method to obtain transient myocardial hypertrophy with absorbable suture, simulating left ventricular hypertrophy decrease after removing pressure overload. It could be valuable for the studies on myocardial hypertrophic preconditioning.

Based on twice transverse aortic constrictions (TACs) in mice, it is proved that myocardial hypertrophic preconditioning (MHP) could attenuate ...

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 ...

Application of a New Mesh Fixation Method in Laparoscopic Incisional Hernia Repair

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing incisional hernias. The laparoscopic IPOM involves implanting the mesh into the abdominal cavity through laparoscopy to repair an abdominal wall hernia. In the IPOM surgery, after the closure of the hernia ring, an anti-adhesion mesh is placed laparoscopically. The correct placement of this mesh is critical to the success of the method, and surgical skills are required to achieve perfect placement. If the mesh placement is not mastered properly, the operation and anesthesia time will be prolonged. In addition, improper placement of the mesh can lead to serious consequences, such as intestinal obstruction and mesh infection. A "contraposition and alignment" mesh fixation method is described in this study, which involves pre-marking the fixation position of the mesh to reduce the difficulty of mesh placement. A properly placed mesh is completely flat on the peritoneum, the edges are not curled or wrapped, and the mesh is adhered firmly such that there is no displacement after removing the pneumoperitoneum pressure. The "contraposition and alignment" mesh fixation technique offers the advantages of reliable placement of the mesh and fewer complications than other techniques, and it is easy to learn and master. It also allows for positioning the nail gun in advance based on the anatomy of the incisional hernia. This enables the use of the minimum number of nails possible while still ensuring good fixation, which can reduce the occurrence of complications and reduce the cost of surgery. Thus, the mesh fixation method described here is highly suitable for clinical applications based on the aforementioned advantages.

Presented here is a method for improving the mesh placement in laparoscopic incisional hernia repair, which can shorten the time required for mesh fixation and reduce the occurrence of postoperative chronic pain.

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing ...

Fluorescent Laparoscopic Central Hepatectomy for Liver Cancer Using Indocyanine Green Negative Staining

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ultrasound, important vascular structures, and surgeon experience. With the development of anatomical hepatectomy, visual surgery technology has gradually been applied to this type of surgery, particularly indocyanine green (ICG)-guided anatomical hepatectomy. As ICG can be specifically ingested by hepatocytes and used for fluorescence tracing, negative staining techniques have been applied according to different tumor positions. Under ICG fluorescent guidance, the surface boundary and deep resection plane can be more accurately displayed during liver resection. Thus, the tumor-bearing liver segment can be anatomically removed, which helps to avoid damage to important vessels and reduce ischemia or congestion of the remaining liver tissue. Finally, the incidence of postoperative biliary fistula and liver dysfunction is reduced; therefore, a better prognosis is obtained after the resection of liver cancer. Centrally located liver cancer is usually defined as a tumor located at segments 4, 5, or 8 that requires resection of the middle section of the liver. These are among the most difficult hepatectomies to perform because of the large surgical wounds and multiple vessel transections. Based on the specific tumor location, we formulated the required resection ranges by designing personalized fluorescent staining strategies. By completing anatomical resection based on the portal territory, this work aims to achieve the best therapeutic effect.

The present protocol describes fluorescent negative staining in laparoscopic central hepatectomy. This technique can make hepatectomy more accurate and precise.

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ...

Reoperative Hiatal Hernia Repair

Technical Considerations and Approach to Redo Foregut Surgery

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical considerations have arisen when dealing with reoperation for complications or surgical failure. This study focuses on the technical considerations and approach when dealing with reoperative foregut surgery, particularly redo&#160;hiatal hernia repair. We describe our approach starting from the preoperative workup to the procedural steps of the surgery. The present study describes the main steps for robotic reoperative hiatal hernia repair in a patient who had previously undergone laparoscopic hiatal hernia repair with Nissen fundoplication but did not present a recurrence of reflux and dysphagia symptoms. The patient is positioned supine with arms out and a footboard for steep Trendelenburg. We place six trocars, including an assistant port and a liver retractor port,&#160;to facilitate visualization and retraction. After docking the robot, we use a combination of electrocautery and sharp dissection&#160;to free the hernia sac and reduce the hiatal hernia. The previous fundoplication is then taken down carefully and the esophagus is mobilized through a transhiatal approach with a combination of blunt and sharp dissection until at least 3 cm of intra-abdominal esophageal length is achieved, after which a leak test is performed. We then perform a crural repair to reapproximate the hiatus with two posterior stitches and one anterior stitch. Lastly, a redo Nissen fundoplication is performed over a bougie, and endoscopy is used to confirm a loose stack-of-coin appearance. By emphasizing the crucial steps of redo hiatal hernia repair, including preoperative evaluation, our goal is to provide an approach for the foregut surgeon to maximize patient outcomes.

Author Spotlight: Recent Advancements in Reoperative Foregut Surgery

Redo foregut surgery is associated with increased patient morbidity and presents a technical challenge for the surgeon. We describe our approach and considerations when performing a redo hiatal hernia repair to provide a guide for other surgeons and improve patient outcomes.