The authors thank Prof. Yu Guo and Prof. Yunpeng Hua (Department of Liver Surgery, the First Affiliated Hospital, Sun Yat-sen University) for providing advice and careful review. This work was supported by the National Natural Science Foundation of China (81201919), the Natural Science Foundation of Guangdong Province (2017A030313495).

Study protocol was approved by the ethics committee of the First Affiliated Hospital of Sun Yat-sen University and the study was conducted in accordance with the Helsinki Declaration. Written informed consents were obtained from patients.
1. Inclusion-exclusion criteria
<ol>
	<li>Include adult acute pancreatitis patients with evidence of infected necrosis that required an indication for invasive intervention. 
	NOTE: Acute pancreatitis is defined when at least two of the three following features are observed in patients 1) typical upper abdominal pain, 2) level of serum amylase or lipase above three times the upper level than normal, 3) typical findings of cross-sectional abdominal CT or MRI imaging10,11,12. Infected necrosis is defined as a positive culture obtained by fine needle aspiration or PCD of necrotic collections, or the presence of gas configurations within necrotic collections on contrast enhanced CT image.</li>
	<li>Exclude patients with previous invasive interventions for necrotizing pancreatitis, acute episode of chronic pancreatitis, recurrent acute pancreatitis and with indications for emergency laparotomy (i.e., abdominal compartment syndrome, perforation or bleeding of a visceral organ, and gastrointestinal or biliary obstruction).</li>
</ol>
2. VARD procedure
<ol>
	<li>Firstly, in acute necrotizing pancreatitis patients with above criteria, place ultrasound-guided percutaneous pigtail catheters (14 Fr or 16 Fr) into the left or right retroperitoneum to drain peripancreatic or necrotic collections, that can be located on the contrast enhanced CT image. (If condition permitted, duration of PCD placement should be maintained within about 4 weeks after the onset of AP for necrotic collections to demarcate and wall-off.</li>
	<li>If infected collections persisted and patients&#39; clinical situation deteriorates (progressive elevation of body temperature, elevated white blood cell count, C-reactive protein and procalcitonin, new onset of progressive organ dysfunction), be sure to provide surgical intervention and apply VARD in these patients1,2.</li>
	<li>Place the patient in supine position or in supine position with the left side 30-40&#176; elevated, and under general anesthesia.</li>
	<li>Make a skin incision (12 mm) at the site of previous pigtail catheter and gently dilate the tract with forceps.</li>
	<li>Insert a 12 mm laparoscopic trocar along the tract to the retroperitoneal necrotic collections followed by the removal of the pigtail catheter.</li>
	<li>Apply carbon dioxide pneumoretroperitoneum (11 mmHg to 12 mmHg) if a wider debridement space is needed by insufflating carbon dioxide through this 12 mm trocar.</li>
	<li>Place a near-infrared fluorescence laparoscopy via the observing trocar and make one additional incision (10 mm) subcostal in the left (or right) flank at the mid-axillary line, under laparoscopy monitoring (the incision can be close to the exit point of the percutaneous drain if another drainage pigtail catheter existed). The incision should be at least at a 8 cm distance from the observing trocar.</li>
	<li>Insert a 10 mm laparoscopic trocar from above the incision and remove necrotic debris using laparoscopic graspers. Necrotic debris turn out to be a retroperitoneal mass with grayish yellow under white light image or low contrasted under fluorescence image. Aspirate the collections by laparoscopic aspirator via the operative trocar. Extend the above incision to 5 cm with electrotome under laparoscopy monitoring if removal of the larger pieces of necrosis is needed.</li>
</ol>
3. ICG-guided intraoperative fluorescence imaging
<ol>
	<li>After insertion of a 10 mm operative trocar and before beginning to separate necrotic debris from adjacent normal tissue using laparoscopic forceps, switch the display mode of the laparoscopy to multi-display mode (white light image and fluorescence image are displayed separately in Picture-in-Picture mode).</li>
	<li>Inject the first bolus of ICG (0.1 mg/kg body weight) intravenously in a peripheral vein. Then, follow with a flush of 10 mL of saline. After 10 to 20 s, visualize peak perfusion of adjacent normal tissues or vessels in the fluorescence field. A clearer separating surface can be distinguished from the debris.</li>
	<li>Only remove poorly perfused and loosely adherent necrotic debris using laparoscopic graspers. Avoid tearing the underlying bowel or vessel.</li>
	<li>Inject another bolus of ICG (0.1 mg/kg body weight) intravenously if ICG fluorescence decay.</li>
	<li>After the removal of the bulk of necrotic debris, irrigate the cavity of the retroperitoneum with saline and aspirate with laparoscopic aspirator until the lavage fluid becomes clear.</li>
	<li>Place at least one pair of drainage tubes at the deepest region of the cavity after debridement. Suture the fascia and skin and close.</li>
</ol>
4. Postoperative management
<ol>
	<li>Perform continuous lavage with sterile saline and repeat CT scan 1 week after the VARD procedure.</li>
</ol>

<ol>
	<li>Trikudanathan, 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=Current+concepts+in+severe+acute+and+necrotizing+pancreatitis:+An+evidence-based+approach.">Current concepts in severe acute and necrotizing pancreatitis: An evidence-based approach.</a> Gastroenterology. 156 (7), 1994-2007 (2019).</li><li>Baron, T. H., DiMaio, C. J., Wang, A. Y., Morgan, K. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=American+Gastroenterological+Association+clinical+practice+update:+Management+of+pancreatic+necrosis.">American Gastroenterological Association clinical practice update: Management of pancreatic necrosis.</a> Gastroenterology. 158 (1), 67-75 (2020).</li><li>Raraty, M. G. 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=Minimal+access+retroperitoneal+pancreatic+necrosectomy:+improvement+in+morbidity+and+mortality+with+a+less+invasive+approach.">Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach.</a> Annals of Surgery. 251 (5), 787-793 (2010).</li><li>Dhingra, 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=Single+or+multiport+percutaneous+endoscopic+necrosectomy+performed+with+the+patient+under+conscious+sedation+is+a+safe+and+effective+treatment+for+infected+pancreatic+necrosis+(with+video).">Single or multiport percutaneous endoscopic necrosectomy performed with the patient under conscious sedation is a safe and effective treatment for infected pancreatic necrosis (with video).</a> Gastrointestinal Endoscopy. 81 (2), 351-359 (2015).</li><li>Gomatos, I. 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=Outcomes+from+minimal+access+retroperitoneal+and+open+pancreatic+necrosectomy+in+394+patients+with+necrotizing+pancreatitis.">Outcomes from minimal access retroperitoneal and open pancreatic necrosectomy in 394 patients with necrotizing pancreatitis.</a> Annals of Surgery. 263 (5), 992-1001 (2016).</li><li>Boni, L., 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=Clinical+applications+of+indocyanine+green+(ICG)+enhanced+fluorescence+in+laparoscopic+surgery.">Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery.</a> Surgical Endoscopy. 29 (7), 2046-2055 (2015).</li><li>Nardi, P. 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=Intraoperative+angiography+with+indocyanine+green+to+assess+anastomosis+perfusion+in+patients+undergoing+laparoscopic+colorectal+resection:+results+of+a+multicenter+randomized+controlled+trial.">Intraoperative angiography with indocyanine green to assess anastomosis perfusion in patients undergoing laparoscopic colorectal resection: results of a multicenter randomized controlled trial.</a> Surgical Endoscopy. 34 (1), 53-60 (2020).</li><li>Newton, A. 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=Intraoperative+near-infrared+imaging+can+identify+neoplasms+and+aid+in+real-time+margin+assessment+during+pancreatic+resection.">Intraoperative near-infrared imaging can identify neoplasms and aid in real-time margin assessment during pancreatic resection.</a> Annals of Surgery. 270 (1), 12-20 (2019).</li><li>Cai, Y., Zheng, Z., Gao, P., Li, Y., Peng, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+duodenum-preserving+total+pancreatic+head+resection+using+real-time+indocyanine+green+fluorescence+imaging.">Laparoscopic duodenum-preserving total pancreatic head resection using real-time indocyanine green fluorescence imaging.</a> Surgical Endoscopy. 35 (3), 1355-1361 (2021).</li><li>Santvoort, H. C. v., 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=Dutch+pancreatitis+study+group.+A+step-up+approach+or+open+necrosectomy+for+necrotizing+pancreatitis.">Dutch pancreatitis study group. A step-up approach or open necrosectomy for necrotizing pancreatitis.</a> The New England Journal of Medicine. 362 (16), 1491-1502 (2010).</li><li>Bakker, O. 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=Dutch+Pancreatitis+Study+Group.+Endoscopic+transgastric+vs+surgical+necrosectomy+for+infected+necrotizing+pancreatitis:+a+randomized+trial.">Dutch Pancreatitis Study Group. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial.</a> JAMA. 307 (10), 1053-1061 (2012).</li><li>Brunschot, S. v., 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=Dutch+Pancreatitis+Study+Group.+Endoscopic+or+surgical+step-up+approach+for+infected+necrotising+pancreatitis:+a+multicentre+randomised+trial.">Dutch Pancreatitis Study Group. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial.</a> Lancet. 391 (10115), 51-58 (2018).</li><li>Bang, J. 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=An+endoscopic+transluminal+approach,+compared+with+minimally+invasive+surgery,+reduces+complications+and+costs+for+patients+with+necrotizing+pancreatitis.">An endoscopic transluminal approach, compared with minimally invasive surgery, reduces complications and costs for patients with necrotizing pancreatitis.</a> Gastroenterology. 156 (4), 1027-1040 (2019).</li></ol>

The authors declare that they have no competing interests.

The present study reveals that ICG-guided real-time intraoperative near-infrared fluorescence imaging may provide benefit to perfusion assessment and visualization of adjacent normal tissues during debridement in VARD.
In the minimally invasive era, the step-up approach consisting of PCD or endoscopic transmural drainage followed by endoscopic necrosectomy or surgical debridement, such as VARD, has been regarded as standard treatment of severe acute necrotizing pancreatitis patients1. As shown in several large randomized trials (PANTER trial, MISER trial, etc.)10,11,12,13 and proven in clinical practice, in the past 10 years, these less invasive strategies compared to traditional open necrosectomy can reduce the risk of surgical stress, new-onset organ dysfunction, incisional hernia, external fistulas, pancreatic exocrine and endocrine insufficiency1,2. Though debridement techniques have achieved great advancement in these years, retroperitoneal debridement is accompanied by a relatively high risk (up to 35%) of vascular injury, external pancreatico-cutaneous or enterocutaneous fistulae, partly since there is rarely a visually clear separating surface in white light image between necrotic debris and adjacent inflammatory normal tissues as a result of extensive retroperitoneal adhesions3,4,5.
Real-time intraoperative near-infrared fluorescence imaging with (ICG) has been successfully applied to facilitate perfusion assessment of bowel for colectomy and visualization of biliary and vascular anatomy for pancreatic surgery or nephrectomy. In view of the above pitfalls of VARD, we apply real-time near-infrared fluorescence imaging with ICG during VARD, that enables visualization of the well-perfused adjacent normal tissues such as bile duct, posterior wall of small intestine and colon, and vascular structure of mesenteric vessels. etc., These are identified as ICG perfused (bright green in the fluorescence mode) while necrotic debris are not perfused (relatively dark in the fluorescence mode) and gray (in the white light mode). This modified technique (ICG-guided VARD) provides a clearer separating surface and reduced risk of iatrogenic vascular or enteric injury during operative debridement.
In conclusion, ICG-guided VARD is an easy and feasible approach to visualize the well-perfused adjacent normal tissues and vascular structure of mesenteric vessels, that may facilitate surgeons to perform safer debridement in treating severe acute necrotizing pancreatitis. It warrants further study to quantitate the time-intensity curve and time to peak perfusion of normal tissues and vessels, and randomized clinical trials to confirm the practicability of ICG-guided VARD in the future.

Acute pancreatitis (AP) is one of the most common digestive diseases and brings enormous medical and economic burden to patients. About 20% of AP patients develop severe acute pancreatitis (SAP) that gets complicated with infected necrosis or persistent organ dysfunction1. SAP is usually associated with higher morbidity rate and mortality rate (up to 30%)1. In SAP patients with infected necrosis having persistent organ dysfunction or failure to recover after percutaneous drainage (PCD), or suffering from gastrointestinal or biliary obstruction, operative debridement should be considered1,2.
In the minimally invasive era, there are multiple approaches to operative debridement beside open surgery, including endoscopic transluminal necrosectomy, laparoscopic or open transgastric debridement, and video-assisted retroperitoneal debridement (VARD), which is the part of the step-up approach1,2. VARD is the preferred approach for patients with left-sided distribution of infected necrosis extended to paracolic gutter or deep to the retroperitoneum2. As there are rarely any visually clear separating surface in white light image under laparoscopy between necrotic debris and adjacent inflammatory normal tissues due to extensive retroperitoneal adhesions, VARD is inevitably accompanied by the risk of vascular injury, external pancreatico-cutaneous, or enterocutaneous fistulae3,4,5.
Real-time intraoperative near-infrared fluorescence imaging with indocyanine green (ICG) has been applied to facilitate perfusion assessment of bowel6,7 and visualization of biliary and vascular anatomy8,9. In view of the above disadvantages of VARD, we apply real-time near-infrared fluorescence imaging with ICG during VARD that enables the visualization of the well-perfused adjacent normal tissues and vascular structure. This modified technique (ICG-guided VARD) can provide a clear separating surface during operative debridement and reduced risk of vascular or enteric injury. ICG-guided VARD may facilitate surgeons to perform safer debridement in treating severe acute necrotizing pancreatitis.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>The 4K Ultra HD Fluorescence Endoscopic Navigation System</td>
			<td>Guangdong OptoMedic Technologies Inc</td>
			<td>OPTO-CAM214K</td>
			<td>fluorescence laparoscopy</td>
		</tr>
		<tr>
			<td>indocyanine green</td>
			<td>DanDong YiChuang Pharmaceutical CO., LTD</td>
			<td>H20055881</td>
			<td>indocyanine green injection for fluorescence imaging</td>
		</tr>
	</tbody>
</table>

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.

ICG-guided VARD had been successfully performed in three severe acute necrotizing pancreatitis patients from June 2021. Characteristics of these patients at baseline and after VARD are included in Table 1. The first patient who received ICG-guided VARD was a male, 41-year-old patient who was admitted on 20th June 2021. He suffered from moderately acute necrotizing pancreatitis. Abdominal contrast enhanced CT scan revealed (as shown in Figure 1 and Table 1) that necrotic collections consist of the lesser arc, peri-pancreatic space, and extended to the bilateral retroperitoneum. Infected necrosis in the right retroperitoneum was persistent after initial PCD drainage and the first VARD was performed about 4 weeks after the onset of pancreatitis (Figure 1). After multidisciplinary team discussion, ICG-guided VARD was applied in this patient. Figure 1 shows representative intraoperative images of necrotic debris and adjacent normal tissue in the cavity of the right retroperitoneum after ICG injection, using near-infrared fluorescence laparoscopy. ICG perfusion of adjacent normal tissues or vessels can be visualized in the fluorescence field and a clearer separating surface can be distinguished from the debris. We removed necrotic debris using laparoscopic graspers while preserving the adjacent normal tissues or vessels. Infected necrosis was resolved and drainage tubes were removed on POD7 after ICG-guided VARD (Figure 2). The patient was discharged on POD14.
Table 1: Characteristics of the Patients at Baseline and after VARD. <a href="https://www.jove.com/files/ftp_upload/63236/Table 1 Characteristics of patients.docx" target="_blank">Please click here to download this Table.</a>
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/63236/63236fig01.jpg" /> 
Figure 1: ICG-guided VARD in the debridement of infected necrosis in the right retroperitoneum. (A) Coronary abdominal contrast enhanced CT image revealed that infected necrosis in the right retroperitoneum was persistent after PCD drainage; (B) intraoperative images of ICG perfused adjacent normal tissues or vessels and necrotic debris in the cavity of the right retroperitoneum by near-infrared fluorescence laparoscopy (simultaneous images of the white light field and the fluorescence field, which were displayed separately in Picture-in-Picture mode). <a href="https://www.jove.com/files/ftp_upload/63236/63236fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/63236/63236fig02.jpg" /> 
Figure 2: Representative contrast enhanced CT images before and after ICG-guided VARD. Consecutive serial coronary abdominal contrast enhanced CT image revealed that infected necrosis (the presence of gas configurations within necrotic collections and indicated by the red arrows) were located in the right retroperitoneum (upper row of CT images revealed pancreatic necrosis before ICG-guided VARD) and were significantly resolved after ICG-guided VARD (lower row of CT images revealed pancreatic necrosis completely resolved after ICG-guided VARD). <a href="https://www.jove.com/files/ftp_upload/63236/63236fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

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Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating 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 ...

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2.3K 조회수.  Sun Yat-sen University. This protocol presents Indocyanine Green-guided video-assisted retroperitoneal debridement (ICG-guided VARD) for treating severe acute necrotizing pancreatitis.

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

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 ...

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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.

Psoas 농양의 신부화에 대한 후방 접근

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

Sodium Taurocholate Induced Severe Acute Pancreatitis in C57BL/6 Mice

Biliary acute pancreatitis induction by sodium taurocholate infusion has been widely used by the scientific community due to the representation of the human clinical condition and reproduction of inflammatory events corresponding to the onset of clinical biliary pancreatitis. The severity of pancreatic damage can be assessed by measuring the concentration, speed, and volume of the infused bile acid. This study provides an updated checklist of the materials and methods used in the protocol reproduction and shows the main results from this acute pancreatitis (AP) model. Most of the previous publications have limited themselves to reproducing this model in rats. We have applied this method in mice, which provides additional advantages (i.e., the availability of an arsenal of reagents and antibodies for these animals along with the possibility of working with genetically modified strains of mice) that may be relevant to the study. For acute pancreatitis induction in mice, we present a systematic protocol, with a defined dose of 2.5% sodium taurocholate at an infusion speed 10 &#181;L/min for 3 min in C57BL/6 mice that reaches its maximal level of severity within 12 h of induction and highlight results with outcomes that validate the method. With practice and technique, the total estimated time, from the induction of anesthesia to the completion of the infusion, is 25 min per animal.

Animal models for severe acute pancreatitis enable the study of pathophysiological changes at the initial stage, facilitating observation of the evolution of inflammatory events. Here we provide a protocol for the induction of severe acute biliary pancreatitis by retrograde infusion of sodium taurocholate into the pancreatic duct of anesthetized C57BL/6 mice.

C57BL/6 마우스에서 타우로콜레이트 나트륨 유도 심한 급성 췌장염

Biliary acute pancreatitis induction by sodium taurocholate infusion has been widely used by the scientific community due to the representation of the ...

Establishment of a Mouse Severe Acute Pancreatitis Model using Retrograde Injection of Sodium Taurocholate into the Biliopancreatic Duct

The prevalence of acute pancreatitis (AP), especially severe acute pancreatitis (SAP), is increasing in younger age groups annually. However, there is a lack of effective treatments in the current clinical practice. With the easy accessibility of transgenic and knockout strains and their small size, which allows minimal doses of drugs required for in vivo evaluation, a well-established experimental model in mice is preferred for AP research. Moreover, SAP induced through sodium taurocholate (TC) is currently one of the most widely used and best characterized models. This model has been investigated for novel therapies and possible molecular events during the process of AP. Here, we present the generation of an AP mouse model using sodium taurocholate and a simple homemade microsyringe. Moreover, we also provide the methodology for the subsequent histology and serological testing.

A mouse model of severe acute pancreatitis is described herein. The procedure presented here is very rapid, simple, and accessible, thereby potentially allowing the study of the molecular mechanisms and different therapeutic interventions in acute pancreatitis in a convenient way.

비리오크크레아티드 덕트에 타우로콜레이트 나트륨의 역행 주입을 사용하여 마우스 심각한 급성 췌장염 모델의 설립

The prevalence of acute pancreatitis (AP), especially severe acute pancreatitis (SAP), is increasing in younger age groups annually. However, there is a ...

Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. Surgery is the cornerstone treatment for patients with BC. While total BC excision and Roux-Y hepaticojejunostomy is the treatment method of the choice in patients with extrahepatic BC (i.e., Todani I-IV), patients with intrahepatic BC (i.e., Todani V) benefit the most from a surgical liver resection. In recent years, minimally invasive liver surgery (MILS) including robotic MILS has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. Robotic major MILS is still considered technically demanding and a detailed description of the technical approach during robotic major MILS has only been limitedly discussed in the literature. The current article describes the main steps for a robotic left hepatectomy in a patient with a large BC Todani Type V. The patient is in French position with 5 trocars placed (4 robotic, 1 laparoscopic assistant). After mobilizing the left hemiliver, the left and right hepatic artery are dissected carefully followed by a cholecystectomy. Intraoperative ultrasound is performed to confirm localization and margins of the BC. The Left hepatic artery and left portal vein are isolated, clipped, and divided. Indocyanine green (ICG) fluorescence imaging is used regularly during the entire procedure to visualize and confirm biliary tract anatomy and the BC. Parenchymal transection is performed with robotic cautery hook for the superficial part and robotic cautery spatula, bipolar cautery, and vessel sealer for the deeper parenchyma. The postoperative course was uncomplicated. A robotic left hepatectomy is technically demanding, yet a feasible and safe procedure. ICG-fluorescence imaging aids in delineating the BC and bile duct anatomy. Further, comparative studies are needed to confirm clinical benefits of robotic MILS for benign and malignant indications.

Robotic liver surgery has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. However, robotic left hepatectomy is still technically demanding. We describe our surgical technique of a robotic left hepatectomy using indocyanine green fluorescence imaging for a large biliary cyst.

간내 복합 담즙 낭종에 대한 Indocyanine Green Fluorescence Imaging 을 사용하는 로봇 왼쪽 간 절제술

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. ...

In Vitro Apical-Out Enteroid Model of Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a devastating disease affecting preterm infants, characterized by intestinal inflammation and necrosis. Enteroids have recently emerged as a promising system to model gastrointestinal pathologies. However, currently utilized methods for enteroid manipulation either lack access to the apical surface of the epithelium (three-dimensional [3D]) or are time-consuming and resource-intensive (two-dimensional [2D] monolayers). These methods often require additional steps, such as microinjection, for the model to become physiologically translatable. Here, we describe a physiologically relevant and inexpensive protocol for studying NEC in vitro by reversing enteroid polarity, resulting in the apical surface facing outward (apical-out). An immunofluorescent staining protocol to examine enteroid barrier integrity and junctional protein expression following exposure to tumor necrosis factor-alpha (TNF-&#945;) or lipopolysaccharide (LPS) under normoxic or hypoxic conditions is also provided. The viability of 3D apical-out enteroids exposed to normoxic or hypoxic LPS or TNF-&#945; for 24 h is also evaluated. Enteroids exposed to either LPS or TNF-&#945;, in combination with hypoxia, exhibited disruption of epithelial architecture, a loss of adherens junction protein expression, and a reduction in cell viability. This protocol describes a new apical-out NEC-in-a-dish model which presents a physiologically relevant and cost-effective platform to identify potential epithelial targets for NEC therapies and study the preterm intestinal response to therapeutics.

In Vitro Apical-Out Enteroid Model of Necrotizing Enterocolitis

This protocol describes an apical-out necrotizing enterocolitis (NEC)-in-a-dish model utilizing small intestinal enteroids with reversed polarity, allowing access to the apical surface. We provide an immunofluorescent staining protocol to detect NEC-related epithelial disruption and a method to determine the viability of apical-out enteroids subjected to the NEC-in-a-dish protocol.

체외 괴사성 장염의 Apical-Out Enteroid 모델

Necrotizing enterocolitis (NEC) is a devastating disease affecting preterm infants, characterized by intestinal inflammation and necrosis. Enteroids have ...

Establishment of a Simple and Effective Rat Model for Intraoperative Parathyroid Gland Imaging

Parathyroid gland (PG) identification is a critical unmet need in thyroidectomy. The identification of the PG is challenging in thyroid surgery as it is similar in color to the thyroid gland. The lack of effective animal models in preclinical research is a severe limitation for the development of PG identification techniques. This protocol allows for the establishment of a simple and effective rat model for PG identification. In this model, black iron oxide nanoparticles (IONPs) are injected locally in the thyroid gland and rapidly diffuse within the thyroid gland but not the PG. A negatively stained PG and a positively stained thyroid gland can be easily identified by the naked eye without requiring external microscopes. The position of the PG can be identified by increasing the color contrast between the thyroid gland and the PG, based on the color of the black IONPs. This rat model is low-cost and convenient for PG identification, and the IONPs are a novel PG contrast agent.

To date, the development of parathyroid gland (PG) identification methods is limited by the lack of animal models in preclinical research. Here, we establish a simple and effective rat model for intraoperative PG imaging and evaluate its effectiveness by using iron oxide nanoparticles as a novel PG contrast agent.

수술 중 부갑상선 영상촬영을 위한 간단하고 효과적인 쥐 모델 구축

Parathyroid gland (PG) identification is a critical unmet need in thyroidectomy. The identification of the PG is challenging in thyroid surgery as it is ...

Enema of Traditional Chinese Medicine for Patients with Severe Acute Pancreatitis

Severe acute pancreatitis (SAP) is characterized by high mortality rates, numerous complications, and extreme difficulties in treatment. A traditional Chinese medicine (TCM) enema has been widely utilized in clinical and experimental studies of SAP. It has been demonstrated to have beneficial effects in protecting pancreatic function and delaying disease progression. The procedure of TCM enema is to perfuse the Chinese medicinal liquid of raw rhubarb (Rheum officinale Baill. DaHuang) from the anus into the rectum and colon. Basic steps of the procedure include boiling the herbal solution in advance, using a disposable enema kit to assist patients in taking a left lying position, raising the patient's hip 10 cm, and carefully inserting the enema 30-35 cm into the anus, with a drip speed of 60-80 drops/min. The medicine liquid temperature should be equivalent to the patient's body temperature, typically between 37-39 &#176;C. The end of the enema operation should be slow, and Tui na (massage therapy) should be administered before extubation. The medication liquid should be kept in the rectum for more than 1 h. After issuing an enema, it is essential to observe the patient's feces and abdomen, and to evaluate the remission of abdominal signs and symptoms.

An enema is a type of traditional Chinese medicine (TCM) therapy used to treat severe acute pancreatitis (SAP). The therapy involves instilling a TCM liquid into the rectum and colon through the anus to keep the liquid in the intestine, absorbing through the intestinal mucosa. This study aims to standardize the enema procedure for SAP patients.

중증 급성 췌장염 환자를위한 중국 전통 의학의 관장

Severe acute pancreatitis (SAP) is characterized by high mortality rates, numerous complications, and extreme difficulties in treatment. A traditional ...

Orthopedic Robot-Assisted Femoral Neck System in the Treatment of Femoral Neck Fracture

Cannulated screw fixation is the main therapy for femoral neck fractures, especially in young patients. The traditional surgical procedure uses C-arm fluoroscopy to place the screw freehand and requires several guide wire adjustments, which increases the operation time and radiation exposure. Repeated drilling can also cause damage to the blood supply and bone quality of the femoral neck, which can be followed by complications such as screw loosening, nonunion, and femoral head necrosis. In order to make fixation more precise and reduce the incidence of complications, our team applied robot-assisted orthopedic surgery for screw placement using the femoral neck system to modify the traditional procedure. This protocol introduces how to import a patient's X-ray information into the system, how to perform screw path planning in software, and how the robotic arm assists in screw placement. Using this method, the surgeons can place the screw successfully the first time, improve the accuracy of the procedure, and avoid radiation exposure. The whole protocol includes the diagnosis of femoral neck fracture; the collection of intraoperative X-ray images; screw path planning in the software; precise placement of the screw under the assistance of the robotic arm by the surgeon; and verification of the implant placement.

This article introduces a method of robot-assisted orthopedic surgery for screw placement during the treatment of femoral neck fracture using the femoral neck system, which allows for more accurate screw placement, improved surgical efficiency, and fewer complications.

대퇴 경부 골절 치료를 위한 정형외과 로봇 보조 대퇴 경부 경부 시스템

Cannulated screw fixation is the main therapy for femoral neck fractures, especially in young patients. The traditional surgical procedure uses C-arm ...

자율 호흡이 보존된 비디오 보조 흉강경 수술을 위한 비삽관 프로토콜

Non-Intubated Video-Assisted Thoracoscopic Surgery

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the lung, and lobectomy. However, there is a high incidence of pulmonary complications arising from general anesthesia with tracheal intubation. Non-intubation with the preservation of voluntary breathing is an alternative to anesthesia. Non-intubation procedures minimize the adverse effects of tracheal intubation and general anesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and post-operative nausea and vomiting. However, the steps for non-intubation procedures are not detailed in many studies. Here, we present a concise non-intubated protocol for the performance of video-assisted thoracoscopic surgery with preserved autonomic breathing. This article identifies the conditions necessary to convert from non-intubated to intubated anesthesia and also discusses the advantages and limitations of non-intubated anesthesia. In this work, this intervention was performed on 58 patients. In addition, the results of a retrospective study are presented. Compared with intubated general anesthesia, patients in the non-intubated video-assisted thoracic surgery group had lower rates of post-operative pulmonary complications, shorter operative times, less intraoperative blood loss, shorter PACU stays, a lower number of days to chest drain removal, less post-operative drainage, and shorter hospital stays.

저자 스포트라이트: Multimodal Analgesia and Sevoflurane Inhalation Anesthesia를 이용한 Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia(다중 모드 진통 및

Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.

삽관되지 않은 비디오 보조 흉강경 수술

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the ...