The authors have no acknowledgments.

All patients provided a signed written informed consent and the approval of the local Ethics Committee (EC/2014/0438) was obtained.
NOTE: The inclusion criteria for the presented protocol were: male; age &#8805;18 years; signed written informed consent; fit for operation; isolated urethral stricture; urethral stricture &#8804;3 cm; urethral stricture only at the bulbar or membranous site. The exclusion criteria were: female; transgender; age &#60;18 years; absence of signed written informed consent; unfit for operation; &#62;1 concomitant urethral strictures; urethral stricture &#62;3 cm; urethral stricture outside of the bulbar or membranous site.
1. Preoperative Work-up
<ol>
	<li>Evaluate the patient through history taking, physical examination, and uroflowmetry followed by an ultrasonic residual volume measurement.</li>
	<li>Confirm the presence of a stricture by urethrography (retrograde and/ or antegrade). If there is any doubt, additionally perform urethroscopy.</li>
	<li>After the appropriate diagnosis, schedule patients with isolated short bulbar urethral strictures or with strictures at the membranous urethra for urethroplasty by vessel-sparing excision and primary anastomosis (vsEPA). Plan the surgery at least 3 months after any urethral manipulation including catheter use, dilation, or direct vision internal urethrotomy (DVIU). In the case of urinary retention, place a suprapubic catheter to ensure urinary derivation. In the case of pelvic fracture-related urethral injuries, perform urethroplasty at least 3 months after the initial trauma.</li>
	<li>Perform preoperative investigations to evaluate the patient&#8217;s fitness for operation as prescribed by local guidelines. If necessary, conduct therapeutic interventions accordingly.</li>
	<li>One week before surgery, perform a urine culture with an antibiogram and, in the case of a urinary infection, start the appropriate antibiotics 24 h before surgery. If there is no urinary infection, administer a single shot of 1 g of cefazoline (dissolved in 10 cc of NaCl, 0.9%) intravenously (through the peripheral venous catheter using a 20 cc syringe and an 18 G needle) at the start of the operation.</li>
	<li>Obtain routine venous thrombo-embolism prophylaxis by the administration of compression stockings.</li>
	<li>Keep the patients sober at least 6 h before surgery.</li>
</ol>
2. Initiation of Surgical Procedure
NOTE: The following steps take place after the surgical safety checklist and the administration of general anesthesia.
<ol>
	<li>Patient&#8217;s positioning
	<ol>
		<li>Place the patient on the operating table in a supine position.</li>
		<li>Place the patient in a modified lithotomy position in which the knees and the hips are flexed 60&#8211;90&#176; with 45&#176; of abduction and the feet and calves are supported in supportive boots or leg holders. Make sure the patient&#8217;s buttocks slightly pass the caudal border of the operating table to provide sufficient accessibility. Check extensively for areas with excessive compression to prevent neurovascular compression syndromes.</li>
		<li>If necessary, obtain a 10&#8211;15&#176; Trendelenburg position to fully visualize the diseased urethra.</li>
	</ol>
	</li>
	<li>Start-up of the surgical procedure
	<ol>
		<li>Shave and disinfect the exposed perineum and external genitals using an iodine-based scrub as antiseptic.</li>
		<li>In the case of the presence of a suprapubic catheter, instill the bladder with 100 mL of diluted (10%) iodine-based scrub.</li>
		<li>Create a sterile operating field by the administration of sterile drapes. Keep the operating field as small as possible and include the penis and scrotum without the anus. In the case of the presence of a suprapubic catheter, include this in the operating field to ensure suprapubic access to the urethra, if necessary.</li>
		<li>As the surgeon is seated between the legs of the patient, position an assistant next to him/ her and place the instrumentalist on the left side of the patient, handing over the instruments from above the operating field.</li>
	</ol>
	</li>
</ol>
3. Surgical Procedure
<ol>
	<li>Accessing the bulbar urethra
	<ol>
		<li>Make a midline perineal skin incision using a scalpel (blade number 24) and dissect the subcutaneous fat tissue through Colles&#8217; fascia with a monopolar electrocauter (coagulation and cutting mode on 25 Watt and pure) until the bulbospongious muscle is encountered. Coagulate any bleeding vessels with the monopolar electrocauter.</li>
		<li>Incise the bulbospongious muscle at the midline using a surgical blade number 24 and dissect it away from the underlying corpus spongiosum with Jones scissors.</li>
		<li>Fix the bulbospongious muscle at the perineal skin using 4 silk 2-0 stay sutures and ensure further surgical exposure by a self-retaining retractor: attach the hooks of the elastic stays to the bulbospongious muscle, create sufficient traction, and secure the elastics to one of the slots of the retractor (Figure 1).</li>
		<li>Identify the bulbar urethra.</li>
	</ol>
	</li>
	<li>Mobilization of the bulbar urethra
	<ol>
		<li>Dissect the bulbar urethra circumferentially in a sharp fashion with Jones scissors starting at the mid-bulbar region. Incise Buck&#8217;s fascia on each side of the bulbar urethra with Jones scissors allowing a further dorsal dissection of the urethra and a detachment of the dorsal Buck&#8217;s fascia from the tunica albuginea of the corpora cavernosa.</li>
		<li>Encircle the bulbar urethra with a vessel loop and secure it with a Kocher clamp to facilitate manipulation (Figure 2).</li>
		<li>First, continue the dorsal dissection and detachment in the distal direction, towards the penoscrotal angle. Use sharp scissors dissection, closely follow Buck&#8217;s fascia in this dorsal detachment as it provides a rather avascular surgical plane. Coagulate the communicating vessels between the corpus spongiosum and the corpora cavernosa with a monopolar electrocauter.</li>
		<li>Continue the dorsal dissection proximally, towards the urogenital diaphragm. Do not dissect the bulb of the corpus spongiosum at the anal side and leave the perineal body intact.</li>
	</ol>
	</li>
	<li>Opening of the stricture
	<ol>
		<li>Introduce a 20Fr silicone urethral catheter&#160;or a 20Fr metal sound in the meatus urethrae and pass it up toward the distal extent of the urethral stricture.</li>
		<li>At this level, open the urethra dorsally in a longitudinal fashion (dorsal stricturotomy) using a scalpel (blade number 15 or 24).</li>
		<li>Place 2 silk 3-0 stay sutures (1 on each side of the opened urethra) to facilitate the exposure of the urethral lumen.</li>
		<li>Insert a 3Fr ureteral catheter through the dorsally-opened urethra and pass it up proximally through the strictured area.</li>
		<li>Further open the stricture on this 3Fr ureteral catheter using Jones scissors or a surgical blade number 15 until healthy urethral tissue is encountered.</li>
		<li>Evaluate the patency and caliber of the proximal urethra by introducing a 20Fr metal sound and move it up toward the bladder.</li>
		<li>Place 2 silk 3-0 stay sutures (1 on each side) on the opened proximal urethra.</li>
		<li>For bulbar strictures, resect the stricture as well as the surrounding spongiofibrosis using Jones scissors until healthy spongious tissue is encountered ventrally. Leave this healthy spongious tissue intact.</li>
		<li>For strictures at the membranous urethra, fully resect the scar tissue using Jones scissors or a surgical blade number 15 until the apex of the prostate is reached. After the removal of the suprapubic catheter, introduce a cystoscope through the suprapubic tract to facilitate the identification of the prostatic apex.</li>
	</ol>
	</li>
	<li>Urethral anastomosis
	<ol>
		<li>If necessary, split the corpora cavernosa to shorten the distance towards the proximal urethra. Use a surgical blade number 15 on the midline between the corpora cavernosa and once the avascular plane between both corpora is encountered, continue with a blunt dissection.</li>
		<li>Grasp the urethral mucosa with a DeBakey forceps with a large grip.</li>
		<li>In the case of a bulbar stricture
		<ol>
			<li>Create the ventral urethral plate by suturing the ventral ends of the proximal and distal urethra from the inside of the urethral lumen using interrupted 4-0 sutures (polyglactin 910).</li>
			<li>Dorsally, spatulate the healthy urethral edges for about 1 cm using Jones scissors and remove the stay sutures.</li>
			<li>Close the dorsal edges of the urethral ends transversely over a 20Fr silicone urethral catheter with interrupted 4-0 sutures (polyglactin 910).</li>
			<li>Close the corpus spongiosum over the urethra (spongioplasty) using 4-0 sutures (polyglactin 910).</li>
		</ol>
		</li>
		<li>In the case of a stricture or obliteration at the membranous urethra
		<ol>
			<li>Spatulate the distal urethral end dorsally and the proximal urethral end ventrally over 1 cm using Jones scissors.</li>
			<li>Place eight 4-0 sutures (polyglactin 910) and pass a 20Fr silicone urethral catheter into the bladder.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Catheter drain and wound closure
	<ol>
		<li>Leave a 20Fr silicone urethral catheter in place.</li>
		<li>Leave a 10Fr suction drain behind between the corpus spongiosum and the bulbospongious muscle. Perforate the skin of the right inguinal region with the 10Fr drain needle. Cut the needle off.</li>
		<li>Cut the stay sutures with Mayo-Stille scissors, remove the retractor, and close the bulbospongious muscle over the underlying urethra, corpus spongiosum, and suction drain using a 3-0 running suture (polyglactin 910).</li>
		<li>Suture Colles&#8217; fascia in a running fashion, also using a 3-0 suture (polyglactin 910). Suture the skin with interrupted Donati stitches using 3-0 sutures (polyglactin 910).</li>
		<li>Fix the suction drain at the groin using a silk 2-0 suture and attach the suction drain to the vacuum flask. Apply a perineal compressive dressing.</li>
		<li>Flip the penis and transurethral catheter toward the lower abdomen and keep them in place by supporting and compressive underwear.</li>
		<li>If a suprapubic catheter was present, remove this, except in the case of previous irradiation.</li>
	</ol>
	</li>
</ol>
4. Postoperative Care
<ol>
	<li>After recovery, bring the patient to his room and provide standard postoperative care.</li>
	<li>Remove the suction drain after 24 h.</li>
	<li>In the case of a preoperatively established urinary infection, continue the antibiotic treatment regimen as prescribed.</li>
	<li>Disinfect the perineal wound repeatedly and use a hair dryer 3&#8211;5x a day to keep the wound dry and neat.</li>
	<li>In the case of no major complications, discharge the patient from the hospital on postoperative day 2 with the indwelling transurethral catheter in place. Give further instructions, especially regarding wound care, and foresee an appointment to remove the catheter.</li>
</ol>
5. Follow-up Visits
<ol>
	<li>After 7 (simple repair) to 14 days (irradiated cases), perform a voiding cystourethrography (VCUG) and, if there is no or insignificant contrast leakage, remove the transurethral catheter. In the case of significant extravasation, replace the transurethral catheter and perform the VCUG again 1 week later.</li>
	<li>Schedule follow-up visits 3 months postoperatively, 12 months postoperatively, and annually thereafter. During these visits, evaluate the patient through history taking, a physical examination, uroflowmetry, and an ultrasonic residual volume measurement. Perform further technical investigations such as retrograde urethrography (RUG), VCUG, or urethroscopy only in the case of arguments for stricture recurrence such as symptoms, an obstructive voiding curve, or high residual urinary volumes.</li>
	<li>Define surgical failure as stricture recurrence requiring additional urethral manipulation, including dilation.</li>
</ol>

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The authors have nothing to disclose.

Urethral stricture repair by vessel-sparing excision and primary anastomosis was initially performed at Ghent University Hospital in 2010. Thereafter, it became a standard of practice in the hospital&#39;s management of patients with isolated short bulbar or posterior urethral strictures. As the bulb remains attached to the perineal body, access to the posterior urethra and the resection of the fibrotic tissue at that site can be compromised. A distortion of the pubic rami due to a pelvic fracture might further impede ac...

Urethroplasty is considered the standard treatment for urethral strictures as it provides excellent long-term success rates1,2. A numerous amount of surgical techniques has been described, challenging the reconstructive urologist to choose the best approach, considering various stricture modalities such as the number of strictures, the stricture length, the stricture location, the etiology, comorbidities, and previous urethral interventions. For isolated short bulbar urethral strictures, the International Consultation on Urologic Diseases (ICUD) recommends urethroplasty by excision and primary anastomosis (EPA) associated with a composite success rate of 93.8%3,4.
Urethroplasty by EPA embodies an approach in which the entire diseased segment of the urethra is removed and replaced by healthy adjacent urethra without the need for grafts or flaps to bridge the gap. Traditionally, this approach included the full thickness transection of the corpus spongiosum at the level of the stricture5. However, as EPA only requires the excision of the narrowed segment and the surrounding spongiofibrosis, a full thickness transection of the corpus spongiosum, and the dual urethral blood supply within it, is usually unnecessary. Given this background, Jordan et al. introduced the idea of a vessel-sparing approach in 2007, offering a non-transecting alternative to the classic transecting EPA (tEPA)6,7. This vessel-sparing EPA (vsEPA) has been uprising ever since and several centers have&#8212;though slightly modified&#8212;implemented this technique in their surgical repertoire8,9,10,11,12.
The vessel-sparing technique aims to reduce surgical trauma, especially to the dual arterial blood supply of the urethra embedded in the corpus spongiosum. The preservation of the bulbar arteries potentially reduces the risk of postoperative erectile dysfunction or glans ischemia. Furthermore, it could be beneficial for subsequent urethral interventions such as redo urethroplasty using a free graft, in which a well-vascularized graft bed is imperative8,9. Nevertheless, these potential benefits are only assumptions as prospective studies comparing the functional outcome of both techniques with validated questionnaires are currently lacking.
As important as the functional outcome is, vsEPA should at least be able to provide similar surgical outcomes as tEPA. Promising short-term results have been published and are in line with the success rates reported by the ICUD, but a direct comparison between both techniques has, so far, not been performed3,4,8,9,10,11,12.
Pelvic fracture-related urethral injuries are associated with scar tissue formation and a subsequent urethral stricture or complete obliteration of the membranous urethra. Posterior strictures might also develop after surgery or irradiation to the prostate13. For these strictures, urethroplasty with the excision of the scar tissue and bulbo-prostatic anastomosis is recommended as well14. Traditionally, the bulbar arteries were ligated during this procedure if not already obliterated due to the pelvic fracture. To avoid this, a vessel-sparing variant has been introduced and reported as well15,16.
The aim of this paper is to give an elaborate, step-by-step overview of how to manage patients with isolated short bulbar or posterior urethral strictures with vsEPA. The main scope is to outline and visualize the surgical technique and to report the representative surgical outcome. An evaluation of the functional outcome parameters is beyond the scope of this paper.

<table><tbody><tr><td>iso-Betadine Dermicum 125 mL (1)</td><td>Meda Pharma</td><td>A-472825</td><td></td></tr><tr><td>Sterile gown (3)</td><td>According to surgeon&#039;s preference</td><td>NA</td><td></td></tr><tr><td>Sterile gloves (3 pairs)</td><td>According to surgeon&#039;s preference</td><td>NA</td><td></td></tr><tr><td>Sterile drapes (4)</td><td>Medline</td><td>AGBBA073A</td><td></td></tr><tr><td>Bard-Parker scalpel number 3 (1)</td><td>Zepf Medical Instruments</td><td>06-1003-00</td><td></td></tr><tr><td>Bard-Parker scalpel number 4 (1)</td><td>KLS Martin Group</td><td>10-100-04</td><td></td></tr><tr><td>Scalpel blade number 15 (1)</td><td>Swann-Morton</td><td>0205</td><td></td></tr><tr><td>Scalpel blade number 24 (1)</td><td>Swann-Morton</td><td>0211</td><td></td></tr><tr><td>Surgical forceps 14 cm (2)</td><td>KLS Martin Group</td><td>12-301-14</td><td></td></tr><tr><td>Monopolar electrocauter Valleylab&amp;nbsp; (1)</td><td>Medtronic</td><td>E2100</td><td></td></tr><tr><td>Electrocauter blade 15 cm (1)</td><td>Comepa</td><td>CO 150i</td><td></td></tr><tr><td>Debakey forceps 20 cm (2)</td><td>D&amp;uuml;fner</td><td>06232-20</td><td></td></tr><tr><td>3-layered compress 30 cm x 45 cm (5)</td><td>M&amp;ouml;lnlycke Health Care</td><td>175260</td><td></td></tr><tr><td>Surgical compress 10 cm x 10 cm (10)</td><td>Hartmann</td><td>232088</td><td></td></tr><tr><td>Mayo-Hegar needle driver 18 cm (1)</td><td>Zepf Medical Instruments</td><td>24-1804-18</td><td></td></tr><tr><td>Mayo-Hegar needle driver 25 cm (1)</td><td>Zepf Medical Instruments</td><td>24-1804-25</td><td></td></tr><tr><td>Jones scissor 18 cm (1)</td><td>D&amp;uuml;fner</td><td>04940-18</td><td></td></tr><tr><td>Mayo-Stille scissor 17 cm (1)</td><td>Zepf Medical Instruments</td><td>08-1700-17</td><td></td></tr><tr><td>Lone Star retractor (1)</td><td>CooperSurgical, Trumbull, CT, USA</td><td>72403867</td><td></td></tr><tr><td>Lone Star elastic stays (4)</td><td>CooperSurgical, Trumbull, CT, USA</td><td>3311-1G</td><td></td></tr><tr><td>Vessel loop 45 cm (1)</td><td>Braun</td><td>1095137</td><td></td></tr><tr><td>Halsted-Mosquito (6)</td><td>KLS Martin Group</td><td>13-317-21</td><td></td></tr><tr><td>20Fr silicone urethral catheter (1)</td><td>Yushin Medical Co.</td><td>1037B-20</td><td></td></tr><tr><td>3Fr ureteral catheter (1)</td><td>Teleflex</td><td>223602</td><td></td></tr><tr><td>20Fr metal sound (1)</td><td>Custom made</td><td>NA</td><td></td></tr><tr><td>Vicryl 4-0 wire (6)</td><td>Ethicon</td><td>V734D</td><td></td></tr><tr><td>Vicryl 3-0 wire (2)</td><td>Ethicon</td><td>VCP316H</td><td></td></tr><tr><td>Vicryl Rapide 3-0&amp;nbsp; wire (1)</td><td>Ethicon</td><td>VF2260</td><td></td></tr><tr><td>10Fr Drain needle (1)</td><td>Vygon</td><td>658.10</td><td></td></tr><tr><td>10Fr Suction drain (1)</td><td>Oriplast</td><td>203102</td><td></td></tr><tr><td>Vacuum flask 400 mL (1)</td><td>Oriplast</td><td>213215AL/QL</td><td></td></tr><tr><td>Zetuvit 10 cm x 20 cm (1)</td><td>Hartmann</td><td>413771</td><td></td></tr></tbody></table>

vessel-sparing excision and primary anastomosis

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short bulbar or posterior urethral strictures, urethroplasty by excision and primary anastomosis (EPA) is recommended. As EPA only requires the excision of the narrowed segment and the surrounding spongiofibrosis, a full-thickness transection of the corpus spongiosum, as performed in the traditional transecting EPA (tEPA), is usually unnecessary. Jordan et al. introduced the idea of a vessel-sparing approach in 2007, aiming to reduce surgical trauma, especially to the dual arterial blood supply of the urethra, and, thus, potentially reducing the risk of postoperative erectile dysfunction or glans ischemia. This approach could also be beneficial for subsequent urethral interventions such as redo urethroplasty using a free graft, in which a well-vascularized graft bed is imperative. Nevertheless, these potential benefits are only assumptions as prospective studies comparing the functional outcome of both techniques with validated questionnaires are currently lacking. Moreover, vessel-sparing EPA (vsEPA) should at least be able to provide similar surgical outcomes as tEPA. The aim of this paper is to give an elaborate, step-by-step overview of how to manage patients with isolated short bulbar or posterior urethral strictures with vsEPA. The main objective of this manuscript is to outline the surgical technique and to report the representative surgical outcome. A total of 117 patients were managed according to the described protocol. The analysis was performed on the entire patient cohort and on the bulbar (n = 91) and posterior (n = 26) vsEPA group separately. Success rates were 93.4% and 88.5% for the bulbar and posterior vsEPA, respectively. To conclude, vsEPA, as outlined in the protocol, provides excellent success rates with low complication rates for isolated short bulbar and posterior urethral strictures.

Between 2011 and 2017, a total of 117 patients with isolated short bulbar (n = 91) or posterior (n = 26) urethral strictures were treated with vsEPA at Ghent University Hospital. The baseline characteristics are displayed in Table 1. The median follow-up was 35 and 45 months for bulbar and posterior strictures, respectively. The strictures were longer in the patients who underwent posterior vsEPA and, accordingly, the number of patients with a calculated...

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Vessel-sparing Excision and Primary Anastomosis

Here, we present an elaborate and efficient protocol to treat isolated short bulbar or posterior urethral strictures with vessel-sparing excision and primary anastomosis.

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short ...

vessel-sparing-excision-and-primary-anastomosis

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11.3K Views.  Ghent University Hospital. Deze vat-spaarzame techniek is gericht op het verminderen van chirurgisch trauma tijdens urethroplastie door excisie en primaire anastomose. Het behoud van de bulbaire slagaders kan het risico van postoperatieve erectiestoornissen en glans ischemie verminderen. Bovendien kan het gunstig zijn voor verdere urethrale interventies die een goed aanhoudende avascularisatie vereisen.Na het bevestigen van de aanwezigheid van een vernauwing door retrograde en/of antegrade urethrography, pas de ...

Video: Vessel-sparing Excision and Primary Anastomosis

Re-Arterialized Rat Partial Liver Transplantation with an in vivo Vessel-Oriented 70% Hepatectomy

Split liver transplantation and living liver donor liver transplantation were developed in the clinic to utilize liver organs in a more efficient manner. To better understand the mechanism behind these surgical procedures, a rat partial liver transplantation (PLTx) model was established for relevant surgical studies. Because of the complexity of the rat PLTx model, a protocol with detailed descriptions is required. An article published previously reported a protocol in which ex vivo hepatectomy was used to achieve 50% rat PLTx. In contrast to this protocol, we introduced a re-arterialized PLTx with an in vivo 70% hepatectomy. An updated vessel-oriented hepatectomy was incorporated into the rat PLTx to refine the microsurgical procedure. The portal veins and hepatic arteries of the left lateral lobe and the median lobe were individually dissected and ligated before removal of the liver parenchyma, thereby decreasing the probability of bleeding in the remnant liver stump. Furthermore, an end-to-side vessel anastomosis between the common hepatic artery and the enlarged proper hepatic artery was introduced to re-arterialize the hepatic artery. By using this end-to-side vessel anastomosis technique, the diameter of the anastomosis was enlarged, thereby decreasing the difficulty of hand suture and maintaining a high rate of anastomotic patency. Moreover, the cuff anastomosis of the infrahepatic vena cava was slightly modified. A section of circumferential liver parenchyma around the vena cava of a recipient was preserved during cuff anastomosis to maintain the three-dimensional shape of the vascular lumen. This section of liver parenchyma was removed after completing the anastomosis. With this modification, the step involving placement of stay sutures was omitted, thereby further shortening the cuff anastomosis time. By using this protocol of rat PLTx, a low liver enzyme level, an intact liver lobular architecture and a high survival rate were achieved after microsurgery.

Re-Arterialized Rat Partial Liver Transplantation with an in vivo Vessel-Oriented 70% Hepatectomy

Here, a protocol involving re-arterialized rat partial liver transplantation is presented. Specifically, 70% liver was resected in vivo by using an updated technique of vessel-oriented hepatectomy. The hepatic artery was reconstructed in an end-to-side manner. The cuff technique was modified to shorten the anastomosis time of the infrahepatic vena cava.

Split liver transplantation and living liver donor liver transplantation were developed in the clinic to utilize liver organs in a more efficient manner. ...

A Modified Murine Heterotopic Heart Transplant Protocol Matching Contemporary Standards of Aseptic Technique, Anesthesia, and Analgesia

The development of experimental models of cardiac transplantation in animals has contributed to many advances in the fields of immunology and solid organ transplantation. While the heterotopic vascularized murine cardiac transplantation model was initially utilized in studies of graft rejection using combinations of mismatched inbred mouse strains, access to genetically modified strains and therapeutic modalities can provide powerful new preclinical insights. Fundamentally, the surgical methodology for this technique has not changed since its development, especially with respect to important factors such as aseptic technique, anesthesia, and analgesia, which make material impacts on postsurgical morbidity and mortality. Additionally, improvements in perioperative management are expected to provide improvements in both animal welfare and experimental outcomes. This paper reports upon a protocol developed in collaboration with a subject matter expert in veterinary anesthesia and describes the surgical technique with an emphasis on perioperative management. Additionally, we discuss the implications of these refinements and provide details on troubleshooting critical surgical steps for this procedure.

The present paper describes a modified technique for heterotopic vascularized cardiac transplantation with updated aseptic technique, analgesia, and anesthesia.

The development of experimental models of cardiac transplantation in animals has contributed to many advances in the fields of immunology and solid organ ...

Immunology and Infection

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction, for cancer of the body-tail of the pancreas. The patient is placed supine with the legs parted and a pneumoperitoneum is established and maintained at 10 mmHg. To use the surgical system, four 8 mm ports and one 12 mm port are required. The optic port is placed at the umbilicus. The other ports are placed, on either side, along the pararectal line and the anterior axillary line at the level of the umbilical line. The assistant port (12 mm) is placed along the right pararectal line. Dissection begins by detaching the gastrocolic ligament, thus opening the lesser sac, and by a wide mobilization of the splenic flexure of the colon. The superior mesenteric vein is identified along the inferior border of the pancreas. Lymph node number 8a is removed to permit clear visualization of the common hepatic artery. A tunnel is then created behind the neck of the pancreas. To permit safe resection and reconstruction of the spleno-mesenteric junction, further preemptive dissection is required before dividing the pancreatic neck to bring in clear view all relevant vascular pedicles. Next, the splenic artery is ligated and divided, and the pancreatic neck is divided, with selective ligature of the pancreatic duct. After vein resection and reconstruction, dissection proceeds to complete the clearance of peripancreatic arteries that are peeled off from all lympho-neural tissues. Both celiac ganglia are removed en-bloc with the specimen. The Gerota fascia covering the upper pole of the left kidney is also removed en-bloc with the specimen. Division of short gastric vessels and splenectomy complete the procedure. A drain is left near the pancreatic stump. The round ligament of the liver is mobilized to protect the vessels.

The robotic technique shown herein aims at faithfully reproducing the open procedure for radical treatment of cancer of the body-tail of the pancreas. The protocol also demonstrates the ability to master involvement of major peripancreatic vessels without conversion to open surgery.

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the ...

Vessel-Sparing Microsurgical Longitudinal Intussusception Vasoepididymostomy to Treat Epididymal Obstructive Azoospermia

The epididymis is a common site of obstruction in obstructive azoospermia (OA). Vasoepididymostomy has become an important method for the treatment of epididymal OA since 2000. There are two challenges in classic microscopic vasoepididymostomy. First, anastomosis of the vas deferens and epididymis is performed with double-needle sutures. However, there is a lack of good-quality and cost-effective double-needle sutures in China, which leads to increased difficulty and poor success rates of anastomosis. Second, the separation of the vas deferens does not retain vasculature, although the vas deferens vasculature plays an important role in the blood supply to the vas deferens, epididymis, and testis. This affects the blood supply to the anastomotic area and epididymis.
Therefore, this team has made innovative improvements to address these problems. Good-quality, cost-effective, single-needle sutures, which are easy to purchase in China and other countries, were used in microsurgical longitudinal intussusception vasoepididymostomy. This can optimize the operation procedure and shorten the operation time while ensuring the success rate of the anastomosis. The surgical method of preserving the vas deferens vessels was innovatively proposed because the etiology of epididymal OA is mostly inflammatory in China. The protection of the blood supply to the vas deferens and epididymis is maximized using microsurgical forceps to separate and protect the vasculature. Patency reached 81.7% in the postoperative follow-up, indicating a better surgical treatment effect.

The present protocol describes a vessel-sparing, longitudinal intussusception vasoepididymostomy using readily available single-needle sutures in China, a safe and effective procedure, which may improve patients' patency and natural pregnancy rates.

The epididymis is a common site of obstruction in obstructive azoospermia (OA). Vasoepididymostomy has become an important method for the treatment of ...

A Modified Vessel-Sparing Microsurgical Vasoepididymostomy

Microsurgical vasoepididymostomy (MVE) is the main surgical treatment for epididymal obstruction. The vasal vessels are ligated during MVE. However, preserving the vasal vessels during MVE might better simulate the normal physiological structure and be meaningful for patients who have undergone varicocelectomy. Nevertheless, preserving the vasal vessels might elevate the risk of increasing the tension of anastomosis, affecting the patency rate and leading to delayed postoperative bleeding. Therefore, we developed a novel vessel-sparing MVE to make it safer. Here is a summary of the improvements to the procedure. 1) The retrograde dissociation of the vasal vessels on the proximal testicular side was adopted as the main method, and the anterograde dissociation of the vasal vessels on the distal testicular side was adopted as a supplement to dissociate the vasal vessels to be preserved. This improvement ensures the blood supply to the vas deferens that will be used for anastomosis and also provides longer vasal vessels, which reduces the tension of anastomosis. 2) By fixing the vas deferens to be anastomosed and the broken end of the vas deferens, the free vasal vessels get fixed, which resolves the problem of transmission of vas tension to the vasal vessels and reduces the risk of vasal vessel hemorrhage. 3) Dissociation of the vas deferens after opening the tunica vaginalis increases the mobilization of the vas deferens, which also makes the new procedure easier to complete. The evaluation of the outcomes of this new procedure showed that no significant postoperative complications occurred in the patients, and the patency rate was no different from that of the conventional procedure. Therefore, this new, improved procedure can be considered safe, with satisfactory postoperative results.

Here, we present a protocol to preserve the vasal vessels in microsurgical vasoepididymostomy. The surgical security is enhanced by preserving the vasal vessels using a retrograde-anterograde dissociation and fixing the vasal vessels.

Microsurgical vasoepididymostomy (MVE) is the main surgical treatment for epididymal obstruction. The vasal vessels are ligated during MVE. However, ...

Bloodless Laparoscopic Partial Splenectomy Assisted by Bipolar Radiofrequency Excision Hemostatic Device

Among the lymphatic system in the human body, the spleen is the most extensive one and has hematopoietic, hemofiltration, blood storage, and immune functions. As a new method of preserving the spleen, laparoscopic partial splenectomy (LPS) has been increasingly applied in clinical practice with people&#39;s deeper insights into minimally invasive treatment and the development of technical equipment. Compared with conventional open splenectomy, LPS can preserve normal spleen tissue as much as possible, decrease the occurrence of complications after total splenectomy, and reduce postoperative hospital stay. The bipolar radiofrequency excision hemostatic device used for LPS can solidify the splenic tissue and close the small blood vessels, which reduces the hemorrhage of the spleen cross-section and clears the operative field, thus achieving the ideal effect of &#34;bloodless partial splenectomy&#34;. Therefore, under the premise of strictly mastering the indications and fully understanding the vascular anatomy of the spleen, the application of the bipolar radiofrequency excision hemostatic&#160;device in LPS is worthy of clinical promotion.

The present protocol describes that bipolar radiofrequency device-assisted laparoscopic partial splenectomy (LPS) is safe and effective. A bipolar radiofrequency device in LPS can reduce intraoperative bleeding and achieve the clinical effect of a "bloodless spleen incision", which is worthy of clinical application.

Among the lymphatic system in the human body, the spleen is the most extensive one and has hematopoietic, hemofiltration, blood storage, and immune ...

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. 
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, ...

Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to the anatomical characteristics of the liver, with intraoperative hemorrhage being a primary concern. Intraoperative blood loss is the leading cause of conversion to open surgery; therefore, effective management of bleeding and hemostasis is crucial for a successful LAH.
The two-surgeon technique is proposed as an alternative to the traditional single-surgeon approach, with potential benefits in reducing intraoperative bleeding during laparoscopic hepatectomy. However, there remains a lack of evidence to determine which mode of the two-surgeon technique yields superior patient outcomes. Besides, to our knowledge, the LAH technique, which involves the use of a cavitron ultrasonic surgical aspirator (CUSA) by the primary surgeon while an ultrasonic dissector by the second surgeon, has been rarely reported before.
Herein, we present a modified, two-surgeon LAH technique, wherein one surgeon employs a CUSA while the other uses an ultrasonic dissector. This technique is combined with a simple extracorporeal Pringle maneuver and low central venous pressure (CVP) approach. In this modified technique, the primary and secondary surgeons utilize a laparoscopic CUSA and an ultrasonic dissectorconcurrently to achieve precise and expeditious hepatectomy. A simple extracorporeal Pringle maneuver, combined with the maintenance of low CVP, is employed to regulate the hepatic inflow and outflow in order to minimize intraoperative bleeding. This approach facilitates the attainment of a dry and clean operative field, which allows for the precise ligation and dissection of blood vessels and bile ducts. The modified LAH procedure is simpler and safer due to its effective control over bleeding as well as the seamless transition between the roles of primary and secondary surgeons. It holds great promise for future clinical applications.

Here, we present a protocol to perform a modified laparoscopic anatomic hepatectomy using improved techniques and instruments.

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to ...

Strategies for Efficient Vascular Anastomosis in Mouse Liver Transplantation

Vascular Reconstruction with the Cuff Technique in Mouse Orthotopic Liver Transplantation

Mouse orthotopic liver transplantation is an effective methodology for investigating the underlying mechanisms of liver ischemia and reperfusion injury. However, the technical challenges pose a barrier to utilizing this valuable experimental model and passing on these skills to the next generation. The most challenging aspect of this procedure is vascular reconstruction, including the portal vein (PV), infrahepatic inferior vena cava (IHIVC), and suprahepatic inferior vena cava. The use of plastic cuffs, rather than sutures, allows for smoother PV and IHIVC reconstruction. Vessels are reconstructed by attaching a cuff made from an intravenous catheter to the tip of the graft vessel and interposing the cuff into the recipient vessel. The two most crucial aspects are properly visualizing the inner lumen of the vessel and avoiding the use of excessive force. Our aim is to provide a technical overview of vascular reconstructions using the cuff technique in recipient surgery. These technical tips for the cuff technique are expected to help microsurgeons facilitate vascular reconstruction and advance their research.

Author Spotlight: Exploring Cold Ischemia and Warm Reperfusion Injury in Fatty Liver Transplantation

This protocol provides technical information for vessel reconstruction using the cuff technique in mouse orthotopic liver transplantation.

Mouse orthotopic liver transplantation is an effective methodology for investigating the underlying mechanisms of liver ischemia and reperfusion injury. ...

Laparoscopic Splenectomy with Pericardial Devascularization for Hypersplenism and Esophageal Variceal Hemorrhage Due to Portal Hypertension

Hypersplenism and esophageal variceal hemorrhage caused by portal hypertension are common and serious complications of decompensated cirrhosis. In recent years, with the widespread application of various therapeutic methods such as drugs, endoscopy, splenic artery embolization, transjugular intrahepatic portal shunt, and liver transplantation, the role of surgery in the treatment of portal hypertension has gradually diminished, and the indications for surgical treatment have become more strictly defined. However, according to the clinical practice in China, surgical treatment of portal hypertension still holds an important role that other treatments cannot fully replace. In fact, surgical treatment of portal hypertension is widely performed in hospitals at all levels in China, saving numerous lives. Splenectomy combined with pericardial devascularization (SPD) is the most common surgical method for treating hypersplenism and esophageal variceal hemorrhage caused by portal hypertension. Long-term clinical practice has proven that SPD is a safe and effective treatment for hypersplenism and esophageal variceal rupture and hemorrhage due to portal hypertension. With the rapid development of laparoscopic techniques, the minimally invasive advantages of laparoscopic splenectomy combined with pericardial devascularization (LSPD) have become increasingly evident. However, the successful performance of LSPD mainly depends on the skill and proficiency of the surgeon. In this context, this article presents detailed techniques for LSPD.

With the rapid advancement of laparoscopic techniques, the minimally invasive benefits of laparoscopic splenectomy combined with pericardial devascularization have become increasingly evident. In this context, we present a protocol for performing laparoscopic splenectomy alongside pericardial devascularization to treat hypersplenism and esophageal variceal hemorrhage resulting from portal hypertension.

Hypersplenism and esophageal variceal hemorrhage caused by portal hypertension are common and serious complications of decompensated cirrhosis. In recent ...

Vessel-sparing Excision and Primary Anastomosis

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