This research was supported by the Key R&#38;D Projects Medical and Health Key Technology Research and Application Program in Guangzhou, China (Project No. 202206010104).

All laparoscopic surgical procedures and postoperative treatments in this study were performed in accordance with the guidelines established by the Laparoscopic Operation Ethics Committee of the First Affiliated Hospital of Sun Yat-Sen University, China. The research protocol and content were explained to all patients, and informed consent was obtained. This study was conducted under the guidance of the ethics committee of the hospital.
1. Case inclusion criteria
<ol>
	<li>Include patients who have been diagnosed with sigmoid colon or high rectal adenocarcinoma (10-15 cm from the anus), who have undergone single-surgeon, three-port laparoscopy with NOSES in the study. Adopt the following inclusion criteria:
	<ol>
		<li>Ensure diagnosis of sigmoid colon or high rectal adenocarcinoma by preoperative colonoscopy and pathological examinations.</li>
		<li>Ensure that enhanced computed tomography (CT) and magnetic resonance imaging (MRI) tests do not reveal any tumor invasion into the surrounding tissues, or bowel obstruction due to distant metastasis.</li>
		<li>Ensure that the tumor circumference is &#60;5 cm.</li>
		<li>Ensure the T stage is &#8804;T4a.</li>
		<li>Ensure that the patients have no major organ diseases and can tolerate surgical treatment.</li>
		<li>Ensure that the patients do not have excessive obesity or mesenteric hypertrophy (BMI &#60; 35 kg/m2).</li>
		<li>Ensure that the patients have not undergone any previous abdominal surgery and do not have pelvic floor adhesions.</li>
	</ol>
	</li>
</ol>
2. Preparation for surgery
<ol>
	<li>Administer oral laxatives and slag-free semi-liquid or liquid food and oral compound polyethylene glycol electrolyte powder (137.12 g) 3 days before the operation to prepare the patients for intestinal surgery.</li>
	<li>Perform an enema the night before and early in the morning of surgery.</li>
	<li>Place the patient in a modified lithotomy position, with the head lowered 15&#176;-20&#176; and the body tilted 15&#176; on the right side.</li>
</ol>
3. Surgical procedure
<ol>
	<li>To perform the three-hole trocar insertion, make a 10 mm incision below the umbilicus and insert a 10 mm trocar. Insert a 12 mm trocar into a 12 mm incision above the line connecting the right umbilicus and the anterior superior iliac spine. Next, insert a 5 mm trocar into a 5 mm incision above the right flat umbilicus. These latter two holes are considered the operating holes.</li>
	<li>After a routine inspection of the abdominal cavity, examine the upper abdominal liver and diaphragmatic peritoneum and check the abdominal cavity counterclockwise. Probe the location of the tumor and adjacent structures. Use anastomosis needles to suspend the uterus (in female patients) to the front of the abdominal wall to expand the surgical field, assist single-surgeon operation, and facilitate the removal of specimens through the vagina and insertion of the stapler seat.</li>
	<li>Dissociate the sigmoid colon and its mesentery, usually done by releasing the left lateral side first, or use a medial dissociation approach, to expose the dissection plane between the Toldt and Gerota fascia. 
	NOTE: However, due to mesangial hypertrophy or lack of help from an assistant, fully exposing the operating field may be challenging. Therefore, the lateral separation approach was preferred in this study.</li>
	<li>Enlarge the cephalic space of Toldt and ligate the inferior mesenteric artery and vein. After releasing the lateral side of the sigmoid mesocolon, adopt the medial approach. Next, lift the mesentery with gastric forceps to expose the mesenteric junction, dissociating it from bottom to top until the horizontal segment of the duodenum is reached, including the dissection of lymph nodes in 253 and 216 groups. After exposing the inferior mesenteric artery, ligate the vessels to expand the Toldt&#39;s space until the lower part of the pancreas is reached, and then ligate the inferior mesenteric vein at a high position.</li>
	<li>Expand the Toldt&#39;s space caudally and pull the inferior mesangium up freely. Pay attention to the movements of the left hand: perform micro-external rotation of the intestinal forceps and pull the proximal colon backward and upward. Expose the hypogastric nerve while protecting it under appropriate tension. After adequate separation of the mesentery, according to the distance from the tumor site, separate the mesentery below the rectum for excision, resulting in a naked intestine. 
	NOTE: Since the lateral mesentery is dissociated first, when the inferior mesentery is released, the sigmoid colon can be lifted smoothly using gastric forceps, properly exposing to show the tension.</li>
	<li>To determine the extent of bowel resection, first prepare an 8-10 cm length of silk thread in vitro, and mark the position of the proximal resection of the intestinal tube with the silk thread on the upper edge of the tumor. Dissociate the proximal bowel canal and expose it using an ultrasonic scalpel. Use an endoscopic linear cut stapler to sequentially transect the proximal and distal ends of the naked intestinal tube.</li>
	<li>Insertion of the stapler anvil seat and specimen removal
	<ol>
		<li>Ensure that the distal rectal stump is flushed when removing the specimen from the rectum. Incise the distal rectal stump and place a clean endoscopic gauze under it to prevent contamination of the surgical field.</li>
		<li>When the specimen is taken out from the vagina, have the assistant irrigate the vagina, and then insert an intestinal pressure plate. Next, make a 3-4 cm incision in the vagina under the guidance of the intestinal pressure plate. Repeatedly disinfect the rectum or vagina with iodophor gauze.</li>
		<li>Insert a specimen bag into the abdominal cavity through the 12 mm trocar as protection during specimen retrieval to prevent tumor seeding or contamination of the rectum or vagina. During this process, place the staple anvil first and then take out the specimen to avoid possible contamination of the staple anvil.</li>
	</ol>
	</li>
	<li>Sutures of the vaginal wall and rectal stump
	<ol>
		<li>Suture the vaginal wall directly with 3-0 antibacterial polydioxanone. After the rectal stump is sutured, lift the thread and close the rectal stump again with an endoluminal cutting and closure device to avoid the possibility of contamination and anastomotic leakage.</li>
	</ol>
	</li>
	<li>Placement of the stapler seat into the proximal bowel
	<ol>
		<li>Incise the proximal intestinal canal, enlarge a 2-3 cm incision, and routinely sterilize it with iodophor gauze. Place an anvil and suture the intestinal canal without knots with 3-0 polyglactin.</li>
	</ol>
	</li>
	<li>Bowel anastomosis and reinforced stitching
	<ol>
		<li>Perform routine end-to-end anastomosis of the bowel through the anus. Insert the ring stapler trigger handle through the anus, pierce the center piercing device of the stapler trigger handle, connect the center rod of the proximal stapler to the nail seat, and rotate the intestinal wall near the proximal and distal ends.</li>
		<li>Press the anastomotic wrench tightly to complete the cutting and anastomosis.</li>
		<li>Suture the full circumference of the anastomosis in a 4-0 knot-free pattern.</li>
	</ol>
	</li>
	<li>Flush the abdominal cavity, place a drainage tube, and place a rubber tube on the left or right side of the pelvis.</li>
</ol>

<ol>
	<li>Wang, X. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Natural Orifice Specimen Extraction Surgery: Colorectal. , (2018).</li><li>Jiang, Z., Chen, Y., Wang, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+radical+resection+of+lower+rectal+cancer+through+transrectal+valgus+resection+without+abdominal+incisions.">Laparoscopic radical resection of lower rectal cancer through transrectal valgus resection without abdominal incisions.</a> Chinese Journal of Gastrointestinal Surgery. 17 (5), 499-501 (2014).</li><li>Liu, Z., Wang, G., Wang, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+median+radical+resection+for+rectal+cancer+through+the+rectum+to+pull+the+specimen+out+of+the+anus+without+abdominal+incision.">Laparoscopic median radical resection for rectal cancer through the rectum to pull the specimen out of the anus without abdominal incision.</a> Chinese Journal of Colorectal Diseases. 2 (6), 331-332 (2013).</li><li>Omori, 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=Transumbilical+single-incision+laparoscopic+distal+gastrectomy+for+early+gastric+cancer.">Transumbilical single-incision laparoscopic distal gastrectomy for early gastric cancer.</a> Surgical Endoscopy. 25 (7), 2400-2404 (2011).</li><li>Song, J. 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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=Clinical+outcomes+of+reduced-port+laparoscopic+surgery+for+patients+with+sigmoid+colon+cancer:+surgery+with+1+surgeon+and+1+camera+operator.">Clinical outcomes of reduced-port laparoscopic surgery for patients with sigmoid colon cancer: surgery with 1 surgeon and 1 camera operator.</a> Annals of Coloproctology. 34 (6), 292-298 (2018).</li><li>Hu, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+total+mesorectal+excision+and+lateral+pelvic+lymph+node+dissection+for+locally+advanced+middle-low+rectal+cancer.">Robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced middle-low rectal cancer.</a> Journal of Visualized Experiments. (180), e62919 (2022).</li><li>Curcillo, P. G., Podolsky, E. R., King, S. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+road+to+reduced+port+surgery:+from+single+big+incisions+to+single+small+incisions,+and+beyond.">The road to reduced port surgery: from single big incisions to single small incisions, and beyond.</a> World Journal of Surgery. 35 (7), 1526-1531 (2011).</li><li>Inaki, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reduced+port+laparoscopic+gastrectomy+for+gastric+cancer.">Reduced port laparoscopic gastrectomy for gastric cancer.</a> Translational Gastroenterology and Hepatology. 1, 38 (2016).</li><li>Takahashi, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prospective+multicenter+study+of+reduced+port+surgery+combined+with+transvaginal+specimen+extraction+for+colorectal+cancer+resection.">Prospective multicenter study of reduced port surgery combined with transvaginal specimen extraction for colorectal cancer resection.</a> Surgery Today. 50 (7), 734-742 (2020).</li><li>Zhou, H., Xu, K., Sun, Q., Wang, Z., Ruan, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Three-port+laparoscopic+sigmoidectomy+with+natural+orifice+specimen+extraction-a+video+vignette.">Three-port laparoscopic sigmoidectomy with natural orifice specimen extraction-a video vignette.</a> Colorectal Disease. 22 (11), 1782-1783 (2020).</li><li>Kim, A. C., Rist, R. C., Zureikat, A. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technical+detail+for+robot+assisted+pancreaticoduodenectomy.">Technical detail for robot assisted pancreaticoduodenectomy.</a> Journal of Visualized Experiments. (151), e60261 (2019).</li></ol>

The authors have no conflicts of interest or financial relationships to disclose.

With the improvement in surgical skills and the advancement in surgical equipment, especially the development of visualization devices, robotic surgery is often considered a reasonable choice for complex procedures, such as lateral pelvic lymph node dissection7. Reduced-port laparoscopic surgery is an emerging procedure, characterized by reduced incision number and size, making the operation less invasive than traditional laparoscopic surgery8. In 2016, Inaki9 proposed that gastrectomy could be completed by porosity reduction laparoscopic surgery. Due to the lack of a long-term radical cure effect on gastric cancer, the laparoscopic procedure should be carefully selected. Prospective multicenter studies should be conducted to establish porosity reduction laparoscopic surgery as a true evidence-based practice, which not only addresses cosmetic concerns but also strikes the right balance between minimal invasiveness and radical cure. Takemasa10 prospectively analyzed the feasibility of pore-reducing laparoscopy combined with transvaginal specimen collection. Previous retrospective and prospective studies have confirmed that porosity reduction laparoscopic surgery with improved minimally invasive surgical skills is feasible in the radical resection of gastrointestinal tumors. In the present study, the statistical analysis of 10 patients (Table 1) showed that transvaginal specimen extraction (TVSE) combined with reduced port surgery (RPS) for colorectal cancer was feasible with less postoperative pain.
Due to the relatively fixed anatomical characteristics of the sigmoid colon and high rectum, radical operation for tumors at these sites can be combined with porosity reduction laparoscopic surgery and natural orifice specimen collection, effectively avoiding additional abdominal incisions. Minimally invasive laparoscopic surgery can effectively reduce postoperative pain and infection, as shown in Table 1. Patients can recover more quickly, and gastrointestinal function is quickly recovered, thereby shortening the hospital stay. However, single-surgeon, three-port, laparoscopic surgery for sigmoid colon or high rectal cancer with NOSES is associated with increased operation time and single-surgeon operational difficulty. Therefore, there is still controversy in the development of this technology. There are currently few reports available on this procedure; although relevant videos are available, no data analysis has been provided11. Some experts believe that adding one or two more trocars can form a good tension with the help of assistants, which is helpful to complete the operation faster, more effectively, and more safely. Compared with the traditional, five-port, laparoscopic surgery, the operative time and incision length are shorter in porosity reduction laparoscopic surgery6. 
There are still different opinions regarding this operation. First, the choice of surgical approach depends on whether it is focused on layer priority or blood vessel priority, and whether it adopts the medial or lateral approach or a combination of these two approaches. In this study, the surgeon first used the lateral (left) approach to facilitate the expansion of the rear Toldt's space when operated by one person, favoring the layer-priority surgical idea. 
Due to the limitations of single-surgeon three-hole operation, whether radical resection and lymph node dissection were sufficient remains unclear. We found that applying muscle relaxants and laparoscopic bowel forceps with a large opening and skillful gauze use might be required for the successful dissection of lymph nodes. 
Because the operation was suitable for sigmoid colon and high rectal cancer, it remains unclear whether there is a need for routine reinforcement and sutures after anastomosis. We believe that all anastomoses must be reinforced. Thus, we suggest adopting enforcement skills, including applying a laparoscopic mirror and performing reinforcement from the right to the left side. Reinforcement and suturing after anastomosis have been proposed by many experts. This operation's difficulty lies in treating the left "horn" and rear reinforcement and stitching. Our principle was to suture to the serosa or mesentery as far as possible, so it was not necessary to suture on the serosa. This experience has also withstood the test in clinical practice.
The principle of tumor-free asepsis was the focus of controversy when the NOSES operation was promoted. Based on our experience, we propose the following: (1) preoperative preparation should be sufficient to reduce the residual intestinal contents; (2) it is better to increase the frequency of use of linear cutting and closure devices and reduce the number of exposures of the bowel; (3) strict surgical indications, especially for patients with too large tumors and hypertrophic mesangium, when taking specimens could easily lead to tumor implantation. 
The placement and fixation of the staple anvil are difficult procedures and controversial points of this operation, since no assistant wasavailable to help fix the bowel. In addition, the operations could easily cause intra-abdominal contamination after a proximal intestinal incision.
Furthermore, when the staple anvil was placed in the abdominal cavity, the swing of the staple anvil might easily have led to a poor suture or incomplete exposure of the staple anvil, excessive cutting content during anastomosis, bleeding, and even fistula. In early practice, using the reverse puncture method to place the bowel could have led to the possibility of the anvil seat sliding into the proximal bowel, and it was not easy to push the anvil seat out by a single operation. In addition, it was difficult for one person to operate and fix the anvil when cutting it simultaneously. After reviewing the literature and studying the videos showing operations by other experts, we made some improvements by tying a No. 4 silk thread to the head end of the anvil before placing it in the abdominal cavity. When suturing the bowel, the thread had to be pulled out of the 12 mm trocar and lifted by the assistant to fix the anvil seat and the bowel, which was beneficial for suturing the bowel. Full-thickness purse-string suture around the staple anvil should be performed. While this method is rarely applied in current clinical operations, it is not complicated to perform and can be widely promoted in primary hospitals.
This operation also has certain limitations. Patients with obesity, excessive mesentery, intestinal edema, large tumor, and external tumor invasion are not suitable for this operation. Moreover, as mentioned before6, there are still problems such as surgical feasibility, tumor effectiveness, and training and education in porosity reduction laparoscopic surgery for malignant tumors. Similar to robotic pancreaticoduodenectomy (RPD), the most difficult pancreaticoduodenectomy, plotting a learning curve and establishing detailed rules are required12. Therefore, performing single-surgeon, three-port, laparoscopic surgery with NOSES requires training.
In summary, after a proper selection of patients and completion of long-term learning, surgeons with independent laparoscopic skills are suitable for performing this operation. This type of operation can reduce the trauma and achieve a more minimally invasive surgical treatment effect. Moreover, fixing the staple anvil by self-traction of external silk thread is simple and practical, and can be widely carried out in primary hospitals.

Natural orifice specimen extraction surgery (NOSES) is a modified approach to open surgery and conventional laparoscopic surgery, which relies on laparoscopic or robotic techniques. Its major advantages include a shorter length of hospital stay, reduction in wound complications and postoperative pain, faster recovery of bowel function, and better cosmetic and psychological effects. During NOSES, the surgical specimen is removed from a natural orifice (rectum or vagina) without requiring an auxiliary incision in the abdominal wall1. The &#34;Expert Consensus on NOSES for Colorectal Tumors (2019 Edition)&#34; recommends NOSES with the five-port technique2,3.
Omori et al.4 first applied reduced-port laparoscopic surgery (RPLS) to treat gastric cancer. In 2016, Kim et al. proposed that porosity reduction laparoscopic surgery was technically feasible and safe for the treatment of colorectal cancer and was comparable to conventional multiport laparoscopic surgery (CMLS) in terms of postoperative pain5. Oh et al., 2 years later, discussed the perioperative clinical outcomes of sigmoid colon cancer patients undergoing RPLS and traditional multiport laparoscopic surgery (MPLS); the results suggested that single-surgeon, three-port, laparoscopic radical sigmoidectomy was a feasible and safe surgical option for patients with favorable tumor characteristics6. However, the surgeries for sigmoid colon or high rectal cancer and specimen extraction through NOSES were mainly performed by one chief surgeon without the help of other assistants during intraoperative separation.
Currently, there are still only a few reports on NOSES. In NOSES, the placement and fixation of the anvil seat, which mainly depends on the tumor&#39;s location, the method of specimen collection, and the surgeon&#39;s ability, may be challenging. At present, a number of anvil fixation methods have been proposed, including the fixed extrusion method, reverse puncture method, snare ligation method, and manual purse-string suture method. Each method has its unique advantages and shortcomings. This study retrospectively analyzed the clinical data of 10 patients who underwent single-surgeon, three-port, laparoscopic surgery for sigmoid colon or high rectal cancer with NOSES to explore the safety and feasibility of this operation. The external anvil seat self-traction and fixation method was creatively improved, which could be used for manual purse-string suture fixation after placement of the anvil seat. Following the principle of tumor-free asepsis, the risk of anastomotic leakage and bleeding could be effectively avoided, and this surgicalprocedure could be widely promoted in primary hospitals.

<table><tbody><tr><td>antibacterial polydioxanone</td><td>Johnson &amp;amp; Johnson</td><td>8622H,SXPP1A403</td><td></td></tr><tr><td>Laparoscopic system</td><td>STORZ</td><td>26003BA</td><td></td></tr><tr><td>Ring stapler</td><td>Johnson &amp;amp; Johnson</td><td>CDH29A</td><td></td></tr><tr><td>Straight cut closure</td><td>Johnson &amp;amp; Johnson</td><td>EC45A</td><td></td></tr><tr><td>Trocar</td><td>Johnson &amp;amp; Johnson</td><td>B5LT,B11LT,B12LT</td><td></td></tr></tbody></table>

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.

Watch this Scientific Journal Video about Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction at JoVE.com

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

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, ...

clinical-application-single-surgeon-three-port-laparoscopic-resection

Universidad San Sebastian

Research

JoVE Journal

Medicine

266 Views.  Sun Yat-sen University. Ons protocol richt zich op de technische punten van resectie en reconstructie en verbetert het gebruik van de procedure voor het fixeren van de hechting van het koord nadat het proximale aambeeld in de buikholte is geplateerd. Het protocol is eenvoudig effectief uit te voeren, waardoor postoperatief anastomoselek en bloedingen als gevolg van overmatig intraoperatief anastomoseweefsel worden vermeden. En dit zou op grote schaal kunnen worden gepromoot in het primaire ziekenhuis. Visueel.

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

Single Port Donor Nephrectomy

In 2007, Rane presented the first single port nephrectomy for a small non-functioning kidney at the World Congress of Endourology. Since that time, the use of single port surgery for nephrectomy has expanded to include donor nephrectomy. Over the next two years the technique was adopted for many others types of nephrectomies to include donor nephrectomy. We present our technique for single port donor nephrectomy using the Gelpoint device. We have successfully performed this surgery in over 100 patients and add this experience to our experience of over 1000 laparoscopic nephrectomies. With the proper equipment and technique, single port donor nephrectomy can be performed safely and effectively in the majority of live donors. We have found that our operative times and most importantly our transplant outcomes have not changed significantly with the adoption of the single port donor nephrectomy. We believe that single port donor nephrectomy represents a step forward in the care of living donors.

Single port laparoscopic surgery is changing the standard of care in surgical care like nothing since the laparoscopic technique was introduced 20 years ago. We present out technique of single port donor nephrectomy using the Gelpoint device. We have successfully performed this surgery in 100 patients.

In 2007, Rane presented the first single port nephrectomy for a small non-functioning kidney at the World Congress of Endourology.  Since that time, the ...

Laparoscopic Left Liver Sectoriectomy of Caroli's Disease Limited to Segment II and III

Caroli's disease is defined as a abnormal dilatation of the intra-hepatica bile ducts: Its incidence is extremely low (1 in 1,000,000 population) and in most of the cases the whole liver is interested and liver transplantation is the treatment of choice. In case of dilatation limited to the left or right lobe, liver resection can be performed. For many year the standard approach for liver resection has been a formal laparotomy by means of a large incision of abdomen that is characterized by significant post-operatie morbidity. More recently, minimally invasive, laparoscopic approach has been proposed as possible surgical technique for liver resection both for benign and malignant diseases. The main benefits of the minimally invasive approach is represented by a significant reduction of the surgical trauma that allows a faster recovery a less post-operative complications.
This video shows a case of Caroli s disease occured in a 58 years old male admitted at the gastroenterology department for sudden onset of abdominal pain associated with fever (>38C&deg; ), nausea and shivering. Abdominal ultrasound demonstrated a significant dilatation of intra-hepatic left sited bile ducts with no evidences of gallbladder or common bile duct stones. Such findings were confirmed abdominal high resolution computer tomography. 
Laparoscopic left sectoriectomy was planned. Five trocars and 30&deg; optic was used, exploration of the abdominal cavity showed no adhesions or evidences of other diseases.
In order to control blood inflow to the liver, vascular clamp was placed on the hepatic pedicle (Pringle s manouvre), Parenchymal division is carried out with a combined use of 5 mm bipolar forceps and 5 mm ultrasonic dissector. A severely dilated left hepatic duct was isolated and divided using a 45mm endoscopic vascular stapler. Liver dissection was continued up to isolation of the main left portal branch that was then divided with a further cartridge of 45 mm vascular stapler.
At his point the left liver remains attached only by the left hepatic vein: division of the triangular ligament was performed using monopolar hook and the hepatic vein isolated and the divided using vascular stapler.
Haemostatis was refined by application of argon beam coagulation and no bleeding was revealed even after removal of the vascular clamp (total Pringle s time 27 minutes).
Postoperative course was uneventful, minimal elevation of the liver function tests was recorded in post-operative day 1 but returned to normal at discharged on post-operative day 3.

This video presents a case of laparoscopic left liver sectoriectomy perfomed in a 53 year old man suffering from Caroli's disease limited to segment II and III of the liver.

Caroli's disease is defined as a abnormal dilatation of the intra-hepatica bile ducts: Its  incidence is extremely low  (1 in 1,000,000 population) and in ...

Biology

Application of Hemostatic Devices in Laparoscopic Hepatectomy

Laparoscopic hepatectomy is considered a conventional method for treating benign and malignant liver diseases because it is a minimally invasive method. Despite its non-invasive aspect, bleeding and bile leakage occur in liver parenchyma tissue resection during the operation or in the post-operation period, indicating the requirement for high-grade hemostatic devices, such as ultrasonic surgical aspiration, bipolar electrocoagulation, etc. The lack of availability of these high-grade hemostatic devices prevents laparoscopic hepatectomy from becoming a generalized procedure in basic medical organizations. In view of the situation mentioned above, a suite of simple and easy hemostatic devices is developed in this protocol, which includes a harmonic scalpel, monopole electrocoagulation, and a single lumen catheter, to innovatively perform liver parenchyma tissue resection. First of all, the porta hepatis or hepatic pedicle is occluded intermittently by a single lumen catheter, followed by clamping for 15 min and releasing for 5 min. Subsequently, using the harmonic scalpel, clamping and crushing of the liver are done to cut off the hepatic parenchyma tissue and to reveal the intrahepatic arteries, veins, and bile ducts. Lastly, the bleeding spots are coagulated by using monopole electrocoagulation at each spot. Intrahepatic pipeline structures are then visible by using these methods, which could stop bleeding easily, reduce the incidence rate of bile leakage, and improve the safety and feasibility of laparoscopic hepatectomy. Therefore, the simple and easy hemostatic devices shown here are suitable for conducting procedures in primary medical institutions.

High-grade hemostatic devices are essential for laparoscopic hepatectomy. However, these devices are not generalized in basic medical organizations. Therefore, a suite of simple and easy hemostatic devices is shown in this article, which can make the laparoscopic hepatectomy easier to perform.

Laparoscopic hepatectomy is considered a conventional method for treating benign and malignant liver diseases because it is a minimally invasive method. ...

Cancer Research

Application of the En Bloc Concept Combined with Anatomic Resection in Laparoscopic Hepatectomy

Laparoscopic hepatectomy has been reported in many studies, and it is the mainstream method of liver resection. In some particular cases, such as when there are tumors adjacent to the cystic bed, surgeons cannot palpate the surgical margins through the laparoscopic approach, which leads to uncertainty about R0 resection. Conventionally, the gallbladder is resected first, and the hepatic lobes or segments are resected second. However, tumor tissues can be disseminated in the above cases. To address this issue, based on the recognition of the porta hepatis and intrahepatic anatomy, we propose a unique approach to hepatectomy combined with gallbladder resection by en bloc anatomic resection in situ. Firstly, after dissecting the cystic duct, without cutting the gallbladder primarily, the porta hepatis is pre-occluded by the single lumen ureter; secondly, the left hepatic pedicle is made free by the gap of the Laennec membrane and Hilar plate; thirdly, the assistant is asked to drag the fundus of the gallbladder, and the liver parenchyma tissue is resected using a harmonic scalpel along the ischemia line on the liver surface and intraoperative ultrasound. The whole middle hepatic vein (MHV) and its tributaries appear completely; lastly, the left hepatic vein (LHV) is disconnected, and the specimen is taken out from the abdominal cavity. The tumor, gallbladder, and other surrounding tissues are resected en bloc, which meets the tumor-free criterion, and a wide incisal margin and R0 resection are achieved. Therefore, the laparoscopic hepatectomy with the combination of the en bloc concept and anatomic resection is a safe, effective, and radical method with low postoperative recurrence and metastasis.

Numerous studies have demonstrated the advantages of anatomic resection. Nonetheless, whether anatomic resection can increase R0 resection rates remains controversial. Consequently, the present study describes an innovative procedure involving the en bloc concept combined with anatomic resection in laparoscopic hepatectomy, which can reduce postoperative recurrence and metastasis.

Laparoscopic hepatectomy has been reported in many studies, and it is the mainstream method of liver resection. In some particular cases, such as when ...

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 ...

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex procedures. The high-quality 3-D visual, multijoint arm and natural tremor filtration allow the surgeon to expose and dissect more accurately with minimal invasion. Total mesorectal excision is the standard surgical technique for the treatment of resectable rectal cancer. To reduce the lateral recurrence rate, lateral pelvic lymph node dissection can be performed, as it is a safe and feasible procedure for locally advanced middle-low rectal cancer with a high possibility of metastasis to the lateral lymph nodes. However, the complexity of the anatomic structures and the high postoperative complication rate limit its application. Recently, several surgeons have increasingly used robotic techniques for total mesorectal excision and lateral pelvic lymph node dissection. Compared with open and laparoscopic surgery, the robotic technique has several advantages, such as less blood loss, fewer blood transfusions, minimal trauma, shorter postoperative hospitalization, and quicker recovery. A robotic approach is generally regarded as a reasonable alternative for complicated procedures such as lateral pelvic lymph node dissection, although there are a limited number of high-quality prospective randomized controlled studies reporting direct evidence. Here, we provide the detailed steps of robot-assisted total mesorectal excision and lateral pelvic lymph node dissection performed at the First Affiliated Hospital of Xi&#39;an Jiaotong University.

The robotic technique described herein aims to detail a stepwise approach to robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced (T3/T4) rectal cancer located below the peritoneal reflection.

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex ...

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

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

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

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

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 ...

Advancing LRPS: Optimal Techniques for Challenging Liver Resections

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

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

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

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

Removal of Subcostal Specimen After Complete Portal Robotic Lobectomy

Subcostal Specimen Removal in Completely Portal Robotic Lobectomy

The Completely Portal Robotic Lobectomy (CPRL-4) technique is increasingly favored for lobectomy procedures due to its advancements over traditional robot-assisted lobectomy (RAL). CPRL-4 integrates a fourth robotic arm and CO2 insufflation, resulting in superior visualization within the intrathoracic cavity owing to enhanced lung deflation. While CPRL-4 effectively achieves pulmonary resection, extracting specimens typically necessitates an intercostal utility thoracotomy, which may pose risks. To address potential damage associated with this method, we introduced a subcostal trans-diaphragmatic access port during resection, later enlarging it for specimen removal post-lobectomy. This study evaluated the efficacy and feasibility of this subcostal trans-diaphragmatic specimen removal approach following CPRL-4 procedures for pulmonary malignancies, all performed by a single surgical team. The findings suggest that subcostal specimen removal post-CPRL-4 offers several advantages, including reduced risk of thoracotomy-related complications, making it a practical, feasible, and safe method. This innovation has the potential to improve outcomes and patient care in pulmonary malignancy surgeries significantly.

This protocol describes the removal of lung specimens following a completely portal robotic lobectomy. Determining the optimal location for specimen extraction is a pertinent question, as both intercostal and subcostal routes can serve as potential extraction paths following robotic or video-thoracoscopic lobectomy. We choose subcostal lung specimen removal over intercostal removal.

The Completely Portal Robotic Lobectomy (CPRL-4) technique is increasingly favored for lobectomy procedures due to its advancements over traditional ...

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

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