This work was supported by grants from the Basic and Applied Basic Research Project of Guangzhou Basic Research Program (No. 2023A04J1917), the Fundamental Research Funds for the Central Universities (No. 21622312), the Special Foundation for Scientific Research Development of the Affiliated Shunde Hospital of Jinan University (No. 202101004), and Guangdong Basic and Applied Research Foundation (No. 2022A1515012581).

The surgical procedure was approved by the institutional review board at The First Affiliated Hospital of Jinan University. The patient, a 58-year-old female, was admitted with a chief complaint of &#34;abdominal pain for 2 months.&#34; A computed tomography (CT) scan conducted at an external hospital revealed a space-occupying lesion in the distal pancreas, raising concerns about the possibility of pancreatic carcinoma. Before the surgery, the patient provided written informed consent. The surgical tools and equipment used for this procedure are listed in the Table of Materials.
1. Preoperative preparation
<ol>
	<li>Prior to the surgery, conduct preoperative blood tests, including a complete blood count, liver and renal function tests, coagulation function test, and serum tumor biomarkers detection10,11. 
	NOTE: The blood sample was drawn by the nurse and sent to the laboratory, where various blood tests were performed, and the results were reported. Serum tumor biomarkers detection revealed elevated levels of carcinoembryonic antigen (48.34 ng/mL) and carbohydrate antigen 125 (131.1 U/mL)10,11.</li>
	<li>Perform preoperative electrocardiogram, abdominal magnetic resonance imaging (MRI), chest CT, and other related examinations10,11. 
	NOTE: In this study, the patient underwent abdominal MRI in the Medical Imaging Department. The results of abdominal MRI indicated that the size of the pancreatic body and tail mass is approximately 3.5 cm &#215; 3.0 cm &#215; 3.0 cm, suggesting an epithelial-derived malignant tumor (Figure 1).</li>
</ol>
2. Surgical technique
<ol>
	<li>After tracheal intubation and general anesthesia (following institutionally approved protocols)12, place the patient in a supine position with their legs apart. Perform routine disinfection with povidone iodine solution. 
	NOTE: The chief surgeon is located on the right side of the patient, the assistant is on the left side, and the endoscope holder is positioned between the patient&#39;s legs.</li>
	<li>Make a longitudinal incision of approximately 1 cm through the umbilicus, insert a pneumoperitoneum needle, inject carbon dioxide gas to maintain an abdominal pressure of 12 mmHg, and place a 10 mm trocar and a 30-degree laparoscope.</li>
	<li>Explore the abdominal cavity to determine if there is any tumor metastasis. Under direct vision, place a 5 mm trocar in the left middle abdomen and right upper abdomen, respectively, and a 10 mm trocar in the left upper abdomen and right middle abdomen, respectively (Figure 2).</li>
	<li>Use non-invasive forceps to lift and pull the stomach toward the cephalic side, and cut the gastrocolic and gastrosplenic ligaments at the upper edge of the transverse colon using an ultrasonic-harmonic scalpel (Figure 3).</li>
	<li>Separate the stomach and spleen by ligating and severing the left gastroepiploic vessels, short gastric vessels, posterior gastric vessels, and left subphrenic vessels near the gastric wall. Enter the lesser omental sac and expose the pancreas. Explore the condition of the pancreatic tumor (Figure 2).</li>
	<li>Separate and expose the common hepatic artery, and remove the lymph nodes adjacent to the common hepatic artery. Suspend the common hepatic artery, separate and expose the celiac trunk and the left gastric artery, and dissect the surrounding lymph nodes (Figure 4).</li>
	<li>Incise the retroperitoneum from the pancreatic neck to the pancreatic tail at the lower margin of the pancreas, and remove the surrounding lymph nodes. Continue to incise the anterior layer of the left Gerota fascia at the lower margin of the pancreas to reveal the left renal vein. Peel the anterior layer of Gerota fascia from the surface of the left kidney along the left renal vein (Figure 5).</li>
	<li>Lift the distal pancreas toward the cephalic side to expose the superior mesenteric artery (SMA) and abdominal aorta, and dissect the surrounding lymph nodes at the same time (Figure 5). Separate and expose the superior mesenteric vein (SMV) at the lower margin of the pancreatic neck, and separate the retropancreatic tunnel along the surface of the SMV and portal vein.</li>
	<li>Sever the pancreas at the neck with a linear stapling device (Figure 6 and Figure 7). Dissect and expose the splenic vein, ligate and sever the root of the splenic vein (Figure 7). Dissect and expose the splenic artery, and remove the surrounding lymph nodes. Then, ligate and cut off the root of the splenic artery (Figure 4).</li>
	<li>Lift the pancreas and the anterior layer of the Gerota fascia toward the cephalic side to expose the left adrenal vessel and sever it (Figure 5). Continue to peel off the anterior layer of the Gerota fascia and the left adrenal gland upwards (Figure 5 and Figure 8).</li>
	<li>Above the pancreas, cut off the posterior peritoneum from right to left along the stomach wall. Clear the connective tissues between the abdominal aorta and the left kidney along the left crus of diaphragm. Sever the Gerota fascia tissues at the upper margin of the left adrenal gland (Figure 8).</li>
	<li>Release the spleen by severing the ligaments and adhesions around the spleen, and ultimately remove the distal pancreas, the anterior layer of the Gerota fascia, the left adrenal gland, and the spleen as a whole (Figure 8). Place the excised specimen into a specimen bag.</li>
	<li>Irrigate the abdominal cavity with sterile distilled water. Carefully examine the surgical field for active bleeding, pancreatic leakage, and gastrointestinal collateral injury. Place a drainage tube beside the incisal margin of the pancreas.</li>
	<li>Extend the umbilical incision to about 5 cm in length, cut the abdominal wall layer by layer, and take out the specimen. Send the specimen for intraoperative rapid frozen pathological examination to see whether there is cancer at the incisal margin of the pancreas (Figure 9).</li>
	<li>Check the number of surgical instruments and gauzes, and remove the trocars under direct vision. Finish the operation after suturing the abdominal wall incisions using 5-0 polypropylene suture.</li>
</ol>
3. Postoperative procedures
<ol>
	<li>Send the patient back to the ward safely after resuscitation.</li>
	<li>Administer intravenous antibiotics and somatostatin after the surgery.</li>
	<li>Start a fluid diet on the first day after surgery.</li>
	<li>Send the abdominal drainage fluid to the laboratory every day to check the amylase concentration.</li>
	<li>Remove the abdominal drainage tube on the fourth day after surgery.</li>
</ol>

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The authors have nothing to disclose.

DPS has been widely used as the standard radical surgery for distal pancreatic carcinoma1,2. However, due to the highly invasive nature of pancreatic cancer, it is easy for the tumor to grow to the edge of the pancreas and even break through the surface of the pancreas. Meanwhile, accompanying chronic pancreatitis makes the boundary between the pancreas and the surrounding tissues unclear. Therefore, it is difficult to achieve R0 resection during conventional sur...

Conventional distal pancreatosplenectomy (DPS) has traditionally been the standard surgical procedure for distal pancreatic carcinoma1,2. Distal pancreatic carcinoma is a highly invasive tumor that easily infiltrates into retroperitoneal tissues. Simultaneously, pancreatic cancer is often accompanied by chronic pancreatitis, making the boundary between the pancreas and adjacent tissues unclear. Consequently, during conventional DPS, there is a risk of tumor cells spreading along the direction of blood circulation and lymphatic return. In addition to the inherent inflammation associated with pancreatic cancer, achieving R0 resection is challenging, leading to a relatively low postoperative survival rate for patients3.
With the advancement of surgical techniques and a deeper understanding of the pancreatic lymphatic system, the high positive rate of the surgical margin and incomplete lymph node dissection in conventional DPS have garnered more attention. In response, radical antegrade modular pancreatosplenectomy (RAMPS) has emerged to address these challenges3,4. RAMPS involves the complete removal of tissues around the body and tail of the pancreas, including the tumor, to ensure a negative incisional margin and thorough dissection of lymph nodes in N1 nodes, the superior mesenteric artery (SMA), and the anterior and left of the celiac trunk3,4.
In 2003, Strasberg first reported RAMPS3. With the development of minimally invasive surgical techniques, there have been sporadic reports of laparoscopic RAMPS (L-RAMPS) in recent years. L-RAMPS is preliminarily considered technically safe and feasible in oncology5,6,7,8,9. However, due to technical difficulties and a lack of supporting evidence for clinical application, only a few institutions are currently conducting L-RAMPS. In light of this situation, this article presents the techniques of laparoscopic posterior radical antegrade modular pancreatosplenectomy (L-pRAMPS) in detail, holding great promise for future clinical application.

<table><tbody><tr><td>10-mm trocar</td><td>Xiamen Surgaid Medical Device Co., LTD</td><td>NGCS 100-1-10</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>12-mm trocar</td><td>Xiamen Surgaid Medical Device Co., LTD</td><td>NGCS 100-1-12</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>5-mm trocar</td><td>Xiamen Surgaid Medical Device Co., LTD</td><td>NGCS 100-1-5</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>Hem-o-lok</td><td>America Teleflex Medical Technology Co., LTD</td><td>544240</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>Linear stapling device</td><td>America Ethicon Medical Technology Co., LTD</td><td>PSEE60A</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>Pneumoperitoneum needle</td><td>Xiamen Surgaid Medical Device Co., LTD</td><td>NGCS 100-1</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>Suction and irrigation tube</td><td>Tonglu Hengfeng Medical Device Co., LTD</td><td>HF6518.035</td><td>Sterile,dry heat sterilized, reusable</td></tr><tr><td>Ultrasounic-harmonic scalpel</td><td>Chongqing Maikewei Medical Technology Co., LTD</td><td>QUHS36S&amp;nbsp;</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr></tbody></table>

laparoscopic posterior radical antegrade modular pancreatosplenectomy for distal pancreatic carcinoma

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

The surgery proceeded smoothly, and the intraoperative rapid frozen pathological examination indicated the absence of cancer at the incisal margin of the pancreas. Throughout the surgery, the patient&#39;s vital signs remained stable, and the anesthesia was effective. The operation duration was 150 min, with an intraoperative blood loss of 80 mL. Anal exhaust occurred 32 h postoperatively. There were no complications such as abdominal hemorrhage, pancreatic leakage, abdominal infection, or incision infection. The postope...

Read this Scientific Article Protocol about Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma at JoVE.com

Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma

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

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

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369 Views.  The First Affiliated Hospital, Jinan University. Gebruik een niet-invasieve pincet om de maag op te tillen en naar de cephalische zijde te trekken en snijd met een ultrasone harmonische scalpel de gastrocolische en gastromiltligamenten aan de bovenrand van de transversale dikke darm door. Om de maag en milt te scheiden, verbindt en snijdt u de linker gastro-epiploïsche vaten, korte maagvaten, achterste maagvaten en linker subfrene vaten nabij de maagwand door. Ga vervolgens de kleine of mentale zak binnen en onderzoek de toestand van de al...

Video: Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer: Surgical Planning and Technique

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), relying on collateral flow to the liver through the gastroduodenal artery (GDA). In the current manuscript, the technical conduct of robotic DP-CAR is outlined. The greater curve of the stomach is mobilized with care to avoid sacrificing the gastroepiploic vessels. The stomach and liver are retracted cephalad to facilitate dissection of the porta hepatis. The hepatic artery (HA) is dissected and encircled with a vessel loop. The gastroduodenal artery (GDA) is carefully preserved. The common HA is clamped and triphasic flow in the proper HA via the GDA is confirmed using intra-operative ultrasound. A retropancreatic tunnel is made over the superior mesenteric vein (SMV). The pancreas is divided with an endovascular stapler at the neck. The inferior mesenteric vein (IMV) and splenic vein are ligated. The HA is stapled proximal to the GDA. The entire specimen is retracted laterally with further dissection cephalad to expose the superior mesenteric artery (SMA). The SMA is then traced back to the aorta. The dissection continues cephalad along the aorta with the bipolar energy device used to divide the crural fibers and celiac nerve plexus. The specimen is mobilized from the patient's right to left until the origin of the celiac axis is identified and oriented towards the left. The trunk is circumferentially dissected and stapled. Additional dissection with hook cautery and the bipolar energy device fully mobilizes the pancreatic tail and spleen. The specimen is removed from the left lower quadrant extraction site and one drain is left in the resection bed. A final intra-operative ultrasound of the proper HA confirms pulsatile, triphasic flow in the artery and liver parenchyma. The stomach is inspected for evidence of ischemia. Robotic DP-CAR is safe, feasible and when used in conjunction with multi-modality therapy, offers potential for long-term survival in selected patients.

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection DP-CAR for Pancreatic Cancer: Surgical Planning and Technique

We present our operative approach to robot assisted distal pancreatectomy, splenectomy, and celiac axis resection (DP-CAR), demonstrating that the procedure is safe and feasible with proper planning, patient selection, and surgeon experience.

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), ...

Cancer Research

Modeling Stroke in Mice: Permanent Coagulation of the Distal Middle Cerebral Artery

Stroke is the third most common cause of death and a main cause of acquired adult disability in developed countries. Only very limited therapeutical options are available for a small proportion of stroke patients in the acute phase. Current research is intensively searching for novel therapeutic strategies and is increasingly focusing on the sub-acute and chronic phase after stroke because more patients might be eligible for therapeutic interventions in a prolonged time window. These delayed mechanisms include important pathophysiological pathways such as post-stroke inflammation, angiogenesis, neuronal plasticity and regeneration. In order to analyze these mechanisms and to subsequently evaluate novel drug targets, experimental stroke models with clinical relevance, low mortality and high reproducibility are sought after. Moreover, mice are the smallest mammals in which a focal stroke lesion can be induced and for which a broad spectrum of transgenic models are available. Therefore, we describe here the mouse model of transcranial, permanent coagulation of the middle cerebral artery via electrocoagulation distal of the lenticulostriatal arteries, the so-called &#8220;coagulation model&#8221;. The resulting infarct in this model is located mainly in the cortex; the relative infarct volume in relation to brain size corresponds to the majority of human strokes. Moreover, the model fulfills the above-mentioned criteria of reproducibility and low mortality. In this video we demonstrate the surgical methods of stroke induction in the &#8220;coagulation model&#8221; and report histological and functional analysis tools.

Various murine models of middle cerebral artery occlusion (MCAO) are widely used in experimental brain research. Here, we demonstrate the model of transcranial permanent distal MCAO which produces consistent cortical infarction of a size corresponding to damage imposed by the majority of human ischemic strokes.

Stroke is the third most common cause of death and a main cause of acquired adult disability in developed countries. Only very limited therapeutical ...

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota&#39;s fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota&#8217;s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (&#62;1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota&#8217;s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...

DIPLOMA Approach for Standardized Pathology Assessment of Distal Pancreatectomy Specimens

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignant cancers. A minority (20%) of PDACs are found in the pancreatic body and tail. Accurate pathology assessment of the pancreatic specimen is essential for providing prognostic information and it may guide further treatment strategies. The recent 8th edition of the American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) staging system for pancreatic tumors has incorporated significant changes to tumor (pT) stage, which is predominantly based on tumor size. This change emphasizes the importance of careful block selection. Owing to the greater prevalence of tumors in the head of the pancreas, efforts are made to standardize the assessment of pancreatoduodenectomy specimens. However, consensus regarding the macroscopic assessment of distal (i.e., left) pancreatectomy specimens is lacking. The DIPLOMA approach includes the standardized measurement of pancreas and other resected organs, inking of relevant surgical margins and anatomical surfaces without removing covering layers of fat, measurement of tumor size (for T-stage), together with assessment of splenic vessel involvement (and other organs if present). All relevant margins are assessed, and relevant blocks are selected to confirm these parameters microscopically. The current protocol describes a standardized approach to the macroscopic assessment of distal pancreatectomy specimens. This approach was developed during several meetings with pathologists and surgeons during the preparation phase for an international multicenter trial (DIPLOMA, ISRCTN44897265), which focuses on radicality of distal pancreatectomy for pancreatic ductal adenocarcinoma. This standardized approach can be instrumental in the design of studies and will uniform reporting on the outcomes of distal pancreatectomy. The described technique is used in the DIPLOMA trial for pancreatic ductal adenocarcinoma but may also be useful for other indications.

The current study highlights a standardized approach to the macroscopic assessment of distal pancreatectomy specimens for pancreatic ductal adenocarcinoma, with special emphasis on the measurement of pancreatic dimensions and those of other organs, inking of margins, measurement of tumor size and proximity to margins, lymph node sampling and block selection.

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignant cancers. A minority (20%) of PDACs are found in the pancreatic body and tail. ...

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 ...

Technical Modification of the Terminal Ureter During Total Transperitoneal Laparoscopic Nephroureterectomy for Upper Urinary Tract Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) accounts for 5%&ndash;10% of all urothelial tumors. Radical nephroureterectomy is the standard treatment procedure. At present, different choices still exist for treating the ureteral end during laparoscopic ureteral bladder sleeve resection. Our center has adopted a new method for treating the ureteral end. This new method can increase the operating space and reduce the difficulty of the surgery compared with current methods.

Here, we present a protocol to increase the surgical field of view and reduce the difficulty of total transperitoneal laparoscopic nephroureterectomy surgery by precutting the umbilical ligament before treating the terminal ureter.

Upper tract urothelial carcinoma (UTUC) accounts for 5%&ndash;10% of all urothelial tumors. Radical nephroureterectomy is the standard treatment ...

Posterior Approach for Debridement of the Psoas Abscess

This method focuses on outlining a safe zone for irrigation and debridement of a psoas abscess through a posterior approach. Initially, an anterior approach to the spine was performed to ensure that the anterior longitudinal ligament and the psoas muscle could be visualized. All the abdominal organs were removed. Subsequently, a posterior approach was performed to remove the paraspinal muscles from L1&#8211;L5. The transverse processes, pars interarticularis and lamina of L1&#8211;L5 were identified. The exiting nerve root was identified between the transverse processes and followed into the substance of the psoas muscle. Using the anterior and posterior approach, the lumbar plexus was isolated from the substance of the psoas muscle. Before and after various steps of dissection, digital photographs were obtained. These images were uploaded into ImageJ and multiple measurements, including the distance between the lateral superior and inferior tip of each TP to the most lateral region of the plexus, the distance between the lateral superior and inferior tip of the TP to the lateral edge of the psoas, and the width of the lumbar plexus were recorded. The safe zone for entering the substance of the psoas muscle was defined between the lateral edge of the psoas muscle and the lateral edge of the lumbar plexus. The relationship of this interval to the tip of the transverse process at each level was measured and reported.

This is a cadaveric study investigating the landmarks for the posterior approach for irrigation and debridement of the psoas abscess. The interval between the transverse processes (TP) was used to access the substance of the psoas muscle.

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

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein&#160;(SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope.
The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

With advancements in laparoscopic techniques, laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been widely recognized. However, owing to several technical difficulties in this procedure, the artery-first approach in L-RAMPS still remains uncommon. Here, we developed the dorsal-caudal artery approach for L-RAMPS, which might be safe and beneficial for pancreatic neck tumors.

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who ...

Robotic Spleen-Preserving Distal Pancreatectomy: The Warshaw and Kimura Techniques

Spleen-preserving distal pancreatectomy offers an alternative surgical approach to the traditional distal pancreatectomy combined with splenectomy for removing benign and low-grade malignant lesions in the distal pancreas, avoiding complications associated with splenectomy. This procedure can be accomplished either by resecting and ligating the splenic vessels (Warshaw technique) or by preserving them (Kimura technique). Currently, the widespread use of minimally invasive surgery has established laparoscopic and robotic approaches for spleen-preserving distal pancreatectomy as valid and safe options for treating such conditions. Our protocol aims to describe how the Warshaw and Kimura techniques of spleen-preserving distal pancreatectomy can be performed robotically. The first patient is a 36-year-old female with a neuroendocrine tumor (NET) in the pancreatic body who underwent a spleen-preserving distal pancreatectomy with the ligation of the splenic vessels (WT). The second patient is a 76-year-old male with chronic pancreatitis presenting with a dilated main pancreatic duct in the tail of the pancreas who underwent a spleen-preserving distal pancreatectomy with a vessel-preserving approach (KT).

Here, we present a step-by-step protocol of robotic spleen preserving distal pancreatectomy, with and without preserving the splenic vessels (i.e., the Kimura and Warshaw techniques, respectively).

Spleen-preserving distal pancreatectomy offers an alternative surgical approach to the traditional distal pancreatectomy combined with splenectomy for ...

Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma

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