Name: modified single-loop reconstruction for pancreaticoduodenectomy
Uploaded: 2019-09-28T12:30:00
Description: Watch this Scientific Journal Video about Modified Single-Loop Reconstruction for Pancreaticoduodenectomy at JoVE.com

Niet van toepassing.

Dit protocol richt zich op de wederopbouwfase van PD met behulp van mSLR en volgt de richtlijnen van de ethische commissie van de Ruhr-Universiteit Bochum, Duitsland.
Opmerking: patiënten met een reseceer tumor van de pancreas hoofd, het papillaire gebied of ernstige refractaire chronische calcifying pancreatitis onderging pd. resectability was aanwezig als de tumor minder dan 50% contact had met de peripancreas slagaders en niet infiltreren in de portaal ader of de superieure mesenterische a...

<ol>
	<li>Cameron, J. L., He, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Two+thousand+consecutive+pancreaticoduodenectomies.">Two thousand consecutive pancreaticoduodenectomies.</a> Journal of American College of Surgeons. 220 (4), 530-536 (2015).</li><li>Keck, 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=Pancreatogastrostomy+Versus+Pancreatojejunostomy+for+RECOnstruction+After+PANCreatoduodenectomy+(RECOPANC,+DRKS+00000767):+Perioperative+and+Long-term+Results+of+a+Multicenter+Randomized+Controlled+Trial.">Pancreatogastrostomy Versus Pancreatojejunostomy for RECOnstruction After PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and Long-term Results of a Multicenter Randomized Controlled Trial.</a> Annals of Surgery. 263 (3), 440-449 (2016).</li><li>Deng, L. H., Xiong, J. J., Xia, Q. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Isolated+Roux-en-Y+pancreaticojejunostomy+versus+conventional+pancreaticojejunostomy+after+pancreaticoduodenectomy:+a+systematic+review+and+meta-analysis.">Isolated Roux-en-Y pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: a systematic review and meta-analysis.</a> Journal of Evidence Based Medicine. 10 (1), 37-45 (2017).</li><li>Klaiber, U., 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=Meta-analysis+of+complication+rates+for+single-loop+versus+dual-loop+(Roux-en-Y)+with+isolated+pancreaticojejunostomy+reconstruction+after+pancreaticoduodenectomy.">Meta-analysis of complication rates for single-loop versus dual-loop (Roux-en-Y) with isolated pancreaticojejunostomy reconstruction after pancreaticoduodenectomy.</a> British Journal of Surgery. 102 (4), 331-340 (2015).</li><li>Eshmuminov, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Systematic+review+and+meta-analysis+of+postoperative+pancreatic+fistula+rates+using+the+updated+2016+International+Study+Group+Pancreatic+Fistula+definition+in+patients+undergoing+pancreatic+resection+with+soft+and+hard+pancreatic+texture.">Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture.</a> HPB (Oxford). 20 (11), 992-1003 (2018).</li><li>Ke, S., 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=A+prospective,+randomized+trial+of+Roux-en-Y+reconstruction+with+isolated+pancreatic+drainage+versus+conventional+loop+reconstruction+after+pancreaticoduodenectomy.">A prospective, randomized trial of Roux-en-Y reconstruction with isolated pancreatic drainage versus conventional loop reconstruction after pancreaticoduodenectomy.</a> Surgery. 153 (6), 743-752 (2013).</li><li>El Nakeeb, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Isolated+Roux+loop+pancreaticojejunostomy+versus+pancreaticogastrostomy+after+pancreaticoduodenectomy:+a+prospective+randomized+study.">Isolated Roux loop pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a prospective randomized study.</a> HPB (Oxford). 16 (8), 713-722 (2014).</li><li>Tani, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Randomized+clinical+trial+of+isolated+Roux-en-Y+versus+conventional+reconstruction+after+pancreaticoduodenectomy.">Randomized clinical trial of isolated Roux-en-Y versus conventional reconstruction after pancreaticoduodenectomy.</a> British Journal of Surgery. 101 (9), 1084-1091 (2014).</li><li>Machado, M. C., da Cunha, J. E., Bacchella, T., Bove, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+modified+technique+for+the+reconstruction+of+the+alimentary+tract+after+pancreatoduodenectomy.">A modified technique for the reconstruction of the alimentary tract after pancreatoduodenectomy.</a> Surgery Gynecology Obstetrics. 143 (2), 271-272 (1976).</li><li>Aghalarov, I., Herzog, T., Uhl, W., Belyaev, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+modified+single-loop+reconstruction+after+pancreaticoduodenectomy+reduces+severity+of+postoperative+pancreatic+fistula+in+high-risk+patients.">A modified single-loop reconstruction after pancreaticoduodenectomy reduces severity of postoperative pancreatic fistula in high-risk patients.</a> HPB (Oxford). 20 (7), 676-683 (2018).</li><li>Marangoni, G., Morris-Stiff, G., Deshmukh, S., Hakeem, A., Smith, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+modern+approach+to+teaching+pancreatic+surgery:+stepwise+pancreatoduodenectomy+for+trainees.">A modern approach to teaching pancreatic surgery: stepwise pancreatoduodenectomy for trainees.</a> Journal of Gastrointestinal Surgery. 16 (8), 1597-1604 (2012).</li><li>. Pyloruserhaltende Duodenohemipankreatektomie nach Traverso-Longmire mit T-Drainage (pp-Whipple) Available from: <a target="_blank" href="https://www.webop.de/Allgemein-und-Viszeralchirurgie/Pankreas-und-Milz/Pyloruserhaltende-Duodenohemipankreatektomie-nach-Traverso-Longmire-mit-T-Drainage-pp-Whipple">https://www.webop.de/Allgemein-und-Viszeralchirurgie/Pankreas-und-Milz/Pyloruserhaltende-Duodenohemipankreatektomie-nach-Traverso-Longmire-mit-T-Drainage-pp-Whipple</a> (2019)</li><li>Machado, M. C., Machado, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Systematic+use+of+isolated+pancreatic+anastomosis+after+pancreatoduodenectomy:+Five+years+of+experience+with+zero+mortality.">Systematic use of isolated pancreatic anastomosis after pancreatoduodenectomy: Five years of experience with zero mortality.</a> European Journal of Surgical Oncology. 42 (10), 1584-1590 (2016).</li><li>Pescio, G., Cariati, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+reconstructive+method+after+pancreaticoduodenectomy:+the+triple+Roux+on+a+"P"+loop.+Rationale+and+radionuclide+scanning+evaluation.">A new reconstructive method after pancreaticoduodenectomy: the triple Roux on a "P" loop. Rationale and radionuclide scanning evaluation.</a> HPB Surgery. 9 (4), 223-227 (1996).</li><li>Kingsnorth, A. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+and+function+of+isolated+Roux+loop+pancreaticojejunostomy+after+Whipple's+pancreaticoduodenectomy.">Safety and function of isolated Roux loop pancreaticojejunostomy after Whipple's pancreaticoduodenectomy.</a> Annals of the Royal College of Surgeons of England. 76 (3), 175-179 (1994).</li><li>Jester, A. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Impact+of+Hepaticojejunostomy+Leaks+After+Pancreatoduodenectomy:+a+Devastating+Source+of+Morbidity+and+Mortality.">The Impact of Hepaticojejunostomy Leaks After Pancreatoduodenectomy: a Devastating Source of Morbidity and Mortality.</a> Journal of Gastrointestinal Surgery. 21 (6), 1017-1024 (2017).</li><li>Funovics, J. M., Zoch, G., Wenzl, E., Schulz, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Progress+in+reconstruction+after+resection+of+the+head+of+the+pancreas.">Progress in reconstruction after resection of the head of the pancreas.</a> Surgery Gynecology Obstetrics. 164 (6), 545-548 (1987).</li><li>Jover, J. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Results+of+defunctionalized+jejunal+loop+after+pancreaticoduodenectomy.">Results of defunctionalized jejunal loop after pancreaticoduodenectomy.</a> Cirurgia Espanola. 80 (6), 373-377 (2006).</li><li>Albertson, D. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreaticoduodenectomy+with+reconstruction+by+Roux-en-Y+pancreaticojejunostomy:+no+operative+mortality+in+a+series+of+25+cases.">Pancreaticoduodenectomy with reconstruction by Roux-en-Y pancreaticojejunostomy: no operative mortality in a series of 25 cases.</a> The Southern Medical Journal. 87 (2), 197-201 (1994).</li></ol>

Tot op heden draagt POPF aanzienlijk bij aan de postoperatieve morbiditeit na PD1.
Een mengsel van gal en pancreas SAP kan leiden tot wederzijdse activering van beide afscheidingen, het verhogen van hun nadelige effecten op de PJ of de HJ9,13,14,15,16. Cytotoxische activiteit van geactiveerde fosfolipase a2, ...

Pancreaticoduodenectomy (PD) wordt beschouwd als een verfijnde chirurgische ingreep. Hoewel de sterfte in de afgelopen decennia is afgenomen, blijft morbiditeit nog steeds hoog1. De meest frequente en gevreesde complicatie is de postoperatieve alvleesklier fistel (popf), die optreedt in meer dan 20% van de operaties2,3,4,5. POPF kan leiden tot daaropvolgende complicaties zoals hemorragie van de postpancreatectomie, vertraagde maaglediging, intraabdominale abces en sepsis. Verhoogde ziekenhuiskosten, langdurig verblijf in het ziekenhuis en vertraagde aanvang van chemotherapie bij kankerpatiënten hebben een dramatische sociaaleconomische impact2,3,4.
In de laatste decennia zijn verschillende chirurgische benaderingen geïntroduceerd om de frequentie en ernst van POPF te verminderen. Een daarvan is de dubbele lus reconstructie (DLR) met geïsoleerde Roux-en-Y loops voor de gal en alvleesklier anastomoses. Scheiden van pancreas sap van gal wordt gedacht aan het verminderen van de nadelige effecten van wederzijds geactiveerde afscheidingen op de pancreaticojejunostomy (PJ). De resultaten in de literatuur zijn bemoedigend6,7,8. De operatieve tijd wordt echter aanzienlijk verlengd met DLR4,9.
We introduceren hier de techniek van gemodificeerde single-loop reconstructie (mSLR) tijdens PD om de secretie van alvleesklier van gal te scheiden in vergelijking met de conventionele single-loop reconstructie (SLR, Figuur 1). Bij deze methode wordt een enkele lange dunne-darm lus gebruikt voor de bouw van de hepaticojejunostomy (HJ) en PJ. Een side-to-side anastomose tussen de afferente en efferente ledemaat van de HJ vergemakkelijkt geïsoleerde stroom van gal en pancreas afscheidingen. De eerste veelbelovende resultaten ter bevestiging van verminderde sterfte en morbiditeit bij patiënten met een hoog risico op pancreata werden gerapporteerd door onze groep in 201810.
Deze methode vermindert de ernst van de POPF door het scheiden van pancreas vloeistof en gal zonder verlenging van de duur van de operatie aanzienlijk in vergelijking met de dubbele-lus reconstructie.

<table>
	<tbody>
		<tr>
			<td>Alexis O XXL</td>
			<td>Applied medical</td>
			<td>C8405</td>
			<td></td>
		</tr>
		<tr>
			<td>Bauchtuch Gr&#252;n 10x90</td>
			<td>Nobatrast</td>
			<td>603219</td>
			<td>abdominal compress</td>
		</tr>
		<tr>
			<td>Bauchtuch Gr&#252;n 45x45</td>
			<td>Nobatrast</td>
			<td>607544</td>
			<td>abdominal compress</td>
		</tr>
		<tr>
			<td>GIA 60mm-3.8mm</td>
			<td>Covidien/Medtronic</td>
			<td>GIA6038S</td>
			<td></td>
		</tr>
		<tr>
			<td>GIA Loading Unit</td>
			<td>Covidien/Medtronic</td>
			<td>GIA6038L</td>
			<td></td>
		</tr>
		<tr>
			<td>OP-Flex Yankauer</td>
			<td>Unomedical</td>
			<td>34094182</td>
			<td>suction device</td>
		</tr>
		<tr>
			<td>Pr&#228;pariertupfer-Set</td>
			<td>Fuhrmann</td>
			<td>32019</td>
			<td>sterile swab</td>
		</tr>
		<tr>
			<td>Schlinggazetupfer 30x40</td>
			<td>Fuhrmann</td>
			<td>32016</td>
			<td>sterile swab</td>
		</tr>
		<tr>
			<td>Telescopic Smoke Pencil</td>
			<td>LiNA Medical</td>
			<td>SHK-TSP-CL</td>
			<td>electro cautery</td>
		</tr>
		<tr>
			<td>Thermocover ECO</td>
			<td>PEMAX</td>
			<td>TC43-75EC2</td>
			<td>bowel cover</td>
		</tr>
		<tr>
			<td>Whipple-Set</td>
			<td>M&#246;lnlycke</td>
			<td>97016042-00</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="4"></td>
		</tr>
		<tr>
			<td colspan="4">Drainages:</td>
		</tr>
		<tr>
			<td>Drainagebeutel</td>
			<td>Coloplast</td>
			<td>?</td>
			<td>drainagebag</td>
		</tr>
		<tr>
			<td>Silikon-Kapillardrainage</td>
			<td>AsidBonz</td>
			<td>551012</td>
			<td>capillary drainage</td>
		</tr>
		<tr>
			<td>Trichteransatz f&#252;r T-Rohr</td>
			<td>R&#252;sch</td>
			<td>333169-000025</td>
			<td>2,5 mm</td>
		</tr>
		<tr>
			<td>T-Rohr nach Kehr</td>
			<td>R&#252;sch</td>
			<td>423600-000025</td>
			<td>t-tube 2,5 mm</td>
		</tr>
		<tr>
			<td colspan="4"></td>
		</tr>
		<tr>
			<td colspan="4">Sutures:</td>
		</tr>
		<tr>
			<td>Ethiloop 2mm 2x45cm</td>
			<td>Ethicon</td>
			<td>EH387</td>
			<td>loop</td>
		</tr>
		<tr>
			<td>Mersilene 0 FSL</td>
			<td>Ethicon</td>
			<td>EH7637</td>
			<td>fixation of the drainage</td>
		</tr>
		<tr>
			<td>PDS 1 CT</td>
			<td>Ethicon</td>
			<td>PDP9234</td>
			<td>suturing of the fascia</td>
		</tr>
		<tr>
			<td>Vicryl 2-0 , 6x45cm</td>
			<td>Ethicon</td>
			<td>VCP1226</td>
			<td>for ligature</td>
		</tr>
		<tr>
			<td>Vicryl 2-0 SHplus, 8x70</td>
			<td>Ethicon</td>
			<td>VCP7850</td>
			<td>for ligature</td>
		</tr>
		<tr>
			<td>Vicryl 3-0 MH-1plus</td>
			<td>Ethicon</td>
			<td>VCP245</td>
			<td>subcutaneous suture</td>
		</tr>
		<tr>
			<td colspan="4"></td>
		</tr>
		<tr>
			<td colspan="4">Pancreatic anastomoses:</td>
		</tr>
		<tr>
			<td>Prolene 5-0 c1</td>
			<td>Ethicon</td>
			<td>8890</td>
			<td>6 x</td>
		</tr>
		<tr>
			<td>PDS 5.0 RB-1plus</td>
			<td>Ethicon</td>
			<td>X1153</td>
			<td>2 x Multipack</td>
		</tr>
		<tr>
			<td>Prolene 4-0 RB-1</td>
			<td>Ethicon</td>
			<td>8871</td>
			<td>2 x holding sutures</td>
		</tr>
		<tr>
			<td colspan="4"></td>
		</tr>
		<tr>
			<td colspan="4">Hepaticojejunostomy:</td>
		</tr>
		<tr>
			<td>Prolene 5-0 c1</td>
			<td>Ethicon</td>
			<td>8890</td>
			<td>2 x holding sutures</td>
		</tr>
		<tr>
			<td>PDS 5-0 c1</td>
			<td>Ethicon</td>
			<td>PDP1013</td>
			<td>7 x</td>
		</tr>
		<tr>
			<td>PDS 6-0 c1</td>
			<td>Ethicon</td>
			<td>PDP1012</td>
			<td>1 x mucosa fixation sutures</td>
		</tr>
		<tr>
			<td colspan="4"></td>
		</tr>
		<tr>
			<td colspan="4">Gastrojejunostomy:</td>
		</tr>
		<tr>
			<td>PDS 4-0 SH-1 plus</td>
			<td>Ethicon</td>
			<td>X1154</td>
			<td>1 x Multipack</td>
		</tr>
		<tr>
			<td colspan="4"></td>
		</tr>
		<tr>
			<td colspan="4">Jejuno-Jejunostomy</td>
		</tr>
		<tr>
			<td>Ligasure</td>
			<td>Covidien</td>
			<td>LS1520</td>
			<td></td>
		</tr>
		<tr>
			<td>PDS 5-0 RB-1 plus</td>
			<td>Ethicon</td>
			<td>X1153</td>
			<td>1 x Multipack</td>
		</tr>
		<tr>
			<td>Prolene 2-0 SH</td>
			<td>Ethicon</td>
			<td>8833</td>
			<td>Vessel-suture, etc.</td>
		</tr>
		<tr>
			<td>Prolene 3-0 SH</td>
			<td>Ethicon</td>
			<td>8832</td>
			<td>Cystic duct, cystic artery</td>
		</tr>
		<tr>
			<td>Prolene 4-0 RB-1</td>
			<td>Ethicon</td>
			<td>8871</td>
			<td>2 mal suturing of the slit in the meso</td>
		</tr>
	</tbody>
</table>

modified single-loop reconstruction for pancreaticoduodenectomy

Gemodificeerde single-lus reconstructie in pancreaticoduodenectomy scheidt pancreas secretie van Gal. Het wordt uitgevoerd in gevallen van hoge-risico-pancreas resten om de ernst van postoperatieve alvleesklier fistels en bovendien de algemene postoperatieve morbiditeit te verminderen. Deze reconstructie techniek wordt gekenmerkt door een extra lange jejunale lus voor de bouw van de pancreaticojejunostomy en hepaticojejunostomy. De langere afstand tussen deze anastomosen en een extra jejuno-jejunostomie tussen de afferente en efferente ledemaat van de hepaticojejunostomie scheiden de vloeistoffen en voorkomen terugstroming van gal naar de pancreaticojejunostomy. Zo kunnen de afscheidingen elkaar niet activeren en een bestaande anastomotische lekkage verergeren. We observeerden een verlaagd tarief van ernstige postoperatieve pancreas fistels na gemodificeerde single-loop reconstructie in vergelijking met conventionele enkelvoudige lusreconstructie. De techniek is gemakkelijk uit te voeren, veilig en minder tijdrovend dan een traditionele dubbele lus reconstructie.

Elke patiënt die PD ondergaat, onderging een onderzoek naar het pancreas weefsel om de indicatie voor mSLR te evalueren. Hoge-risico-pancreas resten (d.w.z. zacht alvleesklier weefsel en een klein hoofd pancreatisch kanaal) werden gereconstrueerd met behulp van een gemodificeerde enkele lus waar mogelijk.
We identificeerden 50 patiënten met een hoog risico op pancreas weefsel en een kleine hoofd alvleesklier kanaal. Ze hebben allemaal mSLR ondergaan. De gemiddelde leeftijd was 63 ± 13 jaar ...

Watch this Scientific Journal Video about Modified Single-Loop Reconstruction for Pancreaticoduodenectomy at JoVE.com

Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

De techniek van gemodificeerde enkelvoudige-lus reconstructie na pancreaticoduodenectomy scheidt de secretie van alvleesklier van gal, waardoor de ernst van POPF verminderen zonder verlenging van de duur van de operatie.

Gemodificeerde single-loop reconstructie voor Pancreaticoduodenectomy

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic ...

Scheiding van pancreasafscheiding van gal vermindert schadelijke effecten van wederzijds geactiveerde afscheidingen op de pancreaticoduodenostomie. Dit vermindert de ernst, maar niet de incidentie, van postoperatieve pancreasfistel. De single-loop reconstructie is een vaak uitgevoerde reconstructie techniek in pancreaticoduodenectomie.De dubbele lus reconstructie is voor het eerst geïntroduceerd in 1976. Het realiseert de theorie van de scheiding van pancreasvloeistof en gal. Deze procedure is echter aanzienlijk tijdrovender dan de conventionele single-loop reconstructie.De gemodificeerde single-loop reconstructie is bedoeld om pancreas vloeistof te scheiden van gal met een lange jejunale ledemaat en een extra jejunale anastomose tussen de afferent en efferent ledemaat van de hepaticojejunostomie. Dit beeld toont de voltooide wederopbouwfase van een pancreaticoduodenectomie met een gewijzigde single-loop wederopbouw. De groene pijlen tonen de pancreaticojejunostomie, de hepaticojejunostomie, en de jejunojejunostomie.De extra lange jejunale ledemaat is duidelijk te zien op deze foto. Het studieprotocol van deze studie waarbij alleen menselijke chirurgie betrokken is, werd goedgekeurd door de Ethische Commissie van de Ruhr-Universiteit van Bochum. Schriftelijke geïnformeerde toestemming werd verkregen van alle patiënten.Dit is de voorbereiding van een teres ligament patch. Het zal worden gewikkeld rond de leverslagader na voltooiing van de anastomose om het risico van erosie bloeden in geval van anastomotische lekkages te verminderen. Begin de wederopbouwfase met immobilisatie van een lange, mobiele jejunalloop.Resect de eerste 10 centimeter van de jejunum om genoeg lengte van de mesentery. Reposit de jejunale lus in de rechter bovenste buikkwadrant. Voer een dubbellaagse intersite duct-to-mucosa pancreaticojejunostomie uit.Gebruik onderbroken polydioxanone 5-0 hechtingen voor de buitenste laag en onderbroken polypropyleen 5-0 hechtingen voor de binnenste laag. Stents of afdichtingsmiddelen zijn niet nodig. Deze sequentie toont de hechting van de binnenste laag van de pancreaticojejunostomie met een onderbroken polypropyleen 5-0 hechting.Plaats de hechtingen dicht bij elkaar om een onuffrigheid van de anastomose te voorkomen. Plaats de hechtingen niet te dicht bij elkaar om necrose van het hechtweefsel te voorkomen. Hier zien we de constructie van de buitenste laag van de pancreaticojejunostomie met een onderbroken polydioxanone 5-0 hechting.De hechtingen worden voorbereid zoals aangetoond in deze volgorde. Nogmaals, plaats de hechtingen niet te dicht bij elkaar. Dit is de afgewerkte dubbele laag in de duct-to-mucosa pancreaticojejunostomie.Bouw de buitenmuur van de jejunojejunostomie voordat de hepaticojejunostomie wordt gebouwd. Dit vergemakkelijkt de bouw van de hepaticojejunostomie. Nu kunnen we duidelijk zien hoe de lange jejunal ledemaat zal worden geplaatst.De jejunale lus tussen hepaticojejunostomie en pancreaticojejunostomie meet 25 tot 35 centimeter in plaats van 10 centimeter. Dit creëert afstand tussen de anastomose voor afleiding van de afscheidingen. Het vergemakkelijkt verder de bouw van een extra jejunojejunostomie tussen de afferent en efferent ledemaat van de hepaticojejunostomie.Voer een enkele laag onderbroken polydioxanone 5-0 hechting voor de hepaticojejunostomie. Split dunwandige en kleine gemeenschappelijke galwegen met een T-buis. Begin de hepaticojejunostomie met vier slijmvliesfixatiehechtingen.Twee polypropyleen 5-0 holding hechtingen vergemakkelijken de bouw van de hepaticojejunostomie. Begin met de bouw van de hepaticojejunostomie met een Roux-en-Y met behulp van onderbroken polydioxanone 5-0 hechtingen. Bereid de chirurgische knopen, maar niet binden ze aan het begin.De voorbereide chirurgische knopen worden daarna gebonden om een gelijke spanning op elke hechting mogelijk te maken. Hier zien we duidelijk de extra lange jejunal ledemaat voor een gemodificeerde single-loop reconstructie. Hier zien we de bouw van de voorste muur van de hepaticojejunostomie.De jejenojejunostomie is een 1,5 centimeter meten van dubbelgelaagde jejunale anastomose uitgevoerd met een polydioxanone 5-0 hechting. Bouw de anastomose op het laagste punt tussen de efferent en afferent ledemaat van de hepaticojejunostomie. Bouw deze anastomose van de pancreaticojejunostomie en de hepaticojejunostomie omdat ze het meest verfijnd zijn.Gebruik monopolaire cautery om het jejunum te openen voor de bouw van jejunojejunostomie. Voer een continue hechting uit met een polydioxanone 5-0 hechting voor de binnenste laag van de achterwand van de jejunojejunostomie. De continue hechting maakt gelijke verdeling van spanning op de anastomose mogelijk.Hier zien we de constructie van de binnenste laag van de voorste wand van de anastomose. Dit is de constructie van de buitenste laag van de voorste wand. Hier zien we de pancreaticojejunostomie, de jejunojejunostomie, en de hepaticojejunostomie op de achtergrond.Sluit het gat in de mesokolonie na omzetting van de jejunale ledemaat om interne hernia te voorkomen. Elke patiënt met een zachte alvleesklierweefsel en een kleine hoofdalvleesklierbuis onderging waar mogelijk een aangepaste single-loop reconstructie. Mobilisatie van de lange jejunale ledemaat was meestal geen probleem.In zeldzame gevallen, mobilisatie was beperkt als gevolg van extreme viscerale obesitas of ernstige verklevingen als gevolg van het verleden chirurgische geschiedenis. Kleine patiënten komen samen met natuurlijk kleinere ruimte in de bovenbuik, waardoor het preparaat ook wordt belemmerd. De continue dubbele laag reconstructie van de jejunojejunostomie werd uitgevoerd zonder problemen bij alle patiënten.Geen anastomotische insufficiëntie vond postoperatief plaats. Deze methode vermindert de incidentie van ernstige postoperatieve pancreasfistel bij alle patiënten met hoog risico pancreasresten. Het aantal postpancreatectomiebloedingen en reoperaties was aanzienlijk lager met een gewijzigde single-loop reconstructie.In vergelijking met de dubbele lus reconstructie, deze procedure is aanzienlijk minder technisch veeleisend en minder tijdrovend. De gewijzigde single-loop reconstructie is een eenvoudige techniek om pancreasafscheiding te scheiden van gal voor vermindering van postoperatieve morbiditeit. Het is veilig en minder tijdrovend dan de dubbele lus reconstructie.

modified-single-loop-reconstruction-for-pancreaticoduodenectomy

Research

JoVE Journal

Medicine

Modified Technique for Coronary Artery Ligation in Mice

Myocardial infarction (MI) is one of the most important causes of mortality in humans1-3. In order to improve morbidity and mortality in patients with MI we need better knowledge about pathophysiology of myocardial ischemia. This knowledge may be valuable to define new therapeutic targets for innovative cardiovascular therapies4. Experimental MI model in mice is an increasingly popular small-animal model in preclinical research in which MI is induced by means of permanent or temporary ligation of left coronary artery (LCA)5. In this video, we describe the step-by-step method of how to induce experimental MI in mice.
The animal is first anesthetized with 2% isoflurane. The unconscious mouse is then intubated and connected to a ventilator for artificial ventilation. The left chest is shaved and 1.5 cm incision along mid-axillary line is made in the skin. The left pectoralis major muscle is bluntly dissociated until the ribs are exposed. The muscle layers are pulled aside and fixed with an eyelid-retractor. After these preparations, left thoracotomy is performed between the third and fourth ribs in order to visualize the anterior surface of the heart and left lung. The proximal segment of LCA artery is then ligated with a 7-0 ethilon suture which typically induces an infarct size ~40% of left ventricle. At the end, the chest is closed and the animals receive postoperative analgesia (Temgesic, 0.3 mg/50 ml, ip). The animals are kept in a warm cage until spontaneous recovery.

The surgical procedure used to induce experimental myocardial infarction in mice begins with left thoracotomy between the third and the fourth ribs in order to visualize the anterior surface of the heart and left lung. The left coronary artery is ligated, the chest is closed and the mouse is allowed to recover spontaneously.

Gewijzigd Techniek voor Coronary Artery Ligatie in Muizen

Myocardial infarction (MI) is one of the most important causes of mortality in humans1-3. In order to improve morbidity and mortality in patients with MI ...

A Modified Method for Heterotopic Mouse Heart Transplantion

Mice are often used as heart transplant donors and recipients in studies of transplant immunology due to the wide range of transgenic mice and reagents available. A difficulty is presented due to the small size of the animal and the considerable technical challenges of the microsurgery involved in heart transplantation. In particular, a high rate of technical failure early after transplantation may result from recipient death and post-operative complications such as hind limb paralysis or a non-beating heart. Here, the complete technique for heterotopic mouse heart transplantation is demonstrated, involving harvesting the donor heart and its subsequent implantation into a recipient mouse. The donor heart is harvested immediately following in situ perfusion with cold heparinized saline and transection of the ascending aorta and pulmonary artery. The recipient operation involves preparation of the abdominal aorta and inferior vena cava (IVC), followed by end-to-side anastomosis of the donor aorta with the recipient aorta using a single running 10-0 microsuture and a similar anastomosis of the donor pulmonary artery with the recipient IVC. Following the operation the animal is injected with 0.6 ml normal saline subcutaneously and allowed to recover on a 37&#160;&#176;C heating pad. The results from 227 mouse heart transplants are summarized with a success rate at 48 hr of 86.8%. Of the 13.2% failures within 48 hr, 5 (2.2%) experienced hind limb paralysis, 10 (4.4%) had a non-beating heart due to graft ischemic injury and/or thrombosis, while 15 (6.6%) died within 48 hr.

A technique is demonstrated for the microsurgical procedure for heterotopic transplantation of hearts in mice, including simplified methods for donor harvesting and recipient vessel anastomosis.

Een gewijzigde methode voor Heterotope Mouse Hart transplantatie

Mice are often used as heart transplant donors and recipients in studies of transplant immunology due to the wide range of transgenic mice and reagents ...

Designing CAD/CAM Surgical Guides for Maxillary Reconstruction Using an In-house Approach

Computer-aided design/computer-assisted manufacturing (CAD/CAM) is now being evaluated as a preparative technique for maxillofacial surgery. Because this technique is expensive and available in only limited areas of the world, we developed a novel CAD/CAM surgical guide using an in-house approach. By using the CAD software, the maxillary resection area and cutting planes and the fibular cutting planes and angles are determined. Once the resection area is decided, the necessary faces are extracted using a Boolean modifier. These superficial faces are united to fit the surface of the bones and thickened to stabilize the solids. Not only the cutting guides for the fibula and maxilla but also the location arrangement of the transferred bone segments is defined by thickening the superficial faces. The CAD design is recorded as .stl files and three-dimensionally (3-D) printed as actual surgical guides. To check the accuracy of the guides, model surgery using 3-D-printed facial and fibular models is performed. These methods may be used to assist surgeons where commercial guides are not available.

Methods for designing a computer-aided design/computer-aided manufacturing (CAD/CAM) surgical guide are shown. Cutting planes are separated, united, and thickened to easily visualize the necessary bone transfer. These designs can be three-dimensional printed and checked for accuracy.

Ontwerpen van CAD/CAM chirurgische gidsen voor maxillaire wederopbouw met behulp van een In-house aanpak

Computer-aided design/computer-assisted manufacturing (CAD/CAM) is now being evaluated as a preparative technique for maxillofacial surgery. Because this ...

Porcine As a Training Module for Head and Neck Microvascular Reconstruction

Live models that resemble surgical conditions of humans are needed for training free-flap harvesting and anastomosis. Animal models for training purposes have been available for years in many surgical fields. We used the female (because they are easy to handle for the procedure) Yorkshire pigs for the head and neck reconstruction by harvesting the deep inferior epigastric artery perforator or the superior epigastric artery perforator flap. The anastomosis site (neck skin defect or tracheal wall defect) was prepared via the dissection of the common carotid artery and the internal jugular vein, in which 3.5&#215; loupe magnification was used for anastomosis as we use on human cases in real life. This procedure demonstrates a new training method using a reliable learning model and provides a detailed anatomy in a live scenario. We focused on the ischemia time, harvesting, vessel anastomosis, and designing the flap to fit the defect site. This model improves tissue handling and with the use of proper instruments can be repeated many times so that the surgeon is fully confident before starting the surgery on humans.

Here we present a protocol for the use of the pig superior epigastric artery perforator flap as a learning module for head and neck microvascular reconstruction.

Varkens als een Module van de opleiding voor hoofd en nek microvasculaire wederopbouw

Live models that resemble surgical conditions of humans are needed for training free-flap harvesting and anastomosis. Animal models for training purposes ...

A Training and Testing System for Performing Vascular Reconstruction In Vitro

Manual vascular reconstruction training is essential for a beginner surgeon. However, an optimal training system for vascular reconstruction in vitro has yet to be developed. In this study, we introduce an in vitro training and testing system using a magnetic anchoring technique with which a trainee can practice manual vascular reconstruction individually. Additionally, this system can also be used to test the quality of the reconstruction. The described system includes a vascular reconstruction training machine, magnetic tractors, and a magnetic suture puller. In this manuscript, we detail an end-to-end vein anastomosis using porcine right and left iliac veins. To identify the potential damage caused by a magnetic suture puller on the suture, we created three groups with six segments of 4-0 polypropylene sutures each: a control group with no intervention on the polypropylene suture, a group in which the polypropylene suture is manually pulled with sterile gloves 20x, and a magnetic puller group in which the magnetic puller pulled the polypropylene suture 20x. These groups were tested by light microscopy and breaking strength tests, and the effect of reconstruction was assessed. In the light microscopy test, the control group was less likely to be damaged (p &#60; 0.05) and the number of damaged points of the manual group and magnetic puller group were similar (p &#62; 0.05). The results of the breaking strength test were compared across groups and no significant difference was observed (p &#62; 0.05). The end-to-end anastomosis of the porcine iliac veins was successfully performed using this training system, and the reconstructed veins could undergo 2.0 kPa perfusion pressure. Using this training and testing system the trainee can practice manual vascular reconstruction in vitro individually with the aid of magnetic tractors and a magnetic suture puller, and the quality of the reconstruction can be tested.

Here we present a training and testing system where a trainee can complete manual vascular reconstruction in vitro individually using a magnetic anchoring technique. The system can also be used to test the quality of reconstruction.

Een trainings-en testsysteem voor het uitvoeren van vasculaire wederopbouw in vitro

Manual vascular reconstruction training is essential for a beginner surgeon. However, an optimal training system for vascular reconstruction in vitro has ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

Technisch detail voor Robot assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

A Postoperative Evaluation Guideline for Computer-Assisted Reconstruction of the Mandible

Valid comparisons of postoperative accuracy results in computer-assisted reconstruction of the mandible are difficult due to heterogeneity in imaging modalities, mandibular defect classification, and evaluation methodologies between studies. This guideline uses a step-by-step approach guiding the process of imaging, classification of mandibular defects and volume assessment of three-dimensional (3D) models, after which a legitimized quantitative accuracy evaluation method can be performed between the postoperative clinical situation and the preoperative virtual plan. The condyles and the vertical and horizontal corners of the mandible are used as bony landmarks to define virtual lines in the computer-assisted surgery (CAS) software. Between these lines the axial, coronal, and both sagittal mandibular angles are calculated on both pre- and postoperative 3D models of the (neo)mandible and subsequently the deviations are calculated. By superimposing the postoperative 3D model to the preoperative virtually planned 3D model, which is fixed to the XYZ axis, the deviation between pre- and postoperative virtually planned dental implant positions can be calculated. This protocol continues and specifies an earlier publication of this evaluation guideline.

Here, we propose a practical, feasible and reproducible evaluation guideline for computer-assisted reconstruction of the mandible in order to create uniformity between studies regarding postoperative accuracy evaluation. This protocol continues and specifies an earlier publication of this evaluation guideline.

Een postoperatieve evaluatierichtlijn voor computerondersteunde wederopbouw van de onderkaak

Valid comparisons of postoperative accuracy results in computer-assisted reconstruction of the mandible are difficult due to heterogeneity in imaging ...

Therapy Interventions for Upper Limb Amputees Undergoing Selective Nerve Transfers

Targeted Muscle Reinnervation (TMR) improves the biological control interface for myoelectric prostheses after above-elbow amputation. Selective activation of muscle units is made possible by surgically re-routing nerves, yielding a high number of independent myoelectric control signals. However, this intervention requires careful patient selection and specific rehabilitation therapy. Here a rehabilitation protocol is presented for high-level upper limb amputees undergoing TMR, based on an expert Delphi study. Interventions before surgery include detailed patient assessment and general measures for pain control, muscle endurance and strength, balance, and range of motion of the remaining joints. After surgery, additional therapeutic interventions focus on edema control and scar treatment and the selective activation of cortical areas responsible for upper limb control. Following successful&#160;reinnervation of target muscles, surface electromyographic (sEMG) biofeedback is used to train the activation of the novel muscular units. Later on, a table-top prosthesis may provide the first experience of prosthetic control. After fitting the actual prosthesis, training includes repetitive drills without objects, object manipulation, and finally, activities of daily living. Ultimately, regular patient appointments and functional assessments allow tracking prosthetic function and enabling early interventions if malfunctioning.

This work presents a protocol to enhance prosthetic function after selective nerve transfer surgery. Rehabilitation interventions include patient information and selection, support of wound healing, cortical re-activation of sensory-motor areas of the upper limb, training of selective muscle activation, prosthetic handling in daily life, and regular follow-up assessments.

Therapie-interventies voor geamputeerden van de bovenste ledematen die selectieve zenuwoverdrachten ondergaan

Targeted Muscle Reinnervation (TMR) improves the biological control interface for myoelectric prostheses after above-elbow amputation. Selective ...

Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy

Laparoscopic pancreatoduodenectomy (LPD) is a demanding abdominal operation that necessitates meticulous surgical skills and teamwork. The management of the pancreatic uncinate process is one of the most important and difficult processes in LPD because of its deep anatomical location and difficult exposure. Complete resection of the uncinate process and mesopancreas has become the cornerstone of LPD. In particular, it is even more difficult to avoid positive surgical margins and incomplete lymph node dissection when the tumor is located in the uncinate process. No-touch LPD, which is an ideal oncological operation process fitting the "tumor-free" principle, has been reported by our group previously. This article introduces the management of the uncinate process in no-touch LPD. Based on the multi-angle arterial approach, in this protocol, the median-anterior and left-posterior approaches to the SMA are used to correctly deal with the important vascular structure, the inferior pancreaticoduodenal artery (IPDA), in order to ensure the safe and complete excision of the uncinate process and mesopancreas. For the achievement of the no-touch isolation technique in LPD, the pancreatic head and the blood supply to the duodenal region must be severed at the very early stage of the operation; after that, the tumor can be isolated intact, resection can be performed in situ, and finally, the tissue can be removed en bloc. This paper aims to show the distinctive ways to manage the uncinate process in no-touch LPD and investigate the viability and safety of this approach. Moreover, the technique may increase the R0 resection rate.

Complete resection of the uncinate process and mesopancreas is one of the most important and difficult processes in laparoscopic pancreatoduodenectomy (LPD). This article presents a method for managing the uncinate process in no-touch LPD using the median-anterior and left-posterior approaches to the superior mesenteric artery (SMA).

Beheer van het uncinaatproces bij no-touch laparoscopische pancreaticoduodenectomie

Laparoscopic pancreatoduodenectomy (LPD) is a demanding abdominal operation that necessitates meticulous surgical skills and teamwork. The management of ...

Digital Model for Horizontal 3D Reconstruction of Pulmonary Nodules

To reconstruct the three-dimensional digital model of the pulmonary nodules, implement the Three-Dimensional Lung Horizon Function in the MATLAB workspace. Then open the Graphical User Interface, or GUI, to check the horizontal three-dimensional model. Drag the scroll bar on the GUI with the mouse to observe the continuous three-dimensional lung structure, allowing for the clear visualization of various types of pulmonary nodules and their relative spatial relationships with the lung tissue.Use the Zoom function to observe the local features of the lesions and relevant three-dimensional structural output pictures. To measure the size of the nodules, use the Mark Pixel Coordinates button to calculate the distance between two points. The default color bar, jet colormap, displays values from low to high in a blue to red range.To reset the GUI, right click the color bar and select the standard gray colormap. If the filter window is not satisfactory, use the left mouse button to adjust the window level by dragging up and down in the middle of the figure. Drag left and right to adjust the window width to display the accurate filtering range on the color bar.The continuous three-dimensional reconstruction resulted in the axial view of the pulmonary nodules and the relationship between the nodules and the surrounding lung tissue.