The surgical procedure and the protocol were explained to the patients, and they signed a consent form. This study was approved by the local ethics committees of the institutional review board and informed consent were collected from patients, register number 1688/20. Patients who underwent transhiatal esophagectomy were included in the protocol, while those patients who underwent a transthoracic approach were excluded.
1. Production of low-cost single-port device
<ol>
	<li>Use a nasogastric tube, a sterile number-eight glove, a sterile sponge, 3 permanent 5-mm trocars and surgical suture materials.</li>
	<li>Make one cylinder with the sterile sponge.</li>
	<li>Use three glove fingers to triangulation the trocars: little finger, middle finger and thumb</li>
	<li>Use the three trocars to pierce the sponge and perform a triangulation (Figure 1 and Figure 2).</li>
	<li>Make one ring with the nasogastric tube.</li>
	<li>Place the sponge, the trocars and the glove between the ring to seal the air leak during mediastinoscopy and to stabilize the structures.</li>
	<li>Use the glove to cover all the structures to prevent air leak again.</li>
</ol>
2. Laparoscopic and transhiatal procedure
<ol>
	<li>Put the patient under general anesthesia in a supine position.</li>
	<li>Insert an orotracheal, a central venous and an invasive arterial pressure catheter respectively in the trachea, jugular vein and radial artery.</li>
	<li>Create a pneumoperitoneum using a Veress needle. Insert the needle in the midline above the umbilical scar.</li>
	<li>Place laparoscopic trocars in the following positions: one 12-mm trocar in the supraumbilical area, two 10-mm trocars in the left and right hypochondrium, and two 5-mm trocars in the right hypochondrium and the epigastrium.</li>
	<li>Perform abdominal cavity inventory to search for peritoneal or liver metastasis.</li>
	<li>Examine the gastroepiploic arcade from the right gastroepiploic artery to the short gastric vessels.</li>
	<li>Open up the gastrocolic ligament to the pilorus to gastric fundus while preserving the gastroepiploic arcade.</li>
	<li>Perform the posterior gastric wall release. Lift up the posterior aspect of the stomach and dissect using an ultrasonic harmonic scalpel to free it from the retroperitoneum. Identify the pancreas, left gastric vessels, and celiac trunk.</li>
	<li>Make a gastric tube with a stapler. Start stapling in the antrum by the lesser curvature and move towards the greater curvature. Make a slim gastric tube to create an anastomosis in the cervical esophagus and empty it properly.</li>
	<li>Perform dissection and ligation of the left gastric vessels at the origin to harvest the appropriate lymph nodes. Perform the dissection cranially to the origin of the left gastric vein and the left gastric artery.
	<ol>
		<li>Use one clip proximally and other distally in the left gastric vein before sealing it. Use two hemolocks proximally and one distally in the left gastric artery before sealing it.</li>
	</ol>
	</li>
	<li>Sequentially dissect all the lymph nodes and connective tissue along the left gastric artery (7), common hepatic artery (8a), celiac trunk (9), proximal splenic artery (11p), lesser curvature (3), and the esophago gastric junction (1) and reflect toward the stomach.</li>
	<li>Perform dissection of the esophageal hiatus. Enlarge the hiatus anteriorly to facilitate dissection and mobilization of the thoracic esophagus and the other mediastinal structures.</li>
	<li>Identify the aorta and dissect the posterior wall of the esophagus from the descending aorta with a harmonic scalpel.</li>
	<li>Continue the dissection of the esophagus in a paraesophageal plane in the lower mediastinum under pneumomediastinum. In the middle to upper portion of the mediastinum, however, this dissection is normally performed blindly and may lead to tracheal lesions or hemorrhage from tearing of the larger vessels.</li>
	<li>Stop the dissection in the transition of the middle to upper mediastinum up to the carina and started with a single-port mediastinoscopic cervical approach using a rendezvous technique (this technique is described below).</li>
</ol>
3. Transcervical procedure
<ol>
	<li>Make an oblique incision along the anterior border of the left lower sternocleidomastoid parallel to the clavicle.</li>
	<li>Identify the sternocleidomastoid muscle and divide.</li>
	<li>Mobilize the cervical esophagus and initiate the dissection of the cervical lymph nodes along the left recurrent laryngeal nerve.</li>
	<li>Insert the single-port device into the cervical wound (Figure 3) and create a pneumomediastinum by carbon dioxide insufflation (8 mmHg). Use a 5-mm Otic and a Harmonic Scalpel for esophagus dissection along with a laparoscopic grasper.</li>
	<li>Dissect the esophagus over the aortic arch and behind the superior portion of the trachea. Perform the dissection of the lymph nodes along the left recurrent laryngeal nerve and trachea.</li>
	<li>After this stage, completely mobilize the esophagus, and reach the region that was dissected using a transhiatal approach. Divide the cervical esophagus, and remove the esophagus with the tumor by an abdominal incision.</li>
	<li>Perform cervical anastomosis with gastric tube and esophageal stump.</li>
</ol>

<ol>
	<li>Borggreve, A. 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=Surgical+treatment+of+esophageal+cancer+in+the+era+of+multimodality+management.">Surgical treatment of esophageal cancer in the era of multimodality management.</a> Annals of the New York Academy of Sciences. 1434 (1), 192-209 (2018).</li><li>Kato, H., Nakajima, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatments+for+esophageal+cancer:+a+review.">Treatments for esophageal cancer: a review.</a> General Thoracic and Cardiovascular Surgery. 61 (6), 330-335 (2013).</li><li>Rice, T. W., Patil, D. T., Blackstone, E. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=8th+edition+AJCC/UICC+staging+of+cancers+of+the+esophagus+and+esophagogastric+junction+application+to+clinical+practice.">8th edition AJCC/UICC staging of cancers of the esophagus and esophagogastric junction application to clinical practice.</a> Annalsof Cardiothoracic Surgery. 6 (2), 119-130 (2017).</li><li>Hulscher, J. B., Tijssen, J. G., Obertop, H., van Lanschot, J. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transthoracic+versus+transhiatal+resection+for+carcinoma+of+the+esophagus:+a+meta-analysis.">Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis.</a> Annals of Thoracic Surgery. 72 (1), 306-313 (2001).</li><li>Rentz, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transthoracic+versus+transhiatal+esophagectomy:+a+prospective+study+of+945+patients.">Transthoracic versus transhiatal esophagectomy: a prospective study of 945 patients.</a> Journal of Thoracic and Cardiovascular Surgery. 125 (5), 1114-1120 (2003).</li><li>Tokairin, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Mediastinoscopic+subaortic+and+tracheobronchial+lymph+node+dissection+with+a+new+cervico-hiatal+crossover+approach+in+thiel-embalmed+cadavers.">Mediastinoscopic subaortic and tracheobronchial lymph node dissection with a new cervico-hiatal crossover approach in thiel-embalmed cadavers.</a> International Surgery. 100, 580-588 (2015).</li><li>Fujiwara, 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=Single-port+mediastinoscopic+lymphadenectomy+along+the+left+recurrent+laryngeal+nerve.">Single-port mediastinoscopic lymphadenectomy along the left recurrent laryngeal nerve.</a> Annals of Thoracic Surgery. 100 (3), 1115-1117 (2015).</li><li>Gupta, V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Major+airway+injury+during+esophagectomy:+experience+at+a+tertiary+care+center.">Major airway injury during esophagectomy: experience at a tertiary care center.</a> Journal of Gastrointestinal Surgery. 13 (3), 438-441 (2009).</li><li>Hulscher, J. B., 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=Injury+to+the+major+airways+during+subtotal+esophagectomy:+incidence,+management,+and+sequelae.">Injury to the major airways during subtotal esophagectomy: incidence, management, and sequelae.</a> Journal of Thoracic and Cardiovascular Surgery. 120 (6), 1093-1096 (2000).</li><li>Fermin, L., Arnold, S., Nunez, L., Yakoub, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Extracorporeal+membrane+oxygenation+for+repair+of+tracheal+injury+during+transhiatal+esophagectomy.">Extracorporeal membrane oxygenation for repair of tracheal injury during transhiatal esophagectomy.</a> Annals of Cardiac Anaesthesia. 20, 67-69 (2017).</li></ol>

There are no disclosures.

The LoCoSP device allows for safer surgery using a transcervical approach in minimally invasive THE. This is accomplished by improving the recognition and dissection of the esophagus, trachea, and the aortic arch under magnified vision. The advantages of THE are amplified. In addition to allowing surgery with less morbidity and fewer pulmonary complications, this technique can improve the dissection of left paratracheal and recurrent lymph nodes. Another advantage of this technique is that it is possible to reduce the risk of tracheal and vascular injury during THE. 
Damage of the posterior wall of the trachea or the main bronchi rarely occurs during esophagectomy, and the reported rates are 1.35%8 to 1.8%9. However, when it does happen, the prognosis is unfavorable10. Dissection with a single-port mediastinoscopic cervical approach allows for direct visualization of the upper esophagus and the trachea, which could possibly decrease the chances of injury to the airways. Finally, the production of the LoCoSP device is easy, and it can be reproduced in other centers. The device is produced using cheap and widely available instruments in any operating room. An important limitation of the technique is the leakage of air through the cervical wound, during the dissection of the upper mediastinum. Nevertheless, the method is still an experimental method, and the real benefit of using the LocOSP device must be studied and analyzed in a greater number of patients.

There are multiple options for the treatment of esophageal cancer, which involve endoscopy, surgery1, neoadjuvant, and definitive treatment with chemoradiotherapy2. Esophagectomy is the most important element in the curative treatment of patients with advanced esophageal cancer3, and the two main approaches currently used for surgical treatment are transthoracic esophagectomy (TTE) and transhiatal esophagectomy (THE). However, the choice of approach remains controversial. Since TTE requires pulmonary collapse during surgery, more frequent pulmonary complications are to be expected than in a transhiatal approach. Minimally invasive techniques are used to reduce access trauma to the lungs and others structures of the thorax, but they do not decrease the morbidity in comparison to THE. Thus, minimally invasive THE has become a more attractive option; however, the upper esophagus and upper mediastinum are difficult areas to dissect due to blind areas, and cervical incision might be not enough to allow a safe dissection of the upper part.
Laparoscopic THE reduces morbidity4 and enhances postoperative recovery with no compromise in cancer recurrence or survival5. THE has been shown to decrease the hospital stay, hospital mortality, surgical time, and blood loss. Furthermore, TTE has a higher risk of pulmonary complications. The patient's stay in the intensive care unit is significantly longer after transthoracic resection, and hospital stay is also significantly prolonged. 
However, there is an issue with THE regarding the lymph node dissection, particularly in the upper mediastinum, which is a blind area. This results in a risk of tracheal and vascular lesions during the surgery. Tokairin6 et al. and Fujiwara et al. described a single-port mediastinoscopic method for upper mediastinal dissection in esophageal cancer surgery. This technique enabled clear visualization of the structures around the aortic arch and safe lymphadenectomy7. A low-cost single-port device was developed to improve upper mediastinal dissection using a left transcervical mediastinoscopic approach, which was used to improve the visibility and dissection in the upper mediastinum around the aortic arch. The aim of this project is to describe the step-by-step process of a laparoscopic THE completed using a mediastinoscopy cervical approach with a low-cost single-port device in a rendezvous technique.

low-cost single-port (locosp) device for a transcervical approach in minimally invasive transhiatal esophagectomy

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains controversial. A transthoracic approach may improve lymph node dissection, but it has considerable morbidity and respiratory complications. Transhiatal access has been demonstrated as an efficient means of minimizing post-operative complications. Minimally invasive transhiatal esophagectomy may reduce operative trauma and morbidity as well as enhance postoperative recovery with no compromise in cancer recurrence or survival. Nevertheless, it has a technical limitation in terms of cervical esophagus dissection. Thus, a low-cost single-port device was developed to complete upper mediastinal dissection by a transcervical approach during minimally invasive transhiatal esophagectomy. This device uses a nasogastric tube, a number-eight sterile glove, a sterile sponge, and 3 permanent 5-mm trocars. The step-by-step process of transhiatal esophagectomy and the development of this device are described. This technique allows for the dissection of the upper mediastinum, as well as the esophagus over the aortic arch and behind the superior portion of the trachea. The harvesting of lymph nodes along the left recurrent laryngeal nerve and paratracheals was improved.

The LoCoSP device is a useful tool for safely dissecting the structures of the upper mediastinum. Direct visualization of the cervical and upper thoracic esophagus allows for safe dissection with less risk of tracheal injury and hemorrhage from tearing of the larger vessels, in addition to improving the lymphadenectomy of the left recurrent laryngeal and paratracheal nodes.
From 2018 to 2020, 12 patients with distal esophageal carcinoma (2 squamous cell carcinoma and 10 adenocarcinoma) were submitted to laparoscopic transhiatal esophagectomy with transcervical access to cervical esophagus dissection and lymphadenectomy. The median age was 62 (60 &#177; 85) years old, only one patient was female. There was no chordal palsy, bleeding, tracheal damage related to the transcervical access. One anastomotic fistula occurred with no clinical complications, spontaneous drainage through the cervical incision. The median operation time was 360 min (300 &#177; 420 min), and the operation time of the transcervical dissection of the cervical esophagus was 60 min (40 &#177; 110 min). The median hospital stay was 10 days (9 &#177; 12 days). All cases were performed with the LoCoSP device (Table 1).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/62509/62509fig01.jpg" /> 
Figure 1: Low-cost single-port device <a href="https://www.jove.com/files/ftp_upload/62509/62509fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/62509/62509fig02.jpg" /> 
Figure 2: Low-cost single-port device (note the triangulation of the three trocars) <a href="https://www.jove.com/files/ftp_upload/62509/62509fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/62509/62509fig03.jpg" /> 
Figure 3: Low-cost single-port device into the cervical wound <a href="https://www.jove.com/files/ftp_upload/62509/62509fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Total Patients</td>
			<td>12</td>
		</tr>
		<tr>
			<td>Median Age (years)</td>
			<td>62</td>
		</tr>
		<tr>
			<td>Number Anastomotic fistula</td>
			<td>1</td>
		</tr>
		<tr>
			<td>Median operation time (minutes)</td>
			<td>360</td>
		</tr>
		<tr>
			<td>Median operation time transcervical dissection (minutes)</td>
			<td>60</td>
		</tr>
		<tr>
			<td>Median Hospital stay (days)</td>
			<td>10</td>
		</tr>
	</tbody>
</table>
Table 1: Surgery results using low cost single-port device

Watch this Scientific Journal Video about Low-Cost Single-Port LoCoSP Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy at JoVE.com

Low-Cost Single-Port LoCoSP Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Here, we describe a step-by-step description of transhiatal esophagectomy and the development of a low-cost single-port device for a transcervical approach in a minimally invasive transhiatal esophagectomy.

Low-Cost Single-Port (LoCoSP) Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains ...

low-cost-single-port-locosp-device-for-transcervical-approach

Nanyang Technological University

Research

JoVE Journal

Medicine

2.8K Views.  University of São Paulo. Here, we describe a step-by-step description of transhiatal esophagectomy and the development of a low-cost single-port device for a transcervical approach in a minimally invasive transhiatal esophagectomy.

Video: Low-Cost Single-Port LoCoSP Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

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 ...

Minimally Invasive Establishment of Murine Orthotopic Bladder Xenografts

Orthotopic bladder cancer xenografts are the gold standard to study molecular cellular manipulations and new therapeutic agents&#160;in vivo. Suitable cell lines are inoculated either by intravesical instillation (model of nonmuscle invasive growth) or intramural injection into the bladder wall (model of invasive growth). Both procedures are complex and highly time-consuming. Additionally, the superficial model has its shortcomings due to the lack of cell lines that are tumorigenic following instillation. Intramural injection, on the other hand, is marred by the invasiveness of the procedure and the associated morbidity for the host mouse.
With these shortcomings in mind, we modified previous methods to develop a minimally invasive approach for creating orthotopic bladder cancer xenografts. Using ultrasound guidance we have successfully performed percutaneous inoculation of the bladder cancer cell lines UM-UC1, UM-UC3 and UM-UC13 into 50 athymic nude. We have been able to demonstrate that this approach is time efficient, precise and safe. With this technique, initially a space is created under the bladder mucosa with PBS, and tumor cells are then injected into this space in a second step. Tumor growth is monitored at regular intervals with bioluminescence imaging and ultrasound. The average tumor volumes increased steadily in in all but one of our 50 mice over the study period.
In our institution, this novel approach, which allows bladder cancer xenograft inoculation in a minimally-invasive, rapid and highly precise way, has replaced the traditional model.

The established technique to inoculate primary invasive orthotopic bladder cancer xenografts requires laparotomy and mobilization of the bladder. This procedure inflicts significant morbidity on the mice, is technically challenging and time-consuming. We therefore developed a high-precision, percutaneous approach utilizing ultrasound guidance.

Orthotopic bladder cancer xenografts are the gold standard to study molecular cellular manipulations and new therapeutic agents&#160;in vivo. Suitable ...

Encapsulation Thermogenic Preadipocytes for Transplantation into Adipose Tissue Depots

Cell encapsulation was developed to entrap viable cells within semi-permeable membranes. The engrafted encapsulated cells can exchange low molecular weight metabolites in tissues of the treated host to achieve long-term survival. The semipermeable membrane allows engrafted encapsulated cells to avoid rejection by the immune system. The encapsulation procedure was designed to enable a controlled release of bioactive compounds, such as insulin, other hormones, and cytokines. Here we describe a method for encapsulation of catabolic cells, which consume lipids for heat production and energy dissipation (thermogenesis) in the intra-abdominal adipose tissue of obese mice. Encapsulation of thermogenic catabolic cells may be potentially applicable to the prevention and treatment of obesity and type 2 diabetes. Another potential application of catabolic cells may include detoxification from alcohols or other toxic metabolites and environmental pollutants.

Here, we present a protocol for encapsulation of catabolic cells, which consume lipids for heat production in intra-abdominal adipose tissue and increase energy dissipation in obese mice.

Cell encapsulation was developed to entrap viable cells within semi-permeable membranes. The engrafted encapsulated cells can exchange low molecular ...

Minimally Invasive Transverse Aortic Constriction in Mice

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard open-chest transverse aortic constriction (TAC). Although transverse aortic constriction is a highly functional method for the induction of high pressure in the left ventricle, it is a more difficult and lengthy procedure due to its use of artificial ventilation with tracheal intubation. TAC is oftentimes also less survivable, as the newer method, MTAC, neither requires the cutting of the ribs and intercostal muscles nor tracheal intubation with a ventilation setup. In MTAC, as opposed to a thoracotomy to access to the chest cavity, the aortic arch is reached through a midline incision in the anterior neck. The thyroid is pulled back to reveal the sternal notch. The sternum is subsequently cut down to the second rib level, and the aortic arch is reached simply by separating the connective tissues and thymus. From there, a suture can be wrapped around the arch and tied with a spacer, and then the sternal cut and skin can be closed. MTAC is a much faster and less invasive way to induce left ventricular hypertension and enables the possibility for high-throughput studies. The success of the constriction can be verified using high-frequency trans-thoracic echocardiography, particularly color Doppler and pulsed-wave Doppler, to determine the flow velocities of the aortic arch and left and right carotid arteries, the dimension of the blood vessels, and the left ventricular function and morphology. A successful constriction will also trigger significant histopathological changes, such as cardiac muscle cell hypertrophy with interstitial and perivascular fibrosis. Here, the procedure of MTAC is described, demonstrating how the resulting flow changes in the carotid arteries can be examined with echocardiography, gross morphology, and histopathological changes in the heart.

Minimally invasive transverse aortic constriction (MTAC) conserves the essentials of regular transverse aortic constriction (TAC) while eliminating the use of a ventilator with tracheal intubation. It proves to be a highly desirable method for high-throughput studies on left ventricular overload, particularly in translational studies.

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard ...

A Minimally Invasive Model to Analyze Endochondral Fracture Healing in Mice Under Standardized Biomechanical Conditions

Bone healing models are necessary to analyze the complex mechanisms of fracture healing to improve clinical fracture treatment. During the last decade, an increased use of mouse models in orthopedic research was noted, most probably because mouse models offer a large number of genetically-modified strains and special antibodies for the analysis of molecular mechanisms of fracture healing. To control the biomechanical conditions, well-characterized osteosynthesis techniques are mandatory, also in mice. Here, we report on the design and use of a closed bone healing model to stabilize femur fractures in mice. The intramedullary screw, made of medical-grade stainless steel, provides through fracture compression an axial and rotational stability compared to the mostly used simple intramedullary pins, which show a complete lack of axial and rotational stability. The stability achieved by the intramedullary screw allows the analysis of endochondral healing. A large amount of callus tissue, received after stabilization with the screw, offers ideal conditions to harvest tissue for biochemical and molecular analyses. A further advantage of the use of the screw is the fact that the screw can be inserted into the femur with a minimally invasive technique without inducing damage to the soft tissue. In conclusion, the screw is a unique implant that can ideally be used in closed fracture healing models offering standardized biomechanical conditions.

This protocol describes a minimally invasive osteosynthesis technique using an intramedullary screw for standardized stabilization of femur fractures, which can be used to analyze endochondral bone healing in mice.

Bone healing models are necessary to analyze the complex mechanisms of fracture healing to improve clinical fracture treatment. During the last decade, an ...

Electromagnetic Navigation Transthoracic Nodule Localization for Minimally Invasive Thoracic Surgery

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or excision. Many of these nodules are identified and excised via minimally invasive thoracic surgery; however, subcentimeter and subsolid nodules are frequently difficult to identify intra-operatively. This can be mitigated by the use of electromagnetic transthoracic needle localization. This protocol delineates the step-by-step process of electromagnetic localization from the pre-operative period to the postoperative period and is an adaptation of the electromagnetically guided percutaneous biopsy previously described by Arias et al. Pre-operative steps include obtaining a same day CT followed by the generation of a three-dimensional virtual map of the lung. From this map, the target lesion(s) and an entry site are chosen. In the operating room, the virtual reconstruction of the lung is then calibrated with the patient and the electromagnetic navigation platform. The patient is then sedated, intubated, and placed in the lateral decubitus position. Using a sterile technique and visualization from multiple views, the needle is inserted into the chest wall at the prechosen skin entry site and driven down to the target lesion. Dye is then injected into the lesion and, then, continuously during needle withdrawal, creating a tract for visualization intra-operatively. This method has many potential benefits when compared to the CT-guided localization, including a decreased radiation exposure and decreased time between the dye injection and the surgery. Dye diffusion from the pathway occurs over time, thereby limiting intra-operative nodule identification. By decreasing the time to surgery, there is a decrease in wait time for the patient, and less time for dye diffusion to occur, resulting in an improvement in nodule localization. When compared to electromagnetic bronchoscopy, airway architecture is no longer a limitation as the target nodule is accessed via a transparenchymal approach. Details of this procedure are described in a step-by-step fashion.

Presented here is a protocol for lung nodule localization using dye marking via electromagnetically navigated transthoracic needle access. The technique described here can be accomplished in the peri-operative period to optimize nodule localization and to successful resection when performing minimally invasive thoracic surgery.

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or ...

Manufacture of a Multi-Purpose Low-Cost Animal Bench-Model for Teaching Tracheostomy

Tracheostomy is one of the most frequent procedures, performed through various techniques in the intensive care unit and emergency situations. Despite this, there is a lack of training on this procedure that affects its outcome, which is also dependent on operator's dexterity. Here, we take the specific training and simulation into consideration. This article aims to describe every step of the manufacture of a new multi-purpose low-cost animal bench-model, with the support of video and images, and to obtain an opinion about the quality of this model by administering a questionnaire to professionals with experience in the procedures. 
Ten experts in the technique were enrolled. The model scored an average of 3.45/5 for its anatomical realism; 4.75/5 for its usefulness as a training tool for simulation courses and assessments. The time necessary to build the model was 15 minutes, and the cost amounted to 10&#8364;. The animal bench-model was considered a very useful simulator for tracheostomy training and assessments. Therefore, it could be used as a tool for medical courses and residencies.

This article illustrates every step of the manufacture of a new multi-purpose low-cost animal bench-model for subglottic airway access management. All the procedures are shown in the video. The model's realism and its suitability for training the given clinical maneuvers were assessed by independent senior otolaryngologists and anesthesiologists.

Tracheostomy is one of the most frequent procedures, performed through various techniques in the intensive care unit and emergency situations. Despite ...

A Pre-clinical Rat Model for the Study of Ischemia-reperfusion Injury in Reconstructive Microsurgery

Ischemia-reperfusion injury is the main cause of flap failure in reconstructive microsurgery. The rat is the preferred preclinical animal model in many areas of biomedical research due to its cost-effectiveness and its translation to humans. This protocol describes a method to create a preclinical free skin flap model in rats with ischemia-reperfusion injury. The described 3 cm x 6 cm rat free skin flap model is easily obtained after the placement of several vascular ligatures and the section of the vascular pedicle. Then, 8 h after the ischemic insult and completion of the microsurgical anastomosis, the free skin flap develops the tissue damage. These ischemia-reperfusion injury-related damages can be studied in this model, making it a suitable model for evaluating therapeutic agents to address this pathophysiological process. Furthermore, two main monitoring techniques are described in the protocol for the assessment of this animal model: transit-time ultrasound technology and laser speckle contrast analysis.

Here, we describe a pre-clinical animal model for studying the pathophysiology of ischemia-reperfusion injury in reconstructive microsurgery. This free skin flap model based on the superficial caudal epigastric vessels in the rat may also allow for the evaluation of different therapies and compounds to counteract ischemia-reperfusion injury-related damage.

Ischemia-reperfusion injury is the main cause of flap failure in reconstructive microsurgery. The rat is the preferred preclinical animal model in many ...

Evaluation of Capnography Sampling Line Compatibility and Accuracy when Used with a Portable Capnography Monitor

Capnography is commonly used to monitor patient&#8217;s ventilatory status. While sidestream capnography has been shown to provide a reliable assessment of end-tidal CO2 (ETCO2), its accuracy is commonly validated using commercial kits composed of a capnography monitor and its matching disposable nasal cannula sampling lines. The purpose of this study was to assess the compatibility and accuracy of cross-paired capnography sampling lines with a single portable bedside capnography monitor. A series of 4 bench tests were performed to evaluate the tensile strength, rise time, ETCO2 accuracy as a function of respiratory rate, and ETCO2 accuracy in the presence of supplemental O2. Each bench test was performed using specialized, validated equipment to allow for a full evaluation of sampling line performance. The 4 bench tests successfully differentiated between sampling lines from different commercial sources and suggested that due to increased rise time and decreased ETCO2 accuracy, not all nasal cannula sampling lines provide reliable clinical data when cross-paired with a commercial capnography monitor. Care should be taken to ensure that any cross-pairing of capnography monitors and disposable sampling lines is fully validated for use across respiratory rates and supplemental O2 flow rates commonly encountered in clinical settings.

The goal of this study was to evaluate the accuracy of capnography sampling lines used in conjunction with a portable bedside capnography monitor. Sampling lines from 7 manufacturers were evaluated for tensile strength, rise time, and ETCO2 accuracy as a function of respiratory rate or supplemental oxygen flow rate.

Capnography is commonly used to monitor patient&#8217;s ventilatory status. While sidestream capnography has been shown to provide a reliable assessment ...

A Minimally Invasive Method for Intratracheal Instillation of Drugs in Neonatal Rodents to Treat Lung Disease

Treatment of neonatal rodent with drugs instilled directly into the trachea could serve as a valuable tool to study the impact of a locally administered drug. This has direct translational impact because surfactant and drugs are administered locally into the lungs. Though the literature has many publications describing minimally invasive transoral intubation of adult mice and rats in therapeutic experiments, this approach in neonatal rat pups is lacking. The small size of orotracheal region/pharynx in the pups makes visualization of laryngeal lumen (vocal cords) difficult, contributing to the variable success rate of intratracheal drug delivery. We hereby demonstrate effective oral intubation of neonatal rat pup - a technique that is non-traumatic and minimally-invasive, so that it can be used for serial administration of drugs. We used an operating otoscope with an illumination system and a magnifying lens to visualize the tracheal opening of the rat neonates. The drug is then instilled using a 1 mL syringe connected to a pipette tip. The accuracy of the delivery method was demonstrated using Evans blue dye administration. This method is easy to get trained in and could serve as an effective way to instill drugs into trachea. This method could also be used for administration of inoculum or agents to simulate disease conditions in animals and, also, for cell-based treatment strategies for various lung diseases.

This technique of instilling drugs directly into the trachea of neonatal rodents is important in studying the impact of locally administered drugs or biologicals on neonatal lung diseases. Additionally, this method can also be used for inducing lung injury in animal models.

Treatment of neonatal rodent with drugs instilled directly into the trachea could serve as a valuable tool to study the impact of a locally administered ...