Written informed consent has been obtained from the patient to use medical data and the operative video for education and scientific purposes. This research was performed in compliance with all institutional, national, and international guidelines for human welfare.
1. Positioning and robot docking
<ol>
	<li>Position the patient on a vacuum mattress in a supine French position. Lower the right arm alongside the body on an arm support and extend the left arm. Tilt the operating table 10-20&#176; in anti-Trendelenburg and 5-10&#176; to the right.</li>
	<li>After all safety procedures (hood, sterile glove, and sterile scrub) are ascertained, create a sterile exposition. Make a 2 mm incision in the left hypochondrium on the midclavicular line and create a pneumoperitoneum with CO2 to 15 mmHg by placing a Veress needle.</li>
	<li>Insert the robotic camera through a visiport 12 mm trocar in the right pararectal space just below the umbilicus and perform a diagnostic laparoscopy. Once diagnostic laparoscopy confirms no contraindication for surgery, place the remaining trocars as shown in Figure 2.
	<ol>
		<li>Place four 8 mm trocars above the umbilicus and introduce a 12 mm laparoscopic assistant trocar for the bedside surgeon on the right side of the umbilicus.</li>
		<li>Ensure that the bedside surgeon can reach the transection area for suctioning, compression, clipping, and stapling without difficulty. The distance between the four ventral trocars is approximately 8 cm.</li>
	</ol>
	</li>
	<li>Place the robot on the right side next to the patient and dock the arms to the four robotic trocars.</li>
	<li>Ensure that the first surgeon takes place at the robot console and the bedside surgeon between the patient&#39;s legs.</li>
</ol>
2. Mobilization
<ol>
	<li>Start with the mobilization of the left lobe. Divide the round and falciform ligaments using the robotic cautery hook and vessel sealer.</li>
	<li>Then, continue the mobilization by dividing the left coronary and triangular ligaments using the robotic cautery hook and/or vessel sealer. 
	NOTE: It is important not to injure the left hepatic vein and branches of the phrenic vein, often located nearby and draining into the left hepatic vein.</li>
	<li>Open the triangular ligament using the robotic cautery hook and/or vessel sealer all the way toward the origin of the left hepatic vein. Dissection is completed until the origin of the left hepatic vein is reached.</li>
	<li>Visualize the lesser omentum by lifting the inferior aspect of the liver cranially. Dissect the lesser omentum using a vessel sealer. 
	&#8203;NOTE: If an aberrant left hepatic artery is present, ligate using the robotic cautery hook and/or vessel sealer.</li>
</ol>
3. Hilar dissection
<ol>
	<li>Identify the proper and left hepatic artery in the hepatoduodenal ligament by lifting the liver cranially and moving the robotic camera to the hilum.</li>
	<li>Dissect and isolate the left hepatic artery using both the robotic cautery hook and bipolar forceps (optional: Maryland bipolar forceps).</li>
	<li>After visualizing the left hepatic artery, identify and dissect the origin of the right hepatic artery to make sure it is preserved.</li>
	<li>Then, dissect and isolate the left portal vein carefully. Switch the view to ICG-fluorescence imaging to identify the exact localization and trajectory of the left bile duct with respect to the left portal vein. 
	&#8203;NOTE: ICG was administered preoperatively in parallel to induction of general anesthesia prior to the start of the surgery.</li>
</ol>
4. Cholecystectomy
<ol>
	<li>Identify the cystic duct and artery.</li>
	<li>First, dissect and isolate the cystic duct and artery using the robotic cautery hook to achieve the critical view of safety, also known as the Calot&#39;s Triangle.</li>
	<li>Clip both cystic duct and artery using polymer locking clips. Place two clips proximally and one distally on the cystic duct. Place one clip proximally and one clip distally for the cystic artery.</li>
	<li>Divide the cystic duct and artery between the clips with robotic scissors.</li>
	<li>Second, dissect the gallbladder circumferentially off the liver using a robotic cautery hook until the gallbladder is detached from the liver.</li>
	<li>Place the resected gallbladder in an extraction bag and position it outside of the working field.</li>
</ol>
5. Vascular transection
<ol>
	<li>Prepare a pringle loop by passing a vessel loop around the hepatoduodenal ligament. During this procedure, the pringle maneuver was not applied.</li>
	<li>Perform an intraoperative ultrasound (IOUS) of the liver to confirm the localization, borders, and depth of the biliary cyst.</li>
	<li>Switch the view to ICG-fluorescence imaging to confirm the trajectory of the right and left hepatic duct before heading to the arterial and venous hilar transection.</li>
	<li>First, clip the left hepatic artery carefully with polymer locking clips by placing two clips proximally and one distally.</li>
	<li>Divide the left hepatic artery between the clips with robotic scissors.</li>
	<li>Pass a vessel loop around the left portal vein using the Maryland bipolar forceps to ensure isolation of the left portal vein with preservation of the segment 1 branch.</li>
	<li>Then, clip the left portal vein with polymer locking clips by placing two clips proximally and one distally.</li>
	<li>Divide the left portal vein between the clips with robotic scissors. 
	&#8203;NOTE: The left hepatic bile duct is not divided during this phase of the procedure to ensure no injury to the right hepatic duct.</li>
</ol>
6. Parenchymal transection
<ol>
	<li>Visualize the ischemia line on the liver surface. The ischemia line should overlap the Cantlie&#39;s line since the aim is to perform anatomical left hepatectomy. Mark the transection line following the ischemia line using a cautery hook.</li>
	<li>Perform the superficial part of the transection using a cautery hook until a depth of 1 cm parenchyma is reached. For the deeper parenchyma, use the vessel sealer, the cautery spatula, and Maryland bipolar forceps.</li>
	<li>Control intrahepatic vascular and biliary structures with the vessel sealer as well. Control any intrahepatic small bleeding using the cautery spatula or bipolar forceps. Now carefully identify the branch of the middle hepatic vein for preservation.</li>
	<li>Transect the parenchyma until the left hepatic vein is reached. Before completion of the parenchymal transection, move back to the hilum to focus on the left hepatic duct.</li>
	<li>Switch the view to ICG-fluorescence imaging to confirm the exact trajectory, size, and localization of the left hepatic duct.</li>
	<li>Dissect the left hepatic duct carefully using the Maryland bipolar forceps.</li>
	<li>At last, clip the left hepatic duct with polymer locking clips by placing one clip proximally and one clip distally. Divide the left hepatic duct between the clips with robotic scissors. The procedure ends with the division of the left hepatic vein.</li>
	<li>Pass a vessel loop around the remaining liver parenchyma and left hepatic vein for the hanging maneuver. 
	NOTE: This allows retraction of the right lobe of the liver toward the right side and puts tension on the remaining liver parenchyma and left hepatic vein to be able to get a better vision and grip on the left hepatic vein.</li>
	<li>Then, divide the left hepatic vein using a laparoscopic stapler.</li>
	<li>After completion of the left hepatectomy, place the resected specimen in an extraction bag and take both the specimen and gallbladder out through a Pfannenstiel incision. No intra-abdominal drain was placed.</li>
</ol>

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The authors have nothing to disclose.

The use of robotic major MILS has increased gradually over the years for both benign and malignant indications. However, robotic major left hepatectomy is still a technically demanding procedure and it is, therefore, suggested to follow a structured approach, including six main steps: positioning and docking of the robotic system, mobilization of the left lobe, hilar dissection, cholecystectomy, vascular transection, and parenchymal transection.
ICG-fluorescence imaging is emerging as a promising and useful tool during robotic liver surgery as applied in the current procedure. While IOUS is routinely performed during robotic MILS and provides the most actual information on number and size of lesions, and its relation to anatomical structures26, it may be technically challenging due to limitations in free-range of motion and lack of information on precise biliary tract anatomy27. ICG-fluorescence imaging can, therefore, aid the surgeon in both visualizing liver lesions and the exact trajectory of intra- and extrahepatic biliary ducts to perform an uncomplicated robotic liver resection. Previously published retrospective studies on ICG-fluorescence imaging during liver surgery primarily focused on the sensitivity of ICG-fluorescence imaging and detection of additional liver lesions as compared to IOUS rather than focusing on the intra- and postoperative impact of enhanced intraoperative visualization of biliary tract anatomy28,29,30. These studies showed that significantly more additional lesions were identified in patients where ICG-imaging was performed compared to IOUS with comparable intra- and postoperative outcomes between both groups. Of note, these studies didn&#39;t include robotic MILS.
Parenchymal transection is one of the most critical steps during robotic MILS and accounts for the majority of blood loss, being a major determinant of morbidity and mortality. A careful and structured approach with the use of appropriate robotic instruments is therefore necessary. Transection techniques have evolved over time from the clamp-crush technique to the use of a variety of energy devices31,32. Ultrasonic dissection devices such as the Cavitron Ultrasonic Aspirator (CUSA) offer superior visualization of intrahepatic structures and are often used during parenchymal transection32. However, the laparoscopic CUSA is the only available ultrasonic dissection device successfully integrated into laparoscopic MILS, not available for robotic MILS33,34. During the current robotic procedure, a cautery hook was used for the superficial part of the liver and both the vessel sealer and the cautery spatula for the deeper parenchyma. Of note, a recent survey study highlighted that 70% of the surgeons performing robotic MILS were dissatisfied with the available robotic instruments for liver parenchymal transection34. The development of new instruments for robotic parenchymal transection might help to further improve outcomes after liver surgery and increase the adoption of robotic MILS.
Blood loss, operative time, and length of hospital stay of the current procedure were favorable and comparable with recent series on major robotic MILS22,23. Furthermore, the robotic procedure has similar intra- and postoperative outcomes as compared to laparoscopic MILS35,36. However, it is important to emphasize that robotic MILS is costly and more challenging as compared to the laparoscopic and open approach. Specific training in robotic MILS in combination with extensive experience in both open and laparoscopic liver surgery is needed to perform robotic MILS safely37. We therefore believe that robotic major MILS such as a robotic left hepatectomy should be limited to high-volume MILS centers and a careful selection of patients should be applied.
In summary, this manuscript provides the detailed steps of a robotic left hepatectomy, as performed at Amsterdam UMC in the Netherlands. A robotic left hepatectomy is technically demanding, yet a feasible and safe procedure. ICG-fluorescence imaging may be helpful in delineating BC and bile duct anatomy. Further comparative studies are needed to confirm clinical benefits of robotic MILS for benign and malignant indications.

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract1. Approximately 1% of all benign biliary diseases are BC with an incidence of 1:1000 in Asian countries and 1:100,000 to 1:150,000 in western countries1,2. While the majority of cases are diagnosed during infancy or childhood, 20% of the cases are diagnosed in adults2. BC are divided into groups as per the Todani classification3. The early diagnosis and treatment are crucial since BC are associated with a risk of carcinogenesis, not only occurring more often in these patients but also 10-15 years before the disease is manifested4,5,6. The overall risk of malignancy has been reported to be 10%-15%, and depends on the Todani classification and age1,6. While patients aged 31-50 years with BC have a risk of 19% of carcinogenesis, 51-70-year-old patients with BC were reported to have a risk of at least 50% of carcinogenesis7. Surgery is the cornerstone treatment of BC8. While total BC excision and Roux-Y hepaticojejunostomy is the treatment method of the choice in patients with extrahepatic BC (i.e., Todani I-IV), patients with intrahepatic BC (i.e., Todani V) benefit the most from a surgical liver resection or liver transplantation in case of bilobar Todani V8.
In recent years, minimally invasive liver surgery (MILS), including laparoscopic and robotic MILS has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications9,10,11,12. According to the most recent international Southampton guidelines on laparoscopic liver surgery, laparoscopy is now seen as the gold standard for minor liver resections and laparoscopic major liver resections are considered feasible and safe in selected patients if performed by surgeons who have completed the learning curve for minor laparoscopic liver surgery. However, laparoscopic liver surgery has some persistent limitations, including restriction of movements, presence of physiologic tremors and reduced visualization13,14. Robotic MILS is, therefore, a valuable alternative to laparoscopic MILS. It is suggested that robotic MILS provides a better magnified three-dimensional view, tremor filtration, improved dexterity with several degrees of freedom, ease of suturing, and better motion scaling, as compared to laparoscopic liver surgery15,16,17. Furthermore, robotic MILS allows the surgeon to remain in a seated posture, reducing fatigue during surgery18. While some studies reported on the potential advantages of robotic MILS as compared to open liver surgery, several high-volume expert centers showed similar outcomes of both minor and major robotic and laparoscopic MILS14,18,19,20. However, major robotic MILS, defined as the resection of three or more Couinaud&#39;s segments21, is still considered technically demanding and a detailed description of the technical approach during robotic major MILS had only been discussed limitedly in the literature. Studies describing the technique and use of robotic MILS for the treatment of BC Todani Type V are lacking.
Here, we describe our robotic technique of a left hepatectomy using Indocyanine green (ICG) fluorescence imaging for a symptomatic complex BC. This case involves a 68-year-old woman who had elevated liver enzymes during a routine check-up without any clinical symptoms. An abdominal ultrasound of the liver revealed intrahepatic dilatation of the biliary ducts specifically in the left hemi liver without a clear lesion. Further diagnostic examinations, including an abdominal CT scan, MRI scan, (Figure 1) and MRCP, showed a large intrahepatic complex cystic lesion of 40 mm on the border of segment 4a and 4b in continuity with the biliary tree with intrahepatic dilatation of biliary ducts in the left lobe. The patient was diagnosed with a large BC Todani Type V of the left hepatic duct and was recommended for a robotic left hepatectomy. Since there were no signs of biliary obstruction, preoperative biliary drainage was not performed.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Systems</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Arietta V70 Ultrasound</td>
			<td>Hitachi</td>
			<td>-</td>
			<td>The ultrasound system.</td>
		</tr>
		<tr>
			<td>da Vinci Surgeon Console</td>
			<td>IS</td>
			<td>SS999</td>
			<td>Used to control the surgical robot.</td>
		</tr>
		<tr>
			<td>da Vinci Vision Cart</td>
			<td>IS</td>
			<td>VS999</td>
			<td>The vision cart houses advanced vision and energy technologies and provides communications across da Vinci system components.</td>
		</tr>
		<tr>
			<td>da Vinci Xi</td>
			<td>IS</td>
			<td>K131861</td>
			<td>The surgical robot: &#8217;patient side-cart&#8217;.</td>
		</tr>
		<tr>
			<td>Robotic ultrasonography transducer</td>
			<td>Hitachi</td>
			<td>L43K</td>
			<td>Used for intraoperative laparoscopic ultrasonography.</td>
		</tr>
		<tr>
			<td>Instruments</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>da Vinci Xi Endoscope with Camera, 8 mm, 30&#730;</td>
			<td>IS</td>
			<td>470027</td>
			<td>The camera of the da Vinci robot.</td>
		</tr>
		<tr>
			<td>EndoWrist Fenestrated Bipolar Forceps</td>
			<td>IS</td>
			<td>470205</td>
			<td>Used for dissection and coagulation.</td>
		</tr>
		<tr>
			<td>EndoWrist HOT SHEARS</td>
			<td>IS</td>
			<td>470179</td>
			<td>Used for cutting and coagulation.</td>
		</tr>
		<tr>
			<td>EndoWrist Maryland Bipolar Forceps</td>
			<td>IS</td>
			<td>470172</td>
			<td>Used for dissection.</td>
		</tr>
		<tr>
			<td>EndoWrist Permanent Cautery Hook</td>
			<td>IS</td>
			<td>470183</td>
			<td>Used for coagulation.</td>
		</tr>
		<tr>
			<td>EndoWrist Medium-Large Clip Applier</td>
			<td>IS</td>
			<td>470327</td>
			<td>Used for clipping with Weck Hem-o-lok medium-large polymer clip</td>
		</tr>
		<tr>
			<td>EndoWrist Stapler 45 Instrument</td>
			<td>IS</td>
			<td>470298</td>
			<td>Used for stappling</td>
		</tr>
		<tr>
			<td>Vessel sealer</td>
			<td>IS</td>
			<td>480322</td>
			<td>Used for vessel sealing and dividing.</td>
		</tr>
	</tbody>
</table>

robotic left hepatectomy using indocyanine green fluorescence imaging for an intrahepatic complex biliary cyst

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. Surgery is the cornerstone treatment for patients with BC. While total BC excision and Roux-Y hepaticojejunostomy is the treatment method of the choice in patients with extrahepatic BC (i.e., Todani I-IV), patients with intrahepatic BC (i.e., Todani V) benefit the most from a surgical liver resection. In recent years, minimally invasive liver surgery (MILS) including robotic MILS has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. Robotic major MILS is still considered technically demanding and a detailed description of the technical approach during robotic major MILS has only been limitedly discussed in the literature. The current article describes the main steps for a robotic left hepatectomy in a patient with a large BC Todani Type V. The patient is in French position with 5 trocars placed (4 robotic, 1 laparoscopic assistant). After mobilizing the left hemiliver, the left and right hepatic artery are dissected carefully followed by a cholecystectomy. Intraoperative ultrasound is performed to confirm localization and margins of the BC. The Left hepatic artery and left portal vein are isolated, clipped, and divided. Indocyanine green (ICG) fluorescence imaging is used regularly during the entire procedure to visualize and confirm biliary tract anatomy and the BC. Parenchymal transection is performed with robotic cautery hook for the superficial part and robotic cautery spatula, bipolar cautery, and vessel sealer for the deeper parenchyma. The postoperative course was uncomplicated. A robotic left hepatectomy is technically demanding, yet a feasible and safe procedure. ICG-fluorescence imaging aids in delineating the BC and bile duct anatomy. Further, comparative studies are needed to confirm clinical benefits of robotic MILS for benign and malignant indications.

Representative results are shown in Table 1. Following the surgical technique in the protocol, the operative time was 189 min with an intraoperative blood loss of 10 mL. No conversion to laparotomy was needed and no intraoperative incidents occurred. The postoperative course was uncomplicated without any postoperative complications. The patient was discharged on postoperative day 4.
The final histopathological examination revealed a large complex cyst of 3.1 cm in continuity with a biliary branch of the left hepatic duct without any suspicion for malignancy.
Comparable result from literature 
Several studies investigated outcomes of major robotic liver surgery, including robotic left hepatectomy22,23,24. An operative time of 383 min (IQR 240-580 min)23 with an estimated intraoperative blood loss of 300 mL (IQR 100-1,000)23 has been described previously. With regards to postoperative outcomes, a length of hospital stay of 3 days (IQR 3-5 days)22,24, a favorable Clavien-Dindo &#8805; grade III complication rate of 7.0%24 and a remarkable low mortality rate (0%)22,23,24 were reported.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/63265/63265fig01.jpg" /> 
Figure 1: The appearance of the biliary cyst and the relationship with the left biliary tree on MRI-scan <a href="https://www.jove.com/files/ftp_upload/63265/63265fig01large.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/63265/63265fig02.jpg" /> 
Figure 2: Trocar placement. R1: robotic trocar at right anterior axillary line; R2: robotic trocar at right mid-clavicular line; R3: robotic trocar on midline; R4: robotic trocar at left mid-clavicular line. L1: laparoscopic assistant trocar on the right side of the umbilicus. This figure is adapted from Ka&#231;maz, E. et al. 202025. <a href="https://www.jove.com/files/ftp_upload/63265/63265fig02large.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>Variable</td>
			<td>Outcome</td>
		</tr>
		<tr>
			<td colspan="2">Intraoperative</td>
		</tr>
		<tr>
			<td>Operative time (min)</td>
			<td>189</td>
		</tr>
		<tr>
			<td>Conversion to laparotomy</td>
			<td>No</td>
		</tr>
		<tr>
			<td>Estimated intraoperative blood loss (mL)</td>
			<td>10</td>
		</tr>
		<tr>
			<td>Intraoperative incidents</td>
			<td>No</td>
		</tr>
		<tr>
			<td colspan="2">Postoperative</td>
		</tr>
		<tr>
			<td>Clavien-Dindo complication</td>
			<td>No</td>
		</tr>
		<tr>
			<td>Clavien-Dindo complication &#8805; grade III</td>
			<td>No</td>
		</tr>
		<tr>
			<td>90-day Reoperation</td>
			<td>No</td>
		</tr>
		<tr>
			<td>Length of hospital stay, days</td>
			<td>4</td>
		</tr>
		<tr>
			<td>90-day readmission</td>
			<td>No</td>
		</tr>
		<tr>
			<td>90-day/in-hospital mortality</td>
			<td>No</td>
		</tr>
		<tr>
			<td>Pathological diagnosis</td>
			<td>Large complex biliary cyst without malignancy</td>
		</tr>
	</tbody>
</table>
Table 1: Outcome of the surgery

Watch this Scientific Journal Video about Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst at JoVE.com

Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

Robotic liver surgery has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. However, robotic left hepatectomy is still technically demanding. We describe our surgical technique of a robotic left hepatectomy using indocyanine green fluorescence imaging for a large biliary cyst.

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. ...

robotic-left-hepatectomy-using-indocyanine-green-fluorescence-imaging

Research

JoVE Journal

Medicine

5.3K Views.  Amsterdam UMC, location University of Amsterdam. Robotic liver surgery has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. However, robotic left hepatectomy is still technically demanding. We describe our surgical technique of a robotic left hepatectomy using indocyanine green fluorescence imaging for a large biliary cyst.

Video: Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

An Investigation of the Effects of Sports-related Concussion in Youth Using Functional Magnetic Resonance Imaging and the Head Impact Telemetry System

One of the most commonly reported injuries in children who participate in sports is concussion or mild traumatic brain injury (mTBI)1. Children and youth involved in organized sports such as competitive hockey are nearly six times more likely to suffer a severe concussion compared to children involved in other leisure physical activities2. While the most common cognitive sequelae of mTBI appear similar for children and adults, the recovery profile and breadth of consequences in children remains largely unknown2, as does the influence of pre-injury characteristics (e.g. gender) and injury details (e.g. magnitude and direction of impact) on long-term outcomes. Competitive sports, such as hockey, allow the rare opportunity to utilize a pre-post design to obtain pre-injury data before concussion occurs on youth characteristics and functioning and to relate this to outcome following injury. Our primary goals are to refine pediatric concussion diagnosis and management based on research evidence that is specific to children and youth. To do this we use new, multi-modal and integrative approaches that will:
 1.Evaluate the immediate effects of head trauma in youth 
2.Monitor the resolution of post-concussion symptoms (PCS) and cognitive performance during recovery 
3.Utilize new methods to verify brain injury and recovery
To achieve our goals, we have implemented the Head Impact Telemetry (HIT) System. (Simbex; Lebanon, NH, USA). This system equips commercially available Easton S9 hockey helmets (Easton-Bell Sports; Van Nuys, CA, USA) with single-axis accelerometers designed to measure real-time head accelerations during contact sport participation 3 - 5. By using telemetric technology, the magnitude of acceleration and location of all head impacts during sport participation can be objectively detected and recorded. We also use functional magnetic resonance imaging (fMRI) to localize and assess changes in neural activity specifically in the medial temporal and frontal lobes during the performance of cognitive tasks, since those are the cerebral regions most sensitive to concussive head injury 6. Finally, we are acquiring structural imaging data sensitive to damage in brain white matter.

This article provides an overview of a multi-modal approach to mild traumatic brain injury diagnosis and recovery in youth. This approach combines neuropsychological testing with functional magnetic resonance imaging and the Head Impact Telemetry System to monitor the relationship between head impacts and brain activity during cognitive testing.

One of the most commonly reported injuries in children who participate in sports is concussion or mild traumatic brain injury (mTBI)1. Children and youth ...

3-Dimensional Resin Casting and Imaging of Mouse Portal Vein or Intrahepatic Bile Duct System

In organs, the correct architecture of vascular and ductal structures is indispensable for proper physiological function, and the formation and maintenance of these structures is a highly regulated process. The analysis of these complex, 3-dimensional structures has greatly depended on either 2-dimensional examination in section or on dye injection studies. These techniques, however, are not able to provide a complete and quantifiable representation of the ductal or vascular structures they are intended to elucidate. Alternatively, the nature of 3-dimensional plastic resin casts generates a permanent snapshot of the system and is a novel and widely useful technique for visualizing and quantifying 3-dimensional structures and networks.
A crucial advantage of the resin casting system is the ability to determine the intact and connected, or communicating, structure of a blood vessel or duct. The structure of vascular and ductal networks are crucial for organ function, and this technique has the potential to aid study of vascular and ductal networks in several ways. Resin casting may be used to analyze normal morphology and functional architecture of a luminal structure, identify developmental morphogenetic changes, and uncover morphological differences in tissue architecture between normal and disease states. Previous work has utilized resin casting to study, for example, architectural and functional defects within the mouse intrahepatic bile duct system that were not reflected in 2-dimensional analysis of the structure1,2, alterations in brain vasculature of a Alzheimer's disease mouse model3, portal vein abnormalities in portal hypertensive and cirrhotic mice4, developmental steps in rat lymphatic maturation between immature and adult lungs5, immediate microvascular changes in the rat liver, pancreas, and kidney in response in to chemical injury6.
Here we present a method of generating a 3-dimensional resin cast of a mouse vascular or ductal network, focusing specifically on the portal vein and intrahepatic bile duct. These casts can be visualized by clearing or macerating the tissue and can then be analyzed. This technique can be applied to virtually any vascular or ductal system and would be directly applicable to any study inquiring into the development, function, maintenance, or injury of a 3-dimensional ductal or vascular structure.

A method of visualizing and quantifying the 3-dimensional structure of mouse hepatic portal vein or intrahepatic bile duct is described. This resin cast technique can also be applied to other ductal or vascular systems and allows for in situ visualization or quantification of a system's intact communicating architecture.

In  organs, the correct architecture of vascular and ductal structures is  indispensable for proper physiological function, and the formation and  ...

Detecting Abnormalities in Choroidal Vasculature in a Mouse Model of Age-related Macular Degeneration by Time-course Indocyanine Green Angiography

Indocyanine Green&#160;Angiography (or ICGA) is a technique performed by ophthalmologists to diagnose abnormalities of the choroidal and retinal vasculature of various eye diseases such as age-related macular degeneration (AMD). ICGA is especially useful to image the posterior choroidal vasculature of the eye due to its capability of penetrating through the pigmented layer with its infrared spectrum. ICGA time course can be divided into early, middle, and late phases. The three phases provide valuable information on the pathology of eye problems. Although time-course ICGA by intravenous (IV) injection is widely used in the clinic for the diagnosis and management of choroid problems, ICGA by intraperitoneal injection (IP) is commonly used in animal research. Here we demonstrated the technique to obtain high-resolution ICGA time-course images in mice by tail-vein injection and confocal scanning laser ophthalmoscopy. We used this technique to image the choroidal lesions in a mouse model of age-related macular degeneration. Although it is much easier to introduce ICG to the mouse vasculature by IP, our data indicate that it is difficult to obtain reproducible ICGA time course images by IP-ICGA. In contrast, ICGA via tail vein injection provides high quality ICGA time-course images comparable to human studies. In addition, we showed that ICGA performed on albino mice gives clearer pictures of choroidal vessels than that performed on pigmented mice. We suggest that time-course IV-ICGA should become a standard practice in AMD research based on animal models.

Indocyanine Green Angiography (or ICGA) performed by tail vein injection provides high quality ICGA time course images to characterize abnormalities in mouse choroid.

Indocyanine Green&#160;Angiography (or ICGA) is a technique performed by ophthalmologists to diagnose abnormalities of the choroidal and retinal ...

Visualization of Vascular and Parenchymal Regeneration after 70% Partial Hepatectomy in Normal Mice

A modified silicone injection procedure was used for visualization of the hepatic vascular tree. This procedure consisted of in-vivo injection of the silicone compound, via a 26 G catheter, into the portal or hepatic vein. After silicone injection, organs were explanted and prepared for ex-vivo micro-CT (&#181;CT) scanning. The silicone injection procedure is technically challenging. Achieving a successful outcome requires extensive microsurgical experience from the surgeon. One of the challenges of this procedure involves determining the adequate perfusion rate for the silicone compound. The perfusion rate for the silicone compound needs to be defined based on the hemodynamic of the vascular system of interest. Inappropriate perfusion rate can lead to an incomplete perfusion, artificial dilation and rupturing of vascular trees.
The 3D reconstruction of the vascular system was based on CT scans and was achieved using preclinical software such as HepaVision. The quality of the reconstructed vascular tree was directly related to the quality of silicone perfusion. Subsequently computed vascular parameters indicative of vascular growth, such as total vascular volume, were calculated based on the vascular reconstructions. Contrasting the vascular tree with silicone allowed for subsequent histological work-up of the specimen after &#181;CT scanning. The specimen can be subjected to serial sectioning, histological analysis and whole slide scanning, and thereafter to 3D reconstruction of the vascular trees based on histological images. This is the prerequisite for the detection of molecular events and their distribution with respect to the vascular tree. This modified silicone injection procedure can also be used to visualize and reconstruct the vascular systems of other organs. This technique has the potential to be extensively applied to studies concerning vascular anatomy and growth in various animal and disease models.

Tools used for visualizing vascular regeneration require methods for contrasting the vascular trees. This film demonstrated a delicate injection technique used to achieve optimal contrasting of the vascular trees and illustrate the potential benefits resulting from a detailed analysis of the resulting specimen using &#181;CT and histological serial sections.

A modified silicone injection procedure was used for visualization of the hepatic vascular tree. This procedure consisted of in-vivo injection of the ...

Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary biliary drainage method whenever possible. Percutaneous Transhepatic Biliary Drainage (PTBD) is used as a salvage method if ERCP fails. Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) provides a feasible alternative biliary drainage method where one of the methods is EUS guided Hepaticogastrostomy (EUS-HGS). Here we describe the EUS-HGS technique in a case of unresectable malignant hilar biliary obstruction to achieve biliary drainage.
Presented here is the case of a 71-year-old female with painless jaundice and weight loss for 2 weeks. Computed Tomography (CT) imaging showed a 4 x 5 cm hilar tumor with lymphadenopathy and liver metastasis. EUS fine needle biopsy (FNB) of the lesion was consistent with cholangiocarcinoma. Her bilirubin levels were 212 &#181;mol/L (&lt;15) during presentation.
A linear echoendoscope was used to locate the left dilated intrahepatic ducts (IHD) of the liver. The segment 3 dilated IHD was identified and punctured using a 19 G needle. Contrast was used to opacify the IHDs under fluoroscopic guidance. The IHD was cannulated using a 0.025-inch guidewire. This was followed by the dilation of the fistula tract using a 6 Fr electrocautery dilator along with a 4 mm biliary balloon dilator. A partially covered metallic stent of 10 cm in length was deployed under fluoroscopic guidance. The distal part opens in the IHD and the proximal part was deployed within the working channel of the echoendoscope that subsequently released into the stomach. The patient was discharged three days after the procedure. Follow up performed in the second and fourth weeks showed that the bilirubin levels were 30 &#181;mol/L and 14 &#181;mol/L, respectively. This indicates that EUS-HGS is a safe method for biliary drainage in unresectable malignant biliary obstruction.

Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) is an alternative method of biliary decompression in malignant biliary obstruction. Here we describe the technique of EUS guided-Hepaticogastrostomy (EUS-HGS) in a case of unresectable malignant hilar biliary obstruction.

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde ...

Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing pancreatitis, if it does not resolve or is accompanied with infected necrosis in the retroperitoneum. As there are rarely any visually clear separating surface in white light image between necrotic debris and adjacent inflammatory normal tissues due to extensive retroperitoneal adhesions, VARD is accompanied with the risk of vascular injury, external pancreatico-cutaneous or enterocutaneous fistulae. In view of the above disadvantages, we apply real-time intraoperative near-infrared fluorescence imaging with indocyanine green (ICG) during VARD, which enables visualization of the well-perfused adjacent normal tissues. This modified technique (ICG-guided VARD) can provide a clear separating surface during debridement and reduce the risk of vascular or enteric injury. ICG-guided VARD may facilitate surgeons to perform safer debridement in treating severe acute necrotizing pancreatitis.

This protocol presents Indocyanine Green-guided video-assisted retroperitoneal debridement (ICG-guided VARD) for treating severe acute necrotizing pancreatitis.

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing ...

Robotic Taj Mahal Hepatectomy for Hilar Cholangiocarcinoma

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In this study, a 32-year-old male patient with Bismuth Type IVa hilar cholangiocarcinoma underwent radical robotic resection of hepatic S4b, S5, and S1 (Taj Mahal hepatectomy) combined with regional lymphadenectomy, hilar bile duct reconstruction, and hepaticojejunostomy by the robotic surgical system. Postoperative pathological examination showed moderately-differentiated adenocarcinoma of the hilar bile duct. The surgical margins of the liver and bile ducts were negative. Recovery was smooth and the patient was discharged on the 17th postoperative day. The robotic surgical system and associated multiple instruments along with flexible and precise movements is suitable for the local hepatectomy around the porta hepatis, and delicate reconstruction of the hilar bile duct with a smaller diameter. This first clinical application study found that robotic Taj Mahal hepatectomy for hilar cholangiocarcinoma is safe and feasible and needs more experience for the evaluation of its long-term outcomes.

Robotic resection of hepatic S4b, S5, and S1 using the Taj Mahal procedure is feasible and safe for selected patients with hilar cholangiocarcinoma. The step-by-step details for this surgery are presented here.

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In ...

Semi-Automated Planimetric Quantification of Dental Plaque Using an Intraoral Fluorescence Camera

Dental plaque accumulation is quantified using clinical indices or, otherwise, the planimetric plaque index (PPI),&#160;which measures the relative area of a tooth that is covered by plaque deposits. Compared to clinical indices, the PPI has a higher discriminatory power, but traditional planimetry is a time-consuming analysis, as the plaque-covered and clean tooth areas have to be determined manually for each image using image-processing software. Here, we present a method for the semi-automated planimetric quantification of dental plaque, which allows for the rapid processing of up to 1,000 images simultaneously. The method exploits the enhanced contrast between disclosed plaque, sound tooth surfaces, and soft tissues in fluorescence images acquired with an intraoral camera. Careful execution of the clinical procedures and accurate image acquisition are crucial steps for the successful semi-automated identification of the plaque-covered areas. The method is suitable for planimetry on sound facial and oral tooth surfaces, on most composite resin restorations, and on teeth with orthodontic brackets, but not on metallic restorations. Compared to traditional PPI recordings, semi-automated planimetry considerably reduces the amount of time spent on the analysis, as well as the subjective human input, thus increasing the reproducibility of planimetric measurements.

This study presents a semi-automated digital image analysis procedure for the planimetric quantification of disclosed dental plaque based on images acquired with an intraoral fluorescence camera. The method allows for the rapid and reliable quantification of dental plaque in the research environment.

Dental plaque accumulation is quantified using clinical indices or, otherwise, the planimetric plaque index (PPI),&#160;which measures the relative area ...

Fluorescent Laparoscopic Central Hepatectomy for Liver Cancer Using Indocyanine Green Negative Staining

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ultrasound, important vascular structures, and surgeon experience. With the development of anatomical hepatectomy, visual surgery technology has gradually been applied to this type of surgery, particularly indocyanine green (ICG)-guided anatomical hepatectomy. As ICG can be specifically ingested by hepatocytes and used for fluorescence tracing, negative staining techniques have been applied according to different tumor positions. Under ICG fluorescent guidance, the surface boundary and deep resection plane can be more accurately displayed during liver resection. Thus, the tumor-bearing liver segment can be anatomically removed, which helps to avoid damage to important vessels and reduce ischemia or congestion of the remaining liver tissue. Finally, the incidence of postoperative biliary fistula and liver dysfunction is reduced; therefore, a better prognosis is obtained after the resection of liver cancer. Centrally located liver cancer is usually defined as a tumor located at segments 4, 5, or 8 that requires resection of the middle section of the liver. These are among the most difficult hepatectomies to perform because of the large surgical wounds and multiple vessel transections. Based on the specific tumor location, we formulated the required resection ranges by designing personalized fluorescent staining strategies. By completing anatomical resection based on the portal territory, this work aims to achieve the best therapeutic effect.

The present protocol describes fluorescent negative staining in laparoscopic central hepatectomy. This technique can make hepatectomy more accurate and precise.

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ...

Microscopic Cyst Resection for the Treatment of Patients Diagnosed with Epididymal Cyst

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative asoedema, hematoma, sustaining pain, and seminal tract obstruction in patients who have undertaken nonmicroscopic epididymal cyst resection or epididymal resection. Nonmicroscopic epididymal cyst surgery is suggested for patients with childbirth plans as a precaution. The treatment of male epididymal cysts via microtechnology is obviously a beneficial option; we took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. From September 2017 to April 2021, 41 young and middle-aged male patients diagnosed with epididymal cysts underwent microtechnology treatment in a program titled &#34;microscopic epididymal exploration and cystectomy&#34;. The postoperative follow-up lasted for 3-50 months. The results confirmed that, as microscopic manipulation largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact under the microscope. Bleeding during the operation was significantly reduced (2-3 mL) and wound drainage was not required. According to follow-up data, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain, thereby promising a higher surgical success rate as well as recurrence prevention. Besides, preliminary experience and reflection suggest that microscopic epididymal exploration and cystectomy provide efficient preservation of the epididymal patency through refined treatment, while a better prognosis can be achieved. We recommend that surgery be carried out before the epididymal cyst develops to 0.8 cm in diameter, for fear that a larger epididymal cyst (&#62;0.9 cm in diameter) could cause the complete destruction of all tubules of the ipsilateral epididymis - a more severe case with damage to the testicular output network.

Here, we present a protocol to treat patients diagnosed with an epididymal cyst using microscopic cyst resection. Based on microscopic manipulation, a largely improved visualization of the subtle tissue structures of the epididymis was obtained, so the cyst could be clearly dissected apart and completely removed intact.

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative ...