Name: modified laparoscopic anatomic hepatectomy: two-surgeon technique combined with the simple extracorporeal pringle maneuver
Uploaded: 2023-06-16T12:40:00
Description: Watch this Scientific Journal Video about Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver at JoVE.com

这项工作得到了中国国家自然科学基金（第81971773号）的资助。

该方案和手术视频演示在手术前获得了患者的知情同意，也获得了中山大学附属第五医院的批准。
1.术前准备
<ol><li>进行实验室检查，包括血液常规检查，肝肾功能检查，消化系统的肿瘤标志物（甲胎蛋白，AFP;癌胚抗原，CEA），凝血酶原时间，国际标准化比值（INR）和15分钟吲哚菁绿保留率（ICG-R15），以评估患者的一般状况。</li>
	<li>进行影像学检查，包括胸?...

<ol>
	<li>Vauthey, J. N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Is+extended+hepatectomy+for+hepatobiliary+malignancy+justified.">Is extended hepatectomy for hepatobiliary malignancy justified.</a> Annals of Surgery. 239 (5), 722-730 (2004).</li><li>Shang, H. 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=Comparison+of+clinical+efficacy+and+complications+between+laparoscopic+partial+and+open+partial+hepatectomy+for+liver+carcinoma:+a+meta-analysis.">Comparison of clinical efficacy and complications between laparoscopic partial and open partial hepatectomy for liver carcinoma: a meta-analysis.</a> Journal of Laparoendoscopic &amp; Advanced Surgical Techniques. Part A. 29 (2), 225-232 (2019).</li><li>Belli, G., 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=Laparoscopic+versus+open+liver+resection+for+hepatocellular+carcinoma+in+patients+with+histologically+proven+cirrhosis:+short-+and+middle-term+results.">Laparoscopic versus open liver resection for hepatocellular carcinoma in patients with histologically proven cirrhosis: short- and middle-term results.</a> Surgical Endoscopy. 21 (11), 2004-2011 (2007).</li><li>Cucchetti, 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=A+comprehensive+meta-regression+analysis+on+outcome+of+anatomic+resection+versus+nonanatomic+resection+for+hepatocellular+carcinoma.">A comprehensive meta-regression analysis on outcome of anatomic resection versus nonanatomic resection for hepatocellular carcinoma.</a> Annals of Surgical Oncology. 19 (12), 3697-3705 (2012).</li><li>Moris, 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=Anatomic+versus+non-anatomic+resection+for+hepatocellular+carcinoma:+A+systematic+review+and+meta-analysis.">Anatomic versus non-anatomic resection for hepatocellular carcinoma: A systematic review and meta-analysis.</a> European Journal of Surgical Oncology. 44 (7), 927-938 (2018).</li><li>Ciria, R., Cherqui, D., Geller, D. 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V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Notes+on+the+arrest+of+hepatic+hemorrhage+due+to+trauma.">Notes on the arrest of hepatic hemorrhage due to trauma.</a> Annals of Surgery. 48 (4), 541-549 (1908).</li><li>Rotellar, F., Pardo, F., Bueno, A., Mart&#237;-Cruchaga, P., Zozaya, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Extracorporeal+tourniquet+method+for+intermittent+hepatic+pedicle+clamping+during+laparoscopic+liver+surgery:+an+easy,+cheap,+and+effective+technique.">Extracorporeal tourniquet method for intermittent hepatic pedicle clamping during laparoscopic liver surgery: an easy, cheap, and effective technique.</a> Langenbeck's Archives of Surgery. 397 (3), 481-485 (2012).</li><li>Piardi, 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=Laparoscopic+Pringle+maneuver:+how+we+do+it.">Laparoscopic Pringle maneuver: how we do it.</a> Hepatobiliary Surgery and Nutrition. 5 (4), 345-349 (2016).</li><li>Aloia, T. 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该协议详细介绍了使用CUSA-超声解剖-体外普林格尔机动技术在我们中心进行的改良LAH。在这种改良的组合技术中，我们同时使用了简单的体外普林格尔操作和低CVP技术来控制和减少术中出血。初级和二级外科医生在实质横断和止血期间分别使用腹腔镜CUSA和超声解剖术，以获得精确和快速的肝切除术。
这位54岁的女性患者是第一个接受我们新的联合技术的患者，其围手术期结?...

近几十年来，肝切除术的安全性显著提高1，随着诊断成像、能量设备和手术技术的快速发展，腹腔镜肝切除术已成为一种广泛实施的手术，可产生良好的临床结果2，3。研究表明，在肝细胞癌4，5 患者中，与非解剖切除术相比，解剖学肝切除术产生更好的结果。因此，腹腔镜解剖肝切除术（LAH）在世界范围内越来越受欢迎6。然而，术中出血仍然是肝切除手术中的主要问题 - 腹腔镜和开放手术涉及解剖和非解剖切除7。此外，术中出血是实质横断面手术从腹腔镜手术转变为开放手术的主要原因8，9。为了有效控制和减少术中出血，广泛建议接受肝切除术的患者将中心静脉压（CVP）保持在5 cmH2O以下10，11.此外，还使用了各种仪器，例如cavitron超声手术吸引器（CUSA）和超声解剖器12，13，并且还记录了许多肝切除技术，包括肝绞痛操作14，Pringle操作15，16和“双外科医生技术”17，18。
Pringle 手法于 1908 年首次报道19，代表了肝流入闭塞最直接的技术，目前在腹腔镜肝切除术中很容易实现，效率很高20，21。
双外科医生技术是作为传统单外科医生方法的替代方案，最初用于开放性肝切除术17。这种方法模糊了初级和二级外科医生之间的分工，两者在实质横断时同时参与，以及使用不同的能量仪器进行止血。研究表明，这种技术可以减少手术时间和术中并发症18，22。Takahisa等人为我们提供了一些执行双外科医生腹腔镜技术的建议23，但不同的中心可能会选择不同的设备来横断肝实质组织，并且仍然缺乏证据证明哪种模式的双外科医生技术产生更好的患者结果。
CUSA是肝切除术中常用的装置，它利用超声波能量破碎和抽吸实质组织，从而实现精确的横切，对血管和胆管的损害最小13。另一个常用的工具是超声波解剖器，它利用两个叶片的振动来破坏氢键并有效切割肝实质，同时凝固直径≤3毫米13的小血管。
2020年7月，我中心首次实施了双外科医生技术。一名外科医生使用CUSA，而另一名外科医生使用超声波解剖。结合简单的体外普林格尔操作和低CVP技术，治疗一名54岁的女性患者，该患者一直出现肝脏肿块，血清甲胎蛋白（AFP）水平升高104ng/mL持续1周。磁共振成像（MRI）（图1A，B）显示位于S5和S8段的肿瘤大小约为2厘米，被认为是原发性肝细胞癌。本文介绍了我们中心在CUSA-超声解剖-体外普林格尔机动技术方面的经验方案。

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>1.0 absorbable suture</td>
			<td>Ethicon Inc</td>
			<td>SN2210023642</td>
			<td>Sterile, radiation sterilization, disposable</td>
		</tr>
		<tr>
			<td>1.0 non-absorbable suture</td>
			<td>Ethicon Inc</td>
			<td>SF1AN</td>
			<td>Sterile, radiation sterilization, disposable</td>
		</tr>
		<tr>
			<td>10-mm trocar</td>
			<td>Hangzhou Optoelectronic Equipment Medical Co., LTD</td>
			<td>121-01715</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>12-mm trocar</td>
			<td>Hangzhou Optoelectronic Equipment Medical Co., LTD</td>
			<td>121-01715</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>5-mm trocar</td>
			<td>Hangzhou Optoelectronic Equipment Medical Co., LTD</td>
			<td>121-01715</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>7.0 non-absorbable suture</td>
			<td>Ethicon Inc</td>
			<td>SF7AN</td>
			<td>Sterile, radiation sterilization, disposable</td>
		</tr>
		<tr>
			<td>Aspirator</td>
			<td>Hangzhou Kangji Medical Instrument Co., LTD</td>
			<td>20172080644</td>
			<td>Sterile,dry heat sterilized, reusable</td>
		</tr>
		<tr>
			<td>Cordless Ultrasonic dissector</td>
			<td>Covidien llc</td>
			<td>SCD396</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>CUSA</td>
			<td>INTEGRA</td>
			<td>HDA1902805IE</td>
			<td>Sterile,dry heat sterilized, reusable</td>
		</tr>
		<tr>
			<td>Electric coagulation hook</td>
			<td>Zhejiang Shuyou Instrument Equipment Co., LTD</td>
			<td>IIIA-D003-SG842</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>Endo-GIA stapler</td>
			<td>Jiangsu Guanchuang Medical Technology Co., LTD</td>
			<td>GCJQB-160</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>Endoscopic specimen bag</td>
			<td>Qingdao Huaren Medical Product Co., LTD</td>
			<td>20192060113</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>Hem-o-lok</td>
			<td>Zhejiang Wedu Medical Instrument Co., LTD</td>
			<td>JY1004-2012003</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>Laparoscopic ultrasound</td>
			<td>BK medical</td>
			<td>flex Focus 800</td>
			<td>Sterile,dry heat sterilized, reusable</td>
		</tr>
		<tr>
			<td>Lumir device (modified Pringle maneuver)</td>
			<td>Shanghai Chester Medical Technology Co., LTD</td>
			<td>016651477</td>
			<td>Sterile,dry heat sterilized, reusable</td>
		</tr>
		<tr>
			<td>Surgicel(absorbable hemostat)</td>
			<td>Ethicon Inc</td>
			<td>LAB0011179V3</td>
			<td>Sterile, radiation sterilization, disposable</td>
		</tr>
		<tr>
			<td>Veress needle</td>
			<td>Hangzhou Kangji Medical Instrument Co., LTD</td>
			<td>20172080644</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
	</tbody>
</table>

modified laparoscopic anatomic hepatectomy: two-surgeon technique combined with the simple extracorporeal pringle maneuver

近年来，腹腔镜解剖肝切除术（LAH）在世界范围内变得越来越普遍。然而，由于肝脏的解剖学特征，LAH仍然是一个具有挑战性的手术，术中出血是主要问题。术中失血是转为开放手术的主要原因;因此，有效管理出血和止血对于成功的LAH至关重要。
建议将双外科医生技术作为传统单外科医生方法的替代方案，在腹腔镜肝切除术期间减少术中出血方面具有潜在益处。然而，仍然缺乏证据来确定哪种模式的双外科医生技术产生更好的患者结局。此外，据我们所知，LAH技术涉及由主外科医生使用cavitron超声手术抽吸器（CUSA），而由第二名外科医生使用超声波解剖器，以前很少有报道。
在这里，我们提出了一种改进的双外科医生LAH技术，其中一名外科医生使用CUSA，而另一名外科医生使用超声解剖器。该技术与简单的体外普林格尔操作和低中心静脉压 （CVP） 方法相结合。在这种改良技术中，初级和二级外科医生同时使用腹腔镜CUSA和超声解剖术来实现精确和快速的肝切除术。采用简单的体外普林格尔手法，结合维持低CVP，以调节肝流入和流出，以尽量减少术中出血。这种方法有助于实现干燥和清洁的手术区域，从而可以精确地结扎和解剖血管和胆管。修改后的LAH程序更简单，更安全，因为它可以有效控制出血以及初级和二级外科医生角色之间的无缝过渡。它为未来的临床应用带来了巨大的希望。

这名 54 岁的女性患者使用 CUSA 超声解剖-体外普林格尔手法技术成功接受了全腹腔镜解剖肝切除术 （S5 + S8v），获得了良好的围手术期结局。在手术过程中，总共进行了四次体外Pringle操作，以控制和减少术中出血。手术持续约145分钟，估计失血量为150毫升。患者迅速康复，术后第6天出院，无并发症。术后CT影像学检查显示无残留肝肿瘤，病理结果提示原发性肝细胞癌，切?...

Watch this Scientific Journal Video about Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver at JoVE.com

Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver

在这里，我们提出了一种使用改进的技术和仪器进行改良腹腔镜解剖肝切除术的方案。

改良腹腔镜解剖肝切除术：双外科医生技术结合简单的体外普林格尔手法

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to ...

这是一段视频，展示了改良的腹腔镜解剖肝切除术，其中包括CUSA和超声解剖术在两位外科医生技术中的结合，以及改良的体外Pringle操作以及低中心静脉压技术。这是一名 54 岁的女性，有一周的肝肿块病史，血清 AFP 水平升高 104 ng/毫升。并且没有其他积极的实验室发现。除心电图心脏超声检查外，肺功能检查显示心肺功能正常。磁共振成像（MRI）显示位于肝脏S5和S8段的肿瘤大小约2厘米，被认为是原发性肝细胞癌。声明，本协议和手术视频演示在手术前获得了患者的知情同意。同时，获得中山大学附属第五医院的批准。方案，术前准备。进行实验室检查，包括血液常规检查、凝血功能检查、肝肾功能检查、AFP、CEA 和 ICG-R15，以评估患者的一般状况。进行影像学检查，包括胸部和上腹部 CT 扫描和肝脏 MRI，以评估肿瘤位置、大小和是否存在远处转移。进行辅助检查，包括心电图、心脏超声和肺功能测试，以评估患者的心肺状况。通过CT体积计算计算肝容量。如果考虑患者进行大切除，两个以上的肝段，保证未来残肝、FLR除肝总体积，TLV比值不低于40%确保患者充分了解自己的医疗状况，并足够冷静，为手术做好良好的身心准备。患者纳入标准。原发性和继发性肝恶性肿瘤以及良性肝病都需要节段切除术。对年龄在15至85岁之间的男性和女性进行手术。确保患者处于良好的一般状况，并能耐受麻醉和腹腔镜肝切除术。确保根据Child-Pugh为A或B.ICG-R15的术前肝功能分类小于10%，FLR除以TLV比率不低于40%的患者排除标准。不包括伴有门静脉和肝静脉浸润的肝细胞癌患者。不要对不受控制的全身感染患者进行手术。如果通过术前 CT 或内窥镜检查诊断出严重的门静脉高压，请勿进行此手术。确保近期无胃或食管静脉曲张出血以及难治性腹水病史。确保没有弥漫性肝内转移。或远处转移。如果腹腔镜手术不可行，则不要进行这种手术，因为先前多次腹部手术导致严重腹部粘连的历史。手术，由于术前MRI显示大部分肿瘤位于S5，一小部分位于S8的腹侧段，没有任何相邻的大血管或胆管，我们计划切除S5加部分S8，以确保广泛的切除边缘以完全切除肿瘤。因此，我们打算结扎S5的椎弓根和S8椎弓根的腹侧分支，以及流入髋中静脉的分支静脉。切除深度可以通过解剖S8节段的腹侧分支和沿S5的肝足来实现。准备阶段。在全身麻醉下，将患者置于仰卧位，双腿分开，头部抬高，双脚放下，形成 30 度的身体角度。麻醉师将液体输注减少到每小时每公斤一毫升，以在手术过程中将CVP保持在五厘米水柱以下。用碘对腹部皮肤进行消毒，并将患者悬垂以准备无菌区域。确保主治外科医生站在右侧。二级外科医生站在左边。助手站在病人的两腿之间。根据肿瘤的位置插入穿刺器。对于该患者，通过在脐下方 1 厘米处插入一个 10 毫米穿刺器来建立观察口。将两个 12 毫米穿刺器双侧放置在腹直肌的侧缘。比脐部高两厘米。沿锁骨中线将两个 5mm 穿刺器放置在肋下缘下方的两侧。结合术前MRI结果，用腹腔镜超声定位并重新评估肿瘤。按计划进行手术。划定切除区域。找到第一个肝炎端口并打开网膜滑囊。将棉绳放入腹腔。使用带有细长头部的腹腔镜镊子将棉绳水平穿过温斯洛的孔。并包围肝十二指肠韧带。将Lumir装置插入腔中以收紧棉绳并阻塞肝脏流入。然后用血管夹固定。将夹紧时间限制为 15 分钟，然后在操作过程中进行 5 分钟的解夹时间。二级外科医生使用超声解剖器沿着标记的边界打开肝囊，而主外科医生使用腹腔镜CUSA以考古学方式粉碎肝实质。每个遇到的小血管和胆管都用超声波解剖直接烧灼。而大的则被Hem-o-lok夹住后被分开。解剖肝中静脉内S8节段的背支和腹支。使用 GIA 内切器夹紧并结扎腹侧分支。同时保留S8的背支和背段。解剖S5段的肝静脉，经Hem-o-lok夹紧后将其分开。解剖 S5 节段的肝蒂，并用内切 GIA 吻合器进行切割。至此，计划中的肝段切除术已经成功完成。松开棉绳，烧灼手术伤口以准确止血。冲洗操作区域并彻底沥干。剪断棉绳以取出 Lumir 装置。用一层可吸收的止血器覆盖手术区域。术后随访。对患者返回普通病房后采取以下管理措施。监测生命体征，静脉营养，内脏功能快速恢复，预防感染和深静脉血栓形成。提供全流质饮食，并在接下来的几天内逐渐过渡到常规饮食。如果患者没有明显的不适，请在前三天保持其余治疗不变。对全血细胞进行实验室检查。肝肾功能检查，电解质水平，凝血功能。此外，进行早期胸部和腹部超声检查，以检查胸水和腹水。进行上腹部 CT 平片扫描，以确认没有残留肿瘤出血和胆汁渗漏。然后移除排水管。一旦引流液最少且清澈。通常是手术后五到六天。患者通常在手术一周后出院，一个月后返回门诊。如有必要，外科医生可以根据患者的病情采取适当措施并延长治疗过程。具有代表性的结果。术后CT影像学检查显示无残留肝肿瘤，病理结果提示原发性肝细胞癌，切除切缘阴性。自 2020 年以来，我们中心常规进行了 CUSA-超声解剖-体外普林格尔机动技术。共有108名患者通过这种方式接受了治疗。在这里，我们回顾性分析了2021年7月至8月期间接受该手术的10名患者。这些患者的中位年龄为53.8岁。他们接受了节段切除术或亚段切除术，在手术期间平均接受了3.5次体外Pringle动作。手术时间和估计的失血量相当不错。没有患者出现重大的术中和术后并发症。并且没有围手术期死亡。所有患者的最终组织病理学结果均为肝细胞癌。结论是，该技术既安全又可行。更容易实现干燥和清洁的手术区域，因此可以准确地结扎和解剖胆管和血管。有效减少术后并发症，如出血和胆漏。在这种技术中也可以保证宽的切除切缘。对于接受LAH的患者来说，这种方法有望成为一种有前途的手术技术。

Research

JoVE Journal

Medicine

Human Skeletal Muscle Biopsy Procedures Using the Modified Bergstr&#246;m Technique

Human Skeletal Muscle Biopsy Procedures Using the Modified BergstrÃƒÆ’Ã‚Â¶m Technique

人骨骼肌活检手术使用修改伯格斯坦技术

The percutaneous biopsy technique enables researchers and clinicians to collect skeletal muscle tissue samples. The technique is safe and highly ...

科研

医学

Re-Arterialized Rat Partial Liver Transplantation with an in vivo Vessel-Oriented 70% Hepatectomy

Re-Arterialized Rat Partial Liver Transplantation with an in vivo Vessel-Oriented 70% Hepatectomy

静脉大鼠部分肝移植的体内血管定向70% 肝切除术

Split liver transplantation and living liver donor liver transplantation were developed in the clinic to utilize liver organs in a more efficient manner. ...

Creating Radio-cephalic Arteriovenous Fistula in the Forearm with a Modified No-Touch Technique

使用改进的非接触技术在前臂中创建放射性头动静脉瘘

Autologous arteriovenous fistula (AVF) is the primary and best option to obtain vascular access for hemodialysis treatment; other options are ...

A Modified Simple Method for Induction of Myocardial Infarction in Mice

一种改良的小鼠心肌梗死诱导简易方法

Myocardial infarction (MI) represents one of the leading causes of death. MI models are widely used for investigating the pathomechanisms of post-MI ...

Modified Technique for the Use of Neonatal Murine Hearts in the Langendorff Preparation

新生儿鼠心在朗根多夫制剂中的应用改良技术

The use of the ex-vivo retrograde perfused heart has long been a cornerstone of ischemia-reperfusion investigation since its development by Oskar ...

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

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

腹腔镜胰十二指肠切除术使用原 位 非接触式隔离技术治疗胰腺癌

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

Robotic Taj Mahal Hepatectomy for Hilar Cholangiocarcinoma

机器人泰姬陵肝切除术治疗肺门胆管癌

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

Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse

腹腔镜非网片环扎胸肌固定术治疗盆腔器官脱垂

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore ...

Modified Posterior Vertebral Column Resection for Patients with Thoracolumbar Kyphotic Deformity

胸腰椎后凸畸形患者改良后椎柱切除术

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may ...

A Modified Technique for Arteriovenous Fistula Construction in Rabbits

一种改良的兔动静脉瘘构建技术

Juxta-anastomotic stenosis is a challenging problem that often causes non-maturation and decreases the patency of an arteriovenous fistula (AVF). Injury ...