Name: application of laparoscopic hepatectomy combined with intraoperative microwave ablation in colorectal cancer liver metastasis
Uploaded: 2023-03-03T14:50:00
Description: Watch this Scientific Journal Video about Application of Laparoscopic Hepatectomy Combined with Intraoperative Microwave Ablation in Colorectal Cancer Liver Metastasis at JoVE.com

Questo lavoro non ha fonti di finanziamento.

Questo studio è stato approvato dal Comitato Etico del Sesto Ospedale Affiliato, Sun Yat-sen University. I criteri diagnostici e le strategie di trattamento fanno riferimento alle linee guida cinesi per la diagnosi e il trattamento completo delle metastasi epatiche del colon-retto (versione 2018) e allo Shanghai International Consensus on Diagnosis and Comprehensive Treatment of Colorectal Liver Metastases (Version 2019). Il paziente presentava sintomi clinici come ematochezia, ostruzione intestinale, dolore al fegato e...

<ol>
	<li>Shi, 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=Long-term+results+of+percutaneous+microwave+ablation+for+colorectal+liver+metastases.">Long-term results of percutaneous microwave ablation for colorectal liver metastases.</a> HPB. 23 (1), 37-45 (2021).</li><li>Xu, 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=Chinese+guidelines+for+the+diagnosis+and+comprehensive+treatment+of+colorectal+liver+metastases+(version+2018).">Chinese guidelines for the diagnosis and comprehensive treatment of colorectal liver metastases (version 2018).</a> Journal of Cancer Research and Clinical Oncology. 145 (3), 725-736 (2019).</li><li>Schnitzbauer, A., Bechstein, W. O., Vogl, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=[Ablative+modalities+in+the+treatment+of+liver+metastases].">[Ablative modalities in the treatment of liver metastases].</a> Zentralblatt fur Chirurgie. 144 (3), 259-263 (2019).</li><li>Stattner, 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=Evolution+of+surgical+microwave+ablation+for+the+treatment+of+colorectal+cancer+liver+metastasis:+Review+of+the+literature+and+a+single+centre+experience.">Evolution of surgical microwave ablation for the treatment of colorectal cancer liver metastasis: Review of the literature and a single centre experience.</a> Surgery Today. 45 (4), 407-415 (2015).</li><li>Takahashi, H., Berber, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Role+of+thermal+ablation+in+the+management+of+colorectal+liver+metastasis.">Role of thermal ablation in the management of colorectal liver metastasis.</a> Hepatobiliary Surgery and Nutrition. 9 (1), 49-58 (2020).</li><li>Livraghi, T., Meloni, F., Solbiati, L., Zanus, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Collaborative+Italian+Group+using+AMICA+system.+Complications+of+microwave+ablation+for+liver+tumors:+Results+of+a+multicenter+study.">Collaborative Italian Group using AMICA system. Complications of microwave ablation for liver tumors: Results of a multicenter study.</a> Cardiovascular and Interventional Radiology. 35 (4), 868-874 (2012).</li><li>Kassahun, W. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Unresolved+issues+and+controversies+surrounding+the+management+of+colorectal+cancer+liver+metastasis.">Unresolved issues and controversies surrounding the management of colorectal cancer liver metastasis.</a> World Journal of Surgical Oncology. 13, 61 (2015).</li><li>Birrer, D. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Multimodal+treatment+strategies+for+colorectal+liver+metastases.">Multimodal treatment strategies for colorectal liver metastases.</a> Swiss Medical Weekly. 151, w20390 (2021).</li><li>Stewart, C. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cytoreduction+for+colorectal+metastases:+liver,+lung,+peritoneum,+lymph+nodes,+bone,+brain.+When+does+it+palliate,+prolong+survival,+and+potentially+cure.">Cytoreduction for colorectal metastases: liver, lung, peritoneum, lymph nodes, bone, brain. When does it palliate, prolong survival, and potentially cure.</a> Current Problems in Surgery. 55 (9), 330-379 (2018).</li><li>Tanaka, K., 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=Outcome+after+hepatic+resection+versus+combined+resection+and+microwave+ablation+for+multiple+bilobar+colorectal+metastases+to+the+liver.">Outcome after hepatic resection versus combined resection and microwave ablation for multiple bilobar colorectal metastases to the liver.</a> Surgery. 139 (2), 263-273 (2006).</li><li>McNally, S. J., Parks, R. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgery+for+colorectal+liver+metastases.">Surgery for colorectal liver metastases.</a> Digestive Surgery. 30 (4-6), 337-347 (2013).</li><li>Robinson, J. R., Newcomb, P. A., Hardikar, S., Cohen, S. A., Phipps, A. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stage+IV+colorectal+cancer+primary+site+and+patterns+of+distant+metastasis.">Stage IV colorectal cancer primary site and patterns of distant metastasis.</a> Cancer Epidemiology. 48, 92-95 (2017).</li><li>Gavriilidis, P., Roberts, K. J., de'Angelis, N., Aldrighetti, L., Sutcliffe, R. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Recurrence+and+survival+following+microwave,+radiofrequency+ablation,+and+hepatic+resection+of+colorectal+liver+metastases:+A+systematic+review+and+network+meta-analysis.">Recurrence and survival following microwave, radiofrequency ablation, and hepatic resection of colorectal liver metastases: A systematic review and network meta-analysis.</a> Hepatobiliary &amp; Pancreatic Diseases International. 20 (4), 307-314 (2021).</li><li>McEachron, K. R., 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+microwave+ablation+of+otherwise+non-resectable+colorectal+cancer+liver+metastases:+Expanding+opportunities+for+long+term+survival.">Surgical microwave ablation of otherwise non-resectable colorectal cancer liver metastases: Expanding opportunities for long term survival.</a> Surgical Oncology. 36, 61-64 (2021).</li><li>Qin, 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=The+local+efficacy+and+influencing+factors+of+ultrasound-guided+percutaneous+microwave+ablation+in+colorectal+liver+metastases:+A+review+of+a+4-year+experience+at+a+single+center.">The local efficacy and influencing factors of ultrasound-guided percutaneous microwave ablation in colorectal liver metastases: A review of a 4-year experience at a single center.</a> International Journal of Hyperthermia. 36 (1), 36-43 (2019).</li><li>Abreu de Carvalho, L. F., 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=Local+control+of+hepatocellular+carcinoma+and+colorectal+liver+metastases+after+surgical+microwave+ablation+without+concomitant+hepatectomy.">Local control of hepatocellular carcinoma and colorectal liver metastases after surgical microwave ablation without concomitant hepatectomy.</a> Langenbeck's Archives of Surgery. 406 (8), 2749-2757 (2021).</li><li>Akgul, O., Cetinkaya, E., Ersoz, S., Tez, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Role+of+surgery+in+colorectal+cancer+liver+metastases.">Role of surgery in colorectal cancer liver metastases.</a> World Journal of Gastroenterology. 20 (20), 6113-6122 (2014).</li><li>Francone, E., 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=Precoagulation-assisted+parenchyma-sparing+laparoscopic+liver+surgery:+Rationale+and+surgical+technique.">Precoagulation-assisted parenchyma-sparing laparoscopic liver surgery: Rationale and surgical technique.</a> Surgical Endoscopy. 31 (3), 1354-1360 (2017).</li><li>Fahy, B. N., Jarnagin, W. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evolving+techniques+in+the+treatment+of+liver+colorectal+metastases:+Role+of+laparoscopy,+radiofrequency+ablation,+microwave+coagulation,+hepatic+arterial+chemotherapy,+indications+and+contraindications+for+resection,+role+of+transplantation,+and+timing+of+chemotherapy.">Evolving techniques in the treatment of liver colorectal metastases: Role of laparoscopy, radiofrequency ablation, microwave coagulation, hepatic arterial chemotherapy, indications and contraindications for resection, role of transplantation, and timing of chemotherapy.</a> The Surgical Clinics of North America. 86 (4), 1005-1022 (2006).</li><li>Wada, 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=Efficacy+of+surgical+treatment+using+microwave+coagulo-necrotic+therapy+for+unresectable+multiple+colorectal+liver+metastases.">Efficacy of surgical treatment using microwave coagulo-necrotic therapy for unresectable multiple colorectal liver metastases.</a> OncoTargets and Therapy. 9, 937-943 (2016).</li><li>Lorentzen, T., Skjoldbye, B. O., Nolsoe, C. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microwave+ablation+of+liver+metastases+guided+by+contrast-enhanced+ultrasound:+Experience+with+125+metastases+in+39+patients.">Microwave ablation of liver metastases guided by contrast-enhanced ultrasound: Experience with 125 metastases in 39 patients.</a> Ultraschall in der Medizin. 32 (5), 492-496 (2011).</li></ol>

Il principale sito metastatico delle metastasi del cancro del colon-retto è il fegato. La resezione epatica è il trattamento per le metastasi epatiche del cancro del colon-retto e la resezione epatica può migliorare il tasso di sopravvivenza dei pazienti11. Poiché il cancro del colon-retto metastatizza al fegato attraverso il sangue, con conseguenti metastasi epatiche multiple in entrambi i lobi, e il volume epatico rimanente è piccolo, circa il 75% delle metastasi epatiche nei pazienti con c...

Il cancro del colon-retto è la terza causa più comune di morte correlata al cancro in tutto il mondo1 e la sede più comune di metastasi ematogene da cancro del colon-retto è il fegato; Questa metastasi si verifica fino al 50% dei pazienti con cancro del colon-retto ed è la principale causa di morte nei pazienti con cancro del colon-retto2. Per i pazienti con carcinoma colorettale senza metastasi epatiche, la sopravvivenza può essere prolungata dalla resezione chirurgica e dalla chemioterapia adiuvante postoperatoria e dalle tecniche interventistiche. Nel caso di metastasi epatiche resecabili, quelle con diametro inferiore a 3 cm possono essere trattate mediante escissione locale chirurgica, intervento radiologico, crioterapia, ablazione con radiofrequenza e ablazione a microonde per migliorare il tasso di sopravvivenza dei pazienti3. Per le metastasi epatiche del cancro del colon-retto non resecabili, la chemioterapia convenzionale, la terapia interventistica e altre strategie di trattamento hanno benefici limitati in termini di sopravvivenza per la stragrande maggioranza dei pazienti.
La chirurgia è il gold standard per le metastasi epatiche da cancro del colon-retto, con un tasso di sopravvivenza a 5 anni del 40%. Solo il 20%-30% dei pazienti con metastasi epatiche del colon-retto può trarre beneficio dal trattamento chirurgico e la maggior parte dei pazienti con metastasi epatiche del colon-retto non resecabili sperimenta un beneficio limitato dal trattamento conservativo tradizionale4. Un metodo importante nel trattamento delle metastasi epatiche del cancro del colon-retto è l'ablazione termica, compresa l'ablazione a microonde e l'ablazione a radiofrequenza; Queste due tecniche inducono la morte cellulare attraverso la necrosi coagulativa causata dall'ipertermia locale. Le principali indicazioni dell'ablazione termica includono (i) lesioni epatiche non resecabili; ii) associazione con epatectomia; (iii) pazienti con gravi comorbilità o scarso performance status (PS); iv) piccole lesioni solitarie (<3 cm) che altrimenti richiederebbero la segmentectomia; e (v) preferenza del paziente5. Tra questi, l'ablazione a microonde (MWA) è un trattamento sicuro ed efficace che può prolungare la sopravvivenza dei pazienti. Ha un'ampia gamma di aree di riscaldamento attive e non dipende dalla conduzione elettrica nel tessuto tumorale. Questo trasferimento di energia non è limitato dalla bruciatura dei tessuti. Rispetto all'ablazione con radiofrequenza, l'ablazione a microonde ha una temperatura più elevata nel tessuto tumorale, un tempo di trattamento più breve e un intervallo di trattamento più ampio6.
Metastasi intraepatiche multiple si verificano spesso nelle metastasi epatiche del cancro del colon-retto. Nel trattamento convenzionale, la chemioterapia, l'immunoterapia, la terapia interventistica, la terapia a microonde, l'ablazione con radiofrequenza e altri metodi possono migliorare il tasso di sopravvivenza dei pazienti. Il tasso di sopravvivenza a 5 anni è del 50%, ma il tasso di sopravvivenza è ancora basso7. La resezione chirurgica è ancora un metodo importante per il trattamento delle metastasi epatiche. A causa di metastasi epatiche multiple, piccolo volume epatico residuo, sanguinamento postoperatorio, perdite biliari e ostruzione del tratto di afflusso o deflusso, che portano al rischio di insufficienza epatica, la resezione chirurgica di metastasi epatiche multiple è difficile. A tre quarti dei pazienti vengono diagnosticate metastasi epatiche non resecabili8. L'epatectomia laparoscopica combinata con l'ablazione a microonde nel trattamento delle metastasi epatiche del cancro del colon-retto può evitare la piccola quantità di fegato residuo limitando l'operazione, ridurre le reazioni avverse della chemioterapia sistemica e superare la barriera di conduzione elettrica dell'ablazione a radiofrequenza, migliorando così il tasso di successo della chirurgia, prolungando il tempo di sopravvivenza dei pazienti e ottenendo una migliore prognosi delle metastasi epatiche del cancro del colon-retto3, 9. Introduzione
Questo protocollo descrive il trattamento di precisione dell'epatectomia laparoscopica combinata con l'ablazione a microonde per tumori <3 cm, metastasi epatiche occulte e metastasi epatiche multiple con posizionamento mediante ecografia laparoscopica.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>0.9% sodium chloride solution</td>
			<td>Foshan Shuanghe Commercial Co., Ltd</td>
			<td>H20013095</td>
			<td>Dilute antibiotics, irrigate.</td>
		</tr>
		<tr>
			<td>2-0 polyglactin 910 sutures</td>
			<td>Johnson &#38; Johnson Medical Devices</td>
			<td>W8400</td>
			<td>Close the Trocar hole.</td>
		</tr>
		<tr>
			<td>3 D laparoscopic</td>
			<td>STORZ</td>
			<td>26605BA</td>
			<td>Surgical treatment under direct vision, minimally invasive</td>
		</tr>
		<tr>
			<td>Absorbable Hemostat</td>
			<td>ETHICON</td>
			<td>1962</td>
			<td>wound hemostasis</td>
		</tr>
		<tr>
			<td>BiClamp E Lap</td>
			<td>ERBE Elektromedizin GmbH</td>
			<td>20195-136</td>
			<td>Intraoperative wound hemostasis</td>
		</tr>
		<tr>
			<td>Cefoperazone Sulbactam Sodium</td>
			<td>Pfizer Pharmaceuticals Ltd</td>
			<td>H20020597</td>
			<td>infection prevention</td>
		</tr>
		<tr>
			<td>Laparoscopic ultrasound probe</td>
			<td>HITACHI</td>
			<td>ALOKA-UST5418</td>
			<td>Intraoperative localization of liver metastases</td>
		</tr>
		<tr>
			<td>LIGACLIP Multiple Clip Applier and Ligating Clips</td>
			<td>Ethicon Endo - Surgery, LLC</td>
			<td>ER320</td>
			<td>Clamp tiny blood vessels and bile ducts</td>
		</tr>
		<tr>
			<td>Microwave ablation System</td>
			<td>Nanjing Yigao Microwave System Engineering Co., Ltd, China</td>
			<td>ECO-100A110</td>
			<td>Microwave ablation of liver metastases</td>
		</tr>
		<tr>
			<td>Polymer ligation clips</td>
			<td>Teleflex Medical, USA</td>
			<td>Hem-lock544233</td>
			<td>Clipping of broken ends of blood vessels and bile ducts</td>
		</tr>
		<tr>
			<td>Silica gel drainage tube</td>
			<td>BAINUS MEDICAL</td>
			<td>YY-Fr16</td>
			<td>Drainage of peritoneal fluid</td>
		</tr>
		<tr>
			<td>Ultrasonic knife</td>
			<td>Johnson &#38; Johnson Medical Devices</td>
			<td>HAR36</td>
			<td>Tissue cutting, microvascular hemostasis</td>
		</tr>
	</tbody>
</table>

application of laparoscopic hepatectomy combined with intraoperative microwave ablation in colorectal cancer liver metastasis

L'epatectomia laparoscopica è un trattamento comune per le metastasi epatiche del cancro del colon-retto. In precedenza, durante l'epatectomia laparoscopica era necessario mantenere un numero sufficiente di masse epatiche funzionali, con un volume epatico residuo del >40% nei pazienti cirrotici e del >30% nei pazienti non cirrotici. L'elevata incidenza di complicanze come sanguinamento, perdita biliare o insufficienza epatica a causa dell'esposizione e della difficoltà della resezione di specifici segmenti epatici come S2 e S7 riduce il tasso di successo della resezione epatica. Attualmente, l'ablazione a microonde viene applicata principalmente nel trattamento delle metastasi epatiche utilizzando un approccio percutaneo, che rende difficile l'identificazione di parti nascoste o piccole lesioni. Per alcuni segmenti epatici, è probabile che la puntura percutanea del segmento epatico 7 (S7) passi attraverso la cavità toracica e la puntura percutanea del segmento epatico 2 (S2) adiacente al diaframma possa danneggiare il diaframma e il cuore; Questi problemi limitano l'applicazione dell'ablazione percutanea nelle metastasi epatiche del cancro del colon-retto. Considerando lesioni multiple, in questo studio è stata eseguita l'ablazione laparoscopica a microonde combinata con l'epatectomia. La posizione delle lesioni è stata determinata mediante ecografia con mezzo di contrasto in laparoscopia e sono state identificate piccole lesioni difficili da rilevare prima dell'operazione. Per le lesioni sparse, che avevano diametri inferiori a 3 cm ed erano difficili da resecare, è stata adottata l'ablazione in sostituzione dell'epatectomia. Questa tecnica ha contribuito a localizzare in modo più esplicito i tumori, ha semplificato le procedure operatorie, ha ridotto il rischio di complicanze come sanguinamento e perdite biliari, ha accorciato i tempi dell'operazione, ha accelerato il recupero postoperatorio, ha migliorato significativamente il tasso di successo dell'operazione e ha migliorato la prognosi clinica delle metastasi epatiche del cancro del colon-retto mediante resezione chirurgica.

Per i pazienti con metastasi epatiche da pregresso carcinoma colorettale, i pazienti con metastasi epatiche unilaterali o i pazienti con poche metastasi epatiche possono essere sottoposti a resezione chirurgica e ottenere una buona prognosi. Tuttavia, nei pazienti con carcinoma colorettale non resecabile con metastasi epatiche multiple in entrambi i lobi, il trattamento conservativo ha una prognosi infausta e un basso tasso di sopravvivenza a 5 anni. Tuttavia, l'epatectomia combinata con l'ablazione a microonde può migl...

Watch this Scientific Journal Video about Application of Laparoscopic Hepatectomy Combined with Intraoperative Microwave Ablation in Colorectal Cancer Liver Metastasis at JoVE.com

Application of Laparoscopic Hepatectomy Combined with Intraoperative Microwave Ablation in Colorectal Cancer Liver Metastasis

Questo protocollo descrive la resezione laparoscopica delle metastasi epatiche del cancro del colon-retto combinata con l'ablazione a microonde ecoguidata. Questa tecnica può trattare in modo sicuro, efficace e accurato le metastasi epatiche refrattarie <3 cm, ridurre le complicanze postoperatorie e accelerare la riabilitazione postoperatoria dei pazienti.

Applicazione dell'epatectomia laparoscopica combinata con l'ablazione intraoperatoria a microonde nelle metastasi epatiche del cancro del colon-retto

Laparoscopic hepatectomy is a common treatment for colorectal cancer liver metastasis. Previously, a sufficient number of functional liver masses had to ...

La resezione chirurgica combinata con l'ablazione a microonde fornisce un metodo sicuro ed efficace per le metastasi epatiche multiple del cancro del colon-retto, soprattutto quando il volume epatico residuo è insufficiente. Questa tecnica semplifica le procedure operatorie, riduce il rischio di complicanze come sanguinamento e perdite biliari, riduce i tempi dell'operazione e accelera il recupero postoperatorio. Oltre alle metastasi epatiche del cancro del colon-retto, questo metodo può essere applicato anche al cancro epatico primario multiplo o ad altri tumori epatici secondari.Si consiglia di padroneggiare la teoria di base dell'ecografia epatica e di praticare la puntura della vena porta, guidata dall'ecografia laparoscopica prima di utilizzare questa tecnica. Inserire un trocar di 12 centimetri nell'ombelico e nella cavità addominale per l'eliminazione. Posizionare trocar di cinque centimetri sotto il processo xifoideo e sotto il margine costale della linea medioclavicolare destra.Esaminare la cavità e gli organi parenchimali inserendo il trocar navale nel laparoscopio. Utilizzando un coltello ad ultrasuoni, separare i legamenti rotondi e flacidi attaccati alla parete addominale e al diaframma epatico. Dopo l'iniezione endovenosa del mezzo di contrasto, posizionare la sonda laparoscopica nella cavità addominale.Quindi esaminare il fegato spostando la sonda sui tessuti. Localizzare i tumori metastatici con mezzo di contrasto nei segmenti epatici S5 e S7 utilizzando gli ultrasuoni. Successivamente, inserisci due trocar da cinque centimetri per facilitare la procedura.Confermare la posizione dei tumori utilizzando la sonda a ultrasuoni. Rimuovere i tessuti di collegamento utilizzando un bisturi ad ultrasuoni. Esporre i peduncoli epatici tra i segmenti due e tre e recidere il ramo della vena della fessura ombelicale.Quindi inizia a sezionare il parenchima del lobo laterale sinistro utilizzando un bisturi ad ultrasuoni. Continuare la dissezione attraverso l'intero lobo. Quindi recidere il lobo laterale sinistro.Raccogli il lobo sezionato. Quindi staccare il fegato rimuovendo il tessuto connettivo circostante. Successivamente, utilizzando l'ecografia laparoscopica, individuare i confini del tumore e segnare la superficie del fegato.Rilevare la posizione delle metastasi epatiche utilizzando una sonda ecografica e contrassegnare la posizione mantenendo meno di un centimetro di margine dal tumore. Inserire l'ago per ablazione a microonde nella cavità addominale attraverso la puntura percutanea. Inserire l'ago al centro del tumore sotto la guida della sonda laparoscopica ed eseguire l'ablazione a microonde.Rimuovere l'ago dopo l'ablazione completa utilizzando un bisturi ad ultrasuoni, elettrocoagulare le sezioni del parenchima epatico. Continuare l'elettrocoagulazione fino all'asportazione del tessuto tumorale. Raccogli il fazzoletto e mettilo nel sacchetto.Posizionare una garza emostatica. Quindi pulire la cavità addominale risciacquando il tessuto e rimuovendo la garza emostatica. Rilasciare la vena della fessura ombelicale e rimuovere i detriti di tessuto.Infine posizionare il tubo di drenaggio. L'intervento ha avuto una durata di 130 minuti. L'ablazione epatica ha avuto successo a meno di 55 watt per cinque minuti, con conseguente bassa perdita di sangue intraoperatoria di 50 millilitri.Non sono state osservate complicanze postoperatorie, il che ha comportato la dimissione del paziente otto giorni dopo l'intervento. L'ecografia laparoscopica di tutto il fegato è molto importante dopo l'iniezione del mezzo di contrasto. Può rivelare lesioni difficili da trovare nell'imaging preoperatorio come la risonanza magnetica o la TC.

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Research

JoVE Journal

Medicine

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during totally laparoscopic gastrectomy (TLG). The aim of this protocol is to introduce a procedure for intraoperative gastroscopy, in order to directly mark tumors during TLG for gastric cancer in the middle third of the stomach. Patients who were diagnosed with adenocarcinoma in the middle third of the stomach were enrolled in this case series. Before surgery, additional gastroscopy for tumor localization is not performed. Under general anesthesia, laparoscopic mobilization of the stomach is performed first. After the first portion of the duodenum is mobilized from the pancreas and clamped, the surgeon moves to the other side for the gastroscopic procedure. On the insertion of a gastroscope through the oral cavity into the stomach, 2 - 3 cc of indigo carmine is administered via an endoscopic injector into the gastric muscle layer at the proximal margin of the stomach. The location of stained serosa in the laparoscopic view is used to guide distal subtotal gastrectomy, however, total gastrectomy is performed if the tumor is too close to the esophagogastric junction. A specimen is sampled after distal gastrectomy to confirm sufficient length from resection margin to tumor before reconstruction. In our case series, all patients had tumor-free margins and required no additional resection. There was no morbidity related to the gastroscopic procedure, and the time required for the procedure has gradually decreased to about five minutes. Intraoperative gastroscopy for tumor localization is an accurate and tolerated method for gastric cancer patients undergoing totally laparoscopic distal gastrectomy.

In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Gastroscopia intraoperatoria per tumore Localizzazione in chirurgia laparoscopica per adenocarcinoma gastrico

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during ...

Ricerca

Medicina

Quantitation of Intra-peritoneal Ovarian Cancer Metastasis

Epithelial ovarian cancer (EOC) is the leading cause of death from gynecologic malignancy in the United States. Mortality is due to diagnosis of 75% of women with late stage disease, when metastasis is already present. EOC is characterized by diffuse and widely disseminated intra-peritoneal metastasis. Cells shed from the primary tumor anchor in the mesothelium that lines the peritoneal cavity as well as in the omentum, resulting in multi-focal metastasis, often in the presence of peritoneal ascites. Efforts in our laboratory are directed at a more detailed understanding of factors that regulate EOC metastatic success. However, quantifying metastatic tumor burden represents a significant technical challenge due to the large number, small size and broad distribution of lesions throughout the peritoneum. Herein we describe a method for analysis of EOC metastasis using cells labeled with red fluorescent protein (RFP) coupled with in vivo multispectral imaging. Following intra-peritoneal injection of RFP-labelled tumor cells, mice are imaged weekly until time of sacrifice. At this time, the peritoneal cavity is surgically exposed and organs are imaged in situ. Dissected organs are then placed on a labeled transparent template and imaged ex vivo. Removal of tissue auto-fluorescence during image processing using multispectral unmixing enables accurate quantitation of relative tumor burden. This method has utility in a variety of applications including therapeutic studies to evaluate compounds that may inhibit metastasis and thereby improve overall survival.

Ovarian cancer metastasis is characterized by numerous diffuse intra-peritoneal lesions, such that accurate visual quantitation of tumor burden is challenging. Herein we describe a method for in situ and ex vivo quantitation of metastatic tumor burden using red fluorescent protein (RFP)-labeled tumor cells and optical imaging.

La quantificazione di intra-peritoneale del cancro ovarico metastasi

Epithelial ovarian cancer (EOC) is the leading cause of death from gynecologic malignancy in the United States.  Mortality is due to diagnosis of 75% of ...

Laparoscopic Technique for Serial Collection of Liver and Mesenteric Lymph Nodes in Macaques

The mesenteric lymph nodes (MLN) and the liver are exposed to microbes and microbial products from the gastrointestinal (GI) tract, making them immunologically unique. The GI tract and associated MLN are sites of early viral replication in human immunodeficiency virus (HIV) infection and the MLN are likely important reservoir sites that harbor latently-infected cells even after prolonged antiretroviral therapy (ART). The liver has been shown to play a significant role in immune responses to lentiviruses and appears to play a significant role in clearance of virus from circulation. Nonhuman primate (NHP) models for HIV and Acquired Immunodeficiency Syndrome (AIDS) closely mimic these aspects of HIV infection and serial longitudinal sampling of primary sites of viral replication and the associated immune responses in this model will help to elucidate critical events in infection, pathogenesis, and the impact of various intervention strategies on these events. Current published techniques to sample liver and MLN together involve major surgery and/or necropsy, which limits the ability to investigate these important sites in a serial fashion in the same animal. We have previously described a laparoscopic technique for collection of MLN. Here, we describe a minimally invasive laparoscopic technique for serial longitudinal sampling of liver and MLN through the same two port locations required for the collection of MLN. The use of the same two ports minimizes the impact to the animals as no additional incisions are required. This technique can be used with increased sampling frequency compared to major abdominal surgery and reduces the potential for surgical complications and associated local and systemic inflammatory responses that could complicate interpretation of results. This procedure has potential to facilitate studies involving NHP models while improving animal welfare.

Here, we describe a minimally invasive laparoscopic technique for serial sampling of liver and mesenteric lymph nodes (MLN) in macaques that allows for increased sampling frequency, and reduces the potential for surgical complications when compared to performing a laparotomy.

Tecnica laparoscopica per la raccolta di serie del fegato e linfonodi mesenterica in macachi

The mesenteric lymph nodes (MLN) and the liver are exposed to microbes and microbial products from the gastrointestinal (GI) tract, making them ...

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

Split liver transplantation and living liver donor liver transplantation were developed in the clinic to utilize liver organs in a more efficient manner. To better understand the mechanism behind these surgical procedures, a rat partial liver transplantation (PLTx) model was established for relevant surgical studies. Because of the complexity of the rat PLTx model, a protocol with detailed descriptions is required. An article published previously reported a protocol in which ex vivo hepatectomy was used to achieve 50% rat PLTx. In contrast to this protocol, we introduced a re-arterialized PLTx with an in vivo 70% hepatectomy. An updated vessel-oriented hepatectomy was incorporated into the rat PLTx to refine the microsurgical procedure. The portal veins and hepatic arteries of the left lateral lobe and the median lobe were individually dissected and ligated before removal of the liver parenchyma, thereby decreasing the probability of bleeding in the remnant liver stump. Furthermore, an end-to-side vessel anastomosis between the common hepatic artery and the enlarged proper hepatic artery was introduced to re-arterialize the hepatic artery. By using this end-to-side vessel anastomosis technique, the diameter of the anastomosis was enlarged, thereby decreasing the difficulty of hand suture and maintaining a high rate of anastomotic patency. Moreover, the cuff anastomosis of the infrahepatic vena cava was slightly modified. A section of circumferential liver parenchyma around the vena cava of a recipient was preserved during cuff anastomosis to maintain the three-dimensional shape of the vascular lumen. This section of liver parenchyma was removed after completing the anastomosis. With this modification, the step involving placement of stay sutures was omitted, thereby further shortening the cuff anastomosis time. By using this protocol of rat PLTx, a low liver enzyme level, an intact liver lobular architecture and a high survival rate were achieved after microsurgery.

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

Here, a protocol involving re-arterialized rat partial liver transplantation is presented. Specifically, 70% liver was resected in vivo by using an updated technique of vessel-oriented hepatectomy. The hepatic artery was reconstructed in an end-to-side manner. The cuff technique was modified to shorten the anastomosis time of the infrahepatic vena cava.

Ri-Arterialized trapianto parziale di fegato del ratto con un in vivo vaso-Oriented 70% Hepatectomy

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

Focal Laser Ablation of Prostate Cancer: An Office Procedure

In this article, we describe and illustrate an outpatient procedure for focal laser ablation (FLA) of prostate cancer (PCa). The procedure is conceptually similar to a fusion biopsy and is performed under local anesthesia in a clinic setting; treatment time is usually less than one hour. Laser insertion is guided by ultrasound; lesion targeting is via magnetic resonance imaging-ultrasound (MRI/US) fusion, as in targeted prostate biopsy. Real-time ablation monitoring is achieved utilizing a thermal probe adjacent to the laser fiber. The video demonstrates procedure planning, patient preparation, various steps during the procedure, and treatment monitoring. Safety, feasibility, and efficacy of this approach have been established during a previous trial. Outpatient FLA under local anesthesia is an option for management of intermediate risk prostate cancer.

This article presents and describes an outpatient treatment for prostate cancer using focal laser ablation. Laser catheter placement is guided by MRI-ultrasound fusion imaging in a fashion similar to prostate needle biopsy. Treatment is monitored in real-time with a thermal probe, placed adjacent to the laser fiber.

Ablazione laser focale del cancro alla prostata: una procedura d'ufficio

In this article, we describe and illustrate an outpatient procedure for focal laser ablation (FLA) of prostate cancer (PCa). The procedure is conceptually ...

Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way

The goal of head and neck oncological surgery is complete tumor resection with adequate resection margins while preserving acceptable function and appearance. For oral cavity squamous cell carcinoma (OCSCC), different studies showed that only 15%-26% of all resections are adequate. A major reason for the low number of adequate resections is the lack of information during surgery; the margin status is only available after the final histopathologic assessment, days after surgery.
The surgeons and pathologists at the Erasmus MC University Medical Center in Rotterdam started the implementation of specimen-driven intraoperative assessment of resection margins (IOARM) in 2013, which became the standard of care in 2015. This method enables the surgeon to turn an inadequate resection into an adequate resection by performing an additional resection during the initial surgery. Intraoperative assessment is supported by a relocation method procedure that allows accurate identification of inadequate margins (found on the specimen) in the wound bed.
The implementation of this protocol resulted in an improvement of adequate resections from 15%-40%. However, the specimen-driven IOARM is not widely adopted because grossing fresh tissue is counter-intuitive for pathologists. The fear exists that grossing fresh tissue will deteriorate the anatomical orientation, shape, and size of the specimen and therefore will affect the final histopathologic assessment. These possible negative effects are countered by the described protocol. Here, the protocol for specimen-driven IOARM is presented in detail, as performed at the institute.

The goal of this protocol is to provide a clear overview of specimen-driven intraoperative assessment of resection margins. It is encouraged to implement this protocol to improve patient care at other institutes.

Valutazione intraoperatoria dei margini di resezione nel cancro del cavo orale: questa è la strada

The goal of head and neck oncological surgery is complete tumor resection with adequate resection margins while preserving acceptable function and ...

Establishment of a Simple and Effective Rat Model for Intraoperative Parathyroid Gland Imaging

Parathyroid gland (PG) identification is a critical unmet need in thyroidectomy. The identification of the PG is challenging in thyroid surgery as it is similar in color to the thyroid gland. The lack of effective animal models in preclinical research is a severe limitation for the development of PG identification techniques. This protocol allows for the establishment of a simple and effective rat model for PG identification. In this model, black iron oxide nanoparticles (IONPs) are injected locally in the thyroid gland and rapidly diffuse within the thyroid gland but not the PG. A negatively stained PG and a positively stained thyroid gland can be easily identified by the naked eye without requiring external microscopes. The position of the PG can be identified by increasing the color contrast between the thyroid gland and the PG, based on the color of the black IONPs. This rat model is low-cost and convenient for PG identification, and the IONPs are a novel PG contrast agent.

To date, the development of parathyroid gland (PG) identification methods is limited by the lack of animal models in preclinical research. Here, we establish a simple and effective rat model for intraoperative PG imaging and evaluate its effectiveness by using iron oxide nanoparticles as a novel PG contrast agent.

Istituzione di un modello di ratto semplice ed efficace per l'imaging intraoperatorio delle ghiandole paratiroidi

Parathyroid gland (PG) identification is a critical unmet need in thyroidectomy. The identification of the PG is challenging in thyroid surgery as it is ...

Application of a New Mesh Fixation Method in Laparoscopic Incisional Hernia Repair

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing incisional hernias. The laparoscopic IPOM involves implanting the mesh into the abdominal cavity through laparoscopy to repair an abdominal wall hernia. In the IPOM surgery, after the closure of the hernia ring, an anti-adhesion mesh is placed laparoscopically. The correct placement of this mesh is critical to the success of the method, and surgical skills are required to achieve perfect placement. If the mesh placement is not mastered properly, the operation and anesthesia time will be prolonged. In addition, improper placement of the mesh can lead to serious consequences, such as intestinal obstruction and mesh infection. A "contraposition and alignment" mesh fixation method is described in this study, which involves pre-marking the fixation position of the mesh to reduce the difficulty of mesh placement. A properly placed mesh is completely flat on the peritoneum, the edges are not curled or wrapped, and the mesh is adhered firmly such that there is no displacement after removing the pneumoperitoneum pressure. The "contraposition and alignment" mesh fixation technique offers the advantages of reliable placement of the mesh and fewer complications than other techniques, and it is easy to learn and master. It also allows for positioning the nail gun in advance based on the anatomy of the incisional hernia. This enables the use of the minimum number of nails possible while still ensuring good fixation, which can reduce the occurrence of complications and reduce the cost of surgery. Thus, the mesh fixation method described here is highly suitable for clinical applications based on the aforementioned advantages.

Presented here is a method for improving the mesh placement in laparoscopic incisional hernia repair, which can shorten the time required for mesh fixation and reduce the occurrence of postoperative chronic pain.

Applicazione di un nuovo metodo di fissazione della rete nella riparazione dell'ernia incisionale laparoscopica

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing ...

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.

Epatectomia centrale laparoscopica fluorescente per il cancro al fegato utilizzando la colorazione negativa verde indocianina

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

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. 
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Applicazione clinica della resezione laparoscopica a chirurgo singolo, a tre porte, per il cancro del colon-retto con estrazione del campione dell'orifizio naturale