The study is self-sponsored.

The protocol follows the guidelines of Kwong Wah Hospital&#39;s human research ethics committee.
1. Pre-operative workup
<ol>
	<li>Check triphasic CT scans to evaluate the extent of disease and vascular anatomy.</li>
	<li>Perform an indocyanine green (ICG) retention test to assess liver function properly. Preferably, ICG retention of less than 15% is required for patients to undergo major liver resection13.</li>
	<li>Perform CT volumetry to ensure adequate residual liver volume (RLV). 40% RLV is required for cirrhotic liver, while 30% RLV is necessary for the normal liver14.</li>
</ol>
2. Anesthesia
<ol>
	<li>Administer pre-operative antibiotics, typically 1.2 g of amoxicillin and clavulanic acid, intravenously on induction of anesthesia.</li>
	<li>Perform deep venous thrombosis prophylaxis with a sequential compression device and compression stockings15.</li>
	<li>Place an arterial line and a central venous line.</li>
	<li>Control low central venous pressure to 3-8 mmHg16. An anesthetist performs this.</li>
</ol>
3. Patient positioning
<ol>
	<li>Position the patient in the Lloyd-Davis position on a split-leg table.</li>
	<li>Set the theatre as depicted in Figure 2, allowing the surgeon to stand between the patient&#39;s legs. 
	NOTE: This position allows the surgeon to operate while standing between the legs, providing ergonomic benefits during such a lengthy procedure and preventing early fatigue.</li>
	<li>Elevate the patient to 30&#176; left lateral position with a pillow during the operation.</li>
</ol>
4. Port site insertion and the laparoscope
<ol>
	<li>Establish access into the intraabdominal cavity with a sub-umbilical incision by open Hasson Technique17.</li>
	<li>Place the remaining ports as depicted in Figure 3.</li>
	<li>Place a 12 mm port in the right upper quadrant along the midclavicular line.</li>
	<li>Place 5 mm laparoscopic assistant port at epigastrium, right flank along the anterior axillary line, and left upper quadrant. 
	NOTE: A laparoscope with a flexible tip is preferred for a better view above the dome of the liver (Figure 4).</li>
</ol>
5. Operative steps
<ol>
	<li>Mobilization of the whole right lobe of the liver
	<ol>
		<li>Expose the root of the right hepatic vein superiorly.
		<ol>
			<li>Complete division of triangular ligament until bare area exposed.</li>
			<li>Expose the groove between the right hepatic veins and the common trunk of the middle and left hepatic veins.</li>
		</ol>
		</li>
		<li>Expose the root of IVC inferiorly.
		<ol>
			<li>Incise inferior peritoneal attachment and drop the adrenal gland to the retroperitoneum.</li>
			<li>Divide the short hepatic veins and vena cava ligament until the inferior border of the right hepatic vein is seen.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Right posterior pedicle control with intrahepatic Glissonian approach18.
	<ol>
		<li>Dissect along the superior border of the right posterior Glissonian pedicle along the Rouviere sulcus while keeping the Laennec capsule intact.</li>
		<li>Transect the caudate process to expose the inferior margin of the right posterior Glissonian pedicle.</li>
		<li>Dissect along the inferior border of the right posterior Glissonian pedicle along the Rouviere sulcus while keeping the Laennec capsule intact.</li>
		<li>Control the right posterior pedicle temporarily with a bulldog clamp.</li>
	</ol>
	</li>
	<li>Determination of the transection plane along the ischaemic line
	<ol>
		<li>Perform Intraoperative ultrasonography (USG) to identify the course of the right hepatic vein19.</li>
		<li>Open the liver capsule with an ultrasonic scalpel (Table of Materials) at the dome of the liver along the left margin of the right hepatic vein to secure a correct transection plane.</li>
		<li>Mark the rest of the transection line along the ischaemic line with diathermy.</li>
	</ol>
	</li>
	<li>Pringle maneuver
	<ol>
		<li>Prepare intracorporeal tourniquet for laparoscopic Pringle maneuver by Huang&#39;s Loop using a shortened Foley catheter20.</li>
	</ol>
	</li>
	<li>Parenchymal transection
	<ol>
		<li>Open the liver capsule with an ultrasonic scalpel along the planned transection line.</li>
		<li>Perform subsequent deep parenchymal transection with the &#39;ultrasonic scalpel mimic CUSA&#39; technique12.
		<ol>
			<li>Keep both arms of the ultrasonic scalpel open.</li>
			<li>Use the active blade of the ultrasonic scalpel to dissect the tissue.</li>
			<li>Activate maximum and move the active blade in a horizontal swinging motion parallel to the vasculobiliary structure.</li>
			<li>Dissect the parenchyma while exposing the individual intrahepatic vessels and leaving them intact.</li>
			<li>Use a suction device with the left hand constantly to keep the surgical field dry.</li>
			<li>Divide small vessels with the ultrasonic scalpel.</li>
			<li>Divide large vessels or pedicle structures between plastic clips (Table of Materials) or metal clips.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Right posterior pedicle transection
	<ol>
		<li>Encircle the right posterior pedicle with vascular tape.</li>
		<li>Transect the right posterior pedicle with a vascular stapler.</li>
	</ol>
	</li>
	<li>Right hepatic vein transection
	<ol>
		<li>Transect the right hepatic vein with a vascular stapler.</li>
	</ol>
	</li>
	<li>Bleeding control
	<ol>
		<li>The right posterior pedicle is temporarily controlled as a form of partial Pringle&#39;s maneuver during parenchymal transection. Meticulous dissection and identification of intrahepatic vessels are critical. Divide portal and hepatic venules with clips or ultrasonic scalpel.</li>
		<li>Use bipolar diathermy for bleeding with simultaneous suctioning to clear the surgical field.</li>
		<li>Increase carbon dioxide pneumoperitoneum (15-20 mmHg) to slow down the bleeding from hepatic veins and use intracorporal suture for significant bleeding, for example, bleeding from the right hepatic vein.</li>
		<li>Use a suture to secure bleeding from large veins or arteries.</li>
	</ol>
	</li>
</ol>
6. Specimen retrieval
<ol>
	<li>The specimen is put into a plastic bag and retrieved through the Pfannenstiel incision.</li>
</ol>

Advancing LRPS: Optimal Techniques for Challenging Liver Resections

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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=Laparoscopic+versus+open+resection+for+colorectal+liver+metastases:+The+OSLO-COMET+randomized+controlled+trial.">Laparoscopic versus open resection for colorectal liver metastases: The OSLO-COMET randomized controlled trial.</a> Annals of Surgery. 267 (2), 199-207 (2018).</li><li>Landi, 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=Short-term+outcomes+of+laparoscopic+vs.+open+liver+resection+for+hepatocellular+adenoma:+a+multicenter+propensity+score+adjustment+analysis+by+the+AFC-HCA-2013+study+group.">Short-term outcomes of laparoscopic vs. open liver resection for hepatocellular adenoma: a multicenter propensity score adjustment analysis by the AFC-HCA-2013 study group.</a> Surgical Endoscopy. 31 (10), 4136-4144 (2017).</li><li>Cho, 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=Safe+and+feasible+extrahepatic+Glissonean+access+in+laparoscopic+anatomical+liver+resection.">Safe and feasible extrahepatic Glissonean access in laparoscopic anatomical liver resection.</a> Surgical Endoscopy. 25 (4), 1333-1336 (2011).</li><li>Oztas, M., Lapsekili, E., Fatih Can, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+liver+right+posterior+sectionectomies;+surgical+technique+and+clinical+results+of+a+single+surgeon+experience.">Laparoscopic liver right posterior sectionectomies; surgical technique and clinical results of a single surgeon experience.</a> Turkish Journal of Surgery. 38 (1), 18-24 (2022).</li><li>Siddiqi, N. 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=Laparoscopic+right+posterior+sectionectomy+(LRPS):+surgical+techniques+and+clinical+outcomes.">Laparoscopic right posterior sectionectomy (LRPS): surgical techniques and clinical outcomes.</a> Surgical Endoscopy. 32 (5), 2525-2532 (2018).</li><li>Machado, M. A., Makdissi, F. F., Galvao, F. H., Machado, M. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intrahepatic+Glissonian+approach+for+laparoscopic+right+segmental+liver+resections.">Intrahepatic Glissonian approach for laparoscopic right segmental liver resections.</a> The American Journal of Surgery. 196 (4), e38-e42 (2008).</li><li>Machado, M. A., Kalil, A. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Glissonian+approach+for+laparoscopic+mesohepatectomy.">Glissonian approach for laparoscopic mesohepatectomy.</a> Surgical Endoscopy. 25 (6), 2020-2022 (2011).</li><li>Topal, B., Aerts, R., Penninckx, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+intrahepatic+Glissonian+approach+for+right+hepatectomy+is+safe,+simple,+and+reproducible.">Laparoscopic intrahepatic Glissonian approach for right hepatectomy is safe, simple, and reproducible.</a> Surgical Endoscopy. 21 (11), 2111 (2007).</li><li>Park, 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=Safety+and+Risk+factors+of+pure+laparoscopic+living+donor+right+hepatectomy:+Comparison+to+open+technique+in+propensity+score-matched+analysis.">Safety and Risk factors of pure laparoscopic living donor right hepatectomy: Comparison to open technique in propensity score-matched analysis.</a> Transplantation. 103 (10), e308-e316 (2019).</li><li>Yang, 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=Laparoscopic+liver+resection+with+&amp;#34;ultrasonic+scalpel+mimic+CUSA&amp;#34;+technique.">Laparoscopic liver resection with &amp;#34;ultrasonic scalpel mimic CUSA&amp;#34; technique.</a> Surgical Endoscopy. 36 (12), 8927-8934 (2022).</li><li>Kitano, S., Kim, Y. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=ICG+clearance+in+assessing+cirrhotic+patients+with+hepatocellular+carcinoma+for+major+hepatic+resection.">ICG clearance in assessing cirrhotic patients with hepatocellular carcinoma for major hepatic resection.</a> HPB Surgery. 10 (3), 182-183 (1997).</li><li>Lim, M. C., Tan, C. H., Cai, J., Zheng, J., Kow, A. W. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=CT+volumetry+of+the+liver:+Where+does+it+stand+in+clinical+practice.">CT volumetry of the liver: Where does it stand in clinical practice.</a> Clinical Radiology. 69 (9), 887-895 (2014).</li><li>Sachdeva, A., Dalton, M., Lees, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Graduated+compression+stockings+for+prevention+of+deep+vein+thrombosis.">Graduated compression stockings for prevention of deep vein thrombosis.</a> Cochrane Database of Systematic Reviews. 11 (11), CD001484 (2018).</li><li>Liu, T. 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=Application+of+controlled+low+central+venous+pressure+during+hepatectomy:+A+systematic+review+and+meta-analysis.">Application of controlled low central venous pressure during hepatectomy: A systematic review and meta-analysis.</a> Journal of Clinical Anesthesia. 75, 110467 (2021).</li><li>Ellison, E. C., Zollinger, R. 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W., Su, W. L., Wang, S. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Alternative+laparoscopic+intracorporeal+Pringle+maneuver+by+Huang's+loop.">Alternative laparoscopic intracorporeal Pringle maneuver by Huang's loop.</a> World Journal of Surgery. 42 (10), 3312-3315 (2018).</li><li>. Laparoscopes articulating HD 3D videoscope ENDOEYE FLEX 3D (LTF-190-10-3D) Available from: <a target="_blank" href="https://medical.olympusamerica.com/products/laparoscopes/endoeye-flex-3d">https://medical.olympusamerica.com/products/laparoscopes/endoeye-flex-3d</a> (2023)</li><li>Welling, A., Scoggins, P., Cummings, J., Clymer, J., Amaral, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Superior+dissecting+capability+of+a+new+ultrasonic+device+improves+efficiency+and+reduces+adhesion+formation.">Superior dissecting capability of a new ultrasonic device improves efficiency and reduces adhesion formation.</a> Global Surgery. 3 (1), (2017).</li><li>Lortat-Jacob, J. L., Robert, H. 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Comprehensive review for the clinical question on the 2nd International Consensus Conference on Laparoscopic Liver Resection.</a> Journal of Hepato-Biliary-Pancreatic Sciences. 22 (5), 363-370 (2015).</li><li>Jia, C., 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+liver+resection:+a+review+of+current+indications+and+surgical+techniques.">Laparoscopic liver resection: a review of current indications and surgical techniques.</a> Hepatobiliary Surgery and Nutrition. 7 (4), 277-288 (2018).</li></ol>

The authors have nothing to disclose.

The critical components of the surgery include the intrahepatic Glissonian approach for inflow control, a &#39;ultrasonic scalpel mimic CUSA&#39; parenchymal transection technique, early identification of right hepatic vein and meticulous bleeding control by bipolar diathermy.
The first critical step in this protocol is identifying and controlling the right posterior pedicle. The Glissonian approach was first introduced as extrahepatic Glissonian pedicle control in open liver surgery<sup class...

Laparoscopic liver surgery has been shown to have several advantages over open liver resection, including reduced blood loss, decreased wound pain, and shorter hospital stay while maintaining comparable oncological outcomes1,2,3,4. Although LRPS was previously considered a relative contraindication due to its deep-seated anatomic location and challenges in bleeding control, recent advancements have proven its safety and feasibility2,5,6,7. Various strategies and surgical devices have been developed to overcome these challenges. However, no consensus exists on the best surgical technique and devices for LRPS.
In this article, we aim to provide a detailed description of the steps involved in LRPS at our centre, with a specific focus on the intrahepatic Glissonian approach for inflow control, a novel technique called the &#39;ultrasonic scalpel mimic Cavitron ultrasonic surgical aspirator (CUSA)&#39; for parenchymal transection, early identification of the right hepatic vein, and meticulous bleeding control using bipolar diathermy. Machado et al. and Topal et al. reported the feasibility and safety of the laparoscopic intrahepatic Glissonian approach8,9,10. Laparoscopic techniques offer improved visualization and precision in dissecting the Glissonian pedicle. The approach maintains the blood flow to the remnant liver, reducing the risk of ischaemic injury. Additionally, this approach allows for the exact demarcation of liver segments that are being resected, making the surgery more precise and reducing the risk of bleeding. Professor Kwon introduced the &#39;ultrasonic scalpel mimic CUSA&#39; technique in 201911, which has been shown to reduce intraoperative blood loss and operative time11,12.
A representative case is discussed in this study to detail the steps performed in the protocol. The patient is a 54-year-old man who is a chronic carrier of hepatitis B. During screening ultrasonography, a liver mass was identified in segment 6. A pre-operative triphasic computed tomography (CT) scan was performed, which revealed a 5.7 cm hypervascular tumor with arterial enhancement and portovenous washout in segment 7 (Figure 1).&#160;The alpha-fetoprotein (AFP) level was 2 ng/ml. The Child-Pugh score was 5 (Grade A). The indocyanine green retention at 15 min was 7.5%. The residual liver volume (RLV) was 45%. Based on the patient&#39;s hepatitis status and the radiological features of the tumor, the mass was treated as hepatocellular carcinoma. The patient was offered a laparoscopic right posterior sectionectomy, including the right hepatic vein.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>3D ENDOEYE Flex</td>
			<td>Olympus&#160;</td>
			<td>LTF-S190-10-3D</td>
			<td>Flexible tip laparoscopic camera</td>
		</tr>
		<tr>
			<td>5 mm ROBI Bipolar Grasping Forceps</td>
			<td>KARL STORZ</td>
			<td>38851 ON</td>
			<td>atraumatic, fenestrated forceps</td>
		</tr>
		<tr>
			<td>AESCULAP Challenger Ti-P</td>
			<td>Barun</td>
			<td>PL520L</td>
			<td>Pneumatic driven multi-fire clip applicator. 5 mm metal clips</td>
		</tr>
		<tr>
			<td>Endo GIA Reloads with Tri-Staple Technology, 30 mm, Tan colour</td>
			<td>Medtronic&#160;</td>
			<td>SIG30AVM</td>
			<td>Tristaple system that has stepped cartridge face that delivers graduated compression and three rows of varied height staples. Staple height 2 mm, 2.5 mm, 3 mm.</td>
		</tr>
		<tr>
			<td>Endo GIA Ultra Universal Stapler</td>
			<td>Medtronic&#160;</td>
			<td>EGIAUSTND</td>
			<td>Manual stapler that compresses tissue while it simultaneously lays down a staple line and transects the tissue</td>
		</tr>
		<tr>
			<td>HARMONIC ACE+7 Shears</td>
			<td>Ethicon</td>
			<td>HARH36</td>
			<td>Curved tip, energy sealing and dissecting, diameter 5 mm, length 36 cm</td>
		</tr>
		<tr>
			<td>Hem-o-lok Clips L</td>
			<td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td>
			<td>544240</td>
			<td>Vascular clip 5&#8211;13 mm Size Range</td>
		</tr>
		<tr>
			<td>Hem-o-lok Clips ML</td>
			<td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td>
			<td>544230</td>
			<td>Vascular clip 3&#8211;10 mm Size Range</td>
		</tr>
		<tr>
			<td>Hem-o-Lok Polymer Ligation System</td>
			<td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td>
			<td>544965</td>
			<td></td>
		</tr>
		<tr>
			<td>Profocus 2202 Ultraview 800</td>
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techniques of laparoscopic right posterior sectionectomy: glissonian approach and a parenchymal transection technique

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver resections, including less blood loss, reduced wound pain, and shorter hospital stays with a comparable oncological outcome. However, laparoscopic resection of lesions in the right posterior section of the liver is challenging due to difficulties in bleeding control and visualizing the surgical field. In the past, laparoscopic right posterior sectionectomy (LRPS) was still in the exploration phase, with undefined risks in the Second International Consensus Conference on LLR in 2014. However, recent technological advancements and increased surgical experience have shown that LRPS can be safe and feasible. It has been found to reduce hospital stay and blood loss compared to open surgery. This manuscript aims to provide a detailed description of the steps involved in LRPS. The key factors contributing to our success in this challenging procedure include proper liver retraction and exposure, the use of an intrahepatic Glissonian approach for inflow control, a technique called the 'ultrasonic scalpel mimic Cavitron ultrasonic surgical aspirator (CUSA)' for parenchymal transection, early identification of the right hepatic vein, and meticulous bleeding control using bipolar diathermy.

In the representative case, the total operative time was 738 min, with an estimated blood loss of 400 mL. The patient was nursed in the intensive care unit for 2 days. The recovery was uneventful, and the patient was discharged on postoperative day 5. Histopathological examination of the specimen revealed moderately differentiated cholangiocarcinoma measured 8.0 cm x 5.5 cm x 4.5 cm. There was no perineural or lymphovascular permeation. The resection margin was 14 mm. The American Joint Committee on Cancer (AJCC) staging...

Watch this Scientific Journal Video about Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique at JoVE.com

Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique

Here, we present a protocol to perform laparoscopic right posterior sectionectomy, focusing on two key aspects: the intrahepatic Glissonian approach for inflow control and a parenchymal transection technique using an ultrasonic surgical aspirator.

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver ...

techniques-laparoscopic-right-posterior-sectionectomy-glissonian

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JoVE Journal

Medicine

706 Views.  Kwong Wah Hospital. Here, we present a protocol to perform laparoscopic right posterior sectionectomy, focusing on two key aspects: the intrahepatic Glissonian approach for inflow control and a parenchymal transection technique using an ultrasonic surgical aspirator.

Video: Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique

Rat Model of Photochemically-Induced Posterior Ischemic Optic Neuropathy

Posterior Ischemic optic neuropathy (PION) is a sight-devastating disease in clinical practice. However, its pathogenesis and natural history have&#160;remained poorly understood. Recently, we developed a reliable, reproducible animal model of PION and tested the treatment effect of some neurotrophic factors in this model1. The purpose of this video is to demonstrate our photochemically induced model of posterior ischemic optic neuropathy, and to evaluate its effects with retrograde labeling of retinal ganglion cells. Following surgical exposure of the posterior optic nerve, a photosensitizing dye, erythrosin B, is intravenously injected and a laser beam is focused onto the optic nerve surface. Photochemical interaction of erythrosin B and the laser during irradiation damages the vascular endothelium, prompting microvascular occlusion mediated by platelet thrombosis and edematous compression. The resulting ischemic injury yields a gradual but pronounced retinal ganglion cell dieback, owing to a loss of axonal input - a remote, injury-induced and clinically relevant outcome. Thus, this model provides a novel platform to study the pathophysiologic course of PION,&#160;and can be further optimized for testing therapeutic approaches for optic neuropathies as well as other CNS ischemic diseases.

The goal of this protocol is to photochemically induce ischemic injury to the posterior optic nerve in rat. This model is critical to studies of the pathophysiology of posterior ischemic optic neuropathy, and therapeutic approaches for this and other optic neuropathies, as well as of other CNS ischemic diseases.

Posterior Ischemic optic neuropathy (PION) is a sight-devastating disease in clinical practice. However, its pathogenesis and natural history ...

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.

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

Posterior Semicircular Canal Approach for Inner Ear Gene Delivery in Neonatal Mouse

Inner ear gene therapy offers great promise as a potential treatment for hearing loss and dizziness. One of the critical determinants of the success of inner ear gene therapy is to find a delivery method which results in consistent transduction efficiency of targeted cell types while minimizing hearing loss. In this study, we describe the posterior semicircular canal approach as a viable method for inner ear gene delivery in neonatal mice. We show that gene delivery through the posterior semicircular canal is able to perfuse the entire inner ear. The easy anatomic identification of the posterior semicircular canal, as well as minimal manipulation of the temporal bone required, make this surgical approach an attractive option for inner ear gene delivery.

In this study, we describe the posterior semicircular canal approach as a reliable method for inner ear gene delivery in neonatal mice. We show that gene delivery through the posterior semicircular canal is able to perfuse the entire inner ear.

Inner ear gene therapy offers great promise as a potential treatment for hearing loss and dizziness. One of the critical determinants of the success of ...

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota&#39;s fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota&#8217;s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (&#62;1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota&#8217;s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...

Posterior Approach for Debridement of the Psoas Abscess

This method focuses on outlining a safe zone for irrigation and debridement of a psoas abscess through a posterior approach. Initially, an anterior approach to the spine was performed to ensure that the anterior longitudinal ligament and the psoas muscle could be visualized. All the abdominal organs were removed. Subsequently, a posterior approach was performed to remove the paraspinal muscles from L1&#8211;L5. The transverse processes, pars interarticularis and lamina of L1&#8211;L5 were identified. The exiting nerve root was identified between the transverse processes and followed into the substance of the psoas muscle. Using the anterior and posterior approach, the lumbar plexus was isolated from the substance of the psoas muscle. Before and after various steps of dissection, digital photographs were obtained. These images were uploaded into ImageJ and multiple measurements, including the distance between the lateral superior and inferior tip of each TP to the most lateral region of the plexus, the distance between the lateral superior and inferior tip of the TP to the lateral edge of the psoas, and the width of the lumbar plexus were recorded. The safe zone for entering the substance of the psoas muscle was defined between the lateral edge of the psoas muscle and the lateral edge of the lumbar plexus. The relationship of this interval to the tip of the transverse process at each level was measured and reported.

This is a cadaveric study investigating the landmarks for the posterior approach for irrigation and debridement of the psoas abscess. The interval between the transverse processes (TP) was used to access the substance of the psoas muscle.

This method focuses on outlining a safe zone for irrigation and debridement of a psoas abscess through a posterior approach. Initially, an anterior ...

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts to spare normal ovarian cortex. Optimization of tubal anatomy is another frequent consideration. Fertility-sparing laparoscopic techniques at the time of cystectomy for ovarian endometrioma seek to limit iatrogenic surgical damage to the ovarian cortex and strategically assess and respond to genital tract patency. Surgical candidates frequently desire relief from endometriosis-associated pain while also seeking to optimize spontaneous or assisted conception rates. Operative benefits include potential for surgical and histopathologic diagnosis of endometriosis, evaluation of genital tract patency, and treatment of visualized lesions. Resection of ovarian endometrioma nonetheless poses significant risks, including surgical injury, blood loss, post-surgical decline in ovarian reserve and post-operative inflammation with adhesion formation, both of which may impair folliculogenesis.
We present the case of a 32-year-old woman with known endometriosis and continued pain refractory to medical management who opted for surgical management of her disease tailored toward optimizing her chances at future conception. Using this case as an example, we describe techniques and considerations for diagnostic laparoscopy, adhesiolysis, ovarian cystectomy, chromopertubation, and salpingectomy with a focus on maintaining a fertility-preserving approach.

This protocol presents techniques to laparoscopically excise ovarian endometrioma, to perform adhesiolysis with sparing electrosurgical application, and to employ intraoperative chromopertubation to assess for genital tract patency. This systematic approach will facilitate optimal endometriosis management, guide concomitant adnexal surgeries, and enhance post-surgical fertility outcomes.

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...

Arthroscopic Double Posteromedial Approach for PCL Cyst Excision

Arthroscopic Excision of Posterior Cruciate Ligament Cysts Using a Double Posteromedial Approach

Cruciate ligament cysts of the knee are a rare condition. Posterior cruciate ligament cysts of the knee are less common than anterior cruciate ligament cysts. In patients with asymptomatic isolated cruciate ligament cysts of the knee, conservative treatment is recommended. Symptomatic cruciate ligament cysts of the knee are mostly manifested as knee hyperflexion pain, straightening pain, knee discomfort after standing for a long time or walking for a long time, etc., which seriously affects the quality of life, surgical treatment can be performed. The surgical treatments can be divided into ultrasound-guided cyst puncture and fluid extraction procedure and arthroscopic cystectomy. Cysts are mostly lobulated with a multi-layer cyst wall, cyst fluid extraction does not remove the cyst wall completely but simply extracts cyst fluid, leading to a high recurrence rate. Arthroscopic surgery can completely remove the cyst wall with little trauma, a low recurrence rate, and fast postoperative recovery, so arthroscopic resection is the most common and preferred method of treatment. Since posterior cruciate ligament cysts mostly occur posterior to the ligament, we remove the cyst wall by adding a double posteromedial approach to the knee joint, and the cyst wall is removed under direct vision, which is simple to operate, the cyst wall is completely cleared, the trauma is small, the postoperative recovery is fast, and there is no recurrence. Here, 8 posterior cruciate ligament cysts were removed with complete postoperative symptom relief, no surgical complications, and no recurrence at 1-year follow-up.

Author Spotlight: Double Posteromedial Approach for Treating Posterior Cruciate Ligament Cysts

We present a surgical approach to treat posterior cruciate ligament cysts by an arthroscopic double posteromedial approach.

Cruciate ligament cysts of the knee are a rare condition. Posterior cruciate ligament cysts of the knee are less common than anterior cruciate ligament ...

Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic capsule to infiltrate surrounding tissues. In conventional distal pancreatosplenectomy (DPS), tumor cells are prone to spread along the direction of blood and lymphatic reflux due to surgical compression. Additionally, inflammation makes it challenging to achieve R0 resection, leading to a lower patient survival rate. To address these limitations, radical antegrade modular pancreatosplenectomy (RAMPS) was developed, emphasizing deeper excision, including the left anterior renal fascia, the left anterior renal adipose sac, and even the left adrenal gland, to improve the R0 resection rate. With the advancement of minimally invasive surgical techniques, laparoscopic RAMPS (L-RAMPS) is being considered technically safe and feasible in oncology. However, due to technical difficulties and a lack of supporting evidence for clinical application, only a few institutions are currently conducting L-RAMPS. In this context, this article presents detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy (L-pRAMPS), offering promise for future clinical applications.

Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) is currently considered technically safe and feasible. However, due to technical challenges and a lack of supporting evidence for widespread clinical applications, only a limited number of institutions are currently conducting L-RAMPS. This article aims to provide detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy.

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic ...

Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic pancreatoduodenectomy (LPD), laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has not yet obtained wide acceptance. This could be attributed to the technical challenges involved in preserving the blood supply of the duodenum and bile duct.
This study describes and demonstrates all the steps of LDPPHR. A 48-year-old woman was diagnosed with a 3.0 cm x 2.5 cm pancreatic head cystic mass, which was detected unexpectedly. The surgery was performed using the 3D laparoscopy via an inferior infracolic approach. The operation lasted approximately 310 min with 100 mL of blood loss. Postoperatively, the patient experienced no complications and was discharged 5 days later. Pathology revealed intraductal papillary mucinous neoplasms.
LDPPHR via an inferior infracolic approach is feasible and safe when performed by experienced surgeons in selected patients with thin mesenteric fat layers. The described technique for LDPPHR via inferior infracolic approach should be well standardized and performed at high-volume centers with experienced surgeons in both open and laparoscopic pancreatology.

This article provides a whole technical process of laparoscopic duodenum-preserving pancreatic head resection via an inferior infracolic approach. This is a surgical approach for benign tumors without intraoperative fluorescence image guidance.

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic ...

Laparoscopic Sectionectomy Using Ligamentum Teres for Bloodless Hepatectomy

Laparoscopic Left Lateral Sectionectomy: Guided by the Ligamentum Teres Hepatis and the Umbilical Fissure Vein

Laparoscopic left lateral sectionectomy (LLLS), a mainstream procedure in liver surgery, often utilizes controlled low central venous pressure (CLCVP) to reduce bleeding in the hepatic venous system. However, anesthesiologists may avoid the use of CLCVP in patients with concurrent cardiovascular and cerebrovascular diseases to prioritize the maintenance of vital organ perfusion. In this report, we present an LLLS guided by the ligamentum teres hepatis (LTH) for dissection of the Glissonian pedicles for segments 2/3 outside the liver, followed by hepatic parenchymal dissection along the falciform ligament and umbilical fissure vein (UFV) while approaching the left hepatic vein root. Guided by LTH and UFV, this LLLS procedure effectively controlled intraoperative bleeding, even in the absence of CLCVP. Additionally, hepatectomy guided by extrahepatic and intrahepatic anatomical landmarks prevents loss of direction during liver dissection and ensures precise hepatic resection. These attributes suggest that the potential benefits extend beyond patients with cardiovascular or cerebrovascular conditions, making it applicable in a wide range of LLLS cases.

Author Spotlight: Advancing Hepatobiliary and Pancreatic Tumor Treatment with Minimally Invasive Surgical Techniques

Laparoscopic left lateral sectionectomy guided by the ligamentum teres hepatis and umbilical fissure vein effectively controls intraoperative bleeding even without controlled low central venous pressure and prevents loss of direction during parenchymal dissection.

Laparoscopic left lateral sectionectomy (LLLS), a mainstream procedure in liver surgery, often utilizes controlled low central venous pressure (CLCVP) to ...