Name: laparoscopic posterior radical antegrade modular pancreatosplenectomy for distal pancreatic carcinoma
Uploaded: 2023-12-29T14:40:00
Description: Read this Scientific Article Protocol about Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma at JoVE.com

This work was supported by grants from the Basic and Applied Basic Research Project of Guangzhou Basic Research Program (No. 2023A04J1917), the Fundamental Research Funds for the Central Universities (No. 21622312), the Special Foundation for Scientific Research Development of the Affiliated Shunde Hospital of Jinan University (No. 202101004), and Guangdong Basic and Applied Research Foundation (No. 2022A1515012581).

The surgical procedure was approved by the institutional review board at The First Affiliated Hospital of Jinan University. The patient, a 58-year-old female, was admitted with a chief complaint of &#34;abdominal pain for 2 months.&#34; A computed tomography (CT) scan conducted at an external hospital revealed a space-occupying lesion in the distal pancreas, raising concerns about the possibility of pancreatic carcinoma. Before the surgery, the patient provided written informed consent. The surgical tools and equipment u...

<ol>
	<li>Mayo, W. J. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+surgery+of+the+pancreas:+I.+Injuries+to+the+pancreas+in+the+course+of+operations+on+the+stomach.+II.+Injuries+to+the+pancreas+in+the+course+of+operations+on+the+spleen.+III.+Resection+of+half+the+pancreas+for+tumor.">The surgery of the pancreas: I. Injuries to the pancreas in the course of operations on the stomach. II. Injuries to the pancreas in the course of operations on the spleen. III. Resection of half the pancreas for tumor.</a> Ann Surg. 58 (2), 145-150 (1913).</li><li>Andr&#233;n-Sandberg, A., Wagner, M., Tihanyi, T., L&#246;fgren, P., Friess, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technical+aspects+of+left-sided+pancreatic+resection+for+cancer.">Technical aspects of left-sided pancreatic resection for cancer.</a> Dig Surg. 16 (4), 305-312 (1999).</li><li>Strasberg, S. M., Drebin, J. A., Linehan, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radical+antegrade+modular+pancreatosplenectomy.">Radical antegrade modular pancreatosplenectomy.</a> Surgery. 133 (5), 521-527 (2003).</li><li>Strasberg, S. M., Linehan, D. C., Hawkins, W. 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(189), e63235 (2022).</li><li>Wu, S., Cai, H., Peng, B., Cai, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=34;Plane+first&amp;#34;+approach+for+laparoscopic+radical+antegrade+modular+pancreatosplenectomy.">34;Plane first&amp;#34; approach for laparoscopic radical antegrade modular pancreatosplenectomy.</a> Surg Endosc. 36 (10), 7471-7476 (2022).</li><li>Kato, 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+radical+antegrade+modular+pancreatosplenectomy+with+anterocranial+splenic+artery-first+approach+for+left-sided+resectable+pancreatic+cancer+(with+Videos).">Laparoscopic radical antegrade modular pancreatosplenectomy with anterocranial splenic artery-first approach for left-sided resectable pancreatic cancer (with Videos).</a> Ann Surg Oncol. 29 (6), 3505-3514 (2022).</li><li>Zhang, R. 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J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=CT+of+pelvic+extraperitoneal+spaces:+an+anatomical+study+in+cadavers.">CT of pelvic extraperitoneal spaces: an anatomical study in cadavers.</a> Clin Radiol. 62 (5), 432-438 (2007).</li><li>Takahashi, 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=Radical+antegrade+modular+pancreatosplenectomy+enhances+local+control+of+the+disease+in+patients+with+left-sided+pancreatic+cancer.">Radical antegrade modular pancreatosplenectomy enhances local control of the disease in patients with left-sided pancreatic cancer.</a> HPB (Oxford). 25 (1), 37-44 (2023).</li><li>Li, 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=Radical+antegrade+modular+pancreatosplenectomy+(RAMPS)+versus+standard+retrograde+pancreatosplenectomy+(SRPS)+for+resectable+body+and+tail+pancreatic+adenocarcinoma:+protocol+of+a+multicenter,+prospective,+randomized+phase+III+control+trial+(CSPAC-3).">Radical antegrade modular pancreatosplenectomy (RAMPS) versus standard retrograde pancreatosplenectomy (SRPS) for resectable body and tail pancreatic adenocarcinoma: protocol of a multicenter, prospective, randomized phase III control trial (CSPAC-3).</a> Trials. 24 (1), 541 (2023).</li><li>Kiritani, 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=Radical+antegrade+modular+pancreatosplenectomy+for+left-sided+pancreatic+ductal+adenocarcinoma+may+reduce+the+local+recurrence+rate.">Radical antegrade modular pancreatosplenectomy for left-sided pancreatic ductal adenocarcinoma may reduce the local recurrence rate.</a> Dig Surg. 39 (4), 191-200 (2022).</li><li>Kuriyama, 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=Anterior+versus+posterior+radical+antegrade+modular+pancreatosplenectomy+for+pancreatic+body+and+tail+cancer:+an+inverse+probability+of+treatment+weighting+with+survival+analysis.">Anterior versus posterior radical antegrade modular pancreatosplenectomy for pancreatic body and tail cancer: an inverse probability of treatment weighting with survival analysis.</a> Surg Today. 53 (8), 917-929 (2023).</li><li>Sato, A., Yazawa, T., Yamamoto, G., Yamamoto, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessment+of+safety+and+benefits+of+posterior+radical+antegrade+modular+pancreatosplenectomy+in+patients+without+invasion+to+left+adrenal+gland.">Assessment of safety and benefits of posterior radical antegrade modular pancreatosplenectomy in patients without invasion to left adrenal gland.</a> Asian J Surg. 46 (1), 587-589 (2023).</li><li>Kwon, 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=Clinical+outcome+of+RAMPS+for+left-sided+pancreatic+ductal+adenocarcinoma:+a+comparison+of+anterior+ramps+versus+posterior+ramps+for+patients+without+periadrenal+infiltration.">Clinical outcome of RAMPS for left-sided pancreatic ductal adenocarcinoma: a comparison of anterior ramps versus posterior ramps for patients without periadrenal infiltration.</a> Biomedicines. 9 (10), 1291 (2021).</li><li>Fern&#225;ndez-Cruz, 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=Curative+laparoscopic+resection+for+pancreatic+neoplasms:+a+critical+analysis+from+a+single+institution.">Curative laparoscopic resection for pancreatic neoplasms: a critical analysis from a single institution.</a> J Gastrointest Surg. 11 (12), 1607-1622 (2007).</li><li>Choi, S. H., Kang, C. M., Lee, W. J., Chi, H. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Multimedia+article.+Laparoscopic+modified+anterior+RAMPS+in+well-selected+left-sided+pancreatic+cancer:+technical+feasibility+and+interim+results.">Multimedia article. Laparoscopic modified anterior RAMPS in well-selected left-sided pancreatic cancer: technical feasibility and interim results.</a> Surg Endosc. 25 (7), 2360-2361 (2011).</li><li>Lee, S. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+RAMPS+in+well-selected+left-sided+pancreatic+cancer+within+Yonsei+criteria:+long-term+(&gt;median+3+years)+oncologic+outcomes.">Minimally invasive RAMPS in well-selected left-sided pancreatic cancer within Yonsei criteria: long-term (&gt;median 3 years) oncologic outcomes.</a> Surg Endosc. 28 (10), 2848-2855 (2014).</li><li>Han, D. H., Kang, C. M., Lee, W. J., Chi, H. 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DPS has been widely used as the standard radical surgery for distal pancreatic carcinoma1,2. However, due to the highly invasive nature of pancreatic cancer, it is easy for the tumor to grow to the edge of the pancreas and even break through the surface of the pancreas. Meanwhile, accompanying chronic pancreatitis makes the boundary between the pancreas and the surrounding tissues unclear. Therefore, it is difficult to achieve R0 resection during conventional sur...

Conventional distal pancreatosplenectomy (DPS) has traditionally been the standard surgical procedure for distal pancreatic carcinoma1,2. Distal pancreatic carcinoma is a highly invasive tumor that easily infiltrates into retroperitoneal tissues. Simultaneously, pancreatic cancer is often accompanied by chronic pancreatitis, making the boundary between the pancreas and adjacent tissues unclear. Consequently, during conventional DPS, there is a risk of tumor cells spreading along the direction of blood circulation and lymphatic return. In addition to the inherent inflammation associated with pancreatic cancer, achieving R0 resection is challenging, leading to a relatively low postoperative survival rate for patients3.
With the advancement of surgical techniques and a deeper understanding of the pancreatic lymphatic system, the high positive rate of the surgical margin and incomplete lymph node dissection in conventional DPS have garnered more attention. In response, radical antegrade modular pancreatosplenectomy (RAMPS) has emerged to address these challenges3,4. RAMPS involves the complete removal of tissues around the body and tail of the pancreas, including the tumor, to ensure a negative incisional margin and thorough dissection of lymph nodes in N1 nodes, the superior mesenteric artery (SMA), and the anterior and left of the celiac trunk3,4.
In 2003, Strasberg first reported RAMPS3. With the development of minimally invasive surgical techniques, there have been sporadic reports of laparoscopic RAMPS (L-RAMPS) in recent years. L-RAMPS is preliminarily considered technically safe and feasible in oncology5,6,7,8,9. However, due to technical difficulties and a lack of supporting evidence for clinical application, only a few institutions are currently conducting L-RAMPS. In light of this situation, this article presents the techniques of laparoscopic posterior radical antegrade modular pancreatosplenectomy (L-pRAMPS) in detail, holding great promise for future clinical application.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>10-mm trocar</td>
			<td>Xiamen Surgaid Medical Device Co., LTD</td>
			<td>NGCS 100-1-10</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>12-mm trocar</td>
			<td>Xiamen Surgaid Medical Device Co., LTD</td>
			<td>NGCS 100-1-12</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>5-mm trocar</td>
			<td>Xiamen Surgaid Medical Device Co., LTD</td>
			<td>NGCS 100-1-5</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>Hem-o-lok</td>
			<td>America Teleflex Medical Technology Co., LTD</td>
			<td>544240</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>Linear stapling device</td>
			<td>America Ethicon Medical Technology Co., LTD</td>
			<td>PSEE60A</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>Pneumoperitoneum needle</td>
			<td>Xiamen Surgaid Medical Device Co., LTD</td>
			<td>NGCS 100-1</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>Suction and irrigation tube</td>
			<td>Tonglu Hengfeng Medical Device Co., LTD</td>
			<td>HF6518.035</td>
			<td>Sterile,dry heat sterilized, reusable</td>
		</tr>
		<tr>
			<td>Ultrasounic-harmonic scalpel</td>
			<td>Chongqing Maikewei Medical Technology Co., LTD</td>
			<td>QUHS36S&#160;</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
	</tbody>
</table>

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.

The surgery proceeded smoothly, and the intraoperative rapid frozen pathological examination indicated the absence of cancer at the incisal margin of the pancreas. Throughout the surgery, the patient&#39;s vital signs remained stable, and the anesthesia was effective. The operation duration was 150 min, with an intraoperative blood loss of 80 mL. Anal exhaust occurred 32 h postoperatively. There were no complications such as abdominal hemorrhage, pancreatic leakage, abdominal infection, or incision infection. The postope...

Read this Scientific Article Protocol about Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma at JoVE.com

Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma

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 ...

Using non-invasive forceps, lift and pull the stomach towards the cephalic side and with an ultrasonic harmonic scalpel, cut the gastrocolic and gastro splenic ligaments at the upper edge of the transverse colon. To separate the stomach and spleen, ligate and sever the left gastroepiploic vessels, short gastric vessels, posterior gastric vessels, and left subphrenic vessels near the gastric wall. Then enter the lesser or mental sac, and explore the condition of the pancreatic tumor.Next, separate and expose the common hepatic artery, followed by the celiac trunk and the left gastric artery, and dissect the lymph nodes surrounding both these arteries. Incise the retroperitoneum from the pancreatic neck to the pancreatic tail at the lower margin of the pancreas, and remove the surrounding lymph nodes. Then continue to incise the anterior layer of the left gerota fascia to reveal the left renal vein.Peel the anterior layer of gerota fascia from the surface of the left kidney along the left renal vein. To expose the superior mesenteric artery and abdominal aorta, lift the distal pancreas toward the cephalic side, and simultaneously dissect the surrounding lymph nodes. Separate the superior mesenteric vein at the lower margin of the pancreatic neck, followed by the retro pancreatic tunnel along the surface of the FMV and portal vein.Using a linear stapling device, sever the pancreas at the neck. After dissecting and exposing the splenic vein, ligate and sever its root. Dissect the splenic artery to remove the surrounding lymph nodes and ligate and cut off the artery root.After lifting the pancreas and the anterior layer of the gerota fascia, sever the left adrenal vessel and peel off the anterior layer of the gerota fascia and the left adrenal gland upwards. Cut off the posterior peritoneum from right to left above the pancreas, and clear the connective tissues between the abdominal aorta and the left kidney along the left cross of diaphragm. Then sever the gerota fascia tissues at the upper margin of the left adrenal gland.Next, sever the ligaments and adhesions around the spleen to release it and excise a distal pancreas, the anterior layer of the gerota fascia, the left adrenal gland, and the spleen as a whole. To carefully examine the surgical field, irrigate the abdominal cavity with sterile distilled water, and place a drainage tube beside the incisal margin of the pancreas. Finally, extend the umbilical incision length to about five centimeters.Cut the abdominal wall layer by layer and take out the specimen. The postoperative CT scan indicates successful tumor removal without significant recurrence or metastasis.

laparoscopic-posterior-radical-antegrade-modular-pancreatosplenectomy

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Medicine

Staining Protocols for Human Pancreatic Islets

Estimates of islet area and numbers and endocrine cell composition in the adult human pancreas vary from several hundred thousand to several million and beta mass ranges from 500 to 1500 mg 1-3. With this known heterogeneity, a standard processing and staining procedure was developed so that pancreatic regions were clearly defined and islets characterized using rigorous histopathology and immunolocalization examinations. 
Standardized procedures for processing human pancreas recovered from organ donors are described in part 1 of this series. The pancreas is processed into 3 main regions (head, body, tail) followed by transverse sections. Transverse sections from the pancreas head are further divided, as indicated based on size, and numbered alphabetically to denote subsections. This standardization allows for a complete cross sectional analysis of the head region including the uncinate region which contains islets composed primarily of pancreatic polypeptide cells to the tail region.
The current report comprises part 2 of this series and describes the procedures used for serial sectioning and histopathological characterization of the pancreatic paraffin sections with an emphasis on islet endocrine cells, replication, and T-cell infiltrates. Pathology of pancreatic sections is intended to characterize both exocrine, ductular, and endocrine components. The exocrine compartment is evaluated for the presence of pancreatitis (active or chronic), atrophy, fibrosis, and fat, as well as the duct system, particularly in relationship to the presence of pancreatic intraductal neoplasia4. Islets are evaluated for morphology, size, and density, endocrine cells, inflammation, fibrosis, amyloid, and the presence of replicating or apoptotic cells using H&amp;E and IHC stains. 
The final component described in part 2 is the provision of the stained slides as digitized whole slide images. The digitized slides are organized by case and pancreas region in an online pathology database creating a virtual biobank. Access to this online collection is currently provided to over 200 clinicians and scientists involved in type 1 diabetes research. The online database provides a means for rapid and complete data sharing and for investigators to select blocks for paraffin or frozen serial sections.

This video demonstrates procedures for characterization of human pancreatic islets using hematoxylin and eosin (H&E) and immunohistochemistry (IHC). Pancreatic sections from head, body, and tail regions are stained by both H&amp;E and IHC to determine islet endocrine composition (insulin, glucagon, and pancreatic polypeptide), cell replication (Ki67), and inflammatory infiltrates (H&E, CD3). The uncinate region is localized using IHC for pancreatic polypeptide.

Estimates of islet area and numbers and endocrine cell composition in the adult human pancreas vary from several hundred thousand to several million and ...

Modeling Stroke in Mice: Permanent Coagulation of the Distal Middle Cerebral Artery

Stroke is the third most common cause of death and a main cause of acquired adult disability in developed countries. Only very limited therapeutical options are available for a small proportion of stroke patients in the acute phase. Current research is intensively searching for novel therapeutic strategies and is increasingly focusing on the sub-acute and chronic phase after stroke because more patients might be eligible for therapeutic interventions in a prolonged time window. These delayed mechanisms include important pathophysiological pathways such as post-stroke inflammation, angiogenesis, neuronal plasticity and regeneration. In order to analyze these mechanisms and to subsequently evaluate novel drug targets, experimental stroke models with clinical relevance, low mortality and high reproducibility are sought after. Moreover, mice are the smallest mammals in which a focal stroke lesion can be induced and for which a broad spectrum of transgenic models are available. Therefore, we describe here the mouse model of transcranial, permanent coagulation of the middle cerebral artery via electrocoagulation distal of the lenticulostriatal arteries, the so-called &#8220;coagulation model&#8221;. The resulting infarct in this model is located mainly in the cortex; the relative infarct volume in relation to brain size corresponds to the majority of human strokes. Moreover, the model fulfills the above-mentioned criteria of reproducibility and low mortality. In this video we demonstrate the surgical methods of stroke induction in the &#8220;coagulation model&#8221; and report histological and functional analysis tools.

Various murine models of middle cerebral artery occlusion (MCAO) are widely used in experimental brain research. Here, we demonstrate the model of transcranial permanent distal MCAO which produces consistent cortical infarction of a size corresponding to damage imposed by the majority of human ischemic strokes.

Stroke is the third most common cause of death and a main cause of acquired adult disability in developed countries. Only very limited therapeutical ...

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 ...

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.

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

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 ...

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction, for cancer of the body-tail of the pancreas. The patient is placed supine with the legs parted and a pneumoperitoneum is established and maintained at 10 mmHg. To use the surgical system, four 8 mm ports and one 12 mm port are required. The optic port is placed at the umbilicus. The other ports are placed, on either side, along the pararectal line and the anterior axillary line at the level of the umbilical line. The assistant port (12 mm) is placed along the right pararectal line. Dissection begins by detaching the gastrocolic ligament, thus opening the lesser sac, and by a wide mobilization of the splenic flexure of the colon. The superior mesenteric vein is identified along the inferior border of the pancreas. Lymph node number 8a is removed to permit clear visualization of the common hepatic artery. A tunnel is then created behind the neck of the pancreas. To permit safe resection and reconstruction of the spleno-mesenteric junction, further preemptive dissection is required before dividing the pancreatic neck to bring in clear view all relevant vascular pedicles. Next, the splenic artery is ligated and divided, and the pancreatic neck is divided, with selective ligature of the pancreatic duct. After vein resection and reconstruction, dissection proceeds to complete the clearance of peripancreatic arteries that are peeled off from all lympho-neural tissues. Both celiac ganglia are removed en-bloc with the specimen. The Gerota fascia covering the upper pole of the left kidney is also removed en-bloc with the specimen. Division of short gastric vessels and splenectomy complete the procedure. A drain is left near the pancreatic stump. The round ligament of the liver is mobilized to protect the vessels.

The robotic technique shown herein aims at faithfully reproducing the open procedure for radical treatment of cancer of the body-tail of the pancreas. The protocol also demonstrates the ability to master involvement of major peripancreatic vessels without conversion to open surgery.

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the ...

Technical Modification of the Terminal Ureter During Total Transperitoneal Laparoscopic Nephroureterectomy for Upper Urinary Tract Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) accounts for 5%&ndash;10% of all urothelial tumors. Radical nephroureterectomy is the standard treatment procedure. At present, different choices still exist for treating the ureteral end during laparoscopic ureteral bladder sleeve resection. Our center has adopted a new method for treating the ureteral end. This new method can increase the operating space and reduce the difficulty of the surgery compared with current methods.

Here, we present a protocol to increase the surgical field of view and reduce the difficulty of total transperitoneal laparoscopic nephroureterectomy surgery by precutting the umbilical ligament before treating the terminal ureter.

Upper tract urothelial carcinoma (UTUC) accounts for 5%&ndash;10% of all urothelial tumors. Radical nephroureterectomy is the standard treatment ...

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 ...

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

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein&#160;(SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

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

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

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

Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore apical support for treating POP. Sacrocolpopexy and pectopexy are indicated for apical prolapse. Using a synthetic mesh in these techniques increases success by enhancing apical support. However, the implantation of synthetic mesh is associated with mesh-related complications. In addition, the exorbitant cost of synthetic mesh and lack of universal access limit the popularity of these procedures. The current study develops a unique technique known as laparoscopic non-mesh cerclage pectopexy (LNMCP), in which permanent cervical cerclage sutures are embedded in the round ligament until the iliopectineal ligament. The iliopectineal ligament was sutured, resulting in a firm cervical suspension. The procedure was successfully performed in 16 cases in the hospital. The surgical duration was 67.8 min &plusmn; 15.5 min, and the blood loss was 73.1 mL &plusmn; 51.1 mL. No procedural complications were seen. LNMCP is associated with an objective success rate of 100% and a subjective success rate of 93.8%. LNMCP for patients with apical prolapse obviates the need for a mesh, thereby avoiding complications associated with mesh erosion and reducing medical costs. In addition, it is easy to perform even in resource-poor areas without access to synthetic mesh.

The present pilot study describes the development of laparoscopic non-mesh cerclage pectopexy to treat pelvic organ prolapse. The procedure can be used to prevent any complications associated with the use of mesh.

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