This paper was supported by funding from the National Natural Science Foundation of China (82060454), the key research and development program of Jiangxi Province of China (20203BBGL73143), and the Jiangxi Province high-level and high-skill leading talent training project (G/Y3035).

The study follows the human research ethics committee of the Second Affiliated Hospital of Nanchang University. Written informed consent was obtained from the patient prior to surgery.
NOTE: The patient was a 65-year-old male presenting with a chief complaint of &#34;generalized jaundice and pruritus for 2 weeks&#34;. A computed tomography (CT) scan at an outside hospital revealed a perihilar bile duct mass with intrahepatic bile duct dilation. The surgical instruments and equipment used are listed in the Table of Materials.
1. Preoperative preparation
<ol>
	<li>Perform routine blood tests preoperatively, including complete blood count, liver and kidney function tests, coagulation profile, and serum tumor markers.
	<ol>
		<li>Draw blood samples, send them to the laboratory for various blood tests, and report the results. 
		NOTE: Liver function tests showed elevated total bilirubin (230.8 &#956;mol/L) and decreased albumin (35.7 g/L). Serum tumor marker tests revealed elevated carbohydrate antigen carbohydrate antigen 199 (184.46 U/mL)4,12.</li>
	</ol>
	</li>
	<li>Perform preoperative electrocardiogram (ECG), abdominal CT, magnetic resonance imaging (MRI) of the abdomen, chest CT, and other relevant examinations4,12. 
	NOTE: In this study, the patient underwent an abdominal CT scan with and without contrast in the radiology department. The scan showed a mass in the perihilar region without involvement of surrounding vessels, suggesting cholangiocarcinoma with obstruction (Figure 1). MRI with and without contrast and magnetic resonance cholangiopancreatography demonstrated a mass in the perihilar bile duct and adjacent liver parenchyma with intrahepatic bile duct dilatation and enlarged perihilar lymph nodes, indicating a neoplastic lesion (Figure 1).</li>
</ol>
2. Surgical procedure
<ol>
	<li>Administer general anesthesia with tracheal intubation, intravenous and inhalational agents. Position the patient supine with the head elevated and legs apart. Perform routine disinfection using povidone-iodine solution. 
	NOTE: The primary surgeon stands on the patient&#39;s right side, the assistant on the left side, and the camera holder between the patient&#39;s legs (Figure 2).</li>
	<li>Make a longitudinal incision of approximately 1 cm at the umbilicus, insert a Veress needle, and insufflate CO2 to maintain an intra-abdominal pressure of 12 mmHg. Insert a 10 mm trocar and a 30&#176; laparoscope. After confirming no distant metastasis via laparoscopy, place the surgical trocars as shown in Figure 2.</li>
	<li>Dissect the cystic artery and cystic duct, then proceed with the retrograde removal of the gallbladder. Use an ultrasonic scalpel to dissect, mobilize, and suspend the common hepatic artery (CHA), gastroduodenal artery (GDA), proper hepatic artery (PHA), and the left hepatic arteries (LHA) (giving off the middle hepatic artery (MHA)) and right hepatic arteries (RHA). Ligate and divide the right gastric arteries (RGA) and LHA (Figure 3).</li>
	<li>Transect the common bile duct (CBD) at the superior border of the pancreas and send the distal margin for frozen section pathology to confirm negative margins.</li>
	<li>Use an ultrasonic scalpel to dissect, mobilize, and suspend the portal vein (PV). Remove the extrahepatic bile duct and lymph node groups 8, 12, and 13 en bloc along the PV towards the hepatic hilum, achieving skeletonization of the hepatoduodenal ligament.</li>
	<li>Ligate and divide the left branch of portal vein (LPV) and caudate lobe portal vein branches.
	<ol>
		<li>Dissect the left hepatic ligaments and divide the short hepatic veins of the caudate lobe, clearly delineating the demarcation line (ischemic line) between the right and left liver lobes.</li>
		<li>After marking the demarcation line, confirm that the fluorescence boundary matched the ischemic line using fluorescence imaging (Figure 4, and Figure 5). 
		NOTE: A negative staining method is used here, with indocyanine green administered via peripheral intravenous injection at a dose of 0.25 mg13,14.</li>
	</ol>
	</li>
	<li>Intermittently occlude the main PV using the Pringle maneuver15. Use an ultrasonic scalpel to transect the liver parenchyma along the demarcation line, then along the plane of the middle hepatic vein (MHV), ensuring to divide its V4b and V4a branches. 
	NOTE:&#160;Patients with a positive liver margin may consider undergoing expanded left hepatectomy (LH), which involves the complete resection of the main trunk of the MHV and the left portions of segments 5 and 8. This approach may improve survival rates16.&#160; &#160; &#160; &#160; &#160; &#160; &#160; &#160;&#160;</li>
	<li>Transect the right hepatic duct approximately 1 cm from the tumor and send the proximal margin for frozen section pathology to confirm negative margins.
	<ol>
		<li>Perform intraoperative frozen section analysis of the proximal hepatic duct margin multiple times as needed to ensure an R0 resection. If the right hepatic duct is extensively divided, consider bile duct reconstruction or double hepaticojejunostomy of the right anterior and right posterior bile ducts.</li>
	</ol>
	</li>
	<li>Transect the left hepatic vein (LHV) using an endoscopic linear cutter stapler (ENDO-GIA). Completely resect the left hemiliver and the entire caudate lobe, and place the specimen in a retrieval bag (Figure 6).</li>
	<li>Transect the jejunum approximately 20 cm distal to the ligament of Treitz. Elevate the distal loop posterior to the colon for an end-to-side anastomosis with the right hepatic duct, using continuous sutures for the anterior and posterior walls (Figure 7). Perform a side-to-side jejunojejunostomy approximately 45 cm distal to the right hepatic duct-jejunal anastomosis.</li>
	<li>Irrigate the abdominal cavity with sterile distilled water. Carefully inspect the surgical field for active bleeding, bile leaks, and gastrointestinal side branch injuries. Place drainage tubes in the left liver section and Winslow&#39;s foramen.</li>
	<li>Extend the umbilical incision by approximately 5 cm and dissect the abdominal wall layer by layer to retrieve the specimen. Verify the count of surgical instruments and gauze. Remove the trocars under direct vision. Close the abdominal wall incision with interrupted 2-0 absorbable sutures to complete the surgery.</li>
</ol>
3. Postoperative care
<ol>
	<li>Transport the patient safely back to the ward after the patient regains consciousness.</li>
	<li>Administer intravenous antibiotics, omeprazole, and nutritional support postoperatively.</li>
	<li>Start a liquid diet on the third postoperative day after the patient passes gas.</li>
	<li>Remove the abdominal drainage tubes on the 4th and 13th postoperative days.</li>
</ol>

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The authors have nothing to disclose.

pCCA is a common malignant tumor of the bile ducts, with radical surgical resection being the only potential curative treatment2. Traditional radical surgery for pCCA typically requires an abdominal incision of 20&#8211;30 cm, resulting in significant surgical trauma. Large incisions often cause considerable postoperative pain, affecting patient comfort and recovery, thereby prolonging hospital stays5,6,7...

Perihilar cholangiocarcinoma (pCCA), also known as Klatskin tumor, was first described by Gerald Klatskin and is a malignant tumor that occurs in the bile duct epithelium at the confluence of the right and left hepatic ducts1. This disease is highly malignant and aggressive, often presenting with jaundice and cholangitis in advanced stages. Despite advancements in diagnosis and treatment, the prognosis for pCCA remains poor, with radical surgical resection still being the only potentially curative approach. Such surgeries typically involve extensive hepatectomy, bile duct resection, and regional lymphadenectomy2. The goal of surgery is to achieve an R0 resection, which significantly improves patient survival rates3,4. However, the complex anatomy of the hilar region and the tumor&#39;s proximity to vital vascular structures make these surgeries highly challenging.
In recent years, the advent of laparoscopic technology has revolutionized surgical oncology, offering potential advantages such as reduced perioperative complications, shorter hospital stays, and faster recovery5,6,7. Nevertheless, the application of laparoscopic surgery in pCCA, particularly for type IIIb cases, remains limited, with only a few reports available3,8. This is primarily due to the technical difficulty in achieving adequate margins and performing complex biliary and vascular reconstructions laparoscopically9. Current guidelines recommend left hemihepatectomy combined with total caudate lobectomy and standardized lymphadenectomy for resectable type IIIb pCCA4,10,11,12. However, evidence supporting the use of laparoscopic methods for this extensive surgery is still accumulating.
This study presents the complete laparoscopic radical resection of type IIIb pCCA. We aim to detail this surgery&#39;s techniques and key steps, including left hemihepatectomy, total caudate lobectomy, regional lymphadenectomy, and Roux-en-Y hepaticojejunostomy. By sharing this protocol, we hope to contribute to the evidence supporting the feasibility and safety of laparoscopic methods in the treatment of type IIIb pCCA, ultimately improving patient outcomes.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>5-mm trocar</td>
			<td>CANWELL MEDICAL Co., LTD</td>
			<td>179094F</td>
			<td>Sterile, ethylene oxide sterilized, 
			disposable</td>
		</tr>
		<tr>
			<td>12-mm trocar</td>
			<td>CANWELL MEDICAL Co., LTD</td>
			<td>NB12STF</td>
			<td>Sterile, ethylene oxide sterilized, 
			disposable</td>
		</tr>
		<tr>
			<td>Absorbable Sutures</td>
			<td>America Ethicon Medical Technology Co., LTD</td>
			<td>W8557/W9109H/VCPB839D</td>
			<td>Sterile, ethylene oxide sterilized, 
			disposable</td>
		</tr>
		<tr>
			<td>Alligaclip Absorbable Ligating Clip</td>
			<td>Hangzhou Sunstone Technology Co., Ltd.</td>
			<td>K12</td>
			<td>Sterile, ethylene oxide sterilized, 
			disposable</td>
		</tr>
		<tr>
			<td>Endoscopic linear cutting stapler</td>
			<td>America Ethicon Medical Technology Co., LTD</td>
			<td>ECR60W/PSEE60A</td>
			<td>Sterile, ethylene oxide sterilized, 
			disposable</td>
		</tr>
		<tr>
			<td>Non-absorbable polymer ligature clip</td>
			<td>Greiner Bio-One Shanghai Co., Ltd.</td>
			<td>0301-03M04/0301-03L04/0301-03ML02</td>
			<td>Sterile, ethylene oxide sterilized, 
			disposable</td>
		</tr>
		<tr>
			<td>NonAbsorbable Sutures</td>
			<td>America Ethicon Medical Technology Co., LTD</td>
			<td>EH7241H/EH7242H</td>
			<td>Sterile, ethylene oxide sterilized, 
			disposable</td>
		</tr>
		<tr>
			<td>Ultrasonic scalpel</td>
			<td>America Ethicon Medical Technology Co., LTD</td>
			<td>HARH36</td>
			<td>Sterile, ethylene oxide sterilized, 
			disposable</td>
		</tr>
	</tbody>
</table>

complete laparoscopic radical resection of perihilar cholangiocarcinoma type iiib

Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With continuous advancements in laparoscopic techniques and instruments, laparoscopic radical surgery for pCCA is now considered technically safe and feasible. However, due to the high complexity of the surgery and the lack of evidence-based clinical support, laparoscopic radical surgery for type IIIb pCCA is performed only in a few large hepatobiliary centers. Current guidelines recommend left hemihepatectomy combined with total caudate lobectomy and standardized lymphadenectomy for resectable type IIIb pCCA. Therefore, in this article, we provide a detailed description of the surgical steps and technical points of complete laparoscopic left hemihepatectomy combined with total caudate lobectomy, regional lymphadenectomy, and right hepatic duct-jejunal Roux-en-Y anastomosis in patients with type IIIb pCCA, using fluorescence navigation technology to enhance surgical precision and safety. By adhering to standardized surgical procedures and precise intraoperative techniques, we offer an effective means to improve patient outcomes.

The surgery progressed smoothly, and intraoperative frozen section pathology showed negative margins at both the distal and proximal bile ducts. Throughout the procedure, the patient&#39;s vital signs remained stable, and anesthesia was effective. The operation lasted 360 min, with PV occlusion time totaling 60 min (15 min + 5 min &#215; 4 times). Intraoperative blood loss was 400 mL, and the patient received 2 units of leukocyte privative red blood cells and 600 mL of fresh frozen plasma. Postoperative flatus was observ...

Complete Laparoscopic Radical Resection of Perihilar Cholangiocarcinoma Type IIIb

Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With ...

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101 Views.  The Second Affiliated Hospital of Nanchang University. Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With continuous advancements in laparoscopic techniques and instruments, laparoscopic radical surgery for pCCA is now considered technically safe and feasible. However, due to the high complexity of the surgery and the lack of evidence-based clinical support, laparoscopic radical surgery for type IIIb pCCA is performed only in...

Video: Complete Laparoscopic Radical Resection of Perihilar Cholangiocarcinoma Type IIIb

Mouse Complete Stasis Model of Inferior Vena Cava Thrombosis

Venous thromboembolism (VTE) includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). In the United States (U.S.), the high morbidity and mortality rates make VTE a serious health concern 1-2. After heart disease and stroke, VTE is the third most common vascular disease 3. In the U.S. alone, there is an estimated 900,000 people affected each year, with 300,000 deaths occurring annually 3. A reliable in vivo animal model to study the mechanisms of this disease is necessary.
The advantages of using the mouse complete stasis model of inferior vena cava thrombosis are several. The mouse model allows for the administration of very small volumes of limited availability test agents, reducing costs dramatically. Most promising is the potential for mice with gene knockouts that allow specific inflammatory and coagulation factor functions to be delineated. Current molecular assays allow for the quantitation of vein wall, thrombus, whole blood, and plasma for assays. However, a major concern involving this model is the operative size constraints and the friability of the vessels. Also, due to the small IVC sample weight (mean 0.005 grams) it is necessary to increase animal numbers for accurate statistical analysis for tissue, thrombus, and blood assays such as real-time polymerase chain reaction (RT-PCR), western blot, enzyme-linked immunosorbent (ELISA), zymography, vein wall and thrombus cellular analysis, and whole blood and plasma assays 4-8.
The major disadvantage with the stasis model is that the lack of blood flow inhibits the maximal effect of administered systemic therapeutic agents on the thrombus and vein wall.

The mouse complete stasis model of inferior vena cava thrombosis yields quantifiable amounts of vein wall tissue and thrombus. It has proven useful for evaluating interactions between the vein wall and the occlusive thrombus and in assessing the progression from acute to chronic inflammation.

Venous thromboembolism (VTE) includes both deep vein thrombosis (DVT) and pulmonary embolism (PE).  In the United States (U.S.), the high morbidity and ...

Murine Ileocolic Bowel Resection with Primary Anastomosis

Intestinal resections are frequently required for treatment of diseases involving the gastrointestinal tract, with Crohn&#8217;s disease and colon cancer being two common examples. Despite the frequency of these procedures, a significant knowledge gap remains in describing the inherent effects of intestinal resection on host physiology and disease pathophysiology. This article provides detailed instructions for an ileocolic resection with primary end-to-end anastomosis in mice, as well as essential aspects of peri-operative care to maximize post-operative success. When followed closely, this procedure yields a 95% long-term survival rate, no failure to thrive, and minimizes post-operative complications of bowel obstruction and anastomotic leak. The technical challenges of performing the procedure in mice are a barrier to its wide spread use in research. The skills described in this article can be acquired without previous surgical experience. Once mastered, the murine ileocolic resection procedure will provide a reproducible tool for studying the effects of intestinal resection in models of human disease.

Ileocolic resection is commonly performed in several human diseases; however, little is known regarding the impact of intestinal resection on surgical illnesses. This article provides instruction on executing the procedure in mice with high success, providing a means to study the effects of ileocolic resection in models of disease.

Intestinal resections are frequently required for treatment of diseases involving the gastrointestinal tract, with Crohn&#8217;s disease and colon cancer ...

The Influence of Liver Resection on Intrahepatic Tumor Growth

The high incidence of tumor recurrence after resection of metastatic liver lesions remains an unsolved problem. Small tumor cell deposits, which are not detectable by routine clinical imaging, may be stimulated by hepatic regeneration factors after liver resection. It is not entirely clear, however, which factors are crucial for tumor recurrence.
The presented mouse model may be useful to explore the mechanisms that play a role in the development of recurrent malignant lesions after liver resection. The model combines the easy-to-perform and reproducible techniques of defined amounts of liver tissue removal and tumor induction (by injection) in mice. The animals were treated with either a single laparotomy, a 30% liver resection, or a 70% liver resection. All animals subsequently received a tumor cell injection into the remaining liver tissue. After two weeks of observation, the livers and tumors were evaluated for size and weight and examined by immunohistochemistry.
After a 70% liver resection, the tumor volume and weight were significantly increased compared to a laparotomy alone (p &#60;0.05). In addition, immunohistochemistry (Ki67) showed an increased tumor proliferation rate in the resection group (p &#60;0.05).
These findings demonstrate the influence of hepatic regeneration mechanisms on intrahepatic tumor growth. Combined with methods like histological workup or RNA analysis, the described mouse model could serve as foundation for a close examination of different factors involved in tumor growth and metastatic disease recurrence within the liver. A considerable number of variables like the length of postoperative observation, the cell line used for injection or the timing of injection and liver resection offer multiple angles when exploring a specific question in the context of post-hepatectomy metastases. The limitations of this procedure are the authorization to perform the procedure on animals, access to an appropriate animal testing facility and acquisition of certain equipment.

A high incidence of tumor recurrence after resection of liver metastases remains an unsolved problem. The illustrated mouse model may be useful to investigate the reasons for such recurrences. It combines a liver resection model with intrahepatic tumor cell injection for the first time.

The high incidence of tumor recurrence after resection of metastatic liver lesions remains an unsolved problem. Small tumor cell deposits, which are not ...

Complete and Partial Aortic Occlusion for the Treatment of Hemorrhagic Shock in Swine

Hemorrhage remains the leading cause of preventable deaths in trauma. Endovascular management of non-compressible torso hemorrhage has been at the forefront of trauma care in recent years. Since complete aortic occlusion presents serious concerns, the concept of partial aortic occlusion has gained a growing attention. Here, we present a large animal model of hemorrhagic shock to investigate the effects of a novel partial aortic balloon occlusion catheter and compare it with a catheter that works on the principles of complete aortic occlusion. Swine are anesthetized and instrumented in order to conduct controlled fixed-volume hemorrhage, and hemodynamic and physiological parameters are monitored. Following hemorrhage, aortic balloon occlusion catheters are inserted and inflated in the supraceliac aorta for 60 min, during which the animals receive whole-blood resuscitation as 20% of the total blood volume (TBV). Following balloon deflation, the animals are monitored in a critical care setting for 4 h, during which they receive fluid resuscitation and vasopressors as needed. The partial aortic balloon occlusion demonstrated improved distal mean arterial pressures (MAPs) during the balloon inflation, decreased markers of ischemia, and decreased fluid resuscitation and vasopressor use. As swine physiology and homeostatic responses following hemorrhage have been well-documented and are like those in humans, a swine hemorrhagic shock model can be used to test various treatment strategies. In addition to treating hemorrhage, aortic balloon occlusion catheters have become popular for their role in cardiac arrest, cardiac and vascular surgery, and other high-risk elective surgical procedures.

Here, we present a protocol demonstrating a hemorrhagic shock model in swine that uses aortic occlusion as a bridge to definitive care in trauma. This model has application in testing a wide range of surgical and pharmacological therapeutic strategies.

Hemorrhage remains the leading cause of preventable deaths in trauma. Endovascular management of non-compressible torso hemorrhage has been at the ...

Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been associated with lesser hernia recurrence when compared to the primary suture repair. The type of mesh that is most appropriate is still debatable. Synthetic and biosynthetic materials have been studied in the literature. It is well documented that a synthetic mesh is associated with esophageal erosion and migration into the stomach. Though there are limited long-term data on biosynthetic mesh, the short-term results are excellent and promising.
This paper illustrates how a biosynthetic prosthesis can be safely used with fibrin glue fixation and anterior Dor fundoplication to repair any para-esophageal defect. The absorbable biosynthetic mesh has been shown to produce good long-term patient satisfaction outcomes and low recurrence rates compared to conventional methods including repair with synthetic mesh. This technique also avoids the risk of esophageal erosion whilst strengthening the repair. Tacks that are still widely used to secure the mesh can be abandoned due to the associated risk of developing cardiac tamponade, or other disastrous consequences. This repair method, also, highlights how the prosthesis can be fashioned into a V-shape and easily placed in an onlay fashion behind the esophagus. The protocol demonstrates an alternative and safer method for mesh fixation using fibrin glue.

Presented here is a protocol of para-esophageal hernia repair. Use of absorbable biosynthetic mesh avoids the risk of erosion through the esophagus whilst reinforcing the repair. Glue fixation is preferred to avoid the risk of trauma such as bleeding or cardiac tamponade, which are associated with stitches or tacks.

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been ...

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 ...

Retzius-Sparing Robot-Assisted Radical Prostatectomy

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The technique is described step-by-step and further illustrated by a video to enhance reproducibility. Early oncological and functional results were evaluated. In total, 77 patients were included with a median follow-up of 11 months (range: 3-21 months). Fifty-one percent of patients had local high-risk or locally advanced prostate cancer. There were no intra-operative complications, and all high-grade complications (2.6%) were related to pelvic lymph node dissection performed concomitant with RS-RARP. Median operation time was 160 min (range: 122-265 min) and median hospital stay was 3 (range: 3-8) days. A positive surgical margin was reported in 42.9%. One-year biochemical recurrence-free survival was 90.1%. After 6 months, all patients were socially continent and after 1 year, 94.3% were fully continent. Of sexually active patients who underwent at least unilateral nerve-sparing, 43.3% were able to have sexual intercourse. This series underlines the surgical safety of performing RS-RARP by a standardized technique and confirms the beneficial effect on the early return of continence. The patient needs to be informed about the risk of a positive surgical margin.

Robot-assisted Retzius-sparing radical prostatectomy is a technique that enables to preserve urinary continence or facilitates recovery of urinary continence in the majority of patients. Patients must be informed about the risk of a positive surgical margin.

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The ...

Robotic Taj Mahal Hepatectomy for Hilar Cholangiocarcinoma

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

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

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

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 ...