Liver Metastasis Resection: A Simple Technique That Makes It Easier

Liver resection is the only therapeutic option that achieves long-term survival for patients with hepatic metastases. We propose a technique that causes traction and countertraction on the resection area, thus easily exposing the structures to be ligated. Because the parenchyma protrudes like a cork from a bottle, we named this procedure the “corkscrew technique”. The objective of this work was to describe an original surgical technique to resect liver metastases. We delimit the resection area at 2 cm from the tumor. We place separated stitches, in a radiate way. The needle diameter must allow passing far from the deepest margin of the tumor. The stitches must be tractioned all together to separate the tumor from the normal parenchyma. Between the years 1983 and 2006, we perform 1,270 liver resections. We used the corkscrew technique-like procedure in only 612 patients, whereas in 129 patients, we associated it to an anatomic resection. Mortality was 1%. Morbidity was 16% with a reoperation rate of 3%. The corkscrew technique is simple and safe, spares surgical time, avoids blood loss, ensures free tumor margins, and is easy to perform. Presented at the 6th Annual Meeting of the European Hepato-Pancreato-Biliary Association (EHPBA), May 25–28, 2005 Heidelberg, Germany (oral presentation).     

无需阻断肝门的简易区域无血肝切除术

目的探讨无需阻断肝门的区域无血肝切除技术的临床应用价值。方法回顾分析48例肝切除患者的治疗过程,其中择期肝切除41例,急诊手术7例;肝段或联合肝段切除37例,左或右半肝切除8例,中肝叶切除3例,采用特制的直型肝针和普通肝针行肝脏预切区域外的交锁缝扎,形成肝脏局部区域无血,术中无需阻断肝门,轻松进行肝切除手术。结果择期手术平均出血142（15～800）ml,无需输血;4例肝癌破裂腹腔大出血患者成功施行了急诊肝切除手术,平均出血2475（2000～3000）ml,输血750（400—1000）ml;另3例急诊手术出血310（50—800）ml,均无需输血。全组术后恢复良好,无术后并发症,无手术死亡。术后平均10（7—15）d出院。结论本方法为一种安全可靠、简易、快捷的区域无血肝切除方法,容易掌握,费用低廉,患者术后恢复快,值得临床推广应用。     

Waterjet Dissection for Partial Nephrectomy Without Hilar Clamping in a Porcine Model

Hilar clamping is typically used in partial nephrectomy to control hemorrhage, which may damage the renal tissue under warm ischemia conditions. The purpose of this study was to evaluate waterjet technology in partial nephrectomy without renal hilar vascular control in a porcine model. Bilateral partial nephrectomy using waterjet was performed in 8 pigs (16 kidneys: 8 for wedge resections, 8 for pole resections). The operations were performed successfully in all animals. The mean dissection time was 30.6 ± 2.9 minutes for pole resections and 36.5 ± 3.5 minutes for wedge resections. The mean blood loss was 51.6 ± 11.7 mL for pole resections and 38.7 ± 9.2 mL for wedge resections. The novel waterjet technique provided precise and effective hydrodissection of the kidney, avoiding damage to the vascular structures or collecting system.Key words: Partial nephrectomy, Waterjet dissection, Animal experimentKidney cancer is one of the most common cancers in the urinary system. More and more asymptomatic small renal tumors are diagnosed because of the wide use of imaging technologies.¹ For decades, radical nephrectomy was considered the gold standard treatment for localized renal cancer. In recent years, nephron-sparing procedures (partial nephrectomy) have been demonstrated to have similar outcomes to traditional radical nephrectomy for small renal tumors.² However, partial nephrectomy is a challenging operation with a high risk of parenchymal bleeding and damage to the collecting system. Renal hilar vessel clamping is still the first choice to minimize the parenchymal bleeding. Partial nephrectomy is then completed expeditiously under warm ischemia with limited time constraints.³ However, temporary warm ischemia may lead to renal function deterioration, especially for solitary kidneys. It is imperative to improve the surgical technique of partial nephrectomy without relying on renal hilar clamping.Waterjet dissection has been used for selective dissection of the parenchyma of liver,^4–6 pancreatic necrosectomy,⁷ and endoscopic submucosal dissection for gastrointestinal tumors.^8–10 In this study, we investigated whether waterjet resection is applicable or feasible for partial nephrectomy without temporary ischemia in a porcine model.     

Stapler Hepatectomy is a Safe Dissection Technique: Analysis of 300 Patients

Background In many surgical procedures, stapling devices have been introduced for safety and to reduce the overall operative time. Their use for transection of hepatic parenchyma is not well established. Thus, the feasibility of stapler hepatectomy and a risk analysis of surgical morbidity based on intraoperative data have been prospectively assessed on a routine clinical basis. Materials and Methods From October 1, 2001, to January 31, 2005, a total of 416 patients underwent liver resection in our department. During this period endo GIA vascular staplers were used for parenchymal transection in 300 cases of primary (22%) and metastatic (57%) liver cancer, benign diseases (adenoma, focal nodular hyperplasia [FNH], cysts) (14%), gallbladder carcinoma (2%), and other tumors (5%). There were 193 (64%) major resections (i.e., removal of three segments or more) and 107 minor hepatic resections. Additional extrahepatic resections were performed in 44 (15%) patients. Results Median values for operative time and intraoperative hemorrhage were 210 minutes and 700 ml, respectively. Further, transfusion of RBC and FFP was needed in 17% and 11% of patients, respectively. A postoperative ICU stay for >2 days was required in 18% of patients. The median postoperative hospital stay was 10 days (IQR 8–14 days). The most frequent surgical complications were bile leak (8%), wound infection (3%), and pneumothorax (2%). In 7% of cases after stapler hepatectomy a relaparotomy was necessary. Treated medical complications were pleural effusion (7%), renal insufficiency (5%), and cardiac insufficiency (3%). Risk assessment revealed that both operative time and indication for resection had significant impact on surgical morbidity. Mortality (4%) and morbidity (33%) were comparable to other high-volume centers performing conventional liver resection techniques. Conclusion In conclusion, stapler hepatectomy can be used in a routine clinical setting with a low incidence of surgical complications.     

Surgical Outcome of Hilar Plate Resection: Extended Hilar Bile Duct Resection Without Hepatectomy

Background

We have done curative or palliative extended extrahepatic bile duct resection at the level of the hilar plate for selected patients with cholangiocarcinoma with hilar spreading, calling this procedure “hilar plate resection” (HPR), but the results of evaluating the clinical benefits of HPR for cholangiocarcinoma with hilar spreading have not been reported.

Patients and Methods

Fifty-two patients with cholangiocarcinoma underwent HPR: the curative procedure was performed in 28 patients (cHPR group) and the palliative in 24 patients (pHPR group). In the same period, 128 patients with cholangiocarcinoma underwent major hepatectomy with intrahepatic cholangiojejunostomy (Hx group). These groups were compared in terms of post-operative complications and survival.

Results

There were no significant differences in the rate of patients with post-operative complications and in post-operative hospital stay. The overall cumulative 5-year survival rates for each procedure (Hx group, cHPR group and pHPR group) were 40, 38 and 11 %, respectively. There was no significant difference between the Hx and cHPR groups in survival rates (p?=?0.87).

Conclusion

In conclusion, HPR appears to be safe and feasible for selected patients with cholangiocarcinoma. However, the indications for HPR should be restricted.     

刮吸解剖法在急性胆囊炎腹腔镜胆囊切除术中的应用

目的探讨刮吸解剖法在急性胆囊炎腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）中的应用价值。方法2002年8月-2008年1月,借助腹腔镜多功能手术解剖器（laparoscopic Peng,s multifunctional operative dissector,LPMOD）应用刮吸解剖法对820例急性胆囊炎施行LC。对有胆道相对探查指征的158例（143例有胆总管扩张）行术中胆道造影,发现胆总管结石17例,其中14例完成腹腔镜下胆总管探查术（laparoscopic common bile duct exploration,LCBDE）。结果812例LC成功,8例中转开腹。LC平均手术时间55 min（25-120 min）,LC＋LCBDE平均手术时间95 min（80-130min）,术中平均出血量25 ml（0.5-80 ml）,术后平均住院5 d（3-9 d）。无胆管损伤、胆漏、术后出血等并发症。804例随访2-18个月,平均11个月,2例胆总管残余结石（1例行开腹胆总管切开取石,1例行EST取石）,其余患者未发现与手术相关并发症。结论在急性胆囊炎腹腔镜胆囊切除术中应用刮吸解剖法能有效防止术中胆道损伤,安全可靠,值得临床推广。     

Role of Hepatectomy in the Treatment of Hilar Bile Duct Carcinoma

Purpose. To clarify the role of hepatic resection in the surgical treatment of hilar bile duct carcinoma.Methods. Between 1980 and 1997, 68 patients underwent surgery for hilar bile duct carcinoma. The patients were divided into a hepatectomy group (n = 40) and a nonhepatectomized group (n = 28) depending on whether they underwent resection of the bile duct confluence in combination with hepatectomy, or alone, respectively. Background data, operative morbidity and mortality, and survival were retrospectively compared between the two groups.Results. There were no significant differences in morbidity and mortality, or in postoperative survival between the two groups (the 5-year survival rates being 20.6% in the hepatectomized group and 7.1% in the nonhepatectomized group; P = 0.0806). However, patients who underwent curative resection had significantly better postoperative survival than those who underwent noncurative resection (P = 0.048). Hepatectomy provided a significantly better cancer-free margin than bile duct resection alone (P = 0.0296).Conclusions. Although a countermeasure must be taken to decrease mortality, the introduction of hepatectomy with bile duct resection would provide a better cancer-free surgical margin than bile duct resection alone for hilar bile duct carcinoma. Curative resection contributed to long-term survival in this series.     

腹腔镜胆囊切除术解剖困难时的对策

目的探讨行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)时对胆囊三角解剖困难者的处理方法。方法回顾性分析胆囊三角解剖困难的LC术23例,行逆行法或顺逆结合法切除胆囊。结果23例LC均成功完成,术后发生胆漏1例,腹腔引流7 d后治愈。无胆管损伤、腹腔感染等并发症。结论胆囊三角解剖困难者采用逆行法或顺逆结合法有利于LC的顺利完成。     

Single-incision Laparoscopic Cholecystectomy: A New Retraction Technique

Background : Laparo-endoscopic single site cholecystectomy receives great interest from the surgical community. It has potential for reducing postoperative pain, length of hospital stay and improving cosmesis. Minimally invasive surgeons have been forced to develop techniques for providing adequate retraction of the gallbladder. Herein, we describe a new retraction technique to improve the dissection of Calot’s triangle.

Surgical technique : Twelve patients underwent laparo-endoscopic single site laparoscopic cholecystectomy using this retraction technique. An intra-umbilical skin incision was made by pulling out the umbilicus. A SILS® port was placed through an open approach. We inserted a 10-mm 30^o camera through the SILS® port without using any trocar. One suture was knotted in the middle of the gallbladder. Gallbladder retraction was achieved by the use of an EndoClose® needle that was inserted into abdominal cavity at the subcostal border. The floppy knot was held by the notched end of the EndoClose^® needle. This device provided retraction of the gallbladder in every direction.

Conclusions : Adequate retraction greatly simplifies laparo-endoscopic single site cholecystectomy. New retraction techniques will enable wider use of this novel minimally invasive approach. Further work is needed to investigate the advantages of this new technique.     

Liver Transplantation With Incidental Gallbladder Carcinoma in the Recipient Hepatectomy

Gallbladder carcinoma(GBCA) is the most common malignancy of the biliary tract¹ and is often found seredipitiously after cholecystectomy. We report the first two cases of incidental GBCA in the native gallbladder of two liver transplant recipients. Both patients are 2.5 years following uneventful orthotopiic liver transplantation(OLTx) with no evidence of recurrent disease. Pathology of both recipients was early and favorable. Neither patient received any further therapy. Given the incidence of GBCA and the evolution of OLTx we would anticipate this finding to be more prevalent.     

Laparoscopic Transumbilical Cholecystectomy: Surgical Technique

Background:

Laparoscopic cholecystectomy is generally performed using 4 ports by transperitoneal access. Recent developments regarding laparoscopic surgery have been directed toward reducing the size or number of ports to achieve the goal of minimally invasive surgery, by minilaparoscopy, natural orifice access, and the transumbilical approach. The aim of this article is to describe our laparoscopic transumbilical cholecystectomy technique using conventional laparoscopic instruments and ports.

Methods:

The Veress needle was placed through the umbilicus, which allowed carbon dioxide inflow. A 5-mm trocar was placed in the periumbilical site for the laparoscope followed by the placement of 2 additional 5-mm periumbilical trocars. The entire procedure was performed using conventional laparoscopic instruments. At the end of the surgery, trocars were removed, and all 3 periumbilical skin incisions were united for specimen retrieval.

Results:

Five transumbilical cholecystectomies were performed following this technique. The mean BMI was 26.6 kg/m². The mean operative time and blood loss were 46.2 minutes and 55 mL, respectively. No intraoperative complications occurred. Analgesia was performed using dipyrone (1g IV q6h) and ketoprofen (100 mg IV q12 h). Time to first oral intake was 8 hours. Mean hospital stay was 19.2 hours.

Conclusion:

Laparoscopic transumbilical cholecystectomy seems to be feasible even using conventional laparoscopic instruments and can be considered a potential alternative for traditional laparoscopic cholecystectomy.     

Partial Aortic Root Remodeling with an Adventitial Inversion Technique for an Acute Type A Aortic Dissection

Abstract This case report describes a partial aortic root remodeling, which applied a valve‐sparing technique, with an adventitial inversion technique for an acute type A aortic dissection with intimal tear extending into the noncoronary sinus of Valsalva. Postoperative computed tomography at six months showed no dissection or pseudoaneurysm in the aortic root. (J Card Surg 2010;25:327‐329)     

体外肝切除自体余肝原位再植术并门腔-心房转流对血流动力学的影响

为研究体外肝切除自体余肝原位再植术中采用门腔－心房体外转流技术对无肝期血流动力学的影响，９只健康幼猪（体重１８～３０ｋｇ）麻醉后经脾静脉，右股静脉置管；全肝血流阻断后，经体外循环泵将血液转流至右心房。左颈外静脉置Ｓｗａｎ～Ｇａｎｚ导管监测血流动力学参数。全肝血流阻断时间为１．１±０．２小时。结果表明：体外肝切除自体余肝原位再植术中存在严重血流动力学紊乱，无肝期采用门腔－心房转流技术能改善其紊乱。术中发生的代谢性酸中毒和低温，可通过补碱和保温得到纠正     

Duct-to-Duct Biliary Reconstruction During Complex Hepatectomy: A Useful Technique in Selected Cases

Background  

Roux-en-Y anastomosis is the standard of care for biliary reconstruction. Yet, a direct bilio-biliary anastomosis preserves the normal sphincter mechanism and endoscopic access to the biliary tree for diagnostic and therapeutic purposes. Duct-to-duct biliary reconstruction is widely used in liver transplantation. The objective of this study was to analyze the feasibility and results of duct-to-duct biliary reconstruction in the setting of complex hepatic resection with limited biliary confluence involvement.     

Human NOTES Cholecystectomy: Transgastric Hybrid Technique

Background  Natural orifice translumenal endoscopic surgery (NOTES) is an emerging field in minimally invasive surgery that is driving the development of new technology and techniques. There are several proposed benefits to the NOTES approach, including potentially decreased abdominal pain, wound infections, and hernia formation Ko and Kalloo (Chin J Dig Dis 7:67–70, 2006); Wagh et al. (Clin Gastroenterol Hepatol 3(9):892–896, 2005); ASGE/SAGES Working Group on Natural Orifice Transluminal Endoscopic Surgery (Gastrointest Endosc 63(2):199–203, 2006); and Pearl and Ponsky (J GI Surg 12:1293–1300, 2008). Cholecystectomy has been one of the most commonly performed NOTES procedures to date, with the majority being performed through the transvaginal approach Marescaux et al. (Arch Surg 142:823–826, 2007); Zorron et al. (Surg Endosc 22:542–547, 2008); and Ramos et al. (Endoscopy 40:572–575, 2008). Transgastric approaches for cholecystectomy have been shown to be technically feasible in animal models and in several unpublished human patients Sumiyama et al. (Gastrointest Endosc 65(7):1028–1034, 2007). This video demonstrates the technique by which we perform transgastric NOTES hybrid cholecystectomy in human patients. Method  Patients with symptomatic gallstone disease are enrolled under an IRB approved protocol. A diagnostic EGD is performed to confirm normal anatomy. Peritoneal access is gained using a needle-knife cautery and balloon dilation under laparoscopic visualization. Dissection of the critical view of safety is performed endoscopically. The cystic duct and artery are clipped laparoscopically and the gallbladder is dissected off of the liver. The gastrotomy is closed intralumenally and over-sewed laparoscopically. The gallbladder is extracted out the mouth. Results  This technique was used to successfully perform four NOTES hybrid transgastric cholecystectomies without operative complications. Conclusions  NOTES hybrid transgastric cholecystectomy can be performed safely in human patients. This procedure is still technically challenging given the current instrumentation that is available. In order to perform a pure NOTES transgastric cholecystectomy, a safe blind access method, improved retraction, endoscopic hemostatic clips, and reliable closure methods need to be developed. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users. Presented at SSAT/DDW, May 2008, San Diego, CA.