Caudate lobectomy: tumor location, topographic classification, and technique using right- and left-sided approaches to the liver

BACKGROUND: Resection of the caudate lobe (involving segments I [dorsal sector] and/or IX [right paracaval region]) often presents a technical challenge. It is difficult to perform because of its deep location and adjacency to the major hepatic vessels (ie, the left and middle hepatic veins). METHODS: A literature review was performed based on a Medline search to identify articles on caudate lobectomy published from 1990 to 2005. This article describes the right and left-sided approaches to the liver for caudate resection according to caudate lobe tumor location and topographic classification. RESULTS: The results of 377 lobectomies were analyzed in this review. The left-sided approach to the liver was used in 55 (14.58%), the right-sided approach in 24 (6.36%), and both approaches in 298 (79.04%) caudate lobectomies. Primary benign and malign liver tumors, as well as secondary liver tumors, were resected. CONCLUSIONS: Access to and resection of the caudate lobe should be determined on the basis of tumor location and hepatic function. The left or right approach to the caudate lobe can be recommended for local resection of tumor located at Spiegel's portion or process portion. Approaches to caudate lobectomy are therefore largely dependent on size and location of the lesion, type of associated resection, and presence of scarring from previous resection.     

Robotic partial nephrectomy: a multi-institutional analysis

Laparoscopic partial nephrectomy for kidney tumors has demonstrated durable oncologic and functional outcomes. The feasibility of robotic partial nephrectomy (RPN) has been demonstrated in several small, single-institution studies. We performed a large, multi-institutional analysis to determine early oncologic results and perioperative outcomes after RPN. Between October, 2002 and September, 2007, 148 patients underwent RPN at six different centers by nine different primary surgeons for localized renal tumors. Medical and operative records were reviewed for clinical characteristics, pathologic findings, and follow-up information. A total of 148 patients underwent RPN. Mean tumor size was 2.8 cm. Renal hilar clamping was utilized in 120 patients, with a mean warm ischemia time of 27.8 min. Positive surgical margins were identified in six patients (4%), of which two had cautery artifact obscuring the margin after off-clamp cautery excision and one underwent completion radical nephrectomy with no evidence of cancer. There is no evidence of tumor recurrence at mean follow-up of 7.2 months (range 2–54 months) overall, and mean follow-up of 18 months (range 12–23 months) for patients with positive surgical margin. Complications occurred in nine patients (6.1%), including hematoma requiring drainage (n = 1), prolonged ileus (n = 3), pulmonary embolus (n = 2), prolonged urine leak (n = 2), and rhabdomyolysis (n = 1). Two patients underwent open conversion for failure to progress, one patient with morbid obesity and one patient with adhesions from prior ureterolithotomy. Mean hospital stay was 1.9 days. In this multi-institutional series of surgeons beginning their initial experience in RPN, the procedure is a feasible option for minimally invasive, nephron-sparing surgery, with immediate oncologic results and perioperative outcomes comparable with more mature laparoscopic series.     

The bottom-up approach to the suprafascial harvest of the radial forearm flap

Suprafascial radial forearm flaps cause far less donor morbidity compared with the conventional method of including the deep fascia. Here we describe our technique of harvesting the flap with a bottom-up approach, which simplifies flap elevation and is safe and expedient. The radial artery pedicle is ligated distally and secured to the flap. Gentle traction on the pedicle presents the inferior surface of the pedicle, facilitating dissection. The superficial layer of the deep fascia is taken with the flap, together with a generous cuff of subcutaneous tissue above the pedicle in which vessels nourishing the flap are located. It is crucial to preserve the conjoin of the deep layer of the deep fascia to the fascia covering the brachioradialis laterally and flexor carpi radialis medially. This fascial layer prevents bow-stringing of the tendons during wrist and finger flexion and allows the use of a full-thickness skin graft to close the donor site. The latter delivers superior cosmetic results than can be achieved with a split-thickness skin graft.     

Laparoscopic right hemihepatectomy for hepatolithiasis

Background Liver resection is the definitive treatment for unilateral hepatolithiasis [1]. Recently, laparoscopic major hepatectomias have become more common and are being performed in highly specialized centers [2–4]. However, few laparoscopic liver resections for hepatolithiasis have been reported. Chen et al. [5] reported two cases of laparoscopic left lobectomy for hepatolithiasis, but to our knowledge, right hepatectomy has never been reported to date. This video demonstrates technical aspects of a totally laparoscopic right hepatectomy in a patient with hepatolithiasis. Methods A 21-year-old woman with right-sided nonoriental primary intrahepatic stones [1] was referred for surgical treatment. The operation followed four distinct phases: liver mobilization, dissection of the right portal vein and right hepatic artery, extrahepatic dissection of the right hepatic vein, and parenchymal transection with harmonic shears and linear staplers for division of segment 5 and 8 branches of the middle hepatic vein. No Pringles’ maneuver was used. In contrast to liver resection for other indications, the right bile duct was enlarged and filled with stones. It was divided during parenchymal transection and left open. After removal of the surgical specimen, the biliary tree was flushed with saline until stone clearance, under radioscopic surveillance, was complete. The right hepatic duct then was closed with running suture. Results The operative time was 240 min, and the estimated blood loss was 120 ml, with no blood transfusion. The hospital stay was 5 days. At this writing, the patient is well and asymptomatic 7 months after the procedure. Conclusion Laparoscopic liver resection is safe and feasible for patients with hepatolithiasis and should be considered for those suffering from intrahepatic stones. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Cuff 套管技术在同系大鼠肺移植中的应用

目的 建立同系大鼠原位肺移植模型,评价Cuff 套管技术应用效果.方法 采取两名手术者同时、分别行供受体手术的方法,行左侧同系原位大鼠肺移植22例,肺动脉、肺静脉、主支气管吻合均采用非缝合的Cuff套管技术,评价其可行性和可靠性.结果 移植手术成功率90.9%(20/22),移植物缺血时间、热缺血时间和总的手术时间分别为(42.5±2.3)min,(17.1±3.6)min和(68.7±5.1)min.同系大鼠移植术后3周以内(12/22)通气和血流灌注良好,手术后6个月(3/22)、9个月(3/22)、12个月后(2/22)移植肺显示通气不良但吻合口开放.结论 大鼠原位肺移植模型采用非缝合的Cuff套管技术行支气管和血管吻合简便、快速和可靠,支气管吻合后能够保持较长时间的管腔开放.     

大鼠肝肾联合移植模型术式的改进

目的探讨大鼠肝肾联合移植动物模型的术式改进方法。方法以0-4℃乳酸钠林格注射液经腹主动脉对供肝和供肾进行原位灌洗。整块切取供鼠肝、肠、胰、脾及与右肾,保存液中修整。移植时血管重建全部采用袖套式吻合,应用支架行胆总管吻合法重建胆道连续性,输尿管带膀胱瓣吻合,建立SD-SD大鼠原位肝肾联合移植模型。结果共行大鼠肝肾联合移植90次,其中预实验50次。正式实验成功率达90%。模型建立降低了难度,具有血管吻合时间短、血流通畅、无肝期短等优点。结论此模型是较为简易、可靠的大鼠肝肾联合移植模型。     

Technical difficulties of removal of locking screw after locking compression plating

Introduction  As there are few reports on the difficulties of removing the locking compression plate (LCP), we prospectively investigated the incidence and difficulties in 58 patients in whom various types of LCPs were taken. Methods  From January 2004 to December 2007, we have removed 159 5.0-self tapping locking screws and 279 3.5- self tapping locking screws. All of the operations were performed by experienced trauma surgeons. All of the screws were inserted with the use of torque limiting attachment according to the manufacturer’s recommendation. During the same period of time we have removed 198 AO-3.5 cortical and 4.0 cancellous screws from various sites. Results  All of 159 5.0-self tapping locking screws were removed without difficulties. A total of 24 out of 279 3.5- self tapping locking screws were removed with many difficulties due to the stripping of the hexagonal recess. The use of conical extraction screw which was developed especially for the removal of stripped locking screws was successful in only six screws. We have removed plates by cutting the plate with metal cutting saw. We describe useful technical trick to remove the plate when there is only one screw left stripped. Compared to the locking screws, only one of 198 3.5-cortical screws was stripped. Conclusion  Care should be taken at the time of removal of the locking compression plate, especially for the 3.5-locking screws.     

Laparoscopic resection of uncinate process of the pancreas

Background  Solid pseudopapillary neoplasm of the pancreas is an uncommon but distinctive pancreatic neoplasm with low metastatic potential [1]. Therefore, whenever feasible, an organ-preserving operation should be performed. As previously reported, women with solid pseudopapillary neoplasm of the pancreas may be best treated by more conservative procedures [2]. Recently, laparoscopic pancreatic resections became more common and are being performed in highly specialized centers. There are only six cases of laparoscopic resection for solid pseudopapillary neoplasm of pancreas published in the English literature and, to our knowledge, laparoscopic resection of uncinate process of the pancreas has never been reported [3–6]. This video demonstrates the technical aspects of a totally laparoscopic resection of the uncinate process of the pancreas in a patient with solid pseudopapillary neoplasm. Methods  A 26-year-old woman with a 4-cm solid pseudopapillary pancreatic neoplasm was referred for surgical treatment. According to preoperative echoendoscopy, there was a safe margin between neoplasm and main pancreatic duct. The patient was placed in supine position with the surgeon standing between her legs. Four trocars, one 10-mm and three 5-mm, were used. At inspection, the inferior vena cava, transverse colon, duodenum, and pancreas are clearly identified. A Kocher maneuver was performed with complete exposure of pancreatic head and uncinate process. The uncinate process was dissected from the superior mesenteric vein and venous branches were divided between metallic clips or by use of laparoscopic coagulation shears (LCS; Ethicon Endo Surgery Industries, Cincinnati, OH, USA). Blood supply of the duodenum was preserved by ligature of small pancreatic branches from inferior pancreatoduodenal artery. Transection of pancreatic parenchyma was performed using laparoscopic coagulation shears, which is an effective tool for cutting the pancreas [7, 8]. Surgical specimen was removed through a suprapubic incision inside a retrieval bag. A hemostatic absorbable tissue (Surgicel; Ethicon Inc., Cincinnati, OH) was placed in the cutting pancreatic surface, and one round 19F Blake abdominal drain (Ethicon) was left in place. Results  Operative time was 180 minutes and blood loss estimated in 40 ml with no blood transfusion. Hospital stay was 4 days. The patient did not have postoperative pancreatitis or pancreatic leakage, and the abdominal drain was removed on the tenth postoperative day. Final pathology confirmed the diagnosis of solid pseudopapillary neoplasm of pancreas with free surgical margins. The patient was well and asymptomatic 2 months after the procedure. Conclusions  Laparoscopic resection of uncinate process of the pancreas is safe and feasible and should be considered for patients suffering from pancreatic neoplasms. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

皮肤再生医疗技术结合红光照射治疗压疮的疗效 分析

目的 探索Ⅲ?Ⅳ期压疮的有效治疗方法?方法 将50 例Ⅲ?Ⅳ期压疮患者随机分为治疗组和对照组, 每组25例, 在积极治疗原发病?及时纠正贫血及低蛋白血症?抗感染等全身综合治疗的基础上, 治疗组 采用皮肤再生医疗技术结合红光照射治疗, 每日照射1 次, 每次15～20 min, 并根据创面情况每日换药1～3 次;对照组采用常规外科换药结合红光照射治疗, 每日照射1 次, 每次15～20 min, 并根据创面情况每日换药1～2次?对比观察两组患者创面愈合情况?结果 治疗组患者的压疮创面全部自行愈合, 愈合时间最短为9d, 最长为91d;对照组患者的压疮创面也全部愈合, 但其中5例采用自体皮移植封闭创面, 愈合时间最短为15d, 最长为108d?两组患者创面愈合时间对比, 差异具有统计学意义(P﹤0.05)? 结论 皮肤再生医疗技结合红光照射治疗Ⅲ?Ⅳ期压疮疗效显著, 可促进创面愈合?减少瘢痕增生, 值得临床推广应用?     

胸腰椎椎弓根螺钉植入技术的研究进展

胸腰椎椎弓根螺钉内固定技术的开展，有力地推动了脊柱外科的发展。该技术的关键是，螺钉的植入必须位于三维空间中唯一的一个正确通道上，即按照正确的矢状面角及水平面角，沿椎弓根的长轴穿过椎弓根这一狭小的骨性管道达惟体内。近年来，胸腰椎椎弓根螺钉植入技术的研究取得了很大发展，尤其是术中监测手段，已从传统的X线透视或摄片监测定位发展到计算机辅助技术进行可视化监测。本文结合国内外研究成果，对胸腰椎椎弓根螺钉植入技术的研究进展进行概述。