Avascular Plane Research Articles

A Study on the Pattern of Arterial Segmentation in the Human Spleen

Abstract Background: Partial splenectomy is preferred after splenic injuries, which will help to preserve healthy splenic tissue, hence the immunity. During splenic surgery particularly in the resection of a segment of the spleen, ligation of branches of the splenic artery is necessary. A precise knowledge of the segmental arteries is prerequisite because the spleen is separated into avascular lobes and segments by splenic arterial branches. The aim of the present work was to study the pattern of arterial segmentation in the human spleen and variations of the splenic arterial pattern. Methodology: The present study was conducted on 31 spleens with intact splenic artery after getting the ethical clearance. Specimens were collected depending on the availability of cadaver or unclaimed autopsy body. Tracing from terminal branches, the segmental branches of the splenic artery were studied by piece-meal dissection. The terminal branches of the splenic artery and its segmental branches were cleaned and observed. The number of the segmental branches of the spleen and the presence of arterial anastomosis between adjacent segmental arteries were noted. Results: The splenic artery terminated as bifurcation in 66.73% and trifurcation in 33.27%. We also found two, three, four, five, six, and seven arterial segments in 2 (6.46%), 14 (45.16%), 7 (22.58%), 3 (9.67%), 3 (9.67%), and 2 (6.46%) specimens, respectively. These segments are separated by an avascular plane in all specimens except one where we found intersegmental arterial anastomosis. Conclusions: Knowledge of the splenic arterial branching pattern of the present study may help the general surgeon as well as surgical gastroenterologist in performing the surgery of the spleen, particularly partial splenectomy after splenic injuries. This may also help anatomists in learning and teaching arterial segmentation of the spleen.

Presenting embryologically defined peripancreatic compartments and fusion planes in the search for pancreatic cancer fields

BackgroundClinical progress in form of “total mesometrial resection” (TMMR) in cervical cancer and “total mesorectal excision” (TME) in rectal cancer can be traced to a paradigm-shift regarding the extent and range of resection. More significance is bestowed upon embryologically defined borders which define compartments, “morphogenetic units” and “cancer fields”, that have to be addressed in order to avoid incomplete tumor resection. We want to transfer this rationale on the pancreas and define such borders for pancreatic compartments. Material and methodsWe used 26 unfixed body donors (16 male, 10 female) ranging in age from 64 to 98 years. Manual preparation consisted of performing the Cattell-Braasch maneuver to restore embryologic anatomy and define fascial remnants of the borders of the dorsal and ventral mesogastrium with focus on the pancreatic fusion fasciae and peripancreatic spaces. ResultsWe tracked what used to be the dorsal and ventral mesogastrium and assigned their remnants to the bowel and pancreas. Following avascular embryologic fascial fusion planes along the mesogastria we could demonstrate peripancreatic spaces, which were sealed off from bordering surfaces of presumably different morphogenetic units and possible cancer fields. Reverting embryologic development also seemed possible within the pancreas, demonstrating the embryologic fusion plane between the ventral and dorsal pancreatic buds as two distinct compartments. ConclusionsFollowing pancreatic fusion fasciae by separating embryologic fusion planes enables to define the pancreatic compartments which might play a major role in applying the success of TMMR and TME on pancreatic resection and define pancreatic cancer fields.

Retroperitoneal fasciae as barriers for nerve and arterial passages connecting the retroperitoneal region to the peritoneal organs.

The fascia of the pancreatic head is referred to as the retropancreatic fascia of Treitz, and that of the body and tail of the pancreas is named the retropancreatic fascia of Toldt. However, the spatial relationship between the nerves, fascia, and the distribution of the fascia on the dorsal side of the pancreas remains unclear. Therefore, this study aimed to explore the distribution of these fasciae and elucidate the spatial relationship between the nerves and arteries connecting the retroperitoneal space and the peritoneal organs by studying eight cadavers using macroscopic anatomical examination, wide-range serial sectioning, and three-dimensional reconstruction. The fasciae of Treitz and Toldt converge caudally to the root of the superior mesenteric artery (SMA), forming a narrower gap around the roots of the celiac trunk and SMA than in the celiac plexus. The fasciae eventually get closer to each other, and the boundary between them becomes obscured, providing coverage to the anterior surface of the aorta between the SMA and the inferior mesenteric artery. The celiac plexus does not penetrate the fascia but converges before spreading into the pancreas. Similarly, the arteries pass through this gap in the fasciae. Our findings suggest that the retroperitoneal space and peritoneal organs are connected through a narrow no-fascia area, with the distribution of the fascia relating to nervous and vascular pathways. Our findings reveal that the distribution of the avascular plane may provide a crucial anatomical foundation for abdominal digestive organ surgery by reducing bleeding volume and determining the dissection region.

Can "membrane bridge" be used to describe the connective tissue between two different embryonic compartments? An exploratory attempt to standardize the description of embryonic compartment hysterectomy

Standardized surgical procedures are crucial for preventing recurrence and ensuring a favorable prognosis in cervical cancer patients. The primary surgical challenge lies in the circumferential en bloc resection of the tissues surrounding the cervix and paravaginal area. This region's complex vascular and neural distribution increases the risk of bleeding, injury, and other surgical complications, which in turn heightens the risk of local tumor recurrence. Recently, the concept of total mesometrial resection (TMMR) guided by embryonic origin principles has shown promise in reducing postoperative recurrence rates. The technique focuses on using embryonic boundaries as surgical margins and entering through avascular planes, thereby minimizing complications while achieving favorable oncological outcomes. However, due to inconsistencies with traditional anatomical terms and surgical approaches, this method has yet to gain widespread adoption. Our team has conducted preliminary explorations into embryonic compartmental-based hysterectomy, yielding encouraging results. We have introduced the concept of the "membrane bridge" to standardize surgical procedures, facilitating the broader adoption of this technique. Due to the unique advantage of the three-dimensional view provided by robotic surgery, we utilized images from robotic procedures to illustrate the different "membrane bridges."

Complete mesocolic excision for colon cancer: current status and controversies.

According to Hohenberger's original description, complete mesocolic excision for colon cancer involves precise dissection of the avascular embryonic plane between the parietal retroperitoneum and visceral peritoneum of the mesocolon. This ensures mesocolic integrity, access to high ligation of the supplying vessels at their origin and an associated extended lymphadenectomy. Results from centres which have adopted this approach routinely have demonstrated that oncological outcomes can be improved by the rigorous implementation of established principles of cancer surgery. Meticulous anatomical dissection along embryonic planes is a well-established principle of precision cancer surgery used routinely by the specialist colorectal surgeon. Therefore, the real question concerns the need for true central vascular ligation and associated extended (D3) lymphadenectomy or otherwise, particularly along the superior mesenteric vessels when performing a right colectomy. Whether this approach results in improved overall or disease-free survival remains unclear and its role remains controversial particularly given the potential for significant morbidity associated with a more extensive central vascular dissection. Current literature is limited by considerable bias, as well as inconsistent and variable terminology, and the results of established randomized trials are awaited. As a result of the current state of equipoise, various national guidelines have disparate recommendations as to when complete mesocolic excision should be performed if at all. This article aims to review the rationale for and technical aspects of complete mesocolic excision, summarize available short and long term outcome data and address current controversies.

Ulnar nerve anteposition with adipofascial flap, an alternative treatment for severe cubital syndrome

BackgroundUlnar nerve entrapment at the elbow is the second most common cause of nerve entrapment in the upper limb. Surgical techniques mainly include simple decompression, decompression with anterior transposition and medial epicondylectomy.MethodsWe performed decompression with anterior transposition and protected ulnar nerve by adipofascial flap (a random flap with radial based vascularization, harvested through the avascular plane of Scarpa’s fascia. We analyzed patients who underwent ulnar nerve ante-position from 2015 to 2022 according to inclusion and exclusion criteria for a total of 57 patients. All patients included were graded on the McGowan's classification Messina criteria and the British Medical Research Council modified by Mackinnon and Dellon.ResultsThe average McGowan’s score was 2.4 (± 0.6), Messina’s criteria 91.2% indicated a satisfactory or excellent result, sensibility at 6 months was 98.5% S3 or more. A preferential technique has not yet been defined.ConclusionsThe adipofascial flap offers numerous advantages in providing a pliable, vascular fat envelope, which mimics the natural fatty environment of peripheral nerves and creates favorable micro-environmental conditions to contribute to neural regeneration via axon outgrowth.

Robotic-Assisted Transabdominal Inferior Retroperitoneal Approach: an Alternative to Cattell-Braash Maneuver

IntroductionThe Cattell-Braasch maneuver has been widely used to provide adequate exposure for aorto-caval space (ACS) since the 1960s. Given its requirement of complex visceral mobilization and significant physiological disturbance, we proposed a new alternative surgical technique to access ACS: the transabdominal inferior retroperitoneal approach (TIRA) with robotic assistance. MethodsPatients were placed in the Trendelenburg position, and the retroperitoneum was accessed from the iliac artery level and dissected toward the 3rd and 4th portion of the duodenum along the anterior surface of IVC and aorta. ResultsTIRA has been used in 5 consecutive patients at our institution whose tumors were located in the ACS below the level of SMA origin. The tumor sizes ranged from 1.7 to 5.6 cm. The median OR time was 192 min with a median EBL of 5 ml. Four out of the five patients passed flatus before or on post operative day (POD) 1, and the other patient passed flatus at POD2. The shortest length of stay was < 24 h, and the longest was 8 days due to pre-existing pain (the median length of stay was 4). ConclusionThe proposed robotic-assisted TIRA procedure is designed for tumors in the inferior portion of ACS, specifically for the tumor involving D3, D4, para-aortic, para-caval, and kidney regions. Since this approach does not involve organ mobilization and all the dissections are following an avascular plane, it can be easily adapted to laparoscopic and/or open surgery setting.

OC-076 LAPAROSCOPIC TAPP REPAIR FOR A LUMBAR HERNIA. STEP-BY-STEP SYSTEMATIZATION

Abstract Aim Lumbar hernias are a rare clinical entity and surgical treatment is constantly evolving and changing. We propose a systematization step-by-step guiding a safe and effective repair with similar conditions to the inguinal region. Material &amp; Methods The patient lies down in a dorsal decubitus position with a 45° elevation of the hernia side. The first port is in the umbilicus access, and the accessory ports are along the middle line. Start the dissection by marking the anatomical limits that involve the semilunar lines, epigastric vessels, spine, and imaginary line between the iliac crest and 11 th rib. Releasing the peritoneal flat until visualizing the psoas iliacus and quadratus muscles until the 11 th ribs, preserving the avascular plane avoids nerves and vascular damage. Hernia sac reduction. Placement of a polypropylene mesh (24×22 cm) covering all the dissected areas. Mesh fixation using absorbable sutures. Closure of the peritoneum.Vacuum maneuver and bulge compression. Results Systematic standardization was applied to all patients. The mean operative time was 90 min. Outpatient surgery was achieved with a fast return to usual activity. The procedures were performed without intraoperative complications, mortality, or conversion to open surgery. Conclusions The step-by-step guide for landmarks and tips provides a safe and effective repair of this rare entity. Finally, clinical studies are needed to measure the impact of this technique's implementation in lumbar hernia repair.

Robotic total mesorectal excision for rectal cancer based on the theory of fundamental use of surgical energy

Improving oncological curability and preserving urinary function must be established in robotic total mesorectal excision (TME) for rectal cancer. To achieve this, it is important to avoid nerve injury by sharp dissection of the avascular plane by the monopolar device and thermal spread. The aim of this study was to improve the robotic TME quality by focusing on the theory of fundamental use of surgical energy (FUSE) of the monopolar device and investigating the surgical procedure. In this single-center retrospective study, 26 consecutive patients who underwent robotic TME for rectal cancer at Tokyo Medical University Hospital between June 2022 and August 2022 were included. All surgeries were performed by FUSE-certified surgeons in accordance with FUSE theory, which was, thermal effect = current density (current/area) squared × tissue resistance × contact time. The median age of the patients was 64years (range 40-79years), and 17 patients were male. The median operative time was 287min (range 229-430min); median bleeding volume, 22ml (range 5-223ml); and the median number of harvested lymph nodes, 17 (range 4-40). The conversion rate to open surgery was 0%. A breakdown of Clavien-Dindo classification Grade ≥ II post-operative complications was as follows: surgical site infection, one patient (3.8%); ileus, one patient (3.8%); and urinary dysfunction, one patient (3.8%). No surgery-related or in-hospital deaths occurred. The pathological positive resection margin was not observed. Robotic TME for rectal cancer based on the theory of FUSE can be safely performed, making it a promising surgical procedure. It is suggested that robotic surgeons acquire surgical operation skills with monopolar devices based on the principles of FUSE, which may lead to an increased quality of robotic TME.

8583 Posterior Approach for Uterine Artery Ligation in TLH (Tackling the Uterine Artery First Before the Bladder Dissection)

<h3>Study Objective</h3> Comparison of uterine artery first, posterior approach of bladder dissection (Newer approach) / versus lateral window approach (Conventional approach) in TLH. <h3>Design</h3> Case control study of total 627 patients of TLH spanning over 5 years. <h3>Setting</h3> All patients in modified dorsal lithotomy position, under GA. <h3>Patients or Participants</h3> Out of 627 patients 307 patients underwent TLH by lateral window approach (Control) and 320 cases done by posterior approach. Study was conducted at a tertiary referral center. <h3>Interventions</h3> In Posterior approach the posterior leaf of broad ligament is opened, and the uterine artery skeletonized and transected first and then the bladder dissection started. This is based on two sound anatomic principles that the plane of uterine artery dissection is the same as bladder dissection and more importantly it is the uterine artery that holds the ureters to the uterus. By first dissecting, coagulating and cutting the uterine artery, this step releases the anterior Mackenrodt's ligament and exposes the cotton candy plane of bladder dissection effortlessly. <h3>Measurements and Main Results</h3> Control group had 307 cases with 124 patients with previous surgery while study group had 320 patients with 150 with previous surgeries. Patients were in age group (30yrs to 73yrs), BMI (16.61kg/m² to 58.11kg/m²), uterine weight (100gm to 3000gm). The ease of bladder dissection in an avascular plane was highly appreciable in posterior approach, i.e the study group. Two bladder injuries noted in conventional approach and no bladder injury noted in newer approach. Lesser time was spent in the uterine artery first approach, more than the time, the ease of achieving the plane of bladder dissection was remarkable. <h3>Conclusion</h3> We propose, the uterine artery first, posterior approach as a novel, safe and avascular dissection of bladder in face of previous surgeries. Sound anatomic principles are applied in formulating this approach.

7585 A Systematic Approach to Endometriosis Lesion Mapping and Radical Excision

<h3>Study Objective</h3> To illustrate a systematic approach to laparoscopic endometriosis lesion mapping and radical wide field excision. Significant variation exists regarding the optimal approach to surgical management of endometriosis with attempts for standardization being fairly recent. We hereby contribute to these efforts by presenting our approach to radical, wide-field endometriosis excision in our institution. <h3>Design</h3> Edited surgical video demonstrating laparoscopic radical wide field endometriosis excision. <h3>Setting</h3> Academically affiliated community hospital. <h3>Patients or Participants</h3> Surgical videos of multiple surgical cases from our practice <h3>Interventions</h3> Laparoscopic radical wide field excision of endometriosiss. <h3>Measurements and Main Results</h3> As illustrated in this video, important considerations are the non-contact, mm by mm dissection along the avascular planes, use of the perirectal tissue fat as an insulator and landmark for dissection, as well as the deliberate use of rectal and vaginal probes in order to delineate anatomy and optimize dissection geometry. <h3>Conclusion</h3> With a systematic approach to radical wide field excision of endometriosis, both in high and low ASRM stage disease, via a lateral to medial approach and clockwise progression from the left pelvic brim to the left pelvic sidewall and so on, virtually all cases will be completed safely and efficiently.

V-040 LAPAROSCOPIC TRANS-ABDOMINAL PREPERITONEAL PROCEDURE (TAPP) FOR RIGHT INGUINAL HERNIA WITH HANDXTM HOOK AND NEEDLE HOLDER

Abstract AIM HandX™ is a handheld, powered laparoscopic device with interchanging single-patient fully articulating instruments. It is electromechanically controlled, and, as the manual interface is handled by the surgeon, beside the patient's bed, the movements of the surgeon's wrist and fingers are translated to the instrument-articulating tip. This report is to show the feasibility and safety of this technology applied in inguinal hernia repair. MATERIALS AND METHODS We report the case of the laparoscopic repair of a right inguinal hernia using HandXTM instruments. RESULTS The index case was a 55-year-old, otherwise healthy male, with an inguinal right hernia. Three trocars were used: one 10 mm umbilical and two of 5 mm, approximately 4 cm laterally from the umbilicus and 1 cm under the level of the horizontal umbilical line. The dissection started with peritoneal cut, from the antero-superior iliac spine to the medial umbilical ligament, into the preperitoneal avascular plane. The anatomical landmarks (epigastric vessels, Cooper and Gimbernat ligaments, the corona mortis and external iliac vessels) were identified and well exposed. A polypropylene mesh was inserted from the optical trocar, placed in the appropriate position and fixed with three separated stiches handled with the articulating needle holder. The peritoneal flap was closed with a readsorbable running suture handled with the HandX instrumentation. No blood loss nor intraoperative or post-operative complications were recorded CONCLUSIONS The report showed how the HandX technology could be safely adopted to obtain both a safe dissection and an ergonomically advantageous suture in laparoscopic TAPP.

P-130 LAPAROSCOPIC LUMBAR HERNIA REPAIR. BASED ON ANATOMICAL LANDMARKS AND SAFETY STATEMENTS

Abstract Aim Lumbar hernias are a rare clinical entity (less than 1% of all abdominal hernias) and their surgical treatment is constantly evolving and changing. The aim is to propose a technical systematization of the steps and landmarks to perform a safe and effective repair of an infrequent pathology. Material &amp; methods We use a tapp approach. The patient is placed in a dorsal decubitus position with a 45° elevation of the hernia side. The first port in the umbilicus access and two ports are placed along the middle line. Start the dissection using novel articulated instruments marking the anatomical limits of the rectangular trapezoid that involves the semilunar lines, epigastric vessels, spine, and imaginary line between the iliac crest and 11 th rib. Releasing the peritoneal flat until visualizing the psoas and quadratus muscles until the 12th rib, preserving the avascular plane avoids nerves and vascular damage. Hernia sac reduction. Tension-free or not closure of the orifice. Placement of a polypropylene mesh covering all the dissected areas. Mesh fixation using absorbable suture. Closure of the peritoneum.Vacuum maneuver and bulge compression. Results The systematic standardization has been applied to all patients. The mean operative time was 90 min. The articulated instruments were useful and allowed safe maneuvers. Outpatient surgery was achieved with a fast return to normal activity. The procedures were performed without intraoperative complications, mortality, or conversion to open surgery. Conclusion The step-by-step guide for anatomical landmarks and proven statements offers a safe and effective repair of this rare entity.

Posterior First Infundibular Dissection: Another Safe Approach in Laparoscopic Cholecystectomy

Objective: To test the efficacy of posterior infundibular dissection during Laparoscopic cholecystectomy Place and duration of the study: Surgical ward of Bakhtawar Amin Trust Teaching Multan for 1 year Study design: A retrospective study Methodology: A total of 150 patients undergoing laparoscopic cholecystectomy were included in the study. Firstly, the bile duct, Calot's node and gallbladder neck were identified along with the lower third of the common duct. An incision was made in the peritoneum anterior to the Calot's node at infundibulum and extended laterally and posteriorly. By retracting the gallbladder cephalad and medially, dissection continued in avascular plane between posterior wall of gall bladder and posterior branch of cystic artery. Anteriorly, a plane is created above the calot’s node and inferior to cystic artery, which was facilitated by posterior dissection of infundibulum. Posterior clipping and division of the cystic artery and duct was done. The rest of the gallbladder was dissected from the liver. Results: 120 patients (80%) had an elective LC status and 30 patients (20%) underwent an emergency LC. 2 patients (1.3%) underwent subtotal cholecystectomy.26 patients (18%) underwent MRCP due to suspicion of stones. Out of these 26 patients, 3 patients (11.5%) underwent ERCP due to the presence of stones.No bile duct injury was recorded. Conclusion: Posterior first infundibular dissection reduces the risk of bile duct injury and ensures safe laparoscopic cholecystectomy. Keywords: Laparoscopic cholecystectomy, infundibular dissection, bile duct injury, cholecystectomy, safe calot’s dissection.

Rhinoplasty on Patients with von Willebrand's Disease

Von Willebrand's disease (VWD) is the most common hereditary bleeding disorder. Due to its frequency, occasionally, patients with this disease apply for rhinoplasty. Classically, desmopressin is used in emergent cases, and it is highly effective. However, the lack of long-term treatment and possible side effects limit the desmopressin treatment. Because the fibrinolytic activity in the nasal mucosa is high, antifibrinolytics such as tranexamic acid are beneficial in all types of VWD. An 18-year-old patient with Type 1 VWD who was operated without facing any complications is presented. Treatment involved 4 days of treatment starting the day before the surgery and healing process was uneventful. Patients with a diagnosis of VWD can be operated successfully with preoperative tranexamic acid treatment and using vasoconstrictor agents and avascular surgery planes. In Type 1 VWD or low von Willebrand's factor cases, tranexamic acid is a safe and successful treatment alternative due to its long-term use, local and systemic applicability, and regional affinity.

Mesentery in Transanal TME.

Oncological adequacy in rectal cancer surgery mandates not only a clear distal and circumferential resection margin but also resection of the entire ontogenetic mesorectal package. Incomplete removal of the mesentery is one of the commonest causes of local recurrences. The completeness of the resection is not only determined by tumor and patient related factors but also by the patient-tailored treatment selected by the multidisciplinary team. This is performed in the context of the technical ability and experience of the surgeon to ensure an optimal total mesorectal excision (TME). In TME, popularized by Professor Heald in the early 1980s as a sharp dissection through the avascular embryologic plane, the midline pedicle of tumor and mesorectum is separated from the surrounding, mostly paired structures of the retroperitoneum. Although TME significantly improved the oncological and functional results of rectal cancer surgery, the difficulty of the procedure is still mainly dependent on and determined by the dissection of the most distal part of the rectum and mesorectum. To overcome some of the limitations of working in the narrowest part of the pelvis, robotic and transanal surgery have been shown to improve the access and quality of resection in minimally invasive techniques. Whatever technique is chosen to perform a TME, embryologically derived planes and anatomical points of reference should be identified to guide the surgery. Standardization of the chosen technique, widespread education, and training of surgeons, as well as caseloads per surgeon, are important factors to optimize outcomes. In this article, we discuss the introduction of transanal TME, with emphasis on the mesentery, relevant anatomy, standard procedural steps, and importance of a training pathway.

Rotational Occipital Scalp Flap for Occipital Pressure Ulcer.

Occipital pressure ulcers and wound gaping may occur in unconscious and malnourished patients. Most of the time, a large defect requires wound coverage by scalp flaps. This video describes a rotational occipital scalp flap for occipital pressure ulcer and wound gaping in a patient of operated midline posterior fossa mass & ventriculoperitoneal shunt. The defect measured 2.25 × 2.5 cm with exposed inion. The wound was included in an imaginary triangle, and the horizontal and vertical incision lengths were about four times the base of the triangle. The flap was based on the left occipital artery and raised in an avascular plane above the periosteum. The wound margins were freshened and undermined. The flap was rotated to bring it over the defect, and suturing was done in the standard manner. The flap had good healing, and the patient continued to be under care for his cerebellar medulloblastoma.

V07-07 ANATOMICAL ROBOTIC-ASSISTED RADICAL PROSTATECTOMY: STEP-BY-STEP NERVE-SPARING TECHNIQUE FOR DIFFERENT GRADES OF PRESERVATION

You have accessJournal of UrologyCME1 May 2022V07-07 ANATOMICAL ROBOTIC-ASSISTED RADICAL PROSTATECTOMY: STEP-BY-STEP NERVE-SPARING TECHNIQUE FOR DIFFERENT GRADES OF PRESERVATION Marcio Covas Moschovas, Travis Rogers, Jonathan Noel, Jaber Abdel, Seetharam Bhat, and Vipul Patel Marcio Covas MoschovasMarcio Covas Moschovas More articles by this author , Travis RogersTravis Rogers More articles by this author , Jonathan NoelJonathan Noel More articles by this author , Jaber AbdelJaber Abdel More articles by this author , Seetharam BhatSeetharam Bhat More articles by this author , and Vipul PatelVipul Patel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002598.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Over the years, since Binder and Kramer described the first Robotic-assisted Radical Prostatectomy (RARP) in 2000, different Nerve-sparing (NS) techniques have been proposed by several authors. However, even with the robotic surgery advantages, functional outcomes following RARP, especially erection recovery, still challenge surgeons and patients. In this scenario, we have described different ways and grades of neurovascular bundle preservation (NVB) using the prostatic artery as a landmark until our most recent technique with lateral prostatic fascia preservation and modified apical dissection. In this video compilation, we have illustrated the details of different grades of NVB preservation. METHODS: Our video describes the details of different degrees of nerve-sparing using anatomical landmarks. We have illustrated the key aspects of a full nerve sparing, partial nerve sparing and intrafascial dissection preserving the lateral prostatic fascia. RESULTS: After the anterior and posterior bladder neck dissection, we lift the prostate by the seminal vesicles to access the posterior aspect of the prostate. Then, we incise the Denonvilliers layers and work between an avascular plane to release the posterior NVB from 5 to 1 and 7 to 11 o’clock positions on the right and left sides, respectively. In sequence, we access the prostate anteriorly by incising the endopelvic fascia bilaterally (close to the prostate) until communicating the anterior and posterior planes. Finally, we control the prostatic pedicles with Hem-o-lok clips and then proceed for the apical dissection preserving the maximum amount of urethra length and periurethral tissues. CONCLUSIONS: Potency recovery following radical prostatectomy remains a challenge due to its multifactorial etiology. However, basic concepts for nerve-sparing are crucial to achieving optimal outcomes, such as minimizing the amount of traction used on dissection, avoiding excessive cautery, and neural preservation based on anatomical landmarks (arteries and planes of dissection). Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e661 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marcio Covas Moschovas More articles by this author Travis Rogers More articles by this author Jonathan Noel More articles by this author Jaber Abdel More articles by this author Seetharam Bhat More articles by this author Vipul Patel More articles by this author Expand All Advertisement PDF downloadLoading ...

Robotic-assisted minimally invasive thymectomy for myasthenia gravis with thymoma.

Robotic-assisted minimally invasive thymectomy for myasthenia gravis with thymoma.

Laparoscopic total mesorectal excision with urogenital fascia preservation for mid-low rectal cancer: Anatomical basis and clinical effect - Experimental research

BackgroundTotal mesorectal excision (TME) is conventionally performed according to Heald's principles through the so-called 'holy plane', between the visceral and parietal fasciae. However, urinary and sexual dysfunctions remain frequent postoperative complications. We proposed to preserve urogenital fascia (UGF) in TME, and this study aimed to clarify the anatomical basis of this technique and evaluate its efficacy and safety. Materials and methodsCadaveric dissection was performed on 26 pelvises, and laparoscopic TME with UGF preservation was performed in 212 patients with mid-low rectal cancer. The fasciae and spaces related to TME were observed and described, and the clinical effect of UGF-preserving TME was analyzed. ResultsIn the 26 cadavers, fascia propria of the rectum (FPR) presents as a fibrous capsule enveloping the mesorectum. UGF extends postero-laterally to the rectum, enveloping the hypogastric nerves and ureters. We demonstrated that the visceral fascia is actually the UGF, and FPR and visceral fascia (i.e. UGF) are two independent layers of fascia. Thus, FPR, UGF and parietal fascia form two avascular spaces behind the rectum. The plane ventral to the UGF is the real 'holy plane' for TME, rather than that dorsal to the UGF as is traditionally thought. Laparoscopic TME with UGF preservation was successfully performed in all 212 patients, with low perioperative complications (10.8%) and a low 3-year local recurrence rate (4.2%). Furthermore, the incidences of urinary and sexual dysfunctions at postoperative 6 months were only 6.1% and 10.8%, respectively. ConclusionThe avascular plane between the FPR and UGF (i.e. visceral fascia) is the real 'holy plane'. Laparoscopic TME with UGF preservation is a feasible radical surgery for mid-low rectal cancer, with better protection of urinary and sexual functions.