Bulldog Clamp Research Articles

Vascular Control during Robotic Myomectomy for 13cm Broad Ligament Fibroid

Study Objective Demonstrate surgical approach for a large 13 cm broad ligament fibroid, highlighting retroperitoneal anatomy and a novel method to decrease blood loss. Design A step-by-step explanation of the surgery using video (instructive video). Setting University hospital. Patients or Participants A 34-year-old woman with a 13 cm broad ligament fibroid who desires future fertility. Interventions We review entry into the retroperitoneum, more specifically, the pararectal space in a case with normal anatomy. Then, we present a case with a large broad ligament fibroid and systematically review the patient's MRI prior to showing surgical footage. The retroperitoneal dissection is initiated by transecting the round ligament and dissection continues parallel to the infundibulopelvic (IP) ligament until the psoas muscle and external iliac are identified. Blunt dissection is used to find the ureter on the medial leaflet of the broad ligament. Ureterolysis is performed given the extent of invasion by the fibroid. The pararectal space is then entered using a push and spread technique. Continued dissection laterally in the areolar tissue is used to localize the uterine artery at its origin. Once the uterine artery is skeletonized, a bulldog clamp is carefully placed to decrease blood flow. The fibroid is dissected in a clockwise fashion, starting from our dissection in the retroperitoneal space. The distal uterine artery, which is wedged between the uterus and the fibroid, is carefully dissected. Once the fibroid is completely separated from the uterine artery and surrounding tissue, the bulldog clamp is removed and vascular supply is restored. Measurements and Main Results EBL during resection of the highlighted fibroid was minimal, with overall EBL 100mL after dissection of several additional fibroids. The patient's symptoms improved and fertility was preserved. Conclusion Using retroperitoneal dissection and bulldog clamps, safe dissection of large broad ligament fibroids can be accomplished with minimal blood loss. Demonstrate surgical approach for a large 13 cm broad ligament fibroid, highlighting retroperitoneal anatomy and a novel method to decrease blood loss. A step-by-step explanation of the surgery using video (instructive video). University hospital. A 34-year-old woman with a 13 cm broad ligament fibroid who desires future fertility. We review entry into the retroperitoneum, more specifically, the pararectal space in a case with normal anatomy. Then, we present a case with a large broad ligament fibroid and systematically review the patient's MRI prior to showing surgical footage. The retroperitoneal dissection is initiated by transecting the round ligament and dissection continues parallel to the infundibulopelvic (IP) ligament until the psoas muscle and external iliac are identified. Blunt dissection is used to find the ureter on the medial leaflet of the broad ligament. Ureterolysis is performed given the extent of invasion by the fibroid. The pararectal space is then entered using a push and spread technique. Continued dissection laterally in the areolar tissue is used to localize the uterine artery at its origin. Once the uterine artery is skeletonized, a bulldog clamp is carefully placed to decrease blood flow. The fibroid is dissected in a clockwise fashion, starting from our dissection in the retroperitoneal space. The distal uterine artery, which is wedged between the uterus and the fibroid, is carefully dissected. Once the fibroid is completely separated from the uterine artery and surrounding tissue, the bulldog clamp is removed and vascular supply is restored. EBL during resection of the highlighted fibroid was minimal, with overall EBL 100mL after dissection of several additional fibroids. The patient's symptoms improved and fertility was preserved. Using retroperitoneal dissection and bulldog clamps, safe dissection of large broad ligament fibroids can be accomplished with minimal blood loss.

Temporary Uterine Artery Occlusion and Surgical Techniques for Stage 4 Endometriosis

<h3>Study Objective</h3> To describe a surgical approach to minimize intraoperative blood loss and improve visualization for stage 4 endometriosis. <h3>Design</h3> Video presentation for surgical management of stage 4 endometriosis. <h3>Setting</h3> The procedure was performed with robot assisted laparoscopy in dorsal lithotomy position. <h3>Patients or Participants</h3> A 39-year-old patient G0 with stage 4 endometriosis and prior failed In Vitro Fertilization. <h3>Interventions</h3> In this Video we describe the surgical approach used for Stage 4 endometriosis after prior failed In Vitro Fertilization. Intraoperatively, Initial survey of the pelvis showed both small and large bowel adhesions to the posterior aspect of the uterus as well as obliteration of the cul-de-sac. We begin by opening the pelvic sidewall bilaterally, parallel and lateral to the infundibulopelvic ligament identifying the pararectal space. The ureters are identified bilaterally and are tagged with a vessel loop for easier identification and manipulation for ureterolysis. Further dissection into the pararectal space is performed to identify the uterine arteries at their origin and are temporarily ligated with vascular bulldog clamps. Ureterolysis is then performed followed by mobilization of the rectum using a lateral to medial approach towards the central pathology. The anatomy of the adnexa is then restored bilaterally and a bilateral salpingectomy was then performed due to hydrosalpinx to improve future attempts of In Vitro Fertilization. The vascular bulldog clamps are then removed at the end of the procedure. <h3>Measurements and Main Results</h3> Patient had significant improvement in pain post operatively and is pending In Vitro Fertilization. <h3>Conclusion</h3> Temporary uterine artery ligation during extensive endometriosis surgery could improve blood loss and visualization intraoperatively and can be utilized during pelvic side wall dissection and identification of critical anatomy.

V05-10 PARTIAL NEPHRECTOMY IN THE TREATMENT OF A POSTERIOR EXCLUDED CALYCEAL DIVERTICULUM WITH A RENAL CALCULUS

You have accessJournal of UrologyUrolithiasis & Endourology (V05)1 Sep 2021V05-10 PARTIAL NEPHRECTOMY IN THE TREATMENT OF A POSTERIOR EXCLUDED CALYCEAL DIVERTICULUM WITH A RENAL CALCULUS Sho Yoshitake, Joshua Sterling, and Sammy Elsamra Sho YoshitakeSho Yoshitake More articles by this author , Joshua SterlingJoshua Sterling More articles by this author , and Sammy ElsamraSammy Elsamra More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002012.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Calyceal diverticula (CD) are protrusions of renal calyces surrounded by renal parenchyma. They are rare and usually asymptomatic. However, they can cause recurrent flank pain, hematuria, and urinary tract infections. Treatment has classically included shock wave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL). SWL can improve symptoms but does not treat the underlying CD. URS is limited to CD with favorable anatomy. PCNL is considered first-line. However, it is not recommended for supracostal or anterior CD and is avoided in patients averse to a nephrostomy tube or ureteral stent. There are limited reports of robotic partial nephrectomy in the treatment of CD and no reports of retroperitoneal robotic approaches, to our knowledge. Yet, robotic partial nephrectomy is a promising option. It treats both the CD and the stones within; ureteral stents or nephrostomy tubes are not needed; and supracostal CD are not contraindicated. In this video, we present a case of a posterior excluded CD with a renal calculus refractory to SWL treated with robotic partial nephrectomy. METHODS: The procedure was performed with the da Vinci Xi system. Patient was placed in the right lateral decubitus position. Following a 12-mm mid-axillary incision, access to the retroperitoneum was gained. A Spacemaker Hasson trocar with the balloon dilator was placed into the retroperitoneum and the balloon was dilated. Ports were placed in standard position for a robotic retroperitoneoscopic renal surgery. The kidney was then elevated and the renal hilum was dissected out. Intraoperative ultrasound was performed to identify the location of the CD with the stone. Following placement of two bulldog clamps on the renal artery, the CD was excised. Deep and capsular renorrhaphy were conducted to close the defect in the collecting system. The bulldogs were then removed, and hemostasis was gained. By the end of the case, there was excellent hemostasis, and a 15-French Blake drain was placed into the retroperitoneal space posterior to the kidney. RESULTS: There were no intra-operative complications. Pathology was consistent with a CD with renal calculi. After an uncomplicated post-operative stay, she was discharged to her home after 1 day. 3 weeks later, she was seen in the office and was symptom free. CONCLUSIONS: Excluded CD with renal calculi have classically been treated with SWL, URS, and PCNL. Robotic partial nephrectomy is a safe, efficient, and often overlooked treatment for stones in an excluded CD. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e389-e389 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sho Yoshitake More articles by this author Joshua Sterling More articles by this author Sammy Elsamra More articles by this author Expand All Advertisement Loading ...

V11-03 ROBOTIC PARTIAL NEPHRECTOMY WITH INFERIOR VENA CAVA THROMBECTOMY

You have accessJournal of UrologyRenal Oncology II (V11)1 Sep 2021V11-03 ROBOTIC PARTIAL NEPHRECTOMY WITH INFERIOR VENA CAVA THROMBECTOMY Ali Merhe, Laura Horodyski, Chad Ritch, Oleksandr Kryvenko, and Mark Gonzalgo Ali MerheAli Merhe More articles by this author , Laura HorodyskiLaura Horodyski More articles by this author , Chad RitchChad Ritch More articles by this author , Oleksandr KryvenkoOleksandr Kryvenko More articles by this author , and Mark GonzalgoMark Gonzalgo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002073.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This is a case of a 55 year old female with an incidentally discovered right renal mass. CT scan showed a 4 cm low density lesion extending from the renal cortex into the renal vein and inferior vena cava (IVC) (level 1 thrombus) with fat content, suggestive of possible angiomyolipoma. Objective: To demonstrate the surgical steps of robotic partial nephrectomy with IVC thrombectomy. METHODS: After trocar placement, the da Vinci Xi Robot system was docked in the standard manner, and the procedure was initiated with mobilization of the colon then identification of the right ureter and gonadal vein. The gonadal vein was followed proximally to its insertion into the IVC. The renal vein and artery were subsequently identified and dissected. A vessel loop was passed around the renal vein to ensure proximal control of the tumor thrombus during excision of the mass. Intraoperative ultrasound was used to identify the location and depth of the mass prior to excision. Bulldog clamps were placed sequentially over the renal artery and renal vein. Traction was applied with the vessel loop and suction irrigator to ensure proximal control of the tumor thrombus. Excision of the mass was accomplished utilizing a combination of sharp and blunt dissection. An incision was made into the branch of the renal vein containing the tumor thrombus. The incision was extended circumferentially to facilitate mobilization and complete en bloc removal of the renal mass and thrombus. The renal vein defect was then closed in 2 layers with 4-0 Prolene suture. Prior to closure of the first layer, the clamp over the renal vein was temporarily released to permit venous backflow in order to minimize the risk of air embolism. The tumor bed defect was closed in 2 layers in a continuous manner with 3-0 V-lock suture. A sliding clip technique was then performed with 3-0 V-lock suture in an interrupted manner to re-approximate the edges of the kidney and complete the reconstruction. RESULTS: Estimated blood loss was 70 cc with a warm ischemia time of 45 minutes. The patient was discharged from the hospital on postoperative day number 1 without complications. Final pathology demonstrated a 2.1 cm angiomyolipoma with negative margins. CONCLUSIONS: Robotic partial nephrectomy with IVC thrombectomy is a feasible and safe surgical option for patients with benign renal masses with extension of tumor thrombus into the IVC. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e858-e858 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ali Merhe More articles by this author Laura Horodyski More articles by this author Chad Ritch More articles by this author Oleksandr Kryvenko More articles by this author Mark Gonzalgo More articles by this author Expand All Advertisement Loading ...

The effect of Camellia sinensis (green tea) with its active compound EGCG on neuronal cell necroptosis in Rattus norvegicus middle cerebral artery occlusion (MCAO) model

To determine the inhibition effect of epigallocatechin gallate (EGCG) and green tea extract on neuronal necroptosis based on necroptosis morphology. In vivo study was performed on male Rattus norvegicus middle cerebral artery occlusion (MCAO) model divided into five groups, MCAO-control groups, EGCG 10mg/kg BW/day, EGCG 20mg/kg BW/day, EGCG 30mg/kg BW/day, and green tea extract 30mg/kg BW/day for 7days treatment. MCAO model was made by modification method using Bulldog clamp. After 7days of treatment, all R.norvegicus were sacrificed. After that, examination using Hematoxylin-Eosin stain was conducted to look at necroptosis morphology in each group. We found that there are significant differences between control group and the other three groups (EGCG 20mg/kg BW/day, EGCG 30mg/kg BW/day, and green tea extract (p<0.05). There is a significant correlation between the number of neuron cell necroptosis and both EGCG and green tea extract (p<0.05). The correlation is negative, which means both EGCG and green tea extract will decrease the number of neuron cell necroptosis. EGCG will decrease neuron cell necroptosis starting from the dose of 20mg/kg BW/day. EGCG 30mg/kg BW/day produces the best result compared to other doses. Camellia sinensis (green tea) with its active compound EGCG decreases neuronal necroptosis morphology in MCAO models.

Comparative analysis of vascular bulldog clamps used in laparoscopic liver resection.

To compare the clinical effect of Bulldog clamps with traditional Pringle for vascular occlusion during laparoscopic hepatectomy.One hundred ten patients were retrospectively investigated in this research from December 2014 to January 2019 in the second hospital of Anhui Medical University, who underwent laparoscopic liver resection using Bulldog (modified group, n = 54) and cotton tourniquet (traditional group, n = 56) for blocking the liver inflow-blood. Intraoperative blood loss, duration of the operation time, clamping time, postoperative outcomes were analyzed.All the operations were accomplished successfully without conversion to laparotomy, perioperative period clinical date was calculated. Intraoperative operative time, blood loss and resection sections had no statistical significance, but the clamping time (36.2 ± 5.6 vs 277.3 ± 88.4 s, P < .001) was significantly shorter in the bulldog group. Albumin, alanine aminotransferase, aspartate aminotransferase and serum total bilirubin had no statistical differences in postoperative day (POD) 1and 3, but POD 5 alanine aminotransferase (71.0 ± 46.8vs 105.8 ± 61.7IU/L P = .018) and aspartate aminotransferase (72.8 ± 39.7 vs 100.2 ± 16.7 IU/L P = .028). The postoperative hospital stays (7.02 ± 1.56 vs 8.50 ± 2.35 days P = .026) in bulldog group were lower than cotton group and differences had statistical significance. The C-reactive protein levels were significantly higher in the traditional group than in the modified group on POD 3 (46.3 ± 19.2 vs 57.7 ± 23.9 mg/L P = .019), and POD5 (13.3 ± 4.2 vs 17.5 ± 7.3 mg/L P = .001). There were 8 postoperative complications occurred in cotton group, while there was 5 in Bulldog group, all patients with complications were discharged after adequate drainage and symptomatic treatment.Bulldog is an effectively performed approach for vascular occlusion during laparoscopic hepatectomy than traditional Pringle maneuver.

50 Vascular bulldog clamps for robotic myomectomy

The objective of this video is to illustrate how to incorporate the use of vascular bulldog clamps for reducing blood loss during robotic-assisted laparoscopic myomectomy. This video provides technical details on the use of robotic bulldog clamps and shows their placement and removal during a robotic myomectomy case. For experienced surgeons comfortable with retroperitoneal dissection, the use of vascular bulldog clamps may be easily incorporated into surgical technique for robotic myomectomy.

The effect of erythropoietin and umbilical cord-derived mesenchymal stem cells on nerve regeneration in rats with sciatic nerve injury

ObjectiveWe aimed to investigate the effects of umbilical cord-derived mesenchymal stem cells and erythropoietin on nerve regeneration in the sciatic nerve ‘crush injury’ in a rat model. MethodsExperimental animals were randomly divided into 5 groups: Crush Injury, Sham, Crush Injury + Erythropoietin, Crush Injury + Mesenchymal Stem Cell, Crush Injury + Erythropoietin + Mesenchymal Stem Cell groups. Crush injury made with bulldog clamp. Mesencyhmal stem cells delivered by enjection locally. Erythropoietin administered by intraperitoneally. On the 0th, 14th and 28th days, all groups underwent a sciatic functional index test. On 28th day, sciatic nerves were harvested and histopathological appearance, axon number and axon diameter of the sciatic nerves were evaluated with Oil Red O staining. Immunoreactivity of nerve growth factor, neurofilament-H and caspase-3 were determined by immunofluorescence staining in nerve tissue. ResultsIn histopathological examination, axons and nerve bundles exhibiting normal nerve architecture in the Sham group. Crush Injury + Mesenchymal Stem Cell group has similar histological appearance to the Sham group. The number of axons were higher in the Mesenchymal Stem Cell groups compared to the Crush Injury group. Nerve growth factor immunoreactivity intensity was significantly lower in Crush Injury + Mesenchymal Stem Cell group compared to Crush Injury group. Neurofilament-H density was higher in the treatment groups when compared to the Crush Injury group. ConclusionsIn this study, it was found that umbilical cord-derived mesenchymal stem cells and erythropoietin treatments effects positively regeneration of crush injury caused by bulldog clamp in the sciatic nerve of rats.

Robotic central hepatectomy: technical tips and tricks

Purpose: Minimal invasive (MI) central hepatectomy is considered a technical complex procedure. The robotic approach could provide benefits over traditional laparoscopy, thanks to 3D visualization, endowrist technology and tremor filtration. Based on three different cases, this video aims to demonstrate technical tips and tricks for robotic central hepatectomy. Methods: The cases consisted of an anatomic segment 4 resection for two hepatocellular carcinoma (HCC), a MI resection of segment 5 and part of segment 8 for a solitary colorectal liver metastasis, and a MI resection of segment 4, 5 and 8 for a mixed cholangiocarcinoma and HCC. Results: A series of tips and tricks are proposed. (1) Installation: supine anti-Trendelenburg position with four robotic ports and an AirSeal port. (2) Exposure: optimal instrument and gauze placement, and application of a percutaneous traction suture to facilitate resection of segment 8 lesions. (3) Intraoperative ultrasound: demarcation of the tumor margins with monopolar scissors. (4) Pringle maneuver: an extracorporeal method with an umbilical tape encircling the hepatoduodenal ligament inserted in a chest tube, versus an intracorporeal method based on the Huang loop technique with application of a vascular bulldog clamp instead of a locking clip to apply tension, allowing to Pringle intermittently. (5) Parenchymal transection: in both healthy and cirrhotic liver tissue the combination of bipolar sealing device, Kelly-crush technique with fenestrated bipolar forceps, and monopolar scissors, proved to be highly efficient. (6) Hemostasis: achieved by preoperative hypovolemic phlebotomy with blood salvage, locking polymer clips, barbed resorbable sutures, hemostatic matrix, fibrillar absorbable haemostat and fibrin sealant patch. Operative time was 198 ± 12.6 minutes. The Pringle maneuver was applied 52.3 ± 8.7 minutes. Blood loss was 60 ± 26.5 cc. No intraoperative complications were encountered. R0-resection was obtained in all patients. The postoperative course was uneventful. Discharge happened on postoperative day 3 ± 1. Conclusion: A systematic approach of robotic central hepatectomy provides a technically feasible and adequate alternative for laparoscopy.

Protective effect of cordycepin on experimental renal ischemia/reperfusion injury in rats.

To date, various molecules have been investigated to reduce the effect of renal ischemia/reperfusion (I/R) injury. However, none have yet led to clinical use. The present study aimed to investigate the protective effect of cordycepin (C) on renal I/R injury in an experimental rat model. Twenty-four mature Sprague Dawley female rat was randomly divided into three groups: Sham, I/R, I/R+C. All animals underwent abdominal exploration. To induce I/R injury, an atraumatic vascular bulldog clamp was applied to the right renal pedicle for 60 minutes (ischemia) and later clamp was removed to allow reperfusion in all rats, except for the sham group. In the I/R + C group, 10 mg/kg C was administered intraperitoneally, immediately after reperfusion. After 4 hours of reperfusion, the experiment was terminated with right nephrectomy. Histological studies and biochemical analyses were performed on the right nephrectomy specimens. EGTI (endothelial, glomerular, tubulointerstitial) histopathology scoring and semi-quantitative analysis of renal cortical necrosis were used for histological analyses and superoxide dismutase (SOD), catalase (CAT), malondialdehyde (MDA), total oxidant status (TOS) for biochemical analyses. Histopathological examination of the tissue damage revealed that all kidneys in the sham group were normal. The I/R group had higher histopathological scores than the I/R + C group. In the biochemical analysis of the tissues, SOD, MDA, TOS values were found to be statistically different in the I/R group compared to the I/R + C group (p: 0.004, 0.004, 0.001 respectively). Intraperitoneal cordycepin injection following ischemia preserve renal tissue against oxidative stress in a rat model of renal I/R injury.

A Novel Technique to Minimize Blood Loss in Robotic-Assisted Laparoscopic Myomectomy

Study Objective To evaluate the effect and feasibility of using bulldog clamps for temporary occlusion of bilateral uterine and utero-ovarian vessels on blood loss during robotic-assisted laparoscopic myomectomy. Design Retrospective chart review. Setting Academic tertiary care center. Patients or Participants A total of 15 consecutive patients, who underwent robotic-assisted laparoscopic myomectomy using bulldog clamps performed by single minimally invasive gynecologic surgeon, from 2018 to 2020. Interventions Patients were taken to the operating room for robotic-assisted laparoscopic myomectomy. Bilateral retroperitoneal dissection was performed with development of avascular spaces and ureterolysis. The uterine artery was skeletonized at its origin bilaterally and bulldog clamp was applied to each side, taking care to avoid ureteral and/or vascular injury. Furthermore, an avascular window was created in the mesosalpinx bilaterally and bulldog clamps were placed, occluding both left and right utero-ovarian vessels. Myomectomy was performed and once completed, all four clamps were removed allowing return of uterine blood flow. Measurements and Main Results Mean age and body mass index were 35.2 and 30.9 kg/m2, respectively. Most patients were black (53.3%). Mean myoma size and total myoma weight per patient were 6.6 cm and 106 g (standard deviation or SD = 82.7). Most leiomyomas were located in the fundus (41.4%). Mean estimated blood loss was 83 ml (range 20-200 ml). Mean operative time was 186 minutes. There were no intraoperative complications and all patients were discharged home on the same day of surgery. Conclusion Temporary bilateral uterine and utero-ovarian vessel occlusion using bulldog clamps can minimize blood loss during robotic-assisted laparoscopic myomectomy. Placement and removal of bulldog clamps for temporary uterine and utero-ovarian vessel occlusion are relatively easy and safe, compared to other methods of uterine artery ligation.

Surgical Management of Cesarean Scar Ectopic with Fertility Preservation

Study Objective To highlight retroperitoneal anatomy and show surgical techniques to minimize blood loss during cesarean scar ectopic resection. Design A step-by-step explanation of the surgery using video (instructive video). Setting University Hospital. Patient was in dorsal lithotomy position. Patients or Participants A 33 year-old woman G4P1 with a cesarean scar ectopic pregnancy at 10weeks gestation that failed methotrexate injection. Interventions This video highlights entry into the retroperitoneal space and dissection technique for identifying the uterine arteries at their origins. Bulldog clamps are placed on all vascular pedicles that supply the uterus (bilateral uterine arteries and bilateral infundibulopelvic ligaments) to aid with hemostasis. Additionally, Vasopressin is used to further reduce blood loss. Applying these techniques allowed for successful resection of the ectopic pregnancy with only 50 cc of estimated blood loss. Control of bleeding resulted in thorough resection of the ectopic pregnancy while conserving as much surrounding myometrium as possible. The uterine defect is repaired in three layers. Measurements and Main Results Operative time was 199 minutes, with an estimated blood loss of 50ml. Surgical resection of the ectopic pregnancy allowed the patient to preserve her fertility. Subsequently, the patient had an uncomplicated pregnancy which resulted in a live birth. Conclusion Knowledge of the avascular spaces and dissection techniques that allow for access to the origin of the uterine artery can be very useful in complex cases. Bulldog clamps can be used for transient occlusion of blood supply to the uterus resulting in resection of a cesarean scar ectopic with minimal blood loss. This is an option for patients who desire future fertility.

Surgical Pearls for Laparoscopic Resection of a Cervical Leiomyoma

Study Objective To describe and demonstrate surgical pearls for complete laparoscopic excision of a cervical leiomyoma. Design Video presentation of a clinical case with imaging, surgical procedure, and key teaching points. Setting Academic Institution. Patients or Participants 33-year old G0 woman with a 4 year history of infertility and abnormal uterine bleeding refractory to hormonal agents. Interventions The patient underwent a diagnostic hysteroscopy, laparoscopic myomectomy, and chromopertubation. Measurements and Main Results Surgical recommendations for safe and effective laparoscopic resection of cervical myomas include dissection of the bladder using a lateral to medial approach, backfilling of the bladder when necessary to avoid injury, and taking care to avoid entry into the cervical canal while achieving complete excision. A pediatric Foley catheter can function as stent to post-operative cervical stenosis. Additional techniques for hemostasis in this type of complex surgery are also reviewed. Retroperitoneal isolation of the uterine arteries and the use of laparoscopic bulldog clamps may be necessary for larger myomas. Conclusion Complete laparoscopic resection of cervical myomas can be performed safely and effectively with preservation of the uterus for future fertility. Several techniques reviewed in this video may be useful to reduce surgical morbidity and allow a minimally invasive approach.

Effect of bile duct clamping versus no clamping on surgical site infections in patients undergoing pancreaticoduodenectomy: a randomized controlled study.

Infectious complications cause significant morbidity after pancreatoduodenectomy (PD). The impact of uncontrolled spillage of bile during PD has not been systematically studied. Patients undergoing PD for malignant lesions between March 2017 and May 2019 were considered for inclusion. All patients underwent standard pre-operative preparation and antibiotic prophylaxis. After confirmation of resectability, the patients were randomized into one of the two groups: common hepatic duct clamping using atraumatic bulldog clamp after biliary division (Group I) or no clamping (Group II). Post-operative outcomes including surgical site infection (SSI) were compared. Fifty-two patients were assessed for eligibility and eventually 40 were randomized (median age: 53.5 years, 28 (70%) males). Twenty patients were randomized into each group and 14 in each group had undergone pre-operative biliary drainage. Incidence of co-morbidities, operative time and blood loss were comparable between the two groups. SSI was significantly lower in Group I (4 (20%) versus 11 (55%), P = 0.02). Number needed to treat to prevent one SSI was 3. Incidence of intra-abdominal collections was higher in Group II, though, not statistically significant (2 (10%) versus 6 (30%), P = 0.23). The duration of post-operative antibiotics was significantly higher in Group II (7 IQR 4 versus 11 IQR 7 days, P = 0.04). Among the risk factor evaluated in the entire population, higher incidence of SSI was seen in patients with positive bile culture (13 (65%) versus 2 (10%), P = 0.04). Bile duct clamping during PD reduces risk of superficial SSI.

V01-10 ROBOTIC-ASSISTED SALVAGE PARTIAL NEPHRECTOMY AFTER CRYOABLATION FAILURE

You have accessJournal of UrologyKidney Cancer I: Partial Nephrectomy & Kidney Preservation Strategies (V01)1 Apr 2020V01-10 ROBOTIC-ASSISTED SALVAGE PARTIAL NEPHRECTOMY AFTER CRYOABLATION FAILURE Candice Debard*, Clément Michiels, Grégoire Capon, Henri Bensadoun, Jean-Marie Ferrière, Grégoire Robert, and Jean-Christophe Bernhard Candice Debard*Candice Debard* More articles by this author , Clément MichielsClément Michiels More articles by this author , Grégoire CaponGrégoire Capon More articles by this author , Henri BensadounHenri Bensadoun More articles by this author , Jean-Marie FerrièreJean-Marie Ferrière More articles by this author , Grégoire RobertGrégoire Robert More articles by this author , and Jean-Christophe BernhardJean-Christophe Bernhard More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000826.010AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This case illustrates the difficulty of a salvage PN after cryoablation. The objective is to show that Image Guided Robot-Assisted Partial Nephrectomy (IGRAPN) with 3D model assistance, intraoperative US, and indocyanine green, as a salvage treatment, allows an excellent renal function preservation without morbidity METHODS: The surgery was performed with the Da-Vinci surgical robot, by using 3 operatives arms, a 30-degree endoscope and 2 ports for the assistant. We used a 3D model image, intraoperative ultrasound (US) and indocyanine green fluorescence. Clinical data, collected after consent, were extracted from the french national database on kidney cancer UroCCR. RESULTS: A 5cm upper and mid pole, posterior and mostly endophytic tumor was discovered in a 72 years old woman with CDK (GFR 34mL/min MDRD) and anticoagulant treatment, and treated by cryoablation. 4 months CT scan showed an extended residual disease in sinusal part of the tumor. It was a highly complex tumor: RENAL score 10ph, PADUA score 12p. Ablated zone was very difficult to dissect because of a sticky fat. Hilum was deeply dissected to enable selective clamping, arterial branchs were encircled with vessel loops. We made hemostasis of feeding tumor veins with Hemolocs. It was difficult to find the tumor plan around the hilum. Intraoperative US was performed to identify the limits of the tumor. An anterior feeding arteria was clamped and the tumorectomy started, dissecting step by step, with no real enucleation plan because of cryoablation. To continue the dissection, we practiced sequential clampage, taking off the bulldog clamp on anterior artery to clamp a more posterior arterial branch. Collecting system was opened, necessary step to permit a complete excision. The tumor was finally removed, and put in an endobag. Collecting system was closed with 4.0 PDS and the tumor bed with a 3.0 Veloc overlock. Patient was discharged at home post-operative day 2, with an unchanged renal function. Tumor was a Renal Cell Carcinoma of 3,5 cm Fuhrman grade 3 staging pT3aR0. 8 months later, renal function was still stable, with no recurrence on CTscan. CONCLUSIONS: A complex PN would become even more complex if performed as a salvage indication. Elect the right treatment option at first. In situations with risk factors for ablation failure, even in case of comorbidities or CKD, PN remains standard treatment Source of Funding: 0 © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e93-e93 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Candice Debard* More articles by this author Clément Michiels More articles by this author Grégoire Capon More articles by this author Henri Bensadoun More articles by this author Jean-Marie Ferrière More articles by this author Grégoire Robert More articles by this author Jean-Christophe Bernhard More articles by this author Expand All Advertisement PDF downloadLoading ...

To clamp or not to clamp?

Introduction: Radical prostatectomy (RP) is the gold-standard surgical treatment for men with clinically localized prostate cancer (PCa). Surgical techniques to minimize intra and post-operative complications are well established, but excessive bleeding during RP continues to be a concern. The objective of our study was to determine whether additional intraoperative temporary occlusion of the internal iliac arteries combined with a penile base tourniquet during open RP improves hemostasis.&#x0D; Methods: We conducted a retrospective chart review of 23 patients who underwent open RP between Jan 2014 to May 2016. Eight patients underwent open RP with additional clamping of the internal iliac arteries using bulldog vascular clamps combined with a penile base penrose drain tourniquet as temporary prostatic arterial and venous control during dorsal venous complex ligation and neurovascular bundle sparing. Our primary outcome was immediate and post-operative day 1 hemoglobin levels. Our main outcome was analyzed using Students t-test with equal variance.&#x0D; Results: We stratified participants by clamping type. Fifteen patients underwent no clamping and 8 patients had the combined temporary clamping. Primary analysis of estimated blood loss showed a reduction in average blood loss among individuals with vascular control technique versus usual technique (516 ml and 754 ml respectively, p= 0.021). There were no obvious intraoperative or postoperative complications noted that could have been attributable to the temporary vascular control techniques.&#x0D; Conclusion: Temporary vascular control with the addition of minor surgical techniques during open RP may improve an objective measure of blood loss immediately after surgery.

Totally Laparoscopic Pancreaticoduodenectomy: Technical Notes

Introduction: Laparoscopic pancreaticoduodendectomy is still rarely adopted due to its inherent complexity. We hereby present our experience of laparoscopic pancreaticoduodenectomy focused on technical notes. Technical description: A 5 trocars technique is used. Vision is provided by a 30 degree scope with 4K technology for the demolitive phase and 3D for the reconstructive phase. The right colic flexure is mobilized and an extensive Kocher maneuver is carried out exposing the inferior vena cava and left renal vein. The gastric antrum is resected with a mechanical stapler. The common hepatic artery is identified behind the superior pancreatic margin; lymphadenectomy of stations 7, 8, 9, 12 a and b is performed, until the gastroduodenal artery is cleared from the lymphatic tissue; a bull-dog clamp is placed to interrupt the arterial flow through the gastroduodenal artery, in order to exclude aberrant vascularization of the liver from the SMA. The common hepatic duct is transected just above the cystic duct. The pancreas is sectioned with monopolar energy, dividing the main pancreatic duct 2-3 mm distal to the parenchymal transection line with cold scissors, as to leave a stump that will facilitate the duct-to-mucosa anastomosis then the first jejunal loop is sectioned. A complete dissection of the mesopancreas is performed, moving from a caudal to cephalad fashion. Prior to perform the pancreatico-jejunal anastomosis, a fistula risk score based on pancreatic parenchymal texture, tumor type, Wirsung diameter, intraoperative blood loss is assessed. The pancreatico-jejunal anastomosis is carried out using prolene and pds sutures. The end-to-side hepaticojejunostomy is performed about 10 cm distant from the pancreaticojejunostomy. The side to- side gastrojejunostomy is performed using a 60 mm linear stapler. Conclusion: Laparoscopic pancreaticoduodenectomy is a demanding procedure affected by high morbidity rates. The standardization of the technique could lead the way to reduce such rates and favor its adoption.

Minimal Blood Loss in Robotic Assisted Laparoscopic Myomectomy: Bulldog Clamp for Temporary Ligation of Uterine Arteries and Uteroovarian Vessels

Video Objective To demonstrate how to reduce the blood loss in minimally invasive myomectomy, with using laparoscopic Bulldog clamps for ligating the uterine arteries and utero-ovarian vessels Setting 42 y/o patient with history of infertility, prior abdominal myomectomy, abnormal uterine bleeding with multiple fibroids largest one 6 cm in dimension, who underwent robotic-assisted laparoscopic myomectomy Interventions Retroperitoneal dissection and ureterolysis were performed to isolate the uterine vessels, then fallopian tubes were isolated from utero-ovarian ligaments bilaterally. Laparoscopic Bulldog clamps were used to temporarily clamp uterine arteries and utero-ovarian ligaments. Robotic Myomectomy was performed and total of 13 fibroids were removed. Uterus was repaired with 2-0 V-locks in multiple layers and reconstructed. At the completion of myomectomy the clamps were removed from the vessels. Total of estimated blood loss was 50 cc. Patient was discharged home in less than 24 hours with no complication. Conclusion Blood loss in myomectomy is related to location, and numbers of myoma. Clamping the uterine vessels and utero-ovarian can significantly reduce the blood loss. This technique requires retroperitoneal dissection and ureterolysis. Knowledge of anatomy is a master key to success.

Comparison of blood flow in single and sequential vein grafts during off-pump coronary artery bypass.

The use of sequential anastomoses in coronary artery bypass grafting (CABG) is still controversial. This study aimed to evaluate the mean blood flow (MBF) rate and pulsatility index (PI) of single and sequential saphenous vein grafts to the posterior descending artery (PDA) in the same patient during off-pump CABG (OPCABG). Sequential saphenous vein grafts were used to bypass the diagonal artery (Diagonal) (side-by-side), obtuse marginal artery (OM) (side-by-side) and PDA (end-to-side). The anastomoses of Diagonal and OM were temporarily occluded with bulldog clamps, making the sequential graft a "single" graft to PDA. The MBF and PI of this "single" graft to PDA were measured with transit-time flow measurement (TTFM). Then the bulldog clamps were removed and the MBF and PI of sequential graft to PDA were measured again and compared to those of the "single" graft in the same patient. Anastomoses were evaluated with coronary CT angiogram at 6 months. A total of 128 patients with triple vessel disease were enrolled (96 men; mean age, 66.0±8.0 years; range, 54-80 years). The MBF of the "single" vs. sequential graft to PDA was 20.6±9.1 vs. 21.4±10.1 mL/min (P=0.472). The PI of 'single graft' vs. sequential graft to PDA was 1.7±0.6 vs. 1.7±0.5 (P=0.941). The patency of all grafts was good in all patients after 6 months of follow-up. There were no hydrodynamic differences between single and sequential grafts to PDA in OPCABG.

Prevention of Back Bleeding During Carotid Endarterectomy: Analysis of Clamping Techniques

Complete control of back bleeding during carotid endarterectomy (CEA) is important. We investigated the causes of back bleeding during CEA and techniques for the control of bleeding. A retrospective review was performed of 214 CEA procedures. We assessed the results of routine preoperative examinations, instruments used for arterial clamping (vessel loop and crude or bulldog clamps), and severity of carotid artery stenosis and arterial wall calcification. The study end point was incomplete control of back bleeding before arteriotomy. Factors associated with back bleeding were identified by univariate analysis. The culprit artery and intraoperative technique used in patients with back bleeding were also determined. Transient back bleeding occurred in 19 CEA procedures (8.9%). Back bleeding was from the ascending pharyngeal artery in 9 cases, common carotid artery in 8 cases, and external carotid artery in 2 cases. Univariate analysis identified the following factors as being related to incomplete control of back bleeding: moderate carotid artery stenosis (20 mm thick) and use of bulldog clamps. Transient back bleeding during CEA was uncommon, with the risk factors being severe carotid calcification and moderate carotid stenosis. Transient back bleeding was managed by clamping an undetected ascending pharyngeal artery or by additional clamping of the common carotid or external carotid artery. The vessel loop and crude were superior to the bulldog clamp for clamping the carotid artery.