Dissection Of Vein Research Articles

Ultrasound-Guided Axillary Access Using a Micropuncture Needle Versus Conventional Cephalic Venous Access for Implantation of Cardiac Devices: A Single-Center Randomized Trial

(1) Background: Ultrasound-guided axillary (USAX) vein puncture is a relatively new method to obtain venous access for the implantation of cardiac implantable electronic devices (CIED). However, its use is limited as most of the operators are not familiar with this technique. Our aim was to investigate the safety and efficacy of the USAX compared with the traditional cephalic vein dissection for venous access in CIED implantation. (2) Methods: This was a single-center, randomized, controlled, superiority trial. A total of 114 patients were randomized (1:1 ratio) to either USAX (u/s axillary group; 59 patients) or cephalic vein access (cephalic group; 55 patients). The primary study endpoint was defined as successful placement of all leads via the chosen access. Secondary study endpoints included time from local anesthetic injection to lead advancement in the SVC, total procedure time (skin to skin), procedure-related complications and pain perception. (3) Results: USAX was superior to cephalic access in terms of primary endpoint (OR: 4.3, 95% CI: 1.3, 14.0; p = 0.012). Total procedure duration was higher in the cephalic group (55.15 ± 16.62 vs. 48.35 ± 12.81 min, p = 0.017) but there was neither a significant difference in fluoroscopy time (p = 0.872) nor in total radiation dose (p = 0.815). The level of pain was higher in the cephalic group (p = 0.016), while the rates of complications were similar in both groups (p > 0.05). (4) Conclusion: USAX was superior to cephalic access regarding success rate, total procedure duration and level of pain, while having no difference in complication rates.

Deep learning-based surgical step recognition for laparoscopic right-sided colectomy.

Understanding the complex anatomy and surgical steps involved in laparoscopic right-sided colectomy (LAP-RC) is essential for standardizing the surgical procedure. Deep-learning (DL)-based computer vision can achieve this. This study aimed to develop a step recognition model for LAP-RC using a dataset of surgical videos with annotated step information and evaluate its recognition performance. This single-center retrospective study utilized a video dataset of laparoscopic ileocecal resection (LAP-ICR) and laparoscopic right-sided hemicolectomy (LAP-RHC) for right-sided colon cancer performed between January 2018 and March 2022. The videos were split into still images, which were divided into training, validation, and test sets using 66%, 17%, and 17% of the data, respectively. Videos were manually classified into eight main steps: 1) medial mobilization, 2) central vascular ligation, 3) dissection of the superior mesenteric vein, 4) retroperitoneal mobilization, 5) lateral mobilization, 6) cranial mobilization, 7) mesocolon resection, and 8) intracorporeal anastomosis. In a simpler version, consecutive surgical steps were combined, resulting in five steps. Precision, recall, F1 scores, and overall accuracy were assessed to evaluate the model's performance in the surgical step classification task. Seventy-eight patients were included; LAP-ICR and LAP-RHC were performed in 35 (44%) and 44 (56%) patients, respectively. The overall accuracy was 72.1% and 82.9% for the eight-step and combined five-step classification tasks, respectively. The automatic surgical step-recognition model for LAP-RCs, developed using a DL algorithm, exhibited a fairly high classification performance. A model that understands the complex steps of LAP-RC will aid the standardization of the surgical procedure.

802. TECHNICAL DETAILS: FREE JEJUNAL GRAFT AND REVERSE SAPHENOUS VEIN GRAFT FOR RECONSTRUCTION AFTER TOTAL PHARYNGO-LARYNGECTOMY AND PROXIMAL ESOPHAGECTOMY

Abstract Background We would like to show our tips for free jejunal graft and vascular reconstruction after pharyngo-laryngectomy and proximal esophagectomy. Methods 65 years-old man with history of hypopharynx squamous cell carcinoma cT3 cN0 cM0 who underwent radical Qt/Rt with initially complete response. After 2 years follow-up, he presented dysphagia and recurrence of squamous cell carcinoma proven by histology. Upper endoscopy shows cervical esophageal stenosis due to tumor infiltration. Rescue surgery was decided after systemic dissemination was ruled out with PET-CT. Results Pharyngo-laryngectomy, total thyroidectomy and proximal esophagectomy was performed. Free margin tumor was confirmed by frozen section. Jejunal segment with adequate vascular supply is selected, preferable with a single artery and vein. Peristaltic direction of the jejunum is marked to avoid mistakes during graft transposition. Division of mesenteric branches to prevent postoperative bleeding. Before jejunal section we recommend administration of hyoscine butilbromide 20 mg iv to avoid jejunal spams. Measuring the length graft needed before dividing the jejunum to avoid redundant or short graft is recommended. We must carefully isolate the pedicle avoiding damaging blood supply. To reduce time of ischemia, jejunal graft pedicle should not be ligated until cervical dissection is completed and we have ruled out if venous graft may be needed. After cervical artery and vein dissection, we ensure adequate blood flow and heparinize vessels before clipping. When dividing the pedicle, artery should be divided before the vein to avoid venous congestion, posteriorly we must heparinize the vessels. Povidone-iodine intraluminal washing is recommended. Jejuno-jejunal anastomosis for GI tract restoration. GI reconstruction first is recommended to avoid unnecessary traction on the vascular anastomosis. After ensuring adequate direction of the jejunal graft jejuno-esophageal anastomosis is performed with interrupted suture. Pharyngo-jejunal anastomosis is performed with barbed 3-0 running suture for anterior and posterior layer. Methylene blue test is performed for check the anastomosis. Vascular reconstruction technique depends on the vascular anatomical variations and availability. In this case, superior thyroid artery and sublingual vein were available. Saphenous vein graft might be needed, this graft must be used in reverse way to avoid the vein valves and length must be adjusted. Venous anastomosis should be performed before than arterial reconstruction after heparinize solution in both vessels to avoid thrombosis. Conclusion Free jejunal graft is a highly complex procedure that must be extremely coordinated and protocolized to avoid longer time of ischemia and risk of thrombosis that might compromise the graft viability. https://1drv.ms/v/s!AmFrct07P6MP1Fbyh_7Ce_OK5bB8?e=OMSjsK

Expeditious management of an unexpected complication of left renal vein ligation during right retroperitoneoscopic simple nephrectomy: A lesson learned the hard way

ABSTRACT We present a case of inadvertent left renal vein clipping during right retroperitoneoscopic nephrectomy (RPN) and describe its expeditious identification and management. A 13-year-old girl underwent RPN for nonfunctioning kidney due to urolithiasis. During the dissection of the right renal vein, the inferior vena cava (IVC) got lifted off the parietal wall and the left renal vein was mistakenly ligated. Based on a strong intra-operative suspicion, the patient underwent an urgent computed tomography angiography which confirmed the ligation of the left renal vein. The patient was reoperated immediately and an end-to-side anastomosis was performed between the left renal vein and the IVC.

Liver Resection Under Total Hepatic Vascular Exclusion with In Situ Hypothermic Isolated Hepatic Perfusion for Advanced Liver Tumors.

Continuous dissection or simultaneous reconstruction of the hepatic vein (HV) and inferior vena cava (IVC) was achieved under total hepatic vascular exclusion (THVE) with in situ hypothermic isolated hepatic perfusion (HIHP) in two cases. CASE 1: The patient previously underwent liver resections with the right HV for colorectal liver metastasis (CRLM). This time, the CRLM had invaded the left HV and IVC, and five courses of FOLFILI plus ramucirumab were given, resulting in stable disease. Due to expected high HV pressure, liver parenchymal transection was started under THVE. Sub-segmentectomy with patch graft plasty of the IVC and reconstruction of the left HV using a jugular vein graft were performed under THVE and HIHP. This patient died at home 3 months after surgery; the cause of death was unknown. CASE 2: Hepatocellular carcinoma in the caudate lobe was in extensive contact with the roots of three main HVs and the IVC, and pressed the hepatocaval confluence, with high HV pressure expected. In addition, tumor thrombosis extended to both the main portal vein and the common bile duct, resulting in the inability to introduce chemotherapy. After tumor thrombectomy, liver parenchymal transection was started under THVE. Extended left hepatectomy with wedge resection, and primary suture of the right HV and IVC was performed under THVE and HIHP. Recurrence-free and overall survivals were 8 months (lung metastasis) and 31 months, respectively. In liver resection for liver tumors located in the hepatocaval confluence, THVE with HIHP is useful for ensuring the safety.

ASO Author Reflections: The Impact of Left Renal Vein Dissection on Renal Function in a Solitary Kidney.

ASO Author Reflections: The Impact of Left Renal Vein Dissection on Renal Function in a Solitary Kidney.

Ratlarda Oluşturulan Renal İskemi Reperfüzyon Hasarında Epibatidinin Etkileri

Objective: The attenuation of renal ischemia reperfusion (I/R) injury by stimulating cholinergic antiinflamatory pathway has been demonstrated in the literature. The purpose of this study is to investigate the protective effects of epibatidine, a non selective nicotinic acethycholine receptor agonist, administered before ischemia on renal ischemia-reperfusion injury. Methods: After Ethics Committee approval, 24 Wistar Albino rats were randomly allocated into 4 groups. Group S: Sham (n=6), Group I/R: Ischemia/reperfusion (n=6), Group I/R-E: Ischemia/ reperfusion-Epibatidine (n=6), Group E: Epibatidine (n=6). All groups underwent laparotomy and bilateral renal artery and vein dissection under anesthesia. No further action was taken in Group S. In Group I/R and Group I/R-E, renal ischemia was applied for 25 minutes and then reperfusion for 24 hours. A single dose of 5 μg kg-1 epibatidine was administered subcutaneously before the laparotomy in Group I/R-E and Group E. At the end of the reperfusion period, blood and urine samples were taken for plasma BUN, creatine, plasma and urinary neutrophil gelatinase associated lipocalin (NGAL) and cystatin C, plasma IL-6 and TNF-α assessment. Results: Plasma BUN, creatine, NGAL, cystatin C, IL-6 and TNF-α levels were significantly higher in Group I/R when compared to Group S (p<0.05). All the levels of the above biomarkers were comparable in Group S and Group I/R-E. Conclusion: These results indicate that epibatidine administration before ischemia has a protective effect on kidney in renal I/R injury induced rats. Keywords: Renal ischemia-reperfusion injury, cholinergic antiinflammatory pathway, n7AchR, epibatidine, NGAL

Quantification of surgical workflow during robotic proctectomy.

Surgical workflow assessments offer insight regarding procedure variability. We utilised an objective method to evaluate workflow during robotic proctectomy (RP). We annotated 31 RPs and used Spearman's correlation to measure the correlation of step time and step visit frequency with console time (CT) and total operative time (TOT). Strong correlations were seen with CT and step times for inferior mesenteric vein dissection and ligation (ρ=0.60, ρ=0.60), lateral-to-medial splenic flexure mobilisation (SFM) (ρ=0.63), left rectal dissection (ρ=0.64) and mesorectal division (ρ=0.71). CT correlated strongly with medial-to-lateral (ρ=0.75) and supracolic SFM visit frequency (ρ=0.65). TOT correlated strongly with initial exposure time (ρ=0.60), and medial-to-lateral (ρ=0.67) and supracolic SFM visit frequency (ρ=0.65). This study correlates surgical steps with CT and TOT through standardised annotation, providing an objective approach to quantify workflow.

Venous cerebral complications after microsurgery for complex aneurysms of the middle cerebral arteries

To evaluate the incidence and types of venous cerebral disorders after microsurgeries for complex MCA aneurysms. A retrospective study included 285 patients with complex MCA aneurysms between 2009 and 2020. Pterional craniotomy and transsylvian approach were used in all cases. Aneurysm clipping was performed in 230 cases, revascularization - 27, trapping without bypass - 17, reinforcement - in 11 cases. Computed tomography within 1-3 days after surgery recognized venous cerebral disorders as heterogeneous foci of abnormal brain density with unclear boundaries. These foci were crescent-shaped as a rule and located in deep and basal parts of the frontal lobes. Venous abnormalities occurred in 76 (26.7%) patients. Thirty-five (12.3%) patients had mild venous edema of the frontal lobe alone. In 35 (12.3%) patients, we found moderate disorders with focus in the frontal lobe and compression of anterior horn of the left lateral ventricle with or without hemorrhagic imbibition. Severe disorders occurred in 6 (2.1%) patients with lesion extending to the frontal, insular and temporal lobes. These lesions were accompanied by hemorrhagic imbibition, and lateral dislocation exceeded 5 mm. Careful dissection of veins in Sylvian fissure with preservation of bridging veins is likely to reduce the risk of this complication. Cauterization of a large vein in Sylvian fissure should be followed by careful hemostasis within frontal or temporal cortex. Bleeding and cortical tension can indicate intracerebral hematoma whose likelihood is higher in patients with venous cerebral disorders.

Valvulotomy of the great saphenous vein in ex situ non-reversed and in situ setting: a multicenter post-market study to assess the safety and efficacy of the AndraValvulotome™”

PurposeTo evaluate the safety and technical success of the AndraValvulotome™ device (Andramed GmbH, Reutlingen, Germany) in patients with peripheral arterial disease (PAD) requiring bypass surgery using the great saphenous vein (GSV) as graft.MethodsThis was a multicenter, post-market observational study conducted in 2021 in 11 German centers. Safety and efficacy data were prospectively collected and analyzed. Primary endpoints were the absence of device-related serious adverse events until 30 ± 7 days follow-up, the clinical efficacy of valvulotomy, which was defined as pulsatile blood flow in the bypass and the number of insufficiently destroyed vein valves. Secondary endpoints were the number of valvulotomy passages, the primary patency rate of the venous bypass (determined by a color-duplex sonography showing a normal blood flow through the bypass and absence of stenosis or occlusion), and the primary technical success defined as the absence of product-specific (serious) adverse events and clinical efficacy.ResultsFifty-nine patients were enrolled. The mean age of the patients was 71 years (46–91), and 74.6% were males. The vein material used for bypass grafting had a median length of 47.5 cm (range 20–70 cm) with a median diameter of 5.0 mm (range 3–6 mm) and 4.0 mm (range 2–6 mm) in the proximal and distal segments, respectively. The technical success rate was 96.6%. The primary patency rate was 89.9% at 30 days follow-up. The clinical efficacy was rated as very good in 81% of patients, fair in 17%, and poor in 2%. Between 1 and 5 (average 2.9) valvulotome passages were performed. One product-related serious adverse event was recorded (bypass vein dissection).ConclusionThe AndraValvulotome™ can be considered a safe and effective device to disrupt venous valves during in situ non-reversed bypass surgeries using GSV grafts in patients with PAD.

Редкий этиологический фактор варикоцеле.

Introduction. Varicocele is detected in 15% of healthy men, in 35% – with primary and in 80% – with secondary infertility. At the moment, microsurgical varicocelectomy by sub-inguinal access is one of the most effective ways to treat varicocele in adult patients. Currently, there is no comprehensive data on the optimal treatment of varicocele recurrence. According to Russian clinical guidelines, testicular vein thrombosis is an extremely rare cause of varicocele development in the practice of a urologist. Material and methods. From November 2018 to February 2023, 118 patients were operated on for varicose veins of the scrotum organs. For all patients with the underlying disease, surgical aid was performed in the amount of micro-surgical subinguinal dissection of the testicular veins from the affected side (sides), or Marmara surgery. Results. The average duration of the operation was 46±11.3 minutes. In all the subjects, the period of hospitalization did not exceed one day. Complications in the postoperative period (according to the Cavien-Dindo scale) were not detected in any of the patients. The severity of the pain syndrome was determined by the VAS scale, and amounted to 0.78 ± 0.6 points. The average dose of non–narcotic analgesics (ketorolac, single dose – 30 mg) was 7.38 ± 3.63 mg. Recurrence of varicocele after microsurgical subinguinal dissection of testicular veins was recorded in 1.7% of patients. Conclusions. Marmara surgery is an effective method of surgical treatment of varicocele in spontaneous thrombosis. Recurrence of varicocele after microsurgical sublingual dissection of the testicular veins was recorded in 1.7% of patients. Spontaneous thrombosis of the branch of the testicular vein is a rare etiological factor of varicocele. The Marmara operation is an effective method of surgical treatment of varicocele with spontaneous thrombosis of the testicular vein.

Comparison of Global Evaluative Assessment of Robotic Surgery with objective performance indicators for the assessment of skill during robotic-assisted thoracic surgery

BackgroundThe Global Evaluative Assessment of Robotic Skills is a popular but ultimately subjective assessment tool in robotic-assisted surgery. An alternative approach is to record system or console events or calculate instrument kinematics to derive objective performance indicators. The aim of this study was to compare these 2 approaches and correlate the Global Evaluative Assessment of Robotic Skills with different types of objective performance indicators during robotic-assisted lobectomy. MethodsVideo, system event, and kinematic data were recorded from the robotic surgical system during left upper lobectomy on a standardized perfused and pulsatile ex vivo porcine heart–lung model. Videos were segmented into steps, and the superior vein dissection was graded independently by 2 blinded expert surgeons with Global Evaluative Assessment of Robotic Skills. Objective performance indicators representing categories for energy use, event data, movement, smoothness, time, and wrist articulation were calculated for the same task and compared to Global Evaluative Assessment of Robotic Skills scores. ResultsVideo and data from 51 cases were analyzed (44 fellows, 7 attendings). Global Evaluative Assessment of Robotic Skills scores were significantly higher for attendings (P < .05), but there was a significant difference in raters’ scores of 31.4% (defined as >20% difference in total score). The interclass correlation was 0.44 for 1 rater and 0.61 for 2 raters. Objective performance indicators correlated with Global Evaluative Assessment of Robotic Skills to varying degrees. The most highly correlated Global Evaluative Assessment of Robotic Skills domain was efficiency. Instrument movement and smoothness were highly correlated among objective performance indicator categories. Of individual objective performance indicators, right-hand median jerk, an objective performance indicator of change of acceleration, had the highest correlation coefficient (0.55). ConclusionThere was a relatively poor overall correlation between the Global Evaluative Assessment of Robotic Skills and objective performance indicators. However, both appear strongly correlated for certain metrics such as efficiency and smoothness. Objective performance indicators may be a potentially more quantitative and granular approach to assessing skill, given that they can be calculated mathematically and automatically without subjective interpretation.

484. ROBOTIC ASSISTED PRONE ESOPHAGECTOMY USING VERSIUS PLATFORM: A PROMISING APPROACH

Abstract Background Esophagectomy for cancer is a complex procedure with high morbidity. Minimally invasive approach offers the benefits of minimal access across the different fields required during this operation. Robotic surgery is becoming an integral part of modern practice. It holds the potential of more precision especially in narrow thoracic space. Currently, Many Robotic platforms exist. This video aims to demonstrate the feasibility of Robotic Mc Keown esophagectomy in the prone position using Versius platform. Methods 56 years old male patient presented with grade I dysphagia of 3 months duration. His complete assessment revealed an 11 cm long invasive non keratinizing squamous cell carcinoma located in the mid esophagus (cT3N1M0). Marked regressive course of the lesion occurred with neoadjuvant chemoradiation. Robotic assisted Mc Keown esophagectomy was performed in the prone position. Thoracic phase was performed with the robotic approach. Bed side units and Port placement is illustrated in the video. The abdominal phase was accomplished laparoscopically. Finally, the stomach was pulled up and the esophagogastric anastomosis was done in the neck. Results No intraoperative adverse events were encountered. The improved vision, dexterity and articulation of instruments facilitated the identification of the thoracic duct, ligation of azygos vein tributaries and dissection of the recurrent laryngeal lymph nodes. Instrument clash was insignificant due to patient’s wide chest cavity and optimal positioning of ports and bed side units improving ergonomics. The operative time of the thoracic phase was 310 min. Blood loss was 300 mL. The postoperative course was uneventful except for chest infection which improved on conservative measures. The length of stay was 18 days. Pathology revealed complete clinical response with 0/25 lymph node yield. Conclusion Robotic assisted esophagectomy is feasible and can be safely performed using Versius robotic platform. The enhanced visualization and articulation enabled meticulous dissection of the recurrent laryngeal lymph nodes. Patient positioning, optimal port and bed side units placement were keys to achieving minimal instrument clash. Further research is needed to confirm these findings and to compare the long-term oncological outcomes and cost effectiveness of this modality. Video links: https://we.tl/t-rpkTHvNlXI or https://drive.google.com/drive/folders/1tOsFPrEBUHBpVn8C9jF7BGoNxlYPuBjq?usp=sharing.

Artificial Intelligence in Minimally Invasive Adrenalectomy: Using Deep Learning to Identify the Left Adrenal Vein.

Minimally invasive adrenalectomy is the main surgical treatment option for the resection of adrenal masses. Recognition and ligation of adrenal veins are critical parts of adrenal surgery. The utilization of artificial intelligence and deep learning algorithms to identify anatomic structures during laparoscopic and robot-assisted surgery can be used to provide real-time guidance. In this experimental feasibility study, intraoperative videos of patients who underwent minimally invasive transabdominal left adrenalectomy procedures between 2011 and 2022 in a tertiary endocrine referral center were retrospectively analyzed and used to develop an artificial intelligence model. Semantic segmentation of the left adrenal vein with deep learning was performed. To train a model, 50 random images per patient were captured during the identification and dissection of the left adrenal vein. A randomly selected 70% of data was used to train models while 15% for testing and 15% for validation with 3 efficient stage-wise feature pyramid networks (ESFPNet). Dice similarity coefficient (DSC) and intersection over union scores were used to evaluate segmentation accuracy. A total of 40 videos were analyzed. Annotation of the left adrenal vein was performed in 2000 images. The segmentation network training on 1400 images was used to identify the left adrenal vein in 300 test images. The mean DSC and sensitivity for the highest scoring efficient stage-wise feature pyramid network B-2 network were 0.77 (±0.16 SD) and 0.82 (±0.15 SD), respectively, while the maximum DSC was 0.93, suggesting a successful prediction of anatomy. Deep learning algorithms can predict the left adrenal vein anatomy with high performance and can potentially be utilized to identify critical anatomy during adrenal surgery and provide real-time guidance in the near future.

Application Value of Artificial Intelligence-assisted Three-dimensional Reconstruction in Planning Thoracoscopic Segmentectomy

The three-dimensional (3D) can assist in planning lung segmentectomy. 3D reconstruction software based on artificial intelligence algorithm is gradually applied in clinic. The aim of this study was to evaluate the accuracy and safety of 3D reconstruction assisted planning of thoracoscopic segmentectomy. A total of 90 patients admitted to Department of Thoracic Surgery of Lanzhou University Second Hospital were evaluated for thoracoscopic segmentectomy. Before operation, artificial intelligence 3D reconstruction software was used to make 3D lung images and conduct preoperative planning. Surgical videos were saved during the operation and perioperative data were recorded. Video recordings of 38 patients were selected to explore the effectiveness of artificial intelligence 3D reconstruction for surgical planning. The results of artificial intelligence 3D reconstruction and Mimics 21 software reconstruction were compared with the actual results in the operation, and the detection and classification ability of bronchus and blood vessels of the two reconstruction methods were compared. All the 90 patients underwent artificial intelligence 3D reconstruction planning, including 57 patients (63.3%) with single lung segmentectomy and 33 patients (36.7%) with combined sub-segmentectomy. The accuracy of artificial intelligence 3D reconstruction for lesion localization was 100.0%, and the accuracy of computed tomography (CT) was 94.4% (85/90). The detection accuracy of artificial intelligence 3D reconstruction and Mimics 21 software was 92.1% (35/38) and 89.5% (34/38), and the anatomic typing accuracy was 89.5% (34/38) and 84.2% (32/38), and the total accuracy was 76.3% (29/38) and 71.1% (27/38). In the comparative observation of 38 surgical videos and reconstructed images, the consistent rates of target segment planning, surgical approach, artery dissection, vein dissection and bronchial dissection for preoperative planning using artificial intelligence 3D reconstruction were 92.1% (35/38), 92.1% (35/38), 89.5% (34/38), 86.8% (33/38) and 94.7% (36/38). The overall planning operational consistency rate was 68.4% (26/38). It is accurate and safe to use artificial intelligence 3D reconstruction to assist planning thoracoscopic segmentectomy.

A novel approach to quantifying surgical workflow in robotic-assisted lobectomy.

Understanding surgical workflow is critical for optimizing efficiencies and outcomes; however, most research evaluating workflow is impacted by observer subjectivity, limiting its reproducibility, scalability, and actionability. To address this, we developed a novel approach to quantitatively describe workflow within robotic-assisted lobectomy (RL). We demonstrate the utility of this approach by analysing features of surgical workflow that correlate with procedure duration. RL was deconstructed into 12 tasks by expert thoracic surgeons. Task start and stop times were annotated across videos of 10 upper RLs (5 right and 5 left). Markov Networks were used to estimate both the likelihood of transitioning from one task to another and each task-transition entropy (i.e. complexity). Associations between the frequency with which each task was revisited intraoperatively and procedure duration were assessed using Pearson's correlation coefficient. Entropy calculations identified fissure dissection and hilar node dissection as tasks with especially complex transitions, while mediastinal lymph node dissection and division of pulmonary veins were less complex. The number of transitions to three tasks significantly correlated with case duration (fissure dissection (R=0.69, p=0.01), dissect arteries (R=0.59, p=0.03), and divide arteries (R=0.63, p=0.03)). This pilot demonstrates the feasibility of objectively quantifying workflow between RL tasks and introduces entropy as a new metric of task-transition complexity. These innovative measures of surgical workflow enable detailed characterization of a given surgery and might indicate behaviour that impacts case progression. We discuss how these measures can serve as a foundation and be combined with relevant clinical information to better understand factors influencing surgical inefficiency.

Step-wise ligation of hilum vs mass ligation during lobectomy of the lung- is it time for a change?

The standard technique for lobectomy followed now is using the superior hilar approach and the bronchus first technique, where the pulmonary artery (PA) vessels are first divided. However, there are certain scenarios where adhesions or extensive lymphadenopathy at the hilum have distorted the vessels. Also, in case of tumors and fistulae, the bronchus and vessels may be in close proximity. Hence, it may be necessary to perform a mass ligation of the hilar structures. The separate dissection of the lobe's vein, artery, and airway forms the basis of lobectomy. The anterior approach, often known as the anterior mediastinum, is currently the most common. To our knowledge, there is limited data to compare the outcomes of step-wise ligation with mass ligation at the hilum for lobectomy. Hence we performed this study where we compared the step-wise with mass ligation of hilar structures during a lobectomy.

Self-taught ultrasound-guided axillary vein access for pacemaker implantations - complication rates and outcomes

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiac implantable electronic devices (CIEDs) are the mainstream therapy for advanced atrioventricular block or sustained ventricular arrhythmia. EHRA survey (1) showed that cephalic vein dissection and blind subclavian vein puncture are the preferred techniques for the implantation of CIED leads in European centres. Ultrasound (US) guided axillary puncture has emerged as feasible alternative for safe and rapid venous access for lead implantation. However, insufficient evidence to support its widespread adoption. Aim To compare the complication rates and clinical outcomes of CIED implantations utilising self-taught US guided axillary puncture versus non-US guided venous access (Subclavian puncture and fluroscopy guided axillary puncture). Assess the mean time to gain venous access and overall success rate in US guided technique. Methods Retrospective , observational study across two sites involving all CIED implantations of four experienced implanters over the year from January 2021 - June 2022. Patient's demographics, venous access time, complications and clinical outcomes were extracted from electronic database. US axillary access technique was self-taught. Results and Outcomes Venous access was obtained by US Guided axillary puncture in 146 patients, non-US guided in 208 patients. Successful axillary venous access by ultrasound guidance is 97%(146/151) with mean time to venous access of 2.1 minutes. Baseline demographics (age, gender) and comorbidities (hypertension, diabetes, cardiomyopathy, coronary artery disease, dyslipidemia, renal failure, oral steroid use, nicotine use) were similar between both US-guide and non-US guided groups, usage of oral anticoagulations (32.9% vs 39.4%,p=0.208) and antiplatelet agents(28.1% vs 35.1%,p=0.164) were not statistically different. Greater proportion of dual chamber pacemakers were implanted in US guided access group versus non-US guided (39.7% vs 27.9%,p=0.015). US Guided axillary access resulted in lower overall complication rate (2.1% vs 8.9%, p=0.0196): lower risk of pneumothorax (0% vs 3.8%,p=0.0236), lower risk of haemathoma (0% vs 3.4%,p=0.0448). No difference in short term pocket/lead infection or lead displacement. Severe vascular complications remains low in both groups. Stepwise binary regression analysis demonstrated US guidance as independent predictor of lower overall complication rate, odd-ratio 0.195 (95% CI 0.054 - 0.706). Summary: This multi-centered, retospective observational study demonstrated that US guided axillary access has high overall success rate, not time consuming and resulted in lower complication rates (especially pneumothorax and pocket haemathoma), despite the US access technique being self-taught and have greater proportion of dual chamber device implantations. US guided axillary access is demonstrated to be independently associated with 5-fold lower risk of complications.

Portal Vein Pull-Through Technique and Thrombectomy for Extensive Portal Vein Thrombosis

Herein, a different technique is presented describing complete dissection of the entire portal vein (PV), superior mesenteric vein (SMV), and splenic vein, thus enabling a complete thrombectomy without the risk of uncontrolled hemorrhage due to blind thrombectomy. In cases where a thrombectomy would not be an option because of extensive thrombosis involving the confluence of the PV and SMV, small branches of the SMV, including the inferior mesenteric vein, were divided. Both the SMV and splenic vein were encircled separately. Then, the side branches of the PV above the pancreas, left gastric vein on the left side, and superior pancreatoduodenal vein on the right side were divided. The lateral and posterior part of the PV were dissected within the pancreas both from above and below, allowing the main PV completely free from attachments. At this point, the splenic vein and SMV were clamped, and the main PV was divided above the pancreas and then pulled back through the pancreatic tunnel. The thrombus was easily dissected of the vein under direct visualization, and afterward the PV was redirected to its original position. Then, the liver transplant was carried out in a regular fashion. This technique was applied to 2 patients. The first was a 43-year-old man who underwent a right lobe living donor liver transplant because of hepatitis B virus-related cirrhosis. The patient is still alive and well with stable liver function after 15 years of follow-up. The second was a 69-year-old woman who underwent a right lobe living donor liver transplant because of hepatitis C virus and hepatocellular carcinoma. She survived the procedure and her liver function was entirely normal afterward. She died of pneumonia and sepsis 5 months after transplant. This technique enables complete dissection of the entire PV, SMV, and splenic vein. Thus, complete thrombectomy under direct visualization without the risk of uncontrolled hemorrhage can be performed.

Management of a Large Endometriotic Nodule of the Right Parametrium Involving the Sacral Roots, Vagina, Rectum, and Sigmoid Colon, with Intraoperative Bleeding

Deep endometriotic lesions may involve the deep parametrium which is highly vascular and includes numerous somatic and autonomous nerves (1,2). Surgeons who dissect in this area, must always be prepared to deal with major bleeding, and to master the different techniques of hemostasis. The goal of this video is to show the steps of laparoscopic excision of deep endometriotic lesion of the parametrium and the steps taken to control the bleeding encountered from one of the venous branches. Surgical educational video. Endometriosis referral center. Excision of the endometriotic parametrial nodule and the release of the sacral plexus, with excision of the vaginal involvement, rectal disc excision, and segmental resection of the sigmoid colon. The video shows the excision of a deep endometriosis involving the right parametrium, the mid rectum, the sigmoid colon, and the vagina. The excision of deep endometriosis of the parametrium followed the 10 steps previously described (1). During this procedure, careful dissection of arteries and veins branching from the internal iliac vessels is a crucial step. However, injury of one or more of the vessels can still occur. The movie presents the different techniques used to control the bleeding from a venous injury faced during the dissection around the nodule in the parametrium, including energy use, clips, hem-o-loks, and direct continuous pressure. Of note, hemostatic agents are available, however we have not yet successfully employed them in these circumstances in which large veins were injured. The ultimate solution in our case was the clamping of the injured vessels, allowing meticulous dissection and sectioning of all the feeding vessels, while taking care not to injure the sacral roots which were just beneath these veins. Total operative time was 4 hours. Surgery of deep endometriosis involving the sacral plexus may be successfully done laparoscopically. Thorough knowledge of the deep pelvis anatomy is mandatory, and the surgeon should master various techniques of hemostasis, particularly on deep veins.