Division Of Vessels Research Articles

Combined Division of the Splenic Vessels and Pancreatic Parenchyma during Laparoscopic Distal Pancreatectomy is a Safe Alternative to Separate Division: A Single-Institution Retrospective Study

BackgroundLimited data exists regarding the safety and outcomes of combined division of the splenic vessels with the pancreatic parenchyma during laparoscopic distal pancreatectomy (LDP). This study aims to evaluate the combined division technique. MethodsPatients who underwent LDP for pancreatic cancer from April 2011 to December 2022 were reviewed and categorized into the following groups: combined (CV) versus separate (SV) division of the splenic vein; combined (CA) versus separate (SA) division of the splenic artery; and combined (CAV) versus separate (SAV) division of the splenic artery and vein, with or without the pancreatic parenchyma. Comparisons were made regarding operative and postoperative outcomes. ResultsAmong the 80 patients included, 44 underwent CV and 36 underwent SV. Operative time and major morbidity were significantly lower in CV compared with SV. Similar findings were observed in CAV versus SAV, as well as lower blood loss in CAV. Operative time was significantly lower in CA versus SA. Pancreatic fistula and postpancreatectomy hemorrhage rates showed no significant differences between groups. No patient developed splenic arteriovenous fistula in follow-up. DiscussionCombined division of the splenic vessels with the pancreatic parenchyma during LDP is safe and associated with improved outcomes compared with separate division.

Perioperative Outcomes Related to Thoracic and Lumbar Spine Exposure During Vertebral Body Tethering for Adolescent Idiopathic Scoliosis: A Large, Single-Institution Retrospective Review

BackgroundVertebral body tethering (VBT) is a novel non-fusion technique for the management of scoliosis. Despite growing popularity, data concerning complications and thoracic surgery-related outcomes are lacking. MethodsA single-institution retrospective review was conducted of patients who underwent VBT with video-assisted thoracic surgical exposure from 1/1/2015-3/1/2022. Data obtained included demographics, comorbidities, hospital course, and outcomes. Results106 patients (81% female) were identified with a mean age at surgery of 12.7±1.5 (range 9-16). Most patients underwent single curve tethering (n=93, 87.7%) with a mean number of vertebral bodies tethered of 8.0 (range 5-13). The mean operative time was 236±96 minutes (range 129-661) minutes with an estimated blood loss of 165±143 mL (range 20-750) and no patients required allogeneic blood transfusion. The extent of tethering was significantly associated with increased operative time, fluids received, and chest tube output. Excluding instrument-related complications, the complication rate was 13.2%, mostly occurring within the first 30 days after surgery and pleural effusion being the most common event. Two patients experienced a postoperative hemothorax requiring reoperation. No patients experienced sequelae of spinal cord ischemia secondary to the division of intercostal and/or lumbar vessels during surgical exposure and no deaths occurred. ConclusionVBT is a seemingly safe alternative to spinal fusion in skeletally immature adolescents, however, there are notable complications of this procedure related to thoracic exposure. Our experience indicates clinically significant pulmonary complications are uncommon and the extent of vertebral body exposure/tethering was strongly associated with operative duration, fluids, and chest tube output. Levels of EvidenceThis original article represents a treatment study of Level IV evidence.

438. TECHNIQUE OF COMPLETELY ROBOTIC MCKEOWN (3-HOLE) ESOPHAGECTOMY WITH INTRA-CORPOREAL GASTRIC CONDUIT CREATION, AND CERVICAL ESOPHAGO-GASTRIC ANASTOMOSIS FOR MID-ESOPHAGEAL ADENOCARCINOMA

Abstract Background Esophageal cancer is the 7th leading cause of cancer deaths, with an estimated total case of 22,370 in both males and females in 2024. Adenocarcinoma and squamous cell carcinoma account for over 90% of histology at diagnosis. The incidence of adenocarcinoma continues to rise due to the rising incidence and prevalence of obesity, gastro-esophageal reflux disease and Barrett's esophagus. Multi-modality treatment is currently the standard of care for locally advanced disease. This consists of neoadjuvant concurrent chemotherapy and radiation therapy, followed by esophagectomy. Minimally invasive approaches to esophagectomy are associated with decreased post-operative morbidities and overall satisfactory outcomes. While the Ivor Lewis esophagectomy with intra-thoracic anastomosis is the most common surgical approach to resection of distal esophageal and gastroesophageal (GE) junction tumors, the McKeown (3-hole) esophagectomy with cervical esophago-gastric anastomosis is best suited for tumors located in the proximal and mid-esophagus. Methods We describe our technique of robotic McKeown (3-hole) esophagectomy for mid-esophageal adenocarcinoma after neoadjuvant concurrent chemo-radiation therapy for clinical stage uT3N0M0 tumor. The thoracic esophagus is completely mobilized from the esophageal hiatus of the diaphragm up to the thoracic inlet via a right thoracoscopic approach, with harvesting of the regional lymph nodes together with the specimen. The left neck incision is made along the anterior border of the sternocleidomastoid muscle and the inferior belly of the omohyoid muscle is transected. The cervical esophagus is then completely mobilized into the wound and secured using a Penrose drain. Using a laparoscopic approach, the entire stomach is mobilized with division of the left gastric vessels but careful preservation of the right gastro-epiploic arcade while transecting the greater omentum and the short gastric vessels. An intra-corporeal creation of the gastric conduit then follows. The gastric conduit, secured to the proximal stomach at the resection staple line, is subsequently tunneled via the esophageal hiatus and through the mediastinum to exit at the left neck incision by applying traction on the cervical esophagus. The specimen is separated from the conduit, and the cervical esophagus is transected at the desired location for the anastomosis. A stapled end-to-side but functional end-to-end esophago-gastric anastomosis (Orringer's technique) is then created. Results A completely robotic technique of McKeown (3-hole) esophagectomy without the need to exteriorize the stomach to fashion the gastric conduit via a (mini)laparotomy is successfully accomplished in the majority of our patients with proximal or mid-esophageal tumors. An uneventful postoperative recovery was made. Fluoroscopic esophagram on post-operative day 5 did not demonstrate leakage from the anastomotic site. Gastric conduit emptying was satisfactory despite the lack of a routine gastric drainage procedure or injection of botulinum toxin into the pyloric ring. Conclusion Robotic-assisted thoracoscopic esophageal mobilization combined with laparoscopic completely intra-corporeal fashioning of gastric conduit with cervical esophago-gastric anastomosis is a technically feasible minimally invasive approach to performing McKeown esophagectomy with satisfactory post-operative outcomes and conduit functioning. https://www.dropbox.com/scl/fi/gzc1vzdzhzqn7niz95b8t/Robotic-McKeown-Esophagectomy-Video-3.mp4?rlkey=c4ja7s1aob10ah6ps500z7y29&dl=0

Division of the iliac vessels in the anterior intrapelvic approach to acetabular fracture

IntroductionThe modified Stoppa approach is gradually becoming the gold standard in pelvic ring and acetabulum surgery. One of the potential intraoperative complications is vascular injury. The aim of this study was to identify the level of division of common iliac vessels with respect to a bone landmark, their inter-individual variability and their correlation with morphological criteria. Material and methodsThis was a single-center continuous retrospective study of patients who had preoperative CT angiography for pelvic fracture between February 2017 and May 2018. The level of arterial and venous division and the angle of vein division were measured bilaterally for each patient from the most antero-inferior part of the sacroiliac joint on multiplanar reconstruction and standardized analysis. Relationships with morphological data (age, gender, BMI, height), anterior column fracture and deep venous thrombosis were analyzed. ResultsThe right arterial division level was 50±16mm (−2.35; 96) from the landmark and the left arterial division level 44±14mm (0; 80). The right venous division level was 30±12mm (−9; 75) and the left venous division level 30±13mm (−5; 66). The right venous bifurcation angle was 65±18° (22; 119) and the left venous bifurcation angle 68±17° (18; 117). The arterial division level was significantly higher on the right side (p=0.007). There were no significant correlations with morphological data. ConclusionThe great inter-individual variability of iliac vessels should prompt analysis of their morphology on routine imaging when planning pelvic surgery using the modified Stoppa approach, in order to anticipate the risk of bleeding. Level of evidenceIV; cases series.

Laparascopic management of non-palpable testis

We present a new approach to high intraabdominal testis (IAT) for elongation of the testicular vessels without division. The technique entails fixation of the testis to a point one inch above and medial to the contralateral anterior superior iliac spine for 12 weeks. Subdartos orchiopexy is then done as the second stage. Both stages are laparoscopically assisted. The a new approach to high intraabdominal testis, two-stage laparoscopic traction-orchiopexy, is useful and resulted in significant elongation of the testicular vessels without atrophy. It is a safe and valid alternative to the two-stage laparoscopic Fowler–Stephens technique, which entails division of the main testicular vessels.

Commentary to Staged laparoscopic orchiopexy of intra-abdominal testis: Spermatic vessels division versus traction? a multicentric comparative study

Commentary to Staged laparoscopic orchiopexy of intra-abdominal testis: Spermatic vessels division versus traction? a multicentric comparative study

Response to commentary on: Staged laparoscopic orchiopexy of intra-abdominal testis: Spermatic vessels division Vs traction? a multicentric comparative study

Response to commentary on: Staged laparoscopic orchiopexy of intra-abdominal testis: Spermatic vessels division Vs traction? a multicentric comparative study

Combined Division of the splenic vessels and pancreatic parenchyma is a safe alternative to separate division: a Single-Institution Retrospective Study

Combined Division of the splenic vessels and pancreatic parenchyma is a safe alternative to separate division: a Single-Institution Retrospective Study

Evidence mapping on how to perform an optimal surgical repair of large hiatal hernias

BackgroundSymptomatic and large hiatal hernia (HH) is a common disorder requiring surgical management. However, there is a lack of systematic, evidence-based recommendations summarizing recent reviews on surgical treatment of symptomatic HH. Therefore, this systematic review aimed to create evidence mapping on the key technical issues of HH repair based on the highest available evidence.MethodsA systematic review identified studies on eight key issues of large symptomatic HH repair. The literature was screened for the highest level of evidence (LE from level 1 to 5) according to the Oxford Center for evidence-based medicine’s scale. For each topic, only studies of the highest available level of evidence were considered.ResultsOut of the 28.783 studies matching the keyword algorithm, 47 were considered. The following recommendations could be deduced: minimally invasive surgery is the recommended approach (LE 1a); a complete hernia sac dissection should be considered (LE 3b); extensive division of short gastric vessels cannot be recommended; however, limited dissection of the most upper vessels may be helpful for a floppy fundoplication (LE 1a); vagus nerve should be preserved (LE 3b); a dorso-ventral cruroplasty is recommended (LE 1b); routine fundoplication should be considered to prevent postoperative gastroesophageal reflux (LE 2b); posterior partial fundoplication should be favored over other forms of fundoplication (LE 1a); mesh augmentation is indicated in large HH with paraesophageal involvement (LE 1a).ConclusionThe current evidence mapping is a reasonable instrument based on the best evidence available to guide surgeons in determining optimal symptomatic and large HH repair.

IBC-Oxford University2023_BJSOral_20Video Presentation: Fundectomy and Indocyanine green fluorescence angiography in revisional laparoscopic Roux-en-Y gastric bypass

Abstract Introduction Revisional bariatric procedures are increasingly prevalent. These procedures are more complex with higher risk of complications as compared to primary procedures. The potential indications for revisional laparoscopic gastric bypass (R-LRYGB) may include weight regain and gastroesophageal reflux disease (GORD). This video abstract presents role of fundectomy and Indocyanine green fluorescence angiography (ICG-FA) for perfusion assessment of gastric pouch in R-LRYGB. Methods and Operative technique A 40-year-old female with previous laparoscopic adjustable gastric band (LAGB) surgery underwent R-LRYGB procedure following approval at bariatric multidisciplinary team meeting. LAGB was removed due to band slippage and chronic pouch dilatation, 2 years prior to the revisional procedure. Preoperative BMI was 53 kg/m2. Pre-operative upper gastrointestinal endoscopy was normal. The operative technique included dissection of angle of His, access into lesser sac along lesser curve below 2nd vessel off left gastric artery (LGA) and division of short gastric vessels to gain access to leaser sac from lateral aspect. The stomach was divided horizontally with linear stapler (EndoGIA 60 Gold cartridge), level with second vessel off LGA followed by creation of vertical gastric pouch over a size 34 Oro-gastric tube, that included excision of gastric fundus. ICG was administered intravenously according to an agreed protocol for the study. Karl Storz Image1 STM Rubina system with overlay and monochromatic modes was used for perfusion assessment. ICG-FA was utilised for qualitative assessment of gastric pouch perfusion before and after linear stapled gastro-jejunal anastomosis. Results Operative time was 240 minutes. Adhesions were encountered in the lesser sac at the site of previous LAGB. Fundectomy allowed better visualisation of lesser sac, adhesiolysis and facilitated creation of gastric pouch. ICG perfusion of gastric pouch was satisfactory. The postoperative length of stay was 2 days. There were nopostoperative complications at 6 months follow-up. The patient achieved 42% excess weight loss (BMI 43) over 6 months period. Conclusions Fundectomy is a safe and feasible operative step in R-LRYGB in patients with previous primary LAGB. ICG-FA is a promising qualitative assessment tool in revisional bariatric procedures.

Techniques of staged laparoscopic orchidopexy for high intra-abdominal testes in children: A systematic review and meta-analysis.

Laparoscopic exploration is currently considered the gold standard for managing nonpalpable intraabdominal testes. The problem of short vascular pedicle is addressed in Fowler-Stephen (FS) technique by the division of testicular vessels and in Shehata technique (ST) by traction on testicular vessels. There is a lack of the consensus among pediatric surgeons on the choice of one technique over other. This analysis compares the reported outcomes of staged laparoscopic orchidopexy by ST with the time tested FS technique in managing high intraabdominal undescended testis. The present systematic review and meta-analysis was conducted as per the preferred reporting items for the systematic review and meta-analyses guidelines. Only randomized controlled trials and comparative studies were included. The primary outcomes compared were the incidence of testicular atrophy, testicular retraction/ascent rate, and operative time of Stage I and Stage II orchidopexy. The present analysis was based on three randomized studies with a total of 119 undescended testes in 117 patients satisfying the inclusion criteria. The operative time was less in Stage I FS technique; however, there was no statistically significant difference in operative time of both procedures during the Stage II laparoscopic orchidopexy. Pooled analysis of postintervention testicular atrophy, testicular retraction rate, and duration of postoperative hospitalization showed no difference between both procedures. Both FS and STs are comparable in terms of postintervention testicular atrophy, testicular retraction/ascent; however, the mean operative time is significantly less with FS technique in Stage I laparoscopic orchidopexy.

Reconstruction of the Flexor Pollicis Longus Tendon with Vascularized Tendon with Ulnar Artery Preservation.

The flexor digitorum superficialis and its gliding tissue were transferred in five patients, based on a branch of the ulnar artery without division of the ulnar vessels. Functional results were evaluated using a total active range of motion and Buck-Gramko score at 10 months by an independent hand therapist. The mean total active motion of the interphalangeal joint was 49 degrees, with a Buck-Gramko score of excellent in three cases and good in two. No complications were recorded. Reconstruction of the flexor pollicis longus tendon with single-staged vascularized FDS transfer without ulnar artery division yielded good results in a small cohort of five cases.

Lymphocele in Kidney Transplantation: A Comparison of Ligation and Non-ligation Technique of Iliac Lymphatic Dissection

To compare the incidence of lymphocele in kidney recipients following 2 lymphatic vessel division techniques: ligation and non-ligation. Retrospective reviews of the records of 402 patients with end-stage renal disease who underwent kidney transplantation from April 2015 to December 2019 at Siriraj Hospital. Four hundred two patients were included in the study: 54.9% of the patients were male, and the patient's mean age was 41 years. There were 25.1% and 74.9% that received kidney grafts from living and deceased donors, respectively. The preoperative renal replacement therapies were 83.3% hemodialysis, 12.9% peritoneal dialysis, and 3.7% preemptive transplantation. Two hundred forty-nine patients received lymphatic division with the ligation technique and 153 patients received the non-ligation. Lymphoceles were found in 31 cases (7.7%). Lymphocele occurrence in the ligation group was lower than in the non-ligation group: 5.2% compared to 11.8% (P value=.017). There were 22.6% of lymphoceles that had a spontaneous resolution with no treatment. The ligation of iliac lymphatic vessels during division reduced the incidence of lymphoceles non-ligation.

312.9: Mathematical Modelling to Determine Segment Perfusion Parameters for Living Donor Liver Transplantation

Introduction: Adult-to-Adult Living Donor Liver Transplantation (A2ALL-1) Cohort Study focused on hepatic blood flow and effect of portal modulation in smaller and left lobe grafts demonstrating a significantly (p = 0.03) higher graft dysfunction in modulated recipients versus unmodulated. The study concluded the need for prespecified portal flow and hepatic venous outflow modulation protocols to better define outcomes of volumetric interventions. We developed a mathematical model of the liver to determine hemodynamic parameters across segments following simulated liver resections and middle hepatic vein interventions in both the remnant donor liver and recipient grafts to predict functional graft outcomes prior to reperfusion. Methods: Arterial/portal/hepatic vein and terminal portal triad diameters from 12 deceased donor livers and biopsies were used in a custom lumped parameter model developed in MATLAB {Fig(a)}. Blood flow is modeled using the Hagen-Poiseuille equation, and the continuity equation is solved to obtain volume flow rate of the whole liver at every point throughout the network {Fig(b)}. Simulated right hepatectomy in the plane of resection shown in Fig(a) is used to derive variations in blood flow and volume through the modeled left liver lobe {Fig(c)}.Results: Schematic illustrations of the modeling components of liver segments demonstrate volume flow rate encoded in pseudocolor mapping in the donor liver before and after right hepatectomy {Fig(b&c)}. Localized increase in blood flow through 2nd and 3rd generations of vessel division is especially apparent in the donor’s simulated remnant left lobe {Fig(c)}. Volume and flow rate alterations in hepatic venous outflow following ligation/reconstruction of middle hepatic veins in the remnant left lobe is evident. Perfusion parameters in the donor graft are also captured to simulate graft perfusion prior to reperfusion in the recipient. Conclusion: Surgical intervention on the middle hepatic vein (MHV) is critical for donor remnant liver outflow and optimal perfusion in the donor graft. Mathematical simulations to predict hemodynamic inflow – outflow parameters in living donor liver transplantation could help guide MHV ligation and reconstruction as well as predict graft perfusion parameters prior to reperfusion.

Comparison of the Behavior of Perivascular Cells (Pericytes and CD34+ Stromal Cell/Telocytes) in Sprouting and Intussusceptive Angiogenesis.

Perivascular cells in the pericytic microvasculature, pericytes and CD34+ stromal cells/telocytes (CD34+SCs/TCs), have an important role in angiogenesis. We compare the behavior of these cells depending on whether the growth of endothelial cells (ECs) from the pre-existing microvasculature is toward the interstitium with vascular bud and neovessel formation (sprouting angiogenesis) or toward the vascular lumen with intravascular pillar development and vessel division (intussusceptive angiogenesis). Detachment from the vascular wall, mobilization, proliferation, recruitment, and differentiation of pericytes and CD34+SCs/TCs, as well as associated changes in vessel permeability and functionality, and modifications of the extracellular matrix are more intense, longer lasting over time, and with a greater energy cost in sprouting angiogenesis than in intussusceptive angiogenesis, in which some of the aforementioned events do not occur or are compensated for by others (e.g., sparse EC and pericyte proliferation by cell elongation and thinning). The governing mechanisms involve cell–cell contacts (e.g., peg-and-socket junctions between pericytes and ECs), multiple autocrine and paracrine signaling molecules and pathways (e.g., vascular endothelial growth factor, platelet-derived growth factor, angiopoietins, transforming growth factor B, ephrins, semaphorins, and metalloproteinases), and other factors (e.g., hypoxia, vascular patency, and blood flow). Pericytes participate in vessel development, stabilization, maturation and regression in sprouting angiogenesis, and in interstitial tissue structure formation of the pillar core in intussusceptive angiogenesis. In sprouting angiogenesis, proliferating perivascular CD34+SCs/TCs are an important source of stromal cells during repair through granulation tissue formation and of cancer-associated fibroblasts (CAFs) in tumors. Conversely, CD34+SCs/TCs have less participation as precursor cells in intussusceptive angiogenesis. The dysfunction of these mechanisms is involved in several diseases, including neoplasms, with therapeutic implications.

Splenic Ischemia in Adolescent Sleeve Gastrectomy.

With rising childhood obesity rates, the sleeve gastrectomy (SG) is the most common bariatric surgery procedure. This surgical technique may result in ischemia to the upper pole of the spleen. While generally self-limiting, splenic ischemia may have similar postoperative symptoms to more severe complications. We retrospectively reviewed 142 surgical videos and medical records from adolescents at our center who underwent SG from 2010 through 2018. The videos were evaluated for splenic ischemia and for the presence of separate segmental polar accessory vessels. The medical records were reviewed for postoperative symptoms of left shoulder pain, fever, leukocytosis, and tachycardia. We found a 31% incidence of splenic ischemia in the cases reviewed. We identified division of segmental vessels to the upper pole as increasing the relative risk of splenic ischemia by 2.3 (p = 0.0055). Immediate ischemic changes noted in the upper pole of the spleen did not correlate with any postoperative symptoms or complications. The incidence of splenic ischemia during an SG in our adolescent population was higher than in other reports. Division of separate polar vessels increased the incidence of localized splenic ischemia. Our findings suggest that splenic ischemia is incidental during an SG in adolescents and does not manifest any clinical significance.

Laparoscopic Right Hemicolectomy With Complete Mesocolic Excision and Central Vascular Ligation Using a Right Colon Rotation Technique (Flip-Flap Method).

Background: Laparoscopic right hemicolectomy (Lap-RHC) with complete mesocolic excision (CME) and central vascular ligation (CVL) is technically challenging. A standardized procedure is thus needed to minimize technical hazards. Technique: We have developed the "flip-flap method," comprising repeated inversion and restoration of the mobilized right colon according to the anatomical complexity and vascularity in Lap-RHC, and showed that this technique is safe, feasible, and useful in terms of CME and CVL. Our study included 30 consecutive patients who underwent Lap-RHC using the flip-flap method between April 2018 and December 2020. The short-term surgical outcomes suggested this method was safe and feasible. We report herein the surgical procedure for this flip-flap method. The hepatic flexure is mobilized, then the ileocecal vessels are divided, and the cecum is separated from the retroperitoneal space. The mobilized right colon is rotated to the left of the superior mesenteric vein, continuing to separate the mesentery from right to left, and the right colic vessels are divided. If division of the right colic vessels is technically difficult, the inverted right colon is restored to its original position, and the right colon vessels are divided. Finally, the transverse mesenteric fat is dissected along the left edge of the superior mesenteric artery to the inferior border of the pancreas. Conclusions: We consider that the most useful point of this technique is the ability to develop an optimal operative field according to the anatomical complexity and vascularity of the individual, securing CME without unexpected bleeding or damage to other organs.

Use of indocyanine green fluorescence angiography during ileal J-pouch surgery requiring lengthening maneuvers.

The purpose of this study was to review whether routine usage of indocyanine green (ICG) perfusion assessment during complex ileal J-pouch surgery requiring lengthening maneuvers reduces ischemic complications. Retrospective chart review of patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) who underwent ileal pouch-anal anastomosis (IPAA) surgery with lengthening maneuvers and intraoperative ICG assessment betweenJanuary 2015 and January 2021. All patients underwent a double stapled anastomosis and were temporarily diverted. All patients underwent laparoscopic and trans-anal ICG assessment of their J-pouch and anastomosis. All J-pouches were evaluated 6weeks after surgery via contrast enema and pouchoscopy. One hundred fifty eight patients underwent ileal J-pouch surgery during the study period. Sixteen patients (10%) underwent lengthening maneuvers and intra-operative ICG assessment. Twelve patients underwent surgery for UC and 4 for FAP. Median age was 40.3years and average body mass index was 24.9kg/m2. Twelve patients underwent a two-stage procedure and the remaining underwent a three-stage procedure. 93.7% of cases were completed laparoscopically (15/16). All patients underwent scoring of the peritoneum and 43% (7/16) underwent division of theileocolic or intermediate mesenteric vessels. There was no mortality or pouch ischemiaand theleak rate was 12.5%. All patients underwent reversal after an average of 18 ± 7weeks. ICG perfusionassessment appears to be of utility in complex IPAA surgery requiring lengthening maneuvers. Its application may be associated with reduced J-pouch ischemia and leak rate in this unique setting.

Transmesocolic approach in laparoscopic complete mesocolic excision for right sided colon cancers.

A mesocolic plane, central vascular ligation (CVL) and proper proximal-distal margins are the essential components of complete mesocolic excision (CME). In the transmesocolic approach, we identify the middle colic vessels and enter the lesser sac through the mesocolon for ascending colon and caecum tumors. To investigate the feasibility and identify the technical details of this technique. The clinical and pathological findings of 26 patients who had undergone laparoscopic right hemicolectomy with CME between 2010 and 2020 were collected retrospectively. All operation videos were recorded and reviewed by the authors with regard to the components of CME. In the transmesocolic approach, dissection starts with identification of the middle colic vessels directly. After division of the middle colic vessels, we enter the omental bursa and dissection continues from superior to inferior direction. There were 26 patients in the study. The mean age was 59.3 ±16.1. There were 15 female and 11 male patients with a mean body mass index of 25.9 ±16.1 kg/m2. The mean operative time was 137.6 ±19.4 min. The mean length of hospital stay and the time to first flatus were 7.5 ±4.6 days and 2.3 ±1.5 days, respectively. None of the patients were re-admitted to the hospital in 30 days. There was no 30-day mortality in the patients. There were no major complications. The transmesocolic approach seems to be feasible and safe for CME in right sided colon cancers. However, more prospective randomized studies are needed to use the transmesocolic approach as a standard technique.

Complete versus non-complete fundoplication in surgical treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease is a common disorder accounting for approximately 75% of esophageal pathology. It seriously compromises quality of life. It develops when the reflux of gastric content causes troublesome symptoms or complications. During the last decades significant changes have occured in the role of surgery for gastroesophageal reflux disease. Initially antireflux surgery was reserved only for patients who had failed any kind of medical therapy. Now the range of indications for antireflux procedures is wide. Operations for gastroesophageal reflux disease are now well established and have good short- and long-term results, but no unique laparoscopic antireflux technique has been accepted so far, and a number of different antireflux procedures with numerous modifications have been reported. A total of 102 consecutive patients with gastroesophageal reflux disease were operated in the clinic of Republican Medical Center ‘’Armenia’’ (Yerevan, Armenia) and Mickaelyan Institute of Surgery (Yerevan, Armenia) from 2010 to 2021. In all cases the esophagogram showed hiatal hernia. Nissen, Nissen-Rossetti and Toupet fundoplications were performed as antireflux procedures. In all cases of combination of hiatal hernia and Gastroesophageal reflux diseasemesh reinforcement was performed. The results of follow-up assessment of the operated patients were compared. The results in early postoperative period were assessed with contrast X-ray examination and 24-hour pH-metry on the 5-th to 7-th days after surgery. The quality-of-life evaluation by the questionnaire showed a significant difference between the two groups, improvement of results in the laparoscopy group with complete fundoplication in comparison with not complete fundoplication. Complete fundoplication is a more reliable method of antireflux procedures for surgical treatment of gastroesophageal reflux disease. The division of short gastric vessels helps to prevent persistent dysphagia. The repair of esophageal hiatus of diaphragm is mandatory in antireflux procedures.