Hilar Dissection Research Articles

Robot-assisted laparoscopic liver resection: First dutch experience

Introduction: Robot-assisted laparoscopy has been introduced to overcome the limitations of conventional laparoscopy. This technique has potential advantages over laparoscopy, such as increased dexterity, 3-dimensional view and a magnified view of the operative field. Therefore, the improved dexterity may make a robotic system particularly suited for liver resections that require non-linear manipulation, such as curved parenchymal transection, hilar dissection and resection of the posterosuperior segments. Methods: Between August 2014 and August 2015, 11 patients underwent robot-assisted laparoscopic liver resection at University Medical Center Utrecht for malignant and benign hepatic lesions. Results: Ten robot-assisted laparoscopic liver resections were performed in a minimally invase manner. One of the procedures was converted. Four patients underwent a resection of an anterior segment (2, 3, 4B, 5, 6). Six patients underwent a resection of a posterosuperior segment (7, 8). Seven patients had previous abdominal surgery. Two patients underwent a laparoscopic bowel resection simultaneously. Median operating time was 184 (60–265) minutes and median blood loss was 225 (5–600) mL. Six patients had a complication, from which 2 patients suffered from a grade III complication (Clavien–Dindo). Median length of stay was 5 (4–8) days. There was no mortality. Conclusion: This prospective study reporting on our initial experience with robot-assisted laparoscopic liver resection demonstrates that this technique is easily adopted, safe and feasible for minor hepatectomies in selected patients. Moreover, it suggests that the robotic platform also enables fully laparoscopic resections of the posterior segments.

The First Case of Total Laparoscopic Living Donor Right Hemihepatectomy in Mainland China and Literature Review

Total laparoscopic living donor right hemihepatectomy (LDRH) has been successfully performed in several transplant centers. Here we report the first LDRH performed in mainland China and review current literature, focusing on perioperative donor evaluation and surgical procedure to secure donor safety. A 47-year-old man volunteered for living donation to his wife who suffered from sclerosing cholangitis-related liver cirrhosis and hepatocellular carcinoma. Donor height is 165 cm and weight is 65 kg, whereas the body mass index is 23.9. The CT volume evaluation showed that the graft-to-body weight ratio was 1.42%, and the remnant liver volume was 36.3% for right graft without middle hepatic vein (MHV). The anatomy of hepatic vein, artery, portal vein, and bile duct was normal. Preoperative liver function tests were normal. Intraoperative biopsy result showed minimal steatosis. A transection was performed along the right side of the MHV. Two branches of MHV (V5 and V8) were <5 mm in diameter, and there was no need for reconstruction in the back table. Hilar dissection was meticulously performed. Right portal vein, hepatic artery, and bile duct were transected above the bifurcation. The right hepatic vein was transected by a laparoscopic linear stapler. The real graft volume was 660 mL, with a revised graft-to-body weight ratio of 1.14%. Warm ischemia time was about 4 minutes. The donor's postoperative course was uneventful. Total LDRH has been proven to be technically feasible in selected adult donors. Following increased experience, it might be a safe and minimally invasive option for adult donors.

Extended right hepatectomy with caudate lobe resection using the hilar “en Bloc” resection technique with a modified hanging maneuver

The hanging liver maneuver is a useful technique to guide the transection of liver parenchyma by lifting a tape passed between the anterior surface of the inferior vena cava and the liver. Modified hanging liver maneuvers have been described in different types of liver resection. Surgical resection of hilar cholangiocarcinoma can involve the portal vein and the caudate lobe for margin clearance. However, hilar dissection and resection of the caudate lobe can be a challenging during the hanging maneuver once the tape is positioned. Here in we describe a modified hanging liver maneuver for a hilar ‘en bloc’ extended right hepatectomy with portal vein resection for the treatment of hilar cholangiocarcinoma including the caudate lobe.

V8-04 ROBOTIC-ASSISTED VERSUS LAPAROSCOPIC LIVING DONOR NEPHRECTOMY: A 12-STEP COMPARISON OF SURGICAL TECHNIQUE

You have accessJournal of UrologyBladder Oncology/Testis/Transplantation/Trauma1 Apr 2016V8-04 ROBOTIC-ASSISTED VERSUS LAPAROSCOPIC LIVING DONOR NEPHRECTOMY: A 12-STEP COMPARISON OF SURGICAL TECHNIQUE Michael Palese, Jamie Pak, Edward Chin, Greg Gin, Daniel Herron, Susan Lerner, Dianne LaPointe Rudow, Antonios Arvelakis, Scott Ames, Alan Benvenisty, Ron Shapiro, and Sander Florman Michael PaleseMichael Palese More articles by this author , Jamie PakJamie Pak More articles by this author , Edward ChinEdward Chin More articles by this author , Greg GinGreg Gin More articles by this author , Daniel HerronDaniel Herron More articles by this author , Susan LernerSusan Lerner More articles by this author , Dianne LaPointe RudowDianne LaPointe Rudow More articles by this author , Antonios ArvelakisAntonios Arvelakis More articles by this author , Scott AmesScott Ames More articles by this author , Alan BenvenistyAlan Benvenisty More articles by this author , Ron ShapiroRon Shapiro More articles by this author , and Sander FlormanSander Florman More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.747AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Laparoscopic donor nephrectomy (LDN) has gained wide acceptance among surgeons and donors due to better short-term donor morbidity compared to the open approach without compromising graft outcome. The first robotic-assisted laparoscopic donor nephrectomy (RDN) was reported in 2002. A recent randomized comparative study reported less postoperative pain, less analgesic requirement, and shorter hospital stay with RDN versus LDN. In this video, we compare the operative technique of RDN vs. LDN at our institution at twelve critical steps of the procedure. METHODS The 12 steps include: 1. Medial reflection of descending colon, 2. Complete mobilization of spleen, 3. Exposure of gonadal vessel and renal vein, 4. Ligation of adrenal, gonadal, and lumbar veins, 5. Mobilization of kidney laterally and posteriorly, 6. Dissection of adrenal off upper pole/superior mobilization, 7. Dissection of renal hilum, 8. Medial rotation of kidney along hilum and posterior hilar dissection, 9. Mobilization and ligation of distal ureter, 10. Preparation for extraction, 11. Ligation of renal artery and vein, and 12. Extraction of kidney. Our case series of RDN were then compared to our historical institutional LDN case series as previously reported in a 2009 manuscript. RESULTS LDN utilizes fenestrated forceps in the left hand and Harmonic Ace shears in the right, while RDN utilizes bipolar precise forceps on the left arm and monopolar cutting scissors on the right. Notable differences also occur at Step 11, when ligation of the renal artery and vein is performed by the bedside surgeon in RDN versus by the primary surgeon in LDN, and Step 12, when LDN involves kidney extraction via a hand-assist device, while RDN utilizes a specimen bag introduced through the assistant port with extraction through a Pfannenstiel incision. A preliminary comparison of 512 historical LDN cases versus 17 RDN cases reveals RDN has a lower intraoperative estimated blood loss, but similar operative time, warm ischemia time, length of stay, rates of transfusion, and conversion rate versus LDN. CONCLUSIONS We outline several differences in operative technique between RDN and LDN during ligation of the renal hilum and extraction of the kidney. Short-term outcomes appear similar between the two approaches, with the exception of significantly less estimated blood loss in RDN. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e772 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Michael Palese More articles by this author Jamie Pak More articles by this author Edward Chin More articles by this author Greg Gin More articles by this author Daniel Herron More articles by this author Susan Lerner More articles by this author Dianne LaPointe Rudow More articles by this author Antonios Arvelakis More articles by this author Scott Ames More articles by this author Alan Benvenisty More articles by this author Ron Shapiro More articles by this author Sander Florman More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Impact factors and effect of longer operation time of laparoscopic spleen-preserving splenic hilar lymph node dissection for upper-or middle-third gastric cancer

Objective To explore the impact factors and effect of longer operation time of laparoscopic spleen-preserving splenic hilar lymph node dissection (SHLND). Methods The method of retrospective casecontrol study was adopted.The clinicopathological data of the 317 patients with upper-or middle-third gastric cancer who underwent laparoscopic spleen-preserving SHLND at the Fujian Medical University Union Hospital between January 2011 and December 2013 were collected.Median operation time was served as a cut-off point, 148 patients with operation time≥24 minutes and 169 patients with operation time <24 minutes were allocated into the long time group and short time group, respectively.Impact factors affecting the operation time of laparoscopic spleen-preserving SHLND were analyzed firstly, and then operation time affecting clinical effect of patients was explored.Measurement data with normal distribution were presented as ±s and analyzed using an independent sample t test.Count data and univariate analysis were done using the chi-square test.Multivariate analysis was done using the Logistic regression model. Results The gender, body mass index (BMI), number of splenic lobar arteries, type of splenic lobar arteries, number of short gastric arteries and experiences of surgeons were factors affecting longer operation time of SHLND in the univariate analysis (χ2=7. 268, 21. 551, 14. 960, 23. 791, 6. 987, 26. 995, P 0. 05).The mortalities were 0.68% (1/ 148)in the long time group and 0.59% (1/ 169)in the short time group, with no significant difference between the 2 groups (χ2 =0. 009, P >0.05). Conclusion Longer operation time of laparoscopic spleen-preserving SHLND is closely associated with gender, BMI, number of splenic lobar arteries, type of splenic lobar arteries and experiences of surgeons, and it should be performed selectively for inexperienced surgeons in order to reduce operation time and enhance postoperative recovery of patients. Key words: Gastric neoplasms; Spleen; Lymph node dissection; Operation time; Laparoscopy

Extended right hepatectomy with caudate lobe resection using the hilar "en bloc" resection technique with a modified hanging maneuver.

The hanging liver maneuver is a useful technique to guide the transection of liver parenchyma by lifting a tape passed between the anterior surface of the inferior vena cava and the liver. Modified hanging liver maneuvers have been described in different types of liver resection. Surgical resection of hilar cholangiocarcinoma can involve the portal vein and the caudate lobe for margin clearance. However, hilar dissection and resection of the caudate lobe can be a challenging during the hanging maneuver once the tape is positioned. Herein, we describe a modified hanging liver maneuver for a hilar "en bloc" extended right hepatectomy with portal vein resection for the treatment of hilar cholangiocarcinoma including the caudate lobe. J. Surg. Oncol. 2016;113:427-431. © 2016 Wiley Periodicals, Inc.

Strategies of laparoscopic spleen-preserving splenic hilar lymph node dissection for advanced proximal gastric cancer.

For advanced proximal gastric cancer (GC), splenic hilar (No. 10) lymph nodes (LN) are crucial links in lymphatic drainage. According to the 14(th) edition of the Japanese GC treatment guidelines, a D2 lymphadenectomy is the standard surgery for advanced GC, and No. 10 LN should be dissected for advanced proximal GC. In recent years, the preservation of organ function and the use of minimally invasive technology are being accepted by an increasing number of clinicians. Laparoscopic spleen-preserving splenic hilar LN dissection has become more accepted and is gradually being used in operations. However, because of the complexity of splenic hilar anatomy, mastering the strategies for laparoscopic spleen-preserving splenic hilar LN dissection is critical for successfully completing the operation.

Vacuum Stabilization of the Spleen in Laparoscopic Splenectomy.

Background and Objectives:Recovery from laparoscopic splenectomy is greatly enhanced when compared with recovery from the laparotomy approach, yet a minority of spleens are removed laparoscopically. The spleen is smooth, rounded, and vascular, making it difficult to directly grasp, stabilize, or retract laparoscopically. The LiVac Retractor is a laparoscopic liver retractor comprising a soft silicone open ring that apposes 2 substantially planar surfaces when a vacuum is applied. It was evaluated for its efficacy in stabilization of the spleen during 2 laparoscopic splenectomies.Methods:The 2 patients gave consent for laparoscopic splenectomy with splenic retraction using the LiVac Retractor. The entire 3-port laparoscopic procedure was video recorded, with the resected spleens weighed as wet specimens. The patients' postoperative courses are described.Results:The spleen was retracted securely for the duration of the hilar dissection in both patients. Exposure of the splenic hilum was excellent. There were no visible signs of injury to either spleen and recovery of both patients was unremarkable.Conclusions:The LiVac Retractor provided stable retraction and excellent exposure of the splenic hilum during both laparoscopic splenectomies, without organ injury. Early hilar dissection with vascular control was facilitated, reducing the risk of bleeding from other components of the dissection.

Hepatoduodenal ligament dissection technique during recipient hepatectomy for liver transplantation: How I do it?

Accurate dissection of the hepatoduodenal ligament in the recipient is vital for the success of liver transplantation surgery. High incidence of anatomic variations at the hepatic artery, portal vein and biliary ducts in the hepatoduodenal ligament is well known. Surgical experience is important to be able to foresee the most common anatomic diversities and the possible variations, in order to make a safe and accurate dissection in the hepatic hilum. Before anastomosis, all these hilar structures must be well identified, safely dissected and must also have a sufficient length for the coming implantation process. At the beginning of our program, we were starting the hepatic hilum dissection close to the liver. In time, however, we modified our surgical technique, preferring to start further away from the liver (closer to the duodenum). This length increased progressively over 1500 liver transplantations (80% living donor liver transplantation). During this process, our main purpose was the early control of the hepatic artery (artery first approach). In this paper, our aim is to share our latest version of the hepatoduodenal ligament dissection technique. We also describe alternative approaches used in extraordinary situations.

Crowdsourcing Assessment of Surgeon Dissection of Renal Artery and Vein During Robotic Partial Nephrectomy: A Novel Approach for Quantitative Assessment of Surgical Performance.

We sought to describe a methodology of crowdsourcing for obtaining quantitative performance ratings of surgeons performing renal artery and vein dissection of robotic partial nephrectomy (RPN). We sought to compare assessment of technical performance obtained from the crowdsourcers with that of surgical content experts (CE). Our hypothesis is that the crowd can score performances of renal hilar dissection comparably to surgical CE using the Global Evaluative Assessment of Robotic Skills (GEARS). A group of resident and attending robotic surgeons submitted a total of 14 video clips of RPN during hilar dissection. These videos were rated by both crowd and CE for technical skills performance using GEARS. A minimum of 3 CE and 30 Amazon Mechanical Turk crowdworkers evaluated each video with the GEARS scale. Within 13 days, we received ratings of all videos from all CE, and within 11.5 hours, we received 548 GEARS ratings from crowdworkers. Even though CE were exposed to a training module, internal consistency across videos of CE GEARS ratings remained low (ICC = 0.38). Despite this, we found that crowdworker GEARS ratings of videos were highly correlated with CE ratings at both the video level (R = 0.82, p < 0.001) and surgeon level (R = 0.84, p < 0.001). Similarly, crowdworker ratings of the renal artery dissection were highly correlated with expert assessments (R = 0.83, p < 0.001) for the unique surgery-specific assessment question. We conclude that crowdsourced assessment of qualitative performance ratings may be an alternative and/or adjunct to surgical experts' ratings and would provide a rapid scalable solution to triage technical skills.

Targeting the Achilles' heel of adult living donor liver transplant: Corner-sparing sutures with mucosal eversion technique of biliary anastomosis.

Biliary complications are regarded as the Achilles' heel of liver transplantation, especially for living donor liver transplantation (LDLT) due to smaller, multiple ducts and difficult ductal anatomy. Overall biliary complications reported in most series are between 10% and 30%. This study describes our modified technique of biliary anastomosis and its effects on incidence of biliary complications. This was a single-center retrospective study of 148 adult LDLT recipients between December 2011 and June 2014. Group 1 (n = 40) consisted of the first 40 patients for whom the standard technique of biliary anastomosis (minimal hilar dissection during donor duct division, high hilar division of the recipient bile duct, and preservation of the recipient duct periductal tissue) was used. Group 2 (n = 108) consisted of 108 patients for whom biliary anastomosis was done with the addition of corner-sparing sutures and mucosal eversion of the recipient duct to the standard technique. Primary outcome measures included biliary complications (biliary leaks and strictures). Biliary complications occurred in 7/40 patients in group 1 (17.5%) and in 4/108 patients in group 2 (3.7%). The technical factors mentioned above are aimed at preserving the blood supply of the donor and recipient ducts and hold the key for minimizing biliary complications in adult-to-adult LDLT.

A preoperatively predictive difficulty scoring system for laparoscopic spleen-preserving splenic hilar lymph node dissection for gastric cancer: experience from a large-scale single center.

The purpose of this study was to evaluate the risk factors that influence the difficulty of performing laparoscopic spleen-preserving splenic hilar lymph node dissection (SHLND) for gastric cancer and to establish a simple and effective scoring system to predict the surgical difficulty preoperatively. Between January 2011 and December 2013, we prospectively collected and retrospectively analyzed the medical records of 317 patients with upper- or middle-third gastric cancer who underwent laparoscopic spleen-preserving SHLND. Univariate and multivariate analyses were performed to determine the independent predictors for surgical difficulty based on the operation time during spleen-preserving SHLND. A logistic regression model was used to identify determinant variables and construct a predictive difficulty scoring system. Multivariate analysis showed that gender, body mass index (BMI), number of splenic lobar arteries (SLAs), and type of SLA were independently predictive factors of operation time. According to these factors, we developed a predictive surgical difficulty scoring system and the difficulty levels are divided into 0, 1, 2, 3, and 4 points or more. Based on the relative risk, we stratified the surgical difficulty into the following three divisions: 0 low difficulty, 1-2 intermediate difficulty, and 3 points or more high difficulty. The patients with long operation time accounted for 19.6, 43.6, and 90.9% for the three groups, respectively (p<0.001). The area under the receiver operating characteristic curve for the logistic regression model and the simplified difficulty scoring prediction model was 0.717 and 0.715, respectively. Based on four independent risk factors, including gender, BMI, number of SLAs, and type of SLA, we developed a simple and effective scoring system to predict the difficulty of laparoscopic spleen-preserving SHLND preoperatively. This novel scoring system might aid surgeons with different experience in performing operations at different levels of difficulty.

En Bloc Hilar Dissection of the Right Hepatic Artery in Continuity with the Bile Duct: a Technique to Reduce Biliary Complications After Adult Living-Donor Liver Transplantation

ObjectiveTechniques that preserve the right hepatic artery and the common bile duct in continuity during the dissection may be associated with lower rates of biliary complications in living-donor liver transplants. This study sought to determine whether en bloc hilar dissections were associated with fewer biliary complications in living-donor liver transplants. MethodsThis was a retrospective review of 41 adult LDLTs performed in a single, liver transplant center between February 2007 and September 2014. The primary outcome of interest was the occurrence of at least one of the following biliary complications: anastomotic leak, stricture, or biloma. The primary predictor of interest was the hilar dissection technique: conventional hilar dissection vs. en bloc hilar dissection. ResultsA total of 41 LDLTs were identified, 24 had a conventional, and 17 an en bloc hilar biliary dissection. The occurrence of any biliary complication was significantly more common in the conventional hilar dissection group compared to the en bloc hilar dissection group (66.7 vs. 35.3 %, respectively, p = 0.047). In particularly, anastomotic strictures were significantly more common in the conventional hilar dissection group compared to the en bloc hilar dissection group (54.2 vs 23.5 %., respectively, p = 0.049). ConclusionEn bloc hilar dissection technique may decrease biliary complication rates in living donor liver transplants.

Clinical Significance of Splenic Hilar Dissection with Splenectomy in Advanced Proximal Gastric Cancer: An Analysis at a Single Institution in Japan.

Significance of splenic hilar node dissection with splenectomy is now denied for advanced gastric cancer of upper one-third of the stomach without invasion to the greater curvature by the Japan Clinical Oncology Group 0110, a pivotal randomized study from Japan. However, a question remains for tumors which involve the greater curvature, as this study excluded such tumors. We retrospectively analyzed 421 consecutive patients with gastric cancer who underwent curative total gastrectomy with splenectomy from 1992 to 2009. The survival curves, state of lymph node (LN) metastasis, and index of the estimated benefit from LN dissection of each station were evaluated according to the tumor location. The incidence of No. 10 metastasis was 9.3 % (39/421), with 15.9 % in patients with tumors involving the greater curvature (Gre group, n = 132) and 6.2 % in those without (non-Gre group, n = 289) (P = 0.032). The 5-year overall survival (OS) of patients with and without No. 10 metastasis was 35.4 and 43.1 % (P = 0.135) in the Gre group and 32.8 and 66.5 % (P = 0.0006) in the non-Gre group, respectively. The index of No. 10 LN dissection was 5.6 and 2.0 in the Gre and non-Gre groups, respectively. In the Gre group, the index was relatively higher in patients aged < 65 years, within pT3, and with Borrmann type 4 tumors. Splenectomy may have a survival benefit when a tumor shows involvement with the greater curvature, especially in relatively young patients and those without serosal exposure.

Laparoscopic splenic hilar lymph node dissection for proximal gastric cancer using integrated three-dimensional anatomic simulation software.

Laparoscopic lymph node (LN) dissection along the distal splenic artery (Station No. 11d) and around the splenic hilum (Station No. 10) remains challenging even for skilled surgeons. The major reason for the difficulty is the complex, multifarious anatomy of the splenic vessels. The latest integrated three-dimensional (3D) simulations may facilitate this procedure. Usefulness of 3D simulation was investigated during 20 laparoscopic total gastrectomies with splenic hilar LN dissection while preserving the spleen and pancreas (LTG+PSP) or with splenectomy (LTG+S). Clinical information acquired by 3D simulation and the consistency of the virtual and real images were evaluated. Furthermore, clinical data of these patients were compared with that of the patients who underwent the same surgery before the introduction of 3D simulation (n=10), to clarify its efficacy. The vascular architecture and morphologic characteristics were clearly demonstrated in 3D simulation, with sufficient consistency. The median durations of 14 LTG+PSP and 6 LTG+S operations were 318 and 322min, respectively. The estimated blood losses were 18 and 38g, respectively. There were no deaths. One postoperative peritoneal abscess (grade II according to Clavien-Dindo) was recorded. A comparison of clinical parameters between surgeries without or with 3D simulation showed no differences in operation time, blood loss, or complication rate; however, the number of retrieved No. 10 LNs has significantly increased in cases with the use of 3D simulation (p=0.006). This kind of surgery is not easy to perform, but the latest 3D computed tomography simulation technology has made it possible to reduce the degree of difficulty and also to enhance the quality of surgery, potentially leading to widespread use of these techniques.

Electrocautery device does not provide adequate pulmonary vessel sealing in transumbilical anatomic pulmonary lobectomy

Safe pulmonary vessel sealing device plays a crucial role in anatomic lung resection. In 2014, we reported high rates of massive bleeding complications during transumbilical lobectomy in a canine model due to difficulty in managing the pulmonary vessel with an endostapler. In this animal survival series, we aimed to evaluate the outcome of pulmonary vessel sealing with an electrocautery device to simplify the transumbilical thoracic surgery. Under general anesthesia, a 3-cm longitudinal incision was made over the umbilicus. Under video guidance, a bronchoscope was inserted through the incision for exploration. The diaphragmatic wound was created with an electrocautery knife and used as the entrance into the thoracic cavity. Using the transumbilical technique, anatomic lobectomy was performed with electrosurgical devices and endoscopic vascular staplers in 15 canines. Transumbilical endoscopic anatomic lobectomy was successfully completed in 12 of the 15 animals. Intraoperative bleeding developed in three animals during pulmonary hilum dissection, where one animal was killed due to hemodynamic instability and the other two animals required thoracotomy to complete the operation. There were five delayed bleeding and surgical mortality cases caused by inadequate vessel sealing by electrosurgical devices. Postmortem examination confirmed correct transumbilical lobectomy in the twelve animals that survived the operations. Transumbilical anatomic lobectomy is technically feasible in a canine model; however, the electrosurgical devices were not effective in sealing the pulmonary vessel in the current canine model.

Pneumonectomy in the Indian scenario—a review of current indications and results

Pneumonectomy is an important procedure in the armamentarium of the thoracic surgeon dealing with both neoplastic and non-neoplastic diseases of the lung especially in a developing country like India where the sequelae of tuberculosis are still rampant and the incidence of lung cancer is on the rise. The indications for pneumonectomy are varied. The operative techniques are standardized. Assessment of risk-benefit ratio is important as pneumonectomy carries considerable morbidity. We present our experience with 74 cases of pneumonectomy performed for varied etiologies, the outcomes of which are retrospectively analyzed in this study. We retrospectively reviewed our institutional database for patients who underwent a pneumonectomy from January 2009 to April 2015. Demography, patient profile, indications for surgery, details of operative technique, development of perioperative complications, and mortality were analyzed. Seventy-four patients underwent pneumonectomy, with a male to female ratio of 2:1. The age range was 6 to 72 years out of which six were children (8.1 %). Post-tuberculosis-destroyed lung was the predominant indication (43.24 %). Nineteen (25.67 %) underwent pneumonectomy for various tumors. Completion pneumonectomy was done in four (5.40 %). Left pneumonectomy was performed in 48 patients (64.86 %). The operative time ranged between 110 and 385 min. The mean post-operative stay was 4 days. Two patients (2.70 %) required emergency cardiopulmonary bypass for torrential hemorrhage during hilar dissection. Post-operative complications encountered were reactionary hemorrhage (1), empyema (2), bronchopleural fistula (1), and chylothorax (1). There was one early post-operative death due to fulminant respiratory failure. Early mortality rate was 1.35 %. The outcomes following pneumonectomy are favorable when careful attention to patient selection, preoperative patient optimization, meticulous surgical technique, and post-operative principles are followed. Pneumonectomy in post-pulmonary tuberculosis-destroyed lungs did not carry extra morbidity or mortality. Pneumonectomy in malignant lung/bronchial diseases is safe. Pneumonectomy in children was remarkably uncomplicated. Completion pneumonectomy can be done with an acceptable morbidity in selected patients. Use of cardiopulmonary bypass when encountered with torrential intraoperative hemorrhage is an acceptable strategy. Outcomes of hand-sewn bronchial closure technique are comparable to stapling devices and cost effective.

Total anatomic vascular dissection for lobectomy by using only energy devices.

The introduction of ultrasonic energy into surgical dissecting devices was a technological breakthrough in minimally invasive surgery in the 1990s. Nowadays, the energy devices are used very often during video-assisted thoracoscopic surgery (VATS) especially for lymph node dissection and for transection of small pulmonary vessels. However these devices can be used for hilar anatomic dissection in expert hands. In this video we show a right lower lobectomy performed by uniportal VATS in where the anatomic dissection of artery, vein and bronchus was performed by only using an ultrasonic energy device (Harmonic scalpel). The total surgical time for lobectomy was 30 minutes and 20 minutes for lymph node dissection. The use of energy devices for vascular and bronchial dissection during lobectomy is feasible and safe when performed by expert thoracoscopic surgeons.

Automatic segmentation of occluded vasculature via pulsatile motion analysis in endoscopic robot-assisted partial nephrectomy video

Hilar dissection is an important and delicate stage in partial nephrectomy, during which surgeons remove connective tissue surrounding renal vasculature. Serious complications arise when the occluded blood vessels, concealed by fat, are missed in the endoscopic view and as a result are not appropriately clamped. Such complications may include catastrophic blood loss from internal bleeding and associated occlusion of the surgical view during the excision of the cancerous mass (due to heavy bleeding), both of which may compromise the visibility of surgical margins or even result in a conversion from a minimally invasive to an open intervention. To aid in vessel discovery, we propose a novel automatic method to segment occluded vasculature from labeling minute pulsatile motion that is otherwise imperceptible with the naked eye. Our segmentation technique extracts subtle tissue motions using a technique adapted from phase-based video magnification, in which we measure motion from periodic changes in local phase information albeit for labeling rather than magnification. Based on measuring local phase through spatial decomposition of each frame of the endoscopic video using complex wavelet pairs, our approach assigns segmentation labels by detecting regions exhibiting temporal local phase changes matching the heart rate. We demonstrate how our technique is a practical solution for time-critical surgical applications by presenting quantitative and qualitative performance evaluations of our vessel detection algorithms with a retrospective study of fifteen clinical robot-assisted partial nephrectomies.

Application of perihilar surgical techniques in biliary tract surgery

Perihilar surgery is full of challenge, risk, variability and uncertainty. Because of the anatomic variability, the pathophysiological complexity and invasion of the diseases, hepatic hilar biliary surgery has the characteristics of high operative difficulties, low resection rate, easy intraoperative bleeding, more postoperative complications, high recurrence rate and mortality rate. The cure rate and safety of the operation can be improved only through comprehensive imaging examinations and preoperative evaluation of liver function as well as the correct use of surgical techniques of anatomic paths, lesions excision and hepatic hilar reconstruction. The core of perihilar surgical techniques is hepatic hilar anatomy and explosion, including hilar plate dissection, dissection of liver along the medial fissure, quadrate lobe of liver resection and perihilar resection. Perihilar surgery is a comprehensive technique involving preoperative, intraoperative and postoperative procedures. The cure rates of perihilar biliary diseases can be improved by a combination of enhanced recovery after surgery and optimized and individualized surgical plans for patients. Key words: Perihilar disease; Biliary tract surgical procedures