Hilar Dissection Research Articles

Teaching video-assisted thoracic surgery (VATS) lobectomy.

Video-assisted thoracic surgery (VATS) lobectomy has become the standard of care for early stage lung cancer throughout the world. Teaching this complex procedure requires adequate case volume, adequate instrumentation, a committed operating room team and baseline experience with open lobectomy. We outline what key maneuvers and steps are required to teach and learn VATS lobectomy. This is most easily performed as part of a thoracic surgery training program, but with adequate commitment and proctoring, there is no reason experienced open surgeons cannot become proficient VATS surgeons. We provide videos showing the key portions of a subcarinal lymph node dissection, posterior hilar dissection of the right upper lobe, fissureless right middle lobectomy, and fissureless left lower lobectomy. These videos highlight what we feel are important principals in VATS lobectomy, i.e., N2 and N1 lymph node dissection, fissureless techniques, and progressive responsibility of the learner. Current literature in simulation of VATS lobectomy is also outlined as this will be the future of teaching in VATS lobectomy.

Curettage and aspiration in splenic hilar lymph node dissection for spleen-preserving radical D2 gastrectomy.

D2 radical gastrectomy is the standard procedure for gastric cancer in the middle or upper part of the stomach. According to the latest Japanese treatment guidelines for gastric cancer, dissection of the splenic hilar lymph nodes is required during the radical treatment for this condition. This study reports a D2 radical total gastrectomy employing the curettage and dissection techniques, in which the resection of the anterior lobe of transverse mesocolon, vascular denudation and splenic hilar lymph node dissection were successfully completed.

Laparoscopic Left Hepatetomy for Intrahepatic Duct Stones in a Patient with Situs Inversus Totalis

Introduction: Situs inversus totalis is a rare congenital condition of mirror-image transposition of the major visceral organs with an incidence of 1:5,000 to 1:20,000 in adults.1,2 Hepatic resection in situs inversus totalis was reported in only seven cases with malignant tumors and open surgery was performed.3 Due to the rare incidence and left-to-right transposition of the visceral organs, laparoscopic surgery is a challenging procedure. We report on a patient who received laparoscopic left hepatectomy for intrahepatic duct stones with situs inversus totalis. Materials and Methods: A 66-year-old woman with situs inversus totalis was diagnosed with intrahepatic duct stones in the left lateral segment of the liver. Four ports were used: a 12-mm camera port into supraumbilicus, a 12-mm and a 5-mm working port in the left and right upper quadrant respectively, and a 5 mm working port in the left flank area. The surgeon was standing in the right side of the patient. The patient was placed supine in 15 degree reverse Trendelenburg position. Left hepatectomy was conducted by the following orders: liver mobilization, cholecystectomy, hilum dissection, division of the left hepatic artery and portal vein, intraoperative ultrasonography, parenchymal transection, division of left intrahepatic duct, division of the left hepatic vein and retrieval of the specimen. During parenchymal transection, the rubber band retraction method was used to expose parenchymal transection plane. Results and Conclusion: The operation time was 386 minutes and estimated blood loss was 150 mL. There were no abnormal findings in the abdominal CT image on the fifth post-operative day. The patient was discharged on the sixth post-operative day without any complications. In conclusion, laparoscopic left hepatectomy seems to be a feasible and safe procedure for a patient with situs inversus totalis. No competing financial interests exist. Runtime of video: 4 mins 54 secs

Anwendung des daVinci-Robotersystems in der Thoraxchirurgie

The latest technical developments of minimally invasive thoracic surgery are characterized by robotic-assisted operative procedures. Robotic-assisted thymectomy is the most advanced method in this field. A systematic literature search (PubMed, Medline) was carried out and the databank system of Intuitive Surgical (Sunnyvale, CA) was analysed. Target criteria were the analysis of the quantitative data over time, technical advantages and limiting factors of robotic-assisted thoracic surgery. The da Vinci robotic system has been used in thoracic surgery since 2001, and up to 2012 a total of 10,895 robotic-assisted lobotomies have been carried out worldwide. A total of 12 ectopic parathyroid glands in the mediastinum were resected and published. Furthermore, more than 3,500 cases of robotic-assisted thymectomy were performed. A rapid increase in the number of operations has occurred particularly for thymectomy and lung resections. Acceptance of robotic-assisted thymectomy for myasthenia and/or thymoma and mediastinal tumors is growing rapidly. For anatomic lung resection in lung cancer, robotic-assisted hilar and lymph node dissection due to this new quality are also comparable to open surgical techniques. The principles form the intrinsic technical advantages of the da Vinci robotic system.

Prognostic impact of lymphovascular invasion compared with that of visceral pleural invasion in patients with pN0 non–small-cell lung cancer and a tumor diameter of 2 cm or smaller

BackgroundBoth visceral pleural invasion (VPI) and lymphovascular invasion (LVI) have been shown to be adverse prognostic factors for early-stage non–small-cell lung cancer (NSCLC). Positive VPI upstages the T category of tumors ≤ 2 cm (T1a) to T2a, whereas LVI is not adapted as a descriptor for the Tumor, Node, Metastasis classification system. This study was conducted to evaluate the prognostic impacts of VPI and LVI in patients with pN0 NSCLC and a tumor diameter of ≤ 2 cm. MethodsWe reviewed records of a total of 142 patients with pN0 NSCLC and a tumor diameter of ≤ 2 cm, who underwent lobectomy with hilar and mediastinal lymph node dissection between January 2001 and December 2009. We conducted univariate and multivariate analyses to evaluate the impact of VPI, LVI, and other clinicopathologic factors on survival. ResultsVisceral pleural invasion and LVI were diagnosed as positive in 18 (12.7%) and 22 (15.5%) patients, respectively. Male sex, squamous cell carcinoma, positive VPI, and positive LVI were risk factors for overall survival. Squamous cell carcinoma, positive VPI, and positive LVI were risk factors for relapse-free survival. In multivariate analysis, squamous cell carcinoma and positive LVI were independent risk factors for overall survival, and positive LVI was an independent risk factor for relapse-free survival. ConclusionsPositive LVI was more important than VPI as a prognostic factor in patients with pN0 NSCLC and a tumor diameter of ≤ 2 cm. Adjuvant chemotherapy should be considered for such patients, to improve the treatment outcomes.

Laparoscopic total gastrectomy with spleen-preserving splenic hilar (No. 10) lymph nodes dissection

Laparoscopic total gastrectomy with spleen-preserving splenic hilar (No. 10) lymph nodes dissection is challenging due to the tortuous splenic vessels and possibility of parenchymal injury to the spleen or pancreas. Based on our anatomical understanding of peripancreatic structures, we combined the characteristics of laparoscopic surgery and developed a strategy using retro-pancreatic approach for laparoscopic spleen-preserving No. 10 lymph nodes dissection.

Does pure robotic partial nephrectomy provide similar perioperative outcomes when compared to the combined laparoscopic-robotic approach?

Laparoscopic and robotic partial nephrectomy have become the preferred option for surgical management of incidentally discovered small renal tumors. Currently there is no consensus on which aspects of the procedure should be performed laparoscopically versus robotically. We believe that combining a laparoscopic exposure and hilar dissection followed by tumor extirpation and renorrhaphy with robotic assistance provides improved perioperative outcomes compared to a pure robotic approach alone. We performed a comparison of perioperative outcomes between combined laparoscopic-robotic partial nephrectomy-or hybrid procedure-and pure robotic partial nephrectomy (RPN). A multi-center retrospective analysis of patients undergoing RPN and hybrid PN using the da Vinci S system(®) was performed. Patient data were reviewed for demographic and perioperative variables. Statistical analysis was performed using the Welch t test and linear regression, and nonparametric tests with similar significance results. Thirty-one patients underwent RPN while 77 patients underwent hybrid PN between 2007 and 2011. Preoperative variables were comparable in both groups with the exception of lesion size and nephrometry score which were significantly higher in patients undergoing hybrid PN. Length of surgery, estimated blood loss and morphine used were significantly less in the hybrid group, while warm ischemia time was significantly longer. The difference in WIT was accounted for in this data by adjusting for nephrometry score. In our multi-center series, the hybrid approach was associated with a shorter operative time, reduced blood loss and lower narcotic usage. We believe this approach is a valid alternative to RPN.

The Optimal Timing for Preparation of Recipient Superficial Femoral Veins to Minimize Intraoperative Blood Loss in Living Donor Liver Transplantation

AimsIntraoperative blood loss (IBL) usually predominates during the dissection of the native liver. A right-lobe living donor liver transplantation (LDLT) sometimes requires an additional procedure to obtain an autologous vein from the recipient for the vascular reconstruction. These procedure can sometime contribute to progressive coagulopathy causing unexpected bleeding. Therefore, we analyzed our cases to determine the optimal timing for vascular preparation from the patient in terms of IBL. MethodsAmong 67 patients included in the study, 30 did not require an additional procedure to obtain the venous graft (group A), and 37 LDLT employed a superficial femoral vein (SFV). Of these, 13 had undergone removal of SFV after the hilar dissection and liver mobilization from retrohepatic area while preserving the inferior vena cava (group B), and 24 removal of the SFV immediately after hilar dissection without liver mobilization from the retrohepatic space (group C). ResultsA significant difference existed only in the scores of the Model for End-stage Liver Disease. Although the median IBL for group C was similar to that for group A, the median IBL for group B was significantly higher than that for other 2 groups. The median duration from skin incision to graft implantation for group B was significantly longer than that for groups A and group C, because of the additional hemostatic procedures in the retrohepatic space including the leg site. ConclusionsThe timing for removal of SFV in LDLT patients affects IBL associated with consumptive coagulopathy and prolongs operative time. Based on our experience, we concluded that SFV preparation should be performed before liver mobilization from the retrohepatic area to minimize IBL.

Retrograde renal hilar dissection and segmental arterial clamping: a simple modification to achieve super-selective robotic partial nephrectomy.

Super-selective vascular control prior to robotic partial nephrectomy (also known as 'zero-ischemia') is a novel surgical technique that promises to reduce warm ischemia time. The technique has been shown to be feasible but adds substantial technical complexity and cost to the procedure. We present a simplified retrograde dissection of the renal hilum to achieve selective vascular control during robotic partial nephrectomy. Consecutive patients with stage 1 solid and complex cystic renal masses underwent robotic partial nephrectomies with selective vascular control using a modification to previously described super-selective robotic partial nephrectomy. In each case, the renal arterial branch supplying the mass and surrounding parenchyma was dissected in a retrograde fashion from the tumor. Intra-renal dissection of the interlobular artery was not performed. Intra-operative immunofluorescence was not utilized as assessment of parenchymal ischemia was documented before partial nephrectomy. Data was prospectively collected in an IRB-approved partial nephrectomy database. Operative variables between patients undergoing super-selective versus standard robotic partial nephrectomy were compared. Super-selective partial nephrectomy with retrograde hilar dissection was successfully completed in five consecutive patients. There were no complications or conversions to traditional partial nephrectomy. All were diagnosed with renal cell carcinoma and surgical margins were all negative. Estimated blood loss, warm ischemia time, operative time and length of stay were all comparable between patients undergoing super-selective and standard robotic partial nephrectomy. Retrograde hilar dissection appears to be a feasible and safe approach to super-selective partial nephrectomy without adding complex renovascular surgical techniques or cost to the procedure.

Use of a novel parenchymal clamp for laparoscopic and open partial nephrectomy.

Increasing data advocates the wider use of partial nephrectomy for renal tumours amenable to this approach. We describe the initial North American use of a novel parenchymal clamp in an open and a laparoscopic partial nephrectomy. Initial results in 3 patients (2 open, 1 laparoscopic) demonstrate excellent preservation of renal function and good oncologic outcomes. Hilar dissection was avoided in all cases and the estimated blood loss was low. In our small series, we found this device to be a safe and useful adjunct to partial nephrectomy.

Lin's clamp revisited: A safe model for training in liver resection

In 1973, Lin described a simplified technique of hepatic resection using his clamp and crush method. It allowed regional vascular control to reduce blood loss during parenchymal transection. This technique was aimed at avoiding hilar dissection and vascular clamping, thereby preventing ischemic–reperfusion injury of the remnant liver. The objective of our study is to report our experience with Lin's technique and discuss its applicability. The perioperative outcomes of patients who underwent hepatic resection with or without Lin's technique were analyzed. Multiple variables were also used to statistically compare outcomes between patients with a cirrhotic liver and a noncirrhotic one and results of performance by junior surgeons (JSs) and an experienced surgeon (ES). The perioperative outcome in patients undergoing hepatectomy with Lin's technique ( N = 18) showed a significantly shorter transection time, lower blood loss, and shorter hospital stay as compared with patients undergoing hepatectomy without Lin's clamp ( N = 17). Lin's technique was adopted in 29 patients. Eleven and 18 cases were operated on by the JSs and ES, respectively. The transection time was significantly longer in the JS group. Thirteen patients had a noncirrhotic liver whereas 16 patients had cirrhosis. There was no statistically significant difference in the perioperative outcomes between cases operated on by the JS and ES and between cases of patients with cirrhosis and those without cirrhosis. There was no incidence of hepatic failure within 90 days. Lin's technique offers less blood loss, a shorter transection time, and a shorter hospital stay. The application of Lin's technique avoids the need for hilar vascular isolation and hilar clamping. JSs can perform hepatectomy with outcomes comparable to those produced by ESs by applying Lin's technique.

Use of Breast Implants to Fill Postinfarct Pneumonectomy Cavity in Cases of Bilateral Lung Transplantation

Infarction of the lung graft following lung transplantation (LTx) needing graft pneumonectomy and retransplantation is rare and carries a poor prognosis. It is important to maintain the volume of hemithorax after pneumonectomy until retransplantation.A young woman who received bilateral LTx for idiopathic pulmonary hypertension underwent left graft pneumonectomy owing to infarction related to obstruction of pulmonary veins. After pneumonectomy, left hemithorax was filled with silicon breast implants (1 × 500 mL and 2 × 250 mL). A Taurolidine drip was started into the left chest cavity and was maintained 24 h/d for 5 d to avoid infection of breast implants (Fig 1). After 9 weeks when suitable single lung donor became available, the left chest was opened, the breast implants were removed, and a new organ was transplanted. The patient made a rapid recovery after retransplantation and was discharged home after 4 weeks. In another woman in her mid 40s with bilateral LTx for pulmonary fibrosis, two 500-mL implants were placed following left graft pneumonectomy for pulmonary artery obstruction (Fig 2). Gas exchange from a single lung was inadequate and required extracorporeal life support, from which she could not be weaned and died after 1 month from refractory liver failure.Fig 2View Large Image Figure ViewerDownload (PPT)In these cases, graft pneumonectomy was performed within the first week of transplantation. The plan was to offer retransplantation as the patients' condition stabilized and suitable donor organs became available. It was important to preserve the space in hemithorax, because mediastinal shift, diaphragmatic elevation, and rib crowding seen after pneumonectomy would have obliterated it. The use of breast implants for filling the hemithorax preserved the space so that the retransplantation with an appropriately sized organ would be possible. Breast implants also had a tamponade effect and prevented bleeding from the hilum and chest wall after pneumonectomy. The risk of herniation of the heart through the pericardial rent made for hilar dissection of the native lung was also prevented by breast implants. Infarction of the lung graft following lung transplantation (LTx) needing graft pneumonectomy and retransplantation is rare and carries a poor prognosis. It is important to maintain the volume of hemithorax after pneumonectomy until retransplantation. A young woman who received bilateral LTx for idiopathic pulmonary hypertension underwent left graft pneumonectomy owing to infarction related to obstruction of pulmonary veins. After pneumonectomy, left hemithorax was filled with silicon breast implants (1 × 500 mL and 2 × 250 mL). A Taurolidine drip was started into the left chest cavity and was maintained 24 h/d for 5 d to avoid infection of breast implants (Fig 1). After 9 weeks when suitable single lung donor became available, the left chest was opened, the breast implants were removed, and a new organ was transplanted. The patient made a rapid recovery after retransplantation and was discharged home after 4 weeks. In another woman in her mid 40s with bilateral LTx for pulmonary fibrosis, two 500-mL implants were placed following left graft pneumonectomy for pulmonary artery obstruction (Fig 2). Gas exchange from a single lung was inadequate and required extracorporeal life support, from which she could not be weaned and died after 1 month from refractory liver failure. In these cases, graft pneumonectomy was performed within the first week of transplantation. The plan was to offer retransplantation as the patients' condition stabilized and suitable donor organs became available. It was important to preserve the space in hemithorax, because mediastinal shift, diaphragmatic elevation, and rib crowding seen after pneumonectomy would have obliterated it. The use of breast implants for filling the hemithorax preserved the space so that the retransplantation with an appropriately sized organ would be possible. Breast implants also had a tamponade effect and prevented bleeding from the hilum and chest wall after pneumonectomy. The risk of herniation of the heart through the pericardial rent made for hilar dissection of the native lung was also prevented by breast implants.

Alternative techniques to reduce warm ischemia time in laparoscopic partial nephrectomy

Demonstrate two alternatives that permit a warm ischemia time reduction during laparoscopic partial nephrectomy. In this video, two cases of intermediate complexity renal tumors according to the RENAL nephrometry renal scoring system illustrating the techniques and our preliminary experience: a 65 year old man with a 4 cm right, posterior renal tumor. This patient underwent an early unclamping and parenchymal suturing using a greek bar continuous suture with hem-o-lock clips attached to the respective extremities of the suture; The second patient is a 49 year old man with a 3 cm renal tumor. The technique utilized was no clamping resection following the ABC Medical School technique: dissection of renal hilum for eventual clamping if necessary, a frontal 360 degrees visualization of tumor limits, pneumoperitoneum pressure elevated to 25mmHg during tumor resection, spiral excavation of normal parenchyma around the tumor and resection with negative margins. We previously performed 15 cases utilizing the early unclamping technique. The mean clamp time was 15 minutes with a mean blood loss of 285 mL. Only 1 patient had focal positive surgical margins, without recurrence demonstrated at 30 months. Fifteen partial nephrectomies were previously performed with on demand clamping. In 3 cases, clamping was necessary with a mean ischemia time of 11 minutes. The mean blood loss was 390 mL and 2 cases required a perioperative blood transfusion. One case presented with a positive focal margin without recurrence demonstrated at 24 months of follow-up. Renal function was preserved in all cases regardless of the technique applied. Warm ischemia time can be reduced and kidney function can be preserved during laparoscopic nephrectomy if either early unclamping or on demand clamping are selectively applied.

Surgical approach and outcomes for treatment of pulmonary metastases

AIMS:To investigate the surgical approach and outcomes, as well as prognostic factors for pulmonary metastasectomy.METHODS:Clinical data of 201 patients treated by pulmonary metastasectomy between January 1990 and December 2009 were retrospectively reviewed. One hundred thirty three patients were received an approach of thoracotomy while 68 with video-assisted thoracoscopic surgery (VATS). There were 54 lobectomies, 139 wedge resections and 8 pneumonectomies. Hilar or mediastinal lymph nodes dissection or sampling was carried out in 38 patients with lobectomy. The Kaplan-Meier method was used for the survival analysis. Cox proportional hazards model was used for multivariate analysis.RESULTS:The 5 years survival rate of patients after metastasectomy was 50.5%, and the median survival time was 65.9 months. The median survival time of patients with hilar or mediastinal lymph nodes metastasis was 23 months. By univariate analysis, significant prognostic factors included disease-free interval (DFI), number of metastases, number of affected lobe, surgical approach (open vs. VATS) and pathology types. DFI, number of metastases, and pathology types were revealed by Cox multivariate analysis as independent prognostic factors.CONCLUSION:Surgical resection of pulmonary metastases is safe and effective. Palpation of the lung is still seen as necessary to detect the occult nodule. More accurate and sensitive pre-operative mediastinal staging are required.

Roentgenological occult large-cell neuroendocrine carcinoma: Report of a long-term survivor

A 64-year-old male patient complained of a one-month history of bloody sputum. A polypoid tumor was almost obstructing the orifice of the subsegmental bronchus (B8b) of the anterior basal segment of the right lower lobe on bronchoscopy. Biopsy specimens of the tumor surface yielded a diagnosis of undifferentiated carcinoma. Clinical staging was T1aN0M0, stage IA. Surgical resection that comprised a right upper lobectomy with systematic mediastinal and hilar lymph node dissection was performed. Histopathologically, the tumor specimen was compatible with large-cell neuroendocrine carcinoma (LCNEC) of the subsegmental bronchus. Pathological staging was T1aN0M0, stage IA. To our knowledge, few cases of central-type LCNEC have been reported in the English literature, and ours is the first report of roentgenological occult LCNEC.

Principles of surgical resection in hilar cholangiocarcinoma

The aim of this article is to describe the surgical techniques for the treatment of hilar cholangiocarcinoma (HC). Resection with microscopically negative margin (R0) is the only way to cure patients with HC. Today, resection of the caudate lobe and part of segment IV, combined with a right or left hepatectomy, bile duct resection, lymphadenectomy of the hepatic hilum and sometimes vascular resection, is the standard surgical procedure for HC. Intraoperative frozen-section examination of proximal and distal biliary margins is necessary to confirm the suitability of resection. Although lymphadenectomy probably has little direct effect on survival, inaccurate staging information may influence post resection treatment recommendations. Aggressive venous and arterial resections should be undertaken in selected cases to achieve a R0 resection. The concept of "no-touch proposed" in 1999 by Neuhaus et al combine an extended right hepatectomy with systematic portal vein resection and caudate lobectomy avoiding hilar dissection and possible intraoperative microscopic dissemination of cancer cells. More recently minor liver resections have been proposed for treatment of HC. As the hilar bifurcation of the bile ducts is near to liver segments IV, V and I, adequate liver resection of these segments together with the bile ducts can result in cure.

Value of splenectomy in patients with Siewert type II adenocarcinoma of the esophagogastric junction

The incidence of adenocarcinoma of the esophagogastric junction (AEG) has been increasing recently in both Western and Eastern countries. However, an optimal treatment strategy for Siewert type II AEG is still unclear. The aim of this study was to clarify the value of splenectomy in patients with Siewert type II AEG. From September 2002 to November 2011, 42 patients underwent total gastrectomy with D2 lymph node dissection for Siewert type II AEG and were included in this study. We used the index of estimated benefit from lymph node dissection (IEBLD) to assess the efficacy of lymph node dissection of each station. Surgical complications were graded by the Clavien-Dindo classification. The overall 5-year survival rate of the 42 patients was 57.5 %. The incidence of splenic hilar lymph node metastasis was 4.8 % and the 5-year survival rate of patients with splenic hilar lymph node involvement was zero. Consequently, the IEBLD of splenic hilar lymph nodes was zero. Postoperative morbidities occurred in 25 patients (59.5 %). Pancreas-related complications were the most frequently observed (28.5 %), followed by intraabdominal abscess (14.3 %) and anastomotic leakage (9.5 %). Splenic hilar lymph node dissection may be omitted without decreasing curability in patients with Siewert type II AEG, although a prospective study is necessary for more conclusive results.

The Optimal Timing for Preparation of Vascular Graft from Recipient to Minimize Intraoperative Blood Loss in Living Donor Liver Transplantation

Aims: The recipient hepatectomy in living donor liver transplantation (LDLT) differs from the deceased donor liver transplantation in that the maximum length of the hepatic artery, portal vein (PV) and hepatic duct and the inferior vena cava (IVC) have to be preserved. Intraoperative blood loss (IBL) usually predominates during the dissection of the native liver. In the absence of venous system from deceased donors, right-lobe LDLT without middle hepatic vein (MHV) sometimes needs the additional surgical procedure such as obtaining an autologous vein from the recipient for vascular reconstruction. We have routinely used recipient's superficial femoral vein (SFV) to reconstruct MHV or PV as an alternative conduit in terms of caliber and wall thickness. These additional procedure sometimes contributes to progressive coagulopathy and cause unexpected bleeding. We analyzed our cases to determine the optimal timing for removing of an SFV from the patient and examine the effects of the timing on progress coagulopathy in terms of IBL. Methods: From March 1996 to January 2011, a total of 69 adult LDLT was performed at Tohoku University Hospital, Sendai, Japan. Of these, 2 were excluded from the study due to cardiac arrest during operation in one case and retransplantation in another. Of the remaining 67 patients included in the study, 30 patients were not required an additional surgical procedure to obtain the venous graft (group A), and 37 patients were performed LDLT using an SFV from the recipient to reconstruct MHV tributaries or PV. Of these, 13 patients had undergone removal of SFV, after hilar dissection and liver mobilization from retro-hepatic area with preserving IVC were completely done (group B), and 24 patients underwent removal of SFV immediately after hilar dissection without liver mobilization from the retro-hepatic space (group C). Results: A significant difference existed only in the median scores of the model for end-staged liver disease in group A, compared with that in group B or C (19 vs 26 vs 25). Three groups were virtually similar except for international normalized ratio (2.1 in group A vs 2.5 in group B vs 2.6 in group C). The actual 1-year patient survival was similar between the three groups (88.1% vs 87.9% vs 91.1%). Although the median IBL for group C was similar to that for group A (161 g/kg vs 189 g/kg), the median IBL for group B (361 g/kg) was significantly higher than that for other 2 groups. The median duration of anhepatic phase for group B was significantly longer than that for group A and group C (221 min in group B vs 126 min in group A vs 135 min in group C), because of the additional hemostatic procedures in the retrohepatic space including the leg site. Conclusions: The timing for undergoing removal of SFV in LDLT patients has effects on IBL associated with consumptive coagulopathy and operation time including anhepatic periods. Based on our experiences, we conclude that SFV preparation for vascular reconstruction should be performed before liver mobilization from the retro-hepatic area to minimize IBL in LDLT.

Continuous Transcutaneous Carbon Dioxide Monitoring in Living-Donor Lobar Lung Transplantation

Background: During lung transplantation (LT) as well as living-donor lobar lung transplantation (LDLLT), patients undergo significant changes in gas exchange, and therefore, arterial carbon dioxide partial pressure (PaCO2) monitoring is crucial; however, transcutaneous carbon dioxide partial pressure (PtcCO2) monitoring is not performed perioperatively. We reviewed our early experiences with continuous PtcCO2 monitoring in LDLLT to evaluate its feasibility in LT. Methods: This retrospective study included 13 cases of LDLLT performed between July 2009 and July 2011. Thirteen patients underwent nocturnal preoperative and intraoperative PtcCO2 monitoring in living-donor lobar lung transplantation (LDLLT). Under anesthesia, each patient was managed according to their preoperative PtcCO2. End-tidal carbon dioxide partial pressure (PETCO2) was also measured during LDLLT. The nocturnal preoperative and intraoperative PtcCO2 data were reviewed. Furthermore, clinical data were collected from medical charts, anesthesia records, and laboratory tests. Results: In all the patients, anesthesia was maintained safely by continuous PtcCO2 monitoring, especially at the induction of anesthesia. There were no complications related to continuous PtcCO2 monitoring. According to the preoperative arterial blood gas analysis, the median PaCO2 was 57 mmHg (range, 40-77). PtcCO2 and arterial carbon dioxide partial pressure (PaCO2; range, 39-192 mmHg) showed significant correlations at several time points (p < 0.0001, r2 = 0.978, n = 37, PtcCO2 = 0.95 × PaCO2 + 4.56). The agreement between these 2 variables was estimated with acceptable precision. Although the relationship between PETCO2 and PaCO2 was significant, their differences varied widely with low coefficient of determination (p = 0.0095, r2 = 0.258, n=25, PETCO2 = 0.26 × PaCO2 + 26.36). The awake stable PaCO2 was 58.0±13.4 mmHg, and the maximal preoperative PtcCO2 was 77.5±31.9 mmHg, possibly because of sleep hypoventilation. The overall maximal PtcCO2 did not surpass the maximal preoperative PtcCO2 in 4 patients. In 4 other patients, the maximal PtcCO2 at induction surpassed the maximal preoperative PtcCO2, but it decreased thereafter to the acceptable range; the mean difference between these 2 values was 10 mmHg (range, 1-22 mmHg). In 2 other patients, PtcCO2 did not decrease below the maximal preoperative PtcCO2 (maximal difference, 28 and 39 mmHg, respectively), but they tolerated the relatively high PtcCO2 levels and low pH-related hemodynamic instability. In these 10 patients, hilar dissection was performed safely without the need of cardiopulmonary bypass (CPB). However, in 3 patients, PtcCO2 reached the maximal value at induction and continued to rise despite modification of the ventilator settings. The mean difference between the maximal PtcCO2 in LT and the maximal preoperative PtcCO2 was 65 mmHg (range, 29-85 mmHg). These patients needed CPB or extracorporeal membrane oxygenation (ECMO) as soon as possible because of the hemodynamic instability related to hypercapnia after the induction of anesthesia. The maximal preoperative PtcCO2 was significantly correlated with the maximal PtcCO2 at induction (p = 0.0076, r2 = 0.49) and overall (p = 0.005, r2 = 0.52). Conclusions: Continuous PtcCO2 monitoring is feasible and recommended because the intraoperative PaCO2 trend can be predicted from the preoperative PtcCO2 trend and timely assessed.

Technique of Dual Hepatic Reconstruction in Living Donor Liver Transplantation

Introduction: Hepatic artery reconstruction is technically the most important anastamosis during implantation as thrombosis of the artery can lead to loss of the graft. Dual hepatic arteries to either half of the lobe in a donor has been a contraindication as reconstruction of these small vessels in the recipient is technically demanding and has high rates of complications. Aim: We demonstrate a novel backbench reconstructive technique to manage dual hepatic arteries in the donor graft. Method: The Donors are assessed with a triphasic CT scan to ascertain the arterial anatomy. In the case of 2 hepatic arteries care is taken in the donor hepatectomy and the arteries are isolated and preserved. A high Hilar dissection approach is used in the recipient hepatectomy. The right and left hepatic arteries are traced back to their common trunk. The common trunk is divided along with its bifurcation in the recipient. The right and left hepatic arteries are anastamosed to the 2 arteries of the graft in the back bench with 8-0 Prolene interrupted. After reperfusion of the graft the arterial conduit is anastamosed to the common hepatic artery of the recipient using the same technique. All anastamosis performed under 4.5 loupe magnification. An on table Doppler is performed to ascertain the flow and RI in both the arteries. Doppler studies are done routinely for 5 post operative days. Results: In the last 100 consecutive Liver transplants, we had used this technique twice with no incidence of Hepatic artery thrombosis. All patients receive low molecular weight heparin once the INR falls below 1.5 and at discharge Aspirin 75mgs is added and is continued for 6 months. Conclusion: The use of the recipient's native common hepatic artery with its bifurcation for the reconstruction of 2 donor arteries is a valuable surgical option in Living donor Liver transplantation.