Hilar Dissection Research Articles

Current status and future perspectives of laparoscopic radical surgery for advanced gastric cancer.

Laparoscopic radical gastrectomy with lymph node dissection has widely penetrated to East Asian countries, where incidence of gastric cancer occurrence is higher than the rest of the world. Laparoscopic distal gastrectomy for cStageI disease is regarded as one of the option in daily practice in the latest Japanese guidelines; however its applicability to more advanced disease (Stage II/III) is still under debate. Actually, operative techniques of laparoscopic D2 dissection is being matured, but still, necessity of total omentectomy, splenic hilar dissection, management of bulky nodes or large primary tumor, high-level anastomosis in esophageal invasion cases, and extensive peritoneal lavage can be raised as technical limitations. In the future perspective, further technological innovation, including next generation surgical robot, may help surgeons overcome these difficulties. Currently, three large-scaled randomized phase-III clinical trials are ongoing in East Asia, in which patients' accruals have been already completed. With coming long-term outcomes of these well-designed studies, oncological validity of laparoscopic approach will be adequately elucidated.

Periarterial papaverine to treat renal artery vasospasm during robot-assisted laparoscopic partial nephrectomy

Renal artery vasospasm can be a troublesome complication during robot-assisted laparoscopic partial nephrectomy. Urologists performing this procedure, especially if utilizing selective arterial vascular microdissection, should be aware of using papaverine for both prevention and treatment of renal artery vasospasm. We present a 33-year-old male who developed severe renal artery vasospasm just with hilar dissection causing the kidney to become ischemic. Papaverine was topically applied on the renal arteries resulting in vasodilation and reperfusion of the kidney. Our objective of this report is to raise awareness of this complication as well as to review the literature on periarterial papaverine use and the dosing for topical applications.

A preoperative scoring system to predict the risk of No.10 lymph node metastasis for advanced upper gastric cancer: a large case report based on a single-center study.

PurposeTo investigate upper stomach carcinoma risk factors for No. 10 lymph node (LN) metastasis, and establish a preoperative scoring system to predict No.10 LN metastasis.MethodBetween January 2011 and December 2014, we prospectively collected and retrospectively analyzed the data of 398 patients with upper-third gastric cancer (GC) who underwent laparoscopic spleen-preserving hilar lymph-node dissection (SHLND). We use the logistics regression analysis risk factors of No. 10 LN metastasis to establish and verify a scoring model.ResultAmong the 398 patients examined, 38 patients had No. 10 LN metastasis, yielding a 9.6% transfer rate. The preoperative risk factor analysis for No. 10 LN metastasis in the modeling group showed that tumor size, preoperative T staging, and preoperative N staging are independent risk factors. To establish a scoring system, we divided the modeling group of patients into three levels: low risk, intermediate risk, and high risk. The No. 10 LN metastasis rates of the low risk, intermediate risk and high risk groups were 2.84%, 13.9% and 34.9% respectively, with statistically significant (P < 0.001). The value for the area under the ROC curve of the scoring system was 0.820, and there were no statistically significant differences between the observed and predicted incidence rates for No. 10 LN metastasis in the validation set (P > 0.05).ConclusionThe scoring system comprising the tumor size, preoperative T stage and N stage is a simple and effective method to predict the risk of No. 10 LN metastasis and to preoperatively select cases suitable for laparoscopic spleen-preserving SHLND.

Spleen-preserving lymphadenectomy versus splenectomy in laparoscopic total gastrectomy for advanced gastric cancer

BackgroundTo investigate the optimal approach for laparoscopic splenic hilum lymph node dissection in proximal advanced gastric cancer, we compared the operative outcomes between laparoscopic spleen-preserving total gastrectomy (sp-LTG) and laparoscopic total gastrectomy with splenectomy (sr-LTG). MethodsA retrospective case-cohort study was conducted between February 2006 and December 2012. The operative outcomes, the number of retrieved splenic hilum lymph node, complication, and patients' survivals were analyzed. Results112 patients who underwent laparoscopic total gastrectomy with or without splenectomy for advanced gastric cancer were enrolled (68 sp-LTGs and 44 sr-LTGs). The mean operation time (227 min vs. 224 min, p = 0.762), estimated blood loss (157 ml vs. 164 ml, p = 0.817), and complication rate (17.6% vs. 13.6%, p = 0.572) were not different between two groups. Regarding splenic lymph node dissection, there were significantly differences in the mean number of retrieved lymph nodes between sp-LTG and sr-LTG (LN no.10; 1.78 vs. 3.21, p = 0.033, LN no.11d; 1.41 vs. 2.76, p = 0.004). The 5-year survivals were 77.3% in sp-LTG and 65.9% in sr-LTG (p = 0.240). The hazard ratio of splenectomy was 1.139 (95% confidence interval 0.514–2.526, p = 0.748). ConclusionIn laparoscopic total gastrectomy for proximal advanced gastric cancer, spleen-preserving hilar dissection showed comparable short-term and long-term outcomes.

Uncommon features of surgically resected ALK-positive cavitary lung adenocarcinoma: a case report

Some features found on chest computed tomography (CT), such as central tumor location, large pleural effusion, and the absence of a pleural tail, and a patient age of less than 60 years, have been suggested to be useful in predicting anaplastic lymphoma kinase (ALK) rearrangement in patients with non-small cell lung cancer (NSCLC).A 68-year-old female patient with a history of gynecological treatment was found to have a cavitary mass in the right lower lobe on an annual chest roentgenogram. The tumor was located in the peripheral area with a pleural tail showing no pleural effusion. In addition, two pure ground-glass-opacity nodules (p-GGNs) in the right upper lobe of the lung were detected on consecutive chest CT scans. The patient underwent right lower lobectomy, partial resection of the right upper lobe, and hilar mediastinal lymph node dissection for complete resection of each tumor. The pathological diagnosis was invasive mucinous adenocarcinoma with signet-ring cells for the cavitary mass in the right lower lobe and invasive adenocarcinoma for the rest of the p-GGNs; subcarinal lymph node metastasis was also detected. The ALK rearrangement was detected by fluorescence in situ hybridization from the cavitary mass. The patient underwent four cycles of cisplatin and vinorelbine chemotherapy as standard adjuvant chemotherapy for pStage III NSCLC. The ALK fusion gene status of NSCLC with atypical CT features should also be investigated.

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 are crucial links in lymphatic drainage. According to the 14th edition of the Japanese GC treatment guidelines, a D2 lymphadenectomy is the standard surgery for advanced GC, and No. 10 lymph nodes 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 lymph node 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 lymph node dissection is critical for successfully completing the operation.

Evaluation of prognostic factors and implication of lymph node dissection in intrahepatic cholangiocarcinoma: 10-year experience at a tertiary referral center

BackgroundIntrahepatic cholangiocarcinoma (ICC) is the second most common primary liver malignancy, and surgical resection remains the only potentially curative treatment. However, the existing literature indicates that those prognostic factors associated with outcome after surgery remain poorly defined. MethodsData were retrospectively collected from 103 patients with ICC who underwent surgical resection between 2005 and 2014. The patients were divided into two groups: one with (D1) and one without (D0) lymph node dissection of hepatic hilum according to the surgery performed. Thereafter, the prognostic values of clinicopathological characteristics were evaluated. ResultsThe median overall survival (OS) after surgical resection of ICC was 43.9 months [95% confidence interval (CI), 11.6–76.2 months]. The 1-, 3-, and 5-year OS rates were 85.5%, 52.8%, and 45.6%, respectively. Multivariable analysis showed that lymph node metastases [hazard ratio (HR), 6.70; 95% CI, 2.18–20.55], positive resection margins (HR, 2.67; 95% CI, 1.14–6.23), periductal infiltration (HR, 3.64; 95% CI, 1.27–10.44), and poor differentiation (HR, 2.90; 95% CI, 1.41–5.95) were independently associated with poor survival. There were no significant differences in clinicopathological characteristics between D1 and D0 groups, except for vascular invasion (p = 0.018) and perineural invasion (p = 0.008). In the D1 group, lymph node metastases were associated with late T stages, multiple tumors, and elevated serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels. ConclusionRegional lymph node metastasis, positive resection margin, periductal infiltration, and poor differentiation were poor prognostic factors in patients with ICC after curative surgery. Lymph node dissection did not show survival benefits, but was useful for nodal staging. However, lymph node metastases were strongly associated with late T stages, multiple tumors, and elevated serum CEA and CA19-9 levels.

Percutaneous Externally Assembled Laparoscopic vs Laparoendoscopic Single-Site Nephrectomy in a Porcine Model: A Prospective, Randomized, Blinded, Study.

To compare the outcomes between laparoendoscopic single-site (LESS) and a novel percutaneous externally assembled laparoscopic (PEAL) nephrectomy in an in vivo porcine model. Ten female farm pigs were randomized to LESS nephrectomy (5) or PEAL nephrectomy (5). Operative times, estimated blood loss, and intraoperative and postoperative complications were compared. The surgeons used a Likert scale to grade difficulty of peritoneal access, port placement, tool assembly, hilar dissection, closure, and overall difficulty of surgery. Scar assessment was performed by a blinded plastic surgeon using the Vancouver Scar Scale. Descriptive statistics were reported as median and range. The Mann-Whitney U test was used for continuous and ordinal variables. A p value <0.05 was considered significant. Median operative time was significantly shorter in the PEAL group vs the LESS group (85 minutes vs 127 minutes, p = 0.03). Median Likert scores showed overall hilar dissection and nephrectomy to be significantly easier using PEAL compared with LESS (2 vs 9, p < 0.01 for both). The PEAL instruments left no visible scar at 5 feet in any animal, and only 1 out of 10 scars could be identified on physical examination. The PEAL surgical paradigm demonstrates nearly scarless outcomes while providing shorter operative times and easier performance than LESS nephrectomy in a porcine model.

CHYLOUS LEAKAGE AFTER LAPAROSCOPIC RENAL AND ADRENAL SURGERY

(Objectives) It is recognized that Chylous leakage is a rare complication but is a relevant clinical problem after major abdominal surgery. It was occasionally reported in urologic surgery, but the data about its incidence and treatment outcome is still lacking. In this study, we reviewed our cases of chylous leakage after laparoscopic adrenalectomy or nephrectomy. (Patients and methods) From January 2005 to September 2014, laparoscopic adrenalectomies or nephrectomies were performed in 300 patients. The factors that affected the development of chylous leakage were analyzed. (Results) The overall incidence of chylous leakage was 4.3% (13 of 300 cases). All chylous leakage was seen on the left side, and it was commonly developed in patients with lymph node dissection or excessive hilar dissection around the left renal pedicle. Importantly, all cases were successfully managed conservatively by a low fat diet with or without octreotide. (Conclusions) Our results suggest that chylous leakage is not a rare complication after laparoscopic adrenalectomy or nephrectomy, but most cases can be treated conservatively. Chylous leakage can occur in patients with lymphadenectomy or hilar dissection on the left side.

P1.03-072 Mediastinal Lymph nodes Staging by PET CT for Resectable Non-Small Cell Lung Cancer in a Tuberculosis Endemic Country

Integrated 18 fluorine fluorodeoxyglucose (18F-FDG) PET-CT has shown somewhat variable sensitivity and specificity for nodal staging in tuberculosis endemic areas. This variation mainly because PET scans show falsely increased 18F-FDG uptake in inflammatory nodes, which may be observed in lymph nodes containing calcification or showing higher attenuations than those of surrounding great vessels on unenhanced CT scans. TB is a major health problem in India, incidence is around 2.1 million cases annually. The purpose of the study was to evaluate the efficacy of PET-CT for mediastinal nodal staging in non-small cell lung cancer (NSCLC) patients in a tuberculosis-endemic country. Prospective assessment of the diagnostic efficacy of integrated PET-CT for detecting mediastinal nodal metastasis was performed from February 2012 to February 2016. A total 160 patients underwent surgery for pathologically proven NSCLC. Patients who received chemotherapy or radiotherapy prior to surgery were excluded from study. Thus assessment of the diagnostic efficacy of integrated PET-CT for detecting nodal metastasis was performed in 46 patients (Male to Female ratio:4; mean age- 55 years). Patients underwent an integrated PET-CT examination and subsequent surgical nodal staging. One radiologist and 1 nuclear medicine specialist together prospectively evaluated PET-CT datasets. Nodes showing greater 18F-FDG uptake at PET without benign calcification or high attenuation >70 household unit (HU) at unenhanced CT were regarded as being positive for malignancy. All patients underwent hilar and mediastinal lymph nodes dissection according to the AJCC lymph node map (nodal stations 2R, 4R, 7, 8 and 9 for a right-sided tumor; 4L, 5, 6, 7, 8 and 9 for a left-sided tumor) after resection of the main tumor. Histologic nodal assessment results were used as reference standards. Of these 55 patients, 10 (20%) had a past history of pulmonary tuberculosis as determined by clinical or imaging studies. Of 230 mediastinal nodal stations evaluated in 46 patients, 5(2%) stations in 4(8%) patients proved to be malignant by histopathologic assessment. Mean number of lymph node stations evaluated were 5. On a per-nodal station basis, the overall sensitivity, specificity, accuracy, PPV, NPV of PET-CT were 60%, 97%, 96%, 38%,99% for mediastinal lymph nodes staging (N2) respectively. Integrated PET-CT provides high specificity and high accuracy, but low sensitivity for mediastinal staging of NSCLCs. The high specificity is achieved at the expense of sensitivity by interpreting calcified nodes or nodes with high attenuation at CT, even with high FDG uptake at PET, as benign in a tuberculosis-endemic region.

SC02.03 Surgery for Ground Glass Opacity: Sublobar Resection?

SC02.03 Surgery for Ground Glass Opacity: Sublobar Resection?

Open surgical approach and technique in left pneumonectomy

The classic posterolateral thoracotomy remains an important incision to any surgeon for lung resections. It allows inspection, complete mobilization of the lung and hilum and access to mediastinal structures. For pneumonectomy, the key-step is the circumferential hilar dissection, exposing the hilar structures, resect lymph nodes and assess resectability in cancer operations. The dissection starts at the level of the left pulmonary artery (PA) and proceeds posteriorly and inferiorly. Suspension of the posterior mediastinum provides excellent exposure of the left main bronchus and the inferior pulmonary vein, while at the same time protects the recurrent nerve and the esophagus. The dissection circumvents the ligament and continues anteriorly, until the superior pulmonary vein is identified and the hilar loop is completed. Isolation of each structure by blunt or even finger dissection commences, and a vascular tape is applied for gentle retraction. The PA is divided first, followed by the inferior and superior pulmonary veins. Either non-absorbable monofilament sutures or staplers may be equally used for the transection of each structure. We suggest initial clamping and then proximal and distal transfixion of the vessels rather than simple ligation if sutures are to be used. Special attention should be paid to the transection of the bronchus, as this step is usually responsible for late complications. The bronchus should be dissected free, up to the level of the carina, retracted, clamped and divided, leaving the shortest possible stump. Either double horizontal mattress sutures or stapler provide equally safe result. The procedure is completed with extended lymph node dissection and air leak assessment.

Eversion Technique to Prevent Biliary Stricture After Living Donor Liver Transplantation in the Universal Minimal Hilar Dissection Era.

Biliary anastomosis stricture (BAS) is still among the major concerns after living donor liver transplantation (LDLT), even after the technical refinements including the universal use of the blood flow-preserving hilar dissection technique. The aim of this study is to investigate what are still the factors for BAS after LDLT. An analysis of 279 adult-to-adult LDLT grafts (left lobe, n = 161; right lobe, n = 118) with duct-to-duct biliary reconstruction, since the universal application of minimal hilar dissection technique and gradual introduction of eversion technique, was performed. There were 39 patients with BAS. Univariate analysis showed that a right lobe graft (P = 0.008), multiple bile ducts (P < 0.001), ductoplasty (P < 0.001), not using the eversion technique (P = 0.004) and fewer biliary stents than bile duct orifices (P = 0.002) were among the factors associated with BAS. The 1-year and 5-year BAS survival rates were 17.7% and 21.2% in the noneversion group (n = 134), and 6.2% and 7.9% in the eversion group (n = 145), respectively (P = 0.002). The perioperative factors including graft biliary anatomy were not different between everted (n = 134) and noneverted (n = 145) patients. The application of eversion technique under minimal hilar dissection technique could be a key for preventing BAS in duct-to-duct biliary reconstruction in LDLT.

Robotic Lobectomy: Left Lower Lobectomy by Surgery

According to National Comprehensive Cancer Network guidelines concerning non–small cell lung cancer, robotic lobectomy is considered an advisable oncologic procedure for patients with lung cancer, with no anatomic or surgical contraindications. At present, da Vinci is the only available robotic system (Intuitive Surgical, Inc., Sunnyvale, CA), with 2 platforms (da Vinci SI and da Vinci XI) requiring different port-mapping and cart positioning. Robotic left lower lobectomy can be considered one of the most technically simple of all lobectomies. We describe our endoscopic technique, with 4 surgical ports, using CO2 insufflation.

Application value of splenic hilar lymphadenectomy in patients with Siewert type II and III adenocarcinoma of esophagogastric junction and a tumor diameter .GEQ.4 cm

Objective To investigate the long-term outcomes of splenic hilar lymphadenectomy (SPL) in patients with Siewert type Ⅱ and Ⅲ adenocarcinoma of esophagogastric junction (AEG) and a tumor diameter≥4 cm after radical total gastrectomy. Methods The retrospectively cohort study was conducted. The clinico-pathological data of 412 patients with Siewert type Ⅱ and Ⅲ AEG and a tumor diameter≥4 cm who were admitted to the Fujian Medical University Union Hospital from December 2007 to December 2013 were collected. Transabdominal and open or laparoscopic radical total gastrectomies were applied to 412 patients by surgeons in the same team. Of 412 patients, 154 receiving spleen-preserving SPL in situ were allocated into the SPL group and 258 who didn′t receive SPL were allocated into the non-SPL group. Observation indicators included: (1) surgical situations, (2) follow-up situations, (3) postoperative survival factors analysis in patients with Siewert type Ⅲ AEG and a tumor diameter≥4 cm. Follow-up using outpatient examination, door-to-door visit, correspondence and telephone interview was performed once every 3 months within 2 years postoperatively and once every 6 months within 3-5 years postoperatively up to June 2015. Follow-up included regular physical examination, laboratory examinations (levels of CA19-9, CA72-4 and CEA), chest X-ray, total abdomen color Doppler ultrasonography or computed tomography (CT) scan and annual gastroscopy. The overall survival was from operation to the last follow-up or death or deadline of follow-up database (loss to follow-up and dying of other diseases). Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using the t test. Measurement data with skewed distribution were described as M (range) and comparison between groups was analyzed using the Mann-Whitney U test. Count data were analyzed using the chi-square test or Fisher exact probability. The survival rate and survival comparison were respectively done by the Kaplan-Meier method and the Log-rank test. The univariate analysis and multivariate analysis were done using the chi-square test and COX regression model. Results (1) Surgical situations: operation time, volume of intraoperative blood loss and number of lymph node dissected were (217±65)minutes, 50 mL (range, 10-1 000 mL), 38±13 in the SPL group and (204±54)minutes, 50 mL (range, 5-2 000 mL), 31±10 in the non-SPL group, respectively, with no statistically significant difference in volume of intraoperative blood loss between the 2 groups (Z=1.495, P>0.05) and with statistically significant differences in operation time and number of lymph node dissected between the 2 groups (t=2.140, 5.400, P 0.05). (2) Follow-up situations: 384 patients were followed up for 48 months (range, 17-89 months). The 3-year overall survival rate and disease-free survival rate were respectively 72.7%, 67.4% in the SPL group and 54.4%, 48.5% in the non-SPL group, with statistically significant differences between the 2 groups (χ2=7.580, 12.380, P 0.05). Among patients with Siewert type Ⅲ AEG, 3-year overall survival rate and disease-free survival rate which were 72.4% and 68.3% in the SPL group were significantly higher than that which were 48.3% and 42.2% in the non-SPL group (χ2=8.990, 14.030, P<0.05). (3) Postoperative survival factors analysis in patients with Siewert type Ⅲ AEG and a tumor diameter≥4 cm: results of univariate analysis showed that age, American Society of Anesthesiologists (ASA) score, tumor differentiation, splenic hilar dissection, T stage, N stage and TNM stage were factors affecting postoperative 3-year overall survival rate in patients with Siewert type Ⅲ AEG and a tumor diameter≥4 cm (χ2=8.825, 7.485, 6.766, 8.996, 14.024, 26.002, 19.461, P<0.05). There were correlations among age, splenic hilar dissection, N stage, TNM stage and postoperative 3-year disease-free survival rate in patients with Siewert type Ⅲ AEG and a tumor diameter≥4 cm (χ2=6.743, 14.038, 26.596, 21.285, P<0.05). Results of multivariate analysis showed that age≥65 years, without splenic hilar dissection, T stage and N stage were independent risk factors affecting postoperative 3-year overall survival rate in patients with Siewert type Ⅲ AEG and a tumor diameter≥4 cm [HR=1.817, 0.458, 1.613, 1.312, 95% confidence interval (CI): 1.117-2.955, 0.292-0.721, 1.129-2.304, 1.004-1.714, P<0.05]. Age≥65 years, without splenic hilar dissection and TNM stage were independent risk factors affecting postoperative 3-year disease-free survival rate in patients with Siewert type Ⅲ AEG and a tumor diameter≥4 cm (HR=1.807, 0.442, 1.799, 95%CI: 1.258-2.596, 0.228-0.679, 1.004-3.224, P<0.05). Conclusions SPL should be performed to patients with Siewert type Ⅲ AEG and a tumor diameter≥4 cm due to higher lymph node metastasis rate, and it will be beneficial to survival of patients. Key words: Esophagogastric junction neoplasms, adenocarcinoma; Siewert classification; Total gastectomy; Splenic hilar lymphadenectomy

Application of Da Vinci surgical robot in the dissection of splenic hilar lymph nodes for gastric cancer patients with total gastrectomy

To investigate the feasibility and safety of Da Vinci surgical robot in the dissection of splenic hilar lymph nodes for gastric cancer patients with total gastrectomy. Clinical data of two cases who underwent total gastrectomy for cardia cancer at our department in January 2016 were analyzed retrospectively. Two male patients were 62 and 55 years old respectively, with preoperative diagnosis as cT2-3N0M0 and cT1-2N0M0 gastric cancer by gastroscope and biopsy, and both received robotic total gastrectomy spleen-preserving splenic hilar lymph node dissection successfully. The operative time for splenic hilar lymph node dissection was 30 min and 25 min respectively. The intraoperative estimated blood loss was both 100 ml, while the number of total harvested lymph node was 38 and 33 respectively. One dissected splenic hilar lymph node and fatty tissues in two patients were proven by pathological examinations. There were no anastomotic leakage, pancreatic fistula, splenic infarction, intraluminal bleeding, digestive tract bleeding, aneurysm of splenic artery, and other operation-associated complications. Both patients suffered from postoperative pneumonia, and were cured by conservative therapy. The robotic spleen-preserving splenic hilar lymph node dissection is feasible and safe, but its superiority needs further evaluation.

Upper midline incision for living donor right hepatectomy.

Living donor liver transplantation is a viable option to increase access to transplantation and techniques to limit the operative incision is one way to increase donation by decreasing donor morbidity. We describe our experience with a limited upper midline incision (UMI) for living donor right hepatectomy. Prospective data were collected on 58 consecutive living liver donors who underwent right hepatectomy via a UMI. Donor median age was 32years, with median body mass index of 24.6. The mean incision length was 11.7cm. Ten liver grafts included middle hepatic vein. The mean graft volume by preoperative imaging was 940cc. The mean operative time was 407minutes; cellsaver was utilized in 35 patients with median of 1 unit. Mean peak aspartate transaminase (AST) and alanine transaminase (ALT) were 492 and 469, and peak bilirubin and international normalized ratio (INR) were 3.3 and 1.8. The average length of stay was 6days. There were 10 Clavien grade I and 11 Clavien grade II complications. Three patients developed an incisional hernia requiring surgical repair. Living liver donor hepatectomy can be safely performed through a UMI. This approach consolidates the steps of liver mobilization, hilar dissection, and parenchymal transection in a single-exposure technique, with incision comparable to the laparoscopic-assisted modality.

Robotic liver resection including the posterosuperior segments: initial experience

BackgroundRobot-assisted laparoscopy has been introduced to overcome the limitations of conventional laparoscopy. This technique has potential advantages over laparoscopy, such as increased dexterity, three-dimensional view, and a magnified view of the operative field. Therefore, improved dexterity may make a robotic system particularly suited for liver resections, which require nonlinear manipulation, such as curved parenchymal transection, hilar dissection, and resection of posterosuperior segments. MethodsBetween August 2014 and March 2016, 16 patients underwent robot-assisted laparoscopic liver resection at University Medical Center Utrecht. ResultsFifteen robot-assisted laparoscopic liver resections were performed in a minimally invasive manner. One procedure was converted. In eight patients, we performed a resection of a posterosuperior segment (segment 7 or 8). Median operating time was 146 (60-265) min, and median blood loss was 150 (5-600) mL. Four patients had a Clavien–Dindo grade III complication. Median length of stay was 4 (1-8) days. There was no mortality. ConclusionsThis 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 shows that the robotic platform also enables fully laparoscopic resections of the posterior segments.

Laparoscopic spleen-preserving hilar lymph node dissection through pre-pancreatic and retro-pancreatic approach in patients with gastric cancer.

BackgroundThe conventional radical resection of proximal gastric cancer is even more risky when performed laparoscopically, though this technique is widely used in gastrointestinal surgery and is accepted as the superior method. This paper explores the feasibility of laparoscopic spleen-preserving hilar lymph node dissection using a retro-pancreatic approach for the treatment of proximal gastric cancer.MethodsTwo cadavers were dissected for examination of and the pre-pancreatic and retro-pancreatic spaces. Following the dissection of the cadavers, ten live patients with proximal gastric cancer from May 2008 to May 2013 at Nanfang Hospital, Guangzhou, China, were given total gastrectomy and adjuvant splenic hilar lymph node clearance through pre-pancreatic and retro-pancreatic approach on the precondition of preserving the pancreas and spleen. The clinicopathologic characteristics, as well as the intraoperative and postoperative variables affecting the procedure, were observed and analyzed.ResultsAnatomy of the space anterior and posterior to the pancreas in the two cadavers demonstrated the feasibility of pre-pancreatic and retro-pancreatic approach. The surgeries were all successfully performed laparoscopically; conversion to laparotomy was not necessary for any of the ten patients. The overall mean operative time was 243.6 ± 45 min. The mean estimated blood loss was 232 ± 80 ml. At the time of follow-up (median 12 months post-surgery), there had been neither local recurrence nor mortality in any of the patients.ConclusionLaparoscopic spleen- and pancreas-preserving splenic hilar lymph node dissection during total gastrectomy, using both pre-pancreatic and retro-pancreatic approaches, is indicated as a safe and feasible method for the treatment of proximal gastric cancer.

Inverting the ALPPS paradigm by minimizing first stage impact: the Mini-ALPPS technique.

The current associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) approach is represented by an aggressive first surgical procedure followed by a shorter and less aggressive second procedure. This paradigm has been associated with high morbidity and mortality. Inverting the aggressiveness of the surgical stages might be beneficial in order to facilitate patient recovery during interval period. We propose a new technical paradigm for the ALPPS approach. During the first stage, partial parenchymal transection combined with intraoperative portal vein embolization (PVE) was performed. Liver mobilization was kept at minimum while hilar plate or hilum dissection was strictly avoided. The completion surgery by means of the anterior approach was carried out once sufficient future liver remnant (FLR) hypertrophy and function were certified. We applied this technique in four patients (hepatocellular carcinoma in a cirrhotic liver = 1 and colorectal liver metastases = 3). The mean FLR hypertrophy was 62.6% (range 49-79). All the four patients underwent the completion surgery with R0 margins, and neither one developed liver failure nor major complications. The technique proposed inverts the current ALPPS strategy, minimizing the first stage impact to promote rapid patient recovery and leaving the main surgical procedure for the second stage. The combination of evidence-based facts such as partial parenchymal transection, intraoperative PVE, and "non-touch" oncological rules was feasible and safe, allowing complete tumor resection in highly selected candidates with extensive liver disease.