Jackknife Position Research Articles

Use of the Profunda Femoris Artery Perforator Flap for Reconstruction after Sarcoma Resection.

Background:Soft tissue sarcomas are rare neoplasms that can occur on any part of the body. The operative position for the resection is determined depending on the site of the soft tissue sarcomas; intraoperative repositioning may be needed for reconstruction. We present the profunda femoris artery perforator (PAP) flap harvest technique (wherein the flap can be used in any position), and suggest that the PAP flap transfer can eliminate the need for intraoperative repositioning.Methods:From December 2018 to January 2020, 7 patients with an average age of 68 years underwent reconstructions using a PAP flap after wide resection of STS. The mean defect size was 11.3 × 16.5 cm (range, 5.5–25 × 11–26 cm). The location of the defects was the medial thigh in 2 patients, the posterior thigh in 1, the popliteal fossa in 1, the groin in 1, and the buttock in 2. The PAP flap was elevated in the supine “frog-leg” position, the prone position, the jack-knife position, or the lateral “crisscross” position; the lateral decubitus position with the donor lower extremity on the bottom.Results:Of the 7 cases, the operations were performed in the supine “frog-leg” position in 3 cases, the prone position in 2 cases, the jack-knife position in 1 case, and the lateral “crisscross” position in 1 case. There were no intraoperative position changes in all cases. The mean size of the PAP flap was 8.7 × 19.9 cm (range, 6–11 × 17–24 cm). One patient had donor site dehiscence, which was treated conservatively. The PAP flaps survived completely in all cases. The mean follow-up period was 10.5 months (range, 6–17 months).Conclusion:Since the PAP flap elevation is feasible in every position, the PAP flap can be considered a versatile reconstruction option after sarcoma resection.

Perineal resection and anorectal amputation with perforator flap reconstruction by a dorsal approach in prone Jackknife position

Some gynecological malignancies, such as vulvar or vaginal cancer, can present a local extension to the anus or rectum due to their close anatomical relationship. The frontline treatment in the...

Transanal total mesorectal excision in the prone jackknife position without being conscious of the size of prostatic enlargement for lower rectal cancer.

In 1982, it was demonstrated that a total mesorectal excision alone could achieve low rectal cancer recurrence rates in the pelvis and high disease-free survival rates. Nowadays, the total mesorectal excision is the gold-standard surgery for rectal cancer. Currently, the transanal total mesorectal excision has attracted attention as a promising alternative to the anterior approach. The transanal approach is superior to the anterior approach, because it facilitates total mesorectal excisions of the lower rectum, improves visualization, and shortens the surgical time. Some factors are particularly favorable for the transanal approach, including lesions in the lower third of the rectum, a narrow pelvis, a large tumor, male sex, and a prostatic enlargement. The transanal total mesorectal excision is commonly performed in the Lloyd-Davies position. However, in the Lloyd-Davies position, the sacral bone prevents the mobilized rectum from moving away from the pelvic base. From the perspective of pelvic morphology, we reasoned that, in the prone jackknife position, the mobilized rectum could spontaneously move toward the head, due to gravity, and this would broaden the pelvic surgical field. Consequently, this position could facilitate the transanal total mesorectal excision. Here, we described a transanal total mesorectal excision performed in the prone jackknife position for treating lower rectal cancer with a prostatic enlargement.

Extralevator abdominoperineal excision

Extralevator abdominoperineal excision (ELAPE) has been introduced to alleviate the disappointing results of conventional abdominoperineal excision (APE) with respect to inadvertent bowel perforation, positive circumferential resection margins (CRM), and local recurrence rates. The main principle of this operation is to shift the resection plane away from the anorectal junction, which is the area at highest risk of perforation and CRM positivity. This is accomplished by resection of the levator ani muscle, which is followed at its outer surface close to its origin at the pelvic side wall. The anterior region is also addressed with comfortable access to the dissection area by placement of the patient in prone jackknife position. All measures aim to avoid a waist at the anorectal junction. This article describes the procedure in detail, including strategies to close the perineal defect. In a brief review of the literature, the favorable results of ELAPE are discussed. Conclusion. It can be concluded that the perineal phase of ELAPE is highly standardized and can be taught in a step-by-step fashion. There is evidence that ELAPE results in lower rates of inadvertent bowel perforations, lower rates of positive CRM, and lower rates of local recurrence.

Abdominoperineal resection in the prone position: early outcomes at a tertiary institution in the Western Cape, South Africa

Background Extra-levator abdominoperineal resection (ELAPE) performed in the prone jack-knife position is a new technique in the developing world. Literature on the outcomes of ELAPE in a developing country context is scarce. The objective was to assess early outcomes after ELAPE in the prone jack-knife position, and to compare outcomes of patients who underwent the abdominal part of the procedure performed laparoscopically with an open group, at a tertiary institution in Cape Town. Methods Records of patients who underwent ELAPE for rectal adenocarcinoma from February 2011 to February 2017 at Tygerberg Hospital were retrospectively reviewed. Variables of interest included staging, rate of circumferential resection margin involvement (CRMI), intraoperative tumour perforation (IOP), perineal wound complications, early postoperative morbidity, length of intensive care unit (ICU) stay, duration of postoperative hospital stay and 30-day mortality rate. Results 52 patients (median age: 59 years) were included in the analysis. CRMI was evident in 16% (8/49) of patients and IOP in 6% (3/52). Perineal wound complications occurred in 32% (16/50) of patients. Median length of ICU and postoperative hospital stay was 3 days and 7 days, respectively. Overall morbidity was 47% (24/51) and the 30-day mortality rate was 3% (2/52). A significant difference in length of hospital stay was evident between the open and laparoscopic groups (11.5 days vs 6 days). Conclusion Prone abdominoperineal resection (APR), ELAPE, and laparoscopic ELAPE are acceptable and feasible procedures for patients with rectal cancer in the developing world, with outcomes being comparable to those determined in the developed world.

Application of KeyPort access to transanal endoscopic mircrosurgery

Objective: To explore the effectiveness of KeyPort access in transanal endoscopic mircrosurgery (TEM). Methods: A descriptive case series study was performed. Clinicopathological data of 20 patients undergoing KeyPort access TEM in Beijing Chaoyang Hospital of Capital Medical University from December 2016 to April 2018 were collected and analyzed retrospectively. Procedure of KeyPort access TEM: general anesthesia or combined spinal epidural anesthesia (CSEA); lithotomy or prone jack-knife position; anal dilation; placement of the KeyPortaccess; connection of TEM pneumoperitoneum device, light source and imaging equipment; placement of 5 mm dedicated endoscope; insufflation of CO2 with pressure of 1.6-2.0 kPa (12-15 mmHg); after rinsing the intestinal lumen, circular resection marginlabeled by the needle-shaped electrocautery;electric coagulation or ultrasonic knife used to perform a full-thickness resection with a 0.5 cm-1 cm margin along the marking line. Indications of KeyPort access TEM: (1) benign large sessile polyps which were difficult to resect under colonoscopy; (2) submucosal lesions with diameter <2 cm; (3) Tis and T1 stage rectal carcinoma without lymph node metastasis; (4) palliative resection of T2 stage rectal carcinoma without lymph node metastasis. Contraindications: (1) accompanying serious diseases without the tolerance of anesthesia and operation; (2) distance from lesion to anal verge >20 cm. Results: There were 10 males and 10 females with age of (63±15) years old and BMI of (24.5±3.3) kg/m(2). The diameter of the lesions was (2.0±1.3) cm, and the distance from lesion to anal verge was (6.2±2.2) cm. One patient had 3 lesions at different positions in rectum with diameters of 0.5 cm, 0.5 cm, and 1 cm, respectively. All operations were accomplished through the KeyPort access TEM and no case was transferred to other methods. The duration of surgery was 75 (30-220) minutes; intraoperative blood loss was 10 (0-30) ml. Two patients with rectal anterior wall lesions underwent full-thickness resection of the intestine wall reaching the peritoneal reflex with penetration into the peritonealcavity, and received suture closure immediately. For the patient with 3 rectal lesions, the 1.0 cm lesion received a full-thickness resection and the other 2 lesions received submucosal resection. No postoperative complication occurred. Postoperative pathology showed that there were 1 case of chronic inflammatory lesion, 4 cases of benign tumor, 3 cases of carcinoma in situ, 4 cases of neuroendocrine tumor, 6 cases of pT1 rectal cancer, 2 cases of pT2 rectal cancer (both invading the superficial muscle layer). The median hospital stay was 6 (3-7) days. The postoperative follow-up was (7.2±3.8) months. No postoperative complication or recurrence was observed. Conclusion: TEM with KeyPort access is safe, rapid and effective in the treatment of rectal tumors.

Transanal Total Mesorectal Excision (TaTME): Experience in Klaipėda University Hospital

Introduction. Colorectal cancer ranks third on the list of the most common cancers. In 1979 R. J. Heald described total mesorectam excision (TME) which became a gold standard for rectal cancer treatment. This operation is performed all over the world open, laparoscopic and robotic. Operating on low and very low rectal cancer, distal bowel mobilisation if often the most difficult part of the operation. Aa a solution to this problem transanal abdominotransanal rectal resection (TATA) and transanal total mesorectal excision (TaTME) were proposed. This article reviews the experience and short-term postoperative outcomes of TaTME performed in Klaipėda University Hospital.Methods. The first stage of surgery was performed with patient placed in the prone jackknife (Kraske) position. Using electrocauthery circular mobilisation of the rectum was performed starting at least 1 cm from the lower edge of the tumour. Up to 10 cm of the rectum was mobilised from below. The second stage was performed with patient in lithotomy position. Laparoscopic TME was performed. For 11 (78.57%) patients hand sown anastomosis was performed and for 1 (7.17%) patient stapler was used. 2 (14.28%) patients underwent the Hartmann’s procedure.Results. In period 2018.03–2019.10 TaTME was performed for 14 patients. The medium tumour high counting from dentate line was 2.54 (±1.28). 13 out of 14 patients were operated from 8 to 12 weeks after chemoradiotherapy. All (100%) rectal resections were radical (R0). On average 11.43 (±3.78) lymphnodes were harvested. 5 (35.71%) patients had complications after surgery.Conclusions. TaTME performed at Klaipėda University Hospital is effective operation for rectal cancer treatment.

Accidental death in a jack-knife position

Postural (or “positional”) asphyxia occurs due to a person being in a prolonged abnormal body position that prevents adequate breathing. Its diagnosis is based on several criteria, in particular the exclusion of involvement of other people and other causes of death. This case report is about a 73-year-old woman whose body was found in a jack-knifed position by her son. She was on the floor, wedged into the space between the legs and seat of a chair. The man attempted unsuccessfully to extricate her from that position and called for medical assistance. The rescuers took pictures of the scene before freeing the victim from the chair and providing unsuccessful resuscitation. External examination disclosed abrasions on the thighs and the back of the victim, which corresponded to parts of the chair, ecchymoses on the upper limbs (ascribed to the gripping attempts), conjunctival petechiae, facial congestion and swelling. Autopsy disclosed brain and lung congestion and edema and atherosclerotic coronary disease without acute cardiac lesions. All these considerations contributed to the cause of death being determined as being due to postural asphyxia.

Gluteal Vein Anatomy: Location, Caliber, Impact of Patient Positioning, and Implications for Fat Grafting.

Deaths in gluteal autografting occur due to gluteal vein injuries, but data are lacking on the precise location and caliber of these veins. The authors sought to present the first in vivo study of gluteal vein anatomy utilizing magnetic resonance imaging. Magnetic resonance imaging venography of 16 volunteer hemi-sections was conducted in the supine, prone, prone with a bump (jack-knife), and left and right decubitus positions in 1 session after a single contrast administration. Caliber and course of the superior and inferior gluteal veins (SGV/IGV) were analyzed vs bony landmarks and position changes. The SGV has a very short submuscular course before splitting into 2 smaller branches superolaterally. The IGV runs immediately deep to the gluteus maximus in the center of the buttock as a single large trunk, on average 56 mm deep (mean 27 mm of muscle belly and 30 mm subcutaneous fat). No intramuscular or subcutaneous branches greater than 2 mm were found. In the prone position, the IGV and SGV have an average caliber of 5.96 mm and 5.63 mm. Vessel caliber decreased by 21% and 27%, respectively, in the jack-knife position and by 14% and 15% in lateral decubitus. The SGV and IGV are immediately deep to gluteus maximus approximately 6 cm deep with a caliber on the order of 6 mm in the prone position. The distribution of these vessels suggests there is no "safe zone" in the intramuscular or submuscular planes. The jackknife or lateral decubitus positions can decrease vein caliber by up to 27%, possibly reducing the risk of injury due to either traction or direct cannula impact.

Avoiding complications in microsurgery and strategies for flap take-back.

The invention of the operating microscope, the introduction of the vessel triangulation technique, and the development of fine microinstruments and microsutures were seminal factors in the widespread adoption of reconstructive microsurgery. In the decades that followed, advances in our understanding and technology have ushered in a new frontier of microsurgery, revolutionizing soft tissue reconstruction. Where skin grafts or pedicled flaps of limited tissue types were once the mainstay of reconstruction, free tissue transfer of multiple tissue types has enabled dramatic improvements in aesthetic and functional results. In the last 45 years since the first free flap, microsurgery has been a process in constant evolution. Success in microsurgery is not an end point, but the culmination of a series of steps that are taken toward achieving a particular objective. Over time and with experience, critical evaluation of each step yields better judgement and alternate, often better ways of doing things. The exercise of physical preparation (staying in “technical shape”), mental reflection, and continual refinement is the key to staying current and obtaining positive results. Indeed, the maxim “Preparation is the only shortcut that you need,” shared many years ago by the esteemed Dr. Robert Acland, remains true today. Rigorous training and sustained practice form the technical foundations of any competent microsurgeon. The learning curve for microsurgery, while steep, can be overcome at a basic level by sufficient practice on ex vivo simulation models and small animals. It has been demonstrated that an average of 25 rat femoral vein anastomoses was necessary to overcome the microsurgical learning curve, with patency rates increasing from 48% to 83.4% [1]. Patient selection is equally important; while there are no absolute contraindications to microsurgical reconstruction, expectations must be managed if compliance to postoperative restrictions and in particular, tobacco use, is likely to be an issue. Smokers should be counselled on the need for smoking cessation several weeks before and after surgery. Systemic comorbidities such as diabetes and cardiopulmonary conditions must be optimized prior to elective reconstruction to minimize patient morbidity. Great care is warranted when operating within an irradiated field, as these tissues tend to be more friable, with a tendency for vessel delamination during dissection. The cornerstone of any successful procedure is obtaining informed consent from the patient and establishing robust lines of communication with his or her family. The reconstructive approach must be tailored to the goals and expectations of the patient. If a proficient surgeon is operating on an optimized patient after obtaining informed consent, then the subsequent considerations are technical. Surgical considerations include the selection of recipient vessels, flap type, intraoperative positioning (or need for position changes), and postoperative care. If a two-team reconstructive approach is to be utilized, this should be discussed with the resecting team. The surgeon performing recipient vessel preparation must be well versed with the regional anatomy, with a plan for a backup vessel should the situation go awry. Postoperative care requirements, such as intensive care unit bookings, must be secured prior to the operation. With the multitude of variables and uncertainties that accompany a complex reconstructive problem, a mental preoperative checklist is a useful tool to ensure that the entire team is on the same page. The reconstructive plan, comprising the first and second choice of flap, recipient vessel selection, sequence of harvest, patient positioning, and microscope location around the table must be discussed with all parties involved. The relevant staff should be briefed on the “how and where” of postoperative monitoring. A bed within the postoperative care area or a room with telemetry facilities for close monitoring of the patient and flap perfusion should be available. Nursing staff must be aware of the reconstruction performed, the location of the pedicle, and region-specific nursing requirements (e.g., jack-knife position nursing, non-weight-bearing status). Medical staff monitoring the flap must be aware of the baseline vascular perfusion of the flap, as well as the method and frequency of flap monitoring.

Posterior retroperitoneoscopic adrenalectomy for pediatric adrenal tumors

Background/aimsPosterior retroperitoneoscoic adrenalectomy has been reported as an option for adrenal tumor resection but is not commonly performed in children owing to the extreme semikneeling position advocated to flatten the lumbar lordosis in order to achieve adequate retroperitoneal space. As children have smaller lordosis angles, flattening of the lordosis and creation of optimal retroperitoneal space may be achieved with less hip flexion. We used pediatric lumbar lordosis measurements to develop a modified prone jackknife position and report our experiences with this setup for posterior retroperitoneoscopic adrenalectomy for adrenal tumors. MethodsLordosis angles were measured on sagittal computed tomography (CT) and magnetic resonance imaging (MRI) studies of patients with adrenal tumors and compared to normal references. The data were used to develop our modified prone jackknife position. Selected patients with adrenal tumors underwent posterior retroperitoneoscopic adrenalectomy in this position. Patient demographics, diagnoses, operative times, complications, postop analgesia requirements, and length of hospitalization were analyzed. ResultsCT and MRI studies were analyzed for 20 patients with adrenal tumors diagnosed in our institution from 2012 to 2017; median lordosis angle was 27.84° (range: 15.50°–36.48°) — less than reference lordosis angles of respective age groups, and flexion angles of common operating tables. Five patients underwent retroperitoneoscopic adrenalectomy between June 2016 and June 2018. Histological diagnoses were neuroblastoma, adrenal hyperplasia, pheochromocytoma, and adrenal angiomatoid fibrous histiocytoma. Median age was 4 years [range: 1–11]. Median operating time was 137 min [range 111–181 min]. No conversions to open surgery were required. One patient had intraoperative bleeding from the adrenal vein. Only 1 patient required postoperative opioids for analgesia. Median length of hospitalization after surgery was 2 days (range: 2–3 days). ConclusionsPediatric patients can achieve flattening of lumbar lordosis with less extreme positioning. Posterior retroperitoneoscopic adrenalectomy in a modified prone jackknife position is a feasible operation for pediatric patients with small adrenal masses. Type of studyClinical research paper. Level of evidenceLevel III.

Perioperative and oncological outcomes of abdominoperineal resection in the prone position vs the classic lithotomy position: A systematic review with meta‐analysis

This study is a systematic review with meta-analysis designed to compare the perioperative and oncological outcomes of the abdominoperineal resection (APR) carried out in the prone jack-knife position (P-APR) vs the classic lithotomy position (C-APR). We conducted an electronic search through PubMed utilizing the PRISMA guidelines. We included all randomized and nonrandomized studies which allowed for comparative analysis between the two groups. Research that focused on and analyzed the extralevator abdominal excision were excluded. Pooled variables and number of events were analyzed using the random-effect model. The final analysis included seven nonrandomized retrospective cohorts encompassing 1663 patients. P-APR was associated with decreased operative time (OT) (DM, -43.8 minutes; P < 0.01) and estimated blood loss (EBL) (DM, 86.9 mL; P < 0.01). There were no observed differences regarding perineal wound infections (PWI) (odds ratio [OR], 0.36; P = 0.18), intraoperative perforation of rectum (IOP) (OR, 0.98; P = 0.97), circumferential resection margin (CRM) positivity (OR, 1.02; P = 0.98) or 5-year LR (OR, 1.00; P = 0.99). The prone approach for APR is associated with decreased EBL and OT, although not with any change in the incidence of PWI or IOP. Moreover, surgical positioning per se does not appear to affect the CRM positivity rates or LR rate.

Meralgia paresthetica following hemorrhoidectomy in the jack-knife position - A case report -

Meralgia paresthetica following hemorrhoidectomy in the jack-knife position - A case report -

A Case of Laterally Spreading Tumor of the Rectum Treated by Endoscope-Assisted Transanal Tumor Resection

Background: Curability and function should be considered in resection of a rectal lateral spreading tumor (LST). Methods: We performed endoscopic transanal resection for a rectal LST extending to the pectinate line to preserve anal function and avoid a colostomy in 1 case and describe our procedure below. An 80-year-old man with a group 5 adenocarcinoma tub1/2 and no metastasis was considered for transanal resection because of his refusal of a colostomy and for staging and preservation of anal function. A strategy involving endoscopic submucosal dissection for mucosal cutting at the proximal side and for submucosal dissection of the maximum area at the anal side of the tumor was chosen, considering the tumor size. With the patient in a jackknife position, the tumor was marked circumferentially with coagulation dots, after which MucoUp with bosmin was injected into the submucosa at the proximal side. Mucosal and submucosal dissection was performed using DualKnife to remove the largest possible area toward the anal side. Transanal resection was performed under direct vision using an anal retractor, wherein the mucosa was cut circumferentially by extending the existing resection line along with removal of the submucosa. Results: En bloc resection with clear margins was achieved. Postoperatively, retroperitoneal emphysema was observed on a computed tomography scan, which resolved after 1 week of fasting. The patient was discharged 20 days postoperatively. Neither recurrence nor metastasis has been observed 1 year postoperatively. Conclusions: Our procedure enabled successful resection of a rectal LST with negative margins and preservation of anal function.

Ultrasound-guided percutaneous nephrolithotomy for upper urinary tract calculi in patients with spinal deformity: a decade's experience.

To evaluate the efficacy and safety of ultrasound (US)-guided percutaneous nephrolithotomy (PCNL) in managing upper urinary tract calculi in patients with spinal deformity based on our experience over the last decade. A retrospective study was conducted on patients with spinal deformity who were admitted to Beijing Tsinghua Changgung Hospital and collaborative hospitals from August 2004 to August 2017. Patients diagnosed with urolithiasis and who underwent US-guided PCNL, performed by the same surgeon, were included. Patients' data were collected and the following variables were analysed: age; sex; plain abdominal radiograph of the kidneys, ureters and bladder (KUB); computed tomography (CT); stone burden; evaluation of spinal anatomy; respiratory function; operative time; and postoperative findings. The severity of surgical complications was determined according to the modified Clavien classification system (MCCS). A total of 72 patients (41 males and 31 females) were included, with a mean (range) age of 35(21-69)years. The mean (range) stone diameter was 38(19-68)mm. Seven patients had bilateral PCNL, completed in staged surgery with a 1-week interval. Five kidneys received staged PCNL because of either large residual stones or the potential risk of a long operation time. In all, 19 patients underwent the surgery in a prone position, 29 lateral, nine oblique supine, and the other 27 in unconventional positions (lateral prone, lateral supine, and lateral jackknife position). All procedures were successfully completed with no major complications during the operation. The mean (SD) tract building time was 8.5(1.7)min. The mean (SD) stone disintegration time was 39.3(14.6)min. The mean (range) temperature and postoperative haemoglobin (Hb) drop on the first postoperative day were 37.6(36.7-39.2)°C and 1.5(0.2-4.3)g/dL, respectively. Four patients needed blood transfusions and none of the patients had septic shock or severe renal bleeding requiring angiographic renal embolisation or nephrectomy. A stone-free status was achieved in 71 kidneys (89.87%). Eight patients with residual fragments ≥4mm were either observed without treatment during follow-up or re-treated with shockwave lithotripsy (SWL) according to clinical significance. PCNL in patients with spinal deformities is challenging but safe and effective. US-guided puncture and access establishment has its unique advantages when such patients are placed in unconventional positions.

A rare solitary fibrous tumor in the ischiorectal fossa: a case report

BackgroundA solitary fibrous tumor (SFT) is a rare mesenchymal tumor that occurs mostly in pleural sites, and an SFT occurring in the ischiorectal fossa is extremely rare. Because of the rarity, there are few reports detailing an SFT in the ischiorectal fossa.Case presentationA pararectal tumor was incidentally found in a 42-year-old man during a routine medical examination. The patient had no symptoms and no previous medical history. In the physical examination, a smooth-margined and hard elastic mass was felt, and in a digital rectal examination, the rectal mucosa appeared normal. A computed tomography (CT) scan showed a 5-cm, well-defined, solid mass in the left ischiorectal fossa. Contrast-enhanced CT in the early phase showed intense heterogeneous enhancement that persisted during the delayed phase. T2-weighted images of magnetic resonance imaging yielded heterogeneous intermediate and low signal intensity. Intense arterial enhancement suggested a hypervascular nature, and persistent delayed enhancement and low signal bands on T2-weighted images suggested a fibrous component of the mass. An SFT was suspected. Most SFTs are benign but have malignant potential. Our patient did not hope for surgery if the tumor was benign; therefore, an ultrasound-guided transperineal core needle biopsy was performed to decide on a treatment strategy. Microscopic examination showed tumor cells appearing as spindle and fibroblast-like cells within a collagenous stroma. Immunohistochemistry identified CD34 and vimentin, supporting the diagnosis of an SFT. The patient consented to excision of the mass. He was placed in a prone jackknife position, and the tumor was removed transperineally using a posterior approach (modified Kraske procedure). The levator ani muscle, external sphincter muscles, and rectum were not involved and separated from the tumor. The tumor was successfully resected en bloc with no complications. Five uneventful days post surgery, the patient was discharged. There was no local recurrence during the year following surgery.ConclusionImaging findings reflect the tissue characterization such as hypervascularity and fibrous nature of SFTs. We have presented a rare case of an SFT in the ischiorectal fossa with useful imaging findings for diagnosis, treatment strategy, and successful surgical removal using a posterior approach.

RA01.01: THORACOSCOPIC ESOPHAGECTOMY IN SEMIPRONE POSITION

Abstract Description To assess the feasibility of Thoracoscopic Esophagectomy in the Dorso-Lateral position with the intention of reducing the disadvantages and increasing the benefits of lateral approach and prone approach which are the 2 conventional approaches. Methods: Thoracoscopic Esophagectomy is routinely performed in 2 positions. The left lateral decubitus position is the commonly used position at most of the centres. However prone jack-knife position as described by Cushieri is another alternative. To combine the advantages and reduce the disadvantages of the these 2, we started performing this procedure in a Dorso-Lateral position since 1st October 2008. This is a position midway between the Lateral and Prone position i.e. Left lateral position with an inclination making an angle of 45 degrees with the horizontal. Operating Surgeon and assistant are positioned anteriorly facing the ventral aspect of the patient. A three-port approach is taken with port placements in the 5th, 7th and 9th intercostals spaces in the posterior, mid and anterior axillary lines. Pneumothorax is created with CO2 pressure of 5–7 mm Hg. Although single lung ventilation is preferable the procedure can be done with routine dual lung ventilation with a 4th port being used to retract the lung if necessary. Esophagus is mobilized en-block with posterior mediastinal lymphadenectomy. The Azygous vein and right Bronchial artery are preferably preserved to maintain vascularity of right bronchus. Following this patient is turned supine and Stomach mobilization and coeliac dissection is done laparoscopically. Left neck incision is taken and esophagus is divided in the neck. Specimen is delivered in the abdomen and extra-corporeally through a mini-laparotomy. Gastric tube is prepared and brought in the neck through posterior mediastinum underneath the azygous vein and rt.bronchial artery for anastamosis in the neck. The video shows the procedure in the Dorso-Lateral Position as we routinely perform at our centre. Conclusion: Thoracoscopic Esophagectomy with Mediastinal Lymphadenectomy in the Dorso-Lateral position is a feasible, more convenient and a safe option which can combine the benefits of the conventional left lateral and prone approaches. Surgeon comfort is enhanced in terms of more comfortable operating position and improved ergonomics. Disclosure All authors have declared no conflicts of interest.

Comparative study between intrathecal injection of hypobaric lidocaine 0.5% and isobaric lidocaine 2% in perianal fistula

Aim: The aim of the study is to evaluate the efficacy of 0.5%lidocaine when given intrathecally in perianal surgery in comparison to lidocaine 2% concentration, and to study the effect of change in patient position on sensory anesthesia.Patient and Methods: forty patients aged between 18–70 years with ASA I– II who were scheduled for perianal fistula surgeries under spinal anesthesia were enrolled in our study after written informed consent and approval of ethical committee; This Study was conducted in Sohag University Hospitals from August 2016 to March 2017. Patients Were divided into 2 equal groups:- (Group I) 20 received 8ml (0.5%) lidocaine (prepared by adding 2ml(40 mg) 2% lidocain to 6ml sterile distilled water ). Subarachnoid block will performed in jack-knife.- (Group II)20 patients received 2ml lidocaine 2% (40mg) with the same technique, After injection patient will turned to lithotomy Position with table in horizontal Level. Under complete aseptic conditions, spinal anesthesia was carried out in the sitting position, at level (L3-4 or L4-5). After a free flow of cerebrospinal fluid was confirmed, each patient received one of the coded spinal solutions (GI or GII).Immediately after administration; the patients were turned into the supine or jack-knife position. Patients were monitored for: Heart rate; NIBP and Oxygen Saturation. Patients were observed for onset, duration of sensory block and motor block,hemo dynamic stability; In the post- anesthesia care unit (PACU). Complications also were observed . Results The onset of sensory is faster in hypobaric lidocain but duration and time needed to reach highest sensory level longer in isobaric, onset of motor block is faster in hypobaric but duration of motor block longer in iso baric lidocain hemo dynamic stability more in iso baric . Conclusion The use of hypo baric lidocain reveal early onset for sensory and motor block with early recovery than isobaric and hemo dynamic stability slight more in iso baric lidocain in short stay surgeries as perianal surgeries.

Ventilation failure after lateral jackknife positioning for robot-assisted lung cancer surgery in a patient after lingula-sparing left upper lobectomy

BackgroundVentilation failure commonly occurs when a standard left-sided double-lumen tube is used in patients after left upper lobectomy having remarkable angulation of the left main bronchus. We present a female without remarkable angulation, in whom ventilation failure occurred after lateral jackknife positioning.Case presentationA 73-year-old female after lingula-sparing left upper lobectomy without remarkable angulation was scheduled for robot-assisted right upper lobectomy. Ventilation failure with a standard left-sided double-lumen tube occurred when she was placed not in the lateral position but in the lateral jackknife position required for robotic surgery. After replacement by the Silbroncho® left-sided double-lumen tube, adequate one-lung ventilation became possible.ConclusionsVentilation failure with a standard tube may occur more easily when patients with bronchial angulation are placed in the lateral jackknife than lateral position due to posture-induced exacerbations of bronchial angulation. The Silbroncho® tube seems useful in such situations.

Surgical and oncological short-term outcomes of prone extralevator abdominoperineal excision for low rectal cancer

IntroductionIn recent years, a standardized surgical approach for low rectal cancer was proposed and adopted in many centres. The extralevator abdominoperineal excision introduce an extensive resection of the pelvic floor and demonstrated superiority if the procedure is done in the prone jack-knife position, especially regarding intraoperative perforation and circumferential resections margins. The aim of this study is to evaluate the surgical and oncological short-term outcomes of prone extralevator abdominoperineal excision. MethodsAll patients registered in our institution from January 2003 to January 2015 who underwent abdominoperineal resection or prone extralevator abdominoperineal excision for low rectal cancer after preoperative chemoradiation were retrospectively included from prospective maintained data base and were compared regarding surgical and oncological outcomes. ResultsEighty-nine patients underwent curative intent resections. Abdominoperineal resection was performed in 67 patients and prone extralevator abdominoperineal excision in 22 patients. There were no statistical significant differences between groups regarding pathological stage, median number of harvested lymph node, intraoperative perforation, circumferential resections margins involvement and recurrence rates. Surgical outcomes were statistically different between groups. Twenty-six patients (29%) developed perineal complications, 21% of the abdominoperineal resection patients and 55% of the prone extralevator abdominoperineal excision (p<0.001). Most of these complications were due to delayed perineal wound healing (12.4%), and wound abscesses (4.5%). However, the readmission rate and median length of hospital stay was higher in the abdominoperineal resection group (p<0.001). ConclusionProne extralevator abdominoperineal excision is comparable to standard abdominoperineal resection. It was associated to a decrease in length of hospital stay and readmission rate, although more perineal complications occurred. We cannot recommend it as a standard technique for all low rectal cancer. Notwithstanding, prone extralevator abdominoperineal excision can be considered a more radical approach when there is sphincter complex or levators muscles invasion.