Lateral Mobilization Research Articles

Deep learning-based surgical step recognition for laparoscopic right-sided colectomy.

Understanding the complex anatomy and surgical steps involved in laparoscopic right-sided colectomy (LAP-RC) is essential for standardizing the surgical procedure. Deep-learning (DL)-based computer vision can achieve this. This study aimed to develop a step recognition model for LAP-RC using a dataset of surgical videos with annotated step information and evaluate its recognition performance. This single-center retrospective study utilized a video dataset of laparoscopic ileocecal resection (LAP-ICR) and laparoscopic right-sided hemicolectomy (LAP-RHC) for right-sided colon cancer performed between January 2018 and March 2022. The videos were split into still images, which were divided into training, validation, and test sets using 66%, 17%, and 17% of the data, respectively. Videos were manually classified into eight main steps: 1) medial mobilization, 2) central vascular ligation, 3) dissection of the superior mesenteric vein, 4) retroperitoneal mobilization, 5) lateral mobilization, 6) cranial mobilization, 7) mesocolon resection, and 8) intracorporeal anastomosis. In a simpler version, consecutive surgical steps were combined, resulting in five steps. Precision, recall, F1 scores, and overall accuracy were assessed to evaluate the model's performance in the surgical step classification task. Seventy-eight patients were included; LAP-ICR and LAP-RHC were performed in 35 (44%) and 44 (56%) patients, respectively. The overall accuracy was 72.1% and 82.9% for the eight-step and combined five-step classification tasks, respectively. The automatic surgical step-recognition model for LAP-RCs, developed using a DL algorithm, exhibited a fairly high classification performance. A model that understands the complex steps of LAP-RC will aid the standardization of the surgical procedure.

Tips and tricks for transluminal specimen extraction and extra-abdominal sigmoid colon resection.

The purpose of this video is to demonstrate how to achieve adequate length and blood supply of the proximal colon for a perineal pull-through procedure, without splenic flexure mobilization during natural orifice specimen extraction. Key steps of the procedure include lateral mobilization of the colon, D3 lymph node dissection, preservation of the left colic artery, low ligation of the inferior mesenteric vein, ligation and washout of the distal bowel lumen, extra-abdominally proximal resection of sigmoid colon, purse-string sutures on the distal sigmoid colon, and an air leak test. Transluminal specimen extraction with extra-abdominal resection was found to be a cost-effective procedure with good cosmetic effects. Tension-free anastomosis was achieved by preservation of the left colic artery and low ligation of the inferior mesenteric vein. The purse-string sutures were placed on the proximal and distal bowel to avoid crossing the staples line. Transluminal specimen extraction with extra-abdominal resection required minimal manipulation intra-abdominally in comparison with other natural orifice specimen extraction techniques.

The effect of myofascial techniques on the electrical activity of the neck muscles

Introduction. Research by foreign scientists often present the results of studies of the effects of specific osteopathic techniques on the body. Myofascial techniques are dynamic low-amplitude techniques in which the myofascial complex of tissues is rhythmically stretched in areas where their mobility is limited. In one study of paravertebral muscles using surface electromyography (sEMG) before and after myofascial techniques, a statistically significant (p<0,05) decrease in their electrical activity was obtained. No publications devoted to the study of the effect of myofascial techniques on the electrical activity of the neck muscles were found.The aim is to study the effect of myofascial techniques on the electrical activity of the neck muscles in individuals with increased tone of these muscles.Materials and methods. A prospective study was conducted in the Department of Osteopathy of Mechnikov North-West State Medical University in which 30 apparently healthy volunteers who did not present active complaints, aged from 23 to 35 years, took part, with a median of 25 years. Inclusion criteria were palpation-determined increased tone of the sternocleidomastoid and upper trapezius muscles. Non-inclusion criteria were the presence of diseases and/or conditions that are an absolute contraindication to osteopathic correction, a history of neck injuries; taking medications that affect muscle tone at the time of the study; neuromuscular diseases. At the beginning of the study, all volunteers underwent palpation of the upper trapezius and sternocleidomastoid muscles on both sides. The degree of increase in muscle tone was assessed in points: 1 — weak; 2 — medium; 3 — strong; 0 — normal tone. Next, they underwent myofascial mobilization techniques: longitudinal and unilateral lateral mobilization of the soft tissues of the neck, separate mobilization of the sternocleidomastoid muscles. Before, immediately after, and three days after the session, muscle tone was recorded using surface electromyography (sEMG), which was performed on a wireless monitoring complex for electrophysiological signals «Kolibri» (OOO NMF «Neurotech», Russia). At rest, the average and maximum amplitude of electrical activity of the sternocleidomastoid and upper trapezius muscles was measured. The recording was made synchronously from the right and left sides of the body.Results. The sEMG indices of muscles with different tone based on the results of subjective assessment were statistically highly significant (p=0,0001). Moreover, according to the A(avg) indicator, the range diagrams either did not intersect or intersected only slightly. The electrical activity of the sternocleidomastoid muscles after myofascial mobilization techniques decreased statistically significantly and remained at the same level for 3 days (p=0,01). Such dynamics were observed in both the average and maximum amplitude of electrical activity. The amplitude of electrical activity of the right sternocleidomastoid muscle was slightly greater than that of the left (all subjects were right-handed), but these differences did not reach statistical significance (p>0,05). After treatment, there was a trend towards a decrease in the asymmetry of electrical activity between the left and right sternocleidomastoid muscles, both middle and maximum, but these changes were not statistically significant (p>0,05). The electrical activity of the upper part of the right trapezius muscle decreased statistically significantly after treatment and remained at this level for 3 days (p=0,01). The left trapezius muscle was excluded from the study due to technical reasons.Conclusion. The study showed that osteopaths (who are completing residency training in osteopathy) palpably distinguish between normal muscle tone and its increase in weak and moderate degrees. One session of myofascial mobilization techniques leads to a decrease in the tone of the sternocleidomastoid muscles and the upper part of the right trapezius muscle according to sEMG. Such changes occur immediately after the session and then persist for at least three days in young people with increased tone of these muscles. Surface electromyography can be used to objectively record and measure the results of specific osteopathic techniques. This is important for increasing the evidence of clinical research in osteopathy.

Dynamic state of plasmid genomic architectures resulting from XerC/D-mediated site-specific recombination in Acinetobacter baumannii Rep_3 superfamily resistance plasmids carrying blaOXA-58 - and TnaphA6-resistance modules.

The acquisition of bla OXA genes encoding different carbapenem-hydrolyzing class-D β-lactamases (CHDL) represents a main determinant of carbapenem resistance in the nosocomial pathogen Acinetobacter baumannii. The blaOXA-58 gene, in particular, is generally embedded in similar resistance modules (RM) carried by plasmids unique to the Acinetobacter genus lacking self-transferability. The ample variations in the immediate genomic contexts in which blaOXA-58 -containing RMs are inserted among these plasmids, and the almost invariable presence at their borders of non-identical 28-bp sequences potentially recognized by the host XerC and XerD tyrosine recombinases (pXerC/D-like sites), suggested an involvement of these sites in the lateral mobilization of the gene structures they encircle. However, whether and how these pXerC/D sites participate in this process is only beginning to be understood. Here, we used a series of experimental approaches to analyze the contribution of pXerC/D-mediated site-specific recombination to the generation of structural diversity between resistance plasmids carrying pXerC/D-bounded bla OXA-58- and TnaphA6-containing RM harbored by two phylogenetically- and epidemiologically-closely related A. baumannii strains of our collection, Ab242 and Ab825, during adaptation to the hospital environment. Our analysis disclosed the existence of different bona fide pairs of recombinationally-active pXerC/D sites in these plasmids, some mediating reversible intramolecular inversions and others reversible plasmid fusions/resolutions. All of the identified recombinationally-active pairs shared identical GGTGTA sequences at the cr spacer separating the XerC- and XerD-binding regions. The fusion of two Ab825 plasmids mediated by a pair of recombinationally-active pXerC/D sites displaying sequence differences at the cr spacer could be inferred on the basis of sequence comparison analysis, but no evidence of reversibility could be obtained in this case. The reversible plasmid genome rearrangements mediated by recombinationally-active pairs of pXerC/D sites reported here probably represents an ancient mechanism of generating structural diversity in the Acinetobacter plasmid pool. This recursive process could facilitate a rapid adaptation of an eventual bacterial host to changing environments, and has certainly contributed to the evolution of Acinetobacter plasmids and the capture and dissemination of bla OXA-58 genes among Acinetobacter and non-Acinetobacter populations co-residing in the hospital niche.

Carry over effect of different cervical mobilization techniques on shoulder muscle strength in rotator cuff tendinitis patients: A randomized control trial

Objective. To study if different cervical mobilizations have a long-term effect on pain relief and strengthening of external rotators and abductors in rotator cuff tendinitis. Method. Seventy-five patients with rotator cuff tendinitis were recruited from outpatient clinic, with age ranged from 25 to 40 years. Group A: C5-6 antero-posterior cervical mobilization and ultrasound therapy. Group B: C5-6 lateral glide cervical mobilization and Ultrasound. Group C: C5-6 Postero-anterior cervical mobilization and US. The Visual Analogue Scale measured pain severity level and Lafayette Manual Muscle Tester measured shoulder external rotators and abductors isometric muscle strength. Results. The Wilcoxon test revealed a statistically significant difference in shoulder external rotators, abductors strength, and pain reduction between pre, immediate post-mobilization, 10 minutes post-mobilization, and 30 minutes post-mobilization within the three groups. But, the immediate post-mobilization and 10 minute post-mobilization median values of external rotators were statistically significant differences among the three groups, while the 30 minute post-mobilization median values of external rotators were not. For Abductors: Among the three groups, there were no statistically significant differences in abductors’ immediate post-mobilization, 10 minute post-mobilization, or 30 minute post-mobilization, but there were statistically significant differences in pain scores immediate post-mobilization, 10 minute post-mobilization, and 30 minute post-mobilization. Conclusion. The study found that all three kinds of cervical mobilization are useful in reducing pain and strengthening the external rotators and abductors muscles and that the most effective method is antero-posterior in treating rotator cuff tendinitis.

Proximal femoral replacement using the direct anterior approach to the hip.

ObjectiveProximal femoral replacement (PFR) is a salvage procedure originally developed for reconstruction after resection of sarcomas and metastatic cancer. These techniques can also be adapted for the treatment of non-oncologic reconstruction for cases involving massive proximal bone loss. The direct anterior approach (DAA) is readily utilized for revision total hip arthroplasty (THA), but there have been few reports of its use for proximal femoral replacement.IndicationsAseptic, septic femoral implant loosening, periprosthetic femoral fracture, oncologic lesions of the proximal femur. The most common indication for non-oncologic proximal femoral placement is a severe femoral defect Paprosky IIIB or IV.ContraindicationsInfection.Surgical techniqueIn contrast to conventional DAA approaches and extensions, we recommend starting the approach 3 cm lateral to the anterior superior iliac spine and performing a straight incision directed towards the fibular head. After identification and incision of the tensor fasciae lata proximally and the lateral mobilization of the iliotibial tract distally, the vastus lateralis muscle can be retracted medially as far as needed. Special care should be taken to avoid injuries to the branches of the femoral nerve innervating the vastus lateralis muscle. If required, the distal extension of the DAA can continue all the way to the knee to allow implantation of a total femoral replacement. The level of the femoral resection is detected with an x‑ray. In accordance with preoperative planning, the proximal femur is resected. Ream and broach the distal femoral fragment to the femoral canal. With trial implants in place, leg length, anteversion of the implant and hip stability are evaluated. It is crucial to provide robust reattachment of the abductor muscles to the PFR prosthesis. Mesh reinforcement can be used to reinforce the muscular attachment if necessary.Postoperative managementWe typically use no hip precautions other than to limit combined external rotation and extension for 6 weeks. In most cases, full weight bearing is possible after surgery.ResultsA PFR was performed in 16 patients (mean age: 55.1 years; range 17–84 years) using an extension of the DAA. The indication was primary bone sarcoma in 7 patients, metastatic lesion in 6 patients and massive periprosthetic femoral bone loss in 3 patients. Complications related to the surgery occurred in 2 patients (both were dislocation). Overall, 1 patient required reoperation and 1 patient died because of his disease. Mean follow-up was 34.5 months.

Application Of Cell Culture System In Radiation Dose Optimization Of Breast Cancer Radiotherapy

Introduction: Metastatic breast cancer causes high mortality in women. Therefore, the search for effective treatment continues. A suitable radiation dose should be determined to cause only a minimum damage to the surrounding tissue. We aimed to determine if cell culture systems can be used to demonstrate the effects of different radiation doses on breast cancer cells. Methods: Here, MDA-MB-231 breast cancer cells were used. The antiproliferative effect of different doses of X-rays was measured by the 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl-tetrazolium bromide test. A wound healing test was performed to assess the metastatic potential, and flow cytometry analysis was used to evaluate the cell cycle. Results: It is found that 2 Gy, 4 Gy, and 8 Gy radiation doses were applied to the cells. Cell proliferation was significantly decreased at all doses (p<0.05). However, there was no significant decrease between the different dose groups (p>0.05). The lateral mobilization potential of MDA-MB-231 cells was decreased significantly in radiation applied cells as compared with the control. Cell cycle analyses showed that different doses of radiation delayed the cells in G1 as compared with control cells in the S phase. Discussion and Conclusion: In the cell culture system, a decrease in proliferation and metastatic potential of breast cancer cells by the application of different doses of radiation is found. Therefore, for effective planning of radiation therapy, additional parameters of radiation should also be assessed via cell culture systems. It has been shown that cell culture systems may be used for dosimetry studies of radiation therapy for breast cancer.

Effect of Sling with Cervical Spine Lateral Mobilization on the Range of Motion and Muscle Stiffness of Cervical Region in Healthy Subjects

Background: Cervical spine mobilization is an effective intervention method to increase cervical range of motion (ROM). However, whether using a sling with cervical spine mobilization can provide a similar positive effect in improving ROM and muscle stiffness as conventional cervical spine mobilization has not yet been proven. Objectives: To investigated the effects of sling with cervical spine lateral mobilization on improving neck ROM and muscle stiffness in healthy subjects. Design: A two-group pre-posttest design. Methods: A total of 20 healthy subjects were allocated to a sling with cervical spine mobilization (SWCM) group (n=10) and a cervical spine mobilization (CM) group (n=10). The mobilization exercise at grade Ⅳ+ amplitude was applied to the left-side and right-side C3-C4 and C4-C5 of each group for three sets. The mobilization exercise was performed for 30 seconds (frequency of two vibrations per second), with a 30-second resting time. The active cervical ROM, muscle tone, and muscle stiffness of the cervical region of each group was measured and compared before and after the intervention. Results: The active cervical ROM of both groups significantly improved after the intervention (p<.05). However, no significant differences in the cervical active ROM, cervical muscle tone, and muscle stiffness were observed between two groups. Conclusion: The application of sling with cervical spine lateral mobilization is an intervention method that can be effectively used to improve the physiological movement of the neck, as well as cervical muscle tone and stiffness.

Immediate Effects of Diaphragmatic Breathing with Cervical Spine Mobilization on the Pulmonary Function and Craniovertebral Angle in Patients with Chronic Stroke.

Background and Objectives: Patients with stroke have a forward neck posture due to neurological damage and often have impaired pulmonary function. This study investigated the effect of diaphragmatic breathing with cervical mobilization to improve pulmonary function cervical alignments. Materials and Methods: This study used a one-group pre-test–post-test design including 20 patients with stroke. Two types of cervical joint mobilization techniques, consisting of left and right lateral glide mobilization and posterior–anterior mobilization, were utilized. During joint mobilization, the patients performed diaphragmatic breathing. The measurements were performed immediately after the intervention. Pulmonary function was evaluated using a spirometer to measure the forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and peak expiratory flow (PEF). The craniovertebral angle (CVA) was measured using lateral photographs. Results: After diaphragm breathing with cervical joint mobilization, subjects had significantly increased FEV1, FVC, PEF and CVA. Conclusion: Diaphragm breathing with cervical joint mobilization are possible interventions to increase pulmonary function and improve the craniovertebral angle in patients with stroke. However, a complete conclusion can be reached only after a follow-up study has been conducted with a comparison of more subjects and controls.

Development and Validation of a 3-Dimensional Convolutional Neural Network for Automatic Surgical Skill Assessment Based on Spatiotemporal Video Analysis

A high level of surgical skill is essential to prevent intraoperative problems. One important aspect of surgical education is surgical skill assessment, with pertinent feedback facilitating efficient skill acquisition by novices. To develop a 3-dimensional (3-D) convolutional neural network (CNN) model for automatic surgical skill assessment and to evaluate the performance of the model in classification tasks by using laparoscopic colorectal surgical videos. This prognostic study used surgical videos acquired prior to 2017. In total, 650 laparoscopic colorectal surgical videos were provided for study purposes by the Japan Society for Endoscopic Surgery, and 74 were randomly extracted. Every video had highly reliable scores based on the Endoscopic Surgical Skill Qualification System (ESSQS, range 1-100, with higher scores indicating greater surgical skill) established by the society. Data were analyzed June to December 2020. From the groups with scores less than the difference between the mean and 2 SDs, within the range spanning the mean and 1 SD, and greater than the sum of the mean and 2 SDs, 17, 26, and 31 videos, respectively, were randomly extracted. In total, 1480 video clips with a length of 40 seconds each were extracted for each surgical step (medial mobilization, lateral mobilization, inferior mesenteric artery transection, and mesorectal transection) and separated into 1184 training sets and 296 test sets. Automatic surgical skill classification was performed based on spatiotemporal video analysis using the fully automated 3-D CNN model, and classification accuracies and screening accuracies for the groups with scores less than the mean minus 2 SDs and greater than the mean plus 2 SDs were calculated. The mean (SD) ESSQS score of all 650 intraoperative videos was 66.2 (8.6) points and for the 74 videos used in the study, 67.6 (16.1) points. The proposed 3-D CNN model automatically classified video clips into groups with scores less than the mean minus 2 SDs, within 1 SD of the mean, and greater than the mean plus 2 SDs with a mean (SD) accuracy of 75.0% (6.3%). The highest accuracy was 83.8% for the inferior mesenteric artery transection. The model also screened for the group with scores less than the mean minus 2 SDs with 94.1% sensitivity and 96.5% specificity and for group with greater than the mean plus 2 SDs with 87.1% sensitivity and 86.0% specificity. The results of this prognostic study showed that the proposed 3-D CNN model classified laparoscopic colorectal surgical videos with sufficient accuracy to be used for screening groups with scores greater than the mean plus 2 SDs and less than the mean minus 2 SDs. The proposed approach was fully automatic and easy to use for various types of surgery, and no special annotations or kinetics data extraction were required, indicating that this approach warrants further development for application to automatic surgical skill assessment.

Three Ways of Approach for Uterine Cervical Myoma during Laparoscopic Hysterectomy

Study Objective To show surgical strategy during laparoscopic hysterectomy for cervical myomas. Design Step-by-step video demonstration of the surgical procedure. Setting Leiomyomas location in the uterine cervix can reduce the mobility of the uterus and also distort the anatomical position of neighboring structures, such as the uterine artery and ureter, possibly leading to massive bleeding or ureteral injury. Thus, the surgery for cervical myomas is difficult and challenging. In this presentation, I will show our surgical strategy during laparoscopic hysterectomy for cervical myomas. Patients or Participants N/A Interventions We categorize our approaches to cervical myoma into three methods based on the myoma size and the mobility of the uterus. 1. The first method is to perform standard Total laparoscopic hysterectomy(TLH) using our usual steps. However, the lateral mobilization of the ureter is occasionally necessary to dissect the area around the cervix and parametrium safely, consequently, separation of the anterior leaf of the vesicouterine ligament may be necessary. 2.The second method is to perform partial or total enucleation of the leiomyoma via laparoscopy. After reducing the volume of the uterus and obtaining uterine mobility by enucleation, hysterectomy is performed. 3. The third method is transvaginal myomectomy assisted laparoscopic hysterectomy. Due to poor Mobility of the uterus, large volume of the myoma and limited working space, we couldn't perform enucleation of the myoma via laparoscopy. Therefore, we tried to performed transvaginal myomectomy. After that, we could resect the uterus via laparoscopy. However, this technique is possible only if there is adequate surgical space in the vagina, and the cul-de-sac can be reached easily. Measurements and Main Results Laparoscopic surgery was completed safely without requiring a conversion to laparotomy. Conclusion Using these three methods step by step customizing the surgery to best address each case, safe laparoscopic surgery is possible, and open surgery can be avoided.

Aspectos tácticos de la resección de recto laparoscópica

Introduction: Laparoscopy is currently the approach of choice for oncological resections of the colon and rectum, since it does not compromise their quality and offers the advantages of minimally invasive surgery. Description of contents: The main tactical aspects of the anterior resection of the rectum are described: patient positioning and surgical equipment, positioning of the trocars and technical steps. Medial dissection of the mesocolon identifying retroperitoneal structures, vascular control of the superior rectal artery and inferior mesenteric vein, lateral mobilization of the colon, meso-rectal dissection, distal rectal section, exteriorization and section of the piece, intracorporeal anastomosis, and drains. In all the steps emphasis is placed on the prophylaxis of accidents and / or intraoperative adverse events. &nbsp

Aspectos tácticos de la resección de recto laparoscópica

&#x0D; Introducción: La laparoscopía es actualmente la vía de abordaje de elección para las resecciones oncológicas de colon y recto, dado que no compromete la calidad de las mismas y ofrece las ventajas de la cirugía mínimamente invasiva.&#x0D; Descripción de contenidos: Se describen los principales aspectos tácticos de la resección anterior de recto: colocación del paciente y equipo quirúrgico, posicionamiento de los trócares y pasos técnicos. Disección medial del mesocolon identificando estructuras retroperitoneales, control vascular de la arteria rectal superior y la vena mesentérica inferior, movilización lateral del colon, disección meso-rectal, sección rectal distal, exteriorización y sección de la pieza, anastomosis intracorpórea y drenajes. En todos los pasos se hace énfasis en la profilaxis de accidentes y/o eventos adversos intraoperatorios.

First interactions with the hydrologic cycle determine pyrogenic carbon's fate in the Earth system

AbstractFires produce an aromatic particulate residue commonly referred to as pyrogenic carbon (PyC). Particulate PyC is low density, high porosity, and is predominantly deposited on the soil surface in post‐fire landscapes. These characteristics create a material that is prone to mobility, both vertically down the soil profile and laterally across the landscape even in low‐relief landforms. Because of its tendency for lateral mobilization, we argue here that PyC's first interaction with water determines its environmental fate and persistence, not its interactions with soil minerals or microbes. PyC's first interactions with water determine: the amount of PyC that will enter the soil profile and experience microbial and geochemical alterations, whether it will be buried in depositional environments and stored on the landscape, or if it will be transported to streams and eventually to the ocean. Here we posit that this crucial first interaction with the hydrologic cycle occurs on the timescale of days to weeks, and therefore supersedes microbial decomposition as the primary control on PyC's environmental persistence. © 2020 John Wiley &amp; Sons, Ltd.

Lateral mobilization of soil carbon induced by runoff along karstic slopes

Soil erosion induced by runoff is a main hydrological pathway for lateral transport of carbon in terrestrial landscapes. More information about how water erosion influences the carbon gains and losses at different erosional and depositional landform positions is critical, especially in fragile agroecosystems with a variety of land uses and ephemeral hydrological and sedimentological pulses, typical of Mediterranean environments. The purpose of this study is to characterize the lateral mobilization of soil organic and inorganic carbon (SOC and SIC) along topographically driven transects over a period of four decades in a sub-humid karstic area in northern Spain. The 137Cs inventories and the characterization of terrain attributes of the study area were used to identify whether erosional or depositional processes have been predominant in the 58 sampling sites. Average soil losses and gains varied between −4 and +4 mm ha−1 yr−1, and the carbon patterns obtained are discussed in the context of the dominant hydrological processes in the study area. Results indicate that SOC and SIC losses were related to an increase in water flow accumulation, while the highest SOC gains were recorded at concave positions. Soil erosion processes and the content of SOC and SIC in soils are the two main factors controlling carbon budgets. The topographical and geomorphological characteristics of the transects, the spatial distribution of land uses and the presence of landscape linear elements such as terraces or paths, affect runoff and determine the sediment connectivity and carbon dynamics along the slopes. The combined use of 137Cs and the perceptual model provides reliable SDR estimates benefiting the appraisals of the redistribution of eroded carbon. The knowledge of processes involved in the lateral carbon movement induced by runoff along karstic hillslopes provides a better understanding of the role of soil erosion as carbon source or sinks in the global carbon cycle.

Laparoscopic liver resection of the spiegel lobe by a lef-sidad approach preserving an accessory left hepatic artery

Presenter: Víctor Molina | Hospital de la Santa Creu i Sant Pau Background: Caudate lobe of the liver can be divided in three portions: Spiegel lobe, para-caval portion and caudate process . The anatomy of the caudate lobe and its proximity to major vascular structures makes this operation a difficult resection, especially for laparoscopic liver surgery. For that reason the Iwate criteria proposed to classify this surgery at the “2nd International Consensus Conference on Laparoscopic Liver Resection” as intermediate or advanced difficulty depending on the type of resection, and the size of the tumor . For tumors located in the Spiegel lobe, the left side approach is preferred Methods: We present a 69-year-old woman with liver metastasis from previously resected sternal condrosarcoma. A Spiegel lobe resection with left side approach preserving an accessory left hepatic artery was performed. Results: The patient was positioned in supine position. Six ports were used, 4 of 12mm and 2 of 5mm. We started the surgery with the left lateral segment mobilization. The gastrohepatic ligament was opened to expose the caudate lobe. In this case we only opened part of the ligament to preserve the accessory left hepatic artery. We continued retracting to the right the hepatic hilium with tissue band used as the external Pringle tourniquet to expose de caudate process and the right side of the Spiegel lobe. The transection of the liver was started with Thunderbeat and ultrasonic dissector. The portal branches to the Spiegel lobe were dissected and controlled with clips. We continued with the blunt dissection of the Spiegel lobe from the inferior vena cava. The fibrous ligament of the Spigel lobe to the crus of the diaphragm was cut and the retrocaudate vessels to the inferior vena cava were individualized and ligated with clips. Finally, we opened the gastrohepatic ligament behind the artery, pulled up the caudate lobe, and finished the liver transection. A closed aspirative drainage was left in place. The specimen was removed from an enlargement of the left subcostal 12mm port. The operative time was 180 min and the total Pringle time was 30 min. Patient was discharged at the 4 postoperative day and there were no postoperative complications. Conclusion: Laparoscopic liver resection of the caudate lobe for condrosarcoma liver metastasis is feasible and safe. Left approach seems the best option for Spiegel lobe resections even in patients with accessory left hepatic artery.

A directional preference approach for chronic pelvic pain, bladder dysfunction and concurrent musculoskeletal symptoms: a case series

ABSTRACT Background Chronic pelvic pain (CPP) with concurrent musculoskeletal and bladder symptoms is a complex and challenging problem. However, clinically the co-existence of these symptoms is not routinely questioned, and their musculoskeletal source is not investigated thoroughly. The purpose of this case series is to present the use of Mechanical Diagnosis and Therapy (MDT) principles in seven patients with concurrent chronic pelvic pain, bladder dysfunction and musculoskeletal symptoms. Case Descriptions Seven patients with coexisting pelvic health and musculoskeletal signs and symptoms were retrospectively reviewed. Most common symptoms were urinary frequency, incontinence, pelvic pain, nocturia, dyspareunia, bladder dyssynergia, and lumbar, pelvic or hip pain. All patients failed to recognize the possible interconnectedness of the two sets of symptoms. Each exhibited a directional preference (DP) and subsequent MDT provisional classification of derangement was established; the use of DP forces abolished or dramatically improved both symptoms and mobility impairments. In all cases DP was for sustained sagittal forces initially, but ultimately lateral forces and mobilization were indicated. Outcomes Changes in Pelvic Floor Impact Questionnaire, Care Connections Pelvic Floor and Lumbar spine were all clinically significant and exceeded minimally Clinical Important Differences several times. Average of 5.8 sessions per patient was noted. Follow-up at an average of 3.3 years revealed ongoing satisfaction and confidence in independent self-management. Discussion These case studies highlight the importance of ensuring expansion of intake questions for possible co-existence of symptoms in both pelvic and musculoskeletal patients, possibly suggesting a mechanical intervention is indicated. Provisional subclassification into ‘Mechanical Pelvic Syndrome’ is proposed. Level of Evidence: 4.

Lateral mobilization

Lateral mobilization

Endoscopic transorbital transtentorial approach to middle incisural space: preclinical cadaveric study.

Endoscopic transorbital approach is a novel development of minimally invasive skull base surgery. Recently, anatomical studies have started to discuss the expanded utilization of endoscopic transorbital route for intracranial intradural lesions. The goal of this cadaveric study is to assess the feasibility of endoscopic transorbital transtentorial approach for exposure of middle incisural space. Anatomical dissections were performed in four human cadaveric heads (8 sides) using 0- and 30-degree endoscopes. A stepwise description of endoscopic transorbital transtentorial approach to middle incisural space and related anatomy was provided. Orbital manipulation following superior eyelid crease incision with lateral canthotomy and cantholysis established space for bone drilling. Extradural stage consisted of extensive drilling of orbital roof of frontal bone, lessor, and greater wings of sphenoid bone. Intradural stage was composed of dissection of sphenoidal compartment of Sylvian fissure, lateral mobilization of mesial temporal lobe, and penetration of tentorium. A cross-shaped incision of tentorium provided direct visualization of crural cistern with anterolateral aspect of cerebral peduncle and upper pons. Interpeduncular cistern, prepontine cistern, and anterior portions of ambient and cerebellopontine cisterns were exposed by 30-degree endoscope. The endoscopic transorbital transtentorial approach can be used as a minimally invasive surgery for exposure of middle incisural space. Extensive drilling of sphenoid wing and lateral mobilization of mesial temporal lobe are the main determinants of successful dissection. Further studies are needed to confirm the clinical feasibility of this novel approach.

Comparative Study between Lateral Band Mobilization and Spiral Retinacular Ligament Reconstruction in Swan Neck Deformity

Background: Sawn neck deformities of the fingers arechallenging and difficult for treatment. Many techniques hadbeen used with different success rates depending on the causeof deformity and the technique used for correction. Techniquesdeal with either lateral band mobilization or oblique retinacularligament reconstruction (ORL) popularly used with manyrefinements.Objectives: To evaluate which surgical maneuver is betterfor correction of swan neck deformity and to compare resultsof lateral band mobilization and oblique retincular ligamentreconstruction.Patients and Method: 11 patients suffered from swanneck deformities. 24 fingers after rheumatoid arthritis, 5post-burn and 3 post-traumatic. Divided into 2 groups, 20fingers were corrected by lateral band mobilization (GroupA). 12 fingers underwent ORL reconstruction (Group B).Assessment was done by measurement of extension lag onDIP by goniometer after 6 months compared with that donepre-operatively.Results: DIP extension lag improved with lateral bandmobilization especially non-rheumatoid patients. But withORL reconstruction the results were not satisfactorty as regardas entension lag and PIP hyperentension.Conclusion: Lateral band mobilization is a reliable methodfor correction of swan neeck deformity especially with nonrheumatoidpatients (burn and trauma), but long-term resultsof lateral band translocation in rheumatoid patients are disappointing,as regard as ORL reconstruction with tendon graft,it did not show satisfactory results in this study.