Left Pedicle Research Articles

OGC SO17 - Right lateral approach to left gastric pedicle and Usage of articulated Signia Tri-stapler in Laparoscopic abdominal phase of a 2-stage Oesophagectomy

Abstract Background Advancements in oesophagectomy surgery over the past decade has seen an increase in minimally invasive oesophagectomies (MIE) being performed. Studies showed MIE had considerable advantages over open oesophagectomy by reducing intraoperative blood loss and post-operative complications while maintaining similar oncological outcomes1. In the abdominal phase of the Ivor-Lewis 2-stage oesophagectomy, a posterior approach is commonly used to dissect posterior gastric and left gastric vessels2. Method A 40-year-old patient with early malignant lesion underwent laparoscopic 2-stage oesophagectomy. In this video, we demonstrate using a right lateral approach to access and divide the left gastric vein and artery. Lymphadenectomy of stations 7 and 8a was also completed. A pyloroplasty is performed along with fashioning a gastric conduit using an articulated Signia tri-stapler, a smart stapler that adapts in real-time to tissue variability. Results The right lateral approach is superior to the more commonly used posterior lesser sac approach as it provides visuals of key vessel structures and spleen thereby reducing the risk of injury and bleeding. In the second stage, the Signia tri-stapler allows precise manoeuvres with fully powered articulation, rotation, and clamping, resulting in consistent staple lines and stronger staple lines. Conclusion Oesophagectomies remain a highly technical surgery with varied practices across centres and we would like to propose using a right lateral approach and articulated tri-stapler as a better technique that would reduce risk of bleeding and leaks.

Haemorrhagic shock in a pregnant patient and the unsuspicious subclavian catheter

Introduction: Central venous catheterisation (CVC) is a commonly performed procedure in clinical practice. Although usually safe, complications can arise such inadvertent vascular lesion. This report is of a case of left brachiocephalic vascular lesion due to a subclavian catheter, thus raising awareness about this potential complication, which is not always immediately recognised. Case report: We report the case of a 31-year-old healthy woman, 42 weeks pregnant, who presented with complications during an elective caesarean section. The patient experienced haemorrhagic shock due to the incomplete rupture of the left ovarian pedicle, further complicated by the accidental lesion of the left brachiocephalic vein caused by the tip of a right subclavian catheter, aggravated by the late discovery only after extubation. This case highlights the importance of patient selection, proper technique and the careful monitoring pre- and post-procedure. Conclusion: Brachiocephalic vein lesions arising from CVC insertions are rare but significant complications that require timely recognition and intervention.

A new hybrid robotic surgery by minimally invasive laparoscopic and robotic (MILAR) system using da Vinci single-port (SP) in distal gastrectomy for gastric cancer.

The da Vinci SP (SP) has only 1 robotic arm, containing 4 channels. It provides a wide space for assistant surgeons using laparoscopic forceps. We performed a new type of minimally invasive surgery using laparoscopy and a robot (MILAR) utilizing the SP in distal gastrectomy for gastric cancer. An incision at the umbilicus was made for the SP, and 2 ports were inserted from the right abdomen for laparoscopic surgery. In the above view, where surgeons look down at the surgical field, the scope was inserted from the channel at 12 o'clock, and the round tooth retractor was inserted from 6 o'clock. In the below view, where surgeons look up at the surgical field, the scope and retractor were inserted from opposite directions. The robotic operator uses 3 forceps and a scope. The laparoscopic operator uses 2 forceps. On the greater curvature side, the left or right epiploic artery pedicles was retracted by the robot operator under the below view. The suprapancreatic area was dissected with the pedicle of the left gastric artery retracted by the laparoscopic operator under the above view. By setting the scope and the retractor in a diagonal direction of 12-6 o'clock, robotic surgeons have a wide space bilaterally for using forceps for nodal dissection under the co-axial setting. Laparoscopic surgeons can use this space easily. Gastrectomy by MILAR using SP could provide quality surgery within a short operative time.

Determining the Optimal Morphometry of Pedicle Screws in Lumbar and Thoracic Spine in the Iranian Population

Background: The improper length and direction of pedicle screw may also cause it to penetrate the adjacent organs. Unknowing the safe zone of dimensions and directions of the pedicles is essential to proper screw placement. Methods: The present study is a cross-sectional morphometric study on patients with spinal trauma referred to the neurosurgical department in 2021. The MARCO PACS software scale measured the CT scan images and included the vertebral left pedicle diameter, pedicle body distance, body aorta distance, pedicle diameter, height, and area. The entry point and direction of the pedicle screw were made with the “free-hand” method. Results: 301 patients were included, consisting of 113 females (37.5%) and 188 males (62.5%). The mean age of the participants was 42.87±12.3 years. “Among all T12 vertebra parameters, just body aorta distance was not significant between genders (p-value=0.311). The pedicle height and body aorta distance were lowest among 18-35 years patients (p-value=0.001) (p-value=0.003), respectively. Post-hoc analysis revealed a significant difference between 18-35 and 51-70 years for body aorta distance in the L1 vertebra (p-value=0.002). Conclusion: The present investigation has shown significant differences between genders for optimal left pedicle screw parameters, which should be considered before surgery.

Chronic central nervous system leptin administration attenuates kidney dysfunction and injury in a model of ischemia/reperfusion-induced acute kidney injury.

In the present study we examined whether chronic intracerebroventricular (ICV) leptin administration protects against ischemia/reperfusion (I/R)-induced acute kidney injury (AKI). Twelve-week-old male rats were implanted with an ICV cannula into the right lateral ventricle and 8-10 days after surgery, leptin (0.021 mg/hr, n=8) or saline vehicle (0.5 ml/h, n=8) was infused via osmotic minipump connected to the ICV cannula for 12 days. On day 8 of leptin or vehicle infusion, rats were submitted to unilateral ischemia/reperfusion (UIR) by clamping the left pedicle for 30 min. To control for leptin-induced reductions in food intake, the vehicle-treated group was pair-fed (UIR-PF) to match the same amount of food consumed by leptin-treated (UIR-Leptin) rats. On the 12th day of leptin or vehicle infusion (4th day after AKI), single-left kidney glomerular filtration rate (GFR) was measured, blood samples were collected to quantify white blood cells, and kidneys were collected for histological assessment of injury. UIR-Leptin treated rats showed reduced right and left kidney weights (right: 1040±24 vs. 1281±36 mg; left: 1127±71 vs. 1707±45 mg, for UIR-Leptin and UIR-PF, respectively). ICV leptin infusion improved GFR (0.50±0.06 vs. 0.13±0.03 ml/min/g KW) and reduced kidney injury scores. ICV leptin treatment also attenuated the reduction in circulating adiponectin levels that was observed in UIR-PF rats, and increased circulating white blood cells count compared to UIR-PF rats (16.3±1.3 vs. 9.8±0.6 k/mL). Therefore, we show that leptin, via its actions on the central nervous system, confers significant protection against major kidney dysfunction and injury in a model of ischemia/reperfusion-induced AKI.

Robotic Left Hepatectomy Using the Glissonean Approach and Saline-Linked Bipolar Clamp-Crush Technique.

We have previously reported a saline-linked bipolar clamp-crush technique as a novel robotic liver resection method. Herein, we present the surgical techniques and outcomes of robotic left hepatectomy using the Glissonean approach and our liver transection technique. The key procedures included the following: (1) encircling the left Glissonean pedicle using the Tip-Up fenestrated grasper, (2) dissecting the liver parenchyma using the saline-linked bipolar clamp-crush technique, (3) moving the endoscope one trocar to the right to facilitate visualisation of the liver transection plane, and (4) stapling the left pedicle and left hepatic vein. Seven robotic left hepatectomies were performed. The median operative time and estimated blood loss were 395min and 50mL, respectively. The median length of postoperative hospital stay was 9days. Pneumothorax was the only severe postoperative complication. Robotics left hepatectomy using the Glissonean approach and the saline-linked bipolar clamp-crush technique appears safe and feasible.

Comparison of intra and postoperative analgesia efficacy of intraperitoneal levobupivacaine alone or in combination with dexmedetomidine in cats undergoing ovariohysterectomy; a randomized, prospective, blinded, clinical trial

This study aimed to compare the analgesic and cardiopulmonary effects of levobupivacaine with or without dexmedetomidine, in cats undergoing ovariohysterectomy. In this prospective, randomized, and blinded clinical trial, 24 healthy cats were recruited. Animals received either saline (S group; 2 mL NaCl), levobupivacaine alone (Lev; 0.35 mg/kg), or levobupivacaine with dexmedetomidine (LevDex group; 0.004 mg/kg), which was infiltrated intraoperatively into the subcutaneous tissue at various incision sites, including the right and left ovarian pedicles and the caudal aspect of the uterine body. Intraoperative analgesia was evaluated using a cumulative pain scale, while postoperative analgesia was assessed at various time points: before surgery (Tb), and at 0 (T0), 1 (T1h), 2 (T2h), 4 (T4h), 8 (T8h), 12 (T12h), and 24 (T24h) hours after the procedure, using the UNESP-Botucatu multidimensional composite pain scale (MCPS). Significant decreases in heart rate, respiratory rate, and mean arterial pressure were observed in LevDex group as compared to S and Lev groups (p < 0.05). The S group required significantly more rescue morphine doses than the LevDex group (p = 0.029), but the difference was not significant when compared to the Lev group (p = 0.123). At T1h and T2h, the S group had significantly higher MCPS scores than both the Lev and LevDex groups (p = 0.029). However, at T8h, no significant difference was found between the S and LevDex groups (p = 0.741). While adding dexmedetomidine to levobupivacaine may slightly prolong postoperative analgesia, this combination does not provide significant additional benefit over levobupivacaine alone in terms of response to surgical stimulation.

How to Find Correct Transection Plane in Laparoscopic Right Hepatectomy Extended to S1 for Bismuth IIIa Perihilar Cholangiocarcinoma.

Perihilar cholangiocarcinoma (pCCA) is one of the most challenging tumours for hepatic surgeons. To reach radical resection, it is mandatory to extend the hepatectomy to segment 1 and biliary tract. With the advent of minimally invasive techniques, an increasing number of centres have begun to treat this tumour using robotic or laparoscopic approaches, demonstrating the ability to maintain oncological standards as well as morbidity and mortality criteria. This video presents a case of a 79-year-old man with pCCA Bismuth type IIIa, undergoing right hepatectomy extended to segment 1 and biliary tract after preoperative optimization including biliary drainage and portal vein and right hepatic vein embolization. Unlike conventional right hepatectomy, extending transection to include segment 1 requires identifying the plane defined by the Arantius duct. To reach this plane, we suggest using three approaches, previously described in other hepatectomies, were employed: dorsal and caudal approaches to the middle hepatic vein (MHV) and an extraglissonian intrahepatic approach to the left portal pedicle. With this method, we achieved oncologically radical resection of pCCA using minimally invasive surgical techniques.

Analysis of Vascular Anatomy in Deep Inferior Epigastric Perforator Flap

Abstract Objectives The deep inferior epigastric artery perforator (DIEP) flap is considered the gold standard in autologous breast reconstruction. One of the existing challenges of the procedure is maintaining a pedicle of suitable length and diameter for flap survival. In this study, we analyzed the vascular anatomy of bi-pedicle DIEP flap cases in terms of the vessel diameter, the rate of secondary venae comitantes, and pedicle length to determine the efficacy of microvascular anastomosis and venous drainage. Methods We retrospectively evaluated 108 patients who underwent immediate breast reconstruction using free bi-pedicle DIEP flaps between 2012 and 2019. The patient characteristics, diameters of the deep inferior epigastric artery (DIEA) and accompanying veins (DIEVs), DIEA pedicle length, vessel re-anastomosis rate, flap failure rate, and fat necrosis were recorded. Results Comparison of the right side and left side diameters and pedicle lengths obtained showed no significant differences (p &gt; 0.05). A total of 148 sides (68.52%) of flaps had double venous drainage, whereas 68 sides (31.48%) of flaps had one. Vein congestion occurred in 5 cases, and all involved with just one DIEV anastomosis. No arterial occlusions were observed. Conclusions This is an analysis of extensive clinical data in terms of DIEA, DIEV, and pedicle length. The low vein congestion rate observed reveals adequate venous drainage was achieved in the DIEV system for DIEP reconstruction. Adequate deep inferior epigastric vessel pedicle length and vessel size, as well as greater than 60% of flaps with secondary DIEV, may allow comfortable microsurgery with reduced complications.

Chronic central leptin administration attenuates kidney dysfunction and injury in a model of ischemia/reperfusion-induced acute kidney injury

Kidney disease occurs in approximately 15% of the adult population, accounting for 37 million people in the US alone. Lack of blood flow is a major driver of kidney injury and no therapeutic modalities have shown substantial effcacy in treating ischemia-induced acute kidney injury (AKI). We recently demonstrated that activation of the brain leptin-melanocortin system dramatically improves cardiomyocyte mitochondrial function, energy metabolism and contractility, preserving cardiac function and preventing progression of heart failure following myocardial infarction and ischemia/reperfusion injury. In the present study we examined whether chronic intracerebroventricular (ICV) leptin administration protects the kidney against ischemia/reperfusion (I/R)-induced AKI. Twelve-week old male rats were implanted with an ICV cannula into the right lateral ventricle and 8-10 days after surgery, leptin (0.021 mg/hr, n=8) or saline vehicle (0.5 ml/h, n=8) was infused via osmotic minipump connected to the ICV cannula for 12 days. On day 8 of leptin or vehicle infusion, rats were submitted to unilateral ischemia/reperfusion (UIR) by clamping the left pedicle for 30 min. To control for leptin-induced reductions in food intake, the vehicle group was pair-fed (UIR-PF) to match the same amount of food consumed by leptin-treated (UIR-Leptin) rats. On the 12th day of leptin or vehicle infusion (i.e. 4th day after AKI), single-left kidney glomerular filtration rate (GFR) was measured, blood samples were collected to quantify white blood cells, and kidneys were collected for histological assessment of injury. Chronic leptin infusion reduced body weight by 20±1% compared to only 10±1% reduction in UIR-PF. UIR-Leptin rats also showed reduced right and left kidney weights (right: 1040±24 vs. 1281±36 and left: 1127±71 vs. 1707±45 mg, for UIR-Leptin and UIR-PF, respectively). Leptin infusion improved GFR (0.50±0.06 vs. 0.13±0.03 ml/min/g KW) and reduced kidney injury scores. Leptin treatment also increased circulating white blood cells count compared to UIR-PF rats (16.3±1.3 vs. 9.8±0.6 k/mL). Thus, leptin, via its actions on the central nervous system, confers significant protection against major kidney dysfunction and damage in a model of ischemia/reperfusion-induced AKI. NIH grants: (1R0DK1121411 (do Carmo), 1R0HL1630376 (da Silva/do Carmo), P20GM104357 (Hall), P30GM149404 (Hall) and U54GM115428 (Hall)). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Dorsal approach in laparoscopic extended left hemi-hepatectomy: A case series.

The utility of the dorsal approach has been reported for laparoscopic left hemi-hepatectomy. The aim of the present study is to show the usefulness of the dorsal approach for laparoscopic extended left-hemi-hepatectomy while ensuring safe identification of hepatic veins and dissection of the dorsal tumor margin. Tumors requiring extended left hemi-hepatectomy. After mobilization of the lateral sector and division of the Arantius plate, parenchyma above the Arantius plate is removed to expose the root of the middle hepatic vein and left hepatic vein. Each of these veins can be isolated separately either intra- or extra-hepatically. After removing the parenchyma on the cranial side of the left Glissonean pedicle continuous with the exposed hepatic veins, the left Glissonean pedicle is isolated using the Glissonean pedicle transection method. After division of the left hepatic vein and Glissonean pedicle, segment 4 (in which the main part of the tumor is commonly located) is dissected from the anterior plane of the paracaval portion of the caudate lobe by the dorsal approach, along with the hepatic hilum. Following dissection of the dorsal side of the tumor, and division of parenchyma from the anterior edge of the liver, the anterior Glissonean branches and middle hepatic vein are divided safely and the specimen is resected. Three patients underwent laparoscopic extended left hemi-hepatectomy, with no open conversions. Operative time and blood loss were 331 (concomitant with another partial hepatectomy), 277, and 315 minutes; and 200, 100, and 100 g, respectively. The postoperative courses were uneventful. The dorsal approach maximizes the advantages of laparoscopic extended left hemi-hepatectomy and can be performed safely.

The widths of the medial and lateral pedicle walls in adolescent idiopathic scoliosis with major thoracic curves

Background contextThe widths of medial and lateral pedicle walls in the normal spine of middle-aged and elderly adults have been investigated and these studies found that the medial pedicle wall was thicker than the lateral pedicle wall. However, none had evaluated the widths of medial and lateral pedicle walls on adolescent or young adult scoliotic spines. PurposeThis study aims to identify the distribution and variation of medial and lateral pedicle wall widths throughout the different vertebral levels of the scoliotic spine and its differences according to age, gender, body mass index (BMI), maturity, curve types and curve severity in adolescent idiopathic scoliotic (AIS) patients with major thoracic curves. Study DesignRetrospective study. Patient sampleA total of 6,230 pedicles (right: 3,064, left: 3,166) from 191 patients were included in this study, with 264 (right: 183, left: 81) fully corticalized pedicles excluded from analysis. Outcome measuresDemographic data were age, gender, height, weight, BMI, Risser grade, Lenke curve types and Cobb angles. The main outcome measures were medial and lateral pedicle wall widths. Associations between pedicle wall widths and demographic data were calculated. MethodsThis was a subanalytical retrospective study done on the same patient population as the previously published study on pedicle grading. The data was obtained from the main computed tomography (CT) scan pedicle study dataset. Medial and lateral pedicle wall widths were measured in the axial slices of CT scans from T1 to L5 vertebrae. ResultsA total of 6,230 pedicles (right: 3,064, left: 3,166) from 191 patients were included in this study with 264 (right: 183, left: 81) fully corticalized pedicles excluded from analysis. Right-sided medial pedicle wall widths were narrower from T4–T10 (0.75±0.23 mm) compared to T1–T3 (0.89±0.28 mm) and T11–L5 (0.92±0.30 mm). Left-sided medial pedicle wall widths were narrower from T4 to T7 (0.76±0.24 mm) compared to T1–T3 (0.88±0.26 mm) and T8–L5 (0.90±0.27 mm). Medial cortical wall widths were significantly thicker compared to lateral cortical wall widths for all vertebras from T1 to L5 (right medial 0.85±0.28 mm vs lateral 0.64±0.26 mm (p<.001), left medial 0.86±0.26 mm vs lateral 0.64±0.26 mm (p<.001)). The left medial pedicle wall widths were marginally significantly (p<.001) thicker than the right side (right medial 0.85±0.28 mm vs left 0.86±0.26 mm). The main notable significant differences were located at the periapical region of the thoracic curve between T7 to T10 with the left concave medial pedicle width being thicker than the right convex medial pedicle width. The thinnest medial pedicle walls were located at right concave T7 (0.73±0.24 mm) and T8 (0.73±0.23 mm). We generally found no significant associations between the medial and lateral pedicle wall widths with age, gender, BMI, Risser grade, Cobb angle and curve types. ConclusionsKnowledge on the widths of medial and lateral pedicle walls, their distribution and differences in a scoliotic spine is important for pedicle screw fixation, especially during pedicle probing to find the pedicle channel. The medial pedicle wall widths were significantly thicker than the lateral pedicle wall widths in AIS patients with major thoracic curves. The right concave periapical region had the thinnest medial pedicle walls.

Renal ischemia and reperfusion impact the purinergic signaling in a vascular bed distant from the injured site

AimsAcute kidney injury (AKI) is a public health problem and represents a risk factor for cardiovascular diseases (CVD) and vascular damage. This study aimed to investigate the impact of AKI on purinergic components in mice aorta. Main methods: The kidney ischemia was achieved by the occlusion of the left kidney pedicle for 60 min, followed by reperfusion for 8 (IR8) and 15 (IR15) days. Renal function was assessed through biochemical assays, while gene expression levels were evaluated by RT-qPCR. Key findings: Analyses of renal parameters showed renal remodeling through mass loss in the left kidney and hypertrophy of the right kidney in the IR15 group. Furthermore, after 15 days, local inflammation was evidenced in the aorta. Moreover, the aorta purinergic components were significantly impacted by the renal ischemia and reperfusion model, with increases in gene expression of the pro-inflammatory purinoceptors P2Y1, P2Y2, P2Y6, and P2X4, potentially contributing to the vessel inflammation. The expression of NTPDase2 and ecto-5′-nucleotidase were also significantly increased in the aorta of the same group. In addition, both ATP and AMP hydrolysis were significantly increased in the aorta from IR15 animals, driving the entire purinergic cascade to the production of the anti-inflammatory adenosine. Significance: In short, this is the first time that inflammation of the aorta due to AKI was shown to have an impact on purinergic signaling components, with emphasis on the adenosinergic pathway. This seems to be closely implicated in the establishment of vascular inflammation in this model of AKI and deserves to be further investigated.

Radiologic Examination of High Riding Vertebral Artery and Analysis of Secure Areas

ObjectiveTo radiologically examine the pedicle, lamina, and vertebral artery foraminal anatomies at the C2 vertebra for pedicular and laminar screw instrumentation at the axis in a Turkish population. Materials and MethodsFrom 2018 to 2019, we evaluated 100 patients who underwent cervical computed tomography (CT) for various reasons (excluding cervical pathologies) at Marmara University Hospital. The C2 pedicles were measured on CT images using measurement tools. In addition, axial computed tomography was performed at 0.1-mm intervals. Bilateral measurements were performed for each case. ResultsThe median right and left pedicle axial diameters were respectively 5.01 and 5.09 mm for the male patients and 4.31 and 4.38 mm for the female patients, showing a statistically significant difference between the sexes (p < 0.01). Of the patients, 15% had narrow pedicles. The pedicle sagittal diameters were smaller than 5 mm in 30% of the computed tomographic series. The internal height was <2 mm in 4% of the cases. ConclusionOur findings suggest significant individual and sex-related differences. Vertebral artery groove anomalies are commonly observed. Before performing a posterior craniocervical instrumentation surgery, a CT examination is beneficial because high-riding vertebral arteries must be kept in mind in determining the appropriate screw diameter and screw trajectory.

Evaluating the safe zone for lumbar pedicle screws: are midline crossing screws indicative of pedicle breach?

BACKGROUND CONTEXTPedicle screw breach (PSB) is not uncommon following lumbar instrumentation, and in some instances, it may lead to vascular and/or neurologic complications. Previous literature suggested that screws crossing the vertebral midline on an anterior-posterior (AP) radiograph (or midsagittal on CT) are concerning for medial pedicle breach. OBJECTIVEOur primary aim was to map out the safe zones (SZ) of bilateral pedicle instrumentation and their relationship at each lumbar vertebral level. Our secondary aim was to evaluate the presence of SZs’ intersection at each lumbar level, denoting safe midline pedicle screw crossing not otherwise associated with medial pedicle breach. STUDY DESIGN/SETTINGRetrospective Anatomical Study. PATIENT SAMPLEAdult patients in the from “The Cancer Imaging Archive” (TCIA) database who have not had thoraco-lumbo-sacral fusion. OUTCOME MEASURESPhysiologic measures obtained through 3D analysis of CT images and virtual pedicle screws. METHODCT scans of 51 patients were randomly selected from “The Cancer Imaging Archive” (TCIA) online database for analysis. The Sectra 3D Spine software was used to create 3D renderings, place virtual screws, and make measurements. At each lumbar vertebra, the right and left pedicle corridors were mapped. At each pedicle, two screw positions were templated, the “medial limit screw” (MLS) and the “lateral limit screw” (LLS). Each limit screw was the most extreme position that the screw could exist in without causing a medial or lateral breach. The safe zone was defined as the zone between MLS and LLS. Measurements were taken for each level (between L1 and L5) and side (Left, Right). RESULTSA total of 253 lumbar vertebrae from 51 patients (mean age 53.1, 56.9% male) were included. Two vertebrae from two patients were removed for poor image quality. Out of the 506 screw positions analyzed in our study, 97.4% had overlapping SZ and crossed the midplane without medial pedicle breach. The significant factors (p<.01) for safe midplane-crossing screws included: the screw length (L1–L5); the laterality of the screw entry point (L1–L4); and the pedicle diameter (L2 and L5). CONCLUSIONSA midline crossing pedicle screw on a lumbar AP radiograph is not necessarily indicative of a medial pedicle screw breach. Anatomical (ie, larger pedicle diameter) and technical (ie, longer screws, and lateral entry points) factors allow for safety zone intersections and indicate safe midline crossing by pedicle screws.

Case Report on Double Primordial Uterine and Vaginal Atresia with Torsion of Left Ovarian Cyst Pedicle

Case Report on Double Primordial Uterine and Vaginal Atresia with Torsion of Left Ovarian Cyst Pedicle

Evaluation of lidocaine administration into the ovarian pedicle for the control of intraoperative and early postoperative pain during ovariohysterectomy in dogs

ObjectiveTo evaluate effects of lidocaine 2% administration into the ovarian pedicle on intraoperative nociception and early postoperative pain in dogs undergoing ovariohysterectomy. Study designProspective, randomized, blinded clinical study. AnimalsA total of 20 healthy adult female dogs of different breeds. MethodsDogs were premedicated with acepromazine (0.02 mg kg–1) and morphine (0.5 mg kg–1) intramuscularly, anesthesia induced with propofol and maintained with isoflurane. Dogs were randomly assigned to be administered 2 mL of saline (group S) or lidocaine 2% (group L) into the mesovarium (1 mL each side). Heart rate (HR) and noninvasive systemic arterial pressure were recorded before surgery (T0), before (T1) and during ligation of the right ovarian pedicle (T2), before (T3) and during ligation of the left ovarian pedicle (T4). Rescue treatment (propofol) was administered if HR or systolic arterial pressure (SAP) increased by 20% compared with the previous time point. Pain, assessed with the Glasgow Composite Measure Pain Scale-Short Form (CMPS-SF) was recorded before premedication (baseline) and after extubation. Administration of postoperative rescue analgesia was recorded. ResultsIn group S, HR was higher at T2 than T1 (112 ± 18 versus 89 ± 21 beats minute–1, p = 0.001) There were no significant differences between treatments at any time. SAP was higher at T2 than T1 in group S (110 ± 12 versus 100 ± 10 mmHg, p = 0.031). SAP was higher in group S than group L at T3 (113 ± 12 and 91 ± 10 mmHg, respectively, p = 0.001). No dogs required propofol intraoperatively. All dogs required postoperative rescue analgesia. Compared with baseline, CMPS-SF increased 60 minutes after extubation (group S; p = 0.019, group L; p = 0.043). Conclusions and clinical relevanceAdministration of lidocaine 2% into the mesovarium did not reduce intraoperative nociception and did not improve postoperative analgesia.

Primary bone diffuse B cell lymphoma of the thoracic spine: a rare entity

Primary bone lymphoma is a rare entity, accounting for approximately 3-7% of malignant bone tumors, 5% of extra-nodal lymphomas and &amp;lt;1% of all non-Hodgkin lymphomas. Primary spine localized lymphoma is 1.7% of all primary bone lymphomas. A 73 year-old female presented with a two month history of severe backache. T1W and T2W MRI showed a hypointense soft tissue component extending from the left posterior elements to Th7 corpus. The patient underwent Th6-7-8 total laminectomy. Th7-8 extradural mass was totally resected. Excisional biopsy was performed through Th7 left pedicle and vertebroplasty was applied. Significant reduction in pain was seen postoperatively. The patient was diagnosed with diffuse large B cell lymphoma. R-CHOP chemotherapy and local radiotherapy were applied. Any other lesions were not detected after the examinations following 6 months period and it was accepted as primary bone lymphoma.

Parental obesity exacerbates immunometabolism and renal dysfunction in offspring exposed to acute kidney injury

Kidney disease is estimated to occur in 37 million people in the US, approximately 15% of the adult population. Obesity is a major driver of kidney disease via mechanisms that are still unclear, and pre-conception obesity in the parents may program kidney dysfunction and inflammation in their offspring. Using a model of parental obesity where male and female mice are fed high fat (H) diet prior to mating, with dams maintained on the H diet during gestation and lactation, we found that male offspring exhibit hypertension and initial signs of kidney injury in adulthood (24 weeks of age). We examined whether offspring from obese parents exhibit worse outcome after acute kidney injury (AKI), and whether this is associated with an immunometabolic shift in macrophages (Mɸ) toward glycolytic and pro-inflammatory phenotypes, as assessed by flow cytometry and Seahorse extracellular flux analysis to measure extracellular acidification rate (ECAR) as a measure of glycolysis. The following groups of male mice were submitted to bilateral renal AKI by clamping the left and right pedicles for 30 min: 1) lean offspring fed normal (N) diet born from N diet lean parents (NN, n=5); 2) obese offspring fed H diet born from N diet parents (NH, n=6); 3) lean offspring fed N diet born from H diet obese parents (HN, n=6); and 4) obese offspring fed H diet born from H diet obese parents (HH, n=7). Compared to NH and NN offspring from lean parents, HH and HN offspring from obese parents exhibited worse kidney dysfunction with higher urinary renal osteopontin (OPN) levels (93.8±8.7 and 73.7±16.6 vs. 213.8±24.0 and 151.1±24.6 μg/24h). We also found increased CD45+ Mɸ-like cells which play a role in initiating and maintaining kidney inflammation, as well as worse kidney injury score, increased tubular cell death, tubular blood clot, and glomerular tubularization in offspring from obese parents. Additionally, HH and HN offspring exhibited expansion of renal M1 Mɸ phenotype 4 days after AKI assessed by ECAR (glycolysis: 5.9±0.8 and 4.1±0.5 vs. 9.5±0.9 and 13.5±0.8 ΔmpH/min). Thus, parental obesity is associated with a shift towards M1 inflammatory Mɸ phenotype and increased risk of worse renal dysfunction in their offspring after AKI, even when offspring remain lean. NIDDK 1R01121411, NIGMS P20GM104357 and NIGMS U54GM115428) This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Application of the En Bloc Concept Combined with Anatomic Resection in Laparoscopic Hepatectomy.

Laparoscopic hepatectomy has been reported in many studies, and it is the mainstream method of liver resection. In some particular cases, such as when there are tumors adjacent to the cystic bed, surgeons cannot palpate the surgical margins through the laparoscopic approach, which leads to uncertainty about R0 resection. Conventionally, the gallbladder is resected first, and the hepatic lobes or segments are resected second. However, tumor tissues can be disseminated in the above cases. To address this issue, based on the recognition of the porta hepatis and intrahepatic anatomy, we propose a unique approach to hepatectomy combined with gallbladder resection by en bloc anatomic resection in situ. Firstly, after dissecting the cystic duct, without cutting the gallbladder primarily, the porta hepatis is pre-occluded by the single lumen ureter; secondly, the left hepatic pedicle is made free by the gap of the Laennec membrane and Hilar plate; thirdly, the assistant is asked to drag the fundus of the gallbladder, and the liver parenchyma tissue is resected using a harmonic scalpel along the ischemia line on the liver surface and intraoperative ultrasound. The whole middle hepatic vein (MHV) and its tributaries appear completely; lastly, the left hepatic vein (LHV) is disconnected, and the specimen is taken out from the abdominal cavity. The tumor, gallbladder, and other surrounding tissues are resected en bloc, which meets the tumor-free criterion, and a wide incisal margin and R0 resection are achieved. Therefore, the laparoscopic hepatectomy with the combination of the en bloc concept and anatomic resection is a safe, effective, and radical method with low postoperative recurrence and metastasis.