Mean Operative Bleeding Research Articles

Single-Incision Laparoscopic Cholecystectomy Using a Set of Novel Needle Instruments.

Although the technique of single-incision laparoscopic cholecystectomy (SILC) has improved remarkably, problems such as limited exposure and instrument collision persist. We describe a new SILC technique that uses a set of specially-designed needle instruments. Fifty-six patients with benign gallbladder disease underwent SILC using the newly-designed needle assembly instruments (NAIs). The NAIs comprise an needle assembly exposing hook for operative field exposure and an needle assembly electrocoagulation hook for dissection. During the operation, the NAIs were assembled and disassembled before and after gallbladder removal within the abdominal cavity. The operative efficacy and postoperative complications of this procedure were evaluated. SILC was completed successfully in 52 cases, and four cases (7.14%) required an additional trocar. There were no conversions to open surgery. The mean operative time was 48.2 ± 21.8min, and the mean operative bleeding volume was 10.5 ± 12.5mL. Minor postoperative complications occurred in 3 cases, including 2 cases of localized fluid accumulation in the abdominal cavity and 1 case of pulmonary infection, and all of them recovered after conservative treatment. There was no occurrence of bile leak, abdominal bleeding, bile duct injury and incisional hernia. The medical cost of each case was saved by approximately $200. The abdominal scars produced by the needle instruments were negligible. NAIs can make SILC safer, more convenient, and less expensive.

Safety and Efficacy Outcomes Following Spinal Endoscopic Procedures for Thoracic Ligamentous Ossification: A Systematic Review and Meta-Analysis.

A systematic review and meta-analysis. This study systematically reviewed and evaluated the safety and efficacy of spinal endoscopic techniques as a treatment for thoracic ligamentum flavum ossification (TOLF). The use of spinal endoscopic techniques for the treatment of TOLF has increased in recent years. The present study is the first comprehensive systematic review and meta-analysis focused on the use of spinal endoscopic techniques for TOLF. The Cochrane Central, PubMed, Web of Science, and Embase databases were systematically searched for studies focused on patients undergoing spinal endoscopic techniques to treat symptomatic TOLF. This meta-analysis included 23 studies. We included 323 patients (177 males, 146 females) with a mean age of 58.40±10.06 years, with 304 total recorded lesion locations of which 245 were located in the lower thoracic spine. Complications affected 35/323 patients, and the mean operative duration for 305 patients was 108.15±47.34 minutes. For 187 patients, the mean operative bleeding was 25.13±12.54 mL,while for 87 patients the mean duration of hospitalization was 4.59±1.93 days. At last follow-up, functional assessment was performed for 260 patients, of whom 200 were in excellent condition, visual analog scale (VAS) scores were assessed for 160 patients, with a mean improvement of 4.40 (3.95, 4.86) Japanese Orthopedic Association (JOA) scores were recorded for 115 patients, with a mean improvement of 3.49 (2.79,4.18), and modified Japanese Orthopedic Association (mJOA) scores were recorded for 208 patients, with a mean improvement of 3.62 (2.89,4.35). These results support several advantages of spinal endoscopic techniques for the treatment of symptomatic TOLF. These include low complication rates, rapid postoperative recovery, and good functional recovery when used for single-segment, non-nodular ossification and no combined dural ossification.

Single-port-plus-one robot-assisted laparoscopic modified Lich-Gregoir direct nipple ureteral extravesical reimplantation in children with a primary obstructive megaureter.

To introduce a new technique of single-port-plus-one robotic laparoscopic-modified Lich-Gregoir direct nipple ureteral extravesical reimplantation and ascertain its validity in the treatment of pediatric primary obstructive megaureter. Between January 2021 and November 2021, we retrospectively analyzed the clinical data of 12 children with primary obstructive megaureter who were admitted to the Department of Pediatric Surgery of Fujian Provincial Hospital. All 12 children were treated with single-port-plus-one robotic laparoscopic Lich-Gregoir direct nipple ureteral extravesical reimplantation. Five of them were female and seven were male, including nine cases were simple obstructive type, while the remaining three cases were obstructive with reflux type. The mean age of the children was 17.33 ± 6.99 (10-36) months and the mean follow-up time was 14.16 ± 1.75 (12-17) months. Changes in preoperative and first-year postoperative parameters were compared. The mean operative time for all 12 children was 123.58 ± 10.85 (110-145) min, with a mean internal operative time of 101.42 ± 0.85 (90-120) min, a mean operative bleeding time of 2.42 ± 0.67 (2-4) ml, and a mean hematuria duration of 16.08 ± 1.44 (14-19) h. The mean indwelling catheterization time was 2.25 ± 0.45 (2-3) days and the mean hospitalization time was 3.83 ± 0.39 (3-4) days. At the postoperative first year, the ureteral diameter, calyceal diameter, and anterior-posterior renal pelvic diameter were found to be significantly smaller than at the preoperative period (18.83 ± 3.21 mm vs. 6.83 ± 1.27 mm, 13.99 ± 3.58 mm vs. 3.5 ± 2.90 mm, and 34.92 ± 4.25 mm vs. 10.08 ± 1.88 mm, P < 0.001). There was a significant increase in renal cortical thickness and the percentage of differential renal function (3.63 ± 1.66 mm vs. 5.67 ± 1.88 mm, 33.75 ± 2.77 mm vs. 37.50 ± 1.31 mm, P < 0.001). The resolution rate of obstruction was 100% and no child developed DeNovo vesicoureteral reflux. The technique of modified Lich-Gregoir direct nipple ureteral extravesical reimplantation can help maintain the physiological direction of the ureter and at the same time enhance the effectiveness of antirefluxing in robotic surgery. The design of a single-port-plus-one wound can produce a cosmetic appearance by concentrating and hiding the wound around the umbilicus. This modified reimplantation procedure has the potential to become a promising technique in the robot-assisted treatment of primary obstructive megaureter.

A Retrospective Study on the Feasibility of Completely Laparoscopic Transabdominal Approach Partial Intersphincteric Resection.

Background: With the development of surgical techniques, gastrointestinal surgeons seek ways to improve the quality of life (QOL) for postoperative patients, while ensuring the tumor radical effect, such as reducing trauma, alleviating pain, and preserving the anus. This article discusses the postoperative outcomes of completely laparoscopic transabdominal approach partial intersphincteric resection (CLTPISR). Materials and Methods: The clinical data of 68 patients who underwent CLTPISR at the Affiliated Hospital of Chengde Medical College between May 2017 and June 2020, including procedure-related data, general postoperative conditions, and postoperative anal function data, were retrospectively analyzed to investigate the feasibility and safety of CLTPISR. Results: All 68 rectal cancer patients completed the CLTPISR. The average age was (60.47 ± 7.08) years, the average operative time was (196.22 ± 8.15) minutes, the mean operative bleeding was (49.12 ± 29.61) mL, and the average postoperative hospital stay was (13.46 ± 4.78) days. The postoperative pathology showed that the circumferential margins and distal margins were all negative, the maximum tumor diameter was (3.26 ± 1.11) cm, the distance from the anal verge was (3.92 ± 0.89) cm, and the average number of lymph nodes cleared was (11.06 ± 3.67). There were 28 stage I patients (41.18%), 21 stage II patients (30.88%), and 19 stage III patients (27.94%). The median follow-up time after surgery was 28 months, and the rates of distant metastasis, disease-free survival, and overall survival of the patients were 8.82%, 91.18%, and 95.59%, respectively. The patient's postoperative anal function gradually recovered as time increased. Conclusions: Under the premise of strictly grasping the indications, the CLTPISR is a safe and feasible surgery. It could achieve maximum anal preservation and improve patients' QOL, while maintaining the tumor radical effect, and had the advantages of the short operation time, low intraoperative bleeding, and quick recovery. The Clinical Trial Registration number is LL2020397.

Posterior Minimally Invasive Transpedicular Approach for Giant Calcified Thoracic Disc Herniation.

Study Design:Retrospective case series.Objective:Posterior surgery for thoracic disc herniation was associated with increased morbidity and mortality and new minimally invasive approaches have been recommended for soft disc herniation but not for calcified central disc. The objective of this study is to describe a posterolateral microscopic transpedicular approach for central thoracic disc herniation.Methods:This is a single center retrospective review of all the cases of giant thoracic calcified disc herniation as defined by Hott et al. Presence of myelopathy, percentage of canal compromise, T2 hypersignal, ASIA score, and ambulatory status were recorded. This posterolateral technique using a tubular retractor was thoroughly described.Results:Eight patients were operated upon with a mean follow-up of 16 months. Mean canal compromise was 61%. Mean operative time was 228 minutes and mean operative bleeding was 250 mL. There were no cases of dural tear or neurologic degradation.Conclusion:This is the first report of posterior minimally invasive transpedicular approach for giant calcified disc herniation. There were neither cases of neurological deterioration nor increased rate of dural tears. This technique is thus safe and could be recommended for treatment of this rare disease.

Observation of clinical effect of LEEP combined with vaginal cytology in the treatment of cervical precancerous lesions

Objective To explore the clinical efficacy of the combination of the vaginal and high frequency electric wave loop(LEEP) in the treatment of cervical precancerous lesions. Methods The clinical data of 76 cases with cervical precancerous lesions confirmed by postoperative pathological examination were collected, Pathologic biopsy was conducted under colposcope. For patients with operative indication, LEEP operation was carried out under colposcope and analyzed vaginal microscopic pathological biopsy diagnosis accurate rate. The operation time, bleeding volume and treatment were observed. Results Satisfactory colposcopy and biopsy results difference had statistical significance; colposcopy with biopsy diagnosis accurate rate was 90.79%.The average operation time was (6.42±1.21)min. The mean operative bleeding was (10.45±2.31)mL. Postoperative 3 months, TCT negative rate was 95.83%(92/96). After 6 months of TCT negative rate was 100.00%(76/76). Conclusion LEEP combined with vaginal cytology in the treatment of cervical precancerous lesions has less invasion, less bleeding, shorter hospitalization time, and can effectively remove the lesion site, it is worthy of recommending. Key words: Precancerous lesion; Vaginal cytology; LEEP operation; Cervical

Situación actual de la histerectomía vaginal por electrocirugía bipolar y morcelación en úteros voluminosos en el Hospital General «General José María Morelos y Pavón». ISSSTE

ObjectiveTo describe and analyze the results of an innovative technique of minimally invasive vaginal hysterectomy. Material and methodsProspective, cross-sectional study, that include 973 patients scheduled for vaginal hysterectomy due to uterine myomas, uterus hemorrhage, and endometrial hyperplasia, using a bipolar forceps for electro surgery with high frequency alternating current and uterine morcellation techniques. ResultsWe successfully operated 973 patients, five required conversion to traditional abdominal hysterectomy. The mean operative time was 40minutes, and the mean operative bleeding was 100ml. There were a total of seven complications, five in the intraoperative and two in the postoperative. ConclusionThe technique of vaginal hysterectomy morcellation fusing simplifies the traditional operation, making it a minimally invasive procedure, with less surgical trauma and shorter hospital stay.

Spindle-like abdominal wall-lifting device in gasless laparoscopic surgery in animal experiments

Introduction: CO2 pneumoperitoneum has been used to establish an operation space in laparoscopic surgery. It may have some bad consequences, such as respiratory and circulatory system changes, hypotension and hypoxia in infants and the release of free tumor cells into the abdominal cavity. Gasless laparoscopic technique can avoid these adverse effects. But present gasless laparoscopic techniques have their own disadvantages. The main shortcoming of gasless laparoscopic techniques is inadequate operative space. Material and methods: We herein describe a new technique. We used a self-designed spindle-like abdominal wall-lifting device to perform gasless laparoscopic cholecystectomy in seven pigs, recording the operation time, bleeding volume and unexpected occurrences during the operation. Results: Seven pigs underwent laparoscopic cholecystectomy using this technique with no conversion to open operation. The operation time was between 21minutes and 65 minutes, with a mean operative time of 42.5 minutes. The range of bleeding volumes was 2 ml to 8 ml, with a mean operative bleeding volume of 4.3ml. There were no massive hemorrhages, internal organ injuries or other complications during the operation. Conclusions: These preliminary outcomes indicate that the spindle-like abdominal wall-lifting device is feasible and safe in gasless laparoscopic cholecystectomy, which can provide sufficient exposure of the operative filed.

Clinical results and intramedullary signal changes of posterior decompression with transforaminal interbody fusion for thoracic myelopathy caused by combined ossification of the posterior longitudinal ligament and ligamentum flavum

Background Surgical treatment of thoracic myelopathy caused by ossification of the posterior longitudinal ligament (OPLL) and ossification of the ligamentum flavum (OLF) is technically demanding, and the results tend to be unfavorable. Various operative approaches and treatment strategies have been attempted, and posterior decompression with transforaminal thoracic interbody fusion (PTTIF) may be the optimal method with which the anterior-posterior compression was removed in one step. It is comparatively less traumatic with fewer serious complications. Methods Sixteen patients with thoracic myelopathy due to concurrent OLF and OPLL at the same level underwent PTTIF. We investigated clinical outcomes and neurological improvements. Magnetic resonance imaging (MRI) was performed on all patients preoperatively and postoperatively, and intramedullary signal changes were evaluated. Results The mean operating time was 275 minutes, and the mean operative bleeding amount was 1031 ml. Cerebrospinal fluid leakage occurred in three patients and healed well after repair. Neurological symptom deterioration occurred in one patient, but the patient recovered to nearly the preoperative level after methylprednisolone treatment. The follow-up period ranged from 28 to 47 months. The mean score on the Japanese Orthopedic Association scale improved from 4.3±1.2 preoperatively to 7.3±1.7 at 3 months postoperatively to 8.5±1.5 at the final follow-up (P &lt;0.01), with a recovery rate of (63.6±20.0)%. Postoperative images showed a significant improvement in local kyphosis (P &lt;0.01). Eleven patients (68.8%) showed increased signal intensity (ISI) on preoperative T2-weighted MRI. At the final follow-up, the intramedullary ISI totally recovered in five patients. Neurological improvement was worse in patients with persistent ISI than in the other patients (P &lt;0.05). Conclusions PTTIF is an effective therapeutic option for combined OPLL and OLF and provides satisfactory neurological recovery and stabilized thoracic fusion through a single posterior approach. Intramedullary signal changes do not always indicate a poor prognosis; only irreversible ISI is correlated with a poor clinical result.

“Transforaminal Thoracic Interbody Fusion” in the Management of Lower Thoracic Spine Fracture Dislocations

A case-control clinical study. To assess the usefulness and safety of a novel reconstructive procedure known as transforaminal thoracic interbody fusion (TTIF) in the treatment of lower thoracic spine fracture dislocations, and to compare its efficacy with posterior/anterior combined surgery (PACS). We developed a TTIF procedure for thoracic spine lesions, and obtained good clinical outcomes for degenerative disorders of the thoracic spine. However, the technique of TTIF in the lower thoracic spine fracture dislocation has never been reported. Seven consecutive patients with lower thoracic spine fracture dislocations underwent TTIF (6 males, 1 female; mean age, 32 y), and 16 consecutive patients with lower thoracic spine fracture dislocations underwent PACS (14 males, 2 females; mean age, 37 y). Surgical complications, clinical outcomes, and sagittal alignment were investigated. Bony fusion was assessed using plain and functional x-rays and computed tomography scans. In the TTIF group and the PACS group, the mean operative times were 153 and 224 minutes, respectively, and the mean operative bleeding was 421 and 698 mL, respectively. All patients in the TTIF group were ambulatory within 2 days after surgery. Preoperative local sagittal alignments (kyphotic angles) were 22.9 and 22.5 degrees, respectively. Postoperative local sagittal alignments were 9.9 and 7.2 degrees, respectively. There were no instances of instrumentation failure or nonunion, and there were no serious complications such as neurological deficits in either group. In addition, a chest tube was necessary in 11 cases (69%) of PACS after thoracotomy, but was not required in any TTIF cases. TTIF achieves posterior rigid fixation with instrumentation, and anterior column reconstruction by interbody fusion. This procedure also enables early postoperative ambulation without respiratory problems. TTIF can be a useful option for reconstructive surgery of the lower thoracic spine after fracture dislocations.

Transperitoneal laparoscopic adrenalectomy

ObjectivesTo present our results with transperitoneal laparoscopic adrenalectomy after completion of 70 procedures. Materials and methodsBetween July 2002 and December 2010, transperitoneal laparoscopic adrenalectomy was performed in 70 patients with the following diagnoses: Conn syndrome (22 cases), nonfunctioning adenomas (18), Cushing syndrome (10), pheochromocytomas (7), myelolipomas (4), metastasis after treatment of primary nonadrenal tumors (6), ganglioneuroma (1), adrenal gland hematoma (1) and adrenal carcinoma (1). We describe the size, surgical and hospitalization times, blood loss, need for transfusion, surgical complications and rate of conversion to open surgery. ResultsOf 70 patients, 35 were men and 35 women (1:1) with a mean age of 58.2 years (range, 82.2–29.1). The most common site was left (58%) compared to right (42%). The mean size of the surgical specimen was 5.11cm, mean surgical time was 119.2min (50–240) and mean operative bleeding was 140.6 (30–800)cm3. Only 3 patients required blood transfusion. The mean time until oral feeding was 17h, and the mean hospital stay was 4.3 (2–15) days. Complications were 2 cases of surgical infections, 1 of prolonged paralytic ileus, and 1 of splenic laceration and 1 of intestinal perforation, which both required reconversion to open surgery (4.28%). ConclusionsLaparoscopic adrenalectomy is a safe procedure, with a low percentage of complications and a short hospital stay. The choice of this approach will depend on the surgeon's experience with the lesion etiology and size in each case.

Suprarrenalectomía laparoscópica transperitoneal

Objectives To present our results with transperitoneal laparoscopic adrenalectomy after completion of 70 procedures. Material and Methods Between July 2002 and December 2010, transperitoneal laparoscopic adrenalectomy was performed in 70 patients with the following diagnoses: Conn syndrome (22 cases), nonfunctioning adenomas (18), Cushing syndrome (10), pheochromocytomas (7), myelolipomas (4), metastasis after treatment of primary nonadrenal tumors (6), ganglioneuroma (1), adrenal gland hematoma (1) and adrenal carcinoma (1). We describe the size, surgical and hospitalization times, blood loss, need for transfusion, surgical complications and rate of conversion to open surgery. Results Of 70 patients, 35 were men and 35 women (1:1) with a mean age of 58.2 years (range, 82.2- 29.1). The most common site was left (58%) compared to right (42%). The mean size of the surgical specimen was 5.11 cm, mean surgical time was 119.2 minutes (50-240) and mean operative bleeding was 140.6 (30-800) cc. Only 3 patients required blood transfusion. The mean time until oral feeding was 17 hours, and the mean hospital stay was 4.3 (2-15) days. Complications included 2 cases of surgical infections, 1 of prolonged paralytic ileus, and 1 of splenic laceration and 1 of intestinal perforation which both which required reconversion to open surgery (4.28%). Conclusions Laparoscopic adrenalectomy is a safe procedure, with a low percentage of complications and a short hospital stay. The choice of this approach will depend on the surgeon's experience with the lesion etiology and size in each case.

Thoracoscopic surgery for pulmonary metastases after chemotherapy using a tailor-made virtual lung

Details with regard to the standard criteria for a therapeutic metastasectomy and the use of video-assisted thoracic surgery (VATS) remain elusive. To evaluate the feasibility of VATS using a tailor-made virtual lung for patients with pulmonary metastases after chemotherapy, we reviewed the following cases. Clinical data from October 2006 to April 2010 were obtained from patients who received chemotherapy before a pulmonary metastasectomy (lobectomy or segmentectomy). VATS was the primarily selected surgical approach except for treating hilar lesions. A lobectomy was performed when the metastasis was greater than 3.0 cm in diameter or located deeply in the lobe. Tailor-made virtual lungs were created using three-dimensional multidetector computed tomography before lobectomy on a routine basis. The virtual lung consisted of three-dimensional pulmonary vessels, a tracheobronchial tree, pulmonary parenchyma, and tumors. Twelve operations, consisting of 1 segmentectomy, 10 lobectomies, and 1 wedge bronchoplasty upper lobectomy, were performed on 11 patients during the study period. VATS was completed in 10 of these 12 operations. The mean operative time for the lobectomies was 257 min, and the mean operative bleeding volume was 215 ml. Two cases experienced postoperative transient atrial fibrillation, and no mortalities associated with these operations were reported. VATS was performed safely in instances of metastasectomy after chemotherapy, and the tailor-made virtual lung assisted in lung orientation during the operation.

Posterior/anterior combined surgery for thoracolumbar burst fractures—posterior instrumentation with pedicle screws and laminar hooks, anterior decompression and strut grafting

A prospective clinical study. The purpose of this study was to evaluate prospectively a large group of patients with thoracolumbar burst fractures who were treated with a posterior/anterior combined procedure and to report on the surgical outcomes, complications and radiographic results. A total of 100 consecutive patients were surgically managed with posterior instrumentation, anterior decompression and anterior strut grafting. There were 71 males and 29 females; the mean age was 36 years. Patients with osteoporotic delayed vertebral body collapse were excluded. The mean follow-up period was 30 months. Surgical outcomes such as operative time, blood loss and sagittal alignment were investigated. A neurological assessment was performed by a rating system based on the American Spine Injury Association impairment scale. An interbody fusion was judged using plain X-ray and computed tomographic scans. The mean operative time was 256 min and the mean operative bleeding was 985 ml. Most of the patients were ambulatory within 3 days after surgery. Of the 76 patients with neurological injury, 54 (71.1%) recovered function following surgery. The mean local kyphosis angle was 12.2° kyphotic preoperatively and 0.8° lordotic at the final observation. The mean correction angle was 15.7° and correction loss was 2.6°. No instrumentation failure was observed and the postoperative fusion rate was 99%. Posterior/anterior combined surgery with posterior pedicle screws and hooks fixation, and reconstruction by simultaneous strut grafting and anterior decompression, achieved short segment fixation and can be a useful option for surgically treating thoracolumbar burst fractures.

A New Thoracic Reconstruction Technique “Transforaminal Thoracic Interbody Fusion”

A preliminary clinical study. The purpose of this study was to introduce a new reconstructive procedure called transforaminal thoracic interbody fusion (TTIF) for thoracic spine lesions and to evaluate its preliminary surgical outcomes. Transforaminal lumbar interbody fusion, which was originally reported as unilateral posterior lumbar interbody fusion, has become a widely used minimally invasive technique. However, such reconstructive procedures have not been reported for the thoracic spine. Ten patients with thoracic spine lesions associated with neurologic deficits were included in this study (6 males, 4 females; mean age, 53 years). Thoracic spine lesions included thoracic disc herniation, spinal trauma, spinal tumor, and arachnoid cyst. We investigated surgical complications and clinical outcomes such as operative time, blood loss, and sagittal alignment. Bony fusion was assessed using plain radiographs and computed tomography scans. Lesion level was at T11-T12 in 4 cases and T12-L1 in 3, while it was at T7-T9, T9-T11, and T10-T11 in 1 case each. The mean operative time was 192 minutes, and the mean operative bleeding was 588 mL. All patients ambulated within 2 days after surgery. The mean follow-up period was 18.4 months (range, 12-44 months). Preoperative and postoperative local sagittal alignments (kyphotic angles) were 12.9 degrees and 7.0 degrees . Fusion was observed in all cases. There were no serious complications such as neurologic deficit or infection. TTIF provides for safe interbody fusion and 270 degrees of decompression using a single posterior approach. TTIF is a useful method for reconstructing thoracic spine lesions associated with neurologic deficits.

Feasibility and Safety for Using Recipient's Middle Hepatic Vein for Drainage of the Right Paramedian Sector in Right Liver Graft

We reported that the use of the recipient's native middle hepatic vein (MHV) trunk for the reconstruction of MHV tributaries is a feasible and valuable surgical strategy in right liver living donor liver transplantation (LDLT), because the use of this MHV trunk does not require additional surgeries for both the donor and recipient (1). However, Ikegami et al. (2) asserted that in-site transection of a liver with hepatocellular carcinomas (HCCs) for obtaining the MHV carried the risk of disseminating HCCs in a recipient because of incomplete accuracy of the pretransplant radiological imaging. In order not to encounter HCC recurrence after transplantation, we have considered cases where the HCC lesion is located 2 cm away from the MHV trunk and not on the ventral side of the MHV trunk as the indication of obtaining the recipient's native MHV trunk. Until July 2008, we performed the reconstruction of the MHV tributaries of the liver graft by obtaining the recipient's MHV trunk in a total of 25 patients with HCC according to these strict criteria. Of the 25 HCC patients in whom the recipient's MHV trunk was used to reconstruct the MHV tributaries of the liver graft, no recurrence of HCC has been observed except one patient in whom the HCC ruptured before the LDLT surgery with a median follow-up of 18 months (6–34 months). Ikegami et al. (2) also suggested that the reconstruction of an accessory hepatic vein in site after reperfusion might be troublesome with the increase the risk of bleeding (2). However, we demonstrated (1) that the operative bleeding and ischemic time were not significant greater in patients with the reconstructed MHV tributaries than in those without reconstructed MHV tributaries. The mean operative bleeding of LDLT with and without the reconstruction of the MHV tributaries were 3954 and 5150 mL, respectively. Judging from our results, we consider our strategy as a clinically acceptable option. Longer-term follow-up is needed to ascertain the feasibility and safety of the in-site transection of a liver with HCC for obtaining the MHV. Hirotaka Tashiro Toshiyuki Itamoto Hironobu Amano Akihiko Oshita Tsuyoshi Kobayashi Kentaro Ide Toshimasa Asahara Hideki Ohdan Second Department of Surgery Hiroshima University Hospital Hiroshima, Japan

PLIF With a Titanium Cage and Excised Facet Joint Bone for Degenerative Spondylolisthesis—In Augmentation With a Pedicle Screw

To determine the validity of posterior lumbar interbody fusion (PLIF) using a titanium cage filled with excised facet joint bone and a pedicle screw for degenerative spondylolisthesis. PLIF using a titanium cage filled with excised facet joint bone and a pedicle screw was performed in 28 consecutive patients (men 10, women 18). The mean age of the patients was 60 years (range, 52 to 75 y) at the time of surgery. The mean follow-up period was 2.3 years (range, 2.0 to 4.5 y). The operation was done at L3/4 in 5, L4/5 in 20, and L3/4/5 in 3 patients. The mean operative bleeding was 318+/-151 g (mean+/-standard deviation), and the mean operative time was 3.34+/-0.57 hours per fixed segment. Clinical outcome was assessed by Denis' Pain and Work scale. Radiologic assessment was done using Boxell's method. Fusion outcome was assessed using an established criteria. On Pain scale, 20 and 8 patients were rated P4 and P5 before surgery, and 11, 12, 2, 2, and 1 patients were rated P1, P2, P3, P4, and P5 at final follow-up, respectively. On Work scale (for only physical labors), 12 and 9 patients were rated W4 and W5, before surgery, and 12, 5, 1, and 3 patients were rated W1, W2, W3 and W5 at final follow-up, respectively. There was significant difference in clinical outcome (P<0.01, Wilcoxon singled-rank test) The mean %Slip and Slip Angle was 17.9+/-8.1% and 3.9+/-5.8 degrees before surgery. The mean % Slip and Slip Angle was 5.4+/-4.4% and -2.0+/-4.8 degrees at final follow-up. There was a significant difference between the values (P<0.01, paired t test). "Union" and "probable union" was determined in 29 (93.5%) and 2 (6.5%) of 31 operated segments at 2.3 years (range, 2.0 to 4.5 y), postoperatively. PLIF using a titanium cage filled with excised facet joint bone and a pedicle screw provided a satisfactory clinical outcome and an excellent union rate without harvesting and grafting the autologous iliac bone.

Prognosis of patients over 75 years of age with a ruptured abdominal aortic aneurysm.

Forty-seven patients (34 males and 13 females) over 75 years of age (mean: 79.7 +/- 3.8 SD) suffering from a ruptured abdominal aortic aneurysm were operated on between 1977 and 1986. In 16 patients (34%), the aneurysm had been diagnosed previously. Seventeen patients (36%) had a delay of 6 hours or more in the beginning of the treatment and 26 (55%) were in shock preoperatively. The mean diameter of the aneurysms was 8.9 +/- 2.6 cm (SD) and the mean operative bleeding was 8.5 +/- 7.8 (SD) liters. The mean operating time was 220 +/- 96 (SD) minutes. The 1-month mortality was 60% (28 patients) and 63% (12 patients) of survivors had postoperative complications, mostly pneumonia. The 5-year survival rate was 26%. In the analysis of risk factors associated with death, preoperative shock, old age, and a previously diagnosed but untreated abdominal aortic aneurysm were associated with a significantly worse prognosis.