Pedicle Approach Research Articles

Clinical significance of modified unilateral puncture percutaneous vertebroplasty guided by 3D- printed guides in the treatment of osteoporotic vertebral compression fractures: a retrospective study

ObjectiveTo investigate the clinical significance of using 3D printing guides in modified unilateral puncture percutaneous vertebroplasty (PVP) for the treatment of osteoporotic vertebral compression fractures (OVCF), and to explore a new method for preventing paravertebral vein leakage during PVP in conjunction with a previous study of the optimal puncture-side bone cement/vertebral volume ratio(PSBCV/VV%).MethodsThis retrospective study analyzed 99 patients who underwent unilateral puncture PVP between January 2023 and December 2023. Patients were divided into a guide plate group (46 patients) and a conventional group (53 patients). The guide plate group underwent modified unilateral puncture PVP with the guidance of 3D printing guides, while the conventional group underwent unilateral puncture PVP using the conventional pedicle approach. The distribution of bone cement, surgical outcomes, and the occurrence of cement leakage into paravertebral veins were observed in both groups.ResultsThe guide plate group had significantly shorter operating time and required fewer fluoroscopies compared to the conventional group. The amount of bone cement volume (BCV) used in the guide plate group was higher, but the amount of bone cement volume on the puncture side(PSBCV), the PSBCV/VV%, and the rate of paravertebral vein leakage were lower in the guide plate group compared to the conventional group (P < 0.05). Within each group, significant improvements in anterior vertebral margin height, Cobb angle, visual analog scale (VAS) score, and Oswestry Disability Index (ODI) were observed at 1 day and 1 month postoperatively compared to preoperative values (P < 0.05).ConclusionUsing 3D printing guides in modified unilateral puncture PVP is a safe and effective method for treating OVCF. And it has the advantages of short operation time, less fluoroscopy, even distribution of bone cement, and a low rate of paravertebral vein leakage.

Effects of tramadol hydrochloride preemptive analgesia in kyphoplasty of thoracolumbar osteoporotic fractures under local anesthesia

To explore preemptive analgesic effect of preoperative intramural tramadol injection in percutaneous kyphoplasty (PKP) of vertebrae following local anesthesia. From August 2019 to June 2021, 118 patients with thoraco lumbar osteoporotic fractures were treated and divided into observation group and control group, with 59 patients in each gruop. In observation group, there were 26 males and 33 females, aged from 57 to 80 years old with an average of (67.69±4.75)years old;14 patients on T11, 12 patients on T12, 18 patients on L1, 15 patients on L2;tramadol with 100 mg was injected intramuscularly half an hour before surgery in observation group. In control group, there were 24 males and 35 females, aged from 55 to 77 years old with an average of (68.00±4.43) years old;19 patients on T11, 11 patients on T12, 17patients on L1, 12 patients on L2;the same amount of normal saline was injected intramuscularly in control group. Observation indicators included operation time, intraoperative bleeding, visual analogue scale (VAS) evaluation and recording of preoperative (T0), intraoperative puncture(T1), and working cannula placement (T2) between two groups of patients, at the time of balloon dilation (T3), when the bone cement was injected into the vertebral body (T4), 2 hours after the operation (T5), and the pain degree at the time of discharge(T6);adverse reactions such as dizziness, nausea and vomiting were observed and recorded;the record the patient's acceptance of repeat PKP surgery. All patients were successfully completed PKP via bilateral pedicle approach, and no intravenous sedative and analgesic drugs were used during the operation. There was no significant difference in preoperative general data and VAS(T0) between two groups (P>0.05). There was no significant difference in operation time and intraoperative blood loss between the two groups (P>0.05). VAS of T1, T2, T3, T4 and T5 in observation group were all lower than those in control group(P<0.05), and there was no significant difference in T6 VAS (P>0.05). T6 VAS between two groups were significantly lower than those of T0, and the difference was statistically significant (P<0.05). There was no significant difference in incidence of total adverse reactions between two groups (P>0.05). There was a statistically significant difference in the acceptance of repeat PKP surgery (P<0.05). Half an hour before operation, intramuscular injection of tramadol has a clear preemptive analgesic effect for PKP of single-segment thoracolumbar osteoporotic fracture vertebral body under local anesthesia, which could increase the comfort of patients during operation and 2 hours after operation, and improve patients satisfaction with surgery.

Right anatomical hepatectomy using extrahepatic glissonean pedicle approach combined liver hanging for hepatocellular carcinoma: Surgical approach in a developing country

Backgrounds/Aims: To evaluate the outcomes of hepatocellular carcinoma (HCC) patients who underwent right anatomical hepatectomy using the combination of the extrahepatic Glissonean pedicle approach (Takasaki’s technique) and liver hanging maneuver (LHM) (Belghiti’s technique). Patients and Methods: A retrospective analysis of 30 cases of HCC treated with right hepatectomy using extrahepatic Glissonean pedicle approach and liver hanging maneuver by only one surgeon at our department from March 2020 to August 2023. Clinical characteristics, pathological results, postoperative outcomes, and survival rate were analyzed. Results: Among the 30 HCC patients analyzed, males accounted for 96.7% of patients. The mean age was 54.9 ± 11 years. 96.7% had normal preoperative liver function (Child-Pugh A). LHM with an extrahepatic Glissonean approach was feasible in 100% of cases with minor blood loss, no blood transfusion, intraoperative complications, or perioperative mortality. The mean operative time was 123.8 ± 29.0 minutes. The mean hospital stay was 9.37 ± 4.02 days. Postoperative liver failure accounted for 6.7%. Pathological results: 63.3% moderately differentiated HCC; 36.7% poorly differentiated HCC. 1-, 2- and 3-year survival rates were 86.1%, 73.8% and 59.0%, respectively. Recurrence was witnessed in 13 (43.3%) cases, with 6 (20%) cases in remnant liver. 1-, 2-, and 3-year disease-free survival were 69.3%, 42.0%, and 28.0% respectively. Conclusion: Right anatomical hepatectomy using extrahepatic Glissonean pedicle approach combined LHM for hepatocellular carcinoma was feasible and safe at our high-volume oncology center in a developing country.

Advantages of laparoscopic segmentectomy of the liver using ICG fluorescent navigation by the negative staining method: A comparison with open procedure.

Laparoscopic segmentectomy (LS) using indocyanine green (ICG) fluorescence navigation with negative staining method has potential for performing accurate and safe anatomical excision. This study aimed to evaluate the significance of LS using ICG fluorescence navigation compared with open segmentectomy (OS). Eighty-seven patients who underwent anatomical segmentectomies were evaluated for OS (n = 44) and LS (n = 43). The Glissonean pedicle approach was performed using either extra- or intrahepatic method, depending on the location of segment in LS. After clamping pedicle, negative staining method was performed. Liver transection was done along intersegmental plane visualizing by overlay mode of ICG camera. Surgical outcomes were compared between two groups. Correlation between predicted resecting liver volume (PRLV) calculated using volumetry and actual resected liver volume (ARLV) was assessed in two groups. Patients who underwent LS showed better outcomes in operative time, blood loss, and length of hospital stay. There were significantly fewer Grade II and Grade III or higher postoperative complications in LS group. Both values of AST (p < 0.001) and ALT (p < 0.001) on postoperative day 1 were significantly lower in LS group than in OS group. PRLV and ARLV were more strongly correlated in LS (r = 0.896) than in OS (r = 0.773). The difference between PRLV and ARLV was significantly lower in LS group than in OS group (p = 0.022), and this trend was particularly noticeable in posterosuperior segment (p = 0.008) than in anterolateral segment (p = 0.811). LS using ICG navigation allows precise resection and may contribute to safer short-term outcomes than OS, particularly in posterosuperior segment.

Are olecranon osteotomies preferred to triceps-elevating approaches in intraarticular distal humerus fractures? a literature review

Abstract Background The outdated ‘bag of bones’ concept for managing intraarticular distal humerus fractures (IDHF) has historically given way to precise articular reduction made possible by modern implant designs and the option of joint replacement as a last resort for unreconstructable fractures. Several posterior approaches to the distal humerus have been described since the last century, among which the olecranon osteotomy is considered the most invasive yet the most employed approach in cases of intraarticular distal humerus fractures. Objectives The advantages and reported complications of the triceps fascial tongue approach, the triceps reflecting anconeus pedicle (TRAP) approach, and the olecranon osteotomy in cases of intraarticular distal humerus fractures were the subjects of a thorough literature search in the PubMed, SCOPUS, Cochrane Library, and Google Scholar databases. This literature review made use of all pertinent data.

Liver resection with combined extrafascial glissionean pedicle approach (Takasaki Technique) and hanging maneuver: experience from a single Vietnamese center

Liver resection with combined extrafascial glissionean pedicle approach (Takasaki Technique) and hanging maneuver: experience from a single Vietnamese center

Treatment of Spinal Aneurysmal Bone Cyst with Percutaneous Injection of Hydroxyapatite Osteoconductive Cement.

The aim of this study was to evaluate treatment efficacy of percutaneous injection of hydroxyapatite-osteoconductive-cement in patients with spinal aneurysmal bone cysts. The study was designed as a retrospective observational clinical study. We included patients who were diagnosed with of spinal aneurysmal bone cyst, at our institution between 2013 and 2020, and treated with percutaneous injection of osteoconductive cement: "Cerament"® (BONESUPPORT AB, Lund, Sweden). Typical clinical and radiological features of the ABCs treatment and follow-up were investigated. Our study included nine patients, two children and seven adults. Three different types of approaches were applied: (single pedicle approach in 3 patients; double pedicle approach in 2 patients; while in the remaining cases, a multiple access approach was used. VAS score decreased from 8.5 ± 0.5 before treatment to 4.1 ± 0.9 at 6-months-follow up. All of the patients reacted well to treatment, with none neurological complications, complete loss of pain and achieved osteosclerosis as radiological marker of treatment success. Treatment of symptomatic spinal ABC's with hydroxyapatite cement is effective to achieve complete pain reduction and sclerosis.

Extended Superior Dermoglandular Pedicle Approach: A Versatile Technique for a Variety of Breast Deformities.

Although the selected pedicle is important in how it maintains nipple viability and is of equal importance, it can be utilized with the remaining breast tissue to reshape the breast mound. It is ideally used as an extended pedicle, as it allows us to use the tissue in the lower pole of the breast. The purpose of this article was to evaluate additional indications and outcomes using the extended superior pedicle approach along with conventional techniques. This is a retrospective study over 5 years of using an extended superior dermoglandular pedicle approach for managing a variety of breast deformities. Postoperative complications, along with patient and surgeon satisfaction, were assessed. All 68 patients expressed that the results were either excellent (85.3%) or very good (14.7%) according to the evaluation parameters. Among the 68 patients, there were 62 very good outcomes (91.2%) and six good outcomes (8.8%) according to surgeon evaluation. Only one reduction experienced a superficial partial loss, which was improved with no intervention. There was minor asymmetry in three patients (4.4%), which was not experienced by the patients, and poor scar quality in one dark-skinned patent. The author was able to expand the utility of extended superior pedicle for various breast deformities, such as reduction mammoplasty; mastopexy; augmentation mastopexy, either autoaugmentation or prosthetic; tuberous breast; after lumpectomy resection; and even in secondary breast deformities with reproducible and reliable outcomes across a wide patient population.

A New Surgical Technique for Female-to-Male Top Surgery: The Posterioinferior Pedicle (PIPe) Approach.

Most of the time, female-to-male (FtoM) chest surgery involves mastectomy techniques and free transplantation of the nipple-areola complex. With the increasing prevalence of gender dysphoria and the demand for female-to-male gender reassignment surgery, the need for FtM top surgery is also rising. To meet this demand, we present a new approach: the PIPe technique, based on a fasciocutaneous flap with a posteroinferior pedicle. All patients with FtoM gender dysphoria undergoing surgery using the posteroinferior pedicle flap technique in the Plastic Surgery Department at Rennes University Hospital Center were included. The procedure involved extensive liposuction of the lower internal and external mammary quadrants, followed by liposuction of deep tissues in the upper quadrants, except in the pedicle area. After removing skin from the lower quadrants down to the dermis and de-epithelializing the posteroinferior pedicle flap, the thoracic flap was lowered and the areola transposed. From July 2022 to March 2023, fifteen patients underwent surgery, and their results were collected prospectively. The average age was 25years, the mean weight was 76.6kg, and the average BMI was 28.1kg/m2. The average operating time was 102min, and the mean weight excised was 459.5g. The average length of hospital stay was 3.3 days, and the drainage duration was 2.4days. No major complications were reported, and there were no cases of reintervention or recurrence. Our study presents a novel surgical approach utilizing the posteroinferior pedicle technique. Its key benefit lies in the preservation of neurovascular function, which makes it an attractive option for patients seeking to retain nipple sensitivity. This procedure is reliable, reproducible, and recommended as a first-line treatment for grade II and III gynecomastia due to its low rate of major complications and favorable functional and aesthetic outcomes. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Narrow inferior-central septum–based pedicle: A safe technique to improve aesthetic outcomes in breast reduction

Inferior-central pedicle has some aesthetic drawbacks, including hypertrophic scar along the inframammary fold (IMF), squaring of the breast contours, and propensity to develop long-term 'bottoming-out.' This study aimed to verify if the narrow inferior-central (NIC) septum-based pedicle can allow the surgeon to improve aesthetic outcomes compared with the traditional inferior-central pedicle approach. Forty breasts underwent NIC-based breast reduction (group A), and 37 underwent traditional inferior-central pedicles (group B). The NIC pedicle was drawn with a width of 3.5-4.5cm. The recorded measurements were sternal notch to nipple distance (S-N) and nipple to IMF distance (N-IMF) at the time of preoperative markings and follow-up 1, 6, and 18 months after the procedure. The two groups were homogeneous regarding demographics, operative data, and preoperative S-N and N-IMF distances. Both groups showed no total or partial nipple-areola necrosis. At the 18-month follow-up, S-N (p<0.00001) and N-IMF (p=0.00039) distances were statistically different between the two groups, in favour of NIC group A. Changes in N-IMF distances between the 1- and 18-month visits were statistically different among groups (p<0.0001), with a length variation of +17.51% and +28.46%, respectively. Patient satisfaction rate regarding "breast shape" (p=0.021), "lower pole appearance" (p=0.00017), and "scar" (p=0.047) were higher in group A. NIC-based pedicle proved to be a safe procedure and allowed us to overcome limitations that typically characterise the inferior pedicle, i.e., 'bottoming-out' deformity, hypertrophic scar of the lower pole, and squaring of the breast contours. II.

Percutaneous elevation of radial head fractures without fixation - a promising technique.

The aim of the study is to describe the surgical technique and to report the outcomes of triceps reflecting anconeus pedicle (TRAP) approach for intercondylar fractures of the humerus. Twenty two patients with intercondylar fractures of the humerus were operated on by open reduction via the TRAP approach and internal fixation with dual precontoured locking plates. Data were collected on union time, postoperative complications, range of motion (ROM), triceps power, and objective clinical measurement. All fractures were united with a mean union time of 16.5 weeks (range 12-22). All patients had good-to-excellent Mayo Elbow Performance (MEP) score results with a mean ROM of 118.2 degrees (range 90-135). Triceps power was grade 5 in 16 patients and grade 4 in 6. There were 3 transient ulnar nerve palsy and 1 heterotopic ossification. TRAP approach is safe and effective in terms of utility for articular reduction, restoration of elbow motion, and triceps function for intercondylar fractures of the humerus.

Survival outcomes of hepatectomy for hepatocellular carcinoma using LigaSure and Kelly forceps for parenchymal excision combined Glissonean pedicle approach: A retrospective single-centre study

Standard procedures in hepatectomy for hepatocellular carcinoma (HCC) include selective pedicle control and anatomical liver resection. We provide our experience using LigaSureTM and Kelly forceps for parenchymal excision combined with the Glissonian pedicle approach for HCC patients. Sixty-seven patients underwent hepatectomy between June 1st 2016 and May 30th 2020. Prospectively gathered data on surgical outcomes and long-term survival results are given. Minor liver resections comprise 85% of all surgical procedures. The median operative time was 132.1 minutes (range, 102 to 195 mins), and the median intraoperative estimated blood loss was 210 ± 158 (range, 150 – 750) mL. The rate of morbidity was 17.9%, including pleural effusion (13,4%), biliary fistula (0%), liver failure (1.5%), and intra-abdominal bleeding (1.5%). The mean overall survival time by Kaplan – Meier method is 33 ± 0.6 months. The rate of overall survival after 1, 2, and 3 years was 95.5%, 84.5% and 79.4%, respectively. The mean disease-free survival (DFS) time was 25.9 ± 2.1 (months). The recurrence rates after 3 months, 6 months, 12 months, and 24 months were 9.6%, 12.4%, 30.5%, and 42.6%, respectively. Conclusion: In a nation with minimal assets, the Glissonian pedicle approach with the Ligasure and Kelly forceps is a safe and successful method for performing hepatectomy. It permits an anatomical excision with minor morbidity when operated by experienced surgeons.

Hemostasis in liver surgery: Indonesian Society of Digestive Surgeons (IKABDI) consensus statements

Liver resection is a complex operation with bleeding control as one of the most crucial factors. It is essential to determine the amount of bleeding to predict the mortality and morbidity after liver surgery. With technology and scientific development, liver resection can use open or laparoscopic surgical techniques supported by various energy devices and medical management. However, the main goal is to remove the tumor with adequate negative margins and good flow. Indonesian Society of Digestive Surgeons agreed to have an agreement using the Modified Delphi method consisting of twenty digestive surgeons. The consensus was established for hemostasis management choices as surgical and medical strategies in liver surgery. The surgical strategies recommendation include performing anatomical resection in primary hepatic tumor and non-anatomical resection for liver metastases; using of Glissonean Pedicle approach as an inflow control option; doing routine intermittent pringle maneuvers; prohibiting total vascular exclusion; and making a statement that no particular energy device preferred for transecting the liver parenchyma. For medical strategies, consensus recommends limiting the transfusion of PRC or any other blood components, antifibrinolytic's role as hemostatic agents, and using fibrin sealant and matrix coagulant sheets for hemostatic agents in liver surgery. These recommendations reflect current knowledge and can be reviewed if new findings are discovered. Hopefully, this consensus can be a valuable guide for surgeons, especially those practicing in Indonesia, to provide low mortality and morbidity in liver resection.

Application of different puncture techniques to inject bone cement in osteoporotic vertebral compression fractures

To study the application of different puncture techniques to inject bone cement in osteoporotic vertebral compression fractures (OVCFs). The clinical data of 282 patients with OVCFs treated from January 2017 to December 2019 were collected for a retrospective study. According to the surgical plan the patients were divided into group A and B, with 141 cases in each group. In group A, extreme lateral puncture was used to inject bone cement through unilateral puncture and bilateral puncture. In group B, bone cement was injected through unilateral pedicle puncture through pedicle approach. The operation status(operation time, radiation exposure time, bone cement injection volume, hospital stay) and complications were observed between two groups. Before operation and 6, 12 months after operation, the pain mediators such as serotonin 5-hydroxytryptamine (5-HT), prostaglandin E2(PGE2), substance P(SP) were compared, bone mineral density, anatomical parameters of the injured vertebrae (height of the anterior edge of the vertebral body, height of the posterior edge of the vertebral body, Cobb angle), visual analogue scale (VAS) and Oswestry disability index (ODI) were evaluated between two groups. There were no significant difference in operation time, radiation exposure time, hospital stay between two groups (P>0.05). The amount of bone cement injected in group A was greater than that in group B (P<0.05). The serum 5-HT, SP and PGE2 levels of group A were lower than those of group B at 12 months after operation (P<0.05). The height of anterior edge and height of the posterior edge of vertebral body in group A were greater than those of group B at 12 months after operation, Cobb angle of group A was smaller than that of group B, VAS and ODI were lower than those of group B(P<0.05). There was no significant difference in bone mineral density between two groups at 6 and 12 months postoperatively(P<0.05). There was no significant difference between two groups in postoperative complications (P>0.05). Compared with unilateral puncture of the pedicle approach, unilateral puncture and bilateral cement injection technique is more conducive to the recovery of the injured vertebral anatomy and function, and do not prolong operation time, radiation exposure time, hospital stay, nor do increase the risk of nerve damage and bone cement leakage, and postoperative bone metabolism and bone mineral density are improved well, which is a safe and reliable surgical method for the treatment of OVCFs.

Comparison of a directional cement delivery device versus conventional device in unilateral percutaneous kyphoplasty for the therapy of osteoporotic thoracolumbar fracture in the elderly

BackgroundPercutaneous kyphoplasty (PKP) has been demonstrated to be effective in the treatment of osteoporotic vertebral compression fractures (OVCF). However, bilateral puncture techniques take more time to accept more X-ray radiation; some spinal surgeons apply unilateral puncture PKP, but the cement cannot be symmetrically distributed in the vertebral body, so we apply a directional bone cement delivery device that undergoes PKP through the unilateral pedicle puncture. This research aims to compare the clinical and radiological results of PKP via unilateral pedicle approach using a traditional bone cement delivery device and a directional bone cement delivery device and determine the value of a directional delivery device for the therapy of thoracolumbar compression fracture in the elderly.MethodsWe undertook a retrospective analysis of patients with single-level OVCF treated with unilateral pedicle puncture PKP from Jan 2018 to Jan 2020. Operation time, radiation exposure, bone cement injection volume, and the incidence of bone cement leakage were recorded for presentation, and the cement leakage and bone cement distribution were measured by X-ray and computed tomography scan. The patients were followed up postoperatively and were assessed mainly with regard to clinical and radiological outcomes.ResultsThere was no significant difference in the operation time, radiation exposure time, and incidence of bone cement leakage between the two groups. A significant difference was observed in the volume of bone cement injection between the two groups. All patients in both groups had significantly less pain after the procedures, compared with their preoperative period pain. There were no significant differences in Visual Analogue Scale, the relative height of the vertebral body, Cobb angle, and Quality of Life Questionnaire of the European Foundation for Osteoporosis between the two groups at 1 week after PKP, significant difference was observed only 12 months after operation.ConclusionApplication of directional bone cement delivery device is safe and feasible, compared with the application of traditional bone cement delivery device, without prolonging the operative time, radiation exposure time, and the incidence of bone cement leakage. It has the advantages of good short- and medium-term effect, excellent bone cement distribution, and low incidence of kyphosis recurrence.

Glissonian Pedicle Approach for Laparoscopic Right Liver Resections (from Right Hepatectomy to Segmental Liver Resections)

Glissonian Pedicle Approach for Laparoscopic Right Liver Resections (from Right Hepatectomy to Segmental Liver Resections)

Breast Lift Algorithm for the Treatment of Breast Implant Illness Requiring Implant Removal.

The recommendation of breast lift surgery in the setting of patients requiring breast implant removal is twofold. First, a breast lift is indicated for patients who present with breast mound or nipple-areolar complex ptosis. Second, a breast lift is indicated to accommodate the forecasted redundancy in skin and breast ptosis created by implant explantation. The most popular approaches to mastopexy include the inferior and superior pedicled breast lifts. We present a surgical algorithm with diagrams and cases clarifying mastopexy approaches for patients desiring breast implant removal in patients presenting with breast implant illness syndrome. An algorithm was developed to explain the process for selecting the ideal pedicle approach for mastopexy and implant removal surgeries. Three cases are presented to illustrate the application of each pedicle under different presentations and goals. Advantages of an inferior pedicle include the capacity for unlimited lifting of the nipple-areola complex and for preservation of maximal breast mound volume. Its disadvantages include the inability to remove the breast capsule simultaneously and contraindicated if the lower breast pole is contracted. The advantages of a superior pedicle include the ability to remove the entire capsule and to eliminate lower breast pole if it is contracted. Its disadvantages include limitations to how high the nipple-areola complex can be lifted and the inability to preserve maximal breast mound volume. With the current trend for the request of implant removal in patients presenting with breast implant illness syndrome, the algorithm presented may assist surgeons with selecting the ideal breast lift and implant removal approach. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Parenchymal Sparing Laparoscopic Segmentectomy III and IV with Indocyanine Green Fluorescence Negative Stain Method Using Glisson Pedicle Approach

BackgroundTo minimize the loss of functional liver volume in cases of severe cirrhosis and repeat hepatectomy for recurrence of hepatocellular carcinoma (HCC), anatomical hepatectomy is gradually extended from major to minor hepatectomy (Miyama et al. in Cancers (Basel):13, 2021; Ishizawa et al. in Ann Surg 256:959–964, 2012). For local located HCC, (sub)segmentectomy can yet be regarded as a choice instead of hemihepatectomy. Indocyanine green (ICG) has been used for tumor location, navigation of resected margin and liver segment, and identification of bile leakage. Negative stain that ICG dye was administered intravenously after occluding the target portal pedicle is more applicable to sectionectomy or hemihepatectomy, especially in cases where multiple target pedicles exist or portal vein puncture is difficult to carry out to achieve anatomic resection. Herein, we present a video of laparoscopic segmentectomy III and IV with ICG fluorescence negative stain using Glisson Pedicle approach. MethodA 49-year-old woman with hepatitis B related cirrhosis for 2 years was referred for treatment of a single nodule in segment IV invading the umbilical portion of left portal vein. The preoperative alpha-fetoprotein (AFP) was 442 ng/ml and protein induced by vitamin K absence or antagonist-II (PIVKA-II) was 122 mAu/ml. Liver function was Child–Pugh A and indocyanine green retention test at 15 min (ICG-R15) was 9.2%. The surgical procedure involved the following steps: (1) Extrahepatic Glisson pedicle dissection based on Laennec’s s capsule (Sugioka et al. in J Hepatobiliary Pancreat Sci 24:17–23, 2017) was performed for isolation of the pedicles towards segments III and IV in the umbilical fossa. (2) Demarcation line was revealed and ICG (1 ml, 5 mg/l) was administered intravenously for the negative stain after dividing the target pedicles. (3) Parenchyma transection was performed along the border of the negative staining area in the cranial and caudal direction. ResultsOperative time was 220 min and blood loss was 150 ml with no transfusion. HCC sized 2.5 cm*1.7 cm*1.2 cm was confirmed in histopathology with a free margin and no microvascular invasion. The fibrosis of the liver parenchyma was S4 based on Ishak system. The patient was discharged on the postoperative day 6 without any complications. No recurrence in residual liver was noted on the CT scan at 9 months during follow-up. ConclusionLaparoscopic segmentectomy III and IV is an effective procedure for HCC especially in cases with demands of hepatic parenchymal preservation. ICG navigation and Glisson Pedicle approach may be particularly helpful.

Evaluation of outcome in arc of motion of elbow after arthrolysis in post-traumatic stiff elbow through posterior triceps reflecting anconeus pedicle approach

Background: The elbow is a synovial hinge joint, with a high chance of stiffness. A stiff elbow is an elbow with a loss of extension of &gt;30° and flexion of &lt;120 which can result due to post-traumatic events around elbow. Surgical intervention is required if conservative treatment fails. The arthrolysis of the elbow by posterior approach has been reported less widely. Aims and Objectives: This study aims at reporting the arc of motion of the elbow after arthrolysis by posterior approach by TRAP approach. Material and Methods: This study was done on 26 patients with post-traumatic elbow stiffness through posterior triceps reflecting anconeus pedicle graft approach. The mean age of patients in our study is 30.8, ranging from 15 to 54 years. After surgery, patients were reviewed to assess arc of motion and fixed flexion deformity (FFD) improvement, MAYO and oxford score. Results: Our study showed increase in arc of motion from 50.7° to 90.7°, FFD decrease from 31.3° to 18.2° and MAYO score which had a pre-operative mean of 77.3, increased to 90 postoperatively with excellent result in 18 cases (69.2%) and good in eight cases (30.8%). Oxford score had an improvement from 21.8 to 40.3 showing satisfactory result in 11 cases. Conclusion: The approach described in our study is ideal for posterior bony blocks with maintaing intact extensor mechanism and less chance of neurovascular damage. Stability of the joint is maintained with feasability to do ulnar nerve transposition.

Counterclockwise modular laparoscopic anatomical mesohepatectomy using combined glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches.

Although laparoscopic anatomical hepatectomy (LAH) is widely adopted today, laparoscopic anatomic mesohepatectomy (LAMH) for patients with hepatocellular carcinoma (HCC) remains technically challenging. In this study, 6 patients suffering from solitary liver tumors located in the middle lobe of the liver underwent counterclockwise modular LAMH using combined Glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches. In this process, the Glissonean pedicle approach (Takasaki approach) was first used to transect the liver pedicles of segment right anterior (G58) and segment 4 (G4). Second, the hepatic vein-guided approach was performed along the umbilical fissure vein (UFV) to sever the liver parenchyma from the caudal to cranial direction, and the middle hepatic vein (MHV) and anterior fissure vein (AFV) were then disconnected at the root. Last, the hepatic vein-guided approach was once more performed along the ventral side of the right hepatic vein (RHV) to transect the liver parenchyma from the cranial to anterior direction, and the middle lobe of the liver, including the tumor, was removed completely. The entire process was applied in a counterclockwise fashion, and the exposure or transection sequence was G58, and G4, followed by UFV, MHV, AFV, and finally, the liver parenchyma along the ventral side of RHV. The counterclockwise modular LAMH using combined Glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches was feasible in all 6 cases. The median duration of the operation was 275 ± 35.07 min, and the mean estimated blood loss was 283.33 ml. All of the 6 patients recovered smoothly. The Clavien-Dindo Grade I-II complications rate was up to 33.33%, mainly characterized by postoperative pain and a small amount of ascites. No Clavien-Dindo Grade III-V complications occurred, and the mean postoperative hospital stay was 6.83 ± 1.47 days. Follow-up results showed that the average disease-free survival (DFS) was 12.17 months, and the 21-months OS rate, DFS rate and tumor recurrent rate were 100%, 83.33% and 16.67% respectively. Counterclockwise modular LAMH using combined Glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches takes the advantages of the two approaches, is a novel protocol for LAMH. It is thought to be technically feasible for patients with a centrally located solitary HCC. The oncologic feasibility of this technique needs to be investigated based on long-term follow-up. A multicenter, large-scale, more careful study is necessary.