Posterior Dissection Research Articles

Pipeline Embolization in Patients with Posterior Circulation Subarachnoid Hemorrhages: Is Takotsubo Cardiomyopathy a Limiting Factor?

Hemorrhagic vascular lesions in the posterior cerebral circulation such as ruptured aneurysms and dissections can be challenging to treat. Flow diversion has become an important off-label option, but few studies have analyzed the safety of these devices in this setting. Using an international, multicenter cohort, we reviewed posterior circulation subarachnoid hemorrhage (SAH) patients treated with the Pipeline Embolization Device (PED) in the acute setting and assessed the incidence of Takotsubo cardiomyopathy (TCM). Eleven neurovascular centers were queried to identify cases of posterior circulation aneurysms or dissections treated with the PED in the acute setting of SAH. Among those, 5 centers had cases that matched the inclusion criteria. The following variables were evaluated: demographics, the location and morphology of the aneurysm, the clinical presentation, the specific form of treatment, complications including the development of TCM, antiplatelet medication regimen, and follow-up time. A total of 23 patients were treated with PED after posterior circulation SAH, and 13% of these developed TCM. The lesions were the result of hemorrhagic intracranial dissection (8 patients), ruptured pseudoaneurysm (3), ruptured saccular aneurysm (7), blister aneurysm (4), and fusiform aneurysm (1). Ninety-one percent of patients had complete or near-complete aneurysm occlusion on follow-up imaging. Five patients died in the perioperative period; 16/18 survivors had a favorable outcome. We describe an unexpectedly high incidence of TCM after the placement of PEDs in patients with posterior circulation SAH in our large case series. Further studies will be needed to elucidate possible causes.

Anatomical observation and clinical significance of rectosacral fascia in total mesorectal resection

Objective: To observe the anatomical architecture of rectosacral fascia and discuss the best plan for accurate peri-rectal dissection in laparoscopic/robotic total mesorectal resection (TME). Methods: A descriptive cohort study was carried out. A total of 127 patients with rectal cancer who underwent TME in the Department of Colorectal Surgery at the affiliated Union hospital of Fujian Medical University were included, patients' demographics with their pathological details and operation videos were collected for analysis. Another 20 high-definition images of post-TME surgical specimens were collected from our digital database. A total of 28 cadaveric models were examined at the Laboratory of Clinical Applied Anatomy, Fujian Medical University, to observe the anatomical details of rectosacral fascia. Results: (1) Anatomical observation showed that the pre-hypogastric fascia attaches to the proper fascia of the mesorectum in a horizontal arc posteriorly, forming the rectosacral fascia. If this fusion couldn't be identified and appropriately transected during posterior space dissection, it would be easy to destroy the proper fascia and dissect through the mesorectum resulting in residual mesorectum tissue. After the fascia transaction, the proper fascia of the mesorectum is still intact distally. The upper part of rectosacral fascia bilaterally re-separated again into the proper fascia and pre-hypogastric fascia. The pre-hypogastric fascia acts as a "fascia barrier" when dissecting the lateral space constantly from posterior to anterior. The right attachment of the rectosacral fascia was gradually transected. The pelvic plexus from the right S2-S4 was covered by the pre-hypogastric fascia which is considered the outer side layer of rectosacral fascia laterally. It was observed that the fascia continued with the anterior layer of the Denonvilliers' fascia, which has been transected during anterior space dissection. The proper fascia, which is the inner side layer of rectosacral fascia laterally, was still intact. The edge of the right rectosacral fascia attachment ran obliquely from the back and upward into the front direction. The left extension was similar to the right. (2) Cadaveric specimens: at the level of the lower edge of S4 vertebral body, the pre-hypogastric fascia fused with the proper fascia to form the rectosacral fascia. The right attachment margin of the rectosacral fascia was cut off step by step. The attachment margin of the rectosacral fascia went from the back and upward to the front downward direction. The right edge of rectosacral fascia attachment continued with the anterior layer of the Denonvilliers' fascia at the pre-rectal space and attached to the pre-hypogastric fascia laterally. The pelvic plexus sends out many tiny rectal branches on the anterolateral side, which pass through the transitional area between pre-hypogastric fascia and the anterior layer of the Denonvilliers' fascia to innervate the rectum. (3) TME specimens observation: the posterior attachment of rectosacral fascia was curved around the mesorectum with bilateral oblique attachments. The mesorectum was covered by fusion fascia below the posterior and bilateral attachment margin while it was covered only by the proper fascia above it. Conclusion: according to the morphological characteristics of rectosacral fascia, the rectosacral fascia should be dissected at the level of S4 vertebral body posterior to the rectum in an arc, shape and then enter the superior-levator space. Before dissecting the bilateral spaces, the anterior space of the rectum should be dissected first. The anterior layer of the Denonvilliers' fascia should be cut off into an inverted "U" shape, and then the lateral space should be dissected from anterior to posterior. Finally, the lateral attachment of rectosacral fascia was transected to ensure the integrity of the mesorectum without damaging the pelvic plexus branches and NVB.

The Geometry of the roots of the Brachial Plexus.

Diffusion tensor magnetic resonance imaging (DTI) can be used to reconstruct the brachial plexus in 3D via tracts connecting contiguous diffusion tensors with similar primary eigenvector orientations. When creating DTI tractograms, the turning angle of connecting lines (step angle) must be prescribed by the user; however, the literature is lacking detailed geometry of brachial plexus to inform such decisions. Therefore, the spinal cord and brachial plexus of 10 embalmed adult cadavers were exposed bilaterally by posterior dissection. Photographs were taken under standardised conditions and spatially calibrated in MATLAB. The roots of the brachial plexus were traced from the dorsal root entry zone for 5 cm laterally using a 2.5‐mm2 Cartesian grid overlay. The trace was composed of points connected by lines, and the turning angle between line segments (the step angle) was resolved. Our data show that the geometry of the roots increased in tortuosity from C5 to T1, with no significant differences between sides. The 1st thoracic root had the most tortuous course, turning through a maximum angle of 56° per 2.5 mm (99% CI 44° to 70°). Significantly higher step angles and greater variability were observed in the medial 2 cm of the roots of the brachial plexus, where the dorsal and ventral rootlets coalesce to form the spinal root. Throughout the brachial plexus, the majority of step angles (>50%) were smaller than 20° and <1% of step angles exceeded 70°. The geometry of the brachial plexus increases in tortuosity from C5 to T1. To reconstruct 99% of tracts representing the roots of the brachial plexus by DTI tractography, users can either customise the step angle per root based on our findings or select a universal threshold of 70°.

Large Cervical Ependymoma: 2-Dimensional Operative Video.

Spinal ependymomas compose approximately 60% of spinal gliomas, the predominance occurring within adults. These tumors are generally benign, and maximal surgical resection with neurological preservation is the surgical goal. This patient had a large upper cervical ependymoma, which was approached through a cervical laminotomy. The surgical resection of this lesion demonstrates the principles of pial venous plexus preservation during posterior midline raphe identification and dissection. Gross total surgical resection was achieved with the preservation of the patient's baseline neurological function. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Safe exposure of the left renal vein during laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: anatomical variations and pitfalls.

The left renal vein is technically difficult to expose during laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma despite being an important landmark for posterior dissection. We hereby propose a novel technique to safely expose the left renal vein while avoiding the associated anatomical pitfalls. The anatomy of the left renal artery and vein was analyzed using multidetector computed tomography. We initially exposed the left renal vein on the left posterior side of the superior mesenteric artery followed by exposure toward the left kidney. We retrospectively examined the perioperative results of this technique in 33 patients who underwent laparoscopic distal pancreatectomy. 15.7% of the patients had an accessory left renal artery coursing cranial to the vein. In 43.1%, the left renal arterial branch ventrally traversed the vein at the renal hilum, thereby posing a risk for arterial injury. The location of the left renal vein varies cranial (17.6%) or caudal (82.4%) to the pancreas. The left renal vein was exposed without any vascular injury using this technique. The median operative time was 259min, blood loss was 18mL, and R0 resection rate was 97.0%. The initial exposure of the left renal vein should, therefore, be on the left posterior side of the superior mesenteric artery.

Accessory V6 during thoracoscopic middle lobectomy: "an uncomfortable presence".

Key messageThe identification of the accessory vein draining the superior segment of the right lower lobe (accessory V6), during the posterior mediastinal lymph node dissection, can help avoid operative complications.

Anterior Bilateral Sacrospinous Ligament Fixation: A Safe Route for Apical Repair

Traditionally, sacrospinous ligament fixation is performed unilaterally with a posterior dissection for correction of apical vaginal prolapse. There is limited information on alternative techniques including bilateral application and use of anterior vaginal dissection for this procedure. The objective of this study is to evaluate the anatomic and perioperative outcomes in women who have undergone bilateral sacrospinous ligament fixation through an anterior approach. This cohort represents women in our prospective repository who underwent anterior approach bilateral sacrospinous ligament fixation between September 2011 and June 2014. Concomitant procedures were performed as indicated. Pelvic organ prolapse quantification points were measured preoperatively and at 6 weeks and 6 months postoperatively and were compared. Perioperative outcome measures and adverse events were also analyzed. In this cohort, 144 women underwent anterior approach to bilateral sacrospinous ligament fixation. The patients' mean age was 57.8 ± 10.9 years, and the average body mass index was 29.6 ± 5.8 kg/m. In patients who underwent anterior approach bilateral sacrospinous ligament fixation, points Aa, Ba, C, Gh, Ap, and Bp remained at stage I or less when compared with pelvic organ prolapse quantification measurements at the baseline. Perioperative and postoperative complications were minimal, with 1 (0.7%) patient requiring a blood transfusion and 3 (2%) patients suffered from intraoperative lower urinary tract injuries, none of which were attributable to the sacrospinous fixation part of the procedure. Anterior approach bilateral sacrospinous ligament fixation is a safe and effective procedure for reestablishing apical support in a patient with apical vaginal prolapse.

Minimal dissection of posterior wall of rectum reduces rectal prolapse in laparoscopic assisted anorectal pull-through

PurposeTo determine if minimal dissection of the posterior wall of rectum can reduce rectal prolapse after laparoscopic assisted anorectal pull-through (LAARP) in male anorectal malformation (ARM) with rectourethral fistula. MethodsEighty-six male patients with ARM who underwent LAARP in our center between 2007 and 2018 were retrospectively analyzed. There were 45 cases of prostatic urethral fistula, 24 bulbar urethral fistulas, and 15 bladder neck fistulas. Two patients had no fistula. To prevent rectal prolapses, we markedly shortened the length of posterior rectal dissection from mid-2016. Dissection of posterior wall of rectum was performed minimally around the level of the fistula and the dissected portion of the posterior rectum was significantly shorter than the previous cases. For comparative analysis, patients were divided into two groups (before and after application of minimal dissection of posterior wall of rectum): Group A, from 2007 to mid-2016 and Group B, from mid-2016 to 2018. ResultsThere were 60 patients in Group A and 26 patients in Group B. Demographic characteristics were not significantly different between the two groups. The median follow-up duration was 52.4 months for Group A and 26.9 months for Group B. Group B had lower incidence of rectal prolapse (11.5%) than Group A (68.3%) (p < 0.001). Upon our subgroup analysis based on types of fistula, patients with recto-prostatic urethral fistula and recto-bulbar urethral fistula showed significant reduction in the incidence of rectal prolapse (both p < 0.001). However, patients with recto-bladder neck fistula showed no statistical significance (p = 0.264). ConclusionMinimal dissection of the posterior wall of rectum can reduce rectal prolapse in LAARP. Level of evidenceIII. Retrospective Comparative Treatment Study

Zoning inside the renal fascia: The anatomical relationship between the urinary system and perirenal fat

ObjectivesTo examine the anatomical relationship between the urinary system and perirenal fat, and to clarify the zoning inside the renal fascia.MethodsUsing computed tomography images from 50 men, we examined perinephric veins to reveal vessel communication in perirenal fat. Nine cadavers were dissected to investigate connective tissue continuity and vessel communication inside the renal fascia. Eight retroperitoneal specimens were macroscopically observed: four from the anterior and four from the posterior aspects. One specimen was used to obtain retroperitoneal transverse sections to study macroscopic anatomy and histology.ResultsPerinephric veins were classified into four types (superior, middle, inferior and lateral) using computed tomography. Most of the inferior perinephric veins were connected to the ipsilateral gonadal vein. In the cadaveric study, the superior and middle perinephric veins communicated with veins deriving from the ipsilateral adrenal gland. A fibrous connective tissue gap between perirenal fat and renal hilar fat was observed in posterior aspect dissection. From the gap, we could dissect the urinary system from perirenal fat en bloc along with a thin fibrous connective tissue layer. Communicating vessels between perirenal fat and the urinary system were rare.ConclusionsOur results suggest that perirenal fat belongs to the connective tissue of the gonad and the adrenal gland. The urinary system is separate from perirenal fat, and is located on the dorsal side inside the renal fascia. This concept of zoning inside the renal fascia is valuable particularly in retroperitoneoscopic donor nephrectomy.

V14-11 TRANSVESICAL ROBOT ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer (V14)1 Apr 2020V14-11 TRANSVESICAL ROBOT ASSISTED RADICAL PROSTATECTOMY Gongxian Wang*, Xiaochen Zhou, Bin Fu, and Cheng Zhang Gongxian Wang*Gongxian Wang* More articles by this author , Xiaochen ZhouXiaochen Zhou More articles by this author , Bin FuBin Fu More articles by this author , and Cheng ZhangCheng Zhang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000982.011AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To introduce the technique and report our initial experience of transvesical robot assisted radical prostatectomy (TvRARP). METHODS: 35 TvRARP for prostate cancer performed by a single surgical team between 2018 April and 2019 April were retrospectively reviewed. Preoperative data of patients [patient age (63.4, [49-73]) years, BMI (28.6 [22.1-35.4]) kg/m2, tPSA (10.8 [4.6-19.5]) ng/ml, biopsy Gleason score 6 (6∼7), prostate volume (30.6 [15.4-61.2]) ml and IIEF-5 score 15 (10∼20)] were collected. Preoperative study revealed 28 cases of cT2a and 7 case of cT2b. All patients were continent preoperatively. Surgical techniques: The surgery was performed with da Vinci Si system via 4 robotic ports and 2 assistant ports as the following: 1) cystotomy, further expended by bilateral suspension stitches. 2) A circumferential incision is made around the internal urethral orifice through the mucosa and muscular layer. 3) Initial dissection of the vas deferens and semi vesicles is carried out through the lower half of the circumferential incision around the internal urethral orifice. 4) Posterior dissection towards the apex of the prostate. 5) Dissection of bilateral NVB. 6) Anterior dissection towards the apex of the prostate. 7) Dissection and transection of the urethra. 8) Urethrovesical anastomosis. 9) 2-layer closure of bladder. RESULTS: All 35 cases were successfully performed robotically without conversion, transfusion or other major intraoperative and postoperative complications. Postoperative pathology confirmed 24 pT2a cases, 9 pT2b cases and 2 pT2c case [Gleason score 6 (6∼8)]. 4 case reported positive surgical margin (12.5%). Operative time was (130 [90-190]) min. Estimated blood loss was (100 [50-250]) ml. Urethral catheter was removed at postoperative 7-day. 32 patients achieved urinary continence (0 pads) immediately after the removal of urinary catheter, while 3 patient returned to full continence in 2 weeks postoperatively. During a mean follow up of 12 months (6∼18 months), no biochemical recurrence was noted (tPSA<0.2ng/ml). At 2-month postoperatively, IIEF-5 score was 15 (10∼19) and not statistically different from preoperative status (p > 0.05). CONCLUSIONS: Transvesical approach is a valid alternative of performing RARP in patients bearing localized low-risk prostate cancer. Tumor control and preservation of erectile function remains to be determined in long term follow up. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1309-e1309 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gongxian Wang* More articles by this author Xiaochen Zhou More articles by this author Bin Fu More articles by this author Cheng Zhang More articles by this author Expand All Advertisement PDF downloadLoading ...

Acute hemorrhagic cerebral artery dissection: Characteristics and endovascular treatment.

Acute hemorrhagic cerebral artery dissection may show a subtle stenosis and bulge on an angiogram, for which diagnosis and treatment are difficult. This report describes seven cases of acute hemorrhagic cerebral artery dissection treated by endovascular techniques. From January 2018 to April 2019, seven patients (22-76 years old) were diagnosed with subarachnoid hemorrhage caused by cerebral artery dissection. Six patients were treated by low-profile visualized intraluminal support stent-assisted coiling and there was a sacrifice of the posterior cerebral artery in one patient. Cerebral angiography results were obtained immediately after intervention and at follow-up. Clinical outcome was evaluated by a modified Rankin Scale score. Four dissections were angiographic changes of subtle stenosis and small bulges; three were apparent angiographic changes of stenosis or fusiform morphologies. All seven aneurysms were completely obliterated, a low-profile visualized intraluminal support stent was used in six patients and coil occlusion of the parent artery in one patient. Complications occurred in two cases of proximal posterior cerebral artery dissection. One bleeding complication was observed intra-procedure and one ischemic complication was observed after stent-assisted coiling. The angiographic and clinical follow-up was obtained at 3-8 months in five patients. Good recovery was achieved for six patients (modified Rankin Score 0); one patient who presented Weber syndrome caused by ischemic complication had a modified Rankin Score of two at 8 months follow-up. Hemorrhagic cerebral artery dissection may show subtle stenosis, small bulges or fusiform morphologies on angiograms. Treatment of proximal posterior cerebral artery dissection is challenging. Endovascular reconstruction with a low-profile visualized intraluminal support stent was effective depending on the angiographic morphology.

Utility of T2-weighted high-resolution vessel wall imaging for the diagnosis of isolated posterior inferior cerebellar artery dissection at acute and early subacute stages

Recent advances in magnetic resonance high-resolution vessel wall imaging (HRVWI), which can detect intramural hematomas (IMH), improve the noninvasive diagnostic accuracy of isolated posterior inferior cerebellar artery dissection (iPICA-D). However, despite the risk of overlooking minute IMH, the utility of T2-weighted HRVWI has not been thoroughly evaluated. This study aimed to compare the utility of T2-weighted HRVWI with that of T1-weighted HRVWI, basiparallel anatomical scanning (BPAS), and magnetic resonance angiography (MRA) for the diagnosis of iPICA-D mainly in the acute and early subacute stages in 6 iPICA-D patients (three acute, two early subacute and one late subacute stages on initial examinations). Dissection-related abnormalities included IMH on T1-weighted HRVWI, aneurysmal dilations on T2-weighted HRVWI and discrepancy between BPAS and MRA. On initial examinations, T2-weighted HRVWI revealed iPICA-D-related abnormalities more conspicuously than did T1-weighted HRVWI and combination of BPAS and MRA. Except in a single case with a discrepancy between the outer contour on BPAS and inner contour on MRA, no specific abnormalities were detected besides T2-weighted HRVWI at acute or early subacute stages. In addition to T1-weighted HRVWI, BPAS and MRA, T2-weighted HRVWI should be performed to diagnose acute and early subacute iPICA-D.

Open Reduction and Pin Fixation of Pediatric Lateral Humeral Condylar Fractures.

Lateral condylar fractures of the humerus are the second most common elbow fracture seen in pediatrics, behind supracondylar humeral fractures. All practicing orthopaedic surgeons should be able to identify and treat these injuries appropriately, as the intra-articular and transphyseal nature of this fracture pattern contributes to the relatively high complication rate. Treatment has evolved with time as classification systems better characterize the different types of lateral condylar fractures, aiding in decision-making for management. This video article reviews the diagnostic findings and classification systems for lateral condylar fractures and then details the surgical technique for open reduction and internal fixation of displaced lateral condylar fractures. Position the patient supine with the arm extended on a hand table with a sterile tourniquet. Center the incision over the capitellum. Follow the rent in the fascia to the fracture. Open the capsule anteriorly to view across the joint, avoiding excess posterior dissection to protect the blood supply. Clear soft tissue from the anterior surface of the fracture fragment, which will allow visualization of the fragment without excessive posterior dissection. Using a long retractor anteriorly to maintain visualization of the articular surface, reduce the fracture with a valgus force. Insert 2 pins percutaneously posterior to the incision. One pin should be parallel to the joint surface; the other should diverge >45° and fixate the medial metaphysis. Confirm reduction by direct visualization as well as by anteroposterior, lateral, and internal oblique radiographs. Cut and bend the pins outside the skin and close the incision with absorbable suture. Apply a long-arm cast. Nonoperative management is reserved for fractures with <2 mm of displacement. Closed reduction can be attempted for fractures with 2 to 4 mm of displacement. Screw fixation may be utilized in some cases. Management of fractures displaced 2 to 4 mm is controversial and surgeon-dependent. Although cast immobilization for these fractures has been reported historically as successful1, close follow-up is required as these fractures can have late displacement. Many authors have a low threshold for operative intervention if close follow-up cannot be guaranteed or if there is concern for increasing displacement2. Both closed reduction and percutaneous pinning with an arthrogram and open reduction with direct visualization and fixation are acceptable treatment methods3. There is consensus that surgery is warranted for a displaced lateral condylar fracture with malrotation or articular incongruity. Although there is 1 report of percutaneous reduction and fixation in substantially displaced fractures4, most surgeons perform open reduction with either pin or lag screw fixation for fractures displaced >4 mm. Although lag screw fixation is biomechanically superior5 and has higher union rates6,7 and lower infection rates8, a second surgery is necessary for implant removal because of growth concerns9. Bone union and good clinical results can be obtained in children with a lateral condylar fracture10. Lateral overgrowth in the form of a "lateral spur" and cubitus valgus are the most common residual deformities seen10. Nonunion, osteonecrosis, fishtail deformity, and ongoing range of motion limitations are seen less commonly in lateral condylar fractures11-13. Reserve nonoperative management for minimally displaced fractures that can be followed closely.An arthrogram is required for closed reduction to ensure joint surface congruity.Avoid posterior dissection as it risks the blood supply to the distal fragment.Counsel parents that lateral overgrowth is to be expected and results in no functional limitations to the patient.

Use of a Bakri balloon in the management of presacral hemorrhage

Presacral hemorrhage after pelvic surgery usually results in massive, life-threatening bleeding. It is often difficult to control this presacral hemorrhage with standard hemostasis techniques after rectal mobilization. Mobilization of the rectum is part of the daily maneuvers of most pelvic surgeons. This review shows a common cause of presacral hemorrhage and demonstrates that the Bakri tamponade balloon catheter can control massive pelvic bleeding. A comprehensive, detailed review of the pelvic anatomy and hemostasis techniques used to control presacral hemorrhage was conducted. Also, a case study illustrated the novel use of the Bakri balloon for effective hemorrhage control. The presacral venous plexus or basivertebral sacral veins may be the sources of significant hemorrhage during rectal mobilization. The Bakri balloon effectively targets them. The standard recommendation for safe posterior dissection of the rectum to prevent presacral hemorrhage is approaching the plane between the mesorectal fascia and presacral fascia. We found that the Bakri balloon tamponade effectively controlled presacral hemorrhage and offers advantages over conventional packing. Massive hemorrhage is a potential complication of pelvic surgical procedures. Surgeons should be aware of hemostasis techniques for managing acute pelvic bleeding. We believe that the Bakri balloon should be included as a treatment option.

Inconspicuous longitudinal tears of the intracranial vertebral artery in traumatic basal subarachnoid hemorrhage.

Blunt force trauma to the head or neck region can cause traumatic basal subarachnoid hemorrhage (TBSAH), which can result in rapid loss of consciousness and death; however, detecting such a vascular injury is difficult. Posterior neck dissection was performed to investigate the bleeding focus in TBSAH cases 2018 and 2019. In all four cases, autopsies revealed a longitudinal tear in the midsection of the vertebral artery’s intracranial portion. The midportion of the intracranial vertebral artery appears to be most vulnerable to TBSAH. Interestingly, three of the cases showed only a vaguely visible longitudinal fissure in the artery without a grossly apparent tear; rupture was confirmed by microscopic examination. Longitudinal fissures of the intracranial vertebral artery, which are difficult to identify without detailed examination, may be overlooked in some cases of TBSAH. Thus, careful gross and microscopic examination of the vertebral artery is recommended in cases of TBSAH.

2040 Three-Arm Robotic Hysterectomy: Choreography for the Trainee

Video Objective To Demonstrate Robot-assisted total laparoscopic hysterectomy, bilateral salpingo-oopherectomy (TLHBSO) using 3 arms and a uterine manipulator Setting The da Vinci XI Platform is used to perform a simple extrafascial TLHBSO Interventions A step-by-step choreography demonstrates 5 main exercises of a robot-assisted TLHBSO mainly; 1- The posterior dissection, 2- The anterior dissection, 3- The lateral dissection, 4- The colpotomy, 5- The cuff closure and suspension. Attention is drawn to the position of the uterus and the direction of counter-traction necessary to complete each step. The function of the third arm is emphasized. Relevant anatomy shown. Necessary laparoscopic surgical techniques demonstrated. Conclusion The principles of this step-by-step choreographed method can be reproducible with every platform, docking preference, and surgeon handedness. The 5 exercises break down the procedure for the trainee as specific tasks to complete and master separately. This facilitates the learning process and maintains operating room efficiency. To Demonstrate Robot-assisted total laparoscopic hysterectomy, bilateral salpingo-oopherectomy (TLHBSO) using 3 arms and a uterine manipulator The da Vinci XI Platform is used to perform a simple extrafascial TLHBSO A step-by-step choreography demonstrates 5 main exercises of a robot-assisted TLHBSO mainly; 1- The posterior dissection, 2- The anterior dissection, 3- The lateral dissection, 4- The colpotomy, 5- The cuff closure and suspension. Attention is drawn to the position of the uterus and the direction of counter-traction necessary to complete each step. The function of the third arm is emphasized. Relevant anatomy shown. Necessary laparoscopic surgical techniques demonstrated. The principles of this step-by-step choreographed method can be reproducible with every platform, docking preference, and surgeon handedness. The 5 exercises break down the procedure for the trainee as specific tasks to complete and master separately. This facilitates the learning process and maintains operating room efficiency.

Brunetti's chisels in anterior and posterior rachiotomy.

Rachiotomy entails vertebral surgical incision, generally followed by exposure of the spinal cord, and is performed primarily for educational, research, or medicolegal purposes. Over time, several tools have been developed for this procedure, but Lodovico Brunetti designed the first effective prototypes in the mid-nineteenth century. To show the technical details of and the necessary maneuvers to be performed for Brunetti's rachiotomies to succeed, a computer-aided systematic literature review of online databases was performed to identify publications concerning Brunetti's chisels used for rachiotomy. Additional references from the studies and treatises included held in the Historical Section of the Medical Library at the University of Padova were checked manually for pertinent information. The known variants of Brunetti's chisels were reported in detail from the first to the third versions produced and intended for both posterior (first and third prototypes) and anterior (second prototype) vertebral dissection. Further evolution that led to the current commercialized model devoted to posterior use also was described. The models' strengths and weaknesses were assessed, as well as the nature of the changes Brunetti introduced over time and their motivation. In conclusion, these tools could represent an alternative to the use of electric saws, particularly for dissectors who prefer to have greater manual control in incising the vertebrae. Clin. Anat. 33:355-364, 2020. © 2019 Wiley Periodicals, Inc.

Reply to comments on "Robotic-assisted right medial and anterior basal segmentectomy (S7+S8)": lymph node dissection and incision.

In this article, we respond to the comments made by Dr. Hanna, Drs. Kim and Jeong on “Robotic-assisted right medial and anterior basal segmentectomy (S7+S8)”. Firstly, I want to explain why we did not describe any dissection of the N2 nodal stations as questioned by Dr. Hanna. We have described N2 nodal dissection in our previously published article (1). For this patient, we simply focused on sharing a step-by-step right S7+8 segmentectomy, and thus did not feel the need to describe N2 lymph node dissection. For pathologically confirmed lung cancer patients, we also start with a posterior mediastinal dissection in the same way that Dr. Hanna does.

Magnet-Assisted Robotic Prostatectomy Using the da Vinci SP Robot: An Initial Case Series.

Introduction: Tissue retraction during minimally invasive surgery has been achieved to date with patient positioning or additional instrumentation. The Levita™ Magnetic Surgical System (San Mateo, CA), a novel, noninvasive, magnetic retraction device for minimally invasive surgery, has been used to facilitate reduced-port robotic prostatectomy using a multiport robotic platform. With the release of the da Vinci SP robotic system (Intuitive, Sunnyvale, CA), we now report a multi-institutional initial case series of magnet-assisted robotic prostatectomy using the single-port robotic platform. Materials and Methods: An IRB-approved, retrospective chart review was performed of all patients undergoing robot-assisted radical prostatectomy using the da Vinci SP surgical system and a single Levita magnetic retractor in treatment of prostatic adenocarcinoma at two institutions from November 2018 to January 2019. Preoperative, intraoperative, and postoperative data were collected for descriptive analysis. Results: A total of 15 men, median age 62 years (range 57-71), with mean PSA 7.0 ± 2.3 underwent surgery. The robotic cannula and a single 12-mm assistant port were utilized in all cases, the latter for suction, suture passage, and clip placement; the magnetic retractor aided with posterior dissection, dorsal venous complex stitch placement, bladder neck dissection, and lymphadenectomy. No cases required conversion to a multiport robotic platform, laparoscopy, or open surgery, nor placement of additional assistant ports. No intraoperative or postoperative complications occurred. Average operative time was 224 ± 43 minutes and blood loss was 198 ± 115 mL. All patients were discharged home within 2 days of surgery. Conclusions: Robotic prostatectomy utilizing the da Vinci SP system is feasible, safe, and effective. Use of the magnetic retractor facilitates tissue exposure and improves procedure ergonomics, mimicking the conventional multiport technique. Further exploration of magnet utilization in robotic surgery and optimization of assistant port placement for true single-site surgery is warranted.

En bloc removal of a large leiomyosarcoma arising from the inferior vena cava using retroperitoneal laparoscopic dissection of posterior vessels followed by cavectomy in a thoracoabdominal approach

A 55-year-old Japanese woman had a large retroperitoneal tumor involving the inferior vena cava (IVC) in the right infrahepatic space. We performed en bloc tumor resection with the right kidney and ipsilateral adrenal gland. Because of the large tumor size, we used a retroperitoneal laparoscopic approach for the posterior dissection and performed renal artery ligation. Following open conversion by a thoracoabdominal anterior approach, the tumor was completely removed without major reconstruction. Pathological examination confirmed a leiomyosarcoma arising from the IVC. Retroperitoneal laparoscopic dissection of the posterior side enabled easy and safe surgery even for a large tumor involving the IVC.