Posterior Peritoneum Research Articles

Development and Evaluation of a Cesarean Hysterectomy Simulation Model

Introduction: Cesarean hysterectomy is a life-saving procedure considered during postpartum hemorrhage in cases of uterine atony refractory to management, placenta accreta spectrum, or other obstetric complications. The procedure has high morbidity and mortality despite the rising rates of worldwide and in the United States. A high percentage of OB/GYN residents graduate without preparedness to perform this procedure post-residency, citing insufficient residency exposure as the primary contributor. This study aims to use evaluation and assessment tools to validate a low-cost, low-fidelity cesarean hysterectomy model at multiple OB/GYN residency training sites across the United States to increase resident confidence and proficiency in performing this critical procedure. Materials and Methods: Model Design and Development: Gynecologic surgeons from two OB/GYN residencies reviewed the literature for cesarean hysterectomy education and simulation. A low fidelity, anatomically accurate model was developed for cesarean hysterectomy simulation purposes. Efforts were made to optimize for anatomic layout and realistic feel, particularly for the anatomic structures relevant to cesarean hysterectomy: uterine vessels, anterior and posterior peritoneum, relation of anterior uterus to the bladder and ureters. Study Design: The study received institutional board review exemption at the Loyola University Medical Center (LUMC) and the University of Toledo (UT). During the last two months of the academic calendar, OB/GYN residents were offered the opportunity to perform a cesarean hysterectomy on the model. Demographics were collected in addition to the number of cesarean and abdominal hysterectomies performed as well as the confidence in cesarean hysterectomies independently. A uniform set of surgical instruments with both appropriate and inappropriate tools were made available for residents to choose from. Throughout the simulation, residents were asked to verbalize each step being performed. One faculty rater at each institution was trained to use the objective and standardized assessment tools and had completed an inter- and intra-rater reliability assessment. All residents were evaluated using the same two objective assessment tools. The two validated assessment tools used to evaluate resident performance using the model were the Task Specific Checklist and the Global Rating Scale. The former assessed residents on a “performed or not” basis on 14 surgical steps specific to cesarean hysterectomy. The latter used a scale of 1 to 5, with higher values representing more advanced skill, to evaluate respect for tissue handling, time and motion, instrument handing, knowledge of instrument selection, operation flow, assistant use, and familiarity with the procedure. Results: A total of 26 residents, 18 of 19 at LUMC and 8 of 17 at UT, completed the cesarean hysterectomy simulation between May and June 2022. At LUMC, no graduating residents had performed a cesarean hysterectomy in their residency. At UT, graduating residents had performed up to 2. All of the residents, including PGY-4s, stated that they either disagree or strongly disagree with the statement “I feel confident performing cesarean hysterectomy independently.” As hypothesized, the median resident scores on the Task Specific Checklist and Global Rating scale correlated with increasing PGY level. The combined TSC+GRS score was a median of 40 out of 49 total for the PGY-4 class, while the PGY-1 class had a median combined TSC+GRS score of 12 of 49. The PGY-2 and -3 class had TSC+GRS scores of 14 and 28 respectively. The simulation model was well-received with a median 4/5 rating for improving comfort level with cesarean hysterectomy and a median 4/5 rating for model realism. Each uterine model cost $6.00 and took approximately 20 minutes to build. The optional base constructed for supporting the model, cost a one-time fee of $160. All materials used for construction were easily available online. Discussion: This study validated an affordable, easily reproducible model that highlights the most important anatomy relevant to a cesarean hysterectomy. The model was developed, produced, and tested at two residency programs with a total of 26 residents participating in the study. This is the first low-fidelity cesarean hysterectomy model inclusive of relevant surgical steps and offers near-real visceral feel that has been developed and assessed for validity. This multisite study created a realistic model with high reproducibility at a low cost. Limitations of this study included the fact that only 27 residents participated in the study from only two institutions. In addition, faculty evaluators were not blinded to the residents they rated. The model is a reliable and affordable way to introduce this procedure at residency programs, particularly those that do not perform a substantial number of cesarean hysterectomies.

Experience of mesenteric sector fixation in mesenteric torsion treatment

Objective: The preliminary results was reported regarding the treatment of mesenteric torsion by mesenteric fixation in the last decade, especially preventing recurrence of mesenteric torsion by mesenteric fan-shaped fixation. Methods: We selected 12 patients who received emergency operation in Chongqing Hospital of the First Affiliated Hospital of Guangzhou University of Chinese Medicine from December 2010 to March 2022. All of them were made a definite diagnose of mesenteric torsion by the preoperative CT scan or exploratory laparotomy. The recurrence of mesenteric torsion will be prevented by taking the operation of mesenteric fan-shaped fixation. This technique is suitable for the patient who is suffering total mesenteric torsion, but enteric necrosis is excluded affirmatively. The operation is consists of the following progress: (1) Exploratory laparotomy to check for necrosis of the bowel and for lesions other than torsion. (2) Mesenteric torsion derotation.(3) Mesenteric linear fixation; the right posterior lower border of the small mesentery (terminal ileal mesentery) is intermittently sutured to the posterior peritoneum of the right lower quadrant to increase the width of the base of the small mesentery. (4) Mesenteric fan-shaped fixation, which is fan-shaped to the lower left and fixed in the posterior peritoneum, shortening the length of the mesentery and further increasing the width of the mesentery and posterior peritoneal fixation. Results: A total of 12 patients with mesenteric torsion were treated by operation for 15 times in all. Among them, 3 cases received resection of most small bowel were performed without recurrence; 3 patients received only derotation for a total of 4 times, 2 cases recurred, 1 of them recurred twice; 4 cases underwent derotation and mesenteric linear fixation,and 1 case recurred. Four patients with derotation and mesenteric fan-shaped fixation recovered well without recurrence. Conclusion: Mesenteric fan-shaped fixation may be an effective operative type to reduce or avoid postoperative recurrence of mesenteric torsion.

Ovarian tissue biopsy for cryopreservation by vaginal natural orifice transluminal endoscopic surgery: a new approach for a minimal invasive ovarian biopsy

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is an emerging surgical procedure that combines the advantages of the vaginal approach with laparoscopic vision and instrumentation. Shorter hospitalization and lesser postoperative pain associated with vNOTES may be explained by the advantages of this innovative surgical approach (e.g., absence of abdominal incisions, shorter operative time, and lower insufflation pressure). Ovarian tissue cryopreservation allows to preserve reproductive and endocrine functions in young women with oncological disease at risk of premature ovarian insufficiency (POI) caused by gonadotoxic treatments. Ovarian tissue biopsy for cryopreservation consists of a large biopsy of 1 or both ovaries that is usually performed by laparoscopy. Then, the removed ovarian tissue is cryopreserved for the future transplant after cancer remission. The volume of ovarian biopsy ranges from 50% of the ovary for women at moderate risk of POI to 70%-100% of it for those at high risk. The inclusion criteria for ovarian tissue cryopreservation are women aged <35 years who cannot delay start of oncological treatments for follicle cryopreservation, with a moderate or high risk of POI and good chance of 5-year survival. Ovarian tissue cryopreservation cannot be performed if tumor treatments include uterine irradiation or for tumors at risk of ovarian metastases (as in the case of ovarian cancer, leukemia, neuroblastoma, or Burkitt lymphoma). Despite widespread adoption of vNOTES in gynecology, ovarian biopsy for cryopreservation has never been performed using this route. Step-by-step explanation of the procedure with descriptive text and narrated video footage. Tertiary-level referral academic center. A 27-year-old patient recently diagnosed with low-grade follicular non-Hodgkin lymphoma was referred to our center for ovarian tissue cryopreservation before chemotherapy. The patient included in this study gave informed consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (e.g., PubMed, ScienceDirect, and Scopus), and other applicable sites. Because of the nature of the study, institutional review board approval was not required. Access to the peritoneal cavity was created by a 3-cm posterior colpotomy. The peritoneum was then opened using cold scissors and temporarily fixed to the posterior vaginal wall. The GelPOINT Mini Advanced Access Platform (Applied Medical, Rancho Santa Margarita, CA), with 1 10-mm and 2 5-mm trocars, was used as the vNOTES port. The inner Alexis ring of the GelPOINT was inserted through the colpotomy into the pouch of Douglas. A hysterometer was placed into the uterine cavity to keep the uterus anteverted during the surgery. A pneumoperitoneum was created to a pressure of 8 mm Hg, and the operating table was tilted to a 20° Trendelenburg position. A 10-mm rigid 30° camera was inserted in the inferior and larger trocar, and both ovaries were visualized. Seventy percent of the left ovary was removed with cold scissors to minimize trauma on the surgical specimen. After removal of the GelPOINT cap, ovarian biopsy was immediately picked up by the biologist of our fertility center. The ovary was coagulated with a bipolar instrument. The hysterometer was then replaced by a uterine manipulator to perform tubal patency test, and blue dye passage through both salpinges was observed. Finally, the Alexis retractor and stich on the posterior peritoneum were removed, and the vagina was sutured using interrupted stiches. The total operative time was 25 minutes. Ovarian tissue biopsy for cryopreservation by vNOTES. No intraoperative and postoperative complications were reported, and the patient was discharged after 24 hours from surgery. Vaginal natural orifice transluminal endoscopic surgery may be a feasible alternative approach to laparoscopy for ovarian tissue cryopreservation: it allows an easy access to the ovaries and removal of different tissue volumes. Patients undergoing ovarian cryopreservation may benefit from the vNOTES approach because a rapid postoperative recovery is crucial to start chemotherapy in a short time. As for other vNOTES procedures, accurate selection of patients seems to be crucial for a successful ovarian tissue cryopreservation. We believe that the inclusion and exclusion criteria reported for other gynecologic procedures performed through vNOTES may also be valid for ovarian tissue cryopreservation by vNOTES. Women at high risk of pelvic adhesions (e.g., coexistent endometriosis, previous pelvic surgery, or inflammatory pelvic disease), those with an increased body mass index or enlarged uterus, and those with cervical, vaginal, or uterine cancer cannot be considered for this approach because all these factors are associated with failure of vNOTES. On the other hand, women with no history of surgery, endometriosis, and large myomas may benefit from the vNOTES approach, and these women represent most of patients who undergo ovarian tissue cryopreservation. Further and larger studies are needed to assess the efficacy and safety of this new approach.

Surgical treatment of recurrent intussusception induced by intestinal lymphoid hyperplasia in a child: is bowel resection always necessary? A case report

BackgroundIntussusception recurrence (IR) induced by intestinal lymphoid hyperplasia (ILH) in children is rare, and surgical treatment is the final resort if IR is refractory to medications and non-surgical interventions. To date, only a few case reports have described surgical management of ILH-induced IR in children, all involving bowel resection regardless of whether there are bowel necrosis and perforation.Case presentationA 2-year-old boy was transferred to our department due to IR. His main complaint was abdominal pain. Color Doppler ultrasound confirmed ileocecal intussusception while no other abnormalities were found. A final diagnosis of IR with unknown causes was made. Repeated saline enema reductions and dexamethasone failed to cure the IR. Laparotomy was eventually performed after almost 10 episodes of IR. Intraoperatively, distal ileum thickening with palpable masses without bowel necrosis and perforation was noted. ILH was suspected and a biopsy of the affected intestine was performed. Histopathological analysis confirmed ILH. The intussusception was manually reduced, the terminal ileum and the ileocecal junction were fixed to the paralleled ascending colon and the posterior peritoneum respectively, and no bowel resection was performed. The postoperative recovery was uneventful and no IR was observed during over 5 years of follow-up.ConclusionsAs far as we are aware, this is the first report of successful surgical treatment of ILH-induced pediatric IR without bowel resection in a child. Our experience suggests bowel resection may be unnecessary if bowel necrosis and perforation are absent.

Appendiceal knotting causing small bowel obstruction: A rare case report

Introduction and importanceAppendicitis causing intestinal obstruction by forming a knot around a small bowel is uncommon. Preoperative diagnosis is challenging as the typical presentations of appendicitis are not usually seen. The diagnosis of appendicular knotting is usually an intraoperative surprise.Case presentationA 34-year-old male patient (BMI-20.86 kg/m2) presented to the surgical emergency unit with colicky central abdominal pain of 2-days duration, which later involved the whole abdomen. In association with this, he had a history of frequent vomiting of ingested matter which later became bilious. The abdominal examination revealed diffuse abdominal tenderness with guarding and rigidity. On midline exploratory laparotomy, the inflamed appendix which was adherent to the distal part of the ileum was observed. The appendix and the encircled segment of the distal ileum were both gangrenous, and the patient underwent resection of the bowel segment in addition to appendectomy.Clinical discussionWhenever an appendix wraps around an intestine or its tip adheres with small bowel, cecum, or posterior peritoneum forming a ring-like structure, and a segment of a bowel herniates through an opening can cause a closed-loop obstruction with or without strangulation. The management for ileo-appendicular knotting associated with gangrenous bowel could be appendectomy and resection of the bowel segment. Postoperatively, the patient had developed diarrhea caused by ileocecal resection, which later subsided by medication.ConclusionIleo-appendicular knotting is a rare cause of small intestinal obstruction, and it's challenging to diagnose during the preoperative period. As surgeons dealing with acute abdomen in routine clinical practice, knowledge of this unusual case is helpful for clinical suspicion and evidence-based management.

OV11 GIANT SPIEGEL HERNIA: 3D PLANNING AND MINIMALLY INVASIVE TREATMENT

Abstract Aim Demonstrate the advantages of 3D technology planning in complex cases of hernia surgery and technical tricks for giant Spiegel hernia repair. Material and Methods 71 year old patient, BMI 38, asthma, hypertensive; long history of symptomatic left flank mass. Giant Spiegel hernia was diagnosed, with significant omentum and colon migration to hernial cavity. It was decided to perform minimally invasive surgery. 3D model of the abdominal scan was performed, assessing hernia size, volume and its relationship with the abdominal cavity. We were able to rule out the possibility of compartment syndrome, and foresee that we could probably close the defect. Results preperitoneal transabdominal repair (TAPP) is performed, beginning with herniated content reduction, a delicate step where injuries should be avoided, with careful traction of the colon and omentum. Hernial defect is assessed, coinciding with the 3D model, the peritoneum sac is reduced, taking as much as possible to facilitate its posterior closure. The entire peritoneum of the Spiegel and inguinal region are dissected en bloc. Defect tension-free closure is performed with 2 continuous V-LOOK 2.0, subsequent placement of 15x15cm polypropylene mesh and posterior peritoneum closure. The patient is discharged the same day without incidents. Conclusions The 3D model allows us to assess the actual abdominal and hernia volume to simulate surgery findings. Its benefits are yet to be developed. Laparoscopic preperitoneal repair is an excellent approach for Spiegel's hernia. Complex cases are also candidates for outpatient surgery.

Large primary retroperitoneal mucinous cystadenoma managed laparoscopically: Case report and literature review

Background: Retroperitoneal cystic lesions (RCLs) are uncommon clinical findings that arise within the retroperitoneal compartments and account for various etiologies. They can be benign or malignant in nature and may present with different manifestations. Case report: A 55-year-old woman presented with nonspecific right sided abdominal pain. Ultrasound detected a large cyst in the right retroperitoneal region, computed tomography revealed a large well-defined cystic lesion measuring 13 X 9 X 6 cm in the right posterior peritoneum extending from the subhepatic area to the right pelvis. Laparoscopic complete resection performed with uneventful perioperative course. Histopathologic findings were suggestive of mucinous cystadenoma. Conclusion: Primary Retroperitoneal Mucinous Cystadenoma (PRMC) is an extremely rare pathology that can pose some challenge for clinicians. Awareness of this entity can help us in establishing the diagnosis and provide an optimal management. Although laparotomy is considered the standard approach of huge mucinous cystadenomas; laparoscopic surgery can be a safe and adequate therapeutic option. Keywords: retroperitoneal cystic lesions (RCL); primary retroperitoneal mucinous cystadenomas (PRMCs); cystadenoma; mucinous; laparoscopy.

Laparoscopic Sacrocervicopexy for Uterovaginal Prolapse: Step by Step for Safety and Efficiency

<h3>Study Objective</h3> The purpose of this video is to demonstrate the step by step of laparoscopic sacrocervicopexy for uterovaginal prolapse using a Y-shaped monofilament polypropylene mesh. <h3>Design</h3> Laparoscopic Subtotal hysterectomy is performed. After that, opening of the posterior peritoneum took place on the sacral promontory and was extended under the right uterosacral ligament. The Douglas pouch was then opened, and the rectovaginal plane was exposed. This maneuver was facilitated by the introduction and the relevant movements of a vaginal malleable valve. Dissecting the inter vesicovaginal space, the anterior mesh is on the anterior vaginal apex with two other sutures and the anterior mesh was fixed on the anterior vaginal wall just before the trigone and at the isthmus of the uterus. After that, the posterior mesh was fixed on the posterior vaginal apex with two other sutures and on the posterior vaginal wall. Both sutures with a 2/0 polygalactin suture. Mesh were anchored on the sacral promontory using a 0 polypropylene non absorbable suture on the longitudinal ligament. At the end, full peritonization of the mesh with a 2–0 polyglactin running suture. <h3>Setting</h3> Patient positioned in a Trendelenburg lithotomy position with legs slightly bent. A 10-mm trocar was placed at the umbilicus, two 5-mm trocars were positioned 2 cm above and medially to the anterior superior iliac spine and a third was positioned midway between the umbilicus and the pubic symphysis. <h3>Patients or Participants</h3> One 56 years old female patient with uterovaginal prolapse stage IV. <h3>Interventions</h3> laparoscopic sacrocervicopexy for uterovaginal prolapse with Y-shaped monofilament macroporous polypropylene mesh. <h3>Measurements and Main Results</h3> The laparoscopic sacrocervicopexy can be performed in patient at stage IV uterovaginal prolapse after partial hysterectomy in an efficient way. After the laparoscopic sacrocervicopexy surgery, the patient evolved with correction of the prolapse to stage I. <h3>Conclusion</h3> Laparoscopic surgery allows a good view of the vaginal walls performing this procedure safely and efficiently

V03-11 ROBOTIC PARTIAL ADRENALECTOMY IN A PEDIATRIC PATIENT

You have accessJournal of UrologyPediatrics (V03)1 Sep 2021V03-11 ROBOTIC PARTIAL ADRENALECTOMY IN A PEDIATRIC PATIENT Amr A. Elbakry, David Zekan, Michael Ost, and Osama Al-Omar Amr A. ElbakryAmr A. Elbakry More articles by this author , David ZekanDavid Zekan More articles by this author , Michael OstMichael Ost More articles by this author , and Osama Al-OmarOsama Al-Omar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001991.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This is a demonstration of technique for robotic approach for partial adrenalectomy in a pediatric patient. METHODS: A 7-year-old female patient who presented with an incidental finding of right adrenal mass measuring 2.5 cm on US imaging. she had no history of hypertension and examination revealed normal BP. Laboratory workup was done and revealed normal levels of serum aldosterone, metanephrines and plasma renin activity. The mass was stable in size after 10 months follow up, however patient's family opted for surgical resection. patient was placed in flank position. We used 4 8 mm robotic ports and a 5 mm assistant port. We started by reflection of the colon and dissection the undersurface of the liver from the IVC and upper surface of the adrenal mass. The posterior peritoneum was incised to expose the plane between the IVC and the adrenal mass. adrenal mass was carefully dissected from the kidney, posterior abdominal wall and the IVC. The right adrenal vein was identified, controlled and divided. The mass was excised with preservation of the normal part of the adrenal gland. RESULTS: Total operative time was 2 hours and 50 minutes. Estimated blood loss was less than 5 milliliters. The patient was discharged home in less than 24 hours. Pathological examination revealed ganglioneuroma. CONCLUSIONS: Robotic approach for adrenalectomy in pediatric patients is a safe and feasible technique. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e225-e225 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amr A. Elbakry More articles by this author David Zekan More articles by this author Michael Ost More articles by this author Osama Al-Omar More articles by this author Expand All Advertisement Loading ...

Laparoscopic ureterolithotomy for large lower ureteral stone: a case series report

BackgroundIdentifying the precise location of the lower ureter is crucial in not only ureteral surgeries but also the other surgeries that may cause ureteral injury. Although a variety of approaches have been applied to detect the location of the lower ureter, the majority of them had an association with several complications or be difficult to perform perfectly or be time-consuming.Case presentationSeven patients with distal ureteric stones of the size ranged from 2 to 3 cm. All patients entered the study after signing the informed consent, and the case report is based on CARE guidelines. After specifying the inner ring of the inguinal canal, the posterior peritoneum was opened and dissected from an area of 2 cm medial and 2 cm inferior to the inner ring. Thereafter, the stone was extracted from the precise location of them, which was identified by ureteral pinching.ConclusionWe assumed that we were easily able to identify the site of the lower ureter through 2 cm medial and 2 cm inferior to the inner ring. The result of our study on seven patients demonstrated that this maneuver can minimize the time of surgery and no complications have been seen while this approach was applied.

Performance Assessment for Total Laparoscopic Hysterectomy in the Operating Room: Validity Evidence of a Procedure-specific Rating Scale

The technical conduct of total laparoscopic hysterectomy (LH) is critical to surgical outcomes. This study explored the validity evidence of an objective scale specific to the assessment of technical skills (H-OSATS) for 7 tasks of an LH with salpingo-oophorectomy procedure performed in the operating room. Observational cohort study. Two academic hospitals in Marseille and Montpellier, France. Three groups of operators (novice, intermediate, and experienced surgeons) were video recorded during their live performances of LH on a simple case. For each group, a dozen unedited videos were obtained for the following tasks: division of the round ligament, division of the infundibulopelvic ligament, creation of the bladder flap, opening of the posterior peritoneum, division of the uterine vessels, colpotomy, and closure of the vault. Two qualified raters blindly assessed each video using the H-OSATS rating scale. Inter-rater reliability and test-retest reliability were calculated as measures of internal structure. In a separate round of evaluations, the raters provided a global competent/noncompetent decision for each performance. As a measure of consequential validity, a pass/fail score was set for each task using the contrasting group method. Three tasks (creation of the bladder flap, colpotomy, and closure of the vault) displayed sound validity evidence: a meaningful total score difference among the 3 groups of experience as well as between the intermediate and experienced surgeons, reliability outcomes of >0.7, and a pass/fail score with a theoretical false-positive rate of <10%. The validity evidence of the H-OSATS rating scale differed for separate evaluations of the 7 tasks. Three tasks (i.e., creation of the bladder flap, colpotomy, and closure of the vault) revealed sound validity evidence, including at the level of the attending surgeon, whereas other tasks were more consistent with low-stakes formative evaluation standards.

A Novel Direct Approach to the Deep Uterine Vein in Laparoscopic Radical Hysterectomy

To describe a direct approach to the deep uterine vein in laparoscopic radical hysterectomy. Demonstration of the laparoscopic technique with narrated video footage. Securing sufficient radicality is extremely important when performing a radical hysterectomy for cervical cancer, either by laparotomy or by minimally invasive surgery. The nerve-sparing Okabayashi radical hysterectomy (NS-RH) was originally aimed at achieving both radical resection and function preservation [1-3]. A key procedure when performing NS-RH is intraoperative identification of the relationship between the deep uterine vein and pelvic splanchnic nerve fibers [4]. With this in mind, a safe and easy method for identifying the crossing point of the deep uterine vein and pelvic splanchnic nerve in the initial phase of the surgery may greatly improve the safety and efficacy of functional preservation in NS-RH. Herein, we describe a minimally invasive "direct approach" to the deep uterine vein. Before undergoing the pelvic lymphadenectomy, all steps of laparoscopic radical hysterectomy were performed. First, we identified the ureter on the posterior peritoneum, and the peritoneum was dissected just above the ureter. By continuously exploring the pelvic cavity along the ureter, especially through the opening of the space below the ureter in a cranial to caudal direction, we could easily identify the deep uterine vein. This procedure also exposed the fibers of the hypogastric nerve, clarifying the relationship of these structures. Because the relationship between the deep uterine vein and nerve fibers is the most important guidepost of this surgery, their identification in the early phase of the surgery enables us to perform the subsequent procedure precisely and securely. This direct approach to the deep uterine vein can be easily and safely performed.

Subperitoneal space and pathways of abdominal and pelvic tumor spread from the perspective of imaging

The abdomen and pelvis have been divided anatomically and clinically into peritoneal cavity and subperitoneal space by peritoneum. The subserosal areolar tissue which lines the inner surfaces of the peritoneum and the musculature of the abdomen and pelvis form the subperitoneal space. The surfaces of organs are covered by peritoneum, therefore, organs are located within subperitoneal space. Those organs that are deep to the posterior peritoneum are called extraperitoneal. Peritoneal reflections comprise the abdominal major ligaments and mesenteries. They contain the branches of the vascular, lymphatic, and nervous systems within subperitoneal space to supply the corresponding organs. Either the relationships of typical location and organ or the landmarks provided by major constituent vessels give a help to recognize ligaments and mesenteries on computed tomographic scans. The abdomen and pelvis may be visualized as unifying, anatomically continuous potential space by ligaments and mesenteries, which provide continuity of anatomic planes and permit the spread of diseases between intraperitoneal compartments, between extraperitoneal spaces, and between intraperitoneal and extraperitoneal localized sites. Understanding the anatomy of subperitoneal space would increase the capabilities to detect pathways of spread and localizing features of infections, malignancies, and traumas.

PARADUODENAL HERNIA- AN OBSCURE AND PERILOUS CAUSE OF INTESTINAL OBSTRUCTION.

Paraduodenal hernias (PDH) constitute more than half of internal hernias. Both left and right PDH occur due to error of rotation of gut and defective fusion of mesocolon and mesentery with posterior parietal peritoneum. Clinical diagnosis of PDH is very difficult because of its varied presentation and nonspecific symptoms. Prompt diagnosis and surgery is imperative to avoid strangulation of bowel which is associated with high mortality. Before the advent of CECT many were discovered during exploratory laparotomy or unrelated abdominal surgery. Now CECT abdomen has become the gold standard for pre-operative diagnosis of PDH. We report two cases of PDH, one on left side and another on right side, diagnosed preoperatively and treated successfully.&#x0D; Keywords: Paraduodenal hernia, Mesocolic hernia, Treitz hernia, Internal hernia

MP61-02 DETAILED CADAVERIC ANALYSIS FOR PERIVESICAL LYMPH NODES WITH POTENTIAL IMPLICATIONS IN BLADDER CANCER

INTRODUCTION AND OBJECTIVE: Perivesical lymph nodes were added to the 8 edition of AJCC staging for bladder cancer. In pN+ patients, positive perivesical lymph nodes are associated with even worse overall survival. These nodes are inconsistently evaluated at the time of radical cystectomy (RC) and can be difficult to differentiate from perivesical fat. Currently, no studies have detailed the presence or anatomic location of perivesical lymph nodes. The objective was to provide a detailed anatomic evaluation of perivesical lymph nodes. METHODS: Six unembalmed cadavers with no prior pelvic malignancy or surgery were utilized. An open RC was performed on all specimens with wide resection of perivesical tissue and meticulous care to separate the pelvic lymph nodes (e.g.obturator, external iliac) from the specimen. The specimens were fixed in a previously validated lymph node revealing solution for 6 hours. Perivesical tissue dissection in 2 mm slices was performed. Lymph node identification and examination were performed by a board-certified pathologist. Perivesical lymph node size and location in relation to bladder wall was recorded. RESULTS: Gross lymph nodes were identified in the perivesical tissue in 50% (3/6) of the specimens, with a total of 6 lymph nodes identified. The mean lymph node size was 7.5 mm (2-16 mm). The mean distance from bladder wall was 9 mm (3-15 mm). Ten potential anatomic locations for perivesical nodes were developed: urachal, anterior bladder wall, posterior peritoneum, periprostatic/bladder neck, bilateral peripedicle, bilateral periseminal vesicle, bilateral lateral bladder wall. Nodes were identified in the: Right peripedicle (2 nodes), left lateral bladder wall (2 nodes), posterior peritoneum (1 node), anterior bladder wall (1 node) (Table). On histologic analysis, 4 of the 6 (66%) grossly identified lymph nodes had confirmed lymphoid tissue. CONCLUSIONS: In a cadaveric model with meticulous dissection, gross and histologically-confirmed lymph nodes were identified in the perivesical space in half of patients. When present, patients had an average of two nodes that were distributed around the bladder and within 15mm of the bladder wall. This data, as well as the inclusion of perivesical lymph nodes in AJCC staging, argues for thorough evaluation of the RC specimen for perivesical lymph nodes.Source of Funding: None

V11-05 RENAL VEIN TRANSPOSITION WITHOUT VENOUS OUTFLOW OCCLUSION

You have accessJournal of UrologyTransplant, Misc GU Cancers & Bladder Reconstruction (non-cancer) (V11)1 Apr 2020V11-05 RENAL VEIN TRANSPOSITION WITHOUT VENOUS OUTFLOW OCCLUSION Kyle Rose*, Matthew Breite, Victor Davila, and Erik Castle Kyle Rose*Kyle Rose* More articles by this author , Matthew BreiteMatthew Breite More articles by this author , Victor DavilaVictor Davila More articles by this author , and Erik CastleErik Castle More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000945.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robot assisted transposition of the renal vein has been described for Nutcracker Syndrome. Unfortunately, surgical repair requires clamping of the venous outflow of the kidney via the left renal vein, which may cause renal parenchymal injury. Our objective was to perform transposition of the renal vein while providing continuous venous outflow from the kidney to avoid venous congestion and renal parenchymal injury. METHODS: A thirty-two year old female with one-year history of left flank pain and inability to walk upright due to this pain. Her computed tomography scan revealed compression of the left renal vein under the superior mesenteric artery. She underwent a venogram with intravenous ultrasound, which demonstrated >90% narrowing of the left renal vein under the SMA, diagnostic for Nutcracker Syndrome. RESULTS: After positioning in Trendelenburg position and obtaining pneumoperitoneum, ports were placed similar to a robot assisted retroperitoneal lymphadenectomy procedure. The retroperitoneum was exposed by incising the posterior peritoneum and tacking this to the anterior abdominal wall. The inferior vena cava (IVC) was identified and skeletonized, with emphasis on identification and dissection of the left renal vein. Vascular control was obtained using modified Rummell tourniquets. During our dissection, we identified a dilated and prominent left gonadal vein. We anastomosed the distal aspect of the left gonadal vein to the IVC, to provide constant venous outflow from the left kidney during transposition of the left renal vein. With the left kidney draining through both the left renal and gonadal vein, the left renal vein was stapled flush with the IVC. We then performed left renal vein transposition by anastomosing the left renal vein to the IVC below the left of the previous insertion with Gore-Tex suture. Vascular clamps were removed to assess the integrity of the anastomoses, and hemostasis was excellent. Total estimated blood loss was 50mL, and total operative time was 3 hours and 19 minutes. Postoperative creatinine improved to 0.57 mg/dL from 0.75 mg/dL preoperatively. The patient was discharged on postoperative day one. At 6 weeks follow up, her flank/abdominal pain had completely resolved. CONCLUSIONS: Robot assisted renal vein transposition is a feasible and safe alternative to open transposition for Nutcracker Syndrome. Transposition of the left renal vein without venous outflow obstruction is possible when utilizing the native gonadal vein as a conduit to the IVC. Using this approach, adequate venous outflow can avoid nephron injury. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1015-e1016 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kyle Rose* More articles by this author Matthew Breite More articles by this author Victor Davila More articles by this author Erik Castle More articles by this author Expand All Advertisement PDF downloadLoading ...

Construction of digital three-dimensional reconstruction model of rabbit vascular network.

In order to study the construction of digital three-dimensional model of rabbit vascular network and provide a powerful basis for the model construction and image processing of human vascular network, in this study, rabbit abdominal and pelvic vessels are perfused with latex-bismuth oxide contrast agent. After that, the internal fibrous structure of the abdominal and pelvic vascular network in rabbits is studied by micro-computed tomography (Micro-CT). Angiography and post-processing software are performed. Firstly, six female rabbits are selected as the study subjects and are anesthetized by intraperitoneal injection of 12% chloral hydrate. After complete anesthesia, laparotomy is performed on the rabbits. The abdominal wall of the rabbit is cut longitudinally to expose the pelvic and abdominal cavity completely. The posterior peritoneum is found and opened. The catheter is inserted into the abdominal aorta and renal artery to complete the abdominal aorta and arterial intubation. Latex, bismuth oxide and potassium hydroxide are mixed in a ratio of 1:1:1 to form latex-bismuth oxide mixed solution as a mixed contrast agent for blood vessel perfusion. After the rabbit is perfused with mixed contrast medium, four organs, including bladder, uterus, small intestine and kidney, are selected as the research organs to construct the three-dimensional model of vascular network in this study. Finally, the above organs are scanned in vitro by micro-CT technology, and the original images of each organ are processed. Then, Mimics 17.0 software is used to build a digital three-dimensional model of the abdominal and pelvic vascular network in rabbits, obtain the information parameters of each network, and analyze the classification and diameter of blood vessels. The results show that the classification of bladder vascular network can only be divided into two levels, uterine vascular network can be divided into three levels, and small intestine and kidney vascular network can be divided into four levels. Therefore, the combination of micro-CT scanning and contrast agent can successfully construct a digital three-dimensional model of rabbit vascular network, which provides a new idea and method for the study of human abdominal and pelvic organs and physiological characteristics.

Ultrasound and MRI features of malignant fibrous histiocytoma of soft tissue

To investigate ultrasound and MRI features of malignant fibrous histiocytoma (MFH) of soft tissue. Ultrasound, MRI images and pathological data of 12 patients with malignant fibrous histiocytoma in soft tissue confirmed by operation and pathology were analyzed from January 2012 to August 2018, inlcuding 7 males and 5 females, aged from 36 to 69 years old with an average age of 53 years old; the courses of disease ranged from 4 to 49 months with an average of 28 months. Clinical manifestations were soft tissue masses and pain in the affected limbs. Ultrasound, MRI and contrast-enhanced examination were performed before operation. The lesions, morphology, echo/signal characteristics, color flow signals and enhancement features were observed and compared with pathology. In 12 patients with MFH, 9 patients were primary lesions and 3 patients were recurrent lesions after operation. There were 7 cases of bilateral thighs, 2 cases of calves, 1 case of upper arm, 1 case of buttocks and 1 case of posterior peritoneum. The size ranged from 5.1 to 17.1 cm with an average of 8.7 cm. Ultrasound feature showed lobulated or agglomerate, and focused on low echo; 5 cases had capsule and with clear border; 7 cases were unclear boundary with surrounding tissues; and 6 cases with irregular echo-free. The blood flow signals were around the CDFI, and the internal blood flow signals were different. MRI feature showed lobulated, agglomerate or irregular shape, T1WI showed slightly lower signal or equal signal, T2WI showed high signal and DWI signal increased. Six patients manifested mixed signal inside, 7 patients manifested low signal separation inside, 5 patients with false envelope, and 9 patients manifested infiltration and growth with peripheral edema. T1WI showed uneven strengthening after enhancement. Immunohistochemical expression of Vim, CD68 were positive. The age, location and imaging features of soft tissue MFH are characteristic. The diagnosis of MFH should be considered when irregular mass occurred in soft tissues of limbs at middle-aged and old people. Echo and signal are homogeneous or mixed. Separation, necrosis and cystic degeneration could be seen in the mass. When the blood flow signals are abundant and solid components are obviously enhanced, the diagnosis of MFH should be considered.

Robot-assisted Partial Nephrectomy and Bilateral Pyelolithotomy in Ectopic Pelvic Kidneys

ObjectiveTo show how to perform a robot-assisted partial nephrectomy and bilateral pyelolithotomy in ectopic pelvic kidneys. This is a congenital abnormality of position and rotation1 frequently associated with urolithiasis.2 Renal cell carcinoma is a very rare event in pelvic kidneys.3,4 These 2 findings in the same patient could be a surgical challenge and whenever possible a “one stage” treatment is preferred. Materials and MethodsA 44-year-old male with bilateral pelvic kidneys admitted because of left back pain. Abdominal CT scan showed a 17 mm stone in the left renal pelvis, a 12 mm stones in the right pelvis and a 34 × 27 mm right lower pole renal mass. A robotic surgery was indicated. Patient was placed in Trendelenburg position with ports configuration as for transperitoneal radical prostatectomy. The right kidney was firstly approached: after isolation of the ureter and suspension of the renal artery, a clampless partial nephrectomy was performed; then through a longitudinal pyelotomy the stone was extracted. To minimize the opening of the posterior peritoneum covering the left kidney, the site of the stone was identified by intraoperative ultrasound; then, through a longitudinal pyelotomy the stone was extracted. Given the watertight sutures and the lack of ureteral obstructions no pigtails ureteral catheters were inserted. A Jackson-Pratt drainage was placed through the inferior port. ResultsConsolle time was 190 minutes. Estimated Blood Loss (EBL) was 50 ml. No complications were reported. The drain was removed on the second postoperative day, assessed that creatinine dosage was equal to serum. The length of stay was 4 days. Histopathology showed a pT1a G2 clear cell renal cell carcinoma with negative surgical margins, while stones analysis was calcium oxalate. ConclusionWith the availability of robotic technology, the indications for minimally invasive surgery may be safely expanded to include concomitant morbidities in uncommon presentations.

Endoscopic trans-esophageal submucosal tunneling surgery: A new therapeutic approach for diseases located around the aorta ventralis.

AIMTo assess the efficiency of endoscopic trans-esophageal submucosal tunneling surgery (EESTS) technique for diseases located around the aorta ventralis.METHODSNine pigs were assigned to EESTs. The procedures were as follows: First, a long esophageal submucosal tunnel was established. Second, full-thickness myotomy was created. Third, an endoscope was entered into the abdominal cavity through a muscle incision and the endoscope was around the aorta ventralis. Eventually, celiac trunk ganglion neurolysis, partial hepatectomy and splenectomy, partial tissue resection in the area of the posterior peritoneum, and endoscopic submucosal dissection (ESD) combined with lymph node dissection were performed. The animals were given antibiotics for 5 d and necropsied 7 d after surgery.RESULTSIn all surgeries, one pig died from intraperitoneal hemorrhage after doing partial splenectomy, while the other pigs were alive after successfully operating other surgeries. For surgery of celiac trunk ganglion damage, at necropsy, there was no exudation in the abdominal cavity. Regarding surgery of partial hepatectomy, the wound with part healing was observed in the left hepatic lobe, and no bleeding or obvious exudation was seen. In surgery of partial splenectomy, massive hemorrhage was observed on the splenic wound surface, and the metal clips could not stop bleeding. After surgery of retroperitoneal tissue resection, mild tissue adhesion was observed in the abdominal cavity of one animal, and another one suffered from severe infection. For surgery of ESD and lymph node dissection, a moderate tissue adhesion was observed.CONCLUSIONEESTS is a feasible and safe technique for diseases located around the aorta ventralis.