Semilateral Position Research Articles

Bullectomy with video-assisted thoracic surgery and minimally invasive repair of pectus excavatum simultaneously

IntroductionPectus excavatum (PE) is the most common chest wall deformity. Surgical treatment with minimally invasive repair (MIRPE) is the most preferred surgical procedure. In the presence of additional pulmonary pathologies, simultaneous surgical procedures have been considered, but there are few cases reported in the literature.Case presentationMIRPE was planned for a 15-year-old male patient due to PE. The day before the surgery, the patient developed sudden onset of shortness of breath. Pneumothorax was observed on the right side in the chest radiograph. Thereupon, the surgery was brought forward. Video-assisted thoracoscopic surgery (VATS) bullectomy was performed in the left lateral decubitus position. MIRPE was then performed through the same incision in the semi-lateral decubitus position. The patient was planned to be discharged on the 7th day, but on the day of discharge, a pneumothorax on the left was observed on the chest x-ray. VATS bullectomy was performed in the left semi-lateral decubitus position. The patient was discharged on postoperative day five.ConclusionSince the long-term results of simultaneous surgical procedures are unknown. With MIRPE, results such as less pain, shorter hospital stays, and earlier involvement in social life are achieved. Keeping in mind that these advantages may be lost with additional procedures, we think that simultaneous procedures should be planned.

Robot-assisted Partial Nephrectomy With Selective Artery Clamping for Renal Cell Carcinoma in Horseshoe Kidney.

Robot-assisted partial nephrectomy (RAPN) has become the standard treatment for small renal tumors, including highly complex cases. However, applying RAPN to renal tumors in the horseshoe kidney (HSK) is clinically challenging due to malformations and complex blood supply. Herein, we present two cases of RAPN in patients with HSK treated using selective artery clamping methods. A 61-year-old male with a 15 mm renal tumor located on the upper pole of the right HSK was referred to our Department. The patient underwent RAPN via the transperitoneal approach, following a three-dimensional computed tomography (3D-CT) assessment. Additionally, before surgery, we confirmed which renal arteries would be clamped in surgery by examining the kidney regions supplied by each renal artery. The second patient referred to our Department, a 45-year-old male, had a 46 mm renal tumor located on the isthmus of the HSK. His tumor received blood supply from two renal arteries, with the bilateral collecting systems converging and forming a ureter on 3D-CT. The patient underwent RAPN through an intraperitoneal approach in the semi-lateral position, with port placement lower than in standard RAPN. Pathological examinations revealed clear-cell renal cell carcinoma with negative surgical margins in both cases. Both patients had no recurrences or metastases at 53 and 13 months post-surgery, respectively. We present cases successfully treated with RAPN with selective artery clamping methods for HSK using 3D-CT without encountering complications, even in isthmus tumors.

Distribution of transpulmonary pressure during one-lung ventilation in pigs at different body positions.

Background. Global and regional transpulmonary pressure (PL) during one-lung ventilation (OLV) is poorly characterized. We hypothesized that global and regional PL and driving PL (ΔPL) increase during protective low tidal volume OLV compared to two-lung ventilation (TLV), and vary with body position. Methods. In sixteen anesthetized juvenile pigs, intra-pleural pressure sensors were placed in ventral, dorsal, and caudal zones of the left hemithorax by video-assisted thoracoscopy. A right thoracotomy was performed and lipopolysaccharide administered intravenously to mimic the inflammatory response due to thoracic surgery. Animals were ventilated in a volume-controlled mode with a tidal volume (VT) of 6mLkg-1 during TLV and of 5mLkg-1 during OLV and a positive end-expiratory pressure (PEEP) of 5 cmH2O. Global and local transpulmonary pressures were calculated. Lung instability was defined as end-expiratory PL<2.9 cmH2O according to previous investigations. Variables were acquired during TLV (TLVsupine), left lung ventilation in supine (OLVsupine), semilateral (OLVsemilateral), lateral (OLVlateral) and prone (OLVprone) positions randomized according to Latin-square sequence. Effects of position were tested using repeated measures ANOVA. Results. End-expiratory PL and ΔPL were higher during OLVsupine than TLVsupine. During OLV, regional end-inspiratory PL and ΔPL did not differ significantly among body positions. Yet, end-expiratory PL was lower in semilateral (ventral: 4.8 ± 2.9 cmH2O; caudal: 3.1 ± 2.6 cmH2O) and lateral (ventral: 1.9 ± 3.3 cmH2O; caudal: 2.7 ± 1.7 cmH2O) compared to supine (ventral: 4.8 ± 2.9 cmH2O; caudal: 3.1 ± 2.6 cmH2O) and prone position (ventral: 1.7 ± 2.5 cmH2O; caudal: 3.3 ± 1.6 cmH2O), mainly in ventral (p ≤ 0.001) and caudal (p = 0.007) regions. Lung instability was detected more often in semilateral (26 out of 48 measurements; p = 0.012) and lateral (29 out of 48 measurements, p < 0.001) as compared to supine position (15 out of 48 measurements), and more often in lateral as compared to prone position (19 out of 48 measurements, p = 0.027). Conclusion. Compared to TLV, OLV increased lung stress. Body position did not affect stress of the ventilated lung during OLV, but lung stability was lowest in semilateral and lateral decubitus position.

Laparoscopic Repair of a Right-Sided Diaphragmatic Hernia

Introduction: Blunt trauma may cause small occult diaphragmatic injuries that increase in size over the course of decades. The gradual increase is secondary to the pressure disparity between the abdominal and thoracic cavities. Over time, visceral contents may traverse the defect and become incarcerated within the thoracic cavity.1 Typically, the defect occurs on the left side with gastric herniation. Rarely, the defect occurs on the RIGHT side since the large right lobe of the liver may preclude herniation through a right-sided diaphragmatic defect.2,3 This video presents a repair of a symptomatic right-sided diaphragmatic hernia that occurred decades after blunt trauma. Materials and Methods: A 58-year-old man was admitted to the emergency department with a 2-day history of acute abdominal pain that was sharp and diffuse. He had vomited several times and denied flatus for 24 hours. He had a history of three prior motor vehicle accidents in the 1980s. He had a history of oropharyngeal cancer that was treated with radiation then a neck dissection 2 years before presentation. He had no history of abdominal or thoracic surgery but had a significant tobacco history for 40 years. His blood work was normal. A CT scan of the abdomen showed a right-sided diaphragmatic hernia defect that contained small intestine and colon. There was no dilated bowel or evidence of a pneumoperitoneum or free fluid. There was air in the rectum. A well-healed old nondisplaced pubic rami fracture was evident also on the scan. Surgical intervention included a laparoscopic possible thoracoscopic diaphragmatic repair. Operatively, he was placed in a semilateral position at 30°. A Veress needle was used to enter the abdomen and three 5 mm ports were placed along the subcostal border. One of the 5 mm ports was upsized to a 10 mm port. Diagnostic laparoscopy delineated the diaphragmatic defect containing bowel. Several adhesions were divided and the colon and small intestine were reduced from the defect. There was no hernia sac and the thoracic cavity was pristine. Once the bowel was reduced, the defect was measured at ~5 cm by 3 cm. The defect was closed with interrupted 0-silk sutures. The suture line was then buttressed with a 15 cm by 10 cm mesh. The mesh was secured with absorbable tacks. A 28F chest tube was placed. Results: The operative time was 90 minutes. The patient was started on a clear liquid diet on postoperative day 1 and advanced to a regular diet on postoperative day 2. Because of social issues, he was discharged on postoperative day 4. A chest CT at ~6 months postoperatively showed no evidence of a recurrent diaphragmatic defect. Conclusions: Minimally invasive techniques are well suited for diaphragmatic defects. If a right-sided symptomatic diaphragmatic hernia is diagnosed, a minimally invasive approach through the abdomen may be performed without a thoracic approach. Adhesions may warrant thoracic access to reduce the abdominal contents, so double lumen intubation is prudent. A durable repair may be obtained by suturing the defect and adding a mesh buttress. Patient consent has been obtained. Authors have received and archived patient consent for video recording/publication of the procedure. There are no conflict of interests associated with this video in terms of commercial or financial interests. Runtime of video: 5 mins 42 secs

Direct femoral head approach without surgical dislocation for femoral head chondroblastoma: a report of two cases

BackgroundChondroblastomas are rare, benign, locally aggressive lesions that appear in the epiphysis. Surgery for femoral head chondroblastoma (FHCB) is difficult. Conventional treatment with curettage via a drilled tunnel along the femoral neck can damage the growth plate and is associated with high local recurrence rates. The trapdoor procedure, which directly facilitates lesion access from the femoral head articular surface, can reduce local recurrence and avoid growth plate damage, although it requires surgical dislocation. Little is known about the long-term results of this direct articular surface approach, and there are no case reports on trapdoor procedures without dislocation.Case presentationWe report two cases (patients aged 12 and 15 years) of FHCB presented with coxalgia treated using the trapdoor procedure without surgical dislocation. Both surgeries were performed with patients in the semi-lateral position. The hip joint was exposed via an anterior approach, and a capsulotomy was performed at the superior rim of the acetabulum, followed by the external rotation of the hip joint. With a fine osteotome, a rectangular flap (trapdoor) was opened on the cartilage surface in the lateral non-weight-bearing area, and curettage of the lesion followed by bone and/or bone substitute grafting was performed. Subsequently, the trapdoor was replaced in its original position. There has been no local recurrence or femoral head aseptic necrosis after more than 6 and 12 years for patients 1 and 2, respectively. Both patients had musculoskeletal tumor society scores of 100% at follow-up and are enjoying a normal active life.ConclusionsThis direct femoral head approach without dislocation may be a simple treatment alternative for FHCB.

A Case-Matched Analysis of Laparoscopic Liver Resection for Hepatocellular Carcinoma Located in Posterosuperior Segments of the Liver According to Adaption of Developed Techniques.

Background and Objectives: Laparoscopic liver resection (LLR) for the hepatocellular carcinoma (HCC) located in posterosuperior (PS) segment is technically demanding, but has been overcome by accumulated experiences and technological improvements. We analyzed peri-and post-operative results before and after the adaptation of the enhanced techniques. Materials and Methods: We retrospectively reviewed 246 patients who underwent LLR for HCC in PS segments from September 2003 to December 2019. According to the introduction of advanced techniques including intercostal trocars, Pringle maneuver, and semi-lateral French position, the patients were divided into Group 1 (n = 43), who underwent LLR from September 2003 to December 2011, and Group 2 (n = 203), who underwent LLR from January 2012 to December 2019. Among these cases, 136 patients (Group 1 = 34, Group 2 = 102) were selected by case-matched analysis using perioperative variables. Results: Mean operation time (362 min vs. 291 min) and hospital stay (11 days vs. 8 days, p = 0.023) were significantly longer in Group 1 than Group 2. Otherwise, disease-free survival (DFS) rate was shorter and resection margin (1.3 mm vs. 0.7 mm, p = 0.034) were smaller in Group 2 than Group 1. However, there was no difference in type of complication (p = 0.084), severity of complication graded by the Clavien–Dindo grade system (p = 0.394), and 5-year overall survival (OS) rates (p = 0.986). In case-matched analysis, operation time (359 min vs. 266 min p = 0.002) and hospital stay (11.5 days vs. 8.0 days, p = 0.032) were significantly different, but there was no significant difference in resection margin, DFS, and OS. Conclusions: The adaptation of improved techniques has reduced the complexity of LLR in PS segments.

Physiological benefits of lung recruitment in the semi-lateral position after laparoscopic surgery: a randomized controlled study

We evaluated the physiological benefits of performing lung recruitment maneuver (LRM) in the semi-lateral position compared in the supine position. Seventy-nine patients undergoing laparoscopic prostatectomy were randomly assigned to either the supine or semi-lateral group according to body position during the LRM. At the end of surgery, LRM (35 cmH2O for 20 s) was performed twice in the assigned posture. The primary outcome was the maximal decrease in systolic arterial pressure during LRM. Secondary outcomes were changes in PaO2/FiO2 and the regional lung volume distribution after LRM. The decrease in systolic arterial pressure during the LRM was significantly higher in the supine group than in the semi-lateral group (mean ± standard deviation, [−] 27.6 ± 14.6% vs. [−] 18.6 ± 9.9%, P = 0.001). Improvement in PaO2/FiO2 ratio after the LRM was evident in both groups but was more prominent in the semi-lateral group than in the supine group (median [interquartile range], 39.3% [20.2, 63.6] vs. 18.2% [8.4, 29.2], P = 0.001). Among the horizontal lung divisions, regional lung volume in the most dependent portion (the dorsal division) was significantly increased after the LRM only in the semi-lateral group (P = 0.024). Performing lung recruitment in a semi-lateral position protected against hemodynamic deterioration during the LRM and increased regional lung ventilation in the dependent portion of the lung, leading to an improvement in arterial oxygenation after laparoscopic procedures.Trial registration Clinical Research Information Service (https://cris.nih.go.kr/). Identifier: KCT0003756.

Abstract P3-19-21: Semi-lateral decubitus position using Alexandria left breast board-16. A prospective study regarding dose distribution and reproduciblity

Abstract Purpose: Organs at risk sparing without compromising adequate coverage to the target volumes is the main challenge during left breast cancer adjuvant radiation therapy. Advanced radiotherapy techniques have been investigated to improve the dose distributions and to reduce toxicities. These techniques includes deep inspiration breath hold, accelerated partial-breast irradiation, Intensity Modulated Radiation Therapy. Supine positioning (SP) is the most commonly used and the standard tangent set-up for breast radiotherapy. Our purpose is to compare the Semi-lateral decubitus position(SLDP) versus SP regarding the dose distribution to the left Chest wall/Whole breast (WB), ipsilateral left axilla, contra-lateral breast, thyroid, spinal cord, ipsilateral lung, heart, LAD (Left Anterior Descending Artery), as well as determining the reproducibility of the Alexandria left breast board-16 (ALB-16) by portal image verification. Methods: We invented a new breast board ALB-16 to induce SLDP allowing tilting the patient towards the right side, elevating the patient's left side at a certain angle adjusted according to the patient’s body surface area and the gantry width of the CT simulator. Simulation process was performed in two different positions whilst the patients were freely breathing, the first scan in SLDP and the second in SP. Fifty women with a left sided breast cancer who underwent either mastectomy or lumpectomy were enrolled in this study for dosimetric comparison between the SLDP and the SP. The mean radiotherapy dose to the CW/WB, axilla, thyroid, left lung, heart, LAD, Spinal cord and the contra-lateral right breast in SLDP and the SP for the same patient were compared. Secondly, analysis was conducted on the fifty patients who were treated in SLDP by ALB-16 in comparison with a control group treated in SP to determine ALB-16 reproducibility. Results: On dosimetric analysis of the two positions, SLDP was found to significantly decrease the mean dose to the heart when compared with SP (2.2Gy vs. 2.9Gy respectively), LAD (5.4Gy vs. 7.2Gy) and the Spinal cord Dmax (7.5Gy vs. 12.6Gy) with a (p&amp;lt;0.01), while maintaining a similar coverage to the axillary lymph nodes levels I, II and III and the SCV group (91.13%, 89.9%, 88.9% and 93.9% vs. 91.3%, 90.2%, 89.5% and 94.1% respectively)(p =0.73, 0.37, 0.29 and 0.67) SLDP improved coverage to the target PTV mean dose (95.2% vs. 94.2%, p&amp;lt;0.01). SLDP decreased the mean dose to the contralateral breast (2.27Gy vs. 2.52Gy, p= 0.08). However, it achieved slightly a higher mean dose to the thyroid gland (79.8Gy vs. 16.8Gy, p= 0.56). The mean dose to the ipsilateral lung was slightly higher than SP (22.5% vs. 20.3%) with a statistically significant difference (p&amp;lt;0.01). For the secondary analysis, setup error in lateral (x) direction was higher in SLDP (0.66cm vs.0.49cm, p=0.028), setup error in vertical (y) direction in SLDP was lower than SP (0.39cm vs. 0.55cm, P=0.013). For the changes in longitudinal direction (Z), there was a slight difference between both positions (0.49cm vs. 0.39cm, p= 0.56). The length of deviation vector (3D vector) was (0.95cm in SLPD vs.0.87 in SP), the mean difference between vector lengths was only (0.08 cm) and this difference wasn’t statistically significant (p= 0.441) indicating the overall reproducibility of the ALB-16 breast board in comparison to standard supine breast board. Conclusions: ALB-16 Breast board is considered a reproducible method of setup for patients receiving left breast cancer adjuvant radiotherapy. It is comparable with the conventional supine breast board in regards of setup errors variability. SLDP spared the heart, LAD and the spinal cord, with a better WB/CW PTV coverage. SLDP can be used in patients whom regional nodal irradiation is indicated while maintaining low contralateral breast dose. Citation Format: Omar Saeed Emam, Mohamed Abouegylah, Rasha Elsaka, Amr Munir, Fady Aziz, Abdelsalam Attia Ismail, Amr Abdelaziz Elsaid. Semi-lateral decubitus position using Alexandria left breast board-16. A prospective study regarding dose distribution and reproduciblity [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-19-21.

Improved Outcomes of Laparoscopic Liver Resection for Hepatocellular Carcinoma Located in Posterosuperior Segments of the Liver

LLR is widely adapted for HCC, while LLR in PS segments is still challenging. With recent improvement of techniques and accumulation of experiences, LLR in PS segments is feasible, but studies investigating the result after the modifications are lacking. In this single-center, retrospective study, 149 patients who underwent LLR for HCC located in PS segments from September 2003 to December 2016 were analyzed. The patients were divided into Group 1 (n=43) and Group 2 (n=106) who underwent LLR before and after 2012, respectively, when advanced techniques including use of intercostal trocars, Pringle maneuver, and semi-lateral position of patient were introduced. Also, these patients were compared with those who underwent open liver resection (OLR; n=124) for HCC in PS segments during the same period. Mean operative time (394.7 minutes vs 331.2 minutes; P=0.013), intraoperative blood loss (1545.8 ml vs 1208.2 ml; P=0.020), and hospital stay (11.6 days vs 9.2, P<0.001) were significantly less in Group 2. Postoperative complication rate (18.6% vs 18.9%; P=0.970), open conversion rate (23% vs 17%; P=0.374), 5-year overall (79% vs 89%; P=0.607) and 5-year disease-free (52% vs 53%; P=0.657) survival rates were not significantly different between the groups. Compared to the OLR group, complication rate (40.3% vs 18.8%; P< 0.001) and hospital stay (17.6 days vs 9.7 days; P< 0.001) were significantly lower in the LLR group. The complexity of LLR for HCC in PS segments is being gradually overcome by the introduction of advanced techniques.

Laparoscopic and left thoracoscopic Ivor-Lewis esophagectomy for Siewert type II esophagogastric junction cancer with right aortic arch: a case report

BackgroundRight aortic arch (RAA) is a congenital malformation detected in 0.04% of the population without heterotaxia and makes esophagectomy and mediastinal lymphadenectomy difficult. A left thoracic approach is recommended in patients with RAA, but a minimally invasive procedure has not yet been established.Case presentationThe case was a 40-year-old man with RAA and Siewert type II adenocarcinoma of the esophagogastric junction with metastases to the adrenal glands and paraaortic lymph nodes. Conversion surgery was performed when radiologic disappearance of metastatic disease was confirmed after first-line treatment consisting of 12 cycles of S-1 plus platinum-based systemic chemotherapy. Minimally invasive laparoscopic and left thoracoscopic Ivor-Lewis esophagectomy was performed in the right semi-lateral decubitus position. The esophagus was easy to see on left thoracoscopy because of the RAA. Esophagectomy with lower mediastinal lymphadenectomy and an intrathoracic esophagogastric anastomosis was performed successfully with laparoscopy and thoracoscopy without a position change. There were no surgical complications, and no residual cancer was detected in the resected specimen on pathological examination. There has been no recurrence during 21 months of follow-up.ConclusionsLaparoscopic and left thoracoscopic Ivor-Lewis esophagectomy in the right semi-lateral decubitus position is a minimally invasive, anatomically novel procedure for Siewert type II esophagogastric junction cancer in patients with RAA.

Improved outcomes of major laparoscopic liver resection for hepatocellular carcinoma

BackgroundMinor laparoscopic liver resection (LLR) is currently becoming standard treatment option for hepatocellular carcinoma (HCC) while major LLR is still challenging. Recent advancement of surgical techniques has enabled surgeons to perform major LLR. This study compared the outcomes of major LLR for HCC before and after the adaptation of technological improvements. MethodsWe retrospectively analyzed 141 patients who underwent major LLR for HCC from January 2004 to July 2018.32 open conversion cases were excluded. We divided the patients into two groups according to the date of operation: Group 1 (n = 38) and Group 2 (n = 71) who underwent major LLR before and after 2012, when advanced techniques including the use of intercostal trocars, Pringle maneuver, and semi-lateral position of patient were introduced. We also compared these patients including open conversion cases (n = 141) with those who underwent major open liver resection (OLR; n = 131) during the same period. ResultsMean operative time (413.0 min vs 331.0 min; P = 0.009), transfusion rate (31.6% vs 11.3%, P = 0.009) and hospital stay (9.8 days vs 8.5 days; P = 0.001) were significantly less in Group 2. Intraoperative blood loss (1269.7 ml vs 844.5 ml; P = 0.341) and postoperative complication (15.8% vs 23.9%; P = 0.320) were not significantly different between the groups. Although tumor size in OLR group and type of resection was different, transfusion rate (36.6% vs 24.1%; P = 0.026), postoperative complication (41.2% vs 25.5%; P = 0.007), and hospital stay (17.2 days vs 10.0 days; P < 0.001) were significantly lower in LLR group. ConclusionDevelopment of surgical techniques have gradually improved the surgical outcomes of the laparoscopic major liver resection.

Arthroscopic Mobilization of the Ankle-subtalar Joint Complex Using a Novel “Infra-fibula-tip” Portal

Category:Arthroscopy; HindfootIntroduction/Purpose:As a minimally invasive surgical option for posterior ankle/subtalar pathologies, the prone hindfoot endoscopy (a.k.a. Van-Dijk’s method) has been becoming the ‘gold standard’ technique. While this technique holds advantage regarding good orientation and safety handling of posteromedial pathologies, it limits access to the anterolateral part, therefore inconvenient when simultaneously dealing with anterior and posterior pathologies. Recently, we have introduced a novel ‘infra- fibula-tip (IFT)’ portal, which permits wide access to the posterior talocalcaneal joint (PTCJ), from anterolateral to posteromedial, with a patient positioned in supine or semi-lateral. The present study reviewed clinical outcomes of a case series of arthroscopic hindfoot mobilization using this new surgical technique, so as to document its clinical utility.Methods:The sequence of surgical procedures is as follows; - Create an IFT portal, from a small incision immediately distal to the fibular tip, through the peroneal tendon sheath (anterior to the tendons, but posterior to the calcanofibular ligament), toward the posterior porch of PTCJ.- Inserting a 30-deg 2.7mm scope to the posterior porch, and broadly observing posterior intraarticular findings.- Gently moving the scope to the anterolateral porch, and broadly observing anterolateral intraarticular findings.- Creating an anterolateral (AL) portal under arthroscopic guidance.- Creating a PL portal at immediately lateral to the Achilles tendon, with guidance of a blunt rod inserted from the AL portal (gently advanced posteriorly through the lateral recess and penetrated the rod toward subcutis).- Executing posterior procedures from the PL portal, while observing from the IFT portal. Executing anterolateral procedures working from the AL portal, while observing from the IFT portal.Results:A total of 7 cases underwent the procedure of interest to date. Subtalar osteoarthritis (OA) occurred in all, with accessory anterolateral talar facet (AALTF) impingement in 3. Ankle OA occurred in 3, with anterior bony impingement in 2. Preceding pathologies included peri-ankle intraarticular fractures (4), talocalcaneal coalition (2), and neurogenic varus foot (1). Mobilization procedures included lateral-to-posterior PTCJ debridement (7), coalition release (2), AALTF removal (3), sinus debridement (2), posterior ankle capsule release (2), anterior ankle debridement (2), talonavicular debridement (1), and Achilles tendon lengthening (1). The surgery duration ranged from 65 to 245 minutes. Postoperatively, of 4 cases followed more than 6 months, remarkable motion improvement (10 degrees or more) occurred in 3, and every case reported symptom relief.Conclusion:The IFT portal accesses the middle of the PTCJ, with a short skin-to-joint distance, allowing flexible exploration of both the posterior and anterior porches. Posteriorly, ability of direct intraarticular access (without extraarticular shaving) reduces surgical invasion, as well as the risk of potential neurovasucular injury. Anteriorly, it helps secure good triangulation for handling sinus pathologies. Since subtalar arthroscopy using the IFT portal is doable in a supine or semi-lateral position, anterior ankle arthroscopy could be simultaneously executed. Arthroscopic hindfoot mobilization using this technique appears to be efficient for dealing with ankle/subtalar contracture due to combined anterior and posterior pathologies.

Awake Craniotomy in a Child: Assessment of Eligibility with a Simulated Theatre Experience

Background Awake craniotomy is a useful surgical approach to identify and preserve eloquent areas during tumour resection, during surgery for arteriovenous malformation resections and for resective epilepsy surgery. With decreasing age, a child's ability to cooperate and mange an awake craniotomy becomes increasingly relevant. Preoperative screening is essential to identify the child who can undergo the procedure safely. Case Description. A 11-year-old female patient presented with a tumour in her right motor cortex, presumed to be a dysembryoplastic neuroepithelial tumour (DNET). We had concerns regarding the feasibility of performing awake surgery in this patient as psychological testing revealed easy distractibility and an inability to follow commands repetitively. We devised a simulated surgical experience to assess her ability to manage such a procedure. During the simulated theatre experience, attempts were made to replicate the actual theatre experience as closely as possible. The patient was dressed in theatre attire and brought into the theatre on a theatre trolley. She was then transferred onto the theatre bed and positioned in the same manner as she would be for the actual surgery. Her head was placed on a horseshoe headrest, and she was made to lie in a semilateral position, as required for the surgery. A blood pressure cuff, pulse oximeter, nasal cannula with oxygen flow, and calf pumps were applied. She was then draped precisely as she would have been for the procedure. Theatre lighting was set as it would be for the surgical case. The application of the monitoring devices, nasal cannula, and draping was meant not only to prepare her for the procedure but to induce a mild degree of stress such that we could assess the child's coping skills and ability to undergo the procedure. The child performed well throughout the simulated run, and surgery was thus offered. An asleep-awake-asleep technique was planned and employed for surgical removal of the tumour. Cortical and subcortical mapping was used to identify the eloquent tissue. Throughout the procedure, the child was cooperative and anxiety free. Follow-up MRI revealed gross total removal of the lesion. Conclusion A simulated theatre experience allowed us to accurately determine that this young patient, despite relative contraindications, was indeed eligible for awake surgery. We will continue to use this technique for all our young patients in assessing their eligibility for these procedures.

Robot-assisted thoracoscopic surgery for mediastinal masses: a single-institution experience.

The objectives of this study were to evaluate the feasibility and safety of robot-assisted thoracic surgery (RATS) using the da Vinci robotic system for mediastinal mass resection and to describe the surgical approach for masses in different mediastinal regions. We retrospectively reviewed data from 84 patients who underwent RATS for resection of a mediastinal mass from June 2015 to April 2019. The results were analyzed with descriptive statistics. The mediastinal mass was resected successfully in all patients, with one patient requiring conversion to conventional open surgery. There were no intraoperative complications. The most common diagnoses were thymoma (n=17), bronchogenic cyst (n=16), and schwannoma (n=12). The surgical approach was determined by the location of the lesion and the planned extent of surgical resection. Resection was performed in the lateral decubitus position in 29 patients with posterior mediastinal tumor, semi-lateral decubitus position in 42 patients who only need resection of anterior mediastinal mass, and reverse Trendelenburg position in 13 patients undergoing thymectomy. The mean (± standard deviation) operation time was 91.86±56.42 min, duration of chest tube use was 1.83±0.93 days, and postoperative hospital stay was 3.62±7.52 days. Three patients (3.5%) developed postoperative complications: one chylous fistula, which required reoperation, and one case each of atrial fibrillation and pulmonary infection, which were treated conservatively. Our experience demonstrated that different surgical approaches of RATS are safe and feasible for mediastinal mass resection. An appropriate approach can be selected based on the mediastinal region in which the tumor is located.

Endotracheal intubation with video laryngoscope at semilateral decubitus position: a case report of a pediatric patient with a back stab wound

Background: Endotracheal intubation is routinely performed in a supine position. However, this position might be difficult for some emergent patients. Although several alternative positions have been suggested for adult patients, such studies on pediatric patients are rare. Case presentation: We present a case of a female pediatric patient with a pencil stab wound to the back requiring an emergent operation under general endotracheal anesthesia. Placing her in supine position would have been inappropriate because of the protruding pencil. The patient was moved to a semilateral decubitus position for intubation. The endotracheal tube was inserted with a video laryngoscope. Her vital signs and oxygen saturation were stable during operation. The patient was discharged without complications. Conclusion: Semilateral intubation in pediatric patients using a video laryngoscope may be feasible under some specific conditions that make it inappropriate to place patients in a supine position.

Lung ultrasound score-based perioperative assessment of pressure-controlled ventilation-volume guaranteed or volume-controlled ventilation in geriatrics: a prospective randomized controlled trial.

PurposeRecent studies have shown the potential benefits of pressure-controlled ventilation-volume guaranteed (PCV-VG) compared to volume-controlled ventilation (VCV), but the results were not impressive. We assessed the effects of PCV-VG versus VCV in elderly patients by using lung ultrasound score (LUS).Patients and methodsElderly patients (aged 65–90 years) scheduled for hip joint surgery were randomly assigned to either the PCV-VG or VCV group during general anesthesia. LUS and mechanical ventilator parameters were evaluated before induction, 30 mins after a semi-lateral position change, during supine repositioning before awakening, and 15 mins after arrival to the post-anesthesia care unit (PACU). Pulmonary function tests were performed before and after surgery. Other recovery indicators were also assessed in the PACU.ResultsA total of 76 patients (40 for PCV-VG and 36 for VCV) were included this study. Demographic data showed no significant difference between the two groups. In both groups, LUSs before induction were significantly lower than those at other time points. LUSs of the VCV group were significantly increased during perioperative periods compared with the PCV-VG group (p=0.049). Visualized LUS modeling suggested an intuitive difference in the two groups and unequal distribution in lung aeration. Higher dynamic compliance and lower inspiratory peak pressure were observed in the PVC-VG group compared to the VCV group (33.54 vs 27.36, p<0.001; 18.93 vs 21.19, p<0.001, respectively). Postoperative forced vital capacity of the VCV group was lower than that of PCV-VG group, but this result was not significant (2.06 vs 1.79, respectively; p=0.091). The other respiratory data are comparable between the two groups.ConclusionThe PCV-VG group showed better LUS compared with the VCV group. Moreover, LUS modeling in both groups suggests non-homogeneous and positional change in lung aerations during surgery.Clinical trial registrationThis study was registered at the UMIN clinical trials registry (unique trial number: UMIN000029355; registration number: R000033510)

Application value of closed single-port thoracoscopic and laparoscopic radical esophagectomy for esophageal cancer

Objective To investigate the application value of closed single-port thoracoscopic and laparoscopic radical esophagectomy for esophageal cancer. Methods The retrospective and descriptive study was conducted. The clinical data of a 49-year-old male patient with esophageal cancer who was admitted to the Fujian Medical University Union Hospital in November 2018 were collected. The patient underwent closed single-port thoracoscopic and laparoscopic radical esophagectomy and three-field lymph node dissection. In the thoracic part, esophageal separation and thoracic lymph node dissection were performed with closed pneumothorax, semi-lateral position and multi suspension methods. In the abdominal part, gastric separation and lymph node dissection were accomplished with lifting of liver lobe and respective separation of greater curvature and lesser curvature of stomach. The operation time, volume of intraoperative blood loss, time for out-of-bed activities, time of postoperative drainage tube removal, volume of thoracic drainage fluid, postoperative complications, postoperative pathological examination results, time for discharge from hospital and results of follow-up were observed. Follow-up using outpatient examination and telephone interview was performed to detect tumor recurrence and metastasis of patients after operation up to February 2019. Count data were described as absolute number. Results The patient underwent successfully closed single-port thoracoscopic and laparoscopic radical esophagectomy and three-field lymph node dissection. The operation time and volume of intraoperative blood loss was 310 minutes and 120 mL. The patient resumed out-of-bed activities at 2 days after operation. The abdominal drainage tube, thoracic closed drainage tube and right cervical drainage tube were removed at 2 days after operation with fasting, acid suppression, nutritional support. The thoracic Abel drainage tube and the left cervical drainage tube were removed at 5 days after operation. The volume of thoracic drainage fluid was 550 mL. No obvious sign of anastomotic leakage was found on esophageal angiography at 5 days after operation. The patient recovered well after operation without hoarseness, pulmonary infection and chylothorax. The postoperative examination result of the patient showed mid-thoracic esophageal squamous cell carcinoma (pT3N1M0G3 ⅢB stage). The patient was discharged at 8 days after operation. The patient was followed up for 3 months, and was able to engage in light physical activity. CT reexamination showed no sign of local recurrence or distant metastasis of the tumor. Conclusion Closed single-port thoracoscopic and laparoscopic radical esopahgectomy for esophageal cancer is safe and feasible, with good short-term efficacy. Key words: Esophageal neoplasms; Esophageal cancer; Radical surgery; Thoracoscopy; Laparoscopy; Single port

A case of laparoscopic hepatectomy for recurrent hepatocellular carcinoma after two previous open hepatectomies.

Introduction: Laparoscopic hepatectomy after open hepatectomy may be relatively easy depending on the positions of the tumor and the previous hepatectomy site. When adhesions are evident, however, laparotomy may be inevitable. We performed laparoscopic liver S5 partial resection for a patient with recurrent hepatocellular carcinoma(HCC) in S5 after having undergone open hepatectomy twice before and transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA) multiple times during the previous 12 years. The video shows the procedure. Method: Patient: A man in his 70s. HPI: Liver S7 segmentectomy had been performed for HCC in 2006. HCC recurred in S1, and liver S1 partial resection was performed in 2009. Thereafter, TACE and RFA were performed four times each until 2018. The posterior branch of the portal vein was narrowed because of RFA. Hepatoma recurred at the inferior border of S5 of the liver in 2018. Laboratory data: HCV antibody positive, PLT 78,000/μl, ICGR15’ 18.0%. Result: Operative procedure: Left semi-lateral position. First, three ports were placed in the lower abdomen for adhesiolysis. After adhesiotomy of the greater omentum and the ascending colon was performed toward the liver, detachment of the descending part of the duodenum proceeded in a caudocranial direction. When the inferior surface of the liver was reached, the target liver tumor was confirmed with intraoperative ultrasonography. Several ports were added, and partial resection of S5 of the liver was performed. Conclusion: Even after two previous open hepatectomies, laparoscopic resection is possible, providing that preoperative image simulation and thorough adhesiotomy of the adjacent organs are performed, and laparoscopic resection should be attempted.

Improved outcomes of laparoscopic liver resection for hepatocellular carcinoma located in posterosuperior segments of the liver

Introduction: We compared outcomes of laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) located in posterosuperior (PS) segments before and after the adaptation of technological improvements. LLR is widely adapted for HCC, while LLR in PS segments is still challenging. However, with recent improvement of techniques and accumulation of experiences, LLR in PS segments is feasible. Method: We retrospectively analyzed 149 patients who underwent LLR for HCC located in PS segments from September 2003 to December 2016. The patients were divided into group 1 (n=43) and group 2 (n=106) who underwent LLR before and after 2012, when advanced techniques including use of intercostal trocars, Pringle maneuver, and semi-lateral position of patient were adapted. We also compared these patients with those who underwent open liver resection (OLR; n=124) for HCC in PS segments at the same period. Result: Mean operative time (395 minutes vs 331 minutes; P=0.013), intraoperative blood loss (1545 ml vs 1219 ml; P=0.020), and hospital stay (12 days vs 9, P<0.001) were significantly less in group 2. Postoperative complication rate (18.6% vs 18.9%; P=0.970), open conversion rate (23% vs 17%; P=0.374), 5-year overall survival (79% vs 89%; P=0.607) and 5-year disease free survival (52% vs 53%; P=0.657) rates were not significantly different between the groups. The proportion of LLR increased (36% vs 69%, P<0.001). Compared to OLR group, complication rate (40.3% vs 18.8%; P< 0.001) and hospital stay (18 days vs 10 days; P< 0.001) were significantly lower in LLR group. Conclusion: The complexity of LLR for HCC in PS segments has been gradually overcoming by the adaptation of advanced techniques.

Laparoscopy-Assisted Cutaneous Ureterostomy in Children: Early Experience.

Laparoscopy-assisted cutaneous ureterostomy (LA-CU) is a minimally invasive approach for temporary urinary diversion in children. We describe the technique, its feasibility, potential advantages, and outcomes in 12 children treated for a variety of conditions. Three trocars were used transperitoneally, one transumbilical, and another placed at the later stoma site. In the semilateral position, with a panoramic view, the ureter of interest is easily identified, mobilized, and exteriorized for stoma creation. We retrospectively reviewed our experience at two tertiary-care centers and included both refluxing and end ureterostomies. The study period was between October 2014 and February 2017. Renal function and growth curves were noted at follow-up. Twelve children underwent LA-CU: 3 end and 9 refluxing ureterostomy. Mean age was 18.75 ± 17.60 months. Mean operating time was 94.44 ± 34.86 minutes. Follow-up ranged from 10 to 38 months. No major postoperative complications occurred. Renal function and growth curves improved in the majority of children. Primary surgical correction of obstructive or refluxing uropathy is the gold standard; however, temporary urinary diversion is useful in specific scenarios. In these patients, laparoscopic assistance may offer better and direct visualization, achieves accurate and rapid identification of ureter, and provides adequate mobilization, tension-free exteriorization, and excision of redundant ureter in some to optimize drainage. One trocar at the eventual stoma site minimizes scarring.