Semilateral Position Research Articles

An All-Anterior Approach for Quadruple Nerve Transfer for Upper Trunk Brachial Plexus Injuries

The most commonly performed nerve transfers in upper trunk (UT) or partial brachial plexus injuries (BPIs) include the spinal accessory nerve to suprascapular nerve, Oberlin, and, lately, radial nerve (RN) (branch to triceps) to axillary nerve (AN) transfers. Routinely, the former 3 procedures are performed through an anterior approach (supraclavicular plus infraclavicular), while the triceps branch of the RN-AN transfer has been performed through a posterior approach with the patient in either the prone or semilateral position, which requires a separate incision in the posterior arm. The aim of the present study was to report the outcomes for 4 cases of quadruple nerve transfers performed for UT BPI using an all-anterior approach. The functional outcomes of 4 consecutive cases of UT BPI treated using an all-anterior approach were analyzed in terms of improvement in motor power and range of motion at the shoulder and elbow joints. The mean age was 27.5 years (range, 16-40). All had sustained injuries from road traffic accidents. The mean injury to surgery interval was 4.5 months (range, 3-6). Of the 4 patients, 2 each had pre- and postganglionic injuries. All 4 patients had 0 of M0 power in shoulder abduction and external rotation, and elbow flexion. At a mean follow-up of 28.6 months, the average shoulder abduction was 157°, with an average of 82° of external rotation. The mean elbow flexion was 104°. This technique appears to be feasible, with good-to-excellent outcomes achieved without requiring a separate posterior arm incision for the RN-AN transfer.

Robotic-assisted right posterior segmentectomies for liver lesions: single-center experience of an evolutional method in left semi-lateral position.

Despite the popularity of minimally invasive surgery (MIS) for hepatectomy, limitations in the approach of the right posterior section of the liver remain. Although skills and approach techniques have been developed for hepatectomy of lesions in the posterior segments of the liver, most are performed laparoscopically and are limited to few experienced hands using rigid laparoscopic instruments. In this study, we tried a different approach area via the aid of a flexible robotic system. Since 2012, we have successfully completed more than 200 robotic hepatectomy procedures in our institution. Two different patient settings have been applied for right posterior segment lesions, including supine position as general setting in early cases and left semi-lateral decubitus setting in our later cases. The demographic data and perioperative outcomes between the two groups were analyzed in regard to different positioning. A total of 25 patients with right posterior segment lesions underwent robotic-assisted resection, 13 were placed in supine position and 12 in left semi-lateral position. The left semi-lateral group had significantly shorter operation time (306.0 versus 416.8min, p = 0.023), less blood loss (203.9 versus 1092.3mL, p = 0.030), and lower transfusion rates (0 versus 46.2%, p = 0.015). We described an evolutionary technique for robotic right posterior segmentectomies with the patient placed in left semi-lateral position. This method can be applied for most patients easily and is demonstrated as a safe and feasible approach in selected patients owing to its ability to overcome the difficulty of MIS hepatectomy for right posterior lesions.

Segment 7 Laparoscopic Liver Resection: Is It Possible to Resect When Metastatic Lesions Border Suprahepatic Veins?

IntroductionAfter nearly 25 years of experience, laparoscopic liver resection (LLR) is now recognized as being feasible and safe.1 However, laparoscopic resections of the posterosuperior segments are more technically demanding. They are associated with higher conversions rates, more intraoperative bleeding, and increased operating time.2 Appropriate training is required to approach these resections safely.3 This video demonstrates the technical maneuvers to laparoscopically approach a segment 7 tumor in contact with the right supra hepatic vein. MethodThe pertinent aspect to perform a segment 7 metastasis resection using minimally invasive techniques is shown. The main steps of this operation include (1) complete release of the right liver from the coronary and triangular ligament, (2) dissection of the retrohepatic vena cava and transection of the hepatocaval ligament, (3) the use of intercostal trocars for direct vision of the inferior vena cava and the right suprahepatic vein,4,5 (4) the use of intraoperative ultrasound to evaluate the position and limits of vascular structures compared to the lesion, (5) careful transection of the hepatic parenchyma, and (6) dissection of the right hepatic vein to separate it from the lesion. ResultsThe surgery was performed in a 68-year-old male patient. The patient developed synchronous metastases to the liver from a sigmoid colon tumor. Two lesions were identified; a 15 mm subcapsular lesion located in segment 5 and a 45 mm lesion located in segment 7 in contact with the right hepatic vein and inferior vena cava confluence. Previously, laparoscopic sigmoidectomy was performed without complications (TNM classification of the specimen: T3N0, with 31 resected lymph nodes, KRAS gene mutated). Following chemotherapy with FOLFOX + bevacizumab, a good response to the liver lesion was noted on imaging. Subsequently, a laparoscopic resection of the metastases in segment 7 and 5 was performed. The surgery lasted 210 min, intraoperative blood loss was 200 cm3, no Pringle maneuver was required, and the postoperative period was uneventful with the patient being discharged on postoperative day number four. Pathology of the liver specimens confirmed metastases from colon adenocarcinoma with free surgical margins. DiscussionSome important points achieving easier and safer approach of the posterior segments of the liver by laparoscopic route should be discussed. First, the patient’s semi-lateral position showed in the video allows placing the ports and the optic in a more comfortable position since the lateral portion of the abdominal and thoracic wall becomes anterior. Another important point is the complete liberation of the hepatorenal, falciform, triangular, and right coronary ligaments in order to fully mobilize the liver and convert a segment that is posterior in the anatomical position to an anterior segment for the surgeon. And finally, the use of intercostal trocars that allows a direct and perpendicular view of the right hepatic vein and vena cava represents the most important point. Interestingly, these specific trocars should be inserted through the pleural cavity, during a forced expiration or apnea to avoid lung injury. In this context, the trocar balloon helps the surgeon to avoid displacement or that pneumoperitoneum enters the pleural cavity. At the end of the procedure, we strongly recommend to stitch laparoscopically these diaphragmatic openings after removing the trocars in order to avoid migration of abdominal fluid or bowel incarceration into the pleural cavity during the postoperative period and also to avoid future diaphragmatic hernia. In the present case, the parenchymal transection was performed with Thunderbeat (Olympus®, Japan), a device integrating both ultrasound dissection and advanced bipolar energy. We use this device because it saves time by sealing vessels up to 7 mm in diameter avoiding the need to use clips in the majority of intrahepatic veins and portal branches. However, currently, several techniques and devices are equivalent for parenchymal transection in laparoscopic liver resection and should be left to the surgeon’s preference, as in open liver procedures. ConclusionUsing laparoscopy to remove lesions in the posterior segments of the liver is safe and feasible. Vision from transthoracic port has the added benefit of making the dissection of right hepatic vein and inferior vena cava safer. Mastery of the anatomy is paramount before attempting this approach with minimally invasive techniques. Surgeons who attempt this operation should have expertise with both laparoscopy and liver surgery.

Modified Semilateral Decubitus Position for Shoulder Arthroscopy and Its Application for Open Surgery of the Shoulder (One Setting for All Shoulder Procedures)

Two standard patient positions for shoulder arthroscopy are the beach-chair and lateral decubitus positions. Both positions have advantages and disadvantages in many aspects. Surgeons choose the position based on their preferences, mainly the orientation of the anatomy. If an operation needs to be converted to an open procedure, a patient who is placed in the lateral decubitus position might need to undergo repositioning and re-draping, which result in extending the operative time and increasing the risk of infection. For this circumstance, the modified semilateral decubitus position offers the same advantages as the lateral decubitus position and can be adjusted to achieve a more upright position similar to the beach-chair position.

Retroperitoneoscopic resection of retroperitoneal nonadrenal ganglioneuromas: our technique and clinical outcomes.

ABSTRACTObjective:To report our experience of retroperitoneoscopic technique in semi-lateral decubitus position for the retroperitoneal nonadrenal ganglioneuromas in 18 patients, and to evaluate its clinical outcomes.Materials and Methods:From January 2012 to May 2016, 18 patients with retroperitoneal nonadrenal ganglioneuromas underwent retroperitoneoscopic resection. With the patients in semi-lateral decubitus position, a 4-port retroperitoneal approach was used. Data were collected on the tumor size, tumor location, perioperative outcomes, pathology, and last-known disease status. We reviewed the operative videos to identify surgical tips and tricks.Results:All procedures were carried out successfully without converting to open surgery. The tumors had an average size of 5.2cm. The mean operative time was 86.5 min, with a mean estimated blood loss of 85.4mL. There were three patients suffering from intraoperative complications. Postoperatively, all patients achieved an uneventful recovery; the mean postoperative hospital stay was 5.5 days. The postoperative pathology revealed to be retroperitoneal ganglioneuromas. With a mean follow-up of 39.5 months, all patients were recurrence free. The review of the operative videos revealed several tips and tricks, including keeping peritoneum and posterior Gerota fascia intact to provide a favorable operative exposure of tumors, and placing the harmonic scalpel through different ports during tumor dissection.Conclusions:With the patient in semi-lateral decubitus position and a 4-port retroperitoneal approach, retroperitoneoscopic resection of retroperitoneal nonadrenal ganglioneuroma is a feasible, effective, and safe procedure. This approach has distinct advantages including direct access to the tumor, optimal exposure of tumor and less intraperitoneal interference.

Досвід оперативного лікування собак при зміщеннях міжхребцевих дисків

Досвід оперативного лікування собак при зміщеннях міжхребцевих дисків

Значение торакоскопии при открытых ранениях грудной клетки для выбора лечебной тактики

Results of 163 thoracoscopic examinations for thoracic trauma are presented. In all cases, the the cause of the injury was stabbing. Among the patients, there were 147 men (90.2 %) and 17 women (9.8 %). Thoracoscopy was performed under local anesthesia or endotracheal anesthesia (predominantly), in a semi-lateral position on the healthy side with a reliable fixation of the patient, which is necessary, since it sometimes there is need to change the position of the table. The first thoracoport was usually introduced into the 5th intercostal space. After the revision of the pleural cavity, according to the indications, places of additional punctures and the introduction of appropriate instruments were determined. For evacuation of blood from the pleural cavity an electric pump was used. For hemostasis, electrocoagulation was commonly applied, and in a number of cases we used the haemostatic sponge. To stop bleeding from the lung tissue, as well as for aerostasis, the Roeder loop was used. After thoracoscopy, the question of further tactics was resolved. With ineffective thoracoscopy, thoracotomy was required. In case of successful thoracoscopy, the operation was finished with draining the pleural cavity through the most adequately located punctures. Thoracoscopy is an effective method of determining further tactics in this pathology. With a trauma in the danger zone, 41 of 62 patients managed to avoid conversion. In many cases thoracoscopy allows to perform hemostasis, aerostasis and other curative measures. It also can reduce the amount of thoracotomy by 2-2.5 times

Kinematic radiography of the hip joint after hip resurfacing arthroplasty.

This study aimed to evaluate the usefulness of dynamic radiography using a dynamic flat-panel detector (FPD) system after hip resurfacing arthroplasty (HRA). A total of 32 hips of 26 patients who underwent HRA were included. Sequential images of active abduction in the supine position and flexion in the 45° semilateral position were obtained using the FPD system. We examined the imaging findings of impingement between the acetabular component and femoral neck with cooperative motion at maximal exercise. Moreover, the central component coordinate of the acetabulum and femoral head sides was measured. For abduction motion, impingement was detected in two (6.3%) hips between the superior portion of the femoral neck and acetabular component. For flexion motion, impingement was detected in 19 (59.4%) hips. There were no findings of subluxation between the acetabular component and femoral neck after impingement, but cooperative motion of lumbar and pelvic flexion was observed. There was no significant difference in the center-to-center distance regardless of the presence or absence of impingement. Detailed postoperative kinematics of the hips after HRA showed that the proposed dynamic FPD system could reveal acquired impingement and cooperative motion as dynamic images and possibly reveal findings that would be unobservable using static images.

Prevention of aspiration of gastric contents during attempt in tracheal intubation in the semi-lateral and lateral positions.

Pulmonary aspiration of gastric contents during tracheal intubation is a life-threatening complication in emergency patients. Rapid sequence intubation is commonly performed to prevent aspiration but is not associated with low risk of intubation related complications. Although it has been considered that aspiration can be prevented in the lateral position, few studies have evaluated the ability to prevent aspiration. Moreover, this position is not always a favorable position for tracheal intubation. If aspiration can be prevented in a clinically relevant semi-lateral position, it may be advantageous. We assessed the ability to prevent aspiration in the lateral position and various degrees of the semi-lateral position using a vomiting-regurgitation manikin model. A manikin's head was placed in the neutral, simple extension, or sniffing position. The amount of aspirated saline into the bronchi during simulated vomiting was measured at semi-lateral position angles of 0º to 90º in 10º increments. The difference in the vertical height between the mouth corner and the inferior border of the vocal cord was measured radiologically at each semi-lateral position in the three head-neck positions. Pulmonary aspiration was prevented at the ≥70º, ≥80º, and 90º semi-lateral positions in the neutral, simple extension, and sniffing positions, respectively. The mouth was lower than the vocal cord in the semi-lateral position in which aspiration was prevented. The lateral or excessive semi-lateral position was necessary to protect the lung from aspiration in the head-neck positions commonly used for tracheal intubation. Prevention of aspiration was difficult within clinically relevant semi-lateral positions.

Combined approaches with a semilateral position for complex tibial plateau fracture

Objective To explore the operation indication feasibility, operation technique and clinical effect of complex tibial plateau fractures with semilateral position through combined approaches. Methods From April 2011 to June 2013, data of 25 patients with complex tibial plateau fractures who were treated by open reduction and interal fixation with semilateral position through anterior lateral incision and an inverse L shaped incision were retrospectively analyzed. There were 15 males and 10 females, with an average age of 49.7 years old (range, 30 to 70 years old). 21 cases were traffic accident injuris and 4 cases were hurt by falling injuries from bicycle. All of the fracture patterns were three pillars of closed fracture of type Ⅵ according to Schatzker classification. The time at surgery was 5-21 days (mean, 9.5 days) after injuries. The posterior condylar and medial condylar fractures were dealt with inverse L shaped incision, and fixated with anatomical locking plate and T shaped plate. The lateral condyle fractures were dealt with anterior lateral incision, and fixated with anatomical locking plate. Results Operating time was 150-250 min with an average time of 197.6 min. Intraoperative blood loss was 150-300 ml with an average of 232 ml. 25 patients were followed-up, and the average duration of followup was 17.8 months (range, 12-24 months). Fracture healing time was 16-24 weeks with an average of 19 weeks. At the time of the latest followup, X-ray showed all the knee joint had smooth surface, and there was no obvious varus or valgus deformity. One year later, the flexion of the knees achieved 115.2° (range, 100°-130°), and the straighten reached 0°. The mean Rasmussen's score of all the patients were 14-18 (average, 16.6), and there were excellent in 11 cases and good in 14. Bassed on the KSS score, the mean score was 88.6 (range, 66-96) one year after operation. The excellent and good rate was 96% (24/25). 2 patients had fat liquefaction of anterolateral incision wound dehiscence, local skin necrosis, and they got good outcomes after debridement dressing and secondary suture. Conclusion Multi plate fixation is more effective and safty treatment for complex tibial plateau fractures which can be operated completely through fixed half lateral position, and the knee joint is allowed to do early functional exercise, achieving good clinical efficacy and good knee function. Key words: Tibial fractures; Fracture fixation, internal; Treatment outcome

The Posterior Approach for Laparoscopic Distal Pancreatectomy: A Valid Choice for Resection of Complex Lesions of the Distal Pancreas.

Laparoscopic distal pancreatectomy (LDP) is replacing open surgery as the technique of choice for benign and premalignant lesions of the left pancreas. In most laparoscopic series, the supine decubitus or semilateral position is preferred. A posterior approach with the patient in full right lateral decubitus (PA-FRLD) has been proposed as an alternative. From July 2012 to November 2014 we performed 14 LDPs. PA-FRLD was chosen in 8 patients; in 6 patients splenectomy was also performed. Definitive diagnoses were 3 cases of pancreatic ductal adenocarcinoma, 2 cases of nonfunctioning neuroendocrine tumors, 1 case of bulky serous cystic neoplasm, 1 case of inflammatory chronic pancreatitis, and 1 case of pancreatic trauma (duct disruption). No conversions were required. No postoperative pancreatic fistula was detected. No patient required transfusion. Two patients had Clavien II and IIIb postoperative complications. In both cases in which preservation of the splenic vessels was attempted, it was successfully achieved. The PA-FRLD position is a valid alternative to the supine or semilateral position for LDP. This approach is especially beneficial for resection of complex and bulky lesions of the tail of the pancreas and those in close contact with retroperitoneal organs and can also facilitate spleen-preserving LDP.

Transperitoneal Laparoscopic Adrenalectomy in Children

Introduction: The use of a minimally invasive approach for adrenalectomy is poorly defined in pediatric patients, although laparoscopic adrenalectomy is considered a standard procedure in adults.1–4 The aim of our video is to describe the safety and feasibility of transperitoneal lateral laparoscopic adrenalectomy in children based on surgical skills and results. Surgical Procedure: The patient was placed in a reverse Trendelenburg semilateral position over a flank lift. A 10 mm Hg pneumoperitoneum was created using a 10- to 12-mm Hasson's trocar and three 5-mm trocars were inserted, as shown in the video. Left Adrenalectomy: A plane along the anterior surface of the kidney, lateral and dorsal to the spleen and tail of pancreas, was established and the splenic ligaments were divided. The dissection proceeded along the anterior surface of the kidney and adrenal gland until the inferior and medial border. The main adrenal vein and artery were isolated and sectioned. The dissection proceeded in a superolateral direction until complete mobilization of the gland. Right Adrenalectomy: The liver was retracted and the right lobe was mobilized, thus revealing the anterior surface of the adrenal gland. The lateral border of the inferior vena cava was isolated to identify the adrenal vein transacted. The dissection proceeded in a mediolateral and superoinferior direction, until complete mobilization of the gland. Materials and Methods: This is a retrospective study of four pediatric laparoscopic adrenalectomies (two right and two left) performed at our center. Preoperative workup included endocrinologic and radiologic investigation to determine the secretory activity, size, and local extent of the lesion. Results: The mean age was 87 months. Indications for surgery were two neuroblastomas, one aldosterone-secreting adrenocortical tumor, and one adrenocortical nodular hyperplasia. The mean size of the lesions was 3.23 cm at the pathologic examination. No intraoperative complications or conversions occurred. The average operating time was 85 minutes for right and 125 minutes for left adrenalectomies. The mean hospital stay was 3.75 days. At 15 months, the follow-up was negative. Conclusions: Transperitoneal laparoscopic adrenalectomy is a safe, feasible, and reproducible approach for the treatment of benign and malignant adrenal masses in children. Furthermore, this approach offers many advantages, including shortening of operating times and postoperative hospital stays, as well as reduction of blood loss and complications; also, a large working space with a clear view of the structure that permitted to perform a controlled resection.5,6 The authors have nothing to disclose. Runtime of video: 8 mins

Lateral Decubitus All-Arthroscopic Latarjet Procedure for Treatment of Shoulder Instability

Shoulder instability can be a challenging condition to treat when it becomes refractory to soft-tissue procedures or when bone loss exceeds 25% to 27% of the glenoid. The Bristow-Latarjet procedure has been developed and popularized to deal with these concerns. Traditionally, the procedure has been performed as an open approach; however, this has been recently supplanted by novel arthroscopic techniques. We present a technique for the procedure performed with the patient in a semi-lateral decubitus position that assists with optimal graft placement on the native glenoid. We use the cannulated Bristow-Latarjet Instability Shoulder System (DePuy Mitek, Raynham, MA). After a diagnostic arthroscopic evaluation, we use multiple arthroscopic anterior portals to debride the rim of the glenoid. The coracoid is prepared and taken down arthroscopically, and the cannulated guide is attached and advanced through an arthroscopically created subscapularis split. With the shoulder held in a reduced position, we are then able to drill and anchor the graft to the native glenoid. The patient is able to begin gentle range-of-motion exercises immediately postoperatively.

Ultrasound guided Transversus Abdominis Plane block through surgical wound.

Sir, A 47-year-old super obese (body mass index >50 kg/m2) male weighing approximately 295 kg, breathless in the supine position, presented for laparoscopic sleeve resection. As laparoscopic instruments with adequate length to reach the abdominal cavity were unavailable, he was scheduled for panniculectomy with vacuum-assisted closure (VAC) initially. Central venous and arterial lines were inserted under ultrasonic guidance on the day of surgery, but we failed to administer epidural or transversus abdominis plane (TAP) block as thickness of adipose tissue itself was >15 cm and deeper structures could not be visualised. Hence, general anaesthesia was administered following awake fibreoptic intubation in the lateral position. The abdominal wall was lifted up with the help of hooks (run through the anterior abdominal wall) hung from a steel frame making mechanical ventilation possible in the supine position. Through a lower transverse abdominal incision 20 kg adipose tissue was excised and VAC therapy was initiated. At the end of surgery, patient was extubated. On 3rd day, patient had tachypnoea (respiratory rate 30/min) oxygen saturation (SpO2) of 90–94% and oliguria with elevated serum creatinine. Since he was haemodynamically stable, he was posted for closure of surgical wound or reapplication of VAC (if there was infection). In the theatre after removing surgical dressings, high-frequency (13–6 MHz) linear ultrasound probe was directly placed over the wound under aseptic precautions with povidone iodine 10% solution as an acoustic couplant which also reduced chance of infection. 60 ml of 1% lignocaine with 1/100,000 adrenaline was injected in the plane between the internal oblique and transversus abdominis muscles using 23 gauge spinal needle on each side keeping the patient on lateral sides [Figure 1]. Injections were made at a depth of 4 cm from the surface, just anterior to mid-axillary line. Thickness of the tissue probably indicated possible oedema secondary to incision and surgical handling. Analgesia was adequate, debridement with reapplication of VAC was performed. The patient came for repeated procedures thrice in 2 weeks and was managed under TAP block using the same technique. Placing bilateral catheters for subsequent blocks was not considered, as catheter through a wound could potentially be a path for infections. The patient unfortunately succumbed to an acute coronary event 4 weeks after surgery. Figure 1 TAP block being given through the surgical wound Morbid obesity commonly results in derangements in most organ systems and is often associated with increased mortality and morbidity. Transversus abdominis plane block provides reliable analgesia to the anterior and lateral abdominal wall and is volume dependent. It can be performed blindly or using ultrasound. But ultrasound guided block helps in better localisation of the planes resulting in improved accuracy.[1,2] It is easier to perform TAP block in semilateral position in the obese.[3] In super obese patients, low-frequency convex probe is preferable as the deeper tissues are visualised better.[4] Since a major thickness of the anterior abdominal wall was bypassed by placing the ultrasound probe directly over the surgical area, the linear probe proved sufficient in our case.

Intraoperative airway obstruction in a Duchenne muscular dystrophy patient

To report a complication of airway obstruction during spinal deformity correction surgery in Duchenne muscular dystrophy (DMD) patient, due to lordoscoliosis, airway malacia, and prone surgical positioning, which was rectified by changing the position of the patient and surgery was successfully completed. A 15-year-old boy was diagnosed with DMD and admitted for surgical treatment of thoracolumbar scoliosis. The patient's preoperative Cobb's angle was 79° and the kyphotic angle was -19°. During the initial period of surgery, while in the prone position, peak inspiratory pressure (PIP) suddenly increased from 20-21 to 38-41 cmH2O, wheezing sounds were heard on auscultation of both lungs, and his blood pressure began to fall. Under suspicion of airway problem, intraoperative fiberoptic bronchoscopy was performed which confirmed airway obstruction. Attributing patient's prone position as the cause of airway obstruction, the surgical position of the patient was changed from prone to semi-lateral. After this change, the PIP stabilized to within normal limits (20-23 cmH2O). The surgical correction was successfully completed with a posterior-only pedicle screw by the free-hand technique, with the patient in the semi-lateral position for the rest of surgery. Lordoscoliosis and airway malacia in a patient with DMD can lead to occlusion of the tracheobronchial lumen when the patient is in the prone position. Changing the patient's position from prone to semi-lateral can be of help to reverse this airway obstruction and complete the surgery. Pedicular screw insertion can be safely and effectively carried out in this position using free-hand technique.

Laparoscopic Ureterolithotomy for Upper Ureter Stone with Some Modified Surgical Tips

Introduction and Objective: To report large upper ureter stone removal by laparoscopic approach with some surgical tips using Carter–Thomason fascial closure and various modified instruments. Methods: A 45-year-old man underwent laparoscopic ureterolithotomy via transperitoneal approach. In semilateral position, skin and fascial incision (1.2 cm) was made lateral to rectus muscle at umbilicus level, and 10-mm balloon trocar was used for scope. Two 5-mm trocars for working channel were inserted consecutively. After periureter tissue dissection, ureter with stone was pulled with nylon tape and black silk. Carter–Thomason fascial closure was used to extract the black silk outside of body and the proper traction tension and level; the angle was adjusted by the black silk extracorporeally to make next procedure more easily. Then, the ureter incision was made by modified instrument: needle holder with broken 15th blade tip, so we can sharply and precisely incise ureter at stone level. Next, the stone was removed, and a modified, both-end-closed ureteral catheter was inserted by bidirectional way using two guide wires. The ureter traction tension and level were readjusted to insert the ureteral catheter more easily. Ureteral incision was closed with an absorbable suture material (vicryl 4-0) by interrupt method, and drain was indwelled. Results: We can finish the whole procedure with a 1.2-mm balloon trocar and two 5-mm working trocars. The removed stone was 1.6 cm. The operative time was 136 minutes and blood loss was minimal. There was no intraoperative or postoperative complication. The patient was discharged 3 days after the operation. Conclusions: Pulling ureter using Carter–Thomason fascial closure and black silk makes ureter handling easier. Needle holder with broken 15th blade tip and a modified, both-end-closed ureteral catheter by bidirectional way using two guide wires make laparoscopic ureterolithotomy more feasible, so we can sharply and precisely incise ureter and insert the ureteral catheter more easily. In our experience, these tiny surgical tips are useful and can be applied to laparoscopic ureterolithotomy. No competing financial interests exist. Runtime of video: 6 mins 3 secs

Is expertise in pediatric surgery necessary to perform laparoscopic splenectomy in children? An experience from a department of general surgery

Splenectomy is frequently required in children for various hematologic pathologic findings. Because of progress in minimally invasive techniques, laparoscopic splenectomy (LS) has become feasible. The objective of this report is to present a monocentric experience and to evaluate the efficacy of and complications observed after laparoscopic splenic procedures in a department of general surgery. 57 consecutive LSs have been performed in a pediatric population between January 2000 and October 2010. There were 33 females and 24 males with a median age of 12years (range 4-17). Indications were: hereditary spherocytosis 38 cases, idiopathic thrombocytopenic purpura 10, sickle cell disease (SCD) 6, thrombocytopenic thrombotic purpura 2 and non-hodgkin lymphoma 1 case. Patients were operated on using right semilateral position, employing Atlas Ligasure vessel sealing system in 49 cases (86%) and Harmonic Scalpel+EndoGIA in 8. In 24 patients (42.1%), a cholecystectomy was associated. Two patients required conversion to open splenectomy (3.5%). In three cases, a minilaparotomy was performed for spleen removal (5.2%). Accessory spleens were identified in three patients (5.2%). Complications (8.8%) included bleeding (two), abdominal collection (one) and pleural effusion (two). There was no mortality. Average operative time was 128min (range 80-220). Average length of stay was 3days (range 2-7). Mean blood loss was 80ml (range 30-500) with a transfusion rate of 1.7% (one patient). Laparoscopic spleen surgery is safe, reliable and effective in the pediatric population with hematologic disorders and is associated with minimal morbidity, zero mortality, and a short length of stay. Ligasure vessel sealing system shortened operative time and blood loss. On the basis of the results, we consider laparoscopic approach the gold standard for the treatment of these patients even in a department of general surgery.

Successful resection of a massive mediastinal liposarcoma that rapidly extended into the entire left thoracic cavity: report of a case

Primary mediastinal liposarcomas are rare malignancies, comprising fewer than 1% of all mediastinal tumors. We herein report a radical resection of a massive liposarcoma arising from the anterior mediastinum. A 63-year-old male patient presented with a 4-week history of dyspnea that had worsened over the previous several days. The patient had also experienced hoarseness for 2 weeks. Chest X-ray and computed tomography revealed a huge tumor occupying the entire left thoracic cavity. Anesthesia was induced when the patient was in the left semilateral position. The patient was moved into the right lateral position after initially stabilizing anesthesia with separate lung ventilation. The fourth rib was initially resected for thoracotomy, but there was no clearance between the tumor and the adjacent mediastinal structures, and two more ribs were therefore removed. The tumor had not invaded the other structures such as the chest wall, lung, or mediastinum. To reduce the tumor blood flow, the left internal mammary artery was ligated before the tumor was resected en bloc. The tumor was diagnosed as a liposarcoma arising from the thymus. The patient remains alive with no evidence of disease recurrence at 22 months after the operation.

Consecutive Concomitant Laparoscopic Splenectomy and Cholecystectomy: An Italian Experience of 30 Patients and Proposition of a Technique

With recent advancements in the field of minimally invasive surgery, combined laparoscopic procedure is now being performed for treating coexisting abdominal pathologies during the same surgery. In some patients, spleen disorders are associated with gallbladder stones. Conventional surgery requires a wide upper abdominal incision for correct exposure of both organs. The aim of this study was to assess the feasibility and outcomes of concomitant laparoscopic treatment for coexisting spleen and gallbladder diseases. Thirty consecutive laparoscopic splenectomy (LS) plus laparoscopic cholecystectomy (LC) have been performed in our department between January 2000 and December 2009 (24% of 125 LS performed in this period). There were 11 female patients and 19 male patients, with a median age of 16.2 years (range: 4-55). Indications were hereditary spherocytosis for 22 cases, idiopathic thrombocytopenic purpura for 3 cases, thalassemia for 4 cases, and sickle cell disease for 1 case. Patients were operated on using right semilateral position, tilting the table from right to left, using a five-trocar technique in 25 cases and a four-trocar technique in the last 5 cases. Cholecystectomy was performed first, then splenectomy was achieved, and spleen was removed in an Endobag. One patient required conversion to open procedure (3.3%) because of splenomegaly. Average operative time was 150 minutes (range: 90-240). Average length of stay was 3.5 days (range: 3-11). Mean blood loss was 60 mL (range: 30-500). Transfusion rate was 3.3%. Mean spleen size and weight were, respectively, 16.5 cm and 410 g. No perioperative mortality occurred in the series. We reported 3 cases of hemoperitoneum, of which one managed conservatively. The results using four trocars were comparable to those with five trocars. With increasing institutional experience, concomitant laparoscopic splenectomy and cholecystectomy is a safe and feasible procedure and may be considered for coexisting spleen and gallbladder diseases. The four-trocar technique guarantees good results.

Laparoscopic Splenectomy Using LigaSure

Laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases. Bleeding is the main complication and cause for conversion. We present our experience with the LigaSure and discuss its advantage as a vessel sealing system in achieving safe vascular control. Over a 3-year period, we performed 12 consecutive LS using LigaSure at a single center. A literature review of all the patients who had undergone laparoscopic splenectomy with of the LigaSure to achieve vascular control at the hilum was carried out, assessing its advantages and outcome. Twelve LS were performed. Eleven of these patients had ITP, and one patient had sickle cell disease. The mean blood loss was 70mL (range, 50 to 460), and operating time was 126 minutes (range, 110 to 240). Two postoperative complications occurred: portal vein thrombosis in one case and subphrenic collection in the other. The literature review revealed 8 studies with 231 cases in which the LigaSure was used to perform laparoscopic splenectomy. A significant reduction in operating time (average 102 minutes) and intraabdominal blood loss (66mL) was observed with the LigaSure compared with endostaplers. The use of LigaSure and the semilateral position results in a gain of time and safety in addition to low intraoperative bleeding, need for transfusion, minimal complications and a low conversion rate.