Surgical Plane Research Articles

Comparative Multimodal Palliative efficacy of gabapentin and tramadol By Using Two Pain Scoring Systems in Cats Undergoing Ovariohysterectomy

Abstract The analgesic efficacy of the gabapentin-tramadol combination was compared with meloxicam-tramadol and tramadol perioperative analgesic regimens in cats brought to the clinic for ovariohysterectomy. Thirty adult cats belonging to comparable demographics (age, body weight), were enrolled into a randomized, blinded study after due consent from their owners into four treatment groups. A Gabapentin-Tramadol group (GT-group, n = 10), Meloxicam-Tramadol group (MT-group, n = 10), and a Tramadol group (T-group, n = 10) were formed. Gabapentin capsules at 50 mg were administered orally 2 hours before surgery while the rest received a placebo dose. Tramadol (2 mg/kg, IM) and meloxicam at (0.2 mg/kg, SC) were injected immediately prior to anesthetic premedication. Anesthetic protocol involved premedication with ketamine and xylazine, while anesthesia was induced using propofol. Inhalant isoflurane anesthesia was used to maintain a surgical plane. GT group scored lower on IVAS as well as CPS than MT group, and T group for up to 8 hours after surgery. The mechanical nociceptive threshold remained higher (98±0) for up to 12 hours postoperatively a nd serum cortisol concentrations remained significantly lower during the 24hr period. The addition of gabapentin to the tramadol regimen significantly improved analgesia and mechanical nociceptive threshold than when used on its own.

The predictive value of intraoperative visual evoked potential for visual outcome after extended endoscopic endonasal surgery for adult craniopharyngioma.

Due to the proximity of craniopharyngioma to the optic apparatus, one of the most common complications after surgery is visual deterioration. Intraoperative visual evoked potential (VEP), as a means of real-time visual function monitoring, has been integrated into transsphenoidal surgery for pituitary adenoma to predict postoperative visual outcome. Compared with pituitary tumor, craniopharyngioma often adheres to optic nerves, with increased risk of postoperative visual impairment. Furthermore, extended endoscopic endonasal surgery (EEES) can provide direct visualization of the surgical plane between the craniopharyngioma and the optic nerves, which contributes to analysis of the mechanism of real-time VEP changes during surgery. Therefore, VEP monitoring applied during EEES for craniopharyngioma may have more clinical value. However, only 9 patients who underwent EEES with VEP monitoring for craniopharyngioma have been sporadically reported to date. In this paper, the authors present the largest series to date analyzing the clinical value of VEP to predict postoperative visual outcome in adult patients with craniopharyngioma. Sixty-five adult patients who underwent EEES with intraoperative VEP monitoring for primary craniopharyngioma were retrospectively reviewed. The association between changes in VEP amplitude and postoperative visual outcome was determined. In addition, other potential prognostic factors with regard to postoperative visual outcomes were included in the analysis. Gross-total resection was achieved in 59 patients (90.8%). Reproducible and stable VEP was recorded in 128 of 130 eyes (98.5%). During surgery, VEP remained stable in 108 eyes, 10 (9.3%) of which had new visual acuity (VA) and/or visual field (VF) defects after surgery. Transient VEP decrease was recorded in 15 eyes, 4 (26.7%) of which had visual deterioration. Of the 5 eyes with permanent VEP decrease, 3 (60%) experienced postoperative visual impairment. Permanent VEP decrease (OR 19.868, p = 0.007) and tight adhesion (OR 6.104, p = 0.040) were independent adverse factors for postoperative VA deterioration. Tight adhesion (OR 7.150, p = 0.002) and larger tumor volume (OR 1.066, p = 0.001) were significant risk factors for postoperative VF defects. Intraoperative VEP monitoring can serve as a real-time warning to guide surgeons to avoid postoperative visual impairment. It effectively predicted VA changes in adult patients with craniopharyngioma after EEES. Tight adhesion and larger tumor volume were also strong predictors of postoperative visual impairment.

Alternative anterior surgical plane of total mesorectal excision for rectal cancer: partial preservation of Denonvilliers' fascia.

Alternative anterior surgical plane of total mesorectal excision for rectal cancer: partial preservation of Denonvilliers' fascia.

Three-dimensional anatomy of the Denonvilliers\u2019 fascia after micro-CT reconstruction

An understanding of the anatomy of the Denonvilliers’ fascia is essential for successful surgical outcomes for patients with rectal cancer in the mid- to lower regions, especially near the seminal vesicles and prostate in males. Whether the correct surgical plane during a total mesorectal excision should be anterior or posterior to the Denonvilliers’ fascia is currently under debate. This study aimed to investigate the Denonvilliers’ fascia using micro-computed tomography (micro-CT) to acquire three-dimensional images nondestructively for assessments of the relationship between the Denonvilliers’ fascia, the mesorectal fascia, and neurovascular bundles to elucidate the correct anterior total mesorectal excision plane. Eight specimens were obtained bilaterally from four fresh human cadavers. Four specimens were stained with phosphotungstic acid to visualize the soft tissue, and micro-CT images were obtained; the other four specimens were stained with Masson’s trichrome to visualize connective tissue. Micro-CT images corroborate that the Denonvilliers’ fascia consists of a multilayered structure that separates the rectum from the seminal vesicles and the prostate. Specimens stained with Masson’s trichrome showed that the urogenital neurovascular bundle located at the posterolateral corner of the prostate is separated from the mesorectum by the Denonvilliers’ fascia. For the preservation of autonomic nerves necessary for urogenital function and optimal oncologic outcomes in patients with rectal cancer, a successful mesorectal excision requires a dissection plane posterior to the Denonvilliers’ fascia.

Video Context Improves Performance in Identifying Operative Planes on Static Surgical Images

Correct identification of the surgical tissue planes of dissection is paramount at the operating room, and the needed skills seem to be improved with realistic dynamic models rather than mere still images. The objective is to assess the role of adding video prequels to still images taken from operations on the precision and accuracy of tissue plane identification using a validated simulation model, considering various levels of surgeons' experience. A prospective observational study was conducted involving 15 surgeons distributed to three equal groups, including a consultant group [C], a senior group [S], and a junior group [J]. Subjects were asked to identify and draw ideal tissue planes in 20 images selected at suitable operative moments of identification before and after showing a 10- second videoclip preceding the still image. A validated comparative metric (using a modified Hausdorff distance [%Hdu] for object matching) was used to measure the distance between lines. A precision analysis was carried out based on the difference in %Hdu between lines drawn before and after watching the videos, and between-group comparisons were analyzed using a one-way analysis of variance (ANOVA). The analysis of accuracy was done on the difference in %Hdu between lines drawn by the subjects and the ideal lines provided by an expert panel. The impact of videos on accuracy was assessed using a repeated-measures ANOVA. The C group showed the highest preciseness as compared to the S and J groups (mean Hdu 9.17±11.86 versus 12.1±15.5 and 20.0±18.32, respectively, p <0.001) and significant differences between groups were found in 14 images (70%). Considering the expert panel as a reference, the interaction between time and experience level was significant ( F (2, 597) = 4.52, p <0.001). Although the subjects of the J group were significantly less accurate than other surgeons, only this group showed significant improvements in mean %Hdu values after watching the lead-in videos ( F (1, 597) = 6.04, p = 0.014). Adding video context improved the ability of junior trainees to identify tissue planes of dissection. A realistic model is recommended considering experience-based differences in precision in training programs.

Laparoscopic Hysterectomy with Large Posterior or Upper Cervical Myomas

Study Objective To present our approach to overcoming surgical challenges of a laparoscopic hysterectomy with a large posterior, upper cervical myoma. Design A guided explanation of the surgery using video. Setting A university hospital. Patients or Participants N/A. Interventions A 49-year-old woman with complaints of pelvic pain from a large posterior, upper cervical myoma desired surgical management with minimally invasive hysterectomy. Magnetic resonance imaging showed a 13 × 9 × 8 cm posterior wall myoma distending the cervical canal and displacing the rest of the uterus superiorly. After counseling, she proceeded with a laparoscopic supracervical hysterectomy, bilateral salpingectomy, and cystoscopy. We present key strategies in managing distorted anatomy, minimizing blood loss, and safe dissection of the myoma. 1. Due to the myoma distortion, a uterine manipulator could not be placed. A laparoscopic tenaculum and vaginal sponge stick were used to mobilize the specimen throughout the case. 2. To minimize blood loss, we secured the four main blood supplies to the uterus before starting the myoma dissection. 3. When dissecting the myoma, the goal is to excise all the layers encasing the myoma. We present a systematic method of proper traction, dissecting on the surface of the myoma and frequent anatomical re-orientation to identify the appropriate surgical planes and prevent injury to surrounding structures. 4. It is important to note the close proximity of the myoma to the bladder and ureters. Backfilling the bladder and dissecting out the ureters are helpful strategies to avoid injury. The specimen was placed in a containment bag and hand morcellated through the umbilicus. The patient was discharged home on postoperative day 0 and recovered without any complications. Measurements and Main Results N/A. Conclusion Large posterior, upper cervical myomas that distort the lower uterine segment and cervix can be surgically challenging when performing a minimally invasive hysterectomy. We demonstrate applicable techniques and strategies to minimize blood loss and prevent complications. To present our approach to overcoming surgical challenges of a laparoscopic hysterectomy with a large posterior, upper cervical myoma. A guided explanation of the surgery using video. A university hospital. N/A. A 49-year-old woman with complaints of pelvic pain from a large posterior, upper cervical myoma desired surgical management with minimally invasive hysterectomy. Magnetic resonance imaging showed a 13 × 9 × 8 cm posterior wall myoma distending the cervical canal and displacing the rest of the uterus superiorly. After counseling, she proceeded with a laparoscopic supracervical hysterectomy, bilateral salpingectomy, and cystoscopy. We present key strategies in managing distorted anatomy, minimizing blood loss, and safe dissection of the myoma. 1. Due to the myoma distortion, a uterine manipulator could not be placed. A laparoscopic tenaculum and vaginal sponge stick were used to mobilize the specimen throughout the case. 2. To minimize blood loss, we secured the four main blood supplies to the uterus before starting the myoma dissection. 3. When dissecting the myoma, the goal is to excise all the layers encasing the myoma. We present a systematic method of proper traction, dissecting on the surface of the myoma and frequent anatomical re-orientation to identify the appropriate surgical planes and prevent injury to surrounding structures. 4. It is important to note the close proximity of the myoma to the bladder and ureters. Backfilling the bladder and dissecting out the ureters are helpful strategies to avoid injury. The specimen was placed in a containment bag and hand morcellated through the umbilicus. The patient was discharged home on postoperative day 0 and recovered without any complications. N/A. Large posterior, upper cervical myomas that distort the lower uterine segment and cervix can be surgically challenging when performing a minimally invasive hysterectomy. We demonstrate applicable techniques and strategies to minimize blood loss and prevent complications.

Tips and Tricks When Performing an Adenomyomectomy

<h3>Study Objective</h3> To present principles and techniques for safe and efficient laparoscopic surgery during excision of an adenomyoma. <h3>Design</h3> Stepwise educational demonstration of techniques with narrated video footage. <h3>Setting</h3> Adenomyomas are not always easily excised and often a surgical plane cannot be easily identified. Similar to myomectomies, an adenomyomectomy may be associated with increased blood loss. In this video, we review key principles and techniques to safely perform a laparoscopic adenomyomectomy. <h3>Patients or Participants</h3> 33-year-old female with a 9cm uterine mass experiencing menorrhagia and dysmenorrhea. <h3>Interventions</h3> The key principles for safe and effective laparoscopic adenomyomectomy include: - Preoperative administration of Misoprostol - Instillation of Vasopressin in planned incision line - Intraoperative use of tranexamic acid - Performing a uterine artery ligation - Knowledge of anatomical landmarks - Performing a careful dissection - Uterine instillation of methylene blue - Appropriate instrument use <h3>Measurements and Main Results</h3> The patient recovered well without any postoperative complications. <h3>Conclusion</h3> Adenomyoma excision can be safely performed if one understands appropriate surgical techniques and solutions to improve surgical outcomes.

Laparoscopic Repair of Colo-Ovarian Fistula

<h3>Study Objective</h3> To demonstrate a unique laparoscopic approach to repair of a colo-ovarian fistula causing recurrent tubo-ovarian abscess. <h3>Design</h3> A step-by-step surgical video highlighting relevant anatomy and describing key steps to repair of colo-ovarian fistula laparoscopically. <h3>Setting</h3> Tertiary care academic teaching hospital. <h3>Patients or Participants</h3> 51-year-old gravida 0 patient with a recurrent tubo-ovarian abscess found to be caused by a colo-ovarian fistula. <h3>Interventions</h3> After failing trial of medical management with antibiotics and interventional radiology-guided drainage of a tubo-ovarian abscess, the patient was taken to surgery for a total laparoscopic hysterectomy and bilateral salpingo-oophorectomy. During the surgery, the patient was found to have a colo-ovarian fistula, which was the cause of recurrent abscess. The patient underwent a successful laparoscopic repair of the colo-ovarian fistula by excision of the fistulous tract and repair of bowel in two layers. <h3>Measurements and Main Results</h3> The laparoscopic repair of a colo-ovarian fistula was completed without complication. The pathology confirmed findings of a fistulous tract. At post-operative follow-up in both one month and two years, the patient was doing well without concerns. <h3>Conclusion</h3> In this video, we propose a novel approach to repair of a colo-ovarian fistula laparoscopically. Although en-bloc resection has been described for repair of colo-ovarian fistula, in this patient without active inflammation, dissection of the fistulous tract could be achieved after control of blood supply and careful interrogation of surgical planes. The defect was then repaired using a two-layered closure. This approach can be applied in appropriately selected patients to offer repair in a minimally invasive fashion.

The expression of carcinoembryonic antigen mRNA in the lavage of the dissected area of the lateral lymph nodes influences the lateral recurrence of lower rectal cancer.

To determine whether or not migrating cancer cells are present on the surgical plane after lateral lymph node dissection (LLND) for lower rectal cancer and related to lateral recurrence (LR), we evaluated the lavage of LLND areas by reverse-transcription polymerase chain reaction (RT-PCR) to check the expression of CEA mRNA in the residual cancer cells. Thirty patients who underwent curative LLND were enrolled. Lavage was collected after LLND and subjected to RT-PCR to detect CEA mRNA. The median follow-up to check for recurrence was 31.4months. CEA mRNA was detected in 9 of the 46 dissected areas. Based on the receiver operating characteristic curves, the cut-off value of PCR was set at 0.025. This cut-off point classified five patients into the high-expression group for CEA mRNA. During follow-up, LR developed in 1 of 40 low-expression areas of CEA mRNA and 3 of 6 high-expression areas. The LR rate was higher in the high-expression group than in the low-expression group (p = 0.015). A multivariate analysis showed that the high expression of CEA mRNA was likely an independent prognostic factor of LR. The expression of CEA mRNA in the lavage of LLND areas indicates the presence of residual cancer cells that cause LR.

The role of hydrodissection in native tissue repair of anterior vaginal wall defects

A variety of surgical techniques are available for vaginal prolapse repair, indicating a lack of consensus. A debate regarding the utility of hydrodissection for splitting the surgical plane of the vaginal wall exists. The aim of this study is to evaluate the impact of hydrodissection in anterior colporrhaphy (AC). Patients undergoing primary AC were randomly assigned to an approach with (study group) versus without (control group) hydrodissection. Five surgeons performed both techniques, and the trimmed vaginal tissue was retrieved for histological analysis. Two pathologists, blinded to the surgical approach, evaluated the presence of a loose connective tissue at the surgical dissection plane (controversially deemed 'fascia', as explained in this article). In addition, we compared the operative time, pain score and haemoglobin levels. After statistical analysis, data were presented using percentile, and statistical significance was tested using the χ2 and Fisher's exact tests. Forty-six patients underwent primary elective AC, with 23 patients in each, the study and control groups. The groups were comparable regarding age (study group 60.33 ± 11.95 years and control group 59.86 ± 12.04, P = 0.90), menopausal status (study group 17 (73.9%) and control group 15 (68.2%), P = 0.67) and other characteristics. We found no difference in sample characteristics between the two groups. Connective tissue was found in only 13.6% (n = 3) of patients after hydrodissection and in 27.3% (n = 6) of patients without hydrodissection (P = 0.46). The hydrodissection group had significantly less bleeding than the control group (ΔHB 0.66 ± 0.66 vs 1.21 ± 0.84, P = 0.05). After hydrodissection, less bleeding was noted without compromise the surgical planes.

구개부 다형선종 수술시 구개건막의 보존 4례

Pleomorphic adenoma is one of the most common benign neoplasm of salivary glands and resection with enough normal tissue margin is important treatment for preventing the local recurrence. For palate tumor involving both soft palate and hard palate, palatal fistula is easier to occur as post-operative complication after resection of the tumor. The palatine aponeurosis is important anatomical barrier between soft palate and nasal cavity, and we found that by using palatine aponeurosis as surgical plane, we can do R0 resection of the tumor with preventing the palatal fistula complication. Also, we used inguinal full thickness skin graft to protect the exposed palatine aponeurosis in some cases. We analyzed 4 cases of palate pleomorphic adenoma resection using palatine aponeurosis as surgical plane and those operations were done by single surgeon. All of 4 patients had no palatal fistula and also had no recurrence of the tumor during the post-operative course. (J Clinical Otolaryngol 2021;32:158-162)

Computer-based multimodal training module facilitates standardization of complete mesocolic excision technique for right-sided colon cancer: Long-term oncological outcomes.

The aim of this study is to demonstrate our video training tool developed to teach and standardize complete mesocolic excision (CME) for right-sided colon cancer and also to present our long-term oncological outcomes. Educational narrative videos were produced to demonstrate the technical steps of CME. First, a three-dimensional animation video was prepared. Then cadaveric dissections were recorded in a step-by-step fashion, following the sequences of open and minimally invasive surgery. These were followed by videos of real-life demonstrations of surgical procedures, enhanced by superimposed animations of key anatomical structures. In order to demonstrate the impact of this training module on outcomes of patients undergoing CME, we retrospectively queried data from before (2005-2010) and after (2011-2019) implementation of standardized CME in our practice. A total of 180 consecutive patients underwent right hemicolectomy between 2005 and 2019. Fifty-four patients underwent surgery before and 126 patients after CME principles were elaborated and standardized. Of those patients who had surgery after the training module, 58 (46%) underwent open surgery and 68 (54%) underwent laparoscopic colectomy. Demographics, perioperative parameters and morbidity were comparable between the groups. The 5-year overall and disease-free survival rates were significantly improved after implementation of CME training (p=0.059 and p=0.041, respectively). Also, 5-year overall and disease-free survival rates for all patients were considerably better than our reported national outcomes. Our comprehensive step-by-step training video module for the CME technique demonstrates surgical anatomical planes and important vascular structures and variations. The video also helps standardization of the CME technique and should contribute to improved histopathological and oncological outcomes.

Inter-fascial dissection in laparoscopic colorectal cancer surgery: principles of retraction and exposure and techniques in fascial separation

Colorectal surgery for malignancies has evolved into an era of careful and precise dissection along mesorectal or mesocolic fascia to achieve the so-called total mesorectal excision or complete mesocolic excision. The wide use of laparoscopic technique prompted more anatomical, histological, and embryological studies. This leads to a deeper and more precise understanding of fascial anatomy concerning colorectal surgery, though controversies exist. The complicated anatomy of multilayer parietal fasciae and dense adhesion between fasciae at specific sites still represent a major hindrance to perform a precise inter-fascial dissection. Colorectal surgeons should be familiar with the onion-like arrangement of the visceral and parietal fasciae. The dedicated assistants should provide three-directional traction and adjust the direction of forces timely in a manner that the resultant forces are always in a direction perpendicular to the fasciae that are to be dissected. The fixation of the mesorectum and the mesocolon to the pelvic and abdominal wall can also be exploited as a natural counter-retraction. To separate loosely attached visceral and parietal fasciae, the application of splitting forces on opposite fasciae or sliding the forceps along the interface will provide quick separation and maintenance of the integrity of the fasciae. In summary, careful attention to the direction and strength of three directional retractions on parietal and visceral fasciae will help stretch and open up the areolar surgical tissue plane, skillful maneuver in separation and dividing of the attachment of two fasciae will ensure a precise inter-fascial dissection and help achieve total mesorectal excision or complete mesocolic excision, reducing the risk of the residual of the mesentery and inadvertent injuries to adjacent tissues and autonomic nerves.

Surgical coaching applied to laparoscopic TME for continuous professional development in rectal surgery: proof of concept.

Coaching is maturing as a strategy for surgeons' continuous professional development in different types of surgery. Laparoscopic total mesorectal excision (LAP TME) is one of the recognized difficult procedures in colorectal surgery. Aim of this trial is to introduce the surgical coaching as a tool for a continuous technical education of LAP TME for cancer in a consultant surgeon carrier. Twelve Italian colorectal surgeons were enrolled as trainees in the AIMS Academy rectal cancer surgical coaching project and attended a face-to-face 90-min surgical coaching on a pre-edited 45-min-long video of a laparoscopic proctectomy according to pre-determined guidelines. At the end of the coaching, all mentors were asked to fill a questionnaire evaluating the trainee's skills. All trainees had to fill a post-coaching questionnaire addressing the appropriateness of the coaching with respect to their actual level. Trainees were more confident in performing the extra-pelvic part of the surgical procedures compared to the intra-pelvic dissection. The most challenging steps according to the trainees were the seminal vesicles identification and the pelvic floor dissection. Mentors found the trainees quite confident in the approach to the vascular structures, lymphadenectomy, stapler utilization and bleeding control. The sharpness and the efficacy of the dissection, the dissection of the surgical planes and the anastomosis fashioning were reported at a lower level of confidence. The higher grade of satisfaction reported by the trainee came from the attention that the mentors demonstrated towards them, from the availability of the mentors to take into consideration the surgical issues raised and from the willingness to apply the suggestions received during their next proctectomies. The surgical coaching applied to LAP TME should be considered as an innovative tool for continuous professional development.

Nerve plane: An optimal surgical plane for laparoscopic rectal cancer surgery?

Radical resection for rectal cancer with total mesorectal excision has been widely recognized in mid-low rectal cancer. Although such surgery reduced the tumor recurrence rate and improved the survival rate of patients, the rate of urinary and sexual dysfunction was high after rectal cancer surgery, which might be attributed to pelvic autonomic nerve injury. The present study found that the pelvic autonomic nerves never exist alone. These are always surrounded by tiny capillaries and adipose tissue and covered by a thin layer of membranous tissue, leading to a continuous plane that should be preserved pelvic autonomic nerve from thermal damage, ischemic injury, nerve stretching, and chemical factors produced by local inflammatory effects. However, the completeness of the continuous plane is easily damaged intraoperatively in routine total mesorectal excision in rectal cancer. Postoperative urinary and sexual dysfunction might be closely associated with the injury of continuous plane. Therefore, the continuous plane should be protected and considered as the optimal surgical plane for rectal cancer surgery.

Microscope-Integrated Intraoperative Optical Coherence Tomography-Guided Big-Bubble Deep Anterior Lamellar Keratoplasty.

The purpose of this study was to evaluate the feasibility of microscope-integrated intraoperative optical coherence tomography (OCT) for real-time quantitative analysis of surgical planes in big-bubble deep anterior lamellar keratoplasty (DALK). In this interventional case series, intraoperative OCT-guided big-bubble DALK was performed in 16 consecutive eyes of 16 patients with keratoconus. Trephination depth was measured using the intraoperative OCT caliper tool. Aiming for a depth within 150 μm from the endothelial surface, the trephination groove was extended to a deeper plane using a 15-degree blade. Repeat OCT scans were taken to measure residual stromal thickness before insertion of the DALK probe from the bottom of the extended trephination. Caliper measurements, success rate of pneumatic dissection, and complications were recorded. After trephination, residual stromal thickness exceeded 150 μm in all eyes and averaged 257.1 ± 42.5 μm. In each case, the initial trephination groove was extended to a depth within 150 μm from the endothelial surface (118.9 ± 27.1 μm). Big-bubble formation was achieved in 12 eyes (75%). Type 1 bubble was obtained in 11 eyes. Perforation requiring conversion to penetrating keratoplasty occurred in 4 eyes during insertion of the cannula into a residual stromal bed of <100 μm (n = 2; 63 and 75 μm) or layer-by-layer dissection (n = 2). Quantitative analysis of intraoperative OCT scans can be used to assist decision-making on whether to proceed with pneumatic dissection or extend the trephination groove, thereby facilitating insertion of the injection cannula at the desired stromal depth.

Above and Beyond: Periorbital Suspension for Endoscopic Access to Difficult Frontal Sinus Pathology.

The periorbital suspension (PS) is an advanced adjunctive technique performed during endoscopic approaches to frontal sinus pathology that would be too far lateral or superior to address using traditional endoscopic transnasal approaches. The objectives of this study are to characterize the utility of this technique for frontal sinus pathology, determine anatomic limitations, and assess clinical outcomes following surgical treatment. Prospective case series. Patient data including demographics, etiology, technique, complications, and clinical follow-up were collected. Preoperative computed tomography scans were reviewed for maximum lateral and superior extent of pathology, supraorbital recess height, anterio-posterior (AP) diameter of the frontal sinus, interorbital distance, and orbital-first olfactory neuron distance. The PS approach was used in 30 surgeries (29 patients) for cerebrospinal fluid leaks (n=5), benign tumors (n=17), malignant tumors (n=5), allergic fungal sinusitis (n=2), and mucocele (n=1) between 2018 and 2020. Approaches included 15 Draf IIB and 15 Draf III frontal sinusotomies. All pathology was surgically accessible using the PS approach and there were no intraoperative or postoperative complications. Postoperative follow-up was 11.7 ± 7.6 months. Mean recorded measurements (in mm) were as follows: maximum lateral extent -15.0 ± 7.7, superior extent 21.2 ± 7.7 in surgical plane and 20.9 ± 9.8 in the vertical plane, supraorbital recess height -2.6 ± 1.9, AP frontal sinus diameter -13.2 ± 4.7, interorbital distance -29.8 ± 5.4, and orbital-olfactory neuron distance -14.8 ± 2.9. The PS technique can be safely and successfully utilized to provide endoscopic endonasal access to lateral and superior frontal sinus pathology. 4 Laryngoscope, 132:538-544, 2022.

High dorsal resection for hepatocellular carcinoma: surgical plane and outcomes.

High dorsal resection (HDR) of the liver is a systematic resection technique for hepatocellular carcinoma (HCC) arising in the caudate lobe. HDR is rarely performed, as the procedure requires a high level of operative skill, knowledge of liver anatomy and is performed in patients with limited hepatic function. Between 2002 and 2012, we performed HDR on 9 patients. The median operation time was 534 min (range, 349-903 min), and the median blood loss volume was 430 mL (range, 94-4,530 mL). The severe morbidity rate was 11.1%, but there was no operative mortality, and the median hospitalization was 13 days (range, 8-93 days). The overall survival was 49.7 months (range, 3.1-89.0 months). Despite the hard-to-approach anatomic location, HDR can be carried out safely with good survival compared to other segments.

Pelvic membrane anatomy and surgery with network preservation of autonomic nervous system for rectal cancer

The principle of total mesorectal excision (TME) standardizes the resection range and surgical dissection plane in radical rectal cancer surgery, reduces the local recurrence rate and improves the long-term survival. TME is the "gold standard" in radical rectal cancer surgery. However, with the progress of laparoscopic surgical instruments and techniques in recent years, further understanding of pelvic membrane anatomy and autonomic nervous system has been gained, which makes the surgical plane of TME more accurate and the autonomic nervous system better preserved. According to anatomical discovery and histological confirmation, there is a fascia between the mesorectal fascia and pelvic parietal fascia, called pre-hypogastric nerve sheath, in which autonomic nervous system courses, including the superior hypogastric plexus, left and right hypogastric nerves, pelvic plexus and the neurovascular bundles, from the abdominal to the pelvic cavity behind the mesorectal fascia. It fuses with the end of the mesorectum at the superior border of musculi puborectalis, and goes around the mesorectum to join with Denonvillier fascia. On the basis of anatomical studies and empirical anatomical observations, we put forward the concept of network preservation of the autonomic nervous system: the main trunk as well as the nerve branches of the pelvic autonomic nervous system and accompanying blood vessels should be preserved to ensure the integrity of the nerve reflex arc. The concept allows the radical resection of rectal cancer to follow the principle of TME, and meanwhile, protect patient's urination function and sexual function to the greatest extent, improving the quality of life of patients after surgery.

Anatomical observation of the left parietal peritoneum and its clinical significance in left retro-mesocolic space dissection

Objective: To investigate the anatomic characteristics of the left parietal peritoneum and its surgical implementation while dissecting in left retro-mesocolic space. Methods: A descriptive case series research methods was used. (1) surgical videos of 35 patients who underwent laparoscopic radical resection (complete mobilization of splenic flexure) of colorectal cancer in Union Hospital of Fujian Medical University between January 2018 and December 2018 were reviewed; (2) four specimens after radical resection of rectal cancer performing in June 2020 were prospectively enrolled and reviewed; (3) five specimens of left parietal peritoneum from 5 cadaveric abdomen (3 males and 2 females) were enrolled and reviewed as well; Tissues of 3 unseparated regions, namely the root of the inferior mesenteric artery (IMA), the medial region and the lateral region (including kidney tissue), from above the 5 cadaveric abdominal specimens were selected to perform Masson staining and histopathological examination. Results: (1) Surgical video observation: "Staggered layer phenomenon" and typical left parietal peritoneum was found in 77.1% (27/35) of patients when the left retro-mesocolic space was separated from the lateral and central approaches. The left parietal peritoneum presented as a rigid fascia barrier between the lateral and central approaches, which was a translucent dense connective tissue fascia. After the splenic flexure were completely mobilized, the left parietal peritoneum stump continued to the cephalic side. (2) Observation of 4 surgical specimens: The dorsal side of the left mesocolon specimen was studied, and the left parietal peritoneum stump edge was identified. The outside of the stump edge was the left hemicolon dorsal layer, which was continuously downward to the rectal fascia propria. (3) Cadaveric abdominal specimens: The left retro-mesocolic space was separated through lateral and central approaches, and the rigid fascia barrier, essentially the left parietal peritoneum and Gerota fascia, was encountered. Cross-section view showed that the left parietal peritoneum could be further detached from the dorsal layer of the left mesocolon from the outside, but could not be further detached from the inside out. (4) Histological examination: There was no obvious fascia structure in the IMA root region, while outside the IMA root region, the left bundle of inferior mesenteric plexus penetrating Gerota fascia was observed. There were 4 layers of fascias in the medial region, including the ventral layer of the left mesocolon, the dorsal layer of the left mesocolon, left parietal peritoneum and Gerota fascia. Small vessels were observed between the dorsal layer of the left mesocolon and the left parietal peritoneum. In lateral region, renal tissue and renal fascia were observed. Three layers of fascia structures were observed clearly under high power field, including the dorsal layer of the left mesocolon, left parietal peritoneum, and Gerota fascia. Conclusions: The left parietal peritoneum is the anatomical basis of the "staggered layer phenomenon" from the lateral or central approaches during the separation of left retro-mesocolic space. The small vessels in the dissection plane are the anatomical basis of intraoperative microbleeding, which need pre-coagulation. The central part of Gerota fascia is penetrated by the branches of the inferior mesenteric plexus, which results in a relatively dense surgical plane. Thus, during the dissection through the central approach, it is easy to involve in wrong surgical plane by deeper dissection.