Transected Research Articles

Population trends in biopsy techniques used to diagnose melanoma: Impacts on microstaging and management

Melanoma rates in Australia are one of the highest in the world. Accurate diagnosis of melanoma is essential for deciding and planning appropriate treatments, achieved through excisional biopsy. Our research has shown increasing rates of shave biopsies as a technique to diagnose melanoma, which are associated with high rates of the tumour being transected at the base, underestimation of tumour thickness and increased number of procedures to achieve safety margins compared to excisional biopsy. This shows a clear shift away from guideline recommendations for melanoma management and highlights important areas for future research.

Transected sciatic nerve repair using poly L-lactic-co-glycolic acid nanofiber scaffolds with nerve growth factor in rat

Transected sciatic nerve repair using poly L-lactic-co-glycolic acid nanofiber scaffolds with nerve growth factor in rat

The veins (V3b and V3a,) the artery (A3) and the bronchus (B3) are prepared and transected with the motorized stapler

The veins (V3b and V3a,) the artery (A3) and the bronchus (B3) are prepared and transected with the motorized stapler

Repairing rat sciatic nerve defects via transplanting bilayer collagen conduit scaffolds carrying bone marrow mesenchymal stem cells

Objective To construct an artificial nerve graft as an alternative for autologous nerve grafting. Methods We fabricated an innovative tissue engineered nerve graft (TENG), which consists of a commercial bilayer collagen membrane (Bio-Gide)-based nerve scaffold and bone marrow mesenchymal stem cells (BMSCs) serving as support cells to bridge a 10 mm long sciatic nerve defect in rats, The 10 mm gap was left empty after resection in the blank group. In the other three groups, the sciatic nerve defect was, respectively, bridged with plain collagen tube (CT group), a collagen tube filled with BMSC suspension (C+ CT group), or reversed transected nerve segment (AG group). Results Histological and functional assessments showed that the developed TENG facilitated nerve regeneration (SFI: CT, -92.490±1.836; C+ CT, -70.010±7.805; AG, -70.130±8.744; F= 17.850, P 0.05) and better outcomes than the plain collagen tube (P<0.05). Conclusion These results manifested that the bilayer collagen conduit loaded BMSCs could be applied as a new biodegradable artificial nerve guide for nerve tissue engineering. Key words: Tissue engineer; Nerve graft; Bone marrow mesenchymal stem cells; Bilayer collagen conduit scaffold; Sciatic nerve injury; Peripheral nerve regeneration

Efficacy of robot-assisted laparoscopic ureteral reimplantation for primary obstructive megaureter in children

Objective To evaluate the clinical efficacy of robot-assisted laparoscopic ureteral reimplantation (RAUR) for primary obstructive megaureter (POM) in children. Methods Twenty-one patients who underwent RAUR for POM in Bayi Children’s Hospital between 2017 April and 2018 April were retrospectively analyzed. The study population consisted of 15 boys and 6 girls aged between 2 months and 11 years. Ten patients had left POMs, 9 had right POMs and two had bilateral POMs. All patients were preoperatively diagnosed with a POM based on urinary system ultrasonography, magnetic resonance urography, and diuretic renal dynamic imaging. Our main technique key steps include: Under general anesthesia, the patients were placed in a Trendelenburg position approximately 40 degrees from the horizon. An 8.5-mm camera port was placed at the level of the umbilicus. Followed by two 5-mm robotic Trocars placed under direct vision 6 cm to the camera port separately, a 5-mm assistant port was placed on the right upper abdominal quadrants which was located 3 cm from the camera and robotic port. The ureter was identified at the pelvic brim. The peritoneum covering the ureter was incised and the ureter was mobilized to the level of the vesico-ureteric junction. The bladder was filled with 60 ml saline and a 5 cm length and 1.5 cm wide submucosal detrusor tunnel was created. The ureter was transected at the bladder mucosa and the narrowed ureteral segment was discarded. The ureteroneocystostomy was performed using 6-0 absorbable suture. Dissecting the perivesical fascia appropriately and using down-top suturing approach, use of an apical stay stitch, and incorporation of the ureteral adventitia during detrusorraphy. Postoperative complications were analysed using the Clavien-Dindo classification. Success was defined as symptomatic relief, decreased hydronephrosis on ultrasound and no evidence of vesicoureteral reflux on voiding cystourethrography. Results All surgeries were successfully completed without conversion and no intra-operative complication was encountered. The mean operative time was 117.6±18.1(89-165)min, the mean estimated blood loss was 11.9±4.3(5-25)ml, the abdominal drainage tubes were removed after a mean of 4.9±1.1(3-8)days, and the mean postoperative hospital stay was 6.3±1.3(4-10) days. Postoperative complications (Clavien Ⅰ-Ⅱ) occurred in 9.5% (two patients had recurrent urinary tract infections postoperatively) children, no grade Ⅲ-Ⅳ complication was observed. The pre-operative symptoms in all patients disappeared. One patient had grade Ⅱ VUR on VCUG, who were followed conservatively. Ultrasound at postoperative follow-up showed that the hydronephrosis was disappeared in 20 ureters and significantly decreased in 3 ureters. The success rate was 95.7% at a mean follow-up of 16.3±4.0(10-23)months. Conclusion RAUR is a safe and feasible option for the treatment of POM in children with higher success rate and lower complication rate. Key words: Laparoscopes; Robot-assisted; Ureter reimplantation; Primary obstructive megaureter; Children

Clinical efficacy of radical resection with individualized surgical approach for borderline resectable pancreatic head carcinoma

Objective To explore the clinical efficacy of radical resection with individualized surgical approach for borderline resectable pancreatic head carcinoma. Methods The retrospective descriptive study was conducted. The clinicopathological data of 54 patients with borderline resectable pancreatic head carcinoma who underwent radical resection with individualized surgical approach in the West China Hospital of Sichuan University from January 2015 to January 2018 were collected. There were 37 males and 17 females, aged from 37 to 73 years, with a median age of 59 years. For venous type borderline resectable pancreatic head carcinoma, surgery for pancreatic head carcinoma and (or) pancreatic head and neck carcinoma was performed via inferior mesenteric vein, and surgery for pancreatic uncinate process carcinoma was performed via inferior colon artery. For arterial type borderline resectable pancreatic head carcinoma, surgery for pancreatic head carcinoma and (or) pancreatic head and neck carcinoma was performed via medial uncinate artery, and surgery for pancreatic uncinate process carcinoma was performed via left posterior artery. Observation indicators: (1) surgical situations; (2) postoperative complications; (3) postoperative pathological examination; (4) follow-up. Patients were followed up by outpatient examination or telephone interview once every 3 months to detect survival up to March 2019. Measurement data with normal distribution were represented by Mean±SD. Measurement data with skewed distribution were represented by M (range), and count data were represented by absolute numbers or percentage. Kaplan-meier method was used to draw the survival curve and calculate the survival rate. Results (1) Surgical situations: all the 54 patients underwent expanded pancreatoduodenectomy combined with superior mesenteric vein/portal vein (SMV/PV) resection, including 15 via inferior mesenteric vein, 20 via inferior colon artery, 12 via medial uncinate artery, and 7 via left posterior artery. The operation time was (320±83)minutes, and the volume of intraoperative blood loss was (865±512)mL. (2) Postoperative complications: of 54 cases, 28 had postoperative complications, including 13 with grade 1 Clavien-Dindo complications, 12 with grade 2 Clavien-Dindo complications, 3 with grade 3 or above Clavien-Dindo complications. One of the 28 patients with postoperative complications died and 27 were improved after symptomatic and supportive treatment. (3) Postoperative pathological examination: of 54 patients, 31 had R0 resection and 23 had R1 resection. In the 23 patients with R1 resection, 5 underwent surgery via the inferior mesenteric vein (4 with involvement of pancreatic anterior surface, 1 with involvement of both pancreatic anterior and posterior surface), 9 underwent surgery via the inferior colon artery (2 with involvement of both pancreatic anterior and posterior surface, 2 with involvement of superior mesenteric artery margin, 2 with involvement of pancreatic posterior surface, 2 with involvement of pancreatic anterior surface, 1 with involvement of superior mesenteric artery margin and pancreatic posterior surface), 5 underwent surgery via the medial uncinate process artery (2 with involvement of superior mesenteric artery margin, 2 with involvement of both pancreatic anterior and posterior surface, 1 with involvement of pancreatic neck transected margin), and 4 underwent surgery via the left posterior artery (3 with involvement of superior mesenteric artery margin, 1 with involvement of both pancreatic anterior and posterior surface). Of 54 patients, 16 had no positive lymph nodes, 26 had 1-3 positive lymph nodes, and 12 had 4 or more positive lymph nodes. The tumor diameter was (3.20±0.14)cm. There were 48 of 54 patients with nerve infiltration, 41 with superior mesenteric vein and/or portal vein infiltration, and 11 with vascular thrombus. There were 17 of 54 patients with high differentiation and medium differentiation, and 37 with low differentiation and undifferentiation. (4) Follow-up: 54 patients were followed up for 1-42 months, with a median time of 19 months. The 1-, 3-year overall survival rate was 78.0%, 11.4%. Conclusion As for the borderline resectable pancreatic head cancer, individualized and customized surgical approach according to the location of tumor and the relationship with blood vessels is helpful to standardize the radical resection and avoid R2 resection. Key words: Pancreatic neoplasms; Pancreatic cancer; Borderline resectable; pancreaticoduodenectomy; Surgical approach; R2 resection; Efficacy

A modified two-stage procedure strategy treat severe hypospadias with preputial flap

Objective To investigate the effect of a modified preputial flap urethroplasty in two-stage treatment of severe hypospadias. Methods The clinical characteristics of the severe hypospadias patients (41 cases) who underwent the staged urethroplasty by using the procedure of preset urethral plate with preputial flap from January 2015 to December 2016 were analyzed retrospectively. We used a modified method (modified group, 23 cases ): Form the distal urethra with the transected distal urethral plate by using tubularize incised plate (TIP) procedure during the first stage operation, after completely straightened the penis, urethral plate was preseted with transverse preputial flap at the penis shaft. While in the traditional group (18 cases), urethral plate was preseted with preputial flap by using Bracka procedure after transecting urethral plate. The corresponding missing part of urethra underwent urethroplasty at the second stage operation six months later. The patients in the modified group were 9 to 18 months old, and the median age was 13 months; meatus were located at the penis shaft in 10 cases, scrotum in 12 cases, perineum in 1 case. The patients in the traditional group were 9 to 18 months old, and the median age was 13 months; meatus were located at the penis shaft in 6 cases, scrotum in 10 cases, and perineum in 2 cases. There was no statistic difference in age and meatus position between the two groups. Results During the first stage operation, distal urethra was repaired by 13-19 mm, with an average of (14.5±1.3) mm, and the proximal urethra was repaired by 0-6 mm, with an average of (3.1±2.4) mm at the modified group. While at the traditional group, the length of proximal urethra was repaired of 0-9 mm, with an average of (5.6±2.9) mm. The urethral length required for reconstruction was measured during the second stage operation, with an average of (26.3±4.4) mm in the modified group and (40.5±3.3) mm in the traditional group (P 0.05). Conclusions The modified staged preputial flap method shorten the new forming urethra by making full use of its own materials at the second stage operation, which was helpful to reduce complications. Key words: Hypospadias; Staged repair; Preputial flap; Urethral plate

Effects of side-to-side neurorrhaphy of phrenic nerve or intercostal nerve on pulmonary function in rats

Objective To verify the safety of a new surgical model by assessing the lung function of phrenic nerve and intercostal nerve via side-to-side with nerve autograft to the neurorrhaphy site of the musculocutaneous nerve in rats. Methods Fifty four SD rats were randomly divided into three groups. Group A was the negative control group, in which the musculocutaneous nerve was transected and directly sutured. The other two groups were the phrenic nerve (group B) and intercostal nerve (group C): after the musculocutaneous nerve was transected and the side-to-side neurorrhaphy was conducted. Sural nerve was used to connect the musculocutaneous nerve neurorrhaphy site and the donor nerve as phrenic nerve or intercostal nerve. Lung function test was conducted at 1, 2 and 3 months postoperatively. Results No significant difference was detected from each parameter including breathing frequency (F), minute ventilation (MV), inspirationand expiration time (Ti and Te), peak inspiratory and expiratory flow (PIF and PEF) and 50% expiratory flow (EF50) of lung function test among group A, B and C at 1, 2 and 3 months postoperatively. Conclusion Side-to-side neurorrhaphy has no obvious damage to pulmonary function. This new method is safe and has great advantages in clinical application. Key words: Rats; Respiratory function tests; Phrenic nerve; Intercostal nerve; Side-to-side neurorrhaphy

Surgical techniques and short-term outcomes of transvesical robot assisted radical prostatectomy

Objective To introduce the technique and report our initial experience of transvesical robot assisted radical prostatectomy (TvRARP). Methods From April 2018 to August 2018, 10 patients underwent TvRARP performed by a single surgical team were retrospectively reviewed. Preoperative data of patients [aged (58.6±9.4) years, BMI (26.5±3.1) kg/m2, tPSA (19.5±4.1) ng/ml, biopsy Gleason score 6(6-7), prostate volume (33.4±15.8)ml and IIEF-5 score 12(10-16)] were collected. Preoperative study revealed 8 cases of cT1c, 1 case of cT2a and 1 case of cT2b. All patients were continent preoperatively. During the surgical procedure, the bladder was opened, and a circumferential incision was then made around the internal urethral orifice. Initially, posterior dissection of bilateral vas deferens and seminal vesicles was performed, followed by posterior dissection towards apex. Lateral dissection of neurovascular bundles was performed before anterior dissection towards apex. The exposed urethra was transected and specimen was removed. Vesicourethral anastomosis and closure of bladder was performed in a standard way. Results All 10 cases were successfully performed robotically without conversion, transfusion or other major intraoperative or postoperative complications. Postoperative pathology confirmed 6 cases of pT2a , 3 cases of pT2b and 1 case of pT2c [median Gleason score 6(6-7)]. One case was reported positive surgical margin. Operative time was (140.5±35.5) mins. Estimated blood loss was (65.5±35.5) ml. Urethral catheter was removed at 7 days postoperatively. Nine patients achieved urinary continence (0 pads) immediately after the removal of urinary catheter, while 1 patient returned to full continence at 2 weeks postoperatively. During a mean follow-up of 3 months (2-4 months), no biochemical recurrence was detected (tPSA 0.05). Conclusions Transvesical approach is a valid alternative of RARP in patients bearing localized low-risk prostate cancer. Tumor control and preservation of erectile function remains to be determined by long term follow-up. Key words: Radical prostatectomy; Robot; Transvesical approach; Localized prostate cancer

Structure styles and tectonic evolution of the Abrolhos Sub-Basin, Perth Basin, Western Australia

Based on examination and re-interpretation of 2D seismic and well data, three groups of faults were recognized in the Abrolhos Sub-basin: a) major normal faults transecting the Permian, Triassic and Jurassic, b) small normal faults developed in the Early Permian, and c) small normal faults developed in the Triassic and Jurassic.

Nerve coaptation on bladder function recovery in rats with end-to-side neurorrhaphy

Objective To investigate the effect of end-to-side nerve coaptation on bladder function recovery in rats with neurogenic bladder. Methods Forty male Sprague-Dawley (SD) rats [mean weight (240-280) g] were randomly divided into end-to-side nerve coaptation group (ETS group, n=15), no coaptation group (NC group, n=15) and blank control group (BC group, n=10). In the ETS group, the left ventral root (VR) and dorsal root (DR) of L6 and S1 were transected, and the distal stump of L6VR was sutured to the lateral face of L4VR. In the NC group, the left VR and DR of L6 and S1 were transected, but coaptation was not performed. In the BC group, no operation was performed. Four months later, bladder function was evaluated by cystometry and electrical stimulation. Results When the spinal nerves were stimulated, the increased maximum intravesical pressure was (34.9±3.1) mmHg (1 mmHg=0.133 kPa) in BC group and (18.3±2.1) mmHg in ETS group. The difference was statistically significant (t=15.317, P 0.05], and that in the ETS and BC groups was greater than in the NC group [(18.8±1.7) mmHg; t=9.446, P<0.01; t=11.504, P<0.01]. Conclusion The bladder can be reinnervated and the bladder function can be partially improved by end-to-side nerve coaptation in rats. Key words: Neurogenic bladder; End-to-side nerve coaptation; Urodynamic; Rats

Application of improved anvil placement in laparoscopic resection of low rectal cancer with resection of anal eversion

To investigate the feasibility and application value of improved anvil placement in laparoscopic resection of low rectal cancer with resection of anal eversion. A retrospective study was performed on 17 patients who were operated by improved extracorporeal anvil placement in laparoscopic resection of low rectal cancer with resection of anal eversion at Huaihe Hospital of Henan University during June 2015 and June 2017. (1) distance from tumor low margin to anal edge was 4 to 6 cm; (2) protrusive type tumor with a circumferential diameter of less than 3 cm; (3) ulcer type tumor with circumferential bowel infiltration of less than 1/2; (4) no distant metastasis(M0) and preoperative MRI of pelvic floor indicating T1-3N0. Patients with BMI>35 kg/m2, or insufficient length of sigmoid and mesentery, or thickening sigmoid and mesentery were excluded. According to total mesorectal excision(TME) principle, rectum and its mesentery was resected completely; the sigmoid colon was cut off at the superior margin of tumor; the oval forceps was placed through anus to clamp and evert the rectum out of the anus; the rectum was transected at 1-2 cm from the lower edge of the tumor; the distal sigmoid colon was pulled out through anus; purse string suture was made after insertion of anvil and was restored to the abdominal cavity; end-to-end anastomosis of the rectum and sigmoid colon was performed after closing rectal stump. Of 17 low rectal cancer patients, 10 were male and 7 were female with age of 42 to 71 (median 58) years old and BMI of 20.6 to 33.5(median 26) kg/m2. Preoperative staging indicated 2 cases of stage I, 15 cases of stage II. Distance from tumor low margin to anal edge was 4 to 6(median 5.0) cm and diameter of tumor was 3.4 to 4.8 (median 4.2) cm. All the patients completed operations successfully without conversion to laparotomy. The operation time was 124 to 182 (median 136) minutes. Distal sigmoid colon was difficult to pull out in 1 patient due to the insufficient free of the mesosigmoid, which was then successful after the mesosigmoid was dissociated with laparoscopy thoroughly again. The intraoperative blood loss was 10 to 50 (median 20) ml. Postoperative pathology reveled 2 cases of stage I, 12 cases of stageII and 3 cases of stage III; 1 case of poorly differentiated adenocarcinoma, 15 cases of moderately differentiated adenocarcinoma and 1 case of highly differentiated adenocarcinoma. The postoperative exhaust time was 24 to 128 (median 36) hours and hospital stay was 5 to 15 (median 8) days. No anastomotic leakage and intra-abdominal infection was found. Fifteen patients were followed up for 5 to 24 months without local recurrence or distant metastasis. The improved anvil placement in laparoscopic resection of low rectal cancer with resection of anal eversion without abdominal incision is safe and feasible.

Reduction anaplasty of zygomatic arch through a minor pre-auricular incision

Objective To explore the clinical application of reduction anaplasty trough a minor pre-auricular incision. Methods A retrospective analysis of 89 patients with wide zygomatic arch treated with reduction anaplasty through pre-auricular incision from 2012 to 2016 in our hospital had been studied. Through a short incision in front of ear, zygomatic arch at the most narrow part, located about 5 cm in front of temporomandibular joint, was completely transected, whereas the junction of malar and zygomatic bone was drilled to make a greenstick fracture. No dissection of zygomatic ligament was perforemed. The dissected zygomatic arch was then pressed down and adjusted into a appropriate position. In the case of the protrusion of zygomatic body, the protrusion part could be reducted using grinding ablation. Results All the patients were followed up for 3 months to 5 years. The results were satisfactory, no serious complications were found, and the facial tissue did not show obvious ptosis. Postoperative numbness occurred on the left side in one patient and recovered spontaneously after two months. Conclusions Reduction anaplasty trough a minor pre-auricular incision is a simple, safe and effective approach for wide zygomatic arch, which could avoid facial tissue ptosis. Key words: Zygomatic arch reduction; Anterior ear incision; Zygomatic arch ligament; Branch fracture; Facial drooping

Study on denervated rat skeletal muscle by 7.0 T 31P-MR phosphorus spectroscopy

Objective To investigate the changes of 31P-MRS in denervated skeletal muscle at 7.0 T MR system. Methods In the experiment group, a total of 18 male Sprague-Dawley rats aged 6-8 weeks old and weighing 200-250 g were obtained. The right posterior femoral nerve were transected, and the proximal stumps were ligated by using 5-0 nylon stitches to preclude spontaneous repair. A sham surgery (incision and exploration of the nerve) was performed at the same time (n=6). Before rat model established and at varying times after initial surgery (3 d, and 1, 2, 4, 6, and 8 weeks). 31P-MR spectra of rat quadriceps femoris were acquired on 7.0 T Agilent small animal MR imaging system. We quantified the phosphocreatine (PCr), adenosine triphosphate(β-ATP), and inorganic phosphate (Pi) using Creatine phosphate disodium salt(10 mmol/L) as an external standard. The ratios, include PCr/Pi, Pi/β-ATP, PCr/β-ATP, PCr/(PCr+Pi) and Pi/(PCr+Pi) were quantified in jMRUI. All data were analyzed by one way analysis of variance (ANOVA) with posttest inter-group comparisons using Bonferroni test. Comparative analysis methods between the experimental and control group were performed via independent samples t test. P<0.05 was considered as statistically significance. Results The average measured concentrations of β-ATP, PCr, and Pi in control groups were (6.654±0.178) μmol/g, (25.656±0.738) μmol/g, and (1.594±0.096) μmol/g, respectively. There were significant statistically differences in β-ATP, PCr, Pi, PCr/Pi, PCr/PCr+Pi,Pi/PCr+Pi between the study and control group(P<0.05) at any measurement time point after denervation. Pi/β-ATP,PCr/β-ATP and pHi in the experimental group significantly statistically differed from those of the control group (all P<0.05)at each time point except on day 3 after operation. The total concentrations of β-ATP and PCr were reduced by 11.5% and 19.7% respectively on day 3. Thereafter, β-ATP and PCr declined rapidly by 63.1% and 68.8% at week 4 respectively, then decreased slowely by 74.0%和82.3% till week 10. The change of PCr/Pi is similar to β-ATP and PCr, but more remarkable. Pi, Pi/PCr+Pi, Pi/ATP showed a progressively increase till week 10. The intra-cellular pH (pHi) of normal rat muscles was 7.033±0.017, While the pHi gently in experiment rat muscles decreased during the entire experiment. Conclusion 31P-MRS with 7.0 T can quantify the temporal changes of energy metabolism and pHi in normal and denervated rat muscles. It shows that the dysfunction of energy metabolism are progressive with time and that they begin within a short period following the nerve section, the change of β-ATP, PCr, PCr/Pi take place primarily within 4 weeks after denervation. β-ATP, PCr, and PCr/Pi may be potential biomarkers of energy metabolism in the evaluation of denervated muscle atrophy. Key words: Magnetic resonance spectroscopy; Muscular disorders, atrophic; Denervation; Energy metabolism; Intracellular pH

Laparoscopic radical treatment with preservation of left colon artery and superior rectal artery for sigmoid colon cancer

During the classical radical treatment for sigmoid colon cancer, ligation of the inferior mesenteric artery (IMA) at its root is typically performed to achieve better dissection of central and intermediate lymph node groups and improve the surgical outcomes. However, the blood supply to the left colon artery (LCA), sigmoid artery, and superior rectal artery (SRA) is blocked after the ligation at the root of the IMA. Here, we report laparoscopic radical treatment with preservation of the LCA and SRA for sigmoid colon cancer to preservation of blood supply to the anastomosis. The method was indicated to treat cancer at the middle portion of sigmoid colon. In the operation, we careful dissection of IMA exposes the trunk of IMA. The surrounding lymphatic tissue is dissected from the IMA root to its distal end. The LCA is preserved. After IMA divides LCA, 2–5 sigmoid colon arteries are transected one after another at the distal end of the LCA until it further divides into left and right rectal arteries before entering the lateral wall of rectum. The inferior mesenteric vein (IMV) is transected at the lower edge of the pancreas, and the mesorectum is cut open towards the spleen curvature at the lower edge of the pancreas. Other procedures are similar with IMA high ligation surgery. Generally, LCA and SRA can be successfully preserved, and if necessary, the colonic splenic flexure should be mobilized to ensure that there is no tension at the anastomosis. The operation doesn’t significantly prolonged operation, but retrieved comparable lymph node counts with IMA high ligation surgery. Dissection of the lymphoadipose tissues at the root of IMA with the preservation of LCA and SRA is an easily performed surgery. It guarantees further prospective clinical research to compare the anastomosis leakage and oncological outcome with IMA high ligation surgery.

Application of the cold cutting technique in transumbilical single-incision laparoscopic liver resection

Objective To study the application of the cold cutting technique in transumbilical single-incision laparoscopic liver resection (TUSI-LLR), and to evaluate its feasibility and treatment results. Methods The clinical data of 35 patients with liver lesions treated by transumbilical single-incision laparoscopic liver resection from 2013 to 2017 were retrospectively analyzed in Shengjing Hospital of China Medical University. In all these patients, the liver parenchyma was transected with the cold cutting technique. The operation time, intraoperative blood loss, postoperative complications, time to remove abdominal drain, and total hospital stay in the patients were analyzed. Results 11 of the 35 patients were male. The average age was (49.9±10.8) years. The average body weight was (63.2±11.1) kg. The diagnoses were hemangiomas in 18 patients, hepatolithiasis in 5 patients, malignant hepatocellular tumors in 5 patients, focal nodular hyperplasia in 3 patients, and others in 4 patients. There were 22 left lateral sectionectomies, 2 left hemihepatectomies, 11 wedge resections (8 in the left and 3 in the right). The operations were all successfully performed, with no conversion to conventional laparoscopic hepatectomy or open surgery. The average operation time was (112.2±51.0) minutes, and the intraoperative blood loss was (105.4±70.1) ml. No patients required intraoperative blood transfusion. The average surgery cost was (36 336.7±5 938.2) yuan. All patients recovered well, with no postoperative hemorrhage, bile leakage, or incisional wound infection. The average time periods for removal of the abdominal drain, and hospital stay were (4.5±1.2) days and (5.2±1.4) days, respectively. All the 35 patients were followed up (1~3 months), with no patients complaining of abdominal distension or abdominal pain. Conclusions The cold cutting technique in transumbi-lical single-incision laparoscopic liver resection was safe and feasible. Its benefits included the operative speed, the small amount of intraoperative blood loss and the rapid postoperative recovery of the patients. Key words: Cold cutting technique; Liver resection, laparoscopic, single incision; Stapling devices

Sensory nerve baby-sitting in reverse end-to-side fashion improves the recovery of denervated muscle in rats

Objective To delay the atrophy of denervated skeletal muscle by baby-sitting in reverse end-to-side fashion and explore the feasibility of this operation to improve the recovery of denervated muscle in rats. Methods From July, 2015 to March, 2016, 32 female SD rats were divided into 4 groups randomly and the tibial nerve of each rats was transected. In immediate repair group, the transected tibial nerve was sutured in situ. In unprotected group, the tibial nerve stump was putting-aside. The sural nerve was transected in other 2 groups. The proximal sural nerve was connected to the distal tibial nerve stump directly in end-to-end (ETE) protected group and to the side of the distal tibial nerve stump in end-to-side (ETS) protected group. After 3 months, connected the two ends of tibial nerve except immediate repair group. After another 3 months, the tibial nerve functional index, electrophysiological testing, histology and morphology were examined. Results The gastrocnemius muscle was atrophy obviously in unprotected group, while in other groups the muscle structure was well protected. The tibial nerve functional index (-39.54±24.32) , motor nerve conduction velocity[ (30.25±12.65) m/s], and muscle contraction [ (0.98 ± 0.38) N) ] indicated that the gastrocnemius muscle function in ETS protected group was statistically better recovery than in unprotected group [-75.65±32.13, (24.93±8.69) m/s and (0.64±0.20) N, respectively] and ETE protected group[-62.34±21.65, (16.90±7.92) m/s and (0.75±0.15) N, respectively] (P 0.05) . Conclusion Sensory nerve baby-sitting in reverse end-to-side fashion is a effective method to improve the recovery of denervated muscle in rats. Key words: Muscular atrophy; Denervated muscle; Nerve baby-sitting; End-to-side suture; Rat

Safety evaluation on initial 100 consecutive procedures of self-pulling and latter transected esophagojejunostomy

To evaluate the feasibility and the short-term safety of self-pulling and latter transected esophagojejunostomy(SPLT) in totally laparoscopic total gastrectomy (TLTG). One hundred patients with gastric cancer received TLTG-SPLT at General Surgery Department of Huashan Hospital (Fudan University) from June 2014 to January 2017(SPLT group). The clinicopathologic characteristics, surgical and postoperative outcomes were collected retrospectively and compared with the conventional group undergoing TLTG plus overlap or functional end-to-end anastomosis from October 2013 to December 2015. D2 lymph node dissection was regularly performed for all the patients. In SPLT group, a sterile hemp rope was held to ligate and drag down the esophagus to maintain "self-pulling" after the duodenum was transected by the first stapler, allowing the detachment of the posterior mediastinum. Then a hole 2-3 cm above the ligature rope was made on the right-posterior wall of the esophagus. When the mesenteric tension was checked, another hole was made at the anti-mesenteric border of the jejunum 20 cm distal to the ligament of Treitz. A side-to-side esophagojejunostomy (E-J) was then performed between the right-posterior wall of esophagus and the anti-mesenteric wall of the jejunum with the second linear stapler, forming an entry hole. The "latter transection" was applied with the third stapler inserted from the assistant's Trocar, which facilitated the esophagus and the afferent loop jejunum to be simultaneously transected above the level of the entry hole. After that, a side-to-side jejunojejunostomy(J-J) with another 2 staplers was carried out between the afferent loop stump and the Roux limb 40 cm below E-J, in which the E-J entry hole could also work as the entrance for the stapler. The TLTG-SPLT was therefore completed and the specimen was removed through the incision from the umbilical Trocar site. There were 66 male and 34 female patients in the SPLT group with median age of 64 years. The clinicopathologic baseline data of two groups were comparable(all P>0.05). All the patients underwent operations successfully, and none was converted to open surgery. No positive margin was found in either group. Mean operation duration was (178.2±35.9) minute in SPLT group, including (22.9±7.1) minute of reconstruction, which both were significantly shorter than those in conventional group [(204.4±55.8) minute, P=0.003; (30.5±7.2) minute, P=0.000]. Less blood loss [(74.3±72.5) ml vs. (104.2±71.6) ml, P=0.017] and earlier time to the first flatus [(1.9±1.6) days vs. (2.7±1.3) days, P=0.001] were observed in SPLT group. There were no significant differences in postoperative hospital stay and pathological findings between the two groups(all P>0.05). Postoperative operation-associated complications were found in 7 cases of SPLT group. Of these 7 patients, 1 case developed gastrointestinal bleeding, 3 pancreatic leakage, 2 chyle leakage, who all were discovered within postoperative 1 week and were cured by conservative treatment, while the other 1 case developed anastomotic fistula complicated with peritoneal infection who received laparoscopic exploration and peritoneal scavenge and drainage, then discharged 34 days later. Six patients in conventional group developed postoperative operation-associated complications, including 1 case of anastomotic bleeding, 3 cases of pancreatic leakage, 1 case of chyle leakage and 1 case of peritoneal infection. Morbidity of postoperative operation-associated complication was not significantly different between two groups [7.0%(7/100) vs. 11.5%(6/52), χ2=0.414, P=0.520]. Fifty patients from two groups underwent endoscopic examination at postoperative 6-month and 12-month, and no obvious anastomotic stenosis and esophageal reflux were observed. SPLT is a safe procedure with feasibibility in intracorporeal esophagojejunostomy.

The establishment of a neurogenic bladder model through spinal nerve transection in rats

Objective To establish a neurogenic bladder (NB) model through spinal nerve transection in rats and to evaluate the model with video-urodynamic. Methods Twenty five female Sprague-Dawley (SD) rats [mean weight (200-220) g, 8 weeks old] were randomly divided into NB group (n=15) and Sham group (n=10). In NB group rats, the bilateral lumbar 6(L6)and sacral 1(S1)spinal nerves were transected in dura. In Sham group rats, only laminectomy was performed. Video-urodynamic assessment was carried out one month postoperatively. Results The voiding dysfunction was observed in NB group rats, which showed full lower abdomen and discharged more urine by squeezing the increased bladder. The Sham group showed no significant abnormality. The video-urodynamic showed detrusor areflexia of rats in the NB group. The maximum bladder capacity (MBC) and bladder compliance (BC) increased significantly in NB group than those of Sham group [MBC: (3.97±0.90) ml vs. (1.03±0.21) ml; BC: (0.203±0.068) ml/cmH2O vs. (0.037±0.01) ml/cmH2O)] (t=10.070, P=0.000; t=7.616, P=0.000). However, the detrusor leak point pressures (DLPP) decreased significantly in NB group than those of Sham group [DLPP: (20.64±5.03) cmH2O vs. (27.88±3.94) cmH2O] (t=3.746, P=0.001). Simultaneous images showed that the bladder volume of the rats in the NB group was increased as rugby compared with Sham group. Conclusion This procedure of spinal nerve transaction can be used to establish NB rat model with acontractile detrusor. Key words: Neurogenic bladder; Spinal nerve; Urodynamic; Rat

Protective measures in laparoscopic resection for upper or mid rectal cancer and sigmoid colon cancer with transrectal specimen extraction surgery

To introduce the use of a self-made specimen protective sleeve in laparoscopic resection for upper or mid rectal cancer and sigmoid colon cancer with transrectal specimen extraction surgery and the improvement of implantation method, so as to avoid and reduce bacterial contamination and tumor cell dissemination in abdominal cavity. During June 2015 and May 2017, 48 cases of high located rectal or sigmoid colon cancer were operated laparoscopically with natural orifices specimen extraction surgery (NOSES) using a self-made specimen protecting sleeve. Operation indication: (1) Rectum and sigmoid colon cancer with the distance of more than 6 cm from tumor inferior margin to dentate line. (2) The maximum diameter of intestine together with mesangial and tumor <7 cm by intraoperative judgment. (3) No anal and distal rectal surgery, no anorectal stenosis or lack of expansion capacity caused by trauma. (4) No ulcerative colitis, Crohn's disease or radiation proctitis. After transecting the rectum, the specimen protective sleeve was inserted through the right lower 12 mm main Trocar (This sleeve was tailored from the laparoscopic protective sleeve produced by China 3L Corporation, which was intercepted with 25-35 cm from one end of the sleeve according to the length of distal rectal retention. One end was ligated and the other was open with a ligature band. About 5 ml paraffin oil was used to rinse and lubricate during the operation). The rectal stump retained 7-8 cm in abdominal cavity. The transanal ligation part of the protective sleeve was cut off, then the stapler nail seat was inserted and specimen was pull out through the sleeve and rectum. There were 30 males and 18 females. The average age was (64.5±14.1) years, the BMI was (25.4±3.9) kg/m2, the tumor diameter was (3.3±1.1) cm, the maximum diameter of specimen was (5.4±1.5) cm and the length of specimen was (18.6±4.3) cm. Among these 48 cases, specimens of 36 patients were pulled out through inside of the sleeve easily, while specimens of 12 patients were quite difficult with resistance. Of 12 cases, 7 needed the help of transverse forceps, 4 needed to make 1 cm incision in pull-through bowel and insert a suction to decrease the volume of large specimens with gathering of gas and fluid, and 1 received small abdominal incision to remove specimen and perform intestinal reconstruction due to big specimen (the diameter of tumor and mesentery was 7.5 cm). Specimen tears of 6 patients didn't result in dissemination thanks to the specimen protecting sleeve. The operation time was (113.2±76.1) min, the bleeding amount was (38.5±17.3) ml, the time to first oral intake was (47.9±4.4) h, and the postoperative hospitalization length was (8.5±1.7) d. Anastomotic leakage occurred in 1 case (2.1%). No intra-abdominal and trocar infection, and obstruction were found. The use of protective sleeve and the improvement of the method of intraperitoneal implantation can effectively reduce the abdominal contamination during the specimen extraction. It can be applied to big specimens as well.