Vein Division Research Articles

Comparative study of acute kidney injury in pararenal aortic aneurysm: open surgical versus endovascular repair.

Pararenal abdominal aortic aneurysms (PR-AAA), constituting around 15%-20% of AAA patients, are defined as having no neck between the aneurysm and the renal arteries. Due to an insufficient sealing zone, open surgical repair (OSR) is the gold standard, while EVAR is reserved for those unfit for surgery. Renal outcomes disturb long-term survival, and they have massive socioeconomic and quality of life implications, especially if patients require dialysis. This study aims to elucidate any difference between EVAR and OSR of PR-AAA, excluding suprarenal aneurysms, with specific emphasis on renal dysfunction over the short and long term. An existing database of PR-AAA between 2002 and 2023 was used to glean information regarding the therapeutic option used. Renal events were defined by the RIFLE criteria. Out of 1,563 aortic interventions, we identified 179 PR-AAA, of which 99 high-risk patients had an aortic neck of less than 10 mm with complete follow-up. We excluded patients with fenestrated EVAR (FEVAR), branched EVAR (BEVAR), or chimney EVAR (Ch-EVAR) and any patients requiring visceral artery reimplantation. In total, 63 patients underwent EVAR, and 36 required OSR. 17.46% of patients who underwent EVAR experienced acute kidney injury (AKI) compared with 36.11% of the OSR group (P = 0.037). The mean post-op creatinine for OSR was 109.88 µmol/L, and for EVAR was 127.06 µmol/L (P = 0.192). The mean difference between long-term (9-12 years) creatinine values in OSR was 14.29 µmol/L (P = 0.191), and the mean difference for EVAR was 25.05 µmol/L (P = 0.024). Furthermore, 27.8% of OSR patients who underwent Left Renal Vein Division and Ligation (LRVDL) experienced an AKI, while 50% who did not undergo LRVDL experienced an AKI (P = 0.382). Thirty-day morbidity in the EVAR group (20.97%) was significantly lower than in the OSR group (42.62%) (P = 0.022). Moreover, 3.17% in EVAR group and 7.14% in OSR group had aneurysm-related mortality (P = 0.584). The rate of renal events for OSR is higher, while the rate of endovascular renal events was lower. Our study shows that PR-AAA undergoing OSR may benefit from endovascular repair.

A real-world study evaluating the safety and utility of a two-row stapler reload on pulmonary vasculature.

Endoscopic staplers are common surgical devices used for the ligation and division of vasculature in thoracic procedures. When a stapler ligates and divides pulmonary vasculature, potentially catastrophic intraoperative bleeding at the staple-line may occur. The aim of this study was to confirm the safety and discuss the utility of a two-row stapler reload, by assessing the incidence of clinically necessary intraoperative hemostatic intervention when applied to pulmonary vasculature in real-world applications. This study was designed as a prospective non-comparative registry study conducted in seven centers across the United States, to confirm the safety and performance of Signia™ Small Diameter Reloads (SDR) when used for indicated thoracic surgical procedures. The primary endpoint was the incidence of hemostatic intervention related to the ligation and division of pulmonary arteries and veins. A five-point Likert scale scored hemostasis of each SDR staple-line. Secondary endpoints included the incidence of device-related only adverse events (AEs), device deficiencies, and procedure-related hospital readmission up to and including 30 days post operation. SDR was fired 302 times across pulmonary vasculature in 120 subjects. Three firings required clinically necessary hemostatic intervention for an intervention rate of 0.99% (3 of 302 firings). Moreover, 97.5% (117 of 120 subjects) had intact SDR staple-lines regardless of surgical access or stapler handle preference. Only 4 (3.3%) thoracoscopic and robotic procedures converted to open, but none were due to SDR staple-lines. There was no statistically significant difference between the Likert score of transected arteries compared to veins (P=0.61). There were no device deficiencies or device-only related AEs reported. In this study, the two-row stapler reloads demonstrated favorable safety and efficacy profiles when fired across hilar vessels in the thoracic space with a 99% hemostatic rate, independent of surgical access and stapler handle preference.

Division of the iliac vessels in the anterior intrapelvic approach to acetabular fracture

IntroductionThe modified Stoppa approach is gradually becoming the gold standard in pelvic ring and acetabulum surgery. One of the potential intraoperative complications is vascular injury. The aim of this study was to identify the level of division of common iliac vessels with respect to a bone landmark, their inter-individual variability and their correlation with morphological criteria. Material and methodsThis was a single-center continuous retrospective study of patients who had preoperative CT angiography for pelvic fracture between February 2017 and May 2018. The level of arterial and venous division and the angle of vein division were measured bilaterally for each patient from the most antero-inferior part of the sacroiliac joint on multiplanar reconstruction and standardized analysis. Relationships with morphological data (age, gender, BMI, height), anterior column fracture and deep venous thrombosis were analyzed. ResultsThe right arterial division level was 50±16mm (−2.35; 96) from the landmark and the left arterial division level 44±14mm (0; 80). The right venous division level was 30±12mm (−9; 75) and the left venous division level 30±13mm (−5; 66). The right venous bifurcation angle was 65±18° (22; 119) and the left venous bifurcation angle 68±17° (18; 117). The arterial division level was significantly higher on the right side (p=0.007). There were no significant correlations with morphological data. ConclusionThe great inter-individual variability of iliac vessels should prompt analysis of their morphology on routine imaging when planning pelvic surgery using the modified Stoppa approach, in order to anticipate the risk of bleeding. Level of evidenceIV; cases series.

The impact of vascular division sequence and epithelial-mesenchymal transition status on postoperative recurrence in lung adenocarcinoma.

The vascular division sequence in video-assisted thoracic surgery (VATS) lung resection is usually determined by the handling difficulty due to the limited surgical view through the scope. However, upfront pulmonary vein division is theoretically desirable to avoid tumor cells spreading by surgical manipulation. Epithelial-mesenchymal transition (EMT) is associated with poor prognosis and an increased number of circulating tumor cells. The purpose of this study is to evaluate the effect of vascular division sequence and EMT on postoperative recurrence. We retrospectively investigated tissue microarrays of 282 lung adenocarcinomas surgically resected between 2001 and 2007. We excluded the cases with segmentectomy, wedge resection, dissemination, insufficient material for staining, or lack of medical records. The effect of vascular division sequence and clinicopathologic factors on recurrence was evaluated in 195 cases. The upfront pulmonary vein division (V-first) was performed in 60 patients, and the upfront pulmonary artery division (A-first) was performed in 135 patients. The recurrence was observed in 67 patients (13 in V-first and 54 in A-first). Epithelial-mesenchymal transition activation was observed in 104 patients. Multivariable analysis with 195 patients revealed that lymph node metastasis and pleural invasion were risk factors for the recurrence. The stratified multivariable analysis showed that vascular division sequence (A-first) was a risk factor only in the EMT-negative group (91 patients). In the EMT-negative subset, the 5-year relapse-free survival rate was significantly lower in the A-first group than the V-first group (72.6% vs. 92.2%, p = 0.0136). The upfront pulmonary artery division might be a risk factor in patients without EMT activation.

FRI207 Challenges Of Pheochromocytoma Management In A Heart Failure Patient

Abstract Disclosure: M. Novitskaya: None. M. Sonbol: None. S. Jafri: None. J. Monye: None. E. Japp: None. Introduction: Successful management of pheochromocytoma in patients with heart failure requires a careful balance between blood pressure control and appropriate perioperative volume resuscitation. Clinical Case: A 38-year-old male with heart failure with reduced ejection fraction (EF 15-20%), HTN, and polysubstance use disorder presented with dyspnea and subsequent in-house PEA arrest. Whole body CT showed an incidental 7.3 cm left adrenal mass. Laboratory work-up was notable for elevated plasma free metanephrines 47.30 nmol/L (n<0.89) and normetanephrines 39.8 nmol/L (n<0.49). Medical management of presumed pheochromocytoma was initiated with doxazosin. Left and right heart catheterization showed elevated intracardiac filling pressures (mmHg): RA 10, RV 66/5 (12), PA 55/29 (43), PCWP 35. Subsequent coronary angiogram was aborted due to hypertensive emergency and flash pulmonary edema for which he required IV hydralazine 20 mg, furosemide 80 mg, labetalol 30 mg, verapamil 5 mg, nitroglycerin 800 mg bolus then gtt at 100 mcg/min to achieve hemodynamic stability. He reached the preoperative BP goal after up titration of doxazosin to 12 mg daily and carvedilol to 25 mg twice daily. He subsequently underwent left adrenalectomy. Intraoperatively, the patient’s abdomen was insufflated to 13 mmHg given his reduced EF, and he received 2 L crystalloid prior to adrenal vein division. After a left adrenalectomy, he developed hypotension despite receiving an additional 3 L crystalloid, and was started on norepinephrine, epinephrine, and vasopressin gtt. Postoperatively, he remained intubated for two days due to distributive shock. With continued diuresis, mean arterial pressure recovered to >65 mmHg and he was extubated. He was successfully discharged on metoprolol succinate 25 mg, spironolactone 25 mg and losartan 25 mg daily. Clinical Lessons: Preoperative management of pheochromocytoma involves alpha-adrenergic blockade followed by beta-adrenergic blockade to target a BP of <130/80. A high sodium diet is recommended after adequate alpha-adrenergic blockade, and volume resuscitation is started preoperatively due to vasodilation after adrenalectomy. Successful management of patients with pheochromocytoma and heart failure requires extra attention to BP and volume status. Our patient’s case was complicated by severe HTN during cardiac catheterization resulting in flash pulmonary edema, and postoperative hypotension requiring vasopressor support due to loss of circulating catecholamines. His estimated risk of morbidity/mortality from adrenalectomy was >25% due to these factors. Multidisciplinary collaboration among endocrinologists, cardiologists, anesthesiologists, surgeons, and perfusionists is crucial to optimize patient outcomes. This patient case adds to the literature in presenting a positive adrenalectomy outcome in a patient with heart failure. Presentation: Friday, June 16, 2023

Venous reconstruction thrombosis after pancreaticoduodenectomy with superior mesenteric/portal vein resection due to pancreatic cancer: an 8 years single institution experience

Background Superior mesenteric/portal vein reconstruction (SMPVR) thrombosis remains a challenging complication following pancreaticoduodenectomy concomitant with venous resection. In this context, we aimed to present our SMPVR experiences and identify potential clinicopathological factors that increased SMPVR thrombosis. Methods A total of 33 patients who underwent SMPVR during pancreaticoduodenectomy were analyzed. Of these, 26 patients who experienced pancreatic head ductal adenocarcinoma met our inclusion criteria. Patients’ data were compared as classified by SMPVR type and the development of SMPVR thrombosis. All interposition grafts were Dacron in this cohort. Results Types of SMPVR included: tangential resection with primary repair (n = 12); segmental resection with splenic vein preservation and either primary anastomosis (n = 8) or 14 mm tubular Dacron grafting (n = 1); segmental resection with splenic vein division either 14 mm tubular Dacron grafting (n = 2) or 14/7 mm ‘Y’–shaped Dacron grafting (n = 3). A total of four patients having 14/7 mm ‘Y’–shaped (n = 3) and 14 mm tubular Dacron (n = 1) developed SMPVR thrombosis (p = .001). Dacron grafting (p = .001) and splenic vein division (p = .010) were associated with SMPVR thrombosis. The median time to detection of SMPVR thrombosis was 4.3 months (2.5–21.0 months). The median follow-up time was 12.2 months (3.0–45 months). Conclusions During pancreaticoduodenectomy for pancreatic head ductal carcinoma, extended venous resection requiring SMPVR with ‘Y’–shaped and use of Dacron interposition grafts appeared to be associated with the development of SMPVR thrombosis. This result warrants further investigations.

A novel approach to quantifying surgical workflow in robotic-assisted lobectomy.

Understanding surgical workflow is critical for optimizing efficiencies and outcomes; however, most research evaluating workflow is impacted by observer subjectivity, limiting its reproducibility, scalability, and actionability. To address this, we developed a novel approach to quantitatively describe workflow within robotic-assisted lobectomy (RL). We demonstrate the utility of this approach by analysing features of surgical workflow that correlate with procedure duration. RL was deconstructed into 12 tasks by expert thoracic surgeons. Task start and stop times were annotated across videos of 10 upper RLs (5 right and 5 left). Markov Networks were used to estimate both the likelihood of transitioning from one task to another and each task-transition entropy (i.e. complexity). Associations between the frequency with which each task was revisited intraoperatively and procedure duration were assessed using Pearson's correlation coefficient. Entropy calculations identified fissure dissection and hilar node dissection as tasks with especially complex transitions, while mediastinal lymph node dissection and division of pulmonary veins were less complex. The number of transitions to three tasks significantly correlated with case duration (fissure dissection (R=0.69, p=0.01), dissect arteries (R=0.59, p=0.03), and divide arteries (R=0.63, p=0.03)). This pilot demonstrates the feasibility of objectively quantifying workflow between RL tasks and introduces entropy as a new metric of task-transition complexity. These innovative measures of surgical workflow enable detailed characterization of a given surgery and might indicate behaviour that impacts case progression. We discuss how these measures can serve as a foundation and be combined with relevant clinical information to better understand factors influencing surgical inefficiency.

Left Renal Vein Division during Open Surgical Repair for Abdominal Aortic Aneurysm May Cause Long-Term Kidney Remodeling

Left renal vein division (LRVD) is a maneuver performed during open surgical repair for abdominal aortic aneurysms. Even so, the long-term effects of LRVD on renal remodeling are unknown. Therefore, we hypothesized that interrupting the venous return of the left renal vein might cause renal congestion and fibrotic remodeling of the left kidney. We used a murine left renal vein ligation model with 8-week-old to 12-week-old wild-type male mice. Bilateral kidneys and blood samples were harvested postoperatively on days 1, 3, 7, and 14. We assessed the renal function and the pathohistological changes in the left kidneys. In addition, we retrospectively analyzed 174 patients with open surgical repairs between 2006 and 2015 to assess the influence of LRVD on clinical data. Temporary renal decline with left kidney swelling occurred in a murine left renal vein ligation model. In the pathohistological assessment of the left kidney, macrophage accumulation, necrotic atrophy, and renal fibrosis were observed. In addition, Myofibroblast-like macrophage, which is involved in renal fibrosis, was observed in the left kidney. We also noted that LRVD was associated with temporary renal decline and left kidney swelling. LRVD did not, however, impair renal function in long-term observation. Additionally, the relative cortical thickness of the left kidney in the LRVD group was significantly lower than that of the right kidney. These findings indicated that LRVD was associated with left kidney remodeling. Venous return interruption of the left renal vein is associated with left kidney remodeling. Furthermore, interruption in the venous return of the left renal vein does not correlate with chronic renal failure. Therefore, we suggest careful follow-up of renal function after LRVD.

Anatomical location of the surgically identifiable bladder branch of the inferior hypogastric plexus for nerve-sparing radical hysterectomy

ObjectiveWe aimed to demonstrate the entire structure of the inferior hypogastric plexus in the female pelvis focusing on surgically identifiable nerve bundles to the urinary bladder. MethodsSurgical videos of transabdominal nerve-sparing radical hysterectomy for 10 patients with cervical cancer at International Federation of Gynecology and Obstetrics (FIGO 2009) stage IB1–IIB were retrospectively analyzed. The paracervical tissue dorsal to the ureter was separated into the lateral component (dorsal layer of the vesicouterine ligament) and medial component (paracolpium) using Okabayashi’s technique. Any bundle-like structures in the paracervical area were isolated and divided using cold scissors, and each cut edge was inspected to determine whether the bundle was a blood vessel or a nerve. ResultsIn all cases, the surgically identifiable nerve bundle of the bladder branch was identified on the rectovaginal ligament running parallel and dorsal to the vaginal vein of the paracolpium. The bladder branch was revealed only after complete division of the vesical veins in the dorsal layer of the vesicouterine ligament where no definitive nerve bundles were observed. The bladder branch was derived laterally from the pelvic splanchnic nerve and medially from the inferior hypogastric plexus. ConclusionsThe surgical identification of the nerve bundle of the bladder branch is essential for a safe and secure nerve-sparing radical hysterectomy. The preservation of the surgically identifiable bladder branch from the pelvic splanchnic nerve as well as from the inferior hypogastric plexus can provide satisfactory postoperative voiding function.

274. AUTOMATED SURGICAL STEP RECOGNITION FOR ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY USING ARTIFICIAL INTELLIGENCE

Abstract More robot-assisted minimally invasive esophagectomy (RAMIE) procedures have been performed owing to three-dimensional field of view, image stabilization, and flexible joint function, however, both the surgeon, and surgical team require proficiency. Therefore, assessing the surgical learning curve and determining the surgical difficulty are essential for reducing complications. This study aimed to establish an artificial intelligence (AI)-based automated surgical phase recognition system for RAMIE by analyzing robotic surgical videos and evaluate the learning curve. This study enrolled 31 patients who underwent RAMIE. We annotated the videos into the following nine surgical phases, namely preparation, lower mediastinal dissection, upper mediastinal dissection, azygos vein division, subcarinal lymph node dissection (LND), right recurrent laryngeal nerve (RLN) LND, left RLN LND, esophageal transection, and post-dissection to completion of surgery to train the AI for automated phase recognition. We divided all patients into two groups, namely early period (20 patients) and late period (11 patients), after which the relationship between the surgical phase duration and learning curve was assessed. Frames were extracted from each video at a rate of one frame per second (fps), with an average of 14517 ± 4770 frames per video, which were used to train and test the AI model. Four-fold cross validation was applied to evaluate the performance of the present model. The AI had an accuracy of 84%. The preparation (p = 0.012), post-dissection to completion of surgery (p = 0.003), and ‘no step’ (p < 0.001) phases predicted by the AI were significant shorter in the late period than in the early period. We established an automated surgical phase recognition system for RAMIE using deep learning. Specific phase durations were significantly associated with surgeons’ learning curve, and similar tendencies were observed on phase durations predicated by the AI. Our AI-based system can be useful for not only education or OR efficiency but also evaluating surgical skill.

Automated Surgical-Phase Recognition for Robot-Assisted Minimally Invasive Esophagectomy Using Artificial Intelligence.

Although a number of robot-assisted minimally invasive esophagectomy (RAMIE) procedures have been performed due to three-dimensional field of view, image stabilization, and flexible joint function, both the surgeons and surgical teams require proficiency. This study aimed to establish an artificial intelligence (AI)-based automated surgical-phase recognition system for RAMIE by analyzing robotic surgical videos. This study enrolled 31 patients who underwent RAMIE. The videos were annotated into the following nine surgical phases: preparation, lower mediastinal dissection, upper mediastinal dissection, azygos vein division, subcarinal lymph node dissection (LND), right recurrent laryngeal nerve (RLN) LND, left RLN LND, esophageal transection, and post-dissection to completion of surgery to train the AI for automated phase recognition. An additional phase ("no step") was used to indicate video sequences upon removal of the camera from the thoracic cavity. All the patients were divided into two groups, namely, early period (20 patients) and late period (11 patients), after which the relationship between the surgical-phase duration and the surgical periods was assessed. Fourfold cross validation was applied to evaluate the performance of the current model. The AI had an accuracy of 84%. The preparation (p = 0.012), post-dissection to completion of surgery (p = 0.003), and "no step" (p < 0.001) phases predicted by the AI were significantly shorter in the late period than in the early period. A highly accurate automated surgical-phase recognition system for RAMIE was established using deep learning. Specific phase durations were significantly associated with the surgical period at the authors' institution.

Left Renal Vein Division for Juxtarenal Aortic Exposure: Influence on Renal Function and Role of the Communicating Lumbar Vein

Left Renal Vein Division for Juxtarenal Aortic Exposure: Influence on Renal Function and Role of the Communicating Lumbar Vein

High inguinal microsurgical denervation of the spermatic cord for chronic scrotal content pain for pediatric patients

ABSTRACT Introduction Microsurgical denervation of the spermatic cord (MDSC) has been demonstrated to be an effective treatment for men with chronic scrotal content pain (CSCP) in adult but not for pediatric patients. Objective The purpose of this study was to investigate the effectiveness and safety, including testicular development, of MDSC for pediatric patients less than 15 years old. Methods A retrospective review of 10 patients who underwent MDSC was performed. A 3-cm transverse incision was made at the middle of the inguinal canal. Macroscopically identified nerves were transected, and the internal surface of the inguinal canal was ablated by bipolar cautery. Under an operating microscope, all the components of spermatic cord were transected, except for the testicular artery, lymphatics, vas system. A 0-10 visual analogue scale (VAS) was compared with pre- and post-MDSC at 12 months. Testicular volume measured by punched-out orchidometer and endocrinological examination was evaluated pre- and post-MDSC at least 12 months. Results The average patient age was 12.7 years (range from 10 to 15 years old). The mean duration of symptoms before surgery was 10 months. The mean operative time was 47 minutes. The mean post-VAS was significantly reduced as compared with pre-VAS (2.1 and 8.7, respectively, p&amp;lt;0.0001). There was no testicular atrophy or scrotal edema. Negative responses to spermatic cord block, depressive symptoms (as screened by the Beck Depression Inventory), and multiple sites of pain were predictors of MDSC failure (p&amp;lt;0.05). Conclusions For both adult and pediatric patients, high inguinal MDSC for CSCP is an effective easier to perform, as it requires fewer divisions of veins and is associated with a larger diameter of the spermatic artery. It also enables complete resection of the nerves, including the nerves running outside the spermatic cord, resulting in high success rates. Disclosure Work supported by industry: no.

Left Renal Vein Division for Juxtarenal Aortic Exposure: Influence on Renal Function and Role of the Communicating Lumbar Vein

BackgroundIn this study, we evaluate the outcome of renal function in patients undergoing juxtarenal abdominal aortic aneurysm repair with or without division of the left renal vein with special focus on the role of the communicating lumbar vein.MethodsA retrospective analysis of prospectively collected data of 110 patients undergoing elective juxtarenal abdominal aortic aneurysm repair between 2000 and 2018 was performed.The demographic characteristics and comorbidities were reviewed in detail and the renal function was analysed pre- and post-operatively. The cohort of patients was split into group A (left renal vein divided) and B (left renal vein mobilised). Group A was further sub-analysed regarding the presence of a communicating lumbar vein on preoperative imaging data (group A+ = vein present, group A− = no communicating lumbar vein present).ResultsThe patients were matched well regarding their demographic characteristics and comorbidities. In the analysis of renal function, no statistically significant difference could be detected between group A and B. In the sub-analysis of group A, the group with a communicating lumber vein (group A+) turned out to have a significantly better renal function in the long term (sCrea 0.87 vs. 1.51; p = 0.016).ConclusionLigation of the left renal vein is a safe procedure in surgery of juxtarenal aortic aneurysms regarding the outcome of the renal function. A communicating lumbar vein between the left renal vein and the left ascending lumbar vein seems to play a key role to provide venous drainage after division of the left renal vein.

Concomitant splenic artery ligation has no preventive effect on left-sided portal hypertension following pancreaticoduodenectomy with the resection of the portal and superior mesenteric vein confluence for pancreatic ductal adenocarcinoma.

BackgroundLeft‐sided portal hypertension (LSPH) caused by splenic vein (SV) division in pancreaticoduodenectomy (PD) with portal vein (PV) resection remains challenging. The current study aimed to investigate the efficacy of splenic artery (SA) ligation in preventing LSPH.MethodsOne‐hundred thirty patients who underwent PD with PV resection for pancreatic ductal adenocarcinoma were classified into SV and SA preservation (SVP, n = 30), SV resection and SA preservation (SVR, n = 59), and SV resection and SA ligation (SAL, n = 41). The postoperative incidence of LSPH was assessed.ResultsThe incidence of variceal formation in SVP, SVR, and SAL were 4.8%, 53.2%, and 46.4% at 3 mo, 13.0%, 71.2%, and 62.5% at 6 mo, and 25.0%, 87.5%, and 87.1% at 12 mo, respectively. The rate was significantly higher in SVR at 3 and 6 mo (P = .001 and P < .001, respectively) and in SVR and SAL (P < .001) at 12 mo. Variceal hemorrhage occurred only in SVR (n = 4). The platelet count ratio at 3, 6, and 12 mo began to significantly decrease from 3 mo in SVR (0.77, 0.67, and 0.60, respectively; P < .001) and 6 mo in SAL (0.91, 0.73, and 0.69, respectively; P < .001). The spleen volume ratio also showed significant increase from 3 mo in SVR (1.24, 1.34, and 1.42, respectively; P < .001) and 6 mo in SAL (1.31, 1.32, and 1.34, respectively; P < .001). SVR and SAL were significant risk factors for variceal formation at 12 mo (odds ratio, 21.0 and 20.3, respectively).ConclusionIn PD with PV resection, SAL delayed LSPH but could not prevent its occurrence.

Application of "suction-guided stapling" during uniportal thoracoscopic major lung resection.

Uniportal thoracoscopic major pulmonary resection is used worldwide as a minimally invasive surgery. Occasionally, it is difficult to insert a stapler smoothly during uniportal thoracoscopic major pulmonary resection because of limited angulation. To address this challenge, we used "suction-guided stapling" to divide the bronchus or pulmonary vein. Here, we provide details of this technique, including division of the pulmonary veins or bronchus in a video. In addition, we validate this technique by showing perioperative results of uniportal thoracoscopic major pulmonary resections in our department.

A Modified Technique of Laparoscopic Lateral Lymph Node Dissection Combining Fascia-Oriented Dissection and Routine Upfront Distal Visceral Vessels Ligation for Mid- to Low-Lying Rectal Cancer.

Lateral pelvic recurrence can be a cause of local failure after surgery for low rectal cancer. Lateral lymph node dissection is often performed in East Asia for patients with enlarged lateral lymph nodes or because of the presence of risk factors. However, the outcomes of the conventional lateral lymph node dissection are unsatisfactory, with a considerably high local recurrence rate for patients with positive lateral nodes. Here, we introduce a modified technique to improve lateral nodes clearance. This modified technique has 4 key steps: 1) separation of the ureterohypogastric nerve fascia medially, 2) identification of the visceral pelvic fascia and dissection along the inferior vesical or vaginal veins down to the pelvic floor, 3) division of the distal ends of visceral vessels according to the orientation of ureterohypogastric nerve fascia and visceral pelvic fascia for better nerve preservation, and 4) en bloc dissection through a lateral approach over the surfaces of the sacral plexus and piriformis muscle to reveal the course of distal internal iliac vessels before the division of visceral veins. Twenty-nine patients underwent laparoscopic lateral lymph node dissection successively with no conversion. The median blood loss for each lateral procedure was 37.5 mL (range, 0-300.0 mL). Eleven lateral nodes (median; range, 1-22 lateral nodes) were harvested for each lateral side. There was no perioperative mortality, and 4 patients developed major complications (Clavien-Dindo III-IV). This modified technique characterized by the routine division of visceral vessels based on ureterohypogastric nerve fascia and visceral pelvic fascia is feasible and safe. It provides good lymph node harvest, autonomic nerve preservation, and improved bleeding control. Additional investigation is warranted to evaluate the safety, functional outcomes, and oncologic outcomes.

Infant En Bloc Lung Transplantation

•The en bloc double lung transplantation technique involves only three anastomosis, reducing cardiopulmonary bypass times and theoretically reducing graft ischemic times. •In our Institution, the en bloc double lung transplantation is the preferred technique for infant population, with favorable outcomes. Only a handful of highly specialized transplant centers across the world are performing pediatric lung transplantation. Growing experience with sequential bilateral transplants has resulted in improved outcomes and it has mostly replaced the en bloc double lung transplant technique. In our institution, however, we preferentially adopted this technique for the infant population and we have noted favorable outcomes with this approach. Median sternotomy and dissection of the aorta, aortopulmonary window and right pulmonary artery is performed. The trachea is exposed between the aorta and the superior vena cava. The lungs are mobilized and the hilar structures are isolated extrapericardially. The pericardium is opened on both sides and pleuropericardial windows are developed. The recipient is cannulated at the ascending aorta, superior vena cava and IVC. Each lung is removed sequentially with the division of the pulmonary veins, pulmonary arteries, and main bronchi all extrapericardially. The donor right and the left lungs are prepared and passed into the respective hemithoraces through their respective pericardial windows. The donor distal trachea is then taken into the posterior mediastinum between the superior vena cava and aortic arch and suture anastomosed with recipient trachea. The recipient main pulmonary artery is divided just proximal to its bifurcation and main pulmonary artery to main pulmonary artery end to end anastomosis is carried out. An oblique atriotomy is made between the ligated stumps of the right and left pulmonary veins, and extended into the left atrial appendage. The donor left atrial cuff is anastomosed to this atriotomy. The lungs are slowly reinflated and ventilated. Only a handful of highly specialized transplant centers across the world are performing pediatric lung transplantation. Growing experience with sequential bilateral transplants has resulted in improved outcomes and it has mostly replaced the en bloc double lung transplant technique. In our institution, however, we preferentially adopted this technique for the infant population and we have noted favorable outcomes with this approach. Median sternotomy and dissection of the aorta, aortopulmonary window and right pulmonary artery is performed. The trachea is exposed between the aorta and the superior vena cava. The lungs are mobilized and the hilar structures are isolated extrapericardially. The pericardium is opened on both sides and pleuropericardial windows are developed. The recipient is cannulated at the ascending aorta, superior vena cava and IVC. Each lung is removed sequentially with the division of the pulmonary veins, pulmonary arteries, and main bronchi all extrapericardially. The donor right and the left lungs are prepared and passed into the respective hemithoraces through their respective pericardial windows. The donor distal trachea is then taken into the posterior mediastinum between the superior vena cava and aortic arch and suture anastomosed with recipient trachea. The recipient main pulmonary artery is divided just proximal to its bifurcation and main pulmonary artery to main pulmonary artery end to end anastomosis is carried out. An oblique atriotomy is made between the ligated stumps of the right and left pulmonary veins, and extended into the left atrial appendage. The donor left atrial cuff is anastomosed to this atriotomy. The lungs are slowly reinflated and ventilated.

Detection of circulatory disturbance after pulmonary vein division during a living donor lobectomy.

Indocyanine green (ICG) is widely used during thoracic surgery to enhance visualization, allowing assessment of the intersegmental plane based on intrapulmonary blood flow (Travis et al. in Ann Thorac Surg 108(2):363-369, 2019; Seshiru et al. in Gen Thorac Cardiovasc Surg 66(2):81-90, 2018). Using ICG to detect blood flow disruption after lung resection, however, has not been addressed. We therefore report a case in which the left lingular pulmonary vein was incidentally divided during left lower lobectomy in a living-lung donor. Intraoperative ICG-enhanced near-infrared fluoroscopic imaging to assess intrapulmonary blood flow detected the problem. We thus avoided potential postoperative residual lung complications in this patient.

CT findings after left renal vein division during abdominal aortic surgery.

The rationale behind left renal vein division (LRVD) is the assumption that adequate collateral draining channels will develop. To describe computed tomography (CT) findings after LRVD during aortic surgery. Among 61 consecutive patients who underwent LRVD during aneurysm repair or revascularization for aortic occlusive disease between January 2003 and December 2017, 51 patients (40 men, mean age 71.4 ± 8.4 years) were enrolled. Contrast-enhanced CT images were analyzed to evaluate collateral drainage, patency, left renal vein diameter, and left renal parenchymal thickness. A total of 115 radiologic reports were reviewed to check whether these findings were accurately mentioned. The median time period of the first postoperative follow-up CT was 36 days (range 7-1351 days). The gonadal vein (n = 47) was the most common collateral draining channel, followed by the retroperitoneal veins (n = 42) and adrenal vein (n = 33). Thrombosis occurred in five patients between postoperative days 7 and 17 in the remnant renal vein (n = 3), remnant renal vein plus gonadal and adrenal veins (n = 1), and gonadal vein (n = 1). There was a significant decrease in renal vein diameter (-0.48 ± 2.12 mm, P = 0.006). There was no significant difference in parenchymal thickness (-0.25 ± 1.27 mm, P = 0.193). Neither LRVD nor any associated findings were correctly stated on radiologic reports. Postoperative contrast-enhanced CT can delineate collateral draining channels and complications following LRVD. However, these findings tend to be either missed or misinterpreted.