Video Article Research Articles

Surgical Ablation Assay for Studying Eye Regeneration in Planarians.

In the study of adult stem cells and regenerative mechanisms, planarian flatworms are a staple in vivo model system. This is due in large part to their abundant pluripotent stem cell population and ability to regenerate all cell and tissue types after injuries that would be catastrophic for most animals. Recently, planarians have gained popularity as a model for eye regeneration. Their ability to regenerate the entire eye (comprised of two tissue types: pigment cells and photoreceptors) allows for the dissection of the mechanisms regulating visual system regeneration. Eye ablation has several advantages over other techniques (such as decapitation or hole punch) for examining eye-specific pathways and mechanisms, the most important of which is that regeneration is largely restricted to eye tissues alone. The purpose of this video article is to demonstrate how to reliably remove the planarian optic cup without disturbing the brain or surrounding tissues. The handling of worms and maintenance of an established colony is also described. This technique uses a 31 G, 5/16-inch insulin needle to surgically scoop out the optic cup of planarians immobilized on a cold plate. This method encompasses both single and double eye ablation, with eyes regenerating within 1-2 weeks, allowing for a wide range of applications. In particular, this ablation technique can be easily combined with pharmacological and genetic (RNA interference) screens for a better understanding of regenerative mechanisms and their evolution, eye stem cells and their maintenance, and phototaxic behavioral responses and their neurological basis.

Anterior Approach for Ankle Arthrodesis.

End-stage ankle arthritis may be treated successfully with either an ankle arthrodesis or arthroplasty. Both surgical interventions have demonstrated success with regard to pain relief and function. Ankle arthrodesis is indicated for patients with recalcitrant ankle pain despite appropriate nonoperative intervention. Patients who have a history of posttraumatic arthritis from a high-energy injury, soft-tissue compromise, limited range of motion, or deformity may be superior candidates for arthrodesis. The surgical technique can be undertaken with either an open or an arthroscopic approach. An open anterior approach with an anatomic precontoured locking plate is ideal for patients with deformity and/or bone loss. Additionally, the use of a precontoured plate assists with achieving a neutral alignment in both the coronal and the sagittal plane, which is critical to the long-term success of the procedure. No hardware, however, substitutes for appropriate surgical technique, which is the focus of this video article. The procedure includes the following steps:An anterior extensile incision is made immediately lateral to the anterior tibial tendon, extending to the level of the talonavicular joint.Dissection is taken with care to avoid the superficial peroneal nerve in the distal aspect of the incision. The extensor retinaculum is incised either longitudinally or in a z-shaped fashion to facilitate closure.Deep dissection may be taken through the sheath of the anterior tibial tendon, which substantially decreases the risk of injury to the deep neurovascular bundle. Alternatively, dissection may be taken through the extensor hallucis longus (EHL) to avoid violation of the anterior tibial tendon sheath. The neurovascular bundle is directly posterior to the EHL at the level of the ankle joint.The ankle joint is exposed, with the removal of tibial and talar osteophytes.The joint surfaces are prepared.The precontoured ankle arthrodesis plate, which is used to improve alignment, is positioned and placed.Compression is achieved using the "Achilles tension band technique," which furthers compression through the ankle.An additional transarticular screw is placed. The expected outcome of the procedure, based on recent clinical outcomes, is osseous union, and the rate of union has been reported to range from 91% to 96%. Improvement in function and pain relief are associated with a successful arthrodesis. Despite a slow deterioration of functional outcomes and radiographic progression of arthritis, clinical improvement with a high rate of patient satisfaction has been noted at a mean of 9 years postoperatively.

LERLIC-MS/MS for In-depth Characterization and Quantification of Glutamine and Asparagine Deamidation in Shotgun Proteomics.

Characterization of protein deamidation is imperative to decipher the role(s) and potentialities of this protein posttranslational modification (PTM) in human pathology and other biochemical contexts. In order to perform characterization of protein deamidation, we have recently developed a novel long-length electrostatic repulsion-hydrophilic interaction chromatography-tandem mass spectrometry (LERLIC-MS/MS) method which can separate the glutamine (Gln) and asparagine (Asn) isoform products of deamidation from model compounds to highly complex biological samples. LERLIC-MS/MS is, therefore, the first shotgun proteomics strategy for the separation and quantification of Gln deamidation isoforms. We also demonstrate, as a novelty, that the sample processing protocol outlined here stabilizes the succinimide intermediate allowing its characterization by LERLIC-MS/MS. Application of LERLIC-MS/MS as shown in this video article can help to elucidate the currently unknown molecular arrays of protein deamidation. Additionally, LERLIC-MS/MS provides further understanding of the enzymatic reactions that encompass deamidation in distinct biological backgrounds.

LERLIC-MS/MS for In-depth Characterization and Quantification of Glutamine and Asparagine Deamidation in Shotgun Proteomics

Characterization of protein deamidation is imperative to decipher the role(s) and potentialities of this protein posttranslational modification (PTM) in human pathology and other biochemical contexts. In order to perform characterization of protein deamidation, we have recently developed a novel long-length electrostatic repulsion-hydrophilic interaction chromatography-tandem mass spectrometry (LERLIC-MS/MS) method which can separate the glutamine (Gln) and asparagine (Asn) isoform products of deamidation from model compounds to highly complex biological samples. LERLIC-MS/MS is, therefore, the first shotgun proteomics strategy for the separation and quantification of Gln deamidation isoforms. We also demonstrate, as a novelty, that the sample processing protocol outlined here stabilizes the succinimide intermediate allowing its characterization by LERLIC-MS/MS. Application of LERLIC-MS/MS as shown in this video article can help to elucidate the currently unknown molecular arrays of protein deamidation. Additionally, LERLIC-MS/MS provides further understanding of the enzymatic reactions that encompass deamidation in distinct biological backgrounds.

Pericardial patch graft repair of severe localized scleral thinning encountered during strabismus surgery

This article presents a surgical technique using a pericardial patch for the permanent repair of severe scleral thinning encountered during strabismus surgery. In the present case scleral thinning resulted from buckle removal. Familiarity with this technique may prove important for the strabismus surgeon treating patients with a history of surface ocular hardware or disease-induced scleral thinning. This video article may be viewed atjaapos.org.

The dynamics of signal complex formation mediating germling fusion in Neurospora crassa

Colony initiation of filamentous fungi commonly involves fusion of germinating vegetative spores. Studies in Neurospora crassa revealed an unusual cell-cell communication mechanism mediating this process, in which the fusion partners coordinately alternate between two physiological stages, probably related to signal sending and receiving. This “cell dialog” involves the alternating, oscillatory recruitment of the SO protein and the MAK-2 MAP kinase module to the apical plasma membrane of growing fusion tips. In this review video article, we show the dynamics of the fluorescent labeled proteins SO and MAK-2 and provide an animated graphical model of the “cell dialog” process.

Deceased donor uterine transplantation

To share our experience in performing the first-ever deceased-donor uterine transplant in the United States. This video uses an animation and footage from a uterine transplantation procedure to review the steps and techniques involved in performing a uterine transplant. Academic, multisite medical center. A reproductive-age patient with Mayer-Rokitansky-Kuster-Hauser syndrome. Transplantation of a viable uterus from a deceased donor. Assessment of posttransplantation uterine graft viability. This video article describes the essential steps in the uterine transplant process, including selecting an appropriate donor with no history of infertility or uterine malformations. Furthermore, a deceased donor should exhibit brain death but not cardiac death. We also review our inclusion criteria for suitable recipients. In this video we outline the key steps in a uterine transplantation procedure and demonstrate footage from an actual transplant procedure. These steps include establishing bilateral end-to-side vascular anastomoses between the donor uterine artery and vein and the recipient's external iliac vessels. Once this has been completed and reperfusion noted of the donor uterus, connection to the recipient vaginal cuff is then performed. Uterine transplantation, although currently experimental, has gained the potential to become the first true treatment for uterine factor infertility. This procedure can become a promising option for the approximately 1.5 million women worldwide for whom pregnancy is not possible because of the absence of the uterus or presence of a nonfunctional uterus. Deceased donor uterine transplantation will further serve to broaden accessibility for this procedure.

Subtalar Arthrodesis for Post-Traumatic Subtalar Arthritis

Subtalar arthrodesis is currently the mainstay treatment option for the management of recalcitrant subtalar arthrosis. Arthrosis is a degenerative joint condition that results in a painful, functionally-impaired joint. In the subtalar joint, this typically follows trauma to the hindfoot resulting in talus or calcaneus fractures in particular. Although anatomic reduction of these injuries reduces the chance of later complications, arthrosis is reported even following anatomical repairs. The goal of the fusion in this circumstance is to remove a painful joint. A broad range of both congenital and acquired foot conditions include subtalar arthrodesis as part of their management strategy. This video article details the methods and techniques involved in subtalar arthrodesis. After an Ollier approach was used to expose the subtalar joint, the subchondral plates were prepared by inserting an autogenous bone graft. Finally, compression was achieved by two lag screws. The process of obtaining an autogenous bone graft from the proximal tibia using a bone harvesting device is also illustrated, and opinions and expectations on the future direction of the management of this arthritic joint condition are discussed.

VIDEO: Preoperative CT Angiography for Anterolateral Thigh Flap Reconstructions.

This video article will review the relevant vascular anatomy of the anterolateral thigh flap, describe the CT angiography (CTA) image acquisition, and describe how to report the locations of the perforating arteries along with characteristics that may be important to the surgeon. Our method of performing and reporting CTA for patients scheduled to undergo anterolateral thigh flap reconstruction provides a reproducible method of identifying perforating vessels and communicating their location to surgeons.

Extended Left Hemihepatectomy with Reconstruction of The Right Liver Vein in a Patient with an Intrahepatic Cholangiocellular Carcinoma

Extended left hemihepatectomy (left trisectionectomy) with resection of liver segments 1, 2, 3, 4 a/b, 5 and 8 is a challenging procedure. In well-selected patients, the indication for this procedure may offer the chance of curative resection for primary or secondary liver tumours in complicated locations. Morbidity and mortality are increased compared to non-extended liver resections. This procedure requires precise imaging and accurate surgical planning in due consideration of the remaining liver volume and additional factors such as preliminary damage of the liver parenchyma caused by chemotherapy or fibrosis/cirrhosis. Left trisectionectomy is necessary in tumours affecting either the middle and left hepatic vein or the blood vessels of the liver hilum to the left and middle liver sector. The procedure necessitates the preservation of the right hepatic vein and the portal-venous and arterial branches supplying segments 6 and 7, as well as the bile ducts of these segments. This video article illustrates the surgical procedure of extended left hemihepatectomy performed due to an intrahepatic cholangiocellular carcinoma, which centrally surrounds the left and middle hepatic vein and potentially infiltrates the right hepatic vein. This condition requires the tangential resection and reconstruction of the right hepatic vein.

Transanal approach for intersphincteric resection of rectal cancer in a patient with a huge prostatic hypertrophy

The gold standard of surgical technique for rectal cancer is total mesorectal excision (TME). Laparoscopic TME has been proven to provide surgical safety and oncological outcomes equivalent to open TME. However, dissection of the lower rectum has some inherent difficulties related to a narrow pelvic space. The challenge of TME in the lower rectum was confirmed by the Colorectal Cancer Laparoscopic or Open Resection (COLOR) II trial showing a 9% positive circumferential margin (CRM) rate in laparoscopic TME and a 22% positive CRM rate in open TME. Recently, transanal TME has attracted intense attention as a promising alternative to laparoscopic TME. In this video article, we show the performance of a transanal approach for intersphincteric resection (ISR) of rectal cancer in a patient with a huge prostatic hypertrophy.

Fu-Chan Wei-Surgeon, Innovator, and Leader of the Legendary Chang Gung Microsurgery Center.

Fu-Chan Wei is a world-renowned plastic and reconstructive surgeon. He is clearly one of the most influential and innovative surgeons in the history of plastic surgery. The Taiwanese legend is the innovator of the osteoseptocutaneous fibula flap, which revolutionized the reconstruction of composite bone and soft tissue defects in the jaw and extremities. He has pioneered several perforator flaps, including the free style variety. He has taken toe-to-hand microsurgical transplantation to a whole new level. He is not only recognized for his surgical skills and clinical innovations, but also for his vision, leadership, and teaching. The establishment and development of the famous Microsurgery Center at Chang Gung Memorial Hospital is unparalleled anywhere. The international fellowship program in microsurgery there remains the envy of all microsurgical trainees. Dr. Wei and his colleagues have trained and influenced more than 1,500 surgeons from all over the world. The aim of this video article is to share what we learned by interviewing Fu-Chan Wei at Chang Gung. The story of Fu Chan Wei, his colleagues, and the development of the Microsurgery Center in Taiwan is worth knowing.

Hysteroscopic morcellator to overcome cervical stenosis

To report a step-by-step technique to using a hysteroscopic morcellator to safely gain access into the intrauterine cavity in two patients with severe cervical stenosis and concomitant intrauterine pathology. Video article introducing the hysteroscopic morcellator for overcoming severe cervical stenosis. Academic-based practice. A 36-year-old G0 female with primary infertility and uterine polyps and a 34-year-old G0 female with uterine polyps and a difficult trial transfer before undergoing an IVF cycle. In both patients, preoperative saline-infused sonography revealed submucosal filling defects and severe cervical stenosis. A hysteroscopic technique using the Hologic Myosure to overcome severe cervical stenosis with or without the use of intraoperative ultrasound. Despite using preoperative Cytotec, cervical stenosis was identified. Under direct visualization, a 4-mm Myosure XL blade was placed through a 7.25-mm Myosure XL hysteroscopy. The cutter blade, powered by an electromechanical drive system, enables simultaneous rotation and reciprocation. The blade allows one to shave and remove tissue and is applied to cervical stenosis, allowing safe access into the intrauterine cavity. The intrauterine hysteroscopic Myosure morcellator allowed for safe and direct entry into the uterine cavity. We have since applied this technique to all patients where cervical stenosis is identified and have minimized potential uterine perforation and false tracks in our patients. Our technique is an alternative method for overcoming severe cervical stenosis and minimizing potential intraoperative complications.

Laparoscopic radical antegrade modular pancreatosplenectomy.

Although laparoscopic distal pancreatectomy is widely accepted for benign or borderline malignant pancreatic diseases, its application for pancreatic ductal adenocarcinoma (PDAC) remains controversial. Several recent reports have shown that laparoscopic surgery, for the treatment of PDAC, is associated with similar postoperative complications and survival outcomes compared with open surgery, and offers several advantages, particularly shorter hospital stay and less blood loss. However, potential risk of bias cannot be excluded because these results were obtained in retrospective studies. More importantly, it is unclear whether the extent of surgical resection is comparable between laparoscopic and open distal pancreatectomy. The aim of this video article is to show the technical feasibility of laparoscopic surgery to reproduce open radical antegrade modular pancreatosplenectomy (RAMPS) in terms of the extent of surgical resection.

PRS Global Open's Evolution: Logo, Growth, and Mission.

PRS Global Open's Evolution: Logo, Growth, and Mission.

Patella navigation in computer-assisted TKA : Intraoperative measurement of patellar kinematics. Video article

Patellofemoral maltracking is arelevant problem after total knee arthroplasty (TKA). Patella navigation is atool that allows real time monitoring of patella tracking. This video contribution demonstrates the technique of patellofemoral navigation and apossible consequence of intraoperative monitoring. Ahigher postoperative lateral tilt is addressed with awidening of the lateral retinaculum in aparticular manner. In selected cases of patellofemoral problems, patella navigation is ahelpful tool to evaluate patellofemoral tracking intraoperatively. Modifications of implant position and soft tissue measurements can then prevent postoperative patellofemoral maltracking.

Surgical Reduction and Fixation of Tibial Spine Fractures in Children: Multiple Fixation Strategies.

A tibial spine fracture is an osseous avulsion of the anterior cruciate ligament (ACL) from its attachment on the intercondylar tibial eminence. Most commonly affecting the immature skeletal systems of children between 8 and 14 years old, tibial spine fractures are frequently regarded as the pediatric equivalent to adult midsubstance ACL injuries. While all nondisplaced and selected partially displaced fractures can be treated nonoperatively, surgical fixation is most frequently used for completely displaced tibial spine fractures. The goals of surgery include osseous union, restoration of knee stability, return to function, treatment of associated injuries, and restoration of the range of motion. Current evidence has demonstrated equivalent outcomes for open and arthroscopic reduction strategies, as well as for screw-based and suture-based fixation techniques. The surgeon should be prepared to offer a multitude of fixation techniques based on intraoperative findings that will provide stable anatomic reduction, including, for instance, the use of suture-based fixation in comminuted fragments. This video article demonstrates an arthroscopic procedure to repair a tibial spine fracture, including 3 methods of fixation, in the following major steps: (1) preoperative planning, (2) patient positioning and surgical exposure, (3) evacuation of the hemarthrosis, (4) diagnostic arthroscopy, (5) preparation of the fracture fragment, (6) reduction of the fracture fragment, (7) fixation option 1: screw fixation, (8) fixation option 2: suture anchor, (9) fixation option 3: suture, and (10) dynamic assessment of stability and closure. Excellent functional outcomes using this procedure have been documented and, with appropriate postoperative care that includes range-of-motion exercises beginning as early as 1 to 2 weeks postoperatively, patients are expected to recover function and to resume a normal activity level. Complications, including nonunion, malunion, and arthrofibrosis, can be reduced when patients with completely displaced tibial spine fractures are treated with surgical management.

Laparoscopic management of diaphragmatic endometriosis by three different approaches

To report our three surgical approaches in the management of diaphragmatic endometriosis. Video article presenting laparoscopic surgical techniques, with and without robotic assistance. University hospital. Nulliparas with deep endometriosis associated with multiple endometriosis lesions of the diaphragm. Laparoscopic approach in women who present with small black-pigmented diaphragmatic lesions, with or without infiltration of the diaphragm, which are ablated using plasma energy. Robotic-assisted laparoscopic route in larger deep infiltrating implants, which are resected. To avoid phrenic nerve injury, robotic-assisted thoracoscopy is preferred in large lesions involving the central tendon of the diaphragm. The steps of each technique are emphasized. Surgical technique reports in anonymous patients are exempted from ethical approval by the Institutional Review Board. Seven patients have been managed by these procedures from July 2015 to March 2016. Patients' functional outcomes were uneventful, with no phrenic nerve palsy or residual chest and right shoulder pain. By combining resection and ablation techniques, the laparoscopy and thoracoscopy route, conventional and robotic-assisted minimally invasive approach, we offer a surgical strategy that is as conservative as possible, with an aim to limit postoperative adhesions between the liver and the diaphragm, and avoid diaphragmatic paralysis.

Mini-laparoscopic sacrocolpopexy for apical and posterior female pelvic organ prolapse.

Mini-laparoscopic surgery is the future for most laparoscopic procedures. Although already applied in some gynaecological surgical interventions, this video is to our knowledge the first publication on the use of the mini-laparoscopic approach to sacrocolpopexy for apical and posterior pelvic organ prolapse following total hysterectomy. The concept of mini-laparoscopic sacrocolpopexy presented in this video article was performed on 12 women with post-hysterectomy apical and posterior pelvic organ prolapse using mini-laparoscopic instruments and ports of 3mm in diameter combined with a 12-mm umbilical port. Surgery was performed with the same principles as for the conventional laparoscopic procedure. The mean operating time was 70min (SD ± 12). The tensile strength of the mini-laparoscopic instruments allowed appropriate manipulation of tissue consistent with that of conventional instruments. No difficulties or complications were experienced in comparison to a conventional technique. All patients were discharged from hospital on day1 postoperatively. The effectiveness, safety and feasibility of the mini-laparoscopic surgical technique was applied to sacrocolpopexy. Because of the initial favourable experience, the mini-laparoscopic sacrocolpopexy could become more widely used in the future.

Creation of a Radial-Cephalic Arteriovenous Fistula

Watch this full-length and narrated video article where Dr. Nahel Elias at MGH treats a patient with progressive renal failure by AV fistula creation for the purposes of aiding in renal replacement therapy. Supplemented by text article and animation.