We thank the anaesthesiologists and operating room nurses who assisted with the operation.

This protocol follows the guidelines of the human research ethics committee of the Sixth Affiliated Hospital, Sun Yat-sen University. Written informed consent was obtained from the patients for performing this study.
NOTE: A 48-year-old female patient presented with an incidental finding of a 3.0 cm x 2.5 cm asymptomatic mass in the head of the pancreas. The patient&#39;s clinical history showed a healthy status. Endoscopic ultrasound (EUS) showed a cystic lesion of the pancreatic head.
1. Preoperative workup
<ol>
	<li>Determine the surgical approach based on the computed tomography (CT) scan to determine the extent of the tumor and any abnormal vasculature, see Figure 1.</li>
	<li>Check for contraindications carefully. 
	NOTE: There are relative contraindications to LDPPHR, including tumors in the portal vein or superior mesenteric vein that need vascular reconstruction, as well as previous major abdominal surgery with possible complications. It depends on preoperative imaging diagnosis and intraoperative diagnosis of vascular invasion. The preoperative enhanced CT and MR imaging are valuable.</li>
</ol>
2. Anesthesia
<ol>
	<li>Apply the antibiotic (2 g of Ceftriaxone sodium) 30 min before the surgery to prevent infection. Puncture and catheterize the radial artery (catheter size, 20 G) and a central venous (catheter size, 8 Fr) under ultrasound guidance. 
	NOTE: The amount of anesthesia administered differs greatly among patients, primarily dependent on individual characteristics such as age and other medical factors.</li>
</ol>
3. Surgical technique
<ol>
	<li>Operation setting
	<ol>
		<li>Position the patient in a reverse Trendelenburg position with the head elevated 30&#176; and legs split apart, see Figure 2.</li>
		<li>Set the standing position as depicted in Figure 2. Use a 5-port technique to perform the procedure. 
		NOTE: The first surgeon is on the right side, the second surgeon is on the left side, and the first assistant stands between the patient&#39;s legs, respectively.</li>
		<li>Place the sub-umbilical 10 mm trocar and then four trocars along a semi-circular plane after creating the pneumoperitoneum. Place two 10 mm trocars to the left and right of the umbilicus and two 10 mm trocars four fingers subcostal to the left and right in the anterior axillary line, see Figure 2.</li>
	</ol>
	</li>
	<li>Exploration phase
	<ol>
		<li>Exclude peritoneal and liver metastases using diagnostic laparoscopy as a routine step. Explore the anterior abdominal wall, the surface of abdominal viscera, pelvic cavity, and the surface of abdominal viscera, the mesentery and the small intestine and stomach and adjacent structures, and the omental bursa in order.
		<ol>
			<li>Ensure that the exploration follows a specific sequence, usually from top to bottom, first examining solid organs before hollow ones, starting with the abdominal cavity followed by the pelvic cavity.</li>
			<li>Conduct a comprehensive examination of all abdominal organs, such as the liver, spleen, stomach, intestines, mesentery, peritoneum, uterus, and adnexa. Simultaneously, perform a focused examination on suspicious areas of pathology.</li>
			<li>Utilize non-traumatic graspers to gradually inspect the intestinal tract, progressing in approximately 5 cm segments per examination from the duodenal suspensory ligament to the ileocecal region and repeating the process in the opposite direction. Ensure that the examination encompasses both the intestinal tract and mesentery.</li>
		</ol>
		</li>
		<li>Retract the ligament to the ventral abdominal wall by placing a straight needle transcutaneously in the epigastric region around the Teres ligament.</li>
	</ol>
	</li>
	<li>Dissection phase
	<ol>
		<li>Suspend the transverse colon enteric fat over the liver falciform ligament to expose the infracolic compartment (see Figure 3A).</li>
		<li>Make an incision in front of the duodenum&#39;s transverse mesocolon to expose the pancreatic head using an ultrasonic scalpel (see Figure 3B).</li>
		<li>Expose the infracolic compartment between the transverse colon and the pancreatic head, fully free the superior mesenteric vein (SMV) from the uncinate process of the pancreas, and transect its tributary using clips (see Figure 3C).</li>
		<li>Dissect the inferior margin of the uncinate process of the pancreas using an ultrasonic scalpel, and pull up the margin of the uncinate process of the pancreas to expose the sub pancreaticoduodenal vessels branch into the uncinate process of the pancreas and transect them using clips (see Figure 3D).</li>
		<li>Restore the transverse colon position and section the gastrocolic ligament to expose the pancreas behind the stomach. Position the patient&#39;s head low and right upside. Suspend the stomach body over the liver falciform ligament to set free it from the pancreas using a red urine catheter and a clip (see Figure 3E).</li>
		<li>Expose the common hepatic artery (CHA) and gastroduodenal artery (GDA) (see Figure 3F). Removed the pancreas from the medial side of the duodenal ring and anterior superior pancreaticoduodenal artery (ASPDA), and ligate and detach the branches of ASPDA into the uncinate process of the pancreas using a clip.</li>
		<li>Cut off the peritoneum at the lower margin of the pancreatic head, ligate, and detach the right gastroepiploic vein. Flip the uncinate process of the pancreas to the head side to expose the SMV to transect the pancreatic neck with Harmonic scissors in front of the SMV. 
		NOTE: The cystic tumor was found behind the uncinate process of the pancreas (see Figure 3G).</li>
		<li>Detach the pancreatic head from the right and dorsal edges of the SMV. Then, detach the upper part to expose the distal CBD.</li>
		<li>Perform dissection along the left and dorsal margins of the common bile duct (CBD) to expose and safeguard the posterior superior pancreatic duodenal artery (PSPDA) (see Figure 3H). This artery originates from the GDA and extends its branches into the distal CBD and the ampulla of Vater. Severe the anterior superior pancreatic duodenal artery (ASPDA) to facilitate deeper dissection.</li>
		<li>Dissect, ligate, and cut off the main pancreatic duct to the ampulla finally using an ultrasonic scalpel (see Figure 3I).</li>
	</ol>
	</li>
	<li>Reconstruction phase
	<ol>
		<li>Transect the jejunum at a distance of 20 cm from the distal Treinz ligament for pancreatojejunal anastomosis and jejunal anastomosis.</li>
		<li>Insert an external ventricular drainage catheter after identifying the main pancreatic duct. Perform an end-to-side pancreaticojejunostomy (duct-to-mucosa) (see Figure 3J) and side-to-side jejunojejunostomy.</li>
		<li>Place the specimen inside a bag and remove it through a 5 cm incision on the lower abdomen. Place two drainage catheters near the pancreaticojejunostomy and the CBD and bring them out through two trocar port sites. 
		NOTE: The texture at the pancreatic stump is quite tough, so we perform an end-to-side pancreaticojejunostomy to reduce the risk of pancreatic fistula. The diameter of drainage catheters with side holes is 1.5 cm.</li>
	</ol>
	</li>
</ol>

<ol>
	<li>Mihaljevic, A. L., Kleeff, J., Friess, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Beger's+operation+and+the+Berne+modification:+Origin+and+current+results.">Beger's operation and the Berne modification: Origin and current results.</a> J Hepatobiliary Pancreat Sci. 17 (6), 735-744 (2010).</li><li>Beger, H. G., Schlosser, W., Friess, H. M., B&#252;chler, M. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Duodenum-preserving+head+resection+in+chronic+pancreatitis+changes+the+natural+course+of+the+disease:+A+single-center+26-year+experience.">Duodenum-preserving head resection in chronic pancreatitis changes the natural course of the disease: A single-center 26-year experience.</a> Ann Surg. 230 (4), 512-519 (1999).</li><li>D'haese, J. G., Ceyhan, G. O., Demir, I. E., Tieftrunk, E., Friess, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+options+in+painful+chronic+pancreatitis:+A+systematic+review.">Treatment options in painful chronic pancreatitis: A systematic review.</a> HPB (Oxford). 16 (6), 512-521 (2014).</li><li>Beger, H. G., Rau, B. M., Gansauge, F., Poch, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Duodenum-preserving+subtotal+and+total+pancreatic+head+resections+for+inflammatory+and+cystic+neoplastic+lesions+of+the+pancreas).">Duodenum-preserving subtotal and total pancreatic head resections for inflammatory and cystic neoplastic lesions of the pancreas).</a> J Gastrointest Surg. 12 (6), 1127-1132 (2008).</li><li>Beger, H. G., B&#252;chler, M., Bittner, R. R., Oettinger, W., Roscher, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Duodenum-preserving+resection+of+the+head+of+the+pancreas+in+severe+chronic+pancreatitis.+Early+and+late+results.">Duodenum-preserving resection of the head of the pancreas in severe chronic pancreatitis. Early and late results.</a> Ann Surg. 209 (3), 273-278 (1989).</li><li>Beger, H. G., Nakao, A., Mayer, B., Poch, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Duodenum-preserving+total+and+partial+pancreatic+head+resection+for+benign+tumors--systematic+review+and+meta-analysis.">Duodenum-preserving total and partial pancreatic head resection for benign tumors--systematic review and meta-analysis.</a> Pancreatology. 15 (2), 167-178 (2015).</li><li>Cao, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+duodenum-preserving+total+pancreatic+head+resection:+A+novel+surgical+approach+for+benign+or+low-grade+malignant+tumors.">Laparoscopic duodenum-preserving total pancreatic head resection: A novel surgical approach for benign or low-grade malignant tumors.</a> Surg Endosc. 33 (2), 633-638 (2019).</li><li>Loomba, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Randomized,+controlled+trial+of+the+fgf21+analogue+pegozafermin+in+nash.">Randomized, controlled trial of the fgf21 analogue pegozafermin in nash.</a> N Engl J Med. 389 (11), 998-1008 (2023).</li><li>Lu, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+duodenum-preserving+pancreatic+head+resection+with+real-time+indocyanine+green+guidance+of+different+dosage+and+timing:+Enhanced+safety+with+visualized+biliary+duct+and+its+long-term+metabolic+morbidity.">Laparoscopic duodenum-preserving pancreatic head resection with real-time indocyanine green guidance of different dosage and timing: Enhanced safety with visualized biliary duct and its long-term metabolic morbidity.</a> Langenbecks Arch Surg. 407 (7), 2823-2832 (2022).</li><li>Huang, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Real-time+fluorescence+imaging+with+indocyanine+green+during+laparoscopic+duodenum-preserving+pancreatic+head+resection.">Real-time fluorescence imaging with indocyanine green during laparoscopic duodenum-preserving pancreatic head resection.</a> Pancreatology. , (2023).</li><li>Hong, D., Cheng, J., Wu, W., Liu, X., Zheng, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=How+to+perform+total+laparoscopic+duodenum-preserving+pancreatic+head+resection+safely+and+efficiently+with+innovative+techniques.">How to perform total laparoscopic duodenum-preserving pancreatic head resection safely and efficiently with innovative techniques.</a> Ann Surg Oncol. 28 (6), 3209-3216 (2021).</li><li>Zhou, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+duodenum-preserving+pancreatic+head+resection:+A+case+report.">Laparoscopic duodenum-preserving pancreatic head resection: A case report.</a> Medicine (Baltimore). 95 (32), 4442 (2016).</li><li>Alvarado-Bachmann, R., Choi, J., Gananadha, S., Hugh, T. J., Samra, J. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+infracolic+approach+to+pancreatoduodenectomy+for+large+pancreatic+head+tumours+invading+the+colon.">The infracolic approach to pancreatoduodenectomy for large pancreatic head tumours invading the colon.</a> Eur J Surg Oncol. 36 (12), 1220-1224 (2010).</li><li>Diener, M. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Duodenum-preserving+pancreatic+head+resection+versus+pancreatoduodenectomy+for+surgical+treatment+of+chronic+pancreatitis:+A+systematic+review+and+meta-analysis.">Duodenum-preserving pancreatic head resection versus pancreatoduodenectomy for surgical treatment of chronic pancreatitis: A systematic review and meta-analysis.</a> Ann Surg. 247 (6), 950-961 (2008).</li><li>Beger, H. G., Mayer, B., Poch, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Duodenum-preserving+pancreatic+head+resection+for+benign+and+premalignant+tumors-a+systematic+review+and+meta-analysis+of+surgery-associated+morbidity.">Duodenum-preserving pancreatic head resection for benign and premalignant tumors-a systematic review and meta-analysis of surgery-associated morbidity.</a> J Gastrointest Surg. 27 (11), 2611-2627 (2023).</li><li>Chen, X., Chen, W., Zhang, Y., An, Y., Zhang, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Short-term+outcomes+of+laparoscopic+duodenum-preserving+total+pancreatic+head+resection+compared+with+laparoscopic+pancreaticoduodenectomy+for+the+management+of+pancreatic-head+benign+or+low-grade+malignant+lesions.">Short-term outcomes of laparoscopic duodenum-preserving total pancreatic head resection compared with laparoscopic pancreaticoduodenectomy for the management of pancreatic-head benign or low-grade malignant lesions.</a> Med Sci Monit. 26, e927248 (2020).</li><li>Takada, T., Yasuda, H., Amano, H., Yoshida, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+duodenum-preserving+and+bile+duct-preserving+total+pancreatic+head+resection+with+associated+pancreatic+duct-to-duct+anastomosis.">A duodenum-preserving and bile duct-preserving total pancreatic head resection with associated pancreatic duct-to-duct anastomosis.</a> J Gastrointest Surg. 8 (2), 220-224 (2004).</li><li>Li, X. L., Gong, L. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preoperative+3d+reconstruction+and+fluorescent+indocyanine+green+for+laparoscopic+duodenum+preserving+pancreatic+head+resection:+A+case+report.">Preoperative 3d reconstruction and fluorescent indocyanine green for laparoscopic duodenum preserving pancreatic head resection: A case report.</a> World J Clin Cases. 11 (4), 903-908 (2023).</li><li>Vlek, S. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Biliary+tract+visualization+using+near-infrared+imaging+with+indocyanine+green+during+laparoscopic+cholecystectomy:+Results+of+a+systematic+review.">Biliary tract visualization using near-infrared imaging with indocyanine green during laparoscopic cholecystectomy: Results of a systematic review.</a> Surg Endosc. 31 (7), 2731-2742 (2017).</li><li>Cai, Y., Zheng, Z., Gao, P., Li, Y., Peng, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+duodenum-preserving+total+pancreatic+head+resection+using+real-time+indocyanine+green+fluorescence+imaging.">Laparoscopic duodenum-preserving total pancreatic head resection using real-time indocyanine green fluorescence imaging.</a> Surg Endosc. 35 (3), 1355-1361 (2021).</li></ol>

The authors report no conflict of interest.

LDPPHR only removes the diseased pancreatic head while preserving the duodenum, stomach, jejunum, common bile duct, and gallbladder that need to be removed in Whipple surgery. Compared to pancreaticoduodenectomy (PD) and pylorus-preserving pancreaticoduodenectomy (PPPD), LDPPHR showed enhancements in mid- and long-term results encompassing hospital stay duration, quality of life, post-surgery recovery, and maintenance of exocrine function5,14. DPPHR only removes ...

In 1972, Prof. Berger first proposed the duodenum-preserving pancreatic head resection (DPPHR) and Roux-en-Y pancreatic-enteral reconstruction as a treatment for chronic pancreatitis1. DPPHR has become the primary surgical treatment for benign lesions of the pancreatic head due to its low incidence of postoperative complications and mortality, as well as its ability to maintain the endocrine and exocrine functions of the pancreas and high remission rate of abdominal pain2,3,4. DPPHR only removes the diseased pancreatic head while preserving the duodenum, stomach, jejunum, common bile duct, and gallbladder that need to be removed in Whipple surgery, resulting in minimal damage and high postoperative quality of life3,5.
Laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has made significant progress in the last decade and is gradually replacing duodenum-preserving pancreatic head resection (DPPHR)6,7. The key to this surgical procedure is to ensure the blood supply of the duodenum and bile duct in order to avoid damage to the duodenum and bile duct, as well as duodenal necrosis and stenosis or atresia of the bile duct caused by ischemia7,8.&#160;A few experienced medical centers have reported LDPPHR9,10,11. As maintaining the integrity of the duodenum and biliary system and preserving complex blood supplies are necessary, the surgical procedure is challenging. It is essential to be very familiar with the special anatomical relationship between the pancreatic head and the duodenum while implementing LDPPHR, which is a difficult surgery that requires stronger surgical skills and psychological qualities.
Previous studies have proved that preserving the integrity of both anterior and posterior pancreaticoduodenal arterial arcades, as well as only preserving the posterior collateral branches of the arteries, will not cause duodenal ischemic necrosis11,12. Some surgeons preserve a thin layer of pancreatic tissue adhering to the common bile duct to avoid ischemia of the bile duct and duodenum but increase the incidence of pancreatic fistula13. In this study, the inferior infracolic approach was chosen for LDPPHR due to the patient with a thin mesenteric fat layer. By taking advantage of the amplification of the 3D laparoscopy, we successfully removed the pancreas from the lateral wall of the common bile duct (CBD) and the medial side of the duodenal ring without intraoperative fluorescence image guidance. This approach ensured the integrity of the vascular arch and reduced intraoperative blood loss, thereby minimizing the risk of pancreatic fistula.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>3D Laparoscope</td>
			<td>STORZ</td>
			<td>TC200,TC302</td>
			<td></td>
		</tr>
		<tr>
			<td>Cisatracurium Besylate Injection</td>
			<td>Hengrui Pharma</td>
			<td>H20183042</td>
			<td></td>
		</tr>
		<tr>
			<td>Drainage catheters</td>
			<td>Jiangsu YUBANG MED-DEVICE</td>
			<td>YB-B-III</td>
			<td></td>
		</tr>
		<tr>
			<td>Harmonic ACE Ultrasonic Surgical Devices</td>
			<td>Ethicon Endo-Surgery</td>
			<td>HAR36</td>
			<td></td>
		</tr>
		<tr>
			<td>Ligating Clips</td>
			<td>Teleflex Medical</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Nacrotrend anaesthesia monitoring system</td>
			<td>Monitor Technik</td>
			<td>Bad Bramsted</td>
			<td></td>
		</tr>
		<tr>
			<td>Trocar</td>
			<td>Ethicon Endo-Surgery</td>
			<td>10 mm</td>
			<td></td>
		</tr>
	</tbody>
</table>

laparoscopic duodenum-preserving pancreatic head resection via inferior infracolic approach: a surgical approach for benign lesions

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic pancreatoduodenectomy (LPD), laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has not yet obtained wide acceptance. This could be attributed to the technical challenges involved in preserving the blood supply of the duodenum and bile duct.
This study describes and demonstrates all the steps of LDPPHR. A 48-year-old woman was diagnosed with a 3.0 cm x 2.5 cm pancreatic head cystic mass, which was detected unexpectedly. The surgery was performed using the 3D laparoscopy via an inferior infracolic approach. The operation lasted approximately 310 min with 100 mL of blood loss. Postoperatively, the patient experienced no complications and was discharged 5 days later. Pathology revealed intraductal papillary mucinous neoplasms.
LDPPHR via an inferior infracolic approach is feasible and safe when performed by experienced surgeons in selected patients with thin mesenteric fat layers. The described technique for LDPPHR via inferior infracolic approach should be well standardized and performed at high-volume centers with experienced surgeons in both open and laparoscopic pancreatology.

The patient&#39;s total pancreatic head, including the cystic tumor, was removed in 3 h with 100 mL of blood loss. The pancreatojejunal (PJ) anastomosis and jejunal anastomosis were completed in 60 min after the pancreatic head was removed from the body. The entire recovery period after surgery went smoothly, with no signs of postoperative pancreatic fistula. The amylase levels in both drains on postoperative day 3 were 1373 U/L and 804 U/L, respectively, but decreased to normal levels by day 5 when the drains were remov...

Read this Scientific Article Protocol about Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions at JoVE.com

Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

This article provides a whole technical process of laparoscopic duodenum-preserving pancreatic head resection via an inferior infracolic approach. This is a surgical approach for benign tumors without intraoperative fluorescence image guidance.

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic ...

laparoscopic-duodenum-preserving-pancreatic-head-resection-via

Research

JoVE Journal

Medicine

282 Views.  The Sixth Affiliated Hospital of Sun Yat-sen University. Per iniziare, eseguire un esame laparoscopico addominale e sospendere il grasso enterico del colon trasverso sopra il legamento falciforme del fegato per esporre il compartimento infrasonico. Con un bisturi a ultrasuoni, praticare un'incisione nella parte anteriore del mesocolon trasverso del duodeno per esporre la testa del pancreas. Successivamente, esporre il compartimento infracolico tra il colon trasverso e la testa pancreatica e liberare completamente la vena mesenterica superiore dal p...

Video: Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

A Novel Surgical Approach for Intratracheal Administration of Bioactive Agents in a Fetal Mouse Model

Prenatal pulmonary delivery of cells, genes or pharmacologic agents could provide the basis for new therapeutic strategies for a variety of genetic and acquired diseases. Apart from congenital or inherited abnormalities with the requirement for long-term expression of the delivered gene, several non-inherited perinatal conditions, where short-term gene expression or pharmacological intervention is sufficient to achieve therapeutic effects, are considered as potential future indications for this kind of approach. Candidate diseases for the application of short-term prenatal therapy could be the transient neonatal deficiency of surfactant protein B causing neonatal respiratory distress syndrome1,2 or hyperoxic injuries of the neonatal lung3. Candidate diseases for permanent therapeutic correction are Cystic Fibrosis (CF)4, genetic variants of surfactant deficiencies5 and &alpha;1-antitrypsin deficiency6.
Generally, an important advantage of prenatal gene therapy is the ability to start therapeutic intervention early in development, at or even prior to clinical manifestations in the patient, thus preventing irreparable damage to the individual. In addition, fetal organs have an increased cell proliferation rate as compared to adult organs, which could allow a more efficient gene or stem cell transfer into the fetus. Furthermore, in utero gene delivery is performed when the individual's immune system is not completely mature. Therefore, transplantation of heterologous cells or supplementation of a non-functional or absent protein with a correct version should not cause immune sensitization to the cell, vector or transgene product, which has recently been proven to be the case with both cellular and genetic therapies7.
In the present study, we investigated the potential to directly target the fetal trachea in a mouse model. This procedure is in use in larger animal models such as rabbits and sheep8, and even in a clinical setting9, but has to date not been performed before in a mouse model. When studying the potential of fetal gene therapy for genetic diseases such as CF, the mouse model is very useful as a first proof-of-concept because of the wide availability of different transgenic mouse strains, the well documented embryogenesis and fetal development, less stringent ethical regulations, short gestation and the large litter size.
Different access routes have been described to target the fetal rodent lung, including intra-amniotic injection10-12, (ultrasound-guided) intrapulmonary injection13,14 and intravenous administration into the yolk sac vessels15,16 or umbilical vein17. Our novel surgical procedure enables researchers to inject the agent of choice directly into the fetal mouse trachea which allows for a more efficient delivery to the airways than existing techniques18.

We developed a novel surgical approach for intratracheal administration of bioactive agents into the mouse fetus. The delivery route is more efficient in targeting the fetal mouse lungs than the commonly used intra-amniotic injection. This procedure has to date not been described in a mouse model.

Prenatal pulmonary delivery of cells, genes or pharmacologic agents could provide the basis for new therapeutic strategies for a variety of genetic and ...

The Mouse Round-window Approach for Ototoxic Agent Delivery: A Rapid and Reliable Technique for Inducing Cochlear Cell Degeneration

Investigators have utilized a wide array of animal models and investigative techniques to study the mammalian auditory system. Much of the basic research involving the cochlea and its associated neural pathways entails exposure of model cochleae to a variety of ototoxic agents. This allows investigators to study the effects of targeted damage to cochlear structures, and in some cases, the self-repair or regeneration of those structures. Various techniques exist for delivery of ototoxic agents to the cochlea. When selecting a particular technique, investigators must consider a number of factors, including the induction of inadvertent systemic toxicity, the amount of cochlear damage produced by the surgical procedure itself, the type of lesion desired, animal survivability, and reproducibility/reliability of results. Currently established techniques include parenteral injection, intra-peritoneal injection, trans-tympanic injection, endolymphatic sac injection, and cochleostomy with perilymphatic perfusion. Each of these methods has been successfully utilized and is well described in the literature; yet, each has various shortcomings. Here, we present a technique for topical application of ototoxic agents directly to the round window niche. This technique is non-invasive to inner ear structures, produces rapid onset of reliably targeted lesions, avoids systemic toxicity, and allows for an intra-animal control (the contra-lateral ear). Results stemming from this approach have helped deeper understanding of auditory pathophysiology, cochlear cell degeneration, and regenerative capacity in response to an acute injury. Future investigations may use this method to conduct interventional studies involving gene therapy and stem cell transplantation to combat hearing loss.

Various methods exist for introducing ototoxic agents to the cochleae of animal models. Presented is a surgical protocol for delivery of ototoxic agents to the round window niche. The procedure is reliable, creates targeted intra-cochlear lesions, and avoids mechanical damage to the microarchitecture. Examination of cochlear self-repair/regeneration is possible.

Investigators have utilized a wide array of animal models and investigative techniques to study the mammalian auditory system. Much of the basic research ...

Surgical Approach for Middle Cerebral Artery Occlusion and Reperfusion Induced Stroke in Mice

Stroke is a leading cause of death worldwide and continues to be one of the major causes of long-term adult disabilities. About 87% of strokes are ischemic in origin and occur in the territory of the middle cerebral artery (MCA). Currently the only Food and Drug Administration (FDA) approved drug for the treatment of this devastating disease is tissue plasminogen activator (tPA). However, tPA has a small therapeutic window for administration (3 - 6 hr), and is only effective in 4% of the patients who actually receive it. Current research focuses on understanding the pathophysiology of stroke in order to find potential therapeutic targets. Thus, reliable models are crucial, and the MCA occlusion (MCAo) model (also termed the intraluminal filament or suture model) is deemed to be the most clinically relevant surgical model of ischemic stroke, and is fairly non-invasive and easily reproducible. Typically the MCAo model is used with rodents, especially with mice due to all the genetic variations available for this species. Here we describe (and present in the video) how to successfully perform the MCAo model (with reperfusion) in mice to generate reliable and reproducible data.

In order to understand the pathophysiology of stroke, it is important to use reliable models. This paper will describe one of the most frequently used stroke models in mice, termed the middle cerebral artery occlusion (MCAo) model (also termed the intraluminal filament or suture model) with reperfusion.

Stroke is a leading cause of death worldwide and continues to be one of the major causes of long-term adult disabilities. About 87% of strokes are ...

Posterior Semicircular Canal Approach for Inner Ear Gene Delivery in Neonatal Mouse

Inner ear gene therapy offers great promise as a potential treatment for hearing loss and dizziness. One of the critical determinants of the success of inner ear gene therapy is to find a delivery method which results in consistent transduction efficiency of targeted cell types while minimizing hearing loss. In this study, we describe the posterior semicircular canal approach as a viable method for inner ear gene delivery in neonatal mice. We show that gene delivery through the posterior semicircular canal is able to perfuse the entire inner ear. The easy anatomic identification of the posterior semicircular canal, as well as minimal manipulation of the temporal bone required, make this surgical approach an attractive option for inner ear gene delivery.

In this study, we describe the posterior semicircular canal approach as a reliable method for inner ear gene delivery in neonatal mice. We show that gene delivery through the posterior semicircular canal is able to perfuse the entire inner ear.

Inner ear gene therapy offers great promise as a potential treatment for hearing loss and dizziness. One of the critical determinants of the success of ...

Designing CAD/CAM Surgical Guides for Maxillary Reconstruction Using an In-house Approach

Computer-aided design/computer-assisted manufacturing (CAD/CAM) is now being evaluated as a preparative technique for maxillofacial surgery. Because this technique is expensive and available in only limited areas of the world, we developed a novel CAD/CAM surgical guide using an in-house approach. By using the CAD software, the maxillary resection area and cutting planes and the fibular cutting planes and angles are determined. Once the resection area is decided, the necessary faces are extracted using a Boolean modifier. These superficial faces are united to fit the surface of the bones and thickened to stabilize the solids. Not only the cutting guides for the fibula and maxilla but also the location arrangement of the transferred bone segments is defined by thickening the superficial faces. The CAD design is recorded as .stl files and three-dimensionally (3-D) printed as actual surgical guides. To check the accuracy of the guides, model surgery using 3-D-printed facial and fibular models is performed. These methods may be used to assist surgeons where commercial guides are not available.

Methods for designing a computer-aided design/computer-aided manufacturing (CAD/CAM) surgical guide are shown. Cutting planes are separated, united, and thickened to easily visualize the necessary bone transfer. These designs can be three-dimensional printed and checked for accuracy.

Computer-aided design/computer-assisted manufacturing (CAD/CAM) is now being evaluated as a preparative technique for maxillofacial surgery. Because this ...

Orthotopic Rat Kidney Transplantation: A Novel and Simplified Surgical Approach

Kidney transplantation offers increased survival rates and improved quality of life for patients with end-stage renal disease, as compared to any type of renal replacement therapy. Over the past few decades, the rat kidney transplantation model has been used to study the immunological phenomena of rejection and tolerance. This model has become an indispensable tool to test new immunomodulatory pharmaceuticals and regimens prior to proceeding with expensive preclinical large animal studies.
This protocol provides a detailed overview of how to reliably perform orthotopic kidney transplantation in rats. This protocol includes three distinctive steps that increase the probability of success: perfusion of the donor kidney by flushing through the portal vein and the use of a cuff system to anastomose the renal veins and ureters, thereby decreasing cold and warm ischemia times. Using this technique, we have achieved survival rates beyond 6 months with normal serum creatinine in animals with syngeneic or tolerant kidney transplants. Depending on the aim of the study, this model can be modified by pre- or posttransplant treatments to study the acute, chronic, cellular, or antibody-mediated rejection. It is a reproducible, reliable, and cost-effective animal model to study different aspects of kidney transplantation.

The purpose of this manuscript and protocol is to explain and demonstrate in detail the surgical procedure of orthotopic kidney transplantation in rats. This method is simplified to achieve the correct perfusion of the donor kidney and shorten the reperfusion time by using the venous and ureteral cuff anastomosis technique.

Kidney transplantation offers increased survival rates and improved quality of life for patients with end-stage renal disease, as compared to any type of ...

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota&#39;s fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota&#8217;s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (&#62;1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota&#8217;s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...

The Microscopic Transcanal Approach in Stapes Surgery Revisited

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the external auditory canal, the middle ear, and epitympanon. Such an approach avoids a retroauricular or endaural skin incision; however, working through a narrow space needs angled microsurgical instruments and specific training in otologic surgery. The transcanal approach restricts the working space; however, it offers a binocular microscopic vision into the middle ear without extended skin incisions and thus, reducing post-operative pain and bleeding. In addition, this minimally invasive approach avoids scar tissue complications, hypoesthesia of the auricle, and potential protrusion of the pinna. Despite its numerous advantages, this method is still not routinely performed by otologic surgeons. Since this minimally invasive technique is more challenging, there is a need for extensive training in order for it to be widely adopted by otologic surgeons. This article provides step-by-step surgical instructions for stapes surgery and reports possible indications, pitfalls, and limitations using this microscopic transcanal technique.

This article describes the microscopic transcanal technique for stapes surgery, providing step-by-step surgical instructions for familiarizing surgeons with this approach.

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the ...

Step-by-Step Stapedotomy through Transcanal Exclusive Endoscopic Approach

In recent years there has been an increasing trend in the use of the endoscope to treat a variety of middle ear pathologies, including otosclerosis. Several studies comparing traditional microscopic and endoscopic stapes surgery have reported similar hearing results and an overall low rate of complications. The endoscope has unraveled its full potential in demanding settings of stapes surgery, such as unfavorable anatomy of the oval window niche or revision cases. Reduced manipulation of the chorda tympani and low rate of post-operative dysgeusia are further benefits to mention for endoscopic stapes surgery.
Being a one-handed technique, management of bleeding, positioning, and crimping of the prosthesis may be challenging for novice endoscopic surgeons, so some training in endoscopic ear surgery is recommended before performing endoscopic stapedotomy. The problem of sharing the surgical field between the endoscope and the operating instruments could be easily overcome if proper instruments positioning is understood. One-handed bleeding control in the narrow space of the ear canal may represent an issue during the elevation of the tympano-meatal flap, possibly discouraging the surgeon since the preliminary steps of surgery. Following appropriate technique to raise the flap and the collaboration with the anesthesiology team in keeping the blood pressure low guarantee an adequate bleeding control in most cases.
The aim of this article is to describe the entire surgical procedure of a transcanal exclusive endoscopic stapedotomy, from operating room set up and patient positioning to post-operative care. A step-by-step description of the surgical maneuvers with technical hints is reported, to guide the surgeon across the procedure and allow any ear surgeon to perform stapes surgery endoscopically.

The aim of this article is to provide a step-by-step method for endoscopic stapes surgery from operating room setting and patient positioning to post-operative care. This work would represent a guide for any otologic surgeon who is willing to treat otosclerosis with endoscopic transcanal technique.

In recent years there has been an increasing trend in the use of the endoscope to treat a variety of middle ear pathologies, including otosclerosis. ...

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope.
The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

With advancements in laparoscopic techniques, laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been widely recognized. However, owing to several technical difficulties in this procedure, the artery-first approach in L-RAMPS still remains uncommon. Here, we developed the dorsal-caudal artery approach for L-RAMPS, which might be safe and beneficial for pancreatic neck tumors.

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who ...