The learning curve for modified hand-assisted retroperitoneoscopic living donor nephrectomy.

BACKGROUND: We aimed to introduce our modified hand-assisted retroperitoneoscopic living donor nephrectomy (HARPLDN) technique and define the learning curve. METHODS: One hundred thirty-eight kidney donors who underwent modified HARPLDN by the same surgeon between May 2015 and March 2022 were included. A cumulative sum (CUSUM) learning curve analysis was performed with the total operation time as the study outcome. RESULTS: In total, the mean operative time was 138.2 ± 32.1 min. The median warm ischemic time (WIT) and estimated blood loss were 90 s and 50 ml, respectively. The learning curve for the total operative time was best modeled as a second-order polynomial with the following equation: CUSUMOT (min) = (-0.09 case number2) + (12.88 case number) - 67.77 (R2 = 0.7875; p<0.05). The CUSUM learning curve included the following three unique phases: phase 1 (the initial 41 cases), representing the initial learning curve; phase 2 (the middle 43 cases), representing expert competence; and phase 3 (the final 54 cases), representing mastery. The overall 6-month graft survival rate was 99.3%, with 94.9% immediate onset of graft function without delayed graft function and 0.7% ureteral complications. CONCLUSIONS: Our modified method is safe and effective for living donor nephrectomy and has the advantages of a shorter operating time and optimized WIT. The surgeon can become familiar with the modified HARPLDN after 41 cases and effectively perform the next 97 cases.

Ultrasound-assisted minimally invasive technique for tissue collection from bovine mammary glands.

BACKGROUND AND AIMS: The objective of this case report was to describe an ultrasound-guided, minimally invasive method for longitudinal mammary gland tissue collection from the bovine species. MATERIALS AND METHODS: Biopsies were performed on 14 8-week-old calves and 113 10-week-old calves. A subset of 36 animals had repeated mammary gland biopsies through the first lactation. Mammary gland biopsies were performed using a disposable biopsy punch. The technique was also performed on multiparous cows on other independent research trials. RESULTS: One-hundred and thirteen animals healed from the 10-week biopsies with no complications. Of the 36 animals that received repeated biopsies, one developed mastitis due to premature suture removal and one had recurring mastitis in all quarters. Thirty-three animals underwent all biopsies during gestation. Thirty of the original 36 are currently in lactation and still undergoing repeated biopsies. The method has also been successfully replicated on multiparous cows in separate studies. DISCUSSION AND CONCLUSION: The described technique is a safe, reliable method for cattle mammary gland biopsies beginning at eight weeks of age and can be utilized to obtain repeated tissue collection from individual animals. The technique is also straightforward to perform and utilizes simple tools while providing acceptable amounts of tissue for most applications, with low risk for infection and long-term tissue damage.

Surgical techniques for cardiac procurement, preparation and perfusion using the Organ Care System.

We provide an audio-visual step-by-step guide to the preparation of a donor heart for the application of normothermic, ex situ cardiac perfusion on the TransMedics Organ Care System using a heart donated after brain death. The use of the Organ Care System increases heart transplantation activity by enabling the utilization of hearts donated after circulatory death, the use of extended criteria grafts and the extension of out-of-body time, which can help overcome geographic or surgical barriers. Ex situ cardiac perfusion is a new technique and is therefore not yet routinely performed in many centres. However, it can be assumed that this technique will become more established and widespread in the future. Our video tutorial, which summarizes all important steps, can therefore be of benefit to surgical teams for planning, training or as a refresher.

Use of Free Internal Mammary Artery Perforator Flap Harvested With Minimally Invasive Approach for Facial Reconstruction: Report of Two Cases.

The internal mammary artery perforator (IMAP) flap has been widely used for chest wall and neck reconstruction. The color of its skin paddle closely resembles that of facial skin, making it attractive for facial reconstruction. However, there has been insufficient investigations reporting the use of free IMAP flap. Furthermore, even in such studies, somewhat invasive procedures, including rib cartilage resection, were employed to ensure sufficient pedicle length, potentially increasing donor morbidity. Our report presents two cases of successful facial defect reconstruction using a free IMAP flap harvested with minimal donor site damage, showing its feasibility. In the first case, a 48-year-old male underwent wide excision for a malignant melanoma on his right cheek, resulting in a 4 × 4.5 cm full-thickness defect. A free IMAP flap with a 2.5 cm pedicle, was harvested without rib cartilage resection, preserving IMA main trunk, and transferred with anastomosed to the angular vessels within the defect. The second patient presented with a 4.5 × 3.5 cm basal cell carcinoma on the left cheek, necessitating wide excision and leaving a 6 × 5 cm defect. A free IMAP flap was harvested with the same approach and successfully reconstructed the defect with connected to the superficial temporal vessels using vascular bridge. Both patients were discharged complication-free, with no recurrence during 24 and 15 months of follow-up, respectively. They were highly satisfied with the final skin color and texture outcomes. Harvesting a free IMAP flap while minimizing donor morbidity may offer an attractive option for facial reconstruction.

Cost-benefit analysis of 3D-printed vascular models in abdominal free flap breast reconstruction.

3D-printed vascular models can enhance flap harvesting efficiency in abdominal free flap breast reconstruction, reducing the use of operating room time. However, no economic analyses with respect to model use in this context have been conducted to date. As such, this study examines model cost-benefit tradeoffs for use in abdominal free flap breast reconstruction.

Freezing does not influence the microarchitectural parameters of the microstructure of the freshly harvested femoral head bone.

The femoral head is one of the most commonly used bones for allografts and biomechanical studies. However, there are few reports on the trabecular bone microarchitectural parameters of freshly harvested trabecular bones. To our knowledge, this is the first study to characterize the microstructure of femoral heads tested immediately after surgery and compare it with the microstructure obtained with conventional freezing. This study aims to investigate whether freezing at -80 °C for 6 weeks affects the trabecular microstructure of freshly harvested bone tissue. This study was divided into two groups: one with freshly harvested human femoral heads and the other with the same human femoral heads frozen at -80 °C for 6 weeks. Each femoral head was scanned using an X-ray microcomputed tomography scanner (µCT) to obtain the microarchitectural parameters, including the bone volume fraction (BV/TV), the mean trabecular thickness (Tb.th), the trabecular separation (Tb.sp), the degree of anisotropy (DA), and the connectivity density (Conn.D). There was no statistically significant difference between the fresh and the frozen groups for any of the parameters measured. This study shows that freezing at -80 °C for 6 weeks does not alter bone microstructure compared with freshly harvested femoral heads tested immediately after surgery.

Osteochondral Allograft Reaming Significantly Affects Chondrocyte Viability.

BACKGROUND: Chondrocyte viability is associated with the clinical success of osteochondral allograft (OCA) transplantation. PURPOSE: To investigate the effect of distal femoral OCA plug harvest and recipient site preparation on regional cell viability using traditional handheld saline irrigation versus saline submersion. STUDY DESIGN: Controlled laboratory study. METHODS: For each of 13 femoral hemicondyles, 4 cartilage samples were harvested: (1) 5-mm control cartilage, (2) 15-mm OCA donor plug harvested with a powered coring reamer and concurrent handheld saline irrigation ("traditional"), (3) 15-mm OCA donor plug harvested while submerged under normal saline ("submerged"), and (4) 5-mm cartilage from the peripheral rim of a recipient socket created with a 15-mm cannulated counterbore reamer to a total depth of 7 mm with concurrent handheld saline irrigation ("recipient"). The 15 mm-diameter plugs were divided into the central 5 mm and the peripheral 5 mm (2 edges) for comparisons. Samples were stained using calcein and ethidium, and live/dead cell percentages were calculated and compared across groups. RESULTS: Compared with the submerged group, the traditional group had significantly lower percentages of live cells across the whole plug (71.54% ± 4.82% vs 61.42% ± 4.98%, respectively; P = .003), at the center of the plug (72.76% ± 5.87% vs 62.30% ± 6.11%, respectively; P = .005), and at the periphery of the plug (70.93% ± 4.51% vs 60.91% ± 4.75%, respectively; P = .003). The traditional group had significantly fewer live cells in all plug regions compared with the control group (77.51% ± 9.23%; P < .0001). There were no significant differences in cell viability between the control and submerged groups (whole: P = .590; center: P = .713; periphery: P = .799). There were no differences between the central and peripheral 5-mm plug regions for the traditional (62.30% ± 6.11% vs 60.91% ± 4.75%, respectively; P = .108) and submerged (72.76% ± 5.87% vs 70.93% ± 4.51%, respectively; P = .061) groups. The recipient group (61.10% ± 5.02%) had significantly lower cell viability compared with the control group (P < .0001) and the periphery of the submerged group (P = .009) but was equivalent to the periphery of the traditional group (P = .990). CONCLUSION: There was a significant amount of chondrocyte death induced by OCA donor plug harvesting using a powered coring reamer with traditional handheld saline irrigation, which was mitigated by harvesting the plug while the allograft was submerged under saline. CLINICAL RELEVANCE: Mitigating this thermally induced damage by harvesting the OCA plug while the allograft was submerged in saline maintained chondrocyte viability throughout the plug and may help to improve the integration and survival of OCAs.

Relationship between surgical difficulty and postoperative complications of hand-assisted laparoscopic living donor nephrectomy and establishment of prediction model.

BACKGROUND: Few studies have systematically explored the factors influencing the difficulty of hand-assisted laparoscopic living donor nephrectomy. To investigate the relationship between the difficulty of hand-assisted laparoscopic living donor nephrectomy and postoperative complications of the donor as well as the recipient, and then build a model for predicting the difficulty of surgery. METHODS: In this study, 60 patients who underwent hand-assisted laparoscopic living donor nephrectomy by the same surgeon from September 2022 to March 2024 were included as the modeling group. 20 patients operated on by another surgeon served as the external validation group. The subjective score (1-3 points) of surgical difficulty was used as the quantitative index of surgical difficulty. Pearson and Spearman correlation tests were used to explore the correlation between preoperative data and surgical difficulty scores of kidney donors, and finally built a prediction model through multiple linear regression analysis. RESULTS: With the increase in the difficulty of operation, both donors and recipients' complications were increased. Linear regression analysis showed that only the number of renal arteries, visceral fat thickness and MAP score were independent risk factors for the difficulty of hand-assisted laparoscopic living donor nephrectomy. The prediction equation is as follows: Difficulty score = 0.584*Number of renal arteries + 0.731*MAP score + 0.110*visceral fat thickness. CONCLUSIONS: Donors with higher surgical difficulty are more likely to have serious complications after surgery as well as the recipient. We also established a reliable prediction model for the difficulty of hand-assisted laparoscopic donor nephrectomy.

Tuscany Normothermic Regional Perfusion Mobile Teams for Controlled Donation After Circulatory Death.

INTRODUCTION: To facilitate the implementation of controlled donation after circulatory death (cDCD) programs even in hospitals not equipped with a local extracorporeal membrane oxygenation (ECMO) team, some countries have launched a local cDCD network with an ECMO mobile team for normothermic regional perfusion (NRP). In the Tuscany region, in 2021, the Regional Transplant Authority launched a cDCD program to make the cDCD pathway feasible even in peripheral hospitals with NRP mobile teams, which were "converted" existing ECMO mobile teams, composed of highly skilled and experienced personnel. METHODS: We describe the Tuscany cDCD program, (2021-2023), for cDCD from peripheral hospitals with NRP mobile teams. RESULTS: Twenty-six cDCDs (26/40, 65%) came from peripheral hospitals. Following the launch of the cDCD program, cDCDs from peripheral hospitals increased, from 33% (2021) to 75% (2022 and 2023) of the overall cDCDs. The mean age was 63 years, with older donors (>75 years) in half the cases. The median warm ischemia time was 45 min (20 min are required by the Italian law for death certification), ranging from 35 to 59 min. Among the 20 livers retrieved and 18 kidneys retrieved, 16 livers, and 11 kidneys (single kidney transplantation) were transplanted, after ex vivo reperfusion, respectively. CONCLUSIONS: The use of NRP mobile teams proved to be feasible and safe in the management of cDCD in peripheral hospitals. No complications were reported with NRP despite the advanced age of most cDCDs.

The Posteromedial Approach for Harvesting Hamstring Autografts Results in Fewer Incidents of Saphenous Nerve Injury Compared to the Conventional Anteromedial Approach: A Systematic Review and Meta-Analysis.

Background: The hamstring autograft can be harvested using various skin incisions, such as vertical, transverse, and oblique incisions, and from different localizations, including anteromedial and posteromedial harvest sites. The aim of this study was to compare studies on the anteromedial and posteromedial approaches for hamstring autograft harvest in terms of clinical outcomes, saphenous nerve injury, infection, operative time, graft length, incision length, range of motion, and patient satisfaction. Methods: Following the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, a search was conducted in PubMed and Scopus, focusing on studies comparing anteromedial and posterior approaches for hamstring harvest. This study was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42023450249). Methodological quality was evaluated using the Modified Coleman Methodology Score. Odds ratios (ORs) and mean differences (MDs) quantified dichotomous and continuous outcomes, respectively. Results: Five articles, involving 405 knees, underwent analysis. Four studies were level 3 evidence, while 1 was level 1. The anteromedial hamstring harvest showed higher rates of saphenous nerve injury (OR, 9.77; 95% confidence interval [CI], 2.19-43.65; p = 0.003) and longer operative times, with an MD of about 13 minutes (MD, 13.33; 95% CI, 0.68-25.97; p = 0.04), compared to the posteromedial approach. The anteromedial method yielded a longer semitendinosus graft, with an MD of about 17 mm (MD, 17.57; 95% CI, 7.17-27.98; p = 0.0009). However, no significant differences existed in range of motion, flexion contracture, unintentional graft harvest, infection rates, and patient-reported outcomes. Notably, the posteromedial group reported higher cosmetic satisfaction, with 92% being very satisfied, compared to the anteromedial group with 80% (p = 0.005). However, overall satisfaction levels were similar between the 2 groups (p = 0.35), with a very satisfied rate of 72% for the anteromedial group and 78% for the posteromedial group. Conclusions: The anteromedial hamstring harvest showed greater saphenous nerve injury and longer operative times compared to the posteromedial approach, along with a longer graft. However, no significant differences were observed in the range of motion, flexion contracture, graft harvest, infection, or patient outcomes.

Optimizing Tissue Harvesting Techniques for Establishing Patient-Derived Glioblastoma Organoids.

OBJECTIVE: Brain tumors display remarkable cellular and molecular diversity, significantly impacting the progression and outcomes of the disease. The utilization of tumor tissue acquired through surgical handheld devices for tumor characterization raises important questions regarding translational research. This study seeks to evaluate the integrity of tissue resected using a microdebrider (MD) in the context of establishing tumor organoids from glioblastomas (GBM). METHODS: Tumor samples were collected from patients with GBM using both tumor forceps (en bloc) and a MD. The time required to protocol completion and cell viability of paired samples was measured. H&E staining was performed to examine histologic morphology. RESULTS: Ten paired samples were obtained from GBM patients using tumor forceps and the MD. Samples collected with the MD demonstrated significantly shorter processing times compared to those obtained through en bloc resection, with overall means of 31.7 ± 2.4 mins and 38.8±3 mins, respectively (P < 0.001). Cell viability measured at the end of protocol completion was comparable between tissues obtained using both the MD and en bloc, with mean viabilities of 80.2 ± 12.4% and 79.1 ± 12.5%, respectively (P = 0.848). H&E examination of tissues revealed no significant differences in the cellular and histologic characteristics of paired samples obtained using both methods across GBM tumors, nor in the corresponding established organoids. CONCLUSIONS: Tumor tissues obtained using the MD and en bloc methods demonstrate a high success rate in establishing GBM organoids, with the MD offering the advantage of significantly reduced processing time. Both methods display comparable cell viability and maintain consistent histologic characteristics in the resected tissue and the corresponding organoids.

Use of excised ovaries for oocyte recovery by ultrasound guided follicular aspiration - Validation of an experimental model for research purposes in live mares ovum pick up.

Ovum pick-up (OPU) by transvaginal ultrasound guided follicle aspiration in mares is a common assisted reproductive technique used for oocyte recovery and in vitro production of horse embryos. There has been relatively little research into the factors influencing oocyte recovery in OPU from live mares. The objective of this study was to compare oocyte recovery and morphology of ultrasound-guided follicle puncture and aspiration in live mares and in postmortem excised ovaries, in order to validate an experimental model for research purposes of the efficiency of OPU in mares. Data from OPU performed in 12 mares from a commercial program (follicle numbers, oocyte recovery and oocyte morphology) were compared to that obtained from ultrasound-guided follicle puncture of 13 postmortem excised ovaries from slaughtered mares processed within 2 h of slaughter. In both groups, the OPU was performed by the same operator using the same equipment and OPU technique. The recovered oocytes per aspirated follicle was higher (P < 0.05) in the postmortem group (105/166, 63.2 %) than in live mares (138/261, 52.9 %). There was more (P < 0.05) expanded cumulus oocyte complexes in the postmortem than in the live mares (18 % vs. 2.9 %). Several oocytes (5 oocytes from 81 aspirated follicles) were found in the leaked fluid which overflowed during follicle flushing of postmortem ovaries. In conclusion, the higher recovery rate obtained in the excised ovaries and the finding of oocytes in the leaked fluid during OPU, suggests that there is still room for improvement in the in vivo OPU technique. Utilizing postmortem excised ovaries could offer an alternative for further research into factors affecting oocyte recovery and oocyte leakage during OPU procedures.

Robotic versus open mini-incision living donor nephrectomy: Single centre experience.

BACKGROUND: Robotic surgery is associated with less tissue manipulation and earlier recovery with minimal incision. The aim of this study was to compare the short-term clinical outcomes between robotic-assisted donor nephrectomy (RDN) and open mini-incision donor nephrectomy (ODN). METHODS: From 2016 to 2019, 141 cases involving RDN were analysed. Patient outcomes were compared with those of 191 patients who underwent ODN from 2010 to 2015. Demographics, operation factors, perioperative outcomes, and complications were retrospectively reviewed. RESULTS: The RDN group presented with less blood loss than the ODN group (p = 0.023). The length of hospital stay was significantly shorter in the RDN group than in the ODN group (p < 0.005). The overall rate of complications was low and there was no significant difference in complication rates between the groups. CONCLUSION: The robotic approach has benefits over the traditional open approach, including shorter length of hospital stay and reduced intraoperative blood loss.

Harvesting, Embedding, and Culturing Dorsal Root Ganglia in Multi-compartment Devices to Study Peripheral Neuronal Features.

The most common peripheral neuronal feature of pain is a lowered stimulation threshold or hypersensitivity of terminal nerves from the dorsal root ganglia (DRG). One proposed cause of this hypersensitivity is associated with the interaction between immune cells in the peripheral tissue and neurons. In vitro models have provided foundational knowledge in understanding how these mechanisms result in nociceptor hypersensitivity. However, in vitro models face the challenge of translating efficacy to humans. To address this challenge, a physiologically and anatomically relevant in vitro model has been developed for the culture of intact dorsal root ganglia (DRGs) in three isolated compartments in a 48-well plate. Primary DRGs are harvested from adult Sprague Dawley rats after humane euthanasia. Excess nerve roots are trimmed, and the DRG is cut into appropriate sizes for culture. DRGs are then grown in natural hydrogels, enabling robust growth in all compartments. This multi-compartment system offers anatomically relevant isolation of the DRG cell bodies from neurites, physiologically relevant cell types, and mechanical properties to study the interactions between neural and immune cells. Thus, this culture platform provides a valuable tool for investigating treatment isolation strategies, ultimately leading to an improved screening approach for predicting pain.

Anterior Iliac Crest Bone Graft Harvest Using Acetabular Reamers.

VIDEO AVAILABLE AT: https://ota.org/education/ota-online-resources/video-library-procedures-techniques/anterior-iliac-crest-bone-0.

Safety and graft outcome of right retroperitoneal laparoscopic donor nephrectomy for living donor kidney transplantation: A comparison with left retroperitoneal laparoscopic donor nephrectomy.

INTRODUCTION: The left kidney is often preferred for living donor kidney transplantation because of its anatomical advantages. However, the right kidney may be procured due to donor conditions. Few studies have assessed the safety and graft outcome of right retroperitoneal laparoscopic donor nephrectomy (RDN). This study aimed to compare the outcomes between right and left RDN with respect to donor outcome and the graft function of recipients. METHODS: This retrospective study included 230 consecutive living donor kidney transplants performed at our institution between May 2019 and March 2023. We reviewed the outcomes of kidney transplant in the right and left kidneys after RDN. RESULTS: A total of 230 living donor kidney transplants were performed, with 32 donors receiving right RDN (right RDN group) and 198 donors receiving left RDN (left RDN group). The renal veins and ureters were significantly shorter in the right RDN group than in the left RDN group (both p < .001). Donor operation and warm ischemia time were significantly longer in the right RDN group than in the left RDN group (p = .012 and p < .001, respectively). None of the groups exhibited any cases of delayed graft function owing to donor-related reasons. Perioperative changes in the estimated glomerular filtration rate of recipients and death-censored graft survival were not significantly different between the two groups. CONCLUSIONS: In RDN, the outcomes of right donor nephrectomy were comparable to those of left donor nephrectomy in terms of donor safety and recipient renal function.

Endoscopic Vein Harvesting - How Do We Do It?

The saphenous vein graft (SVG) remains the most used conduit as a second graft in Coronary Artery Bypass Grafting (CABG).1 Traditionally, surgeons harvest SVG with an open approach, making a long incision along the medial part of the leg or thigh. This procedure can potentially result in important complications, such as delayed wound healing, postoperative pain and infection.2 Thus, less invasive techniques for vessel harvesting have grown in popularity. Endoscopic vein harvesting (EVH) is a minimally invasive harvesting procedure, which only requires a short incision, leading to less wound complications and a faster return to normal daily activities. This article intends to describe how we do EVH technique in our centre, from the preparation of the patient to the postoperative period and share some tips and tricks from our experience.

The prognosis of iatrogenic saphenous nerve injuries during hamstring tendon harvesting in anterior cruciate ligament reconstruction.

PURPOSE: This study aims to evaluate the long-term outcomes of saphenous nerve (SN) injuries from hamstring tendon harvesting during ACL reconstruction, focusing on clinical results and patient satisfaction after at least two years. Additionally, it investigates the incidence, recovery patterns, and impact of these injuries on functional outcomes, daily activities, and ACL re-rupture rates immediately post-surgery and at final follow-up. MATERIALS AND METHODS: A retrospective review was conducted on patients who had undergone ACL reconstruction with hamstring tendon grafts at a single institution between January 2015 and January 2020. The incidence of SN injuries was assessed immediately after surgery and at final follow-up. Additionally, the recovery rate and time were evaluated, and the impact of these injuries on functional outcomes was measured using the Lysholm Knee Score (LKS) and patient-reported effects on daily activities. RESULTS: Of the 159 patients analyzed, iatrogenic SN injuries were initially observed in 87 (54.7%) patients post-ACLR. By the final follow-up, paresthesia had resolved in 36 (22.6%) patients within an average of 11.1 months. Persistent SN injuries were recorded in 51 (32.1%) patients, affecting various extents of the infrapatellar branch (IPBSN) and the sartorial branch (SBSN) of the saphenous nerve. Patients with persistent SN injuries experienced a significant impact on daily activities and had lower LKS scores compared to those without injuries or with recovered injuries. Furthermore, a higher re-rupture rate was associated with persistent SN injuries. CONCLUSIONS: The study finds that SN injuries during hamstring graft harvesting for ACL reconstruction are common, with a significant portion of patients experiencing persistent sensory deficits for at least two years postoperatively. These injuries are observed to adversely affect patient satisfaction and functional outcomes and to increase the re-rupture rate.