Simple technique for gasless transumbilical single-incisional laparoscopic-assisted appendectomy.

PURPOSE: Single-incision laparoscopic surgery has recently received more attention. We developed a novel simple technique of gasless transumbilical single-incisional laparoscopic-assisted appendectomy (TUSILAA) and retrospectively analyzed our initial experience. METHODS: TUSILAA has been attempted in 50 consecutive patients with acute appendicitis. The vertical incision through the umbilicus was used for laparoscopic access and the abdominal wall was lifted by a Kent retractor set system. RESULTS: Our technique was successful in 45 out of 50 (90 %) patients. The median operating time was 59 min (range 35-140). The median length of postoperative hospital stay was 4 days (range 2-12). None of the cases were converted to open appendectomy. There were no perioperative surgical complications. CONCLUSIONS: Our novel technique, gasless TUSILAA, is safe and feasible with acceptable operative time and excellent cosmetic result. Furthermore, this procedure has the advantage of cost-effectiveness since any disposable instruments including trocars, staplers, or expensive devices are not required. Therefore, this could be used as the first-choice surgical procedure for selected patients with uncomplicated acute appendicitis.

[A case of local relapsed rectal cancer responding to low-dose S-1].

We report a case of local recurrent colorectal cancer that has been treated successfully with low-dose oral chemotherapeutic agent. An 80-year-old man underwent a low anterior resection for rectal cancer. Two years and nine months later, a recurrent tumor was revealed in the vicinity of the anastomotic region by colonoscopy. Additional examination by enhanced CT elucidated the tumor infiltrated the sacrum. For this reason, we planned an abdominoperineal resection of rectum with sacrum excision for treatment. However, we considered that he could not overcome the burden of operation for his complication. As a result of informed consent with the patient and his family, we decided a conservative treatment, and started chemotherapy using S-1. The tumor has been diminished slowly on enhanced CT and colonoscopy. The chemotherapy using S-1 has been continued with good quality of life for over five years. S-1 is expected to be an effective choice for the patient of colorectal cancer who cannot be taken the standard treatment for various reasons.

Safety and feasibility for single-incision laparoscopic cholecystectomy in local community hospital: a retrospective comparison with conventional 4-port laparoscopic cholecystectomy.

BACKGROUND: The aim of this study was to evaluate the safety and feasibility for single-incision laparoscopic cholecystectomy (SILC) by retrospective comparison with conventional laparoscopic cholecystectomy (CLC) in a local community hospital. METHODS: SILC was introduced and performed in 57 patients for benign gallbladder diseases. Their clinical data were compared with those of 62 patients treated with CLC. They included patient demographic data and operative outcomes. RESULTS: SILC was attempted in 57 patients and 52 cases (91.2%) were successfully completed. There were no statistical differences between the 2 groups in terms of operative time, blood loss, and postoperative complications. The length of hospital stay in the SILC group was significantly shorter compared with CLC (P < 0.0001). CONCLUSIONS: SILC has been successfully introduced in a local community hospital. The safety and feasibility was also confirmed. The SILC procedure may become 1 standard option for the treatment of benign gallbladder diseases.

Evaluating the hilar bifurcation territory in the human liver caudate lobe to obtain critical information for delimiting reliable margins during caudate lobe surgery: anatomic study of livers with and without the external caudate notch.

The hilar bifurcation (HB), a wedged portion between the left and right portal vein origins, often issues the caudate branch. However, the HB territory in the caudate lobe has not been well recognized during liver surgery. In 50% of 48 human livers (25 usual livers and 23 with the external caudate notch), the HB gave off thick portal branches (> 1 mm) to supply the caudate lobe. Using minute dissections, we identified four cross-sectional configurations of three subdivisions of the caudate lobe (i.e., left, right, and HB portal territories). The HB territory was consistently located in the paracaval portion, although it sometimes (29.2%: type A) extended slightly or deeply into Spiegel's lobe. This leftward HB territorial extension was seen more frequently in livers with the notch (43.6%) than in those without it ("usual" livers) (16.0%). Moreover, in livers with the notch the caudate lobe (usually its right portal territory) tended to extend upward and rightward to attach or surround the terminal portion of the right hepatic vein. Our results suggested that in many cases subdivisions of the caudate lobe cannot be divided simply into right and left portions. The HB branch or territory should be examined to determine the real principal border as well as the subdivisional configuration of the caudate lobe. Combined evaluation of the HB branch(es) and external notch could provide critical information for anatomically sophisticated caudate lobe surgery.

How should we treat short hepatic veins and paracaval branches in anterior hepatectomy using the hanging maneuver without mobilization of the liver? An anatomical and experimental study.

This study investigates the relevant anatomy for applying the hanging maneuver to hepatectomy by an anterior approach, where liver mobilization is not possible. Using 176 cadaveric livers, we morphometrically investigated the distribution of venous openings within the retrohepatic portion of the inferior vena cava (IVC); next, we conducted a series of experiments to identify which course for insertion of a pair of forceps preserved the thickest of these veins. After anterior dissection of the liver, we carried out an anterior incision along a plane within an area free of venous openings in the IVC. The area free of venous openings was between the thickest caudate vein and the inferior right hepatic vein (IRHV), and averaged 16.2 mm in width. When forceps were inserted along the rightward course connecting the right inferior angle of the right lobe and the same pocket-like space between the terminals of the middle and right hepatic veins, the caudate vein was very likely to be preserved, whereas the IRHV was not. In contrast, the leftward course connecting the gallbladder fossa and the pocket-like space provided an almost opposite incidence of damage. The portal territory of the hilar bifurcation was most likely to be damaged during a virtual incision along an avascular plane; however, the caudate branch of left portal origin was rarely damaged. The rightward course may be the best method for forceps insertion in cases where there is no IRHV. To preserve the caudate vein and the IRHV, taping on the right side of the IRHV and retracting to the right, or changing the direction of the forceps from leftward to rightward when the tip of the forceps is anterior to the IVC is recommended. The hanging maneuver by an anterior approach without mobilization is convenient for right or left hepatectomy for large tumors or hardened liver.

An anatomical study of short hepatic veins, with special reference to delineation of the caudate lobe for hanging maneuver of the liver without the usual mobilization.

BACKGROUND/PURPOSE: The present study was designed to anatomically assess a very recently reported hanging maneuver of the liver without mobilization, in which forceps are inserted blindly between the inferior vena cava (IVC) and liver parenchyma. METHODS: We dissected 56 formalin-fixed livers (1) to determine whether preservation of the caudate vein (the largest vein draining Spiegel's lobe) and inferior right hepatic vein (IRHV) was possible and (2) to identify the territories drained by other, non-preserved short hepatic veins. RESULTS: A potential space for insertion of the forceps was found between the openings of the caudate vein and IRHV; however, if preservation of both veins is absolutely necessary, we recommended protecting the IRHV, such as by taping and retracting it. We classified the other short hepatic veins into two categories, i.e., those draining the left portal vein territory and those draining the right territory. The distributions of the openings of the veins in these territories overlapped. CONCLUSIONS: Clear delineation of the left caudate lobe according to the drainage veins appeared to be difficult when the liver was divided along a straight line in front of the IVC.

Cantlie's plane in major variations of the primary portal vein ramification at the porta hepatis: cutting experiment using cadaveric livers.

Major variations of the primary portal vein ramifications at the porta hepatis, such as trifurcation or an anterior sectorial trunk originating from the left portal vein (L+A pattern), seem to be relatively common morphologic features, with an incidence of 10% to 30%. However, it has not been clearly demonstrated whether the usual landmarks of Cantlie's line and the middle hepatic vein (MHV) are reliable indicators of the border between the right and left liver when these variations are present. We searched for any discrepancies between the actual left/right territorial border of the intrahepatic portal vein and the usual position of Cantlie's line or the MHV course using 30 fixed cadaveric livers with major variations including hilar trifurcation and the L+A pattern. In most livers (63.3%) the usual transection plane for left/right hepatectomy was occupied by Couinaud's segment VIII (S8), and the territory of the right portal vein extended to the left of Cantlie's plane. The MHV course did not correspond with the actual border between the right and left liver. Significant rightward shift of the MHV occurred in 76.9% of livers. The severity of the discrepancy seemed to depend on the distance between the origins of the anterior and posterior sectorial trunks along the main portal vein. In conclusion, variations of the primary portal ramifications alter the segmental configurations of the liver. Our results evoke doubt over the reliability of Cantlie's line and the MHV course as landmarks for major hepatectomy when such variations are present.

Immune responses of graft mesenteric lymph node in small bowel transplantation.

BACKGROUND: The high proportions of lymphoid tissues are thought to be one of the underlying factors inducing severe allograft rejection following small bowel transplantation. Mesenteric lymph nodes (MLN) contained in the intestinal graft are not only a source of donor-derived professional antigen-presenting cells, but also offer a field for immune interaction between donor and host cells. We investigated immune responses in graft MLNs with or without FK506 to develop a novel strategy to control small bowel allograft rejection. MATERIALS AND METHODS: Heterotopic small bowel transplantations were performed from Brown Norway donors to Lewis recipients. Changes in population of lymphocytes, expressions of costimulatory molecules, apoptosis, and cytokine profiles in graft MLNs were evaluated. RESULTS: The increase in apoptotic cells and cytokine responses relating to rejection in the graft MLNs developed prior to those in graft jejunum. While donor lymphocytes in graft MLNs were rapidly replaced to host-derived lymphocytes independent of FK treatment, increase in CD8(+) T cells in host population was seen only in recipients without FK506 treatment. The expressions of B7 molecules on donor cells in graft MLNs were significantly lower in the recipients with FK treatment. CONCLUSIONS: Immune responses in graft MLNs have significant impact on the outcome of the small bowel allograft. Apoptosis of graft MLN cells was well correlated with and ahead of progression of acute rejection. Modulation of costimulatory molecules on donor-derived MLN cells in the allograft and specific suppression of host CD8(+) T cells are possible ways to control severe rejection after allogeneic small bowel transplantation.

Bone marrow chimerism and tolerance induced by single-dose cyclophosphamide.

BACKGROUND: Establishment of hematopoietic chimerism is the most stable strategy for donor-specific tolerance. Safer pretreatment regimens are needed for clinical application. We evaluated the efficacy of a simple protocol using cyclophosphamide (CYP) on induction of chimerism and organ transplant tolerance across major histocompatibility complex (MHC) barriers in the rat. MATERIALS AND METHODS: Bone marrow cells from BN (RT1(n)) donors were infused to LEW (RT1(l)) recipients on day 0 after a single injection of CYP at various doses on day -1. Donor-derived hematopoietic chimerism was evaluated by flowcytometry. The recipients received BN or third party (BUF) heart allografts on day 100. RESULTS: While pretreatment with 200 mg/kg of CYP induced high levels of hematopoietic chimerism, six of eight recipients died of severe graft-versus-host-disease (GVHD). CYP at dose of 150 mg/kg induced 36.5 +/- 24.1% of donor-derived chimerism on day 10, and sustained macrochimerism was seen until day 100 without GVHD. Pretreatment with 100 mg/kg of CYP resulted in only transient chimerism (4.8 +/- 5.2%) which disappeared by day 20. In the recipients with 50 mg/kg of CYP, donor bone marrow cells were rapidly rejected and no chimerism was observed. The recipients with 150 mg/kg of CYP accepted BN heart allografts (>100 days x 5), while rejecting BUF allografts by day 12 (n = 4). BN heart allografts were rejected in the recipients with 100 (MST: 57 days, n = 5) and 50 mg/kg (MST: 7 days, n = 5) of CYP. CONCLUSIONS: A single dose of CYP can induce hematopoietic chimerism across MHC-barriers. The dose of 150 mg/kg seems to be optimal to induce organ transplant tolerance without developing GVHD.