Combination of a Glissonean Approach and Indocyanine Green Fluorescence Imaging to Perform a Laparoscopic Right Anterior Sectionectomy.

BACKGROUND: Laparoscopic right anterior sectionectomy (LRAS) remains a technically demanding procedure as it requires two transection planes where the middle and right hepatic veins run; however, the main difficulty is locating these two planes1-3. The aim of this video was to show the technique of an LRAS performed with a transparenchymal glissonean pedicle approach and guided by indocyanine green (ICG) staining. METHODS: This was the case of an 80-year-old man with a history of hemochromatosis and normal liver function. He was diagnosed with a 6 cm hepatocellular carcinoma (HCC) located at segment 8, close to the right anterior pedicle. RESULTS: The technique consisted of parenchymal transection along the main portal fissure along the right border of the middle hepatic vein. Opening the liver facilitated access to the right anterior glissonean pedicle and selective transparenchymal clamping. A negative-stain ICG test permitted to demarcate the transection line along the right lateral portal fissure. The parenchymal transection was carried out in a caudal approach, along two perfectly marked planes, preserving the middle and right hepatic veins. The duration of the procedure was 200 min and blood loss was 300 mL. Postoperative course was uneventful and the patient was discharged on the third postoperative day. CONCLUSION: Guidance during resection, and protection of the right posterior pedicle and right hepatic vein are the key points of the LRAS. The glissonean approach and the ICG imaging technology are of great help in resolving these difficulties.

Acute cholecystitis: preoperative CT can help the surgeon consider conversion from laparoscopic to open cholecystectomy.

PURPOSE: To establish whether preoperative computed tomographic (CT) findings in patients with acute cholecystitis were associated with conversion from laparoscopic to open cholecystectomy in patients with calculous acute cholecystitis. MATERIALS AND METHODS: The study protocol was approved by the local institutional review board, and written informed consent was provided by all patients at enrollment. From 2008 to 2010, all patients admitted to a university medical center with acute calculous cholecystitis and for whom a preoperative contrast material-enhanced CT study was available were prospectively included. Cholecystectomy was always initiated laparoscopically. To identify risk factors for conversion specifically related to acute cholecystitis, CT studies were analyzed according to predefined criteria by two radiologists who were blinded to the patient's conversion status. Associations between conversion and radiologic findings were assessed by using univariate and multivariate logistic models. RESULTS: A total of 108 patients were analyzed (61 men, 47 women; median age, 58 years; age range, 17-88 years). Conversion occurred in 24 (22%) cases. On preoperative CT images, the absence of gallbladder wall enhancement was associated with the presence of gangrenous acute cholecystitis (sensitivity, 73%). The absence of gallbladder wall enhancement (58% and 40% for conversion and nonconversion, respectively; P = .02) and the presence of a gallstone in the gallbladder infundibulum (78% and 22% for conversion and nonconversion, respectively; P = .04) were associated with acute cholecystitis-related conversion in a multivariate analysis. Interobserver agreement for CT study interpretation was very good (median k value, 0.92; range, 0.76-1.00). CONCLUSION: The absence of gallbladder wall enhancement (associated with the presence of gangrenous acute cholecystitis) and the presence of a gallstone in the gallbladder infundibulum are associated with conversion from laparoscopic to open cholecystectomy.

Anatomical background of the perforator flap based on the deep branch of the superficial circumflex iliac artery (SCIP Flap): a cadaveric study.

BACKGROUND: The groin flap, based on the superficial circumflex iliac artery, was the first successful free flap. However, its popularity was lost essentially due to variable arterial anatomy. Clinical applications of perforator flap based on superficial circumflex iliac artery suggest that a dominant perforator based on his deep branch is enough to supply a large groin flap. METHODS: Fresh cadaveric dissections were performed and the perforators of Sartorius based on the deep branch of superficial circumflex iliac artery were identified. The dominant perforator was isolated and injected selectively with methylene blue solution. RESULTS: We performed 20 dissections of superficial circumflex iliac artery and the deep branch. We found a deep branch with 2 perforators penetrating the Sartorius muscle. The diameter of the dominant perforator of the deep branch was 0.85 mm on average and the mean injected skin area was 162 cm(2). CONCLUSIONS: These findings are in agreement with early clinical suggestion. The dominant musculocutaneous perforator of the deep branch of superficial circumflex iliac artery provides constant and reliable blood supply to ensure a relatively large perforator groin flap.