Robotic Left Hepatectomy Using the Glissonean Approach and Saline-Linked Bipolar Clamp-Crush Technique.

BACKGROUND: We have previously reported a saline-linked bipolar clamp-crush technique as a novel robotic liver resection method. Herein, we present the surgical techniques and outcomes of robotic left hepatectomy using the Glissonean approach and our liver transection technique. METHODS: The key procedures included the following: (1) encircling the left Glissonean pedicle using the Tip-Up fenestrated grasper, (2) dissecting the liver parenchyma using the saline-linked bipolar clamp-crush technique, (3) moving the endoscope one trocar to the right to facilitate visualisation of the liver transection plane, and (4) stapling the left pedicle and left hepatic vein. Seven robotic left hepatectomies were performed. RESULTS: The median operative time and estimated blood loss were 395 min and 50 mL, respectively. The median length of postoperative hospital stay was 9 days. Pneumothorax was the only severe postoperative complication. CONCLUSIONS: Robotics left hepatectomy using the Glissonean approach and the saline-linked bipolar clamp-crush technique appears safe and feasible.

Development of microsurgical forceps equipped with haptic technology for in situ differentiation of brain tumors during microsurgery.

The stiffness of human cancers may be correlated with their pathology, and can be used as a biomarker for diagnosis, malignancy prediction, molecular expression, and postoperative complications. Neurosurgeons perform tumor resection based on tactile sensations. However, it takes years of surgical experience to appropriately distinguish brain tumors from surrounding parenchymal tissue. Haptics is a technology related to the touch sensation. Haptic technology can amplify, transmit, record, and reproduce real sensations, and the physical properties (e.g., stiffness) of an object can be quantified. In the present study, glioblastoma (SF126-firefly luciferase-mCherry [FmC], U87-FmC, U251-FmC) and malignant meningioma (IOMM-Lee-FmC, HKBMM-FmC) cell lines were transplanted into nude mice, and the stiffness of tumors and normal brain tissues were measured using our newly developed surgical forceps equipped with haptic technology. We found that all five brain tumor tissues were stiffer than normal brain tissue (p < 0.001), and that brain tumor pathology (three types of glioblastomas, two types of malignant meningioma) was significantly stiffer than normal brain tissue (p < 0.001 for all). Our findings suggest that tissue stiffness may be a useful marker to distinguish brain tumors from surrounding parenchymal tissue during microsurgery, and that haptic forceps may help neurosurgeons to sense minute changes in tissue stiffness.

[Clipping via the Transsylvian Approach:From Basic to Advanced Surgical Techniques].

The transsylvian approach is one of the most commonly used approaches in neurosurgery and is essential for clipping aneurysms located in the anterior cranial circulation, such as the middle cerebral artery, internal carotid artery, and anterior communicating artery. Moreover, basilar artery aneurysms can be clipped using this approach, albeit with some modifications. Important tips for dissecting the Sylvian fissures include reliable visualization, anatomical recognition, and steady manipulation. The actual steps are as follows: determine the affiliation of the arteries and veins, gently move the brain to create a wide space, cut the arachnoid mater, and follow the course of the arteries. In case of subarachnoid hemorrhage, irrigation and flushing out the hematoma is the key step involved in recognizing the structure and safely performing surgery. Here, we describe the basic key operative techniques for performing clipping via the transsylvian approach.

[Neck Clipping via Subtemporal Approach].

The subtemporal approach offers the advantages of a wide surgical field in the anteroposterior direction and easy access to the proximal basilar artery. This approach can be adapted to treat low-positioned aneurysms using a tentorial incision, known as the subtemporal transtentorial approach. However, a disadvantage of the subtemporal approach is the risk of injury to the temporal lobe. To mitigate this risk, it is important to ensure proper positioning, adequate cerebrospinal fluid drainage, preservation of the bridging veins, and intermittent retraction of the temporal lobe.

Endoscopic treatment options in peptic ulcer bleeding.

This review evaluates the evidence for the use of over-the-scope clips (OTSC), topical haemostatic agents (THA), and prophylactic embolisation (PE) in patients with peptic ulcer bleeding (PUB). The use of OTSC and THA may have the potential to increase the rate of endoscopic haemostasis in PUB not responding to conventional endoscopic treatment. In patients at high risk of recurrent bleeding, the performance of PE after achieving endoscopic haemostasis can reduce the risk of rebleeding and the need for surgery. Implementation of a local treatment protocol including these modalities may improve patient outcomes.

Efficacy of a novel traction method: outside-lesion clip-thread method for gastric endoscopic submucosal dissection of lesions of the greater curvature of the upper/middle stomach (with video).

BACKGROUND: Gastric endoscopic submucosal dissection (ESD) for lesions located on the greater curvature of the upper and middle (U/M) third of the stomach remains challenging, even for experienced endoscopists. Accordingly, we have developed a novel traction technique, termed the outside-lesion clip-thread method (O-CTM). In this method, a clip thread is attached to the healthy mucosa outside the circumferential incision line, and traction is applied to bring the scope and lesion into proximity for ESD. Here, we assessed the efficacy of ESD using the O-CTM compared to ESD without the O-CTM. METHODS: We retrospectively reviewed data from 63 consecutive patients who underwent gastric ESD for 63 lesions located on the greater curvature of the U/M third of the stomach between September 2015 and April 2024. The primary outcome was the operation time, and secondary outcomes were resection speed, en bloc resection, R0 resection and complications in the O-CTM and without O-CTM ESD groups. RESULTS: Of the 63 included lesions, 37 were resected without the O-CTM between September 2015 and June 2022 (without O-CTM group), and 26 lesions were resected using the O-CTM between July 2022 and April 2024 (O-CTM group). The O-CTM group had significantly shorter operation times (40 min vs. 77 min, p = 0.01) than the without O-CTM group. The resection speed was also significantly faster (20.1 mm2/min vs. 11.3 mm2/min, p = 0.02). No significant differences in en bloc resection rate, R0 resection rate, and complications were observed. CONCLUSIONS: Gastric ESD using O-CTM is beneficial when compared with the ESD without O-CTM in reducing operation time and improving resection speeds for treating lesions located on the greater curvature of the U/M region.

Evaluating the impact of tubular retractors in glioma surgery: A systematic review and meta-analysis.

BACKGROUND: Achieving safe, maximal tumor resection in gliomas can be challenging due to the tumor's intricate relationship with surrounding structures. Tubular retractors offer a minimally invasive approach, preserving functional pathways and reducing complications. To assess their efficacy and safety, we conducted a systematic review and meta-analysis. METHODS: A search across databases identified 26 studies meeting inclusion criteria, encompassing 106 patients with various glioma types and tumor locations. RESULTS: Among 26 eligible studies, 15 provided sufficient data on 106 patients (median age: 50.5 years). Glioblastoma multiforme constituted 52.4 % of tumors, followed by IDH-mutant astrocytomas at 31.0 %. Tumor locations varied, with intraventricular and thalamic involvement in 16.3 % (16/98) of cases, followed by temporal (12.2 %), frontal and occipital (each 8.16 %), basal ganglia (8.16 %), parietal (7.14 %), optic pathway (2.04 %), and caudate nucleus (1.02 %) involvement. VyCor and Brainpath retractors were most used (22.6 % and 21.7 %, respectively). Tubular retractors were often combined with the exoscope (35.9 %). Gross total resection (GTR) was achieved in 69.4 % of cases, near-total resection (NTR) in 5.1 %, and subtotal resection/partial resection (STR/PR) in 25.5 %. Mean extent of resection (EOR) significantly differed between GTR and STR/NTR/PR groups (p<0.001). Postoperative complications included visual deficits (6.38 %), hemiparesis or weakness (2.13 %), multiple complications (1.06 %), and other unspecified complications (3.19 %). CONCLUSION: Tubular retractors are a valuable intraoperative adjunct and component of the surgical armamentarium for glioma surgery allowing bimanual operative techniques to manage hemostasis directly with excellent surgical outcomes and an acceptable complication profile.

The safety and utility of the semi-sitting position for clipping of posterior circulation aneurysms.

BACKGROUND: The semi-sitting position offers advantages for surgeries in the posterior cranial fossa. However, data on its safety and effectiveness for clipping aneurysms in the posterior cerebral circulation are limited. This retrospective cohort study evaluates the safety and effectiveness of using the semi-sitting position for these surgeries. METHODS: We conducted a retrospective study of 17 patients with posterior cerebral circulation aneurysms who underwent surgical clipping in the semi-sitting position in the Department of Neurosurgery at Hannover Medical School over a 10-year period. RESULTS: The mean age at surgery was 62 years (range, 31 to 75). Fourteen patients were admitted with subarachnoid hemorrhage and 3 patients had incidental aneurysmas. Fifteen patients had PICA aneurysms, and two had aneurysms of the vertebral artery and the superior cerebellar artery, respectively. The median diameter of the aneurysms was 5 mm (range 3-17 mm). Intraoperative venous air embolism (VAE) occurred in 4 patients, without affecting the surgical or clinical course. VAE was associated with a mild decrease of EtCO2 levels in 3 patients and in 2 patients a decrease of blood pressure occurred which was managed effectively. Surgical procedures proceeded as planned in all instances. There were no complications secondary to VAE. Two patients died secondary to respiratory problems (not related to VAE), and one patient was lost to follow-up. Eleven of fourteen patients were partially or completely independent (Barthel index between 60 and 100) at a median follow-up duration of 13.5 months (range, 3-103 months). CONCLUSION: The semi-sitting position is a safe and effective technique for the surgical clipping of aneurysms in the posterior cerebral circulation. The incidence of VAE is comparable to that seen in tumor surgery. However, it is crucial for the surgical and anesthesiological team to be familiar with potential complications and to react immediately in case of an occurrence of VAE.

A Case of Transanal Endoscopic Excision for Rectal Tumor Using Surgical Instruments With Multi-jointed Structures.

BACKGROUND/AIM: Transanal endoscopic local excision requires fine operation in a very narrow space in the rectum. We report a case in which the use of surgical instruments with a multi-jointed structure allowed safe resection of a lesion with a stable field of view, resulting in preservation of postoperative function. CASE REPORT: The patient was a 49-year-old man who had a rectal neuroendocrine tumor (NET) (G1) with erosive changes in the lower rectum. Preoperative imaging showed no evidence of surrounding lymph node or distant metastasis; thus, we performed a transanal endoscopic local excision of the tumor. After positioning the patient under general anesthesia and securing the field of view in the intra-rectal cavity, the flexion of the surgical instruments with a multi-jointed structure was used to secure the operating space to not interfere with the camera and the surgeon's right hand. The operating field was developed, and the tumor was incised by stable traction. After the excision, the needle was advanced in the direction of the intestinal axis using the multi-jointed holder, and continuous suturing was performed. The patient has no recurrence without any defecation disorder. CONCLUSION: The use of multi-jointed surgical instruments in transanal endoscopic excision of rectal tumors can provide a stable operative field and preserve postoperative function. The advanced flexibility of these instruments allows precise manipulation in the narrow rectal space, resulting in successful tumor resection with minimal invasiveness and no postoperative complications. These findings suggest that multi-jointed instruments are valuable for enhancing the safety and efficacy of minimally invasive rectal surgery.

The application and effect of presuturing with clips in endoscopic full-thickness resection.

There are few studies on presuturing for full-thickness resection. To explore the effect of using clips as a presuturing technique for endoscopic snare resection with an elastic band (ESR-EB). The clinical data of patients who underwent ESR-EB at Shenzhen Second People's Hospital between May 2023 and May 2024 were collected. The patients were divided into presuture and non-presuture groups according to whether tissues were stitched before resection. The general clinical characteristics, tumor growth position, tumor size, tumor growth pattern, pathological type, operation time, resection time, complication rate, number of clips, and postoperative antibiotic usage rate were compared. A total of 73 patients were enrolled, 55 of whom were included in the presuture group and 18 were included in the non-presuture group. There was no difference in age, sex, tumor position, tumor size, or tumor growth pattern between the 2 groups (P > .05). There was no significant difference between the 2 groups in terms of operation time, resection time, pathological diagnosis, number of clips, or complication rate (P > .05). Complete resection was achieved in all of the patients. The perforation diameter in the presuture group was significantly smaller than that in the non-presuture group ([3.20 ±â€…1.56] vs [4.67 ±â€…2.79], [P = .006]). Thirty-three (60%) patients in the presuture group and 16 (88.89%) patients in the non-presuture group received postoperative preventive antibiotics, and the difference between the 2 groups was significant (P = .024). Gastric myometrial lesions <10 mm in diameter can be completely removed via ESR-EB. Clips as a means of presuturing can significantly reduce the perforation diameter and the use of postoperative preventive antibiotics. Moreover, clips as a means of presuturing does not increase the total number of clips used for the procedure and therefore should be considered a feasible, safe and effective technique.

Validity of rapid urease test using swab of gastric mucus to mucosal forceps and 13 C-urease breath test: a multicenter prospective observational study.

BACKGROUND: Theoretically, a rapid urease test (RUT) using a swab of the gastric wall (Swab-RUT) for Helicobacter pylori (H. pylori) is safe. However, the validity and utility of Swab-RUT remain unclear. Therefore, we assessed the validity and utility of Swab-RUT compared to RUT using mucosal forceps of the gastric wall (Forceps-RUT) and 13C-urea breath test (UBT). METHODS: This study was a multicenter prospective observational study. When the examinees were suspected of H. pylori infection during esophagogastroduodenoscopy, we performed Swab-RUT and Forceps-RUT continuously. When the examinees were not suspected of H. pylori infection, we performed Swab-RUT alone. We validated the status of H. pylori infection using UBT. RESULTS: Ninety-four examinees were enrolled from four institutions between May 2016 and December 2020 (median age [range], 56.5 [26-88] years). In this study, the sensitivity, specificity, and accuracy of Swab-RUT to UBT were 0.933 (95% confidence interval: 0.779-0.992), 0.922 (0.827-0.974), and 0.926 (0.853-0.970), respectively. The Kappa coefficient of Swab-RUT to UBT was 0.833, and that of Swab-RUT to forceps-RUT was 0.936. No complications were observed in this study. CONCLUSIONS: Swab-RUT is a valid examination for the status of H. pylori infection compared to the conventional Forceps-RUT.

Improved Hysteroscopic Resection of Endometrial Polyps Using 6-Fr Micro-Scissors and Forceps.

Endometrial polyps commonly contribute to female infertility, and hysteroscopic resection is the established surgical approach for their treatment. Numerous resection methods are available, with the most used and cost-effective options being cold resection employing micro-scissors or hot resection using an electric loop. However, both methods involve sharp resection, posing a challenge in achieving complete polyp removal while avoiding damage to the uterine endometrium. To address this issue, this study proposes an innovative approach: the combined use of the 6 Fr micro-scissors and forceps under hysteroscopy. The method entails utilizing 6 Fr micro-scissors to initially remove large polyps, followed by using 6 Fr micro-forceps to extract the remaining polyp tissue expeditiously and bluntly near the basal layer of the endometrium. This approach not only prevents surgical damage to the basal layer of the endometrium but also mitigates the risk of residual polyps resulting from incomplete resection. This method is particularly suitable for women with fertility requirements, offering additional considerations for the selection of treatment options for endometrial polyp resection.

Design and validation a minimally invasive robotic surgical instrument with decoupled pose and multi-DOF.

High-performance miniature surgical instruments play an important role in complicated minimally invasive surgery (MIS). Based on in-depth analysis of the requirements of MIS and the characteristics of the existing minimally invasive surgical instruments, a multiple degrees of freedom (DOF) robotic surgical instrument with decoupled pose was proposed. Firstly, the design concept of the pose decoupling instrument was described in detail, and its physical structure, transmission structure, and mechanical properties were designed and analyzed. A surgical instrument control algorithm based on the master-slave mode was established. Finally, a physical prototype was developed, and its motion ranges of joints, load capacity, and suture operation performance were comprehensively evaluated, which confirmed the effectiveness of the proposed minimally invasive robotic surgical instrument.

Surgical advantage of modified labial salivary gland biopsy using chalazion forceps: a prospective randomized controlled study.

Labial salivary gland biopsy (LSGB) is one of the specific diagnostic criteria for primary Sjögren's syndrome (pSS). In traditional LSGB, there is no lower lip fixation device, the field of view is unclear due to intraoperative bleeding, and the incision is large, which is unfavourable for healing. The use of auxiliary devices to improve the shortcomings of traditional LSGB technique would be meaningful. Therefore, this case-control study aimed to assess the value of modified LSGB using chalazion forceps as compared with traditional LSGB. After obtaining written informed consent from all participating parents and patients, we randomly assigned 217 eligible participants to undergo LSGB using chalazion forceps (n = 125) or traditional LSGB (n = 92). The outcome variables were surgical time, incision length, intraoperative bleeding, pain score at 24 h after surgery, incision healing status at 7 days after surgery, gland collection, and pathological results. The final diagnostic results of the two surgical methods were compared, and the match rates between the pathological results and the final clinical diagnoses were compared between the two groups. The data were analysed using parametric and nonparametric tests. Compared with the traditional group, the modified group had a smaller incision, shorter operative time, less blood loss, lower 24 h pain score, and better Grade A incision healing at 7 days after surgery (p < 0.01). There was no statistically significant difference between the patients in the two surgical-method groups in terms of the positive biopsy results and the final diagnosis based on expert opinions (p > 0.05). By multivariable regression analysis, only a focus score (FS) of ≥ 1 (p < 0.01), dry eye disease (p < 0.05) and anti-nuclear antibodies (ANA) titre ≥ 1:320 (p < 0.05) were correlated with the diagnosis of pSS. The positive biopsy results of patients in the different surgical-method groups had a biopsy accuracy of > 80.0% for the diagnosis of pSS. The positive biopsy results in the different surgical-method groups were consistent with the expert opinions and the 2016 ACR-EULAR primary SS classification criteria. The modified LSGB using an auxiliary chalazion forceps offers a good safety with a small incision, shorter operative time, less bleeding, reduced pain and a low incidence of postoperative complications.The match rate of LSGB pathological results of the proposed surgical procedure with the final diagnosis of pSS is high.

Reducing Unnecessary Instruments in Tonsil Hemorrhage Trays at a Canadian Tertiary Care Center: A Quality Improvement Project.

BACKGROUND: In the emergency department (ED), there are pre-assembled tonsillar hemorrhage trays for management of post-tonsillectomy hemorrhage and peritonsillar abscess. After use, the tray is sent to the medical device reprocessing (MDR) department for decontamination, sterilization, and re-organization, all at a significant cost to the hospital and environment. OBJECTIVE: The goal of this project was to reduce unnecessary instruments on the tonsil hemorrhage tray by 30% by 1 year and report on the associated cost and carbon dioxide (CO2) emissions savings. METHODS: This quality improvement project was framed according to the Institute for Healthcare Improvement's Model for Improvement. ED and Otolaryngology-Head & Neck Surgery staff and residents were surveyed to determine which instruments on the tonsil hemorrhage trays were used regularly. Based on results, a new tray was developed and compared to the old tray using MDR data and existing CO2 emissions calculations. RESULTS: Tray optimization resulted in a total cost reduction from $1092.63 to $330.21 per tray per year, decreased processing time from 12 to 6-8 minutes per tray, and decreased CO2 emissions from 6.11 to 2.85 kg per year for the old versus new tray, respectively. Overall, the new tray contains half the number of instruments, takes half the time to assemble, produces 50% less CO2 emissions, and will save the hospital approximately $100,000 over 10 years. CONCLUSION: Healthcare costs and environmental sustainability are collective responsibilities. Surgical and procedure tray optimization is a simple, effective, and scalable form of eco-action.

Comparative analysis of tubular retractors and hook retractors in oblique lumbar interbody fusion at the initial stage of the learning curve.

PURPOSE: Oblique lumbar interbody fusion (OLIF) still has a steep learning curve that many spinal surgeons who want to develop are hesitant. The purpose of this study is to provide reference for beginners through the comparative analysis of the application of two kinds of retraction devices in the early stage of learning curve. METHOD: We prospectively included the first 60 patients with lumbar degenerative diseases treated with OLIF by a surgeon in our department. According to the application of different retraction devices during the operation, the patients were divided into hook retractor group and tubular retractor group. The clinical effects and complications of the two groups were compared. RESULT: The average age of hook retractor group was 62 years old, the average age of tubular retractor group was 65 years old. There was no significant difference in age, sex, operative segment, follow-up time and blood loss between the two groups. The operation time in hook retractor group was less than that in tubular retractor group. The incidence of complications in hook retractor group (11.8%) was significantly lower than that in tubular retractor group (38.5%). CONCLUSION: The tubular retractor group has a higher risk of neurovascular injury in the initial stage of learning, as well as the risk of vertebral fracture. In contrast, the hook retractor group has the advantages of simple method, high fault tolerance and relatively low incidence of complications. Therefore, we believe that the application of hook retractor in the early stage of OLIF learning curve is easier to increase the operator's confidence and make OLIF more acceptable.

A Retrospective Study of 290 Patients with Resectable Benign and Malignant Gastric Neoplasms to Compare Postoperative Outcomes of Endoscopic Resection with and without the Internal Traction Method Using a Spring-and-Loop with Clip (S-O Clip).

BACKGROUND The spring-and-loop with clip (S-O clip) consists of a spring and a nylon loop located on one side of the claws of the clip, and is used in gastric endoscopic submucosal dissection (ESD) to allow countertraction. This retrospective study included 290 patients with early gastric neoplasms (eGNs) and aimed to compare postoperative outcomes of ESD with and without the use of the S-O clip. MATERIAL AND METHODS We retrospectively reviewed the data of 347 patients with eGN who underwent ESD, with or without an S-O clip, at our institution between April 1, 2017 and March 31, 2023. Overall, 290 patients were analyzed after excluding ineligible participants. The control group (n=149; adenoma: 1, carcinoma: 148) underwent ESD without an S-O clip between April 2017 and March 2020, while the S-O group (n=141; adenoma: 4, carcinoma: 137) used the clip between April 2020 and March 2023. Primary outcomes included procedure time, en bloc resection rate, and complete resection rate. Subgroup analysis for examined procedure time concerning endoscopist expertise, submucosal fibrosis, and neoplasm locations. RESULTS The S-O group had a shorter procedure time (44.4±23.9 vs 61.1±40.9 min, P<0.001) and a higher complete resection rate (97.9% vs 92.6%, P<0.05) than the control group. Subgroup analysis revealed that the S-O clip significantly reduced procedure time for trainees compared to the control group (40.8±18.3 vs 61.1±35.6 min, P<0.05). CONCLUSIONS The scheduled use of S-O clips in gastric ESD is effective in improving procedural time and complete resection rates, benefiting endoscopists across all experience levels.