Search

We report the case of a patient with duplication of the inferior vena cava (DIVC) who underwent anterior laparoscopic resection for rectal cancer. A 66-year-old woman presented with abnormal lung shadows on a chest x-ray during a routine health checkup. She was diagnosed with rectal cancer and lung metastasis using colonoscopy and thoracoabdominal computed tomography (CT). In addition, a 3D CT angiography revealed double inferior vena cava, one on either side of the aorta. The preoperative diagnosis was rectal cancer cT3N0M1a(Lung) cStage IVA with DIVC, and a two-stage surgery was planned. The first stage was high anterior laparoscopic resection. This was safely performed because the pre-hypogastric nerve fascia was preserved and the left inferior vena cava was not visualized during the surgery. During the second stage of the surgery, video-assisted thoracoscopic left lower lobectomy was performed and no recurrence was observed for >6 months after the second surgery. [ABSTRACT FROM AUTHOR]

Background: Body mass index (BMI) is commonly used to classify obesity. However, BMI does not always reflect the degree of visceral fat. This study aimed to clarify the usefulness of measuring the depth from the skin to the celiac artery using computed tomography, as a simple predictive index for longer operation time during laparoscopic distal gastrectomy (LDG).Methods: From September 2012 to March 2016, 66 patients who underwent LDG with D1+ lymph node dissection were included. The depth from the skin to the bifurcation of the celiac artery was defined as ‘skin-to-celiac artery distance (SCD).’ The patients were divided into two groups based on the median operation time. [Time scenarios from omentum incision to specimen extirpation and infrapyloric and suprapancreatic lymph node dissections (I-LND, S-LND) were assessed.] The factors eliciting a longer operation time than the median operation time were investigated.Results: From omentum incision to specimen extirpation, BMI, thickness of subcutaneous fat (TSF), and SCD (P = 0.002, P = 0.039, P < 0.001) were the factors associated with longer operation time. Furthermore, BMI, TSF, and SCD in I-LND (P = 0.008, P = 0.022, P < 0.001) and BMI and SCD in S-LND (P < 0.001, P < 0.001) were associated with longer operation time. The multivariate analysis showed that a long SCD was the only significant independent factor to predict an operation time longer than the median operation time (P = 0.001). The best cutoff level of SCD calculated using the receiver operating characteristic curve was 88 mm.Conclusions: This study demonstrated that SCD is a simple predictive index for longer operation time during LDG. [ABSTRACT FROM AUTHOR]

Purpose: Introduction of three-dimensional (3D) display might remove technical obstacles of laparoscopic surgery and improve laparoscopic skills. We analyzed the effect of 3D technology on operative performance during laparoscopic total gastrectomy (LTG) for gastric cancer and assessed its advantages over two-dimensional (2D) laparoscopy. Methods: This study included 30 consecutive surgeries of LTG with esophagojejunostomy by the overlap method performed (3D group, n = 15, 2D group, n = 15). The surgical outcomes were compared between the 3D and 2D groups. Further, we compared the performance time, the frequency of bleeding requiring hemostasis, and the frequency of remaking the surgical view by the assistant's forceps in each laparoscopic scene between the 3D and 2D groups. Results: All surgeries were completed without any complications. The total time of pure laparoscopic scenes was shorter in the 3D than 2D group (154.2 vs. 182.7 min, P = 0.026), and total blood loss was almost the same (10 vs. 20 g, P = 0.195). The operative time during lymphadenectomy in scenes 6 and 7 were significantly shorter in the 3D than the 2D group (scene 6, 13.5 vs. 17.5 min, P = 0.003, and scene 7, 12.4 vs. 18.4, P = 0.025) and esophagojejunostomy (30.3 vs. 39.4 min, P = 0.008). The frequency of tissue exposure by the assistant was significantly less in the 3D group than the 2D group in scenes 6 and 7 (scene 6, n = 3.0 vs. 4.0, P = 0.006, and scene 7, n = 3.0 vs. 4.0, P = 0.017). Conclusions: 3D display is useful due to improvement of surgical skill during difficult situations such as lymphadenectomy around the celiac artery, which requires handling in the tangential view, and reconstruction using the suturing technique in a narrow space. [ABSTRACT FROM AUTHOR]

Purpose: Minimally invasive esophagectomy (MIE) has less morbidity than the open approach. In particular, thoracoscopic esophagectomy in the prone position (TEP) has been performed worldwide. Using the cumulative sum control chart (CUSUM) method, this study aimed to confirm whether a trainee surgeon who learned established standards would become skilled in TEP with a shorter learning curve than that of the mentoring surgeon. Methods: Surgeon A performed TEP in 100 patients; the first 22 patients comprised period 1. His learning curve, defined based on the operation time (OT) of the thoracic procedure, was evaluated using the CUSUM method, and short-term outcomes were assessed. Another 22 patients underwent TEP performed by surgeon B, with outcomes compared to those of surgeon A's period 1. Results: Using the CUSUM chart, the peak point of the thoracic procedure OT occurred at the 44th case in surgeon A's experience of 100 cases. With surgeon A's first 22 cases (period 1), the peak point of the thoracic procedure OT could not be confirmed and graph is expanding soaring at CUSUM chart. The CUSUM chart of surgeon B's experience of 22 cases clearly indicated that the peak point of the thoracic procedure OT occurred at the 17th case. The rate of recurrent laryngeal nerve palsy for surgeon B (9 %) was significantly lower than for surgeon A in period 1 (36 %) ( p = 0.0266). Conclusions: There is some possibility for a trainee surgeon to attain the required basic skills to perform TEP in a relatively short period of time using a standardized procedure developed by a mentoring surgeon. The CUSUM method should be useful in evaluating trainee competence during an initial series of procedures, by assessing the learning curve defined by OT. [ABSTRACT FROM AUTHOR]

We report a case of successful laparoscopic distal gastrectomy with D2 lymph node dissection preserving the common hepatic artery branched from the left gastric artery for advanced gastric cancer with an Adachi type VI (group 26) vascular anomaly. A 76-year-old female patient was admitted with a diagnosis of advanced gastric cancer at the anterior wall to the lesser curvature of the antrum (cT3N0M0 cStage IIA). Dynamic computed tomography showed the ectopia of the common hepatic artery branched from the left gastric artery. We made a diagnosis of an Adachi type VI (group 26) vascular anomaly and performed the abovementioned operation. In this anomaly pattern, scrupulous attention is required to remove the suprapancreatic lymph nodes because the portal vein is located immediately dorsal to those lymph nodes and is at increased risk for the injury in this situation. The common hepatic artery is branched from the left gastric artery, and the hepatic perfusion from the superior mesenteric artery is not present in group 26. Planning to preserve the artery will improve safety when it is possible oncologically. There were no postoperative complications, and the patient was discharged 9 days after the operation. To our knowledge, the present case is the first reported case of a laparoscopic distal gastrectomy with D2 lymph node dissection with an Adachi type VI (group 26) vascular anomaly. Preoperative diagnostic imaging is very important to prevent surgical complications because the reliable identification of vascular anomaly during an operation is very difficult. [ABSTRACT FROM AUTHOR]

Background: In esophageal cancer, lymph nodes along the recurrent laryngeal nerves (RLNs) are thought to be highly involved. Complete dissection of these lymph nodes is recommended but there is limited working space in the left upper mediastinum and advanced dissection skills are required. We present herein a new method for lymphadenectomy along the left RLN, called the Bascule method during prone esophagectomy. Methods: The fundamental concept of this new method is to draw the proximal portion of the divided esophagus and tissue that includes the left RLN and lymph nodes through a gap between the vertebral body and the right scapula. Using this technique, a two-dimensional membrane, similar to the 'esophageal mesenteriolum' (lateral pedicle), will be easily recognizable. Identification and reliable cutting of the tracheoesophageal artery and distinguishing the left RLN from the lymph nodes should be easy. This technique was evaluated in 39 consecutive cases of prone esophagectomy for squamous cell cancer. Results: There were 18 patients who underwent the new method (Bascule method; Bm) and 21 patients who underwent the conventional method (Cm). The duration of the thoracic procedure and dissection along the left RLN was significantly shorter in Bm group than in Cm group (258 ± 30 vs. 291 ± 39 min; p = 0.007 and 66 ± 9 vs. 75 ± 14 min; p = 0.036, respectively). Estimated blood loss in Bm group was 20 ± 11 g compared to 38 ± 32 g in Cm group ( p = 0.028). No intraoperative morbidity related to the left RLN was observed in either group. The hoarseness rate in Bm group was 28 %, which was lower than that in the Cm group (48 %). Conclusions: The Bascule method for lymphadenectomy along the left RLN during prone esophagectomy is technically safe and feasible and reduces operative time and blood loss. [ABSTRACT FROM AUTHOR]

Background: Totally laparoscopic distal gastrectomy (TLDG) with intracorporeal anastomosis has been introduced to achieve safer anastomosis with good vision, and a small wound. However, little is known about the surgical outcomes of newly introduced TLDG compared with established procedures of laparoscopy-assisted gastrectomy (LADG) with extracorporeal anastomosis. Methods: This retrospective study included 114 patients who underwent laparoscopic distal gastrectomy (LDG) between January 2010 and September 2012. The patients were classified into two groups according to the approach of reconstruction (LADG group: n = 74; TLDG group: n = 40). The parameters analyzed included patients, operation details, and operative outcomes. Results: No complication was observed in the TLDG group. Surgical outcomes of the TLDG group, such as mean operation time, estimated blood loss, and rate of conversion to laparotomy were not inferior to the LADG group. Furthermore, postoperative hospital stay of the TLDG group was significantly shorter than the LADG group ( p < 0.05). Conclusion: Surgical outcomes in the newly introduced phase of TLDG were safe as well as feasible compared with established LADG. TLDG has several advantages over LADG, such as shorter post-hospital stay, no incidence of operative complication, adequate working space, and small wound size. Although prospective, randomized control studies are warranted, we submit that TLDG can be used as a standard procedure for LDG. [ABSTRACT FROM AUTHOR]