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Aim: To report the value of adult cadavers for training in minimally invasive surgical (MIS) techniques for pediatric surgery (PS). Materials and Methods: Three teams, each consisting of a board-certified consultant pediatric surgeon (CS), a senior trainee (ST), and a junior trainee (JT), attended a cadaver surgical training (CST) course involving five procedures: thoracoscopic esophagoesophagostomy (TEE), thoracoscopic right lower lobectomy (TRL), laparoscopic fundoplication (LFN), laparoscopic hepaticoduodenostomy (LHD), and laparoscopic ureteroureterostomy (LUU). The same teams also performed LFN on live pigs. Attendees (3 CSs, 3 STs, and 3 JTs) were administered a questionnaire to rate their CST experience according to five criteria (tissue texture, organ size, operative field, "feel," and anatomic relationships) using a 4-point scale with 0 being the worst response. Scores were averaged per procedure per attendee groups and compared. LFN was also compared between a cadaver and a pig. Results: End-point (1): For LFN, cadaver scores were significantly higher than pig scores for anatomic relationships (P = .0001), operative field (P = .0053), and organ size (P = .0481). End-point (2): TRL and LFN were ranked together as being most realistic, followed by TEE and LUU, then LHD. End-point (3): Anatomic relationships and operative field consistently scored highly for all attendee groups. End-point (4): CSs and STs tended to award higher scores than JTs although differences were not statistically significant. Conclusions: CST is a valuable opportunity for PS trainees to experience highly realistic training in minimally invasive surgery. Pig training was inferior. IRB Number: 2019173.

During choledochal cyst (CC) excision, the hepaticojejunostomy anastomosis (HJA) can be performed conventionally (CHJA) or with a Carrel patch (CPA). CPA can increase CHD diameter to 10-13 mm, preventing anastomotic stenosis and intrahepatic bile duct (IHBD) stones but may be at risk for malignant transformation.The medical records of 83 cystic-type CC with CHD ≤ 9 mm followed up for at least 20 years were reviewed retrospectively. Available excised CC specimens (70/83) were re-examined blindly for pre-malignant changes. A questionnaire about suturing narrow lumens was conducted.All 83 had pancreaticobiliary maljunction. Group data were similar. Anastomoses were CPA (n = 43) and CHJA (n = 40). Mean diameter for CPA was 11.4 mm (range: 10-13 mm); for CHJA was 7.4 mm (range: 5-9 mm). Mean follow-up was 27.7 years (range: 20-42). Postoperative anastomotic stenoses were less after CPA: 1/43 (2.3%) versus 5/40 (12.5%) (p = 0.10), but CHJA had significantly more postoperative IHBD stones: 0% versus 4/40 (10.0%) (p 0.05). All IHBD stone patients had anastomotic stenosis. Excised specimens showed no pre-malignant cytology. Lumen diameter ≤ 9 mm was considered challenging by 10/10 surgical trainees and ≤ 7 mm by 16/22 pediatric surgeons.CPA appears to be oncologically safe because of the absence of malignant transformation for at least 20 years.

Purpose To engraft bladder organoids (BO) on de-epithelialized mouse colon using an epithelial replacement technique. Methods BO cultured using bladder specimens from enhanced green fluorescent protein (EGFP) transgenic mice were engrafted to replace proximal colon epithelium stripped from an approximately 1cm long target site in syngeneic wild-type recipient mice (n = 9) by exposure to ethylenediaminetetraacetic acid by infusion and flushing with phosphate buffered saline. Target sites were harvested on postoperative days 2, 7, and 28 for hematoxylin-eosin staining and immunofluorescence. Results Histology on postoperative days 7 and 28 showed BO derived EGFP + cells forming multiple layers on the luminal surface of the colon. Immunohistochemistry showed that EGFP + areas were positive for CK5 and CK14, markers for basal and immature subtype urothelium, respectively, but negative for CA2, a marker for colonic epithelium. Ki67 was detected predominantly in the basal parts of EGFP + areas on post-operative day 7 and day 28. Conclusions This is the first report of successful engraftment of BO in de-epithelialized colon with urothelial tissue reconstituted by actively-proliferating cells. This technique could be developed for augmentation cystoplasty to prevent bladder calculi formation and malignant transformation.

Purpose: Native liver survivors (NLS) after portoenterostomy (PE) for biliary atresia (BA) with normal biomarkers defined as total bilirubin (T-Bil), aspartate aminotransferase (AST)/alanine aminotransferase (ALT) for liver function (LF), cholinesterase (ChE), platelet count (PC), and absence of portal hypertension (PHT) were reviewed to redefine “successful” PE. Methods: 92 post-PE BA patients were classified as NLS-1: normal biomarkers, PHT (-); NLS-2: at least one abnormal biomarker, PHT (-); NLS-3: normal biomarkers, PHT (+); NLS-4: abnormal biomarkers, PHT (+) and reviewed for a maximum 32 years. Results: As of June 2022, 55/92 (59.8%) had received liver transplants and 37/92 (40.2%) were NLS. NLS patients were classified as excellent outcome (EO): NLS-1 (n=10; 27.0%) or non-EO: NLS-2: (n=8; 21.6%), NLS-3: (n=6; 16.2%), and NLS-4: (n=13; 35.1%). Compared with non-EO, EO had PE earlier (50.5 versus 65 days; not significant; p=0.08), significantly earlier onset of symptoms (13 days versus 32 days; p=0.01) and significantly shorter jaundice-clearance (JC; 34.5 days versus 56.0 days; pConclusions: Incidence of “successful” PE or EO is low and correlated with early onset of symptoms and quicker JC.

To assess mid-/long-term quality of life (QOL) of total colonic aganglionosis (TCA) patients.Modified pre-existing QOL assessment tools for general lifestyle (GL), bowel function (BF), and mental health (MH) were administered to postoperative TCA patients from five institutions, who were at least 7 years old to compare Duhamel (with pouch) and Swenson/Soave (without pouch) techniques between children (Ch 7-12 years old), teenagers (Tn 13-19), and adults (Ad 20 and over). For MH, caregivers were also interviewed, but separately. Maximum scores were 12 for GL/MH and 18 for BF.There were 32 subjects. GL and BF scores increased significantly from Ch (GL 4.8 ± 2.5, BF: 11.3 ± 4.6) to Tn (GL 7.8 ± 2.6, BF 16.2 ± 3.0); scores for MH did not change significantly. Mean caregiver MH scores were significantly lower than mean subject MH scores for all age groups (subject scores: 10.1, 10.7, 10.7 versus caregiver scores: 6.8, 7.8, 8.1 for Ch, Tn, Ad, respectively). PT technique/presence of a pouch did not influence the incidence of enterocolitis or QOL scores.MH responses showed subjects felt better than caregivers believed. This discrepancy could cause conflict despite steadily improving GL/BF. QOL was unaffected by PT technique/presence of a pouch.

Heterophylly is the development of different leaf forms in a single plant depending on the environmental conditions. It is often observed in amphibious aquatic plants that can grow under both aerial and submerged conditions. Although heterophylly is well recognized in aquatic plants, the associated developmental mechanisms and the molecular basis remain unclear. To clarify these underlying developmental and molecular mechanisms, we analyzed heterophyllous leaf formation in an aquatic plant, Callitriche palustris. Morphological analyses revealed extensive cell elongation and the rearrangement of cortical microtubules in the elongated submerged leaves of C. palustris. Our observations also suggested that gibberellin, ethylene, and abscisic acid all regulate the formation of submerged leaves. However, the perturbation of one or more of the hormones was insufficient to induce the formation of submerged leaves under aerial conditions. Finally, we analyzed gene expression changes during aerial and submerged leaf development and narrowed down the candidate genes controlling heterophylly via transcriptomic comparisons, including a comparison with a closely related terrestrial species. We discovered that the molecular mechanism regulating heterophylly in C. palustris is associated with hormonal changes and diverse transcription factor gene expression profiles, suggesting differences from the corresponding mechanisms in previously investigated amphibious plants., We identified the key gene set and the hormonal control basis for the drastic heterophylly of an aquatic plant, Callitriche palustris.

The Internet of Things (IoT) with its support for cyber-physical systems (CPS) will provide many latency-sensitive services that require very fast responses from network services. Mobile edge computing (MEC), one of the distributed computing models, is a promising component of the low-latency network architecture. In network architectures with MEC, mobile devices will offload heavy computing tasks to edge servers. There exist numbers of researches about low-latency network architecture with MEC. However, none of the existing researches simultaneously satisfy the followings: (1) guarantee the latency of computing tasks and (2) implement a real system. In this paper, we designed and implemented an MEC based network architecture that guarantees the latency of offloading tasks. More specifically, we first estimate the total latency including computing and communication ones at the centralized node called orchestrator. If the estimated value exceeds the latency requirement, the task will be rejected. We then evaluated its performance in terms of the blocking probability of the tasks. To analyze the results, we compared the performance between obtained from experiments and simulations. Based on the comparisons, we clarified that the computing latency estimation accuracy is a significant factor for this system.

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an effective biliary drainage procedure in adult cases with difficult biliary access. However, there have been no reports on this procedure being used in pediatric cases. We successfully performed EUS-HGS in a pediatric case with a surgically altered anatomy. A standard convex-type echoendoscope and standard devices were used, and there were no device-related complications. The benefit of EUS-HGS for pediatric patients was avoidance of a percutaneous tube, which is difficult to maintain in active children. The accumulation of further cases and performance of a prospective study are warranted to standardize and expand the experience with this procedure.

The above-ground organs in plants display a rich diversity, yet they grow to characteristic sizes and shapes. Organ morphogenesis progresses through a sequence of key events, which are robustly executed spatiotemporally as an emerging property of intrinsic molecular networks while adapting to various environmental cues. This Review focuses on the multiscale control of leaf morphogenesis. Beyond the list of known genetic determinants underlying leaf growth and shape, we focus instead on the emerging novel mechanisms of metabolic and biomechanical regulations that coordinate plant cell growth non-cell-autonomously. This reveals how metabolism and mechanics are not solely passive outcomes of genetic regulation but play instructive roles in leaf morphogenesis. Such an integrative view also extends to fluctuating environmental cues and evolutionary adaptation. This synthesis calls for a more balanced view on morphogenesis, where shapes are considered from the standpoints of geometry, genetics, energy and mechanics, and as emerging properties of the cellular expression of these different properties.

Purpose: The high incidence of scarring and vascular compromise after failed hypospadias repair greatly compromises salvage urethroplasty. Pedicled soft tissue reinforcement (STR) is presented for enhancing the potential for success.Methods: The impact of lateral reinforcement of the scarred urethral plate to boost thickness and perfusion at the time of curvature correction (called CHARGE by the authors) and covering the neourethra at the time of urethroplasty (NUC) used as STR during salvage tubularized incised plate urethroplasty performed between 2003 and 2019 were assessed by retrospective review of the medical records of 8 cases of failed hypospadias repair. Results: Types of hypospadias were perineal/penoscrotal (n=7), and mid-shaft (n=1). Indications for salvage surgery included residual penile curvature (n=5), urethral diverticulum >15mm (n=3), urethral dehiscence (n=1), and urethral stricture (n=1). Salvage surgery was single-stage (urethroplasty at the same of curvature correction; n=1) or multi-stage (n=7; two-stage: n=4, three-stage: n=3). All cases had NUC and 4/8 had CHARGE. All salvage repairs were successful with no incidence of postoperative complications after mean follow-up of 3.9 years (range: 1.6-6.4 years) after the last procedure.Conclusion: STR most likely enhanced tissue perfusion/pliability which ensured the success of salvage urethroplasty for failed hypospadias repair.

Near-infrared spectroscopy (NIRS) was used to monitor intraoperative regional oxygen saturation (rSONIRS sensors were applied to the forehead and flanks for cerebral rSOMean ages at surgery were N: 5.2 ± 8.2 days, MOp: 2.4 ± 2.9 years, and MMI: 3.8 ± 4.3 years. Despite significantly shorter operative times in N (169 ± 94 min; p 0.0001), PD was significantly worse; PD(C-rSO

Aim: To present the use of an additional trocar (AT) in the lower thorax during thoracoscopic pulmonary lobectomy (TPL) in children with congenital pulmonary airway malformation.Methods: For a lower lobe TPL (LL), an AT is inserted in the 10th intercostal space (IS) in the posterior axillary line after trocars for a 5-mm 30° scope, and the surgeon's left and right hands are inserted conventionally in the 6th, 4th, and 8th IS in the anterior axillary line, respectively. For an upper lobe TPL (UL), the AT is inserted in the 9th IS, and trocars are inserted in the 5th, 3rd, and 7th IS, respectively. By switching between trocars (6th↔8th for the scope, 4th↔6th for the left hand, and 8th↔10th for the right hand during LL and 5th↔7th, 3rd↔5th, and 7th↔9th during UL, respectively), vital anatomic landmarks (pulmonary veins, bronchi, and feeding arteries) can be viewed posteriorly. The value of AT was assessed from blood loss, operative time, duration of chest tube insertion, requirement for post-operative analgesia, and incidence of perioperative complications.Results: On comparing AT+ (n = 28) and AT– (n = 27), mean intraoperative blood loss (5.6 vs. 13.0 ml), operative time (3.9 vs. 5.1 h), and duration of chest tube insertion (2.2 vs. 3.4 days) were significantly decreased with AT (p < 0.05, respectively). Differences in post-operative analgesia were not significant. There were three complications requiring conversion to open/mini-thoracotomy: AT– (n = 2; bleeding), AT+: (n = 1; erroneous stapling).Conclusions: An AT and switching facilitated posterior dissection during TPL in children with congenital pulmonary airway malformation enhancing safety and efficiency.

In children with choledochal cyst (CC), the diameter at the hepaticojejunostomy anastomosis (HJA) is usually less than 10 mm. The da Vinci surgical system (dV) has been used successfully for treating CC in children, but lack of haptic feedback can hinder suturing at times. We describe a simple maneuver that allows dV-assisted HJA (dV-HJA) to be completed successfully without haptic feedback. The maneuver involves placing the final three 5/0 or 6/0 absorbable sutures between the incision in the Roux-loop jejunum and the common hepatic duct for closing the anterior wall, without tying any of them. Only after all sutures have been placed, they are tied. The tie should never be performed before all the sutures have been placed, because if any one of the last 3 sutures is tied prior the others being placed, the surgeon will not be able to “see” where to place the subsequent suture. Even the smallest HJA should be possible to be completed confidently using this maneuver. We treated 13 consecutive children with CC during a recent 3-year period using this maneuver during dV-HJA. Mean age at surgery: 5.8 years (range 1.8–11.2 years); mean weight at surgery: 18.5 kg (range 9.4–35.6 kg). Mean HJA diameter was 7.9 ± 3.2 mm (range 4–15 mm). All HJA were performed successfully with no reports of anastomotic leakage or anastomotic stenosis after a mean follow-up of 22 months (range 4–34 months). The described maneuver provides the surgeon with visual cues to complete suturing successfully and confidently when haptic feedback is lacking.

Introduction: A modified pull-through (PT) distinguished by complete full-thickness removal of the posterior rectal cuff, initially developed as an open procedure in 1980, has been performed with l...

The safety and success of laparoscopic choledochal cyst surgery (LapCC) depends upon two critical elements during the hepaticojejunostomy anastomosis (HJA). These may be termed the Difficulty of Differentiation (DOD) and the Difficulty of Suturing (DOS). The type of imaging system (2 or 4 K) used may influence either of these. We compared outcomes of LapCC using 2 or 4 K imaging systems.LapCC were performed at a single institution by the same team using a 2 K system (2009-2018; n = 26) and a 4 K system (2018-2019; n = 11) were compared. 4 K cases were chosen to match 2 K cases to minimize bias. Five independent senior pediatric surgeons scored DOD and DOS blindly from intraoperative video recordings of LapCC using a subjective 5-point scale (5: impossible, 4: difficult, 3: tedious, 2: slow, and 1: easy) and rated their over all impression as +1 if 4 K was better, 0 if they were the same, and -1 if 4 K was worse. Total HJA anastomosis time (TAT) and TAT/suture were also calculated.LapCC was performed in 37 age/weight/HJA diameter matched children. Scores for DOD (p0.001) were lower with 4 K with less variance, although there was no difference in DOS (p = 0.08). Operative time (p = 0.03) and duration of hospitalization (p 0.001) were significantly shorter with 4 K. 4 K was rated +1 unanimously. There was no difference in TAT (p = 0.17) and TAT/suture (p = 0.22). There was one HJA leak with 2 K (3.8%) and no complications with 4 K.Improved resolution with 4 K improved the progress of surgery as reflected by shorter operative time and duration of hospitalization, enhancing the performance of LapCC in children.III.

Controlling the distribution of stomata is crucial for the adaptation of plants to new, or changing environments. While many plant species produce stomata predominantly on the abaxial leaf surface (hypostomy), some produce stomata on both surfaces (amphistomy), and the remaining few produce them only on the adaxial surface (hyperstomy). Various selective pressures have driven the evolution of these three modes of stomatal distribution. Despite recent advances in our understanding of stomatal development and dorsiventral leaf polarity, the genetic basis for the evolution of different stomatal distributions is still unclear. Here, we propose the genus Callitriche as a new model system to investigate patterns in the evolution of stomatal distribution. Callitriche comprises species with diverse lifestyles, including terrestrial, amphibious, and obligately aquatic plants. We found that species in this genus cover all three modes of dorsiventral stomatal distribution, making it a desirable model for comparative and evolutionary analyses on distribution modes. We further characterized the genetic basis of the different distribution modes, focusing on the stomatal key transcription factor SPEECHLESS. Future research using the promising model system Callitriche would open a new direction for evolutionary developmental biology studies on stomata.

To document the recovery of bowel function (BF) in children after transperitoneal (TP) or retroperitoneal (RP) laparoscopic pyeloplasty. Data were obtained retrospectively from four centers between 2008 and 2019 for TP (n = 51) and RP (n = 58). Each surgeon chose which technique to perform. Subject demographics were not significantly different. Differences in operative times were not significant (RP: 241 min versus TP: 225 min). Mean duration/requirement for postoperative epidural/intravenous analgesia were not significantly different (TP: 1.4 days versus RP: 1.3 days) and (TP: 66.7% versus RP: 67.2%), respectively. Postoperative nasogastric (NG) intubation was more common in RP (TP: 19.6% versus RP: 44.8%; p

Refinement of organoid technology is important for studying physiology and disease of the intestine. We aimed to optimize defined serum-free conditions for human infant small intestinal (SI) organoid culture with predetermined doses of Wnt3a and Rspo1 from surgical specimens. We further assessed whether intestinal specimens could be stored before use as a source of organoids. Different doses of Wnt3a and Rspo1 in a serum-free medium were tested to establish a condition in which surgically resected SI cells grew as organoids over multiple passages. The expression of marker genes for stem and differentiated cells was assessed by quantitative polymerase chain reaction. We also investigated the organoid-forming efficiency of cells in degenerating intestines stored at 4 °C for various intervals post-resection. We determined the doses of Wnt3a and Rspo1 required for the continuous growth of infant SI organoids with multi-differentiation potential. We revealed that, despite the time-dependent loss of stem cells, tissues stored for up to 2 days preserved cells capable of generating amplifiable organoids. SI cells can be grown as organoids under defined conditions. This could provide a reproducible and customizable method of using surgical specimens for the study of intestinal maturation and their relevance to pediatric diseases.

Most of latency-sensitive mobile applications depend on computational resources provided by a cloud computing service. The problem of relying on cloud computing is that, sometimes, the physical locations of cloud servers are distant from mobile users and the communication latency is long. As a result, the concept of distributed cloud service, called mobile edge computing (MEC), is being introduced in the 5G network. However, MEC can reduce only the communication latency. The computing latency in MEC must also be considered to satisfy the required total latency of services. In this research, we study the impact of both latencies in MEC architecture with regard to latency-sensitive services. We also consider a centralized model, in which we use a controller to manage flows between users and mobile edge resources to analyze MEC in a practical architecture. Simulations show that the interval and controller latency trigger some blocking and error in the system. However, the permissive system which relaxes latency constraints and chooses an edge server by the lowest total latency can improve the system performance impressively.

The incidence of perforation during antibiotic therapy (AT) of children triaged as non-complicated acute appendicitis (NC-Ap) was investigated. Abdominal ultrasonography (US) and/or computed tomography (CT) scans from cases of perforation identified at appendectomy for failed AT were reassessed blindly by a panel of board-certified specialists for any evidence of pre-AT morbidity suggestive of perforation. Of 521 cases triaged as NC-Ap, symptoms resolved with AT in 452 cases (86.8%). All 69/521 (13.2%) cases with persistent symptoms had urgent appendectomy, and 12/521 (2.3%) were found to have perforated. Blind reassessment of US and/or CT scans from these cases identified seven with evidence of perforation when they were triaged as NC-Ap. Thus, the actual incidence of perforation during AT for NC-Ap was actually 12–7 = 5/521 (0.95%). Perforation is generally believed to be a complication of AT, but inappropriate triaging of cases for AT can bias results by artificially inflating the number of perforations, in this study, by more than double. We are the first to assess the unbiased incidence of perforation during AT for NC-Ap, by reassessing pre-AT US and/or CT scans. The incidence of perforation during AT is actually negligible.

Aim: In children, the diameter at the hepaticojejunostomy anastomosis (HJA) can range from 10 mm to less than 5 mm, irrespective of the type of choledochal cyst (CC). We developed a maneuv...

We describe our modified retroperitoneal laparoscopic pyeloplasty (MRLP) and assess the incidence of anastomotic stricture and torsion of the ureter in the mid-term. We reviewed 12 patients with ureteropelvic junction obstruction (UPJO) we treated with MRLP between 2013 and 2018. MRLP involves: identifying the lowest point of the renal pelvis and the lateral aspect of the ureter to ensure correct orientation of the anastomosis; placing the first suture between the lower edge of the incised pelvis and the distal end of the spatulated ureter to avoid crushing tissue that will be anastomosed; and complete excision of the narrow segment. All MRLP were completed successfully without conversion. UPJO was resolved completely, both clinically and radiologically, in all cases. Mean age at surgery was 6.8 years (range: 1.7–8.8 years); mean operative time was 212.1 min (range: 170–333 min); mean estimated blood loss was 4.2 mL (range: 2–8 mL); mean follow-up was 36.7 months (range: 6–65 months); mean post-operative differential renal function on the affected side was 53.1 ± 13.7% (range: 37.0–87.2%), increased from 44.9 ± 16.0% (range: 27.0–84.3%), pre-operatively (p = 0.02). All remain completely cured after mean follow-up of 36.7 ± 19.7 months (range: 6–65). Our MRLP is safe and effective despite limited retroperitoneal space.

Packet losses significantly degrade TCP performance in high-latency environments. This is because TCP needs at least one round-trip time (RTT) to recover lost packets. The recovery time will grow longer, especially in high-latency environments. TCP keeps transmission rate low while lost packets are recovered, thereby degrading throughput. To prevent this performance degradation, the number of retransmissions must be kept as low as possible. Therefore, we propose a scheme to apply a technology called “forward error correction” (FEC) to the entire TCP operation in order to improve throughput. Since simply applying FEC might not work effectively, three function, namely, controlling redundancy level and transmission rate, suppressing the return of duplicate ACKs, interleaving redundant packets, were devised. The effectiveness of the proposed scheme was demonstrated by simulation evaluations in high-latency environments.

Background: Multicenter study was undertaken to analyze the results of laparoscopic and open Kasai portoenterostomy. Methods: Subjects were infants with type III biliary atresia who underwent open operation (n = 106) or laparoscopic operation (n = 21) between January 2012 and December 2015. Clinical data were compared between open and laparoscopic operations (2016‐0534). Propensity score matching was performed to reduce the effect of treatment selection bias. Multivariate analyses were used to estimate the effect of the surgical approach on the jaundice clearance rate and the native liver survival rate. Results: The postoperative jaundice clearance rate and the 1‐year native liver survival rate were not significantly different between open and laparoscopic operations. Rates of cholangitis and major complications of laparoscopic operation were comparable to those of open operation. Blood loss, time to resume oral intake, time to drain removal, and duration of analgesic usage of laparoscopic operation were significantly superior to those of open operation. Similar results were observed when analysis was adjusted based on propensity score. Multivariate analyses demonstrated that only age at operation was a poor prognostic factor. Conclusion: Laparoscopic Kasai portoenterostomy was associated with several favorable perioperative outcomes compared with open Kasai portoenterostomy. The difference of surgical approach was not a significant independent predictor., ファイル公開：2020-01-24

Purpose: We compared laparoscopic redo fundoplications performed for failed laparoscopic Toupet fundoplication (LTF) and failed laparoscopic Nissen fundoplications (LNFs). Methods: Redo LTF (R-LTF; n = 4) and redo LNF (R-LNF; n = 6) performed between 2007 and 2014 were assessed retrospectively for severity of intraperitoneal adhesions on a scale of 0–3, identification/preservation of the anterior/posterior/hepatic branches of the vagus nerve (VN), complications, and outcome. Results: Redos were performed after a mean of 34 months in R-LTF and 32 months in R-LNF (P = ns) indicated for sliding hernia (n = 3; 2 with partial wrap dehiscence) and partial wrap dehiscence (n = 1) in R-LTF and sliding hernia (n = 6; 4 with partial wrap dehiscence) in R-LNF. The mean adhesion severity score was 1.5 in R-LTF and 2.5 in R-LNF (P < 0.05). The mean number of VN branches identified/preserved was 2.0 in R-LTF and 0.8 in R-LNF (P < 0.05). Mean operative times and mean blood loss were similar. Intraoperative complications were accidental local trauma (n = 1 in R-LTF and n = 3 in R-LNF, one requiring conversion to open repair) (P = ns). Gastric outlet obstruction developed in two R-LNF cases; both were managed conservatively. There have been no further recurrences to date. Conclusion: Although our series is small, adhesions were less, and identification/preservation of VN was easier during R-LTF.

Significance Plant stomata are produced through divisions and differentiation of stem cells, termed meristemoids. During stomatal development, we see diverse patterns of meristemoid behavior among land plant lineages. However, both the ecological significance and the diversification processes of this diversity remain mostly unknown. Here we report that the ecologically diverse genus Callitriche shows unprecedented intrageneric diversity in meristemoid behavior. While meristemoids in terrestrial species of Callitriche undergo a series of asymmetric divisions before differentiation, those in amphibious species skip the divisions and directly differentiate into stomata. The simple shift in the expression times of two key transcription factors underlies these different patterns. This study provides important insights into the evolution and ecological significance of stomatal patterning., Stomata, the gas exchange structures of plants, are formed by the division and differentiation of stem cells, or meristemoids. Although diverse patterns of meristemoid behavior have been observed among different lineages of land plants, the ecological significance and diversification processes of these different patterns are not well understood. Here we describe an intrageneric diversity in the patterns of meristemoid division within the ecologically diverse genus Callitriche (Plantaginaceae). Meristemoids underwent a series of divisions before differentiating into stomata in the terrestrial species of Callitriche, but these divisions did not occur in amphibious species, which can grow in both air and water, in which meristemoids differentiated directly into stomata. These findings imply the adaptive significance of diversity in meristemoid division. Molecular genetic analyses showed that the different expression times of the stomatal key transcription factors SPEECHLESS and MUTE, which maintain and terminate the meristemoid division, respectively, underlie the different division patterns of meristemoids. Unlike terrestrial species, amphibious species prematurely expressed MUTE immediately after expressing SPEECHLESS, which corresponded to their early termination of stomatal division. By linking morphological, ecological, and genetic elements of stomatal development, this study provides significant insight that should aid ecological evolutionary developmental biology investigations of stomata.