Transumbilical laparoscopic surgery using GelPort through an umbilical zigzag skin incision.

INTRODUCTION: We report herein a new method of transumbilical laparoscopic surgery using a GelPort through an umbilical zigzag skin incision. The method involves collaborating with plastic surgeons to ensure the procedure was minimally invasive. MATERIALS AND SURGICAL TECHNIQUE: After marking a zigzag skin incision in the umbilical region, the skin was incised along this line. Then, a GelPort double-ring wound retractor was inserted through the incision, which enlarged the diameter of the fascial opening to 6 cm. The Gelport was latched on the wound retractor ring, following the inflation of the pneumoperitoneum by CO (2). One or more additional ports were inserted as necessary. All operations were performed in the standard fashion. The specimen was easily extracted from the abdomen through the umbilical incision, and anastomosis was performed. Using the above method, we performed the following procedures: one total gastrectomy, one distal gastrectomy, three gastric local resections, five right hemicolectomies, two high anterior resections, three cholecystectomies, and seven transabdominal preperitoneal hernioplasties. All cases were accomplished without any complications using this method. The wounds of the umbilical region were almost "scarless" in all cases. DISCUSSION: We developed an umbilical zigzag skin incision technique to perform abdominal laparoscopic operations using a GelPort, with a minimal number of skin incisions. We consider that our method reduces the technical difficulties associated with laparoscopic surgery and maintains cosmesis.

New procedure for purse-string suture in thoracoscopic esophagectomy with intrathoracic anastomosis.

BACKGROUND: In endoscopic surgery, one of the greatest problems is the difficulty with the reconstructive procedure. This problem frequently makes operating times longer. The authors have performed thoracoscopic esophagectomy and intrathoracic esophagogastric anastomosis for reconstruction using a circular stapler for the esophageal cancer. Although the circular stapler is a useful device for gastrointestinal anastomosis, it was difficult to place a purse-string suture and to fixate the anvil into the proximal esophagus endoscopically. METHODS: The authors devised a new procedure for the placement of the purse-string suture by using an Endo-Stitch device along with a new method to incise the esophageal wall and thereby facilitate fixation of the anvil. RESULTS: The authors attempted this procedure for five patients. The anastomoses were performed successfully. CONCLUSIONS: The new procedure can make endoscopic intrathoracic anastomosis feasible and safe. In addition, this procedure can be applied widely to other endoscopic reconstructions.

More than 1,000 cases of total parathyroidectomy with forearm autograft for renal hyperparathyroidism.

Between March 1981 and December 2000, we performed 1,053 total parathyroidectomies with forearm autograft for advanced renal hyperparathyroidism (HPT). Based on histopathologic and pathophysiologic investigations, surgical treatment should be considered when parathyroid glands show nodular hyperplasia. Measuring parathyroid volume by ultrasonography was useful to detect nodular glands and to determine surgical indications. The clinical effect of parathyroidectomy on the symptoms and biochemical variables was striking. Skeletal deformity, progressive bone loss, and vessel calcification leading to high mortality risk could not be alleviated by even successful surgery, however. To prevent cardiovascular complications, parathyroidectomy should be performed in the relatively early stage of renal HPT. Total parathyroidectomy with forearm autograft is a suitable procedure for renal HPT, especially in patients who require long-term hemodialysis. For surgeons, it is important to remove all parathyroid glands, including supernumerary glands, at the initial operation and to choose adequate parathyroid tissue for the autograft to prevent persistent and recurrent HPT. Although the risk of graft-dependent recurrent HPT is not negligible, enlarged transplanted parathyroid tissue can be removed easily and noninvasively from the forearm under local anesthesia. There is no risk of hypofunction of the autograft.

Mesh plug repair for a small incisional hernia in a cirrhotic patient with ascites: report of a case.

We report herein the case of a patient with severe liver ascites due to cirrhosis in whom a small incisional hernia on a midline incision was successfully treated by a mesh plug repair, a method most commonly employed for groin hernia repair. The hernia sac was dissected and inverted into the abdominal cavity by the mesh plug under epidural anesthesia. The patient's recovery was quick and relatively painless, and there has been no recurrence after 1 year of followup. This case report demonstrates that the method of mesh plug repair may be appropriate for small incisional hernias as well as groin hernias, performed under epidural anesthesia.

Beneficial effect of donor pretreatment with thromboxane A2 synthase inhibitor on the graft survival in pig liver transplantation.

With a known evidence that thromboxane A2 (TxA2) is elevated in the perfusate of the liver transplant (LTx) recipient, TxA2 is likely to play a role in the pathogenesis of preservation reperfusion injury. In this study, effectiveness of donor pretreatment with TxA2 synthase inhibitor, sodium ozagrel (SO), in the prevention of primary nonfunction (PNF) was investigated. LTx was performed for eight pigs which received the grafts treated with SO during harvest surgery (treatment group). Eight other animals were the control group. All of the animals in the treatment group survived longer than 7 days, whereas 37.5% (three of eight) of the control group died from PNF within 3 days postoperative. Significantly lower serum LDH levels were noted in the treatment group than control. Serum thromboxane B2 (TxB2) and 6-keto-PGF1 alpha were both elevated in the control group. However, a significant decrease in TxB2 was noted in the treatment group after reperfusion of the liver graft. Polymorphonuclear leukocyte (PMN) infiltration in the graft after reperfusion was significantly greater in the control group than in the treatment group. Hepatocyte microsteatosis was prominent in the control group after reperfusion. Donor pretreatment with SO was effective in the prevention of PNF after LTx. The beneficial effects of this drug are improvement in microcirculation allowing better perfusion of cold preservative and the blocking effect of platelet-PMN-endothelial interaction which is thought to be a primary etiology in reperfusion injury.

Effectiveness of Carolina rinse solution after cold ischemic storage of rat livers: biochemical and histological analysis using perfusion model.

Using a rat liver perfusion model, the effectiveness of Carolina rinse solution was assessed for the prevention of reperfusion injury after 48 h of cold storage in UW solution. Transaminase levels (GOT, GPT and LDH) of the perfusate were significantly higher in the Ringer group (17 +/- 8, 17 +/- 9 and 191 +/- 97 IU/l, respectively) than in the Carolina group (6 +/- 4, 5 +/- 4 and 21 +/- 20 IU/l) (p < 0.05). The levels of oxygen consumption were also higher in the Carolina group (233 +/- 54 mm Hg) than in the Ringer group (164 +/- 58 mm Hg) (p < 0.05). Histological examination showed severe parenchymal cell damage in the Ringer group, whereas the damage was slight in the Carolina group. Two newly developed monoclonal antibodies, REC16-11 and REC4-1, which specifically react with rat endothelial cells, were used for immunohistochemical studies of the livers. The endothelial cells of central vein and sinusoids were more severely damaged in the Ringer group than in the Carolina group. The present study suggests that Carolina rinse solution is useful for prevention of liver damage from reperfusion injury after cold storage of the graft for organ transplantation.

Phosphomonoesters in the guinea-pig taenia caeci: pH-dependency of the phosphomonoester peaks in 31P-NMR.

In the smooth muscle of guinea-pig taenia caeci, unlike cardiac and skeletal muscles, two prominent peaks are constantly observed in the phosphomonoester (PME) region (at 6.8 and 6.3 ppm) of 31P-NMR spectra. Tissue extracts, whose pH were adjusted to the intracellular pH of 7.1, also showed such peaks. According to the pH-dependency of the chemical shifts of known PMEs, these peaks were identified as phosphorylethanolamine (PEt) and phosphorylcholine (PCh), the intermediary metabolites of membrane phospholipid turnover. In normal solution, the intracellular pH (pH(i)) which was estimated from the chemical shifts of PMEs (PEt 7.07; PCh 7.17) agreed with that from P(i) (7.10). When preparations were exposed to hypoxia and high-Mg2+ conditions, a reasonable correlation was found between estimations of pH(i) from the PME and P(i) peaks. The chemical shifts of these PME peaks may be used for estimation of pH(i), at least, when there is a need to know relative changes of pH(i), as a complementary purpose, and also whenever the P(i) peak is not clearly observed.

Protective effects of Carolina rinse solution against reperfusion injury in canine renal autotransplantation.

To assess the effect of Carolina rinse solution on the renal graft function after cold ischemic storage in the University of Wisconsin solution for 48 h, canine renal transplantation was performed. Survival rate was higher in the kidneys rinsed with Carolina rinse solution (4 of 5, 80%) than that of kidneys rinsed with lactate Ringer's solution (0 of 5, 0%). Postoperative serum creatinine level on day 2 was significantly lower in the Carolina group (3.48 +/- 0.47 mg/dl) than that in the Ringer group (5.60 +/- 0.68 mg/dl) (p < 0.01). All of the grafts in the Carolina group functioned immediately. Whereas, in the Ringer group, none of the grafts functioned postoperatively. Histologically, severe renal damage was observed in the kidneys perfused by lactate Ringer's solution. On the other hand, the damage to the grafts was minimal in the Carolina group. With immunohistochemical staining using factor-VIII-related antigen, the glomeruli were more severely damaged in the kidneys perfused by lactate Ringer's solution than by Carolina rinse solution. The present study showed that Carolina rinse solution was effective in the prevention of the kidney graft damage from reperfusion injury.

31P nuclear magnetic resonance study of phospholipid metabolites in ischemic liver.

To assess the metabolic alterations induced by normothermic hepatic ischemia, 31P nuclear magnetic resonance analysis was performed on liver samples using perchloric acid extraction. In particular, phosphomonoesters and phosphodiesters, the intermediary metabolites of membrane phospholipid turnover, were characterized precisely and quantitated. Phosphocholine and phosphoethanolamine, the precursors of phospholipid anabolism, did not change, while the phosphodiesters decreased. In contrast, alpha-glycerophosphate, which is both a precursor of phospholipid synthesis and the intermediary product of phospholipid degradation, markedly increased following 30 min of normothermic ischemia. These findings suggest that cellular phospholipids are actively degraded during normothermic hepatic ischemia.

Microvascular changes of the liver preserved in UW solution. Pathological and immunohistochemical examination.

Rat livers preserved in University of Wisconsin (UW) solution for 24 h were compared with those preserved in Euro-Collins (EC) solution before and after liver transplantation using an immunohistochemical method. Tissue ATP and total tissue adenine nucleotide (TAN) were measured using HPLC. The levels of TAN in the UW group or the EC group were significantly low compared with the control group (no preservation) after 24-h storage. In the EC group, the levels of tissue adenine nucleotides (TAN) decreased 1 h after reperfusion and never reached control levels. In the UW group, the levels of TAN increased a little 1 h after reperfusion and increased more 3 h after reperfusion. After 24-h preservation, the expression of factor VIII-related antigen (FRA) in endothelial cells of central veins was weak in the EC group; in the UW group, FRA was clearly detected in these cells. After reperfusion, although severe endothelial cell damage to the central veins and numerous FRA-positive substances were observed in EC group, endothelial cells of central veins retained their normal structure and FRA-positive substances were rarely noted in the UW group. In both groups, no endothelial changes were detected in portal veins. From these results, it is concluded that UW solution prevents endothelial cell damage and microcirculatory injury in zone III during the preservation period resulting in prevention of initial graft nonfunction. Also, measurement of the TAN level after reperfusion is useful to predict the function of the graft.