Novel reconstruction using pedicled ileocolic interposition with intrathoracic esophago-ileal anastomosis after distal esophagectomy for esophagogastric junction cancer: A report of two cases.

There is no optimal reconstruction after radical distal esophagectomy for cancers of the esophagogastric junction. We designed a novel reconstruction technique using pedicled ileocolic interposition with intrathoracic anastomosis between the esophagus and the elevated ileum. Two patients underwent the surgery. Case 1 was a 70-year-old man with esophagogastric junction adenocarcinoma with 3 cm of esophageal invasion. Case 2 was a 70-year-old man with squamous cell carcinoma of the esophagogastric junction; the epicenter of which was located just at the junction. These two patients underwent radical distal esophagectomy and pedicled ileocolic interposition with intrathoracic anastomosis. They were discharged on postoperative days 17 and 14, respectively, with no major complication. Pedicled ileocolic interposition is characterized by sufficient elevation and perfusion of the ileum, which is fed by the ileocolic artery and vein. As a result, we can generally adapt this reconstruction method to most curable esophagogastric junction cancers.

A pediatric case of Burkitt's lymphoma with bile duct obstruction requiring surgical biliary reconstruction.

BACKGROUND: Biliary obstruction due to compression by a B-cell solid tumor occurs rarely. A few reports have described biliary reconstruction surgery for obstructive jaundice caused by Burkitt's lymphoma. However, there are no detailed reports on pediatric cases. We report a pediatric case of obstructive jaundice due to malignant lymphoma treated with biliary reconstruction surgery. CASE PRESENTATION: A 5-year-old girl presented to our hospital with a massive abdominal tumor that caused biliary stricture. Chemotherapy was initiated after an open tumor biopsy. However, endoscopic biliary stent placement was performed owing to elevated bilirubin levels. We treated the patient with chemotherapy for 9 months while endoscopically replacing the biliary stent every few months. She achieved complete tumor remission. However, sclerotic lymph nodes were persistent on the dorsal side of the cholecystic duct junction, and biliary stricture at the same site had changed to stent-dependent biliary obstruction. Therefore, we performed choledochojejunostomy and retrocolic Roux-en-Y reconstruction 15 months after initial admission. There were no postoperative complications or tumor recurrences, and the bilirubin level remained low. Histopathologically, the resected bile duct wall was fibrotic and thick, and the bile duct lumen narrowed. CONCLUSIONS: Biliary reconstruction is effective to achieve long-term biliary patency in pediatric patients with stent-dependent biliary obstruction due to malignant lymphoma. However, the decision on when to stop biliary stent replacement and proceed to biliary reconstruction surgery is a matter of debate. Further case studies are required to address this issue.

Transcriptome Analysis: A Powerful Tool to Understand Individual Microbial Behaviors and Interactions in Ecosystems.

Transcriptome analysis is a powerful tool for studying microbial ecology, especially individual microbial functions in an ecosystem and their interactions. With the development of high-throughput sequencing technology, great progress had been made in analytical methods for microbial communities in natural environments. 16S rRNA gene amplicon sequencing (i.e., microbial community structure analysis) and shotgun metagenome analysis have been widely used to determine the composition and potential metabolic capability of microorganisms in target environments without requiring culture. However, even if the types of microorganisms present and their genes are known, it is difficult to determine what they are doing in an ecosystem. Gene expression analysis (transcriptome analysis; RNA-seq) is a powerful tool to address these issues. The history and basic information of gene expression analysis, as well as examples of studies using this method to analyze microbial ecosystems, are presented.

Assessing microbial stability and predicting biogas production in full-scale thermophilic dry methane fermentation of municipal solid waste.

Compared to typical anaerobic digestion processes, little is known about both sludge microbial compositions and biogas production models for full-scale dry methane fermentation treating municipal solid waste (MSW). The anaerobic sludge composed of one major hydrogenotrophic methanogen (Methanoculleus) and syntrophic acetate oxidizing bacteria (e.g., Caldicoprobacter), besides enrichment of MSW degraders such as Clostridia. The core population remained phylogenetically unchanged during the fermentation process, regardless of amounts of MSW supplied (∼35 ton/d) or biogas produced (∼12000 Nm3/d). Based on the correlations observed between feed amounts of MSW from 6 days in advance to the current day and biogas output (the strongest correlation: r = 0.77), the best multiple linear regression (MLR) model incorporating the temperature factor was developed with a good prediction for validation data (R2 = 0.975). The proposed simple MLR method with only data on the feedstock amounts will help decision-making processes to prevent low-efficient biogas production.

Clinical impact of skeletal muscle mass change during the neoadjuvant chemotherapy period in patients with gastric cancer: An ancillary study of JCOG1002.

BACKGROUND: Recent studies have revealed that sarcopenia is associated with postoperative complications and poor prognosis. Although neoadjuvant chemotherapy is a promising treatment for gastric cancer, its toxicity may lead to the loss of skeletal muscle mass. This study investigates the changes in skeletal muscle mass during neoadjuvant chemotherapy and its clinical impact on patients with locally advanced gastric cancer. METHODS: Fifty patients who completed two courses of neoadjuvant chemotherapy followed by surgery were included. Skeletal muscle mass was measured using computed tomography images before and after chemotherapy. The proportion of skeletal muscle mass change (%SMC) during neoadjuvant chemotherapy and its cutoff value was explored using the receiver operating characteristic for the overall survival of patients undergoing R0 resection. Risk factors of skeletal muscle mass loss were also evaluated. RESULTS: Overall, 64% of patients had skeletal muscle mass loss during neoadjuvant chemotherapy (median %SMC -3.4%; range: -18.9% to 10.3%). Multivariable analysis identified older age (≥70 years) as an independent predictor of skeletal muscle mass loss (mean [95% confidence interval]: -4.70% [-8.83 to -0.58], p = 0.026). Among 43 patients undergoing R0 resection, %SMC <-6.9% was an independent poor prognostic factor for overall survival (hazard ratio, 11.53; 95% confidence interval, 2.78-47.80) and relapse-free survival (hazard ratio 4.54, 95% confidence interval 1.50-13.81). CONCLUSIONS: Skeletal muscle mass loss occurs frequently during neoadjuvant chemotherapy for locally advanced gastric cancer and could adversely affect survival outcomes.

Does self-reported physical activity relate to physical function and walking ability in female patients with hip osteoarthritis? A cross-sectional multicenter study.

BACKGROUND: The effectiveness of a high level of physical activity in maintaining physical function in patients with hip osteoarthritis has not been adequately examined. OBJECTIVE: This study aimed to determine whether self-reported physical activity is associated with physical function and walking ability in female patients with hip osteoarthritis. METHODS: This was a multicenter cross-sectional study. The dependent variables were the lower-limb range of motion and muscle strength, and walking ability. Self-reported physical activity was assessed according to the guidelines of the Japanese Ministry of Health, Labor, and Welfare. Multiple regression models were used to determine whether physical activity was significantly related to the dependent variables after adjusting for confounding factors (age, body mass index, hip pain, comorbidity, and severity of hip osteoarthritis). RESULTS: A total of 167 participants were included in the study. Physical activity was associated with muscle strength in hip flexion (affected/unaffected, ß = 0.18/ß = 0.16), abduction (ß = 0.19/ß = 0.26), knee extension (ß = 0.22/ß = 0.26), Timed Up-and-Go test (ß = -0.16), and 5-m walking time test (ß = -0.15). CONCLUSION: In female patients with hip osteoarthritis, greater physical activity was associated with greater lower extremity muscle strength and walking ability.

Risk factors for abdominal surgical infectious complications after distal gastrectomy for gastric cancer: A post-hoc analysis of a randomized controlled trial (JCOG0912).

BACKGROUND: Abdominal surgical infectious complications (ASIC) after gastrectomy for gastric cancer impair patients' survival and quality of life. JCOG0912 was conducted to compare laparoscopy-assisted distal gastrectomy with open distal gastrectomy for clinical stage IA or IB gastric cancer. The present study aimed to identify risk factors for ASIC using prospectively collected data. METHODS: We performed a post-hoc analysis of the risk factors for ASIC using the dataset from JCOG0912. All complications were evaluated according to the Clavien-Dindo classification (CD). ASIC was defined as CD grade I or higher anastomotic leakage, pancreatic fistula, abdominal abscess, and wound infection. Analyses were performed using the logistic regression model for univariable and multivariable analyses. RESULTS: A total of 910 patients were included (median age, 63 years; male sex, 61 %). Among them, ASIC occurred in 5.8 % of patients. In the univariable analysis, male sex (odds ratio [OR] 2.855, P = 0.003), diabetes (OR 2.565, P = 0.029), and Roux-en-Y (R-Y) reconstruction (vs. Billroth Ⅰ, OR 2.707, P = 0.002) were significant risk factors for ASIC. In the multivariable analysis, male sex (OR 2.364, P = 0.028) and R-Y reconstruction (vs. Billroth Ⅰ, OR 2.310, P = 0.015) were independent risk factors for ASIC. CONCLUSIONS: Male sex and R-Y reconstruction were risk factors for ASIC after distal gastrectomy. Therefore, when performing surgery on male patients or when R-Y reconstruction is selected after gastrectomy for gastric cancer, surgeons should pay special attention to prevent ASIC.

Small gastric synovial sarcoma diagnosed and treatment by laparoscopic-endoscopic cooperative surgery: a case report.

We report a case of small gastric synovial sarcoma (SS) finally diagnosed after laparoscopic-endoscopic cooperative surgery (LECS). A 50 year-old male underwent medical examination for a chief complaint of epigastric pain. Endoscopic examination showed a 20 mm submucosal tumor (SMT) located in the anterior wall which extended to the lesser curvature of the middle stomach. The biopsy tissue did not yield a definitive diagnosis. During 6 months of follow-up for this lesion suspected to be an inflammatory tumor, neither the shape nor the size of the tumor changed. We performed LECS for both diagnosis and treatment. Histologically, the tumor was composed of fascicles of spindle cells. Immunohistochemically, the tumor cells were focally positive for epithelial membrane antigen, cytokeratin (AE1/AE3) and S100 protein, while being negative for desmin, α-smooth muscle actin, CD34, c-kit and DOG1. The expression of INI1 was reduced. Fluorescence in situ hybridization (FISH) detected SS18 rearrangement. The SMT was diagnosed as primary SS. A SMT measuring < 20 mm might be malignant potential tumor such as SS even if there are no typical malignant findings by endoscopy. Surgical resection should be considered for SMT measuring < 20 mm with atypical findings even in the absence of definitive high-risk features.

Rare TCF3 variants associated with pediatric B cell acute lymphoblastic leukemia.

Germline genetic variants influence development of pediatric B cell acute lymphoblastic leukemia (B-ALL). Genome-wide association studies (GWAS) have identified several pediatric B-ALL susceptibility loci. IKZF1 and PAX5, transcription factors involved in B cell development, have been reported as susceptibility genes for B-ALL development. Therefore, we hypothesized that rare variants of genes involved in B cell development would be candidate susceptibility loci for pediatric B-ALL. Thus, we sequenced TCF3, a key transcription factor gene involving in B cell development. Saliva DNA from 527 pediatric patients with pediatric B-ALL in remission who were registered with the Tokyo Children's Cancer Study Group (TCCSG) were examined. As a TCF3 gene-based evaluation, the numbers of rare deleterious germline TCF3 sequence variants in patients with pediatric B-ALL were compared with those in cancer-free individuals using data in public databases. As a TCF3 single-variant evaluation, the frequencies of rare deleterious germline TCF3 sequence variants in patients with pediatric B-ALL were also compared with those in control data. TCF3 gene-based analysis revealed significant associations between rare deleterious variants and pediatric B-ALL development. In addition, TCF3 variant-based analysis showed particularly strong association between variant rs372168347 (three in 521 TCCSG and three in the 15780 gnomAD whole genome analysis cohort, p = 0.0006) and pediatric B-ALL development. TCF3 variants are known to influence B cell maturation and may increase the risk of preleukemic clone emergence.

Integrative single-cell RNA-seq analysis of vascularized cerebral organoids.

BACKGROUND: Cerebral organoids are three-dimensional in vitro cultured brains that mimic the function and structure of the human brain. One of the major challenges for cerebral organoids is the lack of functional vasculature. Without perfusable vessels, oxygen and nutrient supplies may be insufficient for long-term culture, hindering the investigation of the neurovascular interactions. Recently, several strategies for the vascularization of human cerebral organoids have been reported. However, the generalizable trends and variability among different strategies are unclear due to the lack of a comprehensive characterization and comparison of these vascularization strategies. In this study, we aimed to explore the effect of different vascularization strategies on the nervous system and vasculature in human cerebral organoids. RESULTS: We integrated single-cell RNA sequencing data of multiple vascularized and vascular organoids and fetal brains from publicly available datasets and assessed the protocol-dependent and culture-day-dependent effects on the cell composition and transcriptomic profiles in neuronal and vascular cells. We revealed the similarities and uniqueness of multiple vascularization strategies and demonstrated the transcriptomic effects of vascular induction on neuronal and mesodermal-like cell populations. Moreover, our data suggested that the interaction between neurons and mesodermal-like cell populations is important for the cerebrovascular-specific profile of endothelial-like cells. CONCLUSIONS: This study highlights the current challenges to vascularization strategies in human cerebral organoids and offers a benchmark for the future fabrication of vascularized organoids.

Microbially produced fertilizer provides rhizobacteria to hydroponic tomato roots by forming beneficial biofilms.

Hydroponic cultivation of Solanum lycopersicum (tomato) is important, and high tomato production depends on the use of nitrogen and phosphate fertilizers. We had developed a microbial fertilizer (MF), which is mainly composed of nitrate. To investigate the effect of MF on plant growth, hydroponic tomato was grown with MF or commercial inorganic fertilizer (IF), and the microbiomes of the rhizosphere and the liquid phase were analyzed by confocal microscopy and high-throughput sequencing. Plant biomass and biofilm formation were increased by growth in MF compared to IF. The microbial community structures of tomato roots and hydroponic water differed between the two conditions, and three operational taxonomic units (OTUs) dominated in plants grown with MF. The three OTUs were related to Rudaea spp., Chitinophaga spp., and Stenotrophobacter terrae, which are reported to be disease-suppressive epiphytic or endophytic microbes of plant roots. Because these three OTUs also predominated in the MF itself, they were likely provided to the rhizosphere or endophytic environments of tomato roots via hydroponic water. KEY POINTS: • Microbial fertilizer for hydroponic growth enhanced biofilm formation on tomato root. • Microbial fertilizer contains tomato-root epiphytic or endophytic microbes. • Microbial fertilizer provided beneficial microbes to the rhizosphere and endophytic environments of tomato roots via hydroponic water.

Metabolic implications for predatory and parasitic bacterial lineages in activated sludge wastewater treatment systems.

Deciphering unclear microbial interactions is key to improving biological wastewater treatment processes. Microbial predation and parasitism in wastewater treatment ecosystems are unexplored survival strategies that have long been known and have recently attracted attention because these interspecies interactions may contribute to the reduction of excess sludge. Here, microbial community profiling of 600 activated sludge samples taken from six industrial and one municipal wastewater treatment processes (WWTPs) was conducted. To identify the shared lineages in the WWTPs, the shared microbial constituents were defined as the family level taxa that had ≥ 0.1% average relative abundance and detected in all processes. The microbial community analysis assigned 106 families as the shared microbial constituents in the WWTPs. Correlation analysis showed that 98 of the 106 shared families were significantly correlated with total carbon (TC) and/or total nitrogen (TN) concentrations, suggesting that they may contribute to wastewater remediation. Most possible predatory or parasitic bacteria belonging to the phyla Bdellovibrionota, Myxococcota, and Candidatus Patescibacteria were found to be the shared families and negatively correlated with TC/TN; thus, they were frequently present in the WWTPs and could be involved in the removal of carbon/nitrogen derived from cell components. Shotgun metagenome-resolved metabolic reconstructions indicated that gene homologs associated with predation or parasitism are conserved in the Bdellovibrionota, Myxococcota, and Ca. Patescibacteria genomes (e.g., host interaction (hit) locus, Tad-like secretion complexes, and type IV pilus assembly proteins). This study provides insights into the complex microbial interactions potentially linked to the reduction of excess sludge biomass in these processes.

Startup performance and microbial composition of a pilot-scale rapid sand filter for the treatment of manganese-containing mine water.

The inexpensive removal of soluble manganese [Mn(II)] from mine water that contains large quantities of Mn(II) should be prioritized given that large quantities of alkaline reagents are typically used in the chemical treatment of Mn-rich water from abandoned mines. Rapid sand filter (RSF) systems are widely used as a cost-effective technology in drinking water treatment processes to remove iron and Mn from groundwater. Here, we applied a pilot-scale RSF to treat mine water with a neutral pH and containing approximately 22 mg/L of Mn(II). Following a lag phase from its startup (day 1-day 26), Mn removal rates increased to approximately 40% for around 1 month (day 27-day 55) without the use of alkaline reagents but did not increase during further operation. Quantitative elemental analysis revealed Mn oxides on the sand filters during the Mn removal period. The bacterial communities on the RSFs, recorded on day 42 and day 85, were characterized and compared using 16S rRNA gene amplicon sequencing. Although the well-known Mn-oxidizing bacteria (MOB) were not listed among the ten most dominant operational taxonomic units (OTUs) on the sand filters (relative abundances: >0.68%), a significant increase in the OTUs related to well-known alphaproteobacterial MOB, such as Pedomicrobium spp., were observed during the period.

Histological study of the structural layers around the esophagus in the lower mediastinum.

BACKGROUND: In Japan, the transhiatal approach, including lower mediastinal lymph node dissection, is widely performed for Siewert type II esophagogastric junction adenocarcinoma. This procedure is generally performed in a magnified view using laparoscopy or a robotic system, therefore, the microanatomy of the lower mediastinum is important. However, mediastinal microanatomy is still unclear and classification of lower mediastinal lymph nodes is not currently based on fascia or other microanatomical structures. AIM: To clarify the fascia and layer structures of the lower mediastinum and classify the lower mediastinal tissue. METHODS: We dissected the esophagus and surrounding organs en-bloc from seven cadavers fixed in 10% formalin. Organs and tissues were then cut at the level of the lower thoracic esophagus, embedded in paraffin, and serially sectioned. Tissue sections were stained with Hematoxylin-Eosin (all cadavers) and immunostained for the lymphatic endothelial marker D2-40 (three cadavers). We observed the periesophageal fasciae and layers, and defined lymph node boundaries based on the fasciae. Lymphatic vessels around the esophagus were observed on immunostained tissue sections. RESULTS: We identified two fasciae, A and B. We then classified lower mediastinal tissue into three areas, paraesophageal, paraaortic, and intermediate, using these fasciae as boundaries. Lymph nodes were found to be present and were counted in each area. The dorsal part of the intermediate area was thicker on the caudal side than on the cranial side in all cadavers. On the dorsal side, no blood vessels penetrated the fasciae in six of the seven cadavers, whereas the proper esophageal artery penetrated fascia B in one cadaver. D2-40 immunostaining showed lymphatic vessel connections between the paraesophageal and intermediate areas on the lateral and ventral sides of the esophagus, but no lymphatic connection between areas on the dorsal side of the esophagus. CONCLUSION: Histological studies identified two fasciae surrounding the esophagus in the lower mediastinum and the layers separated by these fasciae were used to classify the lower mediastinal tissues.

Distribution of splenic artery lymph nodes and splenic hilar lymph nodes.

BACKGROUND: Total gastrectomy with splenectomy is the standard treatment for advanced proximal gastric cancer with greater-curvature invasion. As an alternative to splenectomy, laparoscopic spleen-preserving splenic hilar lymph node (LN) dissection (SPSHLD) has been developed. With SPSHLD, the posterior splenic hilar LNs are left behind. AIM: To clarify the distribution of splenic hilar (No. 10) and splenic artery (No. 11p and 11d) LNs and to verify the possibility of omitting posterior LN dissection in laparoscopic SPSHLD from an anatomical standpoint. METHODS: Hematoxylin & eosin-stained specimens were prepared from six cadavers, and the distribution of LN No. 10, 11p, and 11d was evaluated. In addition, heatmaps were constructed and three-dimensional reconstructions were created to visualize the LN distribution for qualitative evaluation. RESULTS: There was little difference in the number of No. 10 LNs between the anterior and posterior sides. For LN No. 11p and 11d, the anterior LNs were more numerous than the posterior LNs in all cases. The number of posterior LNs increased toward the hilar side. Heatmaps and three-dimensional reconstructions showed that LN No. 11p was more abundant in the superficial area, while LN No. 11d and 10 were more abundant in the deep intervascular area. CONCLUSION: The number of posterior LNs increased toward the hilum and was not neglectable. Thus, surgeons should consider that some posterior No. 10 and No. 11d LNs may remain after SPSHLD.

Two new species of the genus Lathrobium (Coleoptera: Staphylinidae: Paederinae) from Gotô Islands, Japan.

Lathrobium gotoianum Y. Sato sp. nov. and Lathrobium fukuense Y. Sato sp. nov. are described from Gotô Islands, north of Kyushu, Japan. The previous record of Lathrobium pollens Sharp, 1889 in Gotô Island (Imasaka et al. 1994) may be the result of misidentification of Lathrobium gotoianum Y. Sato sp. nov.

Evaluating the Optimal Oil Concentrations in the Startup Performance of a Membrane Bioreactor Treating Oily Noodle-soup Wastewater.

The discharge of high-strength oily wastewater adversely affects the environment; therefore, the treatment of wastewater containing fats, oils, and grease from the food industry is of importance. In this study, we used a membrane bioreactor (MBR) to treat Ramen noodle-soup wastewater, and we evaluated the optimal oil concentration in the wastewater for the startup of the MBR treatment in winter and summer. The MBR system had a sufficient startup in both seasons when fed with a 20-fold dilution of the original oily wastewater, containing approximately 950 to 1,200 mg/L oil and approximately 3,000 to 4,400 mg/L biological oxygen demand (BOD; BOD-SS load of 0.1 to 0.2 kg/kg/d). The reactor performance in winter were relatively stable during the operation. While, activated sludge microbes in summer were not highly active with a 40-fold dilution of wastewater, because of the decreased mixed liquor suspended solid concentration during the operation period. Population shifts in the sludge microbiome with increasing oil concentrations were analyzed using high-throughput sequencing, and the relative abundance of operational taxonomic units belonging to the phylum Bacteroidetes were highest in both winter and summer when fed with 20-fold dilution of the wastewater. In particular, the family Chitinophagaceae was dominant, with relative abundances of 13.5% in winter and 5.1% in summer, suggesting that this family may play important roles in the startup of a MBR treating the wastewater.

Frequency of lymph node metastasis according to tumor location in clinical T1 early gastric cancer: supplementary analysis of the Japan Clinical Oncology Group study (JCOG0912).

BACKGROUND: The frequency of lymph node metastases per lymph node site in early gastric cancer has not been well clarified from the data based on prospective studies. This exploratory analysis aimed to determine the frequency and location of lymph node metastases in clinical T1 gastric cancer using the data from JCOG0912 to investigate the validity of the extent of standard lymph node dissection defined in Japanese guidelines. METHODS: This analysis included 815 patients with clinical T1 gastric cancer. The proportion of pathological metastasis was identified for each lymph node site per tumor location (middle third and lower third) and four equal parts of the gastric circumference. The secondary aim was identification of the risk factor for lymph node metastasis. RESULTS: Eighty-nine patients (10.9%) had pathologically positive lymph node metastases. Although the overall frequency of metastases was low (0.3-5.4%), metastases were widely located in each lymph node sites when primary lesion was in the middle third of the stomach. No. 4sb and 9 showed no metastasis when primary lesion was in the lower third of the stomach. Lymph node dissection of metastatic nodes resulted in a 5-year survival in more than 50% of patients. A tumor greater than 3 cm and a T1b tumor were associated with lymph node metastasis. CONCLUSIONS: This supplementary analysis demonstrated that nodal metastasis from early gastric cancer is widely and disorderly not depending on the location. Thus, systematic lymph node dissection is necessary to cure the early gastric cancer.

Optimal placement of self-fixating mesh in the rectus abdominis muscle for ventral hernia repair when using the enhanced-view totally extraperitoneal Rives-Stoppa technique.

INTRODUCTION: Laparoscopic retro-muscular Rives-Stoppa (RS) ventral hernia repair using the enhanced-view totally extraperitoneal (eTEP) technique (eTEP-RS) is becoming common. Although self-fixating mesh is useful with good fixation, some surgeons think the fixating surface must be oriented towards the rectus abdominis muscle for safety reasons in eTEP-RS. Attaching the self-fixating mesh to the rectus abdominis, the ceiling of the operative field, is challenging and time-consuming. MATERIAL AND SURGICAL TECHNIQUE: First, the self-fixating mesh is folded in half with the fixation surface facing outwards. Second, we create a partition sheet and insert the sheet between the two arms of the folded mesh. The folded mesh is then inserted intracorporeally. We can unfold the mesh easily from one-quarter width to half width on the rectus abdominis muscle because of the insertion of the partition sheet. Finally, the mesh is unfolded to full width, and the mesh placement is completed. DISCUSSION: The eTEP-RS is still a new procedure and has not yet been standardized. However, our technique will increase the use of self-fixating mesh and improve the outcomes of eTEP-RS.