This work was supported by grants from the Science and Technology Project of Guangzhou City (202102010090).

The operation is routine and received ethics approval. The approvals are as follows: Approval for rapid review by the Clinical Research and Application Ethics Committee of the Second Affiliated Hospital of Guangzhou Medical University: The scientific research ethics review project &#34;Application of simple and easy Hemostatic Devices in Laparoscopic Hepatectomy&#34; (acceptance No.: 2022-hg-ks-02) was approved by the clinical research and application ethics committee of the Second Affiliated Hospital of Guangzhou Medical University. Its research contents and methods meet the medical ethics norms and requirements.
1. Preoperative preparation, operative position, and anesthesia
<ol>
	<li>Ask the patient to consume a liquid diet 1 day before the surgical operation and then abstain from eating food and drinking water at least 8 h before the surgery.</li>
	<li>Place the patient in a supine position and 30&#176; reverse Trendelenburg position, tilted softly to the left. The principal surgeon operates from the patient&#39;s right side.</li>
	<li>Perform endotracheal intubation and give general anesthesia. Judge the anesthetic effect according to the patient&#39;s post-anesthesia and intraoperative conditions, such as complete anesthesia block, no additional drugs during operation, and stable vital signs.</li>
</ol>
2. Surgical technique
<ol>
	<li>Apply direct puncture to establish pneumoperitoneum in laparoscopy. Place five trocars in the following positions: observation hole in the sub-umbilical area 12 mm trocar, right anterior axillary line 5 mm trocar, right midclavicular line under the costal margin 10 mm trocar, ventral midline 10 mm and 5 mm trocar (see Figure 2).</li>
	<li>Assemble the following hemostatic devices: harmonic scalpel, monopole electrocoagulation, and single lumen catheter, to be innovatively used in liver parenchyma tissue resection (see Figure 3).</li>
	<li>Perform a Pringle maneuver. To do so, follow the steps below.
	<ol>
		<li>Occlude the first porta hepatis intermittently by using a single lumen catheter. Clamp the lumen catheter with a hemostatic clip for 15 min, followed by releasing for 5 min.</li>
		<li>When required to release, use the harmonic scalpel to cut off the clip and take the clip out to restore blood supply to the first porta hepatis (see Figure 4).</li>
	</ol>
	</li>
	<li>Separate the hepatic pedicles supplying the tumor. Resect and divide them one by one with a harmonic scalpel (see Figure 5).</li>
	<li>Observe the ischemia line on the liver surface, which becomes visible after the resection of the hepatic pedicles. Use the hook to mark this (see Figure 6).</li>
	<li>Resect the liver parenchyma tissue using the harmonic scalpel with clamping and crushing of the liver little by little. Observe the internal hepatic artery, vein, and bile duct now visible. Resect and divide these pipeline structures (see Figure 7).</li>
	<li>Once bleeding appears, coagulate the bleeding spots on the liver dissection surface immediately using point-to-point monopole electrocoagulation (see Figure 8).</li>
	<li>Use the right posterior hepatic pedicle as a signpost for intrahepatic parenchyma tissue resection. Reserve the main posterior hepatic pedicle (PP) and dissect the branch of pedicles (PPa) supplying the tumor (see Figure 9).</li>
	<li>To complete the operation, wash the liver surface so one can see if there are still bleeding spots. Stop the bleeding on the liver dissection surface and remove the tumor specimen from the abdominal cavity (see Figure 10). 
	&#8203;NOTE: The Paraffin pathology results of the tumor was metastatic adenocarcinoma, which is shown in Figure 11.</li>
</ol>
3. Postoperative nursing
<ol>
	<li>Perform ECG monitoring after the operation. Calculate the total 24 h inflow and outflow and observe the urine volume. 
	NOTE: The patient&#39;s total rehydration volume (antibiotic, amino acid, vitamin, electrolyte, etc.) was 1,750 mL 10.5 h after surgery (after surgery until 7:00 am the next day). The total liquid excretion of the patient at 10.5h after surgery was 1,900ml, including 1,700ml of urine and 200ml of drainage.</li>
	<li>On the first day after the operation, give the patient a liquid diet and instruct the patient to turn over and exercise in bed, such as turning over, patting the back, moving the legs, and other exercises, which are mainly guided by the nurses.</li>
	<li>On day 2 after the operation, assist the patient to get out of bed and carry out daily activities.</li>
	<li>On day 3 after the operation, guide the patient to walk in the corridor and increase gradually the amount of activity in combination with the recovery of the patient&#39;s condition. Implement psychological intervention according to the patient&#39;s situation to improve the patient&#39;s bad mood.</li>
	<li>Finally, according to the patient&#39;s drainage flow, remove the drainage tube. In this case, the drainage tube was removed on the 7th day after the operation when the drainage flow was 50 mL.</li>
</ol>

<ol>
	<li>Hess, K. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Metastatic+patterns+in+adenocarcinoma.">Metastatic patterns in adenocarcinoma.</a> Cancer. 106 (7), 1624-1633 (2006).</li><li>van de Velde, C. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=EURECCA+colorectal:+multidisciplinary+management:+European+consensus+conference+colon+&amp;+rectum.">EURECCA colorectal: multidisciplinary management: European consensus conference colon &amp; rectum.</a> European Journal of Cancer. 50 (1), 1-34 (2014).</li><li>Adams, R. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Selection+for+hepatic+resection+of+colorectal+liver+metastases:+expert+consensus+statement[J].">Selection for hepatic resection of colorectal liver metastases: expert consensus statement[J].</a> HPB. 15 (2), 91-103 (2013).</li><li>Reich, H., McGlynn, F., DeCaprio, J., Budin, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+excision+of+benign+liver+lesions.">Laparoscopic excision of benign liver lesions.</a> Obstetrics and Gynecology. 78 (5), 956-958 (1991).</li><li>Ciria, R., Cherqui, D., Geller, D. A., Briceno, J., Wakabayashi, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparative+short-term+benefits+of+laparoscopic+liver+resection:+9000+cases+and+climbing.">Comparative short-term benefits of laparoscopic liver resection: 9000 cases and climbing.</a> Annals of Surgery. 263 (4), 761-777 (2016).</li><li>Makuuchi, M., Hasegawa, H., Yamazaki, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasonically+guided+subsegmentectomy.">Ultrasonically guided subsegmentectomy.</a> Surgery, Gynecology, and Obstetrics. 161 (4), 346-350 (1985).</li><li>Agrawal, S., Belghiti, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Oncologic+resection+for+malignant+tumors+of+the+liver.">Oncologic resection for malignant tumors of the liver.</a> Annals of Surgery. 253 (4), 656-665 (2011).</li><li>Wakabayashi, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+repeat+liver+resection+after+open+liver+resection:+A+comparative+study+from+a+single-centre.">Laparoscopic repeat liver resection after open liver resection: A comparative study from a single-centre.</a> Journal of Minimal Access Surgery. 16 (1), 59-65 (2020).</li><li>Berardi, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Parenchymal+sparing+anatomical+liver+resections+with+full+laparoscopic+approach:+description+of+technique+and+short-term+results.">Parenchymal sparing anatomical liver resections with full laparoscopic approach: description of technique and short-term results.</a> Annals of Surgery. 273 (4), 785-791 (2021).</li><li>Cho, J. Y., Han, H. S., Yoon, Y. S., Shin, S. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Feasibility+of+laparoscopic+liver+resection+for+tumors+located+in+the+posterosuperior+segments+of+the+liver,+with+a+special+reference+to+overcoming+current+limitations+on+tumor+location.">Feasibility of laparoscopic liver resection for tumors located in the posterosuperior segments of the liver, with a special reference to overcoming current limitations on tumor location.</a> Surgery. 144 (1), 32-38 (2008).</li><li>Ome, Y., Honda, G., Doi, M., Muto, J., Seyama, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+anatomic+liver+resection+of+segment+8+using+intrahepatic+Glissonean+approach.">Laparoscopic anatomic liver resection of segment 8 using intrahepatic Glissonean approach.</a> Journal of the American College of Surgeons. 230 (3), 13-20 (2020).</li><li>Ryu, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Perioperative+and+oncological+outcomes+of+laparoscopic+anatomical+hepatectomy+for+hepatocellular+carcinoma+introduced+gradually+in+a+single+center.">Perioperative and oncological outcomes of laparoscopic anatomical hepatectomy for hepatocellular carcinoma introduced gradually in a single center.</a> Surgical Endoscopy. 32 (2), 790-798 (2018).</li><li>Makabe, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+occlusion+of+hepatic+artery+and+risk+of+carbon+dioxide+gas+embolism+during+laparoscopic+hepatectomy+in+a+pig+model.">Efficacy of occlusion of hepatic artery and risk of carbon dioxide gas embolism during laparoscopic hepatectomy in a pig model.</a> Journal of Hepato-Biliary-Pancreatic Sciences. 21 (8), 592-598 (2014).</li><li>Miyagi, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pure+laparoscopic+hepatectomy+combined+with+a+pure+laparoscopic+pringle+maneuver+in+patients+with+severe+cirrhosis.">Pure laparoscopic hepatectomy combined with a pure laparoscopic pringle maneuver in patients with severe cirrhosis.</a> Case Reports in Gastroenterology. 9 (1), 101-105 (2015).</li></ol>

The authors have no conflicts of interest or financial ties to disclose.

Hepatectomy is one of the most important treatment methods for patients with primary liver cancer and secondary liver cancer. In 1991, Reich et al. applied laparoscopy to remove benign tumors of the liver and completed the world&#39;s first laparoscopic hepatectomy4. After years of rapid development and promotion, laparoscopic hepatectomy has become one of the mainstream methods to treat liver malignant tumors and has been widely carried out in recent years. With the advantages of less intraoperative bleeding, less postoperative pain, low incidence of postoperative complications, short hospital stays, etc., the feasibility and safety of this technique have been confirmed and have led to its extensive use in clinical practice5. Makuuchi et al.6&#160;proposed anatomical hepatectomy according to the anatomical characteristics of the liver. Anatomical hepatectomy removes the tumor completely and preserves normal liver tissue, which avoids postoperative residual liver congestion and reduces the occurrence of biliary fistula. It is the best choice for hepatectomy in the treatment of liver cancer7. The main difference between anatomical hepatectomy and non-anatomical hepatectomy lies in the resection scope. Theoretically, anatomical hepatectomy based on the liver segment can better reduce the risk of recurrence, but the operation requirements are higher7. In recent years, with a better understanding of liver anatomy and the application of ultrasound and ICG fluorescence navigation technology in laparoscopic surgery, laparoscopic anatomical hepatectomy is now carried out in hospitals all over the world. Resection has been performed in various segments and even subsegments, including laparoscopic anatomical middle lobe hepatectomy, right posterior lobe hepatectomy, left lateral lobe hepatectomy, S7+8 hepatectomy, S8 dorsal segment hepatectomy, etc.9,10,11. Liver metastases of the patient presented here showed a lesion located across parts S5 and S6. So, the solution was to trace the hepatic pedicle of S5 and S6, which was considered as a signpost intrahepatic parenchyma tissue resection. Meanwhile, a wide incisal margin (&#62;1 cm) was made. The main posterior hepatic pedicle (PP) and anterior trunk (AT) were reserved, and the branch of pedicles supplying the tumor was dissected.
The advantages of laparoscopic anatomical liver resection have been gradually confirmed in recent years. The reason for the reduction of intraoperative bleeding is that the hepatic blood flow of the pre-resected liver is treated preferentially. This is conducive to the control of bleeding in the process of liver resection. Making an ischemic line helps to find a normal anatomical level and reduce bleeding12. There are many methods to reduce bleeding during hepatectomy. On the one hand, low central venous pressure during hepatectomy can effectively reduce venous bleeding13. On the other hand, blocking the first hepatic portal (Pringle method) has a significant effect on reducing bleeding during hepatectomy. This method is simple, effective, and safe for patients with liver cirrhosis14. At the same time, the use of some advanced hemostatic devices during ultrasonic surgical aspiration and bipolar electrocoagulation plays a very important role in reducing intraoperative hemostasis, but these cannot be popularized in primary medical institutions because of their high price.
The key step of our operation is to use the Pringle method, followed by using the single lumen catheter to intermittently block the porta hepatis or hepatic pedicle, and then using the harmonic scalpel to crush the liver parenchyma tissue, bit by bit, along with coagulation of the bleeding point with the monopole electrocoagulation at the same time. This method can improve the safety and feasibility of laparoscopic anatomical hepatectomy. The hemostatic device is simple and easy, so it is more suitable for use and promotion in medical institutions with basic facilities.
Despite its simplicity and ease of use, the hemostatic device also has its limitations. For example, the hemostatic scalpel is not an advanced hemostatic equipment, and it is difficult to ensure sufficient hemostatic effect in complex hepatectomy. However, in the early stage of laparoscopic hepatectomy, we can use this set of equipment when the operation cannot be carried out due to the lack of advanced hemostatic equipment and then gradually accumulate experience and combine the use of advanced hemostatic equipment to carry out more difficult surgery.
Laparoscopic anatomical hepatectomy is a difficult operation, but we can use this simple device innovatively to reduce the incidence of bleeding and bile leakage and improve the safety and feasibility of laparoscopic anatomical hepatectomy.

Hepatocellular carcinoma is one of the most common malignant tumors of the digestive system. According to the different primary sites, it can be divided into primary hepatocellular carcinoma and secondary liver cancer. Cells can metastasize from primary tumors from organs outside the liver into the liver in various ways, leading to carcinoma in the liver. It has been reported that more than 50% of metastatic cells in the liver come from colorectal cancer, while others are from breast, pancreas, lung, and stomach tumors, etc1. In recent years, many treatments for secondary liver cancer are available, including systematic chemotherapy, interventional therapy, molecular targeted therapy, surgery, etc2. However, radical resection is still the most effective treatment because it can completely remove the cancer3.
With the rapid development of laparoscopic technology, laparoscopic anatomical hepatectomy is gradually recognized by surgeons but is still not widely performed, especially in primary medical institutions. One of the reasons is the requirement for high-grade hemostatic devices. These are required to reduce the risks of bleeding and bile leakage during the operation process. Here, we present a set of simple and easy hemostatic equipment, including a single lumen catheter, harmonic scalpel, and monopole electrocoagulation, for performing laparoscopic hepatectomy. To do this, first the porta hepatis is occluded intermittently by using a single lumen catheter. Liver parenchyma tissue is then resected by using the harmonic scalpel. Bleeding spots are coagulated by monopole electrocoagulation point-to-point. This simple and easy hemostatic equipment uses a single lumen catheter to perform the pringle maneuver and utilizes the hemostasis of the harmonic scalpel and monopole electrocoagulation. The equipment can be found easily in hospitals, thereby providing added ease for performing laparoscopy or training. Thus, these simple and easy hemostatic devices are suitable for conducting procedures in primary medical institutions.
In this study, the patient was a 67-year-old male diagnosed with a moderately differentiated adenocarcinoma of the sigmoid colon metastasized in the liver. Radical resection of the sigmoid colon cancer was performed in January 2021. The pathological results were moderately differentiated adenocarcinoma with the TNM stage of pT4aN2aM1. FOLFOX chemotherapy was given four times after the operation. Following this, the patient&#39;s body condition was deemed suitable to perform laparoscopic anatomical hepatectomy to completely remove the lesion of liver metastases. The Child-Pugh grade of liver function was Grade A. For the liver reserve function test, R15 in the ICG clearance test was 1.6% (&#60;10%). CT showed a 57 mm x 68 mm x 76 mm tumor across the dorsal part of S5 and ventral part of S6 of the liver; the three-dimensional reconstruction model is shown in Figure 1.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>HARMONIC ACE Ultrasonic Surgical Devices</td>
			<td>Ethicon Endo-Surgery,LLC</td>
			<td>HAR36</td>
			<td></td>
		</tr>
		<tr>
			<td>Hem-o-lock</td>
			<td>Teleflex Medical</td>
			<td>544233</td>
			<td></td>
		</tr>
		<tr>
			<td>Monopole Electrocoagulation</td>
			<td>KANGJI MEDICAL</td>
			<td>/</td>
			<td></td>
		</tr>
		<tr>
			<td>single lumen ureter</td>
			<td>WELL LEAD MEDICAL CO.,LTD.</td>
			<td>12F</td>
			<td></td>
		</tr>
	</tbody>
</table>

application of hemostatic devices in laparoscopic hepatectomy

Laparoscopic hepatectomy is considered a conventional method for treating benign and malignant liver diseases because it is a minimally invasive method. Despite its non-invasive aspect, bleeding and bile leakage occur in liver parenchyma tissue resection during the operation or in the post-operation period, indicating the requirement for high-grade hemostatic devices, such as ultrasonic surgical aspiration, bipolar electrocoagulation, etc. The lack of availability of these high-grade hemostatic devices prevents laparoscopic hepatectomy from becoming a generalized procedure in basic medical organizations. In view of the situation mentioned above, a suite of simple and easy hemostatic devices is developed in this protocol, which includes a harmonic scalpel, monopole electrocoagulation, and a single lumen catheter, to innovatively perform liver parenchyma tissue resection. First of all, the porta hepatis or hepatic pedicle is occluded intermittently by a single lumen catheter, followed by clamping for 15 min and releasing for 5 min. Subsequently, using the harmonic scalpel, clamping and crushing of the liver are done to cut off the hepatic parenchyma tissue and to reveal the intrahepatic arteries, veins, and bile ducts. Lastly, the bleeding spots are coagulated by using monopole electrocoagulation at each spot. Intrahepatic pipeline structures are then visible by using these methods, which could stop bleeding easily, reduce the incidence rate of bile leakage, and improve the safety and feasibility of laparoscopic hepatectomy. Therefore, the simple and easy hemostatic devices shown here are suitable for conducting procedures in primary medical institutions.

The operation was completed within 2.5 h and the intraoperative bleeding volume was 100 mL without the blood transfusion. There were no short-term complications, and the patient was discharged from the hospital on the 8th day after the operation. The carcinoembryonic antigen (CEA) level post operation decreased to 110.64 &#181;g/L from the pre-operation level of 1058.69 &#181;g/L (Figure 12). Two months after the operation, the patient returned to the hospital to continue chemotherapy treatment (chemotherapy regimen was mFOLFOX6). The chemotherapy regimen was performed according to the tumor pathology result, which is shown in Figure 11. The CT examination performed when the patient returned to the hospital for re-examination was compared with the CT examination performed before the operation. No signs of tumor regrowth were observed. For details, please see Figure 13.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/63368/63368fig01.jpg" /> 
Figure 1: The 3D digital imaging of the liver tumor. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63368/63368fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/63368/63368fig02.jpg" /> 
Figure 2: The trocar position is shown on the body surface. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63368/63368fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/63368/63368fig03.jpg" /> 
Figure 3: Hemostatic devices: single Lumen catheter, harmonic scalpel, and monopole electrocoagulation. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63368/63368fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/63368/63368fig04.jpg" /> 
Figure 4: Pringle maneuver completed by single lumen catheter. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63368/63368fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/63368/63368fig05.jpg" /> 
Figure 5: Ligation of the first hepatic pedicle of S5. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63368/63368fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/63368/63368fig06.jpg" /> 
Figure 6: Resection area marked by ischemia line. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63368/63368fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/63368/63368fig07.jpg" /> 
Figure 7: Resection of parenchyma tissue by harmonic scalpel. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63368/63368fig07large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/63368/63368fig08.jpg" /> 
Figure 8: Monopole electrocoagulation for stopping the bleeding. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63368/63368fig08large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 9" class="xfigimg" src="/files/ftp_upload/63368/63368fig09.jpg" /> 
Figure 9: Successful appearance of the right posterior hepatic pedicle. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63368/63368fig09large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 10" class="xfigimg" src="/files/ftp_upload/63368/63368fig10.jpg" /> 
Figure 10: The liver dissection surface at the last stage of surgery. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63368/63368fig10large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 11" class="xfigimg" src="/files/ftp_upload/63368/63368fig11.jpg" /> 
Figure 11: The tumor pathology results. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63368/63368fig11large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 12" class="xfigimg" src="/files/ftp_upload/63368/63368fig12.jpg" /> 
Figure 12: Preoperative and postoperative carcinoembryonic antigen (CEA) levels. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63368/63368fig12large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 13" class="xfigimg" src="/files/ftp_upload/63368/63368fig13.jpg" /> 
Figure 13: The CT examination performed when the patient returned to the hospital for re-examination compared with the CT examination performed before the operation. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63368/63368fig13large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Watch this Scientific Journal Video about Application of Hemostatic Devices in Laparoscopic Hepatectomy at JoVE.com

Application of Hemostatic Devices in Laparoscopic Hepatectomy

High-grade hemostatic devices are essential for laparoscopic hepatectomy. However, these devices are not generalized in basic medical organizations. Therefore, a suite of simple and easy hemostatic devices is shown in this article, which can make the laparoscopic hepatectomy easier to perform.

Laparoscopic hepatectomy is considered a conventional method for treating benign and malignant liver diseases because it is a minimally invasive method. ...

application-of-hemostatic-devices-in-laparoscopic-hepatectomy

Nanyang Technological University

Research

JoVE Journal

Cancer Research

2.1K Views.  the Second Affiliated Hospital of Guangzhou Medical University. High-grade hemostatic devices are essential for laparoscopic hepatectomy. However, these devices are not generalized in basic medical organizations. Therefore, a suite of simple and easy hemostatic devices is shown in this article, which can make the laparoscopic hepatectomy easier to perform.

Video: Application of Hemostatic Devices in Laparoscopic Hepatectomy

The Drosophila Imaginal Disc Tumor Model: Visualization and Quantification of Gene Expression and Tumor Invasiveness Using Genetic Mosaics

Drosophila melanogaster has emerged as a powerful experimental system for functional and mechanistic studies of tumor development and progression in the context of a whole organism. Sophisticated techniques to generate genetic mosaics facilitate induction of visually marked, genetically defined clones surrounded by normal tissue. The clones can be analyzed through diverse molecular, cellular and omics approaches. This study describes how to generate fluorescently labeled clonal tumors of varying malignancy in the eye/antennal imaginal discs (EAD) of Drosophila larvae using the Mosaic Analysis with a Repressible Cell Marker (MARCM) technique. It describes procedures how to recover the mosaic EAD and brain from the larvae and how to process them for simultaneous imaging of fluorescent transgenic reporters and antibody staining. To facilitate molecular characterization of the mosaic tissue, we describe a protocol for isolation of total RNA from the EAD. The dissection procedure is suitable to recover EAD and brains from any larval stage. The fixation and staining protocol for imaginal discs works with a number of transgenic reporters and antibodies that recognize Drosophila proteins. The protocol for RNA isolation can be applied to various larval organs, whole larvae, and adult flies. Total RNA can be used for profiling of gene expression changes using candidate or genome-wide approaches. Finally, we detail a method for quantifying invasiveness of the clonal tumors. Although this method has limited use, its underlying concept is broadly applicable to other quantitative studies where cognitive bias must be avoided.

The Drosophila Imaginal Disc Tumor Model: Visualization and Quantification of Gene Expression and Tumor Invasiveness Using Genetic Mosaics

This protocol demonstrates how to generate fluorescently marked, genetically defined clonal tumors in the Drosophila eye/antennal imaginal discs (EAD). It describes how to dissect the EAD and brain from the third instar larvae and how to process them to visualize and quantify gene expression changes and tumor invasiveness.

Drosophila melanogaster has emerged as a powerful experimental system for functional and mechanistic studies of tumor development and progression in the ...

Evaporation-reducing Culture Condition Increases the Reproducibility of Multicellular Spheroid Formation in Microtiter Plates

Tumor models that closely imitate in vivo conditions are becoming increasingly popular in drug discovery and development for the screening of potential anti-cancer drugs. Multicellular tumor spheroids (MCTSes) effectively mimic the physiological conditions of solid tumors, making them excellent in vitro models for lead optimization and target validation. Out of the various techniques available for MCTS culture, the liquid-overlay method on agarose is one of the most inexpensive methods for MCTS generation. However, the reliable transfer of MCTS cultures using liquid-overlay for high-throughput screening may be compromised by a number of limitations, including the coating of microtiter plates (MPs) with agarose and the irreproducibility of uniform MCTS formation across wells. MPs are significantly prone to edge effects that result from excessive evaporation of medium from the exterior of the plate, preventing the use of the entire plate for drug tests. This manuscript provides detailed technical improvements to the liquid-overlay technique to increase the scalability and reproducibility of uniform MCTS formation. Additionally, details on a simple, semi-automatic, and universally applicable software tool for the evaluation of MCTS features after drug treatment is presented.

The uneven loss of medium from microtiter plates affects the reproducibility of uniform multicellular tumor spheroid formation. Improving culture conditions to reduce significant medium loss will improve the reproducibility of spheroid formation and the results of spheroid-based assays using the liquid-overlay technique.

Tumor models that closely imitate in vivo conditions are becoming increasingly popular in drug discovery and development for the screening of potential ...

Application of Laser Micro-irradiation for Examination of Single and Double Strand Break Repair in Mammalian Cells

Highly coordinated DNA repair pathways exist to detect, excise and replace damaged DNA bases, and coordinate repair of DNA strand breaks. While molecular biology techniques have clarified structure, enzymatic functions, and kinetics of repair proteins, there is still a need to understand how repair is coordinated within the nucleus. Laser micro-irradiation offers a powerful tool for inducing DNA damage and monitoring the recruitment of repair proteins. Induction of DNA damage by laser micro-irradiation can occur with a range of wavelengths, and users can reliably induce single strand breaks, base lesions and double strand breaks with a range of doses. Here, laser micro-irradiation is used to examine repair of single and double strand breaks induced by two common confocal laser wavelengths, 355 nm and 405 nm. Further, proper characterization of the applied laser dose for inducing specific damage mixtures is described, so users can reproducibly perform laser micro-irradiation data acquisition and analysis.

Confocal fluorescence microscopy and laser micro-irradiation offer tools for inducing DNA damage and monitoring the response of DNA repair proteins in selected sub-nuclear areas. This technique has significantly advanced our knowledge of damage detection, signaling, and recruitment. This manuscript demonstrates these technologies to examine single and double strand break repair.

Highly coordinated DNA repair pathways exist to detect, excise and replace damaged DNA bases, and coordinate repair of DNA strand breaks. While molecular ...

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis.
The study describes and demonstrates all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contra-indications are body mass index &#62;35 kg/m2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers.
The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent using 3D laparoscopy. Two surgical drains are placed alongside the pancreaticojejunostomy.
The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.

Laparoscopic pancreatoduodenctomy (LPD) may offer advantages over open pancreatoduodenectomy, including early postoperative mobilization, less delayed gastric emptying and a shorter hospital stay. However, LPD is technically challenging and not well-standardized, especially regarding the pancreatic anastomosis. We describe a standardized technique for the pancreatic anastomosis during LPD: modified Blumgart pancreaticojejunostomy.

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal ...

The Application of 1% Methylene Blue Dye As a Single Technique in Breast Cancer Sentinel Node Biopsy

In this study, we injected 1% methylene blue dye (MBD) into the subareolar or peritumoral space of the breast. In the case of breast conserving surgery (BCS), a separate incision in the lower axilla hairline was made to find the sentinel nodes (SNs). In mastectomy, the SNs were identified through the same mastectomy incision. The SNs were described as blue nodes or nodes with lymphatic blue channels. An anatomical landmark in the axilla was used to facilitate SNs identification. The SNs metastases were evaluated by intraoperative frozen section analysis and histopathology examination as it is a gold standard. Here, we described the MBD as the lone technique in breast cancer sentinel node biopsy (SNB) which could be useful when radioisotope tracer or patent or isosulfan blue dye (PBD) cannot be provided.

In Indonesia, sentinel node biopsy (SNB) is not routinely performed for breast cancer surgery because of the limitation to provide radioisotope tracer and isosulfan or patent blue dye (PBD). To overcome this obstacle, we applied 1% methylene blue dye (MBD) as a single agent to map the sentinel nodes (SNs).

In this study, we injected 1% methylene blue dye (MBD) into the subareolar or peritumoral space of the breast. In the case of breast conserving surgery ...

The Clinical Application of Tumor Treating Fields Therapy in Glioblastoma

Glioblastoma is the most common and lethal form of brain cancer, with a median survival of 15 months after diagnosis and a 5 year survival rate of only 5% with current standard of care. Tumors often recur within 9 months following initial surgery, radiation and chemotherapy, at which point treatment options become limited. This highlights the pressing need for the development of better therapeutics to prolong survival and increase the quality of life for these patients.
Tumor Treating Fields (TTFields) therapy was developed to take advantage of the effect of low frequency alternating electrical fields on cells for cancer therapy. TTFields have been demonstrated to disrupt cells during mitosis and slow tumor growth. There is also growing evidence that they act through stimulating immune responses within exposed tumors. The advantages of TTFields therapy include its noninvasive approach and increased quality of life compared to other treatment modalities such as cytotoxic chemotherapies. The Food and Drug Administration approved TTFields therapy for the treatment of recurrent glioblastoma in 2011 and for newly diagnosed glioblastoma in 2015. We report on the effects of TTFields during mitosis, the results of electric fields modeling, and proper transducer array placement. Our protocol outlines the clinical application of TTFields on a patient post-surgery, using the second-generation device.

Glioblastoma is the most common and aggressive primary brain malignancy in adults, with most tumors recurring after initial treatment. Tumor Treating Fields (TTFields) therapy is the newest treatment modality for glioblastoma. Here, we describe the proper application of TTFields-transducer arrays on patients and discuss theory and aspects of treatment.

Glioblastoma is the most common and lethal form of brain cancer, with a median survival of 15 months after diagnosis and a 5 year survival rate of only 5% ...

In Vitro Evaluation of Oncogenic Transformation in Human Mammary Epithelial Cells

Tumorigenesis is a multi-step process in which cells acquire capabilities&#160;that allow their growth, survival, and dissemination under hostile conditions. Different tests seek to identify and quantify these hallmarks of cancerous cells; however, they often focus on a single aspect of cellular transformation and, in fact, multiple tests are required for their proper characterization. The purpose of this work is to provide researchers with a set of tools to assess cellular transformation in vitro from a broad perspective, thereby making it possible to draw sound conclusions.
A sustained proliferative signaling activation is the major feature of tumoral tissues and can be easily monitored under in vitro conditions by calculating the number of population doublings achieved over time. Besides, the growth of cells in 3D cultures allows their interaction with surrounding cells, resembling what occurs in vivo. This enables the evaluation of cellular aggregation and, together with immunofluorescent labeling of distinctive cellular markers, to obtain information on another relevant feature of tumoral transformation: the loss of proper organization. Another remarkable characteristic of transformed cells is their capacity to grow without attachment to other cells and to the extracellular matrix, which can be evaluated with the anchorage assay.
Detailed experimental procedures to evaluate cell growth rate, to perform immunofluorescent labeling of cell lineage markers in 3D cultures, and to test anchorage-independent cell growth in soft agar are provided. These methodologies are optimized for Breast Primary Epithelial Cells (BPEC) due to its relevance in breast cancer; however, procedures can be applied to other cell types after some adjustments.

This protocol provides experimental in vitro tools to evaluate the transformation of human mammary cells. Detailed steps to follow-up cell proliferation rate, anchorage-independent growth capacity, and distribution of cell lineages in 3D cultures with basement membrane matrix are described.

Tumorigenesis is a multi-step process in which cells acquire capabilities&#160;that allow their growth, survival, and dissemination under hostile ...

Co-culture of Glutamatergic Neurons and Pediatric High-Grade Glioma Cells Into Microfluidic Devices to Assess Electrical Interactions

Pediatric high-grade gliomas (pHGG) represent childhood and adolescent brain cancers that carry a rapid dismal prognosis. Since there is a need to overcome the resistance to current treatments and find a new way of cure, modeling the disease as close as possible in an in vitro setting to test new drugs and therapeutic procedures is highly demanding. Studying their fundamental pathobiological processes, including glutamatergic neuron hyperexcitability, will be a real advance in understanding interactions between the environmental brain and pHGG cells. Therefore, to recreate neurons/pHGG cell interactions, this work shows the development of a functional in vitro model co-culturing human-induced Pluripotent Stem (hiPS)-derived cortical glutamatergic neurons pHGG cells into compartmentalized microfluidic devices and a process to record their electrophysiological modifications. The first step was to differentiate and characterize human glutamatergic neurons. Secondly, the cells were cultured in microfluidic devices with pHGG derived cell lines. Brain microenvironment and neuronal activity were then included in this model to analyze the electrical impact of pHGG cells on these micro-environmental neurons. Electrophysiological recordings are coupled using multielectrode arrays (MEA) to these microfluidic devices to mimic physiological conditions and to record the electrical activity of the entire neural network. A significant increase in neuron excitability was underlined in the presence of tumor cells.

Recent works uncover the neuronal impact on high-grade pediatric glioma (pHGG) cells and their reciprocal interactions. The present work shows the development of an in vitro model co-culturing pHGG cells and glutamatergic neurons and recorded their electrophysiological interactions to mimic those interactivities.

Pediatric high-grade gliomas (pHGG) represent childhood and adolescent brain cancers that carry a rapid dismal prognosis. Since there is a need to ...

Flexible Organic Electronic Devices for Pulsed Electric Field Therapy of Glioblastoma

Glioblastoma is difficult to eradicate with standard oncology therapies due to its high degree of invasiveness. Bioelectric treatments based on pulsed electric fields (PEFs) are promising for the improvement of treatment efficiency. However, they rely on rigid electrodes that cause acute and chronic damage, especially in soft tissues such as the brain. In this work, flexible electronics were used to deliver PEFs to tumors and the biological response was evaluated with fluorescent microscopy. Interdigitated gold electrodes on a thin, transparent parylene-C substrate were coated with the conducting polymer PEDOT:PSS, resulting in a conformable and biocompatible device. The effects of PEFs on tumors and their microenvironment were examined using various biological models. First, monolayers of glioblastoma cells were cultured on top of the electrodes to investigate phenomena in vitro. As an intermediate step, an in ovo model was developed where engineered tumor spheroids were grafted in the embryonic membrane of a quail. Due to the absence of an immune system, this led to highly vascularized tumors. At this early stage of development, embryos have no immune system, and tumors are not recognized as foreign bodies. Thus, they can develop fast while developing their own vessels from the existing embryo vascular system, which represents a valuable 3D cancer model. Finally, flexible electrode delivery of PEFs was evaluated in a complete organism with a functional immune system, using a syngenic, orthograft (intracranial) mouse model. Tumor spheroids were grafted into the brain of transgenic multi-fluorescent mice prior to the implantation of flexible organic electrode devices. A sealed cranial window enabled multiphoton imaging of the tumor and its microenvironment during treatment with PEFs over a period of several weeks.

This work describes the development of flexible interdigitated electrodes for implementation in 3D brain tumor models, namely, in vitro culture, in ovo model, and in vivo murine model. The proposed method can be used to evaluate the effects of pulsed electric fields on tumors at different levels of complexity.

Glioblastoma is difficult to eradicate with standard oncology therapies due to its high degree of invasiveness. Bioelectric treatments based on pulsed ...

Generation and Culturing of High-Grade Serous Ovarian Cancer Patient-Derived Organoids

Organoids are 3D dynamic tumor models that can be grown successfully from patient-derived ovarian tumor tissue, ascites, or pleural fluid and aid in the discovery of novel therapeutics and predictive biomarkers for ovarian cancer. These models recapitulate clonal heterogeneity, the tumor microenvironment, and cell-cell and cell-matrix interactions. Additionally, they have been shown to match the primary tumor morphologically, cytologically, immunohistochemically, and genetically. Thus, organoids facilitate research on tumor cells and the tumor microenvironment and are superior to cell lines. The present protocol describes distinct methods to generate patient-derived ovarian cancer organoids from patient tumors, ascites, and pleural fluid samples with a higher than 97% success rate. The patient samples are separated into cellular suspensions by both mechanical and enzymatic digestion. The cells are then plated utilizing a basement membrane extract (BME) and are supported with optimized growth media containing supplements specific to the culturing of high-grade serous ovarian cancer (HGSOC). After forming initial organoids, the PDOs can sustain long-term culture, including passaging for expansion for subsequent experiments.

Patient-derived organoids (PDO) are a three-dimensional (3D) culture that can mimic the tumor environment in vitro. In high-grade serous ovarian cancer, PDOs represent a model to study novel biomarkers and therapeutics.

Organoids are 3D dynamic tumor models that can be grown successfully from patient-derived ovarian tumor tissue, ascites, or pleural fluid and aid in the ...