This research was supported by the Key R&#38;D Projects Medical and Health Key Technology Research and Application Program in Guangzhou, China (Project No. 202206010104).

All laparoscopic surgical procedures and postoperative treatments in this study were performed in accordance with the guidelines established by the Laparoscopic Operation Ethics Committee of the First Affiliated Hospital of Sun Yat-Sen University, China. The research protocol and content were explained to all patients, and informed consent was obtained. This study was conducted under the guidance of the ethics committee of the hospital.
1. Case inclusion criteria
<ol>
	<li>Include patients who have been diagnosed with sigmoid colon or high rectal adenocarcinoma (10-15 cm from the anus), who have undergone single-surgeon, three-port laparoscopy with NOSES in the study. Adopt the following inclusion criteria:
	<ol>
		<li>Ensure diagnosis of sigmoid colon or high rectal adenocarcinoma by preoperative colonoscopy and pathological examinations.</li>
		<li>Ensure that enhanced computed tomography (CT) and magnetic resonance imaging (MRI) tests do not reveal any tumor invasion into the surrounding tissues, or bowel obstruction due to distant metastasis.</li>
		<li>Ensure that the tumor circumference is &#60;5 cm.</li>
		<li>Ensure the T stage is &#8804;T4a.</li>
		<li>Ensure that the patients have no major organ diseases and can tolerate surgical treatment.</li>
		<li>Ensure that the patients do not have excessive obesity or mesenteric hypertrophy (BMI &#60; 35 kg/m2).</li>
		<li>Ensure that the patients have not undergone any previous abdominal surgery and do not have pelvic floor adhesions.</li>
	</ol>
	</li>
</ol>
2. Preparation for surgery
<ol>
	<li>Administer oral laxatives and slag-free semi-liquid or liquid food and oral compound polyethylene glycol electrolyte powder (137.12 g) 3 days before the operation to prepare the patients for intestinal surgery.</li>
	<li>Perform an enema the night before and early in the morning of surgery.</li>
	<li>Place the patient in a modified lithotomy position, with the head lowered 15&#176;-20&#176; and the body tilted 15&#176; on the right side.</li>
</ol>
3. Surgical procedure
<ol>
	<li>To perform the three-hole trocar insertion, make a 10 mm incision below the umbilicus and insert a 10 mm trocar. Insert a 12 mm trocar into a 12 mm incision above the line connecting the right umbilicus and the anterior superior iliac spine. Next, insert a 5 mm trocar into a 5 mm incision above the right flat umbilicus. These latter two holes are considered the operating holes.</li>
	<li>After a routine inspection of the abdominal cavity, examine the upper abdominal liver and diaphragmatic peritoneum and check the abdominal cavity counterclockwise. Probe the location of the tumor and adjacent structures. Use anastomosis needles to suspend the uterus (in female patients) to the front of the abdominal wall to expand the surgical field, assist single-surgeon operation, and facilitate the removal of specimens through the vagina and insertion of the stapler seat.</li>
	<li>Dissociate the sigmoid colon and its mesentery, usually done by releasing the left lateral side first, or use a medial dissociation approach, to expose the dissection plane between the Toldt and Gerota fascia. 
	NOTE: However, due to mesangial hypertrophy or lack of help from an assistant, fully exposing the operating field may be challenging. Therefore, the lateral separation approach was preferred in this study.</li>
	<li>Enlarge the cephalic space of Toldt and ligate the inferior mesenteric artery and vein. After releasing the lateral side of the sigmoid mesocolon, adopt the medial approach. Next, lift the mesentery with gastric forceps to expose the mesenteric junction, dissociating it from bottom to top until the horizontal segment of the duodenum is reached, including the dissection of lymph nodes in 253 and 216 groups. After exposing the inferior mesenteric artery, ligate the vessels to expand the Toldt&#39;s space until the lower part of the pancreas is reached, and then ligate the inferior mesenteric vein at a high position.</li>
	<li>Expand the Toldt&#39;s space caudally and pull the inferior mesangium up freely. Pay attention to the movements of the left hand: perform micro-external rotation of the intestinal forceps and pull the proximal colon backward and upward. Expose the hypogastric nerve while protecting it under appropriate tension. After adequate separation of the mesentery, according to the distance from the tumor site, separate the mesentery below the rectum for excision, resulting in a naked intestine. 
	NOTE: Since the lateral mesentery is dissociated first, when the inferior mesentery is released, the sigmoid colon can be lifted smoothly using gastric forceps, properly exposing to show the tension.</li>
	<li>To determine the extent of bowel resection, first prepare an 8-10 cm length of silk thread in vitro, and mark the position of the proximal resection of the intestinal tube with the silk thread on the upper edge of the tumor. Dissociate the proximal bowel canal and expose it using an ultrasonic scalpel. Use an endoscopic linear cut stapler to sequentially transect the proximal and distal ends of the naked intestinal tube.</li>
	<li>Insertion of the stapler anvil seat and specimen removal
	<ol>
		<li>Ensure that the distal rectal stump is flushed when removing the specimen from the rectum. Incise the distal rectal stump and place a clean endoscopic gauze under it to prevent contamination of the surgical field.</li>
		<li>When the specimen is taken out from the vagina, have the assistant irrigate the vagina, and then insert an intestinal pressure plate. Next, make a 3-4 cm incision in the vagina under the guidance of the intestinal pressure plate. Repeatedly disinfect the rectum or vagina with iodophor gauze.</li>
		<li>Insert a specimen bag into the abdominal cavity through the 12 mm trocar as protection during specimen retrieval to prevent tumor seeding or contamination of the rectum or vagina. During this process, place the staple anvil first and then take out the specimen to avoid possible contamination of the staple anvil.</li>
	</ol>
	</li>
	<li>Sutures of the vaginal wall and rectal stump
	<ol>
		<li>Suture the vaginal wall directly with 3-0 antibacterial polydioxanone. After the rectal stump is sutured, lift the thread and close the rectal stump again with an endoluminal cutting and closure device to avoid the possibility of contamination and anastomotic leakage.</li>
	</ol>
	</li>
	<li>Placement of the stapler seat into the proximal bowel
	<ol>
		<li>Incise the proximal intestinal canal, enlarge a 2-3 cm incision, and routinely sterilize it with iodophor gauze. Place an anvil and suture the intestinal canal without knots with 3-0 polyglactin.</li>
	</ol>
	</li>
	<li>Bowel anastomosis and reinforced stitching
	<ol>
		<li>Perform routine end-to-end anastomosis of the bowel through the anus. Insert the ring stapler trigger handle through the anus, pierce the center piercing device of the stapler trigger handle, connect the center rod of the proximal stapler to the nail seat, and rotate the intestinal wall near the proximal and distal ends.</li>
		<li>Press the anastomotic wrench tightly to complete the cutting and anastomosis.</li>
		<li>Suture the full circumference of the anastomosis in a 4-0 knot-free pattern.</li>
	</ol>
	</li>
	<li>Flush the abdominal cavity, place a drainage tube, and place a rubber tube on the left or right side of the pelvis.</li>
</ol>

<ol>
	<li>Wang, X. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Natural Orifice Specimen Extraction Surgery: Colorectal. , (2018).</li><li>Jiang, Z., Chen, Y., Wang, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+radical+resection+of+lower+rectal+cancer+through+transrectal+valgus+resection+without+abdominal+incisions.">Laparoscopic radical resection of lower rectal cancer through transrectal valgus resection without abdominal incisions.</a> Chinese Journal of Gastrointestinal Surgery. 17 (5), 499-501 (2014).</li><li>Liu, Z., Wang, G., Wang, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+median+radical+resection+for+rectal+cancer+through+the+rectum+to+pull+the+specimen+out+of+the+anus+without+abdominal+incision.">Laparoscopic median radical resection for rectal cancer through the rectum to pull the specimen out of the anus without abdominal incision.</a> Chinese Journal of Colorectal Diseases. 2 (6), 331-332 (2013).</li><li>Omori, 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=Transumbilical+single-incision+laparoscopic+distal+gastrectomy+for+early+gastric+cancer.">Transumbilical single-incision laparoscopic distal gastrectomy for early gastric cancer.</a> Surgical Endoscopy. 25 (7), 2400-2404 (2011).</li><li>Song, J. M., 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=Reduced+port+laparoscopic+surgery+for+colon+cancer+is+safe+and+feasible+in+terms+of+short-term+outcomes:+comparative+study+with+conventional+multiport+laparoscopic+surgery.">Reduced port laparoscopic surgery for colon cancer is safe and feasible in terms of short-term outcomes: comparative study with conventional multiport laparoscopic surgery.</a> Annals of Surgical Treatment and Research. 91 (4), 195-201 (2016).</li><li>Oh, J. 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=Clinical+outcomes+of+reduced-port+laparoscopic+surgery+for+patients+with+sigmoid+colon+cancer:+surgery+with+1+surgeon+and+1+camera+operator.">Clinical outcomes of reduced-port laparoscopic surgery for patients with sigmoid colon cancer: surgery with 1 surgeon and 1 camera operator.</a> Annals of Coloproctology. 34 (6), 292-298 (2018).</li><li>Hu, C., 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=Robot-assisted+total+mesorectal+excision+and+lateral+pelvic+lymph+node+dissection+for+locally+advanced+middle-low+rectal+cancer.">Robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced middle-low rectal cancer.</a> Journal of Visualized Experiments. (180), e62919 (2022).</li><li>Curcillo, P. G., Podolsky, E. R., King, S. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+road+to+reduced+port+surgery:+from+single+big+incisions+to+single+small+incisions,+and+beyond.">The road to reduced port surgery: from single big incisions to single small incisions, and beyond.</a> World Journal of Surgery. 35 (7), 1526-1531 (2011).</li><li>Inaki, N., 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=Reduced+port+laparoscopic+gastrectomy+for+gastric+cancer.">Reduced port laparoscopic gastrectomy for gastric cancer.</a> Translational Gastroenterology and Hepatology. 1, 38 (2016).</li><li>Takahashi, H., 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=Prospective+multicenter+study+of+reduced+port+surgery+combined+with+transvaginal+specimen+extraction+for+colorectal+cancer+resection.">Prospective multicenter study of reduced port surgery combined with transvaginal specimen extraction for colorectal cancer resection.</a> Surgery Today. 50 (7), 734-742 (2020).</li><li>Zhou, H., Xu, K., Sun, Q., Wang, Z., Ruan, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Three-port+laparoscopic+sigmoidectomy+with+natural+orifice+specimen+extraction-a+video+vignette.">Three-port laparoscopic sigmoidectomy with natural orifice specimen extraction-a video vignette.</a> Colorectal Disease. 22 (11), 1782-1783 (2020).</li><li>Kim, A. C., Rist, R. C., Zureikat, A. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technical+detail+for+robot+assisted+pancreaticoduodenectomy.">Technical detail for robot assisted pancreaticoduodenectomy.</a> Journal of Visualized Experiments. (151), e60261 (2019).</li></ol>

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

With the improvement in surgical skills and the advancement in surgical equipment, especially the development of visualization devices, robotic surgery is often considered a reasonable choice for complex procedures, such as lateral pelvic lymph node dissection7. Reduced-port laparoscopic surgery is an emerging procedure, characterized by reduced incision number and size, making the operation less invasive than traditional laparoscopic surgery8. In 2016, Inaki9 proposed that gastrectomy could be completed by porosity reduction laparoscopic surgery. Due to the lack of a long-term radical cure effect on gastric cancer, the laparoscopic procedure should be carefully selected. Prospective multicenter studies should be conducted to establish porosity reduction laparoscopic surgery as a true evidence-based practice, which not only addresses cosmetic concerns but also strikes the right balance between minimal invasiveness and radical cure. Takemasa10 prospectively analyzed the feasibility of pore-reducing laparoscopy combined with transvaginal specimen collection. Previous retrospective and prospective studies have confirmed that porosity reduction laparoscopic surgery with improved minimally invasive surgical skills is feasible in the radical resection of gastrointestinal tumors. In the present study, the statistical analysis of 10 patients (Table 1) showed that transvaginal specimen extraction (TVSE) combined with reduced port surgery (RPS) for colorectal cancer was feasible with less postoperative pain.
Due to the relatively fixed anatomical characteristics of the sigmoid colon and high rectum, radical operation for tumors at these sites can be combined with porosity reduction laparoscopic surgery and natural orifice specimen collection, effectively avoiding additional abdominal incisions. Minimally invasive laparoscopic surgery can effectively reduce postoperative pain and infection, as shown in Table 1. Patients can recover more quickly, and gastrointestinal function is quickly recovered, thereby shortening the hospital stay. However, single-surgeon, three-port, laparoscopic surgery for sigmoid colon or high rectal cancer with NOSES is associated with increased operation time and single-surgeon operational difficulty. Therefore, there is still controversy in the development of this technology. There are currently few reports available on this procedure; although relevant videos are available, no data analysis has been provided11. Some experts believe that adding one or two more trocars can form a good tension with the help of assistants, which is helpful to complete the operation faster, more effectively, and more safely. Compared with the traditional, five-port, laparoscopic surgery, the operative time and incision length are shorter in porosity reduction laparoscopic surgery6. 
There are still different opinions regarding this operation. First, the choice of surgical approach depends on whether it is focused on layer priority or blood vessel priority, and whether it adopts the medial or lateral approach or a combination of these two approaches. In this study, the surgeon first used the lateral (left) approach to facilitate the expansion of the rear Toldt's space when operated by one person, favoring the layer-priority surgical idea. 
Due to the limitations of single-surgeon three-hole operation, whether radical resection and lymph node dissection were sufficient remains unclear. We found that applying muscle relaxants and laparoscopic bowel forceps with a large opening and skillful gauze use might be required for the successful dissection of lymph nodes. 
Because the operation was suitable for sigmoid colon and high rectal cancer, it remains unclear whether there is a need for routine reinforcement and sutures after anastomosis. We believe that all anastomoses must be reinforced. Thus, we suggest adopting enforcement skills, including applying a laparoscopic mirror and performing reinforcement from the right to the left side. Reinforcement and suturing after anastomosis have been proposed by many experts. This operation's difficulty lies in treating the left "horn" and rear reinforcement and stitching. Our principle was to suture to the serosa or mesentery as far as possible, so it was not necessary to suture on the serosa. This experience has also withstood the test in clinical practice.
The principle of tumor-free asepsis was the focus of controversy when the NOSES operation was promoted. Based on our experience, we propose the following: (1) preoperative preparation should be sufficient to reduce the residual intestinal contents; (2) it is better to increase the frequency of use of linear cutting and closure devices and reduce the number of exposures of the bowel; (3) strict surgical indications, especially for patients with too large tumors and hypertrophic mesangium, when taking specimens could easily lead to tumor implantation. 
The placement and fixation of the staple anvil are difficult procedures and controversial points of this operation, since no assistant wasavailable to help fix the bowel. In addition, the operations could easily cause intra-abdominal contamination after a proximal intestinal incision.
Furthermore, when the staple anvil was placed in the abdominal cavity, the swing of the staple anvil might easily have led to a poor suture or incomplete exposure of the staple anvil, excessive cutting content during anastomosis, bleeding, and even fistula. In early practice, using the reverse puncture method to place the bowel could have led to the possibility of the anvil seat sliding into the proximal bowel, and it was not easy to push the anvil seat out by a single operation. In addition, it was difficult for one person to operate and fix the anvil when cutting it simultaneously. After reviewing the literature and studying the videos showing operations by other experts, we made some improvements by tying a No. 4 silk thread to the head end of the anvil before placing it in the abdominal cavity. When suturing the bowel, the thread had to be pulled out of the 12 mm trocar and lifted by the assistant to fix the anvil seat and the bowel, which was beneficial for suturing the bowel. Full-thickness purse-string suture around the staple anvil should be performed. While this method is rarely applied in current clinical operations, it is not complicated to perform and can be widely promoted in primary hospitals.
This operation also has certain limitations. Patients with obesity, excessive mesentery, intestinal edema, large tumor, and external tumor invasion are not suitable for this operation. Moreover, as mentioned before6, there are still problems such as surgical feasibility, tumor effectiveness, and training and education in porosity reduction laparoscopic surgery for malignant tumors. Similar to robotic pancreaticoduodenectomy (RPD), the most difficult pancreaticoduodenectomy, plotting a learning curve and establishing detailed rules are required12. Therefore, performing single-surgeon, three-port, laparoscopic surgery with NOSES requires training.
In summary, after a proper selection of patients and completion of long-term learning, surgeons with independent laparoscopic skills are suitable for performing this operation. This type of operation can reduce the trauma and achieve a more minimally invasive surgical treatment effect. Moreover, fixing the staple anvil by self-traction of external silk thread is simple and practical, and can be widely carried out in primary hospitals.

Natural orifice specimen extraction surgery (NOSES) is a modified approach to open surgery and conventional laparoscopic surgery, which relies on laparoscopic or robotic techniques. Its major advantages include a shorter length of hospital stay, reduction in wound complications and postoperative pain, faster recovery of bowel function, and better cosmetic and psychological effects. During NOSES, the surgical specimen is removed from a natural orifice (rectum or vagina) without requiring an auxiliary incision in the abdominal wall1. The &#34;Expert Consensus on NOSES for Colorectal Tumors (2019 Edition)&#34; recommends NOSES with the five-port technique2,3.
Omori et al.4 first applied reduced-port laparoscopic surgery (RPLS) to treat gastric cancer. In 2016, Kim et al. proposed that porosity reduction laparoscopic surgery was technically feasible and safe for the treatment of colorectal cancer and was comparable to conventional multiport laparoscopic surgery (CMLS) in terms of postoperative pain5. Oh et al., 2 years later, discussed the perioperative clinical outcomes of sigmoid colon cancer patients undergoing RPLS and traditional multiport laparoscopic surgery (MPLS); the results suggested that single-surgeon, three-port, laparoscopic radical sigmoidectomy was a feasible and safe surgical option for patients with favorable tumor characteristics6. However, the surgeries for sigmoid colon or high rectal cancer and specimen extraction through NOSES were mainly performed by one chief surgeon without the help of other assistants during intraoperative separation.
Currently, there are still only a few reports on NOSES. In NOSES, the placement and fixation of the anvil seat, which mainly depends on the tumor&#39;s location, the method of specimen collection, and the surgeon&#39;s ability, may be challenging. At present, a number of anvil fixation methods have been proposed, including the fixed extrusion method, reverse puncture method, snare ligation method, and manual purse-string suture method. Each method has its unique advantages and shortcomings. This study retrospectively analyzed the clinical data of 10 patients who underwent single-surgeon, three-port, laparoscopic surgery for sigmoid colon or high rectal cancer with NOSES to explore the safety and feasibility of this operation. The external anvil seat self-traction and fixation method was creatively improved, which could be used for manual purse-string suture fixation after placement of the anvil seat. Following the principle of tumor-free asepsis, the risk of anastomotic leakage and bleeding could be effectively avoided, and this surgicalprocedure could be widely promoted in primary hospitals.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>antibacterial polydioxanone</td>
			<td>Johnson &#38; Johnson</td>
			<td>8622H,SXPP1A403</td>
			<td></td>
		</tr>
		<tr>
			<td>Laparoscopic system</td>
			<td>STORZ</td>
			<td>26003BA</td>
			<td></td>
		</tr>
		<tr>
			<td>Ring stapler</td>
			<td>Johnson &#38; Johnson</td>
			<td>CDH29A</td>
			<td></td>
		</tr>
		<tr>
			<td>Straight cut closure</td>
			<td>Johnson &#38; Johnson</td>
			<td>EC45A</td>
			<td></td>
		</tr>
		<tr>
			<td>Trocar</td>
			<td>Johnson &#38; Johnson</td>
			<td>B5LT,B11LT,B12LT</td>
			<td></td>
		</tr>
	</tbody>
</table>

clinical application of single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. 
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Watch this Scientific Journal Video about Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction at JoVE.com

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, ...

clinical-application-single-surgeon-three-port-laparoscopic-resection

Nanyang Technological University

Research

JoVE Journal

Medicine

261 Views.  Sun Yat-sen University. Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Video: Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal deviation. It has a long history with multiple variations. In this article, a modified endoscopic septoplasty procedure using the limited two-line resection (2LoRs) technique at the posterior and inferior junction of the cartilaginous and bony septum is presented based on embryologic and anatomic knowledge of the nasal septum and the biomechanics of cartilaginous behavior. With this procedure, the quadrangular cartilage can be preserved as much as possible, which is helpful in retaining the supporting framework and rigidness of the septum. 2LoRs has been proven effective and sound for the correction of nasal septal deviation with rare complications. This modified procedure can be applied to correct the deviated nasal septum in the absence of any external nasal deformity to improve nasal patency or to improve access to the middle meatus or to the axillary region of the middle turbinate. It may also be used to expand the indications of septoplasty to children and adolescents because of its minimally invasive approach.

Endoscopic septoplasty is a time-honored surgical procedure with multiple variations. This paper focuses on a step-by-step surgical approach to perform a modified septoplasty procedure known as limited two-line resection. This surgical technique can be applied to correct a deviated nasal septum in the absence of an external nasal deformity.

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal ...

Proton Therapy Delivery and Its Clinical Application in Select Solid Tumor Malignancies

Radiation therapy is a frequently used modality for the treatment of solid cancers. Although the mechanisms of cell kill are similar for all forms of radiation, the in vivo properties of photon and proton beams differ greatly and maybe exploited to optimize clinical outcomes. In particular, proton particles lose energy in a predictable manner as they pass through the body. This property is used clinically to control the depth at which the proton beam is terminated, and to limit radiation dose beyond the target region. This strategy can allow for substantial reductions in radiation dose to normal tissues located just beyond a tumor target. However, the degradation of proton energy in the body remains highly sensitive to tissue density. As a consequence, any changes in tissue density during the course of treatment may significantly alter proton dosimetry. Such changes may occur through alterations in body weight, respiration, or bowel filling/gas, and may result in unfavorable dose deposition. In this manuscript, we provide a detailed method for the delivery of proton therapy using both passive scatter and pencil beam scanning techniques for prostate cancer. Although the described procedure directly pertains to prostate cancer patients, the method may be adapted and applied for the treatment of virtually all solid tumors. Our aim is to equip readers with a better understanding of proton therapy delivery and outcomes in order to facilitate the appropriate integration of this modality during cancer therapy.

The fundamentals of radiation planning and delivery for proton therapy using prostate cancer as a model are presented. The application of these principles to other selected disease sites highlights how proton radiotherapy may enhance clinical outcomes for cancer patients.

Radiation therapy is a frequently used modality for the treatment of solid cancers. Although the mechanisms of cell kill are similar for all forms of ...

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota&#39;s fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota&#8217;s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (&#62;1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota&#8217;s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein&#160;(SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope.
The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

With advancements in laparoscopic techniques, laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been widely recognized. However, owing to several technical difficulties in this procedure, the artery-first approach in L-RAMPS still remains uncommon. Here, we developed the dorsal-caudal artery approach for L-RAMPS, which might be safe and beneficial for pancreatic neck tumors.

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who ...

Application of a New Mesh Fixation Method in Laparoscopic Incisional Hernia Repair

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing incisional hernias. The laparoscopic IPOM involves implanting the mesh into the abdominal cavity through laparoscopy to repair an abdominal wall hernia. In the IPOM surgery, after the closure of the hernia ring, an anti-adhesion mesh is placed laparoscopically. The correct placement of this mesh is critical to the success of the method, and surgical skills are required to achieve perfect placement. If the mesh placement is not mastered properly, the operation and anesthesia time will be prolonged. In addition, improper placement of the mesh can lead to serious consequences, such as intestinal obstruction and mesh infection. A "contraposition and alignment" mesh fixation method is described in this study, which involves pre-marking the fixation position of the mesh to reduce the difficulty of mesh placement. A properly placed mesh is completely flat on the peritoneum, the edges are not curled or wrapped, and the mesh is adhered firmly such that there is no displacement after removing the pneumoperitoneum pressure. The "contraposition and alignment" mesh fixation technique offers the advantages of reliable placement of the mesh and fewer complications than other techniques, and it is easy to learn and master. It also allows for positioning the nail gun in advance based on the anatomy of the incisional hernia. This enables the use of the minimum number of nails possible while still ensuring good fixation, which can reduce the occurrence of complications and reduce the cost of surgery. Thus, the mesh fixation method described here is highly suitable for clinical applications based on the aforementioned advantages.

Presented here is a method for improving the mesh placement in laparoscopic incisional hernia repair, which can shorten the time required for mesh fixation and reduce the occurrence of postoperative chronic pain.

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing ...

Fluorescent Laparoscopic Central Hepatectomy for Liver Cancer Using Indocyanine Green Negative Staining

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ultrasound, important vascular structures, and surgeon experience. With the development of anatomical hepatectomy, visual surgery technology has gradually been applied to this type of surgery, particularly indocyanine green (ICG)-guided anatomical hepatectomy. As ICG can be specifically ingested by hepatocytes and used for fluorescence tracing, negative staining techniques have been applied according to different tumor positions. Under ICG fluorescent guidance, the surface boundary and deep resection plane can be more accurately displayed during liver resection. Thus, the tumor-bearing liver segment can be anatomically removed, which helps to avoid damage to important vessels and reduce ischemia or congestion of the remaining liver tissue. Finally, the incidence of postoperative biliary fistula and liver dysfunction is reduced; therefore, a better prognosis is obtained after the resection of liver cancer. Centrally located liver cancer is usually defined as a tumor located at segments 4, 5, or 8 that requires resection of the middle section of the liver. These are among the most difficult hepatectomies to perform because of the large surgical wounds and multiple vessel transections. Based on the specific tumor location, we formulated the required resection ranges by designing personalized fluorescent staining strategies. By completing anatomical resection based on the portal territory, this work aims to achieve the best therapeutic effect.

The present protocol describes fluorescent negative staining in laparoscopic central hepatectomy. This technique can make hepatectomy more accurate and precise.

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ...

Application of Laparoscopic Hepatectomy Combined with Intraoperative Microwave Ablation in Colorectal Cancer Liver Metastasis

Laparoscopic hepatectomy is a common treatment for colorectal cancer liver metastasis. Previously, a sufficient number of functional liver masses had to be maintained during laparoscopic hepatectomy, with a residual liver volume of &gt;40% in cirrhotic patients and &gt;30% in non-cirrhotic patients. The high incidence of complications such as bleeding, bile leakage, or liver failure due to the exposure and difficulty of the resection of specific liver segments such as S2 and S7 reduces the success rate of liver resection. At present, microwave ablation is mainly applied in the treatment of liver metastasis using a percutaneous approach, which makes it difficult to identify hidden parts or small lesions. For some liver segments, the percutaneous puncture of liver segment 7 (S7) is likely to pass through the thoracic cavity, and the percutaneous puncture of liver segment 2 (S2) adjacent to the diaphragm is likely to injure the diaphragm and heart; these issues restrict the application of percutaneous ablation in colorectal cancer liver metastasis. Considering multiple lesions, laparoscopic microwave ablation combined with hepatectomy was performed in this study. The location of the lesions was determined by contrast-enhanced ultrasound under laparoscopy, and small lesions that were difficult to detect before the operation were identified. For the scattered lesions, which had diameters less than 3 cm and were difficult to resect, ablation was adopted to substitute hepatectomy. This technique helped to more explicitly locate the tumors, simplified the operation procedures, reduced the risk of complications such as bleeding and bile leakage, shortened the operation time, accelerated the postoperative recovery, significantly improved the success rate of operation, and enhanced the clinical prognosis of colorectal cancer liver metastasis by surgical resection.

This protocol describes the laparoscopic resection of colorectal cancer liver metastases combined with ultrasound-guided microwave ablation. This technique can safely, effectively, and accurately treat refractory liver metastases &lt;3 cm, reduce postoperative complications, and accelerate the postoperative rehabilitation of patients.

Laparoscopic hepatectomy is a common treatment for colorectal cancer liver metastasis. Previously, a sufficient number of functional liver masses had to ...

Robotic D3 Partial Duodenal Resection with Primary Side-to-Side Anastomosis

Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or extrinsic, such as pancreatic pseudocyst, superior mesenteric artery syndrome, and foreign bodies. Current treatments range from endoscopic approaches, such as endoscopic resection and stent placement, to surgical approaches, including duodenal resection, pancreaticoduodenectomy, and gastrointestinal bypass. Minimally invasive robot-assisted surgery is gaining importance due to its potential to decrease surgical stress, intraoperative blood loss, and postoperative pain, while its instruments and 3D-vision facilitate fine dissection and intra-abdominal suturing, all leading to a reduced time to functional recovery and shorter hospital stay. We present a case of a 75-year-old female who underwent robotic D3 partial duodenal resection with primary side-to-side duodeno-jejunal anastomosis for a 5 cm adenoma with focal high-grade dysplasia.

This protocol presents a case of a robotic partial duodenal resection with primary side-to-side duodeno-jejunal reconstruction in a patient with a 5 cm duodenal stenosis. This is done at the third duodenal segment (D3) after an endoscopic mucosal resection (EMR) for a duodenal polyp.

Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or ...

Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic pancreatoduodenectomy (LPD), laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has not yet obtained wide acceptance. This could be attributed to the technical challenges involved in preserving the blood supply of the duodenum and bile duct.
This study describes and demonstrates all the steps of LDPPHR. A 48-year-old woman was diagnosed with a 3.0 cm x 2.5 cm pancreatic head cystic mass, which was detected unexpectedly. The surgery was performed using the 3D laparoscopy via an inferior infracolic approach. The operation lasted approximately 310 min with 100 mL of blood loss. Postoperatively, the patient experienced no complications and was discharged 5 days later. Pathology revealed intraductal papillary mucinous neoplasms.
LDPPHR via an inferior infracolic approach is feasible and safe when performed by experienced surgeons in selected patients with thin mesenteric fat layers. The described technique for LDPPHR via inferior infracolic approach should be well standardized and performed at high-volume centers with experienced surgeons in both open and laparoscopic pancreatology.

This article provides a whole technical process of laparoscopic duodenum-preserving pancreatic head resection via an inferior infracolic approach. This is a surgical approach for benign tumors without intraoperative fluorescence image guidance.

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

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Application of Laparoscopic Hepatectomy Combined with Intraoperative Microwave Ablation in Colorectal Cancer Liver Metastasis

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Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions