Left upper lobectomy with pulmonary artery reconstruction after neoadjuvant therapy in re-VATS

Video-assisted thoracoscopic surgery (VATS) is considered the gold standard for the treatment of early stage non-small-cell lung cancer. Many studies have demonstrated reduced postoperative pain, hospital stay, and morbidity, while achieving the same oncological results. Indeed, it has become a widespread technique in many countries around the world. VATS can be applied also to challenging surgical procedures, such as plasty of the pulmonary artery, to obtain an oncologically radical resection of the tumor, and in the context of an N2 disease even after a previous operation on the thorax. In this case report, we demonstrate how to carry out this procedure safely to achieve radical resection of the diseased tissue.

Bilateral Pulmonary Arteries Reconstruction for Correction of Tetralogy of Fallot with Unilateral Absence of the Pulmonary Artery

Background: Tetralogy of Fallot (TOF) is the most common combined the deformity of unilateral absence of the pulmonary artery (UAPA). The treatment strategy of TOF combined with UAPA is still very controversial. In this study, we analyzed the effect of the bilateral pulmonary reconstruction for patients with TOF combined with UAPA. Methods: A single-institution, retrospective review of all 1713 patients with TOF between January 2009 to November 2021. Eight patients were diagnosed with TOF combined with UAPA, and 7 patients underwent the surgery. Three patients underwent one-stage TOF correction with bilateral pulmonary artery reconstruction. Three patients underwent bilateral pulmonary artery reconstruction, followed by two-stage TOF correction after several months. One patient underwent 2 procedures of left pulmonary artery reconstruction, and the VSD remained open. Results: All 7 patients survived during the postoperative follow-up and showed good cardiac function and normal oxygen saturation >97%. During the follow-up with echocardiograms, it was found that the left pulmonary arteries that were reconstructed with Goretex vessel or direct anastomosis had thrombosis or stenosis. The left pulmonary artery reconstructed with the modified autologous tissue extension technique was unobstructed. Conclusions: In patients with TOF and UAPA, if there is a pulmonary confluence in the affected hilum, it is feasible to implement bilateral pulmonary artery reconstruction for one-stage TOF correction. The use of pulmonary artery extension technique and autologous tissue to bilateral pulmonary reconstruct could reduce the incidence of anastomotic stenosis.

Strategies for a successful hepatic artery anastomosis in liver transplantation: A review of 51 cases

ABSTRACT Introduction: Hepatic artery reconstruction is a critical aspect of liver transplantation. The microsurgeon faces several challenges when reconstructing the hepatic artery—the donor hepatic artery stalk is short and often a poor match for the usually hypertrophic recipient vessels. Previous inflammation impedes vessel dissection, and recipient vessels have a tendency to delaminate with manipulation. We review 51 consecutive liver transplantations to highlight these problems and propose strategies for a successful reconstruction of the hepatic artery. Methods: A prospective study involving all adult patients undergoing liver transplantation at the Singapore General Hospital from January 2015 to December 2018 was undertaken. All hepatic artery anastomoses were performed by 2 microsurgeons at 10x magnification. Patients were started on a standard immunosuppressive regimen. Postoperative ultrasound scans on days 1, 3, 5, 7, 9 and 14 were used to confirm arterial patency. Results: There were 51 patients who underwent liver transplantation during the study period. Of this number, 31 patients received deceased donor grafts and 20 received living donor grafts. A total of 61 anastomoses were performed (5 dual anastomosis, 4 radial artery interposition grafts) with 1 case of hepatic artery thrombosis that was successfully salvaged. The mean (range) postoperative resistive index and hepatic artery peak systolic velocity were 0.69 (0.68–0.69) and 1.0m/s (0.88–1.10m/s), respectively. Conclusion: Hepatic artery thrombosis after liver transplantation is poorly tolerated. The challenges of hepatic artery reconstruction in liver transplantation are related to vessel quality and length. The use of microsurgical technique, appropriate recipient vessel selection, minimisation of vessel manipulation with modified instruments, variation in anastomosis techniques, and use of radial artery interpositional grafts are useful strategies to maximise the chances of success. Keywords: Hepatic artery, hepatology, liver transplant, microsurgery, plastic surgery

The Use And Benefits of 3D Digital Microscope In Hepatic Artery Reconstruction During Living Donor Liver Transplant

Background: To compare the intraoperative process of hepatic artery anastomosis using conventional microscope and novel 3D digital microscope and to share our institute’s experience for better surgical training.Method: A retrospective cohort study with 46 hepatic artery reconstructions in living donor liver transplant patients via operational microscope (Control group) and 3D digital microscope Mitaka Kestrel View II (Study group). We then discuss and share our institution’s experience to improve surgical training. Results: Both operation instruments provide effective and comparable results. There was no statistical significance regarding operational objective results between conventional microscope and exoscope. Both instruments have no hepatic artery size limit, and both have complete vessel patency rate. Conclusions: There was no statistical differences regarding hepatic artery anastomosis between microscope and exoscope cohorts. However, exoscope provided better ergonomics in the operation room and lessen musculoskeletal strain, allowing surgeons to work in a more neutral and comfortable posture and allow first assistant to learn and assist more effectively. Using exoscope with micro-forceps and modified tie technique make artery reconstruction easier.

Vascular Resection in Perihilar Cholangiocarcinoma

Perihilar cholangiocarcinoma (phCC) is the most common type of cholangiocarcinoma, accounting for approximately 60 % of cases, followed by the distal and then the intrahepatic forms. There is not a staging system that allows comparation of all series and extract some conclusions to increase the long-survival rate in this dismal disease. The extension of the resection, which theoretically dependes on the type of phCC, is not closed subject. As surgery is the only known way to achieve a cure, many aggressive approachs have been adopted. Despite extended liver resections and even vascular resections, margins are positive in around one third of patients. In the past two decades, with advances in diagnostic and surgical techniques, the surgical outcomes and survival rates have gradually improved, although variability is the rule, with morbidity and mortality rates ranging from 14% to 76% and from 0% to 19%, respectively. Extended hepatectomies and portal vein resection even right hepatic artery reconstruction for the left side tumors are frequently needed. Salvage procedures when arterial reconstruction is not feasible, as well as hepatopancreatoduodenectomy, are still under evaluation too. In this article, we discuss the aggressive surgical approach to phCC focused on vascular resection. Disparate results on the surgical treatment of phCC made it impossible to reach clear-cut conclusions.