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Strey CW, Wullstein C, Adamina M, Agha A, Aselmann H, Becker T, Grützmann R, Kneist W, Maak M, Mann B, Moesta KT, Runkel N, Schafmayer C, Türler A, Wedel T, Benz S. Laparoscopic right hemicolectomy with CME: standardization using the "critical view" concept. Surg Endosc 2018; 32:5021-5030. [PMID: 30324463 PMCID: PMC6208708 DOI: 10.1007/s00464-018-6267-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 06/07/2018] [Indexed: 12/12/2022]
Abstract
Background Complete mesocolic excision is gradually becoming an established oncologic surgical principle for right hemicolectomy. However, the procedure is technically demanding and carries the risk of serious complications, especially when performed laparoscopically. A standardized procedure that minimizes technical hazards and facilitates teaching is, therefore, highly desirable. Methods An expert group of surgeons and one anatomist met three times. The initial aim was to achieve consensus about the surgical anatomy before agreeing on a sequence for dissection in laparoscopic CME. This proposal was evaluated and discussed in an anatomy workshop using post-mortem body donors along with videos of process-informed procedures, leading to a definite consensus. Results In order to provide a clear picture of the surgical anatomy, the “open book” model was developed, consisting of symbolic pages representing the corresponding dissection planes (retroperitoneal, ileocolic, transverse mesocolic, and mesogastric), vascular relations, and radicality criteria. The description of the procedure is based on eight preparative milestones, which all serve as critical views of safety. The chosen sequence of the milestones was designed to maximize control during central vascular dissection. Failure to reach any of the critical views should alert the surgeon to a possible incorrect dissection and to consider converting to an open procedure. Conclusion Combining the open-book anatomical model with a clearly structured dissection sequence, using critical views as safety checkpoints, may provide a safe and efficient platform for teaching laparoscopic right hemicolectomy with CME. Electronic supplementary material The online version of this article (10.1007/s00464-018-6267-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christoph Werner Strey
- Clinic for General-, Visceral- and Vascular Surgery, Diakovere Hospital Friederikenstift, Humboldtstrasse 5, 30169, Hannover, Germany.
| | - Christoph Wullstein
- Department of Visceral and Minimal Invasive Surgery, Helios Hospital Krefeld, Lutherplatz 40, 47805, Krefeld, Germany
| | - Michel Adamina
- Department Chirurgie, Klinik für Viszeral- und Thoraxchirurgie, Kantonsspital Winterthur, Brauerstrasse 15, Postfach 834, 8401, Winterthur, Switzerland
| | - Ayman Agha
- Klinik für Allgemein-, Viszeral-, Endokrine und Minimal-invasive Chirurgie, Klinikum Bogenhausen, Englschalkinger Straße 77, 81925, Munich, Germany
| | - Heiko Aselmann
- General and Visceral Surgery, DRK-Krankenhaus Clementinenhaus, Lützerodestr. 1, 30161, Hannover, Germany
| | - Thomas Becker
- Klinik für Allgemeine, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Robert Grützmann
- Department of Surgery, University Hospital of Erlangen, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Werner Kneist
- Department of General, Visceral and Transplant Surgery, University Medical Center, University of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Matthias Maak
- Department of Surgery, University Hospital of Erlangen, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Benno Mann
- Klinik für Viszeralchirurgie, Augusta Klinikum Bochum, Bergstrasse 26, 44791, Bochum, Germany
| | - Kurt Thomas Moesta
- Department of General-, Visceral- and Minimalinvasive Surgery, KRH Klinikum Hannover GmbH, Klinikum Siloah, Stadionbrücke 4, 30459, Hannover, Germany
| | - Norbert Runkel
- Sana Klinikum, Starkenburgring 66, 63069, Offenbach, Germany
| | - Clemens Schafmayer
- Department of General Surgery and Thoracic Surgery, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | - Andreas Türler
- Department of Visceral Surgery, Johanniter Hospital Bonn, Johanniterstr. 3, 53113, Bonn, Germany
| | - Thilo Wedel
- Institute of Anatomy, Center of Clinical Anatomy, Christian-Albrechts University Kiel, Otto-Hahn-Platz 8, 24118, Kiel, Germany
| | - Stefan Benz
- Department for Abdominal and Pediatric Surgery, Klinkverbund-Suedwest, Klinken Boeblingen, Bunsenstrasse 120, 71032, Boeblingen, Germany
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Croner R, Hohenberger W, Strey CW. [Comparison of Open vs. Laparoscopic Techniques in Complete Mesocolic Excision (CME) During Right Hemicolectomy]. Zentralbl Chir 2015; 140:580-2. [PMID: 26679481 DOI: 10.1055/s-0035-1558104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIMS The technique of open complete mesocolic excision (CME) has improved the outcomes of patients with colon carcinoma. Meanwhile it has become an established international standard procedure. It remains unclear if laparoscopic procedures are able to match the high quality of open resections. A video comparison of the two methods gives insight into the different dissection techniques. INDICATION Open CME is demonstrated in a 79-year-old female patient with an asymptomatic carcinoma of the ascending colon verified by histopathology. The tumour was diagnosed during routine colonoscopy. No distant metastases were identified during the staging procedure. Laparoscopic CME is performed in a 72-year-old female patient with a biopsy-proven carcinoma of the ascending colon. Similarly this patient was diagnosed during a screening colonoscopy and had no distant metastasis. METHODS During open CME the ascending colon and the duodenum are mobilised by sharp dissection between the parietal and visceral layer of the mesentery. Afterwards the ascending and transverse mesocolon are dissected from the duodenum and pancreas. The parietal and the visceral mesentery are strictly preserved during these procedures. After the exposure of the superior mesenteric artery and vein, a central dissection of the vessels follows. The colon is cut 10 cm distal to the carcinoma. An ileotransversostomy is performed with a running suture. The hole in the mesentery is closed. The laparoscopic CME is performed using the 4-trocar technique with an umbilical camera position following a medial to lateral approach with primary dissection of the superior mesenteric vein. Radicular vessel ligation opens the space dorsal to the mesocolon with the border lamella remaining intact. The space is widened until the ascending colon is entirely mobilised. The mobilised colon is eventrated through an enlarged umbilical midline incision. Colon resection and the subsequent two-layered side-to-side ileotransversostomy are performed in a standard open surgical fashion. CONCLUSION Open and laparoscopic CME enable central vessel dissection while preserving the mesenteric layers. However, the laparoscopic procedure is technically demanding and should therefore only be performed by surgeons experienced in laparoscopy.
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Affiliation(s)
- R Croner
- Allgemein-, Viszeral-, Transplantationschirurgie, Chirurgische Universitätsklinik Erlangen, Deutschland
| | - W Hohenberger
- Allgemein-, Viszeral-, Transplantationschirurgie, Chirurgische Universitätsklinik Erlangen, Deutschland
| | - C W Strey
- Allgemein-, Viszeral-, Gefäßchirurgie, Diakoniekrankenhaus Friederikenstift, Hannover, Deutschland
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Harlaar J, Deerenberg EB, Dwarkasing RS, Kamperman AM, Jeekel J, Lange JF, Samartsev VA, Gavrilov VA, Kuchumov AG, Nyashin YI, Vildeman VE, Slovikov SV, Rubtsova EA, Parshakov AA, Morawski J, Miller A, Kallenberger G, Hannen C, Strey CW, Robin A, López-Monclús J, Melero D, Blazquez L, Moreno A, Palencia N, Cruz A, López-Quindós P, Aguilera A, Jimenez C, Becerra R, García M, Galván A, Gonzalez E, García-Ureña MA, Costa T, Abdalla R, Garcia R, Costa R, Williams Z, Kotwall C, Tenzel P, Alam N, Narang S, Pathak S, Daniels I, Smart N, Guérin G, Ordrenneau C, Bouré L, Turquier F, Abbonante F. Abdominal Wall "Closure". Hernia 2015; 19 Suppl 1:S123-6. [PMID: 26518787 DOI: 10.1007/bf03355338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- J Harlaar
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - E B Deerenberg
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - R S Dwarkasing
- Department of Radiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - A M Kamperman
- Department of Psychiatry, Erasmus University Medical Center, Rotterdam, Netherlands
| | - J Jeekel
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - J F Lange
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - V A Samartsev
- Perm State Medical University named after ac. E.A Wagner, Perm, Russia
| | - V A Gavrilov
- Perm State Medical University named after ac. E.A Wagner, Perm, Russia
| | - A G Kuchumov
- Perm National Research Polytechnical University, Perm, Russia
| | - Y I Nyashin
- Perm National Research Polytechnical University, Perm, Russia
| | - V E Vildeman
- Perm National Research Polytechnical University, Perm, Russia
| | - S V Slovikov
- Perm National Research Polytechnical University, Perm, Russia
| | - E A Rubtsova
- Perm State National Research University, Perm, Russia
| | - A A Parshakov
- Perm State Medical University named after ac. E.A Wagner, Perm, Russia
| | - J Morawski
- Diakoniekrankenhaus Friederikenstift, Hannover, Germany
| | - A Miller
- Diakoniekrankenhaus Friederikenstift, Hannover, Germany
| | | | - C Hannen
- Diakoniekrankenhaus Friederikenstift, Hannover, Germany
| | - C W Strey
- Diakoniekrankenhaus Friederikenstift, Hannover, Germany
| | - A Robin
- Hospital del Henares, Coslada (Madrid), Spain
| | | | - D Melero
- Hospital del Henares, Coslada (Madrid), Spain
| | - L Blazquez
- Hospital del Henares, Coslada (Madrid), Spain
| | - A Moreno
- Hospital del Henares, Coslada (Madrid), Spain
| | - N Palencia
- Hospital del Henares, Coslada (Madrid), Spain
| | - A Cruz
- Hospital del Henares, Coslada (Madrid), Spain
| | | | - A Aguilera
- Hospital del Henares, Coslada (Madrid), Spain
| | - C Jimenez
- Hospital del Henares, Coslada (Madrid), Spain
| | - R Becerra
- Hospital del Henares, Coslada (Madrid), Spain
| | - M García
- Hospital del Henares, Coslada (Madrid), Spain
| | - A Galván
- Hospital del Henares, Coslada (Madrid), Spain
| | - E Gonzalez
- Hospital del Henares, Coslada (Madrid), Spain
| | | | - T Costa
- University of Sao Paulo, Sao Paulo, Brazil
| | - R Abdalla
- University of Sao Paulo, Sao Paulo, Brazil
| | - R Garcia
- Hospital Sirio Libanes, Sao Paulo, Brazil
| | - R Costa
- Hospital Sirio Libanes, Sao Paulo, Brazil
| | - Z Williams
- New Hanover Regional Medical Center, Wilmington, USA
| | - C Kotwall
- New Hanover Regional Medical Center, Wilmington, USA
| | - P Tenzel
- New Hanover Regional Medical Center, Wilmington, USA
| | - N Alam
- HeSRU, Royal Devon and Exeter Hospital, Exeter, UK
| | - S Narang
- HeSRU, Royal Devon and Exeter Hospital, Exeter, UK
| | - S Pathak
- HeSRU, Royal Devon and Exeter Hospital, Exeter, UK
| | - I Daniels
- HeSRU, Royal Devon and Exeter Hospital, Exeter, UK
| | - N Smart
- HeSRU, Royal Devon and Exeter Hospital, Exeter, UK
| | | | | | | | | | - F Abbonante
- Department of Surgery-Plastic Surgery, Catanzaro City Hospital, Catanzaro, Italy
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Strey CW, Siegmund B, Rosenblum S, Marquez-Pinilla RM, Oppermann E, Huber-Lang M, Lambris JD, Bechstein WO. Complement and neutrophil function changes after liver resection in humans. World J Surg 2010; 33:2635-43. [PMID: 19789912 DOI: 10.1007/s00268-009-0209-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Complement activation contributes to the regulation of liver regeneration after liver resection (LR) in mice. METHODS We hypothesized that complement activation and changes in C5a-receptors (C5aR, C5L2) on polymorphonuclear cells (PMN) and monocytes are important in clinical LR. Anaphylatoxin and C5b9 plasma levels were measured (bead-array, ELISA) (25 patients) and receptor expression was assessed after LR (19 patients) (FACS). In vitro PMN C5a-dependent chemotactic response (7 patients) as well as L-selectin shedding and Mac-1 expression (3 patients) was determined. RESULTS C3a increased after LR (31.1 +/- 4 before LR vs. 41.6 +/- 5 ng/ml, 30 min after LR, P < 0.01), as did C5b9 (12.7 +/- 1 before LR vs. 26.9 +/- 3 ng/ml, 60 min after LR, P < 0.001). C4a and C5a decreased after LR, by 25% 24 h after LR and 30% 2 h after LR, respectively (P < 0.01). C5L2 expression decreased at 4 h, rising at 24 h after LR (PMN: 6.3 +/- 1 before LR, 3.1 +/- 1, 4 h, 8.3 +/- 2, 24 h; P < 0.01). The receptor-related changes accompanied a diminished C5a-dependent chemotactic response by PMN (42.1 +/- 17 before LR vs. 2.1 +/- 3 4 h after LR; P < 0.01) and a reduction of activation upon C5a-R stimulation as measured by L-selectin shedding and Mac-1 expression on PMN. Changes in C5L2 expression on monocytes paralleled postoperative impairment of liver function. CONCLUSIONS These results indicate that complement components are released after clinical LR and subsequently PMN display altered C5a-dependent functional responses.
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Affiliation(s)
- Christoph Werner Strey
- Department of General and Vascular Surgery, Medical School, Johann Wolfgang Goethe-University Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany.
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Moench C, Burck I, Bug R, Bak YJ, Richter B, Schroeder R, Klarner A, Strey CW, Vogl T, Bechstein W. [Hepatic angiomyolipoma--a rare liver tumor]. Z Gastroenterol 2008; 46:54-7. [PMID: 18188817 DOI: 10.1055/s-2007-963773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
A 22-year-old woman was treated for a hepatic lesion with a high suspicion of a liver adenoma at another hospital. The patient presented with unspecific abdominal pain. Further physical examination was unremarkable. A biopsy of the liver lesion revealed hepatic adenoma. Because of the increasing tumour size over a one-year period the patient was referred to our department for surgical therapy. On MRI scan, the liver mass measured 10 x 9 x 9 cm in the right liver lobe with contact to the right hilum. Because of the histological signs of adenoma a right hepatic lobectomy was performed. Postoperative follow-up was uneventful. The pathological diagnosis of hepatic angiomyolipoma was obtained. Angiomyolipoma of the liver is a rare benign mesenchymal tumour often mimicking other hepatic lesions. Histological features are thick-walled blood vessels, mature fat and smooth muscle in various proportions. The biological behaviour of the tumour is benign, although distant metastases are occasionally possible. Due to the potential for malignant transformation, tumour resection should be performed.
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Affiliation(s)
- C Moench
- Klinik für Allgemein- und Gefässchirurgie, Klinikum der Johann-Wolfgang-Goethe-Universität, Frankfurt am Main.
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