Methods The clinical data of 4445 cases (5 530 hernias) who underwent LIHR at Ruijin Hospital from Jan 2001 to Dec 2015 were analyzed retrospectively.2 125 cases underwent 2 402 trans-abdominal preperitoneal procedure(TAPP),2 306 cases did 2 907 totally extraperitoneal (TEP),and 21 IPOMs in 20 cases.There were 3 216 indirect hernias (60.3％),1 164 direct hernias (21.8％),399 recurrent hernias (7.5％),479 complex hernias (9.0％),and 72 femoral hernias (1.4％).The median time of follow-up is 51 months with a range between 7 and 187 months.Results The average operation time was 27.1 ± 8.7 min for unilateral hernia repair,and 43.0 ± 11.0 min for bilateral hernia repair.The average hospital stay was 1.4 ± 1.1 d.There were 250 seroma (4.7％),68 urinary retention (1.3％),23 transient neuropraxia (0.4％) and 3 paralytic obstruction of intestines (0.1％).Severe complications included 1 port site hernia,1 intestinal injury,and 1 mechanical intestinal obstruction.After a medium follow-up of 51 months,there were 13 recurrent cases (0.24％),including 5 cases after TAPP,7 after TEP,1 after IPOM.Conclusion LIHR is a safe and efficient technique for hernia repair.

The development of laparoscopic total mesorectal excision (TME) has been promoting the better understanding of the anatomy in pre-rectal space for surgeons.If the dissection in pre-rectal space was inappropriate and entered into wrong anatomic planes,it would be easier to cause the proper fascia of rectum incomplete and damage the neurovascular bundies,and reduce the radical surgery outcome and induce urinary and sexual dysfunction,finally,affect the prognosis in patients.For surgical approach in pre-rectal space,the author proposed:Based on the related literatures,transecting the Denonvilliers' fascia (DVF) when it's definitely thickened after cutting the peritoneum 0.5 cm anterior to peri-toneal reflection,entering and dissecting in the space between DVF and the proper fascia of rectum,and forming a typical Three-line feature,including the cutting line of peritoneal reflection,the proximal and distal cutting lines of DVF,which can serve as the mark line and mark plane of the entrance to pre-rectal space.Not only this approach can keep the proper completeness of rectal fascia,but also it maximally reserves the DVF.Here,this article discussed the embryonic origins and anatomic characters of DVF,the structures of neurovascular bundles,dissection in the pre-rectal space,surgical approach and clinical outcomes between DVF and laparoscopic TME.

Objective To compare predictive power for deep vein thrombosis among hip and knee joint replacement patients using Autar scale and Wells scale.Methods Convenience sampling method was used.Totally 331 patients from ten tertiary hospitals receiving hip and knee joint replacement were recruited.General information questionnaire,Autar scale and Wells scale were used to collect data.Telephone follow-up was performed at 2 weeks,1 month and 3 months after hospital discharge.The primary endpoint of follow-up was occurrence of DVT,and the secondary endpoint was no occurrence of DVT within 3 months after hospital discharge.Results The Cronbach's α coefficients of Autar scale ranged from 0.716 to 0.762 for scores 24h before operation,24h after operation and at the day of discharge,and those of Wells scale ranged from 0.580 to 0.603.The area under the ROC curve of Autar scale ranged from 0.726 to 0.798.The area under the ROC curve of Wells scale ranged from 0.568 to 0.628.Conclusion The predictive power of Autar scale was higher than that of Wells scale which enabled Autar scale to better predict deep vein thrombosis for patients receiving hip and knee joint replacement.

The advancement of laparoscopic surgery serves as a trigger for better understanding of the vascular structure at the inferior border of the pancreas, especially Henle trunk. Henle trunk was first found as convergence to superior mesenteric vein (SMV) conjoined by sub-right colon vein (SRCV) and right gastroepiploic vein (RGEV), but decades later, anterior superior pancreatic duodenal vein (ASPDV) was described as another conjoint vein of Henle trunk. These tributaries are the basic elements of Henle trunk in early years' study. A proper surgical procedure for Henle trunk can significantly reduce the complications of radical right hemi-colectomy (Japanese D3 resection and European complete mesocolic excision, CME). There are four variations of Henle trunk according to the colic venous tributaries that consists the anatomic variations in transverse colon posterior space(TRCPS). These variations are like "fingerprint and pattern" of CME. The recognition and extension of the TRCS is the key to the dissection of Henle trunk in laparoscopic right hemi-colectomy. Our medical center proposed four feasible approaches for extension:(1) hybrid medial approach; (2) completely medial approach; (3)completely medial access by "page-turning" approach; (4) completely medial approach along RCV. Mostly, RCV ended in Henle trunk, and completely medial approach along RCV is efficient to identify the Henle trunk in CME. We suggest dissecting the inferior margin of pancreas along SMV in a bottom-to-top fashion, followed by the dissection of middle colic vessels to reveal the root of Henle trunk. And it's better to dissect Henle trunk by branch rather than at its root for safety. Here, we describe the anatomic characters of Henles trunk, the surgical approach and strategies of Henle trunk in laparoscopic surgery.

Objective To investigate the application value of the modified Overlap esophagojejunostomy in totally laparoscopic total gastrectomy (TLTG).Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 32 patients who underwent TLTG with modified Overlap esophagojejunostomy in the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between January 2015 and December 2017 were collected.The main points of the modified Overlap method:surgeons stood on the right of patients when digestive tract reconstruction,suspension of left half liver and clockwise rotation before esophageal transection were performed,regulating esophageal opening position and building jejunal loop,and then closing openings using 45.0 mm Endo-GIA and barbed wire.Patients who were diagnosed as Ⅰ A stage by postoperative pathological examination were followed up;patients with lymph node metastases underwent chemotherapy of XELOX regimen and patients in Ⅰ B and Ⅱ stages without lymph node metastases underwent oral S-1 single agent.Observation indicators:(1) surgical and postoperative recovery situations;(2) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect postoperative adjuvant therapy,long-term complications and survival up to March 2018.Measurement data with normal distribution were represented as x±s,and measurement data with skewed distribution were described as M(range).Results (1) Surgical and postoperative recovery situations:all the 32 patients underwent successful TLTG and modified Overlap esophagojejunostomy.The operation time,esophagojejunostomy time,volume of intraoperative blood loss,time to initial anal exsufflation,time for initial fluid diet intake,time for initial semifluid diet intake and time of postoperative drainage-tube removal were respectively (227 ± 19) minutes,(22 ±7)minutes,(69±11)mL,(2.1±0.5) days,(3.4±0.4) days,(4.9±0.6) days and (7.5±1.7) days.There was no anastomotic stoma-related complication in 32 patients.One patient was complicated with duodenal stump leakage at 5 days postoperatively and was cured by continuous three-cavity irrigation and conservative treatment.Results of postoperative pathological examination:number of lymph node dissected in 32 patients was 32±4.TNM staging:1,5,7,11,6,1 and 1 patients were detected respectively in Ⅰ A,Ⅰ B,Ⅱ A,Ⅱ B,ⅢA,ⅢB and ⅢC.Duration of postoperative hospital stay of 32 patients was (8.1 ±2.1)days.(2) Follow-up and survival situations:32 patients were followed up for 3-38 months,with a median time of 18 months.During the follow-up,in addition to 1 patient in IA stage,31 patients underwent postoperative adjuvant therapy;patients can take the common soft food,without symptoms of choking and burning feelings,and gastroscopy reexamination was performed at 6 months postoperatively and showed anastomosis patency.One patient died of malignant tumor of maxillary sinus at 9 months postoperatively,1 was detected liver metastasis at 20 months postopeartively and survived with tumor,the other patients had no tumor recurrence or metastasis.Conlusion The modified Overlap esophagojejunostomy is safe and feasible in TLTG,with good short-term outcomes.

Objective To investigate the clinical efficacy of laparoscopic-assisted linea alba reconstruction for postpartum diastasis recti.Methods The retrospective cross-sectional study was conducted.The clinical data of 14 patients with postpartum diastasis recti who were admitted to Ruijin Hospital of Shanghai Jiaotong University School of Medicine between June 2016 and June 2018 were collected.Patients underwent laparoscopic-assisted linea alba reconstruction.Observation indicators:(1) intra-and post-operative recovery situations;(2) follow-up.Follow-up using outpatient examination and telephone interview was performed to detect postoperative long-term complications,diastasis recti and umbilical hernia recurrence up to September 2018.Measurement data with normal distribution were represented as (x)±s and measurement data with skewed distribution were described as M (P25,P75).Results (1) Intra-and post-operative situations:14 patients underwent successful laparoscopic-assisted linea alba reconstruction and 8 complicated with umbilical hernia area of (6± 3) cm2 were sutured and closed.The mesh area,operation time,visual analogue score for pain at the first day after operation,time of postoperative drainage-tube removal and duration of postoperative hospital stay were respectively (214±26) cm2,(74 ± 14) minutes,3.7 ± 0.6,(3.3 ± 0.7) days and (4.1 ± 1.2) days.No patient required administration of analgesics and had postoperative complication.(2) Follow-up:14 patients were followed up for 17 months (5 months,21 months).During the follow-up,1 patient returned visit at postoperative day 10 due to surgical incision drainage and cured after dressing change.The other patients had no complications,without diastasis recti and umbilical hernia recurrence.Conclusion Laparoscopic-assisted linea alba reconstruction for postpartum diastasis recti is safe and effective.

Objective To investigate the safety and short-term outcomes of laparoscopic abdominoperineal resection with pelvic peritoneum closure (LARP-PPC) for low rectal cancer.Methods The retrospective cohort study was conducted.The clinicopathological data of 132 patients with low rectal cancer who were admitted to Ruijin Hospital of Shanghai JiaoTong University School of Medicine from January 2014 to December 2017 were collected.There were 81 males and 51 females,aged from 45 to 83 years,with an average age of 62 years.Among the 132 patients,60 undergoing LARP-PPC were allocated into LARP-PPC group,and 72 patients undergoing conventional LARP were allocated into LARP group.All the patients received standardized preoperative and postoperative treatments.Observation indicators:(1) surgical and postoperative conditions;(2) postoperative pathological examination;(3) postoperative complications.The measurement data with normal distribution were expressed as Mean±SD,and the t test was used for comparison between groups.The measurement data with skewed distribution were expressed as M (range),and the Mann-Whitney U test was used for comparison between groups.The count data were expressed as absolute numbers,and the chi-square test or the Fisher exact probability was used for comparison between groups.Mann-Whitney U test was used for comparison of ordinal data between groups.Results (1) Surgery and postoperative conditions:all the patients in the two groups underwent successful surgery without conversion to open surgery.The operation time,volume of intraoperative blood loss,time to first flatus,and time to first liquid intake of the LARP-PPC group were (163±45) minutes,168 mL(range,85-280 mL),2 days(range,1-5 days),3 days(range,2-6 days),versus (155±39) minutes,160 mL(range,100-305 mL),3 days(range,1-7 days),4 days(range,2-7 days) of the LARP group;there was no differencebetween the two group (t =1.113,Z =-1.623,-1.468,-0.321,P＞0.05).The duration of postoperative hospital stay in the LARP-PPC group and the LARP group were 16 days (range,11-21 days) and 19 days (14-24 days),respectively,with a significant difference between the two groups (Z =-5.888,P＜0.05)].In the LARP-PPC group,time of PPC was (13± 3) minutes.(2) Postoperative pathological examination:the length of specimen,the number of lymph node dissection,tumor diameter,cases with high-,middle-,and low-differentiated tumor in the LARP-PPC group was (18±4)cm,16±t5,(3.7±1.4)cm,10,34,16 in the LARP-PPC group,and (18±4)cm,16±5,(3.9±1.5) cm,13,41,18 in the LARP group,showing no significant difference between the two groups (t =0.779,0.390,0.703,Z=-0.267,P＞0.05).(3) Postoperative complications:cases with perineal wound infection,delayed perineal wound healing,intestinal obstruction,and perineal hernia were 2,1,1,0 in the LARP-PPC group,and 12,10,8,6 in the LARP group,showing significant differences between the two groups (x2 =6.137,6.400,P＜0.05).There were 2 and 4 patients with urinary tract infection in the LARP-PPC group and the LARP group,respectively,showing no significant difference between the two groups (P ＞ 0.05).Conclusion LARP-PPC is safe and feasible for the treatment of low rectal cancer,which can significantly reduce postoperative perineal-related complications and consequently shorten postoperative hospital stay.

Objective:To analyze and summarize the implementation effect of basic essential surgical training (BEST) course of laparoscopic skills over the past 10 years and the practical experience in updating course content and models.Methods:The pre-class assessment questionnaires, basic laparoscopic operation assessment results, and post-class assessment questionnaires of the students who participated in the BEST course of laparoscopic skills were collected. According to the period of the course construction, the students were divided into two groups, namely students who used the course of single training system in the early stage (traditional group) and students who used the course integrating a variety of training systems after the course model was updated in the later stage (test group). The two groups were compared for the scores of track circle moving, tunnel crossing, and high and low columns, as well as their subjective evaluation of course setting and implementation effect. The t-test, Wilcoxon test, or chi-square test was conducted according to the data type using SPSS 13.0. Results:The time for 150 traditional group students to complete track circle moving, tunnel crossing, and high and low columns was 1.08 min (0.81 min, 1.60 min), 2.20 min (1.60 min, 3.27 min), and 4.86 min (3.28 min, 6.36 min), respectively, while the time for 75 test group students to complete the three operations was 1.27 min (0.87 min, 1.83 min), 2.57 min (1.58 min, 4.07 min), and 4.35 min (2.90 min, 6.42 min), respectively, with no significant difference between the two groups ( P>0.05). In terms of students' subjective evaluation of the course, a higher percentage of the test group students were satisfied with classroom environment, teaching method arrangement, training equipment, training opportunities, helping clinical work, and meeting pre-class expectations than those in the traditional group. Conclusion:The constantly updated BEST course can ensure the training quality of trainees and obtain their higher satisfaction. The benefits of this course in clinical practice can be further verified through long-term follow-up of these trainees.

Virtual reality (VR) is a technology that interacts computer-generated three-dimensional scenes with the user′s senses and has been gradually applied in the real medical field. Since the first time of successful attempt in 3D laparoscopic gastrointestinal surgery VR living video broadcast in 2016, the authors have experienced the exploration of the application of this technology (2016-2017) as well as the in-depth research phase (2018-2019). Nowadays, the VR application in our center has entered into the application practice phase (2020 to present). With the technology iteration and more and more application experience acquisition, our current VR application mainly focuses on two practice settings, including the clinical teaching scenarios for early exposure to acute appendicitis for medical undergraduate students and the preoperative communication to give pati-ents an early sense of the process in the operating theatre, and has achieved good application results. With continuous breakthroughs and innovations in software and hardware, we believe that more clinical VR scenarios and the course audience will be expanded to a wider group. The integration of some new hotspots such as Meta-Universe and ChatGPT will make up for the shortcomings in VR content scenarios and interactivity, and its application prospects are infinite.

OBJECTIVE To establish HPLC methods with different separation principles to analyze the relevant impurities in the APIs of bivalirudin from seven enterprises, to provide a basis for the comprehensive control of related substances of bivalirudin. METHODS Reversed-phase high performance liquid chromatography(RP-HPLC) was used to separate and analyze 11 kinds of impurities. Hydrophilic chromatography(HILIC)-HPLC was used to control four process impurities. Polymers were determined by size exclusion chromatography(SEC)-HPLC. RESULTS The established RP-HPLC could effectively separate the principal component and 11 impurities, the correction factors of 11 impurities were between 0.8−1.2, the detection concentration of bivalirudin was 0.1 μg·mL−1, and the detection limit was 0.004%. The established HILIC-HPLC could effectively separate the principal components and four process impurities, and the detection concentration of bivalirudin was 0.3 μg·mL−1, and the detection limit was 0.01%. Under SEC-HPLC conditions, the polymer and bivalirudin peaked sequentially, the resolution of the two was 2.9, the detection concentration of bivalirudin was 6 ng·mL−1, and the detection limit was 0.000 6%. Fifteen kinds of known impurities and polymers in 15 batches of samples from 7 enterprises were calculated by the self-control method of principal components, and the impurity contents from different enterprises had a certain correlation with their production processes. CONCLUSION The three different principles of the method have good specificity, high sensitivity, good durability, and reliable results, and can be used for quality control of substances related to bivalirudin.