Objective:To explore the risk factors for overall complications after laparoscopic pancreaticoduodenectomy(LPD) and to establish postoperative pancreatic fistula prediction model for LPD.Methods:The clinical data of 176 patients undergoing LPD from Jan 2014 to Mar 2018 were retrospectively analyzed.Results:One died within 30 days. Five patients underwent reoperation. Seventy-three patients (41%) had complications including pancreatic fistula in 30 cases(17.0%), postoperative hemorrhage in 16 (9.1%); bile leakage in 10 (5.7%); abdominal infection in 6 (3.4%); wound infection in 4 (2.2%); pulmonary infection in 4 (2.2%); gastric emptying disorder in 3 (1.7%). Age, intraoperative blood loss, diabetes mellitus were risk factors for overall postoperative complications of LPD(all P<0.05); Age, male gender, pancreatic duct diameter, pancreas texture, lesion size were risk factors for pancreatic fistula after LPD(all P<0.05). Conclusions:Age, intraoperative blood loss, diabetes mellitus were risk factors for overall postoperative complications of LPD; Age, male gender, pancreatic duct diameter, pancreas texture, and lesion size were risk factors for pancreatic fistula after LPD.

Objective To study the coordination and function of a laparoscopic assistant in laparoscopic pancreaticoduodenectomy (LPD).Methods A retrospective analysis was conducted on 101 patients who underwent LPD at the Department of Hepatobiliary Surgery,Hunan Provincial People's Hospital,from January 2014 to March 2017.The study aimed to study the coordination and function of a laparoscopic assistant.Results LPD was successfully completed in all the 101 patients.There was no conversion to open surgery.The operation time was (326.0 ± 55.6) min,and the resection time was (174.4 ± 42.5) min.The digestive tract reconstruction time was (101.0 ± 21.4) min.The time of pancreaticojejunostomy was (40.5 ± 8.7) min.The time of gastrointestinal anastomosis was:(26.3 ± 5.5) min.The time of biliary anastomosis was (24.4 ± 6.5) min.The intraoperative bleeding was (175.6 ± 41.1) ml.Postoperative pathological data showed that 27 patients (26.7％) had distal common bile duct cancer,23 patients (22.8％)ampullary carcinoma,39 patients (38.6％) duodenal papillary carcinoma,and 12 patients (11.9％) pancreatic ductal adenocarcinoma.The tumor diameter was (2.3 ± 1.3) cm,and the number of resected lymph nodes was (16.7 ±4.2).The number of positive lymph nodes was 1.3 ± 1.1.The length of postoperative hospital stay was 14.8 (8 ～ 29) d.Twenty-three patients developed postoperative pancreatic fistula,including 17 patients (16.8％) with a biochemical fistula,5 patients (5.0％) with a grade B pancreatic fistula,and 1 patient (1.0％) with a grade C pancreatic fistula.There were 2 patients (3.0％) with bile leakage,7 patients (6.9％) with intra-abdominal bleeding,4 patients (4.0％) with delayed gastric emptying,6 patients (5.9％) with abdominal infection,3 patients (3.0％) with pulmonary infection,2 patients (2.0％)with intestinal obstruction,3 patients (3.0％) required a repeated operation,and 1 patient (1.0％) with death in hospital within 30 days after surgery.Conclusions The laparoscopic assistant should have the perspective of "one axis,two sides and four regions" in LPD,and warn the operator to ensure the safety and fluency of the operation by clearly exposing important blood vessels and organs when performing the Kocher incision and when dissecting the key parts such as the dangerous triangle of the uncinate process.During anastomosis,the laparoscopic assistant should appropriately adjust the distance of vision,clearly reveal the surgical field of the anastomotic area,and help the surgeon in improving the precision of the suture and the quality of the anastomosis.

Objective To provide anatomical information and clinical application of periosteal perforator bone-skin flap of proximal lateral tibia. Methods From March, 2015 to March, 2017, 15 fresh cadavers who underwent injected with imaging technology and dissected with layer by layer. The origins, branches, distribution and anastomosis of periosteal perforator vessels in the proximal lateral tibial were observed. Sixteen patients of composite tissue defect in hands and feet were repaired with the method of free transplantation of this flap from March, 2015 to March, 2017. Injured area was from 3.0 cm × 0.8 cm to 6.0 cm × 5.5 cm. Bony defect size was from 1.7 cm × 1.5 cm × 1.0 cm to 5.0 cm × 1.0 cm × 1.0 cm. The bone-skin flap size ranged respectively from 3.0 cm × 0.8 cm to 6.0 cm × 5.5 cm and 1.6 cm ×1.0 cm × 0.8 cm to 5.0 cm×1.0 cm × 1.0 cm. Postoperative followed-up was done termly. Results The diameter and superficial length of the main perforators respectively were 0.5 to 1.2 mm and from 2.5 to 4.3 cm. The followed-up time was from 6 to 24 months in 14 cases, with the results of the bone-skin flaps presented favourable contours and good functions. The healing time of bone flap was 2 to 4 months. The function of shank was normal. Conclusion The periosteal perforator of proximal lateral tibia has favourable appearance, constant vascular pedi-cle, reliable blood supply and large diameter. The free transplantation of this flap offers a satisfactory alternative for repairing the small and medium-sized area of composite tissue defects of hands and feet.

OBJECTIVETo investigate the morphological features of the perforator from the first plantar metatarsal artery, so as to provide anatomic basis for the reconstruction of soft-tissue defects of the forefoot.

METHODSThe first metatarsophalangeal joint was chosen as the landmark on 30 human cadaveric feet prefused with red latex. The following contents were observed under surgical magnifier: (1)The origin, courses,branches,distribution of the perforator of the first plantar metatarsal artery; (2)The anastomoses among the perforator of the first plantar metatarsal artery and other arteries on the medial aspect of the foot. Simulated operation was performed on one fresh specimen.

RESULTSThe perforator of the first plantar metatarsal artery passed through the space between the tendon, the abductor hallucis and the first metatarsal bone, and its entry point into the deep fascia was located (2. 3 ± 0.7 ) cm proximal to the first metatarsophalangeal joint. The perforator anastomosed with either the medial tarsal artery, the medial anterior malleolus artery or the branch of the medial plantar artery on the superior margin of the abductor hallucis, forming a longitudinal arterial chain,through which small branches were given off to the skin of the medial aspect of the foot. The perforator was( 1. 1 ± 0.2) mm in diameter and(3.2 ± 0.2) cm in length.

CONCLUSIONThe flap based on the perforator of the first plantar metatarsal artery can be harvested as an axial flap to repair the defects of soft tissue on the forefoot.

Anatomic Landmarks ; anatomy & histology ; Arteries ; anatomy & histology ; Cadaver ; Foot ; Foot Injuries ; surgery ; Humans ; Metatarsal Bones ; blood supply ; Metatarsophalangeal Joint ; anatomy & histology ; Muscle, Skeletal ; anatomy & histology ; Perforator Flap ; blood supply ; Reconstructive Surgical Procedures

Objective Through investigating the anatomical features of the perforator from the ulnar palmar digital artery of the little finger and the dorsal descending branch of the ulnar artery,to establish a new approach for the reconstruction of sofi tissue defect of the ulnar palm and the little finger.Methods The fifth caput metacarpale was taken as the observation points on 30 specimens of adult human upper limb perfused with red latex.Something as follows were observed under surgery magnifier:①The origin,external diameter,branches,distribution and the backbone length of the perforator of the ulnar palmar digital artery of the little finger;the distance from the fifth caput metacarpale to the perforate artery ; ② The route and distribution of the dorsal descending branch of the ulnar artery.Mimic operation was performed on another fresh specimen.Results The origin of the ulnar palmar digital artery of the little finger has two different type:93.3％ spring from the external of the arcus volaris superficialis,6.7％ formed by the combination of the third arteriae metacarpeae palmares and the branch from arcus volaris profundus.Although it has two different origins,the perforator has only one piercing point,which located at (1.3 ±0.3)cm upon the fifth caput metacarpale.The perforator,ultimately,combines with the descending branch of the ulnar artery after it pass through the slot between the muscle tendon of hypothenar superficial layer (the flexor digiti minimi brevis and the abductor digiti minimi) and the fifth metacarpale bone.External diameter of the perforator was (0.8 ± 0.4) mm and the backbone length was(2.0 ±0.6)cm.Conclusion The location of the anastomose point between the perforator,which springs from the ulnar palmar digital artery of the little finger,and the dorsal descending branch of the ulnar artery is constant.The perforator flap based on the perforator of ulnar palmar digital artery of the little finger,with sufficient blood supply,can be transferred flexiblely,and can be designed to repaire the defect of soft tissue on the ulnar palm and the little finger.

Objective To provide anatomical basis for lateral antebrachial neurocutaneous flap pedi-cled with inferior cubital artery perforator in repairing tissue defects around elbow joint. Methods Thirty embalmed upper limbs of adult cadavers perfused with red latex were used for this study, and followings were observed:①The course and distribution of lateral antebrachial cutaneous nerve; ②Anastomoses between inferior cubital artery and nutrient vessels of lateral antebrachial cutaneous nerve. Mimic operation was performed on other side of fresh specimen. Results ①The main trunk of lateral antebrachial cutaneous nerve (LACN) lined in the radial forearm and distributed in the 1/3 region of lateral forearm. ①The nutritional vessels of the flap were plurisegmental and polyphyletic. The inferior cubital artery which was relatively constant reached to skin through "V"-shaped peak formed by communicating branches of cephalic vein and deep venous system. They also gave off large number of small veins, which closely aligned with perineural branches and neural stem vascular chain of lateral antebrachial cutaneous nerve. Conclusion The lateral antebrachial neurocutaneos flap pedicled with inferior cubital artery perforator can be formed to repaire tissue defects around elbow joint.

Objective To observe the anatomy of the perforator flap of the posterolateral midforearm. Methods Lateral condyle of the humems wag taken as the observation mark on 30 specimens of adult upper limb perfused with red latex.The surgical magnifier Wag used to obse~e the origin,branches and distribution of the perforating branches of the posterolateral midforearm as well as alanagtomosis between perforating branches and peripheral vessels.Mimic operation WaS performed on the two sides of the fresh specimen.Results The perforating branches of the posterolateral midforearm originated from the radial musculoculancous branches of the posterior interosseous artery,the intermuscular branches of the radial artery and the direct periosteal branch of the radial artery had relatively stable location of piercing the deep fascia.Then,the perforating branches of the posterolateral midforearm pagsed through the deep fascia to the subcutaneous part among the spatium intermusculare of extensor digitorum and extensor carpi radialis brevis,supinator and abductor pollicis longus(within 12.5-15.8 cm below the lateral condyle of the humerus).Large number of small blood Vessels were also separated and closely aligned with the musculoculancous branches vascular,perineural and neural stem vascular chain of lateral branches of posterior antebrachial cutaneous nerve.Then,the vascular plexus was formed along the spatium intermusculare and lateral branches of posterior antebrachial cutaneous nerve longitudinal axis between extensor digitorum and extensor carpi radialis brevis. Conclusion The axial pattern flaps or cross-regional blood supply skin flap pedicled with the perforating branches of the posterolateral midforearm Can be formed to repair the soft tissue defect of tlle forearm and wrist.

Objective To provide anatomical basis for the thigh medial neurocutaneous vascular flap pedicled with descending genicular artery perforators. Methods ① The course and distribution of thigh medial cutaneous nerve. ②Anastomosis between descending genicular artery perforators and thigh medial neurocutaneous vascular, were observed on 40 specimens of adult lower limb perfused with red latex. Mimic operation was performed on one side of fresh specimen. Results ①The line between the midpoint of inguinal ligament and medial femoral condyle can be considered as the projection on body surface of thigh medial cutaneous nerve. ②Perforating branches of descending genicular artery (infrapatellar branch )started from the lower edge of medial femoral condyle about 4 cm, and passed through the deep fascia in which the triangle depression surrounded by the vastus medialis muscle, adductor tendon and the medial femoral condyle to the subcutaneous. They also separated large number of small blood vessels, which closely aligned with the perineural and neural stem vascular chain of thigh medial cutaneous nerve. Then they formated vascular plexus in the upper part of thigh along the thigh medial cutaneous nerve longitudinal axis. Conclusion The thigh medial neurocutaneous vascular flap pedicled with descending genicular artery perforators can be formed to repair soft tissue defect around knee joint.

Objective To provide anatomic basis for sensation restoratiou of distally based island flap pedicled with nutrient vessels of superficial peroneal nerve by use of lateral sural cutaneous nerve. Methods The origin, course and distribution rule of lateral part sensory nerve of leg were dissected and observed in 40 antisepticized adult cadaveric limbs. Results ①Lateral sural cutaneous nerve originated from common peroneal nerve 7cm above apex of fibular head, descended short distance along common peroneal nerve, then passed through pepliteal fascia to facies lateralis cruris,along the way it sent out 1-3 terminal branches, which distributed over the skin of Ⅰ , Ⅱ area in the posterior lateral leg. ②Superficial peroneal nerve originated from common peroneal nerve 1.9cm below apex of fibular head, descended forward between peroneus longus and fibula, then descended between peroneus longus and peroneus brevis, and sent out branches to the two muscles. The nerve bole (pure sensory nerve branch) descended straight between peroneus brevis and anterior cmral intermuscular septum, at the juncture between Ⅱ、Ⅲ area in facies lateralis eruris, passed through deep fascia to subcutaneous tissue, then sent out medial dorsal cutaneous nerve of foot and intermediate dorsal cutaneous nerve of foot, which distributed over the skin of dorsum of foot and Ⅲ area in facies lateralis cmris. Conclusion It may be available in sensation restoration of distally based island flap pedicled with nutrient vessels of superficial peroneal nerve through anastomosis of lateral sural cutaneous nerve bole with sensory nervous ramification of recipient site.

BACKGROUND: The distally based skin flap pedicled with nutrient vessels of saphenous nerve has provided a method with higher achievement ratio to repair the tissue defect of ankle and foot, due to its high rotation point, lacking of distributive characteristics of distally pedicled vessels description for the specific operations, so it is still difficult in clinical application.OBJECTIVE: To investigate the distal artery perforators of medial leg, so as to suggest an anatomical theory for the reasonable design of the distally based compound flap pedicled with nutrient vessels of saphenous nerve-great saphenous vein.DESIGN: A single sample experiment.SETTING: Researching Center of Clinical Anatomy, Military Institute of Orthopaedics, Fuzhou General Hospital of Nanjing Military Area Command of Chinese PLA.MATERIALS: The experiment was carried out in the Researching Center of Clinical Anatomy, Military Institute of Orthopaedics, Fuzhou General Hospital of Nanjing Military Area Command of Chinese PLA from May to October, 2004.Thirty-four adult specimens perfused with red emulsion at lateral arteries of upper lower limbs were provided by the Researching Center of Clinical Anatomy, Military Institute of Orthopaedics, Fuzhou General Hospital of Nanjing Military Area Command of Chinese PLA.METHODS: Specimens of the distal medial legs were dissected with microscope taking the most prominent point of medial malleolus as the pivot point.MAIN OUTCOME MEASURES: ① Distal artery perforators of medial leg; ② Distal nutrient vessels of saphenous nerve-great saphenous vein; ③ Blood supply correlation of nutrient vessel with neighboring muscle, bone and skin.RESULTS: ① The distal artery perforators of medial leg derived from 9 main blood supplying sources were as follows:Intermuscular perforator of posterior tibial artery, superior malleolar branches of anterior tibial artery, osteocutaneous perforators of peroneal artery or posterior tibial artery, medial malleolar branch of medial anterior malleolar artery, tarsal tunnel branch of posterior tibial artery, medial malleolar branch of medial plantar artery, medial malleolar branch of lateral plantar artery, medial malleolar branch of the superficial branch of medial plantar artery and medial maleolar branch of medial tarsal artery. ② The above-mentioned artery perforators sent out cutaneous branches, fascial branches, periosteal branches, nutrient vessels of saphenous nerve and great saphenous vein, thus formed a superior and inferior vascular net of deep fascia, vascular chain of superficial fascia and neurocutaneous superficial vein, and periosteal vascular network. Artery perforators constituted 3 distal longitudinally distributed fascial vascular plexus in medial leg (anterior, middle and posterior), including anterior longitudinally distributed fascial vascular plexus of medial anterior malleolar artery and superior malleolar branch of anterior tibial artery; middle longitudinally distributed fascial vascular plexus of osteocutaneous perforators; posterior longitudinally distributed fascial vascular plexus of malleolar canal artery perforators and intermuscular perforators of posterior tibial arteries.CONCLUSION: The blood supply of distal medial leg, which makes the anatomical basis for distally pedicled compound flaps, has the anatomical characteristics of multiple-sources, longitudinal distribution and homogeneity of nutrient vessels.Three kinds of distally pedicled skin flap supplied by nutrient vessels of saphenous nerve-great saphenous vein can be designed by taking the intermuscular perforator of posterior tibial artery, fascial perforators of medial anterior malleolar artery and artery perforators of tarsal tunnel perforators as pedicle, and the point of rotation is on the plane of medial malleolus, which are suitable for repairing the defects of distal leg, ankle and foot.