Objective:To investigate the application value of Da Vinci robotic surgical system in radical resection of perihilar cholangiocarcinoma (pCCA).Methods:The retrospective and descrip-tive study was conducted. The clinicopathological data of 10 patients undergoing Da Vinci robotic radical resetion of pCCA in Union Hospital, Tongji Medical College, Huazhong University of Science and Technology from September 2018 to March 2021 were collected. There were 6 males and 4 females, aged (58±7)years. Observtaion indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. The patients were followed up by telephone interview and outpatient service to detect survival of patients and tumor recurrence up to June 2021. Measurement data with normal distribution were expressed as Mean± SD, and measurement data with skewed distribu-tion were represented as M(range). Count data were represented as absolute numbers. Results:(1) Surgical situations: 10 patients underwent Da Vinci robotic radical resection of pCCA succe-ssfully, without conversion to laparotomy or intraoperative blood transfusion. The operation time of 10 patients was (465±87)minutes, and the volume of intraoperative blood loss was (167±81)mL. Of the 10 patients, 1 case of Bismuth type Ⅲb had a positive surgical margin and the remaining 9 cases had R 0 resection. (2) Postoperative situations: the time to gastric tube extraction was (2.3±1.9)days, and the duration of postoperative hospital stay of the 10 patients was (19.9±9.0)days. Among the 10 patients, there was no second operation or perioperative death. Of the 10 patients, 6 cases had perioperative complications, including 5 cases wth pleural effusion, 3 cases with peritoneal effusion, and 1 case with intestinal obstruction, some patients had multiple complications. After symptomatic conservative treatment, pleural effusion and peritoneal effusion disappeared and intestinal obstruction was improved. None of the 10 patients had serious complica-tions such as bleeding, biliary fistula or intestinal fistula. (3) Follow-up: 10 patients were followed up for 3-20 months, with a median follow-up time of 11 months. During the follow-up, 3 of 10 patients had tumor recurrence which occurred in intrahepatic bile duct of residual liver, and no implantation metastasis was found in the rest of abdominal cavity. Of the 7 unrecurrent patients, 1 case died of gastrointestinal bleeding and multiple organ failure. Nine of 10 patients survived well. Conclusion:The Da Vinci robotic surgical system used for radical operation of pCCA is feasible.

Portal vein thrombosis is a common complication after esophagogastric devascularization and splenectomy (EDS), with concealment and potential risks, which limited the therapeutic effect. The patients undergoing EDS are often accompanied by severe liver cirrhosis, whose abnormal hemostasis poses a dilemma for antithrombotic therapy. This article reviewed on the research progress of hemostasis of these patients, and risk factors, mechanism, prevention, therapy of post-EDS portal vein thrombosis.

Liver transplantation is an effective curative treatment for hepatocellular carcinoma patients. However, most patients lost the change of surgery when diagnosed as hepatocellular carcinoma. Through local or systemic treatment, hepatocellular carcinoma can be treated in a downstaging manner to reduce tumor burden, so that patients who are beyond the transplantation criteria can still be up to the transplantation criteria after treatment, and finally receive liver transplantation. At present, pre-transplant downstaging treatment has been widely accepted. In this review, we summarized the indications, treatment options, treatment endpoints, and treatment outcomes of pre-transplant downstaging treatment.

Objective To study the combined use of indocyanine green (ICG) fluorescence imaging and intraoperative ultrasound in laparoscopic tumor ablation.Methods This retrospective study was conducted between May 2016 and December 2017 on 81 patients with primary liver carcinoma,metastatic liver cancer and hepatic hemangioma who underwent laparoscopic tumor ablation using fluorescence imaging combined with intraoperative ultrasound guidance at the Union Hospital,Tongji Medical College,Huazhong University of Science and Technology.Preoperative venous injection of ICG was used to result in detection of intraoperative positive staining.Results Of 36 patients with primary liver carcinoma,the intrabepatic lesions in 20 patients could not be detected under fluorescence imaging.The ablation was performed under intraoperative ultrasound guidance.However,for all the subcapsular lesions in 16 patients,including 15 patients with tumors with non-distinguishing boundaries under the bright-field model,the lesions were captured on fluorescence imaging.Of 18 patients with metastatic liver cancer with 54 lesions,all the intrahepatic and subcapsular lesions were not stained by ICG,but the subcapsular lesions could be distinguished by staining of the surrounding liver tissues.Of 27 patients with subcapsular hepatic hemangiomas,the lesions were not stained but they could be distinguished by staining of the peripheral liver tissues.All laparoscopic treatments for the 81 patients were performed successfully without conversion to laparotomy.The average ablation time for a single lesion was (8.5 ± 3.5) minutes.The intraoperative blood loss was 0～20 ml.Two patients developed intraoperative subcutaneous emphysema and 1 patient hemoglobinuria.There was no postoperative bleeding,postoperative renal insufficiency,bile leakage and significant collateral tissue damage.Conclusions Laparoscopic ultrasound guided tumor ablation resulted in low intra-and post-operative complications.The procedure was safe and effective.Ultrasound combined with fluorescence imaging clearly distinguished tumors from the adjacent normal tissues.This technique is clinically useful.

Objective: To apply the Da Vinci Surgical System in laparoscopic splenectomy and pericardial devascularization using " the tunnel-building technique" . Methods: The clinical data of 31 patients who underwent robotic assisted laparoscopic splenectomy from Oct 2017 to Oct 2018 were analyzed. The operative time, intraoperative blood loss, postoperative hospital stay and conversion rate were studied. Results: All patients underwent robotic-assisted laparoscopic splenectomy without conversion to open surgery. The operation time was (216.0±33.5) min, intraoperative blood loss (137.6±53.8) ml, and postoperative stay (9.4±1.9) days. There were no early postoperative complications. Conclusion " The tunnel-building technique" using the Da Vinci Surgical System is feasible and has its unique advantages in laparoscopic splenectomy and pericardial devascularization.

Objective To evaluate the clinical efficiency of Tunnel-building laparoscopic splenectomy and pericardial devascularization (TLSPD) in the treatment of portal hypertension.Methods The clinical data of patients who underwent TLSPD from 2014 Jan to 2017 Jun were retrospectively studied.The operative time,intraoperative blood loss,conversion rate,postoperative complication rate,and the follow-up data analyzed.Result 466 patients underwent surgery successfully.The operative time was (145.0±55.0) min,and the intraoperative blood loss was (60.0±29.0)ml.There were 6 conversions to open surgery.The complication rate was 4.3％.No deaths occurred during the perioperative period.Variceal rebleeding occurred in 9 patients and portal vein thrombosis occurred in 214 patients.Conclusions TLSPD was safe and efficious with a low operative risk.The treatment resulted in a low rate of variceal rebleeding.

Objective To explore the clinical efficacy of the gap above the splenic pedicle in laparoscopic splenectomy (LS).Methods The retrospective cohort study was conducted.The clinical data of 189 patients who underwent LS in the Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between August 2012 and March 2015 were collected.Among 189 patients receiving splenic pedicle division,42 without the application of the gap above the splenic pedicle were allocated into the group A and 147 with the application of the gap above the splenic pedicle were allocated into the group B.Observation indicators included:(1) operation situations:combined operation,operation time (excluding combined operation time),volume of intraoperative blood loss (excluding blood volume of spleen),cases with conversion to open surgery;(2) postoperative situations:time to initial anal exsufflation,time for fluid diet intake,occurrence of postoperative complications and duration of hospital stay;(3) follow-up.Patients were followed up by telephone interview and outpatient examination up to August 2016.Follow-up included routine blood test,coagulation function,liver function,with or without long-term complications.Measurement data with normal distribution were represented as x±s and comparison between groups was analyzed using the t test.Comparisons of count data were analyzed by the chi-square test.Results (1) Operation situations:of 189 patients undergoing LS,136 combined with laparoscopic pericardial devascularization,13 combined with laparoscopic cholecys-tectomy,9 combined with laparoscopic radio frequency ablation (RFA) of liver tumors and 26 combined with pathological examination using laparoscopic liver tissues sampling.Operation time,volume of intraoperative blood loss and cases with conversion to open surgery were (118±31) minutes,(80±38) mL,2 in the group A and (70± 22) minutes,(50± 28) mL,1 in the group B,respectively,with statistically significant differences between the 2 groups (t =12.579,-8.516,x2=4.912,P＜0.05).(2) Postoperative situations:time to initial anal exsufflation,time for fluid diet intake,number of patients with postoperative complications and duration of hospital stay were (22± 10)hours,(3.1 ± 1.3) days,8,(9±3)days in the group A and (23±11)hours,(3.8±1.8)days,13,(8±3)days in the group B,respectively.Pancreatic fistula,intra-abdominal hemorrhage,asymptomatic portal vein thrombosis,pulmonary infection and intraperitoneal infection were respectively detected in 2,2,2,1,1 patients in the group A and 1,2,5,2,3 patients in the group B.There was no significant difference in time to initial anal exsufflation,time for fluid diet intake and duration of hospital stay between the 2 groups (t =1.102,0.745,0.583,P＞0.05),and a statistically significant difference in number of patients with postoperative complications between the 2 groups (x2 =7.259,P＜ 0.05).There were statistically significant differences in cases with pancreatic fistula and intra abdominal hemorrhage (x2=16.021,5.812,P＜0.05) and no significant difference in cases with asymptomatic portal vein thrombosis,pulmonary infection and intraperitoneal infection (x2 =1.391,0.396,0.865,P＞0.05).Patients with postoperative complications were cured by symptomatic treatment.(3) Follow-up:156 of 189 patients (33 in the group A and 123 in the group B) were followed up for 1-18 months,with an average time of 12 months.During the follow-up,13 patients had recurrent hematemesis and melena,including 3 in the group A and 10 in the group B.Eight patients stopped bleeding after conservative treatment,3 stopped bleeding after proxial gastrectomy and 2 died of excessive bleeding and organ failure.Conclusion Splenic pedicle division using Endo-GIA through the gap above the splenic pedicle in LS can reduce operation time,volume of intraoperative blood loss,rate of conversion to open surgery and postoperative complications.

Objective To explore the efficacy and safety of microwave hemostatic device in laparoscopic microwave ablation for exogenic hepatic hemagioma.Methods The clinic data of 62 patients with exogenic hepatic hemagioma who performed with laparoscopic microwave ablation between May 2015 and May 2017 were retrospectively analyzed.According to the different surgical technique,the patients were assigned into microwave hemostatic device combined with microwave ablation group (combination group,29 patients) and microwave ablation group (microwave group,33 patients).The microwave group was performed laparoscopic microwave ablation,and the combination group was pretreated the surface of hemagioma with microwave hemostatic device before laparoscopic microwave ablation.The intraoperative and postoperative conditions of the patients were recorded and analyzed.Results All patients were performed successfully under laparoscope without conversion to laparotomy.The average time of microwave ablation was significantly shorter in combination group than in microwave group [(10.69 ±3.54) min vs.(13.18 ± 4.31) min,P＜0.05].Compared with microwave group,the average bleeding amount of operation was significantly lower in combination group[(48.79±20.30) mL vs.(95.76±90.16) mL,P＜0.05].All patients from both groups recovered uneventfully without any complications such as abdominal bleeding or bile leakage.Conclusion For exogenic hepatic hemagioma,the microwave hemostatic device is used to solidify the surface of hemagioma before microwave ablation,which can improve the safety of the operation,reduce the time of microwave ablation,and avoid tumor hemorrhage caused by puncture.

Objective To investigate the operational technique of laparoscopic splenectomy and pericardial devascularization (LSPD) and evaluate the clinical efficiency of this method for the treatment of portal hypertension.Methods With the new understanding of anatomical space around the spleen,the cardia and the fundus,two gaps and two tunnels can be created in LSPD.Retrospective analysis was made on the clinical data of patients who underwent LSPD from Jun 2013 to Mar 2015.The operative time,intraoperative blood loss,postoperative hospital stay,conversion rate and postoperative complication rate were measured.Results A total of 189 cases underwent surgery successfully,including 34 cases of splenomegaly and 21 cases of severe esophageal varices.The operative time was (125 ± 52) min,intraoperative blood loss (58 ± 32) ml,postoperative hospital stay (7.5-2.1) d.There were 4 conversion cases in this study.Conclusions The splenic pedicle and stomach pedicle can be safely dissected with the two gaps and two tunnels principle,which makes LSPD safe and convenient.

ObjectiveTo construct recombinant adenovirus vector containing human pancreatic and duodenal homeobox factor 1 (PDX1) and detect its expression in human umblical cord mesenchymal stem cells (HUCMSCs). MethodsPDX1 obtained by BgⅢ/XhoI enzyme digestion from pUC57-PDX1 was ligated into the recombinant shuttle vector pShuttle-GFP-CMV to obtain the recombinant shuttle plasmid pShuttle-GFP-CMVPDX1. pShuttle-GFP-CMV- PDX1 was shifted to pAdxsi vector to obtain pAdxsi-GFP-PDX1 virus plasmid. The recombinant plasmid was packaged and amplified in 293 cells. The expression of PDX1 gene and protein in HUCMSCs was detected by fluorescence microscopy, RT-PCB, immunofluorescence, immunohistochemistry, and Western Blot. ResultsPDX1 gene was inserted correctly into shuttle plasmid and the recombinant adenovirus vector was successfully constructed according to the results of sequence and enzyme digestion identification. The adenovirus was effectively transfected into HUCMSCs. RT-PCR verified that PDX1 mRNA was positively expressed in HUCMSCs. Expression of PDX1 protein in the nuclear of HUCMSCs was found by immunofluorescence assay, immunohistochemistry and Western Blot. ConclusionThe adenovirus vector containing PDX1 gene is successfully constructed and effectively expressed in HUCMSCs.