作者感谢在新加坡和曼谷帮助建造模型、提供材料和便利培训讲习班的人们: 颂博士、轭辉坊教授、Viboonchart、金妮、塞西尔、Laureano、培黄宽, 美兰谢, 杰瑞. 肯塔基教授. 材料得到医学 Siriraj 医院、曼谷和国立大学医院、新加坡国家医学研究理事会 (新加坡) 妇产科部门的支持。格兰特 NMRC/CSA/043/2012

从足月分娩中收集的人胎盘是由新加坡努哈 (DSRB C/00/524) 领域专门审查委员会和曼谷 SIRB 医院 Siriraj 机构审查委员会 (Siriraj 704/2559) 批准的。在所有情况下, 病人都给予不同的书面同意, 以使用收集标本。猪膀胱是从新加坡当地的屠夫那里收集来的, 是努哈博士的一种捐赠。非人类灵长类动物 (NHP) 胎盘是在卫生部 (新加坡) 国家医学研究理事会赠款 NMRC/CSA/043/2012 下繁殖的猕猴猴收集的废料, 严格遵守机构新加坡国立大学和新加坡卫生服务私人有限公司 (IACUC 2009-SHS-512) 的动物护理和使用委员会 (IACUC), 是一位来自于杰瑞. 陈教授的亲切捐赠。
1. 使用 Fetoscopy 模拟器熟悉 Fetoscope 处理和胎盘定位
<ol><li>设置 fetoscopy 模拟器和设备 (图 2-c)。<ol>
<li>识别 2.0 mm 光纤直 fetoscope 的部件: 透镜 (0°或 30°)、标准或远程眼盖 (图 2A);3.0 毫米双腔操作鞘, 尖孔尖端直接插入羊膜腔超声引导下, 用于2.0 毫米 fetoscope (图 2B)。</li>
		<li>将 fetoscope 放入操作鞘后, 将闭孔和连接到腹腔镜相机的眼睛盖。 注意: 这些直纤内窥镜是半柔性的, 操作鞘可以仔细地弯曲到20-35°从中线轴提供适当的曲率用于前胎盘。在没有内镜的情况下弯曲操作鞘。其他合适的 fetoscopes 后和前胎盘在材料表中列出。</li>
	</ol>
</li>
	<li>在 "操作者" 附近安排腹腔镜塔和超声波机, 以便在 fetoscope 插入时同时操作超声波探头。<ol>
<li>通过单向阀端口, 将 fetoscopy 模拟器填充到水的边缘。</li>
		<li>将填充的模拟器定位在所需方向的塑料底座上, 以表示前或后胎盘 (图 2C)。 注: 模拟器的上表面现在代表的是前产妇腹部, 在那里的超声探头放置和 fetoscope 应该插入。</li>
	</ol>
</li>
	<li>使用曲线超声探针与水凝胶在透明皮肤的 "前产妇腹部", 以可视化胎盘在 fetoscopy 模拟器。确定胎盘位置和它旁边的一个窗口 (为前胎盘) 放置 fetoscope。</li>
	<li>在连续超声引导下通过端口在操作护套中插入适当的 fetoscope (图 2C)。<ol>
<li>使用 fetoscope 直 fetoscope 后胎盘和对前胎盘的弯曲的 (材料表)。</li>
		<li>通过超声监测 fetoscope 的插入和深度, 使胎盘进入视野。</li>
		<li>调整照相机的焦距, 使视觉进入锐浮雕 (图 2D F)。</li>
	</ol>
</li>
	<li>识别与血管赤道并列的双胞间膜。<ol>
<li>确定胎盘表面的血管赤道, 并系统地探索从端到端的脉管运动, 以确定典型的消融 AVAs。 注: 这些吻合将被视为在绒毛膜表面运行;动脉较暗, 并且始终在静脉上运行 (图 2C、E)。</li>
	</ol>
</li>
	<li>改变模拟器的方向, 以代表后胎盘, 如果实践已经做了与前胎盘, 反之亦然。<ol>
<li>重复超声评估的过程, 规划 fetoscope 输入, 并插入 fetoscope。 注意: 模拟器和胎盘的定位可以每次改变以练习胎盘不同位置的 fetoscopic 位置, 也可测试不同的 (弯曲的, 直的) fetoscopes。</li>
	</ol>
</li>
</ol>2. 直接 Fetoscopic 进入、Seldinger 技术、血管激光凝固的组织模型
<ol><li>组织模型 #1 胎盘在盒中的研究<ol>
<li>使用一个标准, 存储购买的塑料容器 35 x 18 x 15 cm3维度与一个防水锁 (图 3a) 创建框模型。<ol>
<li>切出一个广泛的塑料盖的窗口, 并用超声波透明橡胶 "皮肤" 缝合到封面的边缘。这形成了模拟产妇腹部的前表面, 通过该 fetoscope 放置。在框的底部安装橡胶乳胶板, 以防止超声混响 (图 3-c)。</li>
		</ol>
</li>
		<li>在足月分娩后收集人类胎盘, 并对样品收集进行适当的同意。在水槽中用自来水冲洗胎盘的表面 (最好在运输前在劳动病房的公用房里这样做)。确保胎盘表面是干净的血液和切断脐带使用强组织剪刀到可管理的长度,例如, 5 厘米。<ol>
<li>将胎盘在一个密封的生物危害塑料袋内的第二容器内运送到实验室。 注意: 使用个人防护设备 (一次性手套、护盾、等等) 始终处理胎盘和其他生物物质。在执行这项工作之前, 确保适当的机构伦理批准。</li>
			<li>将脐带的游离端系在缝合带或棉帘线上, 以防止血液从切口末端耗尽。 注: 血管内的血液也有助于模拟激光练习过程中过度凝固的血管撕裂。</li>
		</ol>
</li>
		<li>为了模拟前胎盘, 用透明的塑料线或塑料网将胎盘固定在容器的后盖上, 使其保持到位。</li>
		<li>要模拟后胎盘, 请将胎盘固定在容器底部的橡皮板上, 并用塑料网或小重量 (图 3B) 将其保存到位。</li>
		<li>用自来水把容器装满, 把盖子锁上。</li>
		<li>用工作通道为后胎盘和其操作鞘准备 fetoscope, 以及前胎盘多通道的 fetoscope 曲线 (材料表)。把眼罩连接到相机上。<ol>
<li>准备激光。例如, 如果使用二极管激光器与400微米或600微米激光光纤, 设置初始电压为 15-30 W, 并逐步增加, 如果需要有效的凝固。</li>
		</ol>
</li>
		<li>执行步骤1.3 所述的胎盘超声评估。<ol>
<li>找到一个与前胎盘相邻的无胎盘窗口, 在其中插入弯曲的 fetoscope, 这样透镜位于胎盘中心的上方 (双侧赤道之间有望在 MCDA 胎盘中)。</li>
			<li>确定在哪里插入后胎盘的直 fetoscope, 使该中心透镜定位垂直于胎盘中央。</li>
		</ol>
</li>
		<li>执行直接 fetoscopic 进入通过做一个2毫米刺切口与锋利的刀片在 "皮肤"。在连续超声引导下, 将操作套管插入到充满液体的容器 ("羊膜囊") 中 (这是患者的接受者双胞胎的囊)。<ol>
<li>避免通过在超声视觉下缓慢推进 fetoscope 而刺穿胎盘。在连续超声视觉下, 缓慢地从操作套管中取出锥体闭孔。</li>
			<li>将 fetoscope 的透镜小心地放入先前被闭孔占用的通道中的操作套管, 并将胎盘和表面脉管置于尖锐的焦点 (图 3C)。</li>
		</ol>
</li>
		<li>将激光纤维插入操作侧通道中, 当尖端接近鞘端时缓慢前进。 注意: 保持激光光束尽可能垂直于目标容器, 以使激光效果最大化46,47。<ol>
<li>将激光纤维尖端推进到大约5-10 毫米以外的操作鞘。 注: 如果激光尖端离鞘太远, 它可能会撕裂血管。如果笔尖太近, 则可能危及凝固效果 (图 3D)。激光光纤尖端应从容器表面2-3 毫米, 在发射时不应接触到容器 (图 3D中的黄色箭头)。</li>
		</ol>
</li>
		<li>识别脐带 (图 3E) 和胎盘血管 (图 3F)。通过超声和直接 fetoscopic 视觉的结合, 回顾胎盘血管的端到端。 注: fetoscope 应指向目标容器的90°角。图 3G显示单绒毛膜胎盘中的实际单绒毛膜艾娃。在垂直于血管或吻合的位置使用脚踏板来发射激光。</li>
		<li>凝聚容器, 直到它与无接触技术 blanches, 目的是凝聚1-2 厘米的一段, 直到完全停止的流程完成。该船只应出现扁平 (折叠) 和苍白的凝固被认为是有效的。<ol>
<li>系统地实践了从一个胎盘端到另一端的血管凝固。激光凝聚从外围到容器的中心的厚的船只, 以防止破裂 (因此 "剃" 一个较厚的肿胀容器成一个狭窄的拥挤的一条)。或者, 先将较小的喂养容器在较大的 decongestion 前凝固, 以防止血管破裂。</li>
		</ol>
</li>
		<li>在单独的血管被凝固完成胎盘 dichorionisation48,49之后, 练习所罗门技术。在胎盘表面用激光表面凝固形成一条线, 直到所有的单独凝固的吻合连接。</li>
	</ol></li>
	<li>组织模型 #2-猪膀胱 "子宫" 注: 如果材料容易获得, 可以考虑将猪膀胱和孕中期胎盘相结合的混合组织模型进行模拟。该模型可用于实践喷洒和去除 "子宫" 中的液体, 重现 fetoscopy 等血液染色液的常见并发症, 并实践 fetoscope 插入的 Seldinger 技术。<ol>
<li>获得一个干净的猪膀胱。定位它与更宽的弯曲周长作为上部头侧杆和狭窄的部分作为下尾鳍杆, 因此用户可以对开沿头侧边界和继续 caudally, 这样膀胱打开象翻盖(图 4 a, 断行)。 注: 在使用个人防护设备的生物安全柜中, 与人体和动物组织一起执行所有程序, 并通过适当的机构批准处理生物组织。</li>
		<li>在分娩后或在医学上导致妊娠终止后, 获得一个小的中期妊娠胎盘。确保获得适当的同意, 样品是匿名的。</li>
		<li>用纸巾剪和缝合胎盘 (红色箭头, 胎儿表面向外, 产妇表面向内), 从胎盘上修剪多余的羊膜 (膜状, 白色组织附着在胎儿/脐表面) 到一半的猪膀胱。缝合的猪膀胱 (黑色箭头) 的第二个一半, 以一个水紧的方式在切口周围 (图 4B, C)。</li>
		<li>将 "子宫" 放置在模型骨盆中, 如图 4D所示。定位子宫以模拟前胎盘或后胎 (图 4D)。</li>
		<li>在超声引导下 (如果橡胶皮肤是透明的对超声) 实践直接插入套管针和 fetoscope 在它的操作鞘之内。</li>
		<li>应用 Seldinger 技术, 在实时超声引导下, 在羊膜腔内插入一个锋利的空心套管针。将软 J 尖导丝通过腔内, 取出套管针, 将扩张在导丝上的钝套管插入羊膜腔内, 然后完全取出导丝和扩张, 使套管就位。最后, 通过套管将 fetoscope 插入子宫 (图 4E)。</li>
		<li>检查胎盘表面 fetoscopically 的血管。通过使用50毫升注射器的操作通道减少或添加液体, 以增加或减少 "宫内" 压力, 并用新鲜盐水代替血液染色或混浊液体。</li>
		<li>按照步骤 2.1. 11-2. 1.12 中所述相同的方式练习激光凝固血管。</li>
		<li>根据机构协议, 将模型作为 biohazardous 材料处理。</li>
	</ol></li>
</ol>3. 将模型中所学的技能传授给病人
<ol><li>在 MCDA 双胎妊娠患者中, 对胎盘进行超声检查, 并确定胎盘两胎的脐带插入点。 注 : 在这种情况下 , 其中一根绳子可能入接近 MCDA 胎盘的边缘。设想一条线加入两个胎盘脐带插入, 并确定这条线的中点, 这表明血管赤道的位置, 可能更接近较小的捐献者双胞胎, 而不是等距的两条绳子, 特别是与一个重要的羊膜囊大小差异。血管赤道垂直于连接绳子的线。</li>
	<li>确定 fetoscope 插入的站点。<ol>
<li>对于前胎盘, 找到一个窗口, 在超声可视化胎盘, 没有胎盘组织, 其中弯曲 fetoscope 可以操纵, 使透镜位于血管赤道。</li>
		<li>对于后胎盘, 插入 fetoscope 在大约中点之间的绳子直接在血管赤道。移动 fetoscopic 透镜向上和向下的血管赤道使用一个清扫运动, 同时保持一个大约90°角度赤道, 最佳的激光凝固。 注意: 这可能需要插入部位侧向血管赤道, 就在羊水过多囊一侧胎盘的外围。</li>
	</ol>
</li>
	<li>检查胎儿分娩后胎盘 dichorionization 的完成情况, 以评估残端吻合 (图 5-c)。在必要的准备工作后, 用不同颜色的染料注入脐带血管, 以区分供体和接受者的动脉和静脉, 如前所述44,50。</li>
</ol>

作者没有什么可透露的。

在 fetoscopy 模拟器和组织模型上练习的技能包含了 SFLP 所需的大部分技术能力。这些模型的训练的优点包括学习同时处理超声探头和 fetoscope, 熟悉处理直曲线 fetoscopes, 对整个血管赤道进行系统检查。双胞间膜长度, 以识别高保真 MCDA 胎盘的网状血管, 并学习正确的技术, 使用在大型和高流量的船只, 以避免破裂, 这可能会导致严重的后果, 包括突然丧失视力或者是双胞胎的放血。此外, 还可以对所罗?...

一种新的微创外科技术的获得通常采用传统的外科学徒模式, 在该模型中, 个人从观察一个专家外科医生的工作到一个活的病人, 并最终执行技术下关闭监视1。这一由来已久的模式常常限制从导师到个人受训者的知识的传授, 并严重依赖于资源的可用性, 如培训资金和病人案例加载2。Fetoscopic 手术是一种高风险的微创手术的例子, 在怀孕期间对早产个体进行, 对母亲和胎儿都有风险。与任何外科手术一样, 在学习曲线的初始陡峭斜坡上, 并发症发生率较高。因此, 手术通常由最资深或熟练的外科医生执行, 以满足关键的病例数量来优化患者结局3。
良好的 fetoscopy 技能对于未来的胎儿治疗是很重要的, 它努力进行微创, 即使是对结构缺陷的矫正4,5,6。Fetoscopic 手术在技术上是有挑战性的, 在真实的剧场环境中练习和开发新技能与患者的安全有内在的风险。即使是已建立的外科医生需要时间和一贯的做法, 多名病人获得专业知识, 故障排除的技能, 当出现困难, 以及本能预测和避免陷阱, 在一个新的和复杂的程序。通常与新手 proceduralists7相关的次优结果的耐受性较差。虽然在最初实施 fetoscopic 手术时不损害患者的安全很重要, 但也需要提高所有 proceduralists 的技能和专长, 特别是在较小的临床单位刚开始练习 fetoscopy。需要一个补充传统学徒制的替代制度, 以应付有限的培训资金和一个小的病人基础上的挑战, 以便掌握这些高度专门化的程序。程序学习曲线可以缩短, 并通过对高保真机器或尸体动物模型的训练减少并发症, 与专用的传统指导或远程 proctorship 和过程重点逐步学习8, 9,10,11。熟悉 fetoscope 操作, 血管赤道的宫内取向和激光凝固术前进行实际手术有可能减少手术并发症12,13。这种训练可以缩短新操作员的学习曲线, 因为他们掌握了现实组织模型的基本技能。
单卵双生子孪生发生在全世界范围内的均匀频率影响3-5 每1000怀孕, 和75% 的单卵双生子双胞胎与单绒毛膜 diamniotic (MCDA) 胎有很大的风险 TTTS, 目前复杂约10-15% 的MCDA 怀孕, 或1-3 每1万出生14。在 monozygosity15、16、17、18、19中, 该发病率预计会随体外受精 (IVF) 频率增加2到12倍。TTTS 是通过深 intraplacental 艾娃的单向胎儿间血流产生的。未经治疗, 这对幸存的胎儿有60-100% 的死亡率和严重的发病率20,21,22。
选择性 fetoscopic 激光凝固 (SFLP) 是唯一的治疗干预, 旨在抢救两个双胞胎通过 fetoscopic 鉴定和消融的违规艾娃, 并被认为是护理标准在 TTTS 阶段 (93% 的所有病例) 在妊娠 < 26 周的妊娠, 与临床研究进展, 以确定是否也应适用于选定的第一阶段疾病23,24,25。SFLP 的总体围产期生存率为 ~ 70%, 更高的可能性更高级妊娠和更高的出生体重在交付26,27 , 并认为优于其他干预, 因为它直接矫正TTTS 的基础病理学28,29,30。干预本身不是没有并发症, 激光治疗 TTTS 与复发 (0-16%), 围产期死亡率 (~ 35%), 和5-20% 的可能性长期神经障碍23。获得正确的技能, 在陡峭的学习曲线上建立专门知识, 遵守 fetoscopic 实践的国际标准, 保持外科灵巧, 对于提供这一复杂疾病的最佳结局至关重要13 ,31,32,33。这通常依赖于财务和人力资源以及可能需要很长时间才能获取34的关键案例数量。建立的胎儿治疗中心目前集中在西欧和北美洲, 但预测的人口激增 (因而新的怀孕) 将主要影响亚洲和非洲35,36。因此, 在这些资源较低的人群中, 可预期胎儿畸形的发病率会增加, 而这种情况可能会出现在宫内治疗中。传播诸如 fetoscopic 外科等专门服务是一项挑战, 需要作为区域优先事项37加以解决。在这些地区, 新的胎儿治疗中心必须可靠地提供 SFLP 服务, 以满足社区的需要, 但是新的中心需要大量的投资和时间来实现类似的结果, 如建立的38,39,40,41。
从资源繁重的学徒模式出发, 将有助于向有巨大需求的社区传播技能和专门知识。传统的外科学徒仍然是相关的, 但对于许多较小的临床单位来说是不太实际的, 因为它是时间和资源消耗, 并限制了知识和技能的传授给一个实习生一次。proctorship 下的模拟器培训更适用于更广泛的范围, 通过讲习班和对可靠组织模型的定期技能培训, 促进通过专家向多人传授知识和技能13,42,43. 有人建议, 由于其稀有性, TTTS 治疗应积累在大容量的胎儿中心, 以改善其结果。然而, 还需要建立新的胎儿护理中心, 以改善患者获得治疗的机会。新兴的胎儿护理中心, 如新加坡国立大学医院 (努哈), 将需要遵守某些指导方针, 以维持其手术结局,即, Siriraj 努哈 proctorship 系统, 如图 137 中所示.
在这篇文章中, 我们将描述一个基于模型的系统, 新的 proceduralists 可以在专家的指导下进行串联的技能训练, 并且通过这些技能可以在长时间间隔内练习保持手术的灵巧度。患者.我们将从我们在曼谷的 Siriraj 医院和新加坡的努哈的经验分享实际的要点, 启动胎儿治疗6,44,45。

<table border="0" cellpadding="0" cellspacing="0" style="width:1253px;" width="1253">
	<colgroup>
		<col span="2" />
		<col />
		<col />
	</colgroup>
	<tbody>
		<tr height="84">
			<td height="84" style="height:85px;width:215px;">Fetoscopic Simulator</td>
			<td style="width:215px;">Maternal-Fetal Medicine unit, Department of Obstetrics and Gynaecology, Siriraj Hospital, Bangkok, Thailand</td>
			<td style="width:367px;">NA.</td>
			<td style="width:457px;">Siriraj Fetoscopic Simulator. Customised model of monochorionic anterior/posterior placenta and anastomses produced at the Siriraj Hospital in Bangkok.</td>
		</tr>
		<tr height="66">
			<td height="66" style="height:67px;width:215px;">Laparoscopy tower with light source, camera and video recorder</td>
			<td style="width:215px;">Olympus Singapore</td>
			<td style="width:367px;">Olympus Visera Elite system (Olympus Singapore) with camera OTV-S190 and light source CLV-S190 set at medium intensity (level 0) and video recorder&#160;</td>
			<td style="width:457px;">Laparoscopy tower for fetoscopy and recording of practice</td>
		</tr>
		<tr height="64">
			<td height="64" style="height:64px;width:215px;">Voluson E8 ultrasound machine with 4CD probe</td>
			<td style="width:215px;">GE Healthcare Singapore</td>
			<td style="width:367px;">GE Voluson E8; transabdominal 4CD curved transducer (2-5MHz)&#160;</td>
			<td style="width:457px;">Ultrasound system for guidance of fetoscope introduction and manipulation</td>
		</tr>
		<tr height="60">
			<td height="60" style="height:60px;width:215px;">Minature straight forward telescope 0o (2mm) for posterior placenta</td>
			<td style="width:215px;">KARL STORZ GmbH &#38; Co KG, Tuttlingen, Germany</td>
			<td style="width:367px;">11630AA</td>
			<td style="width:457px;">Fetoscope. 0&#176; lens, diameter 2mm, length 26cm, autoclavable, fibre optic light transmission incorporated. To use with operating sheath 11630KF.</td>
		</tr>
		<tr height="85">
			<td height="85" style="height:86px;width:215px;">Operating sheath, straight with pyramidal obturator.&#160;</td>
			<td style="width:215px;">KARL STORZ GmbH &#38; Co KG, Tuttlingen, Germany</td>
			<td style="width:367px;">11630 KF</td>
			<td style="width:457px;">Size 9 Fr with working channel 1 mm, for use with 11630AA; working channel for laser fibres up to 400&#181;m core.</td>
		</tr>
		<tr height="77">
			<td height="77" style="height:78px;width:215px;">Multichannel miniature straight forward telescope 0&#176; set straight for posterior placenta</td>
			<td style="width:215px;">KARL STORZ GmbH &#38; Co KG, Tuttlingen, Germany</td>
			<td style="width:367px;">11506AAK</td>
			<td style="width:457px;">Fetoscope. 0&#176; lens, diameter 3.3 mm, length 30cm , 30,000 pixels, integrated channels, autoclavable, fibre optic light transmission incorporated.&#160;</td>
		</tr>
		<tr height="77">
			<td height="77" style="height:78px;width:215px;">Multichannel miniature straight forward telescope 0&#176; set curved&#160; for anterior placenta</td>
			<td style="width:215px;">KARL STORZ GmbH &#38; Co KG, Tuttlingen, Germany</td>
			<td style="width:367px;">11508AAK</td>
			<td style="width:457px;">Fetoscope. 0&#176; lens, diameter 3.3 mm, length 30cm , 30,000 pixels, integrated channels, autoclavable, fibre optic light transmission incorporated.&#160;</td>
		</tr>
		<tr height="77">
			<td height="77" style="height:78px;width:215px;">Dornier diode laser with 400um or 600um laser fibre</td>
			<td style="width:215px;">Medilas D Multibeam, Dornier MedTech Asia, Singapore</td>
			<td style="width:367px;">S/N D60-353</td>
			<td style="width:457px;">Laser photocoagulation system. Diode (30-60 W)&#160;</td>
		</tr>
		<tr height="77">
			<td height="77" style="height:78px;width:215px;">Laser fibre&#160;</td>
			<td style="width:215px;">400-600&#181;m laser fiber</td>
			<td style="width:367px;">Disposable LG type D01-6080-BF-0;LOT 1024/0613</td>
			<td style="width:457px;">Use the provided ceramic cutter to refashion the tip of the fibre once coagulated after burning to maintain the sharp focus of the laser.&#160;</td>
		</tr>
		<tr height="77">
			<td height="77" style="height:78px;width:215px;">Large plastic container with ultrasound transparent skin;</td>
			<td style="width:215px;">NA</td>
			<td style="width:367px;">NA.</td>
			<td style="width:457px;">Container is a simple houshold item with a watertight lid that cn be locked in place. The silicon rubber &#34;skin&#34; produced inhouse allows US visualisation of the placenta within the container. Can be used as a simulator for vascular laser coagulation.&#160;</td>
		</tr>
		<tr height="77">
			<td height="77" style="height:78px;width:215px;">Pig bladder and small mid-gestation placenta&#160;</td>
			<td style="width:215px;">NA</td>
			<td style="width:367px;">NA.</td>
			<td style="width:457px;">Obtained from the local butcher. Elastic tissue that can be stretched when filled with large volume of fluid; can incorporate a small human/NHP placenta and used as a simulator for laser coagulation&#160;</td>
		</tr>
	</tbody>
</table>

model surgical training: skills acquisition in fetoscopic laser photocoagulation of monochorionic diamniotic twin placenta using realistic simulators

Fetoscopic 激光凝固动静脉吻合 (艾娃) 在一个单绒毛膜胎盘是标准的双重输血综合征 (TTTS), 但在技术上具有挑战性, 并可能导致重大并发症。获得和保持必要的外科技能需要一致的做法, 关键的工作量和时间。对逼真的外科模拟器的训练可能会缩短这一陡峭的学习曲线, 并使几个 proceduralists 同时获得程序特定的技能。在这里, 我们描述的真实模拟器设计, 使用户熟悉的设备和具体步骤所需的手术治疗 TTTS, 包括 fetoscopic 处理, 方法的前和后胎盘, 承认吻合, 有效的血管凝固。我们描述了在进行胎盘激光凝固时特别重要的技能, 外科医生可以在该模型上进行练习并应用于临床病例。这些模型可以根据材料的可用性和要求标准的 fetoscopy 设备方便地进行调整。这种训练系统是对传统的外科学徒的补充, 可以帮助提供这种临床服务的胎儿医学单位。

fetoscopy 模拟器的基本要求是透明的 "皮肤", 使模型中胎盘的超声可视化和 MCDA 胎盘的典型模型。这里说明的模拟器是在 Siriraj 医院 (曼谷) 开发的, 是一个封闭的系统, 其中包含了妊娠中期单绒毛膜胎盘的硅复制品 (图1)。这种模式的一致使用, 应该增加新手外科医生对胎盘定向和 fetoscope 安置的信心, 并增加对处理直和弯曲 fetoscopes 的熟悉程度。对组织?...

Watch this Scientific Journal Video about Model Surgical Training: Skills Acquisition in Fetoscopic Laser Photocoagulation of Monochorionic Diamniotic Twin Placenta Using Realistic Simulators at JoVE.

模型手术训练：使用真实模拟器获得单绒毛膜双羊膜双胎盘胎儿镜激光光凝术的技能医学|视频

Model Surgical Training: Skills Acquisition in Fetoscopic Laser Photocoagulation of Monochorionic Diamniotic Twin Placenta Using Realistic Simulators

练习 fetoscopic 激光凝固单绒毛膜胎盘吻合术所需的特定技能, 可以帮助经验较少的外科医生克服与这个过程相关的陡峭的学习曲线, 现在被认为是双胎输血综合征的护理标准。

模型外科训练: 用逼真模拟器 Fetoscopic 激光光凝单绒毛膜 Diamniotic 双胎胎盘的技能习得

Fetoscopic laser coagulation of arterio-venous anastomoses (AVA) in a monochorionic placenta is the standard of care for twin-twin transfusion syndrome ...

model-surgical-training-skills-acquisition-fetoscopic-laser

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19.5K 次观看.  Siriraj Hospital. 练习 fetoscopic 激光凝固单绒毛膜胎盘吻合术所需的特定技能, 可以帮助经验较少的外科医生克服与这个过程相关的陡峭的学习曲线, 现在被认为是双胎输血综合征的护理标准。

视频: Model Surgical Training: Skills Acquisition in Fetoscopic Laser Photocoagulation of Monochorionic Diamniotic Twin Placenta Using Realistic Simulators

Guide Wire Assisted Catheterization and Colored Dye Injection for Vascular Mapping of Monochorionic Twin Placentas

Monochorionic (MC) twin pregnancies are associated with significantly higher morbidity and mortality rates than dichorionic twins. Approximately 50% of MC twin pregnancies develop complications arising from the shared placenta and associated vascular connections1. Severe twin-to-twin syndrome (TTTS) is reported to account for approximately 20% of these complications2,3. Inter-twin vascular connections occur in almost all MC placentas and are related to the prognosis and outcome of these high-risk twin pregnancies. The number, size and type of connections have been implicated in the development of TTTS and other MC twin conditions. Three types of inter-twin vascular connections occur: 1) artery to vein connections (AVs) in which a branch artery carrying deoxygenated blood from one twin courses along the fetal surface of the placenta and dives into a placental cotyledon. Blood flows via a deep intraparenchymal capillary network into a draining vein that emerges at the fetal surface of the placenta and brings oxygenated blood toward the other twin. There is unidirectional flow from the twin supplying the afferent artery toward the twin receiving the efferent vein; 2) artery to artery connections (AAs) in which a branch artery from each twin meets directly on the superficial placental surface resulting in a vessel with pulsatile bidirectional flow, and 3) vein to vein connections (VVs) in which a branch vein from each twin meets directly on the superficial placental surface allowing low pressure bidirectional flow. In utero obstetric sonography with targeted Doppler interrogation has been used to identify the presence of AV and AA connections4. Prenatally detected AAs that have been confirmed by postnatal placental injection studies have been shown to be associated with an improved prognosis for both twins5. Furthermore, fetoscopic laser ablation of inter-twin vascular connections on the fetal surface of the shared placenta is now the preferred treatment for early, severe TTTS. 
Postnatal placental injection studies provide a valuable method to confirm the accuracy of prenatal Doppler ultrasound findings and the efficacy of fetal laser therapy6. Using colored dyes separately hand-injected into the arterial and venous circulations of each twin, the technique highlights and delineates AVs, AAs, and VVs. This definitive demonstration of MC placental vascular anatomy may then be correlated with Doppler ultrasound findings and neonatal outcome to enhance our understanding of the pathophysiology of MC twinning and its sequelae. Here we demonstrate our placental injection technique.

Vascular mapping of monochorionic (MC) twin placentas after birth provides a means for detailed demonstration of vascular connections between the twins&#x2019; circulations. 
Imbalance of these connections is thought to play a pivotal role in the development of complications of MC twinning including twin-to-twin transfusion syndrome.

导丝辅助导管和彩色染料注射的双人单绒毛膜胎盘血管映射

Monochorionic (MC) twin pregnancies are associated with significantly higher morbidity and mortality rates than dichorionic twins. Approximately 50% of MC ...

科研

医学

Accurate and Simple Evaluation of Vascular Anastomoses in Monochorionic Placenta using Colored Dye

The presence of placental vascular anastomoses is a conditio sine qua non for the development of twin-to-twin transfusion syndrome (TTTS) and twin anemia polycythemia sequence (TAPS)1,2. Injection studies of twin placentas have shown that such anastomoses are almost invariably present in monochorionic twins and extremely rare in dichorionic twins1. Three types of anastomoses have been documented: from artery to artery, from vein to vein and from artery to vein. Arterio-venous (AV) anastomoses are unidirectional and are referred to as "deep" anastomoses since they proceed through a shared placental cotyledon, whereas arterio-arterial (AA) and veno-venous (VV) anastomoses are bi-directional and are referred to as "superficial" since they lie on the chorionic plate. Both TTTS and TAPS are caused by net imbalance of blood flow between the twins due to AV anastomoses. Blood from one twin (the donor) is pumped through an artery into the shared placental cotyledon and then drained through a vein into the circulation of the other twin (the recipient). Unless blood is pumped back from the recipient to the donor through oppositely directed deep AV anastomoses or through superficial anastomoses, an imbalance of blood volumes occurs, gradually leading to the development of TTTS or TAPS. The presence of an AA anastomosis has been shown to protect against the development of TTTS and TAPS by compensating for the circulatory imbalance caused by the uni-directional AV anastomoses1,2. 
Injection of monochorionic placentas soon after birth is a useful mean to understand the etiology of various (hematological) complications in monochorionic twins and is a required test to reach the diagnosis of TAPS2. In addition, injection of TTTS placentas treated with fetoscopic laser surgery allows identification of possible residual anastomoses3-5. This additional information is of paramount importance for all perinatologists involved in the management and care of monochorionic twins with TTTS or TAPS. Several placental injection techniques are currently being used. We provide a simple protocol to accurately evaluate the presence of (residual) vascular anastomoses using colored dye injection.

Twin-to-twin transfusion syndrome and twin anemia polycythemia sequence are two potentially devastating problems in perinatal medicine. Both disorders occur only in monochorionic twins and result from unbalanced blood flow through placental vascular anastomoses. We provide a simple protocol to accurately evaluate the presence of vascular anastomoses using colored dye injection of placental vessels after birth.

在单绒毛膜胎盘血管吻合用有色染料的精确和简单的评价

The presence of placental vascular anastomoses is a conditio sine qua non for the development of twin-to-twin transfusion syndrome (TTTS) and twin anemia ...

A Murine Model of Muscle Training by Neuromuscular Electrical Stimulation

Neuromuscular electrical stimulation (NMES) is a common clinical modality that is widely used to restore1, maintain2 or enhance3-5 muscle functional capacity. Transcutaneous surface stimulation of skeletal muscle involves a current flow between a cathode and an anode, thereby inducing excitement of the motor unit and the surrounding muscle fibers. 
NMES is an attractive modality to evaluate skeletal muscle adaptive responses for several reasons. First, it provides a reproducible experimental model in which physiological adaptations, such as myofiber hypertophy and muscle strengthening6, angiogenesis7-9, growth factor secretion9-11, and muscle precursor cell activation12 are well documented. Such physiological responses may be carefully titrated using different parameters of stimulation (for Cochrane review, see 13). In addition, NMES recruits motor units non-selectively, and in a spatially fixed and temporally synchronous manner14, offering the advantage of exerting a treatment effect on all fibers, regardless of fiber type. Although there are specified contraindications to NMES in clinical populations, including peripheral venous disorders or malignancy, for example, NMES is safe and feasible, even for those who are ill and/or bedridden and for populations in which rigorous exercise may be challenging. 
Here, we demonstrate the protocol for adapting commercially available electrodes and performing a NMES protocol using a murine model. This animal model has the advantage of utilizing a clinically available device and providing instant feedback regarding positioning of the electrode to elicit the desired muscle contractile effect. For the purpose of this manuscript, we will describe the protocol for muscle stimulation of the anterior compartment muscles of a mouse hindlimb.

A murine model of neuromuscular electrical stimulation (NMES), a safe and inexpensive clinical modality, to the anterior compartment muscles is described. This model has the advantage of modifying a readily available clinical device for the purpose of eliciting targeted and specific muscle contractions in mice.

一个小鼠模型，通过神经肌肉电刺激肌肉训练

Neuromuscular electrical stimulation (NMES) is a common clinical modality that is widely used to restore1, maintain2 or enhance3-5 muscle functional ...

Improved Protocol For Laser Microdissection Of Human Pancreatic Islets From Surgical Specimens

Laser microdissection (LMD) is a technique that allows the recovery of selected cells and tissues from minute amounts of parenchyma 1,2. The dissected cells can be used for a variety of investigations, such as transcriptomic or proteomic studies, DNA assessment or chromosomal analysis 2,3. An especially challenging application of LMD is transcriptome analysis, which, due to the lability of RNA 4, can be particularly prominent when cells are dissected from tissues that are rich of RNases, such as the pancreas. A microdissection protocol that enables fast identification and collection of target cells is essential in this setting in order to shorten the tissue handling time and, consequently, to ensure RNA preservation. 
Here we describe a protocol for acquiring human pancreatic beta cells from surgical specimens to be used for transcriptomic studies 5. Small pieces of pancreas of about 0.5-1 cm3 were cut from the healthy appearing margins of resected pancreas specimens, embedded in Tissue-Tek O.C.T. Compound, immediately frozen in chilled 2-Methylbutane, and stored at -80 &deg;C until sectioning. Forty serial sections of 10 &mu;m thickness were cut on a cryostat under a -20 &deg;C setting, transferred individually to glass slides, dried inside the cryostat for 1-2 min, and stored at -80 &deg;C. 
Immediately before the laser microdissection procedure, sections were fixed in ice cold, freshly prepared 70% ethanol for 30 sec, washed by 5-6 dips in ice cold DEPC-treated water, and dehydrated by two one-minute incubations in ice cold 100% ethanol followed by xylene (which is used for tissue dehydration) for 4 min; tissue sections were then air-dried afterwards for 3-5 min. Importantly, all steps, except the incubation in xylene, were performed using ice-cold reagents - a modification over a previously described protocol 6. utilization of ice cold reagents resulted in a pronounced increase of the intrinsic autofluorescence of beta cells, and facilitated their recognition. For microdissection, four sections were dehydrated each time: two were placed into a foil-wrapped 50 ml tube, to protect the tissue from moisture and bleaching; the remaining two were immediately microdissected. This procedure was performed using a PALM MicroBeam instrument (Zeiss) employing the Auto Laser Pressure Catapulting (AutoLPC) mode. The completion of beta cell/islet dissection from four cryosections required no longer than 40-60 min. Cells were collected into one AdhesiveCap and lysed with 10 &mu;l lysis buffer. Each single RNA specimen for transcriptomic analysis was obtained by combining 10 cell microdissected samples, followed by RNA extraction using the Pico Pure RNA Isolation Kit (Arcturus). This protocol improves the intrinsic autofluorescence of human beta cells, thus facilitating their rapid and accurate recognition and collection. Further improvement of this procedure could enable the dissection of phenotypically different beta cells, with possible implications for better understanding the changes associated with type 2 diabetes.

Laser microdissection is a technique that allows the recovery of selected cells from minute amounts of parenchyma. Here we describe a protocol for acquiring human pancreatic islets from surgical specimens to be used for transcriptomic studies. Our protocol improves the intrinsic autofluorescence of human beta cells, thus facilitating their collection.

从手术标本的人类胰岛细胞激光显微切割的改进方法

Laser microdissection (LMD) is a technique that allows the recovery of selected cells and tissues from minute amounts of parenchyma 1,2. The dissected ...

Transplantation of Pulmonary Valve Using a Mouse Model of Heterotopic Heart Transplantation

Tissue engineered heart valves, especially decellularized valves, are starting to gain momentum in clinical use of reconstructive surgery with mixed results. However, the cellular and molecular mechanisms of the neotissue development, valve thickening, and stenosis development are not researched extensively. To answer the above questions, we developed a murine heterotopic heart valve transplantation model. A heart valve was harvested from a valve donor mouse and transplanted to a heart donor mouse. The heart with a new valve was transplanted heterotopically to a recipient mouse. The transplanted heart showed its own heartbeat, independent of the recipient&#8217;s heartbeat. The blood flow was quantified using a high frequency ultrasound system with a pulsed wave Doppler. The flow through the implanted pulmonary valve showed forward flow with minimal regurgitation and the peak flow was close to 100 mm/sec. This murine model of heart valve transplantation is highly versatile, so it can be modified and adapted to provide different hemodynamic environments and/or can be used with various transgenic mice to study neotissue development in a tissue engineered heart valve.

In order to understand the cellular and molecular mechanisms underlying neotissue formation and stenosis development in tissue engineered heart valves, a murine model of heterotopic heart valve transplantation was developed. A pulmonary heart valve was transplanted to recipient using the heterotopic heart transplantation technique.

肺动脉瓣使用异位心脏移植小鼠模型移植

Tissue engineered heart valves, especially decellularized valves, are starting to gain momentum in clinical use of reconstructive surgery with mixed ...

Intravital Microscopy of Tumor-associated Vasculature Using Advanced Dorsal Skinfold Window Chambers on Transgenic Fluorescent Mice

Tumor and tumor vessel development, as well as tumor response to therapeutics, are highly dynamic biological processes. Histology provides static information and is often not sufficient for a correct interpretation. Intravital evaluation, in which a process is followed in time, provides extra and often unexpected information. With the creation of transgenic animals expressing cell-specific markers and live cell tracers, improvements to imaging equipment, and the development of several imaging chambers, intravital microscopy has become an important tool to better understand biological processes. This paper describes an experimental design for the investigation of tumor vessel development and of therapeutic effects in a spatial and temporal manner. Using this setup, the stage of vessel development, tip cell and lumen formation, blood flow, extravasation, an established vascular bed, and vascular destruction can be visualized and followed. Furthermore, therapeutic effects, intratumoral fate, and the localization of chemotherapeutic compounds can also be followed.

This protocol describes the intravital imaging of transgenic mice expressing cell-specific fluorescent markers. Intravital imaging provides a non-invasive method for high-resolution observations in living animals using implantable windows through which the microscopic visualization of processes is possible. This method is especially useful to study longitudinal processes.

应用先进的背皮窗室对转基因荧光小鼠肿瘤相关血管的活体显微镜观察

Tumor and tumor vessel development, as well as tumor response to therapeutics, are highly dynamic biological processes. Histology provides static ...

Using In Vitro Live-cell Imaging to Explore Chemotherapeutics Delivered by Lipid-based Nanoparticles

Conventional imaging techniques can provide detailed information about cellular processes. However, this information is based on static images in an otherwise dynamic system, and successive phases are easily overlooked or misinterpreted. Live-cell imaging and time-lapse microscopy, in which living cells can be followed for hours or even days in a more or less continuous fashion, are therefore very informative. The protocol described here allows for the investigation of the fate of chemotherapeutic nanoparticles after the delivery of doxorubicin (dox) in living cells. Dox is an intercalating agent that must be released from its nanocarrier to become biologically active. In spite of its clinical registration for more than two decades, its uptake, breakdown, and drug release are still not fully understood. This article explores the hypothesis that lipid-based nanoparticles are taken up by the tumor cells and are slowly degraded. Released dox is then translocated to the nucleus. To prevent fixation artifacts, live-cell imaging and time-lapse microscopy, described in this experimental procedure, can be applied.

Using In Vitro Live-cell Imaging to Explore Chemotherapeutics Delivered by Lipid-based Nanoparticles

Live-cell imaging is a powerful tool to visualize dynamic processes. The examination of fixed cells provides only static pictures, which can lead to misinterpretation and confusion about the process. This work presents a method to study uptake, drug release, and intracellular localization of liposomal nanoparticles in living cells.

使用体外活体细胞成像技术研究脂纳米粒子化疗

Conventional imaging techniques can provide detailed information about cellular processes. However, this information is based on static images in an ...

Surgical Training for the Implantation of Neocortical Microelectrode Arrays Using a Formaldehyde-fixed Human Cadaver Model

This protocol describes a procedure to assist surgeons in training for the implantation of microelectrode arrays into the neocortex of the human brain. Recent technological progress has enabled the fabrication of microelectrode arrays that allow recording the activity of multiple individual neurons in the neocortex of the human brain. These arrays have the potential to bring unique insight onto the neuronal correlates of cerebral function in health and disease. Furthermore, the identification and decoding of volitional neuronal activity opens the possibility to establish brain-computer interfaces, and thus might help restore lost neurological functions. The implantation of neocortical microelectrode arrays is an invasive procedure requiring a supra-centimetric craniotomy and the exposure of the cortical surface; thus, the procedure must be performed by an adequately trained neurosurgeon. In order to provide an opportunity for surgical training, we designed a procedure based on a human cadaver model. The use of a formaldehyde-fixed human cadaver bypasses the practical, ethical and financial difficulties of surgical practice on animals (especially non-human primates) while preserving the macroscopic structure of the head, skull, meninges and cerebral surface and allowing realistic, operating room-like positioning and instrumentation. Furthermore, the use of a human cadaver is closer to clinical daily practice than any non-human model. The major drawbacks of the cadaveric simulation are the absence of cerebral pulsation and of blood and cerebrospinal fluid circulation. We suggest that a formaldehyde-fixed human cadaver model is an adequate, practical and cost-effective approach to ensure proper surgical training before implanting microelectrode arrays in the living human neocortex.

We designed a procedure in which a formaldehyde-fixed human cadaver is used to assist neurosurgeons in training for the implantation of microelectrode arrays into the neocortex of the human brain.

应用甲醛固定人尸体模型植入皮层微电极阵列的外科训练

This protocol describes a procedure to assist surgeons in training for the implantation of microelectrode arrays into the neocortex of the human brain. ...

Surgical Treatment for Benign Prostatic Hyperplasia: Holmium Laser Enucleation of the Prostate (HoLEP).

Benign prostatic hyperplasia (BPH) commonly occurs among elderly males. The condition causes symptoms in the lower urinary tract, thereby reducing the quality of life. BPH includes 2 major treatments: medication and surgery. Surgical treatment is often the most effective and final intervention. Holmium laser enucleation of the prostate (HoLEP), one of the most efficient surgical procedures for BPH, is conducted transurethrally. During surgery, the most important and most difficult part is to locate the surgical capsule of the prostate, which is consistent to the idea of anatomic surgery. Different skills may be needed in treating different parts of the prostate. HoLEP tends to be efficient and safe with good hemostatic properties, and able to treat bladder calculus, which may be the complications of BPH. The technique is particularly suitable for prostate of varying volumes and sizes. Indeed, HoLEP also presents certain disadvantages, such as a long learning curve and costly equipment. Regardless, this method may be the "new standard" and the excellent method for the surgical treatment of BPH.

Surgical Treatment for Benign Prostatic Hyperplasia: Holmium Laser Enucleation of the Prostate HoLEP.

Here we present a safe and efficient protocol, holmium laser enucleation of the prostate, to treat benign prostatic hyperplasia.

良性前列腺增生的外科治疗: 钬激光前列腺摘除术 (计画)。

Benign prostatic hyperplasia (BPH) commonly occurs among elderly males. The condition causes symptoms in the lower urinary tract, thereby reducing the ...

A Rat Model of Orthotopic Liver Transplantation Using a Novel Magnetic Anastomosis Technique for Suprahepatic Vena Cava Reconstruction

The rat model of orthotopic liver transplantation (OLT) is essential for transplant research. It is a very sophisticated animal model and requires a steep learning curve. The introduction of the cuff technique for anastomosis of the portal vein (PV) and infrahepatic vena cava (IHVC) has significantly simplified the transplant procedure in rats. However, due to the short anterior wall of the recipients' suprahepatic vena cava (SHVC), the cuff technique is very difficult to use for the reconstruction of the SHVC. Most researchers in this field still use the hand-suture technique for SHVC reconstruction, which makes it the bottleneck step in rat orthotopic liver transplantation. The magnetic anastomosis technique (i.e., magnamosis) is a method of connecting two vessels using the attractive force between two magnets. Our recent study has shown that the magnetic anastomosis technique is superior to the hand-suture technique for SHVC reconstruction in rats. In this article, we show a step-by-step protocol for SHVC reconstruction in rats using the novel magnetic anastomosis technique. In this model, the reconstruction of the PV and IHVC was performed by the standard cuff technique, while the reconstruction of the bile duct (BD) was performed by a stent technique. The hepatic re-arterialization was not performed. The magnetic anastomosis technique made SHVC reconstruction much easier and significantly shortened the anphepatic phase. After a reasonable learning curve, even researchers without advanced microsurgical skills can produce reliable and reproducible results using this rat model of OLT.

The reconstruction of the suprahepatic vena cava (SHVC) remains a difficult step in rat orthotopic liver transplantation. In this article, we show a step-by-step protocol for SHVC reconstruction in rats using a novel magnetic anastomosis technique.

应用新型磁吻合技术 Suprahepatic 腔静脉重建大鼠原位肝移植模型的研究

The rat model of orthotopic liver transplantation (OLT) is essential for transplant research. It is a very sophisticated animal model and requires a steep ...