作者要感谢法国 Bagneux 的 Collin Medical 的支持，感谢 la Fondation des Gueules Cassées 帮助资助收购 Hôpital Necker - Enfants Malades， APHP 的 RobOtol。

这项研究是按照欧洲GDPR进行的，并在AP-HP，Hôpital Necker - Enfants Malades（编号20200727144143）注册。该研究遵循 CARE 指南12，父母双方都书面同意录制手术视频并发表病例报告13,14。手术策略反映了我们三级转诊中心通常使用的显微镜手术策略，涉及使用双手。主要区别在于手术方法，即经管，无需进行房门切开术或耳道成形术。
1. 术前程序
<ol><li>在诊所耳镜检查中诊断先天性胆脂瘤，在正常鼓膜后面可见白色肿块。与父母（和患者，考虑到他们的年龄）讨论鼓室成形术的程序和方法，解释其益处和风险。</li>
	<li>检查术前听觉检查，以评估传导性听力损失病例的听小骨受累，并验证是否存在相关的感音神经性听力损失。</li>
	<li>通过术前 CT 扫描为鼓室成形术做准备，以评估全内窥镜耳部手术 （TEES） 的可行性并检查乳突受累。 注意：也可以评估听骨受累以确定 Potsic阶段 3。I 期和 II 期患者是 TEES 的理想人选，而 III 期病例可能更具挑战性，因为难以用一只手安全地解剖听骨链。Potsic IV 期病变需要乳突切除术，通常首选传统的耳内或耳后入路。</li>
	<li>使用窥器评估外耳道的大小（ 材料 表），这在婴儿中尤为重要。 注意： 如果可以插入 4 号窥器，则可以轻松执行 TEES。如果可以插入 3 号窥器（管最窄处的宽度在 3 到 4 毫米之间），则更具挑战性，但仍有可能进行 TEES。</li>
</ol>2. 手术准备
<ol><li>执行检查表以确认病变的一侧，并确保在开始手术之前提供 CT 扫描和测听结果。</li>
	<li>将机械臂（内窥镜支架）（见 材料表）安装在机器人上，并确保其处于中立位置。</li>
	<li>患者插管后 13,14，倾斜患者的头部并将其固定在远离外科医生 30° 的旋转中。将患者的头枕向后倾斜，并将手术床倾斜到抗特伦德伦堡位置，使患者的头部水平定位。</li>
	<li>使用放置在前额上的粘性松紧带将患者的头部固定在桌子上。</li>
	<li>设置面神经监测（见 材料表）。</li>
	<li>至少在初始程序中，将手术显微镜悬垂，以便在机器人出现困难时在手术过程中过渡到显微镜。 注意：这对于确保最高质量的患者护理，同时仍然沿着学习曲线前进至关重要。</li>
	<li>将机械臂和机器人悬垂下来。</li>
	<li>将太空鼠标安装到外科医生旁边的手术床上（见 图 1）后，安装并悬垂，该手术床控制机械臂的多向运动。 注意：太空鼠标可以固定在外科医生的任一侧，但在这个螺柱中，它朝向患者的脚，允许外科医生直接坐在擦洗护士旁边（位于患者头部，如 图 2 所示）。</li>
	<li>对手术部位进行消毒，并用手术布覆盖，仅露出外耳。</li>
	<li>将机器人放置在外科医生对面（床的另一侧），以便机械臂（内窥镜支架）可以越过患者的头部向外科医生延伸，与外耳道对齐（如 图 1 所示）。</li>
	<li>将视频塔放置在外科医生的对面，最好位于机器人的两侧（最好朝向患者的脚），以确保屏幕的舒适视野。对于左侧鼓室成形术，将视频塔放置在机器人的右侧（如 图 1 和 图 2 所示）。</li>
</ol>3. 手术开始
<ol><li>将内窥镜支架放在耳道口上方，然后将内窥镜插入内窥镜支架。使用带有机械臂的 25 厘米长望远镜，以降低在手术过程中与外科医生的手发生冲突的风险。 注意：望远镜的宽度为 2.9 毫米，通常使用 0° 示波器，但 30° 或 45° 示波器可能在某些步骤中有用。</li>
	<li>清洁和消毒耳道，仔细检查鼓膜。</li>
	<li>对骨耳道（血管条）的上部进行局部麻醉（使用含有 10 mg/mL 赛洛卡因和 0.005 mg/mL 肾上腺素的溶液）。</li>
	<li>收获耳骨软骨（胆软骨可作为替代方法）。在这个阶段，在耳道中放置一块小纱布，以防止凝固的血液积聚。</li>
</ol>4. 先天性胆脂瘤（CC）手术
<ol><li>在 12 点钟到 8 点钟位置使用低功率（4 瓦）的倾斜烧灼针（见 材料表）进行跨管入路切口，以防止回缩。使用吸力清除任何可能阻碍视线的烟雾或血液。<ol><li>沿鼓索向下、向后和上打开鼓室，直到确定踝颈。 注意： 如果皮瓣有张力，请延长皮肤切口以防止撕裂。</li>
	</ol></li>
	<li>识别和切除病变：确保先天性胆脂瘤 （CC） 的后部清晰可见，并且可以准确评估其与砧骨和镫骨的受累情况。<ol><li>将鼓膜从鼓膜抬高，将鼓膜-尿道瓣向前推。在可控的后下部打开CC基质，并用大吸力将其减大。 注意：III 期 CC 通常太大，无法在不诱发听骨创伤或脱位风险的情况下切除。</li>
	</ol></li>
	<li>使用钩子或针将 CC 与砧骨和镫骨分开，并用 Fisch 显微剖析器将其向前推到锤骨下方（见 材料表）。 注意：要格外小心避免听骨创伤，并在解剖过程中使用抽吸作为反作用力来稳定听小骨。</li>
	<li>从岬角和耳蜗状突中解剖 CC 并去除 CC。 注意：使用钩子或 Fisch 显微分析仪解剖锤骨内侧-前侧时要特别小心。</li>
	<li>使用倾斜的内窥镜检查鼓室。 注意：对于完整的听骨链，必须非常小心地操作内窥镜，尤其是在倾斜的情况下。内窥镜的机器人控制对于将其旋转 360° 非常有用，同时将轴保持在相同的位置和完全相同的深度。要检查听小骨，请使用浸有肥皂的棉球擦拭锤骨和砧骨的内侧以及镫骨的啫骨之间，以检测任何残留的鳞状细胞15。</li>
	<li>加固鼓膜并将软骨插入垫层位置，以防止随后的回缩袋。更换骨管上的鼓膜-尿道瓣，并用可吸收的泡沫填充，从鼓膜的前部开始，以避免任何后续的侧向化。</li>
	<li>根据门诊方案让患者出院。给予耳针抗生素滴剂三周，并在一个月后安排术后检查。 注意： 无需外部敷料。</li>
</ol>

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Yann Nguyen 是法国 Bagneux 的 Collin Medical 的顾问。其他作者没有利益冲突需要声明。

这项研究报告了成功使用机器人辅助的全内窥镜手术切除一名 3 岁儿童的 III 期先天性胆脂瘤。全内窥镜耳部手术 （TEES） 在儿科人群中特别有趣，因为使用锁孔经管方法进行鼓室成形术可减少愈合时间和术后立即护理量。关于胆脂瘤手术，许多研究现在已经证明，与显微镜耳后或耳内入路相比，TEES 在特定患者中的残留率相似（如果不是更小的话）4,5,10</su...

先天性胆脂瘤 （CC） 占儿童胆脂瘤病例的 25%，近年来，由于公共卫生措施的改善和全球早期发现，其在胆脂瘤病例中的比例有所增加 1,2。CC 的大小和听骨受累对预后和手术策略有显著影响。因此，CC 可以根据 Potsic 分类3 进行分类。如果早期诊断，这些病变通常局限于鼓膜腔，或者可能延伸到具有完整基质的上膜，累及听小骨（Potsic III 期）或不累及听小骨（Potsic I 期或 II 期）。在更晚期的病例中，区分 CC 和获得性胆脂瘤可能具有挑战性，在上膜或乳突区域出现扩散性病变和鼓膜改变（Potsic IV 期）。
无乳突受累的 CC 患者（Potsic I 至 III 期）非常适合进行全内窥镜耳部手术 （TEES），该手术涉及最小的经管切口，并提供整个鼓室和上膜区域的良好视野。大量研究表明，与传统的显微方法相比，TEES产生相似的残差率4,5,6,7,8,9。TEES 已被全球许多儿科耳科中心采用，它提供了一种安全高效的技术，还增强了外科医生的人体工程学设计，使他们能够在面对屏幕时坐直 5,7,8,10。然而，在 TEES 期间，由于使用二手仪器时缺乏反稳定性，因此在 III 期病变中安全地解剖听小骨可能具有挑战性，从而增加了听小骨过度活动导致的听骨半脱位和内耳创伤的风险。此外，由于出血或内窥镜起雾，解剖过程中缺乏吸力会导致能见度差。专为中耳手术和人工耳蜗植入而设计的机械臂被用作机器人动态内窥镜支架，在整个手术过程中提供六个自由度，包括三个平移轴和三个旋转轴。在机器人辅助TEES期间的安全性已经在成年人群中报道过11。
本文报告了使用机器人辅助 TEES 治疗 3 岁儿童 III 期先天性胆脂瘤的机器人设置和外科手术。这种方法允许用两只手解剖胆脂瘤，同时受益于内窥镜观察和经管入路。

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>0&#176; 2.9 mm 25 cm Endoscope</td>
			<td>Collin</td>
			<td>RBT-END-0</td>
			<td>Endoscope for otoendoscopy</td>
		</tr>
		<tr>
			<td>Colorado MicroDissection Needle</td>
			<td>Stryker</td>
			<td></td>
			<td>Pointed electrocautery</td>
		</tr>
		<tr>
			<td>Facial nerve monitoring</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>RobOtol</td>
			<td>Collin</td>
			<td></td>
			<td>Robot dedicated to ear surgery</td>
		</tr>
		<tr>
			<td>Space mouse</td>
			<td>3DConnexion</td>
			<td></td>
			<td>RobOtol control arm</td>
		</tr>
		<tr>
			<td>Standard otology surgical material</td>
			<td></td>
			<td></td>
			<td>Including amongst standard instruments: speculum, Fisch dissectors</td>
		</tr>
	</tbody>
</table>

robot-assisted transcanal endoscopic ear surgery for congenital cholesteatoma

先天性胆脂瘤占儿童胆脂瘤病例的25%。经管内窥镜耳部手术 （TEES） 是这些患者的理想选择，因为它提供了中耳的宽内窥镜视野和微创方法。两个主要限制是年幼儿童失去一只手术手和狭窄的外耳道。在这里，我们介绍了一名 3 岁患者的病例，该患者患有 Potsic III 期先天性胆脂瘤，粘附在镫骨的砧骨和分支上。进行了机器人辅助 TEES 手术，在此期间，具有 6 个自由度的机械臂握住一个 0°、2.9 mm 宽的内窥镜，使外科医生能够用双手在狭窄的环境中工作。该过程的持续时间为 2 小时 9 分钟，其中包括 16 分钟的机械臂安装和悬垂。经管入路后，使用针（或镰刀）和抽吸从听小骨中解剖胆脂瘤，以稳定听小骨并限制听力创伤的风险。胆脂瘤被切除以减小其大小，使其能够被推到前踝下方，然后在切除前与其他粘附物分离。使用横骨软骨移植物加固鼓膜。

该案例研究报告了一名 3 岁儿童的 Potsic III 期左先天性胆脂瘤机器人辅助全内窥镜耳部手术 （TEES）。机械臂配备了一个 0° 和 30°、长 25 厘米、宽 2.9 毫米的示波器，连接到 1080p 全高清摄像头和屏幕。
术前检查显示典型的先天性胆脂瘤，CT扫描显示锤骨内侧有一个圆形的前肿块，向后延伸至镫骨间，向前延伸至输卵管上凹陷（图3）。听小骨链保持完整?...

Watch this Scientific Journal Video about Robot-Assisted Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma at JoVE.com

Robot-Assisted Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma

该协议描述了使用双手方法和机器人内窥镜支架的微创经管内窥镜耳部手术切除先天性胆脂瘤。

机器人辅助经管内窥镜耳部手术治疗先天性胆脂瘤

Congenital cholesteatoma accounts for 25% of cholesteatoma cases in children. Transcanal Endoscopic Ear Surgery (TEES) is ideal for these patients because ...

该协议具有重要意义，因为它显示了在三岁儿童狭窄的耳道中采用双手内窥镜技术切除先天性胆脂瘤的可行性。先天性胆脂瘤可见于中耳腔。虽然没有骨侵蚀，但它从听小骨延伸到输卵管上凹陷。将内窥镜插入支架后，仔细检查患者的鼓膜。浸润耳道，防止凝血积聚。使用设置为低功率的倾斜烧灼针，沿鼓索向下、向后和向上打开鼓室，直到识别出踝颈。然后将鼓膜从鼓膜抬高，并将鼓膜口瓣向前推。使用钩子或针头将先天性胆脂瘤与砧骨和镫骨分离，然后用 Fisch 显微剖析器将其向前推到锤骨下方。现在，打开可控后下部的先天性胆脂瘤基质，用大吸力将其减大。从海角和踝骨解剖先天性胆脂瘤，并将其切除。使用倾斜的内窥镜检查鼓室。加固鼓膜并将软骨插入垫层位置，以防止随后的回缩袋。更换体管上的鼓膜瓣，并用可吸收的泡沫填充，从鼓膜的前部开始，以避免任何后续的侧向化。术前测听显示左耳传导性听力损失为10分贝，导致右耳与正常听力有轻微不对称。术后六周，左耳出现 10 分贝传导性听力损失，但值得注意的是，没有感音神经性听力损失。这种机器人技术为未来的研究铺平了道路，使机械臂与CT扫描上的3D映射同步，并开发增强现实。

robot-assisted-transcanal-endoscopic-ear-surgery-for-congenital

Research

JoVE Journal

Medicine

478 次观看.  Université Paris Cité. 该协议具有重要意义，因为它显示了在三岁儿童狭窄的耳道中采用双手内窥镜技术切除先天性胆脂瘤的可行性。先天性胆脂瘤可见于中耳腔。虽然没有骨侵蚀，但它从听小骨延伸到输卵管上凹陷。将内窥镜插入支架后，仔细检查患者的鼓膜。浸润耳道，防止凝血积聚。使用设置为低功率的倾斜烧灼针，沿鼓索向下、向后和向上打开鼓室，直到识别出踝颈。然后将鼓...

视频: Robot-Assisted Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma

Discovering Middle Ear Anatomy by Transcanal Endoscopic Ear Surgery: A Dissection Manual

The middle ear is located in the center of the temporal bone and bears a highly complex anatomy. The recently introduced exclusively endoscopic transcanal approach to the middle ear is a minimally invasive technique sparing the bone and mucosa of the mastoid bone, since the middle ear is accessed through the external auditory canal. This emerging method has several advantages over the traditional (microscopic) approaches to the middle ear such as the panoramic wide-angle views of the anatomy, the possibility to approach and magnify tiny structures, and the possibility of looking around the corner using angled endoscopes.
The cadaveric dissection method presented here consists of an overview on the technical requirements and a precise description of a step-by-step protocol to discover the anatomy of the middle ear. Each step and anatomical structure is carefully described in order to provide a comprehensive guide to endoscopic ear anatomy. In our opinion, this is particularly important to any novice in endoscopic ear surgery as it provides thorough anatomical knowledge and may improve surgical skills.

The aim of this article is to describe the methodology of exclusively endoscopic cadaveric middle ear dissection. Moreover, we aim to provide a comprehensive guide to endoscopic middle ear anatomy.

Transcanal 内窥镜下耳部手术发现中耳解剖: 解剖手册

The middle ear is located in the center of the temporal bone and bears a highly complex anatomy. The recently introduced exclusively endoscopic transcanal ...

科研

医学

Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal deviation. It has a long history with multiple variations. In this article, a modified endoscopic septoplasty procedure using the limited two-line resection (2LoRs) technique at the posterior and inferior junction of the cartilaginous and bony septum is presented based on embryologic and anatomic knowledge of the nasal septum and the biomechanics of cartilaginous behavior. With this procedure, the quadrangular cartilage can be preserved as much as possible, which is helpful in retaining the supporting framework and rigidness of the septum. 2LoRs has been proven effective and sound for the correction of nasal septal deviation with rare complications. This modified procedure can be applied to correct the deviated nasal septum in the absence of any external nasal deformity to improve nasal patency or to improve access to the middle meatus or to the axillary region of the middle turbinate. It may also be used to expand the indications of septoplasty to children and adolescents because of its minimally invasive approach.

Endoscopic septoplasty is a time-honored surgical procedure with multiple variations. This paper focuses on a step-by-step surgical approach to perform a modified septoplasty procedure known as limited two-line resection. This surgical technique can be applied to correct a deviated nasal septum in the absence of an external nasal deformity.

内镜下鼻中隔成形术有限双线切除: 间隔偏差微创手术

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

机器人辅助胰腺切除术的技术细节

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction, for cancer of the body-tail of the pancreas. The patient is placed supine with the legs parted and a pneumoperitoneum is established and maintained at 10 mmHg. To use the surgical system, four 8 mm ports and one 12 mm port are required. The optic port is placed at the umbilicus. The other ports are placed, on either side, along the pararectal line and the anterior axillary line at the level of the umbilical line. The assistant port (12 mm) is placed along the right pararectal line. Dissection begins by detaching the gastrocolic ligament, thus opening the lesser sac, and by a wide mobilization of the splenic flexure of the colon. The superior mesenteric vein is identified along the inferior border of the pancreas. Lymph node number 8a is removed to permit clear visualization of the common hepatic artery. A tunnel is then created behind the neck of the pancreas. To permit safe resection and reconstruction of the spleno-mesenteric junction, further preemptive dissection is required before dividing the pancreatic neck to bring in clear view all relevant vascular pedicles. Next, the splenic artery is ligated and divided, and the pancreatic neck is divided, with selective ligature of the pancreatic duct. After vein resection and reconstruction, dissection proceeds to complete the clearance of peripancreatic arteries that are peeled off from all lympho-neural tissues. Both celiac ganglia are removed en-bloc with the specimen. The Gerota fascia covering the upper pole of the left kidney is also removed en-bloc with the specimen. Division of short gastric vessels and splenectomy complete the procedure. A drain is left near the pancreatic stump. The round ligament of the liver is mobilized to protect the vessels.

The robotic technique shown herein aims at faithfully reproducing the open procedure for radical treatment of cancer of the body-tail of the pancreas. The protocol also demonstrates the ability to master involvement of major peripancreatic vessels without conversion to open surgery.

机器人辅助基质前体模块化胰腺切除术，包括切除和重建的斯普尔诺-梅森特克结

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the ...

Robot-Assisted Kidney Transplantation

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed in the supine Trendelenburg position. Kidney allografts are provided by a living donor. Before vascular anastomosis, the kidney allograft is prepared by inserting a double-J stent in the ureter, and the temperature for the anastomosis is lowered by wrapping it in an ice-packed gauze. A 12 mm or 8 mm port for the robotic camera and three 8 mm ports for robotic arms are placed. A peritoneal pouch is created for the kidney allograft by raising the peritoneal flaps on both sides over the psoas muscle before dissecting the iliac vessels and bladder. A 6 cm Pfannenstiel incision is made to insert the kidney into the peritoneal pouch, lateral to the right iliac vessels. 
After clamping the external iliac vein with Bulldogs clamps, a venotomy is performed, and the graft renal vein is anastomosed to the external iliac vein in an end-to-side continuous manner with a 6/0 polytetrafluoroethylene suture. After clamping the graft renal vein, the iliac vein is declamped. This is followed by clamping of the external iliac artery, arteriotomy, arterial anastomosis with a 6/0 polytetrafluoroethylene suture, clamping of the graft renal artery, and declamping of the external iliac artery. Reperfusion is then carried out, and ureteroneocystostomy is performed using the Lich-Gregoir technique. The peritoneum is closed at a few locations with polymer locking clips, and a closed-suction drain is placed through one of the working ports. After deflating the pneumoperitoneum, all incisions are closed.

This paper provides technical details for robot-assisted kidney transplantation from a living donor.

机器人辅助肾移植

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed ...

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex procedures. The high-quality 3-D visual, multijoint arm and natural tremor filtration allow the surgeon to expose and dissect more accurately with minimal invasion. Total mesorectal excision is the standard surgical technique for the treatment of resectable rectal cancer. To reduce the lateral recurrence rate, lateral pelvic lymph node dissection can be performed, as it is a safe and feasible procedure for locally advanced middle-low rectal cancer with a high possibility of metastasis to the lateral lymph nodes. However, the complexity of the anatomic structures and the high postoperative complication rate limit its application. Recently, several surgeons have increasingly used robotic techniques for total mesorectal excision and lateral pelvic lymph node dissection. Compared with open and laparoscopic surgery, the robotic technique has several advantages, such as less blood loss, fewer blood transfusions, minimal trauma, shorter postoperative hospitalization, and quicker recovery. A robotic approach is generally regarded as a reasonable alternative for complicated procedures such as lateral pelvic lymph node dissection, although there are a limited number of high-quality prospective randomized controlled studies reporting direct evidence. Here, we provide the detailed steps of robot-assisted total mesorectal excision and lateral pelvic lymph node dissection performed at the First Affiliated Hospital of Xi&#39;an Jiaotong University.

The robotic technique described herein aims to detail a stepwise approach to robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced (T3/T4) rectal cancer located below the peritoneal reflection.

机器人辅助全直肠系膜切除术和盆腔外侧淋巴结清扫术治疗局部晚期中低直肠癌

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex ...

The Microscopic Transcanal Approach in Stapes Surgery Revisited

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the external auditory canal, the middle ear, and epitympanon. Such an approach avoids a retroauricular or endaural skin incision; however, working through a narrow space needs angled microsurgical instruments and specific training in otologic surgery. The transcanal approach restricts the working space; however, it offers a binocular microscopic vision into the middle ear without extended skin incisions and thus, reducing post-operative pain and bleeding. In addition, this minimally invasive approach avoids scar tissue complications, hypoesthesia of the auricle, and potential protrusion of the pinna. Despite its numerous advantages, this method is still not routinely performed by otologic surgeons. Since this minimally invasive technique is more challenging, there is a need for extensive training in order for it to be widely adopted by otologic surgeons. This article provides step-by-step surgical instructions for stapes surgery and reports possible indications, pitfalls, and limitations using this microscopic transcanal technique.

This article describes the microscopic transcanal technique for stapes surgery, providing step-by-step surgical instructions for familiarizing surgeons with this approach.

重新审视镫骨手术中的显微经管入路

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the ...

Step-by-Step Stapedotomy through Transcanal Exclusive Endoscopic Approach

In recent years there has been an increasing trend in the use of the endoscope to treat a variety of middle ear pathologies, including otosclerosis. Several studies comparing traditional microscopic and endoscopic stapes surgery have reported similar hearing results and an overall low rate of complications. The endoscope has unraveled its full potential in demanding settings of stapes surgery, such as unfavorable anatomy of the oval window niche or revision cases. Reduced manipulation of the chorda tympani and low rate of post-operative dysgeusia are further benefits to mention for endoscopic stapes surgery.
Being a one-handed technique, management of bleeding, positioning, and crimping of the prosthesis may be challenging for novice endoscopic surgeons, so some training in endoscopic ear surgery is recommended before performing endoscopic stapedotomy. The problem of sharing the surgical field between the endoscope and the operating instruments could be easily overcome if proper instruments positioning is understood. One-handed bleeding control in the narrow space of the ear canal may represent an issue during the elevation of the tympano-meatal flap, possibly discouraging the surgeon since the preliminary steps of surgery. Following appropriate technique to raise the flap and the collaboration with the anesthesiology team in keeping the blood pressure low guarantee an adequate bleeding control in most cases.
The aim of this article is to describe the entire surgical procedure of a transcanal exclusive endoscopic stapedotomy, from operating room set up and patient positioning to post-operative care. A step-by-step description of the surgical maneuvers with technical hints is reported, to guide the surgeon across the procedure and allow any ear surgeon to perform stapes surgery endoscopically.

The aim of this article is to provide a step-by-step method for endoscopic stapes surgery from operating room setting and patient positioning to post-operative care. This work would represent a guide for any otologic surgeon who is willing to treat otosclerosis with endoscopic transcanal technique.

通过经卡全线内窥镜方法进行逐步镫骨切除术

In recent years there has been an increasing trend in the use of the endoscope to treat a variety of middle ear pathologies, including otosclerosis. ...

Endoscopic Cholesteatoma Surgery

Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. Compared to the microscopic approach with an excellent but straight-line view and limited illumination, the introduction of endoscopes provides a wide-angled panoramic view. Moreover, angled lenses allow the surgeon to visualize the middle ear and its hidden recesses through a transcanal, minimally-invasive approach. The endoscope enables the surgeon to remove limited cholesteatoma of the middle ear and its recesses using an exclusive endoscopic technique by taking advantage of these benefits. This reduces the rate of residual disease and sparing external incisions and excessive temporal bone drilling as in a transmastoid approach. Since transcanal endoscopic access is mainly a one-handed technique, it implies the need for specific procedures and technical refinements. This article describes a step-by-step guide as a surgical manual for endoscopic removal of epitympanic cholesteatoma. Different techniques for cholesteatoma dissection and bone removal for epitympanectomy, including curettage and powered instruments such as drills and ultrasonic devices with their outcomes, are discussed. This may offer ear surgeons insight into technical refinements and the latest technological developments and open the horizon for different techniques.

The present protocol describes a step-by-step guide for the complete endoscopic removal of epitympanic cholesteatoma with different techniques for cholesteatoma dissection and bone removal for epitympanectomy.

内窥镜胆脂瘤手术

Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. ...

Retzius-Sparing Robot-Assisted Radical Prostatectomy

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The technique is described step-by-step and further illustrated by a video to enhance reproducibility. Early oncological and functional results were evaluated. In total, 77 patients were included with a median follow-up of 11 months (range: 3-21 months). Fifty-one percent of patients had local high-risk or locally advanced prostate cancer. There were no intra-operative complications, and all high-grade complications (2.6%) were related to pelvic lymph node dissection performed concomitant with RS-RARP. Median operation time was 160 min (range: 122-265 min) and median hospital stay was 3 (range: 3-8) days. A positive surgical margin was reported in 42.9%. One-year biochemical recurrence-free survival was 90.1%. After 6 months, all patients were socially continent and after 1 year, 94.3% were fully continent. Of sexually active patients who underwent at least unilateral nerve-sparing, 43.3% were able to have sexual intercourse. This series underlines the surgical safety of performing RS-RARP by a standardized technique and confirms the beneficial effect on the early return of continence. The patient needs to be informed about the risk of a positive surgical margin.

Robot-assisted Retzius-sparing radical prostatectomy is a technique that enables to preserve urinary continence or facilitates recovery of urinary continence in the majority of patients. Patients must be informed about the risk of a positive surgical margin.

保留 retzius 机器人辅助根治性前列腺切除术

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The ...