The authors have no acknowledgments.

NOTA: Prima di eseguire questa procedura, ottenere tutte approvazione istituzionale necessario e il consenso del paziente. 1. Tecnica chirurgica <ol><li> Indurre paziente con anestesia generale. </li><li> Posizionare linea arteriosa radiale per il monitoraggio della pressione arteriosa. </li><li> Posizionare il paziente in posizione supina sul tavolo operatorio. </li><li> Dopo che la testa è bloccato nel supporto Mayfield Testa utilizzando tecniche standard per una craniotomia pterional, posizionare la testa di 30 ° -45 ° con il lato omolaterale verso il soffitto, tranne-comunicante anteriore aneurismi in cui la testa è posto a 60 ° per consentire una migliore visualizzazione attraverso la fessura interemisferica. </li><li> Posizionare la linea mediana del collo e tradurre anteriormente per massimizzare il drenaggio venoso giugulare per prevenire l&#39;edema cerebrale e quindi estendere la testa per posizionare zigomo omolaterale al più alto punto-questo permette di relax lobo frontale e elevation dal tetto orbitale durante la dissezione senza l&#39;uso di divaricatori. </li><li> Agganciare i capelli, in preparazione per lo standard incisione cuoio pterional; utilizzare circa uno a striscia di due pollici dietro l&#39;attaccatura dei capelli. </li><li> Sterilmente preparare la pelle e drappeggio l&#39;area chirurgica secondo standard di cura. </li><li> Eseguire un cuoio capelluto incisione curva standard per un approccio pterional estende dalla linea mediana del cuoio capelluto dietro la linea sottile con una curva dolce posteriormente ed inferiormente verso la trago porvi fine circa 3 mm anteriormente al trago e al livello del bordo superiore dello zigomo . Eseguire questa incisione fino al cranio sopra la linea temporale superiore e alla fascia muscolare a livello del muscolo temporale. </li><li> Utilizzare elettrobisturi per cute emostasi con il dispositivo bipolare. </li><li> Tagliare il muscolo temporale fino al cranio con il dispositivo di elettrocauterizzazione monopolare Bovie. </li><li> Sollevare un lembo miocutaneo mantenendo il muscolo temporale attaccato alinferiore del cuoio capelluto per ora. Ami sono utilizzati per rovesciare il lembo dopo il muscolo temporale è elevata dal cranio con una combinazione di elettrocauterizzazione monopolare e un scollaperiostio. </li><li> Eseguire una dissezione sottofasciale inversa nel piano avascolare dalla superficie inferiore del lembo miocutaneo con le forbici Metzenbaum, mantenendo la fascia e cuscinetto adiposo subfacsial con il cuoio capelluto per evitare lesioni al nervo facciale. </li><li> Fissare il muscolo temporale posteriormente ed inferiormente per esporre la regione pterional con &quot;stella&quot; ami. </li><li> Tenere tutti i componenti del lembo miocutaneo umido con una garza bagnata. </li><li> Praticare un singolo temporale 5 millimetri bava fori nel lato posteriore-maggior parte del craniotomia pianificata con da 2 mm taglio bava in modo che la piastra di fondo del trapano laterale di taglio può essere inserita in questo foro e quindi utilizzare un trapano side-Taglio con una pedana per rimuovere il pollice dimensioni (circa 3 x 4 cm) a forma di rene craniotomia centecolore rosso anteriormente intorno al pterion. </li><li> Utilizzando un No. 1 Penfield, separare la dura su tutti i lati del pterion e hanno un assistente ritrarre delicatamente la dura dalla superficie dell&#39;osso che viene forato per minimizzare il rischio di penetrazione della dura e causando lesioni corticale. </li><li> Rimuovere il pterion con un trapano: anteriormente, fino a quando gli aspetti superiori e laterali del tetto orbitali sono lisci e appiattiti verso il basso per la tabella esterna corticale dell&#39;osso, senza entrare nell&#39;orbita, per massimizzare l&#39;esposizione subfrontale; medialmente, trapano fino a quando la fessura orbitale superiore dura è esposto e rimuovere eventuali piccoli pezzi di osso che potrebbero interferire con l&#39;esposizione mediale utilizzando una punta da trapano o un dispositivo di taglio portatile Lempert osso. Assicurarsi che eccellente emostasi di tutte le superfici dei tessuti molli e delle ossa sono state ottenute al fine di evitare il sangue che cola nello spazio intradurale durante la dissezione del cervello e l&#39;esposizione aneurisma, utilizzando electrocaurtery e cera osso, se necessario, prima di aprire la dura. </li><li>Elevare delicatamente la dura e utilizzare un bisturi No. 11 per penetrare la dura e quindi utilizzare le forbici durale per creare un&#39;apertura &quot;a C&quot; nella dura con la base al pterion. Fissare il piano dura contro l&#39;osso corticale esterna dell&#39;orbita senza dover volantini ridondante durale che sarebbero visualizzazione altrimenti oscuro prossimale Sylvian Abisso e regione subfrontale. Ciò può essere eseguito utilizzando 4-0 Surgilons suture a virare la dura al cuoio capelluto. </li></ol> 2. Cervello Relax <ol><li> Dare 25-50 g di mannitolo al momento della rimozione lembo osseo per rilassare il cervello, se anestesia concorda sul fatto che la pressione del sangue tollererà diuresi. NOTA: Questo permetterà di tempo per la diuresi a verificarsi e in ultima analisi, sarà rilassare il cervello per aiutare a massimizzare la gravità dipende retrazione del cervello durante la dissezione. </li><li> Tenere fine espirazione pCO2 tra 30-35 mm Hg per raggiungere lieve ipercapnia. NOTA: Questo permetterà in modo sicuro per il relax e il cervello maximize gravità dipendente retrazione del cervello durante la dissezione. </li><li> Evacuare liquido cerebrospinale (CSF) per favorire il rilassamento del cervello aprendo le cisterne aracnoide nel interoptic, carotide ottica, e cisterne carotide-oculomotorie e pazientemente CSF aspirazione fino al raggiungimento del rilassamento del cervello desiderato. NOTA: Questo richiede in genere circa 1 min; senza scarico lombare è necessaria con questa tecnica e si apre drammaticamente corridoi chirurgiche. </li></ol> 3. Sylvian Fissure Dissection <ol><li> Portare il microscopio intraoperatorio con il boccaglio nel campo usando tecniche sterili. Anche portare sedie chirurgici con supporto braccio nel campo sterilmente per massimizzare destrezza bimanuale e per prevenire il braccio chirurgo e l&#39;affaticamento della mano. NOTA: Il boccaglio deve essere regolata prima drappeggio in modo che il chirurgo può spostare il microscopio con la bocca contemporaneamente guardando attraverso i pezzi oculari. </li><li> Eseguire dissezione. NOTA: percomunicante anteriore aneurismi dell&#39;arteria, senza dissezione Sylvian Abisso è necessario e il minimo (2-3 mm solo in casi estremi, ma questo è un evento raro) o nessuna resezione giro retto è necessaria utilizzando dissezione solo subfrontale; tutte le altre località circolo anteriore aneurisma sopraclinoidea (compresi comunicante posteriore) richiedono &lt;1 cm prossimalmente Sylivan Abisso dissezione per esporre il sopraclinoidea arteria carotide interna, i suoi rami (comunicante posteriore e anteriore arterie della coroide), l&#39;interno capolinea carotide, la A1 e M1 origini e prossimali A2 e segmenti M2 distali ai rispettivi biforcazioni. Complessivamente, l&#39;esposizione Sylvian Abisso era dime-size (1 cm x 1 cm) e nessun divaricatori cerebrali sono stati utilizzati per uno dei casi segnalati. Gravity dipendente relax cervello era sufficiente per ottima esposizione delle strutture dei tessuti molli e vasi necessarie per eseguire la clip legatura chirurgica nei settori di cui sopra. </li><li> Utilizzando manipula bimanualzione con microstrumenti chirurgici aprire delicatamente i corridoi aracnoide, tenendo il tessuto cerebrale da parte con il bordo del dispositivo maniglie strumento o di aspirazione, se necessario attraverso questa esposizione. NOTA: la preferenza dell&#39;autore anziano è quello di utilizzare una punta di aspirazione 4-Francese Fukishima nella mano non dominante e nella mano baionette bipolari dominanti per scollamento o microscissors per la dissezione tagliente. Strisce inumidito Telfa sono collocati sulla superficie del cervello nel sito di manipolazione per evitare lesioni corticale. Cottonoids spesso attaccano alla superficie del cervello e non possono essere facilmente avanzati profondo come la dissezione progredisce, senza causare lievi lesioni corticale. </li><li> Utilizzare il boccaglio sul microscopio operatorio frequente per regolare la portata e concentrarsi lunghezza come necessario allontanare le mani nel settore. </li><li> Fissare l&#39;aneurisma in modo standard, utilizzando l&#39;aspirazione più spesso in mano non dominante per mantenere il corridoio chirurgica e la visualizzazione gratuita di CSF. </li><li> Dopo la clip di collocamento, effettuare Doppler intraoperatoria della cupola dell&#39;aneurisma di confermare la cessazione del flusso, così come i vasi di afflusso e deflusso per confermare il flusso ed esaminare con attenzione i vasi del collo dell&#39;aneurisma e genitori. Ci riserviamo intra-operatoria angiografia digitale (DSA) per comunicante anteriore aneurismi e quelle aneurismi tagliate dove afflusso, deflusso, o al collo dell&#39;aneurisma non possono essere visualizzati in tutto o c&#39;è un problema con Doppler intra-operatoria. DSA intra-operatoria è preferito su verde indocianina (ICG) angiografia perché quando più clip da aneurisma sono utilizzate per ricostruire il collo dell&#39;aneurisma, la clip può ostacolare la visualizzazione. NOTA: Una volta che l&#39;aneurisma è stato tagliato in modo sicuro, il microscopio è rimossa dal campo e il cervello irrigato con soluzione fisiologica per minimizzare la quantità di pneumocefalo dopo la chiusura. </li><li> Dopo aver ispezionato la clip per aneurisma occlusione con il Doppler, la cupola aneurisma è il motto di spirito perforata<html> ha 22 ago G attaccato al tubo per via endovenosa e una siringa da 10 ml e aspirazione manualmente aspirato per confermare aneurisma occlusione. </li><li> Reapproximate la dura nativa con 4-0 surgilon e coprire con un sostituto sintetico durale se una chiusura stagna non è in grado di ottenere correttamente. </li><li> Placche ossee sicuri con un sistema di metallizzazione per standard di cura. </li><li> Fissare il bordo frontale del filo lembo osseo contro l&#39;osso nativo per evitare spazio tra i due che non sarebbe esteticamente gradevole dopo i tessuti guariscono. </li><li> Reapproximate la fascia muscolo temporale con interrotti 2-0 punti di sutura Vicryl. Fissare la parte superiore del muscolo temporale con un Vicryl punto 2-0 alla piastra metallica frontale per reapproximate alla linea temporale superiore. </li><li> Reapproximate la galea con 3-0 punti di sutura Vicryl e chiudere il cuoio capelluto in modo standard utilizzando graffette, nylon o prolene. Condite con bende sterili per preferenza del chirurgo. </li></ol>_title &quot;&gt; 4. Post-trattamento di cura <ol><li> Ammettere paziente al reparto di terapia intensiva dopo il trattamento e mobilitare con il personale infermieristico, non appena la sedazione o anestesia generale ha portato fuori abbastanza per farlo, in genere entro 6 ore di estubazione. </li><li> Ordine di terapia fisica e occupazionale per iniziare post-operatorio primo giorno, al fine di valutare il paziente per lo scarico sicuro da casa, se ci fossero dubbi da parte del personale infermieristico. </li><li> Scaricare il paziente quando sono soddisfatti i criteri: dolore controllato solo con farmaci per via orale, minzionali in modo indipendente, deambulazione in modo indipendente, e tollerare l&#39;assunzione di cibo per via orale. </li></ol>

<ol>
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Eric Deshaies è un consulente medico per MicroVention, Covidien neurovascolare, Integra LifeSciences Corporation.

Clip chirurgica legatura di aneurismi intracranici rimane un&#39;opzione rilevante e importante nel trattamento di alcuni tipi di aneurismi, anche se questo ruolo è stato diminuendo nel corso degli ultimi anni, come la tecnologia endovascolare diventa più sicuro e più efficace. Il trattamento endovascolare ha superato un intervento chirurgico per aneurismi cerebrali, ma il tasso di recidiva più alto dopo il trattamento endovascolare, la necessità occasionale per il trattamento chirurgico dopo aneurisma recidiva dal...

Clip chirurgica legatura era stato il cardine del trattamento per aneurismi intracranici, ma è stato recentemente soppiantato lo più da tecniche endovascolari meno invasive. 1,2 Gli studi clinici, tra cui lo Studio Internazionale di non rotto intracraniche aneurismi (ISUIA-1 e ISUIA-2), e l&#39;International Subarachnoid Aneurysm Trial (ISAT) hanno dimostrato una minore morbilità e mortalità, riduzione della durata del soggiorno in ospedale, e la spesa complessiva inferiore, con trattamento endovascolare rispetto al chirurgico clip di legatura. 3 - 5 Tuttavia, il più alto tasso di recidiva dell&#39;aneurisma dopo la terapia endovascolare ha portato alla esame del rischio cumulativo per i pazienti rispetto ai chirurgica fermaglio legatura. 3,4 trattamento chirurgico rimane una modalità importante per la terapia aneurisma, in particolare per aneurismi circolazione anteriore che hanno morfologie che possono essere difficili da trattare con mezzi endovascolari. <p class = &quot;jove_content&quot;&gt; A differenza di avanzamenti nei dispositivi endovascolari, pochi progressi delle tecniche chirurgiche sono state effettuate di recente. Le tecniche per rendere il trattamento chirurgico meno invasivo hanno incluso la craniotomia sopraorbitali combinato con l&#39;incisione sopracciglio per aneurismi circolazione anteriore e &quot;chirurgia retractorless&quot; per ridurre al minimo il trauma chirurgico al cervello durante aneurisma ritaglio 6 -. 8 Questi approcci chirurgici meno invasivi possono ridurre la lunghezza di ospedale stare, la morbilità chirurgica, costo di trattamento, e migliorare i risultati dei pazienti. 9 Qui vi presentiamo la nostra esperienza con un approccio mini-invasivo di chirurgia clip di legatura degli aneurismi intracranici unruptured utilizzando un approccio pterional per anteriori circolazione aneurismi eseguite in un importante centro cerebrovascolare terziario e confrontare i risultati con un&#39;età abbinati dataset dal Nationwide ospedaliera di esempio (NIS ). La tecnica chirurgica sarà rivisto, Compresa la preparazione del paziente, il rilassamento del cervello, Sylvian fessura dissezione, e la chiusura. Saranno inoltre illustrati i requisiti di assistenza e di scarico post-operatorie.

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			<td height="21" style="height:21px;width:407px;">Mayfield Infinity skull clamp</td>
			<td style="width:125px;">Integra</td>
			<td style="width:368px;">A-1114</td>
			<td style="width:64px;"></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Mayfield table attachment</td>
			<td style="width:125px;">Integra</td>
			<td style="width:368px;">A-1018</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">4-French Fukishima suction tip</td>
			<td style="width:125px;">Integra</td>
			<td style="width:368px;">R-8986</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Periosteal elevator (Langenbeck)</td>
			<td style="width:125px;">Codman</td>
			<td style="width:368px;">65-1116</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Metzenbaum scissors</td>
			<td style="width:125px;">Codman</td>
			<td style="width:368px;">36-5023</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Malis dissector, round angled</td>
			<td style="width:125px;">Codman</td>
			<td style="width:368px;">80-1541&#160;</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Penfield dissector, style 1</td>
			<td style="width:125px;">Codman</td>
			<td style="width:368px;">65-1015</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Lempert bone rongeur</td>
			<td style="width:125px;">Codman</td>
			<td style="width:368px;">19-1232</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Malis Irrigation Module</td>
			<td style="width:125px;">Codman</td>
			<td style="width:368px;">Module 1000</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Bovie monopolar electrocautery device</td>
			<td style="width:125px;">Codman</td>
			<td style="width:368px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Insulated blade for electrocautery device</td>
			<td style="width:125px;">Covidien</td>
			<td style="width:368px;">E1455</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Fish-hook retractors</td>
			<td style="width:125px;">Lone Star</td>
			<td style="width:368px;">3350-8G</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Pneumatic drill</td>
			<td style="width:125px;">Medtronic</td>
			<td style="width:368px;">Midas Rex MR7</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Side-cutting drill</td>
			<td style="width:125px;">Medtronic</td>
			<td style="width:368px;">F2/8TA23</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Fluted legend match head tool</td>
			<td style="width:125px;">Medtronic</td>
			<td style="width:368px;">10MH30</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Surgical scalpel No. 10,11,15</td>
			<td style="width:125px;">Bard-Parker</td>
			<td style="width:368px;">0029064 (No.10), 0018291 (No.11), 0018043 (No.15)</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Intra-operative microscope with mouthpiece</td>
			<td style="width:125px;">Leica</td>
			<td style="width:368px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Microscissors</td>
			<td style="width:125px;">V. Mueller</td>
			<td style="width:368px;">NL3785-034(st), NL3785-035(cvd)</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Rhoton dissector, #2</td>
			<td style="width:125px;">V. Mueller</td>
			<td style="width:368px;">NL3785-002&#160;</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Telfa strips</td>
			<td style="width:125px;">American Surgical</td>
			<td style="width:368px;">#80-09 (1/2x3), #80-04 (1/4x3)</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Aneurysm clip</td>
			<td style="width:125px;">Aesculap</td>
			<td style="width:368px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Raney clip applier</td>
			<td style="width:125px;">Aesculap</td>
			<td style="width:368px;">FF012R</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Synthes Matrix metal plating system</td>
			<td style="width:125px;">Synthes</td>
			<td style="width:368px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Braided absorbable surgical sutures (Vicyrl)&#160;</td>
			<td style="width:125px;">Ethicon</td>
			<td style="width:368px;">J790D (3-0), J743D (4-0)</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Braided nylon nonabsorbable surgical sutures (Nurolon) 4-0</td>
			<td style="width:125px;">Ethicon</td>
			<td style="width:368px;">C584D</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Doppler System</td>
			<td style="width:125px;">Mizuho</td>
			<td style="width:368px;">07-150-02</td>
			<td></td>
		</tr>
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minimally invasive thumb-sized pterional craniotomy for surgical clip ligation of unruptured anterior circulation aneurysms

Approcci chirurgici meno invasivi per intracranica aneurisma ritaglio possono ridurre la durata del soggiorno in ospedale, la morbilità chirurgica, costo di trattamento, e migliorare i risultati dei pazienti. Vi presentiamo la nostra esperienza con un approccio mini-invasivo per pterional anteriori circolazione aneurismi eseguite in un importante centro cerebrovascolare terziario e confrontare i risultati con un set di dati abbinato di età compresa tra Nationwide ospedaliera di esempio (NIS). Da agosto 2008 a dicembre 2012, 22 ritagli aneurisma elettive in pazienti ≤55 anni di età sono stati eseguiti dallo stesso duplice fellowship addestrati cerebrovascolari / neurochirurgo endovascolare. Un paziente (4,5%) ha sperimentato transitori complicanze post-operatorie. 18 dei 22 pazienti tornati per il follow-up di immagini e non c&#39;erano recidive attraverso una durata media di 22 mesi. Una ricerca nel database di NIS 2008-2010, anche per i pazienti con età ≤55 anni di età, ha prodotto 1.341 ricoveri per chirurgico clip di legatura di unruptaneurismi cerebrali Ured. Lunghezza ospedaliera di soggiorno e le spese ospedaliere presso il nostro istituto con il mini-invasiva tecnica pterional pollice dimensioni erano circa la metà di quella di NIS (durata del soggiorno: 3,2 contro 5,7 giorni; le spese ospedaliere: $ 52.779 vs $ 101.882). Il mini-invasiva pollice dimensioni craniotomia pterional consente una buona esposizione di piccole e medie imprese sopraclinoidea aneurismi circolazione anteriore unruptured. Il drenaggio del liquido cerebrospinale dai principali cisterne subaracnoidea e costanti tecniche microchirurgiche bimanuali evitare la necessità di avvolgitori che possono causare contusioni, infarti venose localizzate, e post-operatoria edema cerebrale nei siti retrattore. Utilizzando questo insieme di tecniche ha offerto i nostri pazienti con una degenza ospedaliera più breve ad un costo inferiore rispetto alla media nazionale.

Attualmente, presso il nostro istituto oltre 150 aneurismi sono trattati ogni anno. Da agosto 2008 a dicembre 2012, 22 ritagli di aneurisma elettive che utilizzano questa tecnica mini-invasiva craniotomia pterional pollice dimensioni per aneurismi supraclinoidal sul paziente ≤55 anni di età sono stati eseguiti dallo stesso duplice fellowship addestrati cerebrovascolari / neurochirurgo endovascolare che ha sviluppato questa tecnica (EMD ) (Tabella 1). Questo gruppo di età è stata scelta come studi p...

Watch this Scientific Journal Video about Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms at JoVE.com

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

Minimamente invasiva craniotomia pterional pollice dimensioni da aneurisma clipping ha offerto i nostri pazienti con una degenza ospedaliera più breve ad un costo inferiore rispetto alla media nazionale.

Minimamente invasiva Thumb dimensioni Pterional Craniotomy per chirurgica legatura della clip di non rotto Anteriori aneurismi circolazione

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve ...

minimally-invasive-thumb-sized-pterional-craniotomy-for-surgical-clip

Research

JoVE Journal

Medicine

15.4K Views.  Crouse Neuroscience Institute.  Minimamente invasiva craniotomia pterional pollice dimensioni da aneurisma clipping ha offerto i nostri pazienti con una degenza ospedaliera più breve ad un costo inferiore rispetto alla media nazionale. 

Video: Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

Minimally Invasive Establishment of Murine Orthotopic Bladder Xenografts

Orthotopic bladder cancer xenografts are the gold standard to study molecular cellular manipulations and new therapeutic agents&#160;in vivo. Suitable cell lines are inoculated either by intravesical instillation (model of nonmuscle invasive growth) or intramural injection into the bladder wall (model of invasive growth). Both procedures are complex and highly time-consuming. Additionally, the superficial model has its shortcomings due to the lack of cell lines that are tumorigenic following instillation. Intramural injection, on the other hand, is marred by the invasiveness of the procedure and the associated morbidity for the host mouse.
With these shortcomings in mind, we modified previous methods to develop a minimally invasive approach for creating orthotopic bladder cancer xenografts. Using ultrasound guidance we have successfully performed percutaneous inoculation of the bladder cancer cell lines UM-UC1, UM-UC3 and UM-UC13 into 50 athymic nude. We have been able to demonstrate that this approach is time efficient, precise and safe. With this technique, initially a space is created under the bladder mucosa with PBS, and tumor cells are then injected into this space in a second step. Tumor growth is monitored at regular intervals with bioluminescence imaging and ultrasound. The average tumor volumes increased steadily in in all but one of our 50 mice over the study period.
In our institution, this novel approach, which allows bladder cancer xenograft inoculation in a minimally-invasive, rapid and highly precise way, has replaced the traditional model.

The established technique to inoculate primary invasive orthotopic bladder cancer xenografts requires laparotomy and mobilization of the bladder. This procedure inflicts significant morbidity on the mice, is technically challenging and time-consuming. We therefore developed a high-precision, percutaneous approach utilizing ultrasound guidance.

Mini-Invasiva Istituzione di murini ortotopico vescica Xenotrapianti

Orthotopic bladder cancer xenografts are the gold standard to study molecular cellular manipulations and new therapeutic agents&#160;in vivo. Suitable ...

Ricerca

Medicina

Minimal Invasive Surgical Procedure of Inducing Myocardial Infarction in Mice

Myocardial infarction still remains the main cause of death in western countries, despite considerable progress in the stent development area in the last decades. For clarification of the underlying mechanisms and the development of new therapeutic strategies, the availability of valid animal models are mandatory. Since we need new insights into pathomechanisms of cardiovascular diseases under in vivo conditions to combat myocardial infarction, the validity of the animal model is a crucial aspect. However, protection of animals are highly relevant in this context. Therefore, we establish a minimally invasive and simple model of myocardial infarction in mice, which assures a high reproducibility and survival rate of animals. Thus, this models fulfils the requirements of the 3R principle (Replacement, Refinement and Reduction) for animal experiments and assure the scientific information needed for further developing of therapeutical strategies for cardiovascular diseases.

A highly reproducible model for myocardial infarction in mice with minimal invasive manipulations is described. The model can be easily performed, resulting in a high reproducibility and survival rate. Thus, the described model will reduce the number of required animals as requested by the 3R principle (Replacement, Refinement and Reduction).

Minimal procedura chirurgica invasiva di indurre infarto miocardico nei topi

Myocardial infarction still remains the main cause of death in western countries, despite considerable progress in the stent development area in the last ...

Encapsulation Thermogenic Preadipocytes for Transplantation into Adipose Tissue Depots

Cell encapsulation was developed to entrap viable cells within semi-permeable membranes. The engrafted encapsulated cells can exchange low molecular weight metabolites in tissues of the treated host to achieve long-term survival. The semipermeable membrane allows engrafted encapsulated cells to avoid rejection by the immune system. The encapsulation procedure was designed to enable a controlled release of bioactive compounds, such as insulin, other hormones, and cytokines. Here we describe a method for encapsulation of catabolic cells, which consume lipids for heat production and energy dissipation (thermogenesis) in the intra-abdominal adipose tissue of obese mice. Encapsulation of thermogenic catabolic cells may be potentially applicable to the prevention and treatment of obesity and type 2 diabetes. Another potential application of catabolic cells may include detoxification from alcohols or other toxic metabolites and environmental pollutants.

Here, we present a protocol for encapsulation of catabolic cells, which consume lipids for heat production in intra-abdominal adipose tissue and increase energy dissipation in obese mice.

Incapsulamento termogenico preadipocytes al trapianto nel tessuto adiposo Depositi tessuti

Cell encapsulation was developed to entrap viable cells within semi-permeable membranes. The engrafted encapsulated cells can exchange low molecular ...

Minimally Invasive Transverse Aortic Constriction in Mice

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard open-chest transverse aortic constriction (TAC). Although transverse aortic constriction is a highly functional method for the induction of high pressure in the left ventricle, it is a more difficult and lengthy procedure due to its use of artificial ventilation with tracheal intubation. TAC is oftentimes also less survivable, as the newer method, MTAC, neither requires the cutting of the ribs and intercostal muscles nor tracheal intubation with a ventilation setup. In MTAC, as opposed to a thoracotomy to access to the chest cavity, the aortic arch is reached through a midline incision in the anterior neck. The thyroid is pulled back to reveal the sternal notch. The sternum is subsequently cut down to the second rib level, and the aortic arch is reached simply by separating the connective tissues and thymus. From there, a suture can be wrapped around the arch and tied with a spacer, and then the sternal cut and skin can be closed. MTAC is a much faster and less invasive way to induce left ventricular hypertension and enables the possibility for high-throughput studies. The success of the constriction can be verified using high-frequency trans-thoracic echocardiography, particularly color Doppler and pulsed-wave Doppler, to determine the flow velocities of the aortic arch and left and right carotid arteries, the dimension of the blood vessels, and the left ventricular function and morphology. A successful constriction will also trigger significant histopathological changes, such as cardiac muscle cell hypertrophy with interstitial and perivascular fibrosis. Here, the procedure of MTAC is described, demonstrating how the resulting flow changes in the carotid arteries can be examined with echocardiography, gross morphology, and histopathological changes in the heart.

Minimally invasive transverse aortic constriction (MTAC) conserves the essentials of regular transverse aortic constriction (TAC) while eliminating the use of a ventilator with tracheal intubation. It proves to be a highly desirable method for high-throughput studies on left ventricular overload, particularly in translational studies.

Minimamente invasiva trasversale aortica costrizione nei topi

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard ...

An Anatomical Study of Nerves at Risk During Minimally Invasive Hallux Valgus Surgery

The growing popularity of minimally invasive surgical (MIS) procedures makes it necessary that new anatomical references arise, to aid in tridimensional orientation and localization of structures that are not directly visible to the surgeon. This is especially critical for structures at risk like nerves or blood vessels. Optimization of the handling of cadaveric material and the combination of multiple techniques compensate for the limited availability of adequate specimens. The described protocol combines anatomical plane-by-plane dissection and sectional anatomy of fresh-frozen specimens to help localize relevant structures, such as nerves, arteries, veins and to correctly position the portals during MIS procedures. Depiction of these structures in anatomy textbooks can differ from what is encountered in the surgical field; and for this reason, new anatomical studies with a surgical orientation are needed. However, this is a complex, time-consuming technique requiring specific training. The anatomical references described with the so-called 'clock method' provide the surgeon with an easy and reproducible system to locate the path of the nerves at risk in Hallux Valgus MIS procedures. This model can be extrapolated to many other minimally invasive surgical procedures.

Minimally invasive surgical (MIS) procedures rely on anatomical references to localize structures not directly visible to the surgeon. This manuscript describes a combined method of plane-by-plane dissection and sectional anatomy of fresh-frozen specimens to locate the structures at risk during MIS procedures.

Uno studio anatomico dei nervi a rischio durante mininvasiva alluce valgo chirurgia

The growing popularity of minimally invasive surgical (MIS) procedures makes it necessary that new anatomical references arise, to aid in tridimensional ...

Electromagnetic Navigation Transthoracic Nodule Localization for Minimally Invasive Thoracic Surgery

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or excision. Many of these nodules are identified and excised via minimally invasive thoracic surgery; however, subcentimeter and subsolid nodules are frequently difficult to identify intra-operatively. This can be mitigated by the use of electromagnetic transthoracic needle localization. This protocol delineates the step-by-step process of electromagnetic localization from the pre-operative period to the postoperative period and is an adaptation of the electromagnetically guided percutaneous biopsy previously described by Arias et al. Pre-operative steps include obtaining a same day CT followed by the generation of a three-dimensional virtual map of the lung. From this map, the target lesion(s) and an entry site are chosen. In the operating room, the virtual reconstruction of the lung is then calibrated with the patient and the electromagnetic navigation platform. The patient is then sedated, intubated, and placed in the lateral decubitus position. Using a sterile technique and visualization from multiple views, the needle is inserted into the chest wall at the prechosen skin entry site and driven down to the target lesion. Dye is then injected into the lesion and, then, continuously during needle withdrawal, creating a tract for visualization intra-operatively. This method has many potential benefits when compared to the CT-guided localization, including a decreased radiation exposure and decreased time between the dye injection and the surgery. Dye diffusion from the pathway occurs over time, thereby limiting intra-operative nodule identification. By decreasing the time to surgery, there is a decrease in wait time for the patient, and less time for dye diffusion to occur, resulting in an improvement in nodule localization. When compared to electromagnetic bronchoscopy, airway architecture is no longer a limitation as the target nodule is accessed via a transparenchymal approach. Details of this procedure are described in a step-by-step fashion.

Presented here is a protocol for lung nodule localization using dye marking via electromagnetically navigated transthoracic needle access. The technique described here can be accomplished in the peri-operative period to optimize nodule localization and to successful resection when performing minimally invasive thoracic surgery.

Localizzazione di noduli transtoracici di navigazione elettromagnetica per chirurgia toracica minimamente invasiva

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or ...

A Pre-clinical Rat Model for the Study of Ischemia-reperfusion Injury in Reconstructive Microsurgery

Ischemia-reperfusion injury is the main cause of flap failure in reconstructive microsurgery. The rat is the preferred preclinical animal model in many areas of biomedical research due to its cost-effectiveness and its translation to humans. This protocol describes a method to create a preclinical free skin flap model in rats with ischemia-reperfusion injury. The described 3 cm x 6 cm rat free skin flap model is easily obtained after the placement of several vascular ligatures and the section of the vascular pedicle. Then, 8 h after the ischemic insult and completion of the microsurgical anastomosis, the free skin flap develops the tissue damage. These ischemia-reperfusion injury-related damages can be studied in this model, making it a suitable model for evaluating therapeutic agents to address this pathophysiological process. Furthermore, two main monitoring techniques are described in the protocol for the assessment of this animal model: transit-time ultrasound technology and laser speckle contrast analysis.

Here, we describe a pre-clinical animal model for studying the pathophysiology of ischemia-reperfusion injury in reconstructive microsurgery. This free skin flap model based on the superficial caudal epigastric vessels in the rat may also allow for the evaluation of different therapies and compounds to counteract ischemia-reperfusion injury-related damage.

Un modello di ratto preclinico per lo studio delle lesioni ischemia-reperfusione in microchirurgia ricostruttiva

Ischemia-reperfusion injury is the main cause of flap failure in reconstructive microsurgery. The rat is the preferred preclinical animal model in many ...

Evaluation of Capnography Sampling Line Compatibility and Accuracy when Used with a Portable Capnography Monitor

Capnography is commonly used to monitor patient&#8217;s ventilatory status. While sidestream capnography has been shown to provide a reliable assessment of end-tidal CO2 (ETCO2), its accuracy is commonly validated using commercial kits composed of a capnography monitor and its matching disposable nasal cannula sampling lines. The purpose of this study was to assess the compatibility and accuracy of cross-paired capnography sampling lines with a single portable bedside capnography monitor. A series of 4 bench tests were performed to evaluate the tensile strength, rise time, ETCO2 accuracy as a function of respiratory rate, and ETCO2 accuracy in the presence of supplemental O2. Each bench test was performed using specialized, validated equipment to allow for a full evaluation of sampling line performance. The 4 bench tests successfully differentiated between sampling lines from different commercial sources and suggested that due to increased rise time and decreased ETCO2 accuracy, not all nasal cannula sampling lines provide reliable clinical data when cross-paired with a commercial capnography monitor. Care should be taken to ensure that any cross-pairing of capnography monitors and disposable sampling lines is fully validated for use across respiratory rates and supplemental O2 flow rates commonly encountered in clinical settings.

The goal of this study was to evaluate the accuracy of capnography sampling lines used in conjunction with a portable bedside capnography monitor. Sampling lines from 7 manufacturers were evaluated for tensile strength, rise time, and ETCO2 accuracy as a function of respiratory rate or supplemental oxygen flow rate.

Valutazione della compatibilità e dell'accuratezza della linea di campionamento capnografica se utilizzata con un monitor capnografico portatile

Capnography is commonly used to monitor patient&#8217;s ventilatory status. While sidestream capnography has been shown to provide a reliable assessment ...

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts to spare normal ovarian cortex. Optimization of tubal anatomy is another frequent consideration. Fertility-sparing laparoscopic techniques at the time of cystectomy for ovarian endometrioma seek to limit iatrogenic surgical damage to the ovarian cortex and strategically assess and respond to genital tract patency. Surgical candidates frequently desire relief from endometriosis-associated pain while also seeking to optimize spontaneous or assisted conception rates. Operative benefits include potential for surgical and histopathologic diagnosis of endometriosis, evaluation of genital tract patency, and treatment of visualized lesions. Resection of ovarian endometrioma nonetheless poses significant risks, including surgical injury, blood loss, post-surgical decline in ovarian reserve and post-operative inflammation with adhesion formation, both of which may impair folliculogenesis.
We present the case of a 32-year-old woman with known endometriosis and continued pain refractory to medical management who opted for surgical management of her disease tailored toward optimizing her chances at future conception. Using this case as an example, we describe techniques and considerations for diagnostic laparoscopy, adhesiolysis, ovarian cystectomy, chromopertubation, and salpingectomy with a focus on maintaining a fertility-preserving approach.

This protocol presents techniques to laparoscopically excise ovarian endometrioma, to perform adhesiolysis with sparing electrosurgical application, and to employ intraoperative chromopertubation to assess for genital tract patency. This systematic approach will facilitate optimal endometriosis management, guide concomitant adnexal surgeries, and enhance post-surgical fertility outcomes.

Tecniche chirurgiche per ottimizzare la riserva ovarica durante la cistectomia laparoscopica per l'endometrioma ovarico

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...

Clinical Application of Microscope-Assisted Minimally Invasive Anterior Lumbar Interbody Fusion

This study aims to investigate the technical aspects of microscope-assisted anterior decompression fusion and to introduce a spreader system suitable for minimally invasive anterior lumbar interbody fusion (Mini-ALIF). This article is a technical description of anterior lumbar spine surgery under a microscope. We retrospectively collected information on patients who underwent microscope-assisted Mini-ALIF surgery at our hospital between July 2020 and August 2022. A repeated-measures ANOVA was used to compare imaging indicators between periods. Forty-two patients were included in the study. The mean volume of intraoperative bleeding was 180 mL, and the mean operative time was 143 min. The mean follow-up time was 18 months. Apart from one case of peritoneal rupture, no other serious complications occurred. The postoperative foramen and disc height were both higher on average than before surgery. The spreader-assisted micro-Mini-ALIF is simple and easy to use. It can provide good intraoperative disc exposure, good discrimination of important structures, adequate spreading of the intervertebral space, and the restoration of the necessary intervertebral height, which is very helpful for less experienced surgeons.

The technique described in this article is well-suited to the Mini-ALIF procedure, allows for excellent exposure and decompression, and facilitates microscope-assisted manipulation.

Applicazione clinica della fusione intersomatica lombare anteriore minimamente invasiva assistita da microscopio

This study aims to investigate the technical aspects of microscope-assisted anterior decompression fusion and to introduce a spreader system suitable for ...