The authors have no acknowledgments.

注：前にこの手順を実行するには、すべての必要な機関の承認と患者の同意を得ます。 1.手術手技<ol><li>全身麻酔で患者を誘導します。 </li><li>血圧モニタリング用ラジアル動脈ラインを配置します。 </li><li>手術室のテーブルの上に仰臥位で患者を配置します。 </li><li>ヘッドはpterional開頭ための標準的な技術を用いて、メイフィールドヘッドホルダーにクランプされた後、ヘッドが60度に配置された前 - 交通動脈瘤を除いて、天井に向かって同側にヘッドを30°-45°を配置大脳縦裂の両端のより良い視覚化のために可能にします。 </li><li>首の正中線を配置し、脳浮腫を予防し、その後、最高点、これを同側頬骨を配置するために頭を拡張するために頚静脈還流を最大化するために前方に翻訳前頭葉緩和とエルが可能になります開創器を使用することなく、解剖時の軌道屋根からevation。 </li><li>標準pterional頭皮切開の準備のために髪をクリップ。ヘアラインの後ろに2インチのストリップに約1を使用します。 </li><li>無菌皮膚をプリパレーションとケアの標準に応じて手術領域をドレープ。 </li><li>約3mm前方耳珠および頬骨の優れたエッジのレベルでそれを終了耳珠に向かって後方と下方に緩やかな曲線とヘアラインの後ろの頭皮の正中線から延びるpterionalアプローチのための標準的な曲線状の頭皮の切開を行います。優れた時間的な線の上と頭筋のレベルでの筋膜に頭蓋骨までこの切開を行います。 </li><li>バイポーラデバイスで頭皮止血のための電気焼灼を使用してください。 </li><li>ボビーモノポーラ電気メス装置を用いて頭蓋骨に頭筋を削減。 </li><li>に取り付けられた頭筋を維持する筋肉皮弁を上げます今の頭皮の下面。フィッシュフックは頭筋がモノポーラ電気メスと骨膜エレベーターの組み合わせを使用して、頭蓋骨から上昇した後、フラップを裏返すために使用されます。 </li><li>顔面神経の損傷を避けるために、頭皮と筋膜とsubfacsial脂肪パッドを維持、Metzenbaumはさみを使用して、筋肉皮弁の下面から無血管平面内で逆筋膜下切開を行います。 </li><li> 「スター」fishhooksでpterional領域を露出するために後方および下方に頭筋を固定します。 </li><li>湿ったガーゼで湿った筋肉皮弁のすべてのコンポーネントを保管してください。 </li><li>サイドカットドリルのフットプレートが、この穴に挿入した後、サイドカットドリルを使用することができるように、2ミリメートルの切断バリでの計画開頭手術の後、大部分の側面に単一の時間的、5mmのバリ穴を開け親指サイズ（約3×4センチ）腎臓形開頭CENTEを除去するためのフットプレート付きプテリオン周りに前方に赤。 </li><li>第1ペンフィールドを使用して、プテリオンのすべての側面に硬膜を分離し、静かに離れて硬膜を貫通し、皮質の損傷を引き起こす危険性を最小限にするために掘削された骨表面からの硬膜を撤回アシスタントを持っています。 </li><li>ドリルでプテリオンを削除します。前方に、軌道屋根の優れたおよび横方向の側面が滑らかであり、subfrontal露出を最大化するために、軌道に入ることなく、骨の外側皮質テーブルまで平坦化されるまで、内側、上眼窩裂の硬膜までドリルを露出させ、ドリルビットまたは手持ちLempert骨切断装置のいずれかを使用して、内側の暴露を妨げる骨の任意の小片を削除しています。すべての軟部組織および骨表面の優れた止血が硬膜を開く前に、必要に応じてelectrocaurteryと骨ワックスを使用して、脳の解剖や動脈瘤の露光中に硬膜内空間に滴下血液を回避するために得られていることを確認してください。 </li><li>静かに硬膜を上げ、硬膜を貫通した後、プテリオンの塩基との硬膜中の「C字形」の開口部を作成するために硬膜はさみを使用する11番メスを使用しています。その近位シルビウス裂とsubfrontal地域の他の方法で曖昧な視覚化あろう冗長硬膜チラシがなくても、軌道の外側皮質骨に対して平ら硬膜を固定します。これは、頭皮に硬膜をタックSurgilons 4-0縫合糸を用いて行うことができます。 </li></ol> 2.脳リラクゼーション<ol><li>麻酔は、血圧が利尿を許容することに同意した場合、脳をリラックスして骨弁除去の時にマンニトール25〜50 gを得。 注：これは、利尿が発生するための時間を可能にし、最終的には、解剖時に重力に依存する脳の収縮を最大限にするために、脳をリラックスします。 </li><li>わずかhypercapneaを達成するために30〜35ミリメートルHgの間の呼吸終期のpCO 2を保管してください。注：これは、安全に、脳のリラックスとMAを可能にします解剖時に重力依存脳の収縮をximize。 </li><li>希望の脳の緩和が達成されるまでinteroptic、頸動脈光学、および頸動脈 - 動眼水槽にくも膜水槽を開き、辛抱強く吸引CSFによって脳の緩和を促進するために、脳脊髄液（CSF）を避難させます。 注：これは典型的には約1分かかります。何腰椎ドレインは、この技術では必要ありません、それは劇的に外科的回廊を開きます。 </li></ol> 3.シルビウス裂解剖<ol><li>無菌技術を使用して、フィールドに、マウスピースを術中顕微鏡を持参してください。また、両手器用さを最大化し、外科医の腕や手の疲労を防止するために、無菌フィールドに腕をサポートした手術用椅子を持参。 注：マウスピースは同時に眼の作品を見ながら、外科医は口で顕微鏡を移動させることができるように立体裁断前に調整する必要があります。 </li><li>解剖を行います。 注：について動脈瘤を伝える前方には、何のシルビウス裂郭清は必要ありませんし、最小限の（唯一の極端な場合2〜3ミリメートル、これはまれである）のみsubfrontal解剖を使用して必要とされていない状回の直筋切除することです。 （後部交通動脈を含む）他のすべてのsupraclinoid前方循環の動脈瘤の場所はsupraclinoid内頸動脈、その枝（後部が通信および脈絡膜動脈を前方）、内頸動脈の末端、A1とM1を露出するために、&lt;1cmの近位Sylivan割れ目郭清を必要とします起源、およびそれぞれの分岐に対して遠位、近位A2とM2セグメント。総シルビウス裂の露出はダイムサイズ（1センチ×1センチメートル）と全く脳のリトラクターが報告された症例のいずれにも使用されなかったありました。重力に依存する脳の緩和は、前述の領域に外科手術用クリップの連結を実行するために必要な軟組織構造と血管系の優れた露光のために十分でした。 </li><li>両手manipulaを使用外科的microinstrumentsとンを静かにこの露光により、必要に応じて機器のハンドルまたは吸引装置のエッジに脇脳組織を保持し、くも膜廊下を開きます。 注：筆頭著者の好みは、非利き手で、鋭い解剖のための鈍的切開またはmicroscissorsため利き手バイポーラbayonettesに4 - フランスFukishima吸引チップを使用することです。湿らTelfaストリップは皮質損傷を防ぐために、操作部位で脳の表面上に配置されます。 Cottonoidsは、多くの場合、脳の表面に付着し、解剖の進行に伴い、軽度の皮質の損傷を引き起こすことなく、より深く、容易に進めることができません。 </li><li>範囲を調整し、フィールドに両手を維持しながら、必要に応じて長さを集中し、頻繁に手術用顕微鏡にマウスピースを使用してください。 </li><li>外科的回廊とCの自由な可視化を維持するために、非利き手で最も頻繁に吸引を使用して、標準的な方法で動脈瘤を確保SF。 </li><li>クリップを配置した後、流れを確認し、慎重に動脈瘤のネックと親血管を調べるために、フローの停止だけでなく、流入流出血管を確認するために、動脈瘤ドームの術中ドップラーを行います。我々は、動脈瘤および流入、流出、または動脈瘤の首を完全に可視化することができないか、術中ドップラーとの懸念があるそれらのクリップされた動脈瘤を通信するための前方術中デジタルサブトラクション血管造影（DSA）を確保します。多数の動脈瘤クリップを動脈瘤の頸部を再構築するために使用される場合、クリップは可視化を妨害することができるので、術中DSAは、インドシアニングリーン（ICG）血管造影法よりも好ましいです。注：動脈瘤がしっかり切り取られた後、顕微鏡視野から除去され、生理食塩水で灌注脳が閉鎖後pneumocephalusの量を最小限にします。 </li><li>ドップラーで動脈瘤の閉塞のためのクリップを検査した後、動脈瘤のドームは、穿孔ウィットあります<html> haの22 G針が静脈内チューブ、10 mlシリンジおよび動脈瘤の閉塞を確認するために吸引し、手動で吸引に添付します。 </li><li> 4-0 surgilonでネイティブ硬膜をReapproximateと水密閉鎖を適切に得ることができない場合は、合成硬膜代替でカバー。 </li><li>ケアの標準あたりの金属メッキシステムで骨プレートを固定します。 </li><li>組織が治癒した後に、化粧品として喜ばないであろう2の間にスペースを回避するために、ネイティブの骨に対する骨フラップフラッシュの正面端を固定します。 </li><li>中断2-0ビクリル縫合糸で頭筋の筋膜をReapproximate。優れた時間的なラインにreapproximateする前頭金属板に2-0ビクリルステッチと頭筋の上部を固定します。 </li><li> 3-0ビクリル縫合糸を使用してガレアをReapproximateやステープル、ナイロン、またはプロレンのいずれかを使用して標準的な方法で頭皮を閉じます。外科医の好みごとに滅菌包帯のドレス。 </li></ol>_title &quot;&gt; 4。後処理のケア<ol><li>治療後の集中治療室に患者を認めるとすぐに鎮静または全身麻酔は、典型的には、抜管の6時間以内に、これを行うには十分にオフに着用しているように看護スタッフと動員。 </li><li>看護スタッフによる任意の懸念があった場合に自宅に安全に排出するために患者を評価するために、術後初日を開始するために、物理的および作業療法を注文。 </li><li>唯一の経口薬、独立して、排尿独立ambulating、および経口食物摂取を許容して制御痛み：基準が満たされている患者を放電します。 </li></ol>

<ol>
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T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Current+management+of+middle+cerebral+artery+aneurysms:+surgical+results+with+a+&#8220;clip+first&#8221;+policy.">Current management of middle cerebral artery aneurysms: surgical results with a &#8220;clip first&#8221; policy.</a> Neurosurgery. 72 (3), 415-427 (2013).</li><li>Van Lindert, E., Perneczky, A., Fries, G., Pierangeli, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+supraorbital+keyhole+approach+to+supratentorial+aneurysms:+concept+and+technique.">The supraorbital keyhole approach to supratentorial aneurysms: concept and technique.</a> Surgical neurology. 49 (5), 489-490 (1998).</li><li>Dott, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intracranial+aneurysms:+cerebral+arteriography:surgical+treatment.">Intracranial aneurysms: cerebral arteriography:surgical treatment.</a> Edinb Med J. 40, 219-234 (1933).</li><li>Dandy, W. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aneurysm+of+the+anterior+cerebral+artery.">Aneurysm of the anterior cerebral artery.</a> Journal of the American Medical Association. 119 (16), 1253-1254 (1942).</li><li>Yasargil, M., Fox, J., Ray, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+operative+approach+to+aneurysms+of+the+anterior+communicating+artery.">The operative approach to aneurysms of the anterior communicating artery.</a> Advances and Technical Standards in Neurosurgery. 2, 113-170 (1975).</li><li>Al-Mefty, O., Fox, J. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Superolateral+orbital+exposure+and+reconstruction.">Superolateral orbital exposure and reconstruction.</a> Surgical neurology. 23 (6), 609-613 (1985).</li><li>Heros, R. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+supraorbital+&#8220;keyhole&#8221;+approach.">The supraorbital &#8220;keyhole&#8221; approach.</a> Journal of neurosurgery. 114 (3), 850-851 (2011).</li></ol>

エリックDeshaiesのはMicroVention、コヴィディエン神経血管、インテグラライフサイエンス社の医師のコンサルタントです。

血管内技術は、より安全でより効果的になるように、この役割は過去数年間で減少したが、頭蓋内動脈瘤の外科用クリップの連結は、動脈瘤の特定の種類の治療に関連する重要なオプションのまま。血管内治療は、脳動脈瘤の手術を超えている、まだ血管内治療後の高い再発率は、失敗した血管内治療から動脈瘤の再発後の外科的治療のための臨時の必要性は、特定の形態は、ステント留置?...

外科用クリップの連結は、脳動脈瘤の治療の主力であったが、最近、低侵襲性血管内の技術によって主に取って代わられている。 未破裂脳動脈瘤の国際研究（ISUIA-1とISUIA-2）、および国際含め1,2臨床試験くも膜下動脈瘤トライアル（ISAT）は 、外科手術用クリップライゲーションに比べて血管内治療と、より低い罹患率および死亡率、入院期間の長さを短くし、より低い全体の費用を示した。3 - 5しかし、血管内治療後の高い動脈瘤の再発率がにつながっています患者への累積リスクの検査は、外科手術用クリップのライゲーションに比べて。3,4外科的治療は、特に血管内の手段で治療が困難であってもよい形態を持って前方循環動脈瘤のために、動脈瘤の治療のための重要な様式のままです。 6 - 8これらの侵襲性の低い外科的アプローチは、病院の長さを減少させることができます滞在、外科的罹患率、治療費、および患者の予後を改善する。9 ここでは、主要な第三脳血管センターで行わ前方循環動脈瘤のためpterionalアプローチを使用して未破裂脳動脈瘤の外科手術用クリップの結紮に低侵襲性アプローチの経験を提示し、加齢に伴って結果を比較全国入院患者のサンプルからのデータセットを一致（NIS ）。外科的技術が検討されます、患者の準備、脳緩和、シルビウス裂の解剖、および閉鎖を含みます。術後ケアおよび排出要件も概説します。

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	<tbody>
		<tr height="21">
			<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>
	</tbody>
</table>

minimally invasive thumb-sized pterional craniotomy for surgical clip ligation of unruptured anterior circulation aneurysms

頭蓋内動脈瘤クリッピングのための低侵襲性の外科的アプローチは、入院、手術用罹患率、治療費の長さを低減し、患者の転帰を改善することができます。我々は前方循環動脈瘤の主要な第三脳血管センターで行い、全国入院患者のサンプル（NIS）から経年マッチしたデータセットと結果を比較するための低侵襲性pterionalアプローチで我々の経験を提示します。 2008年8月から2012年12月に、患者の年齢の≤55年の22科目動脈瘤のクリッピングは、同じデュアル交わりのトレーニングを受けた脳血管/血管内神経外科医によって行われました。一人の患者（4.5％）は一過性術後合併症を経験しました。 22人の患者の18は、フォローアップのイメージングのために戻され、22ヶ月の平均期間を通る再発はなかったです。 2008年から2010年のNISデータベース内の検索は、また年齢の≤55歳の患者のために、unruptの外科用クリップの連結のために1341の入院をもたらしましたured脳動脈瘤。低侵襲性の親指サイズのpterional技術を用いて、当院での滞在と病院費用の入院の長されたほぼ半分にNISの（滞在の長さ：3.2 5.7対日、入院費：52779ドル対101882ドル）。低侵襲性の親指サイズのpterional開頭術は未破裂中小supraclinoid前方循環動脈瘤の良好な露出を可能にします。キーくも膜下水槽と一定両手顕微技術から脳脊髄液ドレナージは、開創サイトで挫傷、ローカライズされた静脈梗塞、および術後の脳浮腫を引き起こす可能性がリトラクターの必要性を回避します。技術のセットを利用することで、全国平均に比べて低いコストで、より短い入院で私たちの患者を与えています。

現在、私たちの施設で150人以上の動脈瘤は、毎年扱われます。 2008年8月から2012年12月に、年齢の患者の≤55年にsupraclinoidal動脈瘤のためにこの最小侵襲性の親指サイズのpterional開頭技術を用いて22科目動脈瘤のクリッピングは、この技術を開発し、同じデュアル交わりのトレーニングを受けた脳血管/血管内神経外科医（EMDによって行われました）（ 表1）。以前の試験は血管内治?...

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

動脈瘤クリッピングのための低侵襲性の親指サイズのpterional開頭術は、全国平均に比べて低いコストで、より短い入院で私たちの患者を与えています。

未破裂前方循環動脈瘤の外科手術用クリップの連結のための低侵襲親指サイズのPterional開頭術

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 ビュー.  Crouse Neuroscience Institute. 動脈瘤クリッピングのための低侵襲性の親指サイズのpterional開頭術は、全国平均に比べて低いコストで、より短い入院で私たちの患者を与えています。 

ビデオ: 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.

マウス同所性膀胱異種移植片の最小侵襲性の確立

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

医学

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).

マウスにおける心筋梗塞を誘発する低侵襲手術手順

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.

移植のためのカプセル化サーモ前脂肪細胞の脂肪組織デポへ

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

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.

低侵襲外反母趾外反母趾手術中リスクで神経の解剖学的研究

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

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.

2 回線切除と内視鏡 Septoplasty: 隔偏差の低侵襲手術

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

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.

低侵襲胸部手術のための電磁航法経胸結節局在

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.

再建微小外科における虚血再灌流損傷の研究のための前臨床ラットモデル

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.

ポータブル・キャプノグラフィー・モニターで使用した場合の、キャポグラフィー・サンプリング・ラインの適合性と精度の評価

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.

卵巣子宮内膜症の腹腔鏡下膀胱切除術中に卵巣予備を最適化する外科技術

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.

顕微鏡支援低侵襲前腰椎椎体間固定術の臨床応用

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