内分泌学ユニットと彼らの助けのための手術室チームに感謝し、これらの患者の管理のサポートしたいと思います。この作業も利害の対立のための任意の資金源はありません。

ここで示すプロトコル ローザンヌ大学病院の人間研究倫理委員会のガイドラインに従います。
注: ここで説明した手順は、下垂体腺腫に対して古典的なアプローチに焦点を当てた。
1. 術前のプロトコル
<ol><li>体系的に内分泌学的および眼科の評価と術前顎顔面の CT スキャンや MRI を実行します。</li>
</ol>2. 位置決めと麻酔
<ol><li>全身麻酔を誘導し、気管挿管を実行します。</li>
	<li>一般的な麻酔・気管挿管後、仰臥位で患者を置きます。</li>
	<li>ヘッド ホルダーの頭の位置、頭の周り磁気神経ナビゲーションのためのバンドを固定します。</li>
	<li>20 ° 静脈の排水を改善し、対側頭部傾斜を実行中頭、神経外科医に向けて約 30 ° を少し回転するテーブルの頭を上げます。 注: 延長の程度や患者さんの頭の屈曲は依存対象手術: 少し (15-20 °)17セッラ トルコ アプローチは、前頭蓋底手術の中立を曲げて、下斜病変に対する 45 ° までの屈曲します。</li>
	<li>アルコール フリーの chlorexidine ソリューションで顔を殺菌します。キシロカインを希釈を含浸させた綿パッドと上がり前にきれいに消毒液鼻窩アドレナリン (1:1, 000, 000) の 1%。 注意: 局所麻酔と血管収縮に加え内視鏡的アプローチを有効に甲の中間の側面撤回を提供もこのウィッキングします。調節可能な保持アーム (特に中トルコ鞍相) 手術の特定のフェーズで使用される手術台に固定できます。ただし、いくつかの外科内視鏡外科分野のよりダイナミックなビューを修正することを好みます。これらのケースで彼らはどちらか両手で作業できるようにアシスタントに内視鏡を残すまたは彼らは彼ら自身の内視鏡を保持します。</li>
	<li>きれいに右腹部の象限と脂肪移植の術中の脳脊髄液 (CSF) 瘻の場合収穫の可能なサイトを表すので右ペリ臍地域の小さなウィンドウを残しながら腹部をおいましょう。 注: 麻酔科医に深い morphinic の鎮痛のための特別な注意を取る、プロシージャ、鼻粘膜の豊富な神経支配による出血を抑えるための鼻のフェーズでの平均血圧を制御します。</li>
</ol>3. 手術
注: 主に使用される鼻窩の側の選択は鼻によって決まりますが解剖学(隔偏差、メガ鼻甲介、ポリープ、以前の手術等)、水平 (横方向の拡張に対側アプローチ) 腫瘍の拡張機能、と腫瘍 (大きな腫瘍の binostril アプローチ) のサイズ。下垂体腺腫の大半は、一方的なアプローチで腫瘍とその拡張機能の良い露出を得るために十分です。
<ol><li>
鼻相
	<ol>
<li>内側下を識別し、甲を横方向に中央右の鼻および鼻の隔壁に、0 ° 短い硬性内視鏡 (長さ 18 cm 直径 4 mm) をご紹介します。隔偏差、異常や術前画像で検出された特定の腫瘍拡張の甲介の場合に、左の鼻孔アプローチを好みます。</li>
		<li>鼻腔内に入る他の機器に十分なスペースを提供するために鼻孔の優劣の面でいずれかの内視鏡の管を配置します。</li>
		<li>同側の蝶形骨口への幅広いアクセスを達成するために鈍いヘラで中央と優れた甲撤回横方向に優しく。取り消し操作中に骨折を避けるためにヘラで彼らの全体の長さを介して優れたおよび中間甲をサポートする注意してください。</li>
	</ol>
</li>
	<li>
蝶相
	<ol>
<li>Nasoseptal 動脈からの出血を避けるためにモノポーラ蝶形骨 osteum と、choana の間で約 10-15 mm の垂直直線的に鼻粘膜を凝固 (の上縁で実行されている蝶口蓋動脈の枝、choana)。</li>
		<li>開いている、鼻中に対応する、骨の接触まで垂直方向に無愛想なヘラを使って凝固鼻粘膜が感じられます。</li>
		<li>鼻軟骨中隔との接合部まで前方鼻中をに従って、粘膜面のままに世話をしながら反対側の蝶形骨口を公開する左側にそれをプッシュします。</li>
		<li>公開し、蝶形骨吻骨鉗子と 1 つの口が切除を拡張する rongeur を削除します。蝶形骨洞のこの開口部には、exocranial 頭蓋骨底面の露出ことができます。</li>
		<li>トルコ鞍の開口部に干渉する場合、蝶形骨の粘膜を注意深く取り外します。</li>
		<li>トルコ鞍の広い露出を提供する rongeurs と蝶形骨鼻中隔 (多くの場合複数の隔壁が存在) を削除します。</li>
		<li>術前の磁気共鳴画像 (MRI) および/または CT スキャン数とこれら septations; の方向を慎重に分析します。これは、関連する解剖学を認識することが重要です。これら septations のいくつかは頸動脈のプロミネンスに直接挿入ことがあります、したがって、(図 1図 2図 3図 4) 手術のこの段階では重要なランドマークとして識別される必要があります。 注: CT スキャンは 64 検出器行ベースのシステムを使用して実行されました。三次元再構成は、薄いスライス データの一連を使用して処理されました。MRI プロトコルは、3 テスラの撮像素子で実行されました。プロトコルに矢状 T1 強調グラディエント エコー シーケンス (MPRAGE) 造影とが含まれている、160 連続したスライス、1 mm 等方性ボクセル繰り返し時間 (TR) 2,300 ms エコー時間 (TE) 2.98 ms、視野のセグメンテーションのための基礎として 256 mm3 D の T2 のシーケンス。</li>
	</ol>
</li>
	<li>
トルコ鞍の相
	<ol>
<li>前方で正中線で斜凹部に優れたトルコ鞍を識別します。 注: 大規模なおよび/または侵襲的下垂体腫瘍、トルコ鞍底あります非常に薄いまたは完全に侵食されました。トルコ鞍の底は鞍結節部に対応するうつ病を前方と横方向に頸動脈プロミネンスによって制限 (C3 C5 セグメント)、optico 頸動脈凹部。</li>
		<li>頸動脈のプロミネンスの同定は横方向に, 5 mm 大きな骨カッターを調整したり、手術の終わりに位置を変更可能性があります骨フラップのヒンジでトルコ鞍底を開いた後。この時点で、拡大トルコ鞍骨切り横方向または前方骨 rongeurs と対象手術によると。 注: いくつかの外科医は、ダイヤモンド ドリルでトルコ鞍の底を開いて、小さな骨 rongeur と第二を開いて骨を拡大するを好むことがあります。この手順は、高速化できるし、拡張アプローチで一般的に使用されます。プロシージャの最後に骨を移動ことはできませんし、頚動脈への傷害を避けるために正中線でドリルには注意が必要があります。ニューロナビゲーションを使用して、手順をご案内します。</li>
		<li>細石刃を macroadenoma の正中線、または横偏側 microadenomas のケースとトルコ鞍の硬膜を開きます。に応じて、この硬膜開く横方向に拡張し、頚動脈への損傷を避けるために世話をします。</li>
		<li>硬膜の小さな前方開口部を実行することによって前方の凹部のクモ膜の侵害のリスクを抑え、トルコ鞍のコンテンツへのアクセス権を提供するために吸引の先端で硬膜を押し上げます。</li>
		<li>環状斜め用キュレット、鉗子、吸引のヒントと腫瘍組織を削除します。</li>
		<li>セラー内生理食塩水洗浄-アウト後、30 ° 角度の内視鏡を使用して検査によるトルコ鞍内スペースし特に海綿静脈洞への任意の残骸を確認。</li>
		<li>閉鎖手順の前に CSF の漏出を検出するため切除のプロシージャの終わりにバルサルバ法を求めます。</li>
	</ol>
</li>
	<li>
閉鎖
	<ol>
<li>セッラ ・術後 MRI のより正確な解釈を有効にするのに、絶対に必要な場合で、止血材料を配置しないでください。</li>
		<li>患者の生理食塩水灌漑で下垂体セッラとコットンとわずかな圧力内にある止血を入手します。</li>
		<li>生体吸収性人工硬膜の代替 extradurally して (例えばbioglue) 接着剤の薄い層で補強のパッチで痛覚を再構築します。</li>
		<li>骨弁を交換し、手術用の接着剤で固定します。 注: トルコ鞍底がドリルの場合、縫合の演壇や鼻中隔の後部から軟骨の部分が閉じるために使用骨欠損。合成物質 (例えば、Porex プレート) の使用の他のオプションも記載されています。</li>
		<li>任意の慢性的な炎症反応を避けるために蝶形骨洞の人工材料を放置しないでください。</li>
		<li>鼻粘膜、特に術後の鼻出血を防ぐために、両側に翼口蓋動脈の nasoseptal 枝部の止血に注意を払います。</li>
		<li>優しく鈍ヘラで本来の位置に優れたおよび中間甲を置き換えます。</li>
		<li>CSF の漏出はプロシージャの間に観察されている場合、は、小さな脂肪移植を併用したセッラをパックします。鼻のパッキングを使用しない限り、厳密には必要。</li>
	</ol>
</li>
</ol>4. 術後管理
<ol><li>周術期における適切なホルモン置換を提供します。最初の 24 時間 (1 日あたり 100 mg) 中に静脈ヒドロコルチゾンを使用し、経口の置換 (入院中は一日少なくとも 30 mg ですがケースにケースから変数) を入力します。</li>
	<li>血液、尿浸透圧、電解質、尿中密度と共に 1 日 2 回を確認します。尿の量を常に監視します。術後 4 日目で前方の下垂体機能を評価するホルモン チェックを実行します。</li>
	<li>アモキシシリン/クラブラン酸で保つ 1.2 g 1 日 2 回 5 日目まで術後。アセトアミノフェンと NSAID を組み合わせながら標準の鎮痛治療し難治性疼痛に対するトラマドールを提供します。</li>
	<li>術後 crostous 鼻炎のリスクを制限する食塩水を鼻窩を常にきれいに。</li>
	<li>術後最初の週の間に手術部位の正しい治癒バルサルバ演習を避けることの重要性を患者に説明します。</li>
	<li>切除術中の側面が下垂体腺腫、異型の場合、小計を疑いがある場合にのみ、または合併症が疑われる場合、術後早期に mri 検査を実行します。標準手続き後 3 ヶ月で術後脳 MRI を実行します。</li>
	<li>術後 3 ヵ月の最初の評価を実行し内分泌のユニットとのコラボレーションでフォロー アップを編成および病理学および切除範囲に従ってそれらをスケジュールします。</li>
</ol>

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W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Congress+of+Neurological+Surgeons+Systematic+Review+and+Evidence-Based+Guideline+on+Primary+Management+of+Patients+With+Nonfunctioning+Pituitary+Adenomas.">Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Primary Management of Patients With Nonfunctioning Pituitary Adenomas.</a> Neurosurgery. 79 (4), E533-E535 (2016).</li><li>Teixeira, M., Souteiro, P., Carvalho, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prolactinoma+management:+predictors+of+remission+and+recurrence+after+dopamine+agonists+withdrawal.">Prolactinoma management: predictors of remission and recurrence after dopamine agonists withdrawal.</a> Pituitary. , (2017).</li><li>Cappabianca, P., de Divitiis, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopy+and+transsphenoidal+surgery.">Endoscopy and transsphenoidal surgery.</a> Neurosurgery. 54 (5), 1043-1048 (2004).</li><li>Jho, H. D., Carrau, R. L., Ko, Y., Daly, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+pituitary+surgery:+an+early+experience.">Endoscopic pituitary surgery: an early experience.</a> Surg Neurol. 47 (3), 213-222 (1997).</li><li>Borg, A., Kirkman, M. A., Choi, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+Endonasal+Anterior+Skull+Base+Surgery:+A+Systematic+Review+of+Complications+During+the+Past+65+Years.">Endoscopic Endonasal Anterior Skull Base Surgery: A Systematic Review of Complications During the Past 65 Years.</a> World Neurosurg. 95, 383-391 (2016).</li><li>Buchfelder, M., Schlaffer, S. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Novel+Techniques+in+the+Surgical+Treatment+of+Acromegaly:+Applications+and+Efficacy.">Novel Techniques in the Surgical Treatment of Acromegaly: Applications and Efficacy.</a> Neuroendocrinology. 103 (1), 32-41 (2016).</li><li>Shirakawa, M., Yoshimura, S., Yamada, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effectiveness+of+Endoscopic+Endonasal+Transsphenoidal+Surgery+Using+a+Neuronavigation:+Clinical+Results+of+178+Pituitary+Adenomas.">Effectiveness of Endoscopic Endonasal Transsphenoidal Surgery Using a Neuronavigation: Clinical Results of 178 Pituitary Adenomas.</a> Journal of Neurology and Neuroscience. 7 (1:71), (2016).</li><li>Dehdashti, A. R., Ganna, A., Karabatsou, K., Gentili, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pure+endoscopic+endonasal+approach+for+pituitary+adenomas:+early+surgical+results+in+200+patients+and+comparison+with+previous+microsurgical+series.">Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series.</a> Neurosurgery. 62 (5), 1006-1015 (2008).</li><li>Starnoni, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+treatment+of+acromegaly+according+to+the+2010+remission+criteria:+systematic+review+and+meta-analysis.">Surgical treatment of acromegaly according to the 2010 remission criteria: systematic review and meta-analysis.</a> Acta Neurochir (Wien). 158 (11), 2109-2121 (2016).</li><li>Alahmadi, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+technique+on+cushing+disease+outcome+using+strict+remission+criteria.">Impact of technique on cushing disease outcome using strict remission criteria.</a> Can J Neurol Sci. 40 (3), 334-341 (2013).</li><li>Donegan, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+Outcomes+of+Prolactinomas+in+Recent+Era:+Results+of+a+Heterogenous+Group.">Surgical Outcomes of Prolactinomas in Recent Era: Results of a Heterogenous Group.</a> Endocr Pract. 23 (1), 37-45 (2017).</li><li>Andereggen, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=10-year+follow-up+study+comparing+primary+medical+vs.+surgical+therapy+in+women+with+prolactinomas.">10-year follow-up study comparing primary medical vs. surgical therapy in women with prolactinomas.</a> Endocrine. 55 (1), 223-230 (2017).</li><li>Onnestam, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=National+incidence+and+prevalence+of+TSH-secreting+pituitary+adenomas+in+Sweden.">National incidence and prevalence of TSH-secreting pituitary adenomas in Sweden.</a> J Clin Endocrinol Metab. 98 (2), 626-635 (2013).</li><li>Malchiodi, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thyrotropin-secreting+pituitary+adenomas:+outcome+of+pituitary+surgery+and+irradiation.">Thyrotropin-secreting pituitary adenomas: outcome of pituitary surgery and irradiation.</a> J Clin Endocrinol Metab. 99 (6), 2069-2076 (2014).</li><li>Yamada, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinicopathological+characteristics+and+therapeutic+outcomes+in+thyrotropin-secreting+pituitary+adenomas:+a+single-center+study+of+90+cases.">Clinicopathological characteristics and therapeutic outcomes in thyrotropin-secreting pituitary adenomas: a single-center study of 90 cases.</a> J Neurosurg. 121 (6), 1462-1473 (2014).</li></ol>

利害のない衝突。

下垂体腫瘍の大半、手術症状の患者19,20の場合ファーストライン治療のままです。プロラクチン (PRL) のためにだけ-腺を分泌、治療の最初の行は、ドーパミン作動薬と手術が第二選択医療が21を失敗したとき。
1990 年代初頭22,23に対する頭蓋底手術の分野における内視...

頭蓋底手術への内視鏡技術の導入が飛躍的に頭蓋底手術自体または標準の顕微鏡下のアプローチへの補助として使用された場合の結果。内視鏡下鼻アプローチ当初トルコ鞍病変1を治療するために導入されたが、最後の二十年の間にこの手法の適用が重要な技術の進歩のおかげで展開し手術経験を増加.内視鏡的アプローチは、今も拡張傍正中アプローチにより前部と前側壁の頭蓋骨病変のため使用されます。歯突起は前頭蓋底からアプローチが満足のいく結果2,3,4,5多くの専門センターで安全に実行する場合。
実際には、内視鏡では、重要な神経血管構造を横断することがなく自然なアクセスを介して病変の直接可視化ができます。複数のレビューを持って持続的な安全性と従来の顕微鏡ベースの内視鏡の相対的な利点と腫瘍切除やホルモン レベルの変化の程度など、大きな成果がなかったことを確認しました。2 つのアプローチ間で異なる。しかし神経学的合併症, 手術時間入院の長さと、患者の術後の不快感は低かった大幅6内視鏡的アプローチ。挑発的な文書によるとも経験の少ない外科医が非機能のコホート研究における顕微鏡を用いた非常に経験豊富な外科医として完全に内視鏡技術と同様の結果を達成する下垂体腺腫7。
内視鏡下鼻トランス蝶アプローチは海綿静脈洞浸潤や腫瘍摘出した場合でも、セラーの病変で実際に広く勧め。鞍上部拡張機能が非常に重要な場合、残8の自然降下を待っている間、完全に内視鏡 2 段階手順は実行する可能性があります。横隔膜が非常にタイトな場合 (「腰記号」)、鞍上部コンポーネント9に対処するため頭蓋アプローチを行うことができます。海綿静脈洞の浸潤に関する Knosp グレード 2 および 3 の非機能の下垂体腺腫の10、顕微鏡の技術に優れていると思われる内視鏡技術と内視鏡下鼻検査の検出に役立つことがあります、海綿静脈洞11の侵入。
内視鏡的摘出を妨げる可能性がありますの要因: 上記と頭蓋内内内動脈または「頸動脈にキス」、非対称の後延長、モンロー孔に達する腫瘍の存在する側または線維性拡張する腫瘍腫瘍周囲の脳実質9。これらの複雑なケースでは、患者に結合頭蓋アプローチが提案されます。また蝶形骨洞の含気化は、コンチャル型副鼻腔内視鏡的アプローチより12に挑戦をレンダリングするので、手術の可能性を決定する重要な要因です。
下垂体腺腫の約 500 の内視鏡下鼻アプローチの個人的な経験をここで著者は下垂体腫瘍に対するアプローチのさまざまな段階について説明します。手術は 3 つの段階に分けられる: 鼻腔、蝶とトルコ鞍の相。彼らは、完全に内視鏡の操作を行います。ここで説明したコホートには、マイクロ症例や海綿静脈洞、蝶形骨洞や鞍上部スペースにする変数拡張を持つ腺腫のマクロが含まれています。機能と非機能腺腫が含まれていた。
完全に内視鏡が様々 な頭蓋咽頭腫、下垂体転移、斜脊索腫、ペトロ斜髄膜腫など他の病変にも行われます。しかし、これらの病態は多くの場合より広範なアプローチを必要し、本稿の目的を超えてこれらの亜種の説明。
徴候
ここで説明する手順は、下垂体腺腫 (機能または機能していない)。鞍上部拡張手順については、禁忌ではなかったも拡張機能や海綿静脈洞の浸潤。手術前の CT スキャンでは蝶形骨洞の含気化と蝶形骨洞の隔壁の向きを行った。また視神経や内頸動脈の向き手術戦略を計画する重要な要因であった。
この手技では、他の有用なことができます腫瘍は頭蓋咽頭腫13, 症候性ラトケ裂嚢胞、下垂体転移14、またはリンパ腫15のようなトルコ鞍地域に位置します。また、その他の病変があります表皮とトルコ鞍のダイアフラムまたは蝶鏡の髄膜腫など石油斜地域の斜脊索腫5,16, 髄膜腫の内視鏡的アプローチを通して近づいてまたは前橋槽の皮様嚢腫。これらの場合ただし、広いアプローチが必要。

<table>
	<tbody>
		<tr>
			<td>The StealthStation surgical navigation system</td>
			<td>Medtronic</td>
			<td>ENT Fusion Software 9733652</td>
			<td></td>
		</tr>
		<tr>
			<td>4-mm 18cm 0&#176; rigid endoscope</td>
			<td>Karl Storz</td>
			<td>28132AA</td>
			<td></td>
		</tr>
		<tr>
			<td>4-mm 18cm 30&#176; rigid endoscope</td>
			<td>Karl Storz</td>
			<td>28132BVA</td>
			<td></td>
		</tr>
		<tr>
			<td>4-mm 18cm 45&#176; rigid endoscope</td>
			<td>Karl Storz</td>
			<td>28132FVA</td>
			<td></td>
		</tr>
		<tr>
			<td>Suction Tube</td>
			<td>Karl Storz</td>
			<td>28164XA</td>
			<td></td>
		</tr>
		<tr>
			<td>Coagulation Cannulas</td>
			<td>Karl Storz</td>
			<td>28164MXB</td>
			<td></td>
		</tr>
		<tr>
			<td>Bipolar Forceps</td>
			<td>Karl Storz</td>
			<td>28164BDB</td>
			<td></td>
		</tr>
		<tr>
			<td>Kerrison Bone Punches</td>
			<td>Karl Storz</td>
			<td>28164MKA</td>
			<td></td>
		</tr>
		<tr>
			<td>Kerrison Bone Punches</td>
			<td>Karl Storz</td>
			<td>28164MKB</td>
			<td></td>
		</tr>
		<tr>
			<td>Kerrison Bone Punches</td>
			<td>Karl Storz</td>
			<td>28164MKC</td>
			<td></td>
		</tr>
		<tr>
			<td>Ring Curettes</td>
			<td>Karl Storz</td>
			<td>28164RN</td>
			<td></td>
		</tr>
		<tr>
			<td>Ring Curettes</td>
			<td>Karl Storz</td>
			<td>28164RO</td>
			<td></td>
		</tr>
		<tr>
			<td>Ring Curettes</td>
			<td>Karl Storz</td>
			<td>28164RI</td>
			<td></td>
		</tr>
		<tr>
			<td>Ring Curettes</td>
			<td>Karl Storz</td>
			<td>28164RG</td>
			<td></td>
		</tr>
		<tr>
			<td>Ring Curettes</td>
			<td>Karl Storz</td>
			<td>28164GLL</td>
			<td></td>
		</tr>
		<tr>
			<td>Ring Curettes</td>
			<td>Karl Storz</td>
			<td>28164GLR</td>
			<td></td>
		</tr>
		<tr>
			<td>de DIVITIS-CAPPABIANCA Scalpels</td>
			<td>Karl Storz</td>
			<td>28164M</td>
			<td></td>
		</tr>
		<tr>
			<td>Forceps</td>
			<td>Karl Storz</td>
			<td>28164TD</td>
			<td></td>
		</tr>
		<tr>
			<td>High-speed drill</td>
			<td>Midas Rex Medtronic</td>
			<td>1898430</td>
			<td></td>
		</tr>
		<tr>
			<td>Hemostatic agent</td>
			<td>Floseal, Baxter</td>
			<td>1503350</td>
			<td></td>
		</tr>
		<tr>
			<td>Fibrin sealant</td>
			<td>Tisseel, Baxter</td>
			<td>600065</td>
			<td></td>
		</tr>
		<tr>
			<td>CT Lightspeed</td>
			<td>GE medical systems, Milwaukee, WI, USA</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Carestream Vue PACS</td>
			<td>Carestream Health, Rochester, NY, USA</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>3-Tesla Siemens Tim Trio scanner</td>
			<td>Siemens AG, Erlangen, Germany</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

endoscopic endonasal trans-sphenoidal approach: minimally invasive surgery for pituitary adenomas

内視鏡下鼻トランス蝶手術を下垂体腺腫と他の多くの下垂体腫瘍の外科治療のゴールド スタンダードとなりました。ニューロナビゲーション定款、技術の進歩、手術手技の改良はこの手術を低侵襲にレンダリングしています。この手術の合併症発生率は、この方法により優れた結果が得、一貫して非常に低い。
本稿は、個人的な経験に基づいており、この低侵襲手術により得られた結果の詳細を下垂体腺腫のため、段階的な外科的アプローチについて説明します。

2009 年以来、私たちの下垂体プログラムは完全内視鏡下鼻アプローチが優秀な術後結果を下垂体腫瘍の治療に使用されていますどこまで進化しています。2016 年まで 2009 年から (RTD とミリメートル) の 2 つのベテランの外科医は 473 完全内視鏡技術を介して下垂体腺腫患者で運営。組織は、表 1で説明: これらの場合のほとんどであった非機能下垂体腺腫 (57%...

Watch this Scientific Journal Video about Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas at JoVE.com

Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas

本稿の目的は、トルコ鞍に内視鏡下鼻アプローチの別の手順を説明します。

内視鏡内視鏡下鼻内のトランス蝶アプローチ: 下垂体腺腫に対する低侵襲手術

Endoscopic endonasal trans-sphenoidal surgery has become the gold standard for the surgical treatment of pituitary adenomas and many other pituitary ...

endoscopic-endonasal-trans-sphenoidal-approach-minimally-invasive

Research

JoVE Journal

Neuroscience

18.7K ビュー.  University Hospital of Lausanne. 本稿の目的は、トルコ鞍に内視鏡下鼻アプローチの別の手順を説明します。

ビデオ: Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas

Minimally-invasive Technique for Injection into Rat Optic Nerve

The rat optic nerve is a useful model for stem cell regeneration research. Direct injection into the rat optic nerve allows delivery into the central nervous system in a minimally-invasive surgery without bone removal. This technique describes an approach to visualization and direct injection of the optic nerve following minor fascial dissection from the orbital ridge, using a conjunctival traction suture to gently pull the eye down and out. Representative examples of an injected optic nerve show successful injection of dyed beads.

Direct injection into the rat optic nerve is useful for regenerative research. We demonstrate a minimally-invasive technique for direct injection into a rat optic nerve that does not involve opening the skull. Using this method, surgical complications are minimized and recovery is more rapid.

ラット視神経への注入のための低侵襲テクニック

The rat optic nerve is a useful model for stem cell regeneration research. Direct injection into the rat optic nerve allows delivery into the central ...

神経科学

Intramuscular Injections Along the Motor End Plates: A Minimally Invasive Approach to Shuttle Tracers Directly into Motor Neurons

Diseases affecting the integrity of spinal cord motor neurons are amongst the most debilitating neurological conditions. Over the last decades, the development of several animal models of these neuromuscular disorders has provided the scientific community with different therapeutic scenarios aimed at delaying or reversing the progression of these conditions. By taking advantage of the retrograde machinery of neurons, one of these approaches has been to target skeletal muscles in order to shuttle therapeutic genes into corresponding spinal cord motor neurons. Although once promising, the success of such gene delivery approach has been hampered by the sub-optimal number of transduced motor neurons it has so far shown to yield. Motor end plates (MEPs) are highly specialized regions on the skeletal musculature that are in direct synaptic contact to the spinal cord &#945; motor neurons. In this regard, it is important to note that, so far, the efforts to retrogradely transfer genes into motor neurons were made without reference to the location of the MEP region in the targeted muscles. Here, we describe a simple protocol 1) to reveal the exact location of the MEPs on the surface of skeletal muscles and 2) to use this information to guide the intramuscular delivery and subsequent optimal retrograde transport of retrograde tracers into motor neurons. We hope to utilize the results from these tracing experiments in further studies into investigating retrograde transport of therapeutic genes to spinal cord motor neurons through the targeting of MEPs.

The efficacy of intramuscular uptake and retrograde transport of molecules to corresponding motor neurons depends on the location of the injection sites with respect to the motor end plates (MEPs). Here, we describe how to locate MEPs on skeletal muscles to optimise retrograde transport of tracers into motor neurons.

モーターエンドプレートに沿って筋肉内注射：直接運動ニューロンへのシャトルトレーサーへの低侵襲アプローチ

Diseases affecting the integrity of spinal cord motor neurons are amongst the most debilitating neurological conditions. Over the last decades, the ...

Effects of Transcranial Alternating Current Stimulation on the Primary Motor Cortex by Online Combined Approach with Transcranial Magnetic Stimulation

Transcranial Alternating Current Stimulation (tACS) is a neuromodulatory technique able to act through sinusoidal electrical waveforms in a specific frequency and in turn modulate ongoing cortical oscillatory activity. This neurotool allows the establishment of a causal link between endogenous oscillatory activity and behavior. Most of the tACS studies have shown online effects of tACS. However, little is known about the underlying action mechanisms of this technique because of the AC-induced artifacts on Electroencephalography (EEG) signals. Here we show a unique approach to investigate online physiological frequency-specific effects of tACS of the primary motor cortex (M1) by using single pulse Transcranial Magnetic Stimulation (TMS) to probe cortical excitability changes. In our setup, the TMS coil is placed over the tACS electrode while Motor Evoked Potentials (MEPs) are collected to test the effects of the ongoing M1-tACS. So far, this approach has mainly been used to study the visual and motor systems. However, the current tACS-TMS setup can pave the way for future investigations of cognitive functions. Therefore, we provide a step-by-step manual and video guidelines for the procedure.

Transcranial Alternating Current Stimulation (tACS) allows the modulation of cortical excitability in a frequency-specific fashion. Here we show a unique approach which combines online tACS with single pulse Transcranial Magnetic Stimulation (TMS) in order to "probe" cortical excitability by means of Motor Evoked Potentials.

経頭蓋交流電流刺激オンライン結合による一次運動野の経頭蓋磁気刺激の効果

Transcranial Alternating Current Stimulation (tACS) is a neuromodulatory technique able to act through sinusoidal electrical waveforms in a specific ...

Healthy Brain-pituitary Slices for Electrophysiological Investigations of Pituitary Cells in Teleost Fish

Electrophysiological investigations of pituitary cells have been conducted in numerous vertebrate species, but very few in teleost fish. Among these, the clear majority have been performed on dissociated primary cells. To improve our understanding of how teleost pituitary cells, behave in a more biologically relevant environment, this protocol shows how to prepare viable brain-pituitary slices using the small freshwater fish medaka (Oryzias latipes). Making the brain-pituitary slices, pH and osmolality of all solutions were adjusted to values found in body fluids of freshwater fish living at 25 to 28 &#176;C. Following slice preparation, the protocol demonstrates how to conduct electrophysiological recordings using the perforated whole-cell patch-clamp technique. The patch-clamp technique is a powerful tool with unprecedented temporal resolution and sensitivity, allowing investigation of electrical properties from intact whole cells down to single ion channels. Perforated patch is unique in that it keeps the intracellular environment intact preventing regulatory elements in the cytosol from being diluted by the patch pipette electrode solution. In contrast, when performing traditional whole-cell recordings, it was observed that medaka pituitary cells quickly lose their ability to fire action potentials. Among the various perforation techniques available, this protocol demonstrates how to achieve perforation of the patched membrane using the fungicide Amphotericin B.

The article describes an optimized protocol for making viable brain-pituitary tissue slices, using the teleost fish medaka (Oryzias latipes), followed by electrophysiological recordings of pituitary cells using the patch-clamp technique with the perforated patch configuration.

魚類に下垂体細胞の電気生理学的調査のための健康的な脳下垂体スライス

Electrophysiological investigations of pituitary cells have been conducted in numerous vertebrate species, but very few in teleost fish. Among these, the ...

Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation

Intracerebral hemorrhage (ICH) is a subtype of stroke with high mortality and poor functional outcomes, largely because there are no evidence-based treatment options for this devastating disease process. In the past decade, a number of minimally invasive surgeries have emerged to address this issue, one of which is endoscopic evacuation. Stereotactic ICH Underwater Blood Aspiration (SCUBA) is a novel endoscopic evacuation technique performed in a fluid-filled cavity using an aspiration system to provide an additional degree of freedom during the procedure. The SCUBA procedure utilizes a suction device, endoscope, and sheath and is divided into two phases. The first phase involves maximal aspiration and minimal irrigation to decrease clot burden. The second phase involves increasing irrigation for visibility, decreasing aspiration strength for targeted aspiration without disturbing the cavity wall, and cauterizing any bleeding vessels. Using the endoscope and aspiration wand, this technique aims to maximize hematoma evacuation while minimizing collateral damage to the surrounding brain. Advantages of the SCUBA technique include the use of a low-profile endoscopic sheath minimizing brain disruption and improved visualization with a fluid-filled cavity rather than an air-filled one.

This paper details the surgical protocol for minimally invasive endoscopic intracerebral hemorrhage evacuation using the SCUBA technique.

低侵襲内視鏡性脳内出血

Intracerebral hemorrhage (ICH) is a subtype of stroke with high mortality and poor functional outcomes, largely because there are no evidence-based ...

A Minimally Invasive Lesion Technique for Muscles Intrinsic to the Odontophore of Aplysia californica

Aplysia californica is a model system for studying the neural control of learning and behavior. This animal has a semi-open circulatory system, making it possible to access many of its internal structures without causing any significant damage. Many manipulations can be easily performed both in vivo and in vitro, making it a highly tractable model for the analysis of behavior and neural circuitry. To better understand the functions of muscles within the feeding grasper, we have developed a technique for lesioning them without opening the main body cavity of the animal or damaging the outer layers of the feeding organ (i.e., the buccal mass). In this technique, the grasper is partially everted, allowing direct access to the musculature. This procedure allows animals to recover quickly and reliably. This has made it possible to lesion the I7 muscles and sub-radular fibers, allowing us to show that both muscles significantly contribute to the opening in vivo.

A Minimally Invasive Lesion Technique for Muscles Intrinsic to the Odontophore of Aplysia californica

Here we present a protocol for minimally invasive surgical lesioning of muscles intrinsic to the feeding apparatus of the marine mollusk Aplysia californica to understand the roles of these muscles during feeding behavior.

アプリシア・カリフォルニカのオドントフォアに固有の筋肉のための最小限に侵襲的な病変技術

Aplysia californica is a model system for studying the neural control of learning and behavior. This animal has a semi-open circulatory system, making it ...

Statistical Modelling of Cortical Connectivity Using Non-invasive Electroencephalograms

Non-invasive electrophysiological recordings are useful for the evaluation of nervous system function. These techniques are inexpensive, fast, replicable, and less resource-intensive than imaging. Further, the functional data produced have excellent temporal resolution, which is not achievable with structural imaging.
Current applications of electroencephalograms (EEG) are limited by data processing methods. Standard analysis techniques using raw time series data at individual channels are very limited methods of interrogating nervous system activity. More detailed information about cortical function can be achieved by examining relationships between channels and deriving statistical models of how areas are interacting, allowing visualization of connectivity between networks.
This manuscript describes a method for deriving statistical models of cortical network activity by recording EEG in a standard manner, then examining the interelectrode coherence measures to assess relationships between the recorded areas. Higher order interactions can be further examined by assessing the covariance between the coherence pairs, producing high-dimensional &#34;maps&#34; of network interactions. These data constructs can be examined to assess cortical network function and its relationship to pathology in ways not achievable with traditional techniques.
This approach offers greater sensitivity to network level interactions than is achievable with raw time series analysis. It is, however, limited by the complexity of drawing specific mechanistic conclusions about the underlying neural populations and the high volumes of data generated, requiring more advanced statistical techniques for evaluation, including dimensionality reduction and classifier-based approaches.

Standard EEG analysis techniques offer limited insight into nervous system function. Deriving statistical models of cortical connectivity offers far greater ability to investigate underlying network dynamics. Improved functional assessment opens new possibilities for diagnosis, prognostication, and outcome prediction in nervous system diseases.

非侵襲的脳波を用いた皮質接続の統計的モデリング

Non-invasive electrophysiological recordings are useful for the evaluation of nervous system function. These techniques are inexpensive, fast, replicable, ...

A Revised Surgical Approach to Induce Endolymphatic Hydrops in the Guinea Pig

Endolymphatic hydrops is an enlargement of scala media that is most often associated with Meniere&#39;s disease, though the pathophysiologic mechanism(s) remain unclear. In order to adequately study the attributes of endolymphatic hydrops, such as the origins of low-frequency hearing loss, a reliable model is needed. The guinea pig is a&#160;good model because it hears in the low-frequency regions that are putatively affected by endolymphatic hydrops. Previous research has demonstrated that endolymphatic hydrops can be induced surgically via intradural or extradural approaches that involve drilling on the endolymphatic duct and sac. However, whether it was possible to create an endolymphatic hydrops model using an extradural approach that avoided dangerous drilling on the endolymphatic duct and sac was unknown. The objective of this study was to demonstrate a revised extradural approach to induce experimental endolymphatic hydrops at 30 days post-operatively by obliterating the endolymphatic sac and injuring the endolymphatic duct with a fine pick. The sample size consisted of seven guinea pigs. Functional measurements of hearing were made and temporal bones were subsequently harvested for histologic analysis. The approach had a success rate of 86% in achieving endolymphatic hydrops. The risk of cerebrospinal fluid leak was minimal. No perioperative deaths or injuries to the posterior semicircular canal occurred in the sample. The presented method demonstrates a safe and reliable way to induce endolymphatic hydrops at a relatively quick time point of 30 days. The clinical implications are that the presented method provides a reliable model to further explore the origins of low-frequency hearing loss that can be associated endolymphatic hydrops.

This article demonstrates an extradural approach to obliterate the guinea pig endolymphatic sac and injure the endolymphatic duct with a fine pick in order to induce experimental endolymphatic hydrops.

モルモットの内リンパ性水力を誘導する改訂された外科的アプローチ

Endolymphatic hydrops is an enlargement of scala media that is most often associated with Meniere&#39;s disease, though the pathophysiologic mechanism(s) ...

Adaptable Angled Stereotactic Approach for Versatile Neuroscience Techniques

Stereotactic surgery is an essential tool in the modern neuroscience lab. However, the ability to precisely and accurately target difficult-to-reach brain regions still presents a challenge, particularly when targeting brain structures along the midline. These challenges include avoiding of the superior sagittal sinus and third ventricle and the ability to consistently target selective and discrete brain nuclei. In addition, more advanced neuroscience techniques (e.g., optogenetics, fiber photometry, and two-photon imaging) rely on targeted implantation of significant hardware to the brain, and spatial limitations are a common hindrance. Presented here is a modifiable protocol for stereotactic targeting of rodent brain structures using an angled coronal approach. It can be adapted to 1) mouse or rat models, 2) various neuroscience techniques, and 3) multiple brain regions. As a representative example, it includes the calculation of stereotactic coordinates for targeting of the mouse hypothalamic ventromedial nucleus (VMN) for an optogenetic inhibition experiment. This procedure begins with the bilateral microinjection of an adeno-associated virus (AAV) encoding a light-sensitive chloride channel (SwiChR++) to a Cre-dependent mouse model, followed by the angled bilateral implantation of fiberoptic cannulae. Using this approach, findings show that activation of a subset of VMN neurons is required for intact glucose counterregulatory responses to insulin-induced hypoglycemia.

Described here is a stereotactic procedure that can target challenging and difficult-to-reach brain regions (due to spatial limitations) using an angled coronal approach. This protocol is adaptable to both mouse and rat models and can be applied to diverse neuroscientific applications, including cannula implantation and microinjections of viral constructs.

多目的神経科学技術のための適応可能な角度付き定位アプローチ

Stereotactic surgery is an essential tool in the modern neuroscience lab. However, the ability to precisely and accurately target difficult-to-reach brain ...

Role of Diffusion MRI Tractography in Endoscopic Endonasal Skull Base Surgery

Endoscopic endonasal surgery has gained a prominent role in the management of complex skull base tumors. It allows the resection of a large group of benign and malignant lesions through a natural anatomical extra-cranial pathway, represented by the nasal cavities, avoiding brain retraction and neurovascular manipulation. This is reflected by the patients' prompt clinical recovery and the low risk of permanent neurological sequelae, representing the main caveat of conventional skull base surgery. This surgery must be tailored to each specific case, considering its features and relationship with surrounding neural structures, mostly based on preoperative neuroimaging. Advanced MRI techniques, such as tractography, have been rarely adopted in skull base surgery due to technical issues: lengthy and complicated processes to generate reliable reconstructions for inclusion in the neuronavigation system. 
This paper aims to present the protocol implemented in the institution and highlights the synergistic collaboration and teamwork between neurosurgeons and the neuroimaging team (neurologists, neuroradiologists, neuropsychologists, physicists, and bioengineers) with the final goal of selecting the optimal treatment for each patient, improving the surgical results and pursuing the advancement of personalized medicine in this field.

We present a protocol to integrate diffusion MRI tractography in patient work-up to endoscopic endonasal surgery for a skull base tumor. The methods for adopting these neuroimaging studies in the pre- and intra-operative phases are described.

内視鏡内視鏡頭蓋基外科における拡散MRIトラクトグラフィーの役割

Endoscopic endonasal surgery has gained a prominent role in the management of complex skull base tumors. It allows the resection of a large group of ...