この作業は、寧波健康青年技術幹部プログラムの第3バッチ(ビンビン・チュー博士)と浙江医師会臨床研究基金プロジェクト(ビン・ガオ博士)(2018ZYC-A66)によってサポートされました。

この研究は、2018年12月10日に寧波大学医学部(KY20181215)の関連病院の倫理委員会によって承認されました。
1.選択基準
<ol><li>肺水疱切除術、肺ウェッジ切除術、または葉切除術を受けているすべての患者(>18歳)が含まれます。</li>
</ol>2. 除外基準
<ol><li>米国麻酔科学会(ASA)の身体的状態分類に基づいて患者を除外します >315。</li>
	<li>ボディマス指数(BMI)16 >30 kg/ m 2の患者を除外します。</li>
	<li>食道がん、肺全摘出術、および肋骨切除を伴う開心術の患者を除外します。</li>
	<li>気管支拡張症、肺の破壊、または慢性閉塞性肺疾患(COPD)の既往歴のある患者を除外します。</li>
	<li>手術前に明確な複数の肺感染症または炎症、およびその他の重度の全身性疾患のある患者を除外します。</li>
	<li>凝固障害および重度の精神障害または神経障害のある患者を除外します。</li>
</ol>3.麻酔前の準備
<ol><li>手術前に8時間患者を断食する。</li>
	<li>手術室の温度を24°Cから26°Cの間に調整します。</li>
	<li>20 Gの上翼注入針を手の非外科的背静脈に挿入します。</li>
	<li>患者の心電図、血圧、脈拍酸素飽和度(SpO2)、および呼吸数を監視します。</li>
	<li>バイスペクトラルインデックス(BIS)クアトロセンサーを各患者の額に適用します。 注意: 必要に応じて、橈骨動脈圧と中心静脈圧を継続的に監視します。</li>
</ol>4.超音波ガイド下胸部傍脊椎遮断
<ol><li>患者を外側の褥瘡の位置に置きます。</li>
	<li>超音波プローブを第3胸椎と第7胸椎の棘突起の真上に置き、棘突起の断面画像を取得します。 注:画像の中央には、後部音響影を伴う高エコー性棘突起があり、棘突起の両側に後部音響影がある骨構造は、順番に椎板と横突起です。</li>
	<li>超音波プローブを横方向に動かして、横方向のプロセス全体を表示します。</li>
	<li>超音波プローブを外側に動かして、横突起、横肋骨関節、および肋骨を視覚化します。</li>
	<li>横突起、胸膜、およびそれらの間の胸部傍脊椎腔が画像で検出されるまで、超音波プローブを尾側に動かします。</li>
	<li>2 mLの1%リドカインを注射して皮膚を局所麻酔します。.</li>
	<li>超音波ガイダンスの下で面内アプローチでブロック針を外側から内側に挿入します。</li>
	<li>注射前に慎重に吸引を上げてください。血液の逆流が観察されないことを確認してください。 注:このステップの目的は、局所麻酔薬による全身毒性を防ぐことです。</li>
	<li>生理食塩水を2mL注入し、胸膜の前方変位と胸部傍脊椎腔の拡大を超音波で視覚化します。</li>
	<li>T3およびT7のレベルで15mLの0.375%ロピバカインを注射する。</li>
</ol>5.麻酔導入
<ol><li>1%レボブピバカイン(3 mL)を喉にスプレーします。.</li>
	<li>1.5 μg / kgのフェンタニルと1〜1.5 mg / kgのプロポフォールを注射します。.</li>
	<li>継続的な酸素投与のために、フェイシャルマスクを置くか、または喉頭マスク気道を挿入します(ダブルチューブマスク;30-50 kgの場合は#3、50-70 kgの場合は#4、70-100 kgの場合は#5)。酸素は、フェイシャルマスクまたは喉頭マスク を介して 患者の気道に入ります。 注:注射用量を調整して、BIS値を40〜6016にします。</li>
</ol>6.麻酔の維持
<ol><li>0.5〜1リットル/分の酸素流量を維持します。</li>
	<li>人工気胸後にセボフルランの濃度を1.5%〜2.0%に維持する。 注:術中の自発呼吸数が20呼吸/分を超える場合、または縦隔の羽ばたきや咳がある場合は、0.5μg/ kgのフェンタニルを注射します。.セボフルランは、フェイシャルマスクまたは喉頭マスク を介して 患者の気道に入る。</li>
	<li>吸入酸素濃度と潮汐終末二酸化炭素(ETCO2 < 60 mmHg)を監視します。</li>
	<li>体温を監視します。意識のレベルを監視し、BIS値を40-6016,17に維持します。</li>
	<li>患者が洞性徐脈を発症した場合は、20μg / kgのアトロピンを注射します(HR ≤ 50拍/分)。</li>
	<li>収縮期血圧が30%または90mmHg未満の場合は、輸液ポンプを使用して2μg / kg / hのノルエピネフリンを継続的に灌流します。.</li>
	<li>手術終了の15分前に動脈血ガス分析を行います。</li>
	<li>手術終了の30分前に1 mg / kgのフルルビプロフェンを注射します。.</li>
</ol>7.胸腔鏡下迷走神経ブロック技術と胸膜浸潤麻酔
<ol><li>24 Gの上翼注入針を使用して、右側の手順を実行するときに、迷走神経の近くの下部気管レベルで0.375%ロピバカイン(3 mL)の浸潤を生成します。</li>
	<li>24 Gの上翼注入針を使用して、左側の手順を実行するときに、大動脈肺窓のレベルで迷走神経の近くに0.5%ロピバカイン(3 mL)の浸潤を生成します。</li>
	<li>10 mLの注射器を使用して、内臓胸膜の表面に10 mLの2%リドカインをスプレーします。.</li>
</ol>8.挿管されていない麻酔から挿管された全身麻酔への変換
<ol><li>患者が次のいずれかの条件を満たしている場合は、挿管されていない麻酔を挿管された全身麻酔に変換します。 -重度の低酸素血症(パルスオキシメトリ<80%) -重度の高炭酸ガス血症(PaCO2 > 80 mmHg) -血行力学的不安定性:難治性不整脈および右心室不全 -持続的な咳により、手術が困難または不可能になる -開胸術を必要とする術中出血</li>
</ol>9.術後ケア
<ol><li>完全に目覚めた後、患者に深呼吸と咳をして、虚脱した肺を再拡張するように依頼します。</li>
	<li>患者が管理する静脈内鎮痛(PCA)ポンプを、PCAリザーバーバッグ(1 μg / kgのスフェンタニルと0.9%塩化ナトリウム注射を含む)に100 mLの溶液を入れて静脈内カテーテルに接続し、2 mL / hのPCA溶液を滴定します。.</li>
	<li>咳で空気漏れがなく、胸部X線のレビューで明らかな液体気胸がなく、24時間<300mLのドレナージがない場合は、胸腔ドレーンを取り外します。</li>
</ol>

自律呼吸を維持したビデオ支援胸腔鏡手術のための非挿管プロトコル

著者は開示するものは何もありません。

このプロトコルの利点は次のとおりです:(i)胸腔鏡手術中の咳反射を軽減するためのセボフルラン吸入麻酔レジメンの提供;(ii)胸部手術を受ける患者に安全で痛みのない手術環境を提供しながら、過剰鎮静を最小限に抑える。(iii)関連する技術的課題を考慮して、手順中の患者の自発呼吸および縦隔振動を最小限に抑える。これは、先制的な術中局所麻酔を提供することによって達成されまし?...

過去10年間で、挿管されていないビデオ支援胸部手術(NIVATS)麻酔は、臨床診療で徐々に受け入れられてきました1,2,3。この新しい戦略は、患者の迅速な回復を促進し、全身麻酔(GA)と片肺換気4の合併症を回避しますが、多くの外科医は、このアプローチを従来の肺隔離技術よりも望ましくないと考えています。
血中酸素濃度は年齢とともに低下し、一部の患者は肺機能が低下しているか、境界化している可能性があります。GAは、麻酔からの出芽の遅れ、気道合併症、嗄声、低酸素症、披裂脱臼など、そのような患者の合併症のリスクの増加と関連している可能性があります5,6,7,8,9。対照的に、複数の研究では、NIVATSで管理されている患者の入院期間が短く、低リスク患者の全身麻酔と比較して呼吸器合併症が減少していることが記録されています10;さらに、肺機能が非常に悪い高リスク患者でも手術の成功が報告されています11,12,13。
手術中の自発換気は、慎重に投与された局所麻酔または鎮静を補った局所神経ブロックによって達成されますが、予期しない肺の動きを伴う咳反射は、NIVATS中に問題になる可能性があります。縦隔粗動、刺激性咳、または頻呼吸に対する標準的な治療法はほとんど強調されておらず、外科的処置を混乱させる可能性があります。予備観察では、結果は、セボフルランが自発呼吸を維持しながら、NIVATS中の呼吸数と縦隔フラッターの発生を減少させる可能性があることを示しました14。したがって、セボフルラン吸入は咳を防ぎ、機械的換気の必要性を減らし、それによって術後肺合併症(PPC)を減らす可能性があるという仮説を立てることができます。
まず、このレポートは、挿管されていないビデオ支援胸腔鏡手術の実行を詳述する段階的なプロトコルを提示します。第二に、術後転帰に対する挿管されていない麻酔の潜在的な利益を調査するために後ろ向き研究が実施されました。

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>20-G top-winged infusion needle</td>
			<td>BD Intima II</td>
			<td>383012</td>
			<td>Puncture with a 20-G top-winged infusion needle into the dorsal vein of the non-operative side of the hand.</td>
		</tr>
		<tr>
			<td>24-G top-winged infusion needle</td>
			<td>BD Intima II</td>
			<td>383033</td>
			<td>Thoracoscopic vagal block techniques</td>
		</tr>
		<tr>
			<td>Anesthesia&#160;machine</td>
			<td>Drager</td>
			<td>A300</td>
			<td>Maintenance of respiratory function; Inhalation anesthesia; Monitor for electrocardiography, blood pressure, pulse oxygen saturation (SpO2), end-tidal carbon dioxide and respiratory rate</td>
		</tr>
		<tr>
			<td>Atropine</td>
			<td>Jiuquan Dadeli Pharma</td>
			<td>H62020772</td>
			<td>Control of heart rate</td>
		</tr>
		<tr>
			<td>BIS</td>
			<td>COVIDIEN</td>
			<td>B277243</td>
			<td>Monitor the level of consciousness</td>
		</tr>
		<tr>
			<td>Disposable nerve block needle</td>
			<td>Tuoren Medical Device&#160;</td>
			<td>202303007</td>
			<td>Nerve block</td>
		</tr>
		<tr>
			<td>Facial mask</td>
			<td>Emedica</td>
			<td>EM01-105S</td>
			<td>Provides an effective non-invasive breathing circuit</td>
		</tr>
		<tr>
			<td>Fentanyl.</td>
			<td>Renfu Pharma</td>
			<td>21D04021</td>
			<td>Analgesia</td>
		</tr>
		<tr>
			<td>Flurbiprofen</td>
			<td>Daan Pharma</td>
			<td>H20183054</td>
			<td>Analgesia</td>
		</tr>
		<tr>
			<td>Laryngeal mask&#160;</td>
			<td>Ambu Aura-i</td>
			<td>2012-2664652</td>
			<td>Airway management to preserve voluntary breathing</td>
		</tr>
		<tr>
			<td>Levobupivacaine</td>
			<td>Rundu Pharma</td>
			<td>H20050403</td>
			<td>Local Anaesthesia</td>
		</tr>
		<tr>
			<td>Lidocaine</td>
			<td>Kelun Pharma</td>
			<td>F221129C</td>
			<td>Local skin infiltration</td>
		</tr>
		<tr>
			<td>Norepinephrine</td>
			<td>Lijun Pharma</td>
			<td>H61021666</td>
			<td>Control of blood pressure</td>
		</tr>
		<tr>
			<td>Portable color doppler ultrasound</td>
			<td>SonoSite</td>
			<td>M-Turbo</td>
			<td>Guided nerve block</td>
		</tr>
		<tr>
			<td>Propofol</td>
			<td>Guorui Pharma</td>
			<td>H20030114</td>
			<td>Sedation and hypnosis</td>
		</tr>
		<tr>
			<td>Ropivacaine</td>
			<td>Aspen Pharma</td>
			<td>6091403219940</td>
			<td>Paravertebral nerve block</td>
		</tr>
		<tr>
			<td>Saline</td>
			<td>Kelun Pharma</td>
			<td>c221201E1</td>
			<td>Assisted subsonic localisation</td>
		</tr>
		<tr>
			<td>Sevoflurane</td>
			<td>&#160;Shanghai Hengrui Pharmaceutical Co.,Ltd</td>
			<td>9081931</td>
			<td>Anesthesia induction and maintenance</td>
		</tr>
		<tr>
			<td>Sufentanil</td>
			<td>Jiangsu Enhua Pharmaceutical Co., Ltd</td>
			<td>H20203650</td>
			<td>Postoperative analgesia</td>
		</tr>
	</tbody>
</table>

non-intubated video-assisted thoracoscopic surgery

全身麻酔下での二重管腔挿管は、現在、肺摘出術、肺のくさび切除術、および葉切除術で最も一般的に行われている挿管技術です。しかし、気管挿管による全身麻酔に起因する肺合併症の発生率は高い。自発呼吸の維持を伴う非挿管は、麻酔に代わるものです。挿管以外の処置は、挿管関連の気道外傷、換気誘発性肺損傷、残存神経筋遮断、術後の悪心および嘔吐など、気管挿管および全身麻酔の悪影響を最小限に抑えます。ただし、挿管以外の手順の手順は、多くの研究では詳しく説明されていません。ここでは、自律呼吸を維持したビデオ支援胸腔鏡手術を行うための簡潔な非挿管プロトコルを紹介します。この記事では、挿管されていない麻酔から挿管された麻酔に変換するために必要な条件を特定し、挿管されていない麻酔の利点と制限についても説明します。この研究では、この介入は58人の患者に対して行われました。さらに、後ろ向き研究の結果が提示されます。挿管された全身麻酔と比較して、挿管されていないビデオ支援胸部手術群の患者は、術後肺合併症の発生率が低く、手術時間が短く、術中の失血が少なく、PACU滞在が短く、胸腔ドレーン除去までの日数が少なく、術後ドレナージが少なく、入院期間が短かった。

臨床データは、2016年1月から2022年12月までに挿管されていないビデオ支援胸腔鏡手術を受けた58人の連続した患者について遡及的に収集されました。麻酔科医による術前訪問を受け,麻酔前に麻酔インフォームドコンセント書の内容について詳細な説明を受けた.患者は麻酔の2つのグループ(NIVATSグループまたはGAグループ)のいずれかを選択することを許可され、インフォームドコンセントフォ?...

Watch this Scientific Journal Video about A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia at JoVE.com

著者スポットライト:マルチモーダル鎮痛およびセボフルラン吸入麻酔による挿管されていないビデオ支援胸腔鏡手術 

ここでは、自律呼吸を維持しながらビデオ支援胸腔鏡手術を行うための非挿管プロトコルを紹介します。

挿管されていないビデオ支援胸腔鏡手術

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the ...

この研究は、非挿管ビデオ支援胸腔鏡手術の実行を詳述する段階的なプロトコルを提示します。NIVATSのプロトコルは、超音波ガイド下胸部傍脊椎遮断を含むマルチモーダル鎮痛に基づいています。胸腔鏡でブロックを作り、複数の浸潤麻酔をします。マルチモーダル鎮痛は術中の痛みを効果的に和らげ、咳反射を抑制します。このプロトコルは、胸腔鏡手術中の咳反射を軽減し、過鎮静を最小限に抑え、患者に安全で痛みのない手術環境を提供するためのセボフルラン吸入麻酔レジメンを提供します。私たちは、患者の自発呼吸を維持し、関連する支援された技術的課題を考慮しながら、処置中の縦隔振動を最小限に抑えます。

non-intubated-video-assisted-thoracoscopic-surgery

Research

JoVE Journal

Medicine

Non-Intubated Video-Assisted Thoracoscopic Surgery

1.3K ビュー.  Second Affiliated Hospital of Zhejiang University School of Medicine. この研究は、非挿管ビデオ支援胸腔鏡手術の実行を詳述する段階的なプロトコルを提示します。NIVATSのプロトコルは、超音波ガイド下胸部傍脊椎遮断を含むマルチモーダル鎮痛に基づいています。胸腔鏡でブロックを作り、複数の浸潤麻酔をします。マルチモーダル鎮痛は術中の痛みを効果的に和らげ、咳反射を抑制します。このプロトコルは、胸腔鏡手術中の咳?...

ビデオ: 著者スポットライト:マルチモーダル鎮痛およびセボフルラン吸入麻酔による挿管されていないビデオ支援胸腔鏡手術 

Murine Flexor Tendon Injury and Repair Surgery

Tendon connects skeletal muscle and bone, facilitating movement of nearly the entire body. In the hand, flexor tendons (FTs) enable flexion of the fingers and general hand function. Injuries to the FTs are common, and satisfactory healing is often impaired due to excess scar tissue and adhesions between the tendon and surrounding tissue. However, little is known about the molecular and cellular components of FT repair. To that end, a murine model of FT repair that recapitulates many aspects of healing in humans, including impaired range of motion and decreased mechanical properties, has been developed and previously described. Here an in-depth demonstration of this surgical procedure is provided, involving transection and subsequent repair of the flexor digitorum longus (FDL) tendon in the murine hind paw.&#160;This technique can be used to conduct lineage analysis of different cell types, assess the effects of gene gain or loss-of-function, and to test the efficacy of pharmacological interventions in the healing process. However, there are two primary limitations to this model: i) the FDL tendon in the mid-portion of the murine hind paw, where the transection and repair occur, is not surrounded by a synovial sheath. Therefore this model does not account for the potential contribution of the sheath to the scar formation process. ii) To protect the integrity of the repair site, the FT is released at the myotendinous junction, decreasing the mechanical forces of the tendon, likely contributing to increased scar formation. Isolation of sufficient cells from the granulation tissue of the FT during the healing process for flow cytometric analysis has proved challenging; cytology centrifugation to concentrate these cells is an alternate method used, and allows for generation of cell preparations on which immunofluorescent labeling can be performed. With this method, quantification of cells or proteins of interest during FT healing becomes possible.

Flexor tendons in the hand are commonly injured, leading to impaired hand function. However, the scar-tissue healing response is not well characterized. A murine model of flexor tendon healing is demonstrated here. This model can enhance overall understanding of the healing process and assess therapeutic approaches to improve healing.

マウス屈筋腱損傷および修復手術

Tendon connects skeletal muscle and bone, facilitating movement of nearly the entire body. In the hand, flexor tendons (FTs) enable flexion of the fingers ...

医学

Emergency Undocking in Robotic Surgery: A Simulation Curriculum

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of a robotic system. In traditional robotic training for surgeons, a brief web based overview of performing an emergency undocking is provided during initial introductory training to the robotics system. During such a process, there is no training in delineation of interdisciplinary roles for operating room (OR) personnel. The training presented here uses formative simulation and debriefing followed by a lecture. For the simulation, a modified gynecologic simulator is draped in a steep trendelenburg position consistent with most gynecologic laparoscopic surgery. The training torso is modified using tubing hooked to pressure bags of red food colored IV fluid used to simulate a catastrophic vessel injury on demand. Positioned throughout the operating room setting is an interprofessional team consisting of embedded standardized persons (ESPs) to fulfill the roles of a circulating nurse, scrub nurse, anesthesiologist, and bedside assist surgeon. Robotic surgeons are presented a case scenario necessitating emergency undocking, and given control of the robotic instruments. The scenario is terminated following either successful completion of an emergency undock, or at five minutes due to the emergent nature of the case. A debriefing session with hands on training of the steps to emergency undocking, necessary equipment, troubleshooting techniques, and operating room personnel roles follows the simulation. The learners are presented with a short lecture reemphasizing the material presented in the debriefing for their own self-study. This training results in improved time accessing the patient, improved knowledge, confidence, and completion of critical actions, and can be replicated in most institutions. All robotic surgeons should be able to demonstrate competence in this crucial intervention. A limitation of the curriculum is ability to access the in-situ environment for training purposes.

This training platform is designed to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of the robotic system. Training includes the utilization of the technology and equipment to perform an emergency undocking, as well as delineation of roles for such a scenario.

ロボット手術の緊急ドッキング解除: シミュレーション カリキュラム

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of ...

Intraoperative Ultrasound in Spinal Surgery

Since the 1980s, there have been several reports for the use of intraoperative ultrasound as a useful adjunct in spinal surgery. However, with the advent of newer cutting-edge imaging modalities, the use of intraoperative ultrasound in spine surgery has largely fallen out of favor. Despite this, intraoperative ultrasound continues to provide several advantages over other intraoperative techniques such as magnetic resonance imaging and computed tomography including being more cost-effective, efficient, and easy to operate and interpret. Additionally, it remains the only method for the real-time visualization of soft tissue and pathologies. This paper focuses on the advantages of using intraoperative ultrasound, especially in cases of intradural lesions and lesions ventral to the thecal sac when approaching posteriorly.

Here, we present a protocol on the use of intraoperative ultrasound in spinal surgery, particularly in cases of intradural lesions and lesions in the ventral spinal canal when using a posterior approach.

脊椎手術における術中超音波

Since the 1980s, there have been several reports for the use of intraoperative ultrasound as a useful adjunct in spinal surgery. However, with the advent ...

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 ...

Learning Modern Laryngeal Surgery in a Dissection Laboratory

Surgery for laryngeal malignancies requires millimetric accuracy from the different endoscopic and open techniques available. Practice of this surgery is almost completely reserved to a few referral centers that deal with a large proportion of this pathology. Practice on human specimens is not always possible for ethical, economic, or availability reasons. The aim of this study is to provide a reproducible method for the organization of a laryngeal laboratory on ex vivo animal models where it is possible to approach, learn, and refine laryngeal techniques. Porcine and ovine larynges are ideal, affordable, models to simulate laryngeal surgery given their similarity to the human larynx in their anatomical layout and tissue composition. Herein, the surgical steps of transoral laser surgery, open partial horizontal laryngectomy, and total laryngectomy are reported. The merging of endoscopic and exoscopic views guarantees an inside-out perspective, which is vital for the comprehension of the complex laryngeal anatomy. The method was successfully adopted during three sessions of a dissection course &#34;Lary-Gym&#34;. Further perspectives on robotic surgical training are described.

The purpose of this paper is to illustrate how to organize a reproducible laboratory for laryngeal surgery on affordable and closely similar animal laryngeal models in order to improve anatomical and surgical knowledge and skills.

解剖学室での現代喉頭手術の学習

Surgery for laryngeal malignancies requires millimetric accuracy from the different endoscopic and open techniques available. Practice of this surgery is ...

The Microscopic Transcanal Approach in Stapes Surgery Revisited

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

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

ステープ手術における顕微鏡経管アプローチの再考

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

Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing pancreatitis, if it does not resolve or is accompanied with infected necrosis in the retroperitoneum. As there are rarely any visually clear separating surface in white light image between necrotic debris and adjacent inflammatory normal tissues due to extensive retroperitoneal adhesions, VARD is accompanied with the risk of vascular injury, external pancreatico-cutaneous or enterocutaneous fistulae. In view of the above disadvantages, we apply real-time intraoperative near-infrared fluorescence imaging with indocyanine green (ICG) during VARD, which enables visualization of the well-perfused adjacent normal tissues. This modified technique (ICG-guided VARD) can provide a clear separating surface during debridement and reduce the risk of vascular or enteric injury. ICG-guided VARD may facilitate surgeons to perform safer debridement in treating severe acute necrotizing pancreatitis.

This protocol presents Indocyanine Green-guided video-assisted retroperitoneal debridement (ICG-guided VARD) for treating severe acute necrotizing pancreatitis.

急性壊死性膵炎治療のためのビデオ支援後腹膜創面切除を促進するためのインドシアニングリーンガイド下術中イメージング

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing ...

Endoscopic Cholesteatoma Surgery

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

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

内視鏡的胆汁うっ滞症手術

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

再手術裂孔ヘルニアの修復

Technical Considerations and Approach to Redo Foregut Surgery

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical considerations have arisen when dealing with reoperation for complications or surgical failure. This study focuses on the technical considerations and approach when dealing with reoperative foregut surgery, particularly redo&#160;hiatal hernia repair. We describe our approach starting from the preoperative workup to the procedural steps of the surgery. The present study describes the main steps for robotic reoperative hiatal hernia repair in a patient who had previously undergone laparoscopic hiatal hernia repair with Nissen fundoplication but did not present a recurrence of reflux and dysphagia symptoms. The patient is positioned supine with arms out and a footboard for steep Trendelenburg. We place six trocars, including an assistant port and a liver retractor port,&#160;to facilitate visualization and retraction. After docking the robot, we use a combination of electrocautery and sharp dissection&#160;to free the hernia sac and reduce the hiatal hernia. The previous fundoplication is then taken down carefully and the esophagus is mobilized through a transhiatal approach with a combination of blunt and sharp dissection until at least 3 cm of intra-abdominal esophageal length is achieved, after which a leak test is performed. We then perform a crural repair to reapproximate the hiatus with two posterior stitches and one anterior stitch. Lastly, a redo Nissen fundoplication is performed over a bougie, and endoscopy is used to confirm a loose stack-of-coin appearance. By emphasizing the crucial steps of redo hiatal hernia repair, including preoperative evaluation, our goal is to provide an approach for the foregut surgeon to maximize patient outcomes.

著者スポットライト:再手術前腸手術の最近の進歩

Redo foregut surgery is associated with increased patient morbidity and presents a technical challenge for the surgeon. We describe our approach and considerations when performing a redo hiatal hernia repair to provide a guide for other surgeons and improve patient outcomes.