이 작업은 닝보 보건 청소년 기술 간부 프로그램 (Binbin Zhu 박사)의 세 번째 배치와 절강 의학 협회 임상 연구 기금 프로젝트 (Bin Gao 박사) (2018ZYC-A66)의 지원을 받았습니다.

이 연구는 2018 년 12 월 10 일 닝보 대학교 의과 대학 (KY20181215) 부속 병원 윤리위원회의 승인을 받았습니다.
1. 포함 기준
<ol><li>폐수포 절제술, 폐쐐기 절제술 또는 폐엽 절제술을 받는 모든 환자(>18세)를 포함합니다.</li>
</ol>2. 제외 기준
<ol><li>미국마취학회(ASA)의 신체 상태 분류 >315에 따라 환자를 제외한다.</li>
	<li>체질량 지수(BMI)가 16 >30kg/m2인 환자는 제외합니다.</li>
	<li>식도암, 전폐절제술, 갈비뼈 절제술을 동반한 개심술 환자는 제외한다.</li>
	<li>이전에 기관지확장증, 폐 파괴 또는 만성 폐쇄성 폐질환(COPD)의 병력이 있는 환자는 제외합니다.</li>
	<li>수술 전 확실한 다발성 폐 감염 또는 염증 및 기타 심각한 전신 질환이 있는 환자는 제외합니다.</li>
	<li>응고 장애 및 심각한 정신 또는 신경 장애가 있는 환자는 제외합니다.</li>
</ol>3. 마취 전 준비
<ol><li>수술 전 8시간 동안 환자를 금식시킵니다.</li>
	<li>실내 온도를 24°C에서 26°C 사이로 조정합니다.</li>
	<li>20G 상단 날개 주입 바늘을 손의 비수술적 등쪽 정맥에 삽입합니다.</li>
	<li>환자의 심전도, 혈압, 맥박 산소 포화도(SpO2) 및 호흡수를 모니터링합니다.</li>
	<li>BIS(bispectral index) quatro 센서를 각 환자의 이마에 적용합니다. 알림: 필요한 경우 요골 동맥압과 중심 정맥압을 지속적으로 모니터링합니다.</li>
</ol>4. 초음파 유도 흉추 주위 봉쇄
<ol><li>환자를 측면 욕창 위치에 놓습니다.</li>
	<li>초음파 프로브를 세 번째 흉추와 일곱 번째 흉추의 극돌기 바로 위에 놓고 가시돌기의 단면 이미지를 얻습니다. 참고: 이미지 중앙에는 후방 음향 그림자가 있는 고에코 극돌기가 있고, 극돌기의 양쪽에 후방 음향 그림자가 있는 뼈 구조는 순서대로 척추판과 횡돌기입니다.</li>
	<li>초음파 프로브를 측면으로 움직여 횡단 과정을 전체적으로 보여줍니다.</li>
	<li>초음파 프로브를 바깥쪽으로 움직여 횡단 과정, 횡 갈비뼈 관절 및 갈비뼈를 시각화합니다.</li>
	<li>초음파 프로브를 꼬리 방향으로 움직여 횡단 과정, 흉막 및 그 사이의 흉추 주위 공간이 이미지에서 감지됩니다.</li>
	<li>2mL의 1% 리도카인을 주사하여 피부를 국소적으로 마취합니다.</li>
	<li>초음파 유도 하에 면내 접근 방식을 사용하여 블록 바늘을 측면에서 내측으로 삽입합니다.</li>
	<li>주사하기 전에 흡인을 조심스럽게 늘리십시오. 혈액 역류가 관찰되지 않는지 확인하십시오. 참고: 이 단계의 목적은 국소 마취제로 인한 전신 독성을 방지하는 것입니다.</li>
	<li>식염수 2mL를 주입 한 다음 초음파로 흉막의 전방 변위와 흉추 주위 공간의 넓어짐을 시각화합니다.</li>
	<li>T3 및 T7 수준에서 0.375% 로피바카인 15mL를 주사합니다.</li>
</ol>5. 마취 유도
<ol><li>1% 레보부피바카인(3mL)을 목구멍에 뿌립니다.</li>
	<li>펜타닐 1.5μg/kg과 프로포폴 1-1.5mg/kg을 주사합니다.</li>
	<li>지속적인 산소 투여를 위해 페이셜 마스크를 착용하거나 후두 마스크 기도를 삽입합니다(이중 튜브 마스크, 30-50kg의 경우 #3, 50-70kg의 경우 #4, 70-100kg의 경우 #5). 산소는 안면 마스크 또는 후두 마스크를 통해 환자의 기도로 들어갑니다. 참고: 40-60 사이의 BIS 값을 달성하도록 주사 용량을 조정하십시오16.</li>
</ol>6. 마취 유지
<ol><li>0.5-1 L/min의 산소 유량을 유지하십시오.</li>
	<li>인공 기흉 후 세보플루란의 농도를 1.5%-2.0%로 유지하십시오. 참고: 수술 중 자발 호흡수가 0.5회/분 이상이거나 종격동 조동 또는 기침이 있는 경우 20μg/kg의 펜타닐을 주사합니다. 세보플루란은 안면 마스크 또는 후두 마스크를 통해 환자의 기도로 들어갑니다.</li>
	<li>흡입 산소 농도와 호기말 이산화탄소(ETCO2 < 60mmHg)를 모니터링합니다.</li>
	<li>체온을 모니터링하십시오. 의식 수준을 모니터링하고 40-6016,17의 BIS 값을 유지하십시오.</li>
	<li>환자가 부비동 서맥(HR ≤ 50회/분)이 발생하면 20μg/kg의 아트로핀을 주사합니다.</li>
	<li>수축기 혈압이 30% 또는 90mmHg 미만인 경우 주입 펌프를 사용하여 노르에피네프린 2μg/kg/h를 지속적으로 관류합니다.</li>
	<li>수술 종료 15분 전에 동맥혈 가스 분석을 수행합니다.</li>
	<li>수술 종료 30분 전에 플루르비프로펜 1mg/kg을 주사합니다.</li>
</ol>7. 흉강경 미주신경 차단 기술 및 흉막 침윤 마취
<ol><li>24G 상단 날개 주입 바늘을 사용하여 우측 시술을 수행할 때 하부 기관 수준에서 미주 신경 근처에 0.375% 로피바카인(3mL)이 침윤되도록 합니다.</li>
	<li>왼쪽 시술을 수행할 때 24G 상단 날개 주입 바늘을 사용하여 대동맥 폐창 수준에서 미주 신경 근처에 0.5% 로피바카인(3mL)을 침윤시킵니다.</li>
	<li>10mL 주사기를 사용하여 내장 흉막 표면에 2% 리도카인 10mL를 뿌립니다.</li>
</ol>8. 비삽관 마취에서 삽관 전신 마취로의 전환
<ol><li>환자가 다음 조건 중 하나를 충족하는 경우 삽관되지 않은 마취를 삽관된 전신 마취로 전환하십시오. ᆞ 심한 저산소 혈증 (맥박 산소 측정 < 80%) -심한 고탄산혈증(PaCO2 > 80mmHg) -혈역학 적 불안정성 : 난치성 부정맥 및 우심실 부전 - 지속적인 기침으로 인해 수술이 어렵거나 불가능해지는 경우 - 개흉술이 필요한 수술 중 출혈</li>
</ol>9. 수술 후 관리
<ol><li>완전히 깨어난 후 환자에게 심호흡과 기침을 하여 허탈된 폐를 다시 확장하도록 요청하십시오.</li>
	<li>PCA 저장소 백(1μg/kg 및 0.9% 염화나트륨 주사액 포함)에 100mL 용액을 넣고 환자 제어 정맥 진통제(PCA) 펌프를 정맥 카테터에 연결하고 PCA 용액 2mL/h를 적정합니다.</li>
	<li>기침 시 공기 누출이 없고, 흉부 X-레이 검사에서 명백한 체액 기흉이 없고, 24시간 동안 <300mL의 배액이 있을 때 흉부 배액관을 제거합니다.</li>
</ol>

자율 호흡이 보존된 비디오 보조 흉강경 수술을 위한 비삽관 프로토콜

저자는 공개 할 것이 없습니다.

이 프로토콜의 장점은 다음과 같다: (i) 흉강경 수술 동안 기침 반사를 감소시키기 위해 세보플루란 흡입 마취 요법을 제공하는 것; (ii) 흉부 수술을 받는 환자에게 안전하고 통증 없는 수술 환경을 제공하면서 과도한 진정을 최소화합니다. (iii) 관련 기술적 문제를 고려하여 시술 중 환자의 자발 호흡 및 종격동 진동을 최소화합니다. 이것은 선제적 수술 중 국소 마취를 제공함으로써 달성되었습니...

지난 10년 동안, 비삽관 비디오 보조 흉부 수술(NIVATS) 마취가 임상 실습에서 점진적으로 받아들여졌다 1,2,3. 이 새로운 전략이 환자의 빠른 회복을 촉진하고 전신 마취(general anestia, GA) 및 단폐 인공호흡(one-lung ventilation)4의 합병증을 예방하지만, 많은 외과의사들은 이 접근법이 전통적인 폐 격리 기법보다 덜 바람직하다고 생각한다.
혈중 산소 수치는 나이가 들면서 감소하며 일부 환자는 폐 기능이 저하되거나 경계선이 있을 수 있습니다. GA는 마취 지연, 기도 합병증, 쉰 목소리, 저산소증 및 아리테노이드 탈구를 포함하여 이러한 환자에서 합병증의 위험 증가와 관련될 수 있습니다 5,6,7,8,9. 이와는 대조적으로, 여러 연구에서 NIVATS로 관리되는 환자들의 입원 기간이 짧고, 저위험 환자들의 전신 마취에 비해 호흡기 합병증이 감소한 것으로 나타났다10; 또한, 폐 기능이 매우 열악한 고위험 환자에서도 성공적인 수술이 보고되었다11,12,13.
수술 중 자발 환기는 신중하게 투여된 국소 마취 또는 진정제가 보충된 국소 신경 차단술로 이루어지지만 NIVATS 동안 예상치 못한 폐 운동을 동반한 기침 반사는 문제가 될 수 있습니다. 수술 절차를 방해할 수 있는 종격동 조동, 자극성 기침 또는 빈호흡증에 대한 표준 치료법은 거의 강조되지 않습니다. 예비 관찰에서 결과는 세보플루란이 자발 호흡을 유지하면서 NIVATS 동안 호흡수와 종격동 조동의 발생을 감소시킬 수 있음을 보여주었습니다14. 따라서 세보플루란 흡입이 기침을 예방하고 기계적 환기 요구량을 줄여 수술 후 폐 합병증(PPC)을 줄일 수 있다는 가설을 세울 수 있습니다.
첫째, 이 보고서는 삽관되지 않은 비디오 보조 흉강경 수술의 실행을 자세히 설명하는 단계별 프로토콜을 제시합니다. 둘째, 수술 후 결과에 대한 비삽관 마취의 잠재적 이점을 조사하기 위한 후향적 연구가 수행되었습니다.

<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

전신 마취 하에서 이중 내강 삽관은 현재 폐렴 절제술, 폐의 쐐기 절제술 및 폐엽 절제술을 위해 가장 일반적으로 수행되는 삽관 기술입니다. 그러나 기관 삽관으로 전신 마취로 인해 발생하는 폐 합병증의 발생률이 높습니다. 자발적인 호흡을 보존하는 비 삽관은 마취의 대안입니다. 비삽관 절차는 삽관 관련 기도 외상, 환기 유발 폐 손상, 잔류 신경근 차단, 수술 후 메스꺼움 및 구토와 같은 기관 삽관 및 전신 마취의 부작용을 최소화합니다. 그러나 비 삽관 절차의 단계는 많은 연구에서 자세히 설명되지 않습니다. 여기에서는 자율신경 호흡이 보존된 비디오 보조 흉강경 수술을 수행하기 위한 간결한 비삽관 프로토콜을 제시합니다. 이 기사에서는 비삽관 마취에서 삽관 마취로 전환하는 데 필요한 조건을 식별하고 비삽관 마취의 장점과 한계에 대해서도 논의합니다. 이 연구에서이 개입은 58 명의 환자에게 수행되었습니다. 또한 후향적 연구 결과가 제시됩니다. 삽관 전신 마취에 비해 삽관되지 않은 비디오 보조 흉부 수술 그룹의 환자는 수술 후 폐 합병증 발생률이 낮았고, 수술 시간이 짧았으며, 수술 중 출혈이 적고, PACU 체류 기간이 짧고, 흉부 배액 제거 일수가 적고, 수술 후 배액이 적고, 입원 기간이 짧았다.

2016년 1월부터 2022년 12월까지 비삽관 비디오 흉강경 수술을 받은 연속 환자 58명에 대한 임상 데이터를 후향적으로 수집했습니다. 환자들은 마취과 의사의 수술 전 방문을 받았고 마취 전에 마취 동의서의 내용에 대한 자세한 설명을 제공받았습니다. 환자는 마취의 두 그룹(NIVATS 그룹 또는 GA 그룹) 중 하나를 선택할 수 있었고 정보에 입각한 동의서에 서명했습니다.
GA 그룹의 ?...

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

저자 스포트라이트: Multimodal Analgesia and Sevoflurane Inhalation Anesthesia를 이용한 Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia(다중 모드 진통 및

여기에서는 자율신경 호흡이 보존된 비디오 보조 흉강경 수술을 수행하기 위한 비삽관 프로토콜을 제시합니다.

삽관되지 않은 비디오 보조 흉강경 수술

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

이 연구는 삽관되지 않은 비디오 보조 흉강경 수술의 실행을 자세히 설명하는 단계별 프로토콜을 제시합니다. NIVATS의 프로토콜은 초음파 유도 흉추 주위 차단을 포함한 복합 진통제를 기반으로 합니다. 흉강경은 블록을 만들고 복수 침윤 마취를 만듭니다.복합 진통제는 수술 중 통증을 효과적으로 완화하고 기침 반사를 억제합니다. 이 프로토콜은 흉강경 수술 중 기침 반사를 줄이고 과진정을 최소화하는 동시에 환자에게 안전하고 통증 없는 수술 환경을 제공하기 위해 세보플루란 흡입 마취 요법을 제공합니다. 우리는 환자의 자발 호흡을 유지하고 시술 중 종격동 진동을 최소화하는 동시에 관련 보조 기술 문제를 고려합니다.

non-intubated-video-assisted-thoracoscopic-surgery

Research

JoVE Journal

Medicine

Non-Intubated Video-Assisted Thoracoscopic Surgery

1.3K 조회수.  Second Affiliated Hospital of Zhejiang University School of Medicine. 이 연구는 삽관되지 않은 비디오 보조 흉강경 수술의 실행을 자세히 설명하는 단계별 프로토콜을 제시합니다. NIVATS의 프로토콜은 초음파 유도 흉추 주위 차단을 포함한 복합 진통제를 기반으로 합니다. 흉강경은 블록을 만들고 복수 침윤 마취를 만듭니다.복합 진통제는 수술 중 통증을 효과적으로 완화하고 기침 반사를 억제합니다. 이 프로토콜은 흉강경 수술 중 기침 ...

비디오: 저자 스포트라이트: Multimodal Analgesia and Sevoflurane Inhalation Anesthesia를 이용한 Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia(다중 모드 진통 및

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.

쥐의 굴근 힘줄 손상 및 복구 수술

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

연구

의학

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.

로봇 수술에 긴급 도킹 해제: 시뮬레이션 커리큘럼

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

Intra-Operative Neural Monitoring of Thyroid Surgery in a Porcine Model

Intraoperative injury to the recurrent laryngeal nerve (RLN) can cause vocal cord paralysis, which interferes with speech and can potentially interfere with breathing. In recent years, intraoperative neural monitoring (IONM) has been widely adapted as an adjunct technique to localize the RLN, detect RLN injury, and predict vocal cord function during the operations. Many studies have also used animal models to investigate new applications of IONM technology and to develop reliable strategies for preventing intraoperative RLN injury. The aim of this article is to introduce a standard protocol for using a porcine model in IONM research. The article demonstrates the procedures for inducing general anesthesia, performing tracheal intubation, and experimental design to investigate the electrophysiological characteristics of RLN injuries. Applications of this protocol can improve overall efficacy in implementing the 3R principle (replacement, reduction and refinement) in porcine IONM studies.

This study aims to develop a standard protocol of intra-operative neural monitoring of thyroid surgery in a porcine model. Here, we present a protocol to demonstrate general anesthesia, to compare different types of electrodes, and to investigate the electrophysiological characteristics of the normal and injured recurrent laryngeal nerves.

돼지 모델에서 갑 상선 수술의 내부 작용 신경 모니터링

Intraoperative injury to the recurrent laryngeal nerve (RLN) can cause vocal cord paralysis, which interferes with speech and can potentially interfere ...

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.

척추 수술의 수술 중 초음파

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.

최소 침습적 흉부 수술을 위한 전자기 네비게이션 흉부 결절 국소화

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.

해부 실험실에서 현대 후두 수술 배우기

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.

등골 수술의 현미경 횡단 접근법 재검토

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.

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.

내시경 담즙 줄기 종 수술

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

Polytetrafluoroethylene (PTFE) as a Suture Material in Tendon Surgery

With the evolution of suture materials, there has been a change in paradigms in primary and secondary tendon repair. Improved mechanical properties allow more aggressive rehabilitation and earlier recovery. However, for the repair to hold against higher mechanical demands, more advanced suturing and knotting techniques must be assessed in combination with those materials. In this protocol, the use of polytetrafluoroethylene (PTFE) as a suture material in combination with different repair techniques was investigated. In the first part of the protocol, both linear tension strength and elongation of knotted against not-knotted strands of three different materials used in flexor tendon repair were evaluated. The three different materials are polypropylene (PPL), ultra-high molecular weight polyethylene with a braided jacket of polyester (UHMWPE), and polytetrafluoroethylene (PTFE). In the next part (ex vivo experiments with cadaveric flexor tendons), the behavior of PTFE using different suture techniques was assessed and compared with PPL and UHMWPE.
This experiment is comprised of four steps: harvesting of the flexor tendons from fresh cadaveric hands, transection of the tendons in a standardized manner, tendon repair by four different techniques, mounting, and measurement of the tendon repairs on a standard linear dynamometer. The UHMWPE and PTFE showed comparable mechanical properties and were significantly superior to PPL in terms of linear traction strength. Repairs with four- and six-strand techniques proved stronger than two-strand techniques. Handling and knotting of PTFE are a challenge due to very low surface friction but fastening of the four- or six-strand repair is comparatively easy to achieve. Surgeons routinely use PTFE suture material in cardiovascular surgery and breast surgery. The PTFE strands are suitable for use in tendon surgery, providing a robust tendon repair so that early active motion regimens for rehabilitation can be applied.

Polytetrafluoroethylene PTFE as a Suture Material in Tendon Surgery

The present protocol illustrates a method for assessing the biophysical properties of tendon repairs ex vivo. A polytetrafluoroethylene (PTFE) suture material was evaluated by this method and compared to other materials under different conditions.

힘줄 수술에서 봉합사로 사용되는 폴리테트라플루오로에틸렌(PTFE)

With the evolution of suture materials, there has been a change in paradigms in primary and secondary tendon repair. Improved mechanical properties allow ...