Bu çalışma Helsinki Bildirgesi ve yerel klinik etik kuruluna (2018/09) uygun olarak yürütülmüştür.
1. Fizik Muayene
NOT: TOS tanısı için provokatif testler Şekil 1'de gösterilmektedir.
<ol><li>Adson testi için (skalen testi, Şekil 1A), hastanın omzunu hafif abdüksiyon ve biraz ekstansiyon ile dış rotasyona getirin ve radyal nabzı palpe edin. Hastanın başını geriye doğru uzatın ve test edilen omzuna doğru döndürün. Hastadan nefes almasını ve nefesini tutmasını isteyin.<ol><li>Semptomların çoğalması veya radyal nabzın ortadan kaldırılması durumunda, semptomlar başın tartışmalı tarafa dönmesiyle düzelirken testi pozitif olarak düşünün.</li>
	</ol></li>
	<li>Kostoklaviküler korse testi için (Şekil 1B), hastanın kolunu arkaya getirin, ipsilateral taraftaki hastanın kürek kemiğini bastırın ve geri çekin. Nabzı kontrol edin. Radyal nabız kaybolursa veya semptomlar tekrarlanırsa, test pozitif kabul edilir.</li>
	<li>Hiperabdüksiyon testi için (Şekil 1C), hastanın kolunu hafifçe uzatın ve radyal arteri palpe edin. Kolu 90-180° kaçırın. Pozitif bir test, radyal arterin nabzında başlangıçtan yeni pozisyona bir azalmadır.</li>
	<li>Roos (Doğu) testi için (Şekil 1D), testi oturma veya ayakta durma pozisyonunda gerçekleştirin. Hastanın omuzlarını 90° abdüksiyona götürün, dışarıdan döndürün ve dirsekleri 90°'ye kadar bükün. Dirsekler ön düzlemin biraz arkasında olmalıdır. Hastanın 3 dakika boyunca ellerini açıp kapatmasını sağlayın.<ol><li>Hasta ağırlık, iskemik ağrı veya kollarda güçsüzlük veya ellerde uyuşma ve karıncalanma yaşarsa testi pozitif olarak düşünün. Ellerdeki renk değişikliği de test için anlamlıdır. NOT: VTOS olgularında cerrahi tedavi ilk seçenek iken, NTOS olgularında 3 aylık konservatif tedaviden sonra günlük yaşamlarında, iş yaşamlarında ve uyku kalitelerinde düzelme olmadan cerrahi tedavi uygulanmaktadır.</li>
	</ol></li>
</ol>2. Preoperatif klinik ve elektrodiagnostik değerlendirme
<ol><li>Cerrahi tedavi ile klinik iyileşmenin değerlendirilmesi için fizik muayenede klinik bulgular, EMG bulguları ve QuickDASH (Kol, Omuz ve El Özürlülüğü: <a href="https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf">https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf</a>) anketi ile günlük aktivitelerin semptomları ile ilgili sosyal ve psikolojik preoperatif dönemler gereklidir.</li>
	<li>Bileşik motor aksiyon potansiyeli (CMAP), duyusal sinir aksiyon potansiyeli (SNAP), sinir iletim hızı (NCV) ve F dalgası latansını ölçerek preoperatif EMG'leri belirleyin. Ticari bir EMG/NCV/EP ölçüm sistemi kullanarak kayıt yapın (örneğin, Nihon Kohden Neuropack 2).</li>
</ol>3. Transaksiller ilk kaburga rezeksiyonu kademeli olarak
<ol><li>0.6 mg / kg roküronyum bromür, 0.05 mg / kg midazolam ve 1-2 μg / kg fentanil içeren standart bir anestezik indüksiyon protokolü kullanarak anestezi uygulayın.</li>
	<li>Bakım için 6 mg / kg'da tiopental sodyum uygulayın.</li>
</ol>4. Hasta pozisyonu (Şekil 2)
<ol><li>Hastayı lateral dekübit pozisyonuna getirdikten sonra kolu sarın, kaldırın ve 90° abdüksiyon pozisyonunda asın. Gerekirse, postoperatif komplikasyonu önlemek için her 3-5 dakikada bir traksiyonu azaltın.</li>
	<li>Topikal sterilizasyon için% 10 steril povidon-iyot çözeltisi kullanın. Kolu, koltuk altını ve göğsü örtün. Kontaminasyonu önlemek için vücudun geri kalanına steril çarşaflar kullanın.</li>
</ol>5. İlk kaburgaya ulaşmak
<ol><li>Cerrahi aletlerin kullanımı Şekil 3'te ve Malzeme Tablosunda gösterilmiştir.</li>
	<li>Pektoralis kasından öne doğru uzanan aksiller saç çizgisinin altından, arkada latissimus dorsi kasından 5-7 cm uzunluğunda enine bir kesi yapın.</li>
	<li>Göğüs ön duvarına ulaşmak için cildi, deri altı dokusunu ve fasyayı çaprazlayın.</li>
	<li>İlk kaburgaya ulaşmak için künt diseksiyon kullanın.</li>
</ol>6. İlk kaburganın kaslardan ve fasyadan serbest bırakılması
<ol><li>İlk kaburganın üzerindeki fasyayı delin ve kaburganın üst kısmını kaplayan periosteumu inceleyin. Monopolar koter ve kaburga raspatory kullanarak kaburganın alt kenarını çevreleyen kaslardan künt bir şekilde inceleyin.</li>
	<li>İnterkostal kasları, sternokostal bileşkede kostoklaviküler ligamente ve posterior kosovertebral bileşkede açısal kostaya kadar ayırın.</li>
	<li>İlk kaburganın üst kenarında, anterior skalen kasını anteriorda ve medius skalen kasını arkada ortaya çıkarın. Kavisli forsepsleri ön ve orta skalen kasların altına yerleştirin ve kasları, nörovasküler demetten en uzak oldukları ilk kaburga üzerine yerleştirildikleri seviyede kesin.</li>
</ol>7. İlk kaburganın veya servikal kaburganın çıkarılması
<ol><li>İlk kaburganın rezeksiyonuna sternokostal bileşkede anteriordan başlayın. Sternumdan bir kaburga kesici kullanarak rezeke etmek için önce üst kenarından ve ardından alt kenarından çevirin. Nörovasküler yapıların korunduğundan emin olun.</li>
	<li>Daha sonra, kaburganın arka kısmını rezeke edin ve kaburga açısına distal olarak bulunan kısmı ayırın; Bu nedenle kaburga rezeksiyonunu tamamlayın.</li>
	<li>Servikal kaburgayı çevreleyen dokudan tamamen serbest bıraktıktan sonra, enine işlemin eklem yüzeyi görülene kadar kaburgayı rezeke edin ve parçalayın.</li>
</ol>8. Ameliyat Sonrası Dönem
<ol><li>Postoperatif dönemde, pnomotoraks gibi komplikasyonları ekarte etmek için göğüs röntgeni çekin.</li>
	<li>Sorunsuz vakalarda postoperatif 1. günde toraks drenini çıkarın.</li>
	<li>Postoperatif ağrı için steroid olmayan antienflamatuar ilaçlar, narkotik analjezikler ve kas gevşetici kullanın.</li>
	<li>Ameliyat sonrası erken dönemde, ameliyat edilen taraftaki kolun hareketini inceleyin. Ameliyat sonrası ilk iki ay fizik tedaviye devam edin.</li>
	<li>Hastaya ameliyat edilen tarafla herhangi bir yorucu aktivite yapmamasını tavsiye edin.</li>
</ol>9. Postoperatif klinik ve elektrodiagnostik değerlendirme
<ol><li>Cerrahi tedavi ile klinik iyileşmenin değerlendirilmesi için fizik muayenedeki klinik bulguları, EMG bulgularını ve QuickDASH (Kol, Omuz ve El Özürlülüğü: <a href="https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf">https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf</a>) anketi ile günlük aktivite semptomları ile ameliyat öncesi ve sonrası (3 ay) dönemleri karşılaştırınız.</li>
	<li>Bileşik motor aksiyon potansiyeli (CMAP), duyusal sinir aksiyon potansiyeli (SNAP) ve sinir iletim hızı (NCV) ve F dalgası latansını ölçerek preoperatif ve postoperatif EMG'leri karşılaştırın. Ticari bir EMG/NCV/EP ölçüm sistemi kullanarak kayıt yapın (örneğin, Nihon Kohden Neuropack 2).</li>
	<li>Ağrı ve paresteziyi değerlendirmek için ameliyat sonrası fizik muayene yapın.</li>
</ol>

<ol>
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M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+evaluation+of+a+therapeutic+exercise+program.">Thoracic outlet syndrome: evaluation of a therapeutic exercise program.</a> InProc Mayo Clinic. 31, 281-287 (1956).</li><li>Han, 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=Transaxillary+approach+in+thoracic+outlet+syndrome:+the+importance+of+resection+of+the+first-rib.">Transaxillary approach in thoracic outlet syndrome: the importance of resection of the first-rib.</a> European Journal of Cardio-Thoracic Surgery. 24 (3), 428-433 (2003).</li><li>Yavuzer, &. #. 3. 5. 0. ;., Atinkaya, C., Tokat, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+predictors+of+surgical+outcome+in+patients+with+thoracic+outlet+syndrome+operated+on+via+transaxillary+approach.">Clinical predictors of surgical outcome in patients with thoracic outlet syndrome operated on via transaxillary approach.</a> European Journal of Cardio-Thoracic Surgery. 25 (2), 173-178 (2004).</li><li>Roos, D. 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C., 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=Lessons+learned+in+the+surgical+treatment+of+neurogenic+thoracic+outlet+syndrome+over+10+years.">Lessons learned in the surgical treatment of neurogenic thoracic outlet syndrome over 10 years.</a> Vascular and Endovascular Surgery. 49 (1-2), 8-11 (2015).</li><li>Akku&#351;, M., Ya&#287;murlu, K., &#214;zarslan, M., Kalani, M. Y. <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+neurogenic+thoracic+outlet+syndrome+based+on+electrodiagnostic+tests+and+QuickDASH+scores.">Surgical outcomes of neurogenic thoracic outlet syndrome based on electrodiagnostic tests and QuickDASH scores.</a> Journal of Clinical Neuroscience. 58, 75-78 (2018).</li><li>Peek, J., 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=Long-term+functional+outcome+of+surgical+treatment+for+thoracic+outlet+syndrome.">Long-term functional outcome of surgical treatment for thoracic outlet syndrome.</a> Diagnostics. 8 (1), 7 (2018).</li><li>Sanders, R. J., Annest, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technique+of+supraclavicular+decompression+for+neurogenic+thoracic+outlet+syndrome.">Technique of supraclavicular decompression for neurogenic thoracic outlet syndrome.</a> Journal of Vascular Surgery. 61 (3), 821-825 (2015).</li><li>Sanders, R. J., Hammond, S. L., Rao, N. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+a+review.">Thoracic outlet syndrome: a review.</a> The Neurologist. 14 (6), 365-373 (2008).</li><li>Vos, C. G., &#220;nl&#252;, &. #. 1. 9. 9. ;., Vo&#251;te, M. T., van de Mortel, R. H., de Vries, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+First+rib+resection.">Thoracic outlet syndrome: First rib resection.</a> Shanghai Chest. 1 (1), (2017).</li><li>Desai, S. 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=Outcomes+of+surgical+paraclavicular+thoracic+outlet+decompression.">Outcomes of surgical paraclavicular thoracic outlet decompression.</a> Annals of vascular surgery. 28 (2), 457-464 (2014).</li><li>Peek, J., 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=Long-term+functional+outcome+of+surgical+treatment+for+thoracic+outlet+syndrome.">Long-term functional outcome of surgical treatment for thoracic outlet syndrome.</a> Diagnostics. 8 (1), 7 (2018).</li><li>Urschel, H. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transaxillary+first+rib+resection+for+thoracic+outlet+syndrome.">Transaxillary first rib resection for thoracic outlet syndrome.</a> Operative Techniques in Thoracic and Cardiovascular Surgery. 10 (4), 313-317 (2005).</li><li>Sheth, R. N., Campbell, J. N. <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+thoracic+outlet+syndrome:+a+randomized+trial+comparing+two+operations.">Surgical treatment of thoracic outlet syndrome: a randomized trial comparing two operations.</a> Journal of Neurosurgery: Spine. 3 (5), 355-363 (2005).</li><li>Urschel, H. C., Razzuk, 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=Neurovascular+compression+in+the+thoracic+outlet:+changing+management+over+50+years.">Neurovascular compression in the thoracic outlet: changing management over 50 years.</a> Annals of Surgery. 228 (4), 609 (1998).</li><li>Povlsen, B., Hansson, T., Povlsen, S. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+for+thoracic+outlet+syndrome.">Treatment for thoracic outlet syndrome.</a> Cochrane Database of Systematic Reviews. 11, (2014).</li><li>George, R. S., Milton, R., Chaudhuri, N., Kefaloyannis, E., Papagiannopoulos, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Totally+endoscopic+(VATS)+first+rib+resection+for+thoracic+outlet+syndrome.">Totally endoscopic (VATS) first rib resection for thoracic outlet syndrome.</a> The Annals of Thoracic Surgery. 103 (1), 241-245 (2017).</li><li>Strother, E., Margolis, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+first+rib+resection.">Robotic first rib resection.</a> Operative Techniques in Thoracic and Cardiovascular Surgery. 20 (2), 176-188 (2015).</li></ol>

TFRR, TOS 9,10,11 tedavisinde en çok kullanılan cerrahi tekniktir. TFRR'nin avantajı, cerrahi alana ulaşmak için kasların kesilmesine gerek kalmadan koltuk altında gizli bir kesi ile daha iyi bir kozmetik sonuç sağlamasıdır. Dezavantajı nispeten dar ve derin çalışma alanıdır. Arteriyel TOS tedavisi için tercih edilen supraklaviküler yaklaşım, subklavyen arteri daha az hasar riskine sokar12<...

Brakiyal pleksus, subklavyen arter veya venin skalen üçgeninde sıkışması klinik olarak torasik çıkış sendromu (TOS) olarak bilinir ve ilk olarak Peet ve ark.1 tarafından tanımlanır. Torasik outlet sendromu, altta yatan etiyolojiye göre nörojenik (NTOS), arteriyel TOS ve venöz TOS olarak alt bölümlere ayrılır1. NTOS'lu hastalar (TOS vakalarının% 93-95'i) ağrı, uyuşukluk ve ipsilateral güçsüzlük ile başvururlar. Venöz TOS'lu hastalar (%3-5) venöz tromboz, arteriyel TOS'lu hastalar (%1-2) arteriyel tromboembolik olay ve iskemi ile başvururlar. TOS'un konservatif yönetimi, ilaçları ve fizyoterapiyi içerir ve TOS vakaları için ilk tercihtir. Cerrahi tedavi yöntemleri dekompresyon prosedürlerini içerir ve konservatif tedavi başarısız olduktan sonra uygulanır2. Dekompresyon teknikleri arasında transaksiller birinci kaburga rezeksiyonu (TFRR), supraklaviküler birinci kaburga rezeksiyonu skalenektomi (SFRRS), skalektomi (supraklaviküler veya transaksiller yoluyla ilk kaburga rezeksiyonu olmadan) ve posterior yaklaşım ilk kaburga rezeksiyonu (PA-FRR) bulunur3. Roos ve arkadaşları tarafından 1966 yılında tanımlanan bir teknik olan transaksiller ilk kaburga rezeksiyonu, TOS 4,5'in tedavisinde etkili bir yöntemdir. TFRR'nin temel amacı son servikal ve birinci torasik kaburgaların tamamen çıkarılması ve alttaki nörovasküler demeti dekompresyona uğratılmasıdır.
Vasküler TOS (VTOS) tanısı BT anjiyografi, renkli dupleks USG ve arteriyografi veya venografi ile konurken, NTOS tanısı X-ışını, elektrodiagnostik çalışmalar (iğne elektromiyelografisi), renkli dupleks Doppler USG ve servikal MRG ile konur. Ameliyat öncesi diğer bozuklukların dışlanması için fizyoterapist ve psikiyatrist konsültasyonları alınmalıdır. Anterior skalen kasına lidokain enjeksiyonu ile semptomların giderilmesi de NTOS hastalarında tanı ve cerrahi yararın öngörücüsü için iyi bir göstergedir6.

<table>
	<tbody>
		<tr>
			<td>Ag Debakey vascular forceps 24 cm, 3.5 mm</td>
			<td>Lawton medizintechnik</td>
			<td>30-0032</td>
			<td>Check the hemorrhage</td>
		</tr>
		<tr>
			<td>Bone chisels curved 13x9.1/2&#39;&#39;</td>
			<td>Aesculap Inc.</td>
			<td>MB-992R</td>
			<td>Dissect the periost of the first rib</td>
		</tr>
		<tr>
			<td>Doyen-stille retractor 24 cm</td>
			<td>Lawton medizintechnik</td>
			<td>20-0650</td>
			<td>Skin- muscle retraction</td>
		</tr>
		<tr>
			<td>Foerster sponge forceps straight</td>
			<td>Lawton medizintechnik</td>
			<td>07-0156</td>
			<td>For swabbing</td>
		</tr>
		<tr>
			<td>Luer stille bone rongeur curved 27 cm</td>
			<td>Lawton medizintechnik</td>
			<td>38-0703</td>
			<td>Bone punches</td>
		</tr>
		<tr>
			<td>Luer stille rongeur straight 22 cm</td>
			<td>Lawton medizintechnik</td>
			<td>38-0400</td>
			<td>Rib cutter</td>
		</tr>
		<tr>
			<td>Mayo hegar needle holder 20.5 cm</td>
			<td>Lawton medizintechnik</td>
			<td>08-0184</td>
			<td>Suturing</td>
		</tr>
		<tr>
			<td>Metzenbaum scissors curved delicate 23 cm</td>
			<td>Lawton medizintechnik</td>
			<td>05-0665</td>
			<td>Dissection</td>
		</tr>
		<tr>
			<td>Overholt curved forceps delicate 30.5 cm</td>
			<td>Lawton medizintechnik</td>
			<td>06-0807</td>
			<td>Split the scalen muscles from the rib</td>
		</tr>
		<tr>
			<td>Roberts art forceps straight 24 cm</td>
			<td>Lawton medizintechnik</td>
			<td>06-0370</td>
			<td>For sponge and remove remain bone</td>
		</tr>
		<tr>
			<td>Roux retractor medium size 15.5 cm</td>
			<td>Lawton medizintechnik</td>
			<td>20-0402</td>
			<td>Wound retraction</td>
		</tr>
		<tr>
			<td>Semb rasparotry 22,5 cm, 12mm</td>
			<td>Lawton medizintechnik</td>
			<td>39-0252</td>
			<td>Dissect the muscle of the first rib</td>
		</tr>
		<tr>
			<td>Smith peterson model curved osteotome 13x205 mm</td>
			<td>Lawton medizintechnik</td>
			<td>46-0783</td>
			<td>Dissect the muscle of the first rib</td>
		</tr>
		<tr>
			<td>Stille -giertz rib shears 27 cm</td>
			<td>Lawton medizintechnik</td>
			<td>38-0200</td>
			<td>First rib cutting</td>
		</tr>
		<tr>
			<td>Stille osteotome 8x205 mm</td>
			<td>Lawton medizintechnik</td>
			<td>46-0248</td>
			<td>Dissect the periost of the first rib</td>
		</tr>
		<tr>
			<td>Wagner rongeur 5.5x210 mm</td>
			<td>Lawton medizintechnik</td>
			<td>53-0703</td>
			<td>Punches</td>
		</tr>
	</tbody>
</table>

transaxillary first rib resection for treatment of the thoracic outlet syndrome

Torasik outlet sendromu (TOS), önemli bir üretkenlik kaybına neden olan yaygın bir hastalıktır. TOS'da sıkışan nörovasküler yapıların dekompresyonu için transaksiller birinci kaburga rezeksiyonu (TFRR) protokolü kullanılmıştır. Diğer cerrahi prosedürler arasında TFRR'nin avantajı, en düşük nüks oranına ve daha iyi kozmetik sonuçlara sahip olmasıdır. TFRR'nin dezavantajı, vasküler kontrolün sağlanmasını zorlaştıran dar ve derin bir çalışma koridoru sağlamasıdır.

Klinik Sonuçlar Bu çalışmaya toplam 15 hasta dahil edildi. Hastaların üçü (%20) erkek, 12'si (%80) kadındı. Hastaların yaş ortalaması 30.6 ± 8.98 idi. Erkek katılımcıların tamamı ve kadın katılımcıların 5'i beden işçisiydi. NTOS grubunun en sık şikayeti kol-önkol ağrısı ve uyuşma, kavrama güçsüzlüğü ve hipotenar atrofi idi. Postoperatif klinik takipte hastalara parestezi ve ağrı şiddeti, genel memnuniyet, aktivite ve iş durumları soruldu. QuickDASH skorları...

Watch this Scientific Journal Video about Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome at JoVE.com

Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Burada, brakiyal pleksus, subklavyen ven ve arterin basısı sonucu oluşan torasik outlet sendromunun tedavisi için birinci kaburganın transaksiller rezeksiyonu protokolü sunulmaktadır.

Torasik Outlet Sendromunun Tedavisi için Transaksiller Birinci Kaburga Rezeksiyonu

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol ...

transaxillary-first-rib-resection-for-treatment-thoracic-outlet

Research

JoVE Journal

Medicine

2.7K Görüntüleme.  Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital. Burada, brakiyal pleksus, subklavyen ven ve arterin basısı sonucu oluşan torasik outlet sendromunun tedavisi için birinci kaburganın transaksiller rezeksiyonu protokolü sunulmaktadır.

Video: Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Isolated Hepatic Perfusion as a Treatment for Liver Metastases of Uveal Melanoma

Isolated hepatic perfusion (IHP) is a procedure where the liver is surgically isolated and perfused with a high concentration of the chemotherapeutic agent melphalan. Briefly, the procedure starts with the setup of a percutaneous veno-venous bypass from the femoral vein to the external jugular vein. Via a laparotomy, catheters are then inserted into the proper hepatic artery and the caval vein. The portal vein and the caval vein, both supra- and infrahepatically, are then clamped. The arterial and venous catheters are connected to a heart lung machine and the liver is perfused with melphalan (1 mg/kg body weight) for 60 min. This way it is possible to locally perfuse the liver with a high dose of a chemotherapeutic agent, without leakage to the systemic circulation.
In previous studies including patients with isolated liver metastases of uveal melanoma, an overall response rate of 33-100% and a median survival between 9 and 13 months, have been reported. The aim of this protocol is to give a clear description of how to perform the procedure and to discuss IHP as a treatment option for liver metastases of uveal melanoma.

Here, we present a protocol how to perform an isolated liver perfusion (IHP) with melphalan and we also discuss IHP as a treatment option for liver metastases of uveal melanoma.

Uveal Melanom Karaciğer Metastazlı için bir tedavi olarak izole Karaciğer Perfüzyon

Isolated hepatic perfusion (IHP) is a procedure where the liver is surgically isolated and perfused with a high concentration of the chemotherapeutic ...

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Surgical Models of Gastroesophageal Reflux with Mice

Multiple surgical procedures have been reported to induce gastroesophageal reflux in animals. Herein, we report three surgical models with mice aiming to induce reflux of gastric contents, duodenal contents or mixed contents. Surgical procedures and general principles have been described in detail. A researcher with surgical experience should be able to grasp the technique after a short period of practice. After surgery, most mice can survive and develop reflux esophagitis similar to that in humans. However, it should be noted that histological differences between mouse and human esophagus are the inherent limitations of these surgical models. If used for research on Barrett&#8217;s esophagus and adenocarcinoma, these procedures may need to be combined with genetic modifications.

This article demonstrates surgical procedures of gastroesophageal reflux with mice. These models are useful tools for research on mechanisms and treatment of gastroesophageal reflux disease and potentially Barrett&#8217;s esophagus and esophageal adenocarcinoma.

Fare ile Gastroözofageal Reflü Cerrahi Modelleri

Multiple surgical procedures have been reported to induce gastroesophageal reflux in animals. Herein, we report three surgical models with mice aiming to ...

Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control seizures. However, a significant minority of patients continues to exhibit post-operative seizures, even in those cases in which the suspected source of seizures has been correctly localized and resected. The protocol presented here combines a clinical procedure routinely employed during the pre-operative evaluation of temporal lobe epilepsy (TLE) patients with a novel technique for network analysis. The method allows for the evaluation of the temporal evolution of mesial network parameters. The bilateral insertion of foramen ovale electrodes (FOE) into the ambient cistern simultaneously records electrocortical activity at several mesial areas in the temporal lobe. Furthermore, network methodology applied to the recorded time series tracks the temporal evolution of the mesial networks both interictally and during the seizures. In this way, the presented protocol offers a unique way to visualize and quantify measures that considers the relationships between several mesial areas instead of a single area.

This protocol describes a procedure to track the evolution of mesial network measures in temporal lobe epilepsy (TLE) patients. It is based on the combination of intracranial recordings with a novel numerical technique for data analysis. Specifically, we present a protocol for network analyses of foramen ovale recordings.

İlaca dirençli Temporal Lob Epilepsi Hastalarında Foramen Ovale Elektrot Kayıtları Ağ Analizi

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control ...

Laparoscopy-endoscopy Cooperative Surgery for the Treatment of Gastric Gastrointestinal Stromal Tumors

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this approach makes an innovative improvement in the treatment of G-GISTs that are less than 5 cm in size. Laparoscopy-endoscopy cooperative surgery (LECS) is used to combine endoscopic and laparoscopic surgeries, fully realizing their respective advantages and avoiding their drawbacks. The main steps are as follows. First, gastroscopy and laparoscopy are combined to confirm the location and boundary of the tumor. Tumor resection is carried out laparoscopically, guided by a gastroscope. The specimen is removed orally and the gastric wound closed laparoscopically. Then, gastroscopy and laparoscopy are combined to determine whether there is wound bleeding, if the suture is satisfactory, and if the gastric cavity is deformed.
LECS has natural advantages in the treatment of G-GISTs that are less than 5 cm in size. The accurate estimation of tumor location and boundary greatly improves the complete resection rate of tumors. The risk of tumor rupture is substantially reduced, and the long-term prognosis of patients is significantly improved. The process allows for accurate resection of the tumor, maximum preservation of normal gastric tissue and organ function, and avoids postoperative gastric deformation. The patient's postoperative rehabilitation is greatly accelerated, and oral feeding can resume on the day of the operation. The specimen is taken out through the mouth to avoid the need for an extended abdominal incision. This greatly reduces the patient's postoperative pain and scarring. The method greatly shortens the postoperative hospital stay (i.e., discharge is possible on the day after the operation), increasing the turnover of hospital beds.

Laparoscopy-endoscopy cooperative surgery is appropriate for the treatment of gastric gastrointestinal stromal tumors less than 5 cm in size. It can achieve the respective advantages of endoscopic and laparoscopic surgeries while avoiding their drawbacks.

Gastrik Gastrointestinal Stromal Tümörlerin Tedavisinde Laparoskopi-Endoskopi Kooperatifi Cerrahisi

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this ...

Laparoscopic Oocyte Retrieval and Cryopreservation during Vaginoplasty for Treatment of Mayer-Rokitansky-Kuster-Hauser Syndrome

In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, we propose that a concomitant laparoscopic oocyte retrieval for cryopreservation is performed. Oocyte retrieval is pursued at the beginning of the laparoscopy. Right and left 5 mm trocars are positioned, through which a 17 G ovum aspiration needle is used for puncture of the right and left ovaries, respectively. To facilitate exposure of the follicles, the ovaries are mobilized and held with laparoscopic forceps.
When aspirating multiple follicles near each other, the needle tip is retained in the ovary to reduce the number of times that the ovarian cortex is transfixed and due to the inherent risk of bleeding. Subsequent steps are unchanged compared to the Davydov laparoscopic modified technique for vaginoplasty. Prior to surgery, controlled ovarian stimulation is performed with a gonadotropin hormone-releasing hormone (Gn-RH) antagonist protocol, and the concomitant procedure of oocyte retrieval and vaginoplasty is scheduled 36 h after the final follicular maturation trigger. Follicular fluid is collected in the same 10 mL sterile tubes used during transvaginal oocyte retrieval and transferred in a warming block (37 &#176;C) to the assisted reproduction laboratory, where mature (metaphase II) oocytes are vitrified.
In this case, a series of 23 women with MRKH, oocytes were successfully retrieved and cryopreserved in all patients; vaginoplasty was subsequently conducted without modifications, and the inpatient and outpatient postoperative care (day of urinary catheter removal, day of hospital discharge, dilator use, and comfort at follow-up) remained unaffected. One postoperative complication occurred in one patient (fever developing on day 5 post surgery and intraperitoneal fluid detection on transabdominal ultrasound) and resolved after conservative treatment. Rather than performing surgical vaginoplasty and delaying oocyte retrieval in MRKH patients, this approach combines both procedures in a single laparoscopy, thereby minimizing surgical invasiveness and anesthesiologic risks.

A dedicated team can offer Mayer-Rokitansky-Kuster-Hauser patients the option to perform controlled ovarian stimulation and oocyte cryopreservation at the time of laparoscopic vaginoplasty.

Mayer-Rokitansky-Kuster-Hauser Sendromu Tedavisinde Vajinoplasti Sırasında Laparoskopik Oosit Elde Edilmesi ve Kriyoprezervasyonda

In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, ...

Modified Posterior Vertebral Column Resection for Patients with Thoracolumbar Kyphotic Deformity

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may cause severe thoracolumbar kyphotic deformity, often accompanied by intractable low back pain or compression of the spinal cord, leading to severe neurological symptoms or even paralysis. If conservative treatment cannot relieve the symptoms or correct the deformities, surgical treatment is usually needed. For severe kyphotic deformity, reconstruction of the physiological curvature and rigid fixation determine the prognosis of the patients. Osteotomy and orthopedics are the standard procedure for deformities with severe compression of the front and middle column, but the trauma to the patients is high, with a long operation time and massive blood loss. To avoid these disadvantages, we have developed a modified technique to remove the diseased vertebra unilaterally. In this technique, we use a modified trephine to resect the vertebral columns like in the pedicle screw technique by adding a locking instrument that can restrict the trephine to lower the risk of osteotomy and shorten the surgery time and blood loss.

We describe a modified technique for resecting the posterior vertebral column unilaterally based on a modified trephine for patients with thoracolumbar kyphotic deformity.

Torakolomber Kifotik Deformiteli Hastalarda Modifiye Posterior Vertebral Kolon Rezeksiyonu

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may ...

Use of the Scissor-Type Knife During the Peroral Endoscopy Myotomy Procedure for the Treatment of Achalasia

Peroral endoscopic myotomy (POEM) is one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with achalasia. Endoscopists, especially trainees during the learning phase, commonly face difficulty in tissue plane dissection and selective myotomy while working near the esophagogastric junction, with increased risks of inadvertent injury, unexpected bleeding, and inadequate myotomy. To minimize the technical difficulty and improve the safety of POEM, we describe a protocol for using a scissor-type knife for the main steps of POEM, including mucosal incision, submucosal tunneling, myotomy, and hemostasis. The standard techniques used with the scissor-type knife involve grasping the target tissue, and then dissection or coagulation. The confirmation of the cutting line after grasping improves the accuracy and reliability of dissection, which is particularly useful for the selective myotomy of the internal circular muscle. Meanwhile, the scissor-type knife provides enhanced hemostatic capability and enables hemostasis and pre-coagulation without the device exchange for hemostatic forceps. Evaluation of the clinical outcomes in three patients who successfully received POEM using the scissor-type knife revealed no perioperative adverse events. At the 3-month follow-up, all patients achieved clinical success with postoperative Eckardt scores ranging from 0 to 1. In conclusion, the use of a scissor-type knife could minimize the technical difficulty and improve the safety of the POEM procedures, which may be suitable for trainees during the learning phase.

To minimize the technical difficulty and improve the safety of peroral endoscopic myotomy (POEM), we describe a protocol for using a scissor-type knife for the main steps of POEM, including mucosal incision, submucosal tunneling, myotomy, and hemostasis.

Akalazya Tedavisinde Peroral Endoskopi Miyotomisi İşlemi Sırasında Makas Tipi Bıçağın Kullanımı

Peroral endoscopic myotomy (POEM) is one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with ...

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. 
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Doğal Orifis Örneği Ekstraksiyonu ile Kolorektal Kanser için Tek Cerrahlı, Üç Portlu, Laparoskopik Rezeksiyonun Klinik Uygulaması

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, ...

Microscopic Cyst Resection for the Treatment of Patients Diagnosed with Epididymal Cyst

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative asoedema, hematoma, sustaining pain, and seminal tract obstruction in patients who have undertaken nonmicroscopic epididymal cyst resection or epididymal resection. Nonmicroscopic epididymal cyst surgery is suggested for patients with childbirth plans as a precaution. The treatment of male epididymal cysts via microtechnology is obviously a beneficial option; we took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. From September 2017 to April 2021, 41 young and middle-aged male patients diagnosed with epididymal cysts underwent microtechnology treatment in a program titled &#34;microscopic epididymal exploration and cystectomy&#34;. The postoperative follow-up lasted for 3-50 months. The results confirmed that, as microscopic manipulation largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact under the microscope. Bleeding during the operation was significantly reduced (2-3 mL) and wound drainage was not required. According to follow-up data, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain, thereby promising a higher surgical success rate as well as recurrence prevention. Besides, preliminary experience and reflection suggest that microscopic epididymal exploration and cystectomy provide efficient preservation of the epididymal patency through refined treatment, while a better prognosis can be achieved. We recommend that surgery be carried out before the epididymal cyst develops to 0.8 cm in diameter, for fear that a larger epididymal cyst (&#62;0.9 cm in diameter) could cause the complete destruction of all tubules of the ipsilateral epididymis - a more severe case with damage to the testicular output network.

Here, we present a protocol to treat patients diagnosed with an epididymal cyst using microscopic cyst resection. Based on microscopic manipulation, a largely improved visualization of the subtle tissue structures of the epididymis was obtained, so the cyst could be clearly dissected apart and completely removed intact.

Epididim Kisti Tanısı Alan Hastaların Tedavisinde Mikroskobik Kist Rezeksiyonu

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative ...

Korunmuş Otonomik Solunum ile Video Yardımlı Torakoskopik Cerrahi için Entübasyon Dışı Protokol

Non-Intubated Video-Assisted Thoracoscopic Surgery

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the lung, and lobectomy. However, there is a high incidence of pulmonary complications arising from general anesthesia with tracheal intubation. Non-intubation with the preservation of voluntary breathing is an alternative to anesthesia. Non-intubation procedures minimize the adverse effects of tracheal intubation and general anesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and post-operative nausea and vomiting. However, the steps for non-intubation procedures are not detailed in many studies. Here, we present a concise non-intubated protocol for the performance of video-assisted thoracoscopic surgery with preserved autonomic breathing. This article identifies the conditions necessary to convert from non-intubated to intubated anesthesia and also discusses the advantages and limitations of non-intubated anesthesia. In this work, this intervention was performed on 58 patients. In addition, the results of a retrospective study are presented. Compared with intubated general anesthesia, patients in the non-intubated video-assisted thoracic surgery group had lower rates of post-operative pulmonary complications, shorter operative times, less intraoperative blood loss, shorter PACU stays, a lower number of days to chest drain removal, less post-operative drainage, and shorter hospital stays.

Yazar Spotlight: Multimodal Analjezi ve Sevofluran İnhalasyon Anestezisi ile Entübe Edilmemiş Video Yardımlı Torakoskopik Cerrahi 

Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.

Entübe Olmayan Video Yardımlı Torakoskopik Cerrahi

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