<meta charset="utf8"></head><body>Özel Endoskopik Osiküloplasti için Kapsamlı Bir Adım Adım Kılavuz

<ol>
	<li>Bonali, M., 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=The+variants+of+the+retro-+and+hypotympanum:+an+endoscopic+anatomical+study.">The variants of the retro- and hypotympanum: an endoscopic anatomical study.</a> European Archives of Oto-Rhino-Laryngology. 274 (5), 2141-2148 (2017).</li><li>Anschuetz, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Novel+Surgical+and+Radiologic+Classification+of+the+Subtympanic+Sinus:+Implications+for+Endoscopic+Ear+Surgery.">Novel Surgical and Radiologic Classification of the Subtympanic Sinus: Implications for Endoscopic Ear Surgery.</a> Otolaryngology-Head and Neck Surgery. 159 (6), 1945998187180 (2018).</li><li>Marchioni, D., Molteni, G., Presutti, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+anatomy+of+the+middle+ear.">Endoscopic anatomy of the middle ear.</a> Indian Journal of Otolaryngology and Head &amp; Neck Surgery. 63 (2), 101-113 (2011).</li><li>Das, A., Mitra, S., Ghosh, D., Sengupta, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+ossiculoplasty:+Is+there+any+edge+over+the+microscopic+technique.">Endoscopic ossiculoplasty: Is there any edge over the microscopic technique.</a> The Laryngoscope. 130 (3), 797-802 (2020).</li><li>Molinari, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+implications+of+3D+vs+2D+endoscopic+ear+surgery:+A+case-control+study.">Surgical implications of 3D vs 2D endoscopic ear surgery: A case-control study.</a> European Archives of Oto-Rhino-Laryngology. 277 (12), 3323-3330 (2020).</li><li>Kamrava, B., Roehm, P. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Systematic+review+of+ossicular+chain+anatomy:+Strategic+planning+for+development+of+novel+middle+ear+prostheses.">Systematic review of ossicular chain anatomy: Strategic planning for development of novel middle ear prostheses.</a> Otolaryngology-Head and Neck Surgery. 157 (2), 190-200 (2017).</li><li>Mudhol, R. S., Naragund, A. I., Shruthi, V. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ossiculoplasty:+Revisited.">Ossiculoplasty: Revisited.</a> Indian Journal of Otolaryngology and Head and Neck Surgery. 65, 451-454 (2013).</li><li>Wullstein, H., Thieme, O. h. r. ,. N. a. s. e. u. n. d. H. a. l. s. .. 2. n. d. e. d. .. S. t. u. t. t. g. a. r. t. :. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Die+Eingriffe+zur+Geh&#246;rverbesserung+[Surgery+for+hearing+improvement].">Die Eingriffe zur Geh&#246;rverbesserung [Surgery for hearing improvement].</a> Uffenorde W. Anzeige und Ausf&#252;hrung der Eingriffe an Ohr, Nase und Hals. 2nd ed. , 227-258 (1952).</li><li>Marchioni, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Selective+epitympanic+dysventilation+syndrome.">Selective epitympanic dysventilation syndrome.</a> The Laryngoscope. 120 (5), 1028-1033 (2010).</li><li>Yu, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=PORP+vs.+TORP:+A+meta-analysis.">PORP vs. TORP: A meta-analysis.</a> European Archives of Oto-Rhino-Laryngology. 270 (12), 3005-3017 (2013).</li><li>McGee, M., Hough, J. V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ossiculoplasty.">Ossiculoplasty.</a> Otolaryngologic Clinics of North America. 32 (3), 471-488 (1999).</li><li>Javia, L. R., Ruckenstein, M. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ossiculoplasty.">Ossiculoplasty.</a> Otolaryngologic Clinics of North America. 39 (6), 1177-1189 (2006).</li><li>Woods, O., Fata, F. E., Saliba, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ossicular+reconstruction:+Incus+versus+universal+titanium+prosthesis.">Ossicular reconstruction: Incus versus universal titanium prosthesis.</a> Auris Nasus Larynx. 36 (4), 387-392 (2009).</li><li>Bartel, R., 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=Hearing+results+after+type+III+tympanoplasty:+incus+transposition+versus+PORP.+A+systematic+review.">Hearing results after type III tympanoplasty: incus transposition versus PORP. A systematic review.</a> Acta Oto-Laryngologica. 138 (7), 617-620 (2018).</li><li>Tsetsos, N., Vlachtsis, K., Stavrakas, M., Fyrmpas, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+versus+microscopic+ossiculoplasty+in+chronic+otitis+media:+A+systematic+review+of+the+literature.">Endoscopic versus microscopic ossiculoplasty in chronic otitis media: A systematic review of the literature.</a> European Archives of Oto-Rhino-Laryngology. 278 (4), 917-923 (2021).</li><li>Soloperto, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Exclusive+endoscopic+ossiculoplasty+with+autologous+material:+step-by-step+procedure+and+functional+results.">Exclusive endoscopic ossiculoplasty with autologous material: step-by-step procedure and functional results.</a> European Archives of Oto-Rhino-Laryngology. 280 (11), 4869-4878 (2023).</li><li>Alicandri-Ciufelli, M., 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=Epinephrine+use+in+endoscopic+ear+surgery:+Quantitative+Safety+assessment.">Epinephrine use in endoscopic ear surgery: Quantitative Safety assessment.</a> ORL; Journal for Oto-Rhino-Laryngology and its Related Specialties. 82 (1), 1-7 (2020).</li><li>Anschuetz, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Management+of+bleeding+in+exclusive+endoscopic+ear+surgery:+Pilot+clinical+experience.">Management of bleeding in exclusive endoscopic ear surgery: Pilot clinical experience.</a> Otolaryngology-Head and Neck Surgery. 157 (4), 700-706 (2017).</li><li>Beckmann, 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=Endoscopic+cholesteatoma+surgery.">Endoscopic cholesteatoma surgery.</a> Journal of Visualized Experiments. (179), e63315 (2022).</li><li>Anschuetz, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Discovering+middle+ear+anatomy+by+transcanal+endoscopic+ear+surgery:+A+dissection+manual.">Discovering middle ear anatomy by transcanal endoscopic ear surgery: A dissection manual.</a> Journal of Visualized Experiments. (131), e56390 (2018).</li><li>Kim, H. H., Wiet, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preferred+technique+in+ossiculoplasty.">Preferred technique in ossiculoplasty.</a> Operative Techniques in Otolaryngology-Head and Neck Surgery. 14 (4), 243-246 (2003).</li><li>Springer. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Comparative atlas of endoscopic ear surgery: training techniques based on an ovine model. , (2021).</li><li>Dornhoffer, J. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> 28 autograft ossicular reconstruction. The chronic ear. , (2016).</li><li>Malafronte, G., Filosa, B., Mercone, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+double-cartilage+block+ossiculoplasty:+long-term+results.">A new double-cartilage block ossiculoplasty: long-term results.</a> Otology &amp; Neurotology. 29 (4), 531-533 (2008).</li><li>Malafronte, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Early+results+with+semi-synthetic+total+ossicular+replacement+prosthesis.">Early results with semi-synthetic total ossicular replacement prosthesis.</a> Otolaryngology-Head and Neck Surgery. 143 (2), 307-308 (2010).</li><li>Caloway, C. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pediatric+endoscopic+ossiculoplasty+following+surgery+for+chronic+ear+disease.">Pediatric endoscopic ossiculoplasty following surgery for chronic ear disease.</a> The Laryngoscope. 130 (12), 2896-2899 (2020).</li><li>Niederhauser, L., Fink, R. D., Mast, F. W., Caversaccio, M., Anschuetz, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Video+learning+of+surgical+procedures:+A+randomized+comparison+of+microscopic,+2-+and+3-dimensional+endoscopic+ear+surgery+techniques.">Video learning of surgical procedures: A randomized comparison of microscopic, 2- and 3-dimensional endoscopic ear surgery techniques.</a> Otology &amp; Neurotology. 43 (7), e746-e752 (2022).</li><li>Coleman, H., Tikka, T., Curran, J., Iyer, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+endoscopic+vs+microscopic+ossiculoplasty:+A+study+of+157+consecutive+cases.">Comparison of endoscopic vs microscopic ossiculoplasty: A study of 157 consecutive cases.</a> European Archives of Oto-Rhino-Laryngology. 280 (1), 89-96 (2023).</li><li>Amith, N., Rs, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Autologous+incus+versus+titanium+partial+ossicular+replacement+prosthesis+in+reconstruction+of+Austin+type+A+ossicular+defects:+a+prospective+randomised+clinical+trial.">Autologous incus versus titanium partial ossicular replacement prosthesis in reconstruction of Austin type A ossicular defects: a prospective randomised clinical trial.</a> The Journal of Laryngology and Otology. 131 (5), 391-398 (2017).</li><li>Filosa, B., Previtero, G., Novia, G., Trusio, A., Malafronte, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Partial+Ossiculoplasty:+Malafronte's+double+cartilage+block+versus+incus.">Partial Ossiculoplasty: Malafronte's double cartilage block versus incus.</a> Otology &amp; Neurotology. 40 (3), 344-350 (2019).</li><li>Vercruysse, J. P., Offeciers, F. E., Somers, T., Schatteman, I., Govaerts, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+malleus+allografts+in+ossiculoplasty.">The use of malleus allografts in ossiculoplasty.</a> The Laryngoscope. 112 (10), 1782-1784 (2002).</li><li>R&#225;th, G., 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=Ionomer+cement+for+reconstruction+of+the+long+process+of+the+incus:+The+P&#233;cs+experience.">Ionomer cement for reconstruction of the long process of the incus: The P&#233;cs experience.</a> Clinical Otolaryngology. 33 (2), 116-120 (2008).</li><li>Katar, O., K&#305;l&#305;&#231;, S., Bajin, M. D., Sennaro&#287;lu, L. <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+results+of+glass+ionomer+ossiculoplasty.">Long term results of glass ionomer ossiculoplasty.</a> European Archives of Oto-Rhino-Laryngology. 281 (1), 171-179 (2023).</li><li>Moneir, W., Salem, M. A., Hemdan, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+transcanal+management+of+incus+long+process+defects:+rebridging+with+bone+cement+versus+incus+interposition.">Endoscopic transcanal management of incus long process defects: rebridging with bone cement versus incus interposition.</a> European Archives of Oto-Rhino-Laryngology. 280 (2), 557-563 (2023).</li></ol>

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Antifog Solution</td>
			<td>Karl Storz</td>
			<td>15006H</td>
			<td></td>
		</tr>
		<tr>
			<td>Endoscopes 3 mm diameter, 15 cm length 0&#176;, 30&#176;, 45&#176;and&#160; 70&#176;</td>
			<td>Karl Storz</td>
			<td>7220AA/ 7220BA/ 7220FA/ 7220CA</td>
			<td></td>
		</tr>
		<tr>
			<td>Epinephrine 1 mg/mL</td>
			<td>Dr. Bichsel AG</td>
			<td>2824248&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Gelatinous sponge (Gelfoam)</td>
			<td>Pfizer</td>
			<td>GTIN 00300090315085&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Image 1S 4K</td>
			<td>Karl Storz</td>
			<td>TH120</td>
			<td></td>
		</tr>
		<tr>
			<td>ME 102</td>
			<td>KLS Martin</td>
			<td>80-010-02-04&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Microsuction tubes&#160;</td>
			<td>Spiggle&#38;Theis</td>
			<td>301004 - 301014</td>
			<td></td>
		</tr>
		<tr>
			<td>Monitor 32&#34; 4K/3D</td>
			<td>Monitor 32&#34; 4K/3D</td>
			<td>TM350</td>
			<td></td>
		</tr>
		<tr>
			<td>NIM-Neuro 3.0</td>
			<td>Medtronic</td>
			<td>8253402</td>
			<td></td>
		</tr>
		<tr>
			<td>OsseoDuo</td>
			<td>Bien Air</td>
			<td>1700524-001</td>
			<td></td>
		</tr>
		<tr>
			<td>Otosporin (polymyxin, neomycin, hydrocortison)</td>
			<td>GlaxoSmithKline</td>
			<td>2262911000001100.00</td>
			<td></td>
		</tr>
		<tr>
			<td>Piezosurgery device</td>
			<td>Mectron</td>
			<td>N/A</td>
			<td></td>
		</tr>
		<tr>
			<td>PM2 Line Drill</td>
			<td>Bien Air</td>
			<td>1600765-001</td>
			<td></td>
		</tr>
		<tr>
			<td>PORP mCLIP ARC Partial Prosthesis&#160;</td>
			<td>MED-EL</td>
			<td>58502 - 58520</td>
			<td></td>
		</tr>
		<tr>
			<td>Povidone-iodine (Betadine)</td>
			<td>Mundi-Pharma</td>
			<td>7680342821377&#160;&#160;&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Ringer Solution</td>
			<td>B. Braun</td>
			<td>3570000</td>
			<td></td>
		</tr>
		<tr>
			<td>Standard otological instruments (otologic dissectors, needle dissector, round knifes, hooks, curette, microscissors (Bellucci) and microforceps (Hartmann)</td>
			<td>Karl Storz</td>
			<td>N/A</td>
			<td></td>
		</tr>
		<tr>
			<td>Stapes Prosthesis Platin/PTFE</td>
			<td>Spiggle&#38;Theis</td>
			<td>1054040600/10560600</td>
			<td></td>
		</tr>
		<tr>
			<td>Steel and diamond burrs</td>
			<td>Bien Air</td>
			<td>1100290-001 - 1100303-001/ 1100247-001 - 1100260-001</td>
			<td></td>
		</tr>
		<tr>
			<td>Syringe Injekt Solo 10 mL</td>
			<td>Syringe Injekt Solo 10 mL</td>
			<td>4606108N</td>
			<td></td>
		</tr>
		<tr>
			<td>TORP Implant for shortening</td>
			<td>Spiggle&#38;Theis</td>
			<td>11830 - 11870</td>
			<td></td>
		</tr>
	</tbody>
</table>

techniques of endoscopic ossiculoplasty

The use of endoscopes has become prevalent in modern otology. Originally used for diagnostic purposes, the endoscopic technique has gained popularity over time, leading to exclusive endoscopic ear surgery approaches. The endoscopic technique is performed through the auditory canal and requires precise and delicate maneuvers, as the technique must be performed single-handedly. It provides a panoramic view of the middle ear and allows access to hard-to-reach areas, facilitating the elimination of disease by using angled endoscopes1,2. In ossicular chain repair, modern high-definition (HD) or 4k endoscopy, along with its illuminative capabilities directed at specific structures of interest, such as the stapes or its footplate, greatly assists in the recognition of both anatomical and pathological variances3,4,5.
Ossicular chain destruction commonly results from chronic otitis media (COM), but trauma and neoplasms can alter the normal middle ear and, therefore, reduce its sound transmission capabilities6,7. Restoration of normal tympanic membrane (TM) and ossicular chain function has its roots in the 1950s8. The surgical techniques used to treat various pathologies of the middle ear aim not only to eliminate the underlying disease process but also to restore normal auditory function9.Over the past seven decades, various ossiculoplasty (OPL) techniques and prostheses have been studied and reported in the literature7,10,11.&#160;Bioinert materials like titanium gained popularity due to their lightweight, rigidity, and good visualization of their distal end during surgery. Nevertheless, these prostheses are quite expensive, and the reported rate of extrusion (1%-5%) is not negligible12. Autologous materials have demonstrated comparable effectiveness to synthetic prostheses. However, they do present certain drawbacks, such as longer surgical durations required for the remodeling process, the potential for retaining cholesteatoma, and availability limitations depending on the condition of the ossicular chain13,14.
According to Tsetsos et al., exclusive endoscopic ossiculoplasty (EEO) is associated with similar postoperative hearing results compared to the traditional microscopic approach15. A trend towards reduced morbidity and a shorter operative time for the endoscopic approach has been observed. Therefore, EEO can be considered a valid surgical option for reestablishing a functioning ossicular chain with acceptable hearing restoration in children and adults16.
This study aims to provide a comprehensive insight into the various technical refinements and latest developments for EEO. It presents different OPL techniques along with representative outcome data.

<meta charset="utf8"></head><body>Yazar Spotlight: Endoskopik Osiküloplastiyi Geliştirme – Klinik Entegrasyon için Teknikler, Yenilikler ve Pratik Rehberlik

Endoskopik Osiküloplasti Teknikleri

In modern ontology, the use of endoscopes has evolved from diagnostics to exclusive endoscopic ear surgery. Our goal is to offer a comprehensive understanding of the various endoscopic osteoplasty techniques and support their integration into clinical practice. The focused illumination of specific middle ear structures, such as the stay piece and its foot plate allows great precision in prosthesis placement.Furthermore, it facilitates the detection of both anatomical and pathological variances. The endoscopic technique is performed through the auditory canal and requires precise and delicate maneuvers as it's performed single-handedly. Before implementing this technique in the operating room, we strongly advise hands-on training.

Read this Scientific Article Protocol about Author Spotlight: Advancing Endoscopic Ossiculoplasty – Techniques, Innovations, and Practical Guidance for Clinical Integration at JoVE.com

The utilization of endoscopes in modern otology has evolved from diagnostic purposes to the development of exclusive endoscopic ear surgery. This ...

Research

JoVE Journal

Medicine

Techniques of Endoscopic Ossiculoplasty

798 Görüntüleme.  University of Bern. Modern ontolojide, endoskopların kullanımı teşhisten özel endoskopik kulak cerrahisine dönüşmüştür. Amacımız, çeşitli endoskopik osteoplasti teknikleri hakkında kapsamlı bir anlayış sunmak ve bunların klinik uygulamaya entegrasyonunu desteklemektir. Dayanak parçası ve ayak plakası gibi belirli orta kulak yapılarının odaklanmış aydınlatması, protez yerleştirmede büyük hassasiyet sağlar.Ayrıca, hem anatomik hem de patol...