Name: step-by-step stapedotomy through transcanal exclusive endoscopic approach
Uploaded: 2022-03-05T14:00:00
Description: Watch this Scientific Journal Video about Step-by-Step Stapedotomy through Transcanal Exclusive Endoscopic Approach at JoVE.com

这项研究是根据伦理原则进行的，包括世界医学协会赫尔辛基宣言（2002年）和机构人类研究伦理委员会的指导方针（Comitato Etico dell'Area Vasta Emilia Nord）。地方伦理委员会不对病例报告进行正式的伦理评估。
1. 患者的准备
<ol><li>经口气管插管和全身麻醉后，将患者仰卧位，头部向患耳的另一侧倾斜，下巴略微过度伸展。尽可能拉下同侧肩部，在头部和肩部之间形...

<ol>
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W., Brackmann, D. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Facial+nerve+grading+system.">Facial nerve grading system.</a> Otolaryngology - Head and Neck Surgery. 93 (2), 146-147 (1985).</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=Complications+in+endoscopic+ear+surgery.">Complications in endoscopic ear surgery.</a> Otology &amp; Neurotology. 39 (8), 1012-1017 (2018).</li><li>Campbell, K. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+basic+audiologic+assessment.">The basic audiologic assessment.</a> Essential Audiology for Physicians. , (1998).</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. 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=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: JoVE. (131), e56390 (2018).</li><li>Altamami, N. 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=Is+one+of+these+two+techniques:+CO2+laser+versus+microdrill+assisted+stapedotomy+results+in+better+post-operative+hearing+outcome.">Is one of these two techniques: CO2 laser versus microdrill assisted stapedotomy results in better post-operative hearing outcome.</a> European Archives of Oto-Rhino-Laryngology. 276 (7), 1907-1913 (2019).</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=Acquisition+of+surgical+skills+for+endoscopic+ear+and+lateral+skull+base+surgery:+A+staged+training+programme.">Acquisition of surgical skills for endoscopic ear and lateral skull base surgery: A staged training programme.</a> Acta Otorhinolaryngologica Italica. 38 (2), 151-159 (2018).</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=An+ovine+model+for+exclusive+endoscopic+ear+surgery.">An ovine model for exclusive endoscopic ear surgery.</a> JAMA Otolaryngology - Head &amp; Neck Surgery. 143 (3), 247-252 (2017).</li></ol>

本文提出了一种完全EStS的方案，以指导任何耳科医生在内窥镜下进行镫骨手术。
第一个手术步骤（TMF升高）可能是整个过程中最血腥的阶段，对于外科医生来说，这是一个与单手出血控制相关的挑战13。此外，在耳硬化病例中，鼓膜是完整的;因此，应尽最大努力避免损坏它。正如我们的协议中所报告的那样，可以遵循一些技术提示来减少出血并保证皮瓣的?...

自 20 世纪 90 年代首次应用以来，内窥镜在耳部手术中的使用逐渐增加，用于治疗各种中耳病变，包括耳硬化症1。与显微镜相比，内窥镜保证了宽广的曝光区域，高放大倍率和分辨率的图像，减少了骨去除量，并显着改善了手术后的生活质量2，3，4。
一只手的使用被认为是内窥镜技术的局限性，特别是在镫骨手术等功能性手术中5，6。然而，越来越多的论文表明，内镜镫骨手术（EStS）是可行、安全的，并且具有良好的结果，类似于传统的镫骨切开术7，8。此外，内窥镜已经充分发挥了其潜力，特别是在解剖结构不利的患者或翻修病例中，是在这些苛刻的环境中为外科医生提供支持的宝贵工具9，10。对鼓室脊索的有限操作和术后味觉障碍的低发生率是该技术的进一步益处11。
对于在使用内窥镜方面没有太多经验的外科医生来说，EStS可能具有挑战性。如果了解正确的器械处理，可以很容易地克服内窥镜和手术器械之间共享手术区域的问题。在外耳道（EAC）和鼓室狭窄空间内单手控制出血对于新手外科医生来说可能是令人沮丧的12，13。此外，重要的是要正确定位患者并设置手术室，以确保外科医生在整个手术过程中的舒适设置。
本文的目的是展示经卡内膜专用镫镜镫骨切除术的外科手术过程，从手术室的设置和患者定位到术后护理。报告该过程的分步描述，以允许任何耳外科医生理解并可能重现这种干预。
我们报告了一名 56 岁女性因双侧耳硬化而接受右经经管 EStS 治疗的病例。患者报告进展缓慢，双侧听力损失（HL），无眩晕或耳鸣。虽然右耳镜检查正常，但听力测试显示右中度混合HL，术前平均骨传导纯音平均值（BC-PTA）为24 dB，术前平均空气传导纯音平均值（AC-PTA）为71 dB，平均术前空气 - 骨间隙（ABG）为47 dB。鼓室造影为双侧A型，无镬骨反射。认为没有必要进行CT扫描作为术前评估。

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Antifog solution</td>
			<td>GOLFF</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Aspirator system (40L/min power)</td>
			<td>EXTRUDAN SURGERY APS</td>
			<td></td>
			<td>4m long, dimeter ch25</td>
		</tr>
		<tr>
			<td>Cold light source with cable</td>
			<td>STORZ</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Consumables: 
			- Iodopovidone solution 
			- Epinephrine 
			- Sterile water to rinse 
			- Spongostan (adsorbable hemostatic sponge)</td>
			<td>ETHICON INC.</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Cotton pads</td>
			<td>FARMAC ZABBAN</td>
			<td></td>
			<td>10x10cm</td>
		</tr>
		<tr>
			<td>Cottonoid pledgets</td>
			<td>CODMAN</td>
			<td></td>
			<td>10 surgical patties</td>
		</tr>
		<tr>
			<td>Endoscope</td>
			<td>STORZ</td>
			<td></td>
			<td>3mm diameter, 15cm length, 0&#176;</td>
		</tr>
		<tr>
			<td>Local anesthetic with vasoconstrictor in sterile and non-sterile syringe</td>
			<td>GALENICA SENESE</td>
			<td></td>
			<td>10 vials x 5ml</td>
		</tr>
		<tr>
			<td>Otologic set instruments</td>
			<td>STORZ</td>
			<td></td>
			<td>round knife, hook, curette, Bellucci scissors and Hartmann forceps, suction tubes</td>
		</tr>
		<tr>
			<td>Skeeter Drill</td>
			<td>MEDTRONIC</td>
			<td></td>
			<td>0.6 mm diamond burr</td>
		</tr>
		<tr>
			<td>Stapes prosthesis</td>
			<td>SPIGGLE &#38; THEIS</td>
			<td></td>
			<td>0.6x4.75mm</td>
		</tr>
		<tr>
			<td>Surgical scrub set for otologic patients</td>
			<td>EURONDA</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Surgical scrub set for operating surgeon</td>
			<td>EURONDA</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Surgical scrub set for nurse</td>
			<td>EURONDA</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Vesalius molecular resonance electrosurgical unit</td>
			<td>TELEA ELECTRONIC ENGINEERING</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Video equipment: 4K Camera 
			- HD screen 
			- Video processor (Image 1S system)</td>
			<td>STORZ</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

step-by-step stapedotomy through transcanal exclusive endoscopic approach

近年来，使用内窥镜治疗各种中耳病变（包括耳硬化症）的趋势越来越明显。几项比较传统显微镜和内镜镫骨手术的研究报告了相似的听力结果和总体低并发症发生率。内窥镜在苛刻的镫骨手术环境中已经充分发挥了其潜力，例如椭圆形窗口龛位的不利解剖结构或翻修病例。减少鼓室脊索的操作和低术后味觉障碍的发生率是内镜镫骨手术的进一步益处。
作为一种单手技术，对于新手内镜外科医生来说，治疗假体的出血、定位和压接可能具有挑战性，因此建议在进行内镜镫骨切开术之前进行一些内窥镜耳部手术培训。如果了解正确的器械定位，可以很容易地克服内窥镜和手术器械之间共享手术区域的问题。在耳道狭窄的空间内单手控制出血可能是鼓室 - 肉瓣抬高期间的问题，可能从手术的初步步骤开始就阻碍了外科医生。遵循适当的技术来抬高皮瓣，并与麻醉学团队合作保持低血压，在大多数情况下保证足够的出血控制。
本文的目的是描述经卡内窥镜镫骨切开术的整个外科手术过程，从手术室的设置和患者定位到术后护理。报告了手术操作的分步描述和技术提示，以指导外科医生完成整个过程，并允许任何耳外科医生在内窥镜下进行镫骨手术。

患者术后病程正常，无面瘫或眩晕。术后6个月的听力测试16如图 3所示。耳内镜检查显示鼓膜愈合规律。患者否认有任何味觉障碍。
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/63061/63061fig01.jpg"> 图1：用于内窥镜镫骨手术的标准耳科仪器。 最常用的仪器都标有数字。1：单极...

Watch this Scientific Journal Video about Step-by-Step Stapedotomy through Transcanal Exclusive Endoscopic Approach at JoVE.com

Step-by-Step Stapedotomy through Transcanal Exclusive Endoscopic Approach

本文旨在为内镜镫骨手术提供一种从手术室设置和患者定位到术后护理的分步方法。这项工作将代表任何愿意用内窥镜经卡技术治疗耳硬化症的耳科医生的指南。

通过经卡全线内窥镜方法进行逐步镫骨切除术

In recent years there has been an increasing trend in the use of the endoscope to treat a variety of middle ear pathologies, including otosclerosis. ...

通过经卡内窥镜方法进行分步镫骨切开术。我们将展示一个从手术室设置和患者定位到术后护理的内窥镜镫骨手术案例。我将引导您完成外科手术的分步描述，并提供技术提示，以允许任何外科医生以完全内窥镜的方式进行镫骨手术。越来越多的论文表明，内窥镜镫骨手术是安全、可行的，并且具有类似于传统镫骨切除术的有利结果。然而，内窥镜镫骨手术对于没有太多内窥镜使用经验的外科医生来说可能是一个挑战。如果了解正确的器械结局，可以很容易地克服内窥镜和手术器械之间共享手术区域的问题。对于新手外科医生来说，单手十亿控制有时可能会令人沮丧。此外，重要的是要正确定位患者并设置手术室，以确保外科医生在整个过程中的舒适位置。我们报告了一例引起我们注意的56岁女性，她报告了缓慢而渐进的双侧听力损失，没有眩晕或耳鸣。虽然右耳镜检查正常，但听力测试显示右中度混合听力损失。鼓室造影为双侧 A 型，无镭骨反射，提示双侧至硬化症。没有CT扫描被认为是必要的准备评估。经口气管插管和全身麻醉位置后，患者仰卧，头部向患耳的另一侧倾斜，下巴略微过度伸展。尽可能地拉下同侧肩部，以在头部和肩部之间形成一个广角，从而更容易接近耳朵。进行初步麻醉，在外耳道皮肤的四个主要点（后壁，上下角和下角以及经管区域）注射约1-2毫升用血管收缩剂稀释的局部麻醉剂。使用碘伏维酮浸泡的纱布对整个外耳进行消毒，以形成无菌区域。确保碘伏维酮进入外耳道并到达鼓膜。高分辨率监视器放置在外科医生的前面，与外科医生的眼睛水平保持足够的距离，以便在手术过程中保持头部和颈部的舒适位置。将直径3毫米、长15厘米、零度的内窥镜连接到高清数码相机和氙气光源。将光源保持在50%的强度，以防止热损伤内耳。在做白平衡和调整焦点后，准备一个高质量的除雾溶液来清洁内窥镜尖端。在直接内镜下，在管后壁的上细胞平面上进行术中麻醉。在切除外耳道最外侧部分的毛发后，使用单极从5点到12点钟位置描绘鼓膜 - 肉瓣切口，距离环空约8至10毫米。使用圆刀按照先前标记的线进行实际的皮肤切口，并在肾上腺素浸泡的棉质生物的帮助下抬起鼓膜 - 肉瓣。一旦环被确定为鼓膜的白色增厚，继续在其下进行解剖。用哈特曼镊子将pars flaccida从malleus的短过程中分离出来，保持pars tensa粘附在umbus上。在此步骤中，将鼓室琴识别为从绳索突出处冒出的白色弦，并保持原样。为了获得椭圆形窗口区域的良好曝光，应通过刮刀进行痰盂和外耳道后骨部分的可变切除。在某些情况下，即使椭圆形窗口区域完全暴露，也需要一些刮除术才能在镫骨上创建有利的工作区域。为了进一步暴露脚踏板，神经通常主要用钩子移位。确认镫骨固定后，使用带有0.6毫米金刚石毛刺的微型钻头进行后链切开术。然后使用相同的毛刺在踏板的中间后部打孔。用Bellucci剪刀切到镫骨肌腱。现在，在钩子的帮助下，将镫骨从镫骨上拆开，并取下镫骨上层建筑。使用Fisch钩子使脚踏板孔正规化并检查其是否足够口径，以及从前庭上清除可能的小骨头碎片。现在是时候使用吸管将镫骨假体插入外耳道了。在这里，我们使用的是 0.6/4.75 毫米假体。在钩子的帮助下，将其轻轻地放入镫骨切开术孔中。将假体钩固定在茬叶的漫长过程中后，将其压接。轻轻按压锤柄，检查假肢是否正常移动。更换鼓膜-鼻瓣，并用可吸收的止血药包装外部导管。用粘性石膏覆盖耳廓，无需压缩。如果未发生恶心或呕吐，则允许患者在术后至少8小时饮用，进食和站立。第二天，使用House-Brackman量表评估面神经功能，并使用Frenzel护目镜评估是否存在自发性眼球震颤。进行骨传导纯音调测听，以排除感音神经性听力损失。患者术后病程正常，无面瘫或眩晕。术后6个月的听力测试显示空气 - 骨间隙完全闭合。耳内镜检查显示鼓膜愈合正常，患者否认有任何味觉障碍。该协议可以指导任何耳科医生进行内窥镜镫骨手术。我们建议在进行内镜镫骨切开术之前，进行一些基本程序的培训，例如内窥镜下肉豆膜切开术和肉豆蔻成形术。感谢您的关注。

Research

JoVE Journal

Medicine

How to Measure Cortical Folding from MR Images: a Step-by-Step Tutorial to Compute Local Gyrification Index

如何从MR图像测量皮质折叠：一个循序渐进的教程，以计算本地Gyrification指数

Cortical folding (gyrification) is determined during the first months of life, so that adverse events occurring during this period leave traces that will ...

科研

医学

Step By Step: Microsurgical training method combining two nonliving animal models

一步一步：显微外科培训方法相结合的两个无生命的动物模型

The learning of microsurgical techniques and the maintenance of microsurgical skills have been traditionally based on the use of living animals, mainly ...

Heterotopic Renal Autotransplantation in a Porcine Model: A Step-by-Step Protocol

异位自体肾移植的猪模型：有步骤，分步协议

Kidney transplantation is the treatment of choice for patients suffering from end-stage renal disease. It offers better life expectancy and higher quality ...

A Step by Step Protocol for Subretinal Surgery in Rabbits

一种用于兔视网膜下手术分步协议

Age related macular degeneration (AMD), retinitis pigmentosa, and other RPE related diseases are the most common causes for irreversible loss of vision in ...

ADSC-sheet Transplantation to Prevent Stricture after Extended Esophageal Endoscopic Submucosal Dissection

ADSC表移植到扩展食管内镜黏膜下剥离术之后防止狭窄

In past years, the cell-sheet construct has spurred wide interest in regenerative medicine, especially for reconstructive surgery procedures. The ...

Discovering Middle Ear Anatomy by Transcanal Endoscopic Ear Surgery: A Dissection Manual

Transcanal 内窥镜下耳部手术发现中耳解剖: 解剖手册

The middle ear is located in the center of the temporal bone and bears a highly complex anatomy. The recently introduced exclusively endoscopic transcanal ...

Endaural Endoscopic Atticoantrotomy (Retrograde Mastoidectomy) using a Constant Suction Bone-drilling Technique

Endaural Endoscopic Atticoantrotomy Retrograde Mastoidectomy using a Constant Suction Bone-drilling Technique

使用恒定抽吸骨术的内窥镜下盂骨切开术（逆行切除术）

Endoscopic middle ear surgery is a widely employed minimally invasive surgical technique to address middle ear and mastoid pathology. Bone drilling is the ...