No funding sources.

This research is approved by the Affiliated Hospital of the Shanghai Institute for Biomedical and Pharmaceutical Technologies, and the ethics number is 2022001. Written informed consent was obtained from the human subjects to participate in the study. The inclusion criteria were: (1) Diagnosis of varicocele by clinical ultrasound; (2) Age between 20 and 40 years old; (3) Abnormalities detected in semen examination, indicating the need for surgery and consent to undergo the procedure. The exclusion criteria were: (1) Abnormal fever exceeding 38.5 &#176;C within the past 6 months; (2) Presence of major illnesses such as tumors, severe heart, lung, liver, and kidney dysfunction, and mental illnesses. The reagents and equipment needed for this procedure are listed in the Table of Materials.
1. Instrumentation
<ol>
	<li>Ensure the availability of sterilized instruments and other equipment needed for surgery, including the following specific important items: surgical microscope, titanium clips, and microscopic instruments.</li>
</ol>
2. Patient preparation
<ol>
	<li>Perform preoperative skin preparation.
	<ol>
		<li>Apply compound lidocaine cream to cover an area from the anterior superior iliac spine laterally, inferiorly to the level of the pubic tubercle, and superiorly up to 3 cm below the umbilical line 1 h preoperatively (see Figure 1).</li>
	</ol>
	</li>
	<li>Place the patient in the supine position on the operating table. Insert a vein-detained needle into the dorsal metacarpal vein, and use an ECG monitor to monitor the patient&#39;s heartbeat and blood pressure.</li>
	<li>Disinfect the surgical area using Iodophor solution and cover it with sterile drapes.</li>
</ol>
3. Microscopic varicocelectomy
<ol>
	<li>Identify the external inguinal ring above the pubic tubercle by using fingers to palpate the spermatic cord at the base of the scrotum, following it upwards until the external inguinal ring is felt at 1.5 cm above the midpoint of the inguinal ligament.</li>
	<li>Use Hemostatic forceps to grasp the skin to assess the efficacy of anesthesia (Figure 2A), and mark the incision site with methylene blue (Figure 2B).</li>
	<li>Mix Lidocaine (5 mL, 0.1 g) and ropivacaine (10 mL, 0.1 g) in a 1:1 ratio and infiltrate using a 20 mL syringe in layers up to a depth of about 5 cm (see Figure 3).</li>
	<li>Make a 3 cm transverse incision at the external inguinal ring using a scalpel. Sequentially, incise the skin, the Camper&#39;s fascia, and the Scarpa&#39;s fascia using an electrotome.</li>
	<li>Identify the spermatic cord (under direct vision, it appears as a strip with dilated deep blue veins visible, and the vas deferens can be palpated below it) and exteriorize it from the incision with an appendiceal retractor. 
	NOTE: Pay attention to the patient&#39;s heart rate and blood pressure during this step. If a decrease in blood pressure and heart rate is encountered, stop the operation and wait for 3-5 min. If necessary, administer 1 mg of atropine injection and 10 mg of dopamine injection intravenously. Secure the spermatic cord in place (see Figure 4).
	<ol>
		<li>Use an electrotome to dissect the cremaster muscle and the external and internal spermatic fascia of the cord.</li>
		<li>Under 8-10x magnification, observe the pulsation of the arteries to determine their location.</li>
		<li>Carefully identify the spermatic artery (which is surrounded by small veins, has visible pulsation, and a tensed wall). Use micro-scissors and forceps for blunt dissection and mark it with a moistened strip for identification. If available, intraoperative Doppler ultrasound can be used for confirmation (Figure 5).</li>
		<li>Identify and isolate the large spermatic veins. Use micro-titanium clips to clamp both ends before cutting (Figure 6).</li>
		<li>Further dissect and identify small veins adjacent to the spermatic artery. Use micro-titanium clips to clamp them before cutting. For vessels that are difficult to clamp with titanium, use 4-0 coated braided silk to ligate before cutting.</li>
		<li>Ligate all varicose veins, ensuring at least one normal vein is preserved for venous return (Figure 7).</li>
	</ol>
	</li>
	<li>After ligation, suture the cremaster muscle and both the internal and external spermatic fascia using a 6-0 absorbable surgical suture. Close and suture the incision (Figure 8).</li>
</ol>
4. Postoperative care
<ol>
	<li>Apply a 1 kg sandbag for compression and hemostasis 1 h postoperatively.</li>
	<li>Administer oral antibiotics postoperatively (fosfomycin trometamol powder, 3 g) for infection prevention. Administer anti-inflammatory analgesic suppositories rectally if postoperative pain is observed.</li>
	<li>Change the dressing in 3 days and remove the stitches in 7 days.</li>
	<li>Conduct a semen examination after 1 month.</li>
</ol>

Microsurgical Varicocele Removal Under Local Anesthesia

<ol>
	<li>Alsaikhan, B., Alrabeeah, K., Delouya, G., Zini, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Epidemiology+of+varicocele.">Epidemiology of varicocele.</a> Asian J Androl. 18 (2), 179-181 (2016).</li><li>Damsgaard, 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=Varicocele+is+associated+with+impaired+semen+quality+and+reproductive+hormone+levels:+A+study+of+7035+healthy+young+men+from+six+European+countries.">Varicocele is associated with impaired semen quality and reproductive hormone levels: A study of 7035 healthy young men from six European countries.</a> Eur Urol. 70 (6), 1019-1029 (2016).</li><li>Gupta, 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=Microscopic+varicocelectomy+as+a+treatment+option+for+patients+with+severe+oligospermia.">Microscopic varicocelectomy as a treatment option for patients with severe oligospermia.</a> Investig Clin Urol. 59 (3), 182-186 (2018).</li><li>Addar, A. M., Nazer, A., Almardawi, A., Al Hathal, N., Kattan, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+yield+of+microscopic+varicocelectomy+in+men+with+severe+oligospermia.">The yield of microscopic varicocelectomy in men with severe oligospermia.</a> Urol Ann. 13 (3), 268-271 (2021).</li><li>Saredi, 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=Feasibility+of+local+anesthesia+for+varicocele+correction+in+one-day-surgery+setting.+A+single+center+experience.">Feasibility of local anesthesia for varicocele correction in one-day-surgery setting. A single center experience.</a> Arch Ital Urol Androl. 93 (2), 233-236 (2021).</li><li>Jensen, C. F. 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=Varicocele+and+male+infertility.">Varicocele and male infertility.</a> Nat Rev Urol. 14 (9), 523-533 (2017).</li><li>Baazeem, A., 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=Varicocele+and+male+factor+infertility+treatment:+A+new+meta-analysis+and+review+of+the+role+of+varicocele+repair.">Varicocele and male factor infertility treatment: A new meta-analysis and review of the role of varicocele repair.</a> European Urol. 60 (4), 796-808 (2011).</li><li>Maheshwari, A., Muneer, A., Lucky, M., Mathur, R., Mceleny, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+review+of+varicocele+treatment+and+fertility+outcomes.">A review of varicocele treatment and fertility outcomes.</a> Hum Fertil (Camb). 25 (2), 209-216 (2020).</li><li>&#199;ayan, S., Akbay, E., Saylam, B., Kad&#305;o&#287;lu, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+varicocele+and+its+treatment+on+testosterone+in+hypogonadal+men+with+varicocele:+Review+of+the+literature.">Effect of varicocele and its treatment on testosterone in hypogonadal men with varicocele: Review of the literature.</a> Balkan Med J. 37 (3), 121-124 (2020).</li><li>Ulusoy, O., 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=Successful+outcomes+in+adolescent+varicocele+treatment+with+high-level+laparoscopic+varicocelectomy.">Successful outcomes in adolescent varicocele treatment with high-level laparoscopic varicocelectomy.</a> J Pediatr Surg. 55 (8), 1610-1612 (2020).</li><li>Mehta, A., Goldstein, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microsurgical+varicocelectomy:+A+review.">Microsurgical varicocelectomy: A review.</a> Asian J Androl. 15 (1), 56-60 (2013).</li><li>Marmar, J. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+evolution+and+refinements+of+varicocele+surgery.">The evolution and refinements of varicocele surgery.</a> Asian J Androl. 18 (2), 171-178 (2016).</li><li>Wang, X., 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=Prospective+comparison+of+local+anesthesia+with+general+or+spinal+anesthesia+in+patients+treated+with+microscopic+varicocelectomy.">Prospective comparison of local anesthesia with general or spinal anesthesia in patients treated with microscopic varicocelectomy.</a> J Clin Med. 11 (21), 6397 (2022).</li><li>Al-Kandari, A. M., Shabaan, H., Ibrahim, H. M., Elshebiny, Y. H., Shokeir, A. 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+outcomes+of+different+varicocelectomy+techniques:+Open+inguinal,+laparoscopic,+and+subinguinal+microscopic+varicocelectomy:+A+randomized+clinical+trial.">Comparison of outcomes of different varicocelectomy techniques: Open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy: A randomized clinical trial.</a> Urology. 69 (3), 417-420 (2007).</li></ol>

The author has no conflicts of interest to disclose.

Varicocele presents a relatively high prevalence in infertile men of reproductive age, reaching 35%-44%6. The impact of this disease on male fertility cannot be overlooked, as it may lead to imbalances in testicular function, instability in blood supply, and thermoregulatory disturbances, subsequently affecting both the quality and quantity of sperm. More severe consequences include potential testicular atrophy and other related complications. Numerous studies have proved the effects of varicocele...

With the advancement of modern society, male infertility has gradually emerged as a global health issue, with varicocele being one of the predominant causes. The prevalence of varicocele is estimated at 15% in the general healthy population, 35% in those with primary infertility, and can be as high as 80% in the secondary infertility group1. Not only does varicocele lead to a decline in sperm count and quality2, but it also profoundly impacts the psychological well-being and quality of life of affected men.
Contemporary treatment modalities, such as microscopic varicocelectomy, have been widely adopted3,4. However, their limitations are becoming increasingly evident. Traditional microscopic varicocelectomy requires patients to undergo general anesthesia, which not only necessitates preoperative fasting and postoperative recovery inconveniences but also poses a significant challenge. The hemodynamic changes induced by anesthesia might obscure the pulsations of the spermatic artery, subsequently increasing the intricacy of isolating and preserving the vessel during the procedure5.
In light of these challenges, a method of performing microscopic varicocelectomy under local anesthesia was proposed and implemented. The salient advantage of this unique approach lies in its ability to swiftly and accurately pinpoint the pulsating spermatic artery, thus reducing the risk of injury to the vessel. Furthermore, local anesthesia offers a more patient-centric surgical experience, sidestepping the adverse effects of general anesthesia, and potentially reducing medical costs, presenting a more cost-effective and efficient treatment option. Additionally, considering the practical realities and clinical experiences in China, this innovative method proffers a fresh perspective in the treatment of varicocele and holds promise for broader clinical application. Through this research, a safer and more effective treatment alternative for patients would be provided, aiming to enhance their reproductive capabilities and overall quality of life.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>0.9% sodium chloride solution</td>
			<td>Guangdong Otsuka Pharmaceutical Co. LTD</td>
			<td>21M1204</td>
			<td>Preparation for injection of medication during surgery</td>
		</tr>
		<tr>
			<td>20 MHz Microvascular Doppler System</td>
			<td>Vascular Technology, Inc.</td>
			<td>102802</td>
			<td>Doppler ultrasound was used to identify the spermatic artery</td>
		</tr>
		<tr>
			<td>4-0 coated, Braided Silk</td>
			<td>Jiasheng Medical Products Co., Ltd</td>
			<td>1600-31</td>
			<td>Ligation of spermatic vein</td>
		</tr>
		<tr>
			<td>5-0 absorbable surgical suture</td>
			<td>HORCON</td>
			<td>MY313G4</td>
			<td>Skin and fascial suture</td>
		</tr>
		<tr>
			<td>6-0 absorbable surgical suture</td>
			<td>HORCON</td>
			<td>JE1264</td>
			<td>Deep tissue suturing</td>
		</tr>
		<tr>
			<td>Compound lidocaine cream</td>
			<td>Tongfang Pharmaceutical Group</td>
			<td>H20063466</td>
			<td>25mg of propacaine and 25mg of lidocaine per gram for epidermal infiltration anesthesia</td>
		</tr>
		<tr>
			<td>Dianerkang Iodophor Skin Disinfectant</td>
			<td>Shanghai Likang Disinfectant HI-Tech Co,Lid</td>
			<td>31005102</td>
			<td>For skin disinfection and the effective iodine content is from 4.5g/L-5.5g/L</td>
		</tr>
		<tr>
			<td>electrotome</td>
			<td>Shanghai Hutong Electronics Co., Ltd</td>
			<td>GD350-B</td>
			<td>Used to cut open the fascia layer</td>
		</tr>
		<tr>
			<td>Fosfomycin Trometamol Powder</td>
			<td>Shanxi C&#38;Y Pharmaceutical Group Co., Ltd.</td>
			<td>H19994124</td>
			<td>Oral antibiotics for infection prevention</td>
		</tr>
		<tr>
			<td>haemostatic forceps</td>
			<td>SHINVA</td>
			<td>ZH240RN</td>
			<td>Used in surgical procedures</td>
		</tr>
		<tr>
			<td>Lidocaine Hydrochloride Injection</td>
			<td>Shanghai Harvest Pharmaceutical Co., Ltd</td>
			<td>H20023777</td>
			<td>Mixed with Ropivocoine Hydrochloride injection for deep infiltration anesthesia</td>
		</tr>
		<tr>
			<td>methylene blue</td>
			<td>JUMPCAN</td>
			<td>H32025285</td>
			<td>Skin marker</td>
		</tr>
		<tr>
			<td>micro scissors</td>
			<td>SHINVA</td>
			<td>ZF123RN</td>
			<td>Used in surgical procedures</td>
		</tr>
		<tr>
			<td>micro tweezers</td>
			<td>SHINVA</td>
			<td>ZD274RN</td>
			<td>Used in surgical procedures</td>
		</tr>
		<tr>
			<td>needle holder</td>
			<td>SHINVA</td>
			<td>ZM234R/RN/RB</td>
			<td>Used in surgical procedures</td>
		</tr>
		<tr>
			<td>NeutroPhase</td>
			<td>NovaBay Pharmaceuticals,Inc</td>
			<td>CA 94608 USA</td>
			<td>Wound Cleanser</td>
		</tr>
		<tr>
			<td>ophthalmic scissors</td>
			<td>SHINVA</td>
			<td>ZC120R/RN/RB</td>
			<td>Used in surgical procedures</td>
		</tr>
		<tr>
			<td>Ropivocoine Hydrochloride injection</td>
			<td>Jiangsu Hengrui Pharmaceuticals Co., Ltd</td>
			<td>H20060137</td>
			<td>Mixed with Lidocaine Hydrochloride Injection for deep infiltration anesthesia</td>
		</tr>
		<tr>
			<td>Surgical Microscope</td>
			<td>Carl Zeiss Meditec AG</td>
			<td>20162224730</td>
			<td>for microscopic operations</td>
		</tr>
		<tr>
			<td>Titanium Clips</td>
			<td>WECK HORIZON</td>
			<td>002200</td>
			<td>used to clamp vena cava</td>
		</tr>
		<tr>
			<td>Titanium Clips</td>
			<td>WECK HORIZON</td>
			<td>005200</td>
			<td>used to clamp venule</td>
		</tr>
	</tbody>
</table>

microscopic varicocelectomy under local anesthesia as the treatment of varicocele

Varicocele, characterized by the dilation of veins within the spermatic cord, is a prevalent disease in males, accounting for 35%-40% of infertility cases among men of reproductive age. This condition may disrupt normal neuroregulation, blood supply, and temperature regulation in the testicles, thereby impacting sperm count, quality (morphology, fragmentation rate), and functionality (motility). It may even induce symptoms such as pain and testicular atrophy. The international standard treatment method is microscopic varicocelectomy, typically performed under general anesthesia. This requires patients to fast before surgery and necessitates recovery and fasting care postoperatively. The arterial blood pressure drop caused by anesthesia may obscure the fluctuation of the spermatic artery, making the precise intraoperative isolation and protection of the spermatic artery more challenging. Therefore, this study proposes and implements microscopic varicocelectomy under local anesthesia. This method facilitates rapid and precise identification of the fluctuating spermatic artery, reducing the risk of spermatic artery damage. It also provides more humane care for patients, reduces economic burden, and offers a new perspective on the treatment of varicocele.

From July 2022 to May 2023, a total of 158 patients were diagnosed at our hospital with varicocele accompanied by a decline in semen quality and underwent surgery. The average age of the 158 males was 32.15 years &#177; 4.8 years (range: 21-51 years). All the males signed informed consent forms to undergo varicocelectomy under local anesthesia, with an average surgery time of 100.11 min &#177; 9.48 min. Patients experienced no significant pain during the surgery; however, 10 patients developed fat liquefaction postoperat...

Author Spotlight: Advancing Varicocele Treatment Through Enhanced Surgical Techniques

Varicocele accounts for 35%-40% of infertility cases among men of reproductive age. The international standard treatment method is microscopic varicocelectomy, typically performed under general anesthesia. This study proposes and implements microscopic varicocelectomy under local anesthesia, which provides more humane care for patients and reduces the economic burden.

Microscopic Varicocelectomy under Local Anesthesia as the Treatment of Varicocele

Varicocele, characterized by the dilation of veins within the spermatic cord, is a prevalent disease in males, accounting for 35%-40% of infertility cases ...

microscopic-varicocelectomy-under-local-anesthesia-as-treatment

Research

JoVE Journal

Medicine

1.4K Views.  Affiliated Hospital of Shanghai Institute for Biomedical and Pharmaceutical Technologies. Varicocele accounts for 35%-40% of infertility cases among men of reproductive age. The international standard treatment method is microscopic varicocelectomy, typically performed under general anesthesia. This study proposes and implements microscopic varicocelectomy under local anesthesia, which provides more humane care for patients and reduces the economic burden.

Video: Author Spotlight: Advancing Varicocele Treatment Through Enhanced Surgical Techniques

Osteopathic Manipulative Treatment as a Useful Adjunctive Tool for Pneumonia

Pneumonia, the inflammatory state of lung tissue primarily due to microbial infection, claimed 52,306 lives in the United States in 20071 and resulted in the hospitalization of 1.1 million patients2. With an average length of in-patient hospital stay of five days2, pneumonia and influenza comprise significant financial burden costing the United States $40.2 billion in 20053. Under the current Infectious Disease Society of America/American Thoracic Society guidelines, standard-of-care recommendations include the rapid administration of an appropriate antibiotic regiment, fluid replacement, and ventilation (if necessary). Non-standard therapies include the use of corticosteroids and statins; however, these therapies lack conclusive supporting evidence4. (Figure 1)

Osteopathic Manipulative Treatment (OMT) is a cost-effective adjunctive treatment of pneumonia that has been shown to reduce patients&#8217; length of hospital stay, duration of intravenous antibiotics, and incidence of respiratory failure or death when compared to subjects who received conventional care alone5. The use of manual manipulation techniques for pneumonia was first recorded as early as the Spanish influenza pandemic of 1918, when patients treated with standard medical care had an estimated mortality rate of 33%, compared to a 10% mortality rate in patients treated by osteopathic physicians6. When applied to the management of pneumonia, manual manipulation techniques bolster lymphatic flow, respiratory function, and immunological defense by targeting anatomical structures involved in the these systems7,8, 9, 10.

The objective of this review video-article is three-fold: a) summarize the findings of randomized controlled studies on the efficacy of OMT in adult patients with diagnosed pneumonia, b) demonstrate established protocols utilized by osteopathic physicians treating pneumonia, c) elucidate the physiological mechanisms behind manual manipulation of the respiratory and lymphatic systems. Specifically, we will discuss and demonstrate four routine techniques that address autonomics, lymph drainage, and rib cage mobility: 1) Rib Raising, 2) Thoracic Pump, 3) Doming of the Thoracic Diaphragm, and 4) Muscle Energy for Rib 1.5,11

Pneumonia is one of the top ten leading causes of death in the U.S. Osteopathic manipulative techniques (OMT) may be utilized as an adjunctive therapy in the treatment of pneumonia to enhance biomechanical and immune function; and ultimately, to reduce hospital stay, duration of antibiotics, incidence of respiratory failure, and mortality. In this video-article, we will review randomized controlled studies on the use of OMT in pneumonia patients, as well as demonstrate specific hands-on techniques that are routinely practiced by osteopathic physicians when treating pulmonary infections.

Pneumonia, the inflammatory state of lung tissue primarily due to microbial infection, claimed 52,306 lives in the United States in 20071 and resulted in ...

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.

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

MRI-guided dmPFC-rTMS as a Treatment for Treatment-resistant Major Depressive Disorder

Here we outline the protocol for magnetic resonance imaging (MRI) guided repetitive transcranial magnetic stimulation (rTMS) to the dorsal medial prefrontal cortex (dmPFC) in patients with major depressive disorder (MDD). Technicians used a neuronavigation system to process patient MRIs to generate a 3-dimensional head model. The head model was subsequently used to identify patient-specific stimulatory targets. The dmPFC was stimulated daily for 20 sessions. Stimulation intensity was titrated to address scalp pain associated with rTMS. Weekly assessments were conducted on the patients using the Hamilton Rating Scale for Depression (HamD17) and Beck Depression Index II (BDI-II). Treatment-resistant MDD patients achieved significant improvements on both HAMD and BDI-II. Of note, angled, double-cone coil rTMS at 120% resting motor threshold allows for optimal stimulation of deeper midline prefrontal regions, which results in a possible therapeutic application for MDD. One major limitation of the rTMS field is the heterogeneity of treatment parameters across studies, including duty cycle, number of pulses per session and intensity. Further work should be done to clarify the effect of stimulation parameters on outcome. Future dmPFC-rTMS work should include sham-controlled studies to confirm its clinical efficacy in MDD.

Here we outline the procedure for MRI-guided repetitive transcranial magnetic stimulation to the dorsomedial prefrontal cortex as an experimental treatment for major depressive disorder.

Here we outline the protocol for magnetic resonance imaging (MRI) guided repetitive transcranial magnetic stimulation (rTMS) to the dorsal medial ...

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.

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

Topical Airway Anesthesia for Awake-endoscopic Intubation Using the Spray-as-you-go Technique with High Oxygen Flow

A patient&#39;s willingness to cooperate is an absolute precondition for successful awake intubation of the trachea. Whilst drug-sedation of patients can jeopardize their spontaneous breathing, topical anesthesia of the airway is a popular technique. The spray-as-you-go technique represents one of the simplest opportunities to anesthetize the airway mucosa. The application of local anesthetic through the working channel of the flexible endoscope is a widespread practice for anesthetists as well as pulmonologists. There is neither need for additional devices nor special training as a pre-requisite to perform this technique. However, a known clinical problem is the coughing and gagging reflex that may occur when the liquid anesthetic strikes the airway mucosa and other sensitive structures like the vocal cords. This can be avoided by the use of oxygen applied through the working channel with the aim of fogging the local anesthetic into finer particles. Furthermore, the oxygen flow provides a higher oxygen supply and contributes to a better view, dispersing mucus secretions and blood away from the lens. Using an atomizer with a high oxygen flow of 10 L/min we maximized these benefits, caused less coughing and had more satisfied and therefore cooperative patients. Possible, but very rare complications of using oxygen flow including gastric insufflation, organ rupture or barotrauma did not arise. We attribute the complication-free use of high oxygen flow to the design of the set, which permits flow and pressure release.

The topical anesthetic lidocaine was atomized using a high oxygen flow through the working channel of a flexible intubating endoscope to achieve topical airway anesthesia for awake endotracheal intubation. We prefer this modified spray-as-you-go technique for endoscopic intubation to classical bolus application because of higher patient satisfaction and better compliance.

A patient&#39;s willingness to cooperate is an absolute precondition for successful awake intubation of the trachea. Whilst drug-sedation of patients can ...

Novel Methods for Intranasal Administration Under Inhalation Anesthesia to Evaluate Nose-to-Brain Drug Delivery

Intranasal administration has been reported to be a potential pathway for nose-to-brain delivery of therapeutic agents that circumvents the blood-brain barrier. However, there have been few reports regarding not only the quantitative analysis but also optimal administration conditions and dosing regimens for investigations of nose-to-brain delivery. The limited progress in research on nose-to-brain pathway mechanisms using rodents represents a significant impediment in terms of designing nose-to-brain delivery systems for candidate drugs.
To gain some headway in this regard, we developed and evaluated two novel methods of stable intranasal administration under inhalation anesthesia for experimental animals. We also describe a method for the evaluation of drug distribution levels in the brain via the nose-to-brain pathway using radio-labeled [14C]-inulin (molecular weight: 5,000) as a model substrate of water-soluble macromolecules.
Initially, we developed a pipette-based intranasal administration protocol using temporarily openable masks, which enabled us to perform reliable administration to animals under stable anesthesia. Using this system, [14C]-inulin could be delivered to the brain with little experimental error.
We subsequently developed an intranasal administration protocol entailing reverse cannulation from the airway side through the esophagus, which was developed to minimize the effects of mucociliary clearance (MC). This technique led to significantly higher levels of [14C]-inulin, which was quantitatively detected in the olfactory bulb, cerebrum, and medulla oblongata, than the pipette method. This appears to be because retention of the drug solution in the nasal cavity was substantially increased by active administration using a syringe pump in a direction opposite to the MC into the nasal cavity.
In conclusion, the two methods of intranasal administration developed in this study can be expected to be extremely useful techniques for evaluating pharmacokinetics in rodents. The reverse cannulation method, in particular, could be useful for evaluating the full potential of nose-to-brain delivery of drug candidates.

Here, we describe two novel methods of stable intranasal administration under inhalation anesthesia with minimal physical stress for experimental animals. We also describe a method for quantitative evaluation of drug distribution levels in the brain via the nose-to-brain pathway using radiolabeled [14C]-inulin as a model substrate of water-soluble macromolecules.

Intranasal administration has been reported to be a potential pathway for nose-to-brain delivery of therapeutic agents that circumvents the blood-brain ...

CO2-Lasertonsillotomy Under Local Anesthesia in Adults

Tonsil-related complaints are very common among the adult population. Tonsillectomy under general anesthesia is currently the most performed surgical treatment in adults for such complaints. Unfortunately, tonsillectomy is an invasive treatment associated with a high complication rate and a long recovery time. Complications and a long recovery time are mostly related to removing the vascular and densely innervated capsule of the tonsils. Recently, CO2-lasertonsillotomy under local anesthesia has been demonstrated to be a viable alternative treatment for tonsil-related disease with a significantly shorter and less painful recovery period. The milder side-effect profile of CO2-lasertonsillotomy is likely related to leaving the tonsil capsule intact. The aim of the current report is to present a concise protocol detailing the execution of CO2-lasertonsillotomy under local anesthesia. This intervention has been performed successfully in our hospital in more than 1,000 patients and has been found to be safe and to be associated with a steep learning curve.

CO2-Lasertonsillotomy Under Local Anesthesia in Adults

CO2-lasertonsillotomy under local anesthesia is an interesting alternative treatment method for tonsillectomy under general anesthesia for tonsil-related complaints in adults. This report presents a step-by-step protocol detailing the execution of CO2-lasertonsillotomy under local anesthesia.

Tonsil-related complaints are very common among the adult population. Tonsillectomy under general anesthesia is currently the most performed surgical ...

Electroretinogram Recording for Infants and Children under Anesthesia to Achieve Optimal Dark Adaptation and International Standards

Electroretinogram (ERG) is the only clinical objective test available to assess retinal function. Full-field ERG (ffERG) measures the panretinal rod and cone photoreceptor function as well as inner retinal function and is an important measure in the diagnosis and management of inherited retinal diseases as well as inflammatory, toxic, and nutritional retinopathies. Adhering to international standards and maintaining retinal dark adaptation are critical to acquire valid and reliable dark-adapted (scotopic) and light-adapted (photopic) ffERG responses. Performing ffERG in infants and children is challenging and often requires general anesthesia in the operating room. However, maintaining retinal dark adaptation in the operating room is becoming increasingly difficult given the numerous light sources from anesthesiology monitoring systems and other equipment. A practical and widely applicable method for ffERG testing is described in the operating room that optimizes retinal dark adaptation. The method reduces operating room time by dark-adapting the patient before general anesthesiology is instituted. The operating room is modified for dark adaptation and any remaining light source in the darkened operating room is minimized with the use of a modified portable foldable darkroom that encloses the patient&#8217;s head and the ERG examiner during ffERG scotopic recordings. The simple method adheres to ffERG international standards and provides valid reliable scotopic and photopic ffERG recordings that are critical to assess objective retinal function in this young age group where subjective assessment of visual function such as visual acuity and visual fields are not possible. Furthermore, the ffERG is the gold standard clinical test in detecting early onset inherited retinal diseases including Leber congenital amaurosis where approved gene therapy has become available. In sedated conditions, very low amplitude ffERG signals can be detected due to minimal orbicularis muscle activity interference, which is particularly relevant in patients after gene therapy to detect improved amplitude responses.

Adhering to international standards and maintaining retinal dark adaptation are critical to acquire valid full-field electroretinogram responses in the diagnosis and management of inherited retinal diseases. A practical protocol using a portable darkroom is provided to obtain full-field&#160;electroretinogram for infants and children under sedation or general anesthesia in the operating room setting.

Electroretinogram (ERG) is the only clinical objective test available to assess retinal function. Full-field ERG (ffERG) measures the panretinal rod and ...

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.

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

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.

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