Microsurgical Aspects Research Articles

Microsurgical dissection of Sylvian fissure\u2014short technical videos of third generation cerebrovascular neurosurgeons

BackgroundMultiple intracranial pathologies, including aneurysms of the middle cerebral artery, distal basilar artery, and suprasellar pathologies require the microsurgical opening of the Sylvian fissure. Delicate splitting of the arachnoid and safe microdissection of the veins, arteries, and brain parenchyma is the key to successful surgery through the Sylvian fissure corridor. We hypothesize that the geographical and historical environment in which neurosurgeons learn their operative skills is subject to a number of extrinsic influences, including cultural nuances of surgical techniques. Here we try to illustrate some cultural differences and technical aspects of the opening of the Sylvian fissure by four “third generation” cerebrovascular neurosurgeons from three different continents.MethodsIn the video analysis, various microsurgical aspects, including the opening style of the Sylvian fissure, handedness, use of sharp or blunt microinstruments, use of retractors, use of high magnification, and handling of bridging veins are presented.ResultsThe video illustrates the two distinct Sylvian fissure opening styles, namely sharp and blunt microdissection, as well as the extent of the opening namely a wide and focal splitting.ConclusionThe edited video underlines nuances and differences of a few major technical aspects that are perhaps typical to certain surgical environments and cultures. These microsurgical nuances and styles are useful pearls that can be mastered with training by any novice neurosurgeon.

Treatment of giant acoustic neuromas

To analyze the treatment modality and outcome of a series of patients with giant acoustic neuromas, a particular type of tumour characterised by their size (extracanalicular diameter of 4cm or more) and high morbidity and mortality. This was a retrospective unicentre study of patients with acoustic neuromas treated in a period of 12 years. In our institutional series of 108 acoustic neuromas operated on during that period, we found 13 (12%) cases of giant acoustic neuromas. We reviewed the available data of these cases, including presentation and several clinical, anatomical, and microsurgical aspects. All patients were operated on by the same neurosurgeon and senior author (EU) using the suboccipital retrosigmoid approach and complete microsurgical removal was achieved in 10 cases. In one case, near total removal was deliberately performed, in another case a CSF shunt was placed as the sole treatment measure, and in the remaining case no direct treatment was given. One patient died in the immediate postoperative period. One year after surgery, 4 patients showed facial nerve function of iii or more in the House-Brackman scale. The 4 most important prognostic characteristics of giant acoustic neuromas are size, adhesion to surrounding structures, consistency and vascularity. Only the first of these is evident in neuroimaging. Giant acoustic neuromas are characterised by high morbidity at presentation as well as after treatment. Nevertheless, the objective of complete microsurgical removal with preservation of cranial nerve function is attainable in some cases through the suboccipital retrosigmoid approach.

CURRENT DEVELOPMENT OF ENTEROSCOPY

научный биометрический журнал, который знакомит читателя с клиническими рекомендациями и особенностями применения лекарственных и вакцинных средств у детей, предоставляет исчерпывающую информацию о воздействии лекарственных средств на плод, о проводимых в

The paramedian supracerebellar-transtentorial approach to the entire length of the mediobasal temporal region: an anatomical and clinical study

The exploration of lesions in the mediobasal temporal region (MTR) has challenged generations of neurosurgeons to achieve an appropriate approach. To address this challenge, the extensive use of the paramedian supracerebellar-transtentorial (PST) approach to expose the entire length of the MTR, as well as the fusiform gyrus, was investigated. The authors studied the microsurgical aspects of the PST approach in 20 cadaver brains and 5 cadaver heads under the operating microscope. They evaluated the features, advantages, difficulties, and limitations of the PST approach and refined the surgical technique. They then used the PST approach in 15 patients with large intrinsic MTR tumors (6 patients), tumor in the posterior fusiform gyrus with mediobasal temporal epilepsy (MTE) (1 patient), cavernous malformations in the posterior MTR including the fusiform gyrus (2 patients), or intractable MTE with hippocampal sclerosis (6 patients) from December 2007 to May 2010. Patients ranged in age from 11 to 63 years (mean 35.2 years), and in 9 patients (60%) the lesion was located on the left side. In all patients with neuroepithelial tumors or cavernous malformations, the lesions were completely and safely resected. In all patients with intractable MTE with hippocampal sclerosis, the anterior two-thirds of the parahippocampal gyrus and hippocampus, as well as the amygdala, were removed selectively through the PST approach. There was no surgical morbidity or mortality in this series. Three patients (20%) with high-grade neuroepithelial tumors underwent postoperative radiotherapy and chemotherapy but needed a second surgery for recurrence during the follow-up period. In all patients with MTE, antiepileptic medication could be decreased to a single drug at lower doses, and no seizure activity has occurred until this point. The PST approach provides the surgeon precise anatomical orientation when exposing the entire length of the MTR, as well as the fusiform gyrus, for removing any lesion. This is a novel technique especially for removing tumors involving the entire MTR in a single session without damaging neighboring neural or vascular structures. This approach can also be a viable alternative for selective removal of the parahippocampal gyrus, hippocampus, and amygdala in patients with MTE due to hippocampal sclerosis.

Intradural spinal tumours: an overview

This review summarizes the basic knowledge about intradural tumours such as spinal meningiomas, neurinomas and ependymomas. Some own illustrative cases are presented to recall the MRI features and to show some intra-operative microsurgical aspects. With a targeted approach extended over 1–2 segments, no additional stabilization was needed. Resection of the medial 3/4 of the pedicle enabled to remove ventro-laterally located meningiomas through a posterior approach without damaging the cord.

Video-microscopy for use in microsurgical aspects of complex hepatobiliary and pancreatic surgery: a preliminary report

BackgroundThe use of loupe magnification during complex hepatobiliary and pancreatic (HBP) surgery has become routine. Unfortunately, loupe magnification has several disadvantages including limited magnification, a fixed field and non-variable magnification parameters. The aim of this report is to describe a simple system of video-microscopy for use in open surgery as an alternative to loupe magnification. MethodsIn video-microscopy, the operative field is displayed on a TV monitor using a high-definition (HD) camera with a special optic mounted on an adjustable mechanical arm. The set-up and application of this system are described and illustrated using examples drawn from pancreaticoduodenectomy, bile duct repair and liver transplantation. ResultsThis system is easy to use and can provide variable magnification of ×4–12 at a camera distance of 25–35cm from the operative field and a depth of field of 15mm. This system allows the surgeon and assistant to work from a HD TV screen during critical phases of microsurgery. ConclusionsThe system described here provides better magnification than loupe lenses and thus may be beneficial during complex HPB procedures. Other benefits of this system include the fact that its use decreases neck strain and postural fatigue in the surgeon and it can be used as a tool for documentation and teaching.

History of the nervus intermedius of Wrisberg

Although probably identified by Eustachius (1563), the first clearly documented description of the nervus intermedius was completed by Heinrich August Wrisberg at the University of Göttingen in 1777. In 1881, Giuseppe Sapolini defined the nervus intermedius, according to its specific features, as the 13th cranial nerve. In 1908, Ramsay Hunt discovered the correlation between herpes zoster, nervus intermedius and geniculate neuralgia. The combination of venerable accuracy with modern knowledge in electrophysiology, clinical and microsurgical aspects give us an outstanding model of the manner of progress and of the interdisciplinary importance of applied anatomy in medicine. Despite the long history of anatomical description of this small nerve, not all features are well known and the common definition as a purely sensory and parasympathetic root of the facial nerve may not cover all aspects of the nervus intermedius.

O-26-382 - Microsurgical aspects of extramedullary intradural tumors of spinal cord

O-26-382 - Microsurgical aspects of extramedullary intradural tumors of spinal cord

The Transcallosal Interforniceal Approach to the Third Ventricle: Anatomic and Microsurgical Aspects

The Transcallosal Interforniceal Approach to the Third Ventricle: Anatomic and Microsurgical Aspects

The transcallosal interforniceal approach to the third ventricle: anatomic and microsurgical aspects.

The ability to visualize median-sagittal brain structures by magnetic resonance imaging improves planning for surgery to treat lesions of the third ventricle. The most appropriate path to the third ventricle is the transcallosal approach. The present study was undertaken to describe the surgical anatomy and landmarks encountered during this approach. The transcallosal-interforniceal approach was undertaken in 30 formalin-fixed brains using an operating microscope. The surface landmarks for the approach pathway were the two points, P5 and P7, located 5 and 7 cm anterior to the central sulcus, respectively. Using these two points on the cortical surface as references, a variety of measurements were made to provide quantitative information about distances between brain structures that are encountered during the surgical approach. Measurements that were made include the following: 1) the distance between P5 and the cingulate sulcus, 2) the distance between the cingulate sulcus and the corpus callosum, 3) the height of the corpus callosum, 4) the distance between the anterior commissure and the foramen of Monro, and 5) the distance between the lower margin of the corpus callosum and the fornix. Mean values for these key measurements were as follows: 1) 23.96 mm (range, 15.0-32.0 mm); 2) 13.50 mm (range, 8.0-20.0 mm) with reference to P5 and 12.73 mm (range, 16.0-18.0 mm) with reference to P7; 3) 6.12 mm (range, 4.0-8.0 mm) with reference to P5 and 6.60 mm (range, 4.0-9.0 mm) with reference to P7; 4) 4.96 mm (range, 2.5-10.0 mm), independent of P5 and P7; and 5) 8.46 mm (range, 3.0-16.0 mm) with reference to P5 and 11.04 mm (range, 6.0-22.0 mm) with reference to P7. The detailed quantitative information obtained in this study about the interforniceal approach permitted definition of surgical approach pathways that preserve important anatomic structures, such as the motor strip, genu of the corpus callosum, fornical commissure (hippocampal commissure), anterior commissure, and fornical columns. The approach through this surgical corridor can easily be planned and performed in individual cases using median-sagittal magnetic resonance imaging scans.

Microsurgery in trauma

Microsurgery in trauma William W. Shaw and David A. Hidalgo. Mt. Kisco, 1987, Futura Publishing Co., 407 pages, $87.50. This well-illustrated book stems from the work of a small, experienced group of surgeons in a single department of surgery. The vascular surgeon involved in the microsurgical aspects of trauma care will find in this book a comprehensive atlas of most of the free flaps used today in the immediate and delayed reconstruction of traumatized tissue. The remainder of the volume deals with aspects of microsurgery less pertinent to the vascular surgeon but important to others practicing microsurgery. The introductory section on the basic techniques and practical aspects of microsurgery covers magnification, sutures, monitoring techniques and equipment, instruments, vessel preparation, and microanastomosis. The book is not detailed enough to serve as a laboratory manual of the techniques of vessel preparation and microanastomosis; however, it does discuss some of the practical problems microsurgeons will encounter. These problems include ways to deal with vessel size discrepancy, the indications for end-to-end as opposed to end-to-side anastomosis, and the fine points of performing an arteriotomy. The section on replantation gives an overview of anatomic areas (upper and lower extremities, scalp, and penis) where replantations have been successfully performed and summarizes the results without delving deeply into the more controversial issue of the criteria for selecting suitable candidates for replantation. The section on nerve injuries provides a good overview of surgical exposures and indications for nerve repair, and it describes the various types of repair (epineural, group fascicular, combined epineural-perineural, fascicular, and nerve grafting) in a manner that clarifies what can be confusing terminology. There are some problems in this book. The authors sometimes fail to cite additional references that might be of value to the reader. They deal only superficially with microsurgical procedures for the late reconstruction of brachial plexus injuries. They also tend to laud the use of nerve grafts as a means of primary nerve repair in spite of the fact that no one has shown the superiority of nerve grafting in those situations in which end-to-end repair can be achieved without tension at the suture line. Nonetheless the discussion of tissue transplantation alone would make this book a useful addition to the library of any vascular surgeon involved in microsurgery.

Microsurgery of pineal region lesions in children.

Sixteen patients of the pediatric age group (mean age 6.9 years) harboring a tumorous, cystic or vascular mass lesion of the pineal region were evaluated for clinical, neuroradiological and microsurgical aspects. The heterogenous histological pattern of the lesions reflected various clinical signs and neuroradiological features. Computer assisted tomography and magnetic resonance imaging were the main neurodiagnostic tools, although angiography was an important complementary investigation in selected cases. Microsurgical approach and removal of the tumorous and cystic processes proved to be the rational treatment. Additional treatment such as chemotherapy or radiotherapy was performed in malignant processes upon a precise histological evaluation of the tumor specimen.

The role of the microsurgical laboratory in orthopedic training programs.

A well-organized, efficiently run microsurgical research and training laboratory can be a valuable asset to an orthopedic training program. The three areas in which the laboratory can lend support are teaching, research, and clinical. Organization and utilization of the laboratory as a multifunctional facility can enable it to provide maximum support for the microsurgical aspects of the orthopedic training program.

Microsurgical Aspects of Varicocele

Microsurgical Aspects of Varicocele