Microsurgical Procedures Research Articles

Equivalence in Color-coded Duplex Sonography Parameters before Complex Microsurgery.

Color-coded duplex sonography (CCDS) is a widely proposed noninvasive diagnostic tool in microsurgery. CCDS has been applied to lower extremity salvage cases to define appropriate blood flow velocity criteria for achieving arterial success in diabetic foot and complex microsurgery cases. This study aimed to compare the success ratio of free flaps when using CCDS versus cases where CCDS was not used. We included complex microsurgery cases from 2019 to 2021. These cases were subsequently categorized into two groups: group A consisted of cases where CCDS parameters were applied, whereas group B comprised cases where CCDS was not performed at all. The study encompassed 14 cases (11 men and three women). The age range varied from 23 to 62 years, with an average age of 42. Using CCDS analysis and planning demonstrated improved outcomes in comparison with cases where CCDS was not performed, albeit without statistical significance (P = 0.064). The application of CCDS proves to be beneficial in the realm of microsurgery. Although not achieving statistical significance, our data imply that CCDS utilization holds promise for enhancing microsurgical procedures.

Fully endoscopic posterior fossa decompression for Chiari malformation type I: illustrative case.

Surgery for symptomatic Arnold-Chiari malformation type I involves posterior fossa decompression. There are various approaches, including endoscope-assisted ones. New possibilities and fields of application of fully endoscopic techniques are currently being developed since new and advanced endoscopic equipment and instrumentation are available. The authors describe the case of a fully endoscopic microsurgical procedure in a 30-year-old female patient with progressive vertigo who was diagnosed with Chiari malformation type I. Neuronavigation and neuromonitoring were used during the surgery. Fully endoscopic surgery can be successfully performed in patients with Chiari malformation I. Intraoperative neuromonitoring and neuronavigation increase safety during this procedure.

Endovascular glue embolization of the medial posterior choroidal artery aneurysm: A case report and a literature review

Background: The medial posterior choroidal artery (MPCA) aneurysm is extremely uncommon. Thus yet, just a few cases have been reported. Due to the deep position, narrow lumen, fragile walls, and extensive tortuosity, both endovascular and microsurgical procedures are strictly limited. A case study of successful endovascular glue embolization of a left MPCA aneurysm and a literature review is included in this report. Case Description: A 17-year-old female arrived at our institution 2 days after suffering a major intraventricular hemorrhage with a minor subarachnoid hemorrhage. Digital subtraction angiography revealed a left MPCA aneurysm. The patient underwent a successful endovascular glue embolization and had a favorable functional outcome. Conclusion: Endovascular glue embolization yielded favorable clinical and angiographic results in MPCA aneurysms where microcatheter access and maneuverability are challenging.

State-wide Trends and Payments for Microsurgical Lymphedema Procedures in Patients Undergoing Mastectomy from 2016-2020

State-wide Trends and Payments for Microsurgical Lymphedema Procedures in Patients Undergoing Mastectomy from 2016-2020

Microsurgery Robots: Applications, Design, and Development.

Microsurgical techniques have been widely utilized in various surgical specialties, such as ophthalmology, neurosurgery, and otolaryngology, which require intricate and precise surgical tool manipulation on a small scale. In microsurgery, operations on delicate vessels or tissues require high standards in surgeons' skills. This exceptionally high requirement in skills leads to a steep learning curve and lengthy training before the surgeons can perform microsurgical procedures with quality outcomes. The microsurgery robot (MSR), which can improve surgeons' operation skills through various functions, has received extensive research attention in the past three decades. There have been many review papers summarizing the research on MSR for specific surgical specialties. However, an in-depth review of the relevant technologies used in MSR systems is limited in the literature. This review details the technical challenges in microsurgery, and systematically summarizes the key technologies in MSR with a developmental perspective from the basic structural mechanism design, to the perception and human-machine interaction methods, and further to the ability in achieving a certain level of autonomy. By presenting and comparing the methods and technologies in this cutting-edge research, this paper aims to provide readers with a comprehensive understanding of the current state of MSR research and identify potential directions for future development in MSR.

Vascular Repair for Iatrogenic Injury during Microsurgical Procedures: Clinical Investigation and Review of 18 Cases at a Single Institution.

Intracranial vascular injury (VI) due to surgery is a critical complication that can lead to serious neurologic deficits. To our knowledge, only a few review articles on VI during an operation have been published so far. We retrospectively investigated the type, cause, and measurement of VI during surgery at our institution. Unexpected VI cases occurred in 18 of 2,228 craniotomy procedures, including 794 aneurysm clippings and 357 tumor resections. We investigated the causes and coping techniques of the VI cases, as well as their full details. There were six cases of aneurysm neck tear, one case of sylvian vein injury, and one case of superior trunk perforation during direct clipping. Regarding tumor resection procedures, nine cases of arterial injury and one case of cortical vein injury were extracted. Almost all VIs were caused by carelessness or basic manipulation mistakes. We repaired all these cases with simple placement of suture threads with or without pinch clips, flow alteration using bypass techniques, and in 16 cases no neurologic deficit or deterioration on imaging occurred; however, 3 patients were verified to have ischemic changes on postoperative imaging. Most VIs were directly caused by a simple error and carelessness of an operator or an assistant. Many of these injuries can be avoided if a basic set of rules are followed and remembered during the surgical procedure. However, the surgical procedure involves human work, and errors cannot be eradicated even upon maximum concentration levels. Neurosurgeons should be prepared for an eventual quick repair of an unexpected cerebral VI.

Work-related musculoskeletal disorders among otolaryngology-head and neck surgery residents

PurposeSurgical residents are at high risk for work-related musculoskeletal disorders which can impact surgical training and overall quality of life. We sought to assess musculoskeletal symptoms among current United States otolaryngology-head and neck surgery residents. We focused on the upper extremity given fine motor control for microsurgical procedures and increased keyboarding requirements. This study builds on previous research by evaluating setting attribution and attitudes toward ergonomics among otolaryngology residents. Materials and methodsA web-based, cross-sectional survey incorporating Nordic Musculoskeletal Questionnaire and ergonomics-related questions was sent to otolaryngology residency program directors in September of 2021. Descriptive statistics, Spearman's correlation, logistic regression, and comparison of proportions were utilized. ResultsOverall, 148 otolaryngology residents completed the survey; 70 were female (45 %), 83 male (54 %), and 1 non-binary (0.6 %). MSK symptoms were reported in the neck (77.0 %), lower back (45.5 %), and upper back (31.8 %) most frequently. Symptoms were work-related for 80 % of residents, with 84.7 % deemed operating-room-related. Some required treatment (14.5 %) or formal evaluation (11.0 %) of their injury. Injuries prevented residents from working (7.4 %), operating (9.5 %), and performing activities of daily living (27.0 %). Many reported they would use ergonomic equipment (94.2 %), dictation software (74.1 %), and scribes (81.3 %) if available. ConclusionsDespite increased surgical ergonomic awareness, musculoskeletal symptoms are still prevalent among otolaryngology residents. Nearly 1 in 9 residents required evaluation and treatment of their musculoskeletal symptoms, and one third reported lacking various ergonomic measures. Given the high prevalence of work-related musculoskeletal disorders, ergonomic practices for O-HNS trainees should be emphasized by residency programs.

Personalized 3D Printed Eye Gear for Microscopic Surgeons Amidst and beyond COVID-19.

The COVID-19 pandemic underscored the need for enhanced protective measures for healthcare workers, particularly surgeons, who face a heightened risk of exposure to infectious aerosols. However, conventional eye protection equipment such as face shields, goggles, or glasses often leads to ergonomic discomfort and a reduced field of view (FOV), impeding surgeons' ability to perform microsurgical procedures with precision and ease. To address these limitations, this study aimed to develop personalized 3D-printed eye gear for microscopic surgeons based on facial anthropometry data. 3D scanning was employed to obtain facial data from ten neurosurgery residents. Utilizing computer-aided designing, eye gears tailored to the unique facial features of each participant were developed. Finite element analysis-based contact simulation was used to assess the pressure exerted by the eye gear. Multi-material 3D printing was employed to fabricate the personalized eye gear. Participants, while donning the eye gear, engaged in simulation-based micro suturing tasks at various magnifications of the operating microscope, and marked the FOV range. They provided feedback scores (1-10) on the effectiveness of the eye gear through a Likert scale questionnaire (Q1-Q8). Finite element analysis demonstrated uniform strain distribution on the face, indicating that the edges of the customized eye gear fit exactly to the user's face. The average scores for the questionnaire Q1 to Q8 ranged from 6.8 to 8.5, with an overall mean score of 7.6. This indicates that the developed eye gear was simple to use and did not cause any discomfort. Additionally, the average reduction in the FOV was only 10.93% across the different operating microscope magnifications. These findings highlight eye gear's potential to alleviate discomfort and enhance precision in microscopic surgeries. Consequently, personalized 3D-printed eye gear offers a promising solution for providing surgeons with a safe environment while preserving the benefits of the operating microscope.

Dynamic Navigation System vs. Free-Hand Approach in Microsurgical and Non-Surgical Endodontics: A Systematic Review and Meta-Analysis of Experimental Studies.

(1) Background: A Dynamic Navigation System (DNS) is an innovative tool that facilitates the management of complex endodontic cases. Despite the number of advantages and limitations of this approach, there is no evidence-based information about its efficiency in comparison with that of the traditional method in endodontics. (2) Objectives: We aimed to explore any beneficial effects of the DNS and compare the outcomes of DNS vs. free-hand (FH) approaches for non-surgical and microsurgical endodontics. (3) Methods: A literature search was conducted in August 2023 to identify randomized, experimental, non-surgical, and microsurgical endodontic studies that compared the DNS with FH approaches. The procedural time (ΔT, s), substance loss (ΔV, mm3), angular deviation (ΔAD, °), coronal/platform linear deviation (ΔLD_C, mm), and apical linear deviation (ΔLD_A, mm) were recorded and analyzed. Quality and risk of bias assessments were conducted according to the Quality Assessment Tool For In Vitro Studies. A meta-analysis was performed using mean difference and standard deviation for each outcome, and heterogeneity (I2) was estimated. p < 0.05 was considered significant. (4) Results: One-hundred and forty-six studies were identified following duplicate removal, and nine were included in the systematic review and meta-analysis. The overall risk of bias was classified as low. The DNS was found to be more accurate and efficient than the FH approach was, resulting in a significantly shorter operation time (p < 0.00001) and less angular (p ≤ 0.0001) and linear deviation (p ≤ 0.01). For substance loss, the advantage of the DNS was significant only for microsurgery (p = 0.65, and p < 0.005, for non-surgical and microsurgical procedures, respectively). A reduced risk of iatrogenic failure using the DNS was observed for both expert and novice operators. (5) Conclusions: The DNS appears beneficial for non-surgical and microsurgical endodontics, regardless of the operator's experience. However, appropriate training and experience are necessary to access the full advantages offered by the DNS.

A Simple, Cost-effective Microsuction Device.

In our proposed device, we converted a large suction tube into a small tube with reduced suction velocity. This can aid in microsurgical procedures in which meticulous suctioning while minimizing trauma to the surrounding structures is essential. This device can relieve the surgeon from having to be cautious about injuring any anastomoses or neurovascular structures while suctioning.

Patient Blood Management in Microsurgical Procedures for Reconstructive Surgery.

Introduction: The main purpose of reconstructive surgery (RS) is to restore the integrity of soft tissues damaged by trauma, surgery, congenital deformity, burns, or infection. Microsurgical techniques consist of harvesting tissues that are separated from the vascular sources of the donor site and anastomosed to the vessels of the recipient site. In these procedures, there are some preoperative modifiable factors that have the potential to influence the outcome of the flap transfer and its anastomosis. The management of anemia, which is always present in the postoperative period and plays a decisive role in the implantation of the flap, covers significant importance, and is associated with clinical and laboratory settings of chronic inflammation. Methods: Chronic inflammatory anemia (ACD) is a constant condition in patients who have undergone RS and correlates with the perfusion of the free flap. The aim of this treatment protocol is to reduce the transfusion rate by maintaining both a good organ perfusion and correction of the patient's anemic state. From January 2017 to September 2019, we studied 16 patients (16 males, mean age 38 years) who underwent microsurgical procedures for RS. Their hemoglobin (Hb) levels, corpuscular indexes, transferrin saturation (TSAT) ferritin concentrations and creatinine clearance were measured the first day after surgery (T0), after the first week (T1), and after five weeks (T2). At T0, all the patients showed low hemoglobin levels (average 7.4 g/dL, STD 0.71 range 6.2-7.4 g dL-1), with an MCV of 72, MCH of 28, MCHC of 33, RDW of 16, serum iron of 35, ferritin of 28, Ret% of 1.36, TRF of 277, creatinine clearance of 119 and high ferritin levels (range 320-560 ng mL-1) with TSAT less than 20%. All the patients were assessed for their clinical status, medical history and comorbidities before the beginning of the therapy. Results: A collaboration between the two departments (Department of Transfusion Medicine and Department of Reconstructive Surgery) resulted in the application of a therapeutic protocol with erythropoietic stimulating agents (ESAs) (Binocrit 6000 UI/week) and intravenous iron every other day, starting the second day after surgery. Thirteen patients received ESAs and FCM (ferric carboxymaltose, 500-1000 mg per session), three patients received ESAs and iron gluconate (one vial every other day). No patients received blood transfusions. No side effects were observed, and most importantly, no limb or flap rejection occurred. Conclusions: Preliminary data from our protocol show an optimal therapeutic response, notwithstanding the very limited scientific literature and data available in this specific surgical field. The enrollment of further patients will allow us to validate this therapeutic protocol with statistically sound data.

Revision Phalloplasty: Evaluation, Algorithms, and Techniques for Salvage after Major Complications.

Phalloplasty is among the most complex and technically demanding reconstructive procedures. As a larger pool of surgeons perform this difficult procedure, more patients will present with major complications. There are few published data on the comprehensive evaluation and management of these patients, particularly those needing correction of multiple ongoing complications, which may require consideration of starting over with a new microsurgical procedure versus salvage of the existing flap. A literature review on complications of phalloplasty was conducted in combination with drawing upon the experience of 2 high-volume phalloplasty teams (Johns Hopkins/Harvard and GU Recon Clinic/Buncke Clinic) in treating patients with severe postsurgical issues. The purpose was to analyze critical factors and develop algorithms for secondary revision. Common complications of phalloplasty include urethral strictures and fistulas, diverticula, excess bulk, phalloplasty malposition, hypertrophic or keloidal scarring, and partial or total flap loss. In severe cases, local flaps or free flaps may be required for reconstruction. The decision to revise the existing neophallus or start over with a new flap for phalloplasty is particularly critical. Multidisciplinary team collaboration is essential to develop comprehensive plans that will resolve multiple concomitant problems while meeting patient goals for a functional and aesthetic neophallus. Preserving the original flap for phalloplasty is ideal when feasible. Additional local or free flaps are sometimes necessary in situations of significant tissue loss. In severe cases, complete redo phalloplasty is required. The algorithms proposed provide a conceptual framework to guide surgeons in analyzing and managing severe complications after phalloplasty. Therapeutic, V.

Robotic Nerve Surgery: Brachial Plexus.

Management of closed brachial plexus injuries has traditionally favored conservative approaches with lengthy intervals between initial injury and surgical reconstruction. The complex anatomy of this region often requires large incisions with extensive dissection. Recently, the use of robotic systems in plastic and reconstructive surgery has been increasing, and robot-assisted brachial plexus reconstruction is a novel application that is currently being explored. Current literature describing this application is primarily comprised of feasibility studies using animal and cadaver models, and literature describing use in human subjects is limited. Advantages demonstrated by these early studies include the reduction of physiologic tremor, 3D visualization of anatomical structures, and ergonomic positioning; this allows for increased surgical dexterity and the ability to perform minimally invasive microsurgical procedures within the confined anatomical spaces of the brachial plexus. Limitations revolve around inadequate instrumentation, large learning curves, and increased costs that restrict the ability to perform these complex microsurgical procedures reliably and efficiently. As companies continue to develop instrumentation specific to robot-assisted microsurgery, more extensive longitudinal studies outlining long-term costs, changes in operating time, and functional outcomes will be required before a conclusion about the utility of these systems in brachial plexus surgery can be made.

Musculoskeletal demands in microsurgery-an explorative study comparing the ergonomics of microscope and 3D exoscope.

To assess neurosurgeons' physical demands and investigate ergonomic aspects when using microsurgical visualization devices. Six neurosurgeons performed micro-surgical procedures on cadaveric specimens using the prototype of a digital 3D exoscope system (Aeos®, Aesculap, Tuttlingen, Germany) and a standard operating microscope (Pentero 900, Zeiss, Oberkochen, Germany) at two different patient positions (semisitting (SS), supine (SP)). The activities of the bilateral upper trapezius (UTM), anterior deltoid (ADM), and lumbar erector spinae (LEM) muscles were recorded using bipolar surface electromyography and neck flexion, arm abduction, and arm anteversion angles by gravimetrical posture sensors. Perceived discomfort frequency was assessed and subjects compared the two systems in terms of usability, posture, physical and mental demands, and working precision. Using the exoscope led to reduced ADM activity and increased UTM and LEM activity during SS position. The neck was extended when using the exoscope system with lower arm anteversion and abduction angles during the SS position. Subjects reported discomfort at the shoulder-neck area less frequently and lower physical demands when using the Aeos®. However, mental demands were slightly higher and two subjects reported lower working precision. The exoscope system has the potential to reduce the activity of the ADM by changing surgeons arm posture which may be accompanied by less discomfort in the shoulder-neck area. However, dependent on the applied patient position higher muscle activities could occur in the UTM and LEM.

Combined Application of a Novel Robotic System and Exoscope for Microsurgical Anastomoses: Preclinical Performance

Abstract Background The concept of robotic microsurgery is becoming increasingly known as several robotic systems tailored to the specific needs of microsurgery are being introduced. Training with these devices is essential to draw conclusions about their potential clinical utility. This study describes the training and learning curve of experienced microsurgeons and complete novices using such a robotic surgical system in combination with an exoscope. Methods Four experienced microsurgeons and three complete novices performed a total of 62 manual and robot-assisted anastomoses. The time for anastomosis completion and surgeon's satisfaction with the anastomosis and with the robotic system were recorded. The anastomoses' quality was assessed using the Structured Assessment of Microsurgery Skills (SAMS) and the Anastomosis Lapse Index (ALI). The Rapid Entire Body Assessment (REBA) was used for ergonomics evaluation. Results All expert microsurgeons and novices improved their performance during training. The average anastomosis time decreased significantly, while satisfaction with the anastomosis and robotic system increased significantly over time. Multiple SAMS score parameters increased significantly throughout robotic but not manual training and the ALI score demonstrated more errors in the manual group. The REBA score displayed a significantly lower risk for musculoskeletal disorders in the robotic group. Conclusion Currently, the first clinical applications of robotic surgical systems specifically designed for microsurgery are being reported. The introduction of such systems into clinical practice can be expected to have a steep learning curve, as demonstrated in our study. Meanwhile, robotic systems for microsurgical procedures may hold great potential for improvement of surgical quality and ergonomics.

Which incision is better for Lewis to Brown Norway rat liver transplantation, transverse or midline?

Orthotopic rat liver transplantation (OLT) is a complex microsurgical procedure extensively applied to basic science, myriad complications can occur, but incision-related self-biting has not been reported after OLT. For the project of tolerance induction through stem cells, we performed OLT from Lewis to Brown Norway (BN) rats as an acute rejection model and divided the study into the transverse incision group (n = 15) and midline incision group (n = 22), while cyclosporine A was subcutaneously injected for 10-day immunosuppression use, lidocaine cream was used for pain-relieving. The recipient survival and wound status were the primary endpoint of this study. For the transverse incision group, 30-day survival rate was 40% (6/15), self-biting occurred in 13 cases in 7–39 days, the degree 1 of biting occurred in 1 cases, the degree 2 in 2 cases. The degree 3 in 10 cases, which caused death or euthanasia, the self-biting rate was 86.7% (13/15), For the midline incision group, 30-day survival rate was 100% (22/22), the degree 1 of self-biting occurred in 3 cases, no severe self-biting occurred. There were significant differences for survival (p = 0.0003) and for self-biting rate (p < 0.01) between two groups. In conclusion, incision-related self-biting behavior occurs due to incisional injury, the transverse incision is severely pain-causing; the midline one is effective to avert occurrences.

P-107 MICROFLUIDIC SPERM SEXING: An XLD (X-linked Disorder) model for preventing genetic disorders in newborns

Abstract Study question Can sperm sexing based on unique surface membrane markers – enable genotypic sperm sorting by allosomal content to prevent certain X-linked disorders in newborns? Summary answer In an X-Linked-Disorder prevention model, we utilized a microfluidic device functionalized with H-Y monoclonal antibodies attached to magnetic beads to enrich Y-chromosome bearing sperm sorts. What is known already About 4% of newborns are at risk of being born with an X-linked disease such as Fragile X Syndrome. The current clinically approved mitigation plan for preventing such genetic disorders is to consider Preimplantation Genetic Testing for Monogenetic diseases (PGT-M) which involves an invasive microsurgical procedure on fragile embryos. To minimize this invasiveness, we proposed a less invasive microsurgical exclusion approach to prevent such genetic disorders by genotypically sorting sperm cells that can be used for IUI/IVF/ICSI – with microfluidics – using their allosomal characteristics. Study design, size, duration Semen samples purchased from FairFax Cryobank from anonymous donors were used in immuno-magnetic microfluidic sorting protocols with the use of phycoerythrin (PE) binding Tetrameric Antibody Complexes (TAC) coupled with magnetic beads to tag H-Y monoclonal antibody (mab) binding activities on the sperm surface membrane. Participants/materials, setting, methods Immuno-magnetic sorting was conducted with specially fabricated microfluidic-sperm-sorting (MSS) chips. Sort yield and purities of positively selected sperm populations were assessed by flow-cytometry, immunofluorescence, fluorescent-in-situ-hybridization (FISH) and by quantitative-PCR (qPCR – Cq &amp; Tm). Quantitative experiments were run in triplicates and the results were expressed as absolute means for comparison between paired variables. Statistical analyses were performed using Student’s t-test and a p-value of less than 0.05 was considered to be statistically significant. Main results and the role of chance For the assessment of H-Y sperm sorts, our preliminary data showed that flow cytometry was able to confirm the positive sperm selection (which were mostly Y-chromosome bearing sperm cells) in a sperm genotyping protocol – initially utilizing immuno-magnetic sort tubes prior to flowing through microfluidic chips. Both immuno-magnetic sort tubes and the microfluidic chips were able to optimally confirm from qPCR-Cq means – the negative selection – being the X-chromosome bearing sperm that may have been largely unselected by the H-Y-mab. Values for Cq means compared under H-Y-qPCR data sets were statistically significant with a p value of 0.000023 (p values is significant at &amp;lt; 0.05). Our study was able to elucidate a potential less invasive clinical application of genotypically sorting sperm cells with mab-functionalized microfluidic chips for an XLD-model. Molecular down stream applications like flow cytometry may therefore be utilized to experimentally confirm sort purities of positively selected sperm populations (with H-Y markers) – based on the utility of the SMCX and SMCY gene in the X and Y sperm chromosome bearing sperm cells respectively. Limitations, reasons for caution Physiological effect of magnetic fields of varying tesla or gauss strengths on sperm selected with immuno-magnetic beads may warrant further safety studies prior to actual clinical applications. Optimal selection results may be achieved with the use of freshly collected normospermic rather than frozen-thawed samples. Wider implications of the findings Although we had de-emphasized the clinical application of the microfluidic sperm sexing protocol for legitimate use in sex selection and gender balancing, this study design was solely focused on adapting a less invasive method of preventing X-linked genetic disorders with the potential exclusion of microsurgical procedures leading to PGT-M. Trial registration number NA

P-750 A systematic review of vasovasostomy (VV) and vasoepididymostomy (VE) techniques for Vasectomy Reversal: How far have we come?

Abstract Study question A systematic review of current literature evaluating different techniques in performing vasovasostomy (VV) and vasoepididymostomy (VE) including robotic-assisted and minimally invasive techniques and their outcomes Summary answer Macrosurgical, microsurgical and robot-assisted techniques have evidence for use in vasectomy reversal. The use of robotic assistance in may have benefit over standard techniques. What is known already While vasectomy is a common procedure worldwide, six percent of these patients request a reversal procedure. Reasons for this include change of mind, a new relationship, death of a child or wanting more children. While sperm harvest combined with in-vitro fertilisation (IVF) is an alternative, factors including timing of patency and durability of patency need to be considered prior to deciding between vasectomy reversal or sperm harvesting with IVF. In 1977, microsurgical techniques for vasovasostomy were described by Silber and Owen, and microsurgical vasectomy reversal procedures became more common following this. The evidence for differing approaches is lacking. Study design, size, duration A systematic literature review was performed using databases Medline and PubMed was performed, comprising studies between 1979 to July 30 2022. Systematic review and review articles of vasovasostomy and vasoepididymostomy were included. Original studies on robotic- assisted techniques and minimally invasive approaches were also included. Exclusion criteria included animal studies and non-English. Level of evidence was evaluated. Participants/materials, setting, methods From the eligible articles identified from the above criteria, data was extracted from review articles including techniques used for vasovasostomy and vasoepididymostomy. Surgical outcomes including pregnancy rates and postoperative patency were considered surgical outcomes and data was extracted regarding this from above articles. Data from original studies on minimally invasive techniques were also extracted from the above articles. Main results and the role of chance For vasovasostomy, techniques described in the literature include microscopic vasovasostomy, mini-incision microscopic vasovasostomy (MVV), mini incision MVV using Moon’s clamp, and robotic assisted vasovasostomy. Described by surgeons as the “most technically challenging procedure”, the early approach to vasoepididymostomy comprised a 3-4cm scrotal incision for delivery of testis to provide adequate exposure to the entire epididymis and vas deferens. When vasoepididymostomy was compared to vasovasostomy, prolonged recovery periods, increased pain and swelling were identified. The techniques described for vasovasostomy comprise end-to end, end-to side, three-suture triangulation intussusception (TIVE), two-suture longitudinal intussusception (LIVE), deferential vessel-sparing LIVE, mini-incision vasoepididymostomy, robot-assisted vasoepididymostomy (RAVE). Retrospective reviews of microsurgical vasovasostomy using a 2-layer anastomosis report patency rate of 85%, similar to reports from single layer repairs. Microsurgical techniques allow accurate apposition of narrow lumen ends, allowing unobstructed semen flow and low level evidence suggests high patency rates. Macrosurgical vasovasostomy may be more simple, less expensive and a quicker alternative. Elzanaty et al. found no clear difference between microsurgical and microsurgical vasovasostomy in terms of vasal patency. Both techniques appeared to be effective when performed by an experienced surgeon. Preliminary evidence for robotic assistance suggests a role in reduced morbidity and accuracy of repair. Limitations, reasons for caution With low level evidence for each technique, formal clinical guidelines are not forthcoming. Further evaluation and longer follow-up is required to assess clinical usage and true cost-benefit ratio. There is also a need for a standardised measurement tool to provide accurate and objective outcome measures to compare techniques. Wider implications of the findings This systematic review provides evidence for available techniques in vasovasostomy and vasoepididymostomy for vasectomy reversal. Outcome measurement tools are presented, highlighting the lack of standardised definitions of patency and failure. The current review enables surgeons performing vasectomy reversal to determine the most effective, efficient and cost-effective technique for their practice. Trial registration number ‘Not applicable'

Extravascular optical coherence tomography of cerebral vessel walls in vivo.

Evaluation of extravascular, microscope integrated OCT (iOCT) as an in vivo imaging modality of cerebral blood vessels and as an intraoperative imaging method. Microscope integrated optical coherence tomography of major cerebral arteries (n = 13) and superficial sylvian veins (n = 5) and one incidental cerebral vasospasm (n = 1) in (n = 10) patients. Post procedural analysis of OCT volume scans, microscopic images and videos during the time of scan as well as measurements of the diameter of vessel walls and its layers with an accuracy of 7.5 μm. iOCT was feasible during vascular microsurgical procedures. In all scanned arteries a clear delineation of the physiological three layered vessel wall composition could be achieved. Pathological arteriosclerotic alterations of cerebral artery walls could precisely be demonstrated. Major superficial cortical veins conversely presented a mono layered composition. First in vivo measurements of vascular mean diameters were possible. Cerebral artery walls showed a diameter of 296 μm, tunica externa 78 μm, media 134 μm and interna 84 μm. For the first time the microstructural composition of cerebral blood vessels could be illustrated in vivo. Due to an outstanding spatial resolution a clear definition of physiological and pathological characteristics was possible. Therefore, microscope integrated optical coherence tomography holds promise for basic research in the field of cerebrovascular arteriosclerotic diseases and for intraoperative guidance during microvascular surgery.

Surgeon reported practice patterns related to full endoscopic cervical decompression procedures.

The microsurgical anterior approach to the cervical spine is commonplace. Fewer surgeons perform posterior cervical microsurgical procedures on a routine basis for lack of indication, more bleeding, persistent postoperative neck pain, and risk of progressive misalignment. In comparison, the endoscopic technique is preferentially performed through the posterior approach. Many spine surgeons and even surgeons versed in lumbar endoscopy are often reluctant to consider endoscopic procedures in the cervical spine. We report the results of a surgeon survey to find out why. A questionnaire of 10 questions was sent to spine surgeons by email and chat groups in social media networks including Facebook, WeChat, WhatsApp, and LinkedIn to collect practice pattern data about microscopic and endoscopic spine surgery in the lumbar and cervical spine. The responses were cross-tabulated by surgeons' demographic data. Pearson Chi-Square measures, Kappa statistics, and linear regression analysis of agreement or disagreement were performed by analyzing the distribution of variances using the statistical package SPSS Version 27.0. The survey response rate was 39.7%, with 50 of the 126 surgeons who started the survey submitting a completed questionnaire. Of the 50 surgeons, 56.2% were orthopedic, and 42% neurological surgeons. Most surgeons worked in private practice (42%). Another 26% were university-employed, 18% were in private practice affiliated with a university, and the remaining 14% were hospital employed. The majority of surgeons (55.1%) were autodidacts. The largest responding surgeon groups were between 35-44years (38%) and between 45-54years of age (34%). Half of the responding surgeons were routinely performing endoscopic cervical spine surgery. The other half did not perform it for the main hurdle of fear of complications (50%). Lack of appropriate mentorship was listed as second most reason (25.4%). More concerns for not performing cervical endoscopic approaches were the perception of lack of technology (20.8%) and suitable surgical indication (12.5%). Only 4.2% considered cervical endoscopy too risky. Nearly a third (30.6%) of the spine surgeons treated over 80% of their cervical spine patients with endoscopic surgeries. Most commonly performed were posterior endoscopic cervical discectomy (PECD; 52%), posterior endoscopic cervical foraminotomy (PECF; 48%), anterior endoscopic cervical discectomy (AECD; 32%), cervical endoscopic unilateral laminotomy for bilateral decompression (CE-ULBD; 30%), respectively. Cervical endoscopic spine surgery is gaining traction among spine surgeons. However, by far most surgeons performing cervical endoscopic spine surgery work in private practice and are autodidacts. This lack of a teacher to shorten the learning curve as well as fear of complications are two of the major impediments to the successful implementation of cervical endoscopic procedures.