Surgical View Research Articles

A new platform for laparoscopic training: initial evaluation of the ex-vivo live multivisceral training device.

Various training models have been developed for laparoscopic training. Inanimate models including cadavers, ex-vivo simulator, and virtual reality (VR), are less realistic and often fail to display specific events such as bleeding, bile leakage, etc. Animal models provide more realistic experience, but constraints like cost involved, anesthetic requirement, and ethical approval have limited its application. We have designed a new training ex-vivo simulator-Smagister to address these issues. The Smagister consists of a normothermic machine perfusion platform, multivisceral organ of porcine abdominal cavity (liver, gallbladder, pancreas, stomach, intestine, kidney, uterus, bladders, etc.), high-definition display, and software system. Blood gas analysis and number of peristalsis per hour were recorded. A questionnaire was used to subjectively assess vitality of the organ cluster every hour. Three laparoscopic procedures including cholecystectomy (LC), enterotomy closure (LEC) and hepatectomy (LLR) were performed on Smagister, with demonstration of specific events for each procedure. Six experts compared the procedures with actual surgery in terms of feasibility to complete procedures and demonstration of complications. The fluctuation of perfusate glucose (6.1-8.2mmol/L) and lactate (5.82-6.55mmol/L) suggested metabolic function of the multivisceral organs. The mean number of peristalsis was 2.2/min. The simulated surgical view and anatomic structures closely resembled actual surgery during continuous perfusion (3.5 ± 1.0, 3.8 ± 0.8, respectively). The evaluation scores of haptic feedbacks were 3.8 ± 0.8, resembling live tissue handling. LC, LEC, and LLR were performed well on the Smagister, with clear display of the specific events. All six experts considered Smagister as a suitable training modality for both basic and advanced laparoscopic surgery. The amalgamation of live animal model and ex-vivo simulation in Smagister centralizes the virtue of both modalities, expands the training field, and provides high-fidelity laparoscopic training for both novice and senior surgeons.

Effect of gauze placement soaked with adrenaline at suprabullar recess on hemostasis during endoscopic sinus surgery: A randomized controlled trial.

Topical application of vasoconstrictors is necessary for endoscopic sinus surgery (ESS) for a bloodless surgical view and reduced intraoperative bleeding. We aimed to verify the effectiveness of gauze placement soaked with adrenaline at suprabullar recess, where the anterior ethmoidal artery exists, on hemostasis during ESS. A randomized, double-blinded trial was carried out for 26 patients receiving ESS. At the beginning of the surgery, gauze soaked with 2% lidocaine with or without 1:10 000 adrenaline was placed at the suprabullar recess for 8 minutes. Estimated blood loss, surgical field score, and operation time were compared between the two groups. Estimated blood loss and surgical field score were significantly smaller in the adrenaline group than in the no adrenaline group. Operation time was not significantly different between the two groups. Gauze placement soaked with adrenaline at suprabullar recess reduces estimated blood loss and clears the surgical field during ESS.

Solo single-incision laparoscopic liver resection: a cohort series.

Single-incision laparoscopic liver resection (SILLR) is still challenging due to the unstable surgical view, the crowding instruments and its crossover. In this study, we present a new option of solo SILLR for various liver tumours in order to overcome those difficulties. Solo SILLR is indicated for liver tumours located in the left liver or in the superficial right liver. Data for 54 consecutive patients, who underwent solo SILLR between October 2015 and October 2018, were collected and analysed prospectively. A total of 30 patients (55.5%) underwent non-anatomical resection. Left hemi-hepatectomy was performed in 11 patients (20.4%) and left lateral was performed in 13 patients (24.1%). The median operative time was 114 (range 30-335) min with median blood loss of 400 (50-750) mL with no need of blood transfusion and no intraoperative complications. The median length of hospital stay was 3 (range 1-19) days. There was one case of post-operative intra-abdominal fluid collection and one case of incisional hernia during the follow-up. Solo SILLR is more feasible and safer for liver tumours located in the superficial right liver or in the left one. Therefore, solo surgery can be an option in SILLR.

Patella Fracture Fixation Via Wide Awake Local Anesthesia No Tourniquet (Walant) Technique

Introduction:Fracture of the tibia are the most common long bone fracture, with an incidence greater than 75,000 per year in the US1. With the recent breakthrough of operation under WALANT (Wide Awake Local Anaesthesia No Tourniquet) technique. We reported a patient with midshaft tibia fracture who underwent plating under the WALANT techniqueMethodology:18 yearold gentleman sustained a closed fracture of his left tibia after his motorbike skidded. He wascounselled for the surgery to be done under the wide-awake technique as we have limited operating theatre time for the case to be done under general/regional anaesthesia. Preoperatively, the WALANT solution is prepared using 50 cc lidocaine 2%, 1cc of epinephrine, 10cc of sodium bicarbonate 8.4% then dilute into 50 cc normal saline. Total of 50 cc WALANT solution was injected along the planned skin incision and at subperiosteum 30 minutes before operation started.Result:Pain score patient remain 0-3/10 during and after removal of backslab, throughout the surgery and postoperatively. The use of epinephrine for hemostasis provide good surgical field view since there is minimal bleeding. Postoperatively the anaesthesia effect lasted for 6 hour and was patient able to move the leg straight away without have to keep lying in bed for 6 hours after spinal or drowsiness from sedation.Conclusion:Plating of tibia under WALANT is a good alternative for patient who have financial difficulty, high risk operation under general anaesthesia, hospital which have limited slot for operation under general anaesthesia and etc. Additionally, the strength and stability of the plate can be assessed intraoperatively by asking the patient to actively move his limb.Reference: Praemer A, Furner S, Rice DP. Musculoskeletal Conditions in the United States. Park Ridge, IL: American Academy of Orthopaedic Surgeons; 1992.

Pre-Clinical Experience With the VITOM 3D and the ARTip Cruise System for Micro-Laryngeal Surgery.

Pre-Clinical Experience With the VITOM 3D and the ARTip Cruise System for Micro-Laryngeal Surgery.

Pediatric airway surgery under spontaneous respiration using high-flow nasal oxygen

ObjectivesIn pediatric airway surgery, SponTaneous Respiration using IntraVEnous anesthesia and Hi-flow nasal oxygen (STRIVE Hi) has not been well explored. Here, we report our experience of using STRIVE Hi in endoscopic evaluations and surgeries of the pediatric airway. MethodsThis retrospective review was based on 45 airway procedures conducted under STRIVE Hi, performed by a single surgeon at a single institute from May 2017 to September 2018. After induction of anesthesia, continuous infusion with propofol and remifentanil was provided to ensure an adequate level of anesthesia and supply of humidified oxygen via a nasal cannula. Monitoring was conducted using a transcutaneous CO2 sensor and a pulse oximeter, and the oxygen reserve and bispectral indexes were measured. No muscle relaxant was administered. ResultsThe median age of the patients was 16.0 months (range: 1–215 months) and the median weight was 10.2 kg (range: 2.4–38.5 kg). The median duration of spontaneous respiration was min 40 (range: 10–140 min). The airway procedures included diagnostic microlaryngoscopy, tracheocutaneous fistula excision, balloon dilation, supraglottoplasty, laryngeal cleft repair, injection laryngoplasty, papilloma excision, and subglottic cyst removal. During these procedures, STRIVE Hi facilitated evaluation of dynamic obstruction of the airway and the immediate outcome of surgical treatment and provided a good surgical view. Intubation and the termination of spontaneous respiration were required in only five patients. ConclusionsSTRIVE Hi is an effective and feasible anesthesia option in pediatric airway surgery. It provides unobstructed surgical access and is applicable to a wide range of procedures.

Clinical utility of new three-dimensional model using a zero-echo-time sequence in endoscopic endonasal transsphenoidal surgery

ObjectivesRecognizing the anatomical orientation surrounding the sellar floor is crucial in endoscopic endonasal transsphenoidal surgery (ETSS). Zero-echo-time (ZTE) sequences were recently suggested for a new bone identification technique on magnetic resonance imaging (MRI). This study aimed to evaluate the clinical usefulness of three-dimensional (3D)-ZTE-based MRI models in providing anatomical guidance for ETSS. Patients and MethodsZTE-based MRI and magnetic resonance angiography (MRA) data from 15 consecutive patients with pituitary tumor treated between September 2018 and May 2019 were used to create 3D-MRI models. From these, the architecture surrounding the sellar floor, particularly anatomical relationships between tumors and internal carotid arteries (ICAs), was visualized to preoperatively plan surgical procedures. In addition, 3D-ZTE-based MRI models were compared to actual surgical views during ETSS to evaluate model applicability. ResultsThese 3D-ZTE-based MRI models clearly demonstrated the morphology of the sellar floor and matched well with intraoperative views, including pituitary tumor, by successively eliminating sphenoidal structures. The models also permitted determination of the maximum marginal line of the opening of the sellar floor by presenting vital structures such as ICAs and tumors. With such 3D-MRI models, the surgeon could access the intracranial area through the sellar floor more safely, and resect the pituitary tumor maximally without complications. ConclusionOur 3D-MRI models based on ZTE sequences allowed distinct visualization of vital structures and pituitary tumor around the sellar floor. This new method using 3D-ZTE-based MRI models showed low invasiveness for patients and was useful in preoperative planning for ETSS, facilitating maximum tumor resection without complications.

Diagnostic value of the axial view of magnetic resonance imaging to identify two-dimensional shapes of full-thickness rotator cuff tears.

Coronal and sagittal views of magnetic resonance imaging (MRI) were used to determine rotator cuff tear size and fatty infiltration, but these images were not enough to identify the tear shape. To correlate the preoperative axial MRI views and arthroscopic surgical findings to identify the two-dimensional shapes in rotator cuff tears. This study included 166 patients who underwent arthroscopic repair between 2015 and 2018. Preoperative coronal, sagittal, and axial MRI views were evaluated for tear size and geographic configuration in axial sections, and the length and the width were measured and were matched with arthroscopic surgical views by lateral portals. The agreement of axial MRI views with the arthroscopic view was 88.0% in crescent, 97.2% in longitudinal, 78.6% in massive, and 100% in rotator cuff tear arthropathy. The mean agreement rate of axial MRI views with arthroscopic view was 81.9%. Mean mediolateral and anteroposterior tear sizes on axial MRI were 16.68 mm and 19.33 mm, respectively. Mean mediolateral and anteroposterior tear sizes by arthroscopic view were 21.49 mm and 21.04 mm, respectively. Tear sizes by MRI axial images were 71.3% of arthroscopic view. SST/IST degenerative changes were noted in most patients with massive tears and rotator cuff arthropathy (P = 0.001). Rotator cuff tear shape on preoperative axial MRI view had close agreement (81.9%) with arthroscopic findings by lateral portal, and tear size by preoperative axial MRI views was 71.3% of that of arthroscopic view. Axial MRI views helped to predict the geometric tear shape of rotator cuff tears.

Early results of robotically assisted mitral valve repair in a single institution: report of the first 100 cases.

Robotically assisted mitral valve repair was approved for use in Japan in April 2018. The study objective was to assess the safety and clinical outcomes of robotic mitral valve surgery in the first 100 cases performed in our center. We reviewed the first 100 patients who underwent robotic primary mitral valve repair, including concomitant procedures, from April 2018 to August 2019. The cause of mitral valve disease was degenerative (n = 94), endocarditis (n = 2), functional (n = 2), and other (n = 2). There was no in-hospital or 30-day mortality. Mitral valve repair was completed in all patients. Only one patient required conversion to full sternotomy due to left ventricular apex bleeding. In echocardiography performed before hospital discharge, the mitral regurgitation was graded as none or trivial in 94 patients (94%) and mild in 4 (4%). Only two patients required surgical re-intervention due to postoperative hemolysis with moderate mitral regurgitation. For patients who underwent the mitral valve procedure alone, the median times of the total operation, cardiopulmonary bypass, aortic clamping, and console usage were 185, 112, 71, and 60min, respectively. The learning curve showed that the operation time decreased slightly during the first ten cases and then plateaued at a mean of approximately 180min. Robotically assisted mitral valve repair was feasible, safe, and therapeutically effective in the first 100 cases, with a minimal learning curve. The robotically assisted approach provides a high-quality surgical view and tremorless suture/cut handling, which will contribute to further development of minimally invasive mitral valve surgery.

Piezosurgery in Translabyrinthine-Approach Exposure of the Internal Auditory Canal.

To assess the applicability of the piezoelectric device in translabyrinthine-approach exposure of the internal auditory canal. In three cases with vestibular schwannoma, the bone around the internal auditory canal was completely removed by means of piezosurgery. Evaluation was performed by an experienced surgeon, and a second relatively inexperienced surgeon. Irrespective of surgical experience, piezosurgery proved to be a safe method for exposure of the internal auditory canal. Compared with the conventional procedure it provides an improved surgical view and more precise bone removal in a narrow operating field. This novel technique has the characteristics to reduce the corresponding risk of accidental slipping with consequent thermal and mechanical injury to the dura and neurovascular structures. The major disadvantage of piezosurgery is the longer time required for bone removal. The micro-oscillating piezoelectric device is a useful adjunct to the rotating burr during removal of the bone around the internal auditory canal in translabyrinthine approach. It could reduce the risk of injury to neurovascular structures at the bone-to-soft tissue interface.

Added Value of Interactive 3-D Stereo Vision Echocardiography in the Heart Valve Team: A Post Hoc Analysis for Optimal Decision Making in Patients With Mitral Valve Regurgitation.

We assessed the added value of advanced echocardiography post hoc analysis for optimal decision-making in the Heart Valve Team (HVT) using an interactive, dynamic, live visualization system with true three-dimensional (3-D) stereo vision. HVT scrutinized the incremental value of 3 consecutive methods of presentation of full-volume echocardiographic data sets in terms of diagnosis and possibility of repair in 11 selected patients having mitral regurgitation (MR)(Table 1). The questionnaire investigated consecutively (a) standard two-dimensional (2-D) transesophageal echocardiography, (b) single-beat 3-D zoom of the surgical view of the mitral valve, and (c) advanced 3-D volumetric rendering technology (Personal Space Station, Vesalius 3D software, PS-Medtech, Netherlands). In 4 of 11 reviews (36%), single-beat 3-D zoom had additional value over 2-D echocardiography in terms of mechanism/adjustments or adjustment of confirmation of diagnosis. Single-beat 3-D zoom had no additional value over 2-D echocardiography in terms of proposal/probability of repair. In 7 out of 11 (64%) reviews, true stereo 3-D visualization had additional value in terms of mechanism of pathology compared to 2-D and 3-D zoom and in 5 out of 11 (45%) reviews in confirmation of diagnosis. In 3 out of 11 (27%) reviews, true stereo 3-D visualization had additional value in terms of proposal of repair and in 4 of 11 (36%) in probability of repair over 2-D and 3-D zoom. Advanced easy-to-use true 3-D echocardiography limited differences in interpretation and strengthened the confidence in understanding the mechanisms and suitability for repair of mitral valve regurgitation, typically in more complex valve pathology.

P951 Intraprocedural echocardiographic technique to locate the insertion points of artificial chordae during transventricular beating heart mitral valve repair: ultrasound ""starry sky""

Abstract BACKGROUND Mitral valve repair is the preferred surgical treatment for severe mitral regurgitation due to degenerative leaflet prolapse. Within the growing era of transcatheter treatments for valvular heart disease, an innovative micro-invasive trans-ventricular beating-heart procedure was developed. Three-dimensional transoesophageal echocardiographic guidance is crucial to assist the operator in instrument navigation and chords positioning. Indeed, it is important an equidistant chords placement on the leaflet to ensure a uniform force distribution on the prolapsing segment and to avoid damaging of the previously inserted chords. PURPOSE To propose an intraoperative three-dimensional echocardiographic technique that allows operators to see the exact location of the polytetrafluoroethylene (ePTFE) chords used for the mitral repair. METHODS The procedure is performed using a device that is introduced through a posterolateral ventriculotomy and it is advanced towards the mitral valve under real-time 3D transoesophageal guidance. The prolapsing segments are grasped with the jaw of the instrument and the chords are implanted to achieve the proper distribution of forces and then tensioned and secured outside the ventricle. The proposed technique exploits the greater echogenicity of the artificial chord loop compared to native chords and leaflets. By lowering of the gains, remaining in the three-dimensional mitral valve surgical view, the signals of the native structures are attenuated, the underlying ventricular cavity appears black and the insertion points are visible as an intense signal on the virtual free edge of the leaflet treated. Figure 1 shows the intraoperative sequence of images of a case performed at our centre. The images were acquired using real time single beat three-dimensional reconstruction. Figure 1A shows the surgical view of the native valve with prolapse of the P2-P3 scallops. Image 1B reveals the prolapsing leaflet grasping and device location. After gain lowering, it’s possible to see the intense signal of the positioned artificial chord (Figure 1C). It can also be noted how this position matches with the position of the device at the time of grasping. Image 1D shows the partial disappearance of the prolapse during the tensioning test after the positioning of a second chord in a more medial position. Figure 1E shows the correct position of the ePTFE chords. We can notice the second chord placed in a medial position from the first one. This view, with dark ventricular chamber and intense signals of chordae loops, looks like a "STARRY SKY". RESULTS This technique allows to locate the correct insertion points of the artificial chords during the procedure. CONCLUSIONS This is a simple technique to guide operators during trans-ventricular beating heart mitral valve repair with ePTFE chords. Abstract P951 Figure 1

Combined Descemet membrane endothelial keratoplasty and extracapsular cataract extraction: management of an intraoperative challenge

Endothelial corneal transplantation (Descemet membrane endothelial keratoplasty [DMEK]) combined with cataract surgery as a triple procedure has been demonstrated to be safe and cost-effective. Where the corneal opacity is more significant, this may preclude safe phacoemulsification. This may not be apparent during preoperative assessment. An 80-year-old man with corneal decompensation secondary to herpes simplex endotheliitis and cataract underwent combined cataract extraction and DMEK. Intraoperatively, the surgical view became too poor to continue with conventional phacoemulsification. The lens was extracted by conversion to extracapsular surgery (extracapsular cataract extraction [ECCE]). Descemet membrane endothelial keratoplasty surgery was then completed without complication. Postoperatively, the graft remained attached, and by 3 months, acuity improved to 20/32 (Snellen). A poor intraoperative view during the triple procedure does not preclude a successful outcome. Corneal opacity can be overcome, avoiding full-thickness penetrating keratoplasty or discarding healthy graft tissue. Conversion to ECCE combined with DMEK is a feasible option intraoperatively that can still provide good outcomes.

A novel procedure of thoracoscopic 4L lymph node dissection: 4L posterior first technique

Background: Left lower paratracheal (4L) lymph node dissection for left lung cancer is difficult because of the anatomic configurations of the aortic arch, pulmonary artery, and left recurrent nerve. This study aimed to describe a novel procedure of thoracoscopic 4L lymph node dissection and determine its surgical outcomes. Methods: In this study, thoracoscopic lobectomy with lymphadenectomy was performed via four ports with confronting upside-down monitor setting. In our novel procedure, “4L posterior first technique,” we initially dissected the posterior side of 4L lymph nodes. The assistant surgeon retracted the lung with nodal packet, pulmonary artery, and vagus and left recurrent nerves; the retraction provided an excellent surgical view around the recurrent nerve. The bronchial arteries branching from the aorta were clipped and divided at the root. The dissection between the posterior side of nodal packet and the surrounding structures was completed before touching the hilar structures. The outcomes in the novel method group and the conventional method group were compared. Results: From 2016 to 2018, 40 and 38 patients underwent thoracoscopic 4L lymphadenectomy using the novel method and conventional method, respectively. The total operation time was 200±41 min, and the total blood loss was 27±28 mL. The postoperative hospital stay was for 6±3 days. None of the patients died, and none of them was converted to thoracotomy. The matched comparison revealed that the operation time was shorter (194±33 vs . 218±41 min, P=0.01), and the amount of bleeding was relatively smaller (22±21 vs . 33±21 mL, P=0.06) in the novel method group. Transient recurrent nerve paralysis was noted in one patient from the conventional method group (3.7%) and in no one from the novel group (0%). Conclusions: Our 4L posterior first technique is easier to perform and allows a more accurate dissection of thoracoscopic 4L lymph nodes.

Transoral endoscopic thyroid surgery using robotic scope holder: Our initial experiences.

Background:Transoral thyroid surgery represented by the da Vinci system is attracted attention and performed by several institutions. However, the current available da Vinci system still has some limitations to be improved for transoral thyroid surgery including high cost of equipment and expendables, larger diameter scope and instruments and no tactile sensation. It triggered us interest in more easily available robotic scope holder. Soloassist II (AktorMed GmbH, Barbing, Germany) is an active endoscope holder system which is controlled by a joystick. It has total six joints: three joints which are controlled by computer, one is controlled by manual and two act as a gimbal joint following the movement of the main body.Materials and Methods:We tried transoral endoscopic thyroidectomy using Soloassist II (AktorMed GmbH, Barbing, Germany) in December 2017 in our hospital.Results:We successfully performed four thyroid lobectomies in four patients with Soloassist II. We refined and described surgical procedures in each step using video clips. It provided an excellent vibration-free stable surgical view which enabled fatigue-free work, without shaking or tilting the horizon. The surgeon could perform transoral endoscopic thyroid surgery with only one assistant surgeon. Docking and preparation time for Soloassist was within 10 min in all four patients. The setup and dismantling could be performed parallel to the usual workflow. No complication was reported by any patient.Conclusions:The robotic scope holder (Soloassist II) seems to be safe and feasible equipment for performing transoral endoscopic thyroid surgery. Several possible advantages could be expected with this robotic scope holder.

Fully Endoscopic Transforaminal–Transchoroidal Approach for Tectal Area Tumor Removal

The surgical approaches to lesions located in the tectal area have remained controversial. The essential functions in the surrounding areas and the difficulties in obtaining a good surgical view during tumor removal have made these procedures risky and challenging. Endoscopic transforaminal approaches have been previously described for biopsy and intraventricular tumor removal. However, the endoscopic transforaminal-transchoroidal gross resection technique for such cases has barely been described. The endoscopic entry points and trajectories were planned using preoperative magnetic resonance imaging. Once the endoscope was inside the ventricular system, the angles of work and tumor exposure of the upper posterior part of the third ventricle were carefully evaluated. If the angle of work was insufficient for tumor removal, the choroidal fissure was opened using endoscopic bipolar electrode and dissectors. Tumor removal was performed using an endoscopic ultrasonic aspirator. We have presented a 3-case series of patients affected by tectal tumors that were treated using a fully endoscopic transforaminal-transchoroidal approach. Total gross resection of the tumors was achieved in 2 patients. Subtotal resection was achieved in the third patient. No major complications had developed in relationship to the procedure. No new cognitive impairment was reported secondary to this technique. In our experience, a fully endoscopic transforaminal-transchoroidal approach was a suitable treatment for this complex pathological entity. Opening of the choroidal fissure added an extra angle of work and improved the exposure of the upper posterior part of the third ventricle.

Endoscopic tympanoplasty in subtotal perforations: conventional versus circumferential subannular grafting technique

<p class="abstract"><strong>Background:</strong> Tympanoplasty is a surgical procedure to reconstruct hearing mechanism impaired by chronic ear disease<strong>. </strong>Endoscopic technique has advantage of being minimally invasive, having better surgical view of the field, lesser postoperative pain and shorter duration of surgery. The aim of this study was to compare surgical outcomes of two techniques of endoscopic tympanoplasty in subtotal perforations.</p><p class="abstract"><strong>Methods:</strong> This prospective, comparative study was carried out between October 2016 to October 2018, in the Department of ENT, KMCT Medical College. 40 patients were randomly allocated to 2 groups of 20 each, to avoid selection bias and sample size calculated using the sample size formula. Group A underwent endoscopic tympanoplasty by conventional technique and Group B by circumferential subannular graft technique. </p><p class="abstract"><strong>Results:</strong> Post-operative evaluation of the patients for graft status showed 75% had successful graft uptake in Group A and 95% in Group B both groups had comparable, significant hearing improvement post operatively.</p><p class="abstract"><strong>Conclusions:</strong> Our study showed that, in all cases of subtotal perforations, the circumferential sub annular graft technique yielded a superior result with regards to the graft uptake compared to the conventional technique. The closure of the mean air-bone gap were significant, and similar among both the groups.</p>

The supraorbital keyhole approach for clipping of anterior circulation ruptured aneurysms

Introduction. The supraorbital approach has been demonstrated to be useful, particularly in minimization of brain retraction and exposure to air, decreases blood loss, surgical trauma, operative time and infection rates. While its shortcomings include difficult control of frontal air sinus, narrower surgical view and limited exposure of sylvian fissure.
 Patients and methods. We retrospectively reviewed the files of patients who underwent clipping of anterior circulation aneurysms through the supraorbital keyhole approach at Neurosurgery Department, Mansoura University between Jan 2014 and May 2016.
 Results. Twenty-five consecutive patients harbouring aneurysm at anterior circulation underwent clipping through the supraorbital keyhole approach, sixteen A-com artery aneurysms and nine cases of ICA aneurysms Table 1 show the location of aneurysms. Eleven patients were males, and 14 were females. The ages ranged from 44 to 69 with a mean age of 61.9 years. All patients were presented with subarachnoid haemorrhage due to rupture of aneurysms in anterior circulation The Hunt and Hess grade was (1.50 ± 0.65) and Fisher grade was (1.67 ± 0.45). The average operative time was 3.32 ± 1.14 hours. Follow-up ranged from 1 to 16 months with a mean of 7 months
 Conclusion. Surgical clipping of some selected aneurysms of anterior circulation can be operated through minimally invasive supraorbital approach which minimize the dissection and retraction of the brain, reduce operative time and blood loss with small incision and good cosmetic results.

Three-Dimensional Peripheral Bloodstream Model of the Uterus for Laparoscopic Radical Hysterectomy

Trainees require extensive experience to perform radical hysterectomy. Before starting training during an actual operation, trainees should be familiar with the pelvic anatomy and should simulate surgical procedures. Many simulators are available for virtual reality training of laparoscopic operations, but they are very expensive. The materials required to construct our model included sponges and colored wires sold in home improvement stores that allowed for superior cost effectiveness. The model represented almost all peripheral vessels and nerves around the uterus, including the minor vessels. Attaching and detaching the vessels was easy, facilitating reconstruction of the dissected vessels. The wires were easy to bend, ensuring high operability. This model allows for the simulation of laparoscopic radical hysterectomy in a dry box. Our model was superior to a 2-dimensional picture for the memorization of branching and positional relationships of the blood vessels. Comparison of our model with actual operative videos showed that the dry box provided an identical surgical view of an actual laparoscopic radical hysterectomy. We developed a peripheral bloodstream model of the uterus for repeated simulation of laparoscopic radical hysterectomy with an actual surgical view using a dry box.

Oxidized regenerated cellulose for a clear thoracoscopic view: a single-centre randomized trial.

During video-assisted thoracoscopic surgery (VATS), blood oozing from the surface of the access port wound can hamper the surgical view. Although this oozing is difficult to prevent, it can be decreased by placing a wound edge protector with oxidized regenerated cellulose (ORC) on the surface of the access port wound, thereby improving the surgical outcomes and safety of VATS. We conducted a prospective, single-centre, open-label, randomized clinical trial to evaluate the operative outcomes of VATS when using the ORC (ORC group) compared with operative outcomes without using the ORC (non-ORC group). The primary end point was interruption of the operation as a result of blood oozing from the surface of the access port wound. The secondary end points were the other intraoperative and postoperative outcomes. A total of 108 patients were divided into the ORC group (n = 54) and the non-ORC group (n = 54). Compared with the non-ORC group, the ORC group had fewer patients with an interruption in the operation (11.1% vs 51.8%; P < 0.001), less need for wound haemostasis of the access ports during wound closure (44.4% vs 72.2%; P = 0.003), similar rates of postoperative deaths and complications and a tendency for shorter operation times (149.3 vs 168.8 min, respectively; P = 0.083). The use of an ORC sheet around a wound edge protector for haemostasis can ensure a clear view during VATS. UMIN000031112.