Microsurgerical treatment of PCA aneurysms via subtemporal approach monitored by microvascular Doppler(10 cases report)

Objective To summarize the clinical features of intracranial aneurysms of posterior cerebral artery (PCA) ,and the surgical approaches and operative skills to treat them . Methods The aneurysms arose from the P1 segment in 3 patients,the P2 segment in 5 patients and the P3 segment in 2 patients.

Perforating and ophthalmic artery variants from the anterior cerebral artery:Two case reports

BACKGROUND The diagnosis and therapy during surgery depend largely on a full account of anatomic characteristics.Apart from regular structures,the common,less common or even uncommon anatomic variations are critical for procedural planning.This is especially true during craniocerebral microsurgery,where small vascular variations can affect the final surgical results and patient prognosis.CASE SUMMARY Herein,two rare variations concerning the A1(horizontal)segment of anterior cerebral artery(ACA1)were introduced.One enabled the communication between perforating branch of ACA1 and dural artery of anterior skull base,which was discovered during autopsy.The other was ophthalmic artery(OA)originating from ACA1,shown on digital angiography.CONCLUSION In this study,we found two rare anatomical variations.One was an abnormal OA originated from the anterior communicating artery.The other was a perforating branch of the A1 segment of the anterior cerebral artery,which communicated with meningeal vessels in the anterior skull base.This finding is of great significance for the treatment of anterior communicating artery aneurysm or in other anterior skull base surgery.

Application Experience of Eyesi Operation Simulation Training System in the Teaching of Cataract Surgery for Ophthalmology Masters

Objective:To explore the application effect of the Eyesi surgical simulator in the teaching of cataract surgery for professional ophthalmology postgraduate students.Methods:The professional postgraduate students who were trained in the third year of ophthalmology at the First Affiliated Hospital of Xi’an Medical University were selected as the research objects.After passing the theoretical examination,they were randomly divided into the pig eyeball group,Eyesi group,and pig eye+Eyesi group,with 5 students in each group.The pig eyeball,Eyesi surgery simulator,and pig eye+Eyesi surgery simulator were used for microscopic technique operation and cataract surgery steps training,respectively.After the training,the overall training effects of the three groups of postgraduates were scored,and questionnaires were used to objectively evaluate the three training methods.Results:The scores of the students in the pig eye+Eyesi group were better than those in the Eyesi group,and the students in the Eyesi group were better than those in the pig eyeball group.Conclusion:The Eyesi surgical simulation training system can evaluate the microsurgical skills of professional masters and improve their surgical skills.This system is of great significance for the training of the cataract surgery skills of professional masters.

显微手术治疗小脑海绵状血管瘤

目的总结小脑海绵状血管瘤的临床表现及手术治疗效果。方法对12例均经手术切除和病理证实的小脑海绵状血管瘤进行回顾性分析。结果 11例急性起病,表现为小脑自发性出血。慢性起病1例,表现为渐进性共济失调、行走不稳。头颅MRI平扫与增强多表现为T1高信号,T2高或混杂信号,病灶周围有环形低信号带。磁敏感加权成像序列(SWI)更有助于诊断。12例均采用显微手术治疗,所有病灶均完整切除,疗效满意。结论自发性出血是本病的主要症状,多有共济失调等小脑受损体征。MRI具有较高的诊断特异性,手术是处理小脑海绵状血管瘤安全和有效的首选方法。

Microsurgical epididymal sperm aspiration： indications, techniques and outcomes

Microsurgical epididymal sperm aspiration （MESA） refers to retrieval of sperm-containing fluid from optimal areas of the epididymis that are selected and sampled using high-power optical magnification provided by an operating microscope. Retrieved sperm are subsequently used for intracytoplasmic sperm injection （ICSI） to induce fertilization and pregnancy. MESA is considered by many experts to be the gold standard technique for sperm retrieval in men with obstructive azoospermia given its high yield of quality sperm, excellent reported fertilization and pregnancy rates, and low risk of complications. However, MESA must be performed in an operating room, requires microsurgical skills and is only useful for reproduction using ICSI. Herein we present an overview of the evaluation of candidate patients for MESA, the technical performance of the procedure and the outcomes that have been reported.

Microsurgical varicocelectomy： a review

Varicocelectomy is the most commonly performed surgical procedure for the treatment of male infertility. Although several different techniques for varicocele repair have been described in the literature, microsurgical varicocelectomy performed through a subinguinal or inguinal incision is recognized as the gold-standard approach for varicocelectomy, due to high success rates with minimal complications. Standard indications for varicocelectomy include palpable varicocele（s）, with one or more abnormal semen parameters, and, for the couple trying to conceive, in the setting of normal or correctable female infertility. However, varicocele repair is often recommended and undertaken for reasons other than infertility, including low serum testosterone, testicular pain, testicular hypotrophy and poor sperm DNA quality. This article reviews the technical aspects of microsurgical varicocelectomy, and its indications in adults and adolescents.

Clinical features and therapeutic strategies of obstructive azoospermia in patients treated by bilateral inguinal hernia repair in childhood

Childhood inguinal herniorrhaphy is one common cause of seminal tract obstruction. Vasovasostomy （VV） can reconstruct seminal deferens and result in appearance of sperm and natural pregnancy in some patients. Secondary epididymal obstruction caused by a relatively long-term vasal obstruction is a common cause of lower patency compared with VV due to vasectomy in adults. From July 2007 to June 2012, a total of 62 patients, with history of childhood inguinal herniorrhaphy and diagnosed as obstructive azoospermia were treated in our center. The overall patency rate and natural pregnancy rate were 56.5% （35/62） and 25.8% （16/62）, respectively. 48.4% （30/62） of the patients underwent bilateral VV in the inguinal region, with a patency rate of 76.7% （23/30） and a natural pregnancy rate of 36.7% （11/30）, respectively. 30.6% （19/62） of the patients underwent bilateral VV and unilateral or bilateral vasoepididymostomies due to ipsilateral epididymal obstruction with the patency and natural pregnancy rate decreasing to 63.2% （12/19） and 26.3% （5/19）. 21.0% （13/62） of the patients merely underwent vasal exploration without reconstruction due to failure to find distal vasal stump, etc. Our study indicate that microsurgical reanastomosis is an effective treatment for some patients with seminal tract obstruction caused by childhood inguinal herniorrhaphy.

Can inhibin-B predict the outcome of microsurgical epididymal sperm aspiration in patients with suspected primary obstructive azoospermia？

Aim： To evaluate whether inhibin-B can predict the outcome of a microsurgical epidymal sperm aspiration （MESA） procedure in patients with suspected primary obstructive azoospermia （OA） and if inhibin-B can replace testicular biopsy in the diagnostic work-up of these patients. Methods： Inhibin-B levels and testicular biopsy scores were related to the outcome of MESA in 43 patients with suspected primary OA. MESA was considered to be successful when epididymal sperm could be identified during the procedure. Results： Spermatozoa were present in the epididymal aspirate in 28 out of the 43 patients （65%）. lnhibin-B values were not significantly different in patients with successful or unsuccessful MESA. The modified Johnsen score, however, was significantly lower in patients with unsuccessful MESA （P = 0.003）. A rete testis obstruction or epididymal malfunctioning was found in 15% of patients with suspected primary OA, reflected by unsuccessful MESA despite normal inhibin-B levels and normal testicular histology. Conclusion： Inhibin-B cannot replace testicular biopsy as a diagnostic tool in the work-up of patients with suspected primary OA. Testicular biopsy is useful in identifying patients with spermatogenic arrest, who might have normal inhibin-B values.

Microsurgical reconstruction of hepatic artery in A-A LDLT:124 consecutive cases without HAT

AIM:To retrospectively investigate microsurgical hepatic artery(HA) reconstruction and management of hepatic thrombosis in adult-to-adult living donor liver transplantation(A-A LDLT).METHODS:From January 2001 to September 2009,182 recipients with end-stage liver disease underwent A-A LDLT.Ten of these patients received dual grafts.The 157 men and 25 women had an age range of 18 to 68 years(mean age,42 years).Microsurgical techniques and running sutures with back-wall first techniques were performed in all arterial reconstructions under surgical loupes(3.5 ×) by a group of vascular surgeons.Intimal dissections were resolved by interposition of the great saphenous vein(GSV) between the donor right hepatic artery(RHA) and recipient common HA(3 cases) or abdominal aorta(AA)(2 cases),by interposition of cryopreserved iliac vessels between the donor RHA and recipient AA(2 cases).RESULTS:In the 58 incipient patients in this series,hepatic arterial thrombosis(HAT) was encountered in 4 patients,and was not observed in 124 consecutive cases(total 192 grafts,major incidence,2.08%).All cases of HAT were suspected by routine color Doppler ultrasonographic examination and confirmed by contrast-enhanced ultrasound and hepatic angiography.Of these cases of HAT,two occurred on the 1st and 7th d,respectively,following A-A LDLT,and were immediately revascularized with GSV between the graft and recipient AA.HAT in one patient occurred on the 46th postoperative day with no symptoms,and the remaining case of HAT occurred on the 3rd d following A-A LDLT,and was cured by thrombolytic therapy combined with an anticoagulant but died of multiorgan failure on the 36th d after A-A LDLT.No deaths were related to HAT.CONCLUSION:Applying microsurgical techniques and selecting an appropriate anastomotic artery for HA reconstruction are crucial in reducing the high risk of HAT during A-A LDLT.

Optimizing biliary outcomes in living donor liver transplantation:Evolution towards standardization in a high-volume center

Biliary complications have always been a dreaded cause of morbidity after living donor liver transplantation.While intrinsic variations in both graft and recipient biliary anatomy remain a significant factor to the difficulty of biliary reconstruction,our institution has taken advantage of its high volume of cases to critically review and evaluate modifiable operative risk factors,in particular,our surgical protocols.We present herein,the evolution of our reconstructive biliary technique from conventional methods to our current standard of microsurgical biliary reconstruction for both graft and recipient ducts.Over this period of transition,our center has created a classification system for biliary reconstruction that decreased the biliary complication rates from 40.0%to 10.2%.

Morphological characteristics of the lumbosacral spinal cord urogenital center in Sprague Dawley rats

BACKGROUND： Studies have demonstrated that selective innervation of the sacral nerve tract to the bladder plays an important role in bladder functional reconstruction following spinal cord injury. However, there are very few studies reporting detailed morphological characteristics of urogenital center and lumbosacral nerve roots. OBJECTIVE： To analyze the spinal cord segment of the lumbosacral spinal cord urogenital center, and to observe morphological characteristics. DESIGN, TIME AND SETTING： A neuroanatomical study was performed at the Laboratory of Neuroanatomy, Peking University Health Science Center between September 2007 and March 2008. MATERIALS： Horseradish peroxidase-conjugated cholera toxin B subunit （CB-HRP） was purchased from Sigma, USA; surgical microscope was purchased from Zhenjian Zhongtian Optical Instrument, Jiangsu Province, China; BCL-420 biological and functional experimental system was purchased from Taimeng Science and Technology, Sichuan Province, China. METHODS： A total of 36 adult, Sprague Dawley rats were randomly assigned to groups A （n = 10）, B （n = 10）, C （n = 10）, and D （n = 6）. CB-HRP （3%, 10-15 μL） was injected into the bladder detrusor muscle （group A）, external urethral sphincter （group B）, and perineal muscles （group C）, respectively. Rats in group D were not given any treatments. MAIN OUTCOME MEASURES： At 72 hours after CB-HRP injection, CB-HRP-positive neurons were analyzed in lumbosacral segments using 3, 3＇, 5, 5＇-tetramethylbenzidine staining and an Olympus optic microscope, while anatomical structures in the respective spinal nerve tract were observed using a surgical microscope. RESULTS： CB-HRP-positive neurons were distributed in the L6-S1 segments of the spinal cord, and neurons primarily innervating the bladder detrusor muscle were located at the sacral parasympathetic nucleus and the intermediolateral nucleus. In addition, neurons that primarily innervate the external urethral sphincter and perineal muscles were observed in the ventrolateral portion （Onuf＇s nucleus）. The lumbar-sacral nerve roots were composed of varying nerve tracts, Le., they were typically divided into 1-2 sub-bundles, and the sub-bundles were then divided into 2-3 tiny bundles. There were extensive fibro-connections between the rootlets. CONCLUSION： The urogenital center in Sprague Dawley rats was located in the L6 -S1 segments of the spinal cord, and the rootlets were clearly observed. Therefore, this rat experimental model could be utilized for highly selective anterior/posterior rhizotomy.

Multiple Factors Affecting Human Repregnancy after Microsurgical Vasovasostomy

To determine the factors which might affect the recovery of fertility after an accurate microsurgical vasovasostomy, we conducted α 3-year-follow up study in 56 men after microsurgical vasovasostomy. Twenty-two variables as putative factors associated with recovery of fertility were measured. The results of Logistic regression and other statistical analyses suggest that 8 factors including age of husband, age of wife, history of past pregnancies of current wife, number of vasovasostomies, serum FSH, LH and T before vasovasostomy, and sperm granuloma of vas nodule are of no significance in recovery of fertility, whereas 14 factors including years after vasectomy, sperm concentration, progressive motility, sperm motility, viability, normal morphology, sperm-egg penetration rate, TAT and SIT before-and-after vasovasostomy, MAR, IBT adherent IgG and IgA after vasovasostomy are significantly associated with repregnancy.

Application of hybrid operating rooms for clipping large or giant intracranial carotid-ophthalmic aneurysms

BACKGROUND A hybrid operating room(Hybrid-OR)is a surgical theatre that combines a conventional operating room with advanced medical imaging devices.There are still plenty of limitations when endovascular treatment or microsurgical treatment is used individually to treat large or giant carotid-ophthalmic aneurysms.AIM To explore and summarize the technical features and effectiveness of the application of a Hybrid-OR in managing major intracranial carotid-ophthalmic aneurysms.METHODS The Department of Neurosurgery treated 12 cases of large or giant intracranial carotid-ophthalmic aneurysms between March 2013 and December 2019 in a Hybrid-OR.All cases were treated with clipping and parent vessel reconstruction.RESULTS With the assistance of the Hybrid-OR,the rate of incomplete intraoperative aneurysm clipping decreased from 25%(3/12)to 0%,while the rate of vessel stenosis decreased from 16.7%(2/12)to 8.35%(1/12).In terms of thromboembolic events,ischemic infarction complication occurred in only one patient,and none of the patients experienced embolic infarction complications.All 12 patients were followed for an average of 3 years,and no aneurysms recurred.The postoperative recovery was evaluated with the modified Rankin Scale(mRS):11 patients showed no symptoms(mRS=0),1 patient showed slight disability(mRS 1-2),and none of the patients had severe disability(mRS=5)or died(mRS=6).CONCLUSION The Hybrid-OR provides new ideas for the surgical clipping of large or giant intracranial carotid-ophthalmic aneurysms and decreases the rate of intraoperative vessel stenosis and unsuccessful clipping.

The microsurgical treatment of glomus tumor at the nail bed of the finger

Objective： To discuss the diagnosis and treatment of glomus tumor at the nail bed of the finger. Methods： The course and therapeutic outcome of 12 cases of glomus tumor which were resected and confirmed by histology examination were analyzed. Results：All cases were followed up for six months up to 2 years, no recurrences were observed, the shape of the nait was normal. Conclusion： Microsurgical treatment of glomus tumors of the nail bed is effective.

Giant Intracranial Arachnoid Cyst Causing Acute Neurologic Symptoms

Intracranial arachnoid cysts (IAC) are benign lesions containing cerebrospinal fluid (CSF). Most of them are clinically silent and remain static in size. However some may present with mild and slow progressive symptoms caused by the cyst. The authors present the case of 54-year-old woman who presented with acute symptoms of severe headache, vomiting, and gait disturbance of 2 day’s duration. She had no history of head trauma. On admission, neurological examination revealed that the patient had a Glasgow Coma Scale score of 15, and a left side hemiplegia. A CT scan revealed a hypodense fluid collection in the right frontoparietal region that mimicked an arachnoid cyst. The symptoms were improved after an emergency marsupialisation via craniotomy.

Evaluation of 10-year Microsurgical Tubal Reversal after Tubal Sterilization

One thousand and twenty-nine women with microsurgical tubal reversal after tubal sterilization were followed up.The rate of intrauterine pregnancy was found to be 93.29%.The rate of intrauterine pregnancy was the highest(73.28%)in the first year after tubal reversal.In the first year,the chance of pregnancy in the first 6 months was higher (54.81%)than that(40.86%)in the second 6 months(P<0.01),and the chance in the first 3 months was higher(37.41%)than that(27.80%)in the second 3 months(P<0.01).The rates of ectopic pregnancy after tubal reversal in various stages were not significantly different(P>0.05).The rate of intrauterine pregnancy was not related with the period from sterilization to tubal reversal.Early postoperative hydropertubation can only decrease the rate of intrauterine pregnancy.The rate of intra uterine pregnancy of the tubal reversal after Uchida's method and clips tubal sterilization was higher than that after Pomeroy's tubal ligation.The reanastomosis of isthmus and isthmus resulted in the highest rate of intra uterine pregnancy,so we think that Uchida's or elips tubal sterilization in the isthmus of the tubal are ideal and reversible techniques at present.

Serum Total Testosterone Levels Pre- and Post-Subinguinal Microsurgical Varicocelectomy in Men with Clinical Varicoceles

Background: Varicocele is abnormal dilation and tortousity of the scrotal venous pampiniform plexus that drain blood from each testicle. Recently, it has been linked to low serum total testosterone (TT) levels by affecting the optimal functioning of the leydig cell via increasing the scrotal temperature. Varicocele repair has been found post-operatively to increase the serum levels of TT. This study looks at the pre and post-subinguinal microsurgical varicocelectomy serum TT levels in male patients with clinical varicocele. Methods: The study involved 88 male patients with clinical varicoceles who met the inclusion criteria. These patients after good history taking and physical examination had their serum TT levels measured pre varicocelectomy and 6 months post-subinguinal microsurgical varicocelectomy. The varicoceles were diagnosed by physical examination and use of scrotal color Doppler ultrasonography (US). Results: The number of patients with varicocele were 88 males. The mean age of the patients was 33.43 ± 7.82 years. There was isolated left varicocele in 57 (64.8%) patients and bilateral varicocele in 27 (30.7%) patients. Pre varicocelectomy, 61 (69.3%) patients had serum TT of between 100 - 290 nanogram/deciliter (ng/dl) and a mean value of 241 ± 0.91 ng/dl. Post varicocelectomy 56 (63.6%) patients had serum TT in the range of 300 - 490 ng/dl with a mean of 482 ± 2.87 ng/dl, showing a robust significant increase in the serum TT post-operatively (P < 0.001). Conclusion: There was statistically significant improvement in the serum TT levels with 55 (79%) patients exhibiting normalization of serum TT levels after subinguinal microsurgical varicocelectomy.

Abscess in the Splenium of the Corpus Callosum Treated with Direct Drainage via an Occipital Interhemispheric Approach

Lesions in the corpus callosum typically represent malignant tumors such as glioblastoma or lymphoma, because of its compact structure comprising tightly packed white-matter tracts. Brain abscess is rarely seen in the corpus callosum. To the best of our knowledge, solitary bacterial abscess confined to the splenium of the corpus callosum has not been reported previously. We report the case of a 72-year-old woman with rapidly progressing disturbance of consciousness following 1 week of antibiotic treatment for bacterial meningitis. Magnetic resonance imaging demonstrated a ring-enhancing round mass located in the splenium of the corpus callosum on gadolinium-enhanced T1-weighted imaging, also showing a bright signal on diffusion-weighted imaging. The patient underwent occipital craniotomy and direct drainage of the lesion in the splenium through the interhemispheric fissure and achieved complete recovery. Brain abscess should be considered among the differential diagnoses for lesions in the splenium of the corpus callosum. An occipital interhemispheric approach to the splenium might be an important option in cases of brain abscess.

Transdermal Nitroglycerine Patch: An Optional Device to Reduce Flap Venous Congestion? A Case Report

Sometimes in free flap there is a venous congestion without an obstruction of the venous anastomosis or other organic causes of reduction venous drainage (haematoma, seroma compressing the pedicle). In these cases the authors suggest the application of nitroglycerine patch in the congested area of the flap few hours before the surgical exploration of the anastomosis. If there is a fast improvement of the clinical feature of the flap, the surgical exploration could be avoided. The authors underline that applying the nitroglycerin patch should not be regarded in any way as a therapy of a free flap venous thrombosis but only as an useful device, an option to be taken only when the surgeon is undecided whether to revisit the anastomosis or not.

Successful lower leg microsurgical reconstruction in homozygous sickle cell disease: Case report

We present an 18-year-old female with sickle cell disease, who presented with an extensive lower leg ulcer over a 12-year course of the disease. Definitive reconstruction was made using a free latissimus dorsi flap and split-skin grafts. One week before the surgery, the plasmapheresis protocol and blood transfusion were administered, in order to achieve a hemoglobin S level of ≤ 30%. Intraoperatively, the flap pedicle was rinsed with plasminogen activator inhibitor-1 until the thrombolytic agent was obtained from the comitant vein; after the arterial flow had been released, an intravenous bolus dose of heparin(2000 U) was administrated. No vascular complications occurred. Postoperatively, the patient received a 10-d course of hemodilution and a 14-d course of full-dose anticoagulation. After 8 mo postoperatively, the patient was able to walk and run, and showed complete wound healing. This case indicates that sickle cell disease is not a contraindication to free tissue transfer; however, the complications, their rate and overall outcomes for these cases are not yet clear. Herein, we provide an algorithm based on our clinical experience in this type of case and treatment, including several recommendations that may help to reduce thrombosis risk and systemic complications.