Jugular bulb and skull base pathologies: proposal for a novel classification system for jugular bulb positions and microsurgical implications.

OBJECTIVE There is no definitive or consensus classification system for the jugular bulb position that can be uniformly communicated between a radiologist, neurootologist, and neurosurgeon. A high-riding jugular bulb (HRJB) has been variably defined as a jugular bulb that rises to or above the level of the basal turn of the cochlea, within 2 mm of the internal auditory canal (IAC), or to the level of the superior tympanic annulus. Overall, there is a seeming lack of consensus, especially when MRI and/or CT are used for jugular bulb evaluation without a dedicated imaging study of the venous anatomy such as digital subtraction angiography or CT or MR venography. METHODS A PubMed analysis of "jugular bulb" comprised of 1264 relevant articles were selected and analyzed specifically for an HRJB. A novel classification system based on preliminary skull base imaging using CT is proposed by the authors for conveying the anatomical location of the jugular bulb. This new classification includes the following types: type 1, no bulb; type 2, below the inferior margin of the posterior semicircular canal (SCC), subclassified as type 2a (without dehiscence into the middle ear) or type 2b (with dehiscence into the middle ear); type 3, between the inferior margin of the posterior SCC and the inferior margin of the IAC, subclassified as type 3a (without dehiscence into the middle ear) and type 3b (with dehiscence into the middle ear); type 4, above the inferior margin of the IAC, subclassified as type 4a (without dehiscence into the IAC) and type 4b (with dehiscence into the IAC); and type 5, combination of dehiscences. Appropriate CT and MR images of the skull base were selected to validate the criteria and further demonstrated using 3D reconstruction of DICOM files. The microsurgical significance of the proposed classification is evaluated with reference to specific skull base/posterior fossa pathologies. RESULTS The authors validated the role of a novel classification of jugular bulb location that can help effective communication between providers treating skull base lesions. Effective utilization of the above grading system can help plan surgical procedures and anticipate complications. CONCLUSIONS The authors have proposed a novel anatomical/radiological classification system for jugular bulb location with respect to surgical implications. This classification can help surgeons in complication avoidance and management when addressing HRJBs.

Development and validation of an endoscopic ear surgery classification system.

OBJECTIVES/HYPOTHESIS: To design and validate a classification system for endoscopic ear surgery. STUDY DESIGN: Validation study. METHODS: A classification system was devised that quantifies use of the endoscope during middle ear surgery. Otologic operative reports were reviewed by attending surgeons and trainees. A power analysis was performed to determine number of cases needed to review. The following categories were used: class 0 is defined by using the microscope only; class 1 describes the use of endoscope for inspection without dissection; and class 2 describes mixed use of the endoscope and the microscope. It is further subdivided into 2a and 2b, where the endoscope is used for less than 50% of dissection and more than 50% of dissection, respectively. Class 3 describes the use of the endoscope for the entire surgery. Fifty cases were reviewed by three attending otologic surgeons, one resident, and one medical student. RESULTS: Weighted Cohen's Kappa for inter-rater agreement between the two institutional surgeons was 0.79 (95% bias corrected [BC] confidence interval [CI]: 0.58-0.93). Agreement between the external surgeon and the two institutional surgeons was 0.77 (95% BC CI: 0.58-0.89) and 0.76 (95% BC CI: 0.57-0.88). Weighted Kappa between institutional surgeons and a resident was 0.73 (95% BC CI: 0.53-0.88) and 0.62 (95% BC CI: 0.38-0.80), and between institutional surgeons and a medical student was 0.75 (95% BC CI: 0.56-0.89) and 0.70 (95% BC CI: 0.49-0.85). CONCLUSIONS: There was substantial inter-rater agreement. This classification system can be used as a simple and reliable tool to describe the extent to which an endoscope was used during ear surgery. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:967-970, 2018.

Clasificación de las resecciones transorales en la orofaringe: propuesta del grupo de trabajo de la Sociedad Catalana de Otorrinolaringología / Transoral oropharyngeal resection classification: Proposal of the SCORL working group

Introducción y objetivos: La cirugía mínimamente invasiva ha presentado una expansión muy importante en la última década. Con el objetivo de aportar un lenguaje común tras cirugía transoral de la orofaringe, se ha creado un sistema de clasificación de las resecciones en esta zona, independientemente de la instrumentalización utilizada. Métodos: Desde el Grupo de Trabajo en Oncología de la Sociedad Catalana de Otorrinolaringología, se presenta una propuesta de clasificación basada en una división topográfica de las diferentes zonas de la orofaringe, así como en la afectación de las estructuras anexas según las vías anatómicas de extensión de estos tumores. Resultados: La clasificación se inicia utilizando la letra D o I según la lateralidad sea derecha (D) o izquierda (I). A continuación se coloca el número del área resecada. Esta numeración define las zonas iniciando a nivel craneal donde el área I sería el paladar blando, el área II lateral en la zona amigdalina, el área III en la base de lengua, el área IV en los repliegues glosoepiglóticos, la epiglotis y repliegues faringoepiglóticos, el área V pared orofaríngea posterior y VI el trígono retromolar. Se añade el sufijo p si la resección afecta profundamente al plano submucoso de la zona comprometida. Las diferentes áreas propuestas tendrían, de una forma teórica, diferentes implicaciones funcionales. Conclusiones: Propuesta de sistema de clasificación por áreas que permite definir diferentes tipos de cirugía transoral de la orofaringe así como compartir los resultados y ayudar en la docencia de este tipo de técnicas (AU)

Introduction and goals: There has been a very significant increase in the use of minimally invasive surgery has in the last decade. In order to provide a common language after transoral surgery of the oropharynx, a system for classifying resections has been created in this area, regardless of the instrumentation used. Methods: From the Oncology Working Group of the Catalan Society of Otorhinolaryngology, a proposal for classification based on a topographical division of the different areas of the oropharynx is presented, as also based on the invasion of the related structures according to the anatomical routes of extension of these tumours. Results: The classification starts using the letter D or I according to laterality either right (D) or left (I). The number of the resected area is then placed. This numbering defines the zones beginning at the cranial level where area I would be the soft palate, lateral area II in the tonsillar area, area III in the tongue base, area IV in the glossoepiglottic folds, epiglottis and pharyngoepiglottic folds, area V posterior oropharyngeal wall and VI the retromolar trigone. The suffix p is added if the resection deeply affects the submucosal plane of the compromised area. The different proposed areas would, in theory, have different functional implications. Conclusions: Proposal for a system of classification by area to define different types of transoral surgery of the oropharynx, and enable as sharing of results and helps in teaching this type of technique (AU)

Reparación aguda de los tendones flexores / Acute flexor tendon injury repair

Para la correcta ejecución de la Cirugía de Mano es necesario conocer su anatomía, fisiología, biomecánica, así como las diferentes técnicas quirúrgicas. La función principal del tendón es la transmisión de fuerza desde el vientre muscular de origen hacia el hueso final donde se inserta; en el caso de los tendones flexores, la fuerza muscular da como resultado la flexión de los dedos. El objetivo del presente trabajo es conocer la anatomía de los tendones flexores de la mano, el diagnóstico de sus principales lesiones y repasar las principales técnicas quirúrgicas para su tratamiento. El autor lleva a cabo una revisión de los principios básicos de cicatrización tendinosa, de la identificación de las zonas de lesión de los tendones flexores de la mano, de los métodos para su diagnóstico, de las técnicas quirúrgicas para su tratamiento y de su manejo postoperatorio, basándose en los hechos históricos más importantes relativos a todos estos conocimientos y a sus propias aportaciones y experiencia (AU)

In order to archive a correct execution of Hand Surgery, to know the anatomy, physiology, biomechanics and specific surgical techniques is mandatory. The main function of tendons is strength transmission from its origin in the muscular body to the insertion at bone. In flexor tendons, muscular strength has as a result finger flexion. The aim of this paper is to know the anatomy of the flexor tendons of the hand, the diagnostic of their main injuries and to review the most important surgical techniques for their treatment. The author review the basic principles about tendon healing, the identification of the zones of flexor tendons lesions in the hand, the methods for diagnostic, the surgical techniques for treatment, and the postoperative management, based on the most important historic advances and on his own experience and contributions (AU)

Laser-assisted surgery of the upper aero-digestive tract: a clarification of nomenclature. A consensus statement of the European Laryngological Society.

Acronyms and abbreviations are frequently used in otorhinolaryngology and other medical specialties. CO2 laser-assisted transoral surgery of the pharynx, the larynx and the upper airway is a family of commonly performed surgical procedures termed transoral laser microsurgery (TLM). The abbreviation TLM can be confusing because of alternative modes of delivery. Classification and definition of the different types of procedures, performed transorally or transnasally, are proposed by the Working Committee for Nomenclature of the European Laryngological Society, emphasizing the type of laser used and the way this laser is transmitted. What is usually called TLM, would more clearly be defined as CO2 laser transoral microsurgery or CO2 TOLMS or CO2 laser transoral surgery only (with a handpiece) would be defined as CO2 TOLS. KTP transnasal flexible laser surgery would be KTP TNFLS. Transoral use of the flexible CO2 wave-guide with a handpiece would be a CO2 TOFLS. One can argue that these clarifications are not necessary and that the abbreviation TLM for transoral laser microsurgery is more than sufficient. But this is not the case. Laser surgery, office-based laser surgery and microsurgery are frequently and erroneously interchanged for one another. These classifications allow for a clear understanding of what was performed and what the results meant.

General principles and intraventricular neuroendoscopy: endoscopic techniques.

OBJECTIVE: To term and describe neuroendoscopic techniques. METHODS: A classification into three major groups of endoscopic techniques is presented. RESULTS: 1) Endoscopic neurosurgery ("channel" endoscopy) is mainly used in ventricular endoscopy. The surgical instruments are introduced via working channels that are located within the endoscope. 2) Endoscope-controlled microneurosurgery means that the endoscope is the only visualization tool and microsurgical instruments are used along the endoscope. Major applications are endonasal endoscopic skull base surgery, endoport surgery, and endoscopic transcranial surgery. 3) Endoscope-assisted microneurosurgery means that the microscope and the endoscope are used in the same surgery. The endoscopes are applied when hidden structures to be inspected are not visible in straight line with the microscope. CONCLUSIONS: Endoscopic techniques are a valuable addition to the neurosurgeon's armamentarium. Endoscopes are especially beneficial in deep and narrow surgical approaches and when "looking around a corner" is required.

[Composite Tissue Allotransplantation (CTA): organ or tissue transplantation?]. / Composite Tissue Allotransplantation (CTA): Organ- oder Gewebetransplantation?

Plastic surgery has a long tradition in transplantation issues. Skin transplantation has been introduced by plastic surgeons Padgett and Brown. The first kidney transplantation was performed by Dr. Murray, a plastic surgeon. Composite tissue allotransplantation (CTA) is an evolving new field with transplantation of hand, vascularised knees or partial faces. With the European Union (EU) directive 2004/23/EC come into effect with the German tissue law at August 1, 2007 one has question the classification of transplantation of the hands, arms or the face as tissue or organ transplantation. While solid organs are allocated based on the German Deutsche Stiftung Organspende (DSO) and EuroTransplant, this is not the case for tissues. While for example thoracic organ procurement is performed in heart-beating organ donors with established hemodynamics, this is not the case for tissues, either. Given the complexity of a hand or a face as a sample of bones, muscles, nerves, vessels, and skin this has to be taken into account for example in comparison to a cornea as a tissue graft. As such, Dr. Siemionow has proposed a face to be regarded as an organ when comparing it to a kidney. Currently, allocation procedures as well as procurement issues in CTA are much more similar to organ- rather than tissue transplantation. Thus, we believe that CTA of hands or partial faces has more similarities to organ than to mere tissue transplantation.

Microvascular reconstruction of the hypopharynx: defect classification, treatment algorithm, and functional outcome based on 165 consecutive cases.

The objectives of this study were three-fold: to develop a scheme for classification of hypopharyngeal defects, to establish a reconstructive algorithm based on this system, and to assess the functional outcome of such reconstruction. This study is a retrospective review of a 14-year experience with 165 consecutive microvascular reconstructions of the hypopharynx in 160 patients. The average patient age was 59 years (95 percent CI, 37 to 81). Thirty-four patients were operated on for recurrent disease; 71 had preoperative radiotherapy. Partial defects were reconstructed with radial forearm flaps (n = 52); circumferential defects were reconstructed with jejunum (n = 90); and extensive, noncircumferential longitudinal defects were reconstructed with rectus abdominis flaps (n = 23). The overall free flap success rate was 98 percent. Six flaps required reexploration, two of which were salvaged. The incidence of fistula was 7 percent and stricture, 4 percent. Preoperative radiotherapy was significantly associated with risk of recipient site complications (OR, 2.3; 95 percent CI, 1.0 to 5.0). Follow-up data were available on 95 percent of patients: 53 percent were able to tolerate an unrestricted diet, 23 percent a soft diet, 12 percent liquids only, and 12 percent were limited to tube feedings. The treatment algorithm for microvascular hypopharyngeal reconstruction is based on the type of defect with partial defects with radial forearm flaps, circumferential defects reconstructed with free jejunal flaps, and extensive, multilevel defects reconstructed with rectus abdominis myocutaneous flaps. Microvascular reconstruction of pharyngeal defects is highly successful with few postoperative complications. With appropriate flap selection, functional outcome can be optimized.

[A new classification for standardizing nomenclature in wound closure by microvascular flap-plasty]. / Eine neue Klassifizierung für die Standardisierung der Nomenklatur beim Wundverschluss durch mikrovaskuläre Lappenplastiken.

The profusion of terms currently used to describe microvascular flap wound closure according to the time of reconstruction makes reliable comparisons of outcomes between institutions difficult if not impossible. To address the issue, a consistent terminology applicable to microvascular flap wound closure in general was formulated with respect to our experience with a total of 197 microvascular tissue transplantations. The nomenclature presented divides microvascular flap closure into three categories: "primary microvascular flap closure" (within 24 hours). "delayed primary microvascular flap closure" (two to seven days), and "secondary microvascular flap closure" (after seven days). This is consistent with known biological, microbiological, and surgical principles of wound closure in general and should provide a simple basis for classifying microvascular flap wound closure. Sample cases are selected to illustrate the categories within this new classification scheme.

Sanguijuelas medicinales: utilidad en microcirugía. A propósito de un caso / Medical leeches: use in microsurgery. A case report

Las sanguijuelas medicinales han sido utilizadas en la práctica médica desde hace 3.500 años. En la actualidad su uso de halla bien establecido en la cirugía reconstructiva, para el tratamiento del éstasis venoso, especialmente en reimplantes digitales, auriculares y en los colgajos de todo tipo con problemas de retorno venoso. El mecanismo de acción es la disminución de la presión hidrostática tisular en el área adyacente, por la sangría provocada durnte la succión y en el períoso posterior. La hidruina, sustancia anticoagulante que se halla en la saliva de la sanguijuela, prolonga el efecto. Sus contraindiaciones son la presencia de obstrucción arterial, la infección local o sistémica y la presencia de trastornos de la coagulación. Presentamos un caso de reconstrucción microquirúrgica compleja del tercio facial inferior, en el que utilizamos, con éxito , sanguijuelas medicinales para tratar la obstrucción venosa de un colgajo fascio-cutáneo antebraquial (AU)

Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques. The American Society for Dermatologic Surgery, Inc.

Previous attempts at classifying small graft transplants have focused mainly upon graft size and have not taken into consideration other technical factors involved in graft production that may influence the outcome of the surgery. The proposed classification attempts to consider these factors by including various technical aspects of harvesting, dissection, and placement, all of which impact the quality and quantity of the small grafts used in the procedure. By standardizing the nomenclature, as well as the description of the other factors involved in the surgery, communication between physicians and patients may be facilitated. In addition, different procedures may be more accurately studied and compared.

Microdiscectomía lumbar con la técnica de Caspar y ligamentoplastía interespinosa con Ethibon / Lumbar microdiscectomy with caspar technique and interspinal ligamentoplasty with ethilbond

Es un estudio retrospectivo de 44 pacientes con 61 hernias discales, en el cual se valoran los resultados clínicos y radiográficos obtenidos mediante la técnica de microcirugía y ligamantoplastía, para el tratamiento de hernias discales con inestabilidad de la columna lumbar, durante un seguimiento de 39 meses. Encontrando un 88.40 por ciento de excelentes resultados, un 9.30 por ciento de buenos resultados y malos 2.27 por ciento. Se discuten ampliamente las ventajas y desventajas de esta técnica sobre el método convencional

Staging of adnexal adhesions: a brief history.

Arriving at a system for staging adnexal disease is a scientific, clinical and political process which has already begun. Gynecologic oncologists started this process in 1967, and are still arriving at refinements and adjustments in the staging of cancer after 22 years. To rigorously evaluate new medical and surgical technologies in the treatment of adhesions it is important for infertility surgeons to continue the process of working towards a classification system, keeping in mind that it will take a long time.