The"Overlapping"Lymphaticovenous Anastomosis: an overlapped end-to-end anastomosis supermicrosurgical technique.

OBJECTIVE: Lymphaticovenular anastomosis (LVA) is increasingly utilized in the treatment of lymphedema. This study aims to assess the efficacy and safety of the "Overlapping" LVA technique, which addresses the size mismatch between lymphatic and venous vessels in lymphedema treatment. METHODS: Between August 2022 and April 2023, seventeen patients diagnosed with lymphedema were enrolled in this study. The severity of lymphedema in these patients was classified according to the International Society of Lymphology (ISL) staging system.All patient underwent LVA procedures, anastomosis techniques including the Overlapping, end-to-end and octopus anastomosis. The techniques of anastomosis, anastomosis time, patency rate, and volume of limb lymphedema were evaluated. RESULTS: Our study enrolled 17 lymphedema patients who underwent the LVA procedure. All patients showed significant postoperative improvement in limb edema. The mean drainage volume was 472.29 ml. The Overlapping technique demonstrated a 100% success rate as assessed by clinical observation and intraoperative Indocyanine Green (ICG) lymphography. The average anastomosis time was 5.3 min, reducing operative time compared to traditional methods. CONCLUSIONS: These findings suggest that the Overlapping technique could serve as a valuable addition to the current LVA technique. This Overlapping anastomosis technique provides a wide range of applications for lymphatic anastomosis treatment and prevention of lymphedema.

Palatal root endodontic microsurgery in maxillary molars using the palatal approach: a case study.

BACKGROUND: In clinical practice, the buccal approach is typically the primary choice for endodontic microsurgery. Owing to the thickness of the buccal bone plate, the distance between the buccal bone plate and palatal lesion location, and soft tissue traction, the palatal approach may be more suitable for microsurgery for apical periodontitis of the palatal roots of the maxillary molars. However, the length of the palatal root, location of the greater palatine artery (GPA) and foramen (GPF), and surgical field of observation make palatal surgery challenging. CASE PRESENTATION: With the aid of Cone-beam computed tomography imaging, the palatal approach was successfully applied in nine cases of endodontic microsurgery of the palatal root of a maxillary molar with a periapical lesion in Hangzhou Stomatology Hospital from January to December 2022. CONCLUSIONS: Complete healing was assessed based on clinical symptoms and radiographic images at the 3- and 24-month follow-up visits in all nine cases. Several tips have been proposed including surgical positioning, incision design, palate flap modification, bone removal, and root-end resection.

Reevaluation of Recipient Vessel Selection in Breast Free Flap Reconstruction.

BACKGROUND: Current consensus has established the internal mammary vessels (IMV) over the thoracodorsal vessels (TDV) as the preferred recipients for microvascular breast reconstruction due to their superior flow rates and long-established outcomes. Yet, there are occurrences where the IMVs are not reliable and may subsequently prompt intraoperative decision-making. Several options exist, including the contralateral IMVs, thoracoacromial vessels, and TDVs. The appropriate sequence for vessel choice is not universally agreed upon. This study reevaluates the TDVs to highlight their viability as a second-line intraoperative alternative to the IMV and provide reference to the straightforward dissection required for harvest. METHODS: A retrospective, single-institution, breast-level analysis examining 4754 breast free flaps from 2978 patients undergoing bilateral free flap reconstruction was conducted. Postoperative complications within 180 days were evaluated, and cohorts based on anatomic anastomosis (IMV vs. TDV) were created to compare outcomes. Subanalysis was conducted based on flap laterality as well as whether a flap was planned or converted intraoperatively. RESULTS: Of 4754 breast free flaps, 4269 (89.8%) used the IMV while 485 (10.2%) used the TDV. Most complication rates between the TVD and IMV were not significantly different. Rates of flap loss were 1.0% and 1.2% for the IMV and TDV anastomosis (p = 0.59). IMV and TDV anastomosed flaps experienced similar rates of fat necrosis (6.3% vs. 6.2%, p = 0.915). However, multivariable analysis of all breasts regardless of laterality showed that skin necrosis was significantly less likely in TDV breasts (OR 0.45, 95% CI 0.29-0.71, p < 0.001). CONCLUSIONS: Given the relative similarity in cohort outcomes, TDV anastomosis can be considered a viable alternative to the IMV when the IMV is unavailable or technically disadvantageous. The TDV artery remains a robust and reliable option in the present-day plastic surgeon's repertoire for breast reconstruction.

Learning curve of robotic assisted microsurgery in surgeons with different skill levels: a prospective preclinical study.

Achieving precision in microsurgery requires skill, adequate instruments and magnification, as well as extensive training. Dedicated surgical robotic systems have enhanced and expanded the application of (super-)microsurgical techniques by introducing motion scaling and providing improved surgeon ergonomics. In this prospective preclinical trial, we analyzed the learning curve in robotic assisted microsurgery in 13 participants including medical students, residents, and attending physicians. Data on demographics as well as prior experience in surgery, microsurgery, and gaming were collected. In three study sessions, the participants performed nine microsurgical anastomoses each on 2 mm vessel models using the Symani® Surgical System in combination the VITOM 3D exoscope. A senior expert microsurgeon reviewed the de-identified and blinded videos and scored all anastomoses using a modified "Structured Assessment of Microsurgical Skills" (SARMS) score. All participants significantly reduced their time needed per anastomosis and their overall SARMS score, as well as individual scores for motion and speed throughout the trial. We saw a significant correlation of prior years of practice in surgery with the overall mean time and mean SARMS score. In a separate analysis of the three sessions, this influence could no longer be seen in the last session. Furthermore, we found no significant effect of gender, age, hand dominance, or gaming experience on speed and quality of the anastomoses. In this study of 117 robotic assisted anastomoses, a rapid improvement of performance of all participants with different surgical skills levels could be shown, serving as encouraging evidence for further research in the implementation of microsurgical robotic systems.

Use of intraoperative microvascular Doppler during subinguinal microsurgical varicocelectomy in children reduces complications.

Background/Aim: This study assessed the impact of intraoperative microvascular Doppler ultrasonography (MDU) during microsurgical subinguinal varicocele correction in children. Materials and methods: Nineteen patients who underwent intraoperative MDU during subinguinal microsurgical varicocelectomy between 2021 and 2023 were included in this study. Each patient's age, varicocele side, clinical examination findings, preoperative ultrasonography results, intraoperative findings, spermatic artery counts and findings in terms of MDU use, postoperative complications, and results were evaluated. Results: All varicoceles were on the left side and the average age of the patients was 15.2 years. The indications for varicocelectomy were testicular hypotrophy (n = 10) and scrotal pain or fullness (n = 9). When a surgical microscope was used, testicular artery pulsation was detected in only five patients, whereas it was detected in all cases when MDU was used. In 16 cases, a single testicular artery was identified, and two arteries were identified in three cases. Additionally, in a case where a spermatic vein was suspected, it was not ligated due to the detection of pulsation with an arterial pattern using MDU. Two to three lymphatic channels were isolated and preserved, an average of 7.5 vessels were ligated, and five external spermatic veins were identified and ligated. There were no complications, and six of the patients with testicular hypotrophy showed signs of the catch-up growth phenomenon. Conclusion: The use of MDU during subinguinal microsurgical varicocelectomy in children not only increases the success rate but also minimizes complications such as hydrocele and recurrence.

Postoperative dysgeusia following microsurgical resection for acoustic neuroma: a systematic review and meta-analysis.

OBJECTIVE: To determine the collated rate of postoperative dysgeusia after microsurgical intervention in acoustic neuroma patients. METHODS: The systematic review with meta-analysis was undertaken following PRISMA guidelines. A thorough search of PubMed/Medline, the Cochrane Database of Systematic Reviews, and Epistemonikos was undertaken for studies published up until May 16, 2024 reporting postoperative taste disturbance rates after microsurgical intervention for acoustic neuroma. The methodological quality of the included studies was assessed via the Methodological Index for Non-Randomized research (MINORS) tool. Using MedCalc (v. 20.215) software, the random-effects model was developed for proportional meta-analysis. RESULTS: Eight studies, encompassing 2,402 patients (mean age = 49.06 years; 48.54% female population), were included in the analysis. The overall pooled rate of postoperative dysgeusia following microsurgical management of acoustic neuroma was 23.7% (95% CI: 9.266-42.359, p < 0.0001). When stratified by surgical approach, the rate of postoperative dysgeusia for the retrosigmoid approach was 18.8% (95% CI: 2.821-44.461, p < 0.0001). Postoperative dysgeusia data stratified for other major microsurgical approaches (subtemporal and translabirynthine approaches) was not reported by any of the included studies. CONCLUSION: Our systematic review and meta-analysis calculated a collated rate of almost 25% and recognized postoperative dysgeusia as a common complication following microsurgical management of acoustic neuromas. These results highlight the significance of preoperative counselling and the development of strategies that minimize the likelihood of harm to the chorda tympani nerve during microsurgical intervention for acoustic neuroma.

Development of microsurgical forceps equipped with haptic technology for in situ differentiation of brain tumors during microsurgery.

The stiffness of human cancers may be correlated with their pathology, and can be used as a biomarker for diagnosis, malignancy prediction, molecular expression, and postoperative complications. Neurosurgeons perform tumor resection based on tactile sensations. However, it takes years of surgical experience to appropriately distinguish brain tumors from surrounding parenchymal tissue. Haptics is a technology related to the touch sensation. Haptic technology can amplify, transmit, record, and reproduce real sensations, and the physical properties (e.g., stiffness) of an object can be quantified. In the present study, glioblastoma (SF126-firefly luciferase-mCherry [FmC], U87-FmC, U251-FmC) and malignant meningioma (IOMM-Lee-FmC, HKBMM-FmC) cell lines were transplanted into nude mice, and the stiffness of tumors and normal brain tissues were measured using our newly developed surgical forceps equipped with haptic technology. We found that all five brain tumor tissues were stiffer than normal brain tissue (p < 0.001), and that brain tumor pathology (three types of glioblastomas, two types of malignant meningioma) was significantly stiffer than normal brain tissue (p < 0.001 for all). Our findings suggest that tissue stiffness may be a useful marker to distinguish brain tumors from surrounding parenchymal tissue during microsurgery, and that haptic forceps may help neurosurgeons to sense minute changes in tissue stiffness.

From Microscopic to Exoscopic Microsurgery: Are We Facing a Change of Paradigm?

BACKGROUND: Neurosurgery is a medical branch characterized by small and deep surgical field with the need of manipulation and dissection of anatomical structures. High light and magnification are required in order to avoid injuries to important anatomical structures and to avoid permanent neurological deficits. Introduction of operative microscope made a change of paradigm in neurosurgery allowing to better see what could not be seen with common light. Nowadays, introduction of several technologies have increased the safety and efficacy of neurosurgery. Among new technologies, the 3D exoscope is emerging pretending to shift the paradigm of microneurosurgery. In this work, we aim to show our first experience with the use of the exoscope showing advantages and disadvantages. MATERIALS AND METHODS: We reviewed our surgical database from the introduction of the exoscope in our department (in November 2020 temporarily; then from November 2021 definitively) searching for all the microsurgery interventions performed in the period. RESULTS: From the introduction of the exoscope in our department, we operated 244 cases with the OM and 228 with the exoscope. We operated 175 lesions located in the supratentorial compartment, 29 in the infratentorial, and 24 in the spinal column. Regarding the OM, the ratios were as follows: 122 females and 122 males; 235 adults and 9 children; 66 supratentorial lesions, 14 infratentorial lesions, and 164 spine surgeries. Our team showed a progressive switch from the microscope to the exoscope. Only one member of our team preferred to continue to use the standard operative microscope. CONCLUSIONS: Our experience showed no complications related to the use of the exoscope that proved to be safe and effective both for surgery and teaching.

The Impact of Increased Body Mass Index on Patient Outcomes and Complications in Microsurgical Lower Extremity Reconstruction.

BACKGROUND: Elevated body mass index (BMI) is a known perioperative risk factor for complications such as delayed wound healing and infection. However, there is a gap in understanding how elevated BMI impacts outcomes after posttraumatic lower extremity (LE) microvascular reconstruction. METHODS: A retrospective review was performed at a level 1 trauma center between 2007 and 2022 of patients who underwent posttraumatic microvascular LE reconstruction. Demographics, flap/wound details, complications, and outcomes were recorded. Patients were stratified into BMI Center for Disease Control categories. RESULTS: A total of 398 patients were included with an average BMI of 28.2 ± 5.8. Nearly half (45%) of LE defects were located in the distal third of the leg, 27.5% in the middle third, and 34.4% in the proximal third. Most reconstructions utilized muscle-containing flaps (74.4%) compared with fasciocutaneous flaps (16.8%). Surgical approaches included free flaps (47.6%) and local flaps (52.5%). Class III obese patients were significantly more likely to be nonambulatory than nonobese patients (OR: 4.10, 95% CI 1.10-15.2, p = 0.035). At final follow-up, 30.1% of patients with Class III obesity were ambulatory, requiring either wheelchairs (42.3%) or assistance devices (26.9%). There were no significant differences in complication rates based on obesity status (0.704). The average follow-up time for the entire cohort was 5.8 years. CONCLUSIONS: BMI is critical for patient care and surgical decision-making in LE reconstruction. Further research is warranted to optimize outcomes for higher BMI patients, thereby potentially reducing the burden of postoperative complications and enhancing overall patient recovery.

Endoscopic retrosigmoid trans-petrosal fissure approach for vestibular schwannomas: case series.

The management of vestibular schwannoma (VS) remains one of the most formidable challenges in neurosurgery owing to the eloquent nature of surrounding anatomy. Although endoscopy-assisted microsurgery has recently gained momentum in cerebellopontine angle region surgery, the feasibility of pure endoscopic technique has been rarely reported. Here we present the operative technique and preliminary outcomes of fully endoscopic retrosigmoid trans-petrosal fissure approach (ER-TPFA) for VS surgery. Clinical data of 36 consecutive cases of VS treated with the ER-TPFA from March 2021 to March 2023 were analyzed. The patients were placed in a modified lateral park-bench position, with the Dandy incision and suboccipital craniotomy performed. With the endoscopic holder, endoscopic procedures were performed using standard two-hand microsurgical techniques by one surgeon. Arachnoidal dissection of the petrosal fissure was performed for identifying the brainstem end of facial nerve and separating the tumor from the cerebellum, without brain retraction seen in traditional microsurgical technique. The tumors had an averaged size of 3.0 cm in diameter. According to the Hannover classification, nearly all the tumors were grade III-IV (97.3%). Using ER-TPFA, 33 patients (91.7%) achieved gross total resection. Anatomic preservation of the facial nerve was achieved in 35 cases, with 33 patients (91.7%) retaining a House-Brackmann score of 1-2 postoperatively. Four out of ten patients still had serviceable hearing 6 months after operation. Postoperatively, there was no post-craniotomy hematoma, cerebellar edema, and new-onset cerebellar ataxia. With a better visualization of the cerebellopontine angle region, ER-TPFA may help preserve facial nerve function and maintain high gross total resection rate while minimizing complications. We believe this retractorless technique can be a safe and effective alternative for the management of VS with satisfactory clinical results.

State of Head and Neck Microvascular Reconstruction: Current and Future Directions.

Since its inception, microvascular free tissue transfer has broadened possibilities for oncologic ablation and restoration of form and function. Developments throughout recent decades have resulted in increasing flap success rates and complexity. Advances in technology and knowledge gained from past experiences will continue to improve surgical efficiency, flap success rates, and ultimately, patient outcomes.

Establishing Microsurgery Skills Laboratories in Low- and Middle-income Countries with Integrated Remote Teaching: A Novel Approach.

Microneurosurgical techniques remain crucial for managing neurosurgical diseases, especially in low- and middle-income countries (LMICs) where other advanced treatment modalities are not available. The global distribution of these techniques is uneven due to disparities in infrastructure, equipment, and training. Medical professionals from LMICs face barriers in reaching training centers in high-income countries, as well as in accessing microsurgical techniques. To address these disparities in microsurgery training, we offer free and accessible microsurgery training model by combining the donations of microsurgery kits with a comprehensive support system that includes live-streamed, offline, and in-person assistance within LMICs.

[Microsurgery for Vertebral and Posterior Inferior Cerebellar Artery Aneurysms via Lateral Suboccipital Craniotomy].

Among ruptured intracranial aneurysms, aneurysms of the vertebral artery(VA) and posterior inferior cerebellar artery(PICA) are relatively rare, and they exhibit distinct characteristics. These include: 1) a high frequency of diverse aneurysmal morphologies, such as fusiform or dissecting aneurysms; 2) proximity to the lower cranial nerves; 3) the presence of perforators to the medulla oblongata; and, 4) obstruction to the surgical approach by specific bony structures, such as the occipital condyle and jugular tubercle. Consequently, these aneurysms often require interventions that are more complex than simple clipping or coiling, which is typical for anterior circulation aneurysms. Interventions include skull base techniques such as the far-lateral approach and revascularization procedures such as occipital artery(OA)-PICA bypass. Despite these complexities, the rarity of these aneurysms and the recent advancements in endovascular procedures pose challenges for young neurosurgeons in acquiring adequate microsurgical experience. This narrative review addresses the clinical features of VA and PICA aneurysms, the history and variations in the lateral suboccipital approach for these aneurysms, and several bypass techniques for reconstructing the PICA. Lastly, we illustrate our current microsurgical practices through a case presentation accompanied by a surgical video showcasing both the far-lateral approach and the OA-PICA bypass.