Manejo ultra temprano del aneurisma cerebral roto. Reporte de caso y revisión de la literatura / Ultra-early management of ruptured brain aneurysm. A case report and literature review

Introducción : Los aneurismas intracraneales representan el 85% de casos de hemorragias subaracnoideas, dentro de las cuales las no traumáticas tienen una alta tasa de mortalidad (40-60%). En el manejo endovascular y microquirúrgico de esta enfermedad, el debate ha sido siempre intenso respecto a si el tratamiento temprano produce un beneficioso resultado funcional y reduce la morbi-mortalidad del paciente. Caso Clínico : Paciente mujer de 54 años, admitida con cefalea súbita y cuadro neurológico que cursó con rápido deterioro. La tomografía mostró hemorragia subaracnoidea por ruptura aneurísmica del complejo comunicante anterior; fue sometida a microcirugía dentro de las primeras 24 horas y transferida luego a UCI, sin complicaciones. Discusión : El tiempo de resolución, sea mediante clipaje microquirúrgico o tratamiento endovascular es tema de intensos debates. Las guías actuales señalan la necesidad del manejo más temprano posible de la patología. Conclusión : En nuestro caso, se obtuvo un buen resultado funcional debido a varios factores uno de ellos el ingreso precoz a cirugía. La actualización de las guías y nuevos estudios ayudarán a mejorar el conocimiento de la enfermedad y protocolos hospitalarios adecuados a la realidad clínica ayudarán a reducir su tiempo de resolución.

SUMMARY Introduction : Intracranial aneurysms account for 85% of all subarachnoid hemorrhages. Non-traumatic SAH has a high mortality rate (40-60%). Regarding the microsurgical and endovascular management for this pathology, there has been intense debate on whether early action is beneficial in terms of functional outcome and reduction of morbi-mortality. Clinical case : A 54-year-old woman admitted with a sudden, severe headache and a rapidly deteriorating neurological state at baseline, and with deterioration at the next hour. Tomography showed a subarachnoid hemorrhage due to ruptured aneurysm of the anterior communicating artery; the patient underwent surgery within the first 24 hours, with subsequent ICU management without complications. Discussion : The resolution time of this condition, either by micosurgery or endovascular management is a matter of intense debate. International guidelines point out the need of an earliest possible treatment. Conclusion : In our case, a good functional result was obtained due to several factors, one of which was early admission to surgery. The updating of guidelines and new studies will help to better understand the pathophysiology of SAH, and the creation of hospital protocols adapted to clinical realities will assist to reduce the resolution time of this pathology.

O que os olhos não veem a microcirurgia ensina: modelo de treinamento oftalmológico com olho de boi / What the eye cannot see, microsurgery teaches: a model of ophthalmological training with a bull's eye

RESUMO Objetivo Descrever e validar um modelo oftalmológico para treinamento de transplante e microssutura de córnea utilizando globo ocular bovino. Métodos Para a montagem do modelo de treinamento, o globo ocular foi disposto sob o campo cirúrgico, apoiado sobre um recipiente plástico cilíndrico comum de 3,5cm de diâmetro, para a retirada da córnea. Foi realizada uma incisão circular superficial, e, posteriormente, uma tesoura Castroviejo curva de 9 cm foi utilizada para remoção completa da córnea, que foi recolocada em sua posição original, para que, em seguida, fossem confeccionados nove pontos equidistantes, usando fio de nylon 10-0. Por fim, foram avaliados os seguintes critérios: tempo de realização das suturas; evolução do tempo e da qualidade a cada teste; e destreza e aperfeiçoamento da realização das suturas. Resultados O modelo descrito demonstrou-se viável e adequado para o treinamento de microssuturas na córnea, possibilitando aperfeiçoamento e ganho de habilidades cirúrgicas. Conclusão O modelo de treinamento microcirúrgico apresentado possui alta viabilidade para a simulação de cirurgias oftalmológicas e textura semelhante à do olho humano real, o que o torna próximo à realidade.

ABSTRACT Objective To describe and validate an ophthalmic model for corneal transplantation and micro suture training using a bovine eyeball as a model. Methods For the training model, the eyeball was placed under the sanitary field placed on the ends of a common 3.5cm diameter cylindrical plastic container for corneal removal. A superficial circular incision was made, then 9cm curved Castroviejo scissors were used for complete corneal removal. The cornea was replaced in its original position, and 10-0 nylon thread was used to perform the sutures, with 9 equidistant stitches. Finally, the following criteria were evaluated: suturing time, time and quality progression in each attempt, dexterity and suturing improvement. Results The described model proved to be feasible and suitable for corneal micro suture training, allowing improvement and gain of dexterity in the sport. Conclusion The presented microsurgical training model has a high feasibility for the simulation of ophthalmic surgeries, in addition to a texture similar to the real human eye, which makes it close to reality.

Low-fidelity simulation models in urology resident's microsurgery training

Purpose: To evaluate the gain of microsurgical skills and competencies by urology residents, using low-fidelity experimental models. Methods: The study involved the use of training boards, together with a low-fidelity microsurgery simulator, developed using a 3D printer. The model consists in two silicone tubes, coated with a resin, measuring 10 cm in length and with internal and external diameters of 0.5 and 1.5 mm. The support for the ducts is composed by a small box, developed with polylactic acid. The evaluation of the gain of skills and competencies in microsurgery occurred throughout a training course consisting of five training sessions. The first sessions (S1-S4) took place at weekly intervals and the last session (S5) was performed three months after S4. During sessions, were analyzed: the speed of performing microsurgical sutures in the pre and post-training and the performance of each resident through the Objective Structure Assessment of Technical Skill (OSATS) and Student Satisfaction Self-Confidence tools in Learning (SSSCL). Results: There was a decrease in the time needed to perform the anastomosis (p=0.0019), as well as a progressive increase in the score in the OSATS over during sessions S1 to S4. At S5, there was a slightly decrease in performance (p<0.0001), however, remaining within the expected plateau for the gain of skills and competences. The SSSCL satisfaction scale showed an overall approval rating of 96.9%, with a Cronback alpha coefficient of 83%. Conclusions: The low-fidelity simulation was able to guarantee urology residents a solid gain in skills and competencies in microsurgery.

Intense venous reflux, quantified by a new software to analyze presurgical ultrasound, is associated with unfavorable outcomes of microsurgical varicocelectomy / 亚洲男科学杂志(英文版)

The hemodynamic characteristics of venous reflux are associated with infertility in patients with varicocele; however, an effective method for quantifying the structural distribution of the reflux is lacking. This study aimed to predict surgical outcomes using a new software for venous reflux quantification. This was a retrospective cohort study of a consecutive series of 105 patients (age range: 22-44 years) between July 2017 and September 2019. Venous reflux of the varicocele was obtained using the Valsalva maneuver during scrotal Doppler ultrasonography before microsurgical varicocelectomy. Using this software, the colored reflux signals were segmented, and the gray scale of the color pixels representing the reflux velocity was comprehensively quantified into the mean reflux velocity of the green layer (MRVG) and the reflux velocity standard deviation of the green layer (RVSDG). Spontaneous pregnancy and changes from baseline in the semen parameters were assessed during a 12-month follow-up period. Data were analyzed using logistic regression analysis. An association of the high MRVG group with impaired progressive motility (odds ratio [OR] = 2.868, 95% confidence interval [CI]: 1.133-7.265) and impaired sperm concentration (OR = 2.943, 95% CI: 1.196-7.239) was found during multivariate analysis. High MRVG (OR = 2.680, 95% CI: 1.086-6.614) and high RVSDG (OR = 2.508, 95% CI: 1.030-6.111) were found to be independent predictors of failure to achieve pregnancy following microsurgical repair. In summary, intense venous reflux is an independent predictor of impaired progressive motility, sperm concentration, and pregnancy outcomes after microsurgical varicocelectomy.

The effect of BMI and age on the outcomes of microsurgical vasoepididymostomy: a retrospective analysis of 181 patients operated by a single surgeon / 亚洲男科学杂志(英文版)

To design a treatment plan for patients with epididymal obstruction, we explored the potential impact of factors such as body mass index (BMI) and age on the surgical outcomes of vasoepididymostomy (VE). In this retrospective study, 181 patients diagnosed with obstructive azoospermia (OA) due to epididymal obstruction between September 2014 and September 2017 were reviewed. All patients underwent single-armed microsurgical intussusception VEs with longitudinal two-suture placement performed by a single surgeon (KH) in a single hospital (Peking University Third Hospital, Beijing, China). Six factors that could possibly influence the patency rates were analyzed, including BMI, age, mode of anastomosis, site of anastomosis, and sperm motility and quantity in the intraoperative epididymal fluid. Single-factor outcome analysis was performed via Chi-square test and multivariable analysis was performed using logistic regression. A total of 159 (87.8%, 159/181) patients were followed up. The follow-up time (mean ± standard deviation [s.d.]) was 27.7 ± 9.3 months, ranging from 12 months to 48 months. The overall patency rate was 73.0% (116/159). The multivariable analysis revealed that BMI and age significantly influenced the patency rate (P = 0.008 and 0.028, respectively). Younger age (≤28 years; odds ratio [OR] = 3.531, 95% confidence interval [95% CI]: 1.397-8.924) and lower BMI score (<26.0 kg m-2; OR = 2.352, 95% CI: 1.095-5.054) appeared to be associated with a higher patency rate. BMI and age were independent factors affecting the outcomes of microsurgical VEs depending on surgical expertise and the use of advanced technology.

Predictors of microsurgical varicocelectomy efficacy in male infertility treatment: critical assessment and systematization / 亚洲男科学杂志(英文版)

In this review, we tried to systematize all the evidence (from PubMed [MEDLINE], Scopus, Cochrane Library, EBSCO, Embase, and Google Scholar) from 1993 to 2021 on the predictors of microsurgical varicocelectomy efficacy in male infertility treatment. Regarding the outcomes of varicocele repair, we considered semen improvement and pregnancy and analyzed them separately. Based on the 2011 Oxford CEBM Levels of Evidence, we assigned a score to each trial that studied the role of the predictor. We systematized the studied predictors based on the total points, which were, in turn, calculated based on the number and quality of studies that confirmed or rejected the studied predictor as significant, into three levels of significance: predictors of high, moderate, and low clinical significance. Preoperative total motile sperm count (TMSC) coupled with sperm concentration can be a significant predictor of semen improvement and pregnancy after varicocelectomy. In addition, for semen improvement alone, scrotal Doppler ultrasound (DUS) parameters, sperm DNA fragmentation index (DFI), and bilateral varicocelectomy are reliable predictors of microsurgical varicocelectomy efficacy.

Microsurgical Reconstruction in an Orthopedic Hospital: Indications and Outcomes in Adults / Reconstrução microcirúrgica em um hospital ortopédico: Indicações e desfechos em adultos

Abstract Objective Advances in reconstructive microsurgery in orthopedic surgery provided better functional and aesthetic results and avoided many indications for amputation. In high-volume trauma and orthopedic hospitals, microsurgical reconstruction is essential to reduce costs and complications for these complex orthopedic defects. We describe a microsurgical approach to traumatic wounds, tumor resection, bone defects, and free muscle transfer, performed by an orthopedic microsurgery unit. The objective of the present study was to evaluate predictor factors for outcomes of microsurgical flaps for limb reconstruction, and to provide a descriptive analysis of microsurgical flaps for orthopedic indications. Methods Cross-sectional prospective study that included all consecutive cases of microsurgical flaps for orthopedic indications from 2014 to 2020. Data were collected from personal medical history, intraoperative microsurgical procedure, and laboratory blood tests. Complications and free-flap outcomes were studied in a descriptive and statistical analysis. Results We evaluated 171 flaps in 168 patients; the indications were traumatic in 66% of the patients. Type III complications of the Clavien-Dindo Classification were observed in 51 flaps. The overall success rate of the microsurgical flaps was 88.3%. In the multivariate analysis, the risk factors for complications were ischemia time ≥ 2 hours (p= 0.032) and obesity (p= 0.007). Partial flap loss was more common in patients with thrombocytosis in the preoperative platelet count (p= 0.001). Conclusion The independent risk factors for complications of microsurgical flaps for limb reconstruction are obesity and flap ischemia time ≥ 2 hours, and presence of thrombocytosis is a risk factor for partial flap loss.

Resumo Objetivo Os avanços da microcirurgia reconstrutiva na cirurgia ortopédica proporcionaram melhores resultados funcionais e estéticos, evitando as muitas indicações de amputação. Nos hospitais de ortopedia e traumatologia com um grande volume de atendimento, a reconstrução microcirúrgica é essencial, a fim de reduzir os custos e as complicações destes complexos defeitos ortopédicos. Descrevemos uma abordagem microcirúrgica para feridas traumáticas, ressecção tumoral, defeitos ósseos e transferência muscular livre realizada por uma unidade ortopédica especializada em microcirurgia. O objetivo do presente estudo é avaliar os fatores preditivos de resultados dos retalhos microcirúrgicos na reconstrução dos membros, fornecendo uma análise descritiva dos retalhos microcirúrgicos para as indicações ortopédicas. Métodos Estudo prospectivo transversal, que incluiu todos os casos consecutivos de retalhos microcirúrgicos com indicação ortopédica de 2014 a 2020. Foram coletados os dados do histórico clínico pessoal, procedimentos microcirúrgicos intraoperatórios e exames laboratoriais. As complicações e os desfechos de retalho livre foram estudados mediante uma análise descritiva e estatística. Resultados Avaliamos 171 retalhos em 168 pacientes. A indicação mais frequente para a realização de um retalho microcirúrgico foi a traumática, em 66% dos pacientes. Foram observadas complicações cirúrgicas em 51 retalhos, conforme a classificação de Clavien-Dindo do tipo III. A taxa de êxito global dos retalhos microcirúrgicos foi de 88,3%. Na análise multivariada, foram identificados como fatores de risco para complicações tempo de isquemia ≥ 2 horas (p= 0,032) e obesidade (p= 0,007). A perda parcial do retalho foi mais comum em pacientes com trombocitose, com contagem de plaquetas pré-operatória (p= 0,001). Conclusão Os fatores de risco independentes para complicações de retalhos microcirúrgicos para a reconstrução de membro são obesidade e tempo de isquemia do retalho ≥ 2 horas, e a presença de trombocitose como fator de risco para perda parcial do retalho.

Is There Room for Microsurgery in Robotic Surgery? / Existe espaço para a microcirurgia na cirurgia robótica?

Abstract Robotic surgery opened a new era of minimally-invasive procedures, through its improved precision, elimination of tremors, greater degrees of freedom, and other facilitating aspects. The field of robotic microsurgery showed great growth in recent years in particular, since robotics offers a potentially-ideal configuration to perform the sensitive manipulations required in microsurgery. We conducted a systematic review to assess the benefits of robotic surgery and its contributions to microsurgery, comparing it with other surgical techniques used in patients of all age groups. We assessed 25 articles found in the PubMed and Cochrane databases using the terms 'robotic surgery' AND microsurgery, with a filter for studies published in the last five years, and studies conducted in humans and published in English or Portuguese. We concluded that there is plenty of room for robotic surgery in microsurgery, such as in male infertility procedures, neurological microsurgery, ocular and otological surgeries, and transoral, hepatobiliary, microvascular, plastic and reconstructive surgeries.

Resumo A cirurgia robótica abriu uma nova era de procedimentos minimamente invasivos, por meio da sua precisão, da eliminação dos tremores, e dos maiores graus de liberdade e demais aspectos facilitadores. O campo da microcirurgia robótica apresentou grande crescimento nos últimos anos em especial, uma vez que a robótica oferece uma configuração potencialmente ideal para realização das manipulações delicadas exigidas na microcirurgia. Assim, conduzimos uma revisão sistemática com o objetivo de avaliar os benefícios da cirurgia robótica e sua contribuição para a microcirurgia, comparando-a com as demais técnicas cirúrgicas utilizadas em pacientes de todas as faixas etárias. Foram analisados 25 artigos encontrados nas bases de dados PubMed e Cochrane utilizando os descritores robotic surgery AND microsurgery com filtro para os últimos cinco anos, e estudos realizados em humanos e publicados em inglês ou português. Concluímos que existe grande espaço para a cirurgia robótica na microcirurgia, como em procedimentos primários de infertilidade masculina, microcirurgia neurológica, cirurgias oculares e otológicas, cirurgia transoral, hepatobiliar, microvascular, e cirurgia plástica e reconstrutiva.

Terapia descongestiva como complemento a la cirugía de anastomosis linfáticovenosas y transferencia de linfonodos vascularizados: Una revisión de la literatura / Decongestive therapy as an adjunct to lymphatic-venous anastomosis surgery and vascularized lymph node transfer: A review of the literature

Resumen Introducción: El linfedema es una enfermedad inflamatoria crónica que afecta cerca de 250 millones de personas en el mundo. El tratamiento tradicional es la terapia descongestiva. Últimamente, existe la opción de complementar el tratamiento tradicional con procedimientos quirúrgicos fisiológicos como anastomosis linfáticovenosas y transferencia de linfonodos vascularizados. Sin embargo, la evidencia del uso de la terapia descongestiva en los cuidados pre y posoperatorios en estas cirugías es limitada. Objetivo: Evaluar el uso de terapia descongestiva como complemento a la cirugía de linfedema mediante anastomosis linfáticovenosas y transferencia de linfonodos vascularizados. Materiales y Método: Se realizó una revisión de la literatura en las siguientes bases de datos: Cochrane, Pubmed y Google académico, utilizando los siguientes términos mesh: "anastomosis, surgical", "lymphedema", "perioperative care", "microsurgery", "rehabilitation", "therapy", "lymph nodes", "bypass", "lymphedema and microsurgery". Se incluyó aquellos artículos que describían el uso de la terapia descongestiva en los cuidados pre- y posoperatorios. Resultados: Se identificó un total de 201 artículos y 12 fueron incluidos en el análisis. La evidencia reporta que las terapias más usadas en el cuidado pre- y posoperatorio son compresión, drenaje linfático manual y tratamientos personalizados. Sin embargo, la mayoría de los autores hace una descripción vaga de las terapias mencionadas. Discusión y Conclusión: La evidencia respecto al uso de terapia descongestiva como tratamiento complementario es débil. Los expertos recomiendan su uso, sin embargo, se necesitan futuras investigaciones que describan el uso de cada uno de sus componentes como complemento de procedimientos quirúrgicos fisiológicos para el manejo del linfedema.

Background: Lymphedema is a disease that affects about 250 million people around the world. The traditional treatment is decongestive therapy. In the past years, there is the option to complementing the traditional treatment with physiological surgical procedures such as lymphatic-venous anastomosis (LVA) and vascularized lymph node transfer (VLNT). However, the evidence for the use of decongestive therapy in pre- and post-operative care in these surgeries is limited. Aim: To evaluate the use of decongestive therapy as a complement to lymphedema surgery such a lymphatic-venous anastomosis and transfer of vascularized lymph nodes. Materials and Method: A literature review was carried out in the following databases: Cochrane, Pubmed and Academic Google, using the following mesh terms: "anastomosis, surgical", "lymphedema", "perioperative care", "microsurgery", "rehabilitation", "therapy", "lymph nodes","bypass", "lymphedema and microsurgery". "Those articles that described the use of decongestive therapy in pre- and post-operative care were included. Results: 201 articles were identified and 12 were included in the analysis. The evidence reports that the most used therapies in pre- and post-operative care are compression, manual lymphatic drainage and personalized treatments. However, most of the authors give a vague description of the mentioned therapies. Discussion and Conclusion: The evidence regarding the use of decongestive therapy as a complementary treatment is weak. Experts recommend its use; however, future research is needed to describe the use of each of its components as a complement to physiological surgical procedures for the management of lymphedema.

Endoscopic transsphenoidal endonasal surgery in pituitary adenomas / Cirugía endoscópica vía endonasal transesfenoidal en adenomas de hipófisis

The pituitary adenomas comprise the largest part of pituitary neoplasms, representing between 9 and 12% of primary brain tumors. Currently, the treatment of election is the surgical, the trans-sphenoidal endonasal path has provided a broader panoramic view, being feasible more delicate and safe procedures. The objective of this study was to describe the management of pituitary adenomas by endoscopic surgery trans-sphenoidal endonasal path. This is a study in a series of cases, with a sample of 17 patients who met the selection criteria and were attended at the José Carrasco Hospital Arteaga, Cuenca - Ecuador, period 2018 - 2019. All patients presented informed consent for the performance of the surgery and the subsequent dissemination of the results. The 53% of the population belonged to the male gender, 47% were patients between 40 and 60 years old, 65% were detected with macroadenomas, and 29% presented complications such as nasal obstruction, sphenoiditis and headache, the residual tumor stage was due 24%.Endoscopic surgery trans-sphenoidal endonasal path is a safe, minimally invasive tool, a surgical alternative with a high rate of tumor excision, better control and fewer complications, which reduces the morbidity of patients.

Los adenomas de hipófisis comprenden la mayor parte de neoplasias hipofisiarias, representando entre el 9 y 12% de los tumores cerebrales primarios. En la actualidad el tratamiento de elección es el quirúrgico, la vía endonasal transesfenoidal ha proporcionado una visión panorámica más amplia, siendo factibles procedimientos más delicados y seguros. El objetivo de este estudio fue describir el abordaje de adenomas de hipófisis mediante cirugía endoscópica vía endonasal transesfenoidal. Diseñamos un estudio de corte longitudinal, con una muestra de 17 pacientes que cumplieron con los criterios de selección y fueron atendidos en el Hospital José Carrasco Arteaga de la ciudad de Cuenca - Ecuador, periodo 2018 - 2019. Todos los pacientes presentaron consentimiento informado para la realización de la cirugía y la posterior difusión de los resultados. El 53% de la población pertenecieron al sexo masculino, 47% fueron pacientes entre 40 y 60 años, al 65% se le detectó macroadenomas, el 29% presentaron complicaciones como obstrucción nasal, esfenoiditis y cefalea, la tasa de tumor residual fue del 24%. La cirugía endoscópica vía endonasal transesfenoidal es una herramienta segura, mínimamente invasiva, una alternativa quirúrgica con una elevada tasa de exéresis tumoral, mejor control y menos complicaciones, que reduce la morbilidad de los pacientes.

Microcirugía mínimamente invasiva para aneurisma de la arteria comunicante anterior: abordaje supraorbitario lateral más angiografía con fluoresceína intraoperatoria / Minimally invasive micro surgery for aneurysm of the anterior communicating artery: supra-orbitary lateral approach with intraoperative Fluorescein Angiography

RESUMEN Los aneurismas de la arteria comunicante anterior son complejos y requieren de tratamiento endovascular o microquirúrgico según sus características. El uso de enfoques mínimamente invasivos en microcirugía continúa evolucionando. Presentamos el caso de un paciente de 34 años con un aneurisma cerebral no roto de AcoA de cuello ancho, con escala de Glasgow de 15 puntos. Se realizó un abordaje supraorbitario lateral más "clipaje" total del aneurisma usando angio fluoresceína intraoperatoria. Se logró el objetivo con seguridad y eficacia; al mismo tiempo se optimizó el tiempo quirúrgico y hospitalario, maximizando la comodidad del paciente, estética y reanudación a sus actividades tempranas. (AU)

SUMMARY Anterior communicating artery aneurisms (ACAA) are complex and require endovascular or microsurgery approaches. The use of minimally invasive microsurgery techniques is evolving. We present the case of a 34-yearold patient with a broad neck, non-broken, ACAA with a Glasgow coma scale of 15 points. A lateral supra-orbitary approach with total clipping of the ACAA using intra-operatory fluorescein angiography was performed. The objective was accomplished successfully and safe, optimizing both intra-operative and hospitalization times, thus,maximizing patient comfort, esthetic and prompt return to normal duties. (AU)

External Delta Fixator in the Postoperative Management of Microsurgical Flaps in the Lower Limb: Experience of a Tertiary Hospital / Fixador externo tipo delta no manejo pós-operatório de retalhos microcirúrgicos no membro inferior: Experiência de um hospital terciário

Abstract Objective To evaluate the use of external fixators in the delta-type kickstand configuration as an adjuvant method in the postoperative period of patients submitted to free flaps in the lower limbs. Methods A total of 17 external delta fixators were used in patients submitted to free flaps in the lower limbs. The surgical technique was performed in a standardized manner, with the distal pin located 6 cm proximally to the anastomosis, and the proximal pin, 6 cm distally to the anterior tuberosity of the tibia. Results The mean age of the sample was of 34.76 years (range: 15 to 66 years). In total, 11 men and 6 women were selected. The posterior tibial artery was used in 14 cases, and the anterior tibial artery, in 3 cases. The mean time of use of the external fixators was of 3.88 weeks. The rate of reoperation was of 17.64%; that of retail loss was of 11.76%; that of success rate was of 88.23%; and the rate of infection was of 5.9%. Conclusion The use of delta-type fixators as an adjunct method in the postoperative period is reliable; however, more studies are needed to evaluate its true role in the postoperative period.

Resumo Objetivo Avaliar o uso de fixadores externos, na configuração kickstand do tipo delta, como método adjuvante no período pós-operatório de pacientes submetidos a retalhos livres nos membros inferiores. Métodos Ao todo, 17 fixadores externos do tipo delta foram utilizados em pacientes submetidos a retalhos livres nos membros inferiores. A técnica cirúrgica foi realizada de forma padronizada, com o pino distal localizado 6 cm proximal à anastomose, e o pino proximal, 6cm distal à tuberosidade anterior da tíbia. Resultados A idade média da amostra foi de 34,76 anos (variação: 15 a 66 anos). Foram selecionados 11 homens e 6 mulheres. Utilizou-se a artéria tibial posterior em 14 casos, e a tibial anterior, em 3 casos. O tempo médio de uso dos fixadores externos foi de 3,88 semanas. A taxa de reoperação foi de 17,64%; a de perda do retalho foi de 11,76%; a de sucesso foi de 88,23%; e a taxa de infecção foi de 5,9%. Conclusão O uso de fixadores do tipo delta como método adjuvante no pós-operatório é confiável; porém, mais estudos são necessários para avaliar seu verdadeiro papel no pós-operatório.

An in vitro model study of computer-guided endodontic microsurgery / 中华口腔医学杂志

Objective: To assess and compare the accuracies and operating time of endodontic microsurgery performed by operators with different levels of experience in endodontics using computer-guided techniques including dynamic and static navigations in a surgical simulation model. Methods: Six pairs of three dimensional (3D)-printed models of upper and lower jaws were set up on dental manikins. A total of 120 teeth (10 teeth each jaw) were included in the models. Microsurgeries of osteotomy and root-resection were performed on the models by two operators with different experience, namely novices and experts, under of free hand (FH)(n=20), dynamic navigation (DN)(n=20), and static navigation (SN)(n=20) conditions, respectively. The duration of each operation was recorded. Cone-beam CT was taken for 3D-printed models before and after the operation. The path of preoperative surgery planning was simulated. The linear deviations at the entry and the end point and the angular deviation of the access path between the simulated and the actual operation were compared by the software. Results: Significant difference of the entry deviation was observed between the novices and the experts in the FH group [(1.44±0.49) and (1.02±0.58) mm] (q=4.67, P=0.020). There were no significant differences between the novices and the experts in the end point and angular deviations (P>0.05). For the novices, the entry deviations in both DN and SN groups [(0.76±0.32) and (0.66±0.20) mm] were significantly lower than those in FH group (q=7.58, P<0.001; q=8.66, P<0.001). The angular deviations in the abovementioned two groups (5.0°±3.5°, 3.9°±2.1°) were significantly lower than that in FH group (10.9°±6.1°) (q=7.38, P<0.001; q=8.70, P<0.001). For the experts, significant differences were found only in the angular deviations among DN, SN and FH groups (3.6°±1.9°, 3.2°±1.7° and 8.2°±3.9°) (q=5.74, P=0.001; q=6.29, P<0.001). The operation durations were significantly shortened for both the novices [(4.80±2.15), (1.09±0.48) min] (q=14.60, P<0.001; q=20.10, P<0.001) and the experts [(3.40±1.96),(1.02±0.34) min] (q=5.86, P<0.001; q=9.37, P<0.001) by using DN and SN techniques. Regarding the differences between tooth types, in FH group, the operating time on the anterior teeth was significantly shorter than that on the posterior teeth (q=8.14, P<0.001; q=5.20, P=0.007), while in DN and SN groups, there were no significant differences in the operating time between two tooth types (P>0.05). No significant differences were discovered in the accuracies on the anterior and posterior teeth among three techniques or between two kinds of operators (P>0.05). Conclusions: Dynamic and static navigation techniques could assist the clinicians, especially the novices, to improve the accuracies and shorten the operating time of osteotomy and root resection microsurgeries.

Microsurgical arterial anastomosis in young and adult rats: an evolutive and comparative study

Purpose: To evaluate the caliber of an arterial micro-anastomosis in the young growing animal using a continuous suture technique. Additionally, late morphological changes and blood flows distal to the anastomosis were evaluated. Methods: Seventy-four Wistar rats were submitted to laparotomy to access the aorta for blood flow measurement. The aorta was sectioned using microsurgery technique and an end-to-end anastomosis with continuous suture. After a period of six months to one year, the anastomosis was checked. Results: Regarding the size of the aortas, comparing the pre- and postoperative values, there was an increase of 13.33% in adult animals and 25% in young animals, without any difference in the blood flows. Conclusions: The arteries of young rats show signs of growth at the site of the anastomosis performed with continuous suture.

Anatomical description of the extratemporal facial nerve under high-definition system: a microsurgical study in rats

Purpose: To describe the microsurgical anatomical aspects of the extratemporal facial nerve of Wistar rats under a high-definition video system. Methods: Ten male Wistar rats (12­15 weeks old), without veterinary diseases, weighing 220­280 g, were used in this study. All animals in this study were submitted to the same protocol and by the same surgeon. A 10-mm incision was made below the bony prominence of the right or left ear, and extended towards the angle of the mandible. The dissection was performed and the main branches of the facial nerve were dissected. Results: The main trunk of the facial nerve has a length of 0.88 ± 0.10 mm and a length of 3.81 ± 1.03 mm, measured from its emergence from the stylomastoid foramen to its bifurcation. Seven branches originating from the facial nerve were identified: posterior auricular, posterior cervical, cervical, mandibular, buccal, temporal, and zygomatic. Conclusions: The anatomy of the facial nerve is comparable to that of humans, with some variations. The most observed anatomical division was the distribution in posterior auricular, posterior cervical, cervical, mandibular, buccal, temporal, and zygomatic branches. There is no statistical difference between the thickness and distance of the structures compared to the contralateral side.

Microsurgery versus embolization: different risk factors for short- and long- term outcomes of patients with ruptured aneurysms

Purpose: To evaluate the risk factors for poor outcomes after surgical and endovascular treatment of aneurysmal subarachnoid hemorrhage (aSAH). Methods: Patients with ≥ 18-years of age and aSAH were included, while patients who died within 12 h of admission or lost follow-up were excluded. All participants underwent standardized clinical and radiological assessment on admission and were reassessed at discharge and at 6-months follow-up using the Glasgow Outcome Scale (GOS). Results: Death at discharge was associated with female gender, anterior communication artery (ACoA) aneurysm location and presence of atherosclerotic plaque in the surgical group, and with age in the endovascular group. Both groups had clinical condition on follow-up associated with mFisher score on admission and hypertension. GOS on follow-up was also associated with presence of atherosclerotic plaque and multiple aneurysms in surgical group, and with age in endovascular group. Conclusions: Subjects treated surgically are prone to unfavorable outcomes if atherosclerotic plaques and multiple aneurysms are present. In patients with endovascular treatment, age was the main predictor of clinical outcome.

Clinical outcomes following microsurgery and endovascular embolization in the management of spinal dural arteriovenous fistula: A meta-analysis study / 北京大学学报(医学版)

OBJECTIVE@#To compare the clinical effect of microsurgery and endovascular embolization in the treatment of spinal dural arteriovenous fistula (SDAVF) by meta-analysis.@*METHODS@#A systematic review was performed to retrieve all relevant literature about surgical treatment or endovascular embolization of SDAVF up to December 2019 through PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials Results, CNKI, Wanfang Data, and SinoMed. The Chinese and English key words included: "SDAVF", "spinal dural arteriovenous fistula", "spinal AVM", "spinal vascular malformation and treatment". The included studies were evaluated using the Newcastle-Ottawa scale. The early failure rate, long-term recurrence, neurological recovery, and complications were evaluated and the clinical effects of the two methods in the treatment of SDAVF were compared by using RevMan 5.3 software. And a further subgroup analysis of the therapeutic effect of endovascular embolization with different embolic agents was conducted.@*RESULTS@#A total of 46 studies involving 1 958 cases of SDAVF were included, in which 935 cases were treated by microsurgery and 1 023 cases were treated by endovascular embolization. The funnel plot demonstrated that there was no publication bias. The results of meta-analysis showed that the incidence of early surgical failure was lower than that of endovascular embolization (OR=0.20, 95%CI: 0.13-0.30, P < 0.05), and the long-term recurrence was also lower than that of endovascular embolization (OR=0.36, 95%CI: 0.22-0.58, P < 0.05). The improvement of neurological function in the surgical patients is significantly higher than that in the patients treated with endovascular embolization (OR=2.86, 95%CI: 1.36-5.99, P < 0.05). There was no significant difference in the occurrence of complications in these two groups (OR=1.52, 95%CI: 0.88-2.64, P=0.14). In the cases of endovascular embolization, the risk of treatment failure or recurrence was higher with Onyx glue than with n-butyl 2-cyanoacrylate (NBCA), and the difference was statistically significant (OR=4.70, 95%CI: 1.55-14.28, P < 0.05).@*CONCLUSION@#Although the treatment of dural arteriovenous fistulas by intravascular embolization has been widely used, the clinical effect of microsurgery is still better than that of endovascular embolization. Large scale and high-quality randomized controlled trials are required to validate the efficacy and safety of endovascular treatment in SDAVF patients.

What came first: the egg or the microsurgery training? An ophthalmic model for developing basic skills in microsurgery / O que veio primeiro: o ovo ou o treinamento microcirúrgico? Um modelo oftalmológico para desenvolver habilidades básicas em microcirurgia

ABSTRACT Purpose: To describe a new accessible model of ophthalmological training using chicken eggs. Methods: With the aid of a spherical drill, the external calcified layer and the cuticle of the chicken eggshell were removed in a 2cm diameter circle. Using a video-magnification system, the film was dissected and cut to approximately 1.5 cm diameters. The film was removed and repositioned to make interrupted 12-0 nylon microsutures. The parameters analyzed were: cost, facility of acquisition and handling, time for making the model and the microsutures and number of possible uses. Results: In all simulators, it was possible to carry out separated and equidistant micro-sutures in the egg membrane, without the need for reintervention. Conclusion: The new chicken-egg model for ophthalmic surgery training is low-cost, easy to acquire and handle, and viable for the development of basic microsurgery skills.

RESUMO Objetivo: Descrever um novo modelo acessível de treinamento oftalmológico com ovo de galinha. Métodos: Com o auxílio de uma broca esférica, a camada calcificada externa e a cutícula da casca do ovo de galinha foram retiradas em um círculo 2 cm de diâmetro. Mediante um sistema de videomagnificação, a película foi dissecada e cortada em formato aproximado de 1,5 cm de diâmetro. A película foi removida e reposicionada para a confecção de microssuturas interrompidas com nylon 12-0. Os parâmetros analisados foram: custo, facilidade de aquisição e manuseio, tempo para confecção do modelo e para a confecção das microssuturas e número de utilizações possíveis. Resultados: Em todos os simuladores foi possível realizar microssuturas separadas e equidistantes na membrana do ovo, sem necessidade de reintervenção. Conclusão: O novo modelo com ovo de galinha para o treinamento de cirurgia oftalmológica é de baixo custo, fácil aquisição e manuseio, além de ser viável no desenvolvimento de habilidades básicas em microcirurgia.

Implementación de las escalas de evaluación formativa OSATS en habilidades técnicas aplicadas en el laboratorio de microcirugía / Implementation of the OSATS training assessment scales in technical skills applied in the microsurgery laboratory

Introducción. La simulación como estrategia de aprendizaje activo se ha constituido en una herramienta centrada en el estudiante, para la construcción de aprendizajes en entornos seguros y el perfeccionamiento de sus habilidades técnicas. La evaluación objetiva estructurada de habilidades técnicas (OSATS, por sus siglas en inglés) es una herramienta evaluativa en el área quirúrgica, que puede ser implementada en los programas en microcirugía. Métodos. Estudio descriptivo, de corte transversal y doble ciego, donde se incluyeron 34 estudiantes de especialidades quirúrgicas, quienes fueron evaluados mediante los OSATS para los módulos finales: módulo 1: disección vascular; módulo 2: ejecución de sutura de puntos independientes; y módulo 3: ejercicios de revascularización. Al finalizar la materia, los estudiantes evaluaron la implementación de esta metodología por medio de una encuesta de satisfacción. Resultados. La evaluación del diseño de la guía práctica tipo OSATS por los estudiantes fue satisfactoria (88,2 %). Al evaluar la actividad de disección y sutura en microcirugía la consideraron de gran utilidad (88,2 %), para los ejercicios de anastomosis y revascularización (aprobación del 79,5 %). La aplicabilidad práctica y la calidad de los ejercicios mediante guías de evaluación OSATS tuvieron 94,2 % de aceptación. Conclusión. Las escalas OSATS son un instrumento útil, valido y objetivo para el modelo de evaluación por competencias en habilidades técnicas, que puede ser implementado en los modelos de enseñanza en simulación, contando con confiabilidad, validez de contenido y de constructo. Es aplicable en los programas de microcirugía, con una percepción positiva por parte de los estudiantes.

Introduction. Simulation as an active learning strategy has become a student-centered tool for the construction of learning in safe environments and the improvement of their technical skills. The Objective Structured Assessment of Technical Skills (OSATS) is an evaluation tool in the surgical area, which can be implemented in microsurgery programs. Methods. Descriptive, cross-sectional and double-blind study, which included 34 students from surgical specialties, who were evaluated through the OSATS for the final modules: module 1: vascular dissection; module 2: execution of independent sutures; module 3: revascularization exercises. At the end of the course, the students evaluated the implementation of this methodology under evaluation by means of a satisfaction survey. Results. The evaluation of the design of the practical guide OSATS-type by the students was satisfactory (88.2%). When evaluating the dissection and suturing activity in microsurgery, they consider it very useful (88.2%), for anastomosis exercises and revascularization exercise (79.5% approval). The practical applicability and quality of the exercises using OSATS evaluation guides had 94.2% acceptance.Conclusion. The OSATS scales are a useful, valid and objective instrument for the evaluation model for technical skills, which can be implemented in simulation teaching models, with reliability, content and construct validity. It is applicable in microsurgery programs, with a positive perception by students.

Linfedema: de la fisiopatología al tratamiento actual / Lymphedema: from pathophysiology to current treatment

Resumen El linfedema es la acumulación de líquido rico en proteínas en el intersticio debido a una incompetencia de los canales linfáticos. Se clasifica en primario cuando es ocasionado por anormalidades estructurales congénitas en los canales linfáticos, mientras que el secundario está causado por disrupciones en la integridad anatómica, que pueden acontecer después de trauma, infecciones (filariasis linfática), posterior a vaciamientos ganglionares, o iatrogénica. Objetivo: Describir los aspectos más importantes del tratamiento del linfedema entendiéndose este desde la fisiopatología. Metodología: Se incluyeron artículos publicados en idiomas español e inglés, la mayoría entre 2011 y 2021 que tuvieran contenido relacionado con el objetivo del presente manuscrito. Conclusiones: El linfedema se ha convertido en un reto para los profesionales de la salud debido a su complejo tratamiento multidisciplinario, pero gracias al avance de la microcirugía, el manejo quirúrgico se convertido en una creciente alternativa efectiva, especialmente gracias a su enfoque fisiopatológico de la enfermedad. MÉD. UIS.2021;34(3): 61-70.

Abstract Lymphedema is the accumulation of protein-rich fluid in the interstitium due to an incompetence of the lymphatic channels. It is classified as primary when it occurs due to lymphatic channels abnormalities, and secondary lymphedema when it is caused by trauma, infection, venous thrombosis, oncological diseases and iatrogenia, especially after lymph node dissection. Objective: To describe the most important aspects in the treatment of lymphedema, understanding it from a pathophysiological perspective. Methodology: Articles published in Spanish and English were included, the majority between 2011 and 2021 that have content related to the objective of this manuscript. Conclusions: Lymphedema has become a challenge to physicians due to the complex and multidisciplinary treatment that it requires, but, owing to the advance from microsurgery, the surgical management has become an increasingly effective alternative, especially because of its disease pathophysiological approach. MÉD.UIS.2021;34(3): 61-70.