INTRODUÇÃO: Infertilidade atinge aproximadamente 15% dos casais em idade reprodutiva e afeta de maneira profunda a vida dessas pessoas. Dentre as causas identificáveis de infertilidade masculina, a varicocele é a mais frequente e acomete cerca de 40% dos homens inférteis ou subférteis. Um dos maiores desafios na abordagem cirúrgica da varicocele é a identificação de indivíduos que apresentarão maior benefício com o tratamento, uma vez que muitos pacientes não apresentam melhora da análise seminal. OBJETIVOS: Identificar um padrão histológico testicular como prognóstico da melhora da capacidade reprodutiva em pacientes submetidos à varicocelectomia microcirúrgica. METODOLOGIA: Estudo retrospectivo composto pela análise de 60 biópsias testiculares bilaterais de homens inférteis atendidos em clínica especializada de fertilidade masculina, entre os anos de 2006 e 2014. Como critérios de inclusão foram considerados homens com diagnóstico de varicocele clínica e subclínica entre 19 e 50 anos de idade com resultados de análise histopatológica testicular. Os sujeitos de pesquisa foram divididos em dois grupos. Grupo 1: homens com diagnóstico de varicocele subclínica (n = 20). Grupo 2: homens com diagnóstico de varicocele clínica (n =40). Foram excluídos do estudo homens com diagnóstico de criptorquidia, azoospermia obstrutiva e não-obstrutiva, usuários de drogas e anabolizantes, além de pacientes portadores de doenças sexualmente transmissíveis e de neoplasias no trato geniturinário. Os participantes foram submetidos ao exame físico urológico com a avaliação do volume testicular por meio de ultrassonografia da bolsa escrotal com Doppler-Colorido. O diagnóstico da varicocele foi realizado por meio da palpação cuidadosa do plexo pampiniforme com o paciente em posição ortostática. A manobra de Valsava foi utilizada para a classificação clínica do grau de varicocele. Para a determinação de um padrão histológico capaz de predizer a melhora da capacidade reprodutiva, foram criados valores de corte que associam os scores de Johnsen, os índices de Copenhagen e o volume testicular à melhora dos parâmetros seminais. RESULTADOS: No grupo 1, para a melhora da concentração espermática o score de Johnsen deve ser superior a 8,2 (lado esquerdo) e o volume testicular acima de 12,8 mL (lado direito). Adicionalmente, para a avaliação da motilidade total de espermatozoides os scores de Johnsen devem ser superiores a 8,2 (bilateral) e o dígito II de Copenhagen inferior a 2,5 em ambos os testículos. Todavia, para a motilidade progressiva de espermatozoides o score de Johnsen deve ultrapassar a 9,1 (bilateral) e na avaliação da morfologia espermática, este deve se apresentar acima de 7,9 e com volume testicular acima de 13,6 mL (lado direito). Quanto aos valores de corte obtidos no grupo 2, para a concentração de espermatozoides, os scores de Johnsen devem ser superiores a 5,5 com volume testicular acima de 11,5 mL em ambos os testículos. Finalmente, quanto à motilidade espermática total e progressiva, o dígito III do índice de Copenhagen deve ser inferior a 1,5 (lado direito). CONCLUSÃO: Valores prognósticos da melhora da capacidade reprodutiva obtidos por meio de biópsia testicular podem auxiliar com eficácia no prognóstico e na avaliação dos pacientes candidatos à correção microcirúrgica da varicocele / BACKGROUND: Infertility affects approximately 15% of couples in reproductive age and profoundly changes the lives of these people. Among the identifiable causes of male infertility, varicocele is the most common and affects about 40% of infertile or subfertile men. One of the challenges in the surgical approach is the identification of individuals who will present benefits with the treatment, since many patients do not show improvement of semen analysis. OBJECTIVE: To identify a testicular histological pattern as prognostic value of improved reproductive capacity in patients submitted to microsurgical correction of varicocele. METHODS: we retrospectively analyzed bilateral testicular biopsies of 60 men attending specialized clinic of male fertility between the years 2006 and 2014. As inclusion criteria were considered men diagnosed with clinical and subclinical varicoceles between 19 and 50 years old with results of testicular histopathology and seminal analysis. The patients were divided into two groups. Group 1: Men diagnosed with subclinical varicocele (n = 20). Group 2: men diagnosed with clinical varicocele (n = 40). Men diagnosed with cryptorchidism, obstructive and non-obstructive azoospermia, users of drugs and anabolic steroids were excluded of the study. All Participants were submitted to urological physical examination with the evaluation of testicular volume by ultrasonography of the scrotum with Color Doppler. The diagnosis of varicocele was performed by careful palpation of pampiniform plexus with the patient in standing position. The Valsalva maneuver was used to classify the grade of varicocele. The determination of a testicular histological pattern as prognostic value of the improved reproductive capacity was performed by the creation of cut-off values that associate Johnsen scores, Copenhagen indices and testicular volume to improvement in semen parameters. RESULTS: In Group 1, for improvement of sperm concentration, the Johnsen score must be greater than 8.2 (in the left testicle) and testicular volume must be greater than 12.8 mL (in the right testicle). Concerning evaluation of sperm total motility, the Johnsen score must be greater than 8.2 (bilateral) and digit II of Copenhagen indices must be less than 2.5 (bilateral). However, for sperm progressive motility, the Johnsen score must exceed 9.1 (bilateral) and evaluation of sperm morphology must be greater than 7.9 with right testicular volume greater than 13.6 mL. In Group 2, the cut-offs values for sperm concentration indicates that Johnsen scores must be greater than 5.5 with testicular volume greater than 11.5 mL in both testicles. Finally, regarding the sperm total and progressive motility, the digit III of Copenhagen indice must be less than 1.5 (in the right testicle). CONCLUSION: Prognostic values of improved reproductive capacity obtained from testicular biopsy can assist effectively in the prognosis and evaluation of patients candidates for microsurgical correction

INTRODUÇÃO: O acesso cirúrgico ao corno temporal do ventrículo lateral (CTVL) é realizado para tratamento de lesões temporais mediais, dentre as quais se destaca a esclerose hipocampal que leva à epilepsia, e pode ser realizado através das superfícies lateral ou inferior do lobo temporal ou pelo sulco lateral do cérebro (fissura silviana). O parênquima cerebral subcortical localizado entre o sulco limitante inferior da ínsula (SLI) e o CTVL é composto por importantes feixes de fibras brancas, os quais podem eventualmente ser lesionados nos acessos cirúrgicos trans-silvianos. OBJETIVO: Descrever a localização dos principais feixes de fibras brancas na região entre o SLI e o CTVL. MÉTODOS: Os principais feixes de fibras brancas subcorticais foram examinados em 14 hemisférios cerebrais cadavéricos adultos utilizando a técnica de dissecção de Klingler, sendo possível descrever suas posições em relação à extremidade anterior do SLI (nomeado de Ponto Temporal do Límen - PTL). RESULTADOS: Os principais feixes de fibras identificados profundamente ao SLI formam um arranjo multilaminar e podem ser divididos de acordo com a profundidade em que são encontrados. As fibras de associação curta da cápsula extrema, que continuam em direção aos opérculos, formam a camada subcortical mais superficial e foram encontradas sob todo o SLI. As fibras da cápsula externa são encontradas mais profundamente, em uma camada formada por três principais feixes em uma disposição anteroposterior sequencial: o fascículo uncinado (encontrado desde o PTL até 10,0 ± 2.2 mm posteriormente), o fascículo fronto-occipital inferior (encontrado entre 10,0 ± 2,2 mm e 35,5 ± 2,7 mm posterior ao PTL) e fibras claustro-corticais (encontradas desde 35,5 ± 2,7 mm posterior ao PTL até o final desse sulco). A extensão lateral da comissura anterior está logo abaixo dessa camada e suas fibras foram encontradas entre 8,4 ± 1,8 mm e 22,0 ± 6,8 mm posterior ao PTL. A camada mais profunda é formada pelas fibras da cápsula interna/corona radiata, onde se destacam as radiações ópticas cujas fibras foram encontradas entre 10,6 ± 3,4 mm e 34,5 ± 3,5 mm posterior ao PTL. CONCLUSÕES: O fascículo uncinado é aproximadamente encontrado sob o terço anterior do segmento anterior do SLI (entre o PTL e o corpo geniculado lateral), enquanto o fascículo fronto-occipital inferior e as fibras da radiação óptica são encontrados sob os dois terços posteriores deste segmento. Os resultados sugerem que na abordagem trans-silviana transinsular, uma incisão através do SLI, começando no PTL e se estendendo até 6 mm posteriormente, irá atravessar o fascículo uncinado, mas não o fascículo fronto-occipital inferior e as radiações ópticas / INTRODUCTION: The surgical approach to the temporal horn of the lateral ventricle (CTVL) is performed for treatment of medial temporal lesions, among which hippocampal sclerosis leading to epilepsy is emphasized, and can be performed through the lateral or inferior surfaces of the temporal lobe or through the sylvian fissure. The subcortical cerebral parenchyma located between the inferior limiting sulcus of the insula (SLI) and the CTVL is composed of important white matter fiber bundles, which may eventually be injured in transsylvian surgical approaches. OBJECTIVES: To describe the location of the main white matter fiber bundles in the region between SLI and CTVL. METHODS: The main subcortical white matter fiber bundles were examined in 14 adult cadaveric cerebral hemispheres using the Klingler dissection technique, and it was possible to describe their positions in relation to the anterior end of the SLI (named Temporal Limen Point - PTL). RESULTS: The main white matter fiber bundles identified deeply to the SLI form a multi-laminar arrangement that can be understood according to the depth in which they are found. The short association fibers of the extreme capsule, which continue toward the opercula, form the most superficial subcortical layer and were found underneath all the SLI. The external capsule fibers were found more deeply, in a layer formed by three main fiber bundles organized in a sequential anterior-posterior disposition: the uncinate fascicle (found from the PTL to 10.0 ± 2.2 mm posteriorly), the inferior fronto-occipital fascicle (found between 10.0 ± 2.2 mm and 35.5 ± 2.7 mm posterior to the PTL) and claustrocortical fibers (found from 35.5 ± 2.7 mm posterior to PTL to the end of this sulcus). The lateral extension of the anterior commissure was below this layer and its fibers were found between 8.4 ± 1.8 mm and 22.0 ± 6.8 mm posterior to the PTL. The deepest layer is formed by the fibers of the internal capsule/corona radiata, where the optical radiation fibers were distinguished and found between 10.6 ± 3.4 mm and 34.5 ± 3.5 mm posterior to the PTL. CONCLUSIONS: The uncinate fascicle is approximately found under the anterior third of the anterior SLI segment (between the PTL and the lateral geniculate body), while the inferior fronto-occipital fascicle and fibers of the optical radiation are found under the posterior two thirds of this segment. The results suggest that at the transsylvian-transinsular approach, an incision at the SLI, from the PTL to 6 mm posteriorly, will cross the uncinate fascicle, but not the inferior fronto-occipital fascicle and optical radiation fibers

Introdução: A neurocirurgia minimamente invasiva já é uma realidade em muitos centros em todo o mundo. A aplicação de conceitos antigos com a incorporação de novas tecnologias permite o emprego de medidas menos invasivas, mas com a mesma eficácia e segurança. O real papel destas técnicas e o seu efeito sobre a evolução dos doentes ainda é nebuloso. Objetivos: avaliar a segurança e resultados da técnica minimamente invasiva na clipagem de aneurismas cerebrais de circulação anterior e determinar o momento seguro para alta hospitalar. Materiais: Cento e onze doentes adultos com diagnóstico de aneurismas não rotos de circulação anterior foram randomicamente distribuídos e submetidos a cirurgia por um acesso minimamente invasivo (grupo de estudo - 36 pelo acesso transpalpebral e 34 através de craniotomias minipterional reduzida) ou acesso pterional clássico (grupo controle - 41 doentes). O endoscópio acoplado a um telefone celular foi utilizado juntamente com o microscópio durante as cirurgias do grupo de estudo. Os doentes do grupo de estudo foram submetidos a um protocolo específico para avaliação da segurança da alta hospitalar precoce. Foram avaliados desfechos cirúrgicos, clínicos/funcionais, estéticos e sobre qualidade de vida. Resultados: Em ambos os grupos, os dados demográficos e as características dos aneurismas foram similares. O tempo médio das cirurgias foi menor no grupo de estudo (214 min. vs 292 min, p = 0,0008). A necessidade de transfusão sanguínea foi menor no grupo de estudo (1 doente vs 7 doentes, p = 0,018). O número de eventos isquêmicos foi menor no grupo de estudo (4 doentes vs 8 doentes, p = 0,07), mas os eventos com repercussão clínica foram semelhantes (2 doentes vs 3 doentes, p = 0,53). A presença de colo residual na angiografia controle foi menor no grupo de estudo (6 doentes vs 11, p = 0,021), mas foram todos colos pequenos, 1,75 ± 0,68 mm, sendo que apenas um doente do grupo controle foi reoperado. A paralisia do ramo frontal do nervo facial foi menor no grupo de estudo, tanto a temporária (3 vs 14, p = 0,008) quanto a definitiva (0 vs 4, p = 0,032). A atrofia do músculo temporal foi menos frequente e mais leve no grupo de estudo (9 vs 14, p = 0,012). No grupo de estudo, 91,4% dos doentes receberam alta precoce no dia seguinte da cirurgia e nenhum doente apresentou evento adverso por este motivo. Os doentes do grupo de estudo ficaram assintomáticos mais rapidamente no pós-operatório (pela avaliação da escala de Rankin, p = 0,0026), mas não houve diferença entre os grupos dentre as pontuações acima de 1 na escala de Rankin modificada. Um doente do grupo controle faleceu no pós-operatório (0,9%). Conclusões: Os resultados demonstraram que as alternativas minimamente invasivas propostas são seguras e tem resultados clínicos e cirúrgicos iguais ou superiores ao tratamento clássico em vários quesitos. A alta precoce nestes doentes é possível e segura. O acesso nanopterional ou transpalpebral é uma alternativa melhor em relação à craniotomia pterional clássica para tratar aneurismas não rotos da circulação anterior / Introduction: Minimally invasive neurosurgery is already a reality in many centers across the world. The application of old concepts with the incorporation of new technologies allows the use of less invasive measures with the same effectiveness and safety. However, the real role of these techniques and their effect on the outcome of patients is still obscure. Objectives: To evaluate the safety and results of minimally invasive techniques in brain aneurysm clipping and determine the possibility of early hospital discharge. Methods: 111 adult patients with unruptured anterior circulation aneurysms were randomized and underwent a minimally invasive surgical approach, (36 by transpalpebral approach and 34 through a reduced minipterional craniotomy) or classical pterional approach (41 patients). The endoscope coupled to a smart phone was used along with the microscope during surgery (study group only). Patients in the study group were subjected to a specific protocol for assessment of early hospital discharge. Surgical, clinical/functional and aesthetic outcomes were evaluated along with long term quality of life. Results: In both groups, the demographics and characteristics of aneurysms were similar. The average time of surgery was lower in the study group (214 min. vs. 292 min, p = 0.0008). The need for blood transfusion was lower in the study group (1 patient vs 7 patients, p = 0.018). The number of ischemic events was lower in the study group (patients 4 patients vs. 8, p = 0.07), but events with clinical significance were similar (3 patients vs. 2 patients, p = 0.53). The presence of residual neck on control angiography was lower in the study group (6 patients vs 11, p = 0.021), but only small ones were found, 1.75 ± 0.68 mm, and only one control group patient required reoperation for this reason. The paralysis of the frontal branch of the facial nerve was lower in the study group, both temporary (3 vs 14, p = 0.008) and definitive (0 vs. 4, p = 0.032). The atrophy of the temporal muscle was less frequent and less severe in the study group (9 vs 14, p = 0.012). Most patients in the study group (91.4%), were discharged on the next day of the surgery and no patients had any related adverse events. Patients in the study group got asymptomatic faster (assessed by the Rankin scale, p = 0.26), but there was no difference between the groups among scores above 1 on the modified Rankin scale. One control group patient died postoperatively (0,9%). Conclusions: The results showed that the proposed minimally invasive alternatives are safe. Clinical and surgical results are equal or superior to conventional treatment in several topics. Early discharge in these patients is possible and safe. The described approaches (nanopterional or transpalpebral) are better alternatives to the classical pterional craniotomy to treat unruptured aneurysms of the anterior circulation

INTRODUÇÃO: A microanastomose vascular é um componente importante na cirurgia de transferência livre de tecidos. Atualmente, a técnica de sutura convencional ainda é considerada o padrão ouro, no entanto, ela apresenta alguns inconvenientes por ser tecnicamente difícil, consumir muito tempo e ter uma longa curva de aprendizado. Na busca de uma técnica mais fácil e rápida, métodos alternativos de anastomose são estudados incluindo a cola de fibrina. Apesar dos bons resultados publicados, a sua aceitação na prática clínica ainda é limitada. Controvérsias a cerca de sua trombogenicidade e resistência mecânica geram dúvidas em relação a sua segurança. A ausência de um modelo experimental mais fidedigno impede que os potenciais benefícios de sua aplicação clínica sejam apreciados. O objetivo deste estudo é esclarecer essas controvérsias e estudar os benefícios da aplicação da cola de fibrina em um ambiente que simule a prática clínica. MÉTODOS: O modelo experimental utilizado foi a transferência livre de um retalho inguinal para a região cervical anterior. A circulação do retalho era restaurada através de microanastomoses vasculares entre as artérias femoral e carótida (término-lateral) e entre as veias femoral e jugular externa (término-terminal). Utilizamos 20 coelhos que foram divididos em dois grupos (n= 10) de acordo com a técnica de sutura empregada: Grupo I (sutura convencional) e Grupo II (sutura com cola). RESULTADOS: A aplicação da cola de fibrina reduziu significativamente o número de pontos necessários para se completar as anastomoses, 4 pontos a menos nas artérias e 4,5 pontos a menos nas veias. No Grupo I, a média do tempo de anastomose arterial foi de 17,21 minutos, contra 12,72 minutos no Grupo II. Nas anastomoses venosas, a média de tempo no Grupo I foi de 22,93 minutos, contra 16,57 minutos no Grupo II. A aplicação da cola de fibrina também diminuiu o tempo de isquemia do retalho e o tempo de cirurgia em 11,5 minutos e 15,67 minutos, respectivamente. A taxa de sobrevida do retalho foi de 90% nos dois grupos. CONCLUSÕES: A aplicação da cola de fibrina em microanastomoses vasculares demonstrou ser confiável e eficiente no presente estudo. / INTRODUCTION: Microvascular anastomosis is an important component of the free flap surgical procedure. Currently, the conventional suture is still considered the gold standard technique. However, it presents some problems for being technically demanding, time consuming and with a long learning curve. In looking for an easier and faster technique, alternative methods of anastomosis were studied including the fibrin glue. Despite the good results reported in the literature, its acceptance in the clinical setting is still small Controversies regarding its thrombogenicity and mechanical resistance create some concerns about its safeness. The absence of a more realistic experimental model has not allow a full aprecciation of its potencial benefits in clinical use. The aim of this study is clarify these controversies and demonstrate the advantages of fibrin glue application in an environment that can reproduce the clinical practice. METHODS: A free inguinal flap transfer to the anterior cervical region was used as experimental model. The circulation of the flap was restored by means of microvascular anastomosis between the femoral and carotid arteries (end-to-side) and between the femoral and jugular veins (end-to end). The procedures were performed in 20 rabbits that were divided into two groups (n= 10) according to the anastomosis technique: Group I (conventional) and Group II (fibrin glue). RESULTS: The application of fibrin glue significantly reduced the amount of sutures required to complete the anastomoses: 4 less sutures in the arteries and 4,5 less sutures in the veins. In Group I, the mean arterial anastomosis time was 17,21 minutes against 12,72 minutes in Group II. In the veins, the mean anastomosis time in Group I was 22,93 minutes against 16,57 minutes in Group II. The application of fibrin glue also reduced the flap ischemic time and the total operative time by 11,5 minutes and 15,67 minutes, respectively. The flaps\' survival rate was 90% in both groups. CONCLUSIONS: The application of fibrin glue in microvascular anastomoses was reliable and effective in this study.

INTRODUÇÃO: A formação do hematoma intraneural com comprometimento dos nervos periféricos pode ocorrer após traumas ou em associação com distúrbios de coagulação. A opção por conduta conservadora (expectante) ou descompressão cirúrgica ainda é controversa. Essas duas condutas foram analisadas comparativamente por meio de modelo experimental em ratos submetidos a hematoma intraneural associado à compressão extrínseca. MATERIAL E MÉTODOS: Cinqüenta ratos Wistar foram divididos em 5 grupos. Em 4 grupos (A, B, C e D) o nervo ciático direito foi envolvido por tubo de silicone de diâmetro interno maior que o do nervo, simulando o trajeto do nervo periférico através de regiões inextensíveis (exemplo: túnel do carpo). No grupo B, foi realizada injeção intraneural no segmento envolvido pelo tubo de 0,2 ml de sangue autógeno. No grupo C, após produção do hematoma, foi feita a imediata remoção do tubo de silicone simulando-se a descompressão túnel do carpo, e epineurotomia longitudinal complementar. No grupo D, após produção do hematoma, foi realizada apenas a remoção do tubo de silicone. No grupo E (CONTROLE) o nervo foi apenas exposto sem a presença de hematoma ou compressão extrínseca. A avaliação funcional foi feita periodicamente durante 61 dias através do Índice de Função Ciática (IFC) de Bain-Mackinnon-Hunter, e a análise histomorfométrica realizada ao término deste período. RESULTADOS: O grupo A (compressão extrínseca) apresentou IFC inicial de -26,29±2,89 com retorno aos valores pré-operatórios no 5º dia de pós-operatório. O grupo B (hematoma e compressão extrínseca) foi aquele com pior função ciática inicial (IFC -85,23±3,51) com recuperação da função no 23º dia. O grupo C apresentou IFC inicial de -32,78±7,45 com normalização no 5º dia. O grupo D apresentou IFC inicial de -45,13±6,84 com normalização da função ciática no 5º pós-operatório. A análise estatística do IFC identificou diferença significativa (p<0,0001) entre a conduta expectante (grupo B) e o tratamento cirúrgico descompressivo (grupos C e D) até o 19° dia. O número e a densidade de fibras mielínicas em degeneração foi significativamente maior no grupo B quando comparado aos outros grupos. CONCLUSÃO: Neste estudo experimental, descompressão cirúrgica e epineurotomia reduziram a perda de fibras mielínicas e determinaram recuperação funcional mais rápida. / INTRODUCTION: Intraneural hematoma can result in the median nerve in the carpal tunnel after trauma or coagulation disorders. The decision for expectant management or descompressive surgical techniques is still controversial. MATERIAL AND METHODS: Fifty male Wistar rats were divided into 5 groups. The sciatic nerve was wrapped around with a silastic device in 4 groups. Group A the sciatic nerve was just wrapped by the silastic tube. In group B an intraneural injection of autologous blood was added. In group C, after the hematoma creation the silastic device was removed and a longitudinal epineurotomy was performed. In group D, we removed the silastic device after the hematoma but the nerve was not opened. In the group E (sham-operated) sciatic nerve was exposed without hematoma or compression. Nerve function recovery was assessed periodically over 61 days using the Bain-Mackinnon-Hunter Sciatic Function Index (SFI). RESULTS: Group A (extrinsic compression) presented initial SFI of -26.29±2.89, with return to baseline values on the 5th postoperative day. Group B (hematoma and extrinsic compression) exhibited the poorest function (SFI - 85.23±3,51) after surgery and recovery in 23 days. Group C (liberation of silastic and hematoma drainage through epineurotomy) and Group D (only removal of the silastic tube) presented similar initial SFI values of - 32.78±7.45 and - 45.13±6.84, respectively. In both groups SFI values returned to baseline level on 5th postoperative day. The statistical analysis of SFI identified a significant difference (p<0.0001) between the expectant management (group B) and the descompressive surgery approach (groups C & D) by 1st to 19th postoperative day. The number of degenerative fibers and density of degenerative fibers were statistically significant bigger in the group B when compared to the other groups. There was no statistical difference between the other groups when these parameters were analysed. CONCLUSION: Thus, immediate descompressive procedures of the intraneural hematoma provide a faster functional recovery and reduce the damage to the axon fibers.

Vinte e seis pacientes com paralisia facial unilateral de longa duração foram submetidos à reanimação facial em único estágio com transplante do músculo grácil inervado pelo ramo massetérico do nervo trigêmeo. Foram divididos em 2 grupos não-randomizados de acordo com a técnica de fixação: Grupo I (19 pacientes), fixação do músculo com uso do tendão palmar longo inserido no músculo orbicular nos lábios superior e inferior do lado não paralisado (além da linha média); Grupo II (7 pacientes), fixação do retalho apenas com pontos separados no músculo orbicular dos lábios superior e inferior no lado paralisado. A avaliação qualitativa demonstrou melhores resultados no Grupo I (94,1% vs 66,6%). Na comparação do posicionamento do arco de cúpido em repouso, no pré e pós-operatório, observamos melhora estatisticamente significante (p<0,05) em ambos os grupos. Durante o sorriso, entretanto, houve melhora significativamente maior na centralização do arco de cúpido nos pacientes submetidos à fixação com tendão palmar longo (Grupo I) / Twenty-six patients with unilateral long-stading facial palsy underwent 1-stage reanimation with free gracilis muscle transplant innervated by the masseteric branch of the trigeminal nerve. They were divided into 2 nonrandomized groups according to insertion technique: group I (19 patients), palmaris longus tendon graft placed between the gracilis free flap and the orbicularis oris of the upper and lower lip on the nonparalyzed side; group II (7 patients), interrupted suture between the free flap and the orbicularis oris of the upper and lower lip on the paralyzed side. Qualitative evaluation of the smile demonstrated better results in patients from group I (94,1% vs 66,6%). Comparing the position of the Cupid`s bow at rest, pre- and postoperatively in each patient, we observed significant improvement of facial symmetry in both groups. During smile, however, there was significantly higher rate of centralization of the Cupid`s bow in patients submitted to reanimation with the use of the palmaris longus tendon (group I)

Minimally invasive surgery (MIS) consists in operating through small incisions in which a camera and adapted instruments are inserted. It allows to perform many interventions with reduced trauma for the patient. One of these is the ablation of peripheral pulmonary nodules.<p><p>Nevertheless, the means for detecting nodules during MIS are limited. In fact, because of the lack of direct contact, the surgeon cannot palpate the lung to find invisible lesions, as he would do in classical open surgery. As a result, only clearly visible nodules can be treated by MIS presently.<p><p>This work aims at designing, building and controlling a teleoperated palpation instrument, in order to extend the possibilities of MIS in the thoracic field. Such an instrument is made of a master device, manipulated by an operator, and a slave device which is in contact with the patient and reproduces the task imposed by the master. Adequate control laws between these two parts allow to restore the operator's haptic sensation. The goal is not to build a marketable prototype, but to establish a proof of concept.<p><p>The palpation device has been designed in collaboration with thoracic surgeons on the basis of the study of the medical gesture. The specifications have been deduced through experiments with experiencied surgeons from the Erasmus Hospital and the Charleroi Civil Hospital.<p><p>A pantograph has been built to be used as the master of the palpation tool. The slave is made of a 2 degrees of freedom (dof) clamp, which can be actuated in compression and shear. The compression corresponds to vertical moves of the pantograph, and the shear to horizontal ones. Force sensors have been designed within this project to measure the efforts along these directions, both at the master and the slave side, in order to implement advanced force-feedback control laws and for validation purposes.<p><p>Teleoperation control laws providing a suitable kinesthetic force feedback for lung palpation have been designed and validated through simulations. These simulations have been realized using a realistic model of lung, validated by experienced surgeons. Among the implemented control schemes, the 3-Channel scheme, including a local force control loop at the master side, is the most efficient for lung palpation. Moreover, the increased efficiency of a 2 dof device with respect to a 1 dof tool has been confirmed. Indeed, a characteristic force profile due to the motion in 2 directions appeared in the compression force tracking, making the lesion easier to locate. / Doctorat en Sciences de l'ingénieur / info:eu-repo/semantics/nonPublished

Background: The use of intraoperative neurophysiological monitoring, including direct nerve stimulation (especially the facial nerve), acoustic evoked potentials (AEP) and somatosensory evoked potentials (SSEP), is a helpful tool in the microsurgery of vestibular schwannoma to prevent nerve injury. Patient characteristics and intraoperative and postoperative variables might also influence the postoperative facial nerve function. The study was performed to investigate these variables and the intraoperative neurophysiological monitoring values. Methods: Seventy-nine patients with vestibular schwannoma were included consecutively into this study. Intraoperative neurophysiological monitoring, including SSEP, AEP, and direct nerve stimulation for facial and trigeminal nerve electromyography, was performed utilizing digital data storage in all cases. The intensity (in volts) of the direct stimulation and the latency (in ms) for the orbicularis oculi and the orbicularis oris muscle and the amplitude (in mV) was measured. Univariate and multivariate statistical analyses concerning the different parameters was performed directly after the operation and in the subsequent follow-ups 3 and 6 months after the operation. Results: The mean intensity was 0.79 V (SD.29). The latency and amplitude for the oris muscle was 5.2ms (SD 2.07) and 0.68mV (SD.57), respectively. The mean latency for the occuli muscle was 5.58ms (SD 2.2) and the amplitude was 0.58mV (SD 1.04). The univariate and multivariate statistical analyses showed significance concerning the postoperative facial nerve function and the amplitude of the direct stimulation of the facial nerve in the orbicularis oris muscle (p = 0.03), so repeated direct nerve stimulation might show FN function deterioration. The mean diameter of the tumors was 24mm (range 10–57mm). Cross total resection and near total was achieved in 76 patients (96%) and subtotal in three patients (4%). The preoperative House–Brakeman score (HBS) 1 was constant in 65 (82%) cases. The mortality in our series was 0%; the overall morbidity was 10%. The HBS was not influenced concerning the extent of resection. The mean follow-up was 28 months (range 6 to 60 months). The limitations of the study might be a low number of patients and the retrospective character of the study. Conclusion: Intraoperative neurophysiological monitoring is crucial in vestibular schwannoma surgery. Repeated direct nerve stimulation and a detected decreased amplitude might show facial nerve function deterioration.

Aims Use of 3D printed models in Endodontics has been gaining popularity since the technology to create them became more affordable. Currently, there are no studies that evaluate the influence of 3D models on endodontic surgical treatment planning and on operator confidence. Therefore, aims of this study were to: (i) Determine whether the availability of a 3D printed analogue can influence treatment-planning and operator confidence; and, (ii) Assess which factors of operator confidence are influenced, if any. Materials and Methods Endodontists were asked to analyze a pre-selected CBCT scan of an endodontic surgical case and to answer a questionnaire that determined their surgical approach for that case. After 30 days, the same participants were asked to analyze again the same CBCT scan. This time however, a 3D printed model of the scan was made available to the participants and to perform a mock osteotomy on the model. The participants were then asked to respond to the same questionnaire that they responded to 30 days prior to determine if there would be any changes to their treatment plan. A new set of questions were added to the survey to evaluate the influence of the 3D printed model on participants’ confidence in performing endodontic surgery. The responses were statistically analyzed using Chi square test followed by either logistic or ordered regression analysis while adjusting for experience of participant. Adjustment for multiple comparison analysis was done using Bonferroni correction. Statistical significance was set at £0.005. Results Availability of the 3D printed model and the CBCT scan together resulted in statistically significant differences in the participants’ responses to their ability to clearly detect bone landmarks, accurately predict the location of osteotomy, and in determining the following: size of osteotomy, angle of instrumentation, involvement of critical structures in flap reflection and involvement of vital structures during curettage. In addition, the participants’ confidence in performing surgery was significantly higher versus having CBCT scans alone. There were no statistically significant changes with decisions on flap design and extent, visualizing critical structures, lesion size, injury to vital structures during osteotomy, the length of root that could be resected and the number of roots involved. Conclusions The availability of 3D printed models did not alter the participants’ surgical approach, but it significantly improved their confidence for endodontic microsurgery, which can be attributed to better visualization of anatomical structures.

Background Extensive loss of soft tissue and bone due to neoplasia, trauma, or infection in extremities often leads to amputation. Case presentation We present the case of a 72-year-old female patient presenting with an extended cutaneous squamous cell carcinoma of the lower leg, developed on top of necrobiosis lipoidica. After achieving the R0 resection, a 26 × 20-cm soft tissue and 15-cm tibial bone defect resulted. The contralateral leg had been lost due to the same disease 18 years before. We achieved a successful reconstruction of the leg using a pedicled fibula transplantation, an extended anterolateral thigh perforator flap, and an internal fixation with plate and screws. Two years after the original surgery, the patient is relapse-free and mobile, with adequate function of the reconstructed foot. Conclusions Our case presented a unique combination of pedicled fibula transplantation and free extended ALT perforator flap to reconstruct an extensive defect after resection of a rare cSCC on top of NL. In selected cases, the boundaries of limb salvage can be pushed far beyond the current standards of treatment.