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Bloodless Precise Microsurgical Approach and Vascular Reconstructions

Rokuya Tanikawa

October 14, 2020

Transcript

- Hello, ladies and gentlemen, and thank you for joining us for another session of the virtual operating room from "The Neurosurgical Atlas". Our guest tonight is Dr. Rokuya Tanikawa from Sapporo University in Japan. Rokuya, in my personal opinion, is the best bypass surgeon I've ever watched operate and he's truly a gifted neurosurgeon who brings to us the bloodless methodical patient microsurgery that our dear Japanese colleagues are known for. So I'm so honored Rokuya, to have you with us tonight, and I'm very, very interested in learning from your incredible technical skills, so please go ahead.

- Thank you. Okay, thank you very much Aaron. It's a great honor for me to talk about my experience here. Thank you again for your invitation, Aaron. Now, I would like to talk about the Bloodless Precise Microsurgical Approach and Vascular Reconstructions for Intracranial Aneurysms. I always think about, what is accuracy in surgery? It's a confirmation of the anatomy, this is very important. To confirm the anatomy, we need to expose the object in the operative field. To do this, we need a clean and bloodless operative field. We need hemostasis for that. The essentials in neurosurgery are hemostasis, dissection, for example, transylvian dissection, or interhemispheric approach. These separation in, and the major fissure like a sylvian or interhemispheric fissure. It's a common approach in neurosurgery. These are the basic technique to achieve surgery. And dural closure, especially a water-tight dural closure is necessary to avoid any complications after surgery, like sub tunnels or epidural CSF leakage or collection. These may cause some infection. It may change the patient's prognosis very heavily. And as well, the microvascular anastomosis is very important skill to achieve the good result in surgery. I'll show you actual video of the hemostasis during craniotomy. This is arise at the dura craniotomy. After elevating temporal muscle, you can perform the front temporal craniotomy and complete hemostasis in epidural space is the dura walls. If you touch it from in a plate of a skull, the inner is oozing, there is coming from the bones and subbone surface, innerplace surface. So it must be controlled with the way the Surgicel. After complete hemostasis of dura, you can now open dura. Until the culprit, the hemostatic is completed we need a complete hemostasis repeatedly. And this is example of the middle of dissection. Everybody knows if you elevate the middle of dura from the skull base, the many venous oozing is coming, especially from a cabin or sinus. So these bleeding must be controlled completely. This is a very important process. Otherwise we can't confirm here even the important anatomical structures in the middle of Pasa, right from an ovary, rotundum until media lateral triangle or, or read three GSPN, acute eminence triangle. Everything can not be seen in operative field, in bloody operative field. As well, dural closure water-tight closure is very important. This is a example of the drug closure under microscope. I post my young colleagues to teach the dura under microscope meticulously like this. Even after very long operation, this is a very important process to avoid the UCS of leakage. In every institute, the closing head from dura crochet is a world for young, the neurosurgeon or residents. Now this process, in spite of what this process is very important. Some young neurosurgeon cannot close dura water type three, and it goes into something CSF correction epideral sub tunnel space. This is a big program. My teacher, my mentor Professor Kamiyama more than 30 years ago, he taught us that the neurosurgeon who cannot close dura properly water-tightly, cannot perform via micro anastomosis. It's a, it's true. It's a very important thing. And they said, principle dimension, to stitch the dura water type three. If the T here, if the T was thickness of the dura here the stitching a bite should be twice of the thickness of the dura. And if you have a side, the needle must be penetrate same line as here twice over the wall thickness and a stitching interval should be four times wall thickness, two times of the stitching bite. Now, this is the principle to stitch the dura. This is a so-called square node in dura closure. microanastomosis as well, this is a very important, I always show this slide in my lecture. First, the most important thing is fish mouth trimming like this. The inner surface of a Besser wall internal layer must be faced each other like this. Then you can penetrate both or both basal like this. If the visual wall was not able to, it was inverted like this inverted, you can't have the patency of the anastomosis. So this is a very important. Everything, everything is very important. As well the fish mouth striming of the donor vessel is very important in that end two side anaplasmosis. If you perform the SPMC bypass, I recommend you to perform the fish mouth trimming like this that are the end of the donor vessel. You can perform the oblique cutting with a 60 degree, like this 60 degree. And then you can cutting up here. Same length cutting up with the oblique cutting. Then you can make the fish mouth at the end of donor. And this lens, should it be two times of the diameter shrunk diameter of the donor divide by root three. So the total teaching length is a four times shrunk diameter divided root three. This means that at approximately 2.3 times over trunk of the diameter of the vessel. This basic dimension to perform the end to end two side microanasmosis. As well as when we perform via end to end anasmosis, the fish mouth trimming at both end of the vessel makes easier to perform the end to end anasmosis because the each side each end of the vessel can be upside down like this. Then you can imagine, that with the fish mouth trimming in each side, this makes end to end anasmosis like end to side anasmosis. It makes easier to do a stitching microstitching. So I always recommend you to perform the fish mouth training. Not only end to side anasmosis but also end to end anastomosis. So this is a picture of all the stitching bite and stitching interval with a working condition. This is the same principle with a dural stitching. If the wall thickness of the viceral was here, the stitching bite should it be twice of the wall thickness and stitching interval should be four times of wall thickness. Then it can be called the square stitching. With the square stitching with this principle, we have a no leakage of the blood from the interval of stitch. This is appropriate stitching of the vessel. And of course the everything of a both vessel is a very important like this. This is the drawing, a beautiful drawing, my colleague Cosmo Nada he draw a worthy anastomosis especially here. This is a very important condition to perform the microanastomosis. Everything of both vessel, donor and recipient vessel should it be evergreen. And with everything condition it's easy to penetrate the both layer with microneedle. That it makes easier to stitch the vessel. This is very important. As well, this is a drawing by my mentor, professor Tamiama around the 30 years ago, about the side to side anastomosis, especially 8, 3 8, 3 side-to-side anastomosis. The arterio tomy should be like this. Curved incision, symmetrically in left and right side like this. And the lengths out the archaic to me should they be three times of the vessel diameter. Should it be three times. And a bottom side basal wall stitching should it be running stitcher like this here, like this running stitcher. And the upside outside wall can be stated interrupted like this. And here you can already rewrite that wall size stitching is not everything. This is inverted. The bottom side wall is inverted. So here, the cutting edge of the basal wall and crushing the fibre of a cutting edge is exposed into a vessel rumen after thema running suture over the bottom side in side-to-side anastomosis. It may cause acute thrombosis after the flow of the vessel. So this is the reason why I always perform the big make via a big orifice by the long Arturo to me, as I told you three times length of the diameter of the vessel, and make the orifice bigger in a side to side anastomosis. And it can avoid arcute thrombosis here. The side-to-side anastomosis is the one of a dangerous anastomosis because if we failed it, we do both methods. We do the both basal. This means that we may have the bilateral cerebral impulsion This is a big complication, so to avoid it, long and exact stitching is necessary. I show you a representative cases of transsylvian approach. This is a 57-year old man, unruptured pecan aneurysm, asymptomatic patient. This is a right side front temporal craniotomy, and right side transcribing approach. With the highest manipulation of a microscope, we can confirm the between the superficial slyvian veins and in between the frontal and the temporal and anchoring no trouble CRA between arteries and temporal inner surface like this. Then I can put a retractor on the anchas. And in this situation, you can confirm the entire crotchet and a small vessels, small brunches There are three is attaching to the anchas. Now, with the highest monk station, these arachna can be shell pre cut by a micro scissors. Now that we can explore the ocular motor nerve. Now I am incising the between to avoid attention to nerve by a temporary direction. Now, with the lateral view to the aneurysm, we can confirm with the peak of origin, especially very proximal of the Pcom. This is a very important view to see the anatomy regarding the aneurysm. This is very important. Next, I show you a retrograde suction decompression through the superior thyroid artery. This is a 50-year old female, and it captured in symptomatic left side, giant aneurysm, the ophthamic segment aneurysm. In this case left sides cervico carotid is exported and Cipro thyroid the Fisher is cannulated by a five french tube like this. Then, it is a fixed away the suture. And now I am trying to do STA M3 bypass on a temporary surface for the purpose of the assisting bypass during the temporal inclusion of internal. It is predicted that temporal crucial time of the ICA during a section decompression maybe per prlonged. So this is a reason why I did this. Now temporal crip is at a decent crowded proximity to pcom and common carotid and external is occluded and suction decompression through the super tight works well. And now the aneurysm could be shrunk very easily and you can decompress the optic nerve here. And I did say saying, you're expanding this ordering here is an inferior interlateral part of this lateral ring expanded by the anglenow. The camera sign us pressure open and a superior component of this other ring can be insights. Then simultaneously the optic could be open. Now the aneurysm dystonic and the proximal neck could be confirmed like this. Then you can put the grip. This patient is a Russian patient and assumptive with terrible. I operate this patient last year in August in South Dakota. Here to us connect gripping. We can confirm whether the aneurysm is really dead or not. I am compounding inside the aneurysm has a partial thrombosis like this. And you can see the breathing gradually, the Arcadia breathing calm, calm inside angLES. So I am compounding because of the very thin wall in a media aneurysm, that part is cause of a leakage. So I put the to grow the very thin part of the media part of it. And you have the rocket pot take part, additionally, occluded by a short grip tactics. And a CTAA shows a good patency of the parent that the internal and the aneurysm is completely separated, excluded, and our patient recovered well. The assumption decompression works very well in such a complex case. Next case is a 36-year old female. I love to pick on Amanda Ontercor though. So-called the kissing aneurysm. This is the left side. You can see the other corridor aneurysm and that peak home aneurysm without the herring so much. Additionally, the venous structures so much of the Heron. So as well in this case, the super thyroid is canulated and carotid is a temporary corroded and the common carotid and external carotid intracranial picalm and we can put, won't be erectile rice action decompression. Now I am separating pecan aneurysm, and the aneurysm. And I am confirming the origin of There are three, not to agree to the, and the DC, the Pico managers about attaching to a, our age. And right there. Hre is a complication that turn on power. And not to make the remnant media part of aneurysm, I put the grip like this. The such and decompression helps so much to perform with the exact next dripping. Whereas I know that Nick Lebanon. This is a bad example of the kissing aneurysm. I am advising to my collegue, not to put the Crips now, it's a too dangerous without complete separation and a temporary grape on the escrow crying or the cart that has already been put, but this doesn't work a Pico the here has a very thick crack. So it's a dangerous to put the temporary grip here, but this kind of pretty much a rupture happened. We have to put the grip on the and the pcom to control the breathing. And I am immediately three scrubbed in and checking the rapture point. Now I am a completely separate TVA kissing in your demand. Unfortunately, the laceration was on the neck of the distal neck of the pico manual. so I am repairing the laceration point with the 1009 on, and then you can put the grid as a complete net gripping I guess. Now it looks, good and dwell the remaining could be gripped, but I should just shows the occlusion a pcom. So I agree with you the, again, the carotid and the even gate inside of a pcom and interna through the laceration of the aneurysm, with the headliner setting. And I'm confining as a breeding ground, the laceration by opening R2 works well. I could confirm the pecancy of a pcom and internal carotid. Now I should just show the patency of a Pecom and carotid. So we cross and check the postal opera CT angle immediately back. Unfortunately, Pecam was occluded. So immediately I transfer the patient to, or again, and I decided to perform the STA Pcom bypass. Because of hard heterscopid change, that Pcam has us thrombosis due to the inappropriate temporary grip, putting on the corrugate and the pcan. So the STAP can bypass worked well. We could minimize the ischemic region of the, maybe a temporal growth and MRA shows a good latency of STAP can bypass and the concrete exclusion of in gruesome. After surgery patient have the slight consciousness disturbance and right Hemi paralysis right side, that patient recover the well with the two weeks. And now the patient has no neuroid objects. But this is a big program. If we have a such a ischemic complication, and especially in unruptured asymptomatic aneurysm, it's a big program. We should improve the way of surgery. To improve a way of surgery for not only a complex especially kissing aneurysm really like this, the retrograde session decompression works very well. It helps so much neurosurgeon as well as the patient. This is our publication on award the neurosurgery about the retinal reception decompression. You can find it. And I would read to empathize, of course retrograde session decompression technique is very good technique to create the annuals easier, but the much more important thing is not to put a temporary grave on hard arthroscope part of the parent type A especially internal carotid. I have a similar experience with the dissection of carotid and occlusion of it after the temporary grip upright. So after that, I decided to open neck and not to put the pepper grip on exchange. This is a very important. Can I show you a outer tempera approach. This is a 75-year old female on lab 2 of the Beijing, a superior cerebellar artery aneurysm. You can see here, the right side protruding at the aneurysm. This is a transzygmatic approach that taking out the dygmatic arch as a T-bone, right size prone temporal craniotomy as well the corporate hemostatic and ocular Tempra approach. The sphenoparietal sinus bridging tempera and dura is a stretchy. And now I am exposing the supercerebra aneurysm like this, that here is the origin of a supercerebra and a small trunk could be occluded as approximate control that the other side Pcam is occluded. And now I am confirming with these small arteries behind the aneurysm. Here, behind the aneurysm, you can confirm some more artery disease, a branching tool they meet the brain. I am putting it a net gripping with preserving the small important brunches. No, you can. The MRI shows nothing. Normally scan a complication aneurysms. This is a drawing by my young collegue. What do we get? What we confirm? The anatomy like this. Another example. This is an 84-year old female raptured BA top large aneurysm. At first, patient come with a haunt on Courtney grade five, comatose with a Venturi care hamburgers. We observe the patient conservatively, but a patient recovered in 12 hours. So we have a big discussion with the patient family and the patient family strongly hope to perform surgery, to undergo surgery. So I decided to perform the surgery. In this case, the several , that was very thin, so I decided to perform the epidural TransCanada's approach. Now I am opening occular framing. This is a tiny Pcom almost occluded which is connecting to a P1 P2 junction and confirming the touching on the arise at angel neck. Now I put the temporary grip on a vigil trunk proximate to a ACA, and this is a throughout PCA. And this is ipsilateral p2 just distal to a pecom junction and a right ACA occluded as well. Here the He had to three other parent on the aneurysm neck, right side. It can be detach it easily with the highest among patient and the green operatively field. Even in hemorrhage, we should confirm that all micro structures, and I am a confirming the important operators arriving posterial or a aneurysm. And all the important part, right there is detach it. To the other side of the operating as well or detach it. And I am trying to put a grip on the aneurysm neck. I am confirming whether the gripe rate is a biting, something important vessel. So here, the arachnoid is stretched by via net gripping. So this thick arachnoid up is putting the operator posts behind aneurysm. The tiny picmoid is cut. Additionally, I put the three crips on the neck to ensure the occluded annually. I have a doubt still annual to me it's alive. So the aneurysm is a and graded embedding into a third ventricle. I am detaching it from the side ventricle and confirming pointer right there. In the left side here, that was a rupture point and a no breathing come. I could confirm aneurysm is dead. And I showed you shows the good preservation of all the operators behind the aneurysm by lateral postal. This is the final view of the operation, the dura can be stitched water-tightly like this. And immediately three after surgery, the CT, and just show the good latency of the and the exclusion of the aneurysm. patients recovered well in spite of very high age. Next, I show you a bypass for complex aneurysm. This is a 45-year old female asymptomatic on ruptured M1 which form aneurysm. She is gynecologist, the actual doctor. In spite of asymptomatic, but and patients strongly to undergo surgery for her future. In this case I plan to perform the atleast STAMCA bypass to image, to segment, to take care of the breath pro to this time MCA territory. This is M2 segments of your trunk and officials terming of STA. And that this is a fast STA MCA bypass to inferior trunk or M2. And now the first anasmosis is completed. And the second bypass. Now this is a second bypass preparation. Put the rubber gum under drunk of M2 and official storming on another branch of STA and into an end to side anastomosis. Now, the parent got to be open. STA is open. And the IC green shows a good thing of the the both STA and MCA. Now, I exposed the aneurysm and the confirming the anatomy, especially the biggest issue is related. where the goes is arriving from gang, or the more, projecting, no important operator, arose from angles so that we could completely trap the aneurysm like this. And in this case, the parent that we is redundant. So I decided to perform the end to end on anastomosis with a fish monster me in each side, upside down. Then, this, the toe on the Fishman terming can be attaching to a proximal heel. And this toe here can be attached to proximal toe. With this manner, the end to end anastomosis become easier to do simple oblique cutting at the simple perpendicular cutting into anastomosis. Now the IC green show the very good thing of the antegrade from M1 to M2 segment and that could be confirmed which is arriving chroma distal M1. The STMs bypass is left and you can see STMCA bypass is AN, M1 and M2. What do we did, at first before taking aneurysm STMC double bypass and end to end anastomosis after M1 segment after removal. I had to show you actual example of a high flow bypass. This is a 49-year old female that brought the bracelet. No, no, I need the next one. Yeah, raptured blister aneurysm, blood blister aneurysm on the right side. Before attacking aneurysm, I always performed the hydro bypass between and MCA. Now, after the hydro bypass completed, I am compiling the aneurysm and the rapture point. Now this is approximal carotid stroke, rhino segment, and the rupture. Now the temporary cramp on cervical ICA then you can control protocol. And with a point sucking bad profile through the pecan and pcom is climbing. So I am putting the Crips to trap the rapture point. And now, I open the hydrobypass. The ischemic time is, can be minimized with beforehand. And now I am trapping the rupture point to preserve via Pcom and anterior corridor artery. Both Pcom and anterior corridor artery could be preserved with oblique pressing of the Crips to drop the aneurysm. And you can see hydro bypasses Peyton. Unfortunately patient recovered well without great ischemic complication. No, vasospasm, discharge it with modified ranking scale zero. Another case of blood blister aneurysm, a 48 year old man. This surgery is in 2006. Patient actually walked in Honolulu, Hawaii. He's a Japanese. Temporarily, he returned to Tokyo at that time. At that time unfortunately, he had a suburban on the hemorrhage like this. I confirmed the rupture point where the very thick crowd and I a hydro bypass with saphenous vein graft between and M2. This is external carotid and saphenous vein graft is anastomosis. Now, the hydro is opened. I put the temperate grape on proximal to the aneurysm. I am detaching the crowd and confirming the rupture point. Rapture point is here, inferior wall of the aneurysm grows to the Pcam, here. This is a Pcom. And a media to Pcom, there is a rupture point. This is the optic Cartier space. The other side, the laceration of the rupture is extended to a media side, internal quality. So I put the grid of recreate to grow the rupture point, preserving a Pcom oblique, like this. Actually, I tried to teach in the repair of the rapture point with a 10,000 or one 90, or switch about date which was impossible. The visceral wall was very fragile. So I dropped the rupture point and a hyperope bypass worked well. As well, this patient had no vasospasm recovered well. And now he's walking in Honolulu now. Next, I show you anterior interheisphere approach. The anterior interheisphere approach is very useful applicable approach for Acom aneurysm especially for superior projection, or posterior projection of aneurysm at the Acom. This is a good indication for such an aneurysm. All the anatomy of Acom complex can be observed in interheispheric approach. And in case of accident, something or cruising a parent that recent happen, we can perform immediate revascularization where the 88 decided to set down the small. The back is the frontal sinuses opening. We need appropriate management to maintain the patency of another front of that. The key is maintains the patency of another front adult. You take out the proper sign of smoke causal or not. This is a 72-year old female giant Acom aneurysm. Like this, the aneurysm is big and bilateral pericallosal . This is a exposure oF the pay comes out and the aneurysm. At VLS side, we could secure their left A1 and A2 easily. And in front of Virginia, a corpse Carlson, we could secure bilateral and they explained the bottom side on the anastemosis should be upon the running switcher and completed side to side anastemosis. And now we have already made a new Acom at DCRCA. Now if something that happened one side A2IS occluded. We have already done the preparation for a kind of complication. You can see right acorn neck is a very thin, so I repaired with a direct stitch and after neck gripping bilateral aid to either Peyton, but during dissection of right side A2 we attach so much on the annual zone. During dissection, I injured this parent and I repaired. I didn't show you that because of the time limitation, you can see the slight stenosis that can be seen on the CTNG. One week later on the CTNGO here was, but I have already made it nursing. What happened in right side AC territory. So bypass is a kind of insurance. If something projected like this, we should perform the bypass. Okay, it's almost time so, I can skip other presentation. So in conclusion, we need a clean and a bright operative field to see the object, to see the lesion. To do this hemostatis in every step is necessary. It's the most important Highest education to see a tiny structure is quite important to perform the accurate surgery, especially to stitch the micro vessels, to penetrate the needle to stitch the vessel wall, we need the highest magnification exactly compound, and exactly decide the penetrating point and to confirm whether the intima layer can be faced properly as everything. And only arachnoid membrane can be cut. We can't cut any veins, any arteries during approach. This is the principle. We can only cut arachnoid member. This does remain separation became frontend temporal is a basic technique in the microsurgery. Especially this is a very important for microanastemosis. The precise separating the sylvian fissure and preserving veins, especially superficial sylvian veins. With the skill to pre preserve the such veins, tiny veins, it help so much to perform the microanastomosis properly. As well the water-tight dural closure is a good training to perform microanastomosis. During the latency period, we should try to stitch the dura, to close the dura water-tightly, perfectly. This is a very good practice for microanastomosis. Okay, that's all, thank you very much.

- Thank you a million, I think the meticulous technique, the bloodless technique, the attention to details and really very soft management of normal just a very gentle, precise, accurate micro surgery that you demonstrate it is so critical for a good surgery. And this is really those techniques that are great Japanese neurosurgeons are so well-known for and all of us in the United States, Europe and everywhere in the world, we all learn from the great work Japanese neurosugeons do. It is truly an honor to be able to watch master surgeons like you operate. It sets a role model for us. It's truly something special to even watch. So with that in mind, our really saying it sincerely thank you for taking the time this morning, your time to be with us, and we'll look forward to having you with us in the future.

- Thanks again very much.

- Thank you.

- Thank you.

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