Name: model surgical training: skills acquisition in fetoscopic laser photocoagulation of monochorionic diamniotic twin placenta using realistic simulators
Uploaded: 2018-03-21T14:00:00.000+00:00
Duration: 9 min 51 s
Description: Watch this Scientific Journal Video about Model Surgical Training: Skills Acquisition in Fetoscopic Laser Photocoagulation of Monochorionic Diamniotic Twin Placenta Using Realistic Simulators at JoVE.

作者感谢在新加坡和曼谷帮助建造模型、提供材料和便利培训讲习班的人们: 颂博士、轭辉坊教授、Viboonchart、金妮、塞西尔、Laureano、培黄宽, 美兰谢, 杰瑞. 肯塔基教授. 材料得到医学 Siriraj 医院、曼谷和国立大学医院、新加坡国家医学研究理事会 (新加坡) 妇产科部门的支持。格兰特 NMRC/CSA/043/2012

从足月分娩中收集的人胎盘是由新加坡努哈 (DSRB C/00/524) 领域专门审查委员会和曼谷 SIRB 医院 Siriraj 机构审查委员会 (Siriraj 704/2559) 批准的。在所有情况下, 病人都给予不同的书面同意, 以使用收集标本。猪膀胱是从新加坡当地的屠夫那里收集来的, 是努哈博士的一种捐赠。非人类灵长类动物 (NHP) 胎盘是在卫生部 (新加坡) 国家医学研究理事会赠款 NMRC/CSA/043/2012 下繁殖的猕猴猴收集的废料, 严格遵守机构新加坡国立大学和新加坡卫生服务私人有限公司 (IACUC 2009-SHS-512) 的动物护理和使用委员会 (IACUC), 是一位来自于杰瑞. 陈教授的亲切捐赠。
1. 使用 Fetoscopy 模拟器熟悉 Fetoscope 处理和胎盘定位
<ol><li>设置 fetoscopy 模拟器和设备 (图 2-c)。<ol>
<li>识别 2.0 mm 光纤直 fetoscope 的部件: 透镜 (0°或 30°)、标准或远程眼盖 (图 2A);3.0 毫米双腔操作鞘, 尖孔尖端直接插入羊膜腔超声引导下, 用于2.0 毫米 fetoscope (图 2B)。</li>
		<li>将 fetoscope 放入操作鞘后, 将闭孔和连接到腹腔镜相机的眼睛盖。 注意: 这些直纤内窥镜是半柔性的, 操作鞘可以仔细地弯曲到20-35°从中线轴提供适当的曲率用于前胎盘。在没有内镜的情况下弯曲操作鞘。其他合适的 fetoscopes 后和前胎盘在材料表中列出。</li>
	</ol>
</li>
	<li>在 "操作者" 附近安排腹腔镜塔和超声波机, 以便在 fetoscope 插入时同时操作超声波探头。<ol>
<li>通过单向阀端口, 将 fetoscopy 模拟器填充到水的边缘。</li>
		<li>将填充的模拟器定位在所需方向的塑料底座上, 以表示前或后胎盘 (图 2C)。 注: 模拟器的上表面现在代表的是前产妇腹部, 在那里的超声探头放置和 fetoscope 应该插入。</li>
	</ol>
</li>
	<li>使用曲线超声探针与水凝胶在透明皮肤的 "前产妇腹部", 以可视化胎盘在 fetoscopy 模拟器。确定胎盘位置和它旁边的一个窗口 (为前胎盘) 放置 fetoscope。</li>
	<li>在连续超声引导下通过端口在操作护套中插入适当的 fetoscope (图 2C)。<ol>
<li>使用 fetoscope 直 fetoscope 后胎盘和对前胎盘的弯曲的 (材料表)。</li>
		<li>通过超声监测 fetoscope 的插入和深度, 使胎盘进入视野。</li>
		<li>调整照相机的焦距, 使视觉进入锐浮雕 (图 2D F)。</li>
	</ol>
</li>
	<li>识别与血管赤道并列的双胞间膜。<ol>
<li>确定胎盘表面的血管赤道, 并系统地探索从端到端的脉管运动, 以确定典型的消融 AVAs。 注: 这些吻合将被视为在绒毛膜表面运行;动脉较暗, 并且始终在静脉上运行 (图 2C、E)。</li>
	</ol>
</li>
	<li>改变模拟器的方向, 以代表后胎盘, 如果实践已经做了与前胎盘, 反之亦然。<ol>
<li>重复超声评估的过程, 规划 fetoscope 输入, 并插入 fetoscope。 注意: 模拟器和胎盘的定位可以每次改变以练习胎盘不同位置的 fetoscopic 位置, 也可测试不同的 (弯曲的, 直的) fetoscopes。</li>
	</ol>
</li>
</ol>2. 直接 Fetoscopic 进入、Seldinger 技术、血管激光凝固的组织模型
<ol><li>组织模型 #1 胎盘在盒中的研究<ol>
<li>使用一个标准, 存储购买的塑料容器 35 x 18 x 15 cm3维度与一个防水锁 (图 3a) 创建框模型。<ol>
<li>切出一个广泛的塑料盖的窗口, 并用超声波透明橡胶 "皮肤" 缝合到封面的边缘。这形成了模拟产妇腹部的前表面, 通过该 fetoscope 放置。在框的底部安装橡胶乳胶板, 以防止超声混响 (图 3-c)。</li>
		</ol>
</li>
		<li>在足月分娩后收集人类胎盘, 并对样品收集进行适当的同意。在水槽中用自来水冲洗胎盘的表面 (最好在运输前在劳动病房的公用房里这样做)。确保胎盘表面是干净的血液和切断脐带使用强组织剪刀到可管理的长度,例如, 5 厘米。<ol>
<li>将胎盘在一个密封的生物危害塑料袋内的第二容器内运送到实验室。 注意: 使用个人防护设备 (一次性手套、护盾、等等) 始终处理胎盘和其他生物物质。在执行这项工作之前, 确保适当的机构伦理批准。</li>
			<li>将脐带的游离端系在缝合带或棉帘线上, 以防止血液从切口末端耗尽。 注: 血管内的血液也有助于模拟激光练习过程中过度凝固的血管撕裂。</li>
		</ol>
</li>
		<li>为了模拟前胎盘, 用透明的塑料线或塑料网将胎盘固定在容器的后盖上, 使其保持到位。</li>
		<li>要模拟后胎盘, 请将胎盘固定在容器底部的橡皮板上, 并用塑料网或小重量 (图 3B) 将其保存到位。</li>
		<li>用自来水把容器装满, 把盖子锁上。</li>
		<li>用工作通道为后胎盘和其操作鞘准备 fetoscope, 以及前胎盘多通道的 fetoscope 曲线 (材料表)。把眼罩连接到相机上。<ol>
<li>准备激光。例如, 如果使用二极管激光器与400微米或600微米激光光纤, 设置初始电压为 15-30 W, 并逐步增加, 如果需要有效的凝固。</li>
		</ol>
</li>
		<li>执行步骤1.3 所述的胎盘超声评估。<ol>
<li>找到一个与前胎盘相邻的无胎盘窗口, 在其中插入弯曲的 fetoscope, 这样透镜位于胎盘中心的上方 (双侧赤道之间有望在 MCDA 胎盘中)。</li>
			<li>确定在哪里插入后胎盘的直 fetoscope, 使该中心透镜定位垂直于胎盘中央。</li>
		</ol>
</li>
		<li>执行直接 fetoscopic 进入通过做一个2毫米刺切口与锋利的刀片在 "皮肤"。在连续超声引导下, 将操作套管插入到充满液体的容器 ("羊膜囊") 中 (这是患者的接受者双胞胎的囊)。<ol>
<li>避免通过在超声视觉下缓慢推进 fetoscope 而刺穿胎盘。在连续超声视觉下, 缓慢地从操作套管中取出锥体闭孔。</li>
			<li>将 fetoscope 的透镜小心地放入先前被闭孔占用的通道中的操作套管, 并将胎盘和表面脉管置于尖锐的焦点 (图 3C)。</li>
		</ol>
</li>
		<li>将激光纤维插入操作侧通道中, 当尖端接近鞘端时缓慢前进。 注意: 保持激光光束尽可能垂直于目标容器, 以使激光效果最大化46,47。<ol>
<li>将激光纤维尖端推进到大约5-10 毫米以外的操作鞘。 注: 如果激光尖端离鞘太远, 它可能会撕裂血管。如果笔尖太近, 则可能危及凝固效果 (图 3D)。激光光纤尖端应从容器表面2-3 毫米, 在发射时不应接触到容器 (图 3D中的黄色箭头)。</li>
		</ol>
</li>
		<li>识别脐带 (图 3E) 和胎盘血管 (图 3F)。通过超声和直接 fetoscopic 视觉的结合, 回顾胎盘血管的端到端。 注: fetoscope 应指向目标容器的90°角。图 3G显示单绒毛膜胎盘中的实际单绒毛膜艾娃。在垂直于血管或吻合的位置使用脚踏板来发射激光。</li>
		<li>凝聚容器, 直到它与无接触技术 blanches, 目的是凝聚1-2 厘米的一段, 直到完全停止的流程完成。该船只应出现扁平 (折叠) 和苍白的凝固被认为是有效的。<ol>
<li>系统地实践了从一个胎盘端到另一端的血管凝固。激光凝聚从外围到容器的中心的厚的船只, 以防止破裂 (因此 "剃" 一个较厚的肿胀容器成一个狭窄的拥挤的一条)。或者, 先将较小的喂养容器在较大的 decongestion 前凝固, 以防止血管破裂。</li>
		</ol>
</li>
		<li>在单独的血管被凝固完成胎盘 dichorionisation48,49之后, 练习所罗门技术。在胎盘表面用激光表面凝固形成一条线, 直到所有的单独凝固的吻合连接。</li>
	</ol></li>
	<li>组织模型 #2-猪膀胱 "子宫" 注: 如果材料容易获得, 可以考虑将猪膀胱和孕中期胎盘相结合的混合组织模型进行模拟。该模型可用于实践喷洒和去除 "子宫" 中的液体, 重现 fetoscopy 等血液染色液的常见并发症, 并实践 fetoscope 插入的 Seldinger 技术。<ol>
<li>获得一个干净的猪膀胱。定位它与更宽的弯曲周长作为上部头侧杆和狭窄的部分作为下尾鳍杆, 因此用户可以对开沿头侧边界和继续 caudally, 这样膀胱打开象翻盖(图 4 a, 断行)。 注: 在使用个人防护设备的生物安全柜中, 与人体和动物组织一起执行所有程序, 并通过适当的机构批准处理生物组织。</li>
		<li>在分娩后或在医学上导致妊娠终止后, 获得一个小的中期妊娠胎盘。确保获得适当的同意, 样品是匿名的。</li>
		<li>用纸巾剪和缝合胎盘 (红色箭头, 胎儿表面向外, 产妇表面向内), 从胎盘上修剪多余的羊膜 (膜状, 白色组织附着在胎儿/脐表面) 到一半的猪膀胱。缝合的猪膀胱 (黑色箭头) 的第二个一半, 以一个水紧的方式在切口周围 (图 4B, C)。</li>
		<li>将 "子宫" 放置在模型骨盆中, 如图 4D所示。定位子宫以模拟前胎盘或后胎 (图 4D)。</li>
		<li>在超声引导下 (如果橡胶皮肤是透明的对超声) 实践直接插入套管针和 fetoscope 在它的操作鞘之内。</li>
		<li>应用 Seldinger 技术, 在实时超声引导下, 在羊膜腔内插入一个锋利的空心套管针。将软 J 尖导丝通过腔内, 取出套管针, 将扩张在导丝上的钝套管插入羊膜腔内, 然后完全取出导丝和扩张, 使套管就位。最后, 通过套管将 fetoscope 插入子宫 (图 4E)。</li>
		<li>检查胎盘表面 fetoscopically 的血管。通过使用50毫升注射器的操作通道减少或添加液体, 以增加或减少 "宫内" 压力, 并用新鲜盐水代替血液染色或混浊液体。</li>
		<li>按照步骤 2.1. 11-2. 1.12 中所述相同的方式练习激光凝固血管。</li>
		<li>根据机构协议, 将模型作为 biohazardous 材料处理。</li>
	</ol></li>
</ol>3. 将模型中所学的技能传授给病人
<ol><li>在 MCDA 双胎妊娠患者中, 对胎盘进行超声检查, 并确定胎盘两胎的脐带插入点。 注 : 在这种情况下 , 其中一根绳子可能入接近 MCDA 胎盘的边缘。设想一条线加入两个胎盘脐带插入, 并确定这条线的中点, 这表明血管赤道的位置, 可能更接近较小的捐献者双胞胎, 而不是等距的两条绳子, 特别是与一个重要的羊膜囊大小差异。血管赤道垂直于连接绳子的线。</li>
	<li>确定 fetoscope 插入的站点。<ol>
<li>对于前胎盘, 找到一个窗口, 在超声可视化胎盘, 没有胎盘组织, 其中弯曲 fetoscope 可以操纵, 使透镜位于血管赤道。</li>
		<li>对于后胎盘, 插入 fetoscope 在大约中点之间的绳子直接在血管赤道。移动 fetoscopic 透镜向上和向下的血管赤道使用一个清扫运动, 同时保持一个大约90°角度赤道, 最佳的激光凝固。 注意: 这可能需要插入部位侧向血管赤道, 就在羊水过多囊一侧胎盘的外围。</li>
	</ol>
</li>
	<li>检查胎儿分娩后胎盘 dichorionization 的完成情况, 以评估残端吻合 (图 5-c)。在必要的准备工作后, 用不同颜色的染料注入脐带血管, 以区分供体和接受者的动脉和静脉, 如前所述44,50。</li>
</ol>

作者没有什么可透露的。

在 fetoscopy 模拟器和组织模型上练习的技能包含了 SFLP 所需的大部分技术能力。这些模型的训练的优点包括学习同时处理超声探头和 fetoscope, 熟悉处理直曲线 fetoscopes, 对整个血管赤道进行系统检查。双胞间膜长度, 以识别高保真 MCDA 胎盘的网状血管, 并学习正确的技术, 使用在大型和高流量的船只, 以避免破裂, 这可能会导致严重的后果, 包括突然丧失视力或者是双胞胎的放血。此外, 还可以对所罗门技术中使用的表面激光消融进行模拟。获得的技能直接适用于对怀孕病人执行的程序。常规练习将训练外科医生朝着安全地烧蚀 MCDA 胎盘血管赤道上所有可见 AVAs 的目标, 同时尽量减少双贫血红细胞增多症序列 (水龙头) 在 SFLP51之后的风险。
医学 Siriraj 医院的团队开发了一个专有的幻影, 以增强外科医生的学习经验。这35厘米直径软橡胶球形模型模拟宫内环境为技能获取和改善45。它包含一个单绒毛膜胎盘和单向瓣膜端口的橡胶复制品, 以允许 fetoscopes 朝向前和后胎盘。水可以通过这些端口注入, 专有的覆盖材料对超声波是透明的。这种封闭系统模型允许系统检查胎盘血管, 特别是负责 TTTS 的艾娃, 并且可以注入和去除液体, 以模拟血流或混浊羊水的清除。操作人员还可以根据需要在手术中同时处理超声和 fetoscope。
组织模型可以根据任何胎儿治疗单元的可用资源进行修改和调整。猪膀胱可以从当地屠夫购买, 用作 "子宫", 而早产分娩或孕期中期妊娠终止胎盘可用于盒子或膀胱模型, 以更好地模拟孕中期 MCDA 胎盘 fetoscope插入和凝固实践。我们使用的 NHP 胎盘的当量大小, 是废物的材料后, 经伦理批准的 NHP 育种 (见伦理学声明)。这些模型通常易于组装使用可用的材料, 不需要活的动物, 这也被用于 fetoscopy 训练52,53,54。在产科单位内运作的 MFM 小组应该有各种妊娠的胎盘, 以便在适当的道德批准和同意程序中使用。
通过这些现实的组织模型, 操作者能够实践两个, 主要的超声引导 fetoscopic 进入技术和激光凝固的船只在一个实际的设置。操作员可以排练在手术过程中经常需要的实际的故障排除步骤, 例如切断用过的激光尖端来刷新光纤以使激光聚焦, 控制破裂血管的出血, 调整激光纤维的数量从操作鞘延伸到有效的凝固, 清除混浊的 "羊水" 以改善视力。该系统可以将综合评估工具 (如德尔菲法) 纳入独立性能12之前的评估能力。胎盘前后方向均可采用弯曲或直 fetoscopes, 操作者掌握两种器械。这些模型可以快速地制作, 用于车间, 使新的和经验丰富的 proceduralists 在同一时间训练。此外, 外科手术组 (主要的外科医生和助理) 可以一起练习各种步骤, 以提高效率。主要的风险是生物: 动物和人体组织应被视为 biohazardous 材料。应制定协议, 只从没有传染性传染病的产后病人那里获得胎盘。用于缝合和切割的锋利器械应适当小心处理, 妥善处理以避免锐伤。操作者大部分时间都在使用单胎胎盘, 因此不会有机会为艾娃进行筛查。
对逼真模拟器的培训可以让 proceduralists 团队同时掌握技能, 从而促进在新的胎儿治疗中心快速启动服务。在模拟器和组织模型上练习的技能直接适用于病人, 进一步降低了新 proceduralists 的学习曲线, 在最初训练阶段, 应由经验丰富的 fetoscopist 指导, 重点掌握fetoscopy 的具体步骤, 同时尽量减少并发症。外科医生可以定期练习这些模型的技能, 以维持手术的灵活性, 特别是在病人之间的长时间间隔。

一种新的微创外科技术的获得通常采用传统的外科学徒模式, 在该模型中, 个人从观察一个专家外科医生的工作到一个活的病人, 并最终执行技术下关闭监视1。这一由来已久的模式常常限制从导师到个人受训者的知识的传授, 并严重依赖于资源的可用性, 如培训资金和病人案例加载2。Fetoscopic 手术是一种高风险的微创手术的例子, 在怀孕期间对早产个体进行, 对母亲和胎儿都有风险。与任何外科手术一样, 在学习曲线的初始陡峭斜坡上, 并发症发生率较高。因此, 手术通常由最资深或熟练的外科医生执行, 以满足关键的病例数量来优化患者结局3。
良好的 fetoscopy 技能对于未来的胎儿治疗是很重要的, 它努力进行微创, 即使是对结构缺陷的矫正4,5,6。Fetoscopic 手术在技术上是有挑战性的, 在真实的剧场环境中练习和开发新技能与患者的安全有内在的风险。即使是已建立的外科医生需要时间和一贯的做法, 多名病人获得专业知识, 故障排除的技能, 当出现困难, 以及本能预测和避免陷阱, 在一个新的和复杂的程序。通常与新手 proceduralists7相关的次优结果的耐受性较差。虽然在最初实施 fetoscopic 手术时不损害患者的安全很重要, 但也需要提高所有 proceduralists 的技能和专长, 特别是在较小的临床单位刚开始练习 fetoscopy。需要一个补充传统学徒制的替代制度, 以应付有限的培训资金和一个小的病人基础上的挑战, 以便掌握这些高度专门化的程序。程序学习曲线可以缩短, 并通过对高保真机器或尸体动物模型的训练减少并发症, 与专用的传统指导或远程 proctorship 和过程重点逐步学习8, 9,10,11。熟悉 fetoscope 操作, 血管赤道的宫内取向和激光凝固术前进行实际手术有可能减少手术并发症12,13。这种训练可以缩短新操作员的学习曲线, 因为他们掌握了现实组织模型的基本技能。
单卵双生子孪生发生在全世界范围内的均匀频率影响3-5 每1000怀孕, 和75% 的单卵双生子双胞胎与单绒毛膜 diamniotic (MCDA) 胎有很大的风险 TTTS, 目前复杂约10-15% 的MCDA 怀孕, 或1-3 每1万出生14。在 monozygosity15、16、17、18、19中, 该发病率预计会随体外受精 (IVF) 频率增加2到12倍。TTTS 是通过深 intraplacental 艾娃的单向胎儿间血流产生的。未经治疗, 这对幸存的胎儿有60-100% 的死亡率和严重的发病率20,21,22。
选择性 fetoscopic 激光凝固 (SFLP) 是唯一的治疗干预, 旨在抢救两个双胞胎通过 fetoscopic 鉴定和消融的违规艾娃, 并被认为是护理标准在 TTTS 阶段 (93% 的所有病例) 在妊娠 < 26 周的妊娠, 与临床研究进展, 以确定是否也应适用于选定的第一阶段疾病23,24,25。SFLP 的总体围产期生存率为 ~ 70%, 更高的可能性更高级妊娠和更高的出生体重在交付26,27 , 并认为优于其他干预, 因为它直接矫正TTTS 的基础病理学28,29,30。干预本身不是没有并发症, 激光治疗 TTTS 与复发 (0-16%), 围产期死亡率 (~ 35%), 和5-20% 的可能性长期神经障碍23。获得正确的技能, 在陡峭的学习曲线上建立专门知识, 遵守 fetoscopic 实践的国际标准, 保持外科灵巧, 对于提供这一复杂疾病的最佳结局至关重要13 ,31,32,33。这通常依赖于财务和人力资源以及可能需要很长时间才能获取34的关键案例数量。建立的胎儿治疗中心目前集中在西欧和北美洲, 但预测的人口激增 (因而新的怀孕) 将主要影响亚洲和非洲35,36。因此, 在这些资源较低的人群中, 可预期胎儿畸形的发病率会增加, 而这种情况可能会出现在宫内治疗中。传播诸如 fetoscopic 外科等专门服务是一项挑战, 需要作为区域优先事项37加以解决。在这些地区, 新的胎儿治疗中心必须可靠地提供 SFLP 服务, 以满足社区的需要, 但是新的中心需要大量的投资和时间来实现类似的结果, 如建立的38,39,40,41。
从资源繁重的学徒模式出发, 将有助于向有巨大需求的社区传播技能和专门知识。传统的外科学徒仍然是相关的, 但对于许多较小的临床单位来说是不太实际的, 因为它是时间和资源消耗, 并限制了知识和技能的传授给一个实习生一次。proctorship 下的模拟器培训更适用于更广泛的范围, 通过讲习班和对可靠组织模型的定期技能培训, 促进通过专家向多人传授知识和技能13,42,43. 有人建议, 由于其稀有性, TTTS 治疗应积累在大容量的胎儿中心, 以改善其结果。然而, 还需要建立新的胎儿护理中心, 以改善患者获得治疗的机会。新兴的胎儿护理中心, 如新加坡国立大学医院 (努哈), 将需要遵守某些指导方针, 以维持其手术结局,即, Siriraj 努哈 proctorship 系统, 如图 137 中所示.
在这篇文章中, 我们将描述一个基于模型的系统, 新的 proceduralists 可以在专家的指导下进行串联的技能训练, 并且通过这些技能可以在长时间间隔内练习保持手术的灵巧度。患者.我们将从我们在曼谷的 Siriraj 医院和新加坡的努哈的经验分享实际的要点, 启动胎儿治疗6,44,45。

<table><tbody><tr><td>Fetoscopic Simulator</td><td>Maternal-Fetal Medicine unit, Department of Obstetrics and Gynaecology, Siriraj Hospital, Bangkok, Thailand</td><td>NA.</td><td>Siriraj Fetoscopic Simulator. Customised model of monochorionic anterior/posterior placenta and anastomses produced at the Siriraj Hospital in Bangkok.</td></tr><tr><td>Laparoscopy tower with light source, camera and video recorder</td><td>Olympus Singapore</td><td>Olympus Visera Elite system (Olympus Singapore) with camera OTV-S190 and light source CLV-S190 set at medium intensity (level 0) and video recorder&amp;nbsp;</td><td>Laparoscopy tower for fetoscopy and recording of practice</td></tr><tr><td>Voluson E8 ultrasound machine with 4CD probe</td><td>GE Healthcare Singapore</td><td>GE Voluson E8; transabdominal 4CD curved transducer (2-5MHz)&amp;nbsp;</td><td>Ultrasound system for guidance of fetoscope introduction and manipulation</td></tr><tr><td>Minature straight forward telescope 0&lt;sup&gt;o &lt;/sup&gt;(2mm) for posterior placenta</td><td>KARL STORZ GmbH &amp;amp; Co KG, Tuttlingen, Germany</td><td>11630AA</td><td>Fetoscope. 0&amp;deg; lens, diameter 2mm, length 26cm, autoclavable, fibre optic light transmission incorporated. To use with operating sheath 11630KF.</td></tr><tr><td>Operating sheath, straight with pyramidal obturator.&amp;nbsp;</td><td>KARL STORZ GmbH &amp;amp; Co KG, Tuttlingen, Germany</td><td>11630 KF</td><td>Size 9 Fr with working channel 1 mm, for use with 11630AA; working channel for laser fibres up to 400&amp;micro;m core.</td></tr><tr><td>Multichannel miniature straight forward telescope 0&amp;deg; set straight for posterior placenta</td><td>KARL STORZ GmbH &amp;amp; Co KG, Tuttlingen, Germany</td><td>11506AAK</td><td>Fetoscope. 0&amp;deg; lens, diameter 3.3 mm, length 30cm , 30,000 pixels, integrated channels, autoclavable, fibre optic light transmission incorporated.&amp;nbsp;</td></tr><tr><td>Multichannel miniature straight forward telescope 0&amp;deg; set curved&amp;nbsp; for anterior placenta</td><td>KARL STORZ GmbH &amp;amp; Co KG, Tuttlingen, Germany</td><td>11508AAK</td><td>Fetoscope. 0&amp;deg; lens, diameter 3.3 mm, length 30cm , 30,000 pixels, integrated channels, autoclavable, fibre optic light transmission incorporated.&amp;nbsp;</td></tr><tr><td>Dornier diode laser with 400um or 600um laser fibre</td><td>Medilas D Multibeam, Dornier MedTech Asia, Singapore</td><td>S/N D60-353</td><td>Laser photocoagulation system. Diode (30-60 W)&amp;nbsp;</td></tr><tr><td>Laser fibre&amp;nbsp;</td><td>400-600&amp;micro;m laser fiber</td><td>Disposable LG type D01-6080-BF-0;LOT 1024/0613</td><td>Use the provided ceramic cutter to refashion the tip of the fibre once coagulated after burning to maintain the sharp focus of the laser.&amp;nbsp;</td></tr><tr><td>Large plastic container with ultrasound transparent skin;</td><td>NA</td><td>NA.</td><td>Container is a simple houshold item with a watertight lid that cn be locked in place. The silicon rubber &quot;skin&quot; produced inhouse allows US visualisation of the placenta within the container. Can be used as a simulator for vascular laser coagulation.&amp;nbsp;</td></tr><tr><td>Pig bladder and small mid-gestation placenta&amp;nbsp;</td><td>NA</td><td>NA.</td><td>Obtained from the local butcher. Elastic tissue that can be stretched when filled with large volume of fluid; can incorporate a small human/NHP placenta and used as a simulator for laser coagulation&amp;nbsp;</td></tr></tbody></table>

model surgical training: skills acquisition in fetoscopic laser photocoagulation of monochorionic diamniotic twin placenta using realistic simulators

Fetoscopic 激光凝固动静脉吻合 (艾娃) 在一个单绒毛膜胎盘是标准的双重输血综合征 (TTTS), 但在技术上具有挑战性, 并可能导致重大并发症。获得和保持必要的外科技能需要一致的做法, 关键的工作量和时间。对逼真的外科模拟器的训练可能会缩短这一陡峭的学习曲线, 并使几个 proceduralists 同时获得程序特定的技能。在这里, 我们描述的真实模拟器设计, 使用户熟悉的设备和具体步骤所需的手术治疗 TTTS, 包括 fetoscopic 处理, 方法的前和后胎盘, 承认吻合, 有效的血管凝固。我们描述了在进行胎盘激光凝固时特别重要的技能, 外科医生可以在该模型上进行练习并应用于临床病例。这些模型可以根据材料的可用性和要求标准的 fetoscopy 设备方便地进行调整。这种训练系统是对传统的外科学徒的补充, 可以帮助提供这种临床服务的胎儿医学单位。

fetoscopy 模拟器的基本要求是透明的 "皮肤", 使模型中胎盘的超声可视化和 MCDA 胎盘的典型模型。这里说明的模拟器是在 Siriraj 医院 (曼谷) 开发的, 是一个封闭的系统, 其中包含了妊娠中期单绒毛膜胎盘的硅复制品 (图1)。这种模式的一致使用, 应该增加新手外科医生对胎盘定向和 fetoscope 安置的信心, 并增加对处理直和弯曲 fetoscopes 的熟悉程度。对组织模型的实践将提高外科医生对胎盘血管激光凝固的熟悉程度, 并排除诸如快速血管出血和血管破裂等常见缺陷。单胎胎盘是一个很好的替代单绒毛膜胎盘, 如果后者是不可用的。应使用易于使用的设备和足月胎盘 (图 2、图 3) 来组装模型。外科医生应该有信心检查沿整个胎盘长度的船只和他们的系统激光凝固与任何组织模式的一致使用。如果血管凝固完全执行, 这将是明显的, 因为没有深吻合;dichorionization 的完成与所罗门技术烧蚀沿赤道表面的吻合 (图 4)。一旦外科医生对模型磨练出的技能有信心, 向病人过渡就会更顺畅。胎盘的检查和残留的吻合是衡量手术疗效的重要一步;对外科手术组的治疗效率的一致反馈有助于他们认识到技术缺陷, 并在今后的病例中改善其手术结局。
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/57328/57328fig1.jpg"> 图 1: 新 fetoscopy 单元中的工作流.<a href="//cloudflare-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/57328/57328fig1large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/57328/57328fig2.jpg"> 图 2: Fetoscopy 模拟器.fetoscope 的部分包括 (A) 带有0°透镜的直望远镜、用于连接腹腔镜摄像机的远程眼盖, 以及 (B) 用于激光光纤导入和注入/吸入的侧通道的操作鞘流体.这个模拟器可以定位到对前和后胎盘的做法 (C)。该模拟器纳入了中期妊娠单绒毛膜胎盘 (D) 的硅复制副本, 并向操作员提供一系列动静脉吻合 (E, F 箭头), 以识别其他胎盘血管. <a href="//cloudflare-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/57328/57328fig2large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/57328/57328fig3.jpg"> 图 3.组织模型 #1.该模型易于组装, 并要求橡胶 "皮肤" 安装在开口切出的盖子, 这是透明的超声 (A)。胎盘 (红色箭头) 放置在容器的底部, 通过重量按住以模拟后胎盘。操作人员可以对输入站点和 fetoscope 插入同时进行超声评估, 以提高灵活性 (B, C)。激光光凝血管可以练习 (D, 显示激光光纤尖端和激光点的黄色箭头)。在这种单胎胎盘中, 脐带的可视化 (E、白色箭头) 和容器 (F、红色箭头) 允许对实际的单绒毛膜艾娃 (G, 红色箭头) 进行实际的激光练习模拟.<a href="//cloudflare-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/57328/57328fig3large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/57328/57328fig4.jpg"> 图 4.组织模型 #2.这个模型是通过平分一个猪膀胱 (沿黑色断线, a) 和缝合一个猕猴猴胎盘 (红色箭头) 进入内部, 并关闭它在一个防水的方式 (B, 黑色箭头, C)。膀胱 "子宫" 是重建使用两层缝合和注入液体之前, 把它放入一个模型骨盆 (D)。如果骨盆模型覆盖超声透明的 "皮肤", 操作员可以练习超声引导直接和 Seldinger 方法的 fetoscopic 进入 (E), 也增加和减少羊膜内压力, 以改善可视化。<a href="//cloudflare-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/57328/57328fig4large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/57328/57328fig5.jpg"> 图 5.胎盘注射研究.这些染料注射是在 MCDA 胎盘分娩后进行的。(A) 未经治疗的 MCDA 双胞胎没有 TTTS 指示艾娃 (圈子) 和血管赤道 (虚线)。治疗 MCDA 胎盘与凝固的艾娃 (B) 和 dichorionization 由所罗门技术 (C, 黄色箭头) 表明治疗的效率和完整性。<a href="//cloudflare-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/57328/57328fig5large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>

Watch this Scientific Journal Video about Model Surgical Training: Skills Acquisition in Fetoscopic Laser Photocoagulation of Monochorionic Diamniotic Twin Placenta Using Realistic Simulators at JoVE.

模型手术训练：使用真实模拟器获得单绒毛膜双羊膜双胎盘胎儿镜激光光凝术的技能医学|视频

Model Surgical Training: Skills Acquisition in Fetoscopic Laser Photocoagulation of Monochorionic Diamniotic Twin Placenta Using Realistic Simulators

练习 fetoscopic 激光凝固单绒毛膜胎盘吻合术所需的特定技能, 可以帮助经验较少的外科医生克服与这个过程相关的陡峭的学习曲线, 现在被认为是双胎输血综合征的护理标准。

模型外科训练: 用逼真模拟器 Fetoscopic 激光光凝单绒毛膜 Diamniotic 双胎胎盘的技能习得

Fetoscopic laser coagulation of arterio-venous anastomoses (AVA) in a monochorionic placenta is the standard of care for twin-twin transfusion syndrome ...

model-surgical-training-skills-acquisition-fetoscopic-laser

Universidad San Sebastian

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19.5K 次观看.  Siriraj Hospital. 练习 fetoscopic 激光凝固单绒毛膜胎盘吻合术所需的特定技能, 可以帮助经验较少的外科医生克服与这个过程相关的陡峭的学习曲线, 现在被认为是双胎输血综合征的护理标准。

视频: Model Surgical Training: Skills Acquisition in Fetoscopic Laser Photocoagulation of Monochorionic Diamniotic Twin Placenta Using Realistic Simulators

Contrast Imaging in Mouse Embryos Using High-frequency Ultrasound

Ultrasound contrast-enhanced imaging can convey essential quantitative information regarding tissue vascularity and perfusion and, in targeted applications, facilitate the detection and measure of vascular biomarkers at the molecular level. Within the mouse embryo, this noninvasive technique may be used to uncover basic mechanisms underlying vascular development in the early mouse circulatory system and in genetic models of cardiovascular disease. The mouse embryo also presents as an excellent model for studying the adhesion of microbubbles to angiogenic targets (including vascular endothelial growth factor receptor 2 (VEGFR2) or &#945;v&#946;3) and for assessing the quantitative nature of molecular ultrasound. We therefore developed a method to introduce ultrasound contrast agents into the vasculature of living, isolated embryos. This allows freedom in terms of injection control and positioning, reproducibility of the imaging plane without obstruction and motion, and simplified image analysis and quantification. Late gestational stage (embryonic day (E)16.6 and E17.5) murine embryos were isolated from the uterus, gently exteriorized from the yolk sac and microbubble contrast agents were injected into veins accessible on the chorionic surface of the placental disc. Nonlinear contrast ultrasound imaging was then employed to collect a number of basic perfusion parameters (peak enhancement, wash-in rate and time to peak) and quantify targeted microbubble binding in an endoglin mouse model. We show the successful circulation of microbubbles within living embryos and the utility of this approach in characterizing embryonic vasculature and microbubble behavior.

Here, we present a protocol to inject ultrasound microbubble contrast agents into living, isolated late-gestation stage murine embryos. This method enables the study of perfusion parameters and of vascular molecular markers within the embryo using contrast-enhanced high-frequency ultrasound imaging.

对比成像的小鼠胚胎使用高频超声

Ultrasound contrast-enhanced imaging can convey essential quantitative information regarding tissue vascularity and perfusion and, in targeted ...

科研

发育生物学

Instrumentation of Near-term Fetal Sheep for Multivariate Chronic Non-anesthetized Recordings

The chronically instrumented pregnant sheep has been used as a model of human fetal development and responses to pathophysiologic stimuli such as endotoxins, bacteria, umbilical cord occlusions, hypoxia and various pharmacological treatments. The life-saving clinical practices of glucocorticoid treatment in fetuses at risk of premature birth and the therapeutic hypothermia have been developed in this model. This is due to the unique amenability of the non-anesthetized fetal sheep to the surgical placement and maintenance of catheters and electrodes, allowing repetitive blood sampling, substance injection, recording of bioelectrical activity, application of electric stimulation and in vivo organ imaging. Here we describe the surgical instrumentation procedure required to achieve a stable chronically instrumented non-anesthetized fetal sheep model including characterization of the post-operative recovery from blood gas, metabolic and inflammation standpoints.

The chronically instrumented non-anesthetized fetal sheep model is used to study human fetal development in health and disease, because it permits surgical placement and maintenance of catheters and electrodes, repetitive blood sampling, substance injection, recording of bioelectrical activity, and in vivo imaging. We describe the procedures required to establish this model.

仪表近期胎羊多元慢性非麻醉的录音

The chronically instrumented pregnant sheep has been used as a model of human fetal development and responses to pathophysiologic stimuli such as ...

Guide Wire Assisted Catheterization and Colored Dye Injection for Vascular Mapping of Monochorionic Twin Placentas

Monochorionic (MC) twin pregnancies are associated with significantly higher morbidity and mortality rates than dichorionic twins. Approximately 50% of MC twin pregnancies develop complications arising from the shared placenta and associated vascular connections1. Severe twin-to-twin syndrome (TTTS) is reported to account for approximately 20% of these complications2,3. Inter-twin vascular connections occur in almost all MC placentas and are related to the prognosis and outcome of these high-risk twin pregnancies. The number, size and type of connections have been implicated in the development of TTTS and other MC twin conditions. Three types of inter-twin vascular connections occur: 1) artery to vein connections (AVs) in which a branch artery carrying deoxygenated blood from one twin courses along the fetal surface of the placenta and dives into a placental cotyledon. Blood flows via a deep intraparenchymal capillary network into a draining vein that emerges at the fetal surface of the placenta and brings oxygenated blood toward the other twin. There is unidirectional flow from the twin supplying the afferent artery toward the twin receiving the efferent vein; 2) artery to artery connections (AAs) in which a branch artery from each twin meets directly on the superficial placental surface resulting in a vessel with pulsatile bidirectional flow, and 3) vein to vein connections (VVs) in which a branch vein from each twin meets directly on the superficial placental surface allowing low pressure bidirectional flow. In utero obstetric sonography with targeted Doppler interrogation has been used to identify the presence of AV and AA connections4. Prenatally detected AAs that have been confirmed by postnatal placental injection studies have been shown to be associated with an improved prognosis for both twins5. Furthermore, fetoscopic laser ablation of inter-twin vascular connections on the fetal surface of the shared placenta is now the preferred treatment for early, severe TTTS. 
Postnatal placental injection studies provide a valuable method to confirm the accuracy of prenatal Doppler ultrasound findings and the efficacy of fetal laser therapy6. Using colored dyes separately hand-injected into the arterial and venous circulations of each twin, the technique highlights and delineates AVs, AAs, and VVs. This definitive demonstration of MC placental vascular anatomy may then be correlated with Doppler ultrasound findings and neonatal outcome to enhance our understanding of the pathophysiology of MC twinning and its sequelae. Here we demonstrate our placental injection technique.

Vascular mapping of monochorionic (MC) twin placentas after birth provides a means for detailed demonstration of vascular connections between the twins&#x2019; circulations. 
Imbalance of these connections is thought to play a pivotal role in the development of complications of MC twinning including twin-to-twin transfusion syndrome.

导丝辅助导管和彩色染料注射的双人单绒毛膜胎盘血管映射

Monochorionic (MC) twin pregnancies are associated with significantly higher morbidity and mortality rates than dichorionic twins. Approximately 50% of MC ...

医学

Accurate and Simple Evaluation of Vascular Anastomoses in Monochorionic Placenta using Colored Dye

The presence of placental vascular anastomoses is a conditio sine qua non for the development of twin-to-twin transfusion syndrome (TTTS) and twin anemia polycythemia sequence (TAPS)1,2. Injection studies of twin placentas have shown that such anastomoses are almost invariably present in monochorionic twins and extremely rare in dichorionic twins1. Three types of anastomoses have been documented: from artery to artery, from vein to vein and from artery to vein. Arterio-venous (AV) anastomoses are unidirectional and are referred to as "deep" anastomoses since they proceed through a shared placental cotyledon, whereas arterio-arterial (AA) and veno-venous (VV) anastomoses are bi-directional and are referred to as "superficial" since they lie on the chorionic plate. Both TTTS and TAPS are caused by net imbalance of blood flow between the twins due to AV anastomoses. Blood from one twin (the donor) is pumped through an artery into the shared placental cotyledon and then drained through a vein into the circulation of the other twin (the recipient). Unless blood is pumped back from the recipient to the donor through oppositely directed deep AV anastomoses or through superficial anastomoses, an imbalance of blood volumes occurs, gradually leading to the development of TTTS or TAPS. The presence of an AA anastomosis has been shown to protect against the development of TTTS and TAPS by compensating for the circulatory imbalance caused by the uni-directional AV anastomoses1,2. 
Injection of monochorionic placentas soon after birth is a useful mean to understand the etiology of various (hematological) complications in monochorionic twins and is a required test to reach the diagnosis of TAPS2. In addition, injection of TTTS placentas treated with fetoscopic laser surgery allows identification of possible residual anastomoses3-5. This additional information is of paramount importance for all perinatologists involved in the management and care of monochorionic twins with TTTS or TAPS. Several placental injection techniques are currently being used. We provide a simple protocol to accurately evaluate the presence of (residual) vascular anastomoses using colored dye injection.

Twin-to-twin transfusion syndrome and twin anemia polycythemia sequence are two potentially devastating problems in perinatal medicine. Both disorders occur only in monochorionic twins and result from unbalanced blood flow through placental vascular anastomoses. We provide a simple protocol to accurately evaluate the presence of vascular anastomoses using colored dye injection of placental vessels after birth.

在单绒毛膜胎盘血管吻合用有色染料的精确和简单的评价

The presence of placental vascular anastomoses is a conditio sine qua non for the development of twin-to-twin transfusion syndrome (TTTS) and twin anemia ...

Fetal Mouse Cardiovascular Imaging Using a High-frequency Ultrasound (30/45MHZ) System

Congenital heart defects (CHDs) are the most common cause of childhood morbidity and early mortality. Prenatal detection&#160;of the underlying molecular mechanisms of CHDs is&#160;crucial for inventing new preventive and therapeutic strategies. Mutant mouse models are powerful tools to discover new&#160;mechanisms&#160;and environmental stress modifiers that drive cardiac development and their potential&#160;alteration in CHDs. However, efforts to establish the causality of these putative contributors have been limited to histological&#160;and molecular studies&#160;in non-survival animal experiments, in which&#160;monitoring the key physiological and hemodynamic parameters is&#160;often absent. Live imaging technology has become an essential tool to establish the&#160;etiology of CHDs. In particular,&#160;ultrasound imaging can be used prenatally without surgically exposing the fetuses,&#160;allowing maintaining&#160;their baseline physiology while monitoring the impact of environmental stress&#160;on the hemodynamic and structural aspects of cardiac chamber development. Herein, we use the High-Frequency Ultrasound (30/45)&#160;system to examine the cardiovascular system in fetal mice at E18.5 in utero at the baseline and in response to prenatal hypoxia exposure. We demonstrate the feasibility of the system to measure cardiac chamber size, morphology, ventricular function, fetal heart rate, and umbilical artery flow indices, and their alterations in fetal mice exposed to systemic chronic hypoxia in utero in real time.

Fetal Mouse Cardiovascular Imaging Using a High-frequency Ultrasound 30/45MHZ System

High-frequency ultrasound imaging of the fetal mouse has improved imaging resolution and can provide precise non-invasive characterization of cardiac development and structural defects. The protocol outlined herein is designed to perform real-time fetal mice echocardiography in vivo.

用高频超声 (30/45 mhz) 系统对胎儿小鼠进行心血管成像

Congenital heart defects (CHDs) are the most common cause of childhood morbidity and early mortality. Prenatal detection&#160;of the underlying molecular ...

High Frequency Ultrasound for the Analysis of Fetal and Placental Development In Vivo

Ultrasound imaging is a widespread method used to detect organ anomalies and tumors in human and animal tissues. The method is non-invasive, harmless, and painless, and the application is easy, fast, and can be done anywhere, even with mobile devices. During pregnancy, ultrasound imaging is standardly used to closely monitor fetal development. The technique is important to assess intrauterine growth restriction (IUGR), a pregnancy complication with short- and long-term health consequences for both the mother and fetus. Understanding the process of IUGR is indispensable for developing effective therapeutic strategies. 
The ultrasound system used in this manuscript is an ultrasound device produced for the analysis of small animals and can be used in various research fields, including pregnancy research. Here we describe the usage of the system for in vivo analysis of fetuses from natural killer (NK) cell/mast cell (MC)-deficient mothers that give birth to growth-restricted pups. The protocol includes preparation of the system, handling of the mice before and during measurements, and the usage of the B-mode, color doppler mode, and pulse-wave doppler mode. Fetal size, placental size, and blood supply to the fetus were analyzed. We found reduced implantation sizes and smaller placentas in NK/MC-deficient mice from mid-gestation onwards. In addition, MC/NK-deficiency was associated with absent and reversed end diastolic flow in the fetal Arteria umbilicalis(UmA) and an elevated resistance index. The methods described in the protocol can easily be used for related and non-related research topics.

High Frequency Ultrasound for the Analysis of Fetal and Placental Development In Vivo

Here we describe the technique of high frequency ultrasound for in vivo analysis of fetuses in mice. This method allows the follow-up of fetuses and the analysis of placental parameters as well as maternal and fetal blood flow throughout pregnancy.

高频超声在胎儿和胎盘发育分析中的影响

Ultrasound imaging is a widespread method used to detect organ anomalies and tumors in human and animal tissues. The method is non-invasive, harmless, and ...

Medical-grade Sterilizable Target for Fluid-immersed Fetoscope Optical Distortion Calibration

We have developed a calibration target for use with fluid-immersed endoscopes within the context of the GIFT-Surg (Guided Instrumentation for Fetal Therapy and Surgery) project. One of the aims of this project is to engineer novel, real-time image processing methods for intra-operative use in the treatment of congenital birth defects, such as spina bifida and the twin-to-twin transfusion syndrome. The developed target allows for the sterility-preserving optical distortion calibration of endoscopes within a few minutes. Good optical distortion calibration and compensation are important for mitigating undesirable effects like radial distortions, which not only hamper accurate imaging using existing endoscopic technology during fetal surgery, but also make acquired images less suitable for potentially very useful image computing applications, like real-time mosaicing. In this paper proposes a novel fabrication method to create an affordable, sterilizable calibration target suitable for use in a clinical setup. This method involves etching a calibration pattern by laser cutting a sandblasted stainless steel sheet. This target was validated using the camera calibration module provided by OpenCV, a state-of-the-art software library popular in the computer vision community.

This article describes the design and development of a sterilizable custom camera optical distortion calibration target for the peri-operative, fluid-immersed calibration of endoscopes during endoscopic interventions.

对于流体沉浸胎儿镜的光学畸变校正医用灭菌目标

We have developed a calibration target for use with fluid-immersed endoscopes within the context of the GIFT-Surg (Guided Instrumentation for Fetal ...

生物工程

Targeted Laser Ablation in the Embryo of Saccharina latissima

In Saccharina latissima, the embryo&#160;develops as a monolayered cell sheet called the lamina or the blade. Each embryo cell is easy to observe, readily distinguishable from its neighbors, and can be individually targeted. For decades, laser ablation has been used to study embryo development. Here, a protocol for cell-specific laser ablation was developed for early embryos of the brown alga S. latissima. The presented work includes: (1) the preparation of Saccharina embryos, with a description of the critical parameters, including culture conditions, (2) the laser ablation settings, and (3) the monitoring of the subsequent growth of the irradiated embryo using time-lapse microscopy. In addition, details are provided on the optimal conditions for transporting the embryos from the imaging platform back to the lab, which can profoundly affect subsequent embryo development. Algae belonging to the order Laminariales display embryogenesis patterns similar to Saccharina; this protocol can thus be easily transferred to other species in this taxon.

Targeted Laser Ablation in the Embryo of Saccharina latissima

The destruction of specific cells in the embryo is a powerful tool for studying cellular interactions involved in cell fate. The present protocol describes techniques for the laser ablation of targeted cells in the early embryo of the brown alga Saccharina latissima.

靶向激光消融术在乳酸杆菌胚胎中的应用

In Saccharina latissima, the embryo&#160;develops as a monolayered cell sheet called the lamina or the blade. Each embryo cell is easy to observe, readily ...

Simulator Training for Endovascular Neurosurgery

Simulation-based training has become common practice across medical specialties, especially for learning complex skills performed in high-risk environments. In the field of endovascular neurosurgery, the demand for consequence- and risk-free learning environments led to the development of simulation devices valuable for medical trainees. The goal of this protocol is to provide instructive guidelines for the use of an endovascular neurosurgery simulator in an academic setting. The simulator provides trainees with the opportunity to receive realistic feedback on their knowledge of anatomy, as well as haptic feedback indicative of their success in handling the catheter-based systems without negative consequences. The utility of this specific protocol in relation to other neuroendovascular training modalities is also discussed.

Simulation of complex, high-risk procedures is critical to the education of medical trainees. A protocol for simulator-based endovascular neurosurgery training in a controlled academic environment is described. The protocol includes stepwise guidelines for trainees of varying levels, with a discussion of the advantages and limitations of this model.

血管内神经外科模拟器培训

Simulation-based training has become common practice across medical specialties, especially for learning complex skills performed in high-risk ...

神经科学

Evaluation of Color Difference in Placenta with Twin Anemia Polycythemia Sequence

Twin anemia polycythemia sequence (TAPS) occurs in 5% of monochorionic twins and is characterized by large inter-twin hemoglobin differences. The postnatal diagnostic criteria for TAPS are based on hematologic parameters and placental characteristics. Placental examination after birth shows that color of the maternal side between placental territories of the anemic and polycythemic twins is remarkably different. The color difference in TAPS placentas is higher compared to monochorionic placentas with acute peripartum feto-fetal transfusion; thus, this is used as an additional diagnostic criterion for TAPS. Software such as ImageJ enables the computer-based measurement of color intensity in TAPS placentas. However, a detailed method for the calculation of color differences between anemic and polycythemic components of TAPS placentas has not yet been described. The protocol presented here provides a step-by-step method for analyzing color differences in the maternal side of TAPS placentas using ImageJ software.

In monochorionic twins with twin anemia polycythemia sequence (TAPS), the donor twin and its corresponding placenta share are pale, while the recipient twin and its placental share have a plethoric aspect. Presented here is a protocol to quantify the color difference in maternal side of TAPS placenta after birth.