Martin Lehecka – Helsinki Microneurosurgery

Автор: Martin Lehecka
Название: Helsinki Microneurosurgery
Формат: PDF
Тема: Медицина
Количество страниц: 345
Качество: Компьютерное, издательское

TABlE
OF COnTEnTs
1 . I nTRODUCTI On 1 3
2. DEPARTMEnT OF nEUROsURGERY, HElsI nKI
UnIVERsI TY CEnTRAl HOsPI TAl
1 7
2. 1 . HI STORY OF NEUROSURGERY I N HELSI NKI
AND FI NLAND
1 7

2. 1 . 1 . Aarno Snel l man, founder of Fi nni sh
neurosurgery 1 7

2. 1 . 2.
Angi ography i n Fi nl and 1 8
2. 1 . 3. Worl d War I I and l ate 1 940’ s 1 9
2. 1 . 4.
Mi croneurosurgery and endovascul ar
surgery 20
2. 1 . 5.
Changes towards the present ti me 2 1
2. 2.
PRESENT DEPARTMENT SETUP 24
2. 3. STAFF MEMBERS 24

2. 3. 1 . Neurosurgeons 25
2. 3. 2. Neurosurgi cal resi dents 30
2. 3. 3. Neuroanesthesi ol ogi sts 30
2. 3. 4. Neuroradi ol ogi sts 3 1
2. 3. 5. Bed wards 32
2. 3. 6. I ntensi ve care uni t ( I CU) 34
2. 3. 7. Operati ng rooms 36
2. 3. 8. Admi ni strati ve personnel 37
2. 4.
OPERATI NG ROOM COMPLEX 40
2. 4. 1 .
Operati ng room compl ex desi gn 40
2. 4. 2.
Operati ng room ambi ence 41
3. AnEsTHEsI A 45
3. 1 . GENERAL PHYSI OLOGI CAL PRI NCI PLES
AND THEI R I MPACT ON ANESTHESI A 46
3. 1 . 1 . I ntracrani al pressure 46
3. 1 . 2.
Autoregul ati on of cerebral bl ood flo 47
3. 1 . 3. CO2 reacti vi ty 48
3. 1 . 4. Cerebral metabol i c coupl i ng 49
3. 2. MONI TORI NG OF ANESTHESI A 50
3. 3. PREOPERATI VE ASSESSMENT AND
I NDUCTI ON OF ANESTHESI A 51
3. 4. MAI NTENANCE OF ANESTHESI A 53
3. 5. TERMI NATI ON OF ANESTHESI A 55
3. 6. FLUI D MANAGEMENT AND BLOOD
TRANSFUSI ONS 56
3. 7. ANESTHESI OLOGI CAL CONSI DERATI ONS
FOR PATI ENT POSI TI ONI NG 57
3. 7. 1 . Supi ne posi ti on 57
3. 7. 2. Prone, l ateral park bench and
kneel i ng posi ti ons 58
3. 7. 3. Si tti ng posi ti on 62 3. 8. POSTOPERATI VE CARE I N THE I CU 63
3. 9. SPECI AL SI TUATI ONS 65
3. 9. 1 . Temporary cl i ppi ng i n aneurysm
surgery 65
3. 9. 2. Adenosi ne and short cardi ac arrest 66
3. 9. 3. I ntraoperati ve neurophysi ol ogi c
moni tori ng 66
3. 9. 4. Anti thromboti c drugs and
thromboembol i sm 67
4. PRI nCI PlEs OF HElsI nKI
MI CROnEUROsURGERY 69
4. 1 . GENERAL PHI LOSOPHY 69
4. 2.
PRI NCI PLES OF MI CRONEUROSURGERY 70
4. 3. OPERATI NG ROOM SETUP 71
4. 3. 1 . Techni cal setup 71
4. 3. 2. Di spl ays 72
4. 4. POSI TI ONI NG AND HEAD FI XATI ON 73
4. 4. 1 . Operati ng tabl e 73
4. 4. 2.
Pati ent posi ti oni ng 73
4. 4. 3. Neurosurgeon’ s posi ti on and
movement 74
4. 4. 4. Head fixat io 76
4. 5. NECESSARY OR USEFUL TOOLS 77
4. 5. 1 . Operati ng mi croscope 77
4. 5. 2.
Armrest 79
4. 5. 3. Bi pol ar and di athermi a 79
4. 5. 4. Hi gh speed dri l l 80
4. 5. 5. Ul trasoni c aspi rator 82
4. 5. 6. Fi bri n gl ue 83
4. 5. 7. I ndocyani ne green angi ography 84
4. 5. 8. Mi crosurgi cal doppl er and flowmete 85
4. 5. 9. Neuronavi gator 86
4. 5. 1 0. I ntraoperati ve DSA 87
4. 6. MI CROI NSTRUMENTS 88
4. 1 0. CLOSI NG 104
4. 1 1 .
KEY FACTORS I N HELSI NKI STYLE
MI CRONEUROSURGERY 105
4. 1 2. LI ST OF PROF. HERNESNI EMI ’ S GENERAL
HABI TS AND I NSTRUMENTS 106
5. COMMOn APPROACHEs 1 1 1
5. 1 . LATERAL SUPRAORBI TAL APPROACH 1 1 1
5. 1 . 1 . I ndi cati ons 1 1 1
5. 1 . 2.
Posi ti oni ng 1 1 2

5. 1 . 3. I nci si on and crani otomy 1 1 3
5. 2.
PTERI ONAL APPROACH 1 1 8
5. 2. 1 .
I ndi cati ons 1 1 8
5. 2. 2.
Posi ti oni ng 1 1 9
5. 2. 3. I nci si on and crani otomy 1 1 9
5. 3. I NTERHEMI SPHERI C APPROACH 1 24

5. 3. 1 . I ndi cati ons 1 24

5. 3. 2. Posi ti oni ng 1 25
5. 3. 3. I nci si on and crani otomy 1 25
5. 4. SUBTEMPORAL APPROACH 1 32
5. 4. 1 . I ndi cati ons 1 32
5. 4. 2.
Posi ti oni ng 1 33
5. 4. 3. Ski n i nci si on and crani otomy 1 35
5. 5. RETROSI GMOI D APPROACH 1 44
5. 5. 1 . I ndi cati ons 1 45
5. 5. 2.
Posi ti oni ng 1 46
5. 5. 3. Ski n i nci si on and crani otomy 1 49
5. 6. LATERAL APPROACH TO FORAMEN MAGNUM 1 56
5. 6. 1 . I ndi cati ons 1 56
5. 6. 2. Posi ti oni ng 1 56
5. 6. 3. Ski n i nci si on and crani otomy 1 57
5. 7. PRESI GMOI D APPROACH 1 60
5. 7. 1 . I ndi cati ons 1 60
5. 7. 2.
Posi ti oni ng 1 62
5. 7. 3. Ski n i nci si on and crani otomy 1 62
5. 8. SI TTI NG POSI TI ON – SUPRACEREBELLAR
I NFRATENTORI AL APPROACH 1 70
5. 8. 1 . I ndi cati ons 1 71

5. 8. 2. Posi ti oni ng 1 73
5. 8. 3. Ski n i nci si on and crani otomy 1 77
5. 9. SI TTI NG POSI TI ON – APPROACH TO THE
FOURTH VENTRI CLE AND FORAMEN
MAGNUM REGI ON 1 83
5. 9. 1 . I ndi cati ons 1 83
5. 9. 2. Posi ti oni ng 1 83
5. 9. 3. Ski n i nci si on and crani otomy 1 83 6. sPECI FI C TECHnI QUEs AnD sTRATEGI Es FOR
DI FFEREnT PATHOlOGI Es 1 95
6. 1 . ANEURYSMS 1 95
6. 1 . 1 . Approaches for di fferent aneurysm 1 95
6. 1 . 2. General strategy for ruptured
aneurysms 1 96
6. 1 . 3. General strategy for unruptured
aneurysms 1 97
6. 1 . 4. Rel ease of CSF and removal of I CH 1 97
6. 1 . 5. Di ssecti on towards the aneurysm 1 99
6. 1 . 6. Openi ng of the Syl vi an fissur 200
6. 1 . 7. Temporary cl i ppi ng 201
6. 1 . 8. Fi nal cl i ppi ng and cl i p sel ecti on 203
6. 1 . 9. I ntraoperati ve rupture 203
6. 1 . 1 0. Adenosi ne 206
6. 2. ARTERI OVENOUS MALFORMATI ONS 207
6. 2. 1 . General strategy i n AVM surgery 207
6. 2. 2. Preoperati ve embol i zati on 207
6. 2. 3. Approaches 208
6. 2. 4. Dural openi ng and i ni ti al di ssecti on 208
6. 2. 5. Further di ssecti on and use of
temporary cl i ps 2 1 0
6. 2. 6. Coagu l ati on and di ssecti on of smal l
feeders 2 1 1
6. 2. 7. Fi nal stage of AVM removal 2 1 2
6. 2. 8. Fi nal hemostasi s 2 1 2
6. 2. 9. Postoperati ve care and i magi ng 2 1 2
6. 3. CAVERNOMAS 2 1 4
6. 3. 1 . General strategy i n cavernoma
surgery 2 1 4
6. 3. 2. I ntraoperati ve l ocal i zati on 2 1 4
6. 3. 3. Approaches 2 1 5
6. 3. 4. Di ssecti on and removal 2 1 6
6. 3. 5. Postoperati ve i magi ng 2 1 7
6. 4. MENI NGI OMAS 2 1 8
6. 4. 1 . General strategy wi th convexi ty
meni ngi omas 2 1 8
6. 4. 2. General strategy wi th parasagi ttal
meni ngi omas 2 1 9
6. 4. 3. General strategy wi th fal x and
tentori um meni ngi omas 22 1
6. 4. 4. General strategy wi th skul l base
meni ngi omas 222

6. 4. 5. Tumor consi stency 224

6. 4. 6. Approaches 224

6. 4. 7. Devascu l ari zati on
225
6. 4. 8. Tumor removal
225
6. 4. 9. Dural repai r 226
6. 5. GLI OMAS 227

6. 5. 1 . General strategy wi th l ow-grade
gl i omas 227

6. 5. 2. General strategy wi th hi gh-grade
gl i omas 228
6. 5. 3. Approaches 229
6. 5. 4. I ntracrani al ori entati on and
del i neati on of the tumor 229
6. 5. 5. Tumor removal 230
6. 6. COLLOI D CYSTS OF THE THI RD VENTRI CLE 231
6. 6. 1 . General strategy wi th col l oi d cyst
surgery 231
6. 6. 2. Posi ti oni ng and crani otomy 231
6. 6. 3. I nterhemi spheri c approach and
cal l osal i nci si on 232
6. 6. 4. Col l oi d cyst removal 233
6. 7. PI NEAL REGI ON LESI ONS 234
6. 7. 1 . General strategy wi th pi neal regi on
surgery 234
6. 7. 2. Approach and crani otomy 235
6. 7. 3. I ntradural approach 235
6. 7. 4. Lesi on removal 235
6. 8. TUMORS OF THE FOURTH VENTRI CLE 236
6. 8. 1 . General strategy wi th fourth
ventri cl e tumors 236
6. 8. 2. Posi ti oni ng and crani otomy 237
6. 8. 3. I ntradural di ssecti on towards the
fourth ventri cl e 237
6. 8. 4. Tumor removal 238
6. 9. SPI NAL I NTRADURAL TUMORS 240
6. 9. 1 . General strategy wi th i ntradural
spi nal l esi ons 240
6. 9. 2. Posi ti oni ng 241

6. 9. 3. Approach 242
6. 9. 4. I ntradural di ssecti on 243
6. 9. 5. Cl osure 243
7. NEUROSURGI CAL TRAI NI NG, EDUCATI ON
AND RESEARCH I N HELSI NKI 245
7. 1 . NEUROSURGI CAL RESI DENCY I N HELSI NKI 245
7. 1 . 1 . Resi dency program 245
7. 1 . 2. How to become a neurosurgeon
i n Hel si nki – the resi dent years –
Aki Laakso 246
7. 2. ACADEMI C AND RESEARCH TRAI NI NG 250
7. 2. 1 . PhD program 250
7. 2. 2. Maki ng of a PhD thesi s i n Hel si nki ,
my experi ence – Johan Marj amaa 250
7. 3. MI CRONEUROSURGI CAL FELLOWSHI P
WI TH PROFESSOR HERNESNI EMI 253
7. 4. MEDI CAL STUDENTS 254
7. 5. I NTERNATI ONAL VI SI TORS 254
7. 6. I NTERNATI ONAL LI VE SURGERY COURSES 256
7. 6. 1 . Hel si nki Li ve Course 256
7. 6. 2. LI NNC-ACI NR course (Organi zed
by J. Moret and C. I sl ak) 258 7. 7. PUBLI CATI ON ACTI VI TY 260
7. 8. RESEARCH GROUPS AT HELSI NKI
NEUROSURGERY 261
7. 8. 1 . Bi omedi cum group for research
on cerebral aneurysm wal l 261
7. 8. 2. Transl ati onal functi onal
neurosurgery group 262
7. 8. 3. Hel si nki Cerebral Aneurysm
Research ( HeCARe) group 262
8. VI SI TI NG HELSI NKI NEUROSURGERY 265
8. 1 . TWO YEAR FELLOWSHI P –
JOUKE S. VAN POPTA (ZARAGOZA, SPAI N) 265
8. 1 . 1 . Why to do a fel l owshi p? 265
8. 1 . 2. I n search of a fel l owshi p 266
8. 1 . 3. Checki ng i t out 266
8. 1 . 4. Arri val i n Hel si nki 266
8. 1 . 5. The very ?rst day 266
8. 1 . 6. A day i n the l i fe (of a fel l ow) 267
8. 1 . 7. Assi sti ng i n surgery 267
8. 1 . 8. Nurses 268
8. 1 . 9. Anesthesi ol ogi sts 268
8. 1 . 1 0. Musi c i n the OR 269
8. 1 . 1 1 . Rounds 269
8. 1 . 1 2. Vi si tors 271

8. 1 . 1 3. Pi ns and thei r stori es 271

8. 1 . 1 4. LI NNC and Li ve Course 271

8. 1 . 1 5. Weather and the four seasons 272
8. 1 . 1 6. Apartments 273
8. 1 . 1 7. Hel si nki 273
8. 1 . 1 8. Fi nni sh food 273
8. 1 . 1 9. Languages 273
8. 1 . 20. Famous words 274
8. 1 . 21 . Practi ce, practi ce, practi ce 274
8. 1 . 22. Vi deo edi ti ng 274
8. 1 . 23. The surgery of J uha Hernesni emi 274
8. 1 . 24. The choi ce of a fel l owshi p 275
8. 2. ADAPTI NG TO FI NNI SH CULTURE AND
SOCI ETY – ROSSANA ROMANI (ROME, I TALY) 276
8. 2. 1 . The di ?erence between “to tal k
the tal k” and “to wal k the wal k” 276
8. 2. 2. Di ?cu l t to l earn but good for l i fe:
The Fi nni sh l anguage 274
8. 2. 3. When i n Fi nl and do as the Fi nns 280
8. 2. 4. Never good weather 281
8. 2. 5. Fi nni sh atti tude: “Si su” 283
8. 2. 6. He and she = hän 283
8. 2. 7. Concl usi ons 283
8. 3. I MPRESSI ONS OF HELSI NKI : ACCOUNT OF
A VI SI T – FELI X SCHOLTES ( LI ÈGE, BELGI UM) 284
8. 4. TWO YEARS OF FELLOWSHI P AT THE
DEPARTMENT OF NEUROSURGERY I N HEL-
SI NKI – REZA DASHTI ( I STANBUL, TURKEY) 290
. 5. MY MEMORI AL OF “GO GO SURGERY”
I N HELSI NKI – KEI SUKE I SHI I (OI TA, JAPAN) 294
8. 5. 1 . The first impress ion of F inn 294
8. 5. 2. The Hel si nki Uni versi ty Central
Hospi tal 294
8. 5. 3. Professor Hernesni emi and hi s
surgi cal techni ques 294
8. 5. 4. My current days i n Japan 295
8. 5. 5. To concl ude 295
8. 6. AFTER A ONE-YEAR FELLOWSHI P – ONDREJ
NAVRATI L ( BRNO, CZECH REPUBLI C) 296
8. 7. ONE-YEAR FELLOWSHI P AT THE DEPART-
MENT OF NEUROSURGERY I N HELSI NKI –
ÖZGÜR ÇELI K (ANKARA, TURKEY) 300
8. 8. SI X MONTH FELLOWSHI P – MANSOOR
FOROUGHI (CARDI FF, UNI TED KI NGDOM) 302
8. 8. 1 How i t began 302
8. 8. 2. The pl ace and the peopl e 303
8. 8. 3. The Rai nbow team and i ts Chai rman 304
8. 9. TWO MONTH FELLOWSHI P – ROD
SAMUELSON ( RI CHMOND, VI RGI NI A) 308
8. 1 0. MEMORI ES OF HELSI NKI – AYSE KARATAS
(ANKARA, TURKEY) 3 1 2
9. sOME CAREER ADVI CE TO YOUnG
nEUROsURGEOns 3 1 5
9. 1 . READ AND LEARN ANATOMY 3 1 6
9. 2. TRAI N YOUR SKI LLS 3 1 6
9. 3. SELECT YOUR OWN HEROES 3 1 6
9. 4. KEEP FI T
3 1 7
9. 5. BE A MEDI CAL DOCTOR, TAKE
RESPONSI BI LI TY! 3 1 8
9. 6. LEARN YOUR BEST WAY OF DOI NG YOUR
SURGERY 3 1 8
9. 7. OPEN DOOR MI CROSURGERY 3 1 9
9. 8. RESEARCH AND KEEP RECORDS 3 1 9
9. 9. FOLLOW UP YOUR PATI ENTS 320
9. 1 0. WRI TE AND PUBLI SH 320
9. 1 1 . KNOW YOUR PEOPLE 32 1
9. 1 2. ATMOSPHERE 32 1
1 0. lI FE I n nEUROsURGERY: HOW I BECAME
ME – JUHA HERnEsnI EMI 333 1 1 .
FUTURE OF nEUROsURGERY 333
APPEnDI X 1 . PUBlI sHED ARTI ClEs On MI CRO-
nEUROsURGI CAl AnD nEUROAnEsTHEsI OlO-
GI CAl TECHnI QUEs FROM HElsI nKI
337
APPEnDI X 2. lI sT OF ACCOMPAnYI nG VI DEOs 342

4. 7.
SOME HABI TS I N PREPARATI ON AND DRAPI NG 90
4. 8. GENERAL PRI NCI PLES OF CRANI OTOMY 92
4. 9. BASI C MI CROSURGI CAL PRI NCI PLES OF
HELSI NKI STYLE MI CRONEUROSURGERY 94
4. 9. 1 . Si mpl e, cl ean, fast and preservi ng
normal anatomy 94
4. 9. 2. Movements under the mi croscope 95
4. 9. 3. Movi ng the mi croscope 98
4. 9. 4. Left hand – sucti on 99
4. 9. 5. Ri ght hand 100
4. 9. 6. Bi pol ar forceps 101
4. 9. 7. Mi crosci ssors 102
4. 9. 8. Cottonoi ds 102
4. 9. 9. Sharp and bl unt di ssecti on 103
4. 9. 1 0. I rri gati on and water di ssecti on 103
4. 9. 1 1 . Mi ni mal retracti on 104