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    ABSTRACT: Endovascular techniques have been embraced as a minimally-invasive treatment approach within different disciplines of interventional radiology and cardiology. The current practice of endovascular procedures, however, is limited by a number of factors including exposure to high doses of X-ray radiation, limited 3D imaging, and lack of contact force sensing from the endovascular tools and the vascular anatomy. More recently, advances in steerable catheters and development of master/slave robots have aimed to improve these practices by removing the operator from the radiation source and increasing the precision and stability of catheter motion with added degrees-of-freedom. Despite their increased application and a growing research interest in this area, many such systems have been designed without considering the natural manipulation skills and ergonomic preferences of the operators. Existing studies on tool interactions and natural manipulation skills of the operators are limited. In this manuscript, new technical developments in different aspects of robotic endovascular intervention including catheter instrumentation, intra-operative imaging and navigation techniques, as well as master/slave based robotic catheterization platforms are reviewed. We further address emerging trends and new research opportunities towards more widespread clinical acceptance of robotically assisted endovascular technologies.
    No preview · Article · Nov 2013 · Annals of Biomedical Engineering
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    ABSTRACT: Background: Although meningiomas of the spheno-orbital region commonly result in hyperostosis, intraosseous meningiomas, which feature extensive full thickness infiltration of the anterolateral skull base, are rare. In this study, we assess the value of image guidance during surgery for intraosseous spheno-orbital skull-base meningiomas in achieving safe and maximal abnormal bone resection. Method: Only cases with a full thickness and extensive intraosseous component were included. Image guidance was used to guide drilling of hyperostotic bone. Extensive resulting defects of the orbital wall were reconstructed with titanium mesh. Post-operative CT scans were used to assess completeness of abnormal bone resection in the skull base, and MRI scans used to evaluate residual intradural disease. Operative complications to neurovascular structures in adjacent foramina were recorded. Results: Nineteen patients with full-thickness intraosseous spheno-orbital meningiomas underwent image-guided resection. Anterior clinoidectomy to variable extent was necessary in 11 cases with decompression of the optic canal in five. In ten cases, hyperostotic bone was drilled from the middle fossa around the exit foramina of the trigeminal nerve and base of the pterygoid plates. Proptosis was corrected in all cases, and of 11 patients presenting with reduced visual acuity, symptoms improved or stabilized in ten cases. Post-operative CT scans confirmed gross resection of abnormal bone in all cases, but limited residual tumor was present around the cavernous sinus or orbital apex in eight patients. One patient died from a pulmonary embolism, the only mortality of the series. One patient had worsening of pre-existing poor visual acuity, and three patients had worsening of pre-existing ophthalmoplegia. Five patients developed new facial numbness post-operatively, which persisted in three cases. Conclusions: Intra-operative image guidance allowed total or near-total resection of the hyperostotic skull base around the cranial nerve foramina with minimal morbidity in a group of patients with extensive spheno-orbital meningiomas.
    No preview · Article · Mar 2013 · Acta Neurochirurgica
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    ABSTRACT: Introduction: Since the first published work on natural orifice translumenal endoscopic surgery (NOTES) a decade ago, progress has been made in the domain of education and training, although questions posed by the original White Paper remain. This article aims to review the current status of education and training in NOTES. Methods: A review of the literature was conducted to evaluate the following: (1) What are the current training methods/modalities used for NOTES; what is the level of evidence to support their use? (2) How has NOTES clinical training been quantified; what is the evidence relating to performance of different NOTES operators? (3) What clinical NOTES training programs have been established and what are the wider training needs? Results: A total of 25 studies were included: 11 nonanimal studies, 8 animal studies, and 6 descriptions of education programs. Several animal and simulator models demonstrated construct validity, but no study showed human predictive validity. Logarithmic learning curves in animal models demonstrate 10 to 15 cases achieving a proficiency level. Current trends are that gastroenterologists prefer it for diagnostic and basic procedures, whereas surgeons prefer it for complex therapeutic cases. Conclusion: The development of a new specialty is intriguing but currently unviable. Training programs have been initiated, but information is limited; the common theme is surgeons receiving endoscopic training. Despite the research done, our knowledge of training and educating in NOTES procedures is limited, preventing a meta-analysis or formal review from being performed. Further research is needed to integrate NOTES into routine clinical procedure.
    No preview · Article · Jan 2013 · Surgical Innovation
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