Search Results (422)

Non-obstructive azoospermia (NOA), a severe male infertility condition with impaired or absent sperm production, is treated by microsurgical testicular sperm extraction (micro-TESE), whose success depends on identifying seminiferous tubules with active spermatogenesis. To address this challenge, we demonstrate that mid-infrared photothermal (MIP) microscopy can provide label-free molecular signatures to distinguish different NOA subtypes in patient tissues. We applied MIP microscopy and MIP-guided IR spectroscopy to testicular tissues from obstructive azoospermia (normal spermatogenesis) and idiopathic NOA (abnormal spermatogenesis) patients. Tissue classification was performed using a Singular Value Decomposition–Random Forest (SVD-RF) pipeline. MIP imaging revealed distinct lipid distribution and reduced lipid content in NOA tissues compared to normal spermatogenic tissues. Using SVD to extract spectroscopic features and RF for classification, we achieved 94.03% accuracy in distinguishing testicular tissues as normal spermatogenesis or three pathological subtypes of idiopathic NOA. These findings demonstrate MIP microscopy as an effective tool for characterizing the spermatogenic potential of seminiferous tubules based on their molecular composition, potentially facilitating improved sperm retrieval strategies. Full article

Background and Clinical Significance: Modern neuro-oncologists encounter a major challenge when dealing with glioblastomas located in the dominant hemisphere’s temporo-basal area, because their invasive nature disrupts the proximity to eloquent cortical areas (language and speech), as well as skull base venous structures, which can lead to a quick decline in function from the disruptions in these networks and the disconnection of corridor-level pathways. This manuscript illustrates the application of metric-based phenotyping, anatomically defined imaging, and venous-anchored microsurgical techniques that can aid in preserving the remaining functional reserve in patients with dominant hemisphere glioblastomas and demonstrate measurable outcomes through longitudinal follow-up data. Case Presentation: A 48-year-old right-handed male patient presented with a four-week history of progressively worsening symptoms consistent with a dominant hemisphere syndrome, resulting in a significant decrease in his independence (mRS 0 → 4; BI 55/100; IADL 2/8). His symptoms included non-fluent expressive aphasia with a marked inability to generate words and respond to verbal cues (BNT 8/30; SF 4 WPM). Additionally, he experienced prolonged lateralizing hemisensory decompensation and corticospinal tract dysfunction. Imaging studies revealed a large multiloculated cystic lesion located in the left temporo-basal region. The lesion displayed a thick irregular peripheral enhancement pattern with mural nodules and septa, and surrounding T2 hyperintensity extending into the temporal associative white matter, indicating disruption of the lexical–semantic networks and corridor-level tracts. Utilizing continuous SSEPS/MEPs during surgery, a skull base parallel ventral temporal corridor was developed to allow decompression of the cyst first, followed by cyst evacuation, inside-out cytoreduction, subpial dissection, and specific preservation of both superficial and deep temporal veins using selective capsular preservation at venous interface locations where necessary. Postoperative CT scans performed on POD #3 and POD #7 indicated stable decompression without hemorrhage or hydrocephalus complications, followed by rapid quantitative improvement in NIHSS (8 → 2), MoCA (18 → 26), BNT (8 → 26), SF (4 → 12), mRS (2 at discharge, 1 at follow-up), BI (85 at discharge, 95 at follow-up), and IADL (6/8 at discharge, 8/8 at follow-up). Histopathological examination confirmed a diagnosis of glioblastoma. Conclusions: This case study supports a model of a network- and vein-constrained glioblastoma of the dominant hemisphere in the temporo-basal region that can result in substantial restoration of language capabilities and preservation of functional reserves for additional therapies using venous-anchored subpial microsurgical approaches. The use of objective and quantifiable measures of phenotyping and longitudinal follow-up tracking could provide a reproducible method for measuring the degree of recovery of the affected network(s) and establishing safe boundaries for temporal glioma surgery. Full article

Lymphedema is a chronic, incurable disease affecting patients who undergo high-risk cancer treatments. Advances in microsurgical techniques have paved the way for the development of techniques that can prevent or treat this unrelenting condition. In this article we discuss microsurgical interventions for the prevention and treatment of lymphedema, as well as the role of robotics in lymphatic surgery. Full article

Background/Objectives: Simulation has become an integral part of contemporary surgical training, allowing safe acquisition of technical skills with objective performance assessment. Microsurgery and robotic surgery share several technical features, including fine bimanual coordination, precise instrument control, and stereoscopic vision. This study aimed to evaluate whether a structured microsurgical course is associated with improved performance on a robotic surgical simulator and to explore its potential role within robotic training pathways. Methods: A prospective study was conducted between October 2022 and November 2025 at a single academic center, including 56 participants divided into three groups. Group A consisted of surgical residents attending a 3-day Basic Microsurgery Course; Group B included residents who did not undergo training during the same period; and Group C comprised experienced microsurgeons. Groups A and B performed two robotic simulation tasks at baseline (T0) and after three days (T1). Group C was assessed at T1 only as a reference benchmark. Performance was evaluated using simulator-derived metrics. Statistical analysis was performed using paired and unpaired t-tests. Results: Group A showed significant improvement across several performance parameters following training, whereas no comparable changes were observed in Group B. At T1, Group A demonstrated better performance than Group B in multiple metrics. Group C achieved the highest scores and was considered a reference group. Conclusions: Structured microsurgical training was associated with improved performance in a robotic simulation setting. These findings suggest that microsurgical skills may be transferable to robotic tasks and may contribute to the early phases of robotic skill acquisition. Further studies are required to assess their impact in clinical practice. Full article

Background: Aneurysmal subarachnoid hemorrhage (aSAH) remains a devastating neurological condition, with patients presenting with poor-grade aSAH having a particularly limited potential for recovery. Data on outcome trajectories after microsurgical clipping in this subgroup are scarce. The objective of this study was to analyze the functional outcomes in patients with poor-grade aSAH treated with microsurgical clipping, and to identify clinical factors associated with recovery. Methods: This retrospective study included 38 patients (median age 55 years; 60.5% female) with World Federation of Neurosurgical Societies (WFNS) grades 4–5, who underwent microsurgical clipping at a single tertiary care centre between 2016 and 2023. Functional outcome was assessed using the modified Rankin Scale (mRS) at hospital discharge and 6 months follow-up, and functional outcome was analyzed in relation to clinical variables (delayed cerebral ischemia (DCI), intracerebral hemorrhage (ICH), initial seizures, the need for decompressive craniectomy) using correlation and group comparison analyses. Results: The indication for microsurgical clipping was primarily driven by the need for ICH evacuation (50%) or by aneurysm configuration (47.5%). Microsurgical aneurysm clipping was performed on the day of hemorrhage in 25 patients (65.8%), with 16 patients (42.1%) undergoing immediate surgery following direct transfer from the emergency department to the operating theatre. ICH was present in 60.5% and IVH in 92.1%. Decompressive craniectomy was performed in 42.1%. DCI occurred in 21.6% of patients. In-hospital mortality was 15.8%, increasing to 22.6% at 6 months follow-up. Good functional outcome (mRS 0–2) was observed in 10.5% of patients at discharge and improved to 25.8% at 6 months. At hospital discharge, higher mRS scores were associated with the need for immediate aneurysm repair (p = 0.04), primary decompressive craniectomy (p = 0.02), and DCI (p = 0.006). Primary decompressive craniectomy (p = 0.04), reflecting greater disease severity, and DCI (p = 0.002) remained associated with worse functional outcome at 6 months. Conclusions: In poor-grade aSAH patients undergoing microsurgical clipping, mortality remains substantial; however, functional recovery may extend beyond hospital discharge. The need for immediate surgical intervention and primary decompressive craniectomy likely reflects a particularly severe hemorrhagic burden in patients and is associated with worse early functional outcomes, whereas DCI remains an important factor in overall functional recovery. Full article

Objectives: This study aims to define the surgical anatomy, technical feasibility, advantages, and limitations of the TPPA through detailed cadaveric dissection and a representative clinical case, evaluating its potential as a safe and effective alternative to traditional approaches to the mesiotemporal lobe. Methods: A cadaveric dissection was performed on one adult head injected with colored latex, using standard microsurgical instruments and high-definition video documentation. Each procedural step was recorded and illustrated with cadaveric photographs. Additionally, a clinical case of mesiotemporal cavernous hemangioma resected via TPPA is presented, including an operative video. Results: The dissection demonstrated a direct and safe trajectory to the amygdala and hippocampal head, with clear identification of key vascular and white matter landmarks. In the clinical case, the lesion was completely resected with no postoperative neurological deficits. Conclusions: The TPPA represents a novel microsurgical corridor to the mesiotemporal region, minimizing cortical disruption, Sylvian fissure dissection, and manipulation of middle cerebral artery branches. Although its exposure is limited posteriorly, the TPPA could offer an optimal balance between functional preservation and surgical accessibility, constituting a valuable addition to the modern microsurgical armamentarium. Full article

Background/Objectives: Carotid body paragangliomas, commonly referred to as Carotid Body Tumors (CBTs), are rare, highly vascular paragangliomas arising at the carotid bifurcation and pose significant surgical challenges due to their proximity to critical neurovascular structures. Optimal management remains debated, particularly for large or complex lesions. This study aims to present a structured neurosurgical operative workflow as an educational and practical resource to help young surgeons understand operative decision-making and technical execution from a neurosurgical perspective. Methods: We retrospectively reviewed patients diagnosed with CBTs and identified three cases that underwent microsurgical resection by a single neurosurgeon. Clinical presentation, radiographic findings, operative strategies, intraoperative microsurgical techniques, and postoperative outcomes were analyzed. Surgical procedures for all three cases are further illustrated with technical video demonstrations highlighting meticulous microsurgical techniques performed by a single neurosurgeon. Results: All three patients presented with either incidental or slowly progressive neck masses, with imaging demonstrating classic splaying of the internal and external carotid arteries. One patient exhibited elevated catecholamine metabolites, while another had a familial history of paragangliomas. Preoperative embolization was successfully performed in all three cases. Complete tumor resection was achieved in each patient. One patient developed post-embolization embolic ischemic changes with transient neurological deficits that were resolved within several hours. No permanent cranial nerve deficits, vascular injuries, or tumor recurrences were observed. Pathology confirmed paraganglioma in all cases. Conclusions: Surgical resection remains an effective treatment for CBTs, which are commonly managed by vascular or head and neck surgeons. This case series illustrates the technical feasibility of CBT resection using a comprehensive neurosurgical strategy that integrates endovascular preparation, cerebral perfusion assessment, and meticulous microsurgical technique. Rather than proposing novel surgical innovation, this report aims to provide a structured operative framework and detailed video-based illustration of complex carotid bifurcation management from a neurosurgical perspective. Full article

Reconstruction of the ear and temporal region presents unique challenges due to the complex anatomy of the lateral skull base and the need to restore both structural integrity and auditory function. Historically managed as separate entities, auricular reconstruction and hearing rehabilitation are increasingly approached in an integrated manner, supported by advances in microsurgical techniques and implantable hearing technologies. This narrative review synthesizes contemporary evidence on microsurgical reconstruction of the ear and temporal region in conjunction with hearing rehabilitation, analyzing a wide range of existing surgical techniques in an integrative manner. Reconstructive techniques discussed include local and regional flaps, free tissue transfer, auricular framework reconstruction using autologous cartilage or alloplastic materials, external auditory canal reconstruction, and subtotal petrosectomy. Hearing rehabilitation options reviewed encompass bone-anchored hearing systems, active and passive transcutaneous devices, middle ear implants, and cochlear implantation. Simultaneous reconstruction and implantation may reduce surgical burden and enable earlier hearing restoration in carefully selected patients, while staged approaches remain advantageous in complex or high-risk scenarios, particularly in the presence of chronic infection or extensive temporal bone surgery. Multidisciplinary collaboration, meticulous preoperative planning, and long-term follow-up are essential to optimize outcomes. Full article

Background and Objectives: Patients admitted to plastic surgery units increasingly present with multimorbidity, advanced age, diabetes, cardiovascular disease, chronic wounds, and complex metabolic requirements. In several surgical specialties, internal medicine specialist (IMS) co-management has been associated with improved clinical outcomes, yet its potential role in plastic surgery remains unexplored. Materials and Methods: A narrative scoping review conducted using systematic search principles was conducted using MEDLINE, Web of Science, Scopus, and Google Scholar from inception to 1 December 2025. Search terms combined “internal medicine,” “co-management,” and “surgery.” Studies assessing outcomes of IMS involvement in surgical inpatient care were included. Data on population, intervention characteristics, and outcomes were extracted and summarized. PRISMA recommendations were used to report the study selection process. The review focuses on adult and elderly surgical inpatients, as the available evidence is not applicable for pediatric populations. Results: Twenty-two articles met the inclusion criteria. IMS co-management demonstrated consistent benefits across multiple surgical specialties, including reduced length of stay, lower complication rates, improved metabolic and cardiovascular stabilization, enhanced perioperative optimization, and decreased costs. Despite the growing complexity of plastic surgery inpatients, no studies specifically evaluated IMS co-management in this field. Conclusions: Evidence from other surgical specialties suggests that structured IMS co-management may offer substantial benefits for plastic surgery patients, particularly those with multimorbidity, diabetes, severe burns, chronic wounds, or undergoing microsurgical reconstruction. Prospective studies are needed to determine its impact on patient outcomes, resource utilization, and clinical workflows within plastic surgery. Full article

The role of soft tissue reconstruction in infection control of knee periprosthetic joint infection (PJI) treated with a two-stage exchange strategy remains controversial. This retrospective observational study analysed consecutive patients with chronic knee PJI managed with a two-stage protocol between 2010 and 2023, comparing outcomes between cases requiring flap-based soft tissue reconstruction and those achieving primary closure. A total of 118 patients with a minimum follow-up of 24 months were included. Forty patients (33.9%) required soft tissue reconstruction (STR), including 25 pedicled medial gastrocnemius flaps and 15 anterolateral thigh (ALT) microsurgical free flaps. Patients requiring STR showed greater baseline complexity, with a higher number of previous surgical procedures (3.03 vs. 2.08; p = 0.0057) and a higher prevalence of diabetes mellitus and sinus tracts. Despite this, infection control was superior compared with non-reconstructed cases (100% vs. 88.5%; p = 0.029). Within the STR group, both pedicled and microsurgical techniques achieved complete infection eradication; however, ALT flaps were associated with higher complication rates (46.7%), with partial flap necrosis being the most frequent event. The use of microsurgical reconstruction increased progressively over time, reflecting growing reconstructive complexity. Formal soft tissue reconstruction does not compromise and may facilitate infection control within a multidisciplinary pathway. Full article

Background and Clinical Significance: Deep thalamic and periventricular lesions are uncommon in adults but can result in significant loss of function because of their convergence on three interdependent processes: thalamocortical state regulation, throughput of periventricular long association systems, and ventricular compartmental compliance. The resulting combination of executive control collapse, retrieval-weighted language fragility, and load-sensitive gait instability may occur early after a lesion forms an atrial/posterior horn interface, and pressure-linked autonomic symptoms may be late to develop. Screening deficits will likely be minimal and therefore underreported. Objective/Aim: To present a thalamic–atrial/posterior horn tumor case with quantified load-sensitive cognitive–language–gait dysfunction and to detail a physiology-guided, sequence-driven decompression approach emphasizing ventricular relaxation and perforator-preserving, interface-limited thalamic resection. Case Presentation: A 56-year-old female patient experienced a 3-month, rapidly progressive decline in her cognitive and language abilities. The clinical progression was not stepwise or punctuated by a single “sentinel” event. She had a moderate level of cognitive impairment consistent with both Broca’s and Wernicke’s aphasias (MoCA: 22/30) and suffered from significant interference effects and increased cost of task-switching. Her ability to generate novel responses and name objects was significantly impaired; however, she was able to repeat words and phrases appropriately. In addition, she exhibited a severe sustained attention signature and a high error rate during dual-task performance, indicating severe gait instability, although her overall global anchors were nearly neutral (GCS 15; FOUR 15/16; NIHSS 2). Nausea and vomiting occurred simultaneously with the cognitive and language decline, suggesting decreased intracranial compliance. MRI revealed a heterogeneous left-sided thalamic tumor extending into the posterior horn of the lateral ventricle. The tumor caused deformation of the lateral ventricle and midline displacement. The patient underwent microsurgical intervention using a physiology-conscious sequence of graded cerebrospinal fluid (CSF) equilibration and primary mechanical removal of the tumor from the ventricular system. Additionally, decompression of the thalamus was performed in a manner that was cognizant of the boundaries formed by the perforating arteries of the thalamus. Early resolution of pressure symptoms was noted postoperatively. Objective measures demonstrated significant improvement in the patient’s executive functioning, language skills, attentional errors, and dual-task performance stability. The patient remained functionally independent at discharge and at subsequent follow-up visits. Surveillance imaging did not demonstrate any evidence of tumor recurrence. Conclusions: The clinical presentation described above is supportive of a model in which the synergy between deep network damage and distortion of the posterior ventricular compartment amplifies network dysfunction. Additionally, the use of quantitative stress-phenotyping makes it possible to identify deep network pathology early in its course. Finally, the physiology-guided decompression approach that was used in this case has the potential to increase functional reserve in patients with pathology that requires millimeter transitions. Full article

In this paper we present the design of a tolerance analysis-based closed-loop system and a compensation framework applied to high-precision linear Delta robots. It considers the modelling of static and dynamic errors propagation arising from the structural tolerances and the end-effector’s positioning. This approach is combined with a closed-loop control system implemented using high-resolution optical encoders. The model is applied to the ROMI robot, a high-precision experimental Delta robot designed for microsurgical applications. Our simulation results reveal a theoretical home position error (the centre of the robot’s platform) of 1.9 mm, which is effectively compensated through kinematic calibration and a tolerance analysis-based closed-loop system. The proposed framework is evaluated experimentally through proof-of-concept experiments mimicking a microsurgical resection task conducted on a human peripheral nerve sample. The results from executing micrometre scale parallelogram and circular trajectories showed error reduction rates of 92.3% and 51.2% respectively, after five trajectory iterations. These findings confirm that manufacturing-induced errors can be consistently compensated using the proposed methodology, thus eliminating the need for ultra-high-precision machined components. This work establishes a practical and scalable pathway for designing more affordable high-precision robotic systems suitable for microsurgical and other high-precision applications. Full article

The bioactive compounds that are produced by leeches combine traditional and modern treatment since the saliva of the animal contains proteins and peptides with anticoagulant, anti-inflammatory, antimicrobial, antioxidant, and regenerative properties. In this review, their biochemical profile, mechanisms and clinical uses are considered with a special focus on the fact that they are utilized to combine traditional practices with the modern developments in biomedical approaches. Proteomic and transcriptomic research has recently found more than 100 bioactive molecules, such as hirudin, calin, eglins, bdellins and destabilase, which are related to the blood-feeding process and therapeutic processes. These compounds control blood clotting, control inflammatory mediators, block microbes and enhance wound healing and the development of new blood vessels. In clinical practice, leech therapy is common in the reconstruction and microsurgical practice to reduce venous congestion and enhance graft success. They are also shown to be useful in wound healing, cardiovascular health, musculoskeletal conditions and regenerative medicine, as well as emerging drug delivery systems of recombinant proteins and nanocarriers. Some of the challenges involve biological variation, infection or bleeding risks and stringent regulations on purity and standardization. Biotechnology has improved through other developments such as recombinant protein production, high-throughput omics, and nanotechnology, which will help resolve these problems, making them safe and scalable for clinical use. Altogether, leech bioactives are the prime examples of the sophisticated pharmacology of nature, which have the potential of being used as therapeutic agents in the future. The recent approach and incorporation in personalized medicine and bioengineering models reflect the leech’s capacity to address complicated illness and unmet healthcare requirements to reassert its significance in preventive medicine and recent biomedicine. Full article

Lymphovenous anastomosis (LVA) has become an established microsurgical treatment for lymphedema, yet the hemodynamic basis for its efficacy in the lower extremity has not been rigorously examined. Most assessments of anastomotic function are performed in the supine position, where lymphatic pressure exceeds venous pressure, creating a favorable gradient for drainage. However, adults spend 16–18 h daily in upright postures, during which ankle-level venous pressure rises to 80–100 mmHg while lymphatic pressure increases only modestly. This pressure reversal raises questions about whether lower extremity LVA can function during routine daily activities. Several protective mechanisms have been proposed, including careful recipient venule selection, competent venous valves, and calf muscle pump assistance, yet these safeguards are inherently intermittent rather than continuous. Clinical data reveal progressive anastomotic patency decline over time, with some studies reporting 64% occlusion at two years, a pattern consistent with cumulative hemodynamic injury. Notably, clinical improvement sometimes persists despite declining patency, suggesting that concurrent conservative therapy or selection bias may contribute to observed outcomes. This review critically examines the postural hemodynamics relevant to lower extremity LVA, evaluates proposed protective mechanisms, and argues that the fundamental premise of sustained upright-posture drainage remains untested after three decades of clinical practice. Full article