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BACKGROUND: Tentorium resection and detachment from the oculomotor nerve are sometimes required for surgical clipping of unruptured posterior communicating artery (PCoA) aneurysms. Using T2-weighted 3D images, we aimed to identify the preoperative radiological features required to determine the necessity of these additional procedures. METHODS: We reviewed 30 patients with unruptured PCoA aneurysms who underwent surgical clipping and preoperative simulation using T2-weighted 3D images for measurement of the distance between the tentorium and aneurysm. Aneurysms were classified into superior type (superior to the tentorium) and inferior type (inferior to the tentorium). RESULTS: Seven patients (23%) underwent tentorium resection; all had the inferior type (superior vs. inferior, 0% vs. 33%, p = 0.071). In the 21 patients with the inferior type, the distance from the tentorium to the aneurysmal neck was 2.2 ± 1.1 mm and 0.0 ± 0.5 mm without and with tentorium resection (p < 0.01), respectively. An optimal cutoff value of ≤ +0.84 mm was identified for tentorium resection (area under the curve (AUC) = 0.96). Furthermore, 17 patients (57%) showed tight aneurysm attachment to the oculomotor nerve; all had the inferior type (0% vs. 81%, p < 0.01). The distance from the aneurysm tip to the tentorium was 1.1 ± 1.2 mm and -1.7 ± 1.4 mm without and with attachment (p < 0.01). The optimal cutoff value was ≤ +0.45 mm (AUC = 0.92). CONCLUSIONS: Measurement of the distance between the tentorium and aneurysmal neck or tip with T2-weighted 3D images is effective for preoperative simulation for surgical clipping of PCoA aneurysms.

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The purpose of this study is to investigate whether preoperative intubation simulation using custom-made simulator is useful during anesthesia induction for the children who have difficult airway. We included the children under 15 years of age who have difficult airway which had been already known. Prior to the scheduled surgery, CT imaging was performed and a 3D reconstruction of the face from the chest was performed. Then custom-made airway simulator was made. We tried to intubate custom-made simulator of patients preoperatively. We planned how to intubate the patient for anesthesia induction from the result of intubation simulation. The findings of direct laryngoscopy were compared with the findings during intubation. Three patients were included in this study. It took up to 3 weeks to create a simulator, which was difficult due to time constraints to accommodate emergency surgeries. Simulation findings correlated well with findings during anesthesia induction. There were no cases of severe hypotension or hypoxia during induction of anesthesia with the planned intubation method. In conclusion, preoperative intubation simulation using custom-made simulator may be useful for the patients who have difficult airway.

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Background: Hip replacement surgeries are increasing in demand, requiring rigorous improvements to a mature surgical protocol. Postoperative patient dissatisfaction mainly stems from postoperative complications resulting from the inappropriate selection of prostheses to meet the needs of each patient. This results in prosthesis loosening, hospital-related fractures, and postoperative complex pain, which can all be attributed to inappropriate sizing. In this study, we aimed to further explore the intraoperative and postoperative benefits of incorporating computer-aided design (CAD) in preoperative planning for total hip arthroplasty (THA). Methods: A total of 62 patients requiring total hip replacement surgery from January 2021 to December 2021 were collected and randomly divided into a preoperative computer-aided simulated group and a conventional x-ray interpretation group. The accuracy of implant size selection (femoral and acetabular implant) between the preoperative planning and surgical procedure of the two groups was compared. Patient parameters, perioperative Harris hip scores, operative time (skin-to-skin time), surgical blood loss, and postoperative hospital stay were recorded, and the differences between the two groups were statistically compared using a single sample t-test. Results: All patients in the study were successfully operated on and achieved good postoperative functional recovery. With CAD, the selection of the most suitable-sized prosthesis was significantly more accurate compared to the control group (accuracy of the acetabular component between the CAD/control: 80.6%/61.3%, and accuracy of the femoral component: 83.9%/67.7%). Intraoperative blood loss (177.4/231.0 ml, P = 0.002), operation time (84.2 ± 19.8 min/100.3 ± 25.9 min, P = 0.008), duration of hospital stay (6.5 ± 3/9.1 ± 3.9 days, P = 0.003), and postoperative Harris hip score (81.9 ± 6.5/74.7 ± 11.1, P = 0.003) were compared to the control group and showed statistical significance. Conclusion: Incorporating CAD into the preoperative planning of total hip arthroplasty can effectively guide the selection of the most suitable-sized prosthesis, reduce intraoperative blood loss, and promote short-term functional recovery after THA.

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This study aimed to introduce a three-dimensional (3D) images fusion method for preoperative simulation of aneurysm clipping. Consecutive unruptured aneurysm cases treated with surgical clipping from March 2021 to October 2023 were included. In all cases, preoperative images of plain computed tomography (CT), CT angiography, magnetic resonance imaging (MRI) 3D fluid-attenuated inversion recovery, 3D heavily T2-weighted images, and 3D rotational angiography were acquired and transported into a commercial software (Ziostation2 Plus, Ziosoft, Inc. Tokyo, Japan). The software provided 3D images of skull, arteries including aneurysms, veins, and brain tissue that were freely rotated, magnified, trimmed, and superimposed. Using the 3D images fusion method, two operators predicted clips to be used in the following surgery. The predicted clips and actually used ones were compared to give agreement scores for the following factors: (1) type of clips (simple or fenestrated), (2) shape of clips (straight, curved, angled, or bayonet), and (3) clipping strategy (single or multiple). The agreement score ranged from 0 to 3 because a score of 1 or 0 was given for agreement or disagreement on each factor. Interoperator reproducibility was also evaluated. During the study period, 44 aneurysms from 37 patients were clipped. All procedures were successfully completed, thanks to the precisely reproduced surgical corridors with the 3D images fusion method. Agreement in clip prediction was good with mean agreement score of 2.4. Interobserver reproducibility was also high with the kappa value of 0.79. The 3D images fusion method was useful for preoperative simulation of aneurysm clipping.

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BACKGROUND: This study was designed to explore the clinical efficacy of 3-dimensional (3D) printing assisted minimally invasive percutaneous plate osteosynthesis (MIPO) technique by comparing the clinical outcomes with traditional open reduction and internal plating fixation (ORIF) for treating complex middle-proximal humerus fractures (AO 12C fracture type). MATERIALS AND METHODS: The data of 42 participants who received a complicated middle-proximal humerus fracture from the beginning of 2018 to the end of 2022 were retrospectively analyzed. All patients were assigned to two groups: MIPO with detailed preoperative planning assisted by 3D printing technique (MIPO group), and traditional ORIF (ORIF group). RESULTS: This study included 21 patients in the ORIF group and 21 patients in the MIPO group. All patients were followed-up for at least one year (mean: 16.12 ± 4.13 months), and no difference was observed in the range of shoulder joint motion (ROM), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores and Constant scores between the two groups. However, the occurrence of complications (surgical incision site infection, implant loosening, bone nonunion and radial nerve palsy) in ORIF group was remarkably higher compared to the MIPO group. All the cases achieved bone union within the MIPO group. Significant differences were found in surgical time, intraoperative blood loss and fracture healing time between the two groups. CONCLUSION: Preoperative 3D printing assisted MIPO technique exhibits obvious advantages in high operational efficiency and low occurrence of complications, which is worthy of clinical application for treating complex middle-proximal humeral shaft fractures.

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The occipital transtentorial approach (OTA) is one of the useful approaches to the lesions of the pineal region, dorsal brainstem, and supracerebellar region. However, a wide operative field is sometimes difficult to obtain due to the tentorial sinus and bridging veins. This study evaluated the usefulness of preoperative simulation of OTA, specifically including the cerebellar tentorium in 9 patients. All patients underwent computed tomography angiography and venography and gadolinium-enhanced three-dimensional T1-weighted magnetic resonance images (Gd-3D-T1WI). The images were fused, and the cerebellar tentorium, vessels, and tumor were manually extracted from Gd-3D-T1WI to obtain the simulation images. Visualization of the cerebellar tentorium could discriminate between bridging veins from the occipital lobe and cerebellum, and recognize the site of bridging to the tentorial sinus and variants which may interfere with the tentorial incision. Simulation of the tentorial incision was also possible based on the relationships between the tumor, tentorial sinus, bridging vein, and cerebellar tentorium. The simulation suggested that safe tentorial incision was difficult in two sides because of the crossed tentorial sinus draining the left basal vein and draining veins from the glioblastoma. The OTA was performed in eight cases, and no difficulty was experienced in the tentorial incision in all cases. The simulation findings of the bridging vein and tentorial sinus were consistent with the intraoperative findings. Preoperative simulation including the cerebellar tentorium is useful for determining the optimum and safe side and required extent of the tentorial incision necessary for tumor resection with the OTA.

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Preoperative simulation using a three-dimensional printer is effective to perform safe surgery by knowing the range limit of drilling in the temporal bone. Moreover, simulations using models are thought to be useful for education of young surgeon.

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PURPOSE: Proximal humerus fractures (PHFs) are common. With the development of locking plates, open reduction and internal fixation (ORIF) of the proximal humerus can provide excellent clinical outcomes. The quality of fracture reduction is crucial in the locking plate fixation of proximal humeral fractures. The purpose of this study was to determine the impact of 3-dimensional (3D) printing technology and computer virtual technology assisted preoperative simulation on the reduction quality and clinical outcomes of 3-part and 4-part proximal humeral fractures. METHOD: A retrospective comparative analysis of 3-part and 4-part PHFs undergoing open reduction internal fixation was performed. Patients were divided into 2 groups according to whether computer virtual technology and 3D printed technology were used for preoperative simulation: the simulation group and the conventional group. Operative time, intraoperative bleeding, hospital stay, quality of fracture reduction, Constant scores, American Society for Shoulder and Elbow Surgery (ASES) scores, shoulder range of motion, complications, and revision surgeries were assessed. RESULTS: This study included 67 patients (58.3%) in the conventional group and 48 patients (41.7%) in the simulation group. The patient demographics and fracture characteristics were comparable in these groups. Compared with the conventional group, the simulation group had shorter operation time and less intraoperative bleeding (P < 0.001, both). Immediate postoperative assessment of fracture reduction showed a higher incidence of greater tuberosity cranialization of < 5 mm, neck-shaft angle of 120° to 150°, and head shaft displacement of < 5 mm in the simulation group. The incidence of good reduction was 2.6 times higher in the simulation group than in the conventional group (95% CI, 1.2-5.8). At the final follow-up, the chance of forward flexion > 120° (OR 5.8, 95% CI 1.8-18.0) and mean constant score of > 65 (OR 3.4, 95% CI 1.5-7.4) was higher in the simulation group than the conventional group, as well as a lower incidence of complications in the simulation group was obtained (OR 0.2, 95% CI 0.1-0.6). CONCLUSIONS: This study identified that preoperative simulation assisted by computer virtual technology and 3D printed technology can improve reduction quality and clinical outcomes in treatment of 3-part and 4-part PHFs.

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Kyphosis complicates abdominal surgery. Here, we report a case of rectal cancer in a patient with kyphosis who underwent successful laparoscopic surgery after a preoperative simulation. An 81-year-old woman with rectal cancer was admitted to our department, and laparoscopic surgery was planned. Physical examination revealed severe kyphosis. To ensure successful laparoscopic surgery, we conducted a detailed preoperative simulation, including three-dimensional CT simulations of port arrangement and anatomy, simulation of body position, selection of surgical instruments, and preoperative discussion with the anesthesiologist. We planned to insert the first port in the umbilical region for pneumoperitoneum and the camera port in the ventral region under pneumoperitoneum. We planned to insert the ports on the right side of the patient's body from the caudal regions, after considering the location of the inferior mesenteric artery and the limitations in degrees and space attributable to the costal arch and promontorium. Beach chair position was planned. We used a fan-shaped retractor and sponge retractor to remove the small intestine from the surgical view. In preoperative discussions with the anesthesiologist, we decided to maintain pneumoperitoneum pressure at less than 8 mm Hg during the operation, to safeguard respiratory function. Lower anterior resection with D2 lymph node dissection was performed, without intraoperative complications. At 2 years postoperatively, the patient was healthy with no signs of recurrence. Laparoscopic surgery appears to be a suitable choice for patients with kyphosis. We believe that preoperative simulation will result in successful outcomes.

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OBJECTIVE: The authors sought to verify the use of a preoperative simulation software for the treatment of intracranial aneurysms using flow diverters (FDs) based on three-dimensional rotational angiography (3DRA) data. METHODS: Based on 3DRA data, the preoperative simulation software (UKNOW) was used to simulate the deployment of virtual FDs. The length and dimensions of virtual and real devices were compared. The deployment plan recommended by the UKNOW software was preliminarily used to complete implantations in the real world. During the experiment, experienced neurointerventional experts were responsible for supervising and judging information such as the length, dimension, and deployment location of the FDs. RESULTS: This study retrospectively analyzed the data of 29 patients who received FD treatment. There was no statistical difference between the length of the real device and the virtual device (p = 0.6). The dimensions of FDs recommended by the software were consistent with the dimensions used in 24 out of the 29 real cases. In four of the remaining five cases, neurointerventional experts found that the FD dimensions recommended by the software were superior to those were actually used. Thus, the accuracy rate for FD dimension recommendations by the UKNOW software was 96.6% (28/29). Procedures performed in five cases using deployment plans recommended by the UKNOW software all achieved good postoperative results; the deployment positions of the device were reasonable, and all devices showed good wall adherence. CONCLUSIONS: UKNOW software could accurately simulate the length and deployment position of the real FDs and provide suitable device dimensions.

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The development of three-dimensional printers has facilitated the creation of patient-specific hollow vessel models. Preoperative simulations using these types of models have improved our ability to select appropriate devices and embolic materials before performing complex endovascular procedures. This report describes 2 cases of high-flow renal arteriovenous fistulas (r-AVFs) that were successfully treated via short-segment embolization using the preloading coil-in-plug (p-CIP) technique. To our knowledge, this is the first report of r-AVF being treated using the p-CIP technique. Our findings demonstrate that preoperative simulation has the potential to improve the safety and reliability of complex vascular embolization procedures.

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BACKGROUND: To assess the safety and efficacy of preoperative simulation and three-dimensional (3D) models in the treatment of ulnoradial diaphyses fracture. It was hypothesized that preoperative simulation and 3D printing might significantly shorten the mean operative time, intraoperative bleeding, and intraoperative fluoroscopy. MATERIAL AND METHODS: Forty patients with forearm double fracture were divided into 3D printing group and conventional surgery group. Preoperative simulation and 3D printing were performed on patients in the 3D printing group to examine implant reduction and placement as well as preoperative plate/screw size. The operation time, intraoperative bleeding, and frequency of fluoroscopies were recorded. RESULTS: In the conventional surgery group, the operative time, intraoperative bleeding, and the frequency of fluoroscopy were 106.2 ± 15.92 min, 61.45 ± 11.33 ml and 5.65 ± 1.23 times, whereas in the 3D printing group, values of all the three parameters were better than those of the conventional surgery group (91.3 ± 14.85 min, 48.6 ± 10.39 ml and 3.85 ± 1.04 times, respectively). The forearm pronation and supination of the 3D printing group improved to 79.55 ± 5.12° and 76.80 ± 3.96°, respectively. In the conventional surgery group, patients also had significant improvement in these indicators, which improved to 78.60 ± 5.18° and 75.4 ± 5.30°. CONCLUSIONS: The results showed that preoperative simulation and 3D printing can enhance the safety as well as personalization of the surgical process during the treatment of forearm double fracture and therefore holds potential for future application in clinical practice. TRIAL REGISTRY: Name of the registry: This study was registered in the Chinese Clinical Trial Registry; Trial registration number: ChiCTR2100045790.

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Infrared thoracoscopy with intravenous indocyanine green administration is one of the useful methods to identify an appropriate intersegmental line during thoracoscopic pulmonary segmentectomy. In this procedure, we have introduced preoperative simulation to calculate the distance between the target tumour and intersegmental plane using Ziostation2 (Ziosoft, Tokyo, Japan) to ensure sufficient surgical margin without palpation. By using this preoperative simulation, we obtained sufficient surgical margin in a patient with a 16-mm part-solid nodular shadow undergoing infrared thoracoscopic upper division (S1-3) segmentectomy of left upper lobe with intravenous indocyanine green administration. The discrepancy between the virtual and the actual surgical margin was <10 mm. This preoperative simulation can help us obtain sufficient surgical margin without palpation of the tumour in infrared thoracoscopic segmentectomy.

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Although the three-dimensional (3D) printing technology has spread in the field of neurosurgery, the use of 3D print models concerning glioma surgery has rarely reported. For glioma surgery, some preoperative and intraoperative assistive methods have been developed to avoid injury to the cortex and fiber that are related to the neurological function. Furthermore, in order to perform preoperative simulation of glioma surgery, we created a 3D print model using a multi-material 3D printer that provided the flexibility of adjusting the color, hardness, and translucency of each structure arbitrarily. The use of 3D print model was demonstrated in one case involving an intramedullary tumor in the right temporal lobe. The tumor, optic radiation, brain parenchyma, tentorium, ventricle, and sinus were constructed in a single model in one printing process. Design of the degree of resection, insertion of the fence-post, and tumor resection paying attention to the optic radiation were simulated preoperatively using this model. The surgery was performed generally as the simulation and gross total removal of the tumor was achieved. This model was useful for understanding the degree of resection, adequate insertion of the fence-post, and the relationship of the tumor with other important structures. A variety of printing materials contributed to make the model realistic and to understand anatomical relationship. In conclusion, the 3D print model can supplement an image of some portions that are not visible perioperatively and serve as a preoperative assistant modality.

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This study showed that microlaryngeal surgery under general anesthesia is feasible for patients with severe obese elite vocal performers if proper simulations are conducted beforehand and the position of the patient and anesthesia is considered.

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Accurate localization and analyses of functional liver segments are crucial in devising various surgical procedures, including hepatectomy. To this end, they require the extraction of a liver from computed tomography, and then the identification of resection correspondence between individuals. The first part is usually impeded by inherent deficiencies, as present in medical images, and vast anatomical variations across subjects. While the model-based approach is found viable to tackle both issues, it is often undermined by an inadequate number of labeled samples, to capture all plausible variations. To address segmentation problems by balancing between accuracy, resource consumption, and data availability, this paper presents an efficient method for liver segmentation based on a graph-cut algorithm. One of its main novelties is the incorporation of a feature preserving a metric for boundary separation. Intuitive anatomical constraints are imposed to ensure valid extraction. The second part involves the symmetric conformal parameterization of the extracted liver surface onto a genus-0 domain. Provided with a few landmarks specified on two livers, we demonstrated that, by using a modified Beltrami differential, not only could they be non-rigidly registered, but also the hepatectomy on one liver could be envisioned on another. The merits of the proposed scheme were elucidated by both visual and numerical assessments on a standard MICCAI SLIVER07 dataset.

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AIM: Isolating the root of the splenic artery (SPA) is a challenging procedure in laparoscopic distal pancreatectomy (LDP). We investigated the usefulness of evaluation of the relationship between the SPA and pancreatic parenchyma using three-dimensional computed tomography (3D-CT). METHODS: In total, 104 patients were evaluated. The relationship between the SPA and pancreatic parenchyma was classified into two types: buried and non-buried. Video clips of 50 patients who underwent LDP requiring isolation of the SPA root were reviewed to determine whether the classification is related to difficulty of LDP. RESULTS: Of the 50 assessed patients who underwent LDP, the relationship between the SPA and pancreatic parenchyma was the buried type in 30 (60.0%) and non-buried type in 20 (40.0%). The buried type was associated with a significantly longer median operative time than the non-buried type (285.0 vs. 235.5 min, respectively; P < 0.01). The median time required to isolate the SPA in the buried type (25.8 min; range, 4.0-101 min) was significantly longer than that in the non-buried type (7.0 min; range, 1.0-27.0 min) (P < 0.001). CONCLUSION: Preoperative 3D-CT around the pancreas is practical for predicting the difficulty of SPA isolation and determining the safety of the procedure.

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BACKGROUND: As the positions and sizes of nodules in synchronous multiple primary lung cancer (SMPLC) patients differ, the development of surgical strategies to maximize long-term survival and preserved postoperative pulmonary function in SMPLC patients for whom surgical resection is an alternative strategy presents challenges. CASE PRESENTATION: We provide a case managed through video-assisted thoracoscopic surgery (VATS) resection using three-dimensional computed tomography lung reconstruction (3D-CTLR) to reconstruct lobes containing pulmonary nodules to preoperatively simulate and intraoperatively guide the extent and method of resection. CONCLUSION: The successful attempt demonstrates a technically simplified, feasible alternative to preoperative plans utilizing less invasive VATS to manage SMPLC.

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Objective: We present a preoperative simulation of cerebral aneurysm coil embolization using a hollow model of cerebral blood vessels created by a stereolithography (SLA) 3D printer. Case Presentation: The patient was a 66-year-old woman. During follow-up, coil embolization was planned for an expanding paraclinoid aneurysm. A hollow cerebral vascular model was created preoperatively using an SLA 3D printer. The catheter was malleable and inserted into the hollow model, which enabled the surgeons to confirm its movement, stability, and ease of insertion. In the surgical procedure, the catheter was easily inserted into the aneurysm without reshaping. The procedure was completed without stability problems. Conclusion: The use of a hollow model of cerebral blood vessels was useful as a preoperative simulation and improved the safety of the procedure.

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Treatment for idiopathic normal pressure hydrocephalus (iNPH) continues to develop. Although ventriculoperitoneal shunt surgery has a long history and is one of the most established neurosurgeries, in the 1970s, the improvement rate of iNPH triad symptoms was poor and the risks related to shunt implantation were high. This led experts to question the surgical indication for iNPH and, over the next 20 years, cerebrospinal fluid (CSF) shunt surgery for iNPH fell out of favor and was rarely performed. However, the development of programmable-pressure shunt valve devices has reduced the major complications associated with the CSF drainage volume and appears to have increased shunt effectiveness. In addition, the development of support devices for the placement of ventricular catheters including preoperative virtual simulation and navigation systems has increased the certainty of ventriculoperitoneal shunt surgery. Secure shunt implantation is the most important prognostic indicator, but ensuring optimal initial valve pressure is also important. Since over-drainage is most likely to occur in the month after shunting, it is generally believed that a high initial setting of shunt valve pressure is the safest option. However, this does not always result in sufficient improvement of the symptoms in the early period after shunting. In fact, evidence suggests that setting the optimal valve pressure early after shunting may cause symptoms to improve earlier. This leads to improved quality of life and better long-term independent living expectations. However, in iNPH patients, the remaining symptoms may worsen again after several years, even when there is initial improvement due to setting the optimal valve pressure early after shunting. Because of the possibility of insufficient CSF drainage, the valve pressure should be reduced by one step (2-4 cmH2O) after 6 months to a year after shunting to maximize symptom improvement. After the valve pressure is reduced, a head CT scan is advised a month later.