When a chest aortic aneurysm is the cause of recurrent nerve paralysis, the appearance of a hoarseness means the expansion of the aortic aneurysm and it is necessary for an immediate interspeciality correspondence and treatment. We report herein on two cases that caused hoarseness related with a chest aortic aneurysm and which saved with rapid cooperation between cardiovascular medicine and cardiovascular surgery specialists. Case 1 involved a 77-year-old female who had a checkup because of sudden hoarseness, and who had a past of heart trouble. In case 2, a 62-year-old male with a past history of a parathyroid tumor, he had a checkup for hoarseness and the back pain which identified a chest aortic aneurysm. In both cases we were able to save the patients' lives with swift interdisciplinary cooperation. Based on our experience with these two cases, when we suspect recurrent nerve paralysis is associated with a chest aortic aneurysm, it is necessary to perform immediate contrasting CT. When this approach provides a solid diagnosis, quick cooperation between the disciplines of cardiovascular medicine and cardiovascular surgery is very important.

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We report herein on a case of renal cell carcinoma diagnosed through paranasal metastasis. A 64-year-old male complained of swelling of the left upper eyelid area, numbness of the lower limbs and chest pain. CT and MRI suggested a malignant tumor with bone destruction from the left ethmoidal and frontal sinus. CT furthermore demonstrated destruction of the fifth thoracic vertebra and a small nodule which was considered to be metastatic cancer in the right lung. Moreover, a large tumor in the left kidney was considered to be primary tumor, and a nephrectomy was undertaken. The large tumor in the left kidney was diagnosed as clear cell carcinoma. The paranasal sinus tumor was also diagnosed as clear cell carcinoma. We consider it is very difficult to control nasal bleeding from paranasal sinus cancer, therefore, in the future we need to consider endoscopic sinus surgery aimed at improving the quality of life of affected patients.

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[in Japanese]

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As the lateral skull lesion consists of complex anatomical structures involving critical important neural and vascular systems, it would be relatively difficult even for the senior surgeons to acquire proficiency in surgical procedures. Although this area was considered as the defiant lesions, but, in fact, there were some diseases that the only way to treat was operation. A computer assisted surgery may become to be the one of superior methods to solve such contradicting problems.
In general, MRI provides excellent contrast to image anatomy and pathology of soft tissue, whereas HRCT evaluates osseous structures best. That is, we decided to get fusion images of HRCT and 3T-MRI to identify the location of the pathology by using iPlan ENT^®. After making fusion images, we traced the border of the tumor and create a 3 dimensional view. Additionally, we set important surgical points into these images to make them under control. Until now, we have performed 21 cases of lateral skull base surgeries in accurate and successful.
Tumors of the temporal bone are a surgical challenge. The surgical risk is related to the close relationship between the pathology and vital neurovascular structures, even in the skilled surgeon. We emphasized the efficacy of performing preoperative simulations for these lesions.

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We recently reported a noninvasive registration method, namely STAMP, for accurate image-guided temporal bone surgery. In this study, we modified our STAMP method to make the procedure as simple as possible in the operating room. We attached a pole with optical markers on the STAMP template and finished most of the registration process pre-operatively. This “pole STAMP” method offered quicker registration without compromising registration accuracy.

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In 1990's, “Medical models” of first generation have been created with using RP (Rapid Prototyping) technology.
And today, the developments of medical equipments and evolution of the operation techniques are so rapidly. So, these models have been improved according to the increase of the request of customers.
Now we supply the following 3D models.
1. Simulation models in pre-operation.
2. Surface Template-Assisted Marker Positioning Model with a Pole for minimally invasive registration (supervised by Dr. Matsumoto of Kyushu University)
3. Models for endoscopy training (Hands-on training)
➢Transnasal Endoscopic Training Model (supervised by Dr. Tsunoda of Tokyo Medical Dental University)
➢Third Ventriculostomy Training Model (supervised by Dr. Ohira of Keio University)
4. Inner-Structure Colored Temporal Bone Model (Hands-on training: supervised by Dr. Itoh of Tokyo Medical Dental University)
5. Tympanic Membrane Perforation Training Model (Hands-on training: supervised by Dr. Komune of Kyushu University)
6. Temporal Bone Model with Cholesteatoma (supervised by Dr. Kobayashi of Tohoku University)
We'll make as much as our efforts for development of “High-valued medical models”

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Acquisition of ear anatomy is difficult because of complexity of its structure. Three-D images and prototyped models are good educational materials and their usefulness had been reported. The authors used a 3D edit function installed in the 3-D construction software (Materialize^®). It allowed shaving the 3-D image while rotating and magnifying the original image. Slice by slice shaving enabled exposure of the target organ, such as inner ear structure and ossicles. This manipulation using 3-D edit function serves as a good educational tool for acquisition of the ear anatomy.

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The essential role of a navigation system is showing the medical image with high-precision coordinate information through computer technologies and to maximize and expand the role of image guided surgery as of a comprehensive integrated CAS system, two additional elements are so important.
The first one is “integration of various image set” and the second one is “integration of surgical instruments and medical images on one display”.
The current surgeons requirement regarding a navigation system is adapting “increase and diversification of required images” , “ diversification of surgical instruments” and “expansion of adaptive operation”.
The solution for the above demand is the seamless workflow with the further consideration of “integration of various images” and “integration of surgical instruments and images”.
The improvement of a navigation system will lead to the expansion of the adaptability of image guided surgery to new surgical segments and the improvement of safety surgery.

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The Medtronic has sold a surgical navigation system since 1996. At the beginning of this year, we launched the sale of a new navigation system with a refurbished design and function. This system is characterized by adoption of an electromagnetic position detecting system. The tracking system using electromagnetic field will offer a resolution of the challenges in the previous optical system, i.e., device size and restriction of a space recognized by a camera. In addition, the blades with a built-in electromagnetic sensor are available as a Medtronic's unique product lineup, which can be attached to a drill for nasal surgery. This enables an immediate initiation of navigation once the blade is connected, without the need of registering the tip position.
In August 2011, the Surgical Technology Division was established by integrating the Navigation and ENT/NT Divisions which had offered solutions for otorhinolaryngologic surgeries. By this integration, we will offer product support and promote development for our products not only individually but also in combination while putting the synergic effects in perspective.

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About 90% University Hospitals have navigation system. The main purpose to use navigation system is to distinguish where the target points are. Now, navigation system is classified into an optical type and a magnetic field type according to the system of a position detection system, and an optical type is the present mainstream.
An optical type has a fault to which position recognition becomes poor by direction of probe, while there is an advantage that the possibility of interference with operation apparatus is low.
On the other hand, although there is an advantage which can recognize a position regardless of direction of probe by a magnetic field area, there is possibility of a magnetic interference with operation apparatus.
In our hospital, Stealth Station S7: hybrid form navigation system is used from 2011. The hybrid type has the system of both an optical type and a magnetic field type, and it is possible to choose a system according to a situation.
Based on use experience, the advantage and disadvantage of hybrid type navigation system were examined.

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A fibrous dysplasia is a benign disorder, but an operation for the purpose of the conditioning the figure is often necessary because it is an osteophytic disease. In the case of an operation of fibrous dysplasia, right and left equality and security were able to grind down a bone by using navigation system. The postoperative result was a satisfactory.

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LigaSure^TM is a vessel sealing system with reduced thermal spread based on bipolar electrocoagulator. A new type of LigaSure^TM, LigaSure^TM Small Jaw Instrument was used in thyroid surgery. The feature of this handpiece is cutting and abration capabilities. These new functions may contribute to shortening of operation time. We could actually seal most vessels without thermal injury of surrounding tissue and separate tissue in thyroid surgery. This new device was thought to be useful and safe one in thyroid surgery.

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We used the OsiriX software for preoperative and intraoperative MRI multiplanar reconstruction (MPR) interpretation in sinus surgery. It was considered a useful method for the surgery combined with CT MPR.

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In our hospital, Optical navigation system was introduced in 2006. Since then it has been used as surgical support instrument. This study period spanned almost 2 years from November 2009 to September 2011. 289 patients ware treated by endoscopic endonasal surgery. 26 patients of them were treated under Navigation System. We examined and summarized these 26 patients.

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We verified an accuracy of the new navigator for paranasal sinus surgery that we have developed. Using a human model, we performed a simulated endoscopic sinus surgery, and measured the errors. The result indicated that the average error was 1.02mm in the three-dimensional plane. When we verify the error of surgical navigator, caution should be paid with the thickness of the slices, the field of view value, and the partial volume effects in X-ray computed tomography.

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Understanding detailed local anatomy is essential in both endoscopic and microscopic surgery. We developed a software to convert a series of color tomographic images into shape data keeping all details inside, that is printable using a 3D color printer.
Nasal part of the high resolution axial anatomical images of the Visible Human Female (NLM, USA) was converted into a set of PLY format shape data that was modeled using a Z650 (Z Corp., USA) into a life-sized, full-color human model with detailed anatomy.

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We reported the construction of the education system using the paranasal sinus model. The quality of model is not a big problem. It is important how we use it. The advantage of the model are 1) Easy to understand the structure of a complicated paranasal sinus. 2) We can use it for the repeated practice of the basic technique. 3) The recognition of the dangerous part is easy. 4) A demonstration of the operation is possible. We want to use a model for education positively and want to bring up the operator with a constant technique regardless of an institution and an area. We have a duty to bring up the next generation.

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This article introduces assemblable instruments for laparoscopic surgery and a remote operation device for radiation seed implantation for oral cancer that are presented at the 13th conference.
In laparoscopic surgery, only small incisions are made in the abdominal wall and therefore instruments for laparoscopic surgery are slender so that they can pass through small diameter trocars placed in the incisions. To relax this limitation, we have proposed assemblable surgical instruments whose parts are inserted through trocars and put together inside the abdominal cavity.
As a first example, this article introduces an assemblalbe purse-string suture device. A T-shaped purse-string suture device is used to make purse-string suture on the esophagus in open surgery preparatory to the anastomosis of the esophagus and the small intestine with a circular stapler. Because of its shape, it cannot pass through a trocar, which motivated us to develop the assemblalbe purse-suture suture device for laparoscopic surgery.
As a second example, this article introduces assemblable hands that can grasp and/or retract large internal organs. We have taken two different approaches. One approach is to develop a hand that has a single function but can be inserted and assembled through a single port. A three fingered hand with three degrees of freedom is developed. Its assembly method uses a string to suspend a finger module inserted first in the abdominal cavity, which is connected with another finger inserted from the same trocar.
The other approach is to develop a hand that has multiple functions with more degrees of freedom but requires two ports for its assembly. Using this approach, we developed a three-fingered assemblable hand with nine degrees of freedom. The first finger unit is inserted from a first trocar. Then the second and third finger units are inserted from a second trocar facing to the first trocar. The ends of the finger units are inserted to the first trocar from the inside to outside of the abdominal cavity. They are connected to the end of the first finger unit. This assembly method is safe because it connects mechanical parts outside the abdominal cavity. The hand can grasp and retract internal organs, as validated by in vivo experiments.
The second main topic is a remote operation device for radiation seed implantation for oral cancer. Although brachytherapy is minimum invasive for patients, operators are exposed to radiation, which hinders it from being widely adopted as a treatment for oral cancer. This motivates us to develop the remote operation device for radiation seed implantation. The radiation level at a distance of 1m from the radiation seed is significantly reduced. Therefore the developed device is operated at a distance of 1m away from the radiation seed. Unlike the prostate, oral organs are not fixed on other tissues. A grasper that grasps and fixes oral organs is necessary to implant a radiation seed into it. Therefore the remote operation device consists of three sub-devices: an applicator manipulator that inserts a radiation seed, a grasper, and remote operational parts for them.
In addition, this article briefly introduces a lung positioner for thoracoscopic surgery, a sound based force sensor, and a multi-tube propelling device.

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Recently, increasing emphasis on quality-of-life issues in surgery such as relieving patient pain, reducing scarring, and shortening hospital stays has led to wider use of endoscopic surgery. In endoscopic surgery, forceps and other instruments are inserted through a hole made in the abdomen of the patient, and surgery is performed through visualization of the endoscopic image. Though this technique presents a lower burden to the patient than laparoscopic surgery, manipulation of instruments through the insertion hole used as a fulcrum complicates a free approach to the surgical target and demands advanced skills of surgeons.
Consequently, there is active research on free movement of instrument tips through robotics technology in order to alleviate the burden on the physician. As commercialized in the well-known “da Vinci” system, these devices employ a master-slave system comprising a master console operated by the physician, and patient-side slave instruments manipulated after insertion into the body of the patient. The system allows remote procedures providing the sensation that one's own hands are located in the body. However, current master-slave systems operate solely through reliance on image data from an endoscopic camera, and development of devices allowing safer operation is needed. What is particularly desired is a system that senses contact or force at the slave-side instrument and delivers this information to the physician at the master console. However, practical considerations such as compactness and sterility make it undesirable to attach force sensors to forceps for observational purposes. Currently, the patient-side equipment is also driven by electromechanical motors.
In such a context, we have worked on the development of a master slave robotic system for laparoscopic surgery with 7-DOFs. In this system, pneumatic actuators, instead of electric motors, are used to detect external forces based on pressure values without a force sensor. This approach reduces costs and sterilizability demands for forceps manipulator while enable haptic feedback to the surgeons. We have prototyped a model of surgical manipulators named IBIS for its resemblance to the bird which has high performance in the estimation of external force. We evaluated its performance in terms of force estimation. The forces acting on a joint are estimated during contact with the external environment.
Our technical assist system is designed to deliver positioning commands from the master side to the slave side via the internet, estimate contact force at slave-side instrument tips based on the pressure differential with the pneumatic cylinder, and convey this information to the master side. The experimental results indicate that IBIS estimates external forces with a sensitivity of 0.5 N. We also conduct an in vivo experiment and confirm the effectiveness and improvement of the manipulator. Currently, through cooperation with Tokyo Medical and Dental University, animal experiments are ongoing to evaluate the efficacy of the system developed and to continue its improvement.

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Background: The concept of sentinel node (SN) has been established in oral cancer. This study aimed to investigate distribution of the area where SN was located.
Method: Ten patients with T1-2 N0 tongue cancers underwent SN biopsy following partial glossectomy. SNs were detected using gamma camera and gamma probe and were analyzed pathologically.
Result: SN was localized in 9 submandibular, 14 upper jugular, 5 middle jugular, 1 lower jugular area in disease side. SN was also localized in 1 upper jugular, and 1 middle jugular area in the opposite side. Occult SN metastasis was observed in 6 of 10 patients (60%).
Conclusions: It was concluded that the most likely site where SN was detected was upper jugular area in disease side.

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In our hospital we have been treating early stage hypopharyngeal cancers by special transoral surgical technique named ELPS (Endoscopic Laryngo-pharyngeal Surgery) using Sato's curved distending laryngoscope. This special laryngoscope can distend surgical field including deep piriform sinus, postcricoid, deep posterior wall and the entrance of cervical esophagus quite easily. We consider ELPS is a very useful technique to detect and resect the carcinomas in these portions. However, it needs a skilled surgical technique and has the disadvantage of requiring new curved surgical instruments.
We discussed about the necessity of improved surgical instruments used in ELPS in detail and drew the roadmap for the future improvement of it.

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We introduced robotic surgery in Japan. Using da Vinci S with 8mm meryland bipolar and monopolar spatura, postwall of oropharyngeal squamous cell carcinoma was dissected. TORS provide good operation field and view. EndoWrist can dissect any angle. TORS is more suitable and safety for oropharyngeal carcinoma than endoscopic surgery.

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Sinusitis is a frequent cause of olfactory disturbance. The major mechanism of olfactory disorder due to chronic sinusitis is thought to be closing of airway and blockade of odor molecules to the olfactory mucosa. Therefore, the prognosis for recovery of olfactory function is not very bad with medical and surgical interventions. We developed a new surgical technique to obtain further improvement of olfactory function of patients with olfactory disorders due to chronic sinusitis and reported.

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We described the utility of dacryoendoscope during dacryocystorhinostomy. Dacryoendoscope shows the location of lacrimal sac by its light. Because it makes sure the exposure and incision of lacrimal sac. Dacryoendoscope is enabled us to observe the condition of lacrimal passage, which is canaliculus, lacrimal sac, nasolacrimal duct and the obstruction site of passage. Dacryoendoscope clearly shows which NS-tube run along to the true lacrimal passage or the pseudo passage.

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The Short endoscope fiberscope which is under development by Olympus Corporation, has characters of both rigid and flexible endoscope. We used it for observation and treatment after endoscopic sinus surgery and we examined the usefulness and reported refinements.
At the time of easy ambulatory care, the treatment time of Short endoscope was shorter than the rigid endoscope. The Short endoscope was more useful instrument than the rigid endoscope for postoperative care with difficult view reservation. By extending the curve movable direction and the range, the Short endoscope will become more useful instrument.

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A microdebrider system is used also as bur of ESS in many cases. Septoplasty bur for the nasal plastic surgeries was used for the advanced deviation of nasal septum cases.
There is also no involvement of nasal-septum membrane in the case of a crista, a spina, and vomer excision, it was a good feeling of use, and bony deletion could be easy and was able to cut efficiently rather than having used a chisel depending on a case. Septoplasty bur can be comparatively introduced on a low budget.

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Hydrodebrider is an ESS supporting system for carrying out suction removal of the debris, such as a fungus ball, with high-pressure water. Since a mycosis hardly exists in frontal sinus, the very limited case needs the system for frontal sinuses. We performed combined surgery of balloon sinuplasty (BSP) and frontal hydorodebrider for frontal recurrence case. The weak point of BSP to a mucosal lesion was able to be complemented with performing combined surgery.

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Since the navigation surgery started in otolaryngology and head and neck surgery, about 15 years has passed. The total number of institutions taken the navigation surgery was 81/128 (63%), in which the university hospital was 66 (81%), municipal hospital /medical center was 15 (19%), particularly diffusion rate rose by the university hospital. Regarding the registration, the surface method was the mainstream, and its time was shortened around 15 minutes as well as convenience. About precision and error, the intraoperative average error was one or two mm.
The number of navigation surgery cases considerably increased in the nasal surgery with 3,514 cases (87%).
On the other hand, the number of otology and head and neck surgery were 6%. The ratio of“the absolute need” was 15% in ear cases, 23% in nasal cases and drastically increased 46% in head and neck cases.
The answer to the question“which part you were necessary to be concrete”was the confirmation of the petrous part lesion, the meatal atresia, the orientation of the subtotal excision of temporal bone, unusual cochlear implant in the otology, a paranasal cyst, a chronic sinusitis recurrence (a frontal sinus), a nasal cavity tumor (papilloma etc.), choanal atresia, a recurrence of the nasolacrimal duct in rhinology, and skull base surgery, maxillary cancer, pituitary gland surgery, clivus surgery, epipharynx angiofibroma and endoscopic endonasal skull base surgery in head and neck field.
The necessity of the navigation surgery was“need” in 113/128 institutions (88%),“not need” in 2 (2%),“unclear” in 13 (10%). About the complication, two liquorrhea was reported. The development as a new surgery education tool is expected in future.

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