Fine movements of a non-dominant hand and coordination of both hands are essential for safe and reliable achievement of microsurgery. We carried out a microsurgical training exercise using a chicken wing artery, in which an end-to-side anastomosis was performed by a dominant or a non-dominant hand for 5 days running for each hand.
This practice demonstrated that the non-dominant hand training not only improved the fine movements of a non-dominant hand but also established skillful techniques of a dominant hand. This may be explained by the bilateral motion transfer phenomenon seen in mirror image learning applied for rehabilitation of apoplexy patients with hemiplegia.

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It is mandatory to develop microsurgery training methods for young neurosurgeons because the number of surgical cases has been decreasing due to the development of alternative therapy for neurovascular diseases such as radiosurgery, endovascular coil embolization, and stenting. Here we describe our training methods for microvascular anastomosis for young neurosurgeons as well as senior staff with minimum cost and maximum convenience. Our microsurgical training system consists of microanastomosis using an artificial tube and actual surgical microscope in the operating room. The depth and the size of the practical operative field can be changed using simple boxes made by each practitioner. In addition to the basic anastomosis technique, a trainee can anastomose artificial tubes in various surgical environments using an artificial skull and plastic brain with brain retractor. Training for turning the microneedle is also useful for practical microsurgery.
Although there are several training systems for microsurgery, including experimental mammals such as rats and/or chicken wings, it is important for young neurosurgeons to practice micro-anastomosis in an environment similar to that of their institutions.

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We discuss the usefulness of a distal transsylvian (DTS) approach for microsurgical training of young neurosurgeons and assess the safety of this procedure by evaluating the complication ratio in our institute. In this procedure, residents learn the vulnerability of the pia mater, pial capillary vessels and small superficial sylvian veins and acquire the skill to avoid bleeding from these structures. In addition, if these vulnerable structures bleed, they learn how to keep the field dry by using suction or hemostatic materials without bipolar coagulation. These represent basic skills for dissecting the neck of an aneurysm safely and preserving critical perforators and nerves, which are the most vulnerable structures in aneurysmal surgery. From 1993 to 2008, this approach was used by 17 residents in 225 procedures. No morbidity or mortality caused by this procedure was observed.
For young neurosurgeons, the DTS approach is one of the best training methods to acquire delicate microsurgical skills that cannot be acquired in conventional off-the-job training.

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The effectiveness of the middle meningeal artery embolization has been reported for chronic subdural hematoma started acute epidural hematoma is trauma disease. In cases of acute epidural hematoma, we want to report a case of a hematoma removal and middle meningeal artery embolization in the small open head was performed in a hybrid operating room.

66-year-old woman was introduced to fall to our department, it was recognized right of acute subdural hematoma, brain contusion and left acute epidural hematoma in CT. General anesthesia is difficult, I went hematoma removed in the small open head. However, since the opposite side of the epidural hematoma has expanded, it went again hematoma removal. For traumatic DIC it was difficult hemostasis. We have added the embolization of the middle meningeal artery in the hybrid operating room. She has passed without postoperative rebleeding.

Using the hybrid operating room, the middle meningeal artery embolization for acute epidural hematoma was safe and effective hemostasis auxiliary.

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頭頸部がん専門医制度が発足し，すでに第1回の認定試験が行われた。暫定指導医および今回認定された専門医の次の大きな責務の一つは，現在専門医を目指して研修を行っている後進の医師の指導である。専門医委員会では「研修カリキュラム」を制定したが，実際の手術手技の指導法などは各施設に負託しているのが現状であるため，学会としては指導医の指導技術の向上にも貢献していくべきである。その際に参考となるべき事項につき，筆者自身の経験，米国での外科医の教育方法，および国内での他科の外科領域での試みの紹介を行った。今後は実際の指導医や研修医の提言により継続的にカリキュラムやシステムを見直していくことが重要である。

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Microvascular anastomosis is a very important technique for cerebrovascular surgeons, and although it is not frequently used, technical failure is unacceptable because of the high risk of morbidity. Therefore, training using simulation models is essential. However, the required training volume has not been fully clarified in previous reports. Hence, determining the minimum training volume required before performing actual bypass surgery may contribute to more efficient training of young neurosurgeons, enabling them to attain technical expertise in a shorter period.
The author instructed young residents (postgraduate years 2-3) in microvascular anastomosis with the silicone tube training model. The time required to complete one stitch was measured, and these data were used to generate and study the residents' learning curves.
All of our residents achieved a dramatic improvement in dexterity after the initial thirty trials, and the time required to complete one stitch progressively decreased thereafter.
Based on the author's training record and the actual time required for suturing a STA-MCA bypass, the goal to be attained on the silicone tube model was calculated to be 1.10 minutes for one stitch. It was presumed that all trainees would attain this goal after 200 to 300 trials.
Thus, it is possible for a young neurosurgeon with limited training to acquire the technical skills for microvascular anastomosis within 3 to 6 months with appropriate instruction and continuous training.

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A 35-year-old man who underwent canal down operation for a left middle ear cholesteatoma 30 years earlier, suffered from meningitis. He also developed hoarseness and dysphagia while he was hospitalized. CT and MRI scans showed a mass causing these syndromes. To control infection by Pseudomonas aeruginosa and to confirm the focus of infection, we planned a two-stage operation. We first removed a part of the cholesteatoma and left a drainage tube.
After irrigation through the drainage tube and antibiotics therapy for two months, he underwent a second operation to remove the cholesteatoma completely without leakage cerebrospinal fluid.

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 不自然なくも膜下出血分布を呈し, 破裂動脈瘤の診断を誤った多発脳動脈瘤症例を経験した. 症例は32歳女性, 頭痛を主訴に来院した. CTで右側シルビウス裂と不連続に脳幹前面に出血を認め, 造影CTでは右側内頚後交通動脈瘤と脳底動脈窓形成部動脈瘤を認めた. 出血分布の左右差から右側内頚後交通動脈瘤を破裂源と考え, 急性期にクリッピング術を行った. しかし初回手術時に破裂源の動脈瘤であるかどうかの判断が不十分であったため, 追加治療を予定していた矢先, 出血源であると思われる脳底動脈窓形成部動脈瘤が再破裂し血管内治療にて加療した. 今回の多発動脈瘤症例においては破裂動脈瘤の診断が不十分であったため, 再破裂をきたすこととなった. 多発動脈瘤における破裂動脈瘤の診断には困難な症例が存在するが, 予後に直結するため正確な術前術中所見の判断が重要である.

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治療困難な動脈瘤である内頚動脈前壁(背側)動脈瘤(IC dorsal aneurysm:ICDA)の病態と治療法の現状につき,多施設調査の結果を踏まえて検討・報告した.2004年に著者らにより行われた全国調査では,出血発症例における急性期手術成績は,待期後慢性期手術より有意に悪く(p<0.02),死亡率は26%に及ぶ.本態が解離性と推測される症例が36%存在し,それら症例の手術成績は急性期,慢性期ともに非解離性症例における手術生成期より有意に悪い(p<0.01).解離性症例における急性期手術死亡率は36%ときわめて高く,かつ術前に解離-非解離の判別が困難な場合も多いので,有効で安全な治療法の確立が急務である.2008年の頭蓋内動脈解離の多施設研究では,報告された全5例が急性期手術治療を受け,GRが2例あったものの,SD,VおよびDが各1例で,予後不良例が多かった.2009年に施行したICDA治療経験の豊富な12施設の調査では,25例が急性期,9例が慢性期手術を受けたが,両群で転帰に差はなく,前者の死亡率も4%と納得できる数値であった.この調査から,現時点で最も有力な手術法はhigh-flow bypass+内頚動脈trappingであること,clip on wrappingも有効であるが,術後の再出血,瘤の再増大が生じうる点から,今後症例を増やした調査・検討が必要であるとの結果が得られた.最後に,血管分岐のないICの一定個所に,解離および非解離動脈瘤が生じる発生機転につき,内弾性板(IEL)の自発的破綻を軸に考察した.

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Chondromyxoid fibroma (CMF) is an uncommon benign tumor of the bone system first described by Jaffe and Lichtenstein in 1948. A review of world wide literature revealed 38 cases of head and neck CMF lesions up to October 1996. There were 15 cases in the mandible,4 in the maxilla,13 in the cranium,1 in the pterygopalatine fossa,1 in the zygoma and 4 in the nose and paranasal sinus. In this paper we present a new case of CMF which arose in the ethmoid sinus. In addition, a review of the literature is presented. A 34-year-old Japanese man presented with left exophthalmus. The patient had noticed the protuberance on the left side of the nasal base 12 months previously. Anterior nasal specullum examination revealed no tumors in the nasal cavity. A plain CT scan revealed a large lump involving the left ethmoid sinus, extending superiorly into the bilateral frontal sinuses and into the left orbit. R imaging showed a low intensity signal relative to the gray matter on T₁-weighted imMages, isointensity on proton density images, a jagged island like lesion with a hyperintense high signal was seen within the high intensity signal on T₂-weighted images and marked peripheral enhancement was noted on postcontrast (Gd-DTPA) studies of T₂-weighted images. The tumor was removed completely by way of external ethmoid approach. The tumor dimensions were 6×4×3.5 cm. Grossly the surface was grayish-white, capsule-less, lobular, solid in texture and rather firm, but rubbery in consistency. The cut surface of the tumor was glazed and enerally yellowish-white in color. Histopathologic examination confirmed the diagnosis of CMgF. After 34 months of clinical and radiological follow-up, the patient showed no evidence of recurrence.

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An anatomical model (manikin) that can be used for studying anatomy and training for surgery is required in the medical field. By stacking particles that are the same size as the cell, an anatomically accurate manikin would be produced. However, it is difficult to handle cell-sized particles, so we make a manikin by stacking particles with a diameter of 0.33 mm with controlled color and hardness. Manikin is made from two types of silicone oil, a pigment and a photocrosslinker. By irradiating ultraviolet light to silicone oil, silicone gel of any color and hardness would be made. First, a 0.33 mm thickness of transparent silicone gel sheet with dents arranged at intervals of 0.33 mm is produced. Next, a colored silicone oil is dropped into these dents and cured by ultraviolet light to produce a silicone gel sheet with colored particles. Finally, this silicone gel sheet is stacked to make a manikin. Since the hardness and color can be changed for each particle, the manikin is more accurately to the color and hardness of the human body. In this paper, the manikin material and modeling technique are proposed and confirmed by experiments.

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