0:00
SNI, Surgical Neurology International,
0:05
an Internet Journal, and SNI Digital Innovations and Learning, a new video journal in association with the Sub-Saharan African Neurosurgeons
0:18
are pleased to present the 15th installment of the monthly Sub-Saharan Africa International Neurosurgery Grain Rounds held on the first Sunday of every month
0:35
The main topic of each one of these Grand Rounds are its global solutions to clinical challenges in neurosurgery. Moderator is Estrada Bernard and James Osmond, and it's presented with an
0:52
international audience and guests on Sunday, September 7, 2025
1:03
The topic of this Grand Rounds is minimally invasive spine surgery. How do I do it?
1:11
And there are two approaches. One is interlaminar tubular lumbar microdiscectomy, and
1:18
the section second is a full endoscopic approach without using a microscope for lumbar discs using a borescope
1:31
This video program is a wide open discussion on tubular microsurgical or purely endoscopic removal of lumbar discs.
1:42
I believe the purely endoscopic approach could be the way of the future, in my opinion. It
1:51
is an outstanding example of learning by discussion from others which cannot be matched by other methods of teaching. I think it's one of the best programs we have on SI Digital
2:08
The first presentation on minimally invasive spine surgery, how I do it, is on inter-aliminar tubular lumbar micro-dischectomy by Dr. Wagou.
2:21
Dr. Wagou is from the Department of Neurosurgery.
2:29
Hospital, University Hospital, and Dakar, Senegal.
2:34
Senegal is the western most country in the West Africa, in the Sub-Saharan African group.
2:45
And you can see it here, Senegal. You see in red where the capital city is. And throughout in the center of the country, there's a country called the Gambia, which extends on both sides of the
2:57
river that goes in Senegal. Other countries surrounding it are Mauritania, Mali, Guinea, and Guinea-Bissau.
3:07
Senegal is known as the Republic of Senegal,
3:14
and its climate is hot and semi-arid, although there's a rainy season.
4:12
The second presentation is on a full endoscopic approach without the microscope for lumbardis using the boreoscope by Dr. Johan Schokie Veliskes. Dr.
4:29
Veliskes specializes in cerebrovascular and skull-based neurosurgery,
4:34
interventional neuroradiology, stereotactic neurosurgery, radiosurgery,
4:41
and formerly was in the department of neurosurgery in Helsinki, Finland
4:46
at the Helsinki University. He's a close associate and co-author of multiple books and papers with Dr. Ernest Nimi.
4:55
And he is now in charge of the certain neurosurgical unit at the Regional Delcusco School of Medicine, the University in Kelton and Cusco, Cusco Peru. You see on the map here, or Cusco is, it's
5:11
located southeast of the city of Lima, which is in a circle here. Cusco is down here as they wiped out with the red in the middle of a larger red dot,
5:24
and Peru is a country in South America located again on the western side of the country
5:33
Yes, Fretta. Yes. Yoham is
5:39
is from Peru. He's now working in a city called Cusco, and Cusco is very close to Machu Picchu, which is well known as a a very primitive civilization that existed in there, and it was carved out
5:55
of a top of a mountain, and the remains were there. And I don't know what the population is, but it's it's one of the larger cities in Peru. He's had training, he went to Helsinki,
6:11
worked with Professor Ernest Nimi and he's got a PhD degree working at the area. So he's conversant and he's written many, many articles and worked on the books with Professor Ernest Nimi. So he's
6:26
got a huge background. And today is a little diversion. Last time he was with us, he presented some of their work on anterior communicating aneurysms. And today we're going to be, he's going to
6:38
talk about some of his work that he's doing and spine that I assume you've done all along. So we still don't see your slides. Do you see my screen? Yes, we can see it, good, success. Okay,
6:52
okay, I can start. Thank you, everyone, thank you everybody. Thank you, Dr. Professor Osman and Dr. Professor Bena Estrada. Thank you, every stuff. So I'm sorry, first of all, for my
7:07
English. I'm French speakers. So today I'm going to talk about our experience about interlaminar tubular lumbar microdecectomy in
7:19
Dakar. I will do this presentation in two parts. The first part is to summarize how to do the technique and coming to the main part after to share with you our experiences and some case we did in
7:34
Senegal So,
7:39
yeah, just to say is that this last century is marked by the evolvement of MIS technique in all surgery field and in spine more. The most common technique used are microendoscopy and tubular
7:53
retractor system. But it's not something new. So in 1990, when Robert and Caspar developed tubular retractor system by the time we saw in 2003 metric system using navigation was developed. So when
8:09
you see here these pictures to talk about the purpose of MIES surgery in spine, here you see that this is open surgery in open surgery. So you put a retractor and retractor can damage muscles and
8:27
people or patients after surgery got a lot of back pain Or the purpose of MIES surgery is to keep muscles, to keep spine processed, ligament enter and supras, spinous ligament and to keep spine,
8:43
spine balance. So this is the tools we use about MIES technique. So when we do MIES laminectomy, you have to respect 10 steps and it's the same when you do tubular MIES microdisactomy. So most of
9:00
the time if you have like what I show here tubular
9:06
retractor system when you have dilator, you have my cross-cob drill, pituitary forceps and carries on. It's enough to perform this surgery. I will show some video. So, it is very important for
9:21
skin incision to respect some size. When you do a MIS tubular technique for micro-disactomy and micro-laminateomy, you should do your skin incision 15 to
9:37
22 centimeter to the midline. It's very important. If you go far, so you can go outside and
9:46
you can lose your anatomic landmark. So, for tilt, you can go for centimeter to the midline. And the second step, when you put your guide wire here, it's very important. For example, when you
9:59
do tubular dissectomy L4L5,
10:02
your guide wire has to be in L4 laminar. And, After removing missiles, so you have to see interlaminar space, for example, L4, L5 interlaminar space. If you can see, you can touch it. It's
10:16
very important to understand anatomy before starting drilling. And this is two view. You see, this is external view for different dilate, and this is your internal view. And what I told you,
10:30
what I say, it's very important to see here the laminar and the interlaminar space before drilling. And you can do if you have your fluoroscopy or X-ray to see the level you should do your surgery.
10:45
So this is a 10 step. Every surgeon who do MIS tubular detritos should respect for laminectomy. And it's the same step to respect when you do dissect to me. If you understand first of all, your
10:59
anatomy, I say it's this anatomy is a laminar and enter laminar space. So you start breathing. For example, it's in alpha alpha you start drilling the inferior board of alpha and you can
11:15
take your keroson, do your laminectomy until you can see your yellow ligament and you can use ball tip or spatula to remove peacefully with keroson your yellow ligament and at the end you will see
11:29
the dura and your nerve root So if you want to do bilateral laminectomy you should bench the table, respect this angle and go to the contralateral side under the spine process, drilling
11:47
the contralateral laminar to make the contralateral nerve root of free and removing yellow ligament. So when you see literato very quickly comparing MIS, spine surgery and open surgery you see that
12:02
there is a lot of advantages for MIS technique because you can make a prediction in blood loss, but you can have less complication like infection, but also hospitalization time. Most of the time,
12:16
it's like an ambulatory surgery when you do MIS surgery, or a patient can discharge one day after surgery. So when you compare some, also MIS technique itself between endoscopy and tubular, you
12:31
see that endoscopic technique is less invasive than MIS tubular surgery. But for example, this is for microdecectomy, but for example, when you take T-leaf, MIS T-leaf like L5S1 or
12:47
L4L5 compare endoscopic and tubular, you get more, more, you gain some time, this tubular retractor is very advantageous for the time. And let's talking now to our experiences in Senegal, So we
13:03
started the technique 13 months ago. And until we started, 42 cases were drawn about MIS technique. Most of the time, we operate
13:16
MIS laminectomy 1 or 2-level lumbar. We did two cases about dorsal alienated disc. So we did 22 alienated disc using MIS technique. And if you see these pictures, this is our tubular retractor
13:34
system we use here. So this kind of tubular retractor is different to a metric system. So it can do the job. You see, you can have here a different kind of dilator. We need so long material like
13:49
monopoly and bipolar. And this is the arm we use. And this arm sometime can move in every time I will show some video So this is one patient we
14:03
operate here. It's on video, it's not working. This is on video I would like to show how to do it. But this is in skin incision. You see, we need to respect 15, 15 centimeter to the midline and
14:18
after we different dilator and see the picture we have here and this is the arm we use. And after we do X-ray and this is one patient we operate L2, L3, aniotic disc and this one is L4, L5 And
14:34
every time before starting drilling we need to see this anatomy, this laminar and this yellow ligament. So let's talk about first of all this is 42 female with left L5 sciatica without any
14:50
improvement. He previous take medication without improvement and also with physical therapy. So without any improvement we go to have surgery here and you see this negative discussion. in the left
15:06
side, L4, L5, on MRI. So, or also, this is
15:15
a video we need to see, and I don't know what to. Sure, well, the experience in our crop was different than what we were seeing
15:27
in Dakar. They didn't have, and this was presented a couple of
15:33
sessions ago. They didn't have the tubular retractor system. They had a couple of dilators, but they didn't have the arm, and so
15:50
the improvisation that was done was to use the two dilators to get up to a five centimeter syringe of
16:02
which
16:03
the end was done which I wish the end was cut off, and that served as
16:10
a tubular retractor. So we're able to advance it down to the laminar, using the microscope, do the procedure. They didn't have access to a high-speed drill,
16:26
so we did the laminotomy with Keri's and Ron's yours
16:33
And because there wasn't the holding arm, we basically had to suture the syringe to the drape. So it was quite a bit of
16:47
finagling to make it work. And I was
16:51
pleasantly surprised that we were able to make it work, but it was somewhat challenging But I think as Dr. Wagoo has indicated that the key is to be familiar with the anatomy and not just visually,
17:09
but you have to have a tactile sense of the anatomy. As you place your initial dilator, you need to be able to feel the laminar, feel
17:25
where the interlaminar space is, feel where the ligamentum flavum is, and that will guide the placement.
17:37
I think it's important to have
17:42
an operating table that you can adjust, you can rotate from side to side, because that can help you with the contralateral visualization, especially if you're
17:59
doing a spinal stenosis decompression, you'll need to to get access all the way fromipsilateral to contralateral. I
18:10
also found that taking out lesions like synovial cysts, more optimal if you're doing it from the contralateral side. So
18:24
if you're removing a synovial cyst, then coming in from the contralateral side gives you that good visualization to enable you to remove the cyst.
18:38
So, well, it looks like we got, you know, how much is very close here. But first of all, the standard approach is obviously always works everywhere, correct? I was trying to. Sure, yeah.
18:52
The standard approach works everywhere at home. If you don't know what was just presented before the challenge in Sub-Saharan Africa or places where there's a limited, uh, some, uh, some types of
19:07
limited, uh, equipment and so forth that one number, one, you can do a standard approach. Always know how to do that. You can do that. Everybody knows how to do that reasonably. You can always
19:18
get reasonable results. But what they said is the major reason for this is one to have a smaller incision, which means probably a shorter hospitalization, less recovery, less blood loss, which is
19:31
a problem, because I'm sure getting blood there is very difficult, and also earlier ambulation and getting out of the hospital in less costs. So for the patient, in Sub-Saharan Africa, the
19:45
minimally or tubular approaches are attractive. The real problem I was going to ask a question about after everybody finished, is what's the learning curve? How long does it take to become
19:58
proficient at this?
20:01
I think it depends on individual, but I would say three to six months with consistency. And I think the key thing is to do it in stages and take very straightforward cases first and just do it in a
20:22
very slow manner of progression. So start with the simple things, not the complicated ones, right? And you're okay, there you go Okay, so yeah, sorry for these difficulties. So I will present
20:38
this case about the modified endoscopic interlaminar lumbar dissectomy. Yeah, I was in a Reddit that our colleague was presenting. The fundamentals and the essentials of this approach. And but I
20:54
wanted to present this because we have a modified approach, which means that we add some things
21:01
in this approach.
21:10
And in 2017, we started a cooperation with a laboratory of the University, an atomic laboratory of the University here in Cusco So we published this modified periodic scope approach in the nursery,
21:24
since on that time we didn't have the proper endoscope. So we adapted a tool
21:35
called this Boroscope So this Boroscope, which is
21:41
available for everybody and this very low cost in the market, has somehow similar dimensions
21:52
of the of an account of four millimeters in the scope So, and the imaging also is or the images that are produced that are produced by this tool are also quite good. So the diameter of this tool was
22:07
of 55 millimeters and you could use you could sterilize in any
22:14
way and could use immediately. So this tool could be adapted
22:21
to a computer and with a simple software you could use this computer and this tool this balloscope add some kind of
22:33
magnification process for your procedure. So we started with this approach here we made some kind of cranial approaches trying to do some minimally invasive approaches using this tool
22:49
and we saw that
22:53
the images were quite good for example we perform at this sub-occipital approach to the pineal region in a catalytic specimen And you could see that the images of all the venus and arterial or the
23:08
vessel structures inside the
23:11
pineal region were proper. So
23:15
those articles were also included in the thesis, what I performed at Inhale Cinkey.
23:22
And yeah, we could see that this tool was economically accessible and also could offer some kind of good images and good resolution
23:33
images for the training process, yeah? So I put there a table with comparing this, the traditional training systems with this training model. So this borrows costed between 10 to 100 euros. And
23:53
of course the computer, any person can have it And we couldn't. We didn't need a microscope for doing these procedures in. So Cusco or my city here, of course, has a couple of public hospitals.
24:15
But on those times, even the public hospitals, they didn't have microscopes. And also, we had some kind of endoscopes that were used in the other specialities in the hospital But the unit of
24:29
neuroscience didn't have any kind of this magnification tools. So
24:37
those were published. And we could see some kind of limitations and some kind also of benefits using this procedures. And we faced it one case here. And of course, we tried to a patient here with
24:58
a lumbar disc. Yeah, I will present this case. So he's a 25-year-old male. And he,
25:08
he felt when he was a 10-year. And on that time, he presented a severe low back pain and numbness in both limbs.
25:20
Yeah, a little bit more pronounced in the left side. So because he was a student and he was living in some kind of rural areas, he didn't, parents didn't bring him
25:34
to the hospital and he just stayed with this kind of discomfort along here over the last 15 years. But since he started studying in the university, he seemed to increase it there. And
25:52
he started having a guide to a medication and some kind of difficulty for extending. both legs. So finally, he came to the consultation and we could see him. He could walk with some kind of
26:08
limitations. But in the examination, we could see that he couldn't elevate the extended legs. So he
26:20
had this Lasseque sign in both sides. Yeah, but predominantly in the left side We did MRI.
26:30
First, we did some kind of an X-ray. Didn't show anything and a special thing in the kit. But MRI showed a very big lumbar disc.
26:48
We put him in the in the jar in the nursery and we prepared for making
26:56
the. Sorry. We were planning to approach him with a microscope, but on that time, the day of the surgery also,
27:05
the microscope was used for other type
27:09
of procedure, and we didn't have the availability for this. And then we were planning just to do it by direct opening without any kind of modification, or we could use also some kind of lenses But
27:23
finally, we tried to adapt this, our magnification tool for approaching this organization, okay?
27:36
So, here I will show you this video which summarize somehow the situation of the patient. Please let me know if it is going on, is it? Not yet. Is the video going on? No, we don't see it. It
27:58
says that a standstill
28:02
Okay, why don't you just go ahead and describe what you're going to do, the video is not. Actually, it looks like it's moving slowly.
28:11
I think it'll be a next one. Oh, you're extending his leg and you're doing the MRI. Is it? Yeah. You're extending his leg and showing that he's got, he's got a pain with extension of his legs.
28:26
All right
28:28
Yeah, now we see the MRI. Yeah. Yeah. Yeah. Okay.
28:36
Oh
28:39
Um,
28:45
Well, I am not here. My video is already probably in the heart part, but I don't know in which part is that. Anyway, you could see the MRI where we're showing a very large disk urination. And
29:01
then we
29:08
could also one series of 20 millimeters for using this like a tubular channel for approaching. And then also
29:24
I am showing you already how we are using this horoscope for entering this lumbar disk and how we are trying to make the laminectomies, the
29:39
same laminectomies
29:42
in the left side.
29:45
And then
29:48
we will see how we are extracting and removing the disk. So we could see that this was not an acute case. We could see already some kind of very chronic fibrosis in. And space that
30:05
we could remove the disk by this meal as a extraction But finally, we could solve the issue. And we could see directly all this procedure. And
30:22
at the end, I am showing, we're here already showing how the patient improved
30:29
the movement of the legs, the symptoms and the pain released immediately after the surgery. Okay, and the patient was in good condition after the procedure
30:43
Uh, please let me know if the video finished already.
30:48
We still see where you're elevating the leg at the end. Okay, yeah, yeah, this is then the last part. Okay, I changed the slide. So here the patient is already recovered in a good condition.
31:06
And as you could see, the incision is very small, of course And the patient went out
31:15
to home almost immediately. So the procedure was successful and the condition of the patient was okay. Yeah.
31:27
Yeah,
31:29
some kind of small discussion about these procedures were in 2025
31:38
And already this meta-analysis review was published. showing almost similar results than before that, the different types of endoscopic procedures or the different types of procedures for these
31:56
variations show some kind of similar results.
32:02
However, this implantation of internal fixation devices show it a little bit more better results, but without significance, it's statistical significance. But of course, there are not differences
32:21
in the long-term result regarding those treatments. However, we as neurosarios and the practitioners who are following our patients, we could see that the endoscopic serially offer us some
32:36
advantage
32:39
over the traditional serially. For example, the aesthetics are better. Yeah, there's the incisions are very small and patients like that part. The recovery is also a bit faster since the muscles
32:53
are not so open it and so damage it in the endoscopic approach. So the patients feel ready for working and for going out home almost immediately few hours after surgery. And definitely similar to
33:09
the use of the microscope and the scope of a high surgical precision. Since these endoscopic cameras provide a very detailed view and you can also see of course the roots and all the anatomical
33:25
aspects of the surgery. In that way also it produces a greater safety and not so much bleeding, you can control very well all the few complications that you might have during the procedure basically
33:41
bleeding.
33:43
And yeah, you reduced the risk of complications in the immediate and immediate positive time. And of course, also the effectiveness is what's shown already by different
34:02
studies showing similar results to the microscopic approach.
34:07
And it can be used in spinal stenosis and other conditions So here I wanted to show basically this our tool. Now we have our
34:21
own endoscope, but I have bought one endoscope that is
34:35
also used with a monitor in a laptop. So I am using this. But probably many centers around the world that they don't have these microscopes or some kind of magnification tools. benefit of this, of
34:45
this, of this, of this tool, at least in the beginning, or for sure it can be used for training models. Could you go back to the slide before that? The slide, which slide before this? Know
34:59
where you were comparing the costs? This one? Yes. So for educating us, the training mirror is neurosurgery. It's a training microscope.
35:11
Is that necessary in this endoscopic surgery? No, no, no. That is the difference, yeah? So I will show you here. Okay, so the next thing is that, yes, I
35:24
am showing here how much cost this microscope for a train. The next thing is the endoscope. The endoscope is from
35:33
35 to 60, 000, right? And it gives you a raise of angle. It's an endoscopic camera, right? And that's what you're showing in the pictures up there, right? Yes. So it's not the number three is
35:50
our proposal where it interrupt you here. But we have to move along. It says your pro our proposed system.
35:58
What is the baroscope and the computer we know and the total cost? So if I'm an African, I want to get, I want to adopt this technique. I need to spend money to get the endoscope What is the
36:12
baroscope and the computer and so forth? We understand what is that? What's your proposed system? It's the number three where you are seeing their own proposed system. So the ball scope cost
36:25
about100.
36:28
The computer, of course, you can use your own computer. And the total cost means just this between1, 000 to2, 000.
36:36
What is the baroscope? Is that it? Is that an industry?
36:44
The horoscope is this one, is this one. Okay. It's like a flexible endoscope.
36:51
And you're doing that in assisted, you're using a small incision, you're using a microscope or you're using just
37:00
the camera. Just the camera, just the camera. So
37:06
how do you, how do you get it down? You have to make sure, you have to make an incision. So that means you have to have some imaging to show where you want to go, right?
37:19
Yes. And then you insert something down, you, I'm sure to determine that it's the right location. Then you have to make some kind of an incision to get this in there, is that correct? Yes, yes,
37:32
for example, I will show you, yes, that is the reason why I wanted to control the video So I will try to show you again this video.
37:42
But is this this is this ball of scope? Is this ball of scope on the market? And if it's on the market, what is it? What is it usually? What is it?
37:55
You can find an internet. You can find an internet easily. But what is it usually used for? But the ball of scope, what is it through the continues.
38:06
Or some kind of mechanical,
38:10
some kind of
38:12
work for the cars, some kind of electronic works. Sorry for this,
38:23
but I want to stop. I don't think the movie is going to show. Yeah, yeah, yeah.
38:29
We're spending a
38:30
lot of time here
38:34
It offers a good magnification. It offers a good.
38:39
Uh, I
38:42
think we should stop here. We're not, we're, we're spending a lot of time wasting everybody's time. So, so leave this picture right here. Okay. So, so now this bar. Dr. Professor Nimrod was
38:54
asking about the, the baroscope. Basically, it's a, it's a lighted, it's a lighted, uh, scope that gets you down and shows you the, the anatomy. Is that correct?
39:09
Yeah, basically, it allows you to have facial isolation and the scope. Yeah, it improves your visualizations. Yeah. It's not an, are you hearing me? Sorry. It's not an endoscope. Is it or is
39:25
it? I have strata. Can you, I'm trying. Yeah. Well, yeah. Well, I think essentially it's an endoscope. It's just that it's the routine use is, is not medical that it sounds like it's a it's
39:36
a it's an device that's used in industry, it might be used for plumbing or it might be used for in the automobile industry to visualize deep areas that you can't, that you don't readily have access
39:52
to. And they're implementing it in with the medical use. Yes, so let me show you, let me show you. Give me a few seconds. So go ahead and keep talking. I was trying to, we can't spend all this
40:07
time Yes, so. So this is the endoscope. This is the endoscope. I can't see it. Yes, this is the endoscope. So the borrow scope is this one.
40:22
So the Boroscope is this one. It's like a flexible endoscope. So it has like in the tip, it has like a small camera. Yes, yes. So instead of using the endoscope, because this is very expensive,
40:37
this endoscope is expensive. Right. So you use this one, which is
40:43
very, very cheap So it's just a difference. And this you can still realize also in the hospital. So it's a very, you can, you can make it clean very easily. So, so, you know, do you, you
40:59
have to make an incision to put that in there and you have to do some dissection. And that scope that, that it's a television camera at the end of the flexible to right. Yes, yes, yes So, you
41:12
don't need a tube, but you still have to make a small incision and get down and you have to radiographically Well, I hope you, an X-ray.
41:21
know where you're going before you do this, right? So you have to take pictures in the operating room on the table, which shows you exactly where you're going. Then you go directly to this point,
41:31
you insert this television camera. Is this correct? It is, but of course, of course, for the spine procedure. You should use also one small channel, but that small channel can be replaced by
41:43
the syringe. So you can use like one, like 10 millimeter syringe and make like a small channel to approach the spine. Because otherwise, the parabertival muscles will stop the injury. So the
41:57
baroscope
42:01
is a television camera at the end of a flexible tube that gives you excellent light and visualization of where you're working. Is that correct? Yes, yes, it's very, and it's very low cost, right?
42:18
You can find it in the market. And you've used this now for what, how many years each year or so in various ways? Yeah, 2017, but we were, of course, we are only using mostly in training fields,
42:32
but in this case, we could use in the
42:37
salary, because we didn't have this endoscope, we didn't have other tools. So now you can use this endoscope, and this is a modified, this is a home television camera, and at the end of which it
42:49
looks like a circle of light that gives you great exposure, you have to know exactly where you're going anatomically, you can do the surgery, and you're saying that this is a very inexpensive way
43:01
of doing minimally invasive surgery, is that correct? Yes, yes, even though I can add that the visualization is even better with this camera, because with the endoscope, you have this eye fish
43:15
view.
43:18
So it's like a little bit circular, a little bit complex. But with this camera, the W is more complete. So now, let me ask you the key question, Rastran and I were talking about that initially.
43:32
What is the learning curve? What is the learning curve to learn how to do this? Or obviously you have to do standard surgery and you have to become familiar with the anatomy and the approaches and
43:43
then you can make the incision smaller How many cases do you have to do before you're expert and do you do these cases in the autopsy room or Sumpa, how do you learn about this? Well,
43:58
when you are doing already microsurgery, then you are used to the magnification. So you are used to the treatments. For the endoscopic part, you need to manage this blind eye technique. So you
44:13
are seeing the camera and your hands working in other in other space. So like the professional guitar, guitar, guitar man. You need to look some other space and you work with your hands in other
44:25
space. So I think it might take maybe
44:32
Oh, we just lost him. We lost him. Okay, well, let me just say, let me just say, Jim, that you do need a retractor for this, 'cause you have to maintain the exposure. Resposure, right.
44:45
Yeah, so what he did was similar to what we did in our crowd when I was there a couple of months ago, he used the syringe to serve as that retracted the whole to maintain the exposure And then
44:60
working through that, through the syringe, he was able to do the procedure. I thought that was very creative. So you have to use a, you get a tubular channel, it goes down to the operative site.
45:15
And then you could either do the surgery through the microscope, but this camera system gives you tremendous light. It looks like it doesn't, but you don't have 3D vision, right? That's correct,
45:27
that's correct And so how do you get around that? Well, I think that's part of the learning curve you learn. You have to kind of do it in two-dimension. So if somebody wanted to buy this and they
45:39
wanted to try this in Africa and they're great advantages in terms of lower cost, early ambulation, less instrumentation and you can reuse it and so forth. So it would be very attractive, but the
45:53
learning curve you say is you have to know how to do it a general operation first before you can do it I think so, I think so. 'Cause you have to, there's not a substitute, you have to know
46:08
the anatomical structures and if you're working with tissues below where you can
46:18
see, you have to have a tactile sense of where things are as you proceed. Dr. Wagud, it sounds like you have some commentary What are your thoughts? Yeah, oh, thank you. So for me, I started
46:36
doing tubular surgery 13 months ago, before I moved to, before that I went to for off-service ship in Well Corner Hospital, three months off-service ship. But we trained ourself in skull-based lab.
46:51
So we use model to practice. And when I come back, my first case, I use anatomy landmark, but I understand nothing So I convert to the first case. And when I open the patient, I understand that
47:05
I was a little higher. So the second passion I perform, I understand. So I understood. So the first case took me two hours, two hours 30, two hours and a half to do deceptromy. So now, until
47:24
doing a lot of visual learning curve, Now I can do 1 hours 10 minutes to do this. 20 minutes to do one de-sectomy. So yeah, of course there is a learning curve, but there is to understand, I
47:37
think what I do is when I put dilator and removing some muscles and put tributor, we have to see the laminar and interlaminar space. And it helped you to understand it, not to me. And now you can
47:52
go to do the surgery. Yes. Dr. Vago, let me ask you, did you train, how did you learn this? Did you learn around the patients or did you learn it? Go down to the on-time shiver room and learn
48:03
it. How did you do this? Yeah, so I practice first on models
48:10
and what I do is we understand I do a lot of open surgery. And I told myself, this is the thing is just to convert open surgery to MIS surgery. So the first case was, of course, I want patients,
48:27
but I covered the surgery But in the second case, I understand. Yeah, so I practice in model and after I move to patient. Okay, that's very good. And how much time did you spend on the practice
48:39
thing on the model? Was it a week or a month or two months or six months? Yeah, so I, in my practice, I was three months in work on a hospital, but I use models like four times to do laminate to
48:55
me and, yes, and deselect to me on models. Yeah And before you became confident, it took you how many cases, 10 cases or 15 cases or two cases, how many before you became more confident? Or how
49:12
many, sorry, I don't understand how many cases did you have to do before you became more confident in what you were doing? I started initially, you start with simple cases and then - Yeah, yeah,
49:24
yeah. Yeah, I started with simple cases for one level.
49:31
spinal canal stenosis. I start with one case, one level spinal canal cases, like three, four cases. And when I solve the result, and I know that this is very important to do. Yeah, and I move
49:45
back to see videos and, you know, seeing literature. And after 10 cases, I start to be confident. Yeah. So you always knew that if you started out with a simple case and Australia, you should
49:60
jump in here And things weren't working out very well. You could always go back to your standard approach, right? Oh, absolutely. Yeah, yeah. Of course, yeah. That's the case. I should point
50:11
out that your experience, Dr. Wagou, was the same experience I had the first time I did it.
50:18
I got, I was lost. I wasn't that familiar with anatomy and I converted to an open procedure. And, but from there, I was able to progress because I became more. familiar with the anatomy and the
50:32
other thing I should point out is that I have this expectation that once I put the dilators in and put the tubular retractor in it we just have this beautiful exposure but I always initially I just
50:43
had the creep of muscle in there and that just absurd things in and so I had to learn to use the to use the bovii to to clear out some of the muscles there at the bottom you know in order to to be
50:57
able to see and I saw that you had a bovii an extended bovii with tip with with what you with with the equipment that you were showing but I should point out that one thing that I found that made a
51:11
huge difference was to bayonet that that extended bovii so that it was out of your your field of view down going down the tube so we would we would take the straight the straight extended bovi tip and
51:25
bayonet it so that you just like you have for any micro-instrument that be a net a configuration. Terrific information. Very honest, Estrada, because everybody wants it. They got trouble, and I
51:39
was very honest. So that's how you become familiar with this. You can use models like Dr. Waugu did, and then you eventually take a simple case, and you do it. You may have trouble, and you
51:51
make it bigger, like you just said, and eventually you get to doing it. Is that correct? Yes, absolutely, and that's just part of the progression. Okay, and the goal is the end result to
52:04
reduce costs, reduce blood loss, and early ambulation, right? Yes, and I think there's less risk of infection, because you have less
52:15
tissue exposure, less blood loss, and I think there is that aspect of it as well. But now, having said all of that, We have to talk about the potential. risks because you are working in a
52:31
smaller space and there's you're more confined and if you have a if you have a complication like a dural tear and how you're going to be able to address it. Can you expand on that a little bit?
52:48
Those are really important issues. Well so I think if you have a if you have a dural tear you have to deal with it if you don't repair the if you don't repair the dura you're going to have the risk
53:02
of a CSF fistula. So one thing I had to learn was to be able to repair the dura
53:10
through the tube and that can be challenging but with with with microsurgical experience you can do that and so I would I would use a
53:24
micro pituitary around your and a very fine a needle like a TF4, for example, and if I had a lateral nichonodera, it wasn't common, but if you have that, you can repair it with a suture. Some
53:42
people think that
53:45
and have successfully not repair a small tear
53:53
and put
53:56
some substances they like fiber and glue or something, and then as you pull a retractor, I'll close out the dead space and have a tight skin closure. You might not get a CSF fistula, but that is a
54:11
risk because as with
54:13
the open procedure, the preference, the preferable way to do it is to repair, is to do a primary repair. So does that mean that you should have the tubular, if you're operating through a tube,
54:27
Does that mean you have to have a wider tube to do that? No, I mean, if the wider the tube and more exposure, I routinely do monitor lumbar disc,
54:38
or cervical disc through a 14 millimeter diameter tube,
54:44
because that's part of the advantage of
54:49
that technology, of that approach. Okay. Yoham, I see you back, do you have it? You know, one question I had for you is you were working through the syringe, but did you use dilators before
55:05
you placed that syringe through which you worked with the Boroscope? So how did you get to that point? I mean, unfortunately we weren't able to see the video.
55:19
Yes.
55:23
No, actually,
55:26
I just, of course I should enter first. I try to reach the aponeurosis. And then after that, when I open with the electrical theory, the
55:39
aponeurosis, then I use first
55:42
one small syringe, like this
55:46
1 millimeter syringe. Then I close the step to the 5 millimeters, then 10. And finally, I can open with a 20. So that is the process of the aponeurosis. So you're essentially dilating with a
55:60
series of syringes, similar principles? Yes, yes. That makes sense And the other thing that I could also see is that you can also use the same keyhole approach. So you open up on the velocity
56:16
slowly, but deep inside you can move the syringe, superior or inferior. Yeah, so in that way you can wipe a little bit the surgical field, but deep inside. So you can enter just by one
56:31
centimeter, one point five centimeter incision, but inside then you can use the keyhole approach and then you can open, go up or down. So you're, go ahead, I'm sorry. With your approach, your
56:45
arm, are you using an assistant to hold the endoscope? And are you
56:52
securing the syringe in any way? Or are you just leaving it loose? How, what's the mechanics of that? Yeah, we have good holders here, our residents. So our residents are done. Okay. Yeah.
57:09
Can I ask you a question? Oh, you're here, man, if you. We understood what Dr. Raghu did and he explained the training and what the advantages were in the tubular approach and so forth and how
57:22
he could learn it and so forth. But it seems to me that you're also doing something that's almost like an exoscope or you can put the camera down there and we have some questions. Somebody asked,
57:36
is it generate a lot of heat? Is that gonna be a problem and so forth? But you're putting the camera down there and you're looking at your computer screen to see exactly what's going on, correctly?
57:49
Yes, yes, yes.
57:53
The latency time is very small. I mean, it's, it's the real time, yeah. So actually what you're doing is you've got a smaller hole and you're working through the hole but you're looking at your
58:03
computer screen and the instrument is, let's say you wanna drill, you're putting the instrument and there probably covers the hole you have, but it doesn't matter because you've got the camera down
58:13
at the bottom with the light and you see what you're doing. So you have to become very familiar with the anatomy. Is that correct? Yes. Yes. So it's more indirect surgery. It's more indirect
58:27
surgery than direct surgery, right?
58:31
Okay, and that's how you can get away. And
58:36
that's how you can get away with a lower cost system using a computer, which shows you where you're going and you have to do what a strategist you have to do the dilation to get down there. But a
58:49
lot of what you're doing, you're doing right off your television screen, right, or your computer screen. Is that correct?
58:58
Yeah, that's correct. Okay, so that's why you don't need the microscope. Is that correct?
59:05
Yeah, because your visualization and illumination is with this with the Borosco. with the baroscope.
59:14
So if I'm in Africa, that's a very attractive.
59:20
That's a little illumination. So even if you burn the tissues, so it's very soft illumination.
59:31
Yeah, early in my career, we used a flexible camera, a flexible endoscope, flexible, what do you call it? A lighting system, but the lighting wasn't very good, but in this one, it looks like
59:45
you've got terrific lighting. Is that right?
59:49
The Borosco, yeah, but it's a lead system. Yeah, it's a lead system, so it doesn't burn, actually. It doesn't burn. So there's no heat, so it's an LED system. So that was one of the
59:59
questions. And here's another one,
1:00:03
okay, and here's, she'll bear. She'll bear, you said you have a friend in France, who set this endoscopy system up in 1993 and he used this. Is that correct?
1:00:17
No, I tried to read this endoscope 30 years ago, but I used for 40 years microscope. So I did not use this equipment, but I know that it's very useful, this one. And it would seem to be useful
1:00:36
throughout Africa because it's inexpensive, but you just have to learn how to do it. Is that correct, Jo-Mar? Yes, it's correct, but it's not easy to set up such an instrument in Africa. I
1:00:50
think it's easy, look at the shape, it's easy. All right, Jim, I'm gonna share my screen here and I received the presentation from Dr. Wagoo And so I wanted him to have the chance to. to show
1:01:09
the video, I'm gonna go to it. This is it, right, Dr. Wagyu? And let me just, let's just get that. Yes, thank you, thank you, thank you, yes. So we can, so this is our first case of L4,
1:01:24
L5 descent to me. And you see here, this is a yellow ligament and we are drilling a facet joint here a little, keep going. Okay, keep moving. Okay, you see here, your tip is moving because the
1:01:39
arm is not very good. So
1:01:42
we use keroson and we don't have flow seal in Africa. So when I see epidural vein, I make coagulation. And after here, you see, you got the deura and the nerve root here and we take both tips.
1:01:57
This is the deura, you see, and the second is the nerve root and we dissect thing and we see the bulging this down here. So after, okay, we dissecting and you see the bulging disk here for L5
1:02:15
bulging disk and we use 11 knife to open it and to remove the annuity disk here. So this is a 11 knife,
1:02:26
okay. And
1:02:30
we will use a p234 steps. So after we remove its annuity disk, this is this was one of the first case I perform when I come back and we use p234 steps also, okay. Perfect, okay. So this is one.
1:02:51
We can go to the second video, please. Second slide. Is it after this one? Yeah,
1:02:59
after this, yes, after this, yes. You can see the before this, before this, sorry, before this. Okay, yeah, this, this, okay, okay, okay, okay.
1:03:09
or no, 15, 15, slide 15, go ahead, go ahead. Okay, go ahead, 17, sorry, 17. Okay, yes, here, here. Okay, this is the case. So he got L5, S1, big and yet disk, without any
1:03:25
improvement of this video over here in the left side. This one? Yeah, just to show you, yeah, yeah, yeah, yeah
1:03:35
Okay, this is how we put, so the guide and different kind of tubular retractors. This patient,
1:03:45
he doesn't, he didn't want surgery as a first case. So we do medical treatment and physical treatment, even epidurization, but no improvement, he come to have surgery. And I told him he got big
1:04:01
and yet disk in L5, S1 So you can go to the next slide.
1:04:10
Okay, this one, this one, 18 years, 18, okay. So, okay, you see here, we use a, this is a negative disk, which is coming out. Okay, we dissecting, you see the fragment here, and, and
1:04:27
we'll use a P2T for steps after
1:04:32
to remove this donated disk. Sometimes I can use board tip or spatula to dissect it, and after you, you'd see the big fragment inside the disk. Okay, this is a, this is a big fragment. Yeah,
1:04:46
and I use a board tip to check upside, inside the disk, left and right to see, is there any other fragment? And it's a passion for you as a procedure, he's doing very well. So you can move to
1:05:01
next slide
1:05:06
Next slide. Okay. Yeah. Okay. Now this one
1:05:10
to see the case first. Okay. 19. Oh, sorry. 19. Yeah. Okay. So this is 52 years. Our female visco daikino syndrome. And if you see his MRI, he got big, alienated disc and he got in a
1:05:25
rotation and bilateral L5 sciatica deficit. He coming two days before in our department, we took in meeting some surgeon advised me to do open surgery. But I told that we can do it by minimal
1:05:39
invasive surgery, but we can do laminectomy to make more space. Next slide.
1:05:46
So we got a corner coin syndrome. What are econosanromias? Okay, video. Okay, you see here, I do MIS laminectomy first in lateral approach bilateral decompression. And you see the aniotic disc
1:06:00
is here. So we use 11 knife. to open the disk, okay, and here we will dissect the enniated disk using a section and spatula. It has to try to, here it comes, okay, okay, here we see the disk
1:06:25
is here and we use pituitary forceps and the enniot disk is coming out,
1:06:33
okay, this is the first fragment,
1:06:36
okay, there is another big fragment,
1:06:41
yes, okay, this is a big fragment, so, so I did laminate to me to make more space, so I did bilateral laminate to me using unilateral approach to make more space, it allowed to push the dura and
1:06:55
allow me to remove this big energy to disk here, so it remained one small fragment and
1:07:05
Yes, we can use pituital faucet to remove and after we check if the nerve is free and five nerve, of course, in the shoulder and in the in the in the eyes. Okay. So we can move to next life to
1:07:20
show you so much. Wait just a minute. Wait just a minute. Okay. Okay. Yeah. How do you, you said this was so big. Did you have to go both sides or did you go to the other side Yeah,
1:07:34
but it was any lateral approach. And I, I did bilateral laminate to me, because we convinced the table. It's like. Yeah. So you, you decompressed, you decompressed the bony canal so you can
1:07:48
move the, you can move think. But now do you clean out the disk space, because there's a lot of debate about how much do you take out And can you see it through this approach. In other words, do
1:08:00
you go and explore the disk space in all directions. Do you understand what I'm saying, uh,
1:08:09
yeah, well, you have, you have, uh, he's done a bilateral exposure, which you need for, for this case of spinal stenosis. And you have, and the advantage of this is, as I was saying earlier,
1:08:20
because you can rotate the table, you have access to both sides of the, of the disc. Yeah. Yeah. Yeah. Good. Yeah.
1:08:36
We can see here. Yeah. Yeah. Yeah. Okay. Okay. Okay. So we can just, I want to say, I want to show some slide about difficulty to be faced. So yeah, nothing, uh, not this one. 22, 22.
1:08:46
Okay. So this is at the beginning of, it's a video Yes,
1:08:53
it's a video. Okay. Yeah. Yeah. So at the beginning, I did is, as you told, as you say, I try to do such a for the dual tears, but it take me one hours or 45 minutes. So now what I do is I
1:09:11
stop this procedure. When I have dual tears, I take a small piece of muscles or sewage, and I put it. And since I do that, I don't have a CSF leak in post-op. But at the beginning, I do like
1:09:27
this, but it's a part. And it took 30 minutes or sometime 45 minutes, okay. So next slide. That's an excellent job, excellent job. There, wait a minute, there's a question here. And we've
1:09:43
got to get back to you, Ham, for this is about the Boroscope. Can you get different magnification and so forth? Well, we got to come to some questions. Go ahead, but that was very instructive.
1:09:56
This is a very instructive series of videos between the two of you. And I think we ought to open this up for questions people may have a lot of questions. Uh, strata, this is, we're getting
1:10:07
honest, we're getting the truth here. Yeah, no, I think this is excellent. Anyway, well, let, let, let's talk about good finish and then we can have some further discussion. Okay, okay. I
1:10:19
think we got the idea of what each procedure was and they're attractive. Okay. Yes, uh, just this 24, 24, 24. Sorry. Okay. 24. Okay. So this is the arm I use is not very good So even during
1:10:35
the procedure, you see, uh, here the arm can broken. It's not very, so there is a video over here. I use gauze to make a notch and as the doctor John told, I took to the resident to keep the,
1:10:51
the tubular retractor to finish the procedure. But after next slide, next slide. No, this is, this is very good because you gave us a good point as on how to
1:11:04
I had to improvise. So here you see, this is my mechanic car. And I, you see here, this is an older arm, an undescopic older arm. I found in our, our department, in our operating room. And I
1:11:16
moved to my mechanic come to design me this one. You said the last, the last pictures you hear, you see here. And it can stabilize, it can stabilize here. Yes, yes, yes. That's terrific Yes,
1:11:30
and now I'm very happy with these things. So I can work very well without, yes. Does this secure to the table? Yeah, yeah, yeah, of course, it's secure. Because if you see the second picture,
1:11:45
see the arm here, it was an endoscopic holder. Duh-huh, okay, I just, I used to modify. Okay, so this is a skull based lab in New York I was trained myself with Dr. Roger Hatter in New York.
1:12:01
about of service sheet, okay. And yes, thank you so much. Thank you. All right, excellent. That's terrific, Terrific. Shrady, you want to open it up for a seat with questions? Or you got
1:12:13
almost still almost got 40 people here, but anybody have any questions? Regarding these rural years, I think to make this, to make sure there is really hard, as you
1:12:31
mentioned it Yeah. So instead of that, maybe you can, or we can use the Dura clips. There are already some small devices. So you just put them, and we can use this. I saw Professor Herndezini
1:12:44
using that even in vessels in Helsinki. So I think they produce a really good hemostatism also. They close very well this Dura, and they are easily usable, yeah? Yeah, I'll go ahead Now go ahead,
1:12:53
let's hide, hide, you have a
1:13:01
question. No, I have a suggestion, excellent talk for both Dr. Roham and the other doctor. Maybe to get a LED television screen and connect it to your computer, because it has higher resolution
1:13:17
for what you're doing, and also you don't have to focus on the small image and the computer, although I'm sure they have everywhere. Now, LED, you will have a better understanding of the more
1:13:30
detail of what you are doing. That was an excellent job, thank you. Yes, very, very nice. And I think as given the audience ideas about how one can innovate, how one can improvise, what the
1:13:44
pitfalls might be, the challenges. And I think this gives people the vision of where to go. I think there is, as we've discussed before, there's a utility for this minimally invasive approach in
1:13:59
this setting. returns are reducing costs and reducing morbidity, reducing risk of infection. But it's a process that requires development as a learning curve. I mean, excellent presentations,
1:14:13
both of you. Thank you so much. Thank you. Is there anybody in the audience who wants to ask some questions? I mean, no questions are a stupid question because this is, we're all learning from
1:14:24
this. Anybody wanna ask some questions and see on the list here? Let's go base lab in New York I think that's at Wheel Cornell, isn't that right? Yes, that was at Dr. Hartzel. And Dr. Wade,
1:14:37
Dr. Gilberg, so Dr. Wade, we talked about that in France. And another question wanted to know, did your hospital buy the equipment for you and how much did it cost? And there's two different
1:14:49
sets of costs with Dr. Wagou was doing, which was a little more expensive than Neoham was doing. No, what Neoham's doing was very attractive to me because if you get that to work, you're using a
1:15:02
low-cost system that's easy to use with tremendous visualization. Is that right, Jo-ha? Yes, yes, yes.
1:15:12
Geoffrey, Geoffrey had a question. Thank you, sir. Go ahead, Geoffrey. Yeah, hello.
1:15:20
Yes, please go ahead. Yeah, I think my question has been read out by, it was about the cost of the microscope and the metrics path. Rather, the hospital bought for both the instruments for how
1:15:37
the internet was paying. So I think that's one of the challenges that we've faced most of the time. Thank you. Okay, Kim, I think, go ahead. You have a question? Yeah, my question was on the
1:15:46
borrow scope. What's the magnification that he was able to get? And what the borrow scope have additional magnification to be able to get maybe the finer details of. that the surgical bits, that's
1:16:04
my question.
1:16:06
Okay, so Jess, the balloscope is similar than the endoscope. They don't have so much magnification since the magnification you
1:16:17
get, according to how much you approach the tool to the field, to the target. So if you put very close, yeah, the endoscope or the balloscope to the target, then you will see a very magnified
1:16:35
field. If you
1:16:38
take out a bit, then the magnification will reduce. So those endoscope and balloscopes, at least maybe the new generation might have, but usually they don't have magnification per se. It's just
1:16:51
according how much you
1:16:54
increase your approach, yeah, and how much close you come to the target So they work in a similar way. And what is your sterilization process for the Boris scope? Yeah, usually you use liquid,
1:17:10
liquids for sterilizing those. You cannot put in the oven or you must use liquids or plasma or so you can use for them. Okay, Ali, do you have a comment? Yes, I enjoyed all those talks and our
1:17:23
colleagues in Sub-Saharan South America. At UCLA, if you have a surgical science laboratory, two large rooms, and one of the sections is a skull-based laboratory, which previously was done,
1:17:37
Danie Malcassian, who was a neuroanatomist, neurosurgeon, that
1:17:41
they transferred this side. We have multiple beds with head holders and their residents practice all the procedures there, especially their spine, and they bring their companies, bring their
1:17:53
instruments, and they share it with them to practice, because this is a learning care All of you are doing great job. But for the future, maybe there is a possibility because Cadaver is available
1:18:06
at the medical schools. And I know there is some limitation because of the cultural or religious things, certain countries, but consider that. Although the one at Cornell is very good at the
1:18:19
station they have, but we have here for a station in our laboratory. And I recommend you to consider this for your residency training And there are cheaper types of, first of all, you can use the
1:18:34
old main field and there are cheaper types of the head holders and
1:18:40
the instruments, the one which is available for your level of the country, because it's economy and economy. And so everybody can practice there and to make it easier for them to take it to their
1:18:52
patients. Thank you very much. Thank you, thank you very much, Ali. There was another question from somebody, and he just, he just, he just disappeared. Somebody else have another question.
1:19:03
They want to ask this is a great chance to ask everybody about this. So let me ask Dr. Waghu. When you were suturing and the Dura down to two, but what were you using for suturing? Okay, so we
1:19:17
use a problem, you know, problem. Yeah, yeah, sure. And yeah, it's standard. It's like a classical standard search up. Yeah, what instrument did you use?
1:19:33
It's, it's like when you drew classical search up, not for minimal information. Okay, I don't know the name in English. So, yeah, so it's a classic needle driver. Yes, classic needle driver.
1:19:47
Yeah, the point I wanted to make to you is that you already have the pituitary, around yours, the pituitary covers. Yeah, yeah, and that's what I use, because it's being added, You can use
1:20:02
that to hold the needle. And that's what I use.
1:20:07
And because it's awkward using a conventional needle driver down the tube, but if you use a pituitar around your, you can do that quite easily. Well, I mean, it's challenging, but with, I mean,
1:20:22
as a micro-neurist surgeon, I think you would be able
1:20:27
to develop that and do that relatively quickly. That's what I feel Thank you. Okay, thank you. Doctor, what
1:20:35
about the monofilament nylon? There are 508-0 that they use in microsurgery. Also, it's very available for the doing that, for the repair of the suture. I use 609 line. Yes. That's another
1:20:51
option. Yeah. Okay. So we learned two different ways to do this today. One is using the tubular system how he went about doing that. And then, you know, I'm introduced a very interesting
1:21:06
concept, which is almost,
1:21:09
it's almost, I think they call it an exoskeleton or different names, but you can get down to the same anatomy, but using this camera system, which is superb, and with the great lighting, you're
1:21:24
almost operating off your computer screen indirectly So you lose three dimensions, but with the movement, you probably get that back. Is that correct, Johan? Yes, yes, yes. You must, I think
1:21:39
in endoscope, in this bi-dimensional endoscope, you must be always careful about the three-dimensional space. So because sometimes you can lose that. But I think it's just how you train that and
1:21:54
how also how careful you reach that target Once you are in the target, I think that that's it. by dimensional space, it's enough for performing your procedure. I think the other thing to point out,
1:22:07
Jim, is that the cost without having to buy the tubular retractors or dilators, Yoham's process is just using inexpensive syringes. There's a series of syringes. Exactly. Exactly, that's right.
1:22:24
And it's very attractive to me for Africa if I were there I can do it. And Yoham, if you were going to try to repair a dural tear, you just do it, but you're watching the computer screen, right?
1:22:40
Yes, yes, yes, you should do it like that. But as I was telling, maybe nowadays it's better to use these dural clips because
1:22:51
it's practical. It's practical. In a few seconds, you can repair that do that, that do it up in India. Yeah, but Johan, there's also the cost of and getting the clips. Yes, that's what we say.
1:23:02
Yes, well, yes, then we spend there.
1:23:08
But yeah, but as our
1:23:10
colleague was speaking, sometimes maybe it's very impossible to repair, especially those tears that are anterior, that they go anterior, then those are very, very, very tough to repair. So many
1:23:22
times just enough to put some fat tissues, some muscle tissue, some do it again. And that's all, yeah. And the advantage of the small exposure is that you have less dead space. And so you'd be
1:23:39
more of a chance for that to be successful. Somebody has - a couple of people have inquired about the cause of the tubular retractors. I think I've seen them on eBay for500 to1, 000, because I was
1:23:51
looking at this about a couple of months ago So I think that you might find some in that range of - on eBay for a metrics retractor system. Yeah, but your idea of using syringes progressively
1:24:06
dilating them is practical and cheap, right, Astrada? Yes, but if you, you know, just like Dr. Wagoo had to devise an arm that the challenge is going to be, you want to have a structure that's
1:24:21
stable. I mean, what we did in Accra was we suited it to the drapes and to the skin edge, I think And that worked, so yes, you can use that as just not as, it may not be as
1:24:36
rigid or firm or stable or construct. But you may wind up with a little larger diameter or tube to compensate for some of those things to feel some movement and so forth, right? Yeah, well, you
1:24:49
want to tailor your tube size, your incision size to the tubes because you want to have a snug fit otherwise If there's too much wiggle room, then that's going to affect your capacity. And also,
1:25:02
if you have too much space around it, you could have bleeding around the edges and that can be a problem. And what I, one little trick I found was I just took a, I took a gauze. I would take a
1:25:13
gauze and wrap it around at the bottom of it. And especially for people who are obese, that, that helped to push the tissue down and give me a more room to work. So just a little, just a few
1:25:25
little tricks Terrific ideas, terrific ideas. Yeah, I think everybody develops some kind of tricks according to their performance We, for.
1:25:36
example, we don't like so much to put it fix it because the movement gives us the availability to expand the approach. We can go medially if we want to expand a little bit of laminotomy. Or we can
1:25:51
go laterally if we want to expand a little bit more to that, for a minute. Yeah. So I think, yeah, you can get your tricks according to how you are doing your own process. That's true. Yeah,
1:26:03
yeah, otherwise with the tractor system, you have to loosen it, readjust, and then tighten it back. Yes. You know, to go, we have up with Ross Ricardo, medial lateral. Yes, yes, yes, yes.
1:26:18
And Nancy has had some cases, and we just posted one this week with
1:26:26
Dr. Galley using similar approaches, but you always have to be able
1:26:35
to fall back on using a more open procedure if you need to, right? Both of them presented cases where using a minimally invasive approach, they missed a lateral disc in the foramen. And so you
1:26:50
really have to understand by imaging where the problem is and where the end. what the anatomy is 'cause these won't end up being male practice cases
1:27:01
because you missed the pathology. Yeah, well, let me just comment on lateral disc because I've found that to be another approach that you can do. And so
1:27:19
the approach that Dr. Wigoo mentioned today was more for those medial disc, but for lateral disc herniation, you go all the way to lateral and go transfer Ramino. And that's, there's no bone
1:27:28
removal, that's a very nice, I mean, obviously you do that with conventional endoscopes, where you can also do that with a tubular retractor to go through the for Ramen to the disc without any
1:27:39
bone removal. That's applicable for a far lateral disc herniation. Yes. So the imaging and analysis of the imaging becomes very important. Absolutely, absolutely. Okay Everybody, everybody,
1:27:53
anybody else have any questions?
1:27:58
And also I think in the interlaminar approach, finally you will get the surgical field will be what the interlaminar space will give you. So does it matter how much you open the muscles or the skin
1:28:14
or the fat tissue? Finally, when you go interlaminar deep inside, so the target will be found between the two laminas. So in that way, even though you make microsurgery and you open like 10
1:28:27
centimeters scar tissue, the final target will be found just between the two laminas. It's always the same. That is important, yeah. Yes, absolutely. There's some final questions here. Where
1:28:41
can we get the baroscope and what's the cost? The cost you said. Where can they get the baroscope you want? Yeah, I think 50 euro you can find150, 100, 100. You can find in, I won't be the
1:28:56
market in a, but yeah, you can find it. Do they go on the internet? I look on the internet for just search for Boroscope, probably. Look on Boroscope and the internet. Okay, so that's one
1:29:08
question. If you don't know, right? Astrata, he'll tell you. Next question is, I want to congratulate Dr. Volko and the speakers for their courage. Terrific, I'd agree with that. Thanks to
1:29:20
the organizers, so forth and so on And where did you get the tubular tractors? And we just went through some of that. Where do you get the, there's a commercially available tubular tractors?
1:29:33
Everybody has those Astrata or what? Yeah, yeah, well, there's several companies that have them. Metronic is the one that's very popular, but that's what I was saying. You can, you can look,
1:29:44
you can do, you can find refurbished one or second handed ones on eBay And that can be, they can be acquired. relatively inexpensively outstanding. Well, I think we learned several, a lot of
1:29:59
things to say, yes, I. Okay, sir, I really enjoyed all these talks, but I want to remember, I'm sure you remember the reminder that there are a lot of residents here. There is a great book by
1:30:12
Morrocan Norosirjan, La Siatica. It is on the SI book review that I wrote it about it. I highly recommend you to go through this book It is available on an internet and also your center can get it.
1:30:29
Really look at this because we all talk about back pain and all the discriminant work. But you have to know all the other diseases which may complicate
1:30:43
and also show as the back pain that you all should be aware of. I highly recommend all of you to look at this book.
1:30:54
1500 pages, because he developed very beautifully on the topic on all different aspects. I highly recommend all the younger researchers to look at that for their education. Thank you. Would you
1:31:08
send me the reflex in your, I mean, send me the reference and your review of the reference will send it out to everybody, okay? Okay, sir. It is on the SNI-G - Oh, it's okay, but send it to me,
1:31:21
we'll send it out And so I think we learned today, let's try to, it's probably worthwhile to have people send you the presentations 'cause it looks like they're being with limitations and which you
1:31:33
don't have. And I think that makes
1:31:39
it easier. And I think the second thing we learned is a tremendous learning experience by getting everybody to talk about their honest experience. Yeah, absolutely, I think this has been very,
1:31:47
this has been excellent,
1:31:50
Professor Velasquez, Thank you so much, Professor Wargout. Thank you very much. This generated a lot of interesting discussion and I think some good pointers were conveyed to the audience. Let me
1:32:03
just before we leave, Ben Matuso, Ben, do you have any comments you're a pediatric neurosurgeon, but is this any comments you wanna make?
1:32:15
Thank you for the
1:32:18
presentations. I think I've enjoyed what the presenters have been talking about. I don't have a lot of experience with the minimally-invasive spine surgeries, but I think I've learned a lot, and
1:32:35
some of the things that I've picked from here are things that I think I'll be trying as I go.
1:32:45
As I treat the spine patients that we see here Yeah, so thank you very much.
1:32:53
And then you have some thoughts about this, just I think it was a good learning experience. What do you think? Yeah, it was a very, very nice learning experience, especially to see what our
1:33:03
colleagues from French-speaking countries are doing. And I think the important context was the well-connelled lab which we can encourage our residents to go there to get some experience on scalpies
1:33:19
and endoscopic work We have a
1:33:26
microsagerie facility at the University of Nairobi in our anatomy department but it's shared by many, many disciplines and we're still trying to coordinate how we can organize neurosurgical training
1:33:41
programs in that surgical Nairobi, it's called Nairobi Surgical Skills Center. So we still have a lot to achieve on that. So I think it was a very good learning experience, especially about this
1:33:55
borrow scope. And I think we'll just Google on the internet and see how we can improvise it. Thank you. Well, it's great to see the expertise developing on the continent. I think some people
1:34:07
might want to go and visit Dr. Waku and learn from his experiences. I mean, he looks like he's doing an excellent job in advancing that technology Or at some of your national meetings, he could
1:34:22
have a half day or something where you get people from around Africa to present some of the work they're doing. Sam Heigabong, Sam, what did you think about this? I think it's a learning
1:34:34
experience.
1:34:39
I enjoyed the gathering. It's a very useful evening. I'm happy that the Franco-Fung brothers I'm sharing my interest in this Yeah. as an identity to, thanks to Gilbert, Gilbert, I think it's
1:34:54
your handbook.
1:34:57
The accounts, we have other platforms in the continent that bring us together. And
1:35:04
these conferences try to key into what is happening in different parts of the continent, particularly in West Africa, we're trying to grow another branch of the Continental Association But it was
1:35:19
interesting, I wanted to ask a few questions, but we leave it for another day.
1:35:24
But minimally invasive surgery is the way to go. People will like it. I'm not sure whether it's cheaper, those who do eat in Nigeria tend to charge more for doing it than the
1:35:38
even though the pressure excess money and the number of days spent in hospital. But I think the surgery also do it, tend to charge more than those who do the traditional, the same kind of change.
1:35:50
That's a discussion for another question. Yes, yes. Thank you very much. Well, Gilbert, did you have any comments? I appreciate you joining us and - No, no special commentals. It was very
1:36:01
interesting and I'm very happy to see that many male-invasive surgery is coming in Africa and joy that the
1:36:12
young neurosurgeon, Dr. Wagg, he's very active and I hope we'll share his experience during the next meeting in Africa. So thank you very much and have a nice day. We have a nice night. I don't
1:36:28
like what time is it. Thank you very
1:36:31
much, Jim, I think you made a good point about seeing if they could have courses at meetings. I know that Ken's meeting is coming up in October and but meetings like that might be an opportunity
1:36:44
for workshops that could help people to move along with learning some of the things. techniques. Yeah, Alvin Nanny, Alvin, now you're, you got terrific judgment. What did you think? Was this
1:36:55
good learning experience for you? Thank you, Professor. And actually, it is, it was very excellent. And Dr. Wagae, I knew him very well, we trained together in Senegal. And I'm truly proud
1:37:06
of Dr. Wagae for this brainer work, because while we're in training, we were not doing minimum invasive surgery for spine, what I was in training along with Wagae. But
1:37:28
now to see him doing a very beautiful work. I really, I really appreciate this. And for us in Liberia, we are not there yet. We stay struggling with the open
1:37:46
surgery for spine. But I think it is a drug learning opportunity. And we look forward in improving our spunk here year in Liberia. Thank you so much. Yeah, I think for the residents on the call
1:38:03
today, I think this is a demonstration that learning doesn't end that residency. You continue to learn throughout your career. I didn't learn anything. There wasn't any such thing as minimally
1:38:16
invasive surgery when I was in residency. In fact, when I was in residency, it was when they introduced a microscope. But it was later on in my practice that the minimally invasive technique came
1:38:29
on and I learned it. So it's a lifelong process of learning.
1:38:35
Terrific. Australia, I wanted to thank you for getting us all together, organizing it, Johan, we appreciated it and And Dr. Waco, just terrific information, generated a lot of discussion, a
1:38:48
lot of learning. If you compare this to 15 months ago, Australia, I think, we're getting where we wanna be, right? Absolutely, absolutely. I'm very pleased to see the progress. Just the last
1:39:03
word, please. Yes, I wrote a book some years ago in both language for spinal approach from surgery. You can get it on the net And in
1:39:14
French it in English for the younger surgeon, if you have to. Oh, excellent, excellent. Okay, for those of you who didn't notice, Dr. Gilbera has put it in the chat. So please take note of it
1:39:29
and acquire it. Thank you, Gilbera. Terrific, terrific.
1:39:34
This is, here's an orthopedic surgeon from Kenya. Nim, you said about that. That's Jeffrey, are you dead? Do you wanna make any comments, Jeffrey?
1:39:46
So, Tim said he has invited you
1:39:49
to work with him. He's just saying, thank you. Okay. Okay, well, I think we should end it. I think we have had an excellent presentation and discussion and we'll reconvene the first Sunday of
1:40:02
next month. Again, it's a technical issues. We got a solution for
1:40:08
that too. Yes, absolutely. Okay, thank you very much, everybody. Thank you. Bye-bye, and then you, huh? We'll stay on and meet with you. Yes, you are. We wanted to meet with you and Nim
1:40:21
and Sam and
1:40:24
others, if you were to going to talk about getting grand rounds set up in Latin and South America.
1:40:32
Yes. Oh, okay. And Saeed, you should stay for that.
1:40:37
Oops, I think he left. Okay. Okay, so that marks the end I could end the meeting and then we can. We can restart a new one.
1:40:50
These are the references primarily in regard to the bar scope.
1:40:54
You can see these three references. The last is a reference of Dr. Valles-Quiz. It
1:41:03
was an SI, and it can be now, and this is what the reference looks like. And if you search PubMed and you look for it and you find this reference, you can find the full copy of the article. It's
1:41:18
very close to what he presented in this talk.
1:41:22
We hope you enjoyed this presentation.
1:41:27
The views and opinions on this program are those that the authors are interviewing and don't necessarily reflect the official apology or the position of SI digital or its management And the
1:41:39
information in this program should not be considered medical vice, patients should consult their own physicians for that advice. as to their specific medical needs.
1:41:52
Fill out your evaluation of the video on the home page where you see the five stars clicking one to five stars, five being the best,
1:42:02
and it helps us in future programming.
1:42:06
Also, look at this icon at the bottom of the home page. If you want to add questions, comments, or requests for CME credit
1:42:15
The Foundation is supporting these programs as two journals. One is SI, Surgical Neurology International. It's web addresses SIglobal. It's an Internet Journal with Nancy Epstein as its
1:42:28
editor-in-chief. The second journal is SI Digital.
1:42:34
A video journal, interactive with discussion. It's web addresses SI Digital
1:42:42
Both are free 247, 365 on the Internet.
1:42:48
SNI, Surgical Neurology International, is read in 239 countries and territories as the third largest readership in its 15 years of publication.
1:43:02
And SNI Digital has been published for 16 months, it's seen in 152 countries, it's the first video in our surgery journal The goal of the Foundation is supporting these programs is to help people
1:43:17
throughout the world.
1:43:20
SNI Digital offers all of
1:43:23
its programs on podcasts on Apple, Amazon, Spotify, look for
1:43:28
SNI Digital,
1:43:30
and the Foundation supporting these programs supports the medical news network to bring truthful medical and science news to the world
1:43:40
A copyright of this program is in 2025 by the James Iain Curlinar-Ospon Educational Foundation. and All Rights in Reserve. You can reach Dr. Osman at the email address listed. We hope you enjoyed
1:43:55
the program. Thank you for watching.
