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Welcome to the 15th SNI
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and SNI Digital Baghdad Neurosurgery Online Meeting. The meeting originator and coordinator is Samir Haaz of the universities of Baghdad and Cincinnati.
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Today's lecture is a new, simple, cost-effective navigation system for neurosurgical interventions Today's lecture is Monir K. Faraj of
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the Department of Neurosurgery College of Medicine, University of Baghdad, Baghdad, Iraq.
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Today's lecture is 29 minutes. The discussion session is 7 minutes. We had over 100 attendees from 18 countries The
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video editors are Mustafa Ismaou.
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College of Medicine, University of Baghdad, and Fatima Ayad, fourth year medical student from the University of Baghdad -
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I have the honor to introduce Dr. Munir Kamas Varej. He's an eminent Iraqi neurosurgeon. He's a practicing now in Iraq. He's the president of Arabic board of neurosurgery, the Iraq Center, and
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actually his teacher, his leader in neurosurgery in Iraq, he's one I think he's the one or two of the main leader on the current neurosurgery in Iraq. And what I want to say before starting the
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presentation that something very peculiar about Dr. Munir, he's a really supportive person.
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And I think everybody knows how much he spent from his pocket money for every project to make it perfect. That's very interesting. That's very different. And I think for the young generation,
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that's a very,
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very important thing. Actually, we are proud of that. So Dr. Mier, you can share the screen and you can start the talk. And you are more than - Okay. Thank you very much, Dr. Mier. And thank
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you very much to Mr. James Osman at my spiritual
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for giving us a chance to make some two presentations. Each one about 12 minutes. This represent our last issued papers. I will start with, can you hear me - Yes.
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With this an in-symbol cost effective navigation system we name it an easy navigator for neurosurgical interventions. As you all know - Can you share the full screen? Yeah, please. OK. Now, as
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you all know, the navigation techniques was primarily designed in order to reach a deeply seated tumors that cannot visualize easily after opening the bone in
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cranietamies. Traditionally, we have two main tabs, either a elicatromagnetic or an infra-red, which is more commonly used now. Both of these systems depends on registration. Or all known - Can
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you share the full screen? Yeah, please. OK. Now, as you all know, the navigation techniques was primarily designed in order to to reach a deeply seated tumors that cannot visualize easily after
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opening the bone in cranion tummies. Traditionally, we have two main types, either aliquetromagnetic or an infra-red, which is more commonly used now. Both of these systems depends on
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registration of the position of the head and the space during the
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surgery by using, for example, fiducials, or by using laser pointer and register the shape of the head through these infrared cameras and make a fusion of the image with the MRI of the same patient.
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In 2007, actually we faced with a problem that no more brain navigators were available in Iraq as the contracts of the
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maintenance ended and we don't have such an opportunity to work on them again. We started to think out of the box We try to make a new navigation by using a free software, it's available on the
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internets, called the 3D slicer with a computer air mouse.
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How this process is done? Actually we take the MRI sequences of the patient with the special orders that are coronal, the
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axial, sagittal, 1mm thickness, the square image with no overlap or no tilt. and then put this into the software 3D slicer in order to get this 3D image of the brain tissue which is one over one.
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It is the real size of the patient. After which we decide, we study this 3D shape and decide the entry point from where we should pass to be the safest and the nearest point towards the deeply cited
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tumor. Then we put a draw another point at the service of the tumor and another point just less than 1CM outside this cerebral cortex and connect between all these three points in order to get a
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trajectory. And I will come in details for this.
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During surgery, we do the crannion to me We take this. It is just like the lecture presenter, put it on this slide in the trail, opening the air mass and try to point the same entry point that we
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just mentioned in the 3D model of the real patient. Then we try to elevate this air mass through the trailing, just few millimeters away, and then we rotate the whole trail until we adopt the
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position of the trail to be the same position of the trajectory that we made on the 3D model of the patient, after which we will fix it by Leila Detractor or any fixator, and then we start to do the
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surgery along the trajectory reaching to the mass Now how we did that work. It took from us about one and a half year. We started with building a 3D printing model of an actual patients, and we
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tried to do the surgeries on these 3D models. I will show you this 3 minute video to explain what I just say.
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Can you hear the voice or not?
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Yes, no, no. Okay. The video is not there. If you want to comment on it. Okay. This is just a model of a natural size brain tumor patient. At the beginning, we decided where the entry point
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should be
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The technician with me will try to rotate the 3D model on the screen to be just like the position of the patient in surgery.
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Then we use this presenter with air mass facility
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And we try to, this is fixed by Layla Detractor on that side. We take it on.
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We try be as close as possible to the entry point and ask the technician to register this second entry point into the free-day model of the patient.
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by moving the air mouse within an area of 1C and diameter only the movement will be accurate. If you go more than 1 centimeter the calculations will be wrong. That's why it's very important to
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localize the entry point
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Then the technician will try to draw a line from the
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cerebral cortex into eight points toward the service of the tumor and measure the distance in millimeters and draw another point just less than one CM outside the cerebral cortex so that we will have
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a well calculated. trajectory
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Then we will go back
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with the air mass at the entry point.
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then we try to pull it a few millimeters up
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and then we start to rotate the whole tray with the air mass until we reach to the this point and the whole trajectory will be enlightened which means we are on the same trajectory.
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Then we fix it with cell and a cell retain a tractor and that's why we will have this trajectory will operate apart in the same line
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On the next stage, I had the opportunity to have something called Meviant Navigator. It's a new Canadian company, and actually this is the company that manufactured the infrared cameras for the all
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navigators all over the world, even for
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brain lab and for metronics Soon, they decided they manufactured their own navigators, they call it Meviant, which means Navigation A-NT, because they started the B-NT surgery. So, I decided
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with them to cooperate, and we operated upon,
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we used for all those 10 patients, our navigation method, and after we determined the trajectory, we put the indicator for this. conventional navigator and compare the trajectory, especially
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measuring the distance of from the service of the cortex toward the service of the tumor. And in these 10 cases, we noticed that the variation in the variant is more accurate than us, definitely,
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but the variation between their
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measurement and our measurement is just between plus minus two millimeters. We use it by using the scovile, calibrated the scovile to measure from the cerebral cortex toward the service of the tumor.
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After these 10 cases, we decided to work on our own. And we operated upon four cases, and we measure the actual distance from the cerebral cortex toward the tumor, and compare it with what we have
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done in the combinator, and we have the same result it was right between. plus minus 2 millimeters.
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But is it a perfect method? No, it is not a perfect. It's still there are certain limitations. The most important one is that in this method, we are, we depends on the shape of the
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cell side and the gyroyle. Turn now. That's why we can not use this method. This method, for example, with a Berhal biopsy because I need to have a crannet to me and to see the cell side and
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gyroyle.
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In conclusion, it is a simple method. It costs nothing. It is just a
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computer with
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an air mass and that's it. And it even does not, with the well-trained head, it will not cost you more than four minutes in order to do it It basically depends on the air mass, which is a
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Bluetooth technology. It is neither an electric magnetic wave nor an infrared. That's why it is simple, economic, and cost nothing. Actually, this has been published in the world in your
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post-surgery. It will be in the printed version. In the next August 22,
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and even a patent registration will be issued next week in Iraq for it. Thank you very much. This is my first one.
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Before I start the cement trends in designing microsurgical instruments, I would like to make a few simple presentation about the surgical laboratory. This surgical laboratory was established by
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cell funding. It is not governmental, it's by us. In the neuroscience hospital, which have been recently renamed as side and literally hospital. We were able to buy two microscopes and these eyes
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volunteered to bring us another third one. These microscopes we train our board students. They should have at least three training courses in trajectory, intermediate and advanced on chicken pie
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and on a living mouse and then on a 3D models before they participate in the final examination of the Arab board. We also had all the learning the projects of the upsurgeon, the 3D printing models
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which have recently issued, especially in the corona pandemic in order to provide the training to the students as if there is a cadaver and this represents the third training course for our. board
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students. Then we have a 3D printing and we had a
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lot of patents and research papers recorded by using this 3D printing technology. Many papers have been issued and many patents have been registered from this lab and even we have the digital library
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which is now has more than a 25 terabyte of lectures and books in neurosciences.
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My topic will be what are micro-organism, penisization and easy. And actually there are no such words in English language if you look for in the dictionary. From where this micro-organism is came.
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We all know ergonomic That means that we
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design everything we use according to the shape and measurement of the human body. And this approach. have been widely used in the 1980s. We see the special microscope chair with a hand rest, and
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even, for example, Sogita, with a hand rest have been developed in order to reduce the trauma of the neurosurgeon. Even the mouthpiece of the microscope in order to rotate it, it's all related to
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aerodynamic But must surgical instruments have been designed, actually, in order to utilize it for the target tissue, for what they have to do. But unfortunately, we notice that a lot of them
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will not accosting to the surgeon's hand configuration.
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In order to design any surgical instrument, where I share tini principles. I have summarized, for example, these instruments either primary, that's to say this is a direct tool that will direct
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in touch with the human tissue or a secondary tool which will handle another instrument in order to put it in the human tissue like the needle holder or an urismo, a clipper placator. Another
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principle that most of our surgery work depends on vision coherence. In another way, this is an high-high coordination. But still we have something we call hearing coherence. We, just like the
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one who is playing a piano, in manufacturing or designing surgical instruments, sometimes the hearing is important. For example, when we try to design an aer a critical motor drill, we have to
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design it so that we sound. will be differ while dealing on different bond, for example, the cortex or the deploy of the, of the bond. In our practice, we all know that while we are
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concentrating on, for example, posterior faucet humor, our ears always concentrating on the sound of the pulse in order to check if there is anything will happen and what the N-S-T-S, even before
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you notice that Another principle I call a tunnel concept and this tunnel concept is that we are allowed to put anything we want, any modification inside a cylinder, inside the tunnel, as long as
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these utilities will not affect the outer service of the instrument which will be in touch with the human tissue Now we come, what are the problems that we may face with this? instruments and I will
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have an example of the classical needle holder. We all know the problem of long instruments. When you write with a pen on a white board you will have a good writing but if you use a long one your
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drummer will be propagated and that's why the instrument probably to be designed so that the tip of the target of the instrument will be near to the tip of your fingers. Now most of the surgical work
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actually is a supination
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and during supination if you put a piece of clay and do the supination you will notice that the deepest part on the supination will be in the hyperphener MNS and what does it mean? It does mean that
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this is the strongest part
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of your hand during supination hypo-phener, MNS. If you are using the Myo-Hager needle holder, the classical needle holder, you can see that you handle the needle holder with a very long distance
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from the tip, that's why the tremor will be more propagated, and you are very far from the fulcrum, the most powerful part of the hand. And that's why with dealing, suturing, with a tough tissue,
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it is difficult to use this classical needle holder unless you modify your grip to be like this in order to make them period-hundled to the hypo-phener closer much
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MNS, ideally you have much more power to handle the tough tissue.
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This depends actually on what is called the third lever physics law where the effort is close to the fulcrum, the node will be less. than if we close, if we make the upper far from the phallic rum
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which is the hypo-phenor MNS, it is just a simple physics.
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Another concept, besides the microorganism, we call it penisiation. We know that the most difficult work of the hand is writing, and that's why we need several years in order to master this
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question,
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but at the same time, the most beautiful, the most intelligent instrument we created actually is the pen. Why? Because you have 36 degrees of control of all this instrument by your hand That's why
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we had another concept we call it penisiation, and penisiation we mean we try to convert most of our surgical instruments. to make it just like a pen, so that we have 36 degree control over it. Of
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from these two ideas, we had designed what we call Pen Needle Holder. We converted the conventional needle holder into something just like a pen with two synin bursts. This is a 3D print of it.
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'Till now we couldn't manufacture it in a right yet It has a box joint to hold the two jaws with an op to locate. And these two cylinders connected with this sibling in order to elongate or to
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shorten the length of this needle holder. The jaw also has a sharp edge of the distal end. This is a scissor. So that the surgeon can make a the knot and he can catch me. this string without any
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of his assistant, which will be much quicker, especially indeed the small neural spaces. We have this, as you see, this is a groove of an X shape. I will come to it while we did this.
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You know that the needle-de-legrab, basically we have a three type of needle-de-legrab, how to fix the needle into the needle harder. We have this, what we call, sit right needle-de-legrab By
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this we use it when the wound actually is perpendicular to the surgeon position. When we tilt the needle 24-degree tower-de-legrab, we call it oblique needle-de-legrab. And we use it usually when
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we have the wound and parallel to the surgeon. But when you change rotate the whole plane of the needle, tower-de-legrab, this is called rotated needle-de-legrab And it has no use in surgery.
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But when you combine this rotated with the oblique, we call it combined rotated and oblique, this is especially needle-agreb used in deep narrow spaces for handling suchering from the proximal to
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the distal. And when you incline it toward the shaft, it will be a combined use for suchering from the distal toward the proximal margin. This grew way facilitate the position of these
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needle-harders into these two combined grips.
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Now the third concept, easy, what is the easy? It's an electronic integrated with surgical instruments concepts. For example, we are now working on this project. You all know the Dreyritractor,
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may create a pressure over the brain tissue while you are working on deeply seated masses, for example, and between three illusions. And then most of the time we forget it, because we are dealing
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with something else and we end with infarction. So we decided to have an integral of this small chip of a pressure sensor, cover it with a water roof and cell adhesive, and we are now studying how
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to send this signal through a Wi-Fi to a remote sensor inside the operating theater in order to make an alarm if we
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create a greater pressure to warm us to remove it and release the pressure from the brain
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Another thing we are now still not and research is still is to have something like a stand. to cover the suction, the surgical sicker handle, with four touch points, these are an impedance sensor.
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Whenever I touch anything by the measuring the impedance of it, I can't say whether it is a nerve tissue, is it a fibrous tissue, is it a nerve, is it a vessel, I can't compare it without the
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need of the neurophysiology. Another thing, this is now we are working on it, is to build an inside the needle holder, a few vibrators with a sensor, so that in dealing with a tough tissue,
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these vibrators will work in order to push the handle and try to help me in suctioning in tough tissues.
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So in conclusion, these concepts are not recalled previously. and we face many unpublished disadvantages in using classical instruments. But we always accustom ourselves to the engineered design
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and accept what they, companies offer, especially the
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classical instruments. We have to review the instrument, design, evaluate them according to this micro-organic criteria and design to make the instruments more effectively used by adopting their
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design to
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the surgeon's hands. This paper has been issued in last August in the world in neurosurgery. And for the PEN legal holder, we created a patent registration locally. And thank you very much -
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I have a question for Dr. Frawj So that's pretty amazing work with the sensors and the applying ergonomic. principles. I think this is so critical and universal. I mean, it's not, it goes beyond
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neurosurgery, right? This goes beyond, it goes to all technical fields, including general surgery. You mentioned you using the 3D printer in the lab. What type of 3D printer do you use?
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Actually, the 3D printer we started our work with it is channel one with cost less than
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500 dollars. It is not a complicated one just like the upsurgery company which manufactured these simulators for brain surgery training.
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It has a good very well result. And beside, you have opened the talk about other disciplines Actually, now we are trying to cooperate with a general surgeon in order to apply this method. liver
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surgery with deeply liver masses tumors and you are just we start to
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cooperate with them about it. Yeah this is you know that's a perfect example of how neurosurgery always leads the world right I mean we basically invented anesthesia and gave it to the
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anesthesiologists and now you're developing tools and giving it to the
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general surgeon so that's the way to do it. The diaphragmate too
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Right that's right the diaphragmate.
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I had something for Dr. Medefaras I think that the every neurosurgery is that Sped is waiting anxiously for his
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sensor in the tip of the retractors because the cerebellar mutism usually seen after postiophosphorus surgeries do I think to the excessive retraction of the cerebellal hemisphere and damage to the
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dendainuclein know and I do remember I had
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we all speak of 100 students. And after I had a couple of patients like that, I just decided to rely on the ability of the assistant usually at the resident and outstanding residents at UCLA to
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actually do not retract extensively. So the retraction, the lateral retraction and the measure of the pressure accepted will have a great impact. And I agree with Dr. Barrie that we'll have an
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impact below, beyond, as they are saying, they will be using in the surgery, you know. And going to Dr. Barrie, final thing, we have general surgeon and we have martial surgeons. We are the
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martial surgeons - Actually, I hope in the next two weeks, we will able to have the first prototype of this pressure sensor model. I try to work on it on our patients -
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Dr. Vigner, I'm really very much impressed. I'm not surprised with your innovation, with your ability to modify things, to create things since you are a student, you are distinguished, very
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impressed. And I'm so happy that you are leading the new innovations in the country - This is a spectacular, spectacular accomplishment And I congratulate you on independently pursuing this on your
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own when you weren't able to find people who would support you. I think you've had some major discoveries that will have influence around the world, not just in Iraq. I think from Dr. what Kalali
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says, that's your personality and I admire that kind of personality. that is creative and innovative and wants to move forward. And what you've accomplished is absolutely outstanding.
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I would encourage
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you to summarize your work. We'd be happy to publish that and publish anything you'd like. It needs to have exposure to lots and lots of people, but I just compliment you on your individual
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creativity and persistence to achieve excellence. Excellence. And I think the young people who are listening to this and watching this, you have seen presentations today that are outstanding and
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creative.
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You have nothing to feel inferior about in Baghdad, Iraq. And Dr. Barrie has already told you that regard to your stereotactic and functional neurosurgery. And Dr. Kaloni has outlined outstanding
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people you have.
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And Dr. Hose made a presentation of one of our meetings. And next to him was sitting a worldwide famous intensive care person who was a neurologist who was shocked to hear the progress that was made
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in Baghdad, Iraq. He said, you do things better than we do And he was full of one of the best hospitals in the world. And he said, we ought to hear more about you and what you're doing. That's
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what people are thinking. And Dr. Ferraj, you are in that tradition and we congratulate you for that outstanding work. Outstanding work -
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We hope you enjoyed this presentation.
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the references for today's lecture.
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