14 Comments

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    Ira Denton

    Posted March 16, 2011, 7:54 pm

    These blood-blister like aneurysms–dome-shaped and neck-less–are treacherous. Clips sometimes sheer away the vessel wall, and even when a clip appears to hold “perfectly”, the diseased vessel beneath the clip may continue to dilate and rupture postoperatively. So, trapping is often necessary. Alternatively, however, a Sundt-type “clip graft” might manage a BBA without the need of a concurrent bypass. Abe and colleagues published a review of this condition: Abe M, Tabuchi K, Yokoyama H, Uchino A. Blood blisterlike aneurysms of the internal carotid artery. Journal of Neurosurgery. 1998;89(3):419-424.
    Ira Denton

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    Efren Herrera

    Posted March 18, 2011, 1:03 am

    Besutiful video of a succesful procedure masterly performed. I am keen on Trephine craniotomy and are curious to know what kind of trephine Dr. Kelly uses. It is impressive to see the trephine moved by a motor without harming the dura. Perhaps it has a special mechanism? or the depth is adjusted manually according to experience?. Thank you.

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    Patrick Kelly

    Posted March 18, 2011, 4:52 pm

    Dear Efren

    The trephine is a Scoville trephine (available in 1.0 inch, 1.5 inch and 2 inch diameters). There is an external guard that limits the amount of cutting blade exposed. This is manually adjusted based on what the surgeon believes the skull thickness is (there is no automatic stop).

    Until one gains experience, it’s best to go slow and start with the blade quite shallow and get progressively deeper (being sure to inspect the bone incision with each step) until the inner table of the skull is encountered and thinned to a very thin shell with the trephine. Then insert a thin periosteal elevator into the bone incision and pry (break) the bone plug out. Small bits of residual inner table can be removed with a small Kerrison ronguer but it is best to leave a small ridge of inner table as this is what will stop the bone plug from sinking in after closure.

    With some experience I could tell by the sound of the craniotome and the vibration when the inner table was close. By the time I retired I’d done about 5000 technigue craniotomies. It used to take 3 – 4 minutes from start of skin incision to opening the dura.

    These trephines were once available from Codman about 20 years ago, I later got them from COMPASS International(Mr Jon Rousu at http://www.ciimedical.com/). I’m not sure if they’re still available.

    Hope this answers your questions.

    Best regards

    PJ Kelly

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    Rolando Jimenez-Guerra

    Posted April 1, 2011, 5:28 am

    Dear Dr. Kelly
    Thanks for sharing your incredible experience in this video.
    Have you done that without laser and what was your experience?
    Thank you in advance

    Sincerely

    Rolando

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    Patrick J Kelly MD FACS

    Posted April 1, 2011, 9:31 pm

    Dear Rolando

    Thanks for your comment. The answer to your question is “yes”; I have done these procedures without the LASER and the results are essentially the same as with the LASER. The only advantage of the CO2 LASER is that the beam takes up less room in a tight working space (2 cm diameter cylindrical retractor). It’s just a beam of light and the “no-touch” aspect of LASER in dissection when working deep in thalamus/midbrain appealed to me philosophically. But, honestly, I think that I could have done the same job without it.

    Best regards

    PJ Kelly

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    Antonio Berrio

    Posted April 22, 2011, 1:43 am

    El Doctor Jaime Perna de Colombia prersento esta tecnica ideada por El en el Congreso mundial de Neurocirugia en Bostom, USA. y en el XXIV Congreso de Colombia. Lleva 10 años haciendo cirugias Neurologicas con su invento, el cual veo ha sido copiado en todo, y al decir todo es en el aparato que sirve de guia para llegar por medio de estereotaxia. Ha intervenido mas de 50 Pacientes con M.A.V Grado IV y V de spetzler, practicamente condenados a morir, ha salvado sus vidas y hoy por hoy viven dignamente y con poco o nada secuelas Neurologicas. Seria muy lamentable para la Neurocirugia Latinoamericana no apoyar a Dr Perna, ya que este invento y tecnica tiene patente en Colombia desde hace mucho tiempo atras

    Gracias

    A. Berrio

    Reply
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    D.haidar

    Posted April 23, 2011, 9:21 pm

    Besutiful video of a succesful procedure masterly performed. I am keen on Trephine craniotomy and are curious to know what kind of trephine Dr. Kelly uses. It is impressive to see the trephine moved by a motor without harming the dura. Perhaps it has a special mechanism? or the depth is adjusted manually according to experience?. Thank you.

    Reply
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    Patrick J Kelly MD FACS

    Posted April 25, 2011, 6:57 pm

    The trephine is a Scoville trephine (available in 1.0 inch, 1.5 inch and 2 inch diameters). There is an external guard that limits the amount of cutting blade exposed. This is manually adjusted based on what the surgeon believes the skull thickness is (there is no automatic stop).

    Until one gains experience, it’s best to go slow and start with the blade quite shallow and get progressively deeper (being sure to inspect the bone incision with each step) until the inner table of the skull is encountered and thinned to a very thin shell with the trephine. Then insert a thin periosteal elevator into the bone incision and pry (break) the bone plug out. Small bits of residual inner table can be removed with a small Kerrison ronguer but it is best to leave a small ridge of inner table as this is what will stop the bone plug from sinking in after closure.

    With some experience I could tell by the sound of the craniotome and the vibration when the inner table was close. By the time I retired I’d done about 5000 technigue craniotomies. It used to take 3 – 4 minutes from start of skin incision to opening the dura.

    These trephines were once available from Codman about 20 years ago, I later got them from COMPASS International(Mr Jon Rousu at http://www.ciimedical.com/). I’m not sure if they’re still available.

    Reply
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    Patrick J Kelly MD FACS

    Posted June 16, 2011, 3:33 pm

    Dear Dr. Beria

    I appreciate your interest in the stereotactic removal of brain tumors and AVMs. In fact, my group developed this technique in 1980 and reported the methodology and results on various lesions (including vascular lesions) in multiple publications over the past 30 years. Admittedly, the neurosurgical community was slow to adopt these frame-based image-guided volumetric stereotactic resection techniques but I am delighted that some have embraced the concept over the past several years. Nonetheless, I find it difficult to believe that anyone could actually patent or enforce a patent on this method when there is “prior art” in the literature (see references 1-4).
    ,
    1. Kelly PJ, Alker GJ Jr: A method for stereotactic laser microsurgery in the treatment of deep seated CNS neoplasms. Applied Neurophysiology 43:210 215, 1980.

    2. Kelly PJ, Alker GJ Jr: A stereotactic approach to deep seated CNS neoplasms using the carbon dioxide laser. Surgical Neurology, 15:331 334, 1981.

    3. Kelly PJ, Alker GJ Jr, Zoll JG: A microstereotactic approach to deep seated arteriovenous malformation: Case report and technical note. Surgical Neurology 17:260 262, 1982.

    4. Kelly PJ: Kall BA, Goerss SJ, Earnest F: Computer assisted stereotaxic resection of intra axial brain neoplasms. Journal of Neurosurgery 64:427 439, 1986.

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    Love Phipps

    Posted March 16, 2012, 7:21 pm

    Dear Dr. Kelly:
    I’d just like to thank you for all your work in this area for, as you say, 30 years! My friend will soon be facing “stereotactic laser microsurgery in the treatment of deep-seated CNS neoplasms” (metastasized from lung cancer) and I’m realistic, as is she, but I do feel better having read some of your research published over the years. So, again, thank you for your work!

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    Patrick J Kelly MD FACS

    Posted March 16, 2012, 8:41 pm

    Thank you for your kind comments. Prayers for your friend – that she does well in surgery and makes an excellent recovery.

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    Wagner Mariushi

    Posted March 24, 2013, 10:39 am

    Dear Dr Kelly!
    Congratulations for your achievements in these so difficult tumors.
    You’ve said it would be possible remove these deep seated lesions using bipolar coagulation. Which bipolar have you used and which lengths?
    Thanks a lot!

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    Patrick J Kelly

    Posted March 25, 2013, 5:21 pm

    Dear Wagner

    That is an excellent question. Yes, one could remove these tumors without a LASER and I have – when the LASER has malfunctioned. Here one establishes a plane between tumor and surrounding brain with a spreading action of the bipolar. One spreads the bipolar at the tumor/brain interface, staying parallel to that interface then inserting a small suction tip between the blades of the bipolar and use this suction tip as a gentle retractor to allow visualization deeper. With the stereotactic system, I use a 140 mm long cylindrical retractor and a bayonet bipolar with a working length of 160mm. I believe that COMPASS International in Rochester, Minnesota used to sell these – perhaps they still do. And Codman may have them as well.

    Best regards

    PJ Kelly

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    Wagner Mariushi

    Posted June 13, 2013, 11:07 pm

    Dear Dr Kelly
    We have successfully removed a thalamic astrocytoma according your advices (bipolar-suctor maneuver). Instead using a Compass stereotactic system (unavailable to us) we used a tailor made tubular retractor adapted to a neuronavigation system.
    Thanks a lot for sharing your experience!
    Wagner

    Reply

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