Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_3600_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

29.08.2026

Размер:

85 Мб

Скачать

☆

<<< < Предыдущая 1 2 3 4 5 6 78 / 508 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

M. Hadjiandreou and G. Patanis

Various NIRF systems are described in literature including hand-held, non-hand-held and operating microscope (OM)-NIRF system integration [24–31]. There are multiple advantages of OM-NIRF system integration including improved ergonomics, surgeon’s hand freedom and uninterrupted surgical workow. In its simplest form, an OM-NIRF system incorporates an excitation light source, one short- pass lter for light excitation, one long-pass lter for uorescence signal and camera for uorescence capture. The process involves the short-pass lter placed in front of light source and the long-pass lter placed in the observation optical path. The uorescence signal emitted combined with excitation light is ltered by the long-pass lter with combined signal reaching the camera (CCD), surgeon or observer via beam splitters [4, 32]. Figure 7.12 shows a schematic representation of the process.

Holm etal. reported the rst human preliminary study on OM-NIRF that allowed for intraoperative imaging of micro-

Fig. 7.12 Schematic representation of OM-NIRF integration system. (Reproduced from Stummer etal. [32])

surgical anastomoses. The authors utilised an OPMI Pentero IR 800 (Carl Zeiss, Oberkochen Germany) (Table7.1) with integrated indocyanine green technology into the optical path and suggested a considerable potential impact of the microscopic technique on early ap failure [33]. Sugawara etal. evaluated the blood ow after vascular anastomosis in breast reconstruction to the anterograde IMV and the retrograde IMV using a NIRF system installed on a M525 OH4

surgical microscope (Leica Microsystems, Wetzlar, Germany) (Table7.2) [37]. Multiple clinical studies utilised the SPY Elite imaging system (Stryker Corporation, United States) (Table7.2), which consists of an imaging head (cam-

era and laser light source), a mobile cart and an articulated arm. Although the system employs the uorescence properties of ICG, it is not a microscope as the surgeon sees the images on a monitor and not under microscopic vision [30,

31, 38–40] (Fig.7.13). Table7.2 summarises the technical

specications of the three NIRF technologies.

surgeon (stereoscopic)

CCD observer

fluid light guide

beamsplitters

440 nm longpass filter

focussing lens

excitation light (375 - 440 nm)

emitted light

filtered fluorescence (> 440 nm)

7 Novel Microscopic Technologies inReconstructive Microsurgery/Microvascular Surgery

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Table 7.2 Technical characteristics of commonly used NIR OMs in reconstructive microsurgery [34–36]

Technical specications of NIR OMs Name OPMI Pentero IR 800 M525 OH4 Surgical Microscope SPY elite imaging system Design

Components Microscope, articulated arm,

imaging console Magnication range Up to 39× 1.2–12.8× with 10× eyepiece N/A Working distance 200–500mm 207–470mm N/A Imaging agent ICG (IR 800) ICG (FL800) and 5-ALA (FL400) oncological

Mode of Imaging HD, NIR uorescence imaging HD, NIR uorescence imaging NIR uorescence imaging

N/A not applicable

Microscope, articulated arm, imaging console Imaging unit, imaging

console, articulated arm

ICG

uorescence

IMAGING MODULE

Achromat

770 nm dichroic mirror

780 LPF

sCMOS

Fluorescence Channel

RGB CMO

760-nm LASER

770 nm SPF

& Plano convex

Collimator

Beam Shutter

Mirror

sRGB Channel

ILLUMINATION MODULE

Fig. 7.13 Example of detection (blue) and illumination (yellow) modules for attachment on Zeiss OPMI Pentero head without affecting the standard operation of the OM. (Reproduced from Elliott etal. [41])

M. Hadjiandreou and G. Patanis

7.2.2.2 Optical Coherence Tomography

Optical coherence tomography (OCT) is a non-invasive optical imaging technology that can offer micrometre-scaleresolution 2D and 3D high-resolution images of biological samples such as submillimetre vessels and nerves [42, 43]. It has been widely used in the diagnosis and management of ocular pathology including various ophthalmological procedures [44–46], brain tumour imaging [47] and ENT [48, 49]. OCT operates on the principle of optical backscatter detection of NIR light from biological tissue with interferometry employed to measure time delays [43].

Intraoperative OCT has three main types of devices: hand-held OCT, needle-based probes and microscopeintegrated OCT (MiOCT). MiOCT is a key technological advancement of OCT as surgeons can receive intraoperative, cost-effective, nonionising real-time feedback (relative to MRI or CT) with minimal surgical workow interaction [4,

50]. In 2005, Geerling etal. presented a feasibility study on

integrating the OCT technology with the OM for intraoperative 2D visualisation of the anterior segment of the eye [51]. A dichroic mirror was used to fold the OCT beam integrating its optical zoom with the optical zoom of the OM.Hence, the OCT lateral resolution and FOV were dependent on the microscope’s optical zoom which could result in OCT performance compromise. This design was adopted and commercialised in the Haag-Streit Surgical iOCT (Fig. 7.14) [50]. Further MiOCT designs resulted in a number of improvements such as decoupling of the OCT resolution and lateral FOV from the OM zoom level [50], minimising the number of optical elements shared between the two modali-

ties and use of spherical mirror relays to improve the optical transmission. These technological improvements were adopted in MiOCT commercial designs for human ocular surgery (Fig.7.14) [50, 52–54].

MiOCT utilisation in RM is limited. Boppart etal. performed one of the earliest studies of OCT utilisation in microvascular anastomosis of invitro rabbit (Fig.7.14) and human arteries and nerves. It was reported that the imaging capabilities of OCT technology have the potential for intraoperative monitoring to improve patient outcomes (Fig.7.15) [43]. Similarly, Huang etal. performed a proof- of-concept study utilising phase-resolved OCT (PRDOCT), albeit not MiOCT, to assist surgeons in avoiding microvascular anastomosis technical errors and evaluating the surgical outcome in terms of ow, lumen patency and thrombus formation in microvascular anastomosis. An in vivo rat popliteal artery anastomosis (diameter 0.4mm) model was used (Figs. 7.16 and 7.17). It was demonstrated that PRDOCT can guide microvascular anastomosis reducing the risk of technical error and evaluating the surgical outcome [42]. In a further study by Huang et al., PRDOCT was used to generate high- resolution 3D structure views and ow information of 22 mouse femoral artery anastomoses and 17 mouse venous anastomoses. Flow status, vessel inner lumen and early thrombus detection were analysed based on PRDOCT imaging results. It was concluded that PRDOCT is an effective evaluation tool for microvascular anastomosis with 92% sensitivity and 90% specicity for arterial anastomoses [56]. In a step further, Zhu etal. utilised OCT technology for in vivo real-time imaging of

ab c

Fig. 7.14 Commercial MiOCT systems for human ocular procedures. (a) Zeiss RESCAN 700 B permanently integrated OCT system (red arrow) coupled directly prior to the microscope objective [52]. (b) Haag-Streit Surgical iOCT Modular OCT system (red arrow) attached

to the camera port of microscope [53]. (c) Leica Microsystems Bioptigen EnFocus Modular OCT system (red arrow) attached prior to microscope objective [54]. (Reproduced from Carrasco-Zevallos etal. review [50])

7 Novel Microscopic Technologies inReconstructive Microsurgery/Microvascular Surgery

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Fig. 7.15 3D OCT imaging of a rabbit artery anastomosis. (a) Digital image of 1-mm-diameter artery. (b–e) Planes for cross-sectional OCT images. (b, e) Lumen is patent. (c) Lumen partially obstructed with (arrowhead f) depicting thrombosis. (d) Fully obstructed portion of the

anastomoses for supermicrosurgical research. Forty mice underwent end-to-end (ETE) femoral artery anastomosis and invivo monitoring by the OCT system at various time points. OCT was found to be a valid method to evaluate vessel patency, haemodynamics and structural changes of the anastomosed artery [57].

anastomotic site. (f) Longitudinal section of the artery showing obstruction (double-headed arrow o). (g, h) 3D projection of rabbit artery. (Reproduced from Boppart etal. [43])

7.2.2.3 Hyperspectral Imaging

Hyperspectral imaging (HSI) is an emerging optical imaging technique. It uses wavelengths of visible light that detect chromophores for oxygenated and deoxygenated haemoglobin generating a datacube consisting of one spectral and two spatial dimensions (Fig. 7.17c) [55, 58]. The number of

Fig. 7.16 (Top) OCT images showing vessel wall and incorrect suture placement for sutures 3 and 4. (Bottom) OCT showing vessel wall and correct suture placement for sutures 3 and 4. (Reproduced from Huang etal. [42])

M. Hadjiandreou and G. Patanis

abc

Fig. 7.17 (a) Propagation of light in bowel tissue. Light is being reected, scattered or absorbed. (b) Optical properties of major absorbers such as oxygenated haemoglobin (HbO2), deoxygenated haemoglobin (Hb), lipids, water and bilirubin. (c) Multispectral (MSI) Datacube

bands acquired by the imaging system denes whether the system is termed multispectral (MSI; <10s) or hyperspectral (HIS; <100s). HSI offers multiple advantageous intraoperative characteristics: non-contact, non-invasive, nonionising, contrast agent-free and reproducible. HSI has the capacity to extend visual capabilities of surgeons delivering near realtime biomarker information and tissue pathophysiology

of a segment of porcine bowel tissue. The same information in red, green and blue bands are collected by colour cameras to produce a colour image. (Reproduced from Clancy etal. [55])

Table 7.3 Details of the four types of HIS acquisition mode (adapted from Ma L etal. [4])

Acquisition mode Details of acquisition mode

Point scanning Linescanning

through spectral characteristics. Thus, it has the potential of helping in disease diagnosis and surgical guidance [59].

HSI consists of four types of acquisition mode: point scan-

ning, spectral scanning, line-scanning and snapshot [55].

Spectral scanning

Snapshot Spatial and spectral information captured

Table7.3 summarises the four types of acquisition mode.

HSI has not been extensively utilised in RM.Chin etal. demonstrated that HSI technology has the capacity to predictively assess the vascular evolution of wounds, allowing for early intervention [60]. The authors used the OxyVu™-2 (HyperMed™, Inc. Greenwich, Connecticut) device to gen-

erate tissue oxygenation maps of the subpapillary plexus. No intraoperative microscope was used in this study. Similarly, in a more recent animal study, Chin etal. hypothesised that skin oxygenation changes seen at an early stage

Point-by-point scanning, slow and not commonly used Scanning object along one spatial axis, complete spectrum for each pixel acquired in a row of pixels, requires relative motion between camera and patient Capturing one greyscale image of the whole FOV at each step, better spatial and spectral resolution than snapshot

simultaneously, fast video-rate acquisition speed

7 Novel Microscopic Technologies inReconstructive Microsurgery/Microvascular Surgery

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

after ap surgery may non-invasively predict the long-term survival of the tissue in murine models [61]. The authors used the OxyVu™-2 (HyperMed™, Imaging, Inc., Memphis, Tenn.) device with no OM use. The same device has been used in a recent non-inferiority animal study by Jones etal. where an experimental animal model of ischaemic necrosis was used to compare the accuracy of ICG angiography and MSI in assessing tissue perfusion [62]. MSI did not appear to be inferior to ICG in detecting compromised tissue viability. Considering the advantages of the spectral technique, the study emphasised the exciting potential for widespread use of the technique in cosmetic and reconstructive procedures [62].

Currently, there are no reports or studies of operative microscope-integrated hyperspectral imaging (OMiHSI) utilisation in RM; however, other specialities have utilised OMiHSI [63].

7.2.2.4 Photoacoustic Microscopy

Photoacoustics is a physical phenomenon that describes the generation of acoustic waves from an object absorbing pulsed or intensity-modulated optical irradiation. Photoacoustic microscopy (PAM) operates by short-pulsed or intensitymodulated continuous-wave laser beam target irradiation inducing ultrasonic waves as a result of the transient thermoelastic expansion. In this way, excited photoacoustic signals are detected and can reveal the physiologically specic absorption signatures of endogenous chromophores [64].

PAM is an emerging imaging technique with multiple advantages over other established imaging techniques: labelfree optical absorption information, non-invasiveness and high contrast and resolution [65]. PAM has been utilised in animal studies for characterisation of cerebral haemodynamics and oxygen metabolism in CVAs [66] and ocular imaging [67]; however, there has been limited utilisation for reconstructive microsurgical purposes. Hu et al. presented the utilisation of PAM as optical-resolution photoacoustic microscopy (OR-PAM) for characterisation of the microvasculature including microvascular-related physiological and pathophysiological research such as tumour-vascular interaction and haemodynamic monitoring [64]. Figure 7.18 demonstrates a schematic representation of OR-PAM [64]. Another application of PAM in the eld of RM was presented recently by Suzuki etal. via a case series where LVAs were observed by photoacoustic lymphangiography (PAL) to assess the patency of LVAs (Fig.7.19) [68].

7.2.2.5 Laser Speckle Contrast Imaging

Laser speckle contrast imaging (LSCI) is a full-eld, noninvasive perfusion technique that does not require any contrast agents and enables perfusion measurements within seconds. It is based on the phenomenon of backscattering of light from a scattering medium that results in a speckle pattern. The phenomenon occurs due to irregularities in a surface causing a distance difference between the surface and the image plane. If the distance difference between two

Condenser

lens

Dye laserPump laser

Pinhole

Ultrasonic

transducer

Data-acquisition PC

Tr igger

Scanner-control PC

Fig. 7.18 Schematic representation of the OR-PAM. (Reproduced from Hu etal. [64])

Clock

Amplifier

Beam

splitter

Scanner

Eyepiece

Mirror

Objective lens

Correction lens

Right-angle prism

Silicone oil layer

Acoustic lens

Water tank

Membrane

LED

M. Hadjiandreou and G. Patanis

Eyepiece

Camera

NIR

Camer

LSCI

Projector

Real-Time LSCI

of Blood Flow

NIR

Laser

ROI

Fig. 7.19 Cross-sectional view of LVA.Dermal backow is indicated in yellow (superiorly), the lymphatic vessel is indicated in yellow, and the venule is indicated in blue [68]

irregularities corresponds to a multiple of the wavelength of light, there is constructive interference (or amplication). On the contrary, if the distance corresponds to half a wavelength, there is destructive interference (or cancellation). This results in a pattern of light and dark areas on a surface called a speckle pattern [69].

In a recent report of preclinical studies, Mangraviti etal. utilised LSCI technique in combination with the OM (Carl Zeiss OPMI) to develop a direct laser-speckle-videoimaging system, the SurgeON™ for cerebral blood ow assessment [70]. The system complements the OM with real-time LSCI and operates by displaying an on-demand video feed of blood ow information directly in the OM eyepiece. Figure7.20 shows the schematic representation of the system and the imaging specications suitable for neurosurgery [70].

The non-invasiveness and speed of the technique has been acknowledged by reconstructive microsurgeons for intraoperative and postoperative visualisation of surgical ap perfusion. In 1981, Fercher and Briers introduced the technique of single-exposure speckle photography to remove the need for scanning and offer a full-eld technique. The technique was successfully demonstrated for retinal blood ow [71]. Subsequently, Briers and Webster introduced the digital version of the technique, laser speckle contrast analysis (LASCA) (Fig.7.21) [72]. Nguyen etal. utilised LSCI (PeriCam PSI NR System, Perimed AB, Stockholm, Sweden) to examine blood perfusion of random pattern porcine model skin aps after stretching and/ or rotating. LSCI demonstrated two important ndings: (1) blood perfusion is highly dependent on the length of the

Fig. 7.20 Schematic representation of the SurgeON™ system with a NIR laser source (green), a NIR camera (blue) and LSCI projector (yellow). The NIR laser source irradiates the target images which are then captured by the NIR camera. The camera is connected to a computer which acquires laser speckle data, and the blood ow video feed is sent to the LSCI projector to be seen by operator via the eyepieces. (Reproduced from Mangraviti etal. [70])

ap, and (2) rotation of the ap by up to 45° has no signicant impact on blood perfusion. It is worth highlighting that investigators did not use a microscope-integrated LSCI system and commented on the inability of LSCI to quantify blood ow [73]. Similarly, Sheikh etal. investigated perfusion in full-thickness pig eyelid aps measuring microvascular perfusion with the same LSCI system utilised by Nguyen etal. [74]. Du etal. utilised laser speckle imaging in an animal study of the role of haemodynamic alterations in ap delay and found that LSCI is a feasible method for predicting ap viability in rat models [75]. Karakawa etal. used LSCI successfully in a case of Tamai zone I ngertip replantation [76]. In a series of publications, Zötterman etal. evaluated LSCI as a method of perioperative planning in reconstructive surgery. LSCI was hypothesised that it can be utilised perioperatively to show negative perfusion trends to predict ap necrosis [77]. A cranial gluteal artery perforator (CGAP) porcine ap model was used, and it was concluded that a threshold perfusion of <25PU at 30min was a predictor for tissue morbidity 72 h after surgery (Fig.7.22) [77]. In a further prospective case series study, Zötterman etal. used LSCI to investigate perfusion in deep inferior epigastric surgery perforator (DIEP) ap surgery and assess whether the technique assisted in prediction of postoperative complications. It was concluded that LSCI is a promising tool for measurement of ap perfusion and assessment of risk of postoperative ischaemic complications (Fig.7.23) [78].

t = 0 min vs. t = 30 min

7 Novel Microscopic Technologies inReconstructive Microsurgery/Microvascular Surgery

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

aa a

bb b

Fig. 7.21 LASCA hand images at different phases: (1a) hand in cold water, (1b) hand in hot water (contrast scale: contrast decreasing and velocity increasing from left to right), (2a) hand under normal conditions, (2b) hand area rubbed (small red area showing increased perfu-

sion), (3a) hand under normal conditions, (3b) hand when blood pressure cuff is applied (reduced blood ow). (Adapted from Briers and Webster [72])

abc

def

100

Perfusion (A.U.)

Fig. 7.22 Visual appearance (a–c) and perfusion (d–f) in a CGAP ap at time= 0 (a, d) and time = 30min (b, e) after raising the ap. The dashed black line represents the proximal border where compromised circulation is predicted by clinical assessment. The dashed white line

represents the proximal border of actual ischaemic necrosis at time = 72 h. Coloured dots represent the areas where perfusion was measured. (f) shows the change in perfusion from t=0 to t=30min in the ap areas measured. (Reproduced from Zötterman J etal. [77])

0300300300300300300300300

M. Hadjiandreou and G. Patanis

Fig. 7.23 (a) Schematic representation of DIEP ap divided in Hartrampf zones I–IV.Perforator is labelled on zone I superior aspect. (b) LSCI perfusion image with zones I and II being highly perfused and hence more preferable for reconstruction. (Reproduced from Zötterman J etal. [78])

7.3 Heads-Up Operative Microscopes

7.3.1 The Exoscope

Advances in digital imaging and screen technology have led to the development of the exoscope as an alternative to the OM.The exoscope provides an array of theoretical advantages such as high-denition optics, 3D vision, high-quality illumination at depth, improved surgeon ergonomics and ease of use. Exoscopic devices currently available include the VITOM 2D and 3D (Karl Storz), ORBEYE (Sony Olympus) and Modus V (Synaptive Medical Inc.). Table7.4 summarises the key characteristics of the available exoscopic devices [79–82].

Cheng etal. initially presented a 3D stereoscopic monitor system to improve the microsurgery environment during two head and neck cancer reconstruction cases. Although the microvascular anastomoses were successful, they proved time-consuming [83]. Piatkowski et al. per-

formed a microvascular free ap for autologous breast reconstruction utilising the VITOM® 3D.Despite the fact that anastomoses were performed successfully, authors reported on the comfort and resolution while using higher magnications not being adequate for routine microsurgical practice [84]. Ichikawa etal. highlighted the potential advantages of using the 3D exoscope for microvascular anastomosis in two cases of head and neck reconstruction with a free anterolateral thigh ap (ALT) transfer [85]. Patanis etal. performed a simulation non-inferiority trial utilising the Modus V exoscope and concluded patency non-inferiority in the microvascular anastomoses performed under exoscope compared to OM; nevertheless, duration of anastomoses under exoscope proved more time-consuming as previously shown in other studies [79]. In a recent case-control pilot study, Ahmad et al. utilised the ORBEYE exoscope for 49 consecutive microsurgical cases. Interestingly, authors reported that there was no difference in operative time, ischaemia time or microsurgical

7 Novel Microscopic Technologies inReconstructive Microsurgery/Microvascular Surgery

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Table 7.4 Summary of key characteristics of available exoscopic devices (reproduced from Patanis etal. [79])

ORBEYE, 3D-4K video

Systems Demonstration

VITOM® 2D and 3D, Karl Storz. 2011

24,25

Computar MLH-10, CBC 2012

Exoscope, Sony Olympus.

28,29

2017

Modus V™ Synaptive Medical Inc. 2017

Illumination Xenon SPD- 300- W LED ×2 bre optic LED Quad (×4) LED Magnication (optical zoom) <2× 5–20× <6× <12.5× Image quality HD or 4K UHD HD 4K 4K UHD Field of view 50–150mm n/a 7.5–171mm 6.5–207.9mm Portability Portable base—manual

setup Stereopsis– 3D capability Ye s No Yes Pending released (2019) Depth of eld 35–100mm n/a n/a X2 of OM Cost $ (250K USD) n/a $$ (450K USD) $$$ (500-750K USD)

LED light emission diode, HD high denition, UHD ultra high denition, 3D three dimensional, USD United States dollars

Portable Mobile base with wheels Mobile base with castor

complications between the exoscope and conventional microscopy groups, and participants reported favourable ergonomics, excellent image quality and ease of equipment manipulation [80].

7.3.2 Hybrid Visualisation Systems

The hybrid visualisation system, KINEVO® 900 (Carl Zeiss), can be utilised as an optical OM or exoscope with digital

wheel brakes

Table 7.5 Technical specications of the digital and robotic visualisation system; KINEVO® 900 [86, 87]

Technical specications of the KINEVO® 900 Working distance 200–625mm Focal length 170mm Maximum magnication in

exoscope mode XY robotic movement 6 axes 3D4k stereo video cameras 2× 3-chip 4 K, 2160 p Surgeon-controlled robotics Wireless 10-button plus joystick

food control panel

visualisation on an external 55″ 3D4k monitor plus an internal 24″ 3DHD system monitor. Technical specications of the robotic, hybrid visualisation system are summarised in

To the authors’ knowledge, there are currently no studies

published that utilise KINEVO® 900in RM.

Table7.5 [86, 87].

The use of KINEVO® 900 system is still at its early

stages with studies being at a proof-of-concept stage. For

7.3.3 Head-Mounted Microscope

example, Belykh et al. reported on the feasibility and effectiveness of performing microvascular bypass using the system above. The authors concluded on the feasibility to perform a microvascular anastomosis under the 3D hybrid system and, nevertheless, reported being unsuccessful when using the 2D imaging modality, thus emphasising the importance of appropriate depth perception [88]. Roethe et al. investigate the impact of the hybrid exoscope on surgical performance and team workow in preclinical and clinical neurosurgical settings with results supporting clinical integration and improved surgeon ergonomics [86].

Head-mounted microscope (HMM) has been developed in an attempt to improve surgeon’s ergonomics. The Leica HM500 is an ergonomic headset with a magnication capability of 2–9× and working distance of 300–700mm (from eyepiece lens to object). The HMM also offers an automatic or manual focus function. In a preliminary study, Chen etal. utilised the Leica HM500 to perform ve microlaryngoscopic operations. The study demonstrated a decrease in surgical fatigue and improved ergonomics in laryngoscopic microsurgery [89]. To the authors’ knowledge, there is no published evidence of Leica HM500 utilisation in RM.

<<< < Предыдущая 1 2 3 4 5 6 78 / 508 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
29.08.202687 Мб0Книга_3597_Библиотеки_им_академика_М_И_Перельмана.pdf
#
29.08.202686 Мб0Книга_3598_Библиотеки_им_академика_М_И_Перельмана.pdf
#
29.08.202686 Мб0Книга_3599_Библиотеки_им_академика_М_И_Перельмана.pdf
#
02.09.202619 Мб0Книга_36_библиотеки_им_акад_М_И_Перельмана-1.pdf
#
02.09.202619 Мб0Книга_36_библиотеки_им_акад_М_И_Перельмана.pdf
#
29.08.202685 Мб0Книга_3600_Библиотеки_им_академика_М_И_Перельмана.pdf
#
29.08.202684 Мб0Книга_3601_Библиотеки_им_академика_М_И_Перельмана.pdf
#
29.08.202684 Мб0Книга_3602_Библиотеки_им_академика_М_И_Перельмана.pdf
#
29.08.202684 Мб0Книга_3603_Библиотеки_им_академика_М_И_Перельмана.pdf
#
29.08.202683 Мб0Книга_3604_Библиотеки_им_академика_М_И_Перельмана.pdf
#
29.08.202683 Мб0Книга_3605_Библиотеки_им_академика_М_И_Перельмана.pdf