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",isbn:"978-1-83968-924-6",printIsbn:"978-1-83968-923-9",pdfIsbn:"978-1-83968-925-3",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"ea4ec0d6ee01b88e264178886e3210ed",bookSignature:"Dr. Hiran Wimal Amarasekera",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/9500.jpg",keywords:"Bone Tumors, Oncology, Childhood Tumors, Cancer, Risk Factors, Modern Management, Benign Lesions, Tumor-Like Conditions, Immunology, Histochemistry, Cell Oncology, Tumor Markers",numberOfDownloads:389,numberOfWosCitations:0,numberOfCrossrefCitations:1,numberOfDimensionsCitations:1,numberOfTotalCitations:2,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"September 28th 2020",dateEndSecondStepPublish:"October 26th 2020",dateEndThirdStepPublish:"December 25th 2020",dateEndFourthStepPublish:"March 15th 2021",dateEndFifthStepPublish:"May 14th 2021",remainingDaysToSecondStep:"4 months",secondStepPassed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Consultant Orthopaedic Surgeon from Sri Lanka currently working in University Hospitals of Coventry and Warwickshire, UK, trained at the National Hospital of Sri Lanka, at the Oldchurch Hospital in Essex UK and The Avenue Hospital Melbourne, Australia and University Hospitals of Coventry and Warwickshire, UK, obtained the FRCS from Royal College of Surgeons of Edinburgh, Scotland.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"67634",title:"Dr.",name:"Hiran",middleName:"Wimal",surname:"Amarasekera",slug:"hiran-amarasekera",fullName:"Hiran Amarasekera",profilePictureURL:"https://mts.intechopen.com/storage/users/67634/images/system/67634.jpg",biography:"Hiran Amarasekera is a Consultant Orthopaedic Surgeon from Sri Lanka currently working in University Hospitals of Coventry and Warwickshire, the UK as a hip preservation fellow. \r\nHis special interests include young adult hip and knee problems, sports injuries, Hip and knee arthroplasty, and complex arthroscopic procedures. \r\nHe completed the MBBS from Kasturba medical college Manipal, India and did his postgraduate in Trauma and Orthopaedics at the Post-graduate Institute of the Medicine University of Colombo obtained the MS. \r\nHe was initially trained at the National Hospital of Sri Lanka and then completed the further training at the Oldchurch Hospital in Essex UK and The Avenue Hospital Melbourne, Australia and University Hospitals of Coventry and Warwickshire, UK.\r\nHe obtained the FRCS from Royal College of Surgeons of Edinburgh in 2003 and was elected a fellow of Sri Lanka College of surgeons (FCSSL) 2012. \r\nHe has a keen interest in academia and research. Working as a clinical research fellow in Warwick Medical School he obtained the MPhil form University of Warwick and was elected for a research fellowship to University of California Los Angeles (UCLA). \r\nHis research interests include blood flow to the hip, failure of hip resurfacing, designing new hip prosthesis, and surgical approaches to the hip. \r\nHe has over 30 international publications and presentations and several book chapter. \r\nHe also works as a reviewer for international orthopedic journals and has reviewed over 35 papers and is a member of the editorial board of Sri Lanka Journal of Surgery.",institutionString:"University of Warwick Science Park",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"University of Warwick Science Park",institutionURL:null,country:{name:"United Kingdom"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:[{id:"73224",title:"Management of Early Osteoarthritis",slug:"management-of-early-osteoarthritis",totalDownloads:109,totalCrossrefCites:0,authors:[null]},{id:"71336",title:"Non-Surgical Regional Therapy for Osteoarthritis: An Update and Review of the Literature",slug:"non-surgical-regional-therapy-for-osteoarthritis-an-update-and-review-of-the-literature",totalDownloads:165,totalCrossrefCites:0,authors:[{id:"77195",title:"Dr.",name:"Charles",surname:"Mackworth-Young",slug:"charles-mackworth-young",fullName:"Charles Mackworth-Young"}]},{id:"72715",title:"Simultaneous Bilateral Joint Arthroplasties in Treatment of Osteoarthritis",slug:"simultaneous-bilateral-joint-arthroplasties-in-treatment-of-osteoarthritis",totalDownloads:98,totalCrossrefCites:1,authors:[null]},{id:"75062",title:"Bone Cancer Pain, Mechanism and Treatment",slug:"bone-cancer-pain-mechanism-and-treatment",totalDownloads:17,totalCrossrefCites:0,authors:[null]}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"247865",firstName:"Jasna",lastName:"Bozic",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/247865/images/7225_n.jpg",email:"jasna.b@intechopen.com",biography:"As an Author Service Manager, my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"16369",title:"Numerical Simulation of Transient Response in 3-D Multi-Channel Nanowire MOSFETs Submitted to Heavy Ion Irradiation",doi:"10.5772/16827",slug:"numerical-simulation-of-transient-response-in-3-d-multi-channel-nanowire-mosfets-submitted-to-heavy-",body:'The bulk MOSFET scaling has recently encountered significant limitations, mainly related to the gate oxide (SiO2) leakage currents (Gusev et al., 2006; Taur et al., 1997), the large increase of parasitic short channel effects and the dramatic mobility reduction (Fischetti & Laux, 2001) due to highly doped Silicon substrates precisely used to reduce these short channel effects. Technological solutions have been proposed in order to continue to use the “bulk solution” until the 32 nm ITRS node (ITRS, 2009). Most of these solutions envisage the introduction of high-permittivity gate dielectric stacks (to reduce the gate leakage, (Gusev et al., 2006; Houssa, 2004), midgap metal gate (to suppress the Silicon gate polydepletion-induced parasitic capacitances) and strained Silicon channel (to increase carrier mobility (Rim et al., 1998). However, in parallel to these efforts, alternative solutions to replace the conventional bulk MOSFET architecture have been proposed and studied in the recent literature. One solution is the radical change of the device architecture such as in Multiple-Gate devices introducing additional gate electrodes: 2 (double-gate), 3 (FinFET or trigate) or 4 (gate-all-around, completely surrounding the channel). Silicon nanowires MOSFETs with gate-all-around (GAA) provide an original and very promising architecture to further increase the integration density and performances of nano-devices (Park & Colinge, 2002). These structures exhibit a superior control of short channel effects resulting from an exceptional electrostatic coupling between the conduction channel and the surrounding gate electrode. As a result, intrinsic channels can be used leading to higher mobilities and drain currents.
3D Multi-Channel MOSFETs (MCFETs) have been recently proposed to achieve a higher current drivability and a significant enhancement of the on-state current over the off-state current ratio (ION/IOFF) (Bernard et al., 2007; Ernst et al., 2006) compared to conventional single channel devices. MCFETs combine the advantages of excellent control of short-channel effects with a high on-state current due to a multiple-gate architecture and the 3-D integration of vertically stacked channels. GAA devices with ultra-thin and narrow channels (about 10 nm) are seen as the ideal architecture for off-state current control of sub-10 nm gate lengths (Ernst et al., 2006). Meanwhile, the current density per surface of such a device is limited by the lithography pitch, which dictates the distance between nanowires. The current density can be improved by the vertical integration of GAA devices. Thanks to vertical stacked channels, a 5× increase in current density per layout surface can be achieved compared to planar transistors with the same gate stack (Ernst et al., 2006).
As the MOSFET is scaling down, the sensitivity of integrated circuits to radiation, coming from the natural space or present in the terrestrial environment, has been found to seriously increase (Baumann, 2005; Dodd, 1996; Dodd & Massengill, 2003; Dodd, 2005). In particular, ultra-scaled memory ICs are more sensitive to single-event-upset (SEU) and digital devices are more subjected to digital single-event transient (DSETs). Single-event-effects (SEE) are the result of the interaction of highly energetic particles, such as protons, alpha particles, or heavy ions, with sensitive regions of a microelectronic device or circuit. These SEE may perturb the device/circuit operation (e.g., reverse or flip the data state of a memory cell, latch, flip-flop, etc.) or definitively damage the circuit (e.g. gate oxide rupture, destructive latch-up events).
The physical mechanisms related to the production of SEE in microelectronic devices consist in three main successive steps: (1) the charge deposition by the energetic particle striking the sensitive region, (2) the transport of the released charge into the device and (3) the charge collection in the sensitive region of the device. In the following we succinctly describe these different mechanisms, for a detailed presentation we invite the reader to consult (Baumann, 2005; Dodd, 1996; Dodd & Massengill, 2003; Dodd, 2005).
Charge deposition (or generation): When an energetic particle strikes the device, an electrical charge can be deposited by one of the following mechanisms: direct ionization by the interaction with the material or indirect ionization, by secondary particles issued from nuclear reactions with the atoms of the struck material. Direct ionization typically characterizes heavy ions (Z ≥ 2) of the space environment. They interact with the target material mainly by inelastic interactions and transmit a large amount of energy to the electrons of the struck atoms. These electrons produce a cascade of secondary electrons which thermalize and create electron-hole pairs along the particle path. In a semiconductor or insulator, a large amount of the deposited energy is thus converted into electron-hole pairs, the remaining energy being converted into heat and a very small quantity in atoms displacement. It was experimentally shown that the energy necessary for the creation of an electron-hole pair depends on the material bandgap. In a Silicon substrate, one electron-hole pair is produced for every 3.6 eV of energy lost by the ion. Other particles, such as neutrons of the terrestrial environment, do not interact directly with target material since they do not ionize the matter on their passage. However, these particles should not be neglected, because they can produce SEE due to their probability of nuclear reaction with the atoms of materials which compose the microelectronic devices. This mechanism is called indirect ionization. The products resulting from a nuclear reaction can deposit energy along their traces, in the same manner as that of direct ionization. Since the creation of the column of electron-hole pairs of these secondary particles is similar to that of ions, the same models and concepts can be used.
Charge transport: When a charge column is created in the semiconductor by an ionizing particle, the released carriers are quickly transported and collected by elementary structures (e.g. p-n junctions). The transport of charge relies on two main mechanisms: the charge drift in regions with an electric field and the charge diffusion in neutral zones. The deposited charges can also recombine with other mobile carriers existing in the crystal lattice.
Charge collection: The charges transported in the device induce a parasitic current transient, which could induce disturbances in the device and associated circuits. The devices most sensitive to ionizing particle strikes generally contain reversely-biased p-n junctions, because the strong electric field existing in the depletion region of the p-n junction allows a very efficient collection of the deposited charge. The effects of ionizing radiation are different according to the intensity of the current transient, as well as the number of impacted circuit nodes. If the current is sufficiently important, it can induce a permanent damage on gate insulators (gate rupture, SEGR) or the latch-up (SEL) of the device. In usual low power circuits, the transient current may generally induce only an eventual change of the logical state (cell upset).
Modeling and simulating the effects of ionizing radiation has long been used for better understanding the radiation effects on the operation of devices and circuits. In the last two decades, due to substantial progress in simulation codes and computer performances which reduce computation times, simulation reached an increased interest. Due to its predictive capability, simulation offers the possibility to reduce radiation experiments and to test hypothetical devices or conditions, which are not feasible (or not easily measurable) by experiments. Physically-based numerical simulation at device-level presently becomes an indispensable tool for the analysis of new phenomena specific to short-channel devices (non-stationary effects, quantum confinement, quantum transport), and for the study of radiation effects in new device architectures (such as multiple-gate, Silicon nanowire MOSFET), for which experimental investigation is still limited. In these cases, numerical simulation is an ideal investigation tool for providing physical insights and predicting the operation of future devices expected for the end of the roadmap. A complete description of the modeling and simulation of SEE, including the history and the evolution of this research domain, have been presented in the survey papers by Dodd (Dodd, 1996; Dodd & Massengill, 2003; Dodd, 2005) and Baumann (Baumann, 2005). It is also important to note that phenomena related to an ionizing particle striking a microelectronic device are naturally three dimensional (3-D) mechanisms, due to both the tri-dimensional structure of the ion track and the 3-D structure of real devices. 3-D simulation is then necessary not only for actual short/narrow devices, but also for new device architectures for which 3-D electrostatic or quantum confinement effects cannot be taken into account in a 2-D simulation. 3-D simulation is also necessary when considering non-normal incidence of the ion strike on the device.
In this chapter, we investigate the transient response of MCFETs submitted to heavy ion irradiation using 3-D numerical simulation. The MCFET contains GAA and FinFET nanowire MOSFETs with ultra-thin, narrow channels (10 nm) and a 32 nm channel length. Recent simulation studies have shown that GAA MOSFET devices are less sensitive to single event transients (SET) than fully-depleted single-gate SOI devices (Francis et al., 1995; Munteanu et al., 2006; Munteanu et al., 2007). This is due to the improved control of the channel potential which reduces floating body effects and improves the device immunity to single event transients. MCFET devices are then expected to show a very low sensitivity to ionizing radiation.
This chapter is organized as follows: after the presentation of the 3-D simulated structures and simulation models (sections II and III), we will analyze in section IV the effect of the ion strike on the main internal electrical parameters inside the structure and on the drain current transient. In this section we will compare the sensitivity to heavy ion irradiation of the MCFETs with that of other single and multiple-gate devices. Finally, in section V we will investigate the influence of the ion strike parameters (location, direction, and radius of the ion track) and of the lateral spacing between the nanowire stacks on the current transient and charge collection.
The structure of the simulated MCFETs is a 3 x 3 nanowire matrix containing square cross-section nanowires. The description of the 3-D architecture considered here and the definition of the geometrical parameters are shown in Fig. 1. The MCFET matrix is composed of three parallel transistor stacks, each stack containing 3 vertically stacked nanowire devices (2 GAA and 1 FinFET). The MCFET is calibrated to fill the ITRS’2009 (ITRS, 2009) low-power (LP) requirements in terms of off-state current for the technology nodes corresponding to the year 2009 (IOFF < 5×10-3 A/µm). The individual nanowire MOSFETs are designed with a 32 nm gate length, square cross-section with tSi=W=10 nm, and a 3 nm-thick gate oxide. An intrinsic silicon film and a midgap gate are considered. Three lateral spacings, s, between the nanowire stacks are considered: 100, 75, and 50 nm.
Schematic description of the 3-D simulated MCFET structures and their main geometrical parameters. The MCFET matrix is composed of three parallel transistor stacks, each stack containing 3 vertically stacked nanowire devices (2 GAA and 1 FinFET). All nanowires have silicon film with square section (tSi=W=10 nm). For a better view of the nanowires the gate material, spacers, isolation oxide and a part of the source and drain regions are not shown.
3-D numerical simulations have been performed with the DESSIS device simulator from the 3-D Sentaurus code (Sentaurus, 2009). The main models used in simulation are the doping-dependent Shockley-Read-Hall and Auger recombination models and the Fermi-Dirac carrier statistics. The model of the effective intrinsic density includes doping-dependent band-gap narrowing (Slotboom model (Sentaurus, 2009)) and a lattice temperature-dependent band gap. The hydrodynamic model was used for the carrier transport equations, including the energy balance equations for electrons, holes, and the lattice. The impact ionization and the carrier mobility models depend on carrier energy calculated with the hydrodynamic model. The mobility model includes dependencies on the lattice temperature, channel doping level and normal electric field through the Lombardi model (Sentaurus, 2009). In the following we succinctly describe the hydrodynamic transport model used in the present simulation approach.
Historically, the first models used in carrier transport simulation described the physical phenomena taking place in the device as functions of the electric field, even if these phenomena depend on carrier energy (Selberrer, 1984). This is possible when considering that carrier energy is in permanent balance with the electric field. Carrier transport in MOSFET devices is mainly due to electrostatic potential gradients and/or gradients of carrier concentration (Selberrer, 1984). The current density in a biased device is then usually modeled by the sum of a conduction component (drift) and a diffusion component, as follows (for electrons):
where q is the elementary charge, µn is the carrier mobility, Dn is the thermal diffusion coefficient, Ε is the electric field and n is the electron density. Dn and µn depend on material and electric field and are connected by the Einstein’s equation:
with TL the lattice temperature and k is the Boltzmann constant. Similar equations are considered for holes (see the paragraph “Drift-Diffusion” below).
This traditional description of electronic transport constitutes the "Drift Diffusion" (DD) model, the basic model used in CMOS devices simulation (Lundstrom, 2000; Selberrer, 1984). This modeling level is generally adapted for long devices, with either weak or strong electric fields (except for the modeling of impact ionization; see below in this paragraph). When the device feature size is reduced, the electronic transport becomes qualitatively different from the traditional transport model since the average carrier velocity does not depend on the local electric field. Average carrier velocity is a function of the carrier energy which depends on the variations in time and space of the electric field. In short devices, steep variations of electric field take place in the active area of the devices. Then, non-stationary phenomena (such as velocity overshoot (Baccarani & Wordeman, 1985; Jacoboni & Reggiani, 1983) occur following these rapid spatial or temporal changes of high electric fields. In small devices, non-stationary phenomena play an important role and may dominate the device operation. Since DD model neglects non-stationary effects, new advanced transport models become mandatory for accurate transport simulation in ultra-short devices (Apanovich et al., 1994; Blotekjaer, 1970; Stratton, 1962).
The DD model considers that carriers gain maximum energy instantaneously balanced with the electric field (Lundstrom, 2000). Consequently, non-stationary effects (velocity overshoot and carrier transport by thermal diffusion processes associated with electronic temperature gradients) specific to short devices are neglected in DD model, as well as the dependence of impact ionization on the carrier energy.
In reality, the carrier energy does not immediately respond to changes in electric field. Mobility and diffusion coefficients are tensor quantities that depend on several parameters besides electric field (Khanna, 2004). In ultra-short MOSFETs (deca-nanometre channel lengths), the high internal electric fields result in substantial electron heating. The hydrodynamic model, obtained by taking the first three moments of the Boltzmann Transport Equation (BTE), represents the carrier transport effects in short devices more accurately than the DD model. The hydrodynamic model is a macroscopic approximation to the BTE taking into account the relaxation effects of energy and momentum. In this model, the propagation of electrons in a semiconductor is treated as the flow of a charged, thermally conducting gas subjected to an electric field. This model removes several limiting assumptions of DD: the carrier energy can exceed the thermal energy and all physical parameters are energy-dependent. The current density and the energy flow are modelled in HD model by the following equations (given here for electrons (Sentaurus, 2009)):
where Tn is the electron temperature, ξn is a model coefficient,
while the energy density loss Wn is given by:
where τrel is the energy relaxation time, RSRH is the SRH recombination rate, Gn is the impact ionization rate, RnA is the Auger recombination rate, Eg is the Silicon bandgap. Similar equations are used for holes. Usually, the mobility µn is modelled as a decreasing function of energy (because the scattering rate increases with the energy of the particle). Finally, the system of equations of the HD model is completed by the continuity equations:
where R is the generation-recombination rate.
The radiation effects have been simulated using the HeavyIon module of the TCAD Sentaurus toolsuite (Sentaurus, 2009), considering an electron-hole pair column centred on the ion track axis to model the ion strike. The ion track structure to be used as input in simulation is presently a major issue for device simulation. The first representations included a simple cylindrical charge generation with a uniform charge distribution and a constant LET along the ion path. However, the real ion track structure is radial and varies as the particle passes through the matter. When the particle strikes a device, highly energetic primary electrons (called δ-rays) are released. They further generate a very large density of electron-hole pairs in a very short time and in a very small volume around the ion trajectory, referred as the ion track. These carriers are collected by both drift and diffusion mechanisms, and are also recombined by different mechanisms of direct recombination (radiative, Auger) in the very dense core track, which strongly reduces the peak carrier concentration. All these mechanisms modify the track distribution both in time and space. As the particle travel through the matter, it loses energy and then the δ-rays become less energetic and the electron-hole pairs are generated closer to the ion path. Then, the incident particle generates characteristic cone-shaped charge plasma in the device (Dodd, 2005).
The real ion track structure has been calculated using Monte-Carlo methods (Hamm et al., 1979; Martin et al., 1987; Oldiges et al., 2000). These simulations highlighted important differences between the track structure of low-energy and high-energy particles, even if the LET is the same (for details see (Dodd et al., 1998; Dodd, 2005)). High-energy particles are representative for ions existing in the real space environment, but they are not available in typical laboratory SEU measurements (Dodd, 1996). Then the investigation of the effects of high-energy particles by simulation represents an interesting opportunity, which may be difficult to achieve experimentally.
Analytical models for ion track structure have been also proposed in the literature and implemented in simulation codes. One of the most interesting models is the “non-uniform power law” track model, based on the Katz theory (Kobetich & Katz, 1968) and developed by Stapor (Stapor & McDonald, 1988). In this model, the ion track has a radial distribution of excess carriers expressed by a power law distribution and allows the charge density to vary along the track (Dussault et al., 1993). Other analytical models propose constant radius non-uniform track or Gaussian distribution non-uniform track.
In commercial simulation codes, the effect of a particle strike is taken into account as an external generation source of carriers. The electron-hole pair generation induced by the particle strike is included in the continuity equations via an additional generation rate. This radiation-induced generation rate can be connected to the parameters of irradiation, such as the particle Linear Energy Transfer (LET). The LET is the energy lost by unit of length (-dE/dl), which is expressed here in MeV cm²/mg (1pC/µm≈100 MeV cm²/mg). The particle LET can be converted into an equivalent number of electron-hole pairs by unit of length using the mean energy necessary to create an electron-hole pair (Eehp) (Roche, 1999):
where Nehp is the number of electron-hole pairs created by the particle strike. By associating two functions describing the radial and temporal distributions of the created electron-hole pairs, the number of electron-hole pairs is included in the continuity equations (Munteanu & Autran, 2008) via the following radiation-induced generation rate:
where R(w) and T(t) are the functions of radial and temporal distributions of the radiation induced pairs, respectively. Equation (11) assumes the following hypothesis: the radial distribution function R(w) depends only on the distance traversed by the particle in the material and the generation of pairs along the ion path follows the same temporal distribution function in any point. Since function G must fill the condition:
functions R(w) and T(t) are submitted to the following normalization conditions:
The ion track models available in commercial simulation codes usually propose a Gaussian function for the temporal distribution function T(t):
where tC is the characteristic time of the Gaussian function which allows one to adjust the pulse duration. The radial distribution function is usually modelled by an exponential function or by a Gaussian function:
where rC is the characteristic radius of the Gaussian function used to adjust the ion track width. Previous works have demonstrated that the different charge generation distributions used for the radial ion track does affect the device transient response, but the variation is typically limited to ~5% for ion strikes on bulk p-n diodes (Dodd, 2005; Dussault et al., 1993). Considering a LET which is not constant with depth along the path has a more significant impact on the transient response in bulk devices. The key parameters of the single event transient (peak current, time to peak and collected charge) have up to 20% variation when LET is allowed to vary with depth compared to the case of a constant LET (Dussault et al., 1993). Nevertheless, the LET variation with depth has no influence on the transient response of actual SOI devices with thin Silicon film.
In the following simulations, two characteristic radii have been considered for the spatial Gaussian dependence of the ion track: 50 and 20 nm. The Gaussian time distribution (Eq. (15)) is centered on 10 ps and has a characteristic width of 2 ps. The linear energy transfer (LET) value is kept constant along the track. The ion strikes the middle of the channel between the source and the drain and perpendicular to the gate electrode, as shown in Fig. 2. The different ion strike locations considered in this work are schematically presented in Fig. 2.
Positions (arrows) of the ion strike considered in this work; the ion strikes in the middle of the channel (between the source and drain regions). For a better view of the nanowires, the gate material, spacers and isolation oxide are not shown.
Ion strike locations labelled “1”, “2”, “3”, and “4” are parallel to the y-axis (perpendicular to the x-z plane) and the ion strike locations “5”, “6”, and “7” are parallel to the z-axis (perpendicular to the x-y plane). The lateral spacing between locations “1”, “2”, “3”, and “4” are equal to s/2. The 3-D profile of heavy ion charge density generated in the structure is shown in Fig. 3 for the ion strike locations “1”, “2”, “3”, and “4”. The MCFET is biased in the off-state (VG=0 V). The drain terminal is constantly biased at 0.8 V. The collected charge is derived by integrating the drain current over the transient duration.
D profile of the heavy ion charge density for the ion strike locations “1”, “2”, “3”, and “4”. The positions (arrows) of the ion strike considered in this work are also shown; the ion strikes in the middle of the channel (between the source and drain regions). For a better view of the nanowires, the gate material, spacers and isolation oxide are not shown.
Figure 4 shows the 3-D profiles of the electrostatic potential (Fig. 4(a)) and the electron density (Fig. 4(b)) in a 3-D MCFET with a lateral spacing s=100 nm for the ion strike location “2” at t=10 ps (maximum generated charge by the ion strike). The ion track radius considered here is equal to 50 nm. This figure shows that the electrostatic potential profile is perturbed by the ion strike, especially in the first nanowire stack that is struck directly. However, the impact is less visible in the second nanowire stack and is almost undetectable for the third nanowire stack (situated the farthest from the ion strike impact location). For a better view of the potential variation in the MCFET stacks, we plot in Fig. 5 the potential in a cutline along the x-axis in the middle of the channel at different times before and after the ion strike. Two devices are considered: the impacted transistor located in the first nanowire stack (Fig. 5(a)) and the nanowire symmetrically situated in the third nanowire stack (Fig. 5(b)). The variation with time of the potential in the impacted transistor indicates that the parasitic bipolar device is turning on. On the contrary, the potential in the third nanowire stack varies only very slightly, as shown in Fig. 5(b). This is due to the narrow ion track radius compared to the lateral spacing between nanowires.
D profile of electrostatic potential (a) and of electron density (b) in the 3-D MCFET for the ion strike location “2” at t=10 ps. For a better view of the nanowires, the gate material, spacers, isolation oxide, and a part of the source and drain regions are not shown. The MCFET is biased in the off-state (VG=0 V, VD=0.8 V). The nanowire spacing is s=100 nm, the ion strike LET is 10 MeV/(mg/cm2), and the ion track radius is 50 nm. The ion strike location is indicated by the arrow.
The 2-D profiles of the electron density in a cross-section in the MCFET (cut plane C-C’ indicated in Fig. 4(b)) are reported in Fig. 6 before and after the ion strike in location “2”. These profiles give details concerning the distribution inside each nanowire. The electron density is centered in the middle of the film for the GAA devices, which is a typical feature of these devices where the gate is wrapped around the entire channel. In the off-state bias condition, carrier conduction in GAA is dominated by the volume inversion phenomenon (Munteanu & Autran, 2003): carriers flow from source to drain over the entire silicon film thickness. This is not the case for FinFET devices, where the electron density is not centered in the middle of the film. Figure 5(b) also shows that the electron density in the nanowires situated in the third stack is very slightly disturbed by the ion strike. Figure 6 also shows that the electron density is strongly enhanced in the first nanowire stack (the impacted stack) after the ion strike (for t=10 ps in Fig. 6) and decreases as long as the structure relaxes and the deposited charge is collected or recombined. In the same time, the electron density in the third nanowire stack is almost unchanged compared to the electron density before the ion strike. This confirms the above remarks concerning the variation of the electrostatic potential.
D potential profiles at different times in two cut-lines (indicated in Fig. 4(a)) along the x-axis in the middle of the nanowire: (a) cutline A-A’ in the impacted GAA nanowire and (b) cutline B-B’ in the GAA nanowire symmetrically situated in the third stack. The MCFET is biased in the off-state (VG=0 V, VD=0.8 V). The nanowire spacing is s=100 nm, the ion strike LET is 10 MeV/(mg/cm2), and the ion track radius is 50 nm.
D profile of electron density along the cross-section C-C’ of Fig. 4(b) in the 3D MCFET before the ion strike, at t=10 ps and t=100 ps. The gate material is not shown. The ion strike location is indicated by the arrow. Other parameters as in Fig. 4.
Figure 7 shows the drain current transient resulting from the ion strike in location “2”. The variation of the collected charge with time is also reported. The charge collection is very fast in MCFETs, due to the GAA devices which have small active volumes that allow all the excess charge to be quickly evacuated. In addition, the GAA architecture allows the floating body-effects to be reduced, due to an excellent control of the body potential by the gate. It has been shown in (Munteanu et al., 2007) that the individual GAA device (with the same geometrical parameters as in the present work) has a total transient duration of 8 ps at 10% of the peak value for LET=10 MeV/(mg/cm2). The single-event transient of the MCFET simulated here has a total transient duration of 10 ps at 10% of the peak value for a LET of 10 MeV/(mg/cm2). This value is lower than that obtained in (Munteanu et al., 2006) for fully-depleted single-gate SOI devices with 50 nm gate length (where a total transient duration of 15 ps at 10% of the peak value is found). However, in (Munteanu et al., 2006) a LET of 30 MeV/(mg/cm2) and a radius of 14 nm have been used. To facilitate the comparison, we considered here a fully-depleted single-gate SOI device having the same geometrical structure as the multiple-gate devices composing the MCFET. For this device, we have simulated the drain current transient for a LET of 10 MeV/(mg/cm2) and a radius of 50 nm. A transient duration of 13.5 ps at 10% of the peak value has been found. The values obtained for MCFET are consistent with transient duration obtained in simulation in (Ferlet-Cavrois et al., 2005), but they are very low compared with those expected by extrapolation from simulations in (Dodd et al., 2004). This is probably due to the partially depleted structures used in (Dodd et al., 2004), whereas ultra-thin fully-depleted devices are considered here.
To resume, simulation results show that MCFET devices exhibit a quick charge collection, faster than that of fully-depleted/partially-depleted SOI devices with similar structure parameters. This short pulse width in MCFET devices could be interesting for single event transient hardening (Diehl et al., 1983; Dodd et al., 2004). From all these results, we could expect that MCFET devices being less sensitive to heavy ion irradiation than fully-depleted/partially-depleted SOI devices. This is mainly due to the excellent immunity to single-event effects of GAA and to the small active volume of individual nanowire devices.
Drain current transient and collected charge induced by an ion striking in the middle of the silicon film for the ion strike location “2”. The MCFET is off-state biased (VG=0 V, VD=0.8 V). The nanowire spacing is s=100 nm, the LET value is 10 MeV/(mg/cm2), and the ion track radius is 50 nm.
Drain current transients for a vertical ion strike and four ion strike locations are shown in Fig. 8(a) for a MCFET with a lateral spacing s=100 nm and an ion track radius of 50 nm. Figure 8(a) shows that for s=100 nm the ion striking in locations “2” and “4” produces identical drain current peaks and almost identical drain current transients. These locations correspond to a strike centered in the middle of a silicon nanowire, while locations “3” and “1” correspond to a strike between nanowires, on the isolation oxides. The drain current peak obtained for locations “2” and “4” is higher than that for location “3” which is higher than that for location “1”. This is due to the higher deposited charge for locations “2” and “4” than for “3” and “1”. These results are consistent with (Alles et al., 2005). It is interesting to note that for the considered lateral spacing (s=100 nm), which is large compared to the ion track radius (50 nm), the strikes centered on any nanowire (locations “2” or “4”) produces almost the same current transient.
Drain current transients induced by an ion striking vertically (parallel to y axis) in the middle of the structure. Four strike locations are considered (“1” to “4”, as shown in Fig. 2). The MCFET is off-state biased (VG=0 V, VD=0.8 V). The lateral spacing is s=100 nm, the ion LET is 10 MeV/(mg/cm2) and the ion track radius is 50 nm.
An interesting analysis concerns the influence on the drain current transient and collected charge of the lateral spacing between the nanowire stacks. Increasing the lateral spacing between nanowires (and keeping constant the ion track radius) will not change the results compared to those obtained for s=100 nm. The interesting case is when the lateral spacing is reduced and the ion track radius is kept constant. For a thorough investigation, we simulated two additional MCFET structures having lateral spacings of s=75 nm and s=50 nm, and we compare the results with those obtained for s=100 nm. The drain current transients produced by the ion strike are plotted in Fig. 8(b) for the ion strike locations “1” to “4” and for s=50 nm. In these figures the LET value is 10 MeV/(mg/cm2).
We can see that when reducing the lateral spacing from 100 nm to 50 nm, the drain current transients produced by the strikes centered in the middle of the nanowire are no longer identical (the drain transient peak for location “4” becomes lower than for location “2”). For this small spacing between nanowires, the ion strike between the nanowires (ion strike location “3”) produces the highest current peak. These results are consistent with those of (Alles et al., 2005).
Collected charge for the drain current transients shown in Fig. 8: (a) s=100 nm and (b) s=50 nm.
The collected charges extracted as function of time from the drain current transients presented above (Fig. 8) are shown in Fig. 9. For s=100 nm (Fig. 9(a)), the collected charge is slightly higher for location “2” than that for location “4”. The strikes between nanowires give lower collected charges than the strikes on the silicon nanowires.
When the lateral spacing is reduced to s=50 nm (Fig. 9(b)), the collected charge of an ion striking at location “4” becomes higher than those for the other locations. Fig. 9(b) also shows that the collected charge for a ion striking between the silicon nanowires is enhanced when reducing the lateral spacing and becomes closer to that of strikes centered on the nanowire (“2” and “4”) for the smallest spacing s=50 nm. For a better illustration of this point, we compare in Fig. 10 the drain current transients produced by the ion striking in locations “1” and “3” between the silicon nanowires, for the three lateral spacings (50, 75 and 100 nm). The collected charges corresponding to transients of Fig. 10 are plotted in Fig. 11. Figures 12 and 13 show the drain current transients and the corresponding collected charges for locations “2” and “4” for strikes centered on the nanowire.
Drain current transients induced by an ion striking on locations between the silicon nanowire stacks: (a) location “1” and (b) location “3”. Three lateral spacings are considered s=100, 75 and 50 nm. The MCFET is off-state biased (VG=0 V, VD=0.8 V). The LET value is 10 MeV/(mg/cm2) and the ion track radius is 50 nm.
Collected charge for the drain current transients presented in Fig. 10: (a) location “1” and (b) location “3”.
Figures 10(a) and 10(b) indicate that for the locations “1” and “3” strike situated between the nanowires the drain current transients are different for the three lateral spacings. Both the current peak and the collected charge (Figs. 11(a) and 11(b)) increase when the lateral spacing decreases. Figure 12(a) shows that almost the same drain current transient is obtained for the location “2” for large spacing s=100 nm and s=75 nm. The transient peak is higher for s=50 nm than for the larger lateral spacings. For this location, the collected charge decreases when the lateral spacing is increased. For location “4” (Fig. 12(b)) the drain current transient is identical for the three locations; however the collected charge is higher for s=50 nm and is the same for s=75 nm and 100 nm.
Drain current transients induced by an ion striking on locations centered on the silicon nanowire: (a) location “2” and (b) location “4”. Three lateral spacings are considered s=100, 75 and 50 nm. The MCFET is off-state biased (VG=0 V, VD=0.8 V). The LET value is 10 MeV/(mg/cm2) and the ion track radius is 50 nm.
Collected charge for the drain current transients presented in Fig. 12.
We analyze in this section the impact of the direction of the ion strike and the influence of the ion track radius. The results presented above have been obtained for ion striking vertically (parallel to y-axis). Then, we have simulated an ion horizontally striking (parallel to the z-axis) on the gate on locations “5”, “6”, and “7” shown in Fig. 2. Locations “5” and “6” represent a strike in the middle of the silicon GAA nanowire, perpendicular to the gate, while location “7” corresponds to an ion strike on the FinFET device. All these strikes are centered on the silicon nanowire. Figure 14 shows the drain current transients obtained for the three horizontal strikes described above. In this figure, the drain current transient for a vertical strike on location “2” is also reported for comparison. The results show that the transient peaks for horizontal strikes are higher than the peak obtained for a vertical strike on location “2”. This is probably due to the higher deposited charge for a horizontal direction due to the large depth of the MCFET device in the z-direction.
Drain current transients induced by a horizontal ion strike (parallel to z-axis) in the middle of the silicon film. The drain current transient for a vertical strike on location “2” is also reported. The MCFET is off-state biased (VG=0 V, VD=0.8 V). The LET value is 10 MeV/(mg/cm2), the lateral spacing is s=100 nm and the ion track radius is 50 nm.
For the horizontal direction of the ion strike previously considered, an interesting study concerns the impact of the ion track radius. We simulated the ion strike considering two ion track radii, 50 nm and 20 nm. Figure 15(a) shows the drain current transients obtained in these cases for an ion strike in location “6”. Drain current transients obtained for ion strikes in locations “5”, “6” and “7” for a radius of 20 nm are also shown in Fig. 15(b). The current peak is higher when considering a narrow radius, because more of the charge is localized in the nanowire with the smaller characteristic radius, instead of being generated in the wire-to-wire isolation. This is confirmed in Fig. 16, where the collected charge is plotted for different horizontal strike locations. The collected charge is higher for a 20 nm radius that for a 50 nm radius for the three locations of the ion strike. For a narrow radius (=20 nm) the lowest collected charge is obtained for an ion striking on the FinFET device, while for a large radius (=50 nm) the strike on the first GAA device of the stack gives the lowest collected charge. The highest charge is obtained for an ion striking the GAA device located in the middle of the vertical stack for both ion track radii considered here.
Drain current transients induced for a horizontal ion strike (parallel to z axis) and two ion track radii. The MCFET is off-state biased (VG=0 V, VD=0.8 V). The LET value is 10 MeV/(mg/cm2) and the lateral spacing between nanowires is s=100 nm.
Collected charge for the drain current transients in Fig. 15.
This work investigated the single-event response of 3-D multi-channel nanowire MOSFETs using 3-D numerical simulation. We analyze the evolution in time after the ion strike of both the electrostatic potential and the electron density in the 9 individual devices of the MCFET matrix. We show that the drain current transients and collected charge strongly depend on the ion strike location, direction and track radius. The lateral spacing between adjacent nanowire stacks is found to be a key-parameter in the analysis of the worst case location of the ion strike. We show that for a large lateral spacing between stacks compared with the ion track radius, the strikes centered on any nanowire produces almost the same current transients. In this case the transient peak is higher than that obtained for a strike between nanowires on the isolation oxide. On the contrary, for a small lateral spacing, comparable to the ion track radius, the highest current peak is obtained for a strike between the nanowires. However, the highest collected charge is obtained for the strike on the nanowire situated on the center of the MCFET matrix. Finally, our results show that the charge collection is very fast in a MCFET for all ion strike parameters and configurations. This is due to the multiple-gate devices which have small active volumes that allow all the excess charge to be quickly evacuated. The MCFET simulated here has a total transient duration of 10 ps at 10% of the peak value for LET=10 MeV/(mg/cm2), which is almost identical to that of a individual GAA device, but lower than that obtained in simulation of fully-depleted single-gate SOI devices. From these results, we could expect a better immunity to single-event phenomena of MCFETs compared to other conventional structures, such as fully-depleted/partially-depleted SOI devices. This will probably have a consequence on the behaviour under irradiation of circuits based on these devices. However, the single device behaviour is not enough to determine the circuit sensitivity to single-events because this also depends on the load capacitance. Since the single-event transients of MCFETs are high-bandwidth, they are very sensitive to inductive and reactive capacitance (i.e., node loading) in the circuit. More detailed study concerning this point is needed to exactly quantify the sensitivity to single-event of MCFETs-based circuits.
Pheochromocytomas are rare tumors composed of chromaffin tissue that can secrete catecholamines in excess (epinephrine, norepinephrine, and dopamine) and their metabolites (metanephrine, normetanephrine, and 3-methoxytyramine). Pheochromocytomas can develop from the chromaffin cells inside the adrenal gland. Moreover, about 80–85% of these neuroendocrine tumors are localized inside the adrenal gland as pheochromocytomas and 15–20% can be extra-adrenal tumors that are named paragangliomas [1, 2, 3, 4].
The USA has a pheochromocytoma’s annual incidence of 500–1,600 cases per year with equality between genders and a peak incidence in the forth decade of life. The association with hypertension is well known; in the case of patients with hypertension, it is encountered with an incidence of 0.1–0.6% [5]. The classical mode of presentation of a pheochromocytomas case consists of headaches, diaphoresis, flushing and paroxistic hypertension [6].
The latest studies indicate a genetic cause for pheochromocytomas in about 40% of cases, from specific genetic syndromes or de novo mutation [7]. After the biochemical phenotype established, the genetic screening completed, and the imaging investigations performed, the patient has two surgery approaches: through minimally invasive surgical methods or through classical open surgery technique. The surgical method and grade of adrenalectomy can be decided depending on different factors: germline genetic test results, tumor size, body mass index, surgeon experience, and risk of malignancy [1].
The classic surgical methods approaching the adrenal pathology can be transabdominal, transthoracic and retroperitoneal. These include large incisions and extensive plans dissections to offer a reasonable control of vascular pedicles’ maneuvers treatment. Usually, this is the critical point for surgical resection due to the difficulty of reaching the vascular branches and the rule of vein first, artery second (preventing releasing the catecholamine into the bloodstream). Postoperative morbidity can be influenced by the type of surgical approach to the adrenal gland. The development of minimally invasive surgery (MIS) techniques has ensured great changes for most surgical procedures. Adrenalectomy is an excellent example of this. This type of pathology fully benefits from the advantages of laparoscopy.
The first laparoscopic adrenalectomy was performed in 1991 by Dr. Lamar Snow, and in 1992 Dr. Joseph Petelin published the first description of the operation. The first laparoscopic adrenalectomy was performed on January 17th, 1992, by a Japanese surgical team led by Go H at Niigata University School of Medicine, Japan [16]. A significant moment in the evolution of laparoscopic adrenal surgery is the publication of the lateral transperitoneal procedure by Michel Gagner in 1992. This later became the most widely used laparoscopic adrenalectomy procedure. Similar to open procedures, the video-assisted approach recognizes three variants, depending on the patient’s position and the access: first: anterior approach (transperitoneal), second: lateral approach (transperitoneal or retroperitoneal), and the third one is the posterior approach (retroperitoneal). Soon after it, the laparoscopic adrenalectomy became the second gold standard therapy (after cholecystectomy) in the field of surgery.
The accuracy of new imaging techniques for locating preoperative tumors is necessary because surgical exploration in the blind manner is unlikely to identify any unlocated tumor.
The surgical approach of pheochromocytomas can include significant variations in blood pressure values and cardiovascular events such as arrhythmias and tachycardia can appear in the perioperative patient period.
Intraoperatively, patients undergoing surgical resection can have arrhythmias, sustained hypertension or hypotension and also postoperative myocardial infarction, stroke, pulmonary edema, and prolonged intubation.
Heart failure risk can be influenced by high levels of metanephrines and normetanephrines associated with large tumor size and a longer duration of surgery due to technically difficult surgical excision [8].
Preoperative alpha-blockers ensure a significant decrease in the risk of major hypertensive crises intraoperatively. Patients with pheochromocytoma are systematically examined preoperatively by the cardiologist and anesthesiologist, and the latter will be provided at the time of surgery with all necessary material and drug support (invasive monitoring of BP, central venous catheter, sufficient doses of sodium nitroprusside, etc.) [9].
However, experienced medical specialists (surgeons and endocrinologists) agree that preoperative optimisation must include a seated blood preasure of 120–130/80 mmHg, a standing systolic blood pressure over 90 mmHg, a seated heart rate between 60–70 bpm and a heart rate 70–80 bpm in standing position. In addition, is important to encourage patients to supplement their water intake along with a high sodium diet before surgery [8, 10].
Regarding specific drugs utilized in the preoperative period, Phenoxybenzamine is a non-selective alpha receptor blocker that has been associated with better perioperative hemodynamics parameters, compared with other medication [9].
However, due to the slower onset than selective alpha-blockers such as doxazosin or prazosin it is preferably to be used for 10–14 days instead of 4–7 days. In addition, alpha adrenergic blockers side effects can consists of orthostatic hypotension with secondary tachycardia, palpitation, nasal congestion and headache. In terms of pharmacological actions, alpha adrenergic blockers control volume expansion, minimize the frequency of hypertensive peaks during surgery and control blood pressure values [11, 12].
Furthermore, calcium channel blockers represents a proper variant as a primary drug choice or as an alternative medication. In addition, they can counterbalance coronary vasospasm caused by catecholamines and may induce orthostatic hypotension less frequently than alpha blockers.
Methyrosine is a pharmacological blocking agent of the enzyme tyrosine hydroxylase that inhibits the conversion of tyrosine to dihydroxyphenylalanine, thus blocking the catecholamine synthesis pathway.
This drug can be used in patients who do not tolerate treatment with alpha blockers or is reserved for cases of hypertension refractory to the use of alpha-blockers, beta-blockers and calcium channel blockers [11].
Possible unpleasant side effects of this medication include drowsiness, neurological disorders, and intestinal transit disorders.
In addition, the main medical management approaches are: the expansion of intravascular volume with a saline solution together with the control of hypertension or other cardiovascular events, the correction of metabolic and electrolyte imbalance and the treatment of possible anemia.
Beta-adrenergic receptor blockade with propranolol is used in the treatment of catecholamine induced tachycardia after at least three to four days of alpha blockade administration; beta blockers usage is contraindicated until the alpha-adrenergic receptor blockade is done, in order to prevent severe hypertensive crisis caused by unopposed alpha vasoconstriction [12].
Appropriate and smooth venous access and arterial catheters for continuous blood pressure monitoring must be placed before surgery. Communication between the anesthesiologist and surgeon is essential to ensure safe results. Ideally, the anesthesia team should be prepared to use intravenous vasoactive drugs to manage hemodynamic variations and has to remain vigilant throughout the entire medical-surgical procedure [13].
More than that, the timing of surgical dissection should be coordinated with the anesthesiologist’s maneuvers even from the time of pneumoperitoneum inflation – new recordings of blood pressure (BP) of the patient should be registered every minute, according to the gas amount already introduced (until the value of 12 mmHg); if the BP is too high, a lower intraperitoneal pressure should be taken into consideration during the all-time of the procedure. Another example of surgeon-anesthesiologist cooperation can be the proper time of dissection around the gland – touching the gland (with catecholamine release and rapid increase of BP). The surgeon requires rapid measures from the anesthesiologist to control the cardiac output and possible arrhythmias [14, 15, 16].
Surgery is the curative therapy for either benign or malignant pheochromocytoma. Morbidity in adrenalectomy operations is about 40% and can be associated with cardiac events such as arrhythmia, myocardial dysfunction, pulmonary embolism and sepsis. Mortality for adrenalectomy has improved in the last decade, with an under 2% rate of death.
Firstly, the main critical point in adrenalectomy in pheochromocytoma is the minimal manipulation of the tumor to avoid seeding the tumor in adjacent tissues and in order to prevent a hypertensive crisis during the operation (it is said that adrenalectomy should be performed by dissecting away the body from the gland, not the gland from the body). Secondly, another crucial step during the surgical procedure is the control of vascular supply together with the complete tumor resection. All of these can be provided by adequate surgical exposure in order to prevent other organs injuries.
Minimally invasive techniques can be done laparoscopically or robotically. The aim of minimally invasive procedures and open surgical approach is the minimal manipulation of the tumor, in order to prevent catecholamine release as mentioned above; if this is not respected, it can result in hemodynamic instability and tumor rupture.
Also, to diminish the risk of releasing large amounts of hormones, it is indicated to early ligature the adrenal vein. This step can be performed through the transabdominal or posterior surgical approaches.
Furthermore, the surgical approach is dependent on surgeon choise, experience and familiarity with the specific techniques. However, some factors may influence the decision of surgical approach: body mass index, tumor size and location, and patient’s personal pathological history of abdominal or retroperitoneal surgical procedures [14].
Our paper will focus mainly on the minimally invasive laparoscopic approach, being the surgical procedure of choice for adrenal tumors, due to its advantages of surgical technique.
The laparoscopic approach includes normal anatomy and easy conversion to open surgery if necessary for exceptional cases [15].
Although the retroperitoneal approach can directly access the adrenal gland and would require less effort to dissect and mobilize nearby visceral organs, this technique is not easy for general surgeons due to lack of familiarity with it. In addition, the contraindications for the retroperitoneal surgical approach include tumors bigger than seven to eight cm due to the narrow working space and an increased body mass index with increased retroperitoneal fat. Simultaneously, a tumor lying around the inferior vena cava (on the right side) or close to the aorta (on the left side) can lead to a complex surgical resection by retroperitoneal access [13.]
Retrospective studies from literature have shown that robotic and laparoscopic resection of pheochromocytomas are equivalent in terms of operative time, blood loss volumes, intraoperative hemodynamic events, rates of morbidity and mortality, and rates of conversion from minimally invasive approach to open surgery technique [9].
Furthermore, the main advantages of robotic adrenalectomy include: the three dimensional acces, improved wrist mobilization for the surgeon, and a stable camera port. Disadvantages of robotic adrenal surgery include increased cost, insufficient learning curve and lack of tactile feedback.
When invasive malignant pheochromocytoma is suspected or concerned clinically, open approach is the first choice. Open treatment may benefit from a greater risk of tumor rupture, which may lead to pheochromocytoma disease. For patients with confirmed SDHB mutations, that are associated with a higher metastatic disease rate, the open approach is prefered [16].
For patients with pheochromocytoma associated with different syndromes, minimally invasive or open surgical methods can also be used for cortical sparing (partial) adrenalectomies. Patients with multiple endocrine tumor 2 (MEN2) or von Hippel–Lindau disease (VHL) syndrome can benefit from cortical-preserving adrenalectomy in order to preserve and to maximize the adrenal function and to avoid chronic glucocorticoids replacement. Furthermore, cortical sparing technique can reduce the risk of Addisonian disease [17].
The operating table must benefit from adequate mobility in order to allow an adequate angulation in order to optimally open the anatomical space from the costal rim to the iliac crest. The operating surgeon and the cameraman are positioned in front of the patient and the assistant on the opposite side. The patient can be placed on the operating table in a lateral decubitus with a 90-degree angle position to ensure the full retraction of the spleen and a partial retraction of the liver by the gravity force.
At the time of pneumoperitoneum installation, the patient is already lying on his side. The Veress needle will be inserted through the abdominal flank, being warned of the risk of visceral (liver or colon on the right side) or vascular (epigastric pedicle branches) injuries. Classic, there are three subcostal ports that can be positioned on the left and one epigastric port that is localized at the inferior margin of the liver. It is not unusual for the first trocar (corresponding to the left mid-clavicular line) to be inserted just a little bit slower than the other three subcostal trocars in order to offer a comprehensive view of the operative field and to identify the entire trajectory of the left colonic flexure (to facilitate the dissection of the colonic ligament for a lower positioning of the colon and to offer a better view over the left adrenal lodge).
For the left adrenalectomy, the spleen can be mobilized till the gastric fundus appears in the visual field, this can allow the spleen to retract more medially. This maneuvers can develop the plane between the spleen and the pancreas’ tail, up to the left adrenal gland. The first maneuver is the incision made at the later splenic peritoneum. Further dissection is performed in a relatively avascular plane that is located close to the retropancreatic and anterior to the adrenal and renal capsule. Through this conjunctive structure’s transparency, the adrenal tissue specific aspect is easily distinguished as having a specific yellowish color.
Sometimes, it is mandatory to cut the conjunctive tissue between the left colonic flexure (at its highest point) to the abdominal wall and to re-positioning the colon down below the level of the inferior pole of the spleen. After that, a broad view of this area is noticed. More than that, an easy discovery of the kidney superior left pole is possible, and this should be the start to identify (especially on obese patients) the groove between the left kidney and the pancreas – the normal localization of the left adrenal gland. For a pheochromocytoma dissection, the surgical gestures should be delicate, precise, and firm – a proper instrument of dissection should be used (sealing-cutting device, ultrasound device – electrocautery hook is to be avoided by the beginners and is a time-consuming device for an experienced surgeon).
The essential vascular anatomical elements that will be treated in left adrenalectomy are the central vascular pedicle and the upper vascular pedicle. The left central vein (LCV) goes into the left renal vein, most commonly into the common trunk with the lower-left diaphragmatic vein (LLDV), from which it should be disected before injuring or clipping. The sectioning of this common trunk interpreted as LCV will result in the cranial interception of LLDV; a vascular element misinterpreted as an accessory left central vein. The LCV must be double-clipped to the renal vein, for security reasons, and then sectioned with sharp surgical instrument – the latest surgical devices (like a sealing-cutting instrument with a computerized chip for measuring the impedance and secure the ligation) can be safely used with no clips (depending on surgeon’s experience). The left middle adrenal artery comes from the aorta and will be highlighted later. It can be treated by titanium clip or bipolar electrosurgery. By following the upper margin of the adrenal gland, the upper adrenal pedicle branches will be highlighted and treated using an electrocoagulation procedure.
The complete disection of the entire adrenal gland is done by posterior dissection, in a very loose anatomical space, after witch is then separated from the upper renal pole and the muscular abdominal wall (up to the left quadratus lumborum muscle). The final steps of left laparoscopic adrenalectomy are made by the hemostasis, surgery gland extraction and local drainage.
Thoroughly attention should be given to the dissection of the superior part of the adrenal gland near the pancreas’ inferior edge because important vessels are lying over there – including end-parts of the splenic vein and the veins’ and arteries’ network around the pancreatic tail. Finally, pancreatic parenchyma should be carefully avoided to be damaged during dissection to skip a postoperative pancreatic leakage.
For laparoscopic right adrenalectomy, four working trocars (3 of 10 mm and one of 5 mm) are required, arranged on a line parallel to the costal margin, developed between the sub-xiphoid region and the right anatomical flank (below the tip of the right tenth rib). Near the right kidney’s upper pole covered by the right hepatic lobe can be found the the right adrenal gland, lying on the diaphragm, in close contact with the IVC. The right triangular ligament is disected, and the right liver lobe is then retracted with the instrument through the epigastric trocar. Displacemant of the right hepatic lobe depends a lot on obtaining a good and comfortable access in the adrenal gland’s dissection space. The lifting of the hepatic love is performed by an atraumatic instument, of “snake” type or with atraumatic blades, inserted in the sub-xiphoid trocar. In the particular situation of a highly developed right hepatic lobe, additional maneuvers or additional tools are required to obtain a suitable elevation. A slightly reverse-Trendelenburg position also obtains a better position of the patient on the operating table. These exposure gestures are critical to prevent the application of excessive forces intended to widen the operating field. These traumatic maneuvers can lead to damage to the Glisson capsule and tears of the liver parenchyma. Consecutive bleeding significantly alters the dissection conditions, reducing the surgeon’s ability to distinguish the specific appearance of the gland. The crimson-yellow specific gland color is easy to recognise under proper conditions of dissection. The anterior plane of the gland can be exposed by performing a blunt dissection or with the electrocautery. This can be performed in an extracapsular plane, anatomical space occupied by many loose and avascular lax fibrous tissue. The disection plane found between IVC and the right adrenal gland can be exposed. This will be the starting point of the surgical excision of a pheochromocytoma – the surgeon should prioritize the “attack” of the central vein expecially for the right adrenal gland. The arterial sources that approach the gland are anastomosing each other in the next presented way: first the central artery that arises from the aorta, second, the superior arterial pedicle that arises from the right inferior diaphragmatic artery and not the last, the inferior arterial pedicle from the right renal artery. Venous blood can be collected by the homonymous satellite veins, represented by the central vein that is collected directly into the IVC that should be well identified before any maneuver on the adrenal vessels. Any bloody source can be solved by IVC partial clamping only if it is exposed and have a good control. It is mandatory for a safe treatment of the vascular pedicles and for the achievement of complete glandular removal to have a complete exposure of the entire medial and superior margin of the gland [4, 5].
The central vein can be clipped twice at the inferior vena cava margin and with a single clip to the margin of the gland. In approximately 20% of patients, there can be found a central accessory vein, sometimes this is the cause of difficult to control hemorrhage. Due to the lateral decubitus position, after dissecting the central vein, the IVC is mobilized to the medial, and the retro-IVC extension of the gland can be much easily dissected. The central artery can be dissected and sectioned by the branches with electrocautery. Modern means of electrosurgery (sealing-cutting devices or ultrasonic scalpel) offers additional operating comfort and efficiency, but the need to continuously follow the correct anatomical plans must be emphasized.
A complete mobilization of the gland is achieved by posterior dissection, to or from the side, in a loose fibrous anatomical space which is interposed between the renal upper pole and diaphragm until the aspect of the right quadratus lumborum muscle appears in the operating field. It is mandatory not to touch the adrenal tissue, especially the pheochromocytoma tumor, to avoid spillage the tumor cells in the peritoneal cavity. The piece will be placed in a bag and is extracted by widening one of the access wall brackets (usually the one on the right anterior axillary line). After a thorough control of the hemostasis, a drainage tube beneath the right hepatic lobe is placed for 24–48 hours [4].
For situations in which bilateral excision is required in the same operating session, the patient’s position will be changed after removing one of the glands, the entire device is reset to perform the contralateral adrenalectomy.
Although this direction is time-consuming, involves the anesthetic-surgical team’s synchronized effort, determines an increased consumption of materials by reorganizing the operating field, the benefit offered by the advantages of the transperitoneal lateral approach is entirely found in operating comfort [6, 7].
For cortical sparing/preservation technique, once the supraadrenal glands are exposed by the mobilization and dissection of the triangular hepatic ligament on the right side and the spleen on the left side, a mass can be seen in the retroperitoneum. Using the best imaging by ultrasound technique to identify the necessary anatomy, surgeons should try to preserve the adrenal veins to allow proper function of the adrenal remnants. It is recomanded to perform an ultrasound examination to assess relationship between the tumor and the adrenal veins and determin whether there are more nodules in patients with genetic predisposition. If there is only one nodule, a harmonic scalpel can be used to remove the nodule. Since the blood vessels of the adrenal gland are highly vigorous, harmonic activation is performed while the jaws are opened, and the adrenal tissue is slowly compressed to provide excellent hemostasis [4].
Do not use any device to grab the nodule or adrenal gland in any position. Grasping the nodule or the adrenal glands with any device may cause a rupture that lead to pheochromocytomatosis. Grasping a portion of adipose tissue located near the adrenal glands or attached to it, or using gentle retraction will give enucleation appropriate exposure. After the nodule is removed, the remaining adrenal glands should be checked for hemostasis. For multiple nodules suitable for removal, the surgeon should consider proceed as before. However, if there are multiple nodules and the restant gland is less than 30% of the total gland, the surgeon should consider total adrenalectomy. The remaining glands may lose function, and the patient may benefit from total adrenalectomy to avoid the need for reoperation of relapse. After the tumor is removed, put the specimen in the bag and take it out [4, 5, 6, 7].
Laparoscopic adrenalectomy has been found to reduce the need for hospitalization, blood transfusion, postoperative analgesia and recovery. Laparoscopic adrenalectomy is more difficult to perform on the right side because of the exposure problems, the proximity of the gland to the IVC and the short right adrenal vein. Although there are more and more reports of laparoscopic resection of pheochromocytoma, but it should not be considered for malignant pheochromocytomas or tumors greater than 8 cm [2].
Place the patient in a jack-knife position and place a 1.5–2 cm transverse incision under the terlfth rib to access the retroperitoneum space. Digital palpation can be used to develop and disecting spaces. Guided by the surgeon’s index finger, place another trocar along the lateral border of the paraspinous muscle. Similarly, place a side needle under the eleventh rib. Insert another 12 mm blunt balloon trocar into the first incision. When pneumoperitoneum is established, carbon dioxide needs to be injected and kept at 20–24 mmHg. The working space of superior border of the kidney is developed by dissecting the retroperitoneal areolar tissue and Gerota’s fascia. After identifying the adrenal veins, dissect the upper adrenal glands laterally and inferiorly, and finally dissect the upper and mid-medial glands. Identify, dissect and remove the adrenal veins between the clamps. The adrenal gland is firstly dissected laterally and inferiorly and secondly the superior and medial adesions are dissected with the evidentiation of the adrenal vein. The adrenal vein is identified, dissected, and resected between clips. The next step is the dissection of the upper attachment, and then put the specimen into the Endo bag device and removed it from the abdomen [2].
Multiple incisions can be used to exposure the anatomy, including subcostal, midline, and the Makuuchi incision. The aim is to use subcostal incision two to three cm below the costal margin. This incision provides excellent liver and adrenal bed exposure. If a lymph node dissection is planned, the subcostal incision will provide the space betwen aorta and inferior vena cava and between the lymph nodes around the hilum. As with the laparoscopic technique, the triangular ligament on the right is also cut, and the spleen on the left is moved into the retroperitoneal cavity. Very important anatomical landmarks such as inferior vena cava, must be marked on the right, and the tail of the pancreas and the loose plane between the tail and the left adrenal gland on the left must be visualized. For boths sides, the adrenal veins must be identified and cut. Split all remaining attachments and remove the gland. The open transabdominal or thoracoabdominal approaches give the best exposure for resecting extensive tumors, for bilateral adrenalectomy or for metastatic disease [3].
Following surgical approach of pheochromocytoma, 80% of patients are suspected to be again normotensive. Persistent postoperative hypertension can be caused by the residual tumor, intraoperative injury to the kidney’s renal artery or metastatic disease.
Intraoperative hypotension may be caused by (1) hemorrhage during surgery (2) insufficient hormone replacement after left and right adrenal excision (3) vascular compliance changes and immediate reduction of catecholamine levels after tumor removal, (4) myocardial infarction (5) long-term residual effects of prolonged α-blockers before surgery. As shown, hypotension can be effectively controlled by replacing volume and blood transfusion. Use vasopressors only when hypotension fails to respond to sufficient volume replacement [16].
Postoperatively, the majority of patients that had an uneventful intraoperative course with or without hemodynamic instability do not necessitate intensive care supervision. In the first postoperative period, the patients that have pheochromocytoma have also a greater risk of hypoglycemia and hypotension [5]. After catecholamines are suddenly stopped, due to the relative increase in insulin sensitivity, hypoglecemia may occur. Therefore, blood glucose must be supervised every hour for the first three or four hours postoerative. When a total adrenalectomy is planned, glucocorticoid preparations can be taken before surgery, specifically for the patients that have bilateral tumors or a familial pheochromocytoma syndrome. After surgery,incidence of hypoglycemia droped from 15% to 4.2%. Independent predictors related to postoperative hypoglycemia include prolonged operation time and increased urine adrenaline in 24-hour period before surgery. Therefore, glicemia must be checked regularly in the first day after surgery. Isolated episodes of hypotension are very common and can be attribueted to the preoperative alpha blockade residual values, hypovolemia that can be due to intraoperative blood loss or/and preoperative volume contract,. Treatment must be aggressive in terms of IV perfusions and vasopressors [3].
The rate of morbidity in untreated pheochromocytoma is very high and difficult to determin. 71% of patients can die from cardiovascular causes: myocardial infarction, hypertensive heart insuiciency, or hemodynamic instability occurring during different procedures [18].
Postoperative good outcomes for cortical-sparing adrenalectomy is focused on preventing a steroid dependency. The benefit of not having a steroid necesity must be compared to the risk of recurrence in time. The necessity of extensive adrenalectomy depends on the genetic or familial predisposition. The patients that have familial syndromes such as MEN 2B, VHL or/and MEN 2A are the ideal candidates for cortical sparing adrenalectomies. Patients with MEN 2A or 2B syndroms who suffered cortical sparing adrenalectomy have a recurrence risk about 51.8% at ten years. The steroid dependency rate of patients who underwent unilateral or/and bilateral cortical sparing technique was 43%. Cortical sparing adrenalectomy is the elective method for patients with VHL syndrome [19].
Patients with different type of pheochromocytomas should have a whole life follow-up program to avoid possible recurrence or the development of metastatic disease, which can occur up to 40 years after resectioning the tumor [17].
As we all know, about 10% of adrenal pheochromocytomas tumors are malignant, and about 30% of any extra-adrenal tumors are are more commonly malignant. Malignant pheochromocytoma is less frequent in children than in elderly and is mainly at extra-adrenal glands. Pheochromocytomas that are associated with some familial syndromes usually have an early diagnoses and are less malignant than the sporadic forms. The histological criteria that are used to distinguish benign and malignant forms of the tumors are not very accurate, as it happens in others endocrine or glandular tumors. Malignant tumors depend on the clinical tumoral manifestations and are accurantly diagnosed when there is infiltration of adjacent organs, distant metastasis or recurrence. The most common metastasis occur in bones, local LN, peritoneum, lungs and liver. Malignant tumors are commonly much bigger, with a higher frequency of vascular and capsule infiltration. They are usually characterized by DNA tetraploidy or aneuploidy, increased mitosis, angiogenesis, higher serum levels of neuropeptide Y, tumor necrosis, c-myc expression and higher neuron-specific enolase levels. Most malignant pheochromocytomas show increased uptake of metaiodo-benzylguanidine (MIBG). The survival rate at 5 years, for malignant pheochromocytomas is about 44%. In cases of extra-adrenal localization of pheochromocytomas the prognosis is worse than in adrenal tumors. Patients that have associated pulmonary metastasis have a much worse prognosis [18].
There are very common undiagnosed pheochromocytomas during pregnancy, and their maternal and infant mortality rates are very high, up to 58% and 56%. If the diagnosis is madein time, during the pregnancy period, the mortality and morbidity rate can reach below 11%. When the diagnosis is made at the time of delivery, the maternal mortality rate is still high, about 40%. In case of pregnant women the diagnosis of pheochromocytoma can be suspected in case of severe forms of hypertension in the first two months of pregnancy. If hypertension is not controlled in the second trimester, or is related to orthostatic hypotension, or if unexplainable shock occurs suddenly befor delivery, the diagnosis should be focused. The diagnosis as been confirmed by biochemical testing. MRI is the preferred local imaging tehnique to avoid radiation risk. In these cases, the freguently used irritation test is contraindicated, but in some specific cases, the clonidine inhibition test can be used. If the diagnosis is made in first trimester of pregnancy, it is recommended to remove the tumor after proper control of hypertension. In the last trimester of pregnancy, it is recommended to combine pregnancy with selective cesarean C-section intervention and immediate tumor removal under the same anesthesia through medical management. Due to the increased risk of fetal complication and hypertension, spontaneous and vaginal natural delivery methods should be avoided [19].
The surgical methods for pheochromocytomas approach must have in priority list the assesment of the best imaging, the identifying any germline genetic mutations, and of course the utilization of any minimally invasive techniques when feasible and indicated. Biochemical diagnosis and precise tumor localization are necessary.
The minimally invasive technique of the abdominal or retroperitoneal approach is the standard surgical method. For large tumors with risk of rupture and potential malignancy, open surgery is recomanded. The results after surgical resection have a real potential to reduce the incidence of cardiovascular disease. Complete surgical resection is the ultimate treatment for benign and malignant pheochromocytoma that have low morbidity and mortality rates.
Special cases of malignant pheochromocytoma or this pathology’s occurrence in pregnancy must be suppervised and treated with the utmost care. There are not any very accurate of uniform histological criteria so far, to distinguish malignancy in these cases, which depends on the tumor’s clinical behavior.
The authors declare no conflict of interest.
.
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