Abstract
Complete clipping is sometimes difficult in cases with large internal carotid artery (IC) aneurysms adjacent to the distal dural ring even if various approaches are applied. To ensure safe and sure aneurysmal microsurgery, we have been using endoscopes with various angled tips, thus helping to observe the aneurysmal neck and branches from the IC in the blind spot by a surgical microscope. We used endoscopes in the surgery of 12 cases with IC aneurysms adjacent to the distal dural ring out of 85 surgical cases experienced in our institute three recent years.Eleven had unrupted aneurysms, including 1 case with a giant aneurysm and 1 with a ruptured giant IC aneuysm. Because preoperative angiogram, 3-d MRI and 3-d CT suggested difficulties in clipping, thus we prepared an endoscope system. All patients but two underwent surgery with the Dolenc Approach. After endoscopic as well as microscopic detail observation and preparation, a clip was applied with the aid of cerebral blood flow monitoring and Doppler sonography. We used an endoscope after the clip was applied to confirm if branches from the IC artery were preserved and the clip obliterated the aneurysmal neck completely. It was difficult to monitor every checkpoint simultaneously while applying a clip with an endoscope only during aneurysmal surgery. There was not adequate room for inserting an endoscope whose caliber was 4 mm or larger. The rigid endoscope with 1.9 mm caliber was useful and safe for use in the operative field but the monitor image was not large enough.Based on these results, we believe that a small caliber rigid endoscope is useful in observing blind corners of a surgical microscope and confirming safe and complete aneurysmal clipping, especially for the posterior projecting IC aneurysms adjacent to the distal dural ring, which are tough to prepare the aneurysmal neck for complete clipping. Improvement of the endoscope image, superimpose system with microscopic image and a safe but convenient fixation of the endoscope system will be needed.
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