Endoscopic Assistance Research Articles

Laparoscopic excision of symptomatic prostatic utricle following proximal hypospadias repair

Prostatic utricle results from incomplete regression of the Müllerian duct remnant and is closely associated with diseases such as proximal hypospadias. Surgical treatment is indicated for the symptomatic cyst. Laparoscopic excision is a modern and widely used approach. We report a 9-year-old boy with prostatic utricle who underwent proximal hypospadias repair four times in the preschool years. He was hospitalized for recurrent right epididymo-orchitis and his psychological anxiety. The patient was successfully and safely removed from the prostatic utricle by laparoscopy assistance of endoscopy . We suggest that periodic ultrasonography for pre- and post-operative severe hypospadias. Laparoscopic surgery should be the first approach because of its efficacy and safety.

Endoscopic and Endoscopically-Assisted Resection of Intraventricular Lesions Using a Neuroendoscopic Ultrasonic Aspirator.

The development of minimally invasive neuroendoscopy has advanced in recent years. The introduction of the neuroendoscopic ultrasonic aspirator (NUA) broadened the treatment spectrum of neuroendoscopy. We aim to describe our experience with the use of NUA for the resection of intraventricular lesions. Here, we present consecutive retrospective case series of adult and pediatric patients undergoing resection of an intraventricular lesion with a NUA (Endoscopic Neurosurgical Pen, Söring GmbH, Quickborn, Germany) between January 2019 and April 2020. Eight patients between the age of 0.5 and 73 years underwent surgery using NUA and were included in this study. In four patients, an endoscopic assisted (EA) resection of the lesion was undertaken, while in four patients, the lesion was removed using purely endoscopic (PE) resection. In all cases, gross/near total resection was achieved. The average blood loss was 142.5 ± 90.4 mL (range 50–300 mL). Transient morbidity was seen in four patients (50%), while permanent morbidity or mortality did not occur. The NUA seems to be a safe and valuable tool for the minimally invasive resection of intraventricular lesions in selected cases. The type, size, consistency, and vascularization of the lesion limit at times the purely endoscopic use of the NUA.

Analysis of clinical effect of nasal endoscope-assisted nasal columella approach for simultaneous correction of nasal septum deviation and crooked nose deformity

Objective:To analyze the clinical effect of nasal endoscope-assisted nasal columella approach in the correction of nasal septum deviation and crooked nose deformity. Methods:The clinical data of 33 patients with deviation of nasal septum with crooked nose deformity in First Affiliate Hospital of Air Force Military Medical University from January 2016 to June 2019 were collected. All patients underwent surgery under general anesthesia. Nasal columella inverted "V" incision was used to expose and release. The deviated nasal septum cartilage and bone were removed with the assistance of nasal endoscope. Twelve（36.4%） patients underwent osteotomy of nasal bone and frontal process of maxilla at the same time, 13（39.4%） patients used autologous nasal septum to reshape the tip, back and external nose. Results:During a follow-up of 18 months to 60 months, 30（90.9%） patients were satisfied with the improvement of postoperative nasal function, 3（9.1%） patients were basically satisfied; 23（69.7%） patients were satisfied with the appearance of the nose after operation, 8（24.2%） patients were basically satisfied, and 2（6.1%） patients were dissatisfied. No postoperative complications such as nasal adhesion, nasal septum perforation, nasal septum hematoma and nasal dorsal collapse occurred in all patients. Conclusion:The nasal endoscope-assisted nasal columella approach and the correction of nasal septum deviation and crooked nose deformity can solve the nasal deformity and nasal ventilation function at the same time, realize the unity of cosmetology and function, and reduce the frequency and cost of surgical treatment at the same time. The effect is good, and the patients benefit greatly.

Outcomes of the Nonendoscopic Transoral Approach to Subcondylar Mandible Fractures

The transoral approach (TRA) to subcondylar fractures without any endoscopic or transbuccal assistance is not a common technique. The purpose of this study was to measure and compare the quality of open reduction and internal fixation (ORIF) between the TRA and the retromandibular approach (RMB), including types and frequencies of postoperative complications. In our retrospective cohort study, we enrolled a sample of patients with displaced subcondylar mandible fractures treated by ORIF. The predictor was the approach mode: TRA or RMB. In postoperative computed tomography (CT) data sets, we measured the angles of the condylar process in relation to references: 1) midline, 2) lateral ramus border, and 3) posterior ramus border. The primary outcome variable was the reduction outcome, which was calculated as the difference between the total of all angles of the operated side and the non-affected side. Secondary outcomes were postoperative complications extracted from patients' files. Other variables were age, gender, number of plates, operation time and a modified AO trauma score. In bivariate analysis, we compared the outcome between both groups. Sixty-four patients were included in total, with TRA performed in 50%. Patients with TRA were younger (31 vs 41, P=.003), and the trauma score was lower (1.9 vs 3.3, P < .001). Reduction outcome remained comparable between both techniques (mean 3.7° for both, P=.92). Complication rates were similar, although facial nerve palsy was absent for TRA (0 vs 4, P=.039). We suggest TRA for selected patients with displaced, single fragmented subcondylar fractures. Reduction outcome shows a comparable exactness to RMB, while TRA is safer for the facial nerve.

Petrous bone cholesteatoma: our experience of 20years and management of two giant cases affecting rhinopharynx.

To demonstrate our experience in the treatment of petrous bone cholesteatoma (PBC). Data of PBC patients in our hospital from January 2000 to December 2019 were collected. Surgical approaches and facial function were mainly discussed and compared with the literature. The management of 2 giant PBC cases affecting rhinopharynx has been demonstrated. The supralabyrinthine type was the most frequent type followed by the massive type. There were 5 cases with cholesteatoma extending into the clivus (2 cases), sphenoid (1 case) and rhinopharynx (2 cases). The translabyrinthine approach (40%) was our most frequently used approach followed by the middle fossa approach (36%) and the transmastoid approach (11%). There were 10 cases managed with the assistance of endoscope, including 3 cases with cholesteatoma extending into clivus, sphenoid and rhinopharynx separately. Obliteration of the cavity was performed in 70.3% (135/192) cases; 3 of them recurred. For the 2 giant PBC cases affecting rhinopharynx, traditional microscopic surgery assisted with transnasal endoscope was performed. The reduced exposure was beneficial for postoperative recovery, and the approach in the nasal cavity provided a permanent drainage for postoperative examination. Otologic endoscope combined with traditional microscopic surgery could reduce the exposure in surgery. For extremely extended cases of PBC, supplementary transnasal endoscopic approach deserves to be considered for the traditional temporal bone approach.

Microscopic resection of a giant epidermoid tumor of the pineal region via supracerebellar infra and transtentorial approach with endoscope assistance.

The authors present a case of a 22-year-old male who developed hydrocephalus symptoms related to a giant epidermoid tumor at the pineal region. The surgical approach and technique for a large epidermoid tumor in this area are extensively discussed. A paramedian contralateral supracerebellar infratentorial and transtentorial approach was performed, with the patient in a semisitting position. The tumor was removed using a microscopic technique, and endoscope assistance was used in order to reach the areas unable to be visualized under the microscope. The patient was neurologically intact at his 2-year follow-up, and postoperative MRI showed a significant decrease in the tumoral volume.The video can be found here: https://stream.cadmore.media/r10.3171/2021.4.FOCVID2128.

Low Risk of COVID-19 Infection in an Ambulatory Gastrointestinal Endoscopy Center in Argentina

Background and Objectives. Since the onset of the COVID-19 pandemic, concerns have been raised regarding the risk of infection to both healthcare staff and patients during gastrointestinal endoscopy procedures. Given the importance of performing routine endoscopic procedures to an individual’s future health, we sought to estimate the risk of COVID-19 infection for healthcare staff and patients undergoing endoscopic studies at an ambulatory endoscopy center during the pandemic. Material and Methods. This is a prospective(and) analytical cohort study conducted in an ambulatory gastroenterology center located in the Autonomous City of Buenos Aires, Argentina. Patients undergoing different endoscopic procedures were evaluated for COVID-19 between April 14 and August 31, 2020. COVID-19 was also evaluated in all healthcare and associated staff during the same time period. The risk (cumulative incidence) of acquiring COVID-19 in all patients and staff was calculated. Results. Between April 14 and August 31, 2020, procedures were performed in 3,745 patients with a mean age of 51.12 years; 2,102 (56.18%) were male and 1,643 (43.82%) were female. Follow-up was completed in 3,492 patients, 18 of whom tested positive for COVID-19 standing for an incidence of 0.52% (95%CI 0.31 – 0.81%). Six (5.45%) out of 110 staff members were infected with COVID-19 (1 endoscopist, 4 endoscopy assistants and 1 administrative staff member). In this group, the incidence of positive tests for COVID-19 was 5.45% (95%CI: 2.03 – 11.50%). The increased rates of positive cases among our patients and healthcare professionals were respectively 7.9 and 23.6 times lower than in general population. Conclusion. During the study period, the proportion of COVID-19 infections in our ambulatory specialized in gastrointestinal endoscopy was low and much lower than that in the general population for both patients and healthcare professionals. Endoscopic procedures undertaken at this center were low risk, likely due to strict compliance with established pandemic protocols. Future studies should compare the risk of infection in the hospital setting.

Endoscope and image-guided ventral bulla osteotomy in the dog: A cadaveric and patient study.

Surgery of the bulla in the dog can be difficult and associated with suboptimal resolution of disease and risk of complications, particularly in treatment of cholesteatoma. We explored use of image guidance and endoscopic assistance in ventral bulla osteotomy (VBO), initially with cadaveric studies and subsequently on dogs with cholesteatoma. For surgical approach we used cone beam CT with an optical image navigation system. For endoscopic surgery we used 4 mm and 2.7 mm diameter endoscopes and a camera viewing system, with micro-instruments for dissection. Image guidance allowed us to accurately identify and approach the bulla in cadavers (n = 2) and patients (n = 2). The endoscope enabled us to define detailed endoscopic anatomy in cadaveric canine heads (n = 15), and in patients (n = 5) it enabled reliable and safe removal of pathological tissue. Image and endoscopic assistance could be a significant advance to the reliability and safety of VBO. Our techniques may be applicable to other indications and species.

Endoscopic-Assisted Resection of Anterior Foramen Magnum Meningiomas through a Midline Suboccipital Subtonsillar Approach.

Objective This study was aimed to demonstrate the resection of anterior foramen magnum meningiomas through an endoscopic-assisted posterior midline suboccipital subtonsillar approach. Design This study was designed with illustration of the surgical steps and safety of this approach. Setting Evidence of cerebrospinal fluid (CSF) cleft between the tumor and brainstem on MRI was studied ( Fig. 1A and B ). Preoperative tracheotomy was considered in cases of preoperative dysphagia to prevent any further neurological deterioration due to the bilateral access through the lower cranial nerves corridors. Semisitting position with extensive electrophysiological neuromonitoring and transesophageal echocardiogram was adopted. A standard midline incision with bilateral suboccipital craniotomy and C1-laminotomy was performed ( Fig. 2A ). After partial resection and elevation of the tonsils, tumor was debulked unilaterally around the lower cranial nerves and the vertebral artery, devascularized from the clival dura and then dissected from the brainstem ( Fig. 2B, C ). Endoscopic-assisted removal of its anterior portion followed. The same procedure was repeated from the opposite site for the contralateral portion, before approaching the purely anterior part with endoscope assistance ( Fig. 2D ). Participants Four consecutive patients were included in the study. Main Outcome Measures Grade of tumor resection and outcome (mRS) were primary measurement of this study. Results Clinical outcome and grade of resection are comparable to other series of patient treated with other foramen magnum approaches ( Fig. 1C and D ). Conclusion Anterior foramen magnum meningiomas can be safely removed through this relatively faster midline suboccipital approach with bilateral exposure of lower cranial nerves (CNs) and vertebral arteries and lower approach-related morbidity (no condyle drilling). The surgical corridor is created by the tumor during debulking reducing need for brain retraction and the removal of the anterior dural attachment coagulated under the microscope is verified and completed endoscopically with pituitary curettes (Simpson's grade II) ( Fig. 1C and D ). The link to the video can be found at: https://youtu.be/9eACAJVwQBs .

Transcavernous Resection of a Giant Extensive Chondrosarcoma with Endoscopic Assistance.

Chondrosarcomas are one of the major malignant neoplasms which occur at the skull base. These tumors are locally invasive. Gross total resection of chondrosarcomas is associated with longer progression-free survival rates. The patient is a 55-year-old man with a history of dysphagia, left eye dryness, hearing loss, and left-sided facial pain. Magnetic resonance imaging (MRI) showed a giant heterogeneously enhancing left-sided skull base mass within the cavernous sinus and the petrous apex with extension into the sphenoid bone, clivus, and the cerebellopontine angle, with associated displacement of the brainstem ( Fig. 1 ). An endoscopic endonasal biopsy revealed a grade-II chondrosarcoma. The patient was then referred for surgical resection. Computed tomography (CT) scan and CT angiogram of the head and neck showed a left-sided skull base mass, partial destruction of the petrous apex, and complete or near-complete occlusion of the left internal carotid artery. Digital subtraction angiography confirmed complete occlusion of the left internal carotid artery with cortical, vertebrobasilar, and leptomeningeal collateral development. The decision was made to proceed with a left-sided transcavernous approach with possible petrous apex drilling. During surgery, minimal petrous apex drilling was necessary due to autopetrosectomy by the tumor. Endoscopy was used to assist achieving gross total resection ( Fig. 2 ). Surgery and postoperative course were uneventful. MRI confirmed gross total resection of the tumor. The histopathology was a grade-II chondrosarcoma. The patient received proton therapy and continues to do well without recurrence at 4-year follow-up. This video demonstrates steps of the combined microsurgical skull base approaches for resection of these challenging tumors. The link to the video can be found at: https://youtu.be/WlmCP_-i57s .

Endoscopically Assisted Marginal Mandibulectomy Using an Intraoral Approach Alone for Squamous Cell Carcinoma of the Posterior Mandibular Gingiva: A Technical Note.

Technical note. Marginal mandibulectomy is a surgical procedure for treatment of mandibular gingival tumors. The intraoral approach to the posterior region of the mandible for marginal mandibulectomy is difficult due to limited access and operating field visibility; the conventional surgical procedure may require some skin incisions. This report discusses the effectiveness of endoscopic assistance in marginal mandibulectomy. This article describes endoscopically assisted marginal mandibulectomy using an intraoral approach alone for squamous cell carcinoma of the posterior mandibular gingiva. The advantages of this surgical method are twofold: (1) superior visibility to the lower edge of the mandible without any skin incision; and (2) safe surgical confirmation of important anatomy on the buccolingual side (e.g., mental foramen, lingual nerve, mandibular foramen, and neurovascular bundle). This minimally invasive approach without any skin incision, as well as the superior visibility of the operating field, are important advantages of endoscopically assisted marginal mandibulectomy that cannot be obtained by other surgical methods. Endoscopically assisted marginal mandibulectomy using an intraoral approach alone may be useful because it avoids damage to facial skin and improves safety by employing an enlarged bright field.

Surgical Relevance of the Suprameatal Tubercle During Superior Petrosal Vein-Sparing Trigeminal Nerve Microvascular Decompression.

An enlarged suprameatal tubercle (SMT) can obscure visualization of the trigeminal nerve and require removal during microvascular decompression (MVD) surgery, especially when the superior petrosal vein (SPV) complex is preserved. To define the incidence and important variables affecting the need for SMT removal with an SPV-sparing trigeminal nerve MVD. Retrospective single-institution review identified patients who underwent a first-time, SPV-sparing MVD for trigeminal neuralgia (TGN) over a 26-mo period. SMT length (SMT-L), SMT width (SMT-W), and peri-trigeminal cerebellopontine cisternal thickness (CT) were measured from axial high-resolution magnetic resonance images. Need for SMT removal and use of endoscopic assistance was recorded. Data were analyzed using unpaired t-tests, and receiver operating characteristic (ROC)/area under the curve testing. A total of 43 MVD surgeries for TGN on 42 patients (mean age 52.7±14.4 yr) were analyzed. Mean SMT-L, SMT-W, and CT were 9.8±1.6, 2.0±0.8, and 4.2±1.5 mm, respectively. SMT removal via drilling was required in 4/43 cases (9.3%). Endoscopic assistance was used in 3 cases (2 SMT removed and 1 SMT preserved). SMT-W was the biggest predictor of the need for SMT removal on ROC analysis (area under the curve 0.97, 0.92-1.0 95% CI). The combined thresholds of SMT-W≥3.2 mm and CT≤3.5 mm demonstrated 100% sensitive and 100% specificity for the need to remove the SMT on optimal cutoff analysis. SMT drilling is necessary in nearly 10% of SPV-sparing MVDs for TGN. The combination of SMT width and cerebellopontine cistern thickness is predictive of the need for SMT removal.

Endoscopic Assistance in the Deep and Narrow Spaces of the Brain—Microscopic Tumor Surgery Supported by the New Micro-Inspection Tool QEVO® (Technical Note)

Introduction: To evaluate the feasibility and efficacy of the innovative micro-inspection tool QEVO® (Carl Zeiss Meditec, Oberkochen, Germany) as an endoscopic adjunct to microscopes for better visualization of the surgical field in complex deep-seated intracranial tumors in infants and adults.Materials and Methods: We retrospectively assessed the surgical videos of 25 consecutive patients with 26 complex intracranial lesions (time frame 2018–2020). Lesions were classified according to their anatomical area: 1 = sellar region (n = 6), 2 = intra-ventricular (except IV.ventricle, n = 9), 3 = IV.ventricle and rhomboid fossa (n = 4), and 4 = cerebellopontine angle (CPA) and foramen magnum (n = 7). Indications to use the QEVO® tool were divided into five “QEVO® categories”: A = target localization, B = tailoring of the approach, C = looking beyond the lesion, D = resection control, and E = inspection of remote areas.Results: Overall, the most frequent indications for using the QEVO® tool were categories D (n = 19), C (n = 17), and E (n = 16). QEVO® categories B (n = 8) and A (n = 5) were mainly applied to intra-ventricular procedures (anatomical area 2).Discussion: The new micro-inspection tool QEVO® is a powerful endoscopic device to support the comprehensive visualization of complex intracranial lesions and thus instantly increases intraoperative morphological understanding. However, its use is restricted to the specific properties of the respective anatomical area.

Evaluation of a fluorescence endoscope in murine in-vivo auto-fluorescence glioma models

IntroductionThe value of extended and radical resection of high grade gliomas remains controversial, but the neurosurgical procedure is still vital for effective cancer treatment. Fluorescence guided surgery provides aggressive resection within the tumor margins even on microscopic levels. Aim of this study was to evaluate if a new developed fluorescence endoscope can improve intraoperative vision and tumor delineation. MethodsAn autofluoresence C6 glioma cell line was established via GFP-transfection. These GFP-C6 glioma cells were transplanted both in a dorsal skinfold chamber of the mouse and orthotopically in a cranial window chamber of the mouse. After five days, tumors were examinated by intravital fluorescence microscopy, a standard fluorescence operation microscope and a fluorescence endoscope. Images were compared in terms of visualization, magnification and delineation of tumor cells from host tissue. ResultsThe fluorescence endoscope showed improved image quality and higher magnifications compared to the operation microscope. Even smallest tumor extensions were visualized by the fluorescence endoscope nearly reaching the quality of an intravital fluorescence microscope. ConclusionsIn summary better visualization can improve the intraoperative decision making of the surgeons. So endoscopic assistance can be seen as a promising tool for the fluorescence guided resection of high grade gliomas in the next years.

Endoscope-Assisted Neuroportal Transcerebellar Approach to the Fourth Ventricle: An Anatomical Study.

Minimally invasive approaches to deep-seated lesions still represent a fundamental issue in modern neurosurgery. Tubular retractors allow to enhance the operability of intraventricular lesions, minimizing the risk of damages to brain parenchyma. Increasing interest for portal devices has been mainly focused on supratentorial pathologies, while transportal approaches in the posterior cranial fossa have been rarely described. In the present study, the authors aimed to investigate the surgical exposure and operability obtained with a microsurgical neuroportal transcerebellar approach targeting the fourth ventricle, assisted by endoscopic exploration. Six cadaveric specimens were provided for anatomical microsurgical dissection and Vycor ViewSite Brain Access System was used as tubular retractor. Surgical feasibility of the neuroportal transcerebellar approach was demonstrated through a definable and measurable parameter, the operability score. The neuroport provided a surgical corridor away from eloquent structures to target the whole fourth ventricle cavity, preventing injury to cerebellar nuclei and white matter pathways and, potentially, minimizing the risk of surgical morbidity. Maximal operability was reached in the pontomedullary junction and medullary area of the ventricular floor. Transportal endoscopic assistance contributed to a further extension of surgical exposure in blind spots, corresponding to the ipsilateral lateral recess, the uppermost part of the fourth ventricle, and the obex. The neuroportal transcerebellar approach represents a viable alternative route to the fourth ventricle, avoiding vermian splitting or subarachnoid dissection of the cerebellomedullary cistern. Endoscopic assistance enhances the exposure of the surgical field and accomplishes a valid instrument for intraventricular orientation to ease microsurgical procedures.

A124 GASTRIC RETENTION IN CAPSULE STUDIES – IS AN ENDOSCOPY ALWAYS REQUIRED?

Abstract Background Capsule endoscopy (CE) is a non-invasive procedure for evaluating small bowel (SB) disorders but is limited by the completion rate. Gastric retention (GR), whereby the capsule remains in the stomach for the duration of the recording, can contribute to incomplete examinations given CE’s finite battery life. Although this may be mitigated by using real-time imaging and/or endoscopic placement of capsule into the SB, such strategies require additional resource allocation. While other risk factors associated with incomplete examinations are well known, GR is not often discussed in the literature. Aims To describe the management and outcomes of patients with GR. We hypothesize that most patients with previous gastric retention of the capsule, without known obstruction, will pass the capsule normally through the stomach with a second attempt without requiring endoscopic placement into the duodenum. Methods Case series of patients with GR at a tertiary care centre in Vancouver, Canada. Prior to CE, all patients had undergone appropriate investigations to exclude obstructive pathology. All patients ingested 2L of polyethylene glycol-based bowel preparation the evening prior to the procedure and were fasting after midnight. Ingestion of the capsule occurred at 0700h. In patients who required repeat CE due to previous GR, capsule progress was assessed via real-time imaging at 1–2 hrs. If the capsule had not entered the SB by three hours, an attempt at endoscopic advancement of the capsule into the duodenum was made and/or endoscopic placement of capsule was arranged for a later date. Results GR was found in 21 (2%) of 1024 patients between 09/2015 - 09/2020. The mean age of patients with GR was 58 ± 20.9 years (48% female). The most common indication for CE in this group was obscure gastrointestinal bleeding (n = 12, 57%). The mean Charlson Comorbidity Index was 2.9 ± 3.5. Thirteen patients (62%) had a history of abdominal/pelvic surgery. Fourteen patients (67%) had repeat CE, nine (64%) of which passed into the SB without endoscopic assistance. Of those requiring endoscopic assistance (n = 5), two had successful endoscopic placement, one required dilation of pyloric stenosis prior to successful placement, one failed endoscopic placement due to stenotic gastroplasty orifice, and another required upper endoscopy for further evaluation. None experienced delayed adverse events related to GR. Conclusions CE can be safely repeated in patients with previous GR; most capsules will pass through the stomach spontaneously when repeated and do not require endoscopic assistance. Funding Agencies None

Cerebellopontine Angle Epidermoids: Comparative Results of Microscopic and Endoscopic Excision Using the Retromastoid Approach".

Background Densely packed neurovascular structures, often times inseparable capsular adhesions and sometimes a multicompartmental tumor extension, make surgical excision of cerebellopontine angle epidermoids (CPEs) a challenging task. A simultaneous or an exclusive endoscopic visualization has added a new dimension to the classical microscopic approaches to these tumors recently. Methods Eighty-six patients (age: 31.6 ± 11.7 years, M:F = 1:1) were included. Nineteen patients (22.1%) had a multicompartmental tumor. Tumor extension was classified into five subtypes. Sixty-two patients underwent a pure microscopic approach (72%) out of which 10 patients (16%) underwent an endoscope-assisted surgery (11.6%) and 24 patients (28%) underwent an endoscope-controlled excision. Surgical outcomes were retrospectively analyzed. Results Headache (53.4%), hearing loss (46.5%), and trigeminal neuralgia (41.8%) were the leading symptoms. Interestingly, 21% of the patients had at least one preexisting cranial nerve deficit. Endoscopic assistance helped in removing an unseen tumor lobule in 3 of 10 patients (30%). Pure endoscopic approach significantly reduced the hospital stay from 9.2 to 7.3 days ( p = 0.012), and had a statistically insignificant yet a clearly noticeable lesser incidence of subtotal tumor excision (0 vs. 10%, p = 0.18) with comparable cranial nerve deficits but with a higher postoperative cerebrospinal fluid (CSF) leak rate (29% vs. 4.8%, p = 0.004). Conclusion Endoscope assistance in CPE surgery is a useful addition to conventional microscopic retromastoid approach. Pure endoscopic excision in CPE is feasible, associated with a lesser duration of hospital stay, better extent of excision in selected cases, and it has a comparable cranial nerve morbidity profile albeit with a higher rate of CSF leak.

Free tissue transfer for central skull base defect reconstruction: Case series and surgical technique

ObjectivesLocal reconstruction of central skull base defects may be inadequate for large defects or reoperative cases; free tissue transfer may be necessary. Inset of the flap and management of the pedicle can be challenging. We report our experience and approaches. MethodsRetrospective review identifying seven patients with central skull base defects who underwent free flap reconstruction from 2016 to 2020. ResultsFour patients with recurrent nasopharyngeal carcinoma, one with recurrent craniopharyngioma, one with clival-cervical chordoma, and one with meningioma of the middle cranial fossa were analyzed. Six defects were closed with an anterolateral thigh free flap and one with a radial forearm free flap. In two patients, the flap was secured in an onlay fashion to the defect via a Caldwell-Luc transmaxillary approach. In one patient, the flap was passed transorally, and the pedicle was delivered into the neck via Penrose drain. In two patients, a parapharyngeal technique and in two others, a retropharyngeal was used for nasopharyngeal inset with endoscopic assistance. There were no flap failures, with an average follow-up time of 20.1 (range 3.2–47.1) months. One patient required flap repositioning on postoperative day three due to midline shift and intracranial contents compression. The transoral inset flap necessitated flap repositioning on postoperative day 13 to improve the nasopharyngeal airway. ConclusionFree flap reconstruction of the central skull base is challenging, but transmaxillary, transoral, parapharyngeal, and retropharyngeal approaches can be used with endoscopic assistance to ensure secure inset flap and avoid airway obstruction.

Human–Robot Interfaces of the NeuRoboScope: A Minimally Invasive Endoscopic Pituitary Tumor Surgery Robotic Assistance System

Abstract Endoscopic endonasal surgery is a commonly practiced minimally invasive neurosurgical operation for the treatment of a wide range of skull base pathologies including pituitary tumors. A common shortcoming of this surgery is the necessity of a third hand when the endoscope has to be handled to allow active use of both hands of the main surgeon. The robot surgery assistant NeuRoboScope system has been developed to take over the endoscope from the main surgeon's hand while providing the surgeon with the necessary means of controlling the location and direction of the endoscope. One of the main novelties of the NeuRoboScope system is its human–robot interface designs which regulate and facilitate the interaction between the surgeon and the robot assistant. The human–robot interaction design of the NeuRoboScope system is investigated in two domains: direct physical interaction (DPI) and master–slave teleoperation (MST). The user study indicating the learning curve and ease of use of the MST is given and this paper is concluded via providing the reader with an outlook of possible new human–robot interfaces for the robot assisted surgery systems.

Commentary: Hemifacial Spam: Endoscopic Assistance in Facial Nerve Decompression With Lateral Spread Response Corroboration: 2-Dimensional Operative Video.

Commentary: Hemifacial Spam: Endoscopic Assistance in Facial Nerve Decompression With Lateral Spread Response Corroboration: 2-Dimensional Operative Video.