Endoscope-assisted Procedure Research Articles

Comparison of Surgical Outcomes between Endoscopeassisted Evacuation and Conventional Burr Hole Aspiration of Brain Abscess at a Tertiary Care Hospital

Background: Brain abscess is a major health problem with a reasonable morbidity and mortality rate. Objective: The objective of this study was to compare the efficacy between endoscope-assisted evacuations of brain abscess with burr hole aspiration method in a tertiary health care center. Methodology: This non-randomized clinical trial was conducted in the Department of Neurosurgery at Dhaka Medical College Hospital, Dhaka, Bangladesh during the period of July 2016 to December 2017. Patients with the age group of more than or equal to 18 years of both gender presented with brain abscess were enrolled in this study. The endoscope-assisted evacuation of abscess was done on group A patients and burr hole aspiration was done on group B patients. Outcome of the patients was assessed using GCS and MRC muscle power grading and by GOS. Patients were evaluated by contrast enhanced CT scan of head at pre-operative, 1st and 30th postoperative day. Both groups received best available medical treatment along with surgery. Results: The mean age of was 13.0 ± 6.3 years in burr hole group and is 13.1 ± 6.4 years in endoscope-assisted group. The patients presented with GCS was 66.7% in burr hole group and 93.3% in endoscope assisted group. The study showed e”75.0% evacuation of brain abscess at 1st post-operative day in 13(92.9%) patients in endoscope-assisted group and 5(33.3%) patients in burr hole group. The study showed mortality rate of 6.7% in both the groups. Mean residual volume at 30th post operative day was 0.75ml in endoscope-assisted group and 1.75ml in burr hole aspiration group. Conclusion: In conclusion endoscope-assisted procedure has better rate of abscess evacuation, less chance of residual and repeated surgeries than conventional burr hole. Bang. J Neurosurgery 2023; 13(1): 14-19

Brain Abscess: A Comparison of Surgical Outcomes between Conventional Burr Hole Aspiration and Endoscope-assisted Evacuation.

Brain abscess is a major health problem with a significant morbidity and mortality rate. The objective of this study was to compare the surgical efficacy between endoscope-assisted evacuations of brain abscess with a single burr hole aspiration procedure in a tertiary health care center. This single center non-randomized clinical study was conducted in our Department of Neurosurgery during the period of July 2020 to December 2021. Patients under 30 years of age of both genders presented with brain abscess were enrolled in this study. Patients were treated with two different techniques and divided into 2 groups: conventional burr hole aspiration group and endoscope-assisted evacuation group. Thirty patients were enrolled for this study. The mean age was 13.0 ± 6.3 years in burr hole group and is 13.1 ± 6.4 years in endoscope-assisted group. This study showed ≥75.0% evacuation of brain abscess at 1st post-operative day in 13 (92.9%) patients in endoscope-assisted group and 5 (33.3%) patients in burr hole group. This study showed mortality rate of 6.7% in both the groups. Mean residual volume at 30th post-operative day was 0.75 ml in endoscope-assisted group and 1.75 ml in burr hole aspiration group. No patients treated with required endoscope-assisted evacuation required a repeated surgery, whereas 5 patients (33.3%) of patients treated with conventional burr hole required it. This study showed that endoscope-assisted procedure has better rate of abscess evacuation, less chance of residual and repeated surgeries than conventional burr hole.

Evaluation of endoscopic-assisted feline lateral bulla osteotomy: a cadaveric study.

The aims of the study were to investigate if feline middle ear anatomy can be visualized using endoscopy via a lateral bulla approach and to determine if scope-assistance increases rates of successful entry into the hypotympanum during feline total ear canal ablation and lateral bulla osteotomy (TECA-LBO). A total of 13 feline cadaver heads underwent CT to confirm the absence of pre-existing middle ear disease. For each head, an electronic coin toss was used to determine which ear would undergo endoscope-assisted TECA-LBO; a traditional TECA-LBO without the use of the scope was performed on the contralateral side. In endoscope-assisted procedures, a 1.9 mm scope was intermittently inserted into the tympanic bulla via a lateral bulla approach and used to identify middle ear structures, visualize the bony septum and confirm entry into the hypotympanum. After the bilateral TECA-LBO, the cadaver heads were imaged again and assessed for evidence of entry through the septum. Soft tissue and osseus structures of the middle ear were readily visualized with a 1.9 mm scope. Success rates for entry into the hypotympanum were high between both endoscope-assisted and traditional procedures, with entry confirmed for 12/13 ears in each group. Endoscope assistance can facilitate the identification and examination of middle ear structures but does not appear to increase the success rate of entry into the hypotympanum during feline TECA-LBO, as entry through the bony septum was consistently accomplished even without scope-assisted visualization. Alternative benefits to scope assistance may exist, and future studies to elucidate its impact on rates of intraoperative trauma to middle ear structures are indicated.

Endoport-assisted microsurgical treatment for a ruptured posterior cerebral artery aneurysm: A technical note.

Posterior Cerebral Artery aneurysms are scarce, yet its territory is frequently associated to large and giant aneurysms. Treatment is mostly a binary option between microsurgical clipping and endovascular coiling. Hybrid approaches are an option too, whereas innovation with less frequent techniques such as endoscope-controlled and endoscope-assisted procedure may provide a safer surgical approach with same successful results. Hereby we report a case of a 53 years old male examined at the ER after presenting generalized seizures and altered state of consciousness. Upon arrival, neurological evaluation revealed homonymous right hemianopia. Computed tomography (CT) scan revealed a subarachnoid hemorrhage and left parieto-occipital intraparenchymal hemorrhage with intraventricular extension; computed tomography angiogram (CTA) revealed an aneurysm at the left posterior cerebral artery (PCA) in its P4 segment. We performed a vascular exploration with drainage of the occipital and intraventricular hematoma through a single endoscopic port through transulcal approach guided by neuronavigation, in addition to clipping and aneurysmectomy. The combination of microsurgical clipping with previous Endoport-guided endoscopic procedure may be a surgical-operative option that not only may facilitate the approach to the desired lesion, but also provides a safer surgical scenario.

Endoscope-assisted greater neurovascular palatal bundle release in cleft palatoplasty

Performing surgery in the oral cavity is difficult because of the limited view of the surgical field. Intraoral surgery for infantile oral disorders, such as cleft palate, is even more challenging. Endoscopy provides a minimally invasive approach and clear surgical view in surgeries with a constrained field of view. To date, very few reports have described endoscope-assisted palate surgery for children with cleft palate. At the authors’ institution, endoscopes have been used in primary palatoplasty using the double-opposing Z-plasty technique. A novel endoscope-assisted procedure is described herein, in which a dissection around the greater palatine neurovascular bundle is used to obtain tension-free closure of the palatal cleft. With this technique, it was possible to minimize the application of additional von Langenbeck-type relaxation incisions, which were previously introduced in most of our cases; the relaxation incision was successfully circumvented in 42.3% of cases. This led to lesser surgical interference, which possibly resulted in favourable palatal development. It was also found that the endoscopic procedure did not increase the operation time or blood loss when compared to those patients who underwent the non-endoscopic procedure. It is concluded that endoscopic guidance is quite useful in primary palatoplasty procedures with a constricted surgical view.

Transpedicular 3D endoscope-assisted thoracic corpectomy for separation surgery in spinal metastases: feasibility of the technique and preliminary results of a promising experience.

Surgery for spinal metastases has undergone multiple transformations in terms of surgical technique. The need for a more aggressive surgical strategy for local control of the disease, given the advances in radiosurgery and immunotherapy, has met the incorporation of many different technological adjuncts. Separation surgery has become one of the main targets to achieve for surgeons in the treatment of spinal metastases. In this paper a prospective series of 3D endoscope-assisted transpedicular thoracic corpectomies is described. Adult patients with a diagnosis of single-level thoracic metastases requiring surgery for epidural compression were included. Data recorded for each case concerned patient demographics, surgical technique, clinical, radiological and surgical data, intra- and postoperative complications, follow-up. The goal of this study was to verify the achievement of separation surgery with this technique, while confirming the safety and feasibility of the procedure. A total number of nine patients were treated from January to April 2019 with a 3D endoscope-assisted procedure. A circumferential bilateral decompression was achieved in seven cases, while monolateral in the other two. A proper separation between the tumor and the spinal cord was achieved in all cases as confirmed by imaging. Axial pain always improved after the procedure as well as neurological functions, when compromised before surgery. No intra-operative and postoperative complications were recorded. Mean hospital stay was 4 days after surgery with early mobilization. At last follow-up no local recurrences were registered. According to preliminary results, the transpedicular 3D endoscope-assisted approach for corpectomies appeared to be a safe and effective technique to achieve proper circumferential decompression and valid separation surgery in thoracic metastases, potentially decreasing the need for costotransversectomy.

Evaluation of chitosan-based nasal dressing in animal model

The usefulness of nasal packing after endoscopic sinus surgery is still debated in the literature. Our aim was to evaluate the effects of a new chitosan-based nasal dressing in animal model. Standard mucosal damage was caused in both nostrils during endoscope-assisted procedure in ten rabbits. Chitosan nasal packing was inserted in a randomly selected nasal fossa of each animal, while the other side was left unpacked. Symptoms were evaluated during nasal endoscopy on the 12th postoperative week. The degree of mucosal oedema, crusting, adhesions and the nasal discharge were observed according to the modification of the grading system of Berlucchi et al. The higher scores indicated the worse complaints. Assessing the adhesion formation, 1 point was given (mean: 0.1; standard deviation [SD]: 0.32) for the unpacked side, while in the tamponated side no adhesion formation was observed. The total score of crusting in the non-packed side was lower with 1 point (total score: 9, mean: 0.90; SD: 0.74) than in the chitosan side (total score: 10, mean 1.00; SD: 0.82). Discharge or mucosal oedema were not observed during the follow-up period. The mean rate, measured with electronmicroscopy, was 22.06% (SD: 0.25) in the chitosan side, while in the non-packed side it was 36.11% (SD: 0.48). The differences did not show any significance (p = 0.806). During the examinations, none of the animals suffered complications. The symptoms of the packed and the non-packed nasal cavities did not differ significantly on the basis of our examinations. Orv Hetil. 2018; 159(47): 1981-1987.

Endoscope-Assisted Retrosigmoid Approach for Cerebellopontine Angle Epidermoid Tumor.

Objectives Surgical resection is the only effective treatment modality for epidermoid tumors. Complete resection with preservation of neurological function must be pursued whenever possible, because it offers a cure for patients. However, the inability to identify hidden remnants, interdigitating around cranial nerves, especially in larger tumors, may be a contributing factor for incomplete resection. This operative video demonstrates the technical nuances in achieving complete resection of a cerebellopontine angle epidermoid tumor via an endoscope-assisted retrosigmoid approach. Design and Setting Operative video of an endoscope-assisted retrosigmoid, approach for complete resection of a cerebellopontine angle epidermoid tumor. The patient was a 16-year-old female, who presented with 1-year history of worsening headaches and imbalance. Her neurological exam was normal, including normal cranial nerve function, and hearing. Radiological evaluation revealed an epidermoid tumor in the right cerebellopontine angle, extending to the interpeduncular cistern. Surgical resection was recommended. Given extension of the tumor across the midline, an endoscope-assisted procedure was planned to increase the odds of complete resection. Results The video demonstrates the surgical technique applied for tumor resection. The patient's clinical symptoms resolved completely after surgery and she remained neurologically intact. Postoperative magnetic resonance imaging (MRI) confirmed complete tumor resection. There were no postoperative complications. Conclusions The use of endoscopic techniques for resection of cerebellopontine angle epidermoid tumor is safe and effective and may increase the odds of complete resection, especially in larger tumors spreading across the midline, by enabling the surgeon clear visualization of deep-seated and contralateral relevant neurovascular structures, not readily accessible by the surgical microscope. The link to the video can be found at: https://youtu.be/X6YP_7OeQQE .

Incomplete reossification after craniosynostosis surgery-incidence and analysis of risk factors: a clinical-radiological assessment study.

OBJECTIVE One of the principles of the surgical treatment of craniosynostosis includes the release of fused bone plates to prevent recurrence. Such bone defects require a reossification process after surgery to prevent a cosmetic problem or brain vulnerability to damage. The objective of this study is to describe and analyze the radiological and clinical evolution of bone defects after craniosynostosis. METHODS From January 2005 to May 2016, 248 infants underwent surgical correction of craniosynostosis at HUiP La Fe Valencia; the authors analyzed data from 216 of these cases that met the inclusion criteria for this study. Various surgical techniques were used according to the age of the patient and severity of the case, including endoscopic-assisted suturectomy, open suturectomy, fronto-orbital advancement, and cranial vault remodeling. Clinical follow-up and radiological quantitative measurements in 2 periods-12-24 months and 2 years after surgery-were analyzed; 94 patients had a postoperative CT scan and were included in the radiological analysis. RESULTS At the end of the follow-up period, 92 of 216 patients (42.59%) showed complete closure of the bone defect, 112 patients (51.85%) had minor bone defects, and 12 patients (5.56%) had significant bone defects that required surgical intervention. In the multivariate analysis, age at first surgery was not significantly associated with incomplete reossification (p = 0.15), nor was surgical site infection (p = 0.75). Multivariate analysis identified area of cranial defect greater than 5 cm2 in the first CT scan as predictive of incomplete reossification (p = 0.04). The mean area of cranial defect in the first CT scan (12-24 months after surgery) was 3.69 cm2 in patients treated with open surgery and 7.13 cm2 in those treated with endoscopic-assisted procedures; in the multivariate analysis, type of procedure was not related to incomplete reossification (p = 0.46). The positive predictive value of palpation as evaluation of bone cranial defects was 50% for significant defects and 71% for minor defects. CONCLUSIONS The incidence of cranial defects due to incomplete reossification requiring cranioplasty was 5.56% in our series. Defects greater than 5 cm2 in the first postoperative CT scan showed a positive association with incomplete reossification. Patients treated with endoscope-assisted procedures had larger defects in the initial follow-up, but the final incidence of cranial defects was not significantly different in the endoscope-assisted surgery group from that in the open surgery group.

Lumbar Decompressive Laminectomy or Laminotomy for Degenerative Conditions: “Outcome Comparison of Traditional Open versus Less Invasive Techniques”

Abstract Study design: Non-randomized chart review of elective lumbar decompression Objective: Compare patient outcome and health system economic impact associated with direct lumbar decompression. Summary of background data: Degenerative lumbar conditions refractory to non-operative measures are traditionally treated via open decompression. Less invasive techniques assisted by tubular retractors or endoscopic visualization continue to grow in popularity. Methods: 338 consecutive patients with spinal stenosis or disc herniation were treated with: Open, Tube-assisted, or Endoscope-assisted procedures based on the surgeons’ typical indications, practice pattern and procedure of choice. Cases stratified by stenosis requiring decompression without discectomy (Stenosis) or disc herniation requiring discectomy (Disc). Data collected preoperatively, one, four and ten months postoperatively. Within strata, perioperative demographics, intraoperative and postoperative complications, and functional outcomes were compared across procedure types. Outcome measures include VAS (back / leg), Oswestry and Medicare subset for Net revenue. Results: 234 Disc and 104 Stenosis cases. Stenosis patients were significantly older than Disc patients (67.0 vs. 52.3 years, p=0.0001). Disc cases: 42.7% Open, 36.8% Endoscope-assisted, 20.5% Tube-assisted. Stenosis cases: 36.5% Open, 63.5% Tube-assisted. Operative time, estimated blood loss, and length of stay were significantly greater for Open procedures both Disc and Stenosis. Disc cases fluoroscopy time was significantly greater for Endo (p<0.0001). Stenosis cases fluoroscopy time was significantly greater for Tube-assisted. Intraoperative complications occurred in 12 (3.5%) patients, 16 experienced postoperative events. A non-significant trend towards greater post-operative complication was seen in Open – stenosis group. Functional outcome improvements for ODI, VASB, and VASL were experienced regardless of case group or procedure type (p<0.0001). Medicare (n=107) revenue generated net positive regardless of case type or location. Conclusions: Functional improvement following treatment of degenerative lumbar conditions via direct decompression should be anticipated regardless of case group or procedure type. Despite their reduction in fluoroscopy, Open cases are associated with a significant increase in length of stay, operating time, estimated blood loss and potentially postoperative infections.

Anatomic Concepts for Brow Lift Procedures

Brow lifting became a component of the facialplasty procedure 45 years ago, and the original brow-lifting technique incorporating a coronal incision approach is still practiced by many surgeons today. Over the past 15 years, however, the endoscope-assisted procedure and the limited incision, nonendoscopic techniques have evolved as alternate procedures for brow lifting. The level of artistry in performing any brow lift technique is raised when the surgeon acquires knowledge of upper facial anatomy and integrates that knowledge into a working concept of the aging process of the upper face. This article presents one surgeon's concepts of the process that culminate in the typical appearance of the aged upper face. The same understanding of upper facial anatomy that can be called upon to explain the steps in this aging process can also be applied to the technical steps of any foreheadplasty procedure. Those anatomic structures that play a role in this process are examined here. The typical appearance of the aged upper face is the product of muscle action and gravitational forces acting on the unique anatomy of the human face. Interestingly, the appearance of the typical aged upper face exhibits much the same characteristics as one might observe in the face of an individual experiencing the emotions of sadness or grief. It is an inappropriate facial expression of sadness or grief that most often motivates the patient to schedule a consultation with the plastic surgeon. Any of the brow lift procedures used in current clinical practice can provide a successful cosmetic result in selected patients if the procedure incorporates technical steps based on sound anatomic principles.

A SHORT TRAPEZOIDAL SPECULUM FOR SUPRASELLAR AND INFRASELLAR EXPOSURE IN ENDONASAL TRANSSPHENOIDAL SURGERY

A key limitation of the transsphenoidal approach for suprasellar and infrasellar lesions is restricted exposure. Microscope and endoscope-assisted procedures have traditionally used an oval-shaped speculum, the distal end of which restricts superior and inferior visualization. To improve visualization and use of the endoscope, shorter specula, with a trapezoidal distal end, were designed. The new specula have a working length of 60 mm. The proximal 20-mm segment is oval-shaped to conform to the nostril; the middle 20-mm segment has vertically oriented blades; and the distal 20-mm segment transitions to a trapezoidal orientation, with the distal blades angled 15 degrees upward and outward on the suprasellar speculum, or 15 degrees downward and outward on the infrasellar speculum. Both specula have a 5-degree distal outward flare. The upward-angled trapezoidal 60-mm speculum was compared with 70- and 80-mm oval specula in a transsphenoidal clay model. A pen light was projected from the nasal speculum end to a target 100 mm away using a blade opening width of 16 mm. Line drawings were made to quantify the impact of speculum length on the horizontal angle of exposure. The clinical utility of the trapezoidal specula was also assessed. In the model, the 60-mm upward-angled trapezoidal speculum yielded a surface area illumination of 759 mm, as compared with 579 and 432 mm with the 70-and 80-mm oval specula, an increase in exposure of 31 and 76%, respectively. In the line drawings, the 60-mm speculum provided a horizontal angle of exposure of 30 degrees, as compared with 26 and 23 degrees for the 70- and 80-mm specula, an increase of 17 and 33%, respectively. In patients, provided sufficient mucosa and bone are removed from the posterior nasal cavity, the trapezoidal specula provide an expanded working volume that facilitates endoscopy. Short upward- or downward-angled trapezoidal endonasal specula increase parasellar surface area exposure and the horizontal angle of exposure. Initial clinical experience suggests that reducing the speculum length and eliminating the distal curved blades result in greater instrument maneuverability and enhanced visibility for removing parasellar tumors.

Endoscopic and Endoscope-Assisted Neurosurgical Treatment of Suprasellar Arachnoidal Cysts (Mickey Mouse Cysts)

Suprasellar arachnoid cysts represent less than 10% of all intracranial arachnoid cysts. Some of them may be quiescent throughout life, some may become symptomatic as they become enlarged and some disappear spontaneously. In this study we discuss the surgical strategies for endoscopic and endoscope-assisted treatment of suprasellar (Mickey Mouse) cysts and analyze the clinical results and experience collected over some years in our department upon doing these operations routinely. Between December 1996 and December 2003, 13 patients (7 female and 6 male patients), mean age 29 years, underwent endoscopic or endoscope-assisted procedures for suprasellar cysts at our department. The indication for surgical treatment was based on the neurological and radiological examination. The goal of surgical treatment was to normalize the cerebrospinal fluid flow and to establish a communication, permanently, between the cyst cavity and the intraventricular or/and subarachnoid space. Intraoperatively we observed in all patients no complications. Seven of 13 patients, who had received shunt systems in other hospitals before admission in our clinic, remained shunt-free postoperatively. Overall clinical improvement was achieved for a long period of between 6 and 74 months in 11 patients, one developed a psychomotor disturbance and another one, who had epilepsy before treatment, was unchanged postoperatively. Our data suggest that suprasellar cysts are well treated by endoscopic or endoscope-assisted procedures with good clinical outcome and low surgical morbidity.