Endoscopic Surgeon Research Articles

Lateral optico-carotid recess as an anatomical landmark for optimal endoscopic optic nerve decompression.

Transnasal endoscopic decompression of the optic nerve is increasingly gaining acceptance among ear, nose, and throat (ENT) surgeons, however neither strict indications for the procedure nor the precise extent of effective decompression have been firmly established to date. This study aimed to determine the distance between endoscopically visible, anatomical structures within the sphenoid sinus and the posterior (i.e. intracranial) endpoint of decompression. The lateral optico-carotid recess (LOCR) is proposed as a reference for the undertaken measurements. The precise localizations of the LOCR and the point at which the optic nerve is covered by bone only for 180° of its circumference were determined using high-resolution computed tomography performed in 30 subjects (60 orbits). Reformed high-resolution computed tomography scans, perpendicular to the optic canal, were used for all measurements. The point at which optic nerve decompression can be safely terminated was identified in proximity to the medial edge of the LOCR: in all cases, no further than 2.5 mm anterior to this landmark (assigned a negative value) and no further than 1.3 mm posterior (assigned positive values), with a mean of -0.4±1.3 mm. When measured from the orbital apex, the distance ranged from 4.8 to 14.4 mm, with a mean of 8.7±2.5 mm. The LOCR can be directly discernible by the endoscopic surgeon and identified on the reconstructed high-resolution computed tomography scans, offering a reliable landmark for designating the required extent of decompression. Measurements related to the orbital apex proved less credible, and additionally, this landmark is challenging to identify during surgery.

Microsurgical Resection of a Thalamic Tumor Using an Endoscopic Contralateral Supracerebellar Infratentorial Keyhole Approach: 2-Dimensional Operative Video.

The surgical treatment of the thalamic lesions is one of the most technically challenging interventions because of their deep-seated location and the proximity of the surrounding vital neurovascular structures: thalamic nuclei, limbic system components, visual and oculomotricity pathways, deep cerebral veins, and posterior cerebral artery branches.1 Traditional microsurgical approaches for these lesions usually require large open craniotomies and further retraction or resection of neural tissue to facilitate better visualization, associating significant postoperative morbidity or even mortality. The recent improvements in high-resolution fiber optics technology have allowed neurosurgeons to expand their surgical armamentarium for tackling these difficult-to-reach lesions. The patient consented to the procedure, and in this surgical video, we try to emphasize the advantages of an endoscopic supracerebellar infratentorial approach over the classic microsurgical approach, along with the keyhole craniotomy and the sitting positioning of the patient. The endoscope provides better visualization-dynamic in-depth view of the anatomic and pathological structures, angled-optics help the surgeon to see "around-the-corner," and the entire procedure is a more comfortable experience for the surgeon and also for the patient, using the minimally invasive techniques. Moreover, we underline the need for a strong collaboration with an experienced endoscopic surgeon (for eg, ear, nose and throat surgeon), as for other endoscopic skull base approaches. The participants and any identifiable individuals consented to publication of his/her image.

A comparison of swallowing related quality of life in patients undergoing transoral endoscopic versus open thyroid surgery.

It is important for the endoscopic thyroid surgeon to understand the pros and cons of trans-oral endoscopic thyroidectomy-vestibular approach (TOETVA) vis-à-vis, open conventional thyroidectomy (OTx) so he/she can help patients in making informed choices regarding the type of procedure to opt for. Swallowing related quality of life (SWAL-QoL) has not been compared between the two approaches. Using a rigorous qualitative methodology and validated reliable tool, this study set out to compare the swallowing related quality of life in patients undergoing TOETVA versus OTx. Prospective study at 3 time points in patients planned for hemithyroidectomy (Preoperative, 1week and 12weeks). Data were collected on patients at a tertiary teaching institute in India. Participants ranged from age 18-60years with a diagnosis of benign euthyroid nodule undergoing hemithyroidectomy. Exclusion criteria were-(1) pre-existing vocal cord abnormalities, (2) undergoing surgery for recurrent nodules, and (3) any neuro-muscular disease affecting swallowing ability. Main outcome measure was comparison of swallowing related quality of life domain scores between patients undergoing hemithyroidectomy via either endoscopic trans-oral or open approach. Of the 82 included patients, 40 underwent TOETVA and 42 OTx. Both the groups were comparable in terms of demographic and clinicopathological profile. The mean preoperative SWAL-QOL scores were comparable in all domains. Mean SWAL-QoL scores for all domains on postoperative day 7 were significantly better in TOETVA group with domains burden, eating desire, mental health and communication having medium effect sizes. Physical symptom domain was better in the OTx group but had a small effect size. The difference in SWAL-QoL domains between the two groups persisted for 3months also. Swallowing related quality of life after trans-oral endoscopic thyroidectomy compared to conventional open surgery has not been reported in the literature. Our findings suggest that trans-oral endoscopic thyroidectomy results in significant superior swallowing related quality of life in the majority of domains.

Incidence and Risk Factors for Revision Within 1 Year of Primary Carpal Tunnel Release.

The annual volume of carpal tunnel release (CTR) in the United States has been estimated to be 577 000 per year. Our objectives were to evaluate the incidence and risk factors for revision CTR within 1 year of primary CTR. We identified all adult patients undergoing primary CTR from October 2015 to September 2019 in the New York Statewide Planning and Research Cooperative System database using Current Procedural Terminology (CPT) codes. We used the CPT modifier codes to determine laterality of index and revision procedures. We estimated multivariable hierarchical logistic regression models to evaluate risk factors for revision CTR within 1 year. Of the 80 423 primary CTR procedures, 178 (0.22%) underwent a revision CTR within 1 year of the index surgery. The mean (SD) age of the entire cohort was 58.69 (14.43) years, 61.1% were women, 73.2% were non-Hispanic white, 42.9% were covered through private insurance, and 9.5% had diabetes mellitus. Workers' compensation insurance (odds ratio [OR] = 1.83, 95% confidence interval [CI], 1.13-2.98, P = .02) and simultaneous bilateral CTR (OR = 14.91, 95% CI, 9.62-23.12, P < .001) were associated with revision CTR within 1 year of the index procedure. No models demonstrated an association between endoscopic technique or surgeon volume and revision CTR. The incidence of revision CTR within 1 year was lower than that previously reported. Patients covered by workers' compensation and those undergoing simultaneous bilateral CTR had higher likelihood of a revision CTR within 1 year, whereas endoscopic technique and surgeon volume were not associated with revision CTR within 1 year.

Essential Surgical Techniques During Fully Endoscopic Spine Surgery: A Historical Review and Future Perspectives

Full-endoscopic spine surgery (FESS) offers minimally invasive techniques for treating spinal lesions with smaller incisions, leading to reduced tissue damage and consequently more rapid patient recovery. The essential techniques in FESS —namely, the transforaminal and interlaminar approaches—have evolved with technological advances in endoscopic systems and surgeon expertise. The transforaminal approach consists of “inside-out” and “outside-in” techniques that have distinct applications depending on the patient’s condition. The interlaminar approach, similar to traditional spinal surgery techniques, is gaining wider acceptance due to its efficacy in addressing unique anatomical challenges. Advanced procedures, such as endoscopic laminectomy and interbody fusion surgery, coupled with navigation systems, have broadened the scope of endoscopic spine surgery, making it an increasingly vital tool in modern spinal surgery.

Training to be a spinal endoscopic surgeon: What matters?

Spinal endoscopic surgery has been promoted rapidly in the past decade, attracting an increasing number of young, dedicated surgeons. However, it has long been denounced for its long learning curve as a factor impeding the development of this state-of-the-art technique. The aim of the present study was to discover what really matters in the educational process of becoming a spinal endoscopic surgeon. An online survey consisting of 14 compulsory questions was distributed in April and May 2022 through the First Chinese Spinal Endoscopic Surgeons Skills Competition. Reminders were sent to increase response rates. Of the 893 emails that were sent, we received 637 responses. A total of 375 (76.7%) surgeons most frequently used endoscopic techniques in their practices. Regardless of their different backgrounds, 284 (75.7%) surgeons thought it would be necessary for a young spinal endoscopic surgeon to perform 300 cases independently in order to become proficient, followed by 500 (n=43, 11.5%), 100 (n=40, 10.7%), and 1,000 (n=8, 2.1%) cases. According to the surgeons, the most difficult aspect of mastering the endoscopic technique is a disparate surgical view (n=255, 68%), followed by adaption to new instruments (n=86, 22.9%) and hand-eye coordination (n=34, 9.1%). The most helpful training method for helping the spinal endoscopic surgeons of younger generations improve is operating on simulation models or cadaver courses (n=216, 57.6%), followed by online or offline theoretical courses (n=67, 17.9%), acquiring opportunities during surgeries (n=51, 13.6%), and frequently participating in surgeries as an assistant (n=41, 10.9%). From the perspective of surgeons, to be skilled in spinal endoscopic surgery means overcoming a steep learning curve. However, training systems should be given more attention to make them more accessible to younger surgeons so they can work on simulation models or take cadaver courses.

Systematic Review of Current Literature on Clinical Outcomes of Uniportal Interlaminar Contralateral Endoscopic Lumbar Foraminotomy for Foraminal Stenosis

Uniportal interlaminar contralateral endoscopic lumbar foraminotomy (ICELF) aims to achieve decompression of lumbar spinal stenosis in the contralateral lateral recess and foraminal and extraforaminal regions of the same segment. This technique is performed under normal saline irrigation using an endoscope with optical lens magnification close to the targeted stenotic segment and has the potential of lower incidence of exiting nerve root dorsal root ganglion irritation. A systematic review of the ICELF technique was conducted from March 2000 to March 2022. Articles were selected with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Eligibility of studies was independently determined by 2 reviewers, and disagreements were resolved by a third author. Eight retrospective cohort studies comprising 194 patients with foraminal stenosis who underwent uniportal ICELF were selected for systematic review. Mean age range was 62-79 years, and surgical duration was 48-73.5 minutes. There was significant improvement in Oswestry Disability Index and visual analog scale leg pain score in the included studies. Four studies met the minimum clinically significant difference for leg pain, with visual analog scale improved >5 points and Oswestry Disability Index improved >8.2 points. Four studies reported a majority of the operated patients with good or excellent outcomes following surgery, with a low rate of complications in the studies selected. There is low-level evidence that ICELF when performed by an experienced spinal endoscopic surgeon is effective in providing pain relief and improved function with low rate of complications in select patients.

Surgical Outcomes of Full-Endoscopic Lumbar Discectomy in the Early Adoption Phase.

Background We adopted full-endoscopic lumbar discectomy (FELD) in 2019 with the assistance of the Japanese Society for Minimally Invasive and Endoscopic Techniques of Spinal Neurosurgery (JASMETS). This study analyzed short-term outcomes in our initial FELD cases and compared them with microdiscectomy cases performed during the same period. Methods FELD was performed in 21 patients over a period of 2 years and 6 months (15 men and 6 women; mean age, 57.0±17.0 years). The transforaminal approach was performed in 8 patients, the posterolateral approach in 3, and the interlaminar approach in 10. During the same period, microdiscectomy was performed in 30 patients. Japanese Orthopaedic Association (JOA) and visual analog scale (VAS) scores, operation time, blood loss volume, complications, and incidence of lumbar disc herniation recurrence were compared between the groups. Results Preoperative VAS and JOA scores did not significantly differ between the FELD and microdiscectomy groups. JOA and VAS scores significantly improved in both groups after surgery. Operation time and incidence of recurrence rate did not differ. Conclusion Spine surgeons who adopt FELD can achieve good surgical outcomes similar to those of microdiscectomy, even in the early period. Participation in JASMETS seminars and training and proctoring by a certified endoscopic spine surgeon were instrumental in our experience.

Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum. Is this the dawn of the endoscopic cancer surgeon?

Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum. Is this the dawn of the endoscopic cancer surgeon?

Functional Results and Learning Curve of Endoscopic Ossiculoplasty

Background and Objectives Endoscopes are recently being used to manage various middle ear surgeries including ossiculoplasty. Here, we investigated hearing results of endoscopic ossiculoplasty and surgeon’ learning curve in gaining endoscopic ossiculoplasty proficiency. We compared the results with those of microscopic ossiculoplasty.Subjects and Method We analyzed 48 patients of ossiculoplasties performed from 2010 to 2020. Patients were divided into three groups: microscopic technique group (n=16); endoscopic early phase group (n=16); endoscopic late phase group (n=16). Operation time and hearing results including postoperative air-bone gap (ABG) and ABG closure were analyzed. Hearing outcomes were considered “successful” when the postoperative ABG was less than 20 dB and considered “excellent” when ABG was less than 10 dB. The learning curve of the outcomes were analyzed.Results Both operation time and postoperative ABG showed decreasing tendency, but only operation time showed statistical significance. The ratio of successful and excellent operations improved, but did not show statistical significance. Improvement in learning curve was not statistically significant presumably due to the lack of patient numbers.Conclusion Surgeon’s proficiency of endoscopic ossiculoplasty was correlated with the improved clinical outcomes, and proficiently conducted endoscopic ossiculoplasty could be used as a surgical technique comparable to microscopic ossiculoplasty.

Full-endoscopic Foraminotomy in Degenerative Spondylolisthesis: A “Module-based” Approach for Surgical Planning and Execution

Purpose Degenerative Lumbar Spondylolisthesis (DSL) is a common spinal pathology characterized by the anterior slippage of one vertebral body on another. DSL is caused mainly by degeneration of the intervertebral disc in the first place, with subsequent degeneration of the facet joints that end causing the slippage. As the disease evolves, stability is restored as a result of advanced degeneration and disc collapse. But while this natural evolution takes place, DSL may produce radicular symptoms by different mechanisms. To present a “module-based” approach for the surgical planning and execution of full-endoscopic foraminotomy in DSL, combined with case examples of the most common surgical scenarios. Methods We propose a “module-based surgery” using the standard endoscopic foraminotomy technique as a baseline. According to the patient’s clinical and imaging characteristics, several “modules” can be added. The resulting endoscopic surgery is a summation of the basic endoscopic foraminotomy plus all the additional required modules. ResultsSurgical modules description and case examples are provided. ConclusionTransforaminal lumbar endoscopic foraminotomy represents a minimally invasive technique to treat foraminal and combined foraminal-lateral recess stenosis. DSL and its multiple scenarios represent a challenge to the endoscopic surgeon. Module-based approach can help systematize and execute these demanding endoscopic procedures.

'Stenting the Lacrimal System in Modified Denker's for Mucormycosis: Really Needed!'-A Longitudinal Study.

Recent advances in endoscopic paraphernalia have brought the once intricate anterior lateral wall of maxilla, within reach of the endoscopic surgeon. Endoscopic modified Denker's approach provides another route to reach the indiscernible sites of maxillary & other paranasal sinuses along with PPF (pterygo-palatine fossa)/ITF (infra-temporal fossa) region. This approach has been widely used Pan-India during the Post-Covid Mucormycosis Epidemic, in our country. As this approach mandates sacrifice of nasolacrimal duct, the suspicion in some quarters about post-op fibrosis and eventually obstruction of lacrimal drainage is genuine. The aim is to understand the legitimate effect of this approach on lacrimal drainage pathway and to determine the need for modification in this approach, like stenting the NLD. In total, 100 patients who underwent endoscopic modified Denker's maxillectomy for invasive rhino-orbito-cerebral mucormycosis were included in study. The patency of lacrimal drainage was checked by doing lacrimal sac syringing in each patient. Proportion of patients showing obstruction of lacrimal pathway was calculated. The ratio of lacrimal obstruction was found to be 9%. Hence, endoscopic modified Denker's approach for lesions involving anteroinferior and anterolateral part of maxillary sinus does not cause significant obstruction in the lacrimal drainage pathway.

Use artificial neural network to recommend the lumbar spinal endoscopic surgical corridor.

The transforaminal and interlaminar approaches are the two main surgical corridors of full endoscopic lumbar surgery. However, there are no quantifying methods for assessing the best surgical approach for each patient. This study aimed to establish an artificial intelligence (AI) model using an artificial neural network (ANN). Patients who underwent full endoscopic lumbar spinal surgery were enrolled in this research. Fourteen pre-operative factors were fed into the ANN. A three-layer deep neural network was constructed. Patient data were divided into the training, validation, and testing datasets. There were 899 patients enrolled. The accuracy of the training, validation, and test datasets were 87.3%, 85.5%, and 85.0%, respectively. The positive predictive values for the transforaminal and interlaminar approaches were 85.1% and 89.1%, respectively. The area under the curve of the receiver operating characteristic was 0.91. The SHapley Additive exPlanations algorithm was utilized to explain the relative importance of each factor. The surgical lumbar level was the most important factor, followed by herniated disc localization and migrating disc zone level. ANN can effectively learn from the choice of an experienced spinal endoscopic surgeon and can accurately predict the appropriate surgical approach.

Difficulties, Challenges, and the Learning Curve of Avoiding Complications in Lumbar Endoscopic Spine Surgery.

Spinal endoscopy has the stigma of being reserved for only a few surgeons who can figure out how to master the steep learning curve and develop clinical practice settings where endoscopic spine surgery can thrive. In essence, endoscopic treatment of herniated discs specifically and nerve root compression in the lumbar spine in general amounts to replacing traditional open spine surgery protocols with spinal endoscopic surgery techniques. In doing so, the endoscopic spine surgeon must be confident that the degenerative spine's common painful problems can be handled with endoscopic spinal surgery techniques with at least comparable clinical results and complication rates. In this review article, the authors illustrate the difficulties and challenges of the endoscopic lumbar decompression procedure. In addition, they shed light on how to master the learning curve by systematically looking at all sides of the problem, ranging from the ergonomic aspects of the endoscopic platform and its instruments, surgical access planning, challenging clinical scenarios, complications, and sequelae, as well as the training gaps after postgraduate residency and fellowship programs.

Treatment of ureteropelvic junction obstruction and urolithiasis in children with minimally invasive surgery.

Ureteropelvic Junction Obstruction (UPJO) is the most common congenital ureteral anomaly. Nowadays, according to the increasing incidence of urolithiasis, 20% of children with UPJO presents urolithiasis. Open pyeloplasty was the standard treatment before the introduction of minimally invasive surgery (MIS). Nevertheless, only scattered experiences on MIS were previously described and universal agreement on the treatment of UPJO plus urolithiasis is still missing. The study aim was to describe our experience with a series of pediatric patients affected by UPJO and urolithiasis treated with robot-assisted pyeloplasty (RAP) and endoscopic removal of stones using a flexible cystoscope and a stones basket in a singular tertiary referral center. We retrospectively reviewed our data from pediatric patients affected by UPJO and urolithiasis undergoing RAP between April 2013 and December 2019. The analysis was conducted on seven patients. All procedures were performed by one expert robotic surgeon and one endoscopic surgeon skilled in the management of urolithiasis. The mean age was 7 years (IQR 4-16). The median stone area was 77.7 mm two (IQR 50.2-148.4). Most of them (71.4%) presented preoperative symptoms. The median operative time was 110 min (IQR 104-125) with a console time of 90 (IQR 90-105). The median length of stay was 5 days (IQR 4-5). Median follow-up was 16 months (IQR 10-25). RAP with concomitant flexible ureteroscope is a safe and effective option for the simultaneous management of UPJO with urolithiasis with excellent outcomes in children.

Early Career Challenges in Setting Up an Endoscopic Spine Surgery Practice

After the completion of an endoscopic spinal surgery fellowship, the next challenge for the newly minted consultant is to set up a viable and sustainable endoscopic practice. A successful practice of endoscopic spine surgery is dependent on several factors, such as anesthetic support; surgical expertise; support for provision and maintenance of endoscopic equipment; cost of equipment; administrative and nursing support; postoperative care services to optimize patients' outcome and satisfaction; patients' ideas, concerns, and expectations, as well as continuing medical education. In this article, a perspective is given on the early career challenges that a fellowship-trained endoscopic surgeon may encounter in the period leading to first successful endoscopic spinal surgery.

Ventilated Upper Airway Endoscopic Endonasal Procedure Mask: Surgical Safety in the COVID-19 Era.

BACKGROUNDCOVID-19 poses a risk to the endoscopic skull base surgeon. Significant efforts to improving safety have been employed, including the use of personal protective equipment, preoperative COVID-19 testing, and recently the use of a modified surgical mask barrier.OBJECTIVETo reduce the risks of pathogen transmission during endoscopic skull base surgery.METHODSThis study was exempt from Institutional Review Board approval. Our study utilizes a 3-dimensional (3D)-printed mask with an anterior aperture fitted with a surgical glove with ports designed to allow for surgical instrumentation and side ports to accommodate suction ventilation and an endotracheal tube. As an alternative, a modified laparoscopic surgery trocar served as a port for instruments, and, on the contralateral side, rubber tubing was used over the endoscrub endosheath to create an airtight seal. Surgical freedom and aerosolization were tested in both modalities.RESULTSThe ventilated mask allowed for excellent surgical maneuverability and freedom. The trocar system was effective for posterior surgical procedures, allowing access to critical paramedian structures, and afforded a superior surgical seal, but was limited in terms of visualization and maneuverability during anterior approaches. Aerosolization was reduced using both the mask and nasal trocar.CONCLUSIONThe ventilated upper airway endoscopic procedure mask allows for a sealed surgical barrier during endoscopic skull base surgery and may play a critical role in advancing skull base surgery in the COVID-19 era. The nasal trocar may be a useful alternative in instances where 3D printing is not available. Additional studies are needed to validate these preliminary findings.

Learning curve for endoscopic tympanoplasty type I: comparison of endoscopic-native and microscopically-trained surgeons

PurposeType I tympanoplasty is one of the first operations to be performed by ear surgeons in training and is increasingly performed using the endoscopic technique. The aim of the present study is to assess and compare the learning curve for type I tympanoplasties between a microscopically trained and endoscopic native ear surgeon. We hypothesize comparable learning curves between the two surgeons regardless of previous microscopic experience.MethodsRetrospective analysis and comparison of the 25 first consecutive cases of type I tympanoplasty performed by a microscopically trained ear surgeon (MTES) and a native endoscopic ear surgeon (NEES).ResultsMean duration of surgery in MTES and NEES groups was 54 ± 12.3 min and 55.6 ± 17.5 min, respectively. Both surgeons achieved a reduction of the surgery duration over time with statistically significant reduction from the first five cases to the last five cases in both groups. Graft intake rate was 92% after 3 months. Preoperative and postoperative PTA revealed a mean improvement of air bone gap (ABG) of 11.5 ± 7.1 dB HL in MTES group versus 9.3 ± 8.5 dB HL in NEES group, whereby the difference between the two groups was not statistically significant.ConclusionEndoscopic type I tympanoplasty shows comparable results and learning curves in two beginning endoscopic ear surgeons independent of the previous microscopic experience. We recommend if available the parallel learning of both techniques.

Nerve-Sparing Modified Radical Hysterectomy for Severe Endometriosis and Complex Pelvic Pathology.

BackgroundLaparoscopic nerve-sparing modified radical hysterectomy with or without robotic assistance is known for its benefits as a definitive treatment for severe endometriosis. Undiagnosed endometriosis is common in patients with symptomatic fibroids or chronic pelvic pain. There are minimal studies that outline the safety and feasibility of nerve-sparing modified radical hysterectomy for other complex pelvic pathology in addition to endometriosis.ObjectivesThe aim of this study is to evaluate the incidence of hospital readmission, intraoperative and postoperative complications, and long-term pain relief after laparoscopic nerve-sparing modified radical hysterectomy for severe endometriosis and complex benign pelvic pathology.Study designWe performed a retrospective observational study of patients who underwent laparoscopic nerve-sparing modified radical hysterectomy with and without robotic-assistance with a high-volume minimally invasive endoscopic surgeon between November 2017 and December 2019.ResultsA total of 112 patients met the inclusion criteria. There were no cases of vaginal cuff dehiscence, venous thromboembolism, genitourinary system injury, gastrointestinal tract injury, vessel injury, nerve injury, sepsis, or death. Three patients required postoperative hospital admission for the management of umbilical cellulitis, acute blood loss anemia, and possible Addison’s crisis. Other postoperative complications included allergic reaction to adhesives (1.8%) and urinary retention (0.9%). All patients reported significant pain relief at the time of their postoperative visits. Three patients reported return of pain symptoms within the first seven months after surgery, with one requiring an additional surgery for persistent pain.ConclusionsLaparoscopic nerve-sparing modified radical hysterectomy with or without robotic assistance is a safe and feasible alternative that provides long-term symptom relief in patients undergoing hysterectomy for a variety of indications.

Expanded Endoscopic Endonasal Transtuberculum Approach for Tuberculum Sellae Meningioma: Operative Video With 360-Degree Fly-Through and Surgical Rehearsal in Virtual Reality: 2-Dimensional Operative Video.

This video demonstrates the technique of the "Expanded Endoscopic Endonasal Transtuberculum Approach" and the utility of preoperative planning and surgical rehearsal in virtual reality (VR). VR can be utilized to improve endoscopic skull base surgery in various ways. The patient is a 57-yr-old woman with sudden right abducens palsy. Transcranial surgery has been the gold-standard treatment of the tuberculum sellae meningioma that was found, but for suitable tumors, the endoscopic endonasal approach is equally effective for tumor resection with better visual outcomes.1-4 The three-dimensional, 360°, multicolored VR rendering (Surgical Theater SRP7.4.0, Cleveland, Ohio) of her tuberculum sellae meningioma clearly demonstrated that there was no encasement of the anterior cerebral arteries, the tumor did not extend lateral to the carotid arteries, and the surgical corridor was wide enough for endoscopic endonasal resection. The surgical exposure was then rehearsed with the sphenoidectomy and drilling of the sella floor and tuberculum performed in VR space. The step-by-step process of the endoscopic endonasal transtuberculum resection is demonstrated in the operative video. Surgical planning in VR can be helpful to the early-career endoscopic surgeon. The three-dimensional renderings are quick to set up (15 min), and the examination of the anatomy is useful for choosing the surgical approach. Despite the lack of haptic feedback and tissue response such as vascularity and firmness in the current software, rehearsing the drilling for exposure can improve the efficiency in surgery. Patient consent was obtained prior to the creation of the video and is available on request.