Expanded Endoscopic Endonasal Research Articles

Handheld robotic device for endoscopic neurosurgery: system integration and pre-clinical evaluation.

The Expanded Endoscopic Endonasal Approach, one of the best examples of endoscopic neurosurgery, allows access to the skull base through the natural orifice of the nostril. Current standard instruments lack articulation limiting operative access and surgeon dexterity, and thus, could benefit from robotic articulation. In this study, a handheld robotic system with a series of detachable end-effectors for this approach is presented. This system is comprised of interchangeable articulated 2/3 degrees-of-freedom 3 mm instruments that expand the operative workspace and enhance the surgeon's dexterity, an ergonomically designed handheld controller with a rotating joystick-body that can be placed at the position most comfortable for the user, and the accompanying control box. The robotic instruments were experimentally evaluated for their workspace, structural integrity, and force-delivery capabilities. The entire system was then tested in a pre-clinical context during a phantom feasibility test, followed up by a cadaveric pilot study by a cohort of surgeons of varied clinical experience. Results from this series of experiments suggested enhanced dexterity and adequate robustness that could be associated with feasibility in a clinical context, as well as improvement over current neurosurgical instruments.

Efficacy of the Craniopharyngioma Resection via Expanded Endoscopic Endonasal Transsphenoidal Approach in the Treatment of Complex Craniopharyngioma and Its Effect on Pituitary Function and Complications of Patients.

Surgical resection is the most effective method for craniopharyngioma, with complex operations and a high incidence of complications, especially for complex craniopharyngioma. The study focuses on selecting a proper surgical method to treat complex craniopharyngioma. A clinical study was conducted in this direction to explore the efficacy of expanded endoscopic endonasal transsphenoidal approach (EETS) and transcranial approach (TCA) in the treatment of complex craniopharyngioma and their effects on pituitary function and complications of patients. The clinical data of 73 patients with complex craniopharyngioma in Baoding No.2 Central Hospital from December 2017 to December 2022 were retrospectively analyzed. 13 patients who did not meet the admission criteria were excluded, and 60 patients were finally included. The included patients were divided into the TCA and EETS groups according to the treatment method. The surgical conditions, total tumor resection rate, clinical remission rate, and complications of patients in two groups were compared. The pituitary function of all patients, including thyroid stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), and human growth hormone (hGH), was compared. A total of 60 patients were finally included in the study, including 30 cases in the EETS group and 30 cases in the TCA group. The two groups had no statistical difference in baseline demographic characteristics and pathological types (p > 0.05). Compared with the TCA group, the EETS group had less intraoperative blood loss, operation time, tumor resection time, and hospitalization time (p < 0.001) and had a significantly higher total tumor resection rate and clinical remission rate (p < 0.05). The EETS group had higher ACTH and hGH levels than the TCA group (p < 0.05). There was no statistical difference between the two groups incidence of complications and disease recurrence rate (p > 0.05). The craniopharyngioma resection via EETS has a significant therapeutic effect in complex craniopharyngioma with a high total tumor resection rate and clinical remission rate, which can protect the pituitary function of patients and provide more benefits for patients.

Limitations and Outcomes of Minimally Invasive Expanded Endoscopic Endonasal Odontoidectomy: A Retrospective Analysis of the University of Ottawa Experience

Limitations and Outcomes of Minimally Invasive Expanded Endoscopic Endonasal Odontoidectomy: A Retrospective Analysis of the University of Ottawa Experience

Tension Pneumocephalus: A Potentially Fatal Complication of Expanded Endoscopic Endonasal Approach.

While some volume of pneumocephalus occurs following any surgery entailing dural breach, tension pneumocephalus (TP) is a rare complication of endoscopic endonasal surgery described in less than 1% cases including expanded endoscopic endonasal approaches (EEEA). It is a neurosurgical emergency warranting urgent decompression. Two cases, who developed TP following EEEA are presented. One had sinonasal malignancy (adenoid cystic carcinoma) eroding the anterior skull-base (T4N0M0) and the other was a large olfactory groove meningioma. TP was heralded in both by sudden deterioration in neurological status. Both cases underwent bifrontal craniotomy for decompression with simultaneous skull-base repair incorporating a vascularised pericranial flap. Brief literature review regarding the pathophysiology, contributing factors, diagnosis, management, and prevention of TP following EEEA is presented. TP, a life-threatening neurosurgical emergency, warrants meticulous precautions for its prevention, and vigilant postoperative monitoring for early detection. Urgent decompression with thorough skull-base repair is imperative to prevent complications.

Surgical Outcomes and Limitations of Expanded Endoscopic Endonasal Odontoidectomy

Surgical Outcomes and Limitations of Expanded Endoscopic Endonasal Odontoidectomy

Expanded Endonasal Endoscopic Approach for Suprasellar Rathke Cleft Cyst: Treatment Outcome and Surgical Nuances

Rathke cleft cysts (RCCs) are benign lesions originating from remnants of the Rathke pouch. RCCs have been classified into the intrasellar-based or purely suprasellar types. This research aims to study the optimal treatment nuances and evaluate the surgical outcomes of this distinct type of RCCs. This study retrospectively reviewed 36 patients with purely suprasellar RCCs who were treated by expanded endonasal endoscopic approach (EEA) from September 2018 to January 2021. The demographic data, presenting symptoms, endocrine status, imaging findings, operative details, and surgical outcomes were analyzed. According to the relationship with pituitary stalk, the suprasellar RCCs can be divided into 2 different growth patterns: intrastalk cyst (ISC, 52.8%) and extrastalk cyst (ESC, 47.2%). Preoperative endocrine dysfunctions occurred more in patients with ISC than ESC (P= 0.007), which are characterized by hypoadrenalism (P= 0.004) and hypogonadism (P= 0.008). Operation exerted different impacts on endocrine functions between ISC and ESC (P= 0.012). When identifying by single hypothalamic-pituitary axis, 4 patients with normal endocrine function developed a new hormonal deficit, 14 patients with preoperative endocrine dysfunctions benefited from our expanded EEA surgical treatment, and 3 of them completely recovered from the endocrinopathy after surgery. The postoperative endocrinopathy was positively associated with the numbers of preoperative abnormal endocrinal axes. Thirty-four (94.4%) patients had achieved gross total resection. Pituitary stalk was intactly preserved in 23 of 36 patients (63.9%), partly preserved in 10 patients, and not preserved in 3 patients. Purely suprasellar RCCs are a distinct type of RCCs, which originate from the pituitary stalk above the diaphragmatic sellae, and the treatment strategy via expanded EEA is a rational choice. Classification based on growth patterns would be beneficial to reduce endocrine disorders after surgery.

Expanded Endoscopic Endonasal Approach and Adjuvant Radiotherapy for the Treatment of Locally Advanced Sinonasal and Skull Base Adenoid Cystic Carcinoma: Case Report and Literature Review

Expanded Endoscopic Endonasal Approach and Adjuvant Radiotherapy for the Treatment of Locally Advanced Sinonasal and Skull Base Adenoid Cystic Carcinoma: Case Report and Literature Review

A Spherical Joint Robotic End-Effector for the Expanded Endoscopic Endonasal Approach

The endonasal transsphenoidal approach allows surgeons to access the pituitary gland through the natural orifice of the nose. Recently, surgeons have also described an Expanded Endoscopic Endonasal Approach (EEEA) for the treatment of other tumours around the base of the brain. However, operating in this way with nonarticulated tools is technically very difficult and not widely adopted. The goal of this study is to develop an articulated end-effector for a novel handheld robotic tool for the EEEA. We present a design and implementation of a 3.6[Formula: see text]mm diameter, three degrees-of-freedom, tendon-driven robotic end-effector that, contrary to rigid instruments which operate under fulcrum, will give the surgeon the ability to reach areas on the surface of the brain that were previously inaccessible. We model the end-effector kinematics in simulation to study the theoretical workspace it can achieve prior to implementing a test-bench device to validate the efficacy of the end-effector. We find promising repeatability of the proposed robotic end-effector of 0.42[Formula: see text]mm with an effective workspace with limits of [Formula: see text], which is greater than conventional neurosurgical tools. Additionally, although the tool’s end-effector has a small enough diameter to operate through the narrow nasal access path and the constrained workspace of EEEA, it showcased promising structural integrity and was able to support approximately a 6N load, despite a large deflection angle the limiting of which is scope of future work. These preliminary results indicate the end-effector is a promising first step towards developing appropriate handheld robotic instrumentation to drive EEEA adoption.

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.

Commentary: 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.

Commentary: 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.

Concerns of cerebrospinal fluid leak in aggressive expanded endonasal endoscopic approach for craniopharyngiomas

Cerebrospinal fluid leak represents a frequent complication in Craniopharyngioma´s Endoscopic Endonasal Approach. A descriptive observational investigation was performed in 50 adult patients operated of Craniopharyngiomas by aggressive Expanded Endonasal Endoscopic Approach (EEEA) in “Hermanos Ameijeiras” Hospital since 2010 to 2019 using nasoseptal flap. The 14% of all patients develop CSF leak and 85,7 % of these cases had a great communication into third ventricle creating a cisternoventricular space. Was identified relation with tumor size, hypothalamic invasion and adhesion strength of tumour. Surgical cavity suffered hydrostatic and hydrodynamic pression than lead to CSF leak independent of multilayer reparation.

Expanded Endoscopic Endonasal Approach for Resection of Intradural Chordoma: Surgical and Anatomic Nuances: 2-Dimensional Operative Video.

The expanded endoscopic endonasal approach (EEA) has been growing as a surgical alternative for the treatment of clival chordomas because of their frequent midline location and bone erosion. The endoscopic transclival approach provides with a safer and more direct anatomic route for tumors located predominantly in the midline contributing to minimize postoperative comorbidities. In this video, we demonstrate the step-by-step technique for resection of such challenging clival pathology. This is an operative video of an extended endoscopic resection of a clival chordoma with stepwise description of the surgical technique. We present the case of a 49-yr-old man in whom, incidentally in the context of low testosterone level, a clival lesion with purely midline location with intradural extension into the ventral brainstem and occupation of the left cerebellopontine angle was discovered. The patient was submitted to an expanded endoscopic transclival approach and a macroscopic gross total resection was successfully achieved. The final pathology was compatible with a conventional chordoma. This video details the surgical anatomy of the clival region to facilitate the identification of surgical landmarks and anatomic boundaries with the goal of avoiding injury to the neurovascular structures involved in this approach. Extended endoscopic transclival surgery is a useful and safer option for the management of midline chordomas because it provides with a dissection corridor free of major neurovascular structures. Endoscopic techniques are associated with good outcomes in terms of macroscopic gross total resection and low surgical risks in these selected tumors.

Expanded Endoscopic Endonasal Approach to the Inframeatal Area: Anatomic Nuances with Surgical Implications

The inframeatal area represents a challenging region for skull base surgeons. Various surgical corridors have been described to access this area and frequently are used in combination. Recent studies describe the expanded endoscopic endonasal approach (EEA) as an established route for midline regions, particularly medial to the internal carotid arteries (ICA). We sought to evaluate the accessibility, maneuverability, and freedom of movement of the expanded endoscopic endonasal approach to the inframeatal region. An EEA combining a middle and an inferior transclival corridor with an infrapetrous and a supracondylar lateral expansion was performed in 5 embalmed human cadaveric heads. The area of exposure and the surgical freedom to access the inframeatal area were calculated. The angle of attack and distances from the lacerum segment of the ICA to several anatomical targets also were measured. Our database was searched to select clinical case examples. The EEA provided an exposure area of 101.26 ± 16.66 mm2 and an area of surgical freedom of 1208.50 ± 507.01 mm2. The angles of attack in both the sagittal and axial planes were wider at the lacerum segment of the ICA and narrower at the dural entrance zone of cranial nerves VII/VIII. Three chondrosarcomas are presented as case illustrations. The EEA is a feasible route to the inframeatal area. This approach provides a safe working corridor for lesions in this region, as shown by the anatomical and clinical findings presented here. Comparative studies and large case series are warranted to further establish its clinical value.

The Role of the Expanded Endoscopic Endonasal Approach in Staged Surgery for Giant Olfactory Groove Meningioma: Technical Nuances

The Role of the Expanded Endoscopic Endonasal Approach in Staged Surgery for Giant Olfactory Groove Meningioma: Technical Nuances

A Cadaveric Study to Evaluate the Reaches of Far Lateral and Expanded Endonasal Endoscopic Approaches to the Brainstem: Does a Combined Approach Result in Better Visualization versus either Approach Alone?

Objective: A cadaveric study to evaluate the reaches of far lateral and expanded endonasal endoscopic approaches to the brainstem. Does a combined approach result in better visualization versus either approach alone?

Resection of the Odontoid Process through Expanded Endoscopic Endonasal Approach: Our Clinical Experience and Surgical Techniques

Resection of the Odontoid Process through Expanded Endoscopic Endonasal Approach: Our Clinical Experience and Surgical Techniques

Expanded Endoscopic Endonasal Transtuberculum / Transplanum Approach to the Suprasellar Area: A Stepwise Approach

The Expanded Endoscopic Endonasal Transtuberculum / Transplanum (EEETT) approach emerged as an amenable option to remove midline lesions, such as giant pituitary tumors, craniopharyngiomas, and tuberculum sellae meningiomas. Herein, the author's aim is to show a stepwise approach to the suprasellar area by EEETT and a case illustration.

The Expanded Endoscopic Endonasal Approach to Anterior Communicating Artery Aneurysms: A Cadaveric Morphometric Study

The purpose of this study was to explore the endoscopic endonasal approach to the anterior communicating artery complex. Anatomic, morphometric analysis of human cadaver heads. Fifteen latex-injected adult cadaver heads. The anatomic boundaries of the operative field and the dimensions of exposure of the anterior communicating artery (ACoA) complex were measured and clip placement feasibility was assessed. Exposure of the ACoA and bilateral A1 and A2 segments was accomplished in all 15 cadaver heads. Average length of the exposed ACoA was 3 ± 1 mm, the left A1 was 5 ± 3 mm and right A1 was 5 ± 1 mm, while the A2 segment was 5 ± 2 mm bilaterally. The average distance from the alar floor to the ACoA was 95 mm, while proximal lateral limit measured between the alar floor margins was 36 mm. The distal lateral limit as defined by the distance between the lateral most exposed margins of the chiasm was 19 mm. Clip placement was accomplished for the ACoA and the A1 and A2 segments bilaterally in all specimens. The endoscopic, endonasal transtuberculum, transplanum approach is an anatomically feasible alternative to treating select aneurysms of the ACoA complex.

A New Window for the Treatment of Posterior Cerebral Artery, Superior Cerebellar Artery, and Basilar Apex Aneurysm: The Expanded Endoscopic Endonasal Approach

A New Window for the Treatment of Posterior Cerebral Artery, Superior Cerebellar Artery, and Basilar Apex Aneurysm: The Expanded Endoscopic Endonasal Approach

A New Window for the Treatment of Posterior Cerebral Artery, Superior Cerebellar Artery, and Basilar Apex Aneurysm: The Expanded Endoscopic Endonasal Approach.

To explore the feasibility of an endoscopic endonasal transclival approach to treat aneurysms arising in the basilar apex, posterior cerebral arteries, and superior cerebellar arteries. Cadaveric anatomical study. Fifteen cadaveric specimens. Degree of surgical exposure of each artery attained, distance from the nasal vestibule to these three arteries, and feasibility of clipping these vessels using standard vascular clip applicators. Both posterior cerebral arteries were exposed, 0.67 cm (standard deviation [SD]: 0.2) on the right side and 0.59 cm (SD: 0.2) on the left side. Both right and left superior cerebral arteries were exposed, 0.6 cm (SD: 0.2) and 0.7 cm (SD: 0.3), respectively. The length of the basilar artery exposed was 2.6 cm (SD: 0.3). The distance from the nasal vestibule to the posterior cerebral artery, superior cerebellar artery, and basilar apex was 10 cm with an SD of ± 0.7, 0.6, and 0.8 cm, respectively. We were able to apply clips on each of these three vessels with a minimal alteration of surrounding normal tissue. The endoscopic endonasal transclival approach represents a potentially feasible surgical corridor to treat aneurysms arising from these vessels.