Natural Orifice Endoscopic Surgery Research Articles

Comparison of Prone With Lithotomy Position in Removal of Posterior Myoma in Transvaginal Natural Orifice Endoscopic Surgery: A Prospective Cohort Study

ObjectiveVaginal natural orifice transluminal endoscopic surgery (vNOTES) is considered to have the advantages of completely scarless, less postoperative pain, earlier flatus, and faster postoperative recovery. However, posterior myoma are relatively difficult to operate through vNOTES in the conventional lithotomy position. Thus, we innovated the application of prone position in the removal of posterior myoma in vNOTES. The aim of this study is the comparison of myomectomy outcomes of patient for single posterior myoma in prone and lithotomy position. DesignA single-center, prospective study. SettingA university teaching hospital. PatientsA total of 81 patients with posterior myoma who underwent myomectomy in vNOTES from January 2021 to December 2022. InterventionsThe patients underwent myomectomy in vNOTES in prone or lithotomy position. Measurements and Main ResultsAmong the patients who underwent vNOTES myomectomy, 29 (35.8%) were in the lithotomy position group, and 52 (64.2%) in the prone position group. Of note, 4 (4.9%) patients underwent a conversion to LESS during the operation—3 in the lithotomy and 1 in the prone position group. And a patient in the lithotomy position group underwent resurgery for hemostasis due to postoperative pelvic bleeding. Compared with the lithotomy position, prone position significantly shortens the operation time (12.3, 95% CI: 6.811, 17.761. p = .009) without increasing the complications and postoperative discomfort of patients. ConclusionCompared to the lithotomy position, the prone position provides greater convenience for operation and exhibits a lower rate of surgical conversion during the removal of single posterior myomas via vNOTES. Further, for patients selecting vNOTES, surgeons need to conduct sufficient preoperative evaluation, timely hemostasis during surgery, and timely surgical conversion if necessary to ensure patient safety.

Transvaginal natural orifice endoscopic surgery for tubal ectopic pregnancy: A more suitable surgical approach for enhanced recovery after surgery

ObjectiveWe aimed to determine the safety of Vaginal natural orifice transluminal endoscopic surgery (vNOTES) in terms of the Enhanced Recovery after Surgery (ERAS) concept for tubal pregnancy surgery and provide a detailed process of vNOTES for tubal pregnancy surgery, including experience and key points for surgeons performing this procedure. MethodsThe Longitudinal Vaginal Natural Orifice Transluminal Endoscopic Surgery Study (LovNOTESS), which was conducted in Chengdu, China. A total of 219 patients who underwent tubal ectopic pregnancy surgery between September 2021 and March 2022. The patients underwent salpingectomy or salpingostomy using transumbilical laparoendoscopic single-site surgery (LESS) or vNOTES, according to their preferences. This study prospectively collected perioperative and one-year follow-up data on tubal pregnancy outcomes after vNOTES and compared them with those after LESS. ResultsThe vNOTES group showed a shorter surgical duration, hospitalization duration, and postoperative exhaust time and a lower analgesic medication usage rate, but it showed a higher surgical conversion rate. The vNOTES approach reduced the postoperative exhaust time by approximately 9 h (95% confidence interval [CI]: −11.93, −5.57 h, p < .001) and the risk of postoperative analgesic drug use by 77% (odds ratio, 0.23; 95% CI: 0.10, 0.61, p = .023). ConclusionvNOTES can shorten the exhaust time and duration of hospitalization, reduce postoperative pain, and avoid surface surgical scars in tubal pregnancy surgeries, consistent with the ERAS concept. However, more comprehensive preoperative evaluation of patients who choose vNOTES is required to reduce the occurrence of intraoperative conversion.Trial registration: ChiCTR2100053483.

Transvaginal natural orifice endoscopic surgery (vNOTES) for elderly patients.

To evaluate the feasibility and safety of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) in patients 70 years and over. The study consisted of eleven patients aged 70 and over who underwent vNOTES for a variety of gynaecological indications at a tertiary referral hospital. The medical and surgical data were noted: age, parity, history of comorbidity, number and type of previous surgeries, body mass index (BMI), operating time, the requirement of intraoperative conversion, the presence of intra- or postoperative complication, estimated blood loss, pre-and postoperative hemoglobin levels, visual analog scale (VAS) pain scores at 6th, 12th and 24th hours, length of hospital stay, and the final pathology results. vNOTES surgery was performed safely and successfully in eleven patients. There were no intra- and postoperative complications or instances of conversions to conventional laparoscopy or laparotomy. The mean age of patients was 75.91 ± 6.47 (range 70-93), and the mean BMI was 42.49 ± 8.77 kg/m2 (range 30.2-56). Seven cases of endometrioid adenocarcinoma, two cases of uterine leiomyoma, one case of complex atypical hyperplasia, and one case of postmenopausal uterine bleeding due to atrophic endometrium were diagnosed. All endometrial carcinomas were early stage; no adjuvant therapy was needed. vNOTES seems to be a safe and feasible approach for the treatment of gynecologic pathologies in elderly patients. This study suggests that vNOTES become a viable treatment option for existing minimally invasive procedures since it offers better surgical outcomes in various gynecologic surgeries.

Transvaginal natural orifice endoscopic surgery for ovarian cystectomy: a more suitable surgical approach for the day-care procedure.

Although previous studies have shown that vaginal natural orifice transluminal endoscopic surgery (vNOTES) has the advantages of causing less pain, faster recovery, and better concealment of surgical incisions, which aligns with the concept of the day-care procedure, this approach poses a greater risk of damaging adjacent organs (i. e., rectum and bladder) due to its anatomical specificity. Moreover, the day-care procedure may lead to relatively less preoperative evaluation and postoperative care. Hence, it is necessary to explore the safety and effectiveness of vNOTES for ovarian cystectomy in the day-care procedure, to provide a theoretical basis for the wider development of vNOTES surgery. This retrospective study included 131 patients at our hospital who underwent ovarian cystectomy from September 2021 to October 2022. Based on the surgical approach, patients were classified into transumbilical laparoendoscopic single-site surgery (LESS) and vNOTES groups. The patients' demographic characteristics and follow-up data were collected during the perioperative period and 1-month postoperatively. Vaginal natural orifice transluminal endoscopic surgery has less postoperative exhaust time, a lower postoperative 6-hour pain score, and a lower incidence of analgesic drug use, with higher surgical conversion incidence. Multiple linear regression analysis showed that the surgical conversion, chocolate cyst, bilateral cyst, and pelvic adhesion increased the operation duration by ~43 (95% CI: 10.309, 68.152, p < 0.001), 15 (95% CI: 6.342, 45.961, p = 0.036), 10 (95% CI: 3.07, 40.166, p = 0.019), and 8 (95% CI: 4.555, 26.779, p = 0.035) min, respectively. Interestingly, vNOTES decreased the operation duration by ~8.5 min (95% CI: -18.313, -2.699, p = 0.033). Vaginal natural orifice transluminal endoscopic surgery was equally safe and effective for ovarian cystectomy compared to LESS. vNOTES aligned with the concept of the day-care procedure due to its reduced postoperative pain, shorter exhaust time, and absence of scarring. However, surgeons should conduct a comprehensive preoperative evaluation and exclude patients suspected to have severe pelvic adhesions.

Transvaginal natural orifice endoscopic surgery for myomectomy: Can it be a conventional surgery?

As a new minimally invasive surgery, transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has been proved to be suitable for the treatment of a variety of gynecological benign diseases. However, compared with other minimally invasive surgeries that have been widely used, such as conventional multiport laparoscopy and transumbilical laparoendoscopic single-site surgery (LESS), their advantages and disadvantages and how to choose are still unknown. The purpose of our study is to compare the advantages and disadvantages of the three minimally invasive surgeries in myomectomy and to provide theoretical basis for the wider development of vNOTES surgery. This retrospective study included 282 patients at our hospital who underwent laparoscopic myomectomy from May 2021 to March 2022. Based on the surgical approach, patients were classified into multiport, transumbilical LESS, and vNOTES groups. The patients' demographic characteristics and follow-up data were collected during the perioperative period and at 1 month postoperatively. Among the three procedures, vNOTES had the shortest anal exhaust time but also the highest postoperative infection rate. Multiple linear regression analysis showed that the operative time increased by 3.5 min for each 1 cm increase in myoma, and intraoperative bleeding increased by approximately 12 ml. The average duration of single pores increased by 25 min compared to that of multiports, and the operative duration increased by 10.48 min for each degree of adhesion. For gynecologists who have mastered vNOTES, this procedure has the same efficacy and safety as the two existing minimally invasive surgeries in myomectomy, but it shows obvious advantages in postoperative recovery.

Transvaginal natural orifice endoscopic surgery for extremely obese patients with early-stage endometrial cancer.

The purpose of this study was to assess the feasibility and efficacy of transvaginal natural orifice transluminal endoscopic surgery (v-NOTES) staging surgery for extreme obese patients with early-stage type-1 endometrial cancer. Study included cases of extreme obese patients with early-stage endometrial cancer who underwent v-NOTES between January 2019 and June 2019 at a tertiary referral medical center. The following parameters were noted: patient age, body mass index (BMI), operating time, conversion to conventional laparoscopy or laparotomy, any intraoperative or postoperative complications, estimated blood loss, pre- and postoperative hemoglobin levels, postoperative pain scores of the patients using visual analogue scale (VAS) at 6th, 12th and 24th h, length of hospital stay and final pathology report. Six cases of extreme obese patients with early-stage endometrial cancer underwent hysterectomy and bilateral salpingo-oophorectomy via the transvaginal NOTES. These six patients had a mean body mass index of 51.4 kg/m2 (SD = 6,13). No conversion to conventional laparoscopy or even laparotomy was needed in any of these patients. No adjuvant therapy was needed since all of the patients had early-stage endometrial carcinoma. Given the increased risk of surgical morbidity and mortality associated with increasing BMI, it is paramount importance to establish safe surgical approaches to gynecological pathologies. We think that v-NOTES offers greater benefit to obese patients when performed by an experienced surgeon and v-NOTES is a safe, effective and feasible minimally invasive surgery in extreme obese patients with early endometrial cancer.

Outcome of optic nerve decompression through neuroendoscopic transethmoidal-sphenoidal approach in the treatment of traumatic optic neuropathy

Objective To investigate the outcome of optic nerve decompression through neuro-endoscopic transethmoidal-sphenoidal approach in the treatment of traumatic optic neuropathy (TON). Methods The consecutive clinical data of 29 patients (32 sides) with TON who were treated at Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University from December 2013 to February 2018 were retrospectively analyzed. Preoperative visual acuity results were as follows: no light perception (NLP) in 15 sides, light perception in 14 sides, and hand moving in 3 sides. All patients underwent optic nerve decompression through neuroendoscopic transethmoidal-sphenoidal approach assisted with intraoperative neuronavigation. High-resolution skull CT scan was performed before the operation. These aspects were documented including the anatomic landmark observed during operation, visual changes of the patients and operative complications. Results The follow-up periods were 5.2±1.1 months (range: 3 to 6 months). Postoperative visual acuity results were as follows: NLP in 10 sides, light perception in 4 sides, hand moving in 4 sides, counting finger in 5 sides, and logMAR≥0.02 in 9 sides. The effective rate of operation was 59.4% (19/32). No surgical complications such as internal carotid artery injury, cerebrospinal fluid rhinorrhea or anosmia occurred. Conclusion Optic nerve decompression through transethmoidal-sphenoidal approach seems to be an effective method for the treatment of TON. The anatomic landmarks of the surgical approach are clearly defined, and intraoperative neuronavigation contributes to the safety of operation and reduces the occurrence of complications. Key words: Optic nerve injuries; Natural orifice endoscopic surgery; Treatment outcome; Optic nerve decompression; Transethmoidal-sphenoidal approach

Application of multimodal image fusion in neuroendoscopic endonasal treatment of anterior skull base tumors

Objective To explore the value of multimodal image fusion technique in neuroendoscopic endonasal treatment of anterior skull base tumors. Methods The clinical data of 9 patients with anterior skull base tumors who underwent endoscopic surgery at Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University from January 2016 to June 2017 were retrospectively analyzed. CT, MRI, and CT angiography (CTA) images of the patient′s skull were fused before surgery, and intraoperative neuronavigation assisted surgical removal of the tumor was performed based on the results of the image fusion. This paper analyzed the effects of multimodal image fusion technology on demonstration of anterior skull base lesions and adjacent anatomical structures. Results During operation, multimodal image fusion clearly revealed the anterior skull base tumors together with adjacent neural tissues, blood vessels, bone structures, sphenoid sinus and septations. All 9 patients underwent successful operation. Among them, gross total resection of tumor was achieved in 6 cases and subtotal resection in 3 cases. No serious complications such as delayed hemorrhage, brain infection, and cerebrospinal fluid rhinorrhea occurred postoperatively. Conclusions In neuroendoscopic transnasal resection of the anterior skull base tumor, the application of multimodal image fusion technology combined with intraoperative neuronavigation can clearly show the location of tumor and its adjacent important structures, which helps improve the accuracy, safety, and effectiveness of the operation. Key words: Skull base neoplasms; Neurosurgical procedures; Neuronavigation; Natural orifice endoscopic surgery; Multimodal

Clinical outcomes of intraoperative skull base reconstruction in endoscopic endonasal skull base tumor resection

Objective To summarize the reconstruction strategy and efficacy for skull base defect in endoscopic endonasal skull base tumor resection. Methods The clinical outcomes of 202 patients with skull base defect who underwent endoscopic tumor resection at Department of Neurosurgery, Huashan Hospital, Fudan University from April 2011 to February 2016 were retrospectively analyzed. Skull base defects were intraoperatively classified into Ⅰ-Ⅲ grades based on the diameter of dura defect and flow of cerebrospinal fluid (CSF), and corresponding reconstruction strategies were adopted. Results The classification result of 202 skull base defects was 15.8%(32 cases) in Grade Ⅰ, 24.3%(49 cases) in Grade Ⅱ and 59.9%(121 cases) in Grade Ⅲ. Six patients (3.0%) had postoperative CSF rhinorrhea, which resolved following secondary endoscopic repair surgery. Four patients (2.0%) had intracranial infection which was finally cured by antibiotics medication. One elderly patient (0.5%) died of pulmonary infection after prolonged bed rest after surgery. Conclusions Endoscopic surgery seems safe and effective for the reconstruction of skull base defect. The occurrence of postoperative CSF leakage could be effectively avoided when specific reconstruction strategy is adopted according to the classification of skull base defect. Key words: Natural orifice endoscopic surgery; Skull base neoplasms; Reconstructive surgical procedures; Skull base defect

Application of microprobe vascular Doppler in the operation of skull base lesions

Objective To investigate the effect of microprobe vascular Doppler (MVD) on the operation of skull base lesions. Methods From September 2017 to September 2018, 13 patients with skull base lesions at Neurosurgery Department of the first Affiliated Hospital of Soochow University were retrospectively analyzed. The 13 cases included 6 cases of meningioma in Sellar region, 2 cases of meningioma in petroclival region, 3 cases of pituitary adenoma of Knosp Ⅲ-Ⅳ grade, 1 case of chordoma in Sellar clival region, and 1 case of invasive growth of granulation tissue in intraorbital, skull base, sphenoid and ethmoid sinus after Aspergillus infection. The surgical methods included neuroendoscopic transnasal approach and microsurgical resection under craniotomy microscope. MVD was applied in all operations of this series. Medical imaging examination and follow-up were performed after operation. Results Among the 13 patients, total resection of meningioma in Sellar region was performed in 6 cases and subtotal resection in 2, total resection of Knosp grade Ⅲ-Ⅳ pituitary adenoma was conducted in 2 and subtotal resection in 1. Total resection was performed in 1 case of invasive growth of granulation tissue in intraorbital, skull base, sphenoid and ethmoid sinus after Aspergillus infection and 1 case of chordoma in Sellar base clival region. Uncorrected left eye vision was reported in the patient with Aspergillus infection post surgery. Postoperative symptoms of the other patients were improved. The prolactin level of 1 patient with prolactin adenoma was more than 204 ng/ml before operation. At 2 months post operation, the prolactin level was 105.66 ng/ml after oral bromocriptine combined with radiotherapy. The last reexamination was 11.3 ng/ml without hypophysis dysfunction. Six patients had varying degrees of electrolyte disorder after operation. Four patients had fever after operation and all returned to normal before discharge from hospital after treatment. All patients were followed up for (16.1±3.3) months(10-22 months), and there was no recurrence in imaging examination. Conclusion With the aid of MVD during the surgical resection of invasive growth lesions and large space occupying lesions in the skull base, the important blood vessels invaded, wrapped, pushed and displaced by the lesions can be monitored in real time, which might help avoid the disastrous consequences during and after operation and reduce the risk of surgery. Key words: Skull base neoplasms; Microsurgery; Natural orifice endoscopic surgery; Microprobe vascular Doppler

Efficacy of neuronavigation-assisted endoscopic transsphenoidal surgery for invasive pituitary adenomas

Objective To explore the effect of neuronavigation-assisted endoscopic transsphenoidal surgery for invasive pituitary adenomas. Methods A retrospective analysis was conducted on 40 patients with invasive pituitary adenomas admitted to Department of Neurosurgery, Affiliated Dalian Municipal Central Hospital, Dalian Medical University from January 2010 to March 2018. Among those patients, 20 were treated with neuronavigation-assisted endoscopic transnasal sphenoidal surgery (endoscopic group) and the other 20 were treated with traditional transnasal microsurgery (control group). The complete tumor resection rate, postoperative complication rate and tumor recurrence rate were compared between the 2 groups. Results There were no significant differences in gender, age, clinical manifestations, endocrine examination results, Knosp classification of pituitary adenomas or maximum diameter of tumors between the 2 groups (all P>0.05). The total resection rate of endoscopic group was higher than that in the control group[65.0% (13/20) vs. 20.0% (4/20), P 0.05). Conclusion Neuronavigation-assisted endoscopic transnasal sphenoidal surgery for invasive pituitary adenomas is associated with higher total resection rate and lower recurrence rate compared with traditional transnasal sphenoidal microsurgery. Key words: Pituitary neoplasms; Neoplasm invasiveness; Neuronavigation; Natural orifice endoscopic surgery; Treatment outcome

Hysterectomy and Adenextomy via transvaginal natural orifice transluminal endoscopic surgery (vNOTES): A UK perspective with a case series of 33 patients

Objective: To evaluate operative outcomes of hysterectomy +/- adnexectomy by Trans-vaginal Natural Orifice Endoscopic Surgery (vNOTES) in a case series of 33 patients. Study Design: It was a prospective case series study carried out in Darent Valley and Benenden Hospital, to our knowledge, the first units in the United Kingdom to have undertaken VNOTE Hysterectomy.We collected data on a private shared drive noting patient demographics, indications for surgery, operation outcomes and patient follow-up details. Results and Conclusions: Between January and December 2018, 33 patients underwent surgery between two units. Indications for surgery included dysfunctional uterine bleeding, endometrial hyperplasia, pelvic pain, post-menopausal bleeding, prophylactic surgery in BRCA positive patients and one grade 1 stage 1 endometrial cancer in whom laparoscopic hysterectomy was technically difficult and complicated by previous midline laparotomy. Ages ranged from 35 to 75 and BMI from 20-53.Mean operation time was 68.5 min and mean blood loss intraoperatively was 269mls. 15.2% (n = 5) had a blood loss equal or more than 500 mls. There were no intraoperative complications and no conversions to open surgery.The median visual analogue pain score at 6 h post operatively and at discharge was 0. All patients received regular Paracetamol and Ibuprofen and opiate based analgesics were only used on an as required basis.Postoperative complication which included failed trial without catheter, urinary tract infection and urinary dysfunction were reported by four women (12.4%).Only 2 patients re-presented to hospital over a 30-day period and neither required inpatient management.Hysterectomy by vNOTES has advantages over traditional laparoscopic and vaginal hysterectomy that include reduced requirement for intra-abdominal insufflation and head down, absence of trocar related injuries and easier operative access in patients with morbid obesity, or previous abdominal surgery such as midline laparotomy or mesh hernia repair. In addition, both tubes and ovaries can be removed easily due to easier access and visibility and there is no requirement for vaginal descent in order to do so.Plans for a comparative study between laparoscopic hysterectomy and vNOTES hysterectomy are underway.

Neuroendoscopic cisternostomy for the treatment of pediatric intracranial arachnoid cysts

Objective To evaluate the clinical efficacy of neuroendoscopic cisternostomy for the treatment of intracranial arachnoid cysts (IACs) in children. Methods Thirty-one children in total with IACs who underwent neuroendoscopic cisternostomy from January 2010 to August 2017 at Department of Neurosurgery of the First Affiliated Hospital of Zhengzhou University were retrospectively enrolled. All cases were followed up in the aspect of clinical efficacy. Results Among 31 children, the improvement rate of clinical symptoms was 91.0% (20/22) in symptomatic patients after operation. The follow-up period ranged from 13 to 36 months, with an average of 21.0±5.6 months. Compared with preoperative data (Mean: 52.5 ml; P25, P75: 31.3 ml, 167.6 ml), the means of shrinkage rates of cyst volume at 3 months (Mean: 27.8 ml; P25, P75: 15.6 ml, 42.3 ml) and 12 months (Mean: 22.5 ml; P25, P75: 13.9 ml, 34.9 ml) post operation were 62.5+ 15.7% and 68.3+ 12.8% respectively with significant statistical differences (all P<0.05). Complications occurred in 7 (22.6%) cases during perioperative period, including fever in 2, subdural effusion in 3 (volume of effusion decreased significantly in 3 months and disappeared in 12 months after operation without obvious symptoms or particular treatment) and subcutaneous effusion in 2 cases. During the follow-up period, only 1 (3.2%) child developed intractable subcutaneous effusion. Conclusion Neuroendoscopic cisternostomy for the treatment of IACs in children seems safe and effective. Key words: Natural orifice endoscopic surgery; Arachnoid cysts; Child; Cystocisternotomy

Clinical application of in situ bone flap in skull base reconstruction in endoscopic endonasal surgery for craniopharyngioma

Objectives To compare different methods of the skull base reconstruction in craniopharyngioma surgery via extended endoscopic endonasal approach (EEEA) and to investigate the advantage and feasibility of in situ bone flap in skull base reconstruction. Methods Twenty-six cases with craniopharyngiomas who underwent complete osseous skull base reconstruction using in situ bone flap in skull base reconstruction and repair in EEEA were enrolled retrospectively into the experimental group at Department of Neurosurgery, Xijing Hospital, Air Force Medical University from July 2016 to December 2017. Thirty-one cases with craniopharyngiomas who underwent partial osseous skull base reconstruction using fashioned piece of nasoseptal bone or artificial bone matrix from March 2015 to June 2016 were enrolled into the control group. The rates of intracranial infection and lumbar cisterna drainage, time from surgery to out-of-bed activity and hospitalization length were compared between the 2 groups. Results Intracranial infection occurred in 2 cases in the control group, whereas no intracranial infection was reported in experimental group. There was no statistically significant difference between the 2 groups (P=0.291). Lumbar cisterna drainage rate in the control group (29.0%, 9/31)was significantly higher than that in the experimental group (3.8%, 1/26, P=0.013). Compared with those in control group, patients in the experimental group were able to get off bed earlier (7.5±1.1 d vs. 12.1±2.4 d, P<0.001). The hospitalization length in the control group was also longer than that in the experimental group (13.5±1.8 d vs. 8.2±0.9 d, P<0.001). There was no delayed cerebrospinal fluid leak or brain hernia during the follow-up period lasting for 3-32 months. Conclusions The multilayer repair using duramax, in situ bone flap and vascularized pedicled nasoseptal flap could significantly reduce the incidence of cerebrospinal fluid rhinorrhea and shorten hospitalization length. Skull base reconstruction using in situ bone flap seems to be an effective procedure for EEEA. The clinical efficacy of using the method in EEEA for craniopharyngioma is valid with bright prospects and deserves clinical promotion. Key words: Craniopharyngioma; Natural orifice endoscopic surgery; Extended endonasal approach; Skull base reconstruction; In situ bone flap

Anatomical study in exposed area and operating space of extended endonasal approach to the ventral region of cranio-cervical junction

Objective To explore the scope, feasibility and indications of extended neuroendoscopic endonasal approach to reveal the region of cranial-cervical junction. Methods Ten (20 sides) intact frozen adult cadaveric heads were used to simulate the extended neuroendoscopic endonasal approach to remove the anterior tubercle of atlas, part of the atlas anterior arch, odontoid and part of the slope. In the cranial-cervical junction area, we observed the exposed range and measured the distance from the nostril to the anterior tubercle of atlas, the height and width of the anterior arch of the atlas, the distance of bilateral medial margin of occipital condyle, the distance of bilateral medial margin of the foramen lacerum, the vertical distance from the occipital condyle to the homolateral foramen lacerum, and the height, anteroposterior diameter and transverse diameter of the odontoid. Results The exposed range of the extended neuroendoscopic endonasal approach was as follows: when the lesion was located at the foramen magnum, the medial margin of the occipital condyle was the boundary of both sides, the root of the odontoid was the lower boundary, and the lower edge of the occipital bone was the upper boundary. When the lesion was located at the region of cranial-cervical junction, the upper edge of the foramen lacerum on both sides was the upper boundary, and the foramen lacerum and the outer edge of the occipital condyle were the boundaries of both sides of the bone window. By measurement, the distance from the nostril to the anterior tubercle of atlas was 8.9-9.7 cm, with an average of 9.3±0.3 cm. The height of the anterior arch of the atlas was 2.3-3.0 cm, with an average of 2.7±0.3 cm; the width was 1.5-2.0 cm, with an average of 1.8±0.2 cm; the distance of bilateral medial margin of occipital condyle was 1.5-2.0 cm, with an average of 1.8±0.2 cm; the distance of bilateral medial margin of the foramen lacerum was 2.1-2.9 cm, with an average of 2.4 ±0.3 cm; the vertical distance from the occipital condyle to the homolateral foramen lacerum was 1.6-2.2 cm, with an average of 1.9±0.3 cm; the height of the odontoid was 0.9-1.3 cm, with an average of 1.1±0.2 cm, its length was 0.8-1.3 cm, with an average of 1.1±0.2 cm; the transverse diameter of the dentate was 0.9-1.2 cm, with an average of 1.0±0.1 cm.The maximum exposed area of cranio-cervical junction was 6.4-9.8 cm2, with an average of 8.6±1.6 cm2. Conclusion The extended neuroendoscopic endonasal approach with removal of the anterior tubercle of atlas and part of the atlas anterior arch could effectively reveal the cranial-cervical junction area which is suitable for the treatment of odontoid deformity, skull base depression and atlantoaxial joint dislocation as well as resection of epidural tumors in the cranial-cervical junction and ventral and ventral midline tumors. Key words: Natural orifice endoscopic surgery; Anatomy; Cranio-cervical junction; Extended endonasal approach

Application of endoscopic selective posterior rhizotomy in the treatment of limb spasticity following brain injury

Objective To evaluate the efficacy and safety of endoscopic selective posterior/dorsal rhizotomy (SPR) in the treatment of limb spasticity following brain injury in adults. Methods A total of 88 patients with limb spasticity following brain injury treated with SPR from January 2015 to August 2016 at Department of Neurosurgery, Xinxiang Central Hospital were retrospectively enrolled into this study. Russman-Gage standard and Ashworth standard were used to evaluate the degree of limb spasticity and muscle tension after operation. Surface electromyography (SMG) and evoked potential (EP) were used to measure the sensory and motor nerve conduction velocities of affected limbs 3 weeks after operation. Lower extremity motor function was assessed with the Fugl-Meyer scale in lower extremity (FMA-L) at 3 and 8 weeks after operation. Walking ability was assessed with the Functional ambulation category (FAC) scale, and parameters of patients' stride, stride distance, stride speed and toe deflection angle distance were measured. All patients were followed up clinically after operation. The follow-up included observing the remission of limb spasticity and reviewing the lumbar spine radiographs. Results The spasticity of extremities was alleviated in 88 patients after operation. Three weeks after operation, the integrated electromyogram (iEMG) of tibialis anterior muscle in 88 patients was higher than that before operation (1.5±0.2 mV vs. 0.5±0.2 mV, P<0.001), while the gastrocnemius muscle was lower than that before operation (0.7±0.3 mV vs. 1.2±0.2 mV, P<0.001). After detection, latency of cortical somatosensory evoked potential (SEEP) in the dorsomedian part of the head(39.7±3.1 ms) and L2 (18.5±3.5 ms) was longer than that before operation (34.9 ±3.5 ms, 13.3 ±2.3 ms, both P<0.001). The sensory nerve conduction velocities in head (4.9±1.1 cm/ms) and popliteal region to L2(4.8±1.3 cm/ms) region were lower than those before operation (6.6±1.4 cm/ms, 6.3±1.5 cm/ms, both P<0.001). At 3-8 weeks post operation, the scores of FMA-L and FAC scales, stride length, stride distance and stride speed of 88 patients were higher than those before operation (all P<0.05), while the deflection angle of toes was lower (P<0.01). The rising trend time of 88 patients ranged from 6.2 to 26.6 months, with an average of 12.2±6.4 months. There were 83 (83/88, 94.3%) patients who had relief of spasticity in lower limbs and 74 (74/79, 93.7%) whose Achilles tendon reflex disappeared. No spinal deformity was found in the reexamination. Conclusion The neuroendoscopic SPR treatment for limb spasticity after brain injury could effectively relieve the symptoms of limb spasticity and promote the recovery of motor function. It seems safe and worthy of clinical application and promotion. Key words: Natural orifice endoscopic surgery; Craniocerebral trauma; Muscle spasticity; Extremities; selective posterior/dorsal rhizotomy

Comparison of efficacy and safety of three different surgical methods for nasal vestibular cyst

Objective To explore the efficacy and safety of endoscopic nasal vestibule cysts, lip gingival trench path nasal vestibule excision and low temperature plasma radiofrequency ablation under nasal endoscope in the treatment of nasal vestibule cyst. Methods From January 2013 to December 2017, ninety patients with nasal vestibule cyst admitted in Taiyuan Central Hospital were selected.According to different surgical methods, the patients were divided into nasal endoscope nasal vestibule cyst group(A group, 26 cases), cleft lip gingival vestibule cyst excision group(B group, 36 cases), low temperature plasma radiofrequency ablation group under nasal endoscopy(C group, 28 cases). The efficacy and safety of the three types of operation were compared. Results The operation time[(15.5±3.6)min]and wound healing time[(2.3±0.9)d] in A group and the operation time[(16.3±4.5)min], wound healing time[(2.1±0.5)d] in C group were all significantly shorter than those in B group, the differences were statistically significant(t=5.268, 4.698, 5.624, 4.267, all P<0.05). The amount of bleeding in C group[(9.3±0.6)mL] was the least, followed by A group[(12.2±1.7)mL], and the difference among the three groups was statistically significant(t=8.256, 7.254, all P<0.05). The postoperative wound VAS score among the three groups was statistically significant(F=12.674, P<0.001), and the VAS score in C group[(1.6±0.7)points]<A group[(3.2±1.5)points]<B group[(4.9±2.3)points], the differences among the three groups were statistically significant(t=4.256, 3.998, 2.989, all P<0.05). The degree of facial swelling in C group was mild(39.29%) and moderate(60.71%), the differences were statistically significant compared with those in A group and B group(χ2=5.226, 11.651, all P<0.05). The incidence rate of complications in C group (0.00%) was significantly lower than that in A group(11.54%) and B group(16.67%), the difference was statistically significant(χ2=3.934, P<0.05). Conclusion Compared with the endoscopic nasal vestibule cysts, lip gingival trench path nasal vestibule excision, the low temperature plasma ablation under nasal endoscopy in the treatment of nasal vestibular cyst has the best efficacy, it is safe, less painful, and not easy to relapse. Key words: Cysts; Vestibular diseases; Nose; Catheter ablation; Natural orifice endoscopic Surgery; Surgical procedures, operative; Postoperative complications; Comparative effectiveness research

Application of intraoperative magnetic resonance imaging in endoscopic transsphenoidal surgery for recurrent pituitary adenomas

Objective To investigate the clinical value of intraoperative magnetic resonance imaging (iMRI) in endoscopic transsphenoidal surgery for recurrent pituitary adenomas. Methods A retrospective analysis was conducted on 29 cases of surgically treated patients with recurrent pituitary adenomas at Neurosurgery Department of the First Medical Center of Chinese PLA Greneral Hospital from February 2009 to February 2015. All patients underwent surgical resection of tumor with intraoperative magnetic resonance imaging. The parameters evaluated included the extent of tumor resection, scanning frequency and timing, relief of symptoms and signs, follow-up results and complications. Results Among 24 patients with possible totally resection according to the Knosp grading, 16 showed total tumor resection through the first intraoperative scanning and the second intraoperative scanning revealed another 4 cases achieving total resection after extended resection. After more than 3 times of extended resection, intraoperative scanning revealed 2 patients with total resection and the remaining 2 patients had residual tumor tissues. The number of intraoperative scanning was 1.6±0.8 times per case and the average scanning duration was 45.9±19.3 minutes. The total time for surgery was 157.2±55.6 minutes. The postoperative headache remission ratio was 11/13 and the visual dysfunction remission ratio was 12/15. Postoperative pituitary insufficiency occurred in 2 cases, olfactory disorder in 1 case, temporary diabetes insipidation in 7 cases and cerebrospinal fluid leakage in 2 cases. Twenty-nine patients were followed up for 3 to 67 months, with an average of 46.6±19.4 months. There were 2 patients with tumor recurrence among the 22 patients with total tumor resection. Conclusion For recurrent pituitary adenomas, iMRI-assisted endoscopic resection seems to be a safe and effective treatment which has high rate of total resection and less postoperative complications. Key words: Pituitary neoplasms; Neoplasm recurrence, local; Neurosurgical procedures; Intraoperative magnetic resonance imaging; Natural orifice endoscopic surgery

Efficacy study of Chiari type I malformation treatment using neuroendoscope assisted with neuronavigation and intraoperative ultrasound

Objective To explore and evaluate the clinical outcome of neuroendoscopic treatment assisted with neuronavigation and intraoperative ultrasound for Chiari type Ⅰ malformation. Methods Between January 2011 to June 2017, 132 patients underwent neuroendoscopic atlantooccipital decompression at Neurosurgery Department of Shanxi Provincial People′s Hospital. During the operations, the surgical fields were lightened by the illuminator of endoscope. All manipulations were conducted with neuronavigation. Intraoperative ultrasound was applied in 34 cases to detect the flowing speed of cerebrospinal fluid (CSF) which determined whether the outer dura was opened. We evaluated the clinic efficacy based on the Tator criteria which was classified into excellent (symptomatic improvement), good (symptomatic stability) and poor (symptomatic worsening). Results All 132 patients had follow-up lasting for 6-24 months. There were 92 patients who were determined as excellent in recovery, 36 as stable and 4 as worse. The clinical symptoms were improved in 69.7% (92/132). The clinical symptoms were improved in 65.3% (64/98) of the cases without intraoperative ultrasound and 82.4% (28/34) among those with intraoperative ultrasound, although there was no significant difference (P=0.06). MRI follow-up was conducted in 78 cases with comorbidity of myelosyringosis, which was improved in 41.0% (32/78). There were no cases of scalp hydrops in the occipital area or cerebrospinal fluid leakage post operation. Four cases reported intracranial infection. Conclusion Neuroendoscope-assisted atlantooccipital decompression, combined with neurona-vigation, intraoperative ultrasound and dura opening, seems to have satisfactory effect in treatment of Chiari type Ⅰ malformation and low complication rate, which still needs study involving larger number of samples. Key words: Arnold-Chiari malformation; Natural orifice endoscopic surgery; Neuronavigation; Ultrasonography, Doppler; Atlantooccipital decompression

Endoscopic anatomy of superior and inferior transtentorial approach to the posterior third ventricle

Objective To conduct anatomic study of structures and exposure of the posterior third ventricle by simulating superior and inferior transtentorial approach with endoscope and to provide anatomical basis for treatment involving this area with endoscope. Methods Five formalin-fixed cadaver heads (10 sides) were dissected bilaterally. To observe and measure anatomical structures of the posterior third ventricle by endoscopic infratentorial-supracerebellar (midline or paramedian) approach and occipital-tentorial approach with comparison of exposure using different surgical approaches. Results (1) Measurement of anatomical structures: Average number of bridging veins of the cerebellum was 3.6±0.6. The diameter of the vein of Galen was 5.6±0.6 mm. The distance from Habenular commissure to confluence of sinuses was 74.4±6.7 mm and the distance from anterior commissure to confluence of sinuses was 107.2±7.3 mm. (2) Comparison of different surgical approaches: The exposed area of pineal glands was 19.6±2.8 mm2, which was almost the same to that in operations through infratentorial-supracerebellar (midline or paramedian) approach and occipital-tentorial approach. The average of exposed area in splenium of corpus callosum was 55.2±7.9 mm2, 34.7±7.9 mm2 and 44.9±5.9 mm2 , respectively, and in ipsilateral superior colliculus was 153.8±13.4 mm2, 177.5±24.0 mm2 and 197.6±19.8 mm2 , respectively. Both had statistically significant difference (all P<0.05). Conclusions Endoscopic superior and inferior transtentorial approach seems feasible and safe for removal of tumors in the posterior third ventricle. Selection of surgical approaches should be based on the tumor type, size, location and its relationship to the surrounding structures. Key words: Natural orifice endoscopic surgery; Anatomy; Surgical approach; Posterior third ventricle tumor