Nerve Hook Research Articles

Insertion Multi-Parachute Suturing and Knotting (IMS-K) Technique for Aortic Surgery.

Successful surgical interventions for aortic surgery, such as hemiarch repair and total arch replacement, pivot on the foundation of optimal anastomosis. We propose an alternative approach to anastomosis. The "insertion multi-parachute suturing and knotting" (IMS-K) technique entails the deployment of two parachute sutures, which can be effectively employed for both proximal and distal anastomoses. The first suture is applied loosely to the posterior half of the anastomosis and subsequently parachuted down, tightening the suture with a nerve hook. The second suture replicates the procedure in the anterior half of the anastomosis, loosely securing it in a similar manner and tightening it with a nerve hook at the end. As a result, the artificial graft is completely inserted into the aorta with a substantial grip. This technique simplifies the aortic anastomosis by ensuring procedural simplicity while minimizing bleeding risk, thus potentially advancing surgical outcomes.

Simulated outcomes for durotomy repair in minimally invasive spine surgery

Minimally invasive spine surgery (MISS) is increasingly performed using endoscopic and microscopic visualization, and the captured video can be used for surgical education and development of predictive artificial intelligence (AI) models. Video datasets depicting adverse event management are also valuable, as predictive models not exposed to adverse events may exhibit poor performance when these occur. Given that no dedicated spine surgery video datasets for AI model development are publicly available, we introduce Simulated Outcomes for Durotomy Repair in Minimally Invasive Spine Surgery (SOSpine). A validated MISS cadaveric dural repair simulator was used to educate neurosurgery residents, and surgical microscope video recordings were paired with outcome data. Objects including durotomy, needle, grasper, needle driver, and nerve hook were then annotated. Altogether, SOSpine contains 15,698 frames with 53,238 annotations and associated durotomy repair outcomes. For validation, an AI model was fine-tuned on SOSpine video and detected surgical instruments with a mean average precision of 0.77. In summary, SOSpine depicts spine surgeons managing a common complication, providing opportunities to develop surgical AI models.

A Surgical Technique for Closure of 10 mm and Larger Laparoscopic Port Fascial Defects Using a Graham's Nerve Hook.

In order to avoid potential complications from incisional hernias in patients undergoing laparoscopic or robotic procedures with 10 mm or larger ports, a surgeon closes the fascial defects using various techniques. We compared several different techniques of port site closure, which uses the open technique that can be performed with or without laparoscopic visualization. We modified the technique initially described by Dr. H. Aziz. We are introducing a new surgical technique to close the larger port site using Graham's nerve-hook. This new technique is easy to learn, replicate and implement for all body types. We use the commonly available Graham's nerve-hook and two S-retractors to visualize the entire layers of fascia and peritoneum and to pull up both layers to close the larger port site safely and securely with 0 polyglactin absorbable suture. We illustrated this new Lee's port site closure technique with eight separate drawings in this paper. We performed 493 consecutive laparoscopic cases using this new technique. Four years follow up revealed only one incisional hernia using this technique. The patients are routinely followed in one month and six months and a year after the operation. However, not all of the patients are seen after six months unless there was a specific complaint. The new port site closure technique introduced in this paper is found to be easy to learn, fast, and very cost effective due to the reusable, commonly found S-retractors and Graham's nerve hook. After four years of consistent use, this new technique was found to be safe and effective in closure of 10 mm or larger port sites.

Breakage of a Pituitary Rongeur Tip: An Unforeseen Complication of Lumbar Microdiscectomy: A Case Report and Review of Literature.

A 46-year-old man with left leg radiculopathy due to a left L4-5 disc extrusion had a lumbar microdiscectomy that was complicated by the pituitary rongeur tip breaking in the L4-5 disc space. The rongeur tip was successfully retrieved by widening the entry access without damaging the adjoining facet and utilizing a blunt nerve hook and probe dissector. Breakage of the pituitary rongeur tip is an unforeseen complication of lumbar microdiscectomy. Surgeons should be aware of this potential complication, ideally confirm the rongeur is intact prior to wound coverage, and understand the risks versus benefits of attempting to retrieve a broken rongeur tip.

Contralateral Interhemispheric Transfalcine Approach for Intra-Axial Medial Occipital Lesion: 2-Dimensional Operative Video

Safe access to intra-axial mesial cortical lesions is challenging. When approached through standard transcortical approaches, normal white matter tracts such as the superior longitudinal fasciculus, corona radiata, and optic radiations may be violated en route to the lesion. Conversely, use of ipsilateral interhemispheric approaches necessitates retraction and manipulation of edematous and friable perilesional tissue. The contralateral interhemispheric transfalcine (CIHTF) approach may circumvent these challenges. The CIHTF approach uses a gravity-created window between the ipsilateral hemisphere and the falx and allows direct access contralaterally by opening the falx. We demonstrate the CIHTF approach for an intra-axial, medial occipital/precuneus lesion in a 69-yr-old man presenting with left homonymous hemianopia. MRI revealed a heterogeneously enhancing intra-axial lesion in the right mesial occipital lobe. After the patient gave voluntary informed consent, a CIHTF approach was planned, with the patient positioned laterally, right side up (IRB approval was unnecessary). A lumber drain facilitated gravity autoretraction of the ipsilateral lobe. Within the created trajectory, the falx was opened with use of a nerve hook attached to monopolar electrocautery. The contralateral lesion was visualized and removed piecemeal with the assistance of fluorescence imaging. Postoperative MRI showed complete removal. The patient reported a significant vision improvement. The diagnosis was metastatic adenocarcinoma from the lung; subsequent radiosurgery was recommended. MRI at the 8-mo follow-up revealed no recurrence of the lesion. The CIHTF approach is feasible for a mesial intra-axial lesion because it offers gravity autoretraction, a large working angle, and avoidance of parenchymal swelling. Used with permission from Barrow Neurological Institute.

Retaining the medial collateral ligament in high tibial medial open-wedge osteotomy mostly results in post-operative intra-articular gap reduction.

The current study aimed to evaluate how open-wedge high tibial osteotomy (OWHTO) without the release of medial collateral ligament (MCL) changes in vivo intra-articular joint space after the surgery. Patients with varus malalignment of the knee with an indication for OWHTO were included in this study. The intra-articular gap was measured before and 30min after OWHTO without MCL release using a series of calibrated nerve hooks. The association of post-operative gap size with varus angle, medial proximal tibial angle (MPTA), lateral distal femoral angle (LDFA) and joint line convergence angle (JLCA) was also assessed. A total of 42 knees from 38 patients were evaluated. The mean size of the intra-articular gap of the medial compartment was 5.2 ± 1mm before the osteotomy and 3.1 ± 2.2mm at 30min post-osteotomy. The size of the intra-articular gap decreased post-operatively in 30 knees (71.5%), increased in eight knees (19%) and remained the same in the remaining four knees (9.5%). Smaller MPTA and more correction were associated with a decrease in gap size after the osteotomy (p = 0.01 and p = 0.03, respectively). A significant negative correlation was observed between the correction size and the gap size after osteotomy (r = - 0.317, p = 0.04). Intra-articular pressure of the medial compartment increases in the majority of cases following OWHTO without MCL release. Until the factors affecting this increased pressure are thoroughly identified, MCL release seems to be a wiser option during OWHTO. III.

That's irrelevant.

‘What do you need to know to be a GP?’ It’s a question that I find difficult to answer. We might agree that a knowledge of physiology, anatomy, and pathology are relevant. I’m still pleased that I can remember that the recurrent laryngeal nerve hooks around the arch of the aorta, and when, one day, I see a hoarse patient after thyroid surgery, I might accidentally do an inappropriate little dance of joy. Chemistry is still useful to me, when I’m remembering about stomach acid and medications. Physics helps me out with the lens of the eye and the risks of radiology. We all know about statistics …

Unique Complications of Percutaneous Endoscopic Lumbar Discectomy and Percutaneous Endoscopic Interlaminar Discectomy

Background: Percutaneous endoscopic discectomy (PED) includes 2 main procedures: percutaneous endoscopic lumbar discectomy (PELD) and percutaneous endoscopic interlaminar discectomy (PEID), both of which are minimally invasive surgical procedures that effectively deal with lumbar degenerative disorders. Because of the challenging learning curve for the surgeon and the individual characteristics of each patient, preventing and avoiding complications is difficult. The most common complications, such as nucleus pulposus omission, nerve root injury, dural tear, visceral injury, nerve root induced hyperalgesia or burning-like nerve root pain, postoperative dysesthesia, posterior neck pain, and surgical site infection, are difficult to avoid; however, more focus on these issues perioperatively may be in order. Additionally, unique and unexpected complications can also occur, such as retroperitoneal hematoma (RPH), intraoperative seizures, and thrombophlebitis, among others. Objective: We aim to delineate unique complications during PED and accumulate strategies to prevent significant morbidity and improve surgical techniques. Study Design: A retrospective cohort study of patients undergoing PEID or PELD from October 2014 to January 2016. Setting: Affiliated hospitals of Qingdao University. Methods: Patients with lumbar disc herniation (LDH) who underwent PEID and PELD were retrospectively analyzed. Complications were recorded and analyzed pre and postoperatively. We assessed clinical outcomes using the visual analog scale (VAS) and Oswestry Disability Index (ODI) and classified the results into “excellent,” “good,” “fair,” or “poor” based on the modified MacNab criteria. All of the patients were followed for more than one year to evaluate their recovery from complications. Results: From October 2014 to January 2016, 426 patients with LDH underwent PEID (106 cases) or PELD (320 cases). Common complications and occurrence rates were as follows: the incomplete removal of herniated discs was 1.4% (6/426), recurrence 2.8% (12/426), nerve root injury 1.2% (5/426), dural tear 0.9% (4/426), and nerve root induced hyperalgesia or burning-like nerve root pain 2.3% (10/426); no posterior neck pain or surgical site infection occurred. Unique complications included: passage of the working channel through the spinal canal into the disc space (one case), super-elastic nerve hook caught by exiting nerve root (one case), epidural hematoma (one case), radicular artery injury and massive bleeding (one case) which was revised by micro-endoscopic discectomy, and intraoperative seizure (one case). No serious consequences occurred after active medical intervention, and most patients had good recovery by 3 months postoperatively with physical therapy. Limitations: The main limitations of this study are the retrospective study design, limited case number, and short follow-up period. Conclusions: PEDs are effective and minimally invasive methods for the surgical treatment of LDH, causing fewer complications due to the very minimal operational trauma for the muscle-ligament complex and stability of the spine. Nevertheless, because of the difficult learning curve for surgeons, lack of experience with the requisite surgical techniques, and enhanced clinical responsibility, a variety of problems may occur. Especially concerning are the unique complications mentioned here, which potentially lead to severe injury for the patient and require diligent preventive measures. Key words: Unique complications, epidural, hematoma, interlaminar, transforaminal, PEID, PELD

Minimally invasive posterior cervical foraminotomy for treatment of radiculopathy : An effective, time-tested, and cost-efficient motion-preservation technique.

To relieve foraminal root impingement due to lateral soft disc fragments, bony spurs, or other rarer causes. Soft disc fragment whose bulk is>2/3lateral to the lateral border of the thecal sac. Intraforaminal dorsal bony narrowing of the root canal. Intraforaminal synovial cyst, extra/intradural tumor. Paramedian and median soft/hard disc protrusions. Kyphosis of the index level. Patient prone in reverse Trendelenburg position with the head fixed in aMayfield clamp. Cervical spine horizontal and approximately 10 cm above the heart. Microscope from skin to skin. Skin incision: 25 mm, about 10 mm off the midline. Microsurgical blunt splitting of the muscle layers along the fiber direction. An expandable tubular retractor or aminiaturized speculum counter retractor, table anchored, is centered on the target lamino-facet junction as confirmed by fluoroscopy. Drilling of the keyhole. The axilla of the root is exposed while preserving most of the facet complex. Epidural exploration until an extruded or subligamentous disc fragment(s) is removed. If needed, removal of the dorsal bone overlying the root exiting in the foramen. The adequacy of decompression is assessed by palpating the root along its course with asmall nerve hook. Closure by layers. No drain. Same day mobilization. No external brace. Minimally invasive posterior cervical foraminotomy (MI-PCF) was used to treat 103patients for unilateral cervical radiculopathy. Mean follow-up was 32months. Despite 1cerebrospinal fluid leak, 1wound hematoma, and 1radiculitis during the early postoperative period, no patients required revision surgery. Visual analog scale (VAS) scores for neck/shoulder and arm improved significantly in the early postoperative period (3months) and were maintained with time (p< 0.001). Neck Disability Index (NDI) improved significantly postoperatively but worsened slightly during follow-up (p< 0.001). Anterior decompression and fusion (ACDF) was required at the index level by 3patients (mean: 55months later) and at the adjacent level by 4patients (mean: 27months later).

Comparison of safety and efficiency of microendoscopic discectomy with automatic nerve retractor and with nerve hook.

This study compares the safety and efficiency of two techniques in microendoscopic discectomy (MED) for lumbar disc herniation. The two techniques are MED with automatic nerve retractor and MED with nerve hook which had been widely used for many years. The former involves a newly developed MED device which contains three parts to protect nerve roots during operation. Four hundred and twenty-eight patients underwent MED treatments between October 2010 and September 2015 were recruited and randomized to either intraoperative utilization of automatic nerve retractor (n = 315, group A) or application of nerve hook during surgery (n = 113, group B). Operation time and intraoperative bleeding volume were evaluated. Simultaneously, Visual Analogue Scales (VAS) and muscle strength grading were performed preoperatively, and 1, 2, 3 days, 1, 2 weeks, 3 and 6 months postoperatively. No dramatic difference of pain intensity was observed between the two groups before surgery and 6 months after surgery (P > 0.05). The operation time was shorter in group A (30.30 ± 1.89 min) than that in group B (59.41 ± 3.25 min). Group A (67.83 ± 13.14 ml) experienced a significant decrease in the amount of blood loss volume when compared with group B (100.04 ± 15.10 ml). There were remarkable differences of VAS score and muscle strength grading after postoperative 1, 2, 3 days, 1, 2 weeks and 3 months between both groups (P ≤ 0.05). MED with automatic nerve retractor effectively shortened operation time, decreased the amount of bleeding, down-regulated the incidence of nerve traction injury.

Proof of Concept of an Endoscopic Sutureless Valve Sizer.

In this paper, we present an endoscopic expandable sizer conceived to allow thoracoscopic aortic valve replacement with a sutureless prosthesis using a dynamic sizing of the aortic annulus. Ten aortic torsos were prepared using a five-trocar thoracoscopic setting. Once the aortotomy was performed and the aortic valve leaflets removed, the technical feasibility of the endoscopic sizing (introduction into the trocar, expansion into the aortic annulus, determination of the valve size, and retraction) with the device was assessed. In case of successful thoracoscopic sizing, endoscopic implantation of a sutureless valve (five LivaNova Perceval prosthesis and five Medtronic 3f Enable bioprosthesis) was performed. Before ascending aorta closure, we assessed the appropriate sealing of the bioprosthesis in the native annulus with camera visualization and a nerve hook inspection. All the 10 endoscopic sizings were technically feasible. The scheduled aortic sutureless valve implantations were successfully performed. In all cases, fitting and placement of the sutureless bioprosthesis in the flaccid heart was satisfactory, with no paraprosthetic leakage detectable by the nerve hook. The use of the endoscopic expandable sizer is technically possible. In this early-stage test in the flaccid heart, selection of the valve size was satisfactory during thoracoscopic sutureless aortic bioprosthesis implantation. Further laboratory evaluation with fluid dynamics (aortic root pressurization) will be performed before a clinical study is started.

Minimally Invasive Cervical Foraminotomy.

The minimally invasive posterior cervical foraminotomy, a motion-preserving procedure, is an excellent treatment for patients with unilateral radiculopathy secondary to a laterally located herniated disc or foraminal stenosis. Place the patient in a prone position on a Jackson table with 6 posts and with the head resting comfortably on a soft facial pillow, and tape the shoulders down to provide traction to the skin and help with fluoroscopic visualization of the lower cervical levels. Make the skin incision adjacent to the spinous process on the side of the abnormality over the operative level. Use sequential dilators to create a working portal and secure the working tube overlying the lamina-facet junction of the operative level. Perform the laminoforaminotomy with the use of a high-speed drill and a Kerrison rongeur to create a working window into the foramen. Use a nerve hook to superiorly retract the nerve root, and perform a discectomy and decompression. Obtain hemostasis with electrocautery or hemostatic foam and close the wound with a standard layered closure. A systematic review and meta-analysis of studies on open or minimally invasive surgical (MIS) techniques for posterior cervical foraminotomy showed a pooled clinical success rate of 92.7% for the 509 patients managed with the open technique and 94.9% for the 208 patients who had the MIS technique; the difference was not significant (p = 0.418)2.

Robotic total endoscopic sutureless aortic valve replacement: proof of concept for a future surgical setting.

Sutureless valves have recently enabled closed chest aortic valve replacement. This paper evaluates the feasibility of a robotic telemanipulation during thoracoscopic sutureless aortic valve implantation in cadavers. Cadavers were prepared with a five thoracosopic trocar setting, with a transthoracic clamp inserted in the first right intercostal space and the optics inserted in the second. Seven sutureless valve implantations were scheduled using 5 Sorin Perceval and 2 Medtronic 3f Enable valves. In all cases performance of pericardial suspension, aortotomy and root exposure required less than 20 min. Native valve excision and sutureless bioprosthesis implantation was technically feasible in all cases. A satisfactory prosthesis sealing was ascertained visually and the absence of paravalvular leakages was assessed with a nerve hook test around the prosthetic flange. Closed chest and robot assisted sutureless valve implantation is feasible in cadavers. Robotic technology can enhance reproducibility of the technique. Copyright © 2015 John Wiley & Sons, Ltd.

Bilateral Facet Dislocation with Neural Compression from an Avulsed Posterior Longitudinal Ligament

Background and Importance: A review of the literature failed to show evidence of normal appearing posterior longitudinal ligament avulsion as a cause of spinal cord compression after bilateral cervical facet dislocations. We report a case of the posterior longitudinal ligament (PLL) avulsion causing spinal cord compression after bilateral cervical facet dislocation. Clinical presentation: A 93 year female presented with upper extremity numbness and bilateral C5-C6 facet dislocations. The patient was immediately taken for closed reduction and anterior cervical decompression with fusion (ACDF). After awake, closed reduction, an ACDF was immediately performed. After a complete discectomy procedure, the spinal cord could be visualized secondary to an absent PLL. A nerve hook was used to explore behind the C6 vertebral body to decompress the spinal cord. A segment of normal appearing posterior longitudinal ligament, which had avulsed from the superior aspect of C5, was found folded behind the C6 vertebra causing cord compression. There was no herniated disk material discovered. Conclusion: In addition to herniated disk material, avulsed PLL is another potential source of cord compression after closed reduction of cervical facet dislocations and surgeons must be aware of this possible source of compression while exploring and decompressing the spinal canal. This case study elucidates that the PLL is a potential cause of spinal cord compression after traumatic bilateral cervical facet dislocations.

Attachment Rate of the Inferior Alveolar Nerve to Buccal Plate During Bilateral Sagittal Split Osteotomy Influences Self-Reported Sensory Impairment

This study was aimed to investigate a modified buccal osteotomy technique and whether the integrity of the lingual part of the lower border influences the attachment of the neurovascular bundle to the proximal segment of the mandible during a sagittal split osteotomy without increasing the number of bad splits. The presence of self-reported sensibility disturbance in the lower lip at the last follow-up visit was assessed. This study included 220 and 133 patients with bilateral sagittal split osteotomy undergoing the classical and the new modified buccal osteotomy techniques, respectively. In the new technique, the lower border is divided into a lingual fragment that remains incorporated in the tooth-bearing fragment and a buccal fragment that comes with the proximal fragment (buccal plate). In the classical technique, the inferior alveolar nerve was attached to the proximal segment of the mandible in more than one third of operation sites (36.36% on the right and 40.91% on the left) compared with less than one fourth of the operation sites using the new technique (9.73% on the right and 23.01% on the left). The overall figure of self-reported changed sensibility was 09.40% (12/128) in the new technique compared to 15.12% in the classical technique. We present a suitable improvement to the classical buccal osteotomy technique that allows less manipulation and injury of the inferior alveolar nerve with consequent reduction in self-reported postoperative changes in lower lip sensation

Safe surgical access to the mandibular nerve at the infratemporal fossae.

Some anatomic patterns formed by the anterior border of the ascending ramus relative to the mandibular canal can cause nerve complications during surgery. We determined the frequency of obstructive anatomy in patients undergoing jaw surgery, and we described a perioperative method for a bilateral sagittal split osteotomy that ensured inferior alveolar nerve (IAN) protection. The anatomy of the anterior border of the ascending ramus of the mandible was examined on axial and cross-sectional cone beam computed tomographic images of 114 consecutive patients undergoing bilateral sagittal split osteotomies. The thickness of the anterior border of the ascending ramus determined whether the mandibular foramen could be visualized (pattern A) or was obscured (pattern B). Patients with pattern B anatomy received a perioperative procedure. Direct visualization of the mandibular foramen was achieved in 100% of patients with pattern A anatomy. We examined 228 anterior borders of the ascending ramus of the mandible relative to the mandibular foramen in 114 patients. Pattern A was observed in 146 cases (64%); pattern B, in 82 (36%) cases. The use of the nerve hook resulted in no injuries to the IAN in all cases. The described procedure ensured direct visualization of the IAN, which prevented inadvertent damage to the IAN during instrumentation and surgical procedures at the mandibular foramen.

Minimally invasive tethered cord release in children: A technical note

Tethered cord release is commonly performed in pediatric neurosurgery. Nowadays, minimally invasive procedures are created growing interest due to its highly tolerable nature for surgery. It has been main purpose a minimal damaging on access route and maximum protection of normal structures in surgery. We present a surgical treatment of tethered cord syndrome, by which is provided the cord releasing unlike the many methods being applied with tissue removal. The main advantage of performing this surgery through 2 cm hole is to avoid removing ligamentum flavum and bony structure like lamina in addition to reduce the length of the incision and the related scar tissue. Technical note: the patient was taken on the operating table in the sitting-prone position, and L5-S1 distance was determined by fluoroscopy. The skin and subcutaneous tissues was passed via a 2 cm vertical incision settled in 0.5 cm laterally from midline. L5-S1 distance and its covering ligamentum flavum are displayed by the guidance of L5 lamina. Williams’s retractor was placed in the distance after fetching microscope. The foregoing procedures are the same with microdiscectomic surgery. By a vertical incision made on the flavum, its both layer was lifted up and hanged with simple suture on the back tissue for a comfortable exposure of the Dura. Thecal sac was opened by 0.5 cm long vertical incision on the Dura after obtaining secure CSF drainage with the help of yellow-tipped syringe needle. With finding by a nerve hook, the phylum was burned and released securely. Then the Dura was sutured primarily for the closure by means of microsurgery instruments, and flavum was laid on it again.

Technique for Chordae Replacement in Mitral Valve Repair

We describe a simple technique for implantation of neochordae in degenerative mitral regurgitation with elongated or ruptured chords. We have successfully performed 102 mitral valve repairs using this technique and achieved mitral valve competency with no more than trace regurgitation. The technique is easy to perform and reproducible.

A Controlled Laboratory and Clinical Evaluation of a Three-dimensional Endoscope for Endonasal Sinus and Skull Base Surgery

One criticism of current video systems for endoscopic surgery is that two-dimensional (2D) images lack depth perception and may impair surgical dissection. To objectively measure the efficacy of 3D endoscopy, we designed a training model with specific tasks to show potential differences between 2D and 3D endoscopy. Its clinical value was then evaluated during endoscopic sinus and skull base surgical cases. Fifteen subjects were grouped according to endoscopic experience: novices and nonnovices. A training model was constructed to include five tasks: incision manipulation; ring transfer; nerve hook; distance estimation, visual only; and distance estimation, visual and tactile. Each participant was assessed with both a standard 2D endoscope and a 3D endoscope. The clinical value of a 3D endoscope (Visionsense, Ltd., Petach Tikva, Israel) was then examined in four endoscopic sinus cases and four skull base cases. Of the subjects, six (40%) were novices. Overall, the errors committed during any one task were not significantly different between systems. Novices trended toward more success during the nerve hook task using the 3D system. With size cueing versus visualization alone, distance estimation was significantly more accurate. Novices tended to prefer the 3D system and experienced surgeons disliked the initial learning curve. Advantages were particularly noticed during skull base surgery; subjectively improved depth perception was beneficial during vascular dissection. Three-dimensional endoscopy may improve depth perception and performance for novices. The 3D endoscope is a safe and feasible tool for endoscopic sinus and skull base surgery; it is promising for improving microneurosurgical dissection precision transnasally.

Poster 33: Endoscopy Assisted Mandibular Sagittal Split Ramus Osteotomy

Statement of the Problem: The prevalence of inferior alveolar nerve (IAN) parasthesia/dysthesia following a sagittal split osteotomy (SSO) ranges from 9% to 85%. Over zealous retraction and inappropriate positioning of surgical instrumentation often results in excess manipulation/damage of the soft tissues surrounding the IAN thereby inadvertently causing damage to the nerve. Intraoperative identification of the IAN has traditionally relied upon utilization of plain films and radiographic landmarks, tactile identification of the antilingula and IAN foramen utilizing a nerve hook, and direct visualization if possible. Unfortunately, in the absence of direct visualization, these methods lack the necessary precision and accuracy for reliable identification of IAN position. Radiographic determination of the position of the IAN foramen at best only provides a rough estimate of the nerve location. Aziz and coworkers demonstrated that tactile identification of the antilingula to infer position of the lingula is not always reliable. Thus, direct visualization is the most reliable way to identify IAN position. In the present study, a 30 degree Stryker endoscope was used to visualize the medial aspect of the ramus in order to determine IAN location following the initial dissection. We hypothesized that utilization of endoscopy to identify the IAN prior to creation of the medial horizontal osteotomy would limit manipulation of the soft tissues surrounding the IAN, preventing inappropriate positioning of surgical instrumentation, thereby reducing the incidence of parasthesia/dysthesia following an SSO.