Neuroendoscopic Surgery Research Articles

Neurocysticercosis of the third ventricle: illustrative case.

Neurocysticercosis is a parasitic infection of the central nervous system. Cysts located in the ventricles, intraventricular neurocysticercosis (IVNCC), can cause symptoms of increased intracranial pressure and, if untreated, can be fatal. Neuroendoscopic removal of IVNCC is recommended as the first-line treatment. The authors present the case of a healthy 30-year-old male originally from Mexico who presented with headaches and vomiting. He was found to have a cyst in the third ventricle on imaging, consistent with IVNCC. The authors successfully performed neuroendoscopic surgery with removal of the cyst en bloc. A multidisciplinary team of neurosurgery and infectious disease specialists is recommended for successful management of patients with IVNCC. These patients typically require neuroendoscopic surgical removal for definitive treatment. In this case, the authors show surgery resulted in an effective cure without the need for antiparasitic medication and excellent long-term outcomes.

Neurophysiologic Monitoring of Oculomotor Nerves During Transorbital Surgery: Proof of Concept and Anatomic Demonstration.

Transorbital neuroendoscopic surgery (TONES) is continuously evolving and gaining terrain in approaching different skull base pathologies. The objective of this study was to present our methodology for introducing recording electrodes, which includes a new transconjunctival pathway, to monitor the extraocular muscle function during TONES. A translational observational study was performed from an anatomic demonstration focused on the transconjunctival electrode placement technique to a descriptive analysis in our series of 6 patients operated using TONES in association with intraoperative neurophysiologic monitoring of the oculomotor nerves from 2017 to 2023. The stepwise anatomic demonstration for the electrode placement and correct positioning in the target muscle was realized through cadaveric dissection. The descriptive analysis evaluated viability (obtention of the electromyography in each cranial nerve [CN] monitored), security (complications), and compatibility (interference with TONES). In our series of 6 patients, 16 CNs were correctly monitored: 6 (100%) CNs III, 5 (83.3%) CNs VI, and 5 (83.3%) CNs IV. Spontaneous electromyography was registered correctly, and compound muscle action potential using triggered electromyography was obtained for anatomic confirmation of structures (1 CN III and VI). No complications nor interference with the surgical procedure were detected. The methodology for introducing the recording electrodes was viable, secure, and compatible with TONES.

Transorbital neuroendoscopic surgery for treatment of sphenoid wing meningiomas extending to the cavernous sinus: clinical implications and a technical illustration.

The aim of this study was to evaluate the efficacy and safety of transorbital neuroendoscopic surgery (TONES) in the management of sphenoid wing meningiomas (SWMs) with cavernous sinus and orbital invasion. The authors conducted a retrospective review of 32 patients with SWMs treated at Gazi University using TONES from October 2019 to May 2023. The study includes clinical applications to elucidate the endoscopic transorbital approach. Surgical techniques focused on safe subtotal resection, aiming to minimize residual tumor volume for subsequent radiosurgery. Data were collected on patient demographics, tumor characteristics, surgical procedures, complications, and postoperative outcomes, including radiological imaging and ophthalmological evaluations. Surgical dissections delineated a three-phase endoscopic transorbital approach: extraorbital, intraorbital, and intracranial. In the clinical application, gross-total resection was not achieved in any patient because of planned postoperative Gamma Knife radiosurgery. The mean follow-up period was 16.3 months. Of 30 patients with preoperative proptosis, 25 experienced postoperative improvement. No new-onset extraocular muscle paresis or visual loss occurred postoperatively. The average hospital stay was 1.15 days, with minimal complications and no significant morbidity or mortality. Total resection of SWMs invading the cavernous sinus and orbit is associated with substantial risks, particularly cranial nerve deficits. TONES offers a minimally invasive alternative, reducing morbidity compared with transcranial approaches, and represents a significant advancement in the surgical management of SWMs, especially those extending into the cavernous sinus and orbit. The approach provides a safe, effective, and patient-centric approach, prioritizing subtotal resection to minimize neurological deficits while preparing patients for adjunctive radiosurgery. This study positions TONES as a transformative surgical technique, aligning therapeutic efficacy with neurovascular preservation and postoperative recovery.

Clinical application of reserved gastric tube in neuroendoscopic endonasal surgery for pituitary tumor.

The neuroendoscopic approach has the advantages of a clear operative field, convenient tumor removal, and less damage, and is the development direction of modern neurosurgery. At present, transnasal surgery for sphenoidal pituitary tumor is widely used. But it has been found in clinical practice that some patients with this type of surgery may experience post-operative nausea and vomiting and other discomforts. To explore the effect of reserved gastric tube application in the neuroendoscopic endonasal resection of pituitary tumors. A total of 60 patients who underwent pituitary adenoma resection via the endoscopic endonasal approach were selected and randomly divided into the experimental and control groups, with 30 in each group. Experimental group: After anesthesia, a gastric tube was placed through the mouth under direct vision using a visual laryngoscope, and the fluid accumulated in the oropharynx was suctioned intermittently with low negative pressure throughout the whole process after nasal disinfection, during the operation, and when the patient recovered from anesthesia. Control group: Given the routine intraoperative care, no gastric tube was left. The number of cases of nausea/vomiting/aspiration within 24 h post-operation was counted and compared between the two groups; the scores of pharyngalgia after waking up, 6 h post-operation, and 24 h post-operation. The frequency of postoperative cerebrospinal fluid leakage and intracranial infection were compared. The hospitalization days of the two groups were statistically compared. The times of postoperative nausea and vomiting in the experimental group were lower than that in the control group, and the difference in the incidence of nausea was statistically significant (P < 0.05). After the patient woke up, the scores of sore throat 6 h after the operation and 24 h after operation were lower than those in the control group, and the difference was statistically significant (P < 0.05). The number of cases of postoperative cerebrospinal fluid leakage and intracranial infection was higher than that of the control group, but there was no statistically significant difference from the control group (P > 0.05). The hospitalization days of the experimental group was lower than that of the control group, and the difference was statistically significant (P < 0.05). Reserving a gastric tube in the endoscopic endonasal resection of pituitary tumors, combined with intraoperative and postoperative gastrointestinal decompression, can effectively reduce the incidence of nausea, reduce the number of vomiting and aspiration in patients, and reduce the complications of sore throat The incidence rate shortened the hospitalization days of the patients.

New Preoperative Simulations for the Future of Hydrocephalus Surgery

Ventricular puncture is a basic procedure that neurosurgeons learn in the early stages of their careers and is also performed in ventricular drainage and neuroendoscopic surgery. However, few neurosurgeons are confident in their ability to insert and place a ventricular catheter in the optimal position for ventriculoperitoneal(VP)shunting in a single pass. Even experienced neurosurgical consultants confident in difficult microsurgical procedures are uncomfortable with ventricular catheter placement in VP shunting. Moreover, many neurosurgeons believe that they will never perform a ventricular puncture from the posterior horn of the lateral ventricles. The reason for thinking that ventricular puncture via the anterior horn is safer and more accurate compared with the posterior approach is because the anterior approach can use facial landmarks such as eyes, nose, and ears. However, even with the anterior approach in VP shunting, it is more difficult than with ventricular drainage or neuroendoscopic surgery to achieve accurate placement owing to head rotation, and the success rate has been reported to be as high as 50%. In this article, I introduced "fool proof," which uses preoperative simulation to place a ventricular catheter in the optimal position according to the size and shape of each patient's head and ventricles. The first choice for VP shunting is the right parieto-occipital approach with a posterior horn puncture from Frazier's Point and, for L-P shunting, a paramedian puncture from the 2/3 or 3/4 lumbar interspace.

Multimodal image fusion-assisted endoscopic evacuation of spontaneous intracerebral hemorrhage

PurposeAlthough traditional craniotomy (TC) surgery has failed to show benefits for the functional outcome of intracerebral hemorrhage (ICH). However, a minimally invasive hematoma removal plan to avoid white matter fiber damage may be a safer and more feasible surgical approach, which may improve the prognosis of ICH. We conducted a historical cohort study on the use of multimodal image fusion-assisted neuroendoscopic surgery (MINS) for the treatment of ICH, and compared its safety and effectiveness with traditional methods. MethodsThis is a historical cohort study involving 241 patients with cerebral hemorrhage. Divided into MINS group and TC group based on surgical methods. Multimodal images (CT skull, CT angiography, and white matter fiber of MRI diffusion-tensor imaging) were fused into 3 dimensional images for preoperative planning and intraoperative guidance of endoscopic hematoma removal in the MINS group. Clinical features, operative efficiency, perioperative complications, and prognoses between 2 groups were compared. Normally distributed data were analyzed using t-test of 2 independent samples, Non-normally distributed data were compared using the Kruskal-Wallis test. Meanwhile categorical data were analyzed via the Chi-square test or Fisher’s exact test. All statistical tests were two-sided, and p < 0.05 was considered statistically significant. ResultsA total of 42 patients with ICH were enrolled, who underwent TC surgery or MINS. Patients who underwent MINS had shorter operative time (p < 0.001), less blood loss (p < 0.001), better hematoma evacuation (p = 0.003), and a shorter stay in the intensive care unit (p = 0.002) than patients who underwent TC. Based on clinical characteristics and analysis of perioperative complications, there is no significant difference between the 2 surgical methods. Modified Rankin scale scores at 180 days were better in the MINS than in the TC group (p = 0.014). ConclusionsCompared with TC for the treatment of ICH, MINS is safer and more efficient in cleaning ICH, which improved the prognosis of the patients. In the future, a larger sample size clinical trial will be needed to evaluate its efficacy.

Application of Dural Suturing in Reconstruction of Sellar Floor for Cerebrospinal Fluid Leakage During Neuroendoscopic Intranasal Approach Surgery: A Meta-Analysis.

To assess the safety and efficacy of utilizing dural suturing as an adjunctive procedure for saddle floor reconstruction in patients undergoing endoscopic surgery in the sellar region. According to the PRISMA guidelines, we searched the literature on sellar floor reconstruction in endoscopic sellar surgery. Fixed- or random-effects meta-analysis was used to pool the rate of return to postoperative cerebrospinal fluid (poCSF) leakage, repair operations, postoperative hospitalization, complete resection, infection, lumbar drainage (LD), and operative duration. A total of six studies involving 723 participants were included in the current meta-analysis. The pooled results demonstrated that patients in the dural suturing group had a lower incidence of poCSF leakage [odds ratio (OR), 0.18; 95% confidence interval (CI), 0.07 - 0.44; p=0.0002] and repair operation [OR, 0.24; 95% CI, 0.07 - 0.78; p=0.02], as well as a shorter hospitalization period [standardized mean difference (SMD), -0.45; 95% CI, -0.62 - -0.28; p < 0.00001]. There was no significant difference between the two groups in terms of the complete resection [OR, 1.06; 95% CI, 0.62 - 1.80; p=0.84], postoperative infection [OR, 0.49; 95% CI, 0.21 - 1.15; p=0.10] and lumbar drainage (LD) [OR, 0.28; 95% CI, 0.06 - 1.23; p=0.09]. Additionally, the dural suturing group may require a longer operative duration [SMD, 0.29; 95% CI, 0.02 - 0.56; p=0.03]. The results suggest that dural suturing can be advantageous in reducing postoperative complications and shortening postoperative hospitalization following neuroendoscopic surgery in the sellar region without increasing the risk of infection.

Fluorophores in Endoscopic Neurosurgery.

The complexity of intracranial anatomy and pathologies warrants the optimization of multimodal techniques to ensure safe and effective surgical treatment. Endoscopy is being more widely implemented in intracranial procedures as an important visualization tool, as it can offer panoramic views of deep structures while reducing the invasiveness of approaches. Fluorophores are frequently utilized to augment the identification of intracranial anatomic landmarks and pathologies. This chapter discusses the integration of these two surgical adjuncts, highlighting the key fluorophores used in endoscopic neurosurgery and their clinical applications.

Disseminated Intracranial and Spinal Neurenteric Cysts: A Case Report and Literature Review

Neurenteric cysts (NECs) are rare congenital, benign lesions of the central nervous system (CNS), predominantly located within the spinal cord. However, they may also occur less frequently within the brainstem, fourth ventricle, or cerebellopontine angle (CPA). Originating from anomalous interactions between embryonic layers, NECs are recognized for their potential to compress adjacent structures. We report a unique case of disseminated NECs exhibiting few to absent symptoms, which represents an unusual presentation of this disease, with only six similar reports in the literature. A 22‐year‐old female presented to our institute with chronic headaches resistant to nonsteroidal anti‐inflammatory drugs (NSAIDs). Initially treated for intracranial hypertension (ICH) secondary to a cyst in the quadrigeminal cistern at the age of 17 via neuroendoscopic surgery and subsequent ventriculoperitoneal shunting, she experienced transient relief. However, follow‐up at 22 years of age revealed multiple cysts in the basal and spinal cisterns, with MRI findings suggestive of neurocysticercosis. Despite treatment with albendazole and corticosteroids, subsequent MRIs showed no change in the size or number of the cysts. Six years later, symptoms had worsened, previously identified cysts had grown, and the detection of new cysts prompted surgical intervention. Histopathological examination confirmed the presence of NECs. This case highlights the diagnostic challenges posed by NECs, especially in regions endemic for neurocysticercosis, where clinical and radiological findings may initially suggest this condition. It underscores the importance of considering NECs in the differential diagnosis of cystic lesions in the CNS, even in the absence of typical symptoms of spinal cord compression. The recurrence and spread of NECs post‐treatment demand a comprehensive management approach, encompassing surgical intervention and close monitoring.

Neuroanatomical perspectives on transorbital approaches: A meta-analysis.

Transorbital approaches represent a paradigm shift in skull base surgery, focusing on minimally invasive techniques that prioritize patient outcomes and surgical precision. The scientific community, recognizing the significance of these advances, necessitates a possible review and meta-analysis to encapsulate the collective efficacy, safety, and developmental trajectory of these approaches. This was a literature review targeting literature in the past 10 years to present evidence for studies on surgical approaches transorbital. The included articles were analyzed. In addition, the references list of the included papers was searched for further articles. Studies based on the endoscopic endonasal and transorbital approach have emphasized that it is minimally invasive; on the other hand, it offers an advantage to maximal resection success in the case of skull base tumors with advanced endoscopic skills. Transorbital neuroendoscopic surgery was criticized for being highly technical and narrow in its scope, with reduced morbidity. Superior Eyelid Approach involves a direct access with hidden incisions, potential for eyelid complications. Lateral orbitotomy entailed some inherent risks, such as muscle and nerve injury, but it gave excellent exposure to lesions that are lateral in the orbit. The transorbital endoscopic intraconal approach and the transconjunctival approach give direct advantages but are, however, limited to the type of lesion and location. The main technique focused on in this overview is the approaches through orbits, which greatly contribute to further innovation brought into the surgical panorama of skull base interventions. All such techniques do have their characteristics and applications, keeping them moving toward less invasiveness.

Efficacy of neuroendoscopic and small-bone-window craniotomy microsurgery for hypertensive cerebral hemorrhage: a meta-analysis of Chinese RCT studies.

To compare the clinical efficacy of neuroendoscopy and small-bone-window craniotomy microsurgery in the treatment of supratentorial hypertensive intracerebral hemorrhage. A search was conducted for Chinese randomized controlled trials on neuroendoscopy and small-bone-window craniotomy microsurgery treatment of hypertensive intracerebral hemorrhage published before February 1, 2024, in PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wanfang Data, and China Science and Technology Journal Database. Meta-analysis was performed using Review Manager 5.4 software. We included 9 randomized controlled trials, with 391 cases in the neuroendoscopy group and 403 cases in the craniotomy group. The meta-analysis results showed that compared to the small-bone-window craniotomy group, the neuroendoscopy group had a higher rate of hematoma clearance (95% CI [6.65, 18.52], p < 0.00001), less intraoperative bleeding (95% CI [-294.83, -284.75], p < 0.00001), shorter operation time (95% CI [-138.65, -63.04], p < 0.00001), fewer days in the ICU (95% CI [-8.56, -4.04], p < 0.00001), lower rate of postoperative complications (95% CI [0.15, 0.50], p < 0.0001), lower NIHSS score at 3 months postoperatively (95% CI [-6.82, -5.36], p < 0.00001), and higher ADL score (95% CI [16.5, 20.07], p < 0.00001). All comparison results were statistically significant. Compared with small-bone-window craniotomy microsurgery, neuroendoscopic surgery for episodic hypertensive cerebral hemorrhage resulted in a higher rate of hematoma clearance, less intraoperative bleeding, shorter operative time, fewer days in the ICU, a lower rate of postoperative complications and a lower 3-month postoperative NIHSS score, and a higher ADL score.

The biportal transorbital approach: quantitative comparison of the anterior subfrontal craniotomy, bilateral transorbital endoscopic, and microscopic approaches.

The aim of this study was to assess the surgical use and applicability of a biportal bitransorbital approach. Single-portal transorbital and combined transorbital transnasal approaches have been used in clinical practice, but no study has assessed the surgical use and applicability of a biportal bitransorbital approach. Ten cadaver specimens underwent midline anterior subfrontal (ASub), bilateral transorbital microsurgery (bTMS), and bilateral transorbital neuroendoscopic surgery (bTONES) approaches. Morphometric analyses included the length of the bilateral cranial nerves I and II, the optic tract, and A1; the area of exposure of the anterior cranial fossa floor; craniocaudal and mediolateral angles of attack (AOAs); and volume of surgical freedom (VSF; maximal available working volume for a specific surgical corridor and surgical target structure normalized to a height of 10 mm) of the bilateral paraclinoid internal carotid arteries (ICAs), bilateral terminal ICAs, and anterior communicating artery (ACoA). Analyses were conducted to determine whether the biportal approach was associated with greater instrument freedom. The bTMS and bTONES approaches provided limited access to the bilateral A1 segments and the ACoA, which were inaccessible in 30% (bTMS) and 60% (bTONES) of exposures. The average total frontal lobe area of exposure (AOE) was 1648.4 mm2 (range 1516.6-1958.8 mm2) for ASub, 1658.9 mm2 (1274.6-1988.2 mm2) for bTMS, and 1914.9 mm2 (1834.2-2014.2 mm2) for bTONES exposures, with no statistically significant superiority between any of the 3 approaches (p = 0.28). The bTMS and bTONES approaches were significantly associated with decreases of 8.7 mm3 normalized volume (p = 0.005) and 14.3 mm3 normalized volume (p < 0.001) for VSF of the right paraclinoid ICA compared with the ASub approach. No statistically significant difference in surgical freedom was noted between all 3 approaches when targeting the bilateral terminal ICA. The bTONES approach was significantly associated with a decrease of 105% in the (log) VSF of the ACoA compared with the ASub (p = 0.009). Although the biportal approach is intended to improve maneuverability within these minimally invasive approaches, these results illustrate the pertinent issue of surgical corridor crowding and the importance of surgical trajectory planning. A biportal transorbital approach provides improved visualization but does not improve surgical freedom. Furthermore, although it affords impressive anterior cranial fossa AOE, it is unsuitable for addressing midline lesions because the preserved orbital rim restricts lateral movement. Further comparative studies will elucidate whether a combined transorbital transnasal route is preferable to minimize skull base destruction and maximize instrument access.

Long-term outcomes and cost-effectiveness evaluation of robot-assisted stereotactic hematoma drainage for spontaneous intracerebral hemorrhage

BackgroundTo investigate the long-term follow-up and economic estimation outcomes of hematoma drainage for spontaneous intracerebral hemorrhage (SICH) with the assistance of neurosurgical navigation and positioning planning system (referred to as robot).MethodsData were retrospectively obtained from consecutive patients with SICH who were admitted to our single-center between March 2019 and March 2022. Different minimally invasive surgery (MIS) procedures were performed according to the inclusion/exclusion criteria. The different groups were sampled and matched using the propensity score method, with age, sex, history of stroke, hypertension, bleeding volume and site of bleeding as matching variables, and matched with inverse probability weighting using R statistical analysis software. From the time of discharge up until 1 year after the surgery, records were gathered on clinical results and medical expenditures. An analysis was conducted to compare the costs and health outcomes of both robot-assisted stereotactic hematoma drainage and neuro-endoscopic surgery, considering both short-term and long-term effects. Health outputs were measured using modified Rankin scale (mRS) and quality adjusted life years (QALYs).ResultsOf the 142 patients, there were 77 patients in the robotic surgery group and 65 patients in the neuro-endoscopic surgery group. Propensity score sampling was matched, resulting in a balanced and comparable group of 37 patients in each, with the robotic surgery group [mean age (57.29 ± 12.74) years, 27 males (72.97%), hematoma volume (44.54 ± 10.49 ml), 22 deep location (59.46%)] and the neuro-endoscopic surgery group [mean age (57.27 ± 11.12) years, 27 males (72.97%), hematoma volume (44.70 ± 10.86 ml), 23 deep location (62.16%)]. At both three-month and one-year postoperative follow-up, the proportion of mRS scores ≤3 was higher in the robotic surgery group (45.95%,70.27%) than in the neuro-endoscopic surgery group (35.14%, 62.16%), but there was no statistically significant difference (P = 0.344, 0.461). One year after surgery, the robotic group demonstrated cost savings of ¥36,862.14 per individual and a gain of 0.062 QALYs compared to the neuro-endoscopic group.ConclusionOur calculations based on a model for SICH suggest that robotic-assisted stereotactic drainage offers health economic benefits due to its lower cost and higher effectiveness. However, to confirm these findings, more data from multicenter, prospective randomized controlled trials with larger sample sizes are needed.

AUGMENTED REALITY-BASED NASAL ENDOSCOPE VIDEO RECONSTRUCTION AND REGISTRATION

Neuroendoscopic surgery is a minimally invasive surgical technique commonly used to remove a tumor through the patient’s mouth or nose, which requires the surgeon to avoid important neural and vascular structures. Augmented reality-based surgical navigation can provide surgeons with more information and visual aids, clarifying the structure and details of the surgical area. It requires real-time registration of intraoperative endoscopic video with pre-operative CT models. However, 3D reconstruction and camera tracking from nasal endoscopic video are challenging due to the narrow nasal cavity and the lack of texture. Besides, the nasal endoscopic datasets that can be used for deep learning-based depth estimation are scarce and hard to elaborate. To this end, a style-augmented module (SAM) is proposed in this study to minimize discrepancies between different endoscopic datasets. An unsupervised approach was trained to generate depth maps and camera motion paths, which were used to reconstruct the nasal scene’s 3D model. The obtained reconstruction was aligned with a pre-operative CT model for augmented reality-based surgical navigation. The results showed that the proposed SAM improved the generalization of the depth estimation model on nasal endoscopy data. The proposed approach to combining augmented reality technology with surgical navigation is considered instrumental in furnishing surgeons with richer information on the nasal endoscopic surgical scene.

Application of endoport-assisted neuroendoscopic techniques in lateral ventricular tumor surgery.

The objective of this study was to investigate the clinical experience and therapeutic efficiency of Endoport-assisted neuroendoscopic surgery for resection of lateral ventricular tumors. The key points and application value of this surgical technique were additionally discussed. A retrospective analysis was conducted on the clinical and follow-up data of 16 patients who underwent endoport-assisted neuroendoscopic surgery for lateral ventricular tumors at the Department of Neurosurgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, between January 2018 and September 2020. The surgical procedures, complications and outcomes were analyzed. The study included a total of 16 patients (5 males and 11 females) with lateral ventricular tumors, with a mean age of 43.2 years (18-70 years old). The tumors were distributed as follows: 5 cases involved the body of the lateral ventricle, 3 involved the frontal horn and body, 3 involved the occipital horn, 2 involved the trigone, 2 involved the frontal horn, and 1 case involved the occipital horn and body. Perioperative complications were analyzed, revealing 1 case of intraoperative acute epidural hematoma intraoperative and 2 cases of postoperative obstructive hydrocephalus. All complications were promptly managed. Postoperative MRI revealed that 14 cases (88%) achieved total resection, while 2 cases (12%) achieved subtotal resection. During the follow-up of 6-38 months, no recurrence was observed. The patient diagnosed with glioblastoma died 16 months after surgery (GOS=1), while the remaining patients have successfully resumed to normal daily life with a GOS score of 5. In conclusion, endoport-assisted neuroendoscopic surgery proved to be a minimally invasive and effective technique for resecting lateral ventricular tumors, with acceptable complications. It effectively utilizes the benefits of close observation, comprehensive exposure, and reduced tissue damage. Therefore, endoport-assisted neuroendoscopic surgery is suitable for the resection of lateral ventricular tumors.

The Transorbital Approach, A Game-Changer in Neurosurgery: A Guide to Safe and Reliable Surgery Based on Anatomical Principles.

During the last few years, the superior eyelid endoscopic transorbital approach has been proposed as a new minimally invasive pathway to access skull base lesions, mostly in ophthalmologic, otolaryngologic, and maxillofacial surgeries. However, most neurosurgeons performing minimally invasive endoscopic neurosurgery do not usually employ the orbit as a surgical corridor. The authors undertook this technical and anatomical study to contribute a neurosurgical perspective, exploring the different possibilities of this novel route. Ten dissections were performed on ten formalin-fixed specimens to further refine the transorbital technique. As part of the study, the authors also report an illustrative transorbital surgery case to further detail key surgical landmarks. Herein, we would like to discuss equipment, key anatomical landmarks, and surgical skills and stress the steps and details to ensure a safe and successful procedure. We believe it could be critical to promote and encourage the neurosurgical community to overcome difficulties and ensure a successful surgery by following these key recommendations.

Transorbital Microsurgery: An Anatomical Description of a Minimally Invasive Corridor to the Anterior Cranial Fossa and Paramedian Structures.

Objectives Transorbital neuroendoscopic surgery (TONES) has ignited interest in the transorbital access corridor, increasing its use for single and multi-portal skull base interventions. However, the crowding of a small corridor and two-dimensional viewing restrict this access portal. Design Cadaveric qualitative study to assess the feasibility of transorbital microsurgery (TMS). Setting Anatomical dissection steps and instrumentation were recorded for homogeneous methodology. Participants Six cadaveric specimens were systematically dissected using TMS to the anterior cranial fossa and paramedian structures. Main Outcome Measures Anatomical parameters of the TMS craniectomy were established, and the visible and accessible neuroanatomy was highlighted. Results A superior lid crease incision achieved essential orbital rim exposure and preseptal dissection. The orbital roof craniectomy is defined by three boundaries: (1) frontozygomatic suture to the frontosphenoid suture, (2) frontal sinus and cribriform plate, and (3) frontal sinus and orbital rim. The mean (standard deviation) craniectomy was 440 mm 2 (78 mm 2 ). Exposing the ipsilateral optic nerve and internal carotid artery obviated the need for frontal lobe retraction to identify the A1-M1 bifurcation as well as near-complete visualization of the M1 artery. Conclusion TMS is a feasible corridor for intracranial access. Mobilization of orbital contents is imperative for maximal intracranial access and protection of the globe. TMS enables access to the frontal lobe base, ipsilateral optic nerve, and most of the ipsilateral anterior circulation. This cosmetically satisfactory approach causes minimal destruction of the anterior skull base with satisfactory exposure of the anterior cranial fossa floor without sinus invasion.

Perihematomal edema after minimally invasive surgery: a matter of concern to neurosurgeons.

The purpose of this study is to explore the evolution of brain edema after minimally invasive surgery in deep spontaneous cerebral hemorrhage (DSICH) treatment and to analyze the differences in edema after different surgical methods. The clinical data of 105 patients with DSICH treated at Renmin Hospital of Wuhan University from January 2020 to June 2022 were analyzed retrospectively. Among them, 54 patients were treated with minimally invasive puncture and drainage surgery (MIPDS group), and 51 were treated with neuroendoscopic surgery (NES group). Continuous computed tomography images of patients in the hospital and 3D Slicer software were used to quantitatively calculate the edematous area to explore the changes in perihematomal edema volume in the two groups after the operation. The peak volume of postoperative edema (37.36±10.51 mL) in the MIPDS group was more extensive than that in the NES group, and its net increase in edema volume was 16.86±10.01 mL more than that in the NES group. The relative edema index (0.86±0.26) was lower in the NES group than in the MIPDS group (P < 0.05). The peak of postoperative edema in the MIPDS group was at 6-8 days after the operation, and that in the NES group was most often at 3-5 days after the operation. There are differences in perihematomal edema of DSICH treated by different minimally invasive methods. Compared with the MIPDS group, the NES group showed earlier peak of cerebral edema and lower degree of cerebral edema. The absolute regression volume of edema in the MIDPs group was greater than that in the NEs group, but there was no difference in the regression rate of edema between the two groups.

Comparison of the Novel Two-Hand Technique Using the Saraj Endocath with the Traditional Three-Hand Technique in Transnasal Endoscopic Pituitary Surgery: An Innovation for the Future

Endoscopic surgery has become the preferred treatment of sellar lesions because of its minimally invasive nature. Visualization is frequently obscured as a result of the frequent contact of the lens with blood and tissue debris. We seek to alleviate these problems and increase the efficiency and safety of neuroendoscopic surgery by introducing a new device (Saraj Endocath) combining the major function of suction with the endoscope. A total of 75 patients with pituitary macroadenoma who were eligible for transnasal transsphenoidal endoscopic excision were included in the study between January 2020 and January 2023. Forty-one patients were operated on by the traditional 3-hand technique and 34 patients were operated on using the Saraj Endocath. The duration of surgery, in-out frequency of the endoscope, number of wipes needed to clean the endoscopic lens, and outcomes were assessed. A questionnaire regarding assistance, ergonomics, and instrument handling compared the Saraj Endocath procedure with the traditional technique. The 3-hand technique was converted into the 2-hand technique. The mean operative time using the novel technique with the Saraj Endocath was reduced significantly compared with the traditional technique. The mean number of in-out movements of the endoscope and the number of wipes per hour decreased significantly using the Saraj Endocath. There was no dependency on the assistant's expertise and skills. The use of the Saraj Endocath can effectively reduce the mean operative time by decreasing the frequency of in-out movement and wiping off the lens of the endoscope. It reduces fatigue, avoids clustering of instruments and hands, and minimizes the dependency on assistants.

Effect comparison of neuroendoscopy versus microsurgery in the treatment of lateral ventricular tumors.

We sought to reveal the clinical characteristics of lateral ventricle tumors and to evaluate the superior surgical procedure available. There involved a total of of 49 adult patients harboring lateral ventricle tumors in neurosurgery department of our hospital from January 2016 to March 2022. The patients enrolled were retrospectively analyzed, so are their clinical manifestations, pathological characteristics and surgical strategies. The patients were allocated into neuroendoscope group (11 cases) and microsurgery group (38 cases) according to the operation method. The two groups underwent a detailed evaluation of operation effectiveness and safety profile (operation time, intraoperative bleeding, surgical resection rate, postoperative complications) and economic indicators (postoperative hospital stay, hospital costs). The neuroendoscope group demonstrated a markedly shorter operation time than the microsurgery group (p<0.05), with the amount of bleeding significantly less than the microsurgery group (p<0.01). However, there was no significant difference in the resection rate and postoperative complications between the two groups (p>0.05). Significant difference was found in the economic indicators (postoperative hospital stay and hospital costs) of the patients in the neuroendoscope group (p<0.05). Surgery intervention is regarded as the core treatment option for lateral ventricle tumors. Both microsurgery and neuroendoscopy are effective with safety profile. In the selected lateral ventricle tumor surgery, the application of neuroendoscopic surgery showed promising results, in terms of less intraoperative bleeding, and shorter operation time, postoperative hospital stays, and hospital costs. The selection of surgical approach and methods for lateral ventricle tumors is principally depended on the experience of neurosurgeon concerning the surgical approach and related neuroanatomy.