Use Of Endoscopic Assistance Research Articles

Introducing endoscopic assistance on routinary basis for vestibular schwannomas resection: A single centre acceptance analysis

ObjectiveThe use of endoscopic assistance in retrosigmoid approach for tumors of the cerebellopontine angle brought undoubted technological advantages in skull base surgery.Nonetheless, the use of the endoscope is not as widespread as it could be.The aim of the study is to analyze the impressions of neurosurgeons and otologists with different experience in vestibular schwannoma surgery, experiencing the introduction of the endoscope in surgical daily practice. MethodsAll patients undergoing vestibular schwannoma surgery were recruited in the period from January 2019 to December 2020. The endoscope-assistance and a minimum follow-up of 12 months were considered inclusion criteria. An eight items questionnaire was administered to the surgeons who used endoscope-assistance during surgery. ResultsA total number of 20 patients were recruited. Five surgeons experienced the use of 0° and 45° optics in the “pre-resection” and “intra-meatal” phases of the procedures. The survey gave positive feedbacks on the introduction of the endoscope in vestibular schwannoma resection. The main drawback was the difficulty to manage the use of angled optics. ConclusionsDespite the known limitations of the study, the idea of investigating surgeons’ impressions on the use of the endoscope could be another motif to explain why this instrument and its diffusion is limited despite its advantages in vestibular schwannoma surgery.

Surgical Relevance of the Suprameatal Tubercle During Superior Petrosal Vein-Sparing Trigeminal Nerve Microvascular Decompression.

An enlarged suprameatal tubercle (SMT) can obscure visualization of the trigeminal nerve and require removal during microvascular decompression (MVD) surgery, especially when the superior petrosal vein (SPV) complex is preserved. To define the incidence and important variables affecting the need for SMT removal with an SPV-sparing trigeminal nerve MVD. Retrospective single-institution review identified patients who underwent a first-time, SPV-sparing MVD for trigeminal neuralgia (TGN) over a 26-mo period. SMT length (SMT-L), SMT width (SMT-W), and peri-trigeminal cerebellopontine cisternal thickness (CT) were measured from axial high-resolution magnetic resonance images. Need for SMT removal and use of endoscopic assistance was recorded. Data were analyzed using unpaired t-tests, and receiver operating characteristic (ROC)/area under the curve testing. A total of 43 MVD surgeries for TGN on 42 patients (mean age 52.7±14.4 yr) were analyzed. Mean SMT-L, SMT-W, and CT were 9.8±1.6, 2.0±0.8, and 4.2±1.5 mm, respectively. SMT removal via drilling was required in 4/43 cases (9.3%). Endoscopic assistance was used in 3 cases (2 SMT removed and 1 SMT preserved). SMT-W was the biggest predictor of the need for SMT removal on ROC analysis (area under the curve 0.97, 0.92-1.0 95% CI). The combined thresholds of SMT-W≥3.2 mm and CT≤3.5 mm demonstrated 100% sensitive and 100% specificity for the need to remove the SMT on optimal cutoff analysis. SMT drilling is necessary in nearly 10% of SPV-sparing MVDs for TGN. The combination of SMT width and cerebellopontine cistern thickness is predictive of the need for SMT removal.

Features of endoscopic anatomy of the chiasmal-sellar region in transcranial endoscopy via supraorbital keyhole-access

The use of endoscopic assistance in transcranial microsurgical operations has started relatively recently and is not currently used routinely in neurosurgery. With the development of neuroimaging and microsurgical techniques in neurosurgery, minimally invasive surgery is currently actively developing, which provides a reduction in the volume of access and trauma of the intervention. One of the minimally invasive approaches used in chiasmal-sellar surgery is the supraorbital keyhole-access. This work is devoted to the description of features of visualization of anatomical structures of the chiasmal-sellar region using endoscopic techniques through microsurgical supraorbital keyhole-access.

Prospective Evaluation of the Need for Fixed Brain Retractors During Complex Cranial Surgery

The trend toward minimally invasive surgery has led to a reduction in the size of craniotomies, use of endoscopic assistance to minimize the surgeon's footprint and aid with visualization, and use of alternatives to microsurgery, such as endovascular embolization for aneurysms and radiosurgery for skull base pathologies. A movement away from the use of fixed retractors has also been heralded as an advance in skull base surgery, but the data on the utility of a retractorless approach is small and limited to highly experienced surgeons, often with several decades of experience. This has led some to suggest that retractorless surgery may be unsafe, especially in the hands of young surgeons, in an era where the majority of complex vascular pathology has transitioned to endovascular treatment, and many skull base lesions are treated with chemoradiotherapy adjuncts. This 19-month study prospectively analyzed the use of retractorless surgery in a consecutive series of 139 lesions in 119 patients with complex intracranial vascular and skull base pathology undergoing craniotomy by a single surgeon. The microsurgical approaches included orbitozygomatic craniotomy (40 [28.7%]), supratentorial nonskull base approaches (25 [17.9%]), pterional/minipterional (16 [11.5%]), interhemispheric (12 [8.6%]), suboccipital (11 [7.9%]), and an array of other approaches, such as presigmoid, supracerebellar-infratentorial, far lateral, and retrosigmoid approaches. The most common pathology included aneurysms (47 [33.8%]), skull base tumors (32 [23%]), deep-seated lesions (24 [17.3%]), cavernous malformations (10 [7.2%]), arteriovenous malformations (10 [7.2%]), and arteriovenous fistulae (5 [3.6%]). Of the 139 lesions, 8 (5.75%) cases required the use of a fixed retractor. In total, 94.25% of the cases were successfully treated without a self-retaining retractor system. Retractorless surgery can be performed safely, even by young surgeons, in an era where the majority of complex neurovascular and skull base pathology is treated by endovascular and radiosurgical means. Retractorless surgery can be used in the majority of cases, especially if careful attention is paid to patient positioning, microsurgical dissection of arachnoid planes is carried out to access deep corridors, gravity retraction is used in lieu of fixed retractors, and judicious dynamic retraction with the shafts of instruments replaces the blades of a fixed retractor system.

Endoscopic-assisted Transoral Approach to Parapharyngeal Space Tumours

Parapharyngeal space tumours are rare, mostly benign and present few symptoms, being difficult to diagnose it early. CT scan and MR are necessary for topographical diagnosis. Surgical resection is the best possible treatment option, but the approach remains a challenge, as there are several vital elements contained in the parapharyngeal space and, thus, adequate visualization is needed. Different surgical approaches have been described: transcervical-submandibular, transparotid, transmandibular, transoral and combined approaches. Transoral approach is the most controversial one due to cited limited exposure, which can lead to neurovascular injury or incomplete removal of the lesion. It is seldom performed and only for small, extra-parotid and non-vascular tumours of the parapharyngeal space. Wide access to endoscopic equipment in our institute allowed us to perform medium to large benign parapharyngeal tumour resection usig the transoral approach. The use of endoscopic assistance for transoral approach provided direct and magnified visualization of the parapharyngeal space, reducing tissue damage, ensuring adequate hemostasis (which lead to less amount of bleeding) and also confirming complete resection prior to closure. In addition, compared to transcervical approach, transoral approach shortened hospitalization time and improved cosmetic appearance. Benign parapharyngeal space tumours not involving critical structures from the parapharyngeal space can be completely resected by an endoscopic-assisted transoral approach with good functional and cosmetic outcome.

Endoscopic-Assisted Microvascular Decompression of Ectatic Vertebral Artery for Hemifacial Spasm: Operative Video and Technical Nuances

In this operative video atlas manuscript, the authors demonstrate the operative nuances and surgical technique for endoscopic-assisted microvascular decompression of a large ectatic vertebral artery causing hemifacial spasm. A retrosigmoid approach was performed and a large ectatic vertebral artery was transposed away from the root exit zone of cranial nerve VII ( Fig. 1 ). The lateral spread response disappeared, signifying adequate decompression of the facial nerve ( Fig. 2 ). The use of endoscopic-assistance during the microsurgical decompression was very useful to confirm the origin and also the resolution of neurovascular conflict. Postoperatively, the patient experienced immediate resolution of hemifacial spasm with normal facial nerve and hearing function. Written consent was obtained from the patient to publish videos, photographs, and images from the surgery. The link to the video can be found at: https://youtu.be/RlMz44uCDCw .

Minimally invasive approaches to aneurysms of the anterior circulation: selection criteria and clinical outcomes.

Over the last few decades, cerebrovascular surgery has gravitated towards a minimally invasive philosophy without compromising the foundational principles of patient safety and surgical efficacy. Enhanced radiosurveillance modalities and increased average life expectancy have resulted in an increased reported incidence of intracranial aneurysms. Although endovascular therapies have gained popularity in the recent years, microsurgical clipping continues to be of value in the management of these aneurysms owing to its superior occlusion rates, applicability to complex aneurysms and reduced retreatment rates. The concept of keyhole transcranial procedures has advanced the field significantly leading to decreased postoperative neurological morbidity and quicker recovery. The main keyhole neurosurgical approaches include the supraorbital craniotomy (SOC), lateral supraorbital craniotomy (LSOC), mini-pterional craniotomy (MPTC), mini-orbitozygomatic craniotomy and the mini anterior interhemispheric approach (MAIA). As these minimally invasive approaches can have an inherent limitation of a narrow viewing angle and low regional illumination, the use of endoscopic assistance in such procedures is being popularized. Neuroendoscopy can aid in the visualization of hidden neurovascular structures and inspection of the parent arterial segment without undue retraction of the lesion. This review focuses on the historical progression of the surgical management of intracranial aneurysms, the technical details of various minimally invasive approaches, patient selection and clinical outcomes of the anterior circulation aneurysms and useful tenets to avoid complications during these procedures. Meticulous preoperative planning to understand the patient's vascular anatomy, the orientation and relationship of the aneurysm to adjacent structures, use of neuronavigation guidance and endoscopic assistance if needed can lead to an optimal surgical outcome while minimizing neurological morbidity and mortality.

Endoscope-assisted surgery of deep-seated brain tumors

The use of endoscopic procedures in surgery intrinsic tumors and results of clinical studies on the use of endoscopic assistance in neurooncology were discussed. Also the certain advantages of clinical application of endoscopic techniques, ways to ensure the effectiveness of the endoscope-assisted neurosurgery and prospects of further development of neuroendoscopy were identified.

Treatment of Orbital Medial Wall Fractures with Titanium Mesh Plates Using Retrocaruncular Approach: Outcomes with Different Techniques.

Surgical management of medial wall orbital fractures should be considered to avoid diplopia and posttraumatic enophthalmos. Treatment of these fractures remains a challenge for the maxillofacial surgeon because of complex anatomy and limited vision. This article aims to retrospectively evaluate the outcomes in the repair of medial orbital wall fractures using a retrocaruncular approach and titanium meshes, comparing the placement of the titanium mesh with three different techniques: (1) conventional free hand under direct vision, (2) with the assistance of an endoscope, and (c) with the assistance of a navigation system. Eighteen patients who underwent surgery for orbital medial wall fracture were enrolled in the study. On the basis of the implant placement technique, three groups were identified: group 1 (CONV), conventional free hand under direct vision; group 2 (ENDO), endoscopically assisted; group 3 (NAVI), a navigational system assisted (BrainLab, Feldkirchen, Germany). The postoperative quality of orbital reconstruction was assessed as satisfactory in 12 cases, good in 4 cases, and unsatisfactory in 2 cases. Particularly in group 1 (CONV) in four patients out of eight, the posterior ledge of the fracture was not reached by the implant and in one patient the mesh hinged toward the ethmoid. In group 3 (NAVI), in one patient out of five, the posterior ledge of the fracture was not reached. In conclusion, titanium orbital mesh plates and retrocaruncular approach are a reliable method to obtain an accurate orbital medial wall reconstruction. The use of endoscopic assistance through the surgical incisions improves accuracy of treatment allowing better visualization of the surgical field. Navigation aided surgery is a feasible technique especially for complex orbital reconstruction to improve predictability and outcomes in orbital repair.

Endoscopic transaxillary breast augmentation: Clinical evaluation of a series of 306 patients over a 9-year period

Transaxillary breast augmentation was described in the early 1970s. While the traditional blind operation continues to be advocated, the use of endoscopic assistance has been gaining acceptance since its first presentation about 12 years ago. This clinical study presents a series of 306 consecutive patients, who underwent endoscopic transaxillary breast augmentation over a 9-year period between 1996 and 2005-the largest series reported to date for this procedure. An initial 4- to 5-cm incision was made high in the axilla. Dissection was carried out to create an adequate tunnel for insertion of the implant. A subglandular, subfascioglandular, or submusculofascial pocket, depending on the individual case, was developed with endoscopic assistance. Injections of methylene blue through the different anatomic planes proved useful in the dissection of the pocket at the inframammary fold. In our series of 306 patients, we were able to achieve a hidden scar without compromising the aesthetic result. Complications included 3 hematomas, 5 cases of capsular contracture, 1 case of postoperative infection, and a 6.2% reoperation rate to correct implant malposition. Endoscopic transaxillary breast augmentation makes it possible to treat the same deformities, with the same refinements, as the more traditional approaches. The absence of scar in the breast aesthetic unit explains patients' interest in this operation. The technique has withstood the test of time. It has been found to be safe, has a relatively easy learning curve, and produces consistent results.