Comparison of two- and three-dimensional endoscopic visualization for fetal myelomeningocele repair: a pilot study using a fetoscopic surgical simulator

3D vs. 2D simulated fetoscopy for spina bifida repair: a quantitative motion analysis

3D imaging technology is becoming more prominent every day. However, more validation is needed to understand the actual benefit of 3D versus conventional 2D vision. This work quantitatively investigates whether experts benefit from 3D vision during minimally invasive fetoscopic spina bifida (fSB) repair. A superiority study was designed involving one expert team ([Formula: see text] procedures prior) who performed six 2D and six 3D fSB repair simulations in a high-fidelity animal training model, using 3-port access. The 6D motion of the instruments was recorded. Among the motion metrics are total path length, smoothness, maximum speed, the modified Spectral Arc Length (SPARC), and Log Dimensionless Jerk (LDLJ). The primary clinical outcome is operation time (power 90%, 5% significance) using Sealed Envelope Ltd. 2012. Secondary clinical outcomes are water tightness of the repair, CO[Formula: see text] insufflation volume, and OSATS score. Findings show that total path length and LDLJ are considerably different. Operation time during 3D vision was found to be significantly shorter compared to 2D vision ([Formula: see text] vs. [Formula: see text] min; p [Formula: see text] 0.026). These results suggest enhanced performance with 3D vision during interrupted suturing in fetoscopic SBA repair. To confirm these results, a larger-scale follow-up study involving multiple experts and novice surgeons is recommended.

Training model for the fetal myelomeningocele correction with multiportal endoscopic technique

PURPOSE

The recent history of myelomeningocele has shown that treatment during the fetal life may reduce the risk of developing hydrocephalus in individuals by approximately 50%. Thus, a significant advancement involves fetal surgery performed through an endoscopic technique in which portals are placed to introduce the forceps and laparoscopic instruments. However, the development of this technique requires training; therefore, this study aimed to develop a training model for fetal myelomeningocele repair technique with multi-portal endoscopy.

METHODS

Two stages of endoscopic technique development were performed. The first stage consisted of exercises in order to familiarize the surgeon with 2D-vision endoscopic surgery, associated with the application of exercises focused on surgical skills, such as the development of laparoscopic knots in a synthetic model. The second stage involved the creation and application of the stages of myelomeningocele closure with a non-living animal model consisting of a chicken breast to simulate the myelomeningocele and a basketball to simulate the gravid uterus, in which perforations were made to introduce vascular introducers (portals) that, as in vivo, are used as portals (trocars) for the introduction of laparoscopic instruments. Overall, two different scenarios with three portals and two portals were tested.

RESULTS

In three-portal simulator, the triangular apex trocar was used for the introduction of 4-mm 0° or 30° optics or even Minop type neurodoscope (Aesculap®, Germany) that was operated by the assistant surgeon; the other two portals are used for the introduction of laparoscopic instruments. Thus, the surgeon is able to perform maneuvers bimanually since dissection to laparoscopic sutures. In two-portal simulator, the surgeon and assistant stay side by side and one of the portals is used for the optic and the other for the laparoscopic instruments. There is no possibility of bimanual dissection in this method.

CONCLUSION

Realistic simulation models for endoscopic fetal surgery for myelomeningocele correction are easily performed and help develop the necessary skills for fetal surgery teams.

The use of three-dimensional endoscope in transnasal skull base surgery: A single-center experience from China

Objective

The development of skull base surgery in the past decade has been influenced by advances in visualization techniques; recently, due to such improvements, 3D endoscopes have been widely used. Herein, we address its effect for transnasal endoscopic skull base surgery.

Methods

A total of 63 patients who under endoscopic endonasal surgery (EES) with 3-D endoscope were retrospectively reviewed, including pituitary adenomas, craniopharyngiomas, meningiomas, Rathke’s cleft cysts, and chordomas. According to different lesions, transsellar approach (24 cases), transsphenoidal–transtuberculum approach (14 cases), transclival approach (6 cases), and transpterygoid approach (19 cases) were selected.

Results

Total removal of tumors was achieved in 56 patients (88.9%) and subtotal removal in 7 cases (11.1%). Complications included diabetes insipidus in seven patients (11.1%), cerebrospinal fluid (CSF) leakage in two patients (3.2%), major vascular injury occurred in one patient (1.6%), cranial nerve injury in nine patients (14.3%), and meningitis in two patients (3.2%). There was no mortality in the series. All patients recovered and were back to normal daily life, and no tumor recurrence or delayed CSF leakage was detected during the follow-up (2–13 months, mean 7.59 months).

Conclusions

Via 3D EES, it improved depth perception and preserved important neurovascular tissue when tumors were removed, which is important for improving the operative prognosis.

Randomized controlled trials in neurosurgery

Randomized controlled trials (RCTs) have become the standard method of evaluating new interventions (whether medical or surgical), and the best evidence used to inform the development of new practice guidelines. When we review the history of medical versus surgical trials, surgical RCTs usually face more challenges and difficulties when conducted. These challenges can be in blinding, recruiting, funding, and even in certain ethical issues. Moreover, to add to the complexity, the field of neurosurgery has its own unique challenges when it comes to conducting an RCT. This paper aims to provide a comprehensive review of the history of neurosurgical RCTs, focusing on some of the most critical challenges and obstacles that face investigators. The main domains this review will address are: (1) Trial design: equipoise, blinding, sham surgery, expertise-based trials, reporting of outcomes, and pilot trials, (2) trial implementation: funding, recruitment, and retention, and (3) trial analysis: intention-to-treat versus as-treated and learning curve effect.