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Grunert R, Snyderman CH, Gardner P, Busse M, Ahner L, Kropla F, Möbius R, Jung S, Scholz S, Güresir E, Winkler D. NextLens-The Next Generation of Surgical Navigation: Proof of Concept of an Augmented Reality System for Surgical Navigation. J Neurol Surg B Skull Base 2024; 85:363-369. [PMID: 38966300 PMCID: PMC11221910 DOI: 10.1055/a-2083-7766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/24/2023] [Indexed: 07/06/2024] Open
Abstract
Objective The aim of this work was the development of an augmented reality system including the functionality of conventional surgical navigation systems. Methods An application software for the Augmented Reality System HoloLens 2 from Microsoft was developed. It detects the position of the patient as well as position of surgical instruments in real time and displays it within the two-dimensional (2D) magnetic resonance imaging or computed tomography (CT) images. The surgical pointer instrument, including a pattern that is recognized by the HoloLens 2 sensors, was created with three-dimensional (3D) printing. The technical concept was demonstrated at a cadaver skull to identify anatomical landmarks. Results With the help of the HoloLens 2 and its sensors, the real-time position of the surgical pointer instrument could be shown. The position of the 3D-printed pointer with colored pattern could be recognized within 2D-CT images when stationary and in motion at a cadaver skull. Feasibility could be demonstrated for the clinical application of transsphenoidal pituitary surgery. Conclusion The HoloLens 2 has a high potential for use as a surgical navigation system. With subsequent studies, a further accuracy evaluation will be performed receiving valid data for comparison with conventional surgical navigation systems. In addition to transsphenoidal pituitary surgery, it could be also applied for other surgical disciplines.
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Affiliation(s)
- Ronny Grunert
- Department of Neurosurgery, University Leipzig, Leipzig, Germany
- Fraunhofer Plastics Technology Center Oberlausitz, Fraunhofer Institute for Machine Tools and Forming Technology, Zittau, Germany
| | - Carl-Henry Snyderman
- Center for Skull Base Surgery, University Pittsburgh, Medical Center, Pittsburgh, Pennsylvania, United States
| | - Paul Gardner
- Center for Skull Base Surgery, University Pittsburgh, Medical Center, Pittsburgh, Pennsylvania, United States
| | - Michel Busse
- Department of Neurosurgery, University Leipzig, Leipzig, Germany
| | - Lukas Ahner
- Department of Neurosurgery, University Leipzig, Leipzig, Germany
| | - Fabian Kropla
- Department of Neurosurgery, University Leipzig, Leipzig, Germany
| | - Robert Möbius
- Department of Neurosurgery, University Leipzig, Leipzig, Germany
| | - Svenja Jung
- Department of Neurosurgery, University Leipzig, Leipzig, Germany
| | - Sebastian Scholz
- Fraunhofer Plastics Technology Center Oberlausitz, Fraunhofer Institute for Machine Tools and Forming Technology, Zittau, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Leipzig, Leipzig, Germany
| | - Dirk Winkler
- Department of Neurosurgery, University Leipzig, Leipzig, Germany
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Gerlach R, Modesti CL, Rampinelli V. Interdisciplinary Management of Skull Base Tumors. Laryngorhinootologie 2024; 103:S28-S42. [PMID: 38697142 DOI: 10.1055/a-2196-8984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
OBJECTIVE Endoscopic endonasal skull base surgery has gained acceptance worldwide. Comparative analysis has demonstrated that endoscopic skull base surgery may have advantages for many pathologies of the anterior skull base, e. g., sinonasal malignant tumors; pathologies of the central skull base, e. g., pituitary adenomas, craniopharyngiomas; well-selected cases of planum sphenoidale and tuberculum sellae meningiomas; or for clival lesions, e. g., chordomas, chondrosarcomas, or selected meningiomas. Over the past three decades, interdisciplinary surgical teams, consisting of otolaryngologists and neurosurgeons, have provided detailed anatomical knowledge, suggested new approaches or modifications of established surgical techniques, and offered continued surgical education. METHOD A review of pertinent literature was conducted with an emphasis on interdisciplinary endoscopic surgery of skull base lesions. RESULTS Based on the authors̓ surgical experience in two different interdisciplinary endoscopic skull base centers, the authors classify approaches for endoscopic endonasal skull base surgery, describe indications, and key anatomic landmarks for common pathologies, and highlight surgical techniques to avoid complications. CONCLUSION Interdisciplinary endonasal endoscopic surgery combines surgical expertise, improves resection rates for many pathologies, and minimizes morbidity by reducing the incidence of surgical complications.
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Affiliation(s)
| | - Claudia Lodovica Modesti
- Unit of Otolaryngology and Head and Surgery, ASST Spedali Civili di Brescia, University of Brescia, Italy
| | - Vittorio Rampinelli
- Unit of Otolaryngology and Head and Surgery, ASST Spedali Civili di Brescia, University of Brescia, Italy
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Karadag A, Yuncu ME, Middlebrooks EH, Tanriover N. Endoscopic trans-eustachian tube approach: identifying the precise landmarks, a novel radiological and anatomical evaluation. Surg Radiol Anat 2024; 46:625-634. [PMID: 38530385 DOI: 10.1007/s00276-024-03344-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 03/08/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE The endoscopic trans-eustachian approach (ETETA) is a less invasive approach to the infratemporal fossa (ITF), providing superior exposure compared to traditional transcranial approaches. The anatomy of the pharyngotympanic (eustachian) tube and adjacent neurovascular structures is complex and requires in-depth knowledge to safely perform this approach. We present a cadaveric and radiological assessment of critical anatomic considerations for ETETA. METHODS Six adult cadaveric heads were dissected alongside examination of 50 paranasal sinus CT scans. Key anatomic relationships of the pharyngotympanic tube and adjacent structures were qualitatively and quantitatively evaluated. Descriptive statistics were performed for quantitative data. RESULTS Anatomical and radiological measurements showed lateralization of the pharyngotympanic tube allows access to the ITF. The pharyngotympanic tube has bony and cartilaginous parts with the junction formed by the sphenoid spine and foramen spinosum. The bony part and tendon of the tensor tympani muscle were located at the posterior genu of the internal carotid artery. The anterior and inferior wall of the carotid canal was located between the horizontal segment of the internal carotid artery and petrous segment of the cartilaginous pharyngotympanic tube. CONCLUSION The combination of preoperative radiographic assessment and anatomical correlation demonstrates a safe and effective approach to ETETA, which allowed satisfactory visualization of ITF. The morphological evaluation showed that the lateralization of the pharyngotympanic tube and related structures allowed a surgical corridor to reach the ITF. Endoscopic surgery through the pharyngotympanic tube is challenging, and in-depth understanding of the key anatomic relationships is critical for performing this approach.
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Affiliation(s)
- Ali Karadag
- Izmir Faculty of Medicine, Department of Neurosurgery, University of Health Sciences, Izmir, Turkey.
- Department of Neurosurgery, Izmir City Hospital, Laka, Bornova / Izmir, 35040, Turkey.
| | - Mustafa Eren Yuncu
- Department of Neurosurgery, Izmir City Hospital, Laka, Bornova / Izmir, 35040, Turkey
| | - Erik H Middlebrooks
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Necmettin Tanriover
- Cerrahpasa Faculty of Medicine, Department of Neurosurgery, Istanbul University - Cerrahpasa, Istanbul, Turkey
- Cerrahpasa Faculty of Medicine, Department of Neurosurgery, Microsurgical Neuroanatomy Laboratory, Istanbul University - Cerrahpasa, Istanbul, Turkey
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Patel BK, Gowda A, Darshan HR, Binu A, Sudhir BJ, Easwer HV, Krishnakumar K, Nair P. Endoscopic Endonasal Inter-dural Posterior Clinoidectomy and Pituitary Hemitranspostion for Surgical Resection of a Large Suprasellar Ependymoma Involving the Inter-peduncular Cistern. Neurol India 2024; 72:261-265. [PMID: 38817169 DOI: 10.4103/neurol-india.neurol-india-d-24-00115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/28/2024] [Indexed: 06/01/2024]
Affiliation(s)
- Biren Khimji Patel
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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Martins Coelho VDP, Saquy Rassi M, Colli BO. Retrosigmoid versus Retrolabyrinthine Posterior Petrosal Route to the Petroclival Area: Quantitative Assessment of Endoscope-Assisted Approaches and Correlations with Morphometric Features. World Neurosurg 2023; 173:e462-e471. [PMID: 36841534 DOI: 10.1016/j.wneu.2023.02.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 02/19/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVE Using a cadaveric model, we compared endoscope-assisted retrosigmoid (EAR) and endoscope-assisted retrolabyrinthine posterior petrosal (EARPP) approaches towards the petroclival area, regarding surgical exposure and instrument maneuverability, also verifying how some petroclival morphometric parameters correlate with these variables. METHODS In five cadaver heads, EAR approach was performed on one side and EARPP on the other (10 approaches). Under endoscopic view, neuronavigation coordinates were acquired to compute areas of exposure (petroclival and pontomedullary) and maneuverability at Dorello's canal entrance to run the comparison. Correlations of these variables with petroclival angle and clival depth were also analyzed. RESULTS EAR and EARPP showed equivalence regarding surgical exposure (petroclival: 365.85 ± 133.12 mm2 and 320.62 ± 103.44 mm2, respectively, P = 0.69; pontomedullary: 255.83 ± 88.26 mm2 and 229.80 ± 74.39 mm2, respectively, P = 0.83), but EAR afforded greater maneuverability at Dorello's canal (1155.88 ± 134.35 mm2, P = 0.03). The petroclival angle and clival depth showed different strong correlations with maneuverability depending upon the route, but not with surgical exposure in both approaches. CONCLUSIONS Endoscopic techniques can spare the need for additional steps of greater morbidity when approaching the petroclival area in both routes. A simpler and faster approach as EAR was favored over EARPP in this standardized quantitative assessment. The petroclival angle and clival depth may interfere with maneuverability, but not with surgical exposure in both endoscope-assisted approaches.
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Affiliation(s)
- Vicente de Paulo Martins Coelho
- Division of Neurosurgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.
| | - Marcio Saquy Rassi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Division of Neurosurgery, Department of Surgery, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil
| | - Benedicto Oscar Colli
- Division of Neurosurgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
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Guizzardi G, Prats-Galino A, Mosteiro A, Santos C, Topczewski T, Torales J, Roldan P, Reyes L, Di Somma A, Enseñat J. Multiportal Combined Endoscopic Endonasal and Transorbital Pathways: Qualitative and Quantitative Anatomic Studies of the "Connection" Skull Base Areas. Oper Neurosurg (Hagerstown) 2023; 24:e342-e350. [PMID: 36715996 DOI: 10.1227/ons.0000000000000577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 10/07/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Combined endonasal and transorbital multiportal surgery has been recently described for selected skull base pathologies. Nevertheless, a detailed anatomic description and a quantitative comprehensive anatomic study of the skull base areas where these 2 endoscopic routes converge, a so-called connection areas, are missing in the scientific literature. OBJECTIVE To identify all the skull base areas and anatomic structures where endonasal and transorbital endoscopic avenues could be connected and combined. METHODS Five cadaveric specimens (10 sides) were used for dissection. Qualitative description and quantitative analysis of each connection areas were performed. RESULTS At the anterior cranial fossa, the connection area was found at the level of the sphenoid planum; in the middle cranial fossa, it was at the Mullan triangle; finally, in the posterior cranial fossa, the connection area was just behind the medial portion of the petrous apex. The average extradural working areas through the transorbital approach were 4.93, 12.93, and 1.93 cm 2 and from the endonasal corridor were 7.75, 10.45, and 7.48 cm 2 at the level of anterior, middle, and posterior cranial fossae, respectively. CONCLUSION The combined endonasal and transorbital endoscopic approach is an innovative entity of skull base neurosurgery. From the anatomic point of view, our study demonstrated the feasibility of this combined approach to access the entire skull base, by both corridors, identifying a working connection area in each cranial fossa. These data could be extremely useful during the surgical planning to predict which portion of a lesion could be removed through each route and to optimize patients' care.
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Affiliation(s)
- Giulia Guizzardi
- Laboratory of Surgical Neuroanatomy, Universitat de Barcelona, Spain
| | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy, Universitat de Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Alejandra Mosteiro
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Carlos Santos
- Department of Neurological Surgery and Spine Unit, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Thomaz Topczewski
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jorge Torales
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Pedro Roldan
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Luis Reyes
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alberto Di Somma
- Laboratory of Surgical Neuroanatomy, Universitat de Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
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So J, Lee H, Jeong J, Forterre F, Roh Y. Endoscopy-assisted resection of a sphenoid-wing meningioma using a 3D-printed patient-specific pointer in a dog: A case report. Front Vet Sci 2022; 9:979290. [DOI: 10.3389/fvets.2022.979290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 11/02/2022] [Indexed: 11/17/2022] Open
Abstract
A 9-year-old female mixed-breed dog presented for treatment of a presumed sphenoid-wing meningioma. Clinical signs included tonic-clonic seizures lasting <1 min, which had started 3 months previously. The physical examination results were unremarkable. An eccentrically located neoplastic cystic structure in the right sphenoid bone region suggestive of a meningioma and peritumoural brain oedema was observed in pre-operative magnetic resonance imaging (MRI). Prior to surgery, a three-dimensional (3D) patient-specific pointer (PSP) was designed using computed tomography (CT) images and computer-aided 3D design software. After a targeted approach and exposure of the lateral part of the right temporal lobe by a craniectomy guided by the 3D-PSP, complete macroscopic piecemeal resection of the meningioma could be performed using endoscopy-assisted brain surgery. Post-operative MRI confirmed complete excision of the tumor. Anticonvulsive therapy was discontinued after 90 days, and the dosage of anticonvulsants was tapered 2 weeks after surgery. At a follow-up examination 225 days post-operatively, recurrence of seizures was not observed, and the absence of tumor recurrence was confirmed by a repeat MRI examination. To the best of our knowledge, this is the first report in veterinary medicine describing a successful resection of a sphenoid-wing meningioma using a 3D-PSP. 3D-PSP-assisted craniectomy may be a surgical option for some canine skull-based tumors, such as sphenoid wing meningiomas.
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Doniz-Gonzalez A, Vigo V, Nunez MA, Xu Y, Mohyeldin A, Cohen-Gadol AA, Fernandez-Miranda JC. Microsurgical anatomy and the importance of the petrosal process of the sphenoid bone in endonasal surgery. J Neurosurg 2022; 137:1431-1442. [PMID: 35276642 DOI: 10.3171/2021.12.jns212024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The petrosal process of the sphenoid bone (PPsb) is a relevant skull base osseous prominence present bilaterally that can be used as a key surgical landmark, especially for identifying the abducens nerve. The authors investigated the surgical anatomy of the PPsb, its relationship with adjacent neurovascular structures, and its practical application in endoscopic endonasal surgery. METHODS Twenty-one dried skulls were used to analyze the osseous anatomy of the PPsb. A total of 16 fixed silicone-injected postmortem heads were used to expose the PPsb through both endonasal and transcranial approaches. Dimensions and distances of the PPsb from the foramen lacerum (inferiorly) and top of the posterior clinoid process (PCP; superiorly) were measured. Moreover, anatomical variations and the relationship of the PPsb with the surrounding crucial structures were recorded. Three representative cases were selected to illustrate the clinical applications of the findings. RESULTS The PPsb presented as a triangular bony prominence, with its base medially adjacent to the dorsum sellae and its apex pointing posterolaterally toward the petrous apex. The mean width of the PPsb was 3.5 ± 1 mm, and the mean distances from the PPsb to the foramen lacerum and the PCP were 5 ± 1 and 11 ± 2.5 mm, respectively. The PPsb is anterior to the petroclival venous confluence, superomedial to the inferior petrosal sinus, and inferomedial to the superior petrosal sinus; constitutes the inferomedial limit of the cavernous sinus; and delimits the upper limit of the paraclival internal carotid artery (ICA) before the artery enters the cavernous sinus. The PPsb is anterior and medial to and below the sixth cranial nerve, forming the floor of Dorello's canal. During surgery, gentle mobilization of the paraclival ICA reveals the petrosal process, serving as an accurate landmark for the location of the abducens nerve. CONCLUSIONS This investigation revealed details of the microsurgical anatomy of the PPsb, its anatomical relationships, and its application as a surgical landmark for identifying the abducens nerve. This novel landmark may help in minimizing the risk of abducens nerve injury during transclival approaches, which extend laterally toward the petrous apex and cavernous sinus region.
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Affiliation(s)
- Ayoze Doniz-Gonzalez
- 1Department of Neurosurgery, Stanford Hospital, Stanford, California
- 2Department of Neurosurgery, Hospital Universitario de Canarias, La Laguna, Spain
| | - Vera Vigo
- 1Department of Neurosurgery, Stanford Hospital, Stanford, California
| | - Maximiliano Alberto Nunez
- 1Department of Neurosurgery, Stanford Hospital, Stanford, California
- 3Department of Neurosurgery, Hospital El Cruce, Buenos Aires, Argentina
| | - Yuanzhi Xu
- 1Department of Neurosurgery, Stanford Hospital, Stanford, California
- 4Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ahmed Mohyeldin
- 1Department of Neurosurgery, Stanford Hospital, Stanford, California
| | - Aaron A Cohen-Gadol
- 5Department of Neurological Surgery, Indiana University, Indianapolis; and
- 6The Neurosurgical Atlas, Carmel, Indiana
| | - Juan C Fernandez-Miranda
- 1Department of Neurosurgery, Stanford Hospital, Stanford, California
- 6The Neurosurgical Atlas, Carmel, Indiana
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Lee WJ, Kim YH, Hong SD, Rho TH, Kim YH, Dho YS, Hong CK, Kong DS. Development of 3-dimensional printed simulation surgical training models for endoscopic endonasal and transorbital surgery. Front Oncol 2022; 12:966051. [PMID: 35992880 PMCID: PMC9389537 DOI: 10.3389/fonc.2022.966051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundEndoscopic skull base surgery (ESBS) is complex, requiring methodical and unremitting surgical training. Herein, we describe the development and evaluation of a novel three-dimensional (3D) printed simulation model for ESBS. We further validate the efficacy of this model as educational support in neurosurgical training.MethodsA patient-specific 3D printed simulation model using living human imaging data was established and evaluated in a task-based hands-on dissection program. Endoscopic endonasal and transorbital procedures were simulated on the model by neurosurgeons and otorhinolaryngology surgeons of varying experience. All procedures were recorded using a high-definition camera coupled with digital video recorder system. The participants were asked to complete a post-procedure questionnaire to validate the efficacy of the model.ResultsFourteen experts and 22 trainees participated in simulations, and the 32 participants completed the post-procedure survey. The anatomical realism was scored as 4.0/5.0. The participants rated the model as helpful in hand-eye coordination training (4.7/5.0) and improving surgical skills (4.6/5.0) for ESBS. All participants believed that the model was useful as educational support for trainees (4.7 [ ± 0.5]). However, the color (3.6/5.0) and soft tissue feedback parameters (2.8/5) scored low.ConclusionThis study shows that high-resolution 3D printed skull base models for ESBS can be generated with high anatomical accuracy and acceptable haptic feedback. The simulation program of ESBS using this model may be supplemental or provide an alternative training platform to cadaveric dissection.
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Affiliation(s)
- Won-Jae Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yong Hwy Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University School of Medicine, Seoul, South Korea
| | - Sang-Duk Hong
- Department of Otorhinolaryngology—Head & Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Tae-Hoon Rho
- Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, South Korea
| | - Young Hoon Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yun-Sik Dho
- Department of Neurosurgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, South Korea
| | - Chang-Ki Hong
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- *Correspondence: Doo-Sik Kong, /
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Formalin-free soft embalming of human cadavers using N-vinyl-2-pyrrolidone: perspectives for cadaver surgical training and medical device development. Anat Sci Int 2022; 97:273-282. [PMID: 35460067 DOI: 10.1007/s12565-022-00664-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/30/2022] [Indexed: 02/05/2023]
Abstract
The traditional apprenticeship approach to surgical skill education for young surgeons has drastically changed to more systematic surgical training using cadavers. Cadavers fixed with formalin are not suitable for surgical training because of their associated health hazards and overhardening. Recently, we established a formalin-free soft preservation method for human cadavers using N-vinyl-2-pyrrolidone. Since 2012, 61 cadavers have been embalmed with pyrrolidone in our institution. Tissues of pyrrolidone-embalmed cadavers are soft and pliable, and their bodies can be preserved for as long as 37 months without any signs of corruption. In this review, we introduce our recent attempts to apply pyrrolidone-embalmed cadavers in surgical and medical procedure training, including endotracheal intubation, motion physiology of the vocal folds, laparoscopic surgery, endoscopic skull base surgery, and development of novel medical devices. Future research perspectives on pyrrolidone embalming are discussed.
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Karadag A, Kirgiz PG, Bozkurt B, Kucukyuruk B, ReFaey K, Middlebrooks EH, Senoglu M, Tanriover N. The benefits of inferolateral transtubercular route on intradural surgical exposure using the endoscopic endonasal transclival approach. Acta Neurochir (Wien) 2021; 163:2141-2154. [PMID: 33847826 DOI: 10.1007/s00701-021-04835-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/26/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical access to the ventral pontomedullary junction (PMJ) can be achieved through various corridors depending on the location and extension of the lesion. The jugular tubercle (JT), a surgically challenging obstacle to access the PMJ, typically needs to be addressed in transcranial exposures. We describe the endoscopic endonasal transclival approach (EETCA) and its inferolateral transtubercular extension to assess the intradural surgical field gained through JT removal. We also complement the dissections with an illustrative case. METHODS EETCA was surgically simulated, and the anatomical landmarks were assessed in eight cadaveric heads. Microsurgical dissections were additionally performed along the endoscopic surgical path. Lastly, we present an intraoperative video of the trans-JT approach in a patient with lower clival chordoma. RESULTS The EETCA allowed adequate extracranial visualization and removal of the JT. The surgical bony window-obtained along the clivus and centered at the JT via the EETCA-measured 11 × 9 × 7 mm. Removal of the JT provided an improved intradural field within the lower third of the cerebellopontine cistern to expose an area bordered by the cranial nerves VII/VIII and flocculus superior and anterior margin of the lateral recess of the fourth ventricle and cranial nerves IX-XI inferiorly, centered on the foramen of Luschka. CONCLUSIONS Removal of the JT via EETCA improves exposure along the lower third of the cerebellopontine and upper cerebellomedullary cisterns. The inferolateral transtubercular extension of the EETCA provides access to the lateral recess of the fourth ventricle, in combination with the ventral midline pontomedullary region.
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12
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Revuelta Barbero JM, Soriano RM, Bray DP, Rindler RS, Henriquez O, Solares CA, Pradilla G. The Transorbital Pericranial Flap. World Neurosurg 2021; 152:e241-e249. [PMID: 34058363 DOI: 10.1016/j.wneu.2021.05.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of the present study was to describe and evaluate the feasibility, mobility, and surface area provided by the simple and extended transorbital pericranial flap (TOPF). Furthermore, we compared this novel technique with the current practice of pericranial flap harvesting and insetting techniques. We also studied the adequacy of the TOPF in the reconstruction of postoperative anterior cranial fossa (ACF) defects. METHODS The TOPF was performed bilaterally in 5 alcohol-preserved, latex-injected human cadaveric specimens. The TOPF was harvested in 2 stages: the orbitonasal stage and the cranial stage. For the orbitonasal stage, a transorbital superior eyelid approach was used. We have described 2 harvesting techniques for creating 2 distinct TOPF types (simple and extended) according to the main vascular pedicle. The superficial flap areas offered by the simple and extended TOPF and the traditional bicoronal pericranial flap were calculated and compared. The distances from the supratrochlear and supraorbital arteries to specified anatomical landmarks were also measured. Additionally, the ACF defect area of relevant surgical cases performed using endoscopic transcribriform approaches were measured on immediate postoperative computed tomography head scans using radiological imaging software. RESULTS The harvest of both the simple and the extended TOPFs was efficient. As expected, the areas offered by simple and extended TOPFs were smaller than that offered by the traditional bicoronal flap. However, the surface area offered by either the simple or extended TOPF provides sufficient coverage for most ACF defects. A high spatial distribution was observed between the vascular pedicles and their respective foramen or notch. CONCLUSIONS The TOPF represents a novel harvesting, tunneling, and insetting technique that offers a large, versatile, pedicled flap for coverage of most standard ACF defects after endoscopic surgery.
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Affiliation(s)
| | - Roberto M Soriano
- Department of Otolaryngology, Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David P Bray
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rima S Rindler
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Oswaldo Henriquez
- Department of Otolaryngology, Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - C Arturo Solares
- Department of Otolaryngology, Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
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Oyama K, Watanabe K, Hanakita S, Champagne PO, Passeri T, Voormolen EH, Bernat AL, Penet N, Fukushima T, Froelich S. The orbitopterygoid corridor as a deep keyhole for endoscopic access to the paranasal sinuses and clivus. J Neurosurg 2021; 134:1480-1489. [PMID: 32534497 DOI: 10.3171/2020.3.jns2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The anteromedial triangle (AMT) is the triangle formed by the ophthalmic (V1) and maxillary (V2) nerves. Opening of this bony space offers a limited access to the sphenoid sinus (SphS). This study aims to demonstrate the utility of the orbitopterygopalatine corridor (OPC), obtained by enlarging the AMT and transposing the contents of the pterygopalatine fossa (PPF) and V2, as an entrance to the SphS, maxillary sinus (MaxS), and nasal cavity. METHODS Five formalin-injected cadaveric specimens were used for this study (10 approaches). A classic pterional approach was performed. An OPC was created through the inferior orbital fissure, between the orbit and the PPF, by transposing the PPF inferiorly. The extent of the OPC was measured using neuronavigation and manual measurements. Two illustrative cases using the OPC to access skull base tumors are presented in the body of the article. RESULTS Via the OPC, the SphS, MaxS, ethmoid sinus (EthS), and nasal cavity could be accessed. The use of endoscopic assistance through the OPC achieved better visualization of the EthS, SphS, MaxS, clivus, and nasal cavity. A significant gain in the area of exposure could be achieved using the OPC compared to the AMT (22.4 mm2 vs 504.1 mm2). CONCLUSIONS Opening of the AMT and transposition of V2 and the contents of the PPF creates the OPC, a potentially useful deep keyhole to access the paranasal sinuses and clival region through a middle fossa approach. It is a valuable alternative approach to reach deep-seated skull base lesions infiltrating the cavernous sinus and middle cranial fossa and extending into the paranasal sinus.
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Affiliation(s)
- Kenichi Oyama
- 1Department of Neurosurgery, Lariboisière Hospital, University of Paris Diderot, Paris, France, and
| | - Kentaro Watanabe
- 1Department of Neurosurgery, Lariboisière Hospital, University of Paris Diderot, Paris, France, and
| | - Shunya Hanakita
- 1Department of Neurosurgery, Lariboisière Hospital, University of Paris Diderot, Paris, France, and
| | - Pierre-Olivier Champagne
- 1Department of Neurosurgery, Lariboisière Hospital, University of Paris Diderot, Paris, France, and
| | - Thibault Passeri
- 1Department of Neurosurgery, Lariboisière Hospital, University of Paris Diderot, Paris, France, and
| | - Eduard H Voormolen
- 1Department of Neurosurgery, Lariboisière Hospital, University of Paris Diderot, Paris, France, and
| | - Anne Laure Bernat
- 1Department of Neurosurgery, Lariboisière Hospital, University of Paris Diderot, Paris, France, and
| | - Nicolas Penet
- 1Department of Neurosurgery, Lariboisière Hospital, University of Paris Diderot, Paris, France, and
| | - Takanori Fukushima
- 2Department of Neurological Surgery, Duke University, Durham, North Carolina
| | - Sébastien Froelich
- 1Department of Neurosurgery, Lariboisière Hospital, University of Paris Diderot, Paris, France, and
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14
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Di Perna G, Penner F, Cofano F, De Marco R, Baldassarre BM, Portonero I, Garbossa D, Ceroni L, Pecorari G, Zenga F. Skull base reconstruction: A question of flow? A critical analysis of 521 endoscopic endonasal surgeries. PLoS One 2021; 16:e0245119. [PMID: 33720937 PMCID: PMC7959384 DOI: 10.1371/journal.pone.0245119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 12/23/2020] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Post-operative CSF leak still represents the main drawback of Endoscopic Endonasal Approach (EEA), and different reconstructive strategies have been proposed in order to decrease its rate. OBJECTIVE To critically analyze the effectiveness of different adopted reconstruction strategies in patients that underwent EEA. MATERIALS AND METHODS Adult patients with skull base tumor surgically treated with EEA were retrospectively analyzed. Data recorded for each case concerned patient demographics, type of surgical approach, histotype, anatomical site of surgical approach, intra-operative CSF leak grade (no leak (INL), low flow (ILFL), high flow (IHFL)), reconstructive adopted strategy, Lumbar Drain positioning, post-operative CSF leak rate and intra/post-operative complications. RESULTS A total number of 521 patients (January 2012-December 2019) was included. Intra-operative CSF leak grade showed to be associated with post-operative CSF leak rate. In particular, the risk to observe a post-operative CSF leak was higher when IHFL was encountered (25,5%; Exp(B) 16.25). In particular, vascularized multilayered reconstruction and fat use showed to be effective in lowering post-operative CSF leaks in IHFL (p 0.02). No differences were found considering INL and ILFL groups. Yearly post-operative CSF leak rate analysis showed a significative decreasing trend. CONCLUSION Intra-operative CSF leak grade strongly affected post-operative CSF leak rate. Multilayer reconstruction with fat and naso-septal flap could reduce the rate of CSF leak in high risk patients. Reconstructive strategies should be tailored according also to the type and the anatomical site of the approach.
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Affiliation(s)
- Giuseppe Di Perna
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Federica Penner
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Fabio Cofano
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
- Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
| | - Raffaele De Marco
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Bianca Maria Baldassarre
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Irene Portonero
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Luca Ceroni
- Psychological Sciences and Techniques, Psychology Department, University of Turin, Turin, Italy
| | - Giancarlo Pecorari
- Department of Surgical Sciences, ENT Surgery Unit, University of Turin, Turin, Italy
| | - Francesco Zenga
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
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15
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Transorbital endoscopic approaches to the skull base: a systematic literature review and anatomical description. Neurosurg Rev 2021; 44:2857-2878. [PMID: 33479806 PMCID: PMC8490260 DOI: 10.1007/s10143-020-01470-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/09/2020] [Accepted: 12/29/2020] [Indexed: 12/25/2022]
Abstract
Transorbital endoscopic approaches are increasing in popularity as they provide corridors to reach various areas of the ventral skull base through the orbit. They can be used either alone or in combination with different approaches when dealing with the pathologies of the skull base. The objective of the current study is to evaluate the surgical anatomy of transorbital endoscopic approaches by cadaver dissections as well as providing objective clinical data on their actual employment and morbidity through a systematic review of the current literature. Four cadaveric specimens were dissected, and step-by-step dissection of each endoscopic transorbital approach was performed to identify the main anatomic landmarks and corridors. A systematic review with pooled analysis of the current literature from January 2000 to April 2020 was performed and the related studies were analyzed. Main anatomical landmarks are presented based on the anatomical study and systematic review of the literature. With emphasis on the specific transorbital approach used, indications, surgical technique, and complications are reviewed through the systematic review of 42 studies (19 in vivo and 23 anatomical dissections) including 193 patients. In conclusion, transorbital endoscopic approaches are promising and appear as feasible techniques for the surgical treatment of skull base lesions. Surgical anatomy of transorbital endoscopic approaches can be mastered through knowledge of a number of anatomical landmarks. Based on data available in the literature, transorbital endoscopic approaches represent an important complementary that should be included in the armamentarium of a skull base team.
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16
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Modified expanded endonasal approach for the large skull based giant pituitary adenoma. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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17
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Wang EW, Gardner PA, Fraser S, Stefko ST, Fernandez-Miranda JC, Snyderman CH. Reduced Tearing With Stable Quality of Life After Vidian Neurectomy: A Prospective Controlled Trial. Laryngoscope 2020; 131:1487-1491. [PMID: 33247625 DOI: 10.1002/lary.29287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 10/13/2020] [Accepted: 11/17/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES/HYPOTHESIS Although vidian neurectomy (VN) is associated with decreased lacrimation, its impact on dry eye quality-of-life is not well-defined. Endoscopic endonasal transpterygoid approaches (EETA) may require vidian nerve sacrifice. STUDY DESIGN A prospective cohort trial. METHODS A prospective trial evaluating VN during EETA on lacrimation by phenol red thread testing and dry eye severity by the five-item Dry Eye Questionnaire (DEQ-5) was performed. Preservation of the contralateral vidian nerve allowed comparison between the eye subjected to VN and the control eye postoperatively. RESULTS Twenty-one subjects were enrolled with no preoperative difference in lacrimation between eyes (P = .617) and overall mild dry eye severity. Although the control eye had no difference in lacrimation pre- and postoperatively, decreased tearing was noted in the VN eye at 1 month (20.8 mm vs. 15.8 mm, P = .015) and at 3 months (23.2 mm vs. 15.8 mm, P = .0051) postoperatively. Overall, no difference was noted in the DEQ-5 score for dry eye severity between the pre- and postoperative measures. However, six patients were noted to have moderate to severe dry eye severity postoperatively and five of these six had decreased lacrimation (<20 mm) preoperatively. Patients with decreased tearing preoperatively demonstrated significantly worse postoperative DEQ-5 scores when compared to patients with normal tearing (P < .0056). CONCLUSIONS VN during EETA results in decreased tearing but is not associated with increased dry eye severity overall. However, patients with decreased tearing preoperatively are at risk for increased dry eye severity and should be counseled for this risk. LEVEL OF EVIDENCE 2 Laryngoscope, 131:1487-1491, 2021.
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Affiliation(s)
- Eric W Wang
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Shannon Fraser
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - S Tonya Stefko
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
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London NR, Rangel GG, Onwuka A, Carrau RL, Prevedello DM, Leonard JA, Walz PC. Reconstruction of pediatric skull base defects: A retrospective analysis emphasizing the very young. Int J Pediatr Otorhinolaryngol 2020; 133:109962. [PMID: 32109673 DOI: 10.1016/j.ijporl.2020.109962] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/14/2020] [Accepted: 02/15/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Pathology of the pediatric skull base is rare and ranges from congenital defects to malignancy and traumatic defects. Pediatric patients, particularly those ≤6 years of age, present a unique set of anatomic challenges for the skull base surgeon. The goal of this study was to retrospectively review our experience with reconstruction of pediatric skull base defects with particular emphasis on those ≤6 years of age. METHODS A retrospective chart review was conducted of patients ≤20 years of age who underwent endoscopic endonasal and combined endoscopic and open approaches to address cranial base pathology from 2007 to 2018. Patients were divided into two groups; those ≤6 years of age (group A) and those >6 years of age and ≤20 years of age (group B) and reconstructive techniques and outcomes were analyzed. RESULTS Intraoperative communication with the subarachnoid space (CSF leak) was created in 50% (3/6) of patients ≤ 6 years of age compared to 32.7% (16/49) in patients > 6 years and ≤20 years of age (P < 0.40) in management of their skull base disease. A vascularized flap was utilized for reconstruction in 66.7% (4/6) of patients ≤ 6 years of age and included a nasoseptal flap in 33.3% (2/6). A vascularized flap was utilized for reconstruction in 38.8% (19/49) of patients > 6 years and ≤20 years of age and most commonly included a nasoseptal flap (22.4%, 11/49). A lumbar drain was utilized in 50% (3/6) of patients ≤ 6 years of age compared to 18.4% (9/49) in patients > 6 and ≤20 years of age (P < 0.08). Post-operative CSF leaks were encountered in 16.7% (1/6) of patients ≤ 6 years of age compared to 10.2% (5/49) in patients > 6 and ≤20 years of age (P < 0.63). Behavioral issues were noted to potentially contribute to failed skull base reconstruction in patients <6 years of age. CONCLUSIONS Pediatric patients, particularly those ≤6 years of age, present a unique set of anatomic and behavioral challenges for the skull base surgeon as highlighted in this study.
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Affiliation(s)
- Nyall R London
- Department of Otolaryngology Head and Neck Surgery, The Ohio State University, Columbus, OH, USA; Department of Otolaryngology Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA; Sinonasal and Skull Base Tumor Program, National Institute on Deafness and Other Communication Disorders, NIH, Bethesda, MD, USA
| | - Gustavo G Rangel
- Department of Otolaryngology Head and Neck Surgery, The Ohio State University, Columbus, OH, USA; Pediatric Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Amanda Onwuka
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ricardo L Carrau
- Department of Otolaryngology Head and Neck Surgery, The Ohio State University, Columbus, OH, USA; Department of Neurological Surgery, The Ohio State University, Columbus, OH, USA
| | - Daniel M Prevedello
- Department of Otolaryngology Head and Neck Surgery, The Ohio State University, Columbus, OH, USA; Department of Neurological Surgery, The Ohio State University, Columbus, OH, USA
| | - Jeffrey A Leonard
- Department of Neurological Surgery, The Ohio State University, Columbus, OH, USA; Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Patrick C Walz
- Department of Otolaryngology Head and Neck Surgery, The Ohio State University, Columbus, OH, USA; Pediatric Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
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19
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Spock T, Kessler R, Lerner D, Filip P, Del Signore A, Colley P, Morgenstern P, Schaberg M, Bederson J, Govindaraj S, Iloreta AM, Shrivastava R. Endoscopic Skull Base Surgery Protocol From the Frontlines: Transnasal Surgery During the COVID-19 Pandemic. Otolaryngol Head Neck Surg 2020; 163:482-490. [DOI: 10.1177/0194599820931836] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective The coronavirus disease 2019 (COVID-19) pandemic disrupted the standard management paradigms for care of patients with sinus and skull base presentations due to concern for patient and health care provider safety, given the high aerosol-generating potential of endonasal procedures. Data Sources We reviewed the relevant literature complied from available sources, including PubMed, Google Scholar, and otolaryngology journals providing electronic manuscripts ahead of indexing or publication. Review Methods Incorporating available evidence and the projected infection control and resource limitations at our institution, we collectively authored a dynamic set of protocols guiding (1) case stratification, (2) preoperative assessment, (3) operative setup, and (4) postoperative care of patients with sinus or skull base presentations. Due to the rapidly evolving nature of COVID-19 publications, lack of rigorous data, and urgent necessity of standardized protocols, strict inclusion and exclusion criteria were not employed. Conclusions As scarce hospital resources are diverted to COVID-19 care and staff are redeployed to forward-facing roles, endonasal procedures have largely ceased, leaving patients with ongoing sinonasal and skull base complaints untreated. Skull base teams now weigh the urgency of surgery in this population with the regional availability of resources. Implications for Practice The COVID-19 pandemic will have an enduring and unpredictable impact on hospital operations and surgical skull base practices and will require a dynamic set of management protocols responsive to new evidence and changing resources. In the current resource-limited environment, clinicians may utilize these protocols to assist with stratifying patients by acuity, performing preoperative assessment, and guiding peri- and postoperative care.
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Affiliation(s)
- Todd Spock
- Department of Otolaryngology–Head and Neck Surgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Remi Kessler
- Department of Neurosurgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David Lerner
- Department of Otolaryngology–Head and Neck Surgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter Filip
- Department of Otolaryngology–Head and Neck Surgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anthony Del Signore
- Department of Otolaryngology–Head and Neck Surgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Patrick Colley
- Department of Otolaryngology–Head and Neck Surgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter Morgenstern
- Department of Neurosurgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Madeleine Schaberg
- Department of Otolaryngology–Head and Neck Surgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua Bederson
- Department of Neurosurgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Satish Govindaraj
- Department of Otolaryngology–Head and Neck Surgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alfred Marc Iloreta
- Department of Otolaryngology–Head and Neck Surgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raj Shrivastava
- Department of Neurosurgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
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20
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Rezende GL, Neto ORM, Kückelhaus SAS. Morbidity in the postoperative follow-up of endoscopic anterior skull base surgery. Braz J Otorhinolaryngol 2020; 87:689-694. [PMID: 32327364 PMCID: PMC9422415 DOI: 10.1016/j.bjorl.2020.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/25/2019] [Accepted: 02/25/2020] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Endoscopic access to the sellar region by videoendoscopy shows a low rate of surgical complications, with findings that indicate risk factors for reducing morbidities during and after the postoperative period. OBJECTIVE To evaluate, over a nine-year period, the acquisition of skills by the anterior skull base surgical team, according to the time of elimination of nasal crusts and/or the presence of morbidities in the postoperative follow-up of individuals treated in a tertiary public hospital. METHODS After confirming the diagnosis of skull base pathologies, the individuals in this study underwent endoscopic surgery according to the rostrocaudal or coronal axis. For the skull base reconstruction, the nasoseptal flap (associated or not with fascia lata with thigh fat) or free graft was used; clinical follow-up of individuals occurred for a minimum period of 12 months. To assess the impact of the surgical approach on patient clinical evolution, qualitative data related to smoking, post-nasal discharge, nasal flow, smell, taste, clinical symptoms of headache, cranial paresthesia, comorbidities and postoperative morbidities were obtained. RESULTS The most frequent diagnosis was pituitary macroadenoma (84.14%). The mean absence of crusts in this cohort was 124.45 days (confidence interval 95%=119.50-129.39). There was a low cerebrospinal fluid fistula rate (3%). Reconstruction with the nasoseptal flap with a fat graft was an independent variable that recorded the highest mean time for the elimination of nasal crusts (=145 days, confidence interval 95%=127.32-162.68). Allergic rhinitis and smoking were shown to be the most important and independent variables that increased the mean time to eliminate nasal crusts. CONCLUSION The mean time to eliminate nasal crusts did not change over the years during which the procedures were performed, demonstrating the adequate training of the surgical team. Debridement and nasal irrigation with saline solutions should be performed more frequently and effectively in patients with allergic rhinitis, smokers and those who received the nasoseptal flap and fascia lata graft with autologous fat.
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Affiliation(s)
- Gustavo Lara Rezende
- Hospital de Base do Distrito Federal, Brasília, DF, Brazil; Universidade de Brasília, Faculdade de Medicina, Departamento de Morfologia, Brasília, DF, Brazil.
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21
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Meerwein CM, Pazahr S, Soyka MB, Hüllner MW, Holzmann D. Diagnostic accuracy of computed tomography and magnetic resonance imaging compared to surgical exploration for anterior skull base and medial orbital wall infiltration in advanced sinonasal tumors. Head Neck 2020; 42:2002-2012. [DOI: 10.1002/hed.26129] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 02/12/2020] [Accepted: 02/20/2020] [Indexed: 12/16/2022] Open
Affiliation(s)
- Christian M. Meerwein
- Department of Otorhinolaryngology, Head and Neck SurgeryUniversity Hospital Zurich Zurich Switzerland
- University of Zurich Zurich Switzerland
| | - Shila Pazahr
- University of Zurich Zurich Switzerland
- Department of NeuroradiologyUniversity Hospital Zurich Zurich Switzerland
| | - Michael B. Soyka
- Department of Otorhinolaryngology, Head and Neck SurgeryUniversity Hospital Zurich Zurich Switzerland
- University of Zurich Zurich Switzerland
| | - Martin W. Hüllner
- University of Zurich Zurich Switzerland
- Department of Nuclear MedicineUniversity Hospital Zurich Zurich Switzerland
| | - David Holzmann
- Department of Otorhinolaryngology, Head and Neck SurgeryUniversity Hospital Zurich Zurich Switzerland
- University of Zurich Zurich Switzerland
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Mallela AN, Abel TJ. Commentary: Endoscopic Interhemispheric Disconnection for Intractable Multifocal Epilepsy: Surgical Technique and Functional Neuroanatomy. Oper Neurosurg (Hagerstown) 2020; 18:E30-E31. [PMID: 31384942 DOI: 10.1093/ons/opz211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 05/28/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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23
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Karadag A, Senoglu M, Middlebrooks EH, Kinali B, Guvencer M, Icke C, Sayhan S, Karabay N, Camlar M, Olomu OU, Tanriover N. Endoscopic endonasal transclival approach to the ventral brainstem: Radiologic, anatomic feasibility and nuances, surgical limitations and future directions. J Clin Neurosci 2020; 73:264-279. [PMID: 32005412 DOI: 10.1016/j.jocn.2020.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 01/04/2020] [Indexed: 12/25/2022]
Abstract
The endoscopic endonasal transclival approach (EETA) is less invasive than traditional open approaches; however, there is currently limited data on the pre-operative features that may predict success of the EETA. Surgical landmarks and exposure of the EETA and expanded EETA are assessed. We retrospectively measured multiple anatomic features in 154 adult dry skulls, 22 C1 and C2 dry bone vertebrae, and 500 paranasal sinus computed tomography (CT) scans. We also dissected 13 formalin-fixed, silicone-injected adult cadaveric heads. Relevant qualitative and quantitative data were obtained with CT (n = 10) and cadaveric dissection (n = 13). They are expressed as mean (SD), as appropriate and compared with unpaired t tests. Categorical variables were compared with χ2 tests. We determined the prevalence of clival and sphenoid sinus anatomic variations and assessed potential exposure of the craniovertebral region, based on the relative position of the nasal bone tip, posterior point of the hard palate, and their relation to the position of C1 and C2. Depending on anatomic features, EETA should allow visualization of the ventral brainstem. The mean (SD) dimensions of the surgical window for EETA were 43.2 (5.1) × 18.3 (1.1) mm, in the craniocaudad and horizontal dimensions, respectively. The craniocaudad dimension enlarged to 60.2 (4.7) mm with expanded EETA. The EETA allowed satisfactory exposure for odontoid and C1 anterior arch resection (expanded EETA) in all specimens, regardless of the orientation of the palate. The combination of preoperative radiographic assessment and intraoperative considerations allows safe and effective application and facilitate selection of the most appropriate approach.
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Affiliation(s)
- Ali Karadag
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey
| | - Mehmet Senoglu
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey.
| | - Erik H Middlebrooks
- Division of Neuroradiology, Mayo Clinic, Jacksonville, FL, USA; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Burak Kinali
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey
| | - Mustafa Guvencer
- Department of Anatomy, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Cigdem Icke
- Department of Anatomy, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Salih Sayhan
- Department of Anatomy, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Nuri Karabay
- Department of Radiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Mahmut Camlar
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey
| | - Osarenoma U Olomu
- Department of Otorhinolaryngology/Audiology, Mayo Clinic, Jacksonville, FL, USA
| | - Necmettin Tanriover
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Fusion of augmented reality imaging with the endoscopic view for endonasal skull base surgery; a novel application for surgical navigation based on intraoperative cone beam computed tomography and optical tracking. PLoS One 2020; 15:e0227312. [PMID: 31945082 PMCID: PMC6964902 DOI: 10.1371/journal.pone.0227312] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 12/16/2019] [Indexed: 01/11/2023] Open
Abstract
Objective Surgical navigation is a well-established tool in endoscopic skull base surgery. However, navigational and endoscopic views are usually displayed on separate monitors, forcing the surgeon to focus on one or the other. Aiming to provide real-time integration of endoscopic and diagnostic imaging information, we present a new navigation technique based on augmented reality with fusion of intraoperative cone beam computed tomography (CBCT) on the endoscopic view. The aim of this study was to evaluate the accuracy of the method. Material and methods An augmented reality surgical navigation system (ARSN) with 3D CBCT capability was used. The navigation system incorporates an optical tracking system (OTS) with four video cameras embedded in the flat detector of the motorized C-arm. Intra-operative CBCT images were fused with the view of the surgical field obtained by the endoscope’s camera. Accuracy of CBCT image co-registration was tested using a custom-made grid with incorporated 3D spheres. Results Co-registration of the CBCT image on the endoscopic view was performed. Accuracy of the overlay, measured as mean target registration error (TRE), was 0.55 mm with a standard deviation of 0.24 mm and with a median value of 0.51mm and interquartile range of 0.39˗˗0.68 mm. Conclusion We present a novel augmented reality surgical navigation system, with fusion of intraoperative CBCT on the endoscopic view. The system shows sub-millimeter accuracy.
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Zhang L, Shi H, Li D, Ye H, Zhang W, Yin S. Radiofrequency Coblation-Assisted Resection of Skull Base Neoplasms Using an Endoscopic Endonasal Approach. ORL J Otorhinolaryngol Relat Spec 2019; 82:25-33. [PMID: 31739305 DOI: 10.1159/000503974] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 10/07/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We describe our early experiences with resecting skull base tumors using a radiofrequency ablation-assisted endoscopic endonasal approach. Ninety-seven patients with skull base tumors who were admitted to the Otorhinolaryngology department at Shanghai Jiaotong University Affiliated Shanghai Sixth People's Hospital between January 2014 and December 2016 were operated on using a radiofrequency ablation-assisted endoscopic endonasal approach. Complete resection was achieved in all patients. This paper describes the operative technique and presents the degree of resection, complications, and early clinical outcomes. METHODS We investigated the safety and feasibility of the technique and assessed preliminary treatment outcomes. RESULTS No patients experienced a new neurological deficit, cerebrospinal fluid leak, or meningitis after surgery. No deaths related to skull base tumors were observed during the follow-up period (14-50 months). The volume of intraoperative blood loss was 100-1,200 mL (median 350 mL), the duration of operation was 40-510 min (median 180 min), and the hospital stay was 6-65 days (median 18). CONCLUSIONS Our limited experience indicates that this technique is feasible and safe for complete resection of some skull base tumors in selected cases and in the future will have an increasing role to play in endoscopic sinonasal and skull base tumor dissection.
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Affiliation(s)
- Ling Zhang
- Department of Otorhinolaryngology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Haibo Shi
- Department of Otorhinolaryngology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Dawei Li
- Department of Otorhinolaryngology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Haibo Ye
- Department of Otorhinolaryngology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China,
| | - Weitian Zhang
- Department of Otorhinolaryngology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Shankai Yin
- Department of Otorhinolaryngology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
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MARUYAMA K, YOKOI H, NAGASE M, YOSHIDA H, NOGUCHI A, MATSUMURA G, SAITO K, SHIOKAWA Y. Usefulness of N-vinyl-2-pyrrolidone Embalming for Endoscopic Transnasal Skull Base Approach in Cadaver Dissection. Neurol Med Chir (Tokyo) 2019; 59:379-383. [PMID: 31270286 PMCID: PMC6796061 DOI: 10.2176/nmc.oa.2019-0069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/06/2019] [Indexed: 11/23/2022] Open
Abstract
Formalin or formaldehyde is commonly used for cadaver fixation, which is, however, not suitable for endoscopic transnasal skull base approach because of consequent hardening of the soft tissue. Several alternatives have been reported, but each of them also has some limitations. We applied a novel fixation method using N-vinyl-2-pyrrolidone (NVP), a precursor of the water-soluble macromolecular polymer, for endoscopic transnasal skull base approach in six donated cadaver specimens. In four cadavers, elasticity of the soft tissue in the nasal cavity was almost similar to that of living tissue, and a surgical approach similar to the real surgical field was possible. However, the soft tissue was moderately stiffer than living tissue in two specimens so that surgical manipulation was hindered to some extent while NVP concentration was 10% in all the cadavers. Since the brain tissue was too soft and pliable for surgical manipulation in NVP, more careful surgical manipulation than real surgical field was mandatory in order to prevent damage in the brain tissue. Therefore, this concentration of NVP was considered to be appropriate. In conclusion, NVP embalming was effective for endoscopic transnasal skull base approach in cadaver dissection, providing environment similar to the real surgical field.
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Affiliation(s)
- Keisuke MARUYAMA
- Department of Neurosurgery, Faculty of Medicine, Kyorin University, Mitaka, Tokyo, Japan
| | - Hidenori YOKOI
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Kyorin University, Mitaka, Tokyo, Japan
| | - Miki NAGASE
- Department of Anatomy, Faculty of Medicine, Kyorin University, Mitaka, Tokyo, Japan
| | - Hiroki YOSHIDA
- Department of Neurosurgery, Faculty of Medicine, Kyorin University, Mitaka, Tokyo, Japan
| | - Akio NOGUCHI
- Department of Neurosurgery, Faculty of Medicine, Kyorin University, Mitaka, Tokyo, Japan
| | - George MATSUMURA
- Department of Anatomy, Faculty of Medicine, Kyorin University, Mitaka, Tokyo, Japan
| | - Koichiro SAITO
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Kyorin University, Mitaka, Tokyo, Japan
| | - Yoshiaki SHIOKAWA
- Department of Neurosurgery, Faculty of Medicine, Kyorin University, Mitaka, Tokyo, Japan
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Montaser AS, Prevedello DM, Gomez M, Lima L, Beer-Furlan A, Servian D, Otto BA, Carrau RL. Extended Endoscopic Endonasal Clipping of Intracranial Aneurysms: An Anatomic Feasibility Study. World Neurosurg 2019; 133:e356-e368. [PMID: 31521759 DOI: 10.1016/j.wneu.2019.09.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 09/03/2019] [Accepted: 09/05/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Intracranial aneurysms (IAs) located in the midline region represent formidable challenge owing to their deep location. The objective of this study was to assess feasibility and identify the limitations of endoscopic endonasal clipping of IAs. We further aimed to describe the locations and characteristics of aneurysms that may be amenable for endoscopic endonasal clipping; thus outlining the indications of these approaches. METHODS Fifteen latex-injected cadaveric heads were used for endoscopic endonasal exposure of anterior and posterior cerebral circulations. An aneurysm simulator model with 2 different sizes was used at the common sites for IAs to emulate a real surgery. Key measured parameters included "exposure of vessels and their respective perforators," "ability to gain proximal/distal control," and "possibility of clip placement" according to the size, direction, and location of the aneurysm model. Maneuverability of instruments and the need for pituitary gland transposition were assessed and recorded as well. RESULTS Exposure of the anterior communicating artery complex and the common sites of posterior circulation aneurysms were feasible. The size, location, and direction of the aneurysm model had an impact on obtaining proximal and/or distal control, and the ability of clip placement. CONCLUSIONS Clipping of midline aneurysms of the posterior circulation is feasible via endoscopic endonasal approach. Small-sized ventrally and medially directed aneurysm models carried a better probability of getting proximal and/or distal control, as well as better overall ability to place a clip. The endonasal route seems to provide a limited condition for proper management of anterior circulation aneurysms.
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Affiliation(s)
- Alaa S Montaser
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA; Department of Neurological Surgery, Ain Shams University, Cairo, Egypt
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
| | - Matias Gomez
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Lucas Lima
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - André Beer-Furlan
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Diego Servian
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Bradley A Otto
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Evolution of transmaxillary approach to tumors in pterygopalatine fossa and infratemporal fossa: anatomic simulation and clinical practice. Chin Med J (Engl) 2019; 132:798-804. [PMID: 30897594 PMCID: PMC6595853 DOI: 10.1097/cm9.0000000000000142] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The endoscopic transnasal approach has been proven to have advantages on the removal of the tumors in pterygopalatine fossa (PPF) and infratemporal fossa (ITF). Herein, this study aimed to describe a modified approach for resection of the tumors in these areas, both in cadaveric specimen and clinical patients. METHODS The 20 adult cadaveric specimens and five patients with tumors in PPF and ITF were enrolled in this study. For the cadaveric specimens, ten were simulated anterior transmaxillary approach and ten were performed modified endoscopic transnasal transmaxillary approach. The exposure areas were compared between two groups and main anatomic structure were measured. Surgery was operated in the five patients with tumors of PPF and ITF to verify the experience from the anatomy. Perioperative management, intraoperative findings and postoperative complications were recorded and analyzed. RESULTS The modified endoscopic transnasal transmaxillary approach provided as enough surgical exposure and high operability to the PPF and ITF as the anterior transmaxillary approach did. The diameter of maxillary artery in the PPF was 3.77 ± 0.78 mm (range: 2.06-4.82 mm), the diameter of middle meningeal artery in the ITF was 2.79 ± 0.61 mm (range: 1.54-3.78 mm). Four patients who suffered schwannoma got total removal and one of adenocystic carcinoma got subtotal removal. The main complications were facial numbness and pericoronitis of the wisdom tooth. No permanent complication was found. CONCLUSIONS With the widespread use of neuroendoscopy, the modified endoscopic transnasal transmaxillary approach is feasible and effective for the resection of tumors located in PPF and ITF, which has significant advantages on less trauma and complications to the patients.
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Jeon JW, Cho SS, Nag S, Buch L, Pierce J, Su YS, Adappa ND, Palmer JN, Newman JG, Singhal S, Lee JYK. Near-Infrared Optical Contrast of Skull Base Tumors During Endoscopic Endonasal Surgery. Oper Neurosurg (Hagerstown) 2019; 17:32-42. [PMID: 30124919 PMCID: PMC7311828 DOI: 10.1093/ons/opy213] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 08/07/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Near-infrared (NIR) tumor contrast is achieved through the "second-window ICG" technique, which relies on passive accumulation of high doses of indocyanine green (ICG) in neoplasms via the enhanced permeability and retention effect. OBJECTIVE To report early results and potential challenges associated with the application of second-window ICG technique in endonasal endoscopic, ventral skull-base surgery, and to determine potential predictors of NIR signal-to-background ratio (SBR) using endoscopic techniques. METHODS Pituitary adenoma (n = 8), craniopharyngioma (n = 3), and chordoma (n = 4) patients received systemic infusions of ICG (5 mg/kg) approximately 24 h before surgery. Dual-channel endoscopy with visible light and NIR overlay were photodocumented and analyzed post hoc. RESULTS All tumors (adenoma, craniopharyngioma, chordoma) demonstrated NIR positivity and fluoresced with an average SBR of 3.9 ± 0.8, 4.1 ± 1.7, and 2.1 ± 0.6, respectively. Contrast-enhanced T1 signal intensity proved to be the single best predictor of observed SBR (P = .0003). For pituitary adenomas, the sensitivity, specificity, positive predictive value, and negative predictive value of NIR-guided identification of tumor was 100%, 20%, 71%, and 100%, respectively. CONCLUSION In this preliminary study of a small set of patients, we demonstrate that second-window ICG can provide NIR optical tumor contrast in 3 types of ventral skull-base tumors. Chordomas demonstrated the weakest NIR signal, suggesting limited utility in those patients. Both nonfunctional and functional pituitary adenomas appear to accumulate ICG, but utility for margin detection for the adenomas is limited by low specificity. Craniopharyngiomas with third ventricular extension appear to be a particularly promising target given the clean brain parenchyma background and strong SBR.
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Affiliation(s)
- Jun W Jeon
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steve S Cho
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shayoni Nag
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Love Buch
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Pierce
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - YouRong S Su
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nithin D Adappa
- Department of Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James N Palmer
- Department of Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason G Newman
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sunil Singhal
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Y K Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Lavigne P, Faden D, Gardner PA, Fernandez-Miranda JC, Wang EW, Snyderman CH. Validation of training levels in endoscopic endonasal surgery of the skull base. Laryngoscope 2019; 129:2253-2257. [PMID: 30843604 DOI: 10.1002/lary.27895] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/07/2019] [Accepted: 02/04/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE A five-level training program was first proposed 10 years ago for surgeons learning endoscopic endonasal surgery (EES) of the skull base. Levels were based on the complexity of anatomy, risk of neurovascular injury, intradural dissection, technical difficulty and vascularity of tumors. METHOD A three-phase validation concept is proposed: 1) face validity (the classification is related to clinically significant elements), 2) construct validity (the classification predicts the outcome), and 3) inter-team validation (the classification applies to other surgical teams). Consecutive cases over a 1-year time span were retrospectively classified. Primary outcome measures included: complication rates (cranial nerve injury, stroke and vascular injury, cerebrospinal fluid [CSF] leak and infection), estimated blood loss and duration of surgery. RESULTS Two hundred and nine consecutive cases were analyzed. The distribution of cases for each category was: 63 cases in level II, 70 cases in level III, 66 cases in level IV, and 10 cases in level V. Construct validity demonstrated statistical difference with increasing rate of complications from level II to level III and from level III to level IV; also, specific rates of cranial nerve injury and CSF leak increased between levels III and IV. Face validity identified 162 citations since publication of the original article. Inter-team validation demonstrated no difference between two teams of surgeons. CONCLUSION This study provides a three-phase validation of training levels for endoscopic skull base surgery. Adoption of a progressive systematic approach to learning EES from least complex to advanced procedures is expected to minimize the risks while surgical teams gain experience. LEVEL OF EVIDENCE 3 Laryngoscope, 129:2253-2257, 2019.
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Affiliation(s)
- Philippe Lavigne
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Daniel Faden
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Eric W Wang
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Carl H Snyderman
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
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Essayed WI, Unadkat P, Hosny A, Frisken S, Rassi MS, Mukundan S, Weaver JC, Al-Mefty O, Golby AJ, Dunn IF. 3D printing and intraoperative neuronavigation tailoring for skull base reconstruction after extended endoscopic endonasal surgery: proof of concept. J Neurosurg 2019; 130:248-255. [PMID: 29498576 PMCID: PMC6119650 DOI: 10.3171/2017.9.jns171253] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 03/02/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Endoscopic endonasal approaches are increasingly performed for the surgical treatment of multiple skull base pathologies. Preventing postoperative CSF leaks remains a major challenge, particularly in extended approaches. In this study, the authors assessed the potential use of modern multimaterial 3D printing and neuronavigation to help model these extended defects and develop specifically tailored prostheses for reconstructive purposes. METHODS Extended endoscopic endonasal skull base approaches were performed on 3 human cadaveric heads. Pre-Preprocedure and intraprocedure CT scans were completed and were used to segment and design extended and tailored skull base models. Multimaterial models with different core/edge interfaces were 3D printed for implantation trials. A novel application of the intraoperative landmark acquisition method was used to transfer the navigation, helping to tailor the extended models. RESULTS Prostheses were created based on preoperative and intraoperative CT scans. The navigation transfer offered sufficiently accurate data to tailor the preprinted extended skull base defect prostheses. Successful implantation of the skull base prostheses was achieved in all specimens. The progressive flexibility gradient of the models’ edges offered the best compromise for easy intranasal maneuverability, anchoring, and structural stability. Prostheses printed based on intraprocedure CT scans were accurate in shape but slightly undersized. CONCLUSIONS Preoperative 3D printing of patient-specific skull base models is achievable for extended endoscopic endonasal surgery. The careful spatial modeling and the use of a flexibility gradient in the design helped achieve the most stable reconstruction. Neuronavigation can help tailor preprinted prostheses.
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Affiliation(s)
- Walid I. Essayed
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Prashin Unadkat
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ahmed Hosny
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Frisken
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcio S. Rassi
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Srinivasan Mukundan
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - James C. Weaver
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Cambridge, MA, USA
| | - Ossama Al-Mefty
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexandra J. Golby
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ian F. Dunn
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Zoli M, Ratti S, Guaraldi F, Milanese L, Pasquini E, Frank G, Billi AM, Manzoli L, Cocco L, Mazzatenta D. Endoscopic endonasal approach to primitive Meckel's cave tumors: a clinical series. Acta Neurochir (Wien) 2018; 160:2349-2361. [PMID: 30382359 DOI: 10.1007/s00701-018-3708-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 10/16/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Recently, an alternative endoscopic endonasal approach to Meckel's cave (MC) tumors has been proposed. To date, few studies have evaluated the results of this route. The aim of our study was to evaluate long-term surgical and clinical outcome associated with this technique in a cohort of patients with intrinsic MC tumors. METHODS All patients with MC tumors treated at out institution by endoscopic endonasal approach (EEA) between 2002 and 2016 were included. Patients underwent brain MRI, CT angiography, and neurological evaluation before surgery. Complications were considered based on the surgical records. All examinations were repeated after 3 and 12 months, then annually. The median follow-up was of 44.1 months (range 16-210). RESULTS The series included 8 patients (4 F): 5 neuromas, 1 meningioma, 1 chondrosarcoma, and 1 epidermoid cyst. The median age at treatment was 54.5 years (range 21-70). Three tumors presented with a posterior fossa extension. Radical removal of the MC portion of the tumor was achieved in 7 out of 8 cases. Two patients developed a permanent and transitory deficit of the sixth cranial nerve, respectively. No tumor recurrence was observed at follow-up. CONCLUSION In this preliminary series, the EEA appeared an effective and safe approach to MC tumors. The technique could be advantageous to treat tumors located in the antero-medial aspects of MC displacing the trigeminal structures posteriorly and laterally. A favorable index of an adequate working space for this approach is represented by the ICA medialization, while tumor extension to the posterior fossa represents the main limitation to radical removal of this route.
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Kutlay M, Durmaz A, Özer İ, Kural C, Temiz Ç, Kaya S, Solmaz İ, Daneyemez M, Izci Y. Extended endoscopic endonasal approach to the ventral skull base lesions. Clin Neurol Neurosurg 2018; 167:129-140. [DOI: 10.1016/j.clineuro.2018.02.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 02/13/2018] [Accepted: 02/19/2018] [Indexed: 02/08/2023]
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