The incorporation of neuroendoscopy in neurosurgical training programs

The Call for Neuroendoscopy Cadaveric Workshops in Lower-Middle Income Countries

OBJECTIVE

This study aims to assess the impact of the workshops organized during Neuroendocon 23 on the perspective and confidence of neurosurgeons toward endoscopy in a lower-middle income country.

METHODS

Neuroendocon 23 had cranial and spinal endoscopy cadaveric workshops with 30 delegates each. A pre and postworkshop survey was disseminated among the delegates, and statistical analysis was performed with SPSS (version 26) using P < 0.05.

RESULTS

A total of 24 delegates (40%) consented to participate in the study, with only 1 female respondent (4.17%). After the cranial endoscopy workshop, there was an increase in the level of confidence of delegates in cranial endoscopic approaches (P < 0.001). Similarly, after the spine endoscopy workshop, the respondents had increased confidence in managing spine conditions with the endoscopic approach (P = 0.040), to the extent that they preferred the endoscopic over the microsurgical technique (P < 0.001). All respondents (n = 24, 100%) believed that endoscopy should be promoted in lower-middle income countries and integrated into residency curricula.

CONCLUSIONS

Cranial and spinal endoscopy cadaveric workshops could be the first step in stimulating the interest of neurosurgeons in endoscopy.

Establishing the First Neurosurgical Skill Laboratory in West Africa: An Initiative for an Affordable Regional Education Center

Background

The benefits of a neurosurgical skill laboratory (NSL) are unquestionable. Despite the increasing number of sub-Saharan African neurosurgeons, few cadaveric laboratories are available for neurosurgical education. The first of its kind in West Africa, a NSL opened in 2019 in Abidjan, Cote d’Ivoire to promote neurosurgeons' education and technical skills. We have described our experience in creating and running this facility.

Methods

NSL is a private academic center in Abidjan, Cote d’Ivoire. It includes 2 rooms dedicated to cadaveric hands-on training and microscopic neurosurgery and multipurpose rooms, which contain 7 table-mounted microscopes and 3 endoscopes. The designed layout replicates an operating room. The curriculum was designed to meet the needs for training for complex brain and spine surgeries.

Results

The training covers skull base (conventional and extended) approaches, microsuturing, and anterolateral and posterior approaches for spine surgeries. The training was open to residents and consultants. The faculty members included anatomists, neurosurgeons, otolaryngologists, and orthopedists. Additionally, the NSL welcomes fellows from foreign countries. Fellows from 4 countries have been trained, and 14 educational activities have been organized.

Conclusions

In the present report, we have provided insight into a sub-Saharan African neurosurgical laboratory striving toward an affordable and self-sustainable center. The short-term goal of the NSL is to be a center for developing technical skills for African neurosurgeons for better patient outcomes.

Low-Cost Endoscope Camera System for Neurosurgical Cadaveric Laboratory Dissections

OBJECTIVE

Many training institutions in low-income countries do not have the resources to purchase and maintain a clinical-grade endoscopy tower dedicated to the laboratory. This project aimed to create a low-cost endoscope camera system using online-sourced materials to allow the operators to practice endoscopic surgical techniques in a cadaver laboratory setting.

METHODS

A low-cost endoscope system was created using a 34MP camera with recording capabilities and direct streaming to high-definition multimedia interface in full high resolution, with an adjustable focal length coupler and a light-emitting diode light source. The system cost was $443, as the endoscope and the monitor were already in the laboratory.

RESULTS

The system was successfully employed to practice endoscopic dissections in 3 cadaveric specimens with good visualization of relevant structures.

CONCLUSIONS

This article demonstrated how to produce a low-cost endoscope camera system for laboratory training in neuroendoscopy.

Development of a Technical Skills Test to Improve Assessment and Evaluation in Neuroendoscopic Education

BACKGROUND

Endoscopy requires a unique set of skills that are difficult to acquire in most training programs. A method to test technical skills, in a validated manner, has rarely been attempted. The purpose of this study was to develop a technical skills examination for objective assessment in neuroendoscopic education.

METHODS

Twenty-nine participants were included for analysis and divided by seniority level into 2 groups defined as before or upon postgraduation year (PGY) 5 (n = 18, junior surgeons) or after PGY5 (n = 11, senior surgeons). Study participants were assessed for baseline performance and then again following a 4-hour neuroendoscopy course. Wilcoxon test was used to evaluate for performance differences between cohorts. Correlation analyses were performed using the Pearson or Spearman coefficient.

RESULTS

Increasing PGY level was correlated with a decreased average time to complete all 3 tasks (r = -0.44, P = 0.03) at baseline. Overall performance improved in both cohorts following the course (P < 0.001). When comparing junior surgeons after endoscopy training (posttest) to senior surgeons at their baseline (pretest), the junior surgeons were faster after endoscopic training than the senior surgeons were before training (P < 0.001).

CONCLUSIONS

A neuroendoscopic skills test can distinguish between more or less experienced surgeons. Significant overall performance improvement, regardless of seniority level, following neuroendoscopic training demonstrates the accuracy of the test at detecting operating improvement in all stages of learning.

Development and validation of a synthetic 3D-printed simulator for training in neuroendoscopic ventricular lesion removal

OBJECTIVE

Neuroendoscopic surgery using an ultrasonic aspirator represents a valid tool with which to perform the safe resection of deep-seated ventricular lesions, but the handling of neuroendoscopic instruments is technically challenging, requiring extensive training to achieve a steep learning curve. Simulation-based methods are increasingly used to improve surgical skills, allowing neurosurgical trainees to practice in a risk-free, reproducible environment. The authors introduce a synthetic, patient-specific simulator that enables trainees to develop skills for endoscopic ventricular tumor removal, and they evaluate the model’s validity as a training instrument with regard to realism, mechanical proprieties, procedural content, and handling.

METHODS

The authors developed a synthetic simulator based on a patient-specific CT data set. The anatomical features were segmented, and several realistic 1:1 skull models with all relevant ventricular structures were fabricated by a 3D printer. Vascular structures and the choroid plexus were included. A tumor model, composed of polyvinyl alcohol, mimicking a soft-consistency lesion, was secured in different spots of the frontal horn and within the third ventricle. Neurosurgical trainees participating in a neuroendoscopic workshop qualitatively assessed, by means of a feedback survey, the properties of the simulator as a training model that teaches neuroendoscopic ultrasonic ventricular tumor surgery; the trainees rated 10 items according to a 5-point Likert scale.

RESULTS

Participants appreciated the model as a valid hands-on training tool for neuroendoscopic ultrasonic aspirator tumor removal, highly rating the procedural content. Furthermore, they mostly agreed on its comparably realistic anatomical and mechanical properties. By the model’s first application, the authors were able to recognize possible improvement measures, such as the development of different tumor model textures and the possibility, for the user, of creating a realistic surgical skull approach and neuroendoscopic trajectory.

CONCLUSIONS

A low-cost, patient-specific, reusable 3D-printed simulator for the training of neuroendoscopic ultrasonic aspirator tumor removal was successfully developed. The simulator is a useful tool for teaching neuroendoscopic techniques and provides support in the development of the required surgical skills.

Simulation-based Education for Endoscopic Third Ventriculostomy: A Comparison Between Virtual and Physical Training Models

BACKGROUND

The relative educational benefits of virtual reality (VR) and physical simulation models for endoscopic third ventriculostomy (ETV) have not been evaluated "head to head."

OBJECTIVE

To compare and identify the relative utility of a physical and VR ETV simulation model for use in neurosurgical training.

METHODS

Twenty-three neurosurgical residents and 3 fellows performed an ETV on both a physical and VR simulation model. Trainees rated the models using 5-point Likert scales evaluating the domains of anatomy, instrument handling, procedural content, and the overall fidelity of the simulation. Paired t tests were performed for each domain's mean overall score and individual items.

RESULTS

The VR model has relative benefits compared with the physical model with respect to realistic representation of intraventricular anatomy at the foramen of Monro (4.5, standard deviation [SD] = 0.7 vs 4.1, SD = 0.6; P = .04) and the third ventricle floor (4.4, SD = 0.6 vs 4.0, SD = 0.9; P = .03), although the overall anatomy score was similar (4.2, SD = 0.6 vs 4.0, SD = 0.6; P = .11). For overall instrument handling and procedural content, the physical simulator outperformed the VR model (3.7, SD = 0.8 vs 4.5; SD = 0.5, P < .001 and 3.9; SD = 0.8 vs 4.2, SD = 0.6; P = .02, respectively). Overall task fidelity across the 2 simulators was not perceived as significantly different.

CONCLUSION

Simulation model selection should be based on educational objectives. Training focused on learning anatomy or decision-making for anatomic cues may be aided with the VR simulation model. A focus on developing manual dexterity and technical skills using endoscopic equipment in the operating room may be better learned on the physical simulation model.

Learning neuroendoscopy with an exoscope system (video telescopic operating monitor): Early clinical results

CONTEXT

Steep learning curve is found initially in pure endoscopic procedures. Video telescopic operating monitor (VITOM) is an advance in rigid-lens telescope systems provides an alternative method for learning basics of neuroendoscopy with the help of the familiar principle of microneurosurgery.

AIMS

The aim was to evaluate the clinical utility of VITOM as a learning tool for neuroendoscopy.

MATERIALS AND METHODS

Video telescopic operating monitor was used 39 cranial and spinal procedures and its utility as a tool for minimally invasive neurosurgery and neuroendoscopy for initial learning curve was studied.

RESULTS

Video telescopic operating monitor was used in 25 cranial and 14 spinal procedures. Image quality is comparable to endoscope and microscope. Surgeons comfort improved with VITOM. Frequent repositioning of scope holder and lack of stereopsis is initial limiting factor was compensated for with repeated procedures.

CONCLUSIONS

Video telescopic operating monitor is found useful to reduce initial learning curve of neuroendoscopy.

Neuroendoscopy in Kuwait: Evolution, Current Status, and Future Directions

An overview of the development of neuroendoscopy at the neurosurgery department, Ibn Sina Hospital in Kuwait, is presented with an outline of difficulties and obstacles faced by the field until it reached its current status. The factors and solutions that helped us overcome these problems are also elaborated on. After a modest beginning few years ago, endoscopic skull base procedures, intraventricular neuroendoscopy, and spinal endoscopy are regularly performed in the department. Although neuroendoscopy is not per se a neurosurgical subspecialty, it is an area that requires special training. Achieving an appropriate level of care necessitates these highly trained neurosurgeons to collaborate together and with other specialties to create teamsgeared towards offering such treatment options topatients. Importantly, a multitude of essential facilities should be available to make such a pattern of practice possible. In our experience, this was made possible through continued efforts that have finally paid off and gradually led to a complete shift of the face of neuroendoscopic practice in our department. Our future endeavors aim at further development of neuroendoscopy in the department to create a center of excellence.

Comparison of Intracranial Neuroendoscopic Procedures in Children versus Adults

BACKGROUND

The emphasis regarding intracranial neuroendoscopy has been traditionally advocated and focused on the role in pediatric patients, although a significant usage has developed in adult patients. In this study, we examine and contrast the role of predominantly intracranial neuroendoscopy in both a pediatric and adult population with a minimum postprocedure follow-up of 5 years.

METHODS

A retrospective review was conducted for patients in the two hospitals that manage neurosurgical care for Southern Alberta, Canada, undergoing neuroendoscopic surgery between 1994 and 2008. The pediatric group was defined as age ≤17 years and the adult group as age ≥18 years.

RESULTS

A total of 273 patients who underwent a total of 330 procedures with a mean postprocedure follow-up of 12.9 years were identified. There were 161 adult and 112 pediatric patients, and both groups underwent surgery by the same surgeons. The most common procedure was endoscopic third ventriculostomy, accounting for 55% of procedures. One postoperative death occurred in an adult patient. Endoscopic third ventriculostomy success 1-year postprocedure was 81%, with only three late-term failures. Postoperative infection was the most common serious complication (two pediatric/four adult patients). Adult and pediatric patients had similar major complication rates (4.2% vs 5.7%, p=0.547).

CONCLUSIONS

Neuroendoscopy overall had a similar role in both pediatric and adult neurosurgical populations, with the most commonly associated complication being infection. Neuroendoscopy is an important therapeutic modality in the management of appropriate adult patients.

New anatomical simulator for pediatric neuroendoscopic practice

INTRODUCTION

The practice of neuroendoscopic procedures requires many years of training to obtain the adequate skills to perform these operations safely. In this study, we present a new pediatric neuroendoscopic simulator that facilitates training.

DESCRIPTION OF THE SIMULATOR

This realistic simulator was built with a synthetic thermo-retractile and thermo-sensible rubber called Neoderma® which, when combined with different polymers, produces more than 30 different formulae, which present textures, consistencies, and mechanical resistances similar to many human tissues. Silicon and fiberglass molds, in the shape of the cerebral ventricles, constitute the basic structure of the neuroendoscopic training module. The module offers the possibility for practicing many basic neuroendoscopic techniques such as: navigating the ventricular system to visualize important anatomic landmarks (e.g., septal and thalamostriate veins, foramen of Monro, temporal horns, aqueduct, and fourth ventricle), performing third ventriculostomy and choroid plexus cauterization, and resecting intraventricular "tumors" that bleed.

CONCLUSION

It is important to emphasize that it is possible to perform with this simulator not only the rigid but also the flexible endoscopy, with good correspondence to reality and no risks. Notable future perspectives can be considered regarding this new pediatric simulator, for example, to improve the learning curve for nonexperienced neurosurgeons and to spread the flexible endoscopy technique.

Virtual reality simulation: basic concepts and use in endoscopic neurosurgery training

INTRODUCTION

Virtual reality simulation is a promising alternative to training surgical residents outside the operating room. It is also a useful aide to anatomic study, residency training, surgical rehearsal, credentialing, and recertification.

DISCUSSION

Surgical simulation is based on a virtual reality with varying degrees of immersion and realism. Simulators provide a no-risk environment for harmless and repeatable practice. Virtual reality has three main components of simulation: graphics/volume rendering, model behavior/tissue deformation, and haptic feedback. The challenge of accurately simulating the forces and tactile sensations experienced in neurosurgery limits the sophistication of a virtual simulator. The limited haptic feedback available in minimally invasive neurosurgery makes it a favorable subject for simulation.

CONCLUSIONS

Virtual simulators with realistic graphics and force feedback have been developed for ventriculostomy, intraventricular surgery, and transsphenoidal pituitary surgery, thus allowing preoperative study of the individual anatomy and increasing the safety of the procedure. The authors also present experiences with their own virtual simulation of endoscopic third ventriculostomy.