Design and Validation of an Open-Source, Partial Task Trainer for Endonasal Neuro-Endoscopic Skills Development: Indian Experience

Indian Neurosurgeons at the Forefront: A Comprehensive Exploration of their Pioneering Contributions to Neuroendoscopy

This article delves into the profound impact of Indian neurosurgeons on the expansive canvas of neuroendoscopy. By scrutinizing their trailblazing research, innovations, new surgical techniques, and relentless dedication to education and training, we aim to unravel the intricacies of their influence on a global scale. The review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, conducts a comprehensive analysis of the literature related to neuroendoscopy contributed by Indian neurosurgeons. The exploration covers a spectrum of achievements, ranging from pioneering research and innovations to complication avoidance, neuroendoscopic training, and global recognition. Despite challenges, Indian neurosurgeons continue to lead the way in shaping the future of neuroendoscopy, ensuring better patient outcomes and improved quality of life. Many Indian neurosurgeons have contributed significantly to the development of neuroendoscopy in India. Prof. YR Yadav's contributions stand significant in the form of research articles and publications on almost all subjects on neuroendoscopy, the textbook on neuroendoscopy, popularizing neuroendoscopy by starting the first university-certified neuroendoscopy fellowship training program in India, describing many innovative techniques/first report of endoscopic techniques and conducting regular endoscopic workshops in his institutions and other major cities of India.

Training models and simulators for endoscopic transsphenoidal surgery: a systematic review

Endoscopic transsphenoidal surgery is a novel surgical technique requiring specific training. Different models and simulators have been recently suggested for it, but no systematic review is available. To provide a systematic and critical literature review and up-to-date description of the training models or simulators dedicated to endoscopic transsphenoidal surgery. A search was performed on PubMed and Scopus databases for articles published until February 2023; Google was also searched to document commercially available. For each model, the following features were recorded: training performed, tumor/arachnoid reproduction, assessment and validation, and cost. Of the 1199 retrieved articles, 101 were included in the final analysis. The described models can be subdivided into 5 major categories: (1) enhanced cadaveric heads; (2) animal models; (3) training artificial solutions, with increasing complexity (from "box-trainers" to multi-material, ct-based models); (4) training simulators, based on virtual or augmented reality; (5) Pre-operative planning models and simulators. Each available training model has specific advantages and limitations. Costs are high for cadaver-based solutions and vary significantly for the other solutions. Cheaper solutions seem useful only for the first stages of training. Most models do not provide a simulation of the sellar tumor, and a realistic simulation of the suprasellar arachnoid. Most artificial models do not provide a realistic and cost-efficient simulation of the most delicate and relatively common phase of surgery, i.e., tumor removal with arachnoid preservation; current research should optimize this to train future neurosurgical generations efficiently and safely.

Craniotomy Simulator with Force Myography and Machine Learning-Based Skills Assessment

Craniotomy is a fundamental component of neurosurgery that involves the removal of the skull bone flap. Simulation-based training of craniotomy is an efficient method to develop competent skills outside the operating room. Traditionally, an expert surgeon evaluates the surgical skills using rating scales, but this method is subjective, time-consuming, and tedious. Accordingly, the objective of the present study was to develop an anatomically accurate craniotomy simulator with realistic haptic feedback and objective evaluation of surgical skills. A CT scan segmentation-based craniotomy simulator with two bone flaps for drilling task was developed using 3D printed bone matrix material. Force myography (FMG) and machine learning were used to automatically evaluate the surgical skills. Twenty-two neurosurgeons participated in this study, including novices (n = 8), intermediates (n = 8), and experts (n = 6), and they performed the defined drilling experiments. They provided feedback on the effectiveness of the simulator using a Likert scale questionnaire on a scale ranging from 1 to 10. The data acquired from the FMG band was used to classify the surgical expertise into novice, intermediate and expert categories. The study employed naïve Bayes, linear discriminant (LDA), support vector machine (SVM), and decision tree (DT) classifiers with leave one out cross-validation. The neurosurgeons' feedback indicates that the developed simulator was found to be an effective tool to hone drilling skills. In addition, the bone matrix material provided good value in terms of haptic feedback (average score 7.1). For FMG-data-based skills evaluation, we achieved maximum accuracy using the naïve Bayes classifier (90.0 ± 14.8%). DT had a classification accuracy of 86.22 ± 20.8%, LDA had an accuracy of 81.9 ± 23.6%, and SVM had an accuracy of 76.7 ± 32.9%. The findings of this study indicate that materials with comparable biomechanical properties to those of real tissues are more effective for surgical simulation. In addition, force myography and machine learning provide objective and automated assessment of surgical drilling skills.

An Ergonomic Neuroendoscopic Instrument Handle Design using 3D Printing

Background

Minimally invasive neurosurgery poses several challenges to surgeons due to constrained working environment, and its implications on the surgical outcome are an area of growing concern. The instrument handle design directly affects surgeon's performance, and the conventional ring handle causes ergonomic discomfort.

Objective

The aim of this study was to design and validate a palm grasping-based ergonomic handle for skull-base neuroendoscopic instruments.

Materials and Methods

The handle was designed based on the palm grasping technique and to naturally match the contours of hand. The ergonomic handle was fabricated and assembled with the end-effector of biopsy forceps. Fifteen participants with no experience of neuroendoscopic procedures validated the ergonomic handle. During data collection, participants performed the ring transfer task on straight, right tilt (+30°) and left tilt (-30°) of activity plates of neuro-endo-trainer (NET) with 0° and 30° endoscopes.

Results

Feedback from participants indicated that there was significant improvement in degree of discomfort in performing the task on straight (P = 0.006) and tilted plate (P = 0.001) and degree of pain (0.0001) using the ergonomic handle. Furthermore, video analysis of the performed task shows that there was statistical improvement in hitting events (P = 0.001, P = 0.04), tugging events (P = 0.00001, P = 0.00001,) and picking attempts (P = 0.04, P = 0.0004) on straight and tilted plates, respectively. There was reduction in ring drop, jerk, and average moving time, but results were not significant.

Conclusion

The subjective validation of ergonomic handle by neurosurgeons shows that the designed handle offers ergonomic advantages. Objective validation by video analysis shows that the ergonomic handle results in better task performance on NET surgical trainer.

Simulation training in endoscopic skull base surgery: A scoping review

Objective

Methods

Results

Conclusions

Microsurgical suturing assessment scores: a systematic review

Several scoring scales for the assessment of microsurgical skills have been established and validated with the same basic parameters. The study aims to review the existing scales to highlight those parameters, which can be utilized uniformly across all neurosurgical training centers. An online search was conducted and all the surgical scores pertinent to microsurgical suturing were reviewed. The scales were compared to identify parameters, which were important for skill development and assessment in neurosurgical trainees. Seven assessment scales were identified which assessed the trainee's proficiency in microsurgical suturing. The objective structured assessment of technical skills (OSATS) and Northwestern Objective Microanastomosis Assessment Tool (NOMAT) were identified as the most widely used and validated assessment scales. The newer scales University of Western Ontario microsurgical skills acquisition/assessment (UWOMSA) and structured assessment of microsurgery (SAMS) were notable for the division of the skills. The knot strength, suture separation, and suture intervals were the most important parameters in all scales. Each scale has its strength in the assessment of the microsurgical proficiency of neurosurgical trainees. However, a more uniform scale that can be applied as per the level of the neurosurgical trainee is necessary.

Heron-mouth neuroendoscopic sheath-assisted neuroendoscopy plays critical roles in treating hypertensive intraventricular hemorrhage

Introduction

Neuroendoscopy is widely applied for treating hypertensive intracerebral hemorrhage.

Aim

To explore the effects of heron-mouth neuroendoscopic sheath-assisted neuroendoscopy on treatment of hypertensive intraventricular hemorrhage.

Material and methods

A type of heron-mouth neuroendoscopic sheath combining the advantages of minimally invasive columnar endoscopic sheath and open operation methods was designed. The end of sheath catheter could be dilated if necessary, without increasing risk of cortex injury. Heron-mouth neuroendoscopic sheath-assisted neuroendoscopy was applied in treatment of hypertensive intraventricular hemorrhage. A total of 19 patients with hypertensive intraventricular hemorrhage were selected and divided into an external ventricular drainage + urokinase group and a neuroendoscopy group. Hematoma clearance rate, surgical time, ventricular drainage time, intracranial infection, hydrocephalus and Glasgow Outcome Score (GOS) at 3 months after the operation were compared between two groups.

Results

Hematoma clearance rate, ventricular drainage time, mortality rate and GOS at 3 months after surgery in the neuroendoscopy group were significantly better compared to those in the external ventricular drainage + urokinase group (p < 0.05). Postoperative complications, including intracranial infection hydrocephalus and pulmonary infection in the neuroendoscopy group, were less numerous compared to those in the external ventricular drainage + urokinase group, but without statistical significance (p > 0.05). However, surgical time was significantly longer in the neuroendoscopy group compared to that in the external ventricular drainage + urokinase group (p < 0.05). There was no significant difference in incidence rate of hydrocephalus between the two groups (p > 0.05).

Conclusions

Clinical effects of heron-mouth neuroendoscopic sheath-assisted neuroendoscopy were better than those of external ventricular drainage combining urokinase dissolution in treating hypertensive intraventricular hemorrhage.

Three-Dimensional Printed Ergonomically Improved Microforceps for Microneurosurgery

OBJECTIVE

The aim of this study was to develop and validate an ergonomically improved microforceps, which is a neurosurgical instrument used in microscopic procedures. The distance between tips of microforceps becomes large at high magnification of the operating microscope. This results in tips moving out of view and causes ergonomic discomfort.

METHODS

The design criteria for ergonomic microforceps were defined, which primarily involved a reduction in the distance between tips and applied force. Computer models of the existing and modified microforceps were created and fabricated using direct metal laser sintering. Ten neurosurgeons validated the developed instrument and provided feedback. In objective validation, video feed of the operating microscope was marked and analyzed by an expert neurosurgeon.

RESULTS

In subjective validation, most of the neurosurgeons endorsed the ergonomic improvements. The parameters, including microforceps tips moving out of view (P = 0.0005), suture holding attempts (P = 0.001), and needle holding attempts (P = 0.03), were found to be statistically improved (Mann-Whitney U test), whereas the average time taken to tie 1 knot was not statistically improved (P = 0.06). The ergonomic modification also resulted in a reduction of applied force by 47.5%.

CONCLUSIONS

Validation results show that the developed instrument provides several ergonomic benefits for the microsuturing task under high magnification of the operating microscope.

A Review of Physical Simulators for Neuroendoscopy Skills Training

BACKGROUND

Minimally invasive neurosurgical approaches reduce patient morbidity by providing the surgeon with better visualization and access to complex lesions, with minimal disruption to normal anatomy. The use of rigid or flexible neuroendoscopes, supplemented with a conventional stereoscopic operating microscope, has been integral to the adoption of these techniques. Neurosurgeons commonly use neuroendoscopes to perform the ventricular and endonasal approaches. It is challenging to learn neuroendoscopy skills from the existing apprenticeship model of surgical education. The training methods, which use simulation-based systems, have achieved wide acceptance. Physical simulators provide anatomic orientation and hands-on experience with repeatability. Our aim is to review the existing physical simulators on the basis of the skills training of neuroendoscopic procedures.

METHODS

We searched Scopus, Google Scholar, PubMed, IEEE Xplore, and dblp. We used the following keywords "neuroendoscopy," "training," "simulators," "physical," and "skills evaluation." A total of 351 articles were screened based on development methods, evaluation criteria, and validation studies on physical simulators for skills training in neuroendoscopy.

RESULTS

The screening of the articles resulted in classifying the physical training methods developed for neuroendoscopy surgical skills into synthetic simulators and box trainers. The existing simulators were compared based on their design, fidelity, trainee evaluation methods, and validation studies.

CONCLUSIONS

The state of simulation systems demands collaborative initiatives among translational research institutes. They need improved fidelity and validation studies for inclusion in the surgical educational curriculum. Learning should be imparted in stages with standardization of performance metrics for skills evaluation.

Hybrid Robotics for Endoscopic Skull Base Surgery: Preclinical Evaluation and Surgeon First Impression

BACKGROUND

A robotic endoscope holder should theoretically provide various advantages in transnasal endoscopic skull base surgery, but only recently has a robotic system become commercially available. The objective of this study was to provide a preclinical evaluation of potential advantages and surgeon first impression of this robotic hybrid solution.

METHODS

Thirty skull base surgeons, attending the Joint European Diploma of Endoscopic Skull Base Surgery 2018-2019 in Paris, France, were enrolled. A questionnaire, mainly concerning personal surgical experience and habits, was administered. The test phase consisted of 2 different dry-lab tasks, performed with and without EndoscopeRobot, according to randomization and on 2 different days. A modified NASA Task Load Index test was subsequently administered via e-mail to all participants. Completion times and modified Global Evaluative Assessment of Robotic Skills in Endoscopy scores of the videotaped tasks were recorded.

RESULTS

Nineteen otorhinolaryngologic surgeons and 11 neurosurgeons, with different surgical habits and endoscopic experience, were enrolled. No one appeared unfavorable a priori to robotic endoscopic surgery. Although the robot did not provide an advantage in the simple grasping task 1, a trend toward better completion times and efficacy was evident in the bimanual task 2, when performed with the robot and bimanually. According to the modified NASA Task Load Index test, surgeons felt more successful with the robot in task 2, finding it less stressful and mentally demanding.

CONCLUSIONS

Endoscopic skull base surgeons seem to view a hybrid robotic solution positively. EndoscopeRobot seems to provide a benefit to the single surgeon with experience in bimanual endoscopic surgery. Further preclinical and clinical evaluation of this technology is necessary.

Endoscopic Management of Cavernous Carotid Surgical Complications: Evaluation of a Simulated Perfusion Model

OBJECTIVE

Endoscopic surgical treatment of pituitary tumors, lateral invading tumors, or aneurysms requires surgeons to operate adjacent to the cavernous sinus. During these endoscopic endonasal procedures, the carotid artery is vulnerable to surgical injury at its genu. The objective of this simulation model was to evaluate trainees regarding management of a potentially life-threatening vascular injury.

METHODS

Cadaveric heads were prepared in accordance with the Oregon Health & Science University body donation program. An endoscopic endonasal approach was used, and a perfusion pump with a catheter was placed in the ipsilateral common carotid artery at its origin in the neck. Learners used a muscle graft to establish vascular control and were evaluated over 3 training sessions. Simulation assessment, blood loss during sessions, and performance metric data were collected for learners.

RESULTS

Vascular control was obtained at a mean arterial pressure of 65 mm Hg using a muscle graft correctly positioned at the arteriotomy site. Learners improved over the course of training, with senior residents (n = 4) performing better across all simulation categories (situation awareness, decision making, communications and teamwork, and leadership); the largest mean difference was in communication and teamwork. Additionally, learner performance concerning blood loss improved between sessions (t = 3.667, P < 0.01).

CONCLUSIONS

In this pilot endoscopic endonasal simulation study, we successfully demonstrate a vascular complication perfusion model. Learners were able to gain direct applicable expertise in endoscopic endonasal techniques, instrumentation use, and teamwork required to optimize the technique. Learners gained skills of vascular complication management that transcend this model.