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Lin PW, You W, Guo AS, Lin ZR, Wang YZ. Efficiency and safety of optic canal unroofing in tuberculum sellae meningiomas: a meta-analysis and systematic review. Neurosurg Rev 2023; 46:240. [PMID: 37698750 PMCID: PMC10497650 DOI: 10.1007/s10143-023-02151-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 07/31/2023] [Accepted: 09/06/2023] [Indexed: 09/13/2023]
Abstract
Optic canal unroofing (OCU) has gradually become a routine technique for tuberculum sellae meningiomas (TSMs) resection. This meta-analysis aimed to evaluate the efficacy and safety of OCU. A systematic review and meta-analysis of the published literature on this topic from 2003 to 2023 were conducted in accordance with the PRISMA guidelines. Rigorous statistical analysis with a p-value was performed for related change in visual improvement, gross total resection (GTR), visual deterioration, and olfactory nerve damage. The study included 15 articles with 384 patients in whom OCU was performed by the transcranial approach (TCA) or the endoscopic endonasal approach (EEA). Of these, 341 patients had preoperative visual loss, and 266 patients had postoperative visual recovery. The overall rate of visual improvement was 0.803 (95% CI: 0.733-0.874, p < 0.01). The rate of visual improvement in the EEA and TCA groups was 0.884 (95% CI: 0.803-0.965, p < 0.01) and 0.788 (95% CI: 0.700-0.875, p < 0.01). Further analysis of classification shows that the rate of visual improvement in Type I: < 2 cm was 0.889(95% CI: 0.739-0.969), Type II:2-4 cm was 0.844(95% CI: 0.755-0.910), Type III: > 4 cm was 0.500(95% CI: 0.068-0.932) and the total was 0.853(95% CI: 0.779-0.927 p < 0.01) with low heterogeneity of I2 = 20.80%.Twelve studies separately reported GTR with OCU was 293; the rate of GTR was 0.911 (95% CI: 0.848-0.961, p < 0.01). And the rate of GTR in Type I: < 2 cm was 0.933(95% CI: 0.817-0.986), Type II:2-4 cm was 0.880(95% CI: 0.800-0.936), Type III: > 4 cm was 0.600(95% CI: 0.147-0.947). The total was 0.897(95% CI: 0.830-0.965 p < 0.01) with low heterogeneity of I2 = 34.57%. The related complications of OCU were visual deterioration and olfactory nerve damage. Visual decline was reported in nine studies, and the rate was 0.077 (95% CI: 0.041-0.113, p < 0.01). Six studies reported olfactory nerve damage, and the overall rate was 0.054 (95% CI: 0.019-0.090, p < 0.01). OCU could significantly recover preoperative impaired vision and make GTR easier to achieve, which was also a safe and effective technique in TSM.
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Affiliation(s)
- Peng-Wei Lin
- The School of Clinical Medicine, Fujian Medical University, Zhangzhou Affiliated Hospital of Fujian Medical University, Fuzhou, 350122, Fujian Province, China
| | - Wei You
- Department of Neurosurgery, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, Fujian Province, China
| | - Ai-Shun Guo
- Department of Neurosurgery, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, Fujian Province, China.
| | - Zhen-Rong Lin
- Department of Neurosurgery, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, Fujian Province, China
| | - Yu-Zhe Wang
- Department of Neurosurgery, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, Fujian Province, China
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2
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Nair P, Honavalli Murali S, Harihara Venkat E, Poyuran R. Endoscopic Endonasal Transethmoidal Inferomedial Orbitotomy and En Bloc Excision of an Intraorbital Intraconal Cavernous Hemangioma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-00657. [PMID: 36972425 DOI: 10.1227/ons.0000000000000678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/17/2023] [Indexed: 03/29/2023] Open
Affiliation(s)
- Prakash Nair
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Sanjay Honavalli Murali
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Easwer Harihara Venkat
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Rajalakshmi Poyuran
- Department of Pathology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
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Liu J, Zhao J, Wang Y, Wang Z, Li R, Chen Z, Zhao Y, Han J, Yang D. Simultaneous Endoscopic Endonasal Decompression of the Optic Canal, Superior Orbital Fissure, and Proper Orbital Apex for Traumatic Orbital Apex Syndrome: Surgical Anatomy and Technical Note. Front Surg 2022; 8:811706. [PMID: 35127806 PMCID: PMC8814317 DOI: 10.3389/fsurg.2021.811706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives Traumatic orbital apex syndrome (TOAS) is an uncommon but severe ocular complication of craniomaxillofacial fracture. The optimal surgical strategy for TOAS has not been determined. To investigate the endoscopic anatomy of the orbital apex region, propose a protocol for simultaneous endoscopic endonasal decompression of the optic canal, superior orbital fissure, and proper orbital apex (EEDCFA) for TOAS and report its use in two patients. Methods An endoscopic endonasal approach was utilized to dissect the orbital apex region in two silicon-injected adult cadaveric heads. The details of the procedure used for decompression of the orbital apex were determined. The effects of this procedure were determined in two patients with TOAS who underwent simultaneous decompression of the optic canal, superior orbital fissure, and proper orbital apex. Results The orbital apex consisted of three portions, the contents of the optic canal superomedially; the contents of the superior orbital fissure inferolaterally; and the converging portion, or proper orbital apex, anteriorly. From an endoscopic endonasal approach, the optic nerve, superior orbital fissure, and orbital apex convergence prominences were found to form a π-shaped configuration. This π-shaped configuration was indicative of the orbital apex and was an important landmark for decompression of the orbital apex. Endonasal decompression of the orbital apex in the two patients resulted in the satisfactory recovery of extraocular mobility, with no surgical complications. Conclusions EEDCFA is feasible, effective, and safe for patients with TOAS caused by direct compression of displaced fracture segments. The π-shaped configuration is a valuable landmark for EEDCFA.
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Affiliation(s)
- Jianfeng Liu
- Department of Otolaryngology-Head and Neck Surgery, China-Japan Friendship Hospital, Beijing, China
- *Correspondence: Jianfeng Liu
| | - Jianhui Zhao
- Department of Otolaryngology-Head and Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Yibei Wang
- Department of Otolaryngology-Head and Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Zhijun Wang
- Department of Ophthalmology, China-Japan Friendship Hospital, Beijing, China
| | - Rui Li
- Department of Neurosurgery, China-Japan Friendship Hospital, Beijing, China
| | - Zhongyan Chen
- Department of Otolaryngology-Head and Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Yu Zhao
- Department of Otolaryngology-Head and Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jun Han
- Department of Otolaryngology-Head and Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Dazhang Yang
- Department of Otolaryngology-Head and Neck Surgery, China-Japan Friendship Hospital, Beijing, China
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4
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Jeon C, Hong SD, Woo KI, Seol HJ, Nam DH, Lee JI, Kong DS. Use of endoscopic transorbital and endonasal approaches for 360° circumferential access to orbital tumors. J Neurosurg 2021; 135:103-112. [PMID: 32977310 DOI: 10.3171/2020.6.jns20890] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 06/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Orbital tumors are often surgically challenging because they require an extensive fronto-temporo-orbital zygomatic approach (FTOZ) and a multidisciplinary team approach to provide the best outcomes. Recently, minimally invasive endoscopic techniques via a transorbital superior eyelid approach (ETOA) or endoscopic endonasal approach (EEA) have been proposed as viable alternatives to transcranial approaches for orbital tumors. In this study, the authors investigated the feasibility of 360° circumferential access to orbital tumors via both ETOA and EEA. METHODS Between April 2014 and June 2019, 16 patients with orbital tumors underwent either ETOA or EEA at the authors' institution. Based on the neuro-topographic "four-zone model" of the orbit with its tumor epicenter around the optic nerve in the coronal plane, ETOA (n = 10, 62.5%) was performed for tumors located predominantly superolateral to the nerve and EEA (n = 6, 37.5%) for those located predominantly inferomedial to the nerve. Eight patients (50%) presented with intraconal tumors and 8 (50%) with extraconal ones. The orbital tumors included orbital schwannoma (n = 6), cavernous hemangioma (n = 2), olfactory groove meningioma (n = 1), sphenoorbital meningioma (n = 1), chondrosarcoma (n = 1), trigeminal schwannoma (n = 1), metastatic osteosarcoma (n = 1), mature cystic teratoma (n = 1), sebaceous carcinoma (n = 1), and ethmoid sinus osteoma (n = 1). The clinical outcomes and details of surgical techniques were reviewed. RESULTS Gross-total resection was achieved in 12 patients (75%), near-total resection in 3 (18.8%), and subtotal resection in 1 (6.2%). Eight (88.9%) of the 9 patients with preoperative proptosis showed improvement after surgery, and 4 (66.7%) of the 6 patients with visual symptoms demonstrated improvement. Four (40%) of the 10 patients treated with ETOA experienced partial third nerve palsy immediately after surgery (3 transient and 1 persistent). There have been no postoperative CSF leaks or infections in this series. CONCLUSIONS Without transcranial approaches requiring temporalis muscle dissection and orbitozygomatic osteotomy, the selection of ETOA or EEA based on a concept of a four-zone model with its epicenter around the optic nerve successfully provides a minimally invasive 360° circumferential access to the entire orbit with acceptable morbidity.
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Affiliation(s)
| | | | - Kyung In Woo
- 3Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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5
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Abussuud Z, Ahmed S, Paluzzi A. Surgical Approaches to the Orbit: A Neurosurgical Perspective. Skull Base Surg 2020; 81:385-408. [PMID: 33209566 DOI: 10.1055/s-0040-1713941] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Orbital pathologies can be complex to manage surgically. In this article, we describe some of the most common and relevant approaches to orbital tumours. For each approach we describe the appropriate indications, surgical technique, potential complications, and illustrate a case example.
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Affiliation(s)
- Zeid Abussuud
- Department of Neurosurgery (Honorary), Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Shahzada Ahmed
- Department of ENT, Queen Elizabeth Hospital Birmingham, United Kingdom
| | - Alessandro Paluzzi
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, United Kingdom
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6
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Özer Mİ, Kutlay AM, Durmaz MO, Kirik A, Yaşar S, Tehli Ö, Kural C, Temiz NÇ, Durmaz A, Ezgu MC, Daneyemez MK, Izci Y. Extended endonasal endoscopic approach for anterior midline skull base lesions. Clin Neurol Neurosurg 2020; 196:106024. [PMID: 32619902 DOI: 10.1016/j.clineuro.2020.106024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/15/2020] [Accepted: 06/14/2020] [Indexed: 11/29/2022]
Abstract
AIM In recent years, extended endoscopic endonasal approach (EEEA) has been used as an alternative to transcranial approaches in the treatment of anterior midline skull base lesions. We retrospectively reviewed our cases operated using this technique and compared the results with current literature. METHOD The data of 24 patients who were operated using EEEA in our department between 2010-2018 were retrospectively analyzed. The lesions were located in the midline between the posterior wall of the frontal sinus and tuberculum sella. Tumor locations, histopathological diagnoses, surgical techniques, outcomes and complications were documented. RESULTS Eleven patients were female and 13 were male. Their ages ranged between 18-75 years (mean 40.5 years). Considering their locations; 12 were in the anterior fossa (50 %), 7 were in the tuberculum sella (29.1 %), and 5 were in both anatomic sites (20.8 %). Histopathologically, our series consisted of 15 meningiomas, 6 osteomas, 2 dermoid tumors and 1 metastatic carcinoma. We achieved gross total resection in 75 % of our patients. Ten patients presented with visual complaints and 7 of them improved postoperatively. Postoperative cerebrospinal fluid leakage (CSF) was observed in 3 patients and one of them developed meningitis and subsequently died of sepsis. CONCLUSION Although the number of cases is low, EEEA seems like a safe, effective and well-tolerated treatment modality for anterior midline skull base lesions. But strict preventive measures should be taken for a possible CSF leak.
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Affiliation(s)
- Mehmet İlker Özer
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Ahmet Murat Kutlay
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Mehmet Ozan Durmaz
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Alparslan Kirik
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Soner Yaşar
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Özkan Tehli
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Cahit Kural
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Nail Çağlar Temiz
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Abdullah Durmaz
- Department of Otorhinolaryngology, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Mehmet Can Ezgu
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Mehmet Kadri Daneyemez
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Yusuf Izci
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey.
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7
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Technological and Ideological Innovations in Endoscopic Skull Base Surgery. World Neurosurg 2019; 124:513-521. [PMID: 30708082 DOI: 10.1016/j.wneu.2019.01.120] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/25/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Endoscopic skull base surgery has evolved over the last several decades due to technological advances and operative techniques. Several innovations that are not yet mainstream may have significant impact on the future of endoscopic skull base surgery. METHODS Current literature pertaining to innovations in endoscopic skull base surgery was retrieved using PubMed, Embase, Web of Science, and Google Scholar. RESULTS Several recent innovations may play an influential role in the advancement of endoscopic skull base surgery, including fluorescent dyes such as indocyanine green fluorescence, fluorescein, and 5-aminolevulinic acid, 3-dimensional endoscopes, robotic surgery, and intraoperative magnetic resonance imaging. CONCLUSIONS Several technologies are under current investigation with the hope to improve future outcomes in endoscopic skull base surgery. Additional research and evolution are necessary and will require intense scrutiny before becoming standard of care.
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8
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Bernardo A, Evins AI, Mattogno PP, Quiroga M, Zacharia BE. The Orbit as Seen Through Different Surgical Windows: Extensive Anatomosurgical Study. World Neurosurg 2017; 106:1030-1046. [DOI: 10.1016/j.wneu.2017.06.158] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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9
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Maslehaty H, Schultheiss S, Scholz M, Petridis AK. Surgical Anatomy of the Orbit in Human Cadavers-An Endoscopic Pictorial Documentation. J Neurol Surg B Skull Base 2017; 79:173-176. [PMID: 29868323 DOI: 10.1055/s-0037-1606294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 07/25/2017] [Indexed: 10/19/2022] Open
Abstract
Background The aim of our study was a pictorial documentation of the anatomical structures of the orbit. Methods We performed a transmaxillary endoscopic approach in nine formalin-fixed human heads. We identified and documented the anatomy of the inferior part of the orbit. Results The first intraorbital anatomical landmark was the inferior rectus muscle, from which important structures medially and laterally could be identified. Anatomical structures and their relation to each other were documented and presented as illustrative figures. Conclusion Knowledge of the topographic anatomy of the inferior part of the orbit could be sufficiently imparted by our illustrations. The presented transmaxillary approach allowed a wide overview of the anatomical structures located in the inferior part of the orbit. Our pictorial documentation may provide neurosurgeons more safety and the opportunity to become familiar with the endoscopic anatomy.
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Affiliation(s)
| | - Saskia Schultheiss
- Department of Neurosurgery, Academic Teaching Hospital of University Essen-Duisburg, Klinikum Duisburg, Essen-Duisburg, Germany
| | - Martin Scholz
- Department of Neurosurgery, Academic Teaching Hospital of University Essen-Duisburg, Klinikum Duisburg, Essen-Duisburg, Germany
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Matsuo S, Komune N, Iihara K, Rhoton AL. Translateral Orbital Wall Approach to the Orbit and Cavernous Sinus. Oper Neurosurg (Hagerstown) 2016; 12:360-373. [DOI: 10.1227/neu.0000000000001145] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 10/02/2015] [Indexed: 11/19/2022] Open
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Surgical anatomy of the cavernous sinus, superior orbital fissure, and orbital apex via a lateral orbitotomy approach: a cadaveric anatomical study. Acta Neurochir (Wien) 2016; 158:2135-2148. [PMID: 27614437 DOI: 10.1007/s00701-016-2940-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/17/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Tumors of the middle fossa or cavernous sinus (CS), or intraorbital tumors, can penetrate each other through the superior orbital fissure (SOF) or neighboring tissue. These complicated pathologies are often treated with highly invasive surgical procedures. In this article, we demonstrate surgical anatomic dissections of the CS, SOF, orbital apex (OA), and dura mater extending to the periorbita from the middle fossa, by performing an epidural dissection via a lateral orbitotomy approach, and discuss findings that may provide guidance during surgery in these regions. METHODS Lateral orbitotomy was performed on latex-injected cadaver heads by making a 2-cm skin incision lateral to the lateral canthus, drilling the lesser and greater sphenoid wings that form the SOF borders, and removing the bone section between the middle fossa and orbit. Dura mater from the middle fossa to the periorbita was exposed to perform anterior clinoidectomy. Meningeal dura was dissected from the endosteal dura, which forms the lateral wall of the CS, to expose the CS, SOF, and OA for dissections. RESULTS Changing the orientation of the microscope from posterior to anterior enabled regional control for dissection from the Gasserian ganglion to the OA. Cranial nerves that pass through the CS, SOF, and OA were dissected and exposed. The annular tendon was opened, revealing the oculomotor nerves and its branches, as well as the abducens and nasociliary nerves, which pass through the oculomotor foramen and course within the OA and orbit. CONCLUSIONS This approach causes less tissue damage; provides control of the surgical area in spheno-orbital tumors invading the fissure and foramen by changing the orientation of the microscope toward the orbit, OA, SOF, CS, and middle fossa; and expands the indication criteria for lateral orbitotomy surgery. This approach, therefore, represents an alternative surgical method for excising complicated tumors in these regions.
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Singh H, Essayed WI, Jada A, Moussazadeh N, Dhandapani S, Rote S, Schwartz TH. Contralateral supraorbital keyhole approach to medial optic nerve lesions: an anatomoclinical study. J Neurosurg 2016; 126:940-944. [PMID: 27257841 DOI: 10.3171/2016.3.jns1634] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors describe the supraorbital keyhole approach to the contralateral medial optic nerve and tract, both in a series of cadaveric dissections and in 2 patients. They also discuss the indications and contraindications for this procedure. METHODS In 3 cadaver heads, bilateral supraorbital keyhole minicraniotomies were performed to expose the ipsilateral and contralateral optic nerves. The extent of exposure of the medial optic nerve was assessed. In 2 patients, a contralateral supraorbital keyhole approach was used to remove pathology of the contralateral medial optic nerve and tract. RESULTS The supraorbital keyhole craniotomy provided better exposure of the contralateral superomedial nerve than it did of the same portion of the ipsilateral nerve. In both patients gross-total resections of the pathology was achieved. CONCLUSIONS The authors demonstrate the suitability of the contralateral supraorbital keyhole approach for lesions involving the superomedial optic nerve.
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Affiliation(s)
- Harminder Singh
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Walid I Essayed
- Department of 2 Neurosurgery, Weill Cornell Medical College, NewYork-Presbyterian
| | - Ajit Jada
- Department of 2 Neurosurgery, Weill Cornell Medical College, NewYork-Presbyterian
| | - Nelson Moussazadeh
- Department of 2 Neurosurgery, Weill Cornell Medical College, NewYork-Presbyterian.,Division of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | | | - Sarang Rote
- Department of 2 Neurosurgery, Weill Cornell Medical College, NewYork-Presbyterian
| | - Theodore H Schwartz
- Department of 2 Neurosurgery, Weill Cornell Medical College, NewYork-Presbyterian
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13
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Raza SM, Banu MA, Donaldson A, Patel KS, Anand VK, Schwartz TH. Sensitivity and specificity of intrathecal fluorescein and white light excitation for detecting intraoperative cerebrospinal fluid leak in endoscopic skull base surgery: a prospective study. J Neurosurg 2016; 124:621-6. [DOI: 10.3171/2014.12.jns14995] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The intraoperative detection of CSF leaks during endonasal endoscopic skull base surgery is critical to preventing postoperative CSF leaks. Intrathecal fluorescein (ITF) has been used at varying doses to aid in the detection of intraoperative CSF leaks. However, the sensitivity and specificity of ITF at certain dosages is unknown.
METHODS
A prospective database of all endoscopic endonasal procedures was reviewed. All patients received 25 mg ITF diluted in 10 ml CSF and were pretreated with dexamethasone and Benadryl. Immediately after surgery, the operating surgeon prospectively noted if there was an intraoperative CSF leak and fluorescein was identified. The sensitivity, specificity, and positive and negative predictive power of ITF for detecting intraoperative CSF leak were calculated. Factors correlating with postoperative CSF leak were determined.
RESULTS
Of 419 patients, 35.8% of patients did not show a CSF leak. Fluorescein-tinted CSF (true positive) was noted in 59.7% of patients and 0 false positives were encountered. CSF without fluorescein staining (false negative) was noted in 4.5% of patients. The sensitivity and specificity of ITF were 92.9% and 100%, respectively. The negative and positive predictive values were 88.8% and 100%, respectively. Postoperative CSF leaks only occurred in true positives at a rate of 2.8%.
CONCLUSIONS
ITF is extremely specific and very sensitive for detecting intraoperative CSF leaks. Although false negatives can occur, these patients do not appear to be at risk for postoperative CSF leak. The use of ITF may help surgeons prevent postoperative CSF leaks by intraoperatively detecting and confirming a watertight repair.
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Affiliation(s)
- Shaan M. Raza
- 1Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas; and
| | | | | | | | | | - Theodore H. Schwartz
- 2Departments of Neurosurgery,
- 3Otolaryngology, and
- 4Neurology and Neuroscience, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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14
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Gras-Cabrerizo JR, Martel-Martin M, Garcia-Lorenzo J, Rodríguez-Álvarez F, Montserrat-Gili JR, Mirapeix-Lucas R, Massegur-Solench H. Surgical Anatomy of the Medial Wall of the Orbit in 14 Human Cadavers. J Neurol Surg B Skull Base 2016; 77:439-444. [PMID: 27857868 DOI: 10.1055/s-0036-1579544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 01/20/2016] [Indexed: 10/22/2022] Open
Abstract
Objective The aim of our study is to present the anatomical landmarks to perform an endoscopic endonasal approach to the medial wall of the orbit (EEAMO). Material and Methods We performed 14 complete nasal and orbital endoscopic dissections in 7 adult cadaveric heads. Results The EEAMO provides a surgical corridor between the medial rectus muscle superiorly and the inferior rectus muscle inferiorly .The mean distance between the ethmoidal crest and medial rectus muscle was 1.5 cm (range, 1.3-1.9 cm). The width of the medial rectus muscle was 1.2 cm (range, 1-1.5 cm). The main vascular structure in this retrobulbar space was the ophthalmic artery that crosses over the optic nerve in 86% of the cases. In its intraorbital route, the anterior ethmoidal artery and the ethmoidal nerves were situated inferior to the superior oblique muscle in all cases. The posterior ethmoidal artery was found superior to it. We could identify the inferior division of the oculomotor nerve in this surgical approach. Conclusions The EEAMO allows adequate exposure of the space between the medial rectus muscle and the inferior rectus muscle. The location of the ethmoidal crest of the palatine bone, and its relationship with the medial rectus muscle, is a useful anatomical landmark for this surgical approach.
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Affiliation(s)
- Juan R Gras-Cabrerizo
- Department of Otolaryngology/Head and Neck Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria Martel-Martin
- Department of Otolaryngology/Head and Neck Surgery, Hospital de Sant Joan Despí Moisès Broggi de Barcelona, Barcelona, Spain
| | - Jacinto Garcia-Lorenzo
- Department of Otolaryngology/Head and Neck Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Fernando Rodríguez-Álvarez
- Department of Ophthalmology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan R Montserrat-Gili
- Department of Otolaryngology/Head and Neck Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rosa Mirapeix-Lucas
- Unit of Anatomy and Human Embriology, Universitat Autónoma de Barcelona, Spain
| | - Humbert Massegur-Solench
- Department of Otolaryngology/Head and Neck Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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Zaidi HA, Zehri A, Smith TR, Nakaji P, Laws ER. Efficacy of Three-Dimensional Endoscopy for Ventral Skull Base Pathology: A Systematic Review of the Literature. World Neurosurg 2016; 86:419-31. [DOI: 10.1016/j.wneu.2015.10.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 10/01/2015] [Accepted: 10/05/2015] [Indexed: 11/27/2022]
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16
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Dziedzic TA, Anand VK, Schwartz TH. Endoscopic endonasal approach to the lateral orbital apex: case report. J Neurosurg Pediatr 2015; 16:305-8. [PMID: 26053671 DOI: 10.3171/2015.2.peds1575] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Although the medial and inferior orbital apex are considered safely accessible using the endonasal endoscopic approach, the lateral apex has been considered unsafe to access since the optic nerve lies between the surgeon and the pathology. The authors present the case of a 4-year-old girl with recurrent rhabdomyosarcoma attached to the lateral rectus muscle located lateral and inferior to the optic nerve in the orbital apex. The tumor was totally resected through an endoscopic endonasal transmaxillary transpterygoidal approach using a 45° endoscope. A gross-total resection was achieved, and the patient's vision was unchanged. This procedure is a safe, minimal-access alternative to open procedures in selected cases and provides evidence that increases the applicability of the endonasal endoscopic approach to reach the lateral compartment of the orbital apex.
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Affiliation(s)
| | | | - Theodore H Schwartz
- Departments of 1 Neurosurgery.,Otolaryngology, and.,Neuroscience, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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17
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Shin M, Kondo K, Hanakita S, Suzukawa K, Kin T, Shojima M, Nakagawa D, Saito N. Endoscopic transnasal approach for resection of locally aggressive tumors in the orbit. J Neurosurg 2015; 123:748-59. [PMID: 26052982 DOI: 10.3171/2014.11.jns141921] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECT In recent years, application of endoscopic transnasal surgery (ETS) has been expanded to orbital lesions, and preliminary results have started to be published for medially located soft mass lesions. However, reports on experience with endoscopic intraorbital surgery aimed at resection of invasive skull base tumors remains quite limited. This report presents the authors' experience with ETS for locally aggressive tumors involving the orbit. METHODS ETS was performed for 15 cases of aggressive tumors involving the orbit: 5 meningiomas (meningothelial, n = 3; atypical, n = 1; anaplastic, n = 1), 4 chordomas, 2 chondrosarcomas, and 4 others (metastasis from systemic myxofibrosarcoma, schwannoma, inverted papilloma, and acinic cell carcinoma, n = 1 each). Among these, 9 tumors were located outside the periorbita and 6 inside the periorbita. In 6 intraperiosteal tumors, 5 were intraconal lesions, of which 3 arose in the muscle cone (anaplastic meningioma, optic sheath meningioma, and metastatic myxofibrosarcoma), and 2 meningothelial meningioma had invaded from the sphenoid ridge or the cavernous sinus into the muscle cone through the optic canal and the superior orbital fissure. A case of schwannoma originated around the cavernous sinus and pterygopalatine fossa and extended extraconally into the periorbita. Intraoperatively, ethmoid air cells and the lamina papyracea were removed, and extraperiosteal tumors were safely approached. For intraperiosteal tumors, the periorbita was widely opened, and the tumors were approached through the surgical window between the rectus and oblique muscles. RESULTS Gross-total resection was achieved for 12 of the 15 tumors, including 2 intraconal lesions. After surgery, exophthalmos resolved in all 8 patients with this symptom, and diplopia resolved in 5 of 6 patients. Improvement of visual symptoms was reported by 4 of 5 patients with loss of visual acuity or constriction of the visual field. Postoperatively, 1 patient showed mild, transient worsening of existing facial dysesthesia, and another showed transient ptosis and mild hypesthesia of the forehead on the affected side. All those symptoms resolved within 3 months. No patients showed enophthalmos, worsening of diplopia or visual function, or impairment of olfaction after surgery. CONCLUSIONS ETS appears acceptable as a less-invasive alternative for treating aggressive tumors involving the orbit. For extraperiosteal tumors, gross-total removal can generally be achieved without neurological complications. For intraperiosteal tumors, surgical indications should be carefully discussed, considering the relationship between the tumor and normal anatomy. Wide opening of the periorbital window is advocated to create a sufficient surgical pathway between the extraocular muscles, allowing a balance between functional preservation and successful tumor resection.
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Affiliation(s)
| | - Kenji Kondo
- Otolaryngology, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Keigo Suzukawa
- Otolaryngology, The University of Tokyo Hospital, Tokyo, Japan
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Mahvash M, Igressa A, Pechlivanis I, Weber F, Charalampaki P. Endoscopic endonasal transsphenoidal approach for resection of a coexistent pituitary macroadenoma and a tuberculum sellae meningioma. Asian J Neurosurg 2015; 9:236. [PMID: 25685225 PMCID: PMC4323972 DOI: 10.4103/1793-5482.146629] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The coexistence of a pituitary macroadenoma and a tuberculum sellae meningioma is very rare. This article demonstrates the surgical technique of the simultaneous resection of a pituitary macroadenoma and a tuberculum sellae meningioma using an endoscopic, endonasal, biportal, transsphenoidal approach. A 36-year-old woman presented with frontal headache and extended visual field loss of the right eye. She underwent cranial magnetic resonance imaging (MRI) revealing a 2 × 2 × 2.5 mm contrast-enhancing intrasellar and suprasellar lesion with compression of the optic chiasma. The coexistence of a pituitary macroadenoma and meningioma was suggested. A biportal endoscopic endonasal transsphenoidal approach was performed to remove both lesions. The histological results confirmed the coexistence of the pituitary macroadenoma and meningioma, World Health Organization (WHO) grade I. The endoscopic, endonasal, transsphenoidal approach is a safe and reliable minimal invasive surgical alternative for resection of the intra-, supra- and parasellar lesions, avoiding additional craniotomy.
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Affiliation(s)
- Mehran Mahvash
- Department of Neurosurgery, Clinic of Köln-Merheim, University of Witten-Herdecke, Germany
| | - Ahadi Igressa
- Department of Neurosurgery, Clinic of Köln-Merheim, University of Witten-Herdecke, Germany
| | - Ioannis Pechlivanis
- Department of Neurosurgery, Clinic of Köln-Merheim, University of Witten-Herdecke, Germany
| | - Friedrich Weber
- Department of Neurosurgery, Clinic of Köln-Merheim, University of Witten-Herdecke, Germany
| | - Patra Charalampaki
- Department of Neurosurgery, Clinic of Köln-Merheim, University of Witten-Herdecke, Germany
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Transorbital endoscopic assisted resection of a superior orbital fissure cavernous haemangioma: a technical case report. Eur Arch Otorhinolaryngol 2015; 272:3851-6. [DOI: 10.1007/s00405-015-3556-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 02/09/2015] [Indexed: 11/30/2022]
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20
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Banu MA, Rathman A, Patel KS, Souweidane MM, Anand VK, Greenfield JP, Schwartz TH. Corridor-based endonasal endoscopic surgery for pediatric skull base pathology with detailed radioanatomic measurements. Neurosurgery 2015; 10 Suppl 2:273-93; discussion 293. [PMID: 24845548 DOI: 10.1227/neu.0000000000000252] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pediatric anatomy is more restricted, and the propagation of endonasal endoscopic approaches in the pediatric population has been limited. OBJECTIVE To demonstrate the feasibility of the endonasal endoscopic approach in a variety of age groups and to perform measurements of the corridors and spaces available for surgery as a guide for case selection. METHODS Only patients <18 years were included. The choice of operative corridor/approach is described in relation to pathological entity and location. Preoperative/postoperative visual fields and endocrine panels, extent of resection, as well as postoperative long-term complications are described. Prospective magnetic resonance image-based anatomic measurements of key distances were performed to determine age-dependent surgical indications and limitations. RESULTS Forty purely endoscopic procedures were performed in 33 pediatric patients (5-18 years of age) harboring a variety of skull base lesions, from benign tumors to congenital malformations. For the 20 patients in whom gross total resection was the intended goal of surgery, gross total resection was attained in 15 (75%). There were 2 infections (5%) and no cerebrospinal fluid leaks. Significant improvement was shown in 58.3% of patients with visual deficits. Hormone overproduction resolved in 75% of patients, while preoperative hormone insufficiency only improved in 29.2%. Wider intercarotid distance at the superior clivus (P = .01) and shorter nare-dens working distance (P = .001) predicted improved outcomes and fewer postoperative complications. CONCLUSION Endonasal endoscopic skull base approaches are viable in the pediatric population, they are not impeded by sphenoid sinus aeration, and they have minimal risk of cerebrospinal fluid leak and meningitis. Outcomes and complications can be predicted based on specific radio anatomical skull base measurements rather than age.
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Affiliation(s)
- Matei A Banu
- *Department of Neurological Surgery, Weill Cornell Medical College, New York, New York; ‡Department of Pediatrics, Weill Cornell Medical College, New York, New York; §Department of Otolaryngology, Head and Neck Surgery, Weill Cornell Medical College, New York, New York; ‖Department of Neurology and Neuroscience, Brain and Spine Center, Brain and Mind Research Institute, Weill Cornell Medical College, New York, New York
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Marcus HJ, Hughes-Hallett A, Cundy TP, Di Marco A, Pratt P, Nandi D, Darzi A, Yang GZ. Comparative effectiveness of 3-dimensional vs 2-dimensional and high-definition vs standard-definition neuroendoscopy: a preclinical randomized crossover study. Neurosurgery 2014; 74:375-80; discussion 380-1. [PMID: 24220007 PMCID: PMC4053590 DOI: 10.1227/neu.0000000000000249] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND: Although the potential benefits of 3-dimensional (3-D) vs 2-dimensional (2-D) and high-definition (HD) vs standard-definition (SD) endoscopic visualization have long been recognized in other surgical fields, such endoscopes are generally considered too large and bulky for use within the brain. The recent development of 3-D and HD neuroendoscopes may therefore herald improved depth perception, better appreciation of anatomic details, and improved overall surgical performance. OBJECTIVE: To compare simultaneously the effectiveness of 3-D vs 2-D and HD vs SD neuroendoscopy. METHODS: Ten novice neuroendoscopic surgeons were recruited from a university hospital. A preclinical randomized crossover study design was adopted to compare 3-D vs 2-D and HD vs SD neuroendoscopy. The primary outcomes were time to task completion and accuracy. The secondary outcomes were perceived task workload using the NASA (National Aeronautics and Space Administration) Task Load Index and subjective impressions of the endoscopes using a 5-point Likert scale. RESULTS: Time to task completion was significantly shorter when using the 3-D vs the 2-D neuroendoscopy (P = .001), and accuracy of probe placement was significantly greater when using the HD vs the SD neuroendoscopy (P = .009). We found that 3-D endoscopy significantly improved perceived depth perception (P < .001), HD endoscopy significantly improved perceived image quality (P < .001), and both improved participants’ overall impression (P < .001). CONCLUSION: Three-dimensional neuroendoscopy and HD neuroendoscopy have differing but complementary effects on surgical performance, suggesting that neither alone can completely compensate for the lack of the other. There is therefore strong preclinical evidence to justify 3-D HD neuroendoscopy. ABBREVIATIONS: HD, high definition SD, standard definition
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Affiliation(s)
- Hani J Marcus
- *Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, United Kingdom; ‡The Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, United Kingdom
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Marcus HJ, Cundy TP, Hughes-Hallett A, Yang GZ, Darzi A, Nandi D. Endoscopic and keyhole endoscope-assisted neurosurgical approaches: a qualitative survey on technical challenges and technological solutions. Br J Neurosurg 2014; 28:606-10. [PMID: 24533591 PMCID: PMC4032589 DOI: 10.3109/02688697.2014.887654] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION The literature reflects a resurgence of interest in endoscopic and keyhole endoscope-assisted neurosurgical approaches as alternatives to conventional microsurgical approaches in carefully selected cases. The aim of this study was to assess the technical challenges of neuroendoscopy, and the scope for technological innovations to overcome these barriers. MATERIALS AND METHODS All full members of the Society of British Neurosurgeons (SBNS) were electronically invited to participate in an online survey. The open-ended structured survey asked three questions; firstly, whether the surgeon presently utilises or has experience with endoscopic or endoscope-assisted approaches; secondly, what they consider to be the major technical barriers to adopting such approaches; and thirdly, what technological advances they foresee improving safety and efficacy in the field. Responses were subjected to a qualitative research method of multi-rater emergent theme analysis. RESULTS Three clear themes emerged: 1) surgical approach and better integration with image-guidance systems (20%), 2) intra-operative visualisation and improvements in neuroendoscopy (49%), and 3) surgical manipulation and improvements in instruments (74%). DISCUSSION The analysis of responses to our open-ended survey revealed that although opinion was varied three major themes could be identified. Emerging technological advances such as augmented reality, high-definition stereo-endoscopy, and robotic joint-wristed instruments may help overcome the technical difficulties associated with neuroendoscopic approaches. CONCLUSIONS Results of this qualitative survey provide consensus amongst the technology end-user community such that unambiguous goals and priorities may be defined. Systems integrating these advances could improve the safety and efficacy of endoscopic and endoscope-assisted neurosurgical approaches.
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Affiliation(s)
- Hani J Marcus
- Department of Neurosurgery, Imperial College Healthcare NHS Trust , London , UK
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23
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Woodworth GF, Patel KS, Shin B, Burkhardt JK, Tsiouris AJ, McCoul ED, Anand VK, Schwartz TH. Surgical outcomes using a medial-to-lateral endonasal endoscopic approach to pituitary adenomas invading the cavernous sinus. J Neurosurg 2014; 120:1086-94. [PMID: 24527820 DOI: 10.3171/2014.1.jns131228] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT This study details the extent of resection and complications associated with endonasal endoscopic surgery for pituitary tumors invading the cavernous sinus (CS) using a moderately aggressive approach to maximize extent of resection through the medial CS wall while minimizing the risk of cranial neuropathy and blood loss. Tumor in the medial CS was aggressively pursued while tumor in the lateral CS was debulked in preparation for radiosurgery. METHODS A prospective surgical database of consecutive endonasal pituitary surgeries with verified CS invasion on intraoperative visual inspection was reviewed. The extent of resection as a whole and within the CS was assessed by an independent neuroradiologist using pre- and postoperative Knosp-Steiner (KS) categorization and volumetrics of the respective MR images. The extent of resection and clinical outcomes were compared for medial (KS 1-2) and lateral (KS 3-4) lesions. RESULTS Thirty-six consecutive patients with pituitary adenomas involving the CS who had surgery via an endonasal endoscopic approach were identified. The extent of resection was 84.6% for KS 1-2 and 66.6% for KS 3-4 (p = 0.04). The rate of gross-total resection was 53.8% for KS 1-2 and 8.7% for KS 3-4 (p = 0.0006). Six patients (16.7%) had preoperative cranial neuropathies, and all 6 had subjective improvement after surgery. Surgical complications included 2 transient postoperative cranial neuropathies (5.6%), 1 postoperative CSF leak (2.8%), 1 reoperation for mucocele (2.8%), and 1 infection (2.8%). CONCLUSIONS The endoscopic endonasal "medial-to-lateral" approach permits safe debulking of tumors in the medial and lateral CS. Although rates of gross-total resection are moderate, particularly in the lateral CS, the risk of permanent cranial neuropathy is extremely low and there is a high chance of improvement of preexisting deficits. This approach can also facilitate targeting for postoperative radiosurgery.
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Affiliation(s)
- Graeme F Woodworth
- Department of Neurological Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and
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24
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Charalampaki P, Igressa A, Mahvash M, Pechlivanis I, Schick B. Optimal invasive key-hole neurosurgery with a miniaturized 3D chip on the tip: Microendoscopic device. Asian J Neurosurg 2014; 8:125-31. [PMID: 24403954 PMCID: PMC3877498 DOI: 10.4103/1793-5482.121681] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: The goal of the performed study was to evaluate the possibility of a three-dimensional endoscope to become a combined microscope-endoscope device in one. We analyzed the ergonomy of the device, the implementation into the surgical workflow, the image quality, and the future perspectives such devices could have for the next generation of neurosurgeons. Materials and Methods: Within 6 months, 22 patients (10 male, 12 female, 20-65 age) underwent surgery in neuroaxis using the new 3D-microendoscope (ME). The new 3D-ME has (a) the ability to visualize the surgical field from out- to inside with all advantages offered by a microscope, and in the same moment, (b) its design is like a small diameter endoscope that allows stereoscopic views extracorporal, intracorporal, and panoramic “para-side” of the lesion. Results: In general, transcranial 3D-“microendoscopy” was performed in all patients with high-resolution 3D quality. No severe complications were observed intra- or postoperatively. With the addition of depth perception, the anatomic structures were well seen and observed. Conclusion: The 3D-microendoscopy is a very promising surgical concept associated with new technological developments. The surgeon is able to switch to a modern visualization instrument reaching the most optimal surgical approach without compromising safety, effectiveness, and visual information.
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Affiliation(s)
- Patra Charalampaki
- Department of Neurosurgery, Hospital Merheim, University of Witten-Herdecke, Cologne, Germany
| | - Alhadi Igressa
- Department of Neurosurgery, Hospital Merheim, University of Witten-Herdecke, Cologne, Germany
| | - Mehran Mahvash
- Department of Neurosurgery, Hospital Merheim, University of Witten-Herdecke, Cologne, Germany
| | - Ioannis Pechlivanis
- Department of Neurosurgery, Hospital Merheim, University of Witten-Herdecke, Cologne, Germany
| | - Bernhard Schick
- Department of Otorhinolaryngology, Saarland University Medical Center, Homburg/Saar, Germany
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25
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Liu JK, Schmidt RF, Choudhry OJ, Shukla PA, Eloy JA. Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery. Neurosurg Focus 2013; 32:E7. [PMID: 22655696 DOI: 10.3171/2012.5.focus1255] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Extended endoscopic endonasal approaches have allowed for a minimally invasive solution for removal of a variety of ventral skull base lesions, including intradural tumors. Depending on the location of the pathological entity, various types of surgical corridors are used, such as transcribriform, transplanum transtuberculum, transsellar, transclival, and transodontoid approaches. Often, a large skull base dural defect with a high-flow CSF leak is created after endoscopic skull base surgery. Successful reconstruction of the cranial base defect is paramount to separate the intracranial contents from the paranasal sinus contents and to prevent postoperative CSF leakage. The vascularized pedicled nasoseptal flap (PNSF) has become the workhorse for cranial base reconstruction after endoscopic skull base surgery, dramatically reducing the rate of postoperative CSF leakage since its implementation. In this report, the authors review the surgical technique and describe the operative nuances and lessons learned for successful multilayered PNSF reconstruction of cranial base defects with high-flow CSF leaks created after endoscopic skull base surgery. The authors specifically highlight important surgical pearls that are critical for successful PNSF reconstruction, including target-specific flap design and harvesting, pedicle preservation, preparation of bony defect and graft site to optimize flap adherence, multilayered closure technique, maximization of the reach of the flap, final flap positioning, and proper bolstering and buttressing of the PNSF to prevent flap dehiscence. Using this technique in 93 patients, the authors' overall postoperative CSF leak rate was 3.2%. An illustrative intraoperative video demonstrating the reconstruction technique is also presented.
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Affiliation(s)
- James K Liu
- Department of Neurological Surgery, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey 07101, USA.
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26
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Castelnuovo P, Battaglia P, Turri-Zanoni M, Volpi L, Bignami M, Dallan I. Transnasal skull base reconstruction using a 3-d endoscope: our first impressions. J Neurol Surg B Skull Base 2013; 73:85-9. [PMID: 23542468 DOI: 10.1055/s-0032-1311692] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 08/10/2011] [Indexed: 10/28/2022] Open
Abstract
Nowadays endoscopic skull base reconstruction is safely and effectively performed by means of two-dimensional (2-D) endoscopic technique. The aim of our study is to compare our 2-D experience with the novel 3-D technology in the field of skull base reconstruction techniques. In this study four patients treated with various kinds of planned duraplasty are included. The new 3-D technology was compared with the high-definition 2-D scopes during the different steps of the procedures. The 3-D endoscopic skull base reconstruction obtained primary closure without complications in all cases. According to the subjective opinion of experienced endosurgeons, this novel technique improved depth perception, distance and size estimation, ability to identify specific anatomic structures, and hand-eye coordination. The main drawbacks detected were inferior sharpness, contrast and lighting that impaired the application of the technique in narrow sinonasal spaces. According to our preliminary impressions, 3-D endoscopic skull base reconstruction is an effective and safe procedure and could represent a significant advantage for accurate managing of the skull base region.
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Affiliation(s)
- Paolo Castelnuovo
- Department of Otorhinolaryngology, University of Insubria, Varese, Italy
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27
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Felippu A, Mora R, Guastini L, Peretti G. Transnasal Approach to the Orbital Apex and Cavernous Sinus. Ann Otol Rhinol Laryngol 2013; 122:254-62. [DOI: 10.1177/000348941312200407] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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de Divitiis E. Endoscopic endonasal transsphenoidal surgery: from the pituitary fossa to the midline cranial base. World Neurosurg 2012. [PMID: 23182736 DOI: 10.1016/j.wneu.2012.11.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Enrico de Divitiis
- Department of Neurological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy.
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30
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Attia M, Kandasamy J, Jakimovski D, Bedrosian J, Alimi M, Lee DL, Anand VK, Schwartz TH. The Importance and Timing of Optic Canal Exploration and Decompression During Endoscopic Endonasal Resection of Tuberculum Sella and Planum Sphenoidale Meningiomas. Oper Neurosurg (Hagerstown) 2012; 71:58-67. [DOI: 10.1227/neu.0b013e318258e23d] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Suprasellar meningiomas often invade the optic canals (OCs). The feasibility of removing these tumors through a minimal-access endonasal route has been demonstrated, but the importance, safety, and timing of OC exploration and decompression are not well described.
OBJECTIVE:
To create a simple decision-tree algorithm for OC exploration and decompression in the endonasal endoscopic surgery for planum sphenoidale and tuberculum sella meningiomas.
METHODS:
We identified a consecutive series of 8 planum sphenoidale and tuberculum sella meningiomas resected endonasally. “Late” OC exploration and decompression was performed in 4 of 8 patients. The extent of resection, visual outcome, and complications were recorded.
RESULTS:
Five patients had OC invasion on magnetic resonance imaging. Endoscopic inspection did not reveal additional OC invasion. The OC was opened bilaterally in 2 patients and unilaterally in 2 patients. Gross total resection was achieved in 6 of 7 patients in whom it was the goal. Vision improved in 3 patients (3 of 3 OCs opened) and was stable in 4 (1 of 4 OCs opened). In 1 patient, the bitemporal hemianopsia improved, but there was unilateral deterioration (no OC invasion) because the tumor was extremely adherent to 1 optic nerve. After an average follow-up of 20.9 months, all patients had an Glasgow Outcome Scale score of 5, and there were no cerebrospinal fluid leaks.
CONCLUSION:
Exploration and decompression of the OC are feasible, safe, and important to optimize visual outcome and to minimize recurrence in planum sphenoidale and tuberculum sella meningiomas resected endonasally. It may not be important to open the canal early during surgery because tumor debulking can be performed without manipulating the optic nerves. Early decompression, however, is technically feasible.
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Affiliation(s)
| | | | | | | | | | - Dennis L.Y. Lee
- Departments of Otolaryngology, and
- Department of Ear, Nose and Throat, United Christian Hospital, affiliated unit of the Chinese University of Hong Kong, Hong Kong
| | | | - Theodore H. Schwartz
- Departments of Neurosurgery
- Departments of Otolaryngology, and
- Departments of Neurology and Neuroscience, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
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Heath MD, Cohen-Gadol AA. Intraoperative stereoscopic 3D video imaging: pushing the boundaries of surgical visualisation and applications for neurosurgical education. Br J Neurosurg 2012; 26:662-7. [PMID: 22448729 DOI: 10.3109/02688697.2012.672057] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE In the past decades, we have witnessed waves of interest in three-dimensional (3D) stereoscopic imaging. Previously, the complexity associated with 3D technology led to its absence in the operating room. But recently, the public's resurrection of interest in this imaging modality has revived its exploration in surgery. Technological advances have also paved the way for incorporation of 3D stereoscopic imaging in neurosurgical education. METHODS Herein, the authors discuss the advantages of intraoperative 3D recording and display for neurosurgical learning and contemplate its future directions based on their experience with 3D technology and a review of the literature. RESULTS Potential benefits of stereoscopic displays include an enhancement of subjective image quality, proper identification of the structure of interest from surrounding tissues and improved surface detection and depth judgment. Such benefits are critical during the intraoperative decision-making process and proper handling of the lesion (specifically, for surgery on aneurysms and tumours), and should therefore be available to the observers in the operating room and residents in training. Our trainees can relive the intraoperative experience of the primary surgeon by reviewing the recorded stereoscopic 3D videos. CONCLUSION Proper 3D knowledge of surgical anatomy is important for operative success. 3D stereoscopic viewing of this anatomy may accelerate the learning curve of trainees and improve the standards of surgical teaching. More objective studies are relevant in further establishing the value of 3D technology in neurosurgical education.
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Affiliation(s)
- Michael D Heath
- School of Informatics, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
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Castelnuovo P, Dallan I, Locatelli D, Battaglia P, Farneti P, Tomazic PV, Seccia V, Karligkiotis A, Karligktios A, Pasquini E, Stammberger H. Endoscopic transnasal intraorbital surgery: our experience with 16 cases. Eur Arch Otorhinolaryngol 2012; 269:1929-35. [PMID: 22237761 DOI: 10.1007/s00405-011-1917-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Accepted: 12/28/2011] [Indexed: 01/24/2023]
Abstract
The objective of the study is to present our multicentric experience on intraorbital lesions managed by means of an endonasal endoscopic approach. The study design used was multi-institutional retrospective review. We collected data on 16 intraorbital medially-located lesions, all managed by means of an endonasal route, treated in four different skull base centers. We retrospectively reviewed the technical details, complications, histology, and general outcome. The endoscopic endonasal approach was effective in removing completely intraorbital extra-intraconal tumors in 8 cases, in performing biopsies for histological diagnosis in 6 intraorbital intraconal tumors, and in draining 1 extraconal abscess. No major complications were observed; in particular, there was no optic nerve damage. Minor, temporary complications (diplopia) were seen in 3 cases; only 2 patients experienced a permanent diplopia related to medial rectus muscle impairment, in 1 case associated with enophthalmos. Our preliminary multi-centric clinical experience suggests that medially located intraorbital lesions, and in particular the infero-medial ones, can be successfully and safely managed by such an approach. The well-known advantages of the endoscopic techniques, namely the lack of external scars, less bleeding, shorter hospital stay, and fewer complications, are confirmed.
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Affiliation(s)
- Paolo Castelnuovo
- ENT Unit, Azienda Ospedaliero-Universitaria Ospedale di Circolo e Fondazione Macchi, Varese, Italy
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