Combined Exoscopic and Endoscopic Technique for Craniofacial Resection

Combined simultaneous endoscopic endonasal and transcranial surgery using high-definition three-dimensional exoscope for malignant tumors of the anterior skull base

BACKGROUND

Advanced surgical interventions are required to treat malignancies in the anterior skull base (ASB). This study investigates the utility of endoscopic endonasal and transcranial surgery (EETS) using a high-definition three-dimensional exoscope as an alternative to traditional microscopy.

METHODS

Six patients with carcinomas of varying histopathologies underwent surgery employing the EETS maneuver, which synchronized three distinct surgical modalities: harvesting of the anterolateral thigh flap, initiation of the transnasal technique, and initiation of the transcranial procedure.

RESULTS

The innovative strategy enabled successful tumor resection and skull base reconstruction without postoperative local neoplastic recurrence, cerebrospinal fluid leakage, or neurological deficits.

CONCLUSION

The integration of the exoscope and EETS is a novel therapeutic approach for ASB malignancies. This strategy demonstrates the potential of the exoscope in augmenting surgical visualization, enhancing ergonomics, and achieving seamless alignment of multiple surgical interventions. This technique represents a progressive shift in the management of these complex oncological challenges.

A Combined Exoscopic and Endoscopic Approach for Radical Temporal Bone Resection and Usefulness of the Endoscopic Approach to the Medial Aspect of the Temporal Bone

Radical temporal bone resection (TBR) for lateral skull base malignancies is technically challenging because of the vital anatomical structures located at the medial part of the temporal bone and their limited exposure. A possible solution is to adopt an additional endoscopic approach for medial osteotomy to reduce blind spots. The authors aimed to describe a combined exoscopic and endoscopic approach (CEEA) for cranial dissection in radical TBR and to determine the usefulness of the endoscopic approach to the medial aspect of the temporal bone. Having utilized the CEEA in for cranial dissection in radical TBR since 2021, the authors included 5 consecutive patients who underwent the procedure between 2021 and 2022. All surgeries were successful and resulted in no significant complications. The additional use of an endoscope improved visualization of the middle ear in 4 patients and that of the inner ear and carotid canal in 1 patient, enabling precise and safe cranial dissection. Furthermore, surgeons experienced reduced intraoperative postural stress with CEEA than with a microscopic approach. The main advantage of CEEA in radical TBR was the extension of the viewing angles of the endoscope, which allowed observation of the medial aspect of the temporal bone and limited tumor exposure and injury to vital structures. Given the other benefits of exoscopes and endoscopes, including compact size, ergonomics, and surgical field accessibility, CEEA proved to be an efficient treatment option for cranial dissection in radical TBR.

Hybrid endoscopic-microscopic surgery for dumbbell-shaped trigeminal schwannoma: case report and literature review

Background

The surgery of dumbbell-shaped trigeminal neurinomas (TN) remains one of the most formidable challenges for neurosurgeons because of its location at great depth in the cranium and proximity to vital neurovascular structures.

Objective

To describe the feasibility of a novel technique, synchronous endoscopy and microsurgery via combined far-lateral supracerebellar-infratentorial and subtemporal approach, for resection of this rare entity.

Methods

A 53-year-old women presented with progressive left facial numbness for 2 months. Imaging examinations revealed a left-sided dumbbell-shaped TN afflicting the middle and posterior cranial fossa, and a single-stage combined multiportal endoscopic microscopic approach was attempted for tumor resection. Initially, a purely endoscopic far-lateral supracerebellar-infratentorial approach was used to remove the posterior fossa component with the aid of tentorium incision. Subsequently, a microsurgical subtemporal interdural approach was performed for the exposure and separation of tumor within the Meckel cave. Finally, the tumor was pushed into the porus trigeminus under microscopy, thus enabling tumor extraction for the supracerebellar space under endoscopy without anterior petrosectomy.

Results

The patient evolved favorably without additional neurological deficit after surgery, and postoperative imaging showed a complete resection of the tumor.

Conclusion

We describe the first account of multi-corridor hybrid surgery for removal of TN in a dumbbell configuration, which enables one-stage total tumor removal with minimal added morbidity. This hybrid technique may be an effective piece of the surgeon's armamentarium to improve outcomes of patient with complex skull-base lesions. Further studies with larger case numbers are warranted to confirm the prognostic significance of this technique.

High-Definition 3D Exoscope-Assisted Barbed Pharyngoplasty for OSAS and Snoring: Better Than Live

Recently, a high-definition 3D exoscope (VITOM), a new magnification system that provides a 3D image of the surgical field, has been introduced. This study aims to describe the first use of VITOM 3D technology in Barbed Pharyngoplasty (BP) for Obstructive Sleep Apnea (OSA). VITOM 3D technology is used to support visualization during BP in a male patient affected by severe OSA with a circular palatal collapse pattern at drug-induced sleep endoscopy. During the surgical procedure, this approach markedly improves the visualization of the surgical field through anatomic details of the oral cavity, facilitating surgical dissection and enhancing the teaching environment. It allows for a better involvement and more interactions during the surgery, as scrubbed and assistant nurses can see the surgical field and anticipate the surgeon's choice of instrument. VITOM 3D technology, by combining a telescope with a standard endoscope, has been successfully used in various surgical disciplines and could be very useful, especially in teaching hospitals. VITOM 3D can guarantee "a real immersive" surgical experience for all participants in the operating room. Economic and efficacy studies would be conducted to support the use of a VITOM-3D exoscope in common clinical practice.

The Current State of Visualization Techniques in Endoscopic Skull Base Surgery

Skull base surgery has undergone significant progress following key technological developments. From early candle-lit devices to the modern endoscope, refinements in visualization techniques have made endoscopic skull base surgery (ESBS) a standard practice for treating a variety of conditions. The endoscope has also been integrated with other technologies to enhance visualization, including fluorescence agents, intraoperative neuronavigation with augmented reality, and the exoscope. Endoscopic approaches have allowed neurosurgeons to reevaluate skull base neuroanatomy from new perspectives. These advances now serve as the foundation for future developments in ESBS. In this narrative review, we discuss the history and development of ESBS, current visualization techniques, and future innovations.

High Definition Three-Dimensional Exoscope (VITOM 3D) in E.N.T. Surgery: A Systematic Review of Current Experience

Over the last decade, technological growth has developed new devices for more precise surgery based on improved maneuverability, minimally invasive approaches, and magnification of the operating field. In this context, the exoscope has opened a new phase for more accurate and safer microsurgery, improving the perception of the volume of objects and the depth of structures for planning, targeting, and controlling fine movements. The exoscope could be used for middle ear, transcanal, transmastoid, and craniotomy procedures that require two-handed dissection, both to perform both totally VITOM-based techniques and coupled to traditional procedures with an operating microscope or endoscope. In addition, the VITOM 3D system allows the surgeon to work with high-definition images, which is essential in facial nerve surgery or submandibular salivary stone or tear surgery approaches, where magnification plays a fundamental role in surgical success and in reducing operating times. The 3D exoscope approach could also be included in traditional transoral procedures for oropharyngeal carcinoma. The exoscope may provide a relevant approach in teaching surgeons and nurses, allowing adequate training in non-oncological surgical procedures such as a tonsillectomy or lateral pharyngoplasty.