Morphometric measurements of the anterior skull base for endoscopic transoral and transnasal approaches

The objective of this study is to determine the bony limits of the transnasal and transoral approaches to the anterior skull base. The data we present are meant to assist surgeons in preoperative planning for lesions of the sella, clivus, foramen magnum, and odontoid. Using precise measurements undertaken on 41 high-resolution computed tomography scans from patients at the University of Pennsylvania without any history of sinus or sellar pathology, we sought to define the bony limits of transoral and transnasal approaches. Direct measurements and calculated angles were used to assess the dimensions of the anterior skull base. Using our measurements, a transnasal approach can reach an average of 22.5 mm below the plane of the hard palate to the body of C2, and a transoral route can reach 38 mm above the basion along the length of the clivus. Analysis of variance demonstrated no significant differences when subjects were grouped based on race or gender. The measurements outlined within this article help to define the relative dimensions necessary for adapted transoral and transnasal skull base surgeries.     

Intravesical explosions during transurethral endoscopic procedures

Every Urologist, during the course of fulguration treatment of bladder tumours, has at some time or another experienced small intravesical explosions usually manifesting as a “pop”. Major intravesical explosions are rare but potentially devastating complications of transurethral endoscopic resections. The damage to the bladder can range from small mucosal tears to bladder rupture, which can either be intraperitoneal (requiring laparotomy and open bladder repair) or extraperitoneal. We review the literature on intravesical explosions to determine the aetiology of these explosions and suggest strategies to prevent these. A comprehensive literature search was performed using Medline and Ovid to obtain information using search terms: intravesical explosions, transurethral procedures, endoscopic procedures, diathermy Intravesical explosions occur due to the production of explosive gases during use of diathermy on human tissues. The most dangerous combination is hydrogen and oxygen. Hydrogen alone is not explosive and it only becomes explosive when admixed with oxygen. Oxygen is not produced in sufficient quantity during diathermy to cause explosions but can enter into the bladder from the atmosphere during endoscopic procedures. Careful operative technique (correct use of the Ellick evacuator bulb and reducing the frequency of manual irrigations of the bladder) with minimisation of the operative time and using the coagulation current at moderate power as well as judicious coagulation of tissues can reduce the risk of this dangerous complication arising     

The endoscopic supraorbital approach to tumors of the middle cranial base

BACKGROUND: Access to tumors of the middle cranial base has traditionally required wide surgical exposures via open craniotomies. These open techniques often require the use of potentially disfiguring skin incisions and are often associated with a significant degree of brain retraction and potential morbidity. We report our experience with the use of a minimally invasive supraorbital endoscopic approach through the eyebrow for excision of middle cranial base tumors in 2 cases. METHODS: We describe 2 patients with large-sized middle cranial fossa tumors (a medial sphenoid wing meningioma measuring 6 x 4 cm and a recurrent right cavernous sinus meningioma measuring 4 x 3.5 cm) that were entirely removed via a fully endoscopic supraorbital approach using a 1.5-cm keyhole craniotomy. CONCLUSION: These cases demonstrate how the application of endoscopic techniques to surgery of the middle cranial base can eliminate the need for traditional open techniques without compromising surgical success.     

MED治疗腰椎间盘突出症手术规则探讨

目的探讨显微内窥镜切除术(MicroEndoscopicDiscectomyMED)治疗腰椎间盘突出症的手术规则。旨在正确认识这一新的技术,提高手术疗效。方法总结192例MED治疗腰椎间盘突出症的临床资料。结果192例均获得随访,随访时间6个月～3年,按陆裕朴疗效评定标准优138例;良42例;可9例;差3例。优良率93.7%。结论MED手术规则1、术者必须有娴熟的腰椎开放手术的经验,熟练地镜下手术操作技巧。2、遵循微创的原则,严格选择手术适应证。3、选择正确的术式及入路,术中突发情况的处理,术后治疗效果的估计等是手术成功的关键。4、不断地改进MED器械,是扩大手术适应症的唯一途径。只有正确认识到MED的手术规则,才能使这一技术健康发展。     

Intraoperative cranial nerve monitoring during posterior skull base surgery

Intraoperative monitoring of neurophysiologic function is rapidly evolving as an important adjunct during skull base surgery to reduce the incidence of neurologic deficit. Facial nerve monitoring is an excellent model, since electrical and mechanical evoked potentials can be directly presented to the surgeon in real-time through an acoustic loudspeaker display. The lower cranial nerves may also be monitored using similar electromyographic techniques. Auditory system monitoring is more difficult due to the low amplitude response that requires averaging and filtering to extract the evoked potential. In conjunction with auditory monitoring, improved hearing preservation may be further enhanced by concomitant facial nerve monitoring, since the surgeon is alerted to traumatic manipulations that may affect both facial and cochlear nerves. Techniques and interpretative issues are presented to maximize the efficacy and safety of cranial nerve monitoring.     

A new powered endoscope holding arm for endoscopic surgery of the cranial base.

Over the past 20 years endoscopy has become an essential part of nearly all surgical specialities. In the field of skull base surgery recent articles describe new applications and highlight improved results in pituitary adenoma removal, vascular decompression surgery, and in the resection of many other skull base tumors. The strength of the endoscope in skull base surgery lies in its ability to see behind bony apices and neurovascular structures, which normally obscure the view of the operating microscope. Paramount to the success of the endoscope in skull base and pituitary surgery is the ability to secure the arm in position. Operating in the confined spaces of the skull, the instability and difficult adjustment of currently available endoscope holding arms is cumbersome for the surgeon and dangerous to the patient. Many surgeons have commented that the currently available endoscope holding arms are inadequate for contemporary applications of endoscopic skull base surgery. In this article we describe a new pneumatically powered endoscope holding arm, which provides the level of stability and ease of adjustment necessary for current and future applications of endoscope skull base surgery.     

Giant cranial base tumours

Summary Thirty-three patients with giant (diameter4.5 cm) cranial base tumours who underwent surgery at the Hadassah Hospital over the last ten years are described. Twenty-three of the patients had meningiomas, 4 neurinomas, one giant cell tumour, one haemangiopericytoma, and 4 had malignant meningiomas. Four tumours were at the cerebellopontine angle, 9 within the anterior cranial fossa, 8 petroclival, 8 on middle fossa floor, and 4 along the sphenoid ridge.The average pre-operative symptom duration was 31 months, range 3–180 months.Nineteen patients had a radical tumour resection, 10 subtotal, and 4 a partial resection on an average 1.7 operations per patient.The mean follow-up period from the first operation was 39 months (range 2–120). There was no mortality peri-operatively or during the follow-up period. The mean pre-operative Karnofsky score was 68 and at the last follow-up 76. There was no correlation between histology and degree of resection, complications, or status at last follow-up.The best resections (92% radical) and outcome (mean Karnofsky 92) with the least number of operations (mean 1.4) were in the anterior fossa and along the sphenoid wing. The patients requiring the most operations (mean 2.1), having the smallest percentage of radical resections (25%) and the least favourable outcomes (mean Karnofsky 52) were those with petroclival tumours.Patients with giant cranial base tumours have a good overall long-term prognosis, but especially those with petroclival tumours challenge us to improve our techniques.     

Endoluminal management of colon perforations during advanced endoscopic procedures

BackgroundAdvanced endoscopic procedures are gaining attraction despite a steep learning curve, need for high dexterity, and potential complications. Colonic perforation is the most concerning adverse event during advanced endoscopic procedures. This study presents our experience on endoluminal management of iatrogenic colonic perforations.MethodsPatients who underwent advanced endoscopic procedures at a quaternary center from 2016 to 2021 were identified. Patients who had colonic perforations during advanced procedures and treated with endoscopic closure/clipping were included. Retrospective chart review was performed. Figures represent frequency (proportion) or median (interquartile range/range).ResultsThere were 22 (2.3%) immediate colonic perforations treated with endoscopic clipping out of 964 advanced endoscopic resections. The median age was 64 (interquartile range = 57–71) years and 50% of the patients were female; 16 (73%) resections were proximal to the splenic flexure. Median polyp size was 36 (20–55) mm. Closure was performed with endoscopic clips in 18 (82%) patients, and over-the-scope clips in 4 patients. Median hospital stay was 0.8 (0–4) days, and 13 (59%) patients were discharged the same day; 2 patients were admitted to the emergency department ≤24 hours of procedure. They underwent subsequent laparoscopic suture repair the same day. No one had segmental colon resection, and there were no complications within postoperative 30 days. Pathology revealed 9 (41%) tubular adenomas, 7 (32%) tubulovillous adenomas, 6 (27%) sessile serrated lesions, and no adenocarcinoma. No recurrence was observed with median follow-up of 24 months (range = 0–90 months).ConclusionEndoscopic management is an effective treatment approach for the management of iatrogenic colonic perforations.     

A simple way to take pictures during endoscopic procedures

PURPOSE: We describe a new method of taking pictures from endoscopic images using a digital photo camera coupled to the endoscopic lens without an adapter. MATERIALS AND METHODS: We used a digital camera with 3.3 megapixel resolution and 6 x optical zoom. The camera was coupled to the endoscopic lens with no special adapter. The image was accompanied through the LCD (liquid crystal display) visor, and the picture was taken with the flash button on and with no macro resource. The image was then enlarged by optical and digital zoom before being easily stored in photo files at the personal computer. RESULTS: The quality of the photos obtained by this method was at least similar to that of traditional photos, and the data were promptly stored. CONCLUSIONS: We describe a simple method of taking pictures from endoscopic images with the additional advantage of a facility to edit and store the photographs.     

Operative monitoring of hand and axillary temperature during endoscopic superior thoracic sympathectomy for the treatment of palmar hyperhidrosis.

OBJECTIVE: To find out how much the temperature in the palm rises after upper thoracic sympathectomy for palmar hyperhidrosis, and correlate the temperature with the outcome. DESIGN: Retrospective study. SETTING: University hospital, Spain. SUBJECTS: 73 patients (34 women and 39 men, age range 16-42 years, mean 26) who were operated for palmar hyperhidrosis between 1 January 1995 and 31 December 1997. INTERVENTIONS: Bilateral thoracic endoscopic sympathectomy during which the temperature was monitored on the skin of both axillae and thenar eminences, and in the oesophagus. MAIN OUTCOME MEASURES: Morbidity, alleviation of hyperhidrosis, recurrence rate, and differences in temperature postoperatively. RESULTS: There was minor bleeding during operation in 25 cases (34%), but in only 4 was it sufficient to require insertion of a drain; 2 patients developed transient Homer's syndrome; but the most common complication was compensatory hyperhidrosis (n = 52, 71%). In only 5 was this other than mild and required treatment with aluminium chloride in ethanol 25%. Palmar hyperhidrosis was alleviated in all cases, axillary sweating was considerably improved, and there was improvement in the feet in 56 (77%). There were 5 recurrences, all on the right side, during a mean follow up of 9 months (range 2-36), but in no case was the sweating severe. In almost all cases the temperature of the palm was less than that of the axilla before operation by a mean (SD) of 0.9 (0.3) degrees C. The rise in temperature varied from 1.7 (0.4) degrees C to 2.6 (0.4) degrees C. In the 5 patients who developed recurrences the increase was less (0.5 (0.4) degrees C). CONCLUSION: Thoracic endoscopic sympathectomy is safe, simple, and effective in treating palmar hyperhidrosis that has not responded to conservative treatment. Intradermal monitoring is an accurate and cost-effective way of monitoring temperature during operation. Although it is essential to achieve a rise in temperature of 1 degrees C, our most important finding was that the final temperature in both hands and axillae should be above 35 degrees C and as near as possible to 36 degrees C.     

Operative procedures for choledochal cyst

Fifty one operations for choledochal cyst were carried out upon 46 patients: 41 as a primary operation and 10 as reoperation. An excision of choledochal cyst with hepaticojejunostomy in Roux-en-Y fashion at the second laparotomy gave a favorable results in all patients who suffered recurrent symptoms after the previous anastomotic procedure. Comparing operation time, blood loss and operative results of the reoperations with those of the primary, it was concluded that all choledochal cyst should be excised at the first operation unless other reason avoiding excision exists. Hepatic porto-jejunostomy is recommended for choledochal cyst with an associated distal atresia and the hypoplastic hepatic duct. Presensed partly before the 75th annual meeting of Japan Surgical Society in Okayama, Japan in 1975 and the third meeting of Asian Association of Pediatric Surgery in New Dehli, India in 1976.     

甲状腺微小癌手术方式探讨

目的探讨甲状腺微小癌的外科手术方式。方法回顾性分析116例甲状腺微小癌的外科手术方式及效果。结果 116例中,有诸多不同的手术方式,包括甲状腺患侧叶部分切除术、甲状腺次全切除术、甲状腺叶切除术等,术后复发或转移与手术的范围密切相关。本组4例术后复发转移者均为患侧叶部分切除者,占该术式的44.4%;其他术式术后无复发转移者。结论应依据患者病变的不同部位及数目(单发/多发)采用相应的手术方式。推荐行患侧腺叶+峡部切除,或甲状腺次全/近全切除或加行患侧中央区淋巴结清扫术。     

Image-guided endoscopic transnasal removal of recurrent pituitary adenomas

OBJECTIVE: To assess the role that neuronavigation plays in assisting endoscopic transsphenoidal reoperations for recurrent pituitary adenomas. METHODS: During a 45-month period, 19 endoscopic endonasal transsphenoidal reoperations were performed for recurrent pituitary adenomas. In 11 of 19 patients, the procedure was performed with the aid of an optically guided system. Clinical records were reviewed retrospectively, with attention to the following: comparison of baseline clinical data, the duration of surgery, and the postoperative course and complications of both image-guided and non-image-guided endoscopic reoperations. In addition, to test the reliability of the neuronavigation system, we made measurements of intraoperative accuracy in five additional transnasal endoscopic procedures in "virgin" noses and sphenoidal sinuses. RESULTS: In both groups studied, we found no difference with regard to either morbidity or mortality, which were null. The mean setup time was 13 minutes shorter in non-image-guided procedures (P = 0.021), and the operative time was 36 minutes shorter in image-guided procedures (P = 0.038). No other statistically significant differences were found between the two groups. In all cases, we found that the system performed without malfunction. Continuous information regarding instrument location and trajectory was provided to the surgeon. Measurements of the intraoperative accuracy in the axial, coronal, and sagittal planes indicated a mean intraoperatively verified system error of 1.6 +/- 0.6 mm. CONCLUSION: Neuronavigation can be applied during endonasal transsphenoidal endoscopic surgery and requires a minimal amount of time. It makes reoperation easier, faster, and probably safer.     

Abandoned endoscopic procedures

Intraoperatively, it may be prudent at times to abandon or defer the intended therapeutic procedure due to adverse prevailing conditions. A decision to abandon or defer an endoscopic procedure would necessarily result in less morbidity compared with conventional open surgery. A retrospective review of endoscopic procedures that were abandoned or deferred and subsequent patient outcomes were noted. Between January 1998 to May 2003, 48 procedures out of a total of 11,550 endoscopic surgical procedures had to be abandoned. Previously unsuspected intraabdominal malignancy was the cause in 32 patients. Anesthesia-related problems led to the decision in 6 patients. Coincidental tuberculosis and failure in accessing the target organ were the cause in two patients each. An ectopic gallbladder, an absent gallbladder, a pancreatic phlegmon, and a failure to achieve proper single-lung ventilation led to the decision in one patient each. In two patients, presence of dense intraabdominal adhesions that precluded further progress led the surgeon to abandon the surgery. The patients with intraabdominal malignancy were staged for their disease and treated accordingly. Nine patients without malignancy who had their operation deferred due to diverse reasons were operated on a later date, whereas 4 patients were lost to follow-up. The 9 patients who underwent operation at a later date are well on follow-up. Four patients with intraabdominal malignancy died, whereas the others are well in follow-up after being treated according to the stage of their disease. Certain adverse situation encountered intraoperatively may lead the surgeon to change the approach to surgery and abandon the procedure. He may consider operation at a suitable time later or consider a different treatment altogether. The morbidity consequent to such a decision is much less if the operative approach is an endoscopic one.     

Classification and surgical approaches for transnasal endoscopic skull base chordoma resection: a 6-year experience with 161 cases

The aim of this study is to retrospectively analyze 161 cases of surgically treated skull base chordoma, so as to summarize the clinical classification of this tumor and the surgical approaches for its treatment via transnasal endoscopic surgery. Between August 2007 and October 2013, a total of 161 patients (92 males and 69 females) undergoing surgical treatment of skull base chordoma were evaluated with regard to the clinical classification, surgical approach, and surgical efficacy. The tumor was located in the midline region of the skull base in 134 cases, and in the midline and paramedian regions in 27 cases (extensive type). Resection was performed via the transnasal endoscopic approach in 124 cases (77 %), via the open cranial base approach in 11 cases (6.8 %), and via staged resection combined with the transnasal endoscopic approach and open cranial base approach in 26 cases (16.2 %). Total resection was achieved in 38 cases (23.6 %); subtotal resection, 86 cases (53.4 %); partial resection of 80–95 %, 29 cases (18 %); and partial resection <80 %, 8 cases (5 %). The clinical classification method used in this study seems suitable for selection of transnasal endoscopic surgical approach which may improve the resection degree and surgical efficacy of skull base chordoma. Gross total resection of skull base chordoma via endoscopic endonasal surgery (with addition of an open approach as needed) is a safe and viable alternative to the traditional open approach.     

The frontal cortex is activated during learning of endoscopic procedures

Background

To date, several training and evaluation systems for endoscopic surgery have been developed, such as virtual-reality simulators and box trainers. However, despite current advances in these objective assessments, no functional brain studies during learning of endoscopic surgical skills have been carried out. In the present study, we investigated cortical activation using near-infrared spectroscopy (NIRS) during endoscopic surgical tasks.

Study design

A total of 21 right-handed subjects, comprising 4 surgical experts, 4 trainees, and 13 novices, participated in the study. Suturing and knot-tying tasks were performed in a box trainer. Cortical activation was assessed in all subjects by task-related changes in hemoglobin (Hb) oxygenation using NIRS.

Results

In surgical experts and novices with no experience of endoscopic surgical training, we found no changes in oxy-Hb, deoxy-Hb or total-Hb levels in any of the frontal channels. In surgical trainees and one novice with experience of endoscopic surgical training, we found significant increases in oxy-Hb and total-Hb levels in most of the frontal channels. There were significant differences in oxy-Hb and total-Hb levels in CH-19 between surgical experts and trainees (p = 0.02 for both), and between surgical trainees and novices with no experience of endoscopic surgical training (p = 0.008 for both). Furthermore, additional training increased oxy-Hb levels in the frontal cortex of novices with no experience of endoscopic surgical training but had no such effect on surgical experts.

Conclusions

The present data suggest that NIRS is a feasible tool for assessing brain activation during endoscopic surgical tasks, and may have a large impact on the future development of teaching, training, and assessment methods for endoscopic surgical skills.