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Endoscope-assisted supraorbital approach to the retroinfundibular area: a cadaveric study

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Abstract

The purpose of this study is to investigate and evaluate the exposure and maneuverability of this areas provided by an endoscope-assisted supraorbital approach and to compare that to a microscopic supraorbital approach. We exposed microscopically the optico-carotid and the infrachiasmatic windows after a supraorbital craniotomy executed using an eyebrow incision. We then proceeded to explore the retroinfundibular area using these two windows either using the microscope alone or using the endoscope–microscope combination where the microscope was used to (1) guide instrument and endoscope insertion into the surgical field, and (2) explore (with microscopic 3-d vision) subsegments of the endoscopic field of view. We compared the exposure and surgical maneuverability of the approach utilizing the microscopic mode alone with the endoscope-assisted mode. We evaluated the exposure and the surgical maneuverability of key anatomical structures of the retroinfundibular area. The structures evaluated included the diaphragma sellae, the dorsum sellae, the posterior clinoid process, the pituitary stalk, the mammillary bodies, the tuber cinereum, the oculomotor nerves, the basal pons, the upper trunk of the basilar artery, the superior cerebellar arteries, the posterior cerebral arteries, the posterior communicating arteries and the basilar bifurcation. The exposure and the surgical maneuverability were significantly higher in the endoscope-assisted mode (P < 0.0001). Based on our study, the endoscope-assisted supraorbital retroinfundibular approach is associated with larger exposure and maneuverability than the pure microscopic approach. Further clinical information is required to verify the results of this study.

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Acknowledgments

We thank Mr. Mark Whitmer and Mrs. Michelle Whitmer for collecting the embalmed heads used in our project. We also appreciate the Dr. Jun Zhang and Dr. Xiang-Yu Yang who set up the protocol for the head scanning.

Disclosure

The authors have no personal financial or institutional interest/conflict with any of the drugs, materials, or devices described in this article.

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Authors and Affiliations

  1. Department of Neurological Surgery, Ohio State University Medical Center, N1025 Doan Hall, 410 W. 10th Avenue, Columbus, OH, 43210, USA

    Chi-Tun Tang, Nishanta B. Baidya & Mario Ammirati

  2. Department of Neurological Surgery, Tri-service General Hospital/ National Defense Medical Center, Taipei, Taiwan

    Chi-Tun Tang

Authors
  1. Chi-Tun Tang
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  2. Nishanta B. Baidya
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  3. Mario Ammirati
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Corresponding author

Correspondence to Mario Ammirati.

Additional information

Comments

Waleed Azab, Safat, Kuwait

The inherent anatomical complexity, depth, and importance of the neural and vascular structures around the retroinfundibular area make surgery of this area very challenging. Despite the multitude of surgical corridors available, no single approach is actually ideal to tackle lesions situated therein. In this cadaveric study, Dr. Ammirati and his group innovatively use a quantitative method to evaluate the feasibility of utilizing an endoscope-assisted approach and to compare it to a standard microscopic supraorbital keyhole approach to this anatomical region. This work expands the horizon of skull-base surgery and adds to the literature on endoscope-assisted microneurosurgery; a field that is gaining popularity among skull-base surgeons and is indeed worth precise evaluation through cadaveric studies before clinical application.

Ricardo Ramina and Luis Fernando Moura da Silva Jr, Curitiba, Brazil

The authors provide a well-written and well-illustrated cadaveric study on the advantages of endoscopic-assisted approach to the retroinfundibular area. They compared exposure and maneuverability of this difficult region using two surgical approaches: the pure supraorbital microsurgical approach and the supraorbital microsurgical endoscopic-assisted approach.

A good description of all-surgical steps evaluating the exposure of important anatomical structures is presented. The use of endoscope enhances the visualization of the retrosellar structures, but surgical dissection of some vital structures remains limited especially in cases of small lesions or aneurysms when there is limited space for surgical dissection. As the authors stated, positioning and any movement of the endoscope should be performed under microscopic view to avoid damage to vital anatomic structures. This study contributes with important information for the surgical approaches of this challenging region of the brain.

I. Erol Sandalcioglu, Essen, Germany

Tang et al. performed an interesting cadaveric study comparing the microscopic and endoscopic-assisted approach and exposure of the retroinfundibular area after supraorbital eyebrow incision. Different windows were used via this subfrontal approach. Exposure as well as maneuverability were assessed and compared. They point out that the endoscope-assisted mode provides more information, a better visualization and maneuverability of the neurovascular structures.

The fact of better visualization by increased illumination and magnification of the visual field is well described, especially in cases with deep-seated lesions and even near highly eloquent neuronal structures as the brainstem (1).

Despite the advantages of endoscopy in microsurgical procedures, the present study emphasizes the potential risks of the endoscope if used to assist microsurgery, which is, in my opinion, a very important issue. They stress that holding devices and handling during microscopic introduction of the endoscope bears an increased risk to damage important neurovascular structures. Furthermore, the authors point out the impaired surgical view by even mild discoloration of the CSF, thus, bleeding control during surgery is significantly impaired.

However, the use of the endoscope in neurosurgical procedures as an additional tool can help us to improve our results. Particularly for anterior and posterior fossa skull-base lesions, the introduction of 30° and 70° high definition endoscopes, e.g., might improve the detection of residual tumor, which cannot be visualized by the 3D microscopic view alone.

Further clinical studies are necessary, especially the validation of recently introduced 3D endoscopes in neurosurgical procedures, which is currently under clinical evaluation at our institution.

References

1. Sandalcioglu IE, Wiedemayer H, Secer S, Asgari S, Stolke D. (2002 Mar) Surgical removal of brain stem cavernous malformations: surgical indications, technical considerations, and results. J Neurol Neurosurg Psychiatry 72(3):351–5.

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Tang, CT., Baidya, N.B. & Ammirati, M. Endoscope-assisted supraorbital approach to the retroinfundibular area: a cadaveric study. Neurosurg Rev 36, 249–257 (2013). https://doi.org/10.1007/s10143-012-0418-x

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  • DOI: https://doi.org/10.1007/s10143-012-0418-x

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