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Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE...
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Transcript of Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE...
![Page 1: Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE INSTITUTE.](https://reader033.fdocuments.in/reader033/viewer/2022061305/55143fbb550346414e8b48bc/html5/thumbnails/1.jpg)
Minimally Invasive Skull Base Surgery: Fact or
Fantasy?Hrayr K. Shahinian M.D,FACS
SKULL BASE INSTITUTE
![Page 2: Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE INSTITUTE.](https://reader033.fdocuments.in/reader033/viewer/2022061305/55143fbb550346414e8b48bc/html5/thumbnails/2.jpg)
A Need for Improvement...
• Limitations of posterior fossa microscopy– visualization limited to direct anterior-
posterior axis– shallow depth of field– “static” imaging
![Page 3: Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE INSTITUTE.](https://reader033.fdocuments.in/reader033/viewer/2022061305/55143fbb550346414e8b48bc/html5/thumbnails/3.jpg)
A Need for Improvement...
• Limitations of posterior fossa microscopy – clinical implications for MVD
• missed conflicts• inadequate decompressions; recurrence
– clinical implications for pituitary surgery• residual tumor in lateral recesses of sella
turcica
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Technological Advancement
• Rigid endoscopes– varying widths– varying angles of view
• Cameras– single-chip– three-chip– digital– three-dimensional
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Technological Advancement
• Light sources– halogen– metal halide– xenon arc
• Recorders/processors– digital
• Irrigation sheaths• Holding arms
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Animal Experimental Models
• Allow for preliminary evaluation of the effectiveness of the new procedure
• Can be reliably reproduced to increase familiarity with new instruments in a safe and controlled setting
• Provides a means for surgical training before application in the operating room
![Page 7: Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE INSTITUTE.](https://reader033.fdocuments.in/reader033/viewer/2022061305/55143fbb550346414e8b48bc/html5/thumbnails/7.jpg)
Animal Experimental Models
• Choice of porcine model: posterior fossa– bony anatomy and anatomical
relationships of the posterior porcine skull base are analogous to human basicranium
![Page 8: Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE INSTITUTE.](https://reader033.fdocuments.in/reader033/viewer/2022061305/55143fbb550346414e8b48bc/html5/thumbnails/8.jpg)
Animal Experimental Models
• Endoscopic cranial nerve vascular decompression:– aim
• develop animal model for endoscopic surgery of the posterior fossa
![Page 9: Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE INSTITUTE.](https://reader033.fdocuments.in/reader033/viewer/2022061305/55143fbb550346414e8b48bc/html5/thumbnails/9.jpg)
Animal Experimental Models
• Endoscopic cranial nerve vascular decompression:– relevance
• improved surgical therapy for cranial nerve compression syndromes
– trigeminal neuralgia (CN V)– hemifacial spasm (CN VII)– intractable vertigo (CN VIII)– glossopharyngeal neuralgia (CN IX)– spasmodic torticollis (CN XI)
![Page 10: Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE INSTITUTE.](https://reader033.fdocuments.in/reader033/viewer/2022061305/55143fbb550346414e8b48bc/html5/thumbnails/10.jpg)
Animal Experimental Models
• Endoscopic cranial nerve vascular decompression:– method
• 30 kg Hampshire-Yorkshire-Duroc swine• general anesthesia• left lateral decubitus position• 2 cm retrosigmoid craniotomy• endoscopic exploration of posterior fossa• identification of cranial nerves
![Page 11: Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE INSTITUTE.](https://reader033.fdocuments.in/reader033/viewer/2022061305/55143fbb550346414e8b48bc/html5/thumbnails/11.jpg)
Animal Experimental Models
• Endoscopic cranial nerve vascular decompression:– results
• visualization of cerebellum, lower cranial nerves (CN IX-XI), acousticofacial bundle (CN VII-VIII), and trigeminal nerve (CN V)
• panoramic views with addition of angled endoscopes
• impediments to visualization (e.g., petrous apex) circumnavigated
![Page 12: Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE INSTITUTE.](https://reader033.fdocuments.in/reader033/viewer/2022061305/55143fbb550346414e8b48bc/html5/thumbnails/12.jpg)
Animal Experimental Models
• Endoscopic cranial nerve vascular decompression:– conclusion
• “The dynamic optical qualities of the endoscope should allow for more careful navigation through the very constrained cavities of the skull base, for more detailed appreciation of critical surgical anatomy, and for more thorough surgical intervention with fewer complications due to better visualization.”
Jarrahy R, Young J, Berci G, Shahinian HK. Endoscopic skull base surgery II:a new animal model for surgery of the posterior fossa. J Invest Surg 1999;13:1-6.
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Clinical Trials: Endoscopic Posterior Fossa Surgery
• Aim– determine the efficacy of endoscopy
as an imaging modality in posterior fossa microvascular decompression
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Clinical Trials: Endoscopic Posterior Fossa Surgery
• Design– case series (n = 210) with
retrospective review of medical records and operative video
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Clinical Trials: Endoscopic Posterior Fossa Surgery
• Intervention– microvascular decompression via
retrosigmoid craniotomy (traditional approach)
– preliminary endoscopic survey of nerve-vessel conflicts prior to microscopic intervention
– final endoscopic survey to assess adequacy of microscopic therapy
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Clinical Trials: Endoscopic Posterior Fossa Surgery
• Results– 251 total nerve vessel conflicts– 27% not detected by microscopy--
endoscope needed to diagnose and treat these conflicts
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Clinical Trials: Endoscopic Posterior Fossa Surgery
• Results– in 24% of patients, final endoscopic
survey revealed incomplete decompression following microscopic therapy
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Clinical Trials: Endoscopic Posterior Fossa Surgery
• Conclusion– “In this series microscopic exploration of the
surgical field failed to detect roughly one-quarter of the offending vessels. Likewise…, in one-quarter of cases what was deemed to be an adequate decompression of the trigeminal nerve under the microscope proved to be incomplete. These observations emphasize the value of controlled application of endoscopic techniques at the cerebellopontine angle and merit further attention.”
Jarrahy R, Berci G, Shahinian HK. Endoscope-assisted microvascular decompressionof the trigeminal nerve. Otolaryngol Head Neck Surg. Accepted for publication.
![Page 19: Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE INSTITUTE.](https://reader033.fdocuments.in/reader033/viewer/2022061305/55143fbb550346414e8b48bc/html5/thumbnails/19.jpg)
Animal Experimental Models
• Choice of porcine model: anterior fossa– bony anatomy and anatomical
relationships of the anterior porcine skull base are analogous to human basicranium
![Page 20: Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE INSTITUTE.](https://reader033.fdocuments.in/reader033/viewer/2022061305/55143fbb550346414e8b48bc/html5/thumbnails/20.jpg)
Animal Experimental Models
• Endoscopic pituitary surgery:– aim
• develop animal model for pituitary surgery/endoscopic surgery of the anterior fossa
• eliminate invasive techniques associated with traditional approach
– nasal/septal complications– upper labial hypoesthesia– postoperative nasal packing
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Animal Experimental Models
• Endoscopic pituitary surgery:– relevance
• improved surgical therapy resection of pituitary tumors, tumors of the anterior fossa
– chordoma– meningioma– craniopharyngioma– teratoma– other tumors
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Animal Experimental Models
• Endoscopic pituitary surgery:– method
• 30 kg Hampshire-Yorkshire-Duroc swine• general anesthesia• supine position• gross dissection of hard palate• endoscopic exploration of sella turcica,
parasellar and suprasellar areas
![Page 23: Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE INSTITUTE.](https://reader033.fdocuments.in/reader033/viewer/2022061305/55143fbb550346414e8b48bc/html5/thumbnails/23.jpg)
Animal Experimental Models
• Endoscopic pituitary surgery:– results
• clear visualization of pituitary gland, hypophyseal stalk, cavernous sinuses, optic nerves
• angled endoscopes enabled visualization of lateral recesses (cavernous sinuses) and suprasellar areas
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Animal Experimental Models
• Endoscopic pituitary surgery:– conclusion
• “Our results highlight the usefulness of endoscopy in providing superior exposure of the structures that are critical to hypophysectomy.”
Jarrahy R, Young J, Berci G, Shahinian HK. Endoscopic skull base surgery I:a new animal model for surgery of the posterior fossa. J Invest Surg 1999;12:1-5.
![Page 25: Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE INSTITUTE.](https://reader033.fdocuments.in/reader033/viewer/2022061305/55143fbb550346414e8b48bc/html5/thumbnails/25.jpg)
Clinical Trials:Endoscopic Pituitary
Surgery• Aim
– objectively demonstrate that the use of endoscopy in pituitary surgery improves visualization and surgical outcome
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Clinical Trials:Endoscopic Pituitary
Surgery• Design
– case series (n = 229) with retrospective review of medical records and operative videotape
![Page 27: Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE INSTITUTE.](https://reader033.fdocuments.in/reader033/viewer/2022061305/55143fbb550346414e8b48bc/html5/thumbnails/27.jpg)
Clinical Trials:Endoscopic Pituitary
Surgery• Intervention
– transseptal transsphenoidal approach to the sella turcica (traditional microscopic technique)
– final endoscopic survey of sella and parasellar areas following completion of microscopic resection• residual tumor fragments--precursors to
recurrence and persistent endocrinological symptoms--noted and resected
![Page 28: Minimally Invasive Skull Base Surgery: Fact or Fantasy? Hrayr K. Shahinian M.D,FACS SKULL BASE INSTITUTE.](https://reader033.fdocuments.in/reader033/viewer/2022061305/55143fbb550346414e8b48bc/html5/thumbnails/28.jpg)
Clinical Trials:Endoscopic Pituitary
Surgery• Results
– residual tumor noted in 33% of patients (43% of macroadenomas) following what was thought to be complete resection via the microscope
– angled endoscopes were able to expose lateral recesses of sella turcica where these fragments were missed
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Clinical Trials:Endoscopic Pituitary
Surgery• Conclusion
– “…these observations do provide evidence that endoscopic imaging of the intrasellar, parasellar, and suprasellar spaces is more comprehensive than that provided by the operative microscope… [T]he potential impact upon the efficacy of tumor resection and subsequent rates of tumor recurrence is significant when endoscopy is implemented as an imaging modality in the surgical management of pituitary tumors.
Jarrahy R, Berci G, Shahinian HK. Assessment of the efficacy of endoscopy in the resectionof pituitary adenomas. Accepted for publication in Arch Otolaryngol Head Neck Surg.