A third hand to the surgeon: the use of an endoscope holding arm in endonasal sinus surgery and well beyond

Abstract Background Extended endoscopic endonasal operations of the sinuses and the frontal skull base require a bimanual action of the surgeon in many cases. Thus, typically an assistant guides the endoscope and centers the field of view. In this study, we investigate in which cases an endoscope holding arm can be used alternatively. Materials and methods The electromagnetic system ENDOFIXexo was used in different surgical interventions of the paranasal sinuses and beyond questioning ergonomics and geometrical limitations. The realized degrees of freedom were documented, and a topography of possible applications compiled. Results The presented system is limited by the anatomy of the anterior ethmoid and dynamic working conditions in the sagittal direction. Especially in extended interventions in the posterior ethmoid, in which parts of the nasal septum have been resected and a static position of the endoscope is desired the surgeon can greatly benefit from the robotic arm. Moreover, through the high flexibility of the endoscopic arm surgeries of the pharynx and larynx were performed, questioning the current gold standard of microscope-assisted surgical procedures. Conclusion Under the impression of an urging staff shortage and due to its unlimited patience, the ENDOFIXexo arm seems promising. Taking into account the complex anatomy and the limited access, we especially see a favorable field of application in the surgery of the pituitary gland and skull base tumors.

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Endoscopic Endonasal Repair of Spontaneous Cerebrospinal Fluid Leaks Using Multilayer Composite Graft and Vascularized Pedicled Nasoseptal Flap Technique

Allergy & Rhinology ◽

10.1177/2152656719888622 ◽

2019 ◽

Vol 10 ◽

pp. 215265671988862 ◽

Cited By ~ 3

Author(s):

Natalie Kim-Orden ◽

Jasper Shen ◽

Maya Or ◽

Kevin Hur ◽

Gabriel Zada ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Significant Risk ◽

Significant Risk Factor ◽

Composite Graft ◽

Sinus Surgery ◽

Success Rates ◽

Nasoseptal Flap ◽

Endoscopic Repair ◽

Endoscopic Endonasal

Background Endoscopic repair of cerebrospinal fluid (CSF) fistulas is a fundamental practice in anterior skull base surgery due to high success rates and low morbidity profile. However, spontaneous CSF (sCSF) leaks have the highest recurrence rate compared to other etiologies. The most effective management is undetermined due to variations in graft materials and limited evidence. Objective We present the largest study of a standardized endoscopic repair technique for sCSF leaks. Methods Single-institution retrospective review of patients who underwent endoscopic sCSF leak repair between October 2011 and January 2018. All patients underwent repair using a temporary lumbar drain, intrathecal fluorescein, and multilayer reconstruction using bilayered fascia lata autograft and vascularized nasoseptal flap. Results Twenty patients (100% female, mean age: 53.2 years) with 25 separate sCSF leak sites were included. Obesity was present in 15 of 20 patients (mean body mass index [BMI] = 35.3). No patients had previous sinus surgery. Locations of skull base defects included: cribriform plate (44%), ethmoid (32%), lateral sphenoid (12%), and planum sphenoidale (12%). The mean follow-up was 22.8 months and 92% of the leak sites (23/25) were successfully repaired primarily. There were no neurological complications or cases of meningitis. Two patients (mean BMI = 52) with persistent postoperative CSF leaks and elevated intracranial pressure were successfully managed with ventriculoperitoneal shunt placement. BMI was associated with likelihood of repair failure ( P = .003). Conclusions At our institution, endoscopic repair of sCSF leaks using a composite autograft of fascia and a nasoseptal flap demonstrates high success rates. Elevated BMI was a statistically significant risk factor for revision.

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Anterior Skull Base Tumors and Surgery

10.2310/ot.7057 ◽

2021 ◽

Author(s):

Judd H. Fastenberg ◽

Gurston G. Nyquist ◽

Blair M. Barton

Keyword(s):

Skull Base ◽

Anterior Skull Base ◽

Sinus Surgery ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Dural Repair ◽

Endoscopic Techniques ◽

Anterior Cranial Base ◽

Tissue Flaps ◽

Skull Base Defects

Anterior skull base surgery requires intimate knowledge of a highly complex anatomic region containing critical neurovascular structures. A wide array of pathologies can occur along the anterior cranial base, including meningiomas, esthesioneuroblastomas, pituitary adenomas, craniopharyngiomas, chondrosarcomas, and chordomas. Advancements in endoscopic sinus surgery have allowed many of these tumors to be effectively treated via an endoscopic endonasal technique. This approach obviates the need for large incisions causing cosmetic deformity, improves magnification of the surgical field, and offers a direct path to lesions thus avoiding retraction of structures such as the brain and nerves. Surgeons must understand the limitations of endoscopic techniques and consider open or combined open and endoscopic approaches when appropriate. Reconstructive anterior skull base techniques vary depending on the size and location of defects, along with factors such as intracranial pressure and patient co-morbidities. Large skull base defects require multilayer reconstruction that include a watertight primary dural repair with either synthetic or autologous tissue, followed by local vascularized tissue flaps. This review contains 8 figures, 2 videos, 4 tables and 33 references Key words: Anterior skull base, meningioma, esthesioneuroblastoma, chordoma, pituitary, CSF leak, nasosptal flap, dural repair, expanded endonasal approaches, endoscopic surgery

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Endoscopic Study of the Distribution of Olfactory Filaments: A Cadaveric Study

American Journal of Rhinology and Allergy ◽

10.1177/1945892420948784 ◽

2020 ◽

pp. 194589242094878

Author(s):

Roberto M. Soriano ◽

C. Arturo Solares ◽

Gustavo Pradilla ◽

John M. DelGaudio

Keyword(s):

Skull Base ◽

Anatomical Study ◽

Sinus Surgery ◽

Endoscopic Endonasal ◽

Superior Turbinate ◽

Endoscopic Observation ◽

Defect Repair ◽

Skull Base Defect ◽

Student’S T ◽

Student’S T Test

Objective Provide a detailed anatomical description of the olfactory filaments (OF) and their distribution in the nasal cavity through endoscopic endonasal dissection. Methods Four cadaveric specimens (8 sides) were used in this study. Nasoseptal (NSM), middle (MTM) and superior turbinate (STM) mucosa dissection was performed to identify the OF and follow them superiorly to the cribriform plate (CP). Measurements of the OF were taken on the NSM, MTM, STM under direct endoscopic visualization. A Student’s T-Test was performed to compare means. Results The NSM contained a mean of 11 OF, distributed over surface area (SA) of 173 ± 31 mm2 with the highest density of OF being found at the posterior NSM. The MTM contained a mean 6 OF, covering a mean SA of 77 mm2, with the first OF found 5 mm from the anterior border of the MTM, on average. The STM had a mean 9 OF, with the OF covering a mean SA of 96 mm2. Overall mean OF length was 6 mm. The STM OF were significantly greater in number, with a greater distance from the first OF to last OF (p < 0.05) than the MTM OF. Summary The STM and MTM combined were found to have a greater density of OF than the NSM. The STM contains a significantly greater number of OF covering a greater area than the MTM OF. Preservation of the STM and MTM in skull base defect repair, and in routine sinus surgery, can be as beneficial for olfactory function as preservation of the NSM; particularly in CP defect repair. Moreover, our findings indicate that nasoseptal flap harvest performed at least 6 mm from the skull base preserves OF in the NSM. To our knowledge, this is the first anatomical study of the OF through direct endoscopic observation and measurements.

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