Critical Appraisal of Minimally Invasive Keyhole Surgery for Intracranial Meningioma

Purpose Minimally invasive meningioma removal through transcranial and endoscopic endonasal keyhole routes remain controversial. Herein we detail results of keyhole meningioma removal defined as use of a minimally invasive “retractorless” approach for which a traditional larger approach is often used instead. Methods Retrospective analysis from 2008-2021 of consecutive patients undergoing keyhole meningioma removal through one of six approaches: extent of resection, complications, endoscopy use, MRI FLAIR/T2 changes. Surgical goal was maximal safe removal including conservative(subtotal) removal for some invasive locations. Results Of 329 patients, keyhole approaches were utilized in 193(59%) patients (mean age 59±13; 30(15.5%) prior surgery) who underwent 213 operations; 205(96%) were skull base location. Approaches included: endoscopic endonasal(n=74,35%), supraorbital(n=73,34%), retromastoid(n=38,18%), mini-pterional(n=20,9%), suboccipital(n=4,2%), and contralateral transfalcine(n=4,2%). Primary outcomes: Gross total/near total(>90%) resection: 125(59%); (5% for petroclival, cavernous sinus/Meckel’s cave, spheno-cavernous locations vs 77% other locations). Complications included: permanent neurological worsening12(6%); CSF leak 2(1%); meningitis 2(1%); no patients sustained DVT, PE, MI, or 30-day mortality. Median LOS was 3 days with 94% discharged home and 96% with favorable 90-day KPS. Secondary outcomes: Small persistent FLAIR/T2 changes: 11(5.2%) patients. Endoscopy use: 87/139(63%) of craniotomies, facilitating additional tumor removal in 55%. Tumor progression was observed in 26(13%) patients(mean follow-up 42±36 months). Conclusion This analysis suggests keyhole meningioma removal can be associated with reasonable resection rates, low complication rates, short hospitalizations and high 90-day performance scores. Subtotal removal may be appropriate for invasive/adherent meningiomas to avoid complications. With careful patient selection and requisite experience, these approaches may be considered alternatives to traditional approaches.

Real Time Estimator to Perform Targeted Biopsies With a Free-Wrist Robot Despite Large Deformations of the Insertion Orifice

In the context of keyhole surgery, and more particularly of uterine biopsy, the fine automatic movements of a surgical instrument held by a robot with 3 active DOF’s require an exact knowledge of the point of rotation of the instrument. However, this center of rotation is not fixed and moves during an examination. This paper deals with a new method of detecting and updating the interaction matrix linking the movements of the robot with the surgical instrument. This is based on the method of updating the Jacobian matrix which is named the “Broyden method”. It is able to take into account body tissue deformations in real time in order to improve the pointing task for automatic movements of a surgical instrument in an unknown environment.

Punch Incision with Secondary Healing (PISH) Technique for Benign Facial Lesions: An Institutional Experience in 307 Patients

Background Multiple or solitary facial lesions pose a unique challenge to the attending surgeon in terms of delivering the best cosmetic outcome. There are various methods in dealing with them and the preference of using them is based on the surgeon’s experience, patient expectations, and availability of instruments. One such tool, skin-punch, primarily designed for a biopsy can play a very important therapeutic role in this era of keyhole surgery. In this paper, we assess the technique of punch incision with its combination of secondary healing for various facial lesion. Methods This observational study, a total of 307 patients with solitary or multiple benign facial lesions were treated with punch incision technique using 2 to 6 mm sterile, disposable skin biopsy punches. Subsequently, the wounds were managed with healing with secondary intention. Results In our series all superficial wounds epithelized by 7 to 14 days while the deeper lesions epithelized by 14 to 28 days. We had three recurrences which were managed by fusiform excision and one patient had surgical site infection which was managed conservatively. On application of our self-devised facial scar scoring system (SCAR or Scar Cosmesis Assessment and Rating)3 on all the scars, the mean score was 6 at 1 year followup. Conclusion Punch incision with healing by secondary intention is a relatively easy, effective, single-stage office procedure. This method can be considered as an alternative method for the removal of various skin lesions, especially on face, thus providing a simple solution to complex problems.

Keyhole Evacuation for moderate basal ganglia Hematoma superior than Craniotomy

Background: Spontaneous intracerebral hemorrhage (SICH) is the most devastate kind of stokes.For basal ganglia hematoma with volume ranged from 30 to 60 ml, different surgical procedures have been recommended by different neurosurgeons.This study aimed to compare the clinical outcomes and hospitalization cost between keyhole surgery and craniotomy for basal ganglia intracerebral hemorrhage.Methods: A retrospective analysis was performed on clinical data of 63 cases of keyhole procedure and 56 cases of craniotomy procedure. Hematoma evacuation rate, infection rate, re-bleeding, operation time, hospitalization cost and outcome were recorded.Results: The evacuation rate was similar in keyhole group and craniotomy group (P>0.05), and infection rate was lower in keyhole group compared to craniotomy group (P<0.05). Mean operation time and hospitalization cost were less in keyhole group than in craniotomy group (P<0.05). Mortality rate between two groups showed no significant differences. The patients operated within 6h had better outcome than those operated between 6-24h (p<0.05).Conclusion: For patients with basal ganglia hematoma ranged from 30-60 ml, keyhole surgery is safe and feasible, and operation within 6 h can improve the prognosis of the patients.

Prognostic evaluation of serum long non-coding RNA H19 for endoscopic keyhole surgery or craniotomy in glioma

Background Our study aims to explore the effect of serum long non-coding RNA (lncRNA) H19 level on the long-term prognosis of endoscopic keyhole surgery or craniotomy for glioma. Methods A total of 264 glioma patients were selected. Patients were randomly divided into the Craniotomy-high H19 group, the Craniotomy-low H19 group, the Endoscopic keyhole surgery-high H19 group and the Endoscopic keyhole surgery-low H19 group. Results Compared with adjacent tissues (5.19 ± 1.42), H19 level in cancer tissues (7.45 ± 1.60) and serum (6.44 ± 1.57) was significantly increased ( P < 0.05). Compared with serum, H19 level in cancer tissues was significantly increased ( P < 0.05). Pearson correlation analysis found that the relative expression level of serum H19 in glioma patients was positively correlated with cancer tissues ( rPearson = 0.547, P < 0.001), but had no significant correlation with adjacent tissues ( rPearson = 0.126, P = 0.207). The expression of H19 in serum was significantly related to WHO grade ( rPearson = 0.514, P < 0.001). Compared with the Endoscopic keyhole surgery-high H19 group and the Endoscopic keyhole surgery-low H19 group, the survival rate of patients in the Craniotomy-high H19 group (χ2 = 17.115 and log-rank P < 0.001; χ2 = 18.406 and log-rank P < 0.001) and the Craniotomy-low H19 group was significantly reduced (χ2 = 15.007 and log-rank P < 0.001; χ2 = 16.121 and log-rank P < 0.001). Cox regression results showed that serum H19 level, craniotomy and WHO grade were risk factors for glioma. When H19 level was lower than 6.28, the 30-month survival rate of patients with the endoscopic keyhole surgery was 100%. Conclusion For patients with low H19 level (<5.36), both endoscopic keyhole surgery and craniotomy are available, otherwise, endoscopic keyhole surgery is more recommended.