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Name:
10.3171/2023.10.FOCVID23140
Description:
10.3171/2023.10.FOCVID23140
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/28a80ccb-ceaa-4d14-acd7-a5bf81dceca9/videoscrubberimages/Scrubber_460.jpg
Duration:
T00H08M56S
Embed URL:
https://stream.cadmore.media/player/28a80ccb-ceaa-4d14-acd7-a5bf81dceca9
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/28a80ccb-ceaa-4d14-acd7-a5bf81dceca9/5. 23-140.mp4?sv=2019-02-02&sr=c&sig=xENns1ezIODELxfaAMigG6rxvEkPnI0y8TCnVnyv5vY%3D&st=2025-12-02T13%3A21%3A50Z&se=2025-12-02T15%3A26%3A50Z&sp=r
Upload Date:
2023-12-08T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This is an operative video describing an exoscopic supraorbital approach for a preinfundibular supradiaphragmatic craniopharyngioma. The patient is a very pleasant 62-year-old female who presented to the clinic with three months of partially blurred central and upper temporal quadrant vision in the left eye. The patient was initially self-referred to ophthalmology and was recommended for an MRI brain, which revealed a 2.5-cm enhancing suprasellar supradiaphragmatic mass compressing the left optic nerve.
SPEAKER: On neurological exam, patient had 20/25 vision in her right eye and only finger counting at approximately 8 feet in her left eye. Extraocular movements were intact. The patient had no abnormalities in her pituitary hormone profile. The patient was subsequently referred to neurosurgery. While the MRI was critical to evaluate the lesion characteristics and compression on the optic nerve, a CTA was still needed to evaluate surrounding anatomy including the frontal sinus, the nearby internal cerebral arteries and to complete our evaluation on the feasibility of potential surgical approaches.
SPEAKER: In this T1 post-contrast MRI, a partially enhancing cystic suprasellar supradiaphragmatic lesion is visible causing compression on the left optic nerve. The left optic nerve is superiorly displaced. The lesion appears to be isolated to the supradiaphragmatic space without extension into the cell or below. On sagittal and axial MRI, the lesion is noted to be immediately inferior to the optic chiasm displacing the nerve superiorly.
SPEAKER: The CT angiogram reveals no abnormal vasculature or aneurysms and a frontal sinus that's within normal limits. Given the location of this cystic and partially enhancing lesion, craniopharyngioma was highest on the differential diagnosis. Also possible but less likely would be a Rathke's cleft cyst or arachnoid cyst. Given the patient's progressive decline in visual acuity due to optic nerve compression and unknown pathology of the growing mass, the patient was offered surgery for a resection.
SPEAKER: Various surgical approaches are possible to the suprasellar region including pterional, endoscopic endonasal, and supraorbital. A right-sided supraorbital approach was favored due to the lower risk of CSF leak and faster recovery time. The supradiaphragmatic location of the lesion further favored a supraorbital approach due to the high flow of CSF leak that would have been encountered with the endoscopic endonasal approach, which would have required passing through the diaphragm to reach the lesion.
SPEAKER: A cadaveric dissection of the suprasellar region is shown here to display the anatomical relationship of the infundibulum optic chiasm and the ICA. The anatomic structures are labeled. Thoughtful setup of the operating room is integral to success with any surgery. However, this is especially true for surgeries utilizing an exoscope. In addition to the usual considerations for OR setup, surgeries utilizing an exoscope require strategic placement of the 4K monitor in relation to the location and direction of the operating surgeon.
SPEAKER: The location of the monitor should be in a place that allows the surgeon and the surgical scrub to work at various angles while also being able to see the monitor. Multiple monitors can be placed throughout the OR to facilitate this. This graphic represents our room setup for the supraorbital craniotomy. The 4K monitor was placed at the foot of the bed while the surgical chair was at the head of the bed facing directly towards the monitor.
SPEAKER: The exoscope scope base was located to the left of the surgeon with the arm extending above the surgeon's head. The overall setup of the room and the relationship of the surgeon to the 4K monitor facilitates a heads up position with neutral and comfortable neck positioning for the surgeon. Comfortable positioning for the surgeon allows ergonomic utilization of surgical instruments and stamina for longer surgeries.
SPEAKER: The patient was positioned in the neutral position with the head slightly turned to the left to facilitate the right-sided surgical approach. Here, the proposed craniotomy is marked out in order to plan an intra-eyebrow incision. The navigation system is registered and used preoperatively to identify the location of the frontal sinus. Lidocaine with epinephrine is injected in the dermis. Incision is made inside the right eyebrow through the dermis.
SPEAKER: Dissection is carried out down to the frontal bone without the use of monopolar electrocautery. Hooks are placed for retraction. The proposed site of the craniotomy is verified with navigation to ensure it is lateral to the frontal sinus. Multiple options exist for creating a supraorbital craniotomy including a high speed burr versus an ultrasonic burr.
SPEAKER: The advantages of the ultrasonic burr with the knife attachment include performing a craniotomy without the use of a burr hole as well as a thin footprint of the craniotomy edges which allow for an excellent cosmetic appearance once the bone is replaced. The height and width of the craniotomy will influence the surgical corridor. In this case, the craniotomy was approximately 1 cm in height and 2.2 cm in width.
SPEAKER: Once the craniotomy was performed, the floor of the anterior fossa was drilled to improve visualization of the suprasellar region and the working angle towards the floor. This was easily accomplished with the ultrasonic burr as it is gentle on the surrounding soft tissue, which in this case is the dura. The angle at which the work is performed requires the surgeon to lower the exoscope and point it at an acute angle to visualize towards the floor of the anterior fossa.
SPEAKER: With the exoscope, this is accomplished easily without multiple further adjustments such as eyepiece and surgical chair. A C-shaped drill opening is performed and the dura is reflected exposing the frontal pole. Subfrontal dissection is carried down towards the basal cisterns to drain CSF and allow gravity to retract the frontal lobe. A "slider" cottonoid is used here to facilitate retraction while protecting the frontal lobe.
SPEAKER: The long focal length capacity of the exoscope allows the scope to remain at a distance from the patient, which in turn allows the surgeon to operate unencumbered. Here, the focal length is set to 51 cm. Upon visualization of the suprasellar space, a cystic yellow appearing lesion, originating from the pituitary stalk, was readily visible. The right side of the tumor is seen making contact with the left optic nerve, which is labeled in yellow.
SPEAKER: This is consistent with the preoperative imaging findings. Careful manipulation of the tumor with microinstruments allowed for the tumor to be dissected free of surrounding tissue, including the ICA which is seen on the left labeled in red. Frequent changes in working angle, as shown here, highlight the advantage of the exoscope over the microscope as the surgeon is able to change the optical viewing angle, and then quickly resume operating in the same neutral body and neck position.
SPEAKER: This is because a surgeon sitting and working angle is not coupled to the angle of the scope as is the case in a traditional surgical microscope. Once the tumor was dissected free from surrounding structures, its final attachment point was noted to the pituitary stalk. At this point, decision was made to sharply dissect the tumor from the stalk. The structures are marked.
SPEAKER: The optic nerve is labeled in yellow, pituitary stalk in blue, and the diaphragm in green. Once the tumor was removed, visual inspection of the suprasellar space was carried out to ensure no damage to the surrounding structures and adequate hemostasis. The dura was subsequently reapproximated, bone flap was replaced with low profile plating system, and bone edges further augmented with the application of a calcium phosphate bone cement.
SPEAKER: The incision was subsequently closed with 5-0 absorbable monofilament suture in a subcuticular fashion. The patient was noted to have a right frontalis palsy that improved at six week follow up. She did not have transient DI and was discharged on postoperative day one. Pathology report was consistent with craniopharyngioma. The post-operative MRI reveals a gross total resection.
SPEAKER: Although the left optic nerve is still superiorly displaced, the nerve is thoroughly decompressed. The tools available to neurosurgeons for visualization have continued to increase in number and complexity over the years. Advancements in optical technology have resulted in a wide range of tools, including microscopes, endoscopes, and now exoscopes. The OR setup for each one of these entities is unique to one another and understanding those differences lays the groundwork for success with the surgery.
SPEAKER: Overall, we have found that the exoscope allows for better teaching of trainees, surgeon ergonomics, and improved surgical flow, especially in surgeries with challenging visualization angles.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This is an operative video describing an exoscopic supraorbital approach for a preinfundibular supradiaphragmatic craniopharyngioma. The patient is a very pleasant 62-year-old female who presented to the clinic with three months of partially blurred central and upper temporal quadrant vision in the left eye. The patient was initially self-referred to ophthalmology and was recommended for an MRI brain, which revealed a 2.5-cm enhancing suprasellar supradiaphragmatic mass compressing the left optic nerve.
SPEAKER: On neurological exam, patient had 20/25 vision in her right eye and only finger counting at approximately 8 feet in her left eye. Extraocular movements were intact. The patient had no abnormalities in her pituitary hormone profile. The patient was subsequently referred to neurosurgery. While the MRI was critical to evaluate the lesion characteristics and compression on the optic nerve, a CTA was still needed to evaluate surrounding anatomy including the frontal sinus, the nearby internal cerebral arteries and to complete our evaluation on the feasibility of potential surgical approaches.
SPEAKER: In this T1 post-contrast MRI, a partially enhancing cystic suprasellar supradiaphragmatic lesion is visible causing compression on the left optic nerve. The left optic nerve is superiorly displaced. The lesion appears to be isolated to the supradiaphragmatic space without extension into the cell or below. On sagittal and axial MRI, the lesion is noted to be immediately inferior to the optic chiasm displacing the nerve superiorly.
SPEAKER: The CT angiogram reveals no abnormal vasculature or aneurysms and a frontal sinus that's within normal limits. Given the location of this cystic and partially enhancing lesion, craniopharyngioma was highest on the differential diagnosis. Also possible but less likely would be a Rathke's cleft cyst or arachnoid cyst. Given the patient's progressive decline in visual acuity due to optic nerve compression and unknown pathology of the growing mass, the patient was offered surgery for a resection.
SPEAKER: Various surgical approaches are possible to the suprasellar region including pterional, endoscopic endonasal, and supraorbital. A right-sided supraorbital approach was favored due to the lower risk of CSF leak and faster recovery time. The supradiaphragmatic location of the lesion further favored a supraorbital approach due to the high flow of CSF leak that would have been encountered with the endoscopic endonasal approach, which would have required passing through the diaphragm to reach the lesion.
SPEAKER: A cadaveric dissection of the suprasellar region is shown here to display the anatomical relationship of the infundibulum optic chiasm and the ICA. The anatomic structures are labeled. Thoughtful setup of the operating room is integral to success with any surgery. However, this is especially true for surgeries utilizing an exoscope. In addition to the usual considerations for OR setup, surgeries utilizing an exoscope require strategic placement of the 4K monitor in relation to the location and direction of the operating surgeon.
SPEAKER: The location of the monitor should be in a place that allows the surgeon and the surgical scrub to work at various angles while also being able to see the monitor. Multiple monitors can be placed throughout the OR to facilitate this. This graphic represents our room setup for the supraorbital craniotomy. The 4K monitor was placed at the foot of the bed while the surgical chair was at the head of the bed facing directly towards the monitor.
SPEAKER: The exoscope scope base was located to the left of the surgeon with the arm extending above the surgeon's head. The overall setup of the room and the relationship of the surgeon to the 4K monitor facilitates a heads up position with neutral and comfortable neck positioning for the surgeon. Comfortable positioning for the surgeon allows ergonomic utilization of surgical instruments and stamina for longer surgeries.
SPEAKER: The patient was positioned in the neutral position with the head slightly turned to the left to facilitate the right-sided surgical approach. Here, the proposed craniotomy is marked out in order to plan an intra-eyebrow incision. The navigation system is registered and used preoperatively to identify the location of the frontal sinus. Lidocaine with epinephrine is injected in the dermis. Incision is made inside the right eyebrow through the dermis.
SPEAKER: Dissection is carried out down to the frontal bone without the use of monopolar electrocautery. Hooks are placed for retraction. The proposed site of the craniotomy is verified with navigation to ensure it is lateral to the frontal sinus. Multiple options exist for creating a supraorbital craniotomy including a high speed burr versus an ultrasonic burr.
SPEAKER: The advantages of the ultrasonic burr with the knife attachment include performing a craniotomy without the use of a burr hole as well as a thin footprint of the craniotomy edges which allow for an excellent cosmetic appearance once the bone is replaced. The height and width of the craniotomy will influence the surgical corridor. In this case, the craniotomy was approximately 1 cm in height and 2.2 cm in width.
SPEAKER: Once the craniotomy was performed, the floor of the anterior fossa was drilled to improve visualization of the suprasellar region and the working angle towards the floor. This was easily accomplished with the ultrasonic burr as it is gentle on the surrounding soft tissue, which in this case is the dura. The angle at which the work is performed requires the surgeon to lower the exoscope and point it at an acute angle to visualize towards the floor of the anterior fossa.
SPEAKER: With the exoscope, this is accomplished easily without multiple further adjustments such as eyepiece and surgical chair. A C-shaped drill opening is performed and the dura is reflected exposing the frontal pole. Subfrontal dissection is carried down towards the basal cisterns to drain CSF and allow gravity to retract the frontal lobe. A "slider" cottonoid is used here to facilitate retraction while protecting the frontal lobe.
SPEAKER: The long focal length capacity of the exoscope allows the scope to remain at a distance from the patient, which in turn allows the surgeon to operate unencumbered. Here, the focal length is set to 51 cm. Upon visualization of the suprasellar space, a cystic yellow appearing lesion, originating from the pituitary stalk, was readily visible. The right side of the tumor is seen making contact with the left optic nerve, which is labeled in yellow.
SPEAKER: This is consistent with the preoperative imaging findings. Careful manipulation of the tumor with microinstruments allowed for the tumor to be dissected free of surrounding tissue, including the ICA which is seen on the left labeled in red. Frequent changes in working angle, as shown here, highlight the advantage of the exoscope over the microscope as the surgeon is able to change the optical viewing angle, and then quickly resume operating in the same neutral body and neck position.
SPEAKER: This is because a surgeon sitting and working angle is not coupled to the angle of the scope as is the case in a traditional surgical microscope. Once the tumor was dissected free from surrounding structures, its final attachment point was noted to the pituitary stalk. At this point, decision was made to sharply dissect the tumor from the stalk. The structures are marked.
SPEAKER: The optic nerve is labeled in yellow, pituitary stalk in blue, and the diaphragm in green. Once the tumor was removed, visual inspection of the suprasellar space was carried out to ensure no damage to the surrounding structures and adequate hemostasis. The dura was subsequently reapproximated, bone flap was replaced with low profile plating system, and bone edges further augmented with the application of a calcium phosphate bone cement.
SPEAKER: The incision was subsequently closed with 5-0 absorbable monofilament suture in a subcuticular fashion. The patient was noted to have a right frontalis palsy that improved at six week follow up. She did not have transient DI and was discharged on postoperative day one. Pathology report was consistent with craniopharyngioma. The post-operative MRI reveals a gross total resection.
SPEAKER: Although the left optic nerve is still superiorly displaced, the nerve is thoroughly decompressed. The tools available to neurosurgeons for visualization have continued to increase in number and complexity over the years. Advancements in optical technology have resulted in a wide range of tools, including microscopes, endoscopes, and now exoscopes. The OR setup for each one of these entities is unique to one another and understanding those differences lays the groundwork for success with the surgery.
SPEAKER: Overall, we have found that the exoscope allows for better teaching of trainees, surgeon ergonomics, and improved surgical flow, especially in surgeries with challenging visualization angles.
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