Benefits of endoscope-assisted microsurgery in the management of pediatric brain tumors

Abstract

OBJECTIVEMicrosurgical and endoscopic techniques are vastly utilized in brain tumor surgery. Combining both techniques in the same procedure has different forms and applications. The aim of this work was to discuss the usefulness and describe the technical benefits of endoscope-assisted microsurgery (EAMS) in treating pediatric brain tumors in various anatomical locations.METHODSThe medical records of 106 children who had undergone EAMS for brain tumors at Children’s Cancer Hospital Egypt (CCHE-57357) between January 2009 and January 2017 were reviewed. The patients’ ages ranged from 1 to 16 years (mean age 7.5 years). Technical variations, difficulties, complications, strategies, and extent of resection were addressed according to anatomical location.RESULTSIn general, EAMS enabled closer inspection of tumor extension and surrounding vital structures, especially in the hidden corners not appreciable by the microscope alone, such as tumors in the internal auditory canal and cerebellopontine angle contents in 14 cases, all of which were totally excised, and the undersurface of the optic apparatus in 65 craniopharyngiomas. Total excision was achievable in 51 of the 65 craniopharyngiomas; residual tumor was intentionally left behind under endoscopic guidance in the remaining 14 patients to ensure better hypothalamic function. Vision improved in 15 of 16 patients who initially presented with visual defects. Only 4 patients had new-onset postoperative endocrinopathies. For intraventricular tumors, EAMS allowed earlier recognition of tumor pedicle and, hence, earlier control of the blood supply of the tumor and safer total excision of 12 lateral ventricle, 6 pineal and third ventricle, and 9 fourth ventricle tumors. The tandem use of the endoscope and microscope enabled safer tumor dissections that were performed with more confidence in situations in which pure microscopic excision was either not achievable or less safe. Technical strategies, pitfalls, difficulties, and precautions were categorized and described per tumor location.CONCLUSIONSEAMS of pediatric brain tumors is a promising, user-friendly tool that complements microsurgery in the management of these complex lesions. The benefits of 2D endoscopy are added to the benefits of stereoscopic perception. EAMS is especially helpful during the removal of different complex pediatric brain tumors. Simultaneous or tandem endoscopic and microscopic approaches may have the potential for better functional outcomes through better visualization and preservation of vital structures in corners that are hidden from the microscope.

Preliminary Clinical Surgical Experience with Temporary Simultaneous Use of an Endoscope during Exoscopic Neurosurgery: An Observational Study

“…Micro-endoscopic surgery expands the field of view in deeper regions of the body [ 9 , 10 , 11 ]; however, various issues have been pointed out [ 10 , 16 , 18 ], including the difficulty in simultaneously observing both the endoscopic and microscopic fields of view, complexity of setting up the monitoring equipment in the operating room [ 12 , 18 ], interference of the endoscope itself and endoscope fixation devices with surgical operations [ 12 , 16 ], and tissue damage during the insertion and removal of the equipment [ 10 ]. A search on PubMed showed that many studies on the advantages of MES have been published since 1998.…”

“…Microsurgery in the field of neurosurgery has been performed since the 1950s. The usefulness and limitations of the “temporary simultaneous use of an endoscope during microscopic surgery” (herein, micro-endoscopic surgery (MES)) were not reported until the 1990s; it has been used for deep and back-surface observation of anatomical objects [ 9 , 10 , 11 , 12 , 13 ]. For example, endoscope-assisted observation of the perforating branch behind an aneurysm, which helps obtain the necessary information for clipping that cannot be observed with a MS alone, is possible [ 10 ].…”

“…In addition, recent high-resolution technological advances in rigid MS and advances in rigid MS fixtures have improved their functions as tools to support microscopic surgery [ 14 , 15 ]. However, the following problems have been suggested to be disadvantages of MES: the possibility of damage to the surrounding tissues when the endoscope is inserted and removed due to the limitation of the field of view; endoscope interference with instrument insertion, such as scissors and tweezers; and the complexity of alternating between the fields of view of the MS and the endoscope [ 10 , 11 , 16 ]. When a surgeon is operating using an MS, it is difficult to directly observe the surgical field because the eyepiece and objective lens of the MS are in the way, thus limiting the optimal view of the surgical field.…”

Commentary: Single-Center Experience Using a 3D4K Digital Operating Scope System for Aneurysm Surgery

“…2 Over time, the operating microscope and endoscopic systems have become invaluable optical technologies with neurosurgical procedures benefiting from their utilization sometimes even in a complementary manner depending on the specific surgery and stage of the procedure. 3 The neurosurgical application of the exoscope combines some of the advantages of the operating microscope and the endoscope. 4 Surgeons have praised the exoscope for improved surgeon ergonomics.…”

“…2 Over time, the operating microscope and endoscopic systems have become invaluable optical technologies with neurosurgical procedures benefiting from their utilization sometimes even in a complementary manner depending on the specific surgery and stage of the procedure. 3…”