Cerebrospinal fluid reconstitution via a perfusion-based cadaveric model: feasibility study demonstrating surgical simulation of neuroendoscopic procedures

Abstract

Cadaveric surgical simulation carries the advantage of realistic anatomy and haptic feedback but has been historically difficult to model for intraventricular approaches given the need for active flow of CSF. This feasibility study was designed to simulate intraventricular neuroendoscopic approaches and techniques by reconstituting natural CSF flow in a cadaveric model. In 10 fresh human cadavers, a simple cervical laminectomy and dural opening were made, and a 12-gauge arterial catheter was introduced. Saline was continuously perfused at physiological CSF pressures to reconstitute the subarachnoid space and ventricles. A neuroendoscope was subsequently inserted via a standard right frontal bur hole. In 8 of the 10 cadavers, adequate reconstitution and endoscopic access of the lateral and third ventricles were achieved. In 2 cadavers, ventricular access was not feasible, perhaps because of a small ventricle size and/or deteriorated tissue quality. In all 8 cadavers with successful CSF flow reconstitution and endoscopic access, identifying the foramen of Monro was possible, as was performing septum pellucidotomy and endoscopic third ventriculostomy. Furthermore, navigation of the cerebral aqueduct, fourth ventricle, prepontine cistern, and suprasellar cistern via the lamina terminalis was possible, providing a complementary educational paradigm for resident education that cannot typically be performed in live surgery. Surgical simulation plays a critical and increasingly prominent role in surgical education, particularly for techniques with steep learning curves including intraventricular neuroendoscopic procedures. This novel model provides feasible and realistic surgical simulation of neuroendoscopic intraventricular procedures and approaches.

Simulation training methods in neurological surgery

“…Studies have already demonstrated the efficacy of cadaveric models training for skull base tumor debulking,[44] aneurysm clipping,[4445464748] cerebrospinal flow evaluation,[49] and internal carotid artery injury [Table 1]. [50]…”

“…[5,[40][41][42] Furthermore, the quality of the cadaveric tissues relies on the adopted embalming regimen and feedback is not immediate. [42,43] Studies have already demonstrated the efficacy of cadaveric models training for skull base tumor debulking, [44] aneurysm clipping, [44][45][46][47][48] cerebrospinal flow evaluation, [49] and internal carotid artery injury [Table 1]. [50] Virtual Reality Simulation VR simulation relies on different levels of immersion.…”

Expert surgeons and deep learning models can predict the outcome of surgical hemorrhage from 1 min of video

“…Curating 150 videos of real carotid injuries would require tens of thousands of cases, an impossible task without streamlined data-sharing mechanisms; using perfused cadavers and real instruments we collected hundreds of observations of this otherwise rare event. Videos in the simulated environment can complement surgical video datasets that otherwise depict thousands of uncomplicated cases and only a few rare events 14 , 15 , 17 , 18 , 63 – 66 . As more surgical video datasets are developed, we can follow the ‘sim-to-real’ process where models are trained on virtual data and then fine-tuned and validated in the real environment 67 – 69 .…”

Perfusion-based human cadaveric specimen as a simulation training model in repairing cerebrospinal fluid leaks during endoscopic endonasal skull base surgery

“…Perfusion-based human cadaveric specimens have been used in surgical training with great potential in aiding the development of skill sets necessary for specialized surgical procedures. 1,2,7,8,17,22,23,25 Although virtual reality applications for EEAs are available, 16 they are unable to replicate the tissue quality required for adequate training in CSF leak repair. Our model provides a realistic training setup for neurosurgical residents to repair CSF leaks using fresh tissue (fat grafts, fascial grafts, and so forth) and the potential to practice elevating and positioning vascularized nasoseptal flaps.…”