Omar Hospital,
Jail Road,
Lahore, Pakistan.
Endscopic Brain Surgery
Endoscopic Brain Surgery
CRANIAL ENDOSCOPIC PROCEDURES
1. ENDOSCOPIC PITUITARY SURGERY
Endoscopic pituitary surgery is performed through a natural nasal air pathway without any incisions (unlike the conventional microscopic surgery performed with an incision made under the upper lip or inner aspect of a nostril). Endoscopic surgery does not require the use of a metallic transsphenoidal retractor that is used for conventional microscopic surgery. A 4-mm endoscope is placed in front of the tumor in the sphenoidal sinus and the tumor is removed with specially designed surgical tools. Postoperative nasal packing is not necessary, and postoperative discomfort is minimal. Most patients are able to go home the following day. The optical advantages of an endoscope (such as a wide-angled panoramic view, an angled view by angled lens endoscopes, and a view in the tumor removal cavity) enhance tumor removal even in complex cases of bulky tumors.
Advantages of Endoscopic Pituitary Surgery
§ With this newly developed minimally invasive technique, pituitary tumors can be removed through the patient's natural nose.
§ This procedure does not require sublabial or nostril incisions and eliminates the need for occlusive postoperative packing used with the conventional procedures.
§ This method is minimally invasive because it directly approaches the tumor through the patient's nostril thus eliminating facial swelling, decreasing postoperative pain, and making recovery quicker.
§ The procedure is innovative because it utilizes endoscopic technology to improve visualization of the pituitary gland, the tumor, and other anatomical structures.
Most patients can go home the day following their surgery
2. ENDOSCOPIC TREATMENT OF HYDROCEPHALUS
Hydrocephalus a condition in which the normal circulatory pathways of cerebrospinal fluid (CSF) are altered. Hydrocephalus can result from a number of conditions including congenital malformations, infection, hemorrhage, or brain tumors. With the accumulation of CSF, the intracranial pressure increases resulting in symptoms such as headache, vomiting, altered personality, and decreased cognitive performance. Hydrocephalus was perniciously treated by VP and VA shunts which had a significant rate of failure requiring frequent hospitalizations and additional surgery.
In patients with noncommunicating hydrocephalus, endoscopic third ventriculostomy (ETV) can be used to bypass the site of cerebrospinal fluid (CSF) obstruction. ETV is a technique that redirects the flow of CSF by creating a small fenestration or opening in the floor of the third ventricle.
Endoscopic Third Ventriculostomy (ETV)
The procedure is performed through a small incision (approximately 1 inch) behind the hairline. From this site, the endoscope is inserted into the ventricular compartment of the brain and then navigated into the third ventricle. The floor of this compartment is then fenestrated, or opened. The endoscope is then removed and the wound is closed. The procedure is performed in approximately 30 minutes and patients can return home the following day.
The obvious advantage of this procedure is that no implanted shunt is needed thus avoiding the potential long-term risks of shunts including infection, migration, or disconnection.
3. ENDOSCOPIC MANAGEMENT OF INTRAVENTRICULAR
BRAIN TUMORS
The cerebral ventricles are chambers within the brain that contain a clear-colorless fluid called cerebrospinal fluid (CSF). CSF serves as an excellent medium for endoscopy given the clarity and space. Since many varieties of brain tumors can occur in the ventricles, biopsy is commonly recommended in order to define the best type of therapy. Conventional procedures for tumor biopsy involve either a needle biopsy using a frame attached to the skull or an open surgical procedure. Brain tumors situated in the intraventricular compartment are amenable to an endoscopic biopsy or resection.
Endoscopic Tumor Surgery
The procedure is performed through a small incision (approximately 1 inch) behind the hairline. From this site, the endoscope is inserted into the ventricular compartment of the brain and then navigated toward the tumor. The tumor is readily identified due to the difference in appearance from the surrounding tissue. Biopsy forceps are then used to sample the tumor. Because direct vision is being used, samples can be selected avoiding any small blood vessels or other important structures within the ventricle, features that cannot be done with standard "closed" needle biopsies. The endoscope is then removed and the wound is closed. The procedure is performed in approximately 30 minutes and patients can return home the following day.
Endoscopic biopsy for intraventricular brain tumors avoids many of the inherent risks associated with conventional surgical approaches. Because these tumors are typically situated deep within the brain, the ability to approach these tumors with a minimally invasive technique offers a very significant advantage to the patient.
4. ENDOSCOPIC EXCISION OF COLLOID CYSTS
The most common tumor located within the third ventricle is the colloid cyst. This benign tumor can cause a blockage of cerebrospinal fluid (CSF) leading toward increased intracranial pressure and potentially death. The definitive method for treating colloid cysts is surgical removal. Prior to the advent of endoscopic neurosurgery, the removal of colloid cysts relied on an extensive open surgical procedure achieved by way of a craniotomy, an open procedure which requires removal of a portion of the skull.
Colloid Cyst Resection
The procedure is performed through a small incision (approximately 1 inch) behind the hairline. From this site, the endoscope is inserted into the ventricular compartment of the brain and then navigated toward the tumor surface. The wall of the tumor is then coagulated with an electrical current and the cyst is then opened with sharp dissection. A variety of suction catheters are then used to empty the contents of the cyst. The cyst wall is then removed and any remnants are destroyed using an electrical current. The endoscope is then removed and the wound is closed. The procedure averages 45 minutes-1 hour and patients can return home within 1-2 days Because of the deep and central location of these benign tumors the standard surgical procedures are usually lengthy and have significant risk. Highly refined endoscopes with a wide array of compatible instruments allow complete removal of colloid cysts through a much less invasive technique in a fraction of the time.
5. ENDOSCOPIC TREATMENT OF ARACHNOID CYSTS
Developmental cysts of the brain, or arachnoid cysts, cause symptoms based upon the location and size of the cyst. Weakness decreased cognitive performance, spontaneous hemorrhage, and seizures, are common presentations for individuals with intracranial arachnoid cysts. Most common locations include the temporal fossa, the posterior fossa, and the suprasellar region. Treatment has typically involved either the placement of a permanent drainage system (cystoperitoneal shunt) or an open surgical procedure to fenestrate the walls of the cyst. Cyst fenestration is typically favored due to the high success rate of this procedure. However, shunt placement is appealing due to the simplicity of the operation.
Endoscopic Cyst Fenestration
The procedure is performed through a small incision (approximately 1 inch), the location being dictated based upon the location of the cyst. From this site, the endoscope is inserted into the cyst and the wall of the cyst is then opened into one of the natural fluid chambers of the brain. With this opening, the fluid can then exit the cyst and get absorbed through normal means. This procedure averages 30 minutes to 1 hour and patients can return home the following day.