principles and practice of keyhole brain surgery pdf

Principles And Practice Of Keyhole Brain Surgery Pdf

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Neuroendoscopic NE surgery as a minimal invasive treatment for basal ganglia hemorrhage is a promising approach. The present study aims to evaluate the efficacy and safety of NE approach using an adjustable cannula to treat basal ganglia hemorrhage.

Developed 20 years ago by leading innovators in the field, the keyhole concept of brain surgery has become an integral part of the practice of neurosurgery. This timely and comprehensive book covers the thinking, philosophy, and techniques of modern keyhole brain surgery, including a realistic assessment of its benefits and limitations. Written by expert practitioners and highlighted by vivid surgical illustrations and procedural videos, Principles and Practice of Keyhole Brain Surgery functions as an experienced mentor working side by side with neurosurgeons as they master the techniques. Providing all the information necessary to achieve surgical goals through well placed, smaller openings—with the added benefits of shorter procedures, fewer wound complications and better patient outcomes— Principles and Practice of Keyhole Brain Surgery is essential for every neurosurgeon in practice today.

Principles and Practice of Keyhole Brain Surgery

Neuroendoscopic NE surgery as a minimal invasive treatment for basal ganglia hemorrhage is a promising approach. The present study aims to evaluate the efficacy and safety of NE approach using an adjustable cannula to treat basal ganglia hemorrhage.

In this study, we analysed the clinical and radiographic outcomes between NE group 21 cases and craniotomy group 30 cases. The results indicated that NE surgery might be an effective and safe approach for basal ganglia haemorrhage, and it is also suggested that NE approach may improve good functional recovery. However, NE approach only suits the selected patient, and the usefulness of NE approach needs further randomized controlled trials RCTs to evaluate.

Worldwide, intracerebral hemorrhage ICH is a major cause of morbidity and mortality [ 1 ]. Basal ganglia haemorrhage is a common type of ICH, and it is a life-threatening condition that may result in a series of complications, including hematoma expansion, severe brainstem compression, acute hydrocephalus, increased intracranial pressure, seizures, fever, and infections [ 5 ].

To avoid these complications, patients usually need urgent surgical treatment. Surgical management on basal ganglia hemorrhage has unique advantages as it can remove the hematoma effectively and decrease intracranial pressure and the incidence of complications. A large randomized clinical trial [ 8 ] did not show significant benefits of surgery compared to conservative medical treatment.

More recently, with improvements in neuroendoscopic NE techniques, basal ganglia hemorrhage has begun to be approached using the technique of NE [ 10 ]. Some studies indicated that the endoscope-assisted keyhole approach might be an efficiency, safety, and minimal invasiveness surgical intervention [ 11 , 12 ].

This study presented a new adjustable cannula application in NE operation via keyhole approach. At the Clinical Medical College of Yangzhou University, we have been applying the minimally invasive technique of NE approach to evacuate basal ganglia haemorrhage since Here, we compared the clinical and radiological outcomes of two intervention groups NE group versus traditional craniotomy group.

The goals of this study are to evaluate the effectiveness and safety of the NE approach to basal ganglia haemorrhage comparing with the craniotomy and to analyse the influences behind the surgical outcomes. This study was conducted in basal ganglia haemorrhage patients who had undergone NE or craniotomy in our department since June Fifty-one patients were randomly divided into 2 groups, the NE group 21 cases and the traditional craniotomy group 30 cases , that underwent NE surgery or craniotomy, respectively.

The exclusion criteria were any clinical signs of herniation, ICH located in the posterior cranial fossa or extension of the ICH into the brainstem, and any patients with tumor, coagulopathy, vascular lesion, or aneurysm diagnosed by CT scan, CT angiography, or coagulation function tests. Clinical data were collected for all cases during preceding preventative treatment.

CT scans were performed to calculate the intracerebral hematoma volumes and to provide a precise definition of the variations in the preoperative anatomical and pathological structures. The data obtained from these patients were analysed with respect to the clinical and radiographical outcomes, including gender, age, hematoma volume, Glasgow Coma Scale GCS on admission, physiological data, hematoma evacuation rate, operation time, and complications.

We also assessed neurological function recovery. All the patients had undergone neurological examinations at admission, after operation, and at each follow-up appointment. The following neurological treatment details were collected: 1 the GCS on the third postoperative day and at discharge; 2 the Glasgow Outcome Scale GOS at discharge and at follow-up examinations; 3 the modified Rankin Scale mRS on admission, on discharge, and during follow-up examinations conducted 6 months after surgery, and 4 good functional outcome GFO , which is defined as a patient being able to care for himself, corresponding to mRS of 0, 1, 2, or 3 and GOS of 4 or 5.

Evacuation of basal ganglia hemorrhage was performed through a rigid NE with an adjustable cannula developed by our surgical team, as shown in Figure 1. The surgical procedure was conducted under general anesthesia. Linear skin incisions were 4. The bone windows were 1.

The adjustable cannula was inserted followed by stylet application to confirm the location of hematoma. Then the NE, suction unit, or bipolar coagulator was introduced into cannula to evacuate the hematoma. The central part of the hematoma was evacuated using 2.

During the operation, obvious bleeding was stopped using the bipolar coagulator under low output power 4 to 8 Watts. When the evacuation was complete, saline was irrigated to locate any points of bleeding.

Then, homeostatic fibers were used to cover the surface of the hematoma cavity, and the control valve is switched to close the sheath canal again, regaining the bullet shape. Finally the adjustable cannula is pulled out slowly and the operation is finished. After the operation, all patients were transferred to the neurointensive care unit NICU for a few days until their condition began to stabilise.

All statistical analyses were performed using SPSS A probability value of less than 0. The data regarding age, hematoma volume, operation time, GOS score, GCS score, and mRS score were expressed in terms of mean values with corresponding standard deviations. An independent 2-sample -test was employed for comparison of the two intervention groups. A year-old man was transferred to our hospital due to a right basal ganglia cerebral hemorrhage.

On admission, his GCS score was 9. A brain CT scan revealed a right-lateral thalamic hemorrhage with moderate mass effect Figure 2 a. The volume of the hematoma was estimated to be We applied the temporal approach on this patient. Postoperative computed tomographic scanning revealed almost complete removal of the thalamic hematoma Figure 2 b.

The hematoma evacuation rate was The patient regained consciousness 1 week after surgery and could work independently at discharge. The intraoperative photo was shown in Figure 3. Between June and July , patients with basal ganglia hemorrhage were admitted to the Clinical Medical College of Yangzhou University. According to the inclusion and exclusion criteria mentioned above, a total of 51 cases were included, of which 21 involved patients who underwent NE approach and 30 underwent a traditional craniotomy.

This study included 38 men and 13 women, and the mean patient age was All patients underwent surgery within 24 hours of ictus, and 19 patients The mean clinical follow-up was 8.

There were no statistically significant differences in the baseline characteristics of each group, including age, sex, admission GCS score, admission mRS score, history of hypertension, and time between symptom onset and surgery, as shown in Table 1.

There was a statistical difference in the hematoma evacuation rate between the NE and craniotomy groups The mean NICU stay was 6. No patients died in the NE group, and three died in the traditional craniotomy group, but there was no significant difference in the mortality of the two groups. There was 1 case of rebleeding in the endoscopy group and 3 cases in the craniotomy group, but there were no significant differences in the rebleeding rate between the two groups 4.

In terms of infectious complications which included pneumonia and wound infection, there was 1 case of pneumonia and 1 case of wound infection in the endoscopy group and 9 cases of pneumonia and 2 cases of wound infection in the craniotomy group, with a significant difference in the incidence of infectious complications 9. With respect to long-term neurological functional outcomes, there were no significant differences in the mean GOS scores , GCS scores , and mRS scores between the two intervention groups.

However, the GFO was The basal ganglia hemorrhage is a common neurological disease with historically poor prognosis and outcomes [ 15 ]. Virtually all aspects of the management of basal ganglia hemorrhage are still not uniformly agreed upon [ 16 ]. The prognosis is influenced by several factors, including the origin of bleeding, initial GCS score, and hematoma volume.

During the first 12 hours after onset, the intracranial pressure ICP can increase suddenly due to a mass effect associated with hematoma volume [ 17 ]. This factor may cause a significant reduction in cerebral blood flow to the brain tissue surrounding the hematoma, potentially leading to ischemia.

Therefore, hematoma evacuation is a main target of surgical treatment. The early craniotomy surgery could immediate removal of the hematoma, a dramatic reduction of ICP, relief of cerebral edema, improvement in local blood circulation, and a reduction in mortality [ 18 ]. However, early methods of craniotomy failed to protect the still functional brain tissue surrounding the hematoma and caused too much damage. A Cochrane systematic review [ 19 ] revealed that the use of traditional craniotomy for the treatment of ICH remains controversial.

Advances in neuroimaging, together with rising interest in minimally invasive techniques, have resulted in the establishment of modern neuroendoscopy [ 20 ]. NE surgery has many advantages, such as minimally invasive, high evacuation rate, low incidence of complication, better protection of brain tissue, and less surgery related injuries [ 21 ]. In recent decades, some studies of ICH evacuation using the NE approach have placed great emphasis on protection of the surrounding brain regions and demonstrated high evacuation rate ranging from Results of the radiographical outcomes in our study showed that the hematoma evacuation rate in the NE group was higher than in the traditional craniotomy group.

In this present study, we applied NE through an adjustable cannel to treat basal ganglia hemorrhage. This new application has several benefits. Firstly, the end of auxiliary sheath is in bullet shape, which could protect the brain tissues during operation.

Secondly, the precise scales marked on the sheath canal could help surgeon to reach the predicted depth with accuracy. In association with the craniocerebral lesion or the hematoma exacted by sheath canal, the position of brain lesions or hematoma would be determined precisely. Thirdly, the control valve is rotated, being wide enough to form a channel to expose brain lesions to a large extent.

Therefore the surgeon could work more flexibly under endoscopy. Fourthly, the bolt of auxiliary sheath is connected to the fixed operation device, which is beneficial for the removal of cerebellar hematoma or brain lesions under endoscopy. Fifthly, the material of auxiliary sheath is titanium alloy that is light weighted and tough enough to be adopted in this case. Last but not least, this application is designed carefully but not complicated, which makes it easily to be manufactured.

When we applied NE in the treatment of basal ganglia haemorrhage, the follow-up outcomes revealed lower rebleeding rate in the NE group than in the control group 4. However, we found that this approach permitted direct identification of the bleeding points and permitted coagulation of the responsible vessels under endoscopic visualisation without overstretching the brain tissue.

The incidence of infectious complications in the NE group was low, because of milder brain injury, shorter skin incisions, and shorter operation times. The reasons for these benefits are multiple and include the following. The NE provides enough space and visibility to manage intraoperative bleeding. There was excellent visual quality in the deep and narrow fields when using adjustable cannula.

In this study, the offending vessel was found in more than half of the cases. We used the bipolar coagulator on the active bleeding point and gelatin sponge compression hemostasis on the minor bleeding. It was easy to find the bleeding point and to ensure effective hemostasis. The results showed that patients in the NE group stayed in the NICU for a shorter time than patients in the control group.

The NE approach did not require drainage and avoided the ongoing inflammatory response caused by blood and its breakdown products, resulting in faster recovery. The mean operative time resulting from our study showed shorter operation times when using the NE approach. We also summarised the experience of endoscopic surgery for the treatment of SICH.

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While we are building a new and improved webshop, please click below to purchase this content via our partner CCC and their Rightfind service. You will need to register with a RightFind account to finalise the purchase. EN English Deutsch. Your documents are now available to view. Confirm Cancel. Anne-Katrin Hickmann.

Developed 20 years ago by leading innovators in the field, the keyhole concept of brain surgery has become an integral part of the practice of neurosurgery. This timely and comprehensive book covers the thinking, philosophy, and techniques of modern keyhole brain surgery, including a realistic assessment of its benefits and limitations. Written by expert practitioners and highlighted by vivid surgical illustrations and procedural videos, Principles and Practice of Keyhole Brain Surgery functions as an experienced mentor working side by side with neurosurgeons as they master the techniques. Providing all the information necessary to achieve surgical goals through well placed, smaller openings—with the added benefits of shorter procedures, fewer wound complications and better patient outcomes— Principles and Practice of Keyhole Brain Surgery is essential for every neurosurgeon in practice today. A step-by-step guide to modern techniques of keyhole brain surgery Developed 20 years ago by leading innovators in the field, the keyhole concept of brain surgery has become an integral part of the practice of neurosurgery.

It is dedicated to trainees or recent graduates in Neurosurgery but the quality of text provides important informations to senior neurosurgeons …. The book with a high quality text and excellent illustrations is quite classical …. Skip to main content Skip to table of contents. Advertisement Hide. This service is more advanced with JavaScript available.


Principles and Practice of Keyhole Brain Surgery. Charles Teo, AM, MBBS, FRACS. Director. Centre for Minimally Invasive Neurosurgery. Sydney, Australia.


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The initial optimal treatment for most gliomas is maximal surgical removal. For patients with higher grade gliomas, surgery is followed by radiation therapy and chemotherapy. Fortunately, most gliomas can be surgically removed through one of several keyhole routes depending upon tumor location and size. We have a large experience in the comprehensive personalized care of all types of gliomas including low-grade astrocytomas, oligodendrogliomas, anaplastic astrocytomas and glioblastomas.

Figure 1: Harvey Cushing demonstrates creation of a trephine craniotomy at the upper edge of frontal bone work. Note the use of tourniquet to control scalp bleeding. This Cranial Approaches volume provides a road map regarding the indications, rationale, and technical nuances for execution of common supratentorial and infratentorial operative corridors.

The book is the accumulation of 30 years of experience and over brain operations. Your email address will not be published. Notice: It seems you have Javascript disabled in your Browser.

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The book is the accumulation of 30 years of experience and over brain operations.

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The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Kenan I. By: Charles Teo, Michael E.

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