3-D vs. 2-D Endoscopy

By Suzanne Potter, PNA Editor

Two PNA-member neurosurgeons and a Brazilian colleague have collaborated to evaluate the new 3-D endoscope technology. They found that it makes transsphenoidal surgery of pituitary adenomas faster and more efficient, but does not improve outcomes in terms of complication, reoperation, tumor resection, or intraoperative cerebrospinal fluid leaks.

Dr. Garni Barkhoudarian, (with the Brain Tumor Center & Pituitary Disorders Program at the John Wayne Cancer Institute at Saint John's) and Dr. Edward Laws (of Brigham and Women's Hospital) worked with a neurosurgeon in Porto Alegre, Brazil to analyze 160 endoscopic operations over 18 months; 65 used the Visionsense VSII 3-D endoscope and 95 were performed with the 2-dimensional high-definition Storz endoscopes. They concluded that "The 3-D endoscope is a useful alternative to the 2-D HD endoscope for transnasal anterior skull-base surgery. Preliminary results suggest it is more efficient surgically and has a shorter learning curve. As 3-D technology and resolution improve, it should serve to be an invaluable tool for neuroendoscopy." Their article was published in the September 2013 edition of the medical journal Neurosurgery. 

Dr. Garni Barkhoudarian Dr. Edward Laws
Dr. Garni Barkhoudarian Dr. Edward Laws

Evaluation of the 3-Dimensional Endoscope in Transsphenoidal Surgery
Barkhoudarian, Garni MD*; Del Carmen Becerra Romero, Alicia MD, PhD‡; Laws, Edward R. MD§

Author Information
*Brain Tumor Center & Pituitary Disorders Program, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California;

‡Department of Neurosurgery and Skull Base Surgery, Hospital Ernesto Dornelles, Porto Alegre, Brazil;

§Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts

Correspondence: Garni Barkhoudarian, MD, Brain Tumor Center & Pituitary Disorders Program, John Wayne Cancer Institute at Saint John's Health Center, 2200 Santa Monica Blvd, Santa Monica, CA, 90404. E-mail: [email protected]

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site ( www.neurosurgery-online.com).

Received August 29, 2012

Accepted February 05, 2013

Abstract
BACKGROUND: Three-dimensional (3-D) endoscopy is a recent addition to augment the transsphenoidal surgical approach for anterior skull-base and parasellar lesions. We describe our experience implementing this technology into regular surgical practice.

OBJECTIVE: Retrospective review of clinical factors and outcomes.

METHODS: All patients were analyzed who had endoscopic endonasal parasellar operations since the introduction of the 3-D endoscope to our practice. Over an 18-month period, 160 operations were performed using solely endoscopic techniques. Sixty-five of these were with the Visionsense VSII 3-D endoscope and 95 utilized 2-dimensional (2-D) high-definition (HD) Storz endoscopes. Intraoperative and postoperative findings were analyzed in a retrospective fashion.

RESULTS: Comparing both groups, there was no significant difference in total or surgical operating room times comparing the 2-D HD and 3-D endoscopes (239 minutes vs 229 minutes, P = .47). Within disease-specific comparison, pituitary adenoma resection was significantly shorter utilizing the 3-D endoscope (surgical time 174 minutes vs 147 minutes, P = .03). These findings were independent of resident or fellow experience. There was no significant difference in the rate of complication, reoperation, tumor resection, or intraoperative cerebrospinal fluid leaks. Subjectively, the 3-D endoscope offered increased agility with 3-D techniques such as exposing the sphenoid rostrum, drilling sphenoidal septations, and identifying bony landmarks and suprasellar structures.

CONCLUSION: The 3-D endoscope is a useful alternative to the 2-D HD endoscope for transnasal anterior skull-base surgery. Preliminary results suggest it is more efficient surgically and has a shorter learning curve. As 3-D technology and resolution improve, it should serve to be an invaluable tool for neuroendoscopy.

ABBREVIATION: HD, high definition

The first successful transsphenoidal surgery for a pituitary lesion was performed by Schloffer in 1907.1 Harvey Cushing in Baltimore and 2 surgeons in Chicago, Allen Kanavel and Albert Halstead, each reported their results between 1909 and 1910.2-4 During the 1960s, improvements were introduced, such as the operative microscope and video fluoroscopy. Gerard Guiot and Jules Hardy reintroduced and revitalized the transsphenoidal approach for pituitary lesions.5,6 Surgical techniques continued to develop, and transsphenoidal neuroendoscopy became part of the armamentarium.7-9 A major limiting factor for the endoscopic surgeon is to work in a 3-dimensional (3-D) field while viewing a 2-dimensional video image.10,11 The introduction of 3-D neuroendoscopy has begun to address this issue. As experience with these devices increases and the technology matures, the advantages and disadvantages of 3-D neuroendoscopy can be further delineated.9,12 This report describes our experience with implementing this technology into regular surgical practice at the Brigham and Women's Hospital.

PATIENTS AND METHODS

Surgical Approach

The patient is positioned recumbent in a beach-chair fashion, with the head placed in 3-point fixation tilted slightly away from the surgeon. Intraoperative neuronavigation is used routinely. The initial exposure is performed with a short (18-20 cm) endoscope by 1 surgeon (2 hands). After the sella is exposed, the operation is continued via a bi-nostril 2-surgeon (3 or 4 hands) technique. The endoscope is always held by the assistant surgeon (resident or fellow), and the endoscope holder is not used. This allows for the assistant to remain engaged in the operation—a notable aspect in a teaching institution. Additionally, the ability to magnify on a specific area of interest is much quicker than if an endoscope holder was used. Angled endoscopes can be introduced after initial debulking of the tumor. A pedicled, nasoseptal flap is used for closure for extended transsphenoidal approaches. Fat grafts are placed only in the setting of intraoperative cerebrospinal fluid (CSF) leakage. CSF diversion by lumbar drain is used sparingly. Postoperative management includes frequent neurological evaluation, strict fluid management, and hormone replacement when indicated. Routine evaluation for delayed syndrome of inappropriate secretion of antidiuretic hormone and hypocortisolemia is performed 1 week after the operation.

Endoscopy

The high-definition (HD) 2-dimensional (2-D) endoscope (Karl Storz Neuroendoscopy) was used for all 2-D cases. The 3-D endoscope (Visionsense VSII) was introduced at the Brigham and Women's Hospital in November 2010. After a trial period of 20 operations, it was reintroduced in November 2011. From November 2010 to May 2012, 160 endoscope-only transsphenoidal operations were performed, of which 65 were with the 3-D endoscope. Subsequent to the initial trial, the 3-D endoscope was preferentially used when available for each operation. During the period that the 3-D endoscope has been available at our institution, the 2-D HD endoscope was only used for intraoperative magnetic resonance imaging (MRI) operations (5 cases), during technological malfunctions of the 3-D endoscope system (3 cases), and when instrument turnover time prohibited timely availability of the 3-D endoscope (5 cases).

Data Analysis

After approval by the institutional review board (IRB # 2011P001284), all sequential transnasally operated patients since the introduction of the 3-D endoscope at the Brigham and Women's Hospital were identified (November 2010 to May 2012). Patient demographics, pituitary function, intraoperative findings, imaging, pathological evaluation, and postoperative outcomes were recorded and analyzed. Operations that included the use of both the endoscope and microscope were excluded. Statistical analysis was performed with SPSS software package v12. Analysis OF variance was performed for continuous variables. χ2 analysis was performed for nonparametric variables.

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