Tissue dissection before direct manipulation to the pathology with pulsed laser-induced liquid jet system in skull base surgery—preservation of fine vessels and maintained optic nerve function
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Most difficulties in skull base tumor removal are generally caused by adhesion of feeding arteries to the vital structures and cranial nerves. Water jet technology provides tissue dissectability with preservation of fine blood vessels both in experimental and clinical situations. However problems still remain regarding whether tumor removal with preservation of peripheral nerve function is possible or not. This clinical investigation evaluated functional preservation of peripheral nerves and dissectability with a newly developed pulsed laser-induced liquid jet (LILJ) system under intraoperative electrophysiological monitoring.
The LILJ system was used to treat 21 patients with skull base tumors manifesting as severe visual disturbance through the extended transsphenoidal approach. The LILJ system consists of a bayonet-shaped catheter incorporating a jet generator, and total weight is around 7 g. Intraoperative visual evoked potential (VEP), and pre/postoperative conventional visual assessments were investigated.
Precise dissections of the tumor were obtained, resulting in gross total removal in 19 of 21 patients. Two patients with meningiomas with tight adhesion to the origin of the lenticulostriate arteries had small remnants. Of the 21 patients, 16 showed immediate improvement on intraoperative VEP, 2 had no change, and 3 had prolonged latency, which required intermittent suspension of procedure. A total of 20 patients and 40 eyes showed good recovery at discharge, and all patients evaluated had recovered good visual status.
The LILJ system can achieve safe and optimal removal with functional preservation of optic nerves, probably because of the high resistance of the arachnoidal sheath and fine vascular tissue.
KeywordsCranial nerve Functional preservation Ho:YAG laser Skull base tumor Vascular preservation Water jet
Conflicts of interest
Sources of financial and material support
This work was partially funded by Ministry of Economy, Trade, and Industry, Japan as a part of Program to support collaboration between hospitals and businesses for development and improvement of medical equipment and devices to solve unmet medical needs (supplementary budget, 2010FY ZEN 219 to YO, AN, and TT); a Grant-in-Aid for Scientific Research (B) (No. 18390388 to AN), Grants-in-Aid for Young Scientists (A) (Nos. 19689028 and 22689039 to AN), and Challenging Exploratory Research (Nos. 21659313 to AN and 24592152 to YO and AN) from the Japanese Ministry of Education, Culture, Sports, Science, and Technology; the Japanese Foundation for Research and Promotion of Endoscopy Grant (to TN and AN); the Tohoku University Exploratory Research Program for Young Scientists (to AN); the Collaborative Research Project of the Institute of Fluid Science, Tohoku University (to AN); and Ogino Research Facilitating award from Japanese Society of Biomedical Engineering (to AN).
This case was a soft meningioma, which could be partially de-bulked by the LILJ system. Video that demonstrates tissue dissection with fine artery preservation, 1.05 min, 25.2 MB. (MPG 25828 kb)
- 3.Couldwell WT, Weiss MH, Rabb C, Liu JK, Apfelbaum RI, Fukushima T (2004) Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: Surgical experience in 105 cases. Neurosurgery 55:539–550PubMedCrossRefGoogle Scholar
- 4.Hirano T, Nakagawa A, Uenohara H, Ohyama H, Jokura H, Takayama K, Shirane R (2003) Pulsed liquid jet dissector using holmium: YAG laser–a novel neurosurgical device for brain incision without impairing vessels. Acta Neurochir (Wien) 145:401–406Google Scholar
- 6.Huttner HB, Steiner T, Hartmann M, Kohrmann M, Juettler E, Mueller S, Wikner J, Meyding-Lamade U, Schramm P, Schwab S, Schellinger PD (2006) Comparison of ABC/2 estimation technique to computer-assisted planimetric analysis in warfarin-related intracerebral parenchymal hemorrhage. Stroke 37:404–408PubMedCrossRefGoogle Scholar
- 15.Ohki T, Nakagawa A, Hirano T, Hashimoto T, Menezes V, Jokura H, Uenohara H, Sato Y, Saito T, Shirane R, Tominaga T, Takayama K (2004) Experimental application of pulsed Ho:YAG laser-induced liquid jet as a novel rigid neuroendoscopic dissection device. Lasers Surg Med 34:227–234PubMedCrossRefGoogle Scholar