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How I do it: 3D exoscopic endoscope-assisted microvascular decompression

  • How I Do it - Neurosurgical technique evaluation
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Abstract

Background

Microvascular decompression (MVD) is an effective treatment for drug-resistant trigeminal neuralgia and hemifacial spasm. However, failure of symptomatic improvement can arise from difficulties in identifying and/or decompressing the offending vessel. Microscopic and endoscopic techniques have been used to improve visualisation and safety of the procedure but there are limitations to each technique.

Method

A 3D exoscopic endoscope-assisted MVD technique is described, including advice on potential pitfalls.

Conclusion

Compared with the standard microscope-assisted techniques, the 3D exoscopic endoscope-assisted MVD offers an improved visualisation without compromising the field of view within and outside the surgical field.

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Acknowledgments

The authors acknowledge Karl Storz Australia for the support with regard to the use of the 3D VITOM exoscope.

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Authors and Affiliations

  1. Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Neurosurgery Unit, Macquarie University, Level 2, Suite 201, 2 Technology Place, Sydney, NSW, 2109, Australia

    Angela Li Ching Ng & Antonio Di Ieva

Authors
  1. Angela Li Ching Ng
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  2. Antonio Di Ieva
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Corresponding author

Correspondence to Antonio Di Ieva.

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Conflict of interest

The authors declare that they have no conflict of interest.

Informed consent

Informed consent was obtained from the patient included in the study.

Additional information

Summary of key points

• The combined exoscope-endoscopic technique enhances the operative field of view by its bimodal system and makes inserting or removing instruments from the operative field safer.

• The use of EMG and brainstem evoked potential is recommended.

• The exoscope should be used along each surgical step whenever possible.

• The endoscope is used as an adjunct to enhance visualisation and identification of the offending vessel.

• A post-decompression check can also be performed with the endoscope and confirmed by the use of microscope.

• The nerve should be decompressed along the whole length of the nerve, as multiple areas of compression can be present. Careful pre-operative analysis of the CISS-MRI can help to identify further vascular loops causing cranial nerve compression.

• Teflon pledgets can be kept in place using fibrin sealant at the end of the decompression.

• There is a different learning curve to this technique and the use of the combined approach is recommended for simple procedures when starting out.

• Anatomical training lab is essential for mastering the technique, as well as testing the best ergonomics in terms of positioning of the exoscope and endoscope arms, monitors, etc.

• The endoscope can be used pre- and post-decompression to enhance visualisation of the neurovascular complex.

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Li Ching Ng, A., Di Ieva, A. How I do it: 3D exoscopic endoscope-assisted microvascular decompression. Acta Neurochir 161, 1443–1447 (2019). https://doi.org/10.1007/s00701-019-03954-w

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  • DOI: https://doi.org/10.1007/s00701-019-03954-w

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