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Face-to-face four hand technique in vestibular schwannoma surgery: results from 256 Danish patients with larger tumors

  • Original Article - Tumor - Schwannoma
  • Published:
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Abstract

Background

The objective of this study was to investigate the clinical outcome after microsurgical treatment of vestibular schwannomas using face-to-face four hand technique in 256 Danish patients treated in the Department of Neurosurgery at the Copenhagen University Hospital from 2009 to 2018.

Methods

Data were retrospectively collected from patient records.

Results

The mean tumor size was 30.6 mm and approximately 46% of the patients had tumors >30 mm. In around 1/3 of the patients a retrosigmoid approach was used and in 2/3 a translabyrinthine. In 50% of the patients, the tumor was completely removed, and in 38%, only smaller remnants were left to preserve facial function. The median operative time was approximately 2.5 h for retrosigmoid approach, and for translabyrinthine approach, it was around 3.5 h. One year after surgery, 84% of the patients had a good facial nerve function (House-Brackmann grade 1–2). In tumors ≤ 30 mm approximately 89% preserved good facial function, whereas this was only the case for around 78% of the patients with tumors > 30 mm. In 60% of the patients who had poor facial nerve function at hospital discharge, the function improved to good facial function within the 1 year follow-up period. Four patients died within 30 days after surgery, and 6% underwent reoperation for cerebrospinal fluid leakage.

Conclusion

Surgery for vestibular schwannomas using face-to-face four hand technique may reduce operative time and can be performed with lower risk and excellent facial nerve outcome. The risk of surgery increases with increasing tumor size.

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, Copenhagen University Hospital, DK-2100, Copenhagen, Denmark

    Jacob Bertram Springborg, Jeppe Mathias Lang, Kåre Fugleholm & Lars Poulsgaard

Authors
  1. Jacob Bertram Springborg
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  2. Jeppe Mathias Lang
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  3. Kåre Fugleholm
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  4. Lars Poulsgaard
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Corresponding author

Correspondence to Jacob Bertram Springborg.

Ethics declarations

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements) or nonfinancial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in this study were in accordance with the ethical standards of the Danish Health Authority and the Danish Data Protection Agency (RH-2017-103, I-Suite number 05418) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study individual formal consent is not required.

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Comments

In this retrospective study, the authors investigated the outcome of 256 Danish patients with vestibular schwannomas (VS) resected either by a translabyrinthine (TL) or a retrosigmoid (RS) approach. A total of 53.9% VS were smaller than 30 mm and 46.1% were larger. Complete, near total, and partial resections were achieved, respectively, in 50.4%, 38.3%, and 11.3%. Operative time was statistically significantly related to the surgical approach (RS approach: ≃2.5 h vs TL approach: ≃3.5 hours) and the size of the tumor. Tumor size was a statistically significant factor associated with the extent of tumor resection. One year after surgery, 84% of the patients have a good facial nerve function (House-Brackmann grade 1–2). The probability of good facial nerve function was statistically significantly dependent of the tumor size (VS ≤ 30 mm: 89.2%, VS > 30 mm: 77.8%) and intraoperative facial nerve appearance but was not related to the extent of resection. Four patients died within 30 days after surgery. A total of 5.1% had postoperative rhinoliquorrhea which required reoperation in 92.3%, 0.4% had otoliquorrhea, and 9% had skin CSF fistula requiring different reoperations in 34.7%.

The authors used a retractorless four hand technique with 2 skull base surgeons operating face-to-face across the patient’s head. The surgeon’s strategy favored a better postoperative facial nerve function than a higher extent of VS resection. Conceptually, a four hand technique could be associated with some advantages including better tasks distribution with possible subsequent reduction in the operative time, higher teaching opportunities when working with a resident or skills potentiation when 2 experienced neurosurgeons work face-to-face. It requires nevertheless some setup arrangements to minimize mutual interferences, a presupposed need for a wider corridor, a learning curve associated with a different angle of view, and a perfect collaboration. The authors have to be congratulated for detailing their concept. Further studies are needed with analysis of all benefits and potential complications before supporting any generalization of this technique.

Michaël Bruneau

Erasme Hospital, Brussels.

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Springborg, J.B., Lang, J.M., Fugleholm, K. et al. Face-to-face four hand technique in vestibular schwannoma surgery: results from 256 Danish patients with larger tumors. Acta Neurochir 162, 61–69 (2020). https://doi.org/10.1007/s00701-019-04148-0

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  • DOI: https://doi.org/10.1007/s00701-019-04148-0

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