Abstract
Background
A repair strategy for venous bleeding from the superior petrosal vein (SPV) is essential during endoscopic microvascular decompression.
Method
Sliced oxycellulose seats are rounded off, making balls around 10 mm in diameter. When venous bleeding arises from the SPV, the first oxycellulose ball is placed just behind the SPV in the surgical view. A second ball is then applied in front of the SPV. The SPV is thus immediately and entirely covered by oxycellulose, and hemostasis is safely achieved with the preservation of the SPV.
Conclusion
This oxycellulose ball technique offers simple, reliable control of venous bleeding from the SPV.
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References
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The institutional ethics committee approved this study, and informed consent was obtained from the patients.
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The authors declare that they have no conflict of interest.
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Key points
1. Oxycellulose balls around 10 mm in diameter are prepared in advance for venous bleeding from the SPV.
2. Continuous suction and/or intermittent irrigation is needed to maintain a clear surgical field after venous bleeding.
3. The first oxycellulose ball should be applied behind the SPV on the surgical view, not in front of the SPV. The optimally sized oxycellulose ball gently compresses the SPV and its attachment to the SPS.
4. The second oxycellulose ball is applied in front of the SPV on the surgical view, using the first ball as a scaffold.
5. Proper head elevation may expedite control of venous bleeding from the SPV.
6. Excess compression should be avoided to minimize the risk of thrombosis and obstruction in the SPV.
7. Coagulation of the SPV by bipolar forceps should be avoided.
8. Fibrin glue can be applied for reinforcement of the SPV after complete hemostasis, but direct injection into the SPV during bleeding should be avoided to prevent thrombosis in the SPV.
9. All oxycellulose balls are gently removed after complete hemostasis to maintain a clear surgical field for MVD.
10. Postoperatively, the patient must be carefully observed for the possible development of postoperative re-bleeding, venous congestion, and hemorrhagic infarction.
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Video 1
A 4-mm, 0° endoscope is inserted from a retrosigmoid keyhole and the SPV, CN V, and SCA (offending artery) are visualized. While the offending artery is manipulated, the SPV is stretched and venous bleeding is started from the junction of the SPV and SPS. The first oxycellulose ball is applied using single-shaft forceps just behind the SPV in the surgical view. The first oxycellulose ball is fit to the back side of the SPV and its attachment to the SPS. The second oxycellulose ball is applied in front of the SPV in the surgical view. The entire course of the SPV and its attachment to the SPS are immediately covered by oxycellulose balls. After confirming complete hemostasis, the oxycellulose balls are carefully removed. Offending arteries from the SCA are transpositioned using Teflon string fixed to the tentorium cerebelli. Finally, secure MVD is achieved with preservation of the SPV. CN V trigeminal nerve; CN VII, facial nerve; CN VIII, vestibulocochlear nerve; OB, oxycellulose ball; SCA, superior cerebellar artery; SM, suprameatal tubercle; SPV, superior petrosal vein; Tef, Teflon; Tent, tentorium cerebelli. Arrow, venous bleeding. (WMV 95087 kb)
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Komatsu, F., Ghosh, P. & Sengupta, R. How I do it: Management of venous bleeding from the superior petrosal vein during endoscopic microvascular decompression. Acta Neurochir 163, 2403–2405 (2021). https://doi.org/10.1007/s00701-020-04659-1
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DOI: https://doi.org/10.1007/s00701-020-04659-1