Needle path planning in semiautonomous and teleoperated robot-assisted epidural anaesthesia procedure: A proof of concept.

BACKGROUND: Epidural anaesthesia is a Percutaneous Procedure (PP) which plays a crucial role in surgical procedures, where accurate needle insertion is still challenging. The objective of this work is to present a Tuohy needle path planning, which allows an anaesthesiologist to drive semiautonomously, with the assistance of a teleoperated robot, the tip of the needle during this PP. METHODS: We capture, analysed and modelled the anaesthetist hands' motion during the execution of this procedure, by synthetising, programing and simulating a parametrised and normalised kinematic constrains dependent on an insertion variable in a virtual robot. RESULTS: Two preoperative path planning models were obtained, which provide a teleoperated robot with kinematic constraints to semiautonomously drive a Tuohy needle in the epidural anaesthesia procedure. CONCLUSIONS: A semiautonomous robot can assist in the execution of this PP using the kinematic constraints obtained from the study of the movement of a specialist's hands.

Endonasal Endoscopic and Hybrid Surgery Techniques for Blunt Trauma Fractures of the Skull Base With Cerebrospinal Fluid Leaks.

ABSTRACT: Cerebrospinal fluid (CSF) leakage caused by skull base fracture represents high risks of bacterial meningitis, and a rate of mortality of 8.9%. Endoscopic endonasal repair of CSF leaks is quite safe and effective procedure with high rates of success. The aim of this study is to describe our technique for management of skull base CSF leaks secondary to craniofacial trauma based on the anatomic location of the leak. This is a retrospective case series of 17 patients with diagnosis of craniofacial trauma, surgically treated with sole endonasal endoscopic and combined endonasal/transcranial approaches with diagnosis of CSF leak secondary to skull base fractures. Seventeen patients met inclusion criteria for this study. Mean age was 46 years old. Most common etiology was motor vehicle. Early surgery was performed in 8 patients, and late surgery in 9 patients. The most common site of CSF leak was at ethmoid cells or at the fronto-ethmoid junction in 9 patients. Thirteen patients (76.4%) were treated only with endonasal endoscopic technique, and 4 (23.5%) with hybrid surgery, combining endonasal endoscopic and cranial bicoronal approaches with nasal and pericranial vascularized flaps, and nasal mucosal free flaps. Mean hospital stay was 23.7 days.The mean follow-up time was 25.6 months. When surgical reconstruction is indicated for CSF leaks secondary to skull base fractures, endonasal endoscopic techniques should be part of the surgical management either as a sole procedure, or in combination with classical transcranial approaches with high rates of success and low morbidity.

Feasibility of endoscopic endonasal approach for clip application of cerebral aneurysms: a systematic review.

INTRODUCTION: While open, microsurgical clipping and endovascular coiling remain the gold standards for treatment of cerebral aneurysms, a growing number of aneurysms treated via endoscopic endonasal methods have been reported in the literature. The aim of this study was to conduct a systematic review of the literature to gain a more thorough appreciation of the potential benefits and drawbacks of the endoscopic endonasal strategy in this setting. EVIDENCE ACQUISITION: We performed a detailed systematic review of the medical literature on endoscopic endonasal skull base surgery for treatment of cerebral aneurysms utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We identified 9 clinical studies describing treatment of 23 aneurysms utilizing the EEA. Eleven additional cadaveric studies investigating aspects of operative exposure and/or technique in this setting were identified. The full text of these articles was reviewed. EVIDENCE SYNTHESIS: In the 9 clinical studies that met inclusion criteria, 23 aneurysms were treated in 21 patients. The mean patient age was 52.6 years. 15 aneurysms were unruptured and 8 were ruptured. Fourteen aneurysms involved the anterior circulation and 9 involved the posterior circulation. In 21 of 23 aneurysms, complete occlusion was achieved with endonasal clipping. Two aneurysms required additional treatment that included a takeback for clip repositioning and staged endovascular coiling. Complications included post-operative CSF leak (23.8%), stroke (19%), and meningitis (14.3%). Analysis of the combined literature revealed a significantly higher rate of CSF leak with endonasal clipping of posterior circulation aneurysms compared to anterior circulation aneurysms (P=0.047, Fisher's Exact Test). While there was a trend towards increased post-operative neurologic deficit following EEA for posterior circulation aneurysms, this did not reach statistical significance (P=0.063). The majority of post-operative complications in posterior circulation aneurysms occurred during clip application of aneurysms at the level of the basilar apex. In addition to the aforementioned clinical reports, 11 cadaveric studies were identified. 4 of these reports investigated approaches for individual anterior circulation aneurysms, 5 investigated approaches for posterior circulations aneurysms, and 2 involved both anterior and posterior circulation aneurysms. CONCLUSIONS: Despite a moderate increase in utilization, caution should be exercised when choosing an endonasal strategy for treatment of aneurysmal pathology over more traditional and established methods such as microsurgical clip application and endovascular methods. Anecdotal evidence suggests that inferior and/or medial projecting aneurysms involving the paraclinoid ICA not amenable to traditional open/endovascular strategies may be reasonable to consider for EEA clip application. Wide-necked, midline, ventrolaterally-projecting aneurysms involving the vertebrobasilar system may represent an additional exception, as long as the location along the rostrocaudal axis is low enough so as not to compromise visualization. Future improvements in operative technology, including anticipated advances in endoscopic 3-D visualization, may further alter the landscape of treatment involving this complex pathology.

Anatomía microquirúrgica e irrigación arterial de la región uncal / Microsurgical anatomy and arterial irrigation of the uncal region

El objetivo de este trabajo fue realizar una revisión microquirúrgica de los principales ramos arteriales que otorgan irrigación a la región uncal, identificando sus principales variantes y sus relaciones anatómicas mas relevantes con las estructuras circundantes. Se estudiaron 20 hemisferios cerebrales con el sistema arterial perfundido con latex y colorante mediante disección microquirúrgica y bajo aumento con un rango de 3X a 40X. Se realizaron registros morfométricos de las principales estructuras. La irrigación de la región uncal del lóbulo temporal se establece principalmente por tres grupos de ramas uncales: las ramas uncales anteriores provenientes de la arteria temporopolar que es uno de las ramas colaterales que inicialmente se derivan de la arteria cerebral media en su segmento M1. Ramas uncales mediales provenientes de la arteria coroidea anterior en su trayecto cisternal. Ramas uncales posteriores provenientes de los segmentos P2A y P2P de la arteria cerebral posterior. La relevancia de la descripción vascular arterial de la región uncal radica en la aplicación del conocimiento de estas relaciones y variantes durante los diversos procedimientos diagnósticos y quirúrgicos del lóbulo temporal.

The objective of this work was realizing a microsurgical review of the main arterial ramus that distribute irrigation to the uncal region, identifying the most common variations and more relevant relationships with surrounding structures. Twenty (20) fixed human brain hemispheres were studied, with the arterial latex and red colorant perfusion technique for dissection under microscope magnification (3X-40X). Morphometric characterization and data were obtained of the structures studied. Arterial irrigation of the uncal region of the temporal lobe is established by three groups of uncal ramus: the anterior uncal rami, deriving from the temporopolar artery, which is one of the first branches of the middle cerebral artery in segment M1. The medial uncal rami, branches of the cisternal portion of the anterior choroidal artery. The posterior uncal rami, branches of the P2A and P2P segments of the posterior cerebral artery. The relevance of arterial vascular description of the uncus, results in the application of knowledge of the variations and relationships during the diagnostic and surgical procedures of the temporal lobe.