Dual Endoscopic Endonasal Transsphenoidal and Precaruncular Transorbital Approaches for Clipping of the Cavernous Carotid Artery: A Cadaveric Simulation

Abstract

IntroductionEndoscopic endonasal approaches for sellar, parasellar, cavernous sinus, middle fossa, and petrous apex pathology have increased significantly. 1 The increase application of the expanded endoscopic endonasal approach places the cavernous carotid artery (CavCA) at increased risk of injury during the resection of the pathology that affects these regions. Highly vascular, large, calcified lesions that obstruct visualization of the normal anatomic landmarks can limit the extent of resection and lead to poor visualization of the carotid artery subjecting it to injury. Limitations of traditional endoscopic approaches show Keywords ► cavernous carotid artery ► CavCA ► aneurysm clipping ► simulation training ► endonasal transsphenoidal approach ► precaruncular transorbital approach AbstractBackground Endoscopic skull base approaches are being used to address complicated neurovascular pathology. These approaches are safest when proximal vascular control of the cavernous carotid artery (CavCA) can be obtained.Methods We present a cadaver-based anatomic simulation study showing the feasibility of clip placement for the CavCA as it courses through the cavernous sinus. The arterial vessels were injected with red microfil (Flow Tech, Carver, Massachusetts) to enhance visibility. The endoscope was directed through a precaruncular transorbital approach and instrumentation was managed through an endonasal transsphenoidal approach.Results The dual approach minimized the "coning down" and instrument "sword fighting" that occurs as the rod lens endoscope and instruments are used laterally and posterior toward the clivus and brainstem. The precaruncular transorbital approach improved visualization of the clip application and improved the functional working area. The transorbital port allowed better appreciation of the distal clip tines, and the laterally positioned cranial nerves. Conclusions The advantages may be most realized in the setting of endoscopic endonasal resection of highly vascular lesions and/or bleeding from a ruptured aneurysm being clipped. Simulated training provides an excellent opportunity to enhance skill sets and increase familiarity with anatomical visualization before entering the operative arena.

A Systematic Review of Simulation-Based Training in Neurosurgery, Part 1: Cranial Neurosurgery

“…105 . Postsimulation surveys provided favourable responses to the simulation, demonstrating a LoE of 1, however little validity was demonstrated with level 0 achieved in relations to other variables as neurosurgeons were compared with anaesthetists with no significant difference.A task and crisis simulator for vertebroplasty in an immersive operating theatre was rated well for training and realism, by both expert and junior neurosurgeons106 .…”