Robot-assisted endoscopic third ventriculostomy: institutional experience in 9 patients

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>The endoscopic third ventriculostomy (ETV) is an established and effective treatment for obstructive hydrocephalus. In its most common application, surgeons plan their entry point and the endoscope trajectory for the procedure based on anatomical landmarks, then control the endoscope freehand. Recent studies report an incidence of neural injuries as high as 16.6% of all ETVs performed in North America. The authors have introduced the ROSA system to their ETV procedure to stereotactically optimize endoscope trajectories, to reduce risk of traction on neural structures by the endoscope, and to provide a stable mechanical holder of the endoscope. Here, they present their series in which the ROSA system was used for ETVs.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>At the authors’ institution, they performed ETVs with the ROSA system in 9 consecutive patients within an 8-month period. Patients had to have a favorable expected response to ETV (ETV Success Score ≥ 70) with no additional endoscopic procedures (e.g., choroid plexus cauterization, septum pellucidum fenestration). The modality of image registration (CT, MRI, surface mapping, or bone fiducials) was dependent on the case.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Nine pediatric patients with an age range of 1.5 to 16 years, 4 girls and 5 boys, with ETV Success Scores ranging from 70 to 90, underwent successful ETV surgery with the ROSA system within an 8-month period. Their intracranial pathologies included tectal tumors (n = 3), communicating hydrocephalus from hemorrhage or meningeal disease (n = 2), congenital aqueductal stenosis (n = 1), compressive porencephalic cyst (n = 1), Chiari I malformation (n = 1), and pineal region mass (n = 1). Robotic assistance was limited to the ventricular access in the first 2 procedures, but was used for the entirety of the procedure for the following 7 cases. Four of these cases were combined with another procedural objective (3 stereotactic tectal mass biopsies, 1 Chiari decompression). A learning curve was observed with each subsequent surgery as registration and surgical times became shorter and more efficient. All patients had complete resolution of their preprocedural symptoms. There were no complications.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>The ROSA system provides a stable, precise, and minimally invasive approach to ETVs.</jats:p></jats:sec>

Robot-assisted stereotactic biopsy of pediatric brainstem and thalamic lesions

“…In cases involving ETV, the robotic arm was repositioned to Kocher's point and a new burr hole was made. 15 A rigid 0° endoscope was introduced through the robot arm into the ventricles following the preplanned trajectory. A Bugbee wire (Medline) was used to perform a ventriculostomy, which was then dilated with a 3-Fr Fogarty balloon.…”

The endoscope and instruments for minimally invasive neurosurgery

“…The first application of robotic systems in neuroendoscopy was in 2002 by Zimmermann et al [82] when they successfully used Evolution 1 robot for navigated robotic neuroendoscopic procedures in three patients. Since then, the robotic stereotactic assistance system has been used at many institutions for endoscopic third ventriculostomies, among other procedures [83,84] . Robotic guidance systems will eventually provide greater precision, vision, and stability in neuroendoscopy [85] .…”

Neuronavigation-assisted bedside placement of bolt external ventricular drains in the intensive care setting: a technical note

“…Thinking yet further into the future, it is conceivable that technically challenging EVDs will be placed with robot assistance even in the setting of the ICU. The robot-guided optimisation of endoscope trajectories during 9 ventricular procedures has already been described [8] as has robot-guided catheter ventriculostomy [10]. The main setbacks of these systems however include their very large size, complexity and cost [13].…”