Utility of Nasal Access Guides in Endoscopic Endonasal Skull Base Surgery: Assessment of Use during Cadaveric Dissection and Workflow Analysis in Surgery

Abstract

Background A nasal access guide (NAG) for endoscopic endonasal approaches (EEAs) to the skull-base has been developed and approved for clinical use but its utility has not been formally investigated.

Objective The study aims to assess the effect of a NAG on endoscopic visualization during cadaveric dissection and to perform a workflow analysis with process-based performance measures in the operating room and their effect on clinical outcomes.

Methods Skull-base course participants were observed during hands-on cadaveric dissection with and without NAG. Instances of endoscope withdrawal for lens cleaning and inadequate visualization due to lens soiling were tabulated. Participants completed a Likert-scale survey examining the NAG utility and provided an overall grading. Surgical workflow and process-based performance on patients undergoing EEA to the skull-base was analyzed. Passage of powered and dissecting instruments, removal of endoscopes for cleaning, and dislodgment or migration of the device were reviewed. Postoperative assessments included mucosal trauma and synechiae formation.

Results Instances of endoscope soiling and manual cleaning were significantly reduced by 40% and 61% with the NAG during cadaveric dissection. The overall grading of the device was 2.75/3. Surgical workflow was observed in 35 patients. Average number of passes of endoscopes, instruments, and powered tools during a 10-minute observation period were 3,17, and 5 during the surgical approach, and 3, 18, and 1 during tumor dissection. Dislodgement of the device occurred in 25.7% and migration of the device in 2.8% of cases. Postoperative synechiae, exposed cartilage or septal perforation was not observed in follow up.

Conclusion NAG can significantly reduce inadequate visualization during EEA to the skull-base and has the potential to reduce instances of nasal trauma. Participants assessed its overall utility as being “excellent.”

Keywords

Endoscopic Endonasal Approach - lens cleaning - endoscopic visualization - skull base surgery

^* These authors contributed equally to this work.

Publication History

Received: 17 April 2020

Accepted: 25 July 2020

Article published online:
10 September 2020

• References

• 1 Cassera MA, Goers TA, Spaun GO, Swanström LL. Efficacy of using a novel endoscopic lens cleaning device: a prospective randomized controlled trial. Surg Innov 2011; 18 (02) 150-155
• 2 Wiegmann DA, ElBardissi AW, Dearani JA, Daly RC, Sundt III TM. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery 2007; 142 (05) 658-665
• 3 Sutton E, Youssef Y, Meenaghan N. et al. Gaze disruptions experienced by the laparoscopic operating surgeon. Surg Endosc 2010; 24 (06) 1240-1244
• 4 Kreeft D, Arkenbout EA, Henselmans PWJ, van Furth WR, Breedveld P. Review of techniques to achieve optical surface cleanliness and their potential application to surgical endoscopes. Surg Innov 2017; 24 (05) 509-527
• 5 Macia I, Gossot D. Maintaining a clear vision during long-lasting thoracoscopic procedures. Interact Cardiovasc Thorac Surg 2010; 11 (05) 522-524
• 6 Kubo S, Kikawada T, Hasegawa H, Tominaga S, Yoshimine T. Irrigation-suction straw sheath system for a rigid endoscope during endonasal endoscopic pituitary surgery. Minim Invasive Neurosurg 2005; 48 (06) 373-375
• 7 Olympus. Instaclear Lens Cleaner System. ILCS. Accessed April 16, 2020 at: http://olympusmedical.com.sg/products/all-products/other-products/ent-products/instaclear-lens-cleaner-system/index.html
• 8 Medtronic. Inferior Turbinate Blades. E-SLCS. Accessed April 16, 2020 at: https://www.medtronic.com/us-en/healthcare-professionals/products/ear-nose-throat/sleep-disordered-breathing/inferior-turbinate-blades/related-products.html
• 9 Alfieri A. Endoscopic endonasal transsphenoidal approach to the sellar region: technical evolution of the methodology and refinement of a dedicated instrumentation. J Neurosurg Sci 1999; 43 (02) 85-92
• 10 Cappabianca P, Alfieri A, Thermes S, Buonamassa S, de Divitiis E. Instruments for endoscopic endonasal transsphenoidal surgery. Neurosurgery 1999; 45 (02) 392-395 , discussion 395–396
• 11 Jho HD, Alfieri A. Endoscopic endonasal pituitary surgery: evolution of surgical technique and equipment in 150 operations. Minim Invasive Neurosurg 2001; 44 (01) 1-12
• 12 Tatsuki H, Yokobori T, Katayama C. et al. A novel one-step lens cleaning device using air and water flow for endoscopic surgery. PLoS One 2018; 13 (07) e0200749
• 13 Harbison RA, Berens AM, Li Y, Bly RA, Hannaford B, Moe KS. Region-specific objective signatures of endoscopic surgical instrument motion: a cadaveric exploratory analysis. J Neurol Surg B Skull Base 2017; 78 (01) 99-104
• 14 Saafan ME, Ragab SM, Albirmawy OA, Elsherif HS. Powered versus conventional endoscopic sinus surgery instruments in management of sinonasal polyposis. Eur Arch Otorhinolaryngol 2013; 270 (01) 149-155
• 15 Bernstein JM, Lebowitz RA, Jacobs JB. Initial report on postoperative healing after endoscopic sinus surgery with the microdebrider. Otolaryngol Head Neck Surg 1998; 118 (06) 800-803
• 16 Liu J, Zeng Q, Ke X, Yang Y, Hu G, Zhang X. Influence of chitosan-based dressing on prevention of synechia and wound healing after endoscopic sinus surgery: a meta-analysis. Am J Rhinol Allergy 2017; 31 (06) 401-405
• 17 Fernandes Cabral DT, Zenonos GA, Fernandez-Miranda JC, Wang EW, Gardner PA. Iatrogenic seeding of skull base chordoma following endoscopic endonasal surgery. J Neurosurg 2018; 129 (04) 947-953
• 18 SPIWay. SPIWay Endonasal Access Guide. E-SLCS at: http://spiway.com/the-spiway.html