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LETTERS TO EDITOR
Year : 2019  |  Volume : 67  |  Issue : 3  |  Page : 923-925

Surgical nuances to avoid blind areas in endoscopic surgery: A new surgical technique


Department of Neurosurgery, NSCB (Government) Medical College, Jabalpur, Madhya Pradesh, India

Date of Web Publication23-Jul-2019

Correspondence Address:
Dr. Yad Ram Yadav
Department of Neurosurgery, NSCB (Government) Medical College, Jabalpur - 482 003, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.263260

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How to cite this article:
Yadav YR. Surgical nuances to avoid blind areas in endoscopic surgery: A new surgical technique. Neurol India 2019;67:923-5

How to cite this URL:
Yadav YR. Surgical nuances to avoid blind areas in endoscopic surgery: A new surgical technique. Neurol India [serial online] 2019 [cited 2019 Aug 21];67:923-5. Available from: http://www.neurologyindia.com/text.asp?2019/67/3/923/263260




Sir,

Although endoscopic surgeries are increasingly being used in cranial [1],[2],[3],[4] and spinal surgeries,[5],[6],[7],[8] mainly due to their associated advantages of improved visualization, there are some limitations of this technique such as difficulties in controlling the bleeding, the presence of a blind area, and the need to develop unique endoscopic skills. The presence of a blind area in the surgical field is one of the most significant disadvantages of endoscopic surgery. To avoid the blind area, the telescope, instrument, and the desired surgical area should be placed in a triangular arrangement [Figure 1].[9] When the scope, the instrument, and the surgical target are in a straight line, the distal object is not visualized [Figure 2].
Figure 1: The telescope (A), forceps (B), and the desired surgical area (C) should be placed in a triangular arrangement to avoid the blind area in endoscopic surgery

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Figure 2: When the telescope, the drill, and the suction catheter are in a straight line, the distal object (suction catheter) is not visualized

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In a narrow and deep surgical corridor, the straight arrangement cannot be avoided, as seen in the endoscopic partial corpectomy.[10] The distal instrument (suction in this case) is not visualized when there is another equipment (drill) in between the endoscope and suction catheter [Figure 2]. There is a need to keep two instruments in the surgical field, especially in an operating field that is oozing with blood. In such a situation, the distal instrument (suction) cannot be introduced due to non-visualization of the area distal to the drill, and therefore, the suction should be kept beforehand at a more distal site; and, another more active instrument, such as a drill, should be in between the suction and the endoscope. If the suction catheter is kept between the drill and the endoscope, the drill tip will not be visualized, and it will not be possible to work in the surgical field [Figure 3].
Figure 3: When the suction catheter is kept between the drill and the endoscope, the drill tip will not be visualized

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In deep and narrow corridors, there are two options to keep working even when there is a straight arrangement. Option one: The distal instrument (suction) should be introduced first [Figure 4]a, which should be consciously kept at that depth in the blind area, and is followed by the introduction of the drill in between the suction and the endoscope [Figure 4]b. Option two: The endoscope can be placed in the center, and the instruments (the drill and the suction) can be passed from either side of the scope [Figure 5]. Although option two is simpler, this option is not present in most of the available endoscopic sets. Therefore, one has to opt for option one.
Figure 4: The distal instrument (suction) should be introduced first (a), which should be consciously kept at that depth in the blind area, and this followed by the introduction of the drill in between the suction and the endoscope (b)

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Figure 5: The telescope can be placed in the center, and the instruments (the drill and the suction) can be passed from either side of the scope

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This surgical nuance (introducing distal instrument before introducing the middle instrument) has not been described so far in the available literature to the best of my knowledge. We have used it in 25 patients effectively without any side effect. There is a limitation of this surgical nuance, i.e., the suction is present in the blind area. If the suction is slightly retracted, then there will be pooling of blood in the field, and it will not be possible to use the drill in the surgical field. In such a situation, one should remove the drill and reposition the suction at a proper depth. There may be a tendency for the suction to dip inside, which can cause injury to the cord. It is, therefore, essential to consciously keep the suction at low suction pressure and just in close proximity to the dura mater.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yadav YR, Parihar V, Sinha M, Jain N. Endoscopic treatment of the suprasellar arachnoid cyst. Neurol India 2010;58:280-283.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Yadav YR, Yadav S, Sherekar S, Parihar V. A new minimally invasive tubular brain retractor system for surgery of deep intracerebral hematoma. Neurol India 2011;59:74-77.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Yadav YR, Parihar V, Agrawal M, Bhatele PR. Endoscopic third ventriculostomy in tubercular meningitis with hydrocephalus. Neurol India 2011;59:855-60.  Back to cited text no. 3
  [Full text]  
4.
Ratre S, Yadav N, Parihar VS, Dubey A, Yadav YR. Endoscopic surgery of spontaneous basal ganglionic hemorrhage. Neurol India 2018;66:1694-703.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Yadav YR, Parihar V, Ratre S, Kher Y. Endoscopic anterior decompression in cervical disc disease. Neurol India 2014;62:417-22.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Yadav Y, Parihar V, Ratre S, Kher Y, Bhatele P. Endoscopic decompression of cervical spondylotic myelopathy using posterior approach. Neurol India 2014;62:640-5.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Yadav YR, Ratre S, Parhihar V, Dubey A, Dubey NM. Endoscopic technique for single-stage anterior decompression and anterior fusion by transcervical approach in atlantoaxial dislocation. Neurol India 2017;65:341-7.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Yadav YR, Parihar VS, Ratre S, Dubey A, Jindel S, Dubey MN. Endoscopic single stage trans-oral decompression and anterior C1 lateral mass and C2 pedicle stabilization for atlanto-axial dislocation. Neurol India 2019;67:510–5.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Yadav YR, Parihar V, Kher Y. Complication avoidance and its management in endoscopic neurosurgery. Neurol India 2013;61:217–25.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Yadav YR, Ratre S, Parihar V, Dubey A, Dubey MN. Endoscopic partial corpectomy using anterior decompression for cervical myelopathy. Neurol India 2018;66:444–51.  Back to cited text no. 10
[PUBMED]  [Full text]  


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