gms | German Medical Science

Objective: The recent evolution of the endoscopic technique has widened indication of endonasal endoscopic surgery for a variety of skull base lesions. Though the four hands surgery is the style of the majority, two hands (single surgeon) surgery is often preferred in Japan. We demonstrate our method of the surgery and discuss its possible advantage and disadvantage.

Methods: The rigid endoscopes with the diameter of 4.0 mm and the viewing angle of 0-, 30-, 70-° were used. The endoscopes were attached to the pneumatically driven integrated endoscope holding system (EndoArm^™, Olympus Inc.). For laterally extended tumor compartment, various malleable and steerable instruments were developed.

Results: The endonasal endoscopic surgery was performed in 91 cases (81 pituitary lesions, 8 chordomas / chondrosarcoma, 2 meningiomas). Endoscopic procedure was performed by single surgeon without assistant. The EndoArm enabled movement and instant fixation of the endoscope with weightlessness sensation, which enabled the surgeon to perform bimanual meticulous surgical maneuver under the static view analogous to those performed during the open microsurgery. Even the tumor with prominent intradural and lateral extension could thus be managed appropriately.

Conclusions: Though the four hands surgery has the advantage in significantly reducing the conflict of the endoscope with the surgical instruments, the view provided through the endoscope held by the assistant is constantly fluctuating, which might be not favorable during meticulous maneuver in the deepest surgical field. The biggest reason, however, for this type of surgery not becoming popular in Japan might be due to the need for recruitment of experienced endoscope ENT-surgeon.