Utility of a Three-Dimensional Endoscopic System in Skull Base Surgery

Article (PDF Available)inSkull Base 20(4):223-8 · July 2010with24 Reads
DOI: 10.1055/s-0030-1247630 · Source: PubMed
We evaluated the utility of a three-dimensional (3-D) endoscopic system for skull base surgery. We performed a retrospective case series in a tertiary care medical center. Thirty-six patients underwent skull base (nonpituitary) resections via 3-D endoscopic system. Fifteen patients (42%) were operated for excision of malignant tumors, 19 (53%) for excision of benign lesions, and 3 (8.3%) for skull base reconstruction. The tumors involved the cribriform plate (n = 13), sphenoid sinus and planum (n = 17), clivus (n = 7), and sella (n = 7). Complete tumor resection was achieved in 31 patients and subtotal resection in two. Five patients (14%) had postoperative complications. There was one case of meningitis, and there were no cases of cerebrospinal fluid leak. The surgeon's ability to recognize anatomic structures at the skull base was evaluated using the 3-D and two-dimensional systems. The 3-D technique was superior to the conventional technique for identification of the sella, carotid prominence, optic prominence, cribriform plate, sphenoid, and fovea ethmoidalis. The two systems were equal for detection of the turbinates, clivus, maxillary, ethmoids, and frontal sinuses. Endoscopic skull base surgery with stereoscopic viewing is feasible and safe. Further studies are required to evaluate the advantage of binocular vision in skull base surgery.
Utility of a Three-Dimensional Endoscopic
System in Skull Base Surgery
Oshri Wasserzug, M.D.,
Nevo Margalit, M.D.,
Noam Weizman, M.D.,
Dan M. Fliss, M.D.,
and Ziv Gil, M.D., Ph.D.
We evaluated the utility of a three-dimensional (3-D) endoscopic system for skull
base surgery. We performed a retrospective case series in a tertiary care medical center.
Thirty-six patients underwent skull base (nonpituitary) resections via 3-D endoscopic
system. Fifteen patients (42%) were operated for excision of malignant tumors, 19 (53%)
for excisio n of benign lesions, and 3 (8.3%) for skull base reconstruction. The tumors
involved the cribriform plate (n ¼ 13), sphenoid sinus and planum (n ¼ 17), clivus (n ¼ 7),
and sella (n ¼ 7). Complete tumor resection was achieved in 31 patients and subtotal
resection in two. Five patients (14%) had postoperative complications. There was one
case of meningitis, and there were no cases of cerebrospinal fluid leak. The surgeon’s ability
to recognize anatomic structures at the skull base was evaluated using the 3-D and
two-dimensional systems. The 3-D technique was superior to the conventional technique
for identification of the sella, carotid prominence, optic prominence, cribriform plate,
sphenoid, and fovea ethmoidalis. The two systems were equal for detection of the
turbinates, clivus, maxillary, ethmoids, and frontal sinuses. Endoscopic skull base surgery
with stereoscopic viewing is feasible and safe. Further studies are required to evaluate th e
advantage of binocular vision in skull base surgery.
KEYWORDS: Endoscopic approach, stereoscopic view, minimal invasive, skull base,
three-dimensional, surgery
Endoscopic endonasal surgery became the work-
horse for treating inflammatory diseases and neoplasms
involving the paranasal sinuses and skull base over the
past decade.
Endoscopic surgery provides excellent
access to the anterior skull base and to the sphenoeth-
moidal and paranasal cavities while minimizing mor-
bidity. Intradural and extradural tumor resection can be
performed endoscopically in a single procedure that also
allows adequate reconstruction of the dura.
The tech-
nical reproducibility of the endoscopic approach has
several advantages, but one of its major limitations
is the lack of stereoscopic vision. A three-dimensional
(3-D) image of the surgical field is essential for the
perception of depth during microsurgery, and so the
binocular view of the surgical field may be advantageous
for the implementation of new endoscopic proce-
dures and for popularization of this technique.
new 3-D endoscopic systems have been added to our
armamentarium, but questions about their actual benefit
led to their slow integration into practice.
Department of Otolaryngology–Head and Neck Surgery;
The Skull
Base Surgery Service;
Department of Neurosurgery, Tel-Aviv
Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv
University, Tel-Aviv, Israel.
Address for correspondence and reprint requests: Ziv Gil, M.D.,
Ph.D., The Skull Base Surgery Service, Department of Otolaryngol-
ogy–Head and Neck Surgery, Tel-Aviv Sourasky Medical Center, 6
Weizmann St., 64239, Tel-Aviv, Israel (e-mail: ziv@baseofskull.org).
Skull Base 2010;20:223–228. Copyright # 2010 by Thieme Medical
Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.
Tel: +1(212) 584-4662.
Received: September 14, 2009. Accepted after revision: October 26,
2009. Published online: January 29, 2010.
DOI: http://dx.doi.org/10.1055/s-0030-1247630.
ISSN 1531-5010.
The aims of the study were: (1) to assess the safety
of the procedure, (2) to evaluate the ability of the
surgeons to correctly identify specific anatomic land-
marks, and (3) to estimate the adverse effects of the 3-D
system on the surgical team. This is the first study that
evaluates the utility of a new 3-D system dedicated to
nonpituitary, endoscopic skull base surgery.
All patients who underwent endoscopic skull base sur-
geries at the Tel Aviv Sourasky Medical Center Skull
Base Service between June 2008 and September 2009
were eligible to enroll in this study. Of 53 endoscopic
skull base operations performed in our institute using a
3-D endoscopic system, 36 patients underwent non-
pituitary skull base resections. Of these, 29 underwent
surgery via the expanded endoscopic approach (EEA)
alone, and the other seven patients had combined EEA
and frontal craniotomy. All the procedures were per-
formed with the patients in the supine position and
under gener al anesthesia. Verification of anatomic
landmarks was by an intraoperative navigation system
(Vector Vision, Brain Laboratory, Feldkirchen,
Germany). A lumbar spine catheter was inserted for
drainage in cases where a high-flow cerebrospinal fluid
(CSF) leak was encountered during surgery. The pa-
tients were treated with a perioperative prophylactic
antibiotic regimen consisting of parenteral metronida-
zole and cefuroxime with or without vancomycin.
Treatment was initiated 1 hour before surgery and
continued until the nasal packing was removed. Recon-
struction was performed with fascia lata and fat flap in
cases of a low-flo w CSF leak. Inlay fascia lata and
underlay nasal septal flap were used for high-flow CSF
leaks, as previously described.
A vomer bone graft was
used to support the inlay fascia lata flap in two cases of
large anterior skull base defects.
The reconstruction was
covered with strips of Surgicel (Ethicon Inc., Johnson
and Johnson, Somerville, NJ) and fibrin glue as well as
with Gelfoam
sponge (Pfizer Inc., New York, NY) to
provide additional support and separation from the nasal
packing. The reconstruction was supported with a
No. 14 Foley catheter inflated inside the nasopharynx.
The l umbar drain was removed 3 or 5 days after the
operation and the nasal packing was removed on post-
operative day 5 or 7, for low- and high-flow leaks,
respectively. All the study patients were followed on a
regular basis for 1 to 13 months (average 4.2 months)
after discharge.
Endoscopic System
The 3-D endoscopic system uses 0-degree and 30-
degree endoscopes with distal 3-D sensors (Visionsense
Ltd., Petach-Tikva, Israel). The 3-D video endoscope is
a prototype that is 150 mm in length and has an outer
diameter of 5 mm at the distal end. The effective work-
ing distance is between 15 and 50 mm. The endoscopic
images captured at the distal end of the scope by a
charge-coupled device camera are transmitted to the
computer, and the graph ic data are then processed for
3-D imaging. The images are immediately sent to the
display unit.
The stereoscopic technology is based on the
ability to acquire and present different images to the
left and right eyes simultaneously. The sensor at
the tip of the 3-D endoscope is divided into hundreds
of thousands of micron-sized optical elements, which
create a digital map of the surgical field. A computer
program is used to reconstruct natural stereovision from
the raw data. The system requires the use of passive
(polarizing) glasses, which, in combination with a 3-D
screen, emulates the normal visual process of stereopsis,
or spa tial perception. Figure 1 shows a depiction of the
imaging system and a picture of the operating theater.
Data Collection and Analysis
The data were collected prospectively by a researcher who
did not carry out any of the operations included in the
study (O.W.). After each surgery, the operating surgeons
from the head and neck team were asked to score their
ability to identify and recognize each one of the following
anatomic structures: middle turbinate, maxillary sinus,
lamina papyracea, cribriform plate, ethmoidal sinuses,
sphenoid sinus, clivus, fovea ethmoidalis, planum sphe-
noidale, sella turcica, carotid prominence, and optic nerve
prominence. The score was composed of the surgeon
difficulty level to recognize each landmark. Anatomic
verifications were performed with the assistance of the
navigation system. Scores were: (1) 3-D is inferior to the
two-dimensional (2-D) system; (2) 3-D equals the 2-D
system; and (3), 3-D is superior to the 2-D system. All
scores were undertaken after a consensus between the
surgeons had been achieved. For statistical comparison,
Student t test was used. Significance was set at p < 0.01.
Thirty-six patients underwent endoscopic skull base
surgery via a 3-D endoscopic system that was used in
our department during the study period. Table 1 pro-
vides a summary of patients demographic and clinical
data, and Table 2 lists the underlying histology of their
lesions. Fiftee n of these patients had malignant tumors
(42%) and 19 had benign lesions (53%). The remaining
three patients underwent skull base reconstruction for
CSF leak repair (8.3%). The initial Karnofsky score
was 100 for each patient. Thirteen patients (36%) under-
went at least one previous operation, and five patients
(14%) underwent perioperative radiation therapy (three
received preoperative and two received postoperative
external beam radiation). Complete gross tumor resec-
tion was achieved in 31/33 patients (94%). One addi-
tional patient had an olfactory groove meningioma that
involved the cavernous sinus and optic nerves, and 90%
of the tumor was removed. The remaining patient had a
clival chordoma involving both hypoglossal canals, and
95% of the tumor was removed. Tumor resection was
associated with a high-flow intraoperative CSF leak in
16 cases (44%). Figures 2 and 3 show representative cases
before and after tumor res ection.
Table 1 Patients’ Demographics and Clinical
Variable n (%)
Number of patients 36
Age (y)
Mean SD 47.8 19
Median 51
Days in hospital
Mean SD 7.1 1.8
Female 12 (33)
Male 24 (67)
No 23 (64)
Yes 13 (36)
Previous surgery
No 23 (64)
Yes 13 (36)
Previous radiotherapy
No 33 (92)
Yes 3 (8)
Dural involvement
No 25 (69)
Yes 11 (31)
Brain involvement
None 31 (86)
Yes 5 (14)
Surgical approach
EEA alone 29 (83)
EEA and FC 7 (17)
EEA, expanded endoscopic approach; FC, frontal craniotomy; SD,
standard deviation.
Figure 1 The 3-D imaging system used for endoscopic skull base operations. (A) Depiction of the 3-D system. The camera
includes a miniature 3-D sensor that digitally maps the surgical field. An LED light source is mounted on the camera system to
illuminate the surgical field. The signals are digitally sent to the central image processing unit. The camera control unit consists
of a single PC with dedicated hardware and software. The computer is connected to a stereoscopic display. The image is
acquired with polarizing glasses. (B) A picture of the operating theater. Two high-definition 2-D monitors are used (on the right),
next to a 3-D monitor (middle) and navigation system (far left side). The surgeon uses specialized polarizing microscopes to gain
stereoscopic view of the surgical field.
Table 2 Histology
Pathology n (%)
Inverted papilloma 13 (36)
Chordoma 6 (17)
CSF leak 3 (8)
Melanoma 2 (5.5)
Encephalocele 2 (5.5)
Ewing’s sarcoma 1 (2.8)
Craniopharyngioma 1 (2.8)
Adenocarcinoma 1 (2.8)
Esthesioneuroblastoma 1 (2.8)
MPNST 1 (2.8)
SNUC 1 (2.8)
ACC 1 (2.8)
Osteoma 1 (2.8)
1 (2.8)
1 (2.8)
Total 36 (100)
ACC, adenoid cystic carcinoma; JNA, juvenile naso pharyngea l
angiofibroma; MPNST, malignant peripheral nerve sheath tumor;
SNUC, sinonasal undifferentiated carcinoma.
Five patients (14%) had postoperative complica-
tions (Table 3). There was one case of gram-negative
meningitis (2.8%), one case of epiphora (2.8%), and no
cases of pneumocephalus or postoperative CSF leak.
Next, we evaluated the 3-D endoscopic system in
comparison with the conventional 2-D technique. The
surgeons were asked (1) to rate their ability to identify
specific anatomic structures (see Materials and Methods)
and (2) to assess adverse effects of the 3-D system on the
operating team. The 3-D technique was superior to the
conventional technique for identification of the sellar
region, carotid prominence, optic prominence, cribri-
form plate, fovea ethmoidalis, planum, sphenoid, and
sella (n ¼ 14 cases, p < 0.001). Both methods were equal
for detection of the middle turbinate, clivus, maxillary
sinus, ethmoidal sinuses, and frontal sinuses. There were
no complaints of visual strains or headaches, but there
was some facial discomfort that was mostly related to
wearing of the glasses required for the 3-D system.
Advancements in imaging modalities and refinements in
surgical and reconstructive techniques have allowe d an
increasing number of children and adults with skull base
neoplasms to undergo curative surgical resections.
The endoscopic approach provides an excellent access
to the paranasal sinuses and skull base and, therefore, has
become a popular alternative to open procedures for the
treatment of benign tumors and selective malignant
neoplasms. Compensation for the loss of stereoscopic
vision in 2-D endoscopy is achieved by sensorial and
tactile information that the surgeon receives during the
manipulation of instruments and changes in 2-D visual
There has been significant progress in the devel-
opment of new endoscopic imaging modalities, in clud-
ing that of distal chip cameras, 3-D endoscopes, and
robotic surgery.
We considered that perception of
depth and space using 3-D visualization may potentially
Figure 2 Magnetic resonance imaging (MRI) of a 12-year old girl with craniopharyngioma. (A) Preoperative (left) and
postoperative (right) axial plane, T1 MRI with gadolinium. (B) Sagittal plane MRI showing the tumor before (left) and after (right)
the operation.
improve the surgeon ’s ability to perform complex tasks
with minimally invasive skull base surgery. The aim
of the current study was to assess the utility of a 3-D
endoscopic system in a single medical center over a
1-year pe riod. The 3-D technique allowed accurate
identification of the sellar region, carotid prominence,
optic prominence, cribriform plate, and fovea ethmoi-
dalis. However, due to its narrow viewing angle, surgery
in the nasal cavity, maxillary sinus, and frontal sinus
was difficult compared with conventional endoscopy.
Other limitations of the 3-D endoscopic system may
be inferior sharpness and contrast compared with new
high-definition 2-D systems. This may stem from the
distal chip camera, the light-emitting device system, or
the optical glasses, which cause a loss of photons trans-
mitted to the retina. Finally, the short range of focus and
the restricted viewing angle require improvement. Our
surgeons did not report experiencing any adverse effects
during or after surgery.
The value of 2-D and 3-D visual systems has
been tested mainly for minimally invasive general
The system used in the current study was
described previously
and compared with the conven-
tional system in artificial models.
In addition, Tabaee
et al recently demonstrated the utility of 3-D endoscopy
in pituitary surgery.
The current study is the first to
evaluate the utility of the 3-D technology for skull base
Few studies have specifically examined the advan-
tage of 3-D systems over conventional endoscopy, and
most of the studies involved laparoscopic procedures.
Performance studies and skill tests in laparoscopic sim-
ulators revealed significantly faster performances, shorter
execution time, and increased accuracy, all leading to
more rapidly executed and safer endoscopic surgery
under 3-D conditions.
Fraser et al evaluated the
utility of 3-D and 2-D endoscopes by using a task-based
simulator paradigm.
They reported a significantly
higher level of efficiency using the 3-D system than
conventional endoscopes. Others, how ever, reported no
significant advantage of 3-D laparoscopic systems.
We are mindful of several limitations related to
the design of our study. The main one is the lack of
objective m easures to compare the 2-D and 3-D systems.
Second, the data were collected and reported during a
learning period of the prototype 3-D system.
In conclusion, the 3-D imaging system offers
stereoscopic viewing while using endoscopes for surgical
resections of skull base tumors. Surgery using the 3-D
technique is safe and allows accurate perception of
depth. It has been established that a well-trained and
experienced surgeon is able to cope with the limitations
Table 3 Incidence of Postoperative Complications
Complication n (%)
Meningitis 1 (2.8)
Wound infection 2 (5.6)
Epistaxis 1 (2.8)
Epiphora 1 (2.8)
Total 5 (13.9)
Figure 3 Computed tomography images of a 35-year-old man with chordoma invading the dura. (A) Preoperative scan
showing the tumor infiltrating the clivus. (B) Postoperative image. Reconstruction was performed with fascia lata inlay flap, fat,
and nasal septal rotational flap. The arrow indicates the nasal flap rotated over the fat.
of 2-D visualization. However, it is not known whether
3-D endoscopic imaging systems will have an impact on
surgical efficacy, complication rates, or the learning curve
of untrained surgeons. Future studies should integrate
performance parameters for conclusively establishing an
advantage of the 3-D system on conventional methods.
We thank Esther Eshkol for editorial assistanc e. This
work was partially suppor ted by grants from the Israeli
Cancer Association, The US-Israel Binational Science
Foundation, and the Israeli Science Foundation (Z.G.).
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    • "There is therefore important clinical evidence for the use of next-generation 3-D neuroendoscopes, particularly for inexperienced surgeons or when complex surgery is performed [2, 32, 45] . The advantages and limitations of the novel 3-D device in visualization and depth perception have already been reported by the first Author's personal copy comparative publications on the matter [19, 31] and the clinical utility has been proven in different case series [4, 10, 31, 34, 43]. The importance of 3-D visualization in skull base surgery is based on the close proximity of critical neurovascular structures and on the ease in understanding the distances between complex anatomic landmarks. "
    [Show abstract] [Hide abstract] ABSTRACT: Background The evolution of skull base surgery over the past decade has been influenced by advancement in visualization technology. Recently, as a result of such improvements, three-dimensional (3-D) scopes have been widely used during endoscopic endonasal approaches. In the present study, we describe the use of 3-D stereoscopic endoscope for the treatment of a variety of skull base lesions. Methods From January 2010 to June 2015, a 3-D endoscopic endonasal approach (4 and 4.9 mm, 0°, and 30° rigid endoscopes) was performed in 70 patients with the following lesions: 42 large extrasellar pituitary macroadenomas, seven tuberculum sellae meningiomas, seven clivus chordomas, five craniopharyngiomas, three fibrous dysplasia of the clivus, three sinonasal malignancies, one orbital lymphangioma, one trigeminal neurinoma, one primary suprasellar lymphoma. Results Total tumor removal was obtained in 50 patients (71.4 %) while in 14 (20 %), subtotal removal was possible in six (8.6 %) only partial removal was achieved. Overall complications included diabetes insipidus in eight patients (11.4 %), hypopituitarism in seven patients (10 %), CSF leak in five patients (7.1 %), cranial nerve injury in two patients (2.8 %), panhypopituitarism in two patients (2.8 %), meningitis in one (1.4 %) and one postoperative central retinal artery occlusion (1.4 %). There was no mortality in the series. The mean follow-up time was 39 months (range, 6–72 months). Conclusions In our experience, the 3-D endoscope represents a critical development in visualization, thus enabling improved hand–eye coordination and depth perception, which are mandatory for the management of complex intradural neurovascular structures during tumor removal surgery.
    Full-text · Article · Jun 2016
    • "Thus, at present, 3D endoscopes are similar to 2D endoscopes in size and weight. Regarding their advantages as surgical instruments, several authors have reported the results of endoscopic surgical procedures on the skull base [6] [7] [11]. Kari et al. compared the operative time, amount of bleeding, duration of hospital stay, and complications between pituitary surgery, involving 2D and 3D endoscopy, and reported that there were no significant differences [12]. "
    [Show abstract] [Hide abstract] ABSTRACT: To examine the efficacy of a three-dimensional (3D) endoscope for endoscopic sinus and skull base surgery.Methods The study design was a retrospective case series and qualitative research. The clinical efficacy of 3D endoscopes was examined on five cadavers. We performed conventional endoscopic sinus surgery (ESS) in five cases and hypophysectomy in two cases using a 3D endoscope. The educational advantages of the 3D endoscope were assessed using questionnaires given to the participants of cadaver dissection courses.ResultsIn the posterior portion of the nasal cavity, images captured via 3D endoscopy provided a superior perception of depth of information than those via two-dimensional (2D) endoscopy. All endonasal surgeries were completed in clinical settings using a 3D endoscope without perioperative complications. In terms of the operative time and amount of bleeding, the results of 3D endoscopic surgeries were not inferior to those of 2D endoscopic surgeries. Fatigue from 3D viewing through polarized glasses did not adversely affect performance of the surgery. Moreover, questionnaires for the evaluation of educational efficacy were completed by 73 surgeons. Of the respondents, 89% agreed that 3D endoscopy provided a better understanding of the surgical anatomy than did 2D endoscopy. As for the site where 3D endoscopy would be the most useful for understanding surgical anatomy, 40% of the respondents named the skull base; 29%, the posterior ethmoid sinuses; and 26%, the sphenoid sinus; and 9%, the ethmoid bulla and middle turbinate.Conclusion The 3D endoscope contributes to a more precise anatomical understanding of the posterior structures of the sinuses and skull base and ensures a more precise operation of the instruments. Thus, 3D endoscopes will likely become a standard device for endonasal surgery in the near future.
    Article · Nov 2014
    • "The advantages and limitations of the novel 3D device in visualization and depth perception have already been reported by the first comparative publications on the matter 4 5 7 12 and clinical utility has been proven in small case series 3 13 14. "
    [Show abstract] [Hide abstract] ABSTRACT: The recent introduction of the 3D endoscope for endonasal surgery has been welcomed because of its promise to overcome the main limitation of endoscopy, namely the lack of stereoscopic vision. This innovation particularly regarded the most complex transnasal surgery of the skull base. We therefore discuss our early experience as ENT surgeons with the use of a purely 3D endoscopic expanded endonasal approach for supradiaphragmatic lesions in 10 consecutive patients. This article will focus on the surgical technique, the complications, the outcome, and more importantly the advantages and limitations of the new device. We believe that the new 3D system shows its main drawback when surgery is conducted in the narrow nasal spaces. Nevertheless, the improved knowledge of the three-dimensional nasal anatomy enabled the ENT surgeon to perform a more selective demolition of the nasal structures even in the anterior part of the nose. The depth perception obtained with the 3D system also permitted a better understanding of the plasticity of the surgical defects, increasing the confidence to perform successful skull base plasties. We believe that, for both the ENT surgeon and the neurosurgeon, the expanded endonasal approach is the main indication for this exciting tool, although larger prospective studies are needed to determine the equality to the 2D HD endoscope in oncological terms.
    Full-text · Article · Apr 2013
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