Hoshide Reid, Calayag Mark, Meltzer Hal, Levy Michael L, Gonda David
Division of Neurosurgery, Rady Children's Hospital, San Diego, California.
J Neurosurg Pediatr. 2017 Aug;20(2):125-133. doi: 10.3171/2017.3.PEDS16636. Epub 2017 Jun 9.
OBJECTIVE 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. METHODS 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. RESULTS 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. CONCLUSIONS The ROSA system provides a stable, precise, and minimally invasive approach to ETVs.
目的 内镜下第三脑室造瘘术（ETV）是治疗梗阻性脑积水的一种成熟且有效的方法。在其最常见的应用中，外科医生根据解剖标志规划手术的入路点和内镜轨迹，然后徒手控制内镜。最近的研究报告称，在北美进行的所有ETV手术中，神经损伤的发生率高达16.6%。作者已将ROSA系统引入其ETV手术中，以立体定向优化内镜轨迹，降低内镜对神经结构的牵拉风险，并为内镜提供一个稳定的机械固定器。在此，他们展示了使用ROSA系统进行ETV手术的系列病例。方法 在作者所在机构，他们在8个月内连续为9例患者使用ROSA系统进行了ETV手术。患者必须对ETV有良好的预期反应（ETV成功评分≥70），且无需进行额外的内镜手术（如脉络丛烧灼、透明隔造瘘）。图像配准方式（CT、MRI、表面映射或骨标记）取决于具体病例。结果 9例年龄在1.5至16岁的儿科患者，4名女孩和5名男孩，ETV成功评分在70至90之间，在8个月内使用ROSA系统成功进行了ETV手术。他们的颅内病变包括顶盖肿瘤（n = 3）、出血或脑膜疾病导致的交通性脑积水（n = 2）、先天性导水管狭窄（n = 1）、压迫性脑穿通畸形囊肿（n = 1）、Chiari I畸形（n = 1）和松果体区肿块（n = 1）。在前2例手术中，机器人辅助仅限于脑室入路，但在随后的7例手术中用于整个手术过程。其中4例手术结合了另一个手术目标（3例立体定向顶盖肿块活检，1例Chiari减压）。随着每次后续手术中配准和手术时间变得更短且更高效，观察到了学习曲线。所有患者术前症状均完全缓解。无并发症发生。结论 ROSA系统为ETV手术提供了一种稳定、精确且微创的方法。
