Two hundred years of endoscopic surgery: from Philipp Bozzini's cystoscope to paediatric endoscopic neurosurgery

Per-operative modified rigid cholangioscopy for removal of intrahepatic stones associated with choledochal cyst in children

Introduction

Choledochal cyst (CDC) is often associated with intrahepatic stones (IHSs) in children which necessitate their removal during excision. The endoscopic equipment needed for their clearance such as paediatric flexible cholangioscope and other advanced modalities are not freely available in resource-poor setups. We describe per-operative modified rigid cholangioscopy using rigid paediatric cystoscope for stone removal during open CDC excision.

Methods

All children with CDC presenting with IHSs between January 2015 and December 2017 were included in the present study. IHSs were diagnosed by ultrasound/magnetic resonance cholangiopancreatography (MRCP). In these patients, after cyst excision by open technique, a 9 Fr paediatric cystoscope with 4 Fr working channel was inserted into the common hepatic duct for visualisation and clearance of stones from (intrahepatic bile ducts). Follow-up was done using liver function tests, ultrasound and MRCP (if needed). Patients underwent three monthly liver function test and ultrasound and if needed MRCP.

Results

Six cases of CDC presenting with IHS were managed, and one case with post-R-en-Y IHS was treated with this technique. Rigid paediatric cystoscope with working channel and forceps was used. All cases were successfully managed, and one case was found to have intrahepatic duct stenosis was dilated.

Conclusion

Per-operative rigid endoscopy using paediatric cystoscope is an easily available tool in most of the setups for the management of IHS associated with CDC in children.

Philipp Bozzini (1773-1809): The earliest description of endoscopy

The widespread use of endoscopy in today's clinical arena underscores its utility and growing significance within the field of medicine. Primitive forms of endoscopy have existed for hundreds of years, but it was not until the early 19th century that Dr Philipp Bozzini invented an endoscope that would form the basis of modern endoscopy. Born into an influential Italian family, Bozzini practiced medicine in a time and place of conflict and political unrest. His passion, ingenuity, and important social connections allowed him to create and introduce to the medical profession the Lichtleiter (light-conductor), which overcame two key issues plaguing endoscopy: inadequate lighting and poor penetration. A combination of professional rivalry and his premature passing stifled enthusiasm and further work on the Lichtleiter, but its value would not be lost forever. The advancements in the field of endoscopy that have come since the time of the Lichtleiter all build upon the principles of Bozzini, who became widely acknowledged as the father of modern endoscopy.

ETV as a last resort

INTRODUCTION

The field of neuroendoscopy is rapidly expanding with increasing indications for endoscopic third ventriculostomy (ETV).

DISCUSSION

As a treatment for hydrocephalus, ETV has the advantage of providing a more physiological cerebrospinal fluid diversion without shunt hardware which reduces the risk of recurrent infection and malfunction. The success rate of ETV has been increasing with decreasing morbidity and mortality.

CONCLUSION

Originally, ETV was indicated for cases of obstructive hydrocephalus, however the indications are expanding. To highlight this, we present a small series of cases were ETV is not traditionally indicated and was a treatment of last choice.

Choroid plexus coagulation for hydrocephalus not due to CSF overproduction: a review

OBJECTIVE

This study aims to review the role of choroid plexus coagulation (CPC) for hydrocephalus not due to CSF overproduction.

METHODS

The literatures covering CPC/cauterization/extirpation and ablation searched through PubMed were reviewed.

RESULTS

The history of CPC goes back to early 1900s by open surgery. It has evolved to mainly an endoscopic surgery since 1930s. With the development of other treatment methods and the understanding of CSF dynamics, the application of CPC dramatically decreased by 1970s. In late 2000, there was a resurgence of CPC in combination with endoscopic third ventriculostomy (ETV) performed in Africa.

CONCLUSIONS

CPC remains one of the options for the treatment of hydrocephalus in selected cases. CPC might provide a temporary reduction in CSF production to allow the further development of CSF absorption in infant. Adding CPC to ETV for infants with communicating hydrocephalus may increase the shunt independent rate thus avoiding the consequence of late complication related to the shunt device. This is important for patients who are difficult to be followed up, due to geographical and/or socioeconomic constrains. Adding CPC to ETV for obstructive hydrocephalus in infant may also increase the successful rate. Furthermore, CPC may be an option for cases with high chance of shunt complication such as hydranencephaly. In addition, CPC may act as an adjunct therapeutic measure for complex cases such as multiloculated hydrocephalus. In comparison with the traditional treatment of CSF shunting, the role of CPC needs to be further evaluated in particular concerning the neurocognitive development.

Minimally invasive approaches to the anterior skull base

The use of minimally invasive approaches to the anterior skull base is a valuable tool to improving the treatment in patients with aggressive anterior skull base neoplasms. This article discusses the history, advantages and disadvantages relative to open approaches, the corridors and pathways used in approach, the equipment and operating room setup, perioperative care, and complication avoidance. Although outcomes are difficult to compare to open approaches, due to often small and varying patient cohorts, these approaches continue to gain acceptance as an effective treatment of anterior skull base tumors in the experienced surgeon's hands with proper patient selection.

The historical evolution of transsphenoidal surgery: facilitation by technological advances

Over the past century, pituitary surgery has undergone multiple evolutions in surgical technique and technological advancements that have resulted in what practitioners now recognize as modern transsphenoidal surgery (TSS). Although the procedure is now well established in current neurosurgical literature, the historical maze that led to its development continues to be of interest because it allows a better appreciation of the unique contributions by the pioneers of the technique, and of the innovative spirit that continues to fuel neurosurgery. The early events in the history of TSS have already been well documented. This paper therefore summarizes the major early transitions along the timeline, and then further concentrates on some of the more recent advancements in TSS, such as the surgical microscope, fluoroscopy, endoscopy, intraoperative imaging, and frameless guidance. The account of each of these innovations is unique because they were each developed as a response to certain historical needs by the surgeon. An understanding of these more recent contributions, coupled with the early history, provides a more complete perspective on modern TSS.