Indigenous Inexpensive Practice Models for Skill Development in Neuroendoscopy

Neuroendoscopy Training

Neuroendoscopy can be learnt by assisting or doing live human surgery, cadaver dissection with or without augmented pulsatile vessel and cerebrospinal fluid (CSF) perfusion, and practicing on live animal, dead animal model, synthetic models, three-dimensional printing model with or without augmentation with animal, cadaver tissue, pulsatile vessel and reconstructed CSF model, virtual reality (VR) simulator, and hybrid simulators (combined physical model and VR model). Neurosurgery skill laboratory with basic and advanced learning should be there in all teaching hospitals. Skills can be transferred from simulation model or VR to cadaver to live surgery. Staged learning (first with simple model to learn basic endoscopic technique, then animal model, and then augmented cadavers) is the preferred method of learning. Although most surveys favor live surgery and practice on animal models and cadavers as the most preferred training model now, in future VR may also become a favored method of learning. This article is based on our experience in over 10,000 neuroendoscopic surgeries, and feedback from over 950 neuroendoscopic fellows or consultants who attended workshops conducted every 6 monthly since 2010. A literature search was done on PubMed and Google Scholar using (neuroendoscopy) AND (learning), and (neuroendoscopy) AND (training), which resulted in 121 and 213 results, respectively. Out of them, 77 articles were finally selected for this article. Most of the training programs typically focus on microneurosurgical training. There is lack of learning facilities for neuroendoscopy in most centers. Learning of neuroendoscopy differs greatly from microneurosurgery; switching from microneurosurgery to neuroendoscopy can be challenging. Postgraduate training centers should have well-equipped neuroendoscopy skill laboratory and the surgical educational curriculum should include neuroendoscopy training. Learning endoscopy is about taking advantages of the technique and overcoming the limitations of endoscopy by continuous training.

Optimal Concentric Tube Robot Design for Safe Intracerebral Hemorrhage Removal

Purpose

The purpose of this paper is to investigate the geometrical design and path planning of Concentric tube robots (CTR) for intracerebral hemorrhage (ICH) evacuation, with a focus on minimizing the risk of damaging white matter tracts and cerebral arteries.

Methods

To achieve our objective, we propose a parametrization method describing a general class of CTR geometric designs. We present mathematical models that describe the CTR design constraints and provide the calculation of a path risk value. We then use a genetic algorithm to determine the optimal tube geometry for targeting within the brain.

Results

Our results show that a multi-tube CTR design can significantly reduce the risk of damaging critical brain structures compared to the conventional straight tube design. However, there is no significant relationship between the path risk value and the number and shape of the additional inner curved tubes.

Conclusion

Considering the challenges of CTR hardware design, fabrication, and control, we conclude that the most practical geometry for a CTR path in ICH treatment is a straight outer tube followed by a planar curved inner tube. These findings have important implications for the development of safe and effective CTRs for ICH evacuation by enabling dexterous manipulation to minimize damage to critical brain structures.

A Model with Feedback Mechanism for Learning Hand-Eye Coordination: A Pilot Study

BACKGROUND

Practicing neuroendoscopic skills like hand-eye coordination is mandatory before embarking on actual surgeries. Synthetic models are able alternatives for cadavers and animals. Presently available models in the literature are either very costly or lack a feedback mechanism, which makes training difficult.

OBJECTIVE

We aimed to make a basic low-cost neuroendoscopic hand-eye coordination model with a feedback mechanism.

METHODS AND MATERIALS

An electronic circuit in series was designed inside a clay utensil to test inadvertent contact of the working instrument with implanted steel pins, which on completion lighted a light-emitting diode (LED) and raised an alarm. Two exercises-moving-a-rubber exercise and passing copper rings of multiple sizes were made and tested by 15 neurosurgeons.

RESULTS

The moving-a-rubber exercise was completed by 6/15 (40%) neurosurgeons in the first attempt, 6/15 (40%) in the second, and 3/15 (20%) in the third attempt. For the 1.5 cm copper ring passing exercise, 12/15 (80%) successfully performed in the first attempt; for 1 cm copper ring, 6/15 (40%) performed in the first; and for the 0.5 cm copper ring, 1/15 (6.6%) performed in the first attempt. The time to finish all the exercises significantly decreased in the third successful attempt compared to the first.

CONCLUSION

The model gave excellent feedback to the trainee and examiner for basic neuroendoscopic hand-eye coordination skills.

Achieving Surgical, Obstetric, Trauma, and Anesthesia (SOTA) care for all in South Asia

South Asia is a demographically crucial, economically aspiring, and socio-culturally diverse region in the world. The region contributes to a large burden of surgically-treatable disease conditions. A large number of people in South Asia cannot access safe and affordable surgical, obstetric, trauma, and anesthesia (SOTA) care when in need. Yet, attention to the region in Global Surgery and Global Health is limited. Here, we assess the status of SOTA care in South Asia. We summarize the evidence on SOTA care indicators and planning. Region-wide, as well as country-specific challenges are highlighted. We also discuss potential directions-initiatives and innovations-toward addressing these challenges. Local partnerships, sustained research and advocacy efforts, and politics can be aligned with evidence-based policymaking and health planning to achieve equitable SOTA care access in the South Asian region under the South Asian Association for Regional Cooperation (SAARC).

Indian Neurosurgeons at the Forefront: A Comprehensive Exploration of their Pioneering Contributions to Neuroendoscopy

This article delves into the profound impact of Indian neurosurgeons on the expansive canvas of neuroendoscopy. By scrutinizing their trailblazing research, innovations, new surgical techniques, and relentless dedication to education and training, we aim to unravel the intricacies of their influence on a global scale. The review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, conducts a comprehensive analysis of the literature related to neuroendoscopy contributed by Indian neurosurgeons. The exploration covers a spectrum of achievements, ranging from pioneering research and innovations to complication avoidance, neuroendoscopic training, and global recognition. Despite challenges, Indian neurosurgeons continue to lead the way in shaping the future of neuroendoscopy, ensuring better patient outcomes and improved quality of life. Many Indian neurosurgeons have contributed significantly to the development of neuroendoscopy in India. Prof. YR Yadav's contributions stand significant in the form of research articles and publications on almost all subjects on neuroendoscopy, the textbook on neuroendoscopy, popularizing neuroendoscopy by starting the first university-certified neuroendoscopy fellowship training program in India, describing many innovative techniques/first report of endoscopic techniques and conducting regular endoscopic workshops in his institutions and other major cities of India.

Skull base dural reflection models: tool for teaching neuroanatomy at resource-scarce centers

Skull base dural reflections are complex, and along with various ligaments joining sutures of the skull base, are related to most important vessels like internal carotid arteries (ICA), vertebral arteries, jugular veins, cavernous sinus, and cranial nerves which make surgical approaches difficult and need thorough knowledge and anatomy for a safe dissection and satisfactory patient outcomes. Cadaver dissection is much more important for the training of skull base anatomy in comparison to any other subspecialty of neurosurgery; however, such facilities are not available at most of the training institutes, more so in low- and middle-income countries (LMICs). A glue gun (100-Watt glue gun, ApTech Deals, Delhi, India) was used to spread glue over the superior surface of the bone of the skull base over desired area (anterior, middle, or lateral skull base). Once glue was spread over the desired surface uniformly, it was cooled under running tap water and the glue layer was separated from the skull base. Various neurovascular impressions were colored for ease of depiction and teaching. Visual neuroanatomy of the inferior surface of dural reflections of the skull base is important for understanding neurovascular orientations of various structures entering or exiting the skull base. It was readily available, reproducible, and simple for teaching neuroanatomy to the trainees of neurosurgery. Skull base dural reflections made up of glue are an inexpensive, reproducible item that may be used for teaching neuroanatomy. It may be useful for trainees and young neurosurgeons, especially at resource-scarce healthcare facilities.

History of Endoscopic Spine Surgery in India

Endoscopic spine surgeries provide distinct advantages and is therefore a viable alternative to open or microscopic techniques. Indian surgeons have shown their expertise from craniovertebral junction to lumbosacral spine with these techniques. Many novel approaches like endoscopic transcervical, partial corpectomy, and others have been designed, and many technological innovations for these surgeries have been made. With different training programs attracting both native and international surgeons, the future of endoscopic spine surgery is bright.

Surgical innovation in LMICs-The perspective from India

Surgical Innovations are central to surgical progress, and have led to exponential growth in various fields of Surgery. Surgical Innovations in Lower and Middle Income Countries are the result of creativity of frontline health workers in search of simple, safe and ethical solutions for their unique challenges. The key lies in: 'simplifying the idea/technique/device' to find patients' needs-driven low-cost innovative surgical solutions; which can be used on a wider scale to achieve health equity for underserved populations. Local surgeons understand the difficulties and nuances of various problems and can provide local-evidence-based customized solutions for their patients' health problems. We developed a Surgical Innovation Ecosystem allowing us to see difficulties as opportunities, learn from everyone and conduct research on what is 'important' rather than what is 'interesting'. Barriers to Surgical Innovations in Lower and Middle Income Countries are well known; however, a roadmap to overcome these barriers is now available. The right balance has to be found between encouraging creativity and innovation while maintaining ethical awareness and responsibility to patients. Introduction and adoption of Surgical Innovations are governed by evidence-based principles and have to undergo a rigorous and scientific evaluation. Science of Surgical Innovations has finally come of age and is getting its due recognition and the pioneering innovators are receiving the much needed appreciation and support.

Low-Cost Endoscope Camera System for Neurosurgical Cadaveric Laboratory Dissections

OBJECTIVE

Many training institutions in low-income countries do not have the resources to purchase and maintain a clinical-grade endoscopy tower dedicated to the laboratory. This project aimed to create a low-cost endoscope camera system using online-sourced materials to allow the operators to practice endoscopic surgical techniques in a cadaver laboratory setting.

METHODS

A low-cost endoscope system was created using a 34MP camera with recording capabilities and direct streaming to high-definition multimedia interface in full high resolution, with an adjustable focal length coupler and a light-emitting diode light source. The system cost was $443, as the endoscope and the monitor were already in the laboratory.

RESULTS

The system was successfully employed to practice endoscopic dissections in 3 cadaveric specimens with good visualization of relevant structures.

CONCLUSIONS

This article demonstrated how to produce a low-cost endoscope camera system for laboratory training in neuroendoscopy.

Development of a Technical Skills Test to Improve Assessment and Evaluation in Neuroendoscopic Education

BACKGROUND

Endoscopy requires a unique set of skills that are difficult to acquire in most training programs. A method to test technical skills, in a validated manner, has rarely been attempted. The purpose of this study was to develop a technical skills examination for objective assessment in neuroendoscopic education.

METHODS

Twenty-nine participants were included for analysis and divided by seniority level into 2 groups defined as before or upon postgraduation year (PGY) 5 (n = 18, junior surgeons) or after PGY5 (n = 11, senior surgeons). Study participants were assessed for baseline performance and then again following a 4-hour neuroendoscopy course. Wilcoxon test was used to evaluate for performance differences between cohorts. Correlation analyses were performed using the Pearson or Spearman coefficient.

RESULTS

Increasing PGY level was correlated with a decreased average time to complete all 3 tasks (r = -0.44, P = 0.03) at baseline. Overall performance improved in both cohorts following the course (P < 0.001). When comparing junior surgeons after endoscopy training (posttest) to senior surgeons at their baseline (pretest), the junior surgeons were faster after endoscopic training than the senior surgeons were before training (P < 0.001).

CONCLUSIONS

A neuroendoscopic skills test can distinguish between more or less experienced surgeons. Significant overall performance improvement, regardless of seniority level, following neuroendoscopic training demonstrates the accuracy of the test at detecting operating improvement in all stages of learning.

Developing a dynamic simulator for endoscopic intraventricular surgeries

INTRODUCTION

A novel dynamic simulator brain model with hydrocephalus has been developed for endoscopic intraventricular procedures. Detachable components allow enhancement of the walls of the ventricle by choroid plexus, ependymal veins and the membranous floor of the third ventricle which are derived from cadaveric lab animal tissues to give a lifelike appearance. These can be changed for every exercise. Ventricles are filled with injection of saline to give appropriate transparent medium and connected to a device transmitting pulsations creating conditions similar to live surgeries.

MATERIAL AND METHODS

Thirty-five participants have used this model over the last 1 year and found it to be useful for conducting third ventriculostomy. Further development of the model for septostomy, aqueductoplasty and tumour biopsy has also been recently tested successfully by 12 participants.

CONCLUSION

It is hoped that this simulator model for intraventricular endoscopy is comprehensive as a learning tool in carrying out most of the the surgical procedures currently practised.

Endoscopic Anterior Approach for Cervical Disc Disease (Disc Preserving Surgery)

OBJECTIVE

To report our experience of endoscopic disc removal by anterior approach for management of cervical myelopathy in 210 patients.

METHODS

A retrospective study of 187 cases of single- and 23 cases of double-level disc disease was performed. Cases of myelopathy with or without unilateral or bilateral radiculopathy and unilateral radiculopathy with either soft or hard disc prolapse were included. Patients with ≥3 disc levels, unstable spine, infections, trauma, significant posterior compression, congenital canal stenosis, disc extending more than half the vertebral body height, and prior surgery at the same level were excluded.

RESULTS

C5-6 (n = 119 patients), C6-7 (n = 58 patients), C4-5 (n = 49 patients), C3-4 (n = 6 patients), and C2-3 (n = 1 patient) levels were represented. Visual analog scale and Nurick grading system were used to assess severity of neck and arm pain and functional outcomes, respectively. Preoperative mean visual analog scale scores for arm and neck pain were 6.7 and 3.2, respectively, which improved to 1.7 and 1.1 at 3 months after surgery. The average preoperative Nurick grade improved from 2.64 to 0.81 at 6 months postoperatively. Follow-up was 6-54 months.

CONCLUSIONS

Endoscopic anterior discectomy (disc preserving surgery) is an effective and safe alternative in cervical disc disease. Although there was reduction in disc height, clinical outcome was good at an average 29 months of follow-up. Long-term follow-up is required to assess any progressive disc degeneration and clinical results.