Endoscopic Assist for Pediatric Tumors, Vascular, and Hydrocephalus:...

OK. All right. So our, our next speaker, uh, we're going a little bit out of order, uh, because of some scheduling issues. Uh, honored to have, uh, uh, the director of pediatric neurosurgery, uh, at, uh, Stanford, Lucille Packard, uh, Doctor Jerry Grant, um, who is gonna speak to us about endoscopy as an adjunct for tumors, vascular, and shunts, and maybe throw a couple other disorders in there, Jerry, if you can, but sounds like a panacea, uh, enlighten us if you will, and we OK, we'll move forward. Yeah, we'll move forward. Sorry, but I can see you, remain, and Mark. So thank you for inviting me, and, um, this is really an interesting panel. Uh, I think a really nice array of topics, and this topic, as you said, is, is a little bit hodgepodge. It's, uh, several things together, but it, it really is the same theme in how we use the endoscope. To assist us with um operations and there's different kind of types of assists, and we'll go over that. We think about this sometimes for tumors, we think of it for vascular kind of cases, hydrocephalus, um, and it, and I've used it for all these different circumstances, and we'll, we'll kind of go through those together. Um, So, if you think about, can you still see my slides OK for me? Yeah. So endoscopic, there's endoscopic assist versus endoscopic controlled, and you know, one is really using the endoscope to as an assist device where we're basically under the microscope on direct vision doing a craniotomy and we might use the endoscope to assist us in our visualization. And that's different from endoscopic controlled terminology where we basically, we only have the endoscope. That would be an example of a pituitary transnasal case, for example. So they're really very different approaches, but of course, the techniques are very similar. Um, one thing that's technically important, you know, is this sense that, you know, you really need a rigid endoscope holding arm of some sort. It's not something you wanna be holding in there because it kind of takes your hand out of you. And when you're doing a microscopic case with an endoscopic assist, there's only so much room there to, to maneuver, and I really like to fixate these rigid scopes in this kind of setting. Which you may not do in something like Ben was talking about, uh, you, you know, where you're doing very flexible type techniques, and then there's this rigid scope versus flexibility, and to be honest, I, I like more of the rigid, um, I use different angled scopes in this kind of setting, particularly for getting underneath certain areas, looking around the corner. Um, I worry about the flexible scope in these settings, of how to get that flexible scope back out, and you can really cause damage and Uh, this is something that we're always worried about is getting in and getting out, I think are the riskiest times for these scopes. It's supposed to under the microscope. Because if you think about it, you're looking under the microscope and then you have your endoscopic screen, unless you're somehow coupled together in a virtual environment, you can really be distracted and think you're beautifully going down to an area, but unfortunately, you're, you're causing a lot of, you know, destruction along the way, particularly the base of the frontal lobe, for example, or olfactory nerves or optic chiasm or carotid, you know, these are areas that Once you get beyond these structures, you, you won't see them. Uh, you can't see behind your scope. I think that's a critical point of any of these kind of endoscopic assist or controlled environments, spatial awareness is critical to really be on top of that and You know, I'm, essentially, when I'm putting the scope in, I'm using the microscope. I'm watching that scope go down. I'm not even paying attention to what the endoscopic screen is, is looking at. Once I'm down there, I fixate it, and then I can look around and do things and manipulate structures. To, to look around corners or whatever I'm trying to do with these kind of scopes. So, I think these are the important messages. I think the take-home points about safety and being very careful because of the, some of the problems I've seen of just inserting these kind of scopes into that area. You know, of course, we've discussed it, why Ted went over this, uh, Mark, in terms of the transnasal approaches and Jeff Greenfield too, um. You know, these are classic approaches where essentially we've gone from microscope to endoscope. So it's a little different to think about using both, that's that assist approach, where we might go from below, we might do certain cases, uh, for example, like this, I'm not sure if you can see my cursor, um, but going transnasal, then coming back from above. You know, in this area, paracellar area, clivis, there are areas that we'd love to get around the corner, we'd love to look under structures, especially coming from above, you know, when you've done a, a low orbitotomy orbit a zygomatic approach, um, you know, you're always thinking about corridors and clearly the lower we are, the higher we can look. And with the scope, we can even look higher, and that's, I think the real advantage of these kind of rigid scopes, with particularly those acute angles, the 70-degree angles are really nice. When I first go in, I mostly use the 0 degree, then I move up 30 and 70, cause it gets even more challenging to think about where that scope is as you're looking up at or down at some of these structures. And then extended approaches, of course, you might use these different angles and Use a combination of the microscope, especially if you've gone above and below in the same setting for a very wide, large cellar supercellar lesion, for example, you may need combined approaches. Base example of an 11-year-old with 3 or 4 weeks of headaches, nausea and vomiting, with the fun of self examination showing papilloedema. Here you can see the films, you can debate in this kind of setting going from above, going from below. Is it age dependent? What if the sphenoid was ossified? What if this was a 2 year old? How would you get to some of these structures? And of course, we're always thinking about going from below and transnasal for these. But say you had normal pituitary function, very young child, small nares, you know, is that the best approach or not? If we go from above, losing vision, how are we gonna get underneath the optic chiasm? How are we're gonna look to the lamina terminalis? How can we look up into that third ventricle, really reproducing the same kind of view that we get transnasally, but doing this from a subfrontal. Or lateral subtemporal approach. I've used these rigid endoscopes for some of these brain stem lesions, medial temporal areas, quadrigeminal plate coming from the back, coming from the side, really gives you such beautiful optics, um, with that rigid scope, particularly, you know, I, I'm not willing so much to use the flexible because the optics is just so good in these rigid cameras. Um, to get these kind of views that, you know, I'm gonna advance some of this cause, uh, Yeah, I know you've already talked about the transnasal approaches, but thinking about a cranio and, you know, we're spoiled from below and now we're underneath these nerves, but think about being above and looking up at that chiasm in terms of how you would, how you would see those areas. And, you know, we're always trying to get a complete resection if we're in there, we wanna, if anything, look at these chiasm areas from underneath cause that's where we're gonna cause the damage up in these tracks, particularly up near the chiasm tract junction. I think it's a very risky area. Things are distorted, but the scope that allows you to get just like the transnasal approach, but get underneath for some of these really complex lesions. We try to go back cranially from lesions that, you know, we've already done some work from below, then sometimes later in a staged approach, we go from above. Um, and I think these are really nice techniques. Um, again, these corridors are, are really key in terms of preserving the stalk, preserving the chiasm. And these scopes, kind of like our mirror, in the old days, you used to use a swivel mirror. I don't know if any of you or Mark or Rine use those mirrors, but they're really nice to look underneath. They do fog some, you have to be careful with that, but they, they are very safe to use, but that's, you know, directly under the microscope looking at these structures. The endoscopes even better, and, you know, I learned this mostly from doing, doing vascular. This is back when I was in the military, doing all the, these different vascular cases and It, it is wonderful to take these slopes down because we're always use these minimally invasive approaches to get down there. Similar case like this where you, you can go transnasal, another craniphangioma cyst, uh, calcified, um, you can look at these walls carefully. We've been able to look at the endoscope real nicely to, to figure out how to You know, safely resect these. We're always worried about that hypothalamic portion. You know, we're kind of pulling from below. We're just hoping it might come down in that capsule, um, from below, we're, you know, we're used to this, right? In terms of how we pull on these areas and in terms of removing this kind of thing, but doing this from above and pulling up into the hypothalamus, I think is where we cause that risk. How wonderful would it be to actually see these in a direct vision. See those interfaces, so as we pull, we kind of see exactly what that looks like and we might leave these capsules and, you know, if anything, we've become more conservative, right over the years of how we handle the hypothalamic portion, these parts that go way up into that third ventricle. Um, I've done some work with transciliary approaches where Um, there's a series of, uh, about 120 or so we've done of approaches to the anterior cranial fossa. Uh, these are really nice corridors and you can stay nice and low. We do a small orbitotomy, tiny bit of zygoma all through that transciliary eyebrow incision, and this is a great approach where you'd want to think about using a rigid endoscope. The positioning, of course, on these, you, you're in quite a bit of an extension. You're doing a small orbitomy to get extremely low to allow you to pass that endoscope, and I've done these either endoscopic controlled. Remember that's primary endoscope versus endoscopic assist where we're using the endoscope to assist us to do various Acoms or planum sphenoy and meningiomas, small cranopyiomas. Last week, I did a um transtillary approach for a pituitary thickened stalk, concussionable germinoma in a kid with DI. You know, get a biopsy essentially cause it was a question of inflammatory pophicitis, germinoma versus Langerhans, and this is a really nice way to stay nice and low and do these approaches. Use your endoscope to your advantage to look around these corners, look. At the back of the stalk, I think it'd be very difficult open to do that without the scope because you essentially have to move the stalk away, essentially be risking the chiasm, moving the anterior cerebral or the carotid laterally to try to get to these areas. So, as you get more minimally invasive as we think about this for our small corridors or like we're doing now with our, like the metrics approaches where we use these small tubes in the brain. To access these corridors, you know, the endoscope is a beautiful way again to look around those areas cause we have no retractors in. Um, and with these scopes, you can get nice and close, really close to comfort almost to these aneurysms, for example, or any lesion really around this paracellar anterior skull base. I think it's a really nice approach for this region. So I would, I would say it gives us a better view of some of these anatomic features. It's a very clear uh observation of these parent vessels, the branches, um, very nice for some of these cranios going laterally as you're going down to the basil and the PCA. Um, as well as the, the optic chiasm, of course, to get in underneath that chiasm. The 0 degree is great for that illumination even just to get the light at those deep areas. Sometimes our scopes don't have that capability to get in that deep hole. I'm thinking, can I be brighter? Can I be higher. Magnification. This will be interesting how this changes, of course, with some of the exoscopes and some of the synapses, you know, different kind of companies that are working on this, Olympus, Ice, etc. to think about how to get to these deep areas, get that lighting and magnification that right now we use these endoscopes for, and then these 30, 70 degree acute angles to really look around these corners that otherwise, there's no way you could see unless you move these structures. Uh, so the more minimally invasive we get, It's gonna become even more challenging to look at some of these structures to try to get a gross total removal of these tumors. Thinking about from an endoscopic assist point of view for shunts, you know, this has been looked at over the years and of course, the um uh the, the different centers and collaborating um in terms of looking at whether this makes a difference. There have been studies out on this. There is some level of evidence showing that potentially that, you know, the, um, there's a little higher infection risk using an endoscope for a primary shunt. Is that the right thing? Um, does somehow the placement of the tip of the catheter somehow improve the longevity and shunt function. This has been always a question over the years. I don't use this routinely for upfront shunts, but I have used it routinely for revisions. I think this is a really nice way to revise a shunt. We use a very small 1 millimeter scopes. You can use the disposable or non-disposable. There's different ones out now, um. You know, sports as what we're looking at now that we've been using and, and trialing. I think this is a, a really nice uh area that instead of using, um, you know, brain lab or stealth or some other image guidance to get you to these areas, I follow that old track. I look at these kind of cases where the shunt tract is so small, a typical slit ventricle kid where you're really challenged to think about how you're gonna get a new catheter in, you know, the catheter is blocked, but how are we gonna revise this kind of catheter. I think these scopes are beautiful, you know, in this setting. This, I, um, I took through the, the ISPN has this really nice site, you know, that looks at these different areas, um. Uh, for pediatric neurosurgery and the ISPN guide that Rick Abbott's done over the years, and this is an example of the video that he's had in his portfolio that how we follow the tract, essentially put that rigid scope down your, your tract of your old shunt, you can remove it that way. Um, sometimes the tip, of course, is stuck, you have to use the, the, um, Get back to the PowerPoint here. Use the um rugby technique to remove an old catheter is one of the. Sorry, I have to get rid of the uh Stone and the National Board of Review has one of the best pictures of the year. Phantom Thread rated R. I want to get Jim Carrey out of here, one second. Are you with me still? You're good. OK, so here's another view. So once you pop through that area where You've been able to advance that catheter, then you pop into the ventricle. Now you can look in there and you can decide if you want to penetrate something or make two ventricles into one, whatever you might wanna be doing, of course, to advance this, but all in the setting of a really tiny slit ventricle, I think is really nice for these, um, these cases. So something to think about for these kind of problems where I've, I've really been saved, where I, instead of removing that old catheter and trying to find a new tract, I think it's a really nice way to Use this endoscope to assist, especially these tiny ones now that we can do 1 millimeter scopes that um can keep the hole extremely small, um, and revise some of these shunts where they can be very challenging if we can't get back in, for example. We always use that old track and without this kind of ability, we could essentially dissect into the white matter, really not. Know that we're safe. So we use this kind of assists. They're very complimentary. We're always thinking about how to use their rigid scope with an open case to get us that better visualization. Most of this is for skull base. I would say rarely used in the, say, routine medulo of the fourth ventricle, but you, you could do that if you were trying to look up into the aqueduct from the other way. Um, but I, you have to be so careful that Especially along the floor of the brain stem, you, you know, you really need to be watching those scopes, watching first how you get that scope there again, under the microscope. And then later using the endoscope screen to, to look at some of these areas, but always thinking about your spatial awareness of what's around you is critical. This is where your assistant can really help you, keep you safe as you're going in and out, which you really weren't gonna cause that trouble. But it's allowed me, at least in my practice, to really be more aggressive in the skull-based intraventricular lesions back. Vascular lesions, um, shunt revisions, and, you know, the future is this whole 3D scope technology, a lot of this augmented reality, a lot of this space now that we're always thinking about how could we be better in our optics and understand better that 3D relationship with some of these structures, which is critical for this rigid, um, endoscopic assist approach. I think I'll stop there. Maybe if you have questions, we can address those, but I try to give you some highlights of different kinds of cases. Most likely cranioppharyngioma in the pediatric scope is what we'd be using these scopes for. I like the rigid more than flexible because of the optics. And I think the, the readily ability to change your 0 to 30 to 70 is they'll give you amazing views that if you haven't ever looked, I think you'd be surprised of what's around your corner. So thanks so much, Mark and Romaine. I really appreciate the opportunity to, to chat today. Thanks, Jerry. That was, that was wonderful. You mentioned something at the beginning that, that I'd like to bring up is, is the use of the scope itself as, as a tool, um, especially with the metal sheet that sometimes people can use, uh, for, for things like vascular and tumor where you're using it as a, as a, as an adjunct. Have you ever found That sheath to be helpful, and how do you use that uh scope to, to sort of help with the, the adjunct part of the surgery? Obviously, you can't put an aneurysm clip down a, down a scope, um, but what are some, some technical pearls that you can share with the audience for the use of the scope itself? You're talking about for assisting kind of cases or correct, yes, yeah, so it's a really good question, I mean. So I think from an assist perspective, you know, where you're not primarily using the endoscope for your, your sole source of visualization. I've mostly used it purely as an optical device. You have to be careful. The only pearl that I've learned early on with this is, you know, it can heat up at the end of that. And I don't wanna be right up against the carotid essentially with that scope. I, I think there could be some problems, and you, you can see sometimes changes in the vasculature as you're right up against these areas, and you put it against your hand, you realize how hot they get. So be very careful with the illumination in terms of, in keeping your distance from some of these areas, I think is critical. I don't know what that distance is, but I, I think that, that is an important message. So I'm not essentially doing anything primarily with, with the rigid scopes as an endoscopic assist. I also don't use a sheath because you're essentially open. This is an assist device where you've done a craniotomy. And I don't think a sheath would, would help me in that regard. Definitely for endoscopic controlled cases in the brain, I like a sheath going in and out of the cortex. I think it's helpful, um, but be careful of the lighting, be careful of the heat. Keep your field wet, I think is important. Keep it moist. You don't wanna pass. I, I've also seen trouble passing a dry, very dry. Endoscope past, for example, some of these perforators where it can stick, and I think that you don't want anything to stick. You want that field moist. I always irrigate before I put these scopes in to keep everything uh nice and moist. I think that can be helpful. Great. Well, thank you again. Uh, it was a wonderful talk. Um,