Perfusion-based human cadaveric specimen as a simulation training model in repairing cerebrospinal fluid leaks during endoscopic endonasal skull base surgery

Restricted access

OBJECTIVE

Competency in endoscopic endonasal approaches (EEAs) to repair high-flow cerebrospinal fluid (CSF) leaks is an essential component of the neurosurgical training process. The objective of this study was to demonstrate the feasibility of a simulation model for EEA repair of anterior skull base CSF leaks.

METHODS

Human cadaveric specimens were utilized with a perfusion system to simulate a high-flow CSF leak. Neurological surgery residents (postgraduate year 3 or greater) performed a standard EEA to repair a CSF leak using a combination of fat, fascia lata, and pedicled nasoseptal flaps. A standardized 5-point Likert questionnaire was used to assess the knowledge gained, techniques learned, degree of safety, benefit of CSF perfusion during repair, and pre- and posttraining confidence scores.

RESULTS

Intrathecal perfusion of fluorescein-infused saline into the ventricular/subarachnoid space was successful in 9 of 9 cases. The addition of CSF reconstitution offered the residents visual feedback for confirmation of intraoperative CSF leak repair. Residents gained new knowledge and a realistic simulation experience by rehearsing the psychomotor skills and techniques required to repair a CSF leak with fat and fascial grafts, as well as to prepare and rotate vascularized nasoseptal flaps. All trainees reported feeling safer with the procedure in a clinical setting and higher average posttraining confidence scores (pretraining 2.22 ± 0.83, posttraining 4.22 ± 0.44, p < 0.001).

CONCLUSIONS

Perfusion-based human cadaveric models can be utilized as a simulation training model for repairing CSF leaks during EEA.

ABBREVIATIONS CSF = cerebrospinal fluid; EEA = endoscopic endonasal approach; LAC = Los Angeles County; PGY = postgraduate year; USC = University of Southern California.

Article Information

Correspondence Joshua Bakhsheshian, Department of Neurological Surgery, University of Southern California, Keck School of Medicine, 1200 North State St., Ste. 3300, Los Angeles, CA 90033. email: joshuabakh@gmail.com.

INCLUDE WHEN CITING Published online November 3, 2017; DOI: 10.3171/2017.5.JNS162982.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Intrathecal insertion of a pediatric extracorporeal membrane oxygenation (ECMO) cannula after cervical laminectomy and durotomy. Figure is available in color online only.

  • View in gallery

    Suprasellar CSF leak. Figure is available in color online only.

  • View in gallery

    Repair of CSF leak: Step 1, fascia lata (A); Step 2, Surgicel (B); Step 3, nasoseptal flap (C). Figure is available in color online only.

References

  • 1

    Aboud EAboud GAl-Mefty OAboud TRammos SAbolfotoh M: “Live cadavers” for training in the management of intraoperative aneurysmal rupture. J Neurosurg 123:133913462015

  • 2

    Aboud EAl-Mefty OYaşargil MG: New laboratory model for neurosurgical training that simulates live surgery. J Neurosurg 97:136713722002

  • 3

    Arriaga AFBader AMWong JMLipsitz SRBerry WRZiewacz JE: Simulation-based trial of surgical-crisis checklists. N Engl J Med 368:2462532013

  • 4

    Cappabianca PCavallo LMColao Ade Divitiis E: Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 97:2932982002

  • 5

    Couldwell WTKan PWeiss MH: Simple closure following transsphenoidal surgery. Technical note. Neurosurg Focus 20(3):E112006

  • 6

    Dawe SRPena GNWindsor JABroeders JACregan PCHewett PJ: Systematic review of skills transfer after surgical simulation-based training. Br J Surg 101:106310762014

  • 7

    Garrett HE Jr: A human cadaveric circulation model. J Vasc Surg 33:112811302001

  • 8

    Güvençer MSayhan SAy Dereli NTetik SYücesoy KArda MN: Simulation of cerebrovascular circulation in the human cadaver for surgical neuroanatomy training. Turk Neurosurg 17:2432462007

  • 9

    Hadad GBassagasteguy LCarrau RLMataza JCKassam ASnyderman CH: A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 116:188218862006

  • 10

    Kassam ABThomas ACarrau RLSnyderman CHVescan APrevedello D: Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 63:ONS44ONS532008

  • 11

    Kirkman MAAhmed MAlbert AFWilson MHNandi DSevdalis N: The use of simulation in neurosurgical education and training. A systematic review. J Neurosurg 121:2282462014

  • 12

    Koutourousiou MGardner PATormenti MJHenry SLStefko STKassam AB: Endoscopic endonasal approach for resection of cranial base chordomas: outcomes and learning curve. Neurosurgery 71:6146252012

  • 13

    Leng LZBrown SAnand VKSchwartz TH: “Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery 62 (5 Suppl 2):ONSE342ONSE3432008

  • 14

    O’Malley BW JrGrady MSGabel BCCohen MAHeuer GGPisapia J: Comparison of endoscopic and microscopic removal of pituitary adenomas: single-surgeon experience and the learning curve. Neurosurg Focus 25:E102008

  • 15

    Psaltis AJSchlosser RJBanks CAYawn JSoler ZM: A systematic review of the endoscopic repair of cerebrospinal fluid leaks. Otolaryngol Head Neck Surg 147:1962032012

  • 16

    Rosseau GBailes Jdel Maestro RCabral AChoudhury NComas O: The development of a virtual simulator for training neurosurgeons to perform and perfect endoscopic endonasal transsphenoidal surgery. Neurosurgery 73 (Suppl 1):85932013

  • 17

    Russin JJMack WJCarey JNMinneti MGiannotta SL: Simulation of a high-flow extracranial-intracranial bypass using a radial artery graft in a novel fresh tissue model. Neurosurgery 71 (2 Suppl Operative):ons315–ons320 2012

  • 18

    Schlosser RJBolger WE: Nasal cerebrospinal fluid leaks: critical review and surgical considerations. Laryngoscope 114:2552652004

  • 19

    Strickland BLucas JHarris BKulubya EBakhsheshian JLiu C: Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transphenoidal pituitary surgery: surgical experience in a series of 1002 patients. J Neurosurg [epub ahead of print September 29 2017. DOI: 10.3171/2017.4.JNS162451]

  • 20

    Ström PHedman LSärnå LKjellin AWredmark TFelländer-Tsai L: Early exposure to haptic feedback enhances performance in surgical simulator training: a prospective randomized crossover study in surgical residents. Surg Endosc 20:138313882006

  • 21

    Thorp BDSreenath SBEbert CSZanation AM: Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak. Neurosurg Focus 37(4):E42014

  • 22

    Tubbs RSLoukas MShoja MMWellons JCCohen-Gadol AA: Feasibility of ventricular expansion postmortem: a novel laboratory model for neurosurgical training that simulates intraventricular endoscopic surgery. J Neurosurg 111:116511672009

  • 23

    Winer JLKramer DRRobison RAOhiorhenuan IMinneti MGiannotta S: Cerebrospinal fluid reconstitution via a perfusion-based cadaveric model: feasibility study demonstrating surgical simulation of neuroendoscopic procedures. J Neurosurg 123:131613212015

  • 24

    Zada G: Editorial. Vascularized flap reconstruction for CSF leaks during endoscopic skull base surgery. Neurosurg Focus 37(5):E52014

  • 25

    Zada GBakhsheshian JPham MMinneti MChristian EWiner J: Development of a perfusion-based cadaveric simulation model integrated into neurosurgical training: feasibility based on reconstitution of vascular and cerebrospinal fluid systems. Oper Neurosurg (Hagerstown) [epub ahead of print] 2017

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 123 123 28
Full Text Views 223 223 4
PDF Downloads 185 185 3
EPUB Downloads 0 0 0

PubMed

Google Scholar