Comparison of two- and three-dimensional endoscopic visualization for fetal myelomeningocele repair: a pilot study using a fetoscopic surgical simulator.

INTRODUCTION: The objective of this study was to evaluate the utility of three-dimensional (3D) versus conventional two-dimensional (2D) endoscopy for fetal myelomeningocele repair using a low-fidelity fetoscopic surgical simulator. METHODS: A low-fidelity fetoscopic box trainer was developed for surgical simulation of myelomeningocele repair. Participants with varying surgical experience were recruited and completed three essential tasks (cutting skin, dural patch placement, and suturing skin) using both 2D and 3D endoscopic visualization. Participants were randomized to begin all tasks in either 2D or 3D. Time to completion was measured for each task, and each participant subsequently completed the NASA Load Index test and a questionnaire evaluating their experience. RESULTS: Sixteen participants completed the study tasks using both 2D and 3D endoscopes in the simulator. While the mean performance time across all tasks was shorter with 3D versus 2D endoscopy (cutting skin, 47 vs. 54 seconds; dural patch placement, 38 vs. 52 seconds; and suturing skin, 424 vs. 499 seconds), the results did not reach statistical significance. When comparing times to completion of each of the three tasks between levels of expertise, participants in the expert category were faster when suturing skin on the 2D modality (P = 0.047). Under 3D visualization, experts were faster at cutting the skin (P = 0.008). When comparing experiences using the NASA-TLX test, participants felt that their performance was better using 3D over the 2D system (P = 0.045). Overall, 13 of 16 (81.3%) participants preferred 3D over 2D visualization. CONCLUSIONS: Three-dimensional endoscopes could potentially be used in the near future for relative improvement in visualization and possibly performance during complex fetoscopic procedures such as prenatal repair of myelomeningocele defects. Further studies utilizing 3D scopes for other related procedures may potentially support clinical implementation of this technology in fetal surgery and also prove to be a useful tool in surgical training.

The Co-Pilot Project: An International Neurosurgical Collaboration in Ukraine.

OBJECTIVE: We aim to provide a thorough description of the efforts and outcomes of the Co-Pilot Project in Ukraine, which facilitates neurosurgical collaboration between American and Ukrainian physicians. METHODS: The Co-Pilot Project, which operates under its parent nonprofit organization, Razom, organized multiple trips for American physicians to Ukraine. Activities included consulting in clinic, assisting with neurosurgical operations, and providing didactic lectures. Further efforts have included coordinating training opportunities for Ukrainian surgeons. We retrospectively reviewed all operations performed by Ukrainian partner physicians alongside American co-pilot physicians across Ukraine since August 2016. RESULTS: Teams of Ukrainian and American physicians operated on 78 patients (24 children and 54 adults) for a total of 84 procedures in 5 different cities (Kyiv, Lutsk, Lviv, Odessa, and Stryi) of Ukraine. Operations were classified into the following categories: adult brain tumors (n = 39), adult spine tumors (n = 1), epilepsy (n = 9), pain (n = 2), pediatric brain tumors (n = 11), vascular/endovascular (n = 10), and miscellaneous (n = 12). Four illustrative cases are described in detail. Of the patients with brain tumors, 43.5% (20/46) had giant tumors, and gross total resection or near-total resection was achieved in 78.3% (36/46). CONCLUSIONS: Profound disparities in neurosurgical care exist globally, which has led to the formation of collaborative relationships between physicians from various countries. We hope that the work of the Co-Pilot Project in Ukraine can serve as a template for effective international neurosurgical collaboration in other low-to-middle-income countries.

Risk of Infection Associated with Transmucosal Placement of Instrumentation in Clean-Contaminated Field: Systematic Analysis.

Instability of the craniovertebral junction (CVJ) following odontoidectomy is relatively common. Traditionally, separate stage posterior atlantoaxial ± occipitocervical fusion is used for treatment. A transmucosal approach using a clean-contaminated route is associated with hypothetical risks of infectious complications. There is a paucity of information in the literature assessing the risk of surgical site infection (SSI) using the transmucosal approach for hardware placement. The authors conducted a literature search through PubMed identifying patients with pathology requiring transmucosal (i.e., transnasal or transoral) CVJ fixation. Studies that described 1) cases requiring a transmucosal approach and 2) associated infectious complications were included. Rates of SSIs, device removal, unplanned reoperation, and hardware failures were analyzed. Descriptive statistics and odds ratios (ORs) were used to compare complications. Nine studies with a total of 431 patients were identified. There were 4 (0.93%) superficial SSIs and 4 (0.93%) deep SSIs. In total, 1.86% of patients experienced SSI. There were 18 (4.18%) cases of unplanned reoperation, 4 (0.93%) related to SSI. Five (1.16%) patients required removal of their anterior fixation device, 4 (0.93%) related to SSI. ORs comparing our results with Medvedev et al's retrospective National Surgical Quality Improvement Program study assessing the risk associated with posterior cervical fixation showed no statistical difference between postoperative infection rates (OR = 0.72, P = 0.36). An extensive review of the literature found no evidence to suggest placement of spinal hardware via transmucosal corridor is associated with an increased risk of SSI.