The Angelina Dissectors: A Novel Design of Dissectors for Endoscopic Endonasal Approaches

摘要

Background?The description and refinement of the transsphenoidal approach would not be possible without new tools and technologies developed by surgeons to facilitate this approach, which is nowadays the standard procedure for more than 90% of sellar lesions. The latest major change in transsphenoidal surgery was the introduction of the rigid endoscope and the subsequent description of the endoscopic endonasal approach. Traditional bayoneted instruments, when used for this technique, were inadequate. New instruments designed, specifically for this technique, are necessary to facilitate the surgeon's work and improve patient outcome.Objective?This study describes a novel design of dissectors created specifically for endoscopic endonasal approaches.Methods?To develop and design the Angelina dissectors, we used our extensive surgical experience to identify the shortcomings of the available dissectors used for transsphenoidal surgery and created the Angelina dissectors.Results?The Angelina dissector was designed with a unique shaft shape which facilitates endoscopic endonasal surgery.Conclusion?Even though an endoscopic endonasal approach is possible using other instruments, the design of these dissectors aids the surgeon's work. It is our impression, based on personal experience that it allows more freedom of movement and dexterity during the procedure, which could translate as an improved patient outcome. Keywords: design equipment, endoscopy, neurosurgery, otolaryngology, skull baseIntroductionThe historical background and evolution of pituitary surgery and the advances in equipment have been reviewed and highlighted on many articles in the past two decades. The description and refinement of the transsphenoidal approach would not be possible without new tools and technologies developed by surgeons to facilitate this approach which is nowadays the standard procedure for more than 90% of sellar lesions.~(1)~(2)The current technique of the transsphenoidal procedure is, like many advances in medicine, the result of a long and relentless process and it is still ongoing. It has taken open transcranial sellar approaches, marked by the pioneer work of Sir Victor Horsley who performed the first pituitary surgery in 1889 to the current endoscopic endonasal procedure.~(3)The limitations of the transcranial approach inspired the development of the transsphenoidal procedure that evolved from the simultaneous work of Oskar Hirsch in Vienna~(4)and of Harvey Cushing in Boston.~(5)Cushing's pioneer work to developed this procedure could have been lost when, in 1929, he abandoned the transsphenoidal procedure in favor of a transcranial one, leading most surgeons at the time to follow suit. Hirsch, Hannibal Hamlin, Norman Dott, and a few others are notable exceptions that kept performing and refining this procedure and the tools available for it.~(3)The work of Norman Dott and Gerard Guiot returned attention to the transsphenoidal procedure for sellar lesions. Both were noted not only for their surgical ability but also for their ingenuity. Dott and Guiot created new tools and instruments to overcome the limitations of the time for the transsphenoidal approach.~(6)~(7)Norman Dott was a neurosurgeon in the Royal Infirmary of Edinburgh. He spent a year in Dr. Cushing's service in 1923 to 1924 where he learned and studied the transsphenoidal technique and its benefits, despite the difficulties encountered at the time. One of the main problems was the dark and narrow surgical field and Dott designed a modified speculum with lights attached to it to improve lighting.~(3)~(8)After learning the transsphenoidal technique from Norman Dott in 1956, Gerard Guiot returned to France and started using it in lieu of the transcranial approach. He created several surgical instruments to meet his needs during surgery contributing for the advancement of this technique. His group went on working performed approximately 5,500 transsphenoidal surgeries.~(3)~(8)~(9)Optimization of operative results requires the careful selection of instruments.~(10)Many of the breakthroughs and improvements in techniques were possible because of new technologies and tools created, often by or with the assistance of experienced surgeons. The latest advancement in transsphenoidal surgery was the introduction of the rigid endoscope and the subsequent description of the endoscopic endonasal approach by Jho and Carrau, where the “eye” of the surgeon (the endoscope) is in the sinonasal cavity.~(11)~(12)The endoscopic endonasal approach has been growing since and again, instruments designed specifically for this technique are necessary to facilitate the surgeon's work.In this article, we described the rationale and recommended uses of a novel instrument design, created from the senior authors' experiences which are successfully used in our institution for endoscopic endonasal approaches.Instrument Design RationaleTraditional straight instruments, used in open transcranial