Manuscript Submitted to Editorial Office of Minimally Invasive Neurosurgery

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1 Manuscript Submitted to Editorial Office of Minimally Invasive Neurosurgery A HAEMOSTATIC AGENT DELIVERY SYSTEM FOR ENDOSCOPIC NEUROSURGICAL PROCEDURES. Journal: Minimally Invasive Neurosurgery Manuscript ID: MIN--0-0.R Manuscript Type: Technical Note Date Submitted by the Author: n/a Complete List of Authors: Waran, Vicknes; University of Malaya, Division of Neurosurgery, Department of Surgery Weng Yew, Kevin; University of Malaya, Division of Neurosurgery, Department of Surgery Ahmad Bahuri, Nor Faizal; University of Malaya, Division of Neurosurgery, Department of Surgery Narayanan, Prepageran; University of Malaya, ENT Surgery Thambinayagam, Hari Chandran; University of Malaya, Division of Neurosurgery, Department of Surgery Keywords: haemostatic agent, delivery system, neuroendoscopy Abstract: The advent of endoscopic neurosurgery has presented problems with haemostasis due to poor access. We have developed a system which allows the delivery of a variety of haemostatic agents in a more efficacious manner. The system has been used successfully in endoscopic base of skull surgery and endoscopic surgery within the parenchyma of the brain using tube systems. Note: The following files were submitted by the author for peer review, but cannot be converted to PDF. You must view these files (e.g. movies) online. Video Taming Sari Aug Bench low def.wmv Video Taming Sari pub ver- Surgicell and Fibrillar endo TSS.wmv

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3 Manuscript Submitted to Editorial Office of Minimally Invasive Neurosurgery Page of 0 TECHNICAL NOTE A HAEMOSTATIC AGENT DELIVERY SYSTEM FOR ENDOSCOPIC NEUROSURGICAL PROCEDURES. Vicknes Waran FRCS (Surgical Neurology) &*, Kevin Sek MS (Surgery), Nor Faisal Bahuri MS (Surgery), Prepageran Narayanan FRCS(ORL), Hari Chandran (FRCS Surgical Neurology). Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia.. Department of ENT Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia. Centre for Biomedical and Technology Intergration, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia *Corresponding author : Prof. Dr. Vickneswaran Mathaneswaran Mailing address : Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University Malaya, Lembah Pantai, Kuala Lumpur, Malaysia. Tel : Fax : +-- address : cmvwaran@gmail.com Abstract Formatted: Line spacing:. lines Deleted: Deleted:

4 Page of Manuscript Submitted to Editorial Office of Minimally Invasive Neurosurgery 0 The advent of endoscopic neurosurgery has presented problems with haemostasis due to poor access. We have developed a system which allows the delivery of a variety of haemostatic agents in a more efficacious manner. The system has been used successfully in endoscopic base of skull surgery and endoscopic surgery within the parenchyma of the brain using tube systems. Key words: Haemostatic agent, delivery system, neuroendoscopy Introduction The rapid expansion of endoscopic procedures for base of skull [] and intraparenchymal lesions using tube techniques [,,,,,, -] presents surgeons with problems with haemostasis. Conventional bipolar forceps are restricted in their use by poor access for delivery of haemostatic materials such as Surgicel, Fibrillar (Johnson & Johnson), Avitene (Bard) and FloSeal ( Baxter ) and are often clumsy and difficult to use []. We have designed a system that allows the accurate delivery of a variety of haemostatic agents which keeps it in contact with the bleeding source without the haemostatic agent being washed away by the rapid flow of blood. Method Deleted: haemostasis Formatted: Justified Formatted: Font color: Red

5 Manuscript Submitted to Editorial Office of Minimally Invasive Neurosurgery Page of 0 This system consists of two tubes, an internal tube that is connected to suction and a second external tube that has a larger diameter [fig ]. Outside the surgical field the internal tube is introduced into the proximal end of the external tube while pushing a neurosurgical pattie into the external tube until the pattie is about cm from the distal end of the external tube [fig a&b]. Finally any conventionally utilised haemostatic agent like Surgicel, Fibrillar or Avitene is inserted or injected into the distal end of the external tube. The system is now primed and ready for use [fig ]. Once within the operative field and to control bleeding, the inner tube is pushed forward like a piston driving the haemostatic agent and the backing pattie out thereby compressing the haemostatic agent over the bleeding area. [fig a&b] [video ]. When the system is introduced into the operative field, suction across the pattie ensures that blood will be sucked into the external tube past the haemostatic agent (allowing the blood to mix and activate the haemostatic agent) and pattie. The external tube also protects the haemostatic agent and prevents it from being washed away if haemorrhaging is brisk. Results We tested this system in a variety of cases where we encountered brisk haemorrhaging. These occurred from sinus or arterial haemorrhaging during endoscopic pituitary and other anterior skull base endoscopic surgery and intraparenchymal arterial bleeding during excision of intra-parenchymal lesions using an expandable port in conjunction with an endoscope. Deleted: The system consists of an external tube that comes in a variety of diameters and a second internal tube that functions as a suction tube and plunger. The internal tube with a pattie across its tip is introduced into the external tube. Once the tip is almost at the distal end of the external tube, the system is loaded by introducing or injecting the haemostatic agent into the external tube from the distal end (fig & video ). Formatted: Justified Deleted: To control bleeding the sucker that is normally used to keep the field clear of blood is removed and replaced with this system. The inner sucker tube is pushed forward like a piston driving the haemostatic agent and the backing pattie out, thereby compressing the haemostatic agent over the area that is bleeding (fig. & video ).

6 Page of Manuscript Submitted to Editorial Office of Minimally Invasive Neurosurgery 0 This device cannot be used in conventional neurosurgical channel based endoscopic procedures. For sinus haemorrhages we were able to stop the bleeding easily by delivering Surgicel or FloSeal using this system but with intra-parenchymal bleeding we required the use of FloSeal in all cases. When brisk bleeding was encountered in anterior base of skull surgery, the system was able to deliver Avitene (in its powder form) to effectively control the bleeding. We also found that a smaller volume of FloSeal could be used because it was applied more effectively as we were able to introduce the substance directly onto the area of haemorrhage and did not lose a large quantity of the material within the tube provided by the manufacturers and it was not washed away by the rapid flow of blood. Discussion Haemostasis during endoscopic procedures can be especially difficult [,] because access is usually limited as these operations are performed down a long narrow tunnel. In conventional microsurgery a surgeon would have a suction tube over the area of haemorrhage, removing it to introduce the haemostatic agent usually using a bipolar forceps in one hand followed by placing a pattie over the haemostatic agent using the same forceps and following this to position a suction tube over the pattie to gently compress the area of haemorrhage. In endoscopic surgery these actions require time as the surgeon has to manoeuvre these instruments in and out of a long tunnel and in that short time frame the haemostatic material may be washed away especially Formatted: Justified

7 Manuscript Submitted to Editorial Office of Minimally Invasive Neurosurgery Page of 0 if the bleeding is brisk. It is also often difficult to apply the haemostatic material accurately to the bleeding point when using conventional tools. The system we have designed allows the delivery of the haemostatic material with a pattie accurately over the site of haemorrhage with the ability to maintain simultaneously compression and suction so making haemostasis more effective. The several actions that are usually required to control bleeding are incorporated into a single device and the entire process can be performed using only one hand. This ability to perform a variety of tasks simultaneously makes this device suitable when used in conjunction with endoscopic surgery. The device allows us to deliver haemostatic agents for endoscopic procedures more effectively. We are unable to find any similar device that is able to perform haemostasis in such a manner. References. Gardner PA, Kassam AB, Thomas A, Snyderman CH, Carrau RL, Mintz AH, Prevedello DM. Endoscopic endonasal resection of anterior cranial base meningiomas. Neurosurgery. 0 Jul;():-; discussion -.. Kassam AB, Engh JA, Mintz AH, Prevedello DM. Completely endoscopic resection of intraparenchymal brain tumors. J Neurosurg. 0():-, 0. Waran V, Vairavan N, Sia SF, Abdullah B. A new expandable cannula system for endoscopic evacuation of intraparenchymal hemorrhages. J Neurosurg. ():-, 0. Nishihara T, Teraoka A, Morita A, Ueki K, Takai K, Kirino T: A transparent

8 Page of Manuscript Submitted to Editorial Office of Minimally Invasive Neurosurgery 0 sheath for endoscopic surgery and its application in surgical evacuation of spontaneous intracerebral hematomas. J Neurosurg :0-0, 00. Chen CC, Cho DY, Chang CS, Chen JT, Lee WY, Lee HC: A stainless steel sheath for endoscopic surgery and its application in surgical evacuation of putaminal haemorrhage. J Clin Neurosci :-, 0. Ogura K, Tachibana E, Aoshima C, Sumitomo M: New microsurgical technique for intraparenchymal lesions of the brain: transcylinder approach. J Acta Neurochir :-, 0. Nishihara T, Nagata K, Tanaka S, Suzuki Y, Izumi M, Mochizuki Y, et al: New developed endoscopic instruments for the removal of intracerebral hematoma. J Neurocrit Care :- 0. Akai T, Shiraga S, Sasagawa Y, Okamoto K, Tachibana O, Lizuka H: Intra-parenchymal tumor biopsy using neuroendoscopy with navigation. J Minim Invasive Neurosurg :-, 0. Bakshi A: Neuroendoscope-assisted evacuation of large intracerebral hematomas: introduction of a new, minimally invasive technique. J Neurosurg Focus ():E, 0 0. Fadrus P, Smrcka V, Svoboda T, Maca K, Nadvornik P, Neuman E: [Stereotactic evacuation of spontaneous infratentorial hemorrhage with monitoring of intracerebral pressure.] Bratisl Lek Listy -:-, 0 (Czech). Yamamoto T, Nakao Y, Mori K, Maeda M: Endoscopic hematoma evacuation for hypertensive cerebellar hemorrhage. J Minim Invasive Neurosurg :-, 0

9 Manuscript Submitted to Editorial Office of Minimally Invasive Neurosurgery Page of 0. Amano K, Kawamura H, Iwata Y, Tanikawa T, Kawabatake H, Notoni M, et al: Surgical treatment of hypertensive intracerebral haematoma by CT-guided stereotactic surgery. J Acta Neurochir :-,. Auer LM, Deinsberger W, Niederkorn K, Gell G, Kleinert R, Schneider G, et al: Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg :-,. Matsumoto K, Hondo H: CT-guided stereotaxic evacuation of hypertensive intracerebral hematomas. J Neurosurg :-,. Auer LM: Endoscopic evacuation of intracerebral haemorrhage: high-tecsurgical treatment- a new approach to the problem?: J Acta Neurochir - :-,. Di X: Multiple brain tumor nodule resections under direct visualization of a neuronavigated endoscope. J Minim Invasive Neurosurg :-, 0. Akai T, Shiraga S, Sasagawa Y, Okamoto K, Tachibana O, Lizuka H: Intraparenchymal tumor biopsy using neuroendoscopy with navigation. J Minim Invasive Neurosurg :-, 0. Harris AE, Hadjipanayis CG, Lunsford LD, Lunsford AK, Kassam AB: Microsurgical removal of intraventricular lesions using endoscopic visualization and stereotactic guidance. J Neurosurg :-, 0

10 Page of Manuscript Submitted to Editorial Office of Minimally Invasive Neurosurgery 0 Figure Legends: Fig : Inner tube with suction attachment and external tube Fig a: Insertion of Internal suction tube with pattie into external tube Fig b: Internal and external tube with visible pattie string. Fig : Loading of haemostatic agent Surgicel into distal end of system Fig a: Delivery of haemostic agent together with pattie from distal end of system Fig b: Close up view of delivery Video Legends Video : Taming Sari Bench Low Def Video : Taming Sari pub ver- Surgicall and Fibrillar Endo Formatted: Font: Bold, Font color: Auto Formatted: Font: Bold Formatted: Font: Not Bold

11 Manuscript Submitted to Editorial Office of Minimally Invasive Neurosurgery Page 0 of 0 Fig Inner tube with suction attachment and external tube x00mm ( x DPI)

12 Page of Manuscript Submitted to Editorial Office of Minimally Invasive Neurosurgery 0 Fig a Insertion of internal suction tube with into external tube x00mm ( x DPI)

13 Manuscript Submitted to Editorial Office of Minimally Invasive Neurosurgery Page of 0 Fig b Internal tube and external tube with visible pattie string x00mm ( x DPI)

14 Page of Manuscript Submitted to Editorial Office of Minimally Invasive Neurosurgery 0 Fig Loading of haemostatic agent Surgicel into distal end of system x00mm ( x DPI)

15 Manuscript Submitted to Editorial Office of Minimally Invasive Neurosurgery Page of 0 Fig a Delivery of haemostic agent together with pattie out of distal end 00xmm ( x DPI)

16 Page of Manuscript Submitted to Editorial Office of Minimally Invasive Neurosurgery 0 Fig b Delivery of haemostatic agent together with pattie close-up view x00mm ( x DPI)