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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 3  |  Page : 370-374

Evaluation of the clinical usage of the basket-shaped biopsy microseparator


Department of Neurosurgery, Faculty of Medicine, Amasya University, Amasya, Turkey

Date of Acceptance13-Dec-2018
Date of Web Publication6-Mar-2019

Correspondence Address:
Dr. A Gokyar
Department of Neurosurgery, Faculty of Medicine, Amasya University, 05200 Amasya
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_371_18

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   Abstract 


Objective: This experimental study was aimed to assess the use of basket shaped biopsy microseparator. In this study, it was aimed to evaluate the protection of brain tissue during neurosurgery of the brain tissue, clinical usage, and suitability. Materials and Methods: Thirty cadaveric cow brains were used in this experimental feasibility study. Experimental materials were divided into two groups: In Group I, the microsurgical separation of the intrinsic brain parenchyma was performed by using the retraction of microsurgical basket separator. In Group II, the same microsurgical dissections were performed without microsurgical basket separator. The difficulty and suitability of the procedure was divided as three degree: very easy, easy, and difficult. Results: In Group I (n = 30), 20% fresh cadaveric cow brains, the difficulty of the dissection was evaluated as difficult; 60% of the brains were dissected with easy procedure. The remaining 20% of the brain dissection was evaluated as very easy. In Group II (n = 30), 40% fresh cadaveric cow brains, the difficulty of the dissection was evaluated as difficult; 53.33% of the brains were dissected with easy procedure. The remaining 6.67% of the brains were evaluated as very easy. The significance level was set at a P value of <0.046 in all statistical analyses. Conclusion: This study showed that easily performing biopsy procedure and protecting the brain tissue with using of biopsy basket microseparator are feasible. It is thought that this instrument may make a contribution to the practical microsurgery in the protecting brain tissue and adequately performing of biopsy.

Keywords: Biopsy basket microseparator, brain protection, neurosurgery, training in microneurosurgery


How to cite this article:
Gokyar A. Evaluation of the clinical usage of the basket-shaped biopsy microseparator. Niger J Clin Pract 2019;22:370-4

How to cite this URL:
Gokyar A. Evaluation of the clinical usage of the basket-shaped biopsy microseparator. Niger J Clin Pract [serial online] 2019 [cited 2019 May 21];22:370-4. Available from: http://www.njcponline.com/text.asp?2019/22/3/370/253456




   Introduction Top


As neurosurgeons have begun to venture the brain parenchyma under the dura since 19th century, the tools used for surgical operations have been developing as well as brain intraparenchymal retractors have been developing with the advances in neurosurgery. At this point, the main purpose is to supply a better visualization, less brain retraction damage, and to exert less effort.[1] Respectively, spoon retractors, brain spatula, a self-retaining retractor, bubble retractor, and tubular retractors have been developed. Spatula-based retractors, especially those are with sharp edges, cause damage in the brain cortex and deep white matter. In addition, it causes unequal pressure on the parenchyma during a long surgery and cytotoxic edema and cellular damage.[2],[3],[4] It is stated that tubular retractors were useful for diminishing the damage to surrounding issues. The search for an optimum retractor, which can protect the brain tissue is going on and inspite of the existence of multiple retractors, the frequency of brain retraction has been reported between 5% and 10%.[3]

Neuroradiological images and some other software can be used in the fine location of the pathology located inside the brain parenchyma.[5],[6] Intracranial space occupying lesion located deep in the brain parenchyma relatively common in microsurgical practice.[5]

Recently, transparent implants for brain retraction have begun to be developed. In such implants, it was aimed to observe the brain tissue, which is excluded from the main purpose, to realize the simultaneous detection of the damages that can develop in the vessel and cranial nerves.[3],[4]

In microneurosurgical operations, metallic surgical instruments may mechanically injure the delicate brain parenchyma. In the prevention of harmful effect of metallic instruments, limited microsurgical intervention may be used in the protection of brain from the disadvantages of larger surgical site.[5],[6],[7],[8],[9],[10] Sometimes limited craniotomy and minimally invasive microneurosurgical intervention is necessary for some lesions. The basket retractor that we offer in the article appears to provide many advantages in surgery for intracerebral hematoma and deep intra-axial brain tumors [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]. These lesions may be totally or partially removed by using basket-shaped biopsy microseparator in the minimally invasive microneurosurgical procedures to the brain.
Figure 1: The appearance of basket-shaped microsurgical biopsy separator on the lateral side

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Figure 2: The appearance of basket-shaped microsurgical biopsy separator on the superior side

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Figure 3: The using of micro-bayonet through the opening of basket-shaped microsurgical biopsy separator (MB=Micro-bayonet, BMS=Basket microseparator)

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Figure 4: The using of micro-scissor through the opening of basket-shaped microsurgical biopsy separator (MS=Micro-scissors; BMS=Basket microseparator)

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Figure 5: The lateral appearance of the biopsy procedure (MB=Micro-bayonet; BMS=Basket microseparator)

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The aim of this experimental study was to evaluate the feasibility of basket-shaped microsurgical biopsy separator in terms of the protection of brain tissue from the harmful mechanical effect of metallic microsurgical instruments. Experimental findings, suggestions, practical methods, and difficulties were argued in line with the existing literature.


   Materials and Methods Top


Thirty uncovered fresh cadaveric cow brains were utilized in this experimental feasibility study. Experimental microneurosurgical activities in this study were conducted under the operating microscope. For the feasibility study, it was created an experimental microneurosurgical model by using fresh cadaveric uncovered cow brains in the evaluation of the efficacy of biopsy basket microseparator [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]. The appearance of basket-shaped microsurgical biopsy separator was shown on the lateral side in [Figure 1], on superior side in [Figure 2]. Anteriorly, two-third of cow brains were used for interested location in this experimental study. Basket biopsy microseparator was used in the right hemisphere of brain. The left side of the same brain hemisphere was used as control side. Basket microseparator was not used in control side. All surgical procedures were performed by the same researcher.

One-centimeter pial incision was done on the right side of the brain hemisphere just 2 cm lateral to the interhemispheric fissure. Three centimeter in length biopsy basket microseparator was placed with 90-degree angle to deep into the brain [Figure 3] and [Figure 5]. The using of microbayonet through the opening of basket shaped microsurgical biopsy separator was shown in [Figure 3]. The use of microscissors through the opening of basket-shaped microsurgical biopsy separator was shown in [Figure 4]. The lateral appearance of the biopsy procedure was shown in [Figure 5]. Open biopsy was obtained by using biopsy forceps from anterior, medial, posterior, and lateral site at the level of 3 cm deep inside the brain parenchyma. The same procedure for control purposes was made without using a microseparator on the opposite side.

Experimental materials were divided into two groups as microsurgical basket separator (Group I) and without microsurgical basket separator groups (Group II). In Group I, the microsurgical separation of the intrinsic brain parenchyma was performed using the retraction of microsurgical basket separator. In Group II, the same microsurgical dissections were performed without microsurgical basket separator. About 3-cm deep location was reached using bipolar forceps and the tip of the aspirator before obtaining the biopsy. After reaching to the adequate deepness, the open biopsy was performed at the similar places with microsurgical basket biopsy separator. Difficulty of the procedure and suitability of the prototype for clinical usability was divided as three degrees (very easy, easy, and difficult).

The comparisons were done with the opposite side. Following the experiment, all operated brains were sliced regularly (0.5 cm) from anterior to posterior direction for the evaluation of the harmful effects of the metallic instruments to the brain parenchyma. All brain slices were evaluated under the magnification of the operating microscope in terms of contusion, distortion, tearing, laceration, and other traumatic features.

Evaluation of the surgery-related injury to the brain surface was evaluated under surgical microscopic magnification. Injury was quantified according to a modification of a scale from 0 to 3.

Evaluation of the surgery-related injury

0 - Normal surface

1 - Pial and gray matter contusion, distortion injury

2 - Gray and white matter contusion, distortion, tearing injury

3 - Gray and white matter tearing, laceration injury.


   Results Top


In Group I (n = 30), 20% (6) fresh cadaveric cow brains, the difficulty of the dissection was evaluated as difficult; 60% (18) of the brains were dissected with easy procedure. The remaining 20% (6) of the brain dissection was evaluated as very easy. In Group II (n = 30), 40% (12) fresh cadaveric cow brains, the difficulty of the dissection was evaluated as difficult; 53. 33% (16) of the brains were dissected with easy procedure. The remaining 6.67% (2) of the brains was evaluated as very easy [Table 1].
Table 1: Animal numbers and all data

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Statistical analysis

The incidences of surgical injuries, suitability, and difficulty of surgical procedure were compared between the two groups using nonparametric the Kruskal–Wallis and Mann–Whitney U-test. The data were analyzed using a commercially available statistics software package (SPSS ® for Windows v. 12.0, Chicago, IL, USA).

The significance level was set at a P value of <0.046 in all statistical analyses.


   Discussion Top


Brain retraction is performed in large proportion during intracranial operations. Damage due to retraction is very common. Local tissue damage in the brain depends on the type of retraction, shape, and direct mechanical pressure and duration of application.[2],[11]

Such deformations lead to decreased blood flow and the formation of ischemia. The main reason of this injury is the inadequate retraction of the brain tissue.[2]

The retractors are able to directly damage the brain tissue in the form of contusion, distortion, and laceration. This type of damage depends on the shape of the retractor's brain tissue and the number of retractors. The pressure applied on the surface cannot be adjusted in manually operated implants and undesirable unnecessary high pressures cause damage to the surface of the brain. Sliding of retractor's causes direct cuts in the brain tissue, leading to significant complications.[2],[3],[4]

In microsurgical techniques, self-retaining implants have been developed and attempts have been made to reduce the damage due to such manipulations. Self-retaining implants have reduced assistant assistance that has begun to be used as the third or fourth hands of the brain surgeon. The obstacles to be developed by the assistant hand have been reduced the most.[2]

It has been reported that brain retractors have shifted from simple hand retractors to sophisticated hand-free brain retraction systems.[1],[2]

During neurosurgical procedures, a better and more effective protection of the cerebral cortical surface and the surgical pathway in the glial tissue should be guaranteed.[5],[8],[9]

Protection of the brain parenchyma with its arterial and venous vascular structure, and cranial nerves in the course of microsurgical intervention is a critical and extremely important issue in the surgical practice of neurosurgery. Regional microsurgical neuroanatomy and microsurgical instruments should be known and recognized for a safe minimally invasive microsurgical intervention. It is crucial to use these instruments with appropriate microsurgical techniques.[5],[8],[10] It is imperative that surgical techniques should be repeated several times on appropriate models to successfully maintain and terminate microsurgical interventions with appropriately protecting of the neurovascular tissue.[1],[5],[7],[9],[11] A spatula is used to retract parts of the brain to gain access to the surgical target area. Spatulas used in neurosurgery are bendable and can be fitted into any desired shape needed for the specific task.

Splitting of the brain parenchyma using sharp and blunt instruments, such as micro-scissors, micro-bayonet, and the tip of metallic aspirator is the general microsurgical technique to reach down to the pathology seated within the brain. Following reaching down to the lesion, repeatedly moving of the microsurgical instruments in and out is necessary in the removing of the lesion. In this context, microsurgical metallic instruments may bruise the brain parenchyma during their movement throughout the approach.[5],[6],[8],[10] Brain retractors are supposed to prevent such direct surgical instrument injuries. Tubular retractors provide a larger surface area when compared with standard retractors and help to diminish the parenchymal damage.[1],[11]

This experimental study is mainly focused on the prevention of the primary brain injury caused by the metallic microsurgical instruments during their movement. Before a real operation performing on human beings, it is extremely necessary that understanding of the capability of some metallic surgical devices to be used in the microneurosurgical intervention. It is required for the person to develop his or her own abilities and to create integrated personal surgical techniques for the appropriate protection of brain.[5],[6],[7],[8],[9] On the other hand, gaining of detailed theoretical and practical microneurosurgical training study performed on microsurgical models is not completely enough for brain protection. Microsurgical instruments designed for advanced protection of the brain parenchyma can be used in the minimally invasive microneurosurgical intervention. The most crucial element able to reduce collateral brain injury is to minimize the cortical manipulation.

There are some differences between human and cow brains, but almost all mammals' brains are similar. Except some anatomical differences, the locations of the interhemispheric sulcus and the arachnoid membrane have same characteristic feature between human and cow brains.[12] In this experimental model, fresh cadaveric cow brains were used in the evaluation of the efficacy of basket-shaped microsurgical biopsy separator. An appropriate and successful model should have some similarities with the represented human organ or system. On the other hand, another important issue is the easily obtainable and easy preparation period of the model before using under the operating microscope without including any complicated steps. Ethical issues with live models in addition to the above disadvantages also pose problematic limitations in experimental practice.[9] When we think of all these features together, the cow brain should be regarded as a suitable model in the experimental evaluation of the basket-shaped microsurgical biopsy separator.

In this experimental model, the similar microsurgical instruments were used during dissection, separation and distraction of the brain. Micro-scissors and micro-bayonet were used in the dissection and separation of the neural and vascular structures. Contusion, distortion, tearing, and laceration are the common surgical traumatic findings related with the metallic instruments, and inadequate separation and retraction of the brain parenchyma during the microneurosurgical procedures. The differences between the basket-shaped biopsy microseparator and nonseparator procedures in terms of the difficulty of the surgical procedure and the suitability of the prototype for clinical usability were very clear. On the other hand, the brain parenchyma operated with basket-shaped microsurgical biopsy separator has less contusion, distortion, and laceration injury.

The basket-shaped biopsy provides a unique means of deep visualization and even force distribution at the retracted brain tissue. Various shapes and sizes of the basket-shaped biopsy microseparator can be used for microneurosurgery under high magnification.

When we look at the development process of the basket separator, there are some advantages. It can be used in surgical interventions, especially in limited areas, such as deep-seated hematoma evacuation and biopsy in deeply located tumors. There are advantages as follows: it has a structure that can expand as it moves and forms a surgery area; it gives the opportunity of conducting biopsy, thanks to its wall's openness from the surrounding tissue; and being able to see the big vessels directly, decreasing the damage to the surrounding tissue, thanks to its tubular shape.

Limitations

Live subjects were not exposed to evaluation in this study. Tissue damage was assessed quantitatively due to the fresh nature of cadaveric brain study.

Micro separator was used in order to test the convenience of the procedure and its brain-protective effect. The main outcome measurement of the study was indeed difficulty of usability. The scale that was used in the study is a subjective and nongeneralizable one. Another limitation is the potential bias that may arise from the investigators who both performed the study and evaluated the results, which we intend to avoid by assigning different investigators for study and evaluation in the future studies.


   Conclusion Top


In conclusion, easily performing the biopsy procedure and protecting the brain tissue with the use of the basket-shaped microsurgical biopsy separator from the mechanical bruising effect of metallic microsurgical instruments are feasible as shown in this experimental study. It is an additional important feature that it is a tubular structure and allows biopsy from surrounding tissues. We believe that this instrument will contribute to the practical microneurosurgery in the protection of brain tissue and adequately performing of the biopsy.

Financial support and sponsorship

Nil

Conflict of interest

There are no conflicts of interest.



 
   References Top

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Assina R, Rubino S, Sarris CE, Gandhi CD, Prestigiacomo CJ. The history of brain retractors throughout the development of neurological surgery. Neurosurg Focus 2014;36:E8.  Back to cited text no. 1
    
2.
Hansen KV, Brix L, Pedersen CF, Haase JP, Larsen OV. Modelling of interaction between a spatula and a human brain. Med Image Anal 2004;8:23-33.  Back to cited text no. 2
    
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Herrera SR, Shin JH, Chan M, Kouloumberis P, Goellner E, Slavin KV. Use of transparent plastic tubular retractor in surgery for deep brain lesions: A case series. Surg Technol Int 2010;19:47-50.  Back to cited text no. 3
    
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Okudera H, Kobayashi S, Kyoshima K, Goel H. Brain spatula with transparent tip: Technical note. Acta Neurochir 1997;139:977-8.  Back to cited text no. 4
    
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Cokluk C, Aydin K. Maintaining microneurosurgical ability via staying active in microneurosurgery. Minim Invasive Neurosurg 2007;50:324-7.  Back to cited text no. 5
    
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Yadav YR, Parihar V, Ratre S, Kher Y, Iqbal M. Microneurosurgical skills training. J Neurol Surg A Cent Eur Neurosurg 2016;77:146-54.  Back to cited text no. 6
    
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Altunrende ME, Hamamcioglu MK, Hicdonmez T, Akcakaya MO, Birgili B, Cobanoglu S. Microsurgical training model for residents to approach to the orbit and the optic nerve in fresh cadaveric sheep cranium. J Neurosci Rural Pract 2014;5:151-4.  Back to cited text no. 7
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Belykh E, Byvaltsev V. Off-the-job microsurgical training on dry models: Siberian experience. World Neurosurg 2014;82:20-4.  Back to cited text no. 8
    
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Gokyar A, Cokluk C. Using of fresh cadaveric cow brain in the microsurgical training model for sulcal-cisternal and fissural dissection. J Neurosci Rural Pract 2018;9:26-9.  Back to cited text no. 9
    
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Spetzger U, von Schilling A, Brombach T, Winkler G. Training models for vascular microneurosurgery. Acta Neurochir Suppl 2011;112:115-9.  Back to cited text no. 10
    
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Bander ED, Jones SH, Kovanlikaya I, Schwartz TH. Utility of tubular retractors to minimize surgical brain injury in the removal of deep intraparenchymal lesions: A quantitative analysis of FLAIR hyperintensity and apparent diffusion coefficient maps. J Neurosurg 2016;124:1053-60.  Back to cited text no. 11
    
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Turan Suslu H, Ceylan D, Tatarli N, Hicdonmez T, Seker A, Bayri Y, et al. Laboratory training in the retrosigmoid approach using cadaveric silicone injected cow brain. Br J Neurosurg 2013;27:812-4.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

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