Name: the endoscope-assisted minimally invasive retro-sigmoid approach (eamirsa): a combination of techniques for improving middle skull base surgery
Uploaded: 2018-09-20T14:16:24
Description: EAMIRSA is a surgical technique that can be used for the treatment of the cerebellopontine angle (CPA) and internal auditory canal (IAC) diseases, as well ...

Special thanks to the surgery team of Dr. E. Zanoletti and Dr. G.P. Ricci for their support in the study. Thanks to all collaborators of the Permanent Temporal Bone Laboratory of University of Perugia.

This study was approved by the Human Ethic Committee of University Hospital of Perugia and was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.
The sample was represented from subject over 18 years, with equal sex distribution.
1. Preparation of the Patient
<ol>
	<li>Set up the operating room as shown in Figure 1. Place the patient on the surgical table and connect the anesthesia monitoring ...

<ol>
	<li>Marchioni, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Expanded+Transcanal+Transpromontorial+Approach:+A+Novel+Surgical+Technique+for+Cerebellopontine+Angle+Vestibular+Schwannoma+Removal.">Expanded Transcanal Transpromontorial Approach: A Novel Surgical Technique for Cerebellopontine Angle Vestibular Schwannoma Removal.</a> Otolaryngology Head and Neck Surgery. 158 (4), 710-715 (2018).</li><li>Setty, P., Babu, S., LaRouere, M. J., Pieper, D. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fully+Endoscopic+Retrosigmoid+Vestibular+Nerve+Section+for+Refractory+Meniere+Disease.">Fully Endoscopic Retrosigmoid Vestibular Nerve Section for Refractory Meniere Disease.</a> Journal Neurological Surgery Basic Skull Base. 77 (4), 341-349 (2016).</li><li>Bremond, G., Garcin, M., Magnan, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Progres+en+otoneurochirurgie:+l&#8217;abord+a+minima+de+l&#8217;angle+pontocerebelleux+par+la+voie+retrosigmoide.">Progres en otoneurochirurgie: l&#8217;abord a minima de l&#8217;angle pontocerebelleux par la voie retrosigmoide.</a> Acta oto-rhino-laryngologica Belgica. 30, 127-144 (1976).</li><li>Magnan, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Apport+de+l&#8217;endoscopie+de+l&#8217;angle+pontocerebelleux+par+voie+retrosigmoide:+Neurinomes+et+Conflits+vasculo-nerveux+Ann+OtoLaryngo.">Apport de l&#8217;endoscopie de l&#8217;angle pontocerebelleux par voie retrosigmoide: Neurinomes et Conflits vasculo-nerveux Ann OtoLaryngo.</a> Chir Cervicofac (Paris). , 239-265 (1993).</li><li>Badr-El-Dine, M., El-Garem, H. F., Talaat, A. M., Magnan, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopically+assisted+minimally+invasive+microvascular+decompression+of+hemifacial+spasm.">Endoscopically assisted minimally invasive microvascular decompression of hemifacial spasm.</a> Otology and Neurotology. 23 (2), 122-128 (2002).</li><li>Di Stadio, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microsurgical+decompression+of+the+cochlear+nerve+to+treat+disabling+tinnitus+via+an+endoscope-assisted+retro-sigmoid+approach:+the+Padua+experience.">Microsurgical decompression of the cochlear nerve to treat disabling tinnitus via an endoscope-assisted retro-sigmoid approach: the Padua experience.</a> World Neurosurgery. (18), (2018).</li><li>Ricci, G. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscope-assisted+retrosigmoid+approach+in+hemifacial+spasm:+our+experience.">Endoscope-assisted retrosigmoid approach in hemifacial spasm: our experience.</a> Brazilian Journal Otolarhynolaryngology. , (2018).</li><li>Guevara, N., Deveze, A., Buza, V., Laffont, B., Magnan, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microvascular+decompression+of+cochlear+nerve+for+tinnitus+incapacity:+pre-surgical+data,+surgical+analyses+and+long-term+follow-up+of+15+patients.">Microvascular decompression of cochlear nerve for tinnitus incapacity: pre-surgical data, surgical analyses and long-term follow-up of 15 patients.</a> European Archives of Otorhinolaryngology. 265 (4), 397-401 (2008).</li><li>Tolisano, A. M., Littlefield, P. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Adverse+Events+Following+Vestibular+Schwannoma+Surgery:+A.">Adverse Events Following Vestibular Schwannoma Surgery: A.</a> Comparison of Surgical Approach. Otology and Neurotology. 38 (4), 551-554 (2017).</li><li>Shahinian, H. K., Eby, J. B., Ocon, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fully+endoscopic+excision+of+vestibular+schwannomas.">Fully endoscopic excision of vestibular schwannomas.</a> Minimally Invasive Neurosurgery. 47 (6), 329-332 (2004).</li><li>Eriksson, L. I., Fleisher, L. A., Miller, R. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Miller's Anesthesia. , (2015).</li><li>. The Airway Jedi Available from: <a target="_blank" href="https://airwayjedi.com/2016/10/10/intubation-step-by-step/">https://airwayjedi.com/2016/10/10/intubation-step-by-step/</a> (2018)</li><li>F&#224;bregas, N., Craen, R. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anesthetic+Techniques+in+Endoscopic+Sinus+and+Skull+Base+Surgery.">Anesthetic Techniques in Endoscopic Sinus and Skull Base Surgery.</a> Current Opinion in Anesthesiology. 23 (5), 568-575 (2016).</li><li>Surg Sidhwa, F., Itani, K. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Skin+preparation+before+surgery:+options+and+evidence.">Skin preparation before surgery: options and evidence.</a> Surgical infections. 16 (1), 14-23 (2015).</li><li>Jannetta, P. J., Abbasy, M., Maroon, J. C., Ramos, F. M., Albin, M. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Etiology+and+definitive+microsurgical+treatment+of+hemifacial+spasm.+Operative+techniques+and+results+in+47+patients.">Etiology and definitive microsurgical treatment of hemifacial spasm. Operative techniques and results in 47 patients.</a> Journal of Neurosurgery. 47, 321-328 (1977).</li><li>Feng, B. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Management+of+vessels+passing+through+the+facial+nerve+in+the+treatment+of+hemifacial+spasm.">Management of vessels passing through the facial nerve in the treatment of hemifacial spasm.</a> Acta Neurochirurgica. 157, 1935-1940 (2015).</li><li>Sharma, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microvascular+decompression+for+hemifacial+spasm:+A+systematic+review+of+vascular+pathology,+long+term+treatment+efficacy+and+safety.">Microvascular decompression for hemifacial spasm: A systematic review of vascular pathology, long term treatment efficacy and safety.</a> Neurologic India. 65, 493-505 (2017).</li><li>Liu, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microvascular+decompression+for+atypical+hemifacial+spasm:+lessons+learned+from+a+retrospective+study+of+12+cases.">Microvascular decompression for atypical hemifacial spasm: lessons learned from a retrospective study of 12 cases.</a> Journal of Neurosurgery. 124, 397-402 (2016).</li><li>Campero, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microvascular+decompression+in+hemifacial+spasm:+13+cases+report+and+review+of+the+literature.">Microvascular decompression in hemifacial spasm: 13 cases report and review of the literature.</a> Surgical Neurology International. 7, S201-S207 (2016).</li><li>Fukushima, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microvascular+decompression+for+hemifacial+spasm:+result+in+2890+cases.">Microvascular decompression for hemifacial spasm: result in 2890 cases.</a> Neurovascular surgery. , 1133-1145 (1995).</li><li>Hanakita, J., Kondo, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Serious+complications+of+microvascular+decompression+operations+for+trigeminal+neuralgia+and+hemifacial+spasm.">Serious complications of microvascular decompression operations for trigeminal neuralgia and hemifacial spasm.</a> Neurosurgery. 22, 348-352 (1988).</li><li>Kureshi, S. A., Wilkins, R. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Posterior+fossa+re-exploration+for+persistent+or+recurrent+trigeminal+neuralgia+or+hemifacial+spasm:+surgical+findings+and+therapeutic+implications.">Posterior fossa re-exploration for persistent or recurrent trigeminal neuralgia or hemifacial spasm: surgical findings and therapeutic implications.</a> Neurosurgery. 43, 1111-1117 (1988).</li><li>Rak, R., Sekhar, L. N., Stimac, D., Hechl, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscope-assisted+microsurgery+for+microvascular+compression+syndromes.">Endoscope-assisted microsurgery for microvascular compression syndromes.</a> Neurosurgery. 54, 876-881 (2004).</li><li>Magnan, J., Caces, F., Locatelli, P., Chays, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hemifacial+spasm:+endoscopic+vascular+decompression.">Hemifacial spasm: endoscopic vascular decompression.</a> Otolaryngology Head Neck Surgery. 117, 308-314 (1997).</li><li>Badr-El-Dine, M., El-Garem, H. F., Talaat, A. M., Magnan, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopically+assisted+minimally+invasive+microvascular+decompression+of+hemifacial+spasm.">Endoscopically assisted minimally invasive microvascular decompression of hemifacial spasm.</a> Otology and Neurotology. 23, 122-128 (2002).</li><li>Magnan, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Role+of+endoscopy+and+vascular+decompression+in+the+treatment+of+hemifacial+spasm.">Role of endoscopy and vascular decompression in the treatment of hemifacial spasm.</a> Annales of Otolaryngologie et Chirurgie Cervicofaciale. 111, 153-160 (1994).</li><li>Marchioni, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transcanal+Transpromontorial+Acoustic+Neuroma+Surgery:+Results+and+Facial+Nerve+Outcomes.">Transcanal Transpromontorial Acoustic Neuroma Surgery: Results and Facial Nerve Outcomes.</a> Otology and Neurotol. 39 (2), 242-249 (2018).</li></ol>

Loops in the CPA and IAC ultimately manifest with a number of symptoms/signs, including HFS and tinnitus. In our previous studies6,7, we quantified the correlation between the loop presence and the occurrence of HFS (or tinnitus) on the ipsilateral side. We also found that in cases where tinnitus was due to a loop impingement involving the cochlear nerve, the minimum caliber of the impinging vessel was 0.8 mm6.
...

Surgical approaches to the cerebellopontine angle (CPA) and internal auditory canal (IAC) are associated with high risks due to a limited view of the target areas. Techniques that totally rely on endoscopy have been proposed1,2, but the high risk of facial nerve sequelae1, significant learning curves, and the need for a third hand for maintaining the endoscope in position2 have limited their applicability.
The endoscope-assisted minimally invasive retro-sigmoid approach (EAMIRSA), originally proposed in 19763, was further developed in 19934 by Magnan, who used this approach for endoscope-assisted surgery. The technique was improved&#160;by combining a microscope and an endoscope to safely treat neurovascular conflicts in the CPA/IAC5. Furthermore, different from the totally endoscopic transpromontorial approach1, the retrosigmoid route allows a total preservation of the cochlea and labyrinth2,3,4,5,6; this combined approach reduces the risks that are typically associated with approaches that rely on an endoscope only or a microscope only. EAMIRSA&#39;s major advantage lies in the use of the endoscope, which allows a 360&#176; view and thus a complete visualization of the structures&#39; relative positions6,7,8. Additionally, the endoscope allows a minimally invasive approach that reduces the risk of persistent headaches and cerebrospinal fluid (CSF) leak, which are common major complications of this type of surgeries9.
The endoscope improves visibility of the structures&#39; relative positions as the instrument goes inside the surgical area, thereby allowing the surgeon to investigate CPA anatomy via careful movements of the surgical instruments. This improved visualization eliminates the need for the extended craniotomy (commonly performed in CPA surgery to increase visibility and eliminate &#34;blind&#34; angles).
In EAMIRSA, the endoscope is first used to view and inspect the target area, which is then dissected with two hands under microscope vision6,7. EAMIRSA can be used in the treatment of different CPA and IAC diseases, schwannoma removal10, and surgical decompression of cochlear6 or facial nerves7. It has been proven to increase both the short and long-term surgical outcomes with a very low incidence (&#60;1%) of major sequelae5,6,7,8.
In this article, we describe the material necessary for performing EAMIRSA and illustrate the technique using a step-by-step cadaver dissection.

<table>
	<tbody>
		<tr>
			<td>No Consumable</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Facial nerve monitoring system</td>
			<td>NIM (Medtronic Jacksonville (FL), USA)</td>
			<td>8253002</td>
			<td></td>
		</tr>
		<tr>
			<td>Video Column</td>
			<td>AIDA, Storz</td>
			<td>S-1263</td>
			<td></td>
		</tr>
		<tr>
			<td>Video Camera</td>
			<td>STORTZ</td>
			<td>S-1263</td>
			<td></td>
		</tr>
		<tr>
			<td>Focal Operatory microscope</td>
			<td>ZEISS OPMI SENSERA</td>
			<td>S-0607</td>
			<td></td>
		</tr>
		<tr>
			<td>Rigid Endoscope 0&#176;</td>
			<td>STORZ</td>
			<td>7229 AA</td>
			<td></td>
		</tr>
		<tr>
			<td>Rigid Endoscope 45&#176;</td>
			<td>STORZ</td>
			<td>7229 FA</td>
			<td></td>
		</tr>
		<tr>
			<td>Drill Stilus Legend</td>
			<td>MEDTRONIC</td>
			<td>1898001</td>
			<td></td>
		</tr>
		<tr>
			<td>Electric Scalpel DIATERMO MB 380</td>
			<td>GIMA</td>
			<td>30692</td>
			<td></td>
		</tr>
		<tr>
			<td>Aspiration system: 1 continuous and 1 with finger-control</td>
			<td>TOBI</td>
			<td>28234</td>
			<td></td>
		</tr>
		<tr>
			<td>Instruments for the otoneurology approach:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>- Stainless cups.</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>- Large cup warms serum.</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Lempert elevator</td>
			<td>MILTEX</td>
			<td>19-1340</td>
			<td></td>
		</tr>
		<tr>
			<td>- Scalpel Handle No. 3, 4, and 7.</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>- Needle holder: 1 strong, 1 less strong.</td>
			<td>MAYO HEGART</td>
			<td>26531</td>
			<td></td>
		</tr>
		<tr>
			<td>- Two pairs of scissors Allaine: 1courbe, 1 right.</td>
			<td>EMEA</td>
			<td>Curved : PO144123 ; Straight: PO143282</td>
			<td></td>
		</tr>
		<tr>
			<td>-Dissection griffes, foam, De Bakey</td>
			<td>SURGIWAY</td>
			<td>14.1012T</td>
			<td></td>
		</tr>
		<tr>
			<td>- Aspirations:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>o Three Fraziers No. 10.12.15.</td>
			<td>INTEGRA</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>o Otoneurology suction set: 1 * 2.0, 1 * 1.8; 2 * 1.5; 3 * 1.2 (long); 2 * 1.0.</td>
			<td>INTEGRA</td>
			<td>3724218; 3724172; 3724210</td>
			<td></td>
		</tr>
		<tr>
			<td>- Retractors:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>o Faraboeuf: 1pair thin, 1 thick pair 12-14 cm</td>
			<td>INTEGRA</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>o Auto-static of Wulstein or Beckmann</td>
			<td>INTEGRA</td>
			<td>o-28-8</td>
			<td></td>
		</tr>
		<tr>
			<td>DRILL BURRS</td>
			<td>MEDTRONIC</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td></td>
			<td>Cutting</td>
			<td>See on productor catalogue</td>
			<td></td>
		</tr>
		<tr>
			<td></td>
			<td>Diamonds</td>
			<td>See on productor catalogue</td>
			<td></td>
		</tr>
		<tr>
			<td>Micro-instruments of otoneurology:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Fine bipolar forceps Magnan</td>
			<td>INTEGRA</td>
			<td>CP392BI and CP392BS</td>
			<td></td>
		</tr>
		<tr>
			<td>A pair of scissor Sterkers.</td>
			<td>NOT AVAILABLE</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Two pairs of scissors Yasargil (1 right, 1 curve).</td>
			<td>SKLAR</td>
			<td>98-2114</td>
			<td></td>
		</tr>
		<tr>
			<td>Two-surgical forceps (one right, one curve upward).</td>
			<td>INTEGRA Metzbound</td>
			<td>Curved: CP351-3; Straight: CP351-2</td>
			<td></td>
		</tr>
		<tr>
			<td>A dura scalpel</td>
			<td>STORTZ</td>
			<td>28164 EL</td>
			<td></td>
		</tr>
		<tr>
			<td>A dura elevator</td>
			<td>STORTZ</td>
			<td>663535</td>
			<td></td>
		</tr>
		<tr>
			<td>In case of IAC first: surgical scissors straight strong</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Straight instruments:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>A hook</td>
			<td>INTEGRA</td>
			<td>MCO31</td>
			<td></td>
		</tr>
		<tr>
			<td>A blunt hook.</td>
			<td>INTEGRA</td>
			<td>MCO813</td>
			<td></td>
		</tr>
		<tr>
			<td>Two Marquet periostal elevator (1 left, 1 right).</td>
			<td>INTEGRA</td>
			<td>MCO950</td>
			<td></td>
		</tr>
		<tr>
			<td>Bayonet instruments</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>House Hartman</td>
			<td>INTEGRA</td>
			<td>3721036</td>
			<td></td>
		</tr>
		<tr>
			<td>One pointed and sharp hook</td>
			<td>INTEGRA Causse</td>
			<td>MCO657</td>
			<td></td>
		</tr>
		<tr>
			<td>Four small periostal elevator (facing up, down, left, right)</td>
			<td>STORTZ</td>
			<td>223982</td>
			<td></td>
		</tr>
		<tr>
			<td>Four large periostal elevator (facing up, down, left, right)</td>
			<td>INTEGRA</td>
			<td>MCO224A-2-0</td>
			<td></td>
		</tr>
		<tr>
			<td>Four hooks (facing up, down, left, right)</td>
			<td>STORTZ</td>
			<td>223942; 223943</td>
			<td></td>
		</tr>
		<tr>
			<td>MORTINI Set</td>
			<td>STORTZ</td>
			<td>28164 MDA</td>
			<td></td>
		</tr>
		<tr>
			<td>Instruments for otoneurosurgery approach :</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Scalpel n&#176;23</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Dissection griffes</td>
			<td>INTEGRA MAC INDOE</td>
			<td>CP 400 ; CP 407 ;CP 415</td>
			<td></td>
		</tr>
		<tr>
			<td>Wulstein auto-static</td>
			<td>INTEGRA</td>
			<td>o-28-8</td>
			<td></td>
		</tr>
		<tr>
			<td>Elevator Lampert</td>
			<td>MILTEX</td>
			<td>19-1340</td>
			<td></td>
		</tr>
		<tr>
			<td>Bipolair forceps</td>
			<td>INTEGRA</td>
			<td>CP392-2R</td>
			<td></td>
		</tr>
		<tr>
			<td>Scalpel for dura</td>
			<td>STORTZ</td>
			<td>28164 EL</td>
			<td></td>
		</tr>
		<tr>
			<td>Scalpel n&#176;11</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Dissection griff DeBakey</td>
			<td>SURGIWAY</td>
			<td>14.1012T</td>
			<td></td>
		</tr>
		<tr>
			<td>Scissor Allaine</td>
			<td>EMEA</td>
			<td>Curved : PO144123 ; Straight: PO143282</td>
			<td></td>
		</tr>
		<tr>
			<td>Needle holder</td>
			<td>MAYO HEGART</td>
			<td>26531</td>
			<td></td>
		</tr>
		<tr>
			<td>Consumable Material</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Two suction tubes, with suction cannulas of different sizes.</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Operating light handpiece.</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Microscope case, camera cover, instrument pocket.</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Xomed / Medtronic 2-channel electrode set for monitoring the facial nerve.</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Scalpel blades: 22, 11.</td>
			<td>Medtronic</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Glass scalpel blades.</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Surgical gloves and caps</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Adhesive surgical (craniotomy pack).</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Sterile woven and nonwoven compresses.</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Syringe and needle infiltration.</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Drugs: 0.5% adrenaline xylocaine, saline, sterile water</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Neuropatch</td>
			<td>B/Braun-Aesculap, Tuttlingen, Germany</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Fibrillar Surgicel</td>
			<td>Braun</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Biological glue 2ml</td>
			<td>TIssucol</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Horsley Wax</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td colspan="2">Cottons of neurosurgery cut into various sizes that will be carefully counted (opposite)</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Teflon cut into various sizes then crushed to be thinned</td>
			<td>Codman</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Lyophilized hardstock or Durapatch Ethisorb Polyglactin 910 / Polydioxanon</td>
			<td>Bard PTFE</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Re-absorbable suture</td>
			<td>Ethicon</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Not-resorbable suture</td>
			<td>Vicryl</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Urethane sponge</td>
			<td>Novafil 2.0</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

the endoscope-assisted minimally invasive retro-sigmoid approach (eamirsa): a combination of techniques for improving middle skull base surgery

EAMIRSA is a surgical technique that can be used for the treatment of the cerebellopontine angle (CPA) and internal auditory canal (IAC) diseases, as well as for treating schwannoma, for decompression surgeries (e.g., loops of the anterior inferior cerebellar artery (AICA)), and for the vestibular neurectomy in patients with invalidating vertigo. This technique combines the use of an endoscope and a microscope; the former allows a perfect view of the surgical area (CPA, IAC, and brain structures) and the latter ensures safety of the surgery maneuvers. The use of a minimally invasive approach reduces post-surgery headaches and the risk of a Cerebrospinal Fluid (CSF) leak. Our group successfully used EAMIRSA during decompression procedures for treating a hemi-facial spasm and tinnitus. Results were satisfactory in terms of function recovery. Sequelae and surgical complications were observed in less than 1% of patients. In acoustic schwannoma surgery, facial nerve damage was observed in less than 1% of cases and the recurrence rate was 0.3%. This article describes the material necessary for performing EAMIRSA and illustrates the technique using a step-by-step cadaver dissection.

EAMIRSA has been successfully used by several surgeons4,5,6,7,9. Our group has used this technique on patients suffering from facial hemispasm (HFS) due to a vascular loop compression on the VII cranial nerve (facial) and has achieved satisfactory results in the short- and long-term follow-up, including short recovery time, sym...

The endoscope-assisted minimally invasive retro-sigmoid approach (EAMIRSA) is a surgical technique that can be used for the treatment of the cerebellopontine angle (CPA) and internal auditory canal (IAC) disease. Here, we describe the material necessary to perform EAMIRSA and illustrate the technique using a step-by-step cadaver dissection.

The Endoscope-Assisted Minimally Invasive Retro-Sigmoid Approach (EAMIRSA): A Combination of Techniques for Improving Middle Skull Base Surgery

EAMIRSA is a surgical technique that can be used for the treatment of the cerebellopontine angle (CPA) and internal auditory canal (IAC) diseases, as well ...