Robotically-Operated Video Optical Telescopic-microscopy Resection of an Arteriovenous Malformation With Port-Assisted Intraoperative Surgical Devascularization: 2-Dimensional Operative Video

Abstract

Surgical management of cerebral arteriovenous malformations (AVMs) remains challenging carrying significant postoperative neurological morbidities. Advancements in visualization together with minimally invasive techniques have the promise of reducing this morbidity. In this video, grounded on a series of purpose-built cadaveric dissections, the integration of preoperative 3-dimensional diffusion tensor imaging rendering/planning, and a port-based transsulcal/para-fascicular approach coupled with a robotically operated video optical telescopic-microscopy system (ROVOT-m; Synaptive Medical, Toronto, Canada) and intraoperative neuronavigation for the resection of a deep-seated AVM, was demonstrated. The authors present the case of a 30-yr-old right-handed male with nausea, vomiting, dizziness, visual field deficits, and conductive aphasia. Informed consent was obtained from the patient for publication of this surgical video. CTA/Angiograms revealed a 6-cm Spetzler-Martin Grade-V left occipital-temporal-parietal AVM/dural-arteriovenous fistula. Surgical planning via CT/MRI/CTA/Color-Doppler was undertaken. The patient underwent angiographic embolization but a significant portion of the deep feeder arteries, particularly the choroidal arteries and the distal middle and posterior cerebral arteries remained, and could not be effectively embolized. The pedicle in the atrial trigone was targeted and accessed via the parieto-occipital sulcus via the port, in order to provide early control of the deep portion. The port was advanced into the sulcus extrapially then travelled through the U-fibers, along the long axis/parallel (para-fascicular) to white-matter fascicles. Following deep-pedicle devascularization, the port was removed, dura was widely opened, and remaining resection was undertaken using the ROVOT-m exclusively. No perioperative complications occurred and recovery of aphasia and improvement in visual fields was evident in a short-term follow-up. Still following principles of microsurgery, this approach and collaborative technologies, has the potential to enhance safety and efficiency in the surgical management of complicated cerebrovascular lesions.Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opx267 {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Robotically Operated Video Optical Telescopic-microscopy Resection of an Arteriovenous Malformation With Port-Assisted Intraoperative Surgical Devascularization: 2-Dimensional Operative Video","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_0v01omun"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Disclosures Dr Kassam has the following disclosures: (1) Synaptive Medical (consultant), (2) KLS Martin (consultant), and (3) Medtronic Medical (advisory board). This research is supported by an award to the Aurora Research Institute by the Vince Lombardi Cancer Foundation. We would like to thank Nico Corporation, Carl Zeiss, Synaptive Medical, Stryker Medical, and Karl Storz for their donations that made our research possible in the Neuroanatomy Laboratory.