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698
Rengachary
with multiple previous revisions. In a
somewhat desperate situation, he de­
vised a procedure involving placement
of the distal catheter transdiaphragmatically into a space that was unscarred
despite numerous previous abdominal
procedures. Although this particular
case is unique, there are certainly other
patients who present with similar lim­
ited options for shunt revision. The au­
nal fluid absorption from the mesothelial
surface of both cavities. Rengachary pre­
sents a previously undescribed site for
placement of a distal catheter.
Martin B. Camins
Neiu York, New York
Rengachary provides the reader with
a new option for revision of a failed
ventricular shunt system in a patient
Intraoperative Dislocation of the Distal
Lens of a Neuroendoscope: A Very
Rare Complication: Technical
Case Report
J. André Grotenhuis, M.D., Ronald H.M.A. Bartels, M.D.,
Sandor Tael, R.N.
Department of Neurosurgery, University Hospital Nijmegen, Nijmegen, The Netherlands
OBJECTIVE AND IMPORTANCE: A very unusual complication of neuroen­
doscopy that was caused by equipment failure is described.
CLINICAL PRESENTATION: Intraoperatively, the distal lens of a reusable,
rigid, lenscope-type neuroendoscope became dislodged. Fortunately, this
did not have any adverse consequences for the patient.
DISCUSSION: The cause remains obscure but probably relates to the re­
peated use of the scope. Perhaps the use of a disposable neuroendoscope
could have prevented this, but reusable lenscopes are designed to be used
many times.
CONCLUSION: The risk of such equipment failure should be weighed
against the distinct advantage of a much clearer image than is provided by
fiberscopes. (Neurosurgery 41:698-700, 1997)
Keywords: Com plication, Equipment failure, Neuroendoscopy
espite the resurgence of neuroen­
doscopy, reports of complications
are sparse. A case of an extremely rare
complication caused by equipment fail­
ure is presented.
D
CASE REPORT
A 48-year-old man was referred from
another institution to our department
for neuroendoscopic treatment of a
known huge suprasellar cyst with sub­
sequent compression of the third ventri­
cle and supra tentorial hydrocephalus.
The cyst was previously fenestrated
through a trans callosal approach but re­
curred somewhat quickly. The concom­
itant hydrocephalus was already treated
with bilateral shunts, leading to ventric­
ular collapse.
thor has recognized an opportunity that
may prove useful in patients with ab­
dominal adhesions and may thus prove
to be preferable to atrial and pleural
placement of the distal catheter. Al­
though this is only a single case, the
patient was followed for 2 years without
further shunt malfunction,
William F. Chandler
Ann Arbor, Michigan
The patient complained of persisting
headaches and memory disturbances.
Follow-up computed tomography re­
vealed that there was further enlarge­
ment of the cyst,
Because of the collapsed ventricles, it
would have been injudicious to intro­
duce the neuroendoscope. Therefore,
the frontally placed shunt on the left
side was occluded. The day after occlu­
sion, the cyst was approached through
the then somewhat dilated left frontal
horn.
The introduction of a rigid neuroen­
doscope, equipped with a Hopkins rod
optic lens with an outer diameter of 2.4
mm (Smith & Nephew Richards, Mem­
phis TN), was straightforward. This
specific endoscope had been used in our
department since August 1994 for intraventricular procedures only. It had been
used 38 times before being used for the
operation discussed in this article.
Without any problems, partial resec­
tion of the cyst wall at the foramen of
Monro and subsequent fenestration of
the cyst wall toward the in ter peduncu­
lar cistern was achieved. During the fi­
nal inspection of the remaining part of
the cyst wall, attached to the fornix at
the left foramen of Monro, the view be­
came suddenly blurred. We at first
thought that an air bubble obstructed
our view. However, after various ma­
neuvers to remove air bubbles, the vi­
sion remained blurred. The optic equip­
ment was removed from the endoscope
shaft for cleansing of the distal part.
Close inspection of the scope revealed
that the thin covering distal lens of the
endoscope was missing (Fig. 1). Because
Neurosurgery, Voi. 47, No. 3, September 1997
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Grotenhuis et al
Grotenhuis et al. describe a most un­
usual complication relating to equip­
ment that is used routinely in neuroen­
doscopy. The dislodgment of the distal
lens of a rigid rod lenscope encased in a
stainless steel tube may have been an­
ticipated by careful inspection before in­
sertion into the head, This event empha­
sizes, however, the necessity of skilled
interoperative handling, inspection, and
sterilization procedures. As the role of
neuroendoscopy increases in neurosur­
gical procedures, undoubtedly more of
these unusual events will be reported. I
do not agree with the authors, however,
that this event could be construed as
supporting the use of disposable neu­
roendoscopes. The decision regarding a
specific surgical application rests on in­
strumentation considerations and the
availability of instrument channels, the
quality of the image, and the specific
needs of the surgical approach (for ex­
ample, if distal tip steering is needed, it
is available only in a steerable fiber­
scope). As a general rule at this time,
disposable endoscopes have compara­
ble inferior image quality to the rigid
reusable lenscope and offer only the ad­
vantage of greater confidence about
sterilization. As sterilization, procedures
become more rigorous in response to
concerns about viruses, the wear and
tear effect on reusable equipment will
become of greater significance. Image
quality in surgical decision making re­
mains the paramount consideration,
however.
Kim H. Manwaring
Phoenix, Arizona
« *
ANNOUNCEMENT
Foundation for International Education in Neurosurgery Update
and Request for Volunteers
t
The Foundation for International Education in Neurosurgery (FIENS) continues to
develop activities that are primarily designed to foster education in developing areas of
the world. These initiatives are coordinated with the activities of the World Federation
of Neurosurgical Societies, which, through its Education Committee, has sponsored a
number of regional educational programs for neurosurgeons in developing areas. The
Foundation assists in providing faculty for these larger educational efforts. The major
current activities of FIENS consist of programs in Africa, The Foundation has worked
with neurosurgeons in Ghana in an attempt to help develop an indigenous neurosur­
gical training program there. This has involved sending senior level residents and
faculty for varying periods of time, usually 3 to 6 months for residents and 2 to 4 weeks
for faculty support. FIENS has supported a program in Zimbabwe to provide neuro­
surgical assistance to the program already in place in that country, and it has supported
an African trainee, who currently is a resident at Yale, in the initial steps to develop a
neuroscience initiative for Southern Africa. She has been a liaison with the Panafrican
Neurosurgical Association, which strongly supports this concept, and we anticipate
rapid development. Another new project involves a Senior Neurosurgical Interchange
with Peru under the guidance of Dr. Anselmo Pineda and the Peruvian-American
Neurosurgical Society. Opportunities exist for volunteer neurosurgeons to go to Peru
and visit and work in a number of different medical centers around the country. FIENS
maintains a roster of neurosurgeons interested in serving as volunteers. For volunteer
experiences of at least 4 to 6 weeks, the Foundation will support the volunteer's air
travel expenses. The host country is ordinarily able to underwrite most of the volun­
teer's expenses incurred at work. Further information and volunteer request forms can
be obtained from the Office of the Secretary of the Foundation, Dr. David Fairholm:
Division of Neurosurgery, Department of Surgery, Room 3100, 910 W. 10th Avenue,
Vancouver, BC, Canada V5Z 4E3.
Neurosurgery, Vol. 41, No. 3, September 1997