Dual Surgeon Four-Handed Technique for Open Skull Base Surgery: A Technical and Nontechnical Guide and Systematic Review

Introduction: Interdisciplinary and intradisciplinary collaboration is common in skull base neurosurgery owing to the complex, challenging and potentially arduous tumors that require resection. Four handed setups, techniques and working relationships that are common in endoscopic skull base and other disciplines of neurosurgery can be applied to open skull base resections. Four handed open skull base surgery has been the preferred practice for decades at our institution. While this approach is not novel by any means, there continues to be a scarcity of comprehensive written, technical manuals that outline optimal surgical set up, equipment, specific technique, interpersonal relationships, advantages, disadvantages and complications that can arise. Additional barriers to application of this technique include a lack of objective patient outcome measures. Here we aim to provide a technical and nontechnical guide addressing these areas for four handed skull base techniques from two international academic skull base groups and perform a systematic review of available literature regarding four-handed cranial neurosurgery. Methods: The authors performed a detailed literature search using Ovid MEDLINE and EMBASE databases. The search strategy consisted of the following keywords/MESH terms in combination using Boolean terms: four hand* OR ((dual OR two. ADJ3 (neurosurgeon* OR surgeon* OR attending* OR consultant*). AND cranial OR skull base OR spine OR microscop* OR endoscop* OR exoscopic AND surgery OR neurosurgery. Titles/ abstracts for all articles were reviewed by two authors, for relevancy before full text review and data extraction. Duplicates were appropriately excluded and a multi-level screening process was utilized to identify relevant texts. Case reports and series were included. Additional full texts were identified via handsearching. Results: Medline and Embase were last searched on August 31, 2023. A total of 1898 manuscripts were identified before removal of 801 for duplication and/or via title screening. A further 142 papers were excluded via abstract screening before full text review of the remaining 88. A total of 27 papers were included after being assessed as relevant and an additional 2 book chapters identified via handsearching for 29 articles in total. Of these there were 19 studies with 792 patients relevant to four handed endoscopic skull base surgery and 3 studies, 2 book chapters with 353 patients relevant to four handed open skull base surgery. The remaining 5 articles were case reports or technical notes regarding cerebrovascular, trauma or neuro-oncology cases. Overall, no reports provided a direct comparison of outcomes or complications with a four handed technique over standard surgery. A single report related decreased postoperative residual pituitary adenoma (75% vs. 11%) after taking up four handed techniques. For open skull-base surgery, authors propose decreased surgeon-fatigue, real-time interdisciplinary conference, lower operating times and estimated blood loss as the major advantages of four-handed approaches. Conclusion: While limited to large case series, four handed skull base surgery appears, safe, useful and potentially superior to single surgeon approaches for complex lesions. Here we provide the first technical and nontechnical guide for four-handed open skull base surgery generated from over 20 years of skull base experience supplemented with a summary of available data supporting cranial four-handed surgery. Publication History Article published online: 05 February 2024 © 2024. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

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