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Utility of multimaterial 3D printers in creating models with pathological entities to enhance the training experience of neurosurgeons

Waran V, Narayanan V, Karuppiah R, Owen SL, Aziz T

J. Neurosurg., 2014 Feb;120(2):489-92.
PMID: 24321044 DOI: 10.3171/2013.11.JNS131066

The advent of multimaterial 3D printers allows the creation of neurosurgical models of a more realistic nature, mimicking real tissues. The authors used the latest generation of 3D printer to create a model, with an inbuilt pathological entity, of varying consistency and density. Using this model the authors were able to take trainees through the basic steps, from navigation and planning of skin flap to performing initial steps in a craniotomy and simple tumor excision. As the technology advances, models of this nature may be able to supplement the training of neurosurgeons in a simulated operating theater environment, thus improving the training experience.
The utilisation of 3D printing in paediatric neurosurgery

Karuppiah R, Munusamy T, Bahuri NFA, Waran V

Childs Nerv Syst, 2021 05;37(5):1479-1484.
PMID: 33735402 DOI: 10.1007/s00381-021-05123-w

3D printing technology has evolved over the years and there is a growing interest in its application in paediatric neurosurgery. Modern 3D printers have enabled the development of patient-specific 3D models that provide a realistic representation of complex anatomies and will aid in planning complex procedures. Paediatric neurosurgical operations are challenging and hands-on training is restricted. Surgical simulation training with biomodel has provided a new paradigm for trainees to master their surgical skills before encountering similar scenarios in real-life environment. This paper reviews the aspects of 3D printing for preoperative planning and simulation-based surgical training in paediatric neurosurgery.
Fulltext Equitable Access to State-of-the-Art Medical Technology-a Malaysian Mini-Public-Private Partnership Case Study

Waran V, Thillainathan R, Karuppiah R, Pickard JD

World Neurosurg, 2022 01;157:135-142.
PMID: 34687934 DOI: 10.1016/j.wneu.2021.10.112

BACKGROUND: The provision of equitable and affordable health care has become increasingly challenging as advanced technology is introduced, particularly in developing countries. We explored the hypothesis that focused, small-scale mini-public-private partnerships have a potential role in providing equitable and affordable access to advanced technology for the benefit of all patients in developing nations, particularly middle-income countries.
METHODS: A clinician-led financial plan was developed at the University of Malaya to create the Centre for Image Guidance and Minimally Invasive Therapy (CIGMIT) to provide an integrated platform for high-end care for Malaysian patients of all ages, both public and private, requiring complex neurosurgical and spinal procedures and stereotactic and intensity-modulated radiotherapy. The challenges faced during development of the plan were documented together with an audit of patient throughput and analyses of financial risk and return.
RESULTS: CIGMIT opened in 2015. Patient throughput, both public and private, progressively increased in all facilities. In 2015-2019, 37,724 patients used the Centre's facilities. CIGMIT has become progressively more profitable for the University of Malaya, the public and private hospitals, and the investor. CIGMIT has weathered the challenges posed by coronavirus disease 19.
CONCLUSIONS: Focused, small-scale mini-public-private partnerships have a potential role in providing advanced technology for the benefit of patients in developing nations, particularly middle-income countries, subject to an approach that balances equity of access between public and private health care systems with fair reward.
Fulltext [Intractable intraoperative brain herniation secondary to tension pneumocephalus: a rare life-threatening complication during drainage of subdural empyema]

Foo LL, Chaw SH, Chan L, Ganesan D, Karuppiah R

Rev Bras Anestesiol, 2016 09 28;67(6):655-658.
PMID: 27692367 DOI: 10.1016/j.bjan.2015.09.006

Tension pneumocephalus is rare but has been well documented following trauma and neurosurgical procedures. It is a surgical emergency as it can lead to neurological deterioration, brainstem herniation and death. Unlike previous cases where tension pneumocephalus developed postoperatively, we describe a case of intraoperative tension pneumocephalus leading to sudden, massive open brain herniation out of the craniotomy site. The possible causative factors are outlined. It is imperative to rapidly identify possible causes of acute intraoperative brain herniation, including tension pneumocephalus, and institute appropriate measures to minimize neurological damage.
Neurosurgical endoscopic training via a realistic 3-dimensional model with pathology

Waran V, Narayanan V, Karuppiah R, Thambynayagam HC, Muthusamy KA, Rahman ZA, et al.

Simul Healthc, 2015 Feb;10(1):43-8.
PMID: 25514588 DOI: 10.1097/SIH.0000000000000060

Training in intraventricular endoscopy is particularly challenging because the volume of cases is relatively small and the techniques involved are unlike those usually used in conventional neurosurgery. Present training models are inadequate for various reasons. Using 3-dimensional (3D) printing techniques, models with pathology can be created using actual patient's imaging data. This technical article introduces a new training model based on a patient with hydrocephalus secondary to a pineal tumour, enabling the models to be used to simulate third ventriculostomies and pineal biopsies.
Endoscopic skull base training using 3D printed models with pre-existing pathology

Narayanan V, Narayanan P, Rajagopalan R, Karuppiah R, Rahman ZA, Wormald PJ, et al.

Eur Arch Otorhinolaryngol, 2015 Mar;272(3):753-7.
PMID: 25294050 DOI: 10.1007/s00405-014-3300-3

Endoscopic base of skull surgery has been growing in acceptance in the recent past due to improvements in visualisation and micro instrumentation as well as the surgical maturing of early endoscopic skull base practitioners. Unfortunately, these demanding procedures have a steep learning curve. A physical simulation that is able to reproduce the complex anatomy of the anterior skull base provides very useful means of learning the necessary skills in a safe and effective environment. This paper aims to assess the ease of learning endoscopic skull base exposure and drilling techniques using an anatomically accurate physical model with a pre-existing pathology (i.e., basilar invagination) created from actual patient data. Five models of a patient with platy-basia and basilar invagination were created from the original MRI and CT imaging data of a patient. The models were used as part of a training workshop for ENT surgeons with varying degrees of experience in endoscopic base of skull surgery, from trainees to experienced consultants. The surgeons were given a list of key steps to achieve in exposing and drilling the skull base using the simulation model. They were then asked to list the level of difficulty of learning these steps using the model. The participants found the models suitable for learning registration, navigation and skull base drilling techniques. All participants also found the deep structures to be accurately represented spatially as confirmed by the navigation system. These models allow structured simulation to be conducted in a workshop environment where surgeons and trainees can practice to perform complex procedures in a controlled fashion under the supervision of experts.
A new modified speculum guided single nostril technique for endoscopic transnasal transsphenoidal surgery: an analysis of nasal complications

Waran V, Tang IP, Karuppiah R, Abd Kadir KA, Chandran H, Muthusamy KA, et al.

Br J Neurosurg, 2013 Dec;27(6):742-6.
PMID: 23647078 DOI: 10.3109/02688697.2013.791667

Abstract The endoscopic transnasal, transsphenoidal surgical technique for pituitary tumour excision has generally been regarded as a less invasive technique, ranging from single nostril to dual nostril techniques. We propose a single nostril technique using a modified nasal speculum as a preferred technique. We initially reviewed 25 patients who underwent pituitary tumour excision, via endoscopic transnasal transsphenoidal surgery, using this new modified speculum-guided single nostril technique. The results show shorter operation time with reduced intra- and post-operative nasal soft tissue injuries and complications.
Fulltext Telemedicine via Smart Glasses in Critical Care of the Neurosurgical Patient-COVID-19 Pandemic Preparedness and Response in Neurosurgery

Munusamy T, Karuppiah R, Bahuri NFA, Sockalingam S, Cham CY, Waran V

World Neurosurg, 2021 01;145:e53-e60.
PMID: 32956888 DOI: 10.1016/j.wneu.2020.09.076

OBJECTIVE: The coronavirus disease 2019 pandemic poses major risks to health care workers in neurocritical care. Recommendations are in place to limit medical personnel attending to the neurosurgical patient as a protective measure and to conserve personal protective equipment. However, the complexity of the neurosurgical patient proves to be a challenge and an opportunity for innovation. The goal of our study was to determine if telemedicine delivered through smart glasses was feasible and effective in an alternative method of conducting ward round on neurocritical care patients during the pandemic.
METHODS: A random pair of neurosurgery resident and specialist conducted consecutive virtual and physical ward rounds on neurocritical patients. A virtual ward round was first conducted remotely by a specialist who received real-time audiovisual information from a resident wearing smart glasses integrated with telemedicine. Subsequently, a physical ward round was performed together by the resident and specialist on the same patient. The management plans of both ward rounds were compared, and the intrarater reliability was measured. On study completion a qualitative survey was performed.
RESULTS: Ten paired ward rounds were performed on 103 neurocritical care patients with excellent overall intrarater reliability. Nine out of 10 showed good to excellent internal consistency, and 1 showed acceptable internal consistency. Qualitative analysis indicated wide user acceptance and high satisfaction rate with the alternative method.
CONCLUSIONS: Virtual ward rounds using telemedicine via smart glasses on neurosurgical patients in critical care were feasible, effective, and widely accepted as an alternative to physical ward rounds during the coronavirus disease 2019 pandemic.
Fulltext Focused surgical pandemic response in a Malaysian hybrid COVID-19 hospital

Roslani AC, Vythilingam G, Seevalingam KK, Xavier RG, Idris MS, Karuppiah R

Asian J Surg, 2021 Jan;44(1):404-406.
PMID: 33317901 DOI: 10.1016/j.asjsur.2020.10.012
Fulltext Supratentorial cerebrospinal fluid diversion using image-guided trigonal ventriculostomy during retrosigmoid craniotomy for cerebellopontine angle tumors

Roethlisberger M, Eberhard NE, Rychen J, Al-Zahid S, Jayapalan RR, Zweifel C, et al.

Front Surg, 2023;10:1198837.
PMID: 37288135 DOI: 10.3389/fsurg.2023.1198837

BACKGROUND: Cerebellar contusion, swelling and herniation is frequently encoutered upon durotomy in patients undergoing retrosigmoid craniotomy for cerebellopontine angle (CPA) tumors, despite using standard methods to obtain adequate cerebellar relaxation.
OBJECTIVE: The aim of this study is to report an alternative cerebrospinal fluid (CSF)-diversion method using image-guided ipsilateral trigonal ventriculostomy.
METHODS: Single-center retro- and prospective cohort study of n = 62 patients undergoing above-mentioned technique. Prior durotomy, CSF-diversion was performed to the point where the posterior fossa dura was visibly pulsatile. Outcome assessment consisted of the surgeon's intra- and postoperative clinical observations, and postoperative radiological imaging.
RESULTS: Fifty-two out of n = 62 (84%) cases were eligible for analysis. The surgeons consistently reported successful ventricular puncture and a pulsatile dura prior durotomy without cerebellar contusion, swelling or herniation through the dural incision in n = 51/52 (98%) cases. Forty-nine out of n = 52 (94%) catheters were placed correctly within the first attempt, with the majority of catheter tips (n = 50, 96%) located intraventricularly (grade 1 or 2). In n = 4/52 (8%) patients, postoperative imaging revealed evidence of a ventriculostomy-related hemorrhage (VRH) associated with an intracerebral hemorrhage [n = 2/52 (4%)] or an isolated intraventricular hemorrhage [n = 2/52 (4%)]. However, these hemorrhagic complications were not associated with neurological symptoms, surgical interventions or postoperative hydrocephalus. None of the evaluated patients demonstrated radiological signs of upward transtentorial herniation.
CONCLUSION: The method described above efficiently allows CSF-diversion prior durotomy to reduce cerebellar pressure during retrosigmoid approach for CPA tumors. However, there is an inherent risk of subclinical supratentorial hemorrhagic complications.
Injecting realism in surgical training-initial simulation experience with custom 3D models

Waran V, Narayanan V, Karuppiah R, Pancharatnam D, Chandran H, Raman R, et al.

J Surg Educ, 2014 Mar-Apr;71(2):193-7.
PMID: 24602709 DOI: 10.1016/j.jsurg.2013.08.010

The traditionally accepted form of training is direct supervision by an expert; however, modern trends in medicine have made this progressively more difficult to achieve. A 3-dimensional printer makes it possible to convert patients imaging data into accurate models, thus allowing the possibility to reproduce models with pathology. This enables a large number of trainees to be trained simultaneously using realistic models simulating actual neurosurgical procedures. The aim of this study was to assess the usefulness of these models in training surgeons to perform standard procedures that require complex techniques and equipment.
Clinical Studies and Pre-clinical Animal Models on Facial Nerve Preservation, Reconstruction, and Regeneration Following Cerebellopontine Angle Tumor Surgery-A Systematic Review and Future Perspectives

Hostettler IC, Jayashankar N, Bikis C, Wanderer S, Nevzati E, Karuppiah R, et al.

Front Bioeng Biotechnol, 2021;9:659413.
PMID: 34239858 DOI: 10.3389/fbioe.2021.659413

Background and purpose: Tumorous lesions developing in the cerebellopontine angle (CPA) get into close contact with the 1st (cisternal) and 2nd (meatal) intra-arachnoidal portion of the facial nerve (FN). When surgical damage occurs, commonly known reconstruction strategies are often associated with poor functional recovery. This article aims to provide a systematic overview for translational research by establishing the current evidence on available clinical studies and experimental models reporting on intracranial FN injury. Methods: A systematic literature search of several databases (PubMed, EMBASE, Medline) was performed prior to July 2020. Suitable articles were selected based on predefined eligibility criteria following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. Included clinical studies were reviewed and categorized according to the pathology and surgical resection strategy, and experimental studies according to the animal. For anatomical study purposes, perfusion-fixed adult New Zealand white rabbits were used for radiological high-resolution imaging and anatomical dissection of the CPA and periotic skull base. Results: One hundred forty four out of 166 included publications were clinical studies reporting on FN outcomes after CPA-tumor surgery in 19,136 patients. During CPA-tumor surgery, the specific vulnerability of the intracranial FN to stretching and compression more likely leads to neurapraxia or axonotmesis than neurotmesis. Severe FN palsy was reported in 7 to 15 % after vestibular schwannoma surgery, and 6% following the resection of CPA-meningioma. Twenty-two papers reported on experimental studies, out of which only 6 specifically used intracranial FN injury in a rodent (n = 4) or non-rodent model (n = 2). Rats and rabbits offer a feasible model for manipulation of the FN in the CPA, the latter was further confirmed in our study covering the radiological and anatomical analysis of perfusion fixed periotic bones. Conclusion: The particular anatomical and physiological features of the intracranial FN warrant a distinguishment of experimental models for intracranial FN injuries. New Zealand White rabbits might be a very cost-effective and valuable option to test new experimental approaches for intracranial FN regeneration. Flexible and bioactive biomaterials, commonly used in skull base surgery, endowed with trophic and topographical functions, should address the specific needs of intracranial FN injuries.

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