Management of Vascular Injuries During Endoscopic Skull Base Surgery: Current Strategies and Simulation-Based Educational Paradigms

Abstract

Purpose of Review

With fully endoscopic surgery rapidly emerging as a preferred modality of care in the minimally invasive approach to the ventral skull base, surgeons may increasingly encounter critical vascular structures reached via narrow corridors. Internal carotid artery (ICA) injury is a rare but much dreaded complication during endoscopic endonasal approaches (EEA). We reviewed management strategies and outcomes following ICA injury during skull base surgery as well as currently available simulation teaching models.

Recent Findings

Multiple simulation models of ICA injury during EEA have been developed in recent years to prepare surgical trainees for this uncommon intraoperative scenario. These high-flow simulators aim to be reproducible and realistic. Current educational models include a live sheep ICA model, a perfusion-based human cadaveric model, and synthetic skull base models created using selective laser sintering. The live sheep model has allowed further investigation of optimal hemostatic agents and techniques in variable injury patterns, including the crushed muscle patch and endoscopic ligation devices. The perfusion-based human cadaveric model provides the most realistic anatomical scenario for simulation. Emphasized concepts and maneuvers in each of these models include appropriate use of suction, initial packing and hemostasis without causing vessel occlusion, and placement of a muscle patch. Preliminary validation of these simulation models suggests their efficacy in improving psychomotor surgical skills and trainee self-confidence as well as potentially translating to patient outcomes in the post-training incidences of carotid injury.

Summary

It is important for skull base surgeons to be optimally prepared for and adept in the management of ICA injury. Several simulation platforms are highlighted and worthy of incorporation into organized resident and fellow training programs. Further research into hemostatic strategies and biomaterials, and objective validation pertaining to the efficacy of these simulation models are necessary to guide future curriculum development in skull base surgical training.

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