Introduction: As dedicated endoscopy suites for skull base surgery are becoming  more prevalent, it is important to consider the optimal operative room setup. Multiple  techniques have been presented for surgeon  for two-team endoscopic skull  base surgery. Classically, the neurosurgeon and otolaryngologist stand adjacent to  each other on the same side of the patient bed while operating. We describe an  alternative approach utilizing dynamic endoscopy where the two surgeons stand across  from each other. We discuss the merits of this approach from both a neurosurgical and  otolaryngological perspective. Methods and results: We describe our technique of surgeon positioning, monitor  positioning, operating room setup, and their implications on ergonomics and surgeon  fatigability. Conclusion: We believe our approach of surgeon positioning, where surgeons  stand on opposite sides of the patient bed while operating, to be a viable and more  ergonomic alternative to the classical approach.

• Skull base

• Endoscopy

• Operative room setup

• Ergonomic

• Positioning

Gill KS, Rabinowitz M, Hsu D, Evans J, Farrell C, et al. (2016) The Jefferson Operative Room Setup for Endoscopic Skull Base Surgery. Ann Otolaryngol Rhinol 3(5): 1104.

Gill KS, Rabinowitz M, Hsu D, Evans J, Farrell C, et al. (2016) The Jefferson Operative Room Setup for Endoscopic Skull Base Surgery. Ann Otolaryngol Rhinol 3(5): 1104

In contrast to functional endoscopic sinus surgery (FESS), which requires just one surgeon and 2 hands while operating, endoscopic skull base surgery requires 2 surgeons and 4 hands. This has created a unique problem in finding a way to adequately position both surgeons so as to maximize exposure and lend to an ergonomically practical method for long cases. To address these concerns, several authors have popularized various operative techniques as being the mainstay for skull base surgeons.

Snyderman et al. [1] and Louis et al. [2] describe a single-sided technique whereby both surgeons are positioned to the right of the supine patient; the scrub nurse is also positioned to the right of the patient but further towards the foot of the bed (Figure 1).

Figure 1: Classical operative room setup for endoscopic skullbase surgery with both surgeons positioned to the right of the patient.

This setup allows the nurse and surgeon to efficiently transfer instruments without the surgeon turning from the monitor. It also allows for both surgeons to have a comfortable operative position on the patient’s right. Additionally, two video monitors displaying the endoscopic picture are positioned orthogonally to one another, with the possibility for a third monitor for neuronavigation placed in between.

Herein we outline our operative set up for surgeon positioning during endoscopic skull base surgery. In contrast to the previously reported techniques, we routinely perform these cases with the surgeons standing on opposite sides of the patient. In our model, the neurosurgeon stands on the right side of the patient and the otolaryngologist on the left side of the patient. The ENT, however, starts the approach on the patient’s right. Once the approach is complete (sphenoid and sella opened), then the intracranial dissection turns into a two-surgeon approach and the ENT goes to the patient’s left while the neurosurgeon goes to the patients right. The endoscope is placed in the left nostril during the neurosurgical portion of the surgery. After the resection and reconstruction are complete, the ENT goes back to the patient’s right and completes any remaining closure or medialization of the middle turbinates. This allows for both surgeons to work simultaneously -- the otolaryngologist performing dynamic endoscopy while the neurosurgeon performs intracranial work.

The scrub nurse is positioned further down the bed on the same side as the surgeon dedicated to dynamic endoscopy; anesthesia is positioned at the foot of the bed. Ceiling mounted monitor displays are positioned approximately 1 meter directly in front of each surgeon. Additionally, this set up easily allows for simultaneous fascia lata graft harvest without interfering with the surgeons at the head of the patient. Depending on the available space in the operating room, the fascia harvest always takes place on the side opposite the scrub tech. This setup is depicted in (Figure 2).

Figure 2: Jefferson operative room setup for endoscopic skull base surgery with each surgeon standing on opposite sides of the patient.

does not appear to be a noticeable drawback in clinical practice. Furthermore, in our institution, both the neurosurgeon and ENT are capable of controlling bleeding without the need for both surgeons to be on the same side of the patient to rapidly allow ENT to take over control. Occasionally, it may be necessary for the ENT to return to the other side, but this is rare. It is also unusual for the ENT to have to return to take more septum or gain more exposure after the neurosurgeon has begun working. If more exposure is needed, the neurosurgeon can usually accomplish this without the need for the ENT to return to the patient’s right.

There are few studies examining the ergonomics of the overall operative room setup, and scientific data addressing surgeon positioning are even more scarce. Laparoscopic instruments in particular suffer from ergonomically inadequate handle designs and inefficient handle to tip force transmission [3]. Little et al. found that 48/62 (77%) surgeons had experienced physical discomfort or symptoms that they attributed to performing endoscopic endonasal surgery (EES), with 73% claiming that the ergonomics of endoscopic surgery impact surgeon fatigue [4, 5]. Furthermore, 74% of surgeons found endoscopic skullbase surgery to be more ergonomically taxing than functional EES. Upon assessing the ergonomics of the operating room (OR), Berguer states that the traditional OR layout has been created by placing staff and equipment into a predefined space. Instead of forcing the endoscope into the traditional OR setup, he proposes creating a novel layout that is built around the endoscope itself [3,6,7].

Our method of surgeon positioning has several ergonomic advantages. It allows for optimal monitor positioning for each surgeon, which according to a study by Kelts et al. is approximately 1 meter away and directly in front of (180o ) each surgeon with a flexible monitor height of 0-15 degrees below the eye level of each surgeon [8]. Beyond this height range, Bauer and Wittig found that there was increased cervical muscle activity among surgeons [9]. Additionally, van Det et al. found the optimal position to be no more than 15 degrees to the left or right of the surgeon in the horizontal plane [10]. A randomized controlled trial by Haveran et al. found the worst performance was observed when the monitor was located to the right of midline (240o ), with a significantly prolonged time to task completion compared to the 180o position for both experienced (7.9 vs. 7.2 sec, p = 0.04) and novice (11.4 vs. 9.9 sec, p = 0.03) surgeons [11]. With surgeons on opposite sides looking straight ahead at their respective monitors, our setup prevents surgeons from having to turn their necks and decreases cervical muscle strain. Although our setup depicts ceiling-mounted monitors, it can also be applied to cart monitor systems as well. Further, this setup accommodates for issues related to the physical attributes of the surgeons, such as body mass index and height, which are mitigated by having surgeons separated on opposite sides of the bed.

One study by Vaz-Guimaraes et al. sought to compare different endoscope positioning and microsurgical dissection techniques in EES training to determine an optimal standard technique that can be used in teaching EES [12]. In this series, 12 trainees without any or very limited experience were randomly assigned to one of three groups: A) one single surgeon performing binarial two-handed dissection using an endoscope holder (rigid endoscopy); B) two surgeons performing a combined binarial two- and three-handed dissection with one surgeon guiding the endoscope (dynamic endoscopy); C) two surgeons performing a binarial two-handed dissection with one surgeon fully dedicated to endoscope positioning and the other one fully dedicated to a two-handed dissection. A distinction was not made whether both surgeons operated on the same or opposite sides of the bed. Using a global rating scale and specific task checklist, they determined that group C had a significantly positive impact of dynamic endoscopy and bimanual dissection on training performance. Although they did not directly compare the advantage of having both surgeons stand on opposite sides versus the same side, this is one of few studies in the literature with scientific data related to an operative room setup for EES.

As dedicated endoscopy suites for skull base surgery are becoming more prevalent, it is important to consider the optimal operative room setup. This emphasizes the utility of exploring alternative operative room setups, including ours at Jefferson. Those who have trained at Jefferson have taken this technique to their institutions and it is starting to garner more interest internationally. Overall, our setup maximizes surgeon dexterity and maneuverability, offering several ergonomic advantages compared to the classical operative room setup. Further studies with quantifiable outcome measures are needed to confirm the benefit of our operative room setup over others from both an ergonomic and patient care standpoint.

We present an alternative approach of surgeon positioning for two-team endoscopic skull base surgery, where surgeons stand on opposite sides of the patient bed while operating. We believe this to be a viable and more ergonomic alternative to the classical approach of both surgeons operating on the same side of the bed.

1. Snyderman CH, Kassam AB. Endoscopic techniques for pathology of the anterior cranial fossa and ventral skull base. J Am Coll Surg. 2006; 202:563.

2. Louis RG, Eisenberg A, Barkhoudarian G, Griffiths C, Kelly DF. Evolution of minimally invasive approaches to the sella and parasellar region. Int Arch Otorhinolaryngol. 2014; 18:136-148.

3. Berguer R. Surgical technology and the ergonomics of laparoscopic instruments. Surg Endosc. 1998; 12: 458-462.

4. Little RM, Deal AM, Zanation AM, McKinney K, Senior BA, Ebert CS Jr. Occupational hazards of endoscopic surgery. Int Forum Allergy Rhinol. 2012; 2: 212-216.

6. Ramakrishnan VR, Montero PN. Ergonomic considerations in endoscopic sinus surgery: lessons learned from laparoscopic surgeons. Am J Rhinol Allergy. 2013; 27: 245-250.

7. Ayad T, Péloquin L, Prince F. Ergonomics in endoscopic sinus surgery: systematic review of the literature. J Otolaryngol, 2005; 34: 333-340.

8. Kelts GI, McMains KC, Chen PG, Weitzel EK. Monitor height ergonomics: A comparison of operating room video display terminals. Allergy Rhinol (Providence). 2015; 6:28-32.

9. Bauer W, Wittig T. Influence of screen and copy holder positions on head posture, muscle activity and user judgement. Appl Ergon. 1998; 29:185-192.

10. Van Det MJ, Meijerink WJ, Hoff C, Totté ER, Pierie JP. Optimal ergonomics for laparoscopic surgery in minimally invasive surgery suites: a review and guidelines. Surg Endosc. 2009; 23:1279-1285.

11. Haveran LA, Novitsky YW, Czerniach DR, Kaban GK, Taylor M, Gallagher-Dorval K, et al. Optimizing laparoscopic task efficiency: the role of camera and monitor positions. Surg Endosc. 2007; 21:980-984.

12. Vaz-Guimaraes F, Rastelli MM Jr, Fernandez-Miranda JC, Wang EW, Gardner PA, Snyderman CH. Impact of Dynamic Endoscopy and Bimanual-Binarial Dissection in Endoscopic Endonasal Surgery Training: A Laboratory Investigation. J Neurol Surg B Skull Base. 2015; 76:365-371.