Step-by-Step Guide on How to Make a 2-Dimensional Operative Neurosurgical Video: Microsurgical Resection of a Right Lateral Ventricle Subependymoma by an Anterior Interhemispheric Transcallosal Approach
2022; Lippincott Williams & Wilkins; Volume: 22; Issue: 3 Linguagem: Inglês
10.1227/ons.0000000000000073
ISSN2332-4260
AutoresMirza Pojskić, Vincent Nguyen, Andrew J. Gienapp, Kenan I. Arnautović,
Tópico(s)Digital Imaging in Medicine
ResumoThe increasing use of digital videos across medical and surgical disciplines is supported by advancements in computer hardware and software technologies. Online operative videos have become an educational resource for both neurosurgical trainees and established surgeons,1 especially in light of the recent in-person limitations imposed by COVID-19.1,2 Online materials can also help overcome training disparities in programs across the world that lack sufficient resources.3 Digital platforms, such as e-learning, webinars, 3-dimensional (3D) interactive anatomic content, and videos, can provide alternative educational resources to residency programs and trainees in lower income countries.4 The first peer-reviewed 2-dimensional (2D) operative videos were published in the Supplements of American Association of Neurological Surgeons late in the first decade of the 2000s. Over 80% of published video articles are 2D videos.1 2D videos are generally easier to produce compared with 3D videos, although there may be a certain educational disadvantage with the loss of depth perception.5,6 A recent analysis of operative videos found that the most frequently represented subspecialties included vascular (48.3%), tumor (35.2%), and skull base surgery (27.5%); spine surgery videos are less common, but in high demand.1 Several operative video libraries have been collated, including the Neurosurgery Journal, American Association of Neurological Surgeons Neurosurgery YouTube channels, and The Neurosurgical Atlas Operative Video Cases. Three journals now publish and distribute stand-alone videos: Operative Neurosurgery, World Neurosurgery, and Neurosurgical Focus: Video.1 Creation of high-quality surgical videos requires a basic understanding of technical considerations, creativity, and sound aesthetic judgment.7 Although >1200 neurosurgical operative videos have been published,1 no articles describe the step-by-step process of making one. Therefore, we aim to provide the first step-by-step guide for editing and publishing educational neurosurgical operative videos. Microsurgical Resection of Subependymoma of the Right Lateral Ventricle Our 2D video (Video) demonstrates microsurgical resection of subependymoma of the right lateral ventricle by an anterior interhemispheric transcallosal approach (performed by the senior author, K.I.A.). The video was developed with the Operative Neurosurgery's video publishing guidelines.8 Several published operative videos demonstrate an interhemispheric transcallosal approach for resection of intraventricular cavernous malformations,9–12 arteriovenous malformations,13–15 neurocytomas,16 meningiomas,17 craniopharyngiomas,18,19 colloid cysts and other third ventricular lesions,20–22 and clipping of pericallosal aneurysms.23 An operative video of the resection of a fourth ventricular subependymoma has been previously described by our group.24 The patient presented with progressive severe headaches for several months. A nonenhancing T2 and fluid-attenuated inversion recovery (FLAIR) hyperintense lesion was visualized in the right frontal horn of the lateral ventricle. To the best of our knowledge, this is the first video case report in the English peer-reviewed literature of a microsurgical resection of subependymoma of the lateral ventricle. The patient provided written consent for the publication of his image. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_9wjf956g"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} METHODS Step-by-Step Guide for Making a 2D Neurosurgical Operative Video Peer-reviewed journals have a formal structure for video submissions (Table).1 Several software programs can be used, including Adobe Premiere Pro (Adobe), Apple iMovie or Final Cut Pro (Apple), Avid Media Composer (Avid Technology), and Windows Movie Maker (Microsoft Corporation).3 For those in parts of the world with limited resources, 2D videos can also be made with free open-access software (or freeware), such as Shot Cut (for video editing) and Audacity (for audio editing). The role of free online courses and tutorials available in sites such as YouTube is also essential in learning how to use this different software. This tutorial describes a step-by-step process of making a 2D neurosurgical operative video using Adobe Premiere Pro. Brief instructions for Apple iMovie can be found in Supplemental Instructions: Operative Video Creation using Apple iMovie (see also Supplemental Figures 1-8, https://links.lww.com/ONS/A3, https://links.lww.com/ONS/A4, https://links.lww.com/ONS/A6, https://links.lww.com/ONS/A7, https://links.lww.com/ONS/A8, https://links.lww.com/ONS/A9, and https://links.lww.com/ONS/A10; and Supplemental Tables 1 and 2, https://links.lww.com/ONS/A11 and https://links.lww.com/ONS/A12). TABLE. - Formal Structure for Video Submissions • History and physical examination • Pertinent imaging • Positioning • Required equipment • Approach and exposure • Critical surgical steps • Closure • Postoperative course and imaging Step 1. Recording Making surgical videos consists of 3 main steps—recording, editing, and archiving.3 Minimum video-recording specifications have been previously described.1 Intraoperative microscopes and endoscopes used during tumor, vascular, and skull base cases have built-in recording features that provide the surgeon's view not typically required for other subspecialties.1 Overhead lights with built-in cameras, miniature cameras mounted to headlights, and other emerging technologies can be used to capture recordings without a microscope or endoscope,1 which is valuable for surgical elements not performed under the microscope, such as positioning, sterile preparation and draping, skin incision, operative approach (eg, craniotomy or laminectomy), and closure. Most published videos use photographs to describe positioning and approaches. Camera-mounted operative microscopes have become standard in most operative theaters and provide optimal and reliable visualization, including built-in fluorescence filters and augmented reality capabilities. We use Zeiss operative microscopes (Carl Zeiss AG) for recording in an .mpg or .mp4 format that can save to an external universal serial bus drive directly from the microscope. Remember that the patient must provide written consent and permission to publish the surgical video and images. Step 2. Importing Video Footage and Other Media Files Adobe Premiere Pro divides into 4 main windows (Supplemental Figure 9A, https://links.lww.com/ONS/A13): Source is upper left (blue outline), Project is lower left (yellow outline), Program is upper right (red outline), and Timeline is lower right (green outline). Import media files (Supplemental Figure 9B, https://links.lww.com/ONS/A14) in the Assembly workspace (circled in red) or by selecting Window >Media Browser. The Media Browser panel (circles in yellow) opens a list of folders at left (white arrow). Contents are displayed at right (Supplemental Figure 9A, https://links.lww.com/ONS/A13) and uploaded from the Project panel to the Source panel by drag and drop (outlined in pink). Nonvideo data in the Source panel (neuroradiological imaging, photographs, etc.) are transferred by drag and drop to the Timeline panel, which represents the actual video. Perform additional editing in the Program panel (adding titles, labeling, special effects, and audio editing). Step 3. Creation of Text Slides Set a background for use with the text slides in the video that is unique throughout the project. Insert a project title—for our video, the title is “Microsurgical resection of intraventricular ependymoma by an right anterior transcallosal interhemispheric approach.” Insert text by selecting an existing motion graphic template from Premiere Pro (click on Graphics/Titles [circle in green, Supplemental Figure 9B, https://links.lww.com/ONS/A14] on the main control panel). Clinical presentation and Neurological examination slides describe the history and relevant neurological examination findings. In our case, the patient is a 48-year-old with a history of headache but no other deficits (we obtained consent directly from the patient; institutional review board approval was not needed for the study). Rationale for the procedure is to obtain tissue for definitive diagnosis.25Potential benefits include confirming histopathological diagnosis and prevention of hydrocephalus due to Foramen of Monroe blockade. Risks include intraventricular hemorrhage with hydrocephalus, subdural falcine hematoma, cognitive deficits secondary to fornix injury, or hemiparesis secondary to injury of basal ganglia. Alternatives to surgery include conservative management with a serial magnetic resonance imaging (MRI) follow-up. Alternative surgical approaches include right frontal transcortical, transventricular, or endoscopic approaches. Critical equipment includes microsurgical instruments, self-retaining retractor, and endoscope for inspection of the ventricles after resection. Disease background provides a brief description of the disease or surgical technique. For our video, subependymoma is a rare, benign, and slow-growing glial tumor that accounts for just 0.2% to 0.7% of all intracranial tumors and ∼8% of ependymal neoplasms.26 Subependymomas are isointense on T1 and hyperintense on T2-weighted MRI with minimal or no enhancement. They arise most frequently in the fourth ventricle (50%-60%), followed by the lateral ventricle (30%-40%), and less frequently the septum pellucidum and spinal cord; intraparenchymal lesions are extremely rare.26 Microsurgery remains the mainstay treatment, and complete tumor resection is possible and curative with excellent prognosis.27 Step 4. Creation of Text Slides—Imaging Findings Relevant imaging includes preoperative MRI and other imaging (computed tomography, angiography, etc.), and a slide with slices of the pathology or a short video with imaging. We prefer photographs with relevant slices and label the imaging modality and lesion (yellow outline; Supplemental Figure 10, https://links.lww.com/ONS/A15). For our case, brain MRI revealed a T2 and FLAIR hyperintense lesion in the right lateral ventricle without contrast enhancement. Differential diagnosis includes subependymoma, ependymoma, and low-grade glioma. Step 5. Creation of Text Slides—Positioning and Key Surgical Steps Describe positioning with text, narration, or photographs. We prefer narration describing a photograph, if available. For standard positioning, use figures (with permission) from classical neurosurgical textbooks. Our patient was placed supine, head straight with 30° inclination, and fixed in a Mayfield clamp (Integra Life Sciences). We make several slides depicting Key surgical steps (yellow outline; Supplemental Figure 11, https://links.lww.com/ONS/A16). In this case, steps include a right anterior interhemispheric transcallosal approach, right frontoparietal midline craniotomy, midline exposure with a self-retaining retractor, dissection of pericallosal vessels, transcallosal entrance to the right lateral ventricle, and tumor resection. Step 6. Creation of Text Slides—Key Surgical Steps—Operative Approach and Craniotomy Use photographs with a professional camera to depict positioning and craniotomy. Head-mounted cameras enable filming of craniotomy, which can be inserted into the Timeline before the microscopic part of the procedure. Alternatively, use figures and legends from the classics of neurosurgical literature. In our case, craniotomy was demonstrated from the Color Atlas of Microneurosurgery by Wolfgang et al 28 (yellow outline; Supplemental Figure 12, https://links.lww.com/ONS/A17) and anatomic presentation of the right anterior interhemispheric transcallosal approach from the Rhoton atlas29 (yellow outline; Supplemental Figure 13, https://links.lww.com/ONS/A18). Use photograph-editing tools to depict the craniotomy after incision on a photograph of the patient or a cadaver.30 Avoid changing the original performances of the microscope operative video (change of contrast or color properties) because the video does not reflect the actual operative reality. Step 7. Import and Editing of the Microscope Operative Video—First Sequence Operative videos should be edited so that the audience understand all key surgical steps and important operative nuances. Video sections chosen for the final cut can be selected through Mark In/Mark Out option on the Source toolbar (yellow circle; Supplemental Figure 14, https://links.lww.com/ONS/A19) and then dragged and dropped into the video Timeline (green outline). Initial sequences should orient the audience to operative anatomy and boundaries (Supplemental Figure 13, right panel, https://links.lww.com/ONS/A18), enabling better understanding of anatomic relations throughout the procedure. Step 8. Editing of the Microscope Operative Video—Slicing the Video To depict the entire surgery, use the most representative and key surgical steps. Avoid sequences not showing the full view of the surgical field (eg, when the microscope is put aside or something blocks the view). Remove repetitive movements or steps; provide a general idea of a certain surgical step without unnecessary lengthening of the video. For example, stepwise coagulation of vessels cut with microscissors can be shortened by showing a clip of the coagulation and then the final cut. An ideal duration for an operative video should be <10 minutes. Add surgical time to the video abstract to provide perspective. Present sequential steps of the resection—exposure, debulking, coagulation, dissection off of the surrounding structures, and tumor release and extirpation—in a chronological order. Clearly define challenging parts of the tumor dissection and address operative nuances and possible surgical solutions to problems during the resection. Use fade in/out effects to transition between key surgical steps. Clips can be trimmed so that the whole project is shorter (shortening the clip shortens the whole video, called a ripple edit), or shorten one clip while extending the clip next to it (trimming 2 clips at once, called a rolling edit). Precision cuts are best performed using the Program Monitor with the slide tool bar (yellow circle; Supplemental Figure 15, https://links.lww.com/ONS/A20). Step 9. Editing of the Microscope Operative Video—Labeling of Important Neuroanatomic Structures and Pathology Label important neuroanatomic structures and pathology. In our video, we used arrows and stars to label the pericallosal arteries and corpus callosum (yellow outline; Supplemental Figure 16, https://links.lww.com/ONS/A21), tumor, and resection cavity (ie, ventricle) after resection of the subependymoma. Step 10. Follow-up Information Add sufficient follow-up information, including postoperative imaging, so that viewers understand the surgical outcomes.1 Include a text slide or narration of histology. Optionally, include a representative photograph of the microscopic pathology specimen. Videos highlighting techniques for managing complications should be encouraged; viewers are otherwise at risk of developing a false sense of success watching highly selected videos showing only best outcomes,1,3 In our video, we include a picture or video of the patient (with blurred face or black title over the eyes) to demonstrate postsurgical neurological status (yellow outline; Supplemental Figure 17, https://links.lww.com/ONS/A22). Step 11. Narration of the Operative Video Narration is the most important part of the operative video. For ours, we write a script, narrated during the final video editing. We rehearse with the video without recording. The time text slides are displayed can be extended so that the narrator can fully explain the slide or read text. To do this, hold the text slide on the Timeline (green outline) with left mouse click and extend it to the desired duration. Surgical footage can be trimmed, extended, sped up, or slowed down. We prefer to keep the original speed to preserve the original surgical perspective. Advanced trimming workflows are not usually needed. Narration should include detailed descriptions of text slides, key steps, and surgical pearls. Click the voice-over-record button on the Sequence (yellow arrow, Supplemental Figure 18, https://links.lww.com/ONS/A23) to start recording. During the narration, a red line labeled with “Recording” is highlighted in the Program window (red star). When narration is completed, press the space bar to stop (double yellow arrows). Audio data can be additionally edited for better quality using the audio or graphics option in the main control panel. Audio effects are usually sufficient to exclude possible background noise. Step 14. Export of the Video Go to File in the upper menu and click Export and then Media, and then, choose the appropriate file format. We prefer audio video interleave, moving picture experts group (MPEG)2, and MPEG4 video files. RESULTS The patient provided written consent to the publication of his image. The lesion was accessed by a right anterior interhemispheric approach with a right frontal midline craniotomy, followed by a transcallosal approach. The falx cerebri was retracted to widen the interhemispheric approach. The tumor was visualized after a midline corpus callosotomy and dissection through the ependyma to reach the lateral ventricle. Microsurgical dissection was performed to dissect the tumor away from the wall of the body of the lateral ventricle. The tumor was debulked for pathology samples, followed by piecemeal stepwise resection of the tumor. A microsurgical technique was performed until gross total resection of the tumor was achieved. Pathology determined that the tumor was a subependymoma. The remaining cavity was packed with Gelfoam soaked in thrombin (Pfizer) and Surgicel (Ethicon). Watertight dural closure was performed, followed by standard surgical closure. Postoperative MRI showed a small callosotomy of ∼1 cm and complete gross total resection of the tumor. At the final follow-up, the patient experienced complete neurological recovery and resolution of headache. DISCUSSION With the exception of endoscopic procedures, neurosurgical video creation has an advantage over head and neck, thoracic, abdominal, plastic, and trauma surgery. Recording and archiving procedures are connected to the operative microscope. Subspecialty surgeries not typically performed microscopically (ie, functional, spine, and peripheral nerve surgery) can use head-mounted cameras.31 Operative videos performed by master neurosurgeons can be a key tool to refine the art and science of neurosurgery.32–43Video issues44–47 in subspecialty neurosurgical journals have become increasingly popular. Although articles are available on technical aspects of video recording in other surgical specialties,6,48 there are no tutorials for making neurosurgical videos. Neurosurgical residents and junior attendings use online videos to supplement traditional learning and prepare for cases.1,3,49 Video-based training participants can achieve learning milestones with less time by watching a video before a procedure.50 As shown in laparoscopic colorectal cancer surgery, a narrated surgical video can provide important intraoperative information, quality control, and objectivity.51 Reporting bias exists when experiments are only published when they yield the positive results.52 Future educational videos can be improved by including complications and subsequent management strategies. Although virtual resources can supplement—but never replace—the cognitive skillset obtained during live surgical cases, COVID-19–driven innovations in medical education have accelerated improvements, such as with cross-institutional virtual medical student subspecialty training camps.53 Unfortunately, many online operative videos have not been peer-reviewed; poor-quality videos introduce substandard information and techniques, particularly when there are conflict of interest issues in play.3,54 A recent study of 24 neurosurgical YouTube videos found only 33% included auditory commentary and 25% provided educational learning points.55 Neurosurgeons may consider adhering to surgical video reporting guidelines, such as the “SUrgical VIdeo Reporting” Guidelines56 or “Surgical techniqUe rePorting chEcklist and standaRds,”57 to help in standardization of submitted video clips. Our guide aims to improve the quality of educational operative videos. CONCLUSION Surgical video preparation includes 3 steps: recording, editing, and narrating. Neurosurgical operative videos are a useful educational adjunct for trainees and continuing education for attendings. Unfortunately, many operative videos have not been peer-reviewed; poor-quality videos may show incomplete or misleading information or poor techniques. This tutorial provides basic information for editing and transforming video into a valuable educational tool. Analysis and editing of microscopic operative videos should be an obligatory part of education of neurosurgical residents in the 21st century.
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