Acta Neurochir (2015) 157:935–938 DOI 10.1007/s00701-015-2409-5
TECHNICAL NOTE - NEUROSURGICAL TECHNIQUES
Total removal of a trigeminal schwannoma via the expanded endoscopic endonasal approach. Technical note Timothée Jacquesson 1,2 & Moncef Berhouma 1 & Thiébaud Picart 1 & Emmanuel Jouanneau 1
Received: 14 January 2015 / Accepted: 19 March 2015 / Published online: 7 April 2015 # Springer-Verlag Wien 2015
Abstract Background Because of their deep location surrounded by closed numerous neurovascular structures, skull base tumors of the cavernous sinus are still difficult to manage. Recently, the endoscopic endonasal approach commonly used for pituitary tumor resection has been Bexpanded^ to the parasellar, infratemporal and orbital compartments with some advantages compared to the intracranial route. Methods The authors reported the case of a 49-year-old male presenting a large extradural tumor of the left cavernous sinus with extensions toward the orbit, sphenoid sinus and infratemporal fossa. His ophthalmological examination was normal, and the body CT scan revealed no primary neoplasm. Results In this operative video, the approach is described step by step with surgical nuances. The endoscopy provided a close-up panoramic view and various angles of vision. Also, it avoided an invasive craniotomy, cerebral retraction and cranial nerves damages. Thus, it allowed the total removal of this tumor originating from the maxillary branch of the trigeminal nerve. The pathologic examination confirmed a schwannoma.
Conclusion The expanded endoscopic endonasal approach provides an interesting corridor to cavernous sinus tumors with satisfactory control of extensions inferiorly toward the infratemporal fossa, anteriorly via the superior orbital fissure and medially within the sphenoid. Finally, the skull base surgeon has to master this anterior endoscopic route as well as all the other Bopen^ transcranial skull base approaches to propose the best surgical route fitting the tumor characteristics. Keywords Skull base . Schwannoma . Cavernous sinus . Meckel’s cave . Endoscopy . Endonasal
Introduction
Electronic supplementary material The online version of this article (doi:10.1007/s00701-015-2409-5) contains supplementary material, which is available to authorized users.
Skull base tumors growing from the cavernous sinus or Meckel’s cave are difficult to manage because of their close relationships with the internal carotid artery (ICA) and IIIrd to VIth cranial nerves [2, 3, 6, 11]. Biopsy or removal of such symptomatic or growing tumors has already been described via invasive classical subtemporal approaches or the percutaneous Hartel technique [3, 5, 10, 12, 13]. Recently, the endoscopic endonasal approach commonly used for pituitary tumor resection has been Bexpanded^ to the parasellar, infratemporal and orbital compartments with some advantages compared to the transcranial route [1, 4, 7–9].
* Timothée Jacquesson [email protected]
Materiel and methods
1
Multidisciplinary Skull Base Unit, Department of Neurosurgery B, Neurological Hospital Pierre Wertheimer, Hospices Civils de Lyon, 59 Bd Pinel, 69677 Lyon Cedex, France
2
Department of Anatomy, University of Lyon 1, 8 Avenue Rockefeller, 69003 Lyon, France
We reported the case of a 49-year-old male who presented a left arm paresthesia. Then, cerebral imaging incidentally discovered an extradural large tumor of the left cavernous sinus, with moderate heterogeneous gadolinium enhancement and extensions toward the pterygopalatine fossa and the orbit
936
Acta Neurochir (2015) 157:935–938
Fig. 1 Preoperative cerebral T1-weighted MRI with axial (a), sagittal (b) and coronal (c) reconstructions showing an extradural cavernous sinus tumor with moderate heterogeneous gadolinium enhancement and well-defined limits suggesting a nonaggressive tumor
Fig. 2 Preoperative cerebral CT scan with axial (a), sagittal (b) and coronal (c) reconstructions showing a cavernous sinus tumor extending toward the orbit, pterygopalatine fossa and sphenoid sinus. There was a bone lysis of the orbital posterior wall and the temporal fossa excluding the clivus
(Figs. 1 and 2). His ophthalmological examination was normal, particularly the visual acuity and ocular motility. The body CT scan revealed no primary neoplasm. Thus, an expanded endoscopic endonasal approach was performed to achieve an optimal resection and to obtain histological evidence (Video 1). The patient was informed and agreed.
Results
Fig. 3 Endoscopic operative view. After a left uninostril trans-sphenoidal approach, the tumor was progressively discovered. The expected landmarks were identified: the orbital apex and posterior ethmoid superiorly, the sphenoid sinus medially and the pterygopalatine fossa with its sphenopalatine artery inferiorly
After general anesthesia, the patient was positioned supine, and his head was turned toward the operator as for Bpituitary^ surgery. Intraoperative monitoring of the left VIth nerve and MRI guidance were used. On the left side, a uninostril corridor with a short 0° lens allowed for a middle turbinectomy, total ethmoidectomy, maxillotomy and sphenoidotomy. This led to gradually identify the limits of the tumor as well as the surrounding landmarks: the orbital apex, pterygopalatine fossa, sphenoid sinus and anterior cranial base (Fig. 3). The long 0° lens was secured by a self-retaining holder, which allowed a single operator to work with both hands free. The Doppler device was very useful to localize the
Acta Neurochir (2015) 157:935–938
937
Fig. 4 Postoperative cerebral imaging. A cerebral CT scan (a) was performed 1 day after the surgery and showed no bleeding. The surgical corridor included a posterior ethmoidectomy and orbital apex and infratemporal fossa opening. The handiness was increased by resection of the posterior part of the nasal septum. Working through the contralateral
nostril also allowed an enlarged lateral access. A cerebral MRI (b and c) was performed 1 year after the surgery and showed postoperative rearrangements inside the previous tumor location with an inflammatory mucosa but no obvious residual tumor
sphenopalatine artery and the vertical paraclival portion of the ICA. The tumor anterior wall was cut, and a soft lesion was found. Thus, the removal was begun efficiently with suction and ultrasonic devices. The tumor was gradually released with the endoscopic instruments thanks to an extracapsular cleavage plane around it (Video 1). The resection was achieved by alternating tumor partition and dissection. The close-up view and 30° angle of vision of the endoscope permitted the removal of a far lateral residue. Finally, the resection appeared macroscopically complete and this tumor originated from the maxillary branch of trigeminal nerve V2. The closure with bio-glue (Tissucol®, Baxter) was simple as there was no cerebrospinal fluid leakage. The patient was discharged after 4 days with a partial hypoesthesia of the left maxillary nerve territory. The pathologist confirmed a schwannoma, and the 1-year postoperative MRI showed postoperative rearrangements without evidence of residue (Fig. 4).
craniotomy, cerebral retraction and cranial nerve morbidity. Also, it permits satisfactory control of tumor extensions inferiorly in the pterygopalatine fossa anteriorly toward the orbit or medially within the sphenoid [7–9]. Nonetheless, it is not appropriate for hard or fibrous tumors with lateral or superior extension; this is even more the case for intradural locations lateral to the ICA. The risk of cerebrospinal fluid leak always has to be kept in mind for such endoscopic skull base approaches.
Conclusion Finally, the expanded endoscopic endonasal approach provides an interesting access to extradural soft tumors of the cavernous sinus with inferior, anterior and medial extensions. The skull base surgeon has to master this anterior route as well as all the other open approaches to provide the best surgical route fitting the tumor characteristics.
Discussion We report our experience with total removal of a left cavernous sinus tumor via the expanded endoscopic endonasal approach. These tumors growing from the middle cranial fossa toward the sphenoid or orbit can be efficiently reached by this new anterior endoscopic approach [7, 9]. Although classical pterional approaches provide access to the cavernous sinus, Meckel’s cave and orbit, they require crossing cranial nerves and the ICA, so inferior or medial tumor extensions are difficult to control [10, 12]. Thus, the recent expansion of the trans-sphenoidal Bpituitary^ approach brings a new, safe corridor to the parasellar area, orbit and pterygopalatine or infratemporal fossas. With its close-up panoramic view, angle of vision and dedicated instruments, the endoscopy permits overcoming some of the difficulties encountered in microsurgical approaches. In fact, this route avoids an invasive
Conflicts of interest None.
References 1.
2.
3. 4.
Alfieri A, Jho HD (2001) Endoscopic endonasal approaches to the cavernous sinus: surgical approaches. Neurosurgery 49(2):354– 360, discussion 360–362 Ammirati M, Bernardo A (2007) Anatomical study of the superior orbital fissure as seen during a pterional approach. J Neurosurg 106(1):151–156 Beck DW, Menezes AH (1987) Lesions in Meckel’s cave: variable presentation and pathology. J Neurosurg 67(5):684–689 Dallan I, Castelnuovo P, de Notaris M, Sellari-Franceschini S, Lenzi R, Turri-Zanoni M, Battaglia P, Prats-Galino A (2013) Endoscopic endonasal anatomy of superior orbital fissure and
938
5. 6.
7.
8.
9.
10.
11.
12.
13.
Acta Neurochir (2015) 157:935–938 orbital apex regions: critical considerations for clinical applications. Eur Arch Otorhinolaryngol 270(5):1643–1649 Dolenc VV (1994) Frontotemporal epidural approach to trigeminal neurinomas. Acta Neurochir (Wien) 130(1–4):55–65 Janjua RM, Wong KM, Parekh A, van Loveren HR (2010) Management of the great mimicker: Meckel cave tumors. Neurosurgery 67(2 Suppl Operative):416–421 Jouanneau E, Simon E, Jacquesson T, Sindou M, Tringali S, Messerer M, Berhouma M (2014) The endoscopic endonasal approach to the Meckel’s cave tumors: surgical technique and indications. World Neurosurg 82(6S):S155–S161 Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R (2005) Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus 19(1):E6 Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Gardner P, Osawa S, Seker A, Rhoton AL (2009) The front door to Meckel’s cave: an anteromedial corridor via expanded endoscopic endonasal approach- technical considerations and clinical series. Neurosurgery 64(3 Suppl):ons71–ons82, discussion ons82–83 Muto J, Kawase T, Yoshida K (2010) Meckel’s cave tumors: relation to the meninges and minimally invasive approaches for surgery: anatomic and clinical studies. Neurosurgery 67(3 Suppl Operative):ons291–ons298, discussion ons298–299 Rhoton AL (2002) The cavernous sinus, the cavernous venous plexus, and the carotid collar. Neurosurgery 51(4 Suppl):S375– S410 Roche P-H, Troude L, Peyriere H, Noudel R (2014) The epidural approach to the Meckel’s cave: a how I do it. Acta Neurochir (Wien) 156(1):217–220 Rohde V, Schaller K, Hassler W (1995) The combined pterional and orbitocygomatic approach to extensive tumours of the lateral and latero-basal orbit and orbital apex. Acta Neurochir (Wien) 132(1–3):127–130
Comment The authors have to be congratulated for their short, clear and objective technical note on the endoscopic splanchnocranial approach to skull base CN V schwannomas (peripheral type). It goes without saying that the approach to skull base pathologies should be chosen according to the individual case so that it is the least traumatic and most successful. The presented schwannoma originating from V2 could also be easily totally resected via the extradural transcranial approach. However, the transsplanchnocranial endoscopic approach used in this case is superior. It also has to be mentioned that the consistency of the tumor as well as its location and size should be taken into consideration when determining which approach would be best for the individual case. The case so neatly presented here does show a contrast with a giant CN V schwannoma—extending from the middle into the posterior cranial fossa through Meckel’s cave—which is much more easily totally resected via the transcranial epidural approach in one stage. This holds even more for schwannomas originating from the sympathetic cords accompanying the ICA. These tumors are usually extremely hard and necessitate the widest possible epidural approach. The difference in size, location and consistency of the tumors clearly point to the fact that surgeon(s) dealing with skull base pathologies have to be familiar with transcranial epidural as well as splanchnocranial-endoscopic approaches. Adherence to only one approach or the other—which still exists—will soon not be enough for the surgery in this field. A prerequisite for using one or the other approach, or set of approaches, is knowledge of the relevant microanatomy. It has to be mentioned that with the extended reach of either approach the teamwork of specialists is beneficial in Binoperable^ cases of skull base tumors. The Bcaptain^ of the team involved in surgery should be chosen according to the location and size of the lesion. The Bcaptain^ should also be responsible for the entire postoperative treatment and patient care. V. Dolenc Ljubljana, Slovenia
TECHNICAL NOTE - NEUROSURGICAL TECHNIQUES
Total removal of a trigeminal schwannoma via the expanded endoscopic endonasal approach. Technical note Timothée Jacquesson 1,2 & Moncef Berhouma 1 & Thiébaud Picart 1 & Emmanuel Jouanneau 1
Received: 14 January 2015 / Accepted: 19 March 2015 / Published online: 7 April 2015 # Springer-Verlag Wien 2015
Abstract Background Because of their deep location surrounded by closed numerous neurovascular structures, skull base tumors of the cavernous sinus are still difficult to manage. Recently, the endoscopic endonasal approach commonly used for pituitary tumor resection has been Bexpanded^ to the parasellar, infratemporal and orbital compartments with some advantages compared to the intracranial route. Methods The authors reported the case of a 49-year-old male presenting a large extradural tumor of the left cavernous sinus with extensions toward the orbit, sphenoid sinus and infratemporal fossa. His ophthalmological examination was normal, and the body CT scan revealed no primary neoplasm. Results In this operative video, the approach is described step by step with surgical nuances. The endoscopy provided a close-up panoramic view and various angles of vision. Also, it avoided an invasive craniotomy, cerebral retraction and cranial nerves damages. Thus, it allowed the total removal of this tumor originating from the maxillary branch of the trigeminal nerve. The pathologic examination confirmed a schwannoma.
Conclusion The expanded endoscopic endonasal approach provides an interesting corridor to cavernous sinus tumors with satisfactory control of extensions inferiorly toward the infratemporal fossa, anteriorly via the superior orbital fissure and medially within the sphenoid. Finally, the skull base surgeon has to master this anterior endoscopic route as well as all the other Bopen^ transcranial skull base approaches to propose the best surgical route fitting the tumor characteristics. Keywords Skull base . Schwannoma . Cavernous sinus . Meckel’s cave . Endoscopy . Endonasal
Introduction
Electronic supplementary material The online version of this article (doi:10.1007/s00701-015-2409-5) contains supplementary material, which is available to authorized users.
Skull base tumors growing from the cavernous sinus or Meckel’s cave are difficult to manage because of their close relationships with the internal carotid artery (ICA) and IIIrd to VIth cranial nerves [2, 3, 6, 11]. Biopsy or removal of such symptomatic or growing tumors has already been described via invasive classical subtemporal approaches or the percutaneous Hartel technique [3, 5, 10, 12, 13]. Recently, the endoscopic endonasal approach commonly used for pituitary tumor resection has been Bexpanded^ to the parasellar, infratemporal and orbital compartments with some advantages compared to the transcranial route [1, 4, 7–9].
* Timothée Jacquesson [email protected]
Materiel and methods
1
Multidisciplinary Skull Base Unit, Department of Neurosurgery B, Neurological Hospital Pierre Wertheimer, Hospices Civils de Lyon, 59 Bd Pinel, 69677 Lyon Cedex, France
2
Department of Anatomy, University of Lyon 1, 8 Avenue Rockefeller, 69003 Lyon, France
We reported the case of a 49-year-old male who presented a left arm paresthesia. Then, cerebral imaging incidentally discovered an extradural large tumor of the left cavernous sinus, with moderate heterogeneous gadolinium enhancement and extensions toward the pterygopalatine fossa and the orbit
936
Acta Neurochir (2015) 157:935–938
Fig. 1 Preoperative cerebral T1-weighted MRI with axial (a), sagittal (b) and coronal (c) reconstructions showing an extradural cavernous sinus tumor with moderate heterogeneous gadolinium enhancement and well-defined limits suggesting a nonaggressive tumor
Fig. 2 Preoperative cerebral CT scan with axial (a), sagittal (b) and coronal (c) reconstructions showing a cavernous sinus tumor extending toward the orbit, pterygopalatine fossa and sphenoid sinus. There was a bone lysis of the orbital posterior wall and the temporal fossa excluding the clivus
(Figs. 1 and 2). His ophthalmological examination was normal, particularly the visual acuity and ocular motility. The body CT scan revealed no primary neoplasm. Thus, an expanded endoscopic endonasal approach was performed to achieve an optimal resection and to obtain histological evidence (Video 1). The patient was informed and agreed.
Results
Fig. 3 Endoscopic operative view. After a left uninostril trans-sphenoidal approach, the tumor was progressively discovered. The expected landmarks were identified: the orbital apex and posterior ethmoid superiorly, the sphenoid sinus medially and the pterygopalatine fossa with its sphenopalatine artery inferiorly
After general anesthesia, the patient was positioned supine, and his head was turned toward the operator as for Bpituitary^ surgery. Intraoperative monitoring of the left VIth nerve and MRI guidance were used. On the left side, a uninostril corridor with a short 0° lens allowed for a middle turbinectomy, total ethmoidectomy, maxillotomy and sphenoidotomy. This led to gradually identify the limits of the tumor as well as the surrounding landmarks: the orbital apex, pterygopalatine fossa, sphenoid sinus and anterior cranial base (Fig. 3). The long 0° lens was secured by a self-retaining holder, which allowed a single operator to work with both hands free. The Doppler device was very useful to localize the
Acta Neurochir (2015) 157:935–938
937
Fig. 4 Postoperative cerebral imaging. A cerebral CT scan (a) was performed 1 day after the surgery and showed no bleeding. The surgical corridor included a posterior ethmoidectomy and orbital apex and infratemporal fossa opening. The handiness was increased by resection of the posterior part of the nasal septum. Working through the contralateral
nostril also allowed an enlarged lateral access. A cerebral MRI (b and c) was performed 1 year after the surgery and showed postoperative rearrangements inside the previous tumor location with an inflammatory mucosa but no obvious residual tumor
sphenopalatine artery and the vertical paraclival portion of the ICA. The tumor anterior wall was cut, and a soft lesion was found. Thus, the removal was begun efficiently with suction and ultrasonic devices. The tumor was gradually released with the endoscopic instruments thanks to an extracapsular cleavage plane around it (Video 1). The resection was achieved by alternating tumor partition and dissection. The close-up view and 30° angle of vision of the endoscope permitted the removal of a far lateral residue. Finally, the resection appeared macroscopically complete and this tumor originated from the maxillary branch of trigeminal nerve V2. The closure with bio-glue (Tissucol®, Baxter) was simple as there was no cerebrospinal fluid leakage. The patient was discharged after 4 days with a partial hypoesthesia of the left maxillary nerve territory. The pathologist confirmed a schwannoma, and the 1-year postoperative MRI showed postoperative rearrangements without evidence of residue (Fig. 4).
craniotomy, cerebral retraction and cranial nerve morbidity. Also, it permits satisfactory control of tumor extensions inferiorly in the pterygopalatine fossa anteriorly toward the orbit or medially within the sphenoid [7–9]. Nonetheless, it is not appropriate for hard or fibrous tumors with lateral or superior extension; this is even more the case for intradural locations lateral to the ICA. The risk of cerebrospinal fluid leak always has to be kept in mind for such endoscopic skull base approaches.
Conclusion Finally, the expanded endoscopic endonasal approach provides an interesting access to extradural soft tumors of the cavernous sinus with inferior, anterior and medial extensions. The skull base surgeon has to master this anterior route as well as all the other open approaches to provide the best surgical route fitting the tumor characteristics.
Discussion We report our experience with total removal of a left cavernous sinus tumor via the expanded endoscopic endonasal approach. These tumors growing from the middle cranial fossa toward the sphenoid or orbit can be efficiently reached by this new anterior endoscopic approach [7, 9]. Although classical pterional approaches provide access to the cavernous sinus, Meckel’s cave and orbit, they require crossing cranial nerves and the ICA, so inferior or medial tumor extensions are difficult to control [10, 12]. Thus, the recent expansion of the trans-sphenoidal Bpituitary^ approach brings a new, safe corridor to the parasellar area, orbit and pterygopalatine or infratemporal fossas. With its close-up panoramic view, angle of vision and dedicated instruments, the endoscopy permits overcoming some of the difficulties encountered in microsurgical approaches. In fact, this route avoids an invasive
Conflicts of interest None.
References 1.
2.
3. 4.
Alfieri A, Jho HD (2001) Endoscopic endonasal approaches to the cavernous sinus: surgical approaches. Neurosurgery 49(2):354– 360, discussion 360–362 Ammirati M, Bernardo A (2007) Anatomical study of the superior orbital fissure as seen during a pterional approach. J Neurosurg 106(1):151–156 Beck DW, Menezes AH (1987) Lesions in Meckel’s cave: variable presentation and pathology. J Neurosurg 67(5):684–689 Dallan I, Castelnuovo P, de Notaris M, Sellari-Franceschini S, Lenzi R, Turri-Zanoni M, Battaglia P, Prats-Galino A (2013) Endoscopic endonasal anatomy of superior orbital fissure and
938
5. 6.
7.
8.
9.
10.
11.
12.
13.
Acta Neurochir (2015) 157:935–938 orbital apex regions: critical considerations for clinical applications. Eur Arch Otorhinolaryngol 270(5):1643–1649 Dolenc VV (1994) Frontotemporal epidural approach to trigeminal neurinomas. Acta Neurochir (Wien) 130(1–4):55–65 Janjua RM, Wong KM, Parekh A, van Loveren HR (2010) Management of the great mimicker: Meckel cave tumors. Neurosurgery 67(2 Suppl Operative):416–421 Jouanneau E, Simon E, Jacquesson T, Sindou M, Tringali S, Messerer M, Berhouma M (2014) The endoscopic endonasal approach to the Meckel’s cave tumors: surgical technique and indications. World Neurosurg 82(6S):S155–S161 Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R (2005) Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus 19(1):E6 Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Gardner P, Osawa S, Seker A, Rhoton AL (2009) The front door to Meckel’s cave: an anteromedial corridor via expanded endoscopic endonasal approach- technical considerations and clinical series. Neurosurgery 64(3 Suppl):ons71–ons82, discussion ons82–83 Muto J, Kawase T, Yoshida K (2010) Meckel’s cave tumors: relation to the meninges and minimally invasive approaches for surgery: anatomic and clinical studies. Neurosurgery 67(3 Suppl Operative):ons291–ons298, discussion ons298–299 Rhoton AL (2002) The cavernous sinus, the cavernous venous plexus, and the carotid collar. Neurosurgery 51(4 Suppl):S375– S410 Roche P-H, Troude L, Peyriere H, Noudel R (2014) The epidural approach to the Meckel’s cave: a how I do it. Acta Neurochir (Wien) 156(1):217–220 Rohde V, Schaller K, Hassler W (1995) The combined pterional and orbitocygomatic approach to extensive tumours of the lateral and latero-basal orbit and orbital apex. Acta Neurochir (Wien) 132(1–3):127–130
Comment The authors have to be congratulated for their short, clear and objective technical note on the endoscopic splanchnocranial approach to skull base CN V schwannomas (peripheral type). It goes without saying that the approach to skull base pathologies should be chosen according to the individual case so that it is the least traumatic and most successful. The presented schwannoma originating from V2 could also be easily totally resected via the extradural transcranial approach. However, the transsplanchnocranial endoscopic approach used in this case is superior. It also has to be mentioned that the consistency of the tumor as well as its location and size should be taken into consideration when determining which approach would be best for the individual case. The case so neatly presented here does show a contrast with a giant CN V schwannoma—extending from the middle into the posterior cranial fossa through Meckel’s cave—which is much more easily totally resected via the transcranial epidural approach in one stage. This holds even more for schwannomas originating from the sympathetic cords accompanying the ICA. These tumors are usually extremely hard and necessitate the widest possible epidural approach. The difference in size, location and consistency of the tumors clearly point to the fact that surgeon(s) dealing with skull base pathologies have to be familiar with transcranial epidural as well as splanchnocranial-endoscopic approaches. Adherence to only one approach or the other—which still exists—will soon not be enough for the surgery in this field. A prerequisite for using one or the other approach, or set of approaches, is knowledge of the relevant microanatomy. It has to be mentioned that with the extended reach of either approach the teamwork of specialists is beneficial in Binoperable^ cases of skull base tumors. The Bcaptain^ of the team involved in surgery should be chosen according to the location and size of the lesion. The Bcaptain^ should also be responsible for the entire postoperative treatment and patient care. V. Dolenc Ljubljana, Slovenia
