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CC BY 4.0 · J Neurol Surg B Skull Base 2023; 84(05): 423-432
DOI: 10.1055/a-1886-5500
Original Article

Generating Operative Workflows for Vestibular Schwannoma Resection: A Two-Stage Delphi's Consensus in Collaboration with the British Skull Base Society. Part 1: The Retrosigmoid Approach

Hugo Layard Horsfall 
1   Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
2   Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
,
Danyal Z. Khan
1   Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
2   Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
,
Justin Collins
3   Department of Urooncology, University College London Hospitals National Health Service Foundation Trust, London, United Kingdom
,
Stephen Cooke
4   Department of Neurosurgery, Belfast Health and Social Care Trust, Belfast, United Kingdom
,
Simon R. Freeman
5   Department of Otolaryngology, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Salford, United Kingdom
,
Nihal Gurusinghe
6   Department of Neurosurgery, Lancashire Teaching Hospital, Preston, United Kingdom
,
Susie Hampton
7   Department of Ear, Nose and Throat, Belfast Health and Social Care Trust, Belfast, United Kingdom
,
Carl Hardwidge
8   Department of Neurosurgery, University Hospital Sussex, Brighton, United Kingdom
,
Richard Irving
9   Department of Ear, Nose and Throat, Queen Elizabeth Hospital, Birmingham, United Kingdom
,
Neil Kitchen
1   Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
,
Andrew King
10   Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Manchester, United Kingdom
11   Northern Care Alliance National Health Service Group, University of Manchester, Manchester, United Kingdom
,
Sherif Khalil
1   Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
12   The Royal National Throat, Nose and Ear Hospital, London, United Kingdom
,
Chan H. Koh
1   Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
2   Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
,
Colin Leonard
7   Department of Ear, Nose and Throat, Belfast Health and Social Care Trust, Belfast, United Kingdom
,
Hani J. Marcus
1   Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
2   Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
,
William Muirhead
1   Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
2   Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
,
Rupert Obholzer
1   Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
12   The Royal National Throat, Nose and Ear Hospital, London, United Kingdom
,
Omar Pathmanaban
13   Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Salford, United Kingdom
,
Iain J. A. Robertson
14   Department of Neurosurgery, Nottingham University Hospitals, Nottingham, United Kingdom
,
Jonathan Shapey
15   Department of Neurosurgery, Kings College Hospital, London, United Kingdom
,
Danail Stoyanov
2   Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
,
Mario Teo
16   Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, United Kingdom
,
James R. Tysome
17   Department of Ear, Nose and Throat, Cambridge University Hospitals, Cambridge, United Kingdom
,
Shakeel R. Saeed   *
1   Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
12   The Royal National Throat, Nose and Ear Hospital, London, United Kingdom
,
Patrick Grover   *
1   Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
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Abstract

Objective An operative workflow systematically compartmentalizes operations into hierarchal components of phases, steps, instrument, technique errors, and event errors. Operative workflow provides a foundation for education, training, and understanding of surgical variation. In this Part 1, we present a codified operative workflow for the retrosigmoid approach to vestibular schwannoma resection.

Methods A mixed-method consensus process of literature review, small-group Delphi's consensus, followed by a national Delphi's consensus, was performed in collaboration with British Skull Base Society (BSBS). Each Delphi's round was repeated until data saturation and over 90% consensus was reached.

Results Eighteen consultant skull base surgeons (10 neurosurgeons and 8 ENT [ear, nose, and throat]) with median 17.9 years of experience (interquartile range: 17.5 years) of independent practice participated. There was a 100% response rate across both Delphi's rounds. The operative workflow for the retrosigmoid approach contained three phases and 40 unique steps as follows: phase 1, approach and exposure; phase 2, tumor debulking and excision; phase 3, closure. For the retrosigmoid approach, technique, and event error for each operative step was also described.

Conclusion We present Part 1 of a national, multicenter, consensus-derived, codified operative workflow for the retrosigmoid approach to vestibular schwannomas that encompasses phases, steps, instruments, technique errors, and event errors. The codified retrosigmoid approach presented in this manuscript can serve as foundational research for future work, such as operative workflow analysis or neurosurgical simulation and education.

Keywords

retrosigmoid - translabyrinthine - vestibular schwannoma - skull base surgery - consensus - Delphi

Previous Presentations

This work has not been presented, either partly or wholly.


Authors' Contributions

Study conception and methodology was led by H.J.M., J.C., M.F., M.G., D.Z.K., C.H.K., H.L.H. and W.M. Material preparation, data collection and analysis were performed by H.L.H., D.Z.K., J.C., S.C., S.R.F., N.G., S.H., C.H., R.I., N.K., A.K., S.K., C.H.K., C.L., H.J.M., W.M., R.O., O.P., I.J.A.R., J.S., D.S., M.T., J.R.T., S.R.S., and P.G. contributed to data collection. The first draft of the manuscript was written by H.L.H., H.J.M. and P.G. All authors reviewed and edited subsequent versions of the manuscript. All authors read and approved the final manuscript.


Ethical and Informed Consent

Ethical approval and informed consent were unnecessary due to the nature of the study (consensus process amongst health care professionals).


Data Availability

The data for this article is available upon reasonable request.


* Denotes joint senior authorship.


Supplementary Material



Publication History

Received: 03 March 2022

Accepted: 20 June 2022

Accepted Manuscript online:
28 June 2022

Article published online:
10 October 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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