Bibiana Kotrikova

Diagnostic imaging in the management of craniosynostoses

Craniosynostoses are the most frequent craniofacial malformations. However, with a prevalence of 3–6 cases per 10,000 live births they are amongst the rarely seen diseases and their definite diagnosis thus poses a challenge to the physician. When an abnormal calvarial configuration is detected, a radiological evaluation is necessary to characterize the deformity and to guide the corrective surgical procedure. The demand for clear diagnostic criteria is justified by the severity of the disease and the possible consequences of delayed diagnosis. In addition to the clinical signs (deformation of the head), conventional skull X-rays show typical radiological alterations and are used for basic diagnostics. Diagnostic tests that may be performed to confirm the diagnosis and assess the extent of the problem, include computed tomography (CT), 3D-CT, magnetic resonance imaging (MRI) scans, and ultrasonography. In the present review we will describe the most important clinical and radiological characteristics of craniosynostosis by means of clinical, radiological and operative situs examples.

Development and First Patient Trial of a Surgical Robot for Complex Trajectory Milling

Objective: Todays surgical robots normally perform “simple” trajectories, e.g., assisting as tool-holding devices in neurosurgery, or milling linear paths for cavities in total hip replacement. From a clinical point of view, it is still a complex undertaking to implement robots in the operating room. Until now, robot systems have not been used in patient trials to mill “complex” trajectories, which involve many positional and orientation changes and are often necessary in cranio-maxillofacial (CMF) surgery. This paper presents the RobaCKa surgical robot system, which allows more precise execution of surgical interventions and milling of “complex” trajectories. Materials and Methods: The main components of the RobaCKa system are a (former) CASPAR robot system, a POLARIS system, and a force-torque sensor. Results: In the first patient trial (April 2003) the planned trajectory was executed with an error of 0.66 ± 0.2 mm. Conclusions: The use of former industrial robots for surgical applications is possible but complex. The advantages are improved precision and quality and the possibility of documentation. The use of such systems is normally limited to research institutions or large clinics, because it is hardly possible to implement the necessary technical and logistic efforts in routine surgical work.

Operative correction and follow-up of craniofacial duplication

Background: Anterior craniofacial duplication (diprosopus) is an extremely rare form of conjoined twins. The children share a single trunk with normal extremities and varying degrees of facial malformation. Duplication of specific structures, such as the nose (diprosopus dirrhinus), eyes (diprosopus tetraophthalmus), and ears, is possible. The authors present a case of partial facial duplication (diprosopus dirrhinus) in a male infant. Methods: The clinical and radiographic findings and the surgical correction and follow-up are described. Results: In a single surgical session, the authors were able to achieve not only a functionally but also an aesthetically acceptable result. In the postoperative course, the child showed nearly normal growth and satisfactory psychosocial and motor development. However, 40 months postoperatively, we noticed a tendency of the orbitae to diverge (i.e., toward hypertelorism). Conclusions: The surgical management of complex craniofacial malformations such as diprosopus needs a precise morphologic analysis of the patient’s deformity followed by a clear treatment plan. A staged reconstructive approach is carried out to coincide with facial growth patterns and brain and eye function. If the interorbital distance in our patient increases progressively, a second operation for reduction of the interorbital distance may be necessary.

Chirurgieroboter für Kraniotomien – Risikoanalyse und erster Patientenversuch (Surgical Robot for Craniotomies – Risk Analysis and First Patient Trial)

Abstract Innerhalb des Sonderforschungsbereiches SFB 414 — Informationstechnolgie in der Medizin: Rechner- und Sensorgestützte Chirurgie — wurde RobaCKa = Roboter-assistiertes Chirurgiesystem Karlsruhe) entwickelt. Es dient beispielsweise zum Fräsen von Trajektorien im knöchernen Schädel in der cranio-maxillofacialen Chirurgie. Da es sich bei Robotern um komplexe mechatronische Systeme handelt, ist eine systematische Analyse für fehlerfreies Design, Fehlerdetektion und Qualitätssicherung unumgänglich. In Universitäten und Forschungszentren kann hierfür nicht derselbe Aufwand wie in der Industrie bei der Fertigung von Medizinprodukten betrieben werden, da oft nur ein bis zwei Wissenschaftler an solchen Projekten arbeiten. Trotzdem ist es notwendig, ein Qualitätmanagement zu etablieren, nicht zuletzt da ein solches auch für klinische Studien vorgeschrieben ist. Außerdem vereinfacht es später den möglichen Technologietransfer. Außer den Risikomanagementmethoden werden in dieser Arbeit die Tests an Phantomen, Probanden und eine erste Operation am Patienten beschrieben und die Ergebnisse diskutiert.

Operative correction of conjoined twins fused at head.

A 12-month-old boy with craniofacial duplication (diprosopus dirrhinus) was referred to the University of Heidelberg for operative correction. On examination he had two noses, a supernumerary hypoplastic third orbit in the midline, and an enlarged mouth (figure A). CT imaging showed complete duplication of the nasal skeleton, nasal cavity, the medial part of the maxillary bones, and metopic suture. The duplicated orbital parts of the frontal bone and the duplicated orbital lamina of the ethmoid bone formed the third orbit. For the operative correction of the craniofacial duplication, resection of the redundant midface osseous structures in combination with orbital shifting and reconstruction of the nose was necessary. For correction of the noses and lip, the skin excess was excised corresponding to the bone resection, including the two medial parts of the noses and the excessive tissue of the upper lip, to form a single nose and harmonise the lip (figure B, 12 months after the operation). Operative correction of conjoined twins fused at head