Four‐handed, two‐surgeon microsurgery in neurotology

Since the early 1960s, microsurgical removal has been the standard for curative treatment of vestibular schwannomas and neurotologic skull base lesions. The narrow operative corridor with only one surgeon actively operating sometimes interferes with simultaneous application of standard surgical principles such as suction, counter tension, and dissection and makes attempts at “co‐surgery” into “sequential” surgery. Surgical efficiency is often delayed by the need to change surgical instruments and reorient the surgical field. Methods: In this four‐handed technique, the microscope is arranged with binocular microscope heads and the surgeons facing each other at the head of the patient and operating simultaneously. Results: Since 2006, the authors have operated 97 lesions using the four‐handed technique. The distinct visualization advantage of the 180° binocular arrangement over use of a side arm is that both surgeons have the same stereoscopic perspective. Specific ergonomic advantages were identified for rapid debulking in large tumors, simultaneous neurologic mapping for sharp facial nerve dissection, counter traction for tumor dissection, neurologic tissue retraction/protection for safe bipolar cautery, and real‐time intraoperative consultation/collaboration. Conclusions: Specific technical and microscope arrangements are necessary to utilize the four‐handed technique; however, distinct advantages in tissue handling and surgical efficiency are facilitated.