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Endoscopic Strip Craniectomy

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What is endoscopic strip craniectomy?

An endoscopic strip craniectomy is a surgery to remove a fused suture in a baby with craniosynostosis. An endoscopic strip craniectomy is different from the open remodeling technique because your baby wears a helmet to mold their head to a more normal shape in the months after surgery. The open technique may use resorbable plates and screws to reshape the head during the operation. Open surgery requires a larger cut (incision) in the scalp, while endoscopic strip craniectomy uses two smaller incisions and an endoscope camera for the surgeon to perform the procedure.

Endoscopic strip craniectomy may be an option for babies with sagittal or lambdoid craniosynostosis depending on their age.

  • Watch a video in which Dr. Richard Hopper discusses treatment comparisons for sagittal synostosis.

How does it work?

Surgery

An experienced craniofacial plastic surgeon and a neurosurgeon work as a team in the operating room from the beginning to the end of the case, performing all of the surgery. The craniofacial plastic surgeon makes two small incisions in the top of your baby’s head to separate the skin and other soft tissue from the bone underneath.

Next the neurosurgeon makes small holes in the skull or enters the skull through your baby’s soft spot (fontanelle). The neurosurgeon uses an endoscope to separate the dura mater from the inside of the skull to free the bone. Then the neurosurgeon cuts around the fused suture and takes out this strip of bone.

With the fused suture gone, the neurosurgeon separates more of the dura mater from the inside of the skull, moving toward the ears. Then the plastic surgeon removes two wedges of bone from each side of the head.

The wedges are cut into pieces and then put back into places where bone was removed, starting from the top, to help in healing. The incisions are closed with resorbing sutures. The removed pieces of skull bone allow your baby’s skull to expand as the brain grows and to be molded into a more normal and functional shape with a removable helmet. Over time, the pieces of bone will grow together to protect their brain.

After surgery, most babies spend one night in the intensive care unit and one night in a regular hospital room before going home.

Helmet

About two weeks after surgery, your baby will wear a helmet to put gentle pressure on their skull. This molds their head to a more normal shape as their skull heals and grows. It also keeps the suture from fusing again too soon.

This part of the treatment is called helmet therapy or cranial orthosis. In the endoscopic technique, both surgeons are important but the experienced orthotist who creates and fits the molding helmet is also essential. Our two orthotists who perform the post-operative molding are very experienced with helmet technology.

Before surgery, you will meet with an orthotist who will explain how the helmet works and how to use it.

About 10 days after surgery, your baby returns to see the orthotist. This person does a laser scan to create a picture of your baby’s head to make a custom helmet.

The helmet is delivered within about a week. We check to make sure it fits well. Then we see your baby for follow-up visits every one to two weeks to check that the helmet is molding their head the way we want. 

Babies wear the helmet for at least three months and sometimes for up to a year. Some babies need a new helmet made after about six months to keep up with the growth of their head. Your baby will wear the helmet all the time, except during bathing.

Who needs endoscopic strip craniectomy?

An endoscopic strip craniectomy is only a treatment option for babies who:

  • Have a fused sagittal or lambdoid suture.
  • Are 5 months old or younger. After this age, the head is not growing as fast, so the helmet is not likely to work as well.

Even if your baby fits both of these requirements, you can choose for your baby to have open remodeling surgery instead. The open method also works well to reshape the head and does not require the use of a helmet afterwards. Some of the benefits and risks differ. 

Research and experience are not clear as to whether there is any difference in the final outcome between endoscopic strip craniectomy and open surgery for these babies. We offer both endoscopic strip craniectomy and open surgery because our team is experienced and comfortable performing either procedure, recognizing that parents should have the chance to decide what is best for their child and family. The next section explains more about how the two options compare.

What are the benefits of endoscopic strip craniectomy?

Results to date suggest that endoscopic strip craniectomy followed by a helmet works as well as open surgery for babies up to age 5 months with a fused sagittal or lambdoid suture.

The benefits of the endoscopic method over the open technique may include:

  • Smaller incisions and less scarring
  • Less bleeding, so less chance of a blood transfusion
  • Less time in surgery
  • Shorter hospital stay

The main benefit of the open method is that your baby does not need to wear a helmet after surgery and does not need to return for weekly helmet check visits. In open surgery, surgeons make more cuts in the bone than in the endoscopic technique but then use special instruments to reshape the bone into a more round and normal shape.

Occasionally, resorbable plates and screws hold the new head shape while the bone heals. The plates and screws are made of a special material that breaks down and dissolves completely in one or two years. 

The best method is the one that works best for your baby and for your family. Talk with your child’s team in more detail about both options so you can decide together which is the right option for you. Our surgeons and social workers can give you both information and support to help you make a decision.

What is your experience with endoscopic strip craniectomy?

We began offering endoscopic strip craniectomy in January 2012 after evaluating that this procedure is safe and effective. The endoscopic technique uses the same skills and technology our team needs for longstanding cranial surgeries. Seeing more than 70 new children with craniosynostosis each year, our program is one of the largest in the country. Our expertise and experience has helped us determine which babies are most likely to benefit from endoscopic strip craniectomy. 

Our team at Seattle Children’s designed one of the first molding helmets available for the treatment of children with deformational plagiocephaly (back-of-the-head flattening), which uses the same principles as the helmets used after endoscopic craniectomy.

Who is on the endoscopic craniectomy team?

Two of our plastic surgeons and two of our neurosurgeons work in teams to perform endoscopic strip craniectomies.

We have two craniofacial orthotists who work with patients who wear helmets. After surgery, both your plastic surgeon and neurosurgeon will also take part in your baby’s follow-up visits to make sure the helmet is working well.

The entire Craniofacial team at Children’s helps you and your family through the surgery, hospital stay and follow-up visits. Before surgery, you see a craniofacial pediatrician. This doctor checks your baby’s condition and talks with you about treatment options.

We connect you with other team members based on your baby’s and family’s needs. All families who are deciding on surgery for craniosynostosis meet with a social worker from the Craniofacial Center.

Your social worker can help with a range of topics, such as:

  • Asking the surgeons questions, talking about concerns and thinking about which surgery to choose
  • Planning so that treatment goes as smoothly as possible for your family
  • Coping during treatment, including getting your child to wear their helmet
  • Dealing with time off work to come to surgery and follow-up visits
  • Getting resources to travel from home to the hospital
  • Dealing with your insurance and any worries about costs

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