Вы находитесь на странице: 1из 4

Acta Neurochir (2016) 158:2155–2158

DOI 10.1007/s00701-016-2895-0

HOW I DO IT - NEUROSURGICAL TECHNIQUES

Purely endoscopic resection of pineal region tumors


using infratentorial supracerebellar approach: How I do it
Ye Gu 1 & Fan Hu 1,2 & Xiaobiao Zhang 1,2

Received: 22 April 2016 / Accepted: 11 July 2016 / Published online: 9 August 2016
# Springer-Verlag Wien 2016

Abstract Relevant surgical anatomy


Background Infratentorial supracerebellar approach via mi-
croscope still has some limitations in resection of pineal re- The pivotal neurostructures involved in the pineal region con-
gion tumors. sist of the posterior wall of the third ventricle rostrally and
Methods The authors describe a purely endoscopic cerebellar vermis caudally; the splenium of the corpus
infratentorial supracerebellar approach for resection of pineal callosum dorsally; the corpora quadrigemina ventrally; and
region tumors with matched air-driven arm and navigation. the pulvinar and the tentorial incisura bilaterally. The
The lateral oblique position is adopted. The same bimanual quadrigeminal cistern, corresponding to pineal region, com-
microsurgical techniques are utilized in this endoscopic ap- municates with the posterior pericallosal cistern superiorly, the
proach with panoramic view and satisfying comfort. ambient cisterns laterally, the velum interpositum anteriorly
Conclusions Purely endoscopic resection of pineal region tu- and superior cerebellar cistern posteriorly.
mors using infratentorial supracerebellar approach is feasible. The pineal region contains the site of convergence of the
It may be considered as an alternative approach for certain internal cerebral veins, basal veins of Rosenthal, and multiple
pineal region tumors. other tributaries of the galenic complex. Among the galenic
tributaries, the precentral cerebellar vein originating on the
superior cerebellar peduncles and terminates with the superior
Keywords Endoscope . Infratentorial supracerebellar vermian vein in the great vein is of paramount importance.
approach . Pineal region tumor The arterial structures of the pineal region are the medial
posterior choroidal arteries, arising from the proximal part of
the posterior cerebral artery; they frequently turn forward be-
Electronic supplementary material The online version of this article side the pineal body in the quadrigeminal cistern and reach the
(doi:10.1007/s00701-016-2895-0) contains supplementary material, velum interpositum.
which is available to authorized users. Mostly, pineal region tumors are located in the
midportion of the third ventricle and posteriorly to com-
* Xiaobiao Zhang press the anterior portion of the cerebellum; they are sel-
xiaobiao_zhang@163.com
dom beyond the undersurface of the velum interpositum,
1
even though they attach to it at times. The tumor blood
Department of Neurosurgery, Zhongshan Hospital, Fudan
University, 180 Fenglin Road, 200032 Shanghai, People’s Republic
feeding comes mainly from the posterior medial and lateral
of China choroidal arteries, with anastomoses to the pericallosal ar-
2
Shanghai Key Lab of Medical Image Computing and Computer
teries and quadrigeminal arteries. Vein of Galen, internal
Assisted Intervention, Shanghai Medical College, Fudan University, cerebral veins, Rosenthal vein, and precentral cerebellar
Shanghai, People’s Republic of China vein are involved in the site of the tumor.
2156 Acta Neurochir (2016) 158:2155–2158

Description of the technique Storz GmbH & Co., Tuttlingen, Germany) held in a matched,
air-driven arm was introduced above the surgeon’s hands. The
For the infratentorial supracerebellar approach, after intuba- monitor was put in front of the surgeon. The surgical proce-
tion anesthesia, the patient’s head was fixed with a three-pin dure was performed using the same microsurgical technique
Mayfield holder. The patient was positioned lateral oblique but illuminated by endoscope, which enabled a panoramic
with the upper body elevated 15 degrees, to benefit venous scenario and sharp details of the operative field along the
drainage. The neck was slightly flexed to enhance the sur- midline trajectory. To open the quadrigeminal region, some
geon’s comfort when approaching the tumor [3]. The antisep- bridging veins between the superior surface of the cerebellum
tic preparation was completed routinely. The size of the bone and the tentorium were gradually sacrificed without any ad-
flap was approximately 4 × 3 cm, which crossed over the verse consequence. We do not systematically coagulate and
transverse sinus and contained the torcular region. The dura divide the vermian veins. Thereafter, the supracerebellar
was opened in and turned over to the margin of the transverse infratentorial corridor was gained without using a brain retrac-
sinus (Fig. 1). After fixing the dura with suturing, an endo- tor. Next, the thickened and opaque arachnoid membrane over
scope (4-mm diameter, 18-cm length, 0-degree lenses; Karl the quadrigeminal cistern was opened using microdissection

Fig. 1 a Layout in the operating room. b The patient position and the skin incision. c The bone flap, TS transverse sinus, SS sagittal sinus. d The dura
incision
Acta Neurochir (2016) 158:2155–2158 2157

techniques, thus uncovering the precentral cerebellar vein, other than retraction, is essential; (3) the veins in the path to the
which was sacrificed with impunity to further expose the tu- tumor must be protected as much as possible to prevent draining
mor in the pineal region. Followed by intracapsular debulking, obstruction and consequent edema; (4) no resistance from the
the superior and lateral margins of the tumor were dissected proximate side is permitted when advancing the endoscope.
from the surrounding velum interpositum, pulvinar, walls of
the third ventricle, and medial posterior choroidal artery.
Accordingly, the tumor was totally extirpated in a piecemeal Specific perioperative considerations
fashion. The posterior wall of the third ventricle was opened,
so that the contained vital neurostructures were observed. The The perioperative considerations were the same as routine
endoscope was used to further detect any residual portions, surgical treatment of pineal tumors.
which were bound to be resected off, and verify total tumor
removal. Equally important, the intraoperative clot near the
aqueduct of Sylvius was removed, thus reducing the probabil-
ity of postoperative hydrocephalus. After hemostasis was Specific information to give to the patient
achieved, the dura was sutured in a watertight manner and about surgery and potential risks
the bone flap was repositioned (Video 1). If the patient pre-
sents with hydrocephalus, endoscopic third ventriculostomy Surgical excision plays an irreplaceable role in the therapeutic
(ETV) can be performed 1 week before tumor removal. modalities of certain pineal region tumors [7]. An endoscope is
an alternative surgical instrument with inherent advantages
from different lighting principle with flashlight effect. Specific
Indications complications of the endoscope itself could be avoided owing
to our extensive experience from endoscopic skull base surgery.
Tumors with both cystic and solid consistency located within However, the clinical outcome may not be improved affirma-
the quadrigeminal cistern (which is not beyond the splenium tively and the operative complications may not be avoided
of the corpus callosum and the Galenic complex superiorly, absolutely.
the quadrigeminal plate inferiorly and the pulvinar bilaterally)
can be removed via this endoscopic infratentorial–
supracerebellar approach [1, 2, 5–7]. The tumors with soft Key points
and moderate texture but without artery encasement may be
eligible for the technique. The tumors with massive calcifica- 1. The lateral oblique position facilitates the surgeon’s ma-
tion or rich blood supply are not good candidates. nipulation and the layout of the endoscope and naviga-
tion. The chief surgeon’s comfortable experience may be
promptly improved.
Limitations 2. The incision and bone flap are the same or slightly small-
er than an operation with a microscope.
Limitations of the infratentorial supracerebellar approach have 3. An air-driven arm plays a crucial role in endoscopic
been profoundly discussed as the limitation of available surgical surgery. An air-driven arm ensures steady fixation of
field and inconvenience in the case of confronting a very steep the endoscope, thus eliminating manual handling and
tentorium [4]. Despite offering a panoramic view and clear freeing the chief surgeon’s bimanual operation.
details, the current endoscope has its inherent shortcoming of 4. The navigation confirms the initial direction towards to
two-dimensional images and blind region in proximity of the quadrigeminal cistern and the tumor, thus eliminating
lens body. The main cause of transferring to microscope is the unintended injury.
unclear vision hindered from bleeding and unskilled manipula- 5. The endoscope actually shortens the working distance
tions. Hence, the learning curve of endoscopy is imperative. and offers better comfort to the surgeon compared with
a microscope because the chief surgeon may stand closer
to the surgical field.
How to prevent complications 6. Panoramic and extended views afforded by an endo-
scope promote safe surgical dissection and resection.
Efforts should be constantly made to avoid complications as The same bimanual microsurgical techniques are used
follows: (1) the transverse sinus can be free of injury due to in this endoscopic approach.
the proper bone opening; (2) adequate cerebellar relaxation, 7. When advancing the endoscope, prevent both the tip and
allowed by gravity, mannitol, slightly hyperventilation, cerebro- body of the endoscope from injuring adjacent
spinal fluid releasing and sacrifice of few superior bridging veins neurovascular structures, with no sparing effort.
2158 Acta Neurochir (2016) 158:2155–2158

8. The flashlight effect enabled by an endoscope may reduce 2. Gore PA, Gonzalez LF, Rekate HL, Nakaji P (2008)
Endoscopic supracerebellar infratentorial approach for pineal
the retraction of the cerebellum after crossing the culmen.
cyst resection: technical case report. Neurosurgery 62:108–
9. Proprioception with moving of the endoscope may offset 109, Discussion 109
the disadvantage of two-dimensional vision. 3. Gu Y, Zhang XB, Yu Y (2013) Endoscope-assisted microsurgical
10. The learning curve of using an endoscope is imperative. resection for pineal region tumors: preliminary experience. J
Pediatr Oncol 1:17–22
Compliance with ethical standards This study protocol was approved 4. Hart MG, Santarius T, Kirollos RW (2013) How I do it—pineal
by the Research Ethics board in our hospital. All patients signed a written surgery: supracerebellar infratentorial versus occipital transtentorial.
informed consent form that they will be enrolled in this study. Acta Neurochir 155:463–467
5. Sood S, Hoeprich M, Ham SD (2011) Pure endoscopic removal of
Conflict of interest None. pineal region tumors. Childs Nerv Syst 27:1489–1492
6. Thaher F, Kurucz P, Fuellbier L, Bittl M, Hopf NJ (2014) Endoscopic
surgery for tumors of the pineal region via a paramedian
infratentorial supracerebellar keyhole approach (PISKA).
References Neurosurg Rev 37:677–684
7. Tseng KY, Ma HI, Liu WH, Tang CT (2012) Endoscopic
1. Broggi M, Darbar A, Teo C (2010) The value of endoscopy in the supracerebellar infratentorial retropineal approach for tumor resec-
total resection of pineocytomas. Neurosurgery 67:s159–s165 tion. World Neurosurg 77:391–399

Вам также может понравиться