- Department of Surgical Specialties, Neurosurgery Teaching and Assistance Unit, Pedro Ernesto University Hospital, Rio de Janeiro State University, Rio de Janeiro, RJ, Brazil
- Department of Physiological Sciences, Roberto Alcântara Gomes Biology Institute, Rio de Janeiro State University, Rio de Janeiro, RJ, Brazil
- Nervous System Electric Stimulation Laboratory (LabEEL) - Neurosurgery Teaching and Assistance Unit, Pedro Ernesto University Hospital, Rio de Janeiro State University, Rio de Janeiro, RJ, Brazil
Pedro Henrique da C. F. Pinto
Department of Physiological Sciences, Roberto Alcântara Gomes Biology Institute, Rio de Janeiro State University, Rio de Janeiro, RJ, Brazil
Nervous System Electric Stimulation Laboratory (LabEEL) - Neurosurgery Teaching and Assistance Unit, Pedro Ernesto University Hospital, Rio de Janeiro State University, Rio de Janeiro, RJ, Brazil
DOI:10.4103/2152-7806.193926Copyright: © 2016 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Pedro Henrique da C. F. Pinto, Flavio Nigri, Gabriel N. Gobbi, Egas M. Caparelli-Daquer. Conversion technique from neuroendoscopy to microsurgery in ventricular tumors: Technical note. 11-Nov-2016;7:
How to cite this URL: Pedro Henrique da C. F. Pinto, Flavio Nigri, Gabriel N. Gobbi, Egas M. Caparelli-Daquer. Conversion technique from neuroendoscopy to microsurgery in ventricular tumors: Technical note. 11-Nov-2016;7:. Available from: http://surgicalneurologyint.com/surgicalint_articles/conversion-technique-neuroendoscopy-microsurgery-ventricular-tumors-technical-note/
Background:Ventricular tumors represent a major neurosurgical challenge, making endoscopic approach an invaluable tool as it gained importance due to technological advances. Nevertheless, the method is not exempt of risk and limitations, sometimes requiring an open surgery. Thus, initial measurements must be adopted in order to simplify an eventual need for conversion to open craniotomy.
Methods:Here, we describe a series of 6 patients with ventricular tumors approached by neuroendoscopy where the conversion to microsurgery turned out to be necessary. Patients’ average age was 59.5 years (39–75 years). Average tumoral size was 17.8 mm (15–21 mm). There were 2 cases of lateral ventricle subependymoma and 4 cases of third ventricle colloid cysts. A standard surgical incision was performed in the coronal direction, allowing lateral expansion to 10 cm. Moreover, the endoscopic burr hole was enlarged to a 5 cm craniotomy. A small enlargement of the endoscopic cortical access was performed to gain a transcortical microsurgical corridor to the ventricular cavity. The need for conversion arose due to high consistency of the tumor (3 cases), technical problems (2 cases), and cortical collapse (1 case).
Results:There was one case of cerebrospinal fluid fistula and infection and one case of transitory memory disturbance. In both the cases, we obtained a complete functional recovery. Clinical and radiological follow-up showed total tumor removal with no recurrences.
Conclusions:The technique herein described was easy to perform, promptly bypassed the endoscopic limitations, and gathered excellent surgical results. The possibility of adapting the method to other tumor locations may be considered.
Keywords: Conversion technique, microsurgery, neuroendoscopy, open craniotomy, ventricular tumors
Ventricular tumors comprise a variety of benign and malignant mass lesions located within the ventricular cavity or arising from neural structures forming the ventricular system. These tumors are rare comprising less than 1% of all intracranial lesions.[
MATERIALS AND METHODS
From July 1995 to August 2015, 103 patients with ventricular tumors underwent endoscopic surgery for different purposes, e.g., hydrocephalus, biopsy, septostomy, and tumor resection. In 6 patients, the procedure was converted to open craniotomy. There were 4 men and 2 women, ranging in age from 39 to 71 years (mean, 58.83 years). Clinical summary is presented in
All patients followed the same surgical protocol of supine position, head 45° flexed. The entry point was chosen depending on the tumor side and location. For colloid cysts, the entry point was placed 4–5 cm anterior to the coronal suture and 3 cm lateral to the midline. For tumors located in the frontal horn of lateral ventricle, the Kocher's point was chosen [
Description of the conversion technique. Patient in the supine position 45° angle head flexed. (a) 5 cm skin mark parallel to the coronal suture and an additional extension of 2.5 cm to each side to be prepared for conversion. (b) 5 cm skin incision and a burr hole to perform neuroendoscopy. (c) Expansion of the incision and a 5 cm diameter craniotomy extending from the endoscopic burr hole to perform microsurgery. (d) Operative aspect of incision and craniotomy
Total tumor removal was obtained in all patients as illustrated in case 3 [
Case 3. (a) Routine surgical planning skin mark. (b) The craniotomy flap of 5 cm diameter. (c) Durotomy with exposure of the cortex and the hemostatic sponge sealing the endoscopic cortical access (arrowhead). Anterior positioning of the cerebral spatula fixed by the Layla brace for microsurgical exploration through the endoscopic path. (d) Subependymoma removed after conversion. (e) Axial T1-weighted magnetic resonance imaging obtained 2 months preoperative. (f) Axial computed tomography of the head obtained 3 months after the surgery
Microsurgical resection is the standard technique for ventricular tumor treatment.[
Applied by Dandy[
Considering that the endoscopic approach has the same cortical trajectory as the transcortical transventricular approach, the conversion is made just extending the size of the craniotomy. Instead of the classic incision parallel to the sagittal suture, commonly performed in neuroendoscopy, an incision parallel to the coronal suture is chosen. This allowed extending the incision without passing the anterior hairline in cases of conversion to open craniotomy in all patients of this series. There are no data in the literature defining the best conversion technique, however, the operative technique applied in our patients was satisfactory, easy, and fast to perform. Although simple and probably a logical choice for most neurosurgeons, here, we provide evidence that this surgical option is safe and effective.
The standard conversion technique described in this series was easy to perform, showed excellent clinical and radiological results, bypassed endoscopic limitations, and made possible complete resection of ventricular lesions in all patients. There is little information about conversion technique in the literature, and therefore validation through further studies on the subject is necessary. The possibility of adapting the method according to ventricle locations other than the anterior horn of the lateral ventricle and the third ventricle roof may be considered.
Financial support and sponsorship
Authors received financial support from Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ).
Conflicts of interest
There are no conflicts of interest.
We thank Diego Ramon Nigri for his assistance in preparing and drawing the figures.
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