- Department of Neurosurgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan
Department of Neurosurgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan
DOI:10.4103/2152-7806.94033Copyright: © 2012 Masuda Y. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Masuda Y, Ishikawa E, Takahashi T, Ihara S, Yamamoto T, Zaboronok A, Matsumura A. Dual-port technique in navigation-guided endoscopic resection for intraparenchymal brain tumor. Surg Neurol Int 19-Mar-2012;3:35
How to cite this URL: Masuda Y, Ishikawa E, Takahashi T, Ihara S, Yamamoto T, Zaboronok A, Matsumura A. Dual-port technique in navigation-guided endoscopic resection for intraparenchymal brain tumor. Surg Neurol Int 19-Mar-2012;3:35. Available from: http://sni.wpengine.com/surgicalint_articles/dual-port-technique-in-navigation-guided-endoscopic-resection-for-intraparenchymal-brain-tumor-2/
Background:In navigation-guided endoscopic surgery performed via a single port, the interference of surgical instruments often disturbs the resection and hemostasis.
Case Description:With regard to this, we designed a dual-port technique for navigation-guided endoscopic surgery in a 62-year-old man, with intraparenchymal anaplastic astrocytoma. Two transparent sheaths with Nelaton tubes were inserted in the front of the target lesion via an infinity-shaped burr hole, under the control of the navigation system. The lesion was removed partially using a rigid endoscope and several surgical tools through the bilateral ports. Using the new method, it was convenient to perform hemostasis with bipolar coagulation and aspiration, without any interference from the surgical instruments during the surgery.
Conclusion:The offered dual-port technique may be included in surgery planning for elderly patients or patients in particular conditions, with intraparenchymal brain tumors.
Keywords: High-grade glioma, navigation, neuroendoscopy
Biopsy for diagnosis of intraparenchymal tumors of the central nervous system can be performed by various methods, including needle biopsy, using a stereotactic frame, frameless biopsy with image-guided stereotactic techniques, and open biopsy via a small craniotomy. These methods have advantages and disadvantages in sampling accuracy, approach to deep lesions, and sample volume.[
In recent times, navigation-guided endoscopic surgery has been used for the biopsy or resection of intraparenchymal brain tumors.[
A 62-year-old man was admitted to our hospital with a 10-month history of motor aphasia. He had a past history of bifrontal oligodendroglioma and underwent right frontal lobectomy in another hospital, followed by bifrontal radiation therapy 30 years before the admission. Additionally, he had a lacuna infarction in the left frontal lobe six years before the admission. On admission, he had mild motor aphasia, with 90% Karnofsky Index of Performance Status (KPS). Magnetic resonance (MR) imaging revealed a heterogeneously enhanced mass lesion, 2.8 cm in maximum diameter, in the left frontal lobe. After careful informed consent and discussion of alternatives, the patient selected partial removal using navigation-guided endoscopic technique to prevent the deterioration of his higher functions, rather than the conventional microsurgical removal.
For navigation-guided endoscopic biopsy, the patient's head was fixed with a Mayfield frame under general anesthesia. Two transparent sheaths with diameters of 6.8 mm (Neuroport®, mini size; Olympus Corp., Tokyo) with Nelaton tubes (Fr 18) as alternative inner tubes were inserted into the front of the target lesion via an infinity-shaped burr hole, under control of the navigation system (StealthStation®, Medtronic, Inc., Minneapolis, MN) [
(a, b) Tips of two transparent sheaths with diameters of 6.8 mm (Neuroport® mini size; Olympus Corp., Tokyo) are obliquely cut, and the sheaths are combined with Nelaton tubes (Fr 18) as removal inner tubes. (c) The ports are inserted into the front of the target lesion via an infinity-shaped burr hole under control of the navigation system. (d) Scheme of dual-port technique. The front of the tumor lesion is observed with the rigid endoscope (black tube), with the maximal diameter of 2.7 mm (EndoArm®; Olympus Corp. Tokyo, Japan) through the left port, and the lesion is removed using several surgical instruments (white-gray, blue, and gray bars) via two ports in this scheme
Partial removal, with 40% removal rate, using the technique described earlier for navigation-guided endoscopic surgery, with photodynamic diagnosis (PDD) and intraoperative pathological diagnosis (IPD), was performed. During the surgery, convenient hemostasis using bipolar coagulation and aspiration, without any interference from the surgical instruments, was easy to perform. MR imaging revealed partial resection of the mass lesion after the surgery [
In this article, we have described our first experience of using a dual-port technique in navigation-guided endoscopic resection for an intraparenchymal brain tumor, although for ventricular colloid cysts or for shunt replacement the dual-port technique has been reported previously.[
The conventional microsurgical technique will be a better approach for gross-total removal of intraparenchymal malignant tumors. However, in special cases, such as the one described here, when the patient has a high-risk of deterioration in his higher functions due to a previous history of right frontal lobectomy, the operators will have an alternative to choose such an endoscopic surgery. As mentioned in our previous report, tumor biopsy can be done using the single-port technique.[
The possible disadvantage of the dual-port technique could be that the brain damage caused by this method may be larger near the sheath tracts than in a single-port technique. However, the sum of squares of two fine ports (2 × 0.36 cm2) is smaller than that of a single regular port (0.79 cm2). Moreover, even when using the regular port, the actual severe complication rate is not higher than that of the needle biopsy.[
In conclusion, evaluating the first experience of using the new method in the described case, we conclude that the new dual-port technique in navigation-guided endoscopic resection may be considered as an alternative when planning surgery in elderly patients or patients in particular conditions, with intraparenchymal brain tumors.
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