Comparison of endoscope- versus microscope-assisted resection of deep-seated intracranial lesions using a minimally invasive port retractor system

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OBJECT

Tubular brain retractors may improve access to deep-seated brain lesions while potentially reducing the risks of collateral neurological injury associated with standard microsurgical approaches. Here, microscope-assisted resection of lesions using tubular retractors is assessed to determine if it is superior to endoscope-assisted surgery due to the technological advancements associated with modern tubular ports and surgical microscopes.

METHODS

Following institutional approval of the tubular port, data obtained from the initial 20 patients to undergo transportal resection of deep-seated brain lesions were analyzed in this study. The pathological entities of the resected tissues included metastatic tumors (8 patients), glioma (7), meningioma (1), neurocytoma (1), radiation necrosis (1), primitive neuroectodermal tumor (1), and hemangioblastoma (1). Surgery incorporated endoscopic (5 patients) or microscopic (15) assistance. The locations included the basal ganglia (11 patients), cerebellum (4), frontal lobe (2), temporal lobe (2), and parietal lobe (1). Cases were reviewed for neurological outcomes, extent of resection (EOR), and complications. Technical data for the port, surgical microscope, and endoscope were analyzed.

RESULTS

EOR was considered total in 14 (70%), near total (> 95%) in 4 (20%), and subtotal (< 90%) in 2 (10%) of 20 patients. Incomplete resection was associated with the basal ganglia location (p < 0.05) and use of the endoscope (p < 0.002). Four of 5 (80%) endoscope-assisted cases were near-total (2) or subtotal (2) resection. Histopathological diagnosis, presenting neurological symptoms, and demographics were not associated with EOR. Complication rates were low and similar between groups.

CONCLUSIONS

Initial experience with tubular retractors favors use of the microscope rather than the endoscope due to a wider and 3D field of view. Improved microscope optics and tubular retractor design allows for binocular vision with improved lighting for the resection of deep-seated brain lesions.

ABBREVIATIONSEOR = extent of resection; GTR = gross-total resection; NTR = near-total resection; STR = subtotal resection.

Article Information

Correspondence J. Bradley Elder, 410 W. 10th Ave., Doan Hall, N1052, Columbus, OH 43210. email: brad.elder@osumc.edu.

INCLUDE WHEN CITING Published online August 28, 2015; DOI: 10.3171/2015.1.JNS141113.

Disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 14. Microscopic transportal GTR of melanoma metastasis. Preoperative axial T1-weighted MR image (A) after Gd contrast administration demonstrates a left parietal metastasis from melanoma with significant vasogenic edema. Axial T1- (B) and T2-weighted (C) images after Gd contrast administration obtained 1 day after surgery demonstrate complete resection with a minimal surgical corridor and expected postoperative FLAIR changes. Axial T2- (D) and diffusion-weighted (E) images demonstrate the significant reduction of surgical edema and no evidence of ischemia along the surgical corridor 2 months after surgery.

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    Vycor port with Stryker navigation wand embedded in bone wax (inset, top left), which allows for navigation guidance of the port into the tumor, as depicted on the navigation screen to the right of the surgeon. Once the port has achieved the desired position, either the endoscope or microscope can be used for tumor resection via the port. Figure is available in color online only.

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    Case 13. Microscopic transportal GTR of ovarian cancer metastasis. Preoperative axial T1-weighted image (A) after Gd contrast administration demonstrates a heterogeneously enhancing metastatic lesion deep within the right basal ganglia. Axial T1-weighted image after Gd contrast administration (B) and axial T2-weighted FLAIR image (C) obtained 1 day after surgery showing total resection of the lesion and decompression of the ventricles. Postoperative coronal T1-weighted image (D) after Gd contrast administration demonstrates a minimal surgical corridor (white arrow).

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    An intraoperative photograph of a 12-mm (width) × 7-cm (length) Vycor port maintaining the surgical corridor. Cotton is seen within the port. The port is attached to a flexible snake-arm retractor allowing for self-retaining but easily adjustable retraction during surgery. The normal brain is readily seen through the transparent walls of the port (arrowhead) and is evenly distributed along the rounded edges of the port (left-pointing arrow). Minute retractions of the port encourage spongy tumor tissue to emerge into view (right-pointing arrow). Figure is available in color online only.

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    Case 1. Endoscopic transportal GTR of lung cancer metastasis. Preoperative axial (A) and sagittal (B) T1-weighted images after Gd contrast administration demonstrate a right cerebellar lesion. Axial T1-weighted images pre- (C) and post- (D) Gd contrast administration obtained 1 day after surgery demonstrate complete resection and residual hyperintensity consistent with blood products. Axial T1-weighted images, pre- (E) and post-Gd contrast administration (F), obtained 3 months after surgery demonstrate GTR of the lesion.

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    Case 2. Endoscopic transportal NTR of breast cancer metastasis. Preoperative axial (A) and sagittal (B) T1-weighted images after Gd contrast administration demonstrate a right cerebellar lesion. Axial T1-weighted images pre- (C) and (D) post-Gd contrast administration obtained 1 day after surgery demonstrate minor residual enhancement within the surgical bed (white arrow).

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    Case 4. Endoscopic transportal STR of a primitive neuroectodermal tumor. Preoperative sagittal (A) and axial (B) T1-weighted images after Gd contrast administration demonstrate a large lesion within the left frontal lobe. Postoperative axial T1-weighted images pre- (C) and (D) post-Gd contrast administration demonstrate residual enhancement (white arrows). Residual enhancement is further visualized on the postoperative sagittal T1-weighted MR image (E) and demonstrative of STR.

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    Case 8. Microscopic transportal GTR of lung cancer metastasis. Axial (A) and sagittal (B) T1-weighted images obtained after the administration of the Gd contrast agent demonstrate a lesion within the left basal ganglia. T1-weighted images after Gd contrast administration obtained 1 day after surgery demonstrate GTR. The punctate area of enhancement (white arrows) seen on the axial image (C) represents normal choroid plexus, which is better visualized on the coronal image (D).

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    Case 9. Microscopic transportal GTR of low-grade glioma. Preoperative (left) and postoperative (right) axial T2-weighted FLAIR images demonstrate a right temporal lesion that was successfully grossly resected with expected postoperative FLAIR changes.

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    Case 12. Microscopic transportal GTRof glioblastoma multiforme. Preoperative axial (A) and sagittal (B) T1-weighted images after Gd contrast administration demonstrate a right temporo-occipital lesion. Postoperative axial T1-weighted images before (C) and after (D) contrast administration demonstrate GTR. The area of enhancement (white arrow) represents normal choroid plexus.

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    Case 16. Microscopic transportal NTR of glioblastoma multiforme. Preoperative axial (A), coronal (B), and sagittal (C) T1-weighted images after Gd contrast administration demonstrate a lesion within the right basal ganglia and thalamus. Postoperative sagittal (D) and axial (E) T1-weighted images before contrast administration are shown. After contrast administration, axial (F) and coronal (G) images demonstrate residual enhancement (white arrows) suggestive of NTR.

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    Case 6. Microscopic transportal NTR of glioblastoma multiforme. Preoperative axial (A) and coronal (B) T1-weighted images after Gd contrast administration demonstrate a lesion within the left basal ganglia. Postoperative axial (C), sagittal (D), and coronal (E) T1-weighted images after contrast administration demonstrate NTR of the lesion and minimal evidence of a surgical corridor. However, residual enhancement (white arrow) is seen on the axial T1-weighted image (F) within the tumor bed.

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