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Sascha Marx and Henry W. S. Schroeder

plexus is coagulated and cut. Usually, there is a vascularized pedicle that connects the cyst to the tela choroidea. In this phase of the surgery, we apply a bimanual dissection technique to allow better control of the pedicle ( Fig. 5F ). A small flexible grasping forceps is inserted via the left-sided channel of the ventriculoscope to hold up the cyst capsule, allowing visualization of the cyst pedicle. A bipolar diathermy probe is introduced via the main working channel, and the vessels within the pedicle are coagulated ( Figs. 5G and 6F ). Thereafter, the pedicle

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Carlo Serra, Victor E. Staartjes, Nicolai Maldaner, David Holzmann, Michael B. Soyka, Marco Gilone, Christoph Schmid, Oliver Tschopp and Luca Regli

structures is the main argument in favor of this technique. There is, however, no consensus on the technical details of the endoscopic procedure, and several variations have been developed and reported. In the classic endoscopic technique, originally popularized for sinus surgery by Messerklinger, 22 the operating surgeon held the endoscope in one hand and a working instrument in the other. The obvious advantage of bimanual dissection quickly pushed the evolution of the technique either into a 2-surgeon, 3-hand variation or toward the introduction of a mechanical holder

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Justin C. Clark and Curtis A. Dickman

single, small skin incision for this approach creates a tight corridor to the spine, through which the surgeon's line of sight and instruments must pass. This limited corridor can cause the surgeon's hands to encroach on each other and cause the tools to “swordfight” because of the need to approach the lesion from a very small arc. These constraints can limit the surgeon's ability to perform bimanual dissection, to place spinal instrumentation, to work from different angles, and to see the pathology, all of which are necessary for the treatment of TDH and which would

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Sandeep Sood, Eishi Asano, Deniz Altinok and Aimee Luat

placed under neuronavigation guidance into the occipital horn to drain CSF and to achieve brain relaxation. FIG. 2. A: Endoscope with the attached suction and neuronavigation guide is held in the surgeon's left hand, and bimanual dissection is performed with a second instrument held in the surgeon's right hand. B and C: Photographs showing the position and the incision required to perform complete corpus callosotomy using the endoscopic method via the parietooccipital approach with the patient in the prone position. Figure is available in color online only

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Amin B. Kassam, Johnathan A. Engh, Arlan H. Mintz and Daniel M. Prevedello

created through dilated white matter, in an attempt to create a parafascicular approach to the tumor. The conduit (port) creates an air medium that allows bimanual dissection: instruments work parallel to the endoscope, and the technique strictly adheres to proven microsurgical principles. The concept was initially developed by modifying the work of Dr. Patrick Kelly, who pioneered a 20-mm-diameter stereotactic tubular retraction system 7 , 8 , 10 , 11 , 17 for the microscopic resection of deep brain tumors. The conduit required to deliver microscopic visualization is

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Sandeep Sood, Neelesh Nundkumar and Steven D. Ham

a bipolar cautery forceps to control any bleeding ( Video 1 ). V ideo 1. Clip showing the endoscopic view of bimanual dissection in the interhemispheric fissure, opening of the corpus callosum, and resection of the tumor with CUSA. Click here to view with Windows Media Player. Click here to view with Quicktime. F ig . 3. A: Interhemispheric view through the endoscope showing dissection of the arachnoid from the falx. B: Corpus callosum seen through the endoscope with the pericallosal artery seen to the left of the suction catheter. C

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Sandeep Sood, Neena I. Marupudi, Eishi Asano, Abilash Haridas and Steven D. Ham

often results in an irritating instrument “scissoring." We have previously described removal of deep thalamic, intraventricular, and pineal tumors with a bimanual technique (which we also refer to as the 2-handed technique) by using an endoscope with mounted suction in the left hand, and an instrument in the right hand allowing for bimanual dissection, use of regular bipolar cautery, and dissecting instruments. 11 , 12 Cutler et al. 4 have used a custom-made suction device with an endoscope for vestibular neurectomies performed using the same technique. This

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Maria M. Santos and Mark M. Souweidane

technically challenging, has yet to gain widespread appeal, and thus has been infrequently reported. 1 , 2 , 4–6 , 9–13 Often-cited limitations include inadequate bipolar cautery for hemostasis, a limited repertoire of surgical instruments for bimanual dissection, and the lack of adequate instrumentation designed for solid tissue tumor removal. 8 , 10 The risk of CSF seeding of the tumor has never been proved to be higher with endoscopic approaches than with the microsurgical ones. Limitations for solid tumor removal are varied, but hemostasis is paramount. Given this

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Maurizio Iacoangeli, Lucia Giovanna Maria di Somma, Alessandro Di Rienzo, Lorenzo Alvaro, Davide Nasi and Massimo Scerrati

unsafe for completely resecting the capsule because visualization of its insertion site was not adequate. To obtain a better exposure of the roof of the third ventricle and a more posterior access to the colloid cyst, the choroidal fissure was opened, staying medial to the choroid plexus and passing through the tenia fornicis. One of the main limits of this approach was the difficulty of translating into endoscopy the bimanual dissection used in conventional microneurosurgery. However, a sort of bimanual dissection was performed using scissors, bipolar coagulator, or

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Vivek P. Bodani, Gerben E. Breimer, Faizal A. Haji, Thomas Looi and James M. Drake

view, lack of depth perception, limited instrument dexterity and bimanual dissection capabilities, limited ability to achieve hemostasis) and carry the risk for significant morbidity and mortality. 3 Endoscopic colloid cyst resection, in particular, is associated with a steep learning curve and requires extensive training and experience with bimanual intraventricular neuroendoscopic techniques and specialized equipment (i.e., neuronavigation, side-cutting aspiration devices) to achieve good outcomes. 10 , 17 , 23 , 24 The purpose of this study was to develop a