A 3D endoscopic transtubular transcallosal approach to the third ventricle

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OBJECT

Surgical approaches to deep-seated brain pathologies, specifically lesions of the third ventricle, have always been a challenge for neurosurgeons. In certain cases, the transcallosal approach remains the most suitable option for targeting lesions of the third ventricle, although retraction of the fornices and wall of the third ventricle have been associated with neuropsychological and hypothalamic deficits. The authors investigated the feasibility of an interhemispheric 3D endoscopic transcallosal approach through a minimally invasive tubular retractor system for the management of third ventricular lesions.

METHODS

Three-dimensional endoscopic transtubular transcallosal approaches were performed on 5 preserved cadaveric heads (10 sides). A parasagittal bur hole was placed using neuronavigation, and a tubular retractor was inserted under direct endoscopic visualization. Following observation of the vascular structures, fenestration of the corpus callosum was performed and the retractor was advanced through the opening. Transforaminal, interforniceal, and transchoroidal modifications were all performed and evaluated by 3 surgeons.

RESULTS

This approach provided enhanced visualization of the third ventricle and more stable retraction of corpus callosum and fornices. Bayonetted instruments were used through the retractor without difficulty, and the retractor applied rigid, constant, and equally distributed pressure on the corpus callosum.

CONCLUSIONS

A transtubular approach to the third ventricle is feasible and facilitates blunt dissection of the corpus callosum that may minimize retraction injury. This technique also provides an added degree of safety by limiting the free range of instrumental movement. The combination of 3D endoscopic visualization with a clear plastic retractor facilitates safe and direct monitoring of the surgical corridor.

ABBREVIATIONSFM = foramen of Monro; VBAS = ViewSite Brain Access System.

Article Information

Correspondence Antonio Bernardo, Department of Neurological Surgery, Weill Cornell Medical College, 525 E. 68th St., Box 99, New York, NY 10065. email: anb2029@med.cornell.edu.

INCLUDE WHEN CITING Published online January 2, 2015; DOI: 10.3171/2014.11.JNS14341.

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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    Illustrations depicting the transforaminal, transchoroidal (left), and transseptal interforniceal (right) variations of the endoscopic transtubular transcallosal approach. The green arrows depict the direction of endoscopic visualization and dissection, and the blue arrows indicate the direction of retraction applied to the fornices. Copyright Antonio Bernardo. Published with permission.

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    A preoperative neuronavigation screenshot depicting identification of a safe entry zone that avoids the superior sagittal sinus.

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    Graphic depictions of the VBAS tubular retractor with the introducer in situ (upper) and with the introducer being removed (lower).

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    Introduction and advancement of the tubular retractor into the surgical field. A: The tubular retractor, fastened to the self-retaining snake retractor, during insertion. B: View of the interhemispheric fissure through the tubular retractor's introducer. C: The opening in the tip of the introducer allowed for easy passage of microinstruments to release arachnoid adhesions.

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    Identification and retraction of the pericallosal arteries. A: A 2D endoscopic transtubular view of a unilateral pericallosal artery transposition. B and C: The 3D endoscopic transtubular views of a bilateral pericallosal artery retraction and the corpus callosum. The retractor facilitated safe retraction of the vessels around the tip of the device and provided adequate exposure of the corpus callosum.

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    Fenestration of the corpus callosum. Upper: A small opening in the corpus callosum was fashioned prior to advancement of the tubular retractor. Lower: The callosal arteries and a small feeding artery to the corpus callosum were visualized and safely retracted.

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    Advancement of the tubular retractor through the callosotomy. Upper: Passage of the retractor tip through the fenestration in the corpus callosum. Lower: The ependymal lining of the lateral ventricles was observed.

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    The right lateral ventricle and choroid plexus seen through an angled 2D endoscope.

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    Transforaminal modification. The FM was observed through the tubular retractor (upper) and the endoscope was advanced to visualize the choroid plexus (lower).

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    Transchoroidal modification. The subchoroidal fissure was located (upper) and the transchoroidal modification was performed (lower).

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    Transseptal interforniceal modification. The leaflets of the septum (upper) and the fornices (lower) were divided to enable access into the third ventricle.

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