How I do it: minimally invasive resection of a sub-ependymoma of the fourth ventricle
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HOW I DO IT - TUMOR - OTHER
How I do it: minimally invasive resection of a sub-ependymoma of the fourth ventricle Marco V. Corniola 1
&
Torstein R. Meling 1
Received: 2 July 2020 / Accepted: 30 September 2020 # The Author(s) 2020
Abstract Background A 54-year-old female was referred to our clinic with a lesion of the lower fourth ventricle extending to the median aperture. Here, we report the use a minimally invasive sub-occipital approach (MISA) as a safe and effective surgical management. Method We performed a MISA using a short midline incision and a 1-cm sub-occipital craniectomy. Dissection of the lesion was performed, and “en bloc” resection could be achieved. The lesion was confirmed to be a grade I sub-ependymoma. Conclusion MISA can be safely used when confronted to a lesion of the lower fourth ventricle. Keywords Minimally invasive surgery . Sub-occipital approach . Micro-surgery . Sub-ependymoma
Relevant surgical anatomy The anatomy of the fourth ventricle and its surroundings is shown in Fig. 1. The specific surgical anatomy is shown in Fig. 2. The midline skin incision starts 2 to 3 cm below the external occipital protuberance and should extend circa 4 cm inferiorly. Attention should be paid to stay on the midline, i.e., into the nuchal ligament, since it is an avascular plane. Image intensifier control or navigation may be used to avoid unnecessary detachment of the posterior spinal muscles [1–6]. The superficial muscle layers consist of the trapezius (superficially) and splenius capitis (deep) muscles. The intermediate muscle layer consists of semispinalis capitis muscle; the deep muscle layer consists of rectus capitis major (lateral) and minor (medial) muscles. The vertebral artery turns around the lateral mass of the atlas from lateral to medial and enters into the foramen This article is part of the Topical Collection on Tumor - Other Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00701-020-04601-5) contains supplementary material, which is available to authorized users. * Marco V. Corniola [email protected] 1
Department of Clinical Neurosciences, Division of Neurosurgery, Geneva University Hospitals, 4, Rue Gabrielle Perret Gentil, 1205 Geneve, Switzerland
magnum through the atlanto-occipital membrane. The midline of the atlanto-occipital membrane has to be identified before the foramen magnum is carefully drilled. After opening the dura, the cisterna magna is seen. The foramen Magendie and obex are identified, in between the two cerebellar tonsils. The distal floor of the fourth ventricle may be seen (Fig. 3).
Description of the technique A park-bench positioning was used. The head was flexed and slightly rotated towards the floor, using a Mayfield head clamp. To avoid shifting during the surgical approach, the surgeon has to stay on the linea nuchalis: to facilitate orientation, the surgeon can mark the midline before turning the patient head, at the very beginning of the positioning. The head is rotated to maximize exposition and
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