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Journal of Neurosurgical Sciences 2020 Sep 28

DOI: 10.23736/S0390-5616.20.05122-X


language: English

Transcortical endoportal subchoroidal endoscope-assisted approach to the third ventricle: from virtual reality to anatomical laboratory

Carmine A. DONOFRIO 1, 2 , Lucia RICCIO 1, Jody F. CAPITANIO 1, Aalap HERUR-RAMAN 3, Pietro PANNI 1, Filippo GAGLIARDI 1, Anthony J. CAPUTY 4, Pietro MORTINI 1

1 Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; 2 Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK; 3 Surgical Theater LLC, Cleveland, OH, USA; 4 Department of Neurosurgery, George Washington Hospital, George Washington University School of Medicine and Health Sciences, Washington D.C., USA


BACKGROUND: Surgical approaches to the third ventricle (TV) have always represented a technical challenge in neurosurgery. Virtual reality (VR) is attaining increasing relevance in training programs and preoperative planning. The aim of this study is to demonstrate the worthwhile mutual contribution of VR simulations and specimen dissections to develop a new surgical approach to the TV.
METHODS: The transcortical endoportal subchoroidal endoscope-assisted (TEPSEA) approach was planned and simulated thanks to VR (Surgical Theater©, LLC, Cleveland, Ohio), and then implemented on cadaver specimens by using the VBAS portal system (Viewsite™ Brain Access System TC Model, Vycor Medical™ Inc). We assessed anthropometric measurements during VR planning and evaluated surgical operability during anatomical dissections.
RESULTS: Surgical field depths measured between 75.6 and 85.3 mm to mammillary bodies and habenular commissure, which were in mean 20.2 mm away. An 18-mm movement was estimated for 15°-posterior tilting of a 70-mm long VBAS. Excellent exposure and maneuverability were achieved within the TV through a 2.47 cm2 portal working area. The 30°-endoscope assistance expanded the access towards the anterior and posterior walls of the TV particularly to the infundibular recess, mammillary bodies, habenular commissure and pineal recess.
CONCLUSIONS: We documented the utility of a step-by-step VR planning and simulation followed by anatomical dissections to study surgical approaches to deep brain areas. The TEPSEA exploits the portal system and endoscopic assistance to access the entire TV minimizing cortical and white matter manipulation.

KEY WORDS: Minimally invasive neurosurgery; Portal surgery; Third ventricle; Virtual reality; Surgical training

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