Transtentorial approach for tumor surgery in the third ventricle and pineal region

Treating diseases: pineal tumors Indication The third ventricle and pineal region tumor surgery through the occipital cerebellum approach is applicable to tumors that are not sensitive to radiotherapy in the pineal region, especially those with the cerebellum margin as the center or higher than the cerebellum margin. Contraindications 1. The anterior and middle tumors of the third ventricle, this approach is far away. 2. Pineal area germ cell tumor should be the preferred radiotherapy. Preoperative preparation 1. There must be a correct positioning diagnosis before surgery. In recent years, due to advances in imaging inspection technology, clinical applications such as CT, MRI, and DSA have become increasingly widespread. The relationship between the location of the lesion and the surrounding structure should be analyzed before surgery in order to select the appropriate surgical approach, to obtain the best exposure, avoid the important structure of the skull as much as possible, increase the safety of the operation and strive for good Effect. 2. Skin preparation, wash the head with soap and water 1 day before the operation, shave the hair on the morning of the operation. You can also shave your head on the eve of surgery. 3. Fasting the morning of surgery. It can be enema in the evening before surgery, but when the intracranial pressure is increased, the enema should be removed to avoid sudden deterioration of the condition. 4. Give phenobarbital 0.1g orally before surgery to ensure a quiet rest. One hour before the operation, 0.1 g of phenobarbital, 0.4 mg of atropine or 0.3 mg of scopolamine were intramuscularly injected. 5. Severe intracranial pressure increased ventricular drainage before surgery. Surgical procedure Anesthesia and position Tracheal intubation was general anesthesia, using the right lateral position, the head turned slightly to the left, craniotomy in the right occipital. Using the gravity of the brain tissue itself, the brain tissue is removed from the midline to increase exposure and reduce traction. Or use the left lateral position used by Jemesion. Surgical procedure Skin incision After the right craniotomy, the scalp incision starts from the occipital trochanter, first 7-8 cm on the left side of the midline, then 7 cm horizontally to the right, the incision turns downward, and finally the mastoid, the flap flips downward. 2. Bone flap Drilled with 6 skulls, 4 on the right side, 2 on the left side, except for the two parts across the sagittal sinus, sawing the holes between the holes with a wire saw, and then using the rongeur to sag The bone bridge of the sinus is broken, the bone flap is turned to the right, and the bone of the lower edge of the bone window is bitten with a rongeur to reveal the upper edge of the transverse sinus. 3. Dural incision Two triangular dura menings were made from the sagittal sinus and transverse sinus, which were inverted downward and inward. The occipital lobe is then pulled up and outward with a serpentine fixation retractor until the free edge of the cerebellum is revealed. Then, cut the cerebellum along the right side of the straight sinus 1cm, and use the nerve hook to open the free edge of the cerebellum to avoid injury to the locomotive nerve in front of the craniotomy. Cut back to the sinus sinus, use the suture to retract the cerebellum, and if necessary, wedge-cut a piece of cerebellum. When the cerebellar blood vessels bleed, use bipolar coagulation to stop bleeding. Incision of the arachnoid reveals the quadruple pool, the ring pool, and the large cerebral veins. 4. Expose the tumor This arachnoid membrane is often thickened and milky white. Care should be taken when separating. Care should be taken to protect the great cerebral veins and the basal veins, the occipital veins, the bilateral internal cerebral veins and the anterior cerebellar veins. The tumor is in the great cerebral vein. The front. 5. Resection of the tumor Under the operating microscope, the arachnoid and surrounding veins are carefully separated from the tumor, and the tumor can be treated. Ultrasound aspirator or tumor-clamping forceps can be used to remove intratumoral or tumor content to reduce tumor volume, carefully dissipate along the surface of the tumor, treat the surface vessels with bipolar coagulation, and maximally remove the tumor without aggravating the lesion. When treating a meningioma originating from this part, the method of cutting from the outside to the inside and from the bottom to the top is used for the whole cut. The posterior glioma of the third ventricle lacks the capsule, and the pineal somatic cell tumor and the pineal somatic tumor also have no capsule. Only most or part of the resection can be performed, and the cerebrospinal fluid circulation channel can be restored. If it is a teratoma, you should strive for full cut. The dermoid cyst is more severely attached to the surrounding structure, and can only be used for subtotal resection. If the tumor in the pineal region is delayed, the sputum should be partially opened, the lower pole of the tumor should be identified, and then the block should be removed. When the tumor is extended to the corpus callosum, the tumor sac is removed as much as possible, so that the upper part of the tumor enters the surgical field and is removed. Through this approach, the cranial tumor on the cerebellum can also be excised to the fourth ventricle. This approach has the advantage of being short and easy to treat the tumor. 6. Guan skull After the tumor is removed and the hemostasis is completely stopped, the cerebellum is also sutured to prevent the occipital lobe from being paralyzed, and the dura mater can be interrupted or continuously sutured. Do not sew the water. The bone flap is returned, and the scalp is divided into a cap-like aponeurosis and a double suture of the skin. The negative pressure type suction device is placed on the epidural. complication 1. Same-direction hemianopia: usually caused by occipital lobe traction. 2. Silent symptoms: caused by damage to the internal vein of the brain or large cerebral veins.

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