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Keyhole epilepsy surgery: corticoamygdalohippocampectomy for mesial temporal sclerosis

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Abstract

Surgical approaches for medically refractory mesial temporal lobe epilepsy (MTLE) that previously have been reported include anterior temporal lobectomy (ATL), transcortical selective amygdalohippocampectomy, transsylvian amygdalohippocampectomy, and subtemporal amygdalohippocampectomy. Each approach has its advantages and potential pitfalls. The purpose of this report is to describe our technique of keyhole corticoamygdalohippocampectomy for patients with MTLE due to hippocampal sclerosis. Operations were performed through a 6-cm vertical linear incision and a low 2.5-cm keyhole craniotomy at the anterior squamous temporal bone. Resection of the anterior-most portions of the middle and inferior temporal gyri provided a cylinder-like corridor to the mesial temporal lobe. Identification of the temporal horn through a basal approach was followed by resection of the amygdala, uncus, and hippocampus-parahippocampal gyrus. This 9-year series included 683 patients with a minimum follow-up duration of 2 years. Surgery times were short (range, 1 h 35 min to 2 h 30 min). Only a small percentage of patients had complications (1.76 %), and the rate of Engel Class I seizure-free outcome was 87 %. No overt speech problems or visual field deficits were identified. Compared with the most popular conventional trans-middle temporal gyrus approach, this technique can make the operation easier, safer, and less traumatic to functional lateral neocortex.

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Acknowledgments

The authors would like to take this opportunity to express our gratitude to Prof. Tomokatsu Hori (Tokyo Women’s Medical University, Tokyo), who kindly gave us his advice for optimizing our technique in epilepsy surgery in our patients during our learning period and gave us his helpful ideas for our manuscript.

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Authors and Affiliations

  1. Department of Neurosurgery, Fuzhou General Hospital of Nanjing Command, PLA, North Road 156, West, Second Ring, Fuzhou, 350025, China

    Peng-Fan Yang, Hui-Jian Zhang & Jia-Sheng Pei

  2. Department of Epileptology, Fuzhou General Hospital of Nanjing Command, PLA, Fuzhou, 350025, China

    Qiao Lin, Zhen Mei, Yan-Zeng Jia & Zhong-Hui Zhong

  3. Department of Medical Imaging, Fuzhou General Hospital of Nanjing Command, PLA, Fuzhou, 350025, China

    Zi-Qian Chen

  4. Department of Pathology, Fuzhou General Hospital of Nanjing Command, PLA, Fuzhou, 350025, China

    Zhi-Yong Zheng

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  1. Peng-Fan Yang
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Comments

Josef Zentner, Freiburg, Germany

Amygdalohippocampectomy has proven to be effective for the surgical treatment of mesiotemporal epilepsy. Several approaches are available. Lateral approaches can be done with large (standard anterior temporal lobectomy) or limited cortical resection (key-hole approach). For selective amygdalohippocampectomy, the transsylvian, transcortical, transsulcal, or the subtemporal route may be used.

The approach presented by Yang et al. uses a small cylindric cortical incision through the anterior part of the middle and the inferior temporal gyrus to reach the mesiotemporal area. This approach which is called corticoamygdalohippocampectomy by the authors seems to be a modification of the limited lateral approach as proposed by Spencer.

Although the technique described here is not completely new, it seems to be noteworthy. This is especially true since the procedure seems to be quite safe and easily to be done. Moreover, results in terms of epileptological and neuropsychological outcome as reported by the authors are quite favorable with a low morbidity. Therefore, this new approach may enrich the spectrum of surgical techniques for the treatment of mesiotemporal lobe epilepsy.

Harold Rekate, Great Neck, USA

Selective amygdalohippocampectomy (SAH) has been shown effective for treatment of temporal lobe epilepsy in carefully selected patients. The question is what approach is best for this procedure? As described in the article by Yang and colleagues, there are a number of approaches that have been used to perform this procedure with advocates and explanations for the decision by each author. The study describes the surgical technique in detail and presents the outcomes in 683 patients undergoing the Keyhole AHC procedure in Fuzhou General Hospital in southeastern China.

Regardless of the selected approach, the steps in SAH surgery are the same. They include entering the temporal horn of the lateral ventricle, using the anatomy of the temporal horn the Amygdala is identified anteriorly to the tip and using the roof of the temporal horn to define how high the amygdale needs to be resected. The anterior hippocampus is then taken in one piece and the posterior resection of that structure proceeds piecemeal. Approaches include transsylvian, middle temporal gyrus, and subtemporal approaches. The keyhole approach described here is a variation on the trans-middle temporal gyrus approach. The authors recommend a generally more anterior approach than is usually used through the middle temporal gyrus and recommend removing of a core of the anterior temporal lobe in approaching temporal horn. This decreases the need to retract the brain.

This is a very large series with excellent outcomes in the vast majority of patients. Neurosurgeons who perform large numbers of the same cases will over time develop improved techniques that lead to faster or safer surgery. Selective amygdalohippocampectomy is a procedure with a rather steep learning curve. After the surgeon becomes familiar with the anatomy and approach, there is a tendency to change the point of entry through the brain, what you expect to see in terms of the anatomy of the temporal horn is concerned and the instruments that you use at each stage of the procedure. The technique described here almost certainly has evolved from the large experience. The small corticotomy described here would require neuronavigation for a significant number of patients during the beginning of the experience. The authors report that the surgery is much shorter in duration after the first cohort of patients is treated.

The paper is well written and quite clear. It outlines the steps involved in the performance of the procedure so that it is possible for experienced neurosurgeon to perform the procedure from the reading of the article. The outcomes are excellent. From a technical point of view, I think that the use of a Vy cor speculum (Vycor Medical, Boca Raton, Fl) would be useful instead of the micro paddle retractors that have been used in the performance of the amygdalohippocampectomy.

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Yang, PF., Zhang, HJ., Pei, JS. et al. Keyhole epilepsy surgery: corticoamygdalohippocampectomy for mesial temporal sclerosis. Neurosurg Rev 39, 99–108 (2016). https://doi.org/10.1007/s10143-015-0657-8

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