Circumferential dissection and tumor removal

–itself. We identify, thanks to the nice internal debarking, the lateral cleavage plane. The tumor is relatively adherent, but the plane of dissection is relatively easy to identify. It is a long and patient procedure, of course, to perform, but it is very important to always remain into the perfect dissection plane that, as you can see posteriorly and superiorly, brings us relatively quickly inside the lumen of the third ventricle.

After this initial dissection, we continue our internal debulking in order to make it even easier, the working of the section on the right side. You can see that we can continue to follow the plan of dissection, of dissecting the tumor from the walls of the third ventricle, using the bipolar with the low power as frequently as necessary, but trying to dissect more than use a bipolar or other more invasive instrumentation.

Fortunately, the cleavage plane is relatively easy to maintain. And in the depth of the tumor, here, we continue our internal debulking, dissection and debulking, dissection and debulking. And the alternation of these two techniques allows us to reduce progressively the core, the central core of the tumor, and makes the dissection the least invasive and the least traumatic as possible on the walls of the third ventricle.

Here, we dissect the tumor from the small perforating arteries that comes from the Acom complex. And after this initial work of dissection on the right side, you can see that the plane of dissection on the upper pool and on the left side is certainly easier to find. A good coagulation of the capsule makes the tumor smaller and harder to manipulate in order to facilitate the displacement during the dissection maneuvers.

In this phase, you can see that the coagulating capsule is excellent way to make it firmer and easier to manipulate. But also, it identifies a safe and almost avascular area where a debulking can be continued with a rougher instrument, like scissors, like in this case, if the texture of the tumor is too firm or is too hard, and also to have better samples of the tumor and larger samples of the tumor. And that is very important for pathology, especially in tumors of teratomatous origin because of the different areas of tumor histology that can be found inside this kind of tumor.

You can see how firm is the tumor. And in this case, the use of the scissor is helpful to remove a large part and to reach the softer, central part of the tumor. After removal of this fragment, though, we can continue our debulking using the ultrasonic aspirator that is very effective at a lower power to decrease again the volume of the central part of the tumor.

You see that the tumor remains completely avascular in this part of the tumor mass. This certainly makes the work much easier because there is no need to control the bleeding or the hemostasis. At the same time, the dissection with the ultrasonic aspirator must be careful because the texture is so firm, it’s so hard, that the power of the cavitron and the power of the aspiration of the cavitron must remain at a very high level between 70% and 80% in order to remain effective and to obtain the desired effect of internal debulking.

You see that the progressive debulking of the tumor allows the identification of the more anterior plan of dissection. This part is certainly apparently tedious, but it is very important to keep a perfect control of the ultrasonic aspirator because of being too quick or being too aggressive with the ultrasonic aspirator can lead to potential damage of the hypothalamic environment.

Here, you can see that I have displaced the tumor inside the middle of the surgical field. I don’t move in the depth my ultrasonic aspirator, remaining as far as possible from the third ventricle wall. And after this phase of central debarking of the tumor, I finally identify the walls of the third ventricle, and I am able to mobilize the anterior pole of the tumor from the anterior part of the third ventricle.

You can see that it is certainly much easier now that the central core of the tumor has been removed. The tumor remains softer in this area. Here, we can identify the ependymal walls below the tumor, and we can perform a relatively safe dissection. And after complete isolation of the tumor from the anterior and the anterolateral wall of the third ventricle, we can continue our work of internal debulking.

Now, the tumor is almost completely free inside the lumen of the third ventricle. But I do not attempt to make a complete removal now. I prefer to be the less invasive and the most delicate as possible to remove the central core of the tumor in order to avoid any risk of damage to the walls of the third ventricle and to the charismatic hypothalamic area.

You see that this work is extremely easy and facilitated by a proper use of the ultrasonic aspirator. Ultrasonic aspirator works by itself. It is not necessary to move it excessively in a small surgical field. It has all the potential to work with a minimal movement and with the transmission of minimal movement to the lateral wall of the hypothalamus.

You see that the two are very high power. It fragmentates very nicely the tumor. And the aspiration is strong enough to remove immediately the fragments that have been isolated by the tumor. So finally, the tumor is isolated also in the most posterior part. We try to make the control of the small, very small bleeding that can disturb our surgical field that must remain extremely clean throughout the surgery in order to have always a perfect identification.

And here, finally, we have isolated the posterior pole of the tumor. And we can see the light of the third ventricle that is perfectly isolated. And now, we can detach the tumor from the lateral additions to the frontal lobe, and we can finally discover the very last area of adhesion on the right side.

We must remain careful. We must do a nice job here. We see the remnants of the lamina terminalis, and we can identify the tumor and detach it from the remnants of the lamina terminalis. So we can remove atraumatically the most anterior part of the tumor capsule that is inside the lumen of the third ventricle.

You can see very easily and very nicely the tumor here. We work under the communicating artery, and we are very careful, of course, in avoiding sudden movements or rough movements that can injury the anterior communicating artery complex. But the dissection, fortunately, is relatively easy at this level. And we can obtain a good view of the interior part of the third ventricle.

You see that in this part that is crucial for the surgery, we dissect free the most anterior part of the third ventricle wall from the most anterior tumor capsule, and we control perfectly the anterior part of the tumor. At this point, we continue our dissection. We understand that we are very close to the end of the surgery, but we continue to work very slowly without fast movements in order to remain always concentrated on the delicate part of the brain where we are working in the anterior part of the third ventricle.

Now, we have decided that the removal of the most posterior part and the floating into the third ventricle is necessary in order to make the decision a little bit easier. Here, we can identify some area that is immediately below the third ventricle. And we continue our dissection. We identify the dissection plan.

We coagulate and divide the small membranes that separate the lower adhesion of the tumor. The dissection plan is very clear at this level. On the left side, the dissection needs to be improved at this point. But finally, we identify the good plan of this section.

And at this point, we have a much clearer view of how the tumor is attached in the anterior part of the third ventricle. We decide to remove this huge part of the tumor in order to have a clear vision of the surgical field. We dissect the last adhesions of the tumor to the small, perforating arteries. Here, a clear view of a good dissection plan with the third ventricle and the interpeduncular system that is visible below. And now, finally, the tumor is completely free, and that we have a good control of the surgical field, and we can complete our hemostasis with the removal–