Further dissection of the lower and left pole

Complete the further dissection of the contralateral pole and of the upper pole is important at this point. We use angle bipolar in order to better achieve good control of the more distal part of the tumor capsule. Contralateral access, of course, is made possible because of the very large opening of the tentorium that we did at the beginning of the surgery. We see that the dissection plan is a little bit more difficult to control on the contralateral part, if compared to the previous part of the surgery.

And we also discovered that the remaining mass of the tumor is still very significant. So we really need to continue very carefully with the dissection of the capsule that still presents some big vessels in the thickness of the capsule itself. So we have to reposition our self-retaining retractor in order to protect the superior vermian vein and the vein complex that are on the contralateral side, mainly the contralateral vein of Rosenthal. And we can continue our dissection work at this point.

You see that we are achieving an excellent result of control of the tumor capsule. Identifying the dissection plan. And identifying all the minor vessels that need to be dissected and protected.

This work is, of course, of utmost importance. It is very delicate. It must be very slow in order to have the best possible control of the plan of dissection in order to avoid any risk of injury to the contralateral thalamus. You see that the plan of dissection is really very clear. In this case, the self-retaining retractor is extremely helpful in order to allow working with both hands for a single surgeon. Here, we are identifying progressively the dissection plan more and more deep on the contralateral side.

We can protect this neural tissue that is on the other side. The maneuver of coagulation of the capsule is very helpful. And here also, we can use the contact laser in order to coagulate the outer surface of the tumor. And in order to make an incision and facilitate the removal of the bulk of the tumor that is still inside the surgical field.

And then after this maneuver, we can continue in our dissection work. You see that it’s very long and very careful dissection work that must be respected because traction can be extremely dangerous, creating a bleeding from contralateral veins that can be adherent to the tumor capsule. And that can be, of course, important.

Then we continue with the shrinking of the capsule. That is extremely helpful in reducing the mass, increasing the texture of the tumor capsule, and facilitating our dissection work. At this step, of course, we continue with the work of debulking of the tumor. That is safe because of the previous careful work of dissection. And we can identify very nicely the ependymoma of the third ventricle. And debulk the tumor with a relatively safe attitude because we can recognize very nicely the ependymoma in the depth.

And we have knowledge of where the dissection plane is. So here, we remain in the full volume of the tumor. We are far from any neural structure. We can continue our dissection and the debulking of the tumor safely. And we remain on the safe side. You can see that we can remove a large part of the tumor capsule with the very high setting of the Cavitron.