Tumor removal

Tumor removal continue at this point. You see that the deeper is the cavity, the more difficult it is to keep the cavity large because of the sucking power of the ultrasonic respirator. We work in a very, very deep and narrow and dark field, so we need to find some trick in order to keep our surgical field large and to see what we are doing in the depth of the surgical field.

We can continue our biopsy in the depth by removing small pieces of tumor in the depth of the tumor volume at this level, and we continue progressively our tumor removal and debulking with the ultrasonic surgical respirator. You see that this part of the tumor removal is very tedious. We have to be very careful nevertheless because the surgical field is very small, is very narrow, and is very dark, and we have to pay the highest possible attention to the color and to the texture of the tissue that we are progressively aspirating.

We keep the edge of the surgical cavity open by using Rhoton dissector, in this case, but we can also use a Penfield dissector when we go deeper. We can identify the yellowish tissue of the tumor in the depth of our surgical field. You see that the conditions of working are certainly quite extreme because of the narrow opening and of the narrow surgical field. But nevertheless, we can identify the boundary in the depth between the normal tissue and the tumor tissue. And we continue staying on the safe side always removing the tumor tissue that is relatively well recognizable if compared to the normal tissue that is surrounding.

We are continuing our tumor removal in this phase. Some small bleeding can be easily managed by simple irrigation. There is no need really to coagulate in this phase because the tumor volume is relatively small and the vascularization is not very important. So we can continue our tumor debulking with only two instrument, one forceps or one dissector that keep the surgical cavity large and the surgical inlet large, and the ultrasonic respirator that can aspirate the blood.

We are approaching the final phase of our surgery. The surgical cavity is now large enough. We are seeking for the deepest part of the tumor in order to discover the connection with the aqueduct. We now insert cottonoids inside the surgical cavity in order to keep the surgical cavity as large as possible, avoiding a collapse of the walls of the surgical cavity. And looking for the small remnants of tumor on the lateral walls of the surgical cavity.

This work is really quite difficult because of the small surgical field where we are working, and because we know that the lateral boundaries are as difficult to identify as the ones that were identified in the upper part of the tumor. We explore millimeter by millimeter the lateral walls of the surgical field. We can aspirate the blood because the patty that we have inserted into surgical cavity is keeping the cavity large. We can remove with very, very low setting of our surgical aspirator the most posterior part of the tumor.

Here we can see that we are approaching the posterior edge of the tumor and we change our patty in order to continue our exploration of the walls of the surgical cavity. We can still look for the deepest part of our tumor, hopefully identifying the most deep part that could allow the communication with the fourth ventricle. We will insert a cottonoid for hemostasis and after removing this patty, we can reuse our narrow navigation probe to check the depth of our working area. With the Cavitron, we can discover further tumor tissue that is very clearly identified and visible.

The texture is very firm, the color is very different from the clear color of the midbrain, healthy midbrain, and finally, in the very depth we arrive to discover the inlet of the distal part of the aqueduct, and we see the CSF that comes from the fourth ventricle and that can finally communicate with the third ventricle. So we have reached our deepest part of the tumor. We can identify with the Navigator the fourth ventricle, we are sure of the position of our tip of the electromagnetic Navigator, and we can see that we are here approaching the deepest part of the tumor and the communication between the third and the fourth ventricle is now created.

So certainly we have crossed the whole volume of the tumor. We have the feeling that the lateral walls of the cavity are free of tumor, at least in the most anterior part, and we explore as much as we can the lateral walls of the cavity, but we can see that most of the tumor is gone. We enlarge the opening and the communication between the third ventricle and the four ventricle. We enlarge this opening also with bipolar forceps in order to allow the best possible communication of the CSF between the two cavities, but we do not exaggerate of course with this opening because we are working in the deepest part of the midbrain. We insert finally a patty into the cavity of the midbrain and we continue with the hemostasis and closure.