Use of a minimally invasive tubular retraction system for deep-seated tumors in pediatric patients

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Microsurgical removal is the preferred treatment for most deep-seated, intraaxial tumors in the pediatric population. The feasibility of surgery as an option has improved with advances in surgical technology and technique. Tubular retractors disperse retraction forces over a greater surface area than do conventional retractors, which can lower the risk of ischemic complications. The authors describe their experience utilizing a new tubular retractor system specifically designed for cranial applications in conjunction with frameless neuronavigation.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The Vycor ViewSite retractor was used in 4 pediatric patients (ages 15 months and 9, 10, and 16 years) with deep-seated intraaxial tumors. The lesions included a papillary tumor of the pineal region, a low-grade astrocytoma in the occipital lobe, a dysembryoplastic neuroepithelial tumor arising from the basal ganglia, and an intraventricular low-grade glioma. The extent of white matter damage along the surgical trajectory (based on T2 or FLAIR and diffusion restriction/apparent diffusion coefficient signals) and the extent of resection were assessed on postoperative imaging.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Satisfactory resection or biopsy was achieved in all patients. A comparison of pre- and postoperative MR imaging studies revealed evidence of white matter damage along the surgical trajectory in 1 patient. None of the patients demonstrated new neurological deficits postoperatively.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Obtaining surgical access to deep-seated, intraaxial tumors is challenging. In this small series of pediatric patients, the combination of the ViewSite tubular retractor and frameless neuronavigation facilitated the surgical approach. The combination of these technologies adds to the armamentarium to safely approach tumors in deep locations.</jats:p></jats:sec>

A Purely Endoscopic and Simultaneous Transsphenoidal and Transcranial Keyhole Approach for Giant Pituitary Adenoma Resection: A Technical Case Report

“…In particular, planning the surgical corridor with DTI fiber tracking can minimize the risk of neurological deficits that are induced by trajectory injury. 10,19) Furthermore, linear cortical incision can reduce the risk of postoperative seizure, and use of a tubular retractor system also contributes to minimizing the cortical incision and reduces the risk of trajectory injury by distribution of forces on the surrounding white matter. 10,12,17,20) We used a ViewSite tubular retractor that was 17 mm in width and 7 cm in length.…”

“…10,19) Furthermore, linear cortical incision can reduce the risk of postoperative seizure, and use of a tubular retractor system also contributes to minimizing the cortical incision and reduces the risk of trajectory injury by distribution of forces on the surrounding white matter. 10,12,17,20) We used a ViewSite tubular retractor that was 17 mm in width and 7 cm in length. This retractor is made of transparent plastic and is available in four different widths (12 mm, 17 mm, 21 mm, and 28 mm) and three different lengths (3 cm, 5 cm, and 7 cm).…”

“…8,9) This concept is based on the idea that traditional self-retaining retractors may not achieve an appropriate surgical corridor for deep-seated brain tumors. 10,11) Instead, tubular retractors may be more useful for making long surgical corridors and are expected to cause minimal damage to the white matter. 10,11) Therefore, to reduce the invasiveness of the combined transsphenoidal-transcranial approach for the resection of giant fibrous pituitary adenomas, we adopted the keyhole concept using a newly invented tubular retractor.…”

“…10,11) Instead, tubular retractors may be more useful for making long surgical corridors and are expected to cause minimal damage to the white matter. 10,11) Therefore, to reduce the invasiveness of the combined transsphenoidal-transcranial approach for the resection of giant fibrous pituitary adenomas, we adopted the keyhole concept using a newly invented tubular retractor. Here, we describe this novel technique through a case report.…”

Utility of tubular retractors to minimize surgical brain injury in the removal of deep intraparenchymal lesions: a quantitative analysis of FLAIR hyperintensity and apparent diffusion coefficient maps

“…27 The frequency of retraction-based injury has been estimated to be approximately 10% in skull base surgery and 5% in intracranial aneurysm operations. 4 Techniques such as intermittent retraction, 24 endonasal trajectories, 3,6,10,17 and those that use tubular retractors 1,2,7,9,[11][12][13][14][15][16][18][19][20][21][22][23]25 have been used to minimize these injuries.Previously, we reported the successful use of a METRx spinal tubular retractor system, paired with the Brainlab frameless navigation system, for resection of deep-seated intracranial lesions. 9 The advantages of this tubular retractor system include equal distribution of retraction pressure abbreviatioNs ADC = apparent diffusion coefficient; DWI = diffusion-weighted imaging; GTR = gross-total resection; NTR = near-total resection; STR = subtotal resection.…”