Hemostasis Management during Completely Endoscopic Removal of a Highly Vascular Intraparenchymal Brain Tumor: Technique Assessment

Abstract

Background Recently, stereotactic-guided removal of intraparenchymal lesions using endoscopic visualization through a brain port has been successfully reported. Although endoneurosurgical tumor resection uses the same principles as those used in microneurosurgery, the ability to control bleeding through the port requires an adapted technique.

Material and Methods We present a patient that underwent a completely endoscopic resection of a vascular brain tumor through a brain port and describe the hemostatic technique.

Results A 68 year-old female presented with progressive gait difficulties. She had been previously treated for a breast cancer. Magnetic resonance imaging (MRI) showed a right subcortical solitary cerebellar lesion that homogeneously enhanced. The patient underwent an endoscopic brain port removal of a supposed brain metastasis. After port cannulation, the tumor partly delivered itself into the port. Following initial tumor biopsy, active bleeding occurred. Irrigation and application of Surgifoam allowed to control the bleeding. Coagulation with an adapted bipolar and removal of coagulated tissue with the side-cutting aspiration device were sequentially repeated. Once the tumor was resected, the suction served as counter-traction elongating the vessels whereas the bipolar cauterized them over a long segment. Hemostasis was performed circumferentially along the cavity's walls from deep to superficial, benefiting from the endoscope's dynamic properties and magnification. Pathology confirmed intraoperative suspicion of hemangioblastoma.

Conclusion Removal of vascular tumors is feasible through the brain port, despite a relatively narrow corridor of 11.5 mm. However, specific hemostasis techniques are required and adapted instruments are needed to ensure hemostasis through these small corridors.

Keywords

hemostasis - endoscopy - minimally invasive surgery - tumor - vascular lesion

• References

• 1 Lund VJ, Stammberger H, Nicolai P , et al; European Rhinologic Society Advisory Board on Endoscopic Techniques in the Management of Nose, Paranasal Sinus and Skull Base Tumours. European position paper on endoscopic management of tumours of the nose, paranasal sinuses and skull base. Rhinol Suppl 2010; (22) 1-143
• 2 Reisch R, Perneczky A. Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision. Neurosurgery 2005; 57 (4, Suppl) 242-255 , discussion 242–255
• 3 Reisch R, Perneczky A, Filippi R. Surgical technique of the supraorbital key-hole craniotomy. Surg Neurol 2003; 59 (3) 223-227
• 4 Kassam AB, Engh JA, Mintz AH, Prevedello DM. Completely endoscopic resection of intraparenchymal brain tumors. J Neurosurg 2009; 110 (1) 116-123
• 5 Harris AE, Hadjipanayis CG, Lunsford LD, Lunsford AK, Kassam AB. Microsurgical removal of intraventricular lesions using endoscopic visualization and stereotactic guidance. Neurosurgery 2005; 56 (1, Suppl) 125-132 , discussion 125–132
• 6 Engh JA, Lunsford LD, Amin DV , et al. Stereotactically guided endoscopic port surgery for intraventricular tumor and colloid cyst resection. Neurosurgery 2010; 67 (3, Suppl Operative) ons198-ons204 , discussion ons204–ons205
• 7 Fernandez-Miranda JC, Engh JA, Pathak SK , et al. High-definition fiber tracking guidance for intraparenchymal endoscopic port surgery. J Neurosurg 2010; 113 (5) 990-999
• 8 Kassam A, Snyderman CH, Carrau RL, Gardner P, Mintz A. Endoneurosurgical hemostasis techniques: lessons learned from 400 cases. Neurosurg Focus 2005; 19 (1) E7
• 9 Riegel T, Freudenstein D, Alberti O , et al. Novel multipurpose bipolar instrument for endoscopic neurosurgery. Neurosurgery 2002; 51 (1) 270-274 , discussion 274
• 10 Lekovic GP, Gonzalez LF, Feiz-Erfan I, Rekate HL. Endoscopic resection of hypothalamic hamartoma using a novel variable aspiration tissue resector. Neurosurgery 2006; 58 (1, Suppl) ONS166-ONS169 , discussion ONS166–ONS169