Fully endoscopic occipital transtentorial approach for pineal region tumors

Aggressive surgical resection for pineal region tumors, which is a mainstay of management in almost all cases, remains technically challenging because these tumors are located at the geometric center of the brain and surrounded by critical neurovascular structures. Therefore, any refinement in the surgical procedure is desirable. We have recently introduced an endoscope to the occipital transtentorial approach (OTA), which has been one of the most common procedures for reaching the pineal region, to overcome some of the disadvantages of the procedure, including the necessity of a relatively large skin incision and bone opening, the difficulty in orientation due to the obliqueness of the approach, the possibility of retraction injury on the occipital lobe and the corpus callosum, and blind spots at the ipsilateral wall and the roof of the third ventricle.

We performed endoscopic OTA with corresponding advantages, including less invasiveness by virtue of a small entrance limiting the retraction of the occipital lobe, the elimination of blind spots, and the facilitation of fine manipulation based on the bright endoscopic view even at substantial depth, which is panoramic and can be magnified as needed. This procedure was substantially different from a conventional microscopic OTA, though both use a similar corridor. To maximize maneuverability within the limited space in endoscopic OTA, it was necessary to thoroughly understand each step of the procedure, as well as optimal sequence in the procedure.

We found endoscopic OTA to be a promising technique for resectioning pineal region tumors, with the potential for extensive and routine application for surgeons familiar with endoscopic surgery.