Vestibular schwannoma microsurgical technique

Vestibular schwannoma surgery demands much of the surgeon, both in preparation and execution of a surgical plan. We review preoperative aspects, including decision-making and setting up the necessary equipment and surgical environment. The ergonomics of microsurgery and strategies to deal with the surgical burden are reviewed. The steps in tumor resection are described in detail, with the authors' perspective on how each of these stages is best achieved. This incorporates techniques for effective tumor removal while identifying and preserving key structures. We expand upon methods to dissect blood vessels, cranial nerves, and the brainstem, with a focus on tips for facial nerve dissection. A variety of surgical challenges are dealt with, specifically their avoidance as well as how to deal with them should they arise. Scenarios that are covered are venous sinus injury, brain swelling, bleeding, and encountering unexpected pathology. Facial nerve issues discussed are severe tumor adherence, conduction block, and nerve division. Recognition that this is a highly variable pathology and equipping oneself with surgical techniques to deal with the range of challenges encountered are key to mastering this surgery.