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Revisiting the Surgical Nuances of Frontal Lobectomy for Oncology Cases: Evidence From Intraoperative and Laboratory
Eirini Charalampopoulou1,2, Lykourgos Anastasopoulos1,2, Eleftherios Neromyliotis1,2
1Athens Microneurosurgery Laboratory, Evangelismos General Hospital, Athens, Greece.
Background And Objectives:
Frontal lobectomy is a usual procedure for neuro-oncology surgery. Interestingly, the relevant literature lacks a detailed operative roadmap focusing on the intricate parenchymal anatomy. Our aim is to provide a coherent and educational surgical manual that incorporates evidence from intraoperative and laboratory cranial and white matter dissections.
Methods:
Eight cadaveric cerebral hemispheres treated with the Klingler's method and 4 latex injected cadaveric heads were used to investigate the surgical anatomy involved during a frontal lobectomy. Five illustrative cases with preoperative and postoperative scans are also analyzed with respect to the surgical nuances followed in each case. Digital photographs from every dissection step were obtained to enhance understanding and provide a manual of practice.
Results:
The main procedure involves resection of the superior, middle, medial frontal gyri, gyrus rectus, and orbital lobules in a particular manner, sparing the fronto-orbital operculum and keeping a safety margin of 1 cm from the precentral sulcus. Fiber tracts that are inevitably violated are the frontal longitudinal system, the frontal segment of inferior fronto-occipital fasciculus and uncinate fasciculus, the anterior thalamic radiation, the fronto-pontine and fronto-caudate fibers, and part of the forceps minor, while fibers of the frontal aslant tract, superior longitudinal fasciculus/arcuate fasciculus complex, corticospinal, and corticobulbar tracts are preserved. Technical aspects to tackle tumor infiltration of adjacent areas such as the cingulum, corpus callosum, precentral gyrus, inferior frontal gyrus, and insula are also added.
Conclusion:
A thorough yet simple stepwise operative guide to perform a clean and adequate frontal lobectomy for neuro-oncology cases is provided by putting together evidence from laboratory and intraoperative dissections. In addition, the white matter microdissection technique is used to enrich the understanding of the basic subcortical architecture of the frontal lobe.
