Applied anatomical study of pineal region surgery using the Poppen keyhole approach under complete neuroendoscope
Hou He1, Zhang Hengzhu2, Yan Zhengcun2, Wang Xiaodong2, Wang Xingdong2, Wei Min2, Wang Guangjie1, Wang Chenxin3
1Department of Neurosurgery, Yangzhou Clinical Medical College of Dalian Medical University, Yangzhou 225001, China; 2Department of Neurosurgery, Clinical Medicine College of Yangzhou University, Yangzhou 225001, China; 3Department of Neurology, Yangzhou Clinical Medical College of Dalian Medical University, Yangzhou 225001, China
Abstract：Objective To investigate the anatomical characteristic of the operation of pineal region craniotomy using the Poppen keyhole approach with complete neuroendoscope, and explore its feasibility. Methods Twelve adult head wet specimens, including 7 males and 5 females aged 34-71 years, fixed with 10% formaldehyde and perfused with red and blue latices were used for the experiment wet head specimens from adults, were fixed with 10% formaldehyde and perfused with red and blue milk for the experiments. The 12 specimens were randomly divided into the endoscopic group (six specimens) and microscopic group (six specimens) using random number table method. A simulated craniotomy surgery was performed using the complete neuroendoscopic Poppen keyhole approach in the endoscopic group and the conventional Poppen approach with a microscope in the microscopic group. The pineal region and the surgical space were observed with neuronavigation during the operation. (1)The important anatomical structures of pineal region were observed during the simulated operation in the two groups. (2) In the endoscopic group, the exposed area of the pineal region before and after tentorial incision was measured during the simulated operation and compared through paired t-test. (3)During the simulated operation, the exposed areas of the first, second, and third operation spaces of the two groups were measured. The comparison between the two groups was performed through independent sample t-test. (4) The spacing of other important anatomical structures were measured in endoscopic. Results (1) The important blood vessels such as bilateral basal vein, middle cerebellar fissure vein, internal cerebral vein, posterior cerebral artery, superior cerebellar artery, and other important anatomical structures such as trochlear nerve, quadrigeminal body, splenium of corpus callosum and pineal gland were observed in both approaches. However, the conventional Poppen approach had narrow and oblique surgical access and limited visual field. (2) During the simulated operation in the endoscopic group, the exposed area of the pineal region before and after the tentorium cerebelli cut was (73.14±3.38) and (127.77±7.90) mm2, respectively, with a statistically significant difference (t=28.84, P<0.001). (3) Moreover, the exposure areas of the first, second, and third operation spaces were (20.93±2.49), (72.55±4.18), and (208.57±11.79) mm2, respectively. Meanwhile, during the simulated operation in the microscopic group, the exposure areas of the first, second, and third operation spaces were (9.12±1.12), (53.45±3.17), and (175.29±9.98) mm2, respectively. Significant differences were observed between groups (t=14.92, 12.61, 7.41; all P values<0.001). (4) The maximum distance between the bilateral basal veins was (14.41±0.94) mm, the maximum distance between the bilateral middle cerebellar fissure veins was (8.23±0.84) mm, the maximum distance between the bilateral internal cerebral veins was (8.41±0.96) mm, and the minimum distance between the bilateral internal cerebral veins (the narrowest length of the first gap) was (2.58±0.22) mm. The distance from pineal center to occipital center of thalamus was (16.83±1.16) mm. Conclusion The pineal region can be safely reached by means of the Poppen keyhole approach with complete neuroendoscope, and its three surgical spaces are constant. Compared with the conventional Poppen approach under a microscope, the operation space of the Poppen keyhole approach with complete neuroendoscope is larger and the pineal region is more fully exposed.
侯赫, 张恒柱, 严正村, 王晓东, 王杏东, 魏民, 王广杰, 王晨昕. 完全神经内镜下经Poppen锁孔入路松果体区手术的应用解剖学研究[J]. 中华解剖与临床杂志, 2023, 28(4): 209-217.
Hou He, Zhang Hengzhu, Yan Zhengcun, Wang Xiaodong, Wang Xingdong, Wei Min, Wang Guangjie, Wang Chenxin. Applied anatomical study of pineal region surgery using the Poppen keyhole approach under complete neuroendoscope. Chinese Journal of Anatomy and Clinics, 2023, 28(4): 209-217.
Azab WA, Nasim K, Salaheddin W.An overview of the current surgical options for pineal region tumors[J]. Surg Neurol Int, 2014,5:39. DOI: 10.4103/2152-7806.129430.
[2]
Adji NK, Rozidi A, Zharfan RS.Removal of pineal region teratomas using occipital transtentorial approach (OTA) technique: case report and literature review[J]. Int J Surg Case Rep, 2020,76:351-356. DOI: 10.1016/j.ijscr.2020.09.174.
[3]
Ding Y, Sun L, Hu Y, et al.Combined microscopic and endoscopic surgery for pineal region meningiomas using the occipital-parietal transtentorial approach[J]. Front Oncol, 2022,12:828361. DOI: 10.3389/fonc.2022.828361.
[4]
Barkhoudarian G, Farahmand D, Louis RG, et al.Microsurgical endoscope-assisted gravity-aided transfalcine approach for contralateral metastatic deep medial cortical tumors[J]. Oper Neurosurg (Hagerstown), 2017,13(6):724-731. DOI: 10.1093/ons/opx067.
[5]
Maselli G, De Paulis D, Ricci A, et al.Posterior cranial fossa tumors: results and prognostic factors in a consecutive series of 14 operated patients by occipital transtentorial approach[J]. Surg Neurol Int, 2012,3:85. DOI: 10.4103/2152-7806.99911.
[6]
Katyal A, Jadhav A, Katyal A, et al.Occipital transtentorial approach for pineal region lesions: addressing the controversies in conventional teaching[J]. Surg Neurol Int, 2021,12:503. DOI: 10.25259/SNI_168_2021.
[7]
Blasco García de Andoain G, Delgado-Fernández J, Penanes Cuesta JR, et al. Meningiomas originated at the falcotentorial region: analysis of topographic and diagnostic features guiding an optimal surgical planning[J]. World Neurosurg, 2019,123: e723-e733. DOI: 10.1016/j.wneu.2018.12.013.
[8]
Tanikawa M, Yamada H, Sakata T, et al.Exclusive endoscopic occipital transtentorial approach for pineal region tumors[J]. World Neurosurg, 2019,131:167-173. DOI: 10.1016/j.wneu.2019.08.038.
[9]
Miyake S, Suenaga J, Nakamura T, et al.Practical arachnoid anatomy for the technical consideration of galen complex dissection: cadaveric and clinical evaluation[J]. World Neurosurg, 2021,151:e372-e378. DOI: 10.1016/j.wneu.2021.04.041.
[10]
张绍林, 张晓彪, 谢涛, 等. 神经内镜下经颞下锁孔Kawase入路切除三叉神经鞘瘤(附四例报道)[J].中华神经医学杂志,2020,19(6):596-600. DOI: 10.3760/cma.j.cn115354-20191008-00577.Zhang SL, Zhang XB, Xie T, et al.Neuroendoscopic subtemporal keyhole Kawase approach for trigeminal neurinoma resection: an analysis of four cases[J]. Chin J Neuromed,2020,19(6):596-600. DOI: 10.3760/cma.j.cn115354-20191008-00577.
[11]
王小刚, 李凯, 王振刚, 等. 神经内镜经幕下小脑上治疗松果体区肿瘤15例[J].国际神经病学神经外科学杂志,2022,49(1):17-21. DOI: 10.16636/j.cnki.jinn.1673-2642.2022.01.004.Wang XG, Li K, Wang ZG, et al.Experience in neuroendoscopy for the treatment of pineal region tumors via the supra-cerebellar infratentorial approach: an analysis of 15 cases[J]. Journal of International Neurology and Neurosurgery,2022,49(1):17-21. DOI: 10.16636/j.cnki.jinn.1673-2642.2022.01.004.
[12]
Miyake S, Suenaga J, Nakamura T, et al.Practical arachnoid anatomy for the technical consideration of Galen complex dissection: cadaveric and clinical evaluation[J]. World Neurosurg, 2021,151:e372-e378. DOI: 10.1016/j.wneu.2021.04.041.
[13]
Yu L, Orazmyradov B, Qi S, et al.Reinvestigation of the origins of pineal meningiomas based on its related veins and arachnoid membranes[J]. BMC Neurol, 2020,20(1):200. DOI: 10.1186/s12883-020-01783-4.
[14]
Qiu B, Wang Y, Ou S, et al.The unilateral occipital transtentorial approach for pineal region meningiomas: a report of 15 cases[J]. Int J Neurosci, 2014,124(10):741-747. DOI: 10.3109/00207454.2013.878341.
[15]
Moshel YA, Parker EC, Kelly PJ. Occipital transtentorial approach to the precentral cerebellar fissure and posterior incisural space[J]. Neurosurgery, 2009,65(3):554-564; discussion 564. DOI: 10.1227/01.NEU.0000350898.68212.AB.
[16]
Komotar RJ, Starke RM, Raper DM, et al.Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of craniopharyngiomas[J]. World Neurosurg, 2012,77(2):329-341. DOI: 10.1016/j.wneu.2011.07.011.
[17]
Ye P, Sun T, Li Z, et al.An Anatomic study of the keyhole supra-tentorium to infra-tentorium endoscope approach[J]. J Craniofac Surg, 2019,30(6):1884-1887. DOI: 10.1097/SCS.0000000000005361.
[18]
Avci E, Dagtekin A, Akture E, et al.Microsurgical anatomy of the vein of Labbé[J]. Surg Radiol Anat, 2011,33(7):569-573. DOI: 10.1007/s00276-011-0782-1.
[19]
Tubbs RS, Watanabe K, Loukas M, et al.Anatomy of the inferior petro-occipital vein and its relation to the base of the skull: application to surgical and endovascular procedures of the skull base[J]. Clin Anat, 2014,27(5):698-701. DOI: 10.1002/ca.22268.
[20]
Brzegowy K, Solewski B, Zarzecki MP, et al.The anatomy of the convergence of major deep cerebral veins in the pineal region: a computed tomography angiography study[J]. World Neurosurg, 2021,147:e334-e342. DOI: 10.1016/j.wneu.2020.12.057.
[21]
Ye Y, Ding J, Huang S, et al.Related structures in the straight sinus: an endoscopic anatomy and histological study[J]. Front Neuroanat, 2020,14:573217. DOI: 10.3389/fnana.2020.573217.
[22]
Shibao S, Toda M, Fujiwara H, et al.Bridging vein and tentorial sinus in the subtemporal corridor during the anterior transpetrosal approach[J]. Acta Neurochir (Wien), 2019,161(4):821-829. DOI: 10.1007/s00701-019-03857-w.
[23]
Mizutani K, Miwa T, Akiyama T, et al.Fate of the three embryonic dural sinuses in infants: the primitive tentorial sinus, occipital sinus, and falcine sinus[J]. Neuroradiology, 2018,60(3):325-333. DOI: 10.1007/s00234-018-1980-x.
[24]
Delion M, Dinomais M, Mercier P.Arteries and veins of the cerebellum[J]. Cerebellum, 2017,16(5-6):880-912. DOI: 10.1007/s12311-016-0828-3.
[25]
Tsutsumi S, Ono H, Ishii H.Bridging veins of the cerebellum: a magnetic resonance imaging study[J]. Surg Radiol Anat, 2021,43(3):437-444. DOI: 10.1007/s00276-020-02664-8.
2023, Vol. 28 
