October 28, 2019
This video describes the landmarks for performance of a standard frontal lobectomy, both as an oncological procedure and a epilepsy procedure. This is a 45-year-old female who was suffering from left frontal epilepsy. You can see the incision in this case, which is a Soutar incision, starts from anterior to the ear, just above the zygoma, extends all the way to the mid-pupillary line, contralaterally. The dura is open based over the superior sagittal sinus, which is located here. Here's the area of the coronal suture. The corticotomy is conducted just at the level of the coronal suture, or anterior to it. White matter disconnection continues. Stealth neuronavigation can be quite effective. Dissection and disconnection continues to level off the pia over the falx. Here you can see the interhemispheric space. I'll go ahead and cut the pia at this level, however, remain subpial as I get closer to the cingulate gyrus, in order to protect the vascular structures and pericallosal arteries. Here's continuation of the disconnection. The path of disconnection is 45 degrees down toward the sphenoid wing. Neuronavigation may be used in order to avoid entry into the frontal horn. You can see the use of bipolar forceps as scissors. When coagulation is on, here's neuronavigation. Just making sure that the course of dissection skips over the ependym of the frontal horn. Now I redirect the attention to find the sphenoid wing in a moment. I avoid going deep in certain locations, and superficial in the others. Now I look for the sphenoid wing along the latter aspect of the craniotomy. Subpial dissection continues. The bigger mass is removed as soon as possible so I can have more space to work through. Here's the interhemispheric space, staying subpial, close to the A2s and pericallosal arteries. One of the olfactory nerves may have to be sacrificed. Here again, you can see the cribriform plate. The orbital frontal artery that's going to the ipsilateral hemisphere. All the vessels are protected within this subpial space. And the bigger mass is being removed. The filler of the frontal fossa. Again, continuing subpial dissection protecting the A2 and pericallosal branches, ipsilaterally. Again, this is the interhemispheric space. You can see the method of subpial evacuation of the gyrus while protecting the pia over the vessel. Here again is the sphenoid wing, a very important landmark in terms of extent of resection more inferiorly. Neuronavigation can confirm lack of entry into the frontal horn. Thank you.
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