January 29, 2016
The operative agenda should remain flexible and change based on moment to moment intraoperative findings. Let's illustrate this important principle using this video where I changed the plan across the interhemispheric corridor in order to preserve important parasagittal veins. This is a 52-year-old female who presented with left-sided posterior medial frontal metastasis. The location of the mass is obvious. Slight edema is present. This mass is relatively small and close to midline. Therefore, an ipsilateral interhemispheric corridor was chosen. The patient was placed in the lateral position with the left side down to exploit gravity retraction. You can see the location of the midline. The craniotomy was initially performed. The superior sagittal sinus was un-roofed. Again, this is the left side. A large parasagittal vein, most likely to the vein of Trolard was uncovered. You can see the vein is pretty much in the middle of our exposure and very adherent. I attempted to untether the vein, however, despite this maneuver, mobilization of the hemisphere would lead to its injury. You can see the operative quarter's relatively small. I altered my operative plan, expanded my craniotomy on the other side. Approached the tumor via the contralateral interhemispheric transfalcine approach. You can see that gravity retraction facilitates the contralatal hemisphere to fall onto my operative corridor. Therefore, a retractor was used. The vein on this side was relatively well out of our operative corridor after it was untethered. The falx over the tumor was exposed using neuronavigation. A transfalcine approach was created. A medial hemisphere over the tumor was widely exposed. You can see additional dissection of the falx using the blunt hook to mobilize the falx and a 15 blade knife to cut the falx. Here's the medial part of the hemisphere overlying the tumor. There, so, the procedure is very straightforward as the tumor is removed and delivered. Again, you can see the importance of a flexible operative agenda, rather than placing the large parasagittal vein at risk with the associated risks of venous infarction, I redirected my attention to the contralateral side and approached the tumor via the transfalcine approach. Thank you.
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