Endoscopic Third Ventriculostomy and Pineal Biopsy from a Single Entry Point

Endoscopic intraventricular approach are widely used in neurosurgery. Here we describe the full endoscopic technique for third ventriculostomy and pineal biopsy from a single entry point in patient that had obstructive hydrocephalus due to pineal lesions. So endoscopic systems contains bone marrow channel and one irrigation channel.

Bipolar coagulation, nerve balloon, and microforceps are sufficient for the procedure. The advent of advanced technology has enabled the acquisition of high definition HCN for quality images during endoscopic surgeries. Angled and flexible endoscope facilitate more effective work in smaller areas, enhancing the precision and efficiency of surgical procedures.

To begin, insert the 6.1 millimeter wide endoscope into the endoscope sheath, which is already inserted into the lateral ventricular cavity. Identify the septal and thalamostriate veins. Identify and follow the choroid plexus anteriorly up to the third ventricle through the foramen of Monroe, or FOM.

Pass the ventricular scope through the FOM to access the third ventricle. To find the floor of the third ventricle, which is usually thin due to hydrocephalus, identify the mammillary bodies and infundibular recess in the third ventricle. Ensure that the hole at the base of the third ventricle is located at the most translucent point between the infundibular recess and the mammillary bodies.

Use the tip of the four French Fogarty catheter to puncture the base of the third ventricle, then repeatedly inflate and deflate the balloon of the catheter to widen the opening. See the jet flow of CSF when the catheter balloon is deflated. Move the endoscope to the posterior region of the third ventricle, where the pineal gland tumor is located.

Identify the massa intermedia to allow better visualization of the posterior third ventricle. Perform dissection and identify the tumor to examine its growth pattern before carefully coagulating the surface of the tumor using bipolar cautery. After complete coagulation of the tumor surface, take a biopsy using biopsy forceps.

Resect the tumor according to the histopathological diagnosis. Control local hemorrhage with irrigation and bipolar cautery. Remove the endoscopic system before closing the wound with sutures without a drain.