Tumor surgery has greatly benefited from minimally invasive techniques including limited corridors of entry, preoperative embolization, brachytherapy, image guidance, and endocopic assistance. Many of these techniques are discussed in other chapters, but the use of the endoscope in pediatric tumor surgery is worth discussing here. The endoscope can be employed to biopsy and/or resect intraventricular tumors safely. Midline lesions that abut the ventricular system pose an increased surgical risk with stereotactic methods owing to the proximity of critical neurovascular structures, and they also require a large craniotomy to attain the necessary exposure. Ventricular endoscopy may allow safe biopsy in such cases, again touting the advantage of directly visualizing the tumor and the ability to select a less vascular portion of the lesion. In general, endoscopic biopsy is contraindicated in highly vascular lesions as it is hard to control bleeding with the endoscope. The risk of intraventricular seeding of the tumor must be considered, although endoscopy may be advantageous compared with craniotomy because immediate whole craniospinal radiotherapy can be initiated following the minimally invasive endoscopic surgery. Endoscopic biopsy of germinoma in the posterior third ventricle is an
Fig. 1. (A) Preoperative sagittal MRI image of large suprasellar cyst causing obstructive hydrocephalus. (B) Endoscopic view at the foramen of Monroe prior to cyst fenestration. (C) View after initial puncture through the cyst wall. (D) Endoscopic image after wide fenestration of the cyst with the pituitary gland and infundibulum visible through the cyst wall. (E) Postoperative sagittal MRI revealing decreased cyst size and reestablishment of normal third ventricle anatomy. (Figure courtesy of Dr. Liliana Goumnerova. See Color Plate 6 following p. 112.)
excellent example of this. For cases presenting with hydrocephalus, the tumor can be biopsied with either associated third ventriculostomy or immediate postoperative irradiation to treat the hydrocephalus. There is an existing literature on use of the endoscope to resect colloid cysts of the third ventricle (18) with a low complication and recurrence rate; as comfort levels and technology grow, the use of endoscopy will only grow.
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