Transcortical endoportal subchoroidal endoscope-assisted approach to the third ventricle: from virtual reality to anatomical laboratory.

Background: Surgical approaches to the third ventricle (TV) have always represented a technical challenge in neurosurgery. Virtual reality (VR) is attaining increasing relevance in training programs and preoperative planning. The aim of this study is to demonstrate the worthwhile mutual contribution of VR simulations and specimen dissections to develop a new surgical approach to the TV.

Methods: The transcortical endoportal subchoroidal endoscope assisted (TEPSEA) approach was planned and simulated thanks to VR (Surgical Theater, LLC, Cleveland, OH, USA), and then implemented on cadaver specimens by using the VBAS portal system (Viewsite™ Brain Access System TC Model, Vycor Medical™ Inc., Boca Raton, FL, USA). We assessed anthropometric measurements during VR planning and evaluated surgical operability during anatomical dissections.

Results: Surgical field depths measured between 75.6 and 85.3 mm to mammillary bodies and habenular commissure, which were in mean 20.2 mm away. An 18-mm movement was estimated for 15°-posterior tilting of a 70-mm long VBAS. Excellent exposure and maneuverability were achieved within the TV through a 2.47 cm portal working area. The 30°-endoscope assistance expanded the access towards the anterior and posterior walls of the TV particularly to the infundibular recess, mammillary bodies, habenular commissure and pineal recess.

Conclusions: We documented the utility of a step-by-step VR planning and simulation followed by anatomical dissections to study surgical approaches to deep brain areas. The TEPSEA exploits the portal system and endoscopic assistance to access the entire TV minimizing cortical and white matter manipulation.