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      Neurosurgical application of pineal region tumor resection with 3D 4K exoscopy via infratentorial approach: a retrospective cohort study


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          The pineal region tumors are challenging for neurosurgeons and can lead to secondary hydrocephalus. The introduction of the exoscope has provided clinical interventions with high image quality and an ergonomic system for pineal region tumor operations. In this study, the authors describe the exoscopic approach used to facilitate the surgical resection of pineal region tumors and relieve hydrocephalus.

          Materials and methods:

          In this retrospective cohort study, we consecutively reviewed the clinical and radiological data of 25 patients with pineal region lesions who underwent three-dimensional exoscopic tumor resection at a single center.


          The patient cohort consisted of 16 males and 9 females, with an average age of 34.6 years (range, 6–62 years; 8 cases aged ≤18). Pathological examination confirmed eight pineal gland tumors, four gliomas, nine germ cell neoplasms, two ependymomas, and two metastatic tumors. Preoperative hydrocephalus was present in 23 patients. Prior to tumor resection, external ventricular drainage (EVD) with Ommaya reservoir implantation was performed in 17 patients. Two patients received preoperative endoscopic third ventriculostomy (ETV), and five patients received a ventriculoperitoneal (VP) shunt, including one who received both procedures. Gross total resection was achieved in 19 patients (76%) in the ‘head-up’ park bench position using the exoscope. Eight patients (31.6%) with third ventricle invasion received subtotal resection, mainly in glioma cases, which was higher than those without invasion (0%), but not statistically significant ( P=0.278, Fisher’s exact test). No new neurological dysfunction was observed after surgery. Two patients (8%) developed intracranial and pulmonary infections, and two patients (8%) suffered from pneumothorax. Hydrocephalus was significantly relieved in all patients postoperatively, and four patients with relapse hydrocephalus were cured during the long-term follow-up. Postoperative adjuvant management was recommended for indicated patients, and a mean follow-up of 24.8±14.3 months showed a satisfied outcome.


          The exoscope is a useful tool for pineal region tumor resection and hydrocephalus relief, particularly with posterior third ventricle invasion, as total resection could be achieved without obvious complication. The special superiority of the exoscope for the indicated pineal region tumors should be highlighted.

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          Most cited references33

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          STROCSS 2021: Strengthening the reporting of cohort, cross-sectional and case-control studies in surgery

          Introduction Strengthening The Reporting Of Cohort Studies in Surgery (STROCSS) guidelines were developed in 2017 in order to improve the reporting quality of observational studies in surgery and updated in 2019. In order to maintain relevance and continue upholding good reporting quality among observational studies in surgery, we aimed to update STROCSS 2019 guidelines. Methods A STROCSS 2021 steering group was formed to come up with proposals to update STROCSS 2019 guidelines. An expert panel of researchers assessed these proposals and judged whether they should become part of STROCSS 2021 guidelines or not, through a Delphi consensus exercise. Results 42 people (89%) completed the DELPHI survey and hence participated in the development of STROCSS 2021 guidelines. All items received a score between 7 and 9 by greater than 70% of the participants, indicating a high level of agreement among the DELPHI group members with the proposed changes to all the items. Conclusion We present updated STROCSS 2021 guidelines to ensure ongoing good reporting quality among observational studies in surgery. • In order to maintain relevance and continue upholding good reporting quality among observational studies in surgery, STROCSS 2019 guidelines were updated through a DELPHI consensus exercise. • 42 people participated in the development of STROCSS 2021 guidelines and there was a high level of agreement among the DELPHI group members with the proposed changes to all the items. • Updated STROCSS 2021 guideline is presented.
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            Vitom-3D for Exoscopic Neurosurgery: Initial Experience in Cranial and Spinal Procedures.

            The authors describe the application of a new exoscope that offers 3-dimensional (3D) visualization in cranial and spinal neurosurgery in detail.
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              Initial Experience Using a High-Definition 3-Dimensional Exoscope System for Microneurosurgery

              The operative microscope and endoscope have significantly advanced modern neurosurgery. These devices are nonetheless limited by high costs and suboptimal optics, ergonomics, and maneuverability. A recently developed extracorporeal telescope (“exoscope”) operative system combines characteristics from both the operative microscope and endoscope and provides an affordable, portable, high-definition operative experience. Widespread use of exoscopes in neurosurgery has previously been limited by a lack of stereopsis with 2-dimensional(2-D) monitors. To assess the surgical potential of a novel, 3-D, high-definition (4K-HD) exoscope system. Assess dissection time and visualization of critical structures in a series of human cadaveric cranial neurosurgical approaches with the 3-D 4K-HD exoscope as compared to a standard operating microscope. Dissection times and visualization of critical structures was comparable with the 3-D 4K-HD exoscope and a standard operating microscope. The low-profile exoscope nonetheless allowed for larger operative corridors, enhanced instrument maneuverability, and less obstruction in passing instrumentation. The large monitor also resulted in an immersive surgical experience, and gave multiple team members the same high-quality view as the primary operator. Finally, the exoscope possessed a more ergonomically favorable setup as compared to the traditional microscope, allowing the surgeon to be in a neutral position despite the operative angle. The novel 3-D 4K-HD exoscope system possesses favorable optics, ergonomics, and maneuverability as compared to the traditional operating microscope, with the exoscope's shared surgical view possessing obvious educational and workflow advantages. Further clinical trials are justified to validate this initial cadaveric experience.

                Author and article information

                Int J Surg
                Int J Surg
                International Journal of Surgery (London, England)
                Lippincott Williams & Wilkins (Hagerstown, MD )
                December 2023
                27 September 2023
                : 109
                : 12
                : 4062-4072
                [a ]Department of Neurosurgery, Huashan Hospital, Fudan University
                [b ]National Center for Neurological Disorders
                [c ]Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration
                [d ]Neurosurgical Institute of Fudan University
                [e ]Shanghai Clinical Medical Center of Neurosurgery, Shanghai, People’s Republic of China
                Author notes
                [* ]Corresponding author. Address: Department of Neurosurgery, Huashan Hospital, Fudan University, No.12 Wulumuqi Zhong Road, Shanghai 200040, People’s Republic of China. Tel.: +860 215 288 9999; fax: +8602152889999. E-mail: maoying@ 123456fudan.edu.cn (Y. Mao); fax: +8602152887230. E-mail: drzhuwei@ 123456fudan.edu.cn (W. Zhu).
                IJS-D-23-00856 00037
                Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.

                This is an open access article distributed under the Creative Commons Attribution-ShareAlike License 4.0, which allows others to remix, tweak, and build upon the work, even for commercial purposes, as long as the author is credited and the new creations are licensed under the identical terms. http://creativecommons.org/licenses/by-sa/4.0/

                : 10 May 2023
                : 13 August 2023
                Original Research
                Custom metadata

                exoscope,hydrocephalus,infratentorial approach,pediatrics,pineal region tumor,third ventricle
                exoscope, hydrocephalus, infratentorial approach, pediatrics, pineal region tumor, third ventricle


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