52 Endoscopic Septostomy The endoscopic septostomy is a minimally invasive, intraventricular endoscopic procedure. It allows creating a communication between both the lateral ventricles by opening the septum pellucidum. It is indicated in case of obstructive mono-ventricular hydrocephalus. Surgical access to the lateral ventricle is just lateral as compared to the standard approach for the placement of an external ventricular shunt. • Mono-ventricular hydrocephalus due to tumoral or membranous (inflammatory, post-hemorrhagic) obstruction in the region of foramina of Monro or fornix. • Cysts of the septum pellucidum. • Multi-loculated cystic hydrocephalus. • Position: The patient is positioned supine with the head fixed to a three pins Mayfield head-holder. Fig. 52.1 Patient positioning and landmarks. • Body: The body is placed parallel to the horizontal plane in neutral position. • Head: The head is flexed 30° and the neck is kept in straight position. • Linear incision ◦ Incision is located just in front of the coronal suture, according to the selected entry point (see burr hole). ◦ The incision is 3 cm long. • C-shaped incision ◦ The C-shaped incision is based toward the superficial temporal artery. ◦ It is preferred if a cerebro-spinal fluid (CSF) reservoir needs to be implanted. • None • Galea capitis and periosteum ◦ The galea capitis and periosteum are cut according to the shape of the skin incision. • None • Single burr hole ◦ Burr hole is usually 10 mm wide. ◦ It is placed 5 to 7 cm away from the midline, on the side of the dilated ventricle, just anterior to the coronal suture according to the procedure: – Pure septostomy: Hole is placed 5-7 cm paramedian in order to achieve the more perpendicular route to the septum pellucidum. – Septostomy and endoscopic tumor procedures (biopsy or endoscopic excision) in the area of the foramina of Monro: burr hole is placed 5 cm paramedian. – Septostomy and endoscopic third ventriculostomy: Hole is performed 4 cm away from the midline. • None • Cross-shaped fashion ◦ A cortical exposure of 5-7 mm is needed to put the endoscope in place. • None • Intradural procedure comprises the following steps: ◦ Leptomeningeal and cortex bipolar coagulation and incision. ◦ Ventricle tap with a standard catheter to verify accuracy of the planned trajectory and to sample CSF when needed for laboratory testing. ◦ Peel away or endoscopic sheath freehand positioning (with a dynamic reference frame on it, if neuro-navigation tools are used) and fixation on a pneumatic/mechanic holder covered by a sterile drape (see Chapter 27). ◦ Endoscope placement through the sheath. ◦ Inspection of the ventricular cavity and identification of the local anatomy and landmarks (Fig. 52.2). ◦ Pulsated manual irrigation with lactate Ringer’s solution 36-37°C (always check that there is always one irrigation port unlocked to prevent dangerous spikes of intracranial pressure).
52.1 Introduction
52.2 Indications
52.3 Patient Positioning (Fig. 52.1)
Abbreviations: Coronal suture (blue line).
52.4 Skin Incision (Fig. 52.1)
52.4.1 Critical Structures
52.5 Soft Tissue Dissection
52.5.1 Critical Structures
52.6 Craniotomy/Craniectomy (See Chapter 50)
52.6.1 Critical Structures
52.7 Dural Opening
52.7.1 Critical Structures
52.8 Intradural Procedure
Neupsy Key
Fastest Neuropsychology Insight Engine
