Virtual Reality Surgical Rehearsal and 2-Dimensional Operative Video of a Paramedian Supracerebellar Infratentorial Approach Endoscopic Resection of Pineocytoma: 2-Dimensional Operative Video.

An endoscopic "keyhole" approach to a deep-lying skull base lesion can be a daunting challenge. For the pineal region, the techniques for endoscopic resection of solid tumors in this location are also new.1,2 In such a situation, surgical rehearsal in virtual reality (VR) can significantly improve the surgeon's confidence.3 In this operative video, we demonstrate the use of VR in surgical planning and rehearsal to determine the best approach to a large, solid pineal tumor in a 46-yr-old patient. Using the patient's computed tomography angiography and magnetic resonance imaging, a VR model of his anatomy was created (SNAP VR360 version 3.8.0, Surgical Theater Inc, Cleveland, Ohio). VR rehearsal showed that, with the tumor tucked under the corpus callosum and cradled by the internal cerebral veins and veins of Rosenthal, a supratentorial approach would be suboptimal. Because of the steep angle of the patient's tentorium in the midline, a classic supracerebellar infratentorial (SCIT) approach would be challenging, and thus a paramedian variant of SCIT was chosen.4 For a right-handed surgeon, the left side was used, and the endoscope was docked at the extreme left, out of the main surgical corridor. Shown in the video, the endoscopic resection achieved a complete resection. The histopathological diagnosis was a pineocytoma. No adjuvant treatment is recommended. Given the rarity of pineocytoma,5 the novelty of endoscopic resection of solid tumors in the region, and the challenge of "keyhole" approaches to deep-lying targets, VR rehearsal facilitated the achievement of the surgical goal and avoided the morbidity of a more extensive exposure. Patient consent was obtained prior to the creation of the video and available on request. RHOTON images in the video are from The Rhoton Collection®.