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The trilateral peritorcular approach

For more than 20 years, I personally prefer the following approach to the pineal region. The patient is positioned in the supine position with the head fixator applied to keep the face down with slight flexion of the neck. The table is rotated as needed in every stage of the operation. The incision is running vertical 10 cm blow and above the occipital protuberance in the midline. Self-retaining retractors are used. An osteoplastic craniotomy with flap is performed with the center of the bony flap is the torculla Herophili. The bone flap is reflected to the neck direction. At first the pineal area is attacked subtentorially in supracerebellar fashion. In case that, it is necessary to attack the area supratentorially, the dura parallel to the SSS is incised. As mentioned earlier, there is paucity of draining veins in this area. The table is rotated as needed so as to use the gravity to assist the surgeon working without surgical trauma. Most of the time there is no need to coagulate bridging veins. The 2 sides are inspected and the most adequate approach is used. It happens that both sides and the subtentorial approach are used simultaneously. After completing the intracranial part of the operation, water-tight closure of the dura with the bone flap returned to place.

This approach gives an absolute control in all anatomical structures, that make the surgeon able to attack the lesion from all the possible angles. It gives the surgeon the alternative route to avoid damage to the venous structures and preservation of the anatomic structures. For case demonstration, please click here!

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