Neurosurgery - Telovelar approach

 Telovelar approach is carried out for the removal of any pathology that is present inside the 4th ventricle or the rhomboid fossa of the brain.

The Space seen here behind the cerebellum is the rhomboid fossa (Fossa is just a trench or a channel). This rhomboid fossa forms a part of the 4th ventricle, which is connected to the third ventricle above by cerebral aqueduct and then runs downwards into the spinal cord as the central canal of the spinal cord, carrying the CSF (CerebroSpinal Fluid).

The part behind the PONS and between the white core of cerebellum is called as the 4th ventricle.

{For more information on anatomy of brain, please refer to our another blog on BRAIN}

Telovelar approach is done by first clearing out the hair on the back of your head and making incision lines on it.

Then the base of the skull is cracked open to achieve the desired field of view, by separating the fascia, arachnoid, and pia over the cerebellar surface. In order to achieve a wide field of view, sometimes the vertebral area, i.e. C1 and C2 are also dissected. 

Upon opening the scenario looks something like this

PICA = Posterior Inferior Cerebellar Artery

Tonsil = posterior part of cerebellum.

The electrode is taken and the firing potential of surrounding area is noted. This helps in identifying the normal tissue and abnormal tissue as the tumor has erratic potential as compared to the normal firing level of other parts of the brain. A plane of dissection is identified and the operation is carried out. To make thing easier, the gauze piece is placed inside the dissected part which helps in separating the normal tissue and the tumor tissue.

Once sufficient dissection is done, the tumor tissue is debrided into small pieces using a microdebrider. Care is taken again and again to not injure the healthy tissue by constantly checking the potentials and adding gauze pieces.

On complete removal, the gauze pieces are removed and sutures are placed in to keep things together.

Patient is started on antibiotics to prevent any infection.

This image shows the progression of the tumor in the 4th ventricle. You can clearly see the tumor in the 3rd scan taken on april 2016.

This scan shows the preoperative and postoperative improvement after 2.5 years.

Please note: All these scans are used only for educational purposes with no other intent. The identity of the patient is kept secret because of medical purposes. All the pictures of operation and scans are obtained from the video posted by AANSNeurosurgery. All rights and credits to them.