Abstract：
Pineal tumors are rare but surgically challenging due to their deep location and proximity to major veins and brainstem.1,2 Getting a biopsy along with an endoscopic third ventriculostomy is essential before surgical resection.3,4 The supracerebellar infratentorial approach provides direct symmetrical exposure of the pineal region inferior to the vein of Galen.5,6 3-Dimensional (3D) exoscopes are increasingly used due to better ergonomics, greater depth of field, and equivalent image quality of microscope. The endoscope provides angled optics to visualize hidden areas of tumor adherent to neurovascular structures, avoiding blind dissection. These become especially advantageous during suboccipital keyhole surgery in the sitting position, which averts both cerebellar retraction and frequent soiling of the endoscope. In this case of a giant pineal papillary tumor in a 16-year-old patient, we used both a 3D-exoscope and a 45-degree angled endoscope complementarily (Video 1). The tumor underwent straight-ahead internal decompression using an exoscope. Once some space became available, the angled endoscope was inserted to excise the tumor initially in the inferior aspect and then rotated toward either side to dissect the tumor from the basal veins of Rosenthal. Lastly, the superior pole stuck to the undersurface of the vein of Galen was gradually excised. There were no neurologic deficits. Histopathology was a high-grade papillary tumor. Magnetic resonance imaging confirmed gross total resection. This is probably the first report of a supracerebellar infratentorial keyhole approach for gross total resection of a giant pineal tumor, effectively using the better ergonomics and depth of field of a 3D exoscope along with angled optics provided by an endoscope, resulting in an excellent outcome.
摘要：
松果体肿瘤是罕见的，但手术具有挑战性，因为它们的位置很深，靠近大静脉和脑干。1,2在手术切除之前必须进行活检和ETV。更大的景深，和同等的显微镜图像质量。内窥镜提供成角度的光学观察肿瘤的隐藏区域粘附到神经血管结构，避免盲目解剖。这些在坐姿的枕下锁孔手术中变得特别有利，这避免了小脑退缩和内窥镜的频繁污染。在这个16岁的巨大松果体乳头状肿瘤中，我们互补地使用了3D外镜和45°角度的内窥镜。使用外镜对肿瘤进行了直接的内部减压。一旦一些空间变得可用，插入成角度的内窥镜以切除最初位于下方的肿瘤，然后向两侧旋转，从罗森塔尔的基底静脉解剖肿瘤，最后，卡在盖伦静脉下表面的上极被逐渐切除。没有神经缺陷。组织病理学为高度乳头状肿瘤。MRI证实大体全切除。这可能是对巨大松果体肿瘤全切除的小脑上幕下锁孔入路的首次报道。有效地利用更好的人体工程学和景深的3D外镜以及由内窥镜提供的成角度的光学，结果很好。
