Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous disorder. Tubers of the central nervous system are a hallmark of the disorder and often cause epilepsy. Many TSC patients fail to achieve seizure control with medication alone. Several case series have demonstrated high seizure freedom rates after resective surgery. However, the technique for the resection of epileptogenic tubers has largely been unreported. Here the authors present 2 cases to illustrate their multistage approach for localizing and resecting the seizure onset zone in patients with TSC. At their institution, they have excellent seizure outcomes and a low complication rate with this technique. The video can be found here: https://stream.cadmore.media/r10.3171/2024.4.FOCVID2411.

Transopercular approach to the insula is indicated for resection of insular low-grade gliomas, particularly for Yasargil\'s 3B, 5A, and 5B types. Nevertheless, the infrequent location and its challenging approach make it difficult to master the surgery. Consequently, a realistic laboratory training model might help to acquire key surgical skills. In this video, we describe a cadaveric-based model simulating the resection of a temporo-insular low-grade glioma. Kingler\'s fixation technique was used to fix the cadaver head before injecting red and blue colorants for a realistic vascular appearance. Hemisphere was frozen for white matter tract dissection. Tractography and intraoperative eloquent areas were extrapolated from a glioma patient by using a neuronavigation system. Then, a fronto-temporal craniotomy was performed through a question mark incision, exposing from inferior temporal gyrus up to middle frontal gyrus. After cortical anatomic landmark identification, eloquent areas were extrapolated creating a simulated functional cortical map. Then, transopercular noneloquent frontal and temporal corticectomies were performed, followed by subpial resection. Detailed identification of Sylvian vessels and insular cortex was demonstrated. Anatomic resection limits were exposed, and implicated white matter bundles, uncinate and fronto-occipital fascicles, were identified running through the temporal isthmus. Finally, a temporo-mesial resection was performed. In summary, this model provides a simple, cost-effective, and very realistic simulation of a transopercular approach to the insula, allowing the development of surgical skills needed to treat insular tumors in a safe environment. Besides, the integration of simulated navigation has proven useful in better understanding the complex white matter anatomy involved. Cadaver donation, subject or relatives, includes full consent for publication of the images. For the purpose of this video, no ethics committee approval was needed. Images correspond to a cadaver head donation. Cadaver donation, subject or relatives, includes full consent for any scientific purposes involving the corpse. The consent includes image or video recording. Regarding the intraoperative surgical video and tractography, the patient gave written consent for scientific divulgation prior to surgery.

BACKGROUND: Advances in the oncologic and functional results of insular surgery have been reported recently. Such successes have been made possible by the advent of the transopercular approach under awake monitoring and by improved anatomic and functional knowledge of white matter pathways surrounding the insula. Nonetheless, given the rarity of insular tumors, it is difficult to get familiar with the complex 3-dimensional anatomy of the different neuronal and vascular structures encountered during a transopercular insular resection. We thus propose to develop a laboratory model allowing to train transopercular approaches of the insula.
METHODS: Two hemispheres prepared with Klinger\'s technique were dissected under light microscope, preserving all pial membranes. The different steps of the dissection were video recorded.
RESULTS: Preservation of pial membranes enabled us to simulate subpial resection, both during operculum removal and during insular cortex resection. The medial wall of the resection was defined by the inferior-fronto-occipital fasciculus, protecting from the lenticulostriate arteries.
CONCLUSIONS: In this paper, we show that Klinger dissection with preservation of pial membranes provides a realistic model of insular surgery, allowing surgeons to learn and train on this highly specialized surgery.