Use of the 3D exoscope for the supracerebellar infratentorial approach in the concorde position: an effective and ergonomic alternative. Illustrative cases

BACKGROUND: The supracerebellar infratentorial approach provides wide flexibility as a far-reaching corridor to the pineal region, posterior third ventricle, posterior medial temporal lobe, posterolateral mesencephalon, quadrigeminal cistern, and thalamus. Traditionally, the patient is placed in the sitting position, allowing gravity retraction on the cerebellum to widen the supracerebellar operative corridor beneath the tentorium. What this approach gains in anatomical orientation it lacks in surgeon ergonomics, as the sitting position presents technical challenges, forces the surgeon to adopt to an uncomfortable posture while performing the microsurgical dissection/tumor resection under the microscope, and is also associated with an increased risk of venous air embolism. OBSERVATIONS: In this article, the authors present the use of the three-dimensional (3D) exoscope with a standard prone Concorde position as an alternative for the treatment of lesions requiring a supracerebellar infratentorial approach for lesions in the pineal region, posterior third ventricle, and the superior surface of the cerebellar vermis. The authors present four illustrative cases (one pineal cyst, one ependymoma, and two cerebellar metastases) in which this approach provided excellent intraoperative visualization and resulted in good postoperative results. A step-by-step description of our surgical technique is reviewed in detail. LESSONS: The use of the 3D exoscope with the patient in the prone Concorde position is an effective and ergonomically favorable alternative to the traditional sitting position for the treatment of lesions requiring a supracerebellar infratentorial approach. This technique allows improved visualization of deep structures, with a possible decreased risk of potential complications.