The sub-occipital transtentorial approach revisited base on our own experience

The surgical experience of the sub-occipital approach for treatment of pineal gland and pineal region tumors is reported. This approach was originally proposed by Jamieson and modified by Lapras who by changing the shape of the bone flap obtained the elevation of the occipital lobe which consequently resulted in a better exposition of this deep region. The reason why this approach became the basis for their treatment is particularly related to the personal experience of Lapras who reported his fantastic experience of surgery in this deep area and demonstrated the advantages of the sub-occipital transtentorial approach.

Material: Out of 277 patients operated from 1982 to 2012 in Lyon for a pineal tumor, 233 were treated by a sub-occipital approach: 153 males, 125 females, 75 patients of pediatric age. The majority of patients were operated on in a sitting position which represents a surgical specialty of the anesthesiological school of Lyon.

Results: Complete tumor removal was possible in 135 patients (58%) and partial in 60 patients (26%). For 38 patients, it was not possible to establish the quality of surgical resection. The incidence of hemianopsia decreased to less that 2% of cases while the incidence of severe pneumocephaly which requires a prolonged intensive care hospitalization was less than 4% of cases. Mortality related to this surgical approach in the Lyonnais school series was 0% during this period.

Conclusion: In our experience the sub-occipital transtentorial approach seems to us the best approach for pineal tumors because it permits a large exposition of the pineal region favoring the removal of the tumor with a lateral extension and also for tumors extending low into the posterior cranial fossa. In fact, this is our preferred approach because it has been used in a large majority of cases. However, surgeons have to be familiar with other possible approaches to obtain the best result in terms of removal and also to decrease the rate of sequelae to improve the quality of life of these patients.