Cirugía de la región insular. Ventajas de un abordaje quirúrgico combinado Transsilviano + Transcortical

Abstract

Insular lesions generate a constant challenge, due to their location in the depth of Silvio's fissure, being covered by operculums and critical vascular structures, as well as being surrounded by functional cortical structures that include motor and language areas. making the approach to these injuries more complex. Transsylvian (TS) access to these structures requires a wide opening of the Silvio valley, with opercular retraction, which is limited by the superficial vascular structures. The transcortical (TC) access will allow us a greater insular exposure, surgical window and surgical freedom. The versatility between transylvian and transopercular access and the mixture of these techniques allows us to adapt, according to the findings, to a better resection of deep lesions that affect this area. Methodology: Observational, retrospective. The adult population is included, of 22 patients, between the years 2011 to 2020, who underwent resection of lesions in the insular/ para-insular region. We assess the extension of resection (EOR) and demonstrate its impact on the long-term outcome. Results: 33 procedures, 11 patients had low-grade gliomas (LGG) and 11 high-grade gliomas (HGG). The average extension of the resection with the Transilvian + Transcorical approach was 81.3% (range 36-100%). New permanent postoperative deficits were observed in 2 patients. In 50%, more than one intervention was necessary. Six deaths (27%) were identified during a median follow-up of 5 years. EOR predicted progression-free survival (PFS). Conclusions: The TC + TS access offers safety and a wide surgical field in the lesions of the insular region, allows a good vascular control, a strong positive impact on the extension of the tumor resection (EOR), improving the prognosis, preserving the quality of life with acceptable post-operative neurological morbidity.