H20 Dissection Technique of Toth for Opening Nsx Cleavage Planes

8/2/2019 H20 Dissection Technique of Toth for Opening Nsx Cleavage Planes

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Technique

Water dissection technique of Toth for opening neurosurgicalcleavage planes

Laszlo Nagy, MDa, Keisuke Ishii, MD, PhDc, Ayse Karatas, MDc, Hu Shen, MDc,Janos Vajda, MD, PhDa, Mika Niemel7, MD, PhDc, Juha J77skel7inen, MD, PhDc,

Juha Hernesniemi, MD, PhDc,T, Szabolcs Toth, MD, DMScb

aDepartment of Neurosurgery, National Institute of Neurosurgery, and

bDepartment of Neurosurgery, MAV Hospital, Budapest, Hungary

cDepartment of Neurosurgery, Helsinki University Central Hospital, 00260 Helsinki, Finland

Received 10 May 2005; accepted 18 August 2005

Abstract Background: The low-pressure water dissection technique of Toth, first reported in 1987, is amethod to cautiously open neurosurgical cleavage planes such as the sylvian fissure or the

interhemispheric space, and the interfaces between extraparenchymal masses and the adjacent brain.

The aim of this technical report is to present our long-term experience with this simple and elegant

asset of microneurosurgery and to promote its widespread use.

Method: Water is injected under microscopic control by a handheld syringe with a blunt needle or

by an irrigating balloon applying repeated injections of physiological saline into the cleavage plane

to open it.

Findings and Conclusion: The water dissection technique of Toth has been extensively used in

Budapest and Helsinki in thousands of microsurgical cases, in removal of meningiomas and to open

sylvian and interhemispheric fissure. In our experience, there have been no noticeable complications,

and we recommend this technique for widespread use. It is a very inexpensive, simple, and effective

method not requiring any expensive or complicated devices.

D 2006 Elsevier Inc. All rights reserved.

Keywords: Water dissection technique; Subarachnoid space; Cleavage plane; Meningioma; Sylvian fissure dissection;

Microsurgery

1. Introduction

One of the least known and most elegant techniques in

microneurosurgery is the use of WDT. Water dissection

technique, using the separating effect of injected low gentle

pressure physiological saline, was introduced by Toth et al

[18] in early 1980s and published in 1987 (Fig. 1). It is a

simple method to cautiously open natural preformed

cleavage planes such as the sylvian fissure or the inter-

hemispheric space, and the interfaces between the cortex

and extraparenchymal lesions such as meningiomas, aneur-

ysms, and AVMs. The aim of the present technical report is

to present our long-term experience with the low-pressure

water dissection technique as an adjunct to everyday

microneurosurgical practice. An early comparison of micro-

surgery with and without WDT was done by Toth et al [18],

but no randomized trial has been conducted comparing

the pros and cons of the technique.

In the original article by Toth, the method was calledbwater jet dissection technique.Q However, in later publica-

tions on a method called bwater jet resection technique,Q

using high pressure, the tissue incision in experimental

conditions appeared [5,7,10,11,17], and it has also been

introduced into the clinical field, for example, cornea [3],

liver [6,19], and kidney [1,15] surgery. Frankly, these two

are completely different methods indeed. Toth water

dissection is a gentle microsurgical method, but the water

jet resection works more like a bdestructive knife.Q

0090-3019/$ see front matterD 2006 Elsevier Inc. All rights reserved.

doi:10.1016/j.surneu.2005.08.025

Abbreviations: AVMs, arteriovenous malformations; WDT, Water

dissection technique; MCA, middle cerebral artery.

T Corresponding author. Tel.: +358 504270220; fax: +358 9 471 87560.

E-mail address: [email protected] (J. Hernesniemi).

Surgical Neurology 65 (2006) 38 41

www.surgicalneurology-online.com


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2. Neurosurgical cleavage planes

A microneurosurgeon faces many cleavage planes to

be gently opened, thus avoiding damage to the brain

tissue by compression. These cleavage planes include (a)

natural but adherent spaces such as the sylvian fissure in

front of middle cerebral artery aneurysms and insular

tumors, the interhemispheric space above falcine or thirdventricle tumors and distal anterior cerebral artery

aneurysms, the space between the tonsils and medulla

behind posterior inferior cerebellar artery aneurysms, and

the way into the fourth ventricle; and (b) interfaces

formed between brain tissue and solid extraparenchymal

masses, and so on. Meningiomas and large/giant aneur-

ysms, which grow in eloquent cortical or deep areas, may

push these areas to unexpected directions or bury them

into the cleavage plane. After widening the cleavage

planes with WDT, the microsurgical methods to separate

cleavage planes include classic sharp opening of arachnoidal

adhesions and dissection of vessels and nerves with

intermittent use of bipolar or jeweller forceps, suction,

microscissors, and surgical pads to make the way. In our

current practice, we avoid the use of retractors as much as

possible [8].

We provide the water jet by a 20- to 50-mL syringe

with a blunt steel needle or a plastic flexible needle

(Fig. 2A), but an irrigating balloon is also feasible. The

irrigation pressure is hand-controlled according to the

microscopical view of the ongoing dissection, and conse-

quently it requires learning the feasible applications

(Fig. 2B). This technique does not need special equipment,

and it is easily adapted to everyday microsurgical practice.

We do not find constant pressure irrigation provided by apump or a pressurized cuff on a saline bag practical

because the jet pressure cannot be adopted according to the

anatomical findings.

3. Cleavage planes of meningiomas, giant aneurysms,

and AVMs

Meningiomas usually rather compress than infiltrate the

adjacent cortex or cranial nerves (Fig. 3A and B). The

tumor-cortex interface is crossed by varying numbers of

small feeding arteries and veins to be interrupted, non-

feeding arteries, sometimes embedded in meningioma

tissue, and veins to be preserved. Benign meningiomas

may partially disrupt the arachnoidal and pial layers,

which combined with softened, gliotic, and edematous

cortex, make the true arachnoidal cleavage plane hard to

maintain [16]. Genuine infiltration of the brain, seen at

least in grade III tumors [9], also makes the surgical

cleavage uncertain. High-quality magnetic resonance im-

aging and computed tomography may give valuable data

on the cleavage plane, infiltration of the cortex, vascular

supply, and encasement vessels [2,4,13,14,16]. In large/

giant aneurysms that may be filled with thrombus,

previously incompletely coiled or otherwise indicating

reconstruction of its neck, it may be necessary to dissect

the sac loose from the adjoining brain tissue and arteriesbefore resection of the sac and clipping the neck or

reconstruction of the parent vessel. In AVMs, enlarged and

convoluted vessels and the nidus need to be carefully

separated from adjacent, possibly eloquent areas using

their gliotic cleavage (see Video 1).

4. Opening the sylvian fissure

We usually approach nearly all middle cerebral artery

aneurysms directly by opening the fissure laterally,

beginning with jeweller forceps and then continuing with

Fig. 2. A: Simple syringe. B: Intraoperative picture demonstrates the

separation effect of low-pressure WDT under microscope.

Fig. 1. Principle of WDT.

L. Nagy et al. / Surgical Neurology 65 (2006) 38 41 39


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water dissection [12]. Even in acute subaracnoid hemor-

rhage, in most cases enough space can be obtained by

patiently removing cerebrospinal fluid after the fissure is

first open. If the brain is very edematic and swollen andthe fissure very tight, cerebrospinal fluid can be first

removed by opening the frontobasal cisterns, or more

effectively, the lamina terminalis, or both. Gentle injection

of fluid into the sylvian fissure helps tremendously in its

opening. Once enough room is achieved, the lateral

dissection is carried deeper into the fissure, and 1 of the

distal MCA branches is followed to the aneurysm. Many

times, the sylvian fissure is opened straight over the

aneurysm. Usually, at this stage of dissection the need for

lobe retraction is minimal and is achieved with small

cotton patties (see Video 2).

5. Discussion

In 1987, Toth et al [18] published their original article on

3-year clinical experience on WDT, injection of body-

temperature physiological saline by a handheld syringe with

blunt needle or by an irrigating balloon, in the microsurgical

dissection of intracranial meningiomas. The technique has

proven to be a safe and a practical adjunct in careful

separation of tumor tissue from the adjacent cortex, vessels,

and cranial nerves. Since 1984, 3 senior authors (SzT, JV,

and JH) have extensively used WDT in thousands of

microsurgical cases, mainly meningiomas, aneurysms, and

AVMs. Water dissection is aimed to improve (a) cautiousopening of the cleavage plane, (b) avoidance of damage to

the adjacent, possibly eloquent cortex, (c) preservation of

nonfeeding cortical arteries and veins, and (d) avoidance of

the use of retractors.

In most extraparenchymal lesions, cleavage planes are

under pressure by the mass effect. Water dissection

technique should not be used alone against this pressure,

and it is recommended to apply after extensive debulking of

the lesion. The proper management of the cleavage planes

using low-pressure water is then combined with the

routine microsurgical separation of structures, like pulling

arachnoid edges adhered to the lesion along the pial vessels

in the typical triangle fashion.

Limitations of the WDT may arise from firm adhesions

in cleavage spaces or tumor infiltration of the surroundingand softened brain tissue. Potential hazards of the technique

include (a) infusion of saline into brain tissue by using too

high or inappropriately directed pressure; (b) increased

pressure in the cleavage space because of insufficient

outflow of the fluidthe surgeon should provide and

secure sufficient outflow while maintaining adequate

separating pressure; (c) abrupt loss of control of irrigation

pressure because of air in the syringe; and (d) creating a

false cleavage plain. It is very important to avoid infusion

into brain tissue, for example, with meningiomas hiding and

compressing eloquent cortical areas or breaking the pia-

arachnoid layer (malignant meningiomas). All of the

previously mentioned mainly theoretical complications

may be avoided by using careful caution, and in fact, in

our experience, there have not been any such complications.

We recommend the water dissection technique as an asset of

microsurgery for neurosurgeons already in training.

6. Conclusions

Hand-controlled WDT, using the separating property of

the fluid, is a safe, very inexpensive, and effective aid (a) in

the microsurgical removal of solid extraparenchymal space-

occupying lesions and (b) opening of cleavage planes

created by the nature such as the sylvian fissure or theinterhemispheric space. We recommend WDT for wide-

spread use in microneurosurgery. After experience with

thousands of patients, a randomized study seems as

unnecessary as comparing 2 different microinstruments.

Most small microsurgical steps and tricks have taken their

stable places without such studies.

Acknowledgments

The authors thank Drs Jussi Antinheimo, Lorand Eross,

Zerind Szabo, Late Zoltan Toth, and Avula Chakravarthi

Fig. 3. Convexity meningioma and its delicate separation from eloquent cortex with WDT at the beginning (A) and lost stage (B) of surgery (cf Video 1).

L. Nagy et al. / Surgical Neurology 65 (2006) 38 4140


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for their technical support, and Mr Balazs Papp for his

artistic work.

Appendix A

Supplementary data associated with this article (Videos

1 and 2) can be found, in the online version, at doi:10.1016/

j.surneu.2005.08.025.

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Commentary

The low-pressure water jet is used with considerable

success by the authors for the opening of cerebral fissures

and dissection of arachnoid and pial planes. The use of the

technique in freeing meningiomas and aneurisms is well

presented. The dissection pressure is quite low, coming from

a fine blunt needle and connected to a handheld syringe in

the surgeons hand, giving the surgeon complete control of

the pressure. Although the procedure was reported in theUnited States with an article by Pick in J Neurosurg in

1998, it never reached a significant level of usage.

Leonard I. Malis, MDF

F No affiliation is needed. Dr Malis died in early September 2005.

L. Nagy et al. / Surgical Neurology 65 (2006) 38 41 41
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H20 Dissection Technique of Toth for Opening Nsx Cleavage Planes