EPILEPSY SURGERY TECHNIQUES

Corpus callosotomy—Open and endoscopic surgical

techniques
*Matthew D. Smyth, *Ananth K. Vellimana , †‡Eishi Asano , and §Sandeep Sood

Epilepsia, 58(Suppl. 1):73–79, 2017

doi: 10.1111/epi.13681

SUMMARY
Corpus callosotomy is a palliative surgical procedure for patients with refractory epi-
lepsy. It can be performed through an open approach via a standard craniotomy and
the aid of an operating microscope, or alternatively via a mini-craniotomy with endo-
scope assistance. The extent of callosal disconnection performed varies according to
indications and surgeon preference. In this article, we describe both open and endo-
scopic surgical techniques for anterior and complete corpus callosotomy.
KEY WORDS: Corpus callosotomy, Callosotomy technique, Complete callosotomy,
Endoscopic callosotomy, Epilepsy surgery.

Dr. Smyth is a
Professor of
Neurosurgery at
Washington University
and St. Louis
Children’s Hospital.

Corpus callosotomy was introduced by Van Wagenen surgery.2,3,6 Although corpus callosotomy is generally well
and Herren in 1940.1 Over time, numerous refinements in tolerated, transient or permanent postoperative neurologic
surgical technique have occurred and corpus callosotomy is deficits including hemiparesis, aphasia, mutism, akinesia,
now a widely accepted surgical option in appropriately and disconnection syndromes may occur.2,3,6
selected patients. Surgical disconnection of the corpus cal- The extent of callosotomy performed varies across sur-
losum disrupts synchronization of epileptiform discharges gical centers, and many surgeons prefer an anterior half or
between bilateral cerebral hemispheres and is therefore two thirds callosotomy sparing the splenium, as this has a
effective in reducing the severity and frequency of general- lower incidence of postoperative complications. In our
ized seizures. It is a viable palliative surgical procedure for experience, both anterior two thirds and complete calloso-
patients with medically refractory generalized seizures and tomy result in improved seizure control.2,3 However, chil-
partial seizures with rapid secondary generalization in the dren with failed anterior two thirds callosotomy who
absence of an identifiable seizure focus.2–6 Generalized sei- subsequently underwent a second procedure for complete
zures with falls (e.g., myoclonic seizures, tonic seizures, callosotomy, and those who underwent upfront complete
atonic seizures) are particularly likely to respond to callosotomy, experienced improvement of a broader spec-
trum of seizure types than those who underwent only an
Accepted September 13, 2016. anterior two thirds callosotomy.2,3 Moreover, children who
*Department of Neurological Surgery, Washington University School
of Medicine, St. Louis, Missouri, U.S.A.; Departments of †Pediatrics;
underwent an upfront complete callosotomy had broader
‡Neurology; and §Neurosurgery, Wayne State University School of Medi- seizure control than those who underwent a two-stage
cine, Children’s Hospital of Michigan, Detroit, Michigan, U.S.A. complete callosotomy. However, the higher potential for
Address correspondence to Dr. Matthew D. Smyth, One Children’s
Place, Suite 4s20, St. Louis, MO 63110-1077, U.S.A.. E-mail:
postoperative neurologic complications and possible
[email protected] unmasking of dormant seizures after a complete calloso-
Wiley Periodicals, Inc. tomy must be carefully considered when deciding on the
© 2017 International League Against Epilepsy extent of callosal disconnection to be performed.2,3

73
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M. D. Smyth et al.

Key Points
• Callosotomy is effective for atonic seizures and other
generalized seizure types
• Anterior or complete callosotomy may be performed
through a single exposure
• Complete callosotomy may provide better seizure
control than anterior, but slightly increased surgical
complication rates
• Endoscope-assisted callosotomy provides for a smal-
ler incision and craniotomy and may decrease opera-
tive morbidity

Technically, both anterior and complete corpus calloso-

tomies may be performed via an open or endoscopic
approach.3,5 Although how the procedure is done is unli-
kely to affect the outcome, endoscopic corpus callosotomy
does offer the benefit of a smaller incision, minimized
brain retraction, and lower postoperative pain.

Open Corpus Callosotomy

An open corpus callosotomy involves a rectangular cran-
iotomy approximately 8 cm 9 4 cm, eccentric to one side
along the length of the corpus callosum. Our surgical tech- Figure 1.
nique is described below: The patient is positioned supine with the head of bed elevated
approximately 10–20 degrees above horizontal, and the neck is
flexed. A curvilinear incision is marked in the region of the coronal
Positioning suture.
The patient is positioned supine on the operating table Epilepsia ILAE
with the head secured using three-point pin fixation. The
neck is moderately flexed and the torso is elevated 10–20 planned incision. The scalp flap is created in standard fash-
degrees above horizontal. Alternatively, the head can be ion, and then three to six burr holes are placed for adequate
positioned laterally with the right side down, to allow for epidural dissection. An 8 cm (anteroposterior) 9 4 cm
gravity-assisted retraction of the frontal lobe.

Preoperative adjuncts
Preoperative magnetic resonance imaging (MRI) is co-
registered to the scalp and used for frameless stereotactic
navigation. Although not essential, frameless stereotactic
navigation is helpful in developing trajectories to the ante-
rior and posterior limits of the callosotomy and planning a
craniotomy that avoids large bridging cortical veins. The
patient is administered antibiotics, dexamethasone, and
mannitol prior to skin incision. Early administration of man-
nitol and mild hyperventilation help with brain relaxation
and facilitates the interhemispheric approach with minimal
retraction.

Exposure
A trapdoor incision centered on the coronal suture, and Figure 2.
encompassing the contralateral medial parasagittal region, A craniotomy (~4 cm 9 8 cm) is performed straddling the coro-
is planned. Alternatively, a sigmoid or curvilinear bi-coro- nal suture and crossing the midline. Hemostasis is achieved over
nal incision in the region of the coronal suture may be used the superior sagittal sinus using Surgicel, Gelfoam and cottonoids.
(Fig. 1). A limited hair shave is performed around the Epilepsia ILAE

Epilepsia, 58(Suppl. 1):73–79, 2017

doi: 10.1111/epi.13681
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Corpus Callosotomy—Surgical Techniques

carefully separated to each side using the midline avascular

plane (Fig. 4). Further arachnoid dissection exposes the
glistening white corpus callosum. The corpus callosum is
then exposed along the desired extent of the callosotomy.
Neuronavigation may be used to confirm midline and extent
of exposure. It is preferable to complete the entire inter-
hemispheric dissection (depending on whether an anterior
two thirds or complete callosotomy is planned) prior to
starting the callosotomy itself.

Callosotomy
A small callosotomy is initially created with suction and
bipolar cautery under low power, and deepened to expose
the midline cleft between leaves of the septum pellucidum
Figure 3. (Fig. 5). The midline cleft is then followed anteriorly across
A U-shaped dural opening is created and the dura is reflected the genu to the rostrum of the corpus callosum using suction
toward the superior sagittal sinus to expose the interhemispheric and bipolar cautery or ultrasonic aspiration. Care is taken to
fissure. Bridging veins posterior to the coronal suture are pre- preserve the ependymal lining of the ventricle to avoid risk
served.
of postoperative cerebrospinal fluid (CSF) leak and the
Epilepsia ILAE
potential for intraventricular blood. To perform a complete
callosotomy, the bed is then positioned in Trendelenburg
and the microscope is directed posteriorly. An intracallosal
disconnection is then performed from the posterior body to
the splenium. Exposure of the midline pia overlying the vein
of Galen posteriorly and inferiorly confirms adequate dis-
connection of the splenium. Care is taken to preserve the pia
to avoid injury to the internal cerebral veins and vein of
Galen. Posterior callosotomy is often challenging as the
angle of the splenium falls away from the surgeon. If a pos-
terior callosotomy is later indicated, a second-stage proce-
dure through a separate posterior incision and craniotomy
provides a more direct access to the splenium.

Figure 4.
Meticulous arachnoid dissection is performed in the midline avas-
cular plane, and pericallosal arteries are separated to expose the
glistening white corpus callosum.
Epilepsia ILAE

(lateral) bone flap is created, straddling the coronal suture

(Fig. 2). Bleeding over the superior sagittal sinus is usually
controlled using Surgicel, Gelfoam, and cotton strips. The
dura is then opened in a U-shaped fashion and reflected
toward the superior sagittal sinus, until the interhemispheric
fissure is visualized (Fig. 3). Care is taken to preserve all
cortical veins that are at or posterior to the coronal suture.

Interhemispheric approach
Figure 5.
Telfa or cotton strips are placed on the mesial frontal lobe After exposure of the corpus callosum along the length of the
to avoid cortical injury. The interhemispheric fissure is then planned callosotomy, a small opening is created and this is deep-
opened and arachnoid dissection is continued to deepen the ened to expose midline leaves of the septum pellucidum. The cal-
exposure. A retractor blade is positioned for gentle retrac- losotomy is then extended anteriorly and posteriorly to achieve
tion to aid visualization, avoiding retracting the frontal lobe the intended disconnection.
>10–15 mm. Pericallosal arteries are identified and Epilepsia ILAE

Epilepsia, 58(Suppl. 1):73–79, 2017

doi: 10.1111/epi.13681
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M. D. Smyth et al.

Figure 6.
(A) Endoscope with the attached
suction and neuronavigation guide is
held in surgeon’s left hand, and
bimanual dissection is performed
with a second instrument held in
surgeon’s right hand. (B, C) The
incision required to perform
complete corpus callosotomy using
the endoscopic method.
Epilepsia ILAE

Closure space. Moreover, because the field of surgery is larger than

After completion of the callosotomy, careful hemostasis the view through the endoscope, it requires repeated reposi-
is obtained. The dura is closed with a braided nylon suture tioning of the endoscope, and this can be tedious and frus-
in a water-tight fashion. The bone flap is secured to the skull trating. To overcome these limitations, the author (SS) uses
with titanium plates and screws. The galea is approximated a clamp to attach the suction to the endoscope as shown in
with interrupted Vicryl sutures, and the skin is closed with a Figure 6A. This allows the surgeon to use the suction in the
running absorbable suture. left hand and a second instrument in the right hand in a stan-
dard microsurgical fashion. Because the endoscope is
attached to the suction it moves with the suction to the site
Endoscopic Corpus Callosotomy of surgical dissection, thereby eliminating the need for repo-
Endoscopic corpus callosotomy aims at minimizing the sitioning. This two-handed technique has been used by us
size of incision and craniotomy. It was first described by since 2011 and it allows safe control of hemorrhage and per-
Bahuleyan et al. in cadaveric dissection, utilizing anterior mits bimanual microsurgical dissection.5,9
and posteriorly located burr holes.7 This conventional one- Obscuration of vision from the instruments, lighting and
handed technique with instrumentation through the side depth of focus limit usefulness of conventional microscopic
channel did not offer a way of controlling hemorrhage in surgery at a depth of >7–8 cm from the surface of the brain
event of a vascular injury, or the ability to bimanually dis- with a standard sized craniotomy. In contrast, the depth at
sect, and therefore was not practical. An alternative three- which surgery can be performed with an endoscope is deter-
handed technique, traditionally used in endoscopic mined primarily by the length of the endoscope and can be
transsphenoidal surgery, was recently adapted for endo- done with a much smaller craniotomy. Using our technique,
scopic callosotomy by Chandra et al.8 However, in this the depth to which surgery can be performed through a
technique, the endoscope is either held by an assistant or on micro-craniotomy (2–3 cm) can be extended beyond the
a holder so that both hands of the surgeon are free to use limit of the microscope. A stereotactic attachment further
instruments. This technique requires a larger craniotomy aids in surgical navigation. This is especially useful when a
because the crowding of instruments necessitates more two-dimensional (2D) endoscope is used, since beyond a

Epilepsia, 58(Suppl. 1):73–79, 2017

doi: 10.1111/epi.13681
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Corpus Callosotomy—Surgical Techniques

depth of >5 cm, surgical manipulations become difficult the location of bridging veins. A precoronal craniotomy is
and require frequent reassessment of depth with neuronavi- planned to optimize the trajectory that allows access to the
gation. The author (SS) has used both 2D and 3D endo- splenium and also the genu of the corpus callosum in front
scopes for corpus callosotomy but recommends using a 3D of the major bridging veins but behind the hairline. As with
endoscope (such as VisionSense, Philadelphia, PA, U.S.A.). standard corpus callosotomy, antibiotic and mannitol are
Corpus callosotomy is a low-risk operation. An open cal- administered prior to incision; however, we do not use ster-
losotomy usually does not require blood transfusion, and the oid intra- or postoperatively.
risk of new deficits related to the surgical procedure such as
vasospasm, retraction injury, and venous infarct was Positioning
reported by us (MDS) to be about 5%.3 Although none of In the operating room, under standard anesthesia, the patient
the 10 patients who had an endoscopic corpus callosotomy is positioned with the trunk in slight flexion and the head in
at our institution developed new neurologic deficits related mild extension, so that the face is looking straight up and fixed
to surgery, it would require a large number of patients to sta- in a Mayfield head holder (Integra Corp, Plainsboro, NJ,
tistically demonstrate the perceived advantages of endo- U.S.A.). This position puts the head slightly above the heart
scopic callosotomy over standard open callosotomy. and minimizes the intracranial venous pressure. The patient is
Nonetheless a smaller incision means better cosmesis, less appropriately secured to allow for Trendelenburg or reverse
postoperative pain, and potentially a lower risk of infection. Trendelenburg positioning during surgery. With neuronaviga-
tion registration completed, scalp electroencephalography
(EEG) electrodes are placed according to the 10–20 interna-
Surgical Technique tional system of electrode placement in order to monitor EEG
Patient selection during the surgical procedure.
At the present time we do not offer endoscopic calloso-
tomy to patients who have undergone a previous cranial Exposure
operation or who have significantly distorted anatomy with The incision is marked about 1.5 cm lateral to the
a poorly formed falx and interdigitating medial hemi- midline and about 1–1.5 inches in length along the sagit-
spheres. Dissection under endoscopic vision in these patient tal plane (Fig. 6B). This region is clipped and prepped
is difficult because of adhesions and distorted anatomy. with povidone-iodine solution. Infiltration with 1:200,000
epinephrine with 2% lidocaine is used to minimize scalp
Preoperative adjuncts bleeding. A single baby mastoid retractor with sharp
Each patient undergoes a neuronavigation MRI scan and teeth is used to retract the scalp, and subgaleal dissection
an additional Time Resolved Imaging of Contrast KineticS is done without elevating the pericranium. A burr hole is
sequence with magnetic resonance venography to determine made in the midline over the sagittal sinus using

Figure 7.
(A–H) Endoscopic views along the
corresponding trajectories shown in
(I). (See Video S1). CM,
callosomarginal artery; Cg, cingulate
gyrus; Cc, corpus callosum; Pc,
pericallosal artery; ACA, anterior
cerebral artery; Sp, septum
pellucidum; IHF, interhemispheric
fissure; Spl, splenium; Endo,
endoscope; CUSA, Cavitron
aspirator.
Epilepsia ILAE

Epilepsia, 58(Suppl. 1):73–79, 2017

doi: 10.1111/epi.13681
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M. D. Smyth et al.

the ventricle. Any bleeding can be easily controlled with a

bipolar cautery.

Role of intraoperative EEG recording

Intraoperative EEG monitoring is used rather as a confir-
matory diagnostic test at Children’s Hospital of Michigan in
Detroit. When bi-synchronous epileptiform discharges are
present under general anesthesia, the evidence of desyn-
chronization of interictal epileptiform discharges can guide
the extent of callosal resection (Fig. 8). Some investigators
have reported that such interhemispheric desynchronization
became evident only during the resection of the posterior
portion of the corpus callosum.10 Conversely, others suggest
Figure 8. that intraoperative EEG changes alone did not effectively
Scalp EEG in an 11-year-old boy with Lennox-Gastaut syndrome. predict long-term seizure outcome following callosotomy11;
(Left) Prior to the endoscopic corpus callosotomy, scalp EEG thus the extent of callosal resection is determined by
showed frequent bisynchronous spike-wave discharges. (Middle) integration of multiple variables including neurologic-neu-
Upon completion of anterior two thirds corpus callosotomy, EEG ropsychological examinations, preoperative EEG abnor-
still showed frequent bisynchronous spike-wave discharges. (Right) malities, and neuroimaging data.
Upon completion of the total callosotomy, EEG showed occasional
spike-wave discharges independently in the right and left hemi-
Closure
spheres. Postoperatively, the patient has been free from tonic as
well as astatic seizures at a 3-month follow-up period. Once adequate callosal resection is completed, good
Epilepsia ILAE hemostasis is achieved, and the dura is closed in a watertight
fashion with 6-0 Prolene, the bone flap is replaced and
secured with plates and screws. The scalp is closed in a stan-
dard fashion in two layers. All patients are observed in the
MidasRex high speed drill (Minneapolis, MN, U.S.A.).
pediatric intensive care unit (ICU) overnight.
With a B1 Midas attachment, a D-shaped craniotomy is
done with the straight of the D over the midline
(Fig. 6B). The craniotomy bevel medially is outwards Disclosure
and the bevel anteriorly and posteriorly is inwards. This
None of the authors has any conflict of interest to disclose. We confirm
maximizes the angulation required to reach the anterior that we have read the Journal’s position on issues involved in ethical publi-
and posterior limits of resection of corpus callosum. cation and affirm that this report is consistent with those guidelines.
The dura is opened with the flap based on the sagittal
sinus. Gentle lateral retraction of the brain is done to reach
the lower end of the falx. A fingertip retractor may be used
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Epilepsia, 58(Suppl. 1):73–79, 2017

doi: 10.1111/epi.13681