J Neurosurg 114:727–730, 2011

Vacuum-assisted en bloc resection of large

convexity meningiomas

Technical note
Benjamin D. Fox, M.D.,1 Bartley D. Mitchell, M.D.,1 Akash J. Patel, M.D.,1
Katherine Relyea, M.S., 2 Shankar P. Gopinath, M.D.,1,3 Claudio Tatsui, M.D.,1,4
and Bruce L. Ehni, M.D.1,4

Department of Neurosurgery, Baylor College of Medicine; 2Division of Pediatric Neurosurgery, Texas

1

Children’s Hospital; 3Department of Neurosurgery, Ben Taub General Hospital; and 4Department of
Neurosurgery, Michael E. Debakey Veterans Affairs Medical Center, Houston, Texas

Convexity meningiomas are common tumors encountered by neurosurgeons. Retracting, grasping, and mobi-
lizing large convexity meningiomas can be difficult and awkward as well as place unwanted forces on surrounding
neurovascular structures. The authors present a safe alternative to traditional retraction and manipulation methods by
using a modified bulb syringe connected to standard surgical suction to function as a vacuum retractor. This technique
allows for rapid, safe, en bloc resection of large convexity meningiomas with little to no pressure on the surrounding
brain. The authors present an illustrative case and describe and discuss the technique.
(DOI: 10.3171/2010.6.JNS10552)

Key Words      •      convexity meningioma      •      bulb syringe      •

en bloc resection      •      vacuum

C
onvexity meningiomas are among the most com-
mon tumors encountered by neurosurgeons. In
the modern era, small meningiomas are routinely
treated with radiosurgery. Therefore, a greater proportion
of larger and more aggressive meningiomas, including
those that have failed radiosurgery, are now being re-
ferred for surgical resection.3 Manipulating these large
tumors can be difficult and traditional retraction can
place unwanted pressure on surrounding neurovascular
structures. We present a safe alternative to traditional re-
traction and manipulation methods by using a modified
bulb syringe that we connected to standard suction tubing
to function as a vacuum retractor. This technique allows
for rapid, safe, en bloc resection of large convexity men-
ingiomas with minimal to no pressure on the surrounding
brain. We present an illustrative case and then describe
and discuss the technique.
Case Illustration
History and Examination
This 82-year-old man with no significant medical
history experienced new onset seizures in 2003. He was
started on antiepileptic medications and MR imaging of
his brain was obtained demonstrating a large, right-sided,
convexity meningioma. His seizures were well controlled
and he was discharged from the hospital.
Despite the offer of tumor resection on repeated sub-
sequent visits with interval increases in tumor size, he re-
fused surgery. In 2009, he presented acutely in status epi-
lepticus after a few days of left hemiparesis and lethargy.
Once the seizures were controlled, MR imaging was ob-
tained demonstrating a significant increase in the size of
the tumor as well as the mass effect on the brain (Fig. 1A
and B). On examination he was able to be aroused and
would answer some simple questions and follow some
simple commands, but was hemiparetic with antigravity
strength in the left upper and lower extremities.
Operation and Postoperative Course
The patient was taken to surgery and underwent re-
section using the vacuum retractor to assist in tumor ma-
nipulation during the resection. The involved dura was
resected with a 2-cm margin and a pericranial graft was
later sutured in place. Gross-total resection of the tumor
was performed and the operation lasted approximately 75
minutes from skin opening to closure. By 1 week post-
operatively, the patient had returned to full strength and
was at his neurological baseline. He was subsequently
discharged home in good condition. Follow-up CT im-
ages of the head (Fig. 1C) demonstrated good resection,
reexpansion of the brain, and correction of mass effect.
This article contains some figures that are displayed in color
on­line but in black and white in the print edition.

J Neurosurg / Volume 114 / March 2011 727


Fig. 1.  Postcontrast axial (A) and reconstructed sagittal (B) MR im-
ages show a large convexity meningioma (approximately 6 x 4 x 6 cm).
A noncontrast-enhanced axial CT scan (C) obtained approximately 2
months postoperatively shows good tumor resection, resolution of brain
shift and mass effect, and brain reexpansion.
Operative Technique
A standard surgical approach and appropriately sized
craniotomy over the tumor is performed per surgeon pref-
erence. The exposed superficial arachnoid layer at the in-
terface between the tumor and surrounding normal brain
at the exposed surface is identified. Next, this arachnoid
plane is carefully dissected from the brain-tumor surface
to a depth of approximately 1 cm below the surface all
the way around the entire superficial circumference of the
tumor.
Fig. 2.  Intraoperative photographs of the technique and equipment used.  A–D: Images showing how a standard 50-ml
Davol bulb-syringe is converted into a vacuum retractor.  E–G: Views at different stages of resection (E and F) and following
complete resection (G).
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B. D. Fox et al.
The bulb is removed from a standard “turkey-baster”
style 50-ml bulb syringe (Fig. 2A and B). In this case we
used a Davol (C.R. Bard, Inc.) bulb syringe, but any sy-
ringe with a similarly shaped tapered tip will likely suf-
fice. A hole is drilled in the side of the syringe to allow
for finer control of the vacuum force (Fig. 2D). The hole
should be made near the middle of the syringe, but should
be closer to the syringe tip than the bulb side so that tu-
mor bulk does not occlude the hole. This position is sug-
gested because as more and more tumor is freed from the
surrounding brain, the bulk of the tumor can be trans-
ferred into the chamber of the syringe, providing a bet-
ter surgical view. The tip of the bulb syringe is inserted
into standard surgical suction tubing and is then carefully
placed on the surface of the center of the tumor (Figs. 2C
and 3). For larger tumors this will be well away from the
edge of the brain-tumor interface.
The vacuum force of the syringe will draw the tumor
up into the syringe, including the freed tumor, and care
should be taken not to apply too much vacuum force or to
actively pull up on the device. As freed tumor is aspirated
into the syringe chamber, a negative force vector is di-
rected up toward the center of the syringe. As dissection,
then freeing of the tumor, and then transferring the tumor
bulk into the chamber continues, it continuously exposes
the vessels at the edge of the tumor-brain interface, which
are readily controlled (Fig. 3). As the tumor enters the
vacuum the tumor blanches white with minimal subse-
quent bleeding (Fig. 2E–G).
As one approaches the tumor base, a gentle cranial-
to-caudal as well as left-to-right rocking motion will ex-
J Neurosurg / Volume 114 / March 2011
Vacuum-assisted resection of convexity meningiomas
Fig. 3.  Illustrations of the technique. Correct placement of vacuum
retractor on center of tumor is shown (upper right). Hole on side of
vacuum shaft allows for finer finger control of vacuum force. As tumor is
retracted into the vacuum shaft the edges at the brain-tumor interface
become exposed allowing for microsurgical dissection of the arachnoid
plane and coagulation of vessels (center left). As resection proceeds,
a larger volume of the tumor will be transferred into the vacuum shaft,
allowing for better vision of the deeper portions of the brain-tumor inter-
face until en bloc resection is complete (lower).
pose arachnoid attachments and vessels around the edges
and at the base of the tumor (Figs. 2F and 3). Because
of the upward negative force of the vacuum retraction,
the retraction force is nearly always maintained in an up-
ward direction away from the normal brain surface. In
this fashion, the entire tumor can be freed and removed
in an en bloc manner with little to no retraction on ad-
jacent brain structures. Once the entire tumor has been
freed, the bulk of the tumor will reside compressed in the
vacuum syringe container (Figs. 2G and 3).
Discussion
Retracting, grasping, and mobilizing convexity men-
ingiomas can be difficult and awkward, particularly when
these tumors are large and adherent to the pia of the
surrounding brain. Traditional retraction can also place
undesired and damaging pressure on surrounding brain
as the typical retraction force vectors point toward the
direction of “normal” brain on the opposite side. Grasp-
J Neurosurg / Volume 114 / March 2011
ing forceps can crush and tear the tumor surface, which
also causes bleeding and results in the surgeon needing to
constantly control the bleeding and regrasp the macerated
tumor tissue. For these reasons, many surgeons decide not
to attempt en bloc resection of these large tumors, but
instead opt for piecemeal resection with or without the
use of ultrasonic aspirators.1–3 The goal of piecemeal re-
section is to collapse the tumor upon itself and minimize
external forces on the surrounding brain tissue.
Vacuum retraction is an alternative to traditional re-
traction and also minimizes the compressive forces on
surrounding brain tissue by applying negative force in
an upward direction. It must be stressed that the vacuum
retractor does not “aspirate out” the tumor. This would
be unsafe and result in the rupture of many tumor and
adjacent normal brain blood vessels as well as violate the
pial surface of the surrounding normal brain. Standard
microsurgical techniques used by all surgeons to separate
out the arachnoid plane at the periphery of the tumor are
still employed in this technique. The difference is that no
piecemeal debulking is needed because once a portion of
tumor is freed, the bulk can then be transferred into the
syringe chamber, giving a better view of a deeper portion
of the brain tumor interface. This technique is compatible
with the use of the intraoperative microscope; however,
recently we have tended to use loupe magnification alone
and found this to be safe and effective. If one decides
to use the microscope during this procedure, care must
be taken not to have tunnel vision and focus all one’s at-
tention on the dissection at the brain-tumor interface and
lose track of the amount of vacuum force and upward
traction that is placed on the vacuum retractor, which is
out of the field of view.
The technique is simple, inexpensive, and employs
the use of instruments and devices found in nearly ev-
ery operating room around the world. This technique has
been used by the senior author (S.P.G.) multiple times
over the past decade on large convexity meningiomas and
he has not experienced any operative complications.
Although this technique works well for most large
convexity meningiomas it will not work for glial tumors,
most metastases (as the tumor tissue and capsule/pseudo-
capsule are too soft), and large meningiomas involving
the venous sinuses. Also, this technique will not work for
tumors whose exposed surface diameter is smaller than
the external diameter of the bulb syringe. The wings of
the bulb syringe can be drilled down to decrease the size
of this surface and smaller syringes could theoretically be
used if a suitable adaptor could be located to connect the
syringe to the suction tubing. When using this technique,
one must also avoid the temptation to pull up on the tu-
mor or apply too much vacuum force, as this will cause
uncontrolled damage to the surrounding neurovascular
structures.
There is a theoretical risk of encountering a tumor
that is too firm (too fibrous or too calcified) to be drawn
up into the vacuum chamber, which would prevent tumor
volume displacement and make it unsafe to manipulate/
retract the tumor from side-to-side using this technique.
The surgeon must always be cognizant of the brain-tumor
interface, whether any pressure is being applied to the
729

surrounding normal brain, the amount of tumor displace-
ment up into the vacuum chamber, the amount of vacuum
force being applied, and the amount of upward distraction
force exerted on the syringe when using this technique. A
safe resection is always more important than an en bloc
resection. If tumor resection using this technique is not
progressing smoothly or there are any problems (includ-
ing a tumor that will not be drawn into the vacuum cham-
ber), the technique should be abandoned. However, we
have been able to successfully use the vacuum retractor
to remove the meningioma en bloc in every case in which
we decided preoperatively to use this technique and have
never had to abandon this procedure for traditional piece-
meal internal debulking. This may be because we decid-
ed preoperatively (based on imaging) not to employ this
technique on an extremely calcified tumor or due to the
pure chance of having not yet encountered such a tumor.
The vacuum force in this technique is very powerful and
in our experience it has been able to draw in every tumor
(even the fibrous ones) we have encountered.
Conclusions
Vacuum-assisted resection of large convexity men-
ingiomas is a simple technique that requires only a few
modifications of commonly used surgical instruments. It
is safe, easy to perform, and can result in rapid en bloc
resection of large convexity meningiomas without the
need for piecemeal resection or the use of ultrasonic as-
pirators. Future studies as well as modifications to and
improvements on these instruments will hopefully result
in broader application and finer control of this powerful
retraction technique.
Disclosure
The authors report no conflict of interest concerning the mate-
730
B. D. Fox et al.
rials or methods used in this study or the findings specified in this
paper.
Author contributions to the study and manuscript prepara-
tion include the following. Conception and design: Fox, Gopinath,
Tatsui, Ehni. Acquisition of data: Fox. Analysis and interpretation
of data: Fox, Mitchell, Patel, Gopinath, Tatsui, Ehni. Drafting the
article: Fox, Relyea. Critically revising the article: Mitchell, Patel,
Relyea, Gopinath, Tatsui, Ehni. Reviewed final version of the manu-
script and approved it for submission: all authors.
Acknowledgments
The authors thank Dr. Jacob Abraham (former Chairman,
Department of Neurosurgery, Christian Medical College, Vellore,
India) for teaching Dr. Gopinath this technique. Illustrations by
Katherine Relyea.
References
  1.  DeMonte F, Marmor E, Al-Mefty O: Meningiomas, in Kaye
AH, Laws ER Jr (eds): Brain Tumors: An Encyclopedic
Approach, ed 2. London: Churchill Livingstone, 2001, pp
719–750
  2.  Morokoff AP, Zauberman J, Black PM: Surgery for convexity
meningiomas. Neurosurgery 63:427–434, 2008
  3.  Sanai N, Sughrue ME, Shangari G, Chung K, Berger MS,
McDermott MW: Risk profile associated with convexity men-
ingioma resection in the modern neurosurgical era. Clinical
article. J Neurosurg [epub ahead of print July 31, 2009. DOI:
10.3171/2009.6.JNS081490.]
Manuscript submitted April 20, 2010.
Accepted June 30, 2010.
Please include this information when citing this paper: pub-
lished online July 30, 2010; DOI: 10.3171/2010.6.JNS10552.
Address correspondence to: Benjamin D. Fox, M.D., Department
of Neurosurgery, Baylor College of Medicine, 1709 Dryden, Suite
750, Houston, Texas 77030. email: bf131123@bcm.tmc.edu.
J Neurosurg / Volume 114 / March 2011