To begin, administer general anesthesia to the patient before the procedure. Locate the Sylvian fissure, coronal suture, and central sulcus according to anatomical landmarks. Draw a seven-shaped skin incision one centimeter off the midline and two to three centimeters anterior to the coronal suture.
Ensure the posterior margin of the incision includes the precentral gyrus and extends down to the pterygoid region. Position the patient supine with the head turned to the opposite side and place a shoulder pad under the shoulder to help the head turn. After draping the surgical area, incise the scalp and muscles taking care to cut the muscles in layers and separate the scalp and periosteum with a scalpel.
Using a high-speed drill of one-centimeter diameter, drill three one-centimeter holes and mill down the bone flap with a one-millimeter-wide milling cutter. Use bone wax, gelatin sponge, and bipolar cautery to achieve hemostasis. Next, drill four to five holes of one millimeter in the bone margin and suspend the dura to avoid epidural hematoma.
Cut open the dura 0.5 centimeters away from the bone margin. Expose the precentral gyrus, the posterior part of the inferior frontal gyrus, and the beginning of the lateral fissure. Use the stereotactic system software for surgical planning before surgery.
Import the 3D T1 flare-weighted images and PET data into the software for registration and 3D reconstruction. Select the area with the most severe abnormality on preoperative imaging for histological examination. Next, resect the posterior part of the inferior frontal gyrus to fully expose the one and two short gyri of the insula.
Disconnect the base of the frontal lobe and the fibers along the anterior insula to the sphenoid ridge and then to the midline. Then, perform interfrontal disconnection along the precentral sulcus followed by the white matter under the bottom of the sulcus slightly forward to keep the pyramidal tract intact. Conduct a deep resection to ensure the highest chance of seizure freedom due to MOGHE being a white-matter lesion with blurred gray-white matter boundaries, afterward disconnecting at the midline boundary, which is the cerebral falx, and continue down to the cingulate gyrus.
Next, incise the corpus callosum to open the ipsilateral ventricles. Dissect the arcuate fibers completely along the top of the ventricles to the anterior horn meeting the frontal base disconnection line. Afterward, disconnect the anterior corpus callosum to the anterior commissure within the lateral ventricles.
Expose the anterior cerebral artery using it as an anatomical landmark for corpus callosum disconnection. Ensure the posterior portion of the frontobasal disconnection reaches the level of the callosal disconnection. Resect the paraterminal gyrus and posterior gyrus rectus behind the anterior cerebral artery with suction.
Expose the anterior cerebral artery. Ensure the frontobasal disconnection is complete, including the paraterminal gyrus and posterior gyrus rectus. Consider resecting the one or two short insular gyri based on preoperative evaluation.
Suture the dura with 4-0 absorbable sutures to achieve a tight closure and place an epidural drain for two days. Use three absorbable cranial bone locks to fix the bone. Close the subcutaneous layer with 4-0 subcuticular sutures, and suture the skin with a stapler.
After an average of two years of follow-up post surgery, six patients were seizure-free with a seizure-free rate of 75%Developmental assessment performed three months to one year after surgery revealed that four patients experienced cognitive improvement.
