====== Tentorial peeling ======

Peeling of the dural layers of the [[tentorium]].

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The combined [[petrosal approach]] is an excellent [[method]] to access the [[petroclival region]] but has the inherent risk of injury to the [[temporal lobe]] and [[Vein of Labbé]]. [[Tentorial]] [[peeling]] has the potential to largely eliminate these [[risk]]s during the classic combined [[transpetrosal approach]]
((Vidal CHF, Nicácio JA, Hahn Y, Caldas Neto SS, Coimbra CJ. Tentorial Peeling:
Surgical Extradural Navigation to Protect the Temporal Lobe in the Focused
Combined Transpetrosal Approach. Oper Neurosurg (Hagerstown). 2020 Oct
15;19(5):589-598. doi: 10.1093/ons/opaa162. PMID: 32542323.
)).

Anatomical [[dissection]] of three adult injected non-formalin fixed [[cadaveric head]]s was performed. Combined petrosal approach with tentorial peeling was completed. A tentorial [[incision]] just superior and parallel to the [[superior petrosal sinus]] was made to enable peeling of the [[tentorium]] into two layers, the posterior fossa tentorial leaf (PFTL), and the temporal [[tentorial]] leaf (TTL).

Tentorial peeling clearly exposed the continuity between the temporal dura and the TTL as well as the continuity between the presigmoid dura and the PFTL. This enabled the creation of a large dural flap extending to the [[tentorial incisura]], providing wide access to the [[petroclival region]] without any exposure of the temporal lobe and/or basal temporal veins. Techniques to create the dural flap without [[trochlear nerve]] [[injury]] were also explored.

The technique of tentorial peeling into two distinct layers has the potential to reduce the [[morbidity]] associated with [[temporal lobe]] retraction and venous injury. Further cadaveric studies and surgical [[case series]] are needed to validate this important surgical nuance in [[transpetrosal approach]]es.
((Giammattei L, Starnoni D, Ronconi D, Camara B, George M, Cossu G, Messerer M, Peters D, Daniel RT. [[Tentorial peeling]] during combined [[petrosal approach]]: a [[cadaveric dissection]]. Acta Neurochir (Wien). 2022 Sep 26. doi: 10.1007/s00701-022-05370-z. Epub ahead of print. PMID: 36163381.)).