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This video will demonstrate the extended retrosigmoid craniotomy for resection of an abducens schwannoma. The patient was in her mid-70s. She presented with back pain and right leg weakness. Neurological examination revealed distal right lower extremity weakness involving the L2 to S1 muscle groups. Her presentation was related to a tumor found in the lumbar region of the spine, but neuraxis imaging revealed this finding as well. A homogeneously contrast enhancing extra-axial mass lesion is seen here involving the left prepontine cistern and ventral cerebellopontine angle. There is associated compression of the pontine underbelly. An extended retrosigmoid craniotomy was selected, and these illustrations show the lateral position and the craniotomy flap that extends from the jugular bulb up to the transverse sigmoid junction. Key surgical steps included arachnoid dissection to open up the cerebellopontine angle, release CSF from the cisterna magna and relax the cerebellum, central tumor debulking, followed by dissection of the brain tumor interface along the tumor capsule. This tumor was noted to arise from the abducens nerve, which was traced from the brainstem to Dorello's canal. Finally, tumor was left on the abducens nerve to preserve its integrity. Here is my resident doing the initial dissection in the glossopharyngeo-cochlear triangle. He's cauterizing the tumor capsule and performs the initial debulking here with the CUSA. The debulking is done centrally in order to fold the tumor inward on itself. Dissection outside the capsule is deferred until this aggressive internal debulking is completed. This grasping instrument allows the small windows of the triangles here to be exploited without trying to get a large CUSA instrument here. Once this central debulking progresses, we can see that the tumor pulls up nicely from below. The lower cranial nerves and the branches of PICA, as well as the vertebral artery, are being separated here from this lower portion of the tumor. As more of this tumor capsule is freed, it can be aggressively debulked. This piecemeal resection technique is nice because these chunks can be cut into smaller pieces and removed safely. Now, the tumor is mobilized inferiorly. You can see the trigeminal nerve at the left side of your screen, and the upper portions of the tumor capsule here are being debulked. Here now is our first view of the abducens nerve. It is seen here entering Dorello's canal at the clival dura, and interestingly, it bends to the left, meaning that it is descending. It descends from above to reach Dorello's canal. That means that it has been pushed up by the tumor and is draped over the upper and medial aspects of the tumor. With that information in mind, these other portions of the tumor are aggressively debulked. Here the more posterior capsule is pulled away from the interface with the pons, and again, this piecemeal dissection technique is used to elevate the tumor, free it from these rootlets, and remove it. This is the sixth nerve as it's exiting the brainstem and its coursing over the upper pole of the tumor. We can aggressively remove the portions of tumor that are away from the abducens nerve, but we must be mindful of the thin delicate course of the abducens nerve and protect that. Here again, a nice view of the abducens nerve entering Dorello's canal. And here we will now whittle away the tumor along this course of the nerve. Here's a nice view of the basilar trunk deep to the tumor. The portion of the tumor rolls away from the basilar artery, leaving just this rind of tumor which now with the CUSA we will whittle down and thin to just a thin layer of tissue on the undersurface of the abducens nerve. I've left a little rind of tumor here, where the sixth nerve is running, in an effort to preserve the integrity of the nerve and preserve her function. Our patient tolerated the procedure well. She had a transient right abducens nerve palsy postoperatively, but no other neurologic deficits. Her postoperative MRI is shown here, showing a near total resection of the tumor, the exception being that thin layer adjacent to the abducens nerve. In conclusion, large symptomatic posterior fossa tumors are best treated with microsurgical resection to decompress the brainstem. Key principles of skull base surgery include approach optimization, microsurgical dissection at high magnification, central debulking, and dissection of surrounding neurovascular structures once the tumor has been debulked. For benign cranial nerve sheath tumors, near total resection is often preferable to aggressive resection that risks or compromises long-term function of the nerve.