Four-Handed Resection of Vestibular Schwannoma Using Subcapsular Technique: Operative Technique and Single Surgeon Experience of 734 Cases

Introduction: Four-handed surgical technique utilizing a diploscope has gained traction in recent years for improved educational opportunity, reduced surgical time, and reduced morbidity and mortality. Additionally, subperineural or subcapsular technique for VS resection has been more recently recognized as a safe and effective approach to this pathology, however, it remains somewhat controversial due to the “subtotal” nature of leaving the tumoral capsule in situ. We aim to summarize the experience of a single surgical team composed of a fellow-ship trained neurosurgeon and otolaryngologist with resident assistance who have completed a total of 734 cases utilizing both a 4 handed surgical technique and subcapsular dissection with neuromonitoring, primarily through a retrosigmoid craniotomy to resect VS at a tertiary care centre. Methods: A chart review was completed on 734 patients who underwent resection of a vestibular schwannoma between July 1, 2001, and Oct 1, 2024. Follow up was > 10 years for 434 patients. Gross total or near total resection was achieved in 635 cases. Hearing preservation, facial nerve function, and complications are described. Radiographic follow-up including recurrence and timing of post-operative radiation were assessed. Results: Description, diagrams, and intraoperative video are utilized to describe the arrangement of the operating theatre, optimization of the diploscope, and surgical approach. Outcomes and follow-up for 734 cases are summarized. Conclusion: Four-handed surgical technique is an optimal arrangement for intraoperative educational opportunities and provides a safe and effective approach to vestibular schwannoma resection. Additionally, a review of the literature reveals that this is the largest series of patients who have undergone vestibular schwannoma resection using subcapsular dissection to date. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany