Endoscopic Endonasal Surgery for Resection of Giant Craniopharyngioma in a Toddler—Multimodal Presurgical Planning, Surgical Technique, and Management of Complications: 2-Dimensional Operative Video

2019 ◽  
Vol 19 (1) ◽  
pp. E68-E69
Author(s):  
Juan C Fernandez-Miranda ◽  
Peter Hwang ◽  
Gerald Grant
Keyword(s):  
Parent Artery ◽  
Lateral Nasal Wall ◽  
Management Options ◽  
Endoscopic Endonasal ◽  
Pseudoaneurysm Formation ◽  
Surgical Access ◽  
Institutional Review ◽  
Arterial Bleeding ◽  
Management Of Complications ◽  
Giant Craniopharyngioma

Abstract A 2-yr-old patient with a giant craniopharyngioma presented with seizures and panhypopituitarism. The lesion was initially approached at an outside institution with a transfrontal cyst fenestration, but progressive growth occurred later. Multiple management options were considered; we recommended an endoscopic endonasal approach with the goal of maximal safe resection. Virtual reality simulation and 3-dimensional printing were employed to evaluate whether the absence of pneumatization of the sinuses and the overall size of the nasal cavity could preclude effective surgical access. Our lab results suggested the binostril approach was feasible. A wide surgical exposure was performed from planum sphenoidale to clivus and from orbit to orbit. After removing the large calcified tumor portion, we found an accurate plane of dissection between tumor capsule, hypothalami, and visual pathways. By the end of resection, arterial bleeding was encountered secondary to an avulsion of the posterior communicating artery from the posterior cerebral artery. An angled aneurysm clip was placed with a single-shaft applier to secure the site of injury without narrowing the parent artery. Immediate and delayed magnetic resonance imaging and computed tomography angiography studies showed gross total resection, no stroke, and no pseudoaneurysm formation. On postoperative day 9, patient developed neurological decline and pneumocephalus secondary to necrotic nasoseptal flap. Two endonasal repairs with a lateral nasal wall flap were attempted with no success. A temporoparietal fascia flap was then harvested and transposed from the temporal to the pterygopalatine fossa to successfully repair the skull base defect. The patient has made an extraordinary recovery with no neurological sequalae. The patient's parents provided consent for the procedure and use of intraoperative photos and videos for academic purposes. Institutional Review Board approval was not required.

Endoscopic Endonasal Approaches to the Cavernous Sinus: Surgical Approaches

Neurosurgery ◽  
2001 ◽  
Vol 49 (2) ◽  
pp. 354-362 ◽  
Author(s):  
Alessandra Alfieri ◽  
Hae-Dong Jho
Keyword(s):  
Cavernous Sinus ◽  
Middle Turbinate ◽  
Lateral Wall ◽  
Surgical Instruments ◽  
Surgical Approaches ◽  
Lateral Nasal Wall ◽  
Orbital Apex ◽  
Superior Orbital Fissure ◽  
Endoscopic Endonasal ◽  
Surgical Access

Abstract OBJECTIVE After completion of an earlier endoscopic transsphenoidal anatomic study, we studied various endoscopic transsphenoidal approaches using cadaveric specimens to develop endoscopic endonasal surgical approaches to the cavernous sinus. METHODS Ten cavernous sinuses in five artery-injected adult cadaveric heads were studied with 0-, 30-, and 70-degree angled 4-mm rod-lens endoscopes. The extent of the surgical exposure, the skewed endoscopic anatomic view, and the maneuverability of surgical instruments through their relative operating spaces were studied after various endoscopic endonasal approaches via one nostril. RESULTS The paraseptal approach was used between the nasal septum and the middle turbinate and provided exposure at the anteromedial portion of the cavernous sinus. The contralateral paraseptal approach rendered a slightly more medial view at the cavernous sinus than did the ipsilateral approach. This approach offered limited surgical access to the lateral vertical compartment. The middle turbinectomy approach allowed surgical access to the lateral wall of the cavernous sinus, except for the superior orbital fissure and the orbital apex. The middle meatal approach, which was made between the middle turbinate and the lateral nasal wall, revealed the entire lateral vertical compartment of the cavernous sinus, including the orbital apex and the superior orbital fissure. However, its lateral tangential surgical trajectory and the absence of dedicated surgical tools limited the surgeon's surgical maneuverability. A combination of the middle turbinectomy and middle meatal approaches increased the operating space. CONCLUSION Various endoscopic endonasal surgical approaches to the cavernous sinus were studied using adult cadaveric head specimens.

scholarly journals Management of Cerebrospinal Fluid Rhinorrhea in the Sphenoid Sinus Lateral Recess Through an Endoscopic Endonasal Transpterygoid Approach With Obliteration of the Lateral Recess

2020 ◽  
pp. 014556132095514
Author(s):  
Chao He ◽  
Hong-Tao Zhen
Keyword(s):  
Cerebrospinal Fluid ◽  
Sphenoid Sinus ◽  
Surgical Repair ◽  
Endoscopic Endonasal ◽  
Simple Method ◽  
Lateral Recess ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Surgical Access ◽  
Skull Base Defect

Background: Cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess is a rare occurrence and poses unique challenges due to limited surgical access for surgical repair. Objective: To report our experience of surgical repair of cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess through an endoscopic endonasal transpterygoid approach with obliteration of the lateral recess. To evaluate the efficiency of this surgical procedure. Methods: A retrospective study. Twelve cases with cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess were reviewed. Assisted by image-guided navigation, cerebrospinal fluid rhinorrhea was repaired through an endoscopic endonasal transpterygoid approach, with obliteration of the lateral recess. Complications and recurrence were recorded. Medical photographs were used. Results: This surgical approach provided a relatively spacious corridor to dissect the sphenoid sinus lateral recess and do postoperative surveillance. The repair area completely healed in 3 months after surgery. Cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess was successfully repaired on the first attempt in all cases (100%). No main complications or recurrence was observed during a mean follow-up time of 40.3 months. Conclusion: The endoscopic endonasal transpterygoid approach gives appropriate access for the treatment of spontaneous cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess. Multilayer reconstruction of a skull base defect with obliteration of the lateral recess is a reliable and simple method.

Locations, associations and temporal evolution of intracranial arterial infundibular dilatations in children

2019 ◽  
Vol 12 (5) ◽  
pp. 495-498
Author(s):  
Adam A Dmytriw ◽  
Daniel-Alexandre Bisson ◽  
Kevin Phan ◽  
Afsaneh Amirabadi ◽  
Helen Branson ◽  
...  
Keyword(s):  
Temporal Evolution ◽  
Posterior Cerebral Artery ◽  
Parent Artery ◽  
Short Term ◽  
Institutional Review ◽  
Common Location ◽  
History Of ◽  
Imaging Surveillance ◽  
Few Data

BackgroundThere are few data in the literature on the characteristics and natural history of intracranial arterial infundibular dilatations in children.MethodsAn institutional review board-approved retrospective review was performed of infundibula reported on MR angiography in patients <18 years of age at our tertiary pediatric institute from 1998 to 2016. Clinical data (age, sex, diagnosis, other vascular variants/pathologies) were recorded and images assessed for vessel of origin, infundibulum size and exact location. Ratios of infundibulum:parent artery were assessed at diagnosis and last follow-up. Temporal evolution to aneurysm was evaluated.ResultsWe found 60 intracranial infundibula in 60 children (male:female=27:33; mean age 9.7±5.2 years, range 2–18 years,). Family history of aneurysms was present in 2/60 (3.3%). Syndromic association was found in 14/60 (23.3%), most frequently sickle cell disease (4/14=28.6%). Mean infundibulum size was 2.2±0.5 mm, with mean ratio to parent artery of 0.54±0.17. The most common location was on the P1-posterior cerebral artery (34/63=56.7%), whereas posterior communicating infundibula were seen in only 4/60 (6.7%) cases. Other cerebrovascular variants were seen in 12/60 (20%) patients. On follow-up imaging (in 32/60 patients over 86 patient-years, mean 32.3±35.7 months), no significant change in infundibulum:parent artery ratio was noted. None of the infundibular dilatations showed interval evolution to aneurysm.ConclusionWe present the largest reported cohort of pediatric intracranial arterial infundibula, which we found to be distinct from their adult counterparts with regard to location, etiology and temporal evolution. Growth over time and/or aneurysmal formation are rare, not necessitating frequent short-term imaging surveillance during childhood.

scholarly journals Orbitozygomatic Craniotomy for Clipping a Complex Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (2) ◽  
pp. E33-E33
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Video Recording ◽  
Artery Aneurysm ◽  
Sylvian Fissure ◽  
Parent Artery ◽  
Parent Vessel ◽  
Institutional Review ◽  
Vessel Patency ◽  
Mca Aneurysm

Abstract Middle cerebral artery (MCA) aneurysms pose a surgical challenge because of the large caliber of the parent artery and the common need to dissect the sylvian fissure to permit access to the proximal and distal control. The neck of the aneurysm should be generously dissected to permit visualization of any adjacent lenticulostriate perforators. This patient demonstrated a left-sided wide-necked bilobed MCA aneurysm at the M1 bifurcation. The aneurysm was approached using a left orbitozygomatic craniotomy with distal sylvian fissure dissection. A single curved clip was applied for aneurysm occlusion, and postoperative angiography demonstrated aneurysm obliteration with parent vessel patency. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

scholarly journals Orbitozygomatic Craniotomy for Giant Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (1) ◽  
pp. E5-E6
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Video Recording ◽  
Artery Aneurysm ◽  
Anterior Communicating Artery ◽  
Parent Artery ◽  
Aneurysm Neck ◽  
Anterior Communicating Artery Aneurysm ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Vessel Patency ◽  
Aneurysmal Neck

Abstract Giant intracranial aneurysms pose a significant surgical challenge because of the associated difficulty in achieving adequate visualization of the parent artery and aneurysm neck. This patient had an incidentally identified giant anterior communicating artery aneurysm. An orbitozygomatic craniotomy was performed for aneurysm exposure and aneurysmal neck dissection. Aneurysm dome opening and thrombectomy was performed to debulk the aneurysmal mass, which facilitated subsequent aneurysmal neck visualization. Sequential utilization of temporary clips of the bilateral A1 and bilateral A2 vessels reduced hemorrhage during thrombectomy. Multiple permanent clips were applied along the dissected aneurysm neck to permit occlusion. A small fracture of the aneurysm neck was identified, and cotton was applied with subsequent tamponade utilizing a fenestrated clip to maintain hemostasis. Indocyanine green fluoroscopy was used to verify parent and distant vessel patency. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Bilateral “Rescue Strip” Technique for Endoscopic Endonasal Approaches to the Clivus

2020 ◽  
Author(s):  
Matthew Kim ◽  
Marc Otten ◽  
Jonathan B Overdevest ◽  
David A Gudis
Keyword(s):  
Skull Base ◽  
Cerebrospinal Fluid Leak ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Surgical Access ◽  
Flap Repairs ◽  
Skull Base Defects ◽  
Fluid Leak ◽  
Video Demonstration ◽  
Wide Access

Abstract BACKGROUND The vascularized nasoseptal flap (NSF) is a pillar of contemporary endoscopic skull base reconstruction. The pedicle for the NSF is supplied by the posterior septal branch of the sphenopalatine artery, which courses along the arch of the choana and sphenoid rostrum before entering the nasal septum. Resection or mobilization of this region is necessary for surgical access to the clivus. OBJECTIVE To describe a technique for preserving bilateral NSF pedicles during endoscopic endonasal resection of the clivus, thereby safeguarding availability of the flaps for future skull base repair needs. METHODS Report of operative technique with video demonstration. RESULTS This technique for NSF preservation allows for wide access to the clivus while saving the future option for vascularized flap repairs of skull base defects. The patient in whom we demonstrate this technique underwent complete resection of her clivus without cerebrospinal fluid leak and with preservation of both NSF pedicles. CONCLUSION The “rescue strip” technique for endonasal endoscopic clival surgery preserves the bilateral NSF pedicles for future use without compromising surgical access to the clivus.

Endoscopic Management of Gastrointestinal Complications

2018 ◽  
Vol 02 (04) ◽  
pp. 346-358 ◽  
Author(s):  
Samantha Witte ◽  
Eric Pauli
Keyword(s):  
Enhanced Recovery ◽  
Anastomotic Stricture ◽  
Intestinal Resection ◽  
Therapeutic Endoscopy ◽  
Endoscopic Management ◽  
Management Options ◽  
Gastrointestinal Complications ◽  
Management Of Complications ◽  
Recovery Protocols ◽  
Patient Optimization

AbstractDespite improvements in preoperative patient optimization, refinements in surgical methodology and technology, and the implementation of enhanced recovery protocols, complications following gastrointestinal (GI) surgery remain a fact of life. As the rates of GI surgical procedures increase worldwide, so will the volume of complications. The surgical management of complications is often not ideal, as some (such as acute staple line bleeding or the development of an anastomotic stricture) are luminal-based processes that are difficult to approach from an extraluminal (i.e., surgical) perspective. Endoscopy has largely replaced surgery for the management of such postoperative problems. Leak, the most feared complications of GI surgery, can result from intestinal resection, anastomosis formation, or from iatrogenic injury. With advancements in both diagnostic and therapeutic endoscopy, novel endoluminal and transluminal management options for leak continue to evolve. In centers where these interventions are readily available, they are becoming a first-line treatment option. This article will review the endoscopic management of GI complications with a particular focus on the management of postoperative strictures and of full-thickness GI tract defects (perforations, acute leaks, and chronic fistulae).

scholarly journals Ventilated Upper Airway Endoscopic Endonasal Procedure Mask: Surgical Safety in the COVID-19 Era

2020 ◽  
Vol 19 (3) ◽  
pp. 271-280 ◽  
Author(s):  
Samuel N Helman ◽  
Roberto M Soriano ◽  
Martin L Tomov ◽  
Vahid Serpooshan ◽  
Joshua M Levy ◽  
...  
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Critical Role ◽  
Upper Airway ◽  
Contralateral Side ◽  
Pathogen Transmission ◽  
Endoscopic Endonasal ◽  
Surgical Safety ◽  
Endoscopic Skull Base Surgery ◽  
Institutional Review

Abstract BACKGROUND COVID-19 poses a risk to the endoscopic skull base surgeon. Significant efforts to improving safety have been employed, including the use of personal protective equipment, preoperative COVID-19 testing, and recently the use of a modified surgical mask barrier. OBJECTIVE To reduce the risks of pathogen transmission during endoscopic skull base surgery. METHODS This study was exempt from Institutional Review Board approval. Our study utilizes a 3-dimensional (3D)-printed mask with an anterior aperture fitted with a surgical glove with ports designed to allow for surgical instrumentation and side ports to accommodate suction ventilation and an endotracheal tube. As an alternative, a modified laparoscopic surgery trocar served as a port for instruments, and, on the contralateral side, rubber tubing was used over the endoscrub endosheath to create an airtight seal. Surgical freedom and aerosolization were tested in both modalities. RESULTS The ventilated mask allowed for excellent surgical maneuverability and freedom. The trocar system was effective for posterior surgical procedures, allowing access to critical paramedian structures, and afforded a superior surgical seal, but was limited in terms of visualization and maneuverability during anterior approaches. Aerosolization was reduced using both the mask and nasal trocar. CONCLUSION The ventilated upper airway endoscopic procedure mask allows for a sealed surgical barrier during endoscopic skull base surgery and may play a critical role in advancing skull base surgery in the COVID-19 era. The nasal trocar may be a useful alternative in instances where 3D printing is not available. Additional studies are needed to validate these preliminary findings.

scholarly journals 350 Cross Over Septal Flap Technique for Choanal Atresia Surgery: Two Centre Series with Outcomes

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
G Adegboyega ◽  
H A Elhassan ◽  
A Karligkiotis ◽  
K Searyoh ◽  
J Zocchi ◽  
...  
Keyword(s):  
Nasal Cavity ◽  
Choanal Atresia ◽  
Lateral Nasal Wall ◽  
Endoscopic Endonasal ◽  
Female Ratio ◽  
Primary Surgery ◽  
Exposed Bone ◽  
Flap Design ◽  
The Cross ◽  
Age Range

Abstract Introduction Choanal atresia (CA) is a congenital obstruction of the posterior nasal aperture due to nasal cavity canalisation failure. Endoscopic endonasal surgery has led to successful CA repair and fewer complications compared to open surgery. We describe our surgical technique that uses septal mucosal flaps without need for stenting or subsequent intubation. Method A multicentre retrospective review of patients who underwent surgery using the cross over septal technique. Patient demographics and outcomes were recorded. Flap design: bilateral vertical septal mucosa incisions are performed on either side of the posterior third of the septum to form two mucoperiosteal flaps. The posterior vomer and atretic plates are removed. One flap is pedicled superiorly and rotated over the bare sphenoid rostral bone. The contralateral flap is pedicled inferiorly and rotated to cover exposed bone of nasal cavity floor. Lateral nasal wall mucosal integrity is maintained. This technique is used both for unilateral and bilateral atresia. Results Twelve patients from 2013 to 2020 were included. Age range was 0.07-50 years, male to female ratio of 1:5. Ten patients had unilateral CA, two had bilateral. Nine had bony CA, the remainder mixed. 5 patients (mean age 2.8 years) underwent second-look endoscopy under sedation an average 36 days following primary surgery. Conclusions The cross over technique for CA has low morbidity and 100% success in our multicentre series. Use of mucoperiosteal flaps to cover the exposed bone, removal of vomer and minimal instrumentation to the lateral nasal wall are the best ways to avoid postoperative stenosis.

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