scholarly journals Endoscopic extended transsphenoidal resection of craniopharyngiomas: nuances of neurosurgical technique

2014 ◽  
Vol 37 (4) ◽  
pp. E10 ◽  
Author(s):  
Andrew R. Conger ◽  
Joshua Lucas ◽  
Gabriel Zada ◽  
Theodore H. Schwartz ◽  
Aaron A. Cohen-Gadol ◽  
...  
Keyword(s):  
Third Ventricle ◽  
Tumor Resection ◽  
Direct Access ◽  
Complication Rates ◽  
Endoscopic Endonasal ◽  
Transnasal Surgery ◽  
Recovery Times ◽  
Early Tumor ◽  
Ventral Skull Base ◽  
Brain Retraction

Endoscopic approaches to the midline ventral skull base have been extensively developed and refined for resection of cranial base tumors over the past several years. As these techniques have improved, both the degree of resection and complication rates have proven comparable to those for transcranial approaches, while visual outcomes may be better via endoscopic endonasal surgery and hospital stays and recovery times are often shorter. Yet for all of the progress made, the steep learning curve associated with these techniques has hampered more widespread implementation and adoption. The authors address this obstacle by coupling a thorough description of the technical nuances for endoscopic endonasal craniopharyngioma resection with detailed illustrations of the important steps in the operation. Traditionally, transsphendoidal approaches to craniopharyngiomas have been restricted to lesions mostly confined to the sella. However, recently, endoscopic endonasal resections are more frequently employed for extrasellar and purely third ventricle craniopharyngiomas, whose typical retrochiasmatic location makes them ideal candidates for endoscopic transnasal surgery. The endonasal endoscopic approach offers many advantages, including direct access to the long axis of the tumor, early tumor debulking with minimal manipulation of the optic apparatus, more precise visualization of tumor planes, particularly along the undersurface of the chiasm and the roof of the third ventricle, and a minimal-access corridor that obviates the need for brain retraction. Although much emphasis has been placed on technical tenets of exposure and “how to get there,” this article focuses on nuances of tumor resection “when you are there.” Three operative videos illustrate our discussion of technical tenets.

Endoscopic endonasal transplanum transtuberculum approach for resection of retrochiasmatic craniopharyngioma

2012 ◽  
Vol 32 (Suppl1) ◽  
pp. E2 ◽  
Author(s):  
James K. Liu ◽  
Jean Anderson Eloy
Keyword(s):  
Third Ventricle ◽  
Tumor Resection ◽  
Radical Resection ◽  
Optic Chiasm ◽  
Cranial Base ◽  
Surgical Morbidity ◽  
Endoscopic Endonasal ◽  
Retrochiasmatic Region ◽  
Brain Retraction ◽  
Neurovascular Structures

Retrochiasmatic craniopharyngiomas are formidable cranial base tumors to resect because of their intimate relationship with neighboring critical neurovascular structures, particularly the undersurface of the optic chiasm and hypothalamus. Radical resection offers the best chance of minimizing tumor recurrence, although this may be associated with significant surgical morbidity. Although various transcranial approaches have been utilized (transbasal subfrontal, frontobasal interhemispheric, pterional, orbitozygomatic, and petrosal) for resection of retrochiasmatic craniopharyngiomas, each is associated with some degree of brain retraction, and direct visualization of the retrochiasmatic region is often incomplete, therefore resulting in blind dissection. The endoscopic endonasal transplanum transtuberculum approach provides the most direct route to the retrochiasmatic region while affording unmatched visualization of the undersurface of the optic chiasm, third ventricle, and hypothalamus. This advantage allows for direct bimanual tumor dissection off of these critical structures by using microsurgical principles. The endonasal route also has the advantage of avoiding brain retraction and risk of cerebral edema that can be associated with transcranial approaches. In this operative video atlas report, the authors demonstrate their step-by-step techniques for resection of a suprasellar retrochiasmatic craniopharyngioma using a purely endoscopic endonasal transplanum transtuberculum approach. They describe and illustrate the operative nuances and surgical pearls to safely and efficiently perform the approach, tumor resection, and multilayered reconstruction of the cranial base defect. The video can be found here: http://youtu.be/ZIbJvAyRxYU.

scholarly journals Sellar trough technique for endoscopic endonasal transclival repair

2020 ◽  
Vol 11 ◽  
pp. 99
Author(s):  
Andrew K. Wong ◽  
Joseph Raviv ◽  
Ricky H. Wong
Keyword(s):  
Skull Base ◽  
Tumor Resection ◽  
Spinal Fluid ◽  
Direct Access ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Ventral Skull Base ◽  
Fluid Leak ◽  
The Brain

Background: Endoscopic endonasal transclival approaches provide direct access to the ventral skull base allowing the treating of clival and paraclival pathology without the manipulation of the brain or neurovascular structures. Postoperative spinal fluid leak, however, remains a challenge and various techniques have been described to reconstruct the operative defect. The “gasket seal” has been well-described, but has anatomic challenges when applied to clival defects. We describe a modification of this technique for use in endonasal transclival approaches. Methods: Two patients who underwent an endoscopic endonasal transclival approach for tumor resection with an intraoperative spinal fluid leak underwent a modified “gasket seal” closure technique for skull base reconstruction. Results: A 71-year-old woman with a petroclival meningioma and a 22 year old with a clival chordoma underwent endoscopic endonasal transclival resection with the modified repair. No new postoperative deficits occurred and no postoperative spinal fluid leak was seen with a follow-up of 17 and 23 months, respectively. Conclusion: We describe the successful use of a simple, low risk, and technique modification of the “gasket seal” technique adapted to the clivus that allows for hard reconstruction and facilitates placement of the nasoseptal flap.

Expanded endoscopic endonasal transcribriform approach for resection of anterior skull base olfactory schwannoma

2012 ◽  
Vol 32 (Suppl1) ◽  
pp. E3 ◽  
Author(s):  
James K. Liu ◽  
Jean Anderson Eloy
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Tumor Resection ◽  
Cranial Base ◽  
Anterior Skull Base ◽  
Endoscopic Endonasal ◽  
Olfactory Groove ◽  
Anterior Cranial Base ◽  
Ventral Skull Base ◽  
Brain Retraction

Anterior skull base (ASB) schwannomas are extremely rare and can often mimic other pathologies involving the ASB such as olfactory groove meningiomas, hemangiopericytomas, esthesioneuroblastomas, and other malignant ASB tumors. The mainstay of treatment for these lesions is gross-total resection. Traditionally, resection for tumors in this location is performed through a bifrontal transbasal approach that can involve some degree of brain retraction or manipulation for tumor exposure. With the recent advances in endoscopic skull base surgery, various ASB tumors can be resected successfully using an expanded endoscopic endonasal transcribriform approach through a “keyhole craniectomy” in the ventral skull base. This approach represents the most direct route to the anterior cranial base without any brain retraction. Tumor involving the paranasal sinuses, medial orbits, and cribriform plate can be readily resected. In this video atlas report, the authors demonstrate their step-by-step techniques for resection of an ASB olfactory schwannoma using a purely endoscopic endonasal transcribriform approach. They describe and illustrate the operative nuances and surgical pearls to safely and efficiently perform the approach, tumor resection, and multilayered reconstruction of the cranial base defect. The video can be found here: http://youtu.be/NLtOGfKWC6U.

scholarly journals Using the trans-lamina terminalis route via a pterional approach to resect a retrochiasmatic craniopharyngioma involving the third ventricle

2016 ◽  
Vol 40 (videosuppl1) ◽  
pp. 1 ◽  
Author(s):  
Alexander G. Weil ◽  
Thomas Robert ◽  
Sultan Alsaiari ◽  
Sami Obaid ◽  
Michel W. Bojanowski
Keyword(s):  
Third Ventricle ◽  
Direct Access ◽  
Lamina Terminalis ◽  
Pterional Approach ◽  
The Third ◽  
Good Working ◽  
Link Type ◽  
Brain Retraction

Retrochiasmatic craniopharyngiomas involving the anterior third ventricle are challenging to access. Although the pterional approach is a common route for suprasellar lesions, when the craniopharyngioma extends behind the chiasma into the third ventricle, access is even more difficult, and the lamina terminalis may offer a good working window. The translamina terminalis approach provides direct access to the retrochiasmatic portion of the tumor with minimal brain retraction and no manipulation of the visual nerves. In this video, we emphasize the utility of using the lamina terminalis corridor to resect the retrochiasmatic intraventricular portion of a craniopharyngioma.The video can be found here: https://youtu.be/hrLNC0hDKe4.

Extended Endoscopic Endonasal Transsphenoidal Approach to the Suprasellar Area: Anatomic Considerations—Part 1

2007 ◽  
Vol 61 (suppl_3) ◽  
pp. ONS-24-ONS-34 ◽  
Author(s):  
Luigi M. Cavallo ◽  
Oreste de Divitiis ◽  
Salih Aydin ◽  
Andrea Messina ◽  
Felice Esposito ◽  
...  
Keyword(s):  
Third Ventricle ◽  
Transsphenoidal Approach ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Microsurgical Approach ◽  
Transcranial Approach ◽  
Median Approach ◽  
Key Steps ◽  
Brain Retraction

Abstract Introduction: Interest in using the extended endonasal transsphenoidal approach for management of suprasellar lesions, with either a microscopic or endoscopic technique, has increased in recent years. The most relevant benefit is that this median approach permits the exposure and removal of suprasellar lesions without the need for brain retraction. Materials and Methods: Fifteen human cadaver heads were dissected to evaluate the surgical key steps and the advantages and limitations of the extended endoscopic endonasal transplanum sphenoidale approach. We compared this with the transcranial microsurgical view of the suprasellar area as explored using the bilateral subfrontal microsurgical approach, and with the anatomy of the same region as obtained through the endoscopic endonasal route. Results: Some anatomic conditions can prevent or hinder use of the extended endonasal approach. These include a low level of sphenoid sinus pneumatization, a small sella size with small distance between the internal carotid arteries, a wide intercavernous sinus, and a thick tuberculum sellae. Compared with the subfrontal transcranial approach, the endoscopic endonasal approach offers advantages to visualizing the subchiasmatic, retrosellar, and third ventricle areas. Conclusion: The endoscopic endonasal transplanum sphenoidale technique is a straight, median approach to the midline areas around the sella that provides a multiangled, close-up view of all relevant neurovascular structures. Although a lack of adequate instrumentation makes it impossible to manage all structures that are visible with the endoscope, in selected cases, the extended endoscopic endonasal approach can be considered part of the armamentarium for surgical treatment of the suprasellar area.

scholarly journals Combined simultaneous endoscopic endonasal and microscopic transventricular surgery using a port retractor system for giant pituitary adenoma: A technical case report

2021 ◽  
Vol 12 ◽  
pp. 90
Author(s):  
Erika Yamada ◽  
Hiroyoshi Akutsu ◽  
Hiroyoshi Kino ◽  
Shuho Tanaka ◽  
Hidetaka Miyamoto ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Obstructive Hydrocephalus ◽  
Third Ventricle ◽  
Tumor Resection ◽  
Endoscopic Endonasal Surgery ◽  
Endonasal Surgery ◽  
Endoscopic Endonasal ◽  
Giant Pituitary Adenoma ◽  
The Third ◽  
Memory Disturbance

Background: We report a case of a giant pituitary adenoma with marked extension into the third ventricle that was successfully removed using combined simultaneous endoscopic endonasal surgery (EES) and microscopic transventricular port surgery. Case Description: A 47-year-old woman, who complained of memory disturbance, had a giant pituitary adenoma with marked extension into the third ventricle that was causing obstructive hydrocephalus. She underwent combined EES and microscopic transventricular surgery using a port retractor system. Most of the tumor was resected from the EES side with assistance from the transcranial side with minimum cortical trajectory damage. The tumor was completely excised without any complications. Conclusion: For giant pituitary adenoma with marked extension into the third ventricle, combined simultaneous EES and transventricular surgery using a port retractor system is effective to maximize the extent of tumor resection while also preventing complications. Using port surgery on the transcranial side, microscopic secure dissection is possible with minimum additional cortical damage.

scholarly journals Septal transposition: a novel technique for preservation of the nasal septum during endoscopic endonasal resection of olfactory groove meningiomas

2014 ◽  
Vol 37 (4) ◽  
pp. E6 ◽  
Author(s):  
Marc R. Rosen ◽  
Mindy R. Rabinowitz ◽  
Christopher J. Farrell ◽  
Madeleine R. Schaberg ◽  
James J. Evans ◽  
...  
Keyword(s):  
Nasal Septum ◽  
Cranial Base ◽  
Septal Perforation ◽  
Endoscopic Endonasal ◽  
Olfactory Groove ◽  
Anterior Cranial Base ◽  
Nasal Septal Flap ◽  
Early Tumor ◽  
Brain Retraction ◽  
Wide Exposure

Endonasal resection of olfactory groove meningiomas allows for several advantages over transcranial routes, including a direct approach to the bilateral anterior cranial base and dura mater, early tumor devascularization, and avoidance of brain retraction. Although considered minimally invasive, the endoscopicapproach to the cribriform plate typically requires resection of the superior nasal septum, resulting in a large superior septal perforation. The septal transposition technique improves preservation of sinonasal anatomy through the elimination of a septal perforation while allowing for wide exposure to the midline anterior cranial base and harvest of a nasal septal flap. Herein, the authors describe a 39-year-old female who presented with a progressively enlarging olfactory groove meningioma. An endoscopic endonasal resection with a septal transposition technique was performed. On follow-up, the nasal cavity had completely normal anatomy with preservation of the turbinatesand nasal septum. The authors conclude that septal transposition is a useful technique that allows wide exposure of the anterior cranial base with maximal preservation of normal nasal anatomy and avoidance of a large septal perforation.

scholarly journals Extended Endoscopic Endonasal Surgery to Ventral Skull Base Lesions

QJM ◽  
2020 ◽  
Vol 113 (Supplement_1) ◽  
Author(s):  
A S Montaser ◽  
M S Ismail ◽  
O Y Hammad ◽  
Z Y Fayed ◽  
D M Prevedello
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Direct Access ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Invasive Approach ◽  
Skull Base Lesions ◽  
The Mean ◽  
Ventral Skull Base

Abstract Introduction In the last two decades, Endoscopic endonasal approaches (EEAs) have undergone a significant evolution with a major shift from a transsellar approach to a variety of approaches that can directly access the midline and paramedian ventral skull base. Once the technical feasibility of any surgical approach is established; its safety (assessed through complications), and treatment outcomes (assessed through long-term follow-up) should be addressed. Aim of the Study To assess the feasibility, safety, and efficacy of EEA as a minimally invasive approach to ventral skull base lesions. Methodology and Materials this is a prospective observational study of group of 30 patients with ventral skull base lesions that were managed via endoscopic endonasal approaches. All patients’ clinical data, radiographic evaluations, procedural detail, complications, and follow-up data were recorded and analyzed. Results The mean age of patients was 50.8 years (range: 18-74 years), with a male:female ration of 1:1.72. The most commonly encountered pathological entities in the cohort was meningiomas (43.3%), pituitary adenomas (23.3%). and craniopharyngiomas (13.3%). Postoperative CSF leak was observed in 6.6% of cases and was managed successfully. There were no cases with postoperative infection in the cohort. Other procedure-related complications include transient diabetes insipidus (10%), pneumocephaly (3.3%), Syndrome of inappropriate ADH secretion (3.3%). Gross total resection was achieved in 93.3% of cases. Improvement of preoperative symptoms was recorded in 89.2% of cases. The mean follow-up duration was 17.8 ± 2.7 months. Conclusion EEAs provide direct access and better visualization to the ventral skull base without brain retraction and with minimal neurovascular manipulation, leading to less morbidity and mortality. EEA can be considered a feasible, safe, and effective tool on the armamentarium of skull base surgery. EEAs should not be considered as a replacement to the traditional transcranial approaches; rather. EEAs are deemed as a complementary route and a potential alternative to conventional skull base surgery in select cases.

scholarly journals The Posterior Transpetrosal Approach in a Case of Large Retrochiasmatic Craniopharyngioma: Operative Video and Technical Nuances

2018 ◽  
Vol 79 (S 02) ◽  
pp. S205-S207 ◽  
Author(s):  
Moujahed Labidi ◽  
Kentaro Watanabe ◽  
Marie-Pier Loit ◽  
Shunya Hanakita ◽  
Sébastien Froelich
Keyword(s):  
Adjuvant Therapy ◽  
Third Ventricle ◽  
Tumor Resection ◽  
Mass Effect ◽  
Venous Anatomy ◽  
Endoscopic Endonasal ◽  
Optic Chiasma ◽  
Visual Deficits ◽  
The Third ◽  
Accelerated Growth

Objectives To discuss the use of the posterior petrosal approach for the resection of a retrochiasmatic craniopharyngioma. Design Operative video. Results In this case video, the authors discuss the surgical management of a large craniopharyngioma, presenting with mass effect on the third ventricle and optic apparatus. A first surgical stage, through an endoscopic endonasal transtubercular approach, allowed satisfactory decompression of the optic chiasma and nerves in preparation for adjuvant therapy. However, accelerated growth of the tumor, with renewed visual deficits and mass effect on the hypothalamus and third ventricle, warranted a supplementary resection. A posterior transpetrosal1 2 (also called “retrolabyrinthine transtentorial”) was performed to obtain a better exposure of the tumor and the surrounding anatomy (floor and walls of the third ventricle, perforating vessels, optic nerves, etc.)3. Nuances of technique and surgical pearls related to the posterior transpetrosal are discussed and illustrated in this operative video, including the posterior mobilization of the transverse–sigmoid sinuses junction, preservation of the venous anatomy during the tentorial incision, identification and preservation of the floor of the third ventricle during tumor resection, and a careful multilayer closure. Conclusion Retrochiasmatic craniopharyngiomas are difficult to reach tumors that often require skull base approaches, either endoscopic endonasal or transcranial. The posterior transpetrosal approach is an important part of the surgical armamentarium to safely resect these complex tumors.The link to the video can be found at: https://youtu.be/2MyGLJ_v1kI.

scholarly journals Endoscopic endonasal resection of a large tuberculum sella meningioma

2020 ◽  
Vol 2 (2) ◽  
pp. V3
Author(s):  
Ahmed Mohyeldin ◽  
Jayakar V. Nayak ◽  
Juan C. Fernandez-Miranda
Keyword(s):  
Skull Base ◽  
Wide Spectrum ◽  
Direct Access ◽  
Csf Leak ◽  
Anterior Communicating Artery ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Tuberculum Sella ◽  
Ventral Skull Base

Over the past three decades, endoscopic endonasal surgery has unlocked new corridors to treat a wide spectrum of ventral skull base lesions. Tuberculum sella meningiomas represent one of the most ideal pathologies for ventral skull base access. Traditionally, these lesions were approached primarily through various subfrontal and frontal-lateral transcranial approaches that have unfortunately been shown to be associated with worsening visual decline postoperatively. The endoscopic endonasal approach is now being attempted by more surgeons and leverages an infrachiasmatic trajectory that provides direct access to the tuberculum sella where most of the vascular supply for these lesions can be taken early, facilitating more efficient surgical resection and mitigating the risk of optic nerve injury. Here we review a challenging case of a large (∼3 cm) tuberculum sella meningioma, encasing critical vessels off the circle of Willis and resected via an endoscopic endonasal approach. We discuss the technical nuances and relevant surgical anatomy of this approach and highlight important considerations in the safe and successful removal of these meningiomas. We show that certain tumors that appear to encase the supraclinoidal carotid artery can be fully resected via an endonasal approach with precise surgical technique and adequate exposure. Furthermore, this case illustrates the risk of injuring a key perforating vessel from the anterior communicating artery complex, called the subcallosal artery. Injury to this vessel is highly associated with tumors like the one presented here that extend into the suprachiasmatic space between the optic chiasm and the anterior communicating complex. Meticulous surgical dissection is required to preserve this perforating vessel as well as branches from the superior hypophyseal artery. Finally, we review our current closure techniques for these challenging approaches and discuss the use of a lumbar drain for 3 days to lower CSF leak rates.The video can be found here: https://youtu.be/mafyXi5B0MA.

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