Transcript cavallo com

Extended endoscopic
transsphenoidal approach for skull
base lesions, basic concepts and
relevant surgical anatomy
By
Amr Mohamed Madkour
Assisstant lecturer neurosurgery, Alex. University.
History of transsphenoidal approach,
• The ancient Egyptian embalmers used to remove the body
organs from the thorax and the abdomen during the
mummification process and preserve them in canopy, also
they removed the brain through the nose so as not disfiguring
the face and there are several studies on mummies made
with CT and archaeologists have found the instruments used
for such scope.
• David Giordano, chief surgeon of the hospital of venice, start
to use the approach to the sella through an extracranial
transsphenoidal approach at the end of the 19th century.
History of the approach,
•
later on, a series of European and American innovators, such as
Schloffer, Kocher, Hirsch, Halstead, and cushing et al. use the
transsphenoidal surgery, either sublabial or directly transnasal
approach.
• The approach decreased in use after that due to poor illumination
and absence of antibiotics and cortisone therapy.
• The French neurosurgeon Gerard Guiot, was the one who
implemented the standard procedure with the use of intraoperative
fluoroscopy and extend the approach even to the supra and
parasellr pathologies that was exception that time in the second
half of the 50th. Gerard Guiot was the first to use the endoscope for
inspection of the sellar cavity at the end of the surgical procedure in
order to further and deeper inspect of the surgical dome.
History of the approach,
• Jules Hardy later added the routine use of the operating
microscope. then Jules Hardy with the contribution of
Rudolph Fahlbusch in Germany, and Shou in China, and
Edward R, and Laws Jr in USA master the approach.
• The association of an expert in functional endoscopic sinus
surgery, Ricardo Carrau and a brilliant neurosurgeon, Hae
Dong Jho had been characterized the terms and modalities of
the new endoscopic transsphenoidal approach to the sellar
region, strictely endonasal, without the use of a
transsphenoidal retractors. they perform the first case of
pituitary adenoma completely endoscopic in 1996
History of the approach,
• The share of Italian surgeons, Cappabianca and de Divitiis
constituted the European outpost of such more recent
progress in transsphenoidal surgery since 1997and the core
of the Italian connection together with Castelnuovo’s group
and Frank’s group, who remove the tumors through the nose.
Amin Kassam and his group in Pennsulvania, are one the
eminent teams in endoscopic skull base surgey.
Basic concepts for extended approach
(according to kassam and carru)
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Two nostril approach
Middle turbinectomy, unilateral
Posterior ethmoidectomy, unilateral
Removal of the posterior portion of the nasal septum
Wide sphenoidotomy
Free hand endoscope ( three or four hand technique)
Calssic transsphenoidal approach
1- Nasal phase:
2- sphenoidal phase:
Continue,
3- sellar phase:
(A) Extended endoscopic approach to the
suprasellar region
• To expose the suprasellar region and planum sohenoidale, this
require more anterior trajectory with wide opening of the
superior portion of the anterior wall of the sphenoid sinus,
with removal of the superior turbinate on one or both sides,
with drilling of the bone of the tuberculum sellae and planum
sphenoidalae depending on certain anatomical landmarks,
the medial optocarotid recess with carotid and optic
protuberance and posterior ethmoidal artery laterally,
complete removal of the bone from the planum to reach the
falciform ligament or even more anteriorly according to the
lesion.
A, wide spenoidotomy and bilateral posterior
ethmoidectomy to obtain wider view of the
planum sphenoidale; B, both posterior
ethmoidal arteries are visible, they usually
represent a limit when opening the planum
sphenoidale
endoscopic transsphenidal view after removal of
tuberculum sellae and planum sphenoidale up to
the falciform ligament
The suprasellar area is divided into
four regions by Two imaginary
planes, one passing through the
inferior surface of the chiasm and
mammilary bodies, and the other
passing through the posterior edge
of the chiasm and dorsum sellae
1- suprachiasmatic region
• suprachiasmatic region before (A), and after (B) opening the
lamina terminalis
once opening the dura over the planum
sphenoidale and tuberculum sellae, the
chiasmatic cistern with the anterior margin of
the chiasm and medial portion of the optic
nerves are visible. Also the lamina terminalis
cistern is exposed, once opening the
arachnoid, the A1 segments, the anterior
communicating, the recurrent artery of
heubner, A2 segments, and gyri recti of the
frontal lobes are visible
2- subchiasmatic region
• once opening the dura, the pituitary stalk
below the chiasm, the superior hypophyseal
artery and the perforating branches for the
inferior surface of the optic chiasm and
nerves are apparent. Laterally, the origin of
the ophthalmic artery below the optic nerve
is also visible. When the endoscope is
advanced below the chiasm, lateral view
shows the ICA, its bifurication, and the first
A1 segment before it reaches the superior
surface of the chiasm.
3- retrosellar region,
• that can be reached by passing the
endoscope between the pituitary
stalk and ICA above the dorsum
sellae. We can see from inferior to
superior, the upper third of the
basilar artery and the pons below it,
the posterior cerebral artery, the
superior cerebellar arteries, the
occulomotor nerve, the mammillary
bodies, and the floor of the third
ventricle
4- ventricular region,
• it appears by passing the endoscope
into the retrosellar space shows the
floor of the third ventricle in front of
the mammillary bodies. Opening the
floor allows access to the ventriclular
cavity. The lateral ventricle walls
formed by the medial portion of the
thalami are visible with the
interthalamic commissure. The
foramina of Monro are visible
superiorly. Then follow the
interthalamic adhesion toward the
posterior ventricle wall
Ventricular region, cont,
• Once opening of the roof of
the third ventricle, the pineal
gland and internal cerebral
veins lateral to the pineal gland
are visible.
• the endoscope passes below
the interthalamic adhesion, the
pineal gland and both internal
cerebral veins are visible
Transtuberculum, transplanum approach
• Most commen pathologies that can be removed through this
approach including:
- craniopharyngioma
- tuberculum sellae meningeoma
- pituitary adenomas
- ect,
•
de Divitiis E, Cappabianca P, Cavallo LM. Endoscopic
transsphenoidal approach: adaptability of the procedure to
different sellar lesions. Neurosurgery 2002 ;51(3):699-705.
23y female patient complaining of headache , with
bitemporal hemianopia, no hormonal disturbance
Operated for extended endoscopic transsphenoidal
removal of the tumor,( cystic craniopharyngioma)
Postopertive MRI shows complete removal of the
tumor
45y female patient complaining of severe headache, no
hormonal disturbance, with rt superior quadrantanopia
Operated for extended endoscopic approach for
removal of tuberculum sellae meningeoma
Postoperative MRI shows complete tumor removal
(B) Extended endoscopic approach to the
olfactory groove
• This approach facilitates dealing with lesions affecting the
cribriform plate and called transcribriform approach, (crista
galli and olfactory sulci)
.(A), the asterisks marks the olfactory sulcus;
EC, ethmoid cell; LP, lamina papyracea; mewl,
medial wall of ethmoid labyrinth; Pp,
perpendicular plate of the ethmoid; OP, optic
protuberance. (B), The ethmoidal arteries have
been isolated on both sides and the cribriform
plate is removed thus exposing the dura. AEA,
anterior ethmoidal artery; O, orbit; dm, dura
matter; ICAs, sellar portion of the ICA.
The superior portion of the lamina papyracea is removed,
and the anterior and posterior ethmoidal arteries are isolated
and ligated on both sides. The bone of the anterior skull base between
the orbits is removed and the dura mater is opened, allowing
exposure of the intracranial contents. The olfactory nerves and the
basal surfaces of the frontal lobes are initially visualized By
retractingthe medial surfaces of the frontal lobes, it is possible to
expose the two pericallosal arteries in the interhemispheric fissure
Transcribriform approach,
• It is possible to deal with the following lesions through this
approach:
1- CSF leak
2- meningocele, encephalocele
3- ethesioneuroblastoma
4- olfactory groove meningeomas
5- other skull base malignancies
. Limits of bone resection:
- Posterior wall of the frontal sinus
- Medial wall of the orbit
- Posterior ethmoidal arteries (+, -)
37y male patient presented with heaadche and anosmia, operated for
endoscopic transcribriform approach for tumor removal
(C) Extended endoscopic approach to the the
upper clivus
• After removal of the middle turbinate on one side, and wide anterior
sphenoidotomy with removal of all septa and removal of the posterior
portion of the nasal septum, we begin to detach the nasal mucosa from
the vomer and along the inferior wall (floor) of sphenoid sinus and the
mucosa dissected laterally till the vidian nerve which represent the lateral
boundary of the surgical corridor. This mucosal flab dissected inferiorly in
the nasal cavity and can be used for repair later on. According to the
tumor extension, we begin to remove the bone of the clivus till the sella
superiorly, paraclival tracts of the ICA laterally, and below the level of the
paraclival carotid inferiorly.
A- the nasal mucosa has been dissected around the vomer and
laterally toward the vidian canal and nerve which is important surgical
landmark B- after drilling of the upper half of the clivus and exposure
of the dura matter
The bone of the clivus and bone covering the intracavernous carotid has been
removed completely exposing the paraclival carotid, the dorsal meningeal artery and
the abducent nerve behind the paraclival segment of intracavernous carotid.
After opening the dura we see the basilar artery and pons, the course of abducent
nerve from its origin to the cavernous sinus
(D) Extended endoscopic approach to the lower
clivus and craniocervical junction and C1
• This approach can be considered the extreme inferior
extension of the previously described endoscopic approach to
the clivus.
• we extend the bone removal to the posterior portion of the
vomor and the whole sphenoid floor to access the lower
clivus. In this way we achieve wide exposure of the sphenoid
cavity, the rhinopharynx, and sphenoclival region down to C1.
The image shows the lower clivus the rhinopharynx and eustachian tube
after removal of the lower clivus we can see the foramen lacerum which is important
surgical landmark and the lateral limit of the approach at this level
The mucosa of the rhinopharynx has been removed and the longus capitis
and the longus colli muscles have been dissected to expose the
craniovertebral junction
(E) Extended endoscopic approach to parasellar
region and cavernous sinus
•
this drawing shows the middle third of the clivus and petrous bone in
coronal plane, the five zones in black boxes. Zone 1, medial petrous apex
approach; zone 2, petroclival approach; zone 3, inferior cavernous
(quadrangular space) approach; zone 4, superior cavernous sinus
approach; zone 5, trans pterygoid infratemporal fossa approach. CS, the
cavernous sinus above; V, vidian canal leading to the ICA; J, jugular vein.
Extended endoscopic approach to the
infratemporal fossa
• this area can be reached through removal of the medial and
posterior maxillary wall, the medial pterygoid plate (MPP) and
extending upward until in flush with the middle cranial fossa
and foramen rotundum. And extending laterally to the lateral
pterygoid plate (LPP) that should be removed to reach the
infratemporal fossa
endonasal skull base reconstruction,
• It is the most important step that we should prepare for it before starting
bone removal
• The principles of repair, ( according to cappapianca and cavallo) :
1- reduce CSF pulsatile effect on the skull base defect
2- sandwich closure of the osteo dural skull base defect
3- cover skull base defect by free mucosal flab(+,-)
4- sphenoid sinus ballon stenting for two weeks
5- lumber drainage for 3-5 days
Sandwich tichnique
- intradurally: 1. dural layer
2. fat layer
3. dural layer
- extradurally: dural layer
Take home message
• Endoscopic work has steep learning curve
• Attending cadaveric workshops is very important to understand the
relevant surgical anatomy of extended approach
• Be sure that the room setup is well prepared for extended approach
• Aided tools such as dopler probe and neuronavigation should be
available
• We should design the plan of bony work and methods of repair
from the start and should be individualized according to the case
• Put in mind that repair is the most important step in the operation
References,
• Cavallo LM, Messina A, Cappabianca P. Endoscopic endonasal surgery of
the midline skull base: anatomical study and clinical considerations.
Neurosurg Focus 2005; 19:E2.
• Aydin S, Cavallo LM, Messina A. The endoscopic endonasal
transsphenoidal approach to the sellar and suprasellar area. Anatomic
study. J Neurosurg Sci 2007; 51:129-38.
• Kassam A, Gardner P, Snyderman C, Mintz A, Carrau R. Expanded
endonasal approach: fully endoscopic, completely transnasal approach to
the middle third of the clivus, petrous bone, middle cranial fossa, and
infratemporal fossa. Neurosurg. Focus, volume 19, July 2005.
• Cavallo LM, De Divitiis O, Aydin S, et al. Extended endoscopic endonasal
transsphenoidal approachto the suprasellar area, anatomic considerationpart1. Neurosurg 61: ONS-24- ONS-34, 2007.
References,
• Guiot J, Rougerie J, Fourestier M, Fournier A, Comoy C, Vulmiere J, Groux
R. International endoscopic explorations. Presse Med 1963; 71: 12251228.
• Giordano D. Compendio di chirurgia operative italiana. UTET, Torino 1911,
pp 100-103.
• Cushing HW. The pituitary body and its disorders: clinical states produced
by disorders of the hypophysis cerebri. JB Lippincott, Philadelphia, 1912;
pp296-305.
• Hardy J. Transsphenoidal hypophysectomy. J Neurosurg 1971; 34: 582-594.
• Jho HD, Carrau RL, Ko Y. Endoscopic pituitary surgery. In: Reganchary SS,
Willkins RH (eds) Neurosurgical operative atlas. American Association of
Neurological Surgeons, Park Ridge, 1996, IL, pp1-12.
• Carrau RL, Jho HD, Ko Y. Transnasal transsphenoidal endoscopic surgery of
the pituitary gland. Laryngoscope, 1996; 106: 914-918
Thank you for your attention