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Endoscope-assisted microsurgical resection of skull base meningiomas

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Abstract

This study aims to determine the value of endoscope assistance in the microsurgical resection of skull base meningiomas. Fourty-six patients harboring a skull base meningioma underwent an endoscope-assisted microsurgical resection. In 30 patients (65%), tumor parts which could not be visualized under the microscope were detected with the endoscope. In 26 patients (56%), these tumor remnants were removed under endoscopic view. Gross total resection was achieved in 35 patients (76%) and near-total resection in 11 (24%). There was no surgical mortality. The major complication was new cranial nerve deficit. The application of endoscopes was most useful in the small supraorbital craniotomies to look under the ipsilateral optic nerve and internal carotid artery as well as to visualize the diaphragm sellae and olfactory groove. In the retrosigmoid craniotomies, the endoscope was beneficial to inspect the internal auditory canal, to look into Meckel’s cave, or to inspect areas hidden behind the jugular tubercle and tentorial edge. There was no obvious complication related to the application of the endoscope. Endoscope assistance is particularly of value when skull base meningiomas are to be removed via small craniotomies to inspect blind corners which cannot be visualized in a straight line with the microscope. In addition, there is a benefit of using endoscopes with various angles of view in standard craniotomies and skull base approaches to look around bony and dural corners or to look behind neurovascular structures, by which the amount of skull base drilling and retraction to expose the tumor can be reduced.

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Acknowledgment

We thank Marc Matthes, M. Sc., for his help in preparing the illustrations.

Disclosure

HWSS is consultant to Karl Storz GmbH & Co. KG (Tuttlingen, Germany).

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Authors and Affiliations

  1. Department of Neurosurgery, Ernst Moritz Arndt University, Sauerbruchstr, 17487, Greifswald, Germany

    Henry W. S. Schroeder & Jörg Baldauf

  2. Department of Neurosurgery, Katharinenhospital, Stuttgart, Germany

    Anne-Katrin Hickmann

Authors
  1. Henry W. S. Schroeder
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  2. Anne-Katrin Hickmann
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  3. Jörg Baldauf
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Correspondence to Henry W. S. Schroeder.

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Comments

André Grotenhuis, Nijmegen, The Netherlands

In this study, the authors have recorded the benefit of endoscopic application during microneurosurgical resection of 46 skull base meningiomas over a period of 8 years and 3 months prospectively, and the usefulness of the endoscope was assessed regarding the detection of tumor tissue which was not visible under the microscope as well as the ability to remove tumor tissue under endoscopic visualization. However, in the same study period, 97 additional skull base meningiomas were microsurgically resected without additional use of an endoscope because the authors felt it was not of value. So I have to assume that the authors (with the senior author being a well-known expert in this field) have more or less assessed something that they already knew beforehand, i.e., in which cases the use of an endoscope is most likely to be beneficial.

As expected, the application of an endoscope was most useful in the small supraorbital craniotomies. There they found residual tumor which could not be visualized with the operating microscope. In all cases, these tumor remnants were removed under endoscopic vision. But also in other location it was to some extent useful, e.g. in removing tumor parts hidden behind the jugular and suprameatal tubercle as well as in looking into Meckel’s cave.

They also have recorded all technical problems with the endoscopes that occurred during the surgeries. There was no obvious complication related to the application of the endoscope, although they correctly state that it is impossible to rule out completely that some additional trauma to the neurovascular structures occurred while using the endoscope, for example because of the heat at the tip of the endoscope.

They nicely describe and also beautifully illustrate how the endoscope is used during such skull base procedures. There have been quite some reports on endoscope-assisted microneurosurgical procedures, but only few publications really deal with such technical details of how to use the endoscope wisely [1,2]. Endoscopic inspection and dissection was mostly done with the aid of a 30° or 45° scope, because manipulations under 70° endoscopes are much more difficult because of the sharp angle of view. From their illustrations (Figs. 1, 2, and 3), I can only see one difference compared to my own endoscope-assisted technique. When the endoscope is fixed in a holding arm and is inside the surgical site, it is very difficult to bring the instruments from the outside into the viewing field of the endoscope, so therefore I always have the microscope still in place and introduce the instruments under direct vision through the microscope until I can see them on the monitor displaying the endoscopic image. However, it is this switch between the two modalities that is rather inconvenient and for this purpose and exoscope has been developed.

I can only fully agree with their conclusion that it still remains open whether endoscope assistance will improve the results, however, it definitely reduces surgical trauma. Using endoscopes during microsurgical procedures allows a reduction of the craniotomy size, improves illumination and visualization and enables the surgeon to look around bony corners and important neurovascular structures, thus eliminating or at least reducing the need for skull base drilling as well as brain retraction.

References

1. Grotenhuis JA (1995) Endoscope-assisted craniotomy. Techniques in Neurosurgery 1: 201–212

2. Grotenhuis JA (1998) Endoscope-assisted removal of skull base tumors. In: Endoscope-assisted microneurosurgery. A concise guidebook, pp. 57–100. Uitgeverij Machaon, Nijmegen.

Miguel A. Arraez, Malaga, Spain

In this paper of Schroeder and colleagues, the issue of the real usefulness of the endoscope as adjunct tool for the resection of skull base neoplasms arises. It is important to enhance that the radical removal was done in additional 10% of the cases due to the application of this promising technique. Is also important to make a reference of the context in which the endoscopy has been used: supraorbital keyhole approaches or petrosal/parapetrosal skull base approaches with evident limitations to identify all the hidden aspects of the tumors, with special emphasis in the invasion of the internal auditory canal. The authors very honestly state that the main indication in their experience are those particular situations, found in one third of the overall skull base tumors. Pterional and standard transfrontal approaches (non “keyhole”) would not benefit from endoscopic assistance. Regarding the dilemma of transcranial versus transnasal removal of tuberculum sellae meningiomas, the authors do prefer the transcranial approach, being still this matter under debate in the medical literature with obvious bias according to everyone’s experience.

Of paramount importance are also the comments about the specific technique for endoscopic assistance in skull base. The possibility of damage (thermal or mechanical) to neurovascular structures with the tip of the endoscope must be taken into account. Regarding the use of 70º lens endoscope, in our opinion really difficult to deal with at the skull base region.

In summary, this is a very interesting paper pointing out the advantages of this promising technique allowing in some instances good visualization with less invasive approaches for skull base tumor resection.

Salvatore Di Maio, Laligam N. Sekhar, Washington, USA

Schroeder et al. present a series of 46 of 143 patients with skull base meningiomas treated from 2002 to 2009 in which endoscopic-assisted microsurgical resection was performed. The endoscope was used in 30 cases to identify tumor remnants; and in 26 procedures, tumor resection was carried out using the endoscope as the viewing tool.

A gross total resection was performed in 76% of patients, with the remainder having near-total resection. Most of the subtotal resections were in petroclival meningiomas (4/13 gross total resection). No growth of residual tumors was observed over 49 months’ mean follow-up. Complications included cranial nerve deficits in 20 patients (43%) of which seven are permanent. Four patients developed CSF rhinorrhea post-operatively. Of note, it appears that the authors’ practice is to perform smaller craniotomies (e.g., supraorbital craniotomies for anterior fossa meningiomas and retrosigmoid craniotomies for petroclival meningiomas), in which the extent of open exposure is limited and thus the endoscope was relied on to improve visualization.

It is difficult to interpret the rate of gross total resection in these patients because a further 97 patients with skull base meningiomas were treated concomitantly during the treatment period without the use of the endoscope, however the authors’ initial results are appealing and the merits of endoscope assistance are well conveyed. We have been using the endoscope routinely for several types of microsurgical operations, including microvascular decompression, aneurysm surgery, and skull base tumors. It is our experience that the endoscope is a valuable tool for visualization of certain blind spots during open microsurgical approaches; however, it has not changed our practice of applying full but refined skull base approaches to such meningiomas for safe but maximal exposure and resection.

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Schroeder, H.W.S., Hickmann, AK. & Baldauf, J. Endoscope-assisted microsurgical resection of skull base meningiomas. Neurosurg Rev 34, 441–455 (2011). https://doi.org/10.1007/s10143-011-0322-9

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