Skip to main content

Endoscopic endonasal approach to the mesial temporal lobe: anatomical study and clinical considerations for a selective amygdalohippocampectomy



Selective amygdalohippocampectomy (AH) is a surgical option for patients with medically intractable seizures from mesial temporal lobe pathology. The transcranial route is considered the best method to achieve this goal. However, the standard approach through the neocortex is still invasive. The risks can be minimized if the mesial temporal lobe is resected while preserving the lateral temporal lobe and the Meyer’s loop. This study explores the feasibility of selective AH by endoscopic endonasal approach (EEA) in cadaveric specimens.


The endoscopic anatomy of the mesial temporal lobe and the feasibility of a successful selective AH were studied in six hemispheres from three injected human cadavers. Quantitative analyses on the extent of resection and angles of exposure were performed based on CT and MRI studies of pre- and post-selective AH and measurements taken during dissections.


The EEA V1-V2 corridor provided a direct and logical line of access to the mesial temporal lobe, following its natural trajectory with no brain retraction and minimal exposure of the pterygopalatine fossa. The components of the mesial temporal lobe were resected just as selectively and easily as the transcranial route, but without compromising the structures of the lateral temporal lobe or the Meyer’s loop.


The EEA V1-V2 corridor demonstrated its selective resectability and accessibility of the mesial temporal lobe in cadaveric specimens. The clinical value of this approach should be explored responsibly by a surgeon with both competent microsurgical skills and experiences in EEA.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6


  1. Olivier A (2000) Transcortical selective amygdalohippocampectomy in temporal lobe epilepsy. Can J Neurol Sci 27:S68–S76 discussion S92–S96

    Article  Google Scholar 

  2. Yasargil MG, Wieser HG, Valavanis A, von Ammon K, Roth P (1993) Surgery and results of elective amygdala-hippocampectomy in one hundred patients with nonlesional limbic epilepsy. Neurosurg Clin N Am 4:243–261

    Article  CAS  Google Scholar 

  3. Egan RA, Shults WT, So N, Burchiel K, Kellogg JX, Salinsky M (2000) Visual field deficits in conventional anterior temporal lobectomy versus amygdalohippocampectomy. Neurology 55:1818–1822

    Article  CAS  Google Scholar 

  4. Falowski SM, Wallace D, Kanner A, Smith M, Rossi M, Balabanov A, Ouyang B, Byrne RW (2012) Tailored temporal lobectomy for medically intractable epilepsy: evaluation of pathology and predictors of outcome. Neurosurgery 71:703–709

    Article  Google Scholar 

  5. Ipekdal HI, Karadas O, Erdogan E, Gokcil Z (2011) Spectrum of surgical complications of temporal lobe epilepsy surgery: a single - center study. Turk Neurosurg 21:147–151

    PubMed  Google Scholar 

  6. Tanriverdi T, Ajlan A, Poulin N, Olivier A (2009) Morbidity in epilepsy surgery: an experience based on 2449 epilepsy surgery procedures from a single institution: clinical article. J Neurosurg 110:1111–1123

    Article  Google Scholar 

  7. Bahuleyan B, Fisher W, Robinson S, Cohen AR (2013) Endoscopic transventricular selective amygdalohippocampectomy: cadaveric demonstration of a new operative approach. World Neurosurg 80:178–182

    Article  Google Scholar 

  8. Chen HI, Bohman LE, Loevner LA, Lucas TH (2014) Transorbital endoscopic amygdalohippocampectomy: a feasibility investigation. J Neurosurg 120:1428–1436

    Article  Google Scholar 

  9. Kalinin P, Sharipov O, Kutin M, Fomichev D, Gavrjushin A, Polev G, Shults Y, Avdeeva K (2017) Amygdalohippocampectomy via the lateral extended transsphenoidal endoscopic approach through the pterygopalatine fossa: an anatomic study. World Neurosurg 103:457–464

    Article  Google Scholar 

  10. Silbergeld DL, Vollmer DG, Tantuwaya VS, Elchler ME (1994) Endoscopic transventricular hippocampectomy. J Epilepsy 8:68–73

    Article  Google Scholar 

  11. Labidi M, Watanabe K, Hanakita S, Park HH, Bouazza S, Bernat AL, Froelich S (2018) The chopsticks technique for endoscopic endonasal surgery-improving surgical efficiency and reducing the surgical footprint. World Neurosurg 117:208–220

    Article  Google Scholar 

  12. Attiah MA, Paulo DL, Danish SF, Stein SC, Mani R (2015) Anterior temporal lobectomy compared with laser thermal hippocampectomy for mesial temporal epilepsy: a threshold analysis study. Epilepsy Res 115:1–7

    Article  Google Scholar 

  13. Barbaro NM, Quigg M, Ward MM, Chang EF, Broshek DK, Langfitt JT, Yan G, Laxer KD, Cole AJ, Sneed PK, Hess CP, Yu W, Tripathi M, Heck CN, Miller JW, Garcia PA, McEvoy A, Fountain NB, Salanova V, Knowlton RC, Bagic A, Henry T, Kapoor S, McKhann G, Palade AE, Reuber M, Tecoma E (2018) Radiosurgery versus open surgery for mesial temporal lobe epilepsy: the randomized, controlled ROSE trial. Epilepsia 59:1198–1207

    Article  Google Scholar 

  14. Moles A, Guenot M, Rheims S, Berthiller J, Catenoix H, Montavont A, Ostrowsky-Coste K, Boulogne S, Isnard J, Bourdillon P (2018) SEEG-guided radiofrequency coagulation (SEEG-guided RF-TC) versus anterior temporal lobectomy (ATL) in temporal lobe epilepsy. J Neurol 265:1998–2004

    Article  Google Scholar 

  15. Gaab MR, Ehrhardt K, Heissler HE (1989) Local brain pressure microcirculation and pH during neurosurgical operations. In: Hoff JT, Betz AL (eds) Intracranial Pressure VII. Springer, Berlin, pp 886–890

    Chapter  Google Scholar 

  16. Andrews RJ, Bringas JR (1993) A review of brain retraction and recommendations for minimizing intraoperative brain injury. Neurosurgery 33:1052–1063

    CAS  Google Scholar 

  17. Goga C, Ture U (2015) The anatomy of Meyer’s loop revisited: changing the anatomical paradigm of the temporal loop based on evidence from fiber microdissection. J Neurosurg 122:1253–1262

    Article  Google Scholar 

  18. Balakrishnan K, Moe KS (2011) Applications and outcomes of orbital and transorbital endoscopic surgery. Otolaryngol Head Neck Surg 144:815–820

    Article  Google Scholar 

  19. De Battista JC, Zimmer LA, Rodriguez-Vazquez JF, Froelich SC, Theodosopoulos PV, DePowell JJ, Keller JT (2011) Muller’s muscle, no longer vestigial in endoscopic surgery. World Neurosurg 76:342–346

    Article  Google Scholar 

  20. Martins C, Li X, Rhoton AL Jr (2003) Role of the zygomaticofacial foramen in the orbitozygomatic craniotomy: anatomic report. Neurosurgery 53:168–172 discussion: 172–173

    Article  Google Scholar 

  21. Kassam AB, Thomas A, Carrau RL, Snyderman CH, Vescan A, Prevedello D, Mintz A, Gardner P (2008) Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 63(suppl 1):ONS44–ONS52

    PubMed  Google Scholar 

  22. Leng LZ, Brown S, Anand VK, Schwartz TH (2008) “Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery 62:342–343

    Google Scholar 

  23. Luginbuhl AJ, Campbell PG, Evans J, Rosen M (2010) Endoscopic repair of high-flow cranial base defects using a bilayer button. Laryngoscope 120:876–880

    Article  Google Scholar 

  24. Conger A, Zhao F, Wang X, Eisenberg A, Griffiths C, Esposito F, Carrau RL, Barkhoudarian G, Kelly DF (2018) Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients. J Neurosurg 130:861–875

    Article  Google Scholar 

  25. Lai LT, Trooboff S, Morgan MK, Harvey RJ (2014) The risk of meningitis following expanded endoscopic endonasal skull base surgery: a systematic review. J Neurol Surg B Skull Base 75:18–26

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Sébastien Froelich.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For the following retrospective study, formal consents are not required.

Informed consent

Informed consent was obtained from all individual participants included in the study. No identifiable information is available in the article. This article does not contain any studies with human participants performed by any of the authors.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Neurosurgical Anatomy

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Park, H.H., Ronconi, D., Hanakita, S. et al. Endoscopic endonasal approach to the mesial temporal lobe: anatomical study and clinical considerations for a selective amygdalohippocampectomy. Acta Neurochir 162, 881–891 (2020).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Endoscopic endonasal approach
  • Mesial temporal lobe
  • Meyer’s loop
  • Selective amygdalohippocampectomy
  • Temporal lobe epilepsy