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Extended endoscopic approaches for midline skull-base lesions

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The endoscopic transsphenoidal approach has been reported in the literature as a useful tool to treat sellar and parasellar lesions. The endoscope permits a panoramic view instead of the narrow microscopic view, and it allows the inspection and removal of the lesions of sellar, parasellar, and suprasellar compartments by angled-lens endoscopes. On the basis of the experience gained with the use of the endoscope, we have performed extended endoscopic endonasal transsphenoidal approach in 13 of 200 (total endoscopic transphenoidal approaches since September 1997) patients for the last 5 years. Extended endoscopic transsphenoidal approach was performed for three patients with pituitary adenoma, two patients with craniopharyngioma, one patient with metastatic lesion, one patient with anaplastic germinoma, two patients with chordoma, one patient with chondrosarcoma, one plasmocytoma, and two patients with tuberculum sella meningioma. Total removal of the tumor was achieved in nine patients and subtotal removal was achieved in four patients. Extended approaches are essential for reaching the area from lamina cribrosa to the cranio-cervical junction. Endoscopic approach permits reaching the lesion without brain retraction and with minimal neurovascular manipulation. The main problems are related to the hemorrhage control of intracranial vessels and to the closure of the dural and bony defects, with subsequent increased risk of postoperative cerebrospinal fluid leak, tensive pneumocephalus, and/or meningitis.

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Correspondence to Ihsan Anik.

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Luis A Borba, Curitiba, Brazil

I believe that this kind of approach may not be necessary in some cases; an example is the radical removal of plasmocytoma or anaplastic germinomas that could have an increased risk of CSF leakage in the post-RT period, which certainly will need an adjuvant RT or CT, increasing the risk of CSF leakage after the post-RT period.

− Case of chordoma: a MRI in coronal view can demonstrate the “advantage” of the approach, not the sagittal view.

− Case of invasive pituitary adenoma. I cannot see the advantage over the pure endonasal-assisted or not by endoscope, the false invasion of the cavernous sinus (Fig. 5) may be an issue of confusion.

− The meningioma cases: I believe that the first (Fig. 11a) case is a contraindication to the endoscopic procedure, because the tumor is encasing the basal arteries, and I am not surprised about the impossibility to remove the tumor. The second case (Fig. 11c) may be a good candidate.

During the last decade, the utilization of endoscopic approach to sellar and parasellar lesions has increased. The high quality of illumination and the fish-eye view are the greatest advantage of the endoscope. A 30° or 45° scope allows the visualization of corners unreachable by microscopic view. Despite this very important progress, the pure endoscopic technique has several limitations including the 2D view, the utilization of long and unstable instruments, and, in some situations, a one-hand dissection. The endoscope is very welcome in neurosurgery, but it is not a substitute for microsurgical techniques. The need to push new techniques can be, in the future, responsible for its death.

In the present paper and in the literature, the utilization of pure endoscopic approach does not prove to be superior to directly endonasal approach combining microsurgery and assisted endoscope-associated or not to minimal maxillary osteotomes.

The management of frontal base meningiomas through endonasal approach is a new and brave surgical technique. In my opinion, the removal of meningioma through the nose, makes a simple surgical procedure a more dangerous and unsafe method.

I believe that anterior approaches (endoscopic or not) are reserved to midline lesions (medial to both ICA), extradural, with or without intradural extension. A purely intradural lesion must be removed through an intradural approach.

What is new does not mean that it is better; many times it is more dangerous and unsafe.

Robert Reisch, Zurich, Switzerland

In this paper, Ceylan et al. describe their experiences with endoscopic transsphenoidal approaches treating midline skull-base lesions. Extended approaches were performed for 13 of 200 endoscopically treated patients during a period of 5 years.

Endoscopic techniques offer several advantages in transsphenoidal surgery. Advantages in visualization are the increased light intensity in the deep-seated surgical field and the clear representation of patho-anatomical details. The extended viewing angle of endoscopes enables surgeons to observe hidden parts of the surgical field. Advantage in surgical manipulation is the unhindered maneuverability of the micro-instruments. Without using a nasal speculum, surgical dissection is not impeded and the instruments are freely mobile allowing unrestricted approach to the clearly visualized structures.

According to these clear benefits, I obviously recommend the use of endoscopes in transsphenoidal surgery, especially for pituitary tumors and extradural clival lesions of the central skull base. However, in treating intradural lesions, some main problems should be critically discussed:

1. The endoscopic extended transsphenoidal way offers manifest-approach-related traumatization of the nasal cavity. Removal of the middle and superior turbinates, creation of a mucosal septal flap, removal of the posterior septum and wide sphenotomy often cause postoperative nasal fetor and anosmia with long-term problems among patients. In comparison, a supraorbital keyhole craniotomy and transcranial dissection presents a minimal invasive way, approaching similar intracranial lesions.

2. Maneuverability of the instruments through the transnasal way is limited; the often-used “pulling” of the tumor can never be compared with safe microsurgical dissection. Resection of a 4-cm-large meningioma with incorporation of main cerebral vessels is for me a clear contraindication for transsphenoidal surgery.

3. After tumor removal, reconstruction of the cranial base is mandatory and very problematic. The authors describe this problem accurately reporting a CSF leak in 38.46% (five of 13) of patients.

I strongly believe that extradural lesions should be removed via an extradural transsphenoidal way and intradural lesions via an intradural way using minimally invasive endoscopic techniques.


Jho et al. (2004): Minim Invas Neurosurg 47:1-8

Kassam et al. (2005): Neurosurg Focus 19:1-10

Gardner et al. (2008): J Neurosurg 108:395-400

De Divitiis et al. (2006): Neurosurgery 61: 229-238

Hae-Dong Jho, Pittsburgh, US

Ceylan et al. reported their experiences with endoscopic endonasal approaches for midline skull-base lesions that are located beyond the pituitary fossa. Over 5 years, they operated on 13 patients; three with pituitary adenomas, two with craniopharyngiomas, two with meningiomas, three with chordomas or a chondrosarcoma, one with metastasis, one plasmocytoma, and another with a germinoma. They claimed that nine patients had total tumor removal and four, subtotal. One patient died of postoperative hemorrhage. Five out of thirteen patients developed postoperative CSF leakage of which four were treated with lumbar drainage and one required surgical repair. They used a two-nostril technique with two operating surgeons. They used intraoperative neuromonitoring for cranial nerves and intraoperative Doppler for carotid artery localizations. Their patient follow-up was 2–44 months.

I congratulate their successful transition from microscopic transsphenoidal surgery to endoscopic endonasal surgery over the past 10 years. Certainly, there is a steep learning curve for neurosurgeons to perform endoscopic endonasal surgery because neurosurgeons usually do not have formal endoscopic endonasal training during their residency period. Although neurosurgeons perform endoscopic ventricular procedures, endoscopic techniques for endonasal approaches are quite different from endoscopic ventricular surgery. Although the number of cases they have is small and their follow-up period is short, I believe that this paper deserves to be published in order to have readers understand the technical difficulties, potential problems, and intrinsic complications. The endoscope is simply another surgical tool that surgeons can utilize to achieve surgical goals.

The endonasal route is simply another surgical corridor that can be adopted if necessary. However, when surgeons try to use new tools or attempt to perform new techniques, technical difficulties and associated complications are inevitable.

For surgical indications, I agree with them that very select cases of meningiomas at the tuberculum sella, planum sphenoidale, and olfactory groove can be approached with endoscopic endonasal routes. Although I perform endoscopic endonasal approaches for those meningiomas occasionally, I prefer to perform endoscopic transcranial approaches with a mini-incision for meningiomas. Meningiomas usually have a wide tumor base and a wider involvement of the dura mater. Thus, a transcranial route provides better exposure to the whole spectrum of the tumor and its attachment. Occasionally, I still perform endoscopic endonasal approaches for menigiomas, particularly when total resection is certainly feasible in MR findings, or if main mass removal of the tumor alone is sufficient for patients, particularly for very elderly patients. Otherwise, I prefer to perform transcranial endoscopic approaches for meningomas.

Indications for endoscopic endonasal approaches for craniopharyngiomas are also limited to particular cases like the case described in this paper. Whether craniopharyngiomas should be approached through transcranial routes or endonasal routes will be determined by tumor location and its relationships with surrounding tissues. Most pituitary adenomas that require surgery can be approached through endonasal routes. One exception would be a tumor that extends to the middle cranial fossa. Pituitary adenomas that are involving the cavernous sinus can be approached with endonasal routes. However, I have been cautious in approaching the cavernous sinus for pituitary adenomas because radiosurgery is an available treatment option. Surgical attempts also carry higher cranial nerve morbidities. Endoscopic endonasal approaches will be excellent indications for petrous tip cholesterol granulomas, clival chordomas, or chondrosarcomas. Even if total tumor removal is not achieved for clival chordomas or chondrosarcomas, repeated endonasal endoscopic operations in intervals can prolong patient survival quite long following the initial operation and radiation treatment.

S. Ceylan et al., also mention the use of intraoperative neuromonitoring, intraoperative Doppler scanning, and other surgical tools. Although they did not mention it, an image-guiding tool is another tool neurosurgeons are fond of using for complex skull-base surgery. However, we have to balance between what is and is not necessary. Simplifications versus safety have to be judiciously guided. Authors used a two-nostril technique. I prefer to do a one-nostril technique. While the authors like to have two operating surgeons, I prefer one surgeon with endoscope anchored to the endoscope holder. However, the preservation of the nasal anatomy is more important. Surgical approach itself in the nasal cavity should not destroy the normal nasal and paranasal anatomy unnecessarily. As the authors described, skull-base reconstruction is still a main hurdle for endoscopic endonasal approaches to the intracranial pathologies. Although various surgical glues are introduced, they are not yet sufficient to seal the skull base. Various surgical techniques for skull-base reconstructions are still not good enough to prevent postoperative CSF leakage. Although the authors used lumbar drainage in five cases, I personally do not like to use lumbar drainage. When a patient leaks CSF significantly, I prefer to surgically repair it immediately. That hastens the patient’s recovery, shortens their hospital stay, and reduces the chance of developing other complications such as meningitis, pneumonia, or venous thrombosis, and pulmonary embolism.

Again, I praise the authors that they share their experiences with others. I have no doubt that they will continually improve their surgical skills and patient outcomes.

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Ceylan, S., Koc, K. & Anik, I. Extended endoscopic approaches for midline skull-base lesions. Neurosurg Rev 32, 309 (2009). https://doi.org/10.1007/s10143-009-0201-9

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  • Endoscope
  • Skull base
  • Transsphenoidal approach
  • Extended approach