Expanded Endoscopic Endonasal Surgery for Craniopharyngiomas and Technical Notes

Abstract

Despite a benign histological classification, the proximity of craniopharyngiomas to vital neurovascular structures and their high recurrence rates make them one of the most challenging and controversial management dilemmas in neurosurgery. Adherence to the pituitary stalk, hypothalamus, and vital neurovascular structures such as the optic apparatus, and various major/perforating vessels as well as diminutive intraoperative visualization, distorted anatomical relationships, and limited sharp dissection often hinders complete resection regardless of approach.

Expanded endoscopic endonasal surgery (EES) has been recently used to access intrasellar and suprasellar craniopharyngiomas in a few institutions over the last decade with good results. With the increasing use of endoscopic techniques and the improved illumination and expansive view they provide, endonasal approaches have been shown efficacy and safety in treating of these tumors. The EES creates a ventral midline corridor to the sellar, suprasellar, and parasellar compartments that obviates the need for any brain retraction and provides an unprecedented view down the barrel of the tumor to the floor of the hypothalamus and roof of the third ventricle. In addition, unlike the microscope, which is limited by line of sight, the endoscope provides direct access to the long axis of craniopharyngiomas, a factor well recognized as critical for maximal, safe tumor resection without complications associated with brain retraction and extensive craniotomies. In performing a purely endoscopic resection, the main complications are primarily related to control of intracranial vessels, and skull base reconstruction with its associated risk of CSF leak, tension pneumocephalus, and meningitis. So, surgery requires a multidisciplinary team with significant EES experience and advanced equipment (angled endoscopes, endoscopic surgery instruments, image guidance, and neurophysiological monitoring) for safe results. In this regard, we present some precious technical notes and our experience to achieve optimized results.