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Craniopharyngioma: Transtuberculum Approach

April 28, 2016


Let's review another video to discuss technical nuances for resection of a craniopharyngioma via the endoscopic transnasal transtuberculum approach. This is a 62 year old female who presented with visual dysfunction. MRI evaluation revealed a partially cystic mass within the suprasellar area causing optic apparatus compression. You can see the nodule of the mass is very intimately associated with a pituitary stock. This tumor is an excellent candidate for the endoscopic trasnasal approach. You can see the extent of bony opening. Part of the tuberculum has been resected. The inter cavernous sinus has been also exposed. The most posterior part of the basal sphenoid is left behind. Here you can see the intracavernous sinus, Bony opening extends up to the optic foramen. Bipolar forceps are used to coagulate the dura, and assist with hemostasis. Careful dissection is performed. Further bony removal may be necessary just along the tuberculum to completely expose the anterior border of the tumor. After the dural opening, often all the surgeon sees is part of the tumor. However upon tumor debulking, the optic apparatus is readily evident. So, here you can see the arachnoid bands over the tumor. Their incision most likely exposes the optic apparatus and the tumor. Dural opening should be very generous. Only the required amount of bony opening should be achieved so that reconstruction is readily possible at the end of the operation. Aggressive tumor removal can only increase the risk of postoperative CSF leakage without necessarily a significant benefit to the operative trajectories. Here's the chiasm, here's the tumor partially calcified. Very much consistent with a craniopharyngioma. Perforating vessels to the chiasm are protected as much as possible. Frontal lobe. Again, left optic nerve. I like using the angle during curate to mobilize the tumor. Gently also dissect the perforating vessels, creating a corridor to remove this craniopharyngioma, which is primarily retrochiasmatic. First, the capsule of the tumor is opened, and the tumor is debulked using pituitary rongeurs. This is an important step that would assist with gentle mobilization of the tumor capsule during the next phase of the operation. We'll go ahead and now dissect the tumor capsule from the left optic radiations. Can see this piece of the tumor that's been disconnected. Now we have an opening into the third ventricle. Obviously, careful dissection of the chiasm is executed. The hypothalamus is protected. Only the portion of the hypothalamus that is affected by the tumor should be removed. Aggressive pulling on the tumor is avoided unless it's under direct vision, and gentle manipulation is conducted. Here's an opening into the third ventricle. You can see part of the hypothalamus that's not affected by the tumor. Perforating vessels remain intact. Only a small part of the tumor on the right side now requires attention. Here's another nice viewing to the third ventricle. Mass intermedia between the thalami is also apparent. This piece of the tumor appeared more adherent to optic radiations, and therefore further dissection was necessary. You can see the perforating vessels to the hypothalamus. They all appear intact. Here's the dissection of that portion of the tumor on the right side from the area of the optic radiations and hypothalamus. The tumor is removed piecemeal. Here's only a piece of the capsule that is left behind that we're going to also excise as well using sharp dissection techniques. Now that that piece of the capsule is removed, further inspection is conducted to make sure no residual tumors are apparent, angle endoscopes are used. You can see just a small layer of blood, but no obvious tumor is apparent. The pituitary stock had to be sacrificed because of its intimate involvement with the tumor capsule, because a piece of allograft dura is used as an inlay, and the gasket seal technique is utilized to achieve a solid reconstruction of the skull-based defect. Lumber drain is used for about three days after the surgery. The implant is carefully maneuvered so there is no evidence of compression on the optic nerves. The nasal septal flap is also used to cover the area of the craniotomy and skull-based defect. All the edges are well approximated. Surgicel plugs are also used for further reinforcement of our reconstruction. Fibrin glue may also be used for another layer of reconstruction, pieces of gel foam further buttressed our construct. The later stages of our closure are also illustrated. Here's the postoperative MRI, which reveals gross total resection of the tumor without any complicating features. Thank you.

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