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Endoscopic Tuberculum Sella Meningioma: Importance of Adequate Osteotomy

August 02, 2016

Transcript

Let's review the intra-operative findings for the case of another Tuberculum Sella Meningioma Endoscopic Endonasal Approach. This is a 32 year old male who presented with bilateral visual decline. MRI evaluation revealed a small to moderate size Tuberculum Sella Meningioma with potential herniation of the tumor into the bilateral optic canals. Here's the Endonasal Approach. For these tumors, I typically remove the bone over the tuberculum, the anterior half of the sella, as well as the posterior part of planum. It's important that the bony removal is generous enough over the planum, so that the anterior margin or the anterior capsule the tumor can be easily reached upon opening the dura. Remove the bone over the entire face of the sella is non-necessary, only anterior half, more accuracy of removal of the sella can potentially complicate the closure and increase the risk of postoperative CSF leak. So here is the area of tuberculum, posterior planum and anterior half of the sella. The bone can be quite thick due to the presence of the meningioma. Drilling is used. The tumor may be devascularized early, transdurally. Here's again the final bony removal. In this case, I attempted more bony removal anteriorly. And anterior aspect of the sella, tuberculum on over the planum, you can see the bony removal extends laterally so that the optic canals can be decompressed. And the tumor has been devascularized. Location of the optic canal bilaterally is demonstrated. You can see the bone over the canal is decompressed, both on the right and the left side. In another view, planum, tuberculum, anterior face of the sella, optic canal, optic canal, and nice extra dural anatomy of the exposure. Carotid artery would be located here, as well as here. Here, you can see the actually carotid artery on roofed during the final stages of our bony removal. I stay within the midline and open the dura. Here's the tumor. Bipolar forceps are used to debulk the tumor and control the bleeding. European is expanded all the way to the anterior capsule, a tumor. Further decompression can be achieved using an ultrasonic aspirator. Now the left capsule, the tumor is being mobilized from the cerebrovascular structures. Egress off the CSF is a good sign. Here's the section of the tumor from the right optic nerve. Again, aggressive debulking of the tumor is mandatory. So that the cerebrovascular structures are not placed under significant traction during mobilization of the tumor. Importantly, the perforating vessels to the cayezem and the optic nerve should be carefully preserved during microsurgical dissection. The most easiest part of the procedure is dissection of the tumor from the pituitary gland and the stock. Again, microsurgical techniques are mandatory. Part of the tumor daddy's herniating more posteriorly, chantilly mobilized. Here again is microsurgical dissection of the tumor within the diagonal bands away from the stock and membrane of Liliequist. Any perforating vessel directly going to the tumor can be sacrificed. Arachnoid membranes are respected to preserve the perforating vessels. And micro Doppler ultrasound device may be used to further localize the carotid artery. Continue to now dissect the anterior pole of the tumor. As you can see away from the frontal lobe. Here, you can see the underneath surface of the lobe. It's quite important that bony removal extends all the way to the inter aspect off the base of the tumor. Here's the optic chiasm as the tumor is being mobilized more anteriorly. Another view of the chiasm and its perforating vessels between the stock. Various number of angle instruments are used to mobilize the tumor. 45 Degree endoscope is quite effective for visualizing the nerve as it enters the foramen. After the tumor has been thoroughly disconnected from the surrounding structures, it can be gently mobilized out of the operative field. Here's an attachment tool, one of the arachnoid membranes of the frontal lobe. You can see the optic nerve and other one here. ACA's are apparent. Optic nerve on the left, optic nerve on the right. A one, a calm complex pituitary stock, carotid artery. Perforating vessels appear intact. You can see the inspection of the left optic nerve and ophthalmic artery entering the optic foramen. The 45 degree endoscope reveals no evidence of tumor herniating into the canal, beyond the area that has been exposed. Again, a good circumferential inspection of the nerve where it can be visualized using the angled suction devices in the ophthalmic artery. Here's another view of the right optic nerve, ophthalmic artery, carotid artery, olfactory nerve. The edges of the tour are perfectly inspected for any residual tumor within the soft frontal area. These are the operative blind spots or the tumor can be left behind. Here's another view of the operative corridor. Two, three floors seem trapped, behind it membrane of Liliequist. I'm satisfied with the extent of resection and decompression of both optic nerves. Closure is completed in layers. Gasket seal closure is finally accomplished. Obviously one has to be careful not to compress the optic nerves by the prostheses. Doing performance of the gasket seal technique. Postoperative MRI revealed gross total. Removal of the tumor without any complicating features. Thank you.

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