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Endoscopic Tuberculum Sella Meningioma: Maximizing Resection

August 14, 2016


Here's another video in the collection of my videos for resection of tuberculum sellae meningiomas via nasal scopic transnasal approach. This is a 52-year old female, who is presented with visual decline, And more specifically, in the left eye you can see the relatively asymmetric tuberculum sellae Meningioma with encasement of the carotid artery. I do not believe that the encasement of the artery, necessarily, is it contraindication to the endoscopic approach. Let's go ahead and review the methods for removal of this tumor. Here's the initial stages of exposure. The bone over the tuberculum posterior planum and the anterior half of the sellae was removed. In addition, the bone over the proximal optic canals was also decompressed. Here you can see the on over the optic canal on the right side. On the left side. Removing one over posterior planem. Here's the optical carotid recess. The lateral one, and the boney exposure should extend all the way to the interior base of the tumor. Here is again, removing the bone over the proximal optic canal on the right side. Here's opening the dura, removing the portion of the tumor that's relatively easy. The one on the right side, dissecting it from the optic nerve. and you can see the nerve entering its foramen. The tumor almost always infiltrates the medial part of the foramen. Further dural opening and mobilization of the tumor from the optic nerve. Here's the optic nerve at the tip of suction. Again, using micro surgical techniques to dissect the tumor. Keeping their adenoids membranes intact. Here's the ACoA complex and most likely A1. Continuing tumor mobilization, further tumor decompression using pituitary ronjeurs. Opening the dura further, gently mobilizing the tumor under direct vision. Here's another view of the ACoA complex. Obviously, tumor debulking is quite important, before the more lateral capsule, the tumor is mobilized. I'm satisfied with tumor removal around the right optic nerve. Here, the tumor is mobilized. The portion of which, just underneath the chiasm, the pituitary stock is also dissected off. Following dissection of the capsule, the tumor is mobilized into our resection cavity. One has to be careful to avoid any traction on the left optic nerve. Knowing where the chiasm is, I can continue dissection toward the left optic nerve. Further tumor debulking in progress. Here's a view of the left optic nerve, and the tumor is being cut at its base adherent to the dura. Chiasm. Left optic nerve. Right optic nerve. I need to carefully inspect the portion of the left optic nerve entering the foramen. Here's using an angled endoscope, a 45 degree endoscope, to remove the tumor around the foramen of the left optic nerve. Perforating vessels to the chiasm are protected. Using an angled suction, removing the affected dura. Nice view of the nerve entering it's foramen. In the ACoA complex chiasm, nice operative view. It was a small piece of the tumor, adherent on the right optic nerve that was left alone. Getting a good view of the nerve entering its foramen. No residual tumor is apparent. It's a very adherent piece of the tumor. Ophthalmic artery. Carotid artery. One should not mistake the origin of the ophthalmic artery, as a piece of the tumor. Here, you can see the Ophthalmic artery entering the foramen, just underneath the optic nerve. A small piece of tumor actually was eventually removed, adhering to the right optic nerve. It's a final view of our operative corridor. You can see a very limited bony removal. Closure was completed using standard techniques Inlay of allograft dura, followed by the gasket closure technique. Obviously, the prostheses should not compress the optic nerve, may be notched if necessary, where the prostheses comes in contact with the nerves. Again, the construct has to be revised to make sure there's no leakage. Here's the final view. Valsalva maneuver reveals northernness of CSF leak. Here's the nasoseptal flap. Postoperative MRI revealed gross total removal of the tumor, without any complicating features, and this patient made an excellent recovery. Thank you.

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