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Endoscopic Tuberculum Sella Meningioma Resection: Asymmetric Tumor

August 13, 2016


Let's discuss resection of an asymmetric Tuberculum Sella Meningoma. In other words, a tumor that is off midline. Removal of such a tumor, through a midline endonasal approach, can be quite challenging, and this video reviews some of the technical analysis for performance of such a procedure. This is a 32 year-old female, who is presented with a visual decline. MRI evaluation revealed this Tuberculum Sellae Meningoma, relatively small to moderate size. As you can see, asymmetrically located toward the left side. Removal of this portion of the tumor, that is so far to the left, can be quite technically demanding. The tumor has to be generously debulked, so that the finsule of the tumor can be readly dissected, and various number of angle desectors have to be used to accomplish the dissection. After the trance-nasal exposure, you can see this sella tuberculum. Here's the sella tuberculum. Only the removal involves the posterior planum, entire tuberculum, in the anterior face of the sella. Removal of the bone across the entire sella is not required. The anterior margin of the tumor capsule has to be generously exposed. Any bleeding from the hyperostotic bone can be readily controlled. Tumor is accessed via a midline durotomy. You can see the part of the tumor on the right side is relatively non-significant, and the right optic nerve was readily exposed upon dissection of the tumor capsule. Again, the majority of the tumor is located asymmetrically on the left side. The part of the tumor that is intimately associated with the stock was also dissected. Now, the portion of the tumor that is adhering to the subfrontal area is being mobilized. You can see, because the tumor is very asymmetric, it is difficult to mobilize it through a relative midline incision. Therefore, aggressive debulking of the tumor is mandatory, so that the finsule of the tumor is readily mobilizable. Obviously, we should not pull on the tumor capsule and aggressively remove it that way. Here's the ACoA complex. You can see the tumor is being carefully dissected, after it was aggressively debulked. Here are the two A2 complexes. I continue microdissection under direct vision. You can see the tumor cannot be rolled inferiorly. It's hard to even mobilize it into the resection cavity from its posterior capsule. Therefore, I continue to debulk it aggressively. I should not pull too hard on the tumor capsule, so that the left optic nerve is not injured. Here's the use of the 45 degree scope to see cerebrovascular structures, at the tip of my arrow, while the tumor is being moved into the resection cavity. Here is the use of angled micro scissors to dissect the arachnoid planes. Here's the optic nerve. You can see the nerve has been dissected under direct vision. Significant traction on the nerve is avoided. The majority of the tumor is now dissected from the surrounding cerebrovascular structures. Again, I continue to debulk the tumor. So the finsule of tumor is collapsible into our resection cavity. Now, that the capsule is thoroughly dissected, the tumor can be delivered. Here's the resection cavity. You can see the right optic nerve, left optic nerve located here. ACoA complex. Closure is accomplished using standard technique. An inlay of allograph dura, as well as gaskets seal closure. Nasal septal flap completes the skull base reconstruction, and the postoperative MRI demonstrates gross total removal of the mass, without any complicating features and this patient's vision improved after the surgery. Thank you.

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