Endoscopic Tuberculum Sella Meningioma: Steps for Tumor Resection

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Here is another video discussing the extended transnasal transtuberculum approach for resection of the tuberculum sella meningioma. This is a 40-year-old female who presented with progressive visual field decline more on the right than the left side. MRI evaluation revealed a small to moderate size tuberculum sella meningioma. The tumor is not extending too far beyond the optic nerves. And therefore this tumor is a nice candidate for the endonasal approach. The initial bone removal after elevation of the nasal septal flap involves removal of the tumor over the tuberculum and posterior part of planum as well as along the anterior half of the sella. Next, the tumor is mobilized away from the pituitary gland, the pituitary stalk is evident. Microsurgical techniques are used. This is one of our older videos where the quality of video is not as optimal. You can see the view of the intraoperative angular systems after the tumor has been removed against the pituitary stalk. Subsequently, the tumor was dissected away from the frontal lobe. Here's another view of dissection away from the pituitary stalk and the perforators. Here is the tumor being micro surgically and sharply dissected away from the optic apparatus. To be able to handle the tumor more effectively, I cut the tumor in half along the level of the optic chiasm. This maneuver allows me to peel off the tumor in the superior to inferior direction away from the ipsilateral optic nerve. Here's a closeup view of the chiasm and the ACA and Acomm. Here's the use of the ultrasonic aspirator to remove the lateral portion of the tumor on the right side. Now that both the lateral portions of the tumor are removed, I'll go ahead and inspect the optic canals. The optic framing is widened using a Kerrison rongeur, 45-degree angle. The scoop is used to open the optic canal. You can see the tumor herniating into the optic canal. It's being removed. I look for the ophthalmic artery. Here's further inspection of the canal. It reveals no residual tumor. Further inspection of the left optic nerve was also performed. No tumor was noted herniating into that canal. The closure was completed using the gasket seal technique, followed by the use of the nasal septal flap. Postoperative MRI revealed gross total removal of the tumor and this patient had dramatic improvement of the vision postoperatively. Thank you.

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