Small Craniopharyngioma: Transnasal Approach
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Craniopharyngiomas can be effectively resected through the endoscopic transnasal approach. And even a very small, minimalistic boney removal at the level of the skull base through the transnasal approach can achieve a very reasonable resection for small to medium sized tumors. Let's illustrate these principles using the case of a 50 year-old male, who presented with progressive visual dysfunction. And on MRI evaluation was known to have a small to moderate size Craniopharyngioma in the area of the Parasellar Space. This patient subsequently underwent a Transsphenoidal resection because of progressive visual dysfunction. Here is the bone, at the level of the sella. Here is the Tuberculum. Some venous bleeding from the dura can be effectively managed through Thrombin soaked Gelfoam and flow seal, accompanied by gentle tamponade from a piece of cottonwool. Upon removal extend it laterally to the level of the carotid arteries using CT guided navigation. You can see the dura opening. The opening is very limited actually, in this case, you can see only a portion of the tuberculum is removed. Actually the posterior wall of the spheroid sinus is left alone. Upon opening the dura only the tumor is apparent giving you the impression that the exposure is too small. However with gentle decompression of the tumor edge mobilization, the tumor can be decompressed and the optic apparatus can be readily visualized. So here is the capsule the tumor has been carefully dissected using traction, counter traction. The counter traction is provided by the suction device upon removing small piece of the tumor. The chiasm is apparent. An angle dissector can be used, 30 degree endoscopes, surely expand the operative corridors and also keep the head of the endoscope out of the working zone of their suction and dissecting instruments. I continue to dissect the capsule from underneath the chiasm. Here you can see a view of the chiasm and the attachment of the tumor to the floor of the hypothalamus. Angled suction devices can also be used to assist with dissection. You can see that the blunt dissector is mobilizing the tumor from underneath the chiasm. The tumor can be quite adherent laterally, limiting the descent of the tumor and angled green curate with a right angle arm can be specially useful. As you can see here to mobilize the tumor from the lateral arachnoid bands. This is a very important nuance because this part of the tumor appears to always be most challenging to mobilize. Once you have mobilized the tumor bilaterally, the superior pull of the tumor is relatively easy to deliver, obviously while trying to preserve the pituitary stock. Here you can see the gentle, pulling of the tumor under direct vision to assure that none of the vital neurovascular structures are placed under undue traction. Here a piece removal of the tumor and looking for the pituitary stalk, make sure the stalk is not injured or evulsed during the dissection. I think the stalk is now in view, as you can see here, it appears to be still intact. Now the tumor can be readily pulled out since the stalk is not very adherent to the tumor capsule. The lateral portions of the tumor were previously dissected. So now the tumor can be delivered safely. Again, aggressive pulling on the capsule is avoided. Gentle mobilization of the tumor safe. Inspection reveals no obvious residual tumor. You can see the pituitary stalk. You can see the floor of the third ventricle can see the chiasm. Gross total resection is achieved, here we can see good view of the stalk. Carotid artery, optic nerve optic nerve underneath the chiasm A 45 degree endoscope is quite effective for thorough inspection on the lateral gutters. I'm very satisfied with the extent of resection. I measure the extent of bony removal for closure using the gasket seal technique as well as a nasal septal flap coverage. Postoperative MRI demonstrates gross total resection of the tumor without any complicating feature. And this patient recovered from his surgery uneventfully and his vision improved. Thank you.
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