Transcript Integration of Endoscopy into the general frame workup of

Endoscopic Cranial Base Neuroanatomy
as Observed through Endonasal
Transphenoidal Approach
Promod Pillai, Mario Ammirati
NASBS-2007
Evolution of Skull base Neurosurgery
Pioneers ( 19th Century)
 Francesco Durante (1845-1934)-olfactory
groove meningioma
 Charles Balance-earliest case of acoustic tumor
removal
 Fedor Krause (1857-1937)
 de Martel( 1875-1940)
ESBS 2007
Neurosurgery
has changed !
ESBS 2007
Evolution of Skull base Neurosurgery





Early 20th Century
Harvey Cushing(1869-1939)
Walter Dandy (1886-1946)
Hertbert Olivecrona(1891-1980)
Charles Frazier(1870-1936)
ESBS 2007
Evolution of Skull Base Surgery











Contemporary Skull Base Surgery
Al-Mefty
Dolenc
Jannetta
Rhoton
Samii
Sen
Sekhar
Spetzler
Yasargil
many more !
ESBS 2007
Present status of Skull base Surgery


Significant attention and interest in the recent
past.
Skull Base Surgery has benefited from
Advances – Imaging and diagnostic technology,
Surgical instrumentation,
Reconstructive techniques
ESBS 2007
Criticism for Skull Base Surgery



Skull base surgeons seemed more interested in
the surgery itself than in patients!
Is there any justification of Skull base Surgery
programs!
Is there any future for Skull Base Surgery?
ESBS 2007
Criticism for Skull Base Surgery




Whom to blame?
Only the preoperative and postoperative images
were shown demonstrating “complete removal”
of the lesions!
No history or clinical findings given !
What is the quality of life after surgery ?
ESBS 2007
Future of Skull Base Surgery
Quality of life matters!
ESBS 2007
Future of Skull Base Surgery


Adaptation, modification, and expansion of
existing techniques or technologies (often from
other specialties) have been hallmarks of
surgical advancement
Innovation and creativity have been
driving forces behind surgical progress.
ESBS 2007
Multidisciplinary Approach
ESBS 2007
Alternatives or adjuvants to Armamentarium?
Endovascular
Therapy
Molecular Therapy
Endoscope
Stereotactic Radiosurgery
ESBS 2007
ESBS 2007
Mile stone of modern and contemporary
neurosurgery in the treatment of pituitary
tumors
ESBS 2007
Endoscopic Cranial Base Anatomy
Objective

Learn and familiarize with cranial base anatomy
as viewed through sphenoid sinus using
endoscope
ESBS 2007
Endoscopic Cranial Base Anatomy
Material and methods
Six freshly frozen cadaver heads
Endoscopes
Angled lenses for peripheral structures
Dissection was guided with frame less stereotaxy
ESBS 2007
Endoscopic Cranial Base Anatomy
Preliminary dissection
Nasal Cavities
Four walls and 2 opening
ESBS 2007
Endoscopic Cranial Base Anatomy
Nasal Cavity
Walls
Inferior wall- Floor
Medial wall- septum
Lateral nasal wall
Superior wall Roof
ESBS 2007
Endoscopic Cranial Base Anatomy
Nasal Cavity
Openings
Anterior
Posterior
ESBS 2007
Endoscopic Cranial Base Anatomy
Medial wall
“Septum”
ESBS 2007
Endoscopic Cranial Base Anatomy
Lateral wall
ESBS 2007
Endoscopic Cranial Base Anatomy
Sphenoid sinus
ESBS 2007
Endoscopic Cranial Base Anatomy
Exposure of suprasellar region
ESBS 2007
Endoscopic Cranial Base Anatomy
Exposure of retro sphenoid area
ESBS 2007
Endoscopic Cranial Base Anatomy
Exposure of para sellar area
ESBS 2007
Endoscopic Cranial Base Anatomy
Discussion
ESBS 2007
Transphenoidal surgery
Advantages
1.Excellent three dimensional view
2.Easy manipulation of zoom and focus features
3.Speculum protects the mucosa from instruments injury
4.Better manipulability of instruments
ESBS 2007
Transphenoidal surgery
Possible drawbacks
 Limited exposure and Limited working space
 Narrow field of view - “Cant work around the corner”
 Failure to visualize optic chiasma /suprasellar space
during transdiaphramatic dissection
 Sinonasal complications, patient discomfort
ESBS 2007
Neuroendoscopy, past, present and future
Early history
Max Nitze- First endoscope 1879
L'Espinasse(1910) first neuroendoscopic procedure using
cystoscope
Walter Dandy(1922)- Choroid Plexectomy
ESBS 2007
Neuroendoscopy, past, present and future
Decline
Technical difficulties and high death rates
Development of microneurosurgery(1960’s)
As microneurosurgery gained popularity, the use
of endoscopy waned further.
ESBS 2007
Neuroendoscopy, past, present and future
Rediscovery of endoscope with technical
advances
 New lens types -“SELFOC” lens
 Invention of computer chip television video
cameras and CCDs( Charge Coupled Devices)
 Fiberoptics
ESBS 2007
Neuroendoscopy, past, present and future
Rediscovery of Neuroendoscopy
ETV-The success of neuroendoscopy in recent years has
relied heavily on the success of ETV for the treatment of
obstructive hydrocephalus
Intraventricular tumors, skull base tumors,
craniosynostosis, degenerative spine disease,
intracranial cysts, and rare subtypes of hydrocephalus
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques
Present status
 endoscopic transnasal, nontransseptal,
transsphenoidal pituitary surgery
 Jho and Carrau 1990s
 Kassam and Snyderman
 Cappabianca and de Divitiis
 Frank et al
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques
Present status
“Stone in the pond effect!!”
de Divitiis E, Neurosurgery. 2006 Sep;59(3):512-20
ESBS 2007
Endoscopic Pituitary Surgery
Otolaryngeological advantages

Avoids -perforation, septal deformity, saddle
nose deformity, nasal obstruction, and long-term
epistaxis and crusting
ESBS 2007
Endoscopic Pituitary Surgery
Otolaryngeological advantages
 Avoids possible dental complications from the
sublabial approach
 Rapid recovery from the otolaryngologic aspect
of the surgery
 Reduced Postoperative discomfort-pain,
Hospital stay
ESBS 2007
Endoscopic Pituitary Surgery
Neurosurgical advantages
 smaller bony opening makes the reconstruction
quicker and easier
Argument against
 Anterior wall of spehenoid sinus is removed-tight
recconstrucion and packing may be difficultBigger sphenoid opening
ESBS 2007
Endoscopic Pituitary Surgery
Neurosurgical advantages
 “less aggressive and more precise than
traditional surgery”
 “Least traumatic”
Argument against
 Binasal endoscopic approach is “more invasive”
 Possibility of injury to septal mucosa/middle
turbinate
ESBS 2007
Endoscopic Pituitary Surgery
Neurosurgical advantages


Visualization of the lateral sphenoid wall
including the carotid arteries and optic nerves
Direct visualization of normal pituitary and dura
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques
Pitfalls
 Less familiarity- “learning curve”
 Limited Zoom capability
 Need for refocus maneuvers
 Possibility of injury to septal mucosa/middle
turbinate
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques
Pitfalls
 The scope greatly limits the degrees of freedom
of the other instruments, making instrument
manipulations difficult and often ineffective
 Binasal endoscopic approach is “more invasive”
 Visualization is not synonymous with operability
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques
Pitfalls
Two dimensional “Flat” Images- No depth
perception
Anterior wall of spehenoid sinus is removed-tight
recconstrucion and packing may be difficultBigger sphenoid opening
Difficulty in Reconstruction – esp with extended
endonasal approaches
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques
Average duration of surgery-
Minutes
Endoscopic surgery
Microscopic surgery
Endoscopic repeat surgery
Microscopic repeat surgery
98
106
107
129




Frank G et al Neuroendocrinology. 2006;83(3-4):240-8.
ESBS 2007
Outcome
Laws ER Jr et al Clinical series of 3093
patients of transphenoidal surgery-
J Am Coll Surg. 2001 Dec;193(6):651-9
ESBS 2007
Repeated transsphenoidal surgery to treat
recurrent or residual pituitary adenoma.
Benviniste et al J Neurosurg. 2005 Jun;102(6):1004-12
96 patients
No mortality
Morbidity – 1%
Remission 93% for non functioning
57 % for functioning adenomas
3rd surgery in about 10% patients
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques
Complications in Endoscopically treated patients
with recurrent tumors CSF leak during surgery
7 (35%)
 CSF leak after surgery
1 ( 5%)
 Pneumoencephalocele
1 (5%)
 Diabetes insipidus
0
 Hypofunction of the anterior lobe 3 (15%)
Frank G et al Neuroendocrinology. 2006;83(3-4):240-8
ESBS 2007
Complications
Endoscopy Vs Transphenoidal











Nasal septum perforation
Postoperative epistaxis
Anterior pituitary insufficiency
Diabetes insipidus
Loss of vision
Carotid artery injury
CNS injury
Intrasellar hemorrhage
Cerebrospinal fluid leak
Meningitis
Death
Fully endoscopic
300 patients
0.7
1 .3
2.7
5.3
None
None
None
0.7
1.7
None
None
*Transseptal−trans−
sphenoidal6.7
10
19.4
17.8
1.8
1.1
1.3
2.9
3.9
1.5
0.9
Kabil MS et al Minim Invasive Neurosurg. 2005 Dec;48(6):348-54
*Results of a National survey (Ciric et al., 1997).
ESBS 2007
Endoscopic Pituitary SurgeryClinical series
Authors- Year
Patients
Bleedin
g
Kelly RT-2006
90
1
Shaw-2004
26
Rudnik-2005
70
Rudnik A-2006
125
Netea-Maier2005
35
Kabil -2005
300
Jho HD-2001
128
Kenan K-2006
78
1.2
Cappabianca2002
146
1.4
Trans
DI-
7
Perm
-DI
CSF
leak
meningitis
Pituitary
dysfunctio
n
visual
loss
Remission
2
15
4.30
0
71
7
73
77
2
5.3
1.7
2.7
87-93
4
3
6
11
78
5.1
1.2
2.4
2.4
50-66
3.4
3
13.1
1.2
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques
Progression of technique
 Endoscopy has stimulated new applications of
relatively a static surgical technique
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques
Recent advances
 Description of unfamiliar endoscopic anatomy,
the development of supporting technologies
adapted to transnasal endoscopic approaches
 Emergence of “Endoneurosurgeons”
 Expanded endonasal approaches- frontal sinus
to C2 in the sagittal plane and from the sella to
the jugular bulb in the coronal plane
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques
Extended approaches
Modifications of standard endoscopic
transphenoidal approach allow additional
exposure to other cranial base lesions
 Exposure from planum sphenoidale to
craniovertebral junction.

ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques
Challenges of extended approaches
 Proper selection of the patients
 Potential success also depends on anatomy,
consistency, blood supply and relationship to
neurovascular structures
 Reconstruction of Skull Base
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques
Criticisms of extended approaches

Is it really minimally invasive?
 Usefulness in intradural/arachnoidal lesion
 Managing intraoperative catastrophes
 Proper Skull base reconstruction and avoidance
of CSF leak
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques
Criticisms of extended approaches
The claim that endoscopic surgery is superior to
endonasal surgery is sometimes seen as a
marketing device to try to change traditional
patterns of referral for pituitary surgery
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques


We know that the endoscopic techniques in
skull base surgery is going to stay
But we need to know –
are we dealing with treatment modality which
provides significant advantage over the
conventional modality in terms of short and long
term outcomes?
Is it a replacement or adjuvant ?
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques
We clearly need to have outcome studies which
address
 Extent of tumor removal
 Tumor recurrence/residue
 Surgical morbidities
 Reconstruction of anatomy
ESBS 2007
Quantification of exposure with
endoscopic and microscopic
approach to sellar- and supra
sellar region
ESBS 2007
Quantification of exposure with endoscopic
and microscopic approach to sellar- and
supra sellar region


Endonasal transphenoidal approaches were
performed in freshly frozen cadaver heads using
both endoscope and microscope
Using Image guidance , we have attempted to
quantify the surgical exposure in each
approaches
ESBS 2007
Quantification of exposure with endoscopic
and microscopic approach to sellar- and
supra sellar region
Results
 Endoscopic approach provided a
panoramic view
 Exposure in axial and sagittal planes were
significantly improved

Better visualisation of the supradiaphramatic
structures, area behind the anterior wall of the
sella
ESBS 2007
Quantification of exposure with endoscopic
and microscopic approach to sellar- and
supra sellar region
Results
 No significant exposure advantage in the
coronal plane compared with microscopic
approach
 There was limitation of exposure in the
coronal plane ipsilateral to ostium through
which the endoscope is introduced
ESBS 2007
Quantification of exposure with endoscopic
and microscopic approach to sellar- and
supra sellar region
Endoscopic approaches
 2 dimensional view
 Depth perception is poor
 Limited manipulability and working area for
instruments
ESBS 2007
Right Nostril
Middle
Turbinate
Septum
ostium
ostium
Within the sphenoid sinus –through left Nostril
Sphenoid
septum
Diaphragma sella opened exposing the supra sellar structures
Optic Chiasma
Pituitary gland
Floor of
the sella
Lamina terminalis
Optic Chiasma
Infundibulum
Optic Chiasma
Infundibulum
Endoscopic and Minimally Invasive Skull
Base Techniques-Future




Radiographic imaging and image-guided surgery
Three-dimensional imaging and reconstructions
for surgical review and planning
The knowledge and experience of the surgeon is
far more important than any technology or
instrumentation
Continued advances in endoscopic equipment,
radiographic techniques, and IGS systems will
permit to continue to stretch the minimally
invasive boundaries in treating skull base
pathology.
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques-Future

Surgical instrumentation
Image
guidance system
Surgical
simulators and robotics
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques-Future

Evolution of endoscopic neurosurgery
(“endoneurosurgery”) with the description of
unfamiliar endoscopic anatomy, the
development of supporting technologies adapted
to transnasal endoscopic approaches
(endoscopic skull base instruments, image
guidance systems, ultrasonic aspirators), and
the innovations of reconstruction techniques
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques

Choice of approaches?
Microscope
Endoscope
combined
ESBS 2007
Endoscopic and Minimally Invasive Skull
Base Techniques-Future


The future of endoscopy in skull base surgery
will involve its use both as the primary surgical
approach and as an adjunct to the microscope.
New combined endoscopic and microscopic
surgical approaches will play an important role in
the future of skull base surgery.
ESBS 2007