Transcript Fully Endoscopic Supraorbital approach

THE FULLY ENDOSCOPIC SUPRAORBITAL APPROACH
Mohamed S. Kabil, MD Hrayr K. Shahinian, MD, FACS
Introduction
The application of endoscopic approaches to surgery of the
anterior and middle skull base, as well as the parasellar
region, can eliminate the need for traditional open
craniotomies without compromising surgical success. Through
a hidden, skin incision, within the hair of the eyebrow and a
1.5 cm strategically placed supraorbital keyhole craniotomy,
the endoscopic supraorbital approach provides extended
access to all lesions of the skull base that traditionally have
required subfrontal, bilateral subfrontal, transbasal, or
pterional approaches.
PTERIONAL APPROACH
Indications
The fully endoscopic supraorbital approach provides
minimally invasive surgical access to lesions of the midline
anterior skull base, such as olfactory groove or planum
sphenoidale meningiomas, esthesioneuroblastomas, and
transcranial extensions of orbital and paranasal sinus tumors;
lesions of the middle skull base, such as medial sphenoid
wing meningiomas, schwannomas, neurofibromas, and
middle cranial fossa arachnoid cysts; and lesions of the
parasellar region, such as anterior clinoid or suprasellar
meningiomas, craniopharyngiomas, anterior communicating
artery (ACoA) aneurysms, and pituitary macroadenomas with
supra- and parasellar extensions.
Patients and Methods
In the period from July, 2002 to October, 2006, 140 fully
endoscopic supraorbital operations were performed by
surgeons at the Skull Base Institute, in Los Angeles,
California. The operative technique, results and complications
were discussed in details in previous reports 1-5. Pathologies
that were treated inculded anterior and middle skull base
meningiomas, craniopharyngiomas, pituitary adenomas with
extrasellar extensions, arachnoid cysts and other
supratentorial pathologies.
ENDOSCOPIC SUPRAORBITAL
APPROACH
OPERATING ROOM SETUP
PATIENT POSITIONING
ILLUSTRATIVE CASE 1: OLFACTORY GROOVE MENINGIOMA
ENDOSCOPIC VIEWS
MR IMAGING
Results
The majority of lesions were resected in their entirety with no
perioperative complications and with excellent cosmetic
results 1-5.
Operative Technique
The endoscopic equipment, instrumentation and details of
the operative technique have been described in previous
correspondences 1-5. The operating room setup and patient
positioning are shown in the figures.
Conclusion
We believe that access to anterior and middle cranial base
tumors with virtually no brain retraction minimizes the risk of
injury to brain tissue, brainstem, cranial nerves, and vascular
structures. Furthermore, this minimally invasive technique it
results in a more complete tumor removal due to the
superior visibility provided by the endoscope with its different
angles of view. The technique has allowed for rapid recovery
of the patients and resulted in minimal postoperative
discomfort.
INITIAL TUMOR EXPOSURE
a. Olfactory Groove Meningioma (OGM)
b. Cribriform plate and Olfactory Groove Area
c. Lower Surface of Frontal Lobe
COMPLETE
TUMOR REMOVAL
EARLY
PREOPERATIVE
POSTOPERATIVE
a. Gelfoam with Dural Graft Underneath Covering Cribriform Plate
ILLUSTRATIVE CASE 2: RT. MEDIAL SPHENOID WING MENINGIOMA
ENDOSCOPIC VIEWS
MR IMAGING
References
1. The Fully Supraorbital Approach, in Endoscopic Skull Base Surgery, Hrayr K. Shahinian (Author), Kabil M, Jarrahy R, Thill MP,
(CoAuthors), Publisher: Humana Press, Totowa, NJ (Expected Publication: 2007).
2. Kabil MS, Shahinian HK: Fully Endoscopic Supraorbital Resection of Congenital Middle Cranial Fossa Arachnoid Cysts: A Report of 2 Cases.
Pediatric Neurosurgery (In Press).
3. Kabil Ms, Shahinian HK. The endoscopic supraorbital approach to tumors of the middle cranial base. Surg Neurol. 2006 Oct;66(4):396401.
4. Kabil Ms, Shahinian HK. Application of the supraorbital endoscopic approach to tumors of the anterior cranial base.J Craniofac Surg. 2005
Nov;16(6):1070-4; discussion 1075.
5. Kabil Ms, Jarrahy R Shahinian HK.The application of craniofacial techniques and intracranial endoscopy to pituitary surgery. J Craniofac
Surg. 2005 Sep;16(5):812-8.
INITIAL TUMOR EXPOSURE
a. Ipsilateral Sphenoid Ridge
b. Meningioma
c. Lower Surface of ipsilateral Frontal Lobe
d. Arachnoid
THE FULLY ENDOSCOPIC SUPRAORBITAL APPROACH
COMPLETE
TUMOR REMOVAL
a. Endoscopic view following complete tumor removal with Gelfoam in Cavity
b. Outer Surface of Eyebrow
EARLY
PREOPERATIVE
POSTOPERATIVE