Endoscopic Skull Base Surgery

(ESBS)

Dr.Saied Alhabash

Endoscopic Skull Base Surgery

• Expanded Endonasal Skull Base Surgery

• Endoscopic Neurosurgery

• Minimally Invasive Skull Base Surgery

The base of the skull has proven to be one of the most challenging anatomic regions to access (boundary between neurosurgery and Otolaryngology).

Advantages Of ESBS

• reduce the impact on the patient

• lessen the morbidity

• reduce the length of stay in many cases

Half the truth is often a whole lie

Rule No.1 “In sphenoid sinus we believe…”

• The sphenoidal sinus is a window to the anterior, middle, and posterior cranial fossae.(Alfieri and Jho)

Neurosurg Focus 19 (1):E3, 2005

Various endoscopic trajectories

Neurosurg Focus 19 (1):E3, 2005

Binasal approach to allow bimanual dissection (for all expanded endoscopic

approaches)

Neurosurg Focus 19 (1):E3, 2005

The posterior wall of the sphenoid sinus

PINCIPLES

• Corridors

• Bimanual,Binarial

• Principles of microsurgical resection

• The Team

• Reconstruction for Traditional cranial base surgery

• Learning Curve

Advantage of bimanual technique

• Two hands for prepring • Less changing of instruments

• Aspirator always in surgical field

• Optimal view of site • Holding and cutting • Teamworking • Teaching

• Control of bleeding • Tissue-sparing work

EEA Keys

• The Sphenoid is the epicenter and the starting point for all the approaches

• Key anatomical landmarks of the sphenopid include the optic nerve and the carotid

EEA Limits

• From the frontal sinus and crista galli rostrally, to the second cervical vertebra in the saggital plane.

• From the sella to the jugular foramen through the infratemporal fossa in coronal plane

• At the level of the cervicomedullary junction,the coronal plane extends through the lateral mass of C1.

Absolute contraindications for EEA

• Lesion distal or deep to critical neurovascular structure(lateral to optic nerve)

• When resection or reconstuction of amajor vessel is needed

• When a neoplasm invades superficial tissues

Target Approach Corridor Odontoid/Craniove-

rtebral Junction

Transcribriform

Transnasal

Transclival

Transodontoid

Median Cavernous

Sinus

Transsellar Transsphenoidal

Transtuberculum/Trans

planum

Transclival

Transcavernous

Cavernous Sinus Transfovea ethmoidalis transethmoid

Transorbital

Transsphenoidal

Lateral Cavernous

Sinus

Transpterygoidal transmaxillary

Transpterygoidal

Transpterygoidal

Transpterygoidal

Transpterygoidal

Classification Of Endoscopic Approaches

CoronalPlane(Paramedian Saggital Plane(Midline)

Transorbital

Petrous Apex(Medial

Transpetrous)

Transcavernous

Transpterygoid

Transpetrous

Suprapetrous

Infrapetrous

Paraphryngeal Space

Transfrontal

Transcribriform

Transplanum

(Suprasellar/Subchiasmatic)

Transsphenoidal

(Sellar/Transcavernous)

Transclival

Posterior Clinioid/Transdorsal

Mid-Clivus

Cervicomediallary Junction

Foramen Magnum

Transodontoid

ESBS learning curve Complete ESS

Sphenopalatine artery ligation

Level 1

CSF Leak

Lateral Recess Sphenoid

Pituitary Surgery

Level 2

Medial Orbital Decompression

Optic Nerve Decompression

Petrous Apex(medial expansion)

Transclival approaches (extraderal)

Transodontoid Approach(extradural)

Level 3

Exradural

Level 4

Intradural

Level 5

Cerebrovascular Surgery

Pathology: Expanded endonasal Approach CSF Leak

Optic Nerve Decompression

Trauma

Osteomyelitis Infection

Mucocele

Fungal Sinusitis

Inflammatory Sinus Disease

Pituitary Adenoma

Fibro-osseous Lesions

Meningioma

Craniopharyngoma

Angiofibroma

Benign Neoplasm

Sinonasal Malignancies

Estheioneuroblastoma

Chordoma

Chondrosarcoma

Metastasis

Malignant Neoplasm

Rathke Cyst

Dermoid Cyst

AVM

Epidermoid

Miscellaneous

Some ESBS Centers around the world

• Pittsburgh Universiaty:Kassm,Snyderman, • Weil Cornell Medical College:Schwartz and

Anand • University Of Insubria:Paulo Castelnuovo • University Of Napoli:Paulo

cappabianca,Cavallo,Divitiis • Hirslanden Hospital:Simmen,Briner • Skull base Institute-Los Angeles:Shahinian • Hannover Center:Wolfgang Draf • Australia:Peter John Wormald

Technical Equipment

• Endoscopic set: Endoscpopes(0/30) Monitor(medical) Camera (HD) Xenon light Instruments Recorder Suitable Powered Instrumentation

OR

• Another equipments:

Pneumatic Holder

Navigation System

CUSA

MR intraoperative