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Amin Kassam, Carl H. Snyderman, Ricardo L. Carrau, Paul Gardner and Arlan Mintz

The increasing popularity of minimally invasive neurosurgery has led to the development of transnasal expanded approaches for the treatment of skull base lesions. One of the greatest challenges in safely accomplishing resection of tumors, particularly intradural lesions, is effective hemostasis. Over the past 7 years the authors have progressively developed an organized approach to address this challenge. This has required the development of new instrumentation as well as variations on standard techniques. In this report they present the technique that has evolved at their institution for endoneurosurgical hemostasis.

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Amin Kassam, Carl H. Snyderman, Arlan Mintz, Paul Gardner and Ricardo L. Carrau

Object

Transsphenoidal approaches have been used for a century for the resection of pituitary and other sellar tumors. More recently, the standard endonasal approach has been expanded to provide access to other, parasellar lesions. With the addition of the endoscope, this expansion carries significant potential for the resection of skull base lesions.

Methods

The anatomical landmarks and surgical techniques used in expanded (extended) endoscopic approaches to the rostral, anterior skull base are reviewed and presented, accompanied by case illustrations of each segment (or module) of approach. The rostral half of the anterior skull base is divided into modules of approach: sellar/parasellar, transplanum/transtuberculum, and transcribriform. Case illustrations of successful resections of lesions with each module are presented and discussed.

Conclusions

Endoscopic, expanded endonasal approaches to rostral anterior skull base lesions are feasible and hold great potential for decreased morbidity. The effectiveness and appropriate use of these techniques must be evaluated by close examination of outcomes as case series expand.

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Amin Kassam, Carl H. Snyderman, Arlan Mintz, Paul Gardner and Ricardo L. Carrau

Object

Transsphenoidal approaches have been used for a century for the resection of pituitary and other sellar tumors. Recently, however, the standard endonasal approach has been expanded to provide access to other parasellar lesions. With the addition of the endoscope, this expansion has significant potential for the resection of skull base lesions.

Methods

The anatomical landmarks and surgical techniques used in expanded (extended) endoscopic approaches to the clivus and cervicomedullary junction are reviewed and presented, accompanied by case illustrations of each segment (or module) of approach.

The caudal portion of the midline anterior skull base and the cervicomedullary junction is divided into modules of approach: the middle third of the clivus, its lower third, and the cervicomedullary junction. Case illustrations of successful resections of lesions via each module of the approach are presented and discussed.

Conclusions

Endoscopic expanded endonasal approaches to caudally located midline anterior skull base and cervicomedullary lesions are feasible and hold great potential for decreased morbidity. The effectiveness and appropriate use of these techniques must be evaluated by close examination of outcomes as case series expand.

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Amin Kassam, Ajith J. Thomas, Carl Snyderman, Ricardo Carrau, Paul Gardner, Arlan Mintz, Hilal Kanaan, Michael Horowitz and Ian F. Pollack

C onventional anterior skull base surgery in children can potentially cause disruption of growth centers in the craniofacial skeleton that may result in facial asymmetry. 10 Children with anterior skull base lesions may, therefore, benefit from transnasal endoscopic approaches. Although transnasal rod lens endoscopic approaches have been traditionally used for treating inflammatory sinus disease, 23 , 27 , 29 they also provide techniques that have been used successfully for the resection of anterior skull base and parasellar and clival lesions. 9 , 18

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Paul Gardner, Amin Kassam, Carl Snyderman, Arlan Mintz, Ricardo Carrau and John J. Moossy

transsphenoidal surgery: a case series . Surg Neurol 66 : 371 – 376 , 2006 6 Feiz-Erfan I , Han PP , Spetzler RF , Horn EM , Klopfenstein JD , Porter RW , : The radical transbasal approach for resection of anterior and midline skull base lesions . J Neurosurg 103 : 485 – 490 , 2005 7 Forer B , Vasilyev T , Brosh T , Kariv N , Trejo LL , Gil Z , : Dural defect repair with fascia by a CO2 laser system in a porcine model . Laryngoscope 116 : 1002 – 1006 , 2006 8 Gardner P , Kassam AK , Snyderman CS , Carrau RL