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Ahmed Mohyeldin, Peter Hwang, Gerald A. Grant and Juan C. Fernandez-Miranda

, Tyler-Kabara EC , Wang EW , Snyderman CH : Endoscopic endonasal surgery for craniopharyngiomas: surgical outcome in 64 patients . J Neurosurg 119 : 1194 – 1207 , 2013 5 Panesar SS , Magnetta M , Mukherjee D , Abhinav K , Branstetter BF , Gardner PA , : Patient-specific 3-dimensionally printed models for neurosurgical planning and education . Neurosurg Focus 47 ( 6 ): E12 , 2019 6 Stefko ST , Snyderman C , Fernandez-Miranda J , Tyler-Kabara E , Wang E , Bodily L , : Visual outcomes after endoscopic endonasal

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Maria Koutourousiou, Paul A. Gardner, Juan C. Fernandez-Miranda, Alessandro Paluzzi, Eric W. Wang and Carl H. Snyderman

obtain long-term control of tumor growth. 7 , 27 The most common surgical approaches used for the treatment of giant pituitary adenomas are the microscopic transsphenoidal or various frontal and frontotemporal transcranial routes. 7 , 18 , 26 , 27 Endoscopic endonasal surgery, supported by recent technological advancements, has been used increasingly over the last decade for the treatment of many extended skull-base tumors. 5 , 6 , 8 , 15 , 19 , 20 , 30 In this paper we describe our experience in the management of 54 giant pituitary adenomas treated with EES. We

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Maria Koutourousiou, Juan C. Fernandez-Miranda, S. Tonya Stefko, Eric W. Wang, Carl H. Snyderman and Paul A. Gardner

) being used in the early years of macroscopic neurosurgery and the pterional, frontolateral, or frontoorbital approaches being broadly adopted with the development of microscopic techniques. Recently, extended transsphenoidal surgery has become an alternative option for selected suprasellar meningiomas, although its benefits and limitations have yet to be firmly established. 10 , 11 , 13 , 14 , 18 , 26 , 34 , 37 Endoscopic endonasal surgery (EES) provides panoramic visualization and wider access to the anterior skull base compared with the tunnel vision and speculum

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Cheran Elangovan, Supriya Palwinder Singh, Paul Gardner, Carl Snyderman, Elizabeth C. Tyler-Kabara, Miguel Habeych, Donald Crammond, Jeffrey Balzer and Parthasarathy D. Thirumala

S urgical treatment of pediatric cranial base tumors such as craniopharyngiomas, chordomas, angiofi-bromas, pituitary adenomas, and Rathke’s cleft cysts has been evolving from conventional open skull base approaches to novel, less invasive techniques like endoscopic endonasal surgery (EES). 5 , 18 , 19 , 32 , 41 For properly selected tumors, EES offers several advantages over traditional methods, including the sparing of disfiguring facial incisions and craniotomy. EES allows the surgeons to access the entire ventral skull base, from the crista galli to

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Sauson Soldozy, Michelle Yeghyayan, Kaan Yağmurlu, Pedro Norat, Davis G. Taylor, M. Yashar S. Kalani, John A. Jane Jr. and Hasan R. Syed

microscope, although the presence of a sphenoid retractor can reduce visualization. 4 In the pediatric population, a conchal sphenoid sinus and smaller skull base can make an endoscopic approach more challenging. 3 Regardless, the allure of endoscopic endonasal surgery (EES) lies in its ability to reach deep-seated anterior midline structures while causing minimal disruption to eloquent tissues. Currently, EES is widely used for pituitary adenomas, Rathke cleft cysts, craniopharyngiomas, and other sellar lesions, with a significant decline in microscopic procedures in

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Hazem M. Negm, Rafid Al-Mahfoudh, Manish Pai, Harminder Singh, Salomon Cohen, Sivashanmugam Dhandapani, Vijay K. Anand and Theodore H. Schwartz

8 patients (19.5%). The mean interval between the previous surgery and the reoperative endoscopic endonasal surgery was 73 months. This interval was significantly shorter in the endonasal endoscopic group than in the transsphenoidal microscopic group (38 months vs 105 months, respectively; p < 0.01, Mann-Whitney U-test). The interval from prior surgery to reoperation was significantly shorter in patients with hormone-producing than non–hormone-producing adenomas in the endoscopic group (p < 0.01). Tumor Recurrence Owing to the lack of adequate records from the

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Maria Koutourousiou, Paul A. Gardner, Juan C. Fernandez-Miranda, Elizabeth C. Tyler-Kabara, Eric W. Wang and Carl H. Snyderman

cases, conventional radiotherapy in 2, and proton beam in 1. Endoscopic endonasal surgery combined with radiotherapy was more often used in the adult group than in the pediatric group (8 patients vs 1 patient). During a mean follow-up of 38 months (range 1–135 months), 22 patients (34%) had a tumor recurrence (15 adults and 7 children) and were treated with reoperation in 6 cases (EES in 5 and open craniotomy in 1), radiosurgery alone in 1, surgery (EES in 7 and craniotomy in 1) combined with radiotherapy (intracystic irradiation with 32 P in 3 patients and

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Joseph D. Chabot, Chirag R. Patel, Marion A. Hughes, Eric W. Wang, Carl H. Snyderman, Paul A. Gardner and Juan C. Fernandez-Miranda

associated with an unacceptably high rate of postoperative CSF leakage. 8 , 9 , 12 , 42 The routine use of a vascularized nasoseptal flap (NSF) for reconstruction of large skull base defects has drastically decreased the incidence of CSF leakage following endoscopic endonasal surgery (EES) by more than half, from 16% to less than 7% in a recent systematic review, 13 with little added comorbidity. 4 , 28 , 30 , 31 , 39 , 46 The decrease in CSF leaks has also led to a decrease in life-threatening meningitis. Critics of EES may point to the prolonged exposure of the

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David T. Fernandes Cabral, Georgios A. Zenonos, Juan C. Fernandez-Miranda, Eric W. Wang and Paul A. Gardner

bed would be suggestive of surgical pathway seeding. This complication is not approach dependent, but despite an extensive review of the literature, we could not identify any reports on the incidence of iatrogenic seeding following endoscopic endonasal surgery (EES) for resection of skull base chordomas. In this report, we review our experience with 173 EESs for clival chordomas, focusing on cases in which we observed iatrogenic seeding. We discuss the patterns of seeding as well as the potential reasons explaining these patterns. Based on our findings, we have made

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Ryuichi Hirayama, Yasunori Fujimoto, Masao Umegaki, Naoki Kagawa, Manabu Kinoshita, Naoya Hashimoto and Toshiki Yoshimine


Existing training methods for neuroendoscopic surgery have mainly emphasized the acquisition of anatomical knowledge and procedures for operating an endoscope and instruments. For laparoscopic surgery, various training systems have been developed to teach handling of an endoscope as well as the manipulation of instruments for speedy and precise endoscopic performance using both hands. In endoscopic endonasal surgery (EES), especially using a binostril approach to the skull base and intradural lesions, the learning of more meticulous manipulation of instruments is mandatory, and it may be necessary to develop another type of training method for acquiring psychomotor skills for EES. Authors of the present study developed an inexpensive, portable personal trainer using a webcam and objectively evaluated its utility.


Twenty-five neurosurgeons volunteered for this study and were divided into 2 groups, a novice group (19 neurosurgeons) and an experienced group (6 neurosurgeons). Before and after the exercises of set tasks with a webcam box trainer, the basic endoscopic skills of each participant were objectively assessed using the virtual reality simulator (LapSim) while executing 2 virtual tasks: grasping and instrument navigation. Scores for the following 11 performance variables were recorded: instrument time, instrument misses, instrument path length, and instrument angular path (all of which were measured in both hands), as well as tissue damage, max damage, and finally overall score. Instrument time was indicated as movement speed; instrument path length and instrument angular path as movement efficiency; and instrument misses, tissue damage, and max damage as movement precision.


In the novice group, movement speed and efficiency were significantly improved after the training. In the experienced group, significant improvement was not shown in the majority of virtual tasks. Before the training, significantly greater movement speed and efficiency were demonstrated in the experienced group, but no difference in movement precision was shown between the 2 groups. After the training, no significant differences were shown between the 2 groups in the majority of the virtual tasks. Analysis revealed that the webcam trainer improved the basic skills of the novices, increasing movement speed and efficiency without sacrificing movement precision.


Novices using this unique webcam trainer showed improvement in psychomotor skills for EES. The authors believe that training in terms of basic endoscopic skills is meaningful and that the webcam training system can play a role in daily off-the-job training for EES.