Endoscopic endonasal surgery
A neurosurgeon or an otolaryngologist, using an endoscope that is entered through the nose, fixes or removes brain defects or tumors in the anterior skull base.
The use of endoscope was first introduced in Transsphenoidal Pituitary Surgery by R Jankowsky, J Auque, C Simon et al. in 1992 G (Laryngoscope.
[1] However, the precursor to the modern endoscope was invented in the 1800s when a physician in Frankfurt, Germany by the name of Philipp Bozzini, developed a tool to see the inner workings of the body.
[2] Bozzini called his invention a Light Conductor, or Lichtleiter in German, and later wrote about his experiments on live patients with this device that consisted of an eyepiece and a container for a candle.
[1] Following Bozzini's success, The University of Vienna starting using the device to test its practicality in other forms of medicine.
However, Maximilian Nitze and Joseph Leiter used the invention of the light bulb by Thomas Edison to make a more refined device similar to modern day endoscopes.
This iteration was used for urological procedures, and eventually otolaryngologists began to use Nitze and Leiter's device for eustachian tube manipulation and removal of foreign bodies.
[2] The endoscope made its way to the US when Walter Messerklinger began teaching David Kennedy at Johns Hopkins Hospital.
Gerard Guiot popularized the transphenoidal approach which later became part of the neurosurgical curriculum, however he himself discontinued the use of this technique because of inadequate sight.
[1] In the late 1970s, the endoscopic endonasal approach was used by neurosurgeons to augment microsurgery which allowed them to view objects out of their line of sight.
An endocrinologist is only involved in preparation for an endoscopic endonasal surgery, if the tumor is located on the pituitary gland.
The main types of pituitary adenomas are: A neuroradiologist takes images of the defect so that the surgeon is prepared on what to expect before surgery.
[5] The lesions associated with endoscopic endonasal surgery include: Some suprasellar tumors invade the chiasmatic cistern, causing impaired vision.
This approach is used to remove chordomas, chondrosarcoma, inflammatory lesions of the clivus, or metastasis in the cervical spine region.
[2] This approach is the most common and useful technique of endoscopic endonasal surgery and was first described in 1910 concurrently by Harvey Cushing and Oskar Hirsch.
The upper third lies inferior to the dorsum sellae and posterior clinoid processes and superior to the petrous apex, the middle third lies at the level of the petrous segments of the internal carotid artery (ICA), and the inferior third extends from the jugular tubercle to the foramen magnum.
Then the floor of the sella turcica is opened with a high speed drill being careful to not pierce the dura mater.
When technology advanced and larger defects could be fixed endoscopically, more and more failures and leaks started to occur with the free graft technique.
The larger defects are associated with a wider dural removal and an exposure to high flow CSF, which could be the reason for failure among the free graft.
Dr. Paolo Cappabianca described the perfect CRA for this surgery to be a median lesion with a solid parasellar component (beside the sellar) or encasement of the main neuromuscular structures that are localized in the subchiasmatic (below the optic chiasm) and retrochiasmatic (behind the optic chiasm) regions.
[15] Endoscopic endonasal approach has been shown even among young patients to be superior to traditional microscopic transsphenoidal surgery.
[16] The newer 3-D technique is gaining ground as the ideal way to do surgery because it gives the surgeon a better understanding of the spatial configuration of what they are seeing on a computer screen.
In another case study on CRAs,[19] they showed similar results with the CSF leaks being more of a problem in endoscopic patients.
