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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