Endoscopic-Assisted Microsurgical Approach for Anterior Skull Base Lesions

Objective: The priority in contemporary surgery is to achieve the greatest therapeutic effect while causing the least iatrogenic injury. The evolution of microsurgical techniques with refined instrumentation and illumination and the enormous development of preoperative and intraoperative diagnostic tools enable neurosurgeons to treat different lesions through limited and specific keyhole approaches. The concept of keyhole surgery is based on the careful preoperative study of diagnostic images (MRI, CT, angiography) to determine the anatomic windows that provide access to the pathological processes, taking into consideration the individual pathoanatomic situation of the patient. The introduction of the endoscope in neurosurgical procedures has brought a further new dimension into the field of intraoperative visualization. It provides, in contrast to the microscope, a panoramic view of the surgical field, which makes the surgical procedure more controlled, effective, and safe.

Methods: During a 9-year period between October 2000 and June.2010, we have performed 676 endoscopic-assisted microsurgical procedures for ant. Skull base lesions included: 262 aneurysms (ICA, A.C.A, A.Com.A, P.Com.A), 136 meningiomas, 86 craniopharyngiomas, 66 pituitary adenomas, 43 arachnoid cysts, 32 epidermoid/dermoid cysts, 27 astrocytomas, 8 germinomas, 11 teratomas, and 5 hamartomas.

Results: The postoperative complications associated with the approach were: (1) permanent partial supraorbital hypesthesia in 17 patients, (2) palsy of the frontal branch of the facial nerve in 14 cases, (3) permanent hyposmia appeared in 17 patients, (4) wound-healing disturbances in 4 cases, (5) subcutaneous CSF collection and leak in 8 patients, (6) postoperative bleeding 9 cases, and (7) pituitary insufficiency 4 cases.

Conclusion: The supraorbital craniotomy allows a wide, intracranial exposure for extended, bilaterally situated, or even deep-seated intracranial areas, according to the strategy of keyhole craniotomies. The supraorbital craniotomy offers equal surgical possibilities with less approach-related morbidity owing to limited exposure of the cerebral surface and minimal brain retraction. The optical advantages of the endoscopic visualization in anatomical orientation and surgical dissection improve the surgical outcome. All these factors contribute to improving the postoperative results due to reduction of the complications. In addition, the minimal invasiveness of the procedure results in pleasing cosmetic outcome.