Combined Transcranial-Microsurgical and Transnasal-Endoscopic “Handshake Approach” – A Contribution to the Management of Intra-Extracranial Anterior Cranial Base Tumors
Surgical strategy of anterior skull base tumors with invasion of nasal/sinusal and intracranial structures are a very challenging task. Many approaches have been proposed. Some authors addresses transfacial approaches, transnasal or transbasal. Patient's quality of life on post-operative period should always be considered, since this tumors are usually malignant. Transfacial approaches affects facial structures sometimes not involved by the tumor, has a worse cosmetic result and does not offer complete exposure of intra and extracranial compartment without excessive bone removal. Strictly transnasal endoscopic approach has a limitation in dealing with suprabasal structures increasing risk of neurological damage. And skull base reconstruction is less effective and safe than coming from superior. Solely transcranial approach demands excessive retraction of frontal lobe to expose some inferior or posterior structures, such as optic carotid recess. Besides this, in some cases vascularization comes from nasal/parasinusal vessel, being more difficult to deal with them via transcranial. Considering this issues, a simultaneous, one-staged, combined transcranial-microsurgical and transnasal-endoscopic approach should be adopted to blend best aspects of each of them. Using this strategy procedures lasts lass and it is posible to perform a one-stage gross total resection in a safe manner, avoiding long or repeated surgeries reducing risks. The role of transcranial team is to resect dural/intradural component and release the tumor toward the sella and protect neurologic structures. At the end of procedure, they should recontruct anterior skull base. The endonasal team should work on infra-sellar component making its debulking and resection, besides works on corner areas no visible from superior such as optic-carotid recess. Performing removal of the biggest component from inferior makes bleeding come to nose, not to the intracranial space. At the end of removal, both teams should meet and etmoidal plane, concluding the so-called “handshake approach.” The procedure is extensively detailed in a stepwise manner using 5 recent cases operated on by this combined approach. We demonstrate that shaking-hands strategic approach is a feasible, safe option. Its advantages are: one-staged resection, good cosmetic result, excelente surgical field of view, acceptable rate of complications and adequate skull base reconstruction. However, two experienced skull base teams are needed: transcranial (composed by neurosurgeons) and transnasal (composed by ENTs).