Dr. Jho's Endoscopic Skull Base Surgery Through a Nostril: Minimally Invasive Skull Base Brain Tumor Surgery Without A Skin Incision
Home: Dr. Jho's Innovative Minimally Invasive Neurosurgery for Spine and Brain Disorders
Facts About This Surgery
Certain skull base tumors can now be resected through a patient's nostril using an endoscope and without skin incisions
Is less invasive because it bypasses extensive potentially face-disfiguring surgical approaches
Is innovative because it changes the known frontier of skull base surgery by incorporating other technologies
Reduces hospital stay by not requiring extensive bone resection or skin incisions
Discussion
After increased experience with endoscopic resections of pituitary tumors, it was noted that this technique could be applied to tumors of the skull base. Skull base tumors such as chordomas, epidermoid tumors, meningiomas, craniopharyngiomas, germinomas,etc.can now be removed through a patient's nostril, if applicable. This new technique, utilizing endoscopic visualization, avoids extensive face-disfiguring surgical exposure and naturally facilitates quick postoperative recovery. Patients are most often able to leave the hospital the day after their surgery. Cerebrospinal fluid leakage (CSF leak) occurring spontaneously through the nose or developing after sinus surgery, can also be easily repaired with this endoscopic technique.
Images
Left: A schematic drawing demonstrates area of surgical access gained by this approach to the anterior cranial fossa.
Right: A schematic drawing of an axial view depicts access to anterior cranial fossa between the eye sockets.
Endoscopic images obtained during endoscopic resection of a large anterior fossa meningioma. The tumor is in the process of being delivered out (left). The optic chiasm, nerves, pituitary stalk and anterior cerebral artery system are demonstrated after tumor resection (right).
An artistic depiction represents the surgeon's view of the clivus through an endoscope (left). This schematic drawing displays endoscopic access to the clivus and posterior fossa (right).
MR scans, sagittal view, reveal a large tumor encasing the basilar artery with severe indentation into the brainstem preoperatively (left, arrows) and subtotal resection of the tumor postoperatively (right). The tumor resection cavity is replaced with an abdominal fat graft (arrowheads). A small residual tumor, located behind the basilar artery and its branches, was treated with stereotactic gamma-knife surgery.
Left: An intraoperative endoscopic image shows carotid artery (C), sella (S), and tumor (T). Center: This endoscopic image exhibits the basilar artery (B) encased by tumor. Right: Tumor is progressively removed from around the basilar artery.
(Left) View under a 30 degree endoscope showing tumor encasing the distal basilar artery and its branches. The posterior cerebral arteries (P) are visible. This view was obtained during endoscopic removal of a large chordoma in the posterior fossa.
(Right) During the same operation, this view under a 70 degree endoscope, of the superior cerebellar arteries (S), the bilateral posterior cerebral arteries (P), posterior communicating arteries (Pc), bilateral mammillary bodies (M), and bilateral oculomotor nerves (III) was obtained after resection of the tumor.
Left: A clival chordoma in another patient visualized endoscopically (S: sella, C: carotid artery, T: tumor). Center: The tumor is removed (S: sella, C: carotid artery, TR: tumor resection cavity). Right: The tumor is further excised from behind the right carotid artery (RC: right carotid artery, S: sella).
Left: A preoperative sagittal view MRI shows a recurrent malignant pituitary tumor (T). Right: Tumor resection is confirmed and fat graft placement (F), done at the time of tumor resection, can also be visualized in this postoperative sagittal view MRI.
References
Jho HD, Carrau RL, McLaughlin ML and Somaza SC: Endoscopic transsphenoidal resection of a large chordoma in the posterior fossa. case report. Neurosurgical focus 1(1): article 3, 1996
Jho HD, Carrau RL, McLaughlin ML and Somaza SC: Endoscopic transsphenoidal resection of a large chordoma in the posterior fossa: A case report. Acta Neurochirurgica 139: 343-348, 1997
Dr. Jho's Endoscopic Transsphenoidal Pituitary Surgery Through a Nostril: Minimally Invasive Pituitary Tumor Surgery For Pituitary Adenomas, Prolactinomas, Acromegaly, and Cushing's Disease
Home: Dr. Jho's Innovative Minimally Invasive Neurosurgery for Spine and Brain Disorders
"Ideas won't keep: something must be done about them." - Alfred North Whitehead
Facts About This Surgery
Discussion
Endoscopic pituitary surgery can be performed for various types of pituitary tumors such as prolactinomas, Cushing's disease, gigantism or acromegaly, non-secreting adenomas, and for pituitary adenomas invading the cavernous sinus or extending into the suprasellar region. The conventional surgical method for removal of pituitary adenomas involves incisions under the upper lip or in the nostril. This requires the use of postoperative nasal packing. Adapting the use of a small fiberoptic-like catheter shaped tool called an endoscope, a surgical procedure has been developed that not only eliminates the need for nasal packing but heightens the surgeon's visualization of pituitary tumors. Replacing the operating microscope, the endoscope provides the surgeon with a panoramic view of the pituitary gland and surrounding structures. It can also provide a very close view of the pituitary gland and tumor interface. The patient undergoes general anesthesia, the endoscope and surgical instruments are placed in the patient's nostril, and the tumor is removed. No lip or nasal incisions are made, no packing is placed, and patients are generally sent home the day after surgery. Patients can also usually return to work or school in four to six weeks time.
Definitions
adenoma - a benign slow growing tumor of the pituitary gland
Images
Schematic drawings demonstrate techniques of endoscopic pituitary surgery. A transphenoidal retractor is not used. No skin or mucosal incisions are required. No postoperative nasal packing is necessary.
An endoscopic image of the middle turbinate seen during an endoscopic pituitary approach (left). The sphenoid ostia are visible in this photo (right, arrows).
Left and Center: Intraoperative endoscopic images present a close view of the sella (s), optic nerves (o), cavernous sinuses (cs), clivus (c), and tuberculum sella (ts). Right: After completion of tumor removal, the sella is reconstructed with auotgenous bone that was preserved at the time of sphenoidotomy.
An MRI scan, coronal view, shows a large pituitary tumor preoperatively (left). The optic chiasm (arrows) is draped over the tumor. Total resection of the tumor is demonstrated postoperatively (right). The optic chiasm is now free from compression.
A preoperative axial CT scan shows a large pituitary tumor. The patient had previously undergone transphenoidal microscopic removal of the tumor by another surgeon, but due to how hard and fibrotic the tumor was, only biopsy was possible at the time. The biopsy site is visible at the center of the tumor (arrow).
Preoperative axial, coronal, and sagittal MRI images reveal a large pituitary tumor in the same patient.
The corresponding postoperative axial, coronal, and sagittal MRI images present complete tumor resection and fat graft placement. The bright shadow in the the sagittal view (right) is an abdominal fat graft placed at the tumor resection cavity (F).
Nasal packing is not necessary and not used as seen in this patient in the recovery room following endoscopic pituitary tumor surgery (left). The next picture shows the same patient, prior to discharge, on the day following surgery.
An intraoperative endoscopic image of a patient with acromegaly shows a pituitary adenoma (PA), in the left cavernous sinus (left). The tumor is shown to have been completely excised in this endoscopic image (right, S: sella, TR: tumor resection cavity in the cavernous sinus, C: carotid artery (outlined in white). Postoperative cure of the patient's acromegaly was confirmed by endocrinological testing.
Left: A preoperative coronal view MRI shows a recurrent pituitary tumor involving the left cavernous sinus. Right: The corresponding postoperative MRI scan shows complete tumor resection from the left cavernous sinus.
References
Jho HD, Carrau RL: Endoscopic endonasal transsphenoidal surgery: Experience with 50 patients. Neurosurgical focus 1(1): article 2, 1996
Jho HD, Carrau RL, Ko Y: Endoscopic pituitary surgery, in Wilkins RH, Rengachary SS (ed): Neurosurgical Operative Atlas, Park Ridge, III: American Association of Neurological Surgeons, 1996, Vol 5, pp 1-12
Jho HD, Carrau RL: Endoscopy assisted transsphenoidal surgery for pituitary adenoma: Technical note. Acta Neurochirurgica 138: 1416-1425, 1996
Jho HD, Carrau RL: Endoscopic pituitary surgery: An early experience. Surgical Neurology 47: 213-223, 1997
Jho HD: Endoscopic endonasal pituitary surgery: Technical aspects. Contemporary Neurosurgery 19, No.6: 1-8, 1997
Jho HD: Endoscopic surgery of pituitary adenomas. In Krisht AF, Tindall GT (eds), Pituitary Disorder: Comprehensive Management, Williams & Wilkins (in press)
Carrau RL, Jho HD: Pituitary: Endoscopic approach. In Arriaga M, Day J (eds) Neurological Issues in Otolaryngology: Principles and Practice of Collaboration, Lippincott-Raven (in press)
Jho HD: Transsphenoidal endoscopic surgery. In Fessler RG, Sekhar LN (eds), Atlas of Neurosurgical Techniques (in press)
Jho HD: Endoscopic transsphenoidal surgery. In Schmidek HH (ed), Fourth edition of Operative Neurosurgical Techniques: Indications, Methods and Results (in press)
Jho HD: Endoscopic transsphenoidal surgery. In Fisher WS (guest ed), Hadley M (ed), Perspectives in Neurological Surgery (in press)
For referral information or appointment for consultation contact:
Manager: Robin A. Coret, B.S.- (412)359-6110 or e-mail at
Fax: (412)359-8339
Address: JHO Institute for Minimally Invasive Neurosurgery
7th Floor, Snyder Pavilion, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212-4772
Contact Dr. Jho via email: DrJho@DrJho.com