Endoscopic cranial base surgery: classification of operative approaches

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Abstract

OBJECTIVE 

Endoscopic cranial base surgery is a minimal access, maximally aggressive alternative to traditional transfacial, transcranial, or combined open cranial base approaches. Previous descriptions of endoscopic approaches have used varying terminology, which can be confusing to the new practitioner. Indications for surgery are not well defined. Our objective was to create a comprehensive classification system of the various approaches and describe their indications with case examples.

METHODS 

We prospectively compiled a comprehensive database of our endonasal endoscopic operations, detailing the nasal sinus transgressed, the cranial base approach, and the intracranial target for the first 150 consecutive cases performed at our institution. All cases were performed collaboratively by a neurosurgeon and an otolaryngologist.

RESULTS 

We categorized the endonasal endoscopic cranial base operations into four nasal corridors, nine cranial base approaches, and 13 intracranial targets. Each of the various approaches is described in detail and illustrated with case examples. Pathology encountered included pituitary tumor (50%), meningocele/encephalocele (14%), craniopharyngioma and Rathke cleft cyst (10%), meningioma (8%), chordoma (5%), esthesioneuroblastoma (2%), and other (11%).

CONCLUSION 

Endonasal endoscopic cranial base surgery is a minimal access, maximally invasive alternative to open transcranial cranial base approaches for specific indications. A clear understanding of the possible approaches is facilitated by an awareness of the nasal corridors and intracranial targets.

"Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery

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Abstract

OBJECTIVE 

Transnasal endoscopic cranial base surgery is a novel minimal-access method for reaching the midline cranial base. Postoperative cerebrospinal fluid leak remains a persistent challenge. A new method for watertight closure of the anterior cranial base is presented.

METHODS 

To achieve watertight closure of the anterior cranial base, autologous fascia lata was used to create a “gasket seal” around a bone buttress, followed by application of a tissue sealant such as DuraSeal (Confluent Surgical, Inc., Waltham, MA). The gasket-seal closure was used to seal the anterior cranial base in a series of 10 patients with intradural surgery for suprasellar craniopharyngiomas (n = 5), planum meningiomas (n = 3), clival chordoma (n = 1), and recurrent iatrogenic cerebrospinal fluid leak (n = 1). Lumbar drains were placed intraoperatively in five patients and remained in place for 3 days postoperatively.

RESULTS 

After a mean follow-up period of 12 months, there were no cerebrospinal fluid leaks.

CONCLUSION 

The gasket-seal closure is an effective method for achieving watertight closure of the anterior cranial base after endoscopic intradural surgery.

Endoscopic pituitary surgery: a systematic review and meta-analysis

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Abstract

Object

Surgery on the pituitary gland is increasingly being performed through an endoscopic approach. However, there is little published data on its safety and relative advantages over traditional microscope-based approaches. Published reports are limited by small sample size and nonrandomized study design. A meta-analysis allows for a description of the impact of endoscopic surgery on short-term outcomes.

Methods

The authors performed retrospective review of data from their institution as well as a systematic review of the literature. The pooled data were analyzed for descriptive statistics on short-term outcomes.

Results

Nine studies (821 patients) met inclusion criteria. Overall, the pooled rate of gross tumor removal was 78% (95% CI 67–89%). Hormone resolution was achieved in 81% (95% CI 71–91%) of adrenocorticotropic hormone secreting tumors, 84% (95% CI 76–92%) of growth hormone secreting tumors, and 82% (95% CI 70–94%) of prolactin secreting tumors. The pooled complication rates were 2% (95% CI 0–4%) for CSF leak and 1% (95% CI 0–2%) for permanent diabetes insipidus. There were 2 deaths reported in the literature that were both related to vascular injury, giving an overall mortality rate of 0.24%.

Conclusions

The results of this meta-analysis support the safety and short-term efficacy of endoscopic pituitary surgery. Future studies with long-term follow-up are required to determine tumor control.

 

Location-specific outcomes and complications of endoscopic transorbital approaches: A systematic review with novel anatomical grouping

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Abstract

Introduction

Endoscopic transorbital approach (ETOA) is gaining recognition due to lower complication rates and better cosmetic outcomes. Nonetheless, there is no clear anatomical grouping system for lesions that ETOA can address, and location-specific complication rates are still lacking.

Research question

This systematic review provides an anatomical grouping system for ETOA and analyse the location-specific surgical risks and outcomes.

Material and methods

Based on the PRISMA guideline, articles with keywords “Endoscopic” and “Transorbital” were searched and analysed. The cases included are regrouped based on four anatomical locations (I - orbital, II - cavernous sinus, III - extradural, IV - intradural), and outcomes are studied respectively.

Results

Data from 28 published articles with 382 patients were identified. There were 113 orbital lesions, 58 cavernous lesions, 18 extradural lesions, and 150 intradural lesions. There was significant post-operative visual acuity improvement in Groups I (70.6 %), II (56.3 %), and IV (63.3 %). Proptosis shows notable improvement rates across all groups, particularly in Groups II (95.7 %) and IV (87.0 %). There was an observed difference in the rate of CSF leak depending on the location of the lesion: 0 % in both Group I and II versus 11.8 % in Group III and 3.4 % in Group IV (p=0.005).

Discussion and conclusion

This systematic review proposed an anatomical grouping system to analyse location-specific outcomes for ETOA. Our findings highlighted the significance of this new classification for anatomy-based risk assessment. Future, larger-scale, and multicenter research will generate more data, allowing for further stratification of outcomes based on specific pathology subtypes.

Transorbital approach: a bibliometric analysis from 1948 to 2024

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Background
Transorbital surgery has substantially evolved over the last century, with some notable and at times controversial developments, such as its use for transorbital leucotomies, the induction of cerebral ischemia in animal stroke models, and, more recently, the development of neuroendoscopic transorbital procedures. This review aims to analyze the evolution of transorbital surgery from 1948 to 2024 using scientometric techniques, assessing its impact and emerging trends over time, particularly during the past two decades marked by the surge of the endoscopic transorbital approach (eTOA).

Methods
An advanced search of the Web of Science Core Collection was performed using the topic “Transorbital.” Publications from 1948 to 2024 were screened for thematic relevance and analyzed with R (bibliometrix), Python, VOSviewer, Genderize.io, and Microsoft Excel. Scientometric indicators included publication and citation trends, keyword evolution, institutional and geographic output, collaboration networks, and gender distribution. Full and fractional counting were applied for country- and institution-level analyses.

Results
A total of 538 publications were included. Scientific activity increased markedly after 2010, accounting for 64% of all articles and demonstrating higher international collaboration. A thematic shift was observed from early ischemia models toward anatomical and clinical applications of the endoscopic transorbital approach. The most prolific institutions were the University of Naples Federico II, the University of Barcelona, Sungkyunkwan University, and the University of Washington, while the United States, Italy, South Korea, and Spain contributed the largest national outputs. Gender analysis showed persistent underrepresentation of female authors.

Conclusion
The transorbital approach has evolved into a versatile minimally invasive route supported by a rapidly expanding research community. Despite the growth in publication volume and collaborative activity, prospective clinical evidence remains limited. This bibliometric review outlines historical trends, current research structures, and opportunities for future investigation in transorbital surgery.

Impact of removal of the lateral orbital rim on intraorbital pressure during endoscopic trans-orbital approach (ETOA): a cadaveric study

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Abstract

Background

The endoscopic transorbital approach (ETOA) is being established as a new corridor for the lateral portion of the anterior and middle skull base. One of the main concerns is the risk of ophthalmological complications due to orbital retraction. Removal of the lateral orbital rim (LOR) is a simple measure that widens the corridor and may diminish injuries secondary to retraction. This study analyzes the impact of LOR removal on intraorbital pressure (IORP) during the stages of ETOA.

Methods

In this prospective cadaveric study, standard ETOA to the anterior and middle fossae were performed via a superior eyelid crease incision (Fig. 2). On one side, the LOR was preserved; on the other, it was removed. IORP was recorded with an intracranial pressure (ICP) probe during the entirety procedure (Fig. 3). All specimens underwent pre- and post-procedure CT to measure bone removal volume.

Results

Four specimens were used (8 sides, 4 with LOR removal, 4 without). Mean IORP was not statistically different between groups during periorbita detachment, which was prior to LOR removal (117.4 vs 91.5 mmHg, for the LOR removal group and LOR intact group respectively p = 0.217). IORP was consistently reduced in the LOR removal group in every subsequent step (Fig. 3): meningo-orbital band cutting (105.5 to 38.9 mmHg, p < 0.002), temporal fossa drilling (85.3 to 69.5 mmHg, p = 0.232), lateral greater sphenoid wing (GSW) drilling (99.8 to 49.9 mmHg, p < 0.001), medial GSW drilling (85.6 to 17.2 mmHg, p < 0.001), cavernous sinus peeling (85.6 to 3.0 mmHg, p < 0.001). LOR removal increased total bone removal volume from 6.2 cc to 9.4 cc (p = 0.05).

Conclusion

LOR removal decreased IORP, especially when working on the GSW and cavernous sinus, and significantly increased bone removal. These results support LOR removal to reduce orbital retraction stress and widen the working corridor during ETOA.

 

A way to improve skull base surgery through the advanced application of endoscopic techniques.

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