Endoscope-assisted supraorbital approach for excision of tuberculum sella meningioma: Technical nuances.

Background: Tuberculum sellae meningiomas (TSMs) are benign dural-based lesions of the anterior cranial fossa, which mainly present with impaired visual acuity/field deficits secondary to compression of the optic apparatus. Surgical management is recommended as the optimal strategy for large compressive TSMs, with goals of safe maximal resection, optic nerve decompression, and potential vision restoration. The philosophy of adapting keyhole approaches for such resections is commonly highlighted; however, it comes with notable criticism of encountering major blind spots during surgical resection and limited anatomical exposure. Adding angled endoscopes enhances the expanded panoramic view of the skull base and provides a synergistic modality to microsurgery for maximizing total resection and navigating the blind spots. Case Description: This video case presentation aims to highlight the technical nuances of endoscope-assisted microscopic supraorbital craniotomy for TSM resection invading bilateral optic canals in a 66-year-old female presenting with progressive right eye vision loss (OD Hand motion). The video emphasizes traditional skull-base surgical principles of TSM resection through the optics of a keyhole approach augmented by endoscopic tumor removal. Gross total resection was achieved, the patient's vision improved to 20/25, and she was discharged home on postoperative day 2. Conclusion: The endoscope-assisted supraorbital craniotomy offers a safe surgical corridor for TSM, using a limited craniotomy with minimal brain retraction in appropriately selected individuals, particularly with larger tumors with greater lateral extension and above the planum.

Supraorbital keyhole approaches in the first 3 years of practice: outcomes and lessons learned. Patient series.

BACKGROUND: Supraorbital keyhole approaches (SKAs) have garnered criticism for a limited surgical exposure, restrictive surgical freedom, blind spots, and the learning curve. This retrospective study of patients who underwent SKA aims to explore the outcomes, technical nuances, and the learning curve reflected in a single surgeon's experience in the initial 3 years of practice. OBSERVATIONS: A total of 20 SKA operations were performed in 19 patients. Gross- or near-total resection was achieved in 14 of 17 tumor cases. The mean blood loss was 80.5 mL, the mean duration of surgery was 5 hours, and the median stay was 3 days. Endoscopic augmentation was used in 11 cases in which additional tumor removal occurred in 8 of the 11 cases. There were no cases of cerebrospinal fluid leakage or wound infection. A 30-day readmission and typical narcotics after discharge were seen in one patient each. When comparing two halves of a neurosurgery practice over 3 years, the duration of surgery was significantly longer in the later year, which is likely due to operating on a larger tumor size as the years progressed. No cases required static retractors or conversion to larger craniotomies. LESSONS: Careful case selection and respecting the learning curve allows the safe incorporation of SKA in the early stages of neurosurgical practice.