Effect of the extent of posterior septectomy on surgical access during the endoscopic endonasal approach to the sella: A technical note.

Background: Using the bi-nostril 4-hand technique during the endoscopic endonasal approach (EEA) facilitates bimanual microsurgical techniques yet requires resection of the posterior nasal septum. The surgical exposure and degree of maneuverability gained proportionate to the extent of posterior septectomy in the sagittal plane was previously quantified. Research question: We aim to describe our technique of posterior septectomy, and the effect of its extent in the axial plane on surgical access, and instrument maneuverability. Material and methods: After fracturing the posterosuperior nasal septum, we disarticulate the vomer from the sphenoid rostrum and remove its upper part. The sphenoid rostrum is excised next exposing the clival recess where a suction tip without a side channel is anchored, allowing the assisting surgeon to use an additional instrument in their dominant hand. The vomer is removed down to the level of the floor of the sphenoid sinus. Results: A wide exposure is achieved in the coronal plane bilaterally at the level of the sphenoid rostrum allowing unobstructed instrument manipulation in the craniocaudal and cross-court trajectories. Furthermore, the floor of the sella is reached through a straight rather than angled trajectory facilitating surgical access, manipulation, and instrument maneuverability. For lateral lesions requiring contralateral access, the assisting surgeon can assist in dissection from the contralateral nostril without changing the position of the endoscope. Discussion and conclusion: Removing the upper vomer improves surgical access, and instrument maneuverability. Simultaneous dissection from both nostrils might be attempted. Caudally extending the posterior septectomy during the EEA allows better exposure and improves surgical access in all planes.

Perspectives on Endoscopic Transseptal Interforniceal Approach for Retroforaminal Colloid Cysts.

BACKGROUND: Although the interforniceal approach with the preservation of the fornix is useful during the endoscopic approach for retroforaminal colloid cysts, it carries a significant risk of memory and cognitive difficulties. Because most reports have reported the endoscopic approach to colloid cysts through the foramen with little emphasis on retroforaminal cysts, the aim of this study was to investigate colloid cysts as a special entity with regard to their different characteristics and surgical approaches and outcomes. METHODS: In this retrospective study, 12 patients with third ventricular colloid cysts with retroforaminal extensions were included. All patients underwent endoscopic transseptal interforniceal approach with tumor resection. The surgical technique was briefly described, and preoperative and postoperative data were evaluated. RESULTS: Among the 12 patients included in this study, most of our patients were males. Average diameter of the colloid cyst was relatively large (average 22 mm). Gross total resection was achieved in 10 cases (83.3%). The stable images showed no local recurrence in the long-term follow-up period except in 1 case at the 28-month follow-up period. CONCLUSIONS: Retroforaminal colloid cyst represents a unique entity that requires special attention to its mode of growth. The endoscopic approach for retroforaminal colloid cysts is nearly the same as that for foraminal cysts. It has a lower incidence rate of postoperative memory changes, lower chances of total resection, and lower incidence rate of hard contents. Moreover, sufficient knowledge on morbid anatomy is important to avoid fornix injury.

Endoscopic endonasal skull base surgery during the COVID-19 pandemic: A developing country perspective.

BACKGROUND: Although primarily a respiratory disorder, the coronavirus pandemic has paralyzed almost all aspects of health-care delivery. Emergency procedures are likely continuing in most countries, however, some of them raises certain concerns to the surgeons such as the endoscopic endonasal skull base surgeries. The aim of this study is to present the current situation from a developing country perspective in dealing with such cases at the time of the COVID-19 pandemic. METHODS: A cross-sectional analytical survey was distributed among neurosurgeons who performed emergency surgeries during the COVID-19 pandemic in Cairo, Egypt, between May 8, 2020, and June 7, 2020. The survey entailed patients' information (demographics, preoperative screening, and postoperative COVID-19 symptoms), surgical team information (demographics and postoperative COVID-19 symptoms), and operative information (personal protective equipment [PPE] utilization and basal craniectomy). RESULTS: Our survey was completed on June 7, 2020 (16 completed, 100% response rate). The patients were screened for COVID-19 preoperatively through complete blood cell (CBC) (100%), computed tomography (CT) chest (68.8%), chest examination (50%), C-reactive protein (CRP) (50%), and serological testing (6.3%). Only 18.8% of the surgical team utilized N95 mask and goggles, 12.5% utilized face shield, and none used PAPRs. Regarding the basal craniectomy, 81.3% used Kerrison Rongeur and chisel, 25% used a high-speed drill, and 6.3% used a mucosal shaver. None of the patients developed any COVID-19 symptoms during the first 3 weeks postsurgery and one of the surgeons developed high fever with negative nasopharyngeal swabs. CONCLUSION: In developing countries with limited resources, preoperative screening using chest examination, CBC, and CT chest might be sufficient to replace Reverse transcription polymerase chain reaction. Developing countries require adequate support with screening tests, PPE, and critical care equipment such as ventilators.

Surgical resection of low-grade gliomas in eloquent areas with the guidance of the preoperative functional magnetic resonance imaging and craniometric points.

OBJECTIVES: Surgical resection of low-grade gliomas (LGGs) in eloquent areas is one of the challenges in neurosurgery, using assistant tools to facilitate effective excision with minimal postoperative neurological deficits has been previously discussed (awake craniotomy and intraoperative cortical stimulation); however, these tools could have their own limitations thus implementation of a simple and effective technique that can guide to safe excision is needed in many situations. MATERIALS AND METHODS: The authors conducted a retrospective analysis of a prospectively collected data of 76 consecutive surgical cases of LGGs of these 21 cases were situated in eloquent areas. Preoperative functional magnetic resonance imaging (fMRI), pre- and post-operative MRI with volumetric analysis of the tumor size was conducted, and intraoperative determination of the craniometric points related to the tumor (navigation guided in 10 cases) were studied to evaluate the effectiveness of the aforementioned tools in safe excision of the aforementioned tumors. RESULTS: Total-near total excision in 14 (66.67%) subtotal in 6 (28.57%), and biopsy in 1 case (4.57%). In long-term follow-up, only one case experienced persistent dysphasia. CONCLUSION: In spite of its simplicity, the identification of the safe anatomical landmarks guided by the preoperative fMRI is a useful technique that serves in safe excision of LGGs in eloquent areas. Such technique can replace intraoperative evoked potentials or the awake craniotomy in most of the cases. However, navigation-guided excision might be crucial in deeply seated and large tumors to allow safe and radical excision.