Accepted Manuscript Multiportal approach to the skull base: one key, multiple gates Luigi M. Cavallo, MD, PhD, Domenico Solari, MD, PhD, Paolo Cappabianca, MD PII:
S1878-8750(15)00423-4
DOI:
10.1016/j.wneu.2015.04.021
Reference:
WNEU 2846
To appear in:
World Neurosurgery
Received Date: 8 April 2015 Accepted Date: 11 April 2015
Please cite this article as: Cavallo LM, Solari D, Cappabianca P, Multiportal approach to the skull base: one key, multiple gates, World Neurosurgery (2015), doi: 10.1016/j.wneu.2015.04.021. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Multiportal approach to the skull base: one key, multiple gates. Luigi M. Cavallo, MD, PhD, Domenico Solari, MD, PhD, Paolo Cappabianca, MD
Department of Neurosciences, Reproductive and Odontostomatological Sciences
RI PT
Division of Neurosurgery
Corresponding Author:
TE D
M AN U
SC
Università degli Studi di Napoli Federico II, Naples, Italy
EP
Luigi M. Cavallo, MD, PhD
Department of Neurosciences, Reproductive and Odontostomatological Sciences
AC C
Division of Neurosurgery
Università degli Studi di Napoli Federico II Via Pansini 5
80131 Naples, Italy
Tel +39 081 7462582 Fax +39 081 19560905 e-mail: [email protected]
ACCEPTED MANUSCRIPT Multiportal approach to the skull base: one key, multiple gates. In this interesting article of Dallan et al, coming from one of the most experienced groups in the field of endoscopic endonasal surgery, the reader gets the chance to
RI PT
expand the surgical horizons thanks to the terrific anatomical detailing provided. The authors illustrate the possibility of accessing the skull base of the middle cranial fossa and eventually deal with pathologies involving this area, via two
endonasal.
SC
different, complementary, routes, namely the transorbital and the endoscopic From an anatomical standpoint, the contribution of Dallan is
M AN U
praiseworthy as it offer the possibility to expose safely a wide area in regards to the Kassam concept of "do not cross nerves" (3). Accordingly, authors point out the superior orbital fissure as an imaginary limit to spin around: the use of a combined transorbital and endoscopic endonasal route, though, to access and
TE D
remove lesions of middle cranial fossa appears an elegant, respectful and effective way. The authors properly depict the variability of aspects that should be considered when performing this endoscopic transorbital approach, as well as
EP
the versatility of the recent endoscopic endonasal technique.
AC C
This contribution cogently fits the latter era of skull base surgery, leant toward the reduction of morbidity and mortality rates, also related to the approach itself: indeed, it has been the widespread of the endoscopic skull base surgery for the management of different skull base pathologies that has pushed the development of new strategies and the refinement of the already existing ones. The authors follow such new route of surgical and technological progress, and contemporarily move many efforts to provide patients with the best therapeutic
2
ACCEPTED MANUSCRIPT option, backing upon expertise and consciousness. At same time, they have perfectly drawn the attention toward the essence of this kind of surgery, namely the need for anatomic knowledge as well as surgical hand and mind skills,
RI PT
regardless the tools or the technique. A thorough anatomical knowledge is mandatory to create a strictly approachbased decision making process; besides, it cannot be underestimated the
SC
importance of a comprehensive, fully computer-integrated, preoperative study (2).
M AN U
From a strictly surgical-oriented standpoint, it should be considered that lesions involving a median skull base area favour the endonasal route that, being a median natural corridor, allows their safe management. Conversely, if the epicentre of the lesion is identified off the midline, or in cases of lesions
TE D
encroaching the supraclinod ICA and/or extending laterally to the optic nerves; as a matter of facts, the endonasal route could result troublesome when lateral aspects of lesions are out of the visibility and instruments maneuverability of the
EP
endoscopic endonasal route. In these cases, we agree with the indications of the
AC C
use of a transcranial corridor, as clearly defined over the time. Concerning the transorbital route, as authors experienced, the skull base reconstruction seems not overburdening the approach: the orbital content itself offers a natural barrier and a strong support for substitute materials, thus reducing the risk of the feared postoperative CSF leakage occurrence. Of course the authors are conscious that this surgical procedure will take time to be introduced in the daily clinical practice, requiring valuable patient series to be
3
ACCEPTED MANUSCRIPT afforded. Such assessment has to be confirmed with the cogent analysis, to define in the most realistic way the surgical approach possibilities. It should be said that the future applications of the endoscopic transorbital
RI PT
approaches has been not yet thoroughly defined and, so far, seem rapidly expanding. In a recent anatomical study (1), the group of the University of Pennsylvania at Philadelphia describe the endoscopic transorbital approach for a amygdalohippocampectomy. This route allows access to temporo-
SC
selective
mesial structures without disrupting lateral temporal cortex and/or white matter
M AN U
tracts. In our opinion, this implements the effectiveness of this route permitting the eventual access to intracerebral pathologies in a direct, safe way as foir the skull base diseases.
It is though worth highlighting that these broadening of the approach are tightly
TE D
related to the extreme versatility of the endoscopic endonasal technique: this latter has raised the bar, favouring the anatomical and clinical research experience.
EP
The endoscope, bringing the surgeon’s eyes close to the relevant target, has
AC C
provoked favour and disagreement, for the aspects related to the different working conditions of the already solid conventional transcranial surgery. More recently, endoscopic skull base surgery has been further expanding developed thanks to the contribution and cooperation among neurosurgeons on one side and ENT and maxillo-facial surgeons on the other one. We hope that the definition of this new route, i.e. the endoscopic transorbital, will further take the skull base surgery to a higher level: every new surgical
4
ACCEPTED MANUSCRIPT technology and technique is welcome and we are eager to support each and all of
AC C
EP
TE D
M AN U
SC
RI PT
them, whether they improve significantly standard care quality and the results.
5
ACCEPTED MANUSCRIPT REFERENCES
RI PT
SC M AN U TE D
3.
EP
2.
Chen HI, Bohman LE, Loevner LA, Lucas TH: Transorbital endoscopic amygdalohippocampectomy: a feasibility investigation. J Neurosurg 120:1428-1436, 2014. de Notaris M, Palma K, Serra L, Ensenat J, Alobid I, Poblete J, Gonzalez JB, Solari D, Ferrer E, Prats-Galino A: A three-dimensional computer-based perspective of the skull base. World Neurosurg 82:S41-48, 2014. Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P, Zanation A, Duz B, Stefko ST, Byers K, Horowitz MB: Endoscopic endonasal skull base surgery: analysis of complications in the authors' initial 800 patients. J Neurosurg 114:1544-1568, 2011.
AC C
1.
ACCEPTED MANUSCRIPT The transorbital approach is described. Main features pros and cons of this technique are reported.
AC C
EP
TE D
M AN U
SC
RI PT
Future possibilities are discussed
S1878-8750(15)00423-4
DOI:
10.1016/j.wneu.2015.04.021
Reference:
WNEU 2846
To appear in:
World Neurosurgery
Received Date: 8 April 2015 Accepted Date: 11 April 2015
Please cite this article as: Cavallo LM, Solari D, Cappabianca P, Multiportal approach to the skull base: one key, multiple gates, World Neurosurgery (2015), doi: 10.1016/j.wneu.2015.04.021. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Multiportal approach to the skull base: one key, multiple gates. Luigi M. Cavallo, MD, PhD, Domenico Solari, MD, PhD, Paolo Cappabianca, MD
Department of Neurosciences, Reproductive and Odontostomatological Sciences
RI PT
Division of Neurosurgery
Corresponding Author:
TE D
M AN U
SC
Università degli Studi di Napoli Federico II, Naples, Italy
EP
Luigi M. Cavallo, MD, PhD
Department of Neurosciences, Reproductive and Odontostomatological Sciences
AC C
Division of Neurosurgery
Università degli Studi di Napoli Federico II Via Pansini 5
80131 Naples, Italy
Tel +39 081 7462582 Fax +39 081 19560905 e-mail: [email protected]
ACCEPTED MANUSCRIPT Multiportal approach to the skull base: one key, multiple gates. In this interesting article of Dallan et al, coming from one of the most experienced groups in the field of endoscopic endonasal surgery, the reader gets the chance to
RI PT
expand the surgical horizons thanks to the terrific anatomical detailing provided. The authors illustrate the possibility of accessing the skull base of the middle cranial fossa and eventually deal with pathologies involving this area, via two
endonasal.
SC
different, complementary, routes, namely the transorbital and the endoscopic From an anatomical standpoint, the contribution of Dallan is
M AN U
praiseworthy as it offer the possibility to expose safely a wide area in regards to the Kassam concept of "do not cross nerves" (3). Accordingly, authors point out the superior orbital fissure as an imaginary limit to spin around: the use of a combined transorbital and endoscopic endonasal route, though, to access and
TE D
remove lesions of middle cranial fossa appears an elegant, respectful and effective way. The authors properly depict the variability of aspects that should be considered when performing this endoscopic transorbital approach, as well as
EP
the versatility of the recent endoscopic endonasal technique.
AC C
This contribution cogently fits the latter era of skull base surgery, leant toward the reduction of morbidity and mortality rates, also related to the approach itself: indeed, it has been the widespread of the endoscopic skull base surgery for the management of different skull base pathologies that has pushed the development of new strategies and the refinement of the already existing ones. The authors follow such new route of surgical and technological progress, and contemporarily move many efforts to provide patients with the best therapeutic
2
ACCEPTED MANUSCRIPT option, backing upon expertise and consciousness. At same time, they have perfectly drawn the attention toward the essence of this kind of surgery, namely the need for anatomic knowledge as well as surgical hand and mind skills,
RI PT
regardless the tools or the technique. A thorough anatomical knowledge is mandatory to create a strictly approachbased decision making process; besides, it cannot be underestimated the
SC
importance of a comprehensive, fully computer-integrated, preoperative study (2).
M AN U
From a strictly surgical-oriented standpoint, it should be considered that lesions involving a median skull base area favour the endonasal route that, being a median natural corridor, allows their safe management. Conversely, if the epicentre of the lesion is identified off the midline, or in cases of lesions
TE D
encroaching the supraclinod ICA and/or extending laterally to the optic nerves; as a matter of facts, the endonasal route could result troublesome when lateral aspects of lesions are out of the visibility and instruments maneuverability of the
EP
endoscopic endonasal route. In these cases, we agree with the indications of the
AC C
use of a transcranial corridor, as clearly defined over the time. Concerning the transorbital route, as authors experienced, the skull base reconstruction seems not overburdening the approach: the orbital content itself offers a natural barrier and a strong support for substitute materials, thus reducing the risk of the feared postoperative CSF leakage occurrence. Of course the authors are conscious that this surgical procedure will take time to be introduced in the daily clinical practice, requiring valuable patient series to be
3
ACCEPTED MANUSCRIPT afforded. Such assessment has to be confirmed with the cogent analysis, to define in the most realistic way the surgical approach possibilities. It should be said that the future applications of the endoscopic transorbital
RI PT
approaches has been not yet thoroughly defined and, so far, seem rapidly expanding. In a recent anatomical study (1), the group of the University of Pennsylvania at Philadelphia describe the endoscopic transorbital approach for a amygdalohippocampectomy. This route allows access to temporo-
SC
selective
mesial structures without disrupting lateral temporal cortex and/or white matter
M AN U
tracts. In our opinion, this implements the effectiveness of this route permitting the eventual access to intracerebral pathologies in a direct, safe way as foir the skull base diseases.
It is though worth highlighting that these broadening of the approach are tightly
TE D
related to the extreme versatility of the endoscopic endonasal technique: this latter has raised the bar, favouring the anatomical and clinical research experience.
EP
The endoscope, bringing the surgeon’s eyes close to the relevant target, has
AC C
provoked favour and disagreement, for the aspects related to the different working conditions of the already solid conventional transcranial surgery. More recently, endoscopic skull base surgery has been further expanding developed thanks to the contribution and cooperation among neurosurgeons on one side and ENT and maxillo-facial surgeons on the other one. We hope that the definition of this new route, i.e. the endoscopic transorbital, will further take the skull base surgery to a higher level: every new surgical
4
ACCEPTED MANUSCRIPT technology and technique is welcome and we are eager to support each and all of
AC C
EP
TE D
M AN U
SC
RI PT
them, whether they improve significantly standard care quality and the results.
5
ACCEPTED MANUSCRIPT REFERENCES
RI PT
SC M AN U TE D
3.
EP
2.
Chen HI, Bohman LE, Loevner LA, Lucas TH: Transorbital endoscopic amygdalohippocampectomy: a feasibility investigation. J Neurosurg 120:1428-1436, 2014. de Notaris M, Palma K, Serra L, Ensenat J, Alobid I, Poblete J, Gonzalez JB, Solari D, Ferrer E, Prats-Galino A: A three-dimensional computer-based perspective of the skull base. World Neurosurg 82:S41-48, 2014. Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P, Zanation A, Duz B, Stefko ST, Byers K, Horowitz MB: Endoscopic endonasal skull base surgery: analysis of complications in the authors' initial 800 patients. J Neurosurg 114:1544-1568, 2011.
AC C
1.
ACCEPTED MANUSCRIPT The transorbital approach is described. Main features pros and cons of this technique are reported.
AC C
EP
TE D
M AN U
SC
RI PT
Future possibilities are discussed
