Extended Endoscopic Endonasal Approach to Suprasellar Craniopharyngiomas: Results in 10 Cases

Suprasellar craniopharyngiomas are usually approached by a transcranial route, and the transsphenoidal approach is usually employed in cases of purely sellar involvement. After extensive experience with pituitary adenomas (more than 400 endoscopic operations since 1998), the authors, since 2005, have adopted the endoscopic extended transsphenoidal approach even in cases of purely suprasellar tumors, using the 4 hands binostril technique described by Kassam. The surgical team was formed by a neurosurgeon and an ENT surgeon in every case. All the tumors had solid and cystic components and impinged on the third ventricle. Preoperatively, all the patients showed a variable degree of hypopituitarism; 5 had a visual and/or visual field defect. Zero-degree angled optics were used during the approach.

The operation consisted of removal of the middle turbinate on the right side, widely opening the sphenoid sinus, and drilling the tuberculum sellae and partial opening of the sella. The intercavernous sinus was then divided, the dura opened, and the tumor removed by standard microsurgical technique under direct visual control offered by the endoscope with a 30-degree angled lens.

There was no mortality. One patient experienced worsening of his visual status. To achieve complete removal of the tumor, the pituitary stalk was sectioned in 9 cases out of 10. Closure of the bony opening was effected by various means (fascia lata, fat, dural substitutes, pedicled flap, etc.) combined together in more layers; spinal drainage was never used at the first attempt, but 6 patients had to be reoperated on because of a CSF fistula. There were no other complications, and postoperative MRI demonstrated complete tumor removal in every case. All patients needed hormone substitution therapy and now function normally in daily life. There has been no occurrence of neuropsychological defects or pathological obesity. Up to now there have been no recurrences, but the follow-up period is quite short.

In conclusion, the endoscopic endonasal approach proved to be safe, effective, and very well tolerated. Closure of the dural and bony defect is still a major problem in our hands.