This is a full-text article on Medscape! Registration is required, access is free! Enjoy! Evolution of Reconstructive Techniques Following Endoscopic Expanded Endonasal Approaches
Amin Kassam, M.D.; Ricardo L. Carrau, M.D.; Carl H. Snyderman, M.D.; Paul Gardner, M.D.; Arlan Mintz, M.Sc., M.D. Abstract and Introduction Abstract Harvey Cushing first popularized the transsphenoidal route to the sella turcica, and Jules Hardy subsequently refined it by adding the operating microscope. Over the ensuing decades, attempts at extending the application of this approach have been advanced by Edward Laws and others. With the evolution of endoscopic approaches, the natural expansion of their use to intradural lesions followed. For the expanded endonasal approach to become a viable option, the paramount concerns surrounding consistent reconstruction of the dura mater must be overcome. In this review the authors chronicle the evolution of the reconstruction technique they currently use after performing expanded endonasal approaches. They also report the use of a balloon stent to buttress the reconstruction and counter the effects of graft migration and cerebrospinal fluid fistula formation. The technique described in this report represents an important step forward in the reconstruction of defects resulting from expanded endonasal approaches. Introduction Effective and consistent reconstruction of the dura mater has been a major challenge that has significantly hindered the extension of transsphenoidal approaches to regions beyond the paranasal sinuses. For these approaches to be applied fully to the intracranial cavity and become viable options for intradural tumor removal, this issue must be resolved. Over the past decade, significant anatomical and instrumentation advances have been made, facilitating the exposure and resection of intradural lesions via a fully endoscopic expanded endonasal approach. In this report we describe our progressive experience with reconstruction of the defects that ensue from this approach. Our learning curve is described, from our initial reconstructive technique to the approach we currently use, and the lessons learned over the past 7 years are detailed.
The goals in reconstructing defects resulting from the expanded endonasal approach are identical to those of reconstruction after conventional external approaches; that is, to separate the cranial cavity completely from the sinonasal tract, obliterate the dead space, and preserve the neurovascular and ocular function.[5] The underlying principle of multilayered reconstruction to reestablish tissue barriers is also the same. |
