Surgical limits in transnasal approach to opticocarotid region and planum sphenoidale: an anatomic cadaveric study.

BACKGROUND The significance of medial and lateral opticocarotid recesses and the planum sphenoidale region in skull base pathologies for the transsphenoidal-transplanum approach were evaluated. METHODS The sphenoid bone block samples were extracted from adult cadavers. Dissections and measurements in the opticocarotid and planum sphenoidale regions were performed in 29 samples using a surgical microscope. For histologic evaluation, oblique sections through the bilateral opticocarotid regions were obtained and examined in eight samples. RESULTS Optic, carotid prominences, and medial and lateral opticocarotid recesses can be identified as lateral markers intraoperatively to the extent of the exposure. The lateral opticocarotid recess was observed to be prominent in all samples. In all samples, the groove formed by optic and carotid prominences between the medial and lateral opticocarotid recesses was seen. This groove was designated the inter-recess sulcus. In the transsphenoidal-transplanum approach, the area needed for a reliable bone resection was measured as a mean of 237.32 ± 30.96 mm(2). The mean angle between optic nerves was 115.41 ± 18.39 degrees. The mean anteroposterior length of the planum sphenoidale was 14.84 ± 1.52 mm. In histologic sections, collagenous ligaments between the anterior part of cavernous sinus and the adventitia layer of internal carotid artery were more frequent and regular than the inferior part of optic nerve. CONCLUSIONS The lateral opticocarotid recess is a reliable and persistent indicator for extended transsphenoidal surgery. To approach the opticocarotid region near the internal carotid artery and optic nerve, a careful dissection is needed to minimize surgical injuries to the optic nerve and carotid artery. Other factors determining a reliable bone resection are the anteroposterior length of the planum sphenoidale and the distance and width of the angle between optic nerves. Attention should be given to individual anatomic variations of the region when planning and performing transsphenoidal-transplanum surgery.

[1]  S. Yılmazlar,et al.  Comparison of lateral and superior walls of the pituitary fossa with clinical emphasis on pituitary adenoma extension: cadaveric-anatomic study , 2007, Neurosurgical Review.

[2]  B. Hakyemez,et al.  Clinical importance of the basal cavernous sinuses and cavernous carotid arteries relative to the pituitary gland and macroadenomas: quantitative analysis of the complete anatomy. , 2008, Surgical neurology.

[3]  M. Taneda,et al.  Extended transsphenoidal approach with submucosal posterior ethmoidectomy for parasellar tumors. Technical note. , 2001, Journal of neurosurgery.

[4]  F. Esposito,et al.  EXTENDED ENDOSCOPIC ENDONASAL TRANSSPHENOIDAL APPROACH TO THE SUPRASELLAR AREA: ANATOMIC CONSIDERATIONS—PART 1 , 2007, Neurosurgery.

[5]  Amin Kassam,et al.  Endoneurosurgical hemostasis techniques: lessons learned from 400 cases. , 2005, Neurosurgical focus.

[6]  T. Schwartz,et al.  Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. , 2007, Journal of neurosurgery.

[7]  Mario Zuccarello,et al.  Expanding the boundaries of the transsphenoidal approach: A microanatomic study , 2001, Clinical anatomy.

[8]  O. Jesus.  The clinoidal space: Anatomical review and surgical implications , 2005, Acta Neurochirurgica.

[9]  S. Elwany,et al.  Endoscopic anatomy of the sphenoid sinus , 1999, The Journal of Laryngology & Otology.

[10]  A. Rhoton,et al.  The sellar region. , 2002, Neurosurgery.

[11]  R. Carrau,et al.  Endoscopic endonasal transsphenoidal surgery: experience with 50 patients. , 1996, Journal of neurosurgery.

[12]  A. Ragin,et al.  Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. , 1997, Neurosurgery.

[13]  W. Couldwell,et al.  Variations on the Standard Transsphenoidal Approach to the Sellar Region, with Emphasis on the Extended Approaches and Parasellar Approaches: Surgical Experience in 105 Cases , 2004, Neurosurgery.

[14]  E. Laws.  Transsphenoidal microsurgery in the management of craniopharyngioma. , 1980, Journal of neurosurgery.

[15]  J. Doppman,et al.  Selective excision of adenomas originating in or extending into the pituitary stalk with preservation of pituitary function. , 1997, Journal of neurosurgery.

[16]  A. Elhan,et al.  Endoscopic anatomy of sphenoid sinus for pituitary surgery , 2008, Clinical anatomy.

[17]  G. Jallo,et al.  Tuberculum Sellae Meningiomas: Microsurgical Anatomy and Surgical Technique , 2002, Neurosurgery.

[18]  A. Ringer,et al.  Transradial Cerebral Angiography: An Alternative Route , 2002, Neurosurgery.

[19]  E. Laws.  Vascular Complications of Transsphenoidal Surgery , 1999, Pituitary.

[20]  Paolo Cappabianca,et al.  Endoscopic endonasal transsphenoidal surgery. , 2004 .

[21]  A L Rhoton,et al.  Microsurgical anatomy of the sellar region. , 1975, Journal of neurosurgery.

[22]  Felice Esposito,et al.  AVOIDANCE OF CAROTID ARTERY INJURIES IN TRANSSPHENOIDAL SURGERY WITH THE DOPPLER PROBE AND MICRO‐HOOK BLADES , 2007, Neurosurgery.

[23]  K. Fujii,et al.  Neurovascular relationships of the sphenoid sinus. A microsurgical study. , 1979, Journal of neurosurgery.

[24]  H. Kocaeli,et al.  Medial portion of the cavernous sinus: Quantitative analysis of the medial wall , 2005, Clinical anatomy.

[25]  Jiadong Wang,et al.  Transsphenoidal Optic Nerve Decompression: An Endoscopic Anatomic Study , 2008, The Journal of craniofacial surgery.

[26]  Fred Gentili,et al.  EXPANDED ENDOSCOPIC ENDONASAL APPROACH FOR ANTERIOR CRANIAL BASE AND SUPRASELLAR LESIONS: INDICATIONS AND LIMITATIONS , 2009, Neurosurgery.

[27]  W. Hassler,et al.  Neurosurgical management of orbital inflammations and infections , 2004, Acta Neurochirurgica.

[28]  P. Gardner,et al.  Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. , 2005, Neurosurgical focus.

[29]  F. Esposito,et al.  EXTENDED ENDOSCOPIC TRANSSPHENOIDAL APPROACH FOR TUBERCULUM SELLAE MENINGIOMAS , 2007, Neurosurgery.