The expanded endoscopic endonasal approach for primary and recurrent craniopharyngiomas

Craniopharyngiomas are dysembriogenetic, benign tumors responsible for a variety of aspects with unpredictable biological behavior, whose surgical management still represents a challenging matter in neurosurgery. Their treatment classically required different transcranial approaches, whereas the transsphenoidal route was reserved for pure intrasellar-infradiaphragmatic, preferably cystic lesions and/or patients already presenting with panhypopituitarism. Recently, with the progressive use of endoscopes in endonasal surgery, the interest for extended transsphenoidal approaches has been renewed. The expanded endoscopic endonasal transtuberculum and transplanum approaches have been proposed as alternative surgical route for removal of different types of suprasellar tumors including solid craniopharyngiomas, in patients with normal pituitary function and small sella. We present a detailed report of the technique we use for the endoscopic endonasal approach for the resection of primary and recurrent craniopharyngiomas, providing hints and anatomical keypoints throughout each step of the procedure for different types of these tumors, referring to our classification based on the infundibulum. The expanded endoscopic endonasal approach (EEA) for suprasellar craniopharyngiomas is a valid surgical option for the management of these lesions. It provides a wide and multi-angled, close-up view, of the surgical field allowing a safe dissection and removal of the tumor without any brain and/or optic apparatus retraction, even with a normal sized sella. On one hand, the EEA requires a thorough knowledge of ventral skull base anatomy, on the other it definitely facilitates intraoperative understanding of tumor inner features such as growth pattern, adhesion and invasion in regards to the surrounding vital structures.