Endoscopic Brain Surgery

Traditionally, patients harboring lesions extending beyond the pituitary gland region and into the skull base are not candidates for transphenoidal approaches and are treated with open skull base cranial approaches.  However, at Florida Hospital our skull base surgeons can often offer a less invasive alternative called the Expanded Endonasal Approach (EEA).  The EEA is an innovative surgical technique developed to remove brain tumors and lesions—some as large as softballs—all through the nose. A multidisciplinary team of neurosurgeons and otolaryngologists at Florida Hospital has refined this technique over the past decade, and are among the most experienced in the nation. 

An alternative to many open skull base approaches, the expanded endonasal approach allows surgeons to reach various lesions of the skull base extending from the front of the brain all the way down to the top of spine, including the anterior cranial fossa, infratemporal fossa, middle cranial fossa, clivus, cavernous sinus, posterior fossa, and craniocervical junction.  The approach also allows surgeons to go deeper into the brain to treat lesions extending beyond the pituitary gland including giant pituitary adenomas, craniopharyngiomas, chordomas, meningiomas, cavernous sinus tumors, esthesioneuroblastomas, and others.  By creating step-wise modular windows to communicate the various compartments of the nasal passageways, the EEA allows the skull base surgeon to manage various disorders of the skull base using the same surgical principles of safety applied to open approaches, but without the large incisions, long durations of anesthesia, cosmetic disfigurement, and prolonged recoveries seen with open skull base surgery.  Recent advancements in image-guided computer based GPS-like navigation systems and the creation of new devices to control bleeding and dissect through the long angled channels to reach these areas has allowed our skull base team to offer this option to many of our patients.  Advancements in the repair of defects created at the base of the skull during EEA surgery have also dramatically improved the risks of infection and spinal fluid leak over the past five years.

Once the tumor is fully exposed and the pertinent anatomy adjacent to the tumor is identified, highly crafted instruments are used alongside the endoscope for dissection and the tumor is removed. As the tumor is being removed, the endoscope is advanced into the cavity and angled lenses are used to look at all the margins to ensure that the entire tumor is excised.  The endoscope also allows the surgeons to visualize any important structures to which some small remnants of tumor may still be attached.  By visualizing these structures with the endoscope, small amounts of tumor that may otherwise be left behind due to risk of injury to adjacent nerves or blood vessels can be easily removed allowing for a more complete resection and lower likelihood of tumor recurrence. Recently, our team has also employed new 3D endoscope technologies to better visualize the relationship of critical blood vessels, nerves and other structures of the skull base relative to the lesions of interest allowing us to better navigate and remove tumors adherent to these structures with less risk of injury. Once the tumor is completely removed, various biologically compatible glues and patches are used to reconstruct the window that was made to gain access to the tumor.  In some cases, special nasomucosal flaps are used to minimize the risk of spinal fluid leakage when large defects are created and they are kept in place with small temporary balloons placed in the back of the nose.  This creates a barrier between the exposed brain and the nose.  In most cases, no nasal packing is used and patients can breathe freely through their nose immediately after surgery. When nasal balloons are placed, they are painlessly removed in the surgeon’s office 3-10 days after surgery. 

The EEA procedure often lasts 2-7 hours and patients remain in the hospital on average from 1 to 3 days.  Most patients can resume their regular activities within a few weeks and no sutures need to be removed.  At Florida Hospital, these surgeries are performed in dedicated, state-of-the-art suites that incorporate sophisticated imaging technology.

To learn more about our endoscopic brain surgery treatments, contact us.