Posted April 16, 2011, 1:28 pm
Dear Dr. Baskaya,
Very nice case with an excellent result on postMRI and restoration of vision. Two questions: what were your consideration for a left-sided approach? And did you consider an endoscopic transnasal approach in this case? The sphenoid sinus is large, the chiasm is displaced posteriorly, the meningioma is above the pituitary gland and the stalk is also displaced posteriorly. The dural tail above the planum sphenoidale is not very large, so I think this would also have been a suitable approach.
Posted April 16, 2011, 10:42 pm
Dear Dr. Grotenhuis,
Thank you for your constructive comments and interest in this case. The reason I selected left-sided approach was due to the fact that the patient’s vision was worse on the right side. It is my personal bias that I’d prefer the side the patient has worse vision or visual changes unless other factors are important. Regarding endoscopic approach, you might be right that this tumor could be done via endoscopic approach. However, in my opinion, microsurgical approaches are not more invasive than endoscopic approaches if microsurgery is done appropriately. It may allow better resection especially resection of the involved dura. Also, in endoscopic approach we are relying on arachnoid plane which may not be present all the time in every meningioma case. And lastly, it may be still associated with higher CSF leak rate than the open approach at the present. With orbitotomy and wide arachnoid dissection, I don’t use any self-retaining retractors during these surgeries and I can show you flair MR images of these patients which will demonstrate no permanent signal changes in the brain. I think minimally invasive surgeries may not be maximally safe in every case. Again, this is my personal opinion and I cannot substantiate this by any data at this time. As you know, the other way around is correct as well. Again I thank you for you thoughtful comments.
Posted April 21, 2011, 6:40 pm
Very beautiful dissection. In your cases of planum / olfactory groove tumors, what is your technique for ant fossa floor repair (small breach vs large bony erosion/involvement)/ CSF leak prevention. Also, the optics of your microscope appear superior. do you mind sharing the name of the equipment your use? This would help in our cases as well.
Posted April 21, 2011, 8:17 pm
Dear Dr, Baskaya
Very nice video and instructive. Was the extradural cliniodectomy necessary ?
Posted April 24, 2011, 2:49 pm
Dear Drs. BP and van Overbeeke,
1) Extradural clinoidectomy: In tbc sella meningiomas (especially the symptomatic ones, most of cases (up t 70-80% according experiences of Drs. Al-Mefty and Yonekawa and probably 90% in my experience) meningioma extends into the optic canal. By drilling clinoid and unroofing the optic canal on the ipsilateral side, first you achieve early decompression which may allow better and less atrauamatic handling of the optic nerve during intradural dissection. Secondly, the part of the tumor extending into the optic canal is better visualized. Regarding extradural versus intradural drilling of the ACP, it is personal preference. I’d like to do extradural drilling if doable, so I retract the dura not the brain. I’d do intradural clinoidectomy in ophthalmic and sup. hypo. aneurysms.
2) If the bony defect is large I prepare a pedicled vascularized periosteum and lay over the defect. In small defect I’d try piece of muscle/fat.
3) It is Leica (2009) but I don’t know exact model. Video recording is high definition.
Thanks again for thoughtful comments.
Posted May 20, 2011, 12:41 pm
it is very nice surgery and dissection and good result.
i hope see more and good to do work shope for microscopical dissectin to upgrade the skills to our collegeus.
with my regards
Posted October 28, 2011, 5:38 pm
The surgery is fine and the dissection work is wonderfull.
It is good for academic activityes.
Posted December 8, 2011, 12:54 am
Beautiful video and technique. Nice work! Few questions, who makes the arachnoid knife that you were using, also the knife you used to cut the dura over optic nerve. Also what video editing program are you using. Did you consider exploring/decompressing the contralateral optic canal as well. Thank you for sharing your excellent examples of microsurgery techniques. Look forward to more.
Posted December 15, 2011, 2:13 am
Thanks for your comments. Diamond knife by Aesculap. I use round blade (FD 113D) and lancet blade (FD116D). The knife I used to cut the dura is beaver blade by V. Mueller. Microscope is Leica M525 OH4 with ICG. Video editing program we use is iMovie. Regarding exploring contralateral optic nerve, from contralateral approach you see all medial side of the optic nerve and optic canal as well as ophthalmic artery. This is also reason that some surgeons use contralateral approach to ophthalmic aneurysms.
Posted April 30, 2013, 10:23 am
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