Chapter 17 - The Endoscopic Endonasal Approach for Craniopharyngiomas

Abstract

Craniopharyngiomas are benign tumors that arise from Rathke’s pouch and occur anywhere along the ventral midline from the nasopharynx to the hypothalamus. The tumors are often relentlessly adherent to critical neurovascular structures and therefore pose a significant surgical challenge. Craniopharyngiomas can be classified into four main groups based on their anatomic location relative to the infundibulum: type I, preinfundibular; type II, transinfundibular; type III, retroinfundibular; and type IV, isolated third ventricular and/or optic recess. While historically craniopharyngiomas have been removed by open transcranial microsurgical approaches, over the past two decades, the expanded endoscopic endonasal approach (EEA) has gained significant popularity for all except type IV tumors. It provides excellent visualization of the pituitary gland and stalk, as well as critical neurovascular structures resulting in increased extent of resection with improved visual outcomes and reduced postoperative endocrinopathy. Nevertheless, the extended transtubercular transplanum EEA has a steep learning curve and requires a multidisciplinary surgical team with a wide array of specialized instrumentation. In this chapter we review the evolution of the expanded EEA for resection of craniopharyngioma and provide a detailed description of our surgical technique including specific nuances for each tumor sub-type. We also describe several of the seminal reports regarding endoscopic resection of craniopharyngiomas and discuss key outcome data and complications.