Endoscope-assisted supraorbital approach for excision of tuberculum sella meningioma: Technical nuances

Tuberculum sellae meningiomas (TSMs) are benign dural-based lesions of the anterior cranial fossa, which mainly present with impaired visual acuity/field deficits secondary to compression of the optic apparatus. Surgical management is recommended as the optimal strategy for large compressive TSMs, with goals of safe maximal resection, optic nerve decompression, and potential vision restoration. The philosophy of adapting keyhole approaches for such resections is commonly highlighted; however, it comes with notable criticism of encountering major blind spots during surgical resection and limited anatomical exposure. Adding angled endoscopes enhances the expanded panoramic view of the skull base and provides a synergistic modality to microsurgery for maximizing total resection and navigating the blind spots. This video case presentation aims to highlight the technical nuances of endoscope-assisted microscopic supraorbital craniotomy for TSM resection invading bilateral optic canals in a 66-year-old female presenting with progressive right eye vision loss (OD Hand motion). The video emphasizes traditional skull-base surgical principles of TSM resection through the optics of a keyhole approach augmented by endoscopic tumor removal. Gross total resection was achieved, the patient’s vision improved to 20/25, and she was discharged home on postoperative day 2. The endoscope-assisted supraorbital craniotomy offers a safe surgical corridor for TSM, using a limited craniotomy with minimal brain retraction in appropriately selected individuals, particularly with larger tumors with greater lateral extension and above the planum.