Petrosal Approach for Giant Retrochiasmatic Craniopharyngioma: 2-Dimensional Operative Video

Microsurgical resection of craniopharyngiomas poses significant challenges, which are amplified with tumors in the retrochiasmatic location and larger size. Traditional pterional trans-sylvian, subfrontal translamia terminalis, or interhemispheric approaches provide narrow surgical corridors with obstructed visualization of the tumor by the prefixed chiasm and slit optic carotid window.1-5 The superior extension of the tumor compressing the hypothalamus and third ventricle are likewise inaccessible. Dissection through these approaches requires crossing and manipulation of the already compromised optic apparatus with surgical instruments. Finally, the basilar artery and its perforating branches are often adherent to the posterior aspect of the tumor, and are invisible. Endonasal endoscopic techniques have been utilized as a surgical approach that accesses the tumor without crossing the optic apparatus; however, these approaches have a significant risk of cerebrospinal fluid leakage and require dissection of the basilar artery and hypothalamus from long distances with lengthy instruments.6-9 Frequently, the surgeon achieves only partial removal. The petrosal approach is ideal for tumors in the retrochiasmatic location.10-13 Advantages include unhindered access to the retrochiasmatic space without crossing the optic nerve and chiasm. The angle of approach allows visualization superiorly to the hypothalamus. Additionally, the approach shortens the distance to the tumor, allowing for delicate bimanual dissection of the tumor, especially at the basilar artery and hypothalamic interfaces. This video demonstrates three cases of retrochiasmatic craniopharyngioma resection through the petrosal approach, highlighting these advantages to optimize patient outcome. The patients and guardians consented for the surgery, photography, and publication of the patient's image. Figures from Al-Mefty et al11 used with permission from the Journal of Neurosurgery Publishing Group. Additional figures republished from Al-Mefty et al.12 "The petrosal approach for the resection of retrochiasmatic craniopharyngiomas," Neurosurgery, 2008, volume 62, issue 5 Suppl 2 (ONS), ONS331-ONS336, by permission of the Congress of Neurological Surgeons.