title: Endoscopic transnasal skull base surgery: pushing the boundaries.
abstract: The endoscopic endonasal approach (EEA) has significantly evolved since its initial uses in pituitary and sinonasal surgery. The literature is filled with reports and case series demonstrating efficacy and advantages for the entire ventral skull base. With competence in 'minimally invasive' parasellar approaches, larger and more complex approaches were developed to utilize the endonasal corridor to create maximally invasive endoscopic skull base procedures. The challenges of these more complex endoscopic procedures include a long learning curve and navigating in a narrow corridor; reconstruction of defects presented new challenges and early experience revealed a significantly higher risk of cerebrospinal fluid leak. Despite these challenges, there are many benefits to the EEA including avoidance of brain and neurovascular retraction, improved visualization, a direct corridor onto many tumors and the two-surgeon approach. Most importantly, the EEA provides a midline corridor to directly access tumors, which displace critical neurovascular structures laterally, giving it an inherent advantage of minimizing any manipulation of these structures and thus decreasing their potential injury.
authors.affiliation: Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Nathan T
authors.initials: NT
authors.lastname: Zwagerman
authors.affiliation: Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Georgios
authors.initials: G
authors.lastname: Zenonos
authors.affiliation: Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Stefan
authors.initials: S
authors.lastname: Lieber
authors.affiliation: Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Wei-Hsin
authors.initials: WH
authors.lastname: Wang
authors.affiliation: Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.|UPMC Center for Cranial Base Surgery, 200 Lothrop Street, PUH B-400, Pittsburgh, PA, 15213, USA.
authors.forename: Eric W
authors.initials: EW
authors.lastname: Wang
authors.affiliation: Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.|UPMC Center for Cranial Base Surgery, 200 Lothrop Street, PUH B-400, Pittsburgh, PA, 15213, USA.
authors.forename: Juan C
authors.initials: JC
authors.lastname: Fernandez-Miranda
authors.affiliation: Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.|Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.|UPMC Center for Cranial Base Surgery, 200 Lothrop Street, PUH B-400, Pittsburgh, PA, 15213, USA.
authors.forename: Carl H
authors.initials: CH
authors.lastname: Snyderman
authors.affiliation: Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. gardpa@upmc.edu.|UPMC Center for Cranial Base Surgery, 200 Lothrop Street, PUH B-400, Pittsburgh, PA, 15213, USA. gardpa@upmc.edu.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Gardner
mesh_terms: D006801:Humans; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D038361:Neuronavigation / Q000379:methods*; D019635:Neurosurgical Procedures / Q000379:methods*; D019291:Skull Base / Q000601:surgery*; D019292:Skull Base Neoplasms / Q000601:surgery
keywords: Endoscopic endonasal approach; Endoscopic endonasal surgery; Skull base; Transclival; Transcribriform; Transpterygoid