case_images: PMC11799677_01
case_images: (a) Contrast-enhanced sagittaland (b) coronal magnetic resonance imaging (MRI) scans obtained before the endoscopic endonasal approach (EEA), showing the heterogeneously enhancing suprasellar mass with optic chiasma compression. The post-EEA MRI scan shows (c and d) gross total tumour resection with decompression of the optic apparatus and complete reconstruction of the skull base using a well-enhanced pedicled nasoseptal flap (arrow).
case_images: SNI-16-11-g001.jpg
case_images: PMC11799677_01_SNI-16-11-g001.jpg
case_images: F1
case_images: Neuroimaging revealed a suprasellar tumor (maximum diameter, 35 mm) compressing the optic chiasma, suggestive of craniopharyngioma [Figure 1a and b]. The tumor was grossly resected successfully by extending the EEA with high-flow cerebrospinal fluid (CSF) leaks, and the skull base was reconstructed in multiple layers with a fat graft, some dural stitches, hard reconstruction using autologous septal bone, and a pedicled nasoseptal flap [Figure 1c and d].
case_images: Preoperative lumbar drain placement (a) under fluoroscopic guidance (b) with the patient awake and in a sitting position.
case_images: SNI-16-11-g002.jpg
case_images: PMC11799677_01_SNI-16-11-g002.jpg
case_images: F2
case_images: Therefore, an LD was inserted preoperatively under fluoroscopic guidance, with the patient awake and sitting upright [Figure 2a and b].
case_images: The operating room arrangement (a) with two operating tables joined in parallel to accommodate the patient with super-super obesity, and (b) the four-pin head fixation system attached to one of the operating tables.
case_images: SNI-16-11-g003.jpg
case_images: PMC11799677_01_SNI-16-11-g003.jpg
case_images: F3
case_images: To resolve this issue, two operating tables were joined, with one table equipped with a four-pin head fixation system (Sugita Head Holder; Mizuho, Tokyo, Japan) [Figure 3a and b].
case_images: Operating room photographs showing (a and b) the use of the four-pin head fixation system to tilt the head to the left and rotate it to the right to allow a convenient position and direct good view through the nostrils for the surgeon standing on the right side of the patient looking cranially.
case_images: SNI-16-11-g004.jpg
case_images: PMC11799677_01_SNI-16-11-g004.jpg
case_images: F4
case_images: Under general anesthesia, the patient was placed supine on the operating tables, and his head was fixed with the head up and vertex down, facing the surgeon, providing more direct endoscopic access to the nares [Figure 4a and b].