J Neurol Surg B Skull Base 2024; 85(06): 596-605
DOI: 10.1055/s-0043-1775875
Original Article

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Bifrontal Transbasal Approach, Surgical Principles, and Illustrative Cases

Larissa Vilany 
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
2   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
,
Danielle D. Dang 
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
2   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
,
Edoardo Agosti 
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
2   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
3   Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
,
Pedro Plou 
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
2   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
4   Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
,
Luciano C. P. C. Leonel 
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
2   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
,
Stephen Graepel
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
,
Carlos D. Pinheiro-Neto 
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
2   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
5   Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
,
Giuseppe Lanzino 
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
2   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
,
Michael J. Link
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
2   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
,
Maria Peris-Celda 
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
2   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
5   Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
› Author Affiliations Funding This work was supported by the Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota. Joseph I and Barbara Ashkins Endowed Professorship in Surgery and the Radiology Department, Mayo Clinic, Rochester, Minnesota. Charles B and Ann L Johnson Endowed Professorship in Neurosurgery, Mayo Clinic, Rochester, Minnesota.
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Abstract

Introduction The transbasal approach traditionally uses a bicoronal scalp incision with bifrontal craniotomy to establish an extradural midline skull base working corridor. Depending on additional craniofacial osteotomies, this approach can expand its reach to the nasal cavity and paranasal sinuses and may be employed for the resection of particularly complex sinonasal and midline skull base tumors. Given its discrepancy in nomenclature and differences in interoperator technique, we propose a practical, operatively oriented guide for trainees performing this approach.

Methods Three formalin-fixed, latex-injected specimens were dissected under microscopic magnification and endoscopic-assisted visualization. Stepwise dissections of the transcranial-transbasal approach with common modifications were performed, documented with three-dimensional photography, and supplemented with representative case applications.

Results The traditional transbasal approach via bifrontal craniotomy affords wide extradural access to the anterior cranial fossa and central skull base. The addition of craniofacial osteotomies further expands access into the sinonasal cavities, clivus, and craniocervical junction. Key steps described include patient positioning, bicoronal skin incision, pericranial graft harvest, bifrontal craniotomy, orbital rim osteotomy, sphenoidotomy, bilateral ethmoidectomies, and microsurgical dissection of the sellar region. Basal superior sagittal sinus ligation and durotomy allow for intradural exposure. Reconstruction techniques are also discussed.

Conclusion While the transbasal approach is rich with historical descriptions, illustrations, and modifications, its stepwise performance may be relatively unknown and unclear to younger generations of trainees. We present a comprehensive guide to optimize familiarity with the transbasal approach and its indications in the surgical anatomy laboratory, mastery of the relevant microsurgical anatomy, and simultaneous preparation for learning and participation in the operating room.

Keywords

transbasal - bifrontal - central skull base - anterior cranial fossa - tumor - step-by-step - trainee


Publication History

Received: 19 June 2023

Accepted: 12 September 2023

Article published online:
09 October 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

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