Next, this is a great discussion about a fascinating topic. Next speaker is Dr. El Azhari from Morocco. He is going to talk about surgery of the celloturcica. Dr. El Azhari. As you see, my team, my hospital and my university, I am from Casablanca, from Morocco. Casablanca is here, the sunset of the beach of Casablanca and the city of Casablanca. Why this topic? Because we have a centre in Casablanca with the education of Moroccan and African residents, so the distribution of all neurosurgeons we educate is all over the country of Morocco and even in Africa, as you see here from Burkina Faso, Mali, Togo, Niger, Guinea, Congo, Guinea, Bissau and Benin. So, our education, we try to export our philosophy to all this centre which where those neurosurgeons are working. Why this topic? Because it's a small area and in this small area, the tumours grow expensively with the remarkable variation, not only in the direction of expansion but all over. So, the difficulty is the relationship with adjacent structure. It needs anatomical knowledge to know exactly the anatomic vessels and perforators. In this small area, we have to expect every element, if it is a small area, optic, nerves, pituitary stack, hypothalamus and all vessels and especially the hypothalamus, arteries which arise from carotid and which present a danger in surgery. So, when we have this tumour like this case, we have to imagine all the anatomy we have to find here. So, we have to know every element we have to respect and the anatomy, the good anatomy can be very useful because we have to imagine all anatomical situation. It depends on the pathology. For example, if it's craniopharyngioma or meningioma or adenoma, we have to see the horizontal chiasma and sometimes, not all the time with the adenoma, we have to see this view. In reality, we can see the anatomy like this and to look for all arteries and recurrent arteries are choroid and arterial communicant posterior, as you see here, and to see it. But if there is a tumour, all this anatomy is modified. But sometimes, we have some unexpected situation, as you see here. In this case, there is carotid and seven arteries from the carotid. Where is the carotid and the posterior communicant artery? It's difficult to say. The relationship with vessels are modified. It is important to preserve the pathways vessels and because the adherence with the polygons are rare. For the success outcome, different factor, indication for surgery, the timing, the choice of the approach, the micro-surgical tactic and especially the plan to deal with complication and the inspected findings. The strategy is to imagine the route through the school base and to dissect the system which is separated by trabeculation and the system are modified by tumour. But we have to keep in mind the anatomy of the system. In those tumours, different anatomical situations should be considered. The approach depends on the neurosurgeon and the conviction to total removal. The MRI is very useful to know the limit of the operation. As we discussed before in the communication of vestibular neuroma, when we start and when we finish, it's difficult to say, like in this case, for example. The subarachnoid space can provide natural pathways and preserve all important brain structure. Some systems are easily accessible for observation while the other can be partially explored at operation and the drainage is very important to obtain brain relaxation. The section of the arachnoid layer is important to support the vascular nervous element and to debulk the tumour after. The principle approach we did in our department is subfrontal and frontopterional approach. Some technical constraints are when the tumour is intracellular between the nerves, for example meningioma, or lateral extension enter optical carotid in adenoma, or sometimes enter carotid posterior tentorial or high extension in V3. The surgery of thalaturtica, what lessons for the education of our neurosurgeon in our country and in Africa? We teach them that we have some steps to cross. Step one is green, it's easy, it's skin, bone, dura, arachnoid. But step two, we have to explore the tumour to understand the configuration and the dissection which will be careful to preserve nerves, arteries, veins, and tumour revolve. And the step three is the red zone and it occurs frequently complications when in step two it's not respected. For example here, we make video for resident and to show them how it's very important to go slowly in the step one and to dissect element by element and to go to understand the step two. The step two is to tumour explore, to understand the configuration and to preserve nerves and arteries as you see here in this case of cyst of RATC. And in this case the tumour in this step is really easy because there is no adherence and no vessels crossing this. So the removal of the tumour should be carefully and going piece by piece. In the third step, it's very important because sometimes we have to dissect the vessels in order to see the lamina terminalis. For example, here in this case, it's craniopharyngioma and it was very important to open the lamina terminalis and to dissect the arteries which there was a big adherence to optic nerves. And we never tracked the tumour as you see here. In this case, according to this case, we see the hypofasal arteries coming from the carotid which the damage could make a hole in carotid and be very difficult to control. And as you see here, there was a piece of adenoma adherence to vessels here and the dissection piece by piece and as you see here, it's attached to the hypofasal artery. At the end, we cut it and we dissect it and you see here there's a small bleeding from the capsular artery. But at the end, we can see that the hypofasal artery was respected as you see here in this video. Some tumours are soft and others are rigid and it depends which area is and the dissection carefully is very important to do and the bipolar should be used with precaution to shrink the tumour capsula. In these tumours, different anatomical situations. For example, in craniopharyngioma, as you see here, we have to have this plan and as you see in the first video, the opening of lamina terminalis was very important to remove the cyst and it's very important to respect the vessels of the wellies and to continue to remove piece by piece and at the end, the total removal as you see here in this case with historical case and post-operative CT scan. In adenoma, it's this view, it's very important to have in the mind and as you see here in this video, the adenoma is always fibrosis with capsula, with thick capsula and sometimes we have to go between the carotid and optic nerve as you see here and to dissect and to cut sharply in order to not have a problem with the vessels. For the meningioma, it's different so it's very nice tumour because of course it's bleeding but there is no, all the time there is no adherence and for the meningioma of the cella, we can dissect and have at the end as you see here in this video, the total removal and to coagulate the insertion as you see here, it should be Simpson 2 but at the end, it's a very nice view with as you see here, the pituitary stalk respected. For the pathways glioma, it's rare, we have some case in our series, it's different to find the anatomy like in meningioma or in craniopharyngioma but all the time, we have to debulk and to respect only the vessels and to try to don't have the complication as you see here in this case which it was huge. We remove all the anterior part but the posterior part which is going to the posterior area of the brain is left on the place because it was very, very deep. In total, it's a small region but its surgery is different as you see here in the comparison between meningioma, craniopharyngioma, adenoma and glioma. It's the same region but the surgery is different. So, it's important to know that every pathology, we have to have its own technique. Last five years, we operate 26 meningioma with the total resection 20 cases, 80 adenoma with 15 patients operated by subfrontal approach and 25 craniopharyngioma which was pediatric series with the total removal into 22 cases and 8 glioma. During this period, we operate 48 aneurysms. The surgery, why I make this slide? Because this surgery is linked to the sela turcica as we discussed in one of presentation in this morning that this surgery is linked to vascular surgery. So, in the education, the resident should have very nice education of vascular surgery in order to perform the surgery of sela turcica. Neurosurgeon should have education for vascular surgery because it provides self-confidence of the sela turcica and it could manage the risk of artery injury. In conclusion, this surgery should never become vascular surgery. It's very important because if there is vascular surgery, it's a disaster. The necessity to be able to manage all vascular injury, vascular surgery education. And I will just invite you to Morocco for the next 12 pan-Arab neurosurgery which we had in Marrakech in next October. Thank you very much. Thank you so much for that wonderful presentation. Any questions? Any questions at all? Okay. All right. Well, we'll keep... Dr. El-Mefti? What's that? Oh. All the beautiful tips how to deal with these difficult cases. And whoever want to deal with the tumor has to be a vascular surgeon too. Thank you.

Dr. El Azhari

surgery of the celloturcica

neurosurgery

anatomy

vascular surgery