Endoscopic Subperichondral Transseptal (STRAS) Access for Transsphenoidal Transtuberculum Approches to the Skull Base: Surgical Technique and Results in a Prospective Series

Purpose: This article aims to report the surgical technique of the endoscopic subperichondral transseptal (STRAS) access for the transsphenoidal transtuberculum approach for suprasellar lesions, and the results of a series of patients undergoing this approach.

Methods: This is a single-center prospective study including all patients undergoing sellar or suprasellar lesion resection through the STRAS-transtuberculum approach from 2021 to 2023 by a multidisciplinary surgical team (ENT and neurosurgeon). Demographic data, tumor type, complication rate and pre- and postoperative visual, endocrine and tumor status were prospectively analyzed.

Results: The technique used a unilateral right intercolumellar incision, with further bilateral subperichondral dissection of both septal and nasal cavity floor mucosa, a full anterior sphnoidotomy and a standard transsellar-transtuberculum approach. Four-hand technique was used for intradural dissection, and reconstruction was performed with fat graft and repositioning of both sphenoidal mucosa maintained with silicone arches along the septum.

A total of 20 patients were included in this series (16 craniopharyngiomas, 2 meningiomas, and 2 pituitary adenomas). All patients with potential indication of transtuberculum approach were operated with the STRAS access. Full visualization of the sphenoidal landmarks and proper surgical mobility without instruments conflicts were possible in all cases, without any need of turbinate resection, ethmoidectomy or septal resection. No patient died or had neurological post-operative deficit due to vascular or brain injury. Gross-total resection was achieved for 14 patients (70%) and median volume of residual tumor was 0.38 cm³. Postoperative tumoral residues were intentionally left for functional purpose in 5 patients out of the 6 patients with uncomplete resection. In patients with preoperative visual deficit, 70% had postoperative improvement. One patient had postoperative visual deterioration. Post-operative CSF (cerebrospinal fluid) leakage occurred in 3 patients (15%), with one patient (5%) needing a new surgical procedure and two patients (10%) only medical measures (repeated lumbar punctures). Nasal complication rate was very low, with no anosmia (1 patient suffered for transient hyposmia), no septal perforation and no epistaxis. At 3 months, no patient suffered from alteration of quality of life due to nasal issues.

Conclusion: The STRAS approach is an elegant approach to the sphenoid sinus that enables a good exposure of the intrasphenoidal anatomical landmarks and a good access to the sellar and suprasellar intracranial compartments with a maximal preservation of the nasal mucosa. This approach allows a midline intracranial work with great comfort and safety for the surgeon using a two-hand or a four-hand technique. The integrity of both sphenoidal and septal mucosa allows easier reconstruction with higher mechanical resistance and a quick healing of the nasal cavities with very few issues of nasal quality of life alteration.

Publication History

Article published online:
07 February 2025