There are several kinds of craniopharyngioma that can be managed via two variations of the endoscopic endonasal transsphenoidal procedure: the “standard” approach to the sellar region and the “extended” approach to the suprasellar area. These two variations have different indications.
The indications for the standard approach were postulated more than 50 years ago, in the early 1960s, when Guiot and Derome [ 1 ] identifi ed the possibilities of transsphenoidal surgery for craniopharyngiomas retaining suitable for this approach infradiaphragmatic lesions, with enlarged sella that preferably already caused pan hypopituitarism. Still today these guidelines are absolutely valid for both the microsurgical and endoscopic transsphenoidal approaches. The standard transsphenoidal route for infradiaphrag matic craniopharyngiomas provides the advantage of accessing the tumor immediately after dural opening, without entering the subarachnoid space.
Later on, during the 1980s, some authors expanded the classic indications of transsphenoi dal microscopic approach, adopting this route for the management of craniopharyngiomas with extension above the diaphragma sellae, i.e., with an involvement of the subarachnoid space.
Accordingly, in order to allow the proper handling of surgical instruments and the adequate exposure of the tumor, the refi nement of bone and dural opening beyond the limits of the sella, i.e., over the tuberculum sellae and the posterior portion of the planum sphenoidale, was described. A new variation of the transsphenoidal pathway, i.e., the so-called “extended” transsphenoidal approach, was though defi ned [ 2 ].
During more recent years, there have been a worldwide diffusion and acceptance of the endoscope in transsphenoidal approaches. The panoramic and wider view offered by the endoscope increased the versatility of the transsphenoidal pathway, thus permitting the removal even of supradiaphragmatic lesions, including cranio-pharyngiomas [ 3 – 6 ]. The use of the endoscope through this route provides an access to the suprasellar supradiaphragmatic area, regardless of the sellar size (even a not enlarged sella).
It was the group of Pittsburgh, initially Jho [ 7 ] and later Kassam and Carrau [ 8 ], that defi nedand popularized the use of the endoscope in the so called “extended” endoscopic transsphenoidal approaches for the removal of suprasellar lesions.
