Surgery performed by Dr. Rafael Martinez-Perez
The entire surgery can be viewed in the app SurgSchool, where he Dr. Rafael Martinez-Perez (Geisinger, Pennsylvania, United States) shows in detail the resection of a petroclival chondrosarcoma via an extended endoscopic endonasal approach. This is a complex skull base lesion that requires advanced mastery of the transclival corridor and the medial cavernous compartment.
Skull base chondrosarcoma: surgical considerations
El petroclival chondrosarcoma It is a tumor of cartilaginous origin that typically develops in the petroclival synchondrosis, with lateral growth relative to the midline. Unlike chordoma, its expansion pattern dictates the surgical strategy, frequently requiring extended approaches into the cavernous sinus.
The endoscopic endonasal approach (EEA) allows direct access to the clivus and parasellar region without the need for extensive craniotomies, reducing the morbidity associated with open approaches. In this context, Dr. Rafael Martínez-Pérez proposes a combined approach. transcavernous-transclival, key to achieving lateral extension of the tumor.
Preoperative planning and anatomical orientation
Preoperative evaluation using MRI and CT is essential to define:
- Relationship with the internal carotid artery (ICA)
- Extension to the medial cavernous sinus
- Invasion of the clivus and petroclival structures
- Cranial nerve involvement
Chondrosarcoma often presents with eccentric lateral growth, which necessitates anticipating the need to extend the approach beyond the midline.
During the initial phase, Dr. Rafael Martinez-Perez performs a wide sphenoidotomy, exposing key landmarks such as the clivus, carotid prominences, and sphenoidal planum.
Surgical technique: transcavernous-transclival approach
Access to the clivus is achieved through progressive drilling, creating a direct corridor to the tumor. This step is critical for obtaining adequate and safe exposure.
The transcavernous phase is especially relevant in petroclival chondrosarcoma. Dr. Rafael Martinez-Perez carefully dissects the medial cavernous sinus, identifying the internal carotid artery and preserving the neurovascular structures.
Working in subperiosteal planes and using blunt dissection minimize the risk of vascular injury. Controlled mobilization of the internal carotid artery widens the lateral access, facilitating resection of the tumor component beyond the midline.
The resection is carried out progressively, combining aspiration, microsurgical dissection and constant monitoring of anatomical boundaries.
Management of the cavernous sinus and hemostatic control
The transcavernous approach involves navigating a high-risk vascular environment. Venous bleeding from the cavernous sinus can compromise surgical visibility if not properly controlled.
Dr. Rafael Martinez-Perez uses local hemostasis techniques with hemostatic agents and directed pressure, avoiding aggressive maneuvers. The use of intraoperative Doppler and navigation allows for constant confirmation of the internal carotid artery's location.
Tumor resection in petroclival chondrosarcoma
The goal is a maximum safe resectionTaking into account the proximity to critical structures. In chondrosarcoma, lateral extension necessitates extended approaches such as the transcavernous approach.
Angled optics play a fundamental role, allowing for the inspection of recesses and residual cavities. Dr. Rafael Martinez-Perez demonstrates how advanced endoscopy improves visual control in hard-to-reach areas.
Skull base reconstruction
Following resection, reconstruction is essential to prevent CSF leaks. A multilayer technique is used, which may include a vascularized nasoseptal flap, autologous grafts, and synthetic materials.
A tight seal is especially important in large clival defects, as in this case.
Results and key technical points
The transcavernous-transclival endoscopic approach represents an effective strategy for the treatment of petroclival chondrosarcoma, allowing:
- Direct access to the clivus and parasellar region
- Control of the lateral tumor component
- Reduction in morbidity compared to open approaches
Dr. Rafael Martinez-Perez's experience highlights the importance of continuous anatomical orientation, the use of intraoperative technology, and expertise in advanced skull base surgery.
Current role of the endonasal approach in chondrosarcomas
Extended endoscopic approaches have significantly expanded the treatment options for petroclival tumors. In chondrosarcoma, where complete resection may be limited by invasion of critical structures, the balance between radicality and functional preservation is key.
The technique shown by Dr. Rafael Martinez-Perez in SurgSchool It exemplifies the current state of advanced endonasal skull base surgery.
