 So, today is about this extended or expanded endoscopic endonazole approach for supracellar tumors. The extension of endoscopic endonazole approach, which is used for pituitaries beyond the confines of cellar permits approach to approximately 2 centimeter of width of midline scullways and supracellar region and its foundation is laid by neuro navigation. So, to get into extended approach you have to use or you have to have a neuro navigation. So, basically the extended approach is a combination of a target that where we want to go and a cranial base approach that how we will reach there and the third is the nasal corridor that where do we start. So, these three things in supracellar tumors are the target is supracellar system, the cranial base approach is trans tubercular transplenum and the nasal corridor is trans spinoid. So, the whole name to this is endoscopic endonazole transpinoidal trans tubercular transplenum approach. Now, the basic principle of extended approach is to create a large single rectangular cavity within the spinoid sinus for progressive placement of your endoscope and instruments closer to the target so that you use the flashlight effect again that you can study the anatomine detail by taking the endoscope in and with magnification and the position remains same except that in supracellar region you should have a little bit of extension of the forehead chin forward line and these are the various steps and here the addition is the restriction of cisternal stage and the reconstruction which has to be planned before and. So, do not start any extended approach unless you have planned the reconstruction. Now, these are the nasal steps where definitely it has to be a binaustral, binaer 400 technique then lateralization of inferior terminates to produce more space then partial or complete resection of middle terminate, but only on one side only on right side. The other side middle terminate is out fractured and lateralized now the vascularized pedicle nasal septal flap has to be used for the reconstruction and then the CSF leaks have now gone to less than 5 percent with this and then you have to use a reverse flap also to cover the bare cartilage produced as a result of this flap. The posterior septectomy for bimanual maneuverability and a bilateral superior terminate you have to because you have to go into the spinoid and ethmoids so you have to do a bilateral superior terminate. Now this is the bilateral synodotomy and ethmoidectomy and this is the same technique as others. Now the cell is removed and now under the image guidance the tuberculum cellae and plenum synodal are thinned out with a diamond drill again same way like a cella and then the egg cell is removed with the deceptor and which exposes the superior intercavenous sinus. Now I will just show you the anatomy in this patient this was I think a rough case clap cyst which was extended approach was used for this because it was extending there in the supressor region and now you see this video and this is after opening the dura the cyst was incised and you can see clearly the chiasma and then I am going into that linear thermodynamics you can see the ACH this is the pituitary stalk and then this is the basilar artery on the side of the pituitary stalk and the cyst wall was excised completely and this is after and you can see the ACA's on the superior part of this. So this is just a view after the excision of the cyst and this is the third ventricle where we are getting into supra chiasma and these are the third nerves you can see on there and now this is the post-op of the same patient and now there is a because it is a video session so I have just small videos of all pathologies just to show you this is the pituitary and here we use the extended approach because supra cell extension and after doing this drilling there and cell apart now we are opening the dura and after opening the dura I opened it from all around and I wanted to remove it extra capsular a complete excision because this tumor was relatively firmish so after removing this the opening the dura all around and then I was trying to dissect it from the upper part and laterally we just now the extra capsular excision the same way I am trying to remove it but it was a large and could not so then we proceeded to partial removal in piecemeal and this is why I will tell you that why it was not and surprisingly the biopsy of this was hypophagitis this whole of that is hypophagitis so this is I think retrospectively think this is why you are not able to take it out extra capsular now here is the supracellar epidermal so here I will accept that it was a wrong decision to go by this approach in supracellar epidermal and I will tell you why although in the initial pages this is the again the septum this flap and reverse flap and which was just sutured and now I am opening the dura this is the intercavenous sign as you can see now I could remove this epidermoid whatever but after certain stage I was just not able to see the epidermoid because it was more supracellar more lateral and we could see the pituitary stalk so it was a partial removal and then I have to remove this epidermoid by keyhole approach in a second stage after 10 days and we could remove it completely so for epidermoid I am again very low to go by this approach because the basic concept we should consider that the epidermids they are in the system and they grow along the vessels and they never retain a exact midline position they will go here and there so complete removal is less likely with this approach now here is a man in your this is a young girl 22 years she had marriage after three months so maybe after consulting many people she just came to me that removed this by nose I don't want any cranial incision so this is her video that we raised again a flap legio septal flap and the reverse flap sorry this initial part is very now now you remove this vomer and now this is the drilling of the plenum and tuberculum cell and now this is the SIS being coagulated and after cutting this we could see the tumor is being removed gently you have to look and keep looking all around that nothing is adherent to this we just can't pull it once it is free then you can remove it yeah so gradually gradually at this part of the tumor was removed and now we can see the arachnoid there so it's best if you can keep extra arachnoid but the size was little larger it was not possible you can already see the hole in the arachnoid so it doesn't matter but when you put some petty or something that more blood should not go in and this is the reconstruction now this is a craniopharyngeoma which was a quite large and again the flap legio septal flap and then reverse flap and this is the mucoza which was coagulated there and again the same a vomer which was rostrum and vomer which was excised and this is the reverse flap see this is the part of the cartilage which is bare and then you have to suture it to the bare cartilage and now this is the plenum is being removed and now you see the exposure and this is the supia intercavenous sinus of the durage being opened below the sinus and above the sinus and then you coagulate it and cut it and then you hold the ends and coagulate and shrink that so that your exposure of dural opening is better now you already see the craniopharyngeoma there and now this arachnoid was there which was incised and contents evacuated so you have to bimanual means you cannot do this with the one hand and now these are the inferior hypofasial vessels so I will have to now this is the part above the chiasma removed and you see whole of the ACA complex and now is the infra chiasma part is going towards the third ventricle and now we already see some hole in the tumor which is going into the third ventricle and here see this is the attachment of the craniopharyngeoma so it has to be cut sharp so I used the scissors and then cut this attachment sharply and after this with help of the pad because it was large with the bimanual dissection and we could remove it completely so always in stages you just cannot pull it you just deliver it and then hold it further approximately and then gently again remove it and you have to move it look around everywhere that nothing is adhering to this but the part which is in the third ventricle is very easy to dissect it just comes very easily this is the basilar and its bifurcation and now you see the telakoroidia suprapinial recess and when you take the endoscopy and you can see whole of these a lot of things and now they through the foramen of Munro both the foramen Munro are seen and now this is again that same large piece of fat and then it should pulse it and then we put the graft and the flap again now this is again another craniopharyngeoma I think done about 15-20 days back only so again the dura is being opened above and below the sinus sinus being coagulated and if there is any bleeding this flow seal for extended you have to have flow seal with you you just cannot work without flow seal now the craniopharyngeoma again portion and half flow seal so now again piecemeal rumble hold the capsule look all around cut what about circuit we can use Q saw I have used Q saw also through nose and now you hold it and see all around cut it if you see that you can't see further then cut the portion which you can see and now once it's easily delivered now you see that's this capsule can be it was delivered very easily and this is the complete oxygen and this is the repair again the same way it has to be a multi-layered repair and this is the nasal septal flap thank you very much