 Initially we thought nasal cavity is the most worst part in the body, it can take nasal cavity even rectum is more sterile than the nasal cavity. So that is why we are not preferring to enter through the nasal cavity. Now because of technology antibiotics and all we are overcoming through that. So skull base is a no man zone, so anybody can enter or anybody can you can come out from superior to inferior or from inferior to superior. Now what we are doing is from inferior to superior we are going through nasal cavity. Say from superior to inferior when you are coming when you are dissecting the tumor and you are dissecting the arachnoid membrane from the tumor. From here the arachnoid gets separated as you dissect the tumor, so you are not touching the arachnoid. Once you breach the arachnoid then you will have a problem. So to prevent this problem you have to prevent not to touch the arachnoid. Sometimes there is no other go you have to go otherwise your surgery will be incomplete. This came with a seizure and also a loss of smelling, this is the case of plenum spanodal just have a look, say that is the one what you have previous this is all edited in a short period I have to show in a few minutes now that is fine. Now we can see the size of the tumor which is arising from the plenum spanodal which is going towards the cellar part you can see the enhancement this is the tuberculum cellar this is the plenum spanodal which is sinking towards the cellar. So now I am seeing this just entering into that to know where I am. So what you are seeing is this is the coyama when you are selecting you have to select highly when we are in the initial period not to chase all these things otherwise trouble will be more and you may be fed up of doing this surgery. Now why the surgery has become easy now those time to begin with only zero endoscope we are using there was no sheath in it. So whenever it is what is that blurred with the blood you have to remove again clean it put in now because of this advent of sheath. So you can eradicate the blurring area with saline continuously and you can do continuously surgery no need of removing. See that is the coyama see now already I have edited and all I am drilling the area see plenum spanodal area see that is the base of the tumor that is totally coagulated and all enlarging it so that is the tumor what you are seeing it in sizing along with the dura. This is decompression you can do it because when you know major vessels are not there you can use QSA also preoperatively if you want to do angiogram where is the ACA and where is the frontopolar artery which is important and also Hubner also is important sometimes you may coagulate the Hubner's artery when it is arising from A1 division patient may get facial brachial weakness this is the way I am gently pulling the tumor. So we should have a very good patience not to see that is arachnoid say what you are this is the one hall factor in our which is going here can you see this is the one see that is being separated from the tumor it should be very very gentle see how arachnoid will get separated from the tumor can you see this full tumor surface that is the arachnoid posterior here see there we used to separate the arachnoid from the tumor but arachnoid will get separated from the tumor there is following tumor this is the reconstruction following it the glue being injected I did not reflect the mucosa over the tumor this is the end this is following surgery see the depth nearly more than 2 centimeters following surgery patient how see here in this case because when a person after surgery he will be coming in a normal when he started walking brain sits on it when you put a fat muzzle and fascia everything the brain which goes and sits and which seals the that defect so I will tell you in the other side what will be the effect of this that itself is like a tamponid effect so there will be no chances of CSF leak from that defect whereas in other cases it will be different see this is the one lipoma see which is the best best way to remove this one is what is the approach for this see if you want to go posteriorly you cannot go to the opposite side okay so I thought when I am doing endoscopic surgery why can't I try with the endoscope see bone also is very thin once you enter into the you will be straight away you will be seeing the tumor see the basilar artery how it is inside okay in the lower part vertebral arteries are so you should be here when you are going to reach that area we will be shivering only because once the artery is ruptured there is no other go is under percent mortality with that risk I have entered so luckily patient I will show you that see this here can you see the vertebral sorry basilar artery see this is the vertebral artery as it comes basilar artery this is the pawn see here see this is the stretched out medulla see straight away after delivering that I am entering into the dura being inside there see there will be blush of bleeding that is all from the flexes so no need to be panicky see that is the tumor see lipoma see each gentle touch my heart rate was going up whether I am pulling the aika paika or vertebral artery or basilar artery I don't know what is behind it so that is the epidermal that color itself it shows no so that is being removed see the pawns sorry this is the pyramid here pyramid of one side okay this is the area which was there that lipoma that was sucked out this is the pyramid at that stage that is behind his cranial nerves lower cranial nerves this is after that I was afraid to further what is that to go and decompress because for a right-handed people the rights of the patients is nice to decompress and because our flexion is more easy when it is on the left side of the patient see we have a limited we cannot hold the instrument like that we cannot drill like this we can drill on the right side of the patient on the left side of the patient is very very difficult and not only like that there are so many structures so many structure means artery that is where are survival results that is the carotid artery which comes and takes up into the cavernous sinus where when we are drilling it once you miss that area we will end up with the bleeding only so that is why I was not sure enough to take out the tumor I left behind the tumor then there was the lesion which is behind see this is and on which is left behind tumor so I was happy with that this patient presenting with the diplopia and attacks here following this much decompression patient improved started walking and this area was packed with the fascia all the things whatever they say mucosal plus CSF started leaking and waited lumber drain and all everything else then still CSF leak then I re-explored this is re-explored see can you see the basilar artery that is the ICA completely it is on see again I am going with taking risk just again on the opposite side I am decompressing see somewhere here only this carotid artery which comes there there are clival region and valsalva measures which is very very helpful in these conditions so you have to be associated with anesthetist nicely and when they start giving it comes up so I cannot go down when they are giving see there even opposite side ICA can you see inside I will not be knowing what I am doing it with just blindly doing this is all following valsalva maneuver see after completion of the lesion whole tumor was taken out opposite side you have seen this is the patch whatever but still patient is walking around see this is all following surgery all brain stem which has come anteriorly that is in situ this is she is walking but still she is having one or two drops of CSF and the main problem of these patients are post-operative headache what could be the reason it can be pneumocarpitalis or low-pressure headache they say so intense headache as if it is bursting like subarachnoid hemorrhage how the patient presents similarly that is the only thing that has to be replaced with a fluid then when it is started leaking day before yesterday only the coprotonium shunt has been then we do not know whether with that whether it responds or not why CSF leak is common in this condition because whatever thing you put because of gravity see we are not fixing anywhere once you fix at least something is hanging see here whatever you put when the patient is in standing position start walking it is all wet it is not a solid part where the bone or something if you place it it is solid which sits there here it absorbs the fluid once it absorbs you start flowing and it may tend to descend or there may be some leak some area may be open so CSF start leaking that is the disadvantage otherwise this is the excellent surgery in one go you can take out complete tumor see hormone level 442 it was this is the first time I am what is that listening or seeing this much of growth hormone producing in a boy hardly about he is 8 years old then following surgery it came to 104 let us see you see how it is see that it is size of the tumor see following surgery see the roof of the third ventricle can you see the internal cerebral vein they are fully inside see that is the carotid artery see the cerebral you can see there here there is no question of preserving the arachnid at all okay luckily this patient had a hydrocephalus so we did a shunt first then subsequently this is I took a chance this is all following surgery there is a amount of more that is also help to CSF leak so patient was discharged if it were to any leak