 The topic is endo-nasal endoscopic versus supra-orbital keyhole approach. Now, we all know that both are minimally invasive techniques. Now, which one to be used for what? And both of these approaches are useful in anti-cranial fossil lesion or paricellar lesions. Indications are pituitary tumors, meningiomas, craniopharyngeomas, rathcaeclapsis, scordoma, epidermoids and aneurysms. So, first we should understand that in general, the endoscopic endo-nasal approach provides inferior to superior trajectory and direct access to the third ventricle. So, it is preferred in lesions which are confined to cellar like a pituitary macrodinoma or macrodinoma if it is confined to cellar or when there is a significant inferior or sphenoid sinus involvement by any of these lesions like if it is a direct supra-cellar midline extension then very easy to remove it by endo-nasal endoscopic approach. Now, if the lesion is under the epsilon optic nerve work eroded which cannot be seen by supra-tentorquinotomy unless you use the angled endoscope. So, for the lesions which are difficult to visualize supra-tentorially. However, this approach has limitations that in children who have small and narrow nostrils the poor nemitization of system at sinus below 8 years of age. So, below 8 years of age it is really difficult. Now, exposure of lesion lateral to ICA or optic nerve is difficult by this approach. Now, vascular dissection is difficult by this approach endo-nasal endoscopic and the chance age of CSF leak are more because the CSF repair is not 100 percent. Now, this is about the endoscopic endo-nasal. Now, about supra-orbital keyhole approach again in general this approach provides greater micro surgical control and the freedom in dissecting the tumor from the vessels or nerves as compared to endo-nasal approach and it provides enhanced exposure to the lesions lateral to ICA or epsilon optic nerve. So, now we can see that in what situations which approach should be used. So, now I will take one by one like pituitary adenomas. Now, depending on the anatomically the type of the cellar if cellar is cellar or pre-cellar type obviously endo-nasal approach is the choice if it is conical if this approach can still be used by experienced person with use of neuro navigation, but this approach is preferred. Similarly, if the chiasma is pre-fixed normal and post-fixed in all these three this may be preferred, but this can also be used. Now, the location now if the location of the lesion is in the cellar if it is a supra-cell extension involvement of cavernous sinus, islamid sinus section third ventricular extension or anterior cranial fossa extension this approach endo-nasal is preferred. In a anterior cranial fossa extension this can also be done, but supra orbital approach keyhole approach is preferred. Similarly, in para-cellar or lateral that is the middle cranial fossa extension supra orbital keyhole approach is preferred as compared to endo-nasal similarly in multi compartmental extension. Now, depending on the characteristics of the size if it is a micro adenoma and micro adenoma obviously the endo-nasal is preferred nowadays for pituitary, but if it is a giant tumor then the socca is preferred, but this is still a useful approach when your aim is not to remove the tumor completely and you just want to decompress the optic pathways. So, this is still can be used. Now, in general if patient present with CSF in a rhino area of patient of pituitary tumor prolectinoma presenting with CSF rhino area particularly when patient is on bromocaptin. So, obviously the endo-nasal approach is the first choice like if previous intra cranial surgery has been done then obviously endoscopic approach is the preferred. Now, depending on the radiological characteristics if the lesion is solid and if it is fibrous which is denoted by that it is hypo intense on T2 with mild enhancement then obviously this is the choice because if fibrous lesion is very difficult to remove from below if it is a fibrous lesion whereas if it is cellular that is hypo on T2 with strong enhancement then obviously the endo-nasal approach is the choice because it can easily be sucked then removed by the curate. Similarly, if patient has a apoplexy endo-nasal is preferred because everything will just fall down the moment you open the dura everything will go. Vascular adherence or the encasement if it is absent obviously endo-nasal is preferred but if it is present then the supra-orbital keyhole chrysanthemum choice. Now come to craniopharyngeal mass. Similarly, the type of cell if it is normal endoscopic if it is conical supra-orbital keyhole. Similarly, the chiasma the post fixed this is the choice whereas in pre-fixed and normal this is the choice. Now it is relation with infundivolum now this is a recent classification Amin Kasam has published in the relation of craniopharyngeal mass to the infundivolum. So if it is pre-infundivolum or trans-infundivolum endo-nasal is the choice. Similarly, in retroinfundibular which is type A and type B in type A where there is a third ventricular extension where type B is the interpedicular extension in all these this is the preference but a fourth type which is purely third ventricular craniopharyngeal mass. So obviously a supra-orbital keyhole approach is preferred. Similarly, about the location so a craniopharyngeal mass which is in midline cellar supra cellar cavernous involvement, third ventricular involvement, exponent sinus involvement endo-nasal is preferred. Now if it is a anterior cranial force extension so chi is preferred whereas this is also possible because in craniopharyngeal mass trans tubercular transplenum approach can also be done and you can do retro cellar this is a preferred. So in all these retro cellar para cellar lateral extension multi compartmental posterior force extension or retroclival extension supra-orbital keyhole keratomy is preferred. Similarly, for radiology if it is cystic endo-nasal solid endo-nasal but calcified supra-orbital similarly vascular adhesions. Now in general previous intracranial surgery endo-nasal refer now relation to the chiasma same thing if it is a pre-chiasmal or supra-chiasmal this is preferred. Now in general meningeo mass if patient presents with impaired vision and when you do supra-orbital keratomy if you manipulate optic nerve there may be a visual deterioration. So whenever you do this you first cut the felsiform ligament then only manipulate the optic nerve. So this is why the so chi is preferred so that you can open that size less than 3 centimeter endo-nasal more than 3 centimeter supra-orbital. Similarly the para cellar or lateral middle force extension this approach is preferred intracranial extension because again trans tubercular transplanum you can go optic canal extension. So now there is a available literature will say that in all these tuberculum celli or plenum meningeo mass in 70 percent cases there is optic canal environment invasion. So this is why they prefer this approach. Now if extension is lateral to optic nerve or ICA again this is preferred extension lateral to the midpoint of orbits is again important because you cannot approach by an endo-nasal approach beyond the midpoint of the orbit. And if more than 50 percent of tumor is above the plenum then the supra-orbital if it is below the plenum then endo-nasal. Now radiological again the same thing fibrous so chi if it is cellular endo-nasal vascular adygens if absent endo-nasal present so chi. Cortical cuff is very important this denotes that relation of the important vessels particularly the ACA complex with the tumor. So if the cortical cuff is absent then you should go by a supra-orbital approach if it is present then endo-nasal like severe brain edema if it is present then its obvious choice is endo-nasal because you will need lot of brain retraction to remove this region. If a long dural tail so this argues in favor of a soka because you can excise the dural tail also which is supposed to be the cause of recurrence later. Now this is one to work from celli manningioma. Now this is a keyhole manningioma with microscope so with a tiny hole and this hole of the tumor could be excised completely. Now this is being mobilized after the coagulating the surface and when more and more CSF comes out brain becomes lex and your dissection becomes easy. So now this is the lesion hole of the lesion could be removed. So same QSA can be used through this so everything can be done whatever you can do with a big flap same thing can be done by this. Now you can see that the optic nerve yeah and now you can see the pituitary stock preserved other side optic nerve other side carotid and this is a 3 centimeter keratinotomy and here what are 2 centimeter. Now for a Rathke-Clipsis it is like a pituitary tumor endo-nasal is preferred. Now for Cordomage the Cordomage preferred approach is endo-nasal because as we all know that Cordomage are extradural tumors this approach provides the direct access along the long axis of the tumor and it avoids opening of the dura. So the best or preferred approach for Cordomage is endo-nasal. For epidermis they are usually not restricted to the midline they extend laterally. So and they grow diffusely in different CSF systems along the artery so best approach is supra-orbital. Now this is again that girl in whom first the endo-nasal was done so could not be removed now with a supra-orbital keyhole the residual tumor was removed. Now these are the Juga cerebralia the elevations of the orbital roof are drilled extradurally and the inner margin is drilled so that you have sufficient exposure. Now already start seeing the epidermoid medial to optic nerve there and now you see the pituitary stop. So just a piecemeal removal and now it is being dissected from the other side of optic nerve and to the other side of the pituitary stop through the same hole and then you can change the angle of your microscope. Now see lot of the epidermoid under the optic nerve so we are trying to remove this but I was not happy so then I take endoscope and then see and lot of all of the epidermoid was removed you can see the third nerve pituitary stop. So endoscopic help is also very useful and this is after three weeks the same girl and it is well tolerated the scar healing is well tolerated. Now in aneurysms about the endonegal approach the difficulty is in vascular control it is a narrow confined deep corridor and provides 2D vision so it is not used at least I have not used it so far and I do not intend to use it endonegal for any aneurysms. So this is one ECOM aneurysm which I did about 7-8 years back with microscope supra-orbital keyhole approach and just same tiny flap after doing more and more cases flap is going narrow and narrow more and more now directly we see the optic nerve olfactory tract but whenever I am doing it I will come to this when I do with the endoscope will tell you. So now here aneurysm is already seen I am trying to make the space for the clip prongs to go and you can see the whole H whole H and it is important in clipping of ECOM you have to see all the four vessels before doing it and you should see the tips the tips of the clip are not taking something and this is the post-op first day patient very happy with this incision but now earlier I was using this above this now I use within the eyebrow. Now this is a ICA bifurcation very small clip ICA bifurcation aneurysms very simple and purely done by endoscope no microscope was used this is the temporary clip placed on ICA and then I am trying to dissect the neck from the vessel and you can see ICA MCA A1 and this is the aneurysm and after the dissection and directly this aneurysm clip was applied. This is what I will just warn you and tell you do not attempt this unless you have clipped several hundreds of aneurysms by microscope and all these I have used were unruptured to begin with and about 15 cases unruptured aneurysms again this is the MCA large MCA aneurysm purely by endoscope no microscope was used through the keyhole approach. So this is why I was asking you where because space is less and bipolar will not open like this so that that is the issue and now after putting a clip we dissect the aneurysm all around and separate it because I am not happy with the tips where the tips are going. So now after the dissection I can see the tips and I am sure that it is not taking any normal structure or anything then I again put the temporary clip and then aspirate because if it is not secured completely and if you aspirate it without temporary clip it will soil your scope and you will not be able to see anything. Now this is another MCA trifrification aneurysm same through the keyhole endoscopic and it is in much magnified view because in aneurysm whenever mode section is required like if I am not happy that mode I will just give it an endoscope and take microscope I will not hesitate in changing as long as I am happy things are ok dissection is ok fine but if it needs more dissection then I will just take a microscope but this arachnoid dissection and all that can be done easily with the endoscope so I do it with it. So now I can see the aneurysm there and see now here the aim is we can see this the aim is to preserve that vessel so temporary clip and now I am making a place in between the neck of aneurysm and the branch and then the clip by a player so and same instruments what we use in micro surgery and everything is temporary clip removed and now this is one ecomanerysm done endoscopically and I purposefully included it because this aneurysm ruptured and this was a ruptured case ruptured ecomanerysm so this is the sylvian fissure being split and now you can see the olfactory optic ICA M1 A1 this is the A1 and you can see here A1 is in spasm and now you can see the aneurysm there so dissecting on the aneurysm side this is the gyrus rectus being sucked to see the A2 of other side now I am trying to look for A1 of other side so a temporary clip on A1 so while dissecting around the aneurysm you can see the ruptures but since this is what when you are dissecting the aneurysm you should have a temporary clip so that your dissection becomes easy and your control is easy so what I just coagulated the rent and it was and then remove the temporary clip and further dissection continued without temporary clip so when I dissected the aneurysm from all around took it up in the section and put the clip on the neck and now you can see the A1 of other side also I am looking for A2 of other side which is there and then third ventricular stormy laminar turbine was open post-op angio well clipped so to conclude the indications of an approach for these lesions must be individualized depending on the aim of surgery what is your aim? Aim may be just biopsy partial removal total removal or tumor decompression or optic nerve decompression so it depends on your aim what do you want to achieve similarly the anatomical considerations if there are any presence of anomaly like kissing carotids or those kind of things or it is a relation with neuro vascular structures the location and the various extensions depending on pathology what is the pathology radiological appearance, patient's expectations or patient's choice and surgeon's experience which is the most important thank you very much for your attention.