Anterior Transpetrosal Approach: 2-Dimensional Operative Video.
INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE: The anterior transpetrosal approach uses the subtemporal corridor to access the Meckel cave and the upper petroclival region from the dorsum sellae down to the cerebellopontine angle.
ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT: The boundaries of posteromedial triangle of the middle fossa must be adequately visualized for the anterior petrosectomy. They are V3 anteriorly, the petrous ridge medially, GSPN laterally, and the meatal plane posteriorly.
ESSENTIALS STEPS OF THE PROCEDURE: The position is supine with the head fully turned. After a temporal craniotomy, the dura is stripped off the floor of the middle fossa. The middle meningeal artery is coagulated and cut, and the greater superficial petrosal nerve is released to allow access to the petrous apex. The extent of the anterior petrosectomy is case-specific, tailored to the exposure needed. The posterior fossa dura is cut where exposed by the petrosectomy and the middle fossa dura just above level of the tentorium and parallel to it. The superior petrosal sinus is ligated and with tentorial incision up to the incisura, the approach is complete.
PITFALLS/AVOIDANCE OF COMPLICATIONS: The contents of the petrous temporal bone, such as the cochlea and labyrinthine, and the point of crossing of the carotid artery under V3 must be examined preoperatively to avoid injury during drilling.
VARIANTS AND INDICATIONS FOR THEIR USE: The anterior transpetrosal approach can be combined with other approaches to expand surgical access. Two examples of this are included in this video.The patients consented to the surgery and to publication of their images.Image at 0:36 from Kawase T, Toya S, Shiobara R, Mine T, Transpetrosal approach for aneurysm of the lower basilar artery, J Neurosurg, 1981;63(6):857-861, with permission from JNSPG; Image at 1:03 from Jean, Skull Base Surgery: Strategies, edition 1 (9781626239579), with permission from Thieme Publishers.
Published In/Presented At
Kawase, T., & Jean, W. C. (2023). Anterior Transpetrosal Approach: 2-Dimensional Operative Video. Operative neurosurgery (Hagerstown, Md.), 25(1), e22. https://doi.org/10.1227/ons.0000000000000633
Medicine and Health Sciences
Department of Surgery