Cadaver-based dissection model for pterional approach to the sella turcica: a practical tool for neurosurgical training

Abstract

Objectives: This study aims to present a cadaver-based dissection model for the pterional approach, which is widely used in skull base surgery, as a practical tool for educational purposes in accessing the sella turcica Methods: A pterional approach was performed on five cadavers fixed with 10% formalin using an extended craniotomy. The anatomical layers from the skin incision to the sella turcica were dissected step by step, and key neurovascular structures were identified. Results: The model successfully demonstrated critical neurovascular relationships, enabling trainees to visualize the optic nerve, internal carotid artery, anterior clinoid process, and parasellar structures. Participants (n=10 neurosurgery assistants) showed significant improvement in anatomical knowledge (pre-test: 84±11.7 vs. post-test: 96±5.16, p<0.05, Wilcoxon test) and procedural efficiency. The three-dimensional exposure facilitated skill acquisition in bone drilling, dural retraction, and vessel preservation. Conclusion: The presented model offers an effective and reproducible tool for teaching the anatomical details of the pterional approach. Future studies are recommended to expand the model with multiple cadavers and to assess its educational outcomes quantitatively.

Keywords

• sella turcica
• pterional approach
• cadaver dissection
• neuroanatomy
• surgical training

References

1. Rawanduzy CA, Couldwell WT. History, current techniques, and future prospects of surgery to the sellar and parasellar region. Cancers (Basel) 2023;15:2896.
2. Altay T, Couldwell WT. The frontotemporal (pterional) approach: an historical perspective. Neurosurgery 2012;71:481–92.
3. Luzzi S, Lucifero AG, Bruno N, Baldoncini M, Campero A, Galzio R. Pterional approach. Acta Biomed 2022;92:e2021346.
4. Rodriguez Rubio R, Chae R, Vigo V, Abla AA, McDermott M. Immersive surgical anatomy of the pterional approach. Cureus 2019;11:e5216.
5. Gagliardi F, Donofrio CA, Spina A, Bailo M, Gragnaniello C, Gallotti AL, Elbabaa SK, Caputy AJ, Mortini P. Endoscope-assisted transmaxillosphenoidal approach to the sellar and parasellar regions: an anatomic study. World Neurosurg 2016;95:246–52.
6. Park HH, Sung KS, Moon JH, Kim EH, Kim SH, Lee KS, Hong CK, Chang JH. Lateral supraorbital versus pterional approach for parachiasmal meningiomas: surgical indications and esthetic benefits. Neurosurg Rev 2020;43:313–22.
7. Figueiredo EG, Oliveira AM, Plese JP, Teixeira MJ. Perspective of the frontolateral craniotomies. Arq Neuropsiquiatr 2010;68:430–32.
8. Peeters S, July J. Pterional approach. In: July J, Wahjoepramono EJ, editors. Neurovascular surgery: surgical approaches for neurovascular diseases. Singapore: Springer Singapore; 2018. p. 3–10.

9. Hernesniemi J, Andrade-Bazrazarte H, Duarte R, Serone J, Hijazy F. Lateral supraorbital approach. In: July J, Wahjoepramono EJ, editors. Neurovascular surgery: Surgical approaches for neurovascular diseases. Singapore: Springer Singapore; 2018. p. 23–8.
10. Park HH, Sung KS, Moon JH, Kim EH, Kim SH, Lee KS, Hong CK, Chang JH. Lateral supraorbital versus pterional approach for parachiasmal meningiomas: surgical indications and esthetic benefits. Neurosurgical Rev 2020;43:313–22.
11. Van Gerven L, Qian Z, Starovoyt A, Jorissen M, Meulemans J, van Loon J, De Vleeschouwer S, Lambert J, Bex M, Vander Poorten V. Endoscopic, endonasal transsphenoidal surgery for tumors of the sellar and suprasellar region: a monocentric historical cohort study of 369 patients. Front Oncol 2021;11:643550.
12. Zwagerman NT, Zenonos G, Lieber S, Wang WH, Wang EW, Fernandez-Miranda JC, Snyderman CH, Gardner PA. Endoscopic transnasal skull base surgery: pushing the boundaries. J Neurooncol 2016;130:319–30.
13. Sabit I, Schaefer SD, Couldwell WT. Extradural extranasal combined transmaxillary transsphenoidal approach to the cavernous sinus: a minimally invasive microsurgical model. Laryngoscope 2000;110:286–91.
14. Xu Xue Z, Liu J, Bi ZY, Yi ZQ, Bao SD, Liu PN, Yang ZJ. Evolution of transmaxillary approach to tumors in pterygopalatine fossa and infratemporal fossa: anatomic simulation and clinical practice. Chin Med J 2019;132:798–804.
15. Korotkov D, Abramyan A, Wuo-Silva R, Chaddad-Neto F. Cadaveric sheep head model for anterior clinoidectomy in neurosurgical training. World Neurosurg 2023;175:e481–91.
16. da Silva SA, Yamaki VN, Solla DJF, Andrade AF, Teixeira MJ, Spetzler RF, Preul MC, Figueiredo EG. Pterional, pretemporal, and orbitozygomatic approaches: anatomic and comparative study. World Neurosurg 2019;121:e398–403.
17. Campero A, Ajler P, Paíz M, Elizalde RL. Microsurgical anatomy of the interfascial vein. Its significance in the interfascial dissection of the pterional approach. Oper Neurosurg 2017;13:622–6.
18. Ammirati M, Bernardo A. Anatomical study of the superior orbital fissure as seen during a pterional approach. J Neurosurg 2007;106:151–6.
19. Alaywan M, Sindou M. Fronto-temporal approach with orbito-zygomatic removal. Surgical anatomy. Acta Neurochir (Wien) 1990;104:79–83.
20. Salma A, Wang S, Ammirati M. Extradural endoscope-assisted subtemporal posterior clinoidectomy: a cadaver investigation study. Neurosurgery 2010;67(3 Suppl Operative):ons43–8.