Perioperative management of craniopharyngioma resection through endoscopic endonasal approach in a super-super obese patient: A technical case report.

Background: The endoscopic endonasal approach (EEA) is increasingly used in minimally invasive surgeries for skull base lesions such as pituitary tumors. Although experienced facilities and neurosurgeons familiar with this technique can typically perform these surgeries routinely without special techniques or instruments, challenging cases can occasionally arise due to patient factors such as obesity. Here, we describe challenges encountered during neurosurgery in a patient with super-super obesity and introduce our unique technical nuances for management during tumor resection.

Case Description: We report about a 47-year-old man with a body mass index of 62.24 kg/m who presented for neurosurgery with a diagnosis of craniopharyngioma, for which tumor resection using the EEA under general anesthesia was performed. While planning tumor resection using the EEA, several limitations due to extreme obesity were encountered as follows: (1) management of the respiratory and circulatory systems under general anesthesia, (2) non-feasible positioning on a standard operating table, and (3) complications with lumbar drain (LD) replacement to prevent post-operative cerebrospinal fluid leakage. These challenges were overcome through (1) multidisciplinary collaboration with anesthesiologists and cardiologists, (2) the set-up of two operating tables side by side, and (3) LD placement under awake status in the sitting position, respectively. With these innovations, total tumor resection was achieved using the EEA.

Conclusion: This case highlights the successful use of the EEA along with unique technical adaptations in a super-super obese patient with craniopharyngioma, demonstrating the importance of innovation and problem-solving in overcoming surgical challenges.