LOS ANGELES (June 28, 2000) -- A new surgical approach performed at Cedars-Sinai Medical Center is making hospital stays and recovery times shorter for patients who have tumors located along the bottom surface of the brain and directly behind the eyes.
Performed by Hrayr Shahinian, M.D., Director of the Skull Base Institute at Cedars-Sinai, and of the first free-standing Division of Skull Base Surgery in the United States, the procedure is perfectly suited for removing tumors of the anterior fossa, such as olfactory bulb meningiomas and craniopharyngiomas.
"We make a very small opening in the wrinkle at the top of the nose, between the two eyebrows," said Dr. Shahinian, currently believed to be the only surgeon in the United States performing the fully endoscopic glabellar approach. "We go through the frontal sinus and into the anterior fossa. We take out the tumor, close the incision, and a year later the scar will not even be visible."
The procedure is made possible by the creation of extremely thin, flexible and precise endoscopic instruments, which were developed by Dr. Shahinian and his team in collaboration with manufacturers of micro-instruments. The surgeon currently uses the prototypes of those instruments, which are approved by the Food and Drug Administration, and is scheduled to share his experience with an upcoming convention of surgeons in France, where the instruments will be displayed.
According to Dr. Shahinian, endoscopes of various sizes -- ranging from 4 millimeters in thickness down to 2.7 millimeters -- and of various angles -- including 0, 30 and 70 degrees -- make it possible to get into extremely tight spaces and look straight ahead or around corners. From within the skull, the telescopes deliver a highly magnified and detailed picture to video monitors, enabling surgeons to remove a tumor completely and clear away all debris -- without disturbing the brain. A newly designed pneumatically operated robotic arm even holds the endoscope in place to make both of the surgeon's hands available to maneuver instruments.
"Before, we had to open the top of the head and pull the brain out of the way in order to get down to the tumor and take it out," said Dr. Shahinian. "This is the shortest, most direct route. We just put the endoscope in and we're right there. We don't even disturb the brain. The results are shortened length of surgery, shortened length of stay and improved patient outcomes. The patients are awake, alert and ready to go home the next day."
Dr. Shahinian performed the procedure on San Antonio, Texas resident Lionel Garza, 55, on March 29 to remove a craniopharyngioma that has eluded complete eradication since being diagnosed 22 years ago.
"I was going to graduate school and I was studying for my finals when I got an intensive eye pain that would shoot into the eye and down the back of my head. It wouldn't stop," recalled Garza, a devout Catholic and deacon in his church. "I was in and out of hospitals and nobody could tell me what was wrong. So one day while at my desk, I said, 'Lord, I need help. I don't know what else to do.'"
Garza, an electronics engineer for the Department of Defense at Kelly Air Force Base, checked out the only medical book that was in the base's library. He and his wife, Delia, read it together. When she read a section describing his symptoms, he said, "That's it. That's my problem." He talked his highly skeptical doctor into ordering tests to confirm or rule out a tumor near the pituitary gland.
"So he ran the tests. Three days later, he called back and said, 'How soon can you check in to the hospital?'" Garza said.
From 1978 through 1997, Garza underwent four procedures to try to remove the tumor. In the first one, surgeons went under the roof of his mouth and through the sinuses. The second operation, in 1980, was an open craniotomy, which was followed by 30 consecutive days of radiation therapy. In 1990, surgeons approached through Garza's nose and nasal passages. In 1997, Garza opted for radiosurgery, in which the tumor was bombarded with radiation from numerous computer-determined angles.
Each time, the tumor eventually recurred. When he learned this past February that the tumor had come back again, he happened upon an article titled "Same Day Brain Surgery" in a patient newsletter he receives. The story described new minimally invasive procedures being developed at the Skull Base Institute.
"I mailed all my MRIs to Dr. Shahinian and a few days later he called me up personally to tell me he was willing to take my case," said Garza, who was accompanied on the trip to Los Angeles by his wife and adult daughter.
The 10-hour operation took longer than most because two procedures actually had to be done -- one going through the sinuses to take out as much tumor and old scar tissue as possible, and the other entering between the eyes to complete the removal.
Garza was released from the hospital on Friday after the Wednesday operation, then spent the weekend in a Los Angeles hotel. Dr. Shahinian saw him again on Monday morning and told him he could go home. He took four weeks off work, worked half days for a couple of weeks and is now full time again.
"I feel awfully good. If I got any better, I wouldn't know what to do," Garza said. "I haven't had even one tiny, little headache in the past eight weeks, just the first few days after getting out (of the hospital), which is probably due to all the swelling."
Garza said even the sense of pressure he has felt on his right eye for two decades is "99.99 percent gone." "Ever since my first surgery, due to whatever reason, maybe the scar tissue or injury to the optic nerve, there was always a constant pain on my right eye. It always felt heavy, like somebody was pushing it in. And all that is gone after 20 years."
Garza is one of about 15 Skull Base Institute patients who have been treated with the endoscopic frontal craniotomy procedure, which has been under development and going through the various levels of institutional and federal approvals for about 3 1/2 years. The Skull Base Institute was founded by Dr. Shahinian in 1996.
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