Third ventricle tumors including intraventricular craniopharyngiomas have long presented a significant challenge for neurosurgeons. The complex surgical anatomy and proximity to critical surrounding structures such as the optic apparatus, hypothalamus, the circle of Willis, and limbic system demands meticulous planning and surgical technique to ensure safe resection while minimizing postoperative neurocognitive deficits.1, 2, 3 The selection of an optimal surgical approach requires a thorough assessment of the tumor epicenter, the direction and extent of the tumor projection outside the third ventricle, and its relationship with the hypothalamus and optic chiasm. Additionally, the surgeon's experience and familiarity with a selected approach, coupled with the patient's overall medical condition, are important considerations when discussing different options with patients.4, 5, 6 Traditional microsurgical approaches through either lateral ventricle or anterolateral (orbitozygomatic) corridors have limited access to third ventricle craniopharyngiomas with significant lateral extension and those in the retrochiasmatic region, respectively. Transgressing healthy brain tissue, long distances to reach the third ventricle floor, the risk of optic apparatus traction injury, and cosmetic concerns prompting the exploration of alternative techniques.6, 7, 8

In the recent decade, the growing interest in minimally invasive skull base approaches has led to the evolution of the endoscopic endonasal and microscopic supraorbital approaches to reach the lesions in the third ventricle and anterior cranial base.9, 10, 11, 12 Extended transplanum/transtuberculum endoscopic endonasal approaches (EEAs) may address many of the concerns, although they require a favorable angle between the optic chiasm and anterosuperior aspect of the pituitary gland, as well as the involvement of the third ventricle floor by the tumor (Figure 1). Furthermore, these approaches entail a steep learning curve and a slightly higher risk of postoperative cerebrospinal fluid (CSF) leak than transcranial approaches, despite modern skull base repair techniques.13, 14, 15, 16 In the current minimally invasive neurosurgical armamentarium for craniopharyngiomas though, the transcranial and endoscopic approaches cannot substitute each other, as they have their own set of pros and cons, and thus act as complementary working corridors, depending on the patient's characteristics, the surgeon's preferences, and tumor's extension to a particular anatomic compartment within the third ventricle.

Herein, the authors describe the surgical nuances of a fully endoscopic minimally invasive trans-eyebrow supraorbital translaminar approach (ESOTLA) for third ventricle craniopharyngioma, which represents a cosmetically enhanced modification of its conventional microsurgical counterpart through a smaller bony and soft tissue opening. By providing a wider view and improved illumination around the blind corners of the third ventricle, the ESOTLA can potentially overcome the limited rostrocaudal and retrochiasmatic accesses associated with the microsurgical approach.