Surgery

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Brain Tumor Surgery

Of course, one of the surest ways to deal with a brain tumor is to remove it completely.  Tumors that are near the surface and easily accessible are relatively easy to remove. However, those located in the gray matter or near sensitive locations in the brain may not be good candidates for surgery.

Whenever possible, surgeons with the Florida Hospital Brain and Spine Tumor Program will attempt to remove all of the tumor that is visible using surgical techniques. If the tumor is benign, no further treatment is usually necessary. If it is malignant, other treatment options, such as radiation therapy or chemotherapy, may be applied to the tumor.

If a tumor can't be removed because of its location or type, then it may be "debulked," which means reducing the tumor's size. This is often the case when the tumor has invaded surrounding tissue. At this point, removing the entire tumor is difficult, because of its involvement with other tissues. Debulking can alleviate the tumor's symptoms or lessen the pain. It can also reduce the tumor's size to a level where other treatments can be brought into play.

Minimally Invasive Brain Surgery Program

Minimally invasive brain surgery refers to a subspecialty of neurosurgery where various disorders of the brain are treated using surgical procedures that incorporate small surgical incisions or holes, or no incisions at all.  Also known as minimal access brain surgery, this type of surgery utilizes advanced state of the art technologies to more precisely navigate to surgical pathology and treat such pathologies with an accuracy of usually less than one millimeter. Our surgeons utilize special instruments designed specifically for these procedures to be used through such small incisions or even through the body's own natural openings such as the nose.  By incorporating 3-D image-guided computer navigation systems to create a GPS for the brain, Florida Hospital surgeons can navigate through the delicate structures of the brain onto various lesions with confidence and safety. The incorporation of high-definition and 3-D endoscopes, high-resolution microscopes, minimal access brain ports and highly advanced neurophysiological brain mapping and monitoring systems increases the likelihood of success when operating at the depths of the brain.  The result often translates into smaller incisions with less disruption or destruction to surrounding tissues. By applying these minimal access techniques to various pathologies of the brain and skull base, Florida Hospital surgeons can offer treatment options to patients with less pain, less disfigurement, shorter hospitalization and quicker recoveries.

Minimally Invasive Brain Surgery Therapies offered at Florida Hospital include the following:

• Image-guided Endoscopic Pituitary Tumor Surgery
• Image-guided Microscopic Transphenoidal Tumor Surgery
• Image-guided Endoscopic Expanded Endonasal Approach Surgery for Skull Base Tumors
• Image-guided Endoscopic Posterior Fossa Surgery for Cerebellopontine Angle Tumors, Fourth Ventricular Tumors, Trigeminal Neuralgia and Hemifacial Spasm
• Image-guided Endoscopic Intraventricular Tumor Surgery including Colloid Cysts, Meningiomas, Pineal Region Tumors, Neurocytomas, Choroid Plexus Tumors, and Intraventricular Cysts
• BrainPort Image-guided Brain Surgery
• Gamma Knife Radiosurgery

Skull Base Surgery Program

Skull base surgery is a subspecialty committed to techniques designed to reach and manage complex lesions at the base of the brain and skull.  The anatomy of the skull base provides significant challenges to the surgeon and requires a specialized set of skills to be able to navigate safely.  To be able to successfully manage lesions of the skull base a multidisciplinary approach must be taken.  At Florida Hospital, this includes a team of skull base experts from neurosurgery, otolaryngology, neuro-otology, plastic surgery, interventional neuroradiology, neuro-oncology, radiation-oncology, and spine surgery.  This specialized team allows Florida Hospital to successfully and safely treat many tumors and disorders of the skull base that until recently were thought to be untreatable due to unacceptably high risks.

The primary indication for skull base surgery is the removal of various tumors than can compress and injure the multiple delicate and important structures at the base of the brain.  The lesions can involve the anterior cranial fossa under the frontal lobes, the middle cranial fossa including the cavernous sinus, sella / pituitary region, petrosal region and petrous apex, the infratemporal fossa, and the posterior cranial fossa including the clivus, foramen magnum, cerebellopontine angle, brainstem, jugular foramen and internal auditory canal. 

These tumors include pituitary tumors, meningiomas, craniopharyngiomas, chordomas, chondrosarcomas, schwannomas, osteomas, neuromas, hemangiopericytomas, esthesioneuroblastomas, hemangioblastomas, orbital tumors, sinus carcinomas, acoustic neuromas, epidermoid tumors, brainstem astrocytomas, optic gliomas, ependymomas, medulloblastomas, germ cell tumors, paragangliomas / glomus jugulare tumors, cavernous malformations, cholesteotomas, chondromas, angiofibromas, inverting papillomas, fibrous dysplasia, and metastasis.  Non-tumor conditions can also require the skills of a skull base team including encephaloceles, meningoceles, skull base osteomyelitis, allergic fungal sinusitis, basilar invagination, cerebral aneurysms and arteriovenous malformations (AVMs), congenital cysts, Rathke's Cleft Cysts, odontoid rheumatoid pannus, and cerebrospinal fluid leaks.

Open surgery to reach the depths of the skull base can often take specialized skull base surgery teams hours as they meticulously navigate around the critical blood vessels, nerves and tissues of the brain.  Once the skull base team reaches the lesion, the actual removal can take several more hours as the surgeons often work down deep corridors removing the tumor that is often intermingled with important brain structures in a piecemeal fashion until all the tumor is removed.  Reconstruction of the skull opening and lining of the brain can also take several hours once the tumor is removed.  These long surgeries not only require the skills of skull base surgeons but also require a comprehensive ancillary team of doctors, therapists and nurses who have experience in managing these complicated cases.  At Florida Hospital this includes a team of anesthesiologists with specialized training in neuroanesthesiology and years of experience providing care to patients requiring all types of skull base surgery.  It includes neurocritical care nurses and neurocritical care intensivists working together to help patients recover at one of the nation's largest neurosurgical intensive care units.  And finally, it includes a highly motivated team of therapists and rehabilitation physicians who specialize in the rehabilitation of the neurosurgical patients working to get every skull base surgery patient back to their normal activities as early and safely as possible.  

Lesions and tumors of the skull base do not always require open surgery and surgeons at Florida Hospital have always strived to find less invasive ways to improve patient risk, recovery and outcomes.  In 1996, we were the first to bring Gamma Knife Radiosurgery to the region and have since treated thousands of patients, remaining Central Florida's largest Gamma Knife Program.  In addition, our surgeons were one of the first teams to perform minimally invasive endoscopic skull base surgery in the country.  Patients throughout the southeast and the Caribbean have been successfully treated at Florida Hospital utilizing these novel techniques since 2003 including image-guided endoscopic pituitary surgery, expanded endonasal approach (EEA) skull base surgery and image-guided endoscopic posterior fossa tumor surgery.

A multidisciplinary team of neurosurgeons and otolaryngologists at Florida Hospital has refined these techniques, and are among the most experienced in the nation.  By bringing these cutting-edge procedures to the region, patients coming to Florida Hospital for treatment of their skull base lesions can now experience a total hospitalization ranging from hours to a few days compared to several days to weeks with traditional open approaches.  In addition, resuming regular activities can range from the day after a procedure to a few weeks with these new approaches compared to several weeks to months with the standard open approaches.

At Florida Hospital, we take an individualized approach to each patient.  We look at every direction and consider every option to best approach each skull base lesion while at the same time we also determine which option is least risky to that individual.  Cases are presented at our biweekly brain and spine tumor conferences and our multidisciplinary team creates a unique plan for each and every patient.  In some cases, the result may be a single procedure to treat the patient, but for others a multimodality approach may be necessary to cure the patient and minimize risk.  This may include open surgical skull base approaches combined with minimally invasive approaches to attack a tumor from all directions or it may include both surgery and Gamma Knife Radiosurgery if part of a lesion is not resectable without considerable risk but is initially too large for radiosurgery to be effective.  We may also incorporate image-modulated radiation therapy (IMRT), traditional fractionated radiation therapy, or chemotherapy when appropriate to the treatment plan.  In many cases, a combination of surgical and non-operative therapies may be recommended to minimize patient risk but also increase the likelihood of cure.  At Florida Hospital we create hope for many skull base pathologies when in the past no option for cure was available.