ENDOSCOPIC ENDONASAL TRANSSPEHNOIDAL APPROACH FOR REMOVAL OF SELLAR AND PARASELLAR BRAIN LESIONS – ADVANTAGES AND LIMITATIONS
Endoscopic endonasal transsphenoidal approach for removal of sellar and parasellar brain lesions – surgical technique
Abstract
The endoscopic endonasal transsphenoidal surgical approach is a minimally invasive neurosurgical procedure in the treatment of sellar and parasellar brain lesions. According the literature reports, the results are comparable or even better with respect to surgical radicality. This approach is associated with reduced morbidity, faster recovery times, and superior visualization of the surgical field, making it an increasingly preferred option in neurosurgery.
The aim of this study is to update the knowledge and the information of the transnasal transphenoidal surgical approach and treatment of brain lesions, its application and outcomes, advantages and disadvantages of this technique.Increasing experience with this technique can decrease rates of complications. A trend towards a lower total complication rate with increasing study size was observed. The review of complications of transsphenoidal surgery showed that transsphenoidal surgery seems to be a reasonably safe procedure, with a mortality rate of less than 1%, with a significant number of complications which were more frequent in less experienced surgeons. Many researches showed similar results when analyse the complications after endonasl endoscopic surgery. Compared to more traditional surgical techiques, endonasal transphenoidal endoscopy showed lower rate of neurological complications, greater improved in visibility, moderate rate of endocrinological disturbance and higher rate of cerebrospinal leakage. Main advantages of the endonasal approach are the direct access to the sellar region without brain retraction and a straight forward procedure. Major drawbacks are the increased risks for postoperative CSF fistulas, sinonasal complications and the limited access to lateral structures.Modern technical innovations in endoscopic endonasal skull base surgery like enhance the safety, efficacy, and overall success of the endoscopic transnasal approach to sellar, suprasellar and other skull base brain lesions.
Keywords: Endoscopic, endonasal, transsphenoidal, brain lesions, neurosurgical.
References
1. Liu, J., Wang, P., Tang, C., Jiang, H. T., Zhang, G., & Wu, N. (2023). Endoscopic endonasal transsphenoidal approach for craniopharyngioma: A case report. Experimental and therapeutic medicine, 25(3), 114. https://doi.org/10.3892/etm.2023.11813
2. Campero A, Socolovsky M, Torino R, Martins C, Yasuda A, Rhoton AL Jr. Anatomical landmarks for positioning the head in preparation for the transsphenoidal approach: the spheno-sellar point. Br J Neurosurg. 2009;23(3):282-286. doi:10.1080/02688690802630056
3. Alsaleh S, Albakr A, Alromaih S, Alatar A, Alroqi AS, Ajlan A. Expanded transnasal approaches to the skull base in the Middle East: Where do we stand? Ann Saudi Med. 2020;40(2):94-104. doi:10.5144/0256-4947.2020.94
4. Cappabianca P, Cavallo LM, de Divitiis E. Endoscopic endonasal transsphenoidal surgery. Neurosurgery. 2004;55(4):933-941. doi:10.1227/01.neu.0000137330.02549.0d
5. Nejadkazem M, Samii A, Fahlbusch R, Bidadi S. A simplified direct endonasal approach for transsphenoidal surgery. Minim Invasive Neurosurg. 2008;51(5):272-274. doi:10.1055/s-0028-1082324
6. Laws E J. Philadelphia: WB Saunders; 1995. Transsphenoidal approach to pituitary tumours; pp. 283–292
7. Kanter, A. S., Dumont, A. S., Asthagiri, A. R., Oskouian, R. J., Jane, J. A., Jr, & Laws, E. R., Jr (2005). The transsphenoidal approach. A historical perspective. Neurosurgical focus, 18(4), e6. https://doi.org/10.3171/foc.2005.18.4.7).
8. Cavallo, L. M., Cappabianca, P., Galzio, R., Iaconetta, G., de Divitiis, E., & Tschabitscher, M. (2005). Endoscopic transnasal approach to the cavernous sinus versus transcranial route: anatomic study. Neurosurgery, 56(2 Suppl), 379–389
9. (Schroeder, H. W., Oertel, J., & Gaab, M. R. (2004). Endoscopic aqueductoplasty in the treatment of aqueductal stenosis. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery, 20(11-12), 821–827. https://doi.org/10.1007/s00381-004-0937-z
10. Schroeder, H. W., Oertel, J., & Gaab, M. R. (2007). Endoscopic treatment of cerebrospinal fluid pathway obstructions. Neurosurgery, 60(2 Suppl 1), ONS44–ONS52. https://doi.org/10.1227/01.NEU.0000249242.17805.E3)
11. Cappabianca, P., Cavallo, L. M., Esposito, F., De Divitiis, O., Messina, A., & De Divitiis, E. (2008). Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery. Advances and technical standards in neurosurgery, 33, 151–199. https://doi.org/10.1007/978-3-211-72283-1_4
12. de Divitiis, E., Cavallo, L. M., Cappabianca, P., & Esposito, F. (2007). Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: Part 2. Neurosurgery, 60(1), 46–59. https://doi.org/10.1227/01.NEU.0000249211.89096.25
13. Laufer, I., Anand, V. K., & Schwartz, T. H. (2007). Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. Journal of neurosurgery, 106(3), 400–406. https://doi.org/10.3171/jns.2007.106.3.400
14. Yang I, Wang MB, Bergsneider M. Making the transition from microsurgery to endoscopic trans-sphenoidal pituitary neurosurgery. Neurosurg Clin N Am. 2010;21(4):643-vi. doi:10.1016/j.nec.2010.07.008
15. Fomichev, D., Kalinin, P., Kutin, M., & Sharipov, O. (2016). Extended Transsphenoidal Endoscopic Endonasal Surgery of Suprasellar Craniopharyngiomas. World neurosurgery, 94, 181–187. https://doi.org/10.1016/j.wneu.2016.06.124
16. Alalade, A. F., Ogando-Rivas, E., Boatey, J., Souweidane, M. M., Anand, V. K., Greenfield, J. P., & Schwartz, T. H. (2018). Suprasellar and recurrent pediatric craniopharyngiomas: expanding indications for the extended endoscopic transsphenoidal approach. Journal of neurosurgery. Pediatrics, 21(1), 72–80. https://doi.org/10.3171/2017.7.PEDS17295
17. Cavallo, L. M., Prevedello, D. M., Solari, D., Gardner, P. A., Esposito, F., Snyderman, C. H., Carrau, R. L., Kassam, A. B., & Cappabianca, P. (2009). Extended endoscopic endonasal transsphenoidal approach for residual or recurrent craniopharyngiomas. Journal of neurosurgery, 111(3), 578–589. https://doi.org/10.3171/2009.2.JNS081026).
18. Tang, B., Xiao, L., Xie, S., Huang, G., Wang, Z., Zhou, D., Zeng, E., & Hong, T. (2018). Extended endoscopic endonasal approach for recurrent or residual symptomatic craniopharyngiomas. Clinical neurology and neurosurgery, 168, 38–45. https://doi.org/10.1016/j.clineuro.2018.02.002).
19. Wannemuehler TJ, Rubel KE, Hendricks BK, et al. Outcomes in transcranial microsurgery versus extended endoscopic endonasal approach for primary resection of adult craniopharyngiomas. Neurosurg Focus. 2016;41(6):E6. doi:10.3171/2016.9.FOCUS16314
20. Komotar, R. J., Starke, R. M., Raper, D. M., Anand, V. K., & Schwartz, T. H. (2012). Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of craniopharyngiomas. World neurosurgery, 77(2), 329–341. https://doi.org/10.1016/j.wneu.2011.07.011
21. Kshettry, V. R., Do, H., Elshazly, K., Farrell, C. J., Nyquist, G., Rosen, M., & Evans, J. J. (2016). The learning curve in endoscopic endonasal resection of craniopharyngiomas. Neurosurgical focus, 41(6), E9. https://doi.org/10.3171/2016.9.FOCUS16292)
22. Borg A, Kirkman MA, Choi D. Endoscopic Endonasal Anterior Skull Base Surgery: A Systematic Review of Complications During the Past 65 Years. World Neurosurg. 2016;95:383-391. doi:10.1016/j.wneu.2015.12.105).
23. Ciric, I., Ragin, A., Baumgartner, C., & Pierce, D. (1997). Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery, 40(2), 225–237. https://doi.org/10.1097/00006123-199702000-00001).
24. Couldwell, W. T., Weiss, M. H., Rabb, C., Liu, J. K., Apfelbaum, R. I., & Fukushima, T. (2004). Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases. Neurosurgery, 55(3), 539–550. https://doi.org/10.1227/01.neu.0000134287.19377.a2
25. Leng, L. Z., Greenfield, J. P., Souweidane, M. M., Anand, V. K., & Schwartz, T. H. (2012). Endoscopic, endonasal resection of craniopharyngiomas: analysis of outcome including extent of resection, cerebrospinal fluid leak, return to preoperative productivity, and body mass index. Neurosurgery, 70(1), 110–124. https://doi.org/10.1227/NEU.0b013e31822e8ffc)
26. Linsler S, Prokein B, Hendrix P, Oertel J. Sinonasal outcome after endoscopic mononostril transsphenoidal surgery: A single center cohort study. J Clin Neurosci. 2018;53:92-99. doi:10.1016/j.jocn.2018.04.011
27. Zoli M, Mazzatenta D, Valluzzi A, et al. Expanding indications for the extended endoscopic endonasal approach to hypothalamic gliomas: preliminary report. Neurosurg Focus. 2014;37(4):E11. doi:10.3171/2014.7.FOCUS14317
28. Charalampaki P, Ayyad A, Kockro RA, Perneczky A. Surgical complications after endoscopic transsphenoidal pituitary surgery. J Clin Neurosci. 2009;16(6):786-789. doi:10.1016/j.jocn.2008.09.002
29. Ravnik J, Rowbottom H, Snyderman CH, et al. The Impact of Surgical Telementoring on Reducing the Complication Rate in Endoscopic Endonasal Surgery of the Skull Base. Diagnostics (Basel). 2024;14(17):1874. Published 2024 Aug 27. doi:10.3390/diagnostics14171874
30. D'Haens J, Van Rompaey K, Stadnik T, Haentjens P, Poppe K, Velkeniers B. Fully endoscopic transsphenoidal surgery for functioning pituitary adenomas: a retrospective comparison with traditional transsphenoidal microsurgery in the same institution. Surg Neurol. 2009;72(4):336-340. doi:10.1016/j.surneu.2009.04.012
31. Han SJ, Rolston JD, Jahangiri A, Aghi MK. Rathke's cleft cysts: review of natural history and surgical outcomes. J Neurooncol. 2014;117(2):197-203. doi:10.1007/s11060-013-1272-6).
32. Roxbury CR, Ishii M, Richmon JD, Blitz AM, Reh DD, Gallia GL. Endonasal Endoscopic Surgery in the Management of Sinonasal and Anterior Skull Base Malignancies [published correction appears in Head Neck Pathol. 2017 Jun;11(2):268. doi: 10.1007/s12105-017-0816-z]. Head Neck Pathol. 2016;10(1):13-22. doi:10.1007/s12105-016-0687-8
33. Batra PS, Citardi MJ, Worley S, et al. Skull base tumors: comparison of combined traditional and endoscopic techniques. Am J Rhinol. 2005;19:521–528
34. Koutourousiou M, Vaz Guimaraes Filho F, Fernandez-Miranda JC, et al. Endoscopic Endonasal Surgery for Tumors of the Cavernous Sinus: A Series of 234 Patients. World Neurosurg. 2017;103:713-732. doi:10.1016/j.wneu.2017.04.096
35. EMJ Oncol. 2016;4[1]:96-102. DOI/10.33590/emjoncol/10314593. https://doi.org/10.33590/emjoncol/10314593
36. Lund VJ et al. European position paper on endoscopic management of tumours of the nose, paranasal sinuses and skull base. Rhinol Suppl. 2010;(22):1-143.
37. Nicolai P et al. Juvenile angiofibroma: evolution of management. Int J Pediatr. 2012;2012:412545
38. Snyderman CH et al. Endoscopic skull base surgery: principles of endonasal oncological surgery. J Surg Oncol. 2008;97(8):658-64
39. Oertel J et al (2015) Mononostril endoscopic transsphenoidal approach to sellar and peri-sellar lesions: personal experience and literature review. Br J Neurosurg 29(4):532–537 10.3109/02688697.2015.1014997
40. Oertel J, Gaab MR, Linsler S (2016) The endoscopic endonasal transsphenoidal approach to sellar lesions allows a high radicality: the benefit of angled optics. Clin Neurol Neurosurg 146:29–34 10.1016/j.clineuro.2016.04.016
41. Linsler S, Gaab MR, Oertel J. Endoscopic endonasal transspenoidal approach to selar lesions: A detailed Account of mononostril technique. Neurol Surg B, 2013: 74:146-154.
2. Campero A, Socolovsky M, Torino R, Martins C, Yasuda A, Rhoton AL Jr. Anatomical landmarks for positioning the head in preparation for the transsphenoidal approach: the spheno-sellar point. Br J Neurosurg. 2009;23(3):282-286. doi:10.1080/02688690802630056
3. Alsaleh S, Albakr A, Alromaih S, Alatar A, Alroqi AS, Ajlan A. Expanded transnasal approaches to the skull base in the Middle East: Where do we stand? Ann Saudi Med. 2020;40(2):94-104. doi:10.5144/0256-4947.2020.94
4. Cappabianca P, Cavallo LM, de Divitiis E. Endoscopic endonasal transsphenoidal surgery. Neurosurgery. 2004;55(4):933-941. doi:10.1227/01.neu.0000137330.02549.0d
5. Nejadkazem M, Samii A, Fahlbusch R, Bidadi S. A simplified direct endonasal approach for transsphenoidal surgery. Minim Invasive Neurosurg. 2008;51(5):272-274. doi:10.1055/s-0028-1082324
6. Laws E J. Philadelphia: WB Saunders; 1995. Transsphenoidal approach to pituitary tumours; pp. 283–292
7. Kanter, A. S., Dumont, A. S., Asthagiri, A. R., Oskouian, R. J., Jane, J. A., Jr, & Laws, E. R., Jr (2005). The transsphenoidal approach. A historical perspective. Neurosurgical focus, 18(4), e6. https://doi.org/10.3171/foc.2005.18.4.7).
8. Cavallo, L. M., Cappabianca, P., Galzio, R., Iaconetta, G., de Divitiis, E., & Tschabitscher, M. (2005). Endoscopic transnasal approach to the cavernous sinus versus transcranial route: anatomic study. Neurosurgery, 56(2 Suppl), 379–389
9. (Schroeder, H. W., Oertel, J., & Gaab, M. R. (2004). Endoscopic aqueductoplasty in the treatment of aqueductal stenosis. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery, 20(11-12), 821–827. https://doi.org/10.1007/s00381-004-0937-z
10. Schroeder, H. W., Oertel, J., & Gaab, M. R. (2007). Endoscopic treatment of cerebrospinal fluid pathway obstructions. Neurosurgery, 60(2 Suppl 1), ONS44–ONS52. https://doi.org/10.1227/01.NEU.0000249242.17805.E3)
11. Cappabianca, P., Cavallo, L. M., Esposito, F., De Divitiis, O., Messina, A., & De Divitiis, E. (2008). Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery. Advances and technical standards in neurosurgery, 33, 151–199. https://doi.org/10.1007/978-3-211-72283-1_4
12. de Divitiis, E., Cavallo, L. M., Cappabianca, P., & Esposito, F. (2007). Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: Part 2. Neurosurgery, 60(1), 46–59. https://doi.org/10.1227/01.NEU.0000249211.89096.25
13. Laufer, I., Anand, V. K., & Schwartz, T. H. (2007). Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. Journal of neurosurgery, 106(3), 400–406. https://doi.org/10.3171/jns.2007.106.3.400
14. Yang I, Wang MB, Bergsneider M. Making the transition from microsurgery to endoscopic trans-sphenoidal pituitary neurosurgery. Neurosurg Clin N Am. 2010;21(4):643-vi. doi:10.1016/j.nec.2010.07.008
15. Fomichev, D., Kalinin, P., Kutin, M., & Sharipov, O. (2016). Extended Transsphenoidal Endoscopic Endonasal Surgery of Suprasellar Craniopharyngiomas. World neurosurgery, 94, 181–187. https://doi.org/10.1016/j.wneu.2016.06.124
16. Alalade, A. F., Ogando-Rivas, E., Boatey, J., Souweidane, M. M., Anand, V. K., Greenfield, J. P., & Schwartz, T. H. (2018). Suprasellar and recurrent pediatric craniopharyngiomas: expanding indications for the extended endoscopic transsphenoidal approach. Journal of neurosurgery. Pediatrics, 21(1), 72–80. https://doi.org/10.3171/2017.7.PEDS17295
17. Cavallo, L. M., Prevedello, D. M., Solari, D., Gardner, P. A., Esposito, F., Snyderman, C. H., Carrau, R. L., Kassam, A. B., & Cappabianca, P. (2009). Extended endoscopic endonasal transsphenoidal approach for residual or recurrent craniopharyngiomas. Journal of neurosurgery, 111(3), 578–589. https://doi.org/10.3171/2009.2.JNS081026).
18. Tang, B., Xiao, L., Xie, S., Huang, G., Wang, Z., Zhou, D., Zeng, E., & Hong, T. (2018). Extended endoscopic endonasal approach for recurrent or residual symptomatic craniopharyngiomas. Clinical neurology and neurosurgery, 168, 38–45. https://doi.org/10.1016/j.clineuro.2018.02.002).
19. Wannemuehler TJ, Rubel KE, Hendricks BK, et al. Outcomes in transcranial microsurgery versus extended endoscopic endonasal approach for primary resection of adult craniopharyngiomas. Neurosurg Focus. 2016;41(6):E6. doi:10.3171/2016.9.FOCUS16314
20. Komotar, R. J., Starke, R. M., Raper, D. M., Anand, V. K., & Schwartz, T. H. (2012). Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of craniopharyngiomas. World neurosurgery, 77(2), 329–341. https://doi.org/10.1016/j.wneu.2011.07.011
21. Kshettry, V. R., Do, H., Elshazly, K., Farrell, C. J., Nyquist, G., Rosen, M., & Evans, J. J. (2016). The learning curve in endoscopic endonasal resection of craniopharyngiomas. Neurosurgical focus, 41(6), E9. https://doi.org/10.3171/2016.9.FOCUS16292)
22. Borg A, Kirkman MA, Choi D. Endoscopic Endonasal Anterior Skull Base Surgery: A Systematic Review of Complications During the Past 65 Years. World Neurosurg. 2016;95:383-391. doi:10.1016/j.wneu.2015.12.105).
23. Ciric, I., Ragin, A., Baumgartner, C., & Pierce, D. (1997). Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery, 40(2), 225–237. https://doi.org/10.1097/00006123-199702000-00001).
24. Couldwell, W. T., Weiss, M. H., Rabb, C., Liu, J. K., Apfelbaum, R. I., & Fukushima, T. (2004). Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases. Neurosurgery, 55(3), 539–550. https://doi.org/10.1227/01.neu.0000134287.19377.a2
25. Leng, L. Z., Greenfield, J. P., Souweidane, M. M., Anand, V. K., & Schwartz, T. H. (2012). Endoscopic, endonasal resection of craniopharyngiomas: analysis of outcome including extent of resection, cerebrospinal fluid leak, return to preoperative productivity, and body mass index. Neurosurgery, 70(1), 110–124. https://doi.org/10.1227/NEU.0b013e31822e8ffc)
26. Linsler S, Prokein B, Hendrix P, Oertel J. Sinonasal outcome after endoscopic mononostril transsphenoidal surgery: A single center cohort study. J Clin Neurosci. 2018;53:92-99. doi:10.1016/j.jocn.2018.04.011
27. Zoli M, Mazzatenta D, Valluzzi A, et al. Expanding indications for the extended endoscopic endonasal approach to hypothalamic gliomas: preliminary report. Neurosurg Focus. 2014;37(4):E11. doi:10.3171/2014.7.FOCUS14317
28. Charalampaki P, Ayyad A, Kockro RA, Perneczky A. Surgical complications after endoscopic transsphenoidal pituitary surgery. J Clin Neurosci. 2009;16(6):786-789. doi:10.1016/j.jocn.2008.09.002
29. Ravnik J, Rowbottom H, Snyderman CH, et al. The Impact of Surgical Telementoring on Reducing the Complication Rate in Endoscopic Endonasal Surgery of the Skull Base. Diagnostics (Basel). 2024;14(17):1874. Published 2024 Aug 27. doi:10.3390/diagnostics14171874
30. D'Haens J, Van Rompaey K, Stadnik T, Haentjens P, Poppe K, Velkeniers B. Fully endoscopic transsphenoidal surgery for functioning pituitary adenomas: a retrospective comparison with traditional transsphenoidal microsurgery in the same institution. Surg Neurol. 2009;72(4):336-340. doi:10.1016/j.surneu.2009.04.012
31. Han SJ, Rolston JD, Jahangiri A, Aghi MK. Rathke's cleft cysts: review of natural history and surgical outcomes. J Neurooncol. 2014;117(2):197-203. doi:10.1007/s11060-013-1272-6).
32. Roxbury CR, Ishii M, Richmon JD, Blitz AM, Reh DD, Gallia GL. Endonasal Endoscopic Surgery in the Management of Sinonasal and Anterior Skull Base Malignancies [published correction appears in Head Neck Pathol. 2017 Jun;11(2):268. doi: 10.1007/s12105-017-0816-z]. Head Neck Pathol. 2016;10(1):13-22. doi:10.1007/s12105-016-0687-8
33. Batra PS, Citardi MJ, Worley S, et al. Skull base tumors: comparison of combined traditional and endoscopic techniques. Am J Rhinol. 2005;19:521–528
34. Koutourousiou M, Vaz Guimaraes Filho F, Fernandez-Miranda JC, et al. Endoscopic Endonasal Surgery for Tumors of the Cavernous Sinus: A Series of 234 Patients. World Neurosurg. 2017;103:713-732. doi:10.1016/j.wneu.2017.04.096
35. EMJ Oncol. 2016;4[1]:96-102. DOI/10.33590/emjoncol/10314593. https://doi.org/10.33590/emjoncol/10314593
36. Lund VJ et al. European position paper on endoscopic management of tumours of the nose, paranasal sinuses and skull base. Rhinol Suppl. 2010;(22):1-143.
37. Nicolai P et al. Juvenile angiofibroma: evolution of management. Int J Pediatr. 2012;2012:412545
38. Snyderman CH et al. Endoscopic skull base surgery: principles of endonasal oncological surgery. J Surg Oncol. 2008;97(8):658-64
39. Oertel J et al (2015) Mononostril endoscopic transsphenoidal approach to sellar and peri-sellar lesions: personal experience and literature review. Br J Neurosurg 29(4):532–537 10.3109/02688697.2015.1014997
40. Oertel J, Gaab MR, Linsler S (2016) The endoscopic endonasal transsphenoidal approach to sellar lesions allows a high radicality: the benefit of angled optics. Clin Neurol Neurosurg 146:29–34 10.1016/j.clineuro.2016.04.016
41. Linsler S, Gaab MR, Oertel J. Endoscopic endonasal transspenoidal approach to selar lesions: A detailed Account of mononostril technique. Neurol Surg B, 2013: 74:146-154.
Published
2024-10-23
How to Cite
KAMILOSKI, Tomi Viktor et al.
ENDOSCOPIC ENDONASAL TRANSSPEHNOIDAL APPROACH FOR REMOVAL OF SELLAR AND PARASELLAR BRAIN LESIONS – ADVANTAGES AND LIMITATIONS.
Journal of Morphological Sciences, [S.l.], v. 7, n. 2, p. 1-9, oct. 2024.
ISSN 2545-4706.
Available at: <https://jms.mk/jms/article/view/vol7no2-1>. Date accessed: 21 nov. 2024.
Issue
Section
Articles
