Hemostasis is critical for adequate anatomical visualization during endoscopic endonasal skull base surgery. Reduction of intraoperative bleeding should be considered during the treatment planning and continued throughout the perioperative period. Preoperative preparations include the optimization of comorbidities and cessation of drugs that may inhibit coagulation. Intraoperative considerations comprise anesthetic and surgical aspects. Controlled hypotension is the main anesthetic technique to reduce bleeding; however, there is controversy regarding its effectiveness; what the appropriate mean arterial pressure is and how to maintain it. In extradural cases, we advocate a mean arterial pressure of 65–70？mm？Hg to reduce bleeding while preventing ischemic complications. For dealing intradural lesion, controlled hypotension should be cautious. We do not advocate a marked blood pressure reduction, as this often affects the perfusion of neural structures. Further reduction could lead to stroke or loss of cranial nerve function. From the surgical perspective, there are novel technologies and techniques that reduce bleeding, thus, improving the visualization of the surgical field. 1. Introduction Endoscopic surgery is a minimally invasive technique that has found a niche in all surgical fields. Endoscopic endonasal surgery ranges from basic and relatively straightforward procedures (e.g., endoscopic septoplasty, endoscopic turbinoplasty, and functional endoscopic sinus surgery) to advanced surgery (e.g., endoscopic orbital and/or optic nerve decompression, endoscopic dacryocystorhinostomy, and endoscopic endonasal skull base approaches). Its advantages are obviating external scars, reducing damage to normal tissue and bone, and shortening recovery time and length of hospital stay. However, intraoperative bleeding presents a larger obstacle to endoscopic visualization. Blood obscures the anatomy of the surgical field and dirties the endoscope lens causing greater difficulty with visualization. This situation increases the risk of complications, including brain injury, orbital or optic nerve injury, and catastrophic bleeding from major vessels (e.g., internal carotid artery). We advocate careful consideration of all factors regarding the control of bleeding throughout the entire perioperative period. Preoperative preparations include the optimization of co-morbidities and cessation of drugs that may increase the tendency for bleeding. Intraoperative considerations comprise anesthetic and surgical aspects. Some anesthetic aspects are controversial including the
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