Endonasal Endoscopic Surgery for Pituitary Adenoma

Abstract

Introduction: Since the first surgery for pituitary pathology was performed in 1889 by Sir Victor Horsley using a transcranial approach, numerous technical advancements have allowed for safer and more efficacious pituitary surgery.1 Currently, the transsphenoidal approach is used for the vast majority of pituitary adenomas. Over the past 20 years, there has been an evolution of the technique from a microscope-based approach using a sublabial or nasal speculum to a fully endoscopic approach without a speculum for the removal of pituitary adenomas and other parasellar tumors. The reason for this transition to an endoscopic approach is that it affords superior visualization over the microscope into the sellar and suprasellar areas as well as cavernous sinus areas. This superior visualization appears to translate into greater degrees of tumor removal, especially for larger macroadenomas over 2 cm in maximal diameter.2 Since 2009, the senior author has used a solely endoscopic approach for visualization during the endonasal pituitary surgery. This video is intended to illustrate the indications and some of the technical nuances of the endonasal endoscopic approach for pituitary adenomas. Materials and Methods: Endonasal endoscopic pituitary surgery at our center is performed using a two surgeon team. All operations are performed in the endoscopic operating suite, which is equipped with a high-definition operating endoscope camera/recording system and high-definition, ceiling-mounted liquid crystal display screens for each surgeon. Zero degree, 30°, and 45° angled endoscopes are used during the operations. Typically, an otolaryngologist performs the initial endonasal approach to the sphenoid sinus and raises bilateral nasal septal mucosal flaps that aim to preserve the sphenopalatine vascular pedicles to the septal mucosa and the olfactory mucosa. Next, the neurosurgeon, using endoscopic visualization by the otolaryngologist, uses a binostril approach to perform the remainder of the sphenoid sinus and sellar exposure, tumor removal, and sellar skull base reconstruction. Case Example and Results: An endonasal endoscopic pituitary surgery is demonstrated in a man with a nonfunctioning (endocrine-inactive) pituitary macroadenoma associated with hypopituitarism. The video demonstrates the endonasal approach, sphenoidotomy, sellar exposure, tumor removal, and sellar reconstruction. A gross total tumor resection was achieved in this patient, although microscopic tumor likely remains in the right cavernous sinus. The patient did well after the surgery with stable hypopituitarism at 3 months after the surgery; his MRI showed no obvious residual tumor. Conclusions: Endonasal endoscopic pituitary adenoma removal has been shown to be safe and effective with equivalent and possibly better tumor removal rates compared with the traditional microscopic approach. A team approach that includes both neurosurgery and otolaryngology is highly recommended for these technically challenging cases. Daniel F. Kelly receives royalties from Mizuho incorporated. The rest of the authors report no competing financial interests. Runtime of video: 10 mins 22 secs