Endoscopic transsphenoidal tumor surgery

Abstract

Endoscopic endonasal transsphenoidal surgery was developed by the author in 1993 under minimally invasive strategy. It has evolved since then to arrive at the current paraseptal techniques. Endoscope and surgical instruments are inserted parallel to each other through one nostril without traditional mucosal incisions. Unlike conventional transseptal microscopic surgery, it does not require the use of a transsphenoidal retractor, a fluoroscopic C-arm, septal mucosal dissection, and postoperative nasal packing. An endonasal approach is made through a paraseptal route medial to the middle turbinate. The surgical landmark leading to the sella is the inferior margin of the middle turbinate. The line drawn along the inferior margin of the middle turbinate extends to 1 cm inferior to the floor of the sella. Through a small anterior sphenoidotomy hole, the posterior wall of the sphenoidal sinus is exposed. Unlike the narrow exposure at the sella available through an operating microscope, an endoscope discloses a wide panoramic view of the distinct anatomical landmarks around the sella such as the clival indentation, carotid prominences, and carotico-optic recesses. Endoscopic zoom-in enhances magnification of the surgical target for microdissection. Angled lens endoscopic view brings hidden anatomical corners under direct vision. The mean hospital stay for patients is overnight, and postoperative discomfort is minimal. Postoperative nasal drainage also is minimal. This report details the technical aspects of endoscopic endonasal transsphenoidal surgery. As surgical equipment becomes fully developed and neurosurgeons become well trained in endoscopy, endoscopic endonasal transsphenoidal surgery will have a promising future.