Pituitary society expert Delphi consensus: operative workflow in endoscopic transsphenoidal pituitary adenoma resection

Hani J Marcus,Chan Hee Koh,Danyal Z Khan,Pietro Mortini,Anouk Borg,Saurabh Sinha,Justin S Cetas,Danail Stoyanov,Neil Dorward ,Luis V Syro,Georgios Tsermoulas,Justin Collins ,Pamela S Jones,Michael Buchfelder,Mark J Winder,Mark Gurnell,Theodore H Schwartz,Hugo Layard Horsfall,Nelson M Oyesiku,Gabriel Zada,William Muirhead,Maria Fleseriu,Mohsen Javadpour,Adam Williams,Adam N Mamelak,Edward R Laws

doi:10.1007/s11102-021-01162-3

Abstract

PurposeSurgical workflow analysis seeks to systematically break down operations into hierarchal components. It facilitates education, training, and understanding of surgical variations. There are known educational demands and variations in surgical practice in endoscopic transsphenoidal approaches to pituitary adenomas. Through an iterative consensus process, we generated a surgical workflow reflective of contemporary surgical practice.MethodsA mixed-methods consensus process composed of a literature review and iterative Delphi surveys was carried out within the Pituitary Society. Each round of the survey was repeated until data saturation and > 90% consensus was reached.ResultsThere was a 100% response rate and no attrition across both Delphi rounds. Eighteen international expert panel members participated. An extensive workflow of 4 phases (nasal, sphenoid, sellar and closure) and 40 steps, with associated technical errors and adverse events, were agreed upon by 100% of panel members across rounds. Both core and case-specific or surgeon-specific variations in operative steps were captured.ConclusionsThrough an international expert panel consensus, a workflow for the performance of endoscopic transsphenoidal pituitary adenoma resection has been generated. This workflow captures a wide range of contemporary operative practice. The agreed “core” steps will serve as a foundation for education, training, assessment and technological development (e.g. models and simulators). The “optional” steps highlight areas of heterogeneity of practice that will benefit from further research (e.g. methods of skull base repair). Further adjustments could be made to increase applicability around the world.

Highlights

Endonasal transsphenoidal approaches to the skull base are emerging as the first-line approach for resecting the majority of pituitary adenomas which require surgical intervention [1,2,3]
Pituitary (2021) 24:839–853 down into phases which contain a series of steps, generating a dedicated workflow [13]
The refined workflow was sent to a larger group (n = 11)—international members of the Pituitary Society that are recognised experts in the field and nominated by the Physician Education Committee

Summary

Introduction

Endonasal transsphenoidal approaches to the skull base are emerging as the first-line approach for resecting the majority of pituitary adenomas which require surgical intervention [1,2,3]. There is variation in the ways in which these operations are performed, largely based on surgeon preference and training, which may result in differing surgical outcomes [4,5,6,7]. These operations are technically demanding, relatively low volume, with steep learning curves—culminating in the frequent requirement for dedicated fellowships to achieve procedure-specific competency [8,9,10,11]. Surgical workflow analysis seeks to systematically break down surgical procedures into defined tasks and errors [12, 13]. At each step, there is the potential for technical errors (lapses in surgical technique) and adverse events (an event that may lead to adverse outcomes or postoperative complications) [12]

Methods

Results

Conclusion