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J Neurol Surg B Skull Base 2014; 75(06): 415-420
DOI: 10.1055/s-0034-1383855
Original Article
Georg Thieme Verlag KG Stuttgart · New York

The Endoscopic Hemi-Transseptal Approach to the Sella Turcica: Operative Technique and Case-Control Study

Marc A. Tewfik
1   Department of Otolaryngology – Head and Neck Surgery, McGill University, Jewish General Hospital, Montreal, Canada
2   Department of Otolaryngology – Head and Neck Surgery, McGill University, McGill University Health Center, Montreal, Canada
,
Constanza J. Valdes
1   Department of Otolaryngology – Head and Neck Surgery, McGill University, Jewish General Hospital, Montreal, Canada
3   Department of Otolaryngology – Head and Neck Surgery, Universidad de Chile, Hospital del Salvador, Chile
,
Anthony Zeitouni
2   Department of Otolaryngology – Head and Neck Surgery, McGill University, McGill University Health Center, Montreal, Canada
,
Denis Sirhan
4   Department of Neurosurgery, McGill University, Montreal Neurological Hospital, Montreal, Canada
,
Salvatore Di Maio
5   Division of Neurosurgery, McGill University, Jewish General Hospital, Montreal, Canada
› Author Affiliations
Further Information

Publication History

25 July 2013

06 May 2014

Publication Date:
27 June 2014 (online)

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Abstract

Background The hemi-transeptal (Hemi-T) approach was developed to facilitate a binasal two-surgeon endoscopic approach for sellar tumors, with preservation of the nasoseptal flap and selective mobilization for reconstruction.

Methods A retrospective case-control study was performed comparing the Hemi-T approach with previously used methods of sellar exposure and reconstruction. Outcome measures included operative time and postoperative nasal morbidity.

Results A total of 23 patients underwent the Hemi-T approach versus 42 in whom traditional exposure was performed. Operative time was significantly shorter using the Hemi-T technique (152.6 ± 56.8 versus 205.2 ± 61.3 minutes; p = 0.001), as was the length of hospital stay (3.3 ± 1.9 versus 5.4 ± 3.6 days; p = 0.004). There was no difference in the rates of intraoperative or postoperative cerebrospinal fluid leak, cartilage necrosis, septal perforation, or mucosal adhesions.

Conclusion The Hemi-T approach facilitates binasal two-surgeon access to the sella without compromise of the pedicle during the extended sphenoidotomies and tumor removal. Operative time and nasal morbidity is not increased, and iatrogenic injury to the nasal cavity is minimized when a flap is not required.

Keywords

skull base defect - CSF rhinorrhea - endoscopic skull base surgery - reconstruction - nasoseptal flap
 

  • References

  • 1 Hadad G, Bassagasteguy L, Carrau RL , et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006; 116 (10) 1882-1886
    CrossrefPubMedGoogle Scholar
  • 2 Kassam AB, Thomas A, Carrau RL , et al. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 2008; 63 (1) (Suppl. 01) ONS44-ONS52 ; discussion ONS52–ONS53
    CrossrefPubMedGoogle Scholar
  • 3 Rivera-Serrano CM, Snyderman CH, Gardner P , et al. Nasoseptal “rescue” flap: a novel modification of the nasoseptal flap technique for pituitary surgery. Laryngoscope 2011; 121 (5) 990-993
    CrossrefPubMedGoogle Scholar
  • 4 Mehta GU, Oldfield EH. Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas. J Neurosurg 2012; 116 (6) 1299-1303
    CrossrefPubMedGoogle Scholar
  • 5 Senior BA, Ebert CS, Bednarski KK , et al. Minimally invasive pituitary surgery. Laryngoscope 2008; 118 (10) 1842-1855
    CrossrefPubMedGoogle Scholar
  • 6 Dlouhy BJ, Madhavan K, Clinger JD , et al. Elevated body mass index and risk of postoperative CSF leak following transsphenoidal surgery. J Neurosurg 2012; 116 (6) 1311-1317
    CrossrefPubMedGoogle Scholar
  • 7 Han ZL, He DS, Mao ZG, Wang HJ. Cerebrospinal fluid rhinorrhea following trans-sphenoidal pituitary macroadenoma surgery: experience from 592 patients. Clin Neurol Neurosurg 2008; 110 (6) 570-579
    CrossrefPubMedGoogle Scholar
  • 8 Nishioka H, Haraoka J, Ikeda Y. Risk factors of cerebrospinal fluid rhinorrhea following transsphenoidal surgery. Acta Neurochir (Wien) 2005; 147 (11) 1163-1166 ; discussion 1166
    CrossrefPubMedGoogle Scholar
  • 9 Cappabianca P, Cavallo LM, Esposito F, Valente V, De Divitiis E. Sellar repair in endoscopic endonasal transsphenoidal surgery: results of 170 cases. Neurosurgery 2002; 51 (6) 1365-1371 ; discussion 1371–1372
    CrossrefPubMedGoogle Scholar
  • 10 Couldwell WT, Kan P, Weiss MH. Simple closure following transsphenoidal surgery. Technical note. Neurosurg Focus 2006; 20 (3) E11
    CrossrefPubMedGoogle Scholar
  • 11 Hardy J. Transsphenoidal hypophysectomy. J Neurosurg 1971; 34 (4) 582-594
    CrossrefPubMedGoogle Scholar
  • 12 Esposito F, Dusick JR, Fatemi N, Kelly DF. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Neurosurgery 2007; 60 (4) (Suppl. 02) 295-303 ; discussion 303–304
    PubMedGoogle Scholar
  • 13 Di Maio S, Cavallo LM, Esposito F, Stagno V, Corriero OV, Cappabianca P. Extended endoscopic endonasal approach for selected pituitary adenomas: early experience. J Neurosurg 2011; 114 (2) 345-353
    CrossrefPubMedGoogle Scholar
  • 14 Spaziante R, de Divitiis E, Cappabianca P. Reconstruction of the pituitary fossa in transsphenoidal surgery: an experience of 140 cases. Neurosurgery 1985; 17 (3) 453-458
    CrossrefPubMedGoogle Scholar
  • 15 Seiler RW, Mariani L. Sellar reconstruction with resorbable Vicryl patches, gelatin foam, and fibrin glue in transsphenoidal surgery: a 10-year experience with 376 patients. J Neurosurg 2000; 93 (5) 762-765
    CrossrefPubMedGoogle Scholar
  • 16 Yin J, Su CB, Xu ZQ, Xia XW, Song F. Reconstruction of the sellar floor following transsphenoidal surgery using gelatin foam and fibrin glue. Chin Med Sci J 2005; 20 (3) 198-201
    PubMedGoogle Scholar
  • 17 Kelly DF, Oskouian RJ, Fineman I. Collagen sponge repair of small cerebrospinal fluid leaks obviates tissue grafts and cerebrospinal fluid diversion after pituitary surgery. Neurosurgery 2001; 49 (4) 885-889 ; discussion 889–890
    PubMedGoogle Scholar
  • 18 Cappabianca P, Cavallo LM, Valente V , et al. Sellar repair with fibrin sealant and collagen fleece after endoscopic endonasal transsphenoidal surgery. Surg Neurol 2004; 62 (3) 227-233 ; discussion 233
    CrossrefPubMedGoogle Scholar
  • 19 Sherman JH, Pouratian N, Okonkwo DO, Jane Jr JA, Laws ER. Reconstruction of the sellar dura in transsphenoidal surgery using an expanded polytetrafluoroethylene dural substitute. Surg Neurol 2008; 69 (1) 73-76 ; discussion 76
    CrossrefPubMedGoogle Scholar
  • 20 Cappabianca P, Cavallo LM, Mariniello G, de Divitiis O, Romero AD, de Divitiis E. Easy sellar reconstruction in endoscopic endonasal transsphenoidal surgery with polyester-silicone dural substitute and fibrin glue: technical note. Neurosurgery 2001; 49 (2) 473-475 ; discussion 475–476
    CrossrefPubMedGoogle Scholar
  • 21 El-Banhawy OA, Halaka AN, El-Dien AE, Ayad H. Sellar floor reconstruction with nasal turbinate tissue after endoscopic endonasal transsphenoidal surgery for pituitary adenomas. Minim Invasive Neurosurg 2003; 46 (5) 289-292
    Google Scholar
  • 22 Kubo S, Inui T, Hasegawa H, Yoshimine T. Repair of intractable cerebrospinal fluid rhinorrhea with mucosal flaps and recombinant human basic fibroblast growth factor: technical case report. Neurosurgery 2005; 56 (3) E627 ; discussion E627
    CrossrefPubMedGoogle Scholar
  • 23 Arita K, Kurisu K, Tominaga A , et al. Size-adjustable titanium plate for reconstruction of the sella turcica. Technical note. J Neurosurg 1999; 91 (6) 1055-1057
    Google Scholar
  • 24 Dusick JR, Mattozo CA, Esposito F, Kelly DF. BioGlue for prevention of postoperative cerebrospinal fluid leaks in transsphenoidal surgery: A case series. Surg Neurol 2006; 66 (4) 371-376 ; discussion 376
    CrossrefPubMedGoogle Scholar
  • 25 Seda L, Camara RB, Cukiert A, Burattini JA, Mariani PP. Sellar floor reconstruction after transsphenoidal surgery using fibrin glue without grafting or implants: technical note. Surg Neurol 2006; 66 (1) 46-49 ; discussion 49
    CrossrefPubMedGoogle Scholar
  • 26 Wang YY, Kearney T, Gnanalingham KK. Low-grade CSF leaks in endoscopic trans-sphenoidal pituitary surgery: efficacy of a simple and fully synthetic repair with a hydrogel sealant. Acta Neurochir (Wien) 2011; 153 (4) 815-822
    CrossrefPubMedGoogle Scholar
  • 27 Kassam A, Carrau RL, Snyderman CH, Gardner P, Mintz A. Evolution of reconstructive techniques following endoscopic expanded endonasal approaches. Neurosurg Focus 2005; 19 (1) E8
    PubMedGoogle Scholar
  • 28 Schaberg MR, Anand VK, Schwartz TH. 10 pearls for safe endoscopic skull base surgery. Otolaryngol Clin North Am 2010; 43 (4) 945-954
    CrossrefPubMedGoogle Scholar
  • 29 Zanation AM, Thorp BD, Parmar P, Harvey RJ. Reconstructive options for endoscopic skull base surgery. Otolaryngol Clin North Am 2011; 44 (5) 1201-1222
    CrossrefPubMedGoogle Scholar
  • 30 Zanation AM, Carrau RL, Snyderman CH , et al. Nasoseptal flap reconstruction of high flow intraoperative cerebral spinal fluid leaks during endoscopic skull base surgery. Am J Rhinol Allergy 2009; 23 (5) 518-521
    CrossrefPubMedGoogle Scholar
  • 31 Rawal RB, Kimple AJ, Dugar DR, Zanation AM. Minimizing morbidity in endoscopic pituitary surgery: outcomes of the novel nasoseptal rescue flap technique. Otolaryngol Head Neck Surg 2012; 147 (3) 434-437
    CrossrefPubMedGoogle Scholar