Endoscopic Endonasal Infrasellar Approach to the Sellar and Suprasellar Regions: Technical Note

ABSTRACT

We report a technical variation of the endoscopic endonasal approach to the sellar and suprasellar regions which relies on the use of a 45-degree angled endoscope. The so-called “infrasellar approach” aims at excising lesions situated within the intermediate and posterior lobes of the pituitary gland without damaging the anterior lobe, thus potentially minimizing endocrinological morbidity. In this regard the endoscopic infrasellar approach might be advantageous in selected cases when compared with the traditional transsphenoidal approach with the microscope. We describe the technique and illustrate it with representative clinical cases.

KEYWORDS

Endoscopic endonasal approach - infrasellar approach - 45-degrees angled endoscope - Rathke's cleft cysts - Cushing disease - hypothalamic pilocytic astrocytoma

REFERENCES

• 1 Dehdashti A R, Ganna A, Karabatsou K, Gentili F. Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series.  Neurosurgery. 2008;  62 (5) 1006-1015, discussion 1015–1017
• 2 Kassam A, Snyderman C H, Mintz A, Gardner P, Carrau R L. Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica.  Neurosurg Focus. 2005;  19 (1) E3
• 3 Kassam A, Snyderman C H, Mintz A, Gardner P, Carrau R L. Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum.  Neurosurg Focus. 2005;  19 (1) E4
• 4 Kassam A B, Thomas A, Carrau R L et al.. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap.  Neurosurgery. 2008;  63 ONS44-ONS52 discussion ONS52-ONS43
• 5 Aydin S, Cavallo L M, Messina A et al.. The endoscopic endonasal trans-sphenoidal approach to the sellar and suprasellar area. Anatomic study.  J Neurosurg Sci. 2007;  51 (3) 129-138
• 6 Cappabianca P, Cavallo L M, Esposito F, De Divitiis O, Messina A, De Divitiis E. Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery.  Adv Tech Stand Neurosurg. 2008;  33 151-199
• 7 Cavallo L M, Messina A, Cappabianca P et al.. Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations.  Neurosurg Focus. 2005;  19 (1) E2
• 8 de Divitiis E, Cavallo L M, Cappabianca P, Esposito F. Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: Part 2.  Neurosurgery. 2007;  60 46-58 discussion 58-49
• 9 Maartens N F, Kaye A H. Role of transcranial approaches in the treatment of sellar and suprasellar lesions.  Front Horm Res. 2006;  34 1-28
• 10 Schwartz T H, Fraser J F, Brown S, Tabaee A, Kacker A, Anand V K. Endoscopic cranial base surgery: classification of operative approaches.  Neurosurgery. 2008;  62 (5) 991-1002, discussion 1002–1005
• 11 Solov'ev G S, Bogdanov A V, Panteleev S M, Yanin V L. Embryonic morphogenesis of the human pituitary.  Neurosci Behav Physiol. 2008;  38 (8) 829-833
• 12 Buchfelder M, Schlaffer S. Pituitary surgery for Cushing's disease.  Neuroendocrinology. 2010;  92 (Suppl 1) 102-106
• 13 Knappe U J, Engelbach M, Konz K et al.. Ultrasound-assisted microsurgery for Cushing's disease.  Exp Clin Endocrinol Diabetes. 2009;  119 (4) 191-200
• 14 Weil R J, Vortmeyer A O, Nieman L K, Devroom H L, Wanebo J, Oldfield E H. Surgical remission of pituitary adenomas confined to the neurohypophysis in Cushing's disease.  J Clin Endocrinol Metab. 2006;  91 (7) 2656-2664
• 15 Madhok R, Prevedello D M, Gardner P, Carrau R L, Snyderman C H, Kassam A B. Endoscopic endonasal resection of Rathke cleft cysts: clinical outcomes and surgical nuances.  J Neurosurg. 2010;  112 (6) 1333-1339
• 16 Lamberts S W, de Lange S A, Stefanko S Z. Adrenocorticotropin-secreting pituitary adenomas originate from the anterior or the intermediate lobe in Cushing's disease: differences in the regulation of hormone secretion.  J Clin Endocrinol Metab. 1982;  54 (2) 286-291
• 17 Nagaya T, Kuwayama A, Seo H, Tsukamoto N, Matsui N, Sugita K. Endocrinological evaluation of ACTH-secreting pituitary microadenomas: their location and alpha-melanocyte stimulating hormone immunoreactivity.  J Neurosurg. 1992;  76 (6) 944-947
• 18 Gardner P A, Kassam A B, Snyderman C H et al.. Outcomes following endoscopic, expanded endonasal resection of suprasellar craniopharyngiomas: a case series.  J Neurosurg. 2008;  109 (1) 6-16
• 19 Jane Jr J A, Kiehna E, Payne S C, Early S V, Laws Jr E R. Early outcomes of endoscopic transsphenoidal surgery for adult craniopharyngiomas.  Neurosurg Focus. 2010;  28 (4) E9
• 20 Tomita T, Gates E. Pituitary adenomas and granular cell tumors. Incidence, cell type, and location of tumor in 100 pituitary glands at autopsy.  Am J Clin Pathol. 1999;  111 (6) 817-825