Beyond the Learning Curve: Comparison between Microscopic and Endoscopic Approaches in a Series of Highly Experienced Modern Operators

Background: Internal carotid artery (ICA) injury is the most feared and potentially morbid adverse complication of transsphenoidal resection (TSR) for pituitary adenomas. As the endoscopic endonasal approach (EEA) has gained popularity as an alternative to microsurgery (MS) for TSR, numerous studies have attempted to assess the differential risk of ICA injury between the techniques, yet results have been equivocal and contradictory. Our objective was to systematically review and compare MS versus EEA with respect to ICA injury in a cohort of highly experienced neurosurgeons.

Methods: Systematic literature review (2002–2017) of publications reporting ICA injury outcomes in ≥250 cases of either MS or EEA.

Results: Seventeen series met inclusion criteria, reporting a total 11,149 patients (Fig. 1; Table 1). Three were MS series, 13 were EEA, and 1 included adequate samples for each technique. Individual cohorts ranged from 275 to 3,000, with reported ICA injury incidences from 0.0 to 1.6%. MS series documented 5 ICA injuries in 2,672 operations, an overall incidence of 0.2% (range: 0.0–0.4%), while EEA series reported 30 injuries in 8,477 operations, a 0.4% injury rate (range: 0.0–1.6%), a difference that was not significant (Table 2; p = 0.25). Increased operative experience was associated with decreased ICA injury incidence, a finding that was preserved in the overall study cohort, and within the discretely examined MS and EEA subgroups (Fig. 2A–C; overall r ² = 0.08, MS r ² = 0.23, EEA r ² = 0.07).

Conclusion: ICA injury is the most threatening complication of TSR for pituitary neoplasms, and operator inexperience appears to be the most significant risk factor, with comparably low rates of injury obtained by highly experienced surgeons independent of technique. This finding emphasizes the need for consolidated care in pituitary centers of excellence, improvement of high-fidelity simulators, and perhaps most importantly, focused skull base mentorship between senior and junior staff surgeons, particularly during the earliest phase of case accumulation.

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