Endoscopic Endonasal Pituitary Surgery: Evolution of Surgical Technique and Equipment in 150 Operations

Objective: The evolution of the senior author's (HD Jho) surgical experience on endoscopic endonasal transsphenoidal pituitary surgery is reviewed in order to introduce a standardized surgical technique for pituitary endoscopy. Methods: The progressive evolution of the surgical technique and the development of surgical instrumentation in transsphenoidal endoscopy is reviewed based upon the experience of more than 150 operations performed by the senior author between the years 1993 and 1998. Results: An endoscope was used to assist visualization during conventional microscopic surgery in the first four cases (endoscope-assisted microsurgery). Subsequently, endonasal pituitary endoscopy was performed via a nostril. When the endonasal route was adopted, it eliminated the use of a transsphenoidal retractor. The use of vasoconstrictors and any form of nasal packing was discovered to be unnecessary. The inferior margin of the middle turbinate was such a consistent surgical landmark leading to the sella that the use of an intraoperative fluoroscopic C-arm was also eliminated. The adoption of a septal breaker, variously angled suction cannulas and suction-coagulators has made the operation cleaner, easier and faster. As experience increased, the operation time progressively shortened and mucosal trauma became minimal. The median patient hospital stay was one night and postoperative discomfort was noted to be minimal. Conclusions: The evolution of the senior author's endoscopic pituitary surgery is reported with a description of our current standardized surgical technique.

Key words:

Acromegaly - Cushing's Disease - Endoscopy - Pituitary Adenoma - Pituitary Gland - Prolactinoma - Transsphenoidal Surgery

References

• 1 Carrau R L, Jho H D, Ko Y. Transnasal-transsphenoidal endoscopic surgery of the pituitary gland.  Laryngoscope. 1996;  106 914-918
• 2 Jho H D. Endoscopic endonasal pituitary surgery: Technical aspects.  Contemporary Neurosurgery. 1997;  19 (6) 1-7
• 3 Jho H D, Carrau R L, Ko Y. Endoscopic pituitary surgery. In: Wilkins RH, Rengachary SS (eds). Neurosurgical operative atlas Baltimore: Williams & Wilkins vol. 5 (1) 1996: 1-12
• 4 Jho H D, Carrau R L. Endoscopy assisted transsphenoidal surgery for pituitary adenoma. Technical note.  Acta Neurochir (Wien). 1996;  138 1416-1425
• 5 Jho H D, Carrau R L. Endoscopic endonasal transsphenoidal surgery: Experience with 50 patients.  J Neurosurg. 1997;  87 44-51
• 6 Jho H D, Carrau R L, McLaughlin M L, Somaza S C. Endoscopic transsphenoidal resection of a large chordoma in the posterior fossa.  Acta Neurochir (Wien). 1997;  139 343-348
• 7 Jho H D, Carrau R L, Ko Y, Daly M. Endoscopic pituitary surgery: An early experience.  Surg Neurol. 1997;  47 213-223
• 8 Stammberger H. Endoscopic endonasal surgery - concepts in treatment of recurring rhinosinusitis. Part II. Surgical technique.  Otolaryngol Head Neck Surg. 1986;  94 147-156
• 9 Cappabianca P, Alfieri A, de Divitiis E. Endoscopic endonasal transsphenoidal approach to the sella: Towards functional endoscopic pituitary surgery (FEPS).  Minim Invas Neurosurg. 1998;  41 66-73
• 10 Gamea A, Fathi M, EL-Guindy A. The use of the rigid endoscope in trans-sphenoidal pituitary surgery.  J Laryngol Otol. 1994;  108 19-22
• 11 Guiot G, Rougerie J, Fourestler A, Fournier A, Comoy C, Vulmiere J, Groux R. Une nouvelle technique endoscopique. Exploration endoscopiques intracraniennes.  La Presse Medicale. 1963;  71 1225-1228
• 12 Heilman C B, Shucart W A, Rebeiz E E. Endoscopic sphenoidotomy approach to the sella.  Neurosurgery. 1997;  41 602-607
• 13 Helal M Z. Combined micro-endo trans-sphenoid excisions of pituitary macroadenomas.  Eur Arch Otorhinolaryngol. 1995;  252 (3) 186-189
• 14 Jankowski R, Auque J, Simon C, Marchal J C, Hepner H, Wayoff M. Endoscopic pituitary tumor surgery.  Laryngoscope. 1992;  102 198-202
• 15 Rodziewicz G S, Kelly R T, Kellman R M, Smith M V. Transnasal endoscopic surgery of the pituitary gland: Technical note.  Neurosurgery. 1996;  39 189-193
• 16 Sethi D S, Pillay P K. Endoscopic management of lesions of the sella turcica.  J Laryngol Otol. 1995;  109 (10) 956-962
• 17 Shikani A H, Kelly J H. Endoscopic debulking of a pituitary tumor.  Am J Otolaryngol. 1993;  14 (4) 254-256
• 18 Wurster C F, Smith D E. The endoscopic approach to the pituitary gland (letter).  Arch Otolaryngol Head Neck Surg. 1994;  120 674
• 19 Yaniv E, Rappaport Z H. Endoscopic transseptal transsphenoidal surgery for pituitary tumors.  Neurosurgery. 1997;  40 944-946
• 20 Landolt A M. History of transsphenoidal pituitary surgery. In: Landolt AM, Vance ML, Reilly PL (eds). Pituitary adenomas Churchill Livingstone 1996: 307-314
• 21 Griffith H B, Veerapen R. A direct transnasal approach to the sphenoid sinus. Technical Note.  Neurosurg. 1987;  66 140-142
• 22 Cooke R S, Jones R AC. Experience with the direct transnasal transsphenoidal approach to the pituitary fossa.  Br J Neurosurg. 1994;  8 193-196

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