Elsevier

Surgical Neurology

Volume 53, Issue 2, February 2000, Pages 168-173
Surgical Neurology

Endoscopy
Endoscopic-guided direct endonasal approach for pituitary surgery

https://doi.org/10.1016/S0090-3019(99)00195-0Get rights and content

Abstract

BACKGROUND

Submucosal dissection of the nasal septum is often performed as part of the transseptal approach to the sella. To evaluate whether this submucosal dissection is a necessary component of this operation, we compared the morbidity of a direct transmucosal endonasal approach to that of the transseptal approach in patients undergoing pituitary surgery.

METHODS

Forty-one consecutive patients undergoing pituitary surgery from January 1996 to March 1999 were included in this study. The first 21 patients underwent the standard transseptal operation through either a sublabial or columellar incision. The latter 20 patients were operated on through an endoscopically guided, direct endonasal exposure, without any submucosal dissection of the nasal septum. The operative morbidity, the duration of surgery, and the length of hospitalization for each group were compared.

RESULTS

The sphenoid sinus exposure obtained through the endonasal route was comparable with the transseptal approach and was adequate for resection of most pituitary tumors. Although the morbidity of the two approaches was similar, patients undergoing the endonasal operation had less postoperative facial pain. Furthermore, the endonasal approach significantly decreased the length of the operation (116 minutes vs. 161 minutes, p = 0.002) and the duration of hospitalization (3.6 vs. 5.1 days, p = 0.003) as compared with the transseptal route.

CONCLUSIONS

Morbidity of the endonasal approach to the sphenoid sinus is comparable to that of a conventional transseptal approach. By eliminating the submucosal dissection, the endonasal approach reduces postoperative facial discomfort and decreases length of surgery and hospitalization.

Section snippets

Patient population

During a 3-year period (01/96–03/99), 41 patients underwent pituitary surgery by the senior author (BB) at the University of Wisconsin, Madison. The first 21 patients were approached through a TS route, whereas the latter 20 patients were operated on via a direct EN approach with endoscopic guidance. Most (34 of 41, 83%) procedures were done for resection of pituitary adenomas. Other patients included three with Rathke’s cleft cysts (7%), one with craniopharyngioma (2%), one with germinoma

Surgical exposure

The extent of sphenoid sinus exposure gained through the EN route was comparable to that of the TS approach as performed through a columellar incision. Except for one patient with a giant prolactinoma and abnormally enlarged sella, the EN approach allowed for visualization of the entire sella and was adequate for resection of most tumors in this series (see below). In contrast to the sublabial TS approach, however, the EN route provided a narrower path and a more limited exposure of both

Discussion

The art of pituitary surgery has been refined since Horsley’s first attempted pituitary tumor resection in 1886. Constant challenge from suboptimal operating conditions and from high surgical morbidity and mortality in the early years has been the driving force for fresh ideas and has brought forth new techniques in the field of pituitary surgery. Inspired by Kanavel and Hirsch, and later by Halstead, Harvey Cushing developed the sublabial transsphenoidal approach to the sella. Although this

Acknowledgements

The authors thank Ms. Pat Giuliani for editorial support.

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