Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas

Summary

The aim of this paper is to describe the different steps of the endoscopic endonasal approach to the sella turcica.

Abstract

Endoscopic endonasal trans-sphenoidal surgery has become the gold standard for the surgical treatment of pituitary adenomas and many other pituitary lesions. Refinements in surgical techniques, technological advancements, and incorporation of neuronavigation have rendered this surgery minimally invasive. The complication rates of this surgery are very low while excellent results are consistently obtained through this approach.

This paper focuses on the step-by-step surgical approach to pituitary adenomas, which is based on personal experience, and details the results obtained with this minimally invasive surgery.

Introduction

The introduction of endoscopic techniques to the skull base surgery has markedly improved the outcomes of skull base surgery when used in itself or as an adjunct to standard microsurgical approaches. The endoscopic endonasal approach was initially introduced to treat sellar lesions¹, but during the last two decades the applications of this technique have expanded thanks to significant technological improvements and increased surgical experience. The endoscopic approach is now also used for lesions of the anterior and antero-lateral skull base through extended midline and paramedian approaches. Approaches from the anterior skull base to the odon....

Protocol

The protocol here illustrated follows the guidelines of the human research ethics committee at the University Hospital of Lausanne.

NOTE: The procedure explained here is focused on the classical approach performed for pituitary adenomas.

1. Preoperative Protocol

1. Systematically perform a pre-operative craniofacial CT-Scan and MRI, along with the endocrinological and ophthalmological assessments.

2. Positioning and Anesthesia

1. Induce general anesthesia and perform orotracheal intubation.
2. Place the patient in the supine position after general anesth....

Results

Since 2009, our pituitary program has evolved to a point where a fully endoscopic endonasal approach has been used to treat pituitary tumors with excellent postoperative results. From 2009 to 2016, the two senior surgeons (RTD and MM) operated on 473 patients with pituitary adenomas through a full endoscopic technique. The histology is detailed in Table 1: most of these cases were non-functioning pituitary adenomas (57%) (Figure 1), followed .......

Discussion

For the majority of pituitary tumors, surgery remains the first-line treatment in case of symptomatic patients^19,20. Only for prolactin (PRL)-secreting adenomas, the first-line of treatment is dopamine agonists and surgery is chosen secondarily when medical treatment fails²¹.

Since the introduction of the endoscope in the field of skull base surgery in the early 1990's^22,

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
The StealthStation surgical navigation system	Medtronic	ENT Fusion Software 9733652
4-mm 18cm 0° rigid endoscope	Karl Storz	28132AA
4-mm 18cm 30° rigid endoscope	Karl Storz	28132BVA
4-mm 18cm 45° rigid endoscope	Karl Storz	28132FVA
Suction Tube	Karl Storz	28164XA
Coagulation Cannulas	Karl Storz	28164MXB
Bipolar Forceps	Karl Storz	28164BDB
Kerrison Bone Punches	Karl Storz	28164MKA
Kerrison Bone Punches	Karl Storz	28164MKB
Kerrison Bone Punches	Karl Storz	28164MKC
Ring Curettes	Karl Storz	28164RN
Ring Curettes	Karl Storz	28164RO
Ring Curettes	Karl Storz	28164RI
Ring Curettes	Karl Storz	28164RG
Ring Curettes	Karl Storz	28164GLL
Ring Curettes	Karl Storz	28164GLR
de DIVITIS-CAPPABIANCA Scalpels	Karl Storz	28164M
Forceps	Karl Storz	28164TD
High-speed drill	Midas Rex Medtronic	1898430
Hemostatic agent	Floseal, Baxter	1503350
Fibrin sealant	Tisseel, Baxter	600065
CT Lightspeed	GE medical systems, Milwaukee, WI, USA
Carestream Vue PACS	Carestream Health, Rochester, NY, USA
3-Tesla Siemens Tim Trio scanner	Siemens AG, Erlangen, Germany