====== Transsphenoidal approach ======

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===== History =====

As an alternative to the [[transcranial]] route the [[transsphenoidal]] approach was developed simultaneously in the first decade of the 20th century in the [[United States]] and in [[Europe]], in particular in the [[Austria]]n monarchy. One reason that [[Vienna]] became the cradle for the minimally invasive approach to [[pituitary tumor]]s using an [[endonasal]] [[transsphenoidal approach]] was among others due to the basic and detailed anatomical studies of the [[paranasal sinus]]es performed in Vienna by the Austrian anatomist and Violin virtuoso [[Emil Zuckerkandl]] (1849–1910). His main work “On normal and pathological anatomy of the paranasal sinus and its pneumatic adnexes” in [[1882]] was the anatomical presupposition for the Viennese ENT surgeons to successfully develop minimally invasive endonasal approaches to pituitary tumors
((Zuckerkandl E. Normale und pathologische Anatomie der Nasenhöhlen und ihrer pneumatisierten Anhänge. Vienna, Austria: Braumüller; 1882.)).

Initially described by [[Hans Schloffer]]
((Schloffer H: Erfolgreiche Operation eines Hypophysentumors auf nasalem
Wege [Successful operation of a hypophyseal tumor through the nasal pas-
sage]. Wien Klin Wochnschr 20:621–624, 1907.)) 
and Cushing 
((Cushing H: III. Partial hypophysectomy for acromegaly: With remarks on the function of the hypophysis. Ann Surg 50:1002–1017, 1909.))
and subsequently popularized by Guiot 
((Guiot G: Transsphenoidal approach in the surgical treatment of pituitary neuroendocrine tumors: General principles and indications in non-functioning adenomas, in Kohler PO, Ross GT (eds): Diagnosis and Treatment of Pituitary Tumors. New York, American Elsevier, 1973, pp 159–178.))
and Hardy and Wigser 
((Hardy J, Wigser SM: Trans-sphenoidal surgery of pituitary fossa tumors with televised radiofluoroscopic control. J Neurosurg 23:612–619, 1965.)),
the transsphenoidal approach to the sella now represents the preferred approach for removing pituitary neuroendocrine tumors. Traditionally performed with a microscope and a sublabial incision, the implementation of the endoscope and endonasal access has rendered the transsphenoidal approach less invasive and provided improved visualization into and around the sella.

===== Endoscopic transsphenoidal approach =====

[[Endoscopic transsphenoidal approach]].

===== Guidelines =====

see [[Transsphenoidal approach guidelines]].

===== Indications =====

[[Transsphenoidal Approach Indications]].



===== Pre-op orders =====

1. for transsphenoidal approach: Polysporin® ointment (PSO) applied in both nostrils the night before surgery

2. antibiotics: e.g. Unasyn® 1.5 gm (1 gm ampicillin + 0.5 gm sulbactam) IVPB at MN & 6 AM

3. steroids, either:

a) hydrocortisone sodium succinate(Solu-Cortef®)50mg IM at 11 PM & 6 AM.On call to OR: hang 1 L D5LR + 20 mEq KCl/l + 50 mg Solu-Cortef at 75 ml/hr

OR

b) hydrocortisone 100mg PO at MN&IV at 6AM

4. intra-op: continue 100 mg hydrocortisone IV q 8 hrs

===== Complications =====
see [[Transsphenoidal approach complications]].

====Difficulties====
Difficulties achieving radical resection with this method are encountered in patients with [[pituitary neuroendocrine tumor]]s (PA) invading the [[cavernous sinus]] (CS), due to the inability of the standard transsphenoidal approach to expose all tumors adequately.

===== Case series =====

[[Transsphenoidal approach case series]].