Endoscopic transsphenoidal approach technique

J.Sales-Llopis

Neurosurgery Department, Alicante University General Hospital, Alicante, Spain.

• Early Predictors of Remission in Acromegaly Patients after Pure Endoscopic Endonasal Transsphenoidal Surgery
• Augmented reality system for endoscopic pituitary surgery with automatic registration
• First-in-human pilot study of snapshot multispectral endoscopy for delineation of pituitary adenoma
• AENEAS Project: Live Image-Based Navigation and Roadmap Generation in Endoscopic Neurosurgery Using Machine Vision
• Craniopharyngiomas in children: the pendulum moves again for an aggressive surgery-late complications and considerations with a recent series of 26 patients treated in Lyon
• Endoscopic Excision of Transsellar Transsphenoidal Meningoencephalocele Utilizing the Slip-Knot Technique
• Tension pneumosella following transsphenoidal surgery: A systematic review
• Development and validation of a predictive machine learning model for postoperative long-term diabetes insipidus following transsphenoidal surgery for sellar lesions

The endoscopic endonasal transsphenoidal approach is a minimally invasive surgical technique for the removal of the sellar region lesion and parasellar lesions. The procedure is performed via an anterior sphenoidotomy. The two main characteristics of the endoscopic approach, when compared with the standard microsurgical operation, arise from the use of the endoscope as a unique optical device and from the absence of a transsphenoidal retractor. More convenient straight surgical instruments are employed, whereas bayonet-shaped tools are used in the microsurgical procedure, to avoid any interference with the light beam generated by the microscope. The standard surgical technique is composed of three main time phases: the nasal, sphenoid, and sellar phases. During the nasal phase, the scope is introduced through the chosen nostril and advanced up to the sphenoethmoid recess, where the sphenoidotomy is performed. The sphenoid phase consists of the detachment of the nasal septum from the sphenoid rostrum, the anterior sphenoidotomy, removal of the sphenoid septum or septa, and identification of the landmarks inside the sphenoid sinus. In the sellar phase, an opening of the sellar floor is performed for removal of the lesion. A wide view of the sellar environment is obtained through angled scopes to detect eventual tumor remnants. The procedure ends with the reconstruction of the sella and removal of the endoscope from the nostril, without any postoperative nasal packing ¹⁾.

Supine position with the trunk raised 10º and the head in neutral position rotated 10º towards the surgeon. The head is secured in a Horseshoe Headrest without rigid three-pin fixation. The nose is prepared by placing pledgets soaked with 0.02% of Oxymetazoline into each nostril, followed by Povidone Iodine solution applied over the nose and upper lip as well as into the nares with cotton tip applicators.

Under general anesthesia, orotracheal intubation, and antibiotic prophylaxis with cefazolin 2 gr IV. Supine position with a neutral head resting on a donut-type pillow. Preoperative topical intranasal oxymetazoline was applied with lectins.

Right middle turbinate resection. Preparation of a nasoseptal flap with mucosa from the right septum. It is left lodged in the right choana. Posterior septostomy and communication of both nostrils. In the ostium, a tumor is visualized that completely occupies the sphenoid sinus. Wide anterior sphenoidotomy Profuse bleeding throughout the nasal phase comes from the tumor. Part of the left paramedian septum that was encompassed by the tumor was removed.

Excision of the tumor part contained in the sphenoid sinus until the bony limits of the sella turcica were visualized. With the help of neuronavigation and Doppler, both ICAs were located. Clivus partly eroded. In the most inferior and posterior parts, a bone area corresponding to the posterior clinoid is observed, which is moth-eaten and loose, encompassed by a tumor. Intracapsular excision of the tumor is started by way of debulking and sending tumor samples for AP analysis. The tumor shows a friable consistency and a purplish color compatible with a pituitary neuroendocrine tumor. Central excision until visualizing gradual descent of sellar and arachnoid diagrams in the sellar cavity with contained low-flow fistula. Exeresis in the posterior region until observing the dura mater of the posterior fossa. Excision of the lateral walls and part of the cavernous sinus. Hemostasis with Floseal.

Tachosil is placed covering the arachnoid in the area of ​​the contained fistula. A nasoseptal flap is placed in contact with the bone defect around the sellar opening. The flap is fixed with surgicel and tissucol. Rapid -Rhino binasal tires are left. The free mucosa of the middle turbinate is left covering the part of the septum from which the flap has been removed.

see Nasoseptal flap for anterior skull base reconstruction.

Establishing a reconstruction protocol for cerebrospinal fluid fistula prevention in patients undergoing pituitary neuroendocrine tumor surgery is crucial for facilitating intraoperative decision-making and reducing the incidence of complications.

pituitary neuroendocrine tumor surgery is traditionally within the realm of the neurosurgeon. However, since the reintroduction of the transseptal transsphenoidal approach and Endoscopic transsphenoidal approach to the sella turcica for resection of pituitary neuroendocrine tumor, otolaryngologists have been active partners in the surgical management of these patients.

Otolaryngologists have lent their expertise in nasal and sinus surgery, assisting the neurosurgeon with the operation. The otolaryngologist has the advantage of familiarity with the techniques and instruments used to gain exposure of the sella turcica by transnasal approach. Hence, the otolaryngologist provides the exposure, and the neurosurgeon resects the tumour. Such collaboration has resulted in decreased rates of complication and morbidity ²⁾.

Randomized multicenter studies are necessary to resolve the controversy over endoscopic and microsurgical approaches in hypophyseal pathology ³⁾.

Racial, ethnic, and socioeconomic disparities exist for outcomes after pituitary surgery. Black and Hispanic patients have worse postoperative outcomes compared to white patients, as well as disproportionate utilization of Medicaid and low-volume pituitary surgery centers. Further investigations are necessary to uncover the sources of these disparities in an effort to provide safer and more affordable care to all patients ⁴⁾.

Racial and socioeconomic factors play a significant role in the admission of patients to high-volume pituitary surgery centers ⁵⁾.

Patients undergoing transsphenoidal pituitary surgery at high-volume centers (HVCs) have shorter hospitalizations, fewer postoperative electrolyte abnormalities, and lower charges; however, socioeconomic factors may influence access to quality care ⁶⁾.