Endoscopic Trans-sphenoidal Surgery in the Sellar and Parassellar Region

Purpose: Endoscopy has recently been introduced in trans-sphenoidal pituitary surgery as it minimizes surgical trauma to the patient and at the same time provides the surgeon with an excellent illumination of anatomical structure, high magnification, and viewing angles around the corner during the procedure. However, neurosurgeons are used to the handling and the three-dimensional picture of an operating microscope. Thus, a learning curve is needed for this new technique. The question arises whether microsurgery as first step followed by pure endoscopic surgery or endoscopic surgery alone is preferable.

Method: For endoscopy-assisted microsurgery, the transnasal trans-sphenoidal procedure was performed with the aid of an operating microscope and a nasal speculum. Close to the end of tumor resection, angled endoscopes at 30- or 45-degree tip angle were used to check for residual tumor in the parasellar compartments and for direct visualization of the intracavernous internal carotid artery during resection of these critical areas. For the pure endoscopic approach, a transnasal trans-sphenoidal approach was performed using 0-degree endoscopes initially and 30- to 45-degree endoscopes during supra- and parasellar tumor resection.

Result: We report on our experience using a stepwise approach to reach this goal, from endoscopy-assisted surgery to the pure endoscopic videosurgical technique. Before 1995, microsurgical trans-sphenoidal surgeries were performed in our departments without the aid of an endoscope. From 1995 to 2002 we operated on 127 patients with pituitary adenoma using an endoscopic-assisted microsurgical procedure (group 1). From 2002 a purely endoscopic procedure was performed in more than 50 patients (group 2). The operating room setup, special endoscopic equipment, and steps of the surgical approach are highlighted. Advantages and pitfalls of either method, outcomes, and complications are discussed. In a third group, we will discuss the possibilities of endoscopic surgery in nonpituitary pathologies of the sellar and parasellar region.

Conclusion: The advantage using the two-step approach to realize endoscopic trans-sphenoidal surgery is that one can see the advantages of endoscopes during surgery immediately without changing the surgical techniques. Understanding the significant advantages of using endoscopes may make surgeons more ready to change their surgical-endoscopic-technique.