Peer-Review Reports

Endoscopic Endonasal Surgery for Pituitary Adenomas Paolo Cappabianca, Luigi Maria Cavallo, Domenico Solari, Vita Stagno, Felice Esposito, Michelangelo de Angelis

Key words Endoscopic endonasal surgery - Neuroendoscopy - Pituitary adenoma - Pituitary surgery - Transsphenoidal surgery -

Abbreviations and Acronyms CSF: Cerebrospinal fluid ICA: Internal carotid artery Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy To whom correspondence should be addressed: Paolo Cappabianca, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2014) 82, 6S:S3-S11. http://dx.doi.org/10.1016/j.wneu.2014.07.019 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.

INTRODUCTION The use of the endoscope through an endonasal route requires detailed knowledge of the anatomic structures and their variations. In addition, precise technical skills are needed, combined with an appreciation of the pituitary pathophysiology to guarantee a residual pituitary function and to attain the lowest rates of morbidity and mortality in a safe and practical way. It is simplified to consider endoscopic pituitary surgery as merely a surgical procedure, rather the final result is a close cooperation between different specialists (e.g., ophthalmologists, neuroradiologists, endocrinologists, neurosurgeons, otorhinolaryngologists, anesthesiologists, neurophysiologists, pathologists, instrument manufacturers) (7, 36). The endoscope was introduced in clinical neurosurgical practice in 1963 by Gerard Guiot et al. (31) who first proposed its use during a classic transsphenoidal transnasorhinoseptal approach to explore the sellar cavity. However, the idea remained unrecognized until the further contribution of Apuzzo et al. (1) in 1977, followed by Bushe and Halves (2) who shed light again

- BACKGROUND:

Pituitary surgery is a continuous evolving specialty of the neurosurgeons’ armamentarium, which requires precise anatomic knowledge, technical skills, and integrated culture of the pituitary pathophysiology. Actually it cannot be considered only from a technical standpoint, but rather a procedure resulting from the close cooperation among different specialists (e.g., ophthalmologists, neuroradiologists, endocrinologists, neurosurgeons, otorhinolaryngologists, anesthesiologists, neurophysiologists, pathologists, instrument manufacturers). The “pure” endoscopic endonsal surgery is a procedure performed through the nose, with the endoscope alone throughout the whole approach and without any transsphenoidal retractor. The procedure consists of three main aspects: exposure of the lesion, removal of the relevant pathology, and reconstruction, going through three different steps, the nasal, the sphenoid, and the sellar phases.

- METHODS:

- CONCLUSIONS:

The endoscopic approach offers some advantages due to the endoscope itself: a superior close-up view of the relevant anatomy and an enlarged working angle are provided with an increased panoramic vision inside the surgical area. Concerning results in terms of mass removal, relief of clinical symptoms, cure of the underlying disease, and complication rate, these are, at least, similar to those reported in the major microsurgical series, but patient compliance is by far better. Besides the advantages to the patients, the surgeons— because of the wider and closer view of the surgical target area and the increase of the scientific activity as from the peer-reviewed literature on the topic in the past 10 years, the smoothing of interdisciplinary cooperation—, and the institutions (shorter postoperative hospital stay and increase of the case load)— the adoption of endoscopy in transsphenoidal surgery has gained a strong foothold.

on the use of the endoscope. Its use was further developed thanks to optical technical advances. Nevertheless, the endoscope was adopted only in selected cases to complement the microscope in the early or late stages of a traditional procedure, determining the first example of “endoscope-assisted” technique (29, 55). The use of the endoscope in transsphenoidal surgery was successively reconsidered with the development of adequate endoscopic instrumentation and the widespread use of endoscopes in nasal and paranasal sinus surgery by otolaryngologists (33, 42, 62). Three decades after Guiot’s intuition, Jho (35) and Carrau (12) and their colleagues, a neurosurgeon and an ENT surgeon, described in detail a “pure” endoscopic endonasal transsphenoidal technique, with the endoscope used as the sole visualizing

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tool throughout the entire procedure. Thanks to their efforts the shift from the microscope to the endoscope in transsphenoidal surgery has known its affirmation. After these investigators, the new technique was adopted by our group (4, 7) in Naples with new challenges for the succeeding neurosurgeons. Since 1997, at the Department of Neurosurgery of University of Naples we have done more than 1000 procedure through a “pure” endoscopic endonasal transsphenoidal approach to the sellar region (7). Starting in 2004, the approach was extended to the surrounding areas of the skull base (9, 13, 20, 38). When the endoscope was introduced in neurosurgery, it totally transformed the way to look at the pituitary, and more recently, the midline skull base. Compared with the

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previous transsphenoidal microsurgical approach, the endoscopic technique represents a newly established technique, well defined in its main aspects, that offers a panoramic vision, close to the surgical target and within the relevant anatomy (8). At the same time, it allows a less traumatic route to the sella, associated with a lower complication rate (6). During the past decades, endoscopic pituitary surgery has been progressively accepted by surgeons and patients (36, 45, 49). Thanks to the efforts of few valid pioneers this technique is, at present, routinely adopted in many centers worldwide, using the same indications as the conventional microsurgical technique (56). INSTRUMENTATION Proper endoscopic equipment and specially designed surgical tools are needed to obtain the safety and effectiveness in the use of the endoscopic transsphenoidal approach (5, 48). The instrumentation consists of different components: the endoscope, the fiberoptic cable, the light source, the camera, the monitor, and the video recording system. In the operating room these instruments are ergonomically placed behind the head of the patient and in front of the operator, who stands at the right side of the patient and with the assistant surgeon usually at the left in such a way that the operating surgeon and the second surgeon can comfortably look at the monitor. The scrub nurse is positioned at the level of the patient’s legs. Finally, the anesthesiologists with the proper equipment are on the left side of the patient, at the level of the head, whereas the image guidance system, when used, is put besides the main endoscopic monitor. Each component of the equipment should be checked before the start of the procedure. Usually, the entire procedure is performed with a rigid 0-degree endoscope, 18 cm in length, 4 mm in diameter (Karl Storz & Co, Tuttlingen, Germany). Angled scopes (30- or 45-degree lenses) are used in selected patients or during specific steps of the operation, usually at the end of lesion dissection, either to complete the tumor resection or to inspect for possible tumor remnants. The endoscope, which does not have any working channel, can be inserted in a sheath and connected to a manual irrigation shaft to keep the lens clean, thus avoiding exertion on the nostril. A preoperative neuroradiologic plan is essential in disclosing the nasal anatomy

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ENDOSCOPIC ENDONASAL MANAGEMENT OF PITUITARY ADENOMAS

(septal deviations, presence of concha bullosa or onodi cells), the pneumatization of the sphenoid sinus, configuration of its septa, and their relationship to the optic canal and the internal carotid artery (ICA) (16). SURGICAL PROCEDURE The patient is placed under general anesthesia with orotracheal intubation, and positioned supine in the operating table. The trunk is generally elevated 10 degrees and the head, in neutral position, is turned 10 degrees toward the operating surgeon and fixed with tape in a horseshoe headrest. Patient’s eyes can be protected with antibiotic eye cream and a wet pad is generally inserted into the throat to plug the oropharynx and avoid collection of fluid in the airway and stomach during the operation. Before starting the surgical procedure, the nasal cavities are packed with gauze soaked with a diluted 5% chlorexide gluconate solution, gently inserted through a small Killian nasal speculum, avoiding damage to the nasal mucosa. The face and the nose are prepped with the same agent, and then the patient is aseptically draped. Finally, before scrubbing up, the surgeons should adjust the operating table to a comfortable working height. The operation is usually performed through a single nostril up to the anterior sphenoidotomy. During this phase of the procedure the endoscope is held in the surgeon’s nondominant hand. The posterior part of the septum is removed to gain enough space for both the endoscope and one instrument, inserted through one nostril, whereas the main instrument is inserted through the other nostril. The procedure becomes a two-surgeon, twonostril approach. We can consider three main surgical steps: a nasal phase, a sphenoidal phase, and a sellar phase. In the first two steps, exposure of the lesion is performed to create a comfortable working area and a wide surgical corridor to the lesion, In the sellar phase the tumor is removed and the reconstruction of the osteodural defect is realized. Nasal Phase The procedure starts with an initial anatomic orientation. Once the endoscope is inserted into the right nostril, parallel to

the floor of the nasal cavity, the anatomic landmarks become visible. At this level the first structures to be identified are the inferior turbinate laterally and the nasal septum medially. In addition, above the inferior turbinate the head of the middle turbinate can be observed. Then, as the endoscope advances along the nasal floor, the choana is easily reached (Figure 1). It is limited medially by the vomer, which represents an optimal midline marker and, superiorly, by the floor of the sphenoid sinus. Cottonoid pledgets soaked with diluted adrenaline (1/10,000, 1:20 dilution) are inserted between the middle turbinate and the nasal septum to enlarge the virtual space that separate these structures and obtain decongestion of the nasal mucosa (Figure 2A). A sharp instrument, usually a Freer dissector, is then used to gently push laterally the head of the middle turbinate to widen the nasal corridor between the middle turbinate and the nasal septum and create an adequate surgical pathway (Figure 2B). The middle turbinate should be protected with cottonoids during this maneuver to avoid any mucosal tearing, which would lead to unwanted bleedings. Looking upward with the endoscope along the roof of the choana and the sphenoethmoid recess, the sphenoid ostium, usually located approximately 1.5 cm above the roof of the choana, can be identified. The sphenoid sinus can be approached either through its natural ostium or through the sphenoid prow. The sphenoid ostium is extremely variable in shape, size, and position. It can be covered by either the superior or the supreme turbinate. These can be gently lateralized or removed, protecting the lateral lamella of the cribriform plate, on which the turbinate is inserted. In fact, the risk of an ethmoid cerebrospinal fluid (CSF) leak secondary to damage to the cribriform plate during these maneuvers must be considered. Finally, when the sphenoid ostium is not visible, once the choana is identified, access to the sphenoid cavity can be achieved ascending the endoscope along the sphenoethmoid recess for approximately 1.5 cm, applying pressure with a blunt instrument (Figure 3). Sphenoid Phase To avoid arterial bleeding from septal branches of the sphenopalatine artery, the

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Figure 3. Sphenoid phase of the procedure. Opening of the anterior wall of the sphenoid sinus by means of a microdrill with diamond burr. Sm, sphenoid mucosa. Figure 1. Right nostril approach. Nasal phase of the procedure. (A) Positioning of a cottonoid between the middle turbinate and the nasal septum. (B) Lateralization of the middle turbinate with an elevator to expose the sphenoethmoid recess. NS, nasal septum; MT, middle turbinate.

mucosa of the sphenoethmoid recess is coagulated bilaterally (Figure 3). These maneuvers start approximately 0.5 cm from the top of the choana, up to the superior border of the nasal cavity, and comprise the mucosa along with the area around the sphenoid ostium. The nasal septum is detached from the sphenoid rostrum with a high-speed microdrill using a diamond burr (4e5 mm diameter). The procedure continues with the removal of the anterior wall of the sphenoid sinus to create enough working room for the endoscope and instruments inside the sphenoid cavity. The entire anterior wall of the sphenoid sinus is widely opened by mean of a microdrill and/or bone punches, proceeding circumferentially

Figure 2. Right nostril approach. Nasal phase of the procedure: panoramic endoscopic view inside the choana and identification of the main anatomic landmarks. ET, Eustachian tube; Rphx, rhinopharynx; V, vomer.

(Figure 4). Care must be taken to not overextend the opening in the inferolateral direction, where the sphenopalatine artery or its major branches lie. At this point, the posterior part of the nasal septum can be removed to improve instruments maneuverability through both nostrils, thus facilitating a two-nostril, four-handed approach (14). In addition, a new working space is created between the sellar floor in the sphenoid cavity and the nasal septum. Once the anterior sphenoidotomy has been performed, the septa inside the sphenoid sinus, shown by the preoperative neuroradiologic studies, are flattened and the main anatomic landmarks inside the sphenoid sinus are well exposed. The posterior and lateral walls become visible with the sellar floor at the center, the planum sphenoidale above it, and the clival indentation below. In addition, lateral to the sellar floor, the bony prominences of the infraclinoid segment of ICA, the optic nerve, and, between them, the optocarotid recess can be identified (Figure 5). These prominences and depressions, especially in a well-pneumatized sphenoid sinus define a sort of “fetus face” (the forehead corresponds to the sphenoid planum, the eyes to the two optocarotid recesses, the eyebrows to the two optic nerves, the nose to the sella, and the mouth to the clivus, laterally limited by the two paraclival carotid arteries representing the cheeks). Nevertheless, in the presence of a presellar or a conchal sphenoid sinus, where these anatomic landmarks may not be recognizable, the

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image-guidance neuronavigation could be very helpful to achieve the correct orientation, as well as to identify the lateral boundaries of the sella. Sellar Phase The sellar phase of the procedure follows the well-defined rules of the microsurgical transsphenoidal approach. From this step onward the endoscope is held dynamically by an assistant. The so-called three-fourhand technique allows the main surgeon to operate bimanually, thus increasing the maneuverability of the instruments through both nostrils. The opening of the sellar floor can be accomplished using different tools, such as bone punches, or using a high-speed microdrill, according to the sellar floor thickness or tumor infiltration. Once the dura mater becomes visible, the bone opening is enlarged up to the exposure of the sellar venous sinuses (i.e., from the medial aspect of cavernous sinus to the other one and from the superior to the inferior cavernous sinus). In selected patients, depending on lesion removal needs, the bone opening can be extended to other regions of the anterior skull base such as the planum sphenoidale region or the clival indentation. Before the dura opening, an ultrasound Doppler probe can be used to insonate and define the position of both carotid arteries, thus allowing for a safer opening (25). The dura mater is then incised using a scalpel with a telescopic blade, in a linear, rectangular, or cruciate fashion. The dural incision is usually bloodless in patients with macroadenomas, because the superior and inferior intercavernous sinuses are usually compressed and obliterated. On the

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Figure 4. Right nostril approach. Sphenoid phase of the procedure. (A) Exposure of the sphenoethmoid recess and of the posterior nasal septum. (B) Coagulation of the nasal septum by means of a monopolar electrode. MT, middle turbinate; SER, sphenoethmoid recess; ET, Eustachian tube; Co, choana.

contrary, in case of microadenomas, it is most likely that a venous bleeding from these sinuses occurs. In these patients the sinus can be preventively sealed with bipolar coagulation forceps to allow a safe incision of the dura mater. Venous bleeding at the dural opening can be usually controlled by mean of hemostatic cottonoids, gentle compression, and saline irrigation for a few minutes. TUMOR RESECTION Different strategies are currently used for removal of pituitary microadenoma or macroadenoma. For microadenoma, the most critical step of the procedure consists in the identification of a valid surgical plane followed by the dissection of tumor’s pseudocapsule from

Figure 5. Sphenoid phase of the procedure. Identification of the main anatomic landmarks over the posterior wall of the sphenoid sinus. S, sella; CP, carotid protuberance; C, clivus; OP, optic protuberance; OCR, optocarotid recess.

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the pituitary gland tissue to achieve an en-bloc removal rather than an internal debulking (54). Unfortunately, a clear identification of the adenoma is not always feasible. In such cases, the endoscopic close-up view improves the possibility of identifying the pathologic tissue, which differs in color and consistency from normal pituitary tissue. Furthermore in pituitary microadenomas, the risk of postoperative panhypopituitarism is minimized if at least one-third of the normal pituitary gland is preserved, whereas manipulation over the pituitary stalk may always cause a temporary or permanent diabetes insipidus. For macroadenoma, the removal should be accomplished sequentially. The inferior

and lateral components of the lesion should be approached before the superior aspect (Figure 6A). The removal of the superior portion of the macroadenoma may favor the descent of the redundant diaphragma into the operative field, which will limit visualization of tumor fragments located in the lateral portions of the sellar cavity (Figure 6B). Conversely, when descent of the suprasellar portion of the lesion is not directly observed after intrasellar component removal, a Valsalva maneuver can favor it, allowing its protrusion into the sellar cavity (Figure 7A). For adenomas extending into the cavernous sinus, it is as well possible to access and remove lesions through the weak points that the lesion has created into the medial wall. It is worth remarking that two different transsphenoidal corridors permit access medially and laterally to the intracavernous ICA (Figure 7B). The medial compartment is reached more easily by inserting the endoscope through the contralateral nostril of the lesion parasellar extension. Once the intracavernous carotid artery is identified, through its pulsation or by mean of a micro-Doppler probe, angled suctions cannulas and dedicated instruments can be used to remove the parasellar component through the enlarged C-shaped loop of the carotid artery (24, 25). The venous bleeding occurring after the removal of the parasellar component reveals the cavernous sinus decompression (Figure 7B). It can be controlled by a gentle compression

Figure 6. Intraoperative pictures of a case of intrasuprasellar nonfunctioning pituitary adenoma. (A) Upon dura opening the tumor comes out and it is removed by mean of curettage and suction. (B) After tumor removal the suprasellar cistern descends in the sellar cavity, freed from tumor compression, and both medial walls of cavernous sinus are visible. *, tumor.

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Figure 7. Intraoperative close-up pictures of the patient shown in Figure 6. (A) The endoscopic exploration of the sellar cavity shows the suprasellar cistern above, descending into the field, the neurohypophysis compressed on the dorsum sellae posteriorly, and the inferior horizontal tracts of both internal carotid arteries covered by the medial walls of cavernous sinus laterally. (B) Close-up view of the left decompressed medial wall of cavernous sinus, with some venous bleeding. *, neurohypophysis; ICA, internal carotid artery; SC, suprasellar cistern; , venous bleeding through the cavernous sinus medial wall. ˇ

with cottonoids and irrigation for a few minutes. Conversely, lesions extending into the lateral compartment of the cavernous sinus can be approached through the homolateral transethmoid transpterygoid route, by the lateral recess of the sphenoid sinus (15, 27). To create an adequate surgical corridor, the bulla ethmoidalis and the anterior and posterior ethmoid cells are removed unilaterally, followed by the medial pterygoid process drilling, thus providing a direct access to the lateral recess of the sphenoid sinus. Before

opening the dura, a micro-Doppler probe will identify the exact position of the ICA. The tumor removal proceeds from the extracavernous to the intracavernous portion. Delicate maneuvers of curettage and suction usually allow the removal of the parasellar portion of the lesion, in the same fashion as for the intrasellar portion. The lesion itself tends to push laterally the oculomotor nerves, which may be not affected by the surgical maneuvers to remove the tumor. Finally, after lesion removal, an endoscopic exploration of the surgical cavity is recommended before the

Figure 8. (AeC) Preoperative magnetic resonance imaging scans showing an intrasuprasellar, nonfunctioning pituitary macroadenoma. The mass extends upward above the diaphragma sellae, compressing the optic

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reconstruction. Its value in discovering tumor remnants depends on the width of the sella, the descent of the suprasellar cistern, which may obliterate the tumor cavity, and the sellar and/or epidural venous bleeding. In case of unusual presenting features such as dumbbell shape, suprasellar or parasellar extension, and/or fibrous or rubbery consistency—highly likely in case of recurrent tumors (Figure 8)—an extended endoscopic approach is recommended with the possibility to use a double surgical corridor, namely a conventional endosellar extra-arachnoidal and a suprasellar transarachnoidal (24). After an internal debulking of the lesion (Figure 9A), an extended bone removal along the area of the tuberculum sellae (21) is performed to create an adequate corridor (Figure 9B) for an extracapsular dissection. This allows a deeper and precise visualization of the outer cleavage plane, thus permitting a safe dissection of the adenoma from its arachnoid adherences (Figure 10). Finally, the exploration with angled scopes could be helpful to discover and remove tumor remnants, hidden from the surrounding neurovascular structures (Figures 11 and 12). RECONSTRUCTION At the end of the procedure, once tumor removal has been completed and hemostasis is obtained, a reconstruction of the

chiasm. Note the “hourglass” configuration of the adenoma, which displaces the anterior cerebral arteries anteriorly (red arrow) and the optic chiasm posteriorly.

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Figure 9. Intraoperative pictures of the patient shown in Figure 8. (A) Upon opening of the dura the sellar component of the tumor is removed by curettage and suctioning by a standard endoscopic approach. (B) Later the dural opening is extended over the tuberculum sellae to access the suprasellar area. The tuberculum sellae and the posterior portion of the planum sphenoidale are opened between the optic nerves. *, tumor; p, planum sphenoidale.

osteodural defect is performed (10, 17). Only selected patients will require a complete sellar reconstruction, mainly when an intraoperative CSF leak has occurred. The repair should proceed using the Kelly’s paradigm (26): grade 0, absence of CSF leak, confirmed by Valsalva maneuver; grade 1, small “weeping” leak, confirmed by Valsalva maneuver, without obvious arachnoidal defect; grade 2, moderate CSF leak, with obvious arachnoidal defect; and grade 3, large CSF leak created intentionally as part of extended transsphenoidal approaches (minding to properly address the following principles: 1) protect the suprasellar cistern; 2) fill the “dead space”, i.e., the surgical cavity; 3) close the

osteo-dural defect). Accordingly our policy, which is to protect the cistern for grade 0, pack the sella (filling of the dead space) for grade 1 and perform meticulous reconstruction—consisting of accurate sellar packing, sellar closure, and sphenoid packing—in case of grade 2 and 3 intraoperative CSF leaks. Because various techniques have been successfully adopted in the past (intradural and/or extradural closure of the sella and sellar packing with or without packing of the sphenoid sinus), at present it is difficult to draw a conclusion regarding the safest and most effective way to proceed. The aim of sellar repair is to create a protective barrier, reducing the dead

space, and preventing the descent of the chiasm into the sellar cavity. To guarantee this result different materials have been used. The best is to use tissues from the patient (e.g., nasal cartilage, fascia, fat). Another possibility is with autologous or heterologous materials (e.g., dural substitutes, glues) that avoid further incisions, are sterile, and ready to be used. Inadvertent overpacking of the sellar cavity could be responsible for compression of the optic system and must be avoided (6). The use of a lumbar drain is still debated in cases of unexpected postoperative CSF leak, more frequent after extended approaches. The procedure ends when hemostasis is obtained, final irrigation is performed, and the middle turbinate is gently placed back to prevent synechiae with the nasal septum. Packing of nasal cavities is not necessary except in case of copious bleeding from the nasal mucosa (generally in acromegalic patients or in poorly controlled hypertensive patients). At discharge, the patient should wash/rinse the nasal cavities with a salt water solution for a couple of months to clean the nasal corridor from blood clots and prevent possible endonasal synechiae. The patient is then seen in the outpatient clinic, where a nasal endoscopic inspection is performed after 1 month and the patient is referred to an endocrinologist for followup. The patient will be re-examined in the neurosurgical outpatient clinic 3 months after surgery, when a new contrastenhanced magnetic resonance imaging scan is performed (Figure 12). If patients complain of preoperative visual field defects, a 6- to 12-month follow-up visual field examination is needed, starting 2 weeks after surgery. DISCUSSION

Figure 10. Intraoperative pictures of the patient shown in Figure 8. (A) The suprasellar area is entered by the endoscopic endonasal approach. The pituitary stalk is seen at the center of the view and the lesion is followed on its right side. (B) The suprasellar portion of the mass, enclosed in between the anterior communicating artery complex anteriorly and chiasm posteriorly, is removed by suctioning. ps, pituitary stalk; ACoA, anterior communicating artery; *, supradiaphragmatic component of the mass.

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The endoscopic endonasal transsphenoidal approach offers some advantages related to the use of the endoscope itself, above all the absence of nasal speculum (20), a superior close-up view of the relevant anatomy, close to the surgical target, and an enlarged working angle (60). The better identification of the bony anatomic landmarks on the posterior wall of the sphenoid sinus (according to the grade of pneumatization) allows the surgeon’s orientation. However, such intrinsic characteristics are important, especially at

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Figure 11. Intraoperative pictures of the patient shown in Figure 8. (A) After tumor removal a close-up view over the suprasellar and retrosellar spaces is achieved, with the optic chiasm at the center of the view. Anteriorly and above the tumor cavity is seen. (B) The angled scope view (45 degrees) reveals the complete removal of the adenoma, which was compressing the right frontal lobe. Ch, optic chiasm; ON, optic nerve; mb, mammillary bodies; *, postsurgical tumor cavity.

the tumor/gland interface, where a pseudocapsule can be easily identified under endoscopic vision (51). The identification of pseudocapsule, although it is of utmost relevance, as it guides tumor dissection allowing for a safer and more effective total adenoma removal, resulting in better outcomes in terms of remission of the endocrinologic disorder (53, 54). Furthermore, the superior close-up view offered by the endoscope and the enlarged vision inside the surgical area can be helpful in identifying the residual pituitary tissue and in preserving it from further surgical manipulation (16, 59). An important observation, however, is that pituitary function can be preserved in mostpatients who undergo

adenoma resection thanks to the growing experience of the neuroendoscopic surgeon and continuous technological advancements. Despite these advantages, the use of the endoscope has its drawbacks. Neurosurgeons not yet confident with endoscope and video-guided surgery systems are limited by the 2-dimensional vision on the screen, which brings difficulties in handling the surgical instruments and detecting the proper depth of the surgical field. The surgeon can overcome the 2-dimensional vision getting a depth perception by “in-and-out” movements of the endoscope. In addition he or she has to become confident to look at a flat television

Figure 12. (A) and (B) Postoperative magnetic resonance imaging scans showing the complete removal of the lesion and the reconstruction materials filling the sellar cavity and the sphenoid sinus.

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screen, away from the surgical field. There can also occur conflict among instruments and/or among the endoscope and instruments. This will happen especially when the anterior sphenoidotomy has been not widened enough to allow for good surgical maneuverability. When compared with the major microsurgical series, results in term of mass removal, relief of endocrinologic/visual symptoms, and cure of the underlying disease are at least similar to those reported in the recent endoscopic series (18, 19, 23, 28, 30, 32, 34, 43, 65). However, patient compliance is much better—there is less nasal trauma and the absence of nasal packing. The main advantages for the surgeon are the wider and closer view of the surgical target area and the ease of treating recurrences (3). In selected patients, the boundaries of the standard endoscopic transsphenoidal approach have been extended toward other regions of the anterior skull base to offer a better management of the tumor in its supra and/or parasellar extension (13, 39-41, 46, 47, 58, 66). The advantages of the endoscopic endonasal approach have further widened the indications of the transsphenoidal route. The endonasal approach may offer a greater extent of resection for recurrent or residual dumbbell-shaped adenomas, thus avoiding an anterior skull base approach. For patients who have undergone prior craniotomy, the extended transsphenoidal approach offers a virgin surgical corridor on the opposite side of a fibrotic reaction from the intracranial operation. In addition the endonasal route allows the surgeon to reach any residual tumor that may not have been accessible in the first operation, such as retrochiasmatic, subchiasmatic, and, in some cases, sellar components, without disruption by surgical arachnoid scarring. Fibrous macroadenomas, approached transcranially in the past, can now be managed through an extension of the bone window to the tuberculum sellae— recently named the suprasellar notch (21)—and the sphenoid planum. The same principles are valid with giant adenomas, where the extended approach has proved to facilitate, in most instances, a wider lesion exposure just after the dural opening versus the sellar-suprasellar space, thus avoiding any retraction of neurovascular structures (24, 37, 50, 52, 57, 64).

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CONCLUSION The endoscopic endonasal approach has brought several advantages to the surgical treatment of pituitary adenomas. An overall decrease of complications has been reported with the endoscopic endonasal route. The endoscopic approach is still evolving as a surgical modality and, at present, it represents an alternative to the classic microsurgical approach. This procedure is technically demanding and requires endoscopic skills. In addition, the new generation of neurosurgeons need a meticulous preliminary phase, based on solid anatomic knowledge—through anatomic dissection training (11) and virtual rehearsal (22, 44, 57, 61, 63)—together with an adequate endoscopic skill. This is mandatory to successfully treat sellar pathology and achieve improvement of results with minimal morbidity. REFERENCES 1. Apuzzo ML, Heifetz MD, Weiss MH, Kurze T: Neurosurgical endoscopy using the side-viewing telescope. J Neurosurg 46:398-400, 1977. 2. Bushe KA, Halves E: Modified technique in transsphenoidal operations of pituitary adenomas. Technical note [author’s translation]. Acta Neurochir (Wien) 41:163-175, 1978. 3. Cappabianca P, Alfieri A, Colao A, Cavallo LM, Fusco M, Peca C, Lombardi G, de Divitiis E: Endoscopic endonasal transsphenoidal surgery in recurrent and residual pituitary adenomas: technical note. Minim Invasive Neurosurg 43:38-43, 2000. 4. Cappabianca P, Alfieri A, de Divitiis E: Endoscopic endonasal transsphenoidal approach to the sella: towards functional endoscopic pituitary surgery (FEPS). Minim Invasive Neurosurg 41: 66-73, 1998. 5. Cappabianca P, Alfieri A, Thermes S, Buonamassa S, de Divitiis E: Instruments for endoscopic endonasal transsphenoidal surgery. Neurosurgery 45:392-395; discussion 395-396, 1999. 6. Cappabianca P, Cavallo LM, Colao A, de Divitiis E: Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 97: 293-298, 2002. 7. Cappabianca P, Cavallo LM, de Divitiis E: Endoscopic endonasal transsphenoidal surgery. Neurosurgery 55:933-940; discussion 940-941, 2004. 8. Cappabianca P, Cavallo LM, de Divitiis O, Solari D, Esposito F, Colao A: Endoscopic pituitary surgery. Pituitary 11:385-390, 2008. 9. Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A, de Divitiis E: Extended

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37. Kaptain GJ, Vincent DA, Sheehan JP, Laws ER Jr: Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions. Neurosurgery 49:94-101, 2001. 38. Kassam A, Snyderman C, Carrau R: An evolving paradigm to the ventral skull base. Skull Base 14 (suppl 1), February, 2004. 39. Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL: Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 19:E3, 2005. 40. Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL: Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus 19:E4, 2005. 41. Kato T, Sawamura Y, Abe H, Nagashima M: Transsphenoidal-transtuberculum sellae approach for supradiaphragmatic tumours: technical note. Acta Neurochir (Wien) 140:715-719, 1998. 42. Kennedy DW: Functional endoscopic sinus surgery. Technique. Arch Otolaryngol 111:643-649, 1985. 43. Koc K, Anik I, Ozdamar D, Cabuk B, Keskin G, Ceylan S: The learning curve in endoscopic pituitary surgery and our experience. Neurosurg Rev 29:298-305; discussion 305, 2006. 44. Kockro RA, Stadie A, Schwandt E, Reisch R, Charalampaki C, Ng I, Yeo TT, Hwang P, Serra L, Perneczky A: A collaborative virtual reality environment for neurosurgical planning and training. Neurosurgery 61:379-391; discussion 391, 2007. 45. Lanzino G, Laws ER Jr: Pioneers in the development of transsphenoidal surgery: Theodor Kocher, Oskar Hirsch, and Norman Dott. J Neurosurg 95:1097-1103, 2001. 46. Laufer I, Anand VK, Schwartz TH: Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg 106:400-406, 2007.

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 18 September 2013; accepted 25 July 2014

58. Schwartz TH, Anand VK: The endoscopic endonasal transsphenoidal approach to the suprasellar cistern. Clin Neurosurg 54:226-235, 2007.

Citation: World Neurosurg. (2014) 82, 6S:S3-S11. http://dx.doi.org/10.1016/j.wneu.2014.07.019 Journal homepage: www.WORLDNEUROSURGERY.org

59. Snyderman C, Kassam A, Carrau R, Mintz A, Gardner P, Prevedello DM: Acquisition of surgical skills for endonasal skull base surgery: a training program. Laryngoscope 117:699-705, 2007.

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Endoscopic endonasal surgery for pituitary adenomas.

Pituitary surgery is a continuous evolving specialty of the neurosurgeons' armamentarium, which requires precise anatomic knowledge, technical skills,...
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