History of Transsphenoidal Surgery for Pituitary Tumors

Introduction

Like many advances in medicine, the transsphenoidal procedure as we know it today is the result of a long, relentless process. Many bold and creative pioneer surgeons have contributed and continue to contribute to its continuous refinement. In the late 1800s and early 1900s, better understanding of the pathological processes involving the pituitary gland and the introduction of diagnostic x-ray techniques by Roentgen paved the way to the first attempts to surgically resect lesions involving the sellar region.

The Origins

Sir Victor Horsley is credited to have performed the first transcranial pituitary operation in 1889. However, the limitations of this approach were immediately evident primarily because of significant frontal lobe retraction necessary to obtain adequate exposure of the sellar and parasellar structures. These pitfalls encouraged pioneer surgeons at the beginning of the twentieth century to reach the pituitary region through an extracranial route through the paranasal sinuses. In Venice, Davide Giordano had conducted a series of experiments on cadavers and had suggested a transnasal route to approach the pituitary region. Inspired by these studies, Hans Schloffer removed a pituitary tumor through a lateral rhinotomy and a transmaxillary/transethmoidal approach in Innsbruck, Austria, in 1907. Additional initial efforts concentrated on obtaining a short route to the pituitary region through large superficial openings to improve illumination in the depth of the surgical field ( Figure 2-1 ). This quite often resulted in disfiguring scars ( Figure 2-2 ). Moreover, it was difficult to maintain a proper midline orientation in the deep, dark, and narrow surgical field.

Trying to overcome some of these problems, Theodor Kocher ( Figure 2-3 ), a Swiss surgeon who won the Nobel Prize in 1909 for his work on thyroid disease, proposed an approach that encompassed submucosal dissection of the sphenoid septum. The septum was exposed through a complex external incision and dissected submucosally on both sides and the mucosa retracted with a specifically designed speculum. After the resection was completed, gauze saturated with iodine was left in the tumor bed with a string attached to it coming out of the nostril. Kocher’s innovation represented a milestone in the evolution and development of transsphenoidal surgery because it allowed the surgeon to maintain a midline orientation during the procedure and decreased the danger of infection by working through a cleaner route. Additionally, Kocher’s incision, although quite complex, represented a significant improvement over earlier cosmetically disfiguring ones.

Kocher was a legendary figure of early twentieth century surgery and achieved worldwide fame primarily for his expertise in the surgical treatment of thyroid disorders. Harvey Cushing’s, at the suggestion of Halsted, spent some time in Kocher’s clinic during his year in Europe. He was highly impressed with Kocher’s surgical technique and his maniacal attention to careful dissection and hemostasis. Later in the year, Cushing’s (by then world renowned) commemorated Kocher on the occasion of the International Neurological Congress in Berne in 1931:

The most precious heritage of our profession lies in the noble traditions. What has been accomplished does not die, but too often, alas, the personality of those who have handed the torch from one generation to another soon fades into oblivion. So for those of you—his spiritual grandchildren—who have gathered here and to whom Kocher is little more than the name of a street which you have frequently traversed the past few days, I would like to give at least an impression of what he was in life—a slight, sparse man of personal neatness, of quick step and alert hearing, of unfailing courtesy and dignity, precise and scrupulous in all his dealings, professional, public and personal—a man to trust.

Oskar Hirsch and the Endonasal Transseptal Approach

The transsphenoidal procedure as we know it today evolved from the simultaneous work of Oskar Hirsch in Vienna and Harvey Cushing’s in Boston. Oskar Hirsch ( Figure 2-4 ), a young rhinologist in Vienna, proposed at a meeting of the local medical association in March 1909 that the pituitary region could be reached with a much smaller opening of the facial skeleton than the ones proposed by Schloffer, von Eiselberg, and others. Instead he proposed a much smaller opening similar to that used by his teacher Hajek for the treatment of sphenoid sinus infections. Hajek himself, however, had judged this approach too difficult and dangerous. Nevertheless one year later, Hirsch performed the first operation in which the approach was made through a direct transethmoidal route without reflection of the nose. The first operation was carried out in five steps under local anesthesia spanning a period of 2 weeks. At the end, the patient’s vision improved. Hirsch soon modified this operation to a submucosal transseptal method, and on June 4, 1910, he performed his first endonasal, submucosal resection of the septum ( Figure 2-5 ). By coincidence, on the same day on the other side of the Atlantic Ocean, Cushing’s performed his first sublabial transseptal excision of a pituitary tumor. Eventually Hirsch mastered the operation so that it could be conducted in one single step. In Hirsch’s operation, the mucosal flaps were retracted laterally and exposure was maintained by the use of an instrument very familiar to a rhinologist: a nasal speculum (see Figure 2-5 ). Hirsch corresponded with Cushing’s after these early attempts to inquire about Cushing’s own experience with the operation. Hirsch demonstrated the procedure in Vienna for Cushing’s in 1911.

After resection of the tumor, Hirsch added local radiation using a rudimentary apparatus secured to the superior teeth and left in situ for some time. Between 1910 and 1956, 413 patients were treated by Hirsch with a combination of surgical resection followed by local radiotherapy. Hirsch operated with the patient

… seated with the head fixed, while awake and under the influence of no other medication. The nasopharyngeal surface was cocainized and the mucosa infiltrated by a local anesthetic. Hirsch would sit opposite with instruments at hand. Illumination was provided by a reflective-mirrored light, and suction was applied by a foot-pedal rig operated by a faithful dwarf (an ex-patient named Shostel).

Because of the political turmoil in Europe in the late 1930s, Hirsch was forced to leave Vienna and, in 1938, moved to Boston where he continued his work. He was uncompromising in defending the transsphenoidal procedure at a time when every other surgeon in the United States had abandoned it. While in Boston, Hirsch continued to work with a neurosurgeon, Hannibal Hamlin, and together they performed over 500 cases of pituitary surgery. Hamlin continued to use the procedure, defending its advantages in properly selected patients. The challenges faced by these early pioneers are evidenced by the words of Dr. Richard Rovit, who was a young trainee at the Massachusetts General Hospital at the time when Hamlin and Hirsch were still performing their transsphenoidal procedures:

One incident involving Dr. Hirsch stands out in my memory. A 61-year-old woman with hypopituitarism had been followed for years by the staff of endocrine services at MGH. Skull x-ray films revealed progressive ballooning of the sella turcica … she had received two courses of radiation therapy. Despite this therapy, and while being maintained on thyroid medication and cortisone, the patient experienced bitemporal hemianopsia with decreased vision in both eyes, especially the left, and a left sixth nerve paralysis. Because of progressive visual impairment, Dr. Hirsch, assisted by Hannibal Hamlin, performed a transsphenoidal operation in October 1957. The transsphenoidal procedures were performed not in the usual operating rooms but in the neurosurgical x-ray suite. The patient was seated in a chair, fully awake, with the head firmly secured. The nasopharynx was treated with cocaine, and the mucosa was infiltrated with a local anesthetic. Dr. Hirsch sat facing the patient while Dr. Hamlin stood behind the patient’s head wearing a headlight, which was projected into an ear-nose-throat mirror worn by Dr. Hirsch and then reflected into the patient’s nasopharynx. Because no one except Dr. Hirsch could see anything, the resident assigned to the case, presumably to bear witness, would sit in the corner of the room and try to stay awake. In this particular case, Dr. Hirsch entered the sella floor without incident. But after a few manipulations, a sudden torrent of bright red blood gushed from the nose under arterial pressure, splashing everything in the vicinity. After the usual instantaneous profanities, Dr. Hirsch calmly said, ‘This is not the time to curse. This is the time to pray.’ With that admonition and the loss of several hundred additional milliliters of blood, he skillfully packed the nose and the bleeding was controlled. No further bleeding was encountered when the packing was removed several days later. Subsequent angiography revealed a large internal carotid artery aneurysm that filled the sella. The patient initially did well but eventually died after an intracranial procedure with carotid ligation under hypothermia.

Harvey Cushing’s and the Sublabial Transsphenoidal Approach

Contemporarily to Hirsch, Harvey Cushing’s proposed a sublabial transseptal transsphenoidal approach to the pituitary region ( Figure 2-6 ). In his description of the procedure, Cushing’s acknowledged the contributions of several pioneers:

The procedure which I have come to employ is merely a composite of such modifications of the Schloffer operation, suggested by Kanavel, Halsted, Hirsch, and others, as are adapted to my own requirements. It therefore makes no claim for originality. The operation combines all of the advantages of the endonasal procedure of Hirsch, and for one who does not possess the practiced hand of the rhinologist it has the further advantage of affording almost double room that an operation through one nostril permits.