37 Microscopic Endonasal and Sublabial Approach The microscopic endonasal and sublabial approach is a midline skull-base approach, which provides direct access to the sellar and parasellar region with a surgical corridor free from major neurovascular structures. • Intra- and suprasellar pituitary adenomas. • Intra- and suprasellar craniopharyngiomas. • Any other intrasellar lesions. • Suprasellar lesions depending on magnitude of sella enlargement. • Position: Patient is positioned supine with the head on a flat headrest. • Body: The body is positioned straight and flat. • Head: The head is positioned straight, extended 15°. • Cushion is placed under patient’s shoulders. • The upper lip has to be the highest point in the surgical field. Fig. 37.1 Patient positioning. • The right nostril is exposed (if surgeon is right-handed). • The base of right nostril is retracted with Langenbeck retractor. • A straight unilateral incision is performed. ◦ Starting point: Incision starts 4 mm below the surface of right cartilage. ◦ Course: It runs straight above nasal cartilage, parallel to nostril. ◦ Ending point: It ends at the superior medial margin of the right nostril. • The upper lip is retracted with 2 Langenbeck retractors. • A straight unilateral incision is performed (Fig. 37.3). ◦ Starting point: Incision starts at the level of medial canines. ◦ Course: It runs parallel to the plica between gingiva and upper lip (4 mm from plica), crossing the phrenulum. • The anterior margin of nasal cartilage is exposed (Fig. 37.4). • The mucosa is dissected on a sub-perichondrial plane. • The self-retaining speculum is inserted (Fig. 37.5). • Mucosa is detached unilaterally from the cartilaginous septum and the submucosal tunnel is created (Fig. 37.6). • Medial nasal mucosa has to be kept intact by careful stepwise dissection. • A self-retaining speculum is inserted. • The junction of cartilaginous and bony nasal septum is exposed and dissected (Fig. 37.7). • The mucosa is detached bilaterally from the bony nasal septum (Figs. 37.7, 37.8). • The junction of cartilaginous and bony nasal septum is separated. • The paraseptal mucosa is detached bilaterally from the bony nasal septum. • Portions of bony nasal septum are resected (Fig. 37.8). • The self-retaining speculum is inserted (Fig. 37.9).
37.1 Introduction
37.2 Indications
37.3 Patient Positioning (Fig. 37.1)
37.4 Mucosal Incision for Endonasal Approach (Fig. 37.2)
37.5 Mucosal Incision for Sublabial Approach (Figs. 37.3–37.5)
37.6 Soft Tissue Dissection for Endonasal Approach (Figs. 37.6–37.9)
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