Transsphenoidal Approaches to the Sellar and Parasellar Area

11   Transsphenoidal Approaches to the Sellar and Parasellar Area


Daniel M. Prevedello




The sinuses have been used as a corridor to access the pituitary fossa for over 100 years. From the beginning, surgeons appreciated the advantage of approaching the target from below and having direct access to the sella without manipulating the brain.1 The technology at that time was very limited, however, and most surgeons did not feel it safe enough to perform major neurosurgical procedures through narrow nasal pathways. Harvey Cushing is probably the greatest example because he abandoned the transsphenoidal approach in 1927 owing in part to an inability to properly illuminate the surgical field.2,3 Although Norman Dott, who had learned the technique from Cushing, employed a lighted speculum, it was only after the contributions of Gerard Guiot, who added fluoroscopy, and Jules Hardy, who added the operating microscope, that the transsphenoidal route became popular and was disseminated around the world.1


One of the limitations of the transsphenoidal approach performed with the microscope is the relative restriction of parasellar illumination and visualization. Although the sella can be well visualized, areas such as the cavernous sinus and anterior fossa region can be completely out of sight. With that in mind, some neurosurgeons started to add the endoscope to the scene in parallel with the microscope to augment visualization in these particular areas and so improve tumor resection and outcomes. Gerard Guiot was the first neurosurgeon to use the endoscope in the transsphenoidal route in the 1960s, but at that time the technology was still fairly primitive.1 In the late 1970s, Apuzzo and colleagues,4 as well as Bushe and Halves,5,6 demonstrated the use of the endoscope as an adjunctive tool to remove pituitary lesions. Endoscopically “assisted” transsphenoidal microsurgery has since been reported by various authors, emphasizing its importance for tumors that extend beyond the sella.712


Surgeons progressively realized that the combination of speculum and endoscope is not ideal because one limits the other. Roger Jankowski and co-workers reported the first series of three cases in which an endoscopic transsphenoidal approach to the sella was used in 1992.13 Ricardo Carrau and colleagues pursued a purely direct endoscopic endonasal approach to the pituitary fossa and described their experience in 1996,14 followed by their first 50-patient series in 1997.1416 Paolo Cappabianca, Enricode Divitiis, Luigi Cavallo, and colleagues developed appropriate surgical instrumentation and became a world reference for endoscopic pituitary surgery.1727


At the same time that various surgeons were developing and demonstrating the feasibility of gaining access beyond the sella by using the transsphenoidal route, particularly to the midline anterior skull base with the microscope as the primary visualization tool,7,8,2832 Amin Kassam, Ricardo Carrau, Carl Snyderman, and colleagues defined and standardized modules of approaches to the skull base, expanded from the sella, while using the endoscope as the sole tool for illumination and visualization.1,33,34


Although it is still controversial whether the endoscope brings real advantages to dealing with sellar disease in relation to the microscope, the use of endoscopic endonasal techniques to reach the areas beyond the sella has become well accepted.11,3543


images The Sella


The endonasal corridor is a median approach that is in the same axis as the sella and therefore represents an ideal route to reach the sella with no brain manipulation. Historically, craniotomies were the general approach used to deal with sellar disease. However, this concept was completely altered once Jules Hardy brought the operating microscope to the transsphenoidal operation.44 Any transcranial approach requires some level of brain retraction and yields indirect visualization of the pituitary fossa, which is hidden by the planum sphenoidale.45 Currently, fewer than 5% of patients with a pituitary adenoma have a craniotomy as an alternative approach for resection, and it is always related to an extrasellar tumor component.45 There is a consensus that the sellar portion of tumor is better treated by a transsphenoidal route in an approach with the microscope, endoscope, or both.4550


Microscopic Transsphenoidal Approach


The transsphenoidal approach has had some variations over the years. The initial description by Schloffer required a paranasal incision followed by a complete transethmoidal exposure to reach the sphenoid sinus and sella.51 With the evolution of the technique, the approach has become progressively less invasive.


The procedure is performed with the patient under general anesthesia. The patient is positioned typically in a semirecumbent angle with the head tilted to the left.


There are three current variations of the transsphenoidal approach: sublabial, hemitransfixion, and direct endonasal, or “pushover.”


Sublabial

From the time Cushing was using the technique until recently, the transsphenoidal approach was invariably performed as a sublabial procedure. Indeed, it is still performed that way in many centers around the world.47,52


An incision is made under the superior lip inside the mouth, and the mucoperiosteum is elevated from the bone at the piriform aperture. The plane between the mucoperichondrium and the mucoperiosteum posteriorly is encountered and the mucosa is separated from the septum on both sides. The septum is retracted, often to the left side, and a speculum is positioned and advanced until the rostrum of the sphenoid is well exposed in the center of the field. An anterior sphenoidectomy is performed with a rongeur. The sphenoid sinus is visualized, and the position of the sella is confirmed with lateral fluoroscopy or some other type of navigation.53 The sella is opened either with a drill or with a chisel. Once the bone of the sellar face is removed and the dura is exposed, a knife, usually an 11-blade scalpel, is used to incise the dura. The sella is explored and the tumor can be removed, usually with ring curettes.


The sublabial approach has the advantage of creating a broad corridor, which can be as wide as the piriform aperture.47 The disadvantage of the sublabial technique is related to potential complications of the approach. There is a higher incidence of anterior septal perforation with the sublabial approach. The superior anterior teeth can develop various grades of numbness, and saddle nose deformation due to anterior septum manipulation can also occur.


Endonasal

The other commonly used variations of the transsphenoidal route are endonasal procedures performed with the microscope. The transnasal hemitransfixion technique requires an incision in the septal mucosa ~1 cm behind the columella. The speculum is inserted directly in the nostril, and the plane between the mucoperiosteum and the septum is elevated posteriorly as in the sublabial approach. The rest of the procedure continues in a fashion similar to the sublabial approach.


The other variation is the direct endonasal (“pushover”) technique. In this variant, the speculum is introduced earlier in the case, and the nasal pathway is followed directly until the posterior aspect of the septum. The mucosa is not elevated from the septum anteriorly. The middle turbinate is retracted laterally, and the posterior septum is dislocated to the opposite side. The mucosa is then disrupted very posteriorly at the bony septum area. The submucosal plane is elevated and the rostrum is exposed. The rest of the procedure follows the same technique as the sublabial one.


The advantage of the transnasal transsphenoidal approach is that it avoids manipulation of the anterior teeth and saddle nose deformities. On the other hand, it generates a narrower corridor, and the specula used need to be adapted for small nostrils. If the speculum is forced open during the procedure with the intent of creating better exposure, a nasal skin tear may occur. The other disadvantage is related to the fact that the speculum comes obliquely from one of the nostrils. This can generate a false impression of the midline, and the surgeon can inadvertently cross to the other side in the depths without appropriate awareness of the situation. This can be the scenario for a catastrophic complication because the surgeon can open the cavernous sinus directly in front of the internal carotid artery thinking that that is the midline.54,55


Endoscopic Endonasal Approach


Totally endoscopic transsphenoidal surgery started in the 1990s as a collaboration between otolaryngologists and neurosurgeons, with the goal of developing a less disruptive approach to the nasal structures.1,1316,23,56 It consists of a direct endonasal approach to the back of the nasal cavity, followed by identification of the sphenoid ostium. The anterior wall of the sphenoid sinus is opened, and the sinus can be visualized. Although there was an initial trend to perform this approach through only one nostril, currently most centers performing this procedure follow the binostril-bimanual technique, which allows much more freedom of movement.33 A posterior septectomy is performed, communicating both nostrils posteriorly and creating a single working cavity.


The intrasphenoid septa are drilled, allowing broad visualization of all the sphenoid walls. At this point, the surgeon is able to determine with precision the skull base landmarks, particularly in well-pneumatized sinuses, which avoids the absolute need for fluoroscopy or image guidance (Fig. 11.1). Nonetheless, if the surgeons have easy access to image guidance, it is probably wise to use it for every endoscopic case because it is hard to predict in which cases it may be helpful to confirm a certain structure intraoperatively. Of course, cases of nonpneumatized sphenoid sinus clearly benefit from intraoperative image guidance. Such cases are simple to foresee based on preoperative computed tomography. However, cases with unexpected vascular complications or tumor-distorted anatomy can also benefit from intraoperative image guidance, even when there is a wide-open sphenoid sinus.


The face of the sella is then identified, and the bone is removed to expose the dura. The superior and inferior intercavernous sinuses and the face of the cavernous sinuses bilaterally are exposed. This relatively wide exposure coupled with an ample dural opening allows an unencumbered intrasellar dissection.


The dura of the sella is incised with a sharp blade that incises both layers of the dura but does not transgress the pituitary capsule. The dura is elevated from the sellar face, exposing the gland or tumor. An extracapsular resection of the tumor is always attempted, particularly in hyperfunctioning adenomas, to secure a complete resection. Even in cases in which the pituitary gland needs to be explored, in magnetic resonance imaging–negative cases of Cushing disease, for instance, an extracapsular resection of the hidden adenoma is attempted to permit a thorough resection of the functional adenoma and its margins because the pseudocapsule is indeed compact normal gland46,57 (Fig. 11.2). Occasionally, the medial wall of the cavernous sinus needs to be resected to increase the chance of remission in more invasive adenomas. This affords an advantage of the endoscopic technique over the microscopic because the visualization offered by the endoscope laterally is far superior (Fig. 11.3).


images


Fig. 11.1 Endoscopic visualization of the entire sphenoid sinus with a zero-degree endoscope in a cadaveric specimen demonstrating the wide exposure and the clear view of the main landmarks: the optic canals bilaterally (OC), the internal carotid arteries bilaterally (ICA), the tuberculum sellae recess (TS), the sella (S), and the clival recess (CR).


Two surgeons perform the entire procedure. In our personal experience, because there are no data to support a significant difference in the literature, we believe that the visualization allowed by the endoscope is far superior to that from the operating microscope. Furthermore, the illumination and image captured by the endoscope are closer to the target, whereas with the microscope, the imaging is from a greater distance. This is particularly important because the surgeon’s hands can block the view during microscopic surgery. The wide field of visualization provided by the endoscope allows dissection in the parasellar area, which is crucial to resect invasive pituitary adenomas from the cavernous sinus and to deal with extensive suprasellar projections of tumor, always under direct visualization and without the use of blind curettage (Fig. 11.3).


The most common indications for this approach are pituitary adenomas, intrasellar craniopharyngiomas, and Rathke cleft cysts.


images The Parasellar Areas


The use of microscope to reach areas around the sella is possible from a transsphenoidal approach. Because the light source is external, however, there are limitations for visualization of areas that are not in line with the approach. The surgeon often is obliged, in this scenario, to extend the size of the corridor by using a sublabial incision, which can be augmented laterally by a medial maxillectomy or a LeForte maxillary disarticulation.58,59 The other aspect of limitation is related to the focal plane of the microscope, which becomes very constricted as the dissection is performed more deeply. To compensate for this limitation, the surgeon is required to move the microscope often to see areas of the skull base that are not located in the narrow microscopic field.


images


Fig. 11.2 Intraoperative photographs during an extracapsular resection of a pituitary adenoma in a patient with Cushing disease. (A–C) Intraoperative views with a zero-degree endoscope during an endoscopic endonasal transsellar approach. (A) Pituitary gland exposure. (B) Identification of the adenoma with visualization of the pseudocapsule. (C) Removal of the pituitary adenoma extracapsularly. (D) Specimen removed en bloc and sent to pathology (it proved to be an ACTH-staining adenoma).


images


Fig. 11.3 Intraoperative photograph during a resection of a pituitary adenoma that was invading the left cavernous sinus. Note that the pituitary gland (PG) is protected on the right. The left medial wall of the cavernous sinus was opened by resection of the tumor that was invading the cavernous sinus (CS) and encasing the internal carotid artery (ICA). Once a tumor has been removed, the venous bleeding can be profuse, and one can see the roof of the cavernous sinus from below.


Based on the advantages of the endoscopic illumination and wide visualization, it becomes natural to use the endoscope to reach lesions located in the parasellar space. It is ideal when the sellar space is the primary source of the disease, as with pituitary adenomas. However, other lesions, like craniopharyngiomas, meningiomas, chordomas, chondrosarcomas, and schwannomas, may be present in these locations and may be treated by the endoscopic expanded endonasal approaches as well.40,41,6062 It is important to have dynamic endoscopic visualization to compensate for the lack of three-dimensional imaging obtained from a static endoscopic view.


Suprasellar and Anterior Fossa


Very often, a suprasellar tumor is the extension of a disease that started inside the sella, particularly in pituitary adenomas and some craniopharyngiomas. In these cases, most of the time, a sellar approach is sufficient to evacuate the tumor completely, starting with the sellar component and then following the tumor superiorly. Often, the superior tumor descends naturally as the sellar disease is removed. For these cases, a microscopic transsphenoidal approach is a feasible alternative; however, it becomes difficult to determine if there is any residual tumor superiorly at the end of the dissection. One alternative would be the use of interoperative MRI, or the insertion of an angled endoscope for investigation. Nevertheless, because the corridor is not prepared for an endoscopic approach, the surgeon often is able to see residua but ends up having difficulty reaching and removing such residua under direct visualization and frequently uses blind dissection at the corners with instruments like angled ring curettes, which carry some risk, even in experienced hands.


To reach tumors that originate or extend to the suprasellar space from the sella, we prefer an endoscopic endonasal transtuberculum and/or transplanum approach. This approach is defined by the removal of the tuberculum sellae and, depending on the anterior extension of the tumor, the planum sphenoidale. The optic canals mark the lateral limits for this approach. The suprasellar region is well reached through resection of the tuberculum sellae. For most of the macroadenomas that extend to the suprasellar space, a simple bony removal of the tuberculum sellae can be enough to allow the superior component to descend during surgery. Thus, the resection is inside out, and the diaphragma sellae and suprasellar arachnoid are often preserved, avoiding exposure of cerebrospinal fluid (CSF) spaces.


On the other hand, tumors like craniopharyngiomas (Fig. 11.4), tuberculum sellae meningiomas (Fig. 11.5), and some rare pituitary adenomas (Fig. 11.6) require a subarachnoid dissection to free them from critical suprasellar structures (Fig. 11.7).


The critical anatomic landmark for this approach is the medial optic carotid recess, which is the lateral aspect of the tuberculum sellae. It must be removed to allow adequate exposure of the suprasellar compartment. Once the bone is removed, the dura is opened above the superior intercavernous sinus, which is ligated only when there is disease that requires arachnoid dissection involving the sella and suprasellar space. The dural opening can occur from one internal carotid artery to the other with direct safe access to the medial aspect of the carotid cave and the optic canals. The opening is extended anteriorly in case the tumor is located above the planum sphenoidale.


Retrosellar Space and Clivus


Some pituitary macroadenomas can extend posteriorly over the dorsum sellae, reaching the retrosellar space. These lesions are virtually impossible to resect through a standard transsphenoidal microscopic approach. The alternatives are either a retromastoid posterior fossa approach or an endoscopic endonasal transclival approach.


An endonasal transclival approach can be performed in segmental portions (upper, middle, or lower thirds) or as complete removal of the clivus (panclivectomy). The upper third is related to the dorsum sellae in the midline and the posterior clinoids in the paramedian region. The posterior wall of the sella can be removed via a transsellar approach when the tumor has created intrasellar space, or after a pituitary transposition and ligation of the posterior intercavernous sinus.63 The retrosellar bone can also be resected extradurally via a subsellar corridor after removal of the sellar bone and superior retraction of the sellar dura.63 After transposition, the retrodorsal dura containing the basilar plexus is exposed. Dural opening with basilar plexus control provides access to the retrodorsal area and the interpeduncular cistern, surrounded laterally by the posterior communicating arteries and third cranial nerves and posteriorly by the basilar artery with its terminal branches.


images


Fig. 11.4 (A,B) MRI with contrast of a 32-year-old man with a craniopharyngioma who presented with visual loss. The tumor has large components, both solid and cystic. (A) Coronal view. (B) Sagittal view. (C,D) Postoperative MRI with contrast 24 hours after an expanded endonasal transtuberculum and transplanum approach demonstrating complete resection of the craniopharyngioma. (C) Coronal view. (D) Sagittal view. Note the presence of an enhancing nasoseptal flap that was used for reconstruction (black arrow) and the preserved pituitary stalk.


images


Fig. 11.5 MRI with contrast of a 39-year-old woman with a planum sphenoidale meningioma who presented with headaches and mild visual deterioration. (A) Coronal view. (B) Sagittal view. (C,D) Postoperative MRI with contrast 24 hours after an expanded endonasal transplanum approach demonstrating complete meningioma resection. (C) Coronal view. (D) Sagittal view. Note the presence of an enhancing nasoseptal flap that was used for reconstruction (white arrows) and the preserved pituitary gland and stalk.


Along with the indications for resection of macroadenomas invading the posterior fossa and the clivus, a transclival approach is frequently used for the resection of extradural and intradural diseases, such as chordomas and chondrosarcomas (Fig. 11.8). It is also used to access purely intradural disease anterior to the brainstem, such as meningiomas and craniopharyngiomas.


The middle clivus can be directly accessed at the posterior aspect of the sphenoid sinus, and its resection is limited laterally by both internal carotid arteries ascending in the paraclival areas. If the bone drilling continues inferiorly, the lower third of the clivus is restricted laterally by the fossa of Rosenmüller and the torus tubarius. Once intradural, a middle clivectomy gives access to the prepontine cistern and basilar artery, guarded laterally by the sixth cranial nerves. The inferior third gives access to the premedullary cistern, with the vertebral arteries posteriorly and the hypoglossal nerves limiting the approach laterally.


A panclivectomy can extend all the way from the dorsum sellae and posterior clinoids down to the basion at the foramen magnum.


images


Fig. 11.6 MRI with contrast of a 56-year-old man with a pituitary macroadenoma with extension to the anterior fossa who presented with profound bitemporal hemianopsia. (A) Axial view. (B) Sagittal view. (C,D) Postoperative MRI with contrast at 3-month follow-up after an expanded endonasal transtuberculum and transplanum approach demonstrating complete adenoma resection. (C) Axial view. (D) Sagittal view.


images


Fig. 11.7 Intraoperative view of the left suprasellar space with a zero-degree endoscope during dissection of a craniopharyngioma (Tu). Note that the tumor was dissected from the left internal carotid artery (ICA) and chiasmatic perforator, anterior cerebral artery (A1), left optic nerve (ON), and optic tract (OT). Note the anterior choroidal artery running on the surface of the uncus (U). PG, pituitary gland.


Cavernous Sinus and the Meckel Cave


Although pituitary macroadenomas often push the cavernous sinus wall laterally, respecting its limits, they may truly invade that space by crossing the plane of the medial cavernous sinus wall. There is debate in the literature regarding the pattern of this invasion. It is not clear if the invasiveness is a consequence of tumor cell characteristics or if it is related to the fact that some people may have a dehiscence of the medial wall of the cavernous sinus that facilitates adenoma penetration.64 The reality is that any pituitary adenoma that disseminates into the cavernous sinus becomes a challenging entity to be cured, independently of the treatment strategy. Based on the potential morbidity, a surgical procedure, endonasal or craniotomy, will rarely be indicated for an invasive adenoma located inside the cavernous sinus. Radiosurgery and/or medical treatment, particularly in functional adenomas, are generally the most prudent options in these situations. However, there are circumstances in which a cavernous sinus approach is a reasonable option, such as when the patient develops cavernous sinus syndrome with florid cranial nerve neuropathy and decompression is indicated, which can be achieved with an endoscopic endonasal approach or a craniotomy with middle fossa peeling. Another reasonable indication is a patient with a functional pituitary adenoma that is limited to the medial compartment of the cavernous sinus. In this scenario, an endoscopic endonasal approach can be performed to resect the medial cavernous sinus wall and remove the disease located medial to the cavernous internal carotid artery (Fig. 11.3).


Other tumors can be present in these areas, such as meningiomas and schwannomas. When the disease is located lateral to the internal carotid artery in the middle fossa, filling the lateral compartment of the cavernous sinus and the Meckel cave, then a craniotomy with middle fossa skull base exposure becomes a reasonable surgical approach. However, when cavernous sinus meningiomas are resected, independently of the approach, the morbidity can be extremely high since they can invade cranial nerves.65 Trigeminal schwannomas are usually not invasive and can be approached endonasally (Fig. 11.9) or by craniotomy.62


To reach the middle fossa through an endonasal corridor, a transpterygoid approach is performed. Initially, a maxillary antrostomy is developed, exposing the posterior wall of the maxillary sinus. The sphenopalatine artery is identified, and its branches are coagulated and ligated. The posterior wall of the maxillary sinus is removed, and the soft contents of the sphenopalatine fossa are retracted laterally. The vidian foramen and foramen rotundum are identified posteriorly in the sphenoid bone and preserved when possible. The lateral sphenoid recess can be completely exposed once the pterygoid base of the sphenoid plates is drilled. This exposure allows direct access to the middle fossa.


images


Fig. 11.8 MRI with contrast of a 28-year-old man with a recurrent clival chordoma who presented with right sixth cranial nerve palsy. (A) Axial view. (B) Sagittal view. (C,D) Postoperative MRI with contrast at 24 hours after an expanded endonasal transclival approach with intradural and extradural dissection demonstrating thorough chordoma resection. (C) Axial view. (D) Sagittal view. Note the preservation of the pituitary gland and stalk.


images


Fig. 11.9 MRI with contrast of a 20-year-old woman with a left trigeminal schwannoma who presented with left facial partial numbness. (A) Axial view. (B) Coronal view. (C,D) Postoperative MRIs with contrast at 24 hours demonstrating complete resection of the tumor via an endoscopic endonasal approach to Meckel’s cave. (C) Axial view. Note that the left trigeminal nerve can now be visualized in normal position in the cistern. (D) Sagittal view.


The quadrangular space is the front door to the Meckel cave.22,62 This space is outlined by the horizontal petrous internal carotid artery inferiorly, the ascending vertical cavernous/paraclival internal carotid artery medially, the sixth cranial nerve superiorly in the cavernous sinus, and the maxillary division of the trigeminal nerve (V2) laterally. The vidian nerve is followed posteriorly up to the level of the lacerum segment of internal carotid artery. Once the internal carotid artery is identified, it can be skeletonized if needed, depending on the pathology. The bone of the medial temporal fossa is drilled and the periosteum exposed and opened at the quadrangular space, as described above. Tumors commonly encountered in this region are invasive adenoid cystic carcinomas, juvenile nasal angiofibromas, meningiomas, schwannomas, and invasive pituitary adenomas.


The lateral compartment of the cavernous sinus is rarely approached because of the presence of cranial nerves coming and going to the superior orbital fissure. As we mentioned above, this area is explored surgically almost exclusively when the patient already has cranial nerve (III, IV, VI) deficits.


images The Reconstruction


Following the principles of reconstruction in open skull base surgery, we use vascularized tissue to rebuild the skull base defect. Hadad and Bassagasteguy, from Argentina, and colleagues developed a nasoseptal flap supplied by the posterior nasoseptal arteries, which are branches of the sphenopalatine artery.66 This nasoseptal mucosal flap has been our preferred reconstruction technique.67 The flap can be harvested initially in cases in which CSF exposure is likely, or as a rescue flap at the end of the procedure in cases in which there is an unsuccessful attempt to avoid an intraoperative CSF leak. In general, it is harvested on the side that requires less lateral exposure, contralateral to the lesion.67


During this reconstruction, the flap needs to be in contact with the denuded bone for proper defect closing, so all the sinus mucosa is removed.


Besides the nasoseptal flap, we use an inlay subdural graft of collagen matrix. Rarely, in cases in which the nasoseptal flap does not cover the entire defect, an additional onlay fascial graft and/or abdominal free fat is used. It is imperative to avoid any foreign body or nonvascularized tissue between the flap and the surrounding edges of the defect.


When a nasoseptal flap is not available, then other sources of vascularized tissue exist. Excellent alternatives can be encountered in the nasal cavity, such as an inferior turbinate flap, optimized for clival defects, or middle turbinate flaps for anterior fossa small defects.1,68 In situations in which a vascularized flap is not available in the nasal cavity, such as after multiple surgical procedures or radiation, then healthy vascularized tissue can be elevated from outside and rotated into the nasal cavity to cover the defect. Examples of extranasal flaps that can be rotated into the nasal cavity are the transpterygoid temporoparietal fascia flap, based on the superficial temporal artery,69 and a pericranial flap vascularized by the supraorbital artery, which can be elevated endoscopically and transferred to the nasal cavity through an opening in the nasal bone.70


Biological glue helps to fix the flap in place (but should not be overused), and nasal sponge packing or the balloon of a 12F Foley catheter is inserted to press the Hadad-Bassagasteguy flap against the defect. Inflation of the Foley balloon should be under microscopic or endoscopic observation to avoid overdistension and inadvertent compression of intracranial structures or flap vascular pedicle compromise.


images Conclusion


The microscopic transsphenoidal approach is the standard surgical technique for the resection of sellar lesions. However, its main limitation is related to the lack of appropriate visualization of areas distant to the sella. For those locations, the endoscopic endonasal approach is a great substitute based on the inherent characteristics of the endoscope, which allows broad-angle illumination and visualization. Although the endoscopic technique offers superior advantages over microscopic transsphenoidal surgery in dealing with parasellar lesions, it is not clear if the same is true for purely intrasellar lesions. However, the wide field given by the endoscope offers a comprehensive exposure of skull base landmarks, which allows a better surgical orientation and consequently a safer procedure.


References


  1. Fortes FS, Carrau RL, Snyderman CH, et al. The posterior pedicle inferior turbinate flap: a new vascularized flap for skull base reconstruction. Laryngoscope 2007;117(8):1329–1332
  2. Doglietto F, Prevedello DM, Jane JA Jr, Han J, Laws ER Jr. Brief history of endoscopic transsphenoidal surgery–from Philipp Bozzini to the First World Congress of Endoscopic Skull Base Surgery. Neurosurg Focus 2005;19(6):E3
  3. Liu JK, Das K, Weiss MH, Laws ER Jr, Couldwell WT. The history and evolution of transsphenoidal surgery. J Neurosurg 2001; 95(6):1083–1096
  4. Apuzzo ML, Heifetz MD, Weiss MH, Kurze T. Neurosurgical endoscopy using the side-viewing telescope. J Neurosurg 1977; 46(3):398–400
  5. Bushe KA, Halves E. Modified technique in transsphenoidal operations of pituitary adenomas. Technical note (author’s transl). Acta Neurochir (Wien) 1978;41(1–3):163–175
  6. Halves E, Bushe KA. Transsphenoidal operation on craniopharyngiomas with extrasellar extensions. The advantage of the operating endoscope [proceedings]. Acta Neurochir Suppl (Wien) 1979;28(2):362
  7. Dusick JR, Esposito F, Kelly DF, et al. The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 2005;102(5):832–841
  8. Couldwell WT, Weiss MH, Rabb C, Liu JK, Apfelbaum RI, Fukushima T. Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases. Neurosurgery 2004;55(3):539–547, discussion 547–550
  9. Frank G, Pasquini E, Mazzatenta D. Extended transsphenoidal approach. J Neurosurg 2001;95(5):917–918
  10. Catapano D, Sloffer CA, Frank G, Pasquini E, D’Angelo VA, Lanzino G. Comparison between the microscope and endoscope in the direct endonasal extended transsphenoidal approach: anatomical study. J Neurosurg 2006;104(3):419–425
  11. Frank G, Pasquini E, Doglietto F, et al. The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery 2006;59(1, Suppl 1):ONS75–ONS83
  12. de Divitiis E, Cappabianca P. Microscopic and endoscopic transsphenoidal surgery. Neurosurgery 2002;51(6):1527–1529, author reply 1529–1530
  13. Jankowsk i R, Auque J, Simon C, Marchal JC, Hepner H, Wayoff M. Endoscopic pituitary tumor surgery. Laryngoscope 1992;102(2):198–202
  14. Carrau RL, Jho HD, Ko Y. Transnasal-transsphenoidal endoscopic surgery of the pituitary gland. Laryngoscope 1996;106(7):914–918
  15. Jho HD, Carrau RL. Endoscopic endonasal transsphenoidal surgery: experience with 50 patients. J Neurosurg 1997;87(1):44–51
  16. Litynski GS. Endoscopic surgery: the history, the pioneers. World J Surg 1999;23(8):745–753
  17. Cappabianca P, Alfieri A, Colao A, et al. Endoscopic endonasal transsphenoidal surgery in recurrent and residual pituitary adenomas: technical note. Minim Invasive Neurosurg 2000;43(1):38–43
  18. Cappabianca P, Frank G, Pasquini E, de Divitiis E, Calbucci F. Extended endoscopic endonasal transsphenoidal approaches to the suprasellar region, planum sphenoidale and clivus. In: de Divitiis E, Cappabianca P, eds. Endoscopic Endonasal Transsphenoidal Surgery. Springer-Verlag; 2003:176–187
  19. Cavallo LM, Briganti F, Cappabianca P, et al. Hemorrhagic vascular complications of endoscopic transsphenoidal surgery. Minim Invasive Neurosurg 2004;47(3):145–150
  20. Cavallo LM, Cappabianca P, Galzio R, Iaconetta G, de Divitiis E, Tschabitscher M. Endoscopic transnasal approach to the cavernous sinus versus transcranial route: anatomic study. Neurosurgery 2005;56(2, Suppl):379–389, discussion 379–389
  21. Cavallo LM, Messina A, Cappabianca P, et al. Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations. Neurosurg Focus 2005;19(1):E2
  22. Cavallo LM, Messina A, Gardner P, et al. Extended endoscopic endonasal approach to the pterygopalatine fossa: anatomical study and clinical considerations. Neurosurg Focus 2005;19(1):E5
  23. Cappabianca P, Alfieri A, Thermes S, Buonamassa S, de Divitiis E. Instruments for endoscopic endonasal transsphenoidal surgery. Neurosurgery 1999;45(2):392–395, discussion 395–396
  24. Cappabianca P, Cavallo LM, Mariniello G, de Divitiis O, Romero AD, de Divitiis E. Easy sellar reconstruction in endoscopic endonasal transsphenoidal surgery with polyester-silicone dural substitute and fibrin glue: technical note. Neurosurgery 2001;49(2):473– 475, discussion 475–476
  25. Cappabianca P, Cavallo LM, Valente V, et al. Sellar repair with fibrin sealant and collagen fleece after endoscopic endonasal transsphenoidal surgery. Surg Neurol 2004;62(3):227–233, discussion 233
  26. Cappabianca P, de Divitiis E. Back to the Egyptians: neurosurgery via the nose. A five-thousand year history and the recent contribution of the endoscope. Neurosurg Rev 2007;30(1):1–7, discussion 7
  27. de Divitiis E. Endoscopic transsphenoidal surgery: stone-in-the-pond effect. Neurosurgery 2006;59(3):512–520
  28. Dumont AS, Kanter AS, Jane JA Jr, Laws ER Jr. Extended transsphenoidal approach. Front Horm Res 2006;34:29–45
  29. Laws ER Jr. Transsphenoidal microsurgery in the management of craniopharyngioma. J Neurosurg 1980;52(5):661–666
  30. Laws ER, Kanter AS, Jane JA Jr, Dumont AS. Extended transsphenoidal approach. J Neurosurg 2005;102(5):825–827, discussion 827–828
  31. Kaptain GJ, Vincent DA, Sheehan JP, Laws ER Jr. Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions. Neurosurgery 2001;49(1):94– 100, discussion 100–101
  32. Kern EB, Laws ER Jr. The transseptal approach to the pituitary gland. Rhinology 1978;16(2):59–78
  33. 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 2005; 19(1):E4
  34. 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 2005;19(1):E3
  35. de Divitiis E, Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A. Extended endoscopic transsphenoidal approach for extrasellar craniopharyngiomas. Neurosurgery 2007;61(5, Suppl 2):219–227, discussion 228
  36. de Divitiis E, Cavallo LM, Esposito F, Stella L, Messina A. Extended endoscopic transsphenoidal approach for tuberculum sellae meningiomas. Neurosurgery 2008;62(6, Suppl 3):1192–1201
  37. Frank G, Sciarretta V, Calbucci F, Farneti G, Mazzatenta D, Pasquini E. The endoscopic transnasal transsphenoidal approach for the treatment of cranial base chordomas and chondrosarcomas. Neurosurgery 2006;59(1, Suppl 1):ONS50–ONS57
  38. Kassam AB, Prevedello DM, Carrau RL, et al. The front door to Meckel’s cave: an antero-medial corridor via expanded endoscopic endonasal approach- technical considerations and clinical series. Neurosurgery 2009;64(3, Suppl):71–82
  39. Kassam AB, Vescan AD, Carrau RL, et al. Expanded endonasal approach: vidian canal as a landmark to the petrous internal carotid artery. J Neurosurg 2008;108(1):177–183
  40. Prevedello DM, Thomas A, Gardner P, Snyderman CH, Carrau RL, Kassam AB. Endoscopic endonasal resection of a synchronous pituitary adenoma and a tuberculum sellae meningioma: technical case report. Neurosurgery 2007;60(4, Suppl 2):E401, discussion E401
  41. Stippler M, Gardner PA, Snyderman CH, Carrau RL, Prevedello DM, Kassam AB. Endoscopic endonasal approach for clival chordomas. Neurosurgery 2009;64(2):268–277, discussion 277–278
  42. Kassam AB, Mintz AH, Gardner PA, Horowitz MB, Carrau RL, Snyderman CH. The expanded endonasal approach for an endoscopic transnasal clipping and aneurysmorrhaphy of a large vertebral artery aneurysm: technical case report. Neurosurgery 2006;59(1, Suppl 1):E162–E165
  43. Kassam AB, Snyderman C, Gardner P, Carrau R, Spiro R. The expanded endonasal approach: a fully endoscopic transnasal approach and resection of the odontoid process: technical case report. Neurosurgery 2005;57(1, Suppl):E213, discussion E213
  44. Cappabianca P, de Divitiis E. Endoscopy and transsphenoidal surgery. Neurosurgery 2004;54(5):1043–1048
  45. Youssef AS, Agazzi S, van Loveren HR. Transcranial surgery for pituitary adenomas. Neurosurgery 2005;57(1, Suppl):168–175
  46. Prevedello DM, Pouratian N, Sherman J, et al. Management of Cushing’s disease: outcome in patients with microadenoma detected on pituitary magnetic resonance imaging. J Neurosurg 2008;109(4):751–759
  47. Kerr PB, Oldfield EH. Sublabial-endonasal approach to the sella turcica. J Neurosurg 2008;109(1):153–155
  48. Cavallo LM, Prevedello D, Esposito F, et al. The role of the endoscope in the transsphenoidal management of cystic lesions of the sellar region. Neurosurg Rev 2008;31(1):55–64, discussion 64
  49. Jane JA Jr, Han J, Prevedello DM, Jagannathan J, Dumont AS, Laws ER Jr. Perspectives on endoscopic transsphenoidal surgery. Neurosurg Focus 2005;19(6):E2
  50. Nejadkazem M, Samii A, Fahlbusch R, Bidadi S. A simplified direct endonasal approach for transsphenoidal surgery. Minim Invasive Neurosurg 2008;51(5):272–274
  51. Lindholm J. A century of pituitary surgery: Schloffer’s legacy. Neurosurgery 2007;61(4):865–867, discussion 867–868
  52. Er U, Gürses L, Saka C, et al. Sublabial transseptal approach to pituitary adenomas with special emphasis on rhinological complications. Turk Neurosurg 2008;18(4):425–430
  53. Jagannathan J, Prevedello DM, Ayer VS, Dumont AS, Jane JA Jr, Laws ER. Computer-assisted frameless stereotaxy in transsphenoidal surgery at a single institution: review of 176 cases. Neurosurg Focus 2006;20(2):E9
  54. Fatemi N, Dusick JR, de Paiva Neto MA, Kelly DF. The endonasal microscopic approach for pituitary adenomas and other parasellar tumors: a 10-year experience. Neurosurgery 2008;63(4, Suppl 2):244–256, discussion 256
  55. Dusick JR, Esposito F, Malkasian D, Kelly DF. Avoidance of carotid artery injuries in transsphenoidal surgery with the Doppler probe and micro-hook blades. Neurosurgery 2007;60(4, Suppl 2):322– 328, discussion 328–329
  56. Cappabianca P, Alfieri A, de Divitiis E. Endoscopic endonasal transsphenoidal approach to the sella: towards functional endoscopic pituitary surgery (FEPS). Minim Invasive Neurosurg 1998;41(2):66–73
  57. Oldfield EH, Vortmeyer AO. Development of a histological pseudocapsule and its use as a surgical capsule in the excision of pituitary tumors. J Neurosurg 2006;104(1):7–19
  58. Carrabba G, Dehdashti AR, Gentili F. Surgery for clival lesions: open resection versus the expanded endoscopic endonasal approach. Neurosurg Focus 2008;25(6):E7
  59. Al-Mefty O, Kadri PA, Hasan DM, Isolan GR, Pravdenkova S. Anterior clivectomy: surgical technique and clinical applications. J Neurosurg 2008;109(5):783–793
  60. Zanation AM, Snyderman CH, Carrau RL, Gardner PA, Prevedello DM, Kassam AB. Endoscopic endonasal surgery for petrous apex lesions. Laryngoscope 2009;119(1):19–25
  61. Gardner PA, Kassam AB, Thomas A, et al. Endoscopic endonasal resection of anterior cranial base meningiomas. Neurosurgery 2008;63(1):36–52, discussion 52–54
  62. Kassam AB, Prevedello DM, Carrau RL, et al. The front door to Meckel’s cave: an anteromedial corridor via expanded endoscopic endonasal approach- technical considerations and clinical series. Neurosurgery 2009;64(3, Suppl):71–82, discussion 82–83
  63. Kassam AB, Prevedello DM, Thomas A, et al. Endoscopic endonasal pituitary transposition for a transdorsum sellae approach to the interpeduncular cistern. Neurosurgery 2008;62(3, Suppl 1):57– 72, discussion 72–74
  64. Prevedello DM, Jagannathan J, Jane JA Jr, Lopes MB, Laws ER Jr. Relevance of high Ki-67 in pituitary adenomas. Case report and review of the literature. Neurosurg Focus 2005;19(5):E11
  65. Larson JJ, van Loveren HR, Balko MG, Tew JM Jr. Evidence of meningioma infiltration into cranial nerves: clinical implications for cavernous sinus meningiomas. J Neurosurg 1995;83(4): 596–599
  66. Hadad G, Bassagasteguy L, Carrau RL, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006;116(10): 1882–1886
  67. Kassam AB, Thomas A, Carrau RL, et al. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 2008;63(1, Suppl 1):ONS44–ONS52, discussion ONS52–ONS53
  68. Prevedello DM, Barges-Coll J, Fernandez-Miranda JC, et al. Middle turbinate flap for skull base reconstruction: cadaveric feasibility study. Laryngoscope 2009;119(11):2094–2098
  69. Fortes FS, Carrau RL, Snyderman CH, et al. Transpterygoid transposition of a temporoparietal fascia flap: a new method for skull base reconstruction after endoscopic expanded endonasal approaches. Laryngoscope 2007;117(6):970–976
  70. Zanation AM, Snyderman CH, Carrau RL, Kassam AB, Gardner PA, Prevedello DM. Minimally invasive endoscopic pericranial flap: a new method for endonasal skull base reconstruction. Laryngoscope 2009;119(1):13–18

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Feb 8, 2017 | Posted by in NEUROSURGERY | Comments Off on Transsphenoidal Approaches to the Sellar and Parasellar Area

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