Endoscopic endonasal trans-sphenoid surgery of pituitary adenoma

Abstract

Endoscopic endonasal trans-sphenoid surgery (EETS) is increasingly used for pituitary lesions. Pre-operative CT and MRI scans and peroperative endoscopic visualization can provide useful anatomical information. EETS is indicated in sellar, suprasellar, intraventricular, retro-infundibular, and invasive tumors. Recurrent and residual lesions, pituitary apoplexy and empty sella syndrome can be managed by EETS. Modern neuronavigation techniques, ultrasonic aspirators, ultrasonic bone curette can add to the safety. The binostril approach provides a wider working area. High definition camera is much superior to three-chip camera. Most of the recent reports favor EETS in terms of safety, quality of life and tumor resection, hospital stay, better endocrinological, and visual outcome as compared to the microscopic technique. Nasal symptoms, blood loss, operating time are less in EETS. Various naso-septal flaps and other techniques of CSF leak repair could help reduce complications. Complications can be further reduced after achieving the learning curve, good understanding of limitations with proper patient selection. Use of neuronavigation, proper post-operative care of endocrine function, establishing pituitary center of excellence and more focused residency and endoscopic fellowship training could improve results. The faster and safe transition from microscopic to EETS can be done by the team concept of neurosurgeon/otolaryngologist, attending hands on cadaveric dissection, practice on models, and observation of live surgeries. Conversion to a microscopic or endoscopic-assisted approach may be required in selected patients. Multi-modality treatment could be required in giant and invasive tumors. EETS appears to be a better surgical option in most pituitary adenoma.

The Impact of Resident and Fellow Participation in Transsphenoidal Pituitary Surgery

“…The introduction of a new method at the beginning of a learning curve can contribute to more complications . There is a steep learning curve associated with becoming familiar with the endoscope . However, complications are significantly reduced after overcoming the learning curve, which varies from 17 to 50 surgeries according to a review of studies .…”

“…2,3,14 There is a steep learning curve associated with becoming familiar with the endoscope. 15,16 However, complications are significantly reduced after overcoming the learning curve, which varies from 17 to 50 surgeries according to a review of studies. 15 Additionally, the presence of another trained physician, the resident or fellow-especially one at the senior level during the operation-is potentially beneficial.…”

“…15,16 However, complications are significantly reduced after overcoming the learning curve, which varies from 17 to 50 surgeries according to a review of studies. 15 Additionally, the presence of another trained physician, the resident or fellow-especially one at the senior level during the operation-is potentially beneficial. This is a possible contributing factor to the lower surgical complication rate observed in the AR group, which consists of one attending surgeon and at least one resident/ fellow.…”

Isolated double adrenocorticotropic hormone-secreting pituitary adenomas: A case report and review of the literature

“…A total of 18 cases (42.9%) of double pituitary adenomas from the literature were diagnosed during surgery (11,14,18,20,25,30), with the majority of them being clearly visible to the surgeon by the microscopic approach (11). Endoscopic transsphenoidal surgery is used more often than the microscopic approach, particularly in cases of pituitary lesions (32). In the present case, the patient underwent neuroendoscopic transsphenoidal surgery, which allowed for better visualization and enabled the detection of another microadenoma.…”

Endoscopic posterior decompression of lumbar canal stenosis

“…This learning curve can be improved by attending live operative workshops, practice on models and hands on cadaveric dissection. [16,25] …”