Endoscopic Endonasal Transsphenoidal Resection of a Non-functioning Pituitary Adenoma
Sheri K. Palejwala MD, Pacific Neuroscience Institute, Santa Monica, CA Nathan W. Pierce, Pacific Neuroscience Institute, Santa Monica, CA Chester F. Griffiths MD, Pacific Neuroscience Institute, Santa Monica, CA Garni Barkhoudarian MD, Pacific Neuroscience Institute, Santa Monica, CA Daniel F. Kelly MD, Pacific Neuroscience Institute, Santa Monica, CA
This case demonstrates a transsphenoidal resection of an endocrine inactive pituitary macroadenoma. A thorough preoperative vision and endocrine evaluation is necessary. Carotid artery identification with Doppler ultrasound prevents vascular injury. Multi-layered closure helps prevent postoperative CSF rhinorrhea.
A 49-year-old male presented with headaches, fatigue, and erectile dysfunction. Normal vision without deficits was noted on exam. Hormonal testing revealed hypocortisolemia, central hypogonadism, hypothyroidism, and mild hyperprolactinemia.
Endoscopic endonasal transsphenoidal approach Bi-nostril technique with a neurosurgeon and an otolaryngologist 4 mm 0-degree rigid endoscope with 30 and 45-degree endoscopes available
Conservative management Serial MRI surveillance and hormone replacement therapy Alternative surgical approaches Microscopic endonasal transsphenoidal Microscopic sublabial transsphenoidal
Position is as follows: Supine, with a horseshoe head-holder (not fixed) 3-point fixation: longer/more complex cases Neutral to slightly flexed: 0-15 degrees Vertex angled away from surgeon 15-30 degrees Face turned 20-30 degrees to the right (toward surgeons) Neuronavigation is typically used. Helpful for redo and invasive tumors Neuromonitoring is reserved for cases with cavernous sinus invasion, recurrence, or known cranial nerve involvement.
Two HD monitors at 90-degree angles Third monitor for neuronavigation in between
The inferior and middle turbinates are out-fractured. Septal mucosal incision (3 mm below the sphenoid os) for ~2 cm along the vomer and posterior nasal septum, to preserve the septal olfactory strip (SOS) Septal mucosal incision (3 mm below the sphenoid os) for ~2 cm along the vomer and posterior nasal septum, to preserve the septal olfactory strip (SOS) Pedicle-sparing mucosal rescue flaps are dissected inferiorly to be saved if nasoseptal flap is necessary. Sphenoidotomy is performed with Kerrison rongeurs. Posterior septectomy and removal of keel, with pituitary and Kerrison ronguers. The bone graft is harvested for reconstruction. Doppler probe to localize cavernous ICA U-shaped dural opening Elevation of the dural flap Angled ring curettes are used to dissect the adenoma circumferentially. Macroadenomas are removed in a piece-meal fashion. Depends on leak grade Layers Abdominal fat graft Dura Collagen sponge Bone graft Collagen sponge Fibrin glue Mucosal reapproximation Nasal packing as needed
Pearls and Pitfalls
- Avoid carotid artery injury: study anatomy, neuronavigation, Doppler.
- Complete tumor resection: wide sellar exposure, known cavernous/carotid anatomy, capsular dissection when possible.
- Avoid CSF leak: careful with superior dural opening, meticulous multi-layered closure.
- Endoscopic endonasal surgery presents a steep learning curve. A systematic approach can help flatten this curve.
- Familiarity with a standardized technique builds the foundation for complex cases and expanded skull base approaches.
- Sellar reconstruction following adenoma resection should be both meticulous and methodical, tailored to the degree of intraoperative CSF leak.
- Balance of striving for remission and complication avoidance
- Multidisciplinary approach for optimal decision making and multimodality care, including hormonal therapies and radiotherapy