A novel transnasal transsphenoidal speculum: a design for both microscopic and endoscopic transsphenoidal pituitary surgery

Over the last several years minimally invasive surgical approaches to the sella turcica and parasellar regions have undergone significant change. The transsphenoidal approach to this region has evolved from a sublabial transnasal, to transnasal, to pure endonasal approaches with the increasing popularity of endoscopic over microscopic techniques. Endoscopic and microscopic techniques individually or in combination have their own unique advantages, and the preference of one over the other awaits further technological refinements and surgical experience. In parallel with this evolution in techniques for transsphenoidal surgery, the authors designed an adaptable versatile speculum for the endonasal/transnasal transsphenoidal approach to the sella turcica and parasellar regions that can be used equally effectively with a microscope or an endoscope. The development of this instrument and its unique features are described, and its initial clinical use is summarized. This transnasal transsphenoidal speculum has interchangeable blades, unique blade angulations, and independent blade opening mechanisms and allows safe, optimal exposure in all patients regardless of the size and anatomical aberrations of individual nasal and endonasal regions. An attached endoscope carrier further allows it to be used interchangeably with microscopic or endoscopic techniques without having to remove the speculum; likewise, a single surgeon can use both hands without need of an assistant. A forehead headrest component adds further stabilization. This device has been used successfully in 90 transsphenoidal procedures.

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Hermann Schloffer and the origin of transsphenoidal pituitary surgery

Neurosurgical FOCUS ◽

10.3171/2012.5.focus12129 ◽

2012 ◽

Vol 33 (2) ◽

pp. E5 ◽

Cited By ~ 19

Author(s):

Richard F. Schmidt ◽

Osamah J. Choudhry ◽

Ramya Takkellapati ◽

Jean Anderson Eloy ◽

William T. Couldwell ◽

...

Keyword(s):

Transsphenoidal Surgery ◽

Skull Base Surgery ◽

Sella Turcica ◽

Pituitary Surgery ◽

Transsphenoidal Approach ◽

Harvey Cushing ◽

Transsphenoidal Pituitary Surgery ◽

Transsphenoidal Operation ◽

Technological Limitations ◽

The University

A little over a century ago, in 1907, at the University of Innsbruck, Hermann Schloffer performed the first transsphenoidal surgery on a living patient harboring a pituitary adenoma. Schloffer used a superior nasal route via a transfacial lateral rhinotomy incision. This was perhaps his greatest academic contribution to neurosurgery. Despite the technological limitations of that time, Schloffer's operation was groundbreaking in that it laid the foundation for future development and refinement of transsphenoidal pituitary surgery, influencing prominent surgeons such as Oskar Hirsch and Harvey Cushing. Even after undergoing multiple modifications and a brief fall into obscurity, the transsphenoidal approach has endured through generations of surgeons and remains the preferred approach for lesions of the sella turcica to this day. Although Schloffer performed primarily abdominal surgery in his practice, his contributions to the transsphenoidal approach have had a lasting impact in the field of pituitary and skull base surgery. The authors review the life and career of Hermann Schloffer, the surgical details of his transsphenoidal operation, and the legacy that it has left on the field of pituitary surgery.

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Costs and Their Predictors in Transsphenoidal Pituitary Surgery

Neurosurgery ◽

10.1093/neuros/nyy441 ◽

2018 ◽

Vol 85 (5) ◽

pp. 695-707 ◽

Cited By ~ 6

Author(s):

Anthony O Asemota ◽

Masaru Ishii ◽

Henry Brem ◽

Gary L Gallia

Keyword(s):

Health Plan ◽

Pituitary Surgery ◽

Direct Costs ◽

Geographical Region ◽

National Database ◽

Surgical Approaches ◽

Endoscopic Techniques ◽

Hospital Facility ◽

Transsphenoidal Pituitary Surgery ◽

Differential Costs

Abstract BACKGROUND Contemporary surgical approaches to pituitary pathologies include transsphenoidal microsurgical and, more recently, endoscopic techniques. Data reporting direct costs in transsphenoidal pituitary surgery are limited. OBJECTIVE To examine direct costs (including overall total, hospital/facility, and physician payments) of microscopic and endoscopic pituitary surgery and evaluate predictors of differential costs in transsphenoidal pituitary surgery using a national database. METHODS The Truven MarketScan® database 2010-2014 (IBM, Armonk, New York) was queried and patients undergoing microscopic and/or endoscopic transsphenoidal pituitary surgery identified. Mean costs and predictors of differential costs were analyzed using analysis of variance and generalized linear models. Beta-coefficients (β) assessed relative contributions of independent predictors. RESULTS Mean overall total ($34 943.13 [SD ± 19 074.54]) and hospital/facility ($26 505.93 [SD ± 16 819.52]) payments were higher in endoscopic compared to microscopic surgeries (both P < .001). Lengths of hospital stay (LOS) were similar between groups. Predictors of overall total and hospital/facility payments were similar including surgical technique, age, geographical region, comorbidity index, postoperative surgical and medical complications, and LOS with LOS being the most significant predictor (β = 0.27 and β = 0.29, respectively). Mean physician payments ($4549.24 [SD ± 3956.27]) were similar in microscopic and endoscopic cohorts (P = .26). Predictors of physician payments included age, health plan, geographical region, postoperative surgical complications, and LOS with health plan being the most significant predictor (β = –0.21). CONCLUSION Higher overall total and hospital/facility costs are associated with endoscopic transsphenoidal pituitary surgery compared to microsurgery. In contrast, physician reimbursements are similar between techniques. Whereas LOS was the strongest predictor of overall total and hospital/facility costs, health plan was the strongest predictor of differential physician reimbursements.

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Endoscopic Transsphenoidal Surgery

Neurosurgery ◽

10.1227/01.neu.0000227475.69682.77 ◽

2006 ◽

Vol 59 (3) ◽

pp. 512-520 ◽

Cited By ~ 42

Author(s):

Enrico de Divitiis

Keyword(s):

Gold Standard ◽

Transsphenoidal Surgery ◽

Sella Turcica ◽

Clinical Results ◽

Transsphenoidal Approach ◽

Surgical Indications ◽

Endoscopic Transsphenoidal Surgery ◽

Endoscopic Techniques ◽

Effective Removal ◽

Brain Retraction

Abstract THE TRANSSPHENOIDAL MIDLINE route represents the standard approach to the pituitary and sellar area and is used for more than 95% of surgical indications in this region. It is the least traumatic route to the sella turcica, it avoids brain retraction, and it provides excellent visualization of the pituitary gland and lesions related to that structure. The technique has essentially replaced craniotomy and has been used by every pituitary neurosurgeon, representing the “gold standard” of the transsphenoidal approach to the sellar region for more than 30 years. The introduction of endoscopic techniques has produced a “stone-in-the-pond” effect, influencing the relatively peaceful neurosurgical environment. The brilliant increased vision of the surgical target offered by the endoscope can allow more effective removal of the lesion, followed by superior clinical results and a reduction in the incidence of complications. Endoscopy contributes to better and more contemporary knowledge of the possibilities of the transsphenoidal approach, thus increasing the extended approaches, not only for the pituitary area. Whether or not the transsphenoidal approach should be performed with the use of the microscope or the endoscope is finally discussed.

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Endonasal transsphenoidal approach to pituitary surgery: experience of 55 cases

Bangladesh Journal of Otorhinolaryngology ◽

10.3329/bjo.v15i2.5056 ◽

1970 ◽

Vol 15 (2) ◽

pp. 45-49 ◽

Cited By ~ 1

Author(s):

Forhad Hossain Chowdhury ◽

Md Raziul Haque ◽

Md Shafiqul Islam ◽

Mani Lal Aich ◽

Khandkar Ali Kawsar ◽

...

Keyword(s):

Pituitary Tumor ◽

Pituitary Apoplexy ◽

Complete Removal ◽

Pituitary Surgery ◽

Transsphenoidal Approach ◽

Csf Leak ◽

College Hospital ◽

Endoscopic Techniques ◽

Medical College ◽

Transsphenoidal Pituitary Surgery

Transsphenoidal approach to sella is not a new approach. In the last 100 years it has gone numerous changing refinements from using headlight to microscope and more recently the sensitive endoscope. In this prospective study, all patients with pituitary tumor who underwent endonasal transsphenoidal pituitary surgery during the period of January 2006 to July 2009 in the department of neurosurgery, Dhaka Medical College Hospital and Islami Bank Central Hospital, Dhaka, Bangladesh were included. Among the 55 patients 36 cases were operated by combined endoscopic and microscopic techniques and 19 cases were operated by endoscope only. Total 73 procedures were done in 55 patients. Age range was 17 years to 70 years. Follow up period was 03 months to 42 months (mean 14.2 months) .Male: female was almost 1:1. Clinical features were pituitary apoplexy, pituitary apoplexy with 3rd/+6th cranial nerve palsy, headache, amenorrhea, loss of libido, galactorrhoea, gynecomastia, weight gain and psychosis. Visual impairment was in 35 cases. Functioning adenoma was 21 and non functioning adenoma was 34 cases. Among the functioning adenoma acromegaly was seen in 12 cases, gigantism in 01 case, prolactinoma in 05 cases, Cushing's disease 03 cases. Purely sellar tumor was 15, sellar & suprasellar 35 and sellar & parasellar 11 cases. Microscopic plus endoscopic techniques used in 54 procedures. Purely endoscopic procedures were 19. Complete removal of tumor in single stage was done in 33 cases. Complete removal with more than one stage surgery in 13 cases. In our initial cases of the series, we exposed the sella endonasally with endoscope then we used microscope for the rest of the surgery. In the later part of the series we gained experience and confidence for removal of pituitary tumor with an endoscope completely. The rate of diabetes insipidus occurred in 11(20%) cases and all are transient. Postoperative CSF leak was noted in 10(18%) cases. Patient with ocular palsy improved post operatively within 6 weeks. Among non functioning adenoma that were removed completely (30 cases) recurrence occurred in three cases. Eleven patients were stable in vision as preoperative. Other showed visual improvement to variable extents. Key words: Pituitary surgery; Endonasal; Transsphenoidal; Microsurgery; Endoscopic surgery. DOI: 10.3329/bjo.v15i2.5056 Bangladesh J Otorhinolaryngol 2009; 15(2): 45-49

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Increased oxytocin release precedes hyponatremia after pituitary surgery

Pituitary ◽

10.1007/s11102-020-01121-4 ◽

2021 ◽

Author(s):

Paul Eugène Constanthin ◽

Nathalie Isidor ◽

Sophie de Seigneux ◽

Shahan Momjian

Keyword(s):

Transsphenoidal Surgery ◽

Pituitary Surgery ◽

Sodium Balance ◽

Posterior Pituitary ◽

Axon Terminals ◽

Early Marker ◽

Inappropriate Secretion ◽

Oxytocin Release ◽

Transsphenoidal Pituitary Surgery ◽

First Time

Abstract Purpose The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a well-known complication of transsphenoidal pituitary surgery, related to inappropriate secretion of arginine vasopressin (AVP). Its diagnosis is based on hyponatremia, with a peak of occurrence around day 7 after surgery and, to date, no early marker has been reported. In particular, copeptin levels are not predictive of hyponatremia in this case. Oxytocin (OXT) is secreted into the peripheral blood by axon terminals adjacent to those of AVP neurons in the posterior pituitary. Besides its role in childbirth and lactation, recent evidences suggested a role for OXT in sodium balance. The contribution of this hormone in the dysnatremias observed after pituitary surgery has however never been investigated. Methods We analyzed the urinary output of OXT in patients subjected to transsphenoidal pituitary surgery. Results While OXT excretion remained stable in patients who presented a normonatremic postoperative course, patients who were later diagnosed with SIADH-related hyponatremia presented with a significantly increased urinary secretion of OXT 4 days after surgery. Conclusion Taken together, these results show for the first time that urinary OXT output remains normally stable after transsphenoidal pituitary surgery. OXT excretion however becomes abnormally high on or around 4 days after surgery in patients later developing hyponatremia, suggesting that this abnormal dynamics of OXT secretion might serve as an early marker for transsphenoidal surgery-related hyponatremia attributed to SIADH.

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The Nasal Gateway for Pituitary Surgery

American Journal of Rhinology ◽

10.2500/105065888781693005 ◽

1988 ◽

Vol 2 (4) ◽

pp. 193-200 ◽

Cited By ~ 1

Author(s):

Mary D. Lekas

Keyword(s):

Pituitary Gland ◽

Sella Turcica ◽

Pituitary Tumors ◽

Pituitary Surgery ◽

Transsphenoidal Approach ◽

External Rhinoplasty

There has been an evolution in the transseptal transsphenoidal approach for pituitary surgery. The nasal approach to the pituitary gland can be from the sublabial transseptal transsphenoidal; the transseptal transsphenoidal; the alotomy transseptal transsphenoidal; the external rhinoplasty transsphenoidal; the transnasal by mobilizing the whole nose on a pedicle; the transseptal infranasal; the midline columellar incision; all types of nasofacial incisions; and transethmoidal approach with nasal instrumentation. The transsphenoidal hypophysectomy surgery has become a safe and effective approach for pituitary tumors. We are mainly concerned with the transnasal and not the transethmoidal approach to the sella turcica at this time.

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Surgery of pituitary tumours

Oxford Textbook of Endocrinology and Diabetes ◽

10.1093/med/9780199235292.003.2098 ◽

2011 ◽

pp. 165-176

Author(s):

Ian F. Dunn ◽

Edward R. Laws

Keyword(s):

Technological Innovation ◽

Surgical Approach ◽

Transsphenoidal Surgery ◽

Transsphenoidal Approach ◽

Surgical Approaches ◽

Pituitary Tumours ◽

Full Spectrum ◽

Clinical Syndromes ◽

Surgical History ◽

Surgical Options

Pituitary tumours have both endocrine and neuro-oncologic sequelae. Secretory tumours may liberate physiological hormones to pathological excess, generating a full spectrum of metabolic aberrations and hallmark clinical syndromes. Other pituitary tumours are endocrinologically inactive and generate instead a variety of compressive phenomena such as pituitary hypofunction and neurological compromise. Although advances continue to be made in the pharmacological and radiotherapeutic management of pituitary tumours, surgery remains the treatment of choice for most of these lesions. Of the available surgical options, the transsphenoidal route is the dominant surgical approach to these tumours. Shaped by the brilliant insight of individual surgeons and technological innovation, transsphenoidal surgery for the sellar and parasellar regions is a fascinating chronicle in surgical history whose evolution continues unabated. We herein review surgical approaches to pituitary tumours, emphasizing the transsphenoidal approach.

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Endoscopic Transnasal Pituitary Surgery: Report on 180 Cases

American Journal of Rhinology ◽

10.1177/194589240101500411 ◽

2001 ◽

Vol 15 (4) ◽

pp. 281-287 ◽

Cited By ~ 63

Author(s):

Shawn S. Nasseri ◽

Jan L. Kasperbauer ◽

Scott E. Strome ◽

Thomas V. McCaffrey ◽

John L. Atkinson ◽

...

Keyword(s):

Operative Time ◽

Operative Procedure ◽

Full Range ◽

Sella Turcica ◽

Length Of Hospital Stay ◽

Pituitary Surgery ◽

Transsphenoidal Approach ◽

Transnasal Approach ◽

Endoscopic Transnasal Approach ◽

Revision Operations

The endoscopic transnasal approach is an evolving technique for treating lesions in the sella turcica. Since this method was introduced at our institution 4 years ago, the majority of transsphenoidal procedures are performed with it. The records of all patients having endoscopic transnasal hypophysectomy at the Mayo Clinic during the last 4 years were reviewed retrospectively. The criteria analyzed were safety, functional and cosmetic outcome, and complications. During the 4-year period, the operative procedure was modified to improve operative exposure and safety. The results of our review showed a significant decrease in length of hospital stay, reduced operative time, reduced need for nasal packing, and elimination of a sublabial incision. The complication rate was equivalent to that reported for the traditional transseptal transsphenoidal approach. As the neurosurgeons at our institution gained experience with this approach, an increasing number of pituitary microadenomas were resected safely and successfully. In addition, because of the limited septal dissection, this approach is particularly helpful for revision operations. This approach also can be used for the full range of pituitary lesions and in conjunction with adjunctive techniques, including frontal craniotomy and -knife irradiation. Currently, the endoscopic transsphenoidal approach is the method preferred for surgically treating pituitary lesions in adults at our institution.

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Sublabial rhinoseptoplastic technique for transsphenoidal pituitary surgery by a hinged-septum method

Journal of Neurosurgery ◽

10.3171/jns.1980.52.6.0867 ◽

1980 ◽

Vol 52 (6) ◽

pp. 867-870 ◽

Cited By ~ 22

Author(s):

Takanori Fukushima ◽

Keiji Sano

Keyword(s):

Sphenoid Sinus ◽

Sella Turcica ◽

Pituitary Surgery ◽

Anterior Wall ◽

Surgical Instruments ◽

En Bloc ◽

Content Type ◽

Anterior Nasal Spine ◽

Transsphenoidal Pituitary Surgery ◽

Mucosal Perforation

✓ A new modification of the transseptal, transsphenoidal approach to the sella turcica is described. The procedure consists of unilateral dissection of the septal mucosa through a sublabial route, and retraction of the entire nasal septum with its upper attachment as a hinge. For mobilization of the septum, an L-shaped osteotomy is made along the base of the septum and along the anterior wall of the sphenoid sinus. It provides adequate exposure of the sphenoid sinus while preserving the septal structures. The anterior nasal spine and the edges of the nares are also left intact. The anterior wall of the sphenoid sinus is resected en bloc and is used as a bone splint for the reconstruction of the sellar floor. This approach has been performed in 45 cases of pituitary adenoma, one of craniopharyngioma, and one with sphenoid mucocele. There was no instance of complications such as mucosal perforation, septal deformity, or infection. Modifications of the surgical instruments used are described.

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Nasal Septum After Sublabial Transseptal Transsphenoidal Pituitary Surgery

Otolaryngology ◽

10.1016/s0194-5998(96)70138-9 ◽

1996 ◽

Vol 115 (1) ◽

pp. 64-69 ◽

Cited By ~ 12

Author(s):

Andrew C. Urquhart ◽

Fernando B. Bersalona ◽

Victor S. Ejercito ◽

James J. Holt

Keyword(s):

Nasal Septum ◽

Pituitary Surgery ◽

Transsphenoidal Approach ◽

Subjective Improvement ◽

Pituitary Fossa ◽

Presenting Symptoms ◽

Before And After ◽

Transsphenoidal Pituitary Surgery ◽

Nasal Function ◽

Septal Perforations

Transseptal transsphenoidal approach to the pituitary fossa is a well-described and effective procedure. This article relates our experience with this procedure with specific emphasis on the nasal septum, both before and after surgery. It has been our experience that this surgery has minimal local complications in the nose and it would appear to improve septal alignment with subjective improvement in nasal function as reported by the patient. A total of 55 patients undergoing a sublabial transseptal transsphenoidal approach to the pituitary fossa were included in this study. All other approaches to the pituitary gland were excluded. Visual changes and headaches were the most common presenting symptoms, occurring alone or in combination in 28 (51%) patients. Twelve (22%) patients reported symptoms of nasal obstruction before surgery and only one (2%) after surgery. A moderately or severely deviated septum was noted in 30 (54%) patients before surgery and 4 (7%) patients after surgery. The septum was straight in 21 (38%) patients before the procedure and 49 (89%) patients afer the surgery. Sinusitis developed in two patients, and one patient subsequently required surgery. No synechiae or septal perforations were noted.

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