Hermann Schloffer and the origin of transsphenoidal pituitary surgery

2012 ◽  
Vol 33 (2) ◽  
pp. E5 ◽  
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.

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

2011 ◽  
Vol 114 (5) ◽  
pp. 1380-1385 ◽  
Author(s):  
Richard A. Chole ◽  
Chris Lim ◽  
Brian Dunham ◽  
Michael R. Chicoine ◽  
Ralph G. Dacey
Keyword(s):  
Transsphenoidal Surgery ◽  
Sella Turcica ◽  
Pituitary Surgery ◽  
Transsphenoidal Approach ◽  
Surgical Approaches ◽  
Surgical Experience ◽  
Endoscopic Techniques ◽  
Minimally Invasive Surgical ◽  
Transsphenoidal Pituitary Surgery ◽  
Microscopic Techniques

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.

Recognition and management of delayed hyponatremia following transsphenoidal pituitary surgery

2007 ◽  
Vol 106 (1) ◽  
pp. 66-71 ◽  
Author(s):  
Gabriel Zada ◽  
Charles Y. Liu ◽  
Dawn Fishback ◽  
Peter A. Singer ◽  
Martin H. Weiss
Keyword(s):  
Serum Sodium ◽  
Transsphenoidal Surgery ◽  
Pituitary Surgery ◽  
University Hospital ◽  
Outpatient Basis ◽  
Tumor Type ◽  
University Of Southern California ◽  
Female Patients ◽  
Transsphenoidal Pituitary Surgery ◽  
The University

Object The goal of this study was to assess the incidence of symptomatic and occult hyponatremia in patients who had undergone transsphenoidal pituitary surgery. Methods Patients who underwent transsphenoidal surgery at the University of Southern California University Hospital between 1997 and 2004 had serum sodium levels drawn on an outpatient basis on postoperative Day 7. Patient records were retrospectively reviewed to determine the incidence of, and risk factors for, symptomatic and asymptomatic hyponatremia. Two hundred forty-one patients had routine serum sodium levels drawn as outpatients on postoperative Day 7. Twenty-three percent of these patients were found to be hyponatremic (Na ≤ 135 mEq/L). The overall incidence rate of symptomatic hyponatremia in the 241 patients was 5%. The majority of hyponatremic patients (80%) remained asymptomatic, whereas 20% became symptomatic. In patients with symptomatic hyponatremia, the mean sodium level at diagnosis was 120.5 mEq/L, compared with 128.4 mEq/L in asymptomatic, hyponatremic patients (p < 0.0001). Female patients were more likely to develop hyponatremia than male patients (33% compared with 22%, p < 0.03). Fifty-two percent of patients who had transient diabetes insipidus (DI) early in their postoperative course subsequently developed hyponatremia, compared with 21% of those who did not have DI (p < 0.001). Patient age, tumor type, and tumor size did not correlate with development of delayed hyponatremia. Outpatients with moderately and severely low sodium levels were 5 and 12.5 times more likely, respectively, to be symptomatic than were patients with mild hyponatremia. Conclusions Delayed hyponatremia occurs more frequently than was previously suspected in patients who have undergone transsphenoidal surgery, especially in female patients and those who have previously had transient DI. The majority of hyponatremic patients remain asymptomatic. Obtaining a serum sodium value on an outpatient basis 1 week after pituitary surgery is helpful in recognition, risk stratification, and subsequent intervention, and may prevent potentially serious complications.

Norman Dott, Gerard Guiot, and Jules Hardy: key players in the resurrection and preservation of transsphenoidal surgery

2012 ◽  
Vol 33 (2) ◽  
pp. E6 ◽  
Author(s):  
Smruti K. Patel ◽  
Qasim Husain ◽  
Jean Anderson Eloy ◽  
William T. Couldwell ◽  
James K. Liu
Keyword(s):  
Transsphenoidal Surgery ◽  
Image Guidance ◽  
Skull Base Surgery ◽  
Sella Turcica ◽  
Harvey Cushing ◽  
Suprasellar Region ◽  
Key Players ◽  
Transsphenoidal Microsurgery ◽  
Binocular Microscope ◽  
Over Time

Developed over a century ago, the transsphenoidal approach to access lesions of the pituitary gland and sella turcica has transformed the field of neurosurgery, largely due to the work of Oskar Hirsch and Harvey Cushing. Furthermore, its use and modification in the early 1900s was perhaps one of Cushing's greatest legacies to skull base surgery. However, Cushing, who had worked relentlessly to improve the transsphenoidal route to the pituitary region, abandoned the approach by 1929 in his pursuit to master transcranial approaches to the suprasellar region. Hirsch and a few other surgeons continued to perform transsphenoidal operations, but they were unable to maintain the popularity of the approach among their peers. During a time when transsphenoidal surgery was on the brink of extinction, a critical lineage of 3 key surgeons—Norman Dott, Gerard Guiot, and Jules Hardy—would resurrect the art, each working to further improve the procedure. Dott, Cushing's apprentice from 1923 to 1924, brought his experiences with transsphenoidal surgery to Edinburgh, Scotland, and along the way, developed the lighted nasal speculum to provide better illumination in the narrow working area. Guiot, inspired by Dott, adopted his technique and used intraoperative radiofluoroscopic technique for image guidance. Hardy, a fellow of Guiot, from Montreal, Canada, revolutionized transsphenoidal microsurgery with the introduction of the binocular microscope and selective adenomectomy. The teachings of these pioneers have endured over time and are now widely used by neurosurgeons worldwide. In this paper, we review the lineage and contributions of Dott, Guiot, and Hardy who served as crucial players in the preservation of transsphenoidal surgery.

scholarly journals Increased oxytocin release precedes hyponatremia after pituitary surgery

Pituitary ◽  
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.

The Nasal Gateway for Pituitary Surgery

1988 ◽  
Vol 2 (4) ◽  
pp. 193-200 ◽  
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.

scholarly journals Three types of dural suturing for closure of CSF leak after endoscopic transsphenoidal surgery

2019 ◽  
Vol 131 (5) ◽  
pp. 1625-1631 ◽  
Author(s):  
Takayuki Ishikawa ◽  
Kazuhito Takeuchi ◽  
Yuichi Nagata ◽  
Jungsu Choo ◽  
Teppei Kawabata ◽  
...  
Keyword(s):  
Skull Base ◽  
Transsphenoidal Surgery ◽  
Skull Base Surgery ◽  
Sella Turcica ◽  
High Flow ◽  
Anterior Skull Base ◽  
Csf Leak ◽  
Dural Defect ◽  
Csf Leakage ◽  
Dural Suturing

OBJECTIVETranssphenoidal surgery (TSS) is commonly used for anterior skull base surgery, especially in the sella turcica (sellar) region. However, because of its anatomical position, CSF leakage is a major complication of this approach. The authors introduced a new grading reconstruction strategy for anterior skull base surgery with continuous dural suturing in 2013. In this paper the authors report on their methods and results.METHODSAll patients with sellar or anterior skull base lesions that were removed with TSS or extended TSS by a single neurosurgeon between April 2013 and March 2017 at Nagoya University Hospital and several cooperating hospitals were retrospectively identified. Three methods of suturing dura were considered, depending on the dural defect.RESULTSThere were 176 TSS cases (141 conventional TSS cases and 35 extended endoscopic TSS cases) and 76 cases of Esposito’s grade 2 or 3 intradural high-flow CSF leakage. In the high-flow CSF leak group, there were 3 cases of CSF leakage after the operation. The rates of CSF leakage after surgery corresponding to grades 2 and 3 were 2.9% (1/34) and 4.7% (2/42), respectively.CONCLUSIONSDural suturing is a basic and key method for reconstruction of the skull base, and continuous suturing is the most effective approach. Using this approach, the frequency of cases requiring a nasoseptal flap and lumbar drainage can be reduced.

Endoscopic Transnasal Pituitary Surgery: Report on 180 Cases

2001 ◽  
Vol 15 (4) ◽  
pp. 281-287 ◽  
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.

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

1980 ◽  
Vol 52 (6) ◽  
pp. 867-870 ◽  
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.

Endoscopic Transsphenoidal Surgery

Neurosurgery ◽  
2006 ◽  
Vol 59 (3) ◽  
pp. 512-520 ◽  
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.

Nasal Septum After Sublabial Transseptal Transsphenoidal Pituitary Surgery

1996 ◽  
Vol 115 (1) ◽  
pp. 64-69 ◽  
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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