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Microscope transsphenoidal surgery

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Abstract

Background

The transsphenoidal approach to the pituitary using the microscope has undergone continuous modification since its introduction by Hardy over 50 years ago. It is one of the most effective and safest of major neurosurgical procedures with excellent outcomes and low complication rates.

Methods

Although being displaced by the endoscopic approach, it remains the 'gold standard' for a number of pituitary conditions such as Cushing's tumours, and for the majority of the remainder, has yet to be overtaken in outcome results by the endoscopic approach.

Conclusion

This description of the endonasal 'septal pushover' technique is from an author with experience in nearly 4,000 cases. The anatomy is described, and the step-by-step approach and tumour removal for micro- and pituitary macroadenomas are given. Complications and their avoidance are overviewed.

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References

  1. 1.

    Griffith HB, Veerapen R (1987) A direct transnasal approach to the sphenoid sinus. Technical note. J Neurosurgery 66:140–142

  2. 2.

    Powell MP, Lightman SL (1996) Management of Pituitary Tumours, A Clinician’s Guide (1st Edition) Churchill Livingstone, Edinburgh.

  3. 3.

    Couldwell WT, Weiss The transnasal transphenoidal approach. In: Surgery of the Third Ventricle. Ed: MLJ Appuzzo. William and Wilkins, Baltimore 1998, pp 553-574

Historic articles

  1. 4.

    Hardy J. (1969) Transsphenoidal microsurgery of the normal and pathological pituitary. Clin Neurosurg;185–217.

  2. 5.

    Guiot G (1978) Considerations on the surgical treatment of pituitary adenomas. In: Fahlbusch R, Werder KV (eds) European Workshop on the Treatment of Pituitary Adenomas. Thieme, Stuttgart, pp 202–218

Additional reading

  1. 6.

    The B. Braun Aesculap brochure on the Landolt transsphenoidal equipment is extremely useful.

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Acknowledgements

Illustrations, Lamia Nayeb, BSc (Medical Student St George’s Hospital Medical School, London)

Video editing, Huma Sethi FRCS(SN), Consultant neurosurgeon, The National Hospital.

Conflicts of Interest

None.

Author information

Correspondence to Michael Powell.

Additional information

Key points

Equipment (see also illustrations in Fig. 5)

(1) Any modern operating microscope (Zeiss Pentero is preferred) is suitable (older machines are more difficult to use).

(2) C-Arm fluoroscopy, although CT image guidance is helpful for ‘redo’ procedures.

(3) There are many specialised microsurgical instruments. Preferred retractors in 80- and 90-mm lengths are the ‘Papavero’ (B. Braun Medical, Ltd.).

(4) For the initial dissection use a hand-held nasal retractor (Killian).

(5) For mucosal dissection use two Hardy dissectors, which are also useful within the fossa.

(6) Ring curettes in three different sizes for tumour removal.

(7) Rongeurs, such as the ‘Fahlbush (micro) cup’ and ‘Angel James’ (larger) types.

(8) I also use micro rongeurs (‘crocodiles’).

(9) Cranked Hardy knife handles with a no. 11 blade for opening the dura.

(10) For bone removal, two bone punches, 2-mm ‘up’ and ‘down’ Kerrison type, with an angled foot.

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Powell, M. Microscope transsphenoidal surgery. Acta Neurochir 154, 913–917 (2012) doi:10.1007/s00701-012-1286-4

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Keywords

  • Microscope transsphenoidal surgical technique
  • Surgical anatomy
  • Complications