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Chapter 12
https://t.me/med1917
12.1 Indications 116
Endoscopic Sellar
Approach
12.2 General Anatomic
Considerations 116
12.3 Surgical Steps 116
12.4 Neuroimaging Techniques
for Planning 118
12.5 General Surgical Principles
for Endoscopic Endonasal
Transsphenoidal Approach 120
12.6 Surgical Steps 121
12.7 Intradural Dissection 121
12.8 Closure 121
12.9 Case Example 123
12.10 Complications 123
12.11 Conclusion 124
Endoscopic Sellar Approach
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12 Endoscopic Sellar Approach
Matteo de Notaris, Giuseppe Catapano, Vincenzo Seneca, Lili Laleva, Elena D’avella, Alberto Prats-Galino
Introduction
The transsphenoidal route has been used for a century
for the resection of pituitary and other sellar tumors.
the past two decades,
endonasal approach introduced the advantages of a more
direct, minimally invasive modality in performing surgery
for lesions within this area.
coming the standard of care for pituitary tumors. Indeed,
surgery of the sellar region has always been a challenge
due to the complex anatomy of this area, the important
neurovascular structures around the sella, that is, the optic chiasm and nerves, the pituitary stalk, the superior and
inferior hypophyseal arteries, the parasellar segment of
internal carotid artery, and the ophthalmic artery.
The nasal cavities can be considered the natural corridor toward different regions of the skull base and the use
of endoscopes allows for an effective and safe visualization of the operative field (Fig. 12.1).
From a practical perspective, the anatomic knowledge
of the sellar region is essential for the safe conduct of surgical procedures in this area. The aim of this chapter is to
describe the anatomy of the endonasal approach to the
sellar area, highlighting the key points of the surgical approach and the main anatomic landmarks.
3
the advent of the purely endoscopic
4–6
This technique is rapidly be-
1,2
For
12.1 Indications
The purely endoscopic endonasal approach provides
minimally invasive access to sellar region. A soft consistency of the lesions is also an important consideration in
the surgical strategy to remove tumors in this area. The
main contraindications are lesions with prevalent lateral,
posterior, and superior localization to the sella.
It is indicated for the surgical management of the
following:
• Pituitary tumors:
– Macroadenomas.
– Microadenomas.
– Secreting.
– Nonsecreting.
• Rathke’s cleft cysts.
• Selected sellar meningiomas.
• Arachnoid cysts.
• Metastatic tumors.
• Cerebrospinal fluid (CSF) leaks within the sellar area.
12.2 General Anatomic
Considerations
The sellar region lies within the center of middle cranial
fossa and is occupied by major neurovascular and endocrinological structures: internal carotid artery, cavernous sinuses, optic nerves and optic chiasm, and pituitary
gland and stalk. More detailed description of the anatomy
is presented elsewhere in the book. For a minimally invasive approach, it is important to obtain an anatomic orientation with optimal knowledge of the mucosal, bony,
and neurovascular landmarks.
landmarks are nasal septum, choana, inferior turbinate,
middle turbinate, sphenoethmoid recess, sphenoid ostium, and sphenopalatine foramen (Figs. 12.2–12.4). The
sphenoid sinus offers a wide range of pneumatization
models and septations.8 Important landmarks within the
sphenoid sinus are sellar floor, bony prominences of the
intracavernous carotid artery (ICA), the optic nerve, and
opticocarotid recess (OCR) (Figs. 12.5 and 12.6).
7
In the nasal cavity, these
12.3 Surgical Steps
12.3.1 Patient Positioning
The patients is operated on general anesthesia and orotracheal intubation, in supine position with the head
fixed in a standard Mayfield three-pin holder, slightly
flexed and turned 10 degrees toward the surgeon. Flexion
or extension of the head is really important for the approach trajectory, as a minimal change of the head position could lead to an important modification of trajectory
and thus disorientation.
Fig. 12.1 Anatomic pictures showing the concept for direct
endoscopic endonasal approach to midline skull base in a dry
skull model.
116
12.3.2 Ergonomics
Most important thing to consider is comfortable position
with direct sight to the video screen for the surgeon, the
assistant, and the scrub nurse. Depending on the technique used, surgeons can stand on one side or both side
of patients’ head, with the main surgeon on the right side
(if right-handed) and a scrub nurse opposite.
12.3.3 Instrumentation
Visualization is achieved by 0-, 30-, and 45-degree rigid endoscope (18 cm in length, 4 mm in diameter) and
a high-definition video equipment.
reduces the risk of disorientation, but the instruments
9
The 0-degree lens
MT
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Endoscopic Sellar Approach
IT
NS
IT
a b
RHP
MT
ET
NS
IT
c
Fig. 12.2 Nasal step of the endoscopic approach (right nostril). (a) Identifi cation of middle turbinate; (b) identifi cation of choana; (c)
view of the posterior rhinopharynx and eustachian tube; (d) exposure of the sphenoethmoid recess. Co, choana; ET, eustachian tube;
IT, inferior turbinate; MT, middle turbinate; NS, nasal septum; RHP, posterior rhinopharynx; SER, sphenoethmoid recess; ST, superior
turbinate.
d
Co
ST
SER
NS
NS
NS
Fig. 12.3 Nasal step of the endoscopic endonasal approach (left nostril). (a) Identifi cation of choana and sphenoethmoid recess; (b)
view of the posterior rhinopharynx and eustachian tube. Co, choana; ET, eustachian tube; IT, inferior turbinate; MT, middle turbinate;
NS, nasal septum; SER, sphenoethmoid recess.
SER
Co
MT
Co
NS
ET
IT
ba
IT
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ST
SO
MT
ST
MT
ab
ST
SER
Co
NSNS
MT
c d
Fig. 12.4 Sphenoidal step of the endoscopic endonasal approach (right nostril). (a) Lateralization of middle turbinate;
(b) identifi cation of sphenoid ostium; (c) initial cut of the mucosa covering the nasal septum; (d) drilling of the anterior wall of the
sphenoid sinus, starting from the sphenoid ostium. awSphS, anterior wall of sphenoid sinus; Co, choana; ET, eustachian tube; IT,
inferior turbinate; MT, middle turbinate; NS, nasal septum; RHP, posterior rhinopharynx; SER, sphenoethmoid recess; SO, sphenoid
ostium; ST, superior turbinate.
remain in the periphery of the field of vision. With 30-degree endoscopes, there is better control of the instruments
and a wider angle of view.
a clear image without the constant need of removal and
cleaning the tip of the lens. High-speed drill, various dissectors, forceps, scissors, and suctions are available. Bipolar
and hemostatic materials (such as the thrombin hemostatic matrixes and thrombin-soaked gelatin sponges) need
to be available. In cases with complex tumors invading
the para-, supra-, and retrosellar regions, a neuronavigation system is recommended. The micro-Doppler probe is
crucial for localizing the carotid arteries in selected cases.
SO
NS
10
Using an irrigation provides
12.3.4 Preparation
Cottonoids soaked in a special antiseptic preparation with
50% diluted povidone-iodine solution are applied within
the nasal cavity. The mucosa is prepared with adrenaline
MT
awSphS
(1:10,000)/lidocaine (1:20) or xylometazoline hydrochloride–soaked Cottonoids, placed for at least 5 minutes in
the space between the septum and the turbinates, to gain
maximum vasoconstrictor effect and control the mucosal
bleeding.
12.4 Neuroimaging
Techniques for Planning
The advent of 3D computer-generated models provides
accurate patient-specific 3D reconstructions from
neuroimaging data and virtual reality devices, improving
training in endoscopic neurosurgery. Our group has
developed computational models for educational
purposes applied to the transsphenoidal perspective,
guiding the acquisition of specific visual information for
endoscopic approaches to the skull base.
11–13
NS
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SphS
MT
a b
awSphs
PS
*
NS
MT
OP
SPA
NS
Co
PS
OP
SSN
*
SF
C
SPA
iwSphS
c d
Fig. 12.5 Sphenoidal step of the endoscopic endonasal approach. (a) Drilling of the anterior wall of sphenoid sinus (SphS) using
high-speed drill; (b) panoramic view after the removal of anterior wall of the sphenoid sinus and preservation of the sphenopalatine
artery; (c) the sphenoid sinus additionally and widely exposed, a sphenoid septation is unlocked; (d) bony anatomic landmarks within
the sellar region; awSphS, anterior wall of sphenoid sinus; C, clivus; Co, choana; CPs, intracavernous carotid protuberance; iwSphS,
inferior wall of sphenoid sinus; MT, middle turbinate; NS, nasal septum; OP, optic nerve protuberance; PS, planum sphenoidale; SF,
sellar fl oor; SPA, sphenopalatine artery; SSN, suprasellar notch; ST, superior turbinate. *Sphenoid septation.
NS
CPs
SF
C
CPs
OP
CPs
ab
Fig. 12.6 Sphenoidal step of the endoscopic endonasal approach. (a) The removal of the sellar fl oor in the midline, a safe entry zone
to start the drilling; (b) widening the removal of the bone laterally. dm, dura mater; C, clivus; CPs, carotid protuberance (intracavernous
part); OCR, opticocarotid recess; OP, optic nerve protuberance; PS, planum sphenoidale; SF, sellar fl oor; SPA, sphenopalatine artery; SSN,
suprasellar notch; V, vomer.
PS
OP
SSN
SF
CPs
C
OP
OCR
CPs
PS
SSN
dm
OP
OCR
CPs
C
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Preoperative neuroimaging studies were mainly
developed using the Dextroscope (Volume Interactions
Pte. Ltd) and Osirix, (OsiriX open-source imaging
software; Version 5.8.1; free download from http://www.
osirix-viewer.com/) (Fig. 12.7).
12.5 General Surgical Principles
for Endoscopic Endonasal
Transsphenoidal Approach
• Midline is safe. Check on the preoperative images for
reliability of midline structures, such as nasal septum
and intersphenoidal septum, that could have anatomic
variations and deviate from midline; intraoperatively,
the floor of each choana can be very useful to check the
midline orientation.
• The surgeon should have the optimal surgical free-
dom r
equired for the approach.
14,15
To gain comfortable
working space, sufficient bone (i.e., the sphenoid prow)
should be removed, providing optimal movement for
the endoscope and instrument within the nasal cavities.
• Movements should be gentle and under constant endo-
scopic control. Minimal surgical trauma to the mucosa decreases bleeding and the need for nasal packing,
shortening the wound healing time and decreasing
postoperative adhesions, crusting, and postsurgical
septal perforations.
16
• Bipolar is used for small arterial bleeding (i.e., the sphe-
nopalatine artery and its branches). Alternative hemostatic materials should always be available, particularly
for venous bleeding.
Fig. 12.7 CT-based reconstructions
of the skull base (using Dextroscope
[Volume Interactions Pte. Ltd] and
Osirix [OsiriX open-source imaging
software; Version 5.8.1; free download
from http://www.osirix-viewer.com/])
showing anatomic landmarks and
relations to the sellar region: (a) Route
of lacerum, petrous, paraclival, and
parasellar segments of the internal
carotid artery. (b) Reconstruction of
bony septations within the sphenoid
sinus. Co, choana; CPs, carotid
protuberance (intracavernous part);
CP, internal carotid protuberance; OC,
optic canal; PS, planum sphenoidale;
SS, sphenoid sinus; SF, sellar fl oor;
TS, tuberculum sellae; V, vomer.
*,**Sphenoid sinus septations.
120
a
OCR
CPR
TS
CP
SF
L
OC
L
*
**
SS
V
b
CoCo
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12.6 Surgical Steps
Approach could be roughly divided into the following
phases: nasal, sphenoidal, and sellar
12.6.1 The Nasal Phase
A better exposure is gained using the binostril approach (being more comfortable two-surgeon with the
four-handed technique).
in the nasal cavity, the first structure at sight is the inferior turbinate followed superiorly by the middle turbinate (Figs. 12.2 and 12.3). The approach is followed by
mobilization of the middle turbinate laterally to widen
the surgical space and gain access to posterior portion
of nasal cavity (Fig. 12.4). The next step is the identification of the sphenoid ostium. The sphenoethmoid recess is an important landmark to localize the sphenoid
ostium located approximately 1.5 cm above the choana
(Fig. 12.4a). Bleeding during this part of the approach is
usually from the mucosa.
More space for the approach can be obtained by a
gentle out-fracture of the middle turbinate. Concerning
the binostril approach, some authors describe removal
of right middle turbinate and lateralization of the left.
However, this is unnecessary in the majority of cases. The
next step is debriding the mucosa around the sphenoid
ostium, starting the incision in the posterior part of nasal
septum. In doing this, one should always take care not to
go cranially to the superior turbinate and injure olfaction.
12.6.2 The Sphenoidal Phase
The sphenoid ostium is the natural entry point to the sphenoid sinus. The sphenoidectomy starts from here on each
side and both ostia are widened circumferentially. It is crucial to remove enough bone to gain maximum exposure for
the sellar phase of the approach. The margins of a correct
sphenoidectomy include anterior and inferior wall of sphenoid sinus (Fig. 12.5). Attention needs to be paid when enlarging the opening inferiorly to avoid injury of the posterior nasal artery, a branch of the sphenopalatine that runs
along the anterior wall of the sphenoid sinus (Fig. 12.5c).
In case of bleeding, the bipolar coagulation is recommended, as monopolar may create a risk for late rebleeding.
When planning a sellar approach for macroadenomas, in
which the surgical corridor needs to be enlarged and the
risk of a CSF leakage is higher, potential reconstruction of
the skull base with a pedicled flap need to be considered.
In such situation, the incision on the mucoperiosteum of
the vomer may be performed to create a “rescue flap” that
includes the posterior nasal artery, dissected and pushed
downwards with the septal mucosa.
The sphenoid septation should also be removed.
Once the dissection within the sphenoid sinus is completed, the anatomic landmarks on the sellar floor should be
clearly visible (Fig. 12.5d).
16–18
Introducing the endoscope
19
12.6.3 The Sellar Phase
From a transsphenoidal point of view, the sellar region has
the following landmarks (when well pneumatized): sellar
floor, bony prominence of the intracavernous internal
carotid artery, bony prominence of the optic canal, and
lateral OCR (Fig. 12.6). The depth of the lateral OCR is de-
pendent on the pneumatization of anterior clinoid process. In case of a good pneumatization of the sphenoid
sinus, in the inferolateral portion the prominences of V2
and V3 branches of the trigeminal nerve can sometimes
be visualized. Along the lateral sphenoid floor, the pterygoid canal (containing the vidian artery and nerve) can
sometimes be seen.
The sellar floor has to be opened in the midline, which
is a safe entry zone, and then gradually extended laterally to reach medial aspect of each carotid protuberance
(Fig. 12.6). The thickness of the sellar floor may vary
and needs to be checked on the preoperative computed
tomography (CT), even using 3D reconstructions (Fig.
12.7). The margins of the sellar floor opening are: the
suprasellar notch
orly, clivus posteriorly, and cavernous sinus bilaterally.
After a correct and wide craniotomy, “the four blues”
should be visible: both cavernous sinuses laterally and
superior and inferior intercavernous sinuses craniocaudally (Fig. 12.8).
20
and the planum sphenoidale anteri-
12.7 Intradural Dissection
The basal sellar dura is opened in a cross-like fashion and
the pituitary gland is exposed. As a general neurosurgical
principle, it is advisable to use neuronavigation before
opening the dura. At this point, the micro-Doppler could
also be of help to identify the exact position of the ICA.
This structure could be displaced from its usual anatomic location by the underlying pathology or get displaced
while removing macroadenomas compressing or encasing the carotid. Fig. 12.8 shows the anatomic view of the
sellar region after the dural incision.
12.8 Closure
In a standard pituitary surgery, with preservation of
the arachnoid, no CSF leakage is to be expected. Should
that not be the case, then a watertight dural is needed
to avoid a CSF leak. Various techniques have been de-
21
scribed
flap.
tion, but obliteration of the sphenoid sinus is not recommended due to the risk of a mucocele formation on the
long term. Also, overpacking could lead to a compression
of the chiasma.
studies have been conducted. A helpful algorithm is presented by Esposito and Kelly.
: fibrin glue,22 “gasket- seal,”23 and pedicle
24
Sphenoid sinus packing with fat might be an op-
In the decision for a proper closure strategy, different
25
18,21
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PS
OP
OP
LOCR
LOCR
MOCR
CPs
a
SSN
MOCR
CPs
dm
C
PS
Fig. 12.8 Final view of the approach.
(a) Removal of sellar fl oor; (b)
visualization of intracranial anatomy
(with wider bone removal). AcoA,
anterior communication artery; C,
clivus; CPs, carotid protuberance
(intracavernous part); dm, dura mater;
ICA, internal carotid artery; LOCR,
lateral opticocarotid recess; MOCR,
medial opticocarotid recess; ON, optic
nerve; OP, optic nerve protuberance;
PG, pituitary gland; PS, planum
sphenoidale; SSN, suprasellar notch.
ON
ICAs
b
AcoA
PG
C
ON
ICAs
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12.9 Case Example
A previously healthy 61-year-old man was referred by
our endocrinologist for minimally invasive endoscopic
surgery. The patient had developed a progressive visual
field deficits and moderate frontal headaches.
Neuroendocrine studies showed only low testosterone and insulin-like growth factor-1 levels. Magnetic
resonance imaging (MRI) of the sellar region revealed a
large suprasellar tumor with marked compression of the
optic chiasm, erosion of the superior third of clivus, and
enlargement of the diaphragma sellae (Fig. 12.9a–c).
Surgical resection of a fibrous macroadenoma was
achieved through an endoscopic endonasal approach
using image-guided surgical navigation (Fig. 12.10).
This included removal of tumor from the suprasellar
region and upper clivus. Normal gland was visible
toward the posterior portion of the sella and could be
preserved.
After surgery, there was a subjective marked improvement of vision, resolution of headaches, and no additional
endocrine abnormalities. He was dismissed 3 days later.
Three months postoperative MRI shows a total resection
of the tumor with the normal gland deviated in the posterior region of the sella (Fig. 12.9d–f).
12.10 Complications
During nasal phase, there is a risk for bleeding. The more
bone is left denuded, the more postoperative crusting,
and nasal septum perforation may appear in case of larger resection of the vomer and the mucoperiosteum on
both side.
For the sphenoid phase, the potential complication is
the injury of optic nerve while removing the posterior
ethmoid cells anteriorly.
For the sellar part, the injury of the internal carotid
artery may occur when removing bone. The optic nerve
or its chiasm may be at risk; particularly, the injury of the
superior hypophyseal arteries has to be avoided as this
leaves the patient with a tunnel vision. Careful manipulation of the pituitary gland preserves its gland function.
A CSF leak may happen when the arachnoid is opened.
a bc
d e f
Fig. 12.9 T1 weighted image MRI (magnetic resonance images) with contrast enhancement of a large suprasellar pituitary
macroadenoma. (a) preoperative axial view; (b) preoperative coronal view; (c) preoperative sagittal view; (d) postoperative axial view;
(e) postoperative coronal view; (f) postoperative sagittal view.
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ST
SSN
CPs
MT
SER
NS
ICAc
a
CPs
Co
dm
CPs
b
SF
C
T
CPs
ICAc
CPs
T
ICAc
ICAc
C
LRSS
ICAc
dm
C
cd
Fig.12.10 (a–d) Intraoperative photos showing the removal of a pituitary macroadenoma using an endoscopic endonasal approach
to the sellar region. MT; middle turbinate; ST, superior turbinate; NS, nasal septum; Co, choana; SER, sphenoethmoid recess; CPs,
carotid protuberances; ICAc, paraclival segment of the internal carotid artery; C, clivus; SSN, suprasellar notch; SF, sellar fl oor; LRSS,
lateral recess of the sphenoid sinus; dm, dura mater; T, tumor.
12.11 Conclusion
A pure endoscopic endonasal approach to the sellar
region is achieved by a deep knowledge for the anatomic
landmarks and a correct spatial orientation within the
nasal sinuses. A careful preoperative planning based
on radiologic data and careful study of the individual
patients’ anatomy is of great importance for the safety
and the success of the procedure.
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