Transsphenoidal surgery, either microscopic or endoscopic, is a safe procedure in experienced hands, but serious complications still occur and must be reduced as much as possible. Additional improvement can be expected with greater experience and new technical developments. A coordinated team effort with other dedicated colleagues from different specialties is advised.

The endoscopic endonasal transsphenoidal approach has been proposed in the past decade as a minimally invasive surgical technique for the removal of pituitary tumors. From January 1997 to November 1999, 100 consecutive patients with pituitary tumors underwent endoscopic endonasal surgery, according to Jho's technique. We employed 0 degrees, 30 degrees, 45 degrees, and 70 degrees rigid endoscopes, 18 - 30 cm in length, 4 mm in diameter with an outer sleeve for irrigation and secured to a holder. Among the 87 pituitary adenomas, tumor removal was total in 51, subtotal (> 80 %) in 20 and partial in 16 cases. Four craniopharyngiomas were totally removed and an intra-suprasellar arachnoid cyst was emptied; a biopsy was performed in the two patients with a clivus chordoma. The two cases of sphenoid sinusitis were cured by surgery, the three patients with spontaneous CSF rhinorrhea were successfully treated and the residual nasal meningocele was removed. The endoscopic endonasal transsphenoidal approach appeared to be less traumatic than the traditional microsurgical approach, was very effective, and was characterized by a reduced number of complications. However, the relatively small series together with the short follow-up do not allow us to draw definitive conclusions. The post-operative reduction in hospital stay (two days in 40 of 100), significantly reduced the cost of patient's management.

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Object The midline skull base is an anatomical area that extends from the anterior limit of the cranial fossa down to the anterior border of the foramen magnum. Resection of lesions involving this area requires a variety of innovative skull base approaches. These include anterior, anterolateral, and posterolateral routes, performed either alone or in combination, and resection via these routes often requires extensive neurovascular manipulation. The goals in this study were to define the application of the endoscopic endonasal approach and to become more familiar with the views and skills associated with the technique by using cadaveric specimens. Methods To assess the feasibility of the endonasal route for the surgical management of lesions in the midline skull base, five fresh cadaver heads injected with colored latex were dissected using a modified endoscopic endonasal approach. Full access to the skull base and the cisternal space around it is possible with this route. From the crista galli to the spinomedullary junction, with incision of the dura mater, a complete visualization of the carotid and vertebrobasilar arterial systems and of all 12 of the cranial nerves is obtainable. Conclusions The major potential advantage of the endoscopic endonasal approach to the skull base is that it provides a direct anatomical route to the lesion without traversing any major neurovascular structures, obviating brain retraction. Many tumors grow in a medial-to-lateral direction, displacing structures laterally as they expand, creating natural corridors for their resection via an anteromedial approach. Potential disadvantages of this procedure include the relatively restricted working space and the danger of an inadequate dural repair with cerebrospinal fluid (CSF) leakage and potential for meningitis resulting. These approaches often require a large opening of the dura mater over the tuberculum sellae and posterior planum sphenoidale, or retroclival space. In addition, they typically involve large intraoperative CSF leaks, which necessitate precise and effective dural closure.

Standard microscopical transsphenoidal surgery is used world-wide in most sellar lesions, but continuing technological progress leaves room for further possibilities. The authors have employed a slightly modified Jho-Carrau technique for endoscopic endonasal transsphenoidal removal of pituitary lesions. This approach has been successfully used in 15 consecutive patients; the preliminary results are reported. The advantages and the limitations of this technique are discussed and compared to standard transsphenoidal surgery. In consideration of the low invasiveness of this approach and of the improved respect for the inner nose and sinus structures, the authors suggest the new term of Functional Endoscopic Pituitary Surgery (FEPS) to characterize this simple one-nostril endoscopic endonasal procedure.