Combined Microsurgical, Endoscopic and Neuronavigation Assisted Transseptal-Transsphenoidal Resection of Pituitary Tumors

Abstract

<p><strong>Objective. </strong>To describe the technical nuances of multimodal transseptal-transsphenoid surgery for pituitary tumors using a combination of microneurosurgery, neuroendoscopy, and electromagnetic neuronavigation.</p><p><strong>Materials and Methods. </strong>A transnasal approach to the sella is performed endoscopically and widely exposed by an otolaryngologic surgeon. Surgery is next performed by the neurosurgeon with microscope and neuronavigation for microsurgical resection of pituitary tumors. Neuroendoscope is also used at the end of surgery to confirm tumor resection and inspect operative site. During surgery, the patient’s head, angle and height of the microscope, and position of the table are repositionable to allow for multiple angle views. Abdominal fat harvested prior to the procedure is used to ensure cerebrospinal fluid seal.</p><p><strong>Results. </strong>The senior author (KIA) has used the combined approach with 84 consecutive patients. Radical resection was achieved in 66 patients, subtotal in 11, and partial in 7. There were no perioperative complications. Six patients experienced postoperative transient diabetes insipidus. The pituitary gland and stalk were preserved in all cases. Visual symptoms were improved in 78% and endocrinological symptoms in 56% of cases.</p><p><strong>Conclusion. </strong>This combined approach is safe and effective. It increases the efficacy and radicality of surgical resection, helps to preserve the pituitary gland, and improves and resolves preoperatively altered patient hormonal function and impaired vision. It also reduces complications, provides less postoperative pain and discomfort, reduces the surgery time, and enables a shorter hospital-stay.</p>

Neuronavigation-assisted pituitary neuroendocrine tumor resection: a systematic review and meta-analysis

“…Our analysis has shown that the use of iMRI is beneficial for surgery, regardless of the type of mirror and field strength. Additionally, Pojskić et al ( 3 ) considered that the two mirrors were complementary and recommended that both mirrors could be used to optimize the minimally invasive surgical technique. Regarding the selection of field strength, we found little difference among different MRI field strength subgroups.…”

“…Pituitary tumor represents a common intracranial pathology and pituitary neuroendocrine tumor (PitNET) is the most common type of pituitary tumor, in which usually hormones are abnormally secreted and systematic upwards compression of optic structures occurs, resulting in a wide variety of clinical sequelae ( 1 , 2 ). Transsphenoidal surgery (TSS), known for its simplicity and minimal invasiveness, is widely embraced as the primary treatment for most PitNET cases, with both the endoscope and microscope yielding satisfactory clinical outcomes ( 3 , 4 ). For PitNET, gross total resection (GTR) has been found to significantly reduce the chances of recurrence is the surgical ideal target ( 3 , 5 ).…”

“…Transsphenoidal surgery (TSS), known for its simplicity and minimal invasiveness, is widely embraced as the primary treatment for most PitNET cases, with both the endoscope and microscope yielding satisfactory clinical outcomes ( 3 , 4 ). For PitNET, gross total resection (GTR) has been found to significantly reduce the chances of recurrence is the surgical ideal target ( 3 , 5 ). In recent years, intraoperative neuronavigation for intracranial surgery, especially intraoperative magnetic resonance imaging (iMRI) system, has become increasingly popular and has significantly facilitated pituitary and other skull base surgeries ( 6 ).…”

Cisternal, Falciform, and Optic Canal Decompression Influencing Optic Nerve Biomechanics: A Microsurgical Anatomic Study

“…Tension (T) over the nerve was calculated using a mathematical equation derived from simple cable mechanics: T = WL/4d (Figure 4). 12,13 We compared forces, dips, and nerve tensions between superior and lateral pulls and after all 3 mobilizations. Statistical analysis was performed using the Student t test with significance set at P ≥ .05.…”

“…3-9 Furthermore, iatrogenic ON injury may occur during surgery through direct mechanical damage, improper manipulation, heat or vibration transmission, or interruption of vascular supply. 3-9,12-16 In addition, endoscopic endonasal approaches were designed to avoid ON traction.…”