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Relevant surgical anatomy for the transnasal transsphenoidal approach to the pituitary. A) External landmarks on skull. B) Coronal cross section of the cavernous sinus depicting neurovascular relations. C) Oblique lateral view of the sellar/parasellar region. D) Sagittal view of the nasal cavity demonstrating the relationship between the nasal turbinates and the sphenoid sinus. Inset right: Diff erent anatomical confi gurations of the sphenoid sinus relative to the pituitary fossa.
Source publication
Background:
The endoscopic transnasal approach is becoming the preferred minimally invasive approach to the pituitary region. We review the key anatomical landmarks, stepwise description of the surgical technique, technical variations, indications, limitations and important aspects of peri-operative management.
Technique:
The procedure consists...
Contexts in source publication
Context 1
... e natural air spaces leading to the pituitary fossa consist of the nasal cavity and sphenoid sinus (Fig. 1). Th ese structures interface with one another in a modular fashion. It is help- ful to consider the surgical approach in terms of the ' nasal ' , ' sphenoidal ' and ' sella ' stages (Figs. 3 -5). Recognising a number of important anatomical landmarks during each of these stages is also a key to perform the exposure to the sella region ...
Context 2
... above the superior turbinate is the spheno- ethmoidal recess into which the sphenoid sinus drains via the sphenoid ostium ( Figs. 1 and 3). For accessing the pitu- itary, the sphenoid ostium usually marks the superior limit of the opening into the sphenoid sinus ( Fig. 3B and E). ...
Context 3
... epistaxis (Fig. 3B). In the vast majority of the patients, on defl ecting the middle turbinate laterally, the sphenoid ostia come into view or its bony defect can be palpated with a blunt instrument ( Fig. 3B and E). Th ere are various anatomical confi gura- tions to the sphenoid sinus termed ' sellar ' , ' pre-sellar ' and ' chonchal variants (Fig. 1D). Of these, the ' sellar ' variant is the commonest (approximately 75%), and the ' chonchal ' is the least common and is more usually seen in children. 14 Th e sphenoid sinus usually contains one or more septae within it, which are infrequently not in the midline. Close study of the pre-operative imaging (i.e. axial CT scans and/or the ...
Context 4
... or even defi cient in a minor- ity of patients, and care must be taken. Th e optico-carotid recess is frequently seen as the bony depression on the supero-lateral aspect of the sphenoid sinus that demarcates the optic nerve from the carotid arteries ( Fig. 4B and C). It represents the pneumatisation of the anterior clinoid seen intra-cranially (Fig. ...
Context 5
... known as the ' sella turcica ' , the pituitary fossa is a bony depression that occupies the centre of the cranial skull base (Fig. 1). Its key relations are the optic chiasm superiorly and the cavernous sinus located laterally, which harbours the cavernous segment of the internal carotid artery, along with the cranial nerves III, IV, V1, V2 and VI (Fig. 1B and ...
Context 6
... as the ' sella turcica ' , the pituitary fossa is a bony depression that occupies the centre of the cranial skull base (Fig. 1). Its key relations are the optic chiasm superiorly and the cavernous sinus located laterally, which harbours the cavernous segment of the internal carotid artery, along with the cranial nerves III, IV, V1, V2 and VI (Fig. 1B and ...
Context 7
... pituitary stalk passes through the dura of the ante- rior skull base at the sella turcica (Fig. 1B and C). The anterior skull base dura is continuous around the pituitary gland, but the arachnoid envelopes the pituitary stalk and passes over the dome of the pituitary gland and the associ- ated pituitary tumour (Fig. 5F). This part of the arachnoid constitutes the diaphragma sellae that descends into the fossa on removal of the pituitary ...
Context 8
... of the adenoma usually leads to descent of the diaphragma sella into the pituitary fossa ( Fig. 5E and F). (Fig. 4). Th e key factor determining the diffi culty in exposing the pituitary fossa within the sphenoid sinus is the confi gu- ration of the sinus cavity in terms of ' sellar ' , ' pre-sellar ' and ' chonchal ' variants as described above (Fig. 1D). ' Pre-sellar ' and more especially ' chonchal ' variants necessitate greater amount of ' bone-work ' to expose the pituitary fossa, with increasing reliance on use of a high-speed diamond drill and the neuronavigation. Th e sphenoid mucosa is gently dis- sected off the pituitary fossa laterally, and the mucosal bleed- ing is ...
Citations
... Topical nasal decongestant is employed in order to reduce nasal bleeding. It is important to consider preparing the abdominal wall and outer thigh in an antiseptic manner since abdominal fat and fascial graft may be used for reconstruction [5,6]. ...
Craniopharyngiomas (CPs) are Rathke’s cleft-derived benign tumors originating most commonly in the dorsum sellae and representing 2% of intracranial neoplasms. CPs represent one of the more complex intracranial tumors due to their invasive nature, encasing neurovascular structures of the sellar and parasellar regions, making its resection a major challenge for the neurosurgeon with important postoperative morbidity. Nowadays, an endoscopic endonasal approach (EEA) provides an “easier” way for CPs resection allowing a direct route to the tumor with direct visualization of the surrounding structures, diminishing inadvertent injuries, and providing a better outcome for the patient. In this article, we include a comprehensive description of the EEA technique and nuances in CPs resection, including three illustrated clinical cases.
... Both operative techniques have been well described previously and are summarized here [8,13,29]. All patients received broad spectrum peri-operative antibiotics with anaerobic cover. ...
... In the event of CSF leakage, a graded operative repair was undertaken using combinations of haemostatic bioresorbable gelatine sponge and dural sealant (Duraseal, Confluent Surgical, USA) for grade 1 leaks (i.e., minor leak with no obvious arachnoid defect) [29]. In the event of a grade 2 (i.e., moderate CSF leak with visible arachnoid defect) or grade 3 CSF leak (i.e., large CSF leak with large dural defect), in addition to the above, a fat graft, dural substitute (Durafoam, Codman, UK) and/or vascularized nasoseptal flap was used on a selective basis [29]. ...
... In the event of CSF leakage, a graded operative repair was undertaken using combinations of haemostatic bioresorbable gelatine sponge and dural sealant (Duraseal, Confluent Surgical, USA) for grade 1 leaks (i.e., minor leak with no obvious arachnoid defect) [29]. In the event of a grade 2 (i.e., moderate CSF leak with visible arachnoid defect) or grade 3 CSF leak (i.e., large CSF leak with large dural defect), in addition to the above, a fat graft, dural substitute (Durafoam, Codman, UK) and/or vascularized nasoseptal flap was used on a selective basis [29]. ...
Background
T ranssphenoidal surgery (TSS) is the standard approach for resection of pituitary lesions. Historically, this has utilized the microscopic approach (mTSS); however, the past decade has seen widespread uptake of the endoscopic approach (eTSS). The purported benefits of this include improved visualization and illumination, resulting in improved surgical and endocrinological patient outcomes. It is also believed that eTSS results in fewer post-operative nasal symptoms compared to mTSS; however, few papers have directly compared these groups.
Objectives
We sought to compare nasal symptoms after endoscopic uninostril (eTSS-uni), endoscopic binostril (eTSS-bi) and microscopic endoscopic transsphenoidal surgery (mTSS).
Methods
The General Nasal Patient Inventory (GNPI) was prospectively administered to 136 patients (71 non-functioning adenomas, 26 functioning adenomas, 39 other pathology) undergoing transsphenoidal surgery at multiple time points (pre-operatively; days 1, 3 and 7–14; months 1, 3 and 6 and 1 year post-operatively). All surgeries were performed by subspecialist pituitary surgeons in three subgroups — mTSS (25), eTSS-uni (74) and eTSS-bi (37). The total GNPI scores (0–135) and subscores for the 45 individual components were compared across three groups assessing for temporal and absolute changes.
Results
Irrespective of surgical approach used, GNPI scores were significantly higher on post-operative day 1 (p < 0.001) and day 3 (p ≤ 0.03) compared to pre-treatment baseline (mixed-effects model). By 1 month post-operatively, however, post-operative GNPI scores were no different from pre-treatment (p > 0.05, mixed-effects model). Whilst the eTSS-uni group demonstrated significantly lower GNPI scores at day 1 post-op compared to the mTSS group (p = 0.05) and eTSS-bi group (p < 0.001), there was no significant difference in post-operative scores between approaches beyond 1–2 weeks post-operatively. Similar results were obtained when the non-functioning tumour group was analysed separately.
Conclusions
Transsphenoidal pituitary surgery is well tolerated. Post-operative nasal symptoms transiently worsen but ultimately improve compared to pre-operative baseline. Operative approach (microscopic, endoscopic uninostril or endoscopic binostril) only has a transient effect on severity of post-operative nasal symptoms.
... Our surgical technique has been previous described [16]. Antiplatelet medication is discontinued 5 prior to surgery. ...
Purpose
There is no compelling outcome data or clear guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using low molecular weight heparin (chemoprophylaxis) in patients undergoing pituitary surgery. Here we describe our experience of early chemoprophylaxis (post-operative day 1) following trans-sphenoidal pituitary surgery.
Methods
Single-centre review of a prospective surgical database and VTE records. Adults undergoing first time trans-sphenoidal pituitary surgery were included (2009–2018). VTE was defined as either deep vein thrombosis and/or pulmonary embolism within 3 months of surgery. Postoperative haematomas were those associated with a clinical deterioration together with radiological evidence.
Results
651 Patients included with a median age of 55 years (range 16–86 years). Most (99%) patients underwent trans-sphenoidal surgery using a standard endoscopic single nostril or bi-nostril trans-sphenoidal technique. More than three quarters had pituitary adenomas (n = 520, 80%). Postoperative chemoprophylaxis to prevent VTE was administered in 478 patients (73%). Chemoprophylaxis was initiated at a median of 1 day post-procedure (range 1–5 days postoperatively; 92% on postoperative day 1). Tinzaparin was used in 465/478 patients (97%) and enoxaparin was used in 14/478 (3%). There were no cases of VTE, even in 78 ACTH-dependent Cushing’s disease patients. Six patients (1%) developed postoperative haematomas. Chemoprophylaxis was not associated with a significantly higher rate of postoperative haematoma formation (Fisher’s Exact, p = 0.99) or epistaxis (Fisher’s Exact, p > 0.99).
Conclusions
Chemoprophylaxis after trans-sphenoidal pituitary surgery on post-operative day 1 is a safe strategy to reduce the risk of VTE without significantly increasing the risk of postoperative bleeding events.
... 3,5 The binostril approach, allowing a four-handed technique and more flexible movement to lateral anatomy, was advocated by Kassam et al 6 and had been far and away the most common approach for pituitary adenomas, especially in cases of expanded endoscopic transnasal approaches. [7][8][9] The mononostril endoscopic transsphenoidal approach (META) offered a minimal injury to nasal cavity at a cost of surgical manipulation space which is restricted by the interferences between instruments. Limited surgical corridors and nasal turbinates make it difficult to angle instruments to the extreme lateral parasellar region. ...
Objective This article determines which of the one-and-a-half nostril, mononostril, and binostril endoscopic endonasal transsphenoidal approaches provide a superior manipulation during surgery.
Methods The three approaches were orderly performed on 10 silicon-injected cadaveric heads to quantitatively assess surgical freedom and attack angle for sella. Measurements were determined with a standardized method under neuronavigation system using data of computed tomography.
Results The one-and-a-half nostril endoscopic transsphenoidal approach (OETA) offered superior exposed area than that of the mononostril approach (META), and similar to that of the binostril approach (BETA). For surgical freedom at anatomic targets, the OETA showed greater surgical flexibility at pituitary center, the right medial optic carotid recess (R-mOCR), the left mOCR, the medial intersection of the right cavernous internal carotid artery, and extension line of upper margin of the clivus (R-mICC) than those of the META, and similar to those of the BETA.
For sagittal angle of attack to the R-mOCR, R-mICC, and L-mOCR, the OETA can provide better angular freedom for surgeon than that of the META, and similar to that of the BETA. The OETA had the same axial attack to the pituitary center with the BETA. The OETA and the META had limited surgical freedom at L-mICC, and both inferior to the BETA.
Conclusion The OETA has similar exposed area, surgical freedom, and attack angle for most anatomic targets to the BETA without resecting contralateral nasal septal mucosa, and obviously superior to the META.
... This relationship of the sphenoid cavity to the nasal cavity below and the pituitary gland above makes the transsphenoidal route the surgical approach of choice for sellar tumors. 4 The EETA has minimal invasiveness; lower incidence of complications with lower morbidity and mortality rates compared with traditional open approaches. 1,4 Extended approaches through the SS have made it possible to reach different parts of the skull base from the crista galli to the spinomedulary junction. ...
... 4 The EETA has minimal invasiveness; lower incidence of complications with lower morbidity and mortality rates compared with traditional open approaches. 1,4 Extended approaches through the SS have made it possible to reach different parts of the skull base from the crista galli to the spinomedulary junction. 1 Anatomic variations in the nasal cavity and the SS make preoperative imaging evaluation not only useful for diagnosis but also valuable for surgical mapping to ensure safe access and improved surgical outcomes. ...
... That is, the conchal and the presellar types have low prevalence when compared to the sellar and postsellar types with the sellar usually being the most common. 1,4,7,13 Nevertheless, a wide variation exists in the actual prevalence of each variant. The variations range from 2% to 28% conchal, 17%-21% presellar, 54%-85% sellar, and 22%-43.3% ...
Background: The air spaces of the nasal cavity and the sphenoid sinus (SS) constitute a convenient corridor to access lesions of the skull base
using the endoscopic endonasal transsphenoidal approach (EETA). Safe EETA depends on the SS and skull base anatomy of the patient. Individual
variations exist in the degree and pattern of SS pneumatization. This study aims to examine the variations in SS pneumatization, the inter-sphenoid
septum (ISS), and their relationship with the internal carotid artery (ICA) among adult Nigerians. Materials and Methods: We reviewed
computerized tomography (CT) images of 320 adult patients that had imaging for various indications. This excluded those with traumatic,
inflammatory, or neoplastic process that may alter anatomical landmarks. The images were evaluated for the types of SS pneumatization,
number and insertion of ISS, and the protrusion of ICA into the sinus cavity. Results: Prevalence of SS pneumatization types: 1.9% conchal,
1.2% presellar, 56.6% sellar, and 40.2% postsellar. The lateral extension of SS occurred into the pterygoid in 138 patients (45.1%), greater
wing 112 (35%), lesser wing 37 (11.6%), the full lateral type was seen in 97 (30.3%) patients. One ISS occurred in 150 (46.9%) patients,
162 (50.6%) had multiple, and 8 (2.5%) had none. ISS insertion into ICA bony covering occurred in 101 (31.6%) patients, whereas protrusion
of ICA into SS cavity occurred in 110 (34.4%) patients. Conclusion: Variations of the SS, ISS, and ICA anatomy are present among native
Africans. Detailed imaging evaluation of each patient is considered for EETA is mandatory.
... No true consensus is available on psychological outcome and influence on health-related QOL after surgery via different approaches. The transnasal approach is a technique for surgery of anterior skull base lesions that has been increasingly adopted for selected cases and refined tremendously in the recent decades [4,21]. Extents of resection, complication rates, and functional outcomes have been reported to be favorable and in no way inferior to the traditional open craniotomies, when it is applied accordingly and in expert hands [1,2,11,22,23]. ...
Objective
To analyze psychopathological outcome and health-related quality of life (QOL) for cohorts of patients undergoing transcranial or transnasal anterior skull base surgery.
Methods
A prospective study of patients undergoing elective surgery for various entities of the anterior skull base was performed. Evaluation for depression (ADS-K score) and anxiety (PTSS, STAI-S, STAI-T, and ASI-3 scores) was done before surgery, at 3 and 12 months after surgery. The correlation between preoperative psychological burden and postoperative quality of life as measured by the SF-36 and EuroQol questionnaires was analyzed. Incidence and influence of these psychiatric comorbidities on clinical outcome were examined and compared between transnasal and transcranial subgroups.
Results
We included 54 patients scheduled for surgery of a pituitary adenoma or meningioma of the anterior skull base between January 2013 and July 2017. Of these, a cohort of 40 (74.1%) completed follow-up interviews after 3 and 12 months. There were 60.0% female patients, median age was 57 years. 57.5% of patients had a meningioma and were operated transcranially, while 42.5% of patients received transnasal surgery for pituitary adenoma. The proportion of pathological anxiety scores significantly decreased from 75.0 to 45.0% (p = 0.002), without difference between transnasal and transcranial subgroups. After 3 months, mean EuroQol VAS score non-significantly increased by 0.07 (p = 0.236) across the entire cohort without significant difference between transcranial and transnasal subgroups (p = 0.478). The transnasal cohort tended to score higher in anxiety scores, whereas the transcranial cohort demonstrated higher depression scores without significant difference, respectively. The individually declared emotional burden significantly decreased from 6.7 to 4.0 on the ten-point Likert scale (p < 0.001) equally for both subgroups (transnasal, − 2.3; transcranial, − 3.0; p = 0.174). On last examination, about half of the patients in each subgroup (41.2% vs. 52.2%; p = 0.491) expressed a considerable recovery of preoperative bodily complaints such as headaches, dizziness, and unrest defined as a score of at least 8 on the Likert scaled item.
Conclusion
Both transnasal and transcranial approaches yield favorable postoperative QOL and psychopathological outcomes. The postoperative increase in QOL is partly influenced by preoperative expression of mental distress, which tends to resolve postoperatively.
... 5) Line-to-Line Distance Jacobian, J l z ,l of the Manipulator: The line-to-line distance Jacobian and residual are given by taking into account both (45) and (47) as ...
... The target procedure, as surgical procedures in general, has intricate subtasks [45]. A treatise on the entire procedure might require the online calculation of the procedure workflow, which is an active area of research [46], but would be outside of the scope of this paper. ...
... Changes were made to this version by the publisher prior to publication. 5) Line-to-line distance Jacobian, J lz,l of the manipulator: The line-to-line distance Jacobian and residual are given by taking into account both (45) and (47) as ...
... The target procedure, as surgical procedures in general, has intricate subtasks [45]. A treatise on the entire procedure might require the online calculation of the procedure workflow, which is an active area of research [46], but would be outside of the scope of this work. ...
Robotic assistance allows surgeons to perform dexterous and tremor-free procedures, but robotic aid is still underrepresented in procedures with constrained workspaces, such as deep brain neurosurgery and endonasal surgery. In those, surgeons have restricted vision to areas near the surgical tool tips, which increases the risk of unexpected collisions between the shafts of the instruments and their surroundings, in special when those parts are outside the surgical field-of-view. Dynamic active constraints can be used to prevent collisions between moving instruments and prevent damage to static or moving tissues. In this work, our vector field inequality method is extended to provide dynamic active constraints to any number of robots and moving objects sharing the same workspace. The method is evaluated in experiments and simulations in which the robot tools have to avoid collisions, autonomously and in real-time, with a constrained endonasal surgical environment and between each other. Results show that both manipulator-manipulator and manipulator-boundary collisions can be effectively prevented using the vector field inequalities.
... This relationship of the sphenoid cavity to the nasal cavity below and the pituitary gland above makes the transsphenoidal route the surgical approach of choice for sellar tumors. 4 The EETA has minimal invasiveness; lower incidence of complications with lower morbidity and mortality rates compared with traditional open approaches. 1,4 Extended approaches through the SS have made it possible to reach different parts of the skull base from the crista galli to the spinomedulary junction. ...
... 4 The EETA has minimal invasiveness; lower incidence of complications with lower morbidity and mortality rates compared with traditional open approaches. 1,4 Extended approaches through the SS have made it possible to reach different parts of the skull base from the crista galli to the spinomedulary junction. 1 Anatomic variations in the nasal cavity and the SS make preoperative imaging evaluation not only useful for diagnosis but also valuable for surgical mapping to ensure safe access and improved surgical outcomes. ...
... That is, the conchal and the presellar types have low prevalence when compared to the sellar and postsellar types with the sellar usually being the most common. 1,4,7,13 Nevertheless, a wide variation exists in the actual prevalence of each variant. The variations range from 2% to 28% conchal, 17%-21% presellar, 54%-85% sellar, and 22%-43.3% ...
Background:
The air spaces of the nasal cavity and the sphenoid sinus (SS) constitute a convenient corridor to access lesions of the skull base using the endoscopic endonasal transsphenoidal approach (EETA). Safe EETA depends on the SS and skull base anatomy of the patient. Individual variations exist in the degree and pattern of SS pneumatization. This study aims to examine the variations in SS pneumatization, the inter-sphenoid septum (ISS), and their relationship with the internal carotid artery (ICA) among adult Nigerians.
Materials and methods:
We reviewed computerized tomography (CT) images of 320 adult patients that had imaging for various indications. This excluded those with traumatic, inflammatory, or neoplastic process that may alter anatomical landmarks. The images were evaluated for the types of SS pneumatization, number and insertion of ISS, and the protrusion of ICA into the sinus cavity.
Results:
Prevalence of SS pneumatization types: 1.9% conchal, 1.2% presellar, 56.6% sellar, and 40.2% postsellar. The lateral extension of SS occurred into the pterygoid in 138 patients (45.1%), greater wing 112 (35%), lesser wing 37 (11.6%), the full lateral type was seen in 97 (30.3%) patients. One ISS occurred in 150 (46.9%) patients, 162 (50.6%) had multiple, and 8 (2.5%) had none. ISS insertion into ICA bony covering occurred in 101 (31.6%) patients, whereas protrusion of ICA into SS cavity occurred in 110 (34.4%) patients.
Conclusion:
Variations of the SS, ISS, and ICA anatomy are present among native Africans. Detailed imaging evaluation of each patient is considered for EETA is mandatory.
... Sphenoid sinus mucosal samples were collected during the approach for endoscopic trans-sphenoidal surgery for the treatment of PA or NFPAs, as described previously [3]. On induction of general anesthesia all patients received a perioperative dose of antibiotics (1.5 g cefuroxime and 500 mg metronidazole; iv). ...
Purpose:
There is a high incidence of abnormal sphenoid sinus changes in patients with pituitary apoplexy (PA). Their pathophysiology is currently unexplored and may reflect an inflammatory or infective process. In this preliminary study, we characterised the microbiota of sphenoid sinus mucosa in patients with PA and compared findings to a control group of surgically treated non-functioning pituitary adenomas (NFPAs).
Methods:
In this prospective observational study of patients undergoing trans-sphenoidal surgery for PA or NFPA, sphenoid sinus mucosal specimens were microbiologically profiled through PCR-cloning of the 16S rRNA gene.
Results:
Ten patients (five with PA and five with NFPAs) with a mean age of 51 years (range 23-71) were included. Differences in the sphenoid sinus microbiota of the PA and NFPA groups were observed. Four PA patients harboured Enterobacteriaceae (Enterobacter spp., N = 3; Escherichia coli, N = 1). In contrast, patients with NFPAs had a sinus microbiota more representative of health, including Staphylococcus epidermidis (N = 2) or Corynebacterium spp. (N = 2).
Conclusions:
PA may be associated with an abnormal sphenoid sinus microbiota that is similar to that seen in patients with sphenoid sinusitis.
