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SKULL BASE INSTITUTE. The Evolution of Pituitary Surgery: . From an Open Transcranial to a Minimally Invasive Endoscopic Approach. Hrayr K. Shahinian M.D. . Objectives. Describe pituitary anatomy and the various presentations of pituitary adenomas
SKULL BASE INSTITUTE The Evolution of Pituitary Surgery: From an Open Transcranial to a Minimally Invasive Endoscopic Approach. Hrayr K. Shahinian M.D.
Objectives • Describe pituitary anatomy and the various presentations of pituitary adenomas • Discuss the the three standard surgical approaches to pituitary adenomas - Transcranial - Microscopic Transseptal-transsphenoidal - Endoscopic Transnasal-transsphenoidal
Objectives • Discuss results from our latest research comparing outcomes for patients undergoing Microscopic vs. Endoscopic Transsphenoidal Pituitary Adenoma Resection
Transcranial Approach • Requires craniotomy and retraction of the frontal lobes of the brain. • Sub-optimal exposure of inferior and posterior aspects of tumor. • Difficult to distinguish normal gland from tumor from distal perspective.
Transcranial Approach • Forces surgeon to operate between CN I or over orbit risking injury to vision or sense of smell. • Used for large invasive tumors or tumors with significant suprasellar extension. • Often used as a combined second stage approach following a transsphenoidal resection.
Microscopic Transseptal-transsphenoidalApproach • Current standard operation for most pituitary adenomas • Has demonstrated equal outcomes for cure compared to open transcranial approach with less morbidity and mortality. • Allows for more rapid recovery
Endoscopic Transnasal-Transsphenoidal Pituitary Adenoma Resection Made possible by advances in endoscopic technology • Endoscopes – Varying widths and angles of view • Cameras – Three chip, Digital, Three dimensional • Light Sources – Halogen, Metal Halide, Xenon • Recorders/Processors – Digital, Real Time • Irrigation Sheaths • Holding Arms
Endoscopic Procedures Developed Using Animal Models • Animal models developed at SBI have demonstrated the safety and revealed the advantages of the endoscopic approach. • Endoscope allows for clear visualization of pituitary gland, hypophyseal stalk, cavernous sinuses, and optic nerves. • Angled endoscopes enable visualization of lateral recesses and suprasellar areas.
Microscopic Transseptal-transsphenoidal vs. Endoscopic Transnasal-Transsphenoidal Pituitary Adenoma Resection
Combined Micro-endoscopic Approach • SBI began with combined approach in 1996 • Early combined micro-endoscopic series, including one performed at SBI have demonstrated a 33 - 49% incidence of residual tumor, recognized only with the additional visualization provided by the endoscope.
Fully Endoscopic Transnasal-Transsphenoidal Pituitary Adenoma Resection
Fully Endoscopic Transnasal-Transsphenoidal Pituitary Adenoma Resection • In 1998 SBI converted to a fully endoscopic technique. • Since then we have compiled results for all patients undergoing fully endoscopic pituitary adenoma resection. • Submitted these endoscopic results for publication, comparing early outcomes and complication rates to published results using the standard microscopic transsphenoidal operation.
Early Post-operative Remission Rates Endoscopic vs. Microscopic Results a Calculated from several published microscopic series
Complication Rates (percent) Endoscopic vs. Microscopic a Calculated from several published microscopic series
Fully Endoscopic Transnasal-Transsphenoidal Pituitary Adenoma Resection • A safer operation: Improved visualization of surrounding optic bulbs, brainstem, and carotid prominences. Improved ability to differentiate tumor from normal pituitary tissue Completely transnasal approach avoids the risk of naso-oral fistulae, and lip numbness seen with the transseptal approach.
Fully Endoscopic Transnasal-Transsphenoidal Pituitary Adenoma Resection • A more complete operation: Improved visualization sellar and parasellar tumor extension, should result in a lower recurrence rate, as demonstrated by our early results.
Fully Endoscopic Transnasal-Transsphenoidal Pituitary Adenoma Resection • Minimally invasive approach allows for a more rapid recovery with less post-operative discomfort: Most patients discharged within 48 hours. Completely endonasal approach avoids the need for post-operative nasal packing.
The Evolution of Pituitary Surgery:From an Open Transcranial to a Minimally Invasive Endoscopic Approach. Continued research into improved medical and surgical treatment of pituitary adenomas: • New 3-dimensional endoscopes • Animal models using fetal pituitary cell transplantation