Atormac
brintellex
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 2270  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (1,098 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

 
  In this Article
 »  Abstract
 » Training
 » Patient Selection
 »  Knowledge of Ana...
 »  Preoperative Pre...
 »  Anesthesia, Posi...
 » Instrumentation
 » Nasal Stage
 » Sphenoid Stage
 » Sellar Stage
 » Tumor Removal
 » Sella Reconstruction
 » Postoperative Care
 »  Complication Avo...
 » Conclusion
 »  References
 »  Article Figures
 »  Article Tables

 Article Access Statistics
    Viewed180    
    Printed8    
    Emailed0    
    PDF Downloaded43    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents    
REVIEW ARTICLE
Year : 2020  |  Volume : 68  |  Issue : 7  |  Page : 85-91

Complication Avoidance in Endonasal Endoscopic Pituitary Surgery


1 Department of Neurosurgery, Mahatma Gandhi University of Medical Sciences and Technology, Sitapura, Jaipur, Rajasthan, India
2 Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication24-Jun-2020

Correspondence Address:
Prof. Bhawani Shanker Sharma
Department of Neurosurgery, Mahatma Gandhi Medical College, Jaipur, Rajasthan
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.287665

Rights and Permissions

 » Abstract 


Endoscopic endonasal surgery for pituitary tumors can be performed safely with a good outcome. Complications are uncommon and relate most often to nearby structures at risk. The authors detail the nuances, tips and tricks useful in avoiding complications and their early detection and management.


Keywords: Complication avoidance, endoscopic pituitary surgery, tips and tricks
Key Message: Endoscopic pituitary surgery is the best approach to remove pituitary tumors. Adequate training with stepwise shifting from microscopic to endoscopic approach is the best way to avoid complications. Thorough knowledge of anatomy is also must for good outcomes.


How to cite this article:
Sharma BS, Ranwa A, Garg K. Complication Avoidance in Endonasal Endoscopic Pituitary Surgery. Neurol India 2020;68, Suppl S1:85-91

How to cite this URL:
Sharma BS, Ranwa A, Garg K. Complication Avoidance in Endonasal Endoscopic Pituitary Surgery. Neurol India [serial online] 2020 [cited 2020 Sep 20];68, Suppl S1:85-91. Available from: http://www.neurologyindia.com/text.asp?2020/68/7/85/287665




Pituitary adenoma is one of the most commonly diagnosed benign intracranial neoplasms.[1]

They cause symptoms by a) compression of the surrounding structures like optic apparatus, b) compromising normal pituitary function leading to hypopituitarism or c) excess hormone secretion resulting in Cushing's disease or acromegaly. The treatment of choice for pituitary adenomas is surgical removal, except in the case of prolactinomas where medical management is the first line of treatment.

The goals of pituitary tumor surgery are to -

  1. Relieve pressure symptoms such as visual decline and headache
  2. Alleviate hypersecretory conditions such as acromegaly, Cushing's disease
  3. Preservation of the normal pituitary function
  4. Avoid long term hospital stay and avert radiosurgery or redo surgery.


These goals can be achieved by complete excision of the tumor with preservation of the normal pituitary gland. The endoscopic approach to pituitary surgery has been the most successful method of managing such cases and has transformed the field of pituitary surgery for the better in past two decades.[2] The endoscope provides the surgeon better visualization by illumination and magnification, and a panoramic wide close up view.[3] It also provides multi-angled view to look around corners allowing removal of hidden tumor under direct vision as in microscopic technique. Endoscope permits a better distinction between the tumor and normal pituitary gland allowing total excision of the tumor and preservation of the normal pituitary with improvement in preexisting visual deficits, the extent of tumor removal, endocrine remission in functioning tumors, post-operative hypopituitarism.[4],[5] Better distinction between diaphragm and arachnoid helps in prevention of postoperative CSF leak. Endoscopic approach has higher total tumor resection, endocrine remission, visual recovery, and less complications (morbidity of <6% and mortality of <1%) as compared to microscopic approach.[6] It has been shown to be safe and effective way of tumor resection in the elderly as well.[7] A recent systematic review and network meta-analysis concluded that endoscopic transsphenoidal surgery is a far more proper surgery method than microsurgery and recommended it to be the first choice as it appeared to be the more tolerable and safer than microscopic transsphenoidal tumor excision.[2]

The endoscope provides a 2D and requires different hand-eye coordination and dexterity. Hence, a steep learning curve exists during which complications are likely to occur. Complications of endoscopic pituitary surgery can be divided into nasal, neurosurgical, vascular and conversion to microscopic surgery, and are summarized in [Table 1].
Table 1: List of possible complications in endoscopic pituitary surgery

Click here to view


Complications can occur in the learning curve period. With the increasing experience in endoscopic technique, there is a reduction in nasal mucosal trauma, postoperative visual deterioration, postoperative nasal discomfort, CSF leak, duration of surgery and hospital stay. These complications can be avoided by properly structured training, anticipating common pitfalls and following a systematic stepwise approach as described in the subsequent sections.


 » Training Top


A sudden change from microscopic to endoscopic technique is difficult. Hence, a gradual and progressive shift is recommended.[8] We advocate stepwise shifts. First, from sublabial to endonasal microscopic, then to endoscope assisted a retractor, then to endoscopic without retractor up to sellar stage, and finally all stages are done with endoscopic technique. Frustration in first 20-30 cases can be avoided by proper knowledge of the endoscopic equipment, detailed understanding the endoscopic endoscopic perception of anatomy and learning endoscopic skills.

With the increase in the number of practicing neurosurgeons, along with a renewed emphasis on limited working hours for residents, time tested methods of apprenticeship have proven to be less effective in the dissemination of the requisite skills required for endoscopic training. Several simulators and virtual reality-based techniques of hand eye coordination, dexterity and handling endoscopic instruments in a laboratory on models and cadavers[9] are now available at several neurosurgery departments which replicate the surgical experience and enhance the learning of endoscopic techniques for the trainees.[10],[11] Observing or assisting experts and periodic update of knowledge by attending seminars and cadaver training courses and fellowships are the key prerequisites before embarking on an independent endoscopic pituitary surgery.


 » Patient Selection Top


An ideal case for a beginner would be a non-functioning pituitary macroadenoma confined to the sella in an adult patient with well-pneumatized sphenoid sinus. A gradual progression to functional pituitary adenomas with fragile or hypertrophied nasal mucosa, and then to more complex cases like the ones with large suprasellar extension, cavernous sinus invasion, dumb-bell tumors, recurrent tumors, giant adenomas is advisable. Tackling such cases becomes easier with increasing experience and results also improve in the favor of patients.[12]


 » Knowledge of Anatomy and Imaging Top


A thorough and detailed knowledge of the relevant anatomy of nasal cavity, sella and adjacent structures from the endoscopic perspective is essential. A careful assessment of the preoperative imaging should be done. Computed tomography reveals anatomical variations such as deviated nasal septum, turbinate hypertrophy, sinusitis, concha bullosa, extent of pneumatization of the sphenoid sinus, location and number of the sphenoid septum, intercarotid distance, bone dehiscence/enlargement/erosion, and the extent of destruction of the sellar floor.[13],[14] Magnetic resonance imaging shows the extent of the tumor, invasion of the cavernous sinus, encasement of the carotids, displacement and location of the normal pituitary gland, pre and post fixed chiasm, evidence of pituitary apoplexy and the presence of hydrocephalus. Consistency or firmness of the tumor can be gauged on T2 weighted and fluid attenuated inversion recovery (FLAIR) images. Rare anatomical variations, such as kissing carotids should be actively looked for and picked up before taking up the patient for surgery to avoid any inadvertent injury during surgery. A thorough analysis of the tumor and its relations to surrounding structures should be done.[15] The site and side of microadenomas (whether anterior or posteriorly placed; on the right or left side of the sella) should be carefully assessed. Anatomical and tumor characteristics which predict difficult tumor removal include an absence of pneumatization of the sella, fibrotic and solid tumors with large suprasellar extension, dumb-bell tumors with a narrow neck, encasement of the carotids or its branches, anterior cranial fossa extension, brain invasion with perilesional edema, cavernous sinus invasion, significant lateral extension of the tumor and small diaphragm sella. Such extensions of tumors result in poor outcome following an endoscopic endonasal surgery alone and might indicate the need for an additional transcranial approach in order to achieve a good outcome.[16],[17]


 » Preoperative Preparation Top


Preoperative workup should include a complete hormone profile, and documentation of visual acuity and visual fields. Preoperative nasal swab culture to rule out colonization/infection by sinister organisms may be done. Broader spectrum antibiotic is used for 24 hours in the perioperative period. Inclusion of an antibiotic in the fluid used for irrigation during surgery may help in reducing the incidence of post-operative infection. Preparation of nasal mucosa is done by instilling oxymetazoline nasal drops one day before surgery and on the morning of surgery.


 » Anesthesia, Positioning and Operation Room Setup Top


The procedure is performed under general anesthesia with propofol being the preferred maintenance agent in order to reduce intraoperative bleeding.[18] Mean blood pressure is kept around 90 mm Hg and pulse around 60 beats/minute. A surgical pack is placed in the throat to avoid aspiration of any collected blood or secretions.

The patient is positioned supine with hip and knee flexed and the trunk is elevated by 20 degrees. The head is turned 15 degrees towards the surgeon and 15 degrees' lateral flexion is done towards the opposite shoulder. Chin forehead line is maintained parallel to the floor. Proper positioning avoids some unwarranted complications like excessive bleeding. A betadine-soaked cotton patty should be inserted first in the nasal cavity for antisepsis.[16],[7]

The operating room should be ergonomically setup to ensure maximum surgeon comfort and ease. The viewing screen should be behind the patient head, in front of the surgeon at the level of his/her eyes. The endoscope is held in the left hand, while the other instruments are held in the right hand. One can avoid getting into trouble and ensure the smooth progress of surgery by following this set up every time.


 » Instrumentation Top


A zero degree as well as an angled 30 degree endoscope of varying thickness (2.7 mm-children, 4 mm-adults) and length (18 cm-nasal stage, 30 cm-sellar stage) along with a high definition camera and viewing screen are necessary.[12],[19] Image guidance is useful for beginners and in patients with abnormal sphenoid anatomy, kissing carotids, dumb-bell or recurrent tumors, and in extended procedures. The use of an external sheath permits irrigation and cleaning of the lens along with avoidance of frequent in and out movement of the endoscope. Other instruments include long and straight (non-bayoneted) instruments including sickle shaped or an endoscopic retractable knife (Cappabianca), straight and angled scissors, Blakesley Thru-Cut Forcep, cottle dissector back biting forceps and pituitary curettes. Image guidance (navigation), suction coagulator, curved suction, coblator, microdebrider, unipolar and bipolar (Kassam) cautery and a high-powered drill are the other requirements. Glue for skull base repair and hemostatic agents like FLOSEAL™® (Baxter) for stopping cavernous sinus bleeding should be available. The orientation of the endoscope, with all the buttons facing the screen, should be checked every time the scope is taken inside the nasal cavity. A three-dimensional endoscope for depth perception is now available in some setups, though its advantage is yet to be proven.[18],[20],[21]


 » Nasal Stage Top


Gentle handling of nasal mucosa and involvement of an otolaryngologist are the best ways to avoid nasal complications. An aerial view and a sequential diagnostic examination along the three turbinates are first performed to identify the anatomical landmarks such as the nasopharynx, choana, opening of the  Eustachian tube More Detailss and the nasolacrimal duct, sphenoid ostia, uncinate process, hiatus semilunaris and bulla ethmoidalis. Any variation in the nasal anatomy is observed.[13],[14]

Packing the space between the middle turbinate and nasal septum with cotton patties soaked with a solution of adrenaline mixed with xylocaine facilitates decongestion of the mucosa as well as creates space for manipulation. This process may have to be repeated 2-3 times to create adequate space. A similar process is repeated in the contralateral nasal cavity. Investment of 10-15 minutes in selective packing and widening sphenoethmoid recess helps in smooth conduction of further steps of surgery. Inferior margin of middle turbinate leads to clival indentation 1 cm below the level of sellar floor and is a consistent landmark. Inferior turbinates are lateralized and the middle turbinate is lateralized or out fractured. Care must be taken not to damage the mucosa as this can cause postoperative scarring and crusting.

All the cables should be neatly tied together to avoid obstructing the operational field. The scope should always follow the instruments by about 1 cm into the nasal cavity for adequate visualization and both should be moved in a coordinated manner. They should not collide or cross each other. The path to sella should be kept as straight as possible. The scope should not touch the nasal walls to prevent frequent soiling of the lens, and it should always be kept at an 11 o'clock position. Two surgeons with 3 or 4 hand technique working in synchrony as pilot-copilot is preferred. The assistant periodically cleans the lens tip using Savlon solution and provides irrigation using warm saline to defog the lens.[12],[22],[23],[24],[25]

Bleeding from the mucosa should be controlled using infiltration or coagulation at a low setting.[12],[13],[14],[15],[16],[17],[22],[23],[24],[25] Mucosal coagulation in the upper part of the nasal cavity should be avoided to prevent anosmia.[26] Nasal septum should be removed judiciously to avoid post-operative saddle nose deformity. Posterior septal artery (branch of sphenopalatine artery), located superolateral to the choana at the inferolateral margin of the sphenoethmoidal recess near the inferior margin of middle terminate, may be a source of intraoperative bleeding or postoperative epistaxis.[26] This artery may be coagulated when access is made between middle turbinate and nasal septum for anterior sphenoidotomy.[26] In extended endonasal approaches, a vascularized nasoseptal flap based on this artery may be harvested and kept ready at the outset for later use in sellar reconstruction.[27],[28],[29]

Sphenoid ostia are identified medial to the root of the superior turbinate [Figure 1]. It may not be visible easily in some cases. A careful inspection may reveal air bubbles coming through the secretions. Probing at the expected location (1.5 cm above the roof of the choana) in the sphenoethmoid recess or fontanelle may be done to enter the sphenoid sinus.
Figure 1: Classic 'owl's eye' appearance with bilateral sphenoid ostia exposed

Click here to view


Surgeon should be familiar with both the uninostril and binostril approach so that either can be used as per the requirements of a particular case.[30],[31] Neuronavigation can be useful in the initial cases for easy localization of sphenoid ostia and guiding the correct trajectory to the sella.[32],[33]

Recent advances such as the self-expanding retractor (Easytrac) for trans-septal approach to the pituitary have the potential to avoid most of the complications involved in the nasal stage, giving straightforward and easy access to the sella.[34]


 » Sphenoid Stage Top


The sphenoid ostia are enlarged medially and caudally to avoid opening up of the skull base. Posterior septostomy is performed. Vomer is removed en mass and preserved for possible use in sellar floor reconstruction later on. Adequate sphenoidotomy and rectangular opening of the anterior sphenoid wall is done for wide exposure of the sella.[16],[17],[22],[23],[24],[25]

Wide sphenodotomy is done to remove coffin effect [Figure 2]. Limits of sphnoidotomy are superior margin of the sphenoid ostium cranially, crest marking junction of sphenoid with ethmoid laterally, pterigo-sphenoid synchondrosis/palato-vaginal canal for vidian nerve at 5 and 7 O' clock position caudally. Space of more than two suction tips below the sellar floor permits easy instrument manipulation. Sphenoid mucosa is coagulated and removed in a limited fashion wherever absolutely necessary. Sphenoid septum is drilled with diamond burr right up to the sellar floor. For “cavity and half” technique, superior turbinate is excised, bulla ethmoidalis is removed and posterior ethmoid is communicated with sphenoid cavity. Endoscope is parked in the additional space created in posterior ethmoids.
Figure 2: View as seen after sphenoidotmy mimicking fetal face with sella in the centre, tuberculum sellae at 12 O'clock position, clival indentation at 6 O'clock position, optic protuberance at 10 and 2 O'clock position, carotid protuberance at 5 and 7 O' clock position and cavernous sinus at 3 and 9 O' clock position

Click here to view


Paramedian septum often leads to the carotid artery or the optic nerve and should be removed carefully. This should be done only when necessary. Midline is identified after sphenoidotomy by the remains of the rostrum cranially, vomer inferiorly and staying between the carotid bulges on either side. Repeated irrigation with warm saline stops bleeding from the mucosa and keeps the surgical field clear.

Internal carotid injury is rare but most feared and catastrophic complication of endoscopic endonasal approach, and its incidence is inversely related to the surgeon's experience. The narrow corridor and limited space available for maneuvering of instruments make this even more devastating. It is grossly under reported with the incidence ranging from 0-4% in various reports. Puncture or laceration of cavernous segment of the ICA is the most commonly injured segment. It can be prevented by careful preoperative evaluation and looking for any bone dehiscence (in about 25% cases), septations, kissing carotids, vessel encasement by tumor in preoperative MRI/CT. Doppler or neuronavigation may be used for intraoperative identification of carotids. Immediate recognition of an intraoperative carotid injury is necessary. A large bore suction should be immediately introduced to keep the surgical field clear. The head end of the patient should be raised along with carotid artery compression in the neck. Apply immediate tamponade using gelfoam and cotton patties. Foley's bulb is inflated in the tumor cavity as a last resort. Immediate angiogram should be performed to identify the site of injury and any pseudoaneurysm which might have formed. This may be tackled with an endovascular procedure[35],[36] (coiling/flow diverter/carotid stenting).


 » Sellar Stage Top


A small hole is made in the center of the sellar floor. Dry drilling with diamond burr acts as a hemostatic agent and stops bleeding from the bone. A drill is moved in small bursts like a paint brush and is removed out of the surgical field only when it has stopped rotating completely. Sellar floor is removed circumferentially till four blue lines (superior and inferior intercavernous sinus and cavernous sinus on both sides laterally) are seen. The dura is coagulated and cut from 3-9 o'clock position. The opening is extended caudally and obliquely to 5 and 8 o'clock position, thus creating an inferior flap. Linear incision in the superior part is avoided as there may be an arachnoid bulge anterior to the tumor which may cause CSF leak.[22],[23],[24],[25] A cruciate incision may cause the anterior part of the tumor to bulge, thus obscuring the posterior part of the tumor [Figure 3].
Figure 3: Sellar dura opening

Click here to view



 » Tumor Removal Top


1. Macroadenoma – Once the dura is cut, the dural flaps are dissected off the tumor capsule. Superior half of the intact dura holds the superior and anterior part of the tumor in place, thus preventing premature arachnoid bulge. Tumor should be gradually mobilized free and removed in piecemeal manner. It should not be pulled towards the scope to avoid frequent soiling of the lens. Basal and posterior part of the tumor is removed first, followed by the lateral and the superior portion is tackled in the last.[16],[22],[23],[24],[25] The suprasellar part of the tumor gradually descends and is removed concentrically. Failure of diaphragm to descend or asymmetric bulge indicates residual tumor, while uniform bulge and pulsating diaphragm is a robust indicator of complete tumor removal. The space between the posterior clinoid and carotid siphon is the ideal location for removal of tumor from the posterior segment of the cavernous sinus.[16],[22],[23],[24],[25] The normal pituitary should always be predicted in preoperative MRI. It is identified by its pink color, firm consistency and presence of vasculature compared to the tumor and is preserved. It has striated appearance. In macroadenoma, thinned out residual pituitary tissue appears as an apron plastered on the under surface of the diaphragm. The endoscope should be taken deep into the sella, close to the target for a detailed and magnified view (flash light effect). It helps to distinguish between tumor and normal pituitary and between diaphragm and arachnoid. Utmost care should be taken to prevent arachnoid tear and CSF leak. The diaphragm can be pushed carefully with a cotton patty to remove any hidden tumor. Angled endoscope is used to examine the tumor cavity and remove any tumor remnants. The last piece of the tumor is often located at insertion site of pituitary stalk. The most common sites found to retain tumor are angle between optic nerve and carotid artery at medial optico-carotid recess (mOCR) and under the anterior lip of dura at the level of superior intercavernous sinus.

In large suprasellar tumors, removal of planum, tuberculum sellae and MOCR permits retraction of dura up with suction allowing removal of the suprasellar tumor extension under vision.

An extended endonasal approach may be required in cases with large suprasellar extension, dumbbell shaped tumors with narrow neck, anterior extension in the anterior cranial fossa and parasellar extension of the tumor.[37],[38],[39],[40],[41]

2. Microadenoma – A limited sellar opening is done based upon the preoperative assessment of the site and side of the microadenoma. Tumor is identified as yellowish colored, slightly firm lesion separate from the normal pituitary tissue. An extracapsular dissection is done to avoid leaving behind any remnant.[42] A thin shell of normal pituitary is shaved along the tumor cavity to enhance chances of a complete cure in cases of functional adenomas.


 » Sella Reconstruction Top


After tumor resection, Valsalva maneuver is performed to check for any CSF leak. If an arachnoid tear is detected, care should be taken to prevent its further enlargement. Size of the tear dictates the type and the extent of repair. A small tear should be immediately sealed using glue or covered with gel foam to prevent blood seeping into the sub-arachnoid space and its resultant vasospasm. The tumor cavity is filled with fat (even if no CSF leak occurs) to prevent empty sella syndrome and to prevent postoperative CSF leak from arachnoid bulge and rupture into the empty cavity during or after extubation. A single large piece of fat is better than using multiple small pieces.[43],[44] On the contrary, care should be taken not to over pack the cavity, which may itself cause mass effect and compression over the chiasm and pituitary stalk. A practical way to prevent over packing is that the graft must be pulsating. Sellar floor may be reconstructed using bone piece. No foreign material should be left in the sphenoid sinus cavity. Intact residual mucosa keeps the sphenoid sinus as a physiological air-filled cavity. If the sphenoid sinus is packed with fat, all the mucosa should be removed to prevent mucocele formation. A large arachnoid tear or a dural defect warrants a multilayered repair using fat graft, inlay fascia lata, outlay fascia and glue, bone piece followed by fat graft and vascularized nasososeptal flap along with surgicel and gelfoam. This should be followed by a rigid buttress of nasal tampons or an inflated Foley's catheter bulb.[45],[46] The middle turbinates are medialized back to their normal position to keep maxillary ostia patent.[34]


 » Postoperative Care Top


Patient should be shifted to the intensive care unit in the postoperative period, where a close watch on the neurological status, fluid intake/output and electrolyte status is kept. In case of any visual decline, nasal packs are removed immediately. It prompts the surgeon to review the operative steps for any possible surgically correctable cause for the same. Post-operative CT scan should be done routinely to look for any hematoma in the operative cavity or residual tumor apoplexy. If any of these is found and the patient is symptomatic, an immediate re-exploration is warranted, either via transphenoidal or transcranial approach.[47],[48] Post-operative lumbar drain is inserted with an instruction to drain around 5 ml/hr of CSF in cases where CSF leak occurs even after repair. If the CSF leak persists even after 72 hours of lumbar drain insertion, patient should taken up for repacking of the sella. The reported mortality after endoscopic endonasal pituitary surgery is less than 1%.[47],[48],[49]


 » Complication Avoidance Top


Steps that can avoid complications and need of conversion to microscopic include:

  • Knowing endoscopic perspective of anatomy of nasal and surrounding structures
  • Proper orientation of the endoscope all the time
  • Recognition of important fixed anatomical landmarks during each stage and step of surgery
  • Knowledge of endoscopic instrumentation
  • Proper selection of cases in the beginning of career in endoscopic surgery
  • Gradual transition from microscopic to endoscopic
  • Acquiring hand-eye coordination and endoscopic surgical skills in lab on models/cadavers
  • Regular attendance of live workshops/fellowships, watching videos and assisting experts
  • Stepwise progression and knowing tips and tricks.


Nasal complications can be avoided by:

  • Packing of the nasal cavity with a solution containing adrenaline and xylocaine
  • Spending time in sphenoethmoidal recess widening
  • Gentle handling of mucosa
  • Avoiding mucosa injury by passing instrument under endoscope guidance
  • Involvement of an ENT surgeon
  • Coagulation of posterior septal artery
  • Wide sphenoidotomy
  • Sucking blood in choana in between to remove blocked choana effect
  • Adding antibiotic to the irrigation fluid
  • Use of FLOSEAL™ for bleeding from cavernous sinus
  • Leaving minimal raw surface
  • Not leaving any foreign body in sphenoid sinus
  • Selective or complete removal of sphenoid mucosa
  • Medializing middle turbinate at the end of surgery to keep maxillary drainage patent.


ICA injury can be avoided by proper analysis of preoperative CT/MRI and use of neuronavigation and doppler.

Neurosurgical complications can be prevented by-

  • Bi-manual dissection and sequential maximal excision of tumor under vision in a piecemeal fashion after dissecting it free
  • No blind dissection or pulling should be done
  • Using extended approach and neuroimaging in large complex adenomas
  • Use of flashlight effect to preserve normal pituitary/stalk
  • Avoidance of arachnoid tear with consequent intraoperative CSF leak.


A step-wise progressive learning brings confidence and ability to tackle complications. Complications, as and when they happen, should be detected early and managed systematically. Multimodality management is advocated.[50]


 » Conclusion Top


In conclusion, majority of complications can be avoided by the involvement of a rhinologist, two surgeons – 3/4 hand technique, use of neuronavigation, bimanual dissection and maximum tumor removal with preservation of normal pituitary and integrity of arachnoid.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Ezzat S, Asa SL, Couldwell WT, Barr CE, Dodge WE, Vance ML, et al. The prevalence of pituitary adenomas: A systematic review. Cancer 2004;101:613-9.  Back to cited text no. 1
    
2.
Dai W, Zhuang Z, Ling H, Yang Y, Hang C. Systematic review and network meta-analysis assess the comparative efficacy and safety of transsphenoidal surgery for pituitary tumor. Neurosurg Rev 2020. doi: 10.1007/s10143-020-01240-3. [Epub ahead of print]  Back to cited text no. 2
    
3.
Li A, Liu W, Cao P, Zheng Y, Bu Z, Zhou T. Endoscopic versus microscopic transsphenoidal surgery in the treatment of pituitary adenoma: A systematic review and meta-analysis. World Neurosurg 2017;101:236-46.  Back to cited text no. 3
    
4.
Broersen LH, Biermasz NR, van Furth WR, de Vries F, Verstegen MJ, Dekkers OM, et al. Endoscopic vs. microscopic transsphenoidal surgery for Cushing's disease: A systematic review and meta-analysis. Pituitary 2018;21:524-34.  Back to cited text no. 4
    
5.
Li A, Liu W, Cao P, Zheng Y, Bu Z, Zhou T. Endoscopic versus microscopic transsphenoidal surgery in the treatment of pituitary adenoma: A systematic review and meta-analysis. World Neurosurg 2017;101:236-46.  Back to cited text no. 5
    
6.
Zaidi HA, Awad AW, Bohl MA, Chapple K, Knecht L, Jahnke H, et al. Comparison of outcomes between a less experienced surgeon using a fully endoscopic technique and a very experienced surgeon using a microscopic transsphenoidal technique for pituitary adenoma. J Neurosurg 2016;124:596-604.  Back to cited text no. 6
    
7.
Wilson PJ, Omay SB, Kacker A, Anand VK, Schwartz TH. Endonasal endoscopic pituitary surgery in the elderly. J Neurosurg 2018;128:429-36.  Back to cited text no. 7
    
8.
Leach P, Abou-Zeid AH, Kearney T, Davis J, Trainer PJ, Gnanalingham KK. Endoscopic transsphenoidal pituitary surgery: Evidence of an operative learning curve. Neurosurgery 2010;67:1205-12.  Back to cited text no. 8
    
9.
Qureshi T, Chaus F, Fogg L, Dasgupta M, Straus D, Byrne RW. Learning curve for the transsphenoidal endoscopic endonasal approach to pituitary tumors. Br J Neurosurg 2016;30:637-42.  Back to cited text no. 9
    
10.
Baby B, Singh R, Suri A, Dhanakshirur RR, Chakraborty A, Kumar S, et al. A review of virtual reality simulators for neuroendoscopy. Neurosurg Rev 2019. doi: 10.1007/s10143-019-01164-7. [Epub ahead of print].  Back to cited text no. 10
    
11.
Cagiltay NE, Ozcelik E, Isikay I, Hanalioglu S, Suslu AE, Yucel T, et al. The effect of training, used-hand, and experience on endoscopic surgery skills in an Educational computer-based simulation environment (ECE) endoneurosurgery rraining. Surg Innov 2019;26:725-37.  Back to cited text no. 11
    
12.
Cavallo LM, Dal Fabbro M, Jalalod'din H, Messina A, Esposito I, Esposito F, et al. Endoscopic endonasal transsphenoidal surgery. Before scrubbing in: Tips and tricks. Surg Neurol 2007;67:342-7.  Back to cited text no. 12
    
13.
Zada G, Agarwalla PK, Mukundan S Jr, Dunn I, Golby AJ, Laws ER Jr. The neurosurgical anatomy of the sphenoid sinus and sellar floor in endoscopic transsphenoidal surgery. J Neurosurg 2011;114:1319-30.  Back to cited text no. 13
    
14.
Unlu A, Meco C, Ugur HC, Comert A, Ozdemir M, Elhan A. Endoscopic anatomy of sphenoid sinus for pituitary surgery. Clin Anat 2008;21:627-32.  Back to cited text no. 14
    
15.
Chaudhary V, Bano S. Imaging of the pituitary: Recent advances. Indian J Endocrinol Metab 2011;15(Suppl 3):S216-23.  Back to cited text no. 15
    
16.
Sharma BS, Sawarkar DP, Suri A. Endoscopic pituitary surgery: Techniques, tips and tricks, nuances, and complication avoidance. Neurol India 2016;64:724-36.  Back to cited text no. 16
[PUBMED]  [Full text]  
17.
Yadav YR, Sachdev S, Parihar V, Namdev H, Bhatele PR. Endoscopic endonasal trans-sphenoid surgery of pituitary adenoma. J Neurosci Rural Pract 2012;3:328-37.  Back to cited text no. 17
[PUBMED]  [Full text]  
18.
Bickerton R, Nassimizadeh AK, Ahmed S. Three-dimensional endoscopy: The future of nasoendoscopic training. Laryngoscope 2019;129:1280-5.  Back to cited text no. 18
    
19.
Schroeder HW, Nehlsen M. Value of high-definition imaging in neuroendoscopy. Neurosurg Rev 2009;32:303-8; discussion 308.  Back to cited text no. 19
    
20.
Tabaee A, Anand VK, Fraser JF, Brown SM, Singh A, Schwartz TH. Three-dimensional endoscopic pituitary surgery. Neurosurgery 2009;64(5 Suppl 2):288-93; discussion 294-5.  Back to cited text no. 20
    
21.
Uozumi Y, Taniguchi M, Nakai T, Kimura H, Umehara T, Kohmura E. Comparative evaluation of 3-Dimensional high definition and 2-Dimensional 4-K ultra-high definition endoscopy systems in endonasal skull base surgery. Oper Neurosurg (Hagerstown) 2020. pii: opz426. doi: 10.1093/ons/opz426. [Epub ahead of print]  Back to cited text no. 21
    
22.
Jho HD, Alfieri A. Endoscopic transsphenoidal pituitary surgery: Various surgical techniques and recommended steps for procedural transition. Br J Neurosurg 2000;14:432-40.  Back to cited text no. 22
    
23.
Jho HD, Alfieri A. Endoscopic endonasal pituitary surgery: Evolution of surgical technique and equipment in 150 operations. Minim Invasive Neurosurg 2001;44:1-12.  Back to cited text no. 23
    
24.
Cappabianca P, Cavallo LM, de Divitiis E. Endoscopic endonasal transsphenoidal surgery. Neurosurgery 2004;55:933-40.  Back to cited text no. 24
    
25.
Zador Z, Gnanalingham K. Endoscopic transnasal approach to the pituitary – Operative technique and nuances. Br J Neurosurg 2013;27:718-26.  Back to cited text no. 25
    
26.
Griffiths CF, Cutler AR, Duong HT, Bardo G, Karimi K, Barkhoudarian G, et al. Avoidance of postoperative epistaxis and anosmia in endonasal endoscopic skull base surgery: A technical note. Acta Neurochir (Wien) 2014;156:1393401.  Back to cited text no. 26
    
27.
Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: Vascular pedicle nasoseptal flap. Laryngoscope 2006;116:1882-6.  Back to cited text no. 27
    
28.
Thakur B, Jesurasa AR, Ross R, Carroll TA, Mirza S, Sinha S. Transnasal trans-sphenoidal endoscopic repair of CSF leak secondary to invasive pituitary tumours using a nasoseptal flap. Pituitary 2011;14:163-7.  Back to cited text no. 28
    
29.
Shah RN, Surowitz JB, Patel MR, Huang BY, Snyderman CH, Carrau RL, et al. Endoscopic pedicled nasoseptal flap reconstruction for pediatric skull base defects. Laryngoscope 2009;119:1067-75.  Back to cited text no. 29
    
30.
Stamm AC, Pignatari S, Vellutini E, Harvey RJ, Nogueira JF Jr. A novel approach allowing binostril work to the sphenoid sinus. Otolaryngol Head Neck Surg 2008;138:531-2.  Back to cited text no. 30
    
31.
Yano S, Kawano T, Kudo M, Makino K, Nakamura H, Kai Y, et al. Endoscopic endonasal transsphenoidal approach through the bilateral nostrils for pituitary adenomas. Neurol Med Chir 2009;49:1-7.  Back to cited text no. 31
    
32.
Ganslandt O, Behari S, Gralla J, Fahlbusch R, Nimsky C. Neuronavigation: Concept, techniques and applications. Neurol India 2002;50:244-55.  Back to cited text no. 32
[PUBMED]  [Full text]  
33.
Javer AR, Marglani O, Lee A, Matishak M, Genoway KA. Image-guided endoscopic transsphenoidal removal of pituitary tumours. J Otolaryngol Head Neck Surg 2008;37:474-80.  Back to cited text no. 33
    
34.
Chandra PS, Kaur KD. Development of a unique retractor for performing endoscopic pituitary surgery-EASYTRAC. Neurol India 2019;67:1509-12.  Back to cited text no. 34
[PUBMED]  [Full text]  
35.
Padhye V, Valentine R, Wormald PJ. Management of carotid artery injury in endonasal surgery. Int Arch Otorhinolaryngol 2014;18(Suppl 2):S173-8.  Back to cited text no. 35
    
36.
Sylvester PT, Moran CJ, Derdeyn CP, Cross DT, Dacey RG, Zipfel GJ, et al. Endovascular management of internal carotid artery injuries secondary to endonasal surgery: Case series and review of the literature. J Neurosurg 2016;125:1256-76.  Back to cited text no. 36
    
37.
Sankhla SK, Jayashankar N, Khan GM. Surgical management of selected pituitary macroadenomas using extended endoscopic endonasal transsphenoidal approach: Early experience. Neurol India 2013;61:122-30.  Back to cited text no. 37
[PUBMED]  [Full text]  
38.
Zhao B, Wei YK, Li GL, Li YN, Yao Y, Kang J, et al. Extended transsphenoidal approach for pituitary adenomas invading the anterior cranial base, cavernous sinus, and clivus: A single-center experience with 126 consecutive cases. J Neurosurg 2010;112:108-17.  Back to cited text no. 38
    
39.
Kitano M, Taneda M, Shimono T, Nakao Y. Extended transsphenoidal approach for surgical management of pituitary adenomas invading the cavernous sinus. J Neurosurg 2008;108:26-36.  Back to cited text no. 39
    
40.
Rudnik A, Zawadzki T, Galuszka-Ignasiak B, Bazowski P, Duda I, Wojtacha M, et al. Endoscopic transsphenoidal treatment in recurrent and residual pituitary adenomas- first experience. Minim Invasive Neurosurg 2006;49:10-4.  Back to cited text no. 40
    
41.
Dehdashti AR, Ganna A, Witterick I, Gentili F. Expanded endoscopic endonasal approach for anterior cranial base and suprasellar lesions: Indications and limitations. Neurosurgery 2009;64:677-87; discussion 687-9.  Back to cited text no. 41
    
42.
Qu X, Yang J, Sun JD, Mou CZ, Wang GD, Han T, et al. Transsphenoidal pseudocapsule-based extracapsular resection for pituitary adenomas. Acta Neurochir (Wien) 2011;153:799-806.  Back to cited text no. 42
    
43.
Leng LZ, Brown S, Anand VK, Schwartz TH. “Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery 2008;62(5 Suppl 2):ONSE342-3.  Back to cited text no. 43
    
44.
Wormald PJ, McDonogh M. 'Bath-plug' technique for the endoscopic management of cerebrospinal fluid leaks. J Laryngol Otol 1997;111:1042-6.  Back to cited text no. 44
    
45.
Conger A, Zhao F, Wang X, Eisenberg A, Griffiths C, Esposito F, et al. Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: Trends in repair failure and meningitis rates in 509 patients. J Neurosurg 2018;130:861-75.  Back to cited text no. 45
    
46.
Thorp BD, Sreenath SB, Ebert CS, Zanation AM. Endoscopic skull base reconstruction: A review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak. Neurosurg Focus 2014;37:E4.  Back to cited text no. 46
    
47.
Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P, et al. Endoscopic endonasal skull base surgery: Analysis of complications in the authors' initial 800 patients. J Neurosurg 2011;114:1544-68.  Back to cited text no. 47
    
48.
Laws ER, Michael RR, Sheryl LI. Complication of endoscopic pituitary surgery and their avoidance. In: Mishra BK, Laws ER, Kaye AH, editors. Currents Progress in Neurosurgery. Mumbai: Tree Life India; 2014. p. 46-54.  Back to cited text no. 48
    
49.
Kasliwal MK, Srivastava R, Sinha S, Kale SS, Sharma BS. Vasospasm after transsphenoidal pituitary surgery: A case report and review of the literature. Neurol India 2008;56:81-3.  Back to cited text no. 49
[PUBMED]  [Full text]  
50.
McLaughlin N, Laws ER, Oyesiku NM, Katznelson L, Kelly DF. Pituitary centers of excellence. Neurosurgery. 2012;7:916-24; discussion 924-6.  Back to cited text no. 50
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow