Endoscopic endonasal transsphenoidal approach to the sellar region: technical evolution of the methodology and refinement of a dedicated instrumentation.

BACKGROUND: Endoscopic treatment of hydrocephalus has in time acquired a primary position in Neurosurgery. Today endoscopy can be employed in the vast majority of neurosurgical procedures in the realization of the so-called endoscope-assisted microneurosurgery. On the basis of the encouraging results obtained by Jho and Carrau, the authors report the pros and cons of the new endoscopic endonasal technique.
METHODS: An endoscopic endonasal transsphenoidal approach to the sella was performed in 50 patients: 33 females and 17 males, of age included between 16 and 76 years; 45 were affected by pituitary adenomas (9 micro and 36 macro; 10 were recurrences), 3 by craniopharyngiomas, 2 by clival chordomas. The new instrumentation was realized through straight devices with a handle shifted 10-30 degrees horizontally. The possible danger to the nasal structures is reduced not only by the elimination of the bayonet-like shape but also by hiding the cutting extremity in the handle.
RESULTS: The advantages of this technique have been represented by an easier access to the lesion, especially in recurrent tumors, a more complete excision of voluminous neoplasms, a decrease of ENT post-surgical complications and a reduction of hospitalization times and costs. The main limits have been the reduction of field depth and the lack of adequate instrumentation.
CONCLUSIONS: In this peculiar surgery the absence of proper instruments has to be overcome because: a) there is less room to work, b) a conflict between the hands of the surgeon and the endoscope may occur, c) the blind introduction of the instruments in the nostril may cause damage to the nasal structures. The secret for the success of the endoscopic endonasal transsphenoidal technique is to create the optimal conditions, in order to avoid improper manoeuvres that may cause potential dangers.