Endocrinol Metab.  2022 Aug;37(4):608-616. 10.3803/EnM.2022.1546.

Advances in Pituitary Surgery

• Byun YH
• Kang H
• Kim YH

• KMID: 2532860
• DOI: http://doi.org/10.3803/EnM.2022.1546

Abstract

Pituitary surgery has advanced considerably in recent years with the exploration and development of various endoscopic approaches and techniques. Different endoscopic skull base approaches are being applied to access sellar tumors in different locations. Moreover, extracapsular dissection and cavernous sinus exploration have enabled gross total resection of sellar tumors where it could not have been achieved in the past. Techniques for skull base reconstruction have also progressed, allowing surgeons to remove larger and more complicated tumors than before. This review article discusses different endoscopic skull base approaches, surgical techniques for removing pituitary adenomas, and reconstruction methods for repairing postoperative low-flow and high-flow cerebrospinal fluid leakage.

Keyword

Endoscopy; Pituitary gland; Pituitary neoplasms; Cerebrospinal fluid leak

Figure

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  Fig. 1. Extracapsular dissection. (A) After a wide visualization of the sella is achieved, the dura is sharply opened to expose the tumor inside. (B) A plane between the compressed “paper-thin” pituitary gland and the pseudocapsule is dissected in order to achieve extracapsular dissection.

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  Fig. 2. Cavernous sinus exploration. (A) Endoscopic view of the sella and the cavernous sinus (cadaver head) showing the pituitary gland, stalk, inferior parasellar ligament (IPL), and caroticoclinoid ligament (CCL). (B) Intraoperative photo after releasing the medial cavernous sinus wall exposing the cavernous internal carotid artery (ICA) inside. (C) Preoperative magnetic resonance image shows pituitary adenoma involving left cavernous sinus. (D) After opening the inferior intercavernous sinus, the medial cavernous sinus wall was dissected to gain access to the cavernous sinus in this patient. Paraclinoid ICA is identified inside the cavernous sinus.

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  Fig. 3. Removal of pituitary adenoma extending into the third ventricle. (A, B) Preoperative magnetic resonance image (MRI) shows giant pituitary adenoma extending superiorly into the third ventricle via tuber cinereum. (C, D) Postoperative MRI after removing the sellar and intraventricular tumor.

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  Fig. 4. Endoscopic transtubercular/transplanar approach. (A) Preoperative magnetic resonance image (MRI) shows a pituitary adenoma extending anteriorly to cause bilateral frontal base and optic nerve compression. (B) Endoscopic view after removing the tumor shows the frontal lobe anterior cerebral artery complex covered by arachnoid membranes. (C) Postoperative computed tomography after gross total resection of the tumor. Hydroxyapatite cement was used to achieve rigid reconstruction (black asterisk). (D) Postoperative MRI after gross total resection of the tumor.

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  Fig. 5. Craniotomy for pituitary adenoma with frontal lobe cuff. (A) Preoperative magnetic resonance image (MRI) shows pituitary adenoma with suprasellar extension and cuff of the frontal lobe (white asterisk). (B) Postoperative MRI shows the preserved pituitary stalk and gland. (C) Intraoperative photograph of the tumor via anterior interhemispheric approach. Lt, left; Rt, right.

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  Fig. 6. Endoscopic transclival approach. (A) Preoperative magnetic resonance image (MRI) shows a pituitary adenoma extending from the dorsum sellae to middle clivus. (B) Postoperative MRI after gross total resection of the tumor. Note that the sellar and clival portions of the skull base have been removed to access the tumor.

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  Fig. 7. Endoscopic trans-pterygoid palatine fossa approach. (A, B) Preoperative magnetic resonance image (MRI) shows a pituitary adenoma invading into the lateral cavernous sinus. (C, D) Postoperative MRI after gross total resection of the tumor. The pterygopalatine fossa have been opened to access the lateral margin of the tumor. Nasoseptal flap was used for skull base reconstruction.

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