Easy sellar reconstruction in endoscopic endonasal transsphenoidal surgery with polyester-silicone dural substitute and fibrin glue: technical note

Closure strategy for endoscopic pituitary surgery: Experience from 3015 patients

Introduction

Effective strategies are required to ensure optimal management of the crucial closure step in endoscopic pituitary surgery. Many surgical techniques have been reported but no significant consensus has been defined.

Methods

Between January 2006 and March 2022, 3015 adult patients with pituitary adenomas were operated on by a single expert neurosurgical team, using a mononostril endoscopic endonasal approach. Based of preoperative risk factors of and operative findings, a detailed closure strategy was used. Body mass index >40, sellar floor lysis, number of surgeries>2, large skull base destruction, prior radiotherapy were considered as preoperative risk factors for closure failure. All patients treated with an expanded endonasal approach were excluded.

Results

Patients were mostly women (F/M ratio: 1.4) with a median age of 50 (range: 18 -89). Intraoperative CSF leak requiring specific surgical management was observed in 319/3015 (10.6%) of patients. If intraoperative leak occurred, patients with predictive risk factors were managed using a Foley balloon catheter in case of sellar floor lysis or BMI>40 and a multilayer repair strategy with a vascularized nasoseptal flap in other cases. Postoperative CSF leak occurred in 29/3015 (1%) of patients, while meningitis occurred in 24/3015 (0.8%) of patients. In patients with intraoperative leak, closure management failed in 11/319 (3.4%) of cases.

Conclusion

Based on our significant 16-year experience, our surgical management is reliable and easy to follow. With a planned and stepwise strategy, the closure step can be optimized and tailored to each patient with a very low failure rate.

Sinonasal outcomes associated with the use of BioGlue® in endoscopic transsphenoidal pituitary surgery

Concerns have been raised in the neurosurgical literature regarding the use of BioGlue®, a tissue sealant initially developed for cardiothoracic surgery, due to reports of an increased incidence of infection, wound breakdown, and CSF fistulae. The aim of this study was to determine if the use of BioGlue® in skull base repair impacts on the sinonasal outcomes and the incidence of post-operative infection following endoscopic pituitary surgery. SNOT-22 questionnaires were completed pre-operatively, and at 6, 12, and 24 weeks post-operatively by 50 patients. Pre- and post-operative MRI scans were reviewed and assessed for evidence of post-operative sinusitis. Patient records were consulted to ascertain the incidence of post-operative infection. Repeated measures ANOVA and Wilcoxon signed rank test were used for data analysis. Statistical analysis revealed a significant difference in the mean SNOT-22 scores across the four time intervals (F(1.605, 78.642) = 9.180, p = 0.001). This difference was powered by a deterioration at 6 weeks that recovered completely by 12 weeks. The mean SNOT-22 score in the study cohort at 24 weeks was 16.84/110 (range 0-57, ± 2.04) which was lower than the mean pre-operative score and is consistent with mild rhinosinusitis. There were no cases of post-operative meningitis and 1/50 (2%) case of post-operative sinusitis in this cohort. The use of BioGlue® in endoscopic endonasal pituitary surgery does not appear to lead to significant sinonasal morbidity. Previous concerns about the use of BioGlue® in transcranial procedures may not apply to extradural application of this tissue sealant in endoscopic transnasal surgery.

Case Report: Internal Carotid Artery Thrombosis: A Rare Complication After Fibrin Glue Injection for Cavernous Sinus Hemostasis

Background: Fibrin glue injection within the cavernous sinus (CS) is a demonstrably safe and simple technique to control venous bleeding with a low complication rate. However, this technique does have inherent risks. We illustrate 2 cases of internal carotid artery (ICA) thrombosis after fibrin glue injection in the CS for hemostasis.

Methods: After encountering this complication recently, we conducted a retrospective review of the surgical database of 2 senior neurosurgeons who specialize in cerebrovascular and skull base surgery to identify patients with any complications associated with the use of fibrin glue injection for hemostasis. Approval was given by respective institutional review boards, and patient consent was obtained.

Results: Of more than 10,000 microsurgery procedures performed by 2 senior neurosurgeons with a combined experience of 40 years, including procedures for aneurysms and skull base tumors, 2 cases were identified involving ICA thrombosis after fibrin glue injection in the CS for hemostasis. Both cases involved severe ischemic complications as a result of the ICA thrombosis. In this article, we present their clinical presentation, characteristics, management, and outcomes.

Conclusion: Direct injection of fibrin glue into the CS for hemostasis can effectively control venous bleeding and facilitate complex dissections. However, it can be associated with ICA thrombosis, with subsequent serious ischemia and poor prognosis. Although this complication appears to be rare, increased awareness of this problem should temper the routine use of fibrin glue in anterior clinoidectomy and transcavernous approaches.

Deployment of a bioabsorbable plate as the rigid buttress for skull base repair after endoscopic pituitary surgery

Background

Bioresorbable alloplastic implants have become desirable as a rigid buttress for reconstructing skull base defects. This study aimed to describe the use of a biodegradable plate (PolyMax RAPID) in skull base repair of endoscopic endonasal pituitary surgery and to investigate the clinical outcome and safety of this novel method.

Methods

Between January 2019 and January 2020, 22 patients with pituitary adenomas who underwent endoscopic skull base repair with a Polymax RAPID plate were included. After endonasal transsphenoidal surgery, a trimmed bioresorbable plate was placed in the position between the dura and the bone of the skull base to reconstruct the sellar floor and buttress the pituitary gland and sellar packing. The patient demographics, radiologic imaging, and postoperative outcomes were carefully reviewed. All patients were followed up by a routine nasal endoscopic assessment and radiologic examinations.

Results

The present study comprised 10 (45.5%) males and 12 (54.4%) females with an average age of 51.9 years. There were 7 (31.8%) growth hormone (GH) secreting adenomas, 2 (9.1%) thyroid stimulating hormone (TSH) secreting adenomas, and 13 (59.1%) non-functioning adenomas. Enlarged sellar floor and paranasal sinusitis were seen in 13 (59.1%) and 11 (50.0%) cases shown by preoperative computed tomography (CT) or magnetic resonance imaging (MRI), respectively. There were 6 (27.3%) grade-1 and 16 (72.7%) grade-0 cases by intraoperative cerebrospinal fluid (CSF) leak grading. None of these patients received lumbar drains postoperatively and no postoperative CSF rhinorrhea was detected in our series. The PolyMax RAPID plates which could be clearly identified on postoperative CT or sagittal T1-weighted MRI were shown to provide an ideal rigid buttress for sellar repair.

Conclusions

The Polymax RAPID plate can be an optimal implant to achieve rigid repair of sellar floor defects after endonasal transsphenoidal pituitary surgery.

Middle turbinate mucosal flap: Low-morbidity option in the management of skull base defects

BACKGROUND

To describe the low morbidity of middle turbinate mucosal flap (MTMF) to repair anterior skull base defects.

METHODS

Skull base endonasal endoscopic surgeries performed at a tertiary hospital between 2015 and 2018 were analyzed. Patients were divided into two groups according the existence or not of a significant intraoperative cerebrospinal fluid (CSF) leak. In Group 1 (n = 28), gasket seal and a pedicled endonasal flap were used to repair the defect: 13 nasoseptal flaps (NSF), 8 inferolateral wall flaps (ILF), and 7 MTMF. In Group 2 only an endonasal flap was used: 9 NSF, 4 ILF, and 18 MTMF. Surgical and recovery time were analyzed (Student's t test). Our favorite surgical technique is described.

RESULTS

Fifty-nine patients were included. Average surgical time was 27.7, 41.6, and 11.3 min for NSF, ILF, and MTMF, respectively. MTMF showed a faster recovery.

CONCLUSION

MTMF is a safe reconstructive option for anterior skull base defects.

An Algorithm for Sellar Reconstruction Following the Endoscopic Endonasal Approach: A Review of 300 Consecutive Cases

Objectives/Hypotheses  The endoscopic endonasal approach (EEA) is the workhorse endoscopic procedure for sellar and parasellar pathology. Various reconstruction techniques have been reported following EEA surgery, ranging from no reconstruction to vascularized flaps. We review our institution's experience with sellar reconstruction following EEA and propose an evidence-based algorithm. Design  Retrospective review. Setting  Tertiary academic medical center. Participants  Patients who underwent endoscopic EEA surgery for sellar or parasellar pathology between March 1, 2013 and August 31, 2016. Main Outcome Measures  Patient demographic and clinicopathologic data were collected. Outcome measures included intraoperative and postoperative cerebrospinal fluid (CSF) leak rates and extent of resection (gross or subtotal). Results  Three hundred consecutive patients were included. Depending on the presence and grade of intraoperative CSF leak, cases were reconstructed using either a free mucosal graft (FMG) or nasoseptal flap (NSF). Intraoperative and postoperative CSF leak rates were 30.7% and 2.3%, respectively. Multivariable logistic regression found that intraoperative CSF leak was associated with recurrent disease (odds ratio [OR] 2.47, p  = 0.004), with no apparent predictors of postoperative CSF leak. Conclusions  Based on this large series, we propose the following algorithm for sellar reconstruction: FMG for no CSF leak; fat graft + FMG ± rigid fixation for low-grade leaks; and fat graft + NSF ± rigid fixation for high-grade leaks.

A new multilayer reconstruction using nasal septal flap combined with fascia graft dural suturing for high-flow cerebrospinal fluid leak after endoscopic endonasal surgery

This study aimed to evaluate the usefulness and reliability of a new endoscopic multilayer reconstruction using nasal septal flap (NSF) to prevent high-flow cerebrospinal fluid leak after endoscopic endonasal surgery. This study was a retrospective review on 97 patients who underwent multilayer reconstructions using NSF combined with fascia graft dural suturing after endoscopic endonasal surgery between July 2012 and March 2014. Patients were divided into two groups, third ventricle opening group and nonopening group, based on the presence of a direct connection between the third ventricle and the paranasal sinus after tumor removal. Furthermore, we compared this procedure with our previous reconstruction after resection of craniopharyngioma. Finally, we checked the patients who had postoperative prolonged discomfort of the nasal cavity for over a year. Postoperative cerebrospinal fluid (CSF) leak occurred in three patients (3.1 %): one from the third ventricle opening group and the remaining two from the nonopening group. External lumbar drain was performed after surgery in only seven patients (7.2 %). The incidence of postoperative CSF leak was similar in both groups, whereas the rate of craniopharyngioma in the third ventricle opening group was significantly higher. The incidence of postoperative CSF leak after resection of craniopharyngioma was not statistically significant but obviously higher in the previous group (12.2 %) compared with that in the present group (2.3 %). Twelve patients (12.4 %) had postoperative nasal discomfort of the nasal cavity for over a year. Multilayer reconstruction using NSF combined with fascia graft dural suturing is a more reliable method for preventing postoperative high-flow CSF leakage after endoscopic endonasal surgery even if there is a direct connection between the third ventricle and the paranasal sinus. However, we should pay close attention especially to prolonged discomfort of the nasal cavity after harvesting NSF.

Endoscopic Endonasal Reconstruction of Skull Base: Repair Protocol

Background Endoscopic endonasal skull base reconstructions have been associated with postoperative cerebrospinal fluid (CSF) leaks. Objective A repair protocol for endoscopic endonasal skull base reconstruction is presented with the objective of decreasing the overall leak rate. Methods A total of 180 endoscopic endonasal skull base reconstructions were reviewed. Reconstructions were classified I to IV according to the reconstruction method, determined by severity of intraoperatively encountered CSF leaks for types I to III, and planned preoperatively for type IVs, which required nasoseptal flap. Results A total of 11 patients(6%) had postoperative leaks: 0 in type I (0%), 2 in type II (5%), 7 in type III (18%), and 2 (4%) in type IV reconstruction. Type III leak rate was higher than all other reconstructions. Total 31 intraoperative and 16 postoperative lumbar drains were placed. More patients had lumbar drains placed postoperatively for type III and intraoperatively for type IV than all other groups. There were significant overall differences in postoperative CSF leaks and lumbar drain placement between the four reconstruction types. No patient with type III reconstruction and intraoperative lumbar drain had postoperative CSF leak. Conclusions A repair protocol for endoscopic endonasal reconstructions determined by intraoperative CSF leak and preoperative planning minimizes unnecessary repair materials and additional morbidity. Our experience leads to a routine prophylactic lumbar drain placement in all type III leak and reconstructions. We also favor the type III reconstruction for minor intraoperative leaks, and a more generous use of type IV reconstructions in expectation of significant intraoperative CSF leak. The option of rescue flap technique in type III leaks should be strongly considered.

The endoscopic hemi-transseptal approach to the sella turcica: operative technique and case-control study

Background The hemi-transeptal (Hemi-T) approach was developed to facilitate a binasal two-surgeon endoscopic approach for sellar tumors, with preservation of the nasoseptal flap and selective mobilization for reconstruction. Methods A retrospective case-control study was performed comparing the Hemi-T approach with previously used methods of sellar exposure and reconstruction. Outcome measures included operative time and postoperative nasal morbidity. Results A total of 23 patients underwent the Hemi-T approach versus 42 in whom traditional exposure was performed. Operative time was significantly shorter using the Hemi-T technique (152.6 ± 56.8 versus 205.2 ± 61.3 minutes; p = 0.001), as was the length of hospital stay (3.3 ± 1.9 versus 5.4 ± 3.6 days; p = 0.004). There was no difference in the rates of intraoperative or postoperative cerebrospinal fluid leak, cartilage necrosis, septal perforation, or mucosal adhesions. Conclusion The Hemi-T approach facilitates binasal two-surgeon access to the sella without compromise of the pedicle during the extended sphenoidotomies and tumor removal. Operative time and nasal morbidity is not increased, and iatrogenic injury to the nasal cavity is minimized when a flap is not required.

One-piece modified gasket seal technique

Objectives Review the effectiveness of a modified gasket seal technique utilizing a porous high-density polyethylene plate/rectus sheath fascia construct without fat grafting for primary closure of anterior defects following endoscopic skull base surgery. Design Retrospective review (2011-2012). Setting Single academic medical center. Methods A retrospective review of five patients who underwent expanded endoscopic endonasal surgery for various pathologies (two craniopharyngiomas, two tuberculum meningiomas, and one planum meningioma) was performed. Skull base closure was performed using a one-piece modified gasket seal technique. Primary outcome measures included postoperative cerebrospinal fluid (CSF) leaks and donor site morbidity. Results There were no postoperative CSF leaks. Two patients experienced aseptic meningitis treated with a 14-day course of steroids. Two patients experienced new postoperative chronic/recurrent sinusitis treated with oral antibiotics and topical nasal therapy. There was no donor site morbidity such as infection, hematoma, or hernias. Conclusions The one-piece modified gasket-seal closure is a safe and effective method for reconstruction of endonasal defects of the anterior skull base. Rectus sheath fascia is an appropriate dural substitute for free tissue grafting with low donor site morbidity. The construction of the one-piece graft significantly decreases operative time and lowers the learning curve for multilayered closure.

Low-grade CSF leaks in endoscopic trans-sphenoidal pituitary surgery: efficacy of a simple and fully synthetic repair with a hydrogel sealant

BACKGROUND

Intra-operative CSF leak during endoscopic trans-sphenoidal surgery is not uncommon. Surgical repair with a variety of autologous grafts, rigid buttresses and CSF diversion techniques that add time and complexity have been reported.

OBJECTIVE

To describe a simple and purely synthetic closure for low-grade CSF leaks following endoscopic trans-sphenoidal pituitary surgery.

METHODS

A retrospective review of all endoscopic trans-sphenoidal surgery undertaken for pituitary pathology between 2005 and 2010 was carried out. The grade of CSF leak and success of graded repair was noted. Patients with no CSF leak (grade 0) had gelatin sponge placed in the tumour cavity. In those with low-grade CSF leak through small arachnoid defects (grade 1), repair was carried out using gelatin sponge and hydrogel sealant overlay. CSF diversion was not employed for low-grade CSF leaks.

RESULTS

Of the 255 endoscopic trans-sphenoidal surgeries, 158 (62%) had no leak (grade 0) and 74 (29%) had a low-grade leak (grade 1). Repairs in all cases were of grade 0, and all but two cases of grade 1 CSF leak were successful at a mean follow-up of 29 months. The 2 (2.7%) post-operative CSF leaks were seen within 6 weeks of surgery. Both cases were related to bouts of sneezing and were repaired using further trans-sphenoidal surgery and/or lumbar CSF diversion.

CONCLUSIONS

A simple purely synthetic repair of low-grade CSF leaks is described. This repair is safe and comparable in efficacy whilst avoiding the morbidity related to more complex sellar reconstructions previously described.

Extended endoscopic endonasal approach to the suprasellar parachiasmatic cisterns: anatomic study

OBJECTIVE

The objective of this study is to recognize the available endoscopic routes during approaches to the suprasellar region and the surgical endoscopic anatomy of the related neurovascular structures.

MATERIAL AND METHODS

Extended endoscopic endonasal approach to the suprasellar region (EEASR) through the planum sphenoidale was performed in five fresh adult cadavers. The anatomic characteristics of the suprasellar parachiasmatic cisterns were studied and documented following the resection of the planum sphenoidale and opening the dura to expose the anterior incisural space.

RESULTS

Two separate surgical corridors could be used during EEASR: one above and the other below the chiasm. The suprachiasmatic route exposed the gyrus recti, interhemispheric fissure, anterior cerebral artery complex, the lamina terminalis, and through this structure the anterior recess of the third ventricle. The subchiasmatic route exposed the pituitary stalk, superior hypophyseal artery, supraclinoidal internal carotid artery, origin of the ophthalmic artery, anterior choroidal artery, posterior communicating artery, uncus, optic tract, basilar artery and its bifurcation, pons, posterior cerebral artery, superior cerebellar artery, and oculomotor nerve.

CONCLUSION

The EEASR, a minimally invasive route to suprasellar parachiasmatic area, provided wide exposure of the basal cisterns. The surgical areas that were accessed through the subchiasmatic corridor could be divided into a medial part that included the interpeduncular and prepontine cisterns and a lateral part that contained carotid and sylvian cisterns superiorly and the crural and ambient cisterns inferiorly.

Endoscopic endonasal skull base reconstruction using a nasal septal flap: surgical results and comparison with previous reconstructions

The objective of this study is to evaluate the usefulness and reliability of endoscopic endonasal skull base reconstructions using a nasal septal flap. This study is designed as a retrospective review. Between April 2005 and November 2009, we performed 32 endoscopic endonasal skull base reconstructions for closure of large dural defects. Eleven patients underwent reconstructions using fat grafts or the fascia lata (non-flap group). Twenty one patients underwent reconstructions using a nasal septal flap with a balloon catheter (flap group). Incidence of postoperative cerebrospinal fluid (CSF) leaks and perioperative insertion rate of external lumbar drain (ELD) were compared between the two groups. Postoperative CSF leaks occurred in two patients (9.5%) in the flap group. Three patients (27.3%) presented CSF leaks in the non-flap group. The rate of insertion of ELD was 81.8% in the non-flap group. In the flap group, one patient (4.8%) should be placed with ELD postoperatively. The incidence of postoperative CSF leaks in the flap group was lower than in the non-flap group, whereas the rate of insertion of ELD in the non-flap group was higher than in the flap group. Endoscopic endonasal skull base reconstruction using a nasal septal flap without ELD seems to be useful and reliable for ventral skull base defects after endoscopic endonasal approaches as compared with our previous single-layer reconstructions using free fat grafts or fascia lata. The long-term effectiveness of nasal septal flaps to prevent intracranial complications should be confirmed.

Pituitary tumors: our experience in the prevention of postoperative cerebrospinal fluid leaks after transsphenoidal surgery

The objective was to analyze the management of intraoperative CSF leaks in transsphenoidal surgeries to prevent postoperative cerebrospinal fluid (CSF) leaks. Sixty-three pituitary tumors were operated by transnasal approach. In presence of arachnoidal opening, a fat graft was placed into the sellar cavity, followed by collagen sponge layer and fibrin glue. The sphenoid sinus was also packed with fat graft and collagen sponge. An external CSF lumbar drainage was kept for 2-4 days. The variables analyzed were: intraoperative and postoperative CSF leaks, procedures, and related complications. The overall incidence of postoperative CSF leak was 1.5%. Twenty patients (31.7%) had intraoperative arachnoidal opening, 5% of whom had postoperative CSF leak. There were no reoperations because of CSF leak, and no secondary intrasellar arachnoidoceles. Mean follow-up was 3.6 years. The preventive treatment had good results and there were no complications related to the intervention strategy, encouraging us to continue performing this simple, effective, and inexpensive procedure.

Endoscopic endonasal suturing of dural reconstruction grafts: a novel application of the U-Clip technology. Technical note

Cerebrospinal fluid (CSF) leakage following endoscopic endonasal skull base resection can be a significant problem. A method for securing tissue grafts is needed. In this paper the authors used an endonasal suturing device to secure the graft reconstruction following endonasal tumor resection. The U-Clip anastomotic device (Medtronic), developed for cardiovascular anastomoses, was used to secure the tissue graft to native dura. A specialized needle driver and hemoclip applier were used for the application and deployment of this device. No suture tying was necessary, facilitating its endonasal application. The graft was successfully secured in its desired position to native dura by using the U-Clip anastomotic device. The patient did not suffer a postoperative CSF leak, and postoperative imaging and endoscopy revealed that the graft was in a good position. There was no complication from the use of the device. The U-Clip anastomotic device can be used as a suture device during endonasal surgery. It may prevent tissue graft migration and help prevent CSF leakage.

Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions

Object

The extended transsphenoidal approach to the suprasellar region has the advantages of minimal invasiveness and brain manipulation in the surgical treatment of small to medium lesions. At the same time, however, it carries a higher risk of postoperative cerebrospinal fluid (CSF) leakage and related complications than those for the standard transsphenoidal approach. Effective reconstruction of large skull base defects is a major concern in such extended approaches and remains challenging.

Methods

Between January 2004 and April 2006, 21 patients affected by different suprasellar lesions underwent the extended endoscopic endonasal transtuberculum-transplanum approach. Three different techniques were used for the skull base reconstructions. In all cases, dehydrated human pericardium (Tutoplast) for dural reconstruction and a copolymer of l-lactic acid and glycolic acid (LactoSorb) as a bone substitute were used. Collagen sponges, fibrin glue, and an inflated Foley balloon catheter were also used to fill the sphenoid sinus cavity.

Results

Two cases of postoperative CSF leaks (9.5%) and one case of mycotic sinusitis (4.8%) occurred following the intradural (inlay) and intraextradural (inlay-overlay) graft positioning. No cases of postoperative CSF leakage occurred in cases in which the extradural-only reconstruction procedure was applied. No meningitis or other complications related to the closure were noticed.

Conclusions

The rate of postoperative CSF leakage after an extended approach to the suprasellar area is higher compared with that following standard pituitary surgery. Reconstruction after craniopharyngioma surgery exposes patients to an increased risk of postoperative CSF leaks. The extradural (overlay) technique was found to be the most effective in assuring a watertight closure.

History of endoscopic skull base surgery: its evolution and current reality

✓The history of the endoscope exemplifies the manner in which technological advances influence medicine and surgery. Endoscopic systems have evolved and improved, and they currently provide detailed visualization of a variety of deep organ structures. Otorhinolaryngological surgeons have used the endoscope for more than 30 years. In the 1990s, a number of influential neurosurgeons and otorhinolaryngological surgeons began performing purely endoscopic pituitary surgery. Endoscopic transsphenoidal operations are now extending beyond the sella. The collaboration between otorhinolaryngologists and neurosurgeons has produced a new subspecialty of “endoscopic skull base surgery.” There is a great deal of progress still to be made in developing skills, instruments, and improving skull base repair. The extended skull base approaches allow surgical exposures from the olfactory groove to C-2 and to the infratemporal region and jugular fossa laterally. This article discusses the history of the endoscope, the pivotal technological advances, and the key figures in the burgeoning field of endoneurosurgery.

Simple closure following transsphenoidal surgery

✓ The most common nonendocrine complication after transsphenoidal surgery is cerebrospinal fluid (CSF) leak. Many neurosurgeons have advocated the routine reconstruction of the floor of the sella turcica using autologous fat, muscle, fascia, and either cartilage or bone after transsphenoidal surgery to prevent postoperative CSF fistulas. However, the use of autologous grafting requires a second incision, prolongs operative time, and adds to the patient's postoperative discomfort. In addition, the presence of sellar packing may interfere with the interpretation of postoperative images. To avoid these disadvantages, the authors suggest that routine sellar reconstruction or closure after transsphenoidal surgery is unnecessary unless an intraoperative CSF leak is encountered. The incidence of postoperative CSF leakage in the patients reported on in this series is no higher than that reported by others, and no other complications such as pneu-matocele have been encountered in approximately 2700 patients in whom no intraoperative CSF leak was encountered. The authors conclude that routine closure of the floor of the sella turcica or sphenoid is unnecessary in the absence of intraoperative CSF leak.

Brief history of endoscopic transsphenoidal surgery--from Philipp Bozzini to the First World Congress of Endoscopic Skull Base Surgery

Since its inception, one of the major issues in transsphenoidal surgery has been the adequate visualization of anatomical structures. As transsphenoidal surgery evolved, technical advancements improved the surgical view of the operative field and the orientation. The operating microscope replaced Cushing's headlight and Dott's lighted speculum retractor, and fluoroscopy provided intraoperative imaging. These advances led to the modern concept of microsurgical transsphenoidal procedures in the early 1970s. For the past 30 years the endoscope has been used for the treatment of diseases of the sinus and, more recently, in the surgical treatment of pituitary tumors. The collaboration between neurological and otorhinolaryngological surgeons has led to the development of novel surgical procedures for the treatment of various pathological conditions in the skull base. In this paper the authors review the history of the endoscope--its technical development and its application--from the first endoscope described by Philipp Bozzini to the First World Congress of Endoscopic Skull Base Surgery held in 2005 in Pittsburgh, Pennsylvania. Specifically, in this review the history of endoscopy and its application in endonasal neurosurgery are presented.

Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas

OBJECT

To assess postoperative complications related to the surgical procedure, a retrospective analysis was conducted in a series of 146 consecutively treated patients who underwent an endoscopic endonasal transsphenoidal approach to the sellar region for resection of pituitary adenomas between January 1997 and July 2001.

METHODS

Complications were divided into groups (nasofacial, sphenoid sinus, sella turcica, supra or parasellar, and endocrine complications) according to the anatomical structures and the systems involved. Overall, a decreased incidence of complications has been observed, compared with large historical series of the traditional microsurgical transsphenoidal approach, likely because of the overview inside the anatomy facilitated by the endoscope, and the decreased surgical trauma.

CONCLUSIONS

Transsphenoidal surgery, either microscopic or endoscopic, is a safe procedure in experienced hands, but serious complications still occur and must be reduced as much as possible. Additional improvement can be expected with greater experience and new technical developments. A coordinated team effort with other dedicated colleagues from different specialties is advised.