ENDOSCOPIC TRANSSPHENOIDAL PITUITARY SURGERY//CASE PRESENTATION

Steps of Endoscopic Transsphenoidal Pituitary Surgery

1. Preoperative Preparation
• Imaging: MRI (sellar, parasellar, suprasellar), CT scan (bony anatomy).
• Hormonal profile: Prolactin, cortisol, GH, TSH, ACTH, etc.
• ENT and neurosurgical evaluation.
• Lumbar drain: Occasionally used if high risk of CSF leak.
• Antibiotic prophylaxis.

2. Patient Positioning
• Supine, head slightly extended.
• Head fixed in a Mayfield clamp or horseshoe headrest.
• Neuronavigation system may be used.

3. Nasal Phase (Approach to Sphenoid Sinus)
• Endoscopic entry via one nostril (uninasal) or both (binostril technique).
• Lateralize the middle turbinate gently.
• Identify landmarks:
• Sphenoid ostium
• Superior turbinate
• Nasal septum
• Posterior septectomy may be performed for better access.
• Preserve nasoseptal flap (Hadad flap) if a CSF leak is anticipated.

4. Sphenoid Phase (Opening the Sphenoid Sinus)
• Enlarge sphenoid ostium bilaterally.
• Remove intersphenoid septum(s) carefully (may attach to carotid protuberance).
• Identify landmarks inside sphenoid sinus:
• Sella turcica floor
• Optic nerve prominence
• Carotid artery protuberance
• Planum sphenoidale

5. Sellar Phase (Exposure of Pituitary Fossa)
• Remove the sellar floor bone using a Kerrison punch or diamond burr.
• Open sellar dura cruciately or linearly under neuronavigation guidance.
• Take care to avoid cavernous sinus injury.

6. Tumor Removal
• Use suction + ring curettes to debulk tumor.
• Remove soft adenomas piecemeal.
• For fibrous tumors, microdissectors are used.
• Inspect cavity endoscopically for residual tumor.

7. Hemostasis and Reconstruction
• Control bleeding using bipolar cautery or hemostatic agents.
• If CSF leak present:
• Use nasoseptal flap (Hadad flap)
• Gelfoam, fat graft, or fascia lata patch
• Close sphenoid sinus partially with packing.

8. Postoperative Care
• Keep head elevated.
• Monitor for:
• CSF leak
• Diabetes insipidus (polyuria, hypernatremia)
• Hypopituitarism
• Visual changes
• Nasal packing removed after 24–48 hrs.
• MRI follow-up at 3 months.
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