Endoscopic pituitary surgery - A beginner's guide

Endonasal endoscopic surgery is now the preferred technique to tackle pituitary tumours. Our paper describes the stepwise endoscopic approach for surgeons embarking on pituitary surgery. It also highlights the common pitfalls encountered during surgery and the ways to avoid them. One must proceed in a gradual step-wise manner starting from simple exposure of the sphenoid sinus to complete endoscopic tumour removal so as to gain the neurosurgeon's confidence as well as develop our own skills, confidence and ability to tackle complications. We use the endonasal paraseptal trans-sphenoidal approach. Surgery begins with gentle packing between the middle turbinate and septum to expose the anterior sphenoid wall and expose the sphenoid ostium. The ostium is then widened inferiorly and onto the opposite side to expose both sphenoid sinuses. The inter-sphenoid sinus and necessary mucosa is removed to expose the sella. We then use a bone flap technique or punches to open the sella. After incising the dura, tumour is removed with a suction curette. An endoscope holder facilities the operation. The bone flap is replaced at the end of surgery to reconstruct the sella. This is especially important if a CSF leak is present. Nasal packing is usually not required.