Endoscopy and Transsphenoidal Surgery

SPECIAL ARTICLE

ENDOSCOPY AND TRANSSPHENOIDAL SURGERY

Paolo Cappabianca, M.D.Neurosurgery Unit, Department ofNeurological Sciences, Universitàdegli Studi di Napoli “Federico II,”Naples, Italy

Enrico de Divitiis, M.D.Neurosurgery Unit, Department ofNeurological Sciences, Universitàdegli Studi di Napoli “Federico II,”Naples, Italy

Reprint requests:Paolo Cappabianca, M.D.,Department of NeurologicalSciences, Università degli Studi diNapoli “Federico II,” via S. Pansini5, 80131 Naples, Italy.Email: [email protected]

Received, October 9, 2003.

Accepted, December 22, 2003.

ENDOSCOPY OFFERS INTERNAL visualization of many different cavities of thehuman body, with its specific vision inside the anatomy, close to the target area. Theview of the surgical field in transsphenoidal surgery had been obtained with the nakedeye from its beginning in 1907 up to the introduction of the operating microscope byJules Hardy in the 1960s, which represented a great advance in terms of magnificationand illumination. In the past decade, modern rigid endoscopes, with their wider viewnear the relevant anatomy, have permitted minimally traumatic transsphenoidal pro-cedures in and around the sellar area, thus representing a “new wave” in transsphe-noidal history. An overview of the evolution of the endoscope as a visualizing andoperating instrument particularly related to the transsphenoidal approach is presentedhere. The current possibilities of transsphenoidal endoscopy, with its related advan-tages and limitations, are presented.

KEY WORDS: Endoscope, Neuroendoscopy, Transsphenoidal surgery

Neurosurgery 54:1043-1050, 2004 DOI: 10.1227/01.NEU.0000119325.14116.9C www.neurosurgery-online.com

Transsphenoidal surgery is a milestone ofmodern and contemporary neurosur-gery in the treatment of pituitary tumors

and related lesions of the sellar area. Its evo-lution has taken advantage of many of thetechnological advances produced over theyears, among them the endoscope. Transsphe-noidal surgery performed with the aid of anendoscope has developed rapidly in recentyears, and many centers are now performing“pure” or endoscope-assisted transsphenoidalapproaches. We think an overview of the roleof the endoscope in pituitary surgery, fromthe first attempts to the current techniques,may be useful.

Philipp Bozzini (1773–1809), a 32-year-oldGerman physician, developed the idea of en-tering the human body through natural ori-fices or small incisions to perform an internalvisualization. In 1806, he introduced the con-cept of dilating natural cavities to obtain bet-ter visualization and to gain a wider space forsurgery. He created the first endoscope usinglight directed through small mirrors placed atan angle of 45 degrees (9). Around 1877, MaxNitze (1849–1906) greatly improved previousdevices and constructed an instrument for re-moval of bladder stones (he called it a “cysto-scope”) that was made of a series of lensesinside a metallic tube, coupled with a lightsource at its distal end (69). There were other

important stages in technical and instrumentalevolution, but the contribution of Harold H.Hopkins, a British professor of physics at theUniversity of Reading between 1940 and 1950,is the foundation of the current standard ofendoscopy. With the help of Karl Storz (1911–1996) in the 1960s, he pioneered the revolu-tionary cylindrical rod lens endoscopes andfiberoptic bundles that permitted the substan-tial improvement in illumination and imageresolution that is offered by rigid endoscopesused in transsphenoidal surgery, amongmany other endoscopic procedures. Endos-copy offers visualization actually inside theanatomy, close to the surgical target, and withpanoramic views, thanks to the available an-gled scopes.

Between the end of the 1800s and the begin-ning of the 1990s, endoscopy enjoyed a re-markable success among general surgeons; itwas used initially for diagnosis and later foroperations. Neuroendoscopy was born in1910, when Victor Darwin Lespinasse, a urol-ogist from Chicago, performed the first ven-tricular endoscopy and coagulation of the cho-roid plexus for treatment of hydrocephalus,which was not published in the scientific lit-erature but was reported at a local medicalsociety (26). But the pioneer of neuroendos-copy, along with many other innovative neu-rosurgical procedures, was Walter E. Dandy

NEUROSURGERY VOLUME 54 | NUMBER 5 | MAY 2004 | 1043

(1886–1946). He planned to extirpate the choroid plexus underdirect visualization, using a nasal speculum and ultimately a“ventriculoscope” to inspect the ventricles, to treat communi-cating hydrocephalus (23, 24). The neuroendoscopic method,after a few other experiences, then entered a dark period,related primarily to inadequate instrumentation and later, inthe 1970s and 1980s, to the widespread adoption of microsur-gery, which offered neurosurgeons great new advances interms of illumination and magnification of the surgical field.The 1990s brought major progress in technology applied toendoscopy and renewed interest in various cranial and spinalendoscopic procedures, including transsphenoidal surgery,thanks to the contributions of American, Australasian, andEuropean schools. The ongoing evolution in neuroendoscopyhas been possible because of improved diagnostic techniques,improved anatomic knowledge, and refined neurosurgical in-strumentation (34).

Other technical advances, particularly the development ofthe computer chip television video camera in 1986 (77), theso-called “charged coupled device” (CCD) camera, contrib-uted to the explosion of endoscopy, primarily in laparoscopicsurgery. This became possible with the improvement of illu-mination from the original candlelight or sunlight of Bozzini’sera to the recent xenon cold light sources and many otherdevices used in each kind of endoscopic procedure. As amatter of fact, endoscopic surgery can be compared to a chaindrive or to a clock organism, in which every single componenthas to work well, because it influences all the others, and hasto be perfectly integrated with all the remaining componentsof the system to reach optimal overall performance. The re-sulting quality of vision and of surgical intervention dependson the endoscope used (usually rigid, with 0-, 30-, or 45-degreeangled lenses, as appropriate to the different phases of theapproach), on the light source, on the camera (mono or mul-tiple CCD) and the related monitor and video recording unit(preferably a real-time complete digital system), and on thesurgical instruments, permitting safe and effective manipula-tion in all of the areas visible by means of the endoscope (62).

Transsphenoidal surgery, which is the procedure used inthe vast majority of lesions of the sellar area, began with theanatomic studies of the Italian surgeon Davide Giordano inthe late 1800s (6, 37) through a direct transfacial approach andwas performed for the first time on a patient by the Viennesesurgeon Herman Schloffer in 1907 (64). The operation wasthen refined to a transnasal submucosal resection of the nasalseptum, conceived by Kocher in 1909 (60), and a sublabialoronasal approach, favored by Halstead (41) and Cushing (21),in 1910. The contributions of several surgeons were critical inthe development and diffusion of the procedure, and twomain technical contributions, image intensification and fluo-roscopy, introduced by Gerard Guiot (39), and the use of theoperating microscope by Jules Hardy (42), determined itsultimate success.

The surgical environment of the transsphenoidal route isexactly what an endoscope requires, i.e., a natural cavity,which usually does not need to be dilated but only entered.

This is what Guiot et al. (40) recognized in the 1960s, with theirendoscopic exploration of the sellar contents in the course of aclassic transsphenoidal approach. This can be considered thebeginning of endoscope-assisted microneurosurgery in trans-sphenoidal surgery, to expand the field of vision, by means ofthe endoscope, to areas that were previously visually inacces-sible. Apuzzo et al. (5) and Bushe and Halves (10) in the 1970squickly captured this concept, adding a dimension of safetyand precision to the procedure. Subsequently, the confidencewith the endoscope reached by the otorhinolaryngologists inthe field of endoscopic sinus surgery was complemented bythe work of neurosurgeons using the endoscope during tradi-tional transsphenoidal microsurgery, providing new interestin the techniques in the 1990s (8, 31, 33, 36, 44, 45, 55, 63, 76,81). Today, these methods find increasing acceptance.

The other concept of the use of an endoscope in the trans-sphenoidal route is as a stand-alone visualizing and operatinginstrument, i.e., pure endoscopic transsphenoidal surgery,which can be performed in several different ways (via anendonasal or transnasal approach, via one or two nostrils,with or without an endoscope holder or a nasal speculum) (7,20, 22, 27, 43, 44, 47, 71, 72, 74, 78, 80). The endoscopes used arerigid diagnostic scopes with 0-degree and angled lenses (30 or45 degrees). Some authors have reported the use of flexibleendoscopes (56), as used previously in the ventricular system(35), to complement the microscope or the rigid endoscope invisualization during or after tumor removal in particular con-ditions, primarily in narrow lateral or suprasellar areas (34).The most established methodologies, standardized in clinicalpractice, can be considered those of the forerunner of thisapproach, Jho et al. (51), and that described by us (13, 29). Itconsists of an endoscopic endonasal unilateral approach, per-formed via an anterior sphenoidotomy through the sphenoidostium, without a nasal speculum, which permits wide visu-alization of the sphenoid sinus (with the optocarotid protu-berances laterally, the sphenoid planum above, and the clivusbelow), of the sella, and of the suprasellar and parasellar areas(by means of angled scopes), without the use of postoperativenasal packing (Figs. 1 to 3). This approach, in particular, ismore direct and provides the surgeon with an excellent viewof the surgical field with a better identification of many sur-gical landmarks, together with a wide working angle (75). It isversatile, permitting even more limited and minimal ap-proaches and, conversely, allowing for extended surgery inthe suprasellar, parasellar, and cranial base regions for theremoval of craniopharyngiomas, Rathke’s cleft cysts, tubercu-lum sellae meningiomas, or clivus chordomas or the sealing ofanterior cranial base cerebrospinal fluid leaks (19, 28, 32). It isminimally traumatic, permits easier reoperations (12, 68) orintentionally two-staged operations (67), and is very well ac-cepted by patients because of the minimal postoperativetrauma and discomfort (12). In our series of 146 consecutivelytreated patients operated on by means of an endoscopic en-donasal transsphenoidal approach for pituitary adenomas be-tween January 1997 and July 2001, we have experienced alower complication rate and a reduction of cosmetic and func-

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tional disabilities, compared with large historical series oftranssphenoidal microsurgery cases (16), as well as a shorterhospital stay.

The “overview” facilitated by the endoscope, with its widerworking angle, together with the narrower surgical corridorand the absence of the need for a nasal speculum, creates adifferent set of working conditions, with a diminished work-ing channel to the sella (73). This requires the specific skill ofthe endoscopic surgeon, a clear-cut learning curve, and thecreation of refined dedicated instruments (11, 15), some ofwhich are still being developed. In our opinion, there are twopotential problems or limitations with endoscopic pituitarysurgery: 1) The working channel to the sella is different anddiminished, requiring first of all a specific skill, which will bemore easily acquired by the new generations with respect toexperienced microsurgeons. The use of dedicated instrumentsmakes the surgical procedure easier and more effective, as forany other operation. The use of a transsphenoidal speculummight represent a valid alternative to obtain an enlargedworking channel and to allow transsphenoidal microsurgeonsto confidently manage the endoscope, with its advantages ofwider vision, close to the surgical target. 2) There may beprofuse bleeding, which can make surgery troublesome ordisappointing. This problem requires strict cooperation withthe anesthesiologist and underlines the need to always be able

FIGURE 1. A, drawing of lateral view of the surgical field during tradi-tional transsphenoidal microsurgery with the nasal speculum; B, lateralview of the surgical field during endoscopic transsphenoidal surgery; C,frontal view of the surgical field during traditional transsphenoidal micro-surgery with the nasal speculum; D, frontal view of the surgical field dur-ing endoscopic transsphenoidal surgery. Note the difference in the viewingangle, which is much wider in transsphenoidal endoscopy. SS, sphenoidsinus; PG, pituitary gland; DS, dorsum sellae; ICA, internal carotidartery; CAV SIN, cavernous sinus.

FIGURE 2. Endoscopic view of the sphenoid ostium, reached with thesimple introduction of the endoscope into the nasal cavity (right nostril).It provides entrance to a very wide surgical target area. SO, sphenoid osti-um; ST, superior turbinate.

FIGURE 3. Panoramic view inside the sphenoid sinus after the enlarge-ment of the natural ostium (A); closer view of the optocarotid recess (B).*, sphenoid septum; SF, sellar floor; C, clivus; PS, planum sphenoidale;CP, carotid protuberance; OCR, optocarotid recess; OP, opticprotuberance.



to work with two hands, one holding a suction device and theother using a different instrument. For this purpose, an ade-quate enlargement of the sphenoid ostium area for 1.5 to 2 cmis very important so as to have a favorable working angle in alldirections and to allow maneuvering of two instruments plusthe endoscope, fixed to its holder.

Concerning the vision provided by a monocular device, i.e.,the endoscope, compared with the binocular microscope, wedo not consider the endoscopic bidimensional vision lackingin depth of field. The depth of field is located in the mind ofthe neurosurgeon; specifically, it derives from the in-and-outmovements of the scope aimed at locating the many anatomiclandmarks the endoscope shows, most of them stable or evenfixed, such as the bony protuberances of the posterior wall ofthe sphenoid sinus. The vision provided by the scope is closerto the target and much wider, and the depth of field is verysimilar to what we can comprehend on a photographic image,because of its lights and shadows and the protrusions anddepressions visible on the two dimensions of the picture. Thebinocular microscope provides an excellent but restricted fieldof vision, at a given focal distance from the target, with a veryeffective depth of field. The two kinds of vision are different,each with its respective advantages and disadvantages.

We think that there are particular conditions in which eachtechnique, transsphenoidal microsurgery and transsphenoidalendoscopy, may respectively be of greater effectiveness (i.e.,traditional microsurgery in the management of conchal-typesphenoid sinus or of a very small sella; endoscopy in recurrentpituitary adenomas [12]). Furthermore, there is not a neces-sary difference between a microsurgeon and an endoscopicsurgeon; it is rather a neurosurgeon using one or the otherinstrument according to his or her personal experience andconcepts and according to the actual situation, which differsfrom case to case. Both endoscopy and microsurgery allow aneffective transsphenoidal procedure that minimizes functionaland esthetic problems compared with those of the transcranialapproach and its related brain retraction. The microscope hasbeen essential in the development of a reliable procedure, withexcellent-quality optical images, good depth of field, and com-fortable surgical access because of the transsphenoidal retrac-tor, but at a constrained focal distance from the target. Theendoscope offers the opportunity for less intraoperativetrauma and detailed inspection of the anatomy near the site ofsurgery, but it requires a specific set of endoscopic skills thatare not immediately acquired. Conversely, despite recent pre-liminary reports of initial series of pure endoscopic transsphe-noidal surgery (17, 49, 50, 68), conclusive results from this newprocedure in terms of completeness of lesion removal, recur-rence rate, and endocrinological cure are not yet available,delaying a truly objective judgment. We think it is necessary toteach the younger generation to perform both methods, per-haps the endoscopic technique first, because a beginner willnot experience great difficulty starting with the endoscope ifhe or she has performed adequate dissection studies and ismentored by an experienced neurosurgeon.

In our opinion, endoscopy in transsphenoidal surgery rep-resents a “new wave” that has produced a true “transsphe-noidal renaissance,” for five main reasons:

1. It has designed and favored the possibility of “minimallyinvasive transsphenoidal surgery,” through the adoption of anendonasal approach, which was originally proposed by Griffithand Veerapen (38) and has been adopted extensively by bothendoscopic surgeons and microsurgeons (8, 70, 82). Because theoperation effectively starts at the sphenoid sinus level, upper lipcomplications do not occur and nasal complications are greatlyreduced. These advantages should be added to the wider viewoffered by the scope and to the possibility of wider movements ofthe instruments, particularly in the lateral direction, because ofthe absence of the speculum.

2. It has promoted new anatomic studies to thoroughlyinvestigate the possibilities and the limits related to the tran-snasal approach to the cranial base (1–4, 14, 25, 28, 30, 75; LMCavallo, P Cappabianca, R Galzio, G Iaconetta, E de Divitiis, MTschabitscher, submitted for publication).

3. It has favored close interdisciplinary cooperation in theclinical management of the patient and in surgical practice,thus opening new modern perspectives in cranial basesurgery.

4. It has given new impetus to extended cranial base ap-proaches to the parasellar and suprasellar regions (2, 18, 19, 32,48, 52, 57), already managed transsphenoidally in some cen-ters (61, 65, 79) after the pioneer work presented in the liter-ature by Weiss in 1987 (79) about suprasellar transsphenoidalsurgery, and has competed with microsurgical progress, re-sulting in excellent publications (46, 53, 54, 58, 59, 66).

5. It has renewed the positive interaction between scientificmedical innovations and technological industries aimed atimproving existing tools and producing new, ever more effec-tive devices.

Further progress is obviously expected in endoscopic trans-sphenoidal surgery because of technological developmentsand scientific contributions. The next steps are linked to on-going work in intraoperative magnetic resonance imaging androbotics, which already exist in some advanced units; theminiaturization of the optical systems in terms of “chip-sticktechnology” (i.e., miniaturized computer-based cameras heldin the operating area by thin supports); and the cooperationamong different technologies and industries. We cannot reallysay what is around the corner: endoscope-assisted transsphe-noidal microsurgery or “pure” endoscopic transsphenoidalsurgery, without or with the nasal speculum. We can state thatthe work in this field will offer the surgeon additional possi-bilities and the capacity to work with more effectiveness andsafety, will provide improved results to patients, and is al-ready demonstrating the success of contemporary medicine inreaching its goals with minimal invasiveness, which is one ofthe intriguing aspects of “minimalism” in neurological sur-gery. The future will certainly show a combined action ofscientists, engineers, and physicians, with ultrastructural pre-cision at a molecular level. Where the neurosurgeons will be,



together with their endoscopes, is hard to foresee, and wehope to be there to tell the story.

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AcknowledgmentThis work was supported in part by Grant 2003068735 from the Italian

Ministry of University and Research, Rome.

COMMENTS

As Cappabianca and de Divitiis demonstrate in this excel-lent overview, endoscopy has indeed come a long way

since 1806 and has helped transform neurosurgical thinkingabout the possibilities of transsphenoidal surgery. Not onlydoes the endoscope facilitate a minimally invasive transsphe-noidal approach with few postoperative rhinological prob-lems, but it also provides visualization and access to intracra-nial regions that are simply not possible with the tunnel visionafforded by the operating microscope. As one who was ini-tially reluctant and skeptical about the usefulness of the en-doscope and who still routinely performs endonasal pituitarysurgery with the microscope, I have become dependent onangled endoscopes for certain transsphenoidal cases. In thesesituations, the endoscope and the microscope are entirelycomplementary, both being required but at different stages ina given procedure. In particular, the endoscope is extremelyhelpful and perhaps essential for the safe and effective re-moval of certain tumors, including tuberculum sellae menin-giomas, suprasellar craniopharyngiomas, suprasellar and pre-pontine epidermoid tumors, and fibrous macroadenomas withlarge suprasellar extensions.

Although endoscopic technology has evolved significantlyin recent years, there is still room for improvement. Mostimportantly, endoscope optics could be further refined, and



the scope itself often interferes with the manipulation of otherinstruments. Using one instrument alongside the endoscope isgenerally not a problem. However, if, for instance, a suctiontip and a ring curette are introduced down the speculumalongside the endoscope, the scope greatly limits the degreesof freedom of the other two instruments, making instrumentmanipulations difficult and often ineffective. We may hopethat these technical limitations will be overcome or minimizedin the near future. For the present, it is clear that the endo-scope has become an essential tool that has greatly extendedthe surgical horizon of transsphenoidal surgery.

Daniel F. KellyLos Angeles, California

The authors offer a very nice review of the development ofendoscopic techniques from their inception to the present

state of technology. For the most part, they are very objectivein assessing the value and place of endoscopic surgery inneurosurgery today. However, they probably short-changemicrosurgery a bit in terms of its well-established position inneurosurgery in general and in transsphenoidal microsurgeryin particular. For example, the authors describe endoscopictechniques as being less invasive. They support this statementby insisting that endoscopic surgery begins in the depth of thenasal cavity in front of the sphenoid rostrum and also thatthere is no need for packing the nasal cavities. They alsosuggest that the sublabial approach is associated with agreater degree of discomfort and possible side effects andcomplications. Some of this is true, and some of it is not. Ithink that the sublabial microsurgical approach has beenlargely abandoned by the majority of pituitary surgeons. In-deed, transsphenoidal microsurgery also starts in the depth ofthe nasal cavity just anterior to the sphenoid rostrum. Inaddition, there is no need to pack the nose at the completionof a microsurgical procedure. In short, I really do not believethat the patient-related outcomes are very different betweenan endonasal-transsphenoidal microsurgery and an endonasalendoscopic surgery, as long as they are both performed withattention to sound anatomic concepts, correct techniques, etc.In short, I do not believe that the transsphenoidal endoscopicsurgery is experienced by the patient as being less invasivecompared with modern microsurgical techniques. In addition,although the authors correctly emphasize the advantages ofendoscopic surgery, especially the panoramic view and theability to visualize structures beyond the direct line of vision,they do not sufficiently emphasize the main advantage ofmicrosurgery, most notably, the ability to visualize the oper-ative field in three dimensions. To my thinking, this is a hugeadvantage of microsurgery compared with endoscopic sur-gery. I could not agree more with the authors, however, whenthey state that microsurgery and endoscopic surgery shouldbe not mutually exclusive but rather complementary, so thatthe advantages of both can be applied to the benefit of thepatient. Finally, it has always been my own bias that “surgical

minimalism” is not always synonymous with minimally inva-sive surgery.

Ivan S. CiricEvanston, Illinois

In this article, Cappabianca and de Divitiis discuss the history ofneuroendoscopy with an emphasis on the evolution of endo-

scopic transsphenoidal surgery. This group has a significant andpreviously documented track record in endoscopic endonasal sur-gery. Despite their own personal bias toward this approach, theyhave presented a well-balanced, well-written article on the topic. Asthey rightly discuss, even though endoscopy applied to neurosur-gical disease might be considered the “new kid on the block,” it hasbeen around for the major part of the previous century. There is noquestion that the optics of the rigid lens may offer some advantagesover the microscope in certain situations. These would include thewider viewing angle and the ability to see around corners usingangled endoscopes, the high magnification, and the superior illumi-nation. Furthermore, the endoscope is an excellent teaching tool forboth the established surgeon and the surgeon in training. There arealso unique disadvantages of the endoscope, such as the clear learn-ing curve, an additional instrument within an already small opera-tive field, and problems associated with keeping the lens clean. Theincreasingly popular endonasal approach to gain access to the sphe-noid sinus, whether microsurgical or endoscopic, in our experience,obviates some of the previous nasal-related complications of thesublabial or anterior rhinoseptal incision. These postoperative com-plications, such as septal perforations, nasal deformities, and dentalsequelae, are sometimes not recognized by the neurosurgeon butare not infrequently discovered by our otolaryngology colleagues.

We would agree that traditional microsurgical strategies andendoscopy both have roles in the treatment of sellar and parasellarprocesses. Sometimes these roles are dictated by the surgeon’s per-sonal experience or bias, and other times they are self-evident. It isimportant that we keep an open mind when incorporating thesenew technologies into our work, and we must be creative whenlooking for future applications. There is no doubt that we are cur-rently only scratching the surface of what will be possible down theroad. Most importantly, it is incumbent upon us to define theadvantages of each technique objectively in terms of surgical out-come and complication prevention.

Wesley KingKalmon D. PostNew York, New York

In this article, the authors clearly present the case for a technicaladvance in the management of tumors in and around the sella.

The endoscopic approach has matured during the past few years,and its clear virtues are emphasized in this article. After a helpfulhistorical introduction, the authors provide a great deal of wis-dom based on their own extensive experience with purely endo-scopic approaches to the sella. They have done a fine job withthis, and it is essentially certain that the use of the endoscope forpituitary surgery will become more and more common andincreasingly effective as time goes by. These conclusions are



particularly important for young neurosurgeons, who should beencouraged to adopt and to learn this exciting minimally inva-sive surgical technique.

Edward R. Laws, Jr.Charlottesville, Virginia

Cappabianca and de Divitiis have presented an excellentreview of the evolution and application of endoscopic

techniques to the performance of transsphenoidal surgery.Since the pioneering work of Huw Griffith in Bristol, we haveseen major advances in the application of this technology tovarious neurosurgical procedures, and it is now apparent thatendoscopic resection of pituitary and sellar lesions is an effec-tive technical modality. We should all recognize the contribu-tions of Dr. Jho and Dr. Cappabianca to this field, and it isincumbent upon devotees of this surgical arena to develop thisexpertise. It is clear that there are specific advantages to eachof the currently popular approaches to the sellar, sublabialtranssphenoidal, microscopic endonasal, and endoscopic en-donasal areas. The ability to successfully resect ever morecomplicated lesions in this area is dramatically enhanced bythe application of these techniques, which now must be con-sidered standard components of our surgical armamentarium.

Martin H. WeissLos Angeles, California

In this article, Cappabianca and de Divitiis have made aneloquent plea for the possibility of endoscopic surgery for

transsphenoidal resection. Their article describes to some ex-tent the history of this technique and the theoretical reasonsfor its use. However, it may be some time before this tech-nique can be accepted as the standard of care for these tumors.Perhaps most importantly, there have been no studies thatsuggest that it is superior to the traditional endonasal micro-surgical approach. It would be critical to examine the degreeof resection, length of stay in the hospital, complication rate,and time and charges for this surgery to make this claim.

Perhaps the most difficult problem is that endoscopy re-quires an expertise that is slightly foreign to most neurosur-geons. The claim that endoscopic surgery is superior to endo-nasal surgery is sometimes seen as a marketing device to try tochange traditional patterns of referral for pituitary surgery.For these reasons, I believe that the position that Cappabiancaand de Divitiis espouse here must be taken with considerablecare. It may be that endoscopic transsphenoidal surgerywill be the future of this field, but the present pattern is not inthat direction. Perhaps this article will begin to change thatsituation.

Peter McL. BlackBoston, Massachusetts

The Agnew Clinic (oil on canvas, 1889) by Eakins (courtesy of the University of Pennsylvania Collection of Art, Philadelphia).


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Endoscopy and Transsphenoidal Surgery