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FULLY ENDOSCOPICSELLAR AND PARASELLAR
SURGERY
NOVEMBER 01, 2006
Mohamed Kabil, MD
Hrayr Shahinian, MD, FACS
presentation for
The 8th Asian Oceanian International Congress of Skull Base Surgery
Dubai, United Arab Emirates
TABLE OF CONTENTS
02 Objectives
04 Tumors/Anatomy of the Sellar region
06 Brief History
08 Advantages
10 Operation Room Setup
12 Patient Positioning
14 Operative Technique
16 Fully Endoscopic Transcranial Approaches
18 Demographic Information
20 Complication Rates
22 Summary and Conclusion
INTRODUCTION
OBJECTIVES
To compare and contrast the three different surgical approaches to the sellar region including the transcranial, transseptal transsphenoidal and the fully endoscopic endonasal approach
To describe the operative technique and our experience with the fully endoscopic endonasal approach
To display the results from our series of 1,000 patients who underwent fully endoscopic pituitary adenoma resections
To compare the outcomes and complication rates of endoscopic vs. microscopic pituitary surgery
FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY
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INTRODUCTION
TUMORS OF THE SELLAR REGIONPituitary adenomas are the most common sellar tumorsafter the age of 30 and they represent 10% of all intracranial tumors
OTHER TUMORSMay mimic pituitary tumors radiologically and clinically
Craniopharyngiomas
Meningiomas
Rathke's cleft cysts
Epidermoid tumors
Arachnoid cyst
Carotid aneurysms
Others
ANATOMY OF THE SELLAR REGION
FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY
004
INTRODUCTION
BRIEF HISTORY
Transcranial, 1889, Victor Horsley
Transseptal Transsphenoidal, 1909, Harvey Cushing (Schloffler, Kanavel, Halstead, Hirsch, and others)
Microsurgical transsphenoidal, 1970s, Jules Hardy
Early trials with the endoscope, 1970’s – 1990’s (Guiot, Apuzzo, others)
MODERN ENDOSCOPIC PITUITARY SURGERY
Early 1990s, Endoscope-Assisted,
(Including a series of patients at the SBI
demonstrated 33-49% residual tumor
only recognized with the endoscope)
Fully Endoscopic
OPEN TRANSCRANIAL
FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY
006
FULLY ENDOSCOPIC
THE FULLY ENDOSCOPIC ENDONASAL APPROACH
ADVANTAGES
A completely endonasal approach A targeted approach A more clear visualization - Contact anatomy
A panoramic view - Angled endoscopes A more complete operation leading to a lower rate of recurrence
FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY
008
FULLY ENDOSCOPIC ENDONASAL APPROACH
010
FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY
OPERATION ROOM SETUP
THE FULLY ENDOSCOPIC ENDONASAL APPROACH
014
FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY
OPERATIVE TECHNIQUE
THE FULLY ENDOSCOPIC ENDONASAL APPROACH
016
FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY
FULLY ENDOSCOPIC TRANSCRAIAL APPROACHES
TRANSGLABELLAR SUPRAORBITAL SUBTEMPORAL
Feature Number
Total number of Patients 1000
Age (years) Mean Range
45
16 - 78
Sex: F:M 1.6:1
Prior Pituitary Surgery 157
LOS (days) Mean Range
1.3
1 - 4
Follow-up period (months) Mean Range
46.8
2 - 94
DEMOGRAPHIC INFORMATION(November 1998 - October 2006)
ENDOSCOPIC VS. MICROSCOPIC APPROACH
018
FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY
TUMOR CHARACTERISTICS
Tumor type
Tumor Type and Grade Number of Patients (%)
Nonfunctioning Adenoma 511 (51)
Functioning Adenoma 489 (49)
PRL Adenoma 221 (22)
GH Adenoma 158 (16)
ACTH Adenoma 110 (11)
Tumor Grade
Enclosed 481 (48)
I: Sella normal or focally expanded tumor < 10mm 259 (26)
II: Sella enlarged or tumor > 10mm 222 (22)
Invasive 519 (52)
III: Localized perforation of sellar floor 218 (22)
IV: Diffuse destruction of sellar floor 301 (30)
Massive Supra and parasellar extensions 192 (19)
Compression of optic chiasm 314 (31)
Cavernous Sinus invasion 292 (29)
ENDOSCOPIC VS. MICROSCOPIC APPROACH
FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY
ENDOSCOPIC VS. MICROSCOPIC APPROACH
020
COMPLICATION RATES
Complication (%) Endoscopic Microscopic a
Ant. Pit. Insufficiency 2.1 19.4
Diabetes Insipidus 2.5 17.8
Carotid Injury 0 1.1
CNS Injury 0 0.6
Intrasellar Hemorrhage 0.4 2.9
Cerebrospinal Fluid Leak 0.7 3.9
Postoperative epistaxis 0.6 10
Meningitis 0 1.5a. Results of a national survey (Ciric et al., 1997)
Reference: Kabil MS, Eby JB, Shahinian HK: Fully Endoscopic Endonasal vs. Transseptal Transsphenoidal Pituitary Surgery. Minim Invasive Neurosurg. 2005 Dec; 48(6):348-54. (An earlier series, 300 patients)
Reference: Kabil MS, Eby JB, Shahinian HK: Fully Endoscopic Transnasal vs. Transseptal Transsphenoidal Pituitary Surgery. Neurosurg. Q 15(3):2005. (An earlier series, 300 patients)
FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY
SUMMARY AND CONCLUSION
SUMMARY
Endoscopy provides distinct advantages over microscopy
Allows for focus on preserving neurological function and reducing morbidity
Modern pituitary surgery has few complications and requires only a short hospitalization
CONCLUSION
Skull base surgery has benefited significantly from advances in biotechnology
Impact upon the efficacy of tumor resection and subsequent rates of recurrence is significant
New stereoscopic endoscopes
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FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY
