Transsphenoidal Surgery Complication Avoidance and

Management Techniques

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Preface

Over the past decade, there have been significant advances in the field of transsphe-
noidal surgery. Among the most notable is the steady advancement of this funda-
mental concept in approaching a variety of anterior skull base lesions. The
advancements in this field have resulted from improved preoperative and intraop-
erative radiological imaging, enhanced microsurgical and endoscopic techniques,
refinements in the delivery of ionizing radiation including stereotactic radiosurgery,
a more thorough understanding of tumor biology, and development of medical
approaches predicated on the underlying tumor biology. These are essential aspects
of modern skull base surgery and have become a major focus of collegial interdisci-
plinary efforts.
The overall aim of the current work was to detail contemporary clinical knowl-
edge and multidisciplinary approaches for management of patients harboring pitu-
itary adenomas and other types of sellar and parasellar tumors. Many of the chapters
focus on surgical techniques, and particular emphasis is placed not only on the
advantages and disadvantages of a particular approach, but on methods to avoid
complications. The anatomic complexities of the sellar and parasellar area make
this one of the most challenging regions for delivering therapeutic interventions.
Even the best devised therapeutic plans can at times fail and thereby necessitate that
the successful clinician and surgeon must possess an exquisite understanding of
complication recognition and management.
The book spans topics that range from the history of pituitary surgery and the
transsphenoidal approach to the quality of life assessments, so important to our
patients. Intervening chapters focus on preoperative assessment and planning, intra-
operative techniques, postoperative management, and adjuvant therapy for those
patients with recurrent or residual disease. The majority of the chapters contain
illustrations which we believe the readers will find invaluable. The diversity of the
topics also underscores the multidisciplinary team approach essential to successful
management of this patient group.
Each chapter is written by widely recognized and established experts in the field.
Importantly, the contributors share many “pearls” of wisdom gained over decades of
clinical experience. It is from our patients that we learn and perfect the indications
and limitations of our methods, and for that, we owe our patients tremendous grati-
tude and respect. We truly value the substantial contributions to the creation of this
multiauthored work. The professional editorial efforts of Springer, including that of

v
vi Preface

project manager Kevin Wright, have been indispensable On a personal note, we

wish to thank our families for their support throughout this project. They have dem-
onstrated tremendous understanding of our time spent writing and editing this text.
Without the help of so many, this project could not have been brought to fruition.

Charlottesville, VA, USA Jason P. Sheehan

Indianapolis, IN, USA Aaron A. Cohen-Gadol
New York, NY, USA Theodore H. Schwartz
Boston, MA, USA Edward R. Laws, Jr.
Contents

1 Evolution of Pituitary Surgery and the Transsphenoidal

Approach��������������������������������������������������������������������������������������������������    1
Luke Smith, Gautam U. Mehta, and Russell R. Lonser
2 The History of Trans-sphenoidal Surgery for Pituitary
Tumours����������������������������������������������������������������������������������������������������   11
James A.J. King and Andrew H. Kaye
3 Principles and Pitfalls of Anesthesia for Transsphenoidal
Surgery������������������������������������������������������������������������������������������������������   27
Lauren K. Dunn and Edward C. Nemergut
4 Operative Indications and Pitfalls in Patient Selection
for Surgery of Pituitary Tumors ������������������������������������������������������������   43
Chikezie Eseonu, Christina Jackson, and Alfredo Quinones-Hinojosa
5 The Perioperative and Postoperative Care for Pituitary
Patients������������������������������������������������������������������������������������������������������   59
Saira Khan and Roberto Salvatori
6 Neuro-ophthalmology of Pituitary Tumors �������������������������������������������� 71
Robert M. Mallery and Sashank Prasad
7 Rhinologic Evaluation of Patients Undergoing
Transsphenoidal Surgery������������������������������������������������������������������������   87
Michael Freeman, Jose Gurrola II, and Spencer C. Payne
8 Imaging of the Sella and Parasellar Region������������������������������������������   95
Amar P. Patel, Vivek P. Patel, and Max Wintermark
9 Classification, Pathobiology, Molecular Markers,
and Intraoperative Pathology ���������������������������������������������������������������� 113
M. Beatriz S. Lopes
10 Surgical Anatomy of the Sellar Region�������������������������������������������������� 145
Nathan T. Zwagerman, Stefan Lieber, and Juan C. Fernandez-Miranda

vii
viii Contents

11 Combined Hybrid Microscopic and Endoscopic Transsphenoidal

Surgery: Anatomy, Instrumentation, and Technique �������������������������� 167
David S. Baskin and Robert A. Scranton
12 Transcranial Approaches to the Sellar and Parasellar Areas�������������� 191
Bradley N. Bohnstedt, Todd Eads, Jonathan Weyhenmeyer,
and Aaron A. Cohen-Gadol
13 Endoscopic Transsphenoidal Surgery: Anatomy,
Instrumentation, and Technique������������������������������������������������������������ 213
Paolo Cappabianca, Luigi Maria Cavallo, Domenico Solari,
and Alberto di Somma
14 Three-Dimensional Endoscopy for Skull Base Surgery ���������������������� 233
Jason K. Chu, Brandon A. Miller, and Nelson M. Oyesiku
15 Endoscopic Transsphenoidal Pituitary Surgery: Results
and Complications ���������������������������������������������������������������������������������� 245
Harminder Singh, Walid I. Essayed, Ibrahim Hussain,
Kryscilla Yang, Vijay K. Anand, and Theodore H. Schwartz
16 Intraoperative Imaging for Pituitary Surgery�������������������������������������� 259
Peter T. Sylvester and Michael R. Chicoine
17 The Role of Endoscopic Transsphenoidal Surgery
in the Management of Complex Lesions Involving
the Skull Base ������������������������������������������������������������������������������������������ 277
James K. Liu, Eleonora F. Spinazzi, Jean Anderson Eloy,
and William T. Couldwell
18 Closure Methods Following Transsphenoidal Surgery������������������������ 303
Paul A. Gardner, Carl H. Snyderman, Juan C. Fernandez-­Miranda,
and Eric W. Wang
19 Complications with Transsphenoidal Surgery: A Review�������������������� 315
Garni Barkhoudarian and Daniel F. Kelly
20 Rhinological Complications: Avoidance and Management������������������ 345
Gustavo J. Almodovar-Mercador, Theodore H. Schwartz,
and Vijay K. Anand
21 Medical Management for Pituitary Adenoma Patients������������������������ 359
Gregory K. Hong
22 Transsphenoidal Surgery for Recurrent Pituitary Disease������������������ 383
Joshua Bakhsheshian and Gabriel Zada
23 Transsphenoidal Surgery for Craniopharyngiomas���������������������������� 403
Kenneth Foxx, Stephen Sandwell, Howard Silberstein,
G. Edward Vates, Matthew Miller, Ismat Shafiq,
Ekaterina Manuylova, and Laura Calvi
Contents ix

24 Transsphenoidal Surgery for Cushing’s Disease���������������������������������� 427

Kalmon D. Post, Margaret Pain, Hekmat Zarzour,
and Joshua Bederson
25 Transsphenoidal Surgery for Acromegaly �������������������������������������������� 441
Edward R. Laws Jr., David J. Cote, and Sherry Iuliano
26 Transsphenoidal Surgery for Prolactinomas���������������������������������������� 457
Won Kim, Srinivas Chivukula, Anthony Heaney,
Marilene Wang, and Marvin Bergsneider
27 Transsphenoidal Surgery for Nonfunctioning
Pituitary Adenomas �������������������������������������������������������������������������������� 471
Sarah T. Menacho and Ian E. McCutcheon
28 Pituitary Tumors in Pediatric Patients�������������������������������������������������� 487
Robert F. Dallapiazza and John A. Jane Jr.
29 Pituitary Apoplexy ���������������������������������������������������������������������������������� 499
Patrick M. Flanigan, Arman Jahangiri, Han S. Lee,
and Manish K. Aghi
30 Anatomical Approaches to Giant Pituitary Tumors ���������������������������� 517
André Beer-Furlan, Ralph Abi-Hachem, Ali O. Jamshidi,
Ricardo L. Carrau, and Daniel M. Prevedello
31 Postoperative Management of Patients Following
Transsphenoidal Surgery������������������������������������������������������������������������ 531
Martin J. Rutkowski and Sandeep Kunwar
32 Stereotactic Radiosurgery for Pituitary Adenomas������������������������������ 539
Cheng-Chia Lee and Jason P. Sheehan
33 Radiation Therapy for Pituitary Tumors���������������������������������������������� 559
Trevor J. Royce, Jay S. Loeffler, and Helen A. Shih
34 Cytotoxic Chemotherapy and Targeted Therapy
for Aggressive Pituitary Tumors������������������������������������������������������������ 581
Alissa A. Thomas and Camilo E. Fadul
35 Quality of Life in Patients with Pituitary Adenomas���������������������������� 595
Douglas A. Hardesty and Andrew S. Little

Index�������������������������������������������������������������������������������������������������������������������� 611
Contributors

Ralph Abi-Hachem, MD The Ohio State University Wexner Medical Center,

Department of Neurological Surgery, Columbus, OH, USA
Manish K. Aghi, MD, PhD Neurological Surgery, University of California at San
Neurological Surgery Francisco, San Francisco, CA, USA
Vijay K. Anand, MD, FACS Department of Otolaryngology—Head and Neck
Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, Weill
Medical College of Cornell University, New York, NY, USA
Joshua Bakhsheshian, MD, MS Department of Neurological Surgery, Keck
School of Medicine, University of Southern California, Los Angeles, CA, USA
Garni Barkhoudarian, MD Pacific Pituitary Disorders Center, John Wayne
Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA, USA
David S. Baskin, MD, FACS, FAANS Professor, Vice Chair, and Program
Director, Department of Neurosurgery, Houston Methodist Institute, Houston, TX,
USA
Director, Department of Neurosurgery, Kenneth R. Peak Brain and Pituitary Tumor
Treatment Center, Houston Methodist Neurological Institute, Houston, TX, USA
Joshua Bederson, MD Department of Neurosurgery, Mount Sinai School of
Medicine, New York, NY, USA
André Beer-Furlan, MD The Ohio State University Wexner Medical Center,
Department of Neurological Surgery, Columbus, OH, USA
Marvin Bergsneider, MD Department of Neurosurgery, David Geffen School of
Medicine at UCLA, Los Angeles, CA, USA
Bradley N. Bohnstedt, MD Department of Neurosurgery, Oklahoma University
Health Sciences Center, Oklahoma City, Oklahoma, USA
Laura M. Calvi, MD Department of Neurosurgery, University of Rochester
Medical Center, Rochester, NY, USA

xi
xii Contributors

Paolo Cappabianca, MD Division of Neurosurgery, Department of Neurosciences,

Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli
“Federico II”, Naples, Italy
Ricardo L. Carrau, MD The Ohio State University Wexner Medical Center,
Department of Neurological Surgery, Columbus, OH, USA
Luigi Maria Cavallo, MD, PhD Division of Neurosurgery, Department of
Neurosciences, Reproductive and Odontostomatological Sciences, Università degli
Studi di Napoli “Federico II”, Naples, Italy
Michael R. Chicoine, MD Department of Neurological Surgery, Washington
University School of Medicine, St. Louis, MO, USA
Srinivas Chivukula, MD Department of Neurosurgery, David Geffen School of
Medicine at UCLA, Los Angeles, CA, USA
Jason K. Chu, MD, MSc Department of Neurosurgery, Emory University, Atlanta,
GA, USA
Aaron A. Cohen-Gadol, MD, MSc Department of Neurosurgery, Indianapolis
Methodist Hospital, Indianapolis, IN, USA
William T. Couldwell, MD, PhD Department of Neurosurgery, University of
Utah, Salt Lake City, UT, USA
David J. Cote, BS Department of Neurosurgery, Harvard Medical School, Brigham
and Women’s Hospital, Boston, MA, USA
Robert F. Dallapiazza, MD, PhD Department of Neurosurgery, University of
Virginia Health System, Charlottesville, VA, USA
Lauren K. Dunn, MD, PhD University of Virginia, Department of Anesthesiology,
Charlottesville, VA, USA
Todd Eads, MD Department of Neurological Surgery, Goodman Campbell Brain
and Spine, Indiana University, Indianapolis, Indiana, USA
Jean Anderson Eloy, MD Department of Neurological Surgery, Rutgers New
Jersey Medical School, Newark, NJ, USA
Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey,
Rutgers New Jersey Medical School, Newark, NJ, USA
Department of Otolaryngology-Head & Neck Surgery, Rutgers New Jersey, New
Jersey Medical School, Newark, NJ, USA
Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical
School, Newark, NJ, USA
Chikezie Eseonu, MD Johns Hopkins Hospital, Neurosurgery, Baltimore, MD,
USA
Contributors xiii

Walid I. Essayed, MD Department of Neurosurgery, Brigham and Women’s

Hospital, Boston, MA, USA
Camilo E. Fadul, MD, FAAN Department of Neurology, University of Virginia,
Charlottesville, VA, USA
Juan C. Fernandez-Miranda, MD Department of Neurological Surgery,
University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Patrick M. Flanigan, BS Cleveland Clinic Lerner College of Medicine, Cleveland,
OH, USA
Kenneth Foxx, MD Neurosurgery Resident PGY-5, University of Rochester
Medical Center, Rochester, NY, USA
Michael Freeman, BS University of Virginia School of Medicine, Charlottesville,
VA, USA
Sarah T. Menacho, MD University of Texas MD Anderson Cancer Center,
Department of Neurosurgery, Houston, TX, USA
Paul A. Gardner, MD Department of Neurological Surgery, University of
Pittsburgh School of Medicine, Pittsburgh, PA, USA
Jose Gurrola II, MD Department of Otolaryngology, Head & Neck Surgery,
University of Virginia School of Medicine, Charlottesville, VA, USA
Douglas A Hardesty, MD Department of Neurosurgery, Barrow Neurological
Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
Anthony Heaney, MD, PhD Department of Medicine, David Geffen School of
Medicine at UCLA, Los Angeles, CA, USA
Alfredo Quinones-Hinojosa, MD Mayo Clinic Neurosurgery, Jacksonville, FL,
USA
Gregory K. Hong, MD, PhD Division of Endocrinology, Department of Medicine,
University of Virginia Health System, Charlottesville, VA, USA
Ibrahim Hussain Department of Neurosurgery, Weill Cornell Medical College,
New York Presbyterian Hospital, New York, NY, USA
Sherry Iuliano, MSN, NP-C Department of Neurosurgery, Harvard Medical
School, Brigham and Women’s Hospital, Boston, MA, USA
Christina Jackson, MD Johns Hopkins Hospital, Neurosurgery, Baltimore, MD,
USA
Arman Jahangiri, BS University of California at San Francisco, Neurological
Surgery, San Francisco, CA, USA
Ali O. Jamshidi, MD The Ohio State University Wexner Medical Center,
Department of Neurological Surgery, Columbus, OH, USA
xiv Contributors

John A. Jane Jr., MD Department of Neurosurgery, University of Virginia Health

System, Charlottesville, VA, USA
Andrew H. Kaye Department of Neurosurgery, The Royal Melbourne Hospital,
Melbourne, Australia
James A.J. King Department of Neurosurgery, The Royal Melbourne Hospital,
Melbourne, Australia
Won Kim, MD Department of Neurosurgery, David Geffen School of Medicine at
UCLA, Los Angeles, CA, USA
Daniel F. Kelly, MD Pacific Pituitary Disorders Center, John Wayne Cancer
Institute at Providence Saint John’s Health Center, Santa Monica, CA, USA
Saira Khan, MD Division of Endocrinology, Department of Medicine, and
Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, MD,
USA
Sandeep Kunwar, MD California Center for Pituitary Disorders, Department of
Neurological Surgery, University of California, San Francisco, CA, USA
Sarah T. Menacho, MD University of Utah, Department of Neurosurgery, Salt
Lake City, UT, USA
Edward R. Laws, Jr., MD, FACS, FAANS Department of Neurosurgery, Harvard
Medical School, Brigham and Women’s Hospital, Boston, MA, USA
Cheng-Chia Lee, MD Department of Neurosurgery, University of Virginia,
Charlottesville, VA, USA
Han S. Lee, MD, PhD University of California at San Francisco, Neurological
Surgery, San Francisco, CA, USA
Stefan Lieber, MD Department of Neurological Surgery, University of Pittsburgh
Medical Center, Pittsburgh, PA, USA
Andrew S. Little, MD Department of Neurosurgery, Neuroscience Publications,
Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix,
AZ, USA
James K. Liu, MD Department of Neurological Surgery, Rutgers New Jersey
Medical School, Newark, NJ, USA
Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey,
Rutgers New Jersey Medical School, Newark, NJ, USA
Department of Otolaryngology-Head & Neck Surgery, Rutgers New Jersey, New
Jersey Medical School, Newark, NJ, USA
Jay S. Loeffler, MD Harvard Medical School, Department of Radiation Oncology,
Massachusetts General Hospital, Boston, MA, USA
Russell R. Lonser, MD Department of Neurological Surgery, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
Contributors xv

M. Beatriz S. Lopes, MD, PhD Department of Pathology, University of Virginia

School of Medicine and Health System, Charlottesville, VA, USA
Ekaterina Manuylova, MD Department of Medicine, University of Rochester
Medical Center, Rochester, NY, USA
Robert M. Mallery, MD Division of Neuro-Ophthalmology, Department of
Neurology, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA,
USA
Ian E. McCutcheon, MD University of Texas, Anderson Cancer Center,
Neurosurgery, Houston, TX, USA
Gustavo J. Almodovar-Mercador, MD Weill Cornell Medical College, New York
Presbyterian Hospital, Weill Medical College of Cornell University,
Otolaryngology—Head and Neck Surgery, New York, NY, USA
Matthew Miller, MD, FACS Department of Otolaryngology, University of
Rochester Medical Center, Rochester, NY, USA
Department of Neurosurgery, University of Rochester Medical Center, Rochester,
NY, USA
Brandon A. Miller, MD, PhD Department of Neurosurgery, Emory University,
Atlanta, GA, USA
Gautam U. Mehta, MD Surgical Neurology Branch, National Institute of
Neurological Disorders and Stroke, Bethesda, MD, USA
Edward C. Nemergut, MD University of Virginia Health System, Department of
Anesthesiology, Charlottesville, VA, USA
Nelson M. Oyesiku, MD, PhD Department of Neurosurgery, Emory University,
Atlanta, GA, USA
Sashank Prasad, MD Division of Neuro-Ophthalmology, Department of
Neurology, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA,
USA
Amar P. Patel, MD Department of Radiology, Neuroradiology Division, Stanford
University School of Medicine, Stanford, CA, USA
Margaret Pain, MD Department of Neurosurgery, Mount Sinai School of
Medicine, New York, NY, USA
Vivek P. Patel, MD, PhD Department of Radiology, Stanford University School of
Medicine, Stanford, CA, USA
Spencer C. Payne, MD Department of Otolaryngology, Head & Neck Surgery,
Division of Allergy & Clinical Immunology, University of Virginia School of
Medicine, Charlottesville, VA, USA
Kalmon D. Post, MD Department Neurosurgery, Mount Sinai School of Medicine,
Mount Sinai Health System, New York, NY, USA
xvi Contributors

Daniel M. Prevedello, MD The Ohio State University Wexner Medical Center,

Department of Neurological Surgery, Columbus, OH, USA
Trevor J. Royce, MD, MS Harvard Medical School, Department of Radiation
Oncology, Massachusetts General Hospital, Boston, MA, USA
Martin J. Rutkowski, MD Department of Neurological Surgery, University of
California, San Francisco, San Francisco, CA, USA
Stephen Sandwell, MD Neurosurgery Resident PGY-6, University of Rochester
Medical Center, Rochester, NY, USA
Roberto Salvatori, MD Division of Endocrinology, Department of Medicine, and
Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, MD,
USA
Theodore H. Schwartz Department of Neurosurgery, Weill Cornell Medical
College, New York Presbyterian Hospital, New York, NY, USA
Robert A. Scranton, MD Kenneth R. Peak Brain and Pituitary Tumor Treatment
Center and Department of Neurosurgery, Houston Methodist Neurological Institute,
Houston, TX, USA
Harminder Singh, MD Department of Neurosurgery, Stanford University Medical
Center, Stanford, CA, USA
Jason P. Sheehan, MD, PhD Department of Neurological Surgery, University of
Virginia, Charlottesville, VA, USA
Department of Radiation Oncology, University of Virginia, Charlottesville, VA,
USA
Ismat Shafiq, MD Department of Medicine, University of Rochester Medical
Center, Rochester, NY, USA
Department of Neurosurgery, University of Rochester Medical Center, Rochester,
NY, USA
Helen A. Shih, MD, MS, MPH Harvard Medical School, Department of Radiation
Oncology, Massachusetts General Hospital, Boston, MA, USA
Howard Silberstein, MD, FACS Department of Neurosurgery, University of
Rochester Medical Center, Rochester, NY, USA
Luke Smith, MD Department of Neurological Surgery, The Ohio State University
Wexner Medical Center, Columbus, OH, USA
Carl H. Snyderman, MD, MBA University of Pittsburgh School of Medicine,
Otolaryngology and Neurological Surgery, Pittsburgh, PA, USA
Domenico Solari, MD, PhD Division of Neurosurgery, Department of
Neurosciences, Reproductive and Odontostomatological Sciences, Università degli
Studi di Napoli “Federico II”, Naples, Italy
Contributors xvii

Alberto Di Somma, MD Division of Neurosurgery, Department of Neurosciences,

Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli
“Federico II”, Naples, Italy
Eleonora F. Spinazzi, BA Department of Neurological Surgery, Rutgers New
Jersey, New Jersey Medical School, Newark, NJ, USA
Peter T. Sylvester, MD Department of Neurological Surgery, Washington
University School of Medicine, St. Louis, MO, USA
Alissa A. Thomas, MD Department of Neurology, University of Vermont College
of Medicine, Burlington, VT, USA
G. Edward Vates, MD, PhD, FACS Center for Translational Neuromedicine,
University of Rochester Medical Center, Rochester, NY, USA
Eric W. Wang, MD University of Pittsburgh School of Medicine, Otolaryngology,
Pittsburgh, PA, USA
Marilene Wang, MD Department of Head and Neck Surgery, David Geffen
School of Medicine at UCLA, Los Angeles, CA, USA
Jonathan Weyhenmeyer, MD Neurosurgery Resident, Goodman Campbell Brain
and Spine, Indiana University School of Medicine, Indianapolis, IN, USA
Max Wintermark, MD, MAS, MBA Department of Radiology, Neuroradiology
Division, Stanford University School of Medicine, Stanford, CA, USA
Kryscilla Yang, MD Baystate Health, Springfield, MA, USA
Gabriel Zada, MD, MS Neuro-Oncology and Endoscopic Pituitary/Skull Base
Program, Keck School of Medicine, University of Southern California, Los Angeles,
CA, USA
Hekmat Zarzour, MD Department of Neurosurgery, Jefferson University
Hospital, Philadelphia, PA, USA
Nathan T. Zwagerman, Department of Neurological Surgery, University of
Pittsburgh Medical Center, Pittsburgh, PA, USA
Evolution of Pituitary Surgery
and the Transsphenoidal Approach 1
Luke Smith, Gautam U. Mehta, and Russell R. Lonser

Introduction

Although pituitary surgery via the transsphenoidal approach has been performed for
over a century, it has only gained widespread acceptance over the past 50 years.
As various advances in illumination and magnification through microscopic and
endoscopic approaches have improved the safety and efficacy of this technique, it
has become the workhorse approach for surgery on the pituitary gland. Further
advances, including better understanding of pituitary adenoma biology and improved
reconstruction techniques, have extended the utility of this approach to treatment of
pathology beyond the sella turcica and its contents. We review the history of pituitary
surgery with an emphasis on advances with the transsphenoidal approach.

Early Approaches to the Pituitary

The first recorded surgical approach to the pituitary was performed by Sir Victor
Horsley of London in 1889 for pituitary tumor in a patient with visual deficits [24].
Horsley was able to access the pituitary gland using a subfrontal approach, but did
not attempt to extirpate the tumor after identifying the tumor as a malignancy with
poor prognosis. Early subsequent attempts at transcranial approaches were met
with little success and carried high risk of mortality. Caton and Paul, on the advice
of Horsley, performed a temporal decompression for a patient with acromegaly.

L. Smith, MD • R.R. Lonser, MD (*)

Department of Neurological Surgery, The Ohio State University Wexner Medical Center,
Columbus, OH, USA
e-mail: [email protected]
G.U. Mehta, MD
Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke,
Bethesda, MD, USA

© Springer International Publishing AG 2017 1

E.R. Laws, Jr. et al. (eds.), Transsphenoidal Surgery,
DOI 10.1007/978-3-319-56691-7_1
2 L. Smith et al.

The pair performed a craniotomy to relieve intracranial pressure causing severe pain
and distress in the patient. However, the patient was considered too debilitated by
her disease to be considered for a surgical resection of her pituitary tumor and died
3 months later of causes that were not mentioned by Caton [5]. With improving
surgical conditions at the beginning of the twentieth century, Horsley reported ten
operations, using a subtemporal approach, on pituitary tumors with a mortality rate
of only 20% [24]. In 1905, Fedor Krause operated on a patient with visual loss using
an extradural frontal approach to expose a parasellar “fibrosarcoma” [33]. This
would serve as a basis for future transcranial efforts to the sella.
In 1906, a more direct route to the sella turcica was described by Hermann
Schloffer. By performing a lateral rhinotomy, reflecting the nose and resecting the
turbinates, septum, and sinus walls, Schloffer was able to approach the pituitary
gland and partially resect adenoma directly through the sphenoid sinus [41]. He did
so without entering the cranial vault, establishing the transsphenoidal approach.
A similar operation for a patient with acromegaly was performed by Anton von
Eiselberg, later in 1907 [43]. Further improvement of this approach was achieved
by Theodor Kocher. While Kocher was awarded the Nobel Prize in 1909 for his
work on surgery of the thyroid gland, he made critical contributions to the refine-
ment of the transsphenoidal approach to the sella. This included a submucosal-
sublabial variation of the transsphenoidal approach, reducing the cosmetic morbidity
of the approach [31]. Inferior nasal variations, which presaged currently used tech-
niques, were described by Oskar Hirsch and Albert Halstead [16, 23]. These subla-
bial, endonasal transsphenoidal approaches were adopted by Harvey Cushing and
used in more than 200 patients with a mortality rate of 6% (Fig. 1.1) [40].
After systematically characterizing and treating many patients with pituitary
disease, Cushing became an authoritative figure on this subject. Therefore, when he
abandoned the transsphenoidal approach in favor of the transfrontal route, the

Fig. 1.1 Cushing’s

sublabial approach [7]
1 Evolution of Pituitary Surgery and the Transsphenoidal Approach 3

majority of the neurosurgical community followed. He cited improved ability to

decompress the optic apparatus as the rationale for the transcranial approach [40].
Work by George J. Heuer to establish a frontotemporal craniotomy further popular-
ized this approach to pituitary pathology [22]. Because the transsphenoidal approach
was limited by poor illumination down the long, narrow operative corridor, Norman
Dott (a Cushing trainee), who continued to practice the transsphenoidal approach,
developed lighted retractors [10]. Dott taught his improved transsphenoidal
approach to Gerard Guiot, a French neurosurgeon. Guiot further improved the
transsphenoidal approach by using fluoroscopy to confirm instrument trajectory
during surgery [21]. Guiot taught the approach to Jules Hardy, who would later re-­
popularize transsphenoidal surgery. Hardy applied the operative microscope to pitu-
itary surgery via the transsphenoidal approach, resolving the challenges of poor
illumination and magnification (Fig. 1.2) [17–19].
Hardy described this marriage of microneurosurgery and the transsphenoidal
approach [27]:

My contribution, I think, is when I started to use the surgical microscope, which was an old
ENT microscope. And I began to watch carefully what I was doing into the sella and I found
that we could identify the normal gland embedded within the mass of tumor tissue. In the
past … most agreed that it was impossible to distinguish between normal [gland] and
tumor. And whenever we make a sellar cleanout, we remove everything, and all patients
would develop panhypopituitarism. With the help of the surgical microscope, we could
identify [the pituitary gland]. And that was the first step that I started to claim that we could
do selective tumor removal with identification and preservation of the normal gland.

Prior to Hardy’s achievement, pituitary surgery was synonymous with total

hypophysectomy. The magnification and microneurosurgical techniques introduced

Fig. 1.2 Illustration of Hardy’s operative setup of the operative microscope in combination with
radiofluoroscopy [19]
4 L. Smith et al.

Fig. 1.3 Illustration of the transsphenoidal approach via a sublabial incision as described by Jules
Hardy. (a) Incision for the sublabial approach. (b) Nasal Mucosa elevation. (c) Submucosal dissec-
tion. (d) Excision of the septum. (e) Submucosal dissection via sagittal view. (f) View after intro-
duction of the speculum. (g) Positioning of the speculum via Jules Hardy’s approach [19]

by Hardy allowed for surgery within the pituitary gland itself, including selective
adenomectomy of endocrine-active microadenomas (Fig. 1.3) [20]. This significant
advance coincided with improvements in exogenous hormone replacement that
greatly reduced the morbidity of pituitary surgery, which led to more widespread