FULLY ENDOSCOPIC

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FULLY ENDOSCOPIC SELLAR 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
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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
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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

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INTRODUCTION

• TUMORS OF THE SELLAR REGION
• Pituitary adenomas are the most common sellar
  tumors
• after the age of 30 and they represent 10 of all
  
• intracranial tumors
• OTHER TUMORS
• May mimic pituitary tumors radiologically and
  clinically
• Craniopharyngiomas
• Meningiomas
• Rathke's cleft cysts
• Epidermoid tumors
• Arachnoid cyst
• Carotid aneurysms

• ANATOMY OF THE SELLAR REGION

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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, 1970s
  1990s
• (Guiot, Apuzzo, others)
• MODERN ENDOSCOPIC PITUITARY SURGERY
• Early 1990s, Endoscope-Assisted,
• (Including a series of patients at the SBI
• demonstrated 33-49 residual tumor

• OPEN TRANSCRANIAL

FULLY ENDOSCOPIC
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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 ENDONASAL APPROACH

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THE FULLY ENDOSCOPIC ENDONASAL APPROACH
OPERATION ROOM SETUP
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THE FULLY ENDOSCOPIC ENDONASAL APPROACH
OPERATIVE TECHNIQUE
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FULLY ENDOSCOPIC TRANSCRAIAL APPROACHES
TRANSGLABELLAR
SUPRAORBITAL
SUBTEMPORAL

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ENDOSCOPIC VS. MICROSCOPIC APPROACH
DEMOGRAPHIC INFORMATION (November 1998 - October
2006)
Feature Number
Total number of Patients 1000
Age (years) Mean Range
Age (years) Mean Range 45
Age (years) Mean Range 16 - 78
Sex FM 1.61
Prior Pituitary Surgery 157
LOS (days) Mean Range
LOS (days) Mean Range 1.3
LOS (days) Mean Range 1 - 4
Follow-up period (months) Mean Range
Follow-up period (months) Mean Range 46.8
Follow-up period (months) Mean Range 2 - 94
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ENDOSCOPIC VS. MICROSCOPIC APPROACH
TUMOR CHARACTERISTICS
Tumor type Tumor Type and Grade Number of Patients ()
Tumor type Nonfunctioning Adenoma 511 (51)
Tumor type Functioning Adenoma 489 (49)
Tumor type PRL Adenoma 221 (22)
Tumor type GH Adenoma 158 (16)
Tumor type ACTH Adenoma 110 (11)
Tumor Grade Enclosed 481 (48)
Tumor Grade I Sella normal or focally expanded tumor lt 10mm 259 (26)
Tumor Grade II Sella enlarged or tumor gt 10mm 222 (22)
Tumor Grade Invasive 519 (52)
Tumor Grade III Localized perforation of sellar floor 218 (22)
Tumor Grade IV Diffuse destruction of sellar floor 301 (30)
Massive Supra and parasellar extensions Massive Supra and parasellar extensions 192 (19)
Compression of optic chiasm Compression of optic chiasm 314 (31)
Cavernous Sinus invasion Cavernous Sinus invasion 292 (29)
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ENDOSCOPIC VS. MICROSCOPIC APPROACH
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 1.5
a. 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)
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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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