endoscopic pituitary surgery

1. ENDOSCOPIC PITUITARY
SURGERY
Dr ajay kumar
Mch neurosurgery, bin kolkata

2. • The pituitary gland (master gland) is an
endendocrine gland that sits at the base of
the brain synthesizes and releases various
hormones that affect several organs
throughout the body.
• The pituitary gland is entirely ectodermal in
origin the adenohypophysis (anterior
pituitary) and the neurohypophysis (posterior
pituitary).

3. Anatomy
• Pituitary gland is pea-sized and weighs approximately
0.5 g. The adenohypophysis constitutes roughly 80% of
the pituitary . The release of these pituitary hormones
is mediated by hypothalamic neurohormones that are
secreted from the median and that reach the
adenohypophysis via a portal venous system.
• neurohypophysis is not glandular and does not
synthesize hormones. It is a site where axons project
from neuronal cell bodies in the supraoptic and
paraventricular nuclei of the hypothalamus.

4. • The pituitary gland is enveloped by dura and sits within
the sella turcica of the sphenoid bone.
• The sella turcica is a saddle-shaped depression that
surrounds the inferior, anterior, and posterior aspects
of the pituitary. The superior aspect of the pituitary is
covered by the diaphragma sellae, which is a fold of
dura mater that separates the cerebrospinal fluid–filled
subarachnoid space from the pituitary.
• The infundibulum pierces the diaphragma sellae in
order to connect the pituitary to the hypothalamus.

5. • The lateral aspects of the pituitary are
adjacent to the cavernous sinuses . From
superior to inferior, the cavernous sinus
contains cranial nerves III (oculomotor), IV
(trochlear), VI (abducens), V1 (ophthalmic
branch of trigeminal nerve), and V2 (maxillary
branch of trigeminal nerve). The internal
carotid artery also courses through the
cavernous sinus.

8. • Different pneumatization patterns of the sphenoid sinus (conchal,
presellar, sellar, and postsellar) describe the location of the sphenoid sinus
relative to the sella turcica and thus dictate the extent of exposure of the
sellar floor. In the conchal type, pneumatization is absent, and thus the
sphenoid sinus does not contain an air cavity. In the presellar type, there is
minimal posterior extension of an air cavity, whereas in the postsellar
type, there is posterior extension of an air cavity past the level of the sella
turcica.
• Vasculature
• The adenohypophysis receives the majority of its blood supply from the
paired superior hypophyseal arteries B/O internal carotid artery .
• The neurohypophysis is supplied by the inferior hypophyseal arteries.
which arises from the cavernous portion of the internal carotid artery.

10. • The hypophyseal portal veins drain the
primary capillary plexus formed by the
superior hypophyseal arteries, which deliver
blood to the pars distalis. The pars distalis in
turn houses the secondary capillary plexus.
Thus, a portal venous system allows delivery
of hypothalamic prohormones to the
adenohypophysis, and the neurohypophysis
secretes hormones directly into the venous
draining system of the pituitary.

15. • PITUITARY LESIONS
MANAGEMENT OPTIONS
SURGERY
CRANIOTOMY
SUBLABIAL
MICROSCOPIC TRANSSEPTAL
ENDESCOPIC TRANSSPHENOIDAL
GAMMA KNIFE
OBSERVATION

16. • INDICATION
• Hormone-secreting tumors not responding to medical
line of treatment or when there is no appropriate
medical treatment
• Nonhormone-secreting tumors. Leading topressure
symptoms or evidence of compression of surrounding
structures(optic chiasma,cavernous sinus)
• Pt who developed side effects of medical treatment.
• Cancerous tumors.
• Pt with sings of pituitary insufficiency.

17. • Endoscopic trans sphenoid surgery has evolved over
past several decades, because of advances in
technology have been the catalyst for minimally
invasive surgery.
• less invasive approach ,such as transnasal approach
with endoscopic resection of tumor and the completely
endoscopic techinique have less morbidity and shorter
hospital stay then traditional sublabial approaches

18. Endoscopic pituitary surgery is step 1
or 2 from learning curve of skull base
surgeries,it is considered one of the
most reliable routs for treatment of
pituitary surgeries.

19. • Endoscope
• Endoscope opens hidden parts
• The manipulation of endoscope is better than
microscope
• The revolution in technology made
magnificent picture with very high
differentiation.
• Minimally invasive

20. Made possible by advances in endoscopic
technology
• Endoscopes(3/30) – Varying widths and angles of
view
• Cameras HD – Three chip, Digital, Three
dimensional
• Light Sources – Halogen, Metal Halide, Xenon
• Recorders/Processors – Digital, Real Time
• Irrigation Sheaths
• Holding Arms

21. • Other equipment
Pneumatic holder
Nevigation system
CUSA
MR intraoperative

22. • Endoscope allows for clear visualization of
pituitary gland, hypophyseal stalk, cavernous
sinuses, and optic nerves.
• Angled endoscopes enable visualization of
lateral recesses and suprasellar areas.

23. ENDOSCOPIC FULLY
ENDOSCOPIC ENDONASAL
APPROACH
ENDONASAL APPROACH
• ENDOSCOPIC ENDOSANAL APPROACH

24. Fully Endoscopic Transnasal-
Transsphenoidal Pituitary Adenoma
Resection

25. • Endoscopic endonasal surgery was first
described in 1910 concurrently by Harvey
Cushingand Oskar Hirsch. This procedure
allows access to the sellar space, or sella
turcica.. The surgeon starts with the
transnasal approach prior to using the
transsphenoidal approach. This allows access
to the sphenoid ostium and sphenoid sinus.
The sphenoid ostium is located on the
anterosuperior surface of the sphenoid sinus

26. • . The anterior wall of the sphenoid sinus and
the sphenoid rostrum is then removed to
allow the surgeon a panoramic view of the
surgical area.

27. • This procedure also requires the removal of
the posterior septum to allow the use of both
nostrils for tools during surgery. There are
several triangles of blood vessels traversing
this region, which are just very delicate areas
of blood vessels that can be deadly if
injured. A surgeon uses stereotactic imaging
and a micro Doppler to visualize the surgical
field.

28. • The invention of the angled endoscope is used to go beyond
the sella to the suprasellar region. This is done with the addition of
four approaches.
• First the transstuberculant and transplanum approaches are used to
reach the suprasellar cistern.
• The lateral approach is then used to reach the medialcavernous
sinus and petrous apex.
• Lastly, the inferior approach is used to reach the superior clivus. It
is important that the Perneczky triangle is treated carefully. This
triangle has optic nerves, cerebral arteries, the third cranial nerve,
and the pituitary stalk. Damage to any of these could provide a
devastating post-surgical outcome.

29. • A safer operation:
Improved visualization of surrounding optic
bulbs, brainstem, and carotid prominences.
Improved ability to differentiate tumor from
normal pituitary tissue
Completely transnasal approach avoids the risk of
naso-oral fistulae, and lip numbness seen with
the transseptal approach.

30. • A more complete operation:
Improved visualization sellar and parasellar
tumor extension, should result in a lower
recurrence rate, as demonstrated by our early
results.

31. • Minimally invasive approach allows for a
more rapid recovery with less post-operative
discomfort:
Most patients discharged within 48 hours.
Completely endonasal approach avoids the
need for post-operative nasal packing.

32. • COMPLICATIONS
• CSF rhinorrhea. In some cases, another surgery
may be needed to repair this leak.
• Meningitis. . It is more common if the CSF leaks.
• Damage to normal parts of the pituitary gland.
• Diabetes insipidus.
• Severe bleeding. Heavy and persistent bleeding
into the brain or from the nose may occur if a
large blood vessel is damaged during surgery.
• Visual problems.

38. Continued research into improved medical and
surgical treatment of pituitary adenomas:
• New 3-dimensional endoscopes
• Animal models using fetal pituitary cell
transplantation

39. THANK YOU