Transnasal Sphenoidal Approach for Pituitary Tumor Resection: A Modern Minimally Invasive Neurosurgical Technique
Among the most advanced and widely adopted procedures in modern neurosurgery, the transnasal transsphenoidal approach has become the gold standard for pituitary tumor removal. This minimally invasive technique eliminates the need for craniotomy, significantly reducing patient trauma, hospital stay, and recovery time. By accessing the tumor through the nasal cavity, surgeons can effectively resect pituitary adenomas while preserving surrounding neural and vascular structures. The procedure is particularly beneficial for patients experiencing hormonal imbalances, vision disturbances, or headaches caused by pituitary mass effect.
Step 1: Surgical Exposure of the Pituitary Tumor
The operation begins with endonasal access—surgeons navigate through the nostril to reach the middle meatus. Using high-definition endoscopic guidance, the middle turbinate is gently displaced to expose the natural opening of the sphenoid sinus. Advanced imaging, such as intraoperative MRI or CT navigation, assists in precisely identifying anatomical landmarks.
Once the sphenoid sinus is accessed, its anterior wall is carefully opened using specialized neurosurgical drills. The mucosal lining is retracted to reveal the sella turcica—the bony structure housing the pituitary gland. A custom-designed fiber-optic drill is then used to remove the bony floor of the sella, often slightly expanded laterally to ensure optimal visualization. After exposing the dura mater, it is coagulated at the edges using bipolar electrocautery and incised in a cruciate (cross-shaped) pattern. In most cases, the underlying tumor becomes immediately visible upon dural opening.
Step 2: Tumor Removal Using Endoscopic Micro-Instruments
Most pituitary tumors are soft and highly vascular, making them amenable to suction-based resection under continuous endoscopic visualization. Surgeons utilize angled endoscopes (0°, 30°, or 45°) to view hidden compartments and ensure complete tumor clearance without damaging the optic chiasm or cavernous sinus walls.
Techniques Based on Tumor Consistency
Soft tumors: These are typically aspirated using low-pressure suction devices equipped with irrigation to maintain a clear surgical field. Continuous saline irrigation helps prevent overheating from drilling and improves visibility.
Firm or fibrous tumors: For denser lesions resistant to suction, neurosurgeons employ micro-curettes, ring dissectors, and other fine instruments designed specifically for pituitary surgery. These tools allow controlled mechanical dissection and fragmentation of the tumor into extractable pieces, minimizing traction on surrounding tissues.
In cases of hormone-secreting tumors (such as prolactinomas or growth hormone-producing adenomas), rapid removal can lead to immediate clinical improvement, including normalization of hormone levels and symptom relief.
Step 3: Reconstruction of the Skull Base
After complete tumor resection, reconstructing the sellar floor is critical to prevent cerebrospinal fluid (CSF) leaks and reduce postoperative complications like meningitis. A multilayer closure technique is commonly used to ensure durability and sealing integrity.
Materials Used in Sellar Reconstruction
Artificial dural substitutes: Synthetic grafts such as collagen matrices or synthetic dura replacements provide an initial waterproof barrier over the defect.
Autologous fat grafts: Fat tissue, usually harvested from the abdominal subcutaneous layer, is often packed into the resection cavity to fill dead space and support the graft.
Support structures: To reinforce the repair, surgeons may use autologous bone fragments, cartilage from the nasal septum, or synthetic cranial implants. In some approaches, the middle turbinate is reshaped and repositioned to act as a biological splint, promoting mucosal healing and long-term stability.
Finally, nasal packing or a nasoseptal flap may be placed to further secure the reconstruction and facilitate epithelialization. Postoperatively, patients are monitored for signs of CSF rhinorrhea, diabetes insipidus, or hormonal deficiencies, which are generally manageable with medication and close follow-up.
With ongoing advancements in endoscopic technology and surgical techniques, the transsphenoidal approach continues to offer excellent outcomes, high tumor resection rates, and improved quality of life for patients with pituitary pathology. Its minimally invasive nature, combined with rapid recovery and low complication rates, makes it a preferred choice for both neurosurgeons and patients worldwide.