Pituitary Tumor Surgery: A Comprehensive Guide to Endoscopic Transsphenoidal Resection

Modern surgical treatment for pituitary tumors has evolved significantly, with the endoscopic transsphenoidal approach now considered the gold standard. This minimally invasive technique allows neurosurgeons to access the tumor through the nasal cavity, avoiding external incisions and reducing patient recovery time. Using high-definition endoscopes, surgeons navigate through one or both nostrils, carefully reaching the sphenoid sinus. The natural anatomy of the nasal passages is preserved as much as possible, minimizing trauma and postoperative discomfort.

Step-by-Step Surgical Procedure

1. Accessing the Sphenoid Sinus

The procedure begins by identifying and gently dilating the opening of the sphenoid sinus. Specialized instruments are used to move aside mucosal tissue without causing damage. Once the sphenoid sinus is exposed, its walls are carefully opened using a precision fiber drill designed specifically for neurosurgery. This step requires meticulous attention to avoid injuring surrounding critical structures such as the carotid arteries and optic nerves.

2. Exposing the Sellar Floor

After removing the bony barrier of the sellar floor (the roof of the pituitary fossa), the underlying dura mater becomes visible. Under continuous visualization via the endoscope, the dura is incised in a cruciate (cross-shaped) pattern at the midline. In most cases, this reveals the tumor mass, which typically protrudes into the surgical field due to its growth within the confined space of the sella turcica.

Tumor Removal and Preservation of Critical Structures

Most pituitary adenomas are soft and easily aspirated. Once a tissue sample is collected for pathological analysis, the bulk of the tumor is gently suctioned out using fine surgical tools. A key priority during resection is preserving healthy pituitary tissue, the pituitary stalk (infundibulum), suprasellar arachnoid membranes, and the diaphragma sellae. Protecting these elements helps maintain hormonal function and reduces the risk of complications such as cerebrospinal fluid (CSF) leaks.

Managing Larger Tumors and Preventing CSF Leaks

In patients with large or giant adenomas, the diaphragma sellae is often stretched or ruptured preoperatively, increasing the likelihood of intraoperative or postoperative CSF leakage. To address this, surgeons perform a multilayered reconstruction of the skull base. This involves using a combination of materials such as synthetic dural substitutes, autologous fascia (often harvested from the thigh), and sometimes fat grafts to create a watertight seal.

Final Steps: Closure and Recovery

Following complete tumor removal and secure reconstruction, the nasal cavity and sphenoid sinus are packed with absorbable materials to support healing and prevent early displacement of the graft. No external nasal packing is typically required, enhancing patient comfort. Postoperatively, patients are monitored closely for signs of infection, hormonal imbalances, or CSF rhinorrhea. Most individuals experience a relatively quick recovery, with hospital discharge often occurring within 2–3 days.

This advanced endoscopic approach not only improves surgical precision but also enhances patient outcomes by minimizing invasiveness, reducing complication rates, and supporting faster return to normal activities. As technology and techniques continue to advance, transsphenoidal surgery remains at the forefront of effective pituitary tumor management.