Transnasal Pituitary Tumor Removal: A Step-by-Step Guide to Endoscopic Surgery

Understanding Transsphenoidal Surgery for Pituitary Adenomas

Pituitary tumors, though often benign, can significantly impact hormonal balance and overall health. One of the most effective and minimally invasive treatments available today is transnasal endoscopic surgery—also known as endoscopic transsphenoidal surgery. This advanced technique allows neurosurgeons to remove pituitary adenomas through the nose, avoiding external incisions and reducing recovery time. Below is a detailed breakdown of the surgical process, updated with modern practices and patient-centered insights.

Preoperative Preparation and Anesthesia

General anesthesia is essential for this procedure, ensuring the patient remains completely unconscious and pain-free throughout the operation. Once anesthesia is administered, the patient is positioned in a supine (lying on the back) position with the head stabilized using a specialized head holder. This secure positioning allows for precise navigation during the delicate stages of surgery.

Nasal Access and Initial Visualization

Before entering the nasal cavity, the surgical site is thoroughly sterilized and draped to maintain a sterile field. To minimize bleeding and improve visibility, surgeons insert cottonoid pledgets soaked in epinephrine (adrenaline) into the nasal passage. This helps constrict blood vessels and shrink the mucosal lining of the nose. A rigid endoscope—typically 4 to 6 mm in diameter—is then inserted through one nostril. Using either a 0-degree or 30-degree angled lens, the surgeon carefully navigates toward the back of the nasal cavity to locate the natural opening of the sphenoid sinus.

Expanding the Surgical Corridor

Once the sphenoid ostium is identified, the next step involves enlarging the anterior wall of the sphenoid sinus. Specialized instruments such as bone rongeurs are used to carefully remove bone and expand the opening to approximately 2–3 cm. This creates a wide enough pathway for optimal visualization and instrument maneuverability, which is crucial for safe tumor removal.

Reaching the Sella Turcica: Opening the Sphenoid Floor

With the sphenoid sinus fully exposed, any bony septations within the sinus are removed to create a clear path to the sella turcica—the bony structure housing the pituitary gland. The surgeon then uses a high-speed drill or fine rongeurs to open the floor of the sella, typically creating an access point about 2 cm in diameter. This exposes the dura mater, the protective membrane covering the pituitary gland and underlying tumor.

Tumor Resection and Intraoperative Techniques

After the dura is opened and controlled hemostasis is achieved—often using electrocautery—the pituitary tumor becomes visible. Surgeons employ a combination of micro-instruments including pituitary curettes, biopsy forceps, and suction devices to meticulously debulk or completely resect the tumor. The goal is maximal tumor removal while preserving healthy pituitary tissue and surrounding critical structures like the optic nerves and carotid arteries.

Managing Complications and Ensuring Closure

In most cases, transnasal pituitary surgery does not result in cerebrospinal fluid (CSF) leakage due to careful handling of tissues and precise closure techniques. However, if a CSF leak is detected intraoperatively, immediate repair is performed. This may involve using autologous grafts such as fascia lata, fat tissue, or local nasal mucosa flaps to seal the defect and prevent postoperative complications like meningitis.

Postoperative Recovery and Long-Term Outlook

Patients typically remain in the hospital for 1–2 days following the procedure. Because no external incisions are made, recovery is generally faster than with traditional craniotomy approaches. Most individuals experience minimal discomfort and can resume light activities within a week. Hormonal function is closely monitored after surgery, and many patients see significant improvement in symptoms related to hormone overproduction or deficiency.

Why This Procedure Stands Out in Modern Neurosurgery

Endoscopic transnasal surgery represents a major advancement in the treatment of pituitary tumors. Its benefits include reduced trauma, shorter hospital stays, lower infection rates, and excellent visualization thanks to high-definition endoscopic imaging. As technology and surgical techniques continue to evolve, outcomes for patients undergoing this procedure keep improving—making it the gold standard for accessible pituitary lesions.