Endoscopic Endonasal Approach for Pituitary Tumor Removal

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Transcript

00:00The endoscopic endonasal approach provides a unique access to the ventral aspect of the skull base.

00:07The pituitary gland is located at the center of the skull base and is surrounded by critical

00:12neurovascular structures. Above the pituitary gland, we have the optic apparatus. On each side

00:18of the gland, we have the grotate arteries, which provide blood flow to the brain. And below the

00:23pituitary, we have the brainstem and the basilar artery. Tumors can arise from within the pituitary

00:29gland and then grow upwards to compress the optic apparatus, or they can grow to each side to invade

00:35the cavernous sinus. There are many other tumors that can arise in this area, above the pituitary

00:40gland, below, or inside the cavernous sinus. Here we can see a side view of the patient's head,

00:47and we can identify the location of the pituitary gland at the base of the skull and deep into the

00:53nasal cavity. Here we can zoom in and see the relationship of the pituitary gland with the

00:58sphenoid sinus, again, at the deepest point of the sanonasal cavity and at the base of the skull.

01:04We are now going to simulate an endoscopic endonasal approach to the pituitary gland and the base of the

01:10skull. We use the nostrils as natural corridors to access the skull base. We can actually introduce

01:18instruments through each nostril. On one side, the endoscope, and on the other side, dissecting

01:24instruments such as micro-scissors. With the collaboration of our ENT colleagues, we proceed

01:31with opening of the sphenoid sinus. This gives us access to the posterior wall of the sphenoid sinus,

01:39where we can identify the prominence of the pituitary gland, grudal arteries, cavernous sinus,

01:45and optic nerves. Here we can see the location of the endoscope inside the sphenoid sinus and the

01:52close-up view it provides. We use a high-speed drill to carefully remove the bone that covers

02:00the pituitary gland. We continue drilling laterally to perform a wide exposure into the anterior wall of

02:07the cavernous sinus on each side of the pituitary gland. We perform this X-cell technique where very

02:14thin bone is left behind so we can use a kerosene ranger to remove it safely and entirely. After the

02:21dura has been widely exposed, we perform our cruciate dural opening. We use micro-scissors to open the dura in a

02:29cruciate fashion up to the level of the middle wall of the cavernous sinus. After widely opening the dura,

02:37we start identifying the difference between the pituitary gland, which looks well vascularized and

02:43more orange-like, from the pituitary tumor, which is less vascularized and more whitish or pale in

02:49appearance. By identifying this interface between both the pituitary gland and the tumor, we can develop

02:56an accurate plane of dissection to separate the tumor away from the pituitary gland. Whenever possible,

03:03we aim to perform an extracapsular dissection of the tumor to accurately separate it from the pituitary

03:08gland. In certain cases, tumors invade the medial wall of the cavernous sinus and this poses a special

03:16challenge. For this, we have developed an original technique which consists in opening the anterior wall

03:22of the cavernous sinus to directly access the inside of the cavernous sinus and remove the medial wall.

03:28By directly opening the anterior wall of the cavernous sinus, we can identify the corollary

03:33artery in the cavernous sinus, the inferior hypophysial artery running towards the posterior

03:38aspect of the pituitary gland, and we can gently separate the medial wall that contains tumor from

03:44the cavernous corollary artery. The medial wall of the cavernous sinus can be removed and blocked by

03:50performing the disconnection of the corollaryoclinatal ligament superiorly and the disconnection from the

03:55dural floor inferiorly. During this process, it is important to identify and typically coagulate and

04:02transect the inferior hypophysial artery. At the end, we can achieve a complete tumor resection,

04:10including a complete removal of the middle wall of the cavernous sinus, which makes significant

04:15difference in patients' outcome, especially for functional pituitary tumors. As a conclusion,

04:21the endoscopic and nasal approach allows us to perform complete tumor removal with excellent

04:27preservation of the pituitary gland function secondary to the superior visualization provided by the

04:32endoscope.

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