Thoughts on transsphenodial procedures

Dr. Sandeep Kunwar, Surgical Director of the California Center for Pituitary Disorders at UCSF, performing a transsphenodial resection of a pituitary adenoma. Painting by Dr. Lewis Blevins.

The operating microscope, introduced by Dr. Jules Hardy many years ago, revolutionized the transsphenodial approach to resection of pituitary adenomas. The procedure used to be performed utilizing a sublabial approach, an incision of the gum at the junction of the upper lip and gum under the nose wherein the nose is then shoved upwards, but this led to significant morbidity and patient discomfort. Some surgeons, however, still use this approach. The endonasal approach, through a nostril, is now preferred. Some surgeons have abandoned the microscope and are now using the endoscope to operate on all pituitary adenomas. While this technique allows for better visualization, but truly is associated with loss of real depth perception, in some patients it is akin to using a driver to get out of a sand trap close to the green, or using a hammer to drive a screw. The endoscopic procedure is more invasive and there is greater morbidity associated with the procedure. Gimmicky things are not always better! The endoscope is the tool of choice for certain types of tumors and scenarios but should not be the tool of choice for a majority of pituitary adenomas. We will discuss this issue in the future and present the viewpoints of several physicians familiar with the different approaches to accomplishing pituitary operations.  

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