Endoscopic transsphenoidal pituitary surgery: various surgical techniques and recommended steps for procedural transition

Various techniques in pituitary endoscopy are reviewed in the attempt to as semble the transitional steps necessary to take a neurosurgeon from traditi onal microscopic transsphenoidal surgery to endoscopic endonasal pituitary surgery. The senior author's (HDJ) experiences of endonasal endoscopy in mo re than 200 operations as well as the reports in the literature on pituitar y endoscopy are reviewed. Two distinct advantages that an endoscope has ove r an operating microscope are its ability to visualize through a narrow sur gical corridor and its ability to provide angled, close-up views. An endosc ope can be used to assist the operating microscope (endoscope-assisted micr osurgery). Endoscopy can also be used for endonasal retractor placement whe n microscopic surgery is preferred (endoscopic sphenoidotomy). When endonas al endoscopy is chosen, the surgical approach can be made with a deep-trans septal, a paraseptal, a middle turbinectomy or a middle meatal approach (en donasal transsphenoidal endoscopy). Endonasal endoscopy can be performed vi a either one or two nostrils. Working-channel endoscopy can be performed fo r restricted purposes. When a neurosurgeon desires to adopt endoscopy into pituitary surgery, the author recommends endoscope-assisted microsurgery as the first step followed by endoscopic sphenoidotomy as a combined effort b etween an endoscopic rhinologist and the neurosurgeon as the next step lead ing finally to endonasal pituitary endoscopy. Various methods of transsphen oidal endoscopy and the authors' recommendations for transitional steps are reported based on the authors' personal experience and literature review.