The history and evolution of transsphenoidal surgery

Initial attempts at transcranial approaches to the pituitary gland in the l ate 1800s and early 1900s resulted in a mortality rate that was generally c onsidered prohibitive. Schloffer suggested the use of a transsphenoidal rou te as a safer, alternative approach to the sella turcica. He reported the f irst successful removal of a pituitary tumor via the transsphenoidal approa ch in 1906. His procedure underwent a number of modifications by interested surgeons, the culmination of which was A. E. Halstead's description in 191 0 of a sublabial gingival incision for the initial stage of exposure. From 1910 to 1925, Cushing, combining a number of suggestions made by previous a uthors, refined the transsphenoidal approach and used it to operate on 231 pituitary tumors, with a mortality rate of 5.6%. As he developed increasing expertise with transcranial surgery, however, Cushing reduced his mortalit y rate to 4.5%. With the transcranial approach, he was able to verify supra sellar tumors and achieve better decompression of the optic apparatus, resu lting in better recovery of vision and a lower recurrence rate. As a result he and most other neurosurgeons at the time abandoned the transnasal in fa vor of the transcranial approaches. Norman Dott, a visiting scholar who studied with Cushing in 1923, returned to Edinburgh, Scotland, and continued to use the transsphenoidal procedure while others pursued transcranial approaches. Dott introduced the procedure to Gerard Guiot, who published excellent results with the transsphenoidal approach and revived the interest of many physicians throughout Europe in t he early 1960s. Jules Hardy, who used intraoperative fluoroscopy while lear ning the transsphenoidal approach from Guiot, then introduced the operating microscope to further refine the procedure; he thereby significantly impro ved its efficacy and decreased surgical morbidity. With the development of antibiotic drugs and modem microinstrumentation, the transsphenoidal approa ch became the preferred route for the removal of lesions that were confined to the sella turcica. The evolution of the transsphenoidal approaches and their current applications and modifications are discussed.