gms | German Medical Science

ESBS 2005: Skull Base Surgery: An Interdisciplinary Challenge
7th Congress of the European Skull Base Society held in association with
the 13th Congress of the German Society of Skull Base Surgery

18. - 21.05.2005, Fulda, Germany

The endoscopic endonasal bilateral trans-sphenoidal approach to the sellar region

Meeting Contribution

  • D. Locatelli - Neurosurg. Dpt., I.R.C.C.S. San Matteo, Pavia, Italy
  • I. Acchiardi - Neurosurg. Dpt., I.R.C.C.S. San Matteo, Pavia, Italy
  • F. Rampa - Neurosurg. Dpt., I.R.C.C.S. San Matteo, Pavia, Italy
  • M. Bignami - Otolaryngology Dpt., Varese, Italy
  • P. Palma - Otolaryngology Dpt., Varese, Italy
  • G. Tomei - Neurosurg. Dpt., Osp Circolo, Varese, Italy
  • P. Castelnuovo - Otolaryngology Dpt., Varese, Italy

ESBS 2005: Skull Base Surgery: An Interdisciplinary Challenge. 7th Congress of the European Skull Base Society held in association with the 13th Congress of the German Society of Skull Base Surgery. Fulda, 18.-21.05.2005. Düsseldorf: German Medical Science GMS Publishing House; 2009. Doc05esbs45

doi: 10.3205/05esbs45, urn:nbn:de:0183-05esbs459

Published: January 27, 2009

© 2009 Locatelli et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.




The transsphenoidal approach, both microsurgical and more recently endoscopic is nowadays widely used as the primary surgical treatment in patients affected by pituitary adenomas [1].

The experience gathered from otolaryngologyendoscopic approaches was followed by the application of the acquisitions of the treatment of the sellar and parasellar pathologies. The first step consisted in the combined use of the endoscopic procedures and traditional microsurgical transsphenoidal approach [2]. In the first ‘90s Jho, Carrau and Sethi practiced a pure endoscopic technique [3], [4], [5], [6]. In the attempt to obtain minimal invasiveness, several variants of the latter approach were proposed in the following years [7].

Since 1997 the endoscopic bilateral (four hands) endonasal approach was routinely performed in our Department, in collaboration with the otolaryngologists, for the treatment of sellar, parasellar and clival pathology.

169 patients affected by sellar or parasellar lesions have been treated in our Department, including pituitary adenomas, craniopharyngiomas, clivus cordomas and other neoplastic pathologies.

The endoscopic surgery offers surgical and endocrinological outcomes similar to those obtained by the traditional microsurgical approaches with a higher respect for the rhinosinusal morphofunctional structures, thus approaching a functional surgery concept [8].

Materials and methods

From 1997 to 2005 at our Neurosurgical Department and, since 2002, also at the Neurosurgical Department of Varese, with a combined otolaryngologists-neurosurgeons equipe, 169 patients were surgically treated for sellar and parasellar lesions by means of an endoscopic endonasal bilateral transsphenoidal or transethmoidal approach.

For determination of suprasellar extension and invasiveness Hardy’s classification modified by Wilson was adopted.Pre-operative evaluation comprehends baseline endocrinological exams including, when necessary, dynamic stimulation or inhibition tests and study of circadian rhythm of hormonal secretions. Neuroradiologic study with magnetic resonance imaging (MRI) of the sellar region before and after administration of Gd-DTPA and coronal CT scans of the facial mass was routinely performed. Finally, ophthalmologic evaluation with visual acuity and visual field assessment was done.

We adopted the four hands bilateral endoscopic technique, choosing the less invasive access possible according to the anatomy and the specific pathology of the patient, proceding trought both nostrils paraseptal or transethmoidal to the sphenoidal sinus, drilling the rostrum and the sellar floor in order to have an easy bilateral access to the sella and to control up to three instruments and the endoscope in the surgical field.

Follow up at 2 and 6 months comprehends endoscopic endonasal outpatient evaluation, basal hormone tests, MRI of the sellar region before and after administration of Gd-DTPA and ophthalmologic exam with visual field and acuity evaluation. From the comparison between pre- and post-operative laboratory and radiological results, we evaluated the radicality of the exeresis, the improvement of the visual field in macroadenomas, remission of hormone hypersecretion in productive adenomas, the arousal of hypopituitarism, minor and major intraoperative and postoperative complications.

Results and discussion

Through the experience obtained in 169 patients (Figure 1 [Fig. 1]) surgically treated with the four hands technique we define the advantages and limits of these procedures. As mentioned above, we used these endoscopic approaches for a variety of lesions [9], [10], [11], [12], [13].

Our series of macroadenomas (117/147), particularly the giant macroadenomas, seems to be of particular interest for the complexity of surgical treatment, the paucity of the international literature on this argument and for the lack of global “consensus” in the management of such lesions.

According to the classification commonly accepted, macroadenomas exceed 10 mm of diameter. We applied the term of “giant” for tumor size beyond 4 cm. This group contains both those tumors with suprasellar and intrasphenoidal extension but preserved dural integrity, as well as those penetrating its double layer in any direction. Considering the erosion of the sella turcica and the superior or lateral extension, adenomas are classified, according to Hardy, in four grades. The giant macroadenomas of our series are of grade III or IV (C, D, E). Pituitary adenomas require a multidisciplinary approach with the involvement of the endocrinologist, the neurologist, the radiologist, the gynecologist, the ophthalmologist and the neurosurgeon [14].

We used the four hands technique in all our series [15], [16] it was useful in all pituitary adenomas, from microadenomas to giant sized, to optimize the advantages of the endonasal endoscopic technique. In our opinion the monolateral approach and the use of the endoscopic holder both could limit the endoscopic technique itself.

In particular we always obtained an easier approach with minimal distortion of the nasal structures, a better view of the surgical field with optimal exposure of the lesion and wider movements and handling of the surgical instruments, using up to three different tools and one endoscope, thus having two surgeon working at the same target at the same time.

The advantages are that we obtained a better control of the intraoperative bleedings with the possibility to use the endoscope alternatively through one or the other nostril; we also improved the accessibility of different tools such as intraoperative Doppler, neuronavigation probes or laser as well as to microsurgical instruments needed to reach distal or lateral located lesions. As well by this bilateral approach we can use our ‘dive‘ technique to explore the intra and suprasellar compartment. Moreover the sellar repair, when needed, can be easily accomplished by a bilateral approach, so different closure techniques by autologous grafts and, more recently, by the combination of eterologous material such as collagen, collagen and fibrin glue, dural substitute and autologous bone can be applied [17], [18].

It is known that endonasal endoscopic surgery offers optimal results in the management of microadenomas and could be considered an alternative to the medical therapy. On the other hand, it is debated the role of endoscopic surgery for suprasellar and parasellar lesions of different nature. The endoscopic approach applies the concept of minimal invasiveness allowing, with the four hands technique, a wider vision of the surgical field. Futhermore, the constant evolution of new surgical approaches and their refinement and innovation in surgical instrumentation renders possible the continuous improvement of the final outcome.

It is to stress that optimal results necessitate of sufficient skillfulness by the surgeon and obvious knowledge of the anatomy of the sellar region. Futhermore, a necessary learning curve has to be realized in order to acquire different and new “hand-eye” coordination. In this process it has been fundamental the collaboration with the otolaryngologits to add mutual experience to reach good results. The neurosurgeon’s knowledge of the sellar region has to be completed with the capacity of the rhinologic surgeon to respect and preserve the morphofunctional structures of the nose. To obtain best results, a careful selection of either of the two mentioned routes should be operated, in accordance with the indications for the transethmoidal approach we mentioned above.

Our ten years experience of the endoscopic transphenoidal approaches guarantes our incidence of major complications similar to that reported for best microsurgical techniques and lower rate of minor complications that can determine poorer quality of life for patients. This is the direct consequence of the extreme respect of the anatomy and physiology of the nasal cavities leading to minor discomfort in the post-operative period and higher quality of life at the long follow up period.


Laws ER Jr. Hypofisectomy. In: Youmans "Neurological Surgery". Third Edition. Volume Five: Tumors. Chapter 169.
Jho HD, Carrau RL. Endoscopy assisted transsphenoidal surgery for pituitary adenoma. Technical note. Acta Neurochir (Wien). 1996;138(12):1416-25.
Carrau RL, Jho HD, Ko Y. Transnasal-transsphenoidal endoscopic surgery of the pituitary gland. Laryngoscope. 1996;106(7):914-8.
Jho HD, Carrau RL, Ko Y, Daly MA. Endoscopic pituitary surgery: an early experience. Surg Neurol. 1997;47(3):213-23.
Jho HD, Carrau RL. Endoscopic endonasal transsphenoidal surgery: experience with 50 patients. J Neurosurg. 1997;87(1):44-51.
Sethi DS, Pillay PK. Endoscopic management of lesions of the sella turcica. J Laryngol Otol. 1995;109(10):956-62.
Jho HD, Alfieri A. Endoscopic transsphenoidal pituitary surgery: various surgical techniques and recommended steps for procedural transition. Br J Neurosurg. 2000;14(5):432-40.
Cappabianca P, Alfieri A, de Divitiis E. Endoscopic endonasal transsphenoidal approach to the sella: towards functional endoscopic pituitary surgery (FEPS). Minim Invasive Neurosurg. 1998;41(2):66-73.
Castelnuovo P, Locatelli D, Santi L, Emanuelli E, Pagella F, Canevari FR. Sinonasal endoscopic access to the pituitary gland. In: Stammberger, Wolf, editors. ERS & ISIAN Meeting '98. Monduzzi; 1998. p. 337-9.
Castelnuovo P, Locatelli D, Santi L, Emanuelli E, Pagella F, Canevari FR. Endoscopic approach to the skull base and tumors of paranasal sinuses: personal experience. In: Stammberger, Wolf, editors. ERS & ISIAN Meeting '98. Monduzzi; 1998. p. 203-8.
Locatelli D, Castelnuovo P, Santi L, Cerniglia M, Infuso L. Limiti e complicanze dell'endoscopia transfenoidale. Rivista di neuroradiologia. 2000;13:911-5.
Locatelli D, Castelnuovo P, Santi L, Ortolina A, Mauri S, Bignami M, Infuso L. Endoscopic experiences to the cranial base lesions. In: XVII Congress of the European Society for Pediatric Neurosurgery. Graz 17-21 giugno 2000.
Locatelli D, Levi D, Rampa F, Pezzotta S, Castelnuovo P. Endoscopic approach for treatment of relapses in cystic craniopharyngiomas. Childs Nerv Syst. 2004;20(11-12):863-7.
Castelnuovo P, Locatelli D, de Bernardi F, Mauri S, Emanuelli E, Bignami M. Endoscopic approach to sphenoid and sellar lesions. The Nose 2000…and Beyond - Washington, D.C. 20-23 settembre 2000. Am J Rhinol. 2000 Sept; Special Issue.
Locatelli D, Castelnuovo P, Santi L, Cerniglia M, Maghnie M, Infuso L. Endoscopic approaches to the cranial base: perspectives and realities. Childs Nerv Syst. 2000;16(10-11):686-91.
Locatelli D, Castelnuovo P. The four hands' technique. Much more than pure ergonomics. Presented at the International Masterclass, Milano 4-6 marzo 2005.
Castelnuovo P, Mauri S, Locatelli D, Emanuelli E, Delù G, Giulio GD. Endoscopic repair of cerebrospinal fluid rhinorrhea: learning from our failures. Am J Rhinol. 2001;15(5):333-42.
Castelnuovo P, Locatelli D, Mauri S, De Bernardi F. Extended endoscopic approaches to the skull base, anterior cranial base CSF leaks. In: De Divitiis E, Cappabianca P, editors. Endoscopic endonasal trans-sphenoidal surgery. New York, Wien: Springer; 2003. p. 137-8.