The purely endoscopic, non-speculum-based approach for removal of pituitary tumors requires new skills and surgical techniques. The approach necessitates a wider intranasal surgical exposure compared to the standard microscopic approach. Additionally, it facilitates expanded skullbase exposures that provide avenues to parasellar regions not typically accessed using the surgical microscope. We use a dual-surgeon approach, with an otolaryngologist and neurosurgeon working closely together to optimize visualization and operative maneuverability.

The video demonstrates the surgical removal of a growth hormone secreting pituitary macroadenoma that has partially invaded the cavernous sinus. Our room setup and nasal preparation routine are shown. The endoscopic approach to the sphenoid sinus requires partial resection of the middle turbinate. The technique for elevation of a nasoseptal mucosal flap is demonstrated. The high-speed drill is used for wide (expanded) exposure of the sphenoid sinus. Sella durotomy and tumor resection techniques are demonstrated, including exposure and dissection of tumor from the medial cavernous sinus. The reconstruction technique using the nasoseptal flap is demonstrated.

In this illustrative case, an expanded exposure of the right cavernous sinus area is achieved, facilitating a gross total resection of the tumor. No cerebrospinal fluid leak occurred, and therefore a more extensive sellar reconstruction technique was not required.

The endoscopic approach provides an effective and safe technique for resection of pituitary tumors. Common to many endoscopic procedures, there is a steep learning curve. The dual-surgeon technique greatly enhances visualization and the capacity for fine microsurgical dissection.