(Please click on pictures for a more detailed view)

Fig. 6: Tumor Bed After Excision of Tumor

The endoscopic endonasal transsphenoidal procedure is a new and minimally invasive approach for the resection of pituitary tumors (fig 1). Dr. Moreland has pioneered this technique both locally and internationally. He has one of the largest series in the country utilizing this procedure. Compared to the traditional method, it provides reduced invasiveness, operating time, hospital stay and patient discomfort. In addition, the approach provides better tumor visualization and is at least as effective as the traditional approach in debulking and resecting tumors.

The procedure involves passing a 4mm rigid endoscope into the nostril to provide illumination and visualization (figs.2,3). No incision is made nor is it necessary to break the nose with this new technique. Both of these maneuvers are necessary with the older traditional approach and they are a great source of pain and longer hospital stays. The sphenoid sinus and pituitary fossa are then entered using microsurgical instruments. The anatomy as seen by the endoscope is projected onto a television monitor as the surgeon resects the tumor (figs.4-6).

Of the first 19 lesions operated on in this manner by Dr. Moreland, the operation achieved its goal (tumor removal, saving vision, cyst drainage) 85% of the time. This compares favorably with the results of conventional sublabial transeptal transsphenoidal surgery.

The endonasal endoscopic approach offers several distinct advantages over the traditional approach. Firstly, hospital stay is shorter. Since there is less trauma to normal tissue (no septal or peri-chondrial dissection is necessary) patients are routinely discharged from the hospital the day after surgery compared to 4-5 days for the conventional approach.

Secondly, operating and anesthesia times are reduced. The conventional sublabial transeptal approach requires an incision under the upper lip and stripping of the mucosa to the choanae with removal of the septum¹. This exposes the anterior wall of the sphenoid sinus and takes time to perform. Employing the endonasal endoscopic approach, on the other hand, the surgeon is able to reach this point by simply passing the endoscope and surgical instruments through the nostril.

Thirdly, tumor visualization is improved. The "eye" of the endoscope is able to see around corners illuminating areas which would be impossible to see through the speculum used in the conventional approach (figs.9,10).

Finally, patients are more comfortable following the endoscopic procedure. Reduced trauma to normal tissues described above as well as the diminished requirement for nasal packing make this possible.

The advantages of the endoscopic endonasal transsphenoidal approach support its use as an important alternative in many cases of pituitary tumor. 

While numerous successful endoscopic endonasal cases have been performed and reported upon by surgeons in the United Kingdom and other areas, only a few neurosurgeons in the United States have adopted the procedure. This will likely change as more become accustomed to the new technology employed. Currently Douglas B. Moreland, MD performs the procedure at Sisters Hospital in Buffalo, N.Y.

Fig. 7: Pre-Operative Coronal MRI demonstrating Tumor

Fig. 8: Post-Operative MRI with tumor successfully removed.

Fig. 9: Speculum used in conventional transphenoidal surgery has limited range of view

Fig. 10: The endoscope allows for a broader range of view