Extracapsular dissection technique with the Cotton Swab for pituitary adenomas through an endoscopic endonasal approach – How I do it



Pituitary adenomas are often encased in a histological pseudocapsule that separates the tumor from the normal gland. Transsphenoidal adenoma resection may be performed either in an intra- or an extracapsular technique. The extracapsular fashion offers anatomical orientation, removal of a security margin, reduced risk of opening the arachnoid layer with subsequent CSF flow and identification of invasion.


The sella turcica is approached through the classic endoscopic endonasal route. After opening the dura of the sellar floor, the interface between the compressed tissue and the normal gland is used as a surgical plane for dissection. Performing slight counter-traction with the suction tube, the cleavage plane is identified and stepwise unsealed in an atraumatic fashion with the cotton swab. Once the cleavage plane is partially loosened, repeated twisting movements are performed with the cotton swab to enucleate the pseudocapsule and adenoma.


Both micro- and macroadenomas presenting a pseudocapsule may be resected in the extracapsular dissection technique with the cotton swab. Operating in an endoscopic three- to four hands technique enables to visualize the anatomic planes and perform twisting movements with the cotton swab separating pseudocapsule and tumor in order to enucleate the adenoma.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 199

This is the net price. Taxes to be calculated in checkout.


  1. 1.

    Jagannathan J, Smith R, Devroom HL, Vortmeyer AO, Stratakis CA, Nieman LK, Oldfield EH (2009) Outcome of using the histological pseudocapsule as a surgical capsule in Cushing disease. J Neurosurg 111:531–539

  2. 2.

    Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL (2005) Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 19:E3

  3. 3.

    Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P, Zanation A, Duz B, Stefko ST, Byers K, Horowitz MB (2011) Endoscopic endonasal skull base surgery: analysis of complications in the authors’ initial 800 patients. J Neurosurg 114:1544–1568

  4. 4.

    Kawase T, van Loveren H, Keller JT, Tew JM (1996) Meningeal architecture of the cavernous sinus: clinical and surgical implications. Neurosurgery 39:527–534

  5. 5.

    Lee EJ, Ahn JY, Noh T, Kim SH, Kim TS (2009) Tumor tissue identification in the pseudocapsule of pituitary adenoma: should the pseudocapsule be removed for total resection of pituitary adenoma? Neurosurgery 64:62–69

  6. 6.

    Oldfield EH, Vortmeyer AO (2006) Development of a histological pseudocapsule and its use as a surgical capsule in the excision of pituitary tumors. J Neurosurg 104:7–19

  7. 7.

    Prevedello DM, Kassam AB, Gardner P, Zanation A, Snyderman CH, Carrau RL (2010) “cotton swab” retractor in endoscopic cranial base surgery. Neurosurgery 66:363–366

  8. 8.

    Qu X, Xu G, Qu YM, Song T (2011) The pseudocapsule surrounding a pituitary adenoma and its clinical significance. J Neurooncol 101:171–178

  9. 9.

    Rivera-Serrano CM, Snyderman CH, Gardner P, Prevedello D, Wheless S, Kassam AB, Carrau RL, Germanwala A, Zanation A (2011) Nasoseptal “rescue” flap: a novel modification of the nasoseptal flap technique for pituitary surgery. Laryngoscope 121:990–993

  10. 10.

    Yasuda A, Campero A, Martins C, Rhoton AL Jr, Ribas GC (2004) The medial wall of the cavernous sinus: microsurgical anatomy. Neurosurgery 55:179–189

Download references

Conflicts of interest


Author information

Correspondence to Florian H. Ebner.

Electronic supplementary material

Below is the link to the electronic supplementary material.

(MOV 267 mb)


(MOV 267 mb)

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Prevedello, D.M., Ebner, F.H., de Lara, D. et al. Extracapsular dissection technique with the Cotton Swab for pituitary adenomas through an endoscopic endonasal approach – How I do it. Acta Neurochir 155, 1629–1632 (2013).

Download citation


  • Endoscopy
  • Pituitary adenoma
  • Extracapsular dissection
  • Cotton swab