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Endoscopic radical hypophysectomy: how I do it

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Abstract

Background

Total hypophysectomy it is a classical procedure that currently has many indications especially in patients with Cushing syndrome without good endocrine control. Expanded endonasal endoscopic techniques grant us an alternative standpoint to the classic trans-sphenoidal microscopic approach and a comprehensive assessment of the process

Method

The author provides technical nuances and describe step by step the radical endoscopic hypophysectomy. The study of cadaveric specimens adds clarifying dissections.

Conclusions

Radical hypophysectomy is an easily replicable and safe procedure. The most important morbidity is the intraoperative cerebrospinal fluid (CSF) leakage, which is inherent to this technique and can be successfully prevented with a pedicled nasoseptal flap reconstruction.

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Author information

Correspondence to Eugenio Cárdenas Ruiz-Valdepeñas.

Ethics declarations

The study with cadaveric specimens was approved by the Research Ethics board in our hospital.

Conflicts of interest

None.

Funding

No funding was received for this research.

Financial

The authors report no financial disclosures.

Additional information

Key Points

1. Thorough reconstruction planning.

2. Nasoseptal flap tailoring is usually possible. It is the best fit in most cases.

3. Wide bilateral sphenoidotomy and four-hand technique allow a better microsurgery.

4. Wide sellar prominence’s anterior wall resection.

5. Open up both two dural layers on the anterior wall of the sella turcica.

6. Inferior hypophyseal capsule dissection first, followed by lateral side dissection.

7. Bleeding halting with injectable hemostatics on the CS medial wall.

8. Identification and coagulation of inferior hypophyseal arteries.

9. Arachnoid dissection and coagulation / cutting of the hypophyseal stalk.

10. Pituitary ligament remnants sectioning and neurohypophysis releasing from the dorsum sellae.

Electronic supplementary material

Below is the link to the electronic supplementary material.

A video with a complete radical hypophysectomy is attached. We show a patient with a recurrent Cushing’s disease after surgery and resistant to medical treatment with multiple microadenomas. The video shows step by step the entire technique. (MP4 23590 kb)

ESM 1

A video with a complete radical hypophysectomy is attached. We show a patient with a recurrent Cushing’s disease after surgery and resistant to medical treatment with multiple microadenomas. The video shows step by step the entire technique. (MP4 23590 kb)

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Cárdenas Ruiz-Valdepeñas, E., Kaen, A. & Perez Prat, G. Endoscopic radical hypophysectomy: how I do it. Acta Neurochir 158, 2159–2162 (2016). https://doi.org/10.1007/s00701-016-2955-5

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Keywords

  • Extended endonasal endoscopic
  • Radical hypophysectomy
  • Cushing’s disease
  • Pituitary tumour