A technical note on endonasal combined microscopic endoscopic with free head navigation technique of removal of pituitary adenomas


Pituitary surgery exemplifies the continuous refinement of surgical techniques. The transsphenoidal approach is the approach of choice to treat most pituitary adenomas. We report here, as a technical note, an operative nuance that represents an encompassment of various technical steps that we utilize in our current surgery, including the corroboration of navigation system on a free head with combined use of endoscope and microscope techniques.

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Correspondence to Ossama Al-Mefty.

Additional information


Nicholas C. Bambakidis, Cleveland, USA

This is an important and timely review of endonasal surgical approaches for pituitary tumors. While endoscopic approaches are increasingly utilized and have certain advantages, the addition of microscopic techniques enhances the surgical view and is advantageous in combination. Though much emphasis has been placed recently on entirely endoscopic approaches, it cannot be ignored that there are also drawbacks to isolated use of the endoscope, particularly the loss of depth perception. We wholeheartedly agree with the author's comments and technical points and utilize their recommendations in our own practice.


Miguel A. Arraez, Malaga, Spain

This article from Al-Mefty and colleagues has the interest of pointing out the usefulness of combining the approaches that neurosurgeons can use nowadays for pituitary tumor resection: endoscopic and microscopic techniques. Although endoscope is very promising, the view is still limited when compared with the microscope because of the lack of 3D view and, to a lesser degree, the barrel effect among other drawbacks. On the other hand, it is noteworthy that the microsurgical approach is a very simple procedure, good enough to solve many pituitary cases in which there is no need for the additional improvement in view that the endoscope offers (invasive cases). The combination of both techniques adds the less invasive endoscopic approach to the sphenoidal sinus to the simplicity of the microsurgical tumor resection. This procedure is also very appropriate to overcome the learning curve in endoscopy necessary for endoscopic resection of more complex skull base cases. Thus, the technique would start with the less risky part and less familial anatomy for the neurosurgeon (endonasal approach to the sphenoidal sinus through the nostril) and progressively more advanced endoscopic steps can be assumed to deal with the sella and tumor anatomy. Regarding the use of neuronavigation, it is definitely useful in reoperation procedures and invasive cases. For standard cases, the endoscopic technique easily allows just to enter the sphenoidal sinus, getting orientated inside as the sella turcica is usually very well seen, and it is anatomically recognized without the need of additional aid. Finally, in the combined endoscopic-microsurgical approach, when the endoscope is used for a better visualization inside the sella, it is important to remember that the nasal speculum should be removed to increase the angle of mobility and maneuverability of the endoscope and instruments, which are otherwise limited.


Luciano Mastronardi, Rome, Italy

This is a short but very nice overview of combined transsphenoidal microscopic and endoscopic approach for pituitary tumors. Even if the endoscopic transnasal approach is widely used in the majority of neurosurgical divisions, according to Al-Mefty and colleagues the combination with microsurgical technique and neuronavigation seems to make this procedure safer and more effective, with the best possible 3D view.

I completely agree with the authors that the combination of microscopic view with new technologies, endoscope and free head navigation, will transform the surgery of pituitary tumors in a relatively easier procedure for neurosurgeons less experienced in this field.

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Al-Mefty, O., Pravdenkova, S. & Gragnaniello, C. A technical note on endonasal combined microscopic endoscopic with free head navigation technique of removal of pituitary adenomas. Neurosurg Rev 33, 243–249 (2010).

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  • Transsphenoidal surgery
  • Sellar tumors
  • Pituitary adenoma
  • Surgical technique
  • Microsurgery
  • Endonasal endoscopy
  • Neuronavigation
  • Minimal invasive surgery