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Surgical anatomy and nuances of the extended endoscopic endonasal transtuberculum sellae approach: pearls and pitfalls for complications avoidance

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Abstract

Background

Using the expanded endoscopic transtuberculum approach (EETA), the nuances of this technique have rendered a safe, direct, and feasible ventral corridor for the treatment of extending suprasellar pathologies. This study illustrates surgical landmarks and strategies of paramount importance for complications avoidance.

Methods

This study presents the surgical anatomy and nuances of EETA, which can be used to remove large pituitary adenomas with suprasellar extension. Special references to cadaveric dissections highlight anatomical landmarks and surgical key points for complications avoidance.

Conclusion

The EETA represents a versatile route for the treatment of sellar/suprasellar pathologies. Although, sizeable extrasellar pituitary tumors still pose a threat due to displacement/encasement of surrounding structures, necessitating accurate knowledge of correlative operative anatomy with traditional landmarks. Complete resection of extrasellar components is essential to avoid postoperative apoplexy.

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Abbreviations

EEA:

Endoscopic endonasal approach

ICA:

Internal carotid artery

IGS:

Image guidance system

ACP:

Anterior clinoid processes

MCPs:

Middle clinoid processes

PCPs:

Posterior clinoid processes

SSEP:

Somato-sensory-evoked potential

CN-EMG:

Cranial nerve electromyography

e-ICG:

Endoscope-integrated indocyanine green fluorescence

SHA:

Superior hypophyseal artery

MOCR:

Medial opticocarotid recess

LOCR:

Lateral opticocarotid recess

ST:

Sella turcica

CP:

Carotid protuberances

CR:

Clival recess

OC:

Optic canal

EETA:

Endoscopic endonasal transtuberculum approach

References

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Acknowledgments

We thank Thaïs Cristina Rejane-Heim, MD (Department of Pediatric Endocrinology, Nationwide Children’s Hospital, Columbus, Ohio, USA; and Department of Pediatric Endocrinology, Federal University of Santa Catarina, Florianópolis, SC, Brazil), Eduardo Schmidt Bertazzo Silveira, Leonardo Schmidt Bertazzo Silveira, and Andrei Koerbel, MD (Department of Neurological Surgery, University of Joinville, SC, BR), Ahmed Gamal Sholkamy Diab, MD (Department of Otolaryngology-Head and Neck Surgery, Assiut University, Egypt), Mohammad Salah Mahmoud Mady (Department of Otolaryngology-Head and Neck Surgery, Ain Shams University, Egypt), and Ruichun Li, MD (Department of Neurological Surgery, the first affiliated hospital of Xi’an Jiaotong University, China) for their contribution to this project.

Author information

Authors and Affiliations

  1. Department of Neurological Surgery, The Ohio State University Medical Center, N-1049 Doan Hall, 410 West 10th Avenue, Columbus, OH, USA

    Giuliano Silveira-Bertazzo, Thiago Albonette-Felicio, Ricardo L. Carrau & Daniel M. Prevedello

  2. Department of Neurosurgery, University of Joinville Region and Neurosurgical Clinic of Joinville, Joinville, SC, Brazil

    Giuliano Silveira-Bertazzo

  3. Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Medical Center, Columbus, OH, USA

    Ricardo L. Carrau & Daniel M. Prevedello

Authors
  1. Giuliano Silveira-Bertazzo
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  2. Thiago Albonette-Felicio
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  3. Ricardo L. Carrau
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  4. Daniel M. Prevedello
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Corresponding author

Correspondence to Daniel M. Prevedello.

Ethics declarations

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ohio State University Wexner Medical Center institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Conflict of interest

This study was performed at ALT-VISION at The Ohio State University. This laboratory receives educational support from the following companies: Carl Zeiss Microscopy, Intuitive Surgical Corp., KLS Martin Corp., Karl Storz Endoscopy, Leica Microsystems, Medtronic Corp., Stryker Corp., and Vycor Medical. Dr. Prevedello is a consultant for Stryker Corp., and Integra; he has received an honorarium from Mizuho and royalties from KLS- Martin. Ricardo L. Carrau is a consultant for Medtronic Corp.

Additional information

Key points

1. EETA is suitable for extending sellar and suprasellar lesions offering a straight and direct trajectory to these areas while avoid traversing major neurovascular structures and cosmetic deformities.

2. The limbus sphenoidale, LOCR, and MOCR are considered critical landmarks to understand the anatomy and locate the various segments of ICA.

3. In anticipation of the skull base defect, incisions for a rescue flap can be performed initially, and the nasoseptal flap can be entirely raised afterward as needed.

4. Adoption of CT-A/MRI neuronavigation, endoscopic Doppler, and e-ICG allows for concurrent evaluation of osseous, vascular, and soft tissue anatomy.

5. Preservation of essential neurovascular structures inside the subarachnoid space is advocated and can be achieved by earlier dissection of the suprasellar component of the tumor, avoiding blind dissections.

6. Bipolar cautery should be judiciously used in the subarachnoid space to avoid damage to the SHA and small perforators.

7. The bone overlying the ICA should be carefully removed by meticulous drilling using a diamond drill until it is thin enough to be elevated with dissectors (avoiding bitting the bone, which may lead to damage to the ICA).

8. Bleeding from the SICS can be controlled with hemostatic agents (Floseal, Surgiflow, or Spongostan).

9. The transtuberculum approach with suprasellar durotomy and subarachnoid dissection can be helpful in selected cases such as large pituitary adenomas that extends superiorly (beyond the diaphragm sellae into the subarachnoid space) to reduce the possibility of residual tumor and consequent postoperative apoplexy.

10. Multilayer vascularized reconstructions can reduce the risk of postoperative CSF leak, pneumocephalus, and meningitis.

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This article is part of the Topical Collection on Neurosurgical Anatomy

Supplementary Information

A 46-year-old male presented with a known history of a non-functional pituitary adenoma and retrospective history of loss of libido, fatigue, and a left peripheral vision loss. One year before, he had a transsphenoidal surgery performed elsewhere complicated by CSF leak and meningitis initially. The residual suprasellar component of the tumor suffered postoperative apoplexy causing vasospasm and brain ischemia. Consequently, the patient suffered bilateral frontal lobe strokes. He presented with an increased size of the residual pituitary macroadenoma, causing a left visual field cut predominantly in his peripheral visual fields. Preoperative and postoperative MRI are shown in Figure 1. There were no surgical complications, and postoperative MRI demonstrates a complete resection of the tumor. The patient reported an incremental improvement of the left peripheral field cut immediately after the surgery. At a 6-month follow up, the patient is neurologically intact with no need for pituitary hormonal replacement. (MP4 226307 kb)

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Silveira-Bertazzo, G., Albonette-Felicio, T., Carrau, R.L. et al. Surgical anatomy and nuances of the extended endoscopic endonasal transtuberculum sellae approach: pearls and pitfalls for complications avoidance. Acta Neurochir 163, 399–405 (2021). https://doi.org/10.1007/s00701-020-04625-x

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