888 J Med Assoc Thai Vol. 94 No. 7 2011

Correspondence to:Methee W, Division of Neurosurgery, Department of Surgery,Rajavithi Hospital, Bangkok 10400, Thailand.Phone: 081-649-0772E-mail: mathee@hotmail.com

What is the Better Minimally Invasive Surgery in PituitarySurgery: Endoscopic Endonasal Transsphenoidal Approach

or Keyhole Supraorbital Approach?Methee Wongsirisuwan MD*

* Division of Neurosurgery, Department of Surgery, Rajavithi Hospital, College of Medicine,Rangsit University, Bangkok, Thailand

Endoscopic endonasal transsphenoidal approach (EETA) is an acceptable procedure as truly minimally invasiveneurosurgery in handling pituitary tumor. EETA can serve many patients in many aspects especially the hospital stay and thescarification. However, EETA still has some limitations that can cause serious complications. These complications such ascerebrospinal fluid leakage and bleeding control are less likely to occur if neurosurgeons use conventional approach namedas Pterional approach which was described by Yarsargil. To gain the benefit of both pterional approach and minimallyinvasive surgery, Keyhole Supraorbital Approach (KSA) was proposed by Perneczky in 1999. This approach has not thementioned limitation. However, there are many controversies between these two approaches in that what is the betterminimally invasive surgery in pituitary surgery? The present article, by clearing the pro and con of each approach, can helpneurosurgeons select the most appropriate way in handling pituitary surgery.

Keywords: Minimally invasive neurosurgery, Endoscopic endonasal transsphenoidal, Keyhole supraorbital, Pituitary

For a century since the beginning of brainsurgery, surgical treatment for brain lesions wasperformed using large extensive craniotomies. Theuncertain localization of the lesions preoperativelyforced neurosurgeons to make large enoughcraniotomies in removing the intracranial lesions.However, with the new innovative design of manysurgical instruments and equipments including theadvanced preoperative diagnostic imaging devices, thenew developing neurosurgical era called minimallyinvasive neurosurgery has become a reality. Minimallyinvasive surgery offers surgeons much improvementin neurosurgical operations to achieve successfulsurgery and good outcome for the patients. During thepast 10 years, there were many attempts to startminimally invasive neurosurgery. One of them was theattempt in 1945 by Dandy in treating hydrocephalususing the endoscope(1). However, due to the lack ofproper endoscopic instruments at that time, the resultwas unsatisfactory. After that, modern neurosurgical

instruments were much developed. The microscopewas used as an important tool in critical and vitalbrain structures. With this aid of the microscope,neurosurgeons could now develop new techniques inneurosurgical operations and these techniques madethe conventional neurosurgery shift to the minimallyinvasive era. However, the microscope was not asole instrument in developing minimally invasiveneurosurgery. Endoscopic neurosurgical instrumentstogether with the modern counter-balanced mobileoperating microscope also helped neurosurgeons indeveloping new techniques for minimally invasiveneurosurgery. Pituitary tumor surgery was a goodexample that got most benefit from these modernizedequipments. In the past, the most acceptable approachfor pituitary tumor removal was pterional approachproposed by Yasargil. With this approach togetherwith microscopic equipment, a tumor could beremoved with fewer complications. Surgeons could seeall the vital structures nearby the tumor. Bleedingcould be controlled without difficulty. However, thisapproach was still not considered as minimallyinvasive surgery.

After the beginning of the endoscopic era,endonasal endoscopic transsphenoidal approach

J Med Assoc Thai 2011; 94 (7): 888-95Full text. e-Journal: http://www.mat.or.th/journal

Special Article

J Med Assoc Thai Vol. 94 No. 7 2011 889

(EETA) for pituitary tumor removal was considered asa true minimally invasive pituitary neurosurgery.Pituitary tumor could be removed without visiblesurgical scar and the patients could be dischargedwithin a few days if they got no surgical complication.Many reports confirmed that EETA was the minimallyinvasive procedure(2), so many institutes consideredEETA as a first choice surgery in treatment for pituitarytumor. However, the endoscopic transsphenoidalsurgery was not the surgery without complications.In the other way, this approach still had some seriouscomplications compared with the conventional pterionalapproach especially the bleeding complication. Imaginethat a neurosurgeon had to stop arterial bleeding fromthe internal carotid artery in the deep and narrowspace through the nostril. This complication could behandled more easily through pterional approachcompared with endoscopic transsphenoidal approach.If neurosurgeons wanted to perform both minimallyinvasive surgery and safer surgery at the same time,what was the best choice of treatment?

Endoscopic endonasal transsphenoidal approach(EETA)

No one denies that endoscopic surgery is atrue minimally invasive surgery. The endoscope isespecially ideal for obtaining a detailed view in thedeep and narrow space. Such a space like that is theblind spot of microscopic view. Additional informationcan be obtained for safety’s sake during the surgicaldissection of the target area. Avoidance of unnecessaryretraction of critical structures can be expectedunder direct endoscopic view. Usually there are twotechniques regarding endoscopic microneurosurgery,Endoscope-Assisted Microneurosurgery (EAM)and Pure Endoscopic Microneurosurgery (PEM). ForEAM, the endoscope is used as an adjunct tool toprovide more detail in the deep surgical field. Theendoscope can reveal more detail in these blind spotareas such as the undersurface of the optic nerve orchiasm and the posterior surface of internal carotidartery. Usually, the endoscope will be used for a shortperiod. Both microscope and endoscope willsupplement each other due to their different opticalproperties. For PEM, the endoscope is used for thecomplete surgical process. A neurosurgeon can usehis/her hand as a holding device or the endoscope isfixed with a special holding device, offering free handsfor bi-manual dissection under the endoscopic view.EETA is one of the best examples for PEM, another oneis 3rd endoscopic ventriculostomy(3-5).

Keyhole supraorbital approach (KSA)Donald H. Wilson seemed to be the first who

described the term “keyhole surgery” as the extensionof limited trephinations(6,7). However, the aim ofkeyhole neurosurgery is not only limited craniotomybut also limited brain exploration and minimal brainretraction. In short, the criteria of the keyhole conceptis minimum iatrogenic neurotrauma but maximumefficiency in handling the lesions. The advantagesmay contribute to improved postoperative outcomeinclude shorter hospitalization time from lesscomplication compared with conventional technique.In having those advantages, neurosurgeons musthave both basic skill needed in conventional micro-neurosurgery and experience in handling criticalneurosurgical situations. According to Perneczky(6), ifthe diameter of craniotomy is less than 15 millimetersthen the intraoperative use of conventional micro-instruments becomes very limited.

In case of pituitary tumor including othersuprasellar lesions, KSA is done using a small incisionabove just next to the eyebrow about 2-4 cm in length.This incision is just placed above the supraorbitalprominence of the orbital wall. Small craniotomy withonly diameter about 3-5 cm can be used as a door toattack most lesions in the skull base of anteriorcranial fossa. After the dura is opened, surgeons canapproach to the deeper structures such as the planumsphenoidale, pituitary stalk, suprasellar space,ipsilateral and contralateral optic nerves, supraclinoidsegment of internal carotid artery and posteriorcommunicating artery through subfrontal and limitedpterional approach. Using KSA, neurosurgeons canhandle these vital structures as the traditional pterionalapproach does. The main differences between thesetwo approaches are the rapid recovery period andless pain degree. The cosmetic result of supraorbitalcraniotomy is generally excellent and most patientscould accept the visible scar at the eyebrow (Fig. 1).This supraorbital keyhole craniotomy combined withmodern and sophisticated instruments help theneurosurgeons to operate on tumor, intra-cerebralhematoma, aneurysm if anterior circulation with lessinvasive than the conventional pterional approach.

For sellar tumor especially with large supra-sellar or parasellar extension, this keyhole approachcan be used instead of the endonasal transsphenoidalapproach. Surgeons can manipulate the above-mentioned vital structures more effective and saferthan endonasal approach. Most case of suprasellarextension of pituitary tumor encased the optic nerve

890 J Med Assoc Thai Vol. 94 No. 7 2011

and arteries of Circle of Willis. They can be totallyremoved with this keyhole approach and seem to beimpossible for endoscopic transsphenoidal surgery.

In some cases such as craniopharyngioma,this tumor often compresses and encases these vitalstructures in all directions especially the undersurfaceof the optic nerve and chiasm. Under KSA togetherwith microscope, neurosurgeons cannot visualize thementioned undersurface area clearly. Endoscope canbe used as an adjunct to microscope to obliterate thisblind spot. If there are any complications, microscopeplus endoscope assistance is far safer than EETAalone.

Pro and Con between EETA vs. KSAAdvantage of EETA

No visible scarMay be this is the most outstanding

advantage of EETA compared with other approaches.Using endonasal space for the entrance to the sellararea means that there is no skin incision at all. In aneasy case, without using nasal speculum and nodestruction of turbinate or nasal mucosa, the firstanatomy that will be destroyed is sphenoid ostiumand sphenoidal floor. However, the minimally invasiveapproach does not mean the operation without scar.Neurosurgeons have to concern with many factorsbefore making the decision in choosing the bestapproach.

Recovery period and days of admissionIn most cases of EETA, the patients will

have short recovery period and hospital stay. If theyhave not any endocrinologic problem, they can bedischarged early. No need to return for stitch off.

Disadvantage of endoscopic endonasal trans-sphenoidal approach (EETA)

Transsphenoidal surgery, either microscopicor endoscopic, is considered as a safe procedure forpituitary tumor removal especially by experiencedsurgeons(8). However, this is not a safe procedure.Many factors could influence on the success of thiskind of operation(9).

Anatomical variation of endonasal pathwayAlthough endonasal pathway is a straight-

forward route start of opening of the nose up to theostium of sphenoid sinus, but anatomical variationsdo occur frequently and this makes the surgery moredifficult and requires strong surgical knowledge of the

endonasal anatomy(10). After the study of Sazgar et al,63% of patients had septum deviations(11). Conchabullosa presented up to 53% of patients and oftenassociated with the deviation of the nasal septum tothe contralateral side(12,13). This caused narrowing ofthe nasal lumen that can obscure the operative viewincluding the view during the introduction ofsurgical instruments. Another study that showeddiscovery of septal deviation is from Erik J van Lindertwho described 48% of patients have anatomicalvariations of endonasal pathway septum deviation(10).Complications during EETA in endonasal phaseoccurred in 3.8%. Confronting with anatomic variationof the noses may be difficult for neurosurgeons.In such a case, an ear, nose and throat (ENT)surgeon could help neurosurgeons by operating incollaboration. EETA in case of extremely narrowednasal pathway can endanger the patient if there arebleeding problems during the operation especially ifthe bleeding sources are from major arteries suchas sphenopalatine or internal carotid artery. Acoordinated team effort from different specialties isadvised to lessen this morbidity(14).

Image guidance neededImaged guidance is very important for the

newcomers performing EETA. Although there aremany useful landmarks during endonasal approachsuch as the nasal septum, middle turbinate, sphenoidostium, and vomer plate, these landmarks also havemany variations and cannot be easily recognized insome difficult cases. Using C-arm fluoroscope ornavigator is very helpful in such cases. This imageguidance can help the surgeon when he encounteredthe anatomical disorientation during dissection. If hegets lost during the approach, a serious devastatingsituation can occur. For example, if the approach is outof midline in the sphenoidal phase then the internalcarotid artery can be injured and this complication couldbe fatal. Even approaching strictly in the midline, theanatomical variation of internal carotid artery can stillcome in the way. To reduce the risk of deviation inpreoperative evaluation in nasal approach, usingeither MRI or CT scan is very important especially whenthe neurosurgeons are in the learning curve period(15).

Mononostril vs. Binostril approachApproaching in the nasal phase of EETA

has two concepts. One preferred a mononostrilwhile another advocated binostril approach(10). Themononostril will harm nasal mucosa more than the

J Med Assoc Thai Vol. 94 No. 7 2011 891

binostril because surgeons need to put manyinstruments through only one passage. This also canmake the surgery more difficult and may increase thedegree of complications especially in narrowed nasalpassage of some races. In such cases, the patientsmay have the breathing problem for the rest oftheir lives. To increase the space for mononostrilapproach, surgeons often require middle turbinateremoval. However, this can be considered as “minimallyinvasive”?

Skull base destruction and CSF leakage(Table 1)

One of the major and serious complicationsof transsphenoidal approach (both conventional andendonasal) was cerebrospinal fluid (CSF) leakage.This complication was reported in many literaturesand was known as a possible fatal complication(16,17).Especially in the hands of less experienced surgeons,this complication could be more frequent(18). Thiscomplication was rarely seen in conventional pterionalapproach and even in supraorbital keyhole approach.The CSF leak was treated with external lumbar drainageor even reoperation and secured with a fat graft ordural repair (which was not an easy way). Another pitfallduring the surgery, the Onodi cell (Sphenoethmoidalcell) may be mistaken for the sphenoid sinus.Removal of Onodi cell may lead to CSF leakage. Thiscomplication also seemed to occur less often in anexperienced surgeon.

Bleeding controlTo control the bleeding in any deep and

narrowed space is the nightmare for neurosurgeons.This complication strictly relates to the approach. Inpituitary tumor surgery, neurosurgeons are morefamiliar in controlling bleeding through the pterionalapproach much more than the transsphenoidalapproach(10). Even if the bleeding could be controlledsuccessfully, the patients might have a severe epistaxislater. Sphenopalatine artery at the inferolateral borderof the middle turbinate was one of the most commonbleeding sources and must be completely securedduring the operation. Some patients resulted in shockfrom the sphenopalatine artery bleeding. Anothermajor source of bleeding was from internal carotidartery especially if there was an anatomicaldisorientation with loss of route, which occurredduring the sphenoidal phase. Uncontrolled bleedingcan force neurosurgeons to abort the procedure andshift to conventional surgery. To lessen this, imageguidance can restore the anatomical disorientation.

Suprasellar manipulationMost cases of pituitary tumor have suprasellar

and parasellar extension. In such cases, the patientswill complain of a visual problem. Even though,transsphenoidal surgery can remove an intrasellartumor clearly but removing the suprasellar part is noteasy because of the higher extension of suprasellarpart and the deeper surgical depth. Some cases ofpituitary tumor have adhesion with the surroundingstructures, clearing the tumor from these structuresusing endoscope is not easy at all. There are manylimitations using endoscope in such the deep space ofEETA compared with microscope. One of them is oneor two-hands surgery, which will be discussed next.

Advantage of keyhole supraorbital approach (KSA)Familiarity of surgeonThe basic of KSA is much like the subfrontal

approach combined with pterional approach. Surgeonscan operate in the same way they got familiar. Mostof the critical landmarks can be visualized underthe microscope. The new innovated magnetic andcounter-balanced microscope makes the surgeonmore comfortable in such a long operative timecompared with the endoscopic procedure. Moreover,craniotomy skill is much easier compared withendoscopic skill in view of most neurosurgeons.Under critical situations, familiarity with the approachmay save the life of the patients(19).

EETA KSO

Numbers of patients (case) 15 28Operative time (average, in hour) 2.5 1.5Length of Stay (average, in day) 5 3Complication (case)

CSF leakage 4 0Require medication only 1 0Require continuous lumbar drainage 3 0Require reoperation 0 0

Postoperative infection (meningitis) 1 0Diabetes insipidus 3 5Optic nerve injury 0 1Rebleeding 1 0Carotid artery injury 1 0Postoperative epistaxis 2 0

Table 1. Characteristic details in pituitary adenomaapproach

EETA = endoscopic endonasal transsphenoidal approach;KSO = keyhole supraorbital approach

892 J Med Assoc Thai Vol. 94 No. 7 2011

Simple instrumentsCompared with EETA, basic craniotomy set

is much simpler than endoscopic set. Patientsundergoing KSA need no image guidance. In thecontrary, keyhole surgery needs simple anatomicallandmarks such as olfactory tract, internal carotidartery, optic nerve and chiasm, pituitary stalk, planumsphenoidale that can be visualized under direct visionor microscopic view. These landmarks make thesurgeons follow their path easier than EETA. WhilstEETA, this approach needs all new separate set ofinstruments. Most of them are expensive and can beused only in specific surgical operations. In a hospitalwhere cost-benefit is such a great concern, keyholecraniotomy is the best solution in all seasons.

Microscopic vs. Endoscopic skill of surgeonSkill to handle the endoscope is the new

one and demands more surgical experience for thenewcomers. Visualization of microscope is in threedimensions whereas the endoscope is only in twodimensions. Under 3D, a neurosurgeon can utilize hissurgical skill during pituitary tumor surgery betterthan in 2D. Endoscopic endosinus surgery is relativelynew to neurosurgeons, this makes many neuro-surgeons lack of endoscopic skill and may cause fatalcomplications in critical situations especially whenconfronting altogether with anatomical variations.However, for ENT surgeons, they are already well-experienced with endoscopic sinus approach. For thisreason, some neurosurgeons prefer to perform EETAin collaboration with an ENT surgeon.

Variety of applications (Table 2)Case selection for EETA is one of the gold

measures in successful surgery. To remove the tumorunder a deep and narrow space like the EETA, the tumorshould be easily suckable. In some pituitary tumors,

the tumor itself is not easily suckable. Neurosurgeonsneed bipolar cauterization and sharp cut with specialdesign microscissors, this procedure may traumatizecritical structures such as internal carotid artery orhypophyseal branch of pituitary gland. Sometimes,neurosurgeons plan to remove easily suckablepituitary tumor using EETA but finally found that thetumor cannot be easily suckable. If they continueoperation under this situation, the operative timemay take more time and this increased the risk ofcomplications afterwards. In the case of KSA, almostall of the lesions in sellar and suprasellar area can beremoved using KSA. These lesions are not onlypituitary tumor but also included the non-pituitarytumors such as craniopharyngioma, meningioma, andvascular lesion.

Bilateral free handsOperation done under bilateral free hands is

much more comfortable for neurosurgeon, especiallyunder some critical situations. For example, bleedingcontrol from main arterial source is very difficult tostop with only one free hand like EETA. Even thoughneurosurgeons use self endoscopic-holding device,bleeding control under bilateral free hands is still not apiece of cake. The lens surface of the endoscope willbe obscured by blood stream. Under KSA, surgeonswill have bilateral free hands at all time. This makesneurosurgeons feel more comfortable during the wholeperiod in the operating theatre.

Removing encased tumorIn a large pituitary tumor with massive

suprasellar or parasellar extension, the tumor has agreat likelihood to encase the vital structures such asarteries of Circle of Willis, optic nerve, optic chiasm,optic tract. Under EETA, it is impossible to remove thisencased tumor. Surgeons can only decompress thesenearby structures. However, under KSA, removingthis encased lesion is much easier and safer. Using amicroscope with or without endoscope-assistedtechnique, either decompression or removing thisencased tumor is easier compared with EETA.

Bleeding controlMost cases of pituitary tumors can control

bleeding easily using cottonoid together with surgicel®packing. Other bleeding control materials such as gelfoam, helitene®, avitene® are also helpful. However, ifthe bleeding point is from a main arterial bleeding likehypophyseal artery or the more serious source like

EETA KSO

MeningiomaSuprasellar/Planum sphenoidale 1 15

Craniopharyngioma 2 4Pituitary adenoma 15 28Rathke’s pouch cyst 1 2Anterior communicating artery aneurysm 0 2

Table 2. Numbers of cases using EETA/KSO

EETA = endoscopic endonasal transsphenoidal approach;KSO = keyhole supraorbital approach

J Med Assoc Thai Vol. 94 No. 7 2011 893

internal carotid artery, bleeding control in such a deepand narrow space like EETA may be apocalypse.Under KSA, bleeding control is much easier, evenfrom major sources as above-mentioned.

CSF leakageUnder EETA, surgeons have to reconstruct

the sellar floor and sphenoid sinus carefully. IfCSF comes out of this channel, lumbar drainage orreoperation is mandated. However, in the KSA group,surgeons can repair the dura in watertight fashion.In case of dural shortening, fascia combined withbioglue® is very helpful.

Recovery time and days of admissionCompared with EETA, patients operated

under KSA have a rapid recovery time. Most patientscan be extubated immediately after the operation.In cases without endocrine problem, they can bedischarged within a few days. This is the same as in theEETA group.

Disadvantage of KSASpecial designed instrumentsAs described by Perneczky, if the craniotomy

is smaller than 15 mm then the intraoperative use ofconventional microinstruments becomes very limited.Development of new tube-shaft microinstrumentsis mandatory for performing keyhole surgery. Thesespecially designed microinstruments are very expensivecompared with conventional microinstruments inbasic microneurosurgical set.

Visible scarThe distinct difference between EETA and

KSA seem to be the visible scar of KSA. EETA usesthe nasal pathway as the door to the sellar regionwhile KSA uses the supraorbital area, so KSA leavesthe visible scar just next to the eyebrow. To hide thisscar, meticulous subcuticular suture can alleviate thisproblem. In case of serious concern, collaboration witha plastic surgeon may be helpful. However, most scarswill fade out after 3-4 months and are hardly seen after6-12 months (Fig. 1). In clinical practice, most patientsdo not care about the visible scar as much as the resultand the safety of the operation using KSA. For EETA,there will be no visible scar at all. However, in somecases, operations will leave the nasal anomaly such asseptal deviation resulting in breathing difficulty.Though this deviation is not visible, it makes thepatients uncomfortable for the rest of their life.

Another visible scar is from the craniotomyborder. To perform the craniotomy, surgeon must makean initial hole first. Cutting the skull using craniotome,there will be some skull defect that can be seen throughthe forehead. To hide this visible scar, small diameterblade of craniotome and making a small initial hole byusing a small diameter drill are very helpful. Flapfix®,Craniofix®, or Titanium miniplate is very helpful tohide the burr defect. Bone filling substitute can also beused to hide the craniotomy defect.

Numbness of forehead and facial asymmetryTo enter the supraorbital margin, incision

must cut through the supraorbital nerve. This willleave numbness above the incision area and make thewrinkle of the ipsilateral side disappear. This facialasymmetry can be seen clearly when the patientsexpress facial appearance. Like the visible scarproblem, most cases will have spontaneous recoverywithin 6-12 months. In some selected cases, surgeonscan avoid this complication by making an incisionlateral to the supraorbital nerve.

Endocrine problemEntering the sellar and suprasellar area using

KSA has a main difference compared with the EETAin that KSA will reach the suprasellar and pituitarystalk first, whereas the EETA will reach the sellar firstand rarely reach up to the pituitary stalk. Mobilizingor injuring the stalk during KSA will aggravatepostoperative diabetes insipidus. To alleviate thiscomplication, surgeons must try to identify the stalk asearly as possible before cutting or cauterizing thetumor.

Fig. 1 Patients, after KSA, demonstrate visible scar3 months after the operation. The lady on the leftis pituitary tumor. The gentleman on the right isplanum sphenoidale meningioma

894 J Med Assoc Thai Vol. 94 No. 7 2011

Intrasellar viewThe biggest disadvantage of KSA seems to

be this problem. KSA enters the suprasellar and sellarregion in the same way as pterional approach. WhileKSA or pterional approaches have a great advantagein the clear view of sellar region, at the same time, theintrasellar region is the blind spot of this approachunder microscopic view. To reveal this blind spot,removal of planum sphenoidale using a high-speeddrill may be helpful. However, surgeons must use agreat effort during drilling this area because there arelots of critical structures such as optic nerve, arteriesof anterior circulation. EAM is very helpful in thissituation. Endoscope can pass through the keyholegateway while surgeons can operate under themicroscope at the same time. In many cases, endoscopecan also reveal not only the intrasellar area but also theundersurface of optic nerves (Fig. 2). Surgeons canachieve total tumor removal in this blind spot usingboth microscope and endoscope.

ConclusionThe introduction of endoscope into a special

field of surgery seems to be held equivalent with

minimal invasiveness, less traumatization and betterresults. For neurosurgeons, no one denies that EETAis one of the less approach-related morbidity inpituitary tumor surgery. Another than conventionalpterional approach or conventional transsphenoidalapproach, neurosurgeons can use this approach as anarmamentarium in handling a pituitary tumor. EETA is atruly minimally invasive procedure in removing pituitarytumor. However, a truly minimally invasive surgery doesnot mean only the operation without scar or operationwith short recovery period. It should have enoughsafety for the patients themselves. Some seriouscomplications are approach-related complicationssuch as bleeding problem or CSF leakage. In a verydifficult EETA case, having KSA in armamentarium as aminimally invasive procedure may help surgeons avoidunnecessary complications. To achieve a good outcomeunder minimally invasive concept, neurosurgeons mustselect the most appropriate approach based upon hisexperience and skill.

Potential conflicts of interestNone.

References1. Dandy WE. Diagnosis and treatment of strictures of

the aqueduct of Sylvius (causing hydrocephalus).Arch Surg 1945;51:1-14.

2. Dusick JR, Esposito F, Mattozo CA, Chaloner C,McArthur DL, Kelly DF. Endonasal trans-sphenoidal surgery: the patient’s perspective-survey results from 259 patients. Surg Neurol2006; 65: 332-42.

3. Cappabianca P, Alfieri A, de Divitiis E. Endoscopicendonasal transsphenoidal approach to the sella:towards functional endoscopic pituitary surgery(FEPS). Minim Invasive Neurosurg 1998; 41: 66-73.

4. de Divitiis E, Cappabianca P. Endoscopicendonasal transsphenoidal surgery. Adv TechStand Neurosurg 2002; 27: 137-77.

5. Jho HD, Carrau RL. Endoscopic endonasaltranssphenoidal surgery: experience with 50patients. J Neurosurg 1997; 87: 44-51.

6. Perneczky A, Reisch R. Keyhole approaches inneurosurgery. Volume 1: Concept and surgicaltechnique. Wien: Springer-Verlag; 2008.

7. Perneczky A, Muller-Forell W, van Lindert E,Fries G. Keyhole concept in neurosurgery: withendoscope-assisted microneurosurgery and casestudies. New York: Thieme Verlag; 1999.

8. Cappabianca P, Cavallo LM, Colao A, de Divitiis E.

Fig. 2 Endoscopic assisted microneurosurgery via KSAof large sellar and suprasellar tumor. (a) view undermicroscope (after subtotal removal by microscope)(b) endoscope was passed through the keyhole(c) and (d) views under endoscope (e) asterisk (*)is the remaining tumor attached with the stalk(f) pituitary stalk and undersurface of opticchiasm (g) closer view of endoscope demonstratedremaining tumor, Lilequist’s membrane andposterior clinoid process (h) patient 6 monthsafter the operation (i) Preoperative MRI

J Med Assoc Thai Vol. 94 No. 7 2011 895

Surgical complications associated with theendoscopic endonasal transsphenoidal approachfor pituitary adenomas. J Neurosurg 2002; 97: 293-8.

9. White DR, Sonnenburg RE, Ewend MG, SeniorBA. Safety of minimally invasive pituitary surgery(MIPS) compared with a traditional approach.Laryngoscope 2004; 114: 1945-8.

10. van Lindert EJ, Ingels K, Mylanus E, GrotenhuisJA. Variations of endonasal anatomy: relevancefor the endoscopic endonasal transsphenoidalapproach. Acta Neurochir (Wien ) 2010; 152:1015-20.

11. Sazgar AA, Massah J, Sadeghi M, Bagheri A,Rasool E. The incidence of concha bullosa andthe correlation with nasal septal deviation. B-ENT2008; 4: 87-91.

12. Stallman JS, Lobo JN, Som PM. The incidence ofconcha bullosa and its relationship to nasal septaldeviation and paranasal sinus disease. AJNR AmJ Neuroradiol 2004; 25: 1613-8.

13. Mladina R, Cujic E, Subaric M, Vukovic K. Nasalseptal deformities in ear, nose, and throat patients:an international study. Am J Otolaryngol 2008; 29:75-82.

14. Cappabianca P, Cavallo LM, Colao A, de Divitiis E.Surgical complications associated with the

endoscopic endonasal transsphenoidal approachfor pituitary adenomas. J Neurosurg 2002; 97: 293-8.

15. Cavallo LM, Dal Fabbro M, Jalalod’din H,Messina A, Esposito I, Esposito F, et al. Endoscopicendonasal transsphenoidal surgery. Beforescrubbing in: tips and tricks. Surg Neurol 2007; 67:342-7.

16. Cappabianca P, Cavallo LM, Colao A, Divitiis E.Surgical complications associated with theendoscopic endonasal transsphenoidal approachfor pituitary adenomas. J Neurosurg 2002; 51:699-707.

17. Koren I, Hadar T, Rappaport ZH, Yaniv E.Endoscopic transnasal transsphenoidalmicrosurgery versus the sublabial approach forthe treatment of pituitary tumors: endonasalcomplications. Laryngoscope 1999; 109: 1838-40.

18. Cavallo LM, Messina A, Esposito F, de Divitiis O,Dal Fabbro M, de Divitiis E, et al. Skull basereconstruction in the extended endoscopic trans-sphenoidal approach for suprasellar lesions. JNeurosurg 2007; 107: 713-20.

19. Snyderman C, Kassam A, Carrau R, Mintz A,Gardner P, Prevedello DM. Acquisition of surgicalskills for endonasal skull base surgery: a trainingprogram. Laryngoscope 2007; 117: 699-705.

การผาตดแบบทเจบตวนอยทสดสำหรบการผาตดเนองอกบรเวณตอมใตสมอง: การผาตด

แบบสอดกลองผานรจมกหรอการผาตดแบบรกญแจบรเวณเหนอกระบอกตา

เมธ วงศศรสวรรณ

การผาตดเนองอกบรเวณตอมใตสมองโดยการใชกลองเอนโดสโคปสอดเขาทางชองจมกเปนการผาตด

ทไดรบการยอมรบวาเปนการผาตดแบบทเจบตวนอยทสดสำหรบโรคน ผปวยจะไดประโยชนมาก โดยเฉพาะระยะเวลา

ท ตองอย ในโรงพยาบาลและการไมมแผลเปนใด ๆ ใหเหน อยางไรกดการผาตดแบบน มขอจำกดบางอยาง

โดยเฉพาะอยางยงขอจำกดทอาจสงผลใหเกดภาวะแทรกซอนรายแรง โดยเฉพาะอยางยงการเกดภาวะนำไขสนหลง

รว หรอ การหามเลอดททำไดลำบากในบางสถานการณจะเกดไดนอยกวา เมอทำการผาตดแบบปกตผานทาง

Pterional approach ทเสนอโดย Yarsargil ทงนเพอใหไดประโยชนจากทงการผาตดแบบปกต และแบบเจบตวนอย

การผาตดแบบรกญแจผานทางชองเลก ๆ เหนอกระบอกตาจงถกเสนอโดย Perneczky การผาตดดวยวธนไมมขอจำกด

แบบท การผาตดทางกลองผานรจมกมแตศลยแพทยระบบประสาท กยงคงถกเถยงกนวาระหวางสองวธน

วธไหนกนแนท เหมาะสม และเปนการผาตดแบบเจบตวนอยท สดสำหรบผ ปวยเน องอกบรเวณตอมใตสมอง

บทความนไดสรปขอดขอเสยของการผาตดแตละแบบไวเพ อใหประสาทศลยแพทยไดตดสนใจเลอกแนวทาง

ทเหมาะสมทสดในการผาตดเนองอกตอมใตสมอง