The degree of pneumatization and the position of septae in the sphenoid sinus are highly variable. In the majority of cases the pituitary fossa will form a bulge in the posterior or posterosuperior region of the sphenoid and is easily identifiable with the operating endoscope.

1. Dr surbhi
Patna medical college
Pituitary tumors and surgery

2. SURGICAL ANATOMY

6.  The degree of pneumatization and the position of
septae in the sphenoid sinus are highly variable.
 In the majority of cases the pituitary fossa will
form a bulge in the posterior or posterosuperior
region of the sphenoid and is easily identifiable
with the operating endoscope.

9. Historical aspect
driven by the improvement in the optics.
Sir Victor Horsley in 1906 –transfontal craniotomy
Herman Schloffer first described a nasal approach
1907,
Harvey Cushing -transseptal, transsphenoidal
approach.
1960s the operating microscope
the surgeon gets excellent illumination, 3D
perception and two hands free for operating. This
has been the mainstay of pituitary surgery until
recently.

10. surgery in the late 1980s, and the first use in
pituitary surgery rigid endoscopy

11.  12 per cent of all primary brain tumours.
 The majority are adenomas and are benign.

14.  50 per cent of adenomas are nonfunctioning and
will present by virtue of their size as a space-
occupying lesion.

15. PRESENTATION OF PITUITARY
TUMOURS
 PROLACTINOMAS
 secondary amenorrhoea and galactorrhoea.
 dopamine controls prolactin secretion by
inhibiting its release.
 bromocriptine
 cabergoline.

16. GROWTH HORMONE-SECRETING
ADENOMAS
 acromegaly
 soft tissues and membranous derived bones
 coarsening of the facial features
 prognathism,
 hands and the feet increase
 lethargic and sweaty with macroglossia leading to
sleep apnoea.
 The internal changes lead to hepato-
splenomegaly, hypertension and increased risk of
cardiomegaly.

17.  insulin-like growth factor 1 (IGF1),
 Somatostatin
 Octreotide
 Surgery remains the treatment of choice
 Transsphenoidal surgery
 de-bulking of the tumour
 radiotherapy or somatostatin analogues

18. ADRENOCORTICOTROPHIC
HORMONE-SECRETING
ADENOMAS
 Cushing’s disease
 Ketoconazole
 Adenomas that produce ACTH are usually very
active
 Small tumours can be difficult to locate
 Surgical adenomectomy
 inferior petrosal sinus sampling

19.  ACTH levels to be assessed
 Pituitary adenomectomy

20. OTHER SECRETING PITUITARY
TUMOURS
 Thyroid stimulating hormone (TSH) tumours that
produce TSH, l
 uteinizing hormone (LH) and follicle stimulating
hormone (FSH
 less than 1 per cent of pituitary tumours.

21. OTHER LESIONS IN THE PITUITARY
FOSSA
 Rathke’s cleft cysts,
 craniopharyngiomas,
 meningiomas, chordomas and, rarely, aneurysms
of the vessels of the circle of Willis.
 Secondary metastases from primary
malignancies

22. MASS EFFECT PRESENTATION
 50 per cent of adenomas will present with the
hyper-secretion syndromes
 The classical presentation of a nonsecreting
tumour is that of bitemporal hemianopia,
headaches or hypopituitarism.

23.  The nonsecreting tumours cannot be treated
medically, and surgical regimens are the mainstay
of treatment.

24. PREOPERATIVE
MANAGEMENT
 establish whether the lesion is a nonfunctioning
or a functioning
 hormone type
 baseline hormone levels
 suitability for medical treatment
 residual pituitary function needs to be established

25.  Preoperative MR scanning
 computed tomography (CT)
 surgical navigation system
 image intensifier

26. Endoscopic technique
 PREPARATION
 decongestion of the nasal mucosa 10 mins before
 patient is anaesthetized in the reverse
Trendelenburg position
 decongestion

27. STEP 1: SPHENOIDOTOMY

28. STEP 2: RESECTION OF
POSTERIOR SEPTUM AND
ROSTRUM
 good access to the sphenoid sinuses
 Killian’s type incision 1 cm anterior to the front
wall of the sphenoid

29.  The muco-perichondrial flap raised
 The bone of the posterior septum , sections
preserved
 The rostrum of the sphenoid
 the muco-perichondrial flap on the side opposite
to the incision is removed with the micro-debrider.

30. STEP 3: IDENTIFICATION OF
LANDMARKS
 intrasphenoid sinus septae are highly variable
 The septae are reduced
 possible to identify the positions of the carotid
arteries, the bulge of the pituitary fossa and
possibly the optic nerves in the sphenoid.

31.  Careful correlation of the preoperative radiology
and the observed anatomy
 image intensifier or a surgical navigation system
will be necessary in a small minority of cases

32. STEP 4: OPENING OF THE
PITUITARY FOSSA

33. STEP 5: ADENOMECTOMY
 standard pituitary ring curettes.
 Gentle manipulation of the ring curettes
 A normal pituitary gland appears yellower than
tumour tissue and is more adherent to the walls
of the fossa.

34.  positioning the tip of the endoscope inside the
fossa.
 not to breach the diaphragm above the pituitary
fossa
 Large tumours are resected by gently removing
the inferior margin of the tumour

35. STEP 6: CLOSURE
 Small balls
 The dura of the anterior pituitary
 bony defect is repaired by placing a patch of
bone
 Gelfoam over bony opening
 ribbon gauze

36. POST-OPERATIVE
MANAGEMENT
 Neurological observation is recommended for the
first 12–24 hours
 fluid balance charts and daily urea and
electrolytes are monitored
 A regimen of steroid cover
 Antibiotic cover is necessary for 7 days.

37. COMPLICATIONS
 Bleeding
 Cerebrospinal fluid leak
 Infection
 Visual problems
 Endocrine problems

38. RADIOTHERAPY IN THE MANAGEMENT OF
PITUITARY ADENOMA
 Radiotherapy can be an effective treatment for
smaller adenomas and hyper-secretion
syndromes,
 2 to 5 years
 hyper-secretion syndrome
 Normal pituitary function will also decline with
time
 long-term endocrine monitoring and hormone
replacement

39.  residual raised hormone secretion
 Unfit
 Nelson syndrome
 s/e:cva,hypopitutarism,on,bn,sec tumor
 Stereotactic radio-surgery in the form of the
gamma knife or cyber knife
 improved control of hyper-section and a
decreased reduction in residual pituitary function
over conventional radiotherapy.

40. Thankyou