Endoscopic endonasal pituitary and skull base surgery.

Here we describe the procedures of endoscopic pituitary and skull base surgery in our institute. We also review the literature to reveal recent advances in this field. Endonasal approach via the sphenoid ostium was carried out for pituitary lesions without the nasal speculum. Postoperative nasal packing was basically not needed in such cases. For meningiomas, craniopharyngiomas, and giant pituitary adenomas, which required intra-dural procedures, nasal procedures such as middle nasal conchotomy and posterior ethmoidectomy, and skull base techniques such as optic canal decompression and removal of the planum sphenoidale were carried out to gain a wider operative field. Navigation and ultrasonic Doppler ultrasonography were essential. Angled endoscopes allowed more successful removal of tumors under direct visualization extending into the cavernous sinus and lower clivus. If cerebrospinal fluid (CSF) leakage occurred during operation, the dural opening was covered with a vascularized mucoseptal flap obtained from the nasal septum. Lumbar drainage system to prevent postoperative CSF rhinorrhea was frequently not required. Angled suction tips, single-shaft coagulation tools, and slim and longer holding forceps, all of which were newly designed for endoscopic surgery, were essential for smoother procedures. Endonasal endoscopic pituitary surgery allows less invasive transsphenoidal surgery since no postoperative nasal packing and less dependence on lumbar drainage are needed. Endoscopic pituitary surgery will be more common and become a standard procedure. Endoscopic skull base surgery has enabled more aggressive removal of extrasellar tumors with the aid of nasal and skull base techniques. Postoperative CSF leakage is now under control due to novel methods which have been proposed to close the dural defect in a water-tight manner. Endoscopic skull base surgery is more highly specialized, so needs special techniques and surgical training. Patient selection is also important, which needs collaboration with ear, nose, and throat specialists. As a safe and successful procedure in skull base surgery, this complex procedure should be carried out only in specialized hospitals, which deal with many patients with skull base lesions.