The endoscopic endonasal transsphenoidal approach to the suprasellar cistern.

The transsphenoidal transplanum, transtuberculum approach to the suprasellar cistern, also called the “extended” transsphenoidal approach, has been used during the past 10 years by experienced transsphenoidal surgeons to remove a limited number of well-circumscribed suprasellar lesions (7, 8, 10, 17, 20–23, 29). Initially, a sublabial approach was generally used and visualization was provided with a microscope through a Hardy retractor. Many of the lesions were sellar-suprasellar, i.e., sellar lesions that extended through the diaphragma sellae into the suprasellar cistern. In a few instances, surgeons described removal of purely suprasellar lesions that rested above a normal-sized sella. However, the limited field of view provided by the Hardy retractor significantly impaired the widespread application of this approach.6 More recently, with the increasing use of endonasal endoscopy, several authors have begun to adopt a purely endoscopic transsphenoidal approach to the suprasellar cistern.3,4,9,16,18,19,25 The panoramic field of view provided by the endoscope, as well as the ability to use angled scopes, increases the use and applicability, as well as the safety of this approach to remove a variety of both prechiasmal (Fig. 37.1A) and postchiasmal (Fig. 37.1B) lesions. This approach is not only useful in removing lesions that extend into the sella but can also be applied to tumors that sit in the suprasellar cistern above a normal-sized sella.