Endoscopic Pituitary Surgery – Professional Video

Endoscopic Pituitary Surgery by Dr Ahsan ALi Khan and Dr Akbar Abbas

Hello, I’m Dr. Akbar Abbas, and today, along with my colleague from neurosurgery, Dr. Ahsan Ali Khan, we will walk you through an endoscopic pituitary surgery performed at Aga Khan University and Hospital. This case involves a pituitary macroadenoma exceeding 3 cm, which had caused visual disturbances in the patient. We opted for an endoscopic resection to address this issue.

Endoscopic Pituitary Surgical Procedure

1. Initial Marking:
The first step is marking the vertical incision point, which starts just proximal to the mucocutaneous junction at the nasal septum. On this particular day, we used a regular Bovie set at 12 to avoid excessive heat and prevent nasal septum perforation.

2. Raising the Hadad Flap:
Before starting, we identified the opening of the sphenoid sinus. The Hadad flap begins just below this opening and is based on the sphenopalatine vessels. After marking the upper end, we moved to identify the sphenoid sinus opening, then proceeded to mark and raise the inferior part of the flap.

3. Elevating the Flap:
Using a low voltage setting, we carefully marked the superior end to complete the vertical part first. We then started the inferior part of the incision. The size of the flap was adjusted to accommodate the expected CSF leak due to the large tumor.

4. Flap Elevation:
The flap was elevated using a Freer’s elevator and scissors, then parked inferiorly in the naris for future use. This process was repeated on the other side to ensure full visualization and identification of the sphenoid sinus openings.

5. Removal of the Keel:
With the flap secured, we began removing the bony septum with a chisel. The process was meticulous to avoid unnecessary damage and to prepare for tumor removal.

6. Forehand Technique:
In this patient, we employed the forehand technique, where I handled the scope from one side while Dr. Khan, standing on the opposite side, managed the suction and curettage. My role involved creating the approach and guiding the neurosurgeon to the dura.

7. Tumor Exposure and Removal:
Once the keel was exposed and the sphenoid sinus fully visualized, we began removing the tumor using a combination of chisels and mallet. The process involved slow and careful chiseling to prevent CSF leaks and excessive bleeding.

8. Tumor Decompression:
The tumor was systematically removed starting from the inferior part, followed by the lateral sides, and finally the superior part. This gradual approach minimized the risk of CSF leakage and ensured complete tumor removal while preserving the normal pituitary gland.

9. Final Checks and Closure:
After ensuring the tumor was fully removed, we performed a saline washout and prepared for closure. Surgicel was applied to control bleeding, and the Hadad flap was reflected back over the defect, ensuring the mucosal part faced outward to prevent future complications.

10. Sealing the Defect:
Duraseal was applied to the defect, followed by additional Surgicel and gel foam to secure the seal. Permanent packing was not required, ensuring a clean and effective closure.

Conclusion

This step-by-step guide highlights the intricate process of endoscopic pituitary surgery. Through careful planning and execution, we successfully removed the pituitary macroadenoma, alleviating the patient’s symptoms and ensuring a smooth recovery. Thank you for watching and learning with us. Another surgery on the subject can be viewed here.

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This educational video is for students and patients to make informed decisions about their own and others’ health. Dr Akbar Abbas is one of the best ENT specialists in Karachi, Pakistan. He specializes in otolaryngology, cochlear implants, and ear surgery and is one of the few experts on pituitary and head and neck cancer surgery in Pakistan. Presently serving at Aga Khan University Hospital.