FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY NOVEMBER 01

FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY NOVEMBER 01, 2006 Mohamed Kabil, MD Hrayr Shahinian, MD, FACS presentation for The 8 th Asian Oceanian International Congress of Skull Base Surgery Dubai, United Arab Emirates

TABLE OF CONTENTS 02 Objectives 04 Tumors/Anatomy of the Sellar region 06 Brief History 08 Advantages 10 Operation Room Setup 12 Patient Positioning 14 Operative Technique 16 Fully Endoscopic Transcranial Approaches 18 Demographic Information 20 Complication Rates 22 Summary and Conclusion

INTRODUCTION OBJECTIVES § To compare and contrast the three different surgical approaches to the sellar region including the transcranial, transseptal transsphenoidal and the fully endoscopic endonasal approach § To describe the operative technique and our experience with the fully endoscopic endonasal approach § To display the results from our series of 1, 000 patients who underwent fully endoscopic pituitary adenoma resections § To compare the outcomes and complication rates of endoscopic vs. microscopic pituitary surgery FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY 002

INTRODUCTION TUMORS OF THE SELLAR REGION ANATOMY OF THE SELLAR REGION Pituitary adenomas are the most common sellar tumors after the age of 30 and they represent 10% of all intracranial tumors OTHER TUMORS May mimic pituitary tumors radiologically and clinically § Craniopharyngiomas § Meningiomas § Rathke's cleft cysts § Epidermoid tumors § Arachnoid cyst § Carotid aneurysms § Others FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY 004

INTRODUCTION BRIEF HISTORY OPEN TRANSCRANIAL § Transcranial, 1889, Victor Horsley § Transseptal Transsphenoidal, 1909, Harvey Cushing (Schloffler, Kanavel, Halstead, Hirsch, and others) § Microsurgical transsphenoidal, 1970 s, Jules Hardy § Early trials with the endoscope, 1970’s – 1990’s (Guiot, Apuzzo, others) MODERN ENDOSCOPIC PITUITARY SURGERY FULLY ENDOSCOPIC § Early 1990 s, Endoscope-Assisted, (Including a series of patients at the SBI demonstrated 33 -49% residual tumor only recognized with the endoscope) § Fully Endoscopic FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY 006

THE FULLY ENDOSCOPIC ENDONASAL APPROACH ADVANTAGES FULLY ENDOSCOPIC ENDONASAL APPROACH § A completely endonasal approach § A targeted approach § A more clear visualization - Contact anatomy § A panoramic view - Angled endoscopes § A more complete operation leading to a lower rate of recurrence FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY 008

THE FULLY ENDOSCOPIC ENDONASAL APPROACH OPERATION ROOM SETUP FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY 010

THE FULLY ENDOSCOPIC ENDONASAL APPROACH OPERATIVE TECHNIQUE FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY 014

FULLY ENDOSCOPIC TRANSCRAIAL APPROACHES TRANSGLABELLAR SUPRAORBITAL SUBTEMPORAL FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY 016

ENDOSCOPIC VS. MICROSCOPIC APPROACH DEMOGRAPHIC INFORMATION (November 1998 - October 2006) Feature Total number of Patients Age (years) Mean Range Sex: F: M Number 1000 45 16 - 78 1. 6: 1 Prior Pituitary Surgery 157 LOS (days) Mean Range 1. 3 Follow-up period (months) Mean Range 1 -4 46. 8 2 - 94 FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY 018

ENDOSCOPIC VS. MICROSCOPIC APPROACH TUMOR CHARACTERISTICS Tumor Type and Grade Tumor type Nonfunctioning Adenoma 511 (51) Functioning Adenoma 489 (49) PRL Adenoma 221 (22) GH Adenoma 158 (16) ACTH Adenoma 110 (11) Enclosed I: Sella normal or focally expanded tumor < 10 mm Tumor Grade Number of Patients (%) II: Sella enlarged or tumor > 10 mm Invasive 481 (48) 259 (26) 222 (22) 519 (52) III: Localized perforation of sellar floor 218 (22) IV: Diffuse destruction of sellar floor 301 (30) Massive Supra and parasellar extensions 192 (19) Compression of optic chiasm 314 (31) Cavernous Sinus invasion 292 (29) FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY

ENDOSCOPIC VS. MICROSCOPIC APPROACH COMPLICATION RATES Complication (%) Endoscopic Microscopic Ant. Pit. Insufficiency 2. 1 19. 4 Diabetes Insipidus 2. 5 17. 8 Carotid Injury 0 1. 1 CNS Injury 0 0. 6 Intrasellar Hemorrhage 0. 4 2. 9 Cerebrospinal Fluid Leak 0. 7 3. 9 Postoperative epistaxis 0. 6 10 0 1. 5 Meningitis a a. Results of a national survey (Ciric et al. , 1997) Reference: Kabil MS, Eby JB, Shahinian HK: Fully Endoscopic Endonasal vs. Transseptal Transsphenoidal Pituitary Surgery. Minim Invasive Neurosurg. 2005 Dec; 48(6): 348 -54. (An earlier series, 300 patients) Reference: Kabil MS, Eby JB, Shahinian HK: Fully Endoscopic Transnasal vs. Transseptal Transsphenoidal Pituitary Surgery. Neurosurg. Q 15(3): 2005. (An earlier series, 300 patients) FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY 020

SUMMARY AND CONCLUSION SUMMARY § Endoscopy provides distinct advantages over microscopy § Allows for focus on preserving neurological function and reducing morbidity § Modern pituitary surgery has few complications and requires only a short hospitalization CONCLUSION § Skull base surgery has benefited significantly from advances in biotechnology § Impact upon the efficacy of tumor resection and subsequent rates of recurrence is significant § New stereoscopic endoscopes FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY 022