Transsphenoidal surgery, formally named endoscopic endonasal transsphenoidal resection of pituitary adenoma, is a minimally invasive surgical approach for pituitary tumors. Surgeons access the sellar region via natural anatomical corridors consisting of the nasal cavity and sphenoid sinus through the nostril to remove pituitary tumors. This technique avoids traditional craniotomy and minimizes injury to surrounding tissues. Below is a detailed illustration of the surgical workflow, perioperative precautions, potential risks and risk management strategies.

 I. Surgical Workflow

 Preoperative Preparation

① Patient assessment: Physicians conduct comprehensive evaluation including imaging examinations (MRI, CT scans) to confirm tumor location, size and characteristics, as well as endocrine function tests to measure hormone levels.

② Preoperative instructions: Patients are required to fast from food and water to prevent vomiting and aspiration under anesthesia. Meanwhile, surgeons explain surgical details, expected outcomes and potential risks. Nasal cleansing and nasal care may be arranged for patients.

③ Anesthesia: General anesthesia is administered to ensure the patient remains unconscious throughout the operation.

 Surgical Steps

① Nasal access: The patient’s head is slightly elevated and the face turned away from the operative side. An endoscope and micro surgical instruments are inserted through one nostril.

② Septal dissection: Unilateral nasal septal mucosa is incised and dissected to expose the sphenoid ostium.

③ Opening of the sphenoid sinus: Multiple instruments are applied to remove the anterior wall of the sphenoid sinus to expose the sellar floor.

④ Sellar floor osteotomy: The bony sellar floor is carefully drilled open to expose the pituitary adenoma.

⑤ Tumor resection: Under neuroendoscopic or microscopic visualization, ultrasonic scalpels, lasers or conventional surgical instruments are used for meticulous tumor removal with maximum preservation of intact normal pituitary tissue.

⑥ Sellar floor reconstruction: After tumor resection, dural defects are reinforced with artificial dura mater, autologous fat or other graft materials to prevent cerebrospinal fluid (CSF) leakage.

⑦ Intraoperative final inspection: After confirming complete hemostasis and intact sellar reconstruction, surgical instruments are withdrawn and the nasal corridor is closed.

 Postoperative Management

① Monitoring: Patients are transferred to the intensive care unit or post-anesthesia care unit for close surveillance of vital signs, CSF leakage, visual changes and other indicators.

② Wound care: Nasal packing materials are removed within several hours to days to relieve nasal congestion and pain.

③ Pharmacotherapy: Hormone replacement therapy, anti-edema treatment and prophylactic anti-infection medication are administered as indicated.

④ Rehabilitation: Patients gradually resume daily activities and attend regular follow-up visits to monitor recovery progress and pituitary function.

 II. Preoperative and Postoperative Precautions

 For Patients

Prior to surgery, discontinue medications that increase bleeding risk such as aspirin in accordance with medical advice. After surgery, maintain adequate rest, avoid strenuous exercise, take medicines as prescribed, and promptly report any abnormal symptoms.

 For Surgeons and Medical Teams

Preoperatively, meticulously design surgical corridors and prepare necessary equipment and materials. Postoperatively, continuously monitor patient conditions, manage complications timely and provide standardized rehabilitation guidance.

 III. Potential Risks and Risk Management

1. CSF leakage: Cerebrospinal fluid may leak from the operative site intraoperatively or postoperatively. Precise surgical manipulation and proper sellar reconstruction can reduce such risks.

2. Visual impairment: The operative field lies adjacent to the optic nerve; careless manipulation may lead to vision loss. Delicate surgical technique and intraoperative monitoring are essential.

3. Hypopituitarism: Surgical trauma may impair normal pituitary function. Serial perioperative hormone monitoring and timely hormone replacement therapy constitute core management.

4. Infection: The nasal cavity harbors abundant bacteria. Strict aseptic technique and postoperative antibiotic prophylaxis effectively lower infection risks.

5. Altered nasal anatomy: The nasal septum and intranasal structures may be affected, resulting in impaired respiration. Intraoperative tissue protection and standardized postoperative nasal care are critical.

6. Hemorrhage: Intraoperative or postoperative bleeding represents a major hazard. Preoperative discontinuation of anticoagulants, thorough intraoperative hemostasis and continuous postoperative observation are required.

 IV. Risk Reduction Strategies

Surgeons must maintain high concentration and vigilance during surgery and strictly follow standardized surgical protocols. Close interdisciplinary teamwork guarantees adequate preparation and timely supply of surgical instruments and pharmaceuticals. Meanwhile, patients should comply with all preoperative preparation and postoperative care instructions to maximize surgical success and facilitate recovery. Specific strategies are listed below:

1. Accurate diagnosis: Comprehensive preoperative imaging evaluation to delineate tumor boundaries and adjacent anatomical structures.

2. Technical proficiency: The surgical team must master sophisticated neurosurgical skills and accumulate extensive experience in transsphenoidal procedures.

3. Advanced equipment: High-definition neuroendoscopes, ultrasonic scalpels and other state-of-the-art instruments improve surgical precision.

4. Multidisciplinary collaboration: Joint consultation involving endocrinology, neurosurgery and radiology teams to formulate individualized treatment plans.

5. Rigorous postoperative management: Continuous postoperative monitoring, timely complication intervention, systematic patient education and rehabilitation guidance.

 Conclusion

Transsphenoidal surgery for pituitary adenoma is a mature, minimally invasive therapeutic modality. Nevertheless, surgical safety and efficacy largely depend on adequate preoperative preparation, refined surgical skills, standardized postoperative care and proper control of potential risks. Close collaboration between patients and medical teams together with rigorous control of every procedural link is the key to optimizing surgical outcomes and lowering complication rates.

The World Neurosurgery Advisory Group (WANG) under International Neurosurgeon’s Circle (INC) brings together numerous globally renowned neurosurgical professors with exceptional operative skills and abundant clinical cases. One distinguished expert is Professor Sebastien Froelich from France, former Chairman of the Skull Base Surgery Committee of the World Federation of Neurosurgical Societies (WFNS). He specializes in neuroendoscopic endonasal resection of skull base tumors. He performs minimally invasive endoscopic surgery for complex intracranial lesions including chordomas, craniopharyngiomas and pituitary adenomas. His innovative endoscopic Chopstick Technique not only elevates gross total tumor resection rates but also achieves superior long-term prognosis for patients.

The above content regarding the procedure of transsphenoidal surgery for pituitary adenomas serves purely for reference and shall not be regarded as medical treatment guidance. If you wish to learn more information about pituitary adenomas, please contact us. Follow the official website and WeChat official accounts of INC. International Neurosurgeon’s Circle (INC) is an academic physician group dedicated to neurosurgical exchange. Its panel professors are members of WFNS and other international neurosurgical societies, editors of top global neurosurgery journals, and world-class authoritative neurosurgeons after whom surgical approaches and anatomical structures are named in neurosurgical textbooks.