Surgical approaches to suprasellar and parasellar tumors

Uncommonly, pituitary tumors require a complex intracranial approach. In such instances of extensive para- and suprasellar involvement, an approach that incorporates basic techniques enhanced by developments in contemporary cranial base surgery is effective. Tumors with extensive invasion of the cavernous sinus unilaterally are generally best approached by a frontotemporal transcavernous strategy. Those with bilateral cavernous sinus involvement are better suited for a bifrontal transbasal type of approach. Supra-sellar tumors are best exposed by a strategy that affords the surgeon an adequate inferior-to-superior viewing angle, which is generally accomplished by removal of all or part of the orbital rim. These approaches yield benefits in decreased frontal lobe retraction, which may be particularly important in cases requiring a bilateral approach. Finally, some tumors with more modest extensions outside the bounds of the sella are now treated with a more minimalistic type of approach via a small incision in the eyebrow. This marks a move toward a "minimally invasive" type of strategy. Sound judgment based on adequate experience with these approaches must be exercised to ensure appropriate application of this strategy.