Practical and technical aspects of trans-sphenoidal surgery

Trans-sphenoidal surgery was first described more than a century ago. Today, this approach occupies a crucial place in the armamentarium of the neurosurgeon for the management of sellar, suprasellar, and parasellar pathological conditions. Over the years, the procedure has witnessed multiple modifications, benefitting from technological advances and from innovative ideas of pioneering neurosurgeons and otolaryngologists. The introduction of the microscope and then the endoscope allowed progressive improvement of visualization, illumination, and magnification in this restricted surgical corridor. With enhanced knowledge and understanding of the surgical anatomy of the skull base, the application of extended transsphenoidal approaches became possible, thus widening significantly the anatomical area that can be reached through this approach. In addition, the continuous improvement in imaging, image guidance, and microinstruments allowed better planning and precision during surgery. In sum, thanks to recent technological advance, trans-sphenoidal surgery can now be applied to a large area of the skull base and for a wide range of pathological conditions. With growing experience, the procedure is performed with enhanced safety and greater efficacy. In this paper, we review the historical evolution of trans-sphenoidal surgery and describe the modern applications and modifications of the procedure.