The transseptal approach to the pituitary gland

Transseptal, transsphenoidal pituitary surgery is safe and effective in the management of various problems associated with the region of the sella turcica. This series include 285 operations on 272 patients treated from Sept. 1, 1972, to Sept. 1, 1976. The operative mortality was 1.75%. In every patient, the anatomy should be assessed preoperatively by polytomograms of the sella and the sphenoid sinus and by bilateral carotid angiography. The operating microscope and intra-operative x-ray control with the image-intensifier are essentials. Pneumoencephalography is performed whenever the possibility of an empty sella or arachnoidal cyst exists and when angiography does not satisfactorily outline the suprasellar extension of large pituitary tumors. Computerized tomographic scanning is also of value. A new group of pathologic problems, namely microadenomas (tumors less than 1 cm in diameter), has now become amenable to transseptal surgical management. This series includes a group of 50 patients with microadenomas: 45 with functioning pituitary adenomas and 5 with nonfunctioning pituitary adenomas. The transfrontal intracranial surgical approach also has specific indications. This choice is determined by the anatomy and the extent and nature of the pathologic lesion. The rhinologic concepts of exposure and reconstruction are modifications of the "maxilla-premaxilla" (Cottle) approach to the nasal septum. This allows direct midline access to the sphenoid sinus and sella turcica while preserving both the caudal end of the nasal septum and the anterior nasal spine, thereby minimizing rhinologic airway and cosmetic complications. We believe that, by combining the talents of the neurosurgeon, endocrinologist, neuroradiologist, ophthalmologist, and rhinologist, this procedure can be offered to patients with a wide range of disorders and excellent results may be anticipated.