Minimally Invasive Endoscopic Approach to the Sella with Preservation of the Pedicled Nasoseptal Flap

Educational Objectives: Surgical access to the sella has evolved from an open transcranial to a sublabial microscopic and more recently an endoscopic endonasal approach. In certain cases, it is not clear whether a nasoseptal flap (NSF) will be necessary for repair of the cranial base at the start of the procedure. We present two minimally invasive endoscopic approaches to the pituitary that preserve the pedicle of the NSF. Deciding which method to implement depends on the presence of a septal deflection. The “1.5” is the most frequent approach reserved for cases without a septal deformity. In patients with nasal obstruction or when surgical access is limited secondary to a significant septal deviation or spur, the “tunnel” approach is generally used.

Methods: From 2013 to 2017, a total of 346 patients with a pituitary adenoma underwent endoscopic transsphenoidal tumor resections at a single institution. A retrospective review was performed and 292 patients underwent primary surgery using one of the two aforementioned approaches.

Results: In our series, 193 patients underwent a “1.5∀ and 99 had a “tunnel” approach. The overall gross-total resection (GTR) rate was 88% and access to the tumor was not limited in any of the cases. At least one pedicle to the NSF was preserved in 100% of cases with a transition toward bilateral NSF preservation during the course of the study period. There were 36 patients (12%) who ultimately required a NSF and a viable flap was successfully used in each case. 25 cases utilized the NSF at the time of initial surgery and 11 required the NSF during a subsequent procedure. There was no significant difference between the techniques with regard to complications such as sinusitis, crusting, synechiae or septal perforation.

Conclusion: We present a minimally invasive approach to the sella that maintains the integrity of the nasoseptal flap in 100% of cases. Our technique does not limit gross-total resection, simultaneously addresses septal deviations, limits a large posterior septectomy and obviates the need for middle turbinate resection.