Revision Endoscopic Pituitary Surgery: Technical Considerations for Skull Base Reconstruction

Introduction: Revision endoscopic pituitary surgery is associated with a number of challenges, including loss of anatomic markers, distortion of tissue planes, and loss of options for local reconstructive flaps. Modifications in reconstruction technique in these cases remain incompletely described.

Methods: A retrospective case series of all revision endoscopic pituitary surgeries performed over a 2-year period at a single institution was reviewed for reconstruction techniques and perioperative outcomes.

Results: Six patients with a prior history of microscopic trans-sphenoidal surgery underwent revision endoscopic pituitary surgery. The indications for surgery in this series included acromegaly in one patient and nonsecreting macroadenoma with mass effect in five patients. The surgical issues encountered with these patients included loss of anatomic markers of the nasal cavity, sphenoid sinus, and sella. Reconstructive challenges included loss of local nasal tissue and impaired wound healing. All patients underwent endoscopic skull base reconstruction using various modifications of the multilayered free tissue reconstruction and the “gasket-seal” reconstruction. Two patients experienced postoperative cerebrospinal fluid leakage (CSF) in this series; one of which resolved with lumbar drainage alone and one of which resolved following revision endoscopic surgery. All patients were free of CSF leak at last follow-up. The role of various reconstructive options is discussed.

Conclusions: Revision endoscopic pituitary surgery is associated with unique surgical challenges related to both the approach and reconstruction. An understanding of the various technical solutions to these surgical challenges is necessary.