Sublabial transseptal approach with microscopic resection:
An incision is made under the lip and the nasal tissue and a section of the central partition of the nose is removed to form a large opening through which the remainder of the procedure is conducted. An adjustable retractor is placed into space whose blades reach to the sphenoid sinus. An operating microscope is used to resect the anterior wall of the sphenoid sinus, remove the floor of the sella, and incise the dura. The tumor is then removed from the pituitary. Any tumor in the sinuses and on the floor of the sella is also removed. The floor of the sella is then "plugged", usually with a fat graft from the abdomen. The microscope and retractor are removed, and all tissue, including nose and lip, are replaced and the incision is sutured. The nasal cavities are packed with some form of packing. Balloons or tampons are often used, although gauze is still used by some.
Transnasal transseptal approach with endoscopic resection:
An incision is made just inside one or both nostrils and an opening is made in the septum. There are two approaches, one using both nostrils (one for microscope, the other for the endoscope) and one where only one nostril is used. The bone that is removed is usually kept to be used later in the operation. The floor of the sella is again removed and the pituitary tumor is extracted in small fragments using the endoscope. When all tumor has been removed the saved bone is used to refashion the normal housing of the pituitary gland. The incision is sutured and the nostrils are packed similarly to the sublabial approach.
A modification that some surgeons use involves a septal pushover/direct sphenoidotomy: The incision is deeper within the nasal cavity where the cartilage meets the bony part of the septum. Entry to the sinuses are made on either side of the bony septum until the sphenoid sinus is reached.
With yet another possible modification, the posterior part of septum just in front of the sphenoid sinus is moved to one side and the sphenoid sinus can be reached more directly. There are several advantages to these techniques. Usually, packing is not needed with this approach.
Endoscopic approach with endoscopic resection:
No incision is made with this procedure. An endoscope is used alone (no microscope), and is maneuvered through one nostril, forcing the cartilage to separate from the septum allowing passage to the sinuses. The endoscope is used to proceed much like the other approaches. A fat graft is not always needed due to the small size of the opening with a pure endoscope approach. No packing is needed, either.
Watch while a minimally invasive endoscopic surgery is performed at Thomas Jefferson University Hospital (click here).