2. FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY NOVEMBER 01, 2006 Mohamed Kabil, MD Hrayr Shahinian, MD, FACS presentation for The 8th Asian Oceanian International Congress of Skull Base Surgery Dubai, United Arab Emirates

3. TABLE OF CONTENTS 02 Objectives 04 Tumors/Anatomy of the Sellar region 06 Brief History 08 Advantages 10 Operation Room Setup 12 Patient Positioning 14 Operative Technique 16 Fully Endoscopic Transcranial Approaches 18 Demographic Information 20 Complication Rates 22 Summary and Conclusion

4. INTRODUCTION OBJECTIVES  To compare and contrast the three different surgical approaches to the sellar region including the transcranial, transseptal transsphenoidal and the fully endoscopic endonasal approach  To describe the operative technique and our experience with the fully endoscopic endonasal approach  To display the results from our series of 1,000 patients who underwent fully endoscopic pituitary adenoma resections  To compare the outcomes and complication rates of endoscopic vs. microscopic pituitary surgery FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY 002

5. INTRODUCTION TUMORS OF THE SELLAR REGION Pituitary adenomas are the most common sellar tumors after the age of 30 and they represent 10% of all intracranial tumors OTHER TUMORS May mimic pituitary tumors radiologically and clinically  Craniopharyngiomas  Meningiomas  Rathke's cleft cysts  Epidermoid tumors  Arachnoid cyst  Carotid aneurysms  Others ANATOMY OF THE SELLAR REGION FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY 004

6. INTRODUCTION BRIEF HISTORY  Transcranial, 1889, Victor Horsley  Transseptal Transsphenoidal, 1909, Harvey Cushing (Schloffler, Kanavel, Halstead, Hirsch, and others)  Microsurgical transsphenoidal, 1970s, Jules Hardy  Early trials with the endoscope, 1970’s – 1990’s (Guiot, Apuzzo, others) MODERN ENDOSCOPIC PITUITARY SURGERY  Early 1990s, Endoscope-Assisted, (Including a series of patients at the SBI demonstrated 33-49% residual tumor only recognized with the endoscope)  Fully Endoscopic OPEN TRANSCRANIAL FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY 006 FULLY ENDOSCOPIC

7. THE FULLY ENDOSCOPIC ENDONASAL APPROACH ADVANTAGES  A completely endonasal approach  A targeted approach  A more clear visualization - Contact anatomy  A panoramic view - Angled endoscopes  A more complete operation leading to a lower rate of recurrence FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY 008 FULLY ENDOSCOPIC ENDONASAL APPROACH

8. 010 FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY OPERATION ROOM SETUP THE FULLY ENDOSCOPIC ENDONASAL APPROACH

9. 014 FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY OPERATIVE TECHNIQUE THE FULLY ENDOSCOPIC ENDONASAL APPROACH

10. 016 FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY FULLY ENDOSCOPIC TRANSCRAIAL APPROACHES TRANSGLABELLARSUPRAORBITAL SUBTEMPORAL

11. FeatureNumber Total number of Patients1000 Age (years) Mean Range 45 16 - 78 Sex: F:M1.6:1 Prior Pituitary Surgery157 LOS (days) Mean Range 1.3 1 - 4 Follow-up period (months) Mean Range 46.8 2 - 94 DEMOGRAPHIC INFORMATION (November 1998 - October 2006) ENDOSCOPIC VS. MICROSCOPIC APPROACH 018 FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY

12. TUMOR CHARACTERISTICS Tumor type Tumor Type and GradeNumber of Patients (%) Nonfunctioning Adenoma511 (51) Functioning Adenoma489 (49) PRL Adenoma221 (22) GH Adenoma158 (16) ACTH Adenoma110 (11) Tumor Grade Enclosed481 (48) I: Sella normal or focally expanded tumor < 10mm259 (26) II: Sella enlarged or tumor > 10mm222 (22) Invasive519 (52) III: Localized perforation of sellar floor218 (22) IV: Diffuse destruction of sellar floor301 (30) Massive Supra and parasellar extensions192 (19) Compression of optic chiasm314 (31) Cavernous Sinus invasion292 (29) ENDOSCOPIC VS. MICROSCOPIC APPROACH FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY

13. ENDOSCOPIC VS. MICROSCOPIC APPROACH 020 COMPLICATION RATES Complication (%)EndoscopicMicroscopic a Ant. Pit. Insufficiency2.119.4 Diabetes Insipidus2.517.8 Carotid Injury01.1 CNS Injury00.6 Intrasellar Hemorrhage0.42.9 Cerebrospinal Fluid Leak0.73.9 Postoperative epistaxis0.610 Meningitis01.5 a. Results of a national survey (Ciric et al., 1997) Reference: Kabil MS, Eby JB, Shahinian HK: Fully Endoscopic Endonasal vs. Transseptal Transsphenoidal Pituitary Surgery. Minim Invasive Neurosurg. 2005 Dec; 48(6):348-54. (An earlier series, 300 patients) Reference: Kabil MS, Eby JB, Shahinian HK: Fully Endoscopic Transnasal vs. Transseptal Transsphenoidal Pituitary Surgery. Neurosurg. Q 15(3):2005. (An earlier series, 300 patients) FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY

14. SUMMARY AND CONCLUSION SUMMARY  Endoscopy provides distinct advantages over microscopy  Allows for focus on preserving neurological function and reducing morbidity  Modern pituitary surgery has few complications and requires only a short hospitalization CONCLUSION  Skull base surgery has benefited significantly from advances in biotechnology  Impact upon the efficacy of tumor resection and subsequent rates of recurrence is significant  New stereoscopic endoscopes 022 FULLY ENDOSCOPIC SELLAR AND PARASELLAR SURGERY