The Evolution Of The Technique

The existence of a route through the nose to the brain that avoided disfiguring the face was well known to the Egyptians (2600 BC), who used to insert special hooked instruments up through the nostril and the sphenoid sinus to extract the brain in the mummification process.

In the early 1900s, the same route was revived by Hirsch for the treatment of sella turcica lesions. He performed his first operation in a patient with a sellar lesion by means of a five-step procedure under local anesthesia. Despite the success of the operation, which required the removal of the left middle turbi-nate and of the ipsilateral ethmoid sinus without damaging the nasal septum, he changed his technique to Kocher's technique, a submucosal resection of the septum to reach the sphenoid sinus using a transrhinoseptal approach. A few years later in 1914, Cushing standardized the sublabial transeptal transsphenoidal approach that was, until recently, the most common approach used by neurosurgeons to treat sellar lesions. This procedure was adapted and modern-

From: Management of Pituitary Tumors: The Clinician's Practical Guide, Second Edition Edited by: M. P. Powell, S. L. Lightman, and E. R. Laws, Jr. © Humana Press Inc., Totowa, NJ

ized by Guiot (1958), Hardy (1969), Laws (1977), Post (1980), Tindall and Barrow (1986), and many others, improving the technique, thus making it safe and effective and with a low complication rate (1).

Guiot, in 1963 (2), was the first to propose the use of the endoscope within the transnasorhinoseptal microsurgical approach to explore the sellar contents, but his idea was not used. It would be 30 yr before advances in optical technology permitted the development of adequate instrumentation that has allowed the widespread use of endoscopes in nasal and paranasal sinus surgery (FESS) by otolaryngologists (3-5). After a brief period in which some authors (6,7) employed an endoscope-assisted technique, Jho, in 1993 (8), started to perform a "pure" endoscopic endonasal transsphenoidal surgery through the nasal cavity, as Hirsch 80 yr before had proposed and attempted in a primitive form.

Was this article helpful?

0 0

Post a comment