Endoscopic Ethmoido-Pterygoido-Sphenoidal Approach to the Cavernous Sinus in Recurrent Invasive Pituitary Adenoma

Background: Sellar region is an anatomically complex region in close relationship with important neurovascular structures. As such the surgical treatment of recurrent aggressive pituitary adenomas invading the cavernous sinus represents an operative challenge, especially when a reintervention is warranted. Scar tissue and previous interventions materials hinders a clear visualization and understanding of the surgical anatomy through the endoscopic endonasal corridor.

Methods: Throughout a 2D surgical video, we describe in detail the surgical technique of the ethmoido-pterygoido-sphenoidal approach (EPSa) for the surgical re-operation of a recurrent pituitary adenoma in the context of a Nelson´s syndrome after bilateral adrenalectomy.

Results: This video details the surgical anatomy of the sellar region to facilitate the identification of surgical landmarks and anatomic boundaries with the goal of avoiding injury to the neurovascular structures involved in this approach. Anatomically, the authors would like to highlight the importance of few surgical anatomical landmark for getting access to the cavernous sinus: (1) the lateral orbital optic carotid recess (LOCR) is a bony depression that corresponds intracranially to the optic strut, a bony extension inferior to the anterior clinoid process, that separates the carotid artery from the optic nerve (2) the medial optic canal recess located at the inferomedial margin of the paraclinoid ICA; (3) the carotid protuberance; and (4) the vidian canal, which is considered to be the most critical landmark to accessing the anterior genu of the petrous horizontal segment of ICA. It is localized in the pterygoid wedge at the intersection between the sphenoid sinus floor and the medial pterygoid plate

Conclusion: The EPSa is a versatile approach that uses the endoscopic transsphenoidal route and thereby, reduces brain retraction. Anatomic landmarks offer a good sense of the area that is exposed in reoperations and reduce the risk of injury of important neurovascular structures located within the cavernous sinus and the parasellar region.