ABSTRACT
In the 1960s, the advent of operative microscopy and intraoperative fluoroscopy significantly diminished the morbidity of pituitary surgery and made selective microadenomectomy possible by transphenoidal approaches (1-3). Transphenoidal surgery remains the primary approach for the majority of pituitary fossa and parasellar lesions because of its safety, low morbidity, and direct access to the pathology. For experienced surgeons, intraoperative fluoroscopy provides adequate trajectory guidance to the sella in the majority of primary (first operation) cases. However, single plane fluoroscopic images provide only two-dimensional information to the surgeon (i.e., anterior/posterior and rostral/caudal), and do not directly reflect right/left orientation with respect to the midline. The orientation to midline in transphenoidal surgery is especially important because of the potentially devastating consequence of injury to carotid artery, cranial nerves in the skull base, or violation of the middle fossa. In addition, when tumor has destroyed bony landmarks, fluoroscopy may not delineate critical boundaries for the surgeon. In reoperation or in cases where the lesion has extended beyond the sella, anatomic landmarks may be distorted or absent. In these cases, image-guided surgery (IGS) confirms correct trajectory and midline orientation, minimizing the risk of neurovascular complications.
