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  • Transsphenoidal Approach to Lesions of the Sella Turcica: Historical Overview

    Authors

    Giuseppe Lanzino, MD*
    Edward R. Laws, Jr., MD**
    Iman Feiz-Erfan, MD
    William L. White, MD

    Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
    *Current Address: Department of Neurosurgery; University of Illinois College of Medicine at Peoria; Peoria, Illinois
    **Department of Neurosurgery, University of Virginia, Charlottesville, Virginia

    Abstract

    Like many technological and scientific advances, the development of the transsphenoidal approach to treat lesions of the sella turcica represents an evolutionary rather than revolutionary process.  This article summarizes the events and some of the individual contributions that eventually led to the widespread acceptance of this approach.

    Key Words: history, pituitary adenoma, sella turcica, transsphenoidal surgery

    The transsphenoidal procedure as it is now known was successfully performed in the first decade of the 20th century.  Yet, only in the past few decades has this procedure gained widespread acceptance.  Early efforts to resect sellar lesions evolved as a natural consequence of two factors.  First, the introduction of x-rays by Roentgen allowed an enlarged sellar floor in patients with tumors in this region to be visualized.  Second, toward the end of the 19th century, certain endocrinological abnormalities were linked to pituitary tumors.

    Resection of a pituitary tumor through a craniotomy was reported as early as the late 19th century.[8]  However, the high rates of morbidity and mortality associated with craniotomies performed for the treatment of tumors led surgeons to explore alternative avenues to reach the pituitary gland.  Early efforts to reach the sellar region through transfacial approaches, however, also were characterized by high rates of morbidity and disfiguring scars (Fig. 1).[9]  Around 1910, almost contemporarily, Harvey Cushing in North America and Oskar Hirsch, an ear-nose-throat surgeon working in Vienna, integrating the technical minutiae and contributions from many other pioneers, theorized the possibility of a surgical approach, and successfully resected a pituitary lesion through a translabial/transseptal (Cushing’s approach) or a transnasal/transseptal (Hirsch’s approach) route.  With only a few modifications, these two approaches are identical to the ones routinely used today.

    Figure 2. Oskar Hirsch, 1877-1965. From Hamlin H: Oskar Hirsh 1877-1965. Surgical Neurology 16:391-393, 1985, with permission from Elsevier Science.

    Hirsch (Fig. 2), following the example set by his teacher Hajek who had devised an operation to treat sphenoid sinusitis, became interested in the anatomy and pathology of the paranasal sinuses and collected numerous cadaveric specimens, which he used to teach a course at the local university.[2]  According to the custom of the time, Hirsch first demonstrated the transnasal transseptal exposure of the sphenoid sinus and pituitary gland in a cadaveric specimen in front of the medical society of Vienna.[6]  The procedure was received rather coldly and even Hirsch’s mentor, Hajek, judged it too dangerous.[7]Undiscouraged by this skepticism, Hirsch performed the procedure in a living human.[5]  The first patient treated by a transnasal transseptal procedure had lost her vision.  Hirsch incompletely resected a tumor in five stages with the patient under local anesthesia.[5]  After the last procedure, the patient was “. . . so slightly disturbed by the operation that she was able to walk with a nurse from the operating room to her ward . . .!!”  Her vision eventually improved.

    Figure 3. Illustration showing the Hirsch endonasal submucosal transseptal approach to the sella turcica. A speculum is used to retract the mucosal flaps laterally and to maintain exposure. From Hardy J: Transsphenoidal hypophysectomy. J Neurosurg 34:582-594, 1971. With permission from Journal of Neurosurgery.

    Hirsch continued to perfect the procedure until he was able to perform it in a single stage.  Hirsch’s superb concept of exposing the sella is well documented by an artist’s interpretation of his approach (Fig. 3).  Because of the political turmoil in Europe, Hirsch left Vienna and moved to Boston where he continued to perform transsphenoidal surgery.

    Figure 4. Illustration from Cushing’s 1914 article showing his translabial transsphenoidal approach to the sella turcica. Reproduced with permission from Ranice Crosby, John Cody: Max Brödel: The Man Who Put Art Into Medicine. New York: Springer-Verlag, 1991. Original Drawing #75 in the Brödel Archives at Johns Hopkins University, Baltimore, MD.

    In 1910 Harvey Cushing approached the pituitary gland through a translabial transseptal route (Fig. 4).  In his description of the procedure, Cushing acknowledged the contributions of other surgeons: “The procedure which I have come to employ is merely a composite of such modifications of the Schloffler operation, suggested by Kanavel, Halstead, Hirsch, and others, as are adapted to my own requirements.  It therefore makes no claim for originality.”[1]  Until the mid to late 1920s, Cushing continued to use the transsphenoidal approach almost exclusively for the treatment of sellar lesions.

    In 1929 Cushing abandoned the transsphenoidal procedure in favor of the transcranial approach.[10]  The reasons underlying this sudden, dramatic change in preference are mostly unknown, but there are several speculations.  First, the safety of transcranial surgery had greatly improved, primarily under the impulse of Cushing himself.  Second, there was a strong perception that visual field defects, the primary indication for pituitary surgery at that time, improved more after a transcranial approach than after a transsphenoidal approach.  Finally, given the inadequacy of imaging modalities, diagnostic surprises (i.e., intracranial aneurysms or other nonpituitary tumors such as meningiomas, chordomas, and craniopharyngiomas) were common and easier to treat through a craniotomy than through the narrow and dark trajectory provided by the transsphenoidal approach.  Because of Cushing’s authority and influence, the transsphenoidal procedure was almost uniformly abandoned in both North America and Europe.

    Figure 5. Photograph of Norman Dott by Grace Allison, a former patient who as a child had been surgically treated for a pituitary tumor by Dott. From Rush C, Shaw JF: With Sharp Compassion. Norman Dott: Freeman Surgeon of Edinburgh. Edinburgh: Aberdeen University Press, 1990. With permission from John F. Shaw.

    Conceivably, the transsphenoidal procedure would have largely been forgotten if not for the persistence and vision of Norman Dott (Fig. 5), a neurosurgeon from Edinburgh, Scotland.  Dott spent a fruitful year as a Rockafeller Fellow at the Peter Bent Brigham Hospital under Harvey Cushing (Fig. 6) and was impressed by Cushing’s transsphenoidal approach.  Once back in Edinburgh, Dott continued to use the procedure with excellent results.  To overcome some of the difficulties associated with performing such a challenging procedure without proper illumination, Dott devised a special speculum with lights attached to it.  The device became widely known as Dott’s speculum.  The best portraits of Dott available (Fig. 5) were taken by one of his former patients—direct proof of Dott’s surgical mastery.  In her childhood she had been treated for a pituitary lesion causing visual dysfunction.  After Dott’s operation her vision improved to the point that she became a professional photographer.[11]

    Figure 6. Photograph of Cushing’s team during Dott’s stay in Boston. Dott is standing in the back row, last person on the right. Cushing is seated in the front row, center. Reprinted with permission from Rush C, Shaw JF: With Sharp Compassion. Norman Dott: Freeman Surgeon of Edinburgh. Edinburgh: Aberdeen University Press, 1990. With permission from John F. Shaw.

    The lineage of the transsphenoidal procedure passed through France and the work of  Gerard Guiot.  A true pioneer, credited among many other things to have performed the first neurosurgical procedure under cardiac arrest (to treat a complex arteriovenous malformation), Guiot had visited Dott in Edinburgh and was impressed by his results with transsphenoidal surgery.[10]  Back in Paris at the Hospital Foch, Guiot started to perform the procedure himself.  Eventually, he extended the indications of transsphenoidal surgery to other nonpituitary lesions such as chordomas and craniopharyngiomas.  To help the surgeon maintain orientation during the procedure, Guiot added intraoperative fluoroscopy as a surgical adjunct.  This innovation was essential to the popularization of the procedure.  From 1955 to 1999 Guiot and the group at the Hospital Foch, which included Derome, Visot, and Rougerie, among others, performed more than 5000 transsphenoidal procedures (Derome, personal communication, 2001).

    Figure 8. Gerard Guiot (left) and Jules Hardy (right) performing a functional procedure during Hardy’s stay in Paris. Courtesy of Jules Hardy.

    Figure 9. Jules Hardy operating room set-up with the microscope and intraoperative fluoroscopy. From Hardy J: Transsphenoidal hypophysectomy. J Neurosurg 34:582- 594, 1971. With permission from Journal of Neurosurgery.

    The return of the transsphenoidal procedure to North America, its refinement, and its popularization reflect the work and vision of Jules Hardy (Fig. 7).[3,4]  After finishing his neurosurgical training in Montreal, Hardy spent a year with Guiot in Paris to learn functional neurosurgery for the treatment of movement disorders (Fig. 8).  While in Paris, Hardy become interested in Guiot’s transsphenoidal approach to the pituitary gland.  After he returned to Canada, Hardy refined the procedure and introduced the surgical microscope (Fig. 9).  Until then the primary indication for transsphenoidal surgery was decompression of the optic apparatus associated with large tumors.  With the microscope, Hardy became aware of the possibility of visualizing the normal gland and therefore of the possibility of radically resecting pituitary neoplasms while leaving normal pituitary function intact.  He introduced the concept of microadenoma and showed that even small tumors could be removed safely with clinical improvement of the associated endocrinopathies.  This step marked a breakthrough in the field of endocrinology.[3]

    References

    1. Cushing H: The Weir Mitchell lecture.  Surgical experiences with pituitary disorders.  JAMA  63:1515-1525, 1914
    2. Hamlin H: Oskar Hirsch.  Surg Neurol  16:391-393, 1981
    3. Hardy J: Transsphenoidal microsurgery of the normal and pathological pituitary.  Clin Neurosurg 16:185-217, 1969
    4. Hardy J: Transsphenoidal hypophysectomy.  J Neurosurg 34:582-594, 1971
    5. Hirsch O: Endonasal method of removal of hypophyseal tumors.  With report of two successful cases.  JAMA 55:772-774, 1910
    6. Hirsch O: Eine neue methode der endonasalen operation von hypophysentumoren.  Wien Med Wschr 59:636-637, 1909
    7. Landolt A, Strebel P: Techniques of transsphenoidal operation for pituitary tumors.  Adv Tech Stand Neurosurg 7:119-177, 1980
    8. Liu JK, Das K, Weiss MH, et al: The history and evolution of transsphenoidal surgery.  J Neurosurg 95:1083-1096, 2001
    9. Loewe L: Ueber die freilegung der sehnervenkreuzung und der hypophysis und über die beteiligung des siebbeinlabyrinthes am aufbau der supraorbitalplatte.  Z Augenheilk 19:456-464, 1908
    10. Rosegay H: Cushing’s legacy to transsphenoidal surgery.  J Neurosurg 54:448-454, 1981
    11. Rush C, Shaw JF: With Sharp Compassion.  Norman Dott: Freeman Surgeon of Edinburgh. Edinburgh: Aberdeen University Press, 1990

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