Combined Hybrid Microscopic and Endoscopic Transsphenoidal Surgery: Anatomy, Instrumentation, and Technique

Surgical management of pituitary tumors has evolved considerably since the first report by Victor Horsley in the early 1900s. Made largely possible by advancing technology, various approaches have been used including a lateral rhinotomy, sublabial, transcranial, and transnasal to name a few. Presently the transnasal approach is the most popular and has evolved to rely heavily upon the endoscope for visualization though historically it was the operating microscope that made the operation possible. The merits of endoscopic-transnasal versus microscopic-transnasal have been debated much like the clip-versus-coil debate for treatment of intracranial aneurysms. Similar to the vascular debate, no one instrument or technique is superior in all regards. This chapter describes the utility of a hybrid approach combining both endoscopic and microsurgical techniques which are used as individual circumstances dictate. As no single surgical approach is perfect, surgeons should not limit themselves to only one technique or approach, but rather use all options available.