Transnasal Completely Endoscopic Resection of Pituitary Tumors Using a Binostril, Four-Handed Technique While Preserving the Potential for Nasoseptal Flap Reconstruction: The Subseptal Approach

Completely endoscopic transnasal resection of sellar and parasellar lesions is rapidly becoming commonplace. Experienced centers have extended this technique to approach increasingly complex disease. Concomitant improvements in endonasal skull base reconstruction with vascularized nasoseptal flaps have proven invaluable in reducing the associated risk of cerebrospinal fluid (CSF) rhinorrhea. These flaps are pedicled on the posterior septal artery, a terminal branch of the sphenopalatine artery. Traditional approaches to the sella transect this artery during the posterior septectomy, necessitating that the flap be harvested prior to tumor dissection to preserve it as a viable closure option. However, the most pituitary cases are straightforward and have a low incidence of intraoperative CSF leak. The routine early raising or harvest of nasoseptal flaps in every case seems excessive and is not without morbidity. The authors describe a novel technique for a binostril, four-handed approach to the sella, which preserves the nasoseptal flap and allows for its harvest and use at the time of closure only in the presence of an intraoperative CSF leak. Early results in 15 patients are presented.