The Endoscopic Hemi-Transseptal Approach to the Sella Turcica: A Technique Allowing Preservation of the Nasoseptal Flap for Selective Use in Reconstruction

Introduction: The nasoseptal flap has helped to dramatically reduce the rate of CSF fistula following endoscopic skull base surgery, and therefore it has been widely adopted. It is, however, associated with a number of potential drawbacks including prolonged crusting of the donor site, septal cartilage necrosis, and decreased olfaction. Furthermore, the decision to raise the flap is often taken at the beginning of surgery in order not to damage the vascular pedicle during the approach. If no intraoperative CSF leak is encountered, the harvest of this flap is likely unnecessary. Here we describe a surgical approach that allows pituitary tumor resection without sacrifice of the vascular pedicle, with the option of harvesting the flap at the end of surgery if it is deemed necessary.

Methods: We retrospectively reviewed 50 consecutive patients who underwent endoscopic transsphenoidal pituitary resections in our institution. Information on patient demographics, diagnoses, comorbidities, intraoperative findings, and postoperative course was collected and compared based on the type of reconstruction performed.

Results: Forty patients had the nasoseptal flap for reconstruction, and 10 underwent hemi-transseptal access without harvest of the nasoseptal flap. Septal cartilage necrosis occurred in three patients where the flap was used, of which one resulted in an anterior septal perforation. One postoperative infection occurred in the non-flap group, but there were no postoperative CSF leaks in this group.

Conclusion: This study suggests that the nasoseptal flap is useful in many cases of pituitary surgery, but is not necessary in all cases. The technique described allows the decision of whether to raise the septal flap to be made intraoperatively based on the findings during surgery. This technique allows for binasal two-surgeon access to the sella without compromise of the pedicle during the extended sphenoidotomies and tumor removal. Furthermore, when the nasoseptal flap is not required, minimal dissection of the ipsilateral nasal cavity is performed, speeding up the healing process. We describe the technical details of the approach as well as discuss our recommendations for when to use it versus the nasoseptal flap.