*8.2.3 Sellar phase*

From this phase of the procedure, the endoscope can be fixed to the holder, in order to free both of the surgeon's hands. Actually, it is our practice to continue using the endoscope free-hand, which is held dynamically by an assistant, while the surgeon can move the two instruments through one or both nostrils.

The sellar phase of the procedure (**Figure 15**) follows the same rules of the microsurgical transsphenoidal approach. Sellar floor opening is performed using a highspeed microdrill and a Kerrison rongeur usually extending the bone removal from one cavernous sinus to the other and from the tuberculum to the floor of the sella, although its shape and size could be tailored depending on lesion. Microdebrider can be another instrument which can be very helpful in removing the unwanted mucosal and bony debris. During such maneuvers a Doppler ultrasound probe will easily identify the carotid arteries, which will allow a safer opening of the dura that thereafter is incised in a midline position and in a rectangular, linear or cruciate fashion. In case of a macroadenoma, the inferior and lateral components of the lesion are removed before the superior aspect. This sequence will reduce the possibility of

**Figure 15.** *Sellar stage of pituitary surgery. The capsule of pituitary tumor is exposed.*

#### *Endoscopy in Neurosurgery DOI: http://dx.doi.org/10.5772/intechopen.100252*

suprasellar cistern and the redundant diaphragma falling into the operative field and the lateral portions of the lesion will be less difficult to remove. Nevertheless, if the descent of the suprasellar portion of the lesion is not noted, a Valsalva maneuver is helpful to check the protrusion of the suprasellar cistern into the sellar cavity.

Besides, in case of microadenoma, dissecting tumor pseudocapsule from pituitary gland tissue is preferable for a complete 'en bloc' removal of the tumor, when possible, rather than performing an internal debulking [87]. This increases the chances of cure.

Finally, after removal of the lesion, an endoscopic exploration of the tumor cavity, by the means of a 00 and/or angled scope, is performed to assess for the presence of any tumor remnants. In case of hormone secreting tumors, the whole tumor needs to be removed to get a better outcome and angled scopes can contribute a great deal.
