Transsphenoidal pituitary adenoma resection

Treatment of diseases: pituitary adenoma Indication Transsphenoidal pituitary adenoma resection is applicable to: 1. There are no obvious grade I, II, III, IV or 0, A grade tumors on the saddle, especially tumors with active endocrine function: amenorrhea lactation syndrome caused by pituitary adenoma, progressive giant disease or limb Hypertrophy, Cushing disease or other saddle-type pituitary tumors. 2. Class III and IV tumors with obvious sphenoid sinus erosion, no visual field changes or slight changes. 3. E-grade adenoma eroded to the cavernous sinus without obvious visual acuity and visual field changes. 4. For A-B tumors with obvious saddle expansion, if there is no serious visual impairment, there is a saddle and saddle septum enlargement (coronal CT or MRI scan sees the tumor image is round rather than dumbbell), showing The sphenoid sinus approach can be operated on the saddle, and the tumor on the saddle is strictly located in the midline, and the left and right symmetry. Contraindications 1. Nasal infection or chronic sinusitis, mucosal edema and congestion, prone to intracranial infection after surgery. 2. If the adult or sphenoid sinus is not well-formed, if the transsphenoidal approach is necessary, the bone in front of the sella should be ground with a micro-drill under the X-ray TV fluoroscopy. 3. The sphenoid sinus is over-vaporized, and the optic nerve and internal carotid artery can be exposed to the sphenoid sinus mucosa, which is easy to cause damage during operation. 4. Coronal CT scan showed that the tumor mass in the saddle and the sella was dumbbell-shaped, indicating that the saddle septum was small, and the transsphenoidal surgery was not easy to reach the saddle, and the saddle tumor was not easy to be seen after the saddle tumor was removed. Drop into the saddle during intracranial compression. 5. The tumor on the saddle is larger (Grade C) or extends to the anterior, middle, and posterior fossa (Grade D). 6. The upper part of the tumor is larger (B ~ C grade), and the visual field of view damage is serious, transsphenoidal surgery can not perform full optic nerve decompression, postoperative vision field recovery is not as good as transcranial microsurgery. Preoperative preparation Endocrine examination Includes a comprehensive determination of multiple endocrine hormones in the pituitary gland. Such as growth hormone, prolactin, adrenocorticotropic hormone, thyroid stimulating hormone, follicle stimulating hormone, luteinizing hormone and some hypothalamic endocrine hormones. 2. Imaging examination In addition to the normal and multi-trajectory tomograms of the sella, thin-slice CT and MRI scans of the sella should be performed where possible. 3. Drug preparation Patients with obvious hypopituitarism should receive appropriate replacement therapy before surgery, usually given dexamethasone or prednisone for 2 to 3 days. A large pituitary adenoma initially diagnosed as prolactin can be given bromocriptine for 2 to 4 weeks, 7.5 mg per day, which can reduce the tumor or improve vision. However, the preparation and treatment of bromocriptine should not be too long before the operation (not more than 2 to 3 months), otherwise the fibrous tissue in the tumor can be proliferated and the operation is difficult. 4. Repeat the intranasal rinsing of the patient several days before the operation, or periodically add antibiotic solution. The nose hair was cut off 1 day before the operation, and washed, and the antibiotic solution was added dropwise. Surgical procedure 1. Sublabio-septo-sphenoidal approach (1) Incision under the lips and nose: The patient's face is disinfected with a water-soluble sterilizing agent, and the disinfecting towel is laid. Use 0.5% procaine solution (add a small amount of adrenaline) 20 ~ 30ml through the nasal vestibular infiltration into the nasal septum root, nasal mucosa and subperiosteum, use drugs to separate it from the bone and cartilage surface, and then turn to the right nasal septum Mucosa. The upper lip is retracted by a hook, and a transverse incision is made between the canines on both sides of the pleat at the inner side of the upper lip. Close to the maxillary surface and separate upward under the periosteum until the lower edge of the pear-shaped hole. The edge bones are removed with a rongeur or osteotome to enlarge the opening below the pear-shaped hole. The mucosa and periosteum of the lower nasal passage are separated along the bone surface of the nasal cavity on both sides to form a tubular gap. Further raise the upper lip, separate the lower edge of the septal cartilage, and separate the mucosa and periosteum of the right nasal septum from the septal cartilage surface to form another tubular gap. The downward expansion separation is connected to the gap separated from the bottom of the lower nasal passage. Note that there are many fibrous adhesions on the sides of the nasal septal cartilage. Among them, there are branches of the nasal artery, which is prone to bleeding. There is often a prominent nasal septum at the root of the septal cartilage. The mucous membrane is thin and easy to tear. Therefore, it is necessary to carefully separate or use sharp Cut open. When peeling off the mucosa and bone (cartilage) membrane layer, try to get a layer of peeling off; otherwise the mucosal disruption or separation of mucous membrane and periosteum will cause postoperative mucosal necrosis and form nasal septum perforation. After exposing the right nasal septal cartilage surface, continue to separate back to the bone nasal septum and cartilage bonding line, use the nasal septum stripper to gently press the nasal septum cartilage, separate it from the nasal spine and the bony nasal septum, push the septal cartilage to the left The mucosal-periosteal layer was separated along the sides of the bony nasal septum and reached the anterior wall of the sphenoid sinus. The anterior nasal spine between the nasal passages on both sides can be slightly removed. However, it should not be removed too much, so as not to affect the beauty or damage of the superior alveolar nerve in the maxilla, resulting in numbness in the incisors on both sides. Push the septal cartilage to the left and place the Hardy dilator along the sides of the bony nasal septum. Carefully open it, taking care not to tear the nasal mucosa. As the dilator opens, it will cause the middle turbinate to fracture, and the unavailability is too large, otherwise the inner wall of the ethmoid sinus on both sides can also be broken. The above surgical procedures must be performed step by step, carefully maintaining the integrity of the nasal mucosa-periosteal layer. Isolation of the nasal septum mucosa-periosteal layer can also be performed from the left nostril. (2) Entering the sphenoid sinus: After completing the above operation, you can start working under the microscope. Part of the bony nasal septum was removed with an osteotome or micro drill to see the anterior wall of the sphenoid sinus and the vulture bulge. The mucosa-periosteal layer is peeled off from the anterior sphenoid sinus, and the sphenoid sinus opening is visible 1 to several millimeters on both sides of the upper midline, and the anterior wall bone of the ventral side of the sphenoid sinus can be opened with an osteotome or a micro drill underneath. Enter the sphenoid It should be noted that the sphenoid sinus opening is the limit of the upper boundary of the sphenoid sinus bone. If the bone window exceeds this level, it can enter the butterfly plane of the anterior cranial fossa, which is easy to cause cerebrospinal fluid rhinorrhea and difficult to repair. Before opening the sphenoid sinus, the direction and position of the sphenoid sinus retractor must be determined to ensure that the direction of operation is correct. In addition to carefully identifying the position of the sphenoid sinus opening and the vulture bulge under the operating microscope, X-ray TV can be used to fluoroscopy or to take a lateral radiograph. The correct position is that the upper edge of the dilator should point to the saddle nodule. (3) Entering the sella: After piercing the sphenoid sinus, use a rongeur or micro drill to enlarge the opening, remove the sphenoid sinus septum, and fully expose the saddle bottom. Generally, the sphenoid sinus window is about 1.5×2cm. Try to scrape the sphenoid mucosa. At this time, the CT, MRI and sphenoid sinus slices should be reviewed, and the position of the anterior wall of the saddle bottom should be determined according to the type of sphenoid sinus gasification. If it is difficult to judge, the surgical position can be checked again by X-ray TV fluoroscopy or X-ray film. Once the position of the saddle bottom is determined, it can be gently detected with a long handle or a suction head. Generally, the saddle bone of the tumor in the saddle is thinned, and it is easy to sag, or it can be worn by a chisel. The invasive pituitary adenoma (grades III and IV) has eroded into the hole. After the sphenoid sinus mucosa is removed, the tumor is bulged, or the entire saddle is destroyed. The tumor is filled with the sphenoid sinus. Clearing the tumor mass in the sphenoid sinus will reveal a hole in the bottom of the saddle, which can be inserted into the saddle with a slight enlargement. When opening the saddle bottom bone window, pay attention to the surrounding anatomy. Generally, the upper boundary should not exceed the saddle nodule. Otherwise, entering the saddle upper pool or damaging the intercavernous sinus of the saddle root will cause leakage of cerebrospinal fluid or major bleeding that is not easy to repair. In the transsphenoidal approach, a crypt is usually seen in the sphenoid sinus corresponding to the saddle nodule, which is the limit of the upper boundary of the saddle bottom window. If the interscapular sinus is exposed during surgery, it can also be the mark of the upper limit. The outside of the saddle bottom window must not cross the inner edge of the internal carotid artery. In order to avoid damage to the sinus, the bone can be separated from the bone and the dura mater before the bone tissue is removed. The sinus hemorrhage can be stopped by small pieces of muscle, gelatin sponge or special bipolar electrocoagulation. The size of the bone window should vary slightly depending on the size of the sella and the size of the tumor within the sella. The transverse diameter is generally about 1.5 cm and the longitudinal diameter is about 1.0 cm. Properly adjust the magnification of the surgical microscope to include the entire bone window. Carefully observe the presence or absence of abnormally large or ectopic interspongeous sinus in the dura mater of the bone window, and try to avoid it when cutting the dura mater. Invasive pituitary adenomas can be seen as the dura mater is eroded and softened, or the hole is broken. If there is a tumor stroke or an empty sella, the surface of the dura mater is purple-blue, and the thickness is thin and bulging. (4) Incision of the dura mater and resection of the tumor: After electrocautery of the saddle dura mater, puncture the sella with a slender needle to exclude the internal saddle aneurysm and the vacuolar sella. The dura mater is cut with a long-handed small hook knife or a star, and a small hook is inserted into the dura mater and the tissue inside the saddle to determine whether the dura mater has been completely cut. If only the outer layer of the dura mater is cut and separated between the inner and outer layers, it can be mistakenly inserted into the sinus to cause bleeding. The edge of the dural incision can be contracted into a circle after electrocoagulation. Generally, the normal pituitary gland and the dura mater are non-adhesive, and the two are easily separated. Under the microscope, the pituitary gland is slightly flashed and easily recognized. Pituitary microadenomas (Grade I) grow in the pituitary gland, do not break through the pituitary capsule, and retain the subdural space when the dural incision is made. The surface of the pituitary is intact, and the hardness is soft or outward only near the tumor. Grade II pituitary tumors have broken through the pituitary gland and reached the surface of the pituitary. After the dura mater is cut, the tumor is visible. The dura mater of grade III-IV invasive pituitary tumors is often eroded by the tumor, and the altered dura mater is removed for pathological examination. Most of them have a large number of scattered tumor cell nests. Selman (1986) observed that 40% of the tumors eroded the dura mater, while the pathological examination of the dural was 85%. Laws counts 87% of large adenomas and 97% of tumors that extend out of the saddle, and their dura mater is attacked. Blevias (1998) had a hard tissue infiltration of 85% of the pathological examination of the dura mater during surgery. It is believed that except for pituitary growth hormone large adenoma, the incidence of invasiveness of other types of pituitary large adenomas is above 50%. Under the microscope, the color of the anterior and posterior pituitary is different. The anterior leaves are orange-yellow, the texture is tough and firm, and there is a glittering film on the surface, which is white when pressed. The posterior lobe is gray-red, jelly-like, closely adhered to the posterior wall of the sella, buried in a shallow recess in front of the saddle, and is not easily separated from the dura mater. The middle leaf between the anterior and posterior lobes contains many jelly-like substances, and has many microvessels. The structure is loose and can be used as an interface between the anterior and posterior lobes during surgery. Pituitary tumors are generally non-enveloped and do not see a boundary with the anterior pituitary of the pituitary under the operating microscope. The tumor is nodular, and the tumor tissue is gray-white fish-like. If the blood is abundant, it is purple-red, which is different from the normal anterior pituitary tissue. 1 Resection of pituitary microadenoma (microadenoma): pituitary microadenomas (grade 1) with a diameter of 5 to 10 mm are mostly grown inside the pituitary tissue and are not easily seen on the surface. Larger microadenomas can cause the surface of the pituitary to bulge. According to intraoperative observation, Hardy (1973) found that a variety of adenomas with different endocrine functions occur in different parts of the pituitary. For example, prolactin adenomas often occur in the posterior part of the pituitary flank, and growth hormone cell adenomas often occur in the anterior part of the flank. Adrenocorticoid cell adenomas occur mostly in the deep middle of the pituitary, and thyroid-stimulating hormone cell adenomas occur frequently on the surface of the middle leaves. This situation seems to be closely related to the distribution of various cells in the pituitary. Because the normal anterior pituitary can be divided into two lateral leaves and one intermediate leaf, which flank multiple eosinophils, secrete prolactin or growth hormone; and intermediate leaves more basophils, secrete adrenocorticotropic hormone or thyroid stimulating hormone Wait. The distribution of hypersecretory adenomas is basically the same. Understanding the characteristics of the location of the above microadenomas is very important for surgical exploration to determine the location of the tumor. Therefore, in the pituitary microadenomas surgery, if the local pituitary becomes soft or external protrusion after the incision of the dura mater, it can be directly explored there. If there is no change in the surface of the pituitary, a transverse "ten" or "++" incision can be made on the surface of the pituitary, and then the pituitary tissue is separated at the predetermined site of the tumor to find the tumor according to the above principle. Sometimes a slight compression is applied to the surface of the pituitary to squeeze the tumor out. If the tumor tissue can be seen clearly, the incision can be enlarged and the tumor removed with a biopsy forceps or a suction device. Since there is no obvious boundary between the tumor and the normal pituitary tissue, in order to prevent tumor recurrence, it is best to cut the surrounding tissue during the operation for cryosection until it reaches the normal pituitary tissue. Recently, many authors advocate that in addition to the tumor itself, it is necessary to make a thin layer of resection of the surrounding pituitary tissue to prevent future tumor recurrence. 2 large adenoma (macroadenoma) resection: large adenomas >1cm in diameter, if not broken through the pituitary capsule, more shallow, in the anterior pituitary after the dural incision, the softer place is the lesion. If the tumor has broken through the pituitary capsule, the tumor immediately bulges after the dural incision, and adheres to the dura mater or erodes the dura mater to thicken and become brittle. Invasive pituitary tumors destroy the dura mater and saddle bone or invade the sphenoid sinus. In general statistics, about 80% of the tumor tissue is soft and easy to be removed by an aspirator, a small curette or a small bite. About 5% of the tumors have more fibrous tissue (about 30% of prolactin adenomas, acromegaly and non-secretory chromophobic adenomas slightly higher than this). Because the dense fibrous tissue is connected to the surrounding structure and the texture is tough, direct resection is difficult. It can be ablated by electrocautery, and the tumor bed can be stopped by bipolar coagulation or gelatin sponge. If the tumor volume is not large or does not develop on the saddle, the pituitary with an orangey appearance can be seen after the tumor is resected. If the edge of the tumor bed is neat, the tumor can be considered completely or subtotal. In the past, some people (Baskin, Faria) like to use tissue fixatives (such as pure ethanol, Zinker fixative, etc.) on the tumor bed to remove tumor tissue remaining around the tumor bed, but this method may increase pituitary stalk damage, or ethanol damage. It seems that the upper pituitary bundle causes diabetes insipidus, or infiltrates into the saddle upper pool and attaches importance to nerve damage. Currently, neurosurgeons have tended to remove more tumors. Some advocates also need to remove the surrounding normal pituitary tissue. As long as 1/10 of the anterior lobe remains intact, long-term postoperative replacement therapy is not needed. The common experience of neurosurgeons is that transsphenoidal approach is difficult to remove the tumor from the superior and inferior aspect of the saddle, because the area is not easily observed directly by the operating microscope, and the dura mater is often invaded by the tumor. 3 Resection of the saddle on the tumor: After the incision of the tumor in the saddle, if the saddle is larger, the upper part of the saddle of the tumor can fall into the saddle by the pulse of the brain. If you do not fall into the body, you can ask the anesthesiologist to increase the pressure in the chest, compress the bilateral neck veins or use positive end-expiratory breathing, or inject the saline into the plastic tube preset in the spinal canal through the lumbar puncture. The tumor mass on the saddle is pushed down by increasing the intracranial pressure. If the drop is difficult, the tumor can be removed by a circular curette on the saddle under X-ray TV fluoroscopy until the saddle is dropped and pulsation occurs. Sometimes under the X-ray TV perspective, the air gradually enters the upper saddle pool, and the front of the third ventricle expands downward to the normal shape. Be careful not to damage the arachnoid at the saddle septum. Since the upper part of the saddle of the tumor is often stuck to the saddle and the arachnoid, the operation must be gentle and not forceable. If the arachnoid of the saddle septum is not broken, no cerebrospinal fluid will flow out. If there is cerebrospinal fluid outflow, it means that the arachnoid sac has been torn, so that the hole should continue to increase, and the hole should be blocked with muscle pieces, fat blocks, etc., and the saddle should be properly repaired to prevent postoperative cerebrospinal fluid. leak. During the operation, attention should be paid to the variation of the tissue in the saddle. If the observation is unclear, it should not be operated blindly. During the operation, always pay attention to maintain the median approach, not offset, so as not to damage the cavernous sinus on both sides, the internal carotid artery and the 3, 4, and 6 cranial nerves. 4 erosion of the parasitic lesions of the cavernous sinus: invasive pituitary adenomas often expand outward, causing the entire cavernous sinus to be displaced locally or wholly. During the operation, a circular curette can be used to laterally remove the lesion 2 to 3 cm from the midline. The distal side can also be operated with an angled circular curette. If the curette touches the smooth inner wall of the cavernous sinus, it suggests that the tumor extending to the saddle is a non-invasive lesion. After the tumor is removed, the cavernous sinus wall can be reset to the midline, and the process of resetting can be seen under the microscope. In the case of an invasive tumor, the edge or defect of the cavernous wall of the cavernous sinus can be felt by a curette. The surgeon should be familiar with the sinus anatomy and be careful. The internal carotid artery is located on the outside of the field and can be touched with a curette. In severe cases, the internal carotid artery can also be seen under the microscope, or the tumor can be removed laterally or around it under direct vision. After tumor resection, the tumor bed can be hemostasis with gelatin sponge, muscle block or different types of hemostatic agents. Avoid using substances that are prone to swelling after surgery to avoid symptoms of compression in the sella. Some people like to fill the cavity inside the saddle with autologous fat or muscle mass to avoid the vision loss caused by the drooping optic nerve. The closed saddle bottom can be placed between the saddle bone and the dura mater with a bone piece or cartilage slightly larger than the saddle bottom window. Seiler (2000) also proposed the use of Vicryl organically synthesized sheets for repair. However, most authors believe that if there is no serious cerebrospinal fluid leakage, only autologous fat or muscle block plus bio-adhesive bonding can be used. If necessary, the "sphenoid sinus" cavity can also be filled and repaired. Finally, the Cushing dilator is pulled out, the wound is sutured with the gut, and the nasal cavity is filled with oil gauze to prevent bleeding from affecting healing. 2. Nasal vestibular-nasoprio-septo-sphenoidal approach The method of transsphenoidal-nasal septum-sphenoidal approach for the removal of pituitary tumors has certain shortcomings, such as severe oral contamination, upper lip and mucous membrane incision, abundant blood supply, more bleeding, peeling of nasal discharge and maxillary nasal discharge. The phrenic nerve, biting off the lower edge of the pear-shaped hole, is easy to damage the upper alveolar nerve. Therefore, many authors use the nasal vestibular-nasal septal-sphenoid sinus approach. This method was first implemented by Mac Curdy (1978), and later modified by Landolt (1983) and Koltai (1985), and has been widely used at home and abroad. Surgical method: 3 days before surgery, double nose was dripped into 0.25% chloramphenicol solution, and nasal hair was completely removed 1 day before surgery and the nasal cavity was cleaned. Anesthesia and body position are the same as before. At the time of surgery, the nasal mucosa, the nasal column and the nasal wing were infiltrated with 0.25% procaine plus an appropriate amount of epinephrine for mucosal-subperiosteal dissection. Mucosal incision can be used to select the left or right nasal vestibule, depending on the habit of the surgeon. European and American people and a small number of patients with large nostrils in China can make a unilateral nasal vestibule-nasal septum mucosa-periosteal "L"-shaped incision, which reaches the cartilage and bone surface of the nasal septum-nasal base. In our country, the nostrils are generally small. In order to expand the exposure, the nasal column or the side of the nose can be cut by the inverted "V" or "human" incision according to the improved method of Kotai (1985) et al. And the mucosa of the nasal floor, so that there is enough space to put into the dilator, and then further separate the mucosa-periosteal layer of one nasal septum to expose the septal cartilage surface. Disconnect the septal cartilage from the nasal humerus and push it to the opposite side, placing the dilator along the sides of the bony nasal septum. Landolt designed a dilator specifically for this purpose, which is slightly narrower than the Cushing dilator to save space. The remaining steps are the same as the trans-nasal-nasal septal-sphenoidal approach. Compared with the two, the advantages of transnasal vestibular approach are: 1 because there is no upper lip covering, the approach is shortened by 1 to 1.5 cm than the transmural incision, and the dilator is required to be shorter; 2 the operation does not need to peel off the nasal mucosa and The bite of the lower edge of the pear-shaped hole is bitten, and the nasal sinus and the superior alveolar nerve are not damaged; 3 the nasal cavity has less chance of contamination compared with the oral cavity, and the antibiotic preparation is prepared before the operation, the nasal hair is removed and the local disinfection is performed, which can be regarded as relative Sterility; 4 through the lip, affecting the post-operative feeding, can not bite the food for a few days, can only enter the liquid or semi-liquid diet. There are ulcers in the incision of others, which increases the patient's pain, but the nasal vestibular approach does not have this; 5 nasal column incision as long as the exact alignment, thin line suture, scar is very small, it is difficult to see by naked eyes after several months, no Affect beauty. 3. ethmoido-sphenoidal approach Under general anesthesia, the supine position was taken, and the head was raised by 20°. A 3 cm arc-shaped incision was made from the right or left intraocular sac and the midline of the nose along the sacral margin to reach the bone surface. The periosteum was peeled off to the inner wall of the iliac crest, and the contents of the medial malleolar ligament and tendon were retracted outward from the lacrimal sac. Use a micro drill to open the sieving cardboard at the teardrop, bite the inner wall of the iliac crest about 1×2cm, enter the ethmoid sinus and scrape the sinus inner paperboard and its mucosa. Open the posterior ethmoid sinus and see the posterior wall of the sphenoid sinus. Some people still cut the nasal mucosa, removed the posterior part of the nasal sinus, and turned the posterior ethmoid sinus flap downwards to find the sphenoid sinus opening by X-ray. In the midline, the sphenoid bone mouth and the posterior part of the nasal septum were removed with a micro drill. The anterior wall of the sphenoid sinus was opened into the sphenoid sinus. After scraping the sphenoid sinus mucosa, the saddle saddle bottom was seen. The remaining steps were the same as before. The most important consideration for this approach is to maintain a correct approach during surgery to avoid skew. The bone hole through the posterior stencil is an important anatomical landmark, which is the posterior and upper boundary of the sieving plate. In general, when the ethmoid sinus is drilled and the inner wall of the ankle is bitten, the pre-screening hole is first encountered on the forehead screen, and the anterior ethmoid artery and the nerve are passed out. Along the frontal sieve line, 1 cm deep is the post-screening hole, and the posterior artery and nerve are oozing out. 4 ~ 7mm after the sieve hole is the optic nerve hole, there is a bone bridge between the two. The forehead line is the sign of the top wall of the ethmoid sinus, and the anterior cranial fossa is up. The ethmoid resection can damage the optic nerve beyond the posterior stencil. After the sieving artery passes through the posterior sinus sinus, and the posterior inferior wall is the anterior wall of the sphenoid Familiarity with these anatomical landmarks is important to ensure that the surgery proceeds in the right direction. When it is determined that the anterior wall of the sphenoid sinus is difficult, the TV fluoroscopy can be used to monitor the correct direction of the operation, and if necessary, adjust the direction at any time. The advantages of the ethmoid sinus-sphenoid sinus approach are: 1 Compared with the transmural-nasal septum-sphenoid sinus approach, the exposed field is wider and the approach is shorter. Landolt (1980) measured the ethmoid-sphenoid sinus approach, the average distance from the incision to the sella was 55 mm, and the trans-lipar approach was 75 mm; 2 without the nasal cavity, avoiding nasal septum-sphenoidal approach may cause Complications such as perforation of the nasal septum and atrophic rhinitis. The disadvantages of this approach compared with the first two transsphenoidal approach are: 1 because the approach is close to the anterior cranial fossa (frontal sieve line), so after reaching the sella, its field of view is just the value of the sella Directly in front, it is only suitable for resection of tumors that are confined to or within the sphenoid sinus. For tumors that develop on the saddle, it is worse than the oral-nasal-sphenoid sinus or transnasal vestibular-nasal septum-sphenoid sinus approach, and the latter two enter the saddle from the front to the lower, which can better reveal the saddle septum and the saddle septum. Tumor block. 2 Entering the sella on the side of the sinusoidal sphenoid sinus into the route, it is more favorable to expose the mass in front of the side of the sella and the opposite side of the sella, but it is easy to cause damage to the contralateral cavernous sinus and internal carotid artery, unlike the first two Transsphenoidal approach along the midline into the sella can symmetrically expose the two sides of the structure, and is not easy to deviate from the midline, causing damage to the cavernous sinus and arteries. complication 1. Cerebrospinal fluid leakage. 2. Meningitis. 3. Diabetes insipidus. 4. Cavernous sinus, internal carotid artery and cranial nerve injury. 5. Optic nerve or optic chiasm damage. 6. Perforation of the nasal septum. 7. Protracted blood sodium reduction.