Single-Stage Combined Transcranial-Endoscopic Transsphenoidal Approach for Giant Pituitary Adenoma with Unilateral Parasellar Extension: A 2-Dimensional Operative Video.

Purely endoscopic endonasal resection of giant pituitary adenomas can be challenging in selected cases with lateral parasellar extension and close neurovascular relationships.1 We present a case of a 62-year-old male presenting with headache and bilateral blurred vision, with MRI brain confirming a 4.8 x 3.2 x 3.0 cm, Knosp grade 3A giant pituitary adenoma. Our operative video demonstrates how a mono-nostril endoscopic transsphenoidal resection can be augmented by a concurrent, targeted microsurgical transsylvian window. This allowed for meticulous dissection of the tumor's lateral portion from the right optic nerve, A1, and M1 segments-structures at the blind angle of the endoscopic view. The liberated tumor portion was then delivered directly into the endoscopic field, allowing for a safe, controlled piecemeal resection. An extended endonasal or sequential endonasal-first strategy would also represent reasonable alternatives, and selection of a combined approach should be individualized according to tumour anatomy, anticipated accessibility, and surgical experience. Adequate internal debulking and careful, controlled mobilisation of the tumour capsule are particularly important when dissecting adjacent to the optic apparatus. A multilayered skull base reconstruction was then performed, featuring a vascularized nasoseptal flap with perfusion confirmed by indocyanine green fluorescence and Doppler probe. Gross total resection was confirmed on post-operative MRI brain. The patient experienced a transient oculomotor nerve palsy and hypothyroidism, both of which improved on follow up. There was no cerebrospinal fluid leak, intracranial hemorrhage or nasal complaints. In selected giant pituitary adenomas with challenging lateral parasellar extension, a simultaneous combined approach may provide complementary visualization and access when a single operative corridor is considered suboptimal.2-4.