 In this talk of techniques of endoscopic pituitary surgery, a beginner's perspective, I am going to discuss the tricks of the trade. Now endonational transitional surgery using an endoscope as a sole visualizing tool is in place of microscope. It has emerged as a better alternative to microscopic TNTS because the visualization and volume of exposure is superior. It permits the complete removal of tumor from the hidden angles and preserves the normal pituitary, so giving a comfortable postoperative course and the less complications. How we do it? In the position, it's same like any trans microscopic TNTS that patient is put supine with hips and knee flexed, trunk elevated to 20 degrees for the less bleeding and it allows the easy access to the middle turbinate. Now head is rested in neutral position on a horseshoe or fixed in a three pin when you use the neuron navigation. The chin forehead line is maintained parallel to the floor. It's 15 degree turn towards the surgeon and 15 degree counter lateral tilt. So that is the ideal position we use. And hemostatic aids are that adrenaline one in one thousand, the five ampoules are diluted in 30 ml of one percent silo cane and the propofol infusion is used to reduce the bleeding and keeps the BP around 90 or pulse around 60. Now all the cables of the endoscope that is the light, camera or irrigation are tied together to the shaft of the endoscope and the rest on the table away from the patient surgical field. Now the ideal way to hold the endoscope is like you hold a flute in your left hand. You can hold it like a pen other ways but it doesn't really matter. But holding it like this makes your these two fingers to manipulate the zoom and focus. Now the surgical stages are nasal stage, synodal stage, cellular stage or reconstruction stage and the recognition of important landmarks during each of these stages is important for the safe exposure. Now when you start endoscopy first have a overall bird's eye view or overall view of the area then endoscope is inserted parallel to middle terminate at an angle of 25 degrees inferiorly to see the koana first. The inferior terminate points to eustachian tube ultimately when you follow the inferior terminate will take you to the eustachian tube. The koana is the most important anatomical reference point then you go with the scope in between the inferior terminate and septum and then in between the middle terminate and septum into the sphenoidal recess. Now is the super selective packing of 2 to 4 cotton patties which are soaked in the decongestant and then squeezed they are left in this eustenoidal recess and they are pushed from lower down to up and from anterior to posterior and they are left for 5 to 10 minutes to widen this eustenoidal recess. Now this is how you put these patties there. Now once this space is created the fresh cotton patties are pushed back in the sphenoidal recess and to the rostrum of the sphenoid and again left for 2 to 5 minutes and middle terminate is now lateralized with the shaft not the tips because the tips may injure the mucosa. So with the shaft of a freed sector you just lateralize the middle terminate. If it is bulky then another way is that you first you medialize it and then out fracture it so that it will give you a lot of space and I can assure you that investment of 10-15 minutes in these procedures of putting and packing of patties and all that makes your life very comfortable and your operation very safe in the later stages of the surgery. Now avoid injury to nasal mucosa by insertion of the instrument under endoscopic guidance. Don't just put the instrument like that but it will injure the nasal mucosa and keep the suction at low setting and if there is any bleeding from the mucosa the better way to control is you just infiltrate it rather than coagulating. Now the ostium is identified medial and posterior to superior terminate in the lateral corner of the rostrum of the spinoid. In 30 percent of patients you may not see the ostium but it is always there and to look it sometimes you may see some air bubble or probe. You can just probe it about 1.5 centimeter from the roof of the koana if you just probe it you will find it and still if you are not able to find it then there is a part just immediately below this a very thin part of spinoid anterior part which is called fontanelle. So you just put your any instrument gently there it will go into the spinoid sinus and it will perforate it and now this is the ostia this is how it looks like when you take it into the spinoid model resist. Now mucosa over the spinoid sinus is coagulated and nasal septum is gently pushed medially and fractured and is pushed to the other side. Now some mucosal dissection is further carried out along the contralateral side of spinoid rostrum visualizing the ostium of other side. So other side of stium now you see some mucosal and this gives a classical owl eye appearance and this is this is two or the eye and this is the nose of the owl which is the woma. Now avoid mucosal coagulation in upper part of the nasal septum to avoid post-op anosomia and now this is how you see from the both sides you see and these are the ostia and this is a V shaped osteotomy is performed spinoid osteotomy and now again a lot has been said about this posterior septal artery which is branch of sphinopolitan artery which in turn is branch of internal migratory artery that it lies supereolateral to koana inferior lateral corner of its spinoth model recess and medial posterior corner of inferior margin of middle turbinate and this is in the sphinopolitan posa and this artery can be coagulated when excess is made between the middle turbinate and nasal septum for NTS spinodotomy to prevent bleeding during surgery and after all so even in post-op epistexis the commonest cause is bleeding from this artery and usual advice is that this artery when you encounter bleeding bipolar it rather than monopolar but you can use monopolar also at low setting but better to bipolar it. Now sphinodosteum is enlarged medially and inferiorly and V shaped NTS spinotomy is done from the inferior margin of middle turbinate to the sphinodosteum for 15 mm length the rostrum of sphinoid is removed now by doing this and now you can remove this rostrum. The posterior one-third of nasal septum is now removed by backbiter along with the contralateral mucosa of the nasal septum so as to make it approach a binostril or binaris approach and this is how we use this backbiter. Now the techniques differ here it may be a uninostril or binostril it may be a 2 or 3 or 400 surgeon techniques which is preferred which provides you a 3D vision and it depends and differs on extent of middle turbinate lateralization or resection whether partial or complete or the type of cellar floor and one should know all these possible modifications of these techniques so as to tailor according to the specific requirements in a particular patient. So for example a uninostril approach throw a capacious nostril in a adenoma which is confined to the cellar in a patient with DNF is a good option you need not to go by near and then if you are able to do a wide anterior wide sphinodotomy you can take out this tumor by uninostril approach. Now what are the limits of this sphinodotomy is cranially the superior limit is up to sphinodosteum cordially the vomer is drilled up to the pterigo sphinoid synchondrosis or the canal for median nerve which is further lateral seen at 5 and 7 o'clock position creating a space of more than one or two tips of the suction passing through the permitting instrument manipulation under the cellar floor otherwise your instruments will get stuck you will not be able to reach there so when you see the floor of the cellar under the floor of cellar there should be a space of about at least 4 to 6 millimeter so that your instruments can pass there and lateral limit is up to the crest which marks the junction of sphinoid with the ethmoids after sphinodotomy the endoscope may be mounted on a holder or another surgeon holds it who acts as a navigator that is called a co-pilot and with the main dissecting surgeon is known as pilot and this provides a 3D perception and initially I was fixing the holder but now I just don't prefer in and I never do it and one should not do it for the reasons I will tell you later the role of the navigating or a co-pilot surgeon is that he holds the scope with fingers on backside or reverse of the pilot surgeon like you are holding this so the assistant or co-pilot is standing on that side so he holds it like this so that he can show you and his elbow should always be supported so that he can do it precisely the co-pilot stands on the left side of the surgeon and head end of the patient now try to make the path as straight as possible by passing the scope and instruments above the inferior turbulence move the scope in relation to the instruments like pilot and co-pilot they work in synchrony the espionage mucosa on entry of all of the cellar floor is coagulated and not stripped to avoid the bleeding the inner mucosa which is in the espionage sinus it should not be just pulled out because a lot of bleeding can occur so that should be coagulated now repeated warm saline irrigation stops bleeding from the mucosa and cleans the field but one word of caution you should not coagulate inside with the monopolar inside the espionage sinus because there may be bony dehiscence and you might be coagulating on the carotid so just never coagulate there a small bony hole is made in the center of the cellar floor and then the entry of all and floor is removed circumferentially and then the dura is coagulated with a single blade bipolar and there is a technique of a cavity and half so here what you do is you go between the superior terminate and middle terminate lateralize the middle terminate and to open the bull-eyes now here there is a Parsons ridge which separates the synodosteum from the superior terminate which is excites and now it is communicated with the spinoid cavities now communicated with the posterior and this posterior cavity is used to park or keep your scope there so that the spinoid cavity the full spinoid cavities available for the dissection for you and now keep checking the proper orientation for the beginners this is very important that at all the stage of surgery you must keep checking that the buttons of the scope are facing the screen and this is the proper orientation and particularly after each exit and insertion of the scope now if you see observe a semi lunar sign which means your scope is touching that issue so you just rotate it 90 degree will be okay and if there is a fogging it is usually due to humidity and if you irrigate the scope with a warm cell and this will go and this will improve now try and practice or execute in and out movements inside the nasal cavity to judge the depth and to fit the surgical landmarks for proper orientation and depth perception in the beginning you just take out in so that you are aware that how far deep are these structures introduce the scope slowly like going through a tube without touching its wall to prevent or avoid the soiling of your scope now while introducing the scope take advantage of elasticity of the Ella and lift or deform the Ella and keep the scope at 11 o'clock like you are pushing here so you lift this so you use the elasticity of the Ella and your scope should be at 11 o'clock position now instruments are introduced taking the advantage of rigidity of the floor and this gives you orientation you just go directly there and you see the Qana and this is a very basic anatomical reference point and along the nasal septum below the scope through the nostril the instrument should pass below the scope through the lower part of the nostril now distance between the tip of instrument and scope is kept about a centimeter and the instrument should be guided by the endoscope and they should not touch each other or crossover avoid quick movements in the proximity to the surgical target so go slowly and gently after this minute not to me once we have removed the spinoid phase now how to know that where is the midline so the remains of the rostrum that is the vomer inferiorly will guide you to the midline and you stay between the two carotid bulges now you can see the carotid bulges so stay in between the two carotid bulges for midline now when using a drill now drill is first taken close to the target when the tip can be seen in the screen and now you make the drill on and touch to the target and drill in bursts like a painting brush just don't press it against any structure remove the drill only then it has completely stopped otherwise it will injure your mucos on the way or some other structure now dry drilling with burr diamond burr stops the bleeding from the bone this is the one very important method and while drilling keep the endoscope away and zoom to avoid the soiling of the lens now remove the coffin effect by widening nice sometimes you feel that the space is very less so just widen your spinotomy and this will make your life comfortable and sometimes you will find during your surgery that lot of bleeding is coming there so it is nothing but it's a blocked koana so you just go down and suck the fluid from the koana and it will be okay now the paramedian septum they most often lead to carotid or optic nerve so remove them only when it is mandatory and don't remove by a forceps and pinching just you drill them with a diamond to make it flush with your other spinotomy cellar surface now the anatomical landmarks are identified in a panoramic view which mimic a fetal face like the center is the cellar the rostral is the tuber crumb celly at 12 o'clock position cordal clivalent indentation at 6 o'clock position and literally optic protuberance at 10 and 2 o'clock position carotid protuberance at 5 and 7 o'clock position and cavernous sinuses at 3 and 9 o'clock position so this is what you see like a fetal face and this is the classical picture of this here you see this is the area of interest and this is the lateral optical carotid recess and this is how it gives the appearance and this is a live during surgery a photograph just to show you and here you see this septum is paramedic so these septums are hardly ever midline the spinotomy septum now a medium size 3 to more millimeter diamond bar is used to drill the cellar and the drilling of the cellar should be very gentle lazy drilling with diamond bar under low speed then the egg shell which is produced is a dissected and broken with a fine spade sector or a kerosene were up cut punch without taking any bite you just hold the kerosene there and just break it it will just break it without taking any punch and it should be done till you see the four blue lines of superior and inferior intercavernous and both the cavernous sinuses laterally and now this is the initial hole is made in the cellar and then it and then cellar interval and floor is removed circumferentially and these till the four blue lines are seen now the dura is open transfers it may be a straight line it may be cruciate or whatever way you can open but what we find best is that first you make a transfers incision and then you give them five and eight o'clock position creating a inferior flap of the Dura so the advantage is that this part of the Dura supports the upper part of the tumor and restricts doesn't allow the arachnoid to bulge down so that it hinders your view of the tumor within the posterior inferior part now endoscope knife is used for opening the Dura to cut the Dura in the center first and then from very free to midline because it's a copper bank a knife of endoscope knife is a long instrument so you don't have a precise control on this so you should never open it from midline to periphery because you may injure the cavernous so better is from periphery to midline so open it from periphery to and then you can extend it laterally with the seizures if later on it is required and now this is how it's being done the transfers incision is given and this is the five and eight o'clock position we give the incision and now the first the basal and first a part of the tumor is removed through the opening in the inferior flap in posterior trajectory towards clivus dorsal junction in cordal to rostral direction the superior dural flap holds the superior anterior part of the tumor and prevents the premature arachnoid bulge that tumor should first be mobilized free and then taken in a holding forceps or suction in a peacemapes now do not hold any tissue if you cannot see the tips of the instrument and do not pull there's no place for blind defection in this type in endoscopic surgery because the whole idea of endoscopic that you visualize everything next the lateral and lastly the superior part of the tumor is removed with upward angled curates now the tumor decompression is done with bimanual dissection that is the curate in the right hand and suction in the left hand or double suction method where two sections are each hand and the left section delivers the tumor and right section sucks it now the take advantage of the endoscope that take the endoscope inside the cellar close to the target for detailed study and this is what is called the flashlight effect because when you take it close you study the anatomy in detail and you see whether it's a tumor or diaphragm or arachnoid or normal pituitary and then only you tend to remove it and then if you see that this is a tumor then withdraw the endoscope little bit take your instrument and then remove the tumor the removal of the tumor is a dynamic process the arachnoid may bulge down to the diaphragm in front of a thin pituitary stalk so always caution if you see arachnoid don't try to open it the last piece of the tumor is often located at the insertion of the pituitary stalk and the two most common sites which are found to retain tumor is the angle between the optic nerve and carotid artery at medial OCR and under the anterior lip of the dura at level of superior intercavenous sinus and this is how the arachnoid bulge looks like now a 30 degree endoscope visualizes opposite to the cable of the light if the cable is here it means you are visualizing opposite to the cable of the light so when cable is down the scope is kept in the lower part of the nose because you want to dissect superiorly so now a scope comes to the lower part of the nose and your instruments pass in the upper part of the nose so angled endoscope is taken in the cellar to examine the tumor remanence which are removed with a curved or a angled suction to examine the medial cavernous wall you rotate a 30 degree endoscope and ask the assistant to rotate the camera also to maintain the orientation and always again as I said keep the buttons facing the screen now the space between the posterior and the carotid siphon which is like a reverse S represents the ideal entry point for removal of the tumor from the posterior segment of the cavernous sinus and finally inspection of cellar is done in clockwise fashion starting at six o'clock position and using a 30 degree angled endoscope now failure of diaphragm to descent indicates retained tumor in the supracellar space and pulsations visible in the diaphragm is a robust finding of a total tumor removal now normal pituitary should be preserved now how you preserved it that you always predict in preoperatively in MRI that where it is shifted and usually it is posteriorly and superiorly right but you always see it because the posterior pituitary doesn't have blood-brain barrier so it enhances brilliantly so this is the white thing you always look and preoperate MRI and you predict that where is the pituitary shifted it's a normal pituitary is a yellowish in color firm in consistency and there is vasculature on it so this is how you identify it and a thinned out residual normal pituitary appears as a apron plastered to the under surface of diaphragm and should be identified and preserved in functioning a micro adenoma a thin shell of normal pituitary is also removed or shaved along with the tumor cavity to enhance the chances of cure now in the end you ask the anesthetist to give ball cell work to check for CSF leak and always use a large single piece of fat instead of multiple small pieces and use a bath plug technique that you push the fat first and just gently pull it so that it will seal the hole of the dural defect the fat graft must pulsate it shows that it's proper to avoid the over enthusiastic packing of the cellar now medial middle terminate is now medialized back to normal position to keep the maxillary drainage patent and no nasal pecs are required after this and this is just a one edited video of a pituitary adenoma you see this is the Kwanha and this is the ispinoid of Stia as you go up in the ispinoid matrices now you coagulate the mucosa here and now you see this is the austere and this is the boomer and then the fracture the septum has been fractured and now I am dissecting sub mucosaline and that is the other side austere and now we see the anterior ispinoid Rome is done and this is the cellar and this is the septum is leaving to move this cell is opening is widened gradually circumferentially now you see this is the dural opening so earlier we were using the opening like this but now we do the way I showed you and this is that the tumor so first make it free and then then you remove it and it also should be a very gentle traction we never call pull because there's no place for pull in this so it's just gently put a traction and then remove it and now you can see the normal pituitary there and in small pieces or in stages gently and this whole of the tumor is removed and now you can see that I from bulging and then the user and and a pad of fat which is pushing there and you gently withdraw it so that it seals it completely and then use a glue see in in endoscopic surgery the problem is there is no bone to support this graft so this is when you put the fat you have to put some sealing agent so that it is there and then the middle terminates which are medialized they will support it now no foreign material should be left behind in the spinoff sinus cavity because it's postoperatively because there's a lot of crusting intact residual mucosa keeps spinoff sinus as a air filled cavity which is more physiological so you remove the mucosa only covering the cellar and a simple pituitary you need not to remove whole of the mucosa if whole of the spinoff sinus is packed suppose the CSF leak occurred now you want to pack the spinoff sinus then you have to remove whole of the mucosa to prevent mucosil formation and leave minimal raw surface a steep learning curve exists during the change from microscopic to endoscopy and this is the time when complications can occur so a sudden change from microscopic to endoscopic may be difficult and discouraging so the transition should be slow and progressive a steep progressive learning curve can be reduced and by slow progression you gain confidence and you gain ability to tackle the complications if any occurs now you may have a frustrating experience in first 2030 cases because of difficulties in the initial phase of the procedure because we are not used to this initial phase so this can be minimized or overcome or avoided by the knowledge of endoscopic equipment by detailed understanding of endoscopic perception of the anatomy or learning the endoscopy skulls or taking help of your ENT colleagues it's great to be at your own but if you have some difficulties take help of your ENT colleagues follow the techniques step by step knowing the tips and tricks of the trade by assisting and watching the videos of the experts and by practicing in labs on models attending courses and live or cadaver workshops and not only one see one workshop will just orient you so now you go back do some cases come back then learning would be more and more and this is how we always attend old endoscopy workshops and I definitely learned some points from that so for a beginner and selection of cases is also important so the best patient for a beginner is a known functioning adenoma which is well nematized synod sinus and the tumor is confined to cellar so it is the best case for a beginner and the worst is when there is a conical or pre-cellar type of synod nomatization when patient has acromegaly or cushions because they bleed more because the mucosa is fragile hypertrophy then it's more and when if it is a recurrent or dumbbell or a giant pituitary adenoma so do not select these cases in the beginning always review the pre-op MRI and CT scan for assessment of nasal airway for the presence of any DNS or concavulosa and concavulosa is that the middle terminate may be nematized itself so it would be large and bulky so anatomy of paranasal sinus like extent of nematization and presence of intra or interstinal septum that how many septums are there and where they end like in cellar if there is any anatomical variation if there is any bone adhesions or presence of kissing carotids and these are the three types of the cellar so this is the most difficult so avoid in the beginning in doing this type of cellar these are cellar pre-cellar or conical type now a use of neuro navigation is important for the beginners in few cases I always use this just to get oriented to this later on you don't need it like if your anatomy is clear you don't need a navigation when the synod anatomy is not straight like if it is a concal or pre-cellar it's better to have a neuro navigation when it is a re-operation use neuro navigation when there is kissing carotids again use no navigation and when you are doing a extended transitional surgery for dumbbell or giant tumors I always use this now use extended approach for large or giant dumbbell tumors with narrow waist and extended here means is that you just remove the tuberculum celli and medial OCR because this is considered that this is the part of the bone which is making this narrow isthmus so if you remove this then whole tumor you can access it so this permits the retraction of Dura like with the suction then you can retract the Dura and see more tumor which allows the maximum tumor removal under vision so in the beginning the complications of CSF leak is more because when you shift from microscopic to endoscopic there is the visualization is super so there is a aggressive tumor removal tendency then you see the more tumor and you just pull it and then a arachnoid has come and the CSF leak has started so because of superb visualization you have a tendency for more aggressive removal so tend to restrict yourself now there is hardly any bone to support fat graft so the CSF leak may be there if you don't use some glue and all that or if you use the fixed microscope or static microscope because here I must tell you that a fixed endoscope is worse than microscope because it is just 2d only so for visualization and tumor dissection you need 3d vision 3d perception so do not fix the scope because it's worse than microscope 2d only no depth perception 400 or 2 surgeon that is the pilot covalent technique is good for 3d perception which allows you to use the flash light effect dynamic dissection and which helps you to differentiate between the tumor and normal pituitary and between the diaphragm and arachnoid and we have seen that with increasing experience there is improvement in endocrine remission extent of tumor a section preoperative visual deficits improve better post-op high perpetrator in is less because we are able to preserve more and more normal pituitary and there is reduction in duration of surgery mucosal trauma or post-op discomfort hospital stay and CSF leak so to conclude in the beginning one must select cases properly the transition should be gradual from microscopic to endoscopic use extended approach in large fibrotic solid tumors with supra-cellar extension with narrow waist that is the dumbbell or in giant pituitary adenomas spend time in widening of the spinoid model recess recognition of important landmarks during each stage of surgery stay oriented always the buttons must be facing the screen use neuro navigation in complicated cases by manual dissection and sequential tumor removal is the key use flash light effect and preserve normal pituitary avoid arachnoid tear and I tell you if you can avoid arachnoid tear your 90% complications are over because arachnoid tear only causes CSF leak meningitis it only causes damage to the perforators blood goes causes spying if you do intradural dissection you will pull some perforator or something so if you can avoid arachnoid tear 95% of problems are over thank you very much