 Now, as we all know that this endoscopic pituitary surgery has emerged as a better alternative to micro surgery because it has distinct advantage and one of them is that it provides better visualization because of better illumination and magnification. It provides a phenomic view where you can identify structures very clearly which permits a better distinction between the normal pituitary and the tumor. So, you are able to preserve normal pituitary in majority of the cases. Identification of CSF leak is better with endoscope because you can distinguish between normal pituitary, tumor and diaphragm are ignored very clearly. And it permits you to look around in the cellar and which enables to remove the tumor in the corners of the cellar. But there is a steep learning curve and this is the time when the complications can happen and this is said that expect the unexpected in endoscopy any complication could happen but particularly during this steep learning curve. So, the idea of this presentation is just to let you know that what all can be done to minimize these complications. Now, the complications in endoscopic pituitary surgery could be known endocrine and endocrine. Endocrine complications could be again according to the stage of surgery like in nasal stage, sphinodal stage, cellar stage and intradural stage. In nasal stage, the commonest complication is bleeding, bleeding which patient may present with early or late epistexis and usually the cause is a mucosal branch of sphinopolitan artery. Now, enosmia and hyposmia again it is the upper part of the mucosa which is responsible for olfaction. So, always even when you take a mucosal flap that mucosa should be left undisturbed or preserved. Now, the sphinoid or magillary sinusitis, mucosil or synechia formation and these things usually the patient presents with headache, dizziness and fever of about 2 to 3 months duration. So, if patient post-op patient presents like this then you should suspect sinusitis or mucosil in these patients. Carotid injury the cause of carotid injury that you are once you are in and you get lost then because you are not properly oriented. So, this is why you start removing the bone and then you remove the bone over the carotid. The Doppler and the navigation they help you in identifying the area where not to go and this complication must be recognized immediately and you just pack it and leave it and that get the appropriate treatment that is why stenting endovascular stenting. Another complication which is quite common is CSF ranoria causing meningitis or pneumocryphalus. There can be post-operative apoplexy that is in the giant pituitary tumors with partial removal the residual tumor bleeds and that is known as post-op apoplexy or a hematoma formation may be there. You may injure the hypothalamic perforators if you have gone through the arachnoid and remove the tumor from there or if you have pulled some vascular perforator. There may be residual tumor if the arachnoid is torn then the blood can get in which can cause vasoespasm. You may injure some of the perforators or optic nerves if you are too much in so that can cause visual deterioration and even death could occur after this kind of surgery and the cause may be a carotid injury or fulminant meningitis post-op apoplexy or vasoespasm or hypothalamic perforator injury. So these are the grave complications which can lead to mortality in these patients. The endocrine complications are new pituitary hormone deficient. The patient had no hormone deficiency in the pre-op but he can develop later because its normal pituitary has been taken out or the patient can develop diabetes. Now it is well documented that with increasing experience there is improvement in duration of surgery that you more and more you do less time you take during the whole surgery. The pre-operative visual deficits which were there improve after surgery. The endocrine remission may occur if you have removed the tumor and preserved the pituitary and again it improves with the experience. Similarly the post-op hypopituitary chances become less and less. The mucosal trauma chances are less because now your hands are more used to these kinds of surgeries. So is less post-operative discomfort to the patient. Less is a hospital stay and incidence of CSF leak also goes down. Now post-operative results start to see that the post-op complications are less and a clear improvement in your overall results occurs after you have done around 100 pituitary cases. And now this again the aim of this presentation is to highlight the experiences the lessons we learned so that we can shorten the steep learning curve avoid complications and improve the results. Now first thing is that changing from microscopic to endoscopic may be a difficult and discouraging. So do not change suddenly progress slowly. Initially if suppose you are doing a sub labial microscopic pituitary then change it to endonazole. Similarly then start using endoscope so it becomes endoscopic assisted. Then you start doing endoscopy with retractor on and then without retractor but doing the cellular stage or intrarural stage first because you are more used to that and in the last the nasal stage with endoscope and then all stages of pituitary surgery by endoscopy. Now slow progress in steep wise manner brings confidence and ability to control the complication should it happen. Now you may get a very frustrating experience in first 20 to 30 cases because of difficulties in initial phase of procedure but these can be minimized overcome or avoided by knowing the endoscopic equipment fully. By detail understanding of anatomic perception of the endoscopic anatomy. Learning endoscopic skills and knowing the tips and tricks which this article also includes. Now in general the microscopic pituitary surgery has been linked to eating with fork and knife. But endoscopic surgery has been linked to eating with one chopstick in each hand so you have to really learn it and this you can learn only by commitment and dedication. Now selection of cases for a beginner is very important and the best case is a non-functioning adenoma which is confined to the cellar and the spinoid sinus is well nematized. So this is the best case simple case to start with. Whereas the worst is that it's a conical or pre-cellar type of nematization and patient is either acromaglic or cushingoid because where the mucosa is very fragile, hypertrophied and it bleeds. So it would be very frustrating for a beginner. And if it's a recurrent or a dumbbell tumor with narrow neck or a giant pituitary tumor. So never select these cases in the beginning. Always review pre-operative MRI and CT scan to know the size of nasal cavity if there is any deviated nasal septum or concavulosa. Now study the anatomy of perinatal sinus which is important like the extent of nematization and how many septar there in the spinoid sinus which is again very important in the stress. Now see the cellar whether it's enlarged, eroded, any anatomical variation or kissing carotids which is again important. If it's a kissing carotids just avoid doing trans-synodal endoscopy in the beginning. Now if you see a mucosal thickening or enhancement in the spinoid mucosa it may indicate either a sinusitis or a pituitary apoplexy. Now neuro navigation or image guidance should be used by a beginner in early cases when spinoid sinus anatomy is not straight again that concal or a pre-cellar type of cellar if it's a redo surgery if you are doing extended trans-synodal or if the tumor is dumbbell or a giant or there is kissing carotids in these cases you must use image guidance. Now there are technical variations of this endoscopic surgery whether it's a union nostril or binostril or two-hand, three-hand, four-hand technique depends on the extent of resection of middle terminate usually for pituitary no resection is required sometimes maybe partial resection or if it's a very narrow then sometimes middle terminate can be excised. Now depends on type of repair of the cellar what type of repair you do. So you must know all these variations so that you are able to tailor a particular technique in particular situation in a given patient. Now initially you just pass the scope in the nostril inferiorly for about 25 degree and you see the koana or the posterior ferrins and this koana is the anatomic reference and from here you proceed now you take your scope up and then go slowly between inferior terminate and septum then middle terminate and nasal septum. Now the scope is held in the upper part of the nostril and you deforming the nostril so that you get a lot of space there. Now instruments are passed below the scope so far if it's a zero degree the instruments are passed below the scope through the lower part of the nostril. Now in the beginning only you execute in and out movement so that you have an idea of depth and you know the particular anatomical structures relation to that and avoid the quick movements on reaching to the target surgical target. Now we usually use this oxymetazoline nasal drops half an hour prior to say and we ask for a proper fall infusion or the anesthetist because this keeps blood pressure low around 90 and then there's a less of the bleeding from the mucosa and then we pack the nasal cavity with xylokane and adrenaline soaked patties which are first taken to the koana and the concentration we use is the 3-4 ampoules of 1s to 1000 adrenaline is put in 30 ml of xylokane and then you can dilute it further and you pack the nostril and you pack one nostril at a time wait for five minutes then pack the another nostril at a time and if you find some synechia they should not be cut they should be coagulated. Now always avoid injury to nuisal mucosa during insertion of the instruments or taking out the instrument from the nasal cavity and this is done by that your insertion of instruments should be endoscope guided so that you take a tip of the instrument in front of the endoscope always and then you go there and then you can take out the endoscope because the resultant bleeding can be very frustrating and if there is any bleeding from the point it's better controlled by just giving 1 ml of xylane injecting a xylane rather than coagulation now while packing you use the bianet forceps and open the bianet forceps craniocodally because there is limited space so you cannot open it on transversely now 2 to 4 cotton patties which are soaked in the decongestion solution are inserted between the middle terminate and nasal septum anteriorly inferiorly and then you push them push posteriorly gently so that it creates a space and leave them there for 5-10 minutes to widen the space model resist now once space is created then fresh cotton patties are pushed back in the recess at the rostrum of the scenoid sinus and then again wait there and keep them for 2-5 minutes now 10-15 minutes of investment at this stage of surgery pay dividends in rest of the operation your rest of the operation is going to be smooth if you spend some time here next is that you lateralize the middle terminate by pushing it with a desector over the patty do not put a desector directly and you push it then it may start bleeding or if you are using an extended operation then first it should be pushed medially out-fractured and then pushed later so now this is just to show you that between the septum and middle terminate now as we know the stages of the surgical technique are nasal, sphenoidal, cellar and reconstructive stage and recognition of anatomical landmarks in each of these stages is very important for the safe exposure and we already know that this postial septal artery is branch of sphenopyleton artery which is internal branch of internal medullary artery so its location is superior lateral to coana that is inferior lateral corner of sphenoidal recess or the medial posterior corner of inferior margin of middle terminate now the sphenodostia marks the superior limit of opening into the sphenoid sinus and the inferior margin of middle terminate leads to the clival indentation at one centimeter below the level of cellar floor and it's a very constant anatomical landmark and this is why after doing few cases you may stop using image guidance or see arm and all those things now mucosia over the rostrum is coagulated from inferior margin of middle terminate vertically up to the osteum on one side first and while passing the instruments you may endure this middle terminate or mucosia somewhere so in order to avoid that always pass the instruments along the nasal septum so the instrument will go to the desired place and one important fact is that maxillary and this sphenoidostia both are at same level of transverse line passing through the junction of vertical and horizontal part of middle terminate so this anatomy you should remember now how to use the drill that you first take the drill close to the target when you can see the tip of the drill in the screen now you make it on it starts moving then you touch it to the target where you want to remove and use it like a paint brush just like a brush you remove it then you take again and then remove and you remove the drill out only when it has completely stopped never remove a drill which is on now if there is any bleeding from the bone and dry drilling with a diamond bar without saline will stop that bleeding while drilling keep your endoscope away but keep it at high zoom so that it doesn't soil your scope and this is the classical described owl eye appearance where you see that these two eyes of owl are both the sphenoidostia and this is the rostrum and the bowmen now for sphenoidotomy as already told the ostia are enlarged medially and inferiorly and we usually prefer to do it by drill but you can do it by up cut and this is made in a v shape and we don't start superiorly or go superiorly because you may in oriously enter into the intercranial fossa now if you are not able to see any of the ostia then the another point is a sphenoid fontanel this is a very thin bone part just below the ostia where you can just perforate this and enter into the sphenoid signs now sphenoidomy is done for about 15 to 20 millimeters from superior ostia to down for this much distance now the caudally wormer is drilled up to the vaginal canal for vidian nerve or a synchondrosis is there and which are seen at 5 or 7 o'clock position now this creates a sufficient space so that at least you are able to pass a large size sucker below the cellar floor and that will entail that there is sufficient space to put your instruments and manipulate them to the desired size so this much sphenoidotomy should be done now laterally the limit of sphenoidotomy is up to the crest which marks the junction of sphenoid with ethmoids whenever sphenoidotomy is done the margins must be made smooth by a diamond bar if you remove these paraceptal in the sphenoid sinus they invariably lead to carotid artery or optic nerve so remove them only when it is mandatory and remove them by drill not just by the punch and then you pull out and injured them now they just to show you the drilling of the bummer now tie all the cords in the scope together and put them in the front and keep them away from your site of the surgery or from trajectory now keep checking the proper orientation particularly when you are getting in or coming out because this thing moves then you are totally disoriented and you are likely to produce the conflict so when you come out with the endoscope always check that these buttons are facing the screen so this is the always the proper orientation always one must check this and once the sphenotomy is done then you identify the midline by remains of rostrum or bummer inferiorly and by staying it between both the carotid grooves now mucosa over the posterior wall of the sphenoid or cella is not coagulated is coagulated and is not stripped because otherwise bleeding may occur and at this stage just to irrigate this cavity with warm celline and then you start opening the cella at this stage you see a very nice anatomical landmarks which are identified in the panoramic view and this whole picture mimics a fetal phase where you can see in the center is the cella in the rostrum is tuberculums early at 12 o'clock at 6 o'clock is the clivalent indentation laterally optic protuberance at 10 and 2 o'clock carotid protuberance at 5 and 7 o'clock and both cavernous sinuses at 3 and 9 o'clock once you have removed the cella now is the dural opening for opening a dura you use a huletone or a endoscopic knife and just make a cut in the center and then complete this cut by using scissors and don't make a cut in the periphery because in the center and then move to periphery because endoscopy knife is a long instrument if you cut it you don't have a precise control so you are likely to cut cavernous sinuses and those things if you do with this so what you do is just make a central opening and then you extend it with scissors now this opening is extended quarterly at 5 and 8 o'clock positions and upper part of the dura is not opened yet now this technique of opening the dura permits removal of the posterior and lateral part of the tumor first which is likely to be missed if you open the superior part of the dura because the superior part will come and the diaphragm will bulge and this will you will not be able to see the tumor and this upper part of the dura which has not been opened this acts as a retractor or it holds the superior part of the tumor and this prevents the premature bulging of the arachnid now while cutting dura cut dura only don't cut the capsule of the tumor cut the dura make two cuts and then you dissect these dura flaps and reflect them outside so now you see a very clear tumor there now remove the basal part of the tumor from the inferior flap in a posterior trajectory towards the clivus or dorsum junction in from cordal to rostral direction by moving your curate like this and you see the acromeglic tumors are always white now that next the lateral portion of the tumor is removed with upward angled curates and it is the lastly is the superior part which is removed rostral portion of tumor is removed circumferentially from periphery towards the center and proglasie descending supracellular tumor is continuously removed concentrically the tumor decompression is done by manual dissection by curate in right hand and suction is left hand take endoscope closer to the target for detailed study and that is the real beauty of endoscope that it's a flashlight effect so when you take the endoscope closer to the tumor or target you see the anatomy in very much detail but now you cannot pass the instrument so you take it out put the instrument and then take it again close so it's a removal is a dynamic process now once you have removed sufficiently if you see the diaphragm push the diaphragm with cotton and remove the tumor from the recesses lateral recesses now with this endoscopy earlier I was using and fixing the endoscope at a cellar stage but now I don't fix it and because we work as a team and the surgeon and assistant they act as a pilot and co-pilot because it provides a better 3D perception and a flashlight effect can be seen now the capsule is dissected by bimanual again always the dissection has to be bimanual you just cannot pull anything from there it has to be bilateral it has to be bimanual now suction is held in the left hand which gently retracts or holds a tissue precision grip forceps precision grip is that you hold the forceps by doing this movement by doing this this is a power grip so precision grip is always preferred then you put the traction and counter traction and then you separate either the arachnoid or other adherent tissues like if you are holding a tumor in the left suction just retract it and with right side forceps you just tease it away like we do it in acoustic in seventh nerve this is just dissected like this now in functioning adenomal a thin shell of normal pituitary may be excised for the want of the complete cure and while you are removing or delivering the tumor don't pull it towards the endoscope because it will soil it and then surgery time will increase so take it on the sides and then you tend to see if there is something adherent in the depth now angled scope is taken inside the cellar to examine the tumor remunerants if they are there then the curved suction can remove them and now you examine the medial wall of the cavernous sinus when you rotate the 30 degree endoscope ask the assistant to move the camera also because otherwise your orientation will get disturbed so simultaneously the camera should move again so that the buttons are facing to the screen now space between the post triglynoid and the carotid siphon which is like reverse s is the right place to remove the tumor if it is extending to the cavernous sinus now angled scope visualizes opposite to the cable suppose light cable is here then it is visualizing the superior part so if you want to see up then cable should be down and your scope should be kept now in the lower part of the nostril so that your instruments will go from upper because it is showing the superiorly the upper part now your instruments have to go from superior and the scope has to come in the lower part of the nostril now failure of diaphragm descent indicates a retained tumor in the supracellar portion now visible pulsations in the diaphragm is a robust finding of total tumor removal if you see like this the whole thing is collapsed now arachnoid sometimes may bulge down in front of diaphragm so care should be taken not to produce CSF leak now the last part of the tumor usually is located at the insertion of site of the pituitary stalk and other two common sites where tumor may be found is angle between the optic nerve and carotid and under the anterior lip of dura at the level of superior intercavernous sinus now normal or a thinned out pituitary gland is seen as an apron plastered to the under surface of diaphragm which should be identified and preserved finally the inspection of cella is done in clockwise fashion starting at 6 o'clock using a 30 degree angled endoscope so these are the basic techniques of dissection of a tumor whether micro surgery or endoscopic surgery internal debulking, capsule mobilization, extra capsular dissection of neuro vascular structures and arachnoid coagulation and then capsule removal they take precedence over whatever degree of tumor removal is possible if you are not able to remove it completely okay but you cannot deviate from these micro or endoscopic surgical procedures now the extended endoscopic approach is required in a fibrotic and solid tumors which have large supracellular extension if there is extension into the intracranial fossa or if it is a dumbbell with narrow isthomas or the tumor is extended into cavernous sinus for extra capsular dissection of supracellular tumor it is imperative to remove overlying medial OCR now for dumbbell tumor remove the tuberculum celli remember which is the cause of constriction so if you remove the tuberculum celli then it is no more a dumbbell sort of thing and then tumor can come out but no need to open the dura above the superior intracranial sinus but for large supracellular extension or giant tumors remove tuberculum celli part of plenum open the dura so that now you can push the tumor down if still large then you may coagulate the superior intracranial sinus and cut the diaphragm and now you can remove from below more and more tumor use angled scope use image guidance in such cases and try to do maximal tumor removal to prevent the post-op apoplexy in recurrent cases I prefer to take a flap in the very beginning because more chance of CSF leak more chance of infection so better to take a mucosal flap which may be either a rescue flap or a typical haddad flap and avoid tear in the arachnoid at all course because recurrent cases more chance of infection and use image intensifier now do all salva manual to check for CSF leak now tumor resection cavity even if there is no leak we tend to use fat because it prevents any empty cellar syndrome and it prevents a leak because of delayed rupture of arachnoid which can happen during the time of extubation if arachnoid tear occurs the CSF leak is there which is usually grade 1 or 2 now in order to prevent further arachnoid tear now small tear can immediately be sealed with the glue and keep one patty over the defect to prevent blood entering into the subarachnoid space and later on causing vasoespasm now we tend to use a large single piece of fat rather than small pieces and use this bath plug technique to close the defect bone paste from the rostrum or from the nasal septum may be used for cellar reconstruction particularly if CSF leak has been there rescue flap may be used now we have started using this rescue flap so that at least it's covered post-op lumbar drain both ways it's used either you use it only when there is a leak after repair or you use it prophylactically and keep it for 72 hours no foreign material is left in the acenoid sinus the intact residual mucosa keeps the sinus aerated so it is more physiological so we don't just pack unnecessarily the acenoid sinus if whole of the acenoid sinus needs to be packed because of CSF leak and you want to do a solid repair in that case whole of the mucosa should be removed otherwise mucosil formation chances are there now always push the middle terminate back which we have lateralized otherwise maxillary sinus obstruction may occur now we tend to leave a minimal row surface because whenever you leave any row surface it comes in contact with air and there is lot of crusting which is not good for the patient so to conclude the post-operative complications can be avoided by gradual transition from macroscopic to endoscopic surgery by proper selection of cases in the beginning acquiring hand eye coordination and endoscopic surgical skills in the laboratory in cadavors or by assisting the expert surgeons by gently handling the mucosa by spending time in widening the isphanoethymidal recess by recognition of important landmarks during each stage of surgery like middle terminate in nasal stage osteo and isphanoid stage and fetal face appearance in cellar stage bimanual dissection and sequential tumor excision under vision using extended approach in cases of large or giant supracellular tumors image guidance in first 50 cases and later on whenever required use mucosal flap in redo cases avoid arachnotiae whenever possible and preserve normal pituitary so by observing these you can avoid most of these complications so there are just two small videos yeah now here this this patient has concavulosa so it's it's mouths were opened in addition to that now we are trying to make here a small flap and this part of bone septum can be preserved and can be used for the reconstruction and now this this is lower down is the part of womber now you can see that typical appearance owl eye appearance both the osteo and this womber now instead of this you could drill it now we see the inside the cellar and now the cellar floor is being removed with the up cut and now this is the dura over the cellar and how you earlier I used to make cuts like two lateral cuts first to remove the tumor from the lateral side now you see the tumor is bulging on the both sides which was removed so the advantage with these techniques is that your superior or interior part is supported it doesn't come before the other parts of the tumor and now you cut this portion and now this tumor is removed so gently when you hold it you look around everywhere that nothing is adhering to this and now see that this arachnoid started bulging but still there is some tumor on the lateral and posterior part and now you see the arachnoid there and now here the normal pituitary is there which you see there and this is the junction so now when you just tend to remove it in piecemeal the normal pituitary will be left behind and this tumor will come and this is that thing little bit of portion of the tumor little more posteriorly yeah and now you can see the junction of this normal pituitary and this tumor now you see a small tear here in the arachnoid this is the after completing you can see the whole of the diaphragm and this arachnoid bulging and then we tend to put a large piece of the fat there and then we can put glue if required cover it with the sergi cell and then glue yeah now here you will just see the ostea the spinned ostea on this side and this again making a small flap and this is the septum where we have made this and now you see the boomer again and now this is the other side now you see this is the cellar floor now you see the opening is made like what used to do and first the tumor is removed from the lower basal part and then from the lateral part and I see this large bulk of the tumor coming out and I will see again you can see the normal pituitary probably now here the dura was opened superiorly also so now this portion is bulging but then you can retract it with the patty and then remove the regular part and now after remove again a piece of fat and then glue and thank you very much for your patience here