Endoscopic Skull Base Surgery

The history of endoscopic skull base surgery is de facto the history of pituitary surgery. The first pituitary operation was likely performed by Sir Victor Horsley in 1889 via a transfrontal approach though he did not publish his results (1). His compatriots, Caton and Paul, were the first to publish the results of this operation in 1893 (2) in which they reported that their patient was cured of his headaches for the three months he survived post operatively. But, it is Schloffer who is widely regarded as the father of modern pituitary surgery. In 1906 he published a seminal paper discussing the possibility of pituitary surgery via a transsphenoidal approach (3) and performed this operation on March 16, 1907. The operation was performed via nasal translocation and lasted about 75 min. Though there were no intraoperative complications, the patient died two months later and on autopsy was found to have hydrocephalus as a result of residual tumor blocking the foramen of Monro (4). Then in 1910, Oskar Hirsh, an otolaryngologist, introduced a transseptal, transsphenoidal approach to the pituitary gland (5), an operation which is still in use today. Cushing performed his first pituitary operation in 1909 (6) using Schloffer's method but then rapidly adopted Hirsh's approach adding a sublabial incision and a headlamp to improve visualization of the sella. Using this approach he performed 231 oper-ations with a 5.6% mortality rate (7, 8). However, because of difficulties with cerebrospinal fluid (CSF) leak, hemorrhage control, post operative cerebral edema, and concerns regarding vision outcomes and recurrence he eventually abandoned the transsphenoidal approach and went to a transcranial approach. This was a large setback for the transsphenoidal approach as it led to the vast majority of pituitary operations being performed transcranially for the next 35 yr.