The provocative letter of Drs. de Divitiis and Cappabianca highlights a number of points relevant to technical advances in neurosurgery. These points include the relative virtues of endoscopic transsphenoidal pituitary surgery as compared with the standard approach with the binocular operating microscope, methods of teaching trainees new technical advances such as endoscopic neurosurgery, the relative advantages and disadvantages of each technique for the patient with regard to comfort, and the entire concept of minimally invasive surgery.
It is important to remember that the goal of pituitary surgery is not to have the patient leave the hospital the same day or the next day but to achieve effective removal of the offending lesion. At this point, it is not really known whether an experienced surgeon who uses endoscopic techniques for pituitary surgery can match the outcome results achieved with standard transsphenoidal microsurgery. The published case series and follow-up periods simply have not been adequate to make this determination in a scientific fashion. Surely, the efficacy of endoscopic techniques eventually will be determined, but definitive results probably will not be available for several years. In acknowledging this fact, however, one must be impressed by the several technical and conceptual advantages offered by the endoscopic approach. In my opinion, the advantages are compelling enough to permit me to state that every neurosurgical resident should be trained in the effective use of the operating endoscope. If this training is provided, it is nearly certain that younger neurosurgeons and neurosurgeons in training will extend the use of the endoscope to appropriate areas, which surely will include transsphenoidal pituitary surgery. Whether they should start using the endoscope immediately is a matter of debate. My suspicion is that the use of the endoscope in neurosurgery will eventually parallel the adoption of this instrumentation and conceptual methodology by general surgeons. This evolution will be even more certain when endoscopes provide a three-dimensional view, are easily kept clean, or are replaced by miniature television cameras. Drs. de Divitiis and Cappabianca have been among the pioneers in advocating for the more widespread adoption of the endoscopic technique for pituitary surgery, showing an intelligent approach and vigor in the desire to educate others in the use of these techniques (1).
Edward R. Laws Jr.
1. Kaptain GJ, Vincent DA, Sheehan JP, Laws ER Jr: Transsphenoidal approaches for extracapsular resection of midline suprasellar and anterior cranial base lesions. Neurosurgery 49: 94–101, 2001.