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Endoscopic Endonasal Pituitary Hemi-Rotation Approach to the Upper Clivus: Anatomical Study and Clinical Report.

AIM
The upper clivus represents one of the most difficult regions to access, and the endonasal route has been advocated as a valid surgical corridor to access this area. The pituitary gland thus acts as an important anatomical barrier that must be preserved intact, both anatomically and functionally. Therefore, many authors have proposed several techniques that entail pituitary dislocation to increase visibility and maneuverability in such a narrow surgical corridor. This study aimed to report on the endoscopic endonasal pituitary hemi-rotation approach (EPHRA) in a preclinical setting and in a preliminary clinical experience.


MATERIAL AND METHODS
EPHRA was performed in five fresh-frozen head and neck specimens (a total of 10 sides) and in a selected case of a right-sided dorsum sellae chordoma.


RESULTS
The approach described allowed exposure of the lateral part of the upper clivus in all the specimens and in the case reported. To evaluate the maximum possible degree of hypophyseal hemi-rotation, the hemi-rotation angle (HRA) of the approach was measured and reported for all sides of the specimens. In 9 out of 10 cadaver head sides, and in the clinical case, it was possible to avoid sectioning of the inferior hypophyseal artery. No complications occurred during or after the procedure.


CONCLUSION
EPHRA represents an addition to the techniques already described and finds indications in case of non-massive neoformations of the lateral upper clivus. Clinical applications and limitations still need to be clarified in further clinical studies.