The importance of landmarks in endoscopic endonasal reinterventions: the transpterygoid transcavernous approach

Sellar and parasellar regions are anatomically complex region and in close relationship with important neurovascular structures. Hence, surgical treatment of recurrent aggressive pituitary adenomas invading the cavernous sinus represents an operative challenge, given the lack of landmarks that are missed because of the scar tissue and previous interventions. We describe in detail the surgical technique of the transpterygoid transcavernous approach (TPTCa) for the surgical re-operation of a recurrent pituitary adenoma invading the left cavernous sinus in the context of a Nelson syndrome after bilateral adrenalectomy. We highlight the main anatomical key elements involved in this approach as well as the technical aspects for avoiding surgical complications. The TPTCa is a versatile approach that uses the endoscopic transsphenoidal route and thereby, avoids brain retraction. Anatomic landmarks offer a good sense of the area that is exposed in reoperations and reduce the risk of injury of important neurovascular structures located within the cavernous sinus and the parasellar region.