title: Extracapsular dissection technique with the cotton swab for pituitary adenomas through an endoscopic endonasal approach -- how I do it.
abstract: BACKGROUND
  Pituitary adenomas are often encased in a histological pseudocapsule that separates the tumor from the normal gland. Transsphenoidal adenoma resection may be performed either in an intra- or an extracapsular technique. The extracapsular fashion offers anatomical orientation, removal of a security margin, reduced risk of opening the arachnoid layer with subsequent CSF flow and identification of invasion.
  
  
  METHODS
  The sella turcica is approached through the classic endoscopic endonasal route. After opening the dura of the sellar floor, the interface between the compressed tissue and the normal gland is used as a surgical plane for dissection. Performing slight counter-traction with the suction tube, the cleavage plane is identified and stepwise unsealed in an atraumatic fashion with the cotton swab. Once the cleavage plane is partially loosened, repeated twisting movements are performed with the cotton swab to enucleate the pseudocapsule and adenoma.
  
  
  CONCLUSIONS
  Both micro- and macroadenomas presenting a pseudocapsule may be resected in the extracapsular dissection technique with the cotton swab. Operating in an endoscopic three- to four hands technique enables to visualize the anatomic planes and perform twisting movements with the cotton swab separating pseudocapsule and tumor in order to enucleate the adenoma.
authors.affiliation: Department of Neurological Surgery, Wexner Medical Center at The Ohio State University, Columbus, OH, USA.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Prevedello
authors.forename: Florian H
authors.initials: FH
authors.lastname: Ebner
authors.forename: Danielle
authors.initials: D
authors.lastname: de Lara
authors.forename: Leo
authors.initials: L
authors.lastname: Ditzel Filho
authors.forename: Brad A
authors.initials: BA
authors.lastname: Otto
authors.forename: Ricardo L
authors.initials: RL
authors.lastname: Carrau
mesh_terms: D000236:Adenoma / Q000601:surgery*; D004388:Dura Mater / Q000601:surgery; D004724:Endoscopy / Q000379:methods; D006801:Humans; D019635:Neurosurgical Procedures / Q000379:methods*; D009666:Nose / Q000473:pathology; D010911:Pituitary Neoplasms / Q000473:pathology / Q000601:surgery*; D013100:Sphenoid Bone / Q000473:pathology / Q000601:surgery; D016896:Treatment Outcome