Dr. Jho's Endoscopic Endonasal Pituitary Surgery Through a Nostril: Minimally Invasive Pituitary Tumor Surgery For Pituitary Adenomas, Prolactinomas, Acromegaly, and Cushing's Disease

Hae Dong Jho, M.D., Ph.D.

Home: Dr. Jho's Innovative Minimally Invasive Neurosurgery for Spine and Brain Disorders

Link: JHO Institute for Minimally Invasive Neurosurgery

"Ideas won't keep: something must be done about them." - Alfred North Whitehead

Facts About This Surgery


Endoscopic pituitary surgery can be performed for various types of pituitary tumors such as prolactinomas, Cushing's disease, gigantism or acromegaly, non-secreting adenomas, and for pituitary adenomas invading the cavernous sinus or extending into the suprasellar region. The conventional surgical method for removal of pituitary adenomas involves incisions under the upper lip or in the nostril. This requires the use of postoperative nasal packing. Adapting the use of a small fiberoptic-like catheter shaped tool called an endoscope, a surgical procedure has been developed that not only eliminates the need for nasal packing but heightens the surgeon's visualization of pituitary tumors. Replacing the operating microscope, the endoscope provides the surgeon with a panoramic view of the pituitary gland and surrounding structures. It can also provide a very close view of the pituitary gland and tumor interface. The patient undergoes general anesthesia, the endoscope and surgical instruments are placed in the patient's nostril, and the tumor is removed. No lip or nasal incisions are made, no packing is placed, and patients are generally sent home the day after surgery. Patients can also usually return to work or school in four to six weeks time.


adenoma - a benign slow growing tumor of the pituitary gland



Schematic drawings demonstrate techniques of endoscopic pituitary surgery. A transphenoidal retractor is not used. No skin or mucosal incisions are required. No postoperative nasal packing is necessary.


An endoscopic image of the middle turbinate seen during an endoscopic pituitary approach (left). The sphenoid ostia are visible in this photo (right, arrows).


Left and Center: Intraoperative endoscopic images present a close view of the sella (s), optic nerves (o), cavernous sinuses (cs), clivus (c), and tuberculum sella (ts). Right: After completion of tumor removal, the sella is reconstructed with auotgenous bone that was preserved at the time of sphenoidotomy.


An MRI scan, coronal view, shows a large pituitary tumor preoperatively (left). The optic chiasm (arrows) is draped over the tumor. Total resection of the tumor is demonstrated postoperatively (right). The optic chiasm is now free from compression.

A preoperative axial CT scan shows a large pituitary tumor. The patient had previously undergone transphenoidal microscopic removal of the tumor by another surgeon, but due to how hard and fibrotic the tumor was, only biopsy was possible at the time. The biopsy site is visible at the center of the tumor (arrow).


Preoperative axial, coronal, and sagittal MRI images reveal a large pituitary tumor in the same patient.


The corresponding postoperative axial, coronal, and sagittal MRI images present complete tumor resection and fat graft placement. The bright shadow in the the sagittal view (right) is an abdominal fat graft placed at the tumor resection cavity (F).


Nasal packing is not necessary and not used as seen in this patient in the recovery room following endoscopic pituitary tumor surgery (left). The next picture shows the same patient, prior to discharge, on the day following surgery.


An intraoperative endoscopic image of a patient with acromegaly shows a pituitary adenoma (PA), in the left cavernous sinus (left). The tumor is shown to have been completely excised in this endoscopic image (right, S: sella, TR: tumor resection cavity in the cavernous sinus, C: carotid artery (outlined in white). Postoperative cure of the patient's acromegaly was confirmed by endocrinological testing.


Left: A preoperative coronal view MRI shows a recurrent pituitary tumor involving the left cavernous sinus. Right: The corresponding postoperative MRI scan shows complete tumor resection from the left cavernous sinus.


Jho HD, Carrau RL: Endoscopic endonasal transsphenoidal surgery: Experience with 50 patients. Neurosurgical focus 1(1): article 2, 1996

Jho HD, Carrau RL, Ko Y: Endoscopic pituitary surgery, in Wilkins RH, Rengachary SS (ed): Neurosurgical Operative Atlas, Park Ridge, III: American Association of Neurological Surgeons, 1996, Vol 5, pp 1-12

Jho HD, Carrau RL: Endoscopy assisted transsphenoidal surgery for pituitary adenoma: Technical note. Acta Neurochirurgica 138: 1416-1425, 1996

Jho HD, Carrau RL: Endoscopic pituitary surgery: An early experience. Surgical Neurology 47: 213-223, 1997

Jho HD: Endoscopic endonasal pituitary surgery: Technical aspects. Contemporary Neurosurgery 19, No.6: 1-8, 1997

Jho HD: Endoscopic surgery of pituitary adenomas. In Krisht AF, Tindall GT (eds), Pituitary Disorder: Comprehensive Management, Williams & Wilkins (in press)

Carrau RL, Jho HD: Pituitary: Endoscopic approach. In Arriaga M, Day J (eds) Neurological Issues in Otolaryngology: Principles and Practice of Collaboration, Lippincott-Raven (in press)

Jho HD: Transsphenoidal endoscopic surgery. In Fessler RG, Sekhar LN (eds), Atlas of Neurosurgical Techniques (in press)

Jho HD: Endoscopic transsphenoidal surgery. In Schmidek HH (ed), Fourth edition of Operative Neurosurgical Techniques: Indications, Methods and Results (in press)

Jho HD: Endoscopic transsphenoidal surgery. In Fisher WS (guest ed), Hadley M (ed), Perspectives in Neurological Surgery (in press)

Referral Information

For referral information or appointment for consultation contact:

Manager: Robin A. Coret, B.S.- (412)359-6110 or e-mail at


Fax: (412)359-8339

Address: JHO Institute for Minimally Invasive Neurosurgery

7th Floor, Snyder Pavilion, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212-4772

Contact Dr. Jho via email: DrJho@DrJho.com

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