2026 Proffered Presentations
S089: THE SELLAR HINGE: A NOVEL SELLAR RECONSTRUCTION TECHNIQUE FOLLOWING ENDOSCOPIC PITUITARY SURGERY.
Misael Salazar-Alejo1; Astrid Nieto-Gutiérrez1; Rodolfo Villalobos-Díaz2; Luis E Perez-Martinez, MD1; Mario Benvenutti-Regato, MD1; Jose A Figueroa-Sanchez, MD1; Marcos V Sangrador-Deitos1; 1Department of Neurological Surgery, Centro Médico Zambrano-Hellion, TecSalud, San Pedro Garza García, Mexico; 2Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
Introduction: The endoscopic endonasal approach (EEA) now represents the gold standard for resecting pituitary, sellar, and parasellar tumors. Despite these surgical advances, reconstruction techniques lack standardization and vary significantly between surgical centers worldwide. We present the sellar hinge technique (SHT), a novel sellar reconstruction method repurposing the bone defect from the anterior sellar wall. This anatomical approach preserves the normal sellar architecture while eliminating the need for flap harvesting from distant donor sites or the use of synthetic materials.
Methods: We performed the SHT in five patients who underwent EEA for pituitary adenomas during 2023. All patients completed clinical follow-up at 1, 3, and 6 months postoperatively. We assessed neurological, ophthalmological, and endocrine function in all patients before and after surgery. Imaging evaluation included preoperative and postoperative computed tomography (CT) and magnetic resonance imaging (MRI). Patients received immediate postoperative CT scans, with follow-up MRI studies obtained at 3 and 6 months.
Results: Prior to OR arrival and after intubation, nasal decongestion with oxymetazoline was performed. The nasal and sphenoidal phases were completed in a conventional fashion. Once the sella and clival recess was exposed, with bilateral cavernous sinus projections identified, SHT was initiated using a 3-mm diamond bit drill. The ventral hinge opening was drilled at the junction between the anterior sellar wall and floor until the sellar dura was exposed. Next, we approached either the left or right side, carefully thinning the bone at the projected border of the cavernous sinus anterior wall. The lateral drilling extended dorsally toward the anterior intracavernous sinus projection. The dorsal osseous portion between lateral cuts was preserved as the hinge. After drilling, we mobilized the osseous flap dorsally using a Kerrison rongeur or dissector. Following standard dural opening and tumor resection, the flap was repositioned ventrally with tissue sealant application to prevent displacement. No intraoperative CSF leaks occurred, eliminating the need for nasoseptal flaps (NSF). On follow-up, no evidence of CSF leak, infection, or ophthalmologic, neurologic or endocrine sequelae were observed.
Discussion: The SHT enabled effective EEA surgeries with no perioperative complications in this small patient series. This technique preserves structural integrity, potentially reducing migration and infectious complications observed with other reconstruction methods. Moreover, SHT implementation requires no additional costs or operative risks. The technique can be applied to purely transsellar approaches for pituitary adenoma resection without compartmental extension. SHT allows sellar reconstruction using only dural substitutes, eliminating the need for additional bone harvesting, and when necessary, provides an adequate osseous scaffold for NSF adhesion. Further research is required to evaluate SHT efficacy in larger cohorts, identify optimal patient candidates, and compare outcomes with established reconstruction techniques.
Conclusion: SHT represents a novel approach to sellar reconstruction, after purely transsellar approaches, utilizing the surgical defect's inherent anatomy rather than external grafts. This technique can be implemented immediately with no additional costs or operative risks while potentially reducing patient morbidity. SHT offers an innovative approach to skull base reconstruction for small pituitary adenomas confined to the sellar compartment and treated via a purely transsellar approach.