How Is Transsphenoidal Surgery for Acromegaly Performed?

If you are preparing for pituitary surgery to treat acromegaly, it is completely normal to feel anxious. One of the most common worries is whether surgeons will have to cut open your head. The short answer is that in the vast majority of cases, no—your surgeon will not need to cut open your skull or make any incisions on your face ^[1].

Instead, most pituitary tumors are removed using a minimally invasive technique called endoscopic transsphenoidal surgery ^[2]. This approach is performed entirely through your nostrils, using your natural airway as a tunnel to reach the tumor without disturbing the main part of your brain ^[3].

Understanding the Terminology

Medical terms can be intimidating, but breaking them down makes the surgical process much easier to visualize:

• Endoscopic: An endoscope is a thin, rigid tube equipped with a light and a high-definition camera ^[4]. It is inserted through the nose and provides the surgical team with a clear, magnified, wide-angle view of the tumor ^[5].
• Transsphenoidal: “Trans” means across or through. The “sphenoid” is the sphenoid sinus, a natural hollow air space located deep inside your head, directly behind the back of your nose ^[6]. Your pituitary gland sits in a small bony pocket right behind this sinus.

By going “transsphenoidal,” surgeons use the sphenoid sinus as a direct pathway to reach the pituitary gland ^[3].

How the Surgery is Performed

During the procedure, you will be completely asleep under general anesthesia. The surgery typically follows these steps:

1. The Approach: The surgical team (often a neurosurgeon working alongside an ear, nose, and throat specialist) inserts the endoscope and specialized micro-instruments through both of your nostrils ^[2].
2. Accessing the Sinus: They gently navigate to the back of the nasal cavity and make a small opening in the front wall of the sphenoid sinus ^[6].
3. Reaching the Pituitary: Once inside the sphenoid sinus, the surgeons carefully open the thin layer of bone at the back of the sinus to expose the pituitary gland and the tumor ^[3].
4. Removing the Tumor: Using the enhanced visualization of the endoscope, the neurosurgeon meticulously removes the tumor while working to preserve the healthy surrounding pituitary tissue ^[7]. For patients with acromegaly, this modern approach frequently results in excellent rates of early hormone normalization ^[8][9].
5. Reconstruction: After the tumor is removed, the surgeon must seal the area to prevent cerebrospinal fluid (CSF)—the natural fluid that surrounds and protects your brain—from leaking ^[10]. They often patch the opening using natural materials, such as a small flap of tissue taken from the inside of your nose (a nasoseptal flap) or a small fat graft ^[11][12]. Note: If a fat graft is used, the fat is typically taken from a very small incision on your belly or thigh. While this means you may have a minor scar on your body, there will still be no surgical cuts on your head or face.

What This Means for Your Recovery

Because endoscopic transsphenoidal surgery avoids the major incisions required in more invasive open surgeries, the physical impact on your head and brain is significantly reduced.

• No Visible Facial Scars: You will wake up with no surgical cuts, stitches, or scars on your face or scalp ^[1].
• Shorter Operative Times: This technique often allows for a more efficient surgery and faster recovery of normal pituitary function compared to older microscopic methods ^[13][14].
• Nasal Healing: You will likely experience nasal congestion, sinus pressure, or crusting for a few weeks as the inside of your nose heals. Your surgeon may place temporary packing or splints inside your nose to help it heal. Studies show this procedure does not cause long-term negative effects on normal nasal function ^[15].

Post-Operative Precautions

After surgery, you will usually stay in the hospital for a few days to be monitored. Protecting the fragile internal patch where the tumor was removed is the most important part of your early recovery. To prevent a CSF leak, your care team will give you strict instructions to avoid activities that increase pressure in your head.

For the first few weeks, you must not:

• Blow your nose
• Sneeze with your mouth closed (if you must sneeze, open your mouth wide)
• Bend over (e.g., to tie your shoes or pick something up)
• Drink through a straw
• Lift heavy objects or strain during bowel movements

If you notice a clear, watery drip coming from your nose or a constant salty taste in the back of your throat, you should contact your surgical team immediately, as this can be a sign of a CSF leak ^[10].