A Brief History of Endoscopic Transsphenoidal Surgery— from Philipp Bozzini to the First World Congress of Endoscopic Skull Base Surgery

Neurosurg Focus 19 (6):E3, 2005

A brief history of endoscopic transsphenoidal surgery— from Philipp Bozzini to the First World Congress of Endoscopic Skull Base Surgery

FRANCESCO DOGLIETTO, M.D., DANIEL M. PREVEDELLO, M.D., JOHN A. JANE JR., M.D., JOSEPH HAN, M.D., AND EDWARD R. LAWS JR., M.D. Departments of Neurological Surgery and Otorhinolaryngology, University of Virginia Health Systems, Charlottesville, Virginia; and Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy

Since its inception, one of the major issues in transsphenoidal surgery has been the adequate visualization of anatomical structures. As transsphenoidal surgery evolved, technical advancements improved the surgical view of the operative field and the orientation. The operating microscope replaced Cushing’s headlight and Dott’s lighted specu- lum retractor, and fluoroscopy provided intraoperative imaging. These advances led to the modern concept of micro- surgical transsphenoidal procedures in the early 1970s. For the past 30 years the endoscope has been used for the treatment of diseases of the sinus and, more recently, in the surgical treatment of pituitary tumors. The collaboration between neurological and otorhinolaryngological surgeons has led to the development of novel surgical procedures for the treatment of various pathological conditions in the skull base. In this paper the authors review the history of the endoscope—its technical development and its application—from the first endoscope described by Philipp Bozzini to the First World Congress of Endoscopic Skull Base Surgery held in 2005 in Pittsburgh, Pennsylvania. Specifically, in this review the history of endoscopy and its application in endonasal neurosurgery are presented.

KEY WORDS • transsphenoidal approach • endoscope • endoscopic sinus surgery • endoscopic transsphenoidal surgery • skull base surgery • history of neurosurgery

Every step of the procedure must be conducted under the through lenses, and 2) illuminating the organs by using an eye of the operator.—Harvey Cushing internal rather than an external light.44,65 Thomas Edison’s invention of the incandescent light bulb in 1879 allowed THE FIRST ENDOSCOPES further improvements to be made to this endoscope (Fig. 4), with replacement of the cumbersome water-cooled plat- Until the end of the nineteenth century, the main impetus inum wires that had been used as the light source.55 Max for the development of endoscopy came from its use in the Nitze is credited as well for being among the first to take inspection of the bladder, rectum, and pharynx.57,63 The endoscopic photographs and to use cutting loops for oper- word “endoscopy” was used first by Antonin Jean ations inside the bladder.65,68 Desormeaux (1815–1894), a urologist from Paris.5 It is Philipp Bozzini (1773–1809), however, a German physi- Expanding Applications cian born to an aristocratic Italian family, who is credited with the invention of the first endoscope 200 years ago.69 At the beginning of the twentieth century, physicians 68,69 around the world pioneered the use of the endoscope in dif- The “Lichtleiter,” which he demonstrated in 1806 to the 42 Academy of Medicine of Vienna, consisted of an eyepiece ferent specialties. In 1901 Hirschmann used a modified and a container for a candle light, which was reflected by a cystoscope to inspect the maxillary sinus and therefore is mirror through a tube (Fig. 1). Visualization was quite lim- considered to be among the pioneers of paranasal endo- ited and an evaluation conducted with the instrumentation scopic surgery.28 A modified cystoscope was used in 1910 was painful for the patient.44,63,65 by Christian Jacobaeus, professor of medicine in Stock- As detailed by Mouton, et al.,65 Max Nitze (1849–1906) holm, to perform the first endoscopically guided thoraco- improved on the early design (Fig. 2) and constructed an scopy and laparoscopy, as recounted by Mouton, et al.65 In “apparatus for direct illumination and investigation of the same year Victor Darwin Lespinasse (1878–1946), a human and animal hollow organs” featuring a series of urologist from Chicago, performed the first intracranial lenses inside a metallic tube (Fig. 3). This German urolo- intraventricular endoscopy and coagulation of the choroid gist had two fundamental ideas: 1) magnifying the image plexus for the treatment of hydrocephalus in two children;

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Unauthenticated | Downloaded 09/29/21 08:19 AM UTC F. Doglietto, et al. one of his patients died postoperatively, but the second lived for 5 years.35 Initial Neurosurgical Application: Ventricular Endoscopic Neurosurgery Although Lespinasse was the first to use a cystoscope to perform fulguration of the choroid plexus, Walter Dandy is widely recognized as the father of neuroendoscopy. We owe him the name of the procedure, which he first attempt- ed in 1922 with little success.1,24 In 1932, however, he reported using endoscopic ventriculostomy to remove the choroid plexus for the treatment of hydrocephalus (Fig. 5), with outcomes similar to those he had attained with a cran- iotomy.23 According to Duffner, et al.,30 in 1923 William Mixter reported the first endoscopic third ventriculostomy. Therefore, the endoscope’s initial impact in neurosurgery was in its use within the ventricular system. Intraventricular endoscopic surgery likely represented the most important initial influence of this technical adjunct in the field of neurosurgery.40

EVOLUTION OF THE “MODERN” ENDOSCOPE John Logie Baird, who invented the television, patented the idea of transmitting images through a flexible glass cable in 1926. These ideas influenced Harold H. Hopkins, a mathematician and physicist (b. 1918, Leicester, England), who invented the zoom lens in 1948.46 In 1960 Hopkins patented the rod-lens system, which improved the previous Nitze system of a train of glass lenses by inter- spersing neutral gas between them instead of air.21 The optic efficiency was improved ninefold by lowering the refractive index and increasing the functional diameter of the lenses. Hopkins’ rod lenses had clear advantages over the Nitze system in that they provided greater light transmission, a wider view, better image quality, and a smaller diameter for the system. Clinicians then were able to docu- Fig. 1. Drawing of the light source for Bozzini’s endoscope: the ment their endoscopic findings effectively with cameras box contained a simple candle together with a partition arranged in and video systems.4 such a way that the light was not directed toward the observer’s Coincident to this tremendous contribution, Basil eye. (Reprinted with permission from Jackson C: Bronchoscopy Hirschowitz, an American gastroenterologist, developed an and Esophagoscopy; a Manual of Peroral Endoscopy and La- endoscope that featured flexible glass-coated fibers ryngeal Surgery. Philadelphia and London: W.B. Saunders (fiberoptics) illuminated by a simple light bulb at the prox- Company, 1922.) imal end. He called this system a fiberscope and demonstrated it at a meeting of the American Gastroscopic Society otorhinolaryngologists began to develop maxillary antros- on May 16, 1957, in Colorado Springs, Colorado.34,43 Karl Storz (1911–1996) realized that besides transmitting visual tomy, approaching the maxillary sinus primarily through information, the system of glass fibers could be used for the the inferior meatus. Because of technical limitations purpose of light transmission, and he licensed the idea of a encountered at the time, however, this technique was not fiberoptic external cold light transmission coupled with the widely accepted.28 The development of fiberoptic and rod-lens optical system in 1965.55 glass-wool light conductors was a decisive step that Many other improvements were made in the field; one of allowed image-guided biopsy sampling and the more accu- the most important of these is the charge-coupled device rate removal of small lesions.29,36,62,76 Messerklinger revital- camera.4,57 Charge-coupled devices were introduced in ized endoscopy, applying it to rhinologic and sinus surgery 1969 by Bell Laboratories in the US. They are lightweight, as well as using it to 1) examine the sinuses and identify the low-powered, extremely sensitive image sensors, and are cause of sinusitis resistant to medical therapy; 2) locate approximately 15 times more sensitive to light than stan- sites of cerebrospinal fluid rhinorrhea; and 3) perform dard regular photographic film. minor operations while maintaining visual control.5,28 The treatment of medically refractory sinusitis through antros- Application to Diseases of the Paranasal Sinuses tomies was refined by Reynolds and Brandow.70 David Otorhinolaryngologists were naturally the first to use the Kennedy, Heinz Stammberger, and Wolfgang Draf are endoscope in the nasal cavity. After Hirschmann, various some of the otorhinolaryngologists who popularized the

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Fig. 2. Photograph of a set of endoscopic tubes for bronchoscopy, esophagoscopy, and gastroscopy of the type used at the end of the nineteenth century (courtesy of the Claude Moore Health Science Library, Historical Collections University of Virginia). use of modern endoscopy in the paranasal sinuses. They invasive neurosurgery. Other surgeons reported use of this pioneered endoscopic sinus surgery for the maxillary, device in transsphenoidal microsurgery as a technical frontal, and sphenoid sinuses.28 David Kennedy coined the adjunct that was important for its wider panoramic visual- term “functional endoscopic sinus surgery” (also known as ization.33,56 FESS). With advancements in suction and irrigation, the In the early 1990s the pure endoscopic transsphenoidal endoscope could remain in the operative field,78 and this technique (that is, use of the endoscope as the only visual- would lead to the subsequent continued development of izing tool) was introduced as a result of the collaboration endoscopic skull base surgery. between neurological and otorhinolaryngological surgeons. In 1992 Jankowski and coworkers from the Central Endonasal Neurosurgery Hospital of the University of Nancy reported on their experience with three cases in which they used a pure endo- Gerard Guiot is recognized as the first neurosurgeon to scopic transsphenoidal approach to the sella turcica.45 Sethi use the endoscope in the transsphenoidal approach, and Pillay,72 otorhinolaryngological and neurological sur- although he abandoned the procedure because of inade- geons, respectively, from the Singapore General Hospital, quate visualization.37,58 It was not until the late 1970s that reported in 1995 on the use of an endonasal transsphenoidal Apuzzo, et al.,2 as well as Bushe and Halves,6,38 reported the technique. They used a transnasal–transseptal approach use of the endoscope as a technical adjunct in the micro- with a hemitransfixion incision to create a bilateral scopic resection of pituitary lesions with extrasellar exten- mucoperichondrial flap in 40 patients; the flap was held sion. Endoscopy was used initially to augment micro- apart with a self-retaining retractor after removal of the surgery, allowing a view of structures that were out of the nasal septum. In 1996, Rodziewicz and coworkers71 report- line of sight; a view that other surgeons had previously ed a similar technique that they had applied without the achieved with angled mirrors.39,58 Axel Perneczky, who pio- septal bone removal in 10 patients. Similar techniques were neered the use of the endoscope in intracranial neuro- reported by other clinicians.3,41,64,74,79 surgery, emphasized that endoscopy “improved apprecia- Jho and Carrau, a neurosurgeon and otorhinolaryngolo- tion of micro-anatomy not apparent with the gist, respectively, working at the University of Pittsburgh microscope”32,67 and introduced the concept of minimally Medical Center, are recognized as the pioneers of the pure

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Fig. 4. Photograph of an endoscope used mainly in the 1940s, a device in which the light source (magnified in circle) was an Edison lamp positioned at the terminal end of the endoscope, dis- tal to the optic system (courtesy of the Claude Moore Health Science Library Historical Collections, University of Virginia).

experience with the use of the pure endoscopic technique, introducing the term “functional endoscopic pituitary surgery” (also known as FEPS).8 Their work cannot be under- estimated; they developed dedicated endoscopic instrumentation,9 suggested technical improvements,7,15,17 and contributed significantly to the scientific basis12,13,15,16,19,20,25,27 and critical assessment of the technique.7,10,11,14,19,26 These re- ports were followed by many others from around the world.66,73,75 More recently, thanks to the introduction of other technical adjuncts such as neuronavigation and microvascular Doppler ultrasonography, endoscopic transsphenoidal surgery has been extended to the treatment of lesions out- side the sella turcica, introducing the concept of extended approaches to the skull base.48,59 Giorgio Frank and Ernesto Pasquini, a neurosurgeon and otorhinolaryngologist, respectively, from Bologna, developed the ethmoid-ptery- goid-sphenoid (known as EPS) endoscopic approach for the treatment of cavernous sinus lesions.31 They also applied the pure endoscopic technique for resection of suprasellar lesions,17 performing an extended transplanum sphenoidale approach aided by the operating microscope, as described by Weiss in 198777 and used by Laws, et al.,54 and Maira, et al.60 This endoscopic approach includes the initial removal of the tuberculum sellae and posterior part of the planum sphenoidale, and culminates with the opening of diaphragma sellae, which allows access to the suprasellar Fig. 3. Drawing of Nitze’s first cystoscope, in which the light 53 source was situated at the terminal end of the endoscope and was a subarachnoid space, as described by Laws in 1980 for the platinum filament lamp. A water cooling system was included. treatment of suprasellar craniopharyngiomas with the aid (Reprinted with permission from Jackson C: Bronchoscopy and of an operating microscope. More recently, Amin Kassam, Esophagoscopy; a Manual of Peroral Endoscopy and a neurosurgeon, and Ricardo L. Carrau and Carl Snyder- Laryngeal Surgery. Philadelphia and London: W.B. Saunders man, otorhinolaryngologists from the University of Pitts- Company, 1922.) burgh Medical Center, following the lead of Kaptain, et al.,48 and Maroon,61 reported the use of the pure endonasal endoscopic technique for the treatment of various patho- endoscopic endonasal approach for the treatment of pitu- logical conditions of the skull base, widening the concept itary adenomas.16,61 Their experience reflects the history of of transsphenoidal surgery. The sphenoid sinus remains a the procedure; they started using the endoscope as an ad- fundamental anatomical landmark for extended skull base junct to the microscopic technique,18 and then changed to a approaches, extending from the floor of the anterior cranial pure endoscopic technique. In 1997 they were able to fossa to the odontoid process.49–52 report on 50 patients, 46 of whom were treated via a pure The recent interest and developments in endoscopic endoscopic approach.47 Paolo Cappabianca and Enrico de transnasal techniques led to the First World Congress of Divitiis from Naples were among the first to report their Endoscopic Surgery, held in Pittsburgh, Pennsylvania in

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5. Buiter CT: Endoscopy of the Upper Airways. Amsterdam: Excerpta Medica, 1976, pp 41–49 6. Bushe KA, Halves E: Modifizierte Technik bei transnasaler Op- eration der Hypophysengeschwulste. Acta Neurochir (Wien) 41:163–175, 1978 7. Cappabianca P, Alfieri A, Colao A, et al: Endoscopic endonasal transsphenoidal surgery in recurrent and residual pituitary adenomas: technical note. Minim Invasive Neurosurg 43:38–43, 2000 8. Cappabianca P, Alfieri A, de Divitiis E: Endoscopic endonasal transsphenoidal approach to the sella: towards functional endoscopic pituitary surgery (FEPS). Minim Invasive Neurosurg 41:66–73, 1998 9. Cappabianca P, Alfieri A, Thermes S, et al: Instruments for endoscopic endonasal transsphenoidal surgery. Neurosurgery 45:392–395, 1999 10. Cappabianca P, Cavallo LM, Colao A, et al: Endoscopic endonasal transsphenoidal approach: outcome analysis of 100 consecu- tive procedures. Minim Invasive Neurosurg 45:193–200, 2002 11. Cappabianca P, Cavallo LM, Colao A, et al: Surgical complica- Fig. 5. Photograph of the ventriculoscope used by Walter tions associated with the endoscopic endonasal transsphenoidal Dandy to perform intracranial intraventricular procedures such as approach for pituitary adenomas. J Neurosurg 97:293–298. 2002 coagulation and resection of the choroid plexus (courtesy of Dr. 12. Cappabianca P, Cavallo LM, de Divitiis E: Endoscopic endonas- Edward R. Laws Jr.). al transsphenoidal surgery. Neurosurgery 55:933–941, 2004 13. Cappabianca P, Cavallo LM, Esposito F, et al: Endoscopic endonasal transsphenoidal surgery: procedure, endoscopic equip- ment and instrumentation. Childs Nerv Syst 20:796–801, 2004 2005. Neurological and otorhinolaryngological surgeons 14. Cappabianca P, Cavallo LM, Mariniello G, et al: Easy sellar re- from around the world met to suggest new surgical tech- construction in endoscopic endonasal transsphenoidal surgery niques, present surgical outcomes, and discuss complica- with polyester-silicone dural substitute and fibrin glue: techni- tions of this evolving modality. We hope that this Congress cal note. Neurosurgery 49:473–476, 2001 will mark the beginning of a constructive, worldwide criti- 15. Cappabianca P, Cavallo LM, Valente V, et al: Sellar repair with cal appraisal of the endoscope and its application in fibrin sealant and collagen fleece after endoscopic endonasal endonasal skull base surgery. transsphenoidal surgery. Surg Neurol 62:227–233. 2004 16. Cappabianca P, de Divitiis E: Endoscopy and transsphenoidal surgery. Neurosurgery 54:1043–1050, 2004 CONCLUSIONS 17. Cappabianca P, Frank G, Pasquini E, et al: Extended endoscopic endonasal transsphenoidal approaches to the suprasellar The history of the endoscope is an example of how tech- region, planum sphenoidale and clivus, in de Divitiis E, Cappa- nical advancements have influenced medicine. The rela- bianca P (eds): Endoscopic Endonasal Transsphenoidal Sur- tively recent technical improvements led to its introduction gery. Wien: Springer-Verlag, 2003, pp 176–187 in the everyday practice of many different specialties. Its 18. Carrau RL, Jho HD, Ko Y: Transnasal-transsphenoidal endoscopic surgery of the pituitary gland. Laryngoscope 106:914–918, use in endonasal skull base neurosurgery appears to hold 1996 promise but will need to pass the test of time. As stated by 19. Cavallo LM, Briganti F, Cappabianca P, et al: Hemorrhagic 22 Harvey Cushing at the very beginning of the history of vascular complications of endoscopic transsphenoidal surgery. transsphenoidal surgery in 1912, interdisciplinary work is Minim Invasive Neurosurg 47:145–150, 2004 proving once again to be a major component in its devel- 20. Cavallo LM, Cappabianca P, Galzio R, et al: Endoscopic trans- opment. To quote Cushing, “The performance becomes nasal approach to the cavernous sinus versus transcranial route: progressively simplified by the combined suggestion and anatomic study. Neurosurgery 56:379–389, 2005 experience of many.” 21. Cockett WS, Cockett AT: The Hopkins rod-lens system and the Storz cold light illumination system. Urology 51 (5A Suppl): 1–2, 1998 Acknowledgments 22. Cushing H: The Pituitary Body and its Disorders, Clinical We thank the staff of the Claude Moore Health Science Library, States Produced by Disorders of the Hypophysis Cerebri. 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J Neurosurg 102:825–827, 2005 Accepted in final form November 21, 2005. 55. Linder TE, Simmen D, Stool SE: Revolutionary inventions in Address reprint requests to: Edward R. Laws Jr., M.D., Department the 20th century. The history of endoscopy. Arch Otolaryngol of Neurological Surgery, University of Virginia, P.O. Box 800212, Head Neck Surg 123:1161–1163, 1997 Charlottesville, Virginia 22908-00212. email: [email protected].

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