Endoscopic Pituitary Surgery: A Minimally Invasive Approach That Changes How These Tumors Are Treated

For decades, treating pituitary tumors often meant a craniotomy. Large incisions, brain retraction, and longer recovery times were part of the equation, even for benign tumors. 

That is no longer the standard.

Today, most pituitary tumors can be removed through a minimally invasive, endoscopic approach performed entirely through the nasal cavity. It is a fundamental shift in how these tumors are treated, and it is one of the most important reasons why where a patient is referred matters. 

At Atlantic Health’s Gerald J. Glasser Brain Tumor Center, Yaron Moshel, MD, neurosurgeon, and Giant Lin, MD, ENT specialist, work together using a fully endoscopic, transnasal technique. It is not just a different way to reach the tumor. It is a different way to think about the surgery altogether. 

“We’re doing surgery that historically required opening the skull,” Dr. Moshel said. “Now we can access the same area through the nose, without any external incision.”

Through the Nose, Not the Skull: Rethinking Surgical Access 

The pituitary gland sits at the base of the skull, directly above the nasal cavity and beneath the brain. Traditional approaches required coming from above, often working around or even retracting brain tissue to reach the tumor. 

The endoscopic approach flips that perspective. 

“We’re going from below, through the natural corridor of the nose,” Dr. Lin said. “That allows us to reach the tumor directly without disturbing the brain.” 

Using a high-definition endoscope, the surgical team navigates through the nasal passages and sinus cavities to access the skull base. From there, a small opening is created to reach the pituitary gland and tumor. 

The advantages are immediate and meaningful. 

“There are no external incisions, no scars, and we’re not manipulating the brain to get there,” Dr. Moshel said. “That changes both the safety profile and the recovery for patients.” 

Better Visualization Leads to Safer Surgery 

One of the biggest advantages of the endoscopic approach is visualization. 

Traditional microscopic techniques provide a straight-line view. Endoscopes, by contrast, offer angled lenses that allow surgeons to see around corners and into spaces that were previously difficult to access. 

“We have scopes that range from zero to seventy degrees,” Dr. Lin said. “It’s like looking through a keyhole but being able to see the entire room.” 

This expanded field of view is particularly important in pituitary surgery, where critical structures are densely packed. 

The carotid arteries run along either side of the surgical field. The optic nerves sit just above. Even small miscalculations can carry risk. 

“To operate safely, you need to understand exactly where you are at all times,” Dr. Moshel said. “The endoscope gives us that level of detail.” 

That visualization is further enhanced by intraoperative navigation systems, which function like a GPS for the brain, allowing the team to correlate real-time anatomy with preoperative imaging. 

In addition, Doppler ultrasound is used to confirm the location of critical blood vessels before any incision is made. 

“These tools allow us to verify what we’re seeing and avoid structures that we cannot afford to injure,” Dr. Lin said. 

Two Surgeons, One Procedure: The Value of Co-Surgery 

Another defining feature of this approach is the collaborative surgical model. 

Rather than a single surgeon working alone, pituitary surgery at Atlantic Health is performed by both a neurosurgeon and an ENT specialist, each with a distinct role. 

Dr. Lin focuses on access and reconstruction. Dr. Moshel performs the tumor removal. Together, they operate simultaneously using a four-handed technique. 

“We’re both working through the same corridor at the same time,” Dr. Moshel said. “That allows for more control, better efficiency, and ultimately a safer operation.” 

This level of coordination is not incidental. It is the result of a dedicated skull base program where both specialties work closely together on a regular basis. 

“Each of us brings a different expertise,” Dr. Lin said. “When you combine those skill sets, the result is better for the patient.” 

Tumor Removal with Precision and Control 

Once access is established, attention turns to the tumor itself. 

Pituitary tumors often have a soft, gelatinous consistency, allowing them to be removed in a controlled fashion. As the tumor is debulked, the pressure it exerts on surrounding structures begins to resolve. 

“In many cases, the tumor is under pressure,” Dr. Moshel said. “Once you open that space, it can start to come out naturally.” 

A key visual milestone during the procedure is the descent of the diaphragma sellae, a thin membrane above the tumor. 

“When that membrane starts to come down, it tells you the pressure has been relieved,” he said. “That’s when you know you’ve accomplished the main goal of the surgery.” 

Throughout this phase, the focus remains on removing tumor while preserving normal pituitary tissue and protecting nearby structures. 

Reconstruction Matters as Much as Resection 

One of the most critical aspects of pituitary surgery is what happens after the tumor is removed. 

Creating an opening at the skull base introduces the risk of cerebrospinal fluid leak. Preventing that requires careful reconstruction. 

“There’s a whole range of techniques we can use depending on what we encounter,” Dr. Lin said. “The goal is to create a secure, durable closure.” 

In many cases, this involves using native tissue from within the nasal cavity to reconstruct the skull base. This approach supports healing and reduces the risk of complications. 

“It’s not just about getting the tumor out,” Dr. Moshel said. “It’s about closing in a way that prevents problems down the line.” 

Clinical Perspective for Referring Providers 

Not all pituitary surgeries are the same. The approach, the technology, and the experience of the team all influence outcomes. 

For referring physicians, understanding how these procedures are performed provides important context when discussing options with patients. 

“When patients are treated with a minimally invasive approach by an experienced team, the difference in recovery and overall experience can be significant,” Dr. Moshel said. 

Just as important is the collaborative nature of care. 

“Skull base surgery is a team effort,” Dr. Lin added. “From planning to execution to follow-up, it requires coordination across multiple specialties.” 

That level of coordination is what allows for safe, effective treatment of tumors located in one of the most complex areas of the body. 

Learn More or Refer a Patient 

To learn more about pituitary tumor care at Atlantic Health or to schedule a consultation with Dr. Moshel, Dr. Lin, and the multidisciplinary team, visit the Gerald J. Glasser Brain Tumor Center, or call us at 908-522-5914.