The Tran nasal transsphenoidal approach is the preferred route for removal of most lesions of the sella turcica. Since its inception in the early 1900s, the transsphenoidal approach has endured for nearly a century as the preferred operation. This discussion focuses on the contributions of Harvey Cushing and Oskar Hirsch, two pioneers in pituitary surgery in the early 1900s.Their developments in the transsphenoidal approach played a significant role in defining today’s transsphenoidal technique.
In the early 1900s Harvey Cushing and Oskar Hirsch helped establish the transsphenoidal approach as a primary treatment in patients with pituitary adenomas. Detail of Cushing’s sub labial approach and Hirsch’s endonasal approach is compared. These are two most popular route used by pituitary surgeon today. Initial attempts at transcranial approaches to the pituitary gland in the late 1800s and early 1900s resulted in a mortality rate that was generally considered prohibitive. Schloffer performed the first successful removal of a pituitary tumor in 1907 via a superior nasal transsphenoidal approach. Cushing initially performed trans-cranial operations but success of such operation resulted in adopting new technique of Trans sphenoidal route. Cushing performed his first transsphenoidal surgery on March 26, 1909, in Boston. He used a modification of Schloffer’s superior nasal technique. Dissatisfied with superior nasal approaches, Cushing later modified his approach by adopting Kanavel’s inferior nasal approach, incorporating Halstead’s sublabial incision, and using Kocher’s submucous septal resection. He performed his first sublabial submucosal transseptal transsphe- noidal approach on June 4, 1910, which, coincidentally, was the same date that Hirsch first performed his submucosal transseptal transsphenoidal operation endonasally. .Cushing’s modification is remarkably similar to the approach performed by most contemporary neurosurgeons that use the sublabial approach today. Because the operation was a compilation of techniques adopted from various surgeons, Cushing humbly stated, “It therefore makes no claim for originality.” Cushing continued to use this approach from 1910 to 1925 and surgically treated 231 cases of pituitary tumors in which the mortality rate was 5.6%. By 1929, Cushing completely abandoned the transsphenoidal approach in favor of the transcranial route because of less mortality rate of 4.5%, better view of suprasellar portion of tumor and less chance of reoccurrence. Because of Cushing’s dominant influence in American neurosurgery, the use of trans- sphenoidal surgery was suspended for the next 35 years until the efforts of Dott, Guiot, and Hardy.
Like Cushing, Oskar Hirsch (Fig. 7) believed that the approaches advocated by Schloffer, is unnecessary complicated and developed his own endonasal approach. In 1909 at a meeting of the Gesellschaft der Aertze in Vienna, Hirsch demonstrated his endonasal approach to the sella for the removal of hypophysial tumors in a cadaver based on Hajek’s radical operation for removal of chronic empyema of the sphenoid sinus via the ethmoidal route. Skeptics did not enthusiastically embrace Hirsch’s method initially because he did not have the opportunity to demonstrate it in a living patient until almost 1 year later. Hirsch performed his first endonasal operation on March 10, 1910. This operation was done in five stages over several days; later on he developed single stage operation. The best thing about his surgery was that patient walked out of the operation room since done under local anesthesia. He believed that neither through transsphenoidal nor transcranial route can completely remove the tumor, so started applying local irradiation with help of radium particles. By 1937, which marked the end of the pre-antibiotic era, the mortality rate was 5.4% in the 277 patients with pituitary tumors that Hirsch had treated by performing surgery and postoperative radium application, which reduced to 1.5% after antibiotic introduction.
Hirsch, a rhinologist, and Cushing, a neurosurgeon, shared the pioneering spirit of “pushing the envelope” of transsphenoidal surgery for pituitary tumors. It is apparent in the literature that Cushing and Hirsch were critical of each other’s approach. Another major difference between Cushing’s and Hirsch’s operations was the choice of anesthesia, as Cushing was using general anesthesia and Hirsch local anesthesia. Despite the differences in their techniques, Cushing and Hirsch each achieved excellent results and low rates of mortality. Cushing eventually abandoned the transsphenoidal approach in favor of the transcranial approach, whereas Hirsch continued using the technique into the antibiotic era. Nearly a century after the birth of transsphenoidal surgery, the fundamental techniques of Cushing’s and Hirsch’s approaches still resonate