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The patient is positioned supine with no head tilt under endotracheal general anesthesia. Because the head is not fixed, gentle lateral movements of the head can be used to optimize intraoperative visualization.

The oropharynx is carefully packed with cotton gauze to prevent the accumulation of blood into the throat, and eventually into the stomach.The right thigh is prepared sterile, for fascia lata graft, in case the need arises.

After the skin of the face is prepared with an aqueous antiseptic solution, the nostrils are packed with pledgets of cotton gauze soaked in 0.5% xylocaine in 1.200,000 adrenaline and inserted into both nostrils, and allowed to remain in contact with nasal mucosa for 5-10 minutes. 10 to 20ml of a solution of 0.5% xylocaine in 1.200,000 adrenaline is injected submucosally, on the right side of the nasal septum, using a fine needle. Midline orientation is crucial. C-arm guidance helps.

An incision the nasal mucosa of the Septum as posterior as possible is made, and the septum is exposed submucosly with a combination of sharp and blunt dissection.

The articulation of the cartilaginous septum with the maxilla is then dissected free.

A self retaining Hardy’s nasal speculum is introduced through the tunnel; the septum is then pushed aside as a single muco-perichondral flap with the controlateral mucosa The two mucosae are dissected on both side of the sphenoid and pushed aside by the speculum tips. The perpendicular plate of the ethmoid and the sphenoid face are exposed.

Portions of the bony nasal septum in the operative field should be resected, and preserved for use during closure, in case the need arises. Preserving the nasal spine, helps cosmetically. The anterior wall of the sphenoid is opened by grasping the vomer with a punch; chisel may be required at times. The exposure is widened with an angled punch.

The sellar floor should be visible now. Often, the sellar floor is eroded or extraordinarily thin, and can be fractured with a blunt hook; at times a chisel or even a drill may be required.

The dura is cauterized, incised in X fashion, and the dural opening is widened by shrinking the margins with cautery. An attempt is made to develop a cleavage plane between the dura and the tumor in case of macroadenoma, and the tumor is enucleated.

The residual tumor is removed with blunt curette and forceps. Excessive use of suctioning is avoided. Tumor removal starts inferiorly, and proceeded laterally, from inferior to superior aspects removing tumor. Next the central portion is removed, followed by the superior portion. This orderly removal is recommended and minimizes trauma to the pituitary stalk and secondarily to the hypothalamus, and also avoid entrapment of more laterally placed tumor.

Following adequate removal, the diaphragma sellae is seen descending down into the operative field, and reinforce with a fascia lata graft and fibrin glue.