Extended endonasal pituitary surgery: key anatomical landmarks and neurovascular considerations

Abstract Endonasal transsphenoidal approaches are the gold standard for pituitary surgery, utilizing enhanced visualization and precision from endoscopic techniques. Precise identification of anatomical landmarks is crucial, particularly during complex, extended, or revision procedures. This article provides a clear overview of critical nasal, sphenoidal, ethmoidal, and pterygoid landmarks, alongside essential neurovascular structures, to optimize surgical orientation and enhance patient safety. Notable landmarks discussed include the posterior choana, sphenoid ostium, sphenoid keel, opticocarotid recesses, ethmoid sinus anatomy, and the Vidian canal. Additionally, the relationship of cranial nerves within the cavernous sinus and key arterial structures are emphasized to assist safe dissection and minimize complications. Anatomical variations due to ethnicity and individual differences underline the necessity of thorough preoperative imaging. Familiarity with these reference points enables surgeons to navigate confidently, thereby reducing operative risk.