Critical views for safe surgical phase progression in endoscopic endonasal transsphenoidal pituitary adenoma resection: modified Delphi consensus

Tjasa Zaletel, Department of Clinical and Movement Neurosciences, University College London, London, UK.
Danyal Z. Khan, Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK. d.khan@ucl.ac.uk.
Anjana Wijekoon, The UCL Hawkes Institute, University College London, London, UK.
Zhehua Mao, The UCL Hawkes Institute, University College London, London, UK.
Joao Paulo Almeida, Department of Neurosurgery, IU Health, Indiana University, Indianapolis, IN, USA.
Anouk Borg, Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK.
Jonathan Chainey, Division de neurochirurgie, Département de chirurgie, Université de Montréal, Montréal, Canada.
Michael D. Cusimano, Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
Daniel A. Donoho, Division of Neurosurgery, Children's National Hospital, Washington, DC, USA.
Neil Dorward, Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK.
Juan Carlos Fernandez-Miranda, Stanford University School of Medicine, 213 Quarry Road, Palo Alto, USA.
Giorgio Fiore, Unit of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
Theofanis Giannis, Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK.
Alfonso Lagares Gomez-Abascal, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.
Lauren Harris, Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK.
Abhiney Jain, Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK.
Ruth Lau, Department of Neurosurgery, Hospital Universitari Joan XXIII, Universitat Rovira i Virgili, Tarragona, Spain.
Sacit B. Omay, Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA.
Igor Paredes, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.
Daniel Prevedello, Department of Neurosurgery, The Ohio State University and Wexner Medical Centre, Columbus, OH, USA.
Gabriel Zada, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
Danail Stoyanov, The UCL Hawkes Institute, University College London, London, UK.
Sophia Bano, The UCL Hawkes Institute, University College London, London, UK.
Hani J. Marcus, Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK.

Document Type

Journal Article

Publication Date

1-28-2026

Journal

Pituitary

Volume

29

Issue

1

DOI

10.1007/s11102-026-01636-2

Keywords

CVPP; Consensus; Delphi; Endoscopic endonasal; Endoscopic transsphenoidal surgery; Pituitary adenoma

Abstract

PURPOSE: Endonasal transsphenoidal surgery is the gold-standard for pituitary adenoma resection, yet no intraoperative framework exists to confirm safe phase progression. Inspired by the Critical View of Safety in laparoscopic cholecystectomy and engineering “phase-gate” process, we propose the Critical Views for Phase Progression (CVPPs) – a set of visual cues confirming phase objectives and safe phase progression. Designed to be clinically relevant and machine-readable, CVPPs aim to support training and future AI-driven guidance systems. METHODS: A three-round modified Delphi process was conducted involving 15 pituitary surgery experts from 13 centres across Europe and North America. CVPPs for the naso-sphenoid, sellar, and closure phases were classified as “Essential”, “Desirable” or “Not Necessary”. Consensus required ≥ 70% agreement. A local validation study was subsequently performed involving six experts who reviewed 15 intraoperative video clips and rated their confidence to proceed, which was compared against the predefined reference derived from the finalised CVPPs. RESULTS: Consensus identified essential and desirable CVPPs across all three phases for both micro- and macroadenoma variants, reflecting differences in exposure goals and surgical risk. Validation demonstrated high concordance between participant ratings and predefined references. Discrepancies arose only in a minority of intentionally incomplete (“unsafe”) views and were attributable to contextual misinterpretation of short video segments, rather than disagreement with the CVPP framework. CONCLUSION: This international, multicentre consensus is the first to define CVPPs. By standardising intraoperative visual benchmarks, CVPPs can enhance training, mitigate risks, and provide a foundation for future AI-driven guidance systems capable of real-time anatomical annotation and decision support.

Department

Neurological Surgery

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