Repeat trans-sphenoidal surgery for pituitary adenomas is fraught with the risk of injury to the internal carotid artery that can occur either while incising scar tissue in the sphenoid sinus/sella or during tumour decompression. The ensuing complications can be devastating and difficult to manage within the limited confines of the bony sella and sphenoid sinus, and more so when the local anatomy is distorted by previous surgery. This article highlights complications involved in repeat trans-sphenoidal pituitary surgery and outlines the role of image-guided surgery in avoiding them. With the use of modalities like Doppler sonography and neuronavigation, the position of the ICA can be determined accurately in all cases.