垂体瘤 Endonasal CNS case 2

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Endoscopic Endonasal Transsphenoidal Resection of a Non-functioning Pituitary Adenoma

Sheri K. Palejwala MD, Pacific Neuroscience Institute, Santa Monica, CA
Nathan W. Pierce, Pacific Neuroscience Institute, Santa Monica, CA
Chester F. Griffiths MD, Pacific Neuroscience Institute, Santa Monica, CA
Garni Barkhoudarian MD, Pacific Neuroscience Institute, Santa Monica, CA
Daniel F. Kelly MD, Pacific Neuroscience Institute, Santa Monica, CA

Summary

This case demonstrates a transsphenoidal resection of an endocrine inactive pituitary macroadenoma.
A thorough preoperative vision and endocrine evaluation is necessary.
Carotid artery identification with Doppler ultrasound prevents vascular injury.
Multi-layered closure helps prevent postoperative CSF rhinorrhea.

Case Presentation

A 49-year-old male presented with headaches, fatigue, and erectile dysfunction.
Normal vision without deficits was noted on exam.
Hormonal testing revealed hypocortisolemia, central hypogonadism, hypothyroidism, and mild hyperprolactinemia.

Approach

Endoscopic endonasal transsphenoidal approach
Bi-nostril technique with a neurosurgeon and an otolaryngologist
4 mm 0-degree rigid endoscope with 30 and 45-degree endoscopes available

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Alternatives

Conservative management
Serial MRI surveillance and hormone replacement therapy
Alternative surgical approaches
Microscopic endonasal transsphenoidal
Microscopic sublabial transsphenoidal

Positioning

Position is as follows:
Supine, with a horseshoe head-holder (not fixed)
3-point fixation: longer/more complex cases
Neutral to slightly flexed: 0-15 degrees
Vertex angled away from surgeon 15-30 degrees
Face turned 20-30 degrees to the right (toward surgeons)
Neuronavigation is typically used.
Helpful for redo and invasive tumors
Neuromonitoring is reserved for cases with cavernous sinus invasion, recurrence, or known cranial nerve involvement.

Room Set-Up

Two HD monitors at 90-degree angles
Third monitor for neuronavigation in between


Operation

The inferior and middle turbinates are out-fractured.
Septal mucosal incision (3 mm below the sphenoid os) for ~2 cm along the vomer and posterior nasal septum, to preserve the septal olfactory strip (SOS)
Septal mucosal incision (3 mm below the sphenoid os) for ~2 cm along the vomer and posterior nasal septum, to preserve the septal olfactory strip (SOS)
Pedicle-sparing mucosal rescue flaps are dissected inferiorly to be saved if nasoseptal flap is necessary.
Sphenoidotomy is performed with Kerrison rongeurs.
Posterior septectomy and removal of keel, with pituitary and Kerrison ronguers. The bone graft is harvested for reconstruction.
Doppler probe to localize cavernous ICA
U-shaped dural opening
Elevation of the dural flap
Angled ring curettes are used to dissect the adenoma circumferentially.
Macroadenomas are removed in a piece-meal fashion.
Depends on leak grade
Layers
Abdominal fat graft
Dura
Collagen sponge
Bone graft
Collagen sponge
Fibrin glue
Mucosal reapproximation
Nasal packing as needed











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Pearls and Pitfalls

  • Avoid carotid artery injury: study anatomy, neuronavigation, Doppler.
  • Complete tumor resection: wide sellar exposure, known cavernous/carotid anatomy, capsular dissection when possible.
  • Avoid CSF leak: careful with superior dural opening, meticulous multi-layered closure.

Discussion

  • Endoscopic endonasal surgery presents a steep learning curve. A systematic approach can help flatten this curve.
  • Familiarity with a standardized technique builds the foundation for complex cases and expanded skull base approaches.
  • Sellar reconstruction following adenoma resection should be both meticulous and methodical, tailored to the degree of intraoperative CSF leak.
  • Balance of striving for remission and complication avoidance
  • Multidisciplinary approach for optimal decision making and multimodality care, including hormonal therapies and radiotherapy
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