Transsphenoidal pituitary surgery

Since Horsley's successful transcranial pituitary resection in 1898, Schloffer took an extranasal route from 1906 to 1907, but severely affected the function of the nasal cavity and caused scarring on the face. In 1909, cushing first reported a case of partial pituitary resection through the nasal septum to the sphenoid sinus. In 1912, chjari underwent sinus sinus and sphenoid sinus for pituitary resection. It was accepted by otolaryngologists in 1950, and the operation was performed through the ethmoid sinus, maxillary sinus and ankle. Up to now, the surgical methods of pituitary tumors fall into two categories: one is surgery on the sella, that is, the craniotomy of the pituitary tumor is treated by a neurosurgeon. The other is surgery from the sella, the pituitary tumor resection by the nasal sinus and sphenoid sinus, mostly by the otolaryngologist; or the pituitary tumor resection through the subnasal septum to the sphenoid sinus. It is co-processed by neurosurgery and otolaryngologist. Treatment of diseases: craniopharyngioma pituitary adenoma Indication 1. Partial resection of the normal pituitary gland for the treatment of some hormone-dependent diseases, such as breast cancer and prostate cancer with secondary metastatic lesions. Diabetic retinopathy is controlled by pituitary resection. 2. Pituitary tumors: removal of pituitary tumors for the treatment of acromegaly, giant disease, cushing's syndrome, prolactinoma, chromophobe tumors (adenocarcinoma and embryonal tumors, such as seminoma) ), as well as other rare tumors in childhood. 3. Transsphenoidal sinus can also remove craniopharyngioma and chordoma. Contraindications There are serious obstacles to the coagulation mechanism. High blood pressure, diabetes, and some bleeding-prone diseases. Preoperative preparation 1. Need to be used for the determination of all pituitary hormone levels in the internal medicine, glucose tolerance test, serum growth hormone, insulin levels and blood glucose. 2. Blood routine, especially platelet count and output, determination of clotting time, determination of serum electrolytes. If serum potassium is lower than normal, general anesthesia is dangerous. Liver function tests are more important for liver metastases. 3. Prepare blood. 4. Take the conventional lateral lateral radiograph to understand the contour morphology and sphenoid sinus development of the pituitary fossa. The sinus tablets were taken to rule out the presence of sinus inflammation. In addition, it is often necessary to perform examinations such as gas cerebral angiography. Sagittal high-resolution ct scans will yield satisfactory results, providing excellent indications of choice of surgical approach, tumor size and location, and relationship to the cavernous sinus. Guiding significance. 5. For visual field examination. 6. Appropriate steroid supplements should be given before and after surgery. Surgical procedure (a) sphenoid sinus surgery 1. Position: Take the head up to 25°, lying, and the neck is slightly bent. 2. Incision: from the inner end of the brow arch along the inner side of the iliac crest as close as possible to the base of the nose, so as to avoid the lacrimal sac fossa, extending downward into a nasal incision, in order to avoid the trochlear nerve in the upper part of the incision, the incision can be made The upper end extends upward by 1 cm. Cut the skin until it is cut to the bone. 3. Peel the lining of the iliac crest under the periosteum and peel off the anterior ethmoid to see the anterior ethmoid artery. The artery is separated, cut, ligated and burnt with an electric knife. This plane is equivalent to the top of the ethmoid sinus. 4. Continue to peel deep into the area until the posterior stencil artery is seen. Keep this artery as a sign, but be careful not to damage it. 5. In order to avoid damage to the lacrimal sac when inserting the retractor, the lacrimal sac needs to be loosened to release the lacrimal sac, and then the automatic retractor is placed and fixed. 6. Cut the ethmoid sinus cardboard, forward to the anterior ethmoid artery, and back to the posterior stencil artery. The rim can be ground with an electric drill or cut with a round chisel. The nasal frontal tube should not be opened, especially in patients with acromegaly, otherwise soft tissue will be blocked in the nasal frontal tube. 7. The posterior wall of the lacrimal sac is opened into the ethmoid sinus, and the open ethmoid sinus air chamber is cleaned up to the largest air chamber in the posterior ethmoid sinus group. This completes the extranasal ethmoid sinus resection. 8. Open the anterior wall of the sphenoid sinus through the open posterior sinus, first enter the right sphenoid sinus, then open the sphenoid sinus interval, and merge the bilateral sphenoid sinus to fully expand the surgical approach. At the same time, the condyles of the vomer are bitten until the front lower wall of the pituitary fossa is fully exposed to the field of view. (B) through the nasal septum surgery (cushing's method) 1. Operation through the nasal septum (1) A conventional submucosal nasal septum resection is performed from the nasal septum of the right nasal cavity, and the vulture is directly extended to the deep. (2) Using a sharp rongeur to bite the condyle of the vomer and expose the anterior wall of the sphenoid sinus. (3) Use a circular chisel to open the anterior wall of the sphenoid sinus, and bite the sphenoid sinus with a rongeur to fully expand the surgical approach and expose the anterior and posterior wall of the pituitary fossa, the posterior superior wall of the sphenoid sinus. 2. Surgery through the upper lip and lower nasal septum (1) Make a mouth at the labial groove of the upper lip and cross the lip to the bilateral canine. (2) The mucosa is cut open, peeled off to the plow hole, and the mucosa of the pear-shaped hole is cut to sufficiently expose the pear-shaped hole and the nasal floor. (3) Peeling under the mucosa on both sides of the nasal septum and excising the septal cartilage. At the same time, the condyles of the vomer are removed with a rongeur or osteotome. (4) The anterior wall of the sphenoid sinus can be exposed by inserting a large two-leaf spreader between the bilateral septal mucosa membranes. (5) Open the anterior wall of the sphenoid sinus with an osteotome or electric drill and fully expose the sphenoid sinus cavity, remove the sphenoid sinus spacing, make the surgical field wide, and see the posterior superior wall of the sphenoid sinus as the anterior inferior wall of the pituitary fossa. Sometimes it can be seen that the tumor has penetrated the bone wall and protruded into the sphenoid sinus cavity. (3) opening the anterior inferior wall of the pituitary fossa and excising the tumor It needs to be performed under a surgical microscope. 1. Carefully grind the bone under the pituitary fossa with an electric drill, but be careful not to damage the dura mater. Only the bone of the posterior wall of the sphenoid sinus is ground and rubbed to the sides to a firm bone. Be careful not to over-open to both sides. To avoid damage to the cavernous sinus, do not too high to the top to avoid affecting the chiasm. Down to the sphenoid sinus wall, but the bottom wall does not need to be opened to support the filled muscle tissue at the end of the surgery. 2. Expose the dura mater, see the cavernous sinus through the dura mater, do not damage it when cutting the dura mater. Occasionally, patients may be exposed to the carotid artery above the outer wall of the sinus cavity. Do not damage it to avoid the risk of fatal bleeding after injury. Sometimes, a large tumor erodes the bone wall and protrudes into the sphenoid sinus cavity. At this time, the meningeal pulsation can be seen and should be recognized. 3. Open the dura mater to close the two layers of meninges with a diathermy cutter (electrocoagulation) and then open the dura mater. At this point, the pituitary gland or tumor tissue can be exposed. If the tumor is large, the pituitary gland is not easily visible. 4. After the tumor is removed and the tumor pedicle is seen as far as possible, the tumor is removed from the pedicle, and if necessary, the part of the pituitary tissue can be removed together. Some smaller tumors must be removed under a surgical microscope. An insulated bipolar coagulator can be used to gradually separate the resection during surgery. This will ensure that the field is clearly visible. 5. Use a piece of muscle tissue to block into the pituitary fossa, one can stop bleeding, and then prevent cerebrospinal fluid leakage. 6. Fill the sphenoid sinus with gelatin sponge and iodoform gauze. If the nasal sinus sinus approach, the entire right nasal obstruction ethmoid sinus should be blocked. For example, if the patient is operated through the nasal septum, the nasal cavity of the sphenoid sinus is blocked by the finger sleeve and the gauze at the same time, and the mucosa of the nasal septum is tightly attached to both sides. 7. Surgical patients with extranasal ethmoid sinus approach, after nasal incision suture, pressure bandage. However, it should not be too tight to prevent the iodoform gauze from protruding into the eyelids. Patients with upper lip and lower nasal septum surgery suture the cleft lip and incision. complication Blockage in the nose and sinus.