Modification of the Cushing speculum used for transsphenoidal pituitary surgery

1975 ◽  
Vol 42 (1) ◽  
pp. 108-110 ◽  
Author(s):  
Alex M. Landolt ◽  
Michael Novoselac
Keyword(s):  
Pituitary Surgery ◽  
Transsphenoidal Approach ◽  
Content Type ◽  
Transsphenoidal Pituitary Surgery ◽  
Surgical Field ◽  
Fine Print

✓ A modification of the original Cushing speculum used in the sublabial-transseptal-transsphenoidal approach to the pituitary is described. Although the modified speculum has smaller dimensions, it allows better visualization of the surgical field, while a new expanding device permits easier opening of the speculum.

A new bipolar right-angled coagulation forceps for pituitary surgery

1983 ◽  
Vol 58 (4) ◽  
pp. 614-615 ◽  
Author(s):  
Alex M. Landolt
Keyword(s):  
Pituitary Surgery ◽  
Bipolar Coagulation ◽  
Content Type ◽  
Anterior Aspect ◽  
New Instrument ◽  
Transsphenoidal Pituitary Surgery ◽  
Fine Print

✓ A new instrument is described which allows easy and precise bipolar coagulation of the anterior intercavernous sinus. In some cases this sinus covers the anterior aspect of the pituitary and may render transsphenoidal pituitary surgery difficult.

Pathophysiology of hyponatremia after transsphenoidal pituitary surgery

1997 ◽  
Vol 87 (4) ◽  
pp. 499-507 ◽  
Author(s):  
Beatriz R. Olson ◽  
Julie Gumowski ◽  
Domenica Rubino ◽  
Edward H. Oldfield
Keyword(s):  
Water Balance ◽  
Fluid Intake ◽  
Sodium Intake ◽  
Pituitary Surgery ◽  
Dietary Sodium ◽  
Plasma Sodium ◽  
Water Load ◽  
Content Type ◽  
Transsphenoidal Pituitary Surgery ◽  
Fine Print

✓ Hyponatremia after pituitary surgery is presumed to be due to antidiuresis; however, detailed prospective investigations of water balance that would define its pathophysiology and true incidence have not been established. In this prospective study, the authors documented water balance in patients for 10 days after surgery, monitored any sodium dysregulation, further characterized the pathophysiology of hyponatremia, and correlated the degree of intraoperative stalk and posterior pituitary damage with water balance dysfunction. Ninety-two patients who underwent transsphenoidal pituitary surgery were studied. To evaluate posterior pituitary damage, a questionnaire was completed immediately after surgery in 61 patients. To examine the osmotic regulation of vasopressin secretion in normonatremic patients, water loads were administered 7 days after surgery. Patients were categorized on the basis of postoperative plasma sodium patterns. After pituitary surgery, 25% of the patients developed spontaneous isolated hyponatremia (Day 7 ± 0.4). Twenty percent of the patients developed diabetes insipidus and 46% remained normonatremic. Plasma arginine vasopressin (AVP) was not suppressed in hyponatremic patients during hypoosmolality or in two-thirds of the normonatremic patients after water-load testing. Only one-third of the normonatremic patients excreted the water load and suppressed AVP normally. Hyponatremic patients were more natriuretic, had lower dietary sodium intake, and had similar fluid intake and cortisol and atrial natriuretic peptide (ANP) levels compared with normonatremic patients. Normonatremia, hyponatremia, and diabetes insipidus were associated with increasing degrees of surgical manipulation of the posterior lobe and pituitary stalk during surgery. The pathophysiology of hyponatremia after transsphenoidal surgery is complex. It is initiated by pituitary damage that produces AVP secretion and dysfunctional osmoregulation in most surgically treated patients. Additional events that act together to promote the clinical expression of hyponatremia include nonatrial natriuretic peptide—related excess natriuresis, inappropriately normal fluid intake and thirst, as well as low dietary sodium intake. Patients should be monitored closely for plasma sodium, plentiful dietary sodium replacement, mild fluid restriction, and attention to symptoms of hyponatremia during the first 2 weeks after transsphenoidal surgery.

A transparent sheath for endoscopic surgery and its application in surgical evacuation of spontaneous intracerebral hematomas

2000 ◽  
Vol 92 (6) ◽  
pp. 1053-1055 ◽  
Author(s):  
Tetsuhiro Nishihara ◽  
Akira Teraoka ◽  
Akio Morita ◽  
Keisuke Ueki ◽  
Keisuke Takai ◽  
...  
Keyword(s):  
Endoscopic Surgery ◽  
Brain Parenchyma ◽  
Bleeding Point ◽  
Content Type ◽  
Minimal Invasiveness ◽  
Surgical Evacuation ◽  
Endoscopic Evacuation ◽  
Surgical Field ◽  
The Brain ◽  
Fine Print

✓ The authors advocate the use of a transparent sheath for guiding an endoscope, a simple and unique tool for endoscopic surgery, and describe preliminary results of its application in the evacuation of hypertensive intracerebral hematomas. This sheath is a 10-cm-long tube made of clear acrylic plastic, which greatly improves visualization of the surgical field through a 2.7-mm nonangled endoscope inserted within. Between April 1997 and December 1998, the authors performed endoscopic evacuation of intracerebral hematomas by using this sheath inserted into the patients' heads through a burr hole. In nine consecutive cases in which the hematoma was larger than 40 ml in volume, nearly complete evacuation (86–100%) of the lesion was achieved without complication. Excellent visualization of the border between the brain parenchyma and the hematoma facilitated accurate intraoperative orientation, and also allowed easy identification of the bleeding point. Thus, this combination of sheath and endoscope achieves both minimal invasiveness and the maximum extent of hematoma removal with secure hemostasis. This tool will reduce the inherent disadvantage of endoscopic procedures and may expand their application in other areas of neurosurgical management.

The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors

2005 ◽  
Vol 102 (5) ◽  
pp. 832-841 ◽  
Author(s):  
Joshua R. Dusick ◽  
Felice Esposito ◽  
Daniel F. Kelly ◽  
Pejman Cohan ◽  
Antonio DeSalles ◽  
...  
Keyword(s):  
Residual Tumor ◽  
Transsphenoidal Approach ◽  
Total Removal ◽  
Content Type ◽  
Patients Âgés ◽  
Extended Transsphenoidal Approach ◽  
Planum Sphenoidale ◽  
Dural Defects ◽  
Fine Print ◽  
Csf Leaks

Object. The extended transsphenoidal approach, which requires a bone and dural opening through the tuberculum sellae and posterior planum sphenoidale, is increasingly used for the treatment of nonadenomatous suprasellar tumors. The authors present their experiences in using the direct endonasal approach in patients with nonadenomatous suprasellar tumors. Methods. Surgery was performed with the aid of an operating microscope and angled endoscopes were used to assess the completeness of resection. Bone and dural defects were repaired using abdominal fat, collagen sponge, titanium mesh, and, in most cases, lumbar drainage of cerebrospinal fluid (CSF). Twenty-six procedures for tumor removal were performed in 24 patients (ages 9–79 years), including two repeated operations for residual tumor. Gross-total removal could be accomplished in only 46% of patients, with near-gross-total removal or better in 74% of 23 patients (five of eight with craniopharyngiomas, six of seven with meningiomas, five of six with Rathke cleft cysts, and one of two with a dermoid or epidermoid cyst); a patient with a lymphoma only underwent biopsy. Of 13 patients with tumor-related visual loss, 85% improved postoperatively. The complications that occurred included five patients (21%) with postoperative CSF leaks, one patient (4%) with bacterial meningitis; five patients (21%) with new endocrinopathy; and two patients (8%) who needed to undergo repeated operations to downsize suprasellar fat grafts. The only permanent neurological deficit was anosmia in one patient; there were no intracranial vascular injuries. Conclusions. The direct endonasal skull-base approach provides an effective minimally invasive means for resecting or debulking nonadenomatous suprasellar tumors that have traditionally been approached through a sublabial or transcranial route. Procedures in the supraglandular space can be performed effectively with excellent visualization of the optic apparatus while preserving pituitary function in most cases. The major challenge remains developing consistently effective techniques to prevent postoperative CSF leaks.

Unilateral septal technique for transsphenoidal microsurgical approach to the sella turcica

1978 ◽  
Vol 49 (1) ◽  
pp. 138-142 ◽  
Author(s):  
George T. Tindall ◽  
William F. Collins ◽  
John A. Kirchner
Keyword(s):  
Nasal Mucosa ◽  
Nasal Septum ◽  
Sella Turcica ◽  
Practical Approach ◽  
Transsphenoidal Approach ◽  
Content Type ◽  
Microsurgical Approach ◽  
Septal Perforations ◽  
Fine Print

✓ A modification of the transseptal, transsphenoidal approach to the sella turcica is described; it consists of a unilateral separation of the nasal mucosa from the nasal septum. Experience with the technique in 215 cases has indicated that it is a useful, practical approach. The advantages are that the septum is spared, reoperation is made easier, and the procedure is quicker than the bilateral septal procedure. Asymptomatic nasal septal perforations (less than 3 mm) were seen in eight of 215 cases, and represented the only complication related to the operation.

Localization of pituitary adenomas by using intraoperative ultrasoound pituitary in patients with Cushing's disease and no demonstrable tumor on magnetic resonance imaging

1998 ◽  
Vol 89 (6) ◽  
pp. 927-932 ◽  
Author(s):  
Joe C. Watson ◽  
Thomas H. Shawker ◽  
Lynnette K. Nieman ◽  
Hetty L. DeVroom ◽  
John L. Doppman ◽  
...  
Keyword(s):  
Magnetic Resonance ◽  
Mr Imaging ◽  
Cushing’S Disease ◽  
Pituitary Adenomas ◽  
Pituitary Surgery ◽  
Intraoperative Ultrasonography ◽  
Cushing's Disease ◽  
Content Type ◽  
Negative Findings ◽  
Fine Print

Object. Pituitary surgery has been reported to produce remission of Cushing's disease with preservation of pituitary function in only 60 to 70% of patients. The inability to identify an adenoma accounts for most failed sellar explorations. Most negative surgical explorations occur in patients in whom magnetic resonance (MR) imaging of the pituitary demonstrates normal findings, which happens in at least 35 to 45% of patients with Cushing's disease. Methods. To examine the usefulness of intraoperative ultrasonography (IOUS) for identifying an adenoma in patients with no demonstrable tumor (negative findings) on pituitary MR imaging, we prospectively assessed the results of IOUS in 68 patients with a negative (59 patients) or equivocal (nine patients) MR image from a consecutive series of 107 patients with Cushing's disease (64%). We compared surgical findings and outcomes in these 68 patients with a group of 68 patients with Cushing's disease and negative findings on MR imaging in whom IOUS was not available. Intraoperative ultrasonography localized a tumor in 47 (69%) of 68 patients with negative findings on MR imaging. Surprisingly, the size of the adenomas that were detected with IOUS compared with the size of those not detected did not differ (6.8 ± 3.4 mm compared with 6.1 ± 2.8 mm [mean ± standard deviation], respectively [p = 0.5]). In four patients, no adenoma was found at surgery or in the pathological specimen (“true negative”). In eight patients, nine abnormalities detected by IOUS that were suspected adenomas were negative on exploration (“false positive”). Thus, IOUS has a sensitivity of 73% and a positive predictive value of 84% for detecting pituitary adenomas in patients with Cushing's disease and negative findings on MR imaging. Compared with the 68 patients who did not undergo IOUS, remission after surgery was improved (61 patients [90%] compared with 57 patients [84%]), the number of tumors found on exploration was increased (61 tumors compared with 51 tumors; p = 0.02), and the number of hemihypophysectomies was decreased (five compared with 15; p = 0.02) with IOUS. When the groups were compared after excluding patients with prior pituitary surgery, tumors were found in 91% versus 72% (p = 0.008), and remission occurred in 95% versus 87% of patients, respectively, in the groups that had or did not have IOUS. Conclusions. The IOUS is a sensitive imaging modality when used in patients with Cushing's disease in whom findings on pituitary MR imaging are negative. The improved ability to detect and localize these tumors by using IOUS positively affects surgical outcome.

Sublabial rhinoseptoplastic technique for transsphenoidal pituitary surgery by a hinged-septum method

1980 ◽  
Vol 52 (6) ◽  
pp. 867-870 ◽  
Author(s):  
Takanori Fukushima ◽  
Keiji Sano
Keyword(s):  
Sphenoid Sinus ◽  
Sella Turcica ◽  
Pituitary Surgery ◽  
Anterior Wall ◽  
Surgical Instruments ◽  
En Bloc ◽  
Content Type ◽  
Anterior Nasal Spine ◽  
Transsphenoidal Pituitary Surgery ◽  
Mucosal Perforation

✓ A new modification of the transseptal, transsphenoidal approach to the sella turcica is described. The procedure consists of unilateral dissection of the septal mucosa through a sublabial route, and retraction of the entire nasal septum with its upper attachment as a hinge. For mobilization of the septum, an L-shaped osteotomy is made along the base of the septum and along the anterior wall of the sphenoid sinus. It provides adequate exposure of the sphenoid sinus while preserving the septal structures. The anterior nasal spine and the edges of the nares are also left intact. The anterior wall of the sphenoid sinus is resected en bloc and is used as a bone splint for the reconstruction of the sellar floor. This approach has been performed in 45 cases of pituitary adenoma, one of craniopharyngioma, and one with sphenoid mucocele. There was no instance of complications such as mucosal perforation, septal deformity, or infection. Modifications of the surgical instruments used are described.

Pioneers in the development of transsphenoidal surgery: Theodor Kocher, Oskar Hirsch, and Norman Dott

2001 ◽  
Vol 95 (6) ◽  
pp. 1097-1103 ◽  
Author(s):  
Giuseppe Lanzino ◽  
Edward R. Laws
Keyword(s):  
Transsphenoidal Surgery ◽  
Transsphenoidal Approach ◽  
Scientific Concepts ◽  
Content Type ◽  
Theodor Kocher ◽  
Fine Print

✓ The development of new scientific concepts and techniques is usually the result of a progressive evolution. The transsphenoidal approach to pituitary lesions is no exception. Several pioneers contributed to its development and its eventual and nearly unconditional acceptance. In this historical vignette, the contributions of three master surgeons, Theodor Kocher, Oskar Hirsch, and Norman Dott, are reviewed.

Surgical treatment of clival chordomas: the transsphenoidal approach revisited

1996 ◽  
Vol 85 (5) ◽  
pp. 784-792 ◽  
Author(s):  
Giulio Maira ◽  
Roberto Pallini ◽  
Carmelo Anile ◽  
Eduardo Fernandez ◽  
Fabrizio Salvinelli ◽  
...  
Keyword(s):  
Spinal Metastasis ◽  
Postoperative Radiotherapy ◽  
Primary Treatment ◽  
Transsphenoidal Approach ◽  
Total Removal ◽  
Partial Removal ◽  
Content Type ◽  
Mortality And Morbidity ◽  
Lower Clivus ◽  
Fine Print

✓ This is a report of 12 cases of clival chordomas that were surgically treated at the Catholic University Medical School, Rome, Italy, over a 7-year period. The study emphasizes the role of the transsphenoidal approach. The study group included seven men and five women whose ages ranged from 26 to 80 years (mean 49.8 years). Diplopia was the most common presenting symptom (eight cases). The tumor involved the upper and middle clivus in five cases, the middle clivus in five, and the lower clivus in two cases. One patient developed spinal metastasis. On histological examination, eight cases proved to be typical chordomas, three cases had a chondroid component, and one case of chordoma had atypical features. Immunohistological staining for vimentin and epithelial membrane antigen was positive in all cases. Follow-up periods ranged from 14 to 86 months (mean 40.2 months). The primary treatment consisted of surgery. Ten patients with chordomas of the upper and middle clivus underwent a total of 13 transsphenoidal procedures. Total tumor removal was achieved in seven cases, subtotal removal in two, and partial removal in one case. In the two cases of lower clival chordomas, total removal was accomplished in one and partial removal in the other. After total removal, no recurrence was noted at 14 to 86 months (mean 37.5 months). In the cases undergoing operation via a transsphenoidal approach, there was zero morbidity and one cerebrospinal fluid fistula that resolved without surgery. The tumor recurred in two patients after subtotal and partial removal, respectively. The authors opted to reoperate in cases of recurrence. Postoperative radiotherapy was administered in only two cases in which further surgery was not indicated because of medical reasons or because such a procedure was contrary to the patient's wishes. When mortality and morbidity rates of this group are compared to those of chordoma patients who were treated with extensive skull-base surgery, the results prompt a reappraisal of the transsphenoidal approach in the treatment of clival chordomas.

Microsurgical robotic system for the deep surgical field: development of a prototype and feasibility studies in animal and cadaveric models

2005 ◽  
Vol 103 (2) ◽  
pp. 320-327 ◽  
Author(s):  
Akio Morita ◽  
Shigeo Sora ◽  
Mamoru Mitsuishi ◽  
Shinichi Warisawa ◽  
Katopo Suruman ◽  
...  
Keyword(s):  
Degrees Of Freedom ◽  
Control Unit ◽  
Feasibility Studies ◽  
Robotic System ◽  
Content Type ◽  
Field Development ◽  
Six Degrees Of Freedom ◽  
Surgical Field ◽  
Robotic Instruments ◽  
Fine Print

Object. To enhance the surgeon's dexterity and maneuverability in the deep surgical field, the authors developed a master—slave microsurgical robotic system. This concept and the results of preliminary experiments are reported in this paper. Methods. The system has a master control unit, which conveys motion commands in six degrees of freedom (X, Y, and Z directions; rotation; tip flexion; and grasping) to two arms. The slave manipulator has a hanging base with an additional six degrees of freedom; it holds a motorized operating unit with two manipulators (5 mm in diameter, 18 cm in length). The accuracy of the prototype in both shallow and deep surgical fields was compared with routine freehand microsurgery. Closure of a partial arteriotomy and complete end-to-end anastomosis of the carotid artery (CA) in the deep operative field were performed in 20 Wistar rats. Three routine surgical procedures were also performed in cadavers. The accuracy of pointing with the nondominant hand in the deep surgical field was significantly improved through the use of robotics. The authors successfully closed the partial arteriotomy and completely anastomosed the rat CAs in the deep surgical field. The time needed for stitching was significantly shortened over the course of the first 10 rat experiments. The robotic instruments also moved satisfactorily in cadavers, but the manipulators still need to be smaller to fit into the narrow intracranial space. Conclusions. Computer-controlled surgical manipulation will be an important tool for neurosurgery, and preliminary experiments involving this robotic system demonstrate its promising maneuverability.

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