Transsphenoidal Approaches:Microscopic

Cranial,Craniofacial and skull base surgery Ch.16

Outline• Introduction• Surgical technique• Complication

Introduction

• 1905 Frontal transcranial approach to the sella Fedor Krause of Berlin

Sir Victor Horsley, Walter Dandy, and Harvey Cushing

• 1907 First transsphenoidal approach Schloffer,von Eiselsberg and Kocher Require rhinotomy incision• 1920 Endonasal and sublabial• Hirsch and Halstead

Introduction• 1927 transsphenoidal in favor of transcranial Cushing• 19xx use Fluoroscopy

Norman Dott, Gerard Guiot

Surgical technique• General• Patient Positioning and Surgical team positioning• Patient preparation• Adjunctive navigation• Surgical approach

General• Tumors of adenohypophyseal origin

– Pituitary adenoma– Pituitary adenoma–neuronal choristoma (pituitary

adenoma–gangliocytoma)– Pituitary carcinoma

• Tumors of neurohypophyseal origin– Granular cell tumor– Astrocytoma of posterior lobe or stalk, or both (rare)– Chordoma

• Vascular lesions– Saccular aneurysm (intracavernous carotid,supraclinoid

carotid, anterior communicating artery complex, basilar artery tip)

– Cavernous angioma

General• Tumors of nonpituitary origin

– Craniopharyngioma– Germ-cell tumors– Glioma (hypothalamic, optic nerve or chiasm,infundibulum)– Meningioma– Chordoma

• Cysts, hamartomas, and malformations– Rathke’s cleft cyst– Arachnoid cyst– Epidermoid cyst– Dermoid cyst– Hypothalamic hamartoma– Empty sella syndrome

General• Metastatic tumors

– Carcinoma– Plasmacytoma– Lymphoma– Leukemia

• Inflammatory conditions– Pyogenic infection or abscess– Granulomatous infections– Mucocele– Lymphocytic hypophysitis– Sarcoidosis– Langerhans cell histiocytosis– Giant-cell granuloma

Patient positioning

Patient positioning• The patient’s right shoulder is positioned in the top

righthand corner of the operative table• Mayfield hoareshoe head rest or rigid 3 point fixation• The patient’s head is oriented at a right angle to the

walls of the room• The head is positioned so that the trajectory is

toward the sella(dorsum sellae parallel with the floor)• The patient’sright hand is carefully positioned so that

it is located unobtrusively under the buttocks

Patient preparation• Face

– aqueous antiseptic solution• Nare

– topical vasoconstrictors and inject local anesthetic solution– oxymetolazine (Afrin) into the nose before induction and

then pack both nostrils with cotton pledgets soaked in 5% cocaine inserted with bayonets through a nasal speculum, and leave these in for 10–15!minutes

• Umbilical region– small fat graft

• Antibiotic• Cortisol support

Image guidance• Image guidance

Surgical Approaches• 1.The nasal phase, from initial sublabial or

endonasal incision to entry into the sphenoid sinus.• 2. The sphenoid phase, from entry into the

sphenoid sinus to the sellar dura.• 3. The sellar phase, from opening of the sellar dura

to lesion resection to establishment of hemostasis and preparation for closure.

• 4. Reconstruction and closure phase.

Nasal phase• Transnasal Submucosal Transseptal Approach• Sublabial Submucosal Transseptal Approach• Septal Displacement (“Septal Pushover”)

Transnasal Submucosal Transseptal Approach

Transnasal Submucosal Transseptal Approach

• Right-sided hemitransfixion incision in the right nostril with the columella retracted to the patient’s left

• Dissection of the right anterior nasal mucosal tunnel away from the septum

• One side of the septum is exposed submucosally with a combination of sharp and blunt dissection, thereby creating the anterior tunnel

• The dissection continues posteriorly, elevating the nasal mucosa away from the cartilaginous septum back to the junction with the bony septum

Transnasal Submucosal Transseptal Approach

• A vertical incision is then made at this junction, and bilateral posterior submucosal tunnels are created on either side oft he perpendicular plate of the ethmoid

• The articulation of the cartilaginous septum with the maxilla is then dissected free

• The inferior mucosal tunnel on the opposite side is raised so that the cartilaginous septum can be displaced laterally without creating inferior mucosal tears

• A self-retaining nasal speculum can then be introduced to straddle the perpendicular plate of the ethmoid, exposing the face of the sphenoid sinus

Transnasal Submucosal Transseptal Approach

• Advantage– broad septal mobilization– wide surgical corridor– strict fidelity to the midline

• Disadvantage– Sinonasal complications– postoperative discomfort– rhinological complaints including alveolar numbness,– anosmia, saddle nose deformity, and nasal septal

perforations

Sublabial Submucosal Transseptal Approach

• Transverse submucosal gingival sublabial incision from canine to canine

• Dissection from the maxillary ridge and the anterior nasal spine until the inferior aspect of the piriform aperture is exposed

• Working from the lateral border medially, the two inferior nasal tunnels are created by dissecting the mucosa away from the superior surface of the hard palate

• The caudal end of the nasal septum is carefully dissected and a right anterior tunnel is created along the right side of the nasal septum

Sublabial Submucosal Transseptal Approach

Sublabial Submucosal Transseptal Approach• With sharp dissection,the right anterior endonasal

submucosal tunnel and the right inferior tunnels are connected

• the entire right side of the nasal septum is exposed back to the perpendicular plate of the ethmoid

• Using firm, blunt dissection along the right side of the base of the nasal septum

• the cartilaginous portion of the septum is dislocated at its junction with the perpendicular plate of the ethmoid and vomer and is reflected to the left,and a left posterior mucosal tunnel is developed along

• the left side of the bony septum. At this point it should be possible to insert the transsphenoidal retractor

• Advantage– broad septal mobilization– wide surgical corridor

• Disadvantage– complex surgical anatomy– potential complications of numbness

Sublabial Submucosal Transseptal Approach

a.Endonasal approachb.Submucosal endonasal approach

c.Septal displacement approach

Septal Displacement (“Septal Pushover”) transnasal septal displacement

Septal Displacement (“Septal Pushover”)

Sphenoid phase

• C-arm fluoroscopy confirm• Forcep or punch to the vomer• The mucosa in the sinus is resected with a cup

forceps to reduce bleeding and the risk of postoperative mucocele

• Confirm position and trajectory• Removing the sphenoid septations• visualizing the carotid canals, the clivus, the

opticocarotid recesses when possible, and the planum sphenoidale

Sphenoid phase• Confirm trajectory and midline• Chiesel or blunt nerve hook for sellar floor opening• Widening with 1-2 mm Kerison punch• Superior exposure to tuberculum sellae

Sellar phase

Sellar phase

• Ananatomical hazard – cavernous sinuses and carotids laterally– the intercavernous sinuses at the tuberculum superiorly and

the floor of the sella inferiorly– The venous sinuses which may run between the two leaves

of sellar dura• coagulating and opening the dura

– rectangular excision : large tumors (macroadenomas)– cruciate or “x” type : small tumour

• Dura for pathology • Subdural plane using blunt hook or small curette

Sellar phase• The surgeon should remove the inferior and lateral

aspects of the tumor first, allowing suprasellar extension to drop into the operative field

Reconstruction and closure phase.

• If CSF leak fat graft from subumbilical incision• 10% chloramphenicol solution, patted on a cotton

ball in order to incorporate a few wisps of cotton fiber (which provoke a fibrotic reaction), and the fat is then rolled in Avitene (Davol, Cranston, RI) hemostatic collagen powder

• packed into the sellar cavity

Reconstruction and closure phase.• The sellar floor is then reconstructed : bone from the

initial operative phase or artificial constructs such as a MedPor (Porex, Neman, GA) tailored plate

• Blood and surgical debris are carefully suctioned• from the sphenoid cavity and the nasopharynx prior

to closure• no packing is necessary, the turbinates are then

medialized

Complication

Complication• Hypothalamic injury

– Death, coma, DI, memory loss and disturbances of vegetative functions (e.g., morbid obesity, uncontrollable hunger or thirst, disturbances in temperature regulation)

• Visual damage• Vascular complication

– The intracavernous portion of the carotid tends to be most vulnerable, followed by other components of the circle of Willis

– development of spasm or intraluminal thrombosis. Intracranial hemorrhage, thrombotic stroke, embolic stroke, and the development of false aneurysms or carotid-cavernous fistulas

Complication• Cerebrospinal fluid rhinorrhea• Cavernous sinus injury

– The carotid artery and cranial nerve VI are most vulnerable to such maneuvers; cranial nerves III and IV are damaged less frequently

• Iatrogenic hypopituitarism• Brainstem injury• Nasal complication

– febrile sinusitis,Mucocele– Inadequate hemostasis in the nasal portion of the procedure

may lead to superficial wound hemorrhage and swelling– Loss of the sense of smell

• Complication associated with reoperation

Thank you