Endoscopic Transsphenoidal Surgery

Endoscopic Transsphenoidal Surgery

Dr R K Mishra

Introduction:

Transsphenoidal actually interprets “through the sphenoid sinus.” It is a surgical method carried out by means of the nose and sphenoid sinus to eliminate pituitary tumors. Endoscopic Transsphenoidal Surgery can be done with help of a microscope, endoscope, or both. Transsphenoidal surgery is a kind of surgery in which surgical instruments are placed into part of the brain by going through the nose and the sphenoid bone - a butterfly-shaped bone at thebase of the skull. Transsphenoidal surgery is applied to eliminate tumors of the pituitary gland.

A conventional microscopic approach applies a skin cleft beneath the lip and eradication of a massive part of the nasal septum ensuring that the surgeon can precisely look the part. Minimally invasive techniques, known as endoscopic endonasal surgery, makes use of tiny cleft at the countenance of the nasal cavity and triggers small interruption of the nasal tissues. Surgeon works by the nostrils with a small camera and light known as an endoscope. In both techniques, bony openings are made in the nasal septum, sphenoid sinus, and sella to grab the pituitary. Once the pituitary is unearthed, the neurosurgeon flushes out the tumor.

Endoscopic Transsphenoidal Surgery is carried out for:

  • Pituitary adenoma - a tumor which develops from the pituitary gland; may be hormone-secreting or not.
  • Craniopharyngioma - a non-cancerous tumor which develops from cells closed the pituitary stalk; may dominate the third ventricle.
  • Rathke’s cleft cyst - a non-cancerous cyst, or fluid-filled sac, between the anterior and posterior lobes of the pituitary gland.
  • Meningioma - a tumor which develop from the meninges (dura), the membrane which encloses the brain and spinal cord.
  • Chordoma - a malignant bone tumor which develops from embryonic notochord leftover part situated at the bottom of the skull.

Procedure of Endoscopic Transsphenoidal Surgery:

The operation generally takes 2 to 3 hours. Before performing transsphenoidal surgery, an intravenous (IV) line is administered to the patient arm or general anesthesia will be given. The nasal cavity is adjusted with antibiotic and antiseptic solution. An image-guidance system may be inserted on the head of patient. This device is like a global positioning system (GPS) and assisted the surgeon explore by the nose applying a 3D map developed from your CT or MRI scans.

In minimally invasive endoscopic techniques, the ENT surgeon places the endoscope in one nostril and improves it to the back of the nasal cavity. An endoscope is a thin, tube-like instrument with a light and a camera. Video from the camera is seen on a monitor. The surgeon moves massive tools by means of the nostril whereas observing the monitor. A tiny part of the nasal septum cleaving the left and right nostril is eliminated applying bone-biting instruments; the top wall of the sphenoid sinus is exposed. At the back side barrier of the sphenoid sinus is the bone predominant the pituitary gland, known as the sella. The thin bone of the sella is eliminated to open the hard lining of the skull thought as the dura. The dura is exposed to expose the tumor and pituitary gland.

By way of a tiny hole in the sella, the tumor is eliminated in parts with specific instruments called curettes. The center of the tumor is cored out, facilitating the tumor range to drop interiorly so the surgeon can attain it. After all visible tumor is removed, the surgeon develops the endoscope into the sella to view and examine for concealed tumor. Some tumors develop sideways into the cavernous sinus, a collection of veins. It may be hard to entirely eliminate this part of the tumor without triggering injury to the nerves and vessels. Any tumor left behind may be cured by radiation subsequently.

After tumor is removed, the surgeon gets ready to cease the sella cleft. If needed, a little (2cm) skin cleft is formed in the abdomen to attain a tiny part of fat. The fat graft is applied to load the vacant space left by the tumor elimination. The abdominal cleft is cease with sutures.

The opening in the sella floor is substituted with bone insertion from the septum. Synthetic graft material is utilized when there is no appropriate part of septum or the patient has had former surgery. Biologic glue is used over the graft in the sphenoid sinus. This glue facilitates quick recovery and protect against discharging of cerebrospinal fluid (CSF) from the brain into the sinus and nasal cavity. Soft, flexible splints are inserting in the nose along the septum to manage bleeding and protect against swelling. The splints also prevent adhesions from forming that may lead to chronic nasal congestion. After surgery you may feel nasal congestion, nausea, and headache. Medication can control these indications

Restrictions of Endoscopic Transsphenoidal Surgery:

To protect against injury to the surgical site, evade gusting your nose, coughing, sneezing, drinking with a straw, or bending over/straining on the toilet for 4 weeks. After surgery do not drive for 2 weeks. Fatigue is usual after Endoscopic Transsphenoidal Surgery. Slightly get back to your normal activities. Walking is recommended; start with a less distance and slightly enhance to 1 to 2 miles daily.

Risks and complications of Minimally Invasive Transsphenoidal Surgery:

Common complications of any surgery include bleeding, infection, blood clots, and reactions to anesthesia. Specific complications related to pituitary surgery comprise:

  • vision loss
  • damage to normal pituitary gland
  • diabetes insipidus (DI)
  • cerebrospinal fluid (CSF) leak
  • Meningitis: an infection of the meninges often caused by CSF leak.
  • Sinus congestion - small adhesions can stick together and form scars that block air flow through the nose.
  • Nasal deformity - triggered by bone removal or adhesions.
  • Nasal bleeding - continued bleeding from the nose after surgery.
  • Stroke - the carotid arteries and cavernous sinuses located on either side of the pituitary may be damaged during surgery causing an interruption of blood supply to the brain.

World Laparoscopy Hospital, Cyber City, DLF Phase II, Gurugram, NCR Delhi, 122 002, India
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