Endoscopic trans-sphenoidal approach

Considerations

• • Endoscopic trans-nasal trans-sphenoidal approach to a pituitary adenoma is just one approach of many

    • Today, it is the favored approach

    • Studies show it is safe and effective 

  • Other approaches

    • External rhinoplasty 

    • Trans-nasal trans-septal

    • Trans-nasal sublabial 

    • Trans-frontal

Preparation

• • Logistics

    • NSG writes the pre-op note

    • NSG performs lumbar drain and/or abdominal fat graft harvest 

  • Dr. Wynn will then perform the endoscopic trans-nasal sphenoid and harvest the naso-septal flap

  • Dr. Wynn will write the op note

    • We will round if we are involved

• Examine the CT and MRI, note 

  • • The size and nature of the pituitary lesion

• • Inter carotid distance

  • Optic nerve status

  • Space - intradural

• Room set up 

• • CT image guidance (Medtronic Fusion AxieEM system for NSG) - load and check patient scan 

  • Check instruments 

    • • Medtronic Straightshot 

      • Aqua mantis endoscopic bipolar 

      • Endoscrub 

      • NICO Myriad debrider 

  • Check medications 

• • • "Surgifoam" - powderized Gelfoam and 10,000 units thrombin (2 vials), fills a 10 ml syringe 

• Patient prep

• • Plan for Lumbar drain if high CSF leak anticipated, as in 3-4 cm macro adenoma

  • ETT left lower lip, straight connector 

  • Throat pack

  • Prep the abdominal fat pad

    • Drape with sticky drapes

  • Prior to prepping face, cover eyes with Tegaderm

  • Sterile face prep and drape

    • AFTER SCRUBBED place nasal pledgets soaked with 50:50 4% Cocaine and Afrin

      • Both arms tucked 

      • Secure Mitaka (pneumatic arm) to right head of bed, if using Secure emitter to left head of bed - "Mataka" scope holder arm or resident will hold the scope to allow two-handed surgery by main surgeon

    • Turn 90 degrees 

Procedure

• • Tape patient reference to forehead

  • Registrer as many unique points as possible, including the forehead 

  • 1000 drape over face 

  • Instrument wipe and Fred sponge on chest 

  • Lateralize bilateral MTs - may need to Resect for visualization 

    • Straight through cut

    • Remove intact and save 

  • 25 g spinal straight - 1% Lidocaine with Epi into superior turbinate 

  • Straight through cut to incise ST

  • Straight shot to resect ST

  • Do not resect anterior septum 

  • May need to perform posterior ethmoidectomy

  • Injection the septum

  • Incise the septum with th needle tip Bovie 

    • Horizontal at the level of the bony MT axilla 

    • Anterior to the level of the bony head of the IT

    • Inferior horizontal incision, level varies 

    • Raise the flap with the suction free in the submuchoperichondrial plane 

    • If you leave the muchopericondrium, healing may be faster but bleeding is worse 

    • Raise the flap posteriorly to the rostrum of the sphenoid - tuck into NP

    • Preserve the poster septal branch! 

    • Idenity the bony cartilaginous junction and enter the contra lateral side here 

    • Remove the bone and mucosa on the contra lateral side IF NOT raising bilateral flaps 

  • Resect the inter sinus septum with through cutting instruments 

  • Do not rock - usually inserts on the carotid 

  • Widen laterally and inferiorly with mushroom punch and kerasin 

  • Again, do not get the posterior septal artery 

  • Drill down the rostrum with 30K coarse diamond choanal atresia burr (angled 15 degrees) until flush with the sphenoid floor 

• Remove the mucosa off the posterior sphenoid wall 

• Once adequate exposure is gained, hold the scope for the neurosurgeon 

• Enter the sella with the drill at the midline 

• Place right angled pick 

• Widen with kerosin 

• Address the lesion

• Address the defect 

  • For a marsupialization, Tisseal or Duraseal is enough, lay Gelfoam over 

  • Layered closure

    • • Surgicel over the arachnoid, abd fat graft, cartilage or bone graft underlay, nasoseptal flap overlay with mucosa facing outward, spray Duraseal, more fat or Gelfoam, more Duraseal, firm Nasopore 

  • Lumbar drain as needed

Post-op

• • Admit overnight

  • Pod 1 AM cortisol

  • Monitor I/O

  • Neuro and vision checks q1h first day 

  • Saline spray POD 1

  • Augmentin x 10 d

  • Standard sinus precautions 

High-Yield

Links

• • YouTube: (19:20) - Excellent narrated surgical video, step-by-step approach, tumor resection, closure