Chair of Neurosurgery, Medicomilitary Academy, Saint Petersburg, Russia
Surgical Technique
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Fig.1. A general view of the Polystar-2 universal rentgenologic C-arm system (Germany), ensuring lateral fluoroscopy in transsphenoidal removal of pituitary adenomas. |
All interventions were performed with application of multicomponent anesthesia with tracheal intubation. The Polystar-2 universal rentgenologic C-arm system (Germany) was positioned so that lateral views of the skull and chiasm-sellar region could be taken (Fig.1).
A patient was placed on an operating table, whose head end was elevated about 30o. A surgeon stood on the right at the level of his thorax.
Endolumbar administration of oxygen (20ml) was carried out before operation in an extrasellar growth for verifying neoplasm's upper pole and ensuring optimum safety of intraoperative manipulations (Fig.2).
Infiltration anesthesia (10-15ml of 0.5% novocain solution) was followed by hydropreparation of soft tissues of the nasal septum on the left. A
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Fig.2. Intraoperative pneumocisternography in endosuprasellar growth of pituitary adenoma |
vertical incision of the mucous membrane was performed in the area of the septum of the left nasal vestibule (1-2mm backward from a free border of the septum cartilage). The incision ran from the nasal cavity bottom up to a place of junction of the septum and lateral cartilage. Septal mucosa was separated from the cartilage and periosteum by blunt dissection.
A vertical incision of the cartilage was made with involvement of the conralateral side, whose mucosa was then separated by blunt dissection as well.
Temporal packing (for 1-2min) of the nasal cavity with gauze turundae, soaked with 3% hydrogen peroxide solution, was used.
Illumination of an operative field and a straight view, ensured by a binocular optic-fiber magnifier at the stage of resection of the cartilage and a greater part of bone segments of the septum, were sufficient for good visualization of necessary anatomic structures in the majority of cases. Endovideomonitoring started after resection of septal bones with Luk's forceps. Lower segments of the perpendicular plate of the ethmoid bone, upper segments of the vomer, separated and retracted nasal mucosa were visualized at this stage of an operation quite well. In case of bleeding from septal bones or mucosa of posterior segments of the nasal cavity, its source could be visualized without any difficulty. It allowed to provide effective hemostasis. Subsequent removal of
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Fig.3. Stages of an approach to the anterior wall of the sphenoid sinus and the Turkish saddle. |
lower segments of the perpendicular plate of the ethmoid bone and the vomer's upper segments was performed with the help of Luk's forceps and a chisel in the direction of the sphenoid sinus; rostrum sphenoidale was mobilized and removed
(Fig.3).
Use of endovideomonitoring in approaching the anterior wall of the sphenoid sinus was justified, as it permitted to determine localization of rostrum sphenoidale more precisely. Simultaneous lateral fluoroscopy of the skull was aimed at precise choice of a place of trepanizing an anterior wall of the sphenoid sinus. There was no necessity of rigid fixation of an endoscope in an operative wound during resection of the nasal septum.
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