Endovideomonitoring in Transsphenoidal Surgery of Pituitary Neoplasms
V.Yu. Cherebillo, V.R. Gofman, A.V. Polezhaev, V.A. Manukovsky
Chair of Neurosurgery, Medicomilitary Academy, Saint Petersburg, Russia
Surgical Technique
The most important thing in making an approach and using endoscopic landmarks in the sphenoid sinus was to choose a correct place of a puncture and subsequent trephination of the saddle fundus. At first, a thin puncture needle was inserted into an operative wound. Lateral fluoroscopy was used for control of placing its sharp end near the saddle fundus, so that an axis of its route was directed at an upper point of the saddle dorsum. After achieving an optimum position of the needle in a sagittal plane, the endoscope was introduced coaxially into the sinus cavity. It was done with the purpose of verification of accuracy of the instrument position. In case of necessity the needle position could be corrected under simultaneous fluoroscopic and endoscopic control.
The thin needle, used for the saddle puncture, was replaced by a thick one. Obtained defect was widened with Kerrison microforceps up to an approximate size of 10x10 mm. Anatomic landmarks, limiting the saddle fundus defect, were as follows: on the sides - margins of both cavernous sinuses,
on above - a place, where the saddle diaphragm joined its tubercle
(1-2mm below planum sphenoidale), on below - anterior parts of the
clivus cavity. Manipulations with microforceps were performed under
continuous endoscopic control, as magnification of 8-10 times was a
necessary condition for identifying cavernous sinuses
and other important anatomic structures. Introduction of the forceps'
heel under a bone plate of the saddle fundus and careful staged
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Fig.6. An endoscopic view after creation a defect in the saddle fundus and dura dissection. |
widening of a trephination window by nipping off the bone under visual
control was an effective method of creation extensive defect of the
fundus and further adequate examination of the saddle contents (Fig.6).
After trephination dura was incised, using Y- or X-shaped incisions and a microscalpel. Then the rigid endoscope was fixed in an operative wound with a special holder, whose design permitted to place it in a desirable position and to carry out continuous endovideomonitoring. In case of necessity the endoscope position could be changed very quickly and without any technical difficulties.
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