Preoperative preparation
1.Endocrine examination: including the measurement of various endocrine hormones in pituitary gland.
2.Imaging examination: Thin layer CT and MRI scan of the pterygoid saddle should be performed as much as possible.
CT coronal scan of the skull window is necessary to show the developmental status of the pterygoid saddle, the position of the nasal septum of the pterygoid sinus and whether there is damage to the bone of the saddle base.
3, drug preparation: preoperative with pituitary function is significantly low, should be supplemented with hormone 3 days before surgery.
Prednisone 5-10mg and thyroxine 20-40mg should be given orally 3 times a day, and if necessary, hormone supplementation can be given quietly. Large prolactin adenoma can be given bromelain for 2 to 4 weeks before surgery, 7.5mg daily.
4. One week before surgery, use antibiotic solution for nose drops and mouth rinse, and cut nasal hair one day before surgery.
Anesthesia and position.
Surgery under general anesthesia.
Tracheal intubation was fixed at the corner of the mouth.
The oropharyngeal cavity is filled with gauze strips to prevent fluid aspiration into the trachea.
The patient is placed in a flat position with the head tilted back 30o.
Operation methods and procedures.
All procedures were operated under the surgical microscope.
1. Dissection of nasal septal mucosa: transnasal butterfly approach (sublabial approach can be used for smaller nostrils), routine disinfection and towel laying. The mucosa of the right nasal septum is separated, the upper edge of the nasal septal cartilage is separated, the periosteum of the nasal septum and the mucosa of the nasal septum are separated at the same time, the right nasal septal cartilage is exposed until it joins the bony nasal septum, and it is separated from the bony nasal septum, and the mucosa-periosteum layer is continued to be separated until the anterior wall of the pterygoid sinus.
2.Excision of the anterior wall of the pterygoid sinus: retract the septal cartilage and expose the anterior wall of the pterygoid sinus in order to fully reveal the saddle base. Excision of the anterior wall of the pterygoid sinus. The anterior wall of the anterior pterygoid sinus is visible on both sides of the anterior opening of the pterygoid sinus, which is the anterior border of the pterygoid sinus, do not go beyond this border to prevent entering the anterior cranial recess. Cut and peel the mucosa of the pterygoid sinus, use bipolar to make it crumple to avoid unnecessary bleeding.
3.Cutting the saddle base: the scope of the saddle base bony opening should not exceed the inner edge of the internal carotid artery bulge.
4, Incision of saddle base dura: first puncture the center of dura with a thin puncture needle to exclude intra-saddle aneurysm. Sharp knife cross cut the dura, the scope of dural incision should be less than the osseous opening window of the saddle base, so as not to damage the intercavernous sinus causing bleeding (do not use bipolar electrocoagulation to stop bleeding when there is bleeding, using gelatin sponge compression can be used).
5.Tumor resection: Fewer microadenomas grow in the anterior pituitary gland, so it is necessary to cut open the pituitary gland in the cross to find the tumor, and then remove the tumor with specimen clamp or aspirate the tumor.
There is no obvious boundary between microadenoma and normal pituitary gland, so the thin layer of pituitary tissue around the tumor should be removed at the same time to prevent the tumor from recurring. For macroadenomas, the tumor can be removed with scrapers and suction devices, and the arachnoid membrane should be prevented from breaking.
If the arachnoid membrane is already broken, it should be filled with autologous fat or muscle block and sealed with artificial dura mater and biologic glue at the base of the saddle.
After adequate hemostasis, a septal cartilage piece of appropriate size can be placed on the saddle base bone window, and then reinforced with bioadhesive to repair. The pterygoid sinus is adequately hemostatic, and the nasal cavity is filled with oil gauze strips.
Postoperative management.
The stuffed oil gauze strips were removed on the fourth postoperative day. Postoperatively, antibiotics should be given for 1 week, and dexamethasone 10-20 mg/day should be given for 1 week and then gradually reduced or switched to oral supplemental hormones, generally without dehydrating agents such as mannitol.
Those who have urinary collapse should be given antidiuretic hormone treatment and pay attention to adjusting water-electrolyte balance. Those with preoperative diabetes mellitus should pay attention to blood glucose changes.