[Abstract] Objective To study the clinical surgical technique of neuroendoscopic technique for resection of pituitary tumor through the nasopalatine approach.
Methods In 35 patients diagnosed with pituitary tumor by CT scan and MRI examination, a transnasal butterfly approach was performed with the aid of neuroendoscopy. After the above findings were clearly identified, the saddle base was opened with a grinding drill to form a 1 cm size bone window, and the tumor was resected with a hook knife to cut the dura and a circular scraper after puncture to exclude the aneurysm and confirm accurate positioning. The results of preoperative, intraoperative and postoperative recovery follow-up were analyzed, and the anatomical landmarks, surgical procedures and precautions for the nasopalatine approach were summarized.
Results: 30 cases of total resection, 5 cases of near-total resection, 20 cases of postoperative hormone level improvement, 19 cases of postoperative transient uropathy, 6 cases of cerebrospinal fluid nasal leakage, 31 cases of visual acuity improvement, 1 case of internal carotid artery injury, no intracranial infection.
Conclusion Neuroendoscopic-assisted transsphenoidal pituitary tumor resection was short, less traumatic, less surgical risk, high rate of complete tumor resection, and fast recovery of patients.
Surgical method General anesthesia intubation was fixed on one side of the corner of the mouth, supine position, head tilted back 20°, head slightly tilted toward the operator, and disinfection of the operating area and nasal cavity. Under 0° endoscopic illumination, a tampon soaked with epinephrine was filled along the middle nasal passage to the pterygoid septal fossa until the nasal cavity was satisfactorily dilated. The opening of the pterygoid sinus located in the pterygoid septal fossa is sought posteriorly along the middle turbinate and up the posterior nostril. The mucosa of the sinus is removed by biting and exposing the saddle base. In the middle of the saddle base bone elevation, the saddle base bone is grinded with grinding drill, the diameter is about 1cm. After puncturing the saddle base dura with a long needle, except for the aneurysm or deviation from the midline, the tumor tissue can be seen to gush outward, the tumor is usually in the shape of fish flesh. If the suprasellar tumor cannot sink with the resection of the tumor in the saddle, ask the anesthesiologist to assist in holding the patient’s breath to make the intracranial pressure increase, which will cause the suprasellar tumor to sink and facilitate resection. It is not necessary to forcefully remove the suprasellar tumor. Forced traction may cause bleeding from small blood vessels adhering to the top of the tumor, and the bleeding location is deep and difficult to stop bleeding. The second transnasal surgery can be chosen to remove the supra-saddle tumor, because the tumor has the characteristic of growing to the relative weakness, and with the extension of time, the tumor will gradually decline and make the second surgery easy. If the internal carotid artery is inadvertently damaged during surgery, the only feasible solution is to terminate the pituitary tumor resection immediately and stop the bleeding by filling the nasal cavity with gauze.
After tumor resection, the saddle was filled with hemostatic gauze and gelatin sponge to stop the bleeding, and the saddle base was closed with bio-glue after external application of artificial dura. If there is a rupture of saddle septum and cerebrospinal fluid leakage, the saddle base must be closed with autologous tissue. The nasal cavity is filled with iodine spun gauze to keep the posterior nostril open.