Youmans Neurological Surgery

1. Transsphenoidal Approaches:
Microscopic
Cranial,Craniofacial and skull base surgery Ch.16

2. Outline
• Introduction
• Surgical technique
• Complication

3. Introduction
• 1905 Frontal transcranial approach to the sella
Fedor Krause of Berlin
Sir Victor Horsley, Walter Dandy, and
Harvey Cushing
• 1907 First transsphenoidal approach
Schloffer,von Eiselsberg and Kocher
Require rhinotomy incision
• 1920 Endonasal and sublabial
• Hirsch and Halstead

4. Introduction
• 1927 transsphenoidal in favor of transcranial
Cushing
• 19xx use Fluoroscopy
Norman Dott, Gerard Guiot

5. Surgical technique
• General
• Patient Positioning and Surgical team positioning
• Patient preparation
• Adjunctive navigation
• Surgical approach

6. General
• Tumors of adenohypophyseal origin
– Pituitary adenoma
– Pituitary adenoma–neuronal choristoma (pituitary
adenoma–gangliocytoma)
– Pituitary carcinoma
• Tumors of neurohypophyseal origin
– Granular cell tumor
– Astrocytoma of posterior lobe or stalk, or both (rare)
– Chordoma
• Vascular lesions
– Saccular aneurysm (intracavernous carotid,supraclinoid
carotid, anterior communicating artery complex, basilar
artery tip)
– Cavernous angioma

7. General
• Tumors of nonpituitary origin
– Craniopharyngioma
– Germ-cell tumors
– Glioma (hypothalamic, optic nerve or chiasm,infundibulum)
– Meningioma
– Chordoma
• Cysts, hamartomas, and malformations
– Rathke’s cleft cyst
– Arachnoid cyst
– Epidermoid cyst
– Dermoid cyst
– Hypothalamic hamartoma
– Empty sella syndrome

8. General
• Metastatic tumors
– Carcinoma
– Plasmacytoma
– Lymphoma
– Leukemia
• Inflammatory conditions
– Pyogenic infection or abscess
– Granulomatous infections
– Mucocele
– Lymphocytic hypophysitis
– Sarcoidosis
– Langerhans cell histiocytosis
– Giant-cell granuloma

9. Patient positioning

10. Patient positioning
• The patient’s right shoulder is positioned in the top
righthand corner of the operative table
• Mayfield hoareshoe head rest or rigid 3 point fixation
• The patient’s head is oriented at a right angle to the
walls of the room
• The head is positioned so that the trajectory is
toward the sella(dorsum sellae parallel with the floor)
• The patient’sright hand is carefully positioned so that
it is located unobtrusively under the buttocks

11. Patient preparation
• Face
– aqueous antiseptic solution
• Nare
– topical vasoconstrictors and inject local anesthetic solution
– oxymetolazine (Afrin) into the nose before induction and
then pack both nostrils with cotton pledgets soaked in 5%
cocaine inserted with bayonets through a nasal speculum,
and leave these in for 10–15!minutes
• Umbilical region
– small fat graft
• Antibiotic
• Cortisol support

12. Image guidance
• Image guidance

13. Surgical Approaches
• 1.The nasal phase, from initial sublabial or
endonasal incision to entry into the sphenoid sinus.
• 2. The sphenoid phase, from entry into the
sphenoid sinus to the sellar dura.
• 3. The sellar phase, from opening of the sellar dura
to lesion resection to establishment of hemostasis
and preparation for closure.
• 4. Reconstruction and closure phase.

14. Nasal phase
• Transnasal Submucosal Transseptal Approach
• Sublabial Submucosal Transseptal Approach
• Septal Displacement (“Septal Pushover”)

17. Transnasal Submucosal Transseptal Approach

18. Transnasal Submucosal Transseptal Approach
• Right-sided hemitransfixion incision in the right
nostril with the columella retracted to the patient’s left
• Dissection of the right anterior nasal mucosal tunnel
away from the septum
• One side of the septum is exposed submucosally
with a combination of sharp and blunt dissection,
thereby creating the anterior tunnel
• The dissection continues posteriorly, elevating the
nasal mucosa away from the cartilaginous septum
back to the junction with the bony septum
•

19. Transnasal Submucosal Transseptal Approach
• A vertical incision is then made at this junction, and
bilateral posterior submucosal tunnels are created on
either side oft he perpendicular plate of the ethmoid
• The articulation of the cartilaginous septum with the
maxilla is then dissected free
• The inferior mucosal tunnel on the opposite side is
raised so that the cartilaginous septum can be
displaced laterally without creating inferior mucosal
tears
• A self-retaining nasal speculum can then be
introduced to straddle the perpendicular plate of the
ethmoid, exposing the face of the sphenoid sinus

20. Transnasal Submucosal Transseptal Approach
• Advantage
– broad septal mobilization
– wide surgical corridor
– strict fidelity to the midline
• Disadvantage
– Sinonasal complications
– postoperative discomfort
– rhinological complaints including alveolar numbness,
– anosmia, saddle nose deformity, and nasal septal
perforations

21. Sublabial Submucosal Transseptal Approach

22. • Transverse submucosal gingival sublabial incision
from canine to canine
• Dissection from the maxillary ridge and the anterior
nasal spine until the inferior aspect of the piriform
aperture is exposed
• Working from the lateral border medially, the two
inferior nasal tunnels are created by dissecting the
mucosa away from the superior surface of the hard
palate
• The caudal end of the nasal septum is carefully
dissected and a right anterior tunnel is created along
the right side of the nasal septum
Sublabial Submucosal Transseptal Approach

23. Sublabial Submucosal Transseptal Approach
• With sharp dissection,the right anterior endonasal
submucosal tunnel and the right inferior tunnels are
connected
• the entire right side of the nasal septum is exposed
back to the perpendicular plate of the ethmoid
• Using firm, blunt dissection along the right side of the
base of the nasal septum
• the cartilaginous portion of the septum is
dislocated at its junction with the perpendicular plate
of the ethmoid and vomer and is reflected to the
left,and a left posterior mucosal tunnel is developed
along
• the left side of the bony septum. At this point it
should be possible to insert the transsphenoidal
retractor

24. • Advantage
– broad septal mobilization
– wide surgical corridor
• Disadvantage
– complex surgical anatomy
– potential complications of numbness
Sublabial Submucosal Transseptal Approach

25. a.Endonasal approach
b.Submucosal endonasal approach
c.Septal displacement approach

26. Septal Displacement (“Septal Pushover”)
transnasal septal displacement

27. Septal Displacement (“Septal Pushover”)

28. Sphenoid phase
• C-arm fluoroscopy confirm
• Forcep or punch to the vomer
• The mucosa in the sinus is resected with a cup
forceps to reduce bleeding and the risk of
postoperative mucocele
• Confirm position and trajectory
• Removing the sphenoid septations
• visualizing the carotid canals, the clivus, the
opticocarotid recesses when possible, and the
planum sphenoidale

29. Sphenoid phase
• Confirm trajectory and midline
• Chiesel or blunt nerve hook for sellar floor opening
• Widening with 1-2 mm Kerison punch
• Superior exposure to tuberculum sellae

30. Sellar phase

31. Sellar phase
• Ananatomical hazard
– cavernous sinuses and carotids laterally
– the intercavernous sinuses at the tuberculum superiorly and
the floor of the sella inferiorly
– The venous sinuses which may run between the two leaves
of sellar dura
• coagulating and opening the dura
– rectangular excision : large tumors (macroadenomas)
– cruciate or “x” type : small tumour
• Dura for pathology
• Subdural plane using blunt hook or small curette

32. Sellar phase
• The surgeon should remove the inferior and lateral
aspects of the tumor first, allowing suprasellar
extension to drop into the operative field

33. Reconstruction and closure phase.
• If CSF leak  fat graft from subumbilical incision
• 10% chloramphenicol solution, patted on a cotton
ball in order to incorporate a few wisps of cotton fiber
(which provoke a fibrotic reaction), and the fat is then
rolled in Avitene (Davol, Cranston, RI) hemostatic
collagen powder
• packed into the sellar cavity

34. Reconstruction and closure phase.
• The sellar floor is then reconstructed : bone from the
initial operative phase or artificial constructs such as
a MedPor (Porex, Neman, GA) tailored plate
• Blood and surgical debris are carefully suctioned
• from the sphenoid cavity and the nasopharynx prior
to closure
• no packing is necessary, the turbinates are then
medialized

35. Complication

36. Complication
• Hypothalamic injury
– Death, coma, DI, memory loss and disturbances of
vegetative functions (e.g., morbid obesity, uncontrollable
hunger or thirst, disturbances in temperature regulation)
• Visual damage
• Vascular complication
– The intracavernous portion of the carotid tends to be most
vulnerable, followed by other components of the circle of
Willis
– development of spasm or intraluminal thrombosis.
Intracranial hemorrhage, thrombotic stroke, embolic stroke,
and the development of false aneurysms or carotid-
cavernous fistulas

37. Complication
• Cerebrospinal fluid rhinorrhea
• Cavernous sinus injury
– The carotid artery and cranial nerve VI are most vulnerable
to such maneuvers; cranial nerves III and IV are damaged
less frequently
• Iatrogenic hypopituitarism
• Brainstem injury
• Nasal complication
– febrile sinusitis,Mucocele
– Inadequate hemostasis in the nasal portion of the procedure
may lead to superficial wound hemorrhage and swelling
– Loss of the sense of smell
• Complication associated with reoperation

38. Thank you