Lasers in Surgery and Medicine 47:239–242 (2015)
Diode Laser Assisted Minimal Invasive Sphenoidotomy for Endoscopic Transphenoidal Pituitary Surgery: Our Technique and Results Jih-Chin Lee, MD,1,2 Wen-Sen Lai, MD,1,3 Da-Tong Ju, MD,4 Yueng-Hsiang Chu, MD, PhD,1 and Jinn-Moon Yang, PhD2 1 Departmentof Otolaryngology—Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan 2 Department of Biological Science and Technology, Institute of Bioinformatics and Systems Biology, National Chiao Tung University, Hsinchu, Taiwan 3 Department of Otolaryngology—Head and Neck Surgery, Taichung Armed Forces General Hospital, Taichung, Taiwan 4 Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Background and Objective: During endoscopic sinus surgery (ESS), intra-operative bleeding can significantly compromise visualization of the surgical field. The diode laser that provides good hemostatic and vaporization effects and excellent photocoagulation has been successfully applied in endoscopic surgery with several advantages. The current retrospective study demonstrates the feasibility of diode laser-combined endoscopic sinus surgery on sphenoidotomy. Study Design/Materials and Methods: The patients who went through endoscopic transphenoidal pituitary surgery were enrolled. During the operation, the quality of the surgical field was assessed and graded by the operating surgeon using the scale proposed by Boezaart. Results: The mean operation time was 37.80 10.90 minutes. The mean score on the quality of surgical field was 1.95. A positive correlation between the lower surgical field quality score and the shorter surgical time was found with statistical significance (P < 0.0001). No infections, hemorrhages, or other complications occurred intra- or post-operatively. Conclusion: The diode laser-assisted sphenoidotomy is a reliable and safe approach of pituitary gland surgery with minimal invasiveness. It is found that application of diode laser significantly improved quality of surgical field and shortened operation time. Lasers Surg. Med. 47:239–242, 2015. ß 2015 Wiley Periodicals, Inc. Key words: diode laser; sphenoidotomy; endoscopic transsphenoidal approach; surgical field
INTRODUCTION The laser (light amplification by stimulated emission of radiation) is a device capable of emitting an intense, coherent, directional beam, and has been introduced to ENT surgery for more than 30 years [1]. With technological advances during the last decade, laser surgery has been applied in clinical ENT practice with much success. ß 2015 Wiley Periodicals, Inc.
Different types of laser systems have been applied in surgery, such as carbon dioxide (CO2), diode, neodymiumyttrium aluminium garnet (Nd:YAG), frequency doubled Nd:YAG (KTP), and holmium-yttrium aluminium garnet (Ho:YAG) laser. They have differences in emitted wavelength, output power, pulsed versus continuous wave (cw) mode, contact versus non-contact modality, and consequentially lead to various properties for coagulation, cutting and evaporating of tissue. Among them, the diode laser provides advantages such as good hemostatic and vaporization effects and excellent photocoagulation, and has been successfully applied in endonasal surgery [2]. Endoscopic transsphenoidal approach, first described by Griffith in 1987 as a refinement of Hirsch’s original approach [3], is a milestone of modern and contemporary neurosurgery to treat the lesion around the pituitary and sellar areas [4]. It has been evolving by incorporating many advanced technologies, such as endoscope. Endoscope provides a better view of the surgical field with easier identification of surgical landmarks in addition to minimal intra-operative trauma, and has been applied to pituitary gland surgery, vidian neurectomy, and other skull base surgeries [5]. This study demonstrates the clinical advantage to apply diode laser to endoscopic transsphenoidal approach. To our
Conflicts of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Contract grant sponsor: Research Fund of Tri-Service General Hospital; Contract grant numbers: TSGH- C103-042, TSGHC104-015 & 041. Correspondence to: Jih-Chin Lee, MD, Department of Otolaryngology—Head and Neck Surgery, Tri-Service General Hospital, 325, Cheng-Kung Road, Sec. 2, Neihu District, Taipei 114, Taiwan. E-mail: [email protected] Accepted 30 December 2014 Published online 13 March 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/lsm.22340
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knowledge, it is the first report of the diode laser-assisted sphenoidotomy. MATERIALS AND METHODS All patients who had endoscopic transphenoidal surgery for a pituitary adenoma or other parasellar tumor, including extended and transclival procedures, at TriService General Hospital between May 2008 and August 2014 were eligible. The patients who had previous sinonasal surgery, facial trauma, or lacked surgical video image record, were excluded from this study. The medical records were reviewed for demographics, medical history, preoperative and postoperative radiographic data, pre-, intra-, and post-operative endoscopic findings, perioperative complications, and postoperative course. Bilateral endoscopic sphenoidotomy for all patients was performed by the same surgeon. This study was reviewed and approved by the Institutional Review Board of the TriService General Hospital—National Defense Medical Center. Stereotactic computed tomography (CT) image guidance was employed in all cases. General anesthesia was administered, and 4% cocaine with 1:1,000 epinephrine was used for topical nasal preparation. The middle turbinate and posterior septum were then infiltrated with 1% lidocaine with 1:100,000 epinephrine. For documentation and visualization purposes, a rigid endoscope (08/4 and 308/4 mm, Karl Storz, Tuttlingen, Germany) was mounted to a photo- and video-documentation device (Image 1/AIDA System, Karl Storz). The laser beam was on the non-contact continuous mode through a flexible silica fiber (600 mm core diameter), which was fixed onto a simple homemade device composed of an 8 French Frazier suction tube and an intravenous catheter for precise endonasal guidance and aspiration (Fig. 1). In this study, a 940 nm diode laser system (Medilas D MultiBeam, Dornier MedTech Europe, Wessling, Germany) was set at 5 W for operation. Under endoscopic guidance, lateralization of the inferior and middle turbinate with a Freer elevator (Aesculp, Tuttlingen, Germany) increased the space of insertion and manipulation for the instruments. If a concha bullosa or deviated nasal septum caused narrowing of the superior meatus and sphenoethmoidal recess, endoscopic septoplasty or partial resection of the middle turbinate was performed first. The sphenoid rostrum was approached between the middle and superior
Fig. 1. A simple homemade device that can be used as a handpiece of the diode laser fiber and aspirator.
turbinate laterally and the septum medially. The natural ostium of the sphenoid sinus was identified at the rostum, and was confirmed with an ostium seeker or guidance system probe. It was typically located approximately 1 cm superior to the roof of the posterior choana. The natural ostium was enlarged by laser vaporization from the inferiormedial direction to larger than 1.5 cm in diameter (Figs. 2 and 3). For almost all patients, the posterior edge of the nasal septum was also vaporized with the diode laser to gain more space for sphenoidotomy. Following the procedure, the superior meatus was packed for 48 hours, and all patients were discharged after removal of nasal packing. During the endoscopic sphenoidotomy, quality of the surgical field was assessed every 15 minutes by the operating surgeon using a five-point scale proposed by Boezaart to score surgical field bleeding (from no bleeding: 1 to severe bleeding—constant suctioning required: 5) [6]. Statistical analysis was performed using one-way ANOVA test on non-continuous data. A probability value less than 0.05 (P < 0.05) was considered to be statistically significant. RESULTS The study population consisted of 28 (68.3%) male and 13 (31.7%) female patients with the mean age of 50.05 16.83 years (range, 13–81 years). The mean operation time was 37.80 10.90 minutes. The mean score on the Boezaart scale was 1.95. A positive correlation between the lower score of surgical field quality and the shorter surgical time was found with statistical significance (P < 0.0001). The intra-operative and post-operative conditions during admission and at the 6-month follow-up visits were recorded. No infections, hemorrhages, or other complications were identified intra- or post-operatively. DISCUSSION Maintaining a clean surgical field is one of the important factors for the success of endoscopic sinus surgery (ESS). Excessive bleeding may severely compromise the alreadyrestricted endoscopic view, prolong operation time, and lead to increased incidence of both major and minor complications. To minimize perioperative bleeding has become a significant concern in ESS. Endoscopic sphenoidotomy is a common procedure in sinus surgery and transsphenoidal surgery for wide visualization of the sphenoid sinus, the sella, the suprasellar, and parasellar areas. Safe conduction of the sphenoidotomy requires a thorough knowledge of the surrounding anatomy, review of preoperative images, and accurate intraoperative orientation. Potential intra- and post-operative complications include hemorrhage, optic nerve injury, and cerebrospinal fluid (CSF) leak, and the best management approach for them is prevention. Therefore, pre- and intra-operative vigilance is vital to a successful outcome [7]. Application of laser in endoscopic sphenoidotomy does offer certain advantages in this aspect. A wide variety of surgical procedures in rhinologic laser surgery have been suggested. Metson [8] studied the
DIODE LASER ASSISTED MINIMAL INVASIVE SPHENOIDOTOMY
241
Fig. 2. Videoendoscopic recording of endonasal diode laser-assisited sphenoidotomy. The sphenoid ostium was found medial to the superior turbinate and lateral to the nasal septum, then the diode laser was used to enlarge the natural ostium step by step until the sphenoid sinus (asterisk) can be visualized clearly. SO, sphenoid ostium; S, nasal septum; ST, superior turbinate.
Fig. 3. Endoscopic view following the diode laser-assisited sphenoidotomy. (A) Right side of the sphenoid sinus (asterisk). (B) Left side of the sphenoid sinus (asterisk). S, nasal septum.
clinical efficacy of Ho:YAG laser for endoscopic sinus surgery, and found Ho:YAG laser was effective and equivalent to conventional endoscopic sinus surgery in bone removal. Although both methods allowed relief of symptoms in chronic sinusitis, the Ho:YAG laser was effective in removal of the thicker dense bone as well as the thin eggshell bone around the ethmoid and orbit. Gerlinger et. al [1] has successfully utilized the KTP laser for endoscopic sinus surgery, and suggested that the KTP laser offered excellent hemostasis and lessened postoperative pain and nasal fullness. In laser-assisted sphenoidotomy, the laser needed to penetrate the thin layers of anterior wall of sphenoid bone and vaporize surrounding tissues. It may create a bloodfree environment in the spheno-ethmoidal recess to reduce the occurrence of complications. The diode laser was utilized with the advantage of marked hemostatic effects and interactions with tissues to obtain good excision effects [9,10]. It also provides a depth of penetration sufficient to remove tissue with the underlying important structures surrounding the sinuses preserved and protected. Furthermore, the homemade handpiece incorpo-
rated with the flexible fibers of diode laser and suction tube permits almost full access to the sinus areas to stop mucosal bleeding and remove smoke. This simple and inexpensive device has potential for wider application in clinical practice. However, this study is limited because of its retrospective characteristic. One of the major drawbacks is the lack of a control group who were treated with the conventional coldinstrument surgery. Although the data of operation time and quality of the surgical field seems to be good, a further randomized double-blind study should be conducted for confirmation. Moreover, the data came from one tertiary medical center, and the generalizability of the results may be limited. Finally, as application of diode laser to sphenoidotomy is novel, there is no literature available regarding comparison with other laser techniques. CONCLUSIONS The diode laser is excellent in tissue vaporization and coagulation. The current study showed that the diode laser can be attached to a suction tube as a highly cost-effective suction cutter and improve surgical view and shorten
242
LEE ET AL.
operation time. Our results demonstrate that diode laserassisted sphenoidotomy is a reliable and safe approach with minimally invasive therapeutic modality for pituitary gland surgery. ACKNOWLEDMENTS The authors thank the following programs and institution for having supported this work: Research Fund of Tri-Service General Hospital (TSGH- C103-042, TSGHC104-015 & 041). REFERENCES 1. Gerlinger I, Lujber L, Jarai T, Pytel J. KTP-532 laser-assisted endoscopic nasal sinus surgery. Clin Otolaryngol Allied Sci 2003;28:67–71. 2. Sroka R, Janda P, Killian T, Vaz F, Betz CS, Leunig A. Comparison of long term results after Ho:YAG and diode laser treatment of hyperplastic inferior nasal turbinates. Lasers Surg Med 2007;39:324–331. 3. Griffith HB, Veerapen R. A direct transnasal approach to the sphenoid sinus. Technical note. J Neurosurg 1987;66:140– 142.
4. McLaughlin N, Eisenberg AA, Cohan P, Chaloner CB, Kelly DF. Value of endoscopy for maximizing tumor removal in endonasal transsphenoidal pituitary adenoma surgery. J Neurosurg 2013;118:613–620. 5. Cappabianca P, de Divitiis E. Endoscopy and transsphenoidal surgery. Neurosurgery 2004;54:1043–1048; discussions 1048–1050. 6. Boezaart AP, van der Merwe J, Coetzee A. Comparison of sodium nitroprusside- and esmolol-induced controlled hypotension for functional endoscopic sinus surgery. Can J Anaesth 1995;42:373–376. 7. Moeller CW, Welch KC. Prevention and management of complications in sphenoidotomy. Otolaryngol Clin North Am 2010;43:839–854. 8. Metson R. Holmium:YAG laser endoscopic sinus surgery: A randomized, controlled study. Laryngoscope 1996;106:1–18. 9. Caffier PP, Scherer H, Neumann K, Luck S, Enzmann H, Haisch A. Diode laser treatment in therapy-resistant allergic rhinitis: Impact on nasal obstruction and associated symptoms. Lasers Med Sci 2011;26:57–67. 10. Havel M, Sroka R, Leunig A, Patel P, Betz CS. A double-blind, randomized, intra-individual controlled feasibility trial comparing the use of 1,470 and 940 nm diode laser for the treatment of hyperplastic inferior nasal turbinates. Lasers Surg Med 2011;43:881–886.
Diode Laser Assisted Minimal Invasive Sphenoidotomy for Endoscopic Transphenoidal Pituitary Surgery: Our Technique and Results Jih-Chin Lee, MD,1,2 Wen-Sen Lai, MD,1,3 Da-Tong Ju, MD,4 Yueng-Hsiang Chu, MD, PhD,1 and Jinn-Moon Yang, PhD2 1 Departmentof Otolaryngology—Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan 2 Department of Biological Science and Technology, Institute of Bioinformatics and Systems Biology, National Chiao Tung University, Hsinchu, Taiwan 3 Department of Otolaryngology—Head and Neck Surgery, Taichung Armed Forces General Hospital, Taichung, Taiwan 4 Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Background and Objective: During endoscopic sinus surgery (ESS), intra-operative bleeding can significantly compromise visualization of the surgical field. The diode laser that provides good hemostatic and vaporization effects and excellent photocoagulation has been successfully applied in endoscopic surgery with several advantages. The current retrospective study demonstrates the feasibility of diode laser-combined endoscopic sinus surgery on sphenoidotomy. Study Design/Materials and Methods: The patients who went through endoscopic transphenoidal pituitary surgery were enrolled. During the operation, the quality of the surgical field was assessed and graded by the operating surgeon using the scale proposed by Boezaart. Results: The mean operation time was 37.80 10.90 minutes. The mean score on the quality of surgical field was 1.95. A positive correlation between the lower surgical field quality score and the shorter surgical time was found with statistical significance (P < 0.0001). No infections, hemorrhages, or other complications occurred intra- or post-operatively. Conclusion: The diode laser-assisted sphenoidotomy is a reliable and safe approach of pituitary gland surgery with minimal invasiveness. It is found that application of diode laser significantly improved quality of surgical field and shortened operation time. Lasers Surg. Med. 47:239–242, 2015. ß 2015 Wiley Periodicals, Inc. Key words: diode laser; sphenoidotomy; endoscopic transsphenoidal approach; surgical field
INTRODUCTION The laser (light amplification by stimulated emission of radiation) is a device capable of emitting an intense, coherent, directional beam, and has been introduced to ENT surgery for more than 30 years [1]. With technological advances during the last decade, laser surgery has been applied in clinical ENT practice with much success. ß 2015 Wiley Periodicals, Inc.
Different types of laser systems have been applied in surgery, such as carbon dioxide (CO2), diode, neodymiumyttrium aluminium garnet (Nd:YAG), frequency doubled Nd:YAG (KTP), and holmium-yttrium aluminium garnet (Ho:YAG) laser. They have differences in emitted wavelength, output power, pulsed versus continuous wave (cw) mode, contact versus non-contact modality, and consequentially lead to various properties for coagulation, cutting and evaporating of tissue. Among them, the diode laser provides advantages such as good hemostatic and vaporization effects and excellent photocoagulation, and has been successfully applied in endonasal surgery [2]. Endoscopic transsphenoidal approach, first described by Griffith in 1987 as a refinement of Hirsch’s original approach [3], is a milestone of modern and contemporary neurosurgery to treat the lesion around the pituitary and sellar areas [4]. It has been evolving by incorporating many advanced technologies, such as endoscope. Endoscope provides a better view of the surgical field with easier identification of surgical landmarks in addition to minimal intra-operative trauma, and has been applied to pituitary gland surgery, vidian neurectomy, and other skull base surgeries [5]. This study demonstrates the clinical advantage to apply diode laser to endoscopic transsphenoidal approach. To our
Conflicts of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Contract grant sponsor: Research Fund of Tri-Service General Hospital; Contract grant numbers: TSGH- C103-042, TSGHC104-015 & 041. Correspondence to: Jih-Chin Lee, MD, Department of Otolaryngology—Head and Neck Surgery, Tri-Service General Hospital, 325, Cheng-Kung Road, Sec. 2, Neihu District, Taipei 114, Taiwan. E-mail: [email protected] Accepted 30 December 2014 Published online 13 March 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/lsm.22340
240
LEE ET AL.
knowledge, it is the first report of the diode laser-assisted sphenoidotomy. MATERIALS AND METHODS All patients who had endoscopic transphenoidal surgery for a pituitary adenoma or other parasellar tumor, including extended and transclival procedures, at TriService General Hospital between May 2008 and August 2014 were eligible. The patients who had previous sinonasal surgery, facial trauma, or lacked surgical video image record, were excluded from this study. The medical records were reviewed for demographics, medical history, preoperative and postoperative radiographic data, pre-, intra-, and post-operative endoscopic findings, perioperative complications, and postoperative course. Bilateral endoscopic sphenoidotomy for all patients was performed by the same surgeon. This study was reviewed and approved by the Institutional Review Board of the TriService General Hospital—National Defense Medical Center. Stereotactic computed tomography (CT) image guidance was employed in all cases. General anesthesia was administered, and 4% cocaine with 1:1,000 epinephrine was used for topical nasal preparation. The middle turbinate and posterior septum were then infiltrated with 1% lidocaine with 1:100,000 epinephrine. For documentation and visualization purposes, a rigid endoscope (08/4 and 308/4 mm, Karl Storz, Tuttlingen, Germany) was mounted to a photo- and video-documentation device (Image 1/AIDA System, Karl Storz). The laser beam was on the non-contact continuous mode through a flexible silica fiber (600 mm core diameter), which was fixed onto a simple homemade device composed of an 8 French Frazier suction tube and an intravenous catheter for precise endonasal guidance and aspiration (Fig. 1). In this study, a 940 nm diode laser system (Medilas D MultiBeam, Dornier MedTech Europe, Wessling, Germany) was set at 5 W for operation. Under endoscopic guidance, lateralization of the inferior and middle turbinate with a Freer elevator (Aesculp, Tuttlingen, Germany) increased the space of insertion and manipulation for the instruments. If a concha bullosa or deviated nasal septum caused narrowing of the superior meatus and sphenoethmoidal recess, endoscopic septoplasty or partial resection of the middle turbinate was performed first. The sphenoid rostrum was approached between the middle and superior
Fig. 1. A simple homemade device that can be used as a handpiece of the diode laser fiber and aspirator.
turbinate laterally and the septum medially. The natural ostium of the sphenoid sinus was identified at the rostum, and was confirmed with an ostium seeker or guidance system probe. It was typically located approximately 1 cm superior to the roof of the posterior choana. The natural ostium was enlarged by laser vaporization from the inferiormedial direction to larger than 1.5 cm in diameter (Figs. 2 and 3). For almost all patients, the posterior edge of the nasal septum was also vaporized with the diode laser to gain more space for sphenoidotomy. Following the procedure, the superior meatus was packed for 48 hours, and all patients were discharged after removal of nasal packing. During the endoscopic sphenoidotomy, quality of the surgical field was assessed every 15 minutes by the operating surgeon using a five-point scale proposed by Boezaart to score surgical field bleeding (from no bleeding: 1 to severe bleeding—constant suctioning required: 5) [6]. Statistical analysis was performed using one-way ANOVA test on non-continuous data. A probability value less than 0.05 (P < 0.05) was considered to be statistically significant. RESULTS The study population consisted of 28 (68.3%) male and 13 (31.7%) female patients with the mean age of 50.05 16.83 years (range, 13–81 years). The mean operation time was 37.80 10.90 minutes. The mean score on the Boezaart scale was 1.95. A positive correlation between the lower score of surgical field quality and the shorter surgical time was found with statistical significance (P < 0.0001). The intra-operative and post-operative conditions during admission and at the 6-month follow-up visits were recorded. No infections, hemorrhages, or other complications were identified intra- or post-operatively. DISCUSSION Maintaining a clean surgical field is one of the important factors for the success of endoscopic sinus surgery (ESS). Excessive bleeding may severely compromise the alreadyrestricted endoscopic view, prolong operation time, and lead to increased incidence of both major and minor complications. To minimize perioperative bleeding has become a significant concern in ESS. Endoscopic sphenoidotomy is a common procedure in sinus surgery and transsphenoidal surgery for wide visualization of the sphenoid sinus, the sella, the suprasellar, and parasellar areas. Safe conduction of the sphenoidotomy requires a thorough knowledge of the surrounding anatomy, review of preoperative images, and accurate intraoperative orientation. Potential intra- and post-operative complications include hemorrhage, optic nerve injury, and cerebrospinal fluid (CSF) leak, and the best management approach for them is prevention. Therefore, pre- and intra-operative vigilance is vital to a successful outcome [7]. Application of laser in endoscopic sphenoidotomy does offer certain advantages in this aspect. A wide variety of surgical procedures in rhinologic laser surgery have been suggested. Metson [8] studied the
DIODE LASER ASSISTED MINIMAL INVASIVE SPHENOIDOTOMY
241
Fig. 2. Videoendoscopic recording of endonasal diode laser-assisited sphenoidotomy. The sphenoid ostium was found medial to the superior turbinate and lateral to the nasal septum, then the diode laser was used to enlarge the natural ostium step by step until the sphenoid sinus (asterisk) can be visualized clearly. SO, sphenoid ostium; S, nasal septum; ST, superior turbinate.
Fig. 3. Endoscopic view following the diode laser-assisited sphenoidotomy. (A) Right side of the sphenoid sinus (asterisk). (B) Left side of the sphenoid sinus (asterisk). S, nasal septum.
clinical efficacy of Ho:YAG laser for endoscopic sinus surgery, and found Ho:YAG laser was effective and equivalent to conventional endoscopic sinus surgery in bone removal. Although both methods allowed relief of symptoms in chronic sinusitis, the Ho:YAG laser was effective in removal of the thicker dense bone as well as the thin eggshell bone around the ethmoid and orbit. Gerlinger et. al [1] has successfully utilized the KTP laser for endoscopic sinus surgery, and suggested that the KTP laser offered excellent hemostasis and lessened postoperative pain and nasal fullness. In laser-assisted sphenoidotomy, the laser needed to penetrate the thin layers of anterior wall of sphenoid bone and vaporize surrounding tissues. It may create a bloodfree environment in the spheno-ethmoidal recess to reduce the occurrence of complications. The diode laser was utilized with the advantage of marked hemostatic effects and interactions with tissues to obtain good excision effects [9,10]. It also provides a depth of penetration sufficient to remove tissue with the underlying important structures surrounding the sinuses preserved and protected. Furthermore, the homemade handpiece incorpo-
rated with the flexible fibers of diode laser and suction tube permits almost full access to the sinus areas to stop mucosal bleeding and remove smoke. This simple and inexpensive device has potential for wider application in clinical practice. However, this study is limited because of its retrospective characteristic. One of the major drawbacks is the lack of a control group who were treated with the conventional coldinstrument surgery. Although the data of operation time and quality of the surgical field seems to be good, a further randomized double-blind study should be conducted for confirmation. Moreover, the data came from one tertiary medical center, and the generalizability of the results may be limited. Finally, as application of diode laser to sphenoidotomy is novel, there is no literature available regarding comparison with other laser techniques. CONCLUSIONS The diode laser is excellent in tissue vaporization and coagulation. The current study showed that the diode laser can be attached to a suction tube as a highly cost-effective suction cutter and improve surgical view and shorten
242
LEE ET AL.
operation time. Our results demonstrate that diode laserassisted sphenoidotomy is a reliable and safe approach with minimally invasive therapeutic modality for pituitary gland surgery. ACKNOWLEDMENTS The authors thank the following programs and institution for having supported this work: Research Fund of Tri-Service General Hospital (TSGH- C103-042, TSGHC104-015 & 041). REFERENCES 1. Gerlinger I, Lujber L, Jarai T, Pytel J. KTP-532 laser-assisted endoscopic nasal sinus surgery. Clin Otolaryngol Allied Sci 2003;28:67–71. 2. Sroka R, Janda P, Killian T, Vaz F, Betz CS, Leunig A. Comparison of long term results after Ho:YAG and diode laser treatment of hyperplastic inferior nasal turbinates. Lasers Surg Med 2007;39:324–331. 3. Griffith HB, Veerapen R. A direct transnasal approach to the sphenoid sinus. Technical note. J Neurosurg 1987;66:140– 142.
4. McLaughlin N, Eisenberg AA, Cohan P, Chaloner CB, Kelly DF. Value of endoscopy for maximizing tumor removal in endonasal transsphenoidal pituitary adenoma surgery. J Neurosurg 2013;118:613–620. 5. Cappabianca P, de Divitiis E. Endoscopy and transsphenoidal surgery. Neurosurgery 2004;54:1043–1048; discussions 1048–1050. 6. Boezaart AP, van der Merwe J, Coetzee A. Comparison of sodium nitroprusside- and esmolol-induced controlled hypotension for functional endoscopic sinus surgery. Can J Anaesth 1995;42:373–376. 7. Moeller CW, Welch KC. Prevention and management of complications in sphenoidotomy. Otolaryngol Clin North Am 2010;43:839–854. 8. Metson R. Holmium:YAG laser endoscopic sinus surgery: A randomized, controlled study. Laryngoscope 1996;106:1–18. 9. Caffier PP, Scherer H, Neumann K, Luck S, Enzmann H, Haisch A. Diode laser treatment in therapy-resistant allergic rhinitis: Impact on nasal obstruction and associated symptoms. Lasers Med Sci 2011;26:57–67. 10. Havel M, Sroka R, Leunig A, Patel P, Betz CS. A double-blind, randomized, intra-individual controlled feasibility trial comparing the use of 1,470 and 940 nm diode laser for the treatment of hyperplastic inferior nasal turbinates. Lasers Surg Med 2011;43:881–886.
