J Neurosurg 49:138-142, 1978
Unilateral septal technique for transsphenoidal microsurgical approach to the sella turcica Technical note
GEORGE T. TINDALL,M.D., WILLIAM F. COLLINS,JR., M.D.,
AND JOHN A. KIRCHNER, M . D .
Department of Surgery, Division of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, and Department of Surgery, Section of Neurosurgery and Otolaryngology, Yale University School of Medicine, New Haven, Connecticut J" A modification of the transseptal, transsphenoidal approach to the sella turcica is described; it consists of a unilateral separation of the nasal mucosa from the nasal septum. Experience with the technique in 215 cases has indicated that it is a useful, practical approach. The advantages are that the septum is spared, reoperation is made easier, and the procedure is quicker than the bilateral septal procedure. Asymptomatic nasal septal perforations (less than 3 mm) were seen in eight of 215 cases, and represented the only complication related to the operation. KEY WORDS 9 transsphenoidal surgery pituitary surgery
C
URRENTLY, the transsphenoidal microsurgical operation is a satisfactory method for treating most pituitary tumors and for performing hypophysectomy. The advantages of this operative approach include a low incidence of complications, a low mortality rate, and excellent visualization with magnification of the intrasellar structures. While various extracranial surgical approaches to the sella, such as transethmoidsphenoidal and transantral-sphenoidal, have been described, the transnasal, midline septal, transsphenoidal approach used by Halstead s,4 and Cushing 1,2 and modified by Hardy 5 is probably the one most widely employed. While this approach provides excellent ex138
9 seila turcica
9
posure of the sphenoid sinus and floor of the sella, it involves bilateral separation of the mucosa from the nasal septum and removal of the lower portion of the nasal septum. Over the past 3 years, we have used a modification of the technique that involves separation of the mucosa from only one side of the septum. In this report, our modified technique is described and the results of its use in 215 patients are discussed. Operative Technique
The operation is performed with the patient under general anesthesia. The endotracheal tube is brought out the left side of the mouth. J. Neurosurg. / Volume 49 / July, 1978
U n i l a t e r a l t r a n s s p h e n o i d a l sellar a p p r o a c h
FIG. 1. Left." The inferior bony edge of the nares (arrow) is removed on the patient's left side. The anterior portion of the nasal septum is exposed and the mucosa separated from the left side. Sharp dissection aids in starting the initial separation from the septum. Right: Continued separation from the septurn is performed with a Freer dissector.
The head of the table is elevated approximately 15 ~ from the horizontal plane and the patient's head is placed in three-point skeletal fixation using a Mayfield skull clamp and table attachment. The position of the head is arranged so that the surgeon standing on the right side of the patient can work comfortably without the necessity of leaning over the patient's upper trunk. To accomplish this position, the patient's head is extended slightly and tilted over to his left; the skull clamp attachment is then locked. Betadine solution is applied around the nose and mouth and the area draped with sterile linen. The left lower quadrant of the abdomen is prepared with Betadine soap and solution and draped as a separate field in order to obtain an adipose tissue graft for later insertion into the sella turcica and sphenoid sinus. A separate set of sterile instruments is used to obtain this tissue. After the fat is obtained, the abdominal wound is closed in the routine manner. The transsphenoidal operation begins by elevating the upper lip with a small, handheld, multitooth retractor. A small transverse incision is made in the upper gingival mucosa with either a scalpel or cutting cautery. It is important to leave a small cuff of mucosa on the lower gingival edge to allow for later
J. Neurosurg. / Volume 49 / July, 1978
closure. The incision is carried down to the maxilla and the soft tissue separated from the bone in order to expose the floor of the nares and nasal mucosa. Minor bleeding from the bone is stopped with bone wax. The anterior edge of the cartilaginous nasal septum is identified, a step facilitated by a strong upward pull on the upper lip with a vein retractor. A shallow incision with a No. 11 scalpel blade into the cartilage initiates a subchondral separation of the mucosa from the nasal septurn (Fig. 1). Separation of the mucosa from the septum is continued in a posterior plane on the patient's left side only. (In fact, separation can be performed on either side; one of the authors (J.A.K.) routinely makes the unilateral approach on the right side.) The nasopalatine artery, which is located anteriomedially, may occasionally be the source of troublesome bleeding during this phase of the operation and may require coagulation. Next, the nasal septum is fractured and detached at its base allowing it to be displaced more easily to the opposite side. Removal of a small portion of the inferior bony edge of the nares (Fig. 1) facilitates separation of the inferiormedial portion of the mucosa from the septum and insertion of a larger speculum. The initial separation of the mucosa from the left side of the nasal septum is performed ]39
G. T. Tindall, W. F. Collins and J. A. Kirchner
FIG. 2. Left." Continued separation of the nasal mucosa from the septum, particularly posteriorly, is facilitated by using a long, thin nasal speculum held in the left hand. Center."At the junction of the cartilaginous with the thin bony septum, a fracture line is developed with a dissector and one blade of the speculum is inserted on the opposite side of the septum. Right: The mucosa can then be separated bilaterally down to the vomer, exposing the anterior wall of the sphenoid sinus. by using a No. 9 Frazier sucker* held in the left hand and a sharp Freer dissectort in the right to make the actual separation. The sucker tip serves both to retract the mucosa and to clear the blood out of the wound. As the incision deepens, continued separation is performed by means of a small nasal speculum with long, thin blades:l: (Fig. 2 A) held in the left hand. The tips of the blades are advanced and opened just enough to admit the tip of the sucker tube, which is now held in the right hand and which serves to separate the mucosa from the septum. The mucosa is easier to separate posteriorly than anteriorly. Posteriorly, at the point of juncture of the cartilaginous with the thin bony septum, a fracture line is developed with a No. 4 Hardy dissector.w One blade of the nasal speculum can then be placed over the right side of the *Frazier Suction No. 9 manufactured by Codman and Shurtleff, Inc., Randolph, Massachusetts. tFreer septum elevator sharp/blunt (71/~ in.) manufactured by Holco Instrument Corp., New York, New York. :~Killian nasal septum speculum, 3 in., manufactured by Codman and Shurtleff, Inc., Randolph, Massachusetts. w dissector, 9 cm long, manufactured by Codman and Shurtleff, Inc., Randolph, Massachusetts. 140
septum (Fig. 2 B and C) and the mucosa then separated bilaterally down to the anterior wall of the sphenoid sinus. At this point, the small nasal speculum is withdrawn and a Cushing-Landolt I[ speculum inserted slowly until its tip reaches the anterior wall of the sphenoid sinus. The speculum is then opened and the anterior wall of the sphenoid sinus removed. Displacement of the nasal septum to the right side accounts for the fact that even though the speculum is inserted unilaterally, nevertheless, when opened, it is almost in a midline orientation. After making a moderate-sized opening in the sphenoid sinus, the sella turcica is visualized. The remainder of the opening in the anterior wall of the sinus, which is made directly over the sella turcica, is roughly in the shape of a square. The anterior-posterior opening is made slightly larger than the width of the speculum blades, and the lateral extensions of the sphenoid opening are carried just far enough to visualize the most lateral portion of the sella. The reason for carefully opening the sphenoid sinus in this manner is that once the opening is made, the speculum tip is advanced into the sinus, a maneuver that not only brings the operator slightly closer to the sella, [ICushing-Landholt speculum manufactured by Holco In trument Corp., New York, New York. J. Neurosurg. / Volume 49 / July, 1978
Unilateral transsphenoidal sellar approach
Fie. 3. Left: A sheet of Gelfoam is placed between nasal septum and mucosa after withdrawal of the speculum. Right: The mucosal incision is closed by means of absorbable catgut sutures.
but, more importantly, brings the barrel of the speculum directly in line with the center of the sella turcica. It is important that the operator not use a speculum spreader once the tips of the speculum are inserted into the sphenoid sinus. Potentially, this force could result in a basal skull fracture with possible cranial nerve damage. Opening of the sellar floor and dura are performed as described by Hardy .5 The operative closure is relatively simple. Adipose tissue is placed in the sella if a large space is left to be filled, for instance, following removal of a large tumor or hypophysectomy. We differ somewhat in our methods of reconstructing the sellar floor. One of us (G.T.T.) wedges a thin plate of bone obtained during removal of the anterior wall of the sphenoid sinus into the open floor, a step probably important only when there is cerebrospinal fluid (CSF) in the operative wound, as in hypophysectomy. Two of us (W.F.C. and J.A.K.) make no attempt to place either bone or cartilage into the floor of the sella and simply leave an appropriate sized piece of adipose tissue within the sella. Some surgeons apply Surgicel gauze over the reconstructed sellar floor and bond this in place with cyanoacrylate. This appears to be an effective technique. The sphenoid sinus is filled with adipose tissue and the speculum withdrawn. One strip of Gelfoam gauze J. Neurosurg. / Volume 49 / July, 1978
(2 • 6 cm) is laid alongside the septum and mucosa (Fig. 3 A) and one or two absorbable catgut sutures are placed in the gingival mucosa (Fig. 3 B). Either soft rubber airway tubes* or Bacitracin-impregnated gauze packs are inserted into each nostril in order to reattach the nasal mucosa. The tubes or packs are left in place for at least 24 hours. Comment
We have used the technique described in this report in a total of 215 cases over a 3-year period (1974 to 1977). The transsphenoidal operative procedure was performed for hypophysectomy in 90 cases and for pituitary tumor in 125 cases. Our experience has indicated that the unilateral septal approach can be performed as easily as and usually in a shorter time period than the bilateral septal procedure described by Hardy, 5 without creating additional technical problems. Reoperation for CSF rhinorrhea was performed in seven of the 215 cases, at 2, 6, 8, 10, 14, 35, and 39 days postoperatively. Two additional cases required reoperation early in their postoperative course in order to locate and cauterize bleeders from the nasal *Nasopharyngeal airway, Robertazzi style tubes manufactured by Davol, Inc., Providence Rhode Island. 14
G. T. Tindall0 W. F. Collins and J. A. Kirchner mucosa. In each reoperated case, the separation of the septum from the nasal mucosa was made without difficulty and without tearing the mucosa. This is in marked contrast to cases in which the patients have had the lower portion of the nasal septum removed in the bilateral procedure and who upon reexploration after 10 to 14 days are found to have the nasal mucosa of each side so adhered that separation usually results in extensive tears in the mucosa. Nasal septum perforations have been noted in eight of the 215 cases upon postoperative follow-up examination. These have been small (less than 3 mm), and were asymptomatic in each case.
2. Cushing H: Surgical experiences with pituitary disorders. JAMA 63:1515-1525, 1914 3. Halstead AE: Remarks on the operative treatment of tumors of the hypophysis. Surg Gynecol Obstet 10:494-502, 1910 4. Halstead AE: Remarks on the operative treatment of tumors of the hypophysis with the report of two cases operated on by an oronasal method. Trans Am Surg Assoc 28:73-93, 1910 5. Hardy J: Transsphenoidal hypophysectomy. J Neurosurg 34:582-594, 1971
References 1. Cushing H: The Pituitary Body and its Address reprint requests to: George T. Tindall, Disorders, Clinical States Produced by Disorders of the Hypophysis Cerebri. M.D., Division of Neurosurgery, Emory UniverPhiladelphia/London: JB Lippincott, 1912, pp sity Clinic, 1365 Clifton Road, N.E., Atlanta, Georgia 30322. 297-305
142
J. Neurosurg. / Volume 49 / July, 1978
Unilateral septal technique for transsphenoidal microsurgical approach to the sella turcica Technical note
GEORGE T. TINDALL,M.D., WILLIAM F. COLLINS,JR., M.D.,
AND JOHN A. KIRCHNER, M . D .
Department of Surgery, Division of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, and Department of Surgery, Section of Neurosurgery and Otolaryngology, Yale University School of Medicine, New Haven, Connecticut J" A modification of the transseptal, transsphenoidal approach to the sella turcica is described; it consists of a unilateral separation of the nasal mucosa from the nasal septum. Experience with the technique in 215 cases has indicated that it is a useful, practical approach. The advantages are that the septum is spared, reoperation is made easier, and the procedure is quicker than the bilateral septal procedure. Asymptomatic nasal septal perforations (less than 3 mm) were seen in eight of 215 cases, and represented the only complication related to the operation. KEY WORDS 9 transsphenoidal surgery pituitary surgery
C
URRENTLY, the transsphenoidal microsurgical operation is a satisfactory method for treating most pituitary tumors and for performing hypophysectomy. The advantages of this operative approach include a low incidence of complications, a low mortality rate, and excellent visualization with magnification of the intrasellar structures. While various extracranial surgical approaches to the sella, such as transethmoidsphenoidal and transantral-sphenoidal, have been described, the transnasal, midline septal, transsphenoidal approach used by Halstead s,4 and Cushing 1,2 and modified by Hardy 5 is probably the one most widely employed. While this approach provides excellent ex138
9 seila turcica
9
posure of the sphenoid sinus and floor of the sella, it involves bilateral separation of the mucosa from the nasal septum and removal of the lower portion of the nasal septum. Over the past 3 years, we have used a modification of the technique that involves separation of the mucosa from only one side of the septum. In this report, our modified technique is described and the results of its use in 215 patients are discussed. Operative Technique
The operation is performed with the patient under general anesthesia. The endotracheal tube is brought out the left side of the mouth. J. Neurosurg. / Volume 49 / July, 1978
U n i l a t e r a l t r a n s s p h e n o i d a l sellar a p p r o a c h
FIG. 1. Left." The inferior bony edge of the nares (arrow) is removed on the patient's left side. The anterior portion of the nasal septum is exposed and the mucosa separated from the left side. Sharp dissection aids in starting the initial separation from the septum. Right: Continued separation from the septurn is performed with a Freer dissector.
The head of the table is elevated approximately 15 ~ from the horizontal plane and the patient's head is placed in three-point skeletal fixation using a Mayfield skull clamp and table attachment. The position of the head is arranged so that the surgeon standing on the right side of the patient can work comfortably without the necessity of leaning over the patient's upper trunk. To accomplish this position, the patient's head is extended slightly and tilted over to his left; the skull clamp attachment is then locked. Betadine solution is applied around the nose and mouth and the area draped with sterile linen. The left lower quadrant of the abdomen is prepared with Betadine soap and solution and draped as a separate field in order to obtain an adipose tissue graft for later insertion into the sella turcica and sphenoid sinus. A separate set of sterile instruments is used to obtain this tissue. After the fat is obtained, the abdominal wound is closed in the routine manner. The transsphenoidal operation begins by elevating the upper lip with a small, handheld, multitooth retractor. A small transverse incision is made in the upper gingival mucosa with either a scalpel or cutting cautery. It is important to leave a small cuff of mucosa on the lower gingival edge to allow for later
J. Neurosurg. / Volume 49 / July, 1978
closure. The incision is carried down to the maxilla and the soft tissue separated from the bone in order to expose the floor of the nares and nasal mucosa. Minor bleeding from the bone is stopped with bone wax. The anterior edge of the cartilaginous nasal septum is identified, a step facilitated by a strong upward pull on the upper lip with a vein retractor. A shallow incision with a No. 11 scalpel blade into the cartilage initiates a subchondral separation of the mucosa from the nasal septurn (Fig. 1). Separation of the mucosa from the septum is continued in a posterior plane on the patient's left side only. (In fact, separation can be performed on either side; one of the authors (J.A.K.) routinely makes the unilateral approach on the right side.) The nasopalatine artery, which is located anteriomedially, may occasionally be the source of troublesome bleeding during this phase of the operation and may require coagulation. Next, the nasal septum is fractured and detached at its base allowing it to be displaced more easily to the opposite side. Removal of a small portion of the inferior bony edge of the nares (Fig. 1) facilitates separation of the inferiormedial portion of the mucosa from the septum and insertion of a larger speculum. The initial separation of the mucosa from the left side of the nasal septum is performed ]39
G. T. Tindall, W. F. Collins and J. A. Kirchner
FIG. 2. Left." Continued separation of the nasal mucosa from the septum, particularly posteriorly, is facilitated by using a long, thin nasal speculum held in the left hand. Center."At the junction of the cartilaginous with the thin bony septum, a fracture line is developed with a dissector and one blade of the speculum is inserted on the opposite side of the septum. Right: The mucosa can then be separated bilaterally down to the vomer, exposing the anterior wall of the sphenoid sinus. by using a No. 9 Frazier sucker* held in the left hand and a sharp Freer dissectort in the right to make the actual separation. The sucker tip serves both to retract the mucosa and to clear the blood out of the wound. As the incision deepens, continued separation is performed by means of a small nasal speculum with long, thin blades:l: (Fig. 2 A) held in the left hand. The tips of the blades are advanced and opened just enough to admit the tip of the sucker tube, which is now held in the right hand and which serves to separate the mucosa from the septum. The mucosa is easier to separate posteriorly than anteriorly. Posteriorly, at the point of juncture of the cartilaginous with the thin bony septum, a fracture line is developed with a No. 4 Hardy dissector.w One blade of the nasal speculum can then be placed over the right side of the *Frazier Suction No. 9 manufactured by Codman and Shurtleff, Inc., Randolph, Massachusetts. tFreer septum elevator sharp/blunt (71/~ in.) manufactured by Holco Instrument Corp., New York, New York. :~Killian nasal septum speculum, 3 in., manufactured by Codman and Shurtleff, Inc., Randolph, Massachusetts. w dissector, 9 cm long, manufactured by Codman and Shurtleff, Inc., Randolph, Massachusetts. 140
septum (Fig. 2 B and C) and the mucosa then separated bilaterally down to the anterior wall of the sphenoid sinus. At this point, the small nasal speculum is withdrawn and a Cushing-Landolt I[ speculum inserted slowly until its tip reaches the anterior wall of the sphenoid sinus. The speculum is then opened and the anterior wall of the sphenoid sinus removed. Displacement of the nasal septum to the right side accounts for the fact that even though the speculum is inserted unilaterally, nevertheless, when opened, it is almost in a midline orientation. After making a moderate-sized opening in the sphenoid sinus, the sella turcica is visualized. The remainder of the opening in the anterior wall of the sinus, which is made directly over the sella turcica, is roughly in the shape of a square. The anterior-posterior opening is made slightly larger than the width of the speculum blades, and the lateral extensions of the sphenoid opening are carried just far enough to visualize the most lateral portion of the sella. The reason for carefully opening the sphenoid sinus in this manner is that once the opening is made, the speculum tip is advanced into the sinus, a maneuver that not only brings the operator slightly closer to the sella, [ICushing-Landholt speculum manufactured by Holco In trument Corp., New York, New York. J. Neurosurg. / Volume 49 / July, 1978
Unilateral transsphenoidal sellar approach
Fie. 3. Left: A sheet of Gelfoam is placed between nasal septum and mucosa after withdrawal of the speculum. Right: The mucosal incision is closed by means of absorbable catgut sutures.
but, more importantly, brings the barrel of the speculum directly in line with the center of the sella turcica. It is important that the operator not use a speculum spreader once the tips of the speculum are inserted into the sphenoid sinus. Potentially, this force could result in a basal skull fracture with possible cranial nerve damage. Opening of the sellar floor and dura are performed as described by Hardy .5 The operative closure is relatively simple. Adipose tissue is placed in the sella if a large space is left to be filled, for instance, following removal of a large tumor or hypophysectomy. We differ somewhat in our methods of reconstructing the sellar floor. One of us (G.T.T.) wedges a thin plate of bone obtained during removal of the anterior wall of the sphenoid sinus into the open floor, a step probably important only when there is cerebrospinal fluid (CSF) in the operative wound, as in hypophysectomy. Two of us (W.F.C. and J.A.K.) make no attempt to place either bone or cartilage into the floor of the sella and simply leave an appropriate sized piece of adipose tissue within the sella. Some surgeons apply Surgicel gauze over the reconstructed sellar floor and bond this in place with cyanoacrylate. This appears to be an effective technique. The sphenoid sinus is filled with adipose tissue and the speculum withdrawn. One strip of Gelfoam gauze J. Neurosurg. / Volume 49 / July, 1978
(2 • 6 cm) is laid alongside the septum and mucosa (Fig. 3 A) and one or two absorbable catgut sutures are placed in the gingival mucosa (Fig. 3 B). Either soft rubber airway tubes* or Bacitracin-impregnated gauze packs are inserted into each nostril in order to reattach the nasal mucosa. The tubes or packs are left in place for at least 24 hours. Comment
We have used the technique described in this report in a total of 215 cases over a 3-year period (1974 to 1977). The transsphenoidal operative procedure was performed for hypophysectomy in 90 cases and for pituitary tumor in 125 cases. Our experience has indicated that the unilateral septal approach can be performed as easily as and usually in a shorter time period than the bilateral septal procedure described by Hardy, 5 without creating additional technical problems. Reoperation for CSF rhinorrhea was performed in seven of the 215 cases, at 2, 6, 8, 10, 14, 35, and 39 days postoperatively. Two additional cases required reoperation early in their postoperative course in order to locate and cauterize bleeders from the nasal *Nasopharyngeal airway, Robertazzi style tubes manufactured by Davol, Inc., Providence Rhode Island. 14
G. T. Tindall0 W. F. Collins and J. A. Kirchner mucosa. In each reoperated case, the separation of the septum from the nasal mucosa was made without difficulty and without tearing the mucosa. This is in marked contrast to cases in which the patients have had the lower portion of the nasal septum removed in the bilateral procedure and who upon reexploration after 10 to 14 days are found to have the nasal mucosa of each side so adhered that separation usually results in extensive tears in the mucosa. Nasal septum perforations have been noted in eight of the 215 cases upon postoperative follow-up examination. These have been small (less than 3 mm), and were asymptomatic in each case.
2. Cushing H: Surgical experiences with pituitary disorders. JAMA 63:1515-1525, 1914 3. Halstead AE: Remarks on the operative treatment of tumors of the hypophysis. Surg Gynecol Obstet 10:494-502, 1910 4. Halstead AE: Remarks on the operative treatment of tumors of the hypophysis with the report of two cases operated on by an oronasal method. Trans Am Surg Assoc 28:73-93, 1910 5. Hardy J: Transsphenoidal hypophysectomy. J Neurosurg 34:582-594, 1971
References 1. Cushing H: The Pituitary Body and its Address reprint requests to: George T. Tindall, Disorders, Clinical States Produced by Disorders of the Hypophysis Cerebri. M.D., Division of Neurosurgery, Emory UniverPhiladelphia/London: JB Lippincott, 1912, pp sity Clinic, 1365 Clifton Road, N.E., Atlanta, Georgia 30322. 297-305
142
J. Neurosurg. / Volume 49 / July, 1978
