A novel transnasal transsphenoidal speculum: A design for both microscopic and endoscopic transsphenoidal pituitary surgery: Clinical article
Department of Otolaryngology, Washington University School of Medicine, St. Louis, Missouri, USA. Journal of Neurosurgery
(Impact Factor: 3.74).
02/2011; 114(5):1380-5. DOI: 10.3171/2010.11.JNS101167
Over the last several years minimally invasive surgical approaches to the sella turcica and parasellar regions have undergone significant change. The transsphenoidal approach to this region has evolved from a sublabial transnasal, to transnasal, to pure endonasal approaches with the increasing popularity of endoscopic over microscopic techniques. Endoscopic and microscopic techniques individually or in combination have their own unique advantages, and the preference of one over the other awaits further technological refinements and surgical experience. In parallel with this evolution in techniques for transsphenoidal surgery, the authors designed an adaptable versatile speculum for the endonasal/transnasal transsphenoidal approach to the sella turcica and parasellar regions that can be used equally effectively with a microscope or an endoscope. The development of this instrument and its unique features are described, and its initial clinical use is summarized. This transnasal transsphenoidal speculum has interchangeable blades, unique blade angulations, and independent blade opening mechanisms and allows safe, optimal exposure in all patients regardless of the size and anatomical aberrations of individual nasal and endonasal regions. An attached endoscope carrier further allows it to be used interchangeably with microscopic or endoscopic techniques without having to remove the speculum; likewise, a single surgeon can use both hands without need of an assistant. A forehead headrest component adds further stabilization. This device has been used successfully in 90 transsphenoidal procedures.
Available from: Yad R Yadav
- "Special transnasal trans-sphenoidal speculums with interchangeable blades and unique blade angulations were found to be safe. It allows optimal exposure and can be used interchangeably with microscopic or endoscopic techniques. "
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ABSTRACT: Endoscopic endonasal trans-sphenoid surgery (EETS) is increasingly used for pituitary lesions. Pre-operative CT and MRI scans and peroperative endoscopic visualization can provide useful anatomical information. EETS is indicated in sellar, suprasellar, intraventricular, retro-infundibular, and invasive tumors. Recurrent and residual lesions, pituitary apoplexy and empty sella syndrome can be managed by EETS. Modern neuronavigation techniques, ultrasonic aspirators, ultrasonic bone curette can add to the safety. The binostril approach provides a wider working area. High definition camera is much superior to three-chip camera. Most of the recent reports favor EETS in terms of safety, quality of life and tumor resection, hospital stay, better endocrinological, and visual outcome as compared to the microscopic technique. Nasal symptoms, blood loss, operating time are less in EETS. Various naso-septal flaps and other techniques of CSF leak repair could help reduce complications. Complications can be further reduced after achieving the learning curve, good understanding of limitations with proper patient selection. Use of neuronavigation, proper post-operative care of endocrine function, establishing pituitary center of excellence and more focused residency and endoscopic fellowship training could improve results. The faster and safe transition from microscopic to EETS can be done by the team concept of neurosurgeon/otolaryngologist, attending hands on cadaveric dissection, practice on models, and observation of live surgeries. Conversion to a microscopic or endoscopic-assisted approach may be required in selected patients. Multi-modality treatment could be required in giant and invasive tumors. EETS appears to be a better surgical option in most pituitary adenoma.
Available from: Francesco Carinci
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ABSTRACT: To compare endoscopic and neuronavigation-assisted microscopic removal of hypophyseal adenoma in order
to detect those variables statistically associated to clinical failures of each technique. Forty-eight patients (27 males
and 21 females) with hypophyseal adenoma were treated with microscopy (6 patients) or endoscopic removal
(42 patients). Surgery was performed via endonasal trans-sphenoidal approach. Correlations between tumor
dimensions (standard and macro-tumor) or surgical techniques (endoscopy vs. microscopic technique) vs. residual
tumor, surgical complication (i.e. rhinoliquorrea) and persisting visual deficit, were evaluated. No statistical
significance was detected among the studied variables. On the basis of reported data, both techniques are safe if
the surgeon is well trained. Neuronavigation applied during endonasal trans-sphenoidal microscopic surgery can
precisely define the localization and removal of lesions in the sella region with respect to the margins of important
anatomical structures in the neighborhood, decreasing the rate of complications.
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