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Acromegaly: Asymmetric Microadenoma

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Let's review another variation of technique for resection of microadenoma causing acromegaly. This is a 27 year-old female who presented with acromegaly and trigeminal neuralgia. MRI evaluation revealed a sizeable microadenoma on the left side of the pituitary gland. She underwent endonasal transsphenoidal exploration. Here's the floor of the sella. Relatively thick. Small osteotome was used to create the initial small bony opening. Next, Kerrison rongeurs were utilized to expand the bony exposure. For these microadenomas it is quite crucial that the bony removal is thorough and extends from one cavernous sinus to the other. As you saw a moment ago, the bone is quite thick. Hemostasis secured using FLOSEAL. And since the microadenoma is on the left side of the gland, the exposure on the left side was expanded further. Intraoperative image guidance using skull base CT was utilized. The dura was open in cushy fashion and the microadenoma on the left side of the gland was encountered. You can see the gland here. The microadenoma on its left side. First, the adenoma was decompressed and enucleated. You can see the use of pituitary rongeurs to collect the tissue. The edges of the resection cavity were also curated away. Here's the resection cavity. There's some residual tumor on the left side. Hydroscopy was used. You can see the tumor on the left. Image somewhat out of focus. Hard to see differentiation between the tumor and the gland. Here's a more clear view of the gland on the right side. Tumor on the left side as demonstrated. It's important to continue resection until the medial wall of the cavernous sinus is clearly visualized. The most common location for the tumor to hide in is, again, along the medial wall of the cavernous sinus. Additional tumor fragments are removed. Here's the gland. Appears clean. No tumor capsule is apparent on the gland itself, but the most important part right now would be to inspect the medial wall of the cavernous sinus and make sure there's no residual tumor hiding there. Appears relatively clean on the initial inspection. Could be a small amount of tumor capsule left behind. There's the gland itself. There's that small piece of the capsule that was removed. Further inspection reveals the medial wall of the cavernous sinus, without any evidence of residual tumor. And you can see the grayish medial wall of the sinus. Piece of fat was used to reconstruct the defect. And the postoperative MRI immediately after surgery revealed complete removal of the microadenoma. This patient achieved biochemical cure and trigeminal neuralgia improved significantly after surgery. Thank you.

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