August 14, 2016
This is another short video describing the techniques for a sectional focal microadenoma causing Cushing's disease. This is a 20 year old female. MRI evaluation revealed a very focal microadenoma on the right side of the pituitary gland. You can also see the outline of the tumor on the sagittal MRI with contrast. Endoscopic transnasal exposure was accomplished. It is important for the entire cellar to be exposed from one cavernous sinus to the other. The age of the cavernous sinus is exposed as you can see at the tip of my arrow. Here you can see the very wide exposure guided by intraoperative CT navigation. The dura is incised in a cruciate fashion all the way to the edge of the cavernous sinus. In a splitting from the dura among the Cushing's patients is not uncommon. Hemostasis can be rarely achieved via flow seal. After a generous exposure of the gland is achieved, I go ahead and dissect the inner surface of the dura from the gland. Next, you can see the tumor protruding through the gland on the right side as expected. I use a number of different size ring curettes to deliver the tumor. Obviously the cavity of the tumor has to be carefully inspected to make sure that the capsule is also aggressively removed. Now that the tumor is curated away, I slightly extended the incision within the gland and carefully inspect the resection cavity wall to completely confirm gross total removal of the microadenoma. Here, you can see curating of the wall of the resection cavity for aggressive removal of the neoplastic cells. Next, I slightly extend the incision in the gland and look inside, small amount of the capsule wall was removed using suction. You can see now the tumor does not appear to be present anymore. The gland appears very clean. It's important to remember that if you compress the gland during dissection, the gland blanches and can resemble the look of a microadenoma. Therefore, dynamic movement or dynamic retraction of the gland is necessary to clearly differentiate tumor from normal glandular tissue. As you can see, the tumor was removed in gross total fashion. A piece of fat was used to reconstruct the defect and post our pre MRI revealed gross total removal of the mass and this patient achieved biochemical cure. Thank you.
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