Cushing’s Disease: Microadenomectomy

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This video refers to a Resection of Microadenomas causing Cushing's Disease. This is a 52 year-old female with typical findings of Cushing's disease. MRI evaluation reveals as sizeable microadenoma within the center of the pituitary gland as expected for such tumors. She underwent Endonasal Transsphenoidal resection of this tumor using endoscopic techniques. You can see the wide exposure of the sellar. Generous bony removal is mandatory for resection of microadenomas or more specifically their gross total removal. The Dura was open a cushy fashion. A dissector was used to mobilized the dura away from the capsule of the gland. The dura Opening was further extended more posteriorly. Here, You can see the wide exposure of the gland. All the corners were first inspected before an incision is made within the gland itself. Since no tumor was obviously apparent and midline incision within the gland was created. You can see the tumor centrally protruding through our initial incision. I typically attempt extra capsular dissection of the tumor as demonstrated here. This maneuver may not be feasible in all microadenomas. Since the tumor can be quite adherent to the surrounding gland. Here, you can see the nodule of the tumor that is being dissected from the surrounding gland. Further dissection continues around their circumference of the tumor. An interface is created between the tumor and the pituitary gland. Here you can see the tumor somewhat discolored and yellow versus the orangish color of their gland itself. After the dissection is essentially complete. I use an angled sharp ring curette to deliver the tumor as demonstrated here. Tumor remains very adherent to the surrounding normal gland. After the nodule is delivered, I typically remove the pre-tumoral area on declined to maximize the chance of biochemical cure. Here I continue to dissect around the tumor capsule. Ultimately, the nodule is extracted using a pituitary rongeur. Next I continue to inspect a removed pre-tumor area. However, in this case, a piece of tumor is readily apparent along the posterior aspect of the gland. I continue my careful inspection to maximize tumor removal. You can see the three hand technique for improving the efficiency of the operation. In this case, all the corners next to the medial wall of the cavernous sinus are carefully inspected. As these corners are the operative blind spots where residual tumor typically resides. Let's go ahead and use Hydro scopy for further inspection of our operative cavity. Everything appears relatively clean. No obvious tumor is apparent. I'll go ahead and also use Angled Endoscopes to assure complete removal of the tumor. Then the scope is used within the sellar. All the resection cavity walls are inspected when the gland is compressed by manipulation, it may blanche and become fused with tumor. So one has to be careful during inspection of the gland to keep that phenomena in mind. All the corners appear clean. Piece of fat was used wrapped in surges cell to close the resection cavity. Some glue to further reconstruct the skull based defect and the post operative MRI examination reveals gross total removal of the tumor without any evidence of residual mass and this patient achieved by a chemical remission. Thank you.

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