Giant Pituitary Adenoma: Microscopic Transseptal Approach

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Let's discuss resection of a giant pituitary adenoma via the non-endoscopic or microscopic transnasal transseptal approach. This is a 45 year-old male with longstanding history of visual dysfunction who did not seek medical attention. However subsequently developed gait disturbance and MRI evaluation revealed a very large pituitary macroadenoma with evidence of a cystic or necrotic port within the mass, causing distortion of the floor of the third ventricle. This is one of my older cases where I used the endonasal transseptal route for resection of the tumor. Before the era of endoscopy, transseptal approach was conducted. You can see the boney and cartilaginous septi that are being removed. A submucosal trajectory toward interface of the sella. Here's the interface of the sella, navigation was used for localization. Can see the floor, as expected is very much attenuated following removal of the thin sheet of bone over the floor. Ring curettes of various sizes were used to remove the very suckable tumor in this case. The extent of bony removal is quite important for removal of these tumors, therefore, navigation really assisted with a very wide exposure at the floor of the sella. Here are the use of the ring curettes to remove as much of the tumor as possible until diaphragma sella descends into our resection cavity. Part of the tumor had to be extracted using pituitary rongeurs. You can see the view's relatively limited. Here's diaphragma sella descending into our resection cavity. I carefully inspected all the folds to assure myself that there's no residual tumor hiding within the folds of the diaphragma. Very large ring curettes were used to inspect the lateral extent of the sella turcica to assure aggressive removal of this tumor. Obviously part of this tumor is invading cavernous sinus and gross total removal is not safe. Closure was completed in standard fashion. No evidence of CSF leak was apparent. I used glue to reconstruct the floor of the sella, using some of the blood to solidify the glue in this case. And the postoperative MRI as expected demonstrated reasonable resection of the mass with effective decompression of the optic apparatus and the floor of the third ventricle where the residual tumor within the cavernous sinus was left behind. This tumor subsequently showed mild or slight evidence of growth at three year follow-up, and therefore the patient underwent radiosurgical treatment. Thank you.

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