Microadenomectomy for Cushing’s Disease: Maximizing Resection

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Here's another video describing the challenges we face in securing biochemical remission and gross total removal of microadenomectomas causing Cushing's disease. This is a 62-year-old female with advanced Cushing's disease. MRI evaluation was initially read as normal without any obvious evidence of a microadenoma. However, this actual image demonstrates some evidence of a potentially, a sizable microadenoma within the middle of the gland. An endonasal transsphenoidal resection was attempted. Here is the floor of the sella. The bone is obviously normal. A small osteotome is used to remove the bone. Venous bleeding is very common among Cushing's disease, especially around the dura of the sella. I used Floseal to secure hemostasis. Venous bleeding should not be a reason for inadequate bone removal. The floor of sellar should be resected from one cavernous sinus to the other, and all the way from the tuberculum to the posterior edge of the sella. You can see the bleeding from the intercavernous sinus. Here's the edge of the intercavernous sinus. I continue my bone removal. Now I am approaching the right cavernous sinus. More bone removal posteriorly. Here's the final result. Intercavernous sinus expanded, bone removal at the floor of the sella. The dura is opened in the cruciate fashion. The leaflets of the dura are separated from the gland. Here's the portion of the tumor herniating through the gland. Before tumor removal, hemostasis is secured. The microadenoma has entered. Pituitary rongeurs are used for collection of the tumor material. One has to expect that the tumor goes beyond just the small margins in the right side of the tumor based on preoperative MRI findings. Therefore I made an incision within the gland so that the middle of the gland can be adequately inspected as well. Upon opening of the gland, you can see there is ample amount of tumor still hiding within the center of the gland. And obviously for achieving biochemical remission, aggressive removal of this portion of the tumor is mandatory. So I continued to use pituitary rongeurs. The tumor appears somewhat fibrous. That is not unusual for the tumors in the Cushing's patients. Again, this fibrous nature of the tumor and its adherence leads to significant technical challenge in maximizing tumor removal. However, the surgeon has to remain persistent, inspect the entire gland, and make sure these adherent fibrous portions of the tumor are removed. Here is piecemeal removal of the tumor. Here's the posterior aspect of the sella, carefully inspected. The three-hand technique may be utilized to curate away some of the smaller tumor remnants. Here you can see that piece that is hiding within the latter aspect of the sella facing the medial cavernous sinus wall. This part of the tumor is most likely the trickiest to remove. Here's an even a bigger piece that is hiding. That is why it's so critical to inspect the medial cavernous sinus wall after the resection is complete. Again, another small piece of very adherent tumor that is being delivered. Careful inspection is mandatory. On the initial view it appears that everything is clean. Every area is very closely inspected. Hydroscopy may be used to further inspect the smaller areas. Here you can see, potentially a piece of tumor. We'll go ahead and inspect this area carefully. Here is the medial cavernous sinus wall on the left side. The rest of the gland appears relatively clean, at least under hydroscopy. And this is the suspicious area. Dynamic compression of the gland can make the gland blanche, potentially confusing a piece of the tumor with a portion of the normal aspect of the gland. Further inspection was performed. Here you can see very small piece of the tumor hiding and attaching to the medial cavernous sinus wall. The three-hand technique again is required. You can see a ring curette mobilizes the gland, a suction device clears the operative field, while the pituitary rongeur removes the suspicious portion of the tumor. In the medial cavernous sinus wall, aggressive removal of the abnormal tissue is attempted. Here is another small piece. Again, you can see the intricacies involved with gross total removal of fibers and adherent pituitary microadenomas causing Cushing's disease. I'm relatively happy. I don't see any more abnormal tissue in the medial cavernous sinus wall on the right side, The rest of the gland appears unaffected. This area is also being inspected. Everything appeared relatively clean. A piece of fat wrapped in Surgicel was utilized for the closure. Here's the final step in the closure. Postoperative MRI revealed gross total removal of the microadenoma and the patient achieved biochemical cure. Thank you.

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