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Pituitary Macroadenoma: Pitfalls of Inadequate Bone Removal

October 28, 2019


This is another video describing nuance of resection for a pituitary macroadenoma, and more specifically discussing the pitfalls associated with an inadequate bone of removal along the floor of the sellae. In fact, the most common reason for inadequate tumor removal is inadequate bone removal along the floor of the sellae. This is a 62-year-old female who presented with visual decline, MRI evaluation revealed assistive pituitary adenoma within has seen nausea primarily located along the inferior aspect of the tumor. You can see this is relatively a sizeable tumor and causing significant chiasmal compression. Patient underwent endoscopic endonasal approach. You can see the tumor along the interface of the sellae is attenuated. The bone is been removed. Our trainee conducted the initial part of the operation and the tumor was relatively soft however, bony exposure was relatively limited. It was not from one cavernous sinus to the other. Some of the tumor was initially removed. As you can see, it's relatively soft. I enter the operative field next and remove the additional piece of bone all the way to the level of the cavernous sinus using CT intraoperative navigation. You can see how much more dural opening can be performed after additional bone or adequate bone has been removed. Ample amount of tumor now can be removed that was not initially accessible via relatively limited bony opening. Now you can see the diaphragma sellae herniating through our operative cavity and working around the pituitary gland to remove tumor from the areas of the cavernous sinuses and the medial wall of the cavernous sinus. It's important to initially remove laterally and posteriorly and ultimately anteriorly and superiorly. So diaphragma sellae does not herniate through the resection cavity prematurely hiding pieces of the tumor along it's medial walls. Careful inspection reveals no obvious residual tumor, diaphragma is very nicely herniating to our resection cavity. Again, I mobilize the diaphragm and carefully inspect the areas along the medial walls of the cavernous sinus. You can see the wall clearly here. Again, this area is only evident if adequate bone is removed. Here you can see very clear the medial wall, pieces of fat were placed within the resection cavity for reconstruction. And here is the three months MRI reveals a very nice and resection of the tumor with adequate decompression of the chiasm. Again, i want to emphasize the importance of adequate bone removal from one cavernous sinus to the other. So that the tumor along the medial aspect of the wall of the cavernous sinus camp removed. This is specially important so that diaphragma sellae can adequately herniate and descend and all the tumor camp removed. If adequate bone removal is not accomplished, pieces of tumor are left on each side, medial to the wall of the cavernous sinuses. These tumors will hold a piece of tumor just underneath diaphragma sellae in place, therefore preventing adequate descent of the diaphragm. This leads to inadequate tumor removal and inadequate chiasmal decompression. Thank you.

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