Transnasal Transcavernous Route for Multicompartment Adenoma

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Giant multi compartmental pituitary tumors offers significant challenges in their resection in this video. Reviews, some of the challenges we faced during resection of these tumor types. This is 26 year old male who presented with intractable headaches and by temporal hemianopsia MRI evaluation revealed this very multi compartmental, pituitary tumor, relatively asymmetric non-functional, and very much extending into the deep structures. My plan was to maximize the extent of resection through the trans sphenoidal endoscopic approach and hope that I can use a trans cavernous approach to remove as much of the tumor as possible. However, the transcranial route may be necessary to further maximize removal of this tumor. Let's go ahead and review the endonasal part of this procedure. Here is the born in the oval at the level of the cellar portions of the tumor or relatively easily suck able upon further decompression of the cellar, the dura was open in a crucial fashion further the bone removal extended from one side of the cavernous sinus to the other. Here, you can see diaphragms cellar at the ear of the tuberculum. Part of the tuberculum was also removed. Here's diaphragms cellar protruding into our resection cavity after removal of the intracellular portion of the tumor. Next, I use the left cavernous sinus and followed the route of the tumor through the sinus. Some of the acceptations in area where sharply disconnected. Here, you can see some of the area of the lateral portion of the diaphragms. Here are some of the arachnoid bans near the area of the cavernous sinus. Next, I use a variety of angle endoscopes to remove the tumor within the cavernous sinus and continue to work toward the temporal lobe and the base of the thalamus. Some of the arachnoid bands can be readily opened. These are also acceptations within the tumor then unless are opened. Aggressive resection is not possible. Obviously the sixth cranial nerve has to be carefully protected and kept out of harm's way. The principle remains following the route of the tumor in order to remain within the tumor and avoid injury to the surrounding neurovascular structures. Here are some of the arachnoid bands over the medial temporal lobe. I continue to redirect my attention more immediately. So ,the tumor around the lateral parakeet asthmatic areas can also be removed. We can work in within these acceptations to maximize tumor removal and endoscopes are mandatory for adequate visualization in these areas. Dissection continues under direct vision. Blind tumor removal is not advised. No more anterior extended the tumor within the cavernous sinus. This portion of the tumor was more socialized, fragmented, and delivered into our resection cavity. Part of the tumor was actually fibrous and the other part was relatively gelatinous. Again, the nerves within the cavernous sinus were carefully protected, and I worked around the neurovascular structures to maximize tumor removal. Here's not driving my attention more laterally towards the medial temporal lobe or additional fragments of the tumor were delivered into our resection cavity. Ours SAVA maneuvers and patients, on the behalf of the surgeon help assist with the scent of the tumor into our resection cavity. Some of the arachnoid layers are apparent. Ample amount of irrigation was also used to clear the operative cavity or the some of the arachnoid bands over the lateral frontal areas as well. A piece of fat occluded the cavernous sinus without being compressive. The gasket seal technique was used to close the area of the operative cavity. a nasal septal flap was used to also buttress an argument al reconstruction. Here's the final stages of closure. In this case, the post operative MRI revealed aggressive removal the tumor through the cavernous sinus and even part of the tumor along the medial temporal lobe, and even the lateral aspect of the thalamus. Our portion of the tumor remained inaccessible via this route. And this patient subsequently underwent a torsional transcranial approach for removal of the rest of the tumor. They are operative related to the removal of the tumor via the transcranial approach is covered through one of our other videos. This patient made an excellent recovery from the operation with improvement of his vision. Thank you.

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