Grand Rounds-Transsphenoidal Surgery:...

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- Hello ladies and gentlemen, thank you for joining us for part two of our discussion with Dr. Bill Chandler, regarding surgical management of pituitary tumors. This session will mostly involve reviewing some of the basic technical nuances related to pituitary tumor surgery through the transnasal transsphenoidal approach and removing... And also viewing some of the surgical videos as well as reviewing some of the videos with associated complications. Bill, I wanna thank you again for being with us.

- Aaron, thank you very much for having me. And once again, I think this is a wonderful project that you've done along with the AANS, so it's a pleasure to be here.

- Thank you. So here is the disclosure acknowledgements and not of which interferes with the content of discussion today. I really like this statement and has always been in my mind when I get into tough moments in surgery. And I think for William Clowes, the leading surgeon of the Elizabethan, I guess Elizabethan age in 1602 says, "For those which are masters and professors chosen to perform the like operation, ought indeed to have a lion's hearts, a lady's hand, a hawk's eye, for that it is a work of no small importance." And really that defined surgeons and tough moments to have a lion's heart, a lady's hand and a hawk's eye. Not only tough moments, probably any time in surgery related to human brain or spine. And an unknown author mentioned this to me, as you will be reviewing some of my surgical videos where difficult moments happen. "Mistakes are a great educator when is honest enough to admit them and willing to learn from them." With those two thoughts, I thought we should talk a little bit about the father of modern neurosurgery, Harvey Cushing, who has contributed so much in popularization of pituitary surgery. As you will see in a moment, this is a picture of his on the left side. Actually you can see a picture of a patient with Progeria. A young girl, seven years old, and since Cushing was one of the very few in the country who started the era of endocrine physiology and endocrine surgery, many people who really just didn't look right would go to him for help. And as you can see, although this girl has nothing to do with pituitary tumors, really defines with what you can see in the face of her mom standing here. The agony of patients having Acromegaly or Cushing's disease with some of the cosmetic deformities. It is very interesting Bill, in 15,000 pictures of patients of Cushing we reviewed at Yale university, this is the only two where Cushing appears in the picture with a patient. And I can tell you this mostly, the most likely reflects his sincere interest in pituitary tumors. I think that really founded his career, facial pain that really came from management of pain and anesthesia early on working with Halsted, and eventually operating up pituitary tumors put him literally on the green cuff operating under central nervous system. Again, as you can see a very beautiful picture of Cushing holding the hand of a patient obviously with Acromegaly. Cushing was very observant, clinician, a very astute in diagnostics and a great diagnostician. As you can see, he always imaged the patient with the normal nurse or internal resident, and always put the hand of the patient on the chest, obviously defining the changes associated with the hand in Acromegaly. This is not a patient with pituitary tumor but really defines what Cushing was about. Although this patient never had a localizing sign and Cushing was never able to have an MRI to know what's going on, this patient continued to waste as you can see on his autopsy, specimen of the brain had germinoma, both in the suprasellar area and pioneer region. Although he couldn't localize it, he kept the patient in the hospital until the patient passed away, studied the phases of his death and or his demise, and this is a picture of him before he is taken for autopsy in the autopsy room. So he can really analyze every stage of the patient's clinical progress. And the next video that I'll show, really defined the moment of perseverance in difficult times in surgery. And I thought it would be a good way to start this video with this picture. 52 year old female with visual dysfunction. This was a patient I did about a couple of years ago Bill. And she had progressive bitemporal hemianopsia as you can see obviously, a large pituitary tumor. I hope my arrow is showing. Is it showing, I'm gonna go ahead and make sure it's on for our viewers. As you can see a large pituitary tumor with suprasellar extension. One things that was important, and I thought about it before surgery, is one of the carotid arteries, is really more hanging in the middle of the tumor rather than into cavernous sinus and pushing away. And I'm a left-handed surgeon and therefore I approach all the pituitary tumors that I can through the left nostril. And that puts us right in the area of this carotid artery. And as you can see the tumor very much invaded through the sellar in the lower picture and really made orientation very difficult. I did not use neuro navigation and really a lot of heat came toward us, and I'll show you the video in a second. As you can see, we're gonna go ahead and make the video larger for you. This is through the left nostril and I'm just at the level of the floor of the sellar coagulating what I thought was fibrous tissue and tumor. And I use the scissors there because I thought were still pretty superficial. And I wanted just to open the really tough membranes to get into the tumor. And at the time it looked pretty much like a capsule. And as you can see, unfortunately it wasn't a capsule and it really ended up in a torrential bleeding. I want to ask you at this moment, what would be going through your mind and how would you manage this Bill?

- Well, I think it would be pretty clear that the carotid artery is cut. There's nothing else bleeds like that. And I don't think you need a lot of experience, actually no one has much experience. Seeing that, you have to know it's the carotid. And I think the first thing to do is what it looks like you're doing here, is to pack it off and stop the bleeding. And obviously talk to anesthesia about blood pressure, get some mixture, there's plenty of blood available and do whatever it takes. This is a little difficult because it's the... Carotid is really in the middle of the tumors. You don't have the normal bony confines to pack against... But I think that the packing it, you can stop it. And then I think the next step, when it stopped, is to take the... To stop the procedure, take the patient down and do an angiogram. And I think that I've only seen a couple of these knock on wood, I haven't really had one myself, but I did see one in a colleague, and I think the mistake you can make is to assume once it stopped that everything's okay. So you need to do an angiogram and then you need to do something definitive to the carotid artery. I think you can discuss what you did here.

- Okay, and here I am gonna go ahead and restart the video. I packed it, and this thing is just coming at me. It's now on the face of the patient. And here we go, more carotenoids go in there. And eventually we're able to pack it off. I'm not saying this was the right thing to do in this situation, and I do believe the right answer is close and go to an angiogram. At this juncture because I was more feeling that this is not an avulsion injury, the tumor was not eroding through this, this was a sharp cut, I felt a piece of cotton on the carotid artery to keep things onto control and allowing me potentially to remove some tumor, to save her progressively deteriorating vision would be an option. Knowing that the anesthesiologist was comfortable with loss of blood, you can see I have placed a cotton wool on the carotid and I will start removing the tumor. Again, I'm not advocating that in any way, I think it is important to know that coming back to remove this tumor trans cranially would have its own limitations because of potentially a pseudo aneurysm. So as you can see my resident is holding a suction on the carotenoid, over the carotid, you will see intermittently there is bleeding in the area from the carotid. But we felt that the patient hemodynamically was very stable and we therefore continued removing the tumor. And as you can see the flow of the blood, just the area of the focal area that the carotid was cuts.

- [Bill] I think if could I comment here, I guess my only concern with that would be that as you further decompressed things, you could make the opening in the carotid worse by losing any buttressing effect of this fibrous tumor. So I think that's okay, but it actually may be a little bit risky.

- Okay. I think that's an excellent point in cases when you remove a tumor and the tumor was eroding through the carotid, and you just evolved a piece of the carotid wall with you. I think that is... This is not an acceptable maneuver after that occurs. But again, in this situation, you too rather early control the bleeding, it was my judgment to do it, although I don't recommend it. I think this is about the end of the video almost, again showing continuing to remove as much as the tumor, expeditiously as much as possible. Let's go ahead and talk about what happened to this patient after surgery. We went ahead and did an angiogram immediately, as you can see there is evidence of pseudoaneurysm, I hope our viewers can see that. Mike, can we have our arrow there. Yeah. You can see the pseudo aneurysm right on the carotid artery, and this pseudo aneurysm was subsequently stented with two stents to hopefully help its progression. These pseudo aneurysms are extremely dangerous, extremely labile. So the patient would require imaging, I would say within 48 hours later, don't you agree?

- Right, I agree, I go back of course, before the era of stenting and I recall two patients, one, and fortunately neither of these remained,, but one patient, a colleague entered the carotid, everything seemed to be fine. Took the pack out, sent the patient home, and on about the fourth day after surgery, the patient was found dead in their bathroom with epistaxis. He just bled out the nose and the other patient was taken at an injury... He was taken back the or two days later at packing taken out, actually had an angiogram that looked pretty good. Had the packing taken out and developed within a couple of hours a severe epistaxis requiring treatment. So that patient survived. But I think even these angiograms, this one looks pretty good. It's not perfect, but I think you really with today's technology, these all need to be stented.

- Okay. Thank you. And obviously frequent imaging performed, this was the immediate post-operative imaging that showed a suprasellar portion has been decompressed obviously. This was an angiogram about 48 hours later, reviewing no further growth of the pseudo aneurysm. This is an MRA about three months later. She had another MRA six months later, obviously she was carefully followed. These pseudo aneurysms are extremely labile. They can really change quickly and they can cause fatal epistaxis as you very well mentioned Bill. And this is her MRI about, I would say six months later, some residual tumor but vision is improved and all in all, as they say, it's better to be lucky than good, and this patient was able to make it through relatively intact.

- Maybe I could make a comment. I mean, the other way, perhaps to avoid that of course would be with frameless navigation. And I mentioned that I sort of use this spin system to create a CT because I wanna know where the midline is, but if I have a big complicated tumor like this, of course I'll get a pre-operative MRI and simply register the patient at the time of surgery. And that lets you know where you are in relation to the carotid. Because I don't think that position will change much even as you take tumor out, that's pretty fixed.

- Correct, and I think that's what I should have done. I should have appreciated that carotid is more within the tumor than normal and then I should have used neuro navigation in order to avoid it at all costs, thank you. Let's just review some of the basic concepts of pituitary surgery and I would appreciate your thoughts in terms of how you do it and how we can avoid complication in every step. I have really learned to use this positioning from Dr. Edslaws, and the patient is sort of have the nose parallel to the access where you're operating or perpendicular to the floor and then really the shoulders turned away. So although the head always looks like in the anatomical position for you, the shoulder sort of moves out of your way, and that really helps you with your back in terms of leaning over the patient. The anesthesiologist is always added food of the table and the x-ray machine or neuro navigation. How do you position your patient Bill?

- I'm gonna turn on my little dot here as well. You can see that. So I actually put the head straight. I don't find turning it adds enough advantage. And the other thing that I do based on this picture is that I use the microscope as I mentioned most of the time, but I use it with the two heads that are opposite each other. So one person is standing looking this direction, the other is up at the head looking down and I think the best sort of optics are on the ones like we use for spine surgery directly opposite each other. So that works well and then the lateral CR. But it would be very similar to this. I actually extend the head just a little bit, and that seems to work well.

- Okay, and have the assistant across the table from you because the transfer of instruments is a lot easier.

- Yeah, actually I usually have the assistant next to me, but I think this is a good idea, so either way.

- Thank you, and again you said you extend a little bit, I think the position. We have tried to use is try to have the head up a little bit just because to have the blood run away out of the nose and out of the surgical field, but you do extend the head a little bit to get sure trajectory better, is that Bill?

- I actually have the table perfectly flat as you see here. And I extend the head probably about 30 degrees and I... That's what I'm used to then when I'm standing and I sort of switch back and forth to try and give the residents a good feel for both views, just to show I think that we can be versatile. I recently operated on a patient with severe ankylosing spondylitis sort of chin on chest. But interestingly, he had had a craniotomy elsewhere for his pituitary tumor because they said they couldn't go trans nasally and he needed a repeat surgery because a lot of tumor that was there, by simply sitting down next to him looking upward, that worked just fine. So I think we can be pretty versatile.

- Thank you. So let's talk about briefly about a nasal exposure. I think you very well mentioned that you start right at the sort of surface, then we close over the anterior face of this sphenoid. I think there are one variation that we have tried is try to open the mucosa a little bit more distally where the cartilage and bony septum join each other. We have found out that maybe a little bit less invasion of the mucosa because you reflecting everything. But then with this exposure, you end up removing more of the septum. So everything has its own pluses and minuses. But as I remember in your part one presentation, when you discussed your nuances, you very well mentioned that the you start right at the face of the skin or above the mucosa ways, is that correct?

- Yes, that's correct. Years ago I used to go sub lavial and you end up basically starting here and working all the way up. So I've done 900 or so patients by taking out the nasal septum, but really with the small speculum or an endoscope, you can go all the way back to the rostrum of the spheroid sinus and simply go through that bone and gently move the septum to the opposite side. I occasionally you get away with the back and you'll actually cross the bony septum, but rarely do I take more than about five millimeters in the septum out. So I find that it's quite versatile.

- Thank you, and then I guess removing the pulse part of the septum, really reflecting the mucosa from the midland septum, fracture and get obviously putting the retractor on both sides of the bony septum and stripping the mucosa away until you reach the anterior face. Any nuances here, obviously you wanna use lateral fluoroscopy to make sure you're on a right trajectory. Because if you end up too superiorly over here, you will evolve some of the cribriform plate structures and get a CSF leak. Or if you're too inferior, you gonna end up exposing the juror over the basilar artery. Any thoughts there.

- Again, I did mention in the first video that we did, we don't see the turbinates here, but the inferior turbinate is right about here, the middle turbinate is here and when you come in the nose and their speculum, if you're even with the middle turbinate, you're virtually always pointing and you wanna use lateral fluoroscopy, but it's always pointing right at the sellar. So that's a good landmark if I take this image you have drawing over on the right side, I come all the way back to about here, break this over and drill this part away, and then simply move this over with the speculum. So I don't have to take any of the mucosa from here.

- And again, it's removing some of the bone with... I mean the exposing the interface using the hart ford retractor, those are relatively pretty standard. By the time you get here using the osteotome to move the interface of the steroid, and staying close to the midline as much as possible, and stripping the mucosa away. Any nuances or complications at this step that is important to know Bill?

- Yeah, one comment here, this... If you can see my pointer on the upper left-hand groin, this is where the perpendicular plate of the ethmoid meets the rostrum of the sphenoid sinus. And I would say that point is absolutely midline in virtually everybody. That's a strong statement, but I think it's true. Once you... The other thing to remember from that is once you get into these other two pictures show, in the spinal sinus, the septic may be way off the midline angle, they can be vertical, they can be horizontal. But this is a very nice landmark. Right, here in this little crest like a proud of a boat. And if you remember that that's midline and then think about your angle you're coming in, you can sort of extrapolate where midline is a little deeper. It gives you a good idea.

- Yeah, I think another landmark obviously, is the osteo of spinal sinus. I think we really orient you very well if you're too high or too low, don't you think?

- I agree, I've always said, particularly when I came up along the midline, you never go higher than the ostia. You go up to the ostia at the upper edge of the ostia is as high as you need to be.

- Okay, thank you. And then I guess removing the bone most of the time, the bone is pretty thinned out in my clad and almost makes our job easy. But if you are removing bone with an osteotome for my clad because the floor is intact, it cannot be emphasized how important it is not to trust the septi of the spinal sinus rather than really the midline septum of the nose and the rostrum of the spinoroid as the standard for the midline. If you really use any of the osteo, any of the septi of this spheroid, they lead you often to the carotid. I mean, they can be so off, so complex, so confusing, that the surgeon would barely see the floor and he gets sort of looking for a space to remove bone, and what he's removing bone is actually right here, if they're coming from the right side of the patient, they are led on the carotid artery, their removed bone, they can see, so they continue to remove bone to make it bigger, not knowing that actually what it's here is not the lateral wall of this sphenoid sinus, but rather just a large septation. And that leads you in a really wrong path. Would you say that is the most common pathway to get into a disastrous situation Bill?

- Yes, although it turns out there are many pathways, I guess, it's a disaster. One thing I find helpful, I mentioned in many of the cases, I generate essentially a CT scan during surgery, 'cause you get one before surgery, but that serves as a very nice roadmap. You can see the septi in three dimensions. For instance, there might be a septum over here, you say where we need to be just to the left of that, that's where the tumor is. So even if somebody bumped the part of the frame-less system, so you lost it, you still have all this beautiful anatomy, which you really don't get so much on an MRI scan. The middle picture here, I don't use an osteotome, although I have in the past, but again these drills are very nice if the bone is thick. Just usually a small pancake rose into sector, will lift it up in many patients. But again, when you have small tumors like Cushing's, the bone is very thick and there's the opening through the dura can be very hazardous because of the circular sinuses that connect the two cavernous sinuses. So again, the bigger the tumor the easier life is when you have a little tiny tumor with essentially normal anatomy, all of this is more difficult.

- And do you agree that it's really advantageous to use the Michael Doppler, especially in micraodenomas before you open in the dura, just to make sure you're not on the carotid artery.

- I think that's a good technique. I think knowing from your MRI scan where the carotids are, in other words there... Sometimes you use the term kissing carotids where they literally just about meet in the middle. So you need to know if there's an anatomic variant, and then with the frameless, you know where the midline is. So I frankly relied more on that than the Doppler, and I think that's quite accurate.

- Thank you. Let's just go ahead and start some of the discussion about macroadenoma before we go to microadenomas. And here is obviously the door is open. Often, I try to dissect the dura from the capsule of the tumor before opening the capsule, because it's a lot easier to do that at the beginning while the tumor is pushing against you, rather than when it's decompressed and often the capsule gets attached to these dura leaves, their inner surface are maybe difficult to remove and missed at the later parts of the operation, just because the surgeon is so focused on the inside portion of the tumor. And obviously the ring curates are very helpful. Knowing where the pituitary gland is, would be also helpful to avoid any injury especially to the posterior gland. We try to start laterally to remove tumor and posteriorly before anteriorly, because I think if you go anteriorly, the diaphragm falls into you and becomes very patchoulis and you may inadvertently leave tumor on the lateral gutters or posteriorly. How do you start your removal Bill in terms of which site-

- I think with the macroadenoma what I always tell the residents is save the upper part for last, which was exactly your point. If it's a soft tumor and you're destined to get most everything out, if the diaphragms falls down early, you spend a lot of time lifting it back up, trying to find what's below. So I always do one side and then the other, and then clean out all of the inferior part. So you clean sorta from 3:00 o'clock to around 9:00 o'clock and then go superior. And again, I think it's worth emphasizing that these tumors are extremely variable and unpredictable in their sort of the nature of the tumor, the consistency. Some are soft like toothpaste, they're wonderful, others are very fibrous, some are a mixture, and you'll get fooled by this. The center may be sort of liquified and the edges are very fibrous, so they're not always sort of homogeneous.

- Right. And I think one of the common reasons to leave a lot of tumor behind is because you remove a lot of soft tumor, then you get into that septation or the fiber spark, which has soft tumor superior to it. And so you feel like, oh, I'm almost done now, I don't see any more soft tumor, and then you do an MRI and it looks like you were never even there. Is that a reasonable statement Bill?

- Yes, I think easiest way to get fooled is to take out soft tumor. So I think you have to keep... We don't have an intraoperative MRI scan, a few places do, but that's certainly not standard. So I think you need to keep a good sense for what you've taken out and what you expect to take out. And if everything goes easy, but you've only taken out a two centimeters worth of tumor and a four centimeter tumor, you need to keep looking. And oftentimes if your patient, the diaphragma will pulsate down and just keep working at it, working at it, and then sometimes you're rewarded with the whole thing peeling out. Oftentimes you are.

- Right, and I'm gonna show a video where we thought we saw diaphragma sellar, and then the postoperative MRI was very humbling. And I would love to see your opinion in that regard. And that often happens, I think with very large tumors with patchoulis diaphragma sellar, where you get the sense that you see the diaphragm, when actually there's a lot between the folds and other areas. And again just realizing where the carotid artery is, I think this is an exaggeration, this illustration of the exposure. If you're coming from the right, and I hope yeah, from the right nostril, most of the time, you're gonna be able to see this far, this bone would be... I'm sorry, you're gonna be seeing from here to... I apologize, I'm gonna go back Bill. You're gonna see from here to here. You're gonna really move cross court and look that way. You're gonna leave some bone here, and it's important to realize that you're always gonna be deviated cross core the contralatery, and obviously try to dissect the tumor from the pituitary gland. Here is just continue to remove the tumor, as you very well mentioned, build the superior portion and really continuing to realize that there is a capsule to these pituitary macroadenoma, especially when they're not very gelatinous and removing the capsule really helped confirm gross total resection. I think the most common place to get a CSF leak is a right around where the diaphragm attaches to the superior part of your bony removal. Is that correct Bill, or what would you say, where's the most common place?

- I think that's true. I think in addition to a real rupture, like you're showing over here on the right, they're oftentimes little arachnoid foals that come down this picture of, you can see my dot shows a fold, it stops here. But sometimes they come way down and it's just... It's unavoidable the upper edge of the dura. I like to say it's weeping spinal fluid. If you have a big leak, you have to deal with that. But the little leaking part, usually when you put fat into clows and reconstruct this, that will stop. If you have a very large leak, you may need a spinal at the end of the case.

- Okay, and that's an excellent time to talk about that. So if you have a grade one or two leak or the weeping leaks, you put... As you mentioned in the first part of the talk, you put bone fat, bone to seal more buttressing. And if you have a big leak, you do that plus lumbar drain, is that correct Bill?

- That's correct. I think my criteria for a lumbar drain is if... First of all if it's a huge leak, you can count on it. And by that, I mean, if you happen to reach in and grab the diaphragma or it's torn, where it's just pouring out, I think you probably need a drain. But the other criteria I have is if I put fat in, I reconstruct it with bone and I put glue on, it's still seeping out around the edges, I think the drain is a good idea. I do not put them in preoperatively, but I'm willing to put them in post-up. But I would say one in 40 cases, do you need that anymore with the better glues.

- Right, one thing that we have tried and wrote about it is that we do pack exactly what you did. And I actually put fat and I tuck it in and rapid on surgery cell. And this way the fats really sits nicely into that area, right. And getting sucked by your suction as you're manipulating it and put small ones like small pieces of fat, maybe one big one in this small ones, and then push the small ones where you really wanna make it pack very well, rather than put a big one and know no what's going on. And then we use indermil. Indermil is what's used to close the wound. Actually, it's just a glue. It's very cheap. And we put that at the floor of the sellar and put some blood that we have the anesthesiologist withdrawal from the vein, and it really makes it a very nice, a solid reconstruction of the floor. And I'll show that in the video. And we found that very helpful.

- I've not used indermil but I think that sounds like a good trick.

- Thank you. And here is the fat backing, as you said, these are fat sharp bone, whatever you like fat and then more fatter layers. And let's talk about a relatively more difficult case of 45 year old male with progressive hysteria balance difficulties and obviously giant pituitary tumor. My question for you is would you approach this transmit noisily first? Or would you say I'm gonna go transcranial from the beginning Bill?

- Well, it's sort of a difficult choice, I think... I do you have a lateral view of that of sagittal. Did I see one there? Yeah, I think this does come down, and it fills the spinoids. So I would do this from below, I think you can easily get into this. Looks like it has a big system of center and you should be able to get this to come down. So I would go transfer right away.

- Okay. And that's exactly what we did in this video. And I would like to see what your thoughts are. We're gonna go ahead and make the video bigger. Thank you, Michael. So this is going through the nose, just showing that really injection of the epinephrin solution and causing really hydrodissection of the mucosa, removing the bony septum. Again, this is all done on a microscope I'm left-handed. And as you can see, I'll use the left nostril anytime I can. That makes it more difficult for my residents, because then when they come in, they'll have a hard time working. But again using the neural navigation, just like you mentioned is helpful. And that's what we brought in here. You can see just making sure everything is right, because there's no midline septum here. There is no midline spinoid septi. There's no floor. Everything has been eroded. You remove that mucosa, and you're looking at the floor of this or the rostrum of the spinoid, and you're actually just looking at tumor, you have no idea where you are. So neuro navigation is very important. Here we continue to remove tumor and it was relatively bloody and you can see there's a huge hole. And we use some of the larger ring shreds that I hardly ever use, and I never knew why they even make it because it doesn't even go through the nose. But this was one case when it really came handy in terms of using these large reinsures that you'll see in a moment. And here's the diaphragm, you can see over the suction coming down nicely and is a good thick diaphragm makes you feel good because you know you can be more aggressive without getting a CSF leak. And here is that giant ring shred that barely goes through the nose. Any pearls here in removing this tumor Bill?

- [Bill] No, I think you... This is very much what I would do. I also have a couple of these long curates that I don't use very often, that reach way up. And I think when you see the diaphragma come down like this on one hand, that's a very positive sign, but you also don't wanna get fooled and leave a lot of tumor in behind it. So you always wanna push it back up and make sure that it isn't trapping tumor in behind it. You're never gonna get all of this tumor, but you wanna a high percentage.

- And that's using the indermil as I just said. It solidifies pretty well, It's easy to use, it's cheap. And then you sort of put some blood over it and it really forms a very solid cement. And I think one of the common reasons for postoperative CSF leak after a good reconstruction is because your bone or your glue comes off, your fat moves, and then you have a CSF leak. It's not really not because you didn't do a good packing, it's just because your packing moved. So whatever you can do to avoid the movement of your packing with using these tools, I think it does pay off. And here is the postoperative MRI. I mean, adequate resection, obviously we're unable to remove the tumor in the cavernous sinus. And it really was a nice result in terms of avoiding going fast cranially. And here is a sagittal view of showing that how everything descended. By the way, I did use a lumbar drain in surgery and injected air. I inject airbag 10 CC at a time and up to 60 CCS. What are your pearls in terms of using the lumbar drain in giant tumors to force the diaphragm to fall.

- To be honest I've never used that. I find that just the natural intracranial pressure given patients pushes things down. So I've not been a fan of the routine lumbar drain. I guess I grew up at a time when pneumoencephalogram were done and I saw the misery patients went through. Now that was a lot more forced air, but that may have biased me a little bit. So I don't use it routinely and I don't feel that it's critical of myself.

- Okay. We only use it very rarely for giant tumors. But this is another tool we have used Bill in terms of... For giant tumors, where we used the lumbar drain. As you inject air, some of the air accumulates intrathecally, and obviously intro dually on the other side of the diaphragm that you're resecting. And you can put your ring curette against the diaphragm and see if there's air right above you. If there's tumor, obviously no air can accumulate there, but if there's air cumulating there that confirms that you have removed all the tumor. It's again, just for selected cases, maybe a rough way to assure a suprasellar decompression adequately. Let's talk about a 55 year old male with progressive history of visual dysfunction. This patient had a large pituitary tumor, very vertically located. This is a post-operative MRI. And as you can see, I was able to remove the tumor up to here, but none of these descended. And here you can see a humbling postoperative MRI showing that you were there, you did all the work, you thought you saw diaphragm that I'm going to show in the movie, but actually you really didn't do too much. So let's go ahead to talk about the surgical video. This is again an inter operative x-ray reveals that I'm pretty far above the cliner. You can see air over and behind, but again, you can see some evidence that the air does not go over across. So there's probably some tumor hanging around and here's the surgical video. I'm gonna go ahead and move forward. I think we went ahead and reviewed some of the basic techniques in terms of approaching this tumor. Again, this is going on both sides of the septum, removing the septum. I think the first case we presented, or the second case did not have all the details because of the tumor has eroded, had eroded through it. So as you can see, we remove more of the septum than what you do regularly. This is the rostrum, the original where the rostrum Bill you were talking about that is so often constant and important to orient the surgeon. Again, using the... What you call, the osteotomes to remove the rostrum of this spinoid. If you have any thoughts, please go ahead and add.

- [Bill] No, I think that looks like an excellent wide exposure, which you're gonna need for a tumor like this.

- And using the pituitary rongeurs generously here, I think it's much more efficient than a kerrison rongeur in order to be able to remove as much as you can have both sides and get a good tunnel to work through. And here is getting into the sellar, you can see the tumor is very fibrous spill, and very vascular. Nothing is really coming through your ring curettes, you're sort of plowing through this and everything just sort of sits there and just bleeds. And here is when we try to sort of reorganize our plans and after some decompression, which wasn't really major, try to reflect the capsule of this fibrous tumor as they become more fibrous, obviously they have a more easily capsule to maneuver with. What are your thoughts in this situation trying to play with the capsule?

- [Bill] I think some sometimes, and it looks like here that can work your advantage because once you cleaned out the inside, the fibrous capsule literally will fold down. And sometimes you can feel out of a very large piece of this, and then sometimes it breaks up, but you have to be persistent, try to dissect it away from the surrounding bone and dura like you're doing there, not just stay on the inside, but try to dissect it away. Sort of like peeling an egg out from the shell.

- [Aaron] Right. And that's what I'm trying to do again, with these bloodstream curettes. Just pushing this tumor into my resection cavity, not an easy thing to do because there's a lot of pulling and always makes you comfortable what's on the other side that you're gonna pull out. Any pearls for removing these fibrous tumors Bill.

- [Bill] Oh yeah. It looks like you're using a... What I would call a sort of a clamshell, something to grasp the tumor. You have to be careful that you don't grab the diaphragma but a lot of these things need to be grabbed and pulled as well as carotid. So I think it's a combination and you pull it down with your suction and then grasp it and gently pull and tease it out. A little bit like pulling a large disc coming out of the back egg I guess you have sometimes have to tease it was.

- [Aaron] Right, and I think that's very well mentioned again, debulking within the middle, as you can see, awfully fibrous pooling a little bit more than one has comfort zone and I'm continuing removing the tumor. Here's the diaphragm Bill. We felt that we're very comfortable, that was the diaphragm. And I still to this date, I think it is a diaphragm and maybe a little bit difficult to see in the video, but I'm positive that was not a tumor. But again, the post-operative MRI didn't show anything like that, even though you clearly can see diaphragm. What are your thoughts?

- [Bill] Well, I think... I've been fooled a couple of times where you keep looking, something that looked like diaphragm and then it frees up in another large segment comes down. But I think it's extremely important to recognize the diaphragma because if you grab that with your heartland forceps, you're gonna have a giant leak on your hand. So I think you just have to be patient and not sort of give up too soon. You just gotta keep looking. I'm impressed oftentimes how something 10 minutes later looks very different than it did 10 minutes before. And I think that's as the diaphragma pulsates down.

- [Aaron] Right? And as you can see, I sort of went through the folds of the diaphragm you saw about, I think about 30 seconds ago and here is reconstructing with indermil and the blood, which has worked very well for us. We haven't had any really evidence of CSF leak, or maybe one or two patients in the past 200 patients. So I think it's really worked very well in terms of reconstructing the floor. And as you can see three months later, that piece of tumor descended very well. And that's one of the pearls, I think about these tumors where you can leave some on top and give the patient some time for the brain pulsations to push the tumor. In theory, his vision went to normal, he has a little bit of residual tumor, he did not require a transcranial approach. So I think patients in these tumors where you see as sizable suprasellar portion after surgery is important because a lot of them get devascularized by the first surgery and they're cross, a lot of them descent. And also when the tumor is so elevated, as you can see in the case of this patient and attached to the important structures, if you really wanna go and pull it down, you really are more likely to have a periphery injury and a complication. And here is another case again of a relatively not a sizeable tumor that was removed, and this is a post up of MRI, not really a very spectacular MRI, very much humbling. And we just waited and you can see the tumor partially in the cruise and then descended. And the patient did very well. Let's just finish quickly with a couple of quick videos on macroadenoma here. Macroadenoma is obviously exposure of the bone in removal. So bone in removal and exposes is critical, it has to be as wide as possible to expose the pituitary, allow easy identification of the gland and its gutters. And again, opening the gland, dissecting the microadenoma possibly through its pseudo capsule, if necessary, remove a piece of the gland. Do you have any pearls in general for removal of the microadenomas Bill?

- Well, I think one thing I say is the smaller the tumor, the wider the exposure. I think if you're looking for a small tumor, if it's very evident, then perhaps doesn't have to be too wide. But I think particularly in those with negative MR imaging, they need a really wide exposures so you can look side to side because there oftentimes is a clue. And of course, as you've shown here, you have to cut the gland vertically and horizontally. And then you look for a white tumor. I think in the Cushing's, I find that the tumor is usually pretty whitish, more white than an Miguel for some reason, but you have to not be fooled by finding the posterior pituitary, which is also sort of white and it looks like cottage cheese. So I think careful exposure and patients through the whole gland with a nice wide exposure. I know at Oldfield talks a lot about keeping sort of outside the capsule of the tumor, and frankly, that's great when you can do it as you showed here. But honestly, sometimes the tumor is so soft, it just falls apart and you lose that. You try to go back and find it, but the more you can stay outside that capsule is always a good thing.

- Thank you. Here's a patient, very classic features of acromegaly, obviously a picture a few years ahead or before. And as you can see, typical features of acromegaly and here is was his MRI very typical microadenoma located more on the left side. We approached these tumor from right nostril because of the advance of the cross court. And here is really exposure of the sellar actually in this patient, this sellar was relatively generous. And as you expect in these acromegalic patients the sellar floor is always very thick, hypertrophied bone and requires sort of osteotome or drilling as you were rushing and probably drilling is a more elegant way to do it. And this is generous removal of the bone to the point that you really can see any edges of the bone along the floor of the sellar. And then really opening that... And then using that disector ahead of time and dissecting the juror, the inner surface from the tumor before you approach the tumor so you can get as much of the tumor cleared from the inner surface of the dura. This tumor was relatively gelatinous. It really came out very nicely, as you can see, and you sort of used the ring curettes and this soft tumor comes out. It gives you the most amazing feeling that you're really doing your job well. Although the tumors that are more fibrous are located within the gland that we'll see in our last case next is a lot more challenging. And as you can see, the diaphragm has descended very nicely here. It's very clean. The pituitary gland is located in the right upper quadrant. And again, you can see it looked pretty clean until you start giving it some time. And it was just a couple of minutes and then go back to the gutters and there's more tumor. So I think one pearl that worked well for me is if you think you have done all of the work, just give it a couple of minutes, let the pulsations make the tumor come down a little bit more, and when you go in there and there will be more tumor. And as you can see in this case, and really staying on the lateral part of the cavernous sinus as you can see here and making sure you're very far on both sides to assure, remove the tumor on those tough gutters that are often missed. Any other pearls Bill removing these microadenomas?

- No although I'm sort of struck by the fact that we keep using the word patients and unfortunately that's something surgeons don't ever have a lot of, including myself. So I think waiting with these to let the tumor present itself a little bit more, that doesn't mean waiting hours, but sometimes 10, 15 minutes of sort of teasing the tumor and the landscape changes if you're willing to wait.

- Thank you, let's go ahead and finish with a relatively difficult case of Cushing's disease. I find these Cushing patients often the most difficult to treat. Often 40% as you well mentioned on your first part of discussion, you don't even see it on MRI, they have a very narrow sellar. They often... They almost look like Cushing's carotids and very little space to work with. The tumor is often fibrous and really has all the features of trouble written all over it. And as you can see, we use some of the dynamic imaging after we inject gadolinium when the initial MRI is negative to see in if in a delayed fashion we can find anything. And as you can see, we didn't find that a 3T MRI, 3-tesla MRI was negative. As you can see, the carotids are pretty close, not too close although, and the sagittal shows really no tumor, It looks... I mean, the whole gland is so small. It's hard to believe there is a tumor, although chemically or biochemically this patient had the evidence of Cushing's disease. What are your thoughts in these difficult cases Bill?

- Well, I think we... A patient like this would have inferior patrol sinus sampling, and that usually lateralizes the one side. I guess you get 50% by guessing, but that'll take you up to 70 or 75%. So I always look first on the side of the patrol sampling. If I don't find something, I look on the other side, sometimes there's been an obvious tumor on the other side. So if you don't find anything convincing on either side, then I would take out a good half of the gland on the side of the patrol sinus sampling that's positive. And that's really about all you can do. But you really need a good look laterally, and the problem is these are the most difficult cases in terms of exposure because of the bleeding that oftentimes is there from the circuit or sinuses. I've had two patients really within the last number of years, recent years, where I've actually backed out, they both been Cushing's patient and there wasn't any major blood loss that we were worried about. Severe blood loss, I simply couldn't see well enough to proceed. So I opened the dura, let it bleed, packed it off, open it up, let it bleed, and then stopped, went back, say three weeks later, went in, there wasn't a drop of blood. You could explore the entire land. So I think it's good to tell these patients ahead of time that may be necessary and only had to do that twice, but it's really paid off one patient at an excellent cure. And I just couldn't see at this microscopic level well enough to dissect the glance. I said, fine, I'll come back another day. But when you do come back all those edges, you wanna make sure an open as wide as you can sort of take a hit with the venous bleeding, and then when you come back, it's wide open, there's no more bleeding and you can see quite well, so.

- Yeah, I see that's an excellent point. In the Cushing patients the circle of sinuses are very hypertrophy. I'm sorry, you were about to say something, Bill go ahead.

- No, that's really it. I mean, I think these just approach the normal anatomy of a normal gland and it was published years ago. There's a lot of variation in circular sinuses, some of them are minimal, some of them are sort of horrific. I mean not... Again, not I'm worried about the amount of blood loss, but at this microscopic level, it makes it very difficult to see. So you can do your exposure, take a hit with the bleeding, close up and go back.

- Thank you. Let's review this surgical video and... So Bill, this is the video for this case. As you can see, the exposure is awfully tiny there, right angle, this sector has a hard time getting through and I'm using the right angle disector just to inspect and make sure there's no bone left because you wanna make sure you remove as much bone as possible. And I'm sure you're gonna expose part of the carotid arteries by removing the bone. I'm sorry to do over the carotid arteries. Here's the normal pituitary gland. As you can see the more posterior part is that yellowish whitish tumor, and you just have to be patient again the keyword and remove the tumor piece by piece and inspect the gutters carefully. Obviously cure in Cushing's disease is so critical. And these tiny pieces of tumor that often hide in these little gutters, and this is really a posterior part of the sellar, joining the lateral wall of the cavernous sinuses, you can see right there. And you'll have to mobilize the pituitary gland and look around and make sure that tiny piece of the tumor that occasionally comes into view as you'll see in a moment is removed patiently later. As you can see right there, there is a piece that will be removed shortly. Any other thoughts there regarding removal of these challenging microadenomas in Cushing's disease?

- No I think you do need to be patient. You need to look throughout the gland and when you find this little pocket, your curate will literally fall into it and it never falls into the normal gland. The normal gland is too tough, you can cut it and dissect it. But you pretty much know by feel, and then the visual cues. The other thing for the audience looking at this, the view through the actual microscope is of course much more detailed than we're seeing on this video. So you really can see these edges well. The other comment I mentioned about bleeding, sometimes you get sort of a mild to moderate amount of bleeding and you just have to wait until you get this kind of view because you can't operate if you can't see, and by being sort of patient, most of the bleeding stops and you get this terrific views.

- Okay, well Bill, I wanna thank you for your expert opinion. I think this session was very helpful to myself as well. I think your pearls are something all as surgeons should remember. Thanks again, and we hope to work with you in the future for other sessions as well.

- Thank you very much Aaron and for the opportunity to participate, my pleasure.

- Thank you.

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