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Table of Contents    
OPERATIVE NUANCES: STEP BY STEP (VIDEO SECTION)
Year : 2022  |  Volume : 70  |  Issue : 4  |  Page : 1370-1372

Endoscopic Endonasal Transsphenoidal Approach for a Giant Pituitary Adenoma in Pediatric Age Group: Operative Video


1 Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt; Department of Neurosurgery, Greifswald Medical School, University of Greifswald, Germany
2 Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
3 Department of Ear, Nose, and Throat, Faculty of Medicine, Cairo University, Cairo, Egypt

Date of Submission01-Apr-2022
Date of Decision24-May-2022
Date of Acceptance27-May-2022
Date of Web Publication30-Aug-2022

Correspondence Address:
Mohammad Elbaroody
Department of Neurosurgery, Faculty of Medicine, Cairo University, Al-Saray Street, El Manial, Cairo - 11956
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.355124

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  Abstract 




How to cite this article:
Refaee EE, Elbaroody M, Shazly ME, Lasheen H, Yousef A, Abdelaziz AK, Alhayen BI, Ali KB. Endoscopic Endonasal Transsphenoidal Approach for a Giant Pituitary Adenoma in Pediatric Age Group: Operative Video. Neurol India 2022;70:1370-2

How to cite this URL:
Refaee EE, Elbaroody M, Shazly ME, Lasheen H, Yousef A, Abdelaziz AK, Alhayen BI, Ali KB. Endoscopic Endonasal Transsphenoidal Approach for a Giant Pituitary Adenoma in Pediatric Age Group: Operative Video. Neurol India [serial online] 2022 [cited 2022 Oct 2];70:1370-2. Available from: https://www.neurologyindia.com/text.asp?2022/70/4/1370/355124

Key Message: Proper surgical planning for the narrow pediatric nasal corridor and the experience of the surgeon are the key for optimum tumor resection and skull base reconstruction in the pediatric age group.




Pituitary adenoma forms about 3% of pediatric intracranial tumors.[1],[2],[3] Gross total resection is curative in nonfunctioning adenomas, without additional treatment.[4] The endoscopic endonasal transsphenoidal approach is limited by lack of pneumatization of the sphenoid sinus, small intercarotid distance, narrow surgical corridor, and the high surgeon's experience;[3],[4],[5] however, Pandey et al.,[2] reported that the incidence of visual deterioration was high in the transcranial approach, additionally, the transsphenoidal approach has fewer morbidities in their pediatric pituitary adenoma series. The following article demonstrates the surgical technique of the endoscopic endonasal transsphenoidal approach in a young girl, we favored this approach because the main bulk of the tumor was mainly in the midline, to achieve adequate chiasmatic and cavernous sinus decompression, and the long axis of the tumor was in the same angle of attack.


  Objective Top


The video in this article demonstrates the excision of giant pituitary adenoma invading the cavernous sinus using the endoscopic endonasal transsphenoidal approach.

Procedure

The patient was placed in a supine position with the head slightly extended. We worked through both nostrils to gain more surgical room till we reached the sphenoid ostium. The anterior wall of the sphenoid sinus was opened widely, and the posterior nasal septum was removed to create a space for the working instruments. We relied on anatomical landmarks like lateral opticocarotid recess (LOCR) to stop the drilling, then we started removal of the inferior and posterior part of the tumor till we reached the dorsum sella. The tumor was moderately vascular and we removed it in a piecemeal fashion. A curette was used to dissect the tumor from the normal pituitary gland and dura, we did a gentle dissection of the superior part of the tumor using an angled curette, and we used the traction counter traction technique to hold the diaphragma sella. By removal of the whole apparent tumor, the diaphragma sella fall down and fill the sella with prominent transmitted pulsations, the defect in the left cavernous sinus was seen clearly, and we did not extend beyond this defect. A piece of cotton was used to inspect for any apparent residual. Except for the small part left in the left parasellar space, we achieved near-total resection. We packed the sella with a harvested piece of fat, followed by layers of surgicel placed onlay, and the nasal cavity was packed with pledgets.

Video Link

https://youtu.be/cjCcT05D8fY

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Video timeline with audio transcript

00:01–00:10

Here we present an endoscopic endonasal transsphenoidal approach for resection of giant pituitary adenoma invading the cavernous sinus in an 8-year-old girl.

00:11–00:38

She was presented with headache and gradual progressive diminution of vision for 5 months, she also had disfigurement in the form of complete ptosis and squint in her left eye for 20 days. On examination, visual acuity was more affected in her left eye. Additionally, she had left complete oculomotor palsy and the trochlear nerve was affected in the same eye. Visual perimetry showed the classic bitemporal hemianopia for sellar lesions compressing the chiasm.

00:39–00:56

Magnetic resonance imaging (MRI) brain with contrast showed homogeneously enhanced large sellar lesion with suprasellar extension, it was invading the left cavernous sinus with parasellar extension and it was extending up to the third ventricle. She did not have any clinical or laboratory endocrine dysfunctions.

00:57–01:09

The most likely diagnosis was pituitary adenoma, computed tomography (CT) of the paranasal sinuses was done for assessment of the sella turcica and we were lucky enough to find the presellar type with wide sella.

01:10–01:27

Here we favored approaching this tumor through the endoscopic endonasal transsphenoidal approach because the main bulk of the tumor was mainly in the midline, to achieve adequate chiasmatic and cavernous sinus decompression, and the long axis of the tumor was at the same angle of attack.

01:28–01:51

The patient was placed in a supine position with the head slightly extended, working through both nostrils, the middle turbinate was identified and lateralized to gain more surgical room and the endoscope was angled upward to the superior turbinate, which was lateralized, and the sphenoid ostium was visualized.

01:52–02:21

The anterior wall of the sphenoid sinus was opened widely, and the posterior nasal septum was removed to create a space for the working instruments. We used a high-speed micro drill and Kerrison rongeur to remove the residual parts of the sellar floor, we relied on the anatomical landmarks like lateral opticocarotid recess (LOCR) to stop the drilling.

02:22–02:56

The dura was thinned out, and the tumor was bulging in sella turcica. Using long curved suction and angled curette, we started removal of the inferior and posterior part of the tumor till we reached the dorsum sella. The tumor was moderately vascular and we removed it in a piecemeal fashion. Then we started to remove the lateral parts of the tumor on the left side at first, we used a micro dissector to dissect the tumor out of the cavernous sinus, a 30° angled endoscope was used to inspect the corners.

02:57–03:32

The diaphragma sella did not fall in the field, which means there are large tumor parts that are not removed yet. Then we removed the suprasellar part of the tumor, we started lateral to the diaphragma on the left side, and finally on the right side in piecemeal fashion. A curette was used to dissect the tumor from the normal pituitary gland and dura, we did a gentle dissection of the superior part of the tumor using angled curette, and we used the traction-counter-traction technique to hold the diaphragma sella.

03:33–03:59

By removal of the whole apparent tumor, the diaphragma sella fall down and fill the sella with prominent transmitted pulsations, the defect in the left cavernous sinus was seen clearly, and we did not extend beyond this defect. A piece of cotton was used to inspect for any apparent residual. Except for the small part left on the left parasellar space, we achieved near-total resection.

04:01–04:13

We packed the sella with a harvested piece of fat, followed by layers of surgicel placed on lay, and the nasal cavity was packed with pledgets.

04:14–04:34

Histopathological examination confirmed the diagnosis of nonfunctioning pituitary adenoma. Postoperative recovery was smooth, neither endocrine complications nor cerebrospinal fluid (CSF) leaks occurred, and she was discharged on the 4th postoperative day without new neurological deficit.

04:33–04:59

Early postoperative MRI on the 2nd day showed adequate chiasmal and cavernous sinus decompression. After 3 months of follow -up after surgery, MRI showed neither residual nor recurrence, which was confirmed in MRI 1 year later. Ptosis was improved totally at the last follow-up 1 year after surgery.


  Outcome Top


Postoperative recovery was smooth, neither endocrine complications nor cerebrospinal fluid (CSF) leaks occurred, and she was discharged on a postoperative day 4 with no new neurological deficits. Early postoperative MRI on the 2nd day showed adequate chiasmal and cavernous sinus decompression. After 3 months of follow-up after surgery, MRI showed neither residual nor recurrence, which was confirmed in MRI 1 year later. Ptosis was improved totally at the last follow-up 1 year after surgery.

Pearls and pitfalls

The narrow nasal surgical corridor needs proper planning to achieve the best results. It is recommended to work through both nostrils, and perform wide exposure to reach the sella turcica, this will facilitate the use of instruments during tumor removal and will give the chance to use four hands technique. It is recommended to use an intraoperative navigator whenever possible, to identify key landmarks before drilling the sella to avoid vascular injury. Removal of the tumor in a piecemeal fashion till the fall of diaphragma sella is an important sign for gross total resection of the tumor. Multilayer closure of the skull base should be meticulously done to guard against leakage of CSF. The endoscopic endonasal approach is a safe technique and will give the best chance to achieve adequate chiasmatic and cavernous sinus decompression even in the pediatric age group with a narrow surgical corridor.


  Discussion Top


The transnasal endoscopic transsphenoidal approach for pediatric sellar and suprasellar tumors proved itself as an effective and safe technique over years.[2],[3],[6]

The main obstacles to this technique are narrow surgical corridor, inadequate sphenoid sinus pneumatization, and small intercarotid distance.[7] Lateralization of middle turbinates on both sides, wide exposure of the sellar floor, and the use of an intraoperative navigator made the endonasal approach possible in this age group.[5],[6],[7] These tumors could be also approached through the transcranial approach; however, cavernous sinus and optic chiasm decompression would be achieved through the endonasal approach. Pandey et al.,[2] reported that the incidence of visual deterioration was high in the transcranial approach, additionally, the transsphenoidal approach has fewer morbidities in their pediatric pituitary adenoma series. In addition, the endoscope enhances the visualization during the surgery; however, the space occupied by the instruments and the use of four hands technique requires expertise, which may have a steep learning curve.[6],[7]


  Conclusion Top


We have presented a video of giant pituitary adenoma invading the cavernous sinus using the endoscopic endonasal transsphenoidal approach in the pediatric age group. Through adequate preoperative planning and meticulous technique, we achieved an excellent clinical and radiological outcome. We have discussed the operative nuances.

Declaration of patient consent

Full and detailed consent from the patient/guardian has been taken. The patient's identity has been adequately anonymized. If anything related to the patient's identity is shown, adequate consent has been taken from the patient/relative/guardian. The journal will not be responsible for any medico-legal issues arising out of issues related to the patient's identity or any other matters arising from the public display of the video.

Financial support and sponsorship:

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kane LA, Leinung MC, Scheithauer BW, Bergstralh EJ, Laws ER Jr, Groover RV, et al. Pituitary adenomas in childhood and adolescence. J Clin Endocrinol Metabol 1994;79:1135-40.  Back to cited text no. 1
    
2.
Pandey P, Ojha BK, Mahapatra AK. Pediatric pituitary adenoma: A series of 42 patients. J Clin Neurosci 2005;12:124-7.  Back to cited text no. 2
    
3.
Perry A, Graffeo CS, Marcellino C, Pollock BE, Wetjen NM, Meyer FB. Pediatric pituitary adenoma: Case series, review of the literature, and a skull base treatment paradigm. J Neurol Surg B Skull Base 2018;79:91-114.  Back to cited text no. 3
    
4.
Kunwar S, Wilson CB. Pediatric pituitary adenomas. J Clin Endocrinol Metabol 1999;84:4385-9.  Back to cited text no. 4
    
5.
Zhan R, Xin T, Li X, Li W, Li X. Endonasal endoscopic transsphenoidal approach to lesions of the sellar region in pediatric patients. J Craniofac Surg 2015;26:1818-22.  Back to cited text no. 5
    
6.
Quon JL, Kim LH, Hwang PH, Patel ZM, Grant GA, Cheshier SH, et al. Transnasal endoscopic approach for pediatric skull base lesions: A case series. J Neurosurg Pediatr 2019;24:246-57.  Back to cited text no. 6
    
7.
London NR, Rangel GG, Walz PC. The expanded endonasal approach in pediatric skull base surgery: A review. Laryngoscope Investig Otolaryngol 2020;5:313-25.  Back to cited text no. 7
    




 

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