Transsphenoidal hypophysectomy is a surgical procedure for removing tumors of the pituitary gland, described here along with relevant anatomy, indications and contraindications for the surgery, and technical details. Our discussion will center around how the multidisciplinary team can provide the best possible care to these patients.
Schoffer was the first to describe the transsphenoidal method. Halstead modified it, which was popularized by Cushing. In any case, it’s interesting to note that Cushing avoided transsphenoidal procedures towards the end of his career, and increasingly preferred subfrontal procedures.
Transsphenoidal hypophysectomy indications:
Many tumors of the pituitary region can be treated with transsphenoidal surgery.
- Pituitary Adenomas
- Macroadenomas, Generally, they should be centered on the midline.
- Craniopharyngiomas, As long as they are intrasellar.
- A biopsy of the midline sphenoclival region is recommended (e.g. chordoma, aspergilloma, meningioma, etc.).
- Tumors with a larger size are debulked
This means that the size of suprasellar components is not important. Tumor can be delivered into the pituitary fossa as high as the foramen of Monro by Valsalva maneuver and / or lumbar drain to introduce air or sterile fluid.
Transsphenoidal hypophysectomy procedure:
It would be too long to go into detail about the surgery in this article. We will instead focus on a summary that radiologists will comprehend.
- General anesthesia
- The patient is semi-sitting in Mayfield tongs
- Fluoroscopy provides confirmation of instrument positioning during surgery
- Using the operative microscope is possible
- An incision is made under the upper lip on the buccal mucosa.
- A blunt submucosal dissection of the nasal septum from the sphenoid.
- Insertion of speculum.
- Opens the anterior sphenoid sinus wall.
- Sphenoid sinuses and mucosa are removed from the posterior wall.
- Opening of the pituitary fossa’s teroinferior surface.
- Opening dura surface.
- Pituitary rongeurs, for example, are commonly used for removing tumors.
- Surgical defects are filled with fat.
- Bone, cartilage, and glue were used to reconstruct the anterior wall of the fossa.
- Additional fat packing.
- A petroleum jelly (e.g. Vaseline, infused with Bacitracin ointment) can be applied as a compress.
- Liposuction completed.
The development of these techniques has been facilitated by recent advances in endoscopic technology.
There is one drawback to transsphenoidal surgery: the operating corridor is narrow, and it is difficult to treat lateral tumors. If total resection is desired, tumors with a large parasellar component should be treated transcranially.
Here are some complications:
- Hemorrhage following surgery presents differently than pituitary pain.
- There may be CSF leakage resulting in meningitis.
Complications that occur immediately after surgery:
In 6 of every 100 cases, CSF leaks are observed. These leaks can sometimes be prevented with a multilayer seal at the end. Although it is rare, a lumbar drain is often used if there is a chance of a leak during the postoperative period. It is important to check with a physician if the problem does not resolve by the end of 24 hours. There also may be an immediate complication, such as blurred vision, bleeding, or manipulation. A thorough evaluation of preoperative imaging is essential to prevent complications such as optic nerve damage and carotid arterial rupture.
A lumbar drain is used if a possible leak occurs in the postoperative period. CSF leaks, sinusitis, and meningitis are frequently seen complications. CSF leaks typically occur in six out of 100 cases. Patients who do not experience significant improvement within 24 hours should be referred for further investigation and treatment. Other immediate complications include blurred vision, bleeding, or manipulation. If the preoperative imaging is carefully studied, it is possible to avoid potentially fatal outcomes such as ruptured optic nerves and carotid arteries.
Immediately following surgery, patients will likely experience nasal bleeding and congestion. Nasal pain, mucosal scarring, and mucosal crusting are also possible complications. Despite their temporary nature, these complications are more common in sublabial placement than in transnasal surgery, because they involve extensive dissection and injuries to the orbital nerves. By using nasal splints/packs, postoperative morbidity can be worsened.
Patients may experience hyposmia if they experience sinusitis due to mucosal injury. Radiofrequency ablation, nasal isolation, and corticosteroids can be used to treat nasal synechiae.
Patients may need endoscopic surgery to repair the nasal cavity floor using the mucoperiosteal pedicle flap when their septum has been perforated. Other treatment options include nasal irrigation and corticosteroid medication.
During atrophic rhinoitis, regular nasal irrigation may be necessary, and there may need to be soothing nasal drops used.
Complications of the endocrine system:
Among the most common endocrine concerns associated with surgery are ADH (trouble with antidiuretic hormone secretion) and SIDH (inappropriate secretion). Postoperative DI is the most common endocrine issue associated with sealing stomas. An incidence of DI varies from 5% to 35%, with a triphasic response being seen: polyuria, polydipsia, and polyuria for the first 48 hours, then disappearing.
Transsphenoidal Hypophysectomy is a safe and effective procedure for removing intrasellar tumors and pituitary cells. This procedure not only improves endocrine function, but also reduces pressure on the pituitary and surrounding structures.
Follow-up care after transsphenoidal hypophysectomy:
Your endocrinologist may prescribe you Prednisone or Dexamethasone after your surgery, which you should take until directed to stop. After surgery, your sodium and hormone levels can be monitored by your endocrinologist.
After transsphenoidal surgery, what are my options?
For five days, you will feel discomfort from the incisions (cuts) made by the surgeon. Your wound may feel numb or shooting. There may also be swelling and swelling around the eyes. Your wound will become itchy after it heals.
When a pituitary tumour is removed via transsphenoidal hypophysectomy, what is the most frequent postoperative complication?
This study assessed the effects of transsphenoidal removal of pituitary tumors on the postoperative risks of CSF leakage. DI, prolonged postoperative ventilation, PONV, and electrolyte disturbances were other common complications.
After a hypophysectomy, what should you do?
Typically, it takes between 1 and 2 hours for an individual to undergo the procedure. The person will be admitted to a rehabilitation ward for 2 hours before being moved back to the neurosurgery room. The nose is then closed to prevent bleeding. Following surgery, most people go home the same day. Some patients may require hormone replacement therapy.
Living a normal life can be difficult after pituitary cancer?
A patient will be able to live a normal life if a pituitary tumour is not treated, but may have vision problems or high hormone levels.