A Novel Technique for Transpalatal Hypophysectomy

Abstract

Objective A novel technique is described for transpalatal hypophysectomy as an option for sellar region surgery using a microscope and/or endoscope.

Technique A straight submucosal tunnel (approximately 20 mm in diameter; 40–50 mm long—half the length required by conventional transsphenoidal hypophysectomy) is dissected in favorable alignment with the main tumor axis, providing a direct view that allows the surgeon to operate on large suprasellar tumors, even in cases of extra-axial expansion.

Results In a 25-year period, over 50 patients benefited from this surgery. Macroadenomas devoid of extra-axial expansions were totally excised (76.5%), otherwise, partially (23.5%). Forty-nine patients (98%) were extubated soon after surgery. Mean surgery duration was 3 hour 32 minute, with 2 days 6 hour before free feeding was restored. Postoperative hospitalization under neurosurgical care averaged 6 days 6 hour. Currently, patients undergoing the procedure do not require nasal tampons and can eat soft foods soon after recovery from anesthesia. Although two patients (3.9%) presented with oronasal fistulae postoperatively, no episodes of severe hemorrhage occurred during surgery and there were no cases of liquoric fistulae, visual impairment, panhypopituitarism, or severe syndrome of inappropriate antidiuretic hormone secretion.

Conclusion The new surgical approach is safe, effective, and well accepted by patients, who reported low levels of discomfort. Postsurgical complications or sequela are currently rare, but further operations should be performed using more appropriate materials, instruments, and equipment to allow comparisons with other techniques.

Keywords

pituitary adenoma - transsphenoidal hypophysectomy - transpalatal corridor - skull-base surgery - endoscopic surgery - transoral robotic-assisted surgery

• References

• 1 Samii M, Draft W. Surgery of space-occupying lesions of the middle skull base. In: Samii M, Draft W. eds. Surgery of the Skull Base. An Interdisciplinary Approach. Berlin: Springer-Verlag; 1989: 273-296
• 2 Koenig (König) F. Zur totalestirpation der hypophysis cerebri. Berl Klin Wochenschr 1909; 37: 1040
• 3 Guleke N. Die Eingriffe am Gehirnschädel. Gehirn, an der Wirbelsäule und am Rückenmark. Berlin: Aufl Springer; 1950: 335
• 4 Löwe L. Die Eingriffe am Gehirnschädel, Gehirn, an der Wirbelsäule und am Rückenmark. In: Guleke N, Zenker R. eds. Allgemeine und spezielle chirurgiesche Operations-lehre. 2nd ed. Vol 2. Berlin: Springer; 1905: 335
• 5 Fein J. Zur Operation der Hypophyse. Wien Klin Wochenschr 1910; 23: 1035
• 6 Tiefenthal. Technik der Hypophysenoperation. Munch Med Wochenschr 1920; 67: 794
• 7 Preysing H. Beiträge zur Operation der Hypophyse. Verh dtsch Laryng 1913; 20: 51
• 8 Broeckaert J. A contribution to the surgery of the hypophysis. J Laringol. 1913; 28: 340-352
• 9 Maroon JC. Skull base surgery: past, present, and future trends. Neurosurg Focus 2005; 19 (01) E1
• 10 Stone JL. Sir Charles Ballance: pioneer British neurological surgeon. Neurosurgery 1999; 44 (03) 610-631 , discussion 631–632
• 11 Galdino AC, Klescoscki Junior J, Landeiro JA. História da cirurgia da hipófise. Arquivo Brasileiro de Neurocirurgia. 2005; 24 (03) 112-118
• 12 Trible WM, Morse AE. Transpalatal hypophysectomy. Laryngoscope 1965; 75: 1116-1122
• 13 Mattox DE, Carson BS. Transpalatal transsphenoidal approach to the sella in children. In: Skull Base Surgery. Vol 1, No. 3. Baltimore, Maryland: Thieme Medical Publishers, Inc.; 1991: 177-182
• 14 Rose-Innes AP, Oosthuizen JH. The transoral transpalatal approach to the pituitary fossa. Minim Invasive Neurosurg 1995; 38 (01) 22-26
• 15 Ozer E, Durmus K, Carrau RL. et al. Applications of transoral, transcervical, transnasal, and transpalatal corridors for robotic surgery of the skull base. Laryngoscope 2013; 123 (09) 2176-2179
• 16 Chauvet D, Missistrano A, Hivelin M, Carpentier A, Cornu P, Hans S. Transoral robotic-assisted skull base surgery to approach the sella turcica: cadaveric study. Neurosurg Rev 2014; 37 (04) 609-617
• 17 Chauvet D, Hans S, Missistrano A, Rebours C, El Bakkouri W, Lot G. Transoral robotic surgery for sellar tumours: first clinical study. J Neurosurg 2016; 127 (04) 941-948
• 18 Ballenger JJ. ed. The clinical anatomy and physiology of the nose and accessory sinuses. In: Diseases of the Nose, Throat and Ear. Philadelphia, PA: Lea & Febiger; 1977: 2-12
• 19 Berwig LC, Silva AMT, Côrrea ECR, Moraes AB, Montenegro MM, Ritzel RA. Hard palate dimensions in nasal and mouth breathers from different etiologies. J Soc Bras Fonoaudiol 2011; 23 (04) 308-314
• 20 Gardner E, Gray D, O'Rahilly R. Anatomia: Estudo Regional do Corpo Humano. 4. ed. Rio de Janeiro: Guanabara Koogan; 1978
• 21 Gray H. Anatomia. 29ed. Rio de Janeiro: Guanabara Koogan SA; 1988
• 22 Heermann J. História e Perspectivas da Microcirurgia Intranasal. iHIn: Stamm AC. ed. Microcirurgia Naso-Sinusal. Rio de Janeiro: Revinter Ltda; 1995: 1-14
• 23 Junqueira LC, Carneiro J. Histologia Básica. Editora Guanabara Koogan. 9a edição. 1999
• 24 Krayenbühl HA, Yasargil MG. Cerebral Angiography. London: Butterworths; 1968: 129-133
• 25 Krmpotic-Nemanic J, Draft W, Helms J. Chirurgische Anatomie des Kopft-Halls-Bereiches. Berlin, Heidelberg: Springer; 1985
• 26 Lang J. Anatomy of the Sellar Region. In: Samii M, Draft W. ed. Surgery of the Skull Base. An Interdisciplinary Approach. Berlin: Springer-Verlag; 1989: 27-35
• 27 Lang J. Anatomy of the clivus. In: Samii M, Draft W. editor. Surgery of the Skull Base. An Interdisciplinary Approach. Berlin: Springer-Verlag; 1989: 90-95
• 28 Lang J. Anatomy of the Paranasal Sinus. In: Laligam N. Sekhar & Ivo P. Janecka eds. Surgery of Cranial Base Tumors. New York: Raven Press; 1993: 123-130
• 29 Logan BM, Reynolds PA, Hutchings RT. McMinn's Color Atlas of Head and Neck Anatomy. Philadelphia: Elsevier Limited; 2004
• 30 Murta AA, Carneiro CG, Felippu A. Anatomia endoscópica do seio esfenoidal. Rev Bras Otorrinolaringol 2002; 68 (04) 522-525
• 31 Navarro JAC. Anatomia do Nariz, Seios Paranasais e Estruturas Correlatas. In: Stamm AC. ed. Microcirurgia Naso-Sinusal. Rio de Janeiro: Revinter Ltda; 1995: 15-36
• 32 Rhoton Jr AL, Hardy DG, Chambers SM. Microsurgical anatomy and dissection of the sphenoid bone, cavernous sinus and sellar region. Surg Neurol 1979; 12 (01) 63-104
• 33 Rhoton Jr AL. Crânio - Anatomia e Acessos Cirúrgicos - Bases cranianas anterior e média. Rio de Janeiro, RJ: Di Livros Editora Ltda.; 2009: 303-330
• 34 Spalteholz W. ed. Atlas de Anatomia Humana. Rio de Janeiro: Guanabara Koogan, AS; 1956
• 35 Testut L, Latarget A. eds. Tratado de Anatomia Humana. Tomos 1–4. Barcelona: Salvat; 1973
• 36 Fahlbusch R, Buchfelder M. The transsphenoidal approach to invasive sellar and clival lesions. In: Sekhar LN, Janecka IP. eds. Surgery of Cranial Base Tumors. New York: Raven Press; 1993: 337-349