J Korean Neurosurg Soc.  2022 Jan;65(1):114-122. 10.3340/jkns.2021.0047.

Utilizing a Novel Pituitary Retractor for Early Descent of the Diaphragma Sellae during Endoscopic Transsphenoidal Pituitary Surgery

• Park JS
• Chung DS
• Yoon WS

• KMID: 2523919
• DOI: http://doi.org/10.3340/jkns.2021.0047

Abstract

Objective
: Early descent of the diaphragm sellae (DS) during endoscopic endonasal transsphenoidal surgery (EETS) for pituitary macroadenoma surgery is occasionally a troublesome event by blocking the surgical field. Here we introduce an alternative technique with the new pituitary retractor and present our clinical experiences.
Methods
: We designed a simple and rigid pituitary retractor with the least space occupation in the nasal cavity to be compatible in EETS. The pituitary retractor was held by external holder system to support the herniated DS stably. We retrospectively reviewed a clinical 22 cases of pituitary macroadenomas underwent EETS using the pituitary retractor.
Results
: The pituitary retractor stably pushed up the herniated DS in all cases, and the surgeon proceeded the procedure with bimanual maneuver. The pituitary retractor was helpful to remove tumors around the medial cavernous sinus and behind the DS in 16 and seven cases, respectively. In four cases, the meticulous hemostasis was completed with the direct visualization by the DS elevation with this retractor. Gross total tumor resection was performed in 20/22 patients (91%). The impaired visual function and hypopituitarism were improved in 18/20 (90%) and 7/14 (50%) patients after surgery, respectively. There was no complication related with the pituitary retractor.
Conclusion
: During EETS for pituitary macroadenomas, the novel pituitary retractor reported in this study is a very useful technique when the herniated DS block the surgical field and bimanual maneuver. This pituitary retractor can help to result in the excellent surgical outcomes with minimal morbidity.

Keyword

Endoscopy; Pituitary neoplasms; Surgery; Technical report

Figure

• 

  Fig. 1. Schematic illustration of pituitary retractor. A : Early descent of the diaphragma sellae (DS) into sella turcica may obscure the remaining tumor. B : With rigid support of pituitary retractor (asterisk), the DS can be elevated to reveal the concealed tumor. The remaining tumor is easily removed under direct visualization without the interruption of the ballooned DS. T : tumor.

• 

  Fig. 2. Application of new pituitary retractor. A : The metallic pituitary retractor is composed of three parts. Inner part (I) has a narrow and long spatula with slightly angled head to create a working space in the sellar cavity. The middle shaft is a slender rod with a right angle to avoid interference with instruments passing through the nostril. The outer part (O) is thin for fixation to the holding system. B : Pituitary retractor is introduced into left nostril and moved in the cephalic direction to create a working space below the pituitary retractor. The outer part is fixed with the Greenberg holder system (Codman, Dorchester, MA, USA). With fixation of the pituitary retractor, tumor resection is performed with bimanual maneuver.

• 

  Fig. 3. Case No. 17. A : Pituitary macroadenoma compresses optic nerve superiorly and extends laterally to the right superior cavernous compartment over the intracavernous ICA. B : The diaphragma sellae (DS, black asterisk) balloons out into the sella cavity during tumor removal. C : Tumor removal is proceeded using cottonoid patties to support the DS. However, the remaining tumor is not clearly identified due to the pooled blood and the limited maneuverability. D and E : A rigid pituitary retractor supports the DS stably, and the tumor around the right cavernous sinus is removed with a bimanual maneuver. F : Sharp dissection between the DS (black asterisk) and tumor capsule (black arrowhead) is performed under the DS. G : Hemostasis with surgicel is performed with bimanual maneuver under direct visualization. H : After the completion of tumor removal, the DS occupies the sella cavity where the rigid pituitary retractor is removed. I : On postoperative magnetic resonance image, the remaining tumor is not visible and the compressed optic chiasm is relieved.

Reference

References

1. Abdelmaksoud A, Fu P, Alwalid O, Elazab A, Zalloom A, Xiang W, et al. Degrees of diaphragma sellae descent during transsphenoidal pituitary adenoma resection: predictive factors and effect on outcome. Curr Med Sci. 38:888–893. 2018.

2. Bedi AD, Toms SA, Dehdashti AR. Use of hemostatic matrix for hemostasis of the cavernous sinus during endoscopic endonasal pituitary and suprasellar tumor surgery. Skull Base. 21:189–192. 2011.

3. Campero A, Martins C, Yasuda A, Rhoton AL Jr. Microsurgical anatomy of the diaphragma Sellae and its role in directing the pattern of growth of pituitary adenomas. Neurosurgery. 62:717–723. discussion 717-723. 2008.

4. Cappabianca P, Alfieri A, Thermes S, Buonamassa S, de Divitiis E. Instruments for endoscopic endonasal transsphenoidal surgery. Neurosurgery. 45:392–395. discussion 395-396. 1999.

5. Cappabianca P, Cavallo LM, de Divitiis E. Endoscopic endonasal transsphenoidal surgery. Neurosurgery. 55:933–940. discussion 940-941. 2004.

6. Cappabianca P, Cavallo LM, Solari D, Stagno V, Esposito F, de Angelis M. Endoscopic endonasal surgery for pituitary adenomas. World Neurosurg. 82(6 Suppl):S3–S11. 2014.

7. Cavallo LM, Somma T, Solari D, Iannuzzo G, Frio F, Baiano C, et al. Endoscopic endonasal transsphenoidal surgery: history and evolution. World Neurosurg. 127:686–694. 2019.

8. de Divitiis E, Laws ER, Giani U, Iuliano SL, de Divitiis O, Apuzzo ML. The current status of endoscopy in transsphenoidal surgery: an international survey. World Neurosurg. 83:447–454. 2015.

9. Ding ZQ, Zhang SF, Wang QH. Neuroendoscopic and microscopic transsphenoidal approach for resection of nonfunctional pituitary adenomas. World J Clin Cases. 7:1591–1598. 2019.

10. Fahlbusch R, Schott W. Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: surgical results with special consideration of ophthalmological and endocrinological outcomes. J Neurosurg. 96:235–243. 2002.

11. Guinto Balanzar G, Abdo M, Mercado M, Guinto P, Nishimura E, Arechiga N. Diaphragma sellae: a surgical reference for transsphenoidal resection of pituitary macroadenomas. World Neurosurg. 75:286–293. 2011.

12. Jane JA Jr, Han J, Prevedello DM, Jagannathan J, Dumont AS, Laws ER Jr. Perspectives on endoscopic transsphenoidal surgery. Neurosurg Focus. 19:E2. 2005.

13. Jankowski R, Auque J, Simon C, Marchal JC, Hepner H, Wayoff M. Endoscopic pituitary tumor surgery. Laryngoscope. 102:198–202. 1992.

14. Jarrahy R, Berci G, Shahinian HK. Assessment of the efficacy of endoscopy in pituitary adenoma resection. Arch Otolaryngol Head Neck Surg. 126:1487–1490. 2000.

15. Jho David H, Jho Diana H, Jho HD. Endoscopic Endonasal Pituitary and Skull Base Surgery in Alfredo QH. In : Schmidek HH, editor. Schmidek & Sweet operative neurosurgical technique : indications, methods, and results. ed 6. Philadelphia: Saunders;2012. Vol 1:p. 257–279.

16. Jonathan GE, Sarkar S, Singh G, Mani S, Thomas R, Chacko AG. A randomized controlled trial to determine the role of intraoperative lumbar cerebrospinal fluid drainage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas. Neurol India. 66:133–138. 2018.

17. Kobayashi S, Sugita K, Takemae T, Tanizaki Y. Retraction system for transsphenoidal surgery. Technical note. J Neurosurg. 62:307–309. 1985.

18. Koc K, Anik I, Ozdamar D, Cabuk B, Keskin G, Ceylan S. The learning curve in endoscopic pituitary surgery and our experience. Neurosurg Rev. 29:298–305. discussion 305. 2006.

19. Kutlay M, Gönül E, Düz B, Izci Y, Tehli O, Temiz C, et al. The use of a simple self-retaining retractor in the endoscopic endonasal transsphenoidal approach to the pituitary macroadenomas: technical note. Neurosurgery. 73 Suppl Operative 2:ons206–ons209. 2020; discussion ons209-ons210. 2013.

20. Liu B, Wang Y, Zheng T, Liu S, Lv W, Lu D, et al. Effect of intraoperative lumbar drainage on gross total resection and cerebrospinal fluid leak rates in endoscopic transsphenoidal surgery of pituitary macroadenomas. World Neurosurg. 135:e629–e639. 2020.

21. Lucas JW, Bodach ME, Tumialan LM, Oyesiku NM, Patil CG, Litvack Z, et al. Congress of neurological surgeons systematic review and evidencebased guideline on primary management of patients with nonfunctioning pituitary adenomas. Neurosurgery. 79:E533–535. 2016.

22. Mamelak AN. Pro: endoscopic endonasal transsphenoidal pituitary surgery is superior to microscope-based transsphenoidal surgery. Endocrine. 47:409–414. 2014.

23. Mehta GU, Oldfield EH. Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas. J Neurosurg. 116:1299–1303. 2012.

24. Park JH, Choi JH, Kim YI, Kim SW, Hong YK. Modified graded repair of cerebrospinal fluid leaks in endoscopic endonasal transsphenoidal surgery. J Korean Neurosurg Soc. 58:36–42. 2015.

25. Prevedello DM, Kassam AB, Gardner P, Zanation A, Snyderman CH, Carrau RL. “Q-tip” retractor in endoscopic cranial base surgery. Neurosurgery. 66:363–366. discussion 366-367. 2010.

26. Rolston JD, Han SJ, Aghi MK. Nationwide shift from microscopic to endoscopic transsphenoidal pituitary surgery. Pituitary. 19:248–250. 2016.

27. Shikary T, Andaluz N, Meinzen-Derr J, Edwards C, Theodosopoulos P, Zimmer LA. Operative learning curve after transition to endoscopic transsphenoidal pituitary surgery. World Neurosurg. 102:608–612. 2017.

28. Songtao Q, Yuntao L, Jun P, Chuanping H, Xiaofeng S. Membranous layers of the pituitary gland: histological anatomic study and related clinical issues. Neurosurgery. 64 Suppl 3:ons1–ons9. discussion ons9-ons10. 2009.