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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4368_Библиотеки_им_академика_М_И_Перельмана
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Anterior Endoscopic Petrosectomy
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a
c
Fig. 18.4 Cholesterol granuloma at the petrous apex. (a) Axial contrast-enhanced magnetic resonance imaging showing the
cholesterol granuloma at the petrous apex. The tumor enhanced homogenously. (b) CT scan shows the erosion of the bone at left
petrosal apex. (c, d) Postoperative axial CT scans shows the drainage tube inserted into the tumor cavity to the sphenoid sinus.
• Quantitative analysis demonstrated that the EEA corri-
dor could be expanded laterally, with an angled drill, to
obtain a surgical field that is up to 1.8 times wider than
the bone window between both paraclival ICA.
7
b
d
A marsupialization of the lesion was completed via
endonasal approach as described in this chapter. He tolerated the procedure well and post-op imaging remained stable.
• Removal of cortical clival bone causes venous bleed-
ing from the basilar plexus. This is best control with
hemostatic paste but bone wax, oxidized methylcellulose, and gelatin sponges are all useful.
• The selection of a surgical approach depends on the
position of the lesion relative to the ICA, degree of
tumor extension, and pathology. The EEAs are ideal
for lesions that abut the lateral recesses of the sphenoid sinus. Advantages over the transcranial approaches include shorter operative time, no craniotomy, easy
follow-up at the clinic, and faster recovery.
18.5 Case Example
A 35-year-old man initially presented to his primary care
physician with symptoms including intermittent dizziness, fatigue, neck stiffness, and left facial numbness.
A contrasted MRI of the brain revealed a lesion inferomedial to the left internal auditory canal. The lesion was
bright on both T1 and T2 images, suggesting a benign cholesterol granuloma (Fig. 18.4).
References
1. Kawase T, Shiobara R, Toya S. Anterior transpetrosal-transtentorial approach for sphenopetroclival meningiomas: surgical method
and results in 10 patients. Neurosurgery 1991;28(6):869–875,
discussion 875–876
2. Muto J, Kawase T, Yoshida K. Meckel’s cave tumors: relation to the
meninges and minimally invasive approaches for surgery: anatomic and clinical studies. Neurosurgery 2010;67(3, Suppl Operative):ons291–ons298, discussion ons298–ons299
3. Samii M, Tatagiba M, Carvalho GA. Retrosigmoid intradural
suprameatal approach to Meckel’s cave and the middle fossa: surgical technique and outcome. J Neurosurg 2000;92(2):235–241
4. Iaconetta G, Fusco M, Cavallo LM, Cappabianca P, Samii M, Tschabitscher M. The abducens nerve: microanatomic and endoscopic
study. Neurosurgery 2007;61(3, Suppl):7–14, discussion 14
5. Prevedello DM, Pinheiro-Neto CD, Fernandez-Miranda JC, et al.
Vidian nerve transposition for endoscopic endonasal middle fossa
approaches. Neurosurgery 2010;67(2, Suppl Operative):478–484
6. Vescan AD, Snyderman CH, Carrau RL, et al. Vidian canal: analysis and relationship to the internal carotid artery. Laryngoscope
2007;117(8):1338–1342
7. Muto J, Prevedello D, Ditzel Filho L, et al. Comparative analysis of the anterior transpetrosal approach with the endoscopic endonasal approach to the petroclival region. J Neurosurg
2016;125(5):1171–1186
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Section 5
Clivus and Posterior
XXXXXXXX19 Pituitary Gland
Transposition and
Retrosellar Approach 197
Cranial Fossa
20 Transclival Approach 209
21 Endoscopic Approaches to
the Craniovertebral Junction 217
22 The “Far Medial”
(Transcondylar/
Transtubercular) Approach
to the Inferior Third of
the Clivus 231
23 Jugular Foramen Approach 239
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Chapter 19
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19.1 Indications 200
Pituitary Gland
Transposition and
Retrosellar Approach
19.2 Surgical Steps 200
19.3 Case Example 204
19.4 Complications 205
19.5 Tips and Tricks 206
Pituitary Gland Transposition and Retrosellar Approach
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19 Pituitary Gland Transposition and Retrosellar
Approach
Daniel M. Prevedello, Leo F. S. Ditzel Filho, Edward Kerr, Ali Jamshidi, Brad Otto, Ricardo L. Carrau
Introduction
Extradural lesions in the retrosellar space and intradural
lesions in the interpeduncular cistern pose a significant
technical challenge to the surgeon attempting to reach
this region. Critical neurovascular structures including the
oculomotor nerve, trochlear nerve, and posterior communicating artery (with perforators) must be traverse, which
limits the operative window available to address these
lesions from laterally. When approaching this region
from an anterior midline, transsphenoidal route, the
pituitary gland similarly guards access to the retrosellar
space. However, unlike the aforementioned neurovascular
structures, the pituitary gland may be transposed, giving
unfettered access to lesions in this region.
19.1 Indications
• Retrosellar extradural lesions such as chordoma and
chondrosarcoma.
• Retrosellar intradural lesions of the interpeduncular
cistern such as craniopharyngioma and meningiomas.
19.2 Surgical Steps
19.2.1 Sinonasal Cavity Preparation
Cranial fixation pins are applied, the patient is positioned
supine, and the head is translated upward slightly to facilitate the access. Because the sellar and retrosellar regions
are located relatively in-line with the angle created by the
sinonasal access corridor, neither flexion nor extension of
the neck is recommended, as the neutral position is the
most ergonomically favorable for working toward these
regions. If both surgeons are right-handed, which is the
most common case, the neck may be slightly tilted toward
the left (away from the surgeons in the coronal plane of
the patient’s body) and then slightly rotated toward the
right (toward the surgeons) to further improve operative
ergonomics. The patient is then registered to the stereotactic navigation device using preoperative magnetic resonance imaging (MRI) to delineate the lesion of interest
as well as a computed tomography angiogram to highlight the intracranial vasculature.
The nasal cavity is decongested with either 0.05%
oxymetazoline spray or 1:100,000 epinephrine injected
into the axilla of the middle turbinate, anterior nasoseptal mucosa, and the region of the sphenopalatine artery.
A bilateral inferior and middle turbinates are infiltrated
with epinephrine-containing anesthetic to further promote hemostasis. Both inferior turbinates and the left
middle turbine are lateralized bluntly, taking care not
to lacerate their mucosa. The right middle turbinate is
medialized to expose its attachment and then removed
to permit adequate room for both the nasal endoscope
and a suction tip throughout the case. This is done in an
anterior-to-posterior fashion with scissors using multiple
cuts at the attachment, with the scissors oriented parallel with the nasal floor (spreading laterally when opened)
with downward pressure on the turbinate in between
cuts to facilitate hemostasis and to avoid creating an
inadvertent skull base defect. Next, the uncinate process
is removed, revealing the natural ostium of the maxillary
sinus and maximizing the view of the prominent ethmoid
bulla, which is resected with a microdebrider, revealing
the lamina papyracea laterally. The microdebrider is
then used to remove as much of the anterior and posterior ethmoid air cells as is necessary to gain unimpeded
access to the sphenoid sinus. The lamina papyracea serves
as the lateral limit for resection of the ethmoid air cells
to maximize the space available in the sinonasal corridor.
In anticipation of working in the posterior fossa subdural
space, a nasoseptal mucosal flap pedicled on the posterior
nasoseptal artery (a branch of the sphenopalatine artery)
is harvested at this point using needle-tip electrocautery
along the superior and inferior borders of the sphenoid
face, extending anteriorly along the nasal septum 1 to 2
cm below the anterior skull base superiorly (to preserve
olfaction) and roughly at the junction of the nasal septum
and nasal floor.
eral border of the inferior incision to include the inferior
turbinate mucosa, it is rarely necessary or advantageous
to do so. Anteriorly, the inferior and superior incisions are
joined with an incision parallel to the columella just proximal to the mucosal–epidermal junction. The flap is elevated from the nasal septum using a ball-tip probe in an
anterior-to-posterior fashion, taking care not to perforate
the flap or compromise its proximal blood supply, and
then it is stored in the choana for the duration of the case
to prevent accidental blunt injury or entanglement with a
spinning drill. The synostosis of the vomer and the sphenoid rostrum is identified and bluntly disarticulated, and
1 to 2 cm of the bony septum is removed using a backbiting rongeur to facilitate bimanual surgery through
both nares as well as to permit a mucosal “reverse” flap
to cover the denuded nasal septum to avoid postoperative
crusting on it. To create the reverse flap, a vertical incision
in the coronal plane of the rostrum is made in the contralateral mucosa, and horizontal incisions are made 1 cm
caudal to the skull base and at the level of the nasal floor.
This randomly vascularized flap is then pulled forward
to cover the contralateral (typically right-sided) denuded
donor septum, fixed in place with absorbable suture, and
protected with a silicone splint to prevent inadvertent
injury from subsequent instrument passage.
1
Although it is possible to extend the lat-
200
19.2.2 Sphenoid Preparation
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The sphenoid ostia are visible posterolaterally to the rostrum. These can be substantially widened bluntly with a
Cottle dissector and then expanded using a Kerrison rongeur once the surgeon has visualized the roof and lateral
walls of the sinus. The rostrum is then resected entirely,
completing a wide anterior sphenoidotomy, which provides the essential freedom of movement for subsequent
bimanual dissection as well as placement of an angled
endoscope, if necessary, along the sphenoid sinus floor.
The intrasinus septae are visualized (Fig. 19.1) and care-
fully drilled (not cracked, as they nearly always terminate
on an internal carotid artery [ICA])
posterior aspect of the sinus. At this point, the critical
anatomic landmarks of the posterior sphenoid sinus are
identified: the clivus, the paraclival carotid arteries, the
anterior sellar face, the medial and lateral opticocarotid
recesses, the tuberculum sellae, and the parasellar carotid
protuberances (Fig. 19.2).
The anterior sellar bone is thinned with a 3- or
4-mm-diameter coarse diamond drill and extended outward over the tuberculum sellae to include the planum
anterosuperiorly, the medial cavernous sinuses laterally,
and the inferior intercavernous sinus (IIS) and sellar floor
inferiorly. The thinned bone is then flaked off bluntly
from the sellar face and smoothed with a Kerrison rongeur laterally, ensuring the parasellar dura and ICAs are
not injured in doing so. With adequate thinning, the sellar
floor can usually be fractured off with gentle downward
pressure applied with a Cottle dissector below the sellar
dura. Superiorly, an adequately thinned tuberculum can
also be removed bluntly. After bone removal, one should
see the four blues around the sella: bilateral cavernous
sinuses, the superior intercavernous sinus (SIS), and the
IIS confirming an adequate exposure.
2
until flush with the
Pituitary Gland Transposition and Retrosellar Approach
Fig. 19.1 Intrasinus septae visualized from outside the
anterior aspect of the sphenoid sinus leading to the internal
carotid artery protuberances bilaterally.
19.2.3 Intradural Preparation and
Pituitary Transposition
The anterior sellar dura is incised carefully with a feather
blade knife, ensuring the underlying pituitary gland is not
injured. It is especially important to maintain the integrity of the gland’s capsule, as inadvertent injury greatly
increases the difficulty of defining the plane between
the gland and the sellar dura, leading to glandular injury
(Fig. 19.3). Next, the dura of the tuberculum sellae is
incised, ensuring that the underlying prechiasmatic cistern arachnoid is not initially violated (Fig. 19.4).
Between the sellar dura and the tuberculum dura, the SIS
is now isolated and ligated after coagulation with bipolar electrocautery or thrombosis induced by hemostatic
agents (Fig. 19.5). The incision is carried laterally just
below the SIS and at the level of the IIS as well, to view
the entire anterior aspect of the pituitary gland from the
diaphragma to the sellar floor. Laterally, small fibrous attachments tether the pituitary gland to the medial cavernous sinus dural walls (Fig. 19.6). These “pituitary ligaments” must be released, usually by sharp dissection, to
Fig. 19.2 Sphenoid sinus visualized from outside the
anterior aspect with the anterior face removed. The critical
anatomic landmarks are identifi ed: the clivus, the paraclival
carotid arteries, the anterior sellar face, the medial and
lateral opticocarotid recesses, the tuberculum sellae, and the
parasellar carotid protuberances.
significantly reposition the gland.3 Although the gland is
detached from the medial cavernous sinus wall, it should
still be left attached to the posterior sellar dura to maintain venous drainage. The IIS is transected laterally in the
transition between the floor of the sella and the medial
cavernous sinus wall. As the gland is detached laterally,
it “rolls” superiorly even with the posterior attachment
preserved. Additionally, the incision in the inferolateral
aspect of the sellar floor should stop posteriorly at the
entry point of the inferior hypophyseal arteries, which
arise from the intracavernous meningohypophyseal
trunk and traverse the dura of the medial cavernous sinus
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Pituitary Gland Transposition and Retrosellar Approach
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Fig. 19.3 Dissection of the anterior sellar dura from the
pituitary gland with a ball-tip probe. Note the dural incision
is made with attention paid to avoiding laceration of the
underlying gland capsule.
Fig. 19.5 Connecting the sellar and tubercular incisions
through the superior intercavernous sinus using angled scissors.
Fig. 19.4 Refl ection of the dura of the tuberculum sellae
from the optic nerve.
Fig. 19.6 Ball-tip probe adjacent to a pituitary ligament,
which tethers the gland to the medial cavernous sinus wall.
wall (Fig. 19.7). At the same level of the entrance of the
inferior hypophyseal artery, there is a significant point
of glandular venous drainage, which is conserved once
the artery is preserved. Preserving the artery and venous
drainage seems to correlate with less incidence of diabetes insipidus. The final preparatory step involves identifying the anterior fold of dura mater that forms the sellar
roof, termed the diaphragma sellae or central aperture.
Having incised the dura above and below this structure, it
is possible to incise it from anteriorly to posteriorly up to
202
the pituitary stalk, taking care not to violate the prechiasmatic cistern arachnoid superiorly and the pituitary stalk
or superior hypophyseal arteries. Once complete, the pituitary gland is entirely free to transpose superiorly into
the suprasellar space. It is important to understand that
this description is a variation to the technique previously
described.
3
Specifically, the preservation of the posterior
dura still attached to the gland and the respective posterior intercavernous sinus allows for a physiologic preservation of the gland with appropriate venous drainage. The
Fig. 19.7 The right inferior hypophyseal artery, arising
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from the intracavernous meningohypophyseal trunk, is seen
traveling toward the pituitary gland.
drawback of this technique is the fact that the gland may
be pulled down by the posterior dural attachment, and
glue or constant superior retraction may be necessary.
Pituitary Gland Transposition and Retrosellar Approach
Fig. 19.8 A straight dissector retracts the pituitary gland
(without disturbing its attachment to the posterior sellar dura),
revealing the dorsum sellae.
19.2.4 Posterior Clinoidectomies
and Dorsum Sellae Resection
The posterior sellar dura is then retracted superiorly and
the dorsum sellae is exposed (Fig. 19.8). The dorsum sellae
and upper third of the clivus are then entirely drilled until
the underlying dura of the posterior fossa is seen posterior
to it (Fig. 19.9). This bone may be gently peeled from the
dura after doing so under greater control than is possible
without thinning. This is critical in protecting the parasellar segment of the ICA and the abducens nerve from injury. It is important to note that care is taken to drill the
posterior clinoid processes free of the dorsum sellae prior
to its removal (so-called shoulder osteotomies), as they
are attached laterally to the petrous apex and anteriorly
by the interclinoid ligaments. These ligaments are in intimate association with the carotid canal, and mobilizing the
dorsum sellae without disconnecting it from the posterior
clinoids risks arterial injury. Furthermore, the oculomotor
nerves are positioned immediately lateral to the posterior
clinoids, so the osteotomies are crucial to allow the surgeon to dissect the posterior clinoids, mobilizing them
from lateral to medial away from the nerves.
19.2.5 Dissection in the
Interpeduncular Cistern
Resection of the dorsum sellae and apical clivus reveals
the upper posterior fossa dura. This is incised in the midline first, and then the incisions are lateralized, taking
care to avoid neurovascular injury. The presence of the
basilar plexus is the main limitation to reaching the interpeduncular fossa and prepontine cistern, and we utilize
flat bipolar electrocautery to coagulate this plexus prior
to dural incision. Liliequist’s membrane is encountered,
Fig. 19.9 A drill is used to resect the dorsum sellae and upper
third of the clivus, revealing underlying dura of the posterior
fossa.
and dissection through this reveals the posterior fossa
circulation as well as the oculomotor nerve (Fig. 19.10).
The retroinfundibular space is exposed superiorly and
posterior to the pituitary gland, and this is best visualized with an angled endoscope (Fig. 19.11). Often,
pathology in this region transgresses the floor of the
third ventricle, and removal of the lesion yields a view of
the third ventricle from below. Particular caution must
be exercised in this region, as the floor and walls of the
third ventricle comprise the hypothalamus, and injury to
this can be catastrophic for the patient.
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Pituitary Gland Transposition and Retrosellar Approach
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Fig. 19.10 Dissection through Liliequist’s membrane,
revealing the posterior fossa circulation as well as the
oculomotor nerve.
Fig. 19.12 Postcontrast T1-weighted sagittal MRI of the
brain in the case example patient demonstrating a type 3
craniopharyngioma.
Sag
Fig. 19.11 The retroinfundibular space viewed from below
with a 45-degree endoscope angled cranially.
Cor
Fig. 19.13 Postcontrast T1-weighted coronal MRI of the
brain in the case example patient demonstrating a type 3
craniopharyngioma.
19.3 Case Example
A 17-year-old girl presented with amenorrhea, the investigation of which revealed panhypopituitarism but
no cranial nerve deficit or visual defect. Postcontrast
T1-weighted sagittal (Fig. 19.12) and coronal (Fig. 19.13)
MRI of the brain demonstrated a type 3 craniopharyngioma (situated posterior to the pituitary infundibulum)
occupying the interpeduncular cistern and extending
superiorly to the third ventricle.
operating room for resection of the lesion via an endoscopic endonasal approach (EEA) as described in this
chapter. After an uncomplicated sinonasal dissection,
204
4
She was taken to the
including a right middle turbinectomy, posterior septectomy, and nasoseptal flap harvest, the bone overlying the
planum sphenoidale, tuberculum sellae, and sella turcica
was removed. The sellar dura was opened, revealing the
pituitary gland, and this was extended cranially toward
the SIS. The planum dura was then opened toward the
tuberculum sellae, at which point the SIS was cauterized
and incised, connecting the dural incisions. The diaphragma sellae was then incised in an anterior-to-posterior
fashion, exposing the pituitary stalk that proved to be in
front of the tumor (Fig. 19.14). The decision was made
to transpose the gland as the patient had some pituitary
function (panhypopituitarism). The pituitary ligaments
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