DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Pituitary mass.
POSTOPERATIVE DIAGNOSIS: Pituitary macroadenoma.
PROCEDURES PERFORMED:
1. Neuroendoscopy with excision of pituitary tumor, transsphenoidal.
2. Stereotactic computer assisted surgery.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: 200 mL.
SPECIMENS: Pituitary mass.
DESCRIPTION OF OPERATION: The patient was brought to the operating room for neuroendoscopy with excision of pituitary tumor and was placed in the supine position on the operating room table. General face mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. The table was turned 180 degrees.
At that point, 8 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the middle turbinate, septum and sphenoid face bilaterally.
At that point, 5% cocaine-soaked pledgets were placed in the nares bilaterally for further decongestion. At that point, the patient’s image-guided CT scans were then loaded onto the LandmarX imaging guidance machine. The probe was then secured to the patient’s head with a head band.
At that point, several points of registration were chosen on the patient’s forehead. The points were then registered to the CT scan. The field of least error included the sphenoid and sella. The error was 1.6 mm. The image guidance machine was used throughout the entire procedure for localization of the sphenoid sinus, optic nerves and carotid artery.
After the registration, the cocaine-soaked nasal pledgets were then removed from the nose. A 4 mm nasal endoscope was then used to visualize the right nasal cavity. The patient had a moderate right nasal septal deflection. The middle turbinate was visualized and the inferior third was lateralized with a caudal elevator.
At that point, a 4 mm Straightshot microdebrider was used to remove the inferior quarter of the middle turbinate to allow visualization of the superior turbinate. The superior turbinate lower half was then removed with the Straightshot microdebrider. This allowed access to the natural sphenoid ostium. The microdebrider was then used to open the sphenoid os in the medial and inferior direction.
Bleeding was recognized from the right posterior nasal artery and was controlled with suction Bovie cautery. Kerrison rongeurs were then used to enlarge the sphenoid ostium laterally and superior to allow visualization of the right optic nerve and the planum sphenoidale. The sphenoid ostium was opened inferiorly to the floor of the sphenoid sinus.
Attention was then turned towards the left nasal cavity. Again, using a 0 degree 4 mm endoscope, the middle turbinate was identified and lateralized in its lower third with a caudal elevator. A Straightshot microdebrider was then used to remove the inferior quarter of the middle turbinate in an anterior-posterior direction. This allowed access to the superior turbinate, which was again removed in its inferior half with the Straightshot microdebrider.
The natural os of the sphenoid was then again identified and enlarged in an inferior-medial direction with the Straightshot microdebrider. Kerrison rongeurs were then used to enlarge the sphenoid ostium superiorly to the plane of the sphenoidale laterally to allow visualization of the optic nerve and carotid artery, and inferiorly to the floor of the sphenoid sinus. The branches of the posterior nasal artery were cauterized with suction Bovie cautery. Suction Bovie cautery was then used to cauterize the junction of the cartilaginous bony septum in a vertical fashion.
A caudal elevator was then used to transect the septum in a vertical fashion at the border of the cartilaginous and bony septum. The mucosa overlying the bony nasal septum was elevated with a caudal elevator. The elevated mucosa was then removed with the Straightshot microdebrider. The large pituitary was then used to remove the bony portion of the septum and preserved for reconstruction. The intersinus septum was removed with a straight pituitary and Tru-Cut rongeurs. A backbiter was then used to remove 1 cm of the posterior cartilaginous nasal septum.
The wound was then thoroughly irrigated with warm saline. The approach allowed visualization of the carotid arteries bilaterally, the optic nerves bilaterally, the planum sphenoidale superiorly and the floor of the sphenoid sinus inferiorly. The entire sella was within the field of the operation.
At that point, the surgical procedure was turned over to Neurosurgery. The otolaryngologist used the 0 degree nasal endoscope to provide visualization of the entire neurosurgical part of the procedure.
After completion of the neurosurgical part of the procedure, approximately 5 mL of FloSeal was placed in the sphenoid sinus and posterior ethmoid sinuses. Doyle splints were then placed in the nares bilaterally and sewed in the midline with a 3-0 Prolene stitch. Merocel was then placed in the nasal cavities bilaterally for optimized hemostasis.
At that point, the patient went to the MRI for postoperative MRI visualization of the resected tumor. The decision was made, after the MRI by Neurosurgery, to awake the patient from general anesthesia. The patient was transported to the postanesthesia care unit for extubation in stable condition.
