Transsphenoidal hypophysectomy

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Because of the results presently attainable in the remission of diabetic retinopathy and in the palliative treatment of cancer of the breast and prostate, hypophysectomy is recommended in an increasing number of patients.

Although the intracranial operation is attended by relatively low morbidity and mortality when performed by an experienced and skillful surgeon, the recently revived, alternative method of ablating the pituitary through an extracranial transsphenoidal approach has the advantages of providing rapid access to the sella turcica and the certainty of complete extracapsular enucleation of the gland under direct magnified visualization with the dissecting microscope. In addition,

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Address reprint requests to: Jules Hardy, M.D., F.R.C.S., 1386 Sherbrooke Street East, Montreal 133, Quebec, Canada.

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Figures

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    Operative setup for transsphenoidal surgery with the combined use of televised radiofluoroscopic control and the binocular operating microscope.

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    Operative drawings showing the oronasal, rhinoseptal, transsphenoidal approach to the sella turcica. A. Sublabial incision. B. Elevation of the nasal mucosa from the floor. C. Submucosal dissection from the septum (frontal view). D. Resection of the cartilagenous septum with a swiveled knife. E. Sagittal view of the submucosal dissection. F. After introduction of the subnasal speculum, the vomer begins to be seen, resembling the keel of a boat. G. Sagittal view of the speculum in position.

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    Operative drawings showing the sella turcica portion of the procedure. A. Resection of the vomer and the floor of the sphenoid sinus, producing wide exposure of the cavity and of the sella turcica. B. Opening of the floor of the sella. C. Cruciate incision of the sellar dura. D. Elevation of dural flaps and initiation of the dissection of the gland at the superior surface in order to achieve the extracapsular plane of cleavage. E. Identification of the stalk. E-1. Horizontal anatomical section to illustrate the strict midline approach to the sella turcica. F. Low section of the stalk with blunt-ended scissors.

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    Views from television monitoring during placement of instruments in the sella turcica.

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    Enucleation of the pituitary and closure. A. Posterior, lateral, and inferior dissection of the gland. B. Total extracapsular pituitary enucleation. C. Muscle-packing of the sella cavity and preparation of the piece of cartilage carved out from the previously removed nasal septum. D. Cartilage wedged in place. E. A few loose catgut sutures on the alveolar incision. F. Reapproximation of the nasal mucosa with vaseline gauze endonasal packing. It is removed after 24 to 48 hours.

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    Selective removal of intrapituitary microadenoma from the lateral wing of the gland in a case of acromegaly.

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    Successive views during the surgical removal of a large pituitary adenoma with suprasellar expansion. A. Preoperative encephalogram. B. Verification of the position of the curette during surgical maneuver (action recorded on videotape). C. Drawing to illustrate movement of the curette as the adenoma is detached piecemeal. Notice the presence of the normal pituitary remnant inside the “capsule” abutted to the posterior wall of the sella. D. Complete collapse of the suprasellar expansion and detachment of the last fragment from beneath the tuberculum sellae. E. Final air injection via lumbar catheter to confirm that the chiasmatic cistern refills with air. Metallic clips are placed on the collapsed diaphragm for future control with plain skull radiograms.

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    Instrumentation for transsphenoidal hypophysectomy, specially designed with bayonet handle. Left to right: Two pituitary enucleators, a modified Cushing malleable spoon, a modified Ray's curette, and a fork for application of the cartilage. (Made by Downs Brothers and Mayer & Phelps Ltd., in England, U.S.A., and Canada.)

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    Transsphenoidal removal of a craniopharyngioma with a voluminous suprasellar cystic expansion. A. Preoperative pneumogram. B. After transsphenoidal aspiration of 30 cc of dark brown fluid, the cystic cavity is filled with air from the open sella. C. Complete collapse of the cyst capsule within the sella turcica. Capsule and floor of the third ventricle outlined. D. Dissection and removal of the capsule. E. Final position of the diaphragm sellae outlined by a clip marker.

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    Radical excision of a subdiaphragmatic craniopharyngioma. Left. Notice that the pituitary gland is outside the capsule of the tumor. Right. Operative specimen of a solid craniopharyngioma which was completely excised transsphenoidally.

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    Transsphenoidal approach to the clivus for removal of a voluminous chordoma. Televised radiofluoroscopic control view during removal of the chordoma (left) and artist's illustration of the procedure (right).

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