Procedure description

A transsphenoidal surgery for pituitary tumor  is performed to remove/partially remove a benign tumor from within the pituitary gland.   

The patient will be taken to the operating room and put to sleep under general anesthesia.  The surgeon may elect to have a lumbar drain placed.  This is a tube placed within the spinal canal in the low back, and permits crainage of spinal fluid or instillation of air within the spinal canal, which may help the surgeon to perform the surgery.  The head is often placed in three fixation points (Mayfield head pins).  The surgeon may register a navigational device which allows the use of "real time" intraoperative navigation.    A portion of the outer mid thigh is usually exposed to allow the surgeon to take a small tissue graft.  An ENT (ear, nose, throat surgeon) surgeon or the neurosurgeon will make the approach through the upper gum area within the mouth, traversing the deep nasal cavity and sphenoid sinus (a cavity filled with air and mucous membranes, just in front of the pituitary gland:  therefore the term transsphenoidal to describe the route of the surgery), to get to the base of the skull where the pituitary gland lies.  The neurosurgeon will then open the floor of the sella (cavity in the skull base where the pituitary gland lies).  Next the dura (firm tissue lining the sella) will be opened, and the pituitary gland will be seen.  If the tumor is large, the surgeon will immediately see it, but if it is small and buried deeply within the gland, the surgeon will need to open the gland and look for it.  After removing as much of the tumor as possible, the surgeon will achieve hemostasis (stop the bleeding), and may place a graft of fat or fascia lata (firm tissue harvested from the thigh), and place it within the sella and sphenoid sinus.  The nasal cavities and gums will then be closed.            

Procedure Risks

Risks for craniotomy for acoustic neuroma can be broken down into two categories, 1) those related to the operative site, and 2) those related to the risks of anesthesia. 

         Risks related to the operative site

Surgical Exposure:  The patient is placed lying on their back so as to allow good access to the nasal passages and tumor.     There is risk of non healing of the gums through which the incision is made,  post operatively.  Although very uncommon, there can be injury to or tearing of the scalp from the pins on the Mayfield clamp.  There is the potential for spinal fluid leak postoperatively, which may require additional surgery or placement of a lumbar drain to repair.

Brain injury:  The surgery involves opening the nasal passages to expose the tumor.  There can be infection from the oral and nasal cavities.  The pituitary gland is located in a very small space.  Above it is the optic chiasm (nerves to the eyes), and next to it on either side is the cavernous sinus (a large vein) which contains the carotid artery (a critical artery supplying blood to one hemisphere of the brain) and cranial nerves III, IV, and VI (these nerves supply facial sensation and eye movement). Behind the pituitary gland is the brainstem and basilar artery (critical artery supplying the brainstem and rear portions of the brain).  Certainly these structures are at risk, and although damage to them is not likely, if it does occur, the consequences may be devastating, with resulting blindness, paralysis and death.   In addition, if there is brain injury, this could result in weakness, seizures, stroke, paralysis, coma or death.  If a spinal fluid leak occurs, if may be necessary to have additional surgery, or place a lumbar drain.  There is a possibility of tumor remaining after surgery, or of recurrence of tumor in the future.  If there has been impairment of vision preoperatively, due to compression of the optic nerves (nerves going to the eyes), the vision may not necessarily improve with surgery.

General Risks

These include such general difficulties, such as bleeding, infection, stroke, paralysis, coma and death.  Incisions in the gums generally heal well, but could become  tender, numb,  or may heal in an unpleasant manner.    The tumor  may recur, requiring additional surgery or radiation in the future.  In addition, although every attempt is made to protect all areas of the body from pressure on nerves, skin and bones, injuries to these areas can occur, particularly with prolonged cases.

Risks of Anesthesia: Blood clots in the legs, heart attacks, reaction to the anesthetic, reaction to blood transfusion, if it given

 

Post-operative care:

There may be some pain and discomfort associated with transsphenoidal surgery.  Your surgeon will prescribe pain medications for any pain associated with the . 

1. Immediately upon discharge, contact our office and set up an appointment for staple removal if one has not already been set up.
2. Take it easy until seen by the physician.  This does not mean bed rest, but athletic activities during this period are definitely not recommended.  Please give your incision a chance to heal.  Avoid any type of activity which might risk a blow to the head.
3. You may resume activity as your body permits, but avoid extremes.  For example, walking is fine, but avoid any strenuous running.  USE GOOD JUDGMENT  AND COMMON SENSE.  If you have a question, ask your doctor.
4. No driving until cleared with your surgeon.  A driving test may be required, at the discretion of your surgeon.  Even though you may feel fine, your peripheral vision and reflexes may have been affected, and we want you to be safe on the road for yourself as well as for others.
5. You may shower after you go home unless otherwise instructed.  Cover the incision on your thigh with plastic wrap before the shower and remove it afterward.  Change dressing immediately.    You may shower without covering the incision one week after the staples are out.  Follow instructions concerning care of tapestrips, stitches or staples.  Your surgeon or his nurse clinician will explain the techniques used in the closure of your incision.
6. Sexual activities are permitted.
7. If you notice swelling, redness or opening of the incision, or if there is any clear fluid draining from it, please contact your surgeon immediately!  If you develop a fever, stiff neck or chills, contact the office immediately.  Take your temperature at 4:00 PM daily until the clips are removed.  Call if greater than 101 degrees Fahrenheit.
8. If you have a seizure, notify our office or come to the emergency room.
9. If you develop any new weakness or changes in vision, notify our office.
10. If you have any questions, call our office, and for after hours emergencies, call the medical society.
11. Take your medications prescribed on discharge, as directed.  If steroids or hormonal replacements have been prescribed, make sure to follow directions carefully
12. Do not take any medications which will "thin the blood" such as coumadin or aspirin, or other non-steroidal antiinflammatory medications, unless otherwise advised by your physicians.
13. Make sure to follow up with any other physicians involved in your care.  These may include your family physician, neurologist, endocrinologist and radiation oncologist.