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Transantral sphenoidal hypophysectomy
Transantral
Sphenoidal
Hypophysectomy
H. RANDALL TOLLEFSEN, M.D.,THEODORE R. MILLER, M.D.,AND FRANK New York, New York
anatomic region, to utilize the transantral sphenoidal approach as an addition to his surgical armamentarium. Prior to surgery, stereo x-ray studies which include lateral, posteroanterior, and submental vertex views should be obtained to outline the sphenoid sinuses and sella turcica. Hamberger et al. [1] classify the sphenoid sinuses into three types: conchal, presellar, and sellar. This classification depends upon the extent to which the sphenoid bone is pneumatized. In the conchal type (Fig. IA) the sphenoid sinus does not extend into the body of the sphenoid bone. The sella turcica, therefore, is separated from the sinus by a thick layer of cancellous bone, which usually makes the pituitary inaccessible by this approach. This type is better suited to the transcranial procedure. The conchal type occurs in 3 per cent of all skulls studied. In the presellar type (Fig. 1B) the sphenoid sinus extends back to the anterior wall of the sella turcica, but because there is no posterior or posterolateral extension, the bulge into the sinus, which is characteristic of the sellar type, is absent. The presellar type occurs in 11 per cent of cases and, although not an absolute contraindication to the transantral approach, may make the operation more difficult. In the sellar type (Fig. lC), the most common, the sinus extends deeply into the sphenoid bone so that the anterior and inferior wall of the sella turcica bulges into the sinus and is easily visible. This wall is usually thin, approximately 0.5 mm. The sellar type occurs bilaterally in 59 per cent of the cases and at least on one side in 86 per cent. The septum in the sphenoid sinus divides it into the right and left; its position may vary. Ideally, it should be in the midline, with the posterior portion over the sellar bulge, acting as a guide to the midline of the sella turcica. The
From the Head and hTeck Service and the Bone Tumor Service of the Department of Surgery, Memorial Hospital for Cancer and Allied Diseases and James Ewing Hospital, New York, Nrti York.
YPOPHYSECTOMY has been practiced for many years in the treatment of primary tumors of the pituitary gland. It has now become an accepted procedure in the ablative treatment of disseminated mammary cancer. Indications reported by others include cancer of the prostate, melanoma, diabetic retinopathy not responding to insulin, malignant exophthalmos, Cushing’s syndrome, cardiac edema not responding to diuretics, thyroid cancer, and bone sarcoma. Many surgical approaches have been detranscranial, transnasal, namely, scribed, transethmoidal transpalatal, transseptal, through an incision at the inner canthus of the All of these technics, eye, and transantral. except the transcranial, are modified approaches to the sella turcica through the sphenoid sinus. The surgical literature was reviewed and the various technics were carried out on twenty-five cadavers in the anatomy laboratory in an effort to select the best method. We concur with Hamberger et al. [1] that the transantral sphenoidal approach is the safest and simplest for total hypophysectomy. In one year, we have used this procedure in fifty-four patients and have been impressed with the following favorable aspects: the minimum of operative time, blood loss, trauma, morbidity, and low operative mortality, even in patients considered poor risks. This presentation has a twofold purpose: first, to describe, step by step, the technic of hypophysectomy as performed at Memorial Hospital; second, to encourage the head and neck surgeon, with his vast experience in this
H
Vol. 112, October IWd
P. GEROLD, M.D.,
569
Tollefsen, Miller, and Gerold
570
FIG. 1. Classification
of sphenoid sinuses: A, conchal; B, presellar; C, sellar.
position of the septum should be carefully studied in the submental-vertex x-ray films and used as a guide to the sella turcica. To facilitate the operation, the procedure should be planned so that one starts on the side which contains the larger sphenoidal sinus, preferably of the sellar type, with its thinner wall between the sphenoid sinus and the sella turcica. This decision is important because the initial breakthrough is critical. The thinner the wall, the easier it is to make the first small opening through bone so that the pituitary capsule can be visualized. In the presellar type, the thickness of the bone may make it necessary to use
electric burrs under Polaroida x-ray guidance. The operation is performed in two stages. The approach, in which the maxillary, ethmoid, and sphenoid sinuses are broken down and cleared, is the first stage and is relatively simple. This stage requires about twenty-five to thirty minutes of operating time. The beginning of the second stage is the most critical part of the procedure. The decision as to the exact location of the anteroinferior wall of the sella turcica, or “sellar bulge,” must be made. Once this is done, the removal of the pituitary gland can begin. This stage requires about twenty to thirty minutes.
FIG. 2. Incision and anatomy.
FIG. 3. Opening of maxillary antrum. American
Journal
of Surgery
Transantral
Sphenoidal
‘RUM
FIG. 4. Dissection
-.. 8)I 1
Hypophysectomy
then entered by making an opening in the anterior wall (Fig. 3) just above the canine fossa. The anterior wall is removed in all directions, the upper limit of the dissection being the point of exit of the infraorbital branch of the fifth nerve. The mucous membrane is removed from the antrum. The nasal pack is removed, and the mucous membrane and turbinates are then bluntly dissected from the mesial side of the lateral wall of the nasal cavity (Fig. 4) and displaced toward the nasal septum. After this, the bony lateral nasal wall is removed with a Kerrison type of rongeur. After the lateral wall is removed (Fig. 5A), the ethmoid cells are picked away, using an ethmoidal or pituitary forceps. At this point, the sphenopalatine artery is frequently encountered and may give some troublesome bleeding. This can be easily controlled by packing the cavity for a few minutes or by actually clamping the vessel and cauterizing it. After the ethmoid cells have been removed, the ostium of the sphenoid sinus can be seen. The anterior wall of the sphenoid sinus is removed with a rongeur. (Fig. 5B.) The septum of the sphenoid sinus is broken through and the opposite an-
of nasal mucosa and turbinates
FIRST
STAGE
The patient is prepared and draped in a semisitting position, with the back at an angle of approximately 45 degrees. An intraoral cuffed endotracheal tube is introduced and a pack inserted in the hypopharynx after the patient has been anesthetized. After the sinus roentgenograms are studied, the approach is made through the side in which the sphenoid sinus is larger and deeper. An Adrenalin@ pack is inserted in the operative side of the nasal cavity. A single injection of Adrenalin and Novacaine@ is made in the soft tissues of the cheek through the upper gingival buccal gutter on that side to decrease the bleeding and the amount of general anesthesia needed. A Caldwell-Luc type of incision (Fig. 2) is made in the gingival buccal gutter and the soft tissues reflected from the anterior wall of the antrum by blunt dissection with a periosteal elevator. Care should be taken to avoid injury to the infraorbital nerve. The maxillary sinus is Vol. 112, October 1966
A
’
FIG. 5. A, displacement of nasal mucosa and turbinates to septum; B, opening into sphenoid sinus; C, opening into opposite sphrnoid sinus and removal of posterior nasal septum.
Tollefsen,
572
FIG. 6. A,
turcica.
location of sellar bulge;
B,
Miller,
entering the sella
terior wall and sphenoidal cells removed as completely as possible. To facilitate greater visualization of the entire sphenoid cavity, it is frequently advantageous to remove part of the most posterior portion of the nasal septum at this stage. (Fig. 5C.) This is easily accomplished by biting it away with Kerrison forceps, beginning posteriorly. During the preceding dissection, the “sellar bulge” usually can be seen as can small oblique bulges lateral to it which are caused by the underlying internal carotid arteries. This completes the first stage of the operation. SECOND STAGE
The second stage consists in breaking through the posterior wall of the sphenoid sinus overlying the pituitary gland and exposing its capsule. After the capsule is incised, the gland is dissected free and removed intact. Once the mid-portion of the sella turcica has been located, this second stage can begin. If there is any question as to the location of the “sellar bulge” or if, because of a presellar sinus it is not visualized, the sella can be located by
and Gerold use of Polaroid x-ray film technic with a probe or silver clip in place as a marker. After locating the mid-portion (Fig. 6A), a special fine chisel is used to probe the bone in this region until a soft spot is found. A small window is then broken through to the pituitary capsule. (Fig. 6B.) At this time, a small sphenoidal punch is used to remove the anterior bony wall. When a window approximately 0.75 to 1 cm. in diameter has been made, the pituitary capsule can be seen protruding through the opening, and occasionally the transverse portions of the cavernous sinus can be seen. A cruciate incision is then made in the capsule of the pituitary gland using a curved knife. (Fig. 7A.) Care must be taken to avoid incising any bluish area, which may indicate a communication with the cavernous sinus. A special blunt dissector (Fig. 7B) is inserted between the capsule and the hypophysis, carefully dissecting in this plane on all sides. The four edges of the capsule are reflected outward. The gland is thereby loosened from its capsule (Fig. 7C) and, with gentle downward traction, the pituitary stalk is ruptured and the gland lifted out intact. Dissection of the capsule must be performed carefully and gently because of the proximity of the cavernous sinus. The optic chiasm and brain above are protected by the clinoid processes and the diaphragm sellae, through which the stalk of the hypophysis emerges. After rupture of the stalk, a slight gush of spinal fluid and occasionally some bleeding may be encountered. This has never been significant in our experience. After removing the gland in this manner, we have been able to photogra.pl1 the specimen in each case, documenting the completeness of the removal. Prior to making the cruciate incision in the capsule, a 2 cm. cube of muscle is removed from the thigh and kept moist in saline solution. After the pituitary has been removed, a trimmed piece of this muscle is inserted through the opening in the capsule (Fig. 7D), plugging the defect in the sella turcica. This stops any leakage of cerebrospinal fluid and produces a dry field. A 1 inch gauze packing soaked in antibiotic solution is placed in the sphenoid sinus over the muscle plug, and this continuous packing is used to fill the antrum. The end of the pack is brought out through the nose after making an incision through the nasal mucosa near the nostril. The incision in the gingival buccal gutter is closed with interrupted sutures American
Journal
of Surgery
Transantral
Sphenoidal Hypophysectomy
573
INTERNAL
OPTIC
PITUITARY
FIG. i. A, cruciate incision in capsule; B, reflection of capsule; C, intracapsular dissection of pituitary gland; D, muscle and gauze packing in place.
of catgut, completing the operation. The nasal packaging is partially removed on the eighth and ninth postoperative days and completely on the tenth day. The hazards of the operation include possible damage to the base of the brain and/or cranial nerves, especially the optic chiasm, and severe hemorrhage from the carverous sinus or the internal carotid arteries. If the opening toward the sella turcica is made too high, one may get into the transverse portion of the cavernous sinus, optic chiasm, or even the cribriform plate. We have not experienced any of these complications to date. Our only difficulty has been locating the sellar bulge or, in its absence, determining where to make the initial breakthrough into the sella turcica. However, since the first twenty-five cases, we have been utilizing the Polaroid x-ray technic and this has eliminated the problem. Occasionally we have encountered large transverse communications between the cavernous sinuses, which have been troublesome. These obstacles have not caused any injury to Vol. 1117, October
lY66
the patient, but the hemorrhage resulting from the opening of the cavernous sinus is annoying and may make further procedure impossible at this time. The bleeding can be controlled by an Adrenalin pack or a piece of muscle placed against the opening. On the average, the patient loses about 150 cc. of blood during the operation. The procedure takes anywhere from forty-five minutes to one and a half hours and, if the cases are carefully studied and the patients properly positioned, no great difficulties in locating the hypophysis should be encountered. We plan to use an operating microscope to better visualize the capsular dissection in the future. This may prove to be an aid but is certainly not a necessity, in our experience. Postoperatively, the best laboratory indication of the completeness of hypophysectomy is the measurement of thyroid function. The cortisone withdrawal test is equally effective but is rather distressing to the patient and somewhat hazardous. We believe that our photographs (Fig. 8) showing the totally re-
574
Tollefsen, Miller, and Gerold
FIG. 8. A and B, total hypophysectomy. pituitary glands (lines in millimeters).
moved intact glands are the best proof of complete hypophysectomy. The only distressing complication after hypophysectomy has been the problem of diabetes insipidus, which is usually transitory and
Surgical specimens
showing intact
variable in severity. This has been controlled easily by the use of Pitressin@ in oil administered intramuscularly or, in the milder cases, by nasal insufflation of Pitressin snuff. All patients, of course, are cortisone-dependent and usually American Journal of Swgery
Transantral
Sphenoidal Hypophysectomy
575
FIG. 8B
leave the hospital on a daily maintenance dose of 50 mg. of cortisone orally. We have found that the patients complained more of their thigh incisions, where the muscle plug was obtained, than of their hypophysectomy. This speaks well for the nontraumatizing aspects of this approach. Vol. 112, October
1066
Mild rhinorrhea occurred in three of our patients early in the series. In none of these did it last more than five days. At first, we left the nasal packing in place only seven days and believe this was the causative factor. We also found that by keeping the patient in Fowler’s position after removal of the pack, the rhinor-
5’76
Tollefsen, Miller, and Gerold
rhea stopped. Apparently, this position favors tamponading the brain against the diaphragm sella. Since instituting removal of the pack on the tenth postoperative day and keeping the patient in Fowler’s position when in bed, we have not had any leakage of the cerebrospinal fluid. SUMMARY
It is not the purpose of this paper to discuss the indications or end results of hypophysectomy nor to compare hypophysectomy with adrenalectomy in ablative surgery for disseminated cancer. The results of ablative surgery for advanced cancer of the breast have been reported by the Joint Committee on Endocrine Ablative Procedures in Disseminated Mammary Carcinoma [2,3] in two previously published reports. This presentation describes in detail the surgical technic of transantral sphenoidal hypophysectomy. We believe that this is the easiest and best approach for complete removal of the pituitary gland. This procedure does not
require elaborate equipment and takes about forty-five to ninety minutes of operating time. It requires no skin incision, can be performed without the need of a blood transfusion, and is safe even for patients considered very poor surgical risks. We have had no death directly attributable to the operation and no serious complications, such as persistent rhinorrhea. We also believe that if an endocrine ablative procedure is indicated, this operation is safer for the patient and causes less operative morbidity than either bilateral adrenalectomy and oophorectomy or transcranial hypophysectomy. REFERENCES
1. HAMBERGER, C. A., HAMMER, G., SORLEN, G., and SJBGREN, B. Transantrosphenoidal hypophysectomy. Arch. Otolaryng., 74: 22, 1961. 2. Joint Committee on Endocrine Ablative Procedures in Disseminated Mammary Carcinoma. Adrenalectomy and hypophysectomy in disseminated mammary carcinoma. J.A .M.A ., 175: 787, 1961. 3. MACDONALD, I. Endocrine ablation in disseminated mammary carcinoma. Surg. Gynec. & Obst., 115: 215, 1962.
Sphenoidal
Hypophysectomy
H. RANDALL TOLLEFSEN, M.D.,THEODORE R. MILLER, M.D.,AND FRANK New York, New York
anatomic region, to utilize the transantral sphenoidal approach as an addition to his surgical armamentarium. Prior to surgery, stereo x-ray studies which include lateral, posteroanterior, and submental vertex views should be obtained to outline the sphenoid sinuses and sella turcica. Hamberger et al. [1] classify the sphenoid sinuses into three types: conchal, presellar, and sellar. This classification depends upon the extent to which the sphenoid bone is pneumatized. In the conchal type (Fig. IA) the sphenoid sinus does not extend into the body of the sphenoid bone. The sella turcica, therefore, is separated from the sinus by a thick layer of cancellous bone, which usually makes the pituitary inaccessible by this approach. This type is better suited to the transcranial procedure. The conchal type occurs in 3 per cent of all skulls studied. In the presellar type (Fig. 1B) the sphenoid sinus extends back to the anterior wall of the sella turcica, but because there is no posterior or posterolateral extension, the bulge into the sinus, which is characteristic of the sellar type, is absent. The presellar type occurs in 11 per cent of cases and, although not an absolute contraindication to the transantral approach, may make the operation more difficult. In the sellar type (Fig. lC), the most common, the sinus extends deeply into the sphenoid bone so that the anterior and inferior wall of the sella turcica bulges into the sinus and is easily visible. This wall is usually thin, approximately 0.5 mm. The sellar type occurs bilaterally in 59 per cent of the cases and at least on one side in 86 per cent. The septum in the sphenoid sinus divides it into the right and left; its position may vary. Ideally, it should be in the midline, with the posterior portion over the sellar bulge, acting as a guide to the midline of the sella turcica. The
From the Head and hTeck Service and the Bone Tumor Service of the Department of Surgery, Memorial Hospital for Cancer and Allied Diseases and James Ewing Hospital, New York, Nrti York.
YPOPHYSECTOMY has been practiced for many years in the treatment of primary tumors of the pituitary gland. It has now become an accepted procedure in the ablative treatment of disseminated mammary cancer. Indications reported by others include cancer of the prostate, melanoma, diabetic retinopathy not responding to insulin, malignant exophthalmos, Cushing’s syndrome, cardiac edema not responding to diuretics, thyroid cancer, and bone sarcoma. Many surgical approaches have been detranscranial, transnasal, namely, scribed, transethmoidal transpalatal, transseptal, through an incision at the inner canthus of the All of these technics, eye, and transantral. except the transcranial, are modified approaches to the sella turcica through the sphenoid sinus. The surgical literature was reviewed and the various technics were carried out on twenty-five cadavers in the anatomy laboratory in an effort to select the best method. We concur with Hamberger et al. [1] that the transantral sphenoidal approach is the safest and simplest for total hypophysectomy. In one year, we have used this procedure in fifty-four patients and have been impressed with the following favorable aspects: the minimum of operative time, blood loss, trauma, morbidity, and low operative mortality, even in patients considered poor risks. This presentation has a twofold purpose: first, to describe, step by step, the technic of hypophysectomy as performed at Memorial Hospital; second, to encourage the head and neck surgeon, with his vast experience in this
H
Vol. 112, October IWd
P. GEROLD, M.D.,
569
Tollefsen, Miller, and Gerold
570
FIG. 1. Classification
of sphenoid sinuses: A, conchal; B, presellar; C, sellar.
position of the septum should be carefully studied in the submental-vertex x-ray films and used as a guide to the sella turcica. To facilitate the operation, the procedure should be planned so that one starts on the side which contains the larger sphenoidal sinus, preferably of the sellar type, with its thinner wall between the sphenoid sinus and the sella turcica. This decision is important because the initial breakthrough is critical. The thinner the wall, the easier it is to make the first small opening through bone so that the pituitary capsule can be visualized. In the presellar type, the thickness of the bone may make it necessary to use
electric burrs under Polaroida x-ray guidance. The operation is performed in two stages. The approach, in which the maxillary, ethmoid, and sphenoid sinuses are broken down and cleared, is the first stage and is relatively simple. This stage requires about twenty-five to thirty minutes of operating time. The beginning of the second stage is the most critical part of the procedure. The decision as to the exact location of the anteroinferior wall of the sella turcica, or “sellar bulge,” must be made. Once this is done, the removal of the pituitary gland can begin. This stage requires about twenty to thirty minutes.
FIG. 2. Incision and anatomy.
FIG. 3. Opening of maxillary antrum. American
Journal
of Surgery
Transantral
Sphenoidal
‘RUM
FIG. 4. Dissection
-.. 8)I 1
Hypophysectomy
then entered by making an opening in the anterior wall (Fig. 3) just above the canine fossa. The anterior wall is removed in all directions, the upper limit of the dissection being the point of exit of the infraorbital branch of the fifth nerve. The mucous membrane is removed from the antrum. The nasal pack is removed, and the mucous membrane and turbinates are then bluntly dissected from the mesial side of the lateral wall of the nasal cavity (Fig. 4) and displaced toward the nasal septum. After this, the bony lateral nasal wall is removed with a Kerrison type of rongeur. After the lateral wall is removed (Fig. 5A), the ethmoid cells are picked away, using an ethmoidal or pituitary forceps. At this point, the sphenopalatine artery is frequently encountered and may give some troublesome bleeding. This can be easily controlled by packing the cavity for a few minutes or by actually clamping the vessel and cauterizing it. After the ethmoid cells have been removed, the ostium of the sphenoid sinus can be seen. The anterior wall of the sphenoid sinus is removed with a rongeur. (Fig. 5B.) The septum of the sphenoid sinus is broken through and the opposite an-
of nasal mucosa and turbinates
FIRST
STAGE
The patient is prepared and draped in a semisitting position, with the back at an angle of approximately 45 degrees. An intraoral cuffed endotracheal tube is introduced and a pack inserted in the hypopharynx after the patient has been anesthetized. After the sinus roentgenograms are studied, the approach is made through the side in which the sphenoid sinus is larger and deeper. An Adrenalin@ pack is inserted in the operative side of the nasal cavity. A single injection of Adrenalin and Novacaine@ is made in the soft tissues of the cheek through the upper gingival buccal gutter on that side to decrease the bleeding and the amount of general anesthesia needed. A Caldwell-Luc type of incision (Fig. 2) is made in the gingival buccal gutter and the soft tissues reflected from the anterior wall of the antrum by blunt dissection with a periosteal elevator. Care should be taken to avoid injury to the infraorbital nerve. The maxillary sinus is Vol. 112, October 1966
A
’
FIG. 5. A, displacement of nasal mucosa and turbinates to septum; B, opening into sphenoid sinus; C, opening into opposite sphrnoid sinus and removal of posterior nasal septum.
Tollefsen,
572
FIG. 6. A,
turcica.
location of sellar bulge;
B,
Miller,
entering the sella
terior wall and sphenoidal cells removed as completely as possible. To facilitate greater visualization of the entire sphenoid cavity, it is frequently advantageous to remove part of the most posterior portion of the nasal septum at this stage. (Fig. 5C.) This is easily accomplished by biting it away with Kerrison forceps, beginning posteriorly. During the preceding dissection, the “sellar bulge” usually can be seen as can small oblique bulges lateral to it which are caused by the underlying internal carotid arteries. This completes the first stage of the operation. SECOND STAGE
The second stage consists in breaking through the posterior wall of the sphenoid sinus overlying the pituitary gland and exposing its capsule. After the capsule is incised, the gland is dissected free and removed intact. Once the mid-portion of the sella turcica has been located, this second stage can begin. If there is any question as to the location of the “sellar bulge” or if, because of a presellar sinus it is not visualized, the sella can be located by
and Gerold use of Polaroid x-ray film technic with a probe or silver clip in place as a marker. After locating the mid-portion (Fig. 6A), a special fine chisel is used to probe the bone in this region until a soft spot is found. A small window is then broken through to the pituitary capsule. (Fig. 6B.) At this time, a small sphenoidal punch is used to remove the anterior bony wall. When a window approximately 0.75 to 1 cm. in diameter has been made, the pituitary capsule can be seen protruding through the opening, and occasionally the transverse portions of the cavernous sinus can be seen. A cruciate incision is then made in the capsule of the pituitary gland using a curved knife. (Fig. 7A.) Care must be taken to avoid incising any bluish area, which may indicate a communication with the cavernous sinus. A special blunt dissector (Fig. 7B) is inserted between the capsule and the hypophysis, carefully dissecting in this plane on all sides. The four edges of the capsule are reflected outward. The gland is thereby loosened from its capsule (Fig. 7C) and, with gentle downward traction, the pituitary stalk is ruptured and the gland lifted out intact. Dissection of the capsule must be performed carefully and gently because of the proximity of the cavernous sinus. The optic chiasm and brain above are protected by the clinoid processes and the diaphragm sellae, through which the stalk of the hypophysis emerges. After rupture of the stalk, a slight gush of spinal fluid and occasionally some bleeding may be encountered. This has never been significant in our experience. After removing the gland in this manner, we have been able to photogra.pl1 the specimen in each case, documenting the completeness of the removal. Prior to making the cruciate incision in the capsule, a 2 cm. cube of muscle is removed from the thigh and kept moist in saline solution. After the pituitary has been removed, a trimmed piece of this muscle is inserted through the opening in the capsule (Fig. 7D), plugging the defect in the sella turcica. This stops any leakage of cerebrospinal fluid and produces a dry field. A 1 inch gauze packing soaked in antibiotic solution is placed in the sphenoid sinus over the muscle plug, and this continuous packing is used to fill the antrum. The end of the pack is brought out through the nose after making an incision through the nasal mucosa near the nostril. The incision in the gingival buccal gutter is closed with interrupted sutures American
Journal
of Surgery
Transantral
Sphenoidal Hypophysectomy
573
INTERNAL
OPTIC
PITUITARY
FIG. i. A, cruciate incision in capsule; B, reflection of capsule; C, intracapsular dissection of pituitary gland; D, muscle and gauze packing in place.
of catgut, completing the operation. The nasal packaging is partially removed on the eighth and ninth postoperative days and completely on the tenth day. The hazards of the operation include possible damage to the base of the brain and/or cranial nerves, especially the optic chiasm, and severe hemorrhage from the carverous sinus or the internal carotid arteries. If the opening toward the sella turcica is made too high, one may get into the transverse portion of the cavernous sinus, optic chiasm, or even the cribriform plate. We have not experienced any of these complications to date. Our only difficulty has been locating the sellar bulge or, in its absence, determining where to make the initial breakthrough into the sella turcica. However, since the first twenty-five cases, we have been utilizing the Polaroid x-ray technic and this has eliminated the problem. Occasionally we have encountered large transverse communications between the cavernous sinuses, which have been troublesome. These obstacles have not caused any injury to Vol. 1117, October
lY66
the patient, but the hemorrhage resulting from the opening of the cavernous sinus is annoying and may make further procedure impossible at this time. The bleeding can be controlled by an Adrenalin pack or a piece of muscle placed against the opening. On the average, the patient loses about 150 cc. of blood during the operation. The procedure takes anywhere from forty-five minutes to one and a half hours and, if the cases are carefully studied and the patients properly positioned, no great difficulties in locating the hypophysis should be encountered. We plan to use an operating microscope to better visualize the capsular dissection in the future. This may prove to be an aid but is certainly not a necessity, in our experience. Postoperatively, the best laboratory indication of the completeness of hypophysectomy is the measurement of thyroid function. The cortisone withdrawal test is equally effective but is rather distressing to the patient and somewhat hazardous. We believe that our photographs (Fig. 8) showing the totally re-
574
Tollefsen, Miller, and Gerold
FIG. 8. A and B, total hypophysectomy. pituitary glands (lines in millimeters).
moved intact glands are the best proof of complete hypophysectomy. The only distressing complication after hypophysectomy has been the problem of diabetes insipidus, which is usually transitory and
Surgical specimens
showing intact
variable in severity. This has been controlled easily by the use of Pitressin@ in oil administered intramuscularly or, in the milder cases, by nasal insufflation of Pitressin snuff. All patients, of course, are cortisone-dependent and usually American Journal of Swgery
Transantral
Sphenoidal Hypophysectomy
575
FIG. 8B
leave the hospital on a daily maintenance dose of 50 mg. of cortisone orally. We have found that the patients complained more of their thigh incisions, where the muscle plug was obtained, than of their hypophysectomy. This speaks well for the nontraumatizing aspects of this approach. Vol. 112, October
1066
Mild rhinorrhea occurred in three of our patients early in the series. In none of these did it last more than five days. At first, we left the nasal packing in place only seven days and believe this was the causative factor. We also found that by keeping the patient in Fowler’s position after removal of the pack, the rhinor-
5’76
Tollefsen, Miller, and Gerold
rhea stopped. Apparently, this position favors tamponading the brain against the diaphragm sella. Since instituting removal of the pack on the tenth postoperative day and keeping the patient in Fowler’s position when in bed, we have not had any leakage of the cerebrospinal fluid. SUMMARY
It is not the purpose of this paper to discuss the indications or end results of hypophysectomy nor to compare hypophysectomy with adrenalectomy in ablative surgery for disseminated cancer. The results of ablative surgery for advanced cancer of the breast have been reported by the Joint Committee on Endocrine Ablative Procedures in Disseminated Mammary Carcinoma [2,3] in two previously published reports. This presentation describes in detail the surgical technic of transantral sphenoidal hypophysectomy. We believe that this is the easiest and best approach for complete removal of the pituitary gland. This procedure does not
require elaborate equipment and takes about forty-five to ninety minutes of operating time. It requires no skin incision, can be performed without the need of a blood transfusion, and is safe even for patients considered very poor surgical risks. We have had no death directly attributable to the operation and no serious complications, such as persistent rhinorrhea. We also believe that if an endocrine ablative procedure is indicated, this operation is safer for the patient and causes less operative morbidity than either bilateral adrenalectomy and oophorectomy or transcranial hypophysectomy. REFERENCES
1. HAMBERGER, C. A., HAMMER, G., SORLEN, G., and SJBGREN, B. Transantrosphenoidal hypophysectomy. Arch. Otolaryng., 74: 22, 1961. 2. Joint Committee on Endocrine Ablative Procedures in Disseminated Mammary Carcinoma. Adrenalectomy and hypophysectomy in disseminated mammary carcinoma. J.A .M.A ., 175: 787, 1961. 3. MACDONALD, I. Endocrine ablation in disseminated mammary carcinoma. Surg. Gynec. & Obst., 115: 215, 1962.