TUMOR

Instrumentation and Technique

The Use of a Simple Self-Retaining Retractor in the Endoscopic Endonasal Transsphenoidal Approach to the Pituitary Macroadenomas: Technical Note
Murat Kutlay, MD nu l, MD Engin Go lent Du z, MD Bu _ Yusuf Izci, MD zkan Tehli, MD O  lar Temiz, MD C ag Ilker Solmaz, MD Mehmet Daneyemez, MD
Department of Neurosurgery, Gulhane Military Medical Academy, Etlik-Ankara, Turkey Correspondence: Yusuf Izci, MD, Gulhane Askeri Tp Akademisi, Norosirurji AD, 06018 Etlik/Ankara, Turkey. E-mail: yizci@gata.edu.tr; yusufizci@yahoo.com Received, January 9, 2013. Accepted, March 21, 2013. Published Online, April 23, 2013. Copyright 2013 by the Congress of Neurological Surgeons

BACKGROUND: During tumor removal in the endoscopic endonasal approach to pituitary adenomas with a significant suprasellar extension, the early descent of diaphragma sellae obscuring the visualization of the surgical field is a surgical challenge. OBJECTIVE: To describe a simple diaphragma retraction technique to eliminate this problem. METHODS: A transparent flexible material (a strip of polypropylene) was used as a selfretaining retractor to elevate the redundant diaphragma and to maintain the diaphragma elevation. This technique was performed in 3 patients who had pituitary adenoma with suprasellar extension. The degree of tumor removal was determined by a combination of surgeons intraoperative impression and the postoperative magnetic resonance imaging obtained 3 months later. RESULTS: The technique was performed very easily and no complication was observed owing to this technique and self-retaining retractor. Total tumor removal was achieved in 2 patients with this technique and subtotal removal in 1 patient. CONCLUSION: This technique was effective and practicable to elevate the diaphragma sellae during the tumor removal phase of transsphenoidal surgery. This simple selfretaining retractor may support the neurosurgeons skill by providing control of the entire surgical field and adequate working space. It may also eliminate the risks of blind curettage during surgery.
KEY WORDS: Diaphragma herniation, Endoscopic transsphenoidal surgery, Pituitary macroadenoma, Retractor
Neurosurgery 73[ONS Suppl 2]:ons206ons210, 2013
DOI: 10.1227/01.neu.0000430292.39046.10

he endoscopic endonasal approach to the sellar region is a recent evolution of the conventional transsphenoidal technique performed with the operating microscope.1,2 During the past 2 decades this approach has gained significant popularity.2,3 Furthermore, extended versions of this approach are also in use for the removal of various intracranial pathologies along the midline cranial base.1-3 The role of the endoscopic approach has been firmly established in the treatment of pituitary adenomas and this technique is routinely used in many centers throughout the world.1-3 It offers several advantages over the microscopic approach during both the surgical procedure and tumor resection. It provides better illumination, magnification, and visualization than the operating microscope.1-3

However, the early descent of the diaphragma sellae into the sellar cavity is a common problem during the surgical treatment of pituitary tumors with suprasellar extension.2,4 This is not only a problem for the endoscopic approach, but also for the microscopic approach. After the tumor is removed and the sellar cavity is decompressed, the expanded diaphragma always tends to herniate into the surgical field, obscuring the visualization of the lateral parts of the sellar cavity and reducing the possibility of radical removal of the adenoma.2,5 In this report, we describe a simple technique to eliminate this problem. We used a transparent flexible material as a self-retaining retractor to elevate the redundant diaphragma sellae and to maintain the diaphragma elevation. We present the results of this technique as applied to 3 patients with pituitary adenoma with suprasellar extension.

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SIMPLE SELF-RETAINING RETRACTOR

SURGICAL TECHNIQUE
The standard endoscopic transsphenoidal approach has been widely described in the literature.2,5 In pituitary tumors with a significant suprasellar extension, we prefer to use a binasal 3- or 4-hand with a posterior septectomy preserving the middle turbinates. Zero-degree and 30, and less frequently 45, rigid endoscopes that are 18 cm in length (Karl Storz Endoscopy, Tuttlingen, Germany) were used. Both middle turbinates were lateralized to enlarge the space between it and the nasal septum. The sphenoid ostia were identified bilaterally. After displacement of the nasal septum from the rostrum of sphenoid, approximately 1 cm of the posterior nasal septum adjacent to the vomer bone was resected. An anterior sphenoidotomy was performed and the sphenoid septum/s was removed. After the endoscopic identification of all the anatomic landmarks around the sella, its floor was opened and the dura was incised. In all pituitary tumors with suprasellar extension, it was planned to remove the inferior, then the lateral, and finally the superior portions of the tumor. However, when the tumor was gross-totally removed, the expanded diaphragma ballooned into the surgical field, obscuring the lateral portions of the tumor. From this point forward, in 3 patients whose diaphragma descended, we used a transparent flexible material as a self-retaining retractor to elevate the redundant diaphragma and to maintain the diaphragma elevation. A strip of polypropylene (Essix Orthodontic plate, Raintree Essix Inc, Sarasota, Florida) was cut and tailored with scissors to adequate width (to fit the sellar opening) and length (the free tips of the strip should be left outside the sphenoid sinus). The thickness of this strip was 1 mm, and the sizes (length and width) of the strip were determined as mentioned above. The strip was introduced in a bent fashion held by a pituitary rongeur (Figure 1).

It was placed into the sella by slightly elevating the ballooned diaphragma. Because of the elasticity and minimal stiffness of the transparent strip, when it was released, it opened spontaneously and became fixed in place (Figure 2). Once it was in the appropriate position, conventional microsurgical techniques were used under direct endoscopic visualization, and the operative field was explored with 0 and angled (3045) endoscopes for bimanual removal of tumor fragments located laterally (Figure 3). To provide both control of the entire sellar cavity (particularly superior and inferior portions of the surgical field) and the capability to evacuate potential tumor remnants, the transparent strip of polypropylene was removed, rotated 90, and replaced by a pituitary rongeur. This maneuver provides removal of the superior and inferior parts of the tumor. At the end of the procedure the sellar floor was reconstructed by the use of common sellar reconstruction techniques.2,6 We usually used a multilayer technique, using 2 layers of fascia, together with a bone splint to reinforce the reconstruction. We placed an abdominal fat graft within the sella and filled the sphenoid sinus with fat. Postoperative magnetic resonance imaging of the patient confirmed total tumor removal by this technique in comparison with preoperative images (Figure 4).

DISCUSSION
The endoscopic transsphenoidal surgery is a safe, effective approach to sellar region tumors and refers to the removal of tumors with minimal trauma and a low complication rate.1-3 Although the endoscopic approach provides an excellent illumination, high magnification, and a panoramic view of the surgical area,2,5,6 an early prolapsus of the diaphragma sellae into the operative field is a surgical challenge.2,5,7,8 During removal of the majority of macroadenomas, the expanded diaphragma descends by progressive tumor removal and impedes the proper exploration of the surgical area. However, it is well known that a clear vision is mandatory for safety of the surgical procedure. The herniation of the diaphragma is not an unequivocal sign of total tumor removal.2 The descended diaphragma sellae limits the working space and does not allow an effective maneuverability of the surgical instruments. In general, to avoid premature delivery of the redundant diaphragma into the operative field, the stepwise resection plan is performed. The removal of macroadenomas is accomplished sequentially, with the removal of the inferior, then the lateral, and finally the superior portions of the tumor.2,5 Despite these efforts, an early herniation of the diaphragma sellae does still continue to be a surgical challenge. In such situations, most of the surgeons push the diaphragma sellae with the aid of a surgical aspirator and a small cottonoid to visualize the surgical area. The diaphragma can be lifted up with the aspiration cannula and a small cottonoid together with the simultaneous introduction of the right-angled curet; also, a cottonoid can be used to maintain the diaphragma elevation.7,8 But it is impossible to use both hands with this technique. When the surgeon is holding the aspiration cannula to

FIGURE 1. A, photograph of the strip of polypropylene tailored to adequate width (to fit the sellar opening) and length (the free tips of the strip should be left outside the sphenoid sinus). B, it is introduced in a bent fashion with the help of a pituitary rongeur.

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FIGURE 2. A, schematic illustration in sagittal projection of the sellar region showing the ballooned diaphragma sellae into the sella after the tumor was decompressed and after placement of the polypropylene strip as the self-retaining retractor. When it was released it opened spontaneously and became fixed in place because of its elasticity and minimal stiffness. B, note that the position of the elevated diaphragma.

maintain the diaphragma elevation, he/she cannot perform bimanual dissection. Additionally, cottonoid obscures the visualization of the diaphragma and also can make inspecting for tumor remnants more difficult. However, our simple retractor described in this report allows the surgeon to use both hands during surgery. Furthermore, in cases of macroadenomas, the ballooned diaphragma is thin and dilated, and therefore it can be easily perforated while pushing it up. For this reason, it may be possible for some complications to occur such as cerebrospinal fluid leakage or damage to the optic nerve, chiasma, or vascular structures during this type of maneuver.2 A simple self-retaining retractor prevents these complications by elevating the diaphragma sellae.

By using a transparent flexible material like a self-retaining retractor, we were able to achieve good tumor removal without any major complication. For this purpose, a strip of polypropylene was used because of its elasticity, transparency, and minimal stiffness. The usage of this simple retractor prevented the protrusion of the diaphragma sellae into the surgical field and permitted radical removal of the entire tumor with maximum safety in 2 patients, and at least 95% removal of the tumor in 1 patient. Its transparency allowed us to visualize the diaphragma during the procedure of elevation and decreased the chances of diaphragma perforation. Maintaining the position of the elevated diaphragma with the aid of this simple retractor provided both control of the entire operative

FIGURE 3. A, intraoperative endoscopic view through the 0 rigid endoscope after placement of the polypropylene self-retaining retractor, which is used in our technique. The free tips of the strip are outside the sphenoid sinus. B, elevation of the diaphragma allows an effective bimanual control of the surgical instruments (such as ring curettes and aspirator) and eliminates the risk of blind curettage. T, tumor; As, aspirator; R, ring curette; *, self-retaining retractor.

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SIMPLE SELF-RETAINING RETRACTOR

CONCLUSION
The technique described in this report is effective and practicable in preventing an early descent of the diaphragma sellae during the tumor removal phase of endoscopic transsphenoidal surgery. This simple self-retaining retractor may support the neurosurgeons skill, providing control of the entire surgical field and adequate working space. Additionally, it may also increase the safety of this approach by eliminating the risk of blind curettage. Disclosure
The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

REFERENCES
1. Cappabianca P, Alfieri A, de Divitiis E. Endoscopic endonasal transsphenoidal approach to the sella: Towards Functional Endoscopic Pituitary Surgery (FEPS). Minim Invasive Neurosurg. 1998;41(2):66-73. 2. Jane JA Jr, Han J, Prevedello DM, Jagannathan J, Dumont AS, Laws ER Jr. Perspectives on endoscopic transsphenoidal surgery. Neurosurg Focus. 2005;19(6):E2. 3. Cappabianca P, Cavallo LM, Colao A, et al. Endoscopic endonasal transsphenoidal approach: outcome analysis of 100 consecutive procedures. Minim Invasive Neurosurg. 2002;45(4):193-200. 4. Cappabianca P, Alfieri A, Thermes S, Buonamassa S, de Divitiis E. Instruments for endoscopic endonasal transsphenoidal surgery. Neurosurgery. 1999;45(2):392-396. 5. Cappabianca P, Cavallo LM, de Divitiis E. Endoscopic endonasal transsphenoidal surgery. Neurosurgery. 2004;55(4):933-941. 6. Cappabianca P, Cavallo LM, Esposito F, Valente V, De Divitiis E. Sellar repair in endoscopic endonasal transsphenoidal surgery: results of 170 cases. Neurosurgery. 2002;51(6):1365-1372. 7. Jarrahy R, Berci G, Shahinian HK. Assessment of the efficacy of endoscopy in pituitary adenoma resection. Arch Otolaryngol Head Neck Surg. 2000;126(12):14871490. 8. Jho HD. Endoscopic transsphenoidal surgery. In: Schmidek HH, Sweet WH, eds. Operative Neurosurgical Techniques. Orlando, FL: Grune & Stratton; 1988: 385-397.

FIGURE 4. Preoperative contrast-enhanced T1-weighted sagittal (A), and coronal (B) MR images of the patient with a pituitary macroadenoma. Postoperative T1-weighted postgadolinium sagittal (C), coronal (D) MR images of the same patient demonstrating complete removal of the tumor.

field and the increased capability to evacuate tumor. We believe that the direct vision of the surgical area increased the safety of the endoscopic procedure, eliminating the risk of blind curettage. In addition to its simplicity, increased flexibility for the surgeon when maneuvering surgical instruments is an another advantage of this technique. This simple self-retaining retractor not only permits bimanual work, but it also allows the introduction of 2 instruments under the endoscope, without coming into conflict with it. It improves the maneuverability of the surgical instruments, providing adequate working space. Although the endoscopic transsphenoidal approach is now routinely used in many centers throughout the world, the endoscopic technique is relatively new, and appropriate instruments are still in development.1-3 However, the new endoscopic techniques described in the literature may present some problems including learning curve-experience, difficulties in application, and duration of surgery. These techniques may also require expensive equipment. In contrast, the technique used in our study is very easy to use, it can be performed within a few minutes (placement of the strip of polypropylene), and the cost of this technique is negligible. Finally, according to our preliminary results, we think that our technique is a more favorable method than the aspiration cannula & cottonoid pushing technique during the tumor removal phase of the endoscopic transsphenoidal approach.

COMMENTS
he authors have presented a very simple technique for retracting the herniating diaphragma and arachnoid during transsphenoidal surgery. I have commonly used a technique of packing 1 side of the sella with a cottonoid to elevate the arachnoid and diaphragma enough to see the opposite side. It is not ideal, but does work for the lateral tumor, still allowing me to use 2 hands. The issue of whether this will help with the tumor that is left superior to the folded arachnoid severing it from communication with the sella is not clear. Often posterior arachnoid will interrupt the continuity of the sella to the remaining high anterior adenoma, and this technique may not help with that. I do look forward to trying something like this to see just how effective it is. Kalmon D. Post New York, New York he authors presented a technical note on the use of a self-retaining retractor to avoid the herniation of the diaphragma sellae during endoscopic endonasal transsphenoidal surgery for the removal of pituitary adenomas. The article is quite interesting because it focuses on a relevant aspect of pituitary surgery, ie, the management of early descent of

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suprasellar cistern during tumor removal. In order to avoid such an event it is preferable to accomplish lesion removal sequentially: the inferior and lateral aspects of the tumor should be removed before the central and superior components. Indeed, the premature removal of these latter parts will deliver the redundant diaphragma into the operative field, thus obscuring the view of lateral portions and reducing the possibilities of lesion radical removal. Nevertheless, in certain cases the suprasellar cistern falls down into the sellar cavity notwithstanding the accurate sequential removal of the tumor. Therefore, the idea of retracting the cistern with a bundle of polypropylene sounds reasonable. It seems doubtful, however, that the positioning of any device inside the sella could ease tumor removal. Usually, the suprasellar cistern could be effectively lifted protected by a cottonoid and mobilized according to the positioning of

the lesion to be removed. Finally, even though the authors experience is limited to only 3 cases, the technique looks fairly intriguing. Paolo Cappabianca Naples, Italy he authors have presented a simple solution to address a common problem encountered during transsphenoidal surgery. I suspect that pituitary surgeons, whether they use the microscope or endoscope, will be interested in testing out this novel technique. John Jane, Jr Charlottesville, Virginia

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