DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Cystic pituitary lesion.
POSTOPERATIVE DIAGNOSIS: Craniopharyngioma versus Rathke’s cyst.
OPERATION PERFORMED:
1. Excision of pituitary tumor, transnasal with endoscopy.
2. Stereotactic computer assisted navigational surgery.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: 100 mL.
SPECIMENS: Pituitary mass.
DESCRIPTION OF OPERATION: This is the otolaryngology portion of the procedure. The patient came to the operating room and was placed in the supine position on the operating room table. General facemask anesthesia was given until a deep plane of anesthesia was obtained. At that point, the endotracheal tube was placed by the anesthesiology service without difficulty. Once the patient was asleep, approximately 6 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the bilateral septum, middle turbinates and sphenoid face. Cocaine-soaked nasal pledgets 5% were then placed in the nares bilaterally for further decongestion.
At that point, the neural navigational system was attached to the patient’s forehead with the head strap. The patient’s CT images were then loaded onto the computer. The patient’s images were then registered with an error rate of 1.4 mm. The accuracy was then tested. The system was used throughout the case for localization of the sphenoid sinus, plane of sphenoidale, carotid arteries and optic nerves. After registration was completed, the cocaine-soaked nasal pledgets were removed from the nasal cavities bilaterally. A microdebrider was then used on the left nasal cavity to excise the inferior half of the middle turbinate in the entire anterior to posterior length. The superior turbinate was then identified and resected with the microdebrider. The sphenoid os was identified and widely opened with a microdebrider and Kerrison rongeurs.
Attention was then turned towards the right nasal cavity. Again, the middle inferior half of the middle turbinate was resected with the microdebrider in the entire anterior posterior length. The superior turbinate was then identified and resected with the microdebrider. The sphenoid os was then identified and opened widely with the microdebrider. This allowed visualization of the sphenoid sinuses bilaterally.
Attention was then turned towards the posterior third of the septum. The cartilaginous bony junction of the septum was first cauterized with Bovie cautery. A caudal elevator was used to elevate the mucosa bilaterally off of the cartilage and bone. The mucosa was then microdebrided. Pituitary forceps was then used to remove a large piece of cartilage and bone for later reconstruction. Again, the image guidance was used at this point to identify the location of the carotid arteries and optic nerves. Kerrison rongeurs were used to fully open up the sphenoid sinus laterally to visualize the opticocarotid recesses and superiorly to identify the plane of sphenoidale.
A Medtronic high-speed drill was then used to open up the sphenoidotomy to the floor of the sphenoid sinus. Intersinus septum was then removed with the high-speed drill. This allowed clear access to the opticocarotid recesses bilaterally and the entire face of the sella. At that point, the case was turned over to Dr. Jane Doe and her associates for removal of the pituitary lesion. Again, this part will be performed by Dr. Jane Doe.
After completion of the pituitary part of the procedure with closure of the sellar face with fat and bone, the ENT service finished the procedure by placing FloSeal bilaterally in the anterior posterior ethmoids and along the floor of the posterior remaining septum. The nasopharynx was then suctioned out with Frazier suction. The patient was then awoken from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.
