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Surgical anatomy and nuances of the expanded endonasal transdorsum sellae and posterior clinoidectomy approach to the interpeduncular and prepontine cisterns: a stepwise cadaveric dissection of various pituitary gland transpositions

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Abstract

Background

Excelsior knowledge of endoscopic anatomy and techniques to remove the natural barriers preventing full endonasal access to the interpeduncular and prepontine cisterns determines the ease of transposing the pituitary gland (hypophysiopexy) preserving the glandular function without manipulating the optic apparatus and the oculomotor nerves.

Methods

Throughout stepwise cadaveric dissections, we describe the expanded endonasal approach (EEA) to the interpeduncular and prepontine cisterns with special references to the intricate anatomy of the region and techniques for hypophysiopexy and posterior clinoidectomies.

Conclusion

This article illustrates sellar-diaphragmatic dural incisions and various “pituitary gland transpositions” techniques performed via extradural (lifting the gland still covered by both dural layers), interdural (transcavernous), and intradural (between the medial wall of the cavernous sinus and the pituitary tunica) to access the prepontine and interpeduncular cisterns.

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Abbreviations

EEA:

Expanded endoscopic endonasal approaches

ICA:

Internal carotid artery

IGS:

Image guidance system

PCPs:

Posterior clinoid processes

SSEP:

Somato-sensory evoked potential

SICS:

Superior intercavernous sinus

PG:

Pituitary gland

IHA:

Inferior hypophyseal artery

DS:

Dorsum sellae

MWCS:

Medial wall of the cavernous sinus

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Acknowledgments

We thank Ruichun Li, MD (Department of Neurological Surgery, the first affiliated hospital of Xi’an Jiaotong University, China), Nyall R. London Jr, MD (Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA), and Sunil Manjila (Department of Neurological Surgery and Neck Surgery, McLaren Hospital, Bay Region, Bay City, MI, USA) for their contribution to this project. The authors thank Angelina Prevedello for her help in drawing the illustrations for this paper.

Author information

Authors and Affiliations

  1. Department of Neurological Surgery, The Ohio State University Medical Center, Columbus, OH, USA

    Thaïs Cristina Rejane-Heim, Giuliano Silveira-Bertazzo, Ricardo L. Carrau & Daniel M. Prevedello

  2. Department of Pediatric Endocrinology, Nationwide Children’s Hospital, Columbus, OH, USA

    Thaïs Cristina Rejane-Heim

  3. Department of Pediatric Endocrinology, Federal University of Santa Catarina, Florianópolis, SC, Brazil

    Thaïs Cristina Rejane-Heim

  4. Department of Pediatric Neuroendocrinology and Pediatric Endocrinology, Jeser Amarante Faria Children’s Hospital, and Neurological and Neurosurgical Clinic of Joinville, Joinville, SC, Brazil

    Thaïs Cristina Rejane-Heim

  5. Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Medical Center, Columbus, OH, USA

    Ricardo L. Carrau & Daniel M. Prevedello

Authors
  1. Thaïs Cristina Rejane-Heim
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  2. Giuliano Silveira-Bertazzo
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  3. Ricardo L. Carrau
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  4. Daniel M. Prevedello
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Corresponding author

Correspondence to Daniel M. Prevedello.

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Conflict of interest

This study was performed at ALT-VISION at The Ohio State University. This laboratory receives educational support from the following companies: Carl Zeiss Microscopy, Intuitive Surgical Corp., KLS Martin Corp., Karl Storz Endoscopy, Leica Microsystems, Medtronic Corp., Stryker Corp., and Vycor Medical. Dr. Prevedello is a consultant for Stryker Corp., Medtronic Corp., and Integra; he has received an honorarium from Mizuho and royalties from KLS-Martin. Ricardo L. Carrau is a consultant for Medtronic Corp.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ohio State University Wexner Medical Center institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

A summary of 10 key points

1. Superb anatomical knowledge of the suprasellar, parasellar, interpeduncular, and prepontine cisterns is pivotal.

2. Careful identification of the dural layers and ligaments surrounding the pituitary gland is essential to perform any of the pituitary transposition.

3. EEA to the interpeduncular cistern offers a wide ventral corridor, best suited to work in a caudal to rostral manner without manipulating the optic apparatus.

4. Bone removal over dorsum/PCPs increases surgical exposure and maneuverability.

5. Bleeding from the cavernous sinus can be controlled with hemostatic agents (Floseal, Surgiflo, or Spongostan).

6. Sharp dissection avoids damage in the subchiasmatic region and interpeduncular cistern.

7. CT-A/MRI neuronavigation and Doppler probes help to avoid ICA injury.

8. Neuromonitorization with SSEP and cranial nerve electromyography help assess intraoperative cranial nerves and brainstem function.

9. The approach should aim for adequate and safe tumoral resection balancing the need for preservation of the pituitary function.

10. Pre-and-postoperative hormone deficits should be timely managed.

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Rejane-Heim, T.C., Silveira-Bertazzo, G., Carrau, R.L. et al. Surgical anatomy and nuances of the expanded endonasal transdorsum sellae and posterior clinoidectomy approach to the interpeduncular and prepontine cisterns: a stepwise cadaveric dissection of various pituitary gland transpositions. Acta Neurochir 163, 407–413 (2021). https://doi.org/10.1007/s00701-020-04590-5

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