A.V. Polezhaev, V.Yu. Cherebillo, V.R. Gofman, V.A. Manukovsky
Clinic of Neurosurgery, Medicomilitary Academy, Saint Petersburg, Russia
Today development of minimum invasive surgical technique, based on endoscopic endovideomonitoring, is a prospective trend in rhinosurgery of pituitary tumors. Endovideomonitoring provides a smaller-volume approach and makes an operation less traumatic, but no less effective. Besides, it makes it possible to examine and to perform manipulation on the structures, lying beyond the limits of direct visualization, and to obtain their magnified images without changing their microtopography. Nevertheless, more radical interventions demand more effective arrest of bleeding, use of modern devices and hemostatics.
There were 421 cases with pituitary tumors, operated in the Clinic of Neurosurgery of the Medicomilitary Academy in 1997-2003. An endoscopic transsphenoidal approach was used. We want to dwell on three main methods of providing hemostasis under conditions of a narrow and long surgical canal:
It is necessary to note, each stage of intervention requires use of quite definite hemostatic means.
It is expedient to use turundae, soaked with 3% hydrogen peroxide solution, in diffuse capillary bleeding, which starts during performing a transseptal approach to the saddle and opening of the sphenoid sinus. Soring diathermocoagulation is more effective in local bleeding from small arteries.
As a rule, a stage of the saddle bottom trepanation and dura opening is characterized by minor bleeding. Thus, the most effective method is use of 3% hydrogen peroxide solution.
In case of small parenchymal bleeding, watched during removal of neoplastic tissue with the help of a suction device and hypophyseal curettes, the best effect is obtained either with applying dry turundae or 3% hydrogen peroxide solution. If a tumor is dense and removal is performed with the Cusa Excell ultrasonic disintegrator, aspiration with monopolar coagulation is indicated.
Final hemostasis after tumor removal is the most important problem. In case of large neoplasms with marked supra-, retrosellar growth, hemorrhage into a tumor bed in an early postoperative period can lead to fatal complications. That is why, operation cannot be completed, if a surgeon is not sure of hemostasis reliability. In our opinion, it can be done effectively with such preparations as Surgicel, made of oxidized regenerated cellulose, and Tachocomb, which is a collagen plate, covered with components of fibrin glue (thrombin, fibrinogen, aprotinin). Surgicel fragments are placed into a cavity of removed tumor. When hemostasis is ensured, some pieces of Tachocomb are inserted. Their sticky surface is pressed to a defect zone with an exposure of 3-5 min. It should be noted, that Tachocomb use is mandatory in intraoperative liquorrhea, as it provides not only a hemostatic effect but also hermetic sealing of liquor paths. If there is intense bleeding from a tumor bed, it is recommended to use turundae, soaked in caprofer solution and inserted into a tumor cavity for 5-7 minutes.
Thus, the Clinic of Neurosurgery of the Medicomilitary Academy possesses a good arsenal of modern means of achieving hemostasis. Correct use of materials and methods allows to ensure intraoperative arrest of bleeding and to reduce probability of hemorrhage into a tumor bed in an early postoperative period.