J Korean Neurosurg Soc.  2022 Jul;65(4):591-597. 10.3340/jkns.2021.0164.

Arachnoid Remodeling by Clipping Technique Facilitates Surgical Maneuverability during Transsphenoidal Surgery for Pituitary Macroadenoma

• Kim EH
• Park SJ
• Na M
• Moon JH
• Kim SH

• KMID: 2531628
• DOI: http://doi.org/10.3340/jkns.2021.0164

Abstract

Objective
: Pituitary adenomas frequently extend into the suprasellar space. After a suprasellar tumor is removed, the superiorly extended arachnoid becomes redundant and sinks down into the intrasellar space which often hiders visualization and accessibility to the hidden space behind the evaginated arachnoid. We introduced arachnoid remodeling by clipping technique, and evaluated its usefulness and safety during TSS.
Methods
: Total 223 patients who underwent arachnoid remodeling with our new clipping technique were included. Redundant arachnoid was clipped along the dural edge with multiple 2.6-mm titanium clips until the redundant arachnoid membrane no longer blocked the surgical route. To check for possible deterioration of hormonal function by this technique, we assessed anterior pituitary function of 166 patients who underwent arachnoid remodeling by clipping and compared this with those of other 429 control patients.
Results
: Our technique greatly enhanced the accessibility and visualization of intrasellar and parasellar spaces, both of which are generally hindered by redundant arachnoid during transsphenoidal surgery (TSS). We found no difference in anterior pituitary function between a clip-assisted arachnoid remodeling group and the control group, implying that this technique does not result in hypopituitarism.
Conclusion
: During TSS for pituitary adenomas with suprasellar extension, arachnoid remodeling by clipping technique is very useful and convenient for the management of the redundant arachnoid membrane to enhance visualization and surgical accessibility.

Keyword

Arachnoid; Pituitary neoplasms; Surgical instruments

Figure

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  Fig. 1. Photographs of the clips and applier. A : A commercially available 2.6 mm titanium clip is shown. B : Clips are stored in the cartridge. C : Clip is loaded on the tip of applier.

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  Fig. 2. Schematic diagram of the arachnoid remodeling by clipping technique. A : The side oblique view demonstrates that macroadenoma pushes the arachnoid membrane upward. B : After the majority of the tumor is removed, a small remnant tumor is hidden behind the evaginated arachnoid membrane. C : After arachnoid remodeling by clipping, the remnant tumor is directly accessed and removed. D : Anterior view after clipping shows direct visualization of the remnant tumor. ICA : internal carotid artery, PS : planum sphenoidale, OCR : opticocarotid recess, OP : optic protuberance, TS : tuberculum sellae, CP : carotid protuberance.

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  Fig. 3. Preoperative and postoperative magnetic resonance imaging (MRI) of a pituitary macroadenoma in the patient in Supplementary Video 1. Preoperative T1-weighted with contrast enhancement coronal image (A) and T2-weighted sagittal image (B) showed a pituitary macroadenoma with large suprasellar part compressing the optic nerve. Complete tumor removal was followed by the arachnoid remodeling by clipping technique (black arrowheads in E). Immediate postoperative MRI showed that no suprasellar hematoma developed and that the optic nerve was completely decompressed (C and D). Metallic scattered artifacts were minimally observed on postoperative MRI. Postoperative sagittal image of T1-weighted with contrast enhancement is presented in the box. Photograph of arachnoid remodeling by clipping with recess clipping (E). Visualization of the intrasellar space was greatly enhanced by clipping technique, enabling meticulous inspection of the tumor removal space.

Reference

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