Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 58, Num. 6, 2010, pp. 847-851

Neurology India, Vol. 58, No. 6, November-December, 2010, pp. 847-851

Original Article

A new technique for management of intercavernous sinus bleeding with titanium clips in transsphenoidal surgery

Yuan Hong, Sheng Chen, Songxue Guo, Jun Yu, Qun Wu, Jianmin Zhang

Department of Neurosurgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, P. R. China,
Correspondence Address: Jianmin Zhang, Department of Neurosurgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, #88, Jiefang Road, Hangzhou - 310 009, P. R. China. , zjm135vip@sina.com

Date of Acceptance: 12-Aug-2010

Code Number: ni10245

PMID: 21150047
DOI: 10.4103/0028-3886.73742

Abstract

Background: Venous bleeding induced by intercavernous sinus injury during sellar dural opening is a challenging intraoperative complication and is difficult to treat in transsphenoidal surgery. To date, few studies concerning the management of intercavernous sinus bleeding have been reported. Aims: Our aim was to assess the clinical outcomes of a new hemostasis technique utilizing nonpenetrating titanium clips for management of intercavernous sinus bleeding.

Materials and Methods: From January 2007 to July 2008, 242 pituitary tumors were operated using a transnasal transsphenoidal approach. A new technique involving a specially devised clip applier and titanium clips was used to control venous bleeding in 13 (5.4%) patients who exhibited a prominent intercavernous sinus. All patients were evaluated clinically and radiologically at 9 to 24 months, and postoperative magnetic resonance imaging (MRI) was performed at 3 to 18 months.

Results: No operation was interrupted or aborted due to ineffective bleeding control, and there was no delayed bleeding noted as a complication. No complications related to the use of the device occurred. Imaging studies revealed no evidence of significant clip artifact.

Conclusions: Our surgical experience has revealed that this new hemostasis technique can be a safe, rapid and effective method for control of intercavernous sinus bleeding during sellar dural opening in transsphenoidal surgery. However, a further prospective study to evaluate this method more fully is planned.

Keywords: Intercavernous sinus, titanium clips, transsphenoidal surgery

Introduction

Transsphenoidal surgery is generally considered by neurosurgeons to be the first-choice operative approach for pituitary adenoma due to its minimal invasiveness, low morbidity and excellent surgical outcomes. ^[1],[2],[3] The key factors ensuring the aforementioned advantages include no obvious bleeding, clear visualization and complete exposure during operation. However, due to specific position and anatomical variation, some anatomical structures such as intercavernous sinus are prone to bleeding under inappropriate manipulation, which may lead to poor visualization, inadequate exposure, incomplete tumor resection, and on occasion may cause the operation to be prematurely aborted.

Unfortunately, due to the narrow nasal conduit in the transsphenoidal approach, the surgical field may be restricted, limiting the standard dedicated instrument maneuverability. Thus, controlling the troublesome bleeding of the venous channel at the intercavernous sinus during dural incision is often challenging, especially the copious bleeding from the highly developed intercavernous sinus, which covers the major portion of, or occasionally even the entire, anterior surface of the exposed dura mater. A review of published literature reveals that little consideration has till now been given to the details of surgical techniques for the treatment of the bleeding of the intercavernous sinus, and the efficiency of such techniques is uncertain. The intercavernous sinus being located in the potential space between the endo-osteal layer and the meningeal layer of dura offers theoretical possibility for clip to control the sinus bleeding by sealing the two layers. In this article, we describe an approach performed on 13 patients involving the use of titanium clips to control the bleeding of the prominent anterior intercavernous sinus, using a specially devised pistol-shaped clip applier.

Materials and Methods

Concept of the deep pistol-shaped clip applier

The regular clip applier is not practical for transsphenoidal surgery as most of such clip appliers are so bulky that they can impair the surgeon's view. In addition, due to the narrow nasal entrance, its working length is limited with regard to the ability to reach the surgical location. Moreover, the applier tips of conventional systems are straight, which makes it difficult to clip the bleeding from a direction at a wide angle to the longitudinal axis, as in the case of intercavernous sinus bleeding. In this situation, the plenum of bleeding is located between the two sellar dura layers, which are nearly perpendicular to the longitudinal axis [Figure - 1]a. Therefore, we designed a deep pistol-shaped clip applier to overcome some of the deficiencies of conventional sets [Figure - 1]b.

Structure of the deep pistol-shaped clip applier

The newly designed deep pistol-shaped clip applier has a total length of 210 mm and a working length of 150 mm [Figure - 2]a. Thus it is long enough to be placed into the operative field via an endonasal route. The applier is pistol shaped so that it does not impair the operator's visual field. The applier tip is 5 mm long and at a fixed angle of 70° upward to the shaft [Figure - 2]b, thus enabling the bleeding to be clipped from the plenum, which forms a wide angle with the longitudinal axis [Figure - 1]b. The tip has an endo-slot structure and maximum open angle of 50° [Figure - 2]c; therefore, various sizes of titanium clips can be held stable within the tip by operating the handle at the top of the instrument, and the applier can easily be manipulated by one hand via the transsphenoidal approach.

Surgical technique

The operations were performed by the senior author (Zhang JM) using a right unilateral transnasal transsphenoidal approach. After a wide sphenoidotomy, the bony sella was removed with Kerrison rongeur or a high-speed drill. In most of the patients, the opening of the sella floor was extended anteriorly to the planum sphenoidale, laterally to the edges of cavernous sinus, inferiorly to the sellar floor and superiorly to the tuberculum sella. After adequate sellar bone removal, the dura of sellar floor was exposed. In most of the patients , there were no hypertelia anterior intercavernous sinuses; thus a conventional oblique cruciate dural incision was made. The venous bleeding in most of the patients was not severe and could be controlled by conventional hemostasis methods such as bipolar cautery, cotton, microfibrillar collagen, Surgicel or fibrin glue. However, there were occasional cases exhibiting a highly developed intercavernous sinus covering a major portion of, or occasionally even the entire, anterior surface of the exposed dura mater; hence the dural incision can unavoidably cause opening of the intercavernous sinus and be accompanied by brisk bleeding, impeding the remainder of the procedure. In such circumstances, the previously mentioned technique would be inefficient for sealing the two dural layers. Therefore, we applied a protocol to achieve bleeding control with titanium clips using a specially devised pistol-shaped clip applier. The research protocol was approved by the hospital's medical ethics committee.

Based on our experience gained from 242 cases of conventional transsphenoidal surgery, we applied this approach to achieve bleeding control in 13 (5.4%) cases exhibiting prominent anterior intercavernous sinus. First, a small vertical dural incision with a straight-feather microblade was made at the midline position or the position with no sinus underneath. In this step, the incision is made through both of the dural layers. This procedure opens the hypertelia anterior intercavernous sinus underlying the dural mater and induces copious venous bleeding. While the bleeding from the sinus was controlled with suction, two clips were placed across the two dural layers of both borders of the incision using a specially devised deep pistol-shaped clip applier, and the potential space containing the sinus between the endo-osteal layer and the meningeal layer was then sealed off tightly [Figure - 1]b. If the bleeding was not controlled completely, more clips were applied. Then, the dural incision was extended superiorly and laterally as needed with the use of a right-angled microblade, and the venous bleeding from the sinus was continuously controlled by the titanium clips. With the full dura incision, the titanium clips that were located on the edge of the dura mater would also be pulled to the side, far away from the central area of the visual field, and thus would not hinder the removal of the tumor. Ultimately, the dura was opened with a generous window, and tumor resection was then initiated. Theoretically, this procedure minimizes both the opening of the intercavernous sinus and blood loss in most cases.

Results

The procedure described above was successfully performed in 13 patients with a prominent intercavernous sinus during transsphenoidal surgery. Among these patients, there were 11 cases of microadenoma, including 9 cases with adrenocorticotropic hormone (ACTH)-secreting pituitary tumor, 1 with prolactinoma and 1 with somatotroph ic adenomas; the remaining 2 patients had macroadenoma with prolactinoma. No operations were interrupted or aborted due to ineffective bleeding control, and no false aneurysm of the cavernous carotid artery occurred as a delayed complication. Additionally, no complications related to the use of the device occurred in the present study. All patients were evaluated clinically and radiologically, with follow-up at 9 to 24 months. Postoperative MRI was routinely evaluated at 3 to 18 months. Imaging studies revealed no evidence of significant clip artifact. Therefore, the use of the clips would not hinder the evaluation of the completeness of tumor resection in postoperative images.

Illustrative case

A 44-year-old female patient presented with a 10-month history of progressive weight gain and persistent headache. Physical examination revealed hirsutism, facial plethora, hypertension and abdominal purple striae. Laboratory evaluation revealed an elevation of urinary free cortisol and high serum cortisol. MRI scan revealed a pituitary tumor [Figure - 3]a. She underwent operation for tumor resection via a right unilateral transnasal transsphenoidal approach. After the sellar floor was exposed, a highly developed intercavernous sinus was encountered. Copious venous bleeding occurred during the dura incision. Bleeding was temporarily controlled with a suction tube. Two titanium clips were then placed across the two dural layers of both borders of the incision using a pistol-shaped clip applier, thus sealing tightly the potential space between the endo-osteal layer and the meningeal layer of the dura. Then, the dural incision was extended superiorly and laterally, and the clip was continuously used until the bleeding was controlled fully. The titanium clip did not affect the surgical field and tumor removal. Postoperative MRI and x-ray images obtained at 6 months demonstrated no residual tumor and no significant artifact and displacement of the clip [[Figure - 3]b and c].

Discussion

Intercavernous sinuses are venous channels that commonly occupy the space between the endo-osteal layer and the meningeal layer of dura in the sella floor, and communicate between the bilateral cavernous sinuses. On the basis of their relationships to the pituitary, they are designated as the anterior intercavernous, the posterior intercavernous, the inferior intercavernous, and the basilar plexus accordingly. The anterior intercavernous sinus was identified as the most frequently occurring and voluminous sinus according to the studies by Divitiis and Aquini, and was most commonly involved during transsphenoidal surgery. ^[4],[5] In addition, its anatomical configuration is prone to variation under various pathological conditions. In patients with macroadenomas, the intercavernous sinuses are usually compressed and obliterated, which makes the dural incision bloodless; in microadenomas and especially in Cushing disease, however, the intercavernous sinuses are highly developed, hence occupying most of, or even the entire, space under the sellar dura and may induce vigorous bleeding during the dural incision. ^[6],[7] In our 242 patients with pituitary tumors, there were 13 patients with a prominent intercavernous sinus. The incidence of uncontrollable sinus bleeding was 5.4%, which is different from that reported by Kim et al .[8] In the study by Kim et al., 72 of the 940 patients undergoing conventional transsphenoidal surgery had prominent anterior intercavernous sinus bleeding, with the incidence of uncontrollable sinus bleeding being 7.7%. The difference in the incidence between the two studies may be related to the patients' race, the pathological type and size of the tumor. In our 13 pituitary tumor patients who had a highly developed intercavernous sinus, 11 had microadenoma and 9 of these 11 patients had ACTH-secreting pituitary tumor, which is also consistent with the anatomical features of the intercavernous sinus aforementioned.

In order to prevent or arrest venous sinus bleeding during transsphenoidal surgery, various methods have been used to attain hemostasis, such as focal compression, direct suture, bipolar electrocautery, and hemostatic materials (i.e., Gelfoam sponges, Avitene, Floseal, Surgicel and fibrin glue). ^[8],[9],[10] Used routinely, these methods have demonstrated variable efficacy. However, for the very small number of cases with bleeding, especially copious bleeding from the highly developed intercavernous sinus which covers the major portion of, or occasionally even the entire, anterior surface of the exposed dura mater, the treatment is difficult and the effectiveness of the above methods becomes uncertain. Even if the methodology is effective, the process of hemostasis is often complicated and may consume more time, which would extend the length of the operation and increase the risk of the surgery. In addition, these techniques used for hemostasis are also not free of undesired consequences. For example, focal compression and bipolar electrocautery are slow in halting bleeding and inadequately control the brisk venous bleeding. Direct suture is impractical and difficult to achieve under the narrow and deep space. Gelfoam sponges and Surgicel are not ideal, as they need to be left in place, thereby restricting the surgeon's vision. Avitene has been reported to embolize and induce a local inflammatory response. ^[11],[12] Floseal can cause a host-tissue reaction and therefore carries theoretical risks, such as immunologically induced coagulopathy, IgE-mediated anaphylaxis, infections and bovine spongiform encephalitis. ^[13] Fibrin glue does not adhere strongly to wet tissue, has little impact on active bleeding and carries a risk of infection. ^[14],[15] In addition, use of fibrin glue is limited by the time required to obtain and prepare the product. ^[15],[16] Therefore, the search for an effective and rapid hemostasis method for dealing with this type of bleeding is particularly important.

In the present study, we have reported our experience with a new hemostasis technique to manage the intercavernous sinus bleeding with nonpenetrating titanium clips using a specially devised clip applier. The nonpenetrating titanium clip was designed to be used for ligation of vessels and tubular structure. It offers a number of advantages, including ease of use, speed, seal tightness and compatibility with MRI scanning. In addition, the intercavernous sinus being located in the potential space between the endo-osteal layer and the meningeal layer of dura offers theoretical possibility for clip to control the sinus bleeding by sealing the two layers. However, clip placement is not an easy surgical procedure in the deep, narrow surgical field of the transsphenoidal surgery. Some modified appliers with variously angled tips have been described in the literature; however, they were designed for aneurysm surgery and are not suitable for transsphenoidal surgery due to their bulky volume, which may impair the surgeon's view. ^{[17],[18],[19]} Furthermore, all the appliers mentioned in the literature have never been used for clipping the intercavernous sinus bleeding in transsphenoidal surgery. Hence we have developed a novel deep pistol-shaped clip applier to overcome or minimize these problems concerning instrument maneuverability in transsphenoidal surgery. Our initial experience demonstrated that this newly developed instrument provides superior maneuverability for clip placement at various angles in the restricted space and, in addition, is much easier to hold. Furthermore, management of the intercavernous sinus bleeding by titanium clips has also been proved to be a safe, reliable, rapid and effective surgical technique. Its efficacy simplifies the surgical procedure, reduces the duration of operation and facilitates complete tumor excision. No complications related to the use of the device occurred, and no operation was interrupted or aborted due to ineffective bleeding control, and there was no delayed bleeding noted as a complication. However, we would emphasize that since the cohort in the present study was a small one, definite conclusions regarding efficacy and complications and other technique-related issues such as how many clips should be used and whether the clips would interfere with focused radiotherapy for the patient with residual disease could only be fully reached following a further prospective, randomized study.

References

Copyright 2010 - Neurology India

The following images related to this document are available:

Photo images