Transsphenoidal Pituitary Surgery

Airway: Access: Pain: Position: Time: Blood loss: Special:

Intro and technique

Considerations

  • A
    • Oral RAE/Reinforced tube
  • B
    • No HFNP or CPAP post-operatively
      Difficult in OSA patients.
      • Extubate light
      • Consider remifentanil TIVA
  • C
    • Arterial line
    • HTN on nasal preparation
  • D
    • MRI
      Sizing.
  • E
    • Tumour function
      Tumour can be functional or non-functional.
      • Functional
        Present with symptoms from hypersecretion.
      • Non-functional
        Present with compression symptoms.
        • Bitemporal hemianopia
          Optic chiasm compression.
    • Hormonal screen
  • F
    • Diabetes Insipidus
      10-60% of cases occur almost immediately.

Preoperative

Assess:

  • Mass effect

  • Metabolic effects

  • Standard ANZCA monitoring

  • Arterial line

  • Large IV

  • Oral RAE or reinforced tube

  • IDC

Position:

  • Semi-recumbent

Induction

Intraoperative

Surgical Stages

Emergence

Postoperative

Surgical complications:

  • CSF leak
    • Pack sella with fat
    • May need lumbar drain
  • Hydrocephalus
  • Bleeding
  • Visual problems
    • Direct damage
      3.3%.

Hormonal complications:

  • Usually enough residual pituitary tissue is present to provide normal pituitary function
  • Posterior pituitary dysfunction is more common due to oedema
  • Hormonal screen performed 2-3 days
  • DI
    • ~15%
      Bulk of cases develop immediately.
    • Usually transient
  • SIADH
    • Develops slowly

References