A surgery by Dr. Juan C. Fernández-Miranda (Stanford University)
At app SurgSchool, the number one online surgical training platform, presents a new masterclass of surgery Dr. Juan C. Fernández-Miranda, a world leader in endoscopic skull base surgery and professor at Stanford University. In this case, Dr. Fernández-Miranda addresses a growth hormone (GH)-producing pituitary macroadenoma causing acromegaly, with a complex invasion and destruction of the medial wall of the cavernous sinus.
Clinical context and diagnosis
The patient, a 32-year-old woman, presented with classic signs of acromegaly—acral growth, coarse facies, and soft tissue thickening—with levels of Markedly elevated IGF-1. The Brain MRI with contrast revealed a large sellar lesion displacing the pituitary gland to the left side, with multilobulated right cavernous extension.
The standard transphenoidal approach was insufficient to safely expose the cavernous sinus, so the team opted for a extended transpterygoid endonasal strategy.
Surgical technique
The procedure is performed by a Extended endonasal endoscopic approach to the right transpterygoid, opening the maxillary sinus, mobilizing the contents of the pterygopalatine fossa and perforating the pterygoid bone until the cavernous sinus and the paracellular internal carotid artery.
La progressive bone resection includes the median clinoid, the carotid optic recess and bilateral exposure of the carotid canals. Subsequently, a X-shaped dural opening and a careful extracapsular dissection to preserve the remnant of the normal pituitary gland.
El tumor invades the cavernous sinus, with almost complete destruction of its medial wall. After identifying the superior and posterior cavernous compartments, the Dr. Fernández-Miranda uses Doppler ultrasound to delimit the carotid artery and safely access the cavernous space, where the tumor is dissected while respecting the oculomotor nerves and the internal carotid artery.
La hemostasis It is controlled with topical agents, and the reconstruction is done with Abdominal fat graft, duragen, and vascularized septal flap, ensuring a hermetic seal and adequate protection against cerebrospinal fluid fistulas.
Results and evolution
The patient presented a marked decrease in growth hormone on the first postoperative day, an indicator of complete tumor resection and effective endocrinological control.
The video illustrates in a didactic way the three-dimensional anatomy of the cavernous sinus, extracapsular dissection technique, and the safety of the transpterygoid approach in lesions with extensive cavernous invasion.
Teaching importance
This surgery constitutes a reference case in endoscopic skull base surgery, ideal for both neurosurgeons as if to otorhinolaryngologists specialized in extended endonasal approaches. The anatomical precision, management of the cavernous carotid artery, and reconstructive strategy make this procedure a example of technical excellence and multidisciplinary collaboration.
