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Pituitary Surgery – A Modern Approach
Frontiers of
Hormone Research
Vol. 34

Series Editor

Ashley B. Grossman London


Pituitary Surgery –
A Modern Approach

Volume Editors

Edward R. Laws, Jr. Charlottesville, Va.


Jason P. Sheehan Charlottesville, Va.

99 figures, 11 in color, and 34 tables, 2006

Basel · Freiburg · Paris · London · New York ·


Bangalore · Bangkok · Singapore · Tokyo · Sydney
Edward R. Laws, Jr., MD, FACS Jason P. Sheehan, MD, PhD
Department of Neurological Surgery Department of Neurological Surgery
Health Sciences Center Health Sciences Center
University of Virginia University of Virginia
Charlottesville, Va., USA Charlottesville, Va., USA

Library of Congress Cataloging-in-Publication Data

Pituitary surgery : a modern approach / volume editors, Edward R. Laws, Jr.,


Jason P. Sheehan.
p. ; cm. – (Frontiers of hormone research, ISSN 0301-3073 ; v. 34)
Includes bibliographical references and index.
ISBN 3-8055-8051-7 (hard cover : alk. paper)
1. Pituitary gland–Surgery. I. Laws, Edward R. II. Sheehan, Jason
P. III. Series.
[DNLM: 1. Pituitary Neoplasms–surgery. 2. Central Nervous System
Neoplasms–surgery. 3. Endocrine Surgical Procedures–methods.
4. Neurosurgical Procedures–methods. 5. Pituitary Diseases–surgery.
W1 FR946F v.34 2006 / WK 585 P6934 2006]
RD599.5.P58P58 2006
617.4⬘4059–dc22

2005035999

Bibliographic Indices. This publication is listed in bibliographic services, including Current Contents® and
Index Medicus.

Disclaimer. The statements, options and data contained in this publication are solely those of the individ-
ual authors and contributors and not of the publisher and the editor(s). The appearance of advertisements in the
book is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness,
quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property
resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Drug Dosage. The authors and the publisher have exerted every effort to ensure that drug selection and
dosage set forth in this text are in accord with current recommendations and practice at the time of publication.
However, in view of ongoing research, changes in government regulations, and the constant flow of information
relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for
any change in indications and dosage and for added warnings and precautions. This is particularly important when
the recommended agent is a new and/or infrequently employed drug.

All rights reserved. No part of this publication may be translated into other languages, reproduced or
utilized in any form or by any means electronic or mechanical, including photocopying, recording, microcopying,
or by any information storage and retrieval system, without permission in writing from the publisher.

© Copyright 2006 by S. Karger AG, P.O. Box, CH–4009 Basel (Switzerland)


www.karger.com
Printed in Switzerland on acid-free paper by Reinhardt Druck, Basel
ISSN 0301–3073
ISBN 3–8055–8051–7
Contents

VII Foreword
Grossman, A.B. (London)
IX Preface
Laws, E.R., Jr.; Sheehan, J.P. (Charlottesville, Va.)

1 Role of Transcranial Approaches in the Treatment of


Sellar and Suprasellar Lesions
Maartens, N.F.; Kaye, A.H. (Melbourne)

29 Extended Transsphenoidal Approach


Dumont, A.S.; Kanter, A.S.; Jane, J.A., Jr.;
Laws, E.R., Jr. (Charlottesville, Va.)

46 Image Guidance in Pituitary Surgery


Asthagiri, A.R.; Laws, E.R., Jr.; Jane, J.A., Jr. (Charlottesville, Va.)

64 Endoscopic Endonasal Cavernous Sinus Surgery,


with Special Reference to Pituitary Adenomas
Frank, G.; Pasquini, E. (Bologna)

83 Diagnosis and Management of Pediatric Sellar Lesions


Jagannathan, J.; Dumont, A.S.; Jane, J.A., Jr. (Charlottesville, Va.)

105 The Craniopharyngioma


Oskouian, R.J. (Charlottesville, Va.); Samii, A. (Hannover);
Laws, E.R., Jr. (Charlottesville, Va.)

V
127 Rathke’s Cleft Cysts
Kanter, A.S.; Sansur, C.A.; Jane, J.A., Jr.;
Laws, E.R., Jr. (Charlottesville, Va.)

158 Treatment of Cushing’s Disease: A Retrospective Clinical Study of the


Latest 100 Cases
Hofmann, B.M.; Fahlbusch, R. (Erlangen)

185 Stereotactic Radiosurgery for Pituitary Adenomas:


A Review of the Literature and Our Experience
Sheehan, J.P.; Jagannathan, J.; Pouratian, N.; Steiner, L. (Charlottesville, Va.)

206 Neuropathological Considerations of Pituitary Adenomas


Asthagiri, A.; Lopes, M.B.S. (Charlottesville, Va.)

236 Anesthetic and Critical Care Management of Patients Undergoing


Pituitary Surgery
Burton, C.M.; Nemergut, E.C. (Charlottesville, Va.)

256 Vascular Injury and Transsphenoidal Surgery


Oskouian, R.J. (Charlottesville, Va.); Kelly, D.F. (Los Angeles, Calif.);
Laws, E.R., Jr. (Charlottesville, Va.)

279 Author Index


280 Subject Index

Contents VI
Foreword

In the time that I have been practising clinical endocrinology, transsphe-


noidal surgery has gone from being an innovative approach to pituitary adenomas
to having become the standard procedure for a whole variety of sellar and parasel-
lar lesions. However, while many practising clinicians refer patients for this
procedure on a regular basis, there have been few texts able to explain the details
of the technique, its indications and indeed limitations, as well as the newer exten-
sions such as image guidance and endoscopy. I am therefore delighted to
welcome this short volume, where Ed Laws and his colleagues at Charlottesville,
one of the leading international centers in transsphenoidal surgery, offer an
overview of this whole area, including sections on perioperative management
and surgical pathology. Together with other international contributors, they also
identify the complementary roles of radiosurgery and transcranial surgery in the
approach to sellar and suprasellar tumors. I am sure this will be of great value for
all who have to deal with these fascinating and ever-challenging lesions.

Ashley B. Grossman, London

VII
Preface

The management of pituitary adenomas and other sellar tumors is one of


the most difficult tasks for neurosurgeons and endocrinologists. The profound
systemic sequelae of hypersecretory adenomas and the deleterious effects of
local tumor growth must be halted. Medical management, surgical resection,
and adjuvant treatment with radiosurgery are just a few of the tools employed
by physicians to achieve these goals. The tendency for recurrence, either early
or late, demonstrates the need for vigilant follow-up. Optimal treatment
requires a multidisciplinary approach; neurological, ophthalmological, and
endocrinological testing are all required.
Fortunately, the past decade has seen rapid improvements in the manage-
ment of patients with pituitary adenomas and other sellar tumors. Technological
advances including a better understanding of tumor biology, discovery of mole-
cular events at the basis of tumor development, and development of new equip-
ment to treat the tumors have all been made. The wide range of such advances
speaks to the fact that a variety of skills and techniques are typically employed
to diagnosis, treat, and follow patients with sellar tumors. The technical and
personnel resources of a state-of-the-art medical center are ideally utilized
throughout this treatment.
This book aims to provide a comprehensive understanding of the standard
of care for treating sellar tumors. The text includes detailed discussions about
operative approaches, perioperative management, and adjuvant treatment. In
addition, it gives a glimpse of what the future may hold for the treatment of
such tumors. In general, the contributing authors have chosen references based
upon scientific significance, ease of access, and historical interest.

IX
The fruition of this project was the result of hard work by many people.
Unfortunately, it is not possible to adequately acknowledge all those who have
helped. However, we wish to call attention to the assistance of several people.
First and foremost, we thank the contributing authors for their effort. In addi-
tion, Prof. Grossman provided a great deal of stimulation and guidance in this
endeavor. The work of Juliane Sättler and Gunhild Hinderling at Karger
Publishing proved invaluable.
Finally, we are grateful for the patience and support of our wives, Peggy
and Diane.

Edward R. Laws, Jr.


Jason P. Sheehan
Charlottesville, Va.

Preface X
Laws ER Jr, Sheehan JP (eds): Pituitary Surgery – A Modern Approach.
Front Horm Res. Basel, Karger, 2006, vol 34, pp 1–28

Role of Transcranial Approaches in the


Treatment of Sellar and Suprasellar
Lesions
Nicholas F. Maartens, Andrew H. Kaye
Department of Neurosurgery, Royal Melbourne Hospital and Department of Surgery,
University of Melbourne, Melbourne, Australia

Abstract
The principles in the surgical management of sellar and suprasellar tumors are to
relieve mass effect, normalize pituitary hypersecretion, preserve or restore normal pituitary
function, prevent tumor recurrence and to provide tissue for pathological and scientific study.
Over the past century, the transsphenoidal approach has evolved as the approach of choice
for pituitary surgeons. Despite the limitations of transcranial approaches in accessing the
intrasellar component of pituitary adenomas and historically their increased morbidity and
mortality, there are situations where transcranial procedures have considerable advantages
over transsphenoidal approaches. As a consequence, transcranial approaches retain an essen-
tial role in the treatment of certain sellar and suprasellar tumors and it remains necessary for
all pituitary surgeons to master this approach.
Copyright © 2006 S. Karger AG, Basel

‘. . . the hemisphere can be readily compressed upwards by


inserting a flat spatula cautiously beneath it. . . . With this
procedure properly applied to the temporal lobe it is remark-
able how much can be seen and correctly examined. With
good illumination the crura cerebri, the circle of Willis, the
pituitary body and internal carotid, the second and third cra-
nial nerves come into view.’
Sir Victor Horsley (1906) [1]

Introduction

The principles in surgical management of sellar and suprasellar tumors are


to relieve mass effect – particularly on the visual apparatus, normalize pituitary
Table 1. An overview of mortality after transcranial surgery

Author Year Patients Mortality, %

Henderson 1939 205 2.4


Bakay 1950 232 1.4
Elkington and McKissock 1967 260 10
Svien and Colby 1967 117 6.8
Ray and Patterson 1971 146 1.4
McCarty et al. 1973 100 3
Wirth et al. 1974 157 8.9
Symon and Jakubowski 1979 117 2.5
Symon 1979 16 18.7
Fahlbusch 1994 146 2

Table 2. An overview of mortality after transsphenoidal surgery

Author Year Patients Mortality, %

Guiot and Derome 1976 613 1.4


Fahlbusch and Stass 1981 601 1.2
Hardy and Mohr 1985 1,102 0.9
Laws 1982 810 0.5
Landolt 1985 496 0.8
Tindall and Barrow 1985 709 0.3
Fahlbusch 1994 1,688 0.2
Zada 2003 100 0

hypersecretion, preserve or restore normal pituitary function, prevent tumor


recurrence and to provide tissue for pathological and scientific study. In order
to achieve this, one requires a surgical approach that ideally provides the short-
est route to the lesion, confers minimal trauma to surrounding structures, pro-
vides adequate exposure and will permit the manipulation necessary to resect
the lesion. Over the past century, the transsphenoidal approach, first success-
fully performed in 1907 by Hermann Schloffer [2, 3], has evolved as the
approach of choice by virtually all pituitary surgeons. Recent advances with
regard to endoscopic [4] and extended transsphenoidal techniques [5] have
served to further consolidate the advantages of this approach over traditional
transcranial procedures. Despite the limitations of transcranial approaches in
accessing and removing the intrasellar component of pituitary adenomas and
historically their increased morbidity and mortality (tables 1, 2) [6], there are,
however, situations where transsphenoidal procedures may either be limited or

Maartens/Kaye 2
contraindicated and clinical settings where transcranial procedures have consid-
erable advantages over the transsphenoidal approach. As a consequence, tran-
scranial approaches retain an essential role in the treatment of sellar and very
large suprasellar tumors and it is a requirement of all pituitary surgeons to mas-
ter this time-honored approach [7].

History

‘The endonasal technique is entirely foreign to the surgeon’s


experience. From beginning to end the field of operation is
cramped, one must depend on artificial illumination, and at no
time has one what might be called a satisfactory view. It is
quite natural that it should fall to the lot of a nasal specialist,
Hirsch, to originate the endonasal method.’
Charles Frazier (1919) [8]

Until the 18th century, our understanding of the pituitary gland was based
largely on primitive, archaic theories regarding its function. By the 19th century,
however, there had been a resurgence of interest in the pituitary precipitated by
Pierre Marie’s observations with regard to acromegaly [9]. Simultaneously, the
effect of canine hypophysectomy had begun to be investigated [10] and visual
failure being related to pituitary enlargement and certain systemic changes
became appreciated. Eventually in 1889, Sir Victor Horsley (1857–1916; fig. 1)
became the first surgeon to operate on a pituitary tumor. He used a bifrontal
craniotomy approach and a technique he described as ‘cerebral dislocation’
encountering a cystic adenosarcoma which he described as inoperable [11].
The first actual recorded attempt to resect a pituitary tumor surgically was
by Frank Thomas Paul (1851–1941), honorary surgeon to the Royal Infirmary,
Liverpool. In 1893 he operated on a patient of Richard Caton’s, his physician
colleague [12]. He consulted Horsley who recommended a subtemporal
approach. Horsley’s suggestion was influenced by his laboratory work on sheep
in which the pituitary is very accessible subtemporally. The patient was a young
woman with acromegaly. She had presented with headaches, facial pain –
usually a poor prognostic sign to the old surgeons indicating inoperability, and
visual failure. The surgery entailed a two-stage lateral subtemporal decompres-
sion. Unfortunately the tumor could not be accessed and the patient, blind as a
consequence but with her facial pain having resolved, died 3 months later. In
1903, Otto George Theobald Kiliani, a New York surgeon, began practicing a
bifrontal intradural approach to the pituitary region on cadavers [13]. His first
clinical procedure was on a patient presenting with severe pituitary apoplexy

Role of Transcranial Approaches 3


Fig. 1. Sir Victor Horsley (1857– 1916).
From the personal collection of E.R. Laws –
with permission.

complicated by subdural extension of the hemorrhage. After encountering


blood over the convexity and failing in the placement of a ventriculostomy drain
to help contain brain swelling, he abandoned the procedure and the patient died
8 h later. In 1900, in Berlin, Fedor Victor Krause (1857–1937) undertook an
extradural right frontal approach to access and remove a bullet lodged in the
region of the right optic foramen of a patient who had attempted suicide [14].
The patient did remarkably well and Krause was quick to appreciate the signif-
icance of the view he had obtained of the sella turcica. In 1905 he performed the
first successful transfrontal pituitary surgery choosing an extradural approach
to avoid retraction injury to the brain [15]. This procedure provided the basis on
which the majority of subsequent variations of the transcranial approach were
developed [16].
Between 1904 and 1906, Horsley operated on 10 pituitary tumors utilizing
both subfrontal and lateral middle fossa approaches with a mortality rate of
20%, improving on the results of colleagues who hitherto had experienced pro-
hibitive mortality rates ranging between 50 and 80% [1, 17]. He advocated sur-
gical intervention for pituitary region lesions, emphasizing the importance of
relieving mechanical pressure on the chiasm exerted by the tumor in order to
avoid blindness – considerations that are still pertinent today [18]. Horsley’s
approach, however, did not gain universal popularity and Cushing also found it

Maartens/Kaye 4
impracticable [19]. In 1907, after performing a number of cadaver studies,
Braun was convinced that the pituitary should be accessible via a transtemporal
approach through the cavernous sinus but this necessitated division of the max-
illary branch of the trigeminal nerve as well as ligation of the carotid artery in
the neck. In 1908, in order to access a pituitary adenoma, Louis Linn McArthur
(1858–1934) turned a right frontal osteoplastic flap and resected the supraor-
bital rim together with part of the orbital roof. This approach allowed access to
lesions with high suprasellar extension. The entire approach was extradural
until 5 mm proximal to the chiasmatic sulcus [20, 21]. Charles Frazier
(1870–1936) initially adopted this approach but later changed to an intradural
frontobasal approach [22]. Upon experiencing unexpected hypertension, even
in patients who had not experienced significant bleeding, he changed to a two-
stage procedure [23]. He later concluded that the transnasal operation, with
which he had accrued some experience, should not be used for patients with
visual symptoms, a view later shared by Cushing.
In 1910, after a number of experimental hypophysectomies in dogs,
Silbermark suggested an approach to the hypophysis through the Sylvian fis-
sure [11, 24]. In May 1914, George Heuer (1882–1950) of Baltimore, Md., uti-
lized Silbermark’s proposal by performing an intracranial intradural approach
to the chiasm [25, 26]. He was followed shortly afterwards by Alfred Adson
(1887–1951) of the Mayo Clinic [27]. After being conscripted to France in
1917, Heuer’s experience of 20 cases was presented by Walter Dandy before the
Johns Hopkins Medical Society on February 4, 1918, on the insistence of
Halstead.
In March 1907 in Vienna, Schloffer performed the first successful
transsphenoidal removal of a pituitary tumor. The technique subsequently under-
went a number of modifications culminating in the description by Halstead of
the oronasal rhinoseptal submucosal approach with a sublabial gingival incision
subsequently adopted by Cushing [28]. After initial disappointments with tran-
scranial procedures, Cushing adopted this approach. Combining suggestions
from other surgeons and using the submucosal dissection technique advocated
by Eisenberg and Kocher, Cushing went on to perform 231 such procedures
between 1910 and 1925 with a reported mortality of 5.6% [16]. Cushing later, in
fact, abandoned the transsphenoidal approach, reverting back to the transcranial
approach, believing that it enabled the optic apparatus to be more readily decom-
pressed. Due to Cushing’s enormous influence at the time, transsphenoidal pro-
cedures subsequently became largely neglected. Norman McOmish Dott of
Edinburgh (1897–1973), however, who had worked under Cushing, remained
committed to the transsphenoidal approach. Probably out of deference to his
mentor, he never publicized his preference, eventually passing on his skills to
Gérard Guiot (1912–1996) [29] and Jules Hardy [30], respectively. They in turn

Role of Transcranial Approaches 5


then introduced fluoroscopy and the operating microscope to the procedure with
Hardy advancing to pioneer selective adenomectomy as we know it today.
Although this transsphenoidal approach has been universally adopted as the
standard approach for almost all sellar tumors, a role for transcranial approaches
has, nevertheless, persisted.
The advantages of the pterional approach to lesions in the suprasellar area
or inferior third ventricle region, using the natural tissue planes along the sphe-
noid wing at the frontotemporal junction, eventually and rapidly became appar-
ent. This is now the most frequently used transcranial approach to the sellar
region [31]. The pterional approach as we know it today was then refined and
described in detail by Gazi Yasargil who advocated minimizing brain retraction
by splitting the Sylvian fissure and opening the basal arachnoid [32].

Anatomy

The microsurgical anatomy of the sellar region is complex and a detailed


description besides important pertinent surgical points is beyond the scope of
this chapter. It has been reviewed and described in detail by Albert L. Rhoton Jr.
[33, 34]. Both the referenced works analyze the microsurgical sellar region
anatomy firstly from the point of view of the relationships important in perform-
ing the various transcranial and subcranial approaches to pituitary region tumors,
and secondly from the point of view of the various neural, arterial and venous
relationships in the sellar and third ventricular regions that are important in plan-
ning surgery for tumors extending from the pituitary gland into these regions. In
1975, Rhoton, together with Renn dissected and analyzed the microsurgical
anatomy of 50 adult sellar regions removed en bloc. The particular emphasis of
their study was to investigate the implications the variations in the anatomy held
for different surgical approaches and the incidence of each variation [35]. Their
findings considered factors disadvantageous to transsphenoidal surgery were: (a)
large anterior intercavernous sinuses extending anterior to the gland just poste-
rior to the anterior sellar wall (10%); (b) a thin diaphragm (62%) and a
diaphragm with a large opening (56%); (c) carotid arteries exposed in the sphe-
noid sinus with no bone covering (4%); (d) carotid arteries that approach within
4 mm of the midline within the sella (10%; fig. 2); (e) optic canals with bone
defects exposing the optic nerves in the sphenoid sinus (4%); (f) a thick sellar
floor (18%); (g) sphenoid sinuses with no major septum (28%) or a sinus with
the major septum well off midline (47%), and (h) a presellar type of sphenoid
sinus with no obvious bulge of the sellar floor into the sphenoid sinus (20%).
Findings considered disadvantageous to the transfrontal approach were: (a)
a prefixed chiasm (10%) and a normal chiasm with 2 mm or less between the

Maartens/Kaye 6
Fig. 2. Coronal T1 MRI gadolinium-enhanced MRI scan illustrating ‘kissing carotids’
– a relative contraindication for the transsphenoidal resection of a sellar lesion. The narrow
access between the cavernous sinuses predisposes the patient to an iatrogenic carotid artery
injury during the approach.

Prefixed chiasm 9% Normal chiasm 80% Postfixed chiasm 11%

Fig. 3. Diagram illustrating the various anatomical positions of the optic chiasm rela-
tive to the tuberculum sellae. In 9% of cases the chiasm is prefixed, 11% being postfixed.
The former configuration obscures transcranial access to sellar and suprasellar lesions. The
position of the chiasm is regarded as ‘normal’ in 80%.

chiasm and tuberculum sella (14%; figs 3, 4); (b) an acute angle between the
optic nerves as they entered the chiasm (25%); (c) a prominent tuberculum sella
protruding above a line connecting the optic nerves as they entered the optic
canals (44%), and (d) carotid arteries approaching within 4 mm of the midline
within or above the sella turcica (12%) – ‘kissing carotids’ (fig. 2).
The introduction of modern high-speed micro-drills has largely facilitated
being able to approach the pituitary gland through very thick sella floors or in

Role of Transcranial Approaches 7


a b

c d

Fig. 4. Intraoperative photomicrographs illustrating the various anatomical positions


of the optic chiasm relative to the tuberculum sellae. a The chiasm is ‘prefixed’ obscuring the
ACTH-secreting macroadenoma with suprasellar extension as illustrated in figure 5. b After
an initial very limited transsphenoidal resection the large residuum was resected transcra-
nially. Access was obtained predominantly via the optico-carotid triangle and the lamina ter-
minalis. c The intraoperative exposure of the suprasellar/tuberculum meningioma shown in
figure 9. In this case the chiasm was very ‘postfixed’ permitting a large prechiasmal expo-
sure. d The postoperative view showing complete resection.

children with poorly aerated sphenoid sinuses. Uncertainty generated by aber-


rant sphenoid sinus and septal anatomy is overcome by preoperative planning
using coronal bone window CT scans and intraoperative frameless stereotaxy
[36, 37].
The relationship of the optic chiasm to the tuberculum sellae was first
determined by the criteria of Bergland et al. [38] who demonstrated that 9% of
optic chiasms were prefixed, 11% postfixed and 80% ‘normal’ in position
(figs 3, 4). Modern MRI is frequently able to indicate the position of the optic
chiasm preoperatively (fig. 5). This has important implications in the choice of
which transcranial or transsphenoidal approach is indicated and in predicting
how difficult the surgery will be. A postfixed chiasm facilitates a considerably
easier approach and resection as the tumor is accessible between the tuberculum

Maartens/Kaye 8
a b

Fig. 5. Coronal (a) and sagittal (b) T1-weighted contrasted MRI scan illustrating a
recurrent ACTH-secreting macroadenoma with dramatic suprasellar extension. A prefixed
optic chiasm can be seen (arrow) anterior to the tumor (b). The position of the anterior com-
municator as a landmark for the optic chiasm can also be appreciated just above the chiasm.

sellae and the front of the chiasm, negating having to work across and between
the long axis of the optic apparatus and the internal carotid artery risking iatro-
genic visual failure.
During the course of transcranial surgery, the most significant complicat-
ing anatomical feature is the microvascular supply to the hypothalamus and
optic chiasm, the position of the optic apparatus itself. The pituitary tumor
pseudocapsule is usually situated below an arachnoid layer intervening between
these vessels and the surface of the tumor. Despite this these small vessels are
still exposed and even at risk from the tips of coated bipolar forceps.

Indications for the Transcranial Approach

The low morbidity and mortality associated with transsphenoidal surgery


(tables 1 and 2) has encouraged many pituitary surgeons to adopt this approach
as standard for virtually all sellar and suprasellar tumors [39]. There remain,
nevertheless, a few indications for transcranial approaches to lesions in these
anatomical locations (table 3). These indications have, however, continued to
diminish with the recent introduction of extended transsphenoidal approaches
[5, 40], endoscope-assisted pituitary surgery and the readiness of some sur-
geons to widely open the subarachnoid space transsphenoidally [41]. The oper-
ative mortality rate for transsphenoidal procedures is now less than 1% with a
morbidity of less than 10% [39]. These mortality and morbidity rates vary in
relation to different pathologies and increase in proportion to the size of the
tumor. Most giant pituitary adenomas still remain amenable to transsphenoidal

Role of Transcranial Approaches 9


Table 3. Indications for transcranial surgery

1 Tumor with extension into middle, anterior or posterior cranial fossa


2 Dumbell configuration
3 Indurated pituitary adenoma
4 Ectatic ‘kissing’ carotids
5 Sphenoid sinusitis
6 Dural tail of suprasellar/tubercular meningiomas

a b

Fig. 6. Sagittal (a) and coronal (b) T1-weighted contrasted MRI scans demonstrating a
non-functioning pituitary macroadenoma with a bi-lobed configuration due to a narrow
‘waist’ in the suprasellar membrane. In order to resect such a tumor transsphenoidally, the
arachnoid layer would have to be widely transgressed risking a postoperative CSF fistula.

surgery [7]. Ideally such tumors need to be situated directly above the sella tur-
cica, along the axis of the transsphenoidal approach and should not be exces-
sively lobulated or fibrous. However, some large tumors do not meet these
specifications and in these cases transcranial approaches assume an important
role. The indications for craniotomy are: (a) a dumbbell configuration to the
tumor with an hourglass constriction at the level of the diaphragma sella
(fig. 6); (b) a tumor with extension in the anterior, middle or posterior cranial fossa
(fig. 7); (c) sphenoid sinusitis that may delay surgery until adequately treated;

Fig. 7. Preoperative sagittal (a), coronal (b) T1-weighted gadolinium-enhanced MRI


scans and axial contrasted CT scan (c) demonstrating a giant nonfunctioning pituitary
macroadenoma extending out into the right cavernous sinus and temporal lobe regions. The
majority of the tumor was resected transcranially via a right pterional trans-Sylvian craniotomy.
The postoperative axial CT (d) and coronal (e) and sagittal (f) MRI scans demonstrate subtotal
resection of the lesion – namely the intrasellar portion of the adenoma. The residuum was
totally resected transsphenoidally at a second operation.

Maartens/Kaye 10
a b

c d

e f

Role of Transcranial Approaches 11


(d) the presence of ectatic carotid arteries projecting towards the midline –
‘kissing carotid arteries’ (fig. 2); (e) tumors with an indurated or fibrous con-
sistency (reviews of reported surgical series have confirmed that such tumors
are difficult and potentially hazardous to manage via the transsphenoidal
approach, fig. 8) [42]; (f) normal size sella with a substantial component in the
suprasellar cistern (if the chiasm is clearly postfixed a transcranial approach
becomes considerably easier, fig. 4); (g) inaccessible dural ‘tails’ of a suprasel-
lar/tuberculum meningioma (figs 4, 9); (h) uncertainty regarding the diagnosis,
and (i) the transsphenoidal pituitary surgeon not being available.
The transsphenoidal approach can be successfully employed, not only for
lesions confined to the sella, but also for lesions with significant suprasellar
extension where the extension has remained fairly central and the tumor has
maintained a symmetrical configuration. In these cases the suprasellar exten-
sion has gradually stretched the diaphragma above as it has grown out of the
sella and into the suprasellar cistern (fig. 10). By gradual initial resection of the
inferolateral components of such tumors and frequently with the aid of either a
Valsalva maneuver and/or the intrathecal injection of gas or saline [43], descent
of the diaphragma into the surgical field, with the attached residual tumor can
be achieved for complete resection. Occasionally (12%) the diaphragma sella is
partially incompetent around the pituitary stalk [35]. In such cases the adenoma
may extend through the hiatus in the diaphragma before expanding asymmetri-
cally in the suprasellar region (figs 6, 7). The resultant tumor shape is ‘dumb-
bell’ or ‘hourglass’ in configuration. Dealing with lesions of this shape
transsphenoidally requires transgressing the subarachnoid space widely expos-
ing the patient to the risk of postoperative CSF fistula and meningitis. Blindly
exploring with a curette through the constriction can also potentially result in
iatrogenic injury to the optic chiasm. In such instances the options are either to
perform an extended transsellar transdiaphragmatic transsphenoidal approach
or to perform staged transsphenoidal then transcranial approaches.
Size is not a contraindication to the transsphenoidal approach but an
indurated tumor certainly is. If one encounters a very hard tumor transsphe-
noidally, it is best to obtain an adequate biopsy (debulking if possible) using
countertraction with a microsucker and then pack off the sphenoid sinus in
preparation for a transcranial approach so that one does not end up with a defect
into an empty sphenoid sinus through a patent anterior wall of the pituitary
fossa. Traction on and manipulation of fibrous tumors from below may result in
serious morbidity and mortality [44]. Injudicious traction on a fibrous tumor
may result in occult hemorrhage or damage to important structures to which the
tumor may unknowingly be adherent. Fortunately these are not common and
only about 5–7.5% of large pituitary tumors have an indurated consistency
[45, 46]. These tumors are difficult to remove from below (fig. 8) because the

Maartens/Kaye 12
a b

c d

e f

Fig. 8. Sequential sagittal and coronal T1-weighted MRI sections of a nonfunctioning


pituitary macroadenoma. The preoperative sections (a, b) demonstrate the bulbous suprasel-
lar extension. Due to the fibrous consistency of the tumor a very limited transsphenoidal
resection was achieved (c, d). However, after anticipating that a transcranial resection was
required, a delayed MRI scan 3 months postoperatively demonstrated that the tumor had
spontaneously reduced into the pituitary fossa (e, f) enabling complete resection via a second
transsphenoidal approach.

Role of Transcranial Approaches 13


Fig. 9. Midline sagittal T1-weighted gadolinium-enhanced MRI scan demonstrating a
lesion based on the suprasellar membrane and tuberculum with a typical dural tail (arrow)
extending over the planum sphenoidale – very suggestive of a meningioma.

iaphragma

ormal
ituitary

umor

orsum sella

Fig. 10. Sagittal section diagram illustrating a pituitary macroadenoma arising within the
pituitary fossa showing the normal effaced pituitary tissue draped over the superior aspect and
obscuring an approach from above. This explains why transcranial procedures often have a
higher incidence of hypopituitarism than transsphenoidal approaches from below. From Adams
CBT: A Neurosurgeon’s Notebook (Oxford, Blackwell Science, 1998, p 149) – with permission.

suprasellar component will not descend, even if the sella has been adequately
decompressed, leaving a rind of tumor with identical and persistent mass effect.
Occasionally, however, with time such residual tumors can spontaneously
reduce into the sella where they may be accessed via a redo transsphenoidal

Maartens/Kaye 14
procedure (fig. 8). The alternatives in such instances are to approach the lesion
transcranially or to consider an extracapsular transtubercular extended transsphe-
noidal approach [40].
In a retrospective review by Snow and Patterson [47] of 300 consecutive
patients who underwent surgery for pituitary adenomas, only 18 (6%) of the
patients underwent craniotomy, the rest being managed transsphenoidally. The
indications for craniotomy in their series were: (a) the indurated consistency of
the tumors making transsphenoidal reduction and resection hazardous; (b) giant
macroadenomas deemed to be more safely resected transcranially; (c) a dumb-
bell shape, and (d) uncertainty regarding the diagnosis. The dilemma with
regard to indurated tumors is that this is a finding that is usually only appreci-
ated at the time of surgery. In order to address this Snow et al. [42, 48] analyzed
the MRI appearances of 42 patients with large pituitary tumors in which 7 were
found to be indurated or fibrous at surgery. The remaining 35 had the typical
soft ‘cold mushroom soup’ consistency. All 7 in the indurated group had an
isointense signal on long TR MRI sequences and only 3 in the second ‘soft con-
sistency’ group.
The options to be considered with large lesions that are anticipated to
require both transsphenoidal and transcranial approaches is to either perform
the procedure simultaneously as advocated by Barrow et al. [49] and Alleyne
et al. [50] or to stage the procedure performing the transsphenoidal procedure
first. Performing the transsphenoidal procedure first invariably permits ade-
quate decompression of the optic apparatus, the principal reason for the surgery,
and may in fact, with tumor descent, permit resection of sufficient tumor, mak-
ing a subsequent craniotomy superfluous. Performing the transcranial approach
first increases the risk of a postoperative CSF fistula after the subsequent
transsphenoidal operation. If transcranial surgery is performed first and transsphe-
noidal surgery delayed, residual tumor beyond the narrow exposure of the
transsphenoidal approach will then not descend into the operative field of the
subsequent transsphenoidal procedure due to the development of fibrosis and
adhesions. One can usually, during a transcranial approach, even detect a previ-
ous transsphenoidal procedure with intracapsular resection and preservation of
the arachnoid layer by the increased amount of adhesions present in the suprasel-
lar cistern.
Suprasellar meningiomas have traditionally been approached transcra-
nially (figs 4, 9). This approach has the considerable advantage of facilitating
complete resection of dural tails which frequently track anteriorly over the
planum sphenoidale, thereby preventing recurrence. Recently, there have been
reports on series of extended transsphenoidal, endoscope-assisted procedures
for suprasellar meningiomas [40, 41, 51] and recordings of very elegant endo-
scopic resections demonstrated at conferences. Such procedures, however,

Role of Transcranial Approaches 15


a b c

d e

Fig. 11. Axial (a), sagittal (b) T1-weighted gadolinium-enhanced and coronal (c) T2-
weighted MRI scans demonstrating a sellar-based tumor extending into the left cavernous
sinus and temporal lobe regions. This was initially approached transcranially via the optico-
carotid triangle and from between the internal carotid and the tentorium inadvertently injur-
ing the oculomotor nerve. Histopathology confirmed a nonfunctioning macroadenoma.
Immediate postoperative photographs (d, e) of the patient demonstrate a complete third
nerve palsy that later incompletely resolved.

should only be undertaken by experienced pituitary surgeons and on midline


lesions with minimal lateral, anterior or posterior dural extensions. The long-
term recurrence rates for such surgery is still subject to scrutiny.
While a pituitary surgeon, familiar with the transsphenoidal approach, not
being available in a unit, is not really a regular indication for a transcranial pro-
cedure, this is a scenario that is occasionally encountered – particularly with
apoplexy. Under these circumstances transcranial debulking is often performed.
Frequently the optic chiasm is inadequately decompressed, the tumor insuffi-
ciently resected, and the patient left with a neurological deficit. Not infre-
quently, in such a setting, surgery is associated with damage to the oculomotor
nerve on the side of the approach (see section ‘Complications’; fig. 11). Residual

Maartens/Kaye 16
tumor, obscured from view within the fossa, also tends to hemorrhage post-
operatively. Ideally every pituitary service should have a second surgeon capa-
ble of debulking a macroadenoma transsphenoidally to provide continuity of
emergency cover. Occasionally an apoplectic pituitary hemorrhage may rupture
into the brain. This can be a desperate situation but need not be, and here a
transcranial approach may be preferable.

Preoperative Considerations

Minor complications associated with pituitary surgery can usually be


managed without difficulty. However, the anatomical location of the pituitary
fossa may result in more major complications with potentially disastrous
consequences. Meticulous preoperative planning and preparation are therefore
critical and patients should undergo thorough clinical, neurological, neuro-
ophthalmological and endocrinological evaluation preoperatively. All antiplatelet
or anticoagulant drugs should be discontinued preoperatively. Patients should
be assessed and if necessary treated by an endocrinologist in order to avoid
intraoperative catastrophe due to inadequate pituitary reserve. Particular atten-
tion must be paid to cortisol and thyroxine levels and to the possibility of
disturbances of sodium homeostasis. Patients with prolactinomas, particularly
large macroprolactinomas, should be commenced on a trial of dopamine
agonists in order to ascertain whether the lesion responds, thereby potentially
avoiding surgery. Although we do not recommend universal administration of
glucocorticoids for transsphenoidal procedures [52], we frequently administer
dexamethasone for transcranial procedures where dissection across the long
axis of the optic apparatus, with possible consequent trauma, is necessary.
Parenteral hydrocortisone is administered preoperatively, as required, based
on the results of early morning cortisol levels in combination with a short tetra-
cosactrin (Synacthen 250 ␮g) test for pituitary procedures. For very large lesions
with brain swelling or progressive visual failure, dexamethasone 4 mg q.i.d. is
given empirically. Dilantin (loading 15 mg/kg and maintenance 5 mg/kg/day) is
used for seizure prophylaxis. Brain relaxation, if necessary, can be augmented by
using mannitol (1 g/kg) in combination with 10–20 mg furosemide but we find
that gradual drainage of basal cisternal CSF usually suffices.
Preoperative radiological examination usually consists of full diagnostic
MRI in three planes together with the application of fiducials for frameless
stereotaxy co-registration. Additional information about the bony anatomy
from CT using bone windows may be invaluable in planning the approach and
in managing difficulties expectantly. It is still our policy to always obtain plain
skull X-rays in all patients to delineate the size of the frontal sinus. A team

Role of Transcranial Approaches 17


approach, with close consultation between surgeon, endocrinologist, ophthal-
mologist, radiologist and pathologist, cannot be overemphasized and should be
initiated preoperatively.

Pterional Trans-Sylvian Approach

This approach, first proposed by Silbermark [24], and then pioneered by


Heuer [25] and Adson [27] provides the shortest distance to the sellar and is the
approach most frequently used. In the craniopharyngioma series of Fahlbusch
et al. [31] it was used exclusively in 58 of 148 (39.2%) procedures. It is ideal for
situations where the optic chiasm is postfixed but, if required, the pterional
approach also allows access to the inferior anterior third ventricle through the
lamina terminalis.
The patient is positioned supine with the head of the table raised 25⬚ bring-
ing the operative site above the level of the heart. The patient’s neck is slightly
extended and the head rotated 25⬚ to the side opposite to that of the incision.
This positions the ipsilateral malar prominence uppermost in the surgical field
with the medial sphenoid ridge vertical avoiding awkward tilting of the operat-
ing microscope eyepiece. This position also allows the semisolid brain to fall
backwards, creating a vital few extra millimeters of exposure which simultane-
ously helps to minimize brain retraction. The head is secured in a 3-point
Mayfield clamp positioned horizontally. Rotating the head any further will
incrementally obscure the surgeon’s intraoperative view of the contralateral
optic nerve. The side of entry is initially determined by the laterality of
the tumor’s projection. When possible the tumor is approached from the non-
dominant side which is usually the right-hand side. This facilitates a comfort-
able approach for right-handed surgeons. In the event of severe unilateral visual
failure, preservation of vision in the good eye can be optimized by approaching
from the side of the most compromised optic nerve. Dissection across the long
axis of the optic apparatus and injudicious use of bipolar diathermy can exacer-
bate visual failure, particularly in already compromised optic nerves. It is also
easier to decompress an optic nerve by being able to remove the tumor from
below as one is able to do for the optic nerve opposite to the side of the
approach. Cushing exploited the development of unilateral blindness by sec-
tioning the affected optic nerve to improve access. He later abandoned this
practice after appreciating the delayed potential for reversal of visual failure –
even in severely compressed and affected optic nerves.
After marking out the midline and the zygomatic process, a curvilinear
skin incision is placed within the hairline from a point 0.5 cm in front of the
tragus, just above the zygomatic process to a point near the midsagittal plane.

Maartens/Kaye 18
The scalp and temporalis muscle and fascia are then reflected antero-inferiorly
using diathermy to release the temporalis muscle from its insertion into the
temporal bone. Different techniques are described for adequately exposing the
pterion and determined largely by the bulk of the temporalis muscle. The impor-
tant consideration is the preservation of the frontalis branch of the facial nerve.
Three standard burr holes are then marked out; one just behind the zygomatic
process of the frontal bone – the ‘keyhole’, a second on the floor of the middle
fossa, and a third along the superior temporal line off the forehead. The burr
holes are then linked using a craniotome, taking care not to lacerate the dura
and removing the footplate in order to complete the craniotomy over the
pterion. A large craniotomy exposure is seldom necessary. The medial exten-
sion of the craniotomy exposure above the supraorbital ridge can be increased
for tumors with significant suprasellar extension, particularly those projecting
up between the optic nerves with a postfixed chiasm. In order to do so a burr
hole is placed just above the glabella. This facilitates an additional more medial
subfrontal approach. It becomes very useful when planning the craniotomy flap
to be able to utilize frameless stereotaxy in order to map out the superior extent
of the frontal sinus.
Using a diamond burr the sphenoid ridge is then drilled down medially as
far as the lateral aspect of the superior orbital fissure. The frontal bone is drilled
down flush with the floor of the anterior cranial fossa, once again in order min-
imize retraction and increase exposure (fig. 4). If necessary the frontal sinus
may need to be opened as the risk of excessive frontal lobe retraction usually far
outweighs the risk of exposing the frontal sinus. It is, however, best to avoid
opening the sinus if at all possible, being guided by either frameless stereotaxy
or the skull X-ray. If the sinus is transgressed it requires formal cranialization
with removal of all frontal sinus mucosa and obliteration and watertight sealing
of the frontonasal duct. The dura is then incised in an elliptical fashion around
the Sylvian fissure based on the cranial floor and hitched under tension.
Relieving incisions in the dura may be made posteriorly. The operating micro-
scope and brain retractors are then introduced and positioned.
Attention is first turned to the Sylvian fissure which is opened using the
technique described in detail by Yasargil [53]. The larger the tumor, the more
important this step becomes. Initial entry is facilitated by very gentle retraction
on the frontal lobe putting mild tension on the arachnoid overlying the fissure
and incising this layer anterior to the Sylvian veins. This allows identification of
the interpial plane on either side of an M2 branch of the middle cerebral artery.
By following an artery into the fissure, this plane is then gradually developed
down onto the M1 segment. The fissure is then gently opened both proximally
and distally by using deep to superficial dissection. Dissecting medially eventu-
ally exposes the carotid bifurcation allowing identification of the A1 and M1

Role of Transcranial Approaches 19


segments and their relationship to the tumor. Splitting the Sylvian fissure
allows the temporal lobe to disengage from the frontal lobe posteriorly and for
the frontal lobe to fall backwards with gravity creating a 90⬚ exposure. Using
Teflon-coated brain retractors the frontal lobe is then elevated to allow sub-
frontal exploration of the basal cisterns with a microsucker. The olfactory tract
is identified next. Care must be taken to prevent anosmia, a CSF fistula or hem-
orrhage due to avulsion of the olfactory bulb from the cribriform plate. This is
dissected free from the arachnoid adhesions holding it to the undersurface of
the frontal lobes. The carotid and chiasmal cisterns are then opened allowing
gradual egression of CSF. Patient, slow microsuction allows gradual brain
relaxation and identification of the chiasm and the internal carotid artery with
minimal brain retraction. By this stage the tumor should have come in to view
(fig. 4).
The primary concern should be the blood supply to the hypothalamus and
optic chiasm as well as the position of the optic apparatus. Virtually all pituitary
tumors are situated beneath an arachnoid layer. Access is usually obtained via
the optico-carotid triangle if not obscured by perforators. By opening the arach-
noid and then developing a plane beneath this layer, potential compromise to
the vasculature of the optic chiasm and hypothalamus is prevented. At this stage
tumor specimens are taken and sent for frozen section analysis together with
specimens for formal paraffin sections and specimens to be snap-frozen and
banked for research. Priority is then given to decompressing the optic nerves
and chiasm (fig. 4). If the lesion has a cystic component or is of soft con-
sistency, then the tumor can be debulked via one of the various anatomical
windows for access. Depending on the consistency of the lesion, debulking can
be achieved using the precision nosepiece of the CUSA or curettes of variable
lengths and rotations. Fine bipolar diathermy should henceforth be used very
cautiously in order to prevent coagulating microvasculature responsible for per-
fusing the chiasm.
If the tumor is very fibrous or calcified, the falciform ligament over the
optic nerve is released and if necessary the optic canal opened using a micro-
diamond drill bit. Lateral extension of the tumor may also be obscured by the
ipsilateral optic nerve (fig. 11). Initial extensive decompression medial to the
optic nerve followed by subsequent mobilization of the tumor from the lateral
compartment beneath the optic nerve from lateral to medial facilitates mobi-
lization of this remnant. At this stage it is very easy to injure an attenuated ocu-
lomotor nerve resulting in a permanent palsy. This occurs when access via the
optico-carotid triangle is inadequate and exploration posterolateral to the inter-
nal carotid artery is undertaken (fig. 4). The pituitary stalk and the basilar
artery are displaced posteriorly and separated by an intact Liliequist membrane.
Care must also be taken to define the internal carotid artery and its ophthalmic

Maartens/Kaye 20
branch. Perforating vessels from the internal carotid to the posterior aspect of the
chiasm and optic nerve must be preserved. As the tumor is being debulked the
position of the contralateral optic nerve must be anticipated. The rotation of
the head away from the side of the incision alters the position of the optic nerves
and their relationship to the trajectory of the approach. It is critical to have a
clear idea of this relationship during the resection in order to prevent iatrogenic
damage to the optic apparatus and optic nerves. While normal optic nerves may
tolerate some degree of manipulation, this should be avoided. Stretched, attenu-
ated optic nerves have very little reserve. A very useful anatomical feature is
Liliequist’s membrane which, because left intact by suprasellar extension, pro-
tects the underlying basilar artery.
It is important to remember that the primary aim of the operation is to
decompress the optic nerves. It is very unlikely that every last fragment of
tumor will be able to be removed. If the tumor capsule is adherent to the optic
nerves it is best left attached if a good plane of cleavage cannot be identified.
Attempting to dissect it from the optic chiasm may damage the vasa vasorum
of the optic nerves and lead to infarction and visual loss or else injury to the
midline neuraxis. Ultimate tumor control invariably requires delayed adjuvant
radiotherapy. For large tumors, a real concern is postoperative ooze from the
tumor bed – particularly from residual tumor. It is thus important to remove as
much tumor as possible. After irrigating liberally with saline warmed to 37⬚C,
the use of the microfibrillar collagen hemostatic agent Avitene® via the endo-
scopic applicator in combination with patience, pressure and cottonoid patties,
is usually effective in obtaining good hemostasis before covering the tumor
bed with a single carpet of the oxidized regenerated cellulose hemostat
Surgicel®.
The dura is closed in a water-tight fashion using an absorbable 5/0
monofilament suture before being hitched up to the edges of the craniotomy
defect. The bone flap is secured with titanium miniplates and any significant
bone defect filled in with Bonesource® or acrylic cement.

Other Transcranial Approaches

Frontobasal Interhemispheric Approach


In this approach it is critical to extend the frontal exposure low down onto
the anterior fossa floor in order to minimize brain retraction, if necessary cra-
nializing the frontal sinus. In this approach it is critical to open the subarachnoid
space as early as possible and drain CSF slowly to allow brain relaxation. The
main risk of this approach is postoperative seizures as a consequence of frontal
lobe retraction in combination with sacrifice of bridging venous structures. The

Role of Transcranial Approaches 21


aim is to expose the optic nerves, optic chiasm, A2 segments and anterior com-
municating artery by opening up the chiasmatic and interhemispheric cisterns.
Access is obtained through the lamina terminalis for large tumors and the
approach therefore carries less risk to the fornix. It is considered the best tran-
scranial approach for large retrochiasmatic and suprasellar craniopharyngiomas
which can be exposed through the lamina terminalis giving you a midline view
into the interpeduncular cistern [31, 54, 55]. Care must be taken to protect the
optic apparatus during retrochiasmatic removal and the olfactory tracts require
mobilization from the gyrus rectus in order to preserve smell. The midline
approach always confers an advantage in permitting earlier identification of
important midline structures which may be less easily identified via a pterional
approach.

Orbitozygomatic Approach
Technically, this is a more difficult exposure with marginally increased
morbidity. It does, however, provide the versatility of both lateral and anterior
access with absolutely minimal brain retraction. Care must be taken to pre-
serve the supraorbital and supratrochlear nerves which, if sacrificed, can be a
source of considerable postoperative discomfort. The distance to the tumor
from an anterior approach is approximately 2 cm further than the pterional
approach [47].

Combined Transsphenoidal Transcranial Approach


These can be done during the same or at separate sittings. The transcranial
portion is frequently performed first in order to alleviate hydrocephalus by
decompressing the foramina of Monroe or in order to preserve vision by
decompressing the optic apparatus. Exceptional care must be taken with regard
to effecting a watertight dural seal and skull base reconstruction.

Interhemispheric Transcallosal Approach


This approach is usually only necessary for large septated craniopharyn-
giomas [56], for tumors exclusively in the third ventricle or for tumors extend-
ing up to the foramen of Monro (fig. 12). Dilatation of the lateral ventricles
becomes advantageous in the exposure. Care must be taken to avoid excessive
manipulation of the fornix and to preserve both the thalamostriate and internal
cerebral veins. In order to prevent the development of complex hydrocephalus,
the septum pellucidum should be fenestrated and postoperatively a ventricu-
lostomy drain placed under direct vision and left in situ, closed, to be used if
required. Frameless stereotaxy is very useful for precise placement and mini-
mizing the size of the corpus callosum fenestration.

Maartens/Kaye 22
a b

c d

Fig. 12. Preoperative sagittal and coronal (a, b) and postoperative axial and coronal
(c, d) T1-weighted gadolinium-enhanced MRI scans illustrating a large third ventricle cran-
iopharyngioma resected transcallosally. A small residuum is visible beneath the anterior
commissure laterally on the right. Despite being aware of this intraoperatively, exposure was
inadequate to permit safe resection of this residuum.

Complications

The most common complications associated with the transcranial approach


(table 4) are no different from those encountered during other transcranial neu-
rosurgical procedures [7]. Although pituitary surgery with all its modern day
adjuncts has evolved to the point at which the associated morbidity and mortal-
ity is extremely low (tables 1, 2), the location of the sella at the base of the brain
with its intimate and important anatomical associations is a potential source for
serious morbidity and even mortality [57]. Morbidity and mortality rates also

Role of Transcranial Approaches 23


Table 4. Operative complications of
pituitary surgery Parasellar
CSF rhinorrhea
Hypopituitirism
Diabetes insipidus
Cavernous sinus injury
Hemorrhage
Cranial nerve injury
Carotico-cavernous fistula
False aneurysm
Intracranial
Hemorrhage
Hypothalamic damage
Meningitis
Visual loss
Cerebral ischemia

increase as the size of the sellar tumor increases. Surgery for large macroadeno-
mas is thus more risky than surgery for smaller lesions and microadenomas [39].
Hypopituitarism is more common after transcranial surgery for pituitary
adenomas than transsphenoidal resections. Pituitary adenomas arise in the ade-
nohypophysis and as they enlarge they push the normal pituitary tissue postero-
superiorly leaving a thinned out mantle of gland beneath the diaphragma
(fig. 10). One is thus able to understand the considerable advantages for pre-
venting hypopituitarism of being able to gently reduce and resect a pituitary
adenoma from below. With experience a normal gland can be distinguished
from neoplastic tissue by its red/orange color, striated by a fine capillary net-
work. The consistency of the normal gland also distinguishes it from adenoma
as it tends to resist removal by microsuction and gentle curettage more.
Diabetes insipidus, either transient or permanent, is common with manip-
ulation of the pituitary stalk. Once again it is less common after transsphenoidal
surgery for the reasons outlined above and most common after surgery for cran-
iopharyngiomas that frequently arise in the stalk. It is, therefore, best to avoid
diuretics and Mannitol during pituitary surgery. It is also useful to restrict fluids
to 2 liters/day for 48 h postoperatively and not to give unnecessary, excessive
steroids. This will prevent a physiological diuresis confusing the diagnosis of
diabetes insipidus. If a patient’s urine output has been in excess of 250 ml/h for
more than 3 h consecutively then urgent electrolyte analysis together with both
plasma and urine osmolality should be arranged. If the serum sodium is raised
and the plasma osmolality is ⬎295 mosm/kg, then a diagnosis of diabetes
insipidus is likely. Vigilance for and proactive management of diabetes insipidus
is important before more severe hyponatremia supervenes compromising the

Maartens/Kaye 24
patient’s clinical state. It is important to remember that postoperative diuresis is
normal in patients with acromegaly [44] and that excessive glucocorticoids
cause diabetes insipidus.
Visual deterioration is not uncommon after transcranial surgery for sellar
and parasellar tumors, particularly calcified craniopharyngiomas. This is a conse-
quence of having to resect the tumor across the long axis of the optic nerve and
chiasm and may occur in an immediate or delayed manner. As already empha-
sized, normal optic nerves tolerate manipulation to a greater extent than compro-
mised nerves. This tolerance is a function of the degree and chronicity of the
mechanical compression. Factors associated with postoperative visual loss are
prior irradiation, previous surgery, preexisting deficit, technical difficulties with
surgery and diabetes mellitus [58–60]. The most common cause of visual loss is
disruption of the blood supply to the optic chiasm or nerves – even if the anatomic
continuity of these structures is preserved and they are minimally manipulated. A
detailed understanding of the microvascular anatomy of the optic nerves and chi-
asm as well as meticulous microdissection techniques are the most important fac-
tors in preventing postoperative visual deterioration [7]. Perioperative steroid
cover with 4 mg q.i.d. of dexamethasone prophylactically is also recommended.
Hypothalamic injury may occur as a result of direct surgical injury, hemor-
rhage or ischemia. It is rare and frequently lethal. It is more commonly encoun-
tered in patients having undergone previous surgery or radiation therapy.
Clinically it manifests acutely with diabetes insipidus, somnolence or auto-
nomic dysfunction – specifically difficulties with temperature regulation or
chronically with morbid obesity, memory loss, insatiable hunger or thirst. If
severe it manifests with a depressed level of consciousness [61, 62]. Gentle sur-
gical technique, avoidance of traction on the tumor capsule and pituitary stalk,
and retracting on the tumor and not the brain minimizes the occurrence of such
injury. Extensive experience with deformed and pathologic anatomy encoun-
tered with tumors involving the suprasellar and inferior third ventricle region is
very advantageous [7].
Another frequent complication of transcranially resecting the lateral exten-
sion of a pituitary adenoma is not appreciating the presence and position of the
third nerve splayed over the surface of the tumor (fig. 11), particularly when
exploring the lesion posterolateral to the internal carotid artery.

Conclusion

For the majority of large pituitary macroadenomas, an attempt should be


made to resect the tumor via a transsphenoidal route due to the safety of this
approach, its efficacy with regard to tumor resection, preservation of pituitary

Role of Transcranial Approaches 25


function and resolution of visual failure. There are, however, certain situations
where a transcranial procedure is indicated, either de novo or as a secondary
procedure to complete the resection in order to adequately decompress the optic
nerves and in some instances the hypothalamus, frontal or temporal lobes. As
with the surgeons of old, the pterional route with all its variations provides an
ideal approach to lesions extending into the suprasellar cistern and parasellar
regions and should be mastered by all specialist pituitary surgeons.

References

1 Horsley V: On the technique of operations on the central nervous system. BMJ 1906;ii:411–423.
2 Schloffer H: Zur Frage der Operationen an der Hypophyse. Beitr Klin Chir 1906;50:767–817.
3 Schloffer H: Erfolgreiche Operation eines Hypophysentumors auf nasalem Wege. Wien Klin
Wochenschr 1907;20:621–624.
4 de Divitiis E, Cappabianca P (eds): Endoscopic Endonasal Transsphenoidal Surgery. New York,
Springer, 2003.
5 Couldwell WT, Weiss MH, Rabb C, Liu JK, Apfelbaum RI, Fukushima T: Variations on the stan-
dard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and
parasellar approaches: surgical experience in 105 cases. Neurosurgery 2004;55:539–550.
6 Black PM, Zervas NT, Candia GL: Incidence and management of complications of transsphe-
noidal pituitary surgery. Neurosurgery 1987;20:920–924.
7 Krisht AF: The pterional approach; in Krisht AF, Tindall GT (eds): Pituitary Disorders:
Comprehensive Management. Baltimore, Lippincott Williams and Wilkins, 1999, pp 361–368.
8 Frazier C: Choice of method in operations upon the pituitary body. Surg Gynecol Obstet
1919;29:9–16.
9 Marie P: Sur deux cas d’acromégalie: hypertrophie singulière non congénitale, des extrémités
supérieures, et céphalique. Rev Med Liege 1886;6:297–333.
10 Horsely V: Functional nervous disorders due to loss of the thyroid gland and pituitary body. Lancet
1886;ii:5.
11 Landolt A: History of pituitary surgery; in Greenblatt A (ed): A History of Neurosurgery. Park
Ridge, American Association of Neurological Surgeons, 1997, pp 373–400.
12 Caton R, Paul FT: Notes of a case of acromegaly treated by operation. BMJ 1893;ii:1421–1423.
13 Kiliani O: Some remarks on tumours of the chiasm, with a proposal how to reach the same by
operation. Ann Surg 1904;40:35–43.
14 Krause F: Hirnchirurgie. Dtsch Klin 1905;8:953–1024.
15 Krause F: Bemerkungen zur Operation der Hypophysen-geschwulste. Dtsch Med Wochenschr
1927;53:691–694.
16 Liu JK, Das K, Weiss MH, Laws ER Jr, Couldwell WT: The history and evolution of transsphe-
noidal surgery. J Neurosurg 2001;95:1083–1096.
17 Cope V: The pituitary fossa and the methods of the surgical approach thereto. Br J Surg 1916;4:
107–144.
18 Pollock JR, Akinwunmi J, Scaravilli F, Powell MP: Transcranial surgery for pituitary tumours
performed by Sir Victor Horsley. Neurosurgery 2003;52:914–926.
19 Cushing H: Surgical experiences with pituitary disorders. JAMA 1914;63:1515–1525.
20 McArthur L: An aseptic approach to the pituitary body and its neighbourhood. JAMA 1912;58:
2009–2011.
21 McArthur L: Tumor of the pituitary gland: technique of operative approach. Surg Clin Chicago
1918;2:691–699.
22 Frazier C: Lesions of the hypophysis from the viewpoint of the surgeon. Surg Gynecol Obstet
1913;17:724–736.

Maartens/Kaye 26
23 Frazier C: Surgery of the pituitary lesion. Ann Surg 1928;88:1–5.
24 Silbermark M: Die intrakranielle Extirpation der Hypophyse. Wien Klin Wochenschr 1910;23:
467–468.
25 Heuer G: Surgical experiences with intracranial approach to chiasmal lesions. Arch Surg
1920;1:368–381.
26 Heuer G: The surgical approach and the treatment of tumors and other lesions about the optic chi-
asm. Surg Gynecol Obstet 1931;53:489–518.
27 Adson A: Hypophysial tumors through the intradural approach. JAMA 1918;71:721–726.
28 Halstead A: Remarks on the operative treatment of tumours of the hypophysis (two cases operated
on by an oronasal route). Surg Gynecol Obstet 1910;10:494–502.
29 Guiot G: Considerations on the surgical treatment of pituitary adenomas; in Fahlbusch R,
Werder KV (eds): European Workshop on the Treatment of Pituitary Adenomas. Stuttgart,
Thieme, 1978, pp 202–218.
30 Hardy J: Transsphenoidal microsurgery of the normal and pathological pituitary. Clin Neurosurg
1969;16:185–217.
31 Fahlbusch R, Honegger J, Paulus W, Huk W, Buchfelder M: Surgical treatment of craniopharyn-
giomas: experience with 168 patients. J Neurosurg 1999;90:237–250.
32 Guidetti B, Fraioli B, Cantore GP: Results of surgical management of 319 pituitary adenomas.
Acta Neurochir (Wien) 1987;85:117–124.
33 Rhoton AL Jr, Natori Y: The Orbit and Sellar Region. Microsurgical Anatomy and Operative
Approaches. New York, Thieme, 1996, p 311.
34 Rhoton AL Jr: The sellar region. Neurosurgery 2002;51(suppl):S335–S374.
35 Renn WH, Rhoton AL Jr: Microsurgical anatomy of the sellar region. J Neurosurg 1975;43:
288–298.
36 Jane JA Jr, Thapar K, Alden TD, Laws ER Jr: Fluoroscopic frameless stereotaxy for transsphe-
noidal surgery. Neurosurgery 2001;48:1302–1308.
37 Elias WJ, Chadduck JB, Alden TD, Laws ER Jr: Frameless stereotaxy for transsphenoidal surgery.
Neurosurgery 1999;45:271–277.
38 Bergland RM, Ray BS, Torack M: Anatomical variations in the pituitary gland and adjacent struc-
tures in 225 human autopsy cases. J Neurosurg 1968;28:93–99.
39 Zervas N: Surgical results in pituitary adenomas: results of an international survey; in Zervas N,
Black PM, Ridgeway EC (eds): Secretory Tumours of the Pituitary Gland. New York, Raven Press,
1984, pp 377–385.
40 Kaptain GJ, Vincent DA, Sheehan JP, Laws ER Jr: Transsphenoidal approaches for the extracapsu-
lar resection of midline suprasellar and anterior cranial base lesions. Neurosurgery 2001;49:
94–101.
41 Jho HD, Alfieri A: Endoscopic endonasal pituitary surgery: evolution of surgical technique and
equipment in 150 operations. Minim Invasive Neurosurg 2001;44:1–12.
42 Snow RB, Lavyne MH, Lee BCP, Morgello S, Patterson RH Jr: Craniotomy versus transsphe-
noidal excision of large pituitary tumors: the usefulness of magnetic resonance imaging in guiding
the operative approach. Neurosurgery 1986;19:59–64.
43 Kaye AH, Rosewarne F: Forced subarachnoid air for transsphenoidal surgery. J Neurosurg
1990;73:311–312.
44 Adams CBT: A Neurosurgeon’s Notebook. 1998, Oxford: Blackwell Science.
45 Laws ER: Comment. Neurosurgery 1984;14:488.
46 Wilson C: Neurosurgical management of large and invasive pituitary tumours; in Wilson C,
Tindall G (eds): Clinical Management of Pituitary Disorders. New York, Raven Press, 1979,
pp 335–342.
47 Snow RB, Patterson RH Jr: Craniotomy for pituitary tumours; in Kaye AH, Black P (eds):
Operative Neurosurgery. London, Churchill Livingstone, 2000, pp 709–714.
48 Snow RB, Johnson CE, Morgello S, Lavyne MH, Patterson RH Jr: Is magnetic resonance imaging
useful in guiding the operative approach to large pituitary tumors? Neurosurgery 1990;26:
801–803.
49 Barrow DL, Tindall G, Tindall SC: Combined simultaneous transsphenoidal transcranial operative
approach to selected sellar tumours. Perspect Neurol Surg 1992;3:49–57.

Role of Transcranial Approaches 27


50 Alleyne CH Jr, Barrow DL, Oyesiku NM: Combined transsphenoidal and pterional craniotomy
approach to giant pituitary tumours. Surg Neurol 2002;57:380–390.
51 Cooke SW, Smith Z, Kelly DF: Endonasal transsphenoidal removal of tuberculum sellae menin-
giomas: technical note. Neurosurgery 2004;55:239–244.
52 Inder WJ, Hunt P: Glucocorticoid replacement in pituitary surgery: guidelines for perioperative
assessment and management. J Clin Endocrinol Metab 2002;87:2745–2750.
53 Yasargil MG: Microneurosurgery. Stuttgart, Thieme, 1984, vol 2.
54 Hoffman HJ, De Silva M, Humphreys RP, Drake JM, Smith ML, Blaser SI: Aggressive surgical
management of craniopharyngiomas in children. J Neurosurg 1992;76:47–52.
55 Patterson RH Jr, Danylevich A: Surgical removal of craniopharyngiomas by a transcranial
approach through the lamina terminalis and sphenoid sinus. Neurosurgery 1980;7:111–117.
56 Steno J, Malacek M, Bizik I: Tumor-third ventricular relationships in supradiaphragmatic cranio-
pharyngiomas: correlation of morphological, magnetic resonance imaging, and operative find-
ings. Neurosurgery 2004;54:1051–1060.
57 Zada G, Kelly D, Cohan P, Wang C, Swerdloff R: The endonasal transsphenoidal approach for
pituitary adenomas and other sellar lesions: an assessment of efficacy, safety and patient impres-
sions. J Neurosurg 2003;98:350–358.
58 Barrow DL, Tindall G: Loss of vision after transsphenoidal surgery. Neurosurgery 1990;27:60–68.
59 Adams C: The management of pituitary tumours and post-operative visual deterioration. Acta
Neurochir (Wien) 1988;94:103–116.
60 Martins A: Pituitary tumors and intrasellar cysts; in Vonken PJ, Bruyn GW (eds): Handbook of
Clinical Neurology. Amsterdam, North Holland Publishing, 1974, p 431.
61 Tindall CT, Barrow D: Disorders of the Pituitary. St Louis, Mosby, 1986, pp 349–400.
62 Landolt A: Transsphenoidal surgery of pituitary tumors: its pitfalls and complications; in de
Villiers JC (ed): Some Pitfalls and Problems in Neurosurgery. Prog Neurol Surg. Basel, Karger,
1990, vol 13, p 1.

Nicholas F. Maartens, MD
Department of Neurosurgery, Royal Melbourne Hospital
University of Melbourne
Parkville, VIC 3050 (Australia)
Tel. ⫹61 3 93427000, Fax ⫹61 3 93427273, E-Mail niki.maartens@mh.org.au

Maartens/Kaye 28
Laws ER Jr, Sheehan JP (eds): Pituitary Surgery – A Modern Approach.
Front Horm Res. Basel, Karger, 2006, vol 34, pp 29–45

Extended Transsphenoidal Approach


Aaron S. Dumont, Adam S. Kanter, John A. Jane, Jr., Edward R. Laws, Jr.
Department of Neurological Surgery, Health Sciences Center, University of Virginia,
Charlottesville, Va., USA

Abstract
Transsphenoidal surgery is well established as an effective primary treatment for
tumors of the sellar region. The technique of transsphenoidal surgery has evolved over the
years with many prominent surgeons contributing to its present state of refinement. The
transsphenoidal approach can be modified in various ways to permit resection of parasellar
tumors that otherwise would require a transcranial or transbasal operation. Our experience
with these ‘extended’ techniques has primarily involved the transtuberculum sella approach
in which bone is removed from the tuberculum sellae and the posterior portion of the planum
sphenoidale. Experience with this technique continues to burgeon, and offers an excellent
alternative to transcranial surgery in dealing with a difficult constellation of tumors.
Meticulous attention to detail, particularly with respect to reconstruction and closure of the
sellar floor, is necessary for its effective application.
Copyright © 2006 S. Karger AG, Basel

Introduction

The transsphenoidal approach provides safe and effective access to tumors


arising within the sella. Transsphenoidal adenomectomy preserves pituitary
function and decompresses the optic apparatus in the majority of patients. The
approach provides direct access to the sella and pituitary gland without brain
retraction and is generally well tolerated with rare major morbidity.
Extirpation of pituitary adenomas with significant suprasellar extension is
often possible via the standard transsphenoidal approach. Intrasellar tumor
growth expands the sella turcica and creates an adequate surgical corridor for
resection of suprasellar tumor extensions. Without sellar expansion, however,
access to suprasellar and extrasellar components is greatly restricted. Tumors
that do not arise from within the sella are thereby difficult to resect using the
standard transsphenoidal approach. Certain primary suprasellar tumors and
other tumors with suprasellar and/or anterior cranial base extension pose unique
management challenges. These lesions have been traditionally approached
through various transcranial corridors. Although several different transcranial
approaches can be employed, most require some degree of brain retraction.
Transbasal approaches require less brain manipulation but morbidity is not
insignificant. Particularly in the setting of a pre-fixed chiasm, the surgical win-
dow provided by these transcranial approaches is often limited to dissection
between the optic nerves and carotid arteries. More recent modifications to the
standard transsphenoidal approach have brought a portion of these tumors into
the purview of the transsphenoidal corridor. Transsphenoidal removal of the
tuberculum sellae and a portion of the planum sphenoidale along with the ante-
rior wall of the sella provides surgical access to lesions in the suprasellar region
and along the anterior cranial base.

Historical Considerations

The frontal transcranial approach to the sella turcica was introduced by


Krause [1] in 1905. Subsequently, other pioneering neurosurgeons including
Dandy [2], Heuer [3], Frazier [4, 5] and Cushing [6, 7] improved upon this ini-
tial work providing the basis for contemporary transcranial approaches. The ini-
tial difficulties and high complication rates of early transcranial approaches
provided impetus for the development of extracranial approaches to sellar
lesions.
Based upon initial work of Giordano, who proposed a transfacial approach
to the pituitary gland [8], Schloffer [9, 10] reported the first successful resec-
tion of a pituitary tumor via a transsphenoidal approach in March 1907. This
approach was modified by Theodor Kocher [11] in 1909 who resected the sep-
tum submucosally, expanding the visualization of sellar anatomy, and by Oskar
Hirsch [12–14] in 1910 who advocated an endonasal transseptal transsphe-
noidal approach based on the approach to the sphenoid sinus used by his men-
tor, Hajek, for the treatment of sphenoid sinusitis [12]. Hirsch performed his
first transsphenoidal tumor resection in a multi-staged fashion over a 5-week
period, with each session done under local anesthesia (fig. 1). The patient’s
visual symptoms dramatically improved following which Hirsch subsequently
developed more effective and efficient techniques, including the introduction of
the nasal speculum.
Later in 1910, Albert Halstead [15] described his sublabial gingival incision
which remains popular today. Harvey Cushing [6, 7, 16] helped to further refine
the transsphenoidal sublabial approach to the sella (figs 2, 3) although he would

Dumont/Kanter/Jane Jr/Laws Jr 30
Fig. 1. Hirsch’s endonasal, submucosal, transseptal approach to the sella turcica.
A speculum is used to laterally retract the mucosal flaps and to maintain exposure. Courtesy
of Dr. Edward Laws’ personal slide collection.

Fig. 2. Midline sagittal illustration with the nasal speculum in place demonstrating
Cushing’s sublabial approach. From Cushing H: Disorders of the pituitary gland, retrospec-
tive and prophetic. JAMA 1921;76:1721–1726.

abandon it completely from 1929–1932 in favor of the transcranial approach.


The reason for Cushing’s return to the transcranial approach are not entirely
known although it is thought that he felt that intraoperative complications were
more easily dealt with from above. Despite Cushing’s lack of enthusiasm, Hirsch

Extended Transsphenoidal Approach 31


Fig. 3. Cushing’s sublabial approach. Removal of the anterior wall of the sphenoid
sinus. From Cushing H: Disorders of the pituitary gland, retrospective and prophetic. JAMA
1921;76:1721–1726.

continued to perform the procedure, traveling from Vienna to Boston, thus


remaining an ‘obscure voice in the wilderness’ [17].
Although the majority of the neurosurgical community followed Cushing’s
lead, Norman Dott, who studied Cushing’s transsphenoidal approach at the Peter
Bent Brigham Hospital from 1923–1924, continued to use and modify the
transsphenoidal approach upon his return to the Royal Infirmary in Edinburgh
[18]. Dott subsequently designed instruments specifically for the transsphenoidal
procedure, such as a speculum with an attached lighting apparatus [19]. Gerard
Guiot, a French neurosurgeon, learned the technique from Dott and also con-
tributed to its resurgence with the introduction of intraoperative radiological guid-
ance [20] (fig. 4). Jules Hardy from Montreal subsequently learned the technique
from Guiot and further refined it by adopting the operating microscope with its
superior illumination and magnification (fig. 5) [21–23]. Utilizing microscopic
dissection techniques, Hardy introduced the concept of microadenomectomy and
demonstrated the possibility of surgical cure in these small hyperfunctioning
lesions. Equally significant advances in the fields of endocrinology and radiology
during this period indisputably contributed to the transsphenoidal renaissance
which occurred in the late 1960s. Fluoroscopy was introduced, hormones were
isolated, their physiologic roles elucidated, and radioimmunoassays developed for
both diagnosis and post-treatment surveillance [14]. These and other innovations
provided the foundation for the modern transsphenoidal approach practiced by
neurosurgeons throughout the world today.

Dumont/Kanter/Jane Jr/Laws Jr 32
Fig. 4. The addition of mobile fluoroscopic imaging techniques dramatically improved
operative accuracy and efficiency.

a b
Fig. 5. Innovations such as the microscope (a) and later the endoscope (b) further con-
tributed to the evolution of the transsphenoidal approach allowing improved illumination,
magnification, and visualization.

Further refinements have occurred including the introduction of the endo-


scope as a primary or adjunctive tool (fig. 5), use of frameless stereotactic guid-
ance, and aggressive resection of the cranial base; each innovation providing
corridors to previously unreachable tumors while preserving anatomic struc-
tures [24–47].

Extended Transsphenoidal Approach 33


The transsphenoidal transtuberculum sellae approach was originally
described by Weiss [47] in 1987. Contemporary neurosurgical pioneers includ-
ing Oldfield, Kato, Laws, Jho, Frank, de Divitiis, and Cappabianca have subse-
quently adopted and refined the technique for resection of various tumors with
suprasellar, parasellar, and/or anterior cranial base extension including, but not
limited to, craniopharyngiomas, tuberculum sellae meningiomas and Rathke’s
cleft cysts [35, 36, 38–43, 48–50].

Patient Selection

Patients with midline tumors involving an anatomical region extending


from the planum sphenoidale to the lower clivus, who are fit candidates for a
surgical procedure, may potentially be considered candidates for this approach.
Patients with primarily suprasellar tumors without sellar enlargement may also
be considered potential candidates for this approach. However, not every
patient harboring a midline tumor confined to these anatomical boundaries is a
candidate. The normal pituitary is often displaced ventrally and inferiorly and
can be easily injured during the approach as it is encountered before the tumor.
Thus the transsphenoidal approach is sometimes reserved for those patients
with preexisting hypopituitarism and is less desirable in children with normal
pituitary function [51]. Conversely, several biological considerations combined
with modern technologic advances have made operating on the para- and
suprasellar compartment via the extended approach a favorable route. For
example, adenomas with significant extension often exhibit invasive growth
patterns such that radical resection in lieu of vital structure preservation is
unwarranted. Additionally, avoiding brain retraction, cranial nerve dissection,
and skin incisions cannot be underestimated [17].
Careful evaluation of preoperative high-resolution magnetic resonance
(MR) imaging is necessary to guide the decision regarding the appropriateness
of this procedure. The relationship of the tumor to the chiasm, hypothalamus,
third ventricle and major blood vessels must be determined. This is particularly
important when the goal of the surgery is gross total resection. When palliation
is the goal, this procedure can usually be applied safely and effectively. The sur-
gical operating times are significantly shorter than for standard craniotomy. The
extended transsphenoidal approach has also been applied effectively in the set-
ting of multiple prior surgical procedures and/or radiation. The procedure can
also be used to provide a histological diagnosis in lesions not easily amenable to
other surgical approaches.
Despite careful preoperative evaluation and patient selection, some tumors
will prove to be unsuitable for resection based upon intraoperative inspection.

Dumont/Kanter/Jane Jr/Laws Jr 34
In the authors’ experience, an attempted extended transsphenoidal resection
was aborted in 3 cases. For example, in a retroinfundibular meningioma extend-
ing to and abutting the midbrain, the extended transsphenoidal approach was
abandoned due to a firm tumor consistency, large tumor size and adherence to
critical structures, in favor of a later craniotomy.

General Technical Aspects

All patients require a thorough preoperative neurological and endocrino-


logical history and physical examination. Biochemical testing should be per-
formed to screen for pituitary endocrine dysfunction. Formal visual field
testing with static perimetry and visual acuity testing is also mandatory.
Contrast-enhanced MR imaging should also be performed and the authors’
practice has also been to perform sequences for frameless image guidance.
After intubation, a lumbar drain is inserted which allows insufflation of air
intraoperatively as well as cerebrospinal fluid (CSF) diversion during the post-
operative period. The lumbar drain usually remains in place for 48 h postopera-
tively. In a semirecumbent position, patients are placed in a horseshoe headrest
with the head in slight extension. In contradistinction to our traditional sellar
approach in which the head is positioned such that the bridge of the nose is par-
allel to the floor, the slight extension allows a more rostral view towards the
planum sphenoidale. Although patients are not fixated to the table, a head
holder is required to mount the array for frameless stereotaxy.
A direct endonasal or sublabial approach may be used depending upon the
amount of room and scope of vision required (fig. 6). The authors preferentially
elect the latter approach as the direct endonasal approach often leads to inade-
quate working space and all too often an unfavorable angle to the lesion for
proper surgical manipulation, effective bipolar hemostasis, and instrument
maneuverability [17]. Through either approach, a wide anterior sphenoidotomy
is performed to expose the bony landmarks of the sellar floor, cavernous sinus,
and the optic and carotid protuberances (fig. 7). A high speed air drill and
Kerrison punches can be used to open the sellar floor to the limits of the cav-
ernous sinus laterally and the intercavernous sinus superiorly (fig. 8). If the
tumor does not extend inferiorly into the sella, the inferior portion of the pitu-
itary gland does not have to be exposed. Nevertheless, some exposure of the
pituitary gland is necessary, not only to provide a transdural entry point below
the superior intercavernous sinus, but also to allow visualization of the gland
and protection thereof during the operation.
Using frameless stereotactic guidance, the tuberculum sellae and planum
sphenoidale are removed (fig. 8). Although a high-speed drill is usually

Extended Transsphenoidal Approach 35


Fig. 6. Endonasal and sublabial transsphenoidal approaches. The endonasal approach
avoids resection of the anterior nasal spine of the maxilla but limits the extended superior and
lateral visualization afforded by the sublabial approach.

employed, we have also had success using angled punches and curettes.
Neuronavigation is a useful adjunct during this stage allowing the rostral bony
removal to be tailored to the geometry of the tumor and the lateral bony removal
to avoid carotid and optic nerve injury. Generally, the lateral exposure does not
exceed 15 mm in diameter. The position of the carotid arteries may also be con-
firmed through the use of a micro-Doppler probe.
Dural opening requires special attention as the superior intercavernous
sinus may be robust and not amenable to simple bipolar cautery. The sellar
dura is opened parallel and just inferior to the superior intercavernous sinus
which is readily visible through the dura. Surgical clips are then placed across
the sinus which can then be incised. The dura of the anterior cranial fossa is

Dumont/Kanter/Jane Jr/Laws Jr 36
PS

CP
CP
SF
*
C

Fig. 7. Typical endoscopic view of the bony landmarks following removal of the
anterior wall of the sphenoid. C ⫽ Clivus; CP ⫽ carotid protuberance; SF ⫽ sellar floor;
PS ⫽ planum sphenoidale; * ⫽ sphenoid septation.

then coagulated and opened. Following dural opening, extra-arachnoidal dis-


section is performed and the pituitary gland is carefully identified and
protected. The arachnoid is sharply opened and general principles of micro-
surgery are implemented. The capsule of the tumor is delineated and cauter-
ized with bipolar electrocoagulation. Capsular feeders can be identified,
coagulated and cut sharply. The tumor is subsequently debulked, allowing the
capsule to be carefully mobilized. Circumferential dissection of the capsule is
undertaken and extracapsular feeders are controlled as they are encountered.
Meningiomas often respect arachnoidal planes, particularly at the tumor-
chiasm interface. There are often preserved arachnoidal planes between the
tumor and the carotid arteries, although not universally so, and meticulous
microsurgical technique is necessary for removal of the lateral portion of
suprasellar meningiomas arising from the tuberculum sellae or diaphragm
(fig. 9).
The most dorsal and rostral aspects of the tumor can pose a challenge to
removal as it is often adherent to the surrounding brain, as is frequently encoun-
tered in the resection of craniopharyngiomas [51, 52]. Infradiaphragmatic
lesions rarely transgress through the anatomic barrier of the diaphragma sella
thus theoretically enabling a ‘gross total resection’ while those predominantly of

Extended Transsphenoidal Approach 37


Fig. 8. Following removal of the sellar floor, the cavernous and intercavernous sinuses
are visualized (arrows). Further superior bony removal of the planum sphenoidale and tuber-
culum sellae can then ensue paying particular attention to preserve arachnoidal/tumor planes.
From Mason et al. [45].

the suprasellar compartment pose the operative challenges listed above; thereby
limiting safe ‘total’ resection and favoring a palliative goal with subtotal removal
and decompression of the optic apparatus and intracranial structures [52]. The
endoscope is often useful for the careful dissection and removal of this part of
the tumor, either as a primary tool or adjunct. With mobilization of the dorsal
tumor capsule the pituitary stalk is observed and can often be preserved.
As tumor removal proceeds, the local anatomy is exposed (fig. 10) includ-
ing the optic nerves, chiasm, anterior communicating artery complex, and basi-
lar artery. Neuroendoscopy is of particular utility in assessing local anatomy
and the extent of tumor resection without the optical limitations imposed by the
transsphenoidal retractor and is indispensable during these operations [17].
Absolute hemostasis must be ensured upon completion of the procedure.
The endoscope is very useful in this respect, particularly to inspect the resection
cavity if the tumor has been removed into the recesses of the third ventricle.
In many cases, such as following resection of planum sphenoidale menin-
giomas, the dural and cranial base defect can be large. This remains the greatest
challenge of this procedure and a perfect means of closure and reconstruction
has not yet been identified. We have tended to use harvested fat and synthetic

Dumont/Kanter/Jane Jr/Laws Jr 38
Fig. 9. A meticulous microsurgical technique is necessary for removal of the dorsal
and lateral portions of suprasellar lesions arising from the tuberculum sellae or diaphragm.
From Mason et al. [45].

dural substitutes to close the dural defect. The bony defect may then be closed
with an extradural layer of harvested septal bone or fabricated plates of titanium
or bioabsorbable compounds. The intracranial fat graft and dural substitute can
be sutured and cinched down onto this bone graft or plate (fig. 11). Fat is also
placed within the sphenoid sinus and lumbar drainage is maintained postopera-
tively for 2 days (fig. 12). Nasal packing is usually maintained for 24–48 h.
Stress dose hydrocortisone is administered for the first 24 h after surgery
and morning cortisol levels are drawn on postoperative days 2 and 3 to assess
the pituitary-adrenal axis. Patients are monitored closely for diabetes insipidus
using daily serum sodium levels, urinary specific gravity every 4 h, fluid intake
and output, and daily weight.

Complications and Their Avoidance

Complications are a potential consequence of any surgical procedure,


however, there are some unique considerations specific to the transsphenoidal

Extended Transsphenoidal Approach 39


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— Että kuka akan ja sikiöt nyt elättää?

Taivaan Ukko rypisti hopeanhohtavia kulmakarvojaan:

— Me emme täällä Taivaassa puhu sikiöistä, vaan lapsista. Eikä ole


kaunista että te kaikki ränsänrantalaiset sanotte vaimojanne akoiksi.
Jooseppi paransi:

— Ka niin vain että kuka se Kaisa-Reetan ja ne kakarat elättää,


kun minulle näin kävi?

— Kakarat! murisi Ukko, uhaten sormellaan Jooseppia. — Heitä


pois rumat sanat.

Joosepin täytyi sanoa kolmannen kerran:

— Että kun minulle nyt kävi näin huonosti, niin mikä keino siihen
keksitään Herra Taivahan Taatto, jotta rakas vaimoni ja rakkaat
lapseni pysyisivät hengissä siellä ajan laksossa?

— No nyt sanoit kauniisti niinkuin miehen puhua pitää, kiitteli Pyhä


Ukko. — Mutta mitä asiaasi tulee, niin oletkos todella ainoa, joka et
tiedä, ettemme me täällä Taivaassa mahda mitään sille, jos sinun
perheesi kuolee nälkään.

— Mutta sehän on kamala totuus! huudahti Jooseppi.

— Aivan niin, hyvä ystävä, julisti Pyhä Ukko. — Mutta ota


huomioon että Taivas on juuri sitä varten olemassa että ainoastaan
täällä saavat lievityksen kaikki ne, jotka siellä maan päällä kärsivät.

— Hallelujaa! säestivät enkelit ristien silmänsä.

— Meillä, jatkoi Pyhä Ukko, on vain oikeus korjata luoksemme,


kenet me tahdomme. Ja joka tänne pääsee, hän ei totisesti kuole
nälkään.

Jooseppi jäi miettimään pyöritellen lakkiaan. Sanan virkkoi:


— Mutta eikö sitten olisikin parempi, jos nostaisitte koko höskän
minun perässäni tänne Taivaaseen?

— Koko Ryysyrannanko russakoineen! jyrähti Taivaan Pyhä Ukko


silmät suurina. — Johan sinä nyt, Jooseppi rukka, höpiset
mahdottomia. Kyllä täällä tiedetään, kuka kulloinkin on kutsuttava.

Enkelit hymyilivät.

Yhtäkkiä enkelit höristivät korviaan. Oven takaa kuului vikinää ja


raapimista. Yksi enkeleistä meni katsomaan ja raotti ovea:
pystykorva, pörhöinen koira livahti sisään.

Pyhän Ukon hahmo muuttui:

— Gehennan komeroistako tuo koira pääsi?

— Se on minun koirani, esitteli Jooseppi. — Vekku tämä on —


samasta maanpäällisestä helvetistä se tulee kuin minäkin. Se on
uskollinen isännälleen, laukun ja sukset vahtii läpi yön ja kinttuun
tarraa, kuka koskee. Ja hyvin näpeä se on haukkumaan oravia, kehui
Jooseppi. — Näpeä.

Enkelit pyrskähtivät nauramaan.

Taivaan Pyhä Ukko raapasi neuvottomana hopeanhohtavaa


päätään.

— No jaa, Hän sanoi, — ainoastaan Ryysyrannan Joosepille olkoon


sallittu pitää koiransa Taivaassa, mutta meidän kultaisia oraviamme
taatelipalmujen latvoissa sen ei tarvitse haukkua.

Vielä Ukko lisäsi, partaansa mutisten:


— Pyhä Pietari alkaa käydä huolimattomaksi. Kuinka hän saattoi
laskea koiran portista? Ja kuinka unilukkari Olkkonen päästi sen
laukkomaan pitkin Esikartanoitamme?

Enkelit katselivat yhä suuremmalla mielenliikutuksella Jooseppiin,


jonka känsäisiä käsiä Vekku häntäänsä heiluttaen nuoleskeli. Mutta
Taivaan Pyhä Ukko jatkoi:

— Asiaan! Emme oikeastaan ole puhuneet vielä


pääartikkelistakaan.
Kuinka paljon sinulla oikein on syntejä, Jooseppi Kenkkunen?

Jooseppi säikähti ja oli vaiti kuin ahven murrossa.

— Luettele! käski Ukko.

— Kukapa heijät kaikki muistaa…, mutisi vihdoin Jooseppi.

Pyhä Ukko otti puhevuoron:

— Sinulla taitaa olla se harhakäsitys että jos kaikki syntisi luettelet


ja niiden joukossa on paljon painavia, et muka saa jäädä tänne
Taivaaseen?

— Ka sellainenhan minulla on käsityskanta, myönsi Jooseppi arasti


nostaen silmänsä.

— Asianlaita ei ole niin, selitti Taivaan Ukko vakavasti. —


Ylimalkaan se kyllä niin on, mutta teidän rämsänrantalaisten suhteen
on täytynyt tehdä poikkeus. Tosiköyhät ja avuttomat ja henkisesti
vaivaiset teistä päästetään aina Taivaaseen, vaikka syntisiäkin olette
ettekä syntejänne liioin kadu ettekä tunnusta, mutta syntien laadusta
riippuu, missä asemassa täällä Taivaan iloissa lopuksi olla saatte.
Joosepin pienet siansilmät leimahtivat riemukkaasti:

— Onko minulla siis pysyväinen sija täällä Taivaassa?

— Totta kai! nyökkäsi Pyhä Ukko nauttien Joosepin naivisuudesta.

Kenkkunen hädintuskin pysyi housuissaan, kun vastauksen kuuli.


Yhtä hän vain ihmetteli: miksi ei Runtukka-Eemiä, mainiota
ketunpyytäjää oltu huolittu Taivaaseen? Vai olikohan Eemi itse
huipannut suoraan Helvettiin, jos siellä nähtävästi oli hyvät
pyyntipaikat?

Enkelit nykäsivät Jooseppia takin liepeestä ja kuiskasivat:


»Tunnusta pian syntisi, muuten Ukko tekee tottelemattomuudestasi
uuden synnin!»

Jooseppi alkoi rykiä:

— Tuota niin, jotta niistä synneistä…

— Luettele! jymähti Pyhän Ukon ääni.

Mutta Jooseppi yhä vitkasteli, hieroi lakkiaan, raappi jalallaan ja


yritti tirskahuttaa syljenkin kullankarvaiselle matolle.

»Elä Jumalan nimessä sylje!» kuiskasivat kaikki kolme enkeliä


yhtaikaa
Joosepin korvaan.

Taivaan Pyhä Ukko veti kultakellon liivintaskustaan.

— Minä olen nyt tässä kärsivällisesti odottanut kymmenen


minuuttia, hän sanoi, — mutta sinä et puhu suutasi puhtaaksi.
»Sakottavatkohan nuo korpirojun keitosta?» ajattelee Kenkkunen
itsekseen. »Ja kuka tietää ettei niillä täällä Taivaassakin ole linnaa ja
panevat tiilenpäitä lukemaan?»

»Puhu!» kuiskasivat enkelit huolestuksissaan.

Mutta Jooseppi vain hunteerasi, hunteerasi — tahtoi olla kaukaa-


viisas — eikä saanut sanaa suustaan.

Taivaan Pyhän Ukon kärsivällisyys loppui:

— Tuokaa syntirekisteri! komensi Hän ja loi nuhtelevan katseen


asianomaiseen.

— Käskystä, Teidän Taivaallinen Majesteettinne! vastasivat kaikki


kolme enkeliä kuorossa, kantapäänsä yhteen paukauttaen niin että
kultaiset kannukset kilisivät — kuinka kauniisti ne kilisivätkään,
ihmetteli Jooseppi — aivankuin harpun sävelet….

Pyhä Ukko huokasi syvään — oh mikä huokaus — niinkuin tuulen


humaus syksyisessä korvessa. Ja samassa silmänräpäyksessä kun
enkelit katosivat viereiseen konttorihuoneeseen, pistäytyi Ukkokin,
taas omaan yksityiskammioonsa. Jooseppi jäi yksikseen kansliaan.
Koiransa asettui pulpetin alle makaamaan.

Joosepin sydän sykki kiihkeästi. »Minkähän ne nyt tekevät?»

Joku kolkutti oveen, joka johti käytävästä. Vekku nosti nokkaansa


ja alkoi murista. Jooseppi meni avaamaan. Hänen hämmästyksensä
ei ollut vähäinen, kun äijän pötkyssä tunsi edesmenneen vonkalaisen
jätkämiehen Pahan Joopin, Joopi Heikkisen.
Kumpikin näytti ällistyvän sitä että tapasi toisensa Taivaassa. Kovin
halpana oli näet toinen toistaan maan päällä pitänyt.

— Helevetistäkö se sinä —? ärjäsi Joopi, jolla oli karhunsilmät, ja


näytti hampaitaan.

— Ole tuossa nyt, murisi Jooseppi kilpaa koiransa kanssa. —


Taivaan jätkänäkö sitä sinäkin muka myllerrät?

Mutta Joopi, Pahaksi Joopiksi mainittu väkevä ja löylynlyömä


työmies, ei kuullut Joosepin arvosteluita, sillä mies paran oli isänsä
pienenä pieksänyt siksi pahoin ettei kuulo Taivaassakaan parantunut.

Joopi pöllisteli karhunsilmillään ympärilleen ja kysyi:

— Onkohan tuo Ihte kotona?

— Kotona, kotona on Ukko! kiijui Jooseppi karsaasti katsoen


Joopiin, jolla oli ehyt silkkinen pusero — lyysi — ja mikä kaikista
kadehdittavinta — kultaiset työkintaat.

Joopi kuultuaan että Taivaan Isäntä oli kotona, tuppasi suoraan


Isännän kamariin: Jooseppi kuuli hänen läähättäen ja isolla äänellä
pauhaavan Ukolle että:

— Anna Sinä makasiinista se iso-vänkäri — ei kohoa muuten


pintaan se kivenmöhkäle. Voi ryöttä kun se on raskas ja särmikäs —
temanttiako lienöö — ihan oli päälle tulla, kun kintaskopelolla
koetin…

Johon Ukko tuntui huutavan vastaukseksi korvaan:


— Ota, rakas Joopi, itse makasiinista, tässä on avain — minä en
mitenkään nyt pääse — sattui juuri Ryysyrannan Jooseppi tilinottoon.

— Niinhän tuo näkyi olevan, kerjäläinen — laiska raato! jupisi


Joopi vähääkään pelkäämättä Ukkoa. — Koiran rökäleenkin, hylyky,
oli matkaansa völjännyt — no ei nuo ennen koirat koipiansa
nostelleet tämän talon nurkkajuurilla. Tapata se koira rutkale siltä
Joosepilta!

— Minä lupasin hänen pitää koiransa, vastasi Taivaan Isäntä, —


kun vain ei meidän kultaoraviamme haukuta.

— Vae lupasit! ärisi Joopi leveästi. — Välttää!

Ja Joopi Heikkinen kulki läpi kanslian nurkan ärmäkkänä syrinkarin


katsahtaen Kenkkuseen. Taivaan Isäntä huusi vielä oven raosta
taivaallisen jätkänsä perään että:

— Joopi hoi! Jos et yksiksesi jaksa sitä suurta kiveä vääntää, niin
ota
Iso-Heikki avuksesi! Se Toppi-Heikki…

— Hääh? Top! Kyllä minä yksinni pärjään! karjui Joopi vastaan


ulkoa, — kunhan vänkärin kopriini saan.

»Vai on Toppi-Heikkikin Taivaassa», ajattelee Jooseppi itseksensä.


»Onpa, onpa saki — mokraateja!»

*****

Kanslian sivuovi vasemmalta aukesi ja kolme enkeliä astui sisään


läähättäen kantaen mahdottoman paksua kirjaa, joka oli niin suuri ja
raskas ettei sitä voitu pistää pulpetille, vaan täytyi laskea keskelle
lattiaa. Jooseppi tuijotti hämmästyneenä kirjaan, jonka painon hän
vanhana säkin kantajana arvioi noin 70:ksi kiloksi. Kirjan kanteen oli
kullatuin korkokirjaimin painettuna:

Taivaallinen Rämsänrannan Ryysyköyhälistön


Syntirekisteri.

»Taivasten talikynttilät!» huudahti Jooseppi hengessään: »Noinko


vahvasti meikäläisillä löytyy räähkiä?»

Samassa enkelit jo kilahuttivat kullanhelskyviä kannuksiaan


paukauttaen kantapäänsä yhteen, sillä Pyhä Ukko astui jymisten
kammiostaan kansliaan, puettuna lumivalkeaan kauhtanaan, melkein
samanlaiseen kuin mitä Jooseppi muisti nähneensä aluelääkärillä ja
apteekarilla vastaanotoissa kotipitäjänsä kirkonkylässä. Käsissään
Pyhällä Ukolla oli hienoista kultalangoista kudotut sormikkaat.

Vilun väreet kävivät pitkin Joosepin selkärankaa. Toimitus alkoi.

— Avatkaa! käski Pyhä Ukko. Kaikki kolme enkeliä riensivät


irroittamaan remmejä kolmesta kultaisesta soljesta, askarrellen yksi
kutakin solkea kohti. Kaksi enkeleistä ponnisti kaikin voimin
ennenkuin kansi kääntyi saranoillaan naristen — se narina oli niin
oudon juhlallinen että kylmä hiki kohosi Joosepin otsalle.

Ensimäisellä lehdellä välähti esiin Rämsänrannan seurakunnan


kartta — Jooseppi näki tutut järvet ja joet ja jokainen ihmisasunto oli
merkitty numerolla. Toisten päällä oli punaiset numerot, toisten
päällä siniset. Vilkaistessaan Petkeljokeen, oli Jooseppi kuulevinaan
sen koskien kohinan.
— Ole hyvä ja näytä, missä sinun mökkisi sijaitsee? käski Pyhä
Ukko.

Jooseppi hätääntyi ja töykkäsi sormellaan karttaa. Pyhä Ukko


kumartui katsomaan:

— Miekkoiseni, Hän sanoi lempeästi, — tuohan on Vellivaara. Et


kai sinä siellä elänyt? Ja Hänen Taivaallinen Majesteettinsa näytti itse
hansikoidun kätensä pitkällä etusormella:

— Kas tuossa on Ryysyranta. Rekisterissä numero 179, — sininen.


Lyökää auki, pojat!

Enkelit alkoivat lehti lehdeltä selata — sepäs läiskettä kuin aaltojen


loiskina syksyisellä rannalla. Tuulahteli Joosepin tukkaan, Pyhän
Ukon partakin liehahteli. Jokainen lehti oli kuin muokattu
lehmäntalja. Nopeasti selasivat enkelit läpi ja yhtäkkiä selaaminen
seisattui.

— Tässä, Teidän Majesteettinne, ilmoittivat he.

— Lukekaa! käski Ukko istuutuen itse korkean pulpettinsa taakse


verhotuin silmin tuijottaen kultaiseen muistiinpanovihkoonsa. Hänen
Pyhyytensä silmäripset näyttivät hienon hienoilta teräskiiluisilta
sukkapuikoilta.

Enkeleistä ensimäinen ryhtyi metallin-kirkkaalla äänellä lukemaan:

— Petkelkylä — Ryysyranta — Jooseppi Kenkkunen,


korkonimeltään »Kenkku» tai »Ryysy-Jooseppi». Syntynyt 1874
maapallon aikataulun mukaan. Hänen lapsuutensa synnit 3-
vuotiaasta 15-vuotiaaseen saakka ovat seuraavat:
Debet — Synninpaino kilogrammoissa:

Juonitellut äidilleen ….. 1 kg 200 g


Näpistänyt sokuripaloja ….. 900 g
Ryöstänyt petäjäleivän, puolikkaan sisaruksiltaan ….. 500 g
Tottelemattomuuksia isää kohtaan ….. 5 kg
Valehdellut ….. 7 kg 700 g
Huutanut varhain avukseen Perkelettä ….. 10 kg
Repinyt tahallaan ryysynsä ….. 3 kg
Tapellut ….. 650 g
Tappanut huvikseen lintuja ynnä muita luontokappaleita ….. 8 kg
Haukkunut vanhaa mummoa ….. 75 g
Poltellut salaa nurkan takana … 45 g
Rymynnyt juhannuksena kirkon lehteriportaissa …..950 g
Viheltänyt kinkerillä papin kuullen ….. 300 g
Paiskannut Bibliansa tunkiolle ….. 13 kg
Laiskotellut potunnostossa ….. 2 kg 580 g
Tavattu ilkeistä ajatuksista ….. 17 kg
Pienempiä vilpillisyyksiä yhteensä ….. 15 kg 100 g
Sekalaisia rötöksiä ….. 14 kg

Summa summarum 100 kg

Kummissaan kuuntelee Jooseppi enkelin lukemista. Noinko


tarkkaan Taivaassa on seurattu hänen pienimpiäkin kepposiaan?
Lapsuudensyntejä jo täysi 100 kiloa, kuinka painavia mahtaakaan
olla merkittyinä myöhemmältä iältä?

— Lukekaa edelleen! käski Pyhä Ukko.

Toinen enkeleistä astui nyt jättiläiskirjan ääreen. Hänen äänensä


helisi kuin Daavidin kannel, koska hän luki:
— Jooseppi Kenkkusen nuoruuden synnit 25-vuotiaaseen saakka
ovat seuraavat:

Jatkuvia osittain samoja kuin edellä ….. 150 kg


Sylkenyt kirkonlattialle ….. 7 kg
Vetänyt kissanhäntää rippikoulussa ….. 5 kg
Ensikertaisesta viinan maistelemisesta ….. 11 kg
Repinyt autuuden oppinsa ….. 20 kg
Toiskertaisesta humaltumisesta ….. 21 kg
Pelannut korttia ….. 16 kg 600 g
Kolmaskertaisesta päihtymyksestä ….. 31 kg
Petkuttanut pelissä Pöllivaaran poikaa ….. 13 kg 400 g
Karanut kotoa toisen pojan porolla ….. 15 kg
Sotkuja savotassa ….. 10 kg
Ryypänyt uhmapäissään ylenmäärin Pyhää Ehtoollista ….. 70 kg
Kähveltänyt piipun ja lyysin kämpällä ….. 49 kg 500 g
Ollut auttamatta hukkuvaa ….. 50 kg
Riettaita mielitekoja ja tyttöin ahdisteluita ….. 100 kg
Nukkunut tyttöin kanssa heinäladossa ja kirkkonarikassa
ilman rakkautta ….. 200 kg
Sekalaisia törkeitä nuoruuden rikoksia ….. 230 kg 500 g

Summa summarum 1,000 kg

— Voi Herra Jumala! huudahtaa Jooseppi raappien niskaansa. —


Miksi minulle näin mahottomasti on äyrejä pantu? Enhän minä…

— Silentium!

Taivaan Pyhä Ukko katsahtaa Kenkkuseen juhlallisen nuhtelevasti


ja käskee kolmatta enkeliä:
— Lisää!

Se kolmas enkeli lukee matalalla papillisella äänellä, joka kumajaa


kuin urkujen kontrabasso:

Jooseppi Kenkkusen miehuuden aikuiset synnit kuolemaansa asti


100:n prosentin korotuksella kuuluvat Pyhän Ukon nimeen
seuraavasti:

Edellisiä osittain uusittu ….. 600 kg


Soidinsyntejä ….. 50 kg
Salatuulastuksesta Petkeljoella ….. 50 kg
Kähveltänyt tupakoita ….. 50 kg
Hirventapon osuudesta ….. 100 kg
Paliskunnan poron ampumisesta, joskohta nälkäänsä syömisestä…
150 kg
Päästänyt suuren lohen uistin kidassa karkuun ….. 100 kg
Tehnyt itsensä syypääksi eläinrääkkäykseen köykäisillä lintusatimilla
… 250 kg
Löydetyn tavaran omistamisesta ….. 300 kg
Teeskennellyt pudottaneensa asianantajain rahoja ….. 400 kg
Luvannut morsiamelleen loistavammat kihlat kuin koskaan kykeni
antamaan…. 500 kg
Sylkemisestä sopimattomissa paikoissa ….. 500 kg
Rivoista lauluista ….. 100 kg
Niitellyt toisten niittyjä ….. 600 kg
Veneitten ominluvin ottamisesta ….. 700 kg
Sanansa syömisestä seurakunnassa ….. 800 kg
Vääristä lehmä- ja porokaupoista ….. 900 kg
Kaikista salaisimmista petkutuksista ….. 1,000 kg
Pyhän Joutsenen ampumisesta ….. 1,000 kg
Ikuisesta kiroilemisesta, noitumisesta, vannomisesta ja
valehtelemisesta…. 1,500 kg

— Elkää helekutissa niin paljoksi värteeratko! huutaa Jooseppi


väliin, — voimasanat kuuluvat ihmisen kieleen! Eikö siellä näy
pienempiä painoja?

Pyhä Ukko rypistää kulmiaan ja sanoo lukijaenkelille:

— Luettele hänelle pienempiäkin painoja, koska hän niitä haluaa.

Enkeli lukee kirjasta:

Tahallisesta haisemisesta julkisilla paikoilla ….. 50 kg


Aiheettomasta epäluulosta ….. 50 kg
Vahingon ilosta ….. 100 kg
Herrojen imartelusta edessäpäin ….. 150 kg
Herrojen herjaamisesta takanapäin (dito) ….. 150 kg
Käsikähmästä Karihtaniemen Amantan kanssa ….. 150 kg

(Painot alkoivat jälleen nousta Joosepin kauhuksi.)

Ihmisten haukkumisesta ja panettelusta …… 900 kg


Siitä ettei naimisiin mentyäänkään hankkinut Kaisa-
Reetalle paitaa ja kirkkohametta ….. 1,000 kg

(Jooseppi huitoi kämmeniään.)

Lastensa pukimien laiminlyönnistä ja hemmottelusta


tietämättömyydessä ja liassa (dito) ….. 1,000 kg
Perintölaiskuudesta ….. 2,000 kg

— Ohoh! pääsee Joosepilta.


Liiasta työnteosta erinäisissä tapauksissa ….. 1,000 kg

Vaimonsa itkettämisestä ja (enkeli ei lukenut tätä paikkaa)…


1,500 kg
Lattiansa korjaamattomuudesta, kehikon tulipesän
laittamattomuudesta,
russakkain tappamattomuudesta, riihessä kylpemisestä ja
yleensä
pirttinsä pahasta siivosta… 6,000 kg

— Voi raato, kuinka rapiasti rapsautitte! huutaa Jooseppi väliin. —


Mokomaa pöksän röttelöä ei hyövää putsata eikä remontteerata!
Minä panen vastalauseen…

Mutta enkeli tahtoi lukea edelleen:

— Politiikan hulluttelusta ja kommunistisista edesottamisista…

Jooseppi lysähti polvilleen ja kiljui keskeyttäen:

— Silimääni vannon, jotta annoin sille punaselle mykrälle takaisin


sen tuhatmarkkasen! Ei saa panna äyriäkään!

Taivaan Pyhä Ukko ei sallinut häiritä toimitusta, vaan kohotti


kultahansikkaista sormeaan:

— Koetahhan pitää suuelimesi kurissa, rakas Jooseppi! Ja enkelin


puoleen kääntyen: — Immanuel, jatka supliikkia!

Ja enkeli jatkoi kerraten:

… kommunistisista edesottamisista, joista vainaja tosin on


luopunut, vaikka ei vakaumuksesta, vaan raukkamaisesta
pelkuruudesta… 3,300 kg

Jooseppi löi reiteensä ja ajatteli itsekseen: »Vähällä sittenkin


pääsin!» Mutta enkeli luki edelleen:

Nuorimman poikansa ristittämisestä uhmaavilla nimillä, mikä


osaksi
on tapahtunut tuhmanylpeydestä ….. 3,000 kg.

Jälleen keskeytti Jooseppi Kenkkunen:

— Ukko Herra, Ukko Herra, antakaapa kun minäkin sanon…

— No sano häntä! myönsi Taivaan Pyhä armollisesti, — mutta Minä


huomautan että sinun on sopimatonta puhutella Minua täällä
ukkoherraksi — sitä sanaa viljellään vain alhaalla rämsänrantalaisissa
tukkisavotoissa.

Jooseppi kumarsi niin kauniisti kuin osasi, koettaen puhua


hienosti:

— Anteeksi Majesteetti, hän sopersi, — minä pyytäisin vain


huohmauttaa ettei se pikkupoijan kastattaminen tapahtunut uhmasta
eikä pöljyyvestä, vaan silikasta kunnioituksesta esival…

— Riittää! katkaisi Ukko. — Katsoppa tuonne nurkkaan…

Jooseppi käänsi päänsä ja huomasi nyt vasta jättiläiskokoisen


könniläiskellon seinämällä. Lasikaapissa riippui miljoonia hiushienoja
ketjuja, jotka näyttäen suikertavan läpi lattian pitivät lakkaamatonta
värinää. Pitkä, hieno viisari kellontaulussa kierteli herkeämättä
pysähdellen numeroiden ja kirjoitusten kohdalle.
— Se on ryysyköyhälistön sielunbaromeeteri, selitti Pyhä Ukko. —
Täällä ylhäällä tiedetään hiuskarvaa myöten ihmisten mieliteot, mitä
ne rnilloinkin tarkoittavat.

Kyllähän Jooseppi sielunbaromeeterin näki, mutta sittenkin hän


murisi sitä Taivaan sekaantumista hänen yksityisasioihinsa. Ja Vekku,
Pyhän Ukon pulpetin alla, murisi myös säestäen uskollisesti
isäntäänsä. Sattui vielä niin että Ukon kultatohveli vahingossa tallasi
Vekun häntää, jolloin koira yhtäkkiä tokasi Hänen Taivaallisen
Majesteettinsa jalkaan. Majesteetti parkasi kivusta, mutta enkelit
tarttuivat nopeasti Vekkua niskasta ja heittivät ulos korridooriin.
Jooseppi oli kalmankalpea pelosta — että mikä nyt perii? — mutta
Pyhä Ukko ei virkkanut luotuista sanaa, puri vain huulensa yhteen:

— Jatka, Immanuel!

Nyt kajahti Joosepin korviin seikkaperäinen selostus kaikista hänen


viimeaikaisista puuhistaan, joka selostus päättyi sanoihin:

Kieltolakirikoksistaan siis pyöreissä summissa laskien moraalisen


painon mukaan ….. 70,000 kg.

— En saamari-soi elämänpäivinäni niin äärettömiä kilomääriä ole


keittänyt! ulvoi Jooseppi.

Hänen mielenliikutuksensa oli siksi väkevä että miekkonen


pyörtyneenä vaipui lattialle. Saatettiinko Taivaassa mitata väärin?

— Antakaa hänelle virvokkeita! — Kun Jooseppi toipui enkelien


tukemana, tunsi hän suussaan riikapalssamin maun — ei se ollut
oikein riikapalssamiakaan, mutta äärettömän virvoittavaa se oli.
— Tarkistakaamme viimeinen summa, lausui Pyhä Ukko
rauhallisesti. — Sanoppa itse, kuinka paljon jumalanviljaa olet
tuhlannut tuohon aineeseen, jota te siellä nimitätte korpirojuksi?

— Ei niitä sentään seitsentäkymmentätuhatta kartu! penäsi


Jooseppi. —
Piisaa seihtemän sataakin…

— Sinäpä sen sanoit, poikaseni, myhähti Taivaan Ukko kirkkain


silmin katsoen hämmästyneeseen Jooseppiin. — Minä en omasta
puolestani pidä viinanvalmistusta syntinä, kun siihen on oikeat
edellytykset — nektaria täälläkin on juotu hamasta maailman alusta
ja viina ilahduttaa ihmiset ja jumalat — mutta tokko sinulla, poika
parka, on ollut oikeita edellytyksiä? Meillä lasketaan sata kiloa
syntipainoa jok'ikistä jauhokiloa kohti, joka tuhlataan viinaksi leivän
asemesta köyhän maan köyhimmällä perukalla, jossa kansa jyrsii
petäjää. Sinä tunnustit keittäneesi seitsemän sataa kiloa.
Syntipainosi on siis 100 kertaa 700 — toisin sanoen 70,000!

Jooseppi ei virkkanut mitään — hän oli masennettu.

Enkeli Immanuel luki:

— Summa summarum — asianomaisen Jooseppi Kenkkusen


miehuuden aikaiset synnit tekevät yhteensä 100,000 kg ja koko
hänen maallisen vaelluksensa syntitaakka siis, kuten edellä laskettu
on, summarum summa 101,100, sanoo sata yksi tuhatta ja sata
kilogrammaa.

Jooseppi pökertyi toistamiseen. Vekku kanslian oven takana raappi


ja murisi…
*****

Jooseppi Kenkkunen havahtui tajuntaan — taivaallisten urkujen


humina jylisi hänen korvissaan ja lämpöinen lapsen käsi puristi
hänen känsäistä kouraansa. Missä, missä hän oli? Hän avasi silmänsä
— enkelityttö piteli häntä kädestä ja toisella kupeella istui Vekku
nuollen toista kättä. Hänen edessään levisi kuin kirkko, urut jylisivät
lehterillä, mutta alttarilla seisoi jättiläiskokoinen punnituskoje, jonka
toinen vaakalauta oli äärettömän suuri ja väriltään musta, mutta
toinen kuppi pieni, kupera ja kultainen. Vaakalaudat värisivät samalla
tasolla ja sitä Jooseppi ihmetteli.

— Tämä on vaakakirkko, kuiskasi enkelityttö. — Elä hätäile — isä!

— Heittäkää hänen syntipainonsa vaakaan! kuuli Jooseppi Pyhän


Ukon äänen korkeasta saarnastuolista. Jättiläiskokoinen vaakalauta
täyttyi vuoren kokoisella möhkäleellä ja painui ryskyen alas alttarin
lattiaan saakka.

— Ja nyt hänen ansionsa! käski Pyhä Ukko.

Se pieni vaakakuppi täyttyi puhtaalla, kimmeltävällä kullalla, mutta


jättiläisvaakalauta ei ottanut noustakseen.

Pyhä Ukko katsoi muistivihkoonsa:

— Täällä on vielä merkittynä 1,100 kiloa kultaa. Lisätkää se! — Ja


katso! Syntivuori kohosi — molemmat vaakakupit kieppuivat samalla
tasolla.

Pyhän Ukon ääni kajahti:


— Hänen ansionsa korvaavat hänen syntinsä. Jooseppi Kenkkunen
saa syntinsä anteeksi, koska on hän köyhänä syntynyt, köyhyydessä
elänyt ja köyhyydessä kuollut.

— Hallelujaa! lauloi tuhatsiipinen enkelikuoro lehtereillä, ja urkujen


humina soi Joosepin korvissa.

Jooseppi lankesi polvilleen ja pani kätensä ristiin. Riemukkaasta


mielenliikutuksesta hän kolmannen kerran pyörtyi. Mutta Pyhän Ukon
Pyhä Poika seisoi palavan pätsin edessä ja huusi lempeällä äänellä:

— Polttakaamme hänen syntinsä!

*****

Sitten hänet vietiin taivaalliseen päivällispöytään, joka Joosepin


silmissä näytti kilometrin pituiselta. Kultaisista pahkakupeista siinä
aterioitiin kultaisilla kuireilla ja hopeaisilla haarukoilla. Ambroosia,
ambroosia — nääntyneen voimat palasivat nopeasti…

*****

Joosepilla oli siis taattu sijansa Taivaassa, mutta vielä ei juttu ollut
lopussa. Enkelilapsi talutti hänet kädestä läpi pitkien ristikorridoorien
ja pysähtyi vihdoin ovelle, jonka päällä paistoi kirjoitus:

Rämsänrannan ryysyköyhälistön työnvälitystoimisto.

Ihmeekseen tunsi Jooseppi toimiston johtajassa saman henkilön,


joka hänen pikkupoikana ollessaan oli istunut muinaisen Ämmän
rautatehtaan konttorissa — herra Puksin. Herra Birger Belial Bux,
jättiläiskokoinen mies, istui mahtavasti rykien melkein yhtä korkean
pulpetin takana kuin Pyhä Ukko pääkansliassa.
— Eikö se ole Puksi? kysyy Jooseppi iloisesti irvistäen.

— Öhömm! rykäsee työnvälitystoimiston johtaja.

— Vörvalttari minä olen, mutta painahhan sentään puuta. Sinunko


se on koira, joka vinkuu tuolla oven takana?

— Minun, minunhan se on…, jupisee Jooseppi ja puolestaan myös


rykäsee, — tuota noin, mitä varten minut on tänne kutsuttu?

— Mitäkö varten! rykäsee Bux. — Hänen Taivaallisen


Majesteettinsa käskystä. Tottahan sulle joku homma täytyy järjestää,
hönttähousu!

— Vaan minä kun tuota — hömm — meinasin, jotta jos niinkuin


saisin rokulia Taivaassa, tuumii Jooseppi.

— Vai rokulia — tispanssia Taivaassa sinulle — räkänokålle?


huudahtaa herra Bux. — Ei tule mitään. Vai laiskaksi lököttelemään
kuin mikäkin kommunisti — ehei, tavaritsh.

Ja herra Bux, työnvälitystoimiston komea johtaja, entinen Ruukin


vörvalttari, sama, jota ajan laksossa oli nimitetty myös »Nälkämaan
keisariksi», selaili asiapapereitaan:

— Täällä on jo Korkeimman päiväkäsky, jotta Jooseppi Kenkkunen


tästä illasta alkaen määrätään kolmeksi vuodeksi Rämsänrannan
kaikkien vainajain saunottajaksi Taivaallisessa kylpylaitoksessa. Saat
mennä! komensi Bux, jonka selän takana istui kaunis enkelineiti,
toimiston konekirjoittajatar.

Mutta Jooseppi ei hievahtanut.


— Pitääkö minun kylvettää akkaväkikin? kysyi hän
hämmästyneenä.

— Sepä tietty, tuimistui tirehtööri, — Täällä Taivaassa ei sukupuoli


tule kysymykseen.

— En rupea, en! kiljui Jooseppi.

— Mitä hemmettiä, kehtaatko vastustaa Taivaan valtakunnan


päiväkäskyä.
Ja mistä syystä, jos saan luvan kysyä? tiedusti herra Bux ivallisesti.

Jooseppi Kenkkunen raappi niskaansa.

— On kolme vaimonpuolta, jupisi hän, — joita, jos nekin tänne


tupsahtavat, en ikipäivinä ilkeä ruveta kylvettämään!

— Kutka he ovat? uteli Bux.

Jooseppi änkytti:

— Karihtaniemen Amanta — Haukkurannan mummu — ja vanha


postiröökynä…

Herra vörvalttari purskahti nauruun ja tarttui taivaallisen telefoonin


kultaiseen puhelintorveen:

— Halloo. Onko Itse Ukko? Täällä toisessa päässä on vörvalttari


Bux. Kuulehhan nyt kummia, Pyhä Veli, että kun se Kenkkusten
Kenkku kieltäytyy rupeamasta saunamestariksi — ei kuulu kehtaavan
kylvettää kolmea kotipuolen akkaa, jos ne niinkuin sattuvat
pääsemään Taivaaseen. Minkäs peijakkaan pelin hälle nyt arvaa?…
Jooseppi ei voinut kuulla, mitä Pyhä Ukko puhelimessa vastasi.
Kunnes herra Birger Bux itse, sysimustia kulmakarvojaan rypistäen ja
kaikuvasti rykäisten, korkean pulpettinsa takaa julisti Joosepille: —
Hömm. Kuulut saavan mennä riihtä tappamaan.

Meillä puidaan paljasta vehnää. — Ala laputtaa!

*****

Tämä oli Ryysyrannan Joosepin kuolemanuni. Miehessä näytti


olevan hitunen henkeä jälellä, kun hänet puukangilla vääntäen
päällekaatuneen petäjän alta vapautettiin. Mutta samalla hän jo
puhalsi viimeisen henkäyksensä.
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