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On the basis of some selected examples, the problems of micro-surgical operations on parasellar and pre-pontine tumours are discussed. The tumours are divided into five types, according to their localisation. The particular anatomical aspects are discussed in detail.
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In Cushing's disease, selective total removal of a corticotroph tumor of the pituitary regularly results in subnormal ACTH- and cortisol plasma levels. The duration of secondary adrenocortical insufficiency varies widely, with an average of 17 months in our patients. The goal of this study is to elucidate the underlying causes for the variation in duration of postoperative hypocortisolism. In this retrospective study, we evaluated 35 patients with postoperative hypocortisolism lasting more than 36 months, and compared them to 51 patients with a duration of less than 36 months. Preoperative data, intraoperative findings, and postoperative results with follow-up evaluations are presented. Extensive pituitary exploration, medial localization of the tumor, and a higher age were associated with increased risk for isolated secondary long-term hypocortisolism. The histological examination of paraadenomateous tissue identified a significantly larger amount of Crooke's cells in long-term cortisol insufficient patients. Previous pituitary surgery increased the risk for hypopituitarism. In some of our patients, the long-term adrenocortical insufficiency resolved after a period of over five years.
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Although the treatment of colloid cysts remains controversial, high viscosity and small volume are poor prognostic indicators for successful burr hole aspiration and cortical incision via craniotomy may be associated with postoperative epilepsy. The anterior transcallosal approach provides a direct and adequate pathway to the lateral ventricles, where the foramen of Monro serves as a natural entrance into the anterior third ventricle, especially when the foramen is dilated by a lesion. When the midsuperior portion of the IIIrd ventricle cannot be reached, the interforniceal or the subchoroidal exposures have been advocated. Stereotactic techniques contribute to a minimal invasive approach and reduce morbidity. Nine patients harbouring anterior third ventricular cysts (seven colloids and two intrinsic craniopharyngiomas) underwent anterior transcallosal microsurgical excision assisted by an interactive infrared-based image guided system (EasyGuide, Neuro, Philips). There were 4 men and 5 women ranging in age from 15 to 42 years (mean 28.5). Transcallosal transforaminal (5 cases) or interforniceal (4 cases) approaches allowed total excision in eight patients and subtotal in one. Postoperative morbidity included a case of transient hemiparesis and a case of transient short-term memory disturbances; both resolved in the first months. Mortality was zero. Particular advantages of the method were accurate trajectory and position of callosotomy incision determination, visualisation and avoidance of superior saggital sinus, retraction of bridging veins and the often variable pericallosal arteries, spatial orientation within the ventricular system, and identification of the periventricular anatomical structures.
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The authors describe the use of a rigid endoscope lens to enhance microsurgical visualization of the corpus callosum. Using cadaver preparations, endoscopic dissection was carried out through a narrow corridor without significant retraction of the brain. The endoscope improves the operative exposure in corpus callosotomy and other transcallosal procedure.
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Even if a surgical procedure is performed for reconstructive and functional reasons, a plastic surgeon must be responsible for the visible result of the work and for the social reintegration of the patient; therefore, the aesthetic appearance of a microsurgically reconstructed lower leg must be considered. Based on the experience of 124 free-tissue transfers to the lower leg performed in 112 patients between January 1994 and March 2001 (110 [88.7 percent] were transferred successfully), three cases are presented. Considerations concerning flap selection and technical refinements in designing and tailoring microvascular flaps to improve the quality of reconstruction, also according to the aesthetic appearance, are discussed.
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In this paper the authors describe and illustrate a rare anatomic variation of the ulnar artery, a superficial ulnar artery. The possible embryologic events responsible for this variation are discussed. In addition, they describe the surgical considerations that should be kept in mind when this abnormality is encountered in the clinical setting of free-tissue transfer and vascularized nerve grafting.
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A new suction device for microsurgical procedures is presented. This device is made of soft, compliant PVC, which enables all fluids to be evacuated from the surgical field without damaging the surrounding soft tissue. The device is designed with front and radial ports that allow placement onto the blood vessel or nerve while the anastomosis is being performed. There is a tapered end providing the surgeon with fine control of the suction. Unlike other bulky suction devices, this one readily fits into the operative field without inhibiting operative procedures. It also readily fits varying sizes of conventional Frazier-type tips. The device has been used in over 100 microsurgical procedures and it has served well.
The topography of the fascicular groups of the axillary nerve throughout its course from the posterior cord until its passage through the quadrangular space was studied in dissections of 40 brachial plexuses under x3.5 loupe magnification. Additionally, 10 axillary nerves were excised in toto, and histologic serial sections were done to define fascicular arrangement. In all specimens, the motor fascicular group for the deltoid muscle was located most superiorly at the level of the quadrangular space. This motor portion could be identified as a distinct entity, up to 45 mm proximal to this level. In surgical treatment of axillary nerve repair, one should direct special attention to the correct identification, matching, and alignment of this motor fascicle, to avoid wasteful regeneration of axons into the functionally unrelated fascicles to the teres minor and the lateral shoulder skin.
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To characterize the role of interposition vein grafts, and to determine whether their use significantly influences the success of free tissue transfers in head and neck cancer reconstruction, we reviewed 191 consecutive cases with defects involving the aero-digestive tract soft tissues (80), the mandible (75), craniofacial resections (25), or cutaneous coverage (11). One hundred twenty patients had received prior loco-regional therapy, including 63 patients with recurrent lesions. Interposition vein grafts were used for the artery (11), vein (3), or both (3) in a total of 17 cases. The overall technical success rate was 93.2 percent (178/191). Cases in which vein grafts were used had a significantly (p < 0.001) lower success rate, 70.6 percent (12/17), than those without vein grafts, 95 percent (166/175). Grafts were most often used in patients who had received prior therapy (13/17). The use of vein grafts was associated with a significantly higher incidence of flap failure in head and neck cancer reconstruction; however, a causal relationship is not suggested.