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This paper presents the microsurgical transsphenoidal approach to intracranial craniopharygiomas. Essential prerequisites for this route are stressed: enlarged sella, growth into the sphenoid sinus, intact diaphragma sellae. The authors' own material is discussed. It is pointed out that even repeated transsphenoidal decompression of large cystic lesions is well tolerated in elderly patients.
The author describes a miniature bipolar diathermy unit which can be used for several microsurgical purposes. It was developed from a standard endodiathermy instrument which has been in use for pars plana vitrectomy since 1973. It features bipolar forceps which can be used for welding conjunctival flaps and macrohemostasis in strabismus, orbital and lid surgery; bipolar electrodes with and without infusion, for extraocular hemostasis and intraocular microhemostasis in the anterior and posterior segments; bipolar electrodes with infusion for special purposes (still at the experimental stage), for capsulotomy of the anterior lens capsule for extracapsular cataract extraction, section of intraocular strands and membranes and sector iridectomy for tumors or rubeosis of the iris.
The usable reach of microsurgical instruments employed in eye surgery can be recorded on a TABO diagram. This simple, rapid and versatile method can be used on models and in vivo. Its principal benefit is that it teaches beginners the physical limitations placed on their dexterity, but experienced surgeons will also find it useful when testing new instruments and practicing complicated maneuvers involving two or more hands. Familiarity with the reach of the individual instruments helps prevent complications due to improvisation, and fatigue caused by incorrect posture. The full potential of microsurgical methods can only be exploited if the conditions governing them are observed. One of these conditions is that physical proportions appear different under the microscope and therefore stricter rules apply than for operations carried out with the naked eye.
Ciliary arteries, isolated from the eyes of human cadavers, were incised or severed under the microscope in order to test the technical possibilities of placing sutures or creating leak-proof anastomoses in ophthalmic vessels. Commercially available, minute atraumatic needles and 10-0 "Ethilon" or 15-0 Supramid suture material was used. The experiments were successful.
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The Steiner-Lindquist microsurgical stereotaxic guide was used for operations for intra-axial lesions in 15 patients. The lesions were identified by stereotaxic CT or MRI and stereotactic co-ordinates were then calculated and set for the guiding laser beam. The beam was used for planning the craniotomy and its path followed during the microsurgical dissection, until the lesion was reached. Seven lesions were situated in eloquent areas of the brain and could not have been safely attacked without the aid of stereotaxic localization. Five of these and two other lesions were quite small, and would have been difficult to find without jeopardizing normal brain structures. For the remaining lesions the stereotaxic laser guide was facilitatory, but not indispensible. Radical removal was achieved in 11 of the 15 lesions. The Steiner-Lindquist microsurgical guide incorporates the freedom of standard microsurgical techniques with the safety of operating in a stereotaxically defined space.
We report the results of treatment with radiosurgery of 29 tumours in 27 patients with acoustic neuromas between 1986 and 1989. The median follow-up was 6.6 years. The treatment appears to be an effective alternative to surgery for patients with tumours of 3 cm diameter or less. The mortality and morbidity of the treatment and the presentation of cranial nerve function is comparable to the very best surgical results. Every patient with an acoustic neuroma should be informed about this alternative to direct surgery.
Thirty craniopharyngiomas were operated on between 1983 and 1993. Eight patients underwent surgery solely via the transsphenoidal route. None of these had undergone surgery previously. The eight patients were followed up for a period of 120 months (mean 87.5 months). The tumour was removed totally in five and subtotally in three patients. All eight patients had one or more endocrine abnormalities prior to surgery. Five patients presented with visual field defects or decreased visual acuity, which improved postoperatively in all cases. Seven received radiotherapy, with one declining this treatment. No recurrences have occurred during follow-up in any of the group. Primary transsphenoidal surgery is a both safe and effective treatment for those craniopharyngiomas that are located within an enlarged sella, have no calcification and are not adherent to parasellar structures.
We studied retrospectively 102 consecutive free TRAM breast reconstructions that were done outside our own hospital in hospitals that were not used to microsurgical techniques. Twenty-three patients were operated on by an uninfiltrated free TRAM technique, and 79 had 0.5% lignocaine with adrenaline infiltrated along the incision lines before the operation. We lost two flaps and six flaps developed necrosis of the medial edge. Our total complication rate (25%) compared well with those of other studies. Infiltration with lignocaine and adrenaline significantly decreased the operating time (mean (SD) 234 (91) compared with 159 (40) minutes), peroperative bleeding (930 (530) ml compared with 350 (180) ml), peroperative transfusions, and the total number of transfusions, so improving the cost:effect ratio of free TRAM breast reconstructions. Microsurgical free TRAM breast reconstructions can be done with good results in peripheral hospitals.
The purpose of this study was to evaluate our experience of microvascular anastomosis of intraperitoneal vessels. Between 1985 and 1994, 117 microsurgical reconstructions were done using intraperitoneal vessels. These included oesophageal reconstruction (n = 106), reconstruction of the hepatic arterial, superior mesenteric arterial, or portal venous system (n = 8), and reconstruction of the chest or abdominal wall (n = 3). We used 129 intraperitoneal arteries and 117 intraperitoneal veins. Of a total of 246 intraperitoneal vessels, five hepatic arteries, seven splenic, 14 gastroepiploic, six superior mesenteric, 178 jejunal, 30 ileocolic, four middle colic arteries or veins, and two portal veins were used for microvascular anastomosis. The overall successful rate for these reconstructive cases was 97% (114/117). Microsurgical use of intraperitoneal vessels is a safe and developing procedure in plastic and reconstructive surgery.
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Surgical therapy for coexistent proximal and distal obstruction has consisted of combined proximal (reimplantation of reanastomosis) and distal (salpingostomy) repairs. Data suggest that successful relief of proximal obstruction by fluoroscopically guided tubal canalization (FTC) may be achieved in 60% to 95% of cases. We studied the use of FTC as a preoperative adjunct in 14 patients with coexistent proximal tubal obstruction (PTO) and distal tubal obstruction, progressing to surgical repair of distal disease if proximal patency was achieved. Unilateral (9/14) or bilateral (5/14) PTO was demonstrated on at least one hysterosalpingogram (HSG) and during chromotubation performed as part of the diagnostic laparoscopy. FTC was successful in four patients (28%). HSG revealed proximal reocclusion in two patients. Two patients had persistent proximal patency and underwent distal salpingostomies and adhesiolysis for mild hydrosalpinges and pelvic adhesive disease. No pregnancies have been achieved after 12 and 18 months follow-up. The lower patency rate and higher recurrence rates of PTO when compared to data of prior studies suggest that in vitro fertilization, though more costly, ultimately may represent the most expedient and effective method of management of coexistent proximal and distal tubal disease.
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Fertility outcome following microsurgical tubocornual anastomosis by laparotomy was evaluated. A total of 131 women presenting pure proximal occlusion, whether bilateral or in one tube only, were treated between January 1978 and December 1993. Subsequent fertility was studied in 120 patients, 11 being patients lost to follow-up. Cumulative intrauterine pregnancy (IUP) rate, evaluated by life-table analysis, was 68% at 24 months. The overall IUP rate, calculated from a group of 120 women with follow-up > or = 2 years, and including births and miscarriages, was 70% after 2 years. Comparisons of the cumulative IUP rates show that the fertility outcome is significantly better if the woman is aged < or = 36 years and if tubocornual anastomosis is carried out bilaterally. These results from our personal series confirm that microsurgical tubocornual anastomosis is still of prime importance in the treatment of pure proximal occlusions. Nevertheless, considerable progress in the fields of tubal catheterization, Falloposcopy and in-vitro fertilization techniques raises the question of the management of patients presenting with a proximal tubal occlusion. Here we define the indications for microsurgical tubocornual anastomosis.
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