GUIDE TO MINIMALLY
INVASIVE, MICROSCOPIC TSSH
This is a guide
to the pituitary operation I have recommended to you. The medical
name is a TSSH that stands for TranSSphenoidal
Hypophysectomy. The sphenoid is
a part of the skull just in front of the pituitary gland. "Trans-sphenoidal"
means that the approach to the pituitary gland involves going through
this area. The medical name for the pituitary gland is the hypophysis.
As you may know, "-ectomy" means to remove. Therefore
the operation means that the surgeon goes through the sphenoid sinus
to remove the abnormal part of the pituitary gland.
FOR SURGERY: There is no special preparation for
this operation. You should have nothing to eat or drink after midnight
before the day of the surgery. If you take medications in the morning,
please take them as you normally would with a sip of water. There
is no special skin cleansing or preparation.
When you come
into the hospital, you will be directed to a part of the Operating
Room called the "holding area". There you will have an
intravenous placed and talk with the anesthesiology doctor. A light
sedative will probably be given, and you will wait as the surgery
suite is prepared for your microsurgery.
you enter into the Operating Room, you will be given another intravenous
and will drift off to sleep. You will feel and remember nothing
of the operation that generally takes 2 hours. If the operation
starts around 8:00 in the morning, your friends and family can expect
to hear from me before noon.
you are asleep, an approximately 1-inch incision is made under your
upper lip. When this heals, it will not be visible. The operation
involves going underneath the nose, and then through the sphenoid
sinus (a natural, air-filled part of the skull) with the use of
the operating microscope. I then arrive at the pituitary gland that
is covered by a leathery membrane called the dura. An incision
is made in this membrane giving exposure to the front of the pituitary
The tumor can usually be seen easily, though the actual size of
the normal pituitary gland is about that of a marble. The tumor
within can be as small as a BB or as large as a nickel. With microscopic
guidance, the tumor is gently and carefully removed. It is usually
very soft and similar to oatmeal in consistency. On occasion in
the past, I have placed a small TV camera in that area (an endoscope)
to assist in as complete a removal of the tumor as possible.
a hopefully complete removal has been obtained, the procedure is
finished. From the time I can see the front of the pituitary gland
to the time I am finished removing the tumor is about 15 minutes.
The microscope is removed, and then the small incision beneath your
upper lip is stitched up. These stitches will melt on their own,
and do not need to be removed. The membrane is then closed as carefully
above, we have gone underneath the nose to do this procedure. Some
gauze packing is placed in the nostrils overnight to allow them
to heal normally. These are annoying while they are in, as you may
be unable to breathe through your nose during that time.
SURGERY: The hospital stay after this operation is about 2 days.
When you wake up, you may notice that you cannot breathe through
your nose for the reasons mentioned above. There is often swelling
in the middle of your face and sometimes bruising that can track
down along the sides of the mouth towards the chin. This bruising
will go away very quickly and is generally gone within one week
from the time of the surgery.
When you get home, you will have various aches and pains from the
surgery itself. The middle of your face may be swollen and bruised.
You will generally be surprised how quickly this resolves. You may
notice some numbness in the upper lip and the front, upper teeth.
This is annoying, but generally goes away over several months. For
those of you that wear dentures, this is bothersome.
return to work about two weeks after this procedure. During these
two weeks, you may drive and partake in any of your usual activities
apart from competitive sports. Although it is difficult, I encourage
you not to blow your nose, or pick at your nose. After two weeks
it is essentially healed and there are no restrictions on what you
may do. You should note that sometimes for several weeks after the
surgery, small or large bits of clotted blood or mucous will come
from your nose or go down the back of your throat. This is normal
and it may be a full month before it stops occurring.
The benefit of the surgery is to cure your tumor. In general, the
chance of a cure is about 90%. If your tumor is secreting a hormone,
this and the problems it created will generally resolve over a year.
There is the chance that the tumor could come back some day; sometimes
this requires treatment and sometimes it does not. One approach
that has become increasingly useful in recent years is a one-day
radiation treatment called Gamma Knife Radiosurgery.
If your symptom
was loss of vision, in general this will come back very quickly
in a matter of a few days or weeks. Many people comment on the increased
sharpness of their vision and the increased vividness of colors.
Peripheral vision is also often greatly improved.
The risks of
the surgery are loss of vision, stroke, infection, and death. These
occur less than 1% of patients. In the over 25 years I have performed
this procedure, I have caused near-blindness in one man who developed
internal bleeding after a TSSH I performed on him. I caused one
stroke in another man whose left arm and leg became paralyzed after
surgery. He made only a partial recovery. Infections are rare, and
are generally easily treated with antibiotics. I have caused less
than 5. Two patients have died after I performed this procedure
on them; one woman passed away at home of what was likely a heart
attack. Another died in the hospital of a pulmonary embolism.
If your hospital course is uneventful after the procedure, you may
be seeing either me or care providers whom I work with. You and
your family are always free to contact me in my office or through
my answering service.
December 29, 2007
Stephen Saris, M.D.