Management strategies of intercavernous sinus bleeding during transsphenoidal surgery

Abstract

Transsphenoidal surgery has been well established as an effective primary treatment for tumours of the sellar region. During the dural opening, the prominent intercavernous sinus poses limitations for this approach and may contribute to incomplete tumour resections. Based on our experience from 940 cases of conventional transsphenoidal surgery, we have developed a stepwise protocol for achieving bleeding control in 72 cases (7.7%) that had prominent anterior intercavernous sinus. A custom-made 45-degree right- or left-angled bipolar coagulator (38 cases) or Landolt bipolar coagulator (29 cases; Aesculp, Tuttlingen, Germany) was inserted into the small dural opening, and both of the dural layers were coagulated together so that the potential space between the endoosteal layer and meningeal layer could be sealed, and the dural opening could be extended. When the anterior portion of the medial wall of the cavernous sinus was accidentally opened, we then placed a small piece of oxidised regenerated cellulose (Surgicel; Johnson & Johnson, North Yorkshire, UK) at the opening of the medial wall of the cavernous sinus and coagulated both dural layers together starting from the sellar floor side with a custom-made 45-degree angled bipolar coagulator. For the relatively large opening of the cavernous sinus, a microfibrillar collagen haemostat (Avitene; MedChem Products, Woburn, MA) or fleece-coated fibrin glue (TachoComb; Nycomed Austria, Linz, Austria) patch was applied over the opened cavernous sinus with gentle compression and was found to be effective in most cases. Rarely, direct suture of the opened medial wall of the cavernous sinus was necessary in five cases. We describe a stepwise approach to overcome unusual bleedings from the prominent intercavernous sinus during conventional transsphenoidal surgery. Our surgical experience reveals that these methods can be very effective for the control of sinus bleeding.