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Hypophysectomy ENT Medical Transcription Sample Report


Pituitary tumor.

Pituitary tumor.

Transseptal transsphenoidal approach for hypophysectomy.

SURGEON:  John Doe, MD


ANESTHESIA:  General endotracheal.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old female who presented with left retro-orbital headaches.  She also had evidence of endocrinopathy.  MRI scan was consistent with microadenoma.  The patient was scheduled for hypophysectomy per Dr. Jane Doe.  Nasal history is notable for a prior nasal fracture.  The risks, benefits, alternatives, and indications of the above noted procedure and approach were reviewed in detail.  The patient agreed with the procedure planned.

OPERATIVE FINDINGS:  The patient had a septal deviation most notably along the right dorsal aspect.  Intersphenoid sinus septum was located right at the midline.  Therefore, the left sphenoid sinus was larger than the right.  No CSF was encountered.  Doyle splints were used to assist with septal healing.

DESCRIPTION OF OPERATION:  The patient was brought in the operating room and placed on the OR table in the supine position.  After demonstration of adequate general endotracheal anesthesia, the table was turned 90 degrees.  The C-arm was positioned to allow visualization of the sella.  The nose was prepped with 6 mL of 1% lidocaine with 1:100,000 epinephrine into the nasal septum mucosal flaps.  This was also applied on the nasal floors and 1 mL total to the greater palatine foramina.  The patient was then prepped and draped sterilely including the abdomen.

A #15-blade scalpel was used to make a left hemitransfixion incision which was extended down just anterior to the floor.  Submucoperichondrial flaps were elevated with the caudal.  The septal tunnel on the left was elevated with the caudal in the anterior to posterior direction beyond the bony cartilaginous junction onto the area of the rostrum.  This was then taken down over the maxillary crest and nasal floor.  The floor was elevated in a posterior to anterior direction.  The mucosa was swept laterally to ultimately allow space for the Hardy retractor.

Next, an incision was made in the septal cartilage over 1.5 cm posterior to the tip.  A sliver of cartilage was harvested and preserved.  The opposing mucoperichondrial and mucoperiosteal flaps were then elevated with the caudal.  Through the same exposure, I was able to elevate off the maxillary crest on the right posteriorly.  I continued this elevation anteriorly and again swept the nasal floor mucosa laterally.  Anteriorly, the caudal septum was disarticulated from the crest and allowed to swing to the right.  At this time, the longer speculum was used to visualize the rostrum.  It was replaced by the self-retaining Hardy speculum.

A Penfield was used to cannulate the natural ostia of the right followed by the left sphenoid sinus.  Placement within the sinus was confirmed using the C-arm.  Next, 1 and 2 mm rongeurs were used to open up the ostia and connect them in the midline.  The intrasinus septum was visualized right of the midline and extending obliquely to the right side.  A CT scan did show that this was at the posterior attachment within the proximity of the carotid, which was well covered by bone.  It was carefully taken down along its anterior two-thirds with Takahashi forceps.

At this time, the case was turned over to the assisting doctor.  He agreed that the exposure was adequate and proceeded with his portion of the case.  There was no spinal fluid leak reported.  After repair, the case was turned back to me for closure.  The septal flaps were in good condition.  There was a small mucosal opening on the right flap with an intact opposing flap.  This was at the midway point of the septum.  Also note, earlier in the case, there was a thin stream of arterial bleeding from the septal artery on the right, which was fully controlled with the suction Bovie.  The caudal septum was then placed back on the crest using two interrupted #4-0 nylon sutures.

The hemitransfixion incision was closed using interrupted #3-0 chromic sutures.  A running #4-0 fast absorbing on a SC-1 needle was used to close the flaps back together and help prevent hematoma formation.  The Doyle splints were coated with Bactroban ointment and placed on either side of the septum.  They were secured across the membranous septum with a #2-0 nylon suture.  The patient was turned over to the care of the anesthesia team for subsequent extubation and returned to the recovery room.  The patient tolerated the procedure well without any immediate complications.

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