Now that you have dressed appropriately, setup your operating theatre, and have all of your instruments ready, it’s time to get started! First things first: you need to put the patient to sleep (and I don’t mean by showing them slides of your last vacation!). Years ago, surgeons accomplished this with a sponge full of ether and two crossed fingers. Luckily, nowadays we can rely on slightly more reliable means. To anesthetize your patient use a typical low flow inhalation technique: simply place 10.2 mg of methoxyflurane in a wick vaporizer and set the oxygen flow rate so that the rebreathing bag remains partially full. If you can achieve an oxygen flow of 10 ml/kg/min you should be in business!
|
Periodic recycling of the methoxyflurane will prevent the fatal buildup of nitrous byproducts in the blood stream. As the wise old sage once said, "recycled methoxyflurane today equals a healthy patient tomorrow! |
Once your patient has been successfully anesthetized, and his/her metabolic rates are at an acceptable state of equilibrium, it’s time to get cracking! Put on your sterile gloves, a big smile, and an aura of hearty enthusiasm, then:
Open the inferior wall of the sphenoid sinus, strip the mucosa from the superior wall of the sinus which constitutes the bony floor of the sella turcica. Mucosal bleeding can be controlled with bipolar cautery. Open the wall of the sella on the left and resect using a rongeur, exposing the underlying dura of the pituitary fossa.
You’re doing great so far! Take a deep breath, get a drink of water, check your answering machine messages to make sure no one important called (yeah right!), and then:
Make a cruciate incision in the dura. Bleeding from the dural edges can be controlled with bipolar cautery, and oozing from the adjacent cavernous sinus can be controlled with cellulose sponges. The cancerous neural tissue will be gray and soft. Note the adjacent firm, yellow, normal pituitary can be seen. The tissue can be dissected away from the normal gland using standard spatula and loop instruments.
Hang in there, you are almost done! If you have to use the bathroom, this would be a good time…but make sure to wipe those bloody bits of mucous membrane off your hands before using the good towels! Now relax, shake out your arms, and then:
Close the dura with a bovine pericardial patch to accommodate swelling from the dissection. Place a patch of gelfoam in the craniectomy defect and seal the edges with fibrin glue. The incision should then be closed in layers.
Whew! That wasn’t so bad. Now the only difference between you and a real Neurosurgeon is a Porsche and a Swiss bank account! After the patient is revitalized, simply put him under the supervision of a Neurological Intensive Care Unit (or the best alternative), and remember to clean your operating space!
 |
If you used a public area, such as your kitchen table, to perform your surgery, use a good antibacterial soap when cleaning up to make sure that none of those nasty head germs or cancer cells get into the next morning’s breakfast! |
 |
 |
 |