Sample Name: Pituitary Tumor Resection
Description: Transnasal transsphenoidal approach in resection of pituitary tumor. The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.
(Medical Transcription Sample Report)
TITLE OF OPERATION: Transnasal transsphenoidal approach in resection of pituitary tumor.
INDICATION FOR SURGERY: The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor. She was started on Dostinex with increasing dosages. The most recent MRI demonstrated an increased growth with hemorrhage. This was then discontinued. Most recent prolactin was at 70, although normalized, the recommendation was surgical resection given the size of the sellar lesion. All the risks, benefits, and alternatives were explained in great detail via translator.
PREOP DIAGNOSIS: Pituitary tumor.
POSTOP DIAGNOSIS: Pituitary tumor.
PROCEDURE DETAIL: The patient brought to the operating room, positioned on the horseshoe headrest in a neutral position supine. The fluoroscope was then positioned. The approach will be dictated by Dr. X. Once the operating microscope and the endoscope were then used to approach it through transnasal, this was complicated and complex secondary to the drilling within the sinus. Once this was ensured, the tumor was identified, separated from the pituitary gland, it was isolated and then removed. It appeared to be hemorrhagic and a necrotic pituitary, several sections were sent. Once this was ensured and completed and hemostasis obtained, the wound was irrigated. There might have been a small CSF leak with Valsalva, so the recommendation was for a reconstruction, Dr. X will dictate. The fat graft was harvested from the left lower quadrant and closed primarily, this was soaked in fat and used to close the closure. All sponge and needle counts were correct. The patient was extubated and transported to the recovery room in stable condition. Blood loss was minimal.
Keywords: neurosurgery, transnasal transsphenoidal approach, resection, pituitary tumor, transsphenoidal, transnasal, prolactin, tumor, pituitary,