内視鏡下一側経鼻的下垂体腺腫摘出術における手術機器の開発―Q-PALとHP-Jetに関する提案―

Development of New Surgical Tools,Q-PAL and HP-Jet for Endoscopy Only Used Unilateral Transnasal Approach for Pituitary Adenomas

Ⅰ．は じ め に

　われわれは2004年より内視鏡単独で，一側鼻腔から進入し自然孔を拡大，蝶形骨洞内に進入するtransnasal transsphenoidal approach（以下，TNA）にて下垂体手術を行っている．

　TNAは内視鏡を使用するため広い手術視野が確保でき，また経鼻腔到達法であるため上口唇粘膜の切開や鼻腔粘膜の剝離，鼻中隔軟骨の骨折脱臼を必要としないので，通常のtranssphenoidal surgeryより低侵襲に行える手術である（Fig. 1）．一方，経鼻腔手術全般の問題点として手術経路が狭くて深いという特殊性があり，複数の器械を用いて同時に操作することが困難となるため，この点の解決が必要である．

　そこでわれわれは，①狭い術野での止血凝固に有効なPAL-Ⅰ電極を吸引管内に通し，吸引と凝固を同時に行えるように工夫した（通称Q-PAL）．②イリゲーション管を装備した脱着式下垂体イリゲーション吸引管を改変し，用手的に生理食塩水を噴射して腫瘍除去を行う（通称HP-Jet）．これらの器具によって，狭い術野での有効な腫瘍の摘出が可能となったので報告する．

　The aim of this study is to present surgical techniques and results of endoscope-assisted transnasal approach (TNA) for pituitary adenomas. It is a new alternative for Hardy's surgery (TSS). We performed TNA assisted by only endoscope through single nostril.

　Method　We enter the sphenoid sinus directly through the natural ostium and ablate neither the nasal septum nor the vomer bone. We found the hardest problem of this method resides in its deep and narrow working space which obstructs usage of two tools at same time. To overcome this problem we developed two surgical tools,Q-PAL and HP-Jet. Q-PAL is combination of PAL and suction. We place flexible PAL wire electrode through suction tube so as PAL tip protrudes from suction tip. This eliminates coagulation smoke which otherwise disturbs surgeons view. HP-Jet is a combination of a suction tool and an irrigator. The irrigator is connected to syringe containing saline. Saline is injected manually from tip bursting up tumor tissue with its jet pressure. It is safe and effective instrument suitable for extirpation of rather fragile tissue like adenomas existing in deep and blind spaces.

　Cases　Since 2004 we have operated on 16 patients using endoscopic TNA. Eight were non-functioning adenomas,and 8 functioning.

　Results　Results of surgery were compared with those of 10 cases operated by TSS. More than 70％ removal of adenoma was achieved in 75％ of cases with TNA,but in only 71％ with TSS. Postoperative CSF rhinorrhea was seen in one case. Four cases showed postsurgical transient diabetes insipidus. We had no case with postsurgical infection. With the help of instruments having multiple functions in single probe such as Q-PAL and HP-Jet,we can execute endoscopic TNA more smoothly and more safely.