Introduction: A subset of pituitary adenomas invade through the suprasellar arachnoid plane and
encase vital neurovascular structures. Unlike the resection of adenomas that respect
the arachnoid plane, the resection of lesions with subarachnoid invasion requires
a modified surgical technique to avoid inadvertent injury to involved neurovascular
structures. This technique involves an expanded bony exposure, internal debulking,
and meticulous, microsurgical, extracapsular dissection to safely detach the tumor
from associated vascular structures and nerves. Surgical video analysis with artificial
intelligence algorithms provides a mechanism to quantify and delineate these nuances
in surgical technique.
Methods: Surgical videos of patients undergoing an endoscopic endonasal approach for pituitary
adenoma resection from 2022 to 2023 were reviewed. Subarachnoid invasion was identified
in two patients. For comparison, six patients with comparable tumor sizes were also
identified. Surgical videos were uploaded to the Surgical Data Science Collective
and analyzed using built-in machine learning and computer vision modules for instrument
detection. Analysis was performed for the duration of tumor resection, defined from
dural opening to completion of tumor resection. Instrument use statistics, timelines,
and heatmaps were compared across patients with and without subarachnoid invasion.
Results: Tumor sizes across patients with and without subarachnoid invasion were matched,
without significant difference in tumor diameter (26.2 vs. 22.3 mm, p > 0.05). Length of surgical resection was not statistically different across tumors
with and without subarachnoid invasion (96 vs 80 minutes, p > 0.05). Instrument detection analysis identified tear-drop suction, microdissectors,
microscissors, and pituitary grasper with a range of 70 to 99% confidence in detection.
Resection of tumors with subarachnoid invasion was associated with an increased duration
of use of the microdissectors (18.1 vs. 10.3% of total surgical resection time, p = 0.01) and longer average duration of use per instrument appearance (11 vs. 9 seconds
per appearance, p = 0.01). A trend toward increased percentage of microdissector appearances was also
identified during resection of tumors with subarachnoid invasion (22.8 vs. 14.4% of
total instrument appearances, p = 0.06). No significant differences in instrument percentage use, average use duration,
or percentage appearance were identified with the suction, microsscissors, and grasper
across tumors with and without subarachnoid invasion (p > 0.05). Analysis of instrument timelines identified more consistent and prolonged
use of the microdissectors throughout the duration of tumor resection when subarachnoid
invasion was present. In addition, instrument heatmaps demonstrated increased central
and circumferential suction and microdissector use during resection of adenomas with
subarachnoid invasion ([Figs. 1]
[2]
[3]
[4]).
Conclusion: Surgical resection of pituitary adenomas with subarachnoid invasion is associated
with the risk of severe complications, primarily involving vascular injury and subsequent
infarction. A modified surgical technique involving meticulous extracapsular dissection
is necessary to avoid injury to involved neurovascular structures. Machine learning
and computer vision analyses identified increased utilization of the microdissector,
in addition to increased central and circumferential suction and microdissector use
during resection of adenomas with subarachnoid invasion. This serves as an initial
step in quantitatively and qualitatively delineating the nuances in the approach to
resection of adenomas with subarachnoid invasion.
