For all tumors, complete tumor resection is advantageous. In hormonally active tumors, endocrine remission requires complete removal, and for nonfunctioning tumors we believe radical resection is of importance in reducing recurrence. One of the most difficult skills to acquire in pituitary surgery is knowing when this has been achieved. Difficulties in assessing completeness occur for several reasons. These include the small operative field, the need to see recesses of the sella beyond limits of direct vision, the reliance upon indirect clues such as alterations in diaphragmatic contour and descent, and perhaps vague fullness evident upon palpation with micro-instruments.
Intraoperative MRI takes away this reliance on experience and should be a major advance in resection control. Surgery is performed with the patient lying directly on the table of the MRI scanner. After the standard transsphenoidal procedure, an intraoperative MRI scan is performed while the operative exposure and sterile field are both maintained so that if residual tumor is seen, further resection is undertaken. Although the precise role of intraoperative MRI in pituitary tumor surgery awaits further definition, it is possible that future developments in this technology will enhance the effectiveness of trans-sphenoidal surgery.
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