額眶顴入路及其應(yīng)用簡(jiǎn)介

1、額眶顴入路的臨床應(yīng)用,,額眶顴入路的歷史,Yasargil 經(jīng)典的額顳開(kāi)顱 - 翼點(diǎn)入路Jane（1982）打開(kāi)部分眶頂Al-Mefty（1983）打開(kāi)眶上壁和外側(cè)壁額眶顴開(kāi)顱：Pellerin（1984）顱眶溝通腫瘤Hakuba（1986）鞍旁海綿竇腫瘤及基底動(dòng)脈瘤Spetzler（1992）前、中顱底及斜坡上1/3的 腫瘤、動(dòng)脈瘤及海綿

2、狀血管瘤,顱底手術(shù)概念的演變,強(qiáng)調(diào)通過(guò)打開(kāi)骨性結(jié)構(gòu)，減少腦組織的牽拉，以取得滿意的顯露眶顴入路 – 去除眶上壁和外側(cè)壁以及顴弓，顯露海綿竇及上斜坡,增加骨質(zhì)的去除 – 增加手術(shù)并發(fā)癥發(fā)生率，延長(zhǎng)手術(shù)時(shí)間如何平衡？是否真的擴(kuò)大了顯露醫(yī)生的經(jīng)驗(yàn)，個(gè)人手術(shù)風(fēng)格操作角度,對(duì)額眶顴入路的基本評(píng)價(jià),額眶顴入路及其改良,在常規(guī)翼點(diǎn)入路基礎(chǔ)上Pterional approach去除眶緣，眶頂，眶外側(cè)壁及顴弓Rim, roof and la

3、teral wall of the orbit, as well as the zygomatic arch,,,,,,,,美容CosmeticSafe面神經(jīng)額支的保護(hù)避免顳肌萎縮充分顯露，避免咬除骨組織縮短工作距離擴(kuò)大術(shù)野及視角，改善照明和儀器使用Narrow space – wide portal,額眶顴入路的優(yōu)點(diǎn),Supine30-60º to the side opposite to the surgi

4、cal incisionMalar eminence – most superior pointHead fixation,額眶顴入路 – 體位和切口,切口設(shè)計(jì),耳屏前方Tragus耳屏前1cm，顴弓下緣弧形切口curvilinear manner對(duì)側(cè)瞳孔中點(diǎn)延長(zhǎng)線與發(fā)際相交處注意：必須保留顳淺動(dòng)脈后支切口向下延長(zhǎng)不要超過(guò)下頜關(guān)節(jié)平面，避免損傷面神經(jīng)帽狀腱膜下脂肪墊subgaleal fat pad注意面神經(jīng)額支的走行

5、及保護(hù)骨膜下分離顳肌subperiosteal technique慎用單極，避免顳肌萎縮硬膜懸吊dural tacking sutures擺動(dòng)鋸reciprocating saw,眶上神經(jīng)的保護(hù) 眶上神經(jīng)孔標(biāo)準(zhǔn)翼點(diǎn)骨瓣六步法 眶顴Removal顴突根部，切斷顴弓顴突平面上橫斷顴骨，直達(dá)眶下裂眶上緣和眶頂（眶上神經(jīng)孔外側(cè)1-2mm眶上裂和眶下裂之間軟組織的游離硬膜切口針對(duì)一些特殊病變的改良，如磨除前床突,額眶顴入

6、路 – 骨性部分,術(shù)野顯露過(guò)程,硬膜翻轉(zhuǎn)銳性分離視神經(jīng)和頸內(nèi)動(dòng)脈周圍的蛛網(wǎng)膜腦脊液引流 – 腦室穿刺Ventriculostomy、腰穿Lumbar drain、終板造瘺Lamina terminales exposeBony approach + Brain relaxation,病例 – 1 基底動(dòng)脈瘤,病例 – 1 基底動(dòng)脈瘤,病例 – 1 基底動(dòng)脈瘤,病例 – 1 基底動(dòng)脈瘤,入路選擇要素,對(duì)出血的有效控制Vascular

7、 control保留穿通動(dòng)脈Perservation of perforating artery犧牲骨性結(jié)構(gòu)maximize bone removal減少腦組織牽拉（ Less brain retraction）擴(kuò)大顯露范圍improve sxposure,對(duì)出血的控制,切除部分直回Gyrus rectus打開(kāi)縱裂Recurrent arteries of Heubner 下丘腦Temporary clipRemoval

8、 of hematomasSelf-retaining retractor blades ?,手術(shù)的目的,動(dòng)脈瘤 – exclude it from the circulationTCD monitoringAneurysm trapping with or without distal revascularizationSide-to-side A2-to-A2 anastomoses,輔助手段,術(shù)中腦血管造影Intraop

9、erative Angiography術(shù)中腦血流監(jiān)測(cè) Intraoperative Monitoring巴比妥麻醉Barbiturate Administration術(shù)中輕低溫Mild hypothermia 33-35?C銳性分離Sharp dissection避免術(shù)中低血壓No Hypotension,其他選擇,標(biāo)準(zhǔn)翼點(diǎn)入路 + 良好的牽開(kāi)器血管變異 Vascular anomaliesCT angi

10、ography,嚴(yán)密縫合硬膜骨瓣復(fù)位無(wú)需額外的顱骨重建注意解剖復(fù)位，層次對(duì)合,額眶顴入路 – 關(guān)顱,并發(fā)癥,眶周瘀腫Periorbital bruising and swelling Tarsorrhaphy眼瞼縫合術(shù)搏動(dòng)性突眼Pulsatile exophthalmus額神經(jīng)損傷Frontalis nerve injuryEnophthalmos 眼球內(nèi)陷Orbital entrapment復(fù)視Diplopia失明B

11、lindnessZygomatic separationBone reabsorption Cerebrospinal fluid fistulasInfection,病例 – 2 基底動(dòng)脈瘤,病例 – 2 基底動(dòng)脈瘤,病例 – 2 基底動(dòng)脈瘤,病例 – 2 基底動(dòng)脈瘤,病例 – 3 眼動(dòng)脈段動(dòng)脈瘤,病例 – 3 眼動(dòng)脈段動(dòng)脈瘤,參考文獻(xiàn),Joseph M. Zabramski, Talat Kiris, Suresh K. S

12、ankhla, et al. Orbitozygomatic craniotomy. Journal of Neurosurgery, Vol. 89, August, 2019: 336-341L. Fernando Gonzalez, Neil R. Crawford, Michael A. Horgan, et al. Working area and angle of attack in three cranial base

13、approaches: pterional, orbitozygomatic, and maxillary extension of the orbitozygomatic approach. Neurosurgery, Vol. 50, No. 3, March 2019: 550-557Howard A. Riina, G. Michael Lemole Jr., Robert F. Spetzler. Anterior com