神外入路丨翼点入路---SevenAneurysms系列第十期
编者按
本期为Worldneurosurgery定期连载的《动脉瘤大师级神作--Seven Aneurysms》著作第十期。本期主要内容为 翼点入路，《Seven Aneurysms 》系列内容包括 Section I The Tenets：1. 在显微镜下操作；2. 蛛网膜下腔的解剖；3.脑牵拉；4.血管控制；5.临时夹闭；6.永久夹闭；7.夹闭后的检查；8.必要的脑切除；9.术中破裂。Section II The Approaches: 10.翼点入路; 11.眶颧入路; 12.前纵裂入路; 13.远外侧入路。Section IIIThe Seven Aneurysms: 14.后交通动脉瘤; 15.大脑中动脉瘤; 16.前交通动脉瘤; 17.眼动脉动脉瘤; 18.胼周动脉瘤; 19.基底动脉分叉动脉瘤; 20.小脑后下动脉动脉瘤。
锦鲤的价格
【Seven Aneurysms】往期回顾
∙第一期：神外医师基本功-- 在显微镜下操作技巧
∙第二期：神外医师基本功--蛛网膜下腔的解剖
∙第三期：神外医师基本功--脑牵拉
∙第四期：神外医师基本功--血管控制
∙第五期：动脉瘤手术基本功--临时夹闭
∙第六期：动脉瘤手术基本功--永久夹闭
劳动周∙第七期：动脉瘤手术基本功--夹闭后的检查
∙第八期：动脉瘤手术基本功--必要的脑切除
小孩几个月断奶∙美国迪斯尼乐园第九期：动脉瘤手术基本功--术中破裂
中国神话故事大全100第十期：Pterional Approach--翼点入路
■ Position--体位
The patient is positioned supine with a bolster under the shoulder ipsilateral to the aneurysm. The head is rotated 15 to 20 degrees away from the side of the aneurysm. The head is extended approximately 20 degrees, allowing gravity to retract the frontal lobe away from the anterior cranial fossa floor and making malar eminence the high point in the surgical field. The head is then lifted above the level of the heart, out of a depende
nt position. The neck is maintained in a neutral position, avoiding lateral flexion that might clo the angle between the shoulder and head, and
take away valuable working space. This head position aligns the plane of sylvian fissure vertically, allowing frontal and temporal lobes to fall away naturally to either side as the fissure is split later, like pages in a book that rests on its binding. Retractors become unnecessary during the sylvian fissure disction. This head position and some lateral rotation of the operating table will adjust for most variability in the plane of the sylvian fissure. A conventional head position with 30 degrees of lateral rotation often leaves the temporal lobe overlying the sylvian fissure and clos the plane, even with full table rotation toward the side of the aneurysm.
病人平卧位动脉瘤同侧肩下垫长枕。头部向动脉瘤对侧旋转15到20度，后仰约20度，使颧骨隆突位于手术区域的最高处，以便利用重力作用牵拉额叶离开前颅底。然后头抬高使其高于心脏水平，被动体位。 颈部保持中立位，避免侧方弯曲以免缩小肩和头之间的角度，并影响宝贵的操作空间。头位摆放后让大脑侧裂面垂直于地面，以便随着侧裂的两侧分离
后，额叶和颞叶像装订后的书页一样自然分开。这样，大脑侧裂的解剖不必使用牵引器。头位和手术床的左右旋转可以将侧裂的操作平面进行最大程度的调整。传统的头位摆放是横向旋转30度，通常会使颞叶覆盖大脑侧裂并关闭分离界面，即使手术床向动脉瘤一侧充分旋转也不一定能够纠正。
■ Incision--切口
A curvilinear skin incision begins at the zygomatic arch 1 cmanterior to the tragus and arcs to the midline, just behind the hairline at thewidow’s peak (Fig. 10.1A). The two endpoints define the linear fold of thescalp flap, which barely cross the pterion. Therefore, additional inferior retractionof the scalp flap with “fish hooks” on a Leyla bar (Aesculap; San Francisco, CA)is needed to expo pterion thoroughly. A micircular incision maximizes the scalpflap. An incision placed too anteriorly along the hairline, having a J- ratherthan a C-shape, results in a smaller craniotomy becau the bone flap conformsto the scalp flap. A foreshortened craniotomy might limit exposure of theposterior sylvian fissure or mobilization of temporal lobe.
宝宝成长
起自耳屏前1厘米、平颧弓向中线的弧形皮肤切口，止于发际线前缘中点 (图10.1)。头皮切口起/止点之间皮瓣的线性褶皱刚好经过翼点。因此, 需要用“鱼钩”将头皮皮瓣向下稍作牵拉(蛇牌，旧金山,CA)以彻底显露翼点。半圆形的切口可以最大化头皮皮瓣面积。如果太靠前沿着发际线位置设计切口，形成一个J 形而不是C 形皮肤切口，结果会造成骨窗偏小，这是因为骨瓣的大小受限于头皮皮瓣的大小，而颅骨切开骨窗的减小可能会影响大脑侧裂的显露及颞叶的牵开。
■ Extracranial Disction--颅外切开
The scalp is elevated only enough to expo thezygomatic root posterior-inferiorly and the keyhole anteriorly. The superficialfat overlying the temporalis fascia should not be entered becau the frontalisbranch of the facial nerve lies in this tissue plane and can be injured withadditional elevation of the scalp flap. The temporalis muscle is incid from thezygomatic arch to the superior temporal line along the skin incision, thenanteriorly to the keyhole, running 1 cm below the superior temporal line. The temporalis is flapped anteriorly,leaving a cuff of fascia and muscle along the superior tem怎样提高网速
poral line to suturethe muscle to during closure. The fish hooks are repositioned to retract thetemporalis muscle as well as the scalp flap.
智取生辰纲头皮切开程度要求皮瓣翻开后可以显露后下方的颧弓根部以及前部的关键孔。避免切开分离覆盖在颞肌筋膜表面的脂肪，这是由于面神经额支走行在这个平面，并且皮瓣过度的牵拉可以损伤此神经。沿着皮肤切口从颧弓到颞上线切开颞肌，然后在颞上线下方1CM切到前面的关键孔。颞肌翻向前方，在颞上线上保留一条颞肌筋膜以便关闭切口时缝合肌肉。重新调整鱼钩位置以便牵拉颞肌以及皮瓣。
Patients with largefrontal sinus that will be violated by the craniotomy will require avascularized pericranial graft for the repair during closure. Head computed tomography (CT) scans or scoutfilms from the angiogram demonstrate the frontal sinus size. It iasier to harvest this pericranial flap during the opening than later duringthe closure. The depth of the skinincision stops short of the cranium to prerve pericranium, going only throughgalea and deep connective tissue. The scalp flap is elevated away from thepericranium, opening a white, avascular tissue plane sharply with upwardtraction on th
e scalp. The pericranium can be incid well behind the skinincision, extending posteriorly and across midline to enlarge the flap’s size,if necessary. Pericranial flaps elevate cleanly from the bone with blunt disctionand can be prerved during the procedure in moist sponges. Cerebrospinal fluid (CSF) leaks through the frontalsinus are unwanted complications that may require repeat craniotomy, directrepair, and sometimes ventriculo-peritoneal shunting. It is far better toprevent this complication than to have to deal with it later when tissues are scarredand the pericranium is compromid.
