额眶颧入路及其应用简介ppt课件

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1、 强调通过打开骨性结构，减少脑组织的牵强调通过打开骨性结构，减少脑组织的牵拉，以取得满意的显露拉，以取得满意的显露 眶颧入路眶颧入路 去除眶上壁和外侧壁以及颧去除眶上壁和外侧壁以及颧弓，显露海绵窦及上斜坡弓，显露海绵窦及上斜坡 增加骨质的去除增加骨质的去除 增加并发症，延长手术时间增加并发症，延长手术时间 得失的平衡？得失的平衡？是否真的扩大了显露是否真的扩大了显露 医生的经验，个人手术风格医生的经验，个人手术风格 标准翼点入路标准翼点入路 Standard Pterional approachStandard Pterional approach 去除眶缘，眶顶，眶外侧壁及颧弓的一部分去除眶

2、缘，眶顶，眶外侧壁及颧弓的一部分 Rim,roof and lateral wall of the orbit,Rim,roof and lateral wall of the orbit,as well as the Zygomatic archas well as the Zygomatic arch 安全及美容安全及美容 Safe&Safe&Cosmetic Cosmetic 面神经额支的保护面神经额支的保护 避免颞肌萎缩避免颞肌萎缩 充分显露，较少咬除骨组织，免于颅底重建充分显露，较少咬除骨组织，免于颅底重建 缩短工作距离，扩大术野及视角，改善照明缩短工作距离，扩大术野及视角，改善照明

3、 Narrow space Wide portalNarrow space Wide portal SupineSupine 30-60 to the side opposite to the 30-60 to the side opposite to the surgical incisionsurgical incision Malar eminence superior pointMalar eminence superior point Head fixationHead fixation 耳屏耳屏(TragusTragus)前方前方1-2cm1-2cm，颧弓下缘，颧弓下缘 弧形切口弧

4、形切口curvilinear mannercurvilinear manner 对侧瞳孔中点延长线与发际相交处对侧瞳孔中点延长线与发际相交处 注意：必须保留颞浅动脉后支注意：必须保留颞浅动脉后支 切口向下延长不要超过下颌关节平面，切口向下延长不要超过下颌关节平面，避免损伤面神经避免损伤面神经 帽状腱膜下脂肪垫帽状腱膜下脂肪垫 subgaleal fat padsubgaleal fat pad 注意面神经额支的走行及保护注意面神经额支的走行及保护 骨膜下分离颞肌骨膜下分离颞肌 subperiosteal techniquesubperiosteal technique 慎用单极，避免颞肌萎缩慎

5、用单极，避免颞肌萎缩 硬膜悬吊硬膜悬吊 dural tacking suturesdural tacking sutures 摆动锯摆动锯 reciprocating sawreciprocating saw 标准翼点骨瓣，注意眶上神经的保护（眶上孔）标准翼点骨瓣，注意眶上神经的保护（眶上孔）六步法六步法 眶颧眶颧 RemovalRemoval颧突根部，切断颧弓颧突根部，切断颧弓颧突平面上横断颧骨，直达眶下裂颧突平面上横断颧骨，直达眶下裂眶上缘和眶顶（眶上神经孔外侧眶上缘和眶顶（眶上神经孔外侧1-21-2mm)mm)眶上裂和眶下裂之间眶上裂和眶下裂之间 硬膜切口硬膜切口 针对一些特殊病变的改良

6、，如磨除前床突针对一些特殊病变的改良，如磨除前床突 硬膜翻转硬膜翻转 锐性分离视神经和颈内动脉周围的蛛网膜锐性分离视神经和颈内动脉周围的蛛网膜 脑脊液引流脑脊液引流 脑室穿刺脑室穿刺 VentriculostomyVentriculostomy腰穿腰穿Lumbar drainLumbar drain终板造瘘终板造瘘 Lamina terminales exposeLamina terminales expose Bony approach+Brain relaxationBony approach+Brain relaxation 对出血的有效控制对出血的有效控制 Vascular contr

7、olVascular control 保留穿通动脉保留穿通动脉 Preservation of perforating arteryPreservation of perforating artery 牺牲骨性结构牺牲骨性结构 Maximize bone removalMaximize bone removal 减少脑组织牵拉减少脑组织牵拉 Less brain retractionLess brain retraction 扩大显露范围扩大显露范围 Improve exposureImprove exposure 切除部分直回切除部分直回 Gyrus RectusGyrus Rectus 打

8、开纵裂打开纵裂 Recurrent arteries of HeubnerRecurrent arteries of Heubner Temporary clipTemporary clip Removal of hematomaRemoval of hematoma Self-retaining retractor blades?Self-retaining retractor blades?动脉瘤动脉瘤 exclude it from the circulationexclude it from the circulation TCD monitoring TCD monitoring A

9、neurysm trapping with or without distal Aneurysm trapping with or without distal revascularizationrevascularization Side-to-side A2-to-A2 anastomosesSide-to-side A2-to-A2 anastomoses 术中脑血管造影术中脑血管造影Intraoperative AngiographyIntraoperative Angiography 术中脑血流监测术中脑血流监测 Intraoperative MonitoringIntraopera

10、tive Monitoring 巴比妥麻醉巴比妥麻醉Barbiturate AdministrationBarbiturate Administration 术中轻低温术中轻低温Mild hypothermia 33-35Mild hypothermia 33-35 C C 锐性分离锐性分离Sharp dissectionSharp dissection 避免术中低血压避免术中低血压No HypotensionNo Hypotension 标准翼点入路标准翼点入路 +良好的牵开器良好的牵开器 血管变异血管变异 Vascular anomaliesVascular anomalies CT an

11、giographyCT angiography 严密缝合硬膜严密缝合硬膜 骨瓣复位骨瓣复位 无需额外的颅骨重建无需额外的颅骨重建 注意解剖复位，层次对合注意解剖复位，层次对合眶周瘀肿眶周瘀肿Periorbital bruising and swellingPeriorbital bruising and swelling （Tarsorrhaphy Tarsorrhaphy 眼睑缝合术）眼睑缝合术）搏动性突眼搏动性突眼 Pulsatile exophthalmusPulsatile exophthalmus额神经损伤额神经损伤 Frontalis nerve injuryFrontalis n

12、erve injury眼球内陷眼球内陷 EnophthalmosEnophthalmos，Orbital entrapmentOrbital entrapment复视复视 Diplopia Diplopia 失明失明 BlindnessBlindnessZygomatic separationZygomatic separation，Bone reabsorption Bone reabsorption Cerebrospinal fluid fistulasCerebrospinal fluid fistulas，InfectionInfectionJoseph M.Zabramski,Ta

13、lat Kiris,Suresh K.Sankhla,et al.Orbitozygomatic craniotomy.Journal of Neurosurgery,Vol.89,August,1998:336-341L.Fernando Gonzalez,Neil R.Crawford,Michael A.Horgan,et al.Working area and angle of attack in three cranial base approaches:pterional,orbitozygomatic,and maxillary extension of the orbitozygomatic approach.Neurosurgery,Vol.50,No.3,March 2002:550-557Howard A.Riina,G.Michael Lemole Jr.,Robert F.Spetzler.Anterior communicating artery aneurysms.Neurosurgery,Vol.51,No.4,October 2002:993-996谢谢 谢谢 ！谢谢 谢谢 ！