内镜颅底外科带蒂鼻中隔黏膜瓣的制备与使用
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摘要
目的神经内镜在颅底神经外科的应用越来越广泛,带蒂鼻中隔黏膜瓣的使用大大降低了内镜术后脑脊液鼻漏及感染的发生率。本文将总结内镜手术中颅底重建时带蒂鼻中隔黏膜瓣制备及使用的技术要点,以提高颅底重建的成功率,降低并发症的发生。方法回顾性分析2016年1月至2017年6月内镜颅底手术使用带蒂鼻中隔黏膜瓣进行颅底重建的病例,统计黏膜瓣制备及使用过程中遇到的问题,寻找颅底重建失败的原因,随访时间最短6个月。结果本组共有78例患者术者使用带蒂鼻中隔黏膜瓣进行颅底重建,制备过程中主要问题包括黏膜瓣穿孔(4例)、供血动脉损伤(2例)、蒂部损伤而致黏膜瓣游离(1例)、黏膜瓣长度不足(1例)。术后脑脊液鼻漏4例,导致修补失败的原因包括黏膜瓣移位、黏膜瓣下残余蝶窦黏膜、局部愈合不良。4例明确脑脊液鼻漏患者均行2次手术修补。结论带蒂鼻中隔黏膜瓣的使用是颅底重建的最核心环节,了解带蒂鼻中隔黏膜瓣术前、术中、术后的使用及处理细节,能够一定程度上提高颅底重建的成功率,减少内镜颅底手术术后脑脊液鼻漏的发生,保证手术的安全性。
Objective To investigate the technique highlights in preparation and application of pedicle nasal septum mucosal flap in endoscopic skull base surgery in order to increase the success rate of skull base reconstruction and decrease the incidence of postoperative complications.Methods The clinical data about 78 patients who underwent skull base reconstruction by endoscopic skull base surgery with pedicle nasal septum mucosal flap were retrospectively analyzed.The the problems in the preparation and application of pedicle nasal septum mucosal flap in endoscopic skull base surgeryuse were analyzed to find out the reasons for the failure to skull base reconstruction,with the follow-up time being at least 6 months.Results A total of 78 patients who underwent skull base reconstruction by endoscopic skull base surgery with pedicle nasal septum mucosal flap.The main problems included mucoperiosteal flap perforation(4 cases),supply artery injury(2 cases),pedicle injury(1 case) and insufficient mucoperiosteal flap length(1 case).There were 4 cases of cerebrospinal fluid leak after operation.The reasons that resulted in repairing failure included mucosal flap displacement,residual sphenoid sinus mucosa,and poor local healing.And the 4 patients with cerebrospinal fluid leak received the repairing ahain.Conclusion The application of pedicle nasal septum mucosal flap is key link of skull base reconstruction.To deal with the details in application of pedicle nasal septum mucosal flap before operation,during operation and after operation can improve the success rate of skull base reconstruction at some extent and decrease the incidence of cerebrospinal fluid leak after operation and ensure the safety of the operation.
Objective To investigate the technique highlights in preparation and application of pedicle nasal septum mucosal flap in endoscopic skull base surgery in order to increase the success rate of skull base reconstruction and decrease the incidence of postoperative complications.Methods The clinical data about 78 patients who underwent skull base reconstruction by endoscopic skull base surgery with pedicle nasal septum mucosal flap were retrospectively analyzed.The the problems in the preparation and application of pedicle nasal septum mucosal flap in endoscopic skull base surgeryuse were analyzed to find out the reasons for the failure to skull base reconstruction,with the follow-up time being at least 6 months.Results A total of 78 patients who underwent skull base reconstruction by endoscopic skull base surgery with pedicle nasal septum mucosal flap.The main problems included mucoperiosteal flap perforation(4 cases),supply artery injury(2 cases),pedicle injury(1 case) and insufficient mucoperiosteal flap length(1 case).There were 4 cases of cerebrospinal fluid leak after operation.The reasons that resulted in repairing failure included mucosal flap displacement,residual sphenoid sinus mucosa,and poor local healing.And the 4 patients with cerebrospinal fluid leak received the repairing ahain.Conclusion The application of pedicle nasal septum mucosal flap is key link of skull base reconstruction.To deal with the details in application of pedicle nasal septum mucosal flap before operation,during operation and after operation can improve the success rate of skull base reconstruction at some extent and decrease the incidence of cerebrospinal fluid leak after operation and ensure the safety of the operation.
引文
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2 Jho HD,Carrau RL.Endoscopic endonasal transsphenoidal surgery:experience with 50 patients.Journal of Neurosurgery,1997,87:44-51.
3 Hofstetter CP,Shin BJ,Mubita L,et al.Endoscopic endonasal transsphenoidal surgery for functional pituitary adenomas.Neurosurgical Focus,2011,30:E10.
4 Gondim JA,Schops M,de Almeida JP,et al.Endoscopic endonasal transsphenoidal surgery:surgical results of 228 pituitary adenomas treated in a pituitary center.Pituitary,2010,13:68-77.
5 Cappabianca P,Cavallo LM,Esposito F,et al.Extended endoscopic endonasal approach to the midline skull base:the evolving role of transsphenoidal surgery.Springer Vienna,2008.
6 Cavallo LM,Messina A,Esposito F,et al.Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions.Journal of Neurosurgery,2007,107:713-720.
7 Cavallo LM,Prevedello DM,Solari D,et al.Extended endoscopic endonasal transsphenoidal approach for residual or recurrent craniopharyngiomas.Journal of Neurosurgery,2009,111:578-589.
8 Ceylan S,Koc K,Anik I.Endoscopic endonasal transsphenoidal approach for pituitary adenomas invading the cavernous sinus.Journal of Neurosurgery,2010,112:99-107.
9 De DE,Esposito F,Cappabianca P,et al.Endoscopic transnasal resection of anterior cranial fossa meningiomas.Neurosurgical Focus,2008,25:E8.
10 Esposito F,Dusick JR,Fatemi N,et al.Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery.Neurosurgery,2007,60:295.
11 Garcia-navrro V,Anand VK,Schwartz TH.Gasket Seal Closure for Extended Endonasal Endoscopic Skull Base Surgery:Efficacy in a Large Case Series.World Neurosurgery,2013,80:563-568.
12 Gardner PA,Kassam AB,Thomas A,et al.Endoscopic endonasal resection of anterior cranial base meningiomas.Neurosurgery,2008,63:36-52.
13 Koutourousiou M,Fernandezmiranda JC,Stefko ST,et al.Endoscopic endonasal surgery for suprasellar meningiomas:experience with 75 patients.Journal of Neurological Surgery Part B Skull Base,2014,120:1326.
14 Kassam AB,Thomas A,Carrau RL,et al.Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap.Neurosurgery,2008,63:ONS44.
15 Zanation AM,Thorp BD,Parmar P,et al.Reconstructive options for endoscopic skull base surgery.Otolaryngologic Clinics of North America,2011,44:1201-1222.
16 Munich SA,Fenstermaker RA,Fabiano AJ,et al.Cranial base repair with combined vascularized nasal septal flap and autologous tissue graft following expanded endonasal endoscopic neurosurgery.Journal of neurological surgery Part A,Central European neurosurgery,2013,74:101-108.
17 Chabot JD,Patel CR,Hughes MA,et al.Nasoseptal flap necrosis:a rare complication of endoscopic endonasal surgery.Journal of Neurosurgery,2017,39:1-10.
2 Jho HD,Carrau RL.Endoscopic endonasal transsphenoidal surgery:experience with 50 patients.Journal of Neurosurgery,1997,87:44-51.
3 Hofstetter CP,Shin BJ,Mubita L,et al.Endoscopic endonasal transsphenoidal surgery for functional pituitary adenomas.Neurosurgical Focus,2011,30:E10.
4 Gondim JA,Schops M,de Almeida JP,et al.Endoscopic endonasal transsphenoidal surgery:surgical results of 228 pituitary adenomas treated in a pituitary center.Pituitary,2010,13:68-77.
5 Cappabianca P,Cavallo LM,Esposito F,et al.Extended endoscopic endonasal approach to the midline skull base:the evolving role of transsphenoidal surgery.Springer Vienna,2008.
6 Cavallo LM,Messina A,Esposito F,et al.Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions.Journal of Neurosurgery,2007,107:713-720.
7 Cavallo LM,Prevedello DM,Solari D,et al.Extended endoscopic endonasal transsphenoidal approach for residual or recurrent craniopharyngiomas.Journal of Neurosurgery,2009,111:578-589.
8 Ceylan S,Koc K,Anik I.Endoscopic endonasal transsphenoidal approach for pituitary adenomas invading the cavernous sinus.Journal of Neurosurgery,2010,112:99-107.
9 De DE,Esposito F,Cappabianca P,et al.Endoscopic transnasal resection of anterior cranial fossa meningiomas.Neurosurgical Focus,2008,25:E8.
10 Esposito F,Dusick JR,Fatemi N,et al.Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery.Neurosurgery,2007,60:295.
11 Garcia-navrro V,Anand VK,Schwartz TH.Gasket Seal Closure for Extended Endonasal Endoscopic Skull Base Surgery:Efficacy in a Large Case Series.World Neurosurgery,2013,80:563-568.
12 Gardner PA,Kassam AB,Thomas A,et al.Endoscopic endonasal resection of anterior cranial base meningiomas.Neurosurgery,2008,63:36-52.
13 Koutourousiou M,Fernandezmiranda JC,Stefko ST,et al.Endoscopic endonasal surgery for suprasellar meningiomas:experience with 75 patients.Journal of Neurological Surgery Part B Skull Base,2014,120:1326.
14 Kassam AB,Thomas A,Carrau RL,et al.Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap.Neurosurgery,2008,63:ONS44.
15 Zanation AM,Thorp BD,Parmar P,et al.Reconstructive options for endoscopic skull base surgery.Otolaryngologic Clinics of North America,2011,44:1201-1222.
16 Munich SA,Fenstermaker RA,Fabiano AJ,et al.Cranial base repair with combined vascularized nasal septal flap and autologous tissue graft following expanded endonasal endoscopic neurosurgery.Journal of neurological surgery Part A,Central European neurosurgery,2013,74:101-108.
17 Chabot JD,Patel CR,Hughes MA,et al.Nasoseptal flap necrosis:a rare complication of endoscopic endonasal surgery.Journal of Neurosurgery,2017,39:1-10.