我们要感谢内分泌科和手术室小组在这些病人的管理方面给予他们的帮助和支持。我们没有这项工作的资金来源, 也没有利益冲突。

这里的议定书说明了在洛桑大学医院的人类研究伦理委员会的指导方针。
注意: 这里解释的过程集中于对垂体腺瘤进行的经典方法。
1. 术前协议
<ol><li>系统地进行前颅面 CT 扫描和 MRI, 以及内分泌和眼科评估。</li>
</ol>2. 定位和麻醉
<ol><li>诱导全身麻醉并进行口气插管。</li>
	<li>将病人置于全身麻醉和口气插管后的仰卧位。</li>
	<li>将头部定位在头架上, 并固定在头部周围的磁性神经导航带上。</li>
	<li>将表的头部抬高至20°, 以改善静脉引流, 并略微旋转头部约30°对神经外科医生, 同时执行对侧头部倾斜。 注意: 患者头部的伸展或屈曲程度取决于手术靶点: 蝶鞍鞍方法的轻微屈曲 (15-20 °)17 , 对前颅底手术是中性的, 对下斜坡病变可弯曲45°。</li>
	<li>用无酒精的 chlorexidine 溶液消毒脸部。用消毒液清洗鼻腔窝, 然后用棉垫浸渍稀释的因1% 与肾上腺素 (1:1, 000,000)。 注意: 除了局部麻醉和血管收缩外, 这种吸汗还提供了中鼻甲的侧向收缩, 以使内镜的方法。可调节的握臂可固定在手术过程的特定阶段 (特别是在鞍期)。然而, 一些外科医生宁愿不修复内窥镜有一个更动态的视野的外科领域。在这种情况下, 他们要么把内窥镜交给助手, 要么用双手进行工作, 或者把内窥镜本身。</li>
	<li>清洁右腹象限, 并在右侧的围脐区域留下一个小窗口, 同时在术脑脊液瘘的情况下, 它代表一个可能的脂肪接枝收获地点。 注意: 麻醉应特别注意深 morphinic 镇痛, 并在术后的鼻腔阶段控制平均血压, 以减少由于鼻腔粘膜丰富的神经支配而引起的出血。</li>
</ol>3. 手术
注意: 鼻窝一侧的选择主要是由鼻腔解剖 (鼻中隔偏曲, 超鼻甲, 息肉, 既往手术,等) 决定的. 肿瘤的侧向延伸 (侧向伸展), 肿瘤的大小 (binostril 方法用于大肿瘤)。在大多数垂体腺瘤中, 单方面的方法足以使肿瘤及其扩展得到良好的曝光。
<ol><li>
鼻相
	<ol>
<li>介绍0°短刚性内窥镜 (18 厘米长, 4 毫米直径) 进入右鼻孔, 以确定中下鼻甲侧和鼻中隔内侧。喜欢左鼻孔的方法, 以防间隔偏差, 鼻甲异常, 或特定的肿瘤扩展, 在术前成像检测。</li>
		<li>将内窥镜管置于鼻孔的上或下侧, 以便为进入鼻腔的其他仪器提供足够的空间。</li>
		<li>轻轻缩回中间和上级鼻甲与钝刮刀, 以实现广泛的接触同侧蝶窦口。注意支持上级和中间鼻甲通过他们的整个长度与刮刀, 以避免骨折在撤回演习。</li>
	</ol>
</li>
	<li>
蝶相
	<ol>
<li>将鼻粘膜以垂直线性方式凝固, 在蝶骨 osteum 和后之间单约10-15 毫米, 以避免鼻中隔动脉出血 (腭动脉的分支在上缘运行后)。</li>
		<li>垂直打开凝固的鼻粘膜, 直到与犁相对应的骨接触被感觉到。</li>
		<li>跟随犁前直到其与鼻软骨隔膜的交界处, 并把它推向左侧, 露出对侧的蝶骨口, 同时注意保持在粘膜下的平面。</li>
		<li>用骨钳和钳将切除从一个口口延伸到另一口的蝶台上。这个开放的蝶窦允许暴露的 exocranial 颅底面。</li>
		<li>如果蝶骨的黏膜干扰了鞍区的开口, 请轻轻地将其移除。</li>
		<li>切除蝶骨隔膜 (经常有多个隔膜) 与 rongeurs, 以提供广泛的蝶鞍鞍暴露。</li>
		<li>仔细分析术前磁共振成像 (MRI) 和/或 CT 扫描的数量和方向, 这些分隔;这是至关重要的认识到相关的解剖。其中一些分隔可能直接插入颈动脉日珥, 因此应在手术的这一阶段确定为重要的地标 (图 1,图 2,图 3,图 4)。 注: CT 扫描采用64检测器基于系统进行。利用一系列薄切片数据对三维重建进行了处理。MRI 协议是在 3-特斯拉成像仪上进行的。该协议包括一个矢状 T1-weighted 梯度回声序列 (MPRAGE) 与没有对比注射, 160 相邻切片, 1 毫米各向同性体素, 重复时间 (TR) 2300 毫秒, 回声时间 (TE) 2.98 毫秒, 视场 256 mm 为基础的分割,和 3D T2 序列。</li>
	</ol>
</li>
	<li>
鞍期
	<ol>
<li>确定鞍鞍前和优于斜坡休会的中线。 注意: 在大和/或侵袭性垂体肿瘤, 鞍底可能非常薄或完全侵蚀。鞍底是有限的前的抑郁症, 对应于鞍节和横向由颈动脉日珥 (C3 到 C5 段) 和 optico-颈动脉凹陷。</li>
		<li>在侧日珥颈动脉的识别后, 打开鞍底与一个5毫米大的骨刀, 以裁缝或铰链的骨瓣, 可能在手术结束时重新定位。在这一点上, 根据手术目标, 扩大鞍侧截骨或前与骨 rongeurs。 注: 一些外科医生可能更喜欢用菱形钻头打开鞍底地板, 然后用小骨钳扩大骨的张开。此过程可能更快, 并且通常与扩展方法一起使用。然而, 在手术结束时骨不能重新定位, 应注意在中线钻孔以避免颈动脉损伤。使用神经导航来指导过程。</li>
		<li>在侧微的情况下, 在中线为 macroadenoma 或侧面打开鞍硬脑膜。如有需要, 请将此硬脑膜开口侧向, 并注意避免颈动脉损伤。</li>
		<li>通过对硬脑膜进行小的前开口, 并将硬脑膜与吸入尖端一起推上, 以提供足够的通道进入鞍区的内容, 从而限制了前凹槽内蛛网膜破坏的风险。</li>
		<li>用环形角度的刮、镊子和抽吸技巧去除肿瘤组织。</li>
		<li>intra-sellar 生理盐水洗后, 使用30°角内窥镜检查鞍空间, 检查任何残留物, 特别是对海绵窦。</li>
		<li>在切除过程结束前, 要求进行窦机动, 以便在闭合步骤之前检测脑脊液漏。</li>
	</ol>
</li>
	<li>
关闭
	<ol>
<li>如果不是绝对需要, 不要在蝶鞍内放置任何止血材料, 以便更准确地解释术后 MRI。</li>
		<li>在垂体蝶鞍内止血, 用生理盐水冲洗, 用棉垫轻轻按压。</li>
		<li>重建 durotomy 的生物可吸收人工硬脑膜替代物, 被置于 extradurally 和加强它与一薄层的外科粘合剂 (如, bioglue)。</li>
		<li>更换骨瓣, 并用外科粘合剂固定。 注意: 在鞍底被钻孔的情况下, 关节讲台或来自鼻中隔后部的软骨块可用于闭合骨缺损。还介绍了使用合成材料的其他选择 (例如, 如、Porex 板)。</li>
		<li>不要把人工材料留在蝶窦, 以避免任何慢性炎症反应。</li>
		<li>注意鼻腔粘膜的止血, 尤其是两侧腭动脉鼻中隔分支区, 以防止术后出血。</li>
		<li>用钝的刮刀轻轻地将上、中鼻甲替换成原位。</li>
		<li>如果在手术过程中观察到脑脊液漏, 请用小脂肪移植的方法把蝶鞍包起来。除非有必要, 否则不要使用鼻腔包装。</li>
	</ol>
</li>
</ol>4. 术后管理
<ol><li>在围手术期内提供适当的荷尔蒙替代。在前24小时 (100 毫克每天) 使用静脉注射氢化可的松, 然后提供口服替代品 (从病例到病例的变量, 但在住院期间每天至少30毫克)。</li>
	<li>每天两次, 检查血液和尿渗透和电解质, 以及尿密度。持续监测尿量。进行激素检查, 评估术后4天垂体前功能。</li>
	<li>保持阿莫西林/克拉维在1.2 克, 每天两次, 直到5天后。提供标准的止痛治疗, 同时结合醋氨酚和非甾体抗炎药, 提供曲马多止痛。</li>
	<li>经常用生理盐水冲洗鼻窝以限制术后 crostous 鼻炎的风险。</li>
	<li>向病人解释, 避免窦演习的重要性, 以允许正确愈合手术部位在第一个术后几周。</li>
	<li>在术后早期进行 MRI 检查, 如果术中的方面是不典型的垂体腺瘤, 或者怀疑是并发症, 则必须进行手术。术后3月进行脑 MRI 检查。</li>
	<li>在术后3月进行第一次评估, 并与内分泌科合作组织随访, 并根据病理和切除程度进行安排。</li>
</ol>

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M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Novel+Techniques+in+the+Surgical+Treatment+of+Acromegaly:+Applications+and+Efficacy.">Novel Techniques in the Surgical Treatment of Acromegaly: Applications and Efficacy.</a> Neuroendocrinology. 103 (1), 32-41 (2016).</li><li>Shirakawa, M., Yoshimura, S., Yamada, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effectiveness+of+Endoscopic+Endonasal+Transsphenoidal+Surgery+Using+a+Neuronavigation:+Clinical+Results+of+178+Pituitary+Adenomas.">Effectiveness of Endoscopic Endonasal Transsphenoidal Surgery Using a Neuronavigation: Clinical Results of 178 Pituitary Adenomas.</a> Journal of Neurology and Neuroscience. 7 (1:71), (2016).</li><li>Dehdashti, A. R., Ganna, A., Karabatsou, K., Gentili, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pure+endoscopic+endonasal+approach+for+pituitary+adenomas:+early+surgical+results+in+200+patients+and+comparison+with+previous+microsurgical+series.">Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series.</a> Neurosurgery. 62 (5), 1006-1015 (2008).</li><li>Starnoni, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+treatment+of+acromegaly+according+to+the+2010+remission+criteria:+systematic+review+and+meta-analysis.">Surgical treatment of acromegaly according to the 2010 remission criteria: systematic review and meta-analysis.</a> Acta Neurochir (Wien). 158 (11), 2109-2121 (2016).</li><li>Alahmadi, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+technique+on+cushing+disease+outcome+using+strict+remission+criteria.">Impact of technique on cushing disease outcome using strict remission criteria.</a> Can J Neurol Sci. 40 (3), 334-341 (2013).</li><li>Donegan, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+Outcomes+of+Prolactinomas+in+Recent+Era:+Results+of+a+Heterogenous+Group.">Surgical Outcomes of Prolactinomas in Recent Era: Results of a Heterogenous Group.</a> Endocr Pract. 23 (1), 37-45 (2017).</li><li>Andereggen, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=10-year+follow-up+study+comparing+primary+medical+vs.+surgical+therapy+in+women+with+prolactinomas.">10-year follow-up study comparing primary medical vs. surgical therapy in women with prolactinomas.</a> Endocrine. 55 (1), 223-230 (2017).</li><li>Onnestam, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=National+incidence+and+prevalence+of+TSH-secreting+pituitary+adenomas+in+Sweden.">National incidence and prevalence of TSH-secreting pituitary adenomas in Sweden.</a> J Clin Endocrinol Metab. 98 (2), 626-635 (2013).</li><li>Malchiodi, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thyrotropin-secreting+pituitary+adenomas:+outcome+of+pituitary+surgery+and+irradiation.">Thyrotropin-secreting pituitary adenomas: outcome of pituitary surgery and irradiation.</a> J Clin Endocrinol Metab. 99 (6), 2069-2076 (2014).</li><li>Yamada, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinicopathological+characteristics+and+therapeutic+outcomes+in+thyrotropin-secreting+pituitary+adenomas:+a+single-center+study+of+90+cases.">Clinicopathological characteristics and therapeutic outcomes in thyrotropin-secreting pituitary adenomas: a single-center study of 90 cases.</a> J Neurosurg. 121 (6), 1462-1473 (2014).</li></ol>

没有利益冲突。

对于大多数垂体肿瘤, 手术仍然是一线治疗的情况下症状患者19,20。仅对泌乳素分泌腺瘤, 第一行治疗是多巴胺激动剂和手术选择次要时, 医疗治疗失败21。
自从在1990代初的22,23中, 内窥镜在颅底手术领域中的引入, 这项技术在大多数医学中心都得到了普遍的应用<sup class="xr...

采用内窥镜技术的颅底手术已明显改善的结果, 颅底手术本身使用或作为辅助的标准显微外科方法。内镜下鼻方法最初介绍治疗鞍区病变1, 但在过去20年中, 这项技术的应用已经扩大, 得益于重大的技术改进和增加的手术经验.内镜下的方法现在也用于前和前侧颅底的病变, 通过延长中线和旁的方法。从前颅底到齿状突的方法现在安全地在许多专门的中心执行, 并取得满意的结果2,3,4,5。
事实上, 内窥镜允许直接可视化病灶通过自然通路, 而不跨越重要的神经血管结构。多项评价对传统 microscope-based 方法的内镜检查程序的安全性和相对优势进行了维持, 并确认主要结局, 如肿瘤切除的程度和激素水平的变化不两种方法不同。然而, 神经并发症, 手术时间和住院长度, 以及病人的术后不适, 明显低于内镜方法6。根据一项挑衅性的出版物, 即使是经验不足的外科医生也可能会在功能垂体腺瘤的队列中使用显微镜技术作为一名非常有经验的外科医生, 获得一个类似的结果.7。
内镜下鼻跨蝶方法实际上是广泛推荐的鞍区病变, 即使在海绵窦侵袭或鞍延长的情况下。如果鞍扩展非常重要, 则可以执行完全内窥的两阶段过程, 同时等待残滓的自然下降8。如果膜片非常紧 ("腰部标志"), 可以执行经颅的方法来解决鞍组件9。关于海绵窦的侵袭, 内窥镜技术似乎优于 Knosp 级2和3功能垂体腺瘤的显微技术10, 而内镜鼻检查可有助于检测侵入海绵窦11。
可能阻碍内镜根治性切除的因素有: 肿瘤延伸到床内动脉, 或 "接吻动脉", 不对称的额延伸, 肿瘤到达 Monro 的孔, 或纤维侵袭周围脑实质的肿瘤9。在这些复杂的病例中, 可以向患者提出经颅结合的方法。此外, 蝶窦的气化是决定手术可行性的一个重要因素, 因为孔沙尔型鼻窦使内窥镜方法更具挑战性12。
通过他们的个人经验约500内镜鼻方法垂体腺瘤, 作者这里描述的不同阶段的方法垂体肿瘤。手术可分为三主要步骤: 鼻, 蝶, 和鞍期。它们是通过完全内镜手术进行的。这里所描述的队列包括微或巨腺瘤的患者, 有一个可变延伸到海绵窦, 蝶窦, 或鞍空间。包括功能和功能腺瘤。
对于其他各种病变, 如咽、垂体转移、斜坡脊索或石油斜坡脑膜瘤, 也可进行全内窥镜手术。然而, 这些病症往往需要更广泛的方法和描述这些变种超出了本文的目的。
指示
这里描述的程序是垂体腺瘤 (功能或功能)。鞍延长不是手术的禁忌, 也不是扩张或侵入海绵窦。情景 CT 扫描分析蝶窦的气化和蝶窦的内隔膜方向。同时, 视神经和颈内动脉的定位是规划手术策略的重要因素。
这种手术技术也可以用于其他肿瘤位于鞍区像咽13, 症状拉特克的裂囊肿, 垂体转移瘤14, 或淋巴瘤15。此外, 其他病变可通过内镜的方法, 如鞍膜脑膜瘤或蝶平原, 石油斜坡区的脑膜瘤和斜坡脊索5,16, 和表皮样或prepontine 池的皮样囊肿。然而, 在这些情况下, 必须采取更广泛的办法。

<table><tbody><tr><td>The StealthStation surgical navigation system</td><td>Medtronic</td><td>ENT Fusion Software 9733652</td><td></td></tr><tr><td>4-mm 18cm 0&amp;deg; rigid endoscope</td><td>Karl Storz</td><td>28132AA</td><td></td></tr><tr><td>4-mm 18cm 30&amp;deg; rigid endoscope</td><td>Karl Storz</td><td>28132BVA</td><td></td></tr><tr><td>4-mm 18cm 45&amp;deg; rigid endoscope</td><td>Karl Storz</td><td>28132FVA</td><td></td></tr><tr><td>Suction Tube</td><td>Karl Storz</td><td>28164XA</td><td></td></tr><tr><td>Coagulation Cannulas</td><td>Karl Storz</td><td>28164MXB</td><td></td></tr><tr><td>Bipolar Forceps</td><td>Karl Storz</td><td>28164BDB</td><td></td></tr><tr><td>Kerrison Bone Punches</td><td>Karl Storz</td><td>28164MKA</td><td></td></tr><tr><td>Kerrison Bone Punches</td><td>Karl Storz</td><td>28164MKB</td><td></td></tr><tr><td>Kerrison Bone Punches</td><td>Karl Storz</td><td>28164MKC</td><td></td></tr><tr><td>Ring Curettes</td><td>Karl Storz</td><td>28164RN</td><td></td></tr><tr><td>Ring Curettes</td><td>Karl Storz</td><td>28164RO</td><td></td></tr><tr><td>Ring Curettes</td><td>Karl Storz</td><td>28164RI</td><td></td></tr><tr><td>Ring Curettes</td><td>Karl Storz</td><td>28164RG</td><td></td></tr><tr><td>Ring Curettes</td><td>Karl Storz</td><td>28164GLL</td><td></td></tr><tr><td>Ring Curettes</td><td>Karl Storz</td><td>28164GLR</td><td></td></tr><tr><td>de DIVITIS-CAPPABIANCA Scalpels</td><td>Karl Storz</td><td>28164M</td><td></td></tr><tr><td>Forceps</td><td>Karl Storz</td><td>28164TD</td><td></td></tr><tr><td>High-speed drill</td><td>Midas Rex Medtronic</td><td>1898430</td><td></td></tr><tr><td>Hemostatic agent</td><td>Floseal, Baxter</td><td>1503350</td><td></td></tr><tr><td>Fibrin sealant</td><td>Tisseel, Baxter</td><td>600065</td><td></td></tr><tr><td>CT Lightspeed</td><td>GE medical systems, Milwaukee, WI, USA</td><td></td><td></td></tr><tr><td>Carestream Vue PACS</td><td>Carestream Health, Rochester, NY, USA</td><td></td><td></td></tr><tr><td>3-Tesla Siemens Tim Trio scanner</td><td>Siemens AG, Erlangen, Germany</td><td></td><td></td></tr></tbody></table>

endoscopic endonasal trans-sphenoidal approach: minimally invasive surgery for pituitary adenomas

内窥镜下鼻跨蝶手术已成为手术治疗垂体腺瘤和许多其他垂体病变的金标准。外科技术的改进, 技术的进步, 以及神经导航的融合使这项手术微创。这一手术的并发症率很低, 而通过这种方法获得的优异结果始终如一。
本文着重介绍了基于个人经验的垂体腺瘤的 step-by 步手术方法, 并详细介绍了这种微创手术所取得的结果。

自2009年以来, 我们的垂体计划已经发展到一个地步, 一个完整的内镜鼻方法已被用于治疗垂体肿瘤的良好术后结果。从2009年到 2016, 两名高级外科医生 (RTD 和 MM) 通过全内窥镜技术对473例垂体腺瘤患者进行手术。组织学在表 1中详细说明: 这些病例中大多数是功能垂体腺瘤 (57%)(图 1), 其次是生长激素 (GH) 分泌腺瘤 (图 4...

Watch this Scientific Journal Video about Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas at JoVE.com

Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas

本文的目的是描述内镜鼻方法对蝶鞍鞍的不同步骤。

内镜下鼻跨蝶入路: 垂体腺瘤的微创手术

Endoscopic endonasal trans-sphenoidal surgery has become the gold standard for the surgical treatment of pituitary adenomas and many other pituitary ...

endoscopic-endonasal-trans-sphenoidal-approach-minimally-invasive

Research

JoVE Journal

Neuroscience

18.8K 次观看.  University Hospital of Lausanne. 本文的目的是描述内镜鼻方法对蝶鞍鞍的不同步骤。

视频: Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients &#8804;55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged &#8804;55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.

Minimally invasive thumb-sized pterional craniotomy for aneurysm clipping has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.

微创拇指大小翼点入开颅未破裂前循环动脉瘤的手术夹子结扎

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve ...

科研

医学

Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal deviation. It has a long history with multiple variations. In this article, a modified endoscopic septoplasty procedure using the limited two-line resection (2LoRs) technique at the posterior and inferior junction of the cartilaginous and bony septum is presented based on embryologic and anatomic knowledge of the nasal septum and the biomechanics of cartilaginous behavior. With this procedure, the quadrangular cartilage can be preserved as much as possible, which is helpful in retaining the supporting framework and rigidness of the septum. 2LoRs has been proven effective and sound for the correction of nasal septal deviation with rare complications. This modified procedure can be applied to correct the deviated nasal septum in the absence of any external nasal deformity to improve nasal patency or to improve access to the middle meatus or to the axillary region of the middle turbinate. It may also be used to expand the indications of septoplasty to children and adolescents because of its minimally invasive approach.

Endoscopic septoplasty is a time-honored surgical procedure with multiple variations. This paper focuses on a step-by-step surgical approach to perform a modified septoplasty procedure known as limited two-line resection. This surgical technique can be applied to correct a deviated nasal septum in the absence of an external nasal deformity.

内镜下鼻中隔成形术有限双线切除: 间隔偏差微创手术

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal ...

An Endoscopic Transcanal Transpromontorial Approach for Vestibular Schwannomas using a Computer-Based Three-Dimensional Imaging System

A 2D monocular endoscope has been used in transcanal transpromontory vestibular schwannoma surgery instead of craniotomy. However, the absence of depth perception is the limitation of this approach. With the loss of depth perception, the surgeon will be not able to perform delicate and particularly complicated surgery. A binocular endoscope has been developed to provide stereoscopic vision with better depth perception for complicated anatomic structures and has been applied in some endoscopic surgeries. However, the diameter of the endoscope is a limitation in the performance of transcanal otologic surgeries. A small diameter endoscope facilitates easier surgery in a restricted space. A computer-based 3D imaging system can obtain 3D images in real-time using a small monocular endoscope. In this study, to evaluate the feasibility of a computer-based 3D imaging system for endoscopic lateral skull base surgery, we applied this 3D imaging system in a transcanal transpromontorial approach in two patients with vestibular schwannomas. The surgical procedure was completed without complication in these two cases. There was no mortality, perioperative complications, nor notable postoperative complications. Using this computer-based 3D imaging system, a better depth perception and stereoscopic vision was observed compared to a conventional 2D endoscope. The improvement in depth perception offers superior management of the complicated surgical anatomy.

Here, we present a transcanal transpromontorial approach for vestibular schwannomas using a computer-based three-dimensional (3D) imaging system combined with a two-dimensional (2D) endoscope. This system provided stereoscopic vision, better depth perception and reduced visual fatigue. This 3D imaging system enabled the application of 3D vision technology in endoscopic lateral skull base surgery.

A 2D monocular endoscope has been used in transcanal transpromontory vestibular schwannoma surgery instead of craniotomy. However, the absence of depth ...

Role of Diffusion MRI Tractography in Endoscopic Endonasal Skull Base Surgery

Endoscopic endonasal surgery has gained a prominent role in the management of complex skull base tumors. It allows the resection of a large group of benign and malignant lesions through a natural anatomical extra-cranial pathway, represented by the nasal cavities, avoiding brain retraction and neurovascular manipulation. This is reflected by the patients' prompt clinical recovery and the low risk of permanent neurological sequelae, representing the main caveat of conventional skull base surgery. This surgery must be tailored to each specific case, considering its features and relationship with surrounding neural structures, mostly based on preoperative neuroimaging. Advanced MRI techniques, such as tractography, have been rarely adopted in skull base surgery due to technical issues: lengthy and complicated processes to generate reliable reconstructions for inclusion in the neuronavigation system. 
This paper aims to present the protocol implemented in the institution and highlights the synergistic collaboration and teamwork between neurosurgeons and the neuroimaging team (neurologists, neuroradiologists, neuropsychologists, physicists, and bioengineers) with the final goal of selecting the optimal treatment for each patient, improving the surgical results and pursuing the advancement of personalized medicine in this field.

We present a protocol to integrate diffusion MRI tractography in patient work-up to endoscopic endonasal surgery for a skull base tumor. The methods for adopting these neuroimaging studies in the pre- and intra-operative phases are described.

扩散MRI造影术在内窥镜内窥镜颅骨基础外科中的作用

Endoscopic endonasal surgery has gained a prominent role in the management of complex skull base tumors. It allows the resection of a large group of ...

神经科学

Combined Endoscopic and Transoral Approach for Total Maxillectomy

The technique of maxillectomy has been revised since it was first described in the 1820s. During the past decade, the endoscopic approach has been widely practiced for resecting maxilla. Compared with the traditional approaches, the combined endoscopic and transoral approach has many advantages such as avoiding facial incisions and postoperative scars and better visualization of the surgical margin. However, this technique is complicated to master and possess several challenges. Here, we demonstrate this approach step-by-step to show how to perform a total maxillectomy. We also reported nine cases with malignant tumors originating from the maxilla, and for all of them total maxillectomy was performed with combined endoscopic and transoral approach. Our data showed that the combination of the endoscopic and transoral approach could be used to resect the total maxilla successfully, though the tumor extended to the infratemporal and pterygopalatine fossa should be treated very carefully to avoid its spread in the local area. Furthermore, besides denture, other reconstruction methods should be attempted to improve the postoperative quality of life after the total maxillectomy.

The technique of maxillectomy has been revised since it was first described in the 1820s. During the past decade, the endoscopic approach has been widely ...

Endaural Endoscopic Atticoantrotomy (Retrograde Mastoidectomy) using a Constant Suction Bone-drilling Technique

Endoscopic middle ear surgery is a widely employed minimally invasive surgical technique to address middle ear and mastoid pathology. Bone drilling is the main technical challenge of endoscopic middle ear surgery. The accompanying video describes the detailed protocol of a constant-suction bone-drilling technique and the procedure of endaural exclusive endoscopic atticoantrotomy (retrograde mastoidectomy) using this technique. The main components of this bone-drilling technique include a soft and flexible suction tube, which is placed into the tympanic cavity to provide constant suction, and a soft sleeve, which is wrapped around the drill shaft to prevent the high-speed rotating shaft from damaging the lens of the endoscope. With these simple modifications, the traditional otological electrodrill can be used for drilling a tiny endaural incision in endoscopic middle ear surgery. Based on this bone-drilling technique, endaural endoscopic atticoantrotomy (retrograde mastoidectomy) can be successfully established for the removal of various amounts of bone, depending on the extent of the lesion. The short-term postoperative outcome seems promising.

Endaural Endoscopic Atticoantrotomy Retrograde Mastoidectomy using a Constant Suction Bone-drilling Technique

In this paper, we present the protocol and short-term outcomes of endaural exclusive endoscopic atticoantrotomy using a constant suction bone-drilling technique.

使用恒定抽吸骨术的内窥镜下盂骨切开术（逆行切除术）

Endoscopic middle ear surgery is a widely employed minimally invasive surgical technique to address middle ear and mastoid pathology. Bone drilling is the ...

The Microscopic Transcanal Approach in Stapes Surgery Revisited

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the external auditory canal, the middle ear, and epitympanon. Such an approach avoids a retroauricular or endaural skin incision; however, working through a narrow space needs angled microsurgical instruments and specific training in otologic surgery. The transcanal approach restricts the working space; however, it offers a binocular microscopic vision into the middle ear without extended skin incisions and thus, reducing post-operative pain and bleeding. In addition, this minimally invasive approach avoids scar tissue complications, hypoesthesia of the auricle, and potential protrusion of the pinna. Despite its numerous advantages, this method is still not routinely performed by otologic surgeons. Since this minimally invasive technique is more challenging, there is a need for extensive training in order for it to be widely adopted by otologic surgeons. This article provides step-by-step surgical instructions for stapes surgery and reports possible indications, pitfalls, and limitations using this microscopic transcanal technique.

This article describes the microscopic transcanal technique for stapes surgery, providing step-by-step surgical instructions for familiarizing surgeons with this approach.

重新审视镫骨手术中的显微经管入路

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the ...

Full-Endoscopic Surgery for Hypothalamic Hamartoma Resection

Hypothalamic hamartomas (HH) are rare developmental anomalies of the inferior hypothalamus that often cause refractory epilepsy, including gelastic seizures. Surgical resection is an effective method to treat drug-resistant epilepsy and endocrinopathy in a suitable patient group. Open surgery, endoscopic surgery, ablative procedures, and stereotactic radiosurgery can be utilized. In this study, we aimed to describe the full-endoscopic approach for HH resection. The technique involves the use of an intraoperative ultrasonography (USG) system, a 30&#176; rigid endoscope system that has an outside diameter of 2.7 mm with two working channels, a stylet that has an outer diameter of 3.8 mm, a monopolar coagulation electrode, a fiberoptic light guide, and the endovision system. Microforceps and monopolar electrocautery are the two main surgical instruments for HH removal. The protocol is easy to apply after a particular learning curve has been passed and shorter than open surgical approaches. It leads to less blood loss. Full-endoscopic surgery for HH is a minimally invasive technique that can be applied safely and effectively with good seizure and endocrinological outcomes. It provides low surgical site pain and early mobilization.

<meta charset="utf8"></head><body>下丘脑错构瘤切除术的全内窥镜手术

Hypothalamic hamartomas are rare, non-neoplastic congenital malformations mainly arising from the inferior hypothalamus or tuber cinereum. Surgical treatment is one of the most effective options, and the surgical approach must be precisely determined for each patient. Here, we describe the full-endoscopic technique for resecting hypothalamic hamartomas.

下丘脑错构瘤切除术的全内窥镜手术

Hypothalamic hamartomas (HH) are rare developmental anomalies of the inferior hypothalamus that often cause refractory epilepsy, including gelastic ...

Full-Endoscopic Interlaminar Approach for Decompression of Lateral Recess Stenosis

For lateral recess stenosis, extensive decompression with laminectomy is still performed in most centers. However, tissue-sparing surgeries are becoming more common. Full-endoscopic spinal surgeries have the advantages of being less invasive and offering a shorter recovery time. Here, we describe the technique of the full-endoscopic interlaminar approach for the decompression of lateral recess stenosis. The full-endoscopic interlaminar approach for the lateral recess stenosis procedure took approximately 51 min (range of 39-66 min). Blood loss could not be measured due to continuous irrigation. However, no drainage was required. There were no dura mater injuries reported in our institution. Furthermore, there were no injuries to the nerves, no cauda equine syndrome, and no hematoma formation. The patients were mobilized on the same day as surgery and discharged the next day. Therefore, the full-endoscopic technique for lateral recess stenosis decompression is a feasible procedure that lowers the operational time, complications, traumatization, and rehabilitation duration.

Technical advances and increased experience in full-endoscopic spinal surgeries enable these procedures to be performed with minimal incision, muscle retraction, and bone removal.

For lateral recess stenosis, extensive decompression with laminectomy is still performed in most centers. However, tissue-sparing surgeries are becoming ...

内镜下鼻跨蝶入路: 垂体腺瘤的微创手术

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An Endoscopic Transcanal Transpromontorial Approach for Vestibular Schwannomas using a Computer-Based Three-Dimensional Imaging System

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Combined Endoscopic and Transoral Approach for Total Maxillectomy

使用恒定抽吸骨术的内窥镜下盂骨切开术（逆行切除术）

重新审视镫骨手术中的显微经管入路

下丘脑错构瘤切除术的全内窥镜手术

下丘脑错构瘤切除术的全内窥镜手术

Full-Endoscopic Interlaminar Approach for Decompression of Lateral Recess Stenosis