不同解剖入路显露颈静脉孔区的定量研究

目的定量研究枕下远外侧入路及耳后经颞入路对颈静脉孔区的显露程度,为临床个体化选择手术入路、保护重要结构功能提供可靠的解剖依据。方法选择经10％福尔马林固定的成人头颈湿标本各12具（24侧）,采用枕下远外侧入路及耳后经颞入路进行解剖学研究,用脑立体定向仪测定各步骤颈静脉孔区的显露面积,用游标卡尺测量斜坡和三叉神经的显露长度。结果在远外侧入路中,磨除颈静脉突、部分磨除枕髁后对颈静脉孔区显露程度显著增加;在耳后经颞入路中,迷路后入路、部分磨除迷路对颈静脉孔区的显露程度显著增加。结论磨除颈静脉突是枕下远外侧入路显露颈静脉孔的关键;迷路下入路和部分磨除迷路入路是自侧方显露颈静脉孔区的理想手术入路。     

Current status of the hybrid approach for the treatment of hypoplastic left heart syndrome

The hybrid approach for hypoplastic left heart syndrome (HLHS), consisting of bilateral pulmonary artery banding and ductal stenting, has emerged as an alternative to the traditional Norwood approach. This approach defers open heart surgery to beyond the neonatal period, which is believed to reduce postoperative mortality and morbidity and improve neurological development as compared with the conventional approach. However, there have been no scientific studies supporting these hypotheses. Recently, there seems to be a tendency that many centers recommend the hybrid approach as an interim procedure to rescue preoperative high-risk patients. Currently, the decision to adopt the hybrid approach or the Norwood approach seemed to be based on the preference of congenital heart surgeons and cardiologists. Further investigation including a randomized multi-center study would allow a scientific decision as to which approach is more appropriate for the patient with HLHS.     

Interhemispheric approach through the lamina terminalis to tumors of the anterior part of the third ventricle

Operative approaches to tumors of the third ventricle, mainly the bifrontal approach through the lamina terminalis, are discussed. The latter approach has several advantages. First, the main arteries can be exposed and the operative field is sufficiently wide to render the operative procedure safe. Second, cortical incision or excision is unnecessary. By cutting the lamina terminalis, which is usually thin and expanded as a result of hydrocephalus, even a large tumor can be removed. In addition, lethal complications are avoided, because this approach has less possibility of damage to the lateral wall of the third ventricle. Seventeen cases of tumor in the third ventricle underwent operation via this approach. The operative technique for the bifrontal approach through the lamina terminalis and three representative cases are reported. This approach can be applied not only to tumors, but to arteriovenous malformations or giant aneurysms adjacent to the third ventricle.     

复杂性后尿道狭窄的手术径路探讨

目的：总结各种复杂性后尿道狭窄手术径路的应用经验,提高复杂性后尿道狭窄的治疗效果。方法：对72例复杂性后尿道狭窄患者的手术径路进行回顾性分析。结果：64例（89％）一次手术成功,经会阴径路中采用单纯经会阴径路34例中治愈31例（91％）,经会阴耻骨下缘径路14例中治愈13例（93％）,经耻骨径路中采用单纯经耻骨径路6例中治愈4例（67％）,经耻骨联合会阴径路18例中治愈16例（89％0,41例长段后尿道狭窄（＞3cm)者治愈35例（85％）,18例有合并症者治愈17例（94％例）。结论：复杂性后尿道狭窄的各种手术径路均存在一定的优缺点,选择合适的手术径路应综合多种因素考虑,经会阴径路因操作简单,创伤小,并发症少,仍是目前首选的手术径路。     

儿童后尿道狭窄手术径路的应用评价

目的 评价儿童后尿道狭窄各种手术径路的应用,提高儿童后尿道狭窄的治疗效果。方法 对24例儿单后尿道狭窄患者的手术径路进行回顾性分析。结果 19例(79.2％)手术治愈。采用单纯经会阴径路5例中治愈3例(60％);经会阴耻骨下缘径路10例中治愈9例(90％);经耻骨联合会阴径路9例中治愈7例(77.8％)。结论 儿童后尿道狭窄的各种手术径路均存在一定的优缺点。经会阴耻骨下缘径路具有操作方便,创伤小,并发症少,且不破坏骨盆稳定性等优点,尤其适合于儿童。     

Surgical results of the intraoral removal of the submandibular gland

OBJECTIVES: Most patients with benign submandibular disorders have been treated surgically without difficulty via the transcervical approach. An alternative to the standard transcervical approach has been reported such as an intraoral approach. SUBJECTS AND METHODS: Retrospective chart review of the 77 patients with benign submandibular disorders. All patients underwent an excision of the submandibular gland via intraoral approach. RESULTS: Early postoperative complications developed in 74.0% of the temporary lingual sensory paresis followed by 70.1% of temporary limitation of tongue movement. However, these complications soon resolved in all patients spontaneously. Two cases of postoperative bleeding and 1 case of abscess formation were developed. Whereas late complications developed in 4 cases of residual salivary gland and abnormal sense of mouth floor and 1 case of gustatory sweating (Frey's) syndrome. CONCLUSION: The major advantages of this approach are no external scar, no injury to the marginal mandibular nerve. The disadvantage is a more difficult dissection to transcervical approach before proper expert, especially in the severe adhesion of salivary gland to surrounding tissue.     

改良Gibson入路治疗髋臼骨折

目的 :针对Kocher Langenbeck入路的缺点设计改良Gibson入路 ,并探讨改良Gibson入路的优点。方法 :1994年 6月 - 1999年 2月使用Kocher Langenbeck入路治疗 36例髋臼骨折。1999年 3月 - 2 0 0 3年 12月使用改良Gibson入路治疗 32例髋臼骨折。结果 :Kocher Langenbeck入路组达到解剖复位 2 9例 ,复位欠佳 4例 ,不满意复位 3例 ;改良Gibson入路组达到解剖复位 2 8例 ,复位欠佳 3例 ,不满意复位 1例。经统计学检验 ,差异具有显著性 (P <0 0 5 ) ,改良Gibson入路组的骨折解剖复位率明显高于Kocher Langenbeck入路组。Kocher Langenbeck入路组关节功能表现优良者 30例 ,可3例 ,差 3例 ;改良Gibson入路组关节功能表现优良者 2 9例 ,可 2例 ,差 1例。经统计学检验 ,差异具有显著性 (P <0 0 5 ) ,改良Gibson入路组关节功能的优良率明显高于Kocher Langenbeck入路组。 结论 :与Kocher Langenbeck入路相比 ,改良Gibson入路具有显露充分、创伤小、手术时间短、复位质量高、并发症少等优点 ,可以替代Kocher Langenbeck入路。     

Importance of the periareolar approach in the augmentation of the ptotic breast

This is a retrospective review of 66 patients with grade II breast ptosis who underwent augmentation mammaplasty from January 1996 to January 2001. Of these 66 patients, 17 were augmented using a periareolar approach, and 49 were augmented using an inframammary approach. All patients had textured saline implants, and 64 of 66 patients had the implants placed in a submuscular position. Mean photographic follow-up was 4.8 months (range, 6 weeks-1 year). When compared with an inframammary approach in the presence of grade II ptosis, a periareolar approach results in improved fill of the lower pole of the breast, improved centralization of the nipple on the breast mound, and lessening or elimination of undesirable upper pole fullness.     

Anterior approach and osteosynthesis for recent fractures of the pedicles of the axis

The authors report their experiences using the anterior approach and osteosynthesis for recent fractures of the pedicles of the axis in eight patients. They describe the transcervical transclival approach and osteosynthesis and discuss the advantages of and indications for this approach.     

经腹入路两种途径行腹腔镜下左侧输尿管切开取石术在学习初期的比较

目的对经验不足的外科医生,比较腹腔镜下经腹入路肠系膜间途径行输尿管切开取石术与传统经腹入路侧结肠途径行输尿管切开取石术的疗效。方法回顾性分析郑州大学附属洛阳中心医院在2014年3月至2018年3月期间收治的59例左侧肾盂输尿管连接部狭窄患者的资料,采用常规侧结肠入路32例,而经中结肠系膜间入路27例,比较围手术期结果和随访资料,比较两种方法患者的手术时间、术中失血量、术后肠道功能恢复,术后疼痛程度等情况。结果经中结肠入路组手术时间明显短于常规侧结肠入路组(P<0.05),经中结肠系膜间入路组术后疼痛明显减轻,两组患者在术中失血量、术后进食时间、住院时间等方面差异均无统计学意义(P>0.05)。结论通过中结肠系膜间途径直接暴露输尿管可节省游离侧结肠所需时间。该方法对于经验有限的外科医生也是安全可行的,并具有与侧结肠手术相似的成功率。     

Postero-medio-anterior approach of the ankle for the pilon fracture

A good view of the operative field is important for better reduction and fixation in surgical treatment of fractures. The exposure of the ankle joint for the pilon fracture is commonly through the anterior approach, or combined with the medical approach. But sometimes it is still difficult to have complete viewing of the articular surface and to apply internal fixation by that approach. In recent years, we developed a "postero-medio-anterior" approach of the ankle joint by one incision. This approach provides an excellent exposure of the anterior, medial and posterior aspects of the ankle joint with a clear view of the articular surface. In our 45 cases of pilon fracture during 1991 to 1995, there was no incisional injury to the neurovascular bundle. Superficial wound edge necrosis was noted in two cases which healed later without further procedure. Therefore, we recommend this approach as a simple and reliable incision for open reduction of pilon fractures.     

Relationship of postoperative complications to the surgical approach in treating cancer of the proximal portion of the stomach]

The authors have analyzed the interrelationship between postoperative complications and surgical approach in the treatment of carcinoma of the proximal portion of the stomach. The radical operations were carried out upon 140 patients; in 93 of them the transperitoneal approach was applied and in 47-the transpleural one. It has been found that in the transpleural approach the insufficiency of anastomosis sutures and postoperative pancreatitis occur much more seldom, and bronchopulmonary complications rate the first. Such complications are not infrequent after the transperitoneal approach either. The disorders of bronchial permeability constitute the main cause in the occurrence of these complications.     

经腋乳和经胸乳两种途径的腔镜甲状腺手术比较

目的 探讨经腋乳途径和经胸乳途径的腔镜甲状腺手术的方法并比较其优缺点.方法 对2003年12月至2006年1月术前诊断为良性甲状腺疾病的238例患者采用腔镜进行手术.将其随机分为经腋乳途径组123例,经胸乳途径组115例.结果 两组手术均获成功.经腋乳途径组与经胸乳途径组手术时间为(69±29)min与(70±25)min(P＞0.05),术中出血量为(38±11)ml与(40±13)ml(P＞0.05),术后住院天数为(4±1.3)d与(4.5±1.2)d(P＞0.05),对手术后美容效果的满意度为97.5%(120/123)与85.2%(98/115)(P＜0.05).238例患者均无手术并发症,无一例中转开放手术.颈部引流管术后24～36 h拔除.结论 两种手术方式均具有较好的美容效果,但经腋乳途径美容效果比经胸乳途径更佳.术式需根据患者的要求及手术者的技术条件来选择.     

改良胫骨近端后内侧入路在平台后侧骨折中的应用

目的探讨胫骨近端后内侧入路的解剖学基础及其在胫骨平台后侧骨折中的应用。方法 a)成人下肢标本25个,其中福尔马林固定标本20个,新鲜冰冻标本5个,解剖观察并测量与胫骨近端后内侧入路相关的主要血管、神经的走行特点,膝关节后内侧主要肌肉、韧带的分布;b)新鲜冰冻下肢标本5个,按照改良的入路进行模拟手术,评估该入路的可行性。c)在解剖学研究基础上,临床应用该入路治疗涉及后内侧髁的胫骨平台骨折13例,按AO分型,41-B-1.3.2型2例、41-B-3.2.2型2例、41-C-1.3型4例、41-C-3.3型5例;俯卧位经该入路治疗胫骨平台B型骨折,仰卧位经该入路联合前外侧入路治疗胫骨平台C型骨折,观察临床效果。结果 a)改良胫骨近端后内侧入路的手术切口全长均不经过腘窝主要神经、血管;深层经腓肠肌内侧头内侧与半膜肌复合体及腘肌间隙,腘肌下剥离保护了外侧的血管神经束;膝下内侧动脉影响了显露,必要时可予结扎。b)临床应用13例,均取得了满意的疗效。结论改良的胫骨近端后内侧入路具有暴露直接、充分,安全性高,解剖简单等优点,是治疗胫骨平台后内侧骨折的有效入路。     

Classification and quantification of the petrosal approach to the petroclival region

OBJECT: The petrosal approach to the petroclival region has been used by a variety of authors in various ways and the terminology has become quite confusing. A systematic assessment of the benefits and limitations of each approach is also lacking. The authors classify their approach to the middle and upper clivus, review the applications for each, and test their hypotheses on a cadaver model by using frameless stereotactic guidance. METHODS: The petrosal approach to the upper and middle clivus is divided into four increasingly morbidity-producing steps: retrolabyrinthine, transcrusal (partial labyrinthectomy), transotic, and transcochlear approaches. Four latex-injected cadaveric heads (eight sides) underwent dissection in which frameless stereotactic guidance was used. An area of exposure 10 cm superficial to a central target (working area) was calculated. The area and length of clival exposure with each subsequent dissection was also calculated. The retrolabyrinthine approach spares hearing and facial function but provides for only a small window of upper clival exposure. The view afforded by what we have called the transcrusal approach provides for up to four times this exposure. The transotic and transcochlear procedures, although producing more morbidity, add little in terms of a larger clival window. However, with each step, the surgical freedom for manipulation of instruments increases. CONCLUSIONS: The petrosal approach to the upper and middle clivus is useful but should be used judiciously, because levels of morbidity can be high. The retrolabyrinthine approach has limited utility. For tumors without bone invasion, the transcrusal approach provides a much more versatile exposure with an excellent chance of hearing and facial nerve preservation. The transotic approach provides for greater versatility in treating lesions but clival exposure is not greatly enhanced. Transcochlear exposure adds little in terms of intradural exposure and should be reserved for cases in which access to the petrous carotid artery is necessary.     

Comparison of postoperative temporalis muscle atrophy between the muscle-preserving pterional approach and the mini-pterional approach in the treatment of unruptured intracranial aneurysms

Neurosurgical Review - This study aimed to compare the muscle-preserving pterional approach (modified classic pterional approach, mCP) and the mini-pterional approach (mPA) with respect to...     

膝后腓肠肌内侧入路修复后交叉韧带胫骨撕脱骨折

目的 探讨膝后腓肠肌内侧入路修复膝关节后交叉韧带(PCL)胫骨撕脱骨折。方法 应用膝后腓肠肌内侧入路对11例PCL胫骨撕脱骨折行复位固定。结果 膝后腓肠肌内侧入路对修复PCL胫骨撕脱骨折。解剖层次清晰，出血量极少，不需要切断和重新缝合组织，并发症少，简便、安全、快捷、实用。结论 膝后腓肠肌内侧入路非常适于修复PCL胫骨撕脱骨折，同时也适于股骨内侧滑车后部、胫骨平台后内侧骨折复位内固定。     

Evaluation of the surgical results of the interhemispheric approach in comparison with the pterional approach for anterior communicating artery aneurysms]

From 1986 to 1990, 77 cases of ruptured anterior communicating artery (Aco) aneurysms have been operated on through an interhemispheric approach or a pterional approach. In this study, we mainly investigated the following factors: surgical outcome, surgical complications, degree of evacuation of subarachnoid clot, and frequency of symptomatic vasospasm. The difference of outcome between the two surgical groups was not statistically significant. Each operating method had characteristic surgical complications. Pterional approach had a tendency to complicate premature rupture, sacrifice small vessels around the aneurysm, and to result in Korsakoff syndrome and inadequate clipping. Interhemispheric approach was apt to complicate cerebral contusion, bilateral olfactory nerve injury and hemorrhagic infarction due to sacrifice of the bridging veins. The pterional approach could evacuate more of the subarachnoid clot than could the interhemispheric approach, but there was no significant difference in frequency of symptomatic vasospasm depending on which method was used.     

Efficacy and safety of the pterional keyhole approach for the treatment of anterior circulation aneurysms

Keyhole surgery is partly replacing the standard pterional approach in patients undergoing surgery to treat aneurysms of the anterior circulation. We describe the pterional keyhole approach for the clipping of anterior circulation aneurysms and discuss the efficacy and safety of our keyhole craniotomy procedure. We treated 103 patients with 111 intracranial aneurysms by surgical clipping via the pterional keyhole approach and retrospectively compared the characteristics and clinical outcomes of the keyhole procedure and the standard pterional approach. We also compared the surgical results of the keyhole approach when the operator was an experienced neurosurgeon or a less experienced neurosurgeon guided by an experienced colleague. All keyhole operations were carried out successfully without enlargement of the craniotomy or a change to a different approach. The outcomes of the keyhole and the standard pterional approach in patients with subarachnoid hemorrhage were not significantly different. Favorable outcomes were obtained in patients with unruptured aneurysms treated by either experienced or less experienced surgeons. The pterional keyhole approach offers the same surgical possibilities as conventional pterional approaches for the treatment of anterior circulation aneurysms. It is safe and simple and yields favorable outcomes even if the operators are less experienced neurosurgeons. Careful patient selection and sufficient opening of the sylvian fissure are the key points for good outcomes and the prevention of intraoperative complications.     

岩斜区肿瘤手术入路选择的探讨

目的 探讨岩斜区肿瘤的手术入路选择。对53例岩斜区肿瘤患者的手术治疗进行分析。方法患者采用颞底经天幕入路11例,枕下乙状窦后入路12例;（颧弓或眶颧）翼点入路12例;乙状窦前入路2例;颞底、乙状窦后幕上下联合入路7例;颞下前岩骨硬膜外入路7例;扩大的前颅底硬膜外入路2例。结果32例（61％）患者肿瘤全切除,9例（17％）次全切除,12例（22％）大部切除。术后新发生颅神经功能障碍16例（30％）,死亡2例（4％）。结论枕下乙状窦后入路、颞底经天幕入路等岩斜区手术入路均可以在熟练的显微操作技术及神经导航、神经内镜下进行。主体生长于硬膜外的岩斜肿瘤适合于采用硬膜外入路手术切除。幕上下联合入路对巨大岩斜区肿瘤是理想的手术入路。