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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4368_Библиотеки_им_академика_М_И_Перельмана
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Three-Dimensional Anatomy of the Skull Base: The Ventral Pathway
https://t.me/med1917
SCA
BA
Fig. 2.10 Endonasal view of the upper region limits (green box) to gain access to the ventrolateral surface of the brainstem. The
top right image shows a general endoscopic perspective from an endonasal view of this upper region, while the bottom right image
is acquired at higher magnifi cation. BA, basilar artery; SCA, superior cerebellar artery; III, oculomotor nerve; IV, trochlear nerve;
V, trigeminal nerve.
2.3 Conclusion
The 3D models generated using our method could play
an increasing role in the future for the surgical planning
in endoscopic transsphenoidal surgery. Considering the
high anatomic variability of the main mucosal, osseous,
and air-cells landmarks, such model represents a convincing proposal for enhancing the surgeon’s confidence
and exploring the specific anatomy of each patient in a 3D
no-risk environment.
Acknowledgments
This work has been partly supported by the grants
“Marató TV3 Project” (411/U/2011—TITLE: Quantitative
analysis and computer aided simulation of minimally
invasive approaches for intracranial vascular lesions) and
“2012PID-UB/002 Project” (Grupo de Anatomía Virtual
y de Simulación, Universitat de Barcelona).
III
IV
V
15
Three-Dimensional Anatomy of the Skull Base: The Ventral Pathway
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VA
VI
AICA
VII
PICA
XII
IX
VIII
dm
X
BA
VA
Fig. 2.11 Endonasal view of the middle region limits (blue box) to gain access to the ventrolateral surface of the brainstem. The
top right image shows a general endoscopic perspective from an endonasal view of this middle region, while the bottom right image
is acquired at higher magnifi cation. AICA, anteroinferior cerebellar artery; BA, basilar artery; dm, dura mater; PICA, posteroinferior
cerebellar artery; VA, vertebral artery; VI, abducens nerve; VII, facial nerve; VIII, vestibulocochlear nerve; IX, glossopharyngeal nerve;
X, vagus nerve; XII, hypoglossal nerve.
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Three-Dimensional Anatomy of the Skull Base: The Ventral Pathway
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IX
X
VA
PICA
XI
XII
Fig. 2.12 Endonasal view of the lower region limits (yellow box) to gain access to the ventrolateral surface of the brainstem. The
top right image shows a general endoscopic perspective from an endonasal view of this lower region, while the bottom right image
is acquired at higher magnifi cation. PICA, posteroinferior cerebellar artery; VA, vertebral artery; IX, glossopharyngeal nerve; X, vagus
nerve; XI, accessory nerve; XII, hypoglossal nerve.
References
1. de Notaris M, Prats-Galino A, Cavallo LM, et al. Preliminary experience with a new three-dimensional computer-based model for
the study and the analysis of skull base approaches. Childs Nerv
Syst 2010;26(5):621–626
2. de Notaris M, Solari D, Cavallo LM, et al. The use of a three-dimensional novel computer-based model for analysis of the endonasal
endoscopic approach to the midline skull base. World Neurosurg
2011;75(1):106–113, discussion 36–40
3. Mavar-Haramija M, Prats-Galino A, Méndez JA, Puigdelívoll-Sánchez A, de Notaris M. Interactive 3D-PDF presentations for the
simulation and quantification of extended endoscopic endonasal
surgical approaches. J Med Syst 2015;39(10):127
4. de Notaris M, Topczewski T, de Angelis M, et al. Anatomic skull
base education using advanced neuroimaging techniques. World
Neurosurg 2013;79(2, Suppl):S16.e9–13
5. de Notaris M, Esposito I, Cavallo LM, et al. Endoscopic endonasal
approach to the ethmoidal planum: anatomic study. Neurosurg
Rev 2008;31(3):309–317
6. d’Avella E, De Notaris M, Enseñat J, et al. The extended endoscopic
endonasal transplanum transtuberculum approach to the anterior
communicating artery complex: anatomic study. Acta Neurochir
(Wien) 2015;157(9):1495–1503, discussion 1503
7. Di Somma A, de Notaris M, Stagno V, et al. Extended endoscopic endonasal approaches for cerebral aneurysms: anatomical, virtual reality and morphometric study. Biomed Res Int
2014;2014:703792
8. Benet A, Prevedello DM, Carrau RL, et al. Comparative analysis of
the transcranial “far lateral” and endoscopic endonasal “far medial” approaches: surgical anatomy and clinical illustration. World
Neurosurg 2014;81(2):385–396
9. de Notaris M, Cavallo LM, Prats-Galino A, et al. Endoscopic endonasal transclival approach and retrosigmoid approach to the clival
and petroclival regions. Neurosurgery 2009;65(6, Suppl):42–50,
discussion 50–52
10. d’Avella E, Angileri F, de Notaris M, et al. Extended endoscopic
endonasal transclival approach to the ventrolateral brainstem
and related cisternal spaces: anatomical study. Neurosurg Rev
2014;37(2):253–260, discussion 260
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Section 2
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Anatomy of the Lateral
Nasal Wall and the
3 Endoscopic Lateral Nasal
Wall and Anterior and
Posterior Ethmoid
Sinus Dissection 21
Paranasal Sinuses
4 Frontal Sinus and
Draf Approaches 37
5 Sphenoid Sinus 49
6 Medial Maxillectomy 59
7 Anterior and Posterior
Ethmoidal Arteries 67
8 Sphenopalatine and
Maxillary Arteries 75
I
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Chapter 3
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3.1 Indications for Ethmoid
Sinus Surgery 22
Endoscopic Lateral
Nasal Wall and
Anterior and Posterior
Ethmoid Sinus
Dissection
3.2 Surgical Steps 22
3.3 Infundibulotomy 23
3.4 Middle Meatal Antrostomy 27
3.5 Dissection of the Anterior
Ethmoid (Partial Anterior
Ethmoidectomy) 28
3.6 Dissection of the Posterior
Ethmoid (Ethmoidectomy) 31
Endoscopic Lateral Nasal Wall and Anterior and Posterior Ethmoid Sinus Dissection
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3 Endoscopic Lateral Nasal Wall and Anterior and
Posterior Ethmoid Sinus Dissection
Gabriel Martinez Capoccioni, Manuel Bernal-Sprekelsen, Isam Alobid
Introduction
The aim of this chapter is to share basic information of
the anatomy of the lateral nasal wall and the anterior
and posterior ethmoid sinus in a step-by-step manner.
One of the keys to learn endoscopic sinus surgery is
to acquire knowledge of the anatomy of the nose and
the paranasal sinuses. Before performing an endoscopic dissection, it is important to develop an understanding of the gross anatomy of the lateral nasal wall
(Figs. 3.1 and 3.2). This chapter describes sequential
steps for performing the anterior and posterior ethmoid sinus dissection and offers tips on instrument
handling techniques.
3.1 Indications for Ethmoid
Sinus Surgery
• Inflammatory diseases:
– Chronic rhinosinusitis with or without nasal polypo-
sis refractory to medical therapy.
– Sinus mucoceles.
– Allergic fungal sinusitis.
• Neurorhinologic disorders:
– Rhinopathic headaches resistant to medical therapy.
• Orbital indications:
– Severe exophthalmos.
– Nasolacrimal duct obstruction.
• Restorative indications:
– Cerebrospinal fluid leak.
– Severe posterior epistaxis.
– Severe anterior epistaxis.
– Choanal atresia/stenosis.
• Neoplastic diseases:
– Benign tumors.
– Malignant tumors.
• Skull base surgery:
– Transnasal surgical approaches for skull base lesions.
3.2 Surgical Steps
The order of these steps is presented in an anteroposterior procedure. They may be changed or performed
22
ER
ER
ES
MT
Fig. 3.1 Right-side sagittal section of the lateral nasal wall. ER, ethmoid roof; ES, ethmoid sinus; MT, middle turbinate; SS, sphenoid sinus.
SS
Endoscopic Lateral Nasal Wall and Anterior and Posterior Ethmoid Sinus Dissection
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FS
FR
AN
UP
MT
Fig. 3.2 Right-side sagittal section of the lateral nasal wall. Middle turbinate (MT), ethmoidal bulla (EB). Anterior attachment of
middle turbinate, middle meatus, anterior ethmoid sinus , posterior ethmoid sinus, sphenoid sinus (SS), ethmoid roof (ER), uncinate
process (UP), frontal recess (FR), frontal sinus (FS), agger nasi (AN), basal lamellae (BL), lamellae of the superior turbinate (LST), and
optic nerve (ON). AWSS, anterior wall of the sphenoidal sinus.
EB
UP
ER
ER
BL
BL
BL
LST
AWSS
BL
ON
SS
differently, depending on the anatomy, the experience
of the surgeon, the intraoperative bleeding, etc. Detailed
approaches to the frontal and sphenoid sinuses can be
checked in Chapters 4 and 5, respectively.
3.3 Infundibulotomy
It involves removal of the uncinate process. The uncinate
process is classically described as the first ethmoidal
lamellae (Fig. 3.3).
3.3.1 Technique
Gently medialize the middle turbinate with a ball-tipped
probe or a backbiter. The Freer elevator can be used to
palpate the maxillary line (hard bone) and the uncinate
process (bounces back when pushed laterally). It allows
identifying the insertion of the uncinate process to the
maxillary line. Uncinectomy can be performed in two
fashions: anteroposterior and retrograde technique.
3.3.2 The Anteroposterior Approach
It is performed through an initial vertical incision through
the uncinate process. A sickle knife or a Freer’s elevator
is used to incise the uncinate process at the level of its
middle and inferior third; then the incision is extended
inferiorly and posteriorly along its horizontal aspect.
Once it is made sure that there is enough distance to the
papyracea, enlarge the incision superiorly (if indicated)
to open the infundibulum toward the frontal outflow
tract. Remaining superior and inferior attachments of
the uncinate can be cut with a through-cutting forceps.
Alternatively, one may insert a straight-forward Blakesley to grasp the superior attachment and then rotate it
clockwise (on the left side) and counterclock-wise (on the
left side) at its inferior attachment to avoid peeling the
mucosa off the lateral nasal wall and inferior turbinate,
respectively. On the right side of the patients, rotation of
the instrument goes the other way round (Fig. 3.4a).
Then, identify the natural ostium of the maxillary
sinus, the recessus terminalis, if any, and the frontal
recess (Fig. 3.4b).
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Endoscopic Lateral Nasal Wall and Anterior and Posterior Ethmoid Sinus Dissection
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ba
Fig. 3.3 Coronal (a) and axial (b) CT scan showing the uncinate process, middle turbinate, bulla ethmoidalis, and maxillary sinuses.
The natural ostium of the maxillary sinus cannot be
inspected before the uncinectomy with a 0 or a 30- degree
lens, in particular cases with a 45 or a 70- degree
endoscope.
3.3.3 Indications
• Uncinectomy is the first and often the most important
step in most procedures for the ostiomeatal complex.
• An infundibulotomy (also with just a partial resection
of the uncinate) as a sole procedure can be performed
for isolated purulent maxillary sinusitis refractory to
medical treatment.
• Removal of irreversibly diseased mucosa (polyposis) of
the infundibulum.
• Access to the maxillary, anterior and posterior ethmoid,
and frontal sinuses.
The anteroposterior approach has a higher risk of orbital
penetration. Exposed orbital fat should be left alone and
should not be manipulated.
1–4
3.3.4 Posteroanterior Approach
A small backbiter (with branch closed) is introduced into
the middle meatus. The instrument is rotated so that
the biting blade is opened upward, in the vertical plane
of the meatus. The open blade is then rotated horizontally to engage the posterior free edge of the uncinate
process. Try to luxate the uncinate medially along its
entire length so as to facilitate resection. The backbiting
forceps can now cut the luxated aspect of the uncinate
within the middle meatus through its entire thickness
without stripping mucosa of the lateral wall. The upper
uncinate process can now be mobilized with a ball probe
and gently dissected downwards with a curved J-curette.
A 45-degree Blakesley-Weil forceps can now be used to
grasp the mobilized uncinate (Fig. 3.4c).
This approach is safer as one moves away from the orbit
when dissecting, and thus the risk of inadvertently entering the orbit is reduced.
5–8
3.3.5 Tips and Tricks
• Avoid too deep penetration of the tip of the sickle knife
during uncinectomy because it may injure the lamina
papyracea.
• Check the distance between the uncinate and the orbit
in a coronal section of the computed tomography (CT)
scan to avoid orbital penetration.
• While dissection, displace the uncinate process away
from the orbit.
• Palpate the eye softly from outside while working near
the lamina papyracea to check for bony dehiscences of
the papyracea (particularly in a revision case) or even
possible herniation of orbital fat.
• When addressing the frontal outflow tract, it is
important to remove the uncinate process in its most
superior extension to adequately visualize the frontal
outflow tract.
• Avoid using the backbiter just biting anteriorly toward
the lacrimal sac/duct (the bony resistance will increase
here): medialize the uncinate before biting.
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