Kim Eui Hyun, Ahn Jung Yong, Chang Jong Hee, Kim Sun Ho
Department of Neurosurgery, Yonsei Brain Research Institute, Yonsei University College of Medicine, 134, Shinchon-dong, Sudaemoon-gu, Seoul 120-752, Republic of Korea.
Acta Neurochir (Wien). 2009 Jul;151(7):803-8. doi: 10.1007/s00701-009-0356-8. Epub 2009 Apr 30.
Transsphenoidal surgery has been well established as an effective primary treatment for tumours of the sellar region. During the dural opening, the prominent intercavernous sinus poses limitations for this approach and may contribute to incomplete tumour resections.
Based on our experience from 940 cases of conventional transsphenoidal surgery, we have developed a stepwise protocol for achieving bleeding control in 72 cases (7.7%) that had prominent anterior intercavernous sinus.
A custom-made 45-degree right- or left-angled bipolar coagulator (38 cases) or Landolt bipolar coagulator (29 cases; Aesculp, Tuttlingen, Germany) was inserted into the small dural opening, and both of the dural layers were coagulated together so that the potential space between the endoosteal layer and meningeal layer could be sealed, and the dural opening could be extended. When the anterior portion of the medial wall of the cavernous sinus was accidentally opened, we then placed a small piece of oxidised regenerated cellulose (Surgicel; Johnson & Johnson, North Yorkshire, UK) at the opening of the medial wall of the cavernous sinus and coagulated both dural layers together starting from the sellar floor side with a custom-made 45-degree angled bipolar coagulator. For the relatively large opening of the cavernous sinus, a microfibrillar collagen haemostat (Avitene; MedChem Products, Woburn, MA) or fleece-coated fibrin glue (TachoComb; Nycomed Austria, Linz, Austria) patch was applied over the opened cavernous sinus with gentle compression and was found to be effective in most cases. Rarely, direct suture of the opened medial wall of the cavernous sinus was necessary in five cases.
We describe a stepwise approach to overcome unusual bleedings from the prominent intercavernous sinus during conventional transsphenoidal surgery. Our surgical experience reveals that these methods can be very effective for the control of sinus bleeding.
经蝶窦手术已被公认为是治疗鞍区肿瘤的一种有效的主要治疗方法。在打开硬脑膜时，突出的海绵间窦给这种手术方法带来了限制，可能导致肿瘤切除不完全。
基于我们940例传统经蝶窦手术的经验，我们制定了一个逐步方案，用于控制72例（7.7%）海绵间窦前部突出病例的出血。
将定制的45度直角双极电凝器（38例）或兰多尔特双极电凝器（29例；德国图特林根的埃斯库利普公司）插入小的硬脑膜开口，同时对硬脑膜的两层进行电凝，从而封闭骨内膜层和脑膜层之间的潜在间隙，并扩大硬脑膜开口。当海绵窦内侧壁前部意外打开时，我们将一小片氧化再生纤维素（强生公司生产的速即纱，英国北约克郡）置于海绵窦内侧壁开口处，并用定制的45度角双极电凝器从鞍底侧开始同时对硬脑膜的两层进行电凝。对于海绵窦相对较大的开口，应用微纤维胶原止血剂（美国马萨诸塞州沃本的MedChem Products公司生产的速即纱）或纤维蛋白胶贴片（奥地利林茨的Nycomed Austria公司生产的速即纱）覆盖打开的海绵窦，轻轻按压，发现大多数情况下有效。在五例罕见病例中，需要直接缝合打开的海绵窦内侧壁。
我们描述了一种逐步的方法来克服传统经蝶窦手术中来自突出的海绵间窦的异常出血。我们的手术经验表明，这些方法对于控制窦出血非常有效。
