König M A, Milz S, Bayley E, Boszczyk B M
The Centre for Spinal Studies and Surgery, Queens Medical Centre Campus, Nottingham University Hospitals, NHS Trust, Derby Road, Nottingham, NG7 2UH, UK,
Eur Spine J. 2014 Nov;23(11):2265-71. doi: 10.1007/s00586-014-3255-5. Epub 2014 Mar 15.
The thoracolumbar junction (TJ) is traditionally exposed by lateral or posterior approaches. This usually requires splitting of the diaphragm, or extensile removal of the posterior elements. A circumferential exposure (i.e. simultaneous anterior and bilateral exposure) of the vertebral body is not possible. Direct anterior access would allow circumferential exposure of the vertebral body, with adjacent disc levels, and would avoid splitting the diaphragm or extensive removal of the posterior bony structures.
Twelve Thiel cadavers (8 f/4 m) were dissected to access T12 or L1 via a midline laparotomy. Supra- and infragastric laparatomy techniques were investigated. Six cadavers were used to reach T12 through the lesser omentum, six to reach L1 through the greater omentum.
T12 after bluntly dissecting the lesser omentum, the lesser gastric curvature and the caudate lobe of the liver were utilised as landmarks. A small retroperitoneal incision was performed to mobilise the aorta allowing exposure of the T12 vertebra and its adjacent discs. Discectomy, corpectomy and insertion of an anterior column support were possible. The L1 level can be reached through the greater omentum by mobilising the pancreas as a single retroperitoneal structure, leaving the aorta and celiac trunk as landmarks. Retraction of the great vessels is necessary to expose L1 with its adjacent discs. Implantation of an anterior column support was possible utilising this approach.
Direct anterior access to the TJ is feasible in a reproducible manner. This approach would avoid splitting the diaphragm, or dissection of the erector spinae muscles, and is likely to be less invasive than standard lateral or posterior approaches. This technique may offer a significant time reduction to surgery, especially in exposing the spine. Anterior column support can easily be performed, offering a better avoidance of kyphotic deformities.
传统上，胸腰段交界区（TJ）通过外侧或后侧入路进行显露。这通常需要劈开膈肌，或广泛切除后部结构。椎体的环形显露（即同时进行前路和双侧显露）是不可能的。直接前路入路可实现椎体及其相邻椎间盘水平的环形显露，且可避免劈开膈肌或广泛切除后部骨质结构。
解剖12具蒂尔尸体（8例女性/4例男性），通过中线剖腹术显露T12或L1。研究了胃上和胃下剖腹术技术。6具尸体通过小网膜到达T12，6具通过大网膜到达L1。
钝性解剖小网膜后显露T12，胃小弯和肝尾状叶用作标志。做一个小的腹膜后切口以游离主动脉，从而显露T12椎体及其相邻椎间盘。可行椎间盘切除术、椎体次全切除术及植入前路支撑物。通过将胰腺作为单个腹膜后结构进行游离，以大网膜为标志可到达L1水平。为显露L1及其相邻椎间盘，需要牵开大血管。利用此入路可植入前路支撑物。
直接前路进入胸腰段交界区是可行的，且具有可重复性。此入路可避免劈开膈肌或解剖竖脊肌，可能比标准外侧或后侧入路的创伤性更小。该技术可能显著缩短手术时间，尤其是在脊柱显露方面。可轻松进行前路支撑物植入，能更好地避免后凸畸形。
