Departments of1Neurological Surgery and.
2Otorhinolaryngology, Hospital Clínic de Barcelona, Spain.
J Neurosurg. 2020 Jul 10;134(6):1836-1845. doi: 10.3171/2020.4.JNS20707. Print 2021 Jun 1.
Over the years, Meckel's cave pathologies have been judged off-limits because of high rates of morbidity. Even though several studies have defined various surgical routes with tolerable morbidity and mortality rates, controversies related to the optimal avenue to treat different categories of Meckel's cave and cavernous sinus neoplasms persist. With unceasing energy to cultivate minimally invasive neurosurgical approaches, the endoscopic endonasal route has been tested, and the approach effectively performed, to provide a valid surgical window to these areas. In this dynamic and challenging scenario, another ventral endoscopic minimally invasive route-that is, the superior eyelid endoscopic transorbital approach-has been very recently proposed, and used in selected cases, to access the cavernous sinus and Meckel's cave regions.
The authors report the technical nuances of a combined and simultaneous endoscopic endonasal and transorbital surgical treatment of a patient with a Meckel's cave schwannoma. The operation involved collaboration among neurosurgery, otorhinolaryngology, and ophthalmology (oculoplastic surgery). The patient recovered well, had no neurological deficits, and was discharged to home 3 days after surgery.
The multiportal combined route was proposed for the following reasons. The endonasal approach, considered to be more familiar to our skull base team, could allow control of possible damage of the internal carotid artery. From the endonasal perspective, the most inferior and medial portion of the tumor could be properly managed. Finally, the transorbital route, by means of opening the lateral wall of the cavernous sinus via the meningoorbital band, could allow control of the superolateral part of the tumor and, most importantly, could permit removal of the portion entering the posterior cranial fossa via the trigeminal pore. Simultaneous surgery with two surgical teams working together was planned in order to reduce operative time, hospital stay, and patient stress and discomfort, and to ensure "one-shot" complete tumor removal, with minimal or no complications.
This study represents the translation into the real surgical setting of recent anatomical contributions related to the novel endoscopic transorbital approach and its simultaneous integration with the endoscopic endonasal pathway. Accordingly, it may pave the way for future applications related to minimally invasive, multiportal endoscopic surgery for skull base tumors.
多年来，由于高发病率， Meckel 氏腔病变一直被认为是禁区。尽管有几项研究已经确定了各种具有可接受发病率和死亡率的手术途径，但与治疗不同类别 Meckel 氏腔和海绵窦肿瘤的最佳途径相关的争议仍然存在。随着不断努力培养微创神经外科方法，内镜经鼻入路已经过测试，并有效地进行了该入路，为这些区域提供了有效的手术窗口。在这种充满活力和充满挑战的情况下，另一种经鼻内镜下的微创入路，即上睑经眶内窥镜入路，最近被提出，并在选定的病例中用于进入海绵窦和 Meckel 氏腔区域。
作者报告了一例 Meckel 氏腔神经鞘瘤患者采用内镜经鼻和经眶联合微创手术治疗的技术细节。该手术涉及神经外科、耳鼻喉科和眼科（眼整形手术）的合作。患者恢复良好，无神经功能缺损，术后 3 天出院回家。
采用多门户联合入路的原因如下。我们的颅底团队更熟悉经鼻入路，可以控制颈内动脉可能受到的损伤。从经鼻入路的角度来看，可以很好地处理肿瘤的最下部和最内侧部分。最后，经眶入路通过脑膜眶带打开海绵窦的外侧壁，可以控制肿瘤的超外侧部分，最重要的是，可以通过三叉神经孔切除进入后颅窝的部分肿瘤。计划由两个手术团队同时进行联合手术，以减少手术时间、住院时间和患者的压力和不适，并确保“一次性”完全切除肿瘤，且并发症最小或没有。
本研究将与新型经眶内镜入路及其与内镜经鼻入路的同时整合相关的最新解剖学贡献转化为真实的手术环境。因此，它可能为与颅底肿瘤的微创多门户内镜手术相关的未来应用铺平道路。
