Fraioli B, Esposito V, Santoro A, Iannetti G, Giuffrè R, Cantore G
Department of Neurological Sciences, University La Sapienza, Rome, Italy.
J Neurosurg. 1995 Jan;82(1):63-9. doi: 10.3171/jns.1995.82.1.0063.
A transmaxillosphenoidal approach was used to remove sellar tumors invading the cavernous sinus. This procedure, a widening of the standard transsphenoidal approach to the sella turcica, uses the sublabial or transnasal route in which the medial wall of the maxillary sinus is laterally dislocated. This method provides good exposure of the prominences of bone above the carotid artery which lies on the posterolateral wall of the sphenoid sinus. This bone area is the key to opening the cavernous sinus inferomedially and removing lesions within its medial compartment. The inferomedial approach takes an entirely extracerebral route so that tumors invading the cavernous sinus through its medial wall are approached inferomedially following the direction of tumor growth. It also allows direct visualization of the intracavernous carotid artery during tumor removal, thus sparing the cranial nerves, which run on the opposite side. Adequate surgical exposure of a pituitary adenoma is achieved with a custom-made sphenoidal retractor with asymmetric blades, the shorter blade holding aside the thin medial wall of the maxillary sinus. Between October, 1989, and July, 1993, 11 patients with tumors invading the cavernous sinus underwent surgery via this approach; 10 had pituitary adenomas and one had a craniopharyngioma. Eight tumors were treated by primary operation: four tumors were totally and four subtotally (> 80%) removed; one tumor already operated on elsewhere was totally removed; and of two tumors already operated on and irradiated, one was subtotally removed and the other only partially (approximately 40%) removed owing to marked postirradiation scarring. None of the patients suffered permanent cranial nerve deficit and all but one showed marked clinical improvement.
采用经上颌窦蝶骨入路切除侵犯海绵窦的鞍区肿瘤。该手术是对标准经蝶窦入路至蝶鞍的一种扩展，采用唇下或经鼻入路，其中上颌窦内侧壁向外侧移位。该方法能很好地暴露位于蝶窦后外侧壁的颈动脉上方的骨隆起。这个骨区域是向内侧打开海绵窦并切除其内侧隔内病变的关键。内侧下入路完全采用脑外路径，以便沿着肿瘤生长方向从内侧下方向侵犯海绵窦内侧壁的肿瘤进行手术。它还能在肿瘤切除过程中直接观察海绵窦内的颈动脉，从而使走行于对侧的颅神经得以保留。使用定制的不对称刀片蝶骨牵开器可实现对垂体腺瘤的充分手术暴露，较短的刀片将上颌窦薄的内侧壁向一侧拨开。1989年10月至1993年7月，11例侵犯海绵窦的肿瘤患者通过该入路接受了手术；10例为垂体腺瘤，1例为颅咽管瘤。8例肿瘤接受了初次手术治疗：4例肿瘤全切，4例次全切（>80%）；1例曾在其他地方接受过手术的肿瘤被全切；在2例曾接受过手术和放疗的肿瘤中，1例次全切，另1例因放疗后明显瘢痕形成仅部分切除（约40%）。所有患者均未出现永久性颅神经功能缺损，除1例患者外，其余患者均有明显的临床改善。
