Dolenc surgery

Dolenc (1983), according to special measures such as lowering blood pressure, lowering body temperature, cardiopulmonary bypass, cardiac arrest or dehydration, according to the loose tissue between the two layers of the outer wall of the cavernous sinus, except for the oculomotor nerve and the trochlear nerve below the anterior bed The adhesion was slightly tight, and other parts were easily peeled off. After the internal carotid artery of the cavernous sinus segment and the oculomotor nerve, the trochlear and the trigeminal nerve were all exposed from the outer wall of the cavernous sinus, 4 cases of CCF were directly treated, and 2 cases would be treated. The fistula was clipped, and 2 cases were treated with internal carotid artery wall repair. One patient died after operation, and 3 cases performed well. Treatment of diseases: internal carotid cavernous fistula, contraindications Due to the large invasion of Dolenc surgery, it is not suitable for elderly and frail patients with heart and kidney dysfunction. Preoperative preparation It should be understood whether the traffic conditions on the left and right sides of the skull base artery ring are normal. Others are the same general craniotomy. Surgical procedure Craniotomy The wing point and the underarm joint approach are used. The rock bone is exposed from the outside of the epidural to expose the segment of the internal carotid artery, and the sphenoid winglet is bitten from the outside to the anterior crest from the outer point of the dura. 2. Exposing the ocular anterior and internal carotid arteries in the anterior portion of the cavernous sinus The dura mater is cut along the sphenoid wing until the anterior bed is extended and spread over the optic nerve. Use the micro-drill to remove all the anterior bed and the superior and lateral sides of the optic nerve hole, then remove the optic canal a few millimeters forward, remove the bone between the optic nerve and the internal carotid artery, and expose the anterior neck of the ophthalmic artery and cavernous sinus. Arterial segment. The dura mater is continued to be resected from the anterior cleft to the spine along the lateral edge of the cavernous sinus. Electrocoagulation and severing the vein draining from the temporal and lateral fissures to the cavernous sinus. The temporal lobe is retracted, exposing a segment of the cerebellar free margin from the anterior bed to the trochlear nerve into the dura mater. 3. The surface layer of the outer wall of the free cavernous sinus Starting from the trochlear nerve into the cavernous sinus, forward along the inner side of the free edge of the cerebellum, between the two layers of the outer wall of the cavernous sinus, the epidural dura mater of the lateral wall of the cavernous sinus is cut to the entrance of the oculomotor nerve. Continue to extend forward to the supracondylar fissure, and cut back to the round hole along the outer edge of the outer wall of the cavernous sinus. The surface layer of the outer side wall is free from the inner layer containing the moving eye and the trochlear nerve, and is turned back, so that the nerve is not damaged and does not enter the cavernous sinus. 4. Revealing the internal carotid artery The middle meningeal artery was found at the base of the middle cranial fossa and electrocoagulated. Find the arcuate bulge on the surface of the rock bone, and find out that the shallow nerve is cut off to avoid the facial paralysis caused by pulling the genic ganglia. Between the above three points, the anterior superior wall of the internal carotid artery and the bone between the internal carotid artery and the Eustachian tube are removed by micro-drilling, and the internal carotid artery of the rock segment is exposed, so that the internal carotid artery enters the sponge if necessary. Before the sinus, temporarily block it. 5. Continue to separate the surface layer of the outer wall of the cavernous sinus The surface layer of the outer wall of the cavernous sinus and the dura mater continued to separate into the three branches of the semilunar and trigeminal nerves until the upper iliac cleft, the round hole and the foramen ovale, so as to reveal the entire cervical sinus segment. artery. 6. Free internal cavernous sinus internal carotid artery, find the lesion directly Starting from the ophthalmic artery, the horizontal section of the internal carotid artery is separated along the medial side of the internal carotid artery of the saddle; the hemorrhage of the cavernous sinus and the intersponte sinus is filled with Surgicel, and in the case of arterial hemorrhage, the internal carotid artery can be placed in front of the trigeminal mandibular branch. The proximal part of the rock bone segment and the ophthalmic artery were temporarily clamped with arterial clips to stop bleeding. Find the pupil of the internal carotid cavernous sinus fistula and clip it or suture it. After the pupil is processed, remove the temporary blocking clip. 7. Guan skull After the lesion was treated and the internal carotid artery was patency, Surgilel was used around it to further stop the bleeding. The free superficial dural flap was resected and sutured. The bone tissue near the eustachian tube is coated with bone wax to prevent postoperative cerebrospinal fluid leakage. The surface of the internal carotid artery was covered with a free diaphragm. complication 1. Intracranial hematoma, often caused by insufficient hemostasis during surgery. 2. Cerebral vasospasm and cerebral insufficiency, different measures should be taken according to different situations.