Intraorbital and cranio-orbital tumor resection

Tumors that are limited to the sputum are mostly treated by ophthalmology and can also be removed by neurosurgery. Cranio-sac tumors (cranial sputum communication tumors), which are also distributed in the cranial cavity and the eyelids, should be treated by neurosurgery or neurosurgery and ophthalmology. Regarding the classification of cranial and temporal tumors, it has not yet been unified. Domestic scholars generally divide the primary site of the tumor into a sputum source type, a cranial source type and a metastasis type. The sputum-type tumors are mainly meningiomas, dermoid cysts, hemangioma, schwannomas and mixed lacrimal gland tumors; cranial tumors are more common in meningiomas, schwannomas and gliomas. Treatment of diseases: optic glioma Indication The surgical indications and timing of surgery for intraorbital and cranial sac tumors are still controversial. Poppen and Guiot advocated early radical surgery for the sphenoid ridge lateral meningioma, which is mainly invading the sphenoid bone, and simultaneously grows into the cranial cavity and the iliac crest. Stern and Castellano believe that surgery can relieve the eye, It is difficult to improve the course of such patients. For optic nerve sheath meningiomas, because it is very difficult to completely destroy the tumor without damaging the central retinal artery, Miller advocates that if the vision is good, the tumor has not extended to the intracranial, can be observed, and then surgery after loss of vision; but Alper et al advocated Early radical cure, especially in children with optic nerve sheath meningiomas, is quite aggressive and should be removed if necessary. For optic glioma, some scholars pointed out that early resection should be carried out; but recently, it has been found that such tumors have a tendency of "self-limiting growth", quite like a benign hamartoma, so they can be closely observed. When vision loss or tumor continues to grow, Consider surgery again. At present, it is generally believed that the treatment plan for patients with intraorbital and cranial sac tumors should be considered comprehensively considering the nature, location, extent and function and appearance of the patient: it is located outside the intraorbital muscle cone and is not closely related to important intracranial structures. Benign and comparatively limited malignant tumors should be operated early and strive to be completely cut; the tumor is located in the sacral sacral cone or closely related to important intracranial structures, and the patient should remain normal when there is no obvious visual impairment or other dysfunction. Resection of the tumor under the premise of function; those who have been blind should strive for total resection; those who have been affected by the eyeball can also remove the tumor and the eyeball. The surgical approach to intracranial and cranial sac tumors depends primarily on the location of the tumor: 1, shallow anterior temporal tumor can be taken simply by incision (without removal of the bony wall). 2. The tumor of the lateral part of the ankle, the upper part of the ankle or the anterior part of the ankle and the outside of the iliac crest can be removed through the lateral wall of the iliac crest 3, 2 / 3 of the medial side of the iliac crest (ie, not deep and apex) can be removed through the sinus sinus - iliac crest. 4. Tumors involving both the iliac crest and the maxillary sinus, and some tumors after the ball can be removed by maxillary sinus surgery. 5, all cranial sputum communication tumors, apex and/or optic canal tumors should be transcranial resection (dural or intradural approach). Contraindications 1. It is limited to malignant tumors in the sputum and should not be removed by transcranial exploration. 2, a wide range of malignant tumors are generally not suitable for surgery. 3, elderly, poor overall condition, or have important organ dysfunction, surgery should be cautious. 4, patients with sinus inflammation can not undergo sinus surgery. Preoperative preparation 1. If the eyeball is prominent, pay attention to protect the eyeball. If necessary, suture the affected eyelid or place a contact lens, which can protect the cornea and facilitate the observation of intraoperative pupillary changes and visual evoked potential monitoring. 2, blood-rich tumors, can be considered preoperative embolism. Surgical procedure First, the amount of the epidural approach 1, incision and dome resection: supine position, head height 20 °, slightly back. The coronary flap and the frontal frontal bone flap are as usual, and the front edge of the bone flap should be close to the upper edge of the ankle. The dura mater of the anterior cranial fossa is separated, and the frontal lobe is lifted together with the self-sustaining retractor to reveal the dome, and is removed by a high-speed micro drill or a rongeur (bite), depending on the size and location of the tumor. If necessary, the posterior margin of the dome can be removed along the sphenoid winglet to the apex, anterior bed, and optic canal. Sometimes to increase the front exposure, you can also saw and remove the upper ends of the upper edge of the raft. 2. Excision of the tumor: When the dura mater of the anterior cranial fossa is removed and lifted, the intracranial part of the cranial sacral communication tumor can be revealed, and the whole or a block can be removed. If the dura mater is involved, it should be removed and repaired with dura mater. The dome (the crest of the patient with cranial sputum communication tumor may have been destroyed), after resection, through the thin layer of the periosteum, you can see the frontal nerve on the surface of the diaphragm, even if the upper and upper rectus muscles are squeezed by the tumor. It is stretched and stretched to make it difficult to recognize, and the nerve is more recognizable and becomes a useful marker. According to the tumor site, the periosteum is cut in the medial or lateral side of the frontal nerve, and the nerve and the lower and upper rectus muscles are pulled to one side to find the tumor. After the tumor is inoculated by electrocautery, the central part of the tumor is removed as much as possible, and then the surrounding part and the capsule are separated and removed. If you want to remove optic nerve sheath meningioma or optic glioma, and other tumors at the tip of the sacral sac, you can choose the following three options: (1) Medial approach: The superior oblique muscle is pulled to the medial side, and the superior and superior rectus muscles are pulled to the outside to reveal the full length of the optic nerve, and it is the most direct access to the optic nerve of the apex. In this approach, it should be noted that above the optic nerve, 3.2mm, 10.6mm, 10.0mm and 23.9mm from the anterior mouth of the optic canal, respectively, the trochlear nerve, the ophthalmic artery (even under the optic nerve), the nasal ciliary nerve and the eye The vein traverses to the medial side of the ankle. Natori pointed out that it is safer to reach the optic nerve between the trochlear nerve and the ophthalmic artery. In addition, if the Zinn ring is cut, it should be chosen between the superior rectus and the internal rectus. Before cutting, the trochlear nerve should be separated from the surrounding tissue on the tip surface to avoid damage. (2) Central approach: the upper iliac muscle is pulled to the medial side, and the superior rectus muscle is pulled to the outside. The middle part of the optic nerve is reached between the two. As for the frontal nerve, it can be pulled together with the upper iliac muscle. The medial side can also be separated from the superior rectus muscle and then pulled outward with the superior rectus muscle. The former does not damage the nerve, but it can affect the exposure of the optic nerve at the tip of the palate; the latter is better, but it has the nerve of the frontal nerve. The structures that can be seen after retracting the muscles to the sides are: the supraorbital vein, the ciliary artery and the ciliary nerve, the ciliary nerve, the oculomotor nerve to the branch of the superior iliac muscle, the ophthalmic artery and its distribution to the upper iliac muscle. And the branch of the superior rectus muscle, be careful not to damage. (3) Lateral approach: the optic nerve is reached between the lateral rectus muscle and the superior diaphragm and the medial rectus (Figure 4.3.3.3-8). The surgical field is larger than the medial approach and the central approach, and is most suitable for revealing lesions deep in the lateral optic nerve. If the supraorbital vein is pulled to the medial side with the upper and lower rectus muscles, there is no need to separate the vein from the surrounding connective tissue, and the ciliary nerve will not be damaged. However, because the vein affects the line of sight, it may be deep in the tip of the sac. Limited. If the ocular vein is pulled to the outside, it must be separated from the connective tissue, which may damage the nerve; of course, the deep tip of the sacral tip is better exposed. Before removing the optic nerve sheath meningiomas or optic gliomas, the degree of optic nerve involvement and whether the tumor has been extended into the cranial canal should be determined. However, according to preoperative CT and MRI, it is sometimes difficult to determine, and the surgical plan can only be determined according to the patient's vision and intraoperative findings: the tumor extends to the optic canal, and the wall can be opened outside the dura, and the tumor can be removed and removed; for example, a tumor If the brain has been invaded, the dura mater should be treated. A small number of expansively growing optic nerve sheath meningiomas may be carefully removed under the microscope without injury to the optic nerve. If the tumor is invasive, and the visual acuity has been lost or very poor, the tumor should be removed together. If the visual acuity is good, the tumor should be removed as much as possible while retaining the residual vision. The vision is lost and the tumor has been involved. Eyeballs and periosteum should be considered for removal of sputum to prevent the spread of tumors through the supracondylar or inferior palpebral fissure. Before the removal of the intraocular portion of the tumor, the optic canal must be abraded and the periosteal incision is postponed through the Zinn ring to the intradural dura mater. After the tumor was removed together with the optic nerve, and a small piece of diaphragm was used to fill the optic canal, the upper end of the diaphragm was sutured with a 5-0 suture. In young children, the surgical field is limited, the operation is more difficult, and the Zinn ring can not be cut. Instead, the method of removing the tumor and the optic nerve between the Zinn ring and then removing the tumor and nerve between the Zinn ring and the intervertebral cross is used to avoid cutting. And suture the upper diaphragm. 3. Reconstruction and closure of the dome: After the tumor is removed, the periosteum is sutured and covered with a piece of gelatin sponge. Remove an inner plate from the frontal bone flap and rebuild the dome. The use of metal mesh or metal plate can also be used for dome reconstruction, but it is not conducive to postoperative CT and MRI examination, so it is less used. If the upper edge of the sputum is removed, it should be reset, and both ends are fixed by drilling with wire or wire. Close the skull in the usual way. Temporarily suture the affected eyelid. Second, through the frontotemporal (or supra-wing point) intradural approach 1. Flap and bone flap: supine position, head height 20°, then tilt up and rotate to the opposite side 30°. Coronal flap and frontal frontal iliac bone flap. In order to facilitate the exposure, Al-Mefty's recommended supraorbital-wing point approach is also used, which is to remove the superior margin, the iliac crest and part of the dome together with the frontal humerus. The advantage of this approach is that it not only helps the sputum content to be revealed, but also reduces the pulling of the brain tissue, and allows the surgeon to approach the intracranial tumor of the tumor through various routes (subfrontal, lateral fissure, underarm). Partially; after the tumor is removed, the entire frontal iliac bone flap can be implanted back without the need for dome reconstruction. Specific method: After the crown flap is opened, the iliac crest, the sphenoid bone and the frontal bone are exposed from the front of the iliac crest. The periosteum of the frontal bone was dissected along the scalp incision and the upper iliac crest, and it was dissociated forward, and passed over the upper edge of the iliac crest into the iliac crest, separating the periorbital and anterior tibial periosteum from the iliac crest and the iliac crest. There is supraorbital nerve on the upper edge of the iliac crest, and the upper incision can be opened by high-speed micro-drilling, and the nerve is released and pulled forward together with the periosteum. Drill 3 holes in the skull: The first hole is located on the frontal bone above the nasal root (such as the frontal sinus open, after the bone flap is removed, treated as previously described). The second hole (Mac-Carty key hole) at the frontal-butterfly junction behind the frontal condyle, the upper half of the hole should show the dura mater, the lower half reveals the periosteum, which is just the dome. The third hole is close to the bottom of the cranial fossa. The forehead and tibia between the first and third holes, and the sacral and sphenoid bones between the 2nd and 3rd holes are cut with an electric milling cutter. The frontal bone between the 1 and 2 holes (including the upper edge of the upper part, part of the dome and the outer part) The edge is sawed with a wire saw. Note that the periosteum is protected by a brain pressure plate, and the bone flap is lifted forward and outward, and is removed after the base of the sphenoid bone is broken. The outer part of the sphenoid ridge is removed. 2. Reveal the intracranial part of the tumor: cut the dura mater, tear the arachnoid of the lateral fissure pool, and remove the overflowing cerebrospinal fluid. According to the location and size of the tumor, the intracranial part of the tumor is removed through the subfrontal, infraorbital or lateral fissure. 3. Expose the intraorbital part of the tumor: lift the frontal lobe, cut the dura mater at the anterior cranial fossa, and grind (or bite) the posterior part of the crest. If the cranial cavity and the intraorbital tumor communicate with the optic canal, or need to do optic nerve decompression, the optic canal should be opened at the same time. According to the location of the tumor, the periosteum is cut in the medial or lateral side of the frontal nerve, and the method of excising the tumor is the same as that of the "perical extradural approach". It should be pointed out that the primary optic nerve sheath meningioma in the sac can not extend into the cranium without invading the dura mater of the optic canal. Therefore, even if there is no bone hyperplasia or enlargement of the optic canal, the intracranial should be explored. Similarly, even if the optic canal is normal, optic glioma can communicate in the cranial cavity and sacral cavity, so if you want to completely cut the tumor, you often need to cut from the ball to the optic chiasm. 4, Guan skull: After the tumor is resected, the periosteum is sutured. Suture the dura mater in the anterior cranial fossa. If there is a defect, a fascia can be repaired. The frontal humerus flap was fixed and fixed. Finally, the frontal periosteum, diaphragm and scalp were sutured. complication Complications that may occur when the intracranial part of the cranial sac tumor is removed, see the tumor resection at each relevant site. Only the complications of intra-orbital tumor resection are described here. 1, cerebrospinal fluid leakage and infection and resection of the dome, open the paraventricular sinus when opening the optic canal. 2, eyeball protrusion or invagination due to resection of the dome and intraorbital tumor resection, caused by atrophy of the fat in the sputum.