| Objective: To anatomize the cavernous sinus and its adjacent structures by simulating the Dolenc approach and Kawase approach.To observe the anatomical triangle in the lateral wall of the cavernous sinus.To investigate the safe scope and feasibility of the ACP removal.Furthermore,we could investigate the application of two surgical approaches in the treatment of cavernous sinus lesionsMethods:1 Simulating the Dolenc approachBy simulating the Dolenc approach,we anatomize the head specimens perfused with color silica gel with 6.4-40× dissecting microscope.In this study,we investigate the extent of exposure after the ACP,paries superior orbitae,paries lateralis orbitae and optic strut removed and carotid collar cut.At the same time,we measure the important structure and take a picture for the surgical field.Investigate the feasibility and deficiency of Dolenc approach in the treatment of cavernous sinus lesions.2 Simulating the Kawase approachBy simulating the Kawase approach,we anatomize the head specimens perfused with color silica gel with 6.4-40× dissecting microscope.We have not broken the zygomatic arch(if it is necessary,using high speed drill grinding the upper 1/3 part of the zygomatic arch).Expose the posterior part of the cavernous sinus gradually along the petrous bone under the dura.Opening tentorium of cerebellum increases the exposure of the posterior skull base.Changing the visual angle to expose the anterior and posterior temporal pole.At the same time,we measure the important structure and take a picture for the surgical field.Investigate the feasibility and deficiency of Kawase approach in the treatment of cavernous sinus lesions.3 Statistical MethodsIn this study,the data were expressed as mean ± standard deviation(mean±SD).SPSS 21.0 statistical software was used to analyze the data.P<0.05 indicated that the difference was statistically significant.Results:1 In the Dolenc approach surgery simulation,measure the safe scope of the ACP removal and the increasing of surgical field after the ACP removal.The results are as follows.(using the statistical mean plus or minus standard deviation description in SPSS 21.0)(1)The maximum removal range:We treat the trailing edge of sphenoid platform as the limitation to grind the ACP length(9.56±0.14)mm,width(12.23±0.12)mm and thickness(5.29±0.14)mm.(2)The exposure is increasing after grinding of the ACP:(1)optic nerve exposure before the ACP removal:(8.85±0.09)mm;optic nerve exposure after the ACP removal:(20.21±0.64)mm;(2)ICA exposure before the ACP removal:(9.64±0.22)mm,ICA exposure after the ACP removal:(13.57±0.54)mm;(3)Width between ON and ICA before the ACP removal:(4.47±0.75)mm;Width between ON and ICA after the ACP removal:(11.38±0.84)mm;(4)Width between ICA and ?.N before the ACP removal:(6.72±0.98)mm,Width between ICA and ?.N after the ACP removal:(9.24±1.21)mm.The difference of data has statistical significance(p<0.05).2 The size range of the anatomical triangle in the lateral wall of the cavernous sinus is as follow.(using the statistical mean plus or minus standard deviation description in SPSS 21.0)The anatomical triangle in the lateral wall of the cavernous sinus:(1)lateral triangle(Parkinson triangle): the inner edge(the lower edge of the trochlear nerve)length(11.45±0.96)mm,outside edge(superior margin of ophthalmic nerve)length(12.81±0.93)mm,bottom(the trochlear nerve and trigeminal nerve enter into epidural Meckel 's capsule at line)length(7.02±0.82)mm.(2)The paramedial triangle(supratrochlear triangle):inner edge(The lower edge of the oculomotor nerve)length(10.54±0.83mm),outside edge(The upper edge of the trochlear nerve)length(11.05±1.27)mm,bottom(the distance between the oculomotor nerve and trochlear nerve entering the epidural)length(6.16±0.99)mm.(3)the Anterolateral triangle(Mullan triangle): inner edge(Ophthalmic nerve)length(13.12±1.39)mm,outside edge(crotaphitic nerve)length(7.90±1.40)mm,bottom(the distance between SOF and Foramen rotundum)length(5.01±1.47)mm.(4)the far lateral triangle: inner edge(Crotaphitic nerve)(11.64±1.09)mm,outside edge(Mandibular nerve)length(5.33±1.50)mm,bottom(the distance between Foramen ovale and Foramen rotundum)(11.67±1.27)mm.(5)the posterolateral triangle(Glasscock 's triangle): inner edge(mandibular nerve and trigeminal nerve root)length(12.04±1.09)mm,outside edge(the distance between the eminelntia arcuata and the Foramen spinosum)length(12.75±1.26)mm,bottom(the GSPN)length(7.68±1.43)mm.(6)Posteromedial triangle(Kawase' s triangle):inner edge(the GSPN)length(12.64±1.78)mm,outside edge(the superior petrosal sinus)length(11.63±1.74)mm,(the dorsal margin of the mandibular nerve)length(12.50±1.57)mm.Conclusions:1 Through grinding the ACP,we could increase the exposure of optic nerve,internal carotid artery and the intervl between them.This operation increases the operating space.It is helpful to solve the problem of cavernous sinus tumor and vascular disease.Besides,the upper and middle clivus can be revealed after the tentorium cerebelli cut and the posterior clinoid process ground.2 The advantage of Dolenc approach:(1)For the simple epidural lesions in the cavernous sinus region,we could treat the disease only from the epidural space,so as to reduce the direct traction to the temporal lobe brain tissue.It is not easy to contusion,in addition,it will not cause intracranial infection.(2)Because of Removal the ACP from the epidural space,the brain is not easy to be damaged by the dural protection.(3)The removal of the superior orbital fissure and the anterior bone could significantly increase the exposure of the anterior and posterior orbital tissues.It is suitable for the tumorcommunicating of orbital and cavernous sinus.(4)By dissecting the carotid collar,we could completely liberate the internal carotid artery.This is beneficial to expose the aneurysm neck of ophthalmic artery aneurysm,paraclinoid aneurysm and the Cave aneurysm.(5)When the Glasscock triangle is ground,the petrous internal carotid artery can be exposed,and it is more convenient to deal with the hemorrhage of the internal carotid artery.If necessary,we could operate vascular anastomosis on the internal carotid artery.(6)It can fully reveal the superior and lateral wall of cavernous sinus and reveal cranial nerves and blood vessels.The operation can be carried out from any gap and can protect the nerve structure under direct vision.(7)When the Kawase triangle is ground and the tentorium cerebelli is cut,we could expose the upper and middle clivus.It is especially suitable for the orbital-Cavernous sinus-Petroclival region tumor.3 The disadvantage of Dolenc approach:The craniotomy of this approach is complex,so it require the surgeon should has the superior ability of operation.At the same time,this operation trauma is bigger,the patient's recovery is relatively slow.It is not necessary to choose such a complex approach for lesions of small size,especially in the posterior part of the cavernous sinus and the posterior cranial fossa.4 Advantages and disadvantages of Kawase approach:The Kawase approach can grind part of the zygomatic arch and dissect the brain pool to reduce intracranial pressure,reduce the brain traction,increasing operating space.At the same time,it can ensure adequate exposure of the cavernous sinus,retain the zygomatic arch and obtain less surgical injury.This surgical approach remove the tumor from the latter part of the cavernous sinus to the front.In the operation,it is helpful to reveal the anatomical triangle in the posterior part of the cavernous sinus and protect cranial nerves and internal carotid artery.The approach is suitable for the lateral wall of the cavernous sinus,the posterior part of the cavernous sinus and the petrous apex area.It is very difficult for the surgical approach to reach the ACP because of the long path and the sight angle of this operation.Forthe tumor in the anterior part of the cavernous sinus,the hypothalamus and the anterior part of the anterior process,this approach can not expose to the operative field,so we cannot choose the surgical approach in this case.Besides,this surgical approach could not adequately expose the internal carotid artery.For the aneurysm of internal carotid artery and the tumor wrapped around the internal carotid artery,this approach has disadvantage on the ICA protection. |
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