RU2635633C1 - Method of plastics and sealing defects of dura in the field of bone defect of base of skull - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: autograft is formed, consisting of two fragments, the area of each exceeding the area of the defect. Fragments are sewed together in the projection of the center of defect of dura. Formed autograft is placed on the dura defect, with the first fragment of the autograft located behind the inner surface of dura, and the second fragment - from the outer surface of dura in the defect area. Before placement, the sewed fragments of the autograft are additionally stitched in the region of projection of dura defects edges.

EFFECT: method helps to reduce postoperative complications, which is achieved due to additional sewing of the autograft at the edges of the dura defect.

16 cl, 13 dwg, 1 ex

Description

The invention relates to medicine, namely to neurosurgery, and can be used for the prevention and treatment of basal liquorrhea in case of damage to the central parts of the base of the skull.

. Minimal Access Skull Base Surgery: Open and Endoscopic Assisted Approaches // JP Medical Ltd 2016). Этот способ выбран в качестве прототипа предложенного решения.A known method of plastics and sealing a defect in the dura mater in the area of a bone defect in the base of the skull, including the formation of an autograft from the first fragment and the second fragment, interconnected by at least two tightened sutures, placement of the autograft in the defect of the dura mater in such a way that the first autograft fragment is located behind the inner surface of the dura mater, and the second autograft fragment is located on the outer surface side dura (Kofi Boahene, Alfredo

. Minimal Access Skull Base Surgery: Open and Endoscopic Assisted Approaches // JP Medical Ltd 2016). This method is selected as a prototype of the proposed solution.

The disadvantage of this method is that during the placement of the autograft there is no mechanism for its additional fixation. This reduces the reliability of the sealing of the dura mater.

The technical result of the invention is to increase the reliability of the dura mater and sealing the cranial cavity. This is ensured by giving the autograft extra rigidity due to the addition of additional sutures, which increases the strength of the autograft and eliminates the risk of subsequent migration of the autograft. Tightening the additional joints after the autograft is installed allows you to achieve the most accurate integration of the autograft and the dura mater defect area after the autograft is installed, because . this allows you to level out possible defects of the formed autograft due to the features of the anatomical relief of the operation area.

The method is as follows.

An autograft is formed, consisting of two fragments, each with an area exceeding the area of the defect. The first fragment and the second fragment are stitched together by overlapping with tightening at least two sutures in the proposed projection of the center of the dura mater defect. The formed autograft is placed on the dura mater defect, wherein the first autograft fragment is located behind the inner surface of the dura mater in the defect region, and the second autograft fragment is located on the outside of the dura mater in the defect region. Before placement in the area of the dura mater defect, the cross-linked autograft fragments are additionally stitched with at least two sutures in the area of the proposed projection of the edges of the dura mater defect, which are tightened after the autograft is installed on the dura mater defect.

In special cases, the implementation of the developed method:

- as the first fragment of the autograft and the second fragment of the autograft using a wide fascia of the thigh.

- between the first fragment and the second fragment of the autograft an additional autograft is installed, which is congruent to the bone defect of the base of the skull.

- an autobone is used as an additional autograft.

- Auto cartilage is used as an additional autograft.

- an autogyro is used as an additional autograft.

- as an additional autograft, an autocomoperiostal flap is used.

- the first fragment and the second fragment of the autograft are equal in size.

- the first autograft fragment is smaller in size of the second autograft fragment.

- the first autograft fragment is larger in size of the second autograft fragment.

- the first fragment and the second autograft fragments are homogeneous or heterogeneous.

- as a second autograft fragment, an autocompostiostomal flap is used.

- in the case of a round shape of a bone defect in the base of the skull, additional sutures are placed at 3, 6, 9 and 12 hours of the conditional dial.

- in the case of a round shape of a bone defect in the base of the skull, additional sutures are placed at 3, 9 and 12 hours of the conditional dial.

The developed methodology is illustrated in the following figures:

In FIG. 1 shows an autograft, side view.

In FIG. 2 shows an autograft with an additional autograft, side view.

In FIG. 3 shows a transplant placed in a dura mater defect, side view.

In FIG. 4 shows an autograft with an additional autograft located in a dura mater defect, side view.

In FIG. 5 is an isometric image of an autograft.

In FIG. 6 shows an autograft with an additional autograft located in the dura mater in the area of the bone defect in the base of the skull (in the region of the bottom of the Turkish saddle).

In FIG. 7 shows the magnetic resonance imaging of patient C. A large endo-suprasellar pituitary tumor is visualized.

In FIG. Figure 8 shows the step of installing an autograft in the region of a bone defect in the region of the bottom of the Turkish saddle and a dura mater defect.

In FIG. Figure 9 shows the step of installing an autograft in the region of a bone defect in the region of the bottom of the Turkish saddle and a defect in the dura mater (another angle).

In FIG. 10 shows the formation of additional seams from additional threads 12.

In FIG. 11 shows the continuation of the formation of additional seams from additional threads.

In FIG. 12 shows an autograft installed in a region of a bone defect in the region of the bottom of the Turkish saddle and a defect in the dura mater. View after installation with the formation of additional seams.

In FIG. 13 shows a control computed tomogram of patient C. performed after surgery.

The method of plasty and sealing of a defect of the dura mater in the area of a bone defect in the base of the skull is implemented as follows (Fig. 1, Fig. 3, Fig. 5, Fig. 6).

At the first stage, the autograft 1 is formed from the first fragment 2 and the second fragment 3, connected to each other by at least two tightened sutures 4 of the two main threads. As an autograft, for example, a wide fascia of the thigh (or fat) is used, for which an autograft is taken intraoperatively from the anterior outer surface of the patient's thigh.

If necessary, in order to reduce autotransplant 1 flotation and increase autograft 1 rigidity, for example, with a large bone defect 22 of the skull base 23 (more than 15-25 mm) and a large defect 7 of the dura mater 8 (more than 10-20 mm) to form an additional autograft 20, material is taken from the bony part of the nasal septum, the cartilaginous part of the nasal septum, a fragment of the mucoperiostal flap of the nasal septum, and an additional autograft 20 is installed between the first fragment 2 of the autotrans graft 1 and the second fragment 3 of autograft 1.

After this, the first autograft fragment 2 and autograft 1 fragment 3 are formed in such a way that both of these fragments are 5-20 mm larger than the bone defect 22 of the skull base 23 and 3-15 mm larger than the dura mater 7 defect 7. Then, the first fragment 2 of the autograft 1 and the second fragment 3 of the autograft 1 are fixed to each other by forming tightened sutures 4. Then, additional sutures 14 are formed of two additional threads 12, and additional sutures 14 should be as close as possible to the bone defect of the base of the skull (i.e., be located in the projection of the edges of the bone defect).

After this, the autograft 1 is placed in the defect 7 of the dura mater 8 so that the first fragment 2 of the autograft 1 is located behind the inner surface 10 of the dura mater 8, and the second fragment 3 of the autograft 1 is located on the side of the outer surface 11 of the dura mater 8.

After the autograft 1 is installed in the defect 7 of the dura mater 8, additional sutures 12 are tightened.

In one embodiment (FIG. 2, FIG. 4, FIG. 6), an additional autograft 20 is installed between the first fragment 2 and the second fragment 3 of the autograft 1, which is congruent to the bone defect 22 of the base of the skull 23. This increases the strength of the autograft 1, thereby increasing reliability of the dura mater 8 and sealing of the cranial cavity.

There is also an option in which an autobone is used as an additional autograft 20. This greatly increases the strength of the autograft 1, as a result of which the reliability of the dura mater 8 and the sealing of the cranial cavity.

There is also an option in which auto-cartilage is used as an additional autograft 20. This increases the strength of the autograft 1 while maintaining its elasticity, thereby increasing the reliability of the plasty of the dura mater 8 and sealing the cranial cavity.

There is also an option in which autogyro is used as an additional autograft 20. This increases the strength of the autograft 1 while maintaining its elasticity, thereby increasing the reliability of the plasty of the dura mater 8 and sealing the cranial cavity.

There is also an option in which, as an additional autograft 20, an automucoperiostal flap is used. This increases the strength of the autograft 1 while maintaining its elasticity, thereby increasing the reliability of the plasty of the dura mater 8 and sealing the cranial cavity.

There is also an option in which the first fragment 2 and the second fragment 3 of the autograft 1 are equal to each other. Their sizes can be in the range of 15-35 mm. This option is the most universal, and it can often be used with the relative ease of installation of autograft 1.

There is also an option in which the first fragment 2 of the autograft 1 is smaller than the second fragment 3. This difference may be 5-20 mm. This option can be used for defects of the dura mater 8 of relatively small sizes, for example, 2-4 mm and a limited area of manipulation during its installation.

There is also an option in which the first fragment 2 of the autograft 1 is larger than the second fragment 3. This difference may be 5-20 mm. This option can be used for defects of the dura mater of 8 medium sizes, for example, 5-10 mm, or large sizes, for example, 10-15 mm. It has increased reliability of plasty of the dura mater 8 and sealing of the cranial cavity due to the larger contact area of the first fragment 2 with the inner surface 10 of the dura mater 8.

There is also an option in which the first fragment 2 and the second fragment 3 of the autograft 1 can be homogeneous, for example, from the wide fascia of the thigh. This option can be used in most cases and is the most convenient for execution. This also allows to increase the reliability of the plastics of the dura mater 8 and sealing the cranial cavity.

There is also an option in which the first fragment 2 and the second fragment 3 of the autograft 1 can be heterogeneous. This option can be used in individual cases, for example, in the absence of the necessary qualities for the wide fascia of the patient’s thigh, namely, when the thickness of the wide fascia of the thigh is insufficient, there is a defect in it and the size is insufficient at the fence. As the second fragment 3 of the autograft 1, a fragment of the autocomoperiostal flap can be used.

There are also options according to which: in the case of a round shape of a bone defect in the base of the skull, additional sutures are placed at 3, 6, 9 and 12 hours of the conditional dial; and also in the case of a round shape of a bone defect in the base of the skull, additional sutures are placed at 3, 9 and 12 hours of the conditional dial.

There is also an option in which, in the case of an oval-shaped bone defect in the base of the skull, additional sutures are placed at two points farthest from each other.

After the autograft 1 is installed in the area of the bone defect 22 of the base of the skull 23 and the defect 7 of the dura mater 8, the fibrintrombin glue “Tissucol” or “Evicel” can be used, which is applied to the outer surface of the second fragment 3 of the autograft 1.

Clinical example.

Patient S., 61 years old, was admitted to the Federal State Autonomous Institution Scientific Center for Neurosurgery named after Acad. N.N. Burdenko »Ministry of Health of the Russian Federation 01/20/2017 with complaints of decreased vision in both eyes.

An examination by an ophthalmologist revealed a chiasmal syndrome with a large effect on the right optic nerve. Visual acuity: OD = 0.4; OS = 0.7. Fields of vision are changed according to the bitemporal type with a violation of central vision.

On MRI, a large endo-suprasellar pituitary tumor (Fig. 7).

Clinical diagnosis: large endo-suprasellar hormonal inactive pituitary tumor.

January 24, 2017, the operation “Endoscopic transnasal removal of a large endo-suprasellar pituitary tumor” was performed.

Surgery protocol: Anesthesia, endotracheal. An external lumbar drainage is installed. The position of the patient lying with a raised head end. A typical endoscopic access to the anterior sinus of the main bone was made through the right nasal passage. The sinus is trepanized. The entire sinus was occupied by an enlarged Turkish saddle. The turkish saddle is trepidated. The dura mater 8 is opened by a linear incision. Found a tumor of grayish color, moderate density, bleeding. Part of the tumor was taken for examination. The tumor was removed in stages, various suction, curettes, 0 °, 30 ° and 45 ° endoscopes were used. The suprasellar part of the capsule is significantly thinned, through it the basal brain and chiasm are clearly visualized. No obvious tumor remains. Hemostasis using Surgiflo. A Tahokomb is installed in the cavity of the Turkish saddle.

The plastic surgery of the turkish saddle and defect 7 of the dura mater 8 was performed using an autograft 1 (wide fascia of the thigh) using the method developed by the authors (Fig. 8, Fig. 9, Fig. 10, Fig. 11, Fig. 12).

On the outer surface of the autograft 1, 1 ml Evicel adhesive was applied. At the end of the operation, the external lumbar drainage is removed.

The postoperative period was satisfactory.

In neurological status without negative dynamics.

At the control examination of the ophthalmologist: visual functions at the preoperative level.

At the control examination of an ENT doctor: there is no nasal liquorrhea.

With a control CT scan dated January 28, 2017: the tumor was radically removed, there were no hemorrhagic complications, no pneumocephaly (Fig. 13).

The patient was discharged 10 days after surgery.

Claims (20)

1. The method of plastics and sealing the defect of the dura mater in the area of the bone defect of the base of the skull, including the formation of an autograft consisting of two fragments, each with an area exceeding the defect area, the first fragment and the second fragment being stitched together by overlaying with tightening of at least two sutures in the proposed projection of the center of the defect of the dura mater, placing the formed autograft on the dura mater defect, wherein the first autograft fragment is located behind the inner surface of the dura mater in the defect region, and the second autograft fragment is located on the outside of the dura mater in the defect region, characterized in that before placement in the area of the dura mater defect, the cross-linked autograft fragments are additionally stitched with at least two sutures in the area of the proposed projection of the edges of the dura mater defect, which are tightened after the autograft is installed on the dura mater defect. 2. The method according to p. 1, characterized in that as the first fragment of the autograft and the second fragment of the autograft use a wide fascia of the thigh. 3. The method according to p. 1, characterized in that between the first fragment and the second autograft fragment, an additional autograft is installed, which is congruent to the bone defect of the base of the skull. 4. The method according to p. 3, characterized in that as an additional autograft use autologous bone. 5. The method according to p. 3, characterized in that as an additional autograft use auto-cartilage. 6. The method according to p. 3, characterized in that as an additional autograft use autogyro. 7. The method according to p. 3, characterized in that as an additional autograft, an autocompostal graft is used. 8. The method according to p. 1, characterized in that the first fragment and the second fragment of the autograft are equal in size. 9. The method according to p. 1, characterized in that the first autograft fragment is smaller in size of the second autograft fragment. 10. The method according to p. 1, characterized in that the first fragment of the autograft is larger in size of the second fragment of the autograft. 11. The method according to p. 1, characterized in that the first fragment and the second autograft fragments are homogeneous. 12. The method according to p. 1, characterized in that the first fragment and the second fragment of the autograft are heterogeneous. 13. The method according to p. 12, characterized in that as the second fragment of the autograft using autocompostal flap. 14. The method according to p. 1 or 3, characterized in that in the case of a round shape of the bone defect of the base of the skull, additional sutures are placed at 3, 6, 9 and 12 hours of the conditional dial. 15. The method according to p. 1 or 3, characterized in that in the case of a rounded shape of the bone defect of the base of the skull, additional sutures are placed at 3, 9 and 12 hours of the conditional dial. 16. The method according to p. 1 or 3, characterized in that in the case of an oval-shaped bone defect in the base of the skull, additional sutures are placed at two points farthest from each other.

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