Detailed Surgical Procedures and Indication for the Combined Transpetrosal Approach(<SPECIAL ISSUE>Selection of Surgical Approach and Pitfall II)

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  • Goto Takeo
    Department of Neurosurgery, Osaka City University Graduate School of Medicine
  • Ohata Kenji
    Department of Neurosurgery, Osaka City University Graduate School of Medicine

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  • 合併経錐体到達法の適応と手術の実際について(<特集>手術アプローチの選択とピットフォールII-第24回微小脳神経外科解剖セミナーより-)

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Abstract

A combined trans-petrosal approach which includes some degree of anterior petrosectomy and presigmoid posterior petrosectomy is quite an effective procedure for petroclival lesions, offering a wide and shallow surgical field. Several petrosal approach variations have been reported by master skull base surgeons and a detailed anatomy of the temporal bone has been obtained by cadaveric studies. These achievements enhanced the surgical safety and standardization of the procedure. But there still remain some critical risks in the procedure such as CSF leakage, sigmoid sinus injury and damaging the facial and cochlea nerves at petrosectomy. In this report, tips for the procedure including the way to harvest the fascia-pericranial flap to prevent CSF leakage, to expose sigmoid sinus safely, to perform safe petrosectomy and to resect the petroclival tumors caring critical vascular and nerve structures, will be minutely presented. A fascia-pericranial flap with a pedicle of sternocleid mastoid muscle has completely prevented CSF leakage and the following infections. Dissecting the sinus wall at an antegrade direction has enabled the safe and quick exposure of the sigmoid sinus. Both the mastoid antrum and endlymphatic sac are crucial landmarks for detecting the semi-circular canals. Opening Meckel's cave encourages large transposition of the trigeminal nerve which enlarges the exposure of the tumor at the area between the trigeminal and facial-acoustic nerve band. Surgical results of the combined transpetrosal approach have been satisfactorily improved by the accumulated modifications of the procedure.

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